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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: |: q6 R/ i; P7 |: V* g
Boy Induced by Indirect Topical
# M1 ~0 U( \' H5 R3 mExposure to Testosterone
9 C; x6 L6 g0 s+ O. U+ F) DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! G! k$ a1 d, e* nand Kenneth R. Rettig, MD11 f3 C4 j  H3 V) d7 ]
Clinical Pediatrics+ e: V+ _, ?9 e5 e( j
Volume 46 Number 6& l- V5 Z8 N; o/ U$ U
July 2007 540-543
+ q1 e( U3 c# x) }: }© 2007 Sage Publications
$ h/ R7 L& c# ]/ W5 p10.1177/0009922806296651
* A/ V- K. ?5 c/ F( V, mhttp://clp.sagepub.com/ V8 }/ L3 j' f, x( j9 L
hosted at
4 y& t1 Q0 h$ f# xhttp://online.sagepub.com) p7 ^1 v; H& S! M) g5 Q2 y) S* `5 F% B
Precocious puberty in boys, central or peripheral,
6 I& o) k9 j/ v- S' cis a significant concern for physicians. Central
1 i; W0 S& X; W8 bprecocious puberty (CPP), which is mediated* G; n3 f  V8 b: Q
through the hypothalamic pituitary gonadal axis, has! T. S  i% M: u' @$ L$ E0 L; @8 V
a higher incidence of organic central nervous system" E2 d8 n3 ~2 `# a( G# v7 r
lesions in boys.1,2 Virilization in boys, as manifested
, B/ m* c/ R2 O: \9 xby enlargement of the penis, development of pubic
$ z5 f/ q* a7 L! b, O% rhair, and facial acne without enlargement of testi-
5 ]0 q( Q7 a: B' fcles, suggests peripheral or pseudopuberty.1-3 We
1 E, I  L2 W/ m6 U7 q, d4 Xreport a 16-month-old boy who presented with the
  N* G& E# l; |% Nenlargement of the phallus and pubic hair develop-) z- P( p1 r% D6 }9 e
ment without testicular enlargement, which was due
; B( g* s8 J  L% L0 s, Wto the unintentional exposure to androgen gel used by
/ |' j2 t. n% W# ]& O9 E7 N+ gthe father. The family initially concealed this infor-
! b  {" F* C$ l6 ^mation, resulting in an extensive work-up for this
/ c- |2 A1 f! B! M- H, h7 qchild. Given the widespread and easy availability of* X$ z1 H, j9 r9 T
testosterone gel and cream, we believe this is proba-
6 O% j* J  f+ g7 y3 X4 F# Hbly more common than the rare case report in the# c) `: i5 F7 i& ~/ V- P
literature.4
% P& S- e1 J- J( {Patient Report( F9 ~% i& O* y$ {  t
A 16-month-old white child was referred to the4 n. M, f2 n( u% h3 v! C8 P
endocrine clinic by his pediatrician with the concern
0 A, r+ L+ h8 v- xof early sexual development. His mother noticed
/ V6 C. e! N: Alight colored pubic hair development when he was0 i  F# ?6 \0 {
From the 1Division of Pediatric Endocrinology, 2University of6 t) [+ C; B+ h7 j9 ~7 s
South Alabama Medical Center, Mobile, Alabama.
9 ^" V( N( ]2 p5 S$ Z5 m: KAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; [5 H* _. f$ B0 ^+ a; QProfessor of Pediatrics, University of South Alabama, College of
, m' h% S0 ^* Q+ |& ]3 rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. G. Z6 l- Q& O! J+ ~e-mail: [email protected].& W  |# ^; S% ?+ s
about 6 to 7 months old, which progressively became
& V! k0 }, m2 C% t( t* adarker. She was also concerned about the enlarge-; a8 r5 O$ t% v
ment of his penis and frequent erections. The child
/ R+ H" w1 T5 `0 r0 x  y! Twas the product of a full-term normal delivery, with
; T; X/ ^- \# P! ~  m' pa birth weight of 7 lb 14 oz, and birth length of0 E& |1 ?4 y& r' A4 f
20 inches. He was breast-fed throughout the first year. [! w* l0 o9 M0 D  L) n& B# I
of life and was still receiving breast milk along with) M* W2 M1 R- ~6 k. h
solid food. He had no hospitalizations or surgery,4 ~3 l" c& U, L  |3 P! |
and his psychosocial and psychomotor development
+ @* f9 |( x6 ~$ M7 E5 `was age appropriate.4 ^& g7 U) a+ d# O( z, n, u+ O
The family history was remarkable for the father,
( z) }8 o+ \* n' c$ D5 Uwho was diagnosed with hypothyroidism at age 16,1 ?2 Q/ Q0 Y- j3 d1 |4 Y
which was treated with thyroxine. The father’s
: d$ g7 u3 Y$ o4 s# n) pheight was 6 feet, and he went through a somewhat1 Y; k+ V6 T, S
early puberty and had stopped growing by age 14.
  l7 l* P. N" f: _8 ?% c! ZThe father denied taking any other medication. The( ?! c! p$ U0 T
child’s mother was in good health. Her menarche
) W! f1 |2 d5 P1 H5 m+ Nwas at 11 years of age, and her height was at 5 feet
7 v1 L4 ~& z( y3 Q; n1 |& n5 inches. There was no other family history of pre-
% F1 z+ p1 p0 Ucocious sexual development in the first-degree rela-
" ^  f, ^+ L" m* u7 Ctives. There were no siblings.; z: [* \# X8 S8 g5 p# R5 R
Physical Examination! {9 P8 X: u% [7 ^4 ^; T
The physical examination revealed a very active,- P8 ~6 S# Q7 ]6 H/ P/ f
playful, and healthy boy. The vital signs documented
% i( V% ~: _" f$ \  a+ Da blood pressure of 85/50 mm Hg, his length was
+ R) S  y% C+ ]; x$ f0 n- P0 j$ ?" u90 cm (>97th percentile), and his weight was 14.4 kg
, [" b9 C2 V- [# f  h) {(also >97th percentile). The observed yearly growth0 T. \4 B) ]/ ?
velocity was 30 cm (12 inches). The examination of
/ W( O' H$ q4 H. jthe neck revealed no thyroid enlargement.
