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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
& y  q1 x6 T7 H4 o3 N* c$ QBoy Induced by Indirect Topical6 M/ T6 h9 j7 s+ y* E
Exposure to Testosterone
: c) i* x9 w5 H5 X: eSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 F" E- k- c  Sand Kenneth R. Rettig, MD1
( E4 E1 v/ I4 T/ LClinical Pediatrics
/ {- R  r1 _& `/ d3 a$ d6 s5 [Volume 46 Number 6& k; `+ I7 |+ z5 j; X% V
July 2007 540-543
8 {2 h$ u4 Q: b4 ^) s5 P) B( _1 |8 E: h© 2007 Sage Publications' i/ m1 n7 Q  B) P0 ~7 l
10.1177/0009922806296651
6 o6 K( [2 d! f, chttp://clp.sagepub.com7 ]0 r/ u0 r  x
hosted at3 y6 a" L7 u3 O- Y9 a9 L* M5 ^
http://online.sagepub.com
( r1 M" H0 v" f6 L7 bPrecocious puberty in boys, central or peripheral,
# j' P% {7 h: U+ _  W+ {6 xis a significant concern for physicians. Central) o$ @( ~# ^& K$ b( i! T* P
precocious puberty (CPP), which is mediated
6 \& Z' ~' d- B' W9 C( N8 ~5 hthrough the hypothalamic pituitary gonadal axis, has# F. h* z5 m1 m( K
a higher incidence of organic central nervous system
. D, O3 I5 u$ j6 D4 n% {% e; n5 jlesions in boys.1,2 Virilization in boys, as manifested' _0 i$ O( [% W, e
by enlargement of the penis, development of pubic
6 u, Z' E& f, e( t4 B$ lhair, and facial acne without enlargement of testi-) L& `) |  q, a: _& f* s; ?. h
cles, suggests peripheral or pseudopuberty.1-3 We
4 L, g7 f& g8 g2 v+ p& Lreport a 16-month-old boy who presented with the
+ X! |* {8 C4 d! Y4 ienlargement of the phallus and pubic hair develop-1 S& ^+ m2 s7 H, b9 C, e% y
ment without testicular enlargement, which was due1 ]% c- |0 H8 r- K5 u& f0 `
to the unintentional exposure to androgen gel used by
, u  e5 {- q1 ~3 Q7 Q4 S9 N4 ~0 jthe father. The family initially concealed this infor-/ ^5 {: [" ]" M! z
mation, resulting in an extensive work-up for this1 i- p' G& t9 I7 u- s$ V; Y
child. Given the widespread and easy availability of" q- L$ i- U8 J1 T
testosterone gel and cream, we believe this is proba-- T& x3 Z" L- R6 x* |$ z6 L# U8 ]
bly more common than the rare case report in the
2 D: ?; f7 C% h( n2 C1 Gliterature.4. ^% U% [' M$ B2 v! T) \# R$ Q/ B2 ]7 W
Patient Report
0 s6 [. }2 v' [A 16-month-old white child was referred to the# w, @0 A" e% |, v" z/ D: W. s
endocrine clinic by his pediatrician with the concern8 T& _) L6 K7 A; b/ N1 o1 M8 h
of early sexual development. His mother noticed
2 a2 l) U6 x0 {  G: A: U7 Slight colored pubic hair development when he was' C5 s8 r: {5 |9 k$ C
From the 1Division of Pediatric Endocrinology, 2University of2 ?0 W# A1 D* g: }1 o$ Z/ z
South Alabama Medical Center, Mobile, Alabama.
  C$ Q$ e9 E2 XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
$ M, j" g$ y; {; t0 b' cProfessor of Pediatrics, University of South Alabama, College of
; Q- `6 v5 K+ T0 |: XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 l4 f8 T, J+ `7 d+ r$ E5 r1 U
e-mail: [email protected].
: H# v# X' n6 \2 Z6 I, Babout 6 to 7 months old, which progressively became
2 P) C, ~( Q1 f- X% Pdarker. She was also concerned about the enlarge-& F; I3 ?: d6 M* B+ G
ment of his penis and frequent erections. The child3 ^5 {. Q& G5 w9 I1 L6 j
was the product of a full-term normal delivery, with/ E) Z# C) a1 a5 S1 }6 ^- S' w/ k& f
a birth weight of 7 lb 14 oz, and birth length of
9 h+ E& F: V% R20 inches. He was breast-fed throughout the first year
. K% B5 E3 N3 ?. w5 }of life and was still receiving breast milk along with
* `$ S7 ]- V6 msolid food. He had no hospitalizations or surgery," `2 k# W8 [* ~9 C1 z5 C  i$ L# {# S
and his psychosocial and psychomotor development
: r7 o" c0 B+ K7 U9 rwas age appropriate.. {: R8 R  x+ d4 V0 J$ L9 k
The family history was remarkable for the father,
* @! B& e: t6 h% @' E7 ^who was diagnosed with hypothyroidism at age 16," }  X9 |7 z4 q, }, H' I
which was treated with thyroxine. The father’s
6 S5 Y; l9 Q4 s0 r" O7 hheight was 6 feet, and he went through a somewhat
  [( n' T/ L# b3 l1 s$ ]4 ?early puberty and had stopped growing by age 14.! E8 O9 b+ o& C( Q# `
The father denied taking any other medication. The: g, I7 J+ ]1 a6 a1 X% K) {
child’s mother was in good health. Her menarche/ }. r" s, r( X6 O
was at 11 years of age, and her height was at 5 feet
8 g% |  n; i! Z& ~* [9 _5 inches. There was no other family history of pre-
/ v  b/ i/ V3 N% h0 ?- z: @cocious sexual development in the first-degree rela-
1 w' v6 h6 g8 s- l. [tives. There were no siblings.
; _9 N; c6 |& h3 i2 f2 [8 F" ~Physical Examination
: P- K" ~" h0 GThe physical examination revealed a very active,
9 A7 I: L7 _) |1 c  ?playful, and healthy boy. The vital signs documented( @8 y4 T4 \" |( T  C6 k5 G* v
a blood pressure of 85/50 mm Hg, his length was. D  q! t# p+ u! ]! U0 N$ x' i
90 cm (>97th percentile), and his weight was 14.4 kg5 k% a1 I% T1 ?( C( T
(also >97th percentile). The observed yearly growth3 U) y* a- n' O3 w: a3 T" a8 X
velocity was 30 cm (12 inches). The examination of
5 j2 `- B8 V7 j* e. c, r; Othe neck revealed no thyroid enlargement.
