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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-Old8 q$ J' U2 u! s& \+ U) I
Boy Induced by Indirect Topical
0 u. f% l8 {. _& u- V' I7 f1 dExposure to Testosterone; G7 u6 l4 t1 D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 N) v! y* l5 u( wand Kenneth R. Rettig, MD1
% D6 e! o0 N3 Y" s! M# aClinical Pediatrics( u; K: I( W  @1 q/ N
Volume 46 Number 6
7 p. k8 s7 S$ {$ J. \" FJuly 2007 540-543' [8 N! Y$ S$ Q$ Q9 o# n* H' C. T
© 2007 Sage Publications2 z6 F* h* n& t) a3 ^* q! V' ~
10.1177/0009922806296651
; T. h4 m$ u4 Chttp://clp.sagepub.com
4 g( ^9 d! U: G# {2 t! Jhosted at
# @- M- L& K8 q2 V9 y& S+ L# thttp://online.sagepub.com: L3 H! W8 ?& v' C% x
Precocious puberty in boys, central or peripheral,
5 o; X/ i6 g7 S3 m$ x4 Qis a significant concern for physicians. Central9 Q0 [: N- M) o$ d) u* o
precocious puberty (CPP), which is mediated3 e+ H! m" L9 ]8 `0 \
through the hypothalamic pituitary gonadal axis, has+ M# {! S+ k1 t5 S4 ]1 _; B
a higher incidence of organic central nervous system
4 j) Z0 i+ E0 Ulesions in boys.1,2 Virilization in boys, as manifested$ P4 G/ w, J! Q- l* K+ U5 C
by enlargement of the penis, development of pubic6 [1 h8 ?& z% B$ L, n3 T
hair, and facial acne without enlargement of testi-; @. {( K7 G4 r( |
cles, suggests peripheral or pseudopuberty.1-3 We
- i  b% n+ J# @1 [( E& \report a 16-month-old boy who presented with the4 @% ?( Y: c, R
enlargement of the phallus and pubic hair develop-
( p! ~( Z9 \, Z3 o/ N4 Jment without testicular enlargement, which was due" U) J1 G5 X8 G4 n- \
to the unintentional exposure to androgen gel used by
4 H  l  I/ {6 s/ T' V! g6 cthe father. The family initially concealed this infor-
4 i3 _+ j) q7 T4 P! m; Cmation, resulting in an extensive work-up for this5 Z6 D0 o8 n) s) V' k
child. Given the widespread and easy availability of
! D  j% m8 O/ f( [; Z/ q, j% Wtestosterone gel and cream, we believe this is proba-) I; X6 y; O8 e2 N, B
bly more common than the rare case report in the0 H) f3 ]; D0 ~" c
literature.4
% |; u/ f$ t( ~Patient Report
! }* J8 X6 }7 KA 16-month-old white child was referred to the: D' C# }3 L( w
endocrine clinic by his pediatrician with the concern
5 u2 a2 }, k9 v( F6 cof early sexual development. His mother noticed6 f* V2 b3 |% Q3 R- A
light colored pubic hair development when he was
4 o3 t( T# Z+ lFrom the 1Division of Pediatric Endocrinology, 2University of
9 ?! O7 O- x9 D6 @5 tSouth Alabama Medical Center, Mobile, Alabama.! T2 H$ U+ Q8 F' c5 ?4 g
Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 @, T% I- r. SProfessor of Pediatrics, University of South Alabama, College of2 q! \- {2 |3 ^- n( I1 b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& F* s4 _; q& Z; K8 we-mail: [email protected].% U- ?" L: `/ q3 X
about 6 to 7 months old, which progressively became
' g: N. X  R( _" M4 v) D# ~1 \# idarker. She was also concerned about the enlarge-4 c' t( j! d; h2 R& a! m3 o
ment of his penis and frequent erections. The child
7 m+ g- w& c' ]5 _7 J6 ]4 qwas the product of a full-term normal delivery, with
! t2 u# n+ E) y% Qa birth weight of 7 lb 14 oz, and birth length of" j" B! H7 F& V
20 inches. He was breast-fed throughout the first year
4 M. Q0 s: C4 N$ A. M3 W" q5 J1 Dof life and was still receiving breast milk along with$ K6 l# O9 P3 Q1 R; D, @
solid food. He had no hospitalizations or surgery,2 J6 N1 B* O, E* e
and his psychosocial and psychomotor development
# u3 c0 n0 d9 [6 L) zwas age appropriate.- Z$ S/ H0 \( I9 B5 |
The family history was remarkable for the father,8 f- k0 W7 I& f) q* P# t9 T
who was diagnosed with hypothyroidism at age 16,2 i9 `3 Q7 L# _# m4 w8 |6 d
which was treated with thyroxine. The father’s
  a: A/ D5 h; B% H1 f: oheight was 6 feet, and he went through a somewhat
- k# X7 ], Q% F- B  J! ?early puberty and had stopped growing by age 14.
' W. j' b0 t1 Z+ O" Q9 OThe father denied taking any other medication. The. m2 p8 l1 x+ H, t
child’s mother was in good health. Her menarche5 v8 S! L5 n' z& x# P) y
was at 11 years of age, and her height was at 5 feet9 t+ H- u; z; u6 `7 a
5 inches. There was no other family history of pre-
4 @1 J- i- H4 R$ z5 Lcocious sexual development in the first-degree rela-
' Y/ z' |- m% z6 g$ ptives. There were no siblings.- ]2 h% E" [5 B2 O4 t
Physical Examination1 Z2 x: P8 {* H
The physical examination revealed a very active,4 x' \8 h5 D  }8 ]) w  `
playful, and healthy boy. The vital signs documented; m+ r* C7 A. d. j& ^+ y
a blood pressure of 85/50 mm Hg, his length was
( r- a4 h- Y( D& |5 i$ T4 H90 cm (>97th percentile), and his weight was 14.4 kg# N7 u0 {5 S8 R" G( Y' b" x3 o
(also >97th percentile). The observed yearly growth
/ f6 s7 n% i% M9 V5 Q8 Bvelocity was 30 cm (12 inches). The examination of$ J/ s$ }$ f0 [3 x  w0 V
the neck revealed no thyroid enlargement.
