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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
$ L; g* e; b8 K; W, d! V- Q% pBoy Induced by Indirect Topical  M& V! u* U$ a0 v5 ]4 T
Exposure to Testosterone  q) b+ |; ^0 T$ d  v( x
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# ]7 N" [* b9 Z" Aand Kenneth R. Rettig, MD1: P: ^0 F' S4 u( i+ x+ y
Clinical Pediatrics
# K1 F' R* q0 }5 k+ i$ e. J+ K; S  TVolume 46 Number 6/ M6 m1 @, E9 Z" a# I9 R
July 2007 540-543
: e8 L0 f  Q5 Z( G5 L© 2007 Sage Publications) i6 K$ e' b: y6 ~
10.1177/0009922806296651: t9 `4 V' a0 W& l- ?
http://clp.sagepub.com
2 I0 C6 S, h2 j  k/ ~( G4 d8 chosted at
; f3 g3 z* {/ B4 u/ k8 qhttp://online.sagepub.com
2 O6 s- N8 ?! B* GPrecocious puberty in boys, central or peripheral,
) Q5 A; _& W2 his a significant concern for physicians. Central
* s0 K1 y9 z6 B% O/ ~' [! Jprecocious puberty (CPP), which is mediated: q+ e. h0 w( |! L% b7 Q& t8 Y
through the hypothalamic pituitary gonadal axis, has9 }+ A/ q- V9 e; Z
a higher incidence of organic central nervous system6 D0 F2 K9 N: w) V9 ?
lesions in boys.1,2 Virilization in boys, as manifested2 o$ p4 F9 R" ?0 w
by enlargement of the penis, development of pubic
( t0 b" Z' g+ zhair, and facial acne without enlargement of testi-
, s0 c% L% i  z* t6 U2 C5 lcles, suggests peripheral or pseudopuberty.1-3 We" u/ J; ?8 ?' M  Q( X
report a 16-month-old boy who presented with the7 Y, R5 _8 H$ h& X" }1 @9 Y9 A9 h# u
enlargement of the phallus and pubic hair develop-
, ^/ t) v9 c! Y2 |" s& r) C0 oment without testicular enlargement, which was due, V/ V# M  g# T5 x% v3 ?& g
to the unintentional exposure to androgen gel used by
0 C/ {2 _/ `3 N% ~: ?' C9 Othe father. The family initially concealed this infor-* k& O9 U& X3 c  e, U+ d
mation, resulting in an extensive work-up for this! l5 T& K7 ~# O' a/ j
child. Given the widespread and easy availability of
+ j' b/ ]! c9 ntestosterone gel and cream, we believe this is proba-
7 @- {$ }. f0 o! jbly more common than the rare case report in the! H8 [7 v/ B- @6 b' ~, k. P
literature.4
4 `8 r9 p* L$ uPatient Report% k) O5 S) j' K, A7 ]# u. Z
A 16-month-old white child was referred to the
+ p- {( v8 I/ @( K% D2 Bendocrine clinic by his pediatrician with the concern
- s( a* R" {! wof early sexual development. His mother noticed; ~" y( {- q: t7 f
light colored pubic hair development when he was
7 B$ k1 {+ i' QFrom the 1Division of Pediatric Endocrinology, 2University of
' l9 X4 J: Y; lSouth Alabama Medical Center, Mobile, Alabama.
  C' J0 R1 {# OAddress correspondence to: Samar K. Bhowmick, MD, FACE,: p: z& O( V# v4 B  |7 f9 }0 ~
Professor of Pediatrics, University of South Alabama, College of$ q* M; V' A' K4 i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& l% u4 y6 v# W5 o! R( Ne-mail: [email protected].
: S/ a6 W# l) c7 habout 6 to 7 months old, which progressively became
( h0 F" f. ~: `$ Ydarker. She was also concerned about the enlarge-; B2 J. k1 _, R1 ?
ment of his penis and frequent erections. The child7 g: o0 ^* u5 T( y) V8 ~6 ?% _4 L
was the product of a full-term normal delivery, with
: L( p0 M/ \+ Y. wa birth weight of 7 lb 14 oz, and birth length of) C4 g7 b7 _0 D& g0 Y3 G
20 inches. He was breast-fed throughout the first year. D1 c3 f# U3 w5 l
of life and was still receiving breast milk along with: B* a  f7 |' G) Y( t$ |
solid food. He had no hospitalizations or surgery,& t" Y; x) Q7 x$ _
and his psychosocial and psychomotor development
9 |# u1 a: X! c, B# @' Uwas age appropriate.) m/ F& B# J9 e' I) v/ o( a
The family history was remarkable for the father,
- L" _7 {) R& g3 V9 A$ \  cwho was diagnosed with hypothyroidism at age 16,- n$ B6 b& ?2 y5 U3 \4 b
which was treated with thyroxine. The father’s9 P# |* f! T6 U1 |
height was 6 feet, and he went through a somewhat
/ b7 B6 R3 b1 g* n& e* |early puberty and had stopped growing by age 14.8 c7 B" y  t2 ?+ I- z1 a8 D7 Y
The father denied taking any other medication. The
# v- }  M- M) X3 pchild’s mother was in good health. Her menarche% Y1 S  {6 [0 }8 B& t1 W
was at 11 years of age, and her height was at 5 feet
) {' H3 L- W& P7 H; h5 ?9 p5 inches. There was no other family history of pre-
: K8 u* Y4 F1 ?$ k+ _3 @. \cocious sexual development in the first-degree rela-! l% s3 `# J; F! S! `+ t
tives. There were no siblings.
