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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' o* c6 Z7 {# h. G" E
Boy Induced by Indirect Topical7 h( Z2 x" |4 J4 z/ z, S( o) W, B( ~6 B
Exposure to Testosterone
0 M& g- E, a) `% oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 ^" V- }$ ~6 E( n: p6 hand Kenneth R. Rettig, MD1
5 U; |8 [, M7 O1 QClinical Pediatrics
/ q; Q/ x- L# D+ z( `Volume 46 Number 6
6 v5 g( m- y! J* z: N. A- ?July 2007 540-543; P& E8 J6 [& z- O5 R! b& a  e
© 2007 Sage Publications
* c  [' D( j% N9 Z6 T, `# {10.1177/0009922806296651
* {4 T# v  }* c- B" chttp://clp.sagepub.com
6 \- }  Q: n, L( Ihosted at5 E6 ~2 {5 T1 [% ~5 M1 k2 x7 e
http://online.sagepub.com; z9 H7 C; M" l3 t
Precocious puberty in boys, central or peripheral,5 i. y. o+ s4 F7 F# a
is a significant concern for physicians. Central
4 G  R/ i. ^0 V  ~precocious puberty (CPP), which is mediated) X. P* J, P' W$ \3 c( n! w! w
through the hypothalamic pituitary gonadal axis, has0 E/ o* p( D5 x  ?0 S6 Z5 T
a higher incidence of organic central nervous system) q6 v) B; f3 f: h2 O% I, E
lesions in boys.1,2 Virilization in boys, as manifested; I+ E6 _$ M- T2 k' @4 x, y
by enlargement of the penis, development of pubic' e- R+ J* ~1 f3 F6 ~
hair, and facial acne without enlargement of testi-
  L' m! [, O3 y! A# {6 Q* B* Wcles, suggests peripheral or pseudopuberty.1-3 We
! k/ v; _* D: ?- vreport a 16-month-old boy who presented with the, E, E$ F- l* a  ^
enlargement of the phallus and pubic hair develop-
9 L) U' Y9 D" M* B4 ament without testicular enlargement, which was due3 _. H2 W$ W# N8 S5 l
to the unintentional exposure to androgen gel used by
7 a* [# y' `- Y2 Othe father. The family initially concealed this infor-. \# l- b* h8 p, X) f; F$ d( o
mation, resulting in an extensive work-up for this
) h" N) @; d6 T- N( wchild. Given the widespread and easy availability of
! o7 c/ n0 A- f* @testosterone gel and cream, we believe this is proba-" i8 W- X* @% R" \7 `  s
bly more common than the rare case report in the
" u! d5 \& x# uliterature.4) o+ D6 G* o& k5 p" C* L/ f+ ?
Patient Report
. W! o/ ?3 V, k: B. m  _A 16-month-old white child was referred to the9 ~  k& l/ q! B: {+ `
endocrine clinic by his pediatrician with the concern# v: X' k5 x, Z  f. K+ e, u: o5 X
of early sexual development. His mother noticed) N  {: O6 \; h/ _5 d+ v
light colored pubic hair development when he was. t5 }6 q: x$ T# ^
From the 1Division of Pediatric Endocrinology, 2University of. v- o0 h# E/ @: f- [0 [6 o
South Alabama Medical Center, Mobile, Alabama.
7 L# c" Y2 v+ z' j3 W5 ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,% U' c, K1 E5 r
Professor of Pediatrics, University of South Alabama, College of
7 P( r5 W4 |2 j8 w6 k3 Q% vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 \* r6 g3 S( l+ j5 j$ P
e-mail: [email protected].+ p& s% b- O# Q0 C  C. ^" T
about 6 to 7 months old, which progressively became
5 M, V2 L1 @! p6 L2 Edarker. She was also concerned about the enlarge-. x* N8 H" t) s2 c8 {7 [/ w
ment of his penis and frequent erections. The child2 I6 p" h& y2 _
was the product of a full-term normal delivery, with
( t8 l! v: ^. z' ?( U' `6 T4 na birth weight of 7 lb 14 oz, and birth length of4 W9 p+ v' V- [" G% H
20 inches. He was breast-fed throughout the first year9 D( @6 D( ~6 ~3 s- i
of life and was still receiving breast milk along with7 ^! Q8 J  G4 ~( g& W* g2 a
solid food. He had no hospitalizations or surgery,7 m7 c# P4 x  I3 X3 P
and his psychosocial and psychomotor development4 L8 K) X& t9 c* C, D' \2 \" {- ^
was age appropriate.
; A/ Z# A8 {* A) a$ J  V, }# JThe family history was remarkable for the father,; l; [* p9 y" Q- g, M# m4 T
who was diagnosed with hypothyroidism at age 16,8 B( f' d- U0 I7 o1 [# [8 p
which was treated with thyroxine. The father’s
7 y; l; U% ]$ t+ G' ?height was 6 feet, and he went through a somewhat# k' G- D* u( j5 z6 _% K& A
early puberty and had stopped growing by age 14.
( J, z4 X8 ^. R7 H: m; J# s' cThe father denied taking any other medication. The0 e0 z( B1 m, H; u, J
child’s mother was in good health. Her menarche
2 _9 J- u% \( j4 P* Y: awas at 11 years of age, and her height was at 5 feet
9 y% R$ P: R* A( O4 B5 J5 inches. There was no other family history of pre-
! ?2 C3 h+ B- x0 g$ xcocious sexual development in the first-degree rela-
+ r/ {! y: g. s! ltives. There were no siblings.  Q5 u- ?1 o/ u) [
Physical Examination" }4 E+ a6 ?& _! b
The physical examination revealed a very active,* C0 X, Q& x6 m) n4 G0 I4 {
playful, and healthy boy. The vital signs documented+ |6 N/ |7 s: y% S* \! n  Q
a blood pressure of 85/50 mm Hg, his length was/ J4 d2 i. t  c$ p8 v  c
90 cm (>97th percentile), and his weight was 14.4 kg& l- w& X2 _- j8 ~1 R. r
(also >97th percentile). The observed yearly growth
/ }  N2 j& x( g6 `4 {velocity was 30 cm (12 inches). The examination of. `5 V4 C% K7 N
the neck revealed no thyroid enlargement.. ~5 W7 y7 P6 F/ B% w8 S- q5 A
The genitourinary examination was remarkable for$ B5 D4 G. H" `1 }% x! q3 a( r2 w
enlargement of the penis, with a stretched length of
$ }% [% N: \9 ~8 cm and a width of 2 cm. The glans penis was very well
7 U7 z$ N8 S& _developed. The pubic hair was Tanner II, mostly around' M) q5 T- r2 b/ U
540
3 I3 K. F! q/ k0 {2 |: N5 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ H, I; H3 N0 {" H% F9 [the base of the phallus and was dark and curled. The6 X3 t$ z+ b( ?& l0 q
testicular volume was prepubertal at 2 mL each.