5 u; a: o6 J$ S9 d# rThe genitourinary examination was remarkable for
, e8 o. K/ k7 V# L! A: y2 Renlargement of the penis, with a stretched length of
6 ?$ E. r6 W/ |9 _' B7 R; j8 cm and a width of 2 cm. The glans penis was very well
! }- M: D7 r6 sdeveloped. The pubic hair was Tanner II, mostly around, p$ H7 N$ N: u" Q0 [" U2 ~8 Y
540
6 D0 P) |# O: s5 \$ `6 l8 v7 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! I0 |: N. }- Athe base of the phallus and was dark and curled. The) O2 m# S) b  c2 t4 Z; E
testicular volume was prepubertal at 2 mL each.
7 l2 P% x! `: @( i4 L- \The skin was moist and smooth and somewhat
& \9 z! `# E/ B6 H, Ooily. No axillary hair was noted. There were no! [' E  o. ~7 O! {, \# x
abnormal skin pigmentations or café-au-lait spots.
/ Z% ^4 Z  A: u8 `6 r% [: Z! INeurologic evaluation showed deep tendon reflex 2+
; ?0 e% C5 S: Pbilateral and symmetrical. There was no suggestion: o+ R$ z# B& _/ Z& ]; n. {% e4 `
of papilledema.% h" v2 n. u! P% p
Laboratory Evaluation5 o6 J  l/ `2 l+ L/ x4 t: z9 b7 M
The bone age was consistent with 28 months by
& g& ?7 Y1 }. v! g- N/ J1 {5 `using the standard of Greulich and Pyle at a chrono-8 t1 E! H' R8 J) [  [, x' L" c1 R
logic age of 16 months (advanced).5 Chromosomal7 ^8 n+ O; n( O# F
karyotype was 46XY. The thyroid function test
) z! `& H% M- mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-# W* W: S6 ^9 g/ |; Y! d$ D  v0 _- A
lating hormone level was 1.3 µIU/mL (both normal).) {+ c. g( H6 |: A+ p) T
The concentrations of serum electrolytes, blood
) U/ P" Y( g3 V# B3 @& Uurea nitrogen, creatinine, and calcium all were
+ `; S, M' T" Swithin normal range for his age. The concentration
) Z6 G# @) ?5 s/ ]$ L3 ^of serum 17-hydroxyprogesterone was 16 ng/dL
/ L# H+ L6 [2 N( r. `# n(normal, 3 to 90 ng/dL), androstenedione was 20
' z, ?9 m) W+ cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 I6 {& K5 s8 Q$ K% B2 n. gterone was 38 ng/dL (normal, 50 to 760 ng/dL),# t& Q( j# f* e* h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- ?9 A, l( i) W! o9 U( x# X
49ng/dL), 11-desoxycortisol (specific compound S)5 O2 ~6 E6 `6 T  c& e7 K
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; P# G: U# T2 X* w' c6 X! |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 P: E( P, W% q0 A0 Q' S, Rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ {( [2 B# B1 G8 h. Q, r" Band β-human chorionic gonadotropin was less than
- X' `: w; K+ O$ h5 \0 e) s5 mIU/mL (normal <5 mIU/mL). Serum follicular
% j0 F6 k: g" ]+ Z# ^stimulating hormone and leuteinizing hormone
4 o0 Q/ n% {6 M7 f* Iconcentrations were less than 0.05 mIU/mL9 I$ l+ Z8 w6 ~% G
(prepubertal).
: y$ G) G& c. h5 r. D* |' m1 l+ kThe parents were notified about the laboratory
- K9 z/ p) q* _' w! q6 v' Kresults and were informed that all of the tests were- d7 l. F) j2 P. {3 r9 `$ U
normal except the testosterone level was high. The/ m6 }& P2 z- J) f" f+ h7 L
follow-up visit was arranged within a few weeks to; Q: j4 }! n9 w9 j% d: G
obtain testicular and abdominal sonograms; how-. c4 ~- X0 r( O7 |9 P5 N0 [) N
ever, the family did not return for 4 months.4 ^' v7 S. x- O/ @" k5 E: q2 R! Y
Physical examination at this time revealed that the& V" j/ h# P3 c4 ~$ b: J
child had grown 2.5 cm in 4 months and had gained7 F# h- V# _5 b
2 kg of weight. Physical examination remained
, ~6 d# Z8 a" G* Hunchanged. Surprisingly, the pubic hair almost com-( o+ }. g; W7 [& k$ y7 ^. b
pletely disappeared except for a few vellous hairs at
% y  e' b' x8 }& S7 j) P# Uthe base of the phallus. Testicular volume was still 2! L1 ^. K, x/ P+ d( e. |
mL, and the size of the penis remained unchanged.) P2 f# o: |7 {$ Q8 z
The mother also said that the boy was no longer hav-
% _" w( d, U5 k# ~ing frequent erections.+ U5 K, W5 |2 ]4 x+ j  ?
Both parents were again questioned about use of4 N1 y+ b, z. i9 H; q
any ointment/creams that they may have applied to6 H* Y$ }2 G+ R4 L5 r9 }# B# C% D5 j
the child’s skin. This time the father admitted the  H: A' m; E, s* ]0 U
Topical Testosterone Exposure / Bhowmick et al 541$ I% @$ g: q2 G! e' N8 }! |
use of testosterone gel twice daily that he was apply-
3 w( q& {( N2 `' x) Fing over his own shoulders, chest, and back area for6 c& C4 r) Z  M* Z" O/ `" s
a year. The father also revealed he was embarrassed
  l0 F) B- i: y( Eto disclose that he was using a testosterone gel pre-
& v5 H! M1 n: p5 T4 r: N# \scribed by his family physician for decreased libido1 y6 y8 Y; h! z* w3 b
secondary to depression.( z" e* U  ~( ~
The child slept in the same bed with parents.
