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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
3 X' |: g3 Z# B6 c: cBoy Induced by Indirect Topical  w9 D0 F& n' W$ J$ _1 _
Exposure to Testosterone
$ ?- P- h8 a. q" b- W( dSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" A9 L" C/ L0 [& v' \) p5 F
and Kenneth R. Rettig, MD1# C0 f9 K+ f/ ], b4 ~
Clinical Pediatrics' z; k% v9 ~! I7 ]  d% b+ ~
Volume 46 Number 6  ^9 u* Y# s- x; ~" D, w
July 2007 540-543
7 ?/ U/ M; Q/ F# _  c1 E4 d( i© 2007 Sage Publications
" a) X1 R! W8 |& ~; E10.1177/0009922806296651
$ U, F3 p5 L6 a: F& U1 P# j! e. `3 Nhttp://clp.sagepub.com( n7 F6 R! h: `: C3 t
hosted at* E% ^% l$ q" D# ]. ?
http://online.sagepub.com
5 E- r$ r6 @9 _% @Precocious puberty in boys, central or peripheral,
5 W5 r6 F6 Y! ^' @is a significant concern for physicians. Central
- c$ Y4 w; x5 _0 Gprecocious puberty (CPP), which is mediated
  C+ i; n) X  y% G; M. {through the hypothalamic pituitary gonadal axis, has( ^* h/ H3 b) [: a. _
a higher incidence of organic central nervous system& g1 Y4 F8 x$ P/ j. ?- s" n
lesions in boys.1,2 Virilization in boys, as manifested
0 E" K/ x$ O# m6 ]4 p% J/ Nby enlargement of the penis, development of pubic
9 Q# c5 E5 D- ]" L8 rhair, and facial acne without enlargement of testi-" e) g6 \4 `3 E* i; I! e
cles, suggests peripheral or pseudopuberty.1-3 We# R; u& ^5 C# G1 X+ e' I1 M
report a 16-month-old boy who presented with the
" Y3 w9 C8 s& m: U0 ?4 O+ u( Penlargement of the phallus and pubic hair develop-1 h  _: J* d; j& z8 U6 b- j4 t7 h
ment without testicular enlargement, which was due
( `8 z& M8 M2 c1 vto the unintentional exposure to androgen gel used by
' r- Z* ]: [5 U5 Gthe father. The family initially concealed this infor-
* |) L5 N4 J: Hmation, resulting in an extensive work-up for this
# J; E' R; D2 O  M) p" j( Dchild. Given the widespread and easy availability of
; d4 F# H4 V+ T7 Rtestosterone gel and cream, we believe this is proba-
5 a( b& K1 M6 H/ s/ F# C" j1 |1 ^bly more common than the rare case report in the3 s5 s" Y0 t* q3 E5 o! S( I( x, k
literature.4' U* n5 h5 m( K8 M* u# j
Patient Report% f4 O& K2 n1 I! E7 e
A 16-month-old white child was referred to the
' C0 A' w0 u! D$ l# jendocrine clinic by his pediatrician with the concern
# z- A! H  z# r% \/ Hof early sexual development. His mother noticed
. m2 N5 v4 l1 k, _1 |. rlight colored pubic hair development when he was
1 f5 b" ]7 f! A) K, X; c- MFrom the 1Division of Pediatric Endocrinology, 2University of8 Q0 M. g- t" B
South Alabama Medical Center, Mobile, Alabama.
9 q8 R6 |& _$ t* l+ qAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 y7 l- W) U& J6 f0 y0 c% P# H9 ]
Professor of Pediatrics, University of South Alabama, College of
0 N: _+ J% K# e5 bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; f: S3 |& t) M, U$ R
e-mail: [email protected].( D3 w' k% R$ l7 F# G* u
about 6 to 7 months old, which progressively became
% Y2 F# X8 E; G% h+ {1 adarker. She was also concerned about the enlarge-5 J4 n0 _/ k7 Y, q: }, d: H
ment of his penis and frequent erections. The child0 I( B2 a" Y6 d" N" ?6 g5 H) L
was the product of a full-term normal delivery, with
$ c2 {2 T! ^* [/ `+ ]a birth weight of 7 lb 14 oz, and birth length of/ W% K/ X1 k( Z5 O
20 inches. He was breast-fed throughout the first year
1 D& W5 k6 y8 t) Uof life and was still receiving breast milk along with
7 F8 x3 H- a6 n$ I; B  C6 B) ssolid food. He had no hospitalizations or surgery,
1 r3 _1 `8 H. z: ~and his psychosocial and psychomotor development
9 K! \2 @" \1 f4 Bwas age appropriate.
4 e8 J7 U: Y. ]- q; |The family history was remarkable for the father,, x) u& W' A/ G& r
who was diagnosed with hypothyroidism at age 16,6 \+ G( U) P! G
which was treated with thyroxine. The father’s
; @5 ^0 U9 L! O1 Rheight was 6 feet, and he went through a somewhat
; G* h# m" p& g% U+ y& F7 qearly puberty and had stopped growing by age 14.: j6 p$ @: N, J2 e
The father denied taking any other medication. The
; S0 k1 `+ j) L  L, kchild’s mother was in good health. Her menarche, w0 ], F. e: f# n4 A# I! k
was at 11 years of age, and her height was at 5 feet  R' J/ c2 k2 f: \. ~  ~
5 inches. There was no other family history of pre-
3 i5 z# \7 }1 ~( Ccocious sexual development in the first-degree rela-- Y4 ~& c# v/ `! i2 n
tives. There were no siblings.
1 B5 ?+ ^( d/ L$ l: uPhysical Examination5 a! s9 a: I! g4 @4 `( l. [& S
The physical examination revealed a very active,
- d- o1 c# s6 W2 Nplayful, and healthy boy. The vital signs documented7 K9 ]2 t4 H5 `( F
a blood pressure of 85/50 mm Hg, his length was' D) s+ K: v0 T8 ?7 `  f0 Q6 A* n
90 cm (>97th percentile), and his weight was 14.4 kg* J. |, A( F  Z  n
(also >97th percentile). The observed yearly growth9 x) K& L- c& S3 k- F
velocity was 30 cm (12 inches). The examination of
. A& N) X4 Q2 n# t, `1 O1 qthe neck revealed no thyroid enlargement.
