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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$ |" \! M2 x/ ]- H3 ~
Boy Induced by Indirect Topical/ R. X, w% J& `! ~$ @
Exposure to Testosterone9 F  ^7 n9 z$ S* a+ f5 B$ ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# _0 _+ o/ X4 [" ?  @, n9 R9 E
and Kenneth R. Rettig, MD1( B% f8 q/ q( n2 e
Clinical Pediatrics# @. t/ T) t  i7 V" A+ r
Volume 46 Number 6
# H* T! ?, I8 W6 P. F+ D! {, [July 2007 540-543/ {# U) b& H# x& t+ P6 \
© 2007 Sage Publications$ L/ U" C" j% U$ _: r
10.1177/0009922806296651
% i& q6 z3 W6 `# Q6 jhttp://clp.sagepub.com
4 J. W; Q' g2 w: x5 m/ {: W, Mhosted at' E' z" t* h/ y( v
http://online.sagepub.com
; X' C! {+ W- B+ H( TPrecocious puberty in boys, central or peripheral,, @; a, K5 S8 t: Y, s; I
is a significant concern for physicians. Central
& H( E/ b( X7 R2 H  J- I& Oprecocious puberty (CPP), which is mediated5 |4 a  t4 }3 U$ p; H1 Z. H) Z* I& I# S- B
through the hypothalamic pituitary gonadal axis, has' d1 }8 ]( b4 B
a higher incidence of organic central nervous system4 G5 C$ `6 m0 P: S+ t
lesions in boys.1,2 Virilization in boys, as manifested
$ d: h  x0 ^* d, q8 }& L: j9 Oby enlargement of the penis, development of pubic
8 C8 o8 J6 S4 H2 h1 `. \1 ]hair, and facial acne without enlargement of testi-! N2 k+ p: y: Q2 _- b$ u" X  `8 w+ U
cles, suggests peripheral or pseudopuberty.1-3 We# ~' V0 ^6 y8 }) i' m/ K
report a 16-month-old boy who presented with the
& c3 T1 W$ `9 Q" h( y& Renlargement of the phallus and pubic hair develop-
# m" A9 l. ?7 M; Q/ f3 jment without testicular enlargement, which was due: B  ~2 Y/ {' _2 X( Z5 y  ~
to the unintentional exposure to androgen gel used by
* N2 u; J7 A$ B9 E, }4 qthe father. The family initially concealed this infor-, g! u/ V* H, @3 a9 X
mation, resulting in an extensive work-up for this
+ K9 F; t& H( b( Kchild. Given the widespread and easy availability of- U0 d+ s8 d2 f  B4 }7 ~: P. B
testosterone gel and cream, we believe this is proba-. a$ L; J* J. b( F. m
bly more common than the rare case report in the
6 `* r% F4 X3 O- eliterature.45 X* R3 A8 u& G4 k) |
Patient Report- M+ n! e- u, `6 j' i( t
A 16-month-old white child was referred to the
% X# v  s0 z" ~endocrine clinic by his pediatrician with the concern
% W2 m; A, g0 C7 |6 bof early sexual development. His mother noticed+ ?" `' Q: c$ L6 m7 N' j' V
light colored pubic hair development when he was- y! j8 U/ }: o9 Z3 x
From the 1Division of Pediatric Endocrinology, 2University of5 W/ V: [2 |' C% V+ F9 d: f! g. m
South Alabama Medical Center, Mobile, Alabama.
; b# `1 e: E- W% t  P2 h! RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
" h  \! h3 i% p' MProfessor of Pediatrics, University of South Alabama, College of
+ v  s- Z* m+ L, |" d- ^8 n2 LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! Y+ g4 G- O$ [e-mail: [email protected].2 l$ W) J- F; }
about 6 to 7 months old, which progressively became$ h, X; W- p# v" @8 Q. v0 X
darker. She was also concerned about the enlarge-
) D& J/ P6 ]8 c. H; m& l* b. b& e4 Lment of his penis and frequent erections. The child! r6 s* G* L# n
was the product of a full-term normal delivery, with
6 d$ _: @* A8 P3 ba birth weight of 7 lb 14 oz, and birth length of+ u* N  ?1 a( _7 Z) B$ `/ `% Y+ O
20 inches. He was breast-fed throughout the first year& p* p  {- M' r/ p! p9 L
of life and was still receiving breast milk along with; R+ |# {* r1 p$ L% y3 R7 _
solid food. He had no hospitalizations or surgery,
9 v% X: U0 e; @: vand his psychosocial and psychomotor development
. a* Z6 J* U1 l3 Iwas age appropriate.
0 s3 @1 ^% U: N- ~7 z8 s4 @; ~* W4 b( RThe family history was remarkable for the father,6 F- Q/ k* U( k: B( k7 `- F
who was diagnosed with hypothyroidism at age 16,
5 T8 ^- ]9 J# @8 S; [which was treated with thyroxine. The father’s
, Y: s# h. D4 X3 Y8 o- Nheight was 6 feet, and he went through a somewhat7 V! R' I% L$ p7 T. R
early puberty and had stopped growing by age 14.( s8 i& G# I& Z0 I3 p& i
The father denied taking any other medication. The
, \! _/ l# m3 Z/ D  o9 Tchild’s mother was in good health. Her menarche
( K" e0 B) ^/ U1 K; L. M  gwas at 11 years of age, and her height was at 5 feet
  j! p. h9 d' @8 {# f1 Z; q% w  Y2 n5 inches. There was no other family history of pre-
0 v0 ]! |8 b! ^/ D: ^+ E6 W; ~* icocious sexual development in the first-degree rela-
  d2 n- ?4 h  k7 utives. There were no siblings.
) o' H8 j$ Y1 D4 q' x( D, DPhysical Examination) J' C* _9 Y  k; h- X+ x" i
The physical examination revealed a very active,
5 D/ B5 Y' R. V3 o' B5 wplayful, and healthy boy. The vital signs documented" H& m$ t4 C' k9 e9 o- x
a blood pressure of 85/50 mm Hg, his length was; B  H% y7 J- D. G: k0 |( P" ^
90 cm (>97th percentile), and his weight was 14.4 kg! |: ]4 w* `3 Y6 s! Q
(also >97th percentile). The observed yearly growth
7 p6 s1 n- w" K0 k3 A! {: q* [velocity was 30 cm (12 inches). The examination of
; H7 @1 F& ?% ]) z9 M" B8 C4 Mthe neck revealed no thyroid enlargement.