$ O" |  ^) [5 ^% p5 cThe genitourinary examination was remarkable for
' e6 K) Q8 k+ \0 Fenlargement of the penis, with a stretched length of0 Y" L# ^" F; b
8 cm and a width of 2 cm. The glans penis was very well5 g( O% A$ R: u0 D
developed. The pubic hair was Tanner II, mostly around  L5 v. O6 U! ]# i5 ?
540% n6 X. v  v3 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ z# o4 n: |! D% ^! E0 cthe base of the phallus and was dark and curled. The: y% t/ L$ ~1 F1 h9 S
testicular volume was prepubertal at 2 mL each.
2 q4 z  ]4 `, Z# N# G5 n! o# cThe skin was moist and smooth and somewhat( k% j- f' B1 v! P
oily. No axillary hair was noted. There were no
$ D$ E8 |* a2 ]% Z. Z# Rabnormal skin pigmentations or café-au-lait spots.6 T* |! X) B; K5 q
Neurologic evaluation showed deep tendon reflex 2+
) u" l7 }; f1 k! {; a# ybilateral and symmetrical. There was no suggestion* z6 ~$ J3 v$ m3 H! Z
of papilledema.
/ x1 ^, ~6 _5 B- {5 O, \7 c/ H4 lLaboratory Evaluation+ |0 V+ {7 S1 p% Y; m3 R7 k2 H
The bone age was consistent with 28 months by
% {+ s0 ~8 i: E/ _( ousing the standard of Greulich and Pyle at a chrono-
" Q, s9 }% x8 n! K" F+ q1 v* E* {( [logic age of 16 months (advanced).5 Chromosomal
1 r; q1 G/ G* N' ^  qkaryotype was 46XY. The thyroid function test3 O7 Q# G& l: ~% g/ B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 P3 [$ X" T2 T- s  J* P2 |
lating hormone level was 1.3 µIU/mL (both normal).- G0 s  j8 a$ u; x- R, \
The concentrations of serum electrolytes, blood( P8 U* [. k! |# D6 N
urea nitrogen, creatinine, and calcium all were
( b7 ~$ R! r' c; u1 f  ^0 k# Twithin normal range for his age. The concentration
* x$ B5 \' i9 Dof serum 17-hydroxyprogesterone was 16 ng/dL% p3 h. Q$ @3 O9 l9 j9 _% Q
(normal, 3 to 90 ng/dL), androstenedione was 20
2 K# x9 z: z0 |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) M* h% e/ Y+ U+ R( U/ |terone was 38 ng/dL (normal, 50 to 760 ng/dL),
* w- Y3 I  W% G3 {# i( {0 q6 Jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 h, o( e  \. J! P
49ng/dL), 11-desoxycortisol (specific compound S)- Q0 y4 _: n1 n/ I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. p2 T& _$ X: _/ B- f. \  Wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, R7 p, h' d! ]8 d; Q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, t7 S& `0 r0 W! ^/ h' mand β-human chorionic gonadotropin was less than" r3 u3 E4 J. T# G. ~
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# m- s0 p3 Z- l% @stimulating hormone and leuteinizing hormone) p5 r& J" ^- _/ S2 _3 y
concentrations were less than 0.05 mIU/mL5 o, U! j1 u; u/ J1 N3 T5 @7 m
(prepubertal).2 ]6 J4 w( b& H4 U3 c7 y
The parents were notified about the laboratory
  d9 {! Z9 K, Y' O- Hresults and were informed that all of the tests were
* `( T% n/ _2 f9 s5 `' ^normal except the testosterone level was high. The
0 @/ t$ F9 E: M' j$ N. zfollow-up visit was arranged within a few weeks to" Q, I  P2 Z3 M, U
obtain testicular and abdominal sonograms; how-
7 B; y& o5 H7 b( P5 {ever, the family did not return for 4 months.3 c# r$ Z- k; T- F5 B+ |" m) p
Physical examination at this time revealed that the
0 A2 E5 B) F, i* @4 E6 ochild had grown 2.5 cm in 4 months and had gained
* {3 e: w8 x1 W  x) Q2 kg of weight. Physical examination remained1 I7 b, t, K, z/ ^9 n9 V
unchanged. Surprisingly, the pubic hair almost com-
- ]& F( q0 @2 }, M0 x1 c2 |) xpletely disappeared except for a few vellous hairs at
% p8 A+ K- [7 Xthe base of the phallus. Testicular volume was still 2( S: |( j6 t- m3 S
mL, and the size of the penis remained unchanged.' |0 M# m4 E7 E/ F8 p+ o/ t
The mother also said that the boy was no longer hav-4 w+ B& W/ y$ E9 _( C9 ]
ing frequent erections.& r6 @1 _/ W- H" F/ H. I
Both parents were again questioned about use of4 {4 j$ }1 r1 r2 H! Y' j0 S
any ointment/creams that they may have applied to
3 K9 y9 Q; l. v+ E  F7 q. othe child’s skin. This time the father admitted the
2 X& a" M4 A: ~Topical Testosterone Exposure / Bhowmick et al 541  ?3 D. L6 c" Z. S6 I
use of testosterone gel twice daily that he was apply-
3 B5 s* O' r; ying over his own shoulders, chest, and back area for
% B5 N9 K' v: f$ p2 F7 [0 F5 ^a year. The father also revealed he was embarrassed: Z4 i, V& K+ q1 j8 p) K
to disclose that he was using a testosterone gel pre-
+ V3 [% H: U4 D( x! n* |8 J" kscribed by his family physician for decreased libido5 k* f, ]+ g2 f$ \9 a* k. n% }0 [
secondary to depression.4 r" W' H% Q" L+ v6 q$ K0 s* c
The child slept in the same bed with parents.
  O: Y- S/ Q) mThe father would hug the baby and hold him on his$ L$ Y- [5 g9 [- |
chest for a considerable period of time, causing sig-) I9 c, l# |/ y. k
nificant bare skin contact between baby and father.