4 w. }+ V, ~3 q+ }1 N. Q- v" M$ HThe genitourinary examination was remarkable for
3 O( C* ]+ L! @. Jenlargement of the penis, with a stretched length of
4 J4 b4 X0 V( N8 cm and a width of 2 cm. The glans penis was very well' Q+ E( C- q; G+ u  [% }* ^$ Y! R
developed. The pubic hair was Tanner II, mostly around5 S1 J' ]; P) y) p. }, s
540, \0 ~! R. S/ i2 T6 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 B% Q6 E. a2 D2 L7 C1 a: \4 xthe base of the phallus and was dark and curled. The
3 W% B5 X3 x& Ptesticular volume was prepubertal at 2 mL each./ f; p* k3 g4 c
The skin was moist and smooth and somewhat
: F# u* M- h( n: N2 \oily. No axillary hair was noted. There were no
' K1 J5 f# {3 `+ s( {- Kabnormal skin pigmentations or café-au-lait spots./ F* j* I2 C$ \/ `
Neurologic evaluation showed deep tendon reflex 2+3 v/ ?, m. V) R$ J6 H
bilateral and symmetrical. There was no suggestion
, j6 A0 z8 s" zof papilledema.) H3 h9 Q4 M* K6 _* o8 }" n
Laboratory Evaluation3 w+ S% o+ F- \, h$ {, o' j
The bone age was consistent with 28 months by7 @, R4 @8 J0 O, F. f/ h$ P
using the standard of Greulich and Pyle at a chrono-
/ `( e7 |' @7 d: Y9 H( Blogic age of 16 months (advanced).5 Chromosomal; J4 V: m1 W( M5 ^  u
karyotype was 46XY. The thyroid function test
6 ~7 Q6 D7 H, b3 R1 {+ zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: ~4 F* X( [' L2 s( J" R1 [lating hormone level was 1.3 µIU/mL (both normal).
% j9 }  F: j( ~5 q$ T2 eThe concentrations of serum electrolytes, blood
$ l+ @# D2 Z# V5 Y) n3 D4 f; B! [urea nitrogen, creatinine, and calcium all were6 M& t. g8 Q% g- Q
within normal range for his age. The concentration( F' }6 o# c$ D( V# {) D7 ]
of serum 17-hydroxyprogesterone was 16 ng/dL
! P6 R  _/ f7 b  [5 T' o. Q" G7 F(normal, 3 to 90 ng/dL), androstenedione was 202 e# q, Q6 Y8 W% v# ~4 q) x+ [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% g9 \6 k1 y& h/ T% n5 {4 Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 b% p& \2 I7 v" K- A  `, Kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# g. c5 U3 D" |2 n49ng/dL), 11-desoxycortisol (specific compound S)
! ^7 Y) R( ~0 g4 E2 O" D/ o' ?was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 `) Q9 C8 r% j6 n/ j7 U8 U+ `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ D" e# ~& f; z( Y; f. j5 etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* D" ^7 @! ?; N+ ]
and β-human chorionic gonadotropin was less than
7 |8 y3 L3 z7 z7 d; p+ T/ _: U5 mIU/mL (normal <5 mIU/mL). Serum follicular. S  U9 |) i; i* V3 P
stimulating hormone and leuteinizing hormone
! W! I3 I" E- G& Xconcentrations were less than 0.05 mIU/mL
! ]8 p6 x  m" {(prepubertal).8 w+ W' k' d9 k; i& a
The parents were notified about the laboratory8 u6 L. X) U1 Y6 Z5 I
results and were informed that all of the tests were
& T( Y' i: |- g* b0 G$ s  ?normal except the testosterone level was high. The- s) T3 I) n& J8 j
follow-up visit was arranged within a few weeks to
" [9 @  m0 O) m# E& r  Jobtain testicular and abdominal sonograms; how-' [  H7 M' ]3 ]& S$ \6 B( h
ever, the family did not return for 4 months.$ \( I/ V( G2 ^: d8 r
Physical examination at this time revealed that the
# F) N* {% D+ p8 achild had grown 2.5 cm in 4 months and had gained
# Z' h8 {. h/ x4 L5 z# |0 T2 kg of weight. Physical examination remained
" ~% C- `+ H3 t* C0 aunchanged. Surprisingly, the pubic hair almost com-
; z( S. ?% N  N1 Y8 c8 F- u; U/ dpletely disappeared except for a few vellous hairs at0 a4 \: ~$ T) z: `
the base of the phallus. Testicular volume was still 2, P# o1 z* C4 F4 o& g' A
mL, and the size of the penis remained unchanged.
5 H, M) k" V% \The mother also said that the boy was no longer hav-6 E0 g# U: ^. ~& S: J
ing frequent erections.& ^. `1 j3 ^3 r: `# L
Both parents were again questioned about use of
& }) x7 I5 X$ o7 K! c5 o7 Aany ointment/creams that they may have applied to; z% L; M; P1 ]1 P
the child’s skin. This time the father admitted the+ P7 x( j4 W" V( x: H
Topical Testosterone Exposure / Bhowmick et al 541# ]' ?- E) E! r3 w3 o1 L
use of testosterone gel twice daily that he was apply-" [8 U+ ^8 T6 [- B7 H
ing over his own shoulders, chest, and back area for' ^& C& F" f: R' T& [3 U5 o- T
a year. The father also revealed he was embarrassed
8 v+ S. ^+ S7 s& J  {* u5 Sto disclose that he was using a testosterone gel pre-# i8 _, a4 D) {" i) |
scribed by his family physician for decreased libido
: N# h0 i: n# E- Z$ S0 Qsecondary to depression.4 ~& {/ Z1 D2 {+ x
The child slept in the same bed with parents.# \- a. q) {+ E% s/ |: u5 r
The father would hug the baby and hold him on his+ E: P, D: ~- F8 J
chest for a considerable period of time, causing sig-
, B; P/ T1 @* V! @% Znificant bare skin contact between baby and father.