0 p' ?$ K5 B! j% `+ hThe genitourinary examination was remarkable for# _% t% _/ \3 ?8 @
enlargement of the penis, with a stretched length of  l& |. l0 C2 E/ h  m3 J5 @& a2 E
8 cm and a width of 2 cm. The glans penis was very well& |* I% Q0 R' u6 z. k
developed. The pubic hair was Tanner II, mostly around/ {; a- N8 x! J
540
1 H6 S7 S( z% M6 c6 i4 z5 a: W+ Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- j/ p% x# d! E! s
the base of the phallus and was dark and curled. The
. y1 R: ]; D0 P* s( s* P6 u/ N" N5 Etesticular volume was prepubertal at 2 mL each.
+ F) a' p' x, k! f. p! uThe skin was moist and smooth and somewhat2 @" e0 b! A5 {" `9 U0 S
oily. No axillary hair was noted. There were no
5 B" x  X- |# Pabnormal skin pigmentations or café-au-lait spots.
0 `4 i9 `" b" `9 `4 d# M9 u# }8 xNeurologic evaluation showed deep tendon reflex 2+1 \" J  Y( i* c1 n
bilateral and symmetrical. There was no suggestion) Z% m; A6 e1 L; c# X/ @
of papilledema.
6 f: X* q( I" K8 fLaboratory Evaluation1 m+ F: j7 p5 i! Y+ ~
The bone age was consistent with 28 months by9 N/ K6 W' @, X. a
using the standard of Greulich and Pyle at a chrono-+ @; E. }" y1 T" e
logic age of 16 months (advanced).5 Chromosomal" \2 r- `* J  v) T+ d# a6 o; A
karyotype was 46XY. The thyroid function test
1 a* C7 g& t6 Q& V' V/ Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 _8 n/ n' X8 D! V* Xlating hormone level was 1.3 µIU/mL (both normal).
& P  @: {& l; r7 g7 @  k  z( c/ YThe concentrations of serum electrolytes, blood
8 d: U7 j7 T; t7 l. ?1 qurea nitrogen, creatinine, and calcium all were
( }4 l) q; K$ iwithin normal range for his age. The concentration
" q( f5 H1 h  ]: C; `8 xof serum 17-hydroxyprogesterone was 16 ng/dL
1 G, q2 X  F# L- T6 m! G(normal, 3 to 90 ng/dL), androstenedione was 20
2 O1 s$ D" |" e# f/ kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& J- n' ]& R. _" ~/ v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),1 r/ L1 Z- ~% ?% S0 v4 A+ a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* y$ I9 o8 j5 i9 V  w, g49ng/dL), 11-desoxycortisol (specific compound S)
- ]6 Q4 h/ y; b+ e: `" @+ c7 [was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 b0 `0 Q. A6 m$ l8 `3 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 s4 \9 s# l8 [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 D& V+ j; q4 N! S; nand β-human chorionic gonadotropin was less than
$ P2 |& l( f9 B" h+ y* z5 mIU/mL (normal <5 mIU/mL). Serum follicular- h2 o8 m3 `3 q/ P' l( i+ E* k7 H, y
stimulating hormone and leuteinizing hormone) }8 j/ R! R7 k4 K% [
concentrations were less than 0.05 mIU/mL
5 ~& S, g, @3 _6 [( V2 ]) i6 V(prepubertal).4 A) J7 m6 @! E5 K  o
The parents were notified about the laboratory
+ V+ Z3 q+ [3 a  ~4 l6 mresults and were informed that all of the tests were) ^2 O" X: A, p
normal except the testosterone level was high. The% F2 R4 K' o# P# y' w
follow-up visit was arranged within a few weeks to
& X( [3 j3 g6 l% nobtain testicular and abdominal sonograms; how-
9 o/ T8 c* _1 Y2 L) r% pever, the family did not return for 4 months.
8 S, D2 c3 A. M3 j7 tPhysical examination at this time revealed that the9 K# C4 N6 V' ]7 S. ?
child had grown 2.5 cm in 4 months and had gained- V% v0 d) p: P% v- a! z9 {4 D
2 kg of weight. Physical examination remained
5 f2 |' Y2 X" D( j. c  Zunchanged. Surprisingly, the pubic hair almost com-
6 I4 n  e( j0 i/ B( apletely disappeared except for a few vellous hairs at
9 O9 V  m+ W: e! ~3 f/ c/ r+ \the base of the phallus. Testicular volume was still 2
, ~; D5 ]. q) [( bmL, and the size of the penis remained unchanged.. i. u8 E' f+ a
The mother also said that the boy was no longer hav-) U2 i) T) v5 Z& _" s  s, T
ing frequent erections.
! z$ [/ b& F! S+ y1 l% g, tBoth parents were again questioned about use of9 I3 P, y. M3 Z! Q5 r" M
any ointment/creams that they may have applied to
+ G4 x) Q; u- H5 }$ J) athe child’s skin. This time the father admitted the
; M# J6 _+ g9 lTopical Testosterone Exposure / Bhowmick et al 541
( N" c1 Y7 g0 yuse of testosterone gel twice daily that he was apply-( e$ M  e* c# K5 W( u& g- ]8 [
ing over his own shoulders, chest, and back area for9 @4 ^7 T+ d. Y; U4 p' [  L, R
a year. The father also revealed he was embarrassed
; Q) {, R. p) Z: yto disclose that he was using a testosterone gel pre-
. }- w, a. k5 T" yscribed by his family physician for decreased libido8 Q5 K  F3 Y" b
secondary to depression.* l0 g9 Q% X2 o& Y) ^7 ?: J. ?6 q
The child slept in the same bed with parents.