) A6 K5 Y( F# b% `7 W$ QThe father also admitted that after the phone call,
% _7 D, I, j" T0 H: |when he learned the testosterone level in the baby
% N( B( L8 j3 Iwas high, he then read the product information6 P$ d3 _$ W/ l* w0 D9 K6 J
packet and concluded that it was most likely the rea-* V4 y5 L" `- N6 H( B, G' N, C
son for the child’s virilization. At that time, they  r3 h- |7 Y2 N- b; S; L
decided to put the baby in a separate bed, and the3 d. n- }1 e) Z$ W
father was not hugging him with bare skin and had9 N8 a, {/ h7 H
been using protective clothing. A repeat testosterone
  `) B& H8 X6 a' h1 {% u! |test was ordered, but the family did not go to the& P2 y* P4 Z. ?/ J% S
laboratory to obtain the test.# w$ u; _2 g9 B6 A- l  V
Discussion! d! J# _8 o$ k0 ?  j7 u
Precocious puberty in boys is defined as secondary7 k! e/ b2 F# f: Z& o; I' X
sexual development before 9 years of age.1,4/ [, e: ?/ p, M8 ]' J# R* A
Precocious puberty is termed as central (true) when* i( R0 [; D- q
it is caused by the premature activation of hypo-
  C; t/ }" K/ y4 B2 Nthalamic pituitary gonadal axis. CPP is more com-
4 ~" y4 Y+ _% e( v4 vmon in girls than in boys.1,3 Most boys with CPP% E" s* V4 Y6 {) k6 G8 S
may have a central nervous system lesion that is
& \/ j' a2 A3 n: D6 u- d' s3 }  Rresponsible for the early activation of the hypothal-
' Q$ n8 E: k: d! x* _3 Gamic pituitary gonadal axis.1-3 Thus, greater empha-" S& S( Q7 {) w; m" V
sis has been given to neuroradiologic imaging in! B0 S& j4 @& r5 [  ]
boys with precocious puberty. In addition to viril-
( |9 @, v, |/ \2 B- t# k! cization, the clinical hallmark of CPP is the symmet-2 w0 t# E4 |9 w  I' j/ j
rical testicular growth secondary to stimulation by
( d/ t2 r  [, b! n+ B4 W6 Ygonadotropins.1,3
0 u& u5 Y3 c9 P+ W- m5 H! kGonadotropin-independent peripheral preco-
% B9 p$ l9 E( V! Ocious puberty in boys also results from inappropriate, p5 n7 A% [- m
androgenic stimulation from either endogenous or( p1 ]* O+ t$ `" @/ {" k! _
exogenous sources, nonpituitary gonadotropin stim-
+ ~; D% c6 v% Pulation, and rare activating mutations.3 Virilizing
- |6 i( e9 f+ V% Bcongenital adrenal hyperplasia producing excessive( W$ S! Z9 u" m7 ~6 V
adrenal androgens is a common cause of precocious
/ y" O) g7 N8 `( @" l4 G- Wpuberty in boys.3,4
! {- @3 M+ l: H- P' wThe most common form of congenital adrenal
% ~  _2 r0 k# Lhyperplasia is the 21-hydroxylase enzyme deficiency., N* o+ N( }: i' s( x9 a) q7 L
The 11-β hydroxylase deficiency may also result in
0 w$ z. U. U* F# {0 X0 a, T  h9 P( qexcessive adrenal androgen production, and rarely,5 |' Q- I% @) }: H
an adrenal tumor may also cause adrenal androgen/ \* U; r% S8 ^; g/ q
excess.1,3; z2 `% q$ `; h1 \. n. K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 F. K3 _. B/ |+ o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* w% `2 d$ |! m9 W$ Q4 KA unique entity of male-limited gonadotropin-
: U+ a* u) N/ zindependent precocious puberty, which is also known. |& a$ R/ v( y" E. ^
as testotoxicosis, may cause precocious puberty at a
/ H* ]5 |! H3 P/ V) hvery young age. The physical findings in these boys4 x$ O% L( Z, a# R8 U$ m
with this disorder are full pubertal development,
7 ?& S/ t/ P  M2 b8 h: I8 r% j5 {( ?including bilateral testicular growth, similar to boys4 S( |' P3 e9 `1 y9 k4 L
with CPP. The gonadotropin levels in this disorder
" Q2 j, e7 H& s3 zare suppressed to prepubertal levels and do not show
+ I8 ?0 a( p) j) Npubertal response of gonadotropin after gonadotropin-1 Y/ f9 H# T3 U8 N4 h; V& Z
releasing hormone stimulation. This is a sex-linked
4 u9 `  p2 V; T# z* N' S% iautosomal dominant disorder that affects only
0 g1 C2 f' t. X+ Imales; therefore, other male members of the family9 R/ N- O, _' f. {
may have similar precocious puberty.3
. l8 `) n1 _5 p! J- cIn our patient, physical examination was incon-
# ^5 N9 n( l1 N9 _/ Nsistent with true precocious puberty since his testi-: d3 K, x8 z) D6 k4 z* }* \
cles were prepubertal in size. However, testotoxicosis
. J$ B7 F. s9 q' t: zwas in the differential diagnosis because his father
' X8 R$ g5 C) J; bstarted puberty somewhat early, and occasionally,
* J4 B0 f1 q7 o0 q7 [testicular enlargement is not that evident in the& ~! q' s+ c) Y. {; ?
beginning of this process.1 In the absence of a neg-
/ s* G& L5 E& ]  m& qative initial history of androgen exposure, our- M" Z& e3 H* P# q. n
biggest concern was virilizing adrenal hyperplasia,
" P) P- T: `; J) E( Z2 ceither 21-hydroxylase deficiency or 11-β hydroxylase5 R5 e' N' B% I+ P; u
deficiency. Those diagnoses were excluded by find-
* o3 c8 o+ g7 x7 ~ing the normal level of adrenal steroids.
1 p' K% X3 J; {# EThe diagnosis of exogenous androgens was strongly1 [% C- Y, u: H2 x5 @
suspected in a follow-up visit after 4 months because; c+ p) H& ^9 D6 i
the physical examination revealed the complete disap-2 ^7 \- J7 j! A- ^, q. h" A
pearance of pubic hair, normal growth velocity, and
9 Q7 z. F7 e( o, T0 R+ R+ |decreased erections. The father admitted using a testos-
9 K' @0 x1 J* f8 _- J7 H2 ?& P# {terone gel, which he concealed at first visit. He was9 I1 [8 F+ a0 U6 Z) F/ y1 R
using it rather frequently, twice a day. The Physicians’5 A, T. z' {1 F. [6 g; v+ C
Desk Reference, or package insert of this product, gel or
% }* E! m0 R  J. q  A8 b/ hcream, cautions about dermal testosterone transfer to
2 {# l2 E& g$ b5 o1 }* s$ K+ Gunprotected females through direct skin exposure.