: T( h. G: u  p! S9 \0 TThe father also admitted that after the phone call,8 i1 c9 r7 b& f
when he learned the testosterone level in the baby. p" i6 a( I( U
was high, he then read the product information: ^) x- m( ?* F) Q& V8 I) L5 L
packet and concluded that it was most likely the rea-
& p% z- _% v. R& o+ W6 F: c; Json for the child’s virilization. At that time, they
: L1 p0 X; c0 Q& U- bdecided to put the baby in a separate bed, and the$ X6 L. j( ]: F: d/ `
father was not hugging him with bare skin and had
. y, X" ]3 f0 [4 }3 ibeen using protective clothing. A repeat testosterone
  ?4 j# o1 j/ E" W5 y5 ^test was ordered, but the family did not go to the
7 ]: |6 E/ Q2 k4 g- slaboratory to obtain the test.
! [1 c) @; r9 h. [- G. F5 SDiscussion
/ u. e6 h# ?5 v0 gPrecocious puberty in boys is defined as secondary5 |; D: O, E# }- v5 T- c6 O
sexual development before 9 years of age.1,4
- n: n) P+ w1 zPrecocious puberty is termed as central (true) when
' a$ E% p1 p7 z& c: l9 i* o! Iit is caused by the premature activation of hypo-
# i( |, ?. W2 z( ?$ {thalamic pituitary gonadal axis. CPP is more com-% }& z. c- r! x4 x  s
mon in girls than in boys.1,3 Most boys with CPP
7 @3 Y0 H( f( E% W+ W. M8 Qmay have a central nervous system lesion that is+ D4 [2 Y- g+ b" Y+ N& W) [( X8 r" Y
responsible for the early activation of the hypothal-- X; G, F1 Q  k9 y  K. N
amic pituitary gonadal axis.1-3 Thus, greater empha-2 a# x+ X! x7 p6 C6 O+ T
sis has been given to neuroradiologic imaging in4 j3 E4 m9 X7 x1 W6 w
boys with precocious puberty. In addition to viril-0 s* z$ e( ]2 _; |' \
ization, the clinical hallmark of CPP is the symmet-2 k8 A4 w9 k; g! K. Q0 Z6 T
rical testicular growth secondary to stimulation by
5 Q, F, D; v- X" j4 Lgonadotropins.1,3
0 Q+ s/ ~  Y1 Z- w& o# G4 b( d# l5 [Gonadotropin-independent peripheral preco-
9 ]% g! _, e5 U/ g! Z& n- s# W+ j  Hcious puberty in boys also results from inappropriate
7 ~; _4 n/ e) H0 G; Tandrogenic stimulation from either endogenous or
0 J0 @, y' q/ [* k5 T9 Mexogenous sources, nonpituitary gonadotropin stim-
6 k4 [2 }! F1 P3 g; [! Q# M7 M! _ulation, and rare activating mutations.3 Virilizing; {0 P; j$ ~4 H/ [8 K0 P/ t* s
congenital adrenal hyperplasia producing excessive
4 e% Y# d( B; ^/ b2 w! |9 aadrenal androgens is a common cause of precocious
6 C# n2 ~& N7 K6 U3 K- P3 Apuberty in boys.3,4
1 p; T3 s  y9 d- kThe most common form of congenital adrenal6 m- f- L' L7 I8 m- u
hyperplasia is the 21-hydroxylase enzyme deficiency.* e5 s/ S! j( N$ ~7 H& @& a+ Q9 W1 M# ^
The 11-β hydroxylase deficiency may also result in
, V0 ~0 `/ X" R' C4 u3 }excessive adrenal androgen production, and rarely,
* U. O- X9 E% s3 s4 X: pan adrenal tumor may also cause adrenal androgen
: a! n: F0 k3 S* cexcess.1,3
. I3 }* S+ B: |1 I! k* Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 X* p+ ~8 o0 p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 s9 V) ]8 Z$ iA unique entity of male-limited gonadotropin-
+ |% T( J$ v# r9 zindependent precocious puberty, which is also known$ `. g" H' ~2 U
as testotoxicosis, may cause precocious puberty at a7 R2 ?+ I$ D+ L' A/ y: n& M0 M3 v
very young age. The physical findings in these boys
- ?+ ?# O. [3 S( }$ K7 {with this disorder are full pubertal development,
' W  X- _  L( K1 o7 Lincluding bilateral testicular growth, similar to boys8 p* k/ M* n" ~  x; r
with CPP. The gonadotropin levels in this disorder$ _% @6 O% k6 I2 n* A
are suppressed to prepubertal levels and do not show
7 i2 U) ]; j: Wpubertal response of gonadotropin after gonadotropin-3 Z2 \' I, Y2 K9 n
releasing hormone stimulation. This is a sex-linked) F& Z1 b7 [& ~$ l1 [
autosomal dominant disorder that affects only
, `+ t; ]* `: F9 Imales; therefore, other male members of the family7 a1 a  a  d, W
may have similar precocious puberty.3/ j7 n) f% v' u2 b+ T1 j/ w5 k
In our patient, physical examination was incon-
( y3 {4 v$ a0 l2 Y! d- Esistent with true precocious puberty since his testi-
; {) h- Z0 v9 l$ D6 kcles were prepubertal in size. However, testotoxicosis# U( A9 F& p7 y
was in the differential diagnosis because his father
$ I2 X+ X, L5 B! T2 U3 lstarted puberty somewhat early, and occasionally,/ h+ j1 Q/ H" u% x+ U# Q9 r4 W0 m
testicular enlargement is not that evident in the6 l1 j3 ?" Z, d+ `
beginning of this process.1 In the absence of a neg-4 d/ L  z0 f6 c: n0 J' m
ative initial history of androgen exposure, our- a/ T2 ^' ^9 C
biggest concern was virilizing adrenal hyperplasia,
$ b$ p) @# v( D& l% K  xeither 21-hydroxylase deficiency or 11-β hydroxylase/ n- a+ T+ C  I& m6 @. ~
deficiency. Those diagnoses were excluded by find-
  u. {) g7 q5 zing the normal level of adrenal steroids.