' `& s! W- n0 z# e4 jThe father would hug the baby and hold him on his. ]# x" N0 g# z$ O2 J4 _
chest for a considerable period of time, causing sig-
9 z! Z# ~8 R: e" Z; p; cnificant bare skin contact between baby and father.! @8 Y! ]9 l0 a* z
The father also admitted that after the phone call,
& y  Z0 n) e2 X: z' ?+ H& Kwhen he learned the testosterone level in the baby
0 b' \; m# o4 k3 K9 @was high, he then read the product information0 q, g& c) y$ L$ j2 }! L  ~
packet and concluded that it was most likely the rea-% \# U" x3 W/ w3 B
son for the child’s virilization. At that time, they! s% P! h- G' S# \+ z3 z
decided to put the baby in a separate bed, and the8 c5 _, q) q1 i. f
father was not hugging him with bare skin and had9 Q/ |7 S; p* q1 e; J+ _. [  w
been using protective clothing. A repeat testosterone, F6 D: _  W4 \, G' o) S+ A
test was ordered, but the family did not go to the
* r$ k) `, J  m) b% Y) J) Olaboratory to obtain the test.
1 [- N) i, t! e/ `$ I& E' l! hDiscussion0 @. S! X1 h/ w7 f  I
Precocious puberty in boys is defined as secondary
6 }% X) [' F' ?: K$ z, ksexual development before 9 years of age.1,43 {# b$ @7 S" g8 O1 d& e
Precocious puberty is termed as central (true) when
6 Z' x5 p3 Z: F& E) Z* ?it is caused by the premature activation of hypo-
. c6 g8 y" t4 Zthalamic pituitary gonadal axis. CPP is more com-% I% G; a- v$ D) {! \$ n9 [
mon in girls than in boys.1,3 Most boys with CPP/ Z1 P* j+ l2 f: ~( E
may have a central nervous system lesion that is) s. _  Y6 Y% V) H+ C
responsible for the early activation of the hypothal-* Y9 B) X7 v2 f4 \# _
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ t) p& ~! g7 p6 ~sis has been given to neuroradiologic imaging in
9 B4 Y+ w* O% E+ E9 Cboys with precocious puberty. In addition to viril-
+ y1 m% w4 c/ h4 yization, the clinical hallmark of CPP is the symmet-7 m! o- h( U5 a8 h" ]( m: ]
rical testicular growth secondary to stimulation by
: a; X) t4 Y8 f/ {# rgonadotropins.1,3
- p5 l. A6 [' f* c6 p& C  ZGonadotropin-independent peripheral preco-* _6 G' j$ Y8 Z, z% ]8 `5 G) J5 d
cious puberty in boys also results from inappropriate
$ l. X' Y/ M& @+ v( t5 Zandrogenic stimulation from either endogenous or$ l2 z0 D+ a9 m7 a- h' u1 I3 ^
exogenous sources, nonpituitary gonadotropin stim-; ^$ `& o0 V) l" g$ M5 k. G
ulation, and rare activating mutations.3 Virilizing) n/ X/ k8 q$ P) ]' U/ Z8 a/ b
congenital adrenal hyperplasia producing excessive! i; r2 U- u+ K/ s/ A) R  b' A
adrenal androgens is a common cause of precocious
! D1 ]  N, U4 m0 Tpuberty in boys.3,4
  x% I  {6 u+ j( b3 QThe most common form of congenital adrenal
  ^% t! y+ @+ Z; `hyperplasia is the 21-hydroxylase enzyme deficiency.( h8 O* Y  w9 u0 U; [
The 11-β hydroxylase deficiency may also result in
# [- N  _- \8 n: ~excessive adrenal androgen production, and rarely,
% W1 e5 F# m, v) nan adrenal tumor may also cause adrenal androgen8 j# _5 T2 k( J- D( \5 D
excess.1,3
6 C( n. Z7 U  cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% \7 B' M0 S+ s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ N1 X! ?. _( J) G' E/ LA unique entity of male-limited gonadotropin-# l3 d) d$ m8 j% i, N7 e
independent precocious puberty, which is also known
& C; w- d0 h; Y6 a! j3 Y% j8 h2 i; Mas testotoxicosis, may cause precocious puberty at a' j4 b% Q0 A/ d
very young age. The physical findings in these boys; ^6 ?. R/ K6 B; U0 T8 w# [
with this disorder are full pubertal development,+ X5 ^. ^. |, P* N0 E! U
including bilateral testicular growth, similar to boys
' E; n5 O# X, q/ F* J( Rwith CPP. The gonadotropin levels in this disorder& O/ G: ^2 D% w; }8 ^
are suppressed to prepubertal levels and do not show; ^$ k% o# C6 f% h
pubertal response of gonadotropin after gonadotropin-+ D, P7 I% U7 _/ n( C
releasing hormone stimulation. This is a sex-linked7 Y, y1 y8 F3 E* l" f1 H
autosomal dominant disorder that affects only5 `; c) \' i8 `% m
males; therefore, other male members of the family8 z2 l) _7 k3 t3 o3 ^/ I' n
may have similar precocious puberty.3
( i$ b5 i( h1 t. r- W# q0 J2 \In our patient, physical examination was incon-' v% e8 Q. L. k( u# M; d
sistent with true precocious puberty since his testi-" k& m; E+ }+ J( Z
cles were prepubertal in size. However, testotoxicosis
/ @6 u& x" ^, gwas in the differential diagnosis because his father% y+ r2 k1 b- D# U# [* G+ j
started puberty somewhat early, and occasionally,
' K; i$ d) d: W" `testicular enlargement is not that evident in the
( X6 C' `) w0 n2 ?beginning of this process.1 In the absence of a neg-0 k% s. ^2 ^  k9 d
ative initial history of androgen exposure, our  Q+ L  y; ~+ @
biggest concern was virilizing adrenal hyperplasia,5 b) u2 j1 _1 g6 M
either 21-hydroxylase deficiency or 11-β hydroxylase4 ^( D+ M; Q9 \' b2 f4 O( f5 W
deficiency. Those diagnoses were excluded by find-# u) I% z& G2 _0 m' z9 o$ \$ T9 X4 o# B
ing the normal level of adrenal steroids.3 n$ ^/ N) w1 V* [- O
The diagnosis of exogenous androgens was strongly
* }0 a$ f3 F  R- p& N2 O& Ususpected in a follow-up visit after 4 months because
! K4 o+ Z5 F+ Jthe physical examination revealed the complete disap-4 Y" }4 z2 \9 l! p
pearance of pubic hair, normal growth velocity, and
" t+ K' W- o* h! _4 Ndecreased erections. The father admitted using a testos-' Z. R5 H: j. z' N1 {
terone gel, which he concealed at first visit. He was
; \$ K' k" T/ n+ k- y$ O) eusing it rather frequently, twice a day. The Physicians’) Q. |9 V# a( L$ Z# }# _
Desk Reference, or package insert of this product, gel or
4 b6 b, g( N& [( ?* s4 Kcream, cautions about dermal testosterone transfer to
7 r6 W% o  Y* [+ z- ^unprotected females through direct skin exposure.