8 t$ R* `3 p  l2 RThe genitourinary examination was remarkable for
: ?) |8 v- k* n+ I5 W; G8 Benlargement of the penis, with a stretched length of7 F" N( ~% p3 v: R2 E4 W3 U. K  x
8 cm and a width of 2 cm. The glans penis was very well
. ~  g5 j  K* r* _# O  ]" S9 Gdeveloped. The pubic hair was Tanner II, mostly around
/ x" X4 H6 C5 z/ a+ e2 C6 F0 ?- v540
) Z% {1 _' @. t7 R) zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- L- \' K' A  p& n. c7 ethe base of the phallus and was dark and curled. The" }8 ]' ]5 N3 O, M6 c
testicular volume was prepubertal at 2 mL each.. q/ r+ z1 H* P- {" F  O6 c* @
The skin was moist and smooth and somewhat7 f. {  v; a3 b' W
oily. No axillary hair was noted. There were no
$ ?$ H, E! \. l" N) _abnormal skin pigmentations or café-au-lait spots.
' K4 T6 m) p& H7 h, v& Y( K( UNeurologic evaluation showed deep tendon reflex 2+
% q0 l9 g/ r$ `: Y+ O4 Y7 Fbilateral and symmetrical. There was no suggestion
+ T6 z. \* m! s" pof papilledema.6 \  I2 u  a- Z' L% V% ?5 I
Laboratory Evaluation$ M: t2 o6 x9 B& D# f  G
The bone age was consistent with 28 months by6 ~7 V  N8 u1 I" ?, s! `- J
using the standard of Greulich and Pyle at a chrono-
" @" z( C8 V" @8 K; P' _logic age of 16 months (advanced).5 Chromosomal
7 \$ t, @2 I+ o3 `2 K- Q) C: Zkaryotype was 46XY. The thyroid function test
9 D, ]$ s8 \/ E; |) ]) Wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 p$ P' i2 g4 J4 y1 z
lating hormone level was 1.3 µIU/mL (both normal).
/ J. Q) q. P# \5 R9 yThe concentrations of serum electrolytes, blood5 A, P) v4 e, ~' P1 S
urea nitrogen, creatinine, and calcium all were
- B7 J- i4 x( A& Qwithin normal range for his age. The concentration
: S/ A5 K; t5 F  |) S1 E% Xof serum 17-hydroxyprogesterone was 16 ng/dL! i: N% P" i' q9 X4 D
(normal, 3 to 90 ng/dL), androstenedione was 20% [" W( z& D4 m& A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 O! e9 d) p0 w1 B& U# R
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  I6 j2 p/ P$ [+ ]" J
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* I& h3 |: u$ x0 a
49ng/dL), 11-desoxycortisol (specific compound S)  y  t6 m; u* J1 X+ b- U+ k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 H$ ^# |8 f/ f4 O  Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 M. S( M# S& |# S: X: Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& `! s1 O; \+ g. O2 L% B2 t
and β-human chorionic gonadotropin was less than
: H" v$ w& k8 K8 m+ {" ]& l5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 x3 p2 d3 L% Q2 T% ?stimulating hormone and leuteinizing hormone' Z4 o/ h3 h) R8 H6 ?
concentrations were less than 0.05 mIU/mL
, R9 S# e3 g/ J' B(prepubertal).9 r1 s) v# _2 W+ |% K/ m
The parents were notified about the laboratory
/ }! h/ p( C" z- Y8 u+ D# }8 ?results and were informed that all of the tests were" R' f, N1 v, I* D% o5 p  n
normal except the testosterone level was high. The5 p7 s8 Q, A; n4 q
follow-up visit was arranged within a few weeks to; E& R6 L3 N$ o2 L* D
obtain testicular and abdominal sonograms; how-2 L8 n, a+ ?6 V2 i/ H% ]
ever, the family did not return for 4 months.
# M1 c7 f3 u9 K! Q# iPhysical examination at this time revealed that the
. p8 E! r1 b2 x* Achild had grown 2.5 cm in 4 months and had gained: G% h+ u4 \- w
2 kg of weight. Physical examination remained6 y- ]: |. f9 i0 z4 u. r
unchanged. Surprisingly, the pubic hair almost com-
+ t0 Q5 {, `0 F9 R0 }pletely disappeared except for a few vellous hairs at
; b3 w: }/ v" f6 Mthe base of the phallus. Testicular volume was still 2
% O# {1 Q0 D' a9 u2 tmL, and the size of the penis remained unchanged.- E/ u3 b( p( ~" }
The mother also said that the boy was no longer hav-3 h; u0 b) m& i2 Z0 P( f
ing frequent erections.
6 t4 g5 _% t0 L) e- x) ^7 t. MBoth parents were again questioned about use of8 e3 A. }7 S4 c, U' ^% u$ `
any ointment/creams that they may have applied to
! R/ N4 G6 E: d# \  R& E/ z: Jthe child’s skin. This time the father admitted the8 S2 D6 y! Y2 C( Y
Topical Testosterone Exposure / Bhowmick et al 541
) k5 v7 _2 ~- s2 Xuse of testosterone gel twice daily that he was apply-$ E0 ?- `& V  l
ing over his own shoulders, chest, and back area for" a' @% _4 E# I6 v9 ?" G
a year. The father also revealed he was embarrassed
' o5 T* z. ^! F! h' tto disclose that he was using a testosterone gel pre-# F1 z; a+ w  ^9 M, ?
scribed by his family physician for decreased libido6 |9 J; L8 L0 X# a; ]9 T- W0 Z
secondary to depression.. ^% ^% T/ V) ?  W
The child slept in the same bed with parents.
