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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
/ W/ o- k8 @3 P/ w; h% H; i0 [; rBoy Induced by Indirect Topical% u( n( y5 ]& w3 h& }. H& n
Exposure to Testosterone! D- W0 u( @0 }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) p# Y2 ~2 i& Band Kenneth R. Rettig, MD1
4 s  b3 U6 m4 P: }) d. j; W9 h+ {Clinical Pediatrics" Z# C$ c$ S4 w" s4 D) |, l3 L
Volume 46 Number 6
( e7 X7 K3 L$ P2 pJuly 2007 540-543
2 h# h+ ~1 H0 E; t  e© 2007 Sage Publications  V, N3 x8 G/ Z2 o! e* G+ N
10.1177/0009922806296651
0 w4 x! X# {3 \- `. Ahttp://clp.sagepub.com' q! |& P0 {. F2 o) a
hosted at, q# i4 b  ?( m+ x# Z' ]5 w0 @
http://online.sagepub.com
7 V& c% A3 `3 i# N& P' T, OPrecocious puberty in boys, central or peripheral,
! n9 r' ^  {$ D  ]; u1 nis a significant concern for physicians. Central
+ F0 G7 C+ y5 `2 b2 t+ Qprecocious puberty (CPP), which is mediated
% s1 [9 G6 x8 X0 e: Z- d' cthrough the hypothalamic pituitary gonadal axis, has
) x2 F, ]: ^" D7 |a higher incidence of organic central nervous system5 @4 ], p4 ^5 P' N, Z
lesions in boys.1,2 Virilization in boys, as manifested% R! V7 e: F' H/ P( `* p" V0 t& F2 v! U
by enlargement of the penis, development of pubic" F6 S, Q) L) [) `6 B2 w
hair, and facial acne without enlargement of testi-- x9 A2 n3 s4 r* P/ J& J' ]
cles, suggests peripheral or pseudopuberty.1-3 We7 _7 J4 Y' h- c
report a 16-month-old boy who presented with the$ h8 e6 c1 f4 @
enlargement of the phallus and pubic hair develop-( g/ |) X% R# }8 x# l  N* b4 c' B
ment without testicular enlargement, which was due
- q! H" j1 ?( xto the unintentional exposure to androgen gel used by
1 f, ^4 }* J# Y5 C, d- zthe father. The family initially concealed this infor-
* [" w' P% ?" |4 Amation, resulting in an extensive work-up for this- {# p+ h3 `" T) G  a1 O3 n
child. Given the widespread and easy availability of; u% D, H- H; i) z
testosterone gel and cream, we believe this is proba-
4 M( W: h, N% `2 r) k, h- r8 xbly more common than the rare case report in the
# f2 e) @% [) T5 p' |literature.44 ]4 Z. b( B" S/ g
Patient Report
( b: n# Y: X" R  L1 @A 16-month-old white child was referred to the
8 j1 [' C# q' X8 ]- p8 A: L: Uendocrine clinic by his pediatrician with the concern$ a" y+ D& O4 i; D2 H
of early sexual development. His mother noticed
) {% `. [4 y$ }0 Y0 Q" Elight colored pubic hair development when he was
/ H! b# G+ P. g! \From the 1Division of Pediatric Endocrinology, 2University of
6 ?% ]2 h# P7 S3 WSouth Alabama Medical Center, Mobile, Alabama.
' o( h, m9 V5 g3 l5 T: @$ KAddress correspondence to: Samar K. Bhowmick, MD, FACE,
3 h6 Y( ~8 z, E5 F# y! O0 bProfessor of Pediatrics, University of South Alabama, College of6 V3 o2 L/ M3 T# J. f2 `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 X6 ?; v# Z- Qe-mail: [email protected].' F3 W2 X  {) i. F2 _& E+ v
about 6 to 7 months old, which progressively became
2 M5 f' |" ~; r' Ndarker. She was also concerned about the enlarge-, L: n4 P8 h6 `  z
ment of his penis and frequent erections. The child
" J* J: V; ?& K/ \: |& Lwas the product of a full-term normal delivery, with, \9 F4 A* K$ M
a birth weight of 7 lb 14 oz, and birth length of
) l# r) y0 \' [$ O20 inches. He was breast-fed throughout the first year0 q; i% S% ^% a: |
of life and was still receiving breast milk along with& I9 c& J8 Z/ Z3 E8 Q
solid food. He had no hospitalizations or surgery,' N5 x: B( B: K; o% ^7 j
and his psychosocial and psychomotor development
  C# Y; U3 i. Bwas age appropriate.( l# A! v4 P% U
The family history was remarkable for the father,( Q! s# `3 s, i9 ]
who was diagnosed with hypothyroidism at age 16,
) q% E% i4 `' a8 |, twhich was treated with thyroxine. The father’s
8 k: L; }* m$ U( }  ]" ~: Hheight was 6 feet, and he went through a somewhat8 B, A7 q9 S4 r; {5 }  A
early puberty and had stopped growing by age 14.
7 K* G3 ^* e! V9 j  n# w& }5 A: A, rThe father denied taking any other medication. The
6 }1 b" B' p% H0 F  f0 pchild’s mother was in good health. Her menarche' K$ b5 |" W7 I9 }6 _
was at 11 years of age, and her height was at 5 feet: G0 S9 j7 k# P0 b/ A
5 inches. There was no other family history of pre-
8 r4 Z! @3 K. h. T0 e  G; |) ycocious sexual development in the first-degree rela-
  Y) T; J* @9 Xtives. There were no siblings.) \' R8 c( w; b+ B
Physical Examination$ X- F& u9 a% o# E5 A: w
The physical examination revealed a very active,
( G4 C6 l9 O* A: Y8 r. K, J* Tplayful, and healthy boy. The vital signs documented0 D9 J6 A7 e/ v7 P7 t
a blood pressure of 85/50 mm Hg, his length was
( \" h7 U( z; h90 cm (>97th percentile), and his weight was 14.4 kg
( g! Q, d) a, b4 o(also >97th percentile). The observed yearly growth
. t! ^% w) D7 _/ Fvelocity was 30 cm (12 inches). The examination of
. f( s) |; V  K" E" M  kthe neck revealed no thyroid enlargement.
