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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-Old
# C  ^# S& D' m: ZBoy Induced by Indirect Topical* c, k7 Q4 z# w8 }
Exposure to Testosterone
) l1 U- I. w# s  U$ d/ bSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  ~! X- i* w: y6 b5 e8 _
and Kenneth R. Rettig, MD1
- r% V5 o: K5 u% l. {7 N% k9 JClinical Pediatrics
  w  x' G* }3 V7 ^Volume 46 Number 65 x" P1 A& g& {$ r0 g
July 2007 540-543
8 C% A+ }! a( i' f4 v© 2007 Sage Publications) `- h, O2 J8 ?" c2 L" q
10.1177/00099228062966513 q  I! s8 P5 C
http://clp.sagepub.com
& M5 ~# j7 S5 Bhosted at
# P7 b! I6 G- S3 Y) ^& rhttp://online.sagepub.com5 E0 O9 D5 ~' z7 x7 D. s3 U( Q
Precocious puberty in boys, central or peripheral,0 ]8 ?. _2 Q% E) x
is a significant concern for physicians. Central. J5 A# x$ n6 O
precocious puberty (CPP), which is mediated
* S8 x. e' t  ]. S* T/ c/ H+ }through the hypothalamic pituitary gonadal axis, has& u$ a8 X! s1 e" X; r4 @; f9 q$ A1 k
a higher incidence of organic central nervous system: K8 I# R( m; I* \
lesions in boys.1,2 Virilization in boys, as manifested$ I; ^; M' ?) g8 ^; [5 h* o
by enlargement of the penis, development of pubic
, ]0 [# i$ O5 G6 e# @! m5 ~hair, and facial acne without enlargement of testi-
* L9 ^8 }8 M2 \7 b) f+ ?cles, suggests peripheral or pseudopuberty.1-3 We! |. J7 C2 u9 g4 _2 k
report a 16-month-old boy who presented with the
9 m3 R7 j& o5 r* R. Venlargement of the phallus and pubic hair develop-% r+ ^# X# |% x6 F# k& Q
ment without testicular enlargement, which was due$ ^7 d4 C+ C5 X# H
to the unintentional exposure to androgen gel used by' C& ]$ H! I. _$ G4 c1 d
the father. The family initially concealed this infor-
& v$ d' k0 [, _# a  n7 Zmation, resulting in an extensive work-up for this
; |' V1 l# @0 C4 J  W; x6 Z. Jchild. Given the widespread and easy availability of
* G+ M% T* R" j, ~8 x8 h+ ~testosterone gel and cream, we believe this is proba-9 X/ ~% a& [+ M, Z8 d2 F' n
bly more common than the rare case report in the
- m* B9 J! @% {; X, X3 ^literature.4( L6 Z+ w( I6 i1 c
Patient Report& m/ o2 r' j  V
A 16-month-old white child was referred to the* x- l8 }% E3 v& A& \( d7 v
endocrine clinic by his pediatrician with the concern
- d% l9 v" j% Q6 Z( |of early sexual development. His mother noticed
" Q* E4 m: A  Q0 o+ \light colored pubic hair development when he was" k' C7 N9 k; T
From the 1Division of Pediatric Endocrinology, 2University of4 L( }( q" R' u; }8 g: J& j
South Alabama Medical Center, Mobile, Alabama.
. r+ {( v4 \4 l& YAddress correspondence to: Samar K. Bhowmick, MD, FACE,! y; {. i0 ~( Y1 ]
Professor of Pediatrics, University of South Alabama, College of
7 J6 q( ?" r& g9 n) JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 m2 H: @, K4 [6 g4 m  G
e-mail: [email protected].7 J3 `1 a0 ?. V5 f7 ^' r
about 6 to 7 months old, which progressively became
/ s, `/ P# V, cdarker. She was also concerned about the enlarge-  ^1 Q+ F$ |, ?: \) w% h
ment of his penis and frequent erections. The child
+ U6 N* T: ~+ |was the product of a full-term normal delivery, with* \# G2 U+ t' Z
a birth weight of 7 lb 14 oz, and birth length of
8 A9 R" A6 P; i9 p20 inches. He was breast-fed throughout the first year1 C5 I2 Z; Y- x. @% r
of life and was still receiving breast milk along with1 D2 k( H: l8 k) c+ u
solid food. He had no hospitalizations or surgery,
: b! L- G7 A6 Sand his psychosocial and psychomotor development
) K0 M9 p2 k. D+ l+ l2 Swas age appropriate.
0 T  A) X# Z# a7 d. ZThe family history was remarkable for the father,
# k! O' ~; Y/ k/ i- A( l. M" Xwho was diagnosed with hypothyroidism at age 16,
1 Y8 n/ P! O4 i. Awhich was treated with thyroxine. The father’s
. n* j/ J1 c1 P) Y, p# t/ lheight was 6 feet, and he went through a somewhat5 F( l7 T& T) h2 O
early puberty and had stopped growing by age 14.
* m6 M5 X% G& @! L0 QThe father denied taking any other medication. The
9 d& A: z7 s6 z" fchild’s mother was in good health. Her menarche
* O" k+ j6 E; e5 Y& twas at 11 years of age, and her height was at 5 feet
2 x8 O! u/ \! L+ p! a5 inches. There was no other family history of pre-
2 L) _/ ~- Q' m6 icocious sexual development in the first-degree rela-* A4 W! _: l* y) d( p
tives. There were no siblings.  ?. s) ]/ W6 Z3 u: j0 [2 `
Physical Examination6 W# i$ s6 D. h6 x
The physical examination revealed a very active,4 s4 ?$ Y- F1 m" }
playful, and healthy boy. The vital signs documented+ T6 i# ~2 z. ?3 h
a blood pressure of 85/50 mm Hg, his length was
  y7 i9 y3 g. K/ h90 cm (>97th percentile), and his weight was 14.4 kg
% u: E' ?! _- `% O( c/ |( ?(also >97th percentile). The observed yearly growth
6 I# v5 |: A5 |$ w- fvelocity was 30 cm (12 inches). The examination of
! L( O+ H" C. q' t6 Y' k, ~" fthe neck revealed no thyroid enlargement.