0 m" m* F1 s" G' l5 M% D" H3 cThe father would hug the baby and hold him on his
4 X# ~- P$ b* R0 d4 T- j8 Qchest for a considerable period of time, causing sig-- Q% [' D# a/ Z9 o% C/ s, v
nificant bare skin contact between baby and father.# T8 j, @, K: O5 }+ l- c
The father also admitted that after the phone call,7 G0 j$ H6 p1 @' Z
when he learned the testosterone level in the baby" ^6 Z, @" u& }1 W. i3 f! O, l7 k8 g5 t
was high, he then read the product information6 ^" L& v, J2 C, x
packet and concluded that it was most likely the rea-
3 M$ m5 _, ?; V/ lson for the child’s virilization. At that time, they  A5 I! {3 Q9 e
decided to put the baby in a separate bed, and the! F/ Q9 L: Q2 x* G4 t
father was not hugging him with bare skin and had
' \; h) N. Z- Z. _been using protective clothing. A repeat testosterone
) N: H3 y. Y# O4 @$ @test was ordered, but the family did not go to the  W& l# r$ z) Q. k
laboratory to obtain the test.4 i0 S( m- \/ K% W2 j
Discussion
" z0 m9 M8 d0 J) R) z. {' kPrecocious puberty in boys is defined as secondary! ]/ |- O5 ?* v  w+ @, [8 O/ E
sexual development before 9 years of age.1,4
; L5 A0 E* R. APrecocious puberty is termed as central (true) when4 w. i4 ~. w' y
it is caused by the premature activation of hypo-3 O5 E+ r" m5 u. u: U: l
thalamic pituitary gonadal axis. CPP is more com-
& |$ E9 o3 G# a4 B6 G- Ymon in girls than in boys.1,3 Most boys with CPP
8 e6 Y, X" ^5 E) `may have a central nervous system lesion that is4 i& ~; A9 t: ~
responsible for the early activation of the hypothal-; G. ~3 Q7 |7 \5 X: G- n
amic pituitary gonadal axis.1-3 Thus, greater empha-
- g' t& L2 A0 k! O! o- d2 dsis has been given to neuroradiologic imaging in8 ?( ^+ X9 ]: L4 |8 d6 y$ ?
boys with precocious puberty. In addition to viril-" m! }# ]: X3 n) ^9 D% D: }
ization, the clinical hallmark of CPP is the symmet-& v2 J* s5 [9 u0 X* V. ^
rical testicular growth secondary to stimulation by
2 A3 D- Y& G/ X. u5 Rgonadotropins.1,3; L# U# b1 i/ }' F" K- O* c+ E
Gonadotropin-independent peripheral preco-
; z6 O4 |! h  Q- Hcious puberty in boys also results from inappropriate
& [( [5 M3 }" @4 aandrogenic stimulation from either endogenous or# S' A) [6 W$ P" X4 i
exogenous sources, nonpituitary gonadotropin stim-
+ e8 ~& |0 \1 d( e: ^7 Y( U# Zulation, and rare activating mutations.3 Virilizing
! x% v4 a+ D/ }8 Ccongenital adrenal hyperplasia producing excessive5 r) T- S- ~+ ?6 ~/ A9 \3 d, n9 G
adrenal androgens is a common cause of precocious
! v4 {" h$ P& X2 w) vpuberty in boys.3,4: K6 ^) `9 b8 A/ \
The most common form of congenital adrenal( ^  N) K# d' Z' I9 \
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 L3 p8 T( K' k" _# g; qThe 11-β hydroxylase deficiency may also result in: {7 p" G9 H1 n8 ^, w
excessive adrenal androgen production, and rarely,
3 ?0 W! _( h/ i+ c! x9 x! N/ Van adrenal tumor may also cause adrenal androgen
) l# v$ [& f  W! y; }2 Fexcess.1,3& ]7 n9 V+ X( Y/ i: X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, s" O2 S8 @$ e( R2 o
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 R0 M1 H2 ?9 h- G8 J2 z8 ]) D
A unique entity of male-limited gonadotropin-
: x. L3 A* N7 B  _" }0 m4 b4 N3 H" Hindependent precocious puberty, which is also known* x) e* Q8 n) Y/ `0 s" E% q
as testotoxicosis, may cause precocious puberty at a
9 T/ H! ^) v, }" v8 r/ avery young age. The physical findings in these boys
3 F2 `# s2 J0 ^8 [. uwith this disorder are full pubertal development,
; n5 M6 G: x# p/ `" N0 J" A  Oincluding bilateral testicular growth, similar to boys
0 ^6 J3 X2 r. N1 H4 T0 c( M7 Swith CPP. The gonadotropin levels in this disorder4 w5 n& }+ I4 T0 ~
are suppressed to prepubertal levels and do not show4 ~( p( H& U6 `7 d3 Y5 `( ]1 D! [
pubertal response of gonadotropin after gonadotropin-
1 n" o  @2 c7 R' O, o+ e0 }releasing hormone stimulation. This is a sex-linked0 _4 h) f* [: |( g( @, f6 a
autosomal dominant disorder that affects only! C% P; p) b. ]6 {
males; therefore, other male members of the family
1 y! x! I! s+ @  M1 n  |' X9 {may have similar precocious puberty.3& A; Q0 Y7 c! E6 N% x7 o9 S9 |
In our patient, physical examination was incon-" {; w0 f, M8 G+ f  p
sistent with true precocious puberty since his testi-
6 @+ i9 Z$ h$ l# E# A. y8 }: ]5 ^cles were prepubertal in size. However, testotoxicosis2 U; J- Y' n8 o0 p$ ]  m, R: ^) I
was in the differential diagnosis because his father) w+ h$ L8 v' `1 ?. }7 R2 ?
started puberty somewhat early, and occasionally,
! Z3 J$ n+ u+ r' w  B6 |testicular enlargement is not that evident in the' ]5 C$ y3 S5 D" ]+ b' Y+ b& ^
beginning of this process.1 In the absence of a neg-
# h4 T# {( E0 T# {: a1 Qative initial history of androgen exposure, our" l8 ]6 \. N( M/ E# z$ M( [$ X/ P
biggest concern was virilizing adrenal hyperplasia,
! p6 m0 Z" J; O8 M! r1 j- P2 A1 Beither 21-hydroxylase deficiency or 11-β hydroxylase
/ f6 z4 Z0 C" Mdeficiency. Those diagnoses were excluded by find-& l" c% l. q/ }: y6 _
ing the normal level of adrenal steroids.' q0 E' R' w9 _; i
The diagnosis of exogenous androgens was strongly* j$ l" V& o- l/ F3 e0 Y# w/ \
suspected in a follow-up visit after 4 months because8 t1 L/ B7 y, {  j+ Y
the physical examination revealed the complete disap-" q/ r1 @% d; c' Q) U
pearance of pubic hair, normal growth velocity, and9 c9 v$ \4 o+ s: T1 Z( j
decreased erections. The father admitted using a testos-
, L' m1 V% m) V1 y& aterone gel, which he concealed at first visit. He was
* a3 n. F" ?* M' ?1 susing it rather frequently, twice a day. The Physicians’
2 q) U) C# O2 c4 M. LDesk Reference, or package insert of this product, gel or, w$ R  ~# b# F3 z% Q7 R. p3 `
cream, cautions about dermal testosterone transfer to
) T4 M( V( |2 j+ M# _- }3 Cunprotected females through direct skin exposure.3 {  Q) ^" ]' W+ H, c
Serum testosterone level was found to be 2 times the% u0 w* P7 S8 F( \% D
baseline value in those females who were exposed to) z. \6 i3 ]6 G: d* L0 ]
even 15 minutes of direct skin contact with their male
9 z; d7 h8 E7 n) z$ Ipartners.6 However, when a shirt covered the applica-
( Q- T3 A- ]5 H3 h, R9 G, z& Rtion site, this testosterone transfer was prevented.