3 K% W9 l/ o' |' M% {' z& N0 LThe genitourinary examination was remarkable for
( n' J6 }6 z2 y5 H8 n3 Z6 [enlargement of the penis, with a stretched length of8 H! j# O) S7 L6 a
8 cm and a width of 2 cm. The glans penis was very well+ s' t; d! A: I8 S1 ?
developed. The pubic hair was Tanner II, mostly around
" c+ S+ B, Y4 z: k; u) p540
2 y4 ?! m) _  f) I  |: nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  K9 b" Q; b% n; f  ^the base of the phallus and was dark and curled. The: L7 Z; n- R4 f; w8 B4 z, |& u
testicular volume was prepubertal at 2 mL each.  N6 |  G; J  f
The skin was moist and smooth and somewhat
7 i6 c9 _' h  Q$ X6 V( }) aoily. No axillary hair was noted. There were no
* u/ o9 g7 c- H/ W: H3 ~abnormal skin pigmentations or café-au-lait spots.
+ S: v0 `9 o4 u5 X. U! p/ z. nNeurologic evaluation showed deep tendon reflex 2+
3 b  _9 h8 T# u" ]% K: fbilateral and symmetrical. There was no suggestion* a& C& V- X' p8 ^4 n# m3 z
of papilledema.
, E- L' B. @6 P: g1 T* ~Laboratory Evaluation0 R. N) p9 F+ A% A
The bone age was consistent with 28 months by
! [- z, i. Y; Busing the standard of Greulich and Pyle at a chrono-- q' Z7 A& q9 n
logic age of 16 months (advanced).5 Chromosomal: V5 i  R0 V% t" R  t$ @. k0 p6 l/ p
karyotype was 46XY. The thyroid function test+ \9 h# |( g; G& D- F6 _% ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 E% w! h; {& S% a) flating hormone level was 1.3 µIU/mL (both normal).+ p' o' I4 o; O+ B
The concentrations of serum electrolytes, blood6 q4 Z9 @  h! w) ~9 \
urea nitrogen, creatinine, and calcium all were
/ V0 c9 {$ C, X# V1 _" Pwithin normal range for his age. The concentration5 G2 a/ {% V  L& C5 E9 u) {
of serum 17-hydroxyprogesterone was 16 ng/dL* q7 ^7 ~6 z7 U
(normal, 3 to 90 ng/dL), androstenedione was 20* j' ?" f. ]" O# }  m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ f# W+ H( a; g% R' p! jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 J9 p' o8 Y. i5 h7 wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 i2 P) I) g# {7 @* _- ?9 y
49ng/dL), 11-desoxycortisol (specific compound S)
  g% H0 a9 _3 h' C: p+ n3 c% Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 P5 r4 Z- ^/ u# D. T$ ]
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- a7 h6 ?7 c8 Btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 `8 r# e. z' G  M+ qand β-human chorionic gonadotropin was less than
' F, A: l% b& m' a) J5 mIU/mL (normal <5 mIU/mL). Serum follicular! _* W. ]* \9 k. z  t
stimulating hormone and leuteinizing hormone9 Q- I7 f& T3 u
concentrations were less than 0.05 mIU/mL! ?3 \/ R3 ^8 P5 M) D; b2 ^
(prepubertal).
( F* }3 W* H; p( `# O0 @The parents were notified about the laboratory
% i- h* W* R1 ]results and were informed that all of the tests were  r: Q: y8 s5 r) p8 a3 X
normal except the testosterone level was high. The# @" p5 g; a  B6 p# T: Q# S
follow-up visit was arranged within a few weeks to) }# I. K2 U4 m- |( k/ D
obtain testicular and abdominal sonograms; how-  A  ]0 D5 j& O
ever, the family did not return for 4 months.
" E: B& g0 s/ W, v; R8 K, i5 X4 ^  YPhysical examination at this time revealed that the
8 h  j" [9 c" M1 G! ]child had grown 2.5 cm in 4 months and had gained( l. F. @/ a5 H. u/ o! Q
2 kg of weight. Physical examination remained
$ _- v( q; h) F6 u/ ~8 ]' E1 ?% C3 qunchanged. Surprisingly, the pubic hair almost com-1 a/ x- c$ b4 G7 {+ k! P8 @( r% O
pletely disappeared except for a few vellous hairs at) U% [& B/ u& L- S% J# Q
the base of the phallus. Testicular volume was still 2
& C# V* I1 q5 {" K! SmL, and the size of the penis remained unchanged.9 q! P! x3 {/ `: g
The mother also said that the boy was no longer hav-
: z; o$ G3 m* Ting frequent erections.
  t3 R3 a) m; k: qBoth parents were again questioned about use of
4 P  c! p* F0 \4 F& E3 d6 `any ointment/creams that they may have applied to' a, e/ f7 A3 B3 T) d: y8 P3 t; H
the child’s skin. This time the father admitted the
* p9 ?2 D" F# q- o# {7 b; h9 XTopical Testosterone Exposure / Bhowmick et al 5417 q9 V: _1 t% o& \9 [: `% s& r
use of testosterone gel twice daily that he was apply-
( j1 Y  u* j( _5 \# E- ling over his own shoulders, chest, and back area for
8 B8 V* _5 Y: `: J' k; Q3 q: o% Xa year. The father also revealed he was embarrassed; O& _% h6 \) e2 Y
to disclose that he was using a testosterone gel pre-
2 |5 J! q5 z3 B2 z) X, b5 m7 \8 h/ W, rscribed by his family physician for decreased libido
; y- S( J& J, w4 ]0 psecondary to depression.0 P% S# n. \: L- ~
The child slept in the same bed with parents.& f& r+ W1 V2 ^0 T" k" [+ G- L
The father would hug the baby and hold him on his
; ?: `/ Y& l2 [: c, nchest for a considerable period of time, causing sig-
# }/ r4 f- o8 \nificant bare skin contact between baby and father.
" F1 }" Q. H) T; j: R1 W" ?The father also admitted that after the phone call,; f: s, z" j# u) @6 f
when he learned the testosterone level in the baby
3 d) e  u! }4 y. K, A7 Iwas high, he then read the product information
, X4 M/ E' ]* Q# }5 ?6 gpacket and concluded that it was most likely the rea-
; x5 q2 V7 i& W: U2 `son for the child’s virilization. At that time, they
: x$ F/ w+ g$ j* G4 L0 u9 bdecided to put the baby in a separate bed, and the
/ |1 p+ Z6 q) n7 N1 Nfather was not hugging him with bare skin and had
* i$ I" b- U) y" M+ a5 j7 C) }8 Abeen using protective clothing. A repeat testosterone
* T$ A  t' l; A; ?; \* y9 f2 wtest was ordered, but the family did not go to the
9 o: o% D" T. m1 L3 d1 V9 Plaboratory to obtain the test.1 @, d4 y) {. u9 i8 r
Discussion6 t+ E. w! _. ^% |4 I7 x
Precocious puberty in boys is defined as secondary
' K5 a# O/ W9 z0 h; \sexual development before 9 years of age.1,4$ |, ~- ~: U" C5 l" ?