0 C5 J, r+ ?: E- ]( \/ zThe skin was moist and smooth and somewhat6 P8 R/ r: D5 \$ O9 m4 ~# a
oily. No axillary hair was noted. There were no
) S) p& x# b4 d! F; C% i& b; f( {$ sabnormal skin pigmentations or café-au-lait spots.
: x8 O1 D" T+ J8 N' u/ ^Neurologic evaluation showed deep tendon reflex 2+
( M2 q, W  ^, A. B8 ?1 s! Hbilateral and symmetrical. There was no suggestion
4 }. t& C- T4 W/ ?of papilledema.. k  B3 k6 C/ T! y" o, S4 w0 N6 h
Laboratory Evaluation
; t. N) f" H# f6 ?  K5 I( [The bone age was consistent with 28 months by" q4 ^' ?9 R. p- s
using the standard of Greulich and Pyle at a chrono-- N' d5 U+ ~" v7 H- e9 P
logic age of 16 months (advanced).5 Chromosomal
; K- x. U) Q. f$ n; ]% Nkaryotype was 46XY. The thyroid function test* w# E9 w8 D2 b' ?3 D, ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ U% k$ [1 }" G0 U1 r0 Z% }, F
lating hormone level was 1.3 µIU/mL (both normal).
7 v6 Z' I1 H& DThe concentrations of serum electrolytes, blood% n6 G7 o2 F+ B
urea nitrogen, creatinine, and calcium all were. P! U& |; v0 D" V/ R- I
within normal range for his age. The concentration; i& S0 T$ i5 _8 [6 M
of serum 17-hydroxyprogesterone was 16 ng/dL
( W/ o. s! i' _, h* l: j( n(normal, 3 to 90 ng/dL), androstenedione was 20; R8 ~+ R; {) w* A0 E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' z# N5 h- Z* _' l8 G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. Z# G5 E/ g+ q7 e  c/ Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; L. I. C6 ]( ?' l1 R# p* E49ng/dL), 11-desoxycortisol (specific compound S): U, \6 L: E& W0 H! b3 a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- x/ ?" G' }* S9 h% C! S8 Z0 X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# H. i, J& n0 O3 }- |0 ]% D5 J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ X: Q, e$ U3 {2 m6 k: ~2 Qand β-human chorionic gonadotropin was less than
" ?. ]9 C& @6 @. i# d9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular) o  r- o: m( M! P& O! V# x, i# S1 ]
stimulating hormone and leuteinizing hormone! Z: g5 @1 y2 h5 \2 \/ ^
concentrations were less than 0.05 mIU/mL; O9 h! H9 e' Y- C/ ^
(prepubertal).
6 M6 P- R8 i' E( ~: tThe parents were notified about the laboratory
; `: S: ~5 K: ~9 E$ lresults and were informed that all of the tests were
% y' a: A! I( D6 xnormal except the testosterone level was high. The7 w3 W8 r7 F/ S* n* G
follow-up visit was arranged within a few weeks to
1 @2 F2 L+ [+ [! L9 i" {" Vobtain testicular and abdominal sonograms; how-
" e9 ]) a8 R  l# g5 `3 q) Xever, the family did not return for 4 months.9 ~7 ~3 x5 n0 M% d3 f1 e7 ~
Physical examination at this time revealed that the
$ u7 U% N, p- C5 H% Pchild had grown 2.5 cm in 4 months and had gained
4 W5 }1 b0 M9 `  S2 kg of weight. Physical examination remained2 M9 M. H  X) c. K( o% l
unchanged. Surprisingly, the pubic hair almost com-
* D' S% L4 V7 O. [! Z1 @) p2 Kpletely disappeared except for a few vellous hairs at
+ |# Y+ i- g# Wthe base of the phallus. Testicular volume was still 2! V$ {9 |$ r. [/ I
mL, and the size of the penis remained unchanged.. p4 o% m* i. z8 D- E7 H
The mother also said that the boy was no longer hav-
# ]' {( W& @. W% J# Ving frequent erections.6 {$ ^4 \6 a+ Z
Both parents were again questioned about use of
0 I3 K7 l# Q0 ?* q: M  j7 ~any ointment/creams that they may have applied to) U0 z# N( O- B. |" z0 s
the child’s skin. This time the father admitted the( a* ]. Q  M( j; A% Z
Topical Testosterone Exposure / Bhowmick et al 541/ u0 W$ V6 @5 p
use of testosterone gel twice daily that he was apply-
5 B9 Y2 w8 n$ R; o2 eing over his own shoulders, chest, and back area for
+ Q- B! I) R% \5 ta year. The father also revealed he was embarrassed% e# W1 E! X8 q6 `4 N5 u
to disclose that he was using a testosterone gel pre-5 e- \/ }0 H) L& Q
scribed by his family physician for decreased libido
9 n7 P/ q3 Z, H: D9 g) nsecondary to depression.