$ Y2 v4 S$ X! mOur patient’s testosterone level was 60 ng/mL,/ K! ^  U6 ]3 H1 W9 x+ x
which was clearly high. Some studies suggest that4 y' h" e1 Q& @: C1 h0 H" Q" H
dermal conversion of testosterone to dihydrotestos-9 L6 P1 s1 E' d0 \1 R: `, B0 I
terone, which is a more potent metabolite, is more
$ ~4 D# M* t) Cactive in young children exposed to testosterone
. z2 x) b  @3 i% T2 T- dexogenously7; however, we did not measure a dihy-
& i! W/ b: m+ g0 X6 L0 T0 Pdrotestosterone level in our patient. In addition to
! s5 f! g& G& a6 J9 k  Q' x( N, zvirilization, exposure to exogenous testosterone in  v/ N+ q3 l9 T( Z5 J. x
children results in an increase in growth velocity and2 X2 x! v5 D( `& s& a, P* b# m
advanced bone age, as seen in our patient.6 M' I- H: M9 N2 U8 F7 j
The long-term effect of androgen exposure during
% d& \, U/ g" L# P9 [5 j( t. ?early childhood on pubertal development and final
, b: R& y) X  D4 a! Dadult height are not fully known and always remain% Z  D/ j' I. i- N4 W: W; j* |, H3 y& x
a concern. Children treated with short-term testos-4 Z! L" q& N" s( Q& e
terone injection or topical androgen may exhibit some
) @# x; Q( S$ k7 \7 u; Eacceleration of the skeletal maturation; however, after) p' c+ f+ `3 @/ T4 \7 d
cessation of treatment, the rate of bone maturation
1 |5 Q9 ]4 t2 s+ p! z6 h$ ~decelerates and gradually returns to normal.8,9
% r1 N: l" j. ^# y6 YThere are conflicting reports and controversy
1 F: j5 Q- s# e& d, Hover the effect of early androgen exposure on adult
6 `- q% N; q( @* n% ppenile length.10,11 Some reports suggest subnormal# u# Z6 Z$ o' N4 S6 K7 ]
adult penile length, apparently because of downreg-
" n, {' p% q1 F/ Y' I& O  \ulation of androgen receptor number.10,12 However,1 A' b5 Y/ E9 \6 f8 w4 `+ t
Sutherland et al13 did not find a correlation between
0 t- X! ]. q5 H2 E4 wchildhood testosterone exposure and reduced adult
+ r, T, ^" p' X9 D" Cpenile length in clinical studies.6 J; C, Q# i$ s' \  @* s( S- I
Nonetheless, we do not believe our patient is
& ?# ?0 T( i3 ~# \% L; v' mgoing to experience any of the untoward effects from  z% \$ S8 q+ ]) |
testosterone exposure as mentioned earlier because0 Y. ~, ^  O+ f2 }' V/ }
the exposure was not for a prolonged period of time.
0 i9 T% j# L  }7 {2 F1 z1 X: UAlthough the bone age was advanced at the time of3 }! s% @- T( k) R% K
diagnosis, the child had a normal growth velocity at! T! z: p/ [4 S' x  h( @! G
the follow-up visit. It is hoped that his final adult' w' F. u4 W; g" H
height will not be affected.: @" @& l+ {* |% Q
Although rarely reported, the widespread avail-
* ~  v1 S/ ~) |2 o, hability of androgen products in our society may
' A) w# H  ]0 A- r4 lindeed cause more virilization in male or female
+ @5 q" r3 l$ ochildren than one would realize. Exposure to andro-' u: u% E' u+ _! i. y" f" ]0 h
gen products must be considered and specific ques-
! n" F' m' @3 C( ~4 _8 Mtioning about the use of a testosterone product or. B4 U6 o9 g4 B: h. i6 b
gel should be asked of the family members during
, Z( T& S6 u( l# x) ~, c+ Athe evaluation of any children who present with vir-2 h9 P/ C: r, v* s7 Y
ilization or peripheral precocious puberty. The diag-, m( y/ z% Y" t2 P
nosis can be established by just a few tests and by( c# s3 L& B) \- z1 T
appropriate history. The inability to obtain such a
, D9 j3 T4 H6 D$ C) K& N* Jhistory, or failure to ask the specific questions, may
; B+ p0 `$ b4 k. yresult in extensive, unnecessary, and expensive& l! q% e$ n8 {, Q: e1 T" \) N
investigation. The primary care physician should be
8 h, R; \/ G3 z' V' saware of this fact, because most of these children
, K$ I: w0 C9 L4 |may initially present in their practice. The Physicians’
# c/ P# ], Q# kDesk Reference and package insert should also put a' q7 m% s! R( K0 ~0 h! K2 M
warning about the virilizing effect on a male or. L$ e7 o! K. k  v# _
female child who might come in contact with some-
; T. H& |& G& N  C' y1 Lone using any of these products.