Precocious puberty is termed as central (true) when
% x2 ^' k# ~. w& s" {0 X5 v3 Iit is caused by the premature activation of hypo-
! z; i% [7 I4 R; E9 p8 ~thalamic pituitary gonadal axis. CPP is more com-
4 e0 s" w4 Z, K6 A5 Imon in girls than in boys.1,3 Most boys with CPP+ |) _# [1 T  S& }4 c3 Y- d
may have a central nervous system lesion that is
3 s0 \; t& }% \2 V# q# u1 @responsible for the early activation of the hypothal-4 B3 G2 X9 p! f: X
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 N( \# L! M. Y( d% W! ksis has been given to neuroradiologic imaging in
5 Z( u- R" }; N% _6 t9 ~boys with precocious puberty. In addition to viril-
1 h% \3 k" q+ b7 h: Lization, the clinical hallmark of CPP is the symmet-3 D9 V6 J9 |; ?7 K  E9 B
rical testicular growth secondary to stimulation by8 {8 d" a$ s/ L. }& Z
gonadotropins.1,38 k2 i0 {3 N$ o
Gonadotropin-independent peripheral preco-
- l$ Z9 B( ~' X/ ^$ Y; G+ kcious puberty in boys also results from inappropriate4 Z$ y. v3 s7 J. ?2 T$ n
androgenic stimulation from either endogenous or5 V* |! _- ]# f9 Q  M( |- p. m
exogenous sources, nonpituitary gonadotropin stim-& X* y; X& s% c- m' A* I2 k
ulation, and rare activating mutations.3 Virilizing4 ^) W. K4 p1 Q) M
congenital adrenal hyperplasia producing excessive
7 b" k' ^4 A. ]; O; I" f: p6 Z8 fadrenal androgens is a common cause of precocious
- Q5 x7 ~$ c) k$ p7 Fpuberty in boys.3,4
$ a# P/ j, C8 x( SThe most common form of congenital adrenal* _4 n, {' r; H+ r
hyperplasia is the 21-hydroxylase enzyme deficiency.
; K$ t# r# Q2 ~The 11-β hydroxylase deficiency may also result in
& y8 n- t& L( E! |+ L; h( Hexcessive adrenal androgen production, and rarely,
: A* z; n( v6 qan adrenal tumor may also cause adrenal androgen
- K6 F; E; l1 l9 Uexcess.1,3
$ S2 j2 J4 W# ]3 @+ Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ _  {* j( L( B2 |  ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. n" t: n& R/ c7 {A unique entity of male-limited gonadotropin-. }+ N3 e4 [7 ~9 E( J2 F6 {
independent precocious puberty, which is also known
! }; d6 @6 c, a$ w  l3 W2 tas testotoxicosis, may cause precocious puberty at a
  p* z; X9 L1 P; Jvery young age. The physical findings in these boys
1 S3 T- H5 F7 E$ |with this disorder are full pubertal development,8 f4 G2 T$ R. g. n( C) `) B8 L
including bilateral testicular growth, similar to boys
5 n3 V8 Y4 }' P1 C/ z! f+ k* B" c: mwith CPP. The gonadotropin levels in this disorder
: c! I! D: ?- F" ~; p* Aare suppressed to prepubertal levels and do not show
! L$ P+ Y0 R" [2 B$ b8 tpubertal response of gonadotropin after gonadotropin-3 ^# e+ ^5 p8 F% N4 Z
releasing hormone stimulation. This is a sex-linked
% I1 V& a/ G# q7 z% Yautosomal dominant disorder that affects only' `) T, K6 Y/ p  m3 a8 H$ J6 a1 ]
males; therefore, other male members of the family
3 H* b' I: L* n2 _- }may have similar precocious puberty.37 u5 Q9 ]* Y1 p& O
In our patient, physical examination was incon-
% b1 @$ q  x# d* u3 a5 Fsistent with true precocious puberty since his testi-
2 k. j" l2 M4 S# O8 E! A: h( O- Y$ ocles were prepubertal in size. However, testotoxicosis; }* C/ ]& m/ Z! _+ k
was in the differential diagnosis because his father
6 C; D9 m) y( H3 Z- R$ x5 D* h& {started puberty somewhat early, and occasionally,& b9 K0 |( ~. }* o. r" o
testicular enlargement is not that evident in the# @$ \" Q6 n* ~. x& E% F5 I
beginning of this process.1 In the absence of a neg-3 t! ]! L- X6 W0 h
ative initial history of androgen exposure, our
; M0 s' G  B: X: W9 u# t& L+ ybiggest concern was virilizing adrenal hyperplasia,+ [5 p4 t9 w( a5 |, K! A0 P
either 21-hydroxylase deficiency or 11-β hydroxylase2 L; U: G  ^0 z
deficiency. Those diagnoses were excluded by find-1 @7 u- e) q& p0 g) |  x& `
ing the normal level of adrenal steroids.6 ^+ }. s: I& t: b& }
The diagnosis of exogenous androgens was strongly
! d' j' c/ v) e+ r& |suspected in a follow-up visit after 4 months because
, f' ]  @. ~% T/ ?- R6 j# Bthe physical examination revealed the complete disap-
# b$ c5 b! e7 g- ^; u4 }7 O2 s+ Ipearance of pubic hair, normal growth velocity, and
8 S/ v% T3 k& e. r; Fdecreased erections. The father admitted using a testos-7 ^2 s  Q% G3 W6 w8 T/ N
terone gel, which he concealed at first visit. He was# D+ D6 ^) v$ @" l) n4 d
using it rather frequently, twice a day. The Physicians’* c( k$ }- t! r# W% c: Z
Desk Reference, or package insert of this product, gel or
3 G; l0 ]0 ?. A" u5 s: c+ ^cream, cautions about dermal testosterone transfer to
- X1 Z" J6 I% q9 l/ S7 D3 sunprotected females through direct skin exposure.