4 C6 `% {8 c3 VThe father would hug the baby and hold him on his+ e) O) x  \' z$ S
chest for a considerable period of time, causing sig-& v% r6 _5 m) p9 ?& e5 v/ Z; g
nificant bare skin contact between baby and father.; U& A& a# S3 Z  Z5 D7 d
The father also admitted that after the phone call,/ W  d6 ]! A5 W& w8 a
when he learned the testosterone level in the baby
) m; i$ H3 }6 @4 Awas high, he then read the product information, t8 [) [6 g! a1 N) F7 _
packet and concluded that it was most likely the rea-( D- m/ ?9 w! G  \
son for the child’s virilization. At that time, they% m% w% _7 \1 [' H" C( E
decided to put the baby in a separate bed, and the+ I; P+ e1 K& j% L4 e0 m3 K
father was not hugging him with bare skin and had2 j! R( ~, e+ {( E
been using protective clothing. A repeat testosterone1 f+ A  A: u6 v( K0 s7 ]& _) N
test was ordered, but the family did not go to the
5 I+ y# l# m$ m/ y, Ylaboratory to obtain the test.3 B+ s! C- \4 n$ x  v% c0 b
Discussion
, K% W# t# C& ^! K3 z' l2 WPrecocious puberty in boys is defined as secondary
& e9 T) D1 j) ?+ Q( H) t' esexual development before 9 years of age.1,4
, [& P4 D, `9 k+ z$ ZPrecocious puberty is termed as central (true) when2 J9 ^/ ~. Z0 [" p
it is caused by the premature activation of hypo-
& K& j& d2 A* x4 }( T( ythalamic pituitary gonadal axis. CPP is more com-! R: @! b. ]' Q: {8 p
mon in girls than in boys.1,3 Most boys with CPP
; ~4 Z; y  N+ ?may have a central nervous system lesion that is5 |4 b# Y' L; E& r
responsible for the early activation of the hypothal-
8 K7 ~7 {2 M) r0 Z" [3 k: d9 v- |6 Camic pituitary gonadal axis.1-3 Thus, greater empha-7 u( C( f* L/ A+ L8 F
sis has been given to neuroradiologic imaging in( n' M* P) B4 s5 r% t. i2 g3 C
boys with precocious puberty. In addition to viril-
" k5 f! Z) T* A# \ization, the clinical hallmark of CPP is the symmet-1 s$ u8 w  Z; {; K: U+ a
rical testicular growth secondary to stimulation by1 l0 p: i0 ~: ~" m
gonadotropins.1,3) o/ J' v4 h" R- Y4 a, w- x
Gonadotropin-independent peripheral preco-- \/ {. X8 S; I* t1 D# f
cious puberty in boys also results from inappropriate
6 }$ t# o/ u% A  E" `androgenic stimulation from either endogenous or) l& w. T9 \( {* T! @6 K
exogenous sources, nonpituitary gonadotropin stim-4 L6 ^; }" u+ R4 B5 c
ulation, and rare activating mutations.3 Virilizing+ y/ m% P2 C5 _
congenital adrenal hyperplasia producing excessive
8 J+ b0 P+ h, S* v6 \3 padrenal androgens is a common cause of precocious
% q) @& r9 V4 I# O! vpuberty in boys.3,42 T  W" c4 a2 Z$ ~
The most common form of congenital adrenal; E+ h- q! @, u
hyperplasia is the 21-hydroxylase enzyme deficiency.
( b; e" z# a) bThe 11-β hydroxylase deficiency may also result in2 G$ I: T3 o# l
excessive adrenal androgen production, and rarely,: N: }! S0 I. n8 C" h* i) R
an adrenal tumor may also cause adrenal androgen/ k. ]0 R+ s7 o0 o: n
excess.1,3! y0 m$ R9 x  ]$ j' C# r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 R/ W3 Q, S5 O0 b$ N. d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- d; V: i4 m& r% w% x, T& KA unique entity of male-limited gonadotropin-
% B. _8 R, d1 Z2 }$ N8 L$ Xindependent precocious puberty, which is also known
4 O) |# t2 @+ Pas testotoxicosis, may cause precocious puberty at a& T7 o- x+ \5 h- Z6 M0 e$ |# F. L
very young age. The physical findings in these boys' O/ E. X: m3 g. n
with this disorder are full pubertal development,
( J9 G2 \; Q! m5 X/ Gincluding bilateral testicular growth, similar to boys
! s0 \) X' @* F2 owith CPP. The gonadotropin levels in this disorder" o& j' o" T; q
are suppressed to prepubertal levels and do not show0 i7 c$ ^% s: D5 }; k) M' y
pubertal response of gonadotropin after gonadotropin-
! ?9 N" J% @$ lreleasing hormone stimulation. This is a sex-linked0 T+ ~' K- y, y
autosomal dominant disorder that affects only
8 w( ~# i) k" N9 [% [  T& Lmales; therefore, other male members of the family
% P4 ]% Y' `+ r5 M# }4 v" o' pmay have similar precocious puberty.3
% Y  f6 o1 g) _In our patient, physical examination was incon-% ?6 G8 D( }5 z9 C
sistent with true precocious puberty since his testi-9 j8 q. t& X7 ?  x
cles were prepubertal in size. However, testotoxicosis
6 ^( n- r$ o# {$ Xwas in the differential diagnosis because his father+ _9 E- ]- W2 N9 A$ |+ B( X5 A
started puberty somewhat early, and occasionally,
: n2 J/ w; r  f- l" n0 ctesticular enlargement is not that evident in the( A, X1 ?' w4 u" L+ t0 D, _' k2 Y
beginning of this process.1 In the absence of a neg-4 c4 w: x* |: m5 h
ative initial history of androgen exposure, our6 G# W* ?% C! Q( f7 ?+ j0 b4 b4 o8 E
biggest concern was virilizing adrenal hyperplasia,$ D: N# o6 Z! F9 q. ]# D: d
either 21-hydroxylase deficiency or 11-β hydroxylase. p: L* E! o/ K# Y( Y
deficiency. Those diagnoses were excluded by find-
0 M! [: `/ u  E- k4 v5 Ying the normal level of adrenal steroids.
1 p  n* w9 V# W% UThe diagnosis of exogenous androgens was strongly
- D7 H2 [& C9 V* l: [5 ]. m. f( Gsuspected in a follow-up visit after 4 months because
  J% ?' M+ g" k5 ethe physical examination revealed the complete disap-3 J/ |4 d* Q. e, `8 g. g
pearance of pubic hair, normal growth velocity, and; N9 \1 }' N  o7 {3 z
decreased erections. The father admitted using a testos-
. y6 t! Q' W7 {/ a0 Hterone gel, which he concealed at first visit. He was
  F% W" V! ~" susing it rather frequently, twice a day. The Physicians’& c7 p4 t& p3 j6 M6 E- d1 m
Desk Reference, or package insert of this product, gel or
' l2 I5 {$ F; mcream, cautions about dermal testosterone transfer to
8 G8 G' u! P3 h9 f, k) g# w5 Q: Kunprotected females through direct skin exposure.
$ j3 S  V. A9 H  X0 QSerum testosterone level was found to be 2 times the
" B9 B. m/ z) u- P8 Wbaseline value in those females who were exposed to
; g1 j* V3 `, h- A7 a/ Eeven 15 minutes of direct skin contact with their male
7 \8 c6 w, u5 p1 ^; |partners.6 However, when a shirt covered the applica-3 m* o; C1 Z) `
tion site, this testosterone transfer was prevented.