4 B' y4 V$ S  UReferences
% B. b* a5 o) F1. Styne DM. The testes: disorder of sexual differentiation1 ^" Y- d0 t; a7 r, o
and puberty in the male. In: Sperling MA, ed. Pediatric3 G0 y" y9 I5 q& N9 M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ R+ W( T' q9 p2002: 565-628.: I: H2 c  i- I$ z, [, e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 q* J6 J; V- R# d
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
% T/ U' m& o2 b# U7 u& [) a0 w! \Boy Induced by Indirect Topical
1 T( j' H& X& z3 x+ f6 @Exposure to Testosterone
0 ~3 C. c* t* D2 v7 M; Q7 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. R6 S; B; ?4 Q5 L2 z. {7 k! q% x
and Kenneth R. Rettig, MD1
0 v; {  G9 C% D% y' eClinical Pediatrics
, `( g5 |* y: h& h$ ?1 L0 Q" {; F4 SVolume 46 Number 6
$ o2 I& _! X/ P1 M2 e/ ]) s& pJuly 2007 540-543' p* R* S4 O+ k, r# L
© 2007 Sage Publications) \8 P+ `4 }) w; G
10.1177/0009922806296651* a3 D, E2 y4 ^5 s; x3 {7 Y5 G% ?  K
http://clp.sagepub.com
( f4 G) T$ _. I3 e5 X0 M4 ~hosted at( A( g8 p0 `1 a. C7 I
http://online.sagepub.com
2 e$ e9 U2 F3 D5 u1 F& m3 lPrecocious puberty in boys, central or peripheral,
7 A/ g* ~8 X( N& M) }4 q  iis a significant concern for physicians. Central
! M: \/ o9 c7 {# H" o# M, V& yprecocious puberty (CPP), which is mediated
2 S" c+ Q* {0 \- Z6 ?through the hypothalamic pituitary gonadal axis, has
8 |7 s8 C# ]- b% E1 \) ba higher incidence of organic central nervous system
7 p- H3 M! D9 dlesions in boys.1,2 Virilization in boys, as manifested
7 y4 D9 V) [+ Yby enlargement of the penis, development of pubic
6 H: Q0 ^, B- Nhair, and facial acne without enlargement of testi-% [) p3 G( {( U
cles, suggests peripheral or pseudopuberty.1-3 We* W7 w( V9 {; H( H- F9 o; b
report a 16-month-old boy who presented with the; u9 `/ n& h. H5 {
enlargement of the phallus and pubic hair develop-! g4 j2 x' Z. U  m
ment without testicular enlargement, which was due
7 }1 D5 g& ]4 r0 p" b* g6 Gto the unintentional exposure to androgen gel used by4 Q0 _. ^9 t; C: p: c
the father. The family initially concealed this infor-
  ]! c7 N$ R1 ^mation, resulting in an extensive work-up for this
& q. _9 z' c' Pchild. Given the widespread and easy availability of6 s0 X! m2 h$ c% S4 J
testosterone gel and cream, we believe this is proba-
4 w+ B( [! A# m/ v' Z6 k# ?0 P3 ably more common than the rare case report in the
/ ?# d- u- f. s$ f2 [literature.4! G, {4 s- D) A6 N
Patient Report
8 O: ~3 E4 r+ xA 16-month-old white child was referred to the
/ A, O) V2 m" i! e- m4 Hendocrine clinic by his pediatrician with the concern7 |" h- g1 R2 [, a
of early sexual development. His mother noticed
5 z3 V, n6 x1 y% h; r$ B5 l3 e; {light colored pubic hair development when he was
9 d5 A5 n9 H: a: t3 P' k3 K/ DFrom the 1Division of Pediatric Endocrinology, 2University of
: w0 w6 N( \& ?7 WSouth Alabama Medical Center, Mobile, Alabama.
6 Z5 ]+ w$ n1 q" U3 J4 \Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ o1 `2 [! d' b/ `1 M# J2 OProfessor of Pediatrics, University of South Alabama, College of5 U6 j: ]' r7 k8 Z9 P( I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: y2 D, i- a- pe-mail: [email protected].
/ {4 K0 W; z- L5 h; {" W4 @7 aabout 6 to 7 months old, which progressively became6 v* D) W0 Y* J1 g6 G5 y  M
darker. She was also concerned about the enlarge-
9 T9 d- B" g4 l( }0 f) Ament of his penis and frequent erections. The child
, d) `5 @$ a- ]7 q0 T, {, Q4 |was the product of a full-term normal delivery, with
8 O( f# W; \% v6 v( J( E" _  i0 oa birth weight of 7 lb 14 oz, and birth length of! M- s% M4 H: D8 A# ]
20 inches. He was breast-fed throughout the first year! F4 @' V3 w  e7 Z
of life and was still receiving breast milk along with
6 U3 Z6 Z; V- r" I; x/ rsolid food. He had no hospitalizations or surgery,
( ~) |* x' {& z; ~. r: g; gand his psychosocial and psychomotor development
; H! Q+ G$ T- I: h# Y3 Owas age appropriate.( R/ c+ Y) k6 B; A& n* c6 O# Q$ l% l
The family history was remarkable for the father,! E& m& m/ t) R+ k
who was diagnosed with hypothyroidism at age 16,
% I  C0 V$ k8 t0 G: {which was treated with thyroxine. The father’s" _& B; x5 `$ u7 K
height was 6 feet, and he went through a somewhat3 ]/ P# T! y! Z+ D, b
early puberty and had stopped growing by age 14.. K6 v/ X# D* f: p! H
The father denied taking any other medication. The* z/ g7 Q3 H/ H9 H( D! k
child’s mother was in good health. Her menarche
( N/ C: B( b4 \* pwas at 11 years of age, and her height was at 5 feet# g6 |" a' G1 z& l
5 inches. There was no other family history of pre-
% y4 E& ^" s* y% ?7 _7 mcocious sexual development in the first-degree rela-
& O2 E) G8 V& o6 G) T7 X2 Htives. There were no siblings.( h  k& D) y3 O6 j: J! t
Physical Examination7 k8 A3 M/ P8 c. w
The physical examination revealed a very active,& n: ]2 W! `6 _# y% U
playful, and healthy boy. The vital signs documented
: [5 S8 c0 ]* i3 O2 M7 P1 Ya blood pressure of 85/50 mm Hg, his length was
+ s; q1 K# b1 @( k: \0 b) n% Z+ U90 cm (>97th percentile), and his weight was 14.4 kg
% X' y" K: g& P$ Z- P7 P(also >97th percentile). The observed yearly growth
" s7 a% }$ l  H1 u  @velocity was 30 cm (12 inches). The examination of
: p, l. y. b5 S- zthe neck revealed no thyroid enlargement.