# e- a6 Q4 o9 B, {9 o/ U6 {The child slept in the same bed with parents.
9 u2 W8 x2 F  h4 o3 @( |The father would hug the baby and hold him on his
3 D9 A5 }9 a3 ^4 rchest for a considerable period of time, causing sig-
8 g5 {6 x( _" `: K( I# B/ w$ znificant bare skin contact between baby and father.6 a% J  a; V8 Q: [) Y& t3 S% S3 r
The father also admitted that after the phone call,# ~5 R" T+ Y4 b1 t
when he learned the testosterone level in the baby
, B# u' V$ U! r$ Awas high, he then read the product information
* m, S$ N$ u7 r4 i' v2 @, P7 Ipacket and concluded that it was most likely the rea-/ L9 ?5 y9 j( _+ `$ {
son for the child’s virilization. At that time, they
% P- M# Z( [) O+ G/ b2 Ddecided to put the baby in a separate bed, and the
0 ~6 A% s+ `: w9 m5 u, Q. c, dfather was not hugging him with bare skin and had
# _. d. y/ L( J$ h2 \. w, S7 Ibeen using protective clothing. A repeat testosterone
! @! C* d! E1 j! z0 Etest was ordered, but the family did not go to the
2 S  q+ o4 a+ i* q! @laboratory to obtain the test.
, |3 s( t+ c; i2 y1 R, d2 a1 f" vDiscussion* ~% @& s1 [% W+ |/ L
Precocious puberty in boys is defined as secondary. m3 I) ^- Q% U4 T, B9 l- o# `" s
sexual development before 9 years of age.1,4
* z/ l. [4 M8 J: QPrecocious puberty is termed as central (true) when
+ x" Z0 `6 \7 j1 j6 Mit is caused by the premature activation of hypo-
' `3 b5 V8 v, d- {0 v: ?0 lthalamic pituitary gonadal axis. CPP is more com-" b8 P5 ?, N. H
mon in girls than in boys.1,3 Most boys with CPP& Y" e  Q$ i  r7 |( \6 b, x' r
may have a central nervous system lesion that is
5 p. e3 E9 U1 A) J( R) F7 Cresponsible for the early activation of the hypothal-
% l; ~0 ~0 b7 @0 I, ]" samic pituitary gonadal axis.1-3 Thus, greater empha-, x1 l5 L% Z$ ^
sis has been given to neuroradiologic imaging in6 t$ R  r* Z6 e4 z, }4 s1 V
boys with precocious puberty. In addition to viril-. e% y: T/ q; k
ization, the clinical hallmark of CPP is the symmet-
) ~6 p7 K0 x( w: m" S- D4 l- ]rical testicular growth secondary to stimulation by
& P6 O- p) J  sgonadotropins.1,3( t1 `8 e5 k- h
Gonadotropin-independent peripheral preco-
2 m6 W  A5 X! C) F1 u- H4 w! A3 z) vcious puberty in boys also results from inappropriate
0 X7 g, Y# Q& T  nandrogenic stimulation from either endogenous or
9 N- R- s+ M4 H2 R" L# c# Bexogenous sources, nonpituitary gonadotropin stim-$ ]! T) S  }2 S0 D% Q1 P
ulation, and rare activating mutations.3 Virilizing4 ^: u: |4 i; _
congenital adrenal hyperplasia producing excessive
( v# i0 n! d, padrenal androgens is a common cause of precocious+ [# p4 ~0 D6 V$ V) ^9 U) y
puberty in boys.3,47 s1 y9 K. ?: R
The most common form of congenital adrenal+ Y& `  g! Z$ @' ~5 u
hyperplasia is the 21-hydroxylase enzyme deficiency.9 j% z6 s8 l8 _1 g
The 11-β hydroxylase deficiency may also result in
% M' V# r, ^7 T) d0 [excessive adrenal androgen production, and rarely,
2 i) v+ X# J4 D: C$ V$ I+ ]- Zan adrenal tumor may also cause adrenal androgen
$ g8 r# O4 W, I, E! z3 c" xexcess.1,32 f# h- E& Z. S& m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 m# z8 \: v& H" Q( u7 ^, }
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 N1 d( c  f- T5 p6 o
A unique entity of male-limited gonadotropin-
) _2 K2 q) w  H2 f1 \2 h7 iindependent precocious puberty, which is also known
! N5 G; z% [( b& B+ y7 \) P6 X3 Vas testotoxicosis, may cause precocious puberty at a
4 L' C  S$ r2 Kvery young age. The physical findings in these boys
. q- L5 L. N; k6 Mwith this disorder are full pubertal development,! C9 e$ O0 J; }1 a, e! H8 J
including bilateral testicular growth, similar to boys) f7 o  |9 k; j
with CPP. The gonadotropin levels in this disorder- Z+ r7 Z9 ]0 ~
are suppressed to prepubertal levels and do not show6 i+ C8 B& z3 l
pubertal response of gonadotropin after gonadotropin-
& ]- H& C! J& ~4 _$ S8 }releasing hormone stimulation. This is a sex-linked
6 `% e2 N0 z) N$ R$ C: t$ |" }# kautosomal dominant disorder that affects only+ m0 A, k' S1 u: T: _3 m2 i
males; therefore, other male members of the family
. o. G/ R. A: Fmay have similar precocious puberty.39 v( y4 h% s. u  T
In our patient, physical examination was incon-
3 u/ E. s% g: a( J+ @) q+ R% m1 @sistent with true precocious puberty since his testi-2 _, X. R3 {2 M
cles were prepubertal in size. However, testotoxicosis/ }3 s8 ~: b5 K5 x
was in the differential diagnosis because his father
* ?1 W, Q5 Z" ]5 U' x0 @) T4 l0 ^started puberty somewhat early, and occasionally,
& m/ t5 n+ X' J. l5 Y! Ltesticular enlargement is not that evident in the( F+ K* a4 N3 S% O) P; u4 G
beginning of this process.1 In the absence of a neg-; x* h$ `# n: M! }
ative initial history of androgen exposure, our+ y5 [2 V4 e* i/ E; b( `
biggest concern was virilizing adrenal hyperplasia,$ M+ E: C( `& \- E+ y+ |9 T  ?
either 21-hydroxylase deficiency or 11-β hydroxylase/ t! Y4 Y+ h: x# c" ~1 q
deficiency. Those diagnoses were excluded by find-3 z0 K! d. B- O. O8 Y+ H- N. @
ing the normal level of adrenal steroids.' x/ D# L' ~8 E! J
The diagnosis of exogenous androgens was strongly
$ ]2 v8 w! b" ^; S8 y+ Rsuspected in a follow-up visit after 4 months because
: e( f( v$ s; `" l5 B/ |7 pthe physical examination revealed the complete disap-
4 J/ Z. o: `. }6 {! p( p9 mpearance of pubic hair, normal growth velocity, and" x1 D# B8 g% A% B7 ]6 b1 l
decreased erections. The father admitted using a testos-
4 g9 v; W/ I% I1 S2 J0 bterone gel, which he concealed at first visit. He was+ ^( c6 ^/ I, O8 X* Z0 P
using it rather frequently, twice a day. The Physicians’
0 R* T1 K. @4 E% D2 M! a3 P+ Z  z% p5 wDesk Reference, or package insert of this product, gel or) b( U8 S+ f6 _& `
cream, cautions about dermal testosterone transfer to; n0 V/ W& o4 x/ b
unprotected females through direct skin exposure.