9 Z: @3 p, T3 H4 G0 POur patient’s testosterone level was 60 ng/mL,1 Y# }$ A: n$ ^. x) q* a) Z
which was clearly high. Some studies suggest that) `, m: s; X5 e( M# V1 L# U
dermal conversion of testosterone to dihydrotestos-7 L2 Q! R) g( J: X, A! x6 a" Q
terone, which is a more potent metabolite, is more
( s+ b/ }- Y7 Z: Z! Pactive in young children exposed to testosterone) R7 e9 A. ~8 P& F5 d
exogenously7; however, we did not measure a dihy-4 j7 @% I: @, u! U0 t7 e
drotestosterone level in our patient. In addition to
- ?/ ?' X3 z. H$ t! A; }+ ivirilization, exposure to exogenous testosterone in
+ H5 j* R! @$ W, dchildren results in an increase in growth velocity and
& r* p- j' |! t. padvanced bone age, as seen in our patient.% C3 @; O4 F7 {. g. |3 g% V" R( y
The long-term effect of androgen exposure during
! F7 X0 A+ h1 |& b; Dearly childhood on pubertal development and final: G0 [0 y) W: a, K! J; i
adult height are not fully known and always remain' W1 I$ b6 F( G: L7 f3 Y( f
a concern. Children treated with short-term testos-
. ~5 X! ~9 t' W( G, [terone injection or topical androgen may exhibit some. H9 _+ l* r' s
acceleration of the skeletal maturation; however, after% _# |# V, j/ J5 i
cessation of treatment, the rate of bone maturation
) @/ R/ [' j" n! E% ndecelerates and gradually returns to normal.8,9
9 s" v$ Y4 Q+ \7 @$ B! j0 kThere are conflicting reports and controversy
0 s" w9 z, t+ @! D8 `over the effect of early androgen exposure on adult
% ^; u8 U5 \& l  w- X: Spenile length.10,11 Some reports suggest subnormal
, j* R3 M- ^6 x4 C% T, b3 Y4 Y0 v! }adult penile length, apparently because of downreg-
1 Q% z* V& s5 h/ u, Uulation of androgen receptor number.10,12 However,: [4 q; O) f6 `) h# m
Sutherland et al13 did not find a correlation between6 [+ k3 p- D' j% u
childhood testosterone exposure and reduced adult
! q; `' ^4 r1 d, ~, u8 l* qpenile length in clinical studies.
- j0 T1 @- h; S) t  Y" L0 `5 y" ^Nonetheless, we do not believe our patient is
5 ~/ a1 M* K9 o" U% Z, _, Wgoing to experience any of the untoward effects from( L* a  {, N. G3 v4 v" E% Q7 w& ~
testosterone exposure as mentioned earlier because; w) Z" _" k' x% f7 `- J
the exposure was not for a prolonged period of time.
2 ~; M$ B# K. M' K1 z0 }Although the bone age was advanced at the time of
& }9 C) s4 q1 Q4 z+ s. qdiagnosis, the child had a normal growth velocity at
' S6 G7 M; j$ Y& ?: `the follow-up visit. It is hoped that his final adult
8 r- E8 [' _1 _+ Oheight will not be affected.
# O; W& n5 q: z$ ^Although rarely reported, the widespread avail-( |0 h: x, {% j# o
ability of androgen products in our society may- }7 D: ?, f% B; S7 c& Q
indeed cause more virilization in male or female: T; i6 }7 p; p9 P/ }
children than one would realize. Exposure to andro-; u! j# ?) q, B& T* K( x: k
gen products must be considered and specific ques-/ K+ Y6 y( F, Y+ W' ?- f
tioning about the use of a testosterone product or
) r* w5 x1 K  H/ E* A) k, m. c, K. Ogel should be asked of the family members during
' U3 U* _2 m! O- Ythe evaluation of any children who present with vir-4 @; D1 K: _' a$ |  ^1 H1 e
ilization or peripheral precocious puberty. The diag-
1 E- l! E- l- }0 ]" ]8 [/ p! Bnosis can be established by just a few tests and by
% Z9 x3 C1 n+ F+ |appropriate history. The inability to obtain such a
/ u. N( s5 r8 ~. c( t' [: ~  zhistory, or failure to ask the specific questions, may
: v) M) q: ^' eresult in extensive, unnecessary, and expensive% {3 F. Z" m% I4 h8 ~/ g
investigation. The primary care physician should be+ v3 n" C8 L: G% b" R, k$ ~
aware of this fact, because most of these children
8 ~+ j8 R# |, O/ g" H, m2 wmay initially present in their practice. The Physicians’
5 E2 F! v- ^! w3 {. v1 h% n, fDesk Reference and package insert should also put a, J# Q* d; p. g- d
warning about the virilizing effect on a male or% u4 Y0 d+ n8 w
female child who might come in contact with some-2 O9 T; e- ^( ~! V) t( F7 X
one using any of these products.
( [9 l7 C  `) F9 FReferences: y9 }3 r* v3 J/ A
1. Styne DM. The testes: disorder of sexual differentiation, u8 D; z9 q( f- s0 o3 G
and puberty in the male. In: Sperling MA, ed. Pediatric: r% O: ^( n3 w6 p3 C
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! J  x; t5 x% j* v2 T( d2002: 565-628.