* G: V, ]; D* g" p+ n2 TThe genitourinary examination was remarkable for% X1 {( ^! |' D/ @
enlargement of the penis, with a stretched length of: |+ g0 G& F4 m4 c3 z1 |; [
8 cm and a width of 2 cm. The glans penis was very well7 w, H+ T# L5 n
developed. The pubic hair was Tanner II, mostly around+ K6 `9 C( D1 {+ n/ s
540* J2 M% o0 M  k4 y/ f; p& Z6 o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 e* M6 @/ C5 ]0 a3 ?
the base of the phallus and was dark and curled. The' P8 H) ]* S3 s( N9 R; H
testicular volume was prepubertal at 2 mL each.; p& s# p1 U+ ]- n# W
The skin was moist and smooth and somewhat
( u- ?, S/ n+ W, Eoily. No axillary hair was noted. There were no- b$ L: e/ E  v: N
abnormal skin pigmentations or café-au-lait spots./ T0 s8 N' w+ I( ^+ M
Neurologic evaluation showed deep tendon reflex 2+% K+ C/ x3 r+ K
bilateral and symmetrical. There was no suggestion
! c' y7 E$ h4 y( oof papilledema.
& u0 M  M. _3 s. f2 A8 T2 ULaboratory Evaluation
0 _$ \* y  S. s* t. R5 h7 j/ wThe bone age was consistent with 28 months by+ a" y4 @; j+ A* R1 o
using the standard of Greulich and Pyle at a chrono-3 C# ?; B# r; F1 l- g# Q
logic age of 16 months (advanced).5 Chromosomal
. ?2 z/ j& d2 b8 r3 I8 i. Gkaryotype was 46XY. The thyroid function test
" o- _4 S7 m9 W! k' vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 e! u7 D1 s9 i$ A5 f, K  _6 _7 [
lating hormone level was 1.3 µIU/mL (both normal).7 e0 u( y; ^3 v* [
The concentrations of serum electrolytes, blood
9 U* D; S% V. G! x' x  g4 W! Hurea nitrogen, creatinine, and calcium all were7 R' h0 r" Z9 X; @6 r5 C1 u
within normal range for his age. The concentration  k$ Z; `6 o* l* A& A% d
of serum 17-hydroxyprogesterone was 16 ng/dL
7 A( A& B1 Y, K9 J5 @; z( v(normal, 3 to 90 ng/dL), androstenedione was 20! {# B% R) B9 m$ f* j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ a: k& F% j; {8 T  v% X$ E8 D* p. I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 j- w1 Q% E1 U: e' d1 d  s1 ]% o3 gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# O! f; S1 h. r! t. q49ng/dL), 11-desoxycortisol (specific compound S)* K7 s% V( _3 ?% ~2 n
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, u& w1 ~8 X) G+ q. w3 b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 @6 d7 p% L& c. h) ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% x  A3 x0 w" j2 L. }; [
and β-human chorionic gonadotropin was less than1 w3 I0 v: y& `6 ?3 `
5 mIU/mL (normal <5 mIU/mL). Serum follicular, T. b; o% m4 H0 u3 c2 J$ M- v7 ?
stimulating hormone and leuteinizing hormone
$ U6 M: s4 _. f! `& q- J& I% M# O& i( }concentrations were less than 0.05 mIU/mL
. \# ?, n- V9 ~) I: ?(prepubertal)." {% i- u; p# c1 k3 b+ \
The parents were notified about the laboratory  `! D/ `+ ~1 f
results and were informed that all of the tests were# o2 j. T, _7 ^5 W  T2 i
normal except the testosterone level was high. The, s" r7 W1 L6 G8 F2 B# R- m
follow-up visit was arranged within a few weeks to, B, y" V& n4 t6 j- j; B6 E
obtain testicular and abdominal sonograms; how-
9 U. o3 `; b+ ~ever, the family did not return for 4 months.
# r. G, {. L" B0 S, i; u! {, }( SPhysical examination at this time revealed that the0 M9 }7 I% }6 V9 S! ]# u, I. b. c
child had grown 2.5 cm in 4 months and had gained5 @& E+ m7 j! G9 V% }7 G6 Z7 R, z
2 kg of weight. Physical examination remained
7 _: K. \! q5 V+ E# {3 V/ s# `unchanged. Surprisingly, the pubic hair almost com-! R3 x$ ^3 h. G' m7 V% f( V  n/ N! e
pletely disappeared except for a few vellous hairs at
% L- x( i' ?$ B8 Bthe base of the phallus. Testicular volume was still 2+ L( Y8 {7 R; H) W' A
mL, and the size of the penis remained unchanged.
. Q2 X" f2 ?- X9 rThe mother also said that the boy was no longer hav-! Y7 y0 E! h8 i2 k6 u7 S3 {% Z$ C
ing frequent erections." d: e, \& \3 h, z/ h/ u2 S
Both parents were again questioned about use of
, A- F4 r7 I( O  Uany ointment/creams that they may have applied to. s, Y' H2 s. N- v1 O/ F
the child’s skin. This time the father admitted the
: g0 k) g1 I; m; vTopical Testosterone Exposure / Bhowmick et al 5415 Q2 g6 g  P7 @4 \
use of testosterone gel twice daily that he was apply-2 V7 b7 Q" l) d! s& z1 J
ing over his own shoulders, chest, and back area for
7 d2 u/ n5 x3 e) w" p2 Ka year. The father also revealed he was embarrassed
8 E( e( w$ I3 l) J. n: rto disclose that he was using a testosterone gel pre-6 l- T2 x6 C) x: j
scribed by his family physician for decreased libido: E0 v4 E4 z7 x( i5 i2 Q! g  v5 D
secondary to depression.9 r& u. e4 a- t
The child slept in the same bed with parents.
. i4 R  q; C% f" G+ e3 JThe father would hug the baby and hold him on his
; v3 E. ]# p- `! u, D+ ]chest for a considerable period of time, causing sig-% |! {0 f0 e) F+ W
nificant bare skin contact between baby and father.