) x( `6 ?8 G& e+ y. gSerum testosterone level was found to be 2 times the
6 u7 Q2 l& K5 [( p& H4 h( c1 bbaseline value in those females who were exposed to- W$ c; ^4 N( N8 E
even 15 minutes of direct skin contact with their male) z+ S+ L! Y7 `# }! x& y
partners.6 However, when a shirt covered the applica-9 r8 t$ p# k) X; Y+ `# o5 }, p" w
tion site, this testosterone transfer was prevented.
0 k1 ?7 Q, k# Q8 e0 jOur patient’s testosterone level was 60 ng/mL,
* J! B4 W" V' |% `7 g5 E9 Xwhich was clearly high. Some studies suggest that
3 c7 V" j0 j. a0 E* h' `dermal conversion of testosterone to dihydrotestos-9 p; A" q; ]0 S* K  I( G
terone, which is a more potent metabolite, is more2 C! d8 q& m% g! Y
active in young children exposed to testosterone- L  b4 q: R  T
exogenously7; however, we did not measure a dihy-+ L# a  R& a5 h; @
drotestosterone level in our patient. In addition to, Y% J! ]% j5 _2 e2 O. U: N
virilization, exposure to exogenous testosterone in
# z0 G' D! D' O% j" U/ ochildren results in an increase in growth velocity and8 ]* y6 P6 e( }' }
advanced bone age, as seen in our patient.
0 b8 X" q+ w" jThe long-term effect of androgen exposure during
/ d$ p$ t1 _  E* ~3 Eearly childhood on pubertal development and final, q* d' A1 r- q
adult height are not fully known and always remain; ?# |$ b  B6 y: c  }, Q
a concern. Children treated with short-term testos-& i" k* J  X# D5 p$ v. p# a7 W1 ~
terone injection or topical androgen may exhibit some
& y: n+ C. E% r; v5 Qacceleration of the skeletal maturation; however, after- F4 k: f" A( Z& J5 g
cessation of treatment, the rate of bone maturation
5 x9 A5 N0 H/ @/ g, h# Q. udecelerates and gradually returns to normal.8,9
% E4 \& ], e8 k2 }, mThere are conflicting reports and controversy
% _; T5 }, }  y4 rover the effect of early androgen exposure on adult& ~, e1 P) ^* F9 N
penile length.10,11 Some reports suggest subnormal
  c; i+ y* \5 n& U" h5 K5 ^# Uadult penile length, apparently because of downreg-
6 b$ l! N  P6 J9 [' D7 O1 `+ y. }ulation of androgen receptor number.10,12 However,
5 D/ j4 s. K# g/ u% FSutherland et al13 did not find a correlation between
' V. ^! a, j& d1 zchildhood testosterone exposure and reduced adult
: C- S5 D; @: Y# d; wpenile length in clinical studies.
) `$ _& h6 p, {4 n* INonetheless, we do not believe our patient is2 [1 x  }% |$ c  h
going to experience any of the untoward effects from) K- E; l$ j1 ?
testosterone exposure as mentioned earlier because
/ O. m- w; h" B; N, u$ Kthe exposure was not for a prolonged period of time.
8 _* Q& A* D, j+ d: ]* a1 |0 s; jAlthough the bone age was advanced at the time of( e& W" Q  W# {& s  M8 q$ m
diagnosis, the child had a normal growth velocity at
7 X5 y- k( a4 Gthe follow-up visit. It is hoped that his final adult! R: s9 B. E7 `, i0 y& H
height will not be affected.
5 m- R% ]3 i0 |  C6 ^Although rarely reported, the widespread avail-! \& B! ?$ g! {3 w6 ]+ C' }
ability of androgen products in our society may
- f! ?: L& O( ]! J; L( Qindeed cause more virilization in male or female! H; v9 r+ q! C; z! ?1 }
children than one would realize. Exposure to andro-
7 N) A1 f. J: m' vgen products must be considered and specific ques-8 t3 ]5 Y/ I( U/ V- d: {
tioning about the use of a testosterone product or
" Z% n, m* {( `gel should be asked of the family members during
# K+ E6 y  o: {! _the evaluation of any children who present with vir-
" E; S6 ]* w9 p8 R+ filization or peripheral precocious puberty. The diag-
" H1 Y) Q" w0 I/ y. p% b& r. F* d/ Qnosis can be established by just a few tests and by" l$ H$ m8 M  k$ j
appropriate history. The inability to obtain such a
3 R4 w& e: s. }0 _- L- G  y0 }history, or failure to ask the specific questions, may% n$ {3 o- ~, Z
result in extensive, unnecessary, and expensive* n( I4 ~1 Q* \- M5 [6 N
investigation. The primary care physician should be) n+ i- A9 `& E( o- _) R
aware of this fact, because most of these children; h) y) b9 x. \8 `6 f
may initially present in their practice. The Physicians’+ O1 P5 U# Q; b8 A
Desk Reference and package insert should also put a
/ j% Z7 I; s$ W3 F* rwarning about the virilizing effect on a male or: u3 M: ~8 r0 ^& Z, M
female child who might come in contact with some-1 ]2 ?7 t, P# [0 d. `) [
one using any of these products.7 i* a2 b7 ?) P: N
References4 i8 x" Q7 l  B/ e' A" W8 E( ?
1. Styne DM. The testes: disorder of sexual differentiation
" @0 ^, k* p. I6 Z) u/ D8 Uand puberty in the male. In: Sperling MA, ed. Pediatric' _5 o) A7 y) e' x+ ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& e  _# f2 V- c5 r2 t: v
2002: 565-628.