+ N5 D! J* O+ \# Z# k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& b1 Z/ c' O4 L, q! C( U! @
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
9 S0 r7 R1 Z: S% t: G, ZBoy Induced by Indirect Topical
/ @" \: _0 M, q  l" v# \$ d! s# q4 {Exposure to Testosterone  S0 ^4 ^# g8 H- j" v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* x# O9 \' T7 w$ }/ iand Kenneth R. Rettig, MD1
7 i$ |3 K# W* m5 k* dClinical Pediatrics' P- B8 n5 Y: M* q% c  a; M
Volume 46 Number 6+ ?9 F8 g' u. Y! t; G7 r6 j% w8 t/ @
July 2007 540-543" r. _+ G% N1 L# P9 @; |; A
© 2007 Sage Publications7 D6 n8 b: d4 \. R
10.1177/0009922806296651
$ c9 b7 E! p- N/ H8 j$ {) `4 mhttp://clp.sagepub.com
3 `# z3 I- C; C) J7 `2 c1 y# D0 y% Shosted at" f& e5 n2 S( @" \  s) b
http://online.sagepub.com: ^( U* N) k9 e5 [; m2 f6 N  r
Precocious puberty in boys, central or peripheral,
1 o# N5 `5 J$ ]7 C$ M" a8 pis a significant concern for physicians. Central
* u- E* R: }* F8 Gprecocious puberty (CPP), which is mediated
+ ~  r5 x' B# F) h6 r* othrough the hypothalamic pituitary gonadal axis, has
$ S7 B- k- C6 g2 @0 u' r6 K: Aa higher incidence of organic central nervous system
* D$ z) X) {: n0 Ilesions in boys.1,2 Virilization in boys, as manifested; F& Q. A* J; C4 b
by enlargement of the penis, development of pubic4 d" R$ `2 @5 ?: k
hair, and facial acne without enlargement of testi-7 a" z; K# x9 j0 y6 h( N
cles, suggests peripheral or pseudopuberty.1-3 We  H9 o6 C/ g2 N
report a 16-month-old boy who presented with the
0 y% t. t# j5 [# ~enlargement of the phallus and pubic hair develop-
( |6 i& z9 e3 h; L5 O: _ment without testicular enlargement, which was due
$ k7 J/ K4 j/ `& }' |& x: D: ], sto the unintentional exposure to androgen gel used by' v# ]* @' }: U! o( y$ |
the father. The family initially concealed this infor-
5 m8 m( Q: {) H' }mation, resulting in an extensive work-up for this9 t& [4 h4 G+ }* p$ \- j  O
child. Given the widespread and easy availability of- Q& c1 g9 h- x9 R% ~
testosterone gel and cream, we believe this is proba-8 y2 A' B: C& Y" }+ C
bly more common than the rare case report in the
! K: T( S  l+ {: S7 z- b# Y3 ^" kliterature.48 D. }$ x9 |: Q- E+ @( d
Patient Report
1 e! ~# W( N0 `! CA 16-month-old white child was referred to the) Z" H& [# _, w6 \
endocrine clinic by his pediatrician with the concern
) {/ l/ _* }) Sof early sexual development. His mother noticed
2 ^- c! j8 f6 M# h7 F0 ~. k! x; ?light colored pubic hair development when he was
2 I) j$ s# `8 ~4 _From the 1Division of Pediatric Endocrinology, 2University of
" H: s# ?* z1 M2 uSouth Alabama Medical Center, Mobile, Alabama.
$ {9 |: h2 S' W! S" yAddress correspondence to: Samar K. Bhowmick, MD, FACE,/ c/ }0 X* o) g2 S) N8 M) q- H
Professor of Pediatrics, University of South Alabama, College of
+ ]0 N1 x# k7 g9 f3 v4 mMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 Z% A7 ?) s8 Se-mail: [email protected].7 |5 a$ {6 F& S( {' S! p
about 6 to 7 months old, which progressively became
' P8 X+ M% U$ V6 }5 W6 ~darker. She was also concerned about the enlarge-' Y' Q4 _9 P. W6 N" N- Q
ment of his penis and frequent erections. The child4 L6 e8 C0 f: {! x0 {7 _
was the product of a full-term normal delivery, with
' J/ `8 G* E. va birth weight of 7 lb 14 oz, and birth length of
& X) O$ s- X) P1 V4 H: t) u20 inches. He was breast-fed throughout the first year
* a4 v8 L" r# @# _* sof life and was still receiving breast milk along with
" A3 H* }  x( B9 @$ x) l4 h4 Zsolid food. He had no hospitalizations or surgery,$ t4 d" M4 f, P8 ]# W  m; y
and his psychosocial and psychomotor development* k# C0 {" P8 Z2 i& q; A
was age appropriate.
  o. d$ b1 |$ h( [* eThe family history was remarkable for the father,
: N1 I3 ?6 _; s9 gwho was diagnosed with hypothyroidism at age 16,
8 D' \6 G' u/ ~% E0 K1 Ewhich was treated with thyroxine. The father’s: j: c7 X) d3 j5 P) ~. M! ~$ V
height was 6 feet, and he went through a somewhat
$ o9 }: i  z, @# z: mearly puberty and had stopped growing by age 14.* v5 R6 P- |) S$ N; j3 W
The father denied taking any other medication. The
, N1 ]0 v/ @2 L1 r; {$ h* cchild’s mother was in good health. Her menarche; K3 _8 `5 w; f+ D
was at 11 years of age, and her height was at 5 feet$ u; v- Q$ E6 _3 J9 d0 ~
5 inches. There was no other family history of pre-9 k; Y- i% W( U
cocious sexual development in the first-degree rela-
( ~; A; h0 Y) M. O* c( e% a* }tives. There were no siblings.