) l" ~8 q/ ]  a/ h/ B  I; A! zThe genitourinary examination was remarkable for
! T) [6 P/ j8 f7 j7 J. oenlargement of the penis, with a stretched length of1 T' T/ F; `% q! M
8 cm and a width of 2 cm. The glans penis was very well
+ t/ y0 L  {/ A# I$ W9 Y, ^* Tdeveloped. The pubic hair was Tanner II, mostly around
  f$ l  x# P7 B5 R- c4 Z540
& B0 a  l/ k) ^! sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 R$ d! }  R# M
the base of the phallus and was dark and curled. The
# y, R$ `) l0 c; ?2 wtesticular volume was prepubertal at 2 mL each.
" A& Y7 X5 v0 e1 I, x' mThe skin was moist and smooth and somewhat
9 H9 Q: y( T) N8 Coily. No axillary hair was noted. There were no5 Y' z  }, p& e6 `0 i& K
abnormal skin pigmentations or café-au-lait spots.
9 U+ Z& h& I+ h% \+ S0 _6 S% ZNeurologic evaluation showed deep tendon reflex 2+7 H6 }$ e4 u; g5 h! I
bilateral and symmetrical. There was no suggestion
! ], M6 @6 M+ _' f. d' Sof papilledema.  v" N( `4 A1 @* [% m, |! C1 v6 ]
Laboratory Evaluation
/ [0 O% {: ~/ M3 ]The bone age was consistent with 28 months by6 K& P* Y8 Z8 Q$ Z
using the standard of Greulich and Pyle at a chrono-
/ I& i7 h  \5 \- N, A# Jlogic age of 16 months (advanced).5 Chromosomal
$ a) [1 M' _7 k. F; L) c  Wkaryotype was 46XY. The thyroid function test
2 k7 S, ^2 Y+ ~2 ?& R4 ]# kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 u; V# x- G. w. V" tlating hormone level was 1.3 µIU/mL (both normal).
' l# K7 t2 p: C3 h& |+ V; dThe concentrations of serum electrolytes, blood& o( p/ w, F4 G( M" o+ P+ R6 h
urea nitrogen, creatinine, and calcium all were
' A0 f5 a) w4 \( e! P& qwithin normal range for his age. The concentration
- _' F! N3 v6 Gof serum 17-hydroxyprogesterone was 16 ng/dL7 f  I4 [( j, P# a( r& H5 p
(normal, 3 to 90 ng/dL), androstenedione was 20
8 S5 a, O) W' i5 b2 Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 E9 e5 C& B; @% h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, [1 u' `% J8 B* l, u9 Q, g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- u/ v( \4 D  c' x; j9 }* E49ng/dL), 11-desoxycortisol (specific compound S)3 ], L: r) \# O5 y& d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! T; r8 D- J: |' t3 a% e; v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( e3 ?( q$ a# s8 i. h: Y6 X8 Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ L# A% H$ n9 |( v3 S) H
and β-human chorionic gonadotropin was less than
2 ]3 M) i; n. k% j$ z6 Z% v' t5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 I) Q. q; p8 Q( \3 I3 k- N0 }' U* Cstimulating hormone and leuteinizing hormone
4 T( Y$ y- S' y6 [4 bconcentrations were less than 0.05 mIU/mL
+ h" K& _2 a1 D" g! `(prepubertal).
' P5 r2 ?+ E% M" _8 k) cThe parents were notified about the laboratory
: X/ [4 H5 z0 O8 W3 ]" B3 z* K) tresults and were informed that all of the tests were
. W% |0 u. _8 H/ S! r  ?$ unormal except the testosterone level was high. The
9 C. r' [% _& F% _follow-up visit was arranged within a few weeks to
& q3 i4 o0 U* ]obtain testicular and abdominal sonograms; how-* v( L' e! B! l! z! V
ever, the family did not return for 4 months.  f; i3 k1 z' h0 s# A
Physical examination at this time revealed that the
1 h  M! i& ]0 i) Z: ochild had grown 2.5 cm in 4 months and had gained! E! G3 N& o* y% |
2 kg of weight. Physical examination remained* M/ s& u3 X( }3 ~* V, D) t
unchanged. Surprisingly, the pubic hair almost com-' i$ H4 c' ~, T: P
pletely disappeared except for a few vellous hairs at; B' k+ P1 [3 D+ \# X
the base of the phallus. Testicular volume was still 2/ ?8 o- v# y! T; s4 Q$ ]
mL, and the size of the penis remained unchanged.; w% q% B2 J. h# ]/ R- ?: L- |. X
The mother also said that the boy was no longer hav-0 t! W+ e3 `3 y8 z& L! T
ing frequent erections.
' h- J+ F* F3 rBoth parents were again questioned about use of
& H  S9 Y' K& C7 |+ O  J' c; Iany ointment/creams that they may have applied to. |. ~1 Y, X' b/ c, c( B* |- N
the child’s skin. This time the father admitted the, u8 B" o' P1 r9 }6 n  O5 C
Topical Testosterone Exposure / Bhowmick et al 5418 ^. X: C: d# _' @, |( K# A, X
use of testosterone gel twice daily that he was apply-
/ G% o' J. h/ z0 ?9 F( Qing over his own shoulders, chest, and back area for- m. [, `! \+ O4 h  B  H( z
a year. The father also revealed he was embarrassed' W: F% t$ T+ K$ t
to disclose that he was using a testosterone gel pre-
0 I) m  a: w9 v- |% @8 N: Zscribed by his family physician for decreased libido5 F  f+ {( \- Q# s
secondary to depression.! ?) t: v9 Y# M; C1 v
The child slept in the same bed with parents." i( D6 P1 ~$ ]: x2 L
The father would hug the baby and hold him on his7 \$ a+ p' V3 L1 G( |1 l$ H/ {5 u
chest for a considerable period of time, causing sig-; ~7 e! F& X! R' R: @
nificant bare skin contact between baby and father.