+ y0 m' \6 W& nSerum testosterone level was found to be 2 times the
' t* x* ^* B8 x/ c/ f1 Y4 `9 h( Mbaseline value in those females who were exposed to
0 j  q4 j' u% Jeven 15 minutes of direct skin contact with their male
6 l8 Q. Z) J( Q* kpartners.6 However, when a shirt covered the applica-
: |& t4 P2 t! r3 B9 Ation site, this testosterone transfer was prevented.) I$ u  ]% ~9 _/ H
Our patient’s testosterone level was 60 ng/mL,
' w  D, k6 B1 ~3 Pwhich was clearly high. Some studies suggest that9 G, z6 N- m0 t/ ]1 F5 e; [
dermal conversion of testosterone to dihydrotestos-
8 M  r# P" B3 H/ q1 r6 Zterone, which is a more potent metabolite, is more, T( C1 I$ |% F% o6 j
active in young children exposed to testosterone, l( k% _: C/ d) y" Q8 a; L3 e! f2 e- F
exogenously7; however, we did not measure a dihy-
% S1 u2 g. Y+ Z# x0 ldrotestosterone level in our patient. In addition to2 Y# L2 z( K  i% \
virilization, exposure to exogenous testosterone in
0 ]# J5 i& y3 Q5 [, }6 Dchildren results in an increase in growth velocity and4 l. ]9 {- R7 h7 _, G4 Q3 C
advanced bone age, as seen in our patient./ [, T0 y3 H3 }+ z/ H0 z) e& T9 k
The long-term effect of androgen exposure during
+ X# a' A) T- d+ w) V! c2 nearly childhood on pubertal development and final5 d, ]4 s- {4 r9 z
adult height are not fully known and always remain8 a4 I4 e* P9 {
a concern. Children treated with short-term testos-- O1 R. T7 `/ S+ a
terone injection or topical androgen may exhibit some
, @& }6 \) U8 S  facceleration of the skeletal maturation; however, after
3 ^0 W: P# }. S% m0 rcessation of treatment, the rate of bone maturation
  e4 F: i' A8 P+ p. g  gdecelerates and gradually returns to normal.8,9
: u7 [  Q5 w% D1 z. z& `There are conflicting reports and controversy
7 A2 v8 X7 L# v! `6 Zover the effect of early androgen exposure on adult1 n( D+ S. Q5 s, w; z  `
penile length.10,11 Some reports suggest subnormal& n. k( w) n* r9 w( n1 x/ u
adult penile length, apparently because of downreg-; Y' a# t; n# K% v" W8 z4 V: w4 q7 ~
ulation of androgen receptor number.10,12 However,8 g1 Y; q" k; B0 Q, ?% w2 _
Sutherland et al13 did not find a correlation between: L7 E4 o; e( _8 w1 S/ H
childhood testosterone exposure and reduced adult/ w7 ]; i8 x* W5 G( g
penile length in clinical studies.7 {! j) L8 r/ @' O' e4 [2 w
Nonetheless, we do not believe our patient is3 G) s, T4 V- L5 I: c4 K
going to experience any of the untoward effects from
9 t* M% B/ f% L" D! Ctestosterone exposure as mentioned earlier because
1 R- e- |( Q  j: B# Athe exposure was not for a prolonged period of time.* L+ ~- e, Z* D9 \6 v- @
Although the bone age was advanced at the time of
& ]& _6 q! \" ]! Q- q% y6 ndiagnosis, the child had a normal growth velocity at
0 S5 N9 i! H0 F: ?0 |) q9 R2 Z; C( h5 Wthe follow-up visit. It is hoped that his final adult
% [! r5 W0 ]5 @  yheight will not be affected.
( F) ^2 S/ `3 g# b$ O0 `Although rarely reported, the widespread avail-1 K' z5 ?, K$ n% S
ability of androgen products in our society may$ B1 s: j+ i3 v; |2 E3 G; s& D4 A& F2 z/ ~
indeed cause more virilization in male or female
0 ]3 g- A) X, ?' H. rchildren than one would realize. Exposure to andro-' ?* D; @& }: W/ a
gen products must be considered and specific ques-' O$ S2 M7 q% g  C' M" e3 m
tioning about the use of a testosterone product or0 w% y  _, O0 H: K
gel should be asked of the family members during5 I8 _! ?: W4 M  D$ {7 a
the evaluation of any children who present with vir-" l, A& h5 Y; _5 g0 w
ilization or peripheral precocious puberty. The diag-
: E8 ^0 H8 t; p5 gnosis can be established by just a few tests and by
, G4 C/ Q, u" [! @2 Y) L0 {4 sappropriate history. The inability to obtain such a
1 Q- Y: z6 n" C' Y! m7 U+ _2 U. ?- uhistory, or failure to ask the specific questions, may
/ k9 i0 V& g2 o2 r. I2 Uresult in extensive, unnecessary, and expensive
6 t: G: e$ F& C. Pinvestigation. The primary care physician should be5 s# y* }7 X7 |. c/ Q2 S- K
aware of this fact, because most of these children
3 @: _% a7 n8 }2 f$ P9 b( _may initially present in their practice. The Physicians’: f/ E: w" _. `$ @& |/ S
Desk Reference and package insert should also put a3 v  M7 Z( {$ C) ^
warning about the virilizing effect on a male or
& G) N0 n0 s- Dfemale child who might come in contact with some-* Q- J& q- d* p$ H/ u2 Y
one using any of these products.2 V) Q; a, f* r' L1 l3 J( p  h
References  B* Z- E# ?. e; e/ q$ r6 k
1. Styne DM. The testes: disorder of sexual differentiation
2 t, o9 V) Z& g; }4 fand puberty in the male. In: Sperling MA, ed. Pediatric1 @, G7 g+ i& j9 s& e# G2 q% a$ F. i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 z  G4 a5 R& x1 Q$ l$ q2002: 565-628.0 `3 r1 o( k/ u! w