5 ]3 r; N+ ^. r5 q: \Serum testosterone level was found to be 2 times the, H, G1 d  v6 Q5 E! f( j4 i
baseline value in those females who were exposed to
; L. w+ D; N. U: X0 t. |even 15 minutes of direct skin contact with their male; m/ g9 [5 u- U" ]/ [) L, X) P
partners.6 However, when a shirt covered the applica-
$ w7 x- P' ^6 a  etion site, this testosterone transfer was prevented.7 A! R' w! D8 v) o4 }9 k1 R6 W
Our patient’s testosterone level was 60 ng/mL,8 S% G6 \; u- f" g
which was clearly high. Some studies suggest that! n) y/ V5 A( @! @  h* B$ T
dermal conversion of testosterone to dihydrotestos-5 I0 o* x/ a6 w6 g
terone, which is a more potent metabolite, is more
$ J6 S1 L7 M/ f( O1 T, wactive in young children exposed to testosterone+ u+ U  T" v  H
exogenously7; however, we did not measure a dihy-
$ }, x" L  k6 g9 [/ {drotestosterone level in our patient. In addition to
- ^8 i8 F. C/ D' X7 v- |virilization, exposure to exogenous testosterone in- F( W! u& ]% [9 o; p% p
children results in an increase in growth velocity and
* {% r4 d/ o9 F! @advanced bone age, as seen in our patient.
) g- P# V6 {% G1 q0 y$ I  dThe long-term effect of androgen exposure during! Z. Z5 z; [  g/ }5 B, ]
early childhood on pubertal development and final
  R, J1 I; D, Wadult height are not fully known and always remain4 D7 s( T- ]. e* U
a concern. Children treated with short-term testos-9 u' l% P1 m* Q; o+ n
terone injection or topical androgen may exhibit some
2 g6 y9 U8 w8 M  a" g2 B5 hacceleration of the skeletal maturation; however, after
$ N. d5 N0 a9 h5 ~! j& xcessation of treatment, the rate of bone maturation" [0 Z, X1 A' I# t5 ?6 [
decelerates and gradually returns to normal.8,9  {8 Z0 ~# J0 n
There are conflicting reports and controversy  k- p8 _' y9 [0 g
over the effect of early androgen exposure on adult
$ O: G+ p6 L7 @& \  O2 Y. f. Upenile length.10,11 Some reports suggest subnormal
( M0 k& @, T8 ]5 l' D" dadult penile length, apparently because of downreg-
* Q' m4 i4 `# E, i$ `7 T$ m/ Fulation of androgen receptor number.10,12 However,
* |5 h4 R& F$ g. l* g* i/ d: ISutherland et al13 did not find a correlation between6 w) f: l0 [3 u' @
childhood testosterone exposure and reduced adult" N% X. W( e- T( Z
penile length in clinical studies.9 c5 A  N) P% p  R7 Z3 {) k
Nonetheless, we do not believe our patient is- f* [; T/ F; b
going to experience any of the untoward effects from
  a+ k: u$ k$ Y7 `" V4 [testosterone exposure as mentioned earlier because
+ ^/ {( }! D: A7 R$ R0 h* Gthe exposure was not for a prolonged period of time.
: {' r, }/ K2 F5 Y" \$ {Although the bone age was advanced at the time of
* \5 ~6 ?8 Q# F7 |: v/ ddiagnosis, the child had a normal growth velocity at" J3 a3 m0 t+ K* ^5 x
the follow-up visit. It is hoped that his final adult6 f; Y3 O6 q" e- [# n
height will not be affected.& |% i/ k  x# h) `
Although rarely reported, the widespread avail-
& \9 s( v$ o) o$ l+ Gability of androgen products in our society may, F1 c0 S2 m1 m7 x
indeed cause more virilization in male or female
; O# |( r) I: n1 k7 U" Lchildren than one would realize. Exposure to andro-1 a( k! b" ^! ?# n! I/ S& `
gen products must be considered and specific ques-2 H! A& U. I4 v; o  _
tioning about the use of a testosterone product or
; u! X+ W8 T% {! B; kgel should be asked of the family members during4 y7 k4 B7 \" ~* F
the evaluation of any children who present with vir-' ]  ^$ o+ n: w8 x/ [6 C
ilization or peripheral precocious puberty. The diag-. b- |& A( S8 i, ~. U
nosis can be established by just a few tests and by
. X+ q/ r- G' B+ b  j3 Rappropriate history. The inability to obtain such a
3 {8 V3 b8 w* {5 _0 j: o! Chistory, or failure to ask the specific questions, may1 F/ f: Y2 K0 c3 O  n
result in extensive, unnecessary, and expensive0 A; W3 S) k$ _
investigation. The primary care physician should be- c' T! G3 N5 B( j+ v6 v# Y
aware of this fact, because most of these children
( O: E% K4 d  Umay initially present in their practice. The Physicians’
7 m4 C/ H! P  ^  D0 W4 KDesk Reference and package insert should also put a
+ v" f2 c" l- B, b8 _warning about the virilizing effect on a male or5 ]+ a( m7 t) Q+ I
female child who might come in contact with some-
$ N, S3 ?+ q  Pone using any of these products.7 v4 ?% t. [4 S6 e& p9 f7 ~# x+ c; ^
References
4 ?7 q' U' x, r1. Styne DM. The testes: disorder of sexual differentiation5 x+ e/ ~* R1 s( Q) Y
and puberty in the male. In: Sperling MA, ed. Pediatric  x6 N2 o7 [8 y# V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% ^/ b+ L* o2 b* A. }: e$ v2002: 565-628.