* x" l9 i+ W! v8 V# pThe father also admitted that after the phone call,! I1 i8 A0 p% i1 y% K' l
when he learned the testosterone level in the baby1 a% I% U" G9 W) N9 ~
was high, he then read the product information
5 G3 a1 n7 s- P( W3 U: I" ^packet and concluded that it was most likely the rea-
0 R  |! v% Q# V$ T7 T9 G/ F& kson for the child’s virilization. At that time, they
9 ~" O2 G+ `6 i0 }$ fdecided to put the baby in a separate bed, and the
2 i, O% S$ K8 F5 yfather was not hugging him with bare skin and had5 m: v2 W9 [! U# W& v- Z* c! A
been using protective clothing. A repeat testosterone  n, l  p8 m2 x5 y/ m5 U
test was ordered, but the family did not go to the
# L9 }0 O. q3 I  ^3 |3 t3 slaboratory to obtain the test.
6 n" ]4 r$ e1 hDiscussion. v$ ?" J7 @; n4 v8 u" l) T' d3 X8 `
Precocious puberty in boys is defined as secondary
# |) f& i) Y) _7 L  jsexual development before 9 years of age.1,4! s5 z* Y4 V) c6 R; K; F5 j, e
Precocious puberty is termed as central (true) when8 K! H2 ~% M+ ]4 R7 L
it is caused by the premature activation of hypo-4 a; [: V6 v' |5 z
thalamic pituitary gonadal axis. CPP is more com-( g9 f, V# k8 k
mon in girls than in boys.1,3 Most boys with CPP
: n  r8 g& V1 dmay have a central nervous system lesion that is
/ b( q+ L  j: Y+ @: Dresponsible for the early activation of the hypothal-( g. c  [) U) C- j" ^# {1 u  x2 c
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 X7 U' a9 i+ esis has been given to neuroradiologic imaging in
" _9 {$ a- T; H5 C/ Y+ dboys with precocious puberty. In addition to viril-8 S1 l2 I* t3 j: B* M9 `9 ~
ization, the clinical hallmark of CPP is the symmet-0 V# S. e4 G0 }
rical testicular growth secondary to stimulation by
+ h1 z4 j3 z5 u* c" y* G0 R6 ngonadotropins.1,3* D! b/ U  B3 v- y& G
Gonadotropin-independent peripheral preco-
4 w' V5 p2 ?2 e. M8 Z0 K% n: z* Zcious puberty in boys also results from inappropriate7 b' B+ w* Y' _& [
androgenic stimulation from either endogenous or. o8 t: E( s' E& r  c, z% V9 S
exogenous sources, nonpituitary gonadotropin stim-
9 u3 q0 s0 H/ K* {6 |& Gulation, and rare activating mutations.3 Virilizing( h" f8 V- @" V, j# ?7 T: x
congenital adrenal hyperplasia producing excessive
$ q/ h9 A4 O' S0 Eadrenal androgens is a common cause of precocious
8 @* I/ r3 g4 dpuberty in boys.3,4
1 ?' m- F& P( A5 s* n. u0 n* SThe most common form of congenital adrenal0 v  k7 j3 Y/ h$ F) ^( Y9 V% m
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ y% C4 E; p8 y" o, N* gThe 11-β hydroxylase deficiency may also result in$ l' w) {- m, }1 e. s9 N
excessive adrenal androgen production, and rarely,7 ?' j- }/ R7 t$ l
an adrenal tumor may also cause adrenal androgen) E8 q$ t6 ?7 @% a. k& T& ~  N
excess.1,3$ m1 d( z: y% F/ G4 q' \7 G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  n$ k8 |- k, X) Z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( n0 U6 Y/ m* t8 z3 G7 J( j; ?
A unique entity of male-limited gonadotropin-
: |# P7 f/ i$ l+ Dindependent precocious puberty, which is also known7 o0 a7 I8 }% e$ d7 h# t
as testotoxicosis, may cause precocious puberty at a3 [( M& I, g4 ~- b$ L- I: p
very young age. The physical findings in these boys( t- C9 v. u0 A' Z$ |
with this disorder are full pubertal development," d( I) y' R5 y6 }! c
including bilateral testicular growth, similar to boys: L  W/ A/ D' ~" S; ^9 q
with CPP. The gonadotropin levels in this disorder2 n; Y# Z  g: W, H# P9 o5 T, n
are suppressed to prepubertal levels and do not show2 d6 X: F( V* B7 a- T7 _
pubertal response of gonadotropin after gonadotropin-
, J* q" ~$ T/ m7 \% N: J8 L  j! Treleasing hormone stimulation. This is a sex-linked- |2 U" f1 `) C' W$ `
autosomal dominant disorder that affects only# J; d- t4 E& }
males; therefore, other male members of the family$ e+ |8 r8 `3 W7 r. @* \
may have similar precocious puberty.3
/ {: }' q: e9 jIn our patient, physical examination was incon-
3 U6 K# ?7 ^$ J- W8 ssistent with true precocious puberty since his testi-* x/ u% s! @, @! i" L4 G9 K
cles were prepubertal in size. However, testotoxicosis( z! h( O0 t  o3 ?* a
was in the differential diagnosis because his father
' A# D# a% K. p/ q7 V2 Zstarted puberty somewhat early, and occasionally,
4 T# x& X. c& M' z2 Btesticular enlargement is not that evident in the
4 [# p5 B1 C- ^- p% i7 tbeginning of this process.1 In the absence of a neg-( ?; d8 v3 J; [3 C4 A
ative initial history of androgen exposure, our
* e0 A1 s; M* M) X& j/ Z) Y4 @biggest concern was virilizing adrenal hyperplasia,
  J/ m1 Y) A+ w+ D' _  |. deither 21-hydroxylase deficiency or 11-β hydroxylase6 l3 t5 P! ~& e2 A! g! |/ G
deficiency. Those diagnoses were excluded by find-
6 t4 [8 F2 u' R( m2 M9 h/ uing the normal level of adrenal steroids.7 y; T$ I& B' t/ l0 |* k
The diagnosis of exogenous androgens was strongly
+ }) b* s$ h' o9 ]. a! N' [suspected in a follow-up visit after 4 months because& G* @1 H; l. B+ W# t
the physical examination revealed the complete disap-
& G5 _8 y1 [& \: {. h& K/ H9 ipearance of pubic hair, normal growth velocity, and
1 @6 `" _5 t2 Q$ Q' Ndecreased erections. The father admitted using a testos-
6 W- n" p3 n# O7 X. {: {terone gel, which he concealed at first visit. He was
1 t) J* s* e5 t2 A  I+ u- e$ C; y, yusing it rather frequently, twice a day. The Physicians’
. J& H* T6 h5 U. v( G2 q- cDesk Reference, or package insert of this product, gel or9 d9 R6 Y8 S" K$ L; ]" X8 W/ ]( J
cream, cautions about dermal testosterone transfer to. b0 C! J+ R' y9 o. }8 K
unprotected females through direct skin exposure.