1 F6 H) R$ c5 f1 v% s& }( m5 }Physical Examination
/ u" A2 ?2 g. A9 @/ Z4 @The physical examination revealed a very active,
, l, e) y" |' a9 m, Oplayful, and healthy boy. The vital signs documented* Z5 _% u7 M3 ?6 V* P0 {+ t
a blood pressure of 85/50 mm Hg, his length was/ W7 c8 X+ N* }+ |- D0 f' m
90 cm (>97th percentile), and his weight was 14.4 kg/ F8 O& Z: |$ `$ ~" h  d( [0 x
(also >97th percentile). The observed yearly growth( ?: h0 V$ a( m
velocity was 30 cm (12 inches). The examination of% P6 @% L* G' V' c
the neck revealed no thyroid enlargement.& G) v, U& N$ H8 N5 o
The genitourinary examination was remarkable for
6 R# C* a# n+ z3 Q% ]enlargement of the penis, with a stretched length of; ]2 L3 f5 F5 z) _1 z6 u
8 cm and a width of 2 cm. The glans penis was very well
- L$ y9 u0 T( |. _1 `developed. The pubic hair was Tanner II, mostly around% k- v8 s2 j! Y6 G9 s
540- Q) D6 x2 Z/ v! e7 a6 s- V* ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ w% W; B2 ~% [2 Z( hthe base of the phallus and was dark and curled. The
$ E, u1 g: V  `" F# Htesticular volume was prepubertal at 2 mL each./ }" X! d8 n+ ^7 H) Y) g# i
The skin was moist and smooth and somewhat7 B. s' x+ b- l/ \
oily. No axillary hair was noted. There were no
8 n9 B9 N7 N8 y' {abnormal skin pigmentations or café-au-lait spots.
/ u# G5 G1 T# ~9 p, `. uNeurologic evaluation showed deep tendon reflex 2+1 K) V# [4 l8 r5 P) z$ {
bilateral and symmetrical. There was no suggestion
( t( F4 `# f& G9 T6 a  Vof papilledema.
# z! S! |! z4 Y1 ~* ALaboratory Evaluation
! N; }9 Q; ?) ~The bone age was consistent with 28 months by
6 I" w5 ^' ~% D7 c3 t! X3 Husing the standard of Greulich and Pyle at a chrono-
: u- H8 H- S; mlogic age of 16 months (advanced).5 Chromosomal
9 L9 s% ]/ t9 g: Q& v7 ukaryotype was 46XY. The thyroid function test. e+ ^1 h3 R% b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 E3 _1 W" i5 w& t1 F; C7 u
lating hormone level was 1.3 µIU/mL (both normal).& w, l+ X( m4 \, A6 E" Y
The concentrations of serum electrolytes, blood
* I. ^* u9 d0 I  L: Lurea nitrogen, creatinine, and calcium all were
. I+ G9 U9 n8 ~" l5 q: s# |! Dwithin normal range for his age. The concentration
# Q) K& a2 @. g0 L2 u' S2 [. Sof serum 17-hydroxyprogesterone was 16 ng/dL
0 _; l0 h. c5 D! T9 }(normal, 3 to 90 ng/dL), androstenedione was 20/ i8 n. b  _. \" `7 |$ i; w3 |. m5 w0 M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. |4 U8 }( T+ [& l; q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* D. a5 {) u6 a" U% D: E! l0 g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 _( y( C. R; R
49ng/dL), 11-desoxycortisol (specific compound S)2 P+ ~) X3 j, R# I3 G1 A
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  T1 m- S9 v2 H, A1 c: L
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 d# P  P1 @  k1 E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& g# H2 R  {- _; t+ a& t( u
and β-human chorionic gonadotropin was less than! r# `: g3 J" g5 G/ E% U
5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ `8 C1 @/ y4 ~5 ^3 e5 A# j* ~stimulating hormone and leuteinizing hormone
9 J1 k$ r* N9 H: [concentrations were less than 0.05 mIU/mL
; Z* m& w/ K( A& z2 k0 w/ @(prepubertal).
" g; H: h8 F0 h# t# U8 @The parents were notified about the laboratory* z9 }: A& S. |
results and were informed that all of the tests were: [# M" c% }+ _8 X; L/ N2 |
normal except the testosterone level was high. The
7 p& L) [3 e: V3 j; m- jfollow-up visit was arranged within a few weeks to3 M( j7 i- f3 z* y* r9 W7 M
obtain testicular and abdominal sonograms; how-
1 q# G/ P' M3 q/ M. `' Cever, the family did not return for 4 months.
; |8 m' I% [) X' r7 H- a8 g: u( rPhysical examination at this time revealed that the
5 E8 q; p1 ^* g0 Zchild had grown 2.5 cm in 4 months and had gained
7 h3 m; A3 _4 B2 kg of weight. Physical examination remained6 n# ^: g% q0 a% O, n" h& {( [6 I
unchanged. Surprisingly, the pubic hair almost com-; k+ X* t% q  a5 ~% Z: g$ [
pletely disappeared except for a few vellous hairs at$ Z4 x  J5 B& N( n7 S: q: f
the base of the phallus. Testicular volume was still 29 b7 J3 H: j6 j1 V5 z+ o1 z
mL, and the size of the penis remained unchanged.
/ p9 r  u# |7 M$ ^0 O! C4 A( x( tThe mother also said that the boy was no longer hav-4 A( W$ e& n- I! H  \7 L
ing frequent erections.
' `3 J2 `2 P& g, TBoth parents were again questioned about use of8 ]% s' _9 R9 }: |8 {* H' a
any ointment/creams that they may have applied to- A8 O0 @/ ?6 y) k) k. n3 M# f
the child’s skin. This time the father admitted the
6 `& M' D6 q" C$ K$ c3 ~+ A( |Topical Testosterone Exposure / Bhowmick et al 541- L0 d' M. f7 J) V5 y+ }
use of testosterone gel twice daily that he was apply-3 g$ i: u% F  Z+ R$ b4 @, Z
ing over his own shoulders, chest, and back area for
1 m/ _0 f1 e% Z+ v6 Da year. The father also revealed he was embarrassed( i  W* y6 O8 E1 M$ E2 w1 U
to disclose that he was using a testosterone gel pre-
$ R. d5 Y% Z  H& B  f# Ascribed by his family physician for decreased libido
1 S  m! p0 s, Tsecondary to depression.
9 h; }* o/ l: g2 Y7 E/ {( K* m: D4 ~( OThe child slept in the same bed with parents.