( _; ]& V* A2 V" y) j9 m% M  PSerum testosterone level was found to be 2 times the+ q  C+ \' f, r: |5 F
baseline value in those females who were exposed to
* L! d$ T& m$ \5 S2 Geven 15 minutes of direct skin contact with their male* A$ v; G+ K6 l$ v( X
partners.6 However, when a shirt covered the applica-
- @) z! I* H5 G, H) f& B  _tion site, this testosterone transfer was prevented.
* t! k: V9 C' Z/ b8 V+ BOur patient’s testosterone level was 60 ng/mL,: `. b8 G" I' e' c. X, E3 h' X
which was clearly high. Some studies suggest that
. k( [  R, g8 T5 e* ldermal conversion of testosterone to dihydrotestos-
- y+ z* _" \  Q3 z: m0 o5 Aterone, which is a more potent metabolite, is more/ o) C# G6 a' G. W3 u% {$ ^
active in young children exposed to testosterone
* }; w9 c" H8 \3 o) C6 Sexogenously7; however, we did not measure a dihy-
7 G+ Q: ^6 e1 c0 v1 k9 L) Udrotestosterone level in our patient. In addition to
: [" S) I2 A2 }$ @virilization, exposure to exogenous testosterone in
6 o& o1 b$ t( r, _children results in an increase in growth velocity and1 a+ M1 w8 j, g
advanced bone age, as seen in our patient.+ i* ^9 e+ z- [( N- s
The long-term effect of androgen exposure during7 e2 W# `$ O* I9 J- Z
early childhood on pubertal development and final5 g' H+ C1 ^4 c% n
adult height are not fully known and always remain
1 H+ v, a6 v  B6 fa concern. Children treated with short-term testos-- x+ _; z% s! X" x6 [  K% ^
terone injection or topical androgen may exhibit some+ A) }- v5 ]7 T
acceleration of the skeletal maturation; however, after- V' Q) @: ]2 A' I# ~( q
cessation of treatment, the rate of bone maturation
7 `" e3 Y4 M0 qdecelerates and gradually returns to normal.8,9
3 H$ A: p7 @( kThere are conflicting reports and controversy
" L4 H; h) N; C* Q) t" N( @* Sover the effect of early androgen exposure on adult
8 b  g# d" O1 n" |8 Kpenile length.10,11 Some reports suggest subnormal
7 ^8 q' ^( k* _  o! g8 wadult penile length, apparently because of downreg-
6 T3 G& x4 W4 [ulation of androgen receptor number.10,12 However,7 M4 f( i6 T2 |
Sutherland et al13 did not find a correlation between
& Y! [. s2 s: {$ `! k9 ^! pchildhood testosterone exposure and reduced adult
% m' G0 K; X+ c/ L0 `7 hpenile length in clinical studies.
" G5 b/ g0 W7 p& L- ~  aNonetheless, we do not believe our patient is* Q% Y5 o  e4 p3 N
going to experience any of the untoward effects from4 U. S/ q; P8 Q6 @, U) X
testosterone exposure as mentioned earlier because8 c7 H# n2 V3 Q' e7 e
the exposure was not for a prolonged period of time.
% }3 }1 j& b% f6 oAlthough the bone age was advanced at the time of  U* }  [( i7 t: O; @
diagnosis, the child had a normal growth velocity at$ K8 i% i! Q* k! i! j
the follow-up visit. It is hoped that his final adult" ~8 Y% l& L. t# H! |2 A$ V7 f. L
height will not be affected.: `3 D; |8 D6 T+ C% b
Although rarely reported, the widespread avail-
. D: k7 ^/ q) b- w; iability of androgen products in our society may7 e* W0 |4 F: k. s
indeed cause more virilization in male or female
, u, v* t6 B4 e1 e% D8 d3 V/ Cchildren than one would realize. Exposure to andro-$ w0 b# X9 }- B! K1 R0 n+ X
gen products must be considered and specific ques-
# L4 [8 R" D3 u- r/ {% Ationing about the use of a testosterone product or
5 o0 Y. F5 c; s; A+ {' ^, Mgel should be asked of the family members during
# {, ?  b0 F. Pthe evaluation of any children who present with vir-+ V" {: O6 Y0 S8 ^8 P
ilization or peripheral precocious puberty. The diag-
% c; N9 B. X, V+ ]+ \nosis can be established by just a few tests and by
* V$ @5 T$ o  U) f- _; N" Nappropriate history. The inability to obtain such a2 h7 s! }9 U4 G& q; z6 I
history, or failure to ask the specific questions, may- M0 F, N& |2 G! W9 W) ^
result in extensive, unnecessary, and expensive
% G. F9 V3 `9 @; d9 n6 h5 D3 dinvestigation. The primary care physician should be  H0 F+ P7 X4 D9 J! d7 C2 r
aware of this fact, because most of these children3 L0 F4 Z# C/ U9 ~
may initially present in their practice. The Physicians’
- Y3 \& p1 ~6 v$ {6 o" ]Desk Reference and package insert should also put a
& c& _8 O, |+ t5 W! E. Kwarning about the virilizing effect on a male or% ?- o, v, H) K! ~' \( D* C- M
female child who might come in contact with some-$ p! Y# q7 d7 ], j; \; R: K
one using any of these products.# E; {; ]8 p7 H+ I, l1 ^
References
9 Z$ b# ], m$ r/ f# i$ f, j" f1. Styne DM. The testes: disorder of sexual differentiation
/ K6 x. v8 i, z. _0 Tand puberty in the male. In: Sperling MA, ed. Pediatric
) A+ }) K% o+ R' v0 WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& m/ Q. O' `( b1 w) I2002: 565-628.