, ]: o$ Y& o2 l9 HSerum testosterone level was found to be 2 times the8 Y! ?! F8 `, \0 q9 K0 @
baseline value in those females who were exposed to; S" W% N6 Z  D. \
even 15 minutes of direct skin contact with their male- I$ y0 q7 a7 F6 \6 w0 C
partners.6 However, when a shirt covered the applica-( b$ y$ m/ b" r" ~( {# Q* Q) ]
tion site, this testosterone transfer was prevented.- Z9 B; h* ~$ k6 R1 K2 {: p+ T
Our patient’s testosterone level was 60 ng/mL,
6 c& }; T5 I6 e/ k+ I4 o. {& Bwhich was clearly high. Some studies suggest that
3 C0 |6 s6 s5 H0 xdermal conversion of testosterone to dihydrotestos-6 n  q* L: ]/ [; I
terone, which is a more potent metabolite, is more
. G  o; F' [7 J8 Zactive in young children exposed to testosterone3 ]8 K( |4 Y. p6 ^8 }" y
exogenously7; however, we did not measure a dihy-6 T7 Y% j4 l# N" d5 s9 ~5 W& o
drotestosterone level in our patient. In addition to! X; r$ [9 }3 T, L4 b
virilization, exposure to exogenous testosterone in2 u% T, ^4 B- {' M; ^5 l2 S( D% l
children results in an increase in growth velocity and
0 ~2 J( s: b3 L# o) u! `8 @8 Madvanced bone age, as seen in our patient.
% C' M) n8 i$ m  i% fThe long-term effect of androgen exposure during! ^) g$ p/ t; f% U3 h6 x# t& z
early childhood on pubertal development and final
! [4 q( D# ]- f, |$ o* ~1 U5 qadult height are not fully known and always remain; R0 M2 c8 ?2 y3 ^
a concern. Children treated with short-term testos-
0 t; {5 R9 r/ V$ }7 S) ^terone injection or topical androgen may exhibit some
3 i6 |( H5 e- k! m/ L, ~# r% K- a+ aacceleration of the skeletal maturation; however, after" n& m, s- E  N
cessation of treatment, the rate of bone maturation
; U7 l) a+ ~3 Z7 c( J- e% ]decelerates and gradually returns to normal.8,9# c- _2 L0 i+ Y$ e6 ~
There are conflicting reports and controversy: T( r2 p- [! L: I$ L/ f8 L
over the effect of early androgen exposure on adult# b+ G5 R3 l0 \& o! e* a9 X
penile length.10,11 Some reports suggest subnormal
8 U7 g/ L/ f# \% \adult penile length, apparently because of downreg-: g& R! i# d8 i0 d* O; P: j
ulation of androgen receptor number.10,12 However,
0 T; K$ \, i' u, ASutherland et al13 did not find a correlation between
1 n( l5 L7 |$ G8 Ychildhood testosterone exposure and reduced adult
8 e9 l$ y2 r7 |- m: `% F+ Q+ Ppenile length in clinical studies.
8 u1 e) a- Q0 p7 n& n% BNonetheless, we do not believe our patient is
0 K0 T# ~5 Z" b+ B" P1 j0 `4 o6 zgoing to experience any of the untoward effects from$ \) W. M% u! _" R2 ]9 W0 A
testosterone exposure as mentioned earlier because3 [3 y* d0 u: U: @' j1 P7 k6 K( D/ G# e
the exposure was not for a prolonged period of time.
, _) A; W% u9 N- r0 TAlthough the bone age was advanced at the time of
$ J$ K% G( i, O! g+ [2 s2 Pdiagnosis, the child had a normal growth velocity at; m6 J& [9 g- z0 I
the follow-up visit. It is hoped that his final adult6 _, V$ A( u6 r- X& h5 L
height will not be affected.
4 Z/ O% |/ A9 a. e7 i$ oAlthough rarely reported, the widespread avail-0 i" }% E1 p2 j$ c7 L3 [$ g
ability of androgen products in our society may; o/ j. E/ C% Y0 A* m
indeed cause more virilization in male or female
( C. k+ f- r. L! O) Wchildren than one would realize. Exposure to andro-' u2 T; d" b7 k# t; a
gen products must be considered and specific ques-: S. w7 H- _7 I# h0 E
tioning about the use of a testosterone product or9 p# b' D7 X' S2 d. y5 K; s
gel should be asked of the family members during% e+ J2 m* j9 z& H4 y3 Q
the evaluation of any children who present with vir-
6 }1 b8 p" q" q  g$ T+ Wilization or peripheral precocious puberty. The diag-' J2 v/ c2 u, r
nosis can be established by just a few tests and by
2 _, G2 x6 `9 w  Z/ H! happropriate history. The inability to obtain such a  Y) g$ s" [9 z3 _6 @
history, or failure to ask the specific questions, may4 t# s% b, e+ x8 S
result in extensive, unnecessary, and expensive
9 v* `7 y. ~$ [+ tinvestigation. The primary care physician should be% @$ P3 W3 @8 o# S( ?+ i# L5 n8 I
aware of this fact, because most of these children
" Z. d2 P/ w4 J) Kmay initially present in their practice. The Physicians’
, }; |" ?4 P+ a1 h! L; ~Desk Reference and package insert should also put a+ \) q$ ]' n, C% V/ T
warning about the virilizing effect on a male or
3 p) m  @' ?7 n) K) afemale child who might come in contact with some-
" _/ n, @  e5 `, T1 M7 A  sone using any of these products.  w( d' z  A. N4 ^1 s( A* f- |& ^
References9 s/ e  U* k# x4 F) ^1 F
1. Styne DM. The testes: disorder of sexual differentiation: Q" x0 m" a  H" R& E' v( E6 j
and puberty in the male. In: Sperling MA, ed. Pediatric
6 k( T! ]% M. Y  J- k% ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% ~- o  N$ b2 a7 W8 d2002: 565-628.