) K# [3 k: a5 y& C6 G; a& Q" F* o2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# C# d! J) Z2 r, j, D* z) l
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old7 J) D; V$ P* J6 m7 \- U
Boy Induced by Indirect Topical
# q* n: o, Q% W* h* H5 y9 M( b) ]Exposure to Testosterone: W8 p/ K6 F5 p1 ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) l2 i! j4 p* }2 J( t. j  L% zand Kenneth R. Rettig, MD1
; h3 I! O# `6 @Clinical Pediatrics; A; E5 B. o7 z! z  ?1 ]3 z
Volume 46 Number 6+ d& T: T- V) u9 Y/ I
July 2007 540-5435 g3 X* ~3 L8 _0 p' m
© 2007 Sage Publications
& M% A& `3 C4 K" C& X+ r10.1177/0009922806296651
3 d% I1 P! @* z4 chttp://clp.sagepub.com1 x5 W' `  _( a& I: I
hosted at  [3 G4 T; B0 i, `; t  u& v2 C
http://online.sagepub.com
# P) E9 K2 C( v2 g. mPrecocious puberty in boys, central or peripheral,
" e" t& m+ J; ^: c3 pis a significant concern for physicians. Central
: p( M2 R$ r; G- b! R+ _/ ]precocious puberty (CPP), which is mediated
* v2 o1 A5 r7 m# {through the hypothalamic pituitary gonadal axis, has
4 J" _. r. ?, }! ya higher incidence of organic central nervous system; X- l) E( M0 I; @' U
lesions in boys.1,2 Virilization in boys, as manifested+ D5 t) y8 ~5 M. p' |
by enlargement of the penis, development of pubic7 e) f* f2 _- C$ L4 _
hair, and facial acne without enlargement of testi-4 L5 l; s8 V6 P' M) t3 j, C/ q' n
cles, suggests peripheral or pseudopuberty.1-3 We
6 S1 O- c5 [* r7 K$ nreport a 16-month-old boy who presented with the) p: E/ W7 u( C, h- B" x9 x- _
enlargement of the phallus and pubic hair develop-/ x4 \' o! Z/ d1 l$ K& K# g
ment without testicular enlargement, which was due/ [2 ~9 B" r  n5 [: C) [9 o  ]8 g
to the unintentional exposure to androgen gel used by; ^4 ^( r: k9 B) Q+ A# p6 v
the father. The family initially concealed this infor-
4 `- h* S% r: \$ \+ Kmation, resulting in an extensive work-up for this
$ h7 F- J# h7 p0 S/ ^( ~: [child. Given the widespread and easy availability of9 Q; }! X4 N. U, m1 w
testosterone gel and cream, we believe this is proba-
$ r, [* J# x2 e5 m9 Zbly more common than the rare case report in the) |! F4 {+ e8 E* S0 P. o6 K
literature.4
  I6 h" M- Z# }4 s- C1 EPatient Report
; f" J( R' @  _1 h9 @* QA 16-month-old white child was referred to the
# u2 |5 _# W- o7 S9 X% hendocrine clinic by his pediatrician with the concern
( L, b1 ]0 M) z$ D% K. Hof early sexual development. His mother noticed
2 o/ H+ `& B) }5 U0 o4 klight colored pubic hair development when he was- u4 q5 y. a' u: B4 m  O
From the 1Division of Pediatric Endocrinology, 2University of; T+ j, s7 l/ Y- [/ K. ?0 y) x
South Alabama Medical Center, Mobile, Alabama.
/ V) X: a$ T9 D2 r/ l/ JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
" l' N4 j1 X) D! t  XProfessor of Pediatrics, University of South Alabama, College of6 r( h- i) N# e- L' l8 |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 t/ p5 Y8 ]& J; Y. H2 P
e-mail: [email protected].
7 S0 f7 x% c. ~: aabout 6 to 7 months old, which progressively became
- K6 \. Z* |) ^darker. She was also concerned about the enlarge-! h/ r. ]. O1 D( I
ment of his penis and frequent erections. The child4 x/ g+ T: A, t& t/ `' V9 Z: e1 w) o
was the product of a full-term normal delivery, with+ M6 v5 V) w) V; s; M
a birth weight of 7 lb 14 oz, and birth length of8 X% Z8 z, a, X7 u$ I
20 inches. He was breast-fed throughout the first year
5 I# n  l  \! d6 sof life and was still receiving breast milk along with/ I3 A8 c" @6 `! s& b( Q2 y
solid food. He had no hospitalizations or surgery,
7 `" r- p' |- B( [: nand his psychosocial and psychomotor development
9 H" R0 S% }( W- jwas age appropriate.  r7 }5 S1 P  v6 Z$ P2 s
The family history was remarkable for the father,
  d& r+ W5 m! G7 V7 O$ owho was diagnosed with hypothyroidism at age 16,  |) q, K+ L' Z( a- V- y
which was treated with thyroxine. The father’s
; d8 ^! H# r, c( K2 Z. lheight was 6 feet, and he went through a somewhat. @1 \. u. y. ^% B8 ^. Z
early puberty and had stopped growing by age 14.* J3 i. j3 x7 N0 _
The father denied taking any other medication. The
" m8 m* H, B! h! {: ~child’s mother was in good health. Her menarche
! R/ c% P4 U. i/ X. uwas at 11 years of age, and her height was at 5 feet
* r' h, z5 W/ e+ G5 inches. There was no other family history of pre-# s; ~$ u$ X. d
cocious sexual development in the first-degree rela-- U( M" \4 Q* V2 E, ?
tives. There were no siblings./ |& R  O5 b3 ~0 V. ^9 F. N
Physical Examination  b" Z8 ~( T2 ^" \( K
The physical examination revealed a very active,
2 F: h6 q( g" @8 p/ b* bplayful, and healthy boy. The vital signs documented
! s6 w0 g1 v. s* ?8 l; w0 sa blood pressure of 85/50 mm Hg, his length was3 r7 @( l/ Z- y$ o
90 cm (>97th percentile), and his weight was 14.4 kg4 q# Q' X1 I; p: O, }* P
(also >97th percentile). The observed yearly growth* {' X# R- e. U! G% z! W
velocity was 30 cm (12 inches). The examination of5 b  b$ P2 ?2 ]& G# Z& R
the neck revealed no thyroid enlargement.0 B; d' y5 v- K$ `& |
The genitourinary examination was remarkable for
3 K' p. O% j* o7 ^, uenlargement of the penis, with a stretched length of% p; H/ v7 U; l1 c3 w  P. P+ M
8 cm and a width of 2 cm. The glans penis was very well
& T/ o9 {' P) f) U, X; Z5 ideveloped. The pubic hair was Tanner II, mostly around
- g5 m& J- T6 x* A540% [% U. N' V0 \. V- S' _; D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, x' b" I6 l% v/ h! J4 W3 W
the base of the phallus and was dark and curled. The
. T3 d3 k0 }) S' h( F5 S$ xtesticular volume was prepubertal at 2 mL each.  V+ i: }5 z9 Y: {
The skin was moist and smooth and somewhat
! |- [9 Y4 T$ e5 h6 hoily. No axillary hair was noted. There were no
& [6 D0 \! `9 m5 habnormal skin pigmentations or café-au-lait spots.