% `# F  m* t8 W: k& N1 U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& l* ~& v# w" v# M
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ d; Z8 {2 W% t( _3 H( p' x. qBoy Induced by Indirect Topical- M  C7 H9 _% ?( K8 F
Exposure to Testosterone
) S1 J! ~4 ~$ S  f8 i, QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 L  o1 S! ]1 r5 e6 H
and Kenneth R. Rettig, MD1" Q) M: |* l" ?& K  X
Clinical Pediatrics
( H; |6 t( J% C( |8 F2 I' |! eVolume 46 Number 65 n" U, H& ^9 s6 N0 {
July 2007 540-543
4 o0 p( i& b4 |( n2 z3 C© 2007 Sage Publications5 k, y! [8 i8 C! S
10.1177/00099228062966516 Q' G# S: K2 w( t0 m  B4 t
http://clp.sagepub.com7 [% Q5 R- s) E" M; S3 I3 ?
hosted at
4 |' s( X, `7 W! r. t8 Shttp://online.sagepub.com4 _& j3 G2 G& h% e
Precocious puberty in boys, central or peripheral,# P1 U- C; D$ Y2 Z+ g$ }& u" i
is a significant concern for physicians. Central$ N- r$ w2 I8 p: }, R
precocious puberty (CPP), which is mediated
+ O% {& X' ~" r* m* `# tthrough the hypothalamic pituitary gonadal axis, has
. G: a: d# B) D2 Y% J8 xa higher incidence of organic central nervous system
; ?0 y  O5 F7 C( o8 B- b9 alesions in boys.1,2 Virilization in boys, as manifested$ d, m  K/ p* h. p. L3 u" h
by enlargement of the penis, development of pubic
4 D& N  ^; R. [- Y2 A0 \; n. Lhair, and facial acne without enlargement of testi-  D  [4 u5 g* s" `7 {  T
cles, suggests peripheral or pseudopuberty.1-3 We9 k* i* X5 u: q
report a 16-month-old boy who presented with the# \+ v5 h3 Y) L" Z1 X1 D
enlargement of the phallus and pubic hair develop-
3 x6 i! p: f5 h7 t. Nment without testicular enlargement, which was due
6 y1 P0 V! t# L; d7 W9 Mto the unintentional exposure to androgen gel used by
7 p8 R5 H+ Q, o! Gthe father. The family initially concealed this infor-/ `' U$ _  l- f; A) d8 y
mation, resulting in an extensive work-up for this1 Z% }& U. C* d1 t5 \3 W/ j2 z
child. Given the widespread and easy availability of
. S: C5 C6 f* Y) ]8 D9 gtestosterone gel and cream, we believe this is proba-0 Q* _; }' a$ h! O, S+ @6 Q
bly more common than the rare case report in the
' I; c. C: [* ~2 u; pliterature.47 T9 \. @3 b0 y: ?
Patient Report
3 S. o6 j4 h) B" m* t) e* w, @! xA 16-month-old white child was referred to the
$ M4 G, |6 E8 F1 Z% s/ i9 t2 V& hendocrine clinic by his pediatrician with the concern$ N2 R* a6 t  r5 i4 G; ?
of early sexual development. His mother noticed$ M* n: Q# }. A" N( e. j; R- n
light colored pubic hair development when he was
: W5 Q0 m1 @) I. R% `" c( P9 s! LFrom the 1Division of Pediatric Endocrinology, 2University of8 \4 A6 p. u# j/ S3 S# ]
South Alabama Medical Center, Mobile, Alabama.+ `7 k( e8 e: f7 Q' z0 \3 B! o
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ _& `0 f& F( [2 s$ Z; x
Professor of Pediatrics, University of South Alabama, College of: A1 D8 Q/ b" ?( T( |; r6 G4 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ O, ]# O! C% E2 t/ l/ H
e-mail: [email protected].
; ]; N" ~$ M+ ]9 q6 N6 s: S9 kabout 6 to 7 months old, which progressively became8 L) f1 Z) [) A0 _0 @
darker. She was also concerned about the enlarge-
% a8 w- {' [% b; w5 l7 k% bment of his penis and frequent erections. The child; J2 `+ u- O1 P; }4 C
was the product of a full-term normal delivery, with
. I6 i# ~7 o# [8 ra birth weight of 7 lb 14 oz, and birth length of5 k3 U9 }' K8 ?0 ~) W% |, h% R
20 inches. He was breast-fed throughout the first year2 d6 n5 S* x  l# O9 z, ^
of life and was still receiving breast milk along with& O1 g0 N7 [1 o7 L2 t/ ^$ ?
solid food. He had no hospitalizations or surgery,/ f' s* c: H% Q! r; c& v8 Y
and his psychosocial and psychomotor development% {  Q. [+ b. o4 R5 ^! r
was age appropriate.
3 @& Z) E8 T6 }8 tThe family history was remarkable for the father,; F0 H! G# ^) r/ ]# ]: e% d5 w
who was diagnosed with hypothyroidism at age 16,
$ ^7 C6 t$ t9 ~: G) `, Twhich was treated with thyroxine. The father’s" f; D, l" w6 Q+ P( y& F
height was 6 feet, and he went through a somewhat% e7 @/ `5 g( ^' P9 E
early puberty and had stopped growing by age 14.
: J/ s5 N; R1 C- o5 |1 j' I3 F! cThe father denied taking any other medication. The
  f3 [2 f7 Y. D" I, C. schild’s mother was in good health. Her menarche' ]+ Y$ K5 h; |( E- {: i+ S, a7 P
was at 11 years of age, and her height was at 5 feet! ^3 a& v* b) A8 L: N# K5 Y8 x
5 inches. There was no other family history of pre-6 `. F2 r: z$ w! ?7 i. g6 c
cocious sexual development in the first-degree rela-
9 q- a! T! v# z9 I* E/ Etives. There were no siblings.7 l+ a/ ?8 q1 O  @
Physical Examination+ d3 K, F& n: `# E
The physical examination revealed a very active,# d1 t- Q3 c6 Y6 a% E, [
playful, and healthy boy. The vital signs documented
+ \% J7 R* h5 C  g+ o' ma blood pressure of 85/50 mm Hg, his length was; P2 n7 k! r1 `+ Q7 i: j" x/ E
90 cm (>97th percentile), and his weight was 14.4 kg
3 u" w, J6 c0 \7 f. b4 K(also >97th percentile). The observed yearly growth
: }/ l# s, K* L2 j% Qvelocity was 30 cm (12 inches). The examination of% q; k! [8 M; H9 K5 M
the neck revealed no thyroid enlargement.+ }! D5 v' R! a2 y
The genitourinary examination was remarkable for7 ~0 o+ Q5 x: }5 t4 ^
enlargement of the penis, with a stretched length of1 ~# a, |( j& D- f% h3 C
8 cm and a width of 2 cm. The glans penis was very well) V$ [' ~& @5 i6 a& t
developed. The pubic hair was Tanner II, mostly around2 y# h+ c5 x9 D' b7 x; O7 b
540
$ u8 Z7 k5 t0 R8 v# X$ Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 T. ~( x7 a$ O3 ]$ O$ D( {9 `the base of the phallus and was dark and curled. The
' v: P+ i3 D6 W0 {8 `- Ltesticular volume was prepubertal at 2 mL each.