3 N% I9 j# H5 I/ LThe diagnosis of exogenous androgens was strongly' ]# C& U! L4 `7 @3 M4 _
suspected in a follow-up visit after 4 months because& Z- @) p9 B4 X: j4 N  p9 b
the physical examination revealed the complete disap-
7 F7 K0 v+ d' |3 Jpearance of pubic hair, normal growth velocity, and
4 ~0 w$ O+ o% ]: ]decreased erections. The father admitted using a testos-
1 Z% c& ^" f4 O; t3 Eterone gel, which he concealed at first visit. He was
) G  m, h, V1 T( @. Rusing it rather frequently, twice a day. The Physicians’" M* q1 o" X- w- |2 n  C: z5 e- v7 C
Desk Reference, or package insert of this product, gel or- O  X) \' D) o/ B, P: s- s# P5 C2 ^
cream, cautions about dermal testosterone transfer to
4 G$ f6 g6 x  Q( t7 c1 y4 ^8 j. xunprotected females through direct skin exposure.& M* b5 e, W! |: u1 x9 h2 p0 j
Serum testosterone level was found to be 2 times the% k% U# P& N/ z9 ?$ N+ V$ p
baseline value in those females who were exposed to8 S0 E3 m+ p4 @* p7 f, O7 s
even 15 minutes of direct skin contact with their male
# s2 u& d. p* K- |) w, \) jpartners.6 However, when a shirt covered the applica-' S6 \: L5 h0 R/ T4 P5 E+ D
tion site, this testosterone transfer was prevented.) k! {$ M/ \3 r9 x- C2 p: q
Our patient’s testosterone level was 60 ng/mL,
( C$ D! Y) |3 C5 f8 g% Qwhich was clearly high. Some studies suggest that+ V2 x5 M! L9 r0 K
dermal conversion of testosterone to dihydrotestos-; S% R1 G: _. k8 q- c+ L6 m, f
terone, which is a more potent metabolite, is more& E! U. x- `! R# K
active in young children exposed to testosterone: ^; `9 ^- a- M% v' j# t
exogenously7; however, we did not measure a dihy-
# ?6 B. O1 O6 |3 F9 adrotestosterone level in our patient. In addition to
; y; I) |# [& bvirilization, exposure to exogenous testosterone in9 e" k  @0 Z+ M6 v! K+ C1 L
children results in an increase in growth velocity and
2 U( y$ N! V# |5 {, Jadvanced bone age, as seen in our patient.3 i4 D( B; p8 }; g0 G+ }) h
The long-term effect of androgen exposure during; ?" @, ~% J* R) h
early childhood on pubertal development and final; Z5 b  D! n# G8 T; c9 z
adult height are not fully known and always remain
: x7 ~5 n6 H" B# R) j" g) z. T- ha concern. Children treated with short-term testos-
- s/ W$ U  I9 L# B4 Zterone injection or topical androgen may exhibit some2 Y7 p$ [. D  }5 x' m, x% o
acceleration of the skeletal maturation; however, after" q  z# Z' Z$ t( l; l
cessation of treatment, the rate of bone maturation8 W' H* F: g4 D4 e
decelerates and gradually returns to normal.8,9% T( n% A* [  _) X2 L$ R
There are conflicting reports and controversy: m! w; O" ?0 d) n7 N( K8 u
over the effect of early androgen exposure on adult
) C* k/ a" n7 ]1 g% Apenile length.10,11 Some reports suggest subnormal9 P. r2 k% j9 |/ u
adult penile length, apparently because of downreg-
4 j$ V, R3 z. y$ G( ~7 T- b+ d3 Mulation of androgen receptor number.10,12 However,
4 T$ g) V- K6 c1 E4 J* \2 i# q6 mSutherland et al13 did not find a correlation between1 s3 Z& j! ]9 ~  o( i+ ~( l4 F$ M
childhood testosterone exposure and reduced adult3 U: A# |0 L) n
penile length in clinical studies.
% N8 |  l7 w! X' \8 L# i4 ?Nonetheless, we do not believe our patient is' _: B3 m, U2 U
going to experience any of the untoward effects from
4 _# q) R& ?; o  V; H/ ltestosterone exposure as mentioned earlier because$ ^+ E8 |) n0 g. k
the exposure was not for a prolonged period of time.
! I' _( P7 J0 J( y  `; ^/ [Although the bone age was advanced at the time of" b: s: d: A7 P
diagnosis, the child had a normal growth velocity at3 }0 ~. A, {# ?) \" v0 ?
the follow-up visit. It is hoped that his final adult
2 U8 z) n! e& Q* L2 _) `9 j- qheight will not be affected.! T5 ?4 y' f% `
Although rarely reported, the widespread avail-
& I8 t& ?  Y) _- C9 Dability of androgen products in our society may5 s; m, f; C1 X* S* _9 V" y2 U2 J3 M
indeed cause more virilization in male or female
: J4 O9 I1 w' g1 S/ P8 S  [! Zchildren than one would realize. Exposure to andro-: [# Z# u) K' ^& q% J$ O
gen products must be considered and specific ques-
( `9 a( [5 `8 U( U' p' dtioning about the use of a testosterone product or1 o( o1 }6 ?8 s. `! ~/ R2 }
gel should be asked of the family members during
% @( J3 n5 \6 L0 h% Pthe evaluation of any children who present with vir-
6 m, a( `) C# J- Gilization or peripheral precocious puberty. The diag-
, {1 a) c! y) U- ^# N0 P) znosis can be established by just a few tests and by
* c3 e- _! ]+ y! E( |) T* oappropriate history. The inability to obtain such a
' R: ~/ j& T9 J+ \( ghistory, or failure to ask the specific questions, may' p( Y+ \( d0 ?+ Z2 g+ q7 F4 G
result in extensive, unnecessary, and expensive) Y* i! e  X2 Z) I
investigation. The primary care physician should be
+ t! z; i4 D" m& V. l9 ]+ ~aware of this fact, because most of these children+ M# c, \4 i" S, m
may initially present in their practice. The Physicians’. u3 U6 X4 Z% B3 ~5 z* l& l& N: a7 S' [
Desk Reference and package insert should also put a# O, R- p+ g. i  Z& ^- C8 m
warning about the virilizing effect on a male or
. }5 Y4 v3 K! Xfemale child who might come in contact with some-
% C5 D# M& v, y' q1 Lone using any of these products.: o' r8 y1 j2 r& U0 K
References' B! s! h6 {/ H* j7 ]7 D
1. Styne DM. The testes: disorder of sexual differentiation) h8 g0 d8 b6 X$ t+ o; J1 F
and puberty in the male. In: Sperling MA, ed. Pediatric$ l/ O" x( k; {' {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ C: a, o; k  V4 ~2002: 565-628.8 T2 R2 t  O: f
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ Z+ `- q7 R8 w$ Jpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
; X! ?7 r$ J# p' Y, ABoy Induced by Indirect Topical# Z- _3 m2 C; N9 E
Exposure to Testosterone
: s- ~# o9 V- R+ j2 b' XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 _# _6 _; y, O- J7 R* ^and Kenneth R. Rettig, MD1# {' H0 l# c/ I* s; b
Clinical Pediatrics; L# X5 I9 E9 i  c  y9 b( n
Volume 46 Number 6
1 Q! T9 O$ b# t1 c' OJuly 2007 540-543: w4 O' v2 p$ t3 T( `
© 2007 Sage Publications4 f- y0 L8 F2 p1 s6 d5 ~
10.1177/00099228062966510 }9 p0 d* k+ N. h: ]4 Q. Z
http://clp.sagepub.com
' N; K( T$ X/ Bhosted at; ?( H) c! {$ S: E  S
http://online.sagepub.com& A8 f" }! P; a4 c7 H. x4 ]
Precocious puberty in boys, central or peripheral,
4 M" ^- r2 y/ l9 n0 p6 Xis a significant concern for physicians. Central
, S. e: ?! Z" o6 |3 vprecocious puberty (CPP), which is mediated
2 y0 `) h+ t5 z( o# ?through the hypothalamic pituitary gonadal axis, has
; ^1 b' {7 c2 p3 {a higher incidence of organic central nervous system! i* r: _- h2 e" V% m# \
lesions in boys.1,2 Virilization in boys, as manifested. X1 S: C! I! K2 x3 d
by enlargement of the penis, development of pubic, n0 Q; T/ ^) j- v3 p/ r! d7 ?