) Q1 R2 S; t: }( |The father also admitted that after the phone call,
: O1 E5 I( Y4 o" ?6 ]7 H9 _7 uwhen he learned the testosterone level in the baby; G' l  n- b+ u) v3 P
was high, he then read the product information
% c$ l( M6 t# cpacket and concluded that it was most likely the rea-
0 f( d! w2 P# G* r! _' d: b) Kson for the child’s virilization. At that time, they
3 l* x0 _- ?0 _+ W2 @& e/ ?9 v( \6 Ddecided to put the baby in a separate bed, and the
( f- w2 a$ P7 @# ?- ifather was not hugging him with bare skin and had+ T2 V. C) C& c
been using protective clothing. A repeat testosterone
: x! }7 m  u) X' X  g/ Otest was ordered, but the family did not go to the( P0 S" w$ `6 ]# j8 }' ^7 p
laboratory to obtain the test.
) @! X* u1 u* f* R( f, EDiscussion
# O" @4 }9 h3 M1 l  m2 rPrecocious puberty in boys is defined as secondary" H9 [6 m8 a$ r1 A
sexual development before 9 years of age.1,4
/ T" Z  G. K+ D, X3 X& bPrecocious puberty is termed as central (true) when/ _0 q( L& ^' t2 K6 U+ T2 p. l, q: U
it is caused by the premature activation of hypo-) @! E+ a3 G" |& |8 B
thalamic pituitary gonadal axis. CPP is more com-$ l; ~5 m$ d8 R2 X  B) _$ u6 }& l9 O8 [1 r
mon in girls than in boys.1,3 Most boys with CPP2 O# B/ U1 a6 m  G/ t9 g
may have a central nervous system lesion that is
* [; t0 e$ e9 `. Gresponsible for the early activation of the hypothal-
3 |4 ?9 g5 D& W# Q3 C- O: C& kamic pituitary gonadal axis.1-3 Thus, greater empha-
$ D6 G6 z3 y9 u' U- Q6 _) g2 n9 Z3 @4 ]sis has been given to neuroradiologic imaging in* E+ `( _5 ?  ]0 M- b
boys with precocious puberty. In addition to viril-
# m) C6 p8 g; p0 W, {* Cization, the clinical hallmark of CPP is the symmet-$ o/ n1 n; i+ }
rical testicular growth secondary to stimulation by
* o8 g# D0 [6 d' Y+ e+ Tgonadotropins.1,39 M2 r/ }( ^5 H8 H  O
Gonadotropin-independent peripheral preco-! c4 }  W9 T0 x- B4 I" t* s) v
cious puberty in boys also results from inappropriate: \2 w0 v# F" |4 K
androgenic stimulation from either endogenous or
) g3 m/ z% z1 c! b4 ~' {& T2 Nexogenous sources, nonpituitary gonadotropin stim-
" X' b7 u" i+ O8 G5 d( Eulation, and rare activating mutations.3 Virilizing
$ V5 G3 t% R# [2 J! Z4 g8 Kcongenital adrenal hyperplasia producing excessive; M5 q+ ]4 q& E! k  {$ k
adrenal androgens is a common cause of precocious
) }( C- v5 O, r9 s/ J2 ~/ G& }puberty in boys.3,4
" o& K0 ^' H' y5 g4 sThe most common form of congenital adrenal
1 U  c; \0 d) @; S* K1 Vhyperplasia is the 21-hydroxylase enzyme deficiency.
/ F' D" W5 U0 JThe 11-β hydroxylase deficiency may also result in
7 z4 C6 T' s+ }# v( Z, Texcessive adrenal androgen production, and rarely,2 @+ ^/ v- f6 {$ B4 d5 e, w8 p  }
an adrenal tumor may also cause adrenal androgen
( j* B" C& K! `/ O9 R: qexcess.1,3& c& a/ g( {" [% W+ E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: e3 B! M  n# d5 p- e  ]" T2 V/ D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& k4 }. w9 x) x) o6 Y8 TA unique entity of male-limited gonadotropin-
( M$ F( e* U, Gindependent precocious puberty, which is also known
; |* U3 s$ R' V' Z" {0 _! [& jas testotoxicosis, may cause precocious puberty at a
0 ]. s$ S, N! k3 _, svery young age. The physical findings in these boys
! a. J4 a9 n* }( t+ h% }8 Xwith this disorder are full pubertal development,
4 U: Y+ w: p' Q* B; Q7 [$ Eincluding bilateral testicular growth, similar to boys
  _+ c, p0 b6 K# T* l/ D3 J; [1 cwith CPP. The gonadotropin levels in this disorder9 W! a8 f. k& u/ v
are suppressed to prepubertal levels and do not show# s. f7 a1 i" m" o4 K' G/ t
pubertal response of gonadotropin after gonadotropin-2 @& U1 f, T$ g2 Y9 _9 ^) U$ {
releasing hormone stimulation. This is a sex-linked3 p8 h: q$ ?3 c) o
autosomal dominant disorder that affects only7 |& e$ R2 S# W, g" p( B) |
males; therefore, other male members of the family
! [9 w9 _0 W* Zmay have similar precocious puberty.3+ q/ S& G5 b( p& O
In our patient, physical examination was incon-( x" x% s) b6 k+ q3 v" A9 d
sistent with true precocious puberty since his testi-
* I( h/ E4 D/ |' Qcles were prepubertal in size. However, testotoxicosis! H9 i$ x+ M, V  @9 J9 a. K
was in the differential diagnosis because his father7 [( k7 e+ `+ d1 C
started puberty somewhat early, and occasionally,2 P9 j6 c' I( P& E9 b% {' a  k( p
testicular enlargement is not that evident in the
9 s+ j9 R. m; a. j2 o8 ~: ybeginning of this process.1 In the absence of a neg-% U% R2 k2 U" {
ative initial history of androgen exposure, our, m! `! Z0 _2 P. ^- O' [
biggest concern was virilizing adrenal hyperplasia,
( s  o& c' k  Y9 z0 `" teither 21-hydroxylase deficiency or 11-β hydroxylase$ k( y! J# A! r+ j* @
deficiency. Those diagnoses were excluded by find-
) ?, j- i! w5 n( Z' z0 ~) u6 Jing the normal level of adrenal steroids.# H" h' q0 e) d& Z$ N. b4 s
The diagnosis of exogenous androgens was strongly/ O7 c; y( w; J# P
suspected in a follow-up visit after 4 months because
" e( N7 l# _! d* M: Pthe physical examination revealed the complete disap-
. k, k2 w+ d. y$ @% W+ `pearance of pubic hair, normal growth velocity, and
! V0 @2 Y0 t; r0 T1 |decreased erections. The father admitted using a testos-! B+ r2 s: I! A0 d5 N
terone gel, which he concealed at first visit. He was- n1 w7 w- d/ Y  ?- V6 c# l