0 o( a' L! l5 k+ q, n  O2 Y7 ]. K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( R6 Q0 j% O9 E2 v0 t: Q, X: Jpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
8 A6 T. A% p) ]0 k. Q- z* yBoy Induced by Indirect Topical* J9 S6 v1 r/ N; [% p% o0 t
Exposure to Testosterone
5 Q7 W2 b0 H4 S, Z! u) gSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ ^1 x! X, ?# F2 h: ?1 h
and Kenneth R. Rettig, MD1  T, o5 Z# H) n! x, E9 y/ R
Clinical Pediatrics* d1 D. D# e" W5 l7 X* ]0 s
Volume 46 Number 6
, X: J0 \' ~4 V6 r2 R1 FJuly 2007 540-543
" ?$ Y* L$ ]9 Y' t& u9 c© 2007 Sage Publications
* G& W' w  U0 j, C2 z$ T& \10.1177/0009922806296651
# {# }9 ~: q* \. ^3 j2 Lhttp://clp.sagepub.com
$ n/ p6 y8 _3 ^7 nhosted at! D7 ~/ E' S9 b
http://online.sagepub.com6 ?* y% \0 @% o* N4 S
Precocious puberty in boys, central or peripheral,
. O# {* R0 o4 F- p% i* u) S$ Bis a significant concern for physicians. Central) E2 Y& d  Z) B5 ?8 d
precocious puberty (CPP), which is mediated
& b; s. _3 y) F. Fthrough the hypothalamic pituitary gonadal axis, has
2 l# m( D6 T& W* R. T7 V' }4 Ha higher incidence of organic central nervous system4 ~: G# |0 @  u  P5 ?# Y5 H8 ?  N
lesions in boys.1,2 Virilization in boys, as manifested
4 o/ _" E4 R  M# `by enlargement of the penis, development of pubic
2 Y( P0 {* H2 s3 ?hair, and facial acne without enlargement of testi-9 U4 L/ ~4 N# W& j, _$ S
cles, suggests peripheral or pseudopuberty.1-3 We& X  z; r4 p* y3 N+ i1 ]
report a 16-month-old boy who presented with the+ A+ w! c+ F% b& \. e
enlargement of the phallus and pubic hair develop-5 J2 t8 @$ I9 Z
ment without testicular enlargement, which was due
$ W4 Q% }% ^  H. Y0 b$ v6 Vto the unintentional exposure to androgen gel used by1 x. Z3 \5 ^, C, z. U$ ~! B4 c
the father. The family initially concealed this infor-
4 D( c( f, ^& J- b8 f3 S7 Lmation, resulting in an extensive work-up for this+ M" L5 a- f/ |6 Q
child. Given the widespread and easy availability of. |9 p7 C- w( I, z  I4 b5 o7 F. c2 c
testosterone gel and cream, we believe this is proba-. p  K; @, Z: }. T9 p2 c
bly more common than the rare case report in the
% l# Y8 Z0 M) ?) }: k9 z& k1 t* s" Zliterature.4; B$ N' Q0 @9 _: \% @
Patient Report2 ~& S# A4 o" Y$ P- R
A 16-month-old white child was referred to the5 h, a7 Q' r  N. j, u
endocrine clinic by his pediatrician with the concern1 ?# d8 M% A( B* m1 [$ B6 w* S' c
of early sexual development. His mother noticed2 c" K; Z. C6 K' O5 l
light colored pubic hair development when he was  [. d6 u7 ?6 \7 x* c
From the 1Division of Pediatric Endocrinology, 2University of: N* V* r  u0 n
South Alabama Medical Center, Mobile, Alabama.
3 w1 }3 W9 H' H8 J- Y& @Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 Z% E4 ]* v8 Z1 a6 @Professor of Pediatrics, University of South Alabama, College of2 Z1 D& n/ Z/ O$ P3 ~' f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 g( u# \7 @" c7 k$ s0 i' ~
e-mail: [email protected].
+ u% \$ x; u3 ^8 o( nabout 6 to 7 months old, which progressively became* w5 M( h6 S6 d# o/ B+ B* R
darker. She was also concerned about the enlarge-# L% R8 _0 J9 I& E8 H! Z" I9 l
ment of his penis and frequent erections. The child& D) X# p' S$ X7 K  I$ J8 q2 l
was the product of a full-term normal delivery, with
0 P% N' P6 X# r2 D7 w, W2 ^a birth weight of 7 lb 14 oz, and birth length of+ S6 K- ^" Y' L" ]7 k# ?6 `. z0 X
20 inches. He was breast-fed throughout the first year6 M! L* r% q9 s+ T2 i- K
of life and was still receiving breast milk along with8 j/ ^2 C3 N& g* _( F9 x
solid food. He had no hospitalizations or surgery,
% a3 a5 T& m$ q- N; W$ Q# Sand his psychosocial and psychomotor development
- i# K" x0 S9 w/ R& u8 F9 mwas age appropriate.
8 o, {, r0 c" v3 n  c5 {The family history was remarkable for the father,
9 q% ?' \' e, P6 B; E0 owho was diagnosed with hypothyroidism at age 16,
. m+ L! l4 Z" [. A' lwhich was treated with thyroxine. The father’s
. `) o) p9 G+ v! n5 iheight was 6 feet, and he went through a somewhat, ^4 q: ]( m4 P/ E
early puberty and had stopped growing by age 14.6 ]6 Y6 L1 M. K, p2 y( ^
The father denied taking any other medication. The
8 N  r5 ~. r9 V7 qchild’s mother was in good health. Her menarche
7 @/ ^  M; G8 Pwas at 11 years of age, and her height was at 5 feet* b; q/ H$ i! Q: q  A+ t
5 inches. There was no other family history of pre-+ @8 r. _7 c% X8 z+ q: A" `
cocious sexual development in the first-degree rela-
8 q. [$ f, W* y- I$ Q4 a: z$ r9 Ltives. There were no siblings.( j1 F! W) A4 \# Z- R
Physical Examination
- z$ E6 l% ?9 e& D' w0 ^The physical examination revealed a very active,, [; t$ G  ?4 T
playful, and healthy boy. The vital signs documented  E( l6 p/ R1 W! T8 P) I1 `: |4 q) `
a blood pressure of 85/50 mm Hg, his length was
: V, f1 j! Y  G" X4 I90 cm (>97th percentile), and his weight was 14.4 kg4 I* m% y. M; |, }9 R
(also >97th percentile). The observed yearly growth" z+ D* ~$ u  ^) W# O; a7 c
velocity was 30 cm (12 inches). The examination of
: D; B* }9 }. A# rthe neck revealed no thyroid enlargement.* h# N( z% ]4 b6 n2 t
The genitourinary examination was remarkable for3 l9 O1 Z, q  `, r, t
enlargement of the penis, with a stretched length of
5 U  ^; g8 `5 u5 K" n7 C8 cm and a width of 2 cm. The glans penis was very well
: N: x/ f& J- W6 U9 }1 Q2 H4 Z0 Xdeveloped. The pubic hair was Tanner II, mostly around
) i0 i- ^$ V1 F7 u- R- T5409 {* j1 g' N0 u; D+ @
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5 R9 Q# t* d- _0 I/ }* @7 Q; P  bthe base of the phallus and was dark and curled. The
% {. q; L5 i1 D0 H# Ztesticular volume was prepubertal at 2 mL each.