hair, and facial acne without enlargement of testi-
1 V5 j( g1 [4 J( h& @  j. tcles, suggests peripheral or pseudopuberty.1-3 We
) q* k7 l8 m/ f- L% oreport a 16-month-old boy who presented with the
/ C) F; J$ [. d, `, t  a& D- e- uenlargement of the phallus and pubic hair develop-1 @0 Z8 }6 E" w* N) I/ v
ment without testicular enlargement, which was due4 {7 E8 r0 i! x0 m
to the unintentional exposure to androgen gel used by
; K  H  y) ~9 ]" `6 `; pthe father. The family initially concealed this infor-+ p, e$ Q% [  ]+ A& ^3 m( ]3 n
mation, resulting in an extensive work-up for this
! d# V5 `& m8 R0 c8 W1 F1 Achild. Given the widespread and easy availability of9 e4 m( p8 D8 E. t4 L! V) E! a5 ^& p4 I
testosterone gel and cream, we believe this is proba-
, Z' v* N8 p3 h. z+ M4 n' y4 ^bly more common than the rare case report in the5 m+ K! \' A2 c" q
literature.4- `7 S  d) `: u
Patient Report
/ Z4 c% `5 O- ~7 ~6 n* AA 16-month-old white child was referred to the" v  B! k& ~8 y3 Q8 t
endocrine clinic by his pediatrician with the concern" @& ^- W% s( p; a
of early sexual development. His mother noticed/ Y/ z" c7 M4 J7 W: A
light colored pubic hair development when he was
; J3 K9 G4 M; I$ Q- OFrom the 1Division of Pediatric Endocrinology, 2University of" i# M& U. ^7 r+ _
South Alabama Medical Center, Mobile, Alabama.
2 y, H9 G1 _. b# x( u+ W0 UAddress correspondence to: Samar K. Bhowmick, MD, FACE,& ?/ u. V( k4 O3 i' a
Professor of Pediatrics, University of South Alabama, College of3 t: B  k8 ]% s; w! E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: _6 v3 E& s' E; L7 g- Y
e-mail: [email protected].  d; S1 r/ |5 I- s
about 6 to 7 months old, which progressively became; e+ b9 c% i! Q4 T8 N
darker. She was also concerned about the enlarge-
5 s9 a, B7 o" W, }' X3 j  ament of his penis and frequent erections. The child
8 @" z8 p0 ?; _was the product of a full-term normal delivery, with( I6 G! x6 ?8 E. z" l+ H& L
a birth weight of 7 lb 14 oz, and birth length of
3 \# K* V  H% h. H$ [% [7 a20 inches. He was breast-fed throughout the first year2 A5 G; Y1 A% O' f
of life and was still receiving breast milk along with' @* t3 E' M, j! U0 \  R4 r
solid food. He had no hospitalizations or surgery,
5 {5 D/ D/ \. c2 ]/ g# pand his psychosocial and psychomotor development
5 |" ~3 H% I! o# I( g! Xwas age appropriate.3 \- S' @: o! X+ u+ z4 w8 S
The family history was remarkable for the father,
  U8 m; Z2 T2 twho was diagnosed with hypothyroidism at age 16,
( m9 t5 r$ d6 nwhich was treated with thyroxine. The father’s' j7 x. q! n! N
height was 6 feet, and he went through a somewhat6 N& i/ {) D0 B/ @: Y$ U3 r# B
early puberty and had stopped growing by age 14.
! F" M% T2 G3 A3 wThe father denied taking any other medication. The! R$ |7 C8 F8 f7 c- W8 i4 ^
child’s mother was in good health. Her menarche& Q& {2 C" k$ f4 j& b
was at 11 years of age, and her height was at 5 feet  O) s$ G8 Z7 t) L1 h
5 inches. There was no other family history of pre-, v# x* [4 E& q9 u- W6 f
cocious sexual development in the first-degree rela-9 Q  N2 Y3 Z2 R* N
tives. There were no siblings.