4 ?1 k, q4 M/ P2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 \- E; h6 o- @$ l; [5 j6 gpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
: m* E8 ]9 _' l& [  TBoy Induced by Indirect Topical
- E1 P% T8 D  X$ ?Exposure to Testosterone5 s4 J, Z- v9 ^+ f% @  [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" ^' F8 y& Q% I* d
and Kenneth R. Rettig, MD1# D6 l5 x" a' h" Q+ Y
Clinical Pediatrics
: y- `0 R, x# y2 V: wVolume 46 Number 6
; d, v' N* D" X- CJuly 2007 540-543
: v2 L- V7 \- |. v' B0 C© 2007 Sage Publications
, z4 G) J7 `) j: g10.1177/0009922806296651, n9 N6 t: H( X; Y
http://clp.sagepub.com1 @2 V0 F% `: s
hosted at1 F4 g7 A( Y# M7 \+ f
http://online.sagepub.com0 E% D  i+ C) L+ ?/ v8 ^; d- t
Precocious puberty in boys, central or peripheral,! e, ?9 K* S- z: _
is a significant concern for physicians. Central
- i, {/ R" w* G/ O- I$ j. p8 Q4 X4 y- oprecocious puberty (CPP), which is mediated
9 x+ \0 C- B* f4 athrough the hypothalamic pituitary gonadal axis, has
. O2 w3 z( ?9 q# M, S1 h( ^a higher incidence of organic central nervous system
# ^' S7 I( b* J  ]lesions in boys.1,2 Virilization in boys, as manifested
/ b2 F9 \  K6 K+ d* }by enlargement of the penis, development of pubic2 X1 X8 r( f8 r
hair, and facial acne without enlargement of testi-
- s8 c: o* w: }: Gcles, suggests peripheral or pseudopuberty.1-3 We
$ o: O' _& r5 O3 E  Breport a 16-month-old boy who presented with the
# `1 ?# N0 D: p  c3 Z% |enlargement of the phallus and pubic hair develop-: k' C+ J  X1 Q6 Y- T
ment without testicular enlargement, which was due1 l- o3 r3 ?  A3 ]
to the unintentional exposure to androgen gel used by& A1 ?' ]3 L2 X& J% x
the father. The family initially concealed this infor-
0 z2 U: ]% R8 ^! Q2 xmation, resulting in an extensive work-up for this
( ]2 V7 o$ m, e  W& \child. Given the widespread and easy availability of/ a, r; e7 G: ?6 Q
testosterone gel and cream, we believe this is proba-. b8 X# Z( P2 a5 x3 C4 ~' w
bly more common than the rare case report in the
# [2 g  @5 B: l8 E2 v, S! Vliterature.4+ r# o3 F$ S/ f+ ^& w. g4 n' i
Patient Report0 F3 ~" z; P: }" i" M3 r) N
A 16-month-old white child was referred to the& i+ A1 {4 O  g$ X
endocrine clinic by his pediatrician with the concern
4 ]. T- |, \' }7 t, j1 B% cof early sexual development. His mother noticed
; W8 G. C4 w, Qlight colored pubic hair development when he was: `1 L+ d: L. i) r
From the 1Division of Pediatric Endocrinology, 2University of
8 N+ Y3 R$ P; u4 {South Alabama Medical Center, Mobile, Alabama.
; e' X' w$ r; w  e: Y6 oAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 {8 V4 i: L# b6 ?  o
Professor of Pediatrics, University of South Alabama, College of+ w9 I8 U1 P2 C2 ]! C. c6 `, }( ~& U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ f: }4 U7 ^- L3 \- He-mail: [email protected].
  H  ?# k. [6 K# t/ D# F6 zabout 6 to 7 months old, which progressively became4 ]6 b; _: p* B$ ~4 K$ m) K
darker. She was also concerned about the enlarge-# l3 E; @9 ~3 Y4 l
ment of his penis and frequent erections. The child, r/ N6 i" k, Y3 N) d: k! f& H
was the product of a full-term normal delivery, with& `' t, b+ `$ Z0 A. A3 S; [
a birth weight of 7 lb 14 oz, and birth length of/ x, x5 G" j0 f( A, d$ q5 }" |
20 inches. He was breast-fed throughout the first year. G7 l, d' t1 U0 R$ L' _
of life and was still receiving breast milk along with
3 Q0 o2 D: K% o) w! _& @, Jsolid food. He had no hospitalizations or surgery,
7 c  g+ |  r) j( G9 v6 }5 A* ?/ Vand his psychosocial and psychomotor development! Z* Z8 B) x4 c* ?
was age appropriate.
) @5 f* a1 }1 D# z  sThe family history was remarkable for the father,
$ O' ?, L7 N/ [who was diagnosed with hypothyroidism at age 16," g0 Z# F, H/ ?7 [6 X- H" @, ]
which was treated with thyroxine. The father’s* Z+ d0 m! d: H0 V% C2 @
height was 6 feet, and he went through a somewhat
7 P! l! h( d8 s4 k7 Rearly puberty and had stopped growing by age 14.
  _' Z/ z5 j( ~; tThe father denied taking any other medication. The$ [& r8 k, x9 |8 y. A
child’s mother was in good health. Her menarche: o  _5 B& F* z. }: E
was at 11 years of age, and her height was at 5 feet
  B  N7 M4 ?, X5 inches. There was no other family history of pre-
+ {* a. E9 o- ^. y1 ?4 Jcocious sexual development in the first-degree rela-
% T9 t; u- j( [- p/ n% Utives. There were no siblings.
) d/ s/ z# v8 e7 W. b# n# h/ LPhysical Examination9 b2 R. O9 @, B1 {2 [# l
The physical examination revealed a very active,: p3 W9 z: I# z" K
playful, and healthy boy. The vital signs documented
% ^( M: Y, f" u* _. x  xa blood pressure of 85/50 mm Hg, his length was
# N" k, X! n" x% O' X1 c( z/ u90 cm (>97th percentile), and his weight was 14.4 kg
$ W+ T/ t: O* b' F(also >97th percentile). The observed yearly growth# s& S6 I  r7 m3 n( K+ W. P0 ^+ g
velocity was 30 cm (12 inches). The examination of
/ w; a9 Q. l2 V2 Nthe neck revealed no thyroid enlargement.