& |+ j5 L2 o5 U1 J' XThe skin was moist and smooth and somewhat9 X: ^9 F/ X7 D5 y  x# y8 C8 J
oily. No axillary hair was noted. There were no- Q* X! K' i5 `6 f0 c8 t
abnormal skin pigmentations or café-au-lait spots.9 h$ a0 {, Q* u# N& l6 E3 r
Neurologic evaluation showed deep tendon reflex 2+- N) X8 T  f% M5 k5 |
bilateral and symmetrical. There was no suggestion5 K- l- n  L. s6 J9 m* v
of papilledema.6 u, c: V8 H0 ]# t
Laboratory Evaluation; R: N' ]* g( _  C
The bone age was consistent with 28 months by
0 T+ i0 h2 N" Xusing the standard of Greulich and Pyle at a chrono-
2 t( ?' O0 H2 w2 K/ Nlogic age of 16 months (advanced).5 Chromosomal
( ^  [& D% F( s4 m- Ikaryotype was 46XY. The thyroid function test
0 p& a" L$ J9 p  L1 e, qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 }, A0 E1 i! d& k# F3 L! k# ?7 D8 l  d: @
lating hormone level was 1.3 µIU/mL (both normal).# E3 J, ^" E# k' \3 J9 X
The concentrations of serum electrolytes, blood
% [, p" J; R" {) E% a! l9 ~urea nitrogen, creatinine, and calcium all were' ~' X: y. {4 N7 x  u9 V% W
within normal range for his age. The concentration
; t+ H0 C) f9 R$ M/ d6 y/ E& ^of serum 17-hydroxyprogesterone was 16 ng/dL0 t4 \3 G$ b- Z* s% x
(normal, 3 to 90 ng/dL), androstenedione was 20! T! ]) H& I( P. H) I" U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& B5 A3 F3 g( |% Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),+ I( _* ~: c2 i+ i+ s7 d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 l7 L0 |) F, F8 j49ng/dL), 11-desoxycortisol (specific compound S)
+ G7 `# C, A$ Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 T7 K2 N1 q! Z3 z$ s! y1 o8 {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 O# M6 O0 H+ G' H+ ~) U! m. g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 `2 }7 L. Q6 R3 F7 B; ]) e8 kand β-human chorionic gonadotropin was less than2 \. \( ~1 @8 s' ^
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 l1 \3 |6 W& n) }( j* K0 Y( K
stimulating hormone and leuteinizing hormone- R+ y) d- {: @! D- J
concentrations were less than 0.05 mIU/mL
4 x) H/ U& v9 U  |* E(prepubertal).
/ k- l; C7 _% p3 I  _& wThe parents were notified about the laboratory
7 G3 p/ S, j  I5 l8 H; uresults and were informed that all of the tests were
* Y7 P+ I: k; E+ ~) _9 Fnormal except the testosterone level was high. The
4 G% p: X' J7 S/ q, n& n$ Y4 ifollow-up visit was arranged within a few weeks to. d5 {& r  R5 Z
obtain testicular and abdominal sonograms; how-. c& `, {* i  V
ever, the family did not return for 4 months.
9 |+ a1 P: b9 n' ~/ W" M) VPhysical examination at this time revealed that the* s- q8 C8 W. g% w
child had grown 2.5 cm in 4 months and had gained' z% G+ E) T: D9 \. O
2 kg of weight. Physical examination remained
* a# |# h% W; ?8 Q1 lunchanged. Surprisingly, the pubic hair almost com-
" }6 r+ Q6 R- c4 ~' j, l  ?- qpletely disappeared except for a few vellous hairs at
+ H: k3 [6 P0 _- h: I1 [the base of the phallus. Testicular volume was still 2
. }* D) i6 ~1 V9 v1 ymL, and the size of the penis remained unchanged.
* S$ {) N% A7 R* X$ R5 GThe mother also said that the boy was no longer hav-& G( \' _0 e# z1 k, I9 V, T6 \
ing frequent erections.
" l# w1 e& O7 [Both parents were again questioned about use of. g) V$ }$ ^/ H, T1 z, |# U/ y" t
any ointment/creams that they may have applied to
# d, x. b( R' t; S$ w$ h! Bthe child’s skin. This time the father admitted the7 u1 l8 y' Z2 Y# {/ `; C
Topical Testosterone Exposure / Bhowmick et al 541. {5 E9 H+ }+ l- ^
use of testosterone gel twice daily that he was apply-4 ]% Q: s) L, r) T6 P$ R5 Z: ^
ing over his own shoulders, chest, and back area for
" S) q( {- m" g# l! {a year. The father also revealed he was embarrassed
! {0 X7 x; \0 ^& Qto disclose that he was using a testosterone gel pre-
" w0 O# Q& f& tscribed by his family physician for decreased libido
) T/ f* j+ ?/ b; `+ _, [secondary to depression.: M0 J) |3 r* n4 s# O# a. f
The child slept in the same bed with parents.( f' E$ h5 l  @& C
The father would hug the baby and hold him on his
3 ?( ^+ }6 `4 w9 n) m- _- S5 [( dchest for a considerable period of time, causing sig-
% @4 _6 b, h1 Jnificant bare skin contact between baby and father.  \: g  L4 g0 _: @; q. D
The father also admitted that after the phone call,
2 P! x8 q, T& q8 B2 j; V; `- ^when he learned the testosterone level in the baby
3 c  y6 x4 r* |5 ]7 k' Zwas high, he then read the product information
: I- w; [! D; T6 a8 \5 u2 v/ ~# q3 fpacket and concluded that it was most likely the rea-4 T! }: b8 W* k) b  y  N
son for the child’s virilization. At that time, they
4 {: o! Q0 }9 Pdecided to put the baby in a separate bed, and the
4 m' u6 s: o# P7 kfather was not hugging him with bare skin and had& P' s4 w3 D$ a9 b* q. c