, T2 ~* w) B0 x  H) c0 k4 h$ V" IPhysical Examination, N% e; m9 A/ t
The physical examination revealed a very active,
( \1 w7 y! U( c: K' d2 gplayful, and healthy boy. The vital signs documented  v( L1 b% T5 m
a blood pressure of 85/50 mm Hg, his length was
# |" @+ ]3 C$ {90 cm (>97th percentile), and his weight was 14.4 kg! }0 o- o( Q( W
(also >97th percentile). The observed yearly growth
# q0 A  h) \6 N6 s6 Z6 pvelocity was 30 cm (12 inches). The examination of" J+ i$ i( V7 D; r; d( v$ ~( m
the neck revealed no thyroid enlargement.' F) m7 K' d, x+ x; y: p
The genitourinary examination was remarkable for
+ x+ h( Z& `" c1 W/ K8 Tenlargement of the penis, with a stretched length of
+ f2 O5 B, ]& G. B" s( l8 cm and a width of 2 cm. The glans penis was very well( Q9 S& ~! w' }
developed. The pubic hair was Tanner II, mostly around
! A. V( Q( T8 a, r& a540/ B: `& _, R2 R' l$ B. r. z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 [9 ]1 v* _5 C2 F2 gthe base of the phallus and was dark and curled. The
2 T( X! E9 y5 l3 |! J5 `testicular volume was prepubertal at 2 mL each.- ^* f: l6 K1 b0 m2 a
The skin was moist and smooth and somewhat
. c$ R) v+ @4 W1 `" S! R3 Z7 Doily. No axillary hair was noted. There were no, q" ]8 N1 {  X; ?" Y$ G% F& t9 f
abnormal skin pigmentations or café-au-lait spots.( q$ X0 |6 F) W0 g
Neurologic evaluation showed deep tendon reflex 2+9 b% H/ _# \; f6 e
bilateral and symmetrical. There was no suggestion, S: M; `4 H2 \/ X( r
of papilledema.
  ?: i, y- @1 R1 A: N+ KLaboratory Evaluation
- U9 K2 Y  d  ~" u, rThe bone age was consistent with 28 months by( J8 [$ ?6 s, x1 S) q. G
using the standard of Greulich and Pyle at a chrono-: x9 q1 c% d4 e. \& F# Y% u4 M# _
logic age of 16 months (advanced).5 Chromosomal
. L7 D' U7 A& G8 ^9 t/ M5 T! Y8 Wkaryotype was 46XY. The thyroid function test6 c' l  r/ ~, Y0 y5 ^% J- G  S# b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 U$ z2 H0 D& r7 a
lating hormone level was 1.3 µIU/mL (both normal)." X0 l6 `: }, l
The concentrations of serum electrolytes, blood
9 J8 \" D5 H3 F, q* h2 hurea nitrogen, creatinine, and calcium all were
" F4 w1 {! O& c3 Y9 e! M+ R' fwithin normal range for his age. The concentration+ H4 O: h, i" D* s+ q) `1 j6 z
of serum 17-hydroxyprogesterone was 16 ng/dL
8 t8 F+ Y8 h- P9 o' A" e(normal, 3 to 90 ng/dL), androstenedione was 205 \9 W: @8 f  {7 d, s2 H  k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" N, u; |& W. p# k/ \6 x+ cterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 z& Y2 W# q" a% Z  C" |5 M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; B8 L5 Z! M  h- J49ng/dL), 11-desoxycortisol (specific compound S)
) L/ p' V$ D! v0 Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# a0 U8 k0 H) \0 Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 v) m) ]  `7 m) m% }  B$ b! o" d* Q6 ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* ^8 ?. H/ l; }and β-human chorionic gonadotropin was less than' m) T( `! [6 c, h+ v* M7 d
5 mIU/mL (normal <5 mIU/mL). Serum follicular' p* D- a- o0 d% S: U: U
stimulating hormone and leuteinizing hormone# {/ R/ @. Y& S( ]& P  D
concentrations were less than 0.05 mIU/mL
1 J8 U% B/ f9 n/ S+ t3 \(prepubertal).
: j7 y' F+ M1 }! p1 a% B4 M% jThe parents were notified about the laboratory
5 t0 s1 l4 q6 B4 {0 j0 E% eresults and were informed that all of the tests were$ }% n6 e9 n' Q) q# v6 V* U7 r
normal except the testosterone level was high. The% m2 T# i* U6 E& K* W9 X. G
follow-up visit was arranged within a few weeks to
' A! Y0 ]. i0 xobtain testicular and abdominal sonograms; how-* g. k6 g+ O+ {
ever, the family did not return for 4 months.; |( t1 @1 s7 l; i% z* r
Physical examination at this time revealed that the- j6 ^2 ~' T' A. z
child had grown 2.5 cm in 4 months and had gained
4 g* M; t+ S% A* R2 q6 Q2 kg of weight. Physical examination remained
( i3 f/ X% i3 }% ^' l2 [7 ounchanged. Surprisingly, the pubic hair almost com-
0 Q+ K6 u5 Z- p9 z1 L4 O  qpletely disappeared except for a few vellous hairs at& m. R3 p4 G  Y5 f8 D7 w: T* D& R
the base of the phallus. Testicular volume was still 2/ l- R, @* X: b$ ^/ [3 x# O
mL, and the size of the penis remained unchanged.
! h; U3 ~% `. p" JThe mother also said that the boy was no longer hav-
5 N0 o9 y1 h* V+ i$ d8 {ing frequent erections.
7 l3 R/ ?: X& B9 c6 Y. b, a/ `Both parents were again questioned about use of; J5 Q, H4 `, o* y. |
any ointment/creams that they may have applied to/ S7 e- V$ ^. w2 @2 w8 L( {  t
the child’s skin. This time the father admitted the4 v2 b9 T4 P/ c, c0 l% W
Topical Testosterone Exposure / Bhowmick et al 541/ X  C: i! U5 M2 c& z
use of testosterone gel twice daily that he was apply-
2 C+ G5 {2 Y' t& Ning over his own shoulders, chest, and back area for
8 @; l* ~+ b* ]: Wa year. The father also revealed he was embarrassed
8 g1 F" T% l3 a! ^1 P0 zto disclose that he was using a testosterone gel pre-6 g6 W8 `' ~" `' c
scribed by his family physician for decreased libido: s% G' t; C. N) i& x: ~( I$ n
secondary to depression.+ O- Y2 R2 `9 Z( a) y
The child slept in the same bed with parents.
9 Y7 I, n2 S: rThe father would hug the baby and hold him on his
$ {7 p/ T7 b# v% f/ n* M+ C7 q! s  pchest for a considerable period of time, causing sig-0 c( G2 ~( J1 C# ~: b& u8 y, S- j
nificant bare skin contact between baby and father.& b; `0 t# c; v1 m7 L# l
The father also admitted that after the phone call,* \2 U6 q' V4 ]4 l% @7 s0 V
when he learned the testosterone level in the baby$ q) L; `0 L' ]- S
was high, he then read the product information% ^; S0 S* W8 W/ u* d
packet and concluded that it was most likely the rea-
. m/ j! V2 I0 y/ g6 c3 r5 {son for the child’s virilization. At that time, they/ `7 S1 e% q) p
decided to put the baby in a separate bed, and the
8 O( j6 V1 ]" z8 l+ N  M3 pfather was not hugging him with bare skin and had
1 T. g8 c- l1 e7 U# f+ Sbeen using protective clothing. A repeat testosterone
  O& P# k' l7 T5 O# j  \test was ordered, but the family did not go to the5 h/ R& [. A: B
laboratory to obtain the test.