8 c0 B8 H! u) I$ Y" TThe genitourinary examination was remarkable for
- t, L5 l, q: \$ G% _0 ?9 x9 lenlargement of the penis, with a stretched length of: I9 i) a! ~! `7 [  U
8 cm and a width of 2 cm. The glans penis was very well8 E5 g1 J$ P# v
developed. The pubic hair was Tanner II, mostly around+ B' n. Z) w2 w% v, y# I# [3 z* E
540) P; i" p  Q& r/ J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 `' t6 r9 }5 o) F- Q
the base of the phallus and was dark and curled. The: f' G  D6 ~1 r- g$ i# A& n
testicular volume was prepubertal at 2 mL each.
0 L+ _) W6 [1 J: j  ~The skin was moist and smooth and somewhat0 Z# |" m8 w& ~3 t
oily. No axillary hair was noted. There were no
; {; _# m0 a; c0 Z+ ^abnormal skin pigmentations or café-au-lait spots.) n/ L; A" S0 }$ @9 \0 X. g
Neurologic evaluation showed deep tendon reflex 2+0 C6 @6 h& m# x% T# c  O( e
bilateral and symmetrical. There was no suggestion7 X) S$ ~  z* C: a) ?
of papilledema.' J- }$ T$ v/ ~% j; q
Laboratory Evaluation
3 v2 {9 s1 O  J8 X& C/ \0 xThe bone age was consistent with 28 months by; z  ]  f1 E; F* H/ G5 }
using the standard of Greulich and Pyle at a chrono-; \$ j* |+ h) l1 N8 N# n
logic age of 16 months (advanced).5 Chromosomal
% b5 E+ w7 S6 }* z- n/ Xkaryotype was 46XY. The thyroid function test
3 I* b6 O) F% @1 Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ f( S/ `( K7 J2 ^lating hormone level was 1.3 µIU/mL (both normal).
/ u( z: Z  V: n) O& SThe concentrations of serum electrolytes, blood5 c& p( X' |( Z* v7 C
urea nitrogen, creatinine, and calcium all were0 K6 k6 P7 M- c5 e6 @9 h
within normal range for his age. The concentration
4 C! V. G" M7 A6 F( b0 }of serum 17-hydroxyprogesterone was 16 ng/dL
% |& M4 Z; {  p: q8 V5 u8 b4 F8 J5 I(normal, 3 to 90 ng/dL), androstenedione was 20
* u! p" |: X* m  u9 e! z1 C- Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* F" S/ N7 p  n' ^" G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 x/ e: Y3 H" U2 H. P( U, T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' _0 z* W/ j' h0 _9 d( u0 R: _49ng/dL), 11-desoxycortisol (specific compound S)5 ~  Q! n' B3 J) f2 a9 p# t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 c& O" x; }  {" x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  [) b) C# ]" jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% m6 p- y) X2 z7 q7 [and β-human chorionic gonadotropin was less than
* i3 V, `; Y0 T8 B5 mIU/mL (normal <5 mIU/mL). Serum follicular" D" n7 v0 t1 l& S* h$ }% F
stimulating hormone and leuteinizing hormone
% l) y) E, a9 ~4 ]5 f: U% Y; cconcentrations were less than 0.05 mIU/mL9 o9 W) Y. N8 ^# T7 S2 K
(prepubertal).4 D* Y3 {. b# Z" j4 S' O  L
The parents were notified about the laboratory
0 V; z$ D8 F5 u% D5 c( vresults and were informed that all of the tests were
; w6 p. }# B/ C5 b1 O" j3 W# t- w  Unormal except the testosterone level was high. The
2 H) ~+ m0 E! H2 ^4 h7 Y  Hfollow-up visit was arranged within a few weeks to
7 l' h, Z( ^% W8 s0 L- E- h' nobtain testicular and abdominal sonograms; how-
) v( h) H& H9 x! e# j) ^ever, the family did not return for 4 months.6 C  g3 [6 K! j0 C% B& U% M1 t- ^
Physical examination at this time revealed that the7 `% ~( ], O& B# `& Y) l; }5 }
child had grown 2.5 cm in 4 months and had gained
3 u* x) a; M( ?9 B; V2 kg of weight. Physical examination remained5 s! M" |' T7 S# B2 [& j0 }
unchanged. Surprisingly, the pubic hair almost com-
; P2 G( T; x+ C0 A7 f9 ypletely disappeared except for a few vellous hairs at7 }' o+ ?2 f& @( w; {
the base of the phallus. Testicular volume was still 2( P. w1 m9 x' K# m6 E  X! C- o
mL, and the size of the penis remained unchanged.4 |& ]) I9 V  L+ ]4 l. V! I
The mother also said that the boy was no longer hav-
2 L5 b3 a1 M, xing frequent erections.
' e; Z, Y: E  M( q; S, {Both parents were again questioned about use of: b4 z0 F; j2 n* _
any ointment/creams that they may have applied to0 _" o1 u1 t: A) y, J2 C
the child’s skin. This time the father admitted the/ g# k7 Y0 e- I
Topical Testosterone Exposure / Bhowmick et al 541
2 M! @- I; ]5 G+ ~$ Huse of testosterone gel twice daily that he was apply-/ T: E& g3 Y+ y' ]" x3 H9 T
ing over his own shoulders, chest, and back area for
# a) w1 K0 ~; z: da year. The father also revealed he was embarrassed
  s6 r7 t0 b* r; ato disclose that he was using a testosterone gel pre-& Q! ?# ^2 ?3 v0 W
scribed by his family physician for decreased libido
! z6 q$ c, D. @9 _7 s1 J6 asecondary to depression.9 |3 F5 {+ k2 Z0 b
The child slept in the same bed with parents.
0 S: u0 j. B5 _The father would hug the baby and hold him on his4 E$ Y7 v* ~/ |8 j7 {2 x
chest for a considerable period of time, causing sig-! G* J% B; ?; O! R8 F$ W
nificant bare skin contact between baby and father.