; }; |3 N0 p: dNeurologic evaluation showed deep tendon reflex 2+; y; S3 b, F* Q& _% ?1 p
bilateral and symmetrical. There was no suggestion7 Z9 ?  X( K0 \! l; U; E3 z  P
of papilledema.
/ C  X& m" @. p9 n* g7 w) E" A; H5 rLaboratory Evaluation
( f% H, |7 ]: L! B5 y. p; ?' gThe bone age was consistent with 28 months by, B4 |7 l: m& I: X& b: c- K
using the standard of Greulich and Pyle at a chrono-
3 a; G6 C3 N9 L- D* f' vlogic age of 16 months (advanced).5 Chromosomal
' e; _* k: i( [3 a0 i. Xkaryotype was 46XY. The thyroid function test0 x0 A# M6 O- O! v! ~% f' G3 ^
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 `9 a9 c% h, q# F$ \2 K$ W
lating hormone level was 1.3 µIU/mL (both normal).
" r- C" x6 p3 RThe concentrations of serum electrolytes, blood
: J4 V3 R& H; u2 p  Lurea nitrogen, creatinine, and calcium all were
. L( v% W# I3 ]: awithin normal range for his age. The concentration
, Q- i' M* `9 a7 o% B3 Fof serum 17-hydroxyprogesterone was 16 ng/dL
- ~: x& g/ x; D) j% C1 \& m(normal, 3 to 90 ng/dL), androstenedione was 20
0 h' \& N+ c8 }  H, f* Z! x: O: xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 R1 j" L3 V+ d( s3 K5 p* D( w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 ]9 D3 N4 o8 h7 m/ S  Y9 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ x; w8 {& F( Y$ F+ L
49ng/dL), 11-desoxycortisol (specific compound S)
; A- j  ^! p( {, k8 E- A$ pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! ^, C9 T7 ?0 r) ^' ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 o9 ~4 H1 _  u: `4 i& U: h$ F; r4 f& x5 gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! I$ d% e0 v+ Y6 R; Cand β-human chorionic gonadotropin was less than; [9 p, D  S- \% h% A% t: ]0 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 ^2 ^4 Q& N7 Y! F6 `. ^8 [# k5 v2 ostimulating hormone and leuteinizing hormone  P0 ]  l. N. ]( z, o. ]1 y1 U
concentrations were less than 0.05 mIU/mL
' i) ]( a! l) J8 _% Z(prepubertal).
# g8 J2 V9 X7 a/ \- r2 wThe parents were notified about the laboratory% I$ c2 K4 `6 ~2 \% M* L5 T; O
results and were informed that all of the tests were2 K2 n1 o6 S3 I; \6 ^
normal except the testosterone level was high. The
$ ?) \% |5 V2 R/ P; jfollow-up visit was arranged within a few weeks to* I3 [8 F4 v& `8 B
obtain testicular and abdominal sonograms; how-
# w: A/ s, D/ P! `* `2 gever, the family did not return for 4 months.
* X0 q# D, G& U" z5 C( l$ D; VPhysical examination at this time revealed that the
8 Z) I$ k4 S+ B5 y8 K1 }( B- Hchild had grown 2.5 cm in 4 months and had gained
, F( }5 b8 I. S0 F8 s2 kg of weight. Physical examination remained* G5 ?4 {3 k  L
unchanged. Surprisingly, the pubic hair almost com-
' \8 a6 _5 X, {5 T3 O" Mpletely disappeared except for a few vellous hairs at
# t  f5 e9 C9 B& h1 U1 @' tthe base of the phallus. Testicular volume was still 21 ]8 }, p# V8 j# n3 U
mL, and the size of the penis remained unchanged.
- a- ?7 o7 n2 ?1 s! v& qThe mother also said that the boy was no longer hav-( |- E. f; Y. h. l
ing frequent erections.
( G, w. M, d: z# K% \" q, sBoth parents were again questioned about use of5 O4 C" `2 ]6 i
any ointment/creams that they may have applied to" P+ E. g% k& N) z, g8 P8 D
the child’s skin. This time the father admitted the
* i1 E; Y9 E' Y( R! z* b# C9 VTopical Testosterone Exposure / Bhowmick et al 541. ]; t! P2 [- R
use of testosterone gel twice daily that he was apply-
( M5 y( e* Y9 Ling over his own shoulders, chest, and back area for
5 k! g5 ~2 C6 e. W' U: Ia year. The father also revealed he was embarrassed, o' z$ e! h2 i4 y8 I
to disclose that he was using a testosterone gel pre-
" T( ?6 A' J( r, R5 c. g" ]5 _: vscribed by his family physician for decreased libido
. T4 t# z  C; H) ^2 W" tsecondary to depression.  B2 t% w+ {( i; E( [% l
The child slept in the same bed with parents.9 g: a7 s, ]( l& Q/ |
The father would hug the baby and hold him on his( W/ G# ~/ f+ ]- K  b4 |  `
chest for a considerable period of time, causing sig-5 F' e8 x2 I' ]; E3 o
nificant bare skin contact between baby and father.