using it rather frequently, twice a day. The Physicians’- b' t% i8 S+ R
Desk Reference, or package insert of this product, gel or
5 t8 S3 O: i* B! R1 {4 ~2 Ocream, cautions about dermal testosterone transfer to
" H6 h) U9 K2 Q8 lunprotected females through direct skin exposure.0 b: P! ]0 w* q$ U3 g6 U' R
Serum testosterone level was found to be 2 times the
# n# T/ n- {/ D( r) hbaseline value in those females who were exposed to
! S! R& l1 B6 reven 15 minutes of direct skin contact with their male; v3 _8 U: h; x9 d# z6 ^
partners.6 However, when a shirt covered the applica-
# h% S1 o; l9 A& M! u0 a. stion site, this testosterone transfer was prevented.2 _# w5 D1 w6 z" C! k( @
Our patient’s testosterone level was 60 ng/mL,; Y/ L- Z  e, A
which was clearly high. Some studies suggest that  p5 I4 `$ {, {2 C
dermal conversion of testosterone to dihydrotestos-6 Q8 V* h7 P  D
terone, which is a more potent metabolite, is more
1 t3 U8 `% ~, h& ^# B" E  ^  sactive in young children exposed to testosterone; {5 m8 d" ~! x8 [) ^& e* _
exogenously7; however, we did not measure a dihy-
/ N. \1 r( p4 v/ edrotestosterone level in our patient. In addition to, r# j4 e- g/ d
virilization, exposure to exogenous testosterone in0 ?/ `( ~1 I3 }5 |5 @, ?4 L
children results in an increase in growth velocity and
6 {. A3 B. F+ d% }1 L' Z/ qadvanced bone age, as seen in our patient." q8 }5 U8 p  s% K* a
The long-term effect of androgen exposure during% p8 |% S8 }& [$ I; M, F+ p' N
early childhood on pubertal development and final
' `) C* z6 L, ]1 H; [! Kadult height are not fully known and always remain) M' h) @% b. z  [, F
a concern. Children treated with short-term testos-! t1 M6 S8 s  w( M
terone injection or topical androgen may exhibit some  P4 E. _3 v" q: k$ l
acceleration of the skeletal maturation; however, after
, ?% P" b  y/ {9 ~+ ccessation of treatment, the rate of bone maturation
; n5 R% Q2 s, o% L6 W& Z+ Gdecelerates and gradually returns to normal.8,9
/ r9 b. I+ }! G4 Z: \4 DThere are conflicting reports and controversy
2 y$ n7 s" h. M! A; }# D4 g& lover the effect of early androgen exposure on adult: L8 q& S6 D* W! H( w
penile length.10,11 Some reports suggest subnormal
/ g9 O) A9 e0 c8 Y' [. l; Hadult penile length, apparently because of downreg-! H8 {# \2 G5 n: d
ulation of androgen receptor number.10,12 However,
, ~! {2 ~9 H9 Z4 M  x; B' `: {" xSutherland et al13 did not find a correlation between5 g7 y/ B  s5 R7 ?5 W
childhood testosterone exposure and reduced adult
3 w. j+ T5 M! ^  l" T2 a/ wpenile length in clinical studies.
: C- ]+ n6 _: S  V+ m* qNonetheless, we do not believe our patient is+ s" a! {+ {0 w
going to experience any of the untoward effects from- i7 w7 M; v0 f+ j4 G
testosterone exposure as mentioned earlier because
5 @7 V3 _5 M+ ]( cthe exposure was not for a prolonged period of time.- M% o+ T9 y2 o4 N$ ]4 s3 a+ t
Although the bone age was advanced at the time of
4 n( g& n8 N" A+ |4 U6 K7 a+ \diagnosis, the child had a normal growth velocity at
" y1 \# C9 w5 e1 }6 P$ f% t2 M' p8 dthe follow-up visit. It is hoped that his final adult( \  x$ p  U+ H
height will not be affected.! B# |3 g4 D; K: z5 p; R' s7 `
Although rarely reported, the widespread avail-
7 j. O1 ?# f: u) m/ z  ?ability of androgen products in our society may
" f7 D; ^% Q) u* O1 Y1 x* rindeed cause more virilization in male or female
: q; v$ {4 h0 i  V# t7 b5 Rchildren than one would realize. Exposure to andro-
2 d! L/ h0 |* N7 U% Egen products must be considered and specific ques-$ [) n2 m% Z7 j* Q' b8 ~+ ^
tioning about the use of a testosterone product or
+ m0 X, S( Z1 J; `gel should be asked of the family members during  U5 S* m, S% [9 B) d% R
the evaluation of any children who present with vir-3 |6 u5 k  S* ?% b1 z
ilization or peripheral precocious puberty. The diag-
, \% v+ I6 h7 z- inosis can be established by just a few tests and by. _+ V% A6 @7 k- z2 V- r4 s* M
appropriate history. The inability to obtain such a
, T7 y8 b% n- uhistory, or failure to ask the specific questions, may- g" B& E- m1 G0 S
result in extensive, unnecessary, and expensive
8 l: v$ r; h) k! ]) z, w$ `( sinvestigation. The primary care physician should be
# w  P8 j3 p% jaware of this fact, because most of these children
3 O" _( x- q: d+ l% Wmay initially present in their practice. The Physicians’; E; m  i* g- G8 a5 m* q' N. d
Desk Reference and package insert should also put a
% N) \0 n5 F, g! g3 |* p6 iwarning about the virilizing effect on a male or
. n' G% m9 a( A5 V7 B. |* j9 Hfemale child who might come in contact with some-
( i/ A% M* W- s" {2 done using any of these products.. B$ [: v, y5 O1 P7 C# R! W
References
+ j: l% P5 `* p& c" {1. Styne DM. The testes: disorder of sexual differentiation
  k0 c( f, Z5 yand puberty in the male. In: Sperling MA, ed. Pediatric5 ~. a: V9 F  F: A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; S. \0 Z0 j: V4 z: N1 r2002: 565-628.: [7 e2 i' d) y9 H: K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, o4 v* P# g; m: L( ~6 E% }puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

0 K0 s6 [8 U; h- {7 B4 {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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