- x' a) T+ d9 Q& m, s, ]. \8 ^4 Q( R- IThe skin was moist and smooth and somewhat
( c) F- F! u/ Y, {9 m! W- Uoily. No axillary hair was noted. There were no
' s; W  e9 q5 d, D( Babnormal skin pigmentations or café-au-lait spots.
. ]; n4 k4 @7 p9 N" BNeurologic evaluation showed deep tendon reflex 2+- W% @' u" [: R  _+ {( Z
bilateral and symmetrical. There was no suggestion
4 d  P4 n7 t& K& U+ Oof papilledema.
$ i/ M( P' Z* B0 {8 a% `Laboratory Evaluation# z: h. Y8 O- _5 M
The bone age was consistent with 28 months by& ?+ K6 p$ m0 t& y9 Y9 N
using the standard of Greulich and Pyle at a chrono-
! `% z" ?9 P7 ^5 w' Qlogic age of 16 months (advanced).5 Chromosomal& D( B: m* ?/ |4 \: A# h
karyotype was 46XY. The thyroid function test
" V9 l+ q" V5 w7 ]! L8 P- Y0 lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  D+ A7 i! Z  y8 M! y6 w' k# O& klating hormone level was 1.3 µIU/mL (both normal).
' j- U+ m- `! X- T/ {" y5 QThe concentrations of serum electrolytes, blood
" P- g% _1 {* F. W  V) burea nitrogen, creatinine, and calcium all were" J% P8 N. F1 M$ y6 s7 B. J
within normal range for his age. The concentration
/ G+ X3 O% M# X' {) Zof serum 17-hydroxyprogesterone was 16 ng/dL5 K6 b3 g: K- x9 B0 |1 ?/ t& S
(normal, 3 to 90 ng/dL), androstenedione was 20
. H5 C1 y$ E5 `/ L0 V4 C" a# zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) Q4 I' {( q% ]& \3 Mterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ u8 F; T1 d8 u6 e  y: H/ P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- F7 w, U' n8 ~  g49ng/dL), 11-desoxycortisol (specific compound S)% W3 p; e+ s: [2 d5 [/ ?1 r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ w" `7 }! [0 N& _6 w+ P- m$ J5 @0 mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: M3 U# B) Q) P5 Z: M9 p6 F
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
. B, u! U( j* [1 |! Q$ }0 p+ Fand β-human chorionic gonadotropin was less than
4 y2 y- l/ w$ t. z3 _* E5 mIU/mL (normal <5 mIU/mL). Serum follicular; K6 _  G  J  F8 \$ ?: L8 G7 M
stimulating hormone and leuteinizing hormone
0 O  V) }$ K* |5 pconcentrations were less than 0.05 mIU/mL
/ t2 R2 B! ]3 N6 k' Y" K* V* M. M( ?(prepubertal).& o& O% Y4 p2 m, F% h7 U' |
The parents were notified about the laboratory
7 W2 T! @5 s9 G! ]8 P6 M2 q8 c" R& Vresults and were informed that all of the tests were: A1 D# L: b* V# z
normal except the testosterone level was high. The
# Z: _; `" ~. n4 @2 v: j+ O# i% Jfollow-up visit was arranged within a few weeks to
' U  I. b# G* A& [( Kobtain testicular and abdominal sonograms; how-
: H8 S4 [0 u& L3 n9 M" R# Oever, the family did not return for 4 months.8 e/ H3 M; ?. l+ U) P$ r
Physical examination at this time revealed that the# |- w8 Z. K) d# i
child had grown 2.5 cm in 4 months and had gained
6 z5 x1 }' }/ p! R6 W% c9 s; f- I5 W2 kg of weight. Physical examination remained! A% Y, Q/ a  I* r
unchanged. Surprisingly, the pubic hair almost com-, m: N; u, M+ l$ o8 e
pletely disappeared except for a few vellous hairs at: W+ u9 V. [7 q7 N* X% H
the base of the phallus. Testicular volume was still 27 Y3 K$ P9 X) g9 I3 A: y
mL, and the size of the penis remained unchanged.6 k: J+ z, h% [: B
The mother also said that the boy was no longer hav-  J0 T9 {. L4 j$ g) i  I
ing frequent erections.
/ R2 a2 P- r5 q, L) T5 ABoth parents were again questioned about use of
' b1 s3 Y! u, V+ O5 Cany ointment/creams that they may have applied to7 k' W( e6 I5 I. X- [: d1 v/ D& q
the child’s skin. This time the father admitted the' {- l0 l( t, }9 W
Topical Testosterone Exposure / Bhowmick et al 541# |/ t. o1 S" Z6 U/ Q% S' E, \
use of testosterone gel twice daily that he was apply-/ [: y: p( p; W1 I
ing over his own shoulders, chest, and back area for7 D8 U- P6 Q9 Q/ F, _, T
a year. The father also revealed he was embarrassed
# K! d* j  q' }0 X4 a& W( ~" [6 dto disclose that he was using a testosterone gel pre-! Y& h7 U3 Y. F7 z
scribed by his family physician for decreased libido
' d0 z+ `+ K% csecondary to depression.
, u" j: Z. m2 F0 I! @, _0 b, pThe child slept in the same bed with parents.3 ^# L% g; b$ v; B( @
The father would hug the baby and hold him on his9 ~6 V1 M; N. X/ k, B( E
chest for a considerable period of time, causing sig-" C: s# M3 P5 Z/ l
nificant bare skin contact between baby and father.