& e( {5 u+ W$ e: u7 ?5 W' l: c+ NThe father also admitted that after the phone call,
4 ~" c8 g' e" C* l: Y  b, hwhen he learned the testosterone level in the baby
, g6 G( j( J% l0 P0 \was high, he then read the product information
+ B8 B, B2 S# \6 w! Y0 ypacket and concluded that it was most likely the rea-1 m; G+ e$ W$ }1 f2 Z2 n7 t
son for the child’s virilization. At that time, they
$ F: ]( S7 `3 a4 P; }$ H( p; ]decided to put the baby in a separate bed, and the; L1 a" G7 _" m, j' h5 n) y
father was not hugging him with bare skin and had$ ~8 g9 W/ q$ O3 |4 t5 S3 b1 @3 |
been using protective clothing. A repeat testosterone
+ |) h; |: i- l- Y* _9 Btest was ordered, but the family did not go to the
# V8 M( R. n' k7 T% ?+ Q) P" alaboratory to obtain the test.
' C& `8 ]! q! m# T* |Discussion) T( C) J2 z) H  W
Precocious puberty in boys is defined as secondary2 @$ w6 T' M9 f' m6 P4 w  ~
sexual development before 9 years of age.1,4
% e) E) A% D& ^Precocious puberty is termed as central (true) when
! s/ Q! M) I7 Tit is caused by the premature activation of hypo-
! D6 Z9 o, M4 `0 ^3 Y" Zthalamic pituitary gonadal axis. CPP is more com-  ?, r% t. }- ]# N! x
mon in girls than in boys.1,3 Most boys with CPP" [$ z$ ?' D4 r# R4 D% `
may have a central nervous system lesion that is
7 y, V2 x' d% W" R! _. ]responsible for the early activation of the hypothal-  d- S! z- o! B8 e4 T1 p: p9 i
amic pituitary gonadal axis.1-3 Thus, greater empha-
' S" j) P( P, Ysis has been given to neuroradiologic imaging in/ \/ g7 `7 W* Y9 r2 ]0 @* l4 O
boys with precocious puberty. In addition to viril-
6 g/ w+ m% B) t+ x; t9 J' p5 gization, the clinical hallmark of CPP is the symmet-% B: M  S6 E" c1 F; A
rical testicular growth secondary to stimulation by- W7 O, Z6 b( D! I4 J6 }* H
gonadotropins.1,3: ^4 W0 {, z$ {) F
Gonadotropin-independent peripheral preco-( s6 E- z! p1 K/ o1 o$ h
cious puberty in boys also results from inappropriate
; P, ?6 P- _' r5 dandrogenic stimulation from either endogenous or7 V+ I/ Q% p8 {
exogenous sources, nonpituitary gonadotropin stim-; p. ]& x- h7 S+ c3 _4 V
ulation, and rare activating mutations.3 Virilizing
& T. P) p' i) F5 W* econgenital adrenal hyperplasia producing excessive; |' P  [2 M; Z) [8 A
adrenal androgens is a common cause of precocious7 p- ~% K# M- X8 g6 e& R/ v1 T
puberty in boys.3,4
& F3 K0 ~* r9 q& H+ LThe most common form of congenital adrenal
2 I' R/ T7 L2 a" lhyperplasia is the 21-hydroxylase enzyme deficiency.
; b* Q4 U0 P0 _4 i  uThe 11-β hydroxylase deficiency may also result in
) Q( W; Y3 M! S0 L7 E/ q$ oexcessive adrenal androgen production, and rarely,0 s( C. M- \$ v4 d% l$ N: M; U
an adrenal tumor may also cause adrenal androgen7 d* \+ R  i4 c. R' u. q" n$ v5 A
excess.1,3
9 T/ s3 _! _; ~. L) U) ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 i( c1 x! u7 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 o& M" @5 z/ F( f9 {! X/ Q2 w! D
A unique entity of male-limited gonadotropin-. Y$ g/ l. r( [2 |( w0 ^9 G5 j" E
independent precocious puberty, which is also known" J' D- {, p: y/ f( c
as testotoxicosis, may cause precocious puberty at a+ m. P  u5 l  T& n5 J  e9 n# l; W
very young age. The physical findings in these boys
0 e7 ?5 G7 P, H% }  W' U8 Fwith this disorder are full pubertal development,$ v8 z: [0 Q) F/ E3 e- Z$ d
including bilateral testicular growth, similar to boys
5 K! h/ Z8 f" }with CPP. The gonadotropin levels in this disorder- \/ p$ x- p9 Y0 d: B7 v" u
are suppressed to prepubertal levels and do not show" ^) R; S7 U2 ?, B  S% V1 r% J
pubertal response of gonadotropin after gonadotropin-+ ]6 u9 ~+ Y- {2 U+ N
releasing hormone stimulation. This is a sex-linked
# r( y& `# T; L/ g, a4 \' B% Nautosomal dominant disorder that affects only3 Z3 o: O1 }$ p" f! w: d7 n
males; therefore, other male members of the family4 l6 {/ {+ a# q2 L7 @! v! k! z
may have similar precocious puberty.3. {& r$ K( Q4 e- j9 d9 J
In our patient, physical examination was incon-
2 y# ~5 G- u9 r  R% [$ ksistent with true precocious puberty since his testi-3 Y4 {+ }, K- M5 k7 Y2 X7 M5 r3 j
cles were prepubertal in size. However, testotoxicosis- Q' ?: g3 U& Z& l8 Z* v1 b
was in the differential diagnosis because his father
( ^7 ]( L/ g& D' ystarted puberty somewhat early, and occasionally,
# _+ A) E7 p7 M& M7 ]* Utesticular enlargement is not that evident in the# C/ p; A: ?* J- J# |
beginning of this process.1 In the absence of a neg-
% F- i, Q; K. K: N8 K& C  ]  W+ cative initial history of androgen exposure, our
" {/ m0 q& [& Y8 z1 @3 E$ Abiggest concern was virilizing adrenal hyperplasia,
. U0 \: B! }: Heither 21-hydroxylase deficiency or 11-β hydroxylase
  B; h1 t# Y2 Q( B! v+ Jdeficiency. Those diagnoses were excluded by find-/ l$ [3 Z* t$ m: s7 k* y3 N* m
ing the normal level of adrenal steroids.5 T) L# b; p5 }9 M7 ?+ L
The diagnosis of exogenous androgens was strongly2 S& S% c( c' U4 g
suspected in a follow-up visit after 4 months because
$ D  ~0 G" F- U. G7 rthe physical examination revealed the complete disap-
( Y; }6 }, q2 spearance of pubic hair, normal growth velocity, and
" u# ^* _4 T, u9 h9 B# @3 ddecreased erections. The father admitted using a testos-+ U) P" l. ]* c' @2 ^1 _
terone gel, which he concealed at first visit. He was
  S" X" C2 g1 q! m- d: G! Wusing it rather frequently, twice a day. The Physicians’
- A4 T- I3 _) GDesk Reference, or package insert of this product, gel or
7 }5 e7 z: j5 \( _9 g+ ~cream, cautions about dermal testosterone transfer to
3 ~/ Y& Y8 O$ Q; U, U0 d7 `7 n2 ^unprotected females through direct skin exposure.