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: G2 W0 l1 ]( i. v- e5 Y; A5 W
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
+ t1 U3 K% S! ?/ A4 y. J4 YBoy Induced by Indirect Topical
, v$ w$ o7 t  D, y" W3 eExposure to Testosterone
  M9 f& G  a1 V& M, L' vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: k( ~; E* l- E8 G- B: ^and Kenneth R. Rettig, MD1
; ^' r4 X0 J( u6 JClinical Pediatrics
+ L2 G% s( z9 x# y2 T9 X0 fVolume 46 Number 6, ~4 s# a' s0 n: u  R& v
July 2007 540-543
' p) s* d# X$ B1 ~. E© 2007 Sage Publications' G4 p1 U+ x) H1 m) I" j
10.1177/0009922806296651. u( ^5 F6 W$ n* Q1 Y( u1 b. @
http://clp.sagepub.com& L9 V* O$ Y1 s: [' s' K
hosted at4 p: E# D; ?# \* h
http://online.sagepub.com
0 O: q. r4 z  x  {/ \3 l  R4 n5 ?2 _Precocious puberty in boys, central or peripheral,9 l  v" j) p9 D
is a significant concern for physicians. Central) [) X# p5 H0 F2 m3 u
precocious puberty (CPP), which is mediated
% H, E4 }+ A2 ^  d  d) q4 [through the hypothalamic pituitary gonadal axis, has- Y" Q* E  C' U5 W5 d' W$ H, a8 T
a higher incidence of organic central nervous system: m( ~' A5 F, s! z( {- k7 I2 d  K
lesions in boys.1,2 Virilization in boys, as manifested
4 w$ y. J5 W; [. d% Aby enlargement of the penis, development of pubic$ u3 o2 T9 k+ o' M) O/ C9 L/ S
hair, and facial acne without enlargement of testi-
$ b& ]. c% ]2 O) w- mcles, suggests peripheral or pseudopuberty.1-3 We/ q1 Q. ]9 i8 U' h* M4 k$ ]/ X
report a 16-month-old boy who presented with the' k1 Y8 ?$ t. B" `& t
enlargement of the phallus and pubic hair develop-
4 i% u9 J: S/ Y7 b. Z% G% z3 t8 Iment without testicular enlargement, which was due
4 Y: [% f# g4 I" u/ m  Uto the unintentional exposure to androgen gel used by
: b6 |, a/ k" Cthe father. The family initially concealed this infor-
5 ]* ]% [' s7 kmation, resulting in an extensive work-up for this) Q, X9 P9 b6 e5 X) [- ^
child. Given the widespread and easy availability of% R1 ?; A* b, M, f- _  J" q
testosterone gel and cream, we believe this is proba-
  V8 L" z, i3 dbly more common than the rare case report in the3 u$ h; R8 P4 V) X( ~
literature.4
/ d$ O' u% m- T' H% EPatient Report+ V# V, f" B& U& R% U/ D; @
A 16-month-old white child was referred to the
& n/ l5 a& N6 @6 P% dendocrine clinic by his pediatrician with the concern
3 T" K) F2 a# c* Oof early sexual development. His mother noticed
' F* X$ `  U  Y9 V. K8 _light colored pubic hair development when he was7 K) }5 T/ L. W" C9 ?: Q
From the 1Division of Pediatric Endocrinology, 2University of
0 v& D) v; X) y" R' V. \( x' GSouth Alabama Medical Center, Mobile, Alabama.
% {. W# t* l& b; I8 RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; u# [2 L- c3 x2 j9 kProfessor of Pediatrics, University of South Alabama, College of4 _, W2 q0 C8 w, f; V# @  G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( Z8 S, [5 C" l9 r! Me-mail: [email protected].
. a; ]' I9 v3 K  m( Rabout 6 to 7 months old, which progressively became0 I& g, M' t  l% W2 P
darker. She was also concerned about the enlarge-' G6 u) @4 V3 ~! c6 U$ z' S  v
ment of his penis and frequent erections. The child
7 ?" r9 C3 p3 I  I2 W- Vwas the product of a full-term normal delivery, with
/ G  c* ^" C# T- y, }  l+ V5 ga birth weight of 7 lb 14 oz, and birth length of7 e2 w+ }! U9 L% B1 u; L
20 inches. He was breast-fed throughout the first year; A) W: [; R7 I# ~# o0 r8 |
of life and was still receiving breast milk along with2 Z! w; O3 Q$ o, A
solid food. He had no hospitalizations or surgery,
" y$ v& P7 P  r# h# Land his psychosocial and psychomotor development  m- p$ j1 ]  F0 T% B( s
was age appropriate.
. J% O" r- M( J3 W% r8 vThe family history was remarkable for the father,
0 A- B$ T2 g9 P$ Mwho was diagnosed with hypothyroidism at age 16,
: b, ~. Z+ R2 u0 Rwhich was treated with thyroxine. The father’s& k- v. m) m, w0 @0 ~
height was 6 feet, and he went through a somewhat
0 N1 Z# k7 R& P1 K* i5 cearly puberty and had stopped growing by age 14.
8 ?( y# i5 e+ d  |% ~5 A( ?; AThe father denied taking any other medication. The
) G9 p& [, _+ y* M+ {& tchild’s mother was in good health. Her menarche. [+ O8 O9 v, Z9 `1 B5 X  v6 g
was at 11 years of age, and her height was at 5 feet+ P4 v, Y, t7 w& B
5 inches. There was no other family history of pre-
' L: q$ \1 B. l. j8 h6 A6 ?cocious sexual development in the first-degree rela-
* G. S$ k. E3 xtives. There were no siblings.
: L6 ]! t$ S+ d: F: R. r; h: \0 XPhysical Examination
* |1 s( a. V* {) ^& XThe physical examination revealed a very active,
# e% ~- e) j! p8 G8 y' J( Wplayful, and healthy boy. The vital signs documented1 p6 j, z7 k) y# ?  ^
a blood pressure of 85/50 mm Hg, his length was# `5 P; m/ l  i' p% I
90 cm (>97th percentile), and his weight was 14.4 kg7 A1 Y. h1 e& d6 i* O7 K. ?