$ X6 n8 p# C9 O6 \7 y) s/ }The father would hug the baby and hold him on his9 K) n+ C3 l  E, V
chest for a considerable period of time, causing sig-9 P0 \: U* \0 L8 o) m) I
nificant bare skin contact between baby and father.: n" `" _4 Z& S1 a0 H
The father also admitted that after the phone call,
+ B! h5 b; l* g: L; h/ D% {5 Swhen he learned the testosterone level in the baby
, x" x& @5 S# M" `' J) {was high, he then read the product information" P" D& f# r. U, j0 |
packet and concluded that it was most likely the rea-
* @  z( D9 K% I! V  ~  h, Ason for the child’s virilization. At that time, they1 `: U0 q. h/ f; i; b
decided to put the baby in a separate bed, and the
1 C, o9 {9 r) ofather was not hugging him with bare skin and had4 J% q: H: V) D) i7 k
been using protective clothing. A repeat testosterone
! n& s5 R  J8 k& a; l1 S" qtest was ordered, but the family did not go to the
6 [2 z9 v) [1 o1 q: Q% A8 o1 tlaboratory to obtain the test.' W5 _$ Y( A9 i+ X+ q6 k/ l
Discussion$ O5 `2 g( I9 X8 V$ }) y# j& g
Precocious puberty in boys is defined as secondary
& g) G; l/ G0 f: n2 W4 fsexual development before 9 years of age.1,4
7 Q6 C# U' `8 i1 P  o% ?Precocious puberty is termed as central (true) when7 h* }9 N6 T- B/ o
it is caused by the premature activation of hypo-; w+ E7 Q2 S+ h" a1 b9 u/ v3 R3 y& X* e
thalamic pituitary gonadal axis. CPP is more com-  Q" Z& A* i- C
mon in girls than in boys.1,3 Most boys with CPP9 Q/ C0 {% z# Y$ X: n  R0 E
may have a central nervous system lesion that is
# a3 p  u$ V& y4 _7 z* [responsible for the early activation of the hypothal-
4 U! _( ^- _& j" S" e# wamic pituitary gonadal axis.1-3 Thus, greater empha-
' ?# }5 @. ?& J! t8 Isis has been given to neuroradiologic imaging in
& ]6 ^% e' P* `+ f2 g, s. dboys with precocious puberty. In addition to viril-
. J5 o. |% \  c* Vization, the clinical hallmark of CPP is the symmet-
6 S  t. [& \- e6 Z( x8 j, _rical testicular growth secondary to stimulation by
; c8 B$ d+ x  f% j1 n+ Y! vgonadotropins.1,3! L- c9 F1 j: C& f* I% z
Gonadotropin-independent peripheral preco-
3 D7 f0 V: d2 ^/ b' D2 O+ zcious puberty in boys also results from inappropriate  v9 `9 a. v% P" w
androgenic stimulation from either endogenous or
, p+ S! X: `5 P4 Vexogenous sources, nonpituitary gonadotropin stim-
  r. r0 M/ W( Lulation, and rare activating mutations.3 Virilizing
( _) ^. R: [, L  x6 ]) O: V% B/ `) }1 ^congenital adrenal hyperplasia producing excessive0 E1 h0 S6 U& E9 q% {$ ^, O; J) L; ~
adrenal androgens is a common cause of precocious! B6 S2 m3 S$ ^9 l
puberty in boys.3,4+ u* u5 ?( U) C) T% H; b+ j
The most common form of congenital adrenal
  F% f$ t2 z$ F, p" j7 P7 [hyperplasia is the 21-hydroxylase enzyme deficiency." L% V  s& Z$ ~# g0 y9 m# O
The 11-β hydroxylase deficiency may also result in
4 h8 r7 X) D7 g, Z# b2 }excessive adrenal androgen production, and rarely,1 g; b# g# d2 ?2 ?. Y. U
an adrenal tumor may also cause adrenal androgen
' c) x) N% Y+ q) K" sexcess.1,3
4 o8 i" e0 q8 _1 R  x* z) s8 v2 M' {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: D( G8 i' J3 P- p' u, ]  O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; b$ |/ U2 i. W" P1 M2 F8 bA unique entity of male-limited gonadotropin-- I. x: N* Q/ z! u+ U( n5 m, v
independent precocious puberty, which is also known
' m  A( a* i" f/ y) }as testotoxicosis, may cause precocious puberty at a# O5 y3 v3 \. H
very young age. The physical findings in these boys
4 D# g5 v4 E9 O! {6 [) W& swith this disorder are full pubertal development,
9 P4 ~; Z) ?+ I* \" f% A/ u7 h3 g! kincluding bilateral testicular growth, similar to boys/ t! ~9 G+ w9 q$ S
with CPP. The gonadotropin levels in this disorder" u" l3 d, S7 ^' n- K- a
are suppressed to prepubertal levels and do not show
9 I/ Z: R. ~1 B# E8 j. t2 opubertal response of gonadotropin after gonadotropin-
$ U; \, ^5 n- B! g: Treleasing hormone stimulation. This is a sex-linked
) z7 i7 k1 G% Z) n6 j3 Gautosomal dominant disorder that affects only
) J1 ~9 d1 K1 Q# ~( s/ Hmales; therefore, other male members of the family% p. ^. `& [- w5 v" q2 F3 |$ d
may have similar precocious puberty.3! d, [" ?% e! Y5 G0 z
In our patient, physical examination was incon-, y4 a& f0 K+ v5 x4 N$ ?
sistent with true precocious puberty since his testi-3 L: J! Z& @9 r5 I
cles were prepubertal in size. However, testotoxicosis
4 W/ {; a3 Z8 Zwas in the differential diagnosis because his father7 w. g8 o0 _) o" C" J8 h. n% R$ _
started puberty somewhat early, and occasionally,
- Q2 s+ `7 o1 L( rtesticular enlargement is not that evident in the
( c* I% X  c* |. D! ^beginning of this process.1 In the absence of a neg-
$ u# ]& B4 T$ ~6 n# `. i6 Eative initial history of androgen exposure, our
# d4 ]1 s+ {: [; Kbiggest concern was virilizing adrenal hyperplasia,1 S8 m) n5 x  Q* b& T. q
either 21-hydroxylase deficiency or 11-β hydroxylase& D) x( q! u, ?0 k. h  }+ e# r* y
deficiency. Those diagnoses were excluded by find-
5 ?% V! N* s8 b1 jing the normal level of adrenal steroids.% o/ m; j6 R; A: v0 y) f0 x; X
The diagnosis of exogenous androgens was strongly$ Y% f9 @+ k! r8 H
suspected in a follow-up visit after 4 months because9 s7 f9 H! M- ], _
the physical examination revealed the complete disap-
% u7 p! j# w, ^) Tpearance of pubic hair, normal growth velocity, and% @- [. @. `/ ^) `
decreased erections. The father admitted using a testos-
3 _, E3 k  [/ R% b6 @" C  T- H/ W2 {; u/ Vterone gel, which he concealed at first visit. He was0 H( U& }1 |9 `
using it rather frequently, twice a day. The Physicians’, Q0 j* U0 e. M; l
Desk Reference, or package insert of this product, gel or+ |6 D1 ~* Y7 l/ Z/ L3 Q3 A