1 F- ]# Y7 Q. K5 ]& |+ ~/ _The father also admitted that after the phone call,% Y/ h5 N0 ~4 \( k0 f
when he learned the testosterone level in the baby
8 G; W, v- T! ~, wwas high, he then read the product information
' `8 D2 u- r1 F* \5 w6 q4 d9 L% U5 w: p2 xpacket and concluded that it was most likely the rea-! W3 O5 b8 H/ B# t4 h4 i* W" c
son for the child’s virilization. At that time, they1 ^9 Q' e3 o. r0 z  k0 l  {1 w! k
decided to put the baby in a separate bed, and the. J* B; D7 _% Z
father was not hugging him with bare skin and had- Z8 x0 c2 d, N; i
been using protective clothing. A repeat testosterone
' @" p: s2 f0 S6 htest was ordered, but the family did not go to the- f& v. J$ Q7 Z% j8 ?( b
laboratory to obtain the test.' I" B3 S2 v4 Z# ~, ]- F* o6 m
Discussion
; x+ _% H; f2 v& }" v  KPrecocious puberty in boys is defined as secondary
* l5 M8 _* o$ K4 j: c2 \sexual development before 9 years of age.1,4
+ {, S0 I; s) M& u7 @Precocious puberty is termed as central (true) when
" C( G; m+ d2 `' {# b8 _0 T# bit is caused by the premature activation of hypo-
$ H% B( ^& @' d: P  Ethalamic pituitary gonadal axis. CPP is more com-; W4 _( u5 t  A% d; ~
mon in girls than in boys.1,3 Most boys with CPP8 T" }& F# n9 G/ O7 ~' C
may have a central nervous system lesion that is3 k, _% L  F9 r2 D7 z  H
responsible for the early activation of the hypothal-
# p/ X1 O) M8 q5 y; ~) Lamic pituitary gonadal axis.1-3 Thus, greater empha-
. |7 x: {9 }: B8 a$ Wsis has been given to neuroradiologic imaging in
- k' G' w8 a9 g" N& C* hboys with precocious puberty. In addition to viril-5 G2 f. D: F8 ?* |" X
ization, the clinical hallmark of CPP is the symmet-
) p& [, B* ^, [rical testicular growth secondary to stimulation by* K2 x; @3 ~, S
gonadotropins.1,3
! `7 k7 U9 W1 n. U- a9 h+ jGonadotropin-independent peripheral preco-
( ~) ]7 y; }, L& W2 m/ W; \2 Icious puberty in boys also results from inappropriate
+ S! w5 }. n$ B& y4 \androgenic stimulation from either endogenous or4 s2 U  P( H3 b) ~, I3 Q
exogenous sources, nonpituitary gonadotropin stim-
4 e! W1 y+ A* F8 D4 b1 y6 i/ uulation, and rare activating mutations.3 Virilizing
. R! G+ y7 a2 ?+ ]congenital adrenal hyperplasia producing excessive* H- z3 m9 P6 [& ?! y- Z/ d
adrenal androgens is a common cause of precocious
& d2 C: c5 {/ ^+ G( opuberty in boys.3,4
. B$ L7 a  @% }, q; l% i. D" \The most common form of congenital adrenal
/ ^$ I# D9 b" s- {9 }8 Mhyperplasia is the 21-hydroxylase enzyme deficiency.3 w& V* z( J8 e
The 11-β hydroxylase deficiency may also result in
8 }" @$ t. u6 \excessive adrenal androgen production, and rarely,; ?* C) F! q; x1 A3 L0 q5 _# w
an adrenal tumor may also cause adrenal androgen$ V+ Q; J, M. _: t3 E
excess.1,3) i% }! H0 f3 C- D: A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 X9 M4 x! {# o8 G2 W
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% T7 N" H0 M! q/ h2 s6 M
A unique entity of male-limited gonadotropin-0 n$ s, f2 L- C$ {: J( g
independent precocious puberty, which is also known0 O" X# [% T/ G" X$ ?/ f
as testotoxicosis, may cause precocious puberty at a/ h, z! |6 J1 c7 g! f- H
very young age. The physical findings in these boys' V" `6 J( c  @
with this disorder are full pubertal development,3 B4 S9 Q) I4 `; U, g0 x
including bilateral testicular growth, similar to boys
; g. Z; A" D6 p- T- ~" Zwith CPP. The gonadotropin levels in this disorder; Y) W- \& e8 T) e3 t
are suppressed to prepubertal levels and do not show! D7 E) E6 }7 \( V$ c
pubertal response of gonadotropin after gonadotropin-
  C: U5 W- V4 ]7 Oreleasing hormone stimulation. This is a sex-linked
, M/ |% ]" b' l( G+ ]4 x% W+ s6 Rautosomal dominant disorder that affects only
. B& U# ~& T- r3 G: U  Emales; therefore, other male members of the family
" ~8 O& ?+ y% [may have similar precocious puberty.3
8 Z" |( l4 v2 J; \: ~. P5 ?7 |- vIn our patient, physical examination was incon-
2 h; m6 [+ V, w1 ^  T2 Lsistent with true precocious puberty since his testi-
$ D) }. {3 ]! C2 S4 n7 Dcles were prepubertal in size. However, testotoxicosis( `  q; A3 x. J8 T! j  D/ N% M+ U
was in the differential diagnosis because his father; Q# y' l1 e. E
started puberty somewhat early, and occasionally,! u% \, G; i/ q8 x
testicular enlargement is not that evident in the
- f! j, Z" R& D$ ebeginning of this process.1 In the absence of a neg-/ D! r. g% A' ]2 B, v/ x7 Z  O( x
ative initial history of androgen exposure, our
; `6 b% b2 a, z7 g: Z( M: c2 }biggest concern was virilizing adrenal hyperplasia,
3 k) e% n, T( Aeither 21-hydroxylase deficiency or 11-β hydroxylase% ^3 }; o1 Q6 c. W6 C- i  Y0 [9 M6 P
deficiency. Those diagnoses were excluded by find-
; D* \5 r) I9 X2 Ring the normal level of adrenal steroids.- g5 z8 o1 J( `  K8 ?1 J- v+ g+ E: T
The diagnosis of exogenous androgens was strongly5 G# W; \& X0 Q" K, X% M* j+ l0 c8 Y
suspected in a follow-up visit after 4 months because6 j) F+ a! O: P; ~: H) z2 _( o
the physical examination revealed the complete disap-6 n3 n! e, g6 ~9 X# X# ^) C* }
pearance of pubic hair, normal growth velocity, and& F# ~! z* c$ c- j% c
decreased erections. The father admitted using a testos-
" X% C, L6 a4 T' _( @6 j2 I3 v$ Tterone gel, which he concealed at first visit. He was* s  n* S7 n( Q0 {! Q7 Q0 J
using it rather frequently, twice a day. The Physicians’
4 @) n* q$ \4 R4 h5 nDesk Reference, or package insert of this product, gel or0 W) L! @2 m# p3 e7 g! ^
cream, cautions about dermal testosterone transfer to
. w- @6 @: _" g( t5 N  P3 punprotected females through direct skin exposure.7 w; z- Y; c+ @7 q2 `. [) S9 m5 {
Serum testosterone level was found to be 2 times the
3 s- d. n- K8 ?baseline value in those females who were exposed to
* m3 |1 v* U( feven 15 minutes of direct skin contact with their male" F  J! y; w& `# m4 v8 }2 H
partners.6 However, when a shirt covered the applica-- K8 m* C0 ?$ ^. b/ s$ u1 G
tion site, this testosterone transfer was prevented.