( V& Q, k7 q) }' ]1 MDiscussion
1 z3 L2 B0 E; Q$ m, l& F, `Precocious puberty in boys is defined as secondary
) p8 d$ i/ I' Z7 {; }sexual development before 9 years of age.1,4! |7 ~- o9 `  Z  q" _
Precocious puberty is termed as central (true) when" Y! r& I& Y: S4 o8 n  o6 I2 o6 L
it is caused by the premature activation of hypo-( _2 }/ U+ D6 [0 [1 n2 f
thalamic pituitary gonadal axis. CPP is more com-: x! Y5 e# a* e3 r* k6 V
mon in girls than in boys.1,3 Most boys with CPP! V9 N4 K# A/ |
may have a central nervous system lesion that is/ ^& x0 [/ Z' X7 ^* I
responsible for the early activation of the hypothal-
8 `/ t4 B$ Q. `0 Tamic pituitary gonadal axis.1-3 Thus, greater empha-
$ Q) Z) m% C' \9 asis has been given to neuroradiologic imaging in
3 r+ V! ]8 E6 Yboys with precocious puberty. In addition to viril-
' U5 v  J% i  f" S5 j, Rization, the clinical hallmark of CPP is the symmet-
, ~0 P- H! @# v; d' o" `rical testicular growth secondary to stimulation by5 t  J  _7 `+ e: [, W& P2 f7 G
gonadotropins.1,3- b3 ]; X: B) i0 a
Gonadotropin-independent peripheral preco-
. k6 o5 y/ k. ^: R% T- O: scious puberty in boys also results from inappropriate
9 B0 d; M% u3 z: Bandrogenic stimulation from either endogenous or1 T, e8 U: |/ n
exogenous sources, nonpituitary gonadotropin stim-4 w( f- s& V# _* W8 r
ulation, and rare activating mutations.3 Virilizing
( v! X* g9 \0 z$ kcongenital adrenal hyperplasia producing excessive& G1 Q, S" V+ W1 t4 n
adrenal androgens is a common cause of precocious$ a0 J! T, M# H! f" L! u
puberty in boys.3,42 \0 ^1 w; Q% ^! n7 p/ p
The most common form of congenital adrenal1 L7 j, l7 @) y7 Z
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 A8 @! K- G  C" v: i. r. kThe 11-β hydroxylase deficiency may also result in8 r* i; z& m- i) s
excessive adrenal androgen production, and rarely,- F- X4 Y; }; l0 E  n1 ^
an adrenal tumor may also cause adrenal androgen9 i9 Z! x# h. S2 P# h" v
excess.1,3) o8 F$ J, u2 ?  o6 |1 A6 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, I- ]$ L4 d4 a) X( m, E, g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! _  d+ [  d8 S! L3 D  H2 xA unique entity of male-limited gonadotropin-
% R& A1 X8 s1 \- T1 ~independent precocious puberty, which is also known
- ]+ R# Z; w4 _6 Kas testotoxicosis, may cause precocious puberty at a; ^) r9 g% W; A, h# a6 Z
very young age. The physical findings in these boys& t0 L) `% x& Y0 R! \7 q% H
with this disorder are full pubertal development,
7 s* j% [" X2 {" {- ^including bilateral testicular growth, similar to boys
1 ~' E* b% h5 D# u7 R* h" Q2 xwith CPP. The gonadotropin levels in this disorder* b5 A, Y: w  A; H: x9 w
are suppressed to prepubertal levels and do not show' S7 L& M" m0 q; ~, E: |# x
pubertal response of gonadotropin after gonadotropin-
1 i, H0 \9 n( K  b3 S0 z% wreleasing hormone stimulation. This is a sex-linked3 X: {9 F. f" B4 o3 z
autosomal dominant disorder that affects only* d+ m; f3 V* C/ c+ k
males; therefore, other male members of the family5 O& ^7 V2 R+ x8 u" c
may have similar precocious puberty.3* @; r. c; N+ [$ h
In our patient, physical examination was incon-. E! j4 @5 S, _  s+ _' O1 M/ q( q/ B. K
sistent with true precocious puberty since his testi-
1 E( p; y* M  Z* c0 r1 T5 f9 q) |* Y: scles were prepubertal in size. However, testotoxicosis
! U' I7 Y9 h+ L$ }0 G& xwas in the differential diagnosis because his father  d* L3 f- A% {/ p+ t# e# k8 ?; G
started puberty somewhat early, and occasionally,# y" n$ ]' f+ i" f$ P
testicular enlargement is not that evident in the
6 v" w1 ~$ k" K) p, `2 {beginning of this process.1 In the absence of a neg-
+ H" [5 m1 L; hative initial history of androgen exposure, our( r& x: E" y# P6 p. j. _3 D
biggest concern was virilizing adrenal hyperplasia," u3 ^- _$ L3 `
either 21-hydroxylase deficiency or 11-β hydroxylase4 P- c: w( k! A5 O1 e* ^$ X8 s
deficiency. Those diagnoses were excluded by find-* Q4 V* x% y7 h  c/ x6 T
ing the normal level of adrenal steroids.7 l4 p0 [" R* q' T. [6 h$ x# n
The diagnosis of exogenous androgens was strongly4 x5 R' y" u7 ~+ X. J
suspected in a follow-up visit after 4 months because+ G; H9 b/ c4 a. k  g
the physical examination revealed the complete disap-- n) i) H# `7 Z1 A3 M6 B$ E8 ?