(also >97th percentile). The observed yearly growth
* v' B' v2 k( `2 H0 Z  Hvelocity was 30 cm (12 inches). The examination of
9 Y$ W% y6 L1 e2 v9 ^/ l( L! K1 mthe neck revealed no thyroid enlargement.
# k  s1 W( V: a" `) M1 {+ BThe genitourinary examination was remarkable for
' l5 c7 y: ]1 r' cenlargement of the penis, with a stretched length of, V% s# {, g# a) u# n) x; K: [- N0 G
8 cm and a width of 2 cm. The glans penis was very well
( s' F3 L6 ^; S3 N+ P( ]3 qdeveloped. The pubic hair was Tanner II, mostly around" F  e7 T4 B) }: O7 Z
540
% O; L. r0 j" d) Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  P; @5 S( B/ _, m' S4 J' R: {the base of the phallus and was dark and curled. The9 H( R0 }; p! N7 `, E! ~( u: X
testicular volume was prepubertal at 2 mL each.  ^: r1 }6 P9 W# Q( V
The skin was moist and smooth and somewhat
9 t& D! @+ d# H$ ?/ t6 ]oily. No axillary hair was noted. There were no4 R% ?# v8 c7 H( j
abnormal skin pigmentations or café-au-lait spots.) C& e: e8 m6 G/ M8 G
Neurologic evaluation showed deep tendon reflex 2+
5 s0 o( m& h5 ?bilateral and symmetrical. There was no suggestion& }2 `9 S9 `2 z" j4 K
of papilledema.0 y% X8 z+ n! r% ^: S4 W, d
Laboratory Evaluation
9 F' F- r+ o$ d" s. J# xThe bone age was consistent with 28 months by/ `& H# k( t* f
using the standard of Greulich and Pyle at a chrono-" F' N3 t  k+ O3 G8 [9 L  Q: P
logic age of 16 months (advanced).5 Chromosomal: F  \% D- Q8 A: N* ]
karyotype was 46XY. The thyroid function test
/ o! M  X& u' ~' Q; J+ B1 C0 @- _( v. F3 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. `' ~+ q5 a; k' R( ulating hormone level was 1.3 µIU/mL (both normal).! H. g! U) o: m2 q. b- L) f
The concentrations of serum electrolytes, blood
6 g7 a$ [5 [8 _0 Q! A* Z& {- ]urea nitrogen, creatinine, and calcium all were; f- K5 F  j) _9 W5 \; [7 m
within normal range for his age. The concentration
& R. p2 z5 F% I9 Hof serum 17-hydroxyprogesterone was 16 ng/dL  N) ^& E# F1 E/ t7 ]* j% {& u, _) r% |
(normal, 3 to 90 ng/dL), androstenedione was 20
# T) k1 I/ R7 T9 y. A# {( Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# ]5 _6 E9 w/ p- t, U/ mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: G8 Q+ `& W/ pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 |/ {/ c3 c6 ?1 ]" l5 Y; n8 x# k( n
49ng/dL), 11-desoxycortisol (specific compound S)# [, j5 p2 S$ t+ D5 V/ I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 t5 Q. {- E* c" @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 X, f: ~6 [% P8 o: `# Z2 q' r8 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 w9 z5 j: @0 m& ]# Zand β-human chorionic gonadotropin was less than6 j$ I! @" _, L$ h/ P, ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 s! F* U7 ~5 v# ]
stimulating hormone and leuteinizing hormone
9 I; ?6 ]) i) N5 `concentrations were less than 0.05 mIU/mL1 u9 |: Q. S# m. {$ {4 f( K, c
(prepubertal).  g% j  Z9 D$ n) K* |3 K6 y
The parents were notified about the laboratory
% K# q) @1 a: zresults and were informed that all of the tests were
, {  E, u# `. l* K* @) hnormal except the testosterone level was high. The
# v( m" l3 j( p8 {0 s. Pfollow-up visit was arranged within a few weeks to2 D0 _' O) y7 Z  g. N- j/ k
obtain testicular and abdominal sonograms; how-% m# O0 K3 A1 x/ [( f
ever, the family did not return for 4 months.
- l* |7 m; h/ Q. kPhysical examination at this time revealed that the* b3 o# C4 a; _& C3 A6 H( W( ?
child had grown 2.5 cm in 4 months and had gained
5 w' ^8 Y/ N: e) E, `2 kg of weight. Physical examination remained( |  K0 e5 h' t
unchanged. Surprisingly, the pubic hair almost com-
. T# Y  K4 ?5 C, x# l) B6 jpletely disappeared except for a few vellous hairs at# M5 N# Z' W* b) L  g
the base of the phallus. Testicular volume was still 2
: }! }5 K3 ]& T" e# G# A, t! `& KmL, and the size of the penis remained unchanged.
4 s* ^$ E: O; i# o9 G. [7 BThe mother also said that the boy was no longer hav-5 u6 C; H& H3 w' ~2 \6 m
ing frequent erections.
+ s4 F5 }/ Y4 |  f* @- I. {Both parents were again questioned about use of
4 S9 d( o. a$ \4 m- I! Nany ointment/creams that they may have applied to
4 @& ?4 r* H# o( \9 A" q0 ?the child’s skin. This time the father admitted the
' F! C% q; W  p% f4 gTopical Testosterone Exposure / Bhowmick et al 541
4 D' D, W5 K" z  }5 z" n4 R8 Puse of testosterone gel twice daily that he was apply-
1 S* ^: a. h  R3 \: K) ^$ King over his own shoulders, chest, and back area for! I# E! i& u1 _" `5 g
a year. The father also revealed he was embarrassed
. |8 z" A; M" M: T& M' e" Tto disclose that he was using a testosterone gel pre-
5 r+ J5 U8 N7 K, O: m) jscribed by his family physician for decreased libido
2 b1 g4 B8 Z6 G2 ]secondary to depression.
/ w1 r) s2 F: `: c+ W6 Y2 |9 YThe child slept in the same bed with parents.
4 \- d0 ~3 m' MThe father would hug the baby and hold him on his
$ }6 v( T' i" X+ ^; lchest for a considerable period of time, causing sig-" ^4 k) ?; d) X; ?+ s. l, x# B
nificant bare skin contact between baby and father.