7 I" q! Y# f! ZSerum testosterone level was found to be 2 times the
& L, ^8 y" z& O* G& c5 jbaseline value in those females who were exposed to
9 ~4 C% A. h( beven 15 minutes of direct skin contact with their male0 N5 F$ [# V+ T( e9 G' B* \
partners.6 However, when a shirt covered the applica-
5 C9 Q# g, D: d5 k" ]tion site, this testosterone transfer was prevented.
+ {5 m' U- D+ {9 [Our patient’s testosterone level was 60 ng/mL,
# d; R3 d5 t* Swhich was clearly high. Some studies suggest that( G8 V% E: H, e
dermal conversion of testosterone to dihydrotestos-
5 E3 q- u5 `. K5 p4 Uterone, which is a more potent metabolite, is more6 ]8 }* z) Z0 q
active in young children exposed to testosterone) E( H# k$ D; _0 }* E0 `! n- @
exogenously7; however, we did not measure a dihy-9 B5 J9 c9 J* b1 l6 H. z6 |  c
drotestosterone level in our patient. In addition to
4 p; C8 g' L+ z# y0 M0 hvirilization, exposure to exogenous testosterone in
5 ?" ?& C$ D( dchildren results in an increase in growth velocity and
( V% o, z/ \% Eadvanced bone age, as seen in our patient.1 y) `( ~: t4 b6 e, u, ?8 K
The long-term effect of androgen exposure during
* a: x7 C5 V8 w* {early childhood on pubertal development and final
( g* E: F+ _+ s6 a0 E) ]3 `adult height are not fully known and always remain3 i% h8 {/ H! m1 o- ]0 Y
a concern. Children treated with short-term testos-) h2 F& X3 |4 L" F" L3 O' N+ f
terone injection or topical androgen may exhibit some
' I! G2 }1 M& r, U' Facceleration of the skeletal maturation; however, after
9 ?+ Y, K: F+ Y! Tcessation of treatment, the rate of bone maturation
6 P- Q! Y5 M" L6 o* B/ mdecelerates and gradually returns to normal.8,9/ N" D- ^3 R2 P  V: ~/ |
There are conflicting reports and controversy
+ g! }4 V0 i# t2 {3 a# v# [5 L% yover the effect of early androgen exposure on adult, l2 t/ H7 @5 ~" D; p$ j
penile length.10,11 Some reports suggest subnormal
" E5 I* ?4 a. l2 y/ o/ Kadult penile length, apparently because of downreg-* c# |+ \& z1 D8 ?' H% X
ulation of androgen receptor number.10,12 However,' C- H' P7 i% D: H
Sutherland et al13 did not find a correlation between+ t6 @  k3 z9 A3 X3 k5 w7 U
childhood testosterone exposure and reduced adult4 A' Z3 @4 r" e
penile length in clinical studies.
( Z+ c4 V( s+ t- z+ Y6 \Nonetheless, we do not believe our patient is
0 a) |  n, D* o0 k; ngoing to experience any of the untoward effects from
4 N2 i0 S5 t2 d* Otestosterone exposure as mentioned earlier because
( B  M8 L0 _1 j! E5 x6 I5 Uthe exposure was not for a prolonged period of time.
; h+ d  m) F! _/ b" [3 c. L& eAlthough the bone age was advanced at the time of/ J/ |0 e# K- f
diagnosis, the child had a normal growth velocity at9 K5 h1 p2 U6 P2 ~
the follow-up visit. It is hoped that his final adult. A) T/ P& l  d7 }, _, d. w
height will not be affected.
4 b  {* R8 _( J+ K' R8 r6 IAlthough rarely reported, the widespread avail-2 k0 T7 c- E2 [1 E( y0 P
ability of androgen products in our society may" w& w, X/ B9 `4 Q, J
indeed cause more virilization in male or female; g1 r; _/ l% c0 }5 c( }
children than one would realize. Exposure to andro-
5 C* T3 H" w  ]# H' kgen products must be considered and specific ques-4 P3 i/ m( T8 W6 ^; ^
tioning about the use of a testosterone product or
" K3 G" s5 d# J$ @4 m/ F1 agel should be asked of the family members during
) {- Q) f- Y* ~, ~6 Q' C1 H- Gthe evaluation of any children who present with vir-
& @; L) A* K1 |8 V1 rilization or peripheral precocious puberty. The diag-4 W, U( |4 `6 K: I& }% O8 D
nosis can be established by just a few tests and by& V& w! }; _" v9 C" R! Q( v  z& z$ N
appropriate history. The inability to obtain such a4 b" G% r) `) |' r: D; _; H6 i, r
history, or failure to ask the specific questions, may+ ]0 K% @. c2 F4 q9 w
result in extensive, unnecessary, and expensive
+ x4 m2 M$ z/ u! sinvestigation. The primary care physician should be9 T0 ?, ~+ ^; H3 y9 T( L3 k9 X. Q" ?
aware of this fact, because most of these children
# A# f) N, O( c  o8 b, ~) @6 ?may initially present in their practice. The Physicians’5 W' k; y$ M0 g& M* I! ]( Y' {
Desk Reference and package insert should also put a
9 S8 f5 w7 C! s! Z' Dwarning about the virilizing effect on a male or+ |( `8 M2 X, O( f& w' J9 [
female child who might come in contact with some-  e/ s& a; Q- Y/ l' O+ C  @5 Z: l$ T
one using any of these products.* C2 U1 l' J! u3 ~. h4 s
References
! G. |/ p/ X# F& A- i! S8 Q1. Styne DM. The testes: disorder of sexual differentiation
! c) s3 ~  Y. ]6 i& Xand puberty in the male. In: Sperling MA, ed. Pediatric
6 }  \  Z- L' \$ c# t5 {% @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, c1 `2 j, W, @$ m
2002: 565-628.
4 _3 [3 g6 r! @2 @2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: u" N7 `% S! Q9 L0 a( c* O( v
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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

: ]# O# e, ?' X+ Y2 b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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