cream, cautions about dermal testosterone transfer to
2 D8 X6 z! p8 v  b& [4 P1 hunprotected females through direct skin exposure.
' u9 |# S& ?& @Serum testosterone level was found to be 2 times the
% P: I3 x0 q: W( p9 gbaseline value in those females who were exposed to( a1 |* f  [4 h% t/ e
even 15 minutes of direct skin contact with their male  p4 L  \( s! X
partners.6 However, when a shirt covered the applica-
/ v+ U& U. ]- Xtion site, this testosterone transfer was prevented.
+ k: x" x- T  o% i" v' @Our patient’s testosterone level was 60 ng/mL,
. \7 q; S" _/ ?8 V: z7 Twhich was clearly high. Some studies suggest that) p, P. ~( f! C$ R# a
dermal conversion of testosterone to dihydrotestos-) Y7 T$ d% W$ X* f9 Z8 l, J
terone, which is a more potent metabolite, is more* {. W8 `0 s* @/ e. K. e9 |
active in young children exposed to testosterone
8 f, n4 F. w0 ?exogenously7; however, we did not measure a dihy-
4 U8 L( }7 o: u8 Z2 bdrotestosterone level in our patient. In addition to
& L) b3 C  ~+ W) w; _4 }virilization, exposure to exogenous testosterone in. S' z! n; f0 K  [; }; \  z
children results in an increase in growth velocity and6 @- Q6 s0 {. Y5 K3 l$ z1 ^
advanced bone age, as seen in our patient.
1 d' {2 J3 ^) m% u/ IThe long-term effect of androgen exposure during
$ N. k& Y$ B7 |3 t& Dearly childhood on pubertal development and final
' `2 _# F! C% G0 k- f5 m( eadult height are not fully known and always remain
. c+ `0 C; W& e; k4 C6 x: Va concern. Children treated with short-term testos-
5 Y4 u/ H) s8 Q7 |7 r" Tterone injection or topical androgen may exhibit some2 B$ X" u- X- f- }3 j
acceleration of the skeletal maturation; however, after
7 c3 B1 V0 H# [3 ucessation of treatment, the rate of bone maturation
% B: V' j  }" x# a% e3 idecelerates and gradually returns to normal.8,9
( `& _; \* {! A. K  K7 Q8 g/ AThere are conflicting reports and controversy9 r! a/ t) N  }, ?  P# j
over the effect of early androgen exposure on adult
0 S( o8 K: J+ {penile length.10,11 Some reports suggest subnormal
3 V* Z& G/ X4 Q% n0 ]adult penile length, apparently because of downreg-( U( K! a! B4 k
ulation of androgen receptor number.10,12 However,
8 U; d) L3 W- w6 A- SSutherland et al13 did not find a correlation between! L& I  \  e/ _7 r- M# S( s
childhood testosterone exposure and reduced adult' W/ j" |" F6 P+ u9 r2 E  M
penile length in clinical studies./ h3 f- H- O- x6 C* ]
Nonetheless, we do not believe our patient is' A1 ^  q1 l' Z* X0 ?+ Z+ _" l
going to experience any of the untoward effects from
7 N& a0 r( k2 M1 t- \testosterone exposure as mentioned earlier because
- S, Q7 `. m; C/ s% vthe exposure was not for a prolonged period of time.- U. Y' _6 _) N+ h: Q
Although the bone age was advanced at the time of
+ a$ u# C! D, p/ G: E, ddiagnosis, the child had a normal growth velocity at
6 X) C  Y! O( B  }, Pthe follow-up visit. It is hoped that his final adult
& g6 r1 b4 p3 {% E0 d- A: o( |6 nheight will not be affected.
2 a# N9 m7 m, AAlthough rarely reported, the widespread avail-  P. j/ L7 }0 w7 g0 r" ]  n( t( ?) e
ability of androgen products in our society may
6 W9 n! P7 C+ findeed cause more virilization in male or female
5 T; y4 m8 |* Y% }, }children than one would realize. Exposure to andro-& m: G+ ]! x  z/ ~
gen products must be considered and specific ques-( l7 e& s7 W3 ^% s9 T
tioning about the use of a testosterone product or" f  r3 J& |, B  y
gel should be asked of the family members during% ^& {; ~4 [' j) j- f- |
the evaluation of any children who present with vir-2 D8 J* H, h! p9 |
ilization or peripheral precocious puberty. The diag-3 r2 V  Y( ?: |3 c. N
nosis can be established by just a few tests and by9 g& _. F( e; U' P2 A
appropriate history. The inability to obtain such a
# f2 t$ Y+ f$ A" ]history, or failure to ask the specific questions, may( H0 }/ _2 l) {% Q; J4 j
result in extensive, unnecessary, and expensive
  S/ ]$ O% a( O. v: n8 W9 P. H; linvestigation. The primary care physician should be
# y' m& ]; B. [8 I6 h% Z: taware of this fact, because most of these children
; y, ?1 y: p6 b/ A8 B# Emay initially present in their practice. The Physicians’
# K: }9 D& r+ ~Desk Reference and package insert should also put a0 |! Q0 R' k. d0 ]  \  u  u
warning about the virilizing effect on a male or
: n- e6 S) z0 n, Rfemale child who might come in contact with some-8 v& g! ~/ g1 _  c  N' D
one using any of these products.
- J# G, Q/ C2 U- Q! N+ vReferences9 ]; T4 g$ ~+ X9 ~$ u! S
1. Styne DM. The testes: disorder of sexual differentiation& K* v" X; v) W9 s4 t
and puberty in the male. In: Sperling MA, ed. Pediatric
5 G1 B# b; ~( DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 D& B5 F4 l4 M- W
2002: 565-628.4 t$ |' X# d4 d# {5 P, m) v
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 D, X8 o5 j8 P' W: L
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
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
( f) a% X, l3 W$ _3 a. L
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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