3 `- M1 s+ X7 p) d4 F) yThe father also admitted that after the phone call,
5 {* U: N1 u  P# [) @8 q8 Dwhen he learned the testosterone level in the baby0 n. m5 Y4 T2 f9 K
was high, he then read the product information9 p$ T1 g: ]  H
packet and concluded that it was most likely the rea-
! ~7 k$ M0 {+ r# uson for the child’s virilization. At that time, they
0 i' y3 D5 H2 e7 Kdecided to put the baby in a separate bed, and the% z( Z# P4 K7 u. @8 u$ X
father was not hugging him with bare skin and had+ J  J3 K4 a+ R1 B5 p) D
been using protective clothing. A repeat testosterone6 ~! ^3 F, q! H: K% z3 _8 u
test was ordered, but the family did not go to the* m3 h. j# q( G5 S
laboratory to obtain the test.
5 R( g5 p' U: C9 i  e6 V* p+ T; nDiscussion% f6 L, t2 g- w5 _1 F3 K+ w5 X5 J
Precocious puberty in boys is defined as secondary
% H% \. e6 H+ I2 H& bsexual development before 9 years of age.1,4
+ k, Z$ N9 K1 m2 Y. D& \! WPrecocious puberty is termed as central (true) when
& Y: G7 _: t, z( Z  c# rit is caused by the premature activation of hypo-
- W2 G6 W6 a7 N, Dthalamic pituitary gonadal axis. CPP is more com-
4 x! o; F+ Z/ }/ M! X/ ^" n% U7 cmon in girls than in boys.1,3 Most boys with CPP  [3 p* I! h  u6 `: z! R
may have a central nervous system lesion that is  j+ X  @( P5 k7 B
responsible for the early activation of the hypothal-6 P  W7 R. f; y7 {, [( i( p9 w- V
amic pituitary gonadal axis.1-3 Thus, greater empha-) b* [0 L) o; l  o6 K6 h3 r" j
sis has been given to neuroradiologic imaging in
/ S5 E# I- m, G# |8 Yboys with precocious puberty. In addition to viril-
: v3 l4 Q' W8 ~) W7 U6 Hization, the clinical hallmark of CPP is the symmet-7 w( Z+ Y& i- e. F
rical testicular growth secondary to stimulation by' X5 ?5 r' O9 U7 c2 U
gonadotropins.1,37 U! ~# ?9 |4 k8 ~
Gonadotropin-independent peripheral preco-
9 n( ~* w! ~6 E; n: n- Ccious puberty in boys also results from inappropriate
# p7 O3 t, X7 r" N" a8 wandrogenic stimulation from either endogenous or0 A. c* k8 b% v* [6 h# E2 V
exogenous sources, nonpituitary gonadotropin stim-
* f# j+ p- D' k3 dulation, and rare activating mutations.3 Virilizing
2 W& n* u) P; f: x' Mcongenital adrenal hyperplasia producing excessive; i8 R1 C; L( B  K0 U+ R' G- E! }
adrenal androgens is a common cause of precocious/ O- |4 x& g+ p" O7 p7 k
puberty in boys.3,4
- l: ^3 |2 e5 `6 g( a, Q+ f9 RThe most common form of congenital adrenal
! Z* @) d6 C& ahyperplasia is the 21-hydroxylase enzyme deficiency.* }! q, U" r+ @! ~, D, l" g
The 11-β hydroxylase deficiency may also result in
2 d( v! g# R5 kexcessive adrenal androgen production, and rarely,
, F# l3 X2 C0 e" s* c$ O  a- {& jan adrenal tumor may also cause adrenal androgen1 x0 u! ?- b, T0 R. h$ Q+ `
excess.1,3
0 N: c1 e; @4 y4 \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 Y0 n8 M4 f5 i" K& E+ W4 m
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. U" Q: j6 W. w
A unique entity of male-limited gonadotropin-7 G2 M. Y6 e7 N
independent precocious puberty, which is also known6 J! q( m) c7 Y$ n
as testotoxicosis, may cause precocious puberty at a  _6 x2 |$ ]# s) Q! G( [
very young age. The physical findings in these boys  N- X  s" s1 u/ d; d
with this disorder are full pubertal development,
' V4 m9 U8 K% C( }+ aincluding bilateral testicular growth, similar to boys0 `. @; M. ^3 n: B* g! O9 |
with CPP. The gonadotropin levels in this disorder0 _% [$ O% W# V- X3 D# W- s
are suppressed to prepubertal levels and do not show' `4 q  D# v/ v; J4 h! k/ {1 Q" w
pubertal response of gonadotropin after gonadotropin-% X6 o4 Q6 ^( W4 h1 o
releasing hormone stimulation. This is a sex-linked* @7 y; O+ O' |" w
autosomal dominant disorder that affects only) C% F% a+ U3 o+ O
males; therefore, other male members of the family
! o  e% e* H" {" Y+ _% e+ dmay have similar precocious puberty.3
9 [7 p7 f% c/ P" L% l, D$ GIn our patient, physical examination was incon-
2 c7 T* E$ M" t( msistent with true precocious puberty since his testi-' j9 y, e( Q5 Y( A8 O
cles were prepubertal in size. However, testotoxicosis
: ^/ _# I0 |$ `8 N1 |% S: Xwas in the differential diagnosis because his father4 |+ P$ M! S, U- \6 q
started puberty somewhat early, and occasionally,) K) p% Y% e" O! u! F4 j
testicular enlargement is not that evident in the
! m- U" c% C6 D6 wbeginning of this process.1 In the absence of a neg-
# L3 G. Y  b) v( B2 R5 p1 dative initial history of androgen exposure, our
% w/ B- a) ?' \/ Y( _! gbiggest concern was virilizing adrenal hyperplasia,& z% e5 j; W! m3 F9 Y- u7 ~% z3 x6 ^
either 21-hydroxylase deficiency or 11-β hydroxylase$ D0 S$ ~$ M( G  o; I
deficiency. Those diagnoses were excluded by find-- R( N4 N/ @0 A+ t9 I2 T& `- D
ing the normal level of adrenal steroids.2 x5 N- s, O' d8 s+ R% V  k
The diagnosis of exogenous androgens was strongly8 r! D5 [( z5 K4 ]5 O! y
suspected in a follow-up visit after 4 months because
, z& D% P, q7 K' O3 d1 Nthe physical examination revealed the complete disap-/ Y7 j  q+ a* P! a2 ?1 P
pearance of pubic hair, normal growth velocity, and6 K* ^4 L7 W$ p! I/ s
decreased erections. The father admitted using a testos-
8 r1 Y' N# D. J6 _4 b# b: gterone gel, which he concealed at first visit. He was5 s1 n8 L" E# u
using it rather frequently, twice a day. The Physicians’7 x  k  |$ R- n/ r: ?0 B
Desk Reference, or package insert of this product, gel or8 e1 [, ~. C& g( w! Q3 d: ]