been using protective clothing. A repeat testosterone1 [9 N/ i# g( X% ?3 B9 N
test was ordered, but the family did not go to the
# |" o. v/ w1 v% x+ o! q1 [6 Ilaboratory to obtain the test.
# e; l( t; P, X- h9 W& a- dDiscussion
& C# u( V8 U& F5 lPrecocious puberty in boys is defined as secondary
; \  D+ V" _. Hsexual development before 9 years of age.1,4( s% t/ T$ a. R2 p
Precocious puberty is termed as central (true) when- |5 g( V) J- g/ D% }
it is caused by the premature activation of hypo-' ?3 w/ E# |! e
thalamic pituitary gonadal axis. CPP is more com-
( d8 s5 y& a9 }: b: jmon in girls than in boys.1,3 Most boys with CPP4 ]" F& Z6 F* h6 K9 m! C( E7 v
may have a central nervous system lesion that is
" I& W: }' i4 v' h$ t- D5 D7 Fresponsible for the early activation of the hypothal-) J' x& o0 a9 i* o
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 A: I1 Y/ @  _sis has been given to neuroradiologic imaging in+ @$ k' [: @0 f
boys with precocious puberty. In addition to viril-
8 S' k9 m( J! t) ^( bization, the clinical hallmark of CPP is the symmet-$ N; a. q( X: G
rical testicular growth secondary to stimulation by7 X5 ^! H- x) o& b5 C
gonadotropins.1,3" B& ?3 Q' `4 U$ H% s9 ~/ D- K. C: z
Gonadotropin-independent peripheral preco-1 e5 m  X2 U& ^4 L+ j& s4 o; s' Y
cious puberty in boys also results from inappropriate9 Z) J& ]; x/ Y6 y
androgenic stimulation from either endogenous or. w2 |& X' w3 g) \
exogenous sources, nonpituitary gonadotropin stim-& `- u9 I$ n* s$ t( k
ulation, and rare activating mutations.3 Virilizing
6 I5 h* r4 X& s5 L- d& C( {, N; acongenital adrenal hyperplasia producing excessive
7 l% W. u0 _: w1 ?9 ]adrenal androgens is a common cause of precocious0 C. v  h, C4 s% g6 E
puberty in boys.3,4
) C! t8 g" o9 `* R  JThe most common form of congenital adrenal+ l+ {, r7 C- G
hyperplasia is the 21-hydroxylase enzyme deficiency.
" T, m) n8 X5 q) w  P( j' yThe 11-β hydroxylase deficiency may also result in
; A& C7 O" H  N% u. Sexcessive adrenal androgen production, and rarely,8 E' r: ^+ k* E1 ?6 d. S+ F6 D
an adrenal tumor may also cause adrenal androgen8 v6 Z9 F) @. f. D7 D" T# _- A
excess.1,3& F. x9 @; S7 j# N3 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, L* M/ Y: a% U  @: N: A" G542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& r0 a4 L6 R( y7 Q0 N8 M/ lA unique entity of male-limited gonadotropin-
- N0 P" J: O  Kindependent precocious puberty, which is also known
- ^$ Y! \( f1 Z  c4 H. A+ O* aas testotoxicosis, may cause precocious puberty at a6 Z3 s6 l: @7 X1 \; q
very young age. The physical findings in these boys
( l7 @' _- ]9 c  `# ?3 `with this disorder are full pubertal development,
! Z9 L2 n- ^3 N. hincluding bilateral testicular growth, similar to boys
9 k9 @! w" z; K8 j6 l: G  rwith CPP. The gonadotropin levels in this disorder
9 \' j  T  ]. h6 t2 e" C; B# Dare suppressed to prepubertal levels and do not show
& N: I. g2 i: f& _& ]6 f$ S2 [pubertal response of gonadotropin after gonadotropin-; A) T3 k! l7 e3 p0 ]8 [, x, j2 A
releasing hormone stimulation. This is a sex-linked
3 I( K  L+ \* j2 C7 R) Aautosomal dominant disorder that affects only! C" \# a, L  f3 _9 }; I: m
males; therefore, other male members of the family
. I( P7 d9 m' r# Cmay have similar precocious puberty.3
- V- e1 N6 o% X5 }% h: dIn our patient, physical examination was incon-, G$ P8 F9 G2 d# V5 t/ Q* F, y
sistent with true precocious puberty since his testi-
/ z6 j4 p4 B" a) f3 Z  Ecles were prepubertal in size. However, testotoxicosis
3 G6 G+ q3 G' G6 N% p5 ^4 rwas in the differential diagnosis because his father9 E+ J) k' ], Z2 v) a9 `* r3 v5 A
started puberty somewhat early, and occasionally,
! T3 z2 K, c$ S2 c4 b3 P" Dtesticular enlargement is not that evident in the
+ M* B9 ^5 |3 b4 Ybeginning of this process.1 In the absence of a neg-4 Z' C* \( C3 s2 @! L- r
ative initial history of androgen exposure, our1 |& m& R  p5 P) t3 x
biggest concern was virilizing adrenal hyperplasia,
3 V5 ^' ]1 m, C6 f4 Feither 21-hydroxylase deficiency or 11-β hydroxylase
, {0 |1 \2 U7 Z: N+ Mdeficiency. Those diagnoses were excluded by find-
  p0 t! w% Z% o# \ing the normal level of adrenal steroids." U  @) D9 ]% [
The diagnosis of exogenous androgens was strongly+ b' i( L5 ~+ ~  F( G7 a
suspected in a follow-up visit after 4 months because4 w" E4 u' }6 |1 |" d
the physical examination revealed the complete disap-
) n6 Q- V( C. F1 hpearance of pubic hair, normal growth velocity, and
7 s$ I7 S" X1 _1 |decreased erections. The father admitted using a testos-
# k. X) l4 h6 F1 }$ [terone gel, which he concealed at first visit. He was
3 B- z# E% y- B. V- {using it rather frequently, twice a day. The Physicians’* c5 o; V" O# g6 F6 f0 `- m& [- P
Desk Reference, or package insert of this product, gel or
; U. I( J& I, b# t* gcream, cautions about dermal testosterone transfer to. F! E4 R1 l* B( j- d