0 C# _, ?  E; p( P( [" M7 [Our patient’s testosterone level was 60 ng/mL,
$ P7 C9 V5 J4 R+ W# Q! Q+ Z/ uwhich was clearly high. Some studies suggest that
, Q3 r% x2 E) ^0 m5 a4 Ldermal conversion of testosterone to dihydrotestos-  a. |2 v+ j- E5 R1 B0 K  W
terone, which is a more potent metabolite, is more3 r/ T; I1 f5 O
active in young children exposed to testosterone
; _& S# w+ H* b: wexogenously7; however, we did not measure a dihy-2 j0 F9 _3 a! P1 Y$ }
drotestosterone level in our patient. In addition to& ~8 h  Y  Z& _2 S* e
virilization, exposure to exogenous testosterone in9 J7 D3 J3 c+ O
children results in an increase in growth velocity and
$ v" S% _! o% Wadvanced bone age, as seen in our patient.) W  g1 Q& @; Z; V1 H( A3 S
The long-term effect of androgen exposure during1 {' f4 b$ ^+ b
early childhood on pubertal development and final
+ [* j6 O( ]5 W2 p9 {; ^adult height are not fully known and always remain/ n) B5 n" g7 b8 Q/ F0 e! F
a concern. Children treated with short-term testos-8 z: f% z; Q+ }- \/ ^2 D- O! X* {
terone injection or topical androgen may exhibit some
+ O) a+ F7 O* r0 Y; Iacceleration of the skeletal maturation; however, after
, F. x0 D% W/ `4 Z1 ycessation of treatment, the rate of bone maturation! s5 [: d: a4 B+ X; u
decelerates and gradually returns to normal.8,9
) z5 ^' ]9 g2 T1 p! A- J: MThere are conflicting reports and controversy
% H1 P, O$ {% r; `6 y/ ^7 r8 eover the effect of early androgen exposure on adult
- D: J8 ~5 Z, V/ P% zpenile length.10,11 Some reports suggest subnormal
8 T9 P1 H: h" y! Hadult penile length, apparently because of downreg-8 Y6 O/ j4 B, Q& x4 u) Z
ulation of androgen receptor number.10,12 However,, u8 K2 K# t" G5 H2 U2 z
Sutherland et al13 did not find a correlation between2 ?- R5 h# ~7 H$ S* u
childhood testosterone exposure and reduced adult$ O% ~' A8 `6 I4 L, N$ _
penile length in clinical studies.' A3 e! r: h, J9 [% _7 h! G; g
Nonetheless, we do not believe our patient is
6 s& l$ j- |4 k# \" Cgoing to experience any of the untoward effects from
, a2 @% N$ p$ x9 E5 u; \9 D6 ntestosterone exposure as mentioned earlier because
: n0 u1 I0 J" g4 F+ s. xthe exposure was not for a prolonged period of time.. J( Q* i% L& w! \3 h, n  R
Although the bone age was advanced at the time of- j) p" ~" R5 u; H+ H
diagnosis, the child had a normal growth velocity at% n( M0 A! J. I
the follow-up visit. It is hoped that his final adult: K/ l/ [& C' _
height will not be affected.
, w' S- b' y9 w5 P: r) h. wAlthough rarely reported, the widespread avail-; v: a8 |0 y2 y, ]
ability of androgen products in our society may$ c2 S# H& i3 }0 s5 q, T" m7 U
indeed cause more virilization in male or female
  c: {6 q  ~! p9 i7 h) n8 U: Echildren than one would realize. Exposure to andro-; W" _: B* d( {5 l, Y
gen products must be considered and specific ques-
$ k' T3 X6 B/ C. z1 ]3 W, ]tioning about the use of a testosterone product or
3 ~$ t* u( n1 qgel should be asked of the family members during  a6 P9 R' K& c4 J
the evaluation of any children who present with vir-: o& l$ w- W3 [' f" v6 a: G
ilization or peripheral precocious puberty. The diag-9 w5 T5 M) A! P! f
nosis can be established by just a few tests and by
2 _9 g' ^( `! Happropriate history. The inability to obtain such a* I+ Z) }1 n5 g0 _
history, or failure to ask the specific questions, may( O6 I6 o4 M0 ^* J. b! v+ Q/ d
result in extensive, unnecessary, and expensive
* V# \4 [+ G0 finvestigation. The primary care physician should be  T3 b) d: {+ S' [9 i
aware of this fact, because most of these children6 Y8 }0 E9 y3 `
may initially present in their practice. The Physicians’
7 G6 U5 i% }& q; \Desk Reference and package insert should also put a9 N/ I2 @( }! ~( Y9 }5 B( d- ?
warning about the virilizing effect on a male or
' K' e4 Q5 N6 P% Q+ X7 Wfemale child who might come in contact with some-
5 Y- F( `3 c: l. R9 _1 Bone using any of these products., \( ^& v- |7 E
References% n  L" j+ f* _, D+ w% }& J* z5 n
1. Styne DM. The testes: disorder of sexual differentiation, o% k0 T8 g+ \& i& I& C3 p
and puberty in the male. In: Sperling MA, ed. Pediatric
9 U6 s  M9 [0 g3 B' ^, LEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. ^5 `- ?; k% Q
2002: 565-628.
2 E: {+ s8 C. B" t/ z, g8 _& u8 E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  f" Q: W" i' q0 H2 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

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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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