cream, cautions about dermal testosterone transfer to
1 H2 b* G3 t! M" Funprotected females through direct skin exposure.
7 K& u1 t9 _0 x5 Z- N) y$ LSerum testosterone level was found to be 2 times the
: [2 s& ^3 k) {6 _baseline value in those females who were exposed to8 U+ q: B4 @0 L
even 15 minutes of direct skin contact with their male
- ^2 S& x$ I5 m, O- S5 O9 l3 upartners.6 However, when a shirt covered the applica-& \) ~, b$ p* P5 w0 P$ y' h% A/ H
tion site, this testosterone transfer was prevented.: T* l3 B! R, p
Our patient’s testosterone level was 60 ng/mL,
! X4 \) D7 \) q0 l% o4 |: `which was clearly high. Some studies suggest that
# g2 T+ P) k( B. j/ Bdermal conversion of testosterone to dihydrotestos-
, \( s6 a0 I' @terone, which is a more potent metabolite, is more3 Y) B) X; p4 B' n1 _) ~
active in young children exposed to testosterone/ ^! t( _% X1 D
exogenously7; however, we did not measure a dihy-
. ]+ K- l3 [* O5 Tdrotestosterone level in our patient. In addition to4 s' k% f1 d1 @, V1 U, l7 p
virilization, exposure to exogenous testosterone in" H) n" P( ]0 `3 }) y1 M
children results in an increase in growth velocity and. W& ?4 i% b! R& D- D
advanced bone age, as seen in our patient.# C2 G* N  z$ i; N$ m- |
The long-term effect of androgen exposure during* E8 ~% t0 O/ a
early childhood on pubertal development and final0 N- |  w! D) ~7 ~( G: G* I
adult height are not fully known and always remain
# ^9 a; x, S/ o' [3 J2 ca concern. Children treated with short-term testos-
- L) N3 ^; o% K7 }terone injection or topical androgen may exhibit some
5 w+ d# F6 Z/ ^1 r3 jacceleration of the skeletal maturation; however, after' G; h# q+ w3 ~
cessation of treatment, the rate of bone maturation
% A+ r2 P3 w0 j( m0 Cdecelerates and gradually returns to normal.8,9
0 Y0 A2 w; _9 fThere are conflicting reports and controversy
4 ]  ]  W0 H0 x3 r  R8 P) Lover the effect of early androgen exposure on adult7 Y# b. `1 [% v/ C& l* j5 Q
penile length.10,11 Some reports suggest subnormal( n9 n  ?# Z! t5 q/ H+ J
adult penile length, apparently because of downreg-
& g8 _& O( ?4 _( r0 f( uulation of androgen receptor number.10,12 However,7 P4 q3 a1 ?4 V+ Y
Sutherland et al13 did not find a correlation between* O7 a( ]& L) J
childhood testosterone exposure and reduced adult
% ]/ v9 D% ^: M2 H( I: s" h$ epenile length in clinical studies.; V! T- \* I7 X: @5 `
Nonetheless, we do not believe our patient is, F' u2 w. l' b9 w" t
going to experience any of the untoward effects from
+ u, n: C- V/ d7 U3 Etestosterone exposure as mentioned earlier because
5 m" S% l& R4 O& G: p) vthe exposure was not for a prolonged period of time.
9 c; l1 {+ h7 m8 @: lAlthough the bone age was advanced at the time of
) v% z/ N" k* \! B: @! c$ ~diagnosis, the child had a normal growth velocity at
% d4 a( X- U5 D& n' {' Pthe follow-up visit. It is hoped that his final adult/ w: i( w; \( ]' Q
height will not be affected.& o( J$ T3 I8 N/ r
Although rarely reported, the widespread avail-. S: S1 y. O8 ^9 r5 Z4 K
ability of androgen products in our society may6 z! ^# C. n& ?% [# n/ g  O
indeed cause more virilization in male or female
, l: W& u) `5 _9 M+ t  w3 @! Hchildren than one would realize. Exposure to andro-
7 |6 j7 ^, G* ?& B* ~gen products must be considered and specific ques-
+ T/ a5 L- q0 a9 Utioning about the use of a testosterone product or' q3 |2 t4 x  f  u9 ~
gel should be asked of the family members during% D$ J/ j) D. a3 b
the evaluation of any children who present with vir-
8 M% ^2 }5 a8 O+ [$ v% Uilization or peripheral precocious puberty. The diag-  e: W2 C# E. V0 y1 e' l1 f' m
nosis can be established by just a few tests and by* U. W7 I" I' Q2 I
appropriate history. The inability to obtain such a$ m* K' _( w. h( D+ S; x' w
history, or failure to ask the specific questions, may! Z! s5 _' Q: _4 Q/ @' s0 t. `
result in extensive, unnecessary, and expensive
. C) O' R4 F; ^2 M4 linvestigation. The primary care physician should be
  Z% s; m+ X  L& ~aware of this fact, because most of these children
( |. W9 V5 j% ~may initially present in their practice. The Physicians’
' ]% `& y8 \, p" a5 m. ODesk Reference and package insert should also put a+ @% |, `4 `" j$ X
warning about the virilizing effect on a male or. P5 B+ S2 g& Z. q2 U1 n
female child who might come in contact with some-
1 |6 |# N$ S8 I" D8 |' yone using any of these products.0 n8 L5 X3 ]9 F! l; L5 Z
References/ J0 T! ]7 R  K& r
1. Styne DM. The testes: disorder of sexual differentiation, S/ o& h* ~1 m  W- x8 {: r  Y- R: g) _
and puberty in the male. In: Sperling MA, ed. Pediatric/ [& `8 P& ~% p0 ~# t# B2 [$ d" P
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 v8 ^+ ?' S& p
2002: 565-628.) u) M8 e; |! b; s) i4 B) v5 k% y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# T2 v7 g6 K$ K1 @( H. Y$ p
puberty 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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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

& T2 @, d9 {7 o# p1 N! Z& U# s' w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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