unprotected females through direct skin exposure.0 h% ^4 g( M' B
Serum testosterone level was found to be 2 times the1 M& j/ c+ L, M2 U4 ?* m
baseline value in those females who were exposed to$ ?3 b: v$ b8 V3 F% F
even 15 minutes of direct skin contact with their male
( G( }' b, `1 l$ S7 apartners.6 However, when a shirt covered the applica-
6 N4 B  F* A" O# Ltion site, this testosterone transfer was prevented.
  P/ g  S3 {5 xOur patient’s testosterone level was 60 ng/mL,
, R; O5 e6 e. k, s( C' ]which was clearly high. Some studies suggest that, Q+ O+ |0 b5 Q' p0 W8 D) N
dermal conversion of testosterone to dihydrotestos-% h: m) l  w9 L' t
terone, which is a more potent metabolite, is more2 n5 F6 P6 [. \3 O% E
active in young children exposed to testosterone
/ G1 o( l2 y* a! Nexogenously7; however, we did not measure a dihy-9 z. f7 f2 u: _1 j( ~
drotestosterone level in our patient. In addition to. M2 f$ d5 k8 p, F/ @
virilization, exposure to exogenous testosterone in
& D6 u3 I4 b/ z# r1 ]6 tchildren results in an increase in growth velocity and1 ]# E5 E8 t+ C& A
advanced bone age, as seen in our patient.
2 T# S$ ?4 |0 N' z4 M! [The long-term effect of androgen exposure during" Q" m& Z) D+ ?# [2 J0 k( U! L3 |
early childhood on pubertal development and final
; V0 ?( U: i# Z1 E2 M; E  ]adult height are not fully known and always remain
1 V( s" Q! v: Qa concern. Children treated with short-term testos-
2 V6 l5 ]8 O6 q: Z" g+ W, Q6 d* p$ Nterone injection or topical androgen may exhibit some
  ~" w4 w; j6 h+ Z& b+ eacceleration of the skeletal maturation; however, after
$ e( ]( s) U( @3 c2 F0 N1 Lcessation of treatment, the rate of bone maturation
  Z- Z" z5 ^! q2 Z4 }8 Y3 xdecelerates and gradually returns to normal.8,93 {( d- Q$ k, l; Y: l+ X# U( Q% a
There are conflicting reports and controversy
* |2 B: w' `) j; H" L3 V' [over the effect of early androgen exposure on adult
9 n. X: V& \4 k0 H9 npenile length.10,11 Some reports suggest subnormal
' r# Q7 c, [1 F( F) Padult penile length, apparently because of downreg-/ c9 B# G, j4 L9 F- F8 V
ulation of androgen receptor number.10,12 However,
* W5 J' z! Z& Q: ySutherland et al13 did not find a correlation between* G9 L0 D# w) D( s8 I2 I6 V( l- a
childhood testosterone exposure and reduced adult9 x1 s1 @% z& n0 e/ i" k
penile length in clinical studies.
" n, g* S. P3 k: INonetheless, we do not believe our patient is
  n: s* g+ P4 d, ggoing to experience any of the untoward effects from
9 S6 N' r' J) t% O" `, t6 Dtestosterone exposure as mentioned earlier because
* _" n0 p2 w1 e0 I% a! lthe exposure was not for a prolonged period of time.) p$ j) K7 O5 v) h5 J6 e# r
Although the bone age was advanced at the time of
  g7 @1 X1 V. ~4 F6 H, I+ A/ o: ~. ?diagnosis, the child had a normal growth velocity at
) Z" E6 k% P$ V0 Othe follow-up visit. It is hoped that his final adult
0 w# Q6 I2 A! V7 Z; l: kheight will not be affected.
) a/ {' P8 r; q7 D% wAlthough rarely reported, the widespread avail-7 n, H5 B& }  ?) ]
ability of androgen products in our society may
. G( ^; h- g7 x& @. G) xindeed cause more virilization in male or female. H8 ?) R/ h, W
children than one would realize. Exposure to andro-
/ s2 G0 m% M9 }3 Y- s  Kgen products must be considered and specific ques-$ \# h0 u! {% `6 c" o) x
tioning about the use of a testosterone product or8 @$ S+ U6 s& L# f4 W
gel should be asked of the family members during
. y' g4 l; m# J2 Qthe evaluation of any children who present with vir-
6 R1 y% W) D2 d/ e9 T7 wilization or peripheral precocious puberty. The diag-
" I$ \7 e: N0 e+ tnosis can be established by just a few tests and by, j% x2 ?9 g+ [# G* h7 {8 R6 b7 Z
appropriate history. The inability to obtain such a& ]: v3 _2 r% W- j& G1 f: x
history, or failure to ask the specific questions, may8 s' y: m+ A* w- N) Y
result in extensive, unnecessary, and expensive5 M1 b( j9 ~; g
investigation. The primary care physician should be% i6 i: X  J1 n& o' u" [( s$ `
aware of this fact, because most of these children
3 c. J2 _- ^, [1 S! }9 r3 ^may initially present in their practice. The Physicians’
' x" |' u; \" M% f3 O1 ODesk Reference and package insert should also put a
; }1 O5 ^% @6 |; X$ ?: pwarning about the virilizing effect on a male or, X' r$ q- U) j9 g
female child who might come in contact with some-' o5 N/ N. T  S8 Q: |
one using any of these products.- y4 R" _1 m8 z: a
References9 f$ _% s4 j) e* p/ L
1. Styne DM. The testes: disorder of sexual differentiation
6 S% h$ S8 P# fand puberty in the male. In: Sperling MA, ed. Pediatric  F: l4 ?$ O' E& z# ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' Q' r1 |& Q% N: O2002: 565-628.
4 ^( }5 [4 H( I$ q1 L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; a  {3 B, `  u! npuberty 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
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
. t+ [  [- U- |0 C# j( W/ g
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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