pearance of pubic hair, normal growth velocity, and7 |& S0 T3 O2 x. u1 s
decreased erections. The father admitted using a testos-4 O) [" l! C4 p9 e/ k( a( o
terone gel, which he concealed at first visit. He was- u* }4 E* w/ Y
using it rather frequently, twice a day. The Physicians’
. a/ o! z! J0 g% i( `$ ~2 VDesk Reference, or package insert of this product, gel or
5 Q# b. E4 w3 H1 w) ]% k; {; Fcream, cautions about dermal testosterone transfer to
3 T. F) x2 j( v) S' K9 t8 T1 _+ yunprotected females through direct skin exposure.) n' g7 ]3 O1 Y2 B1 M) t9 G
Serum testosterone level was found to be 2 times the+ _1 f3 f0 W) \- b
baseline value in those females who were exposed to$ L& Q+ H  [  g9 L6 v
even 15 minutes of direct skin contact with their male
0 g6 `/ u! g2 y1 |8 F- n5 bpartners.6 However, when a shirt covered the applica-' ~# t- M) f) y' }# Y) V5 [
tion site, this testosterone transfer was prevented.( O( n$ B. p1 R
Our patient’s testosterone level was 60 ng/mL,
$ z* d$ T2 P$ P2 E, M$ iwhich was clearly high. Some studies suggest that
; q+ Y8 S3 l* }" H# t1 M$ Udermal conversion of testosterone to dihydrotestos-
% m/ m8 [+ l$ j( Z' Uterone, which is a more potent metabolite, is more% @' ^$ F6 F8 y& ?; o# a
active in young children exposed to testosterone2 w( B+ U5 u6 [0 E
exogenously7; however, we did not measure a dihy-
) K. S; p: F3 F/ U6 Y+ u7 Wdrotestosterone level in our patient. In addition to
9 y% o  Q$ }* T( o" ?3 dvirilization, exposure to exogenous testosterone in
3 Q8 Z' |6 i  N5 r: q8 fchildren results in an increase in growth velocity and1 F7 _$ {3 J8 a4 [; @
advanced bone age, as seen in our patient.
* y! i& Z/ M6 k9 @) v  a, hThe long-term effect of androgen exposure during7 i/ ~/ g: N' ^% O$ z+ f2 M, t
early childhood on pubertal development and final
) |% b. k# x4 S$ I4 U5 l/ [2 zadult height are not fully known and always remain
9 Q3 |0 X) s0 y( ia concern. Children treated with short-term testos-
2 }6 A+ P9 R9 C2 {3 Xterone injection or topical androgen may exhibit some) b' @$ _$ D  z: N: p( Z' H
acceleration of the skeletal maturation; however, after& v& N2 h# T, Q( e6 I! [  I
cessation of treatment, the rate of bone maturation9 E& ~9 S* q0 [2 }
decelerates and gradually returns to normal.8,9
# a. c; V: b# S' }There are conflicting reports and controversy
# P2 R9 C4 O0 {9 Cover the effect of early androgen exposure on adult
% }; }# d. M5 V7 W" P" t; Jpenile length.10,11 Some reports suggest subnormal
2 d9 P* f: X; y+ ^( e- v0 T0 hadult penile length, apparently because of downreg-) J1 k3 P8 t8 k% U' k$ l. {
ulation of androgen receptor number.10,12 However,( A0 `  ]& S; a6 w6 a
Sutherland et al13 did not find a correlation between
6 D' i5 F9 c! W& {- b: ~0 e# [childhood testosterone exposure and reduced adult# X( o% E. y. b0 N  C
penile length in clinical studies.
& r$ }. H# A+ p( sNonetheless, we do not believe our patient is
5 S3 c9 O: M" ~0 c' k8 B0 Ngoing to experience any of the untoward effects from3 \  A, [# K; r: Q
testosterone exposure as mentioned earlier because
: b, `+ ~4 g5 E. o4 ]# k  z) {the exposure was not for a prolonged period of time.4 _7 A6 O( y$ \9 m9 X+ L  t8 z: z+ m
Although the bone age was advanced at the time of9 B  Z7 A! R; c/ L/ Q) }
diagnosis, the child had a normal growth velocity at
9 R' a' U6 ~, J. s! g9 R; m0 Jthe follow-up visit. It is hoped that his final adult
$ F3 }7 T6 m  I& jheight will not be affected.
& ^% g" H+ G6 Z) Q- gAlthough rarely reported, the widespread avail-. K! ]# H8 h! s! N5 T
ability of androgen products in our society may
8 S! p1 T+ Y, ?indeed cause more virilization in male or female7 `0 d! M5 _2 j* E2 y/ _  p
children than one would realize. Exposure to andro-: H( A: W/ x& V4 T1 C; j" Y
gen products must be considered and specific ques-
; r4 ~  W( l2 [  e! Q" @& Xtioning about the use of a testosterone product or, U- l  g2 Q/ G( I
gel should be asked of the family members during
4 ?: N* j' u9 _$ F" }, Mthe evaluation of any children who present with vir-$ C( I# w9 Q$ G: v
ilization or peripheral precocious puberty. The diag-
8 c* Q4 K6 X6 ]: r( Wnosis can be established by just a few tests and by, q1 }! p( z% ^0 v* B& G6 V1 r
appropriate history. The inability to obtain such a3 m) c# z: p# _" w  J$ O- _. m
history, or failure to ask the specific questions, may
0 c3 D/ G$ T6 z3 ^1 R$ s6 v4 h/ z) Presult in extensive, unnecessary, and expensive
9 s3 _9 l7 [/ ~& n+ `: ~* U& B" winvestigation. The primary care physician should be5 z1 ]$ C! N2 N1 |( F
aware of this fact, because most of these children9 p* N, o2 w& U* k0 z- l
may initially present in their practice. The Physicians’) @1 P' L0 ?( t( j" |
Desk Reference and package insert should also put a
6 S3 y2 y# I- j0 Y# r9 iwarning about the virilizing effect on a male or+ {' ^/ ?% |+ I$ w' ~' ^4 \
female child who might come in contact with some-- r1 [' r, G) w
one using any of these products.
6 l, K) a/ i3 VReferences3 m0 t0 O$ _3 Y6 E% B3 x
1. Styne DM. The testes: disorder of sexual differentiation& W, ?( [; H8 b1 K3 `- n- u
and puberty in the male. In: Sperling MA, ed. Pediatric; n* V/ t0 J1 n& @% `0 F
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. I& F1 B2 K9 l+ ^2002: 565-628.
, U5 s/ q4 k& O9 C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 z6 m* l) ^% F. g% o' h1 Kpuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

8 k6 H$ M, E- z, {: {1 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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