1 Z8 X- k  A( O/ d1 l/ g' kThe father also admitted that after the phone call,( H" x  m: V4 ^1 J# {' J
when he learned the testosterone level in the baby+ ~) x; `  }# h# S: L/ Y
was high, he then read the product information  m" e# y, U" A3 a5 j
packet and concluded that it was most likely the rea-* Z. E2 `- d0 Z
son for the child’s virilization. At that time, they
+ j6 w, o! t* gdecided to put the baby in a separate bed, and the* \% h9 l& I) v+ q, W
father was not hugging him with bare skin and had
% o' o& Q7 v7 ]$ `been using protective clothing. A repeat testosterone/ w% N5 `) X" @/ i$ \( X, k
test was ordered, but the family did not go to the! s+ D8 h; f7 D8 i% F, f: H& B- }
laboratory to obtain the test.* Y) s' e, ?6 B1 Y1 R3 R( {
Discussion
& A( e( T! \3 ~4 YPrecocious puberty in boys is defined as secondary
& v6 a5 ?; o9 Q& k! }sexual development before 9 years of age.1,4$ K9 u; R! f- v$ M' F( M+ E  r( y& ^
Precocious puberty is termed as central (true) when
6 b* K, @+ m& W0 f  W0 \it is caused by the premature activation of hypo-! H- l9 j- S, o2 p- S! z
thalamic pituitary gonadal axis. CPP is more com-# L, V& M* x9 `' W- }
mon in girls than in boys.1,3 Most boys with CPP
& l' c( B. Q+ o/ `2 Q6 m+ Pmay have a central nervous system lesion that is
6 b0 s) B" k& l' d' @responsible for the early activation of the hypothal-6 ]9 H' `- {" w: g0 g( _
amic pituitary gonadal axis.1-3 Thus, greater empha-: |+ @2 X3 V7 \( {$ H/ {
sis has been given to neuroradiologic imaging in
* q/ W/ U, A6 Qboys with precocious puberty. In addition to viril-0 m% H7 H2 S* l- l
ization, the clinical hallmark of CPP is the symmet-
5 t' s5 k* x7 x7 L4 g* v6 rrical testicular growth secondary to stimulation by
% r  T- G8 s2 u3 ^gonadotropins.1,3
( a: D" Q  g3 w+ V9 gGonadotropin-independent peripheral preco-
/ R8 j  \2 n5 k) tcious puberty in boys also results from inappropriate
8 d9 g- ]. D0 b, \* c* z) candrogenic stimulation from either endogenous or3 Z5 `8 ]9 d, L
exogenous sources, nonpituitary gonadotropin stim-5 q5 |2 ^# o2 W+ _* i
ulation, and rare activating mutations.3 Virilizing& R9 O* O9 \! V
congenital adrenal hyperplasia producing excessive
: ~9 T: W3 U  c' x  N- y& Eadrenal androgens is a common cause of precocious
1 ^3 S5 ~3 X/ epuberty in boys.3,42 j  p/ j. L* P
The most common form of congenital adrenal) U7 a) \) k% ~& Y# I$ }$ P
hyperplasia is the 21-hydroxylase enzyme deficiency.
) a, Y5 l- B$ q3 [The 11-β hydroxylase deficiency may also result in
3 \6 @/ K5 L4 sexcessive adrenal androgen production, and rarely,$ r6 D2 U( f  A: o. {- Z' D! X1 g
an adrenal tumor may also cause adrenal androgen
$ b- {- `* C9 p: [+ xexcess.1,3$ e; m$ V! d2 s2 @% ^5 @; G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* l6 s2 o! R* |1 d* b" h542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 ~! ]+ m* ~& r3 G' E) aA unique entity of male-limited gonadotropin-
- c2 ~- v4 d* n. w1 oindependent precocious puberty, which is also known; k" y/ Q6 c9 X. u: m
as testotoxicosis, may cause precocious puberty at a  V/ ^; S$ D' b0 e# K. a7 s
very young age. The physical findings in these boys
: I, y7 G: H7 i2 a# `8 lwith this disorder are full pubertal development,
# j+ S: A: p1 N9 n3 iincluding bilateral testicular growth, similar to boys4 h' S& y) E) v* ]; p2 |! Y
with CPP. The gonadotropin levels in this disorder' X  j" B. q% v
are suppressed to prepubertal levels and do not show; r* Q$ X4 N! N8 G& w3 \
pubertal response of gonadotropin after gonadotropin-
5 ~. F. ^& n' W% \, S  p/ D) r/ Hreleasing hormone stimulation. This is a sex-linked
5 j0 ?0 _% u. O4 A+ Rautosomal dominant disorder that affects only; T. ^# D) y5 j
males; therefore, other male members of the family
0 [2 ~1 Z* g, A" d& X1 t. kmay have similar precocious puberty.36 y, G( W7 L) n* A2 g
In our patient, physical examination was incon-" N! H) u& B( o  ^, U6 `& U
sistent with true precocious puberty since his testi-
, R. s$ x! \& ~& L6 Y. R- qcles were prepubertal in size. However, testotoxicosis
3 ?6 C7 S/ \, B4 Nwas in the differential diagnosis because his father/ M0 \& b8 S9 b7 k0 m0 v
started puberty somewhat early, and occasionally,
! c( v/ M6 n; G2 I) p& x. V* Utesticular enlargement is not that evident in the
2 S3 s! L5 `* m; Z6 W- l; obeginning of this process.1 In the absence of a neg-
0 N" I6 w0 s- q4 a, V% gative initial history of androgen exposure, our
) Z* w. w2 h# q" cbiggest concern was virilizing adrenal hyperplasia,) y, T' [: H# i, Y  Z
either 21-hydroxylase deficiency or 11-β hydroxylase2 x3 `  R  s0 P+ T9 L
deficiency. Those diagnoses were excluded by find-
" ?' h# P) ~" L! I* o& }% @ing the normal level of adrenal steroids.
, s* _0 A7 C: `  [) ?! qThe diagnosis of exogenous androgens was strongly' e! W# R5 Z1 A' \' b4 J
suspected in a follow-up visit after 4 months because
0 n* f, V" J' J; {; B$ x8 lthe physical examination revealed the complete disap-7 w' n0 `. A$ W% k5 z% k2 a3 P
pearance of pubic hair, normal growth velocity, and2 X% E# \3 g% U; T8 y, K
decreased erections. The father admitted using a testos-0 Q# ?1 P+ x: s, ^8 J5 M5 Q/ [
terone gel, which he concealed at first visit. He was
2 _: R, {- W. \6 D! c# j5 Yusing it rather frequently, twice a day. The Physicians’# C" [: O7 n' p/ c9 H* B
Desk Reference, or package insert of this product, gel or  u, ?: n; R; X4 X
cream, cautions about dermal testosterone transfer to# b. w6 K3 j: a) m$ H
unprotected females through direct skin exposure.9 [6 L0 l  m, }: ~
Serum testosterone level was found to be 2 times the
1 z# h# m& @0 h. P1 A8 b1 w$ k3 Obaseline value in those females who were exposed to
: E$ s& L5 l* geven 15 minutes of direct skin contact with their male
' G. R' P- Q; Mpartners.6 However, when a shirt covered the applica-! D: ~; B9 Y% ?: u0 {
tion site, this testosterone transfer was prevented.) M5 l( C. f6 d2 u; T6 G1 u
Our patient’s testosterone level was 60 ng/mL,
& q2 _: n( Y* c) J+ {  xwhich was clearly high. Some studies suggest that
2 X& ~. E; {0 p( X6 Ddermal conversion of testosterone to dihydrotestos-7 a( P+ Q1 H! j: L
terone, which is a more potent metabolite, is more
7 P, S% D! ]6 M9 T! Sactive in young children exposed to testosterone% P4 h6 _2 v- J1 O
exogenously7; however, we did not measure a dihy-
$ n& |- D5 I( [; ]* udrotestosterone level in our patient. In addition to( f" M9 [, N4 I3 e
virilization, exposure to exogenous testosterone in) q7 R' P0 m* ?5 @; {3 x5 |
children results in an increase in growth velocity and, d- p9 W6 g7 N  G6 N+ S; y
advanced bone age, as seen in our patient.
: F4 m3 A+ k4 m5 _" E' B6 ^' jThe long-term effect of androgen exposure during* z  `* k; [' L* U' X& Q8 V% ^
early childhood on pubertal development and final
+ K4 y$ ^- O* O8 l% d, Dadult height are not fully known and always remain
) w& m5 m5 N" Q# Q2 J6 q2 Z  G9 L5 oa concern. Children treated with short-term testos-6 _" K3 o" D7 r9 X4 m  s9 |
terone injection or topical androgen may exhibit some  E: K3 J! h2 [
acceleration of the skeletal maturation; however, after
0 P6 n' s5 g0 Hcessation of treatment, the rate of bone maturation) _; M$ L6 V0 D% ?2 X# Q
decelerates and gradually returns to normal.8,9: i9 L9 A. Q7 v  W
There are conflicting reports and controversy
! B# O7 n$ z- G1 x* p2 C% v9 xover the effect of early androgen exposure on adult/ f  y8 Q% o6 ^, Y
penile length.10,11 Some reports suggest subnormal
- n" w% c( i( V& X3 x7 Fadult penile length, apparently because of downreg-
# e& l+ A+ l$ p1 x3 p- s  B5 aulation of androgen receptor number.10,12 However,
( n' u3 ~5 o, j4 zSutherland et al13 did not find a correlation between4 h$ m1 s0 y1 W5 n. V
childhood testosterone exposure and reduced adult  U# O4 v) |. v* G6 U$ R
penile length in clinical studies.
, B: _+ E  h- X6 l0 `Nonetheless, we do not believe our patient is
0 P) i9 d/ S* @( k) D' @going to experience any of the untoward effects from$ \, A$ w! ~* P* D/ _' b) Q
testosterone exposure as mentioned earlier because
; w6 E& P* K6 g0 O# _the exposure was not for a prolonged period of time./ s  Z" O. J: T/ ]  t4 j9 I( N
Although the bone age was advanced at the time of
7 \% W; D. x& K  M) N* Cdiagnosis, the child had a normal growth velocity at
6 }  e9 z9 }  `* Othe follow-up visit. It is hoped that his final adult  P% N  m+ u1 d4 O, D
height will not be affected.9 o% u  _) f  v4 P( i( `: Y
Although rarely reported, the widespread avail-
6 n) R% A2 Q- e/ I& vability of androgen products in our society may0 S- \) k4 \# ?# \; z1 `* z) _) U
indeed cause more virilization in male or female2 G7 D  R7 s) m0 \5 Y; C
children than one would realize. Exposure to andro-5 F2 n" `. v5 H
gen products must be considered and specific ques-! V8 }; @1 |6 G$ ~8 k2 x! P
tioning about the use of a testosterone product or" a; C& S5 l, ~# N
gel should be asked of the family members during2 F" D1 @# z9 a( F, @
the evaluation of any children who present with vir-. w) P+ c4 r+ \2 A5 N+ ?
ilization or peripheral precocious puberty. The diag-
) z  ^" v- f. p3 ?& r1 Nnosis can be established by just a few tests and by
6 {$ E  ^& ], {- rappropriate history. The inability to obtain such a
6 @, Z. B: B. yhistory, or failure to ask the specific questions, may
  y* D" Y" ?; r$ m( {! J4 lresult in extensive, unnecessary, and expensive2 z: ^3 Q! T, C9 A3 v
investigation. The primary care physician should be
. l2 L5 e: c6 M, Gaware of this fact, because most of these children
% z! I( U: u) m- fmay initially present in their practice. The Physicians’
' I% q. a5 V3 v# w/ W$ M4 o3 jDesk Reference and package insert should also put a
" n: |" x: M2 Y: V5 Twarning about the virilizing effect on a male or
$ C0 X* P$ ~3 ofemale child who might come in contact with some-2 @' I9 S: b3 }& v% v
one using any of these products." L% j+ o9 N$ z! g. p
References
4 Z8 J0 X9 f# j4 w+ `; c1. Styne DM. The testes: disorder of sexual differentiation) w) d* A$ S  R  K; R) j/ d6 I* e
and puberty in the male. In: Sperling MA, ed. Pediatric
9 }7 P9 e% ~1 n% t3 J0 {0 e" lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 `4 k! a4 g% ^: i/ w' m2002: 565-628.! R4 g+ D" \/ j  T4 r4 _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# V5 D6 P/ f* T  i
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

  ~( s0 y* }+ o1 h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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