8 C2 o- ]8 m7 {$ `- w. {Physical Examination/ F/ q2 D! K, y, k0 A' a9 N
The physical examination revealed a very active,
. |1 |" ^' ~6 N# Qplayful, and healthy boy. The vital signs documented. L4 Y  y2 b6 ?! E5 C
a blood pressure of 85/50 mm Hg, his length was
* @+ f+ d" G& e+ E- D8 g. ]* f/ x90 cm (>97th percentile), and his weight was 14.4 kg
4 {  G% m' H8 L(also >97th percentile). The observed yearly growth
- U1 `, {1 k( q/ r/ n$ w) @& X# `8 Xvelocity was 30 cm (12 inches). The examination of* d0 M4 M. T$ _7 @9 J1 f4 B9 A
the neck revealed no thyroid enlargement.7 k' z% }9 ]9 B/ C' {
The genitourinary examination was remarkable for
. k$ k" x- H0 L& @. z$ a6 Menlargement of the penis, with a stretched length of: H  @) ]& y# ~1 ?: P& |7 m
8 cm and a width of 2 cm. The glans penis was very well
# ]) v% C" u9 V/ g7 c& vdeveloped. The pubic hair was Tanner II, mostly around
6 }1 o" a' ~; i) G5407 `  a0 |4 t, j4 D$ N, S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 s$ X+ t, v/ k% Athe base of the phallus and was dark and curled. The7 p: @5 J* D* Z4 K/ Z
testicular volume was prepubertal at 2 mL each.( Y. N5 K+ \6 `, D/ i
The skin was moist and smooth and somewhat
0 D( I, O  ?* ~' F% [: |$ qoily. No axillary hair was noted. There were no8 s. \/ l4 {5 N! i
abnormal skin pigmentations or café-au-lait spots.
7 u* z5 k( ~9 x/ ~  y! b+ x3 `Neurologic evaluation showed deep tendon reflex 2+, A( p; @- u4 T$ `1 `1 U) M  \
bilateral and symmetrical. There was no suggestion# L5 P" l( `  ?0 h/ I/ s7 l
of papilledema.
# U( z( M* Z. C+ K8 G! O6 i9 CLaboratory Evaluation
7 v. Q  s9 ^( D2 U7 x4 c! C2 zThe bone age was consistent with 28 months by
+ z5 c/ Y: a) }4 y# h3 j# pusing the standard of Greulich and Pyle at a chrono-+ g; ]! \+ r( f4 O+ c
logic age of 16 months (advanced).5 Chromosomal" B. \: f7 w2 U$ u* g6 Y7 w
karyotype was 46XY. The thyroid function test
' O' v8 ^5 e5 F* n2 ?9 f3 qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-/ f8 q* D  r; E, \" H6 g
lating hormone level was 1.3 µIU/mL (both normal)." H# q$ a4 R' m2 {5 W0 u. F
The concentrations of serum electrolytes, blood
: p! y2 g- V$ _9 kurea nitrogen, creatinine, and calcium all were  g) @) M5 @, B5 c% A
within normal range for his age. The concentration
! ^# E: J# L6 P2 r% }' c0 jof serum 17-hydroxyprogesterone was 16 ng/dL
( H6 p" J, R0 w(normal, 3 to 90 ng/dL), androstenedione was 20
  b( @; k6 L! f$ F4 u. h7 }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 I9 K" ~+ u6 n  `$ w. u! }5 ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ i% l7 Q2 n! d" P; K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ R* K$ J2 F' D$ E7 V$ w4 m+ }49ng/dL), 11-desoxycortisol (specific compound S)
3 }+ M$ P$ x% f5 z/ `) [5 |6 {was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; N8 r  _1 E9 |; l( d! p1 t9 @5 k  i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& B5 M' U! i, u# |) rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" a0 b; E- L6 q: M5 L8 F. \3 Iand β-human chorionic gonadotropin was less than0 y/ i6 u0 n' S! [4 L) j! l7 l: R
5 mIU/mL (normal <5 mIU/mL). Serum follicular( ]" _: H% ]0 \; ]. E
stimulating hormone and leuteinizing hormone4 _+ u0 E8 I' \$ q) W
concentrations were less than 0.05 mIU/mL
8 p. X. |7 Z4 q. Z* Y8 \( B7 c(prepubertal).
* S9 s/ p3 e2 z2 CThe parents were notified about the laboratory
$ M3 a  {/ f6 u- w3 |results and were informed that all of the tests were9 R8 r2 S$ A- C; }
normal except the testosterone level was high. The7 y5 `3 e# I: `( j) \: r- f
follow-up visit was arranged within a few weeks to& x$ z9 }4 W5 @7 m2 }2 F! C
obtain testicular and abdominal sonograms; how-
9 W9 {3 ~) O9 @1 `ever, the family did not return for 4 months.
- `+ p7 m. y% {0 C8 S6 ~' FPhysical examination at this time revealed that the! j1 S: V: q: q9 d; [
child had grown 2.5 cm in 4 months and had gained$ |3 q, n) W( L  N( L
2 kg of weight. Physical examination remained5 W) v5 p) `( x) ?  J! P
unchanged. Surprisingly, the pubic hair almost com-9 T: _, j. `! w4 a" Z
pletely disappeared except for a few vellous hairs at0 c4 X  R  y  ~- a) X% X
the base of the phallus. Testicular volume was still 2
3 J" P4 Q( u9 d3 N, w! ZmL, and the size of the penis remained unchanged.
/ S2 w* l! r8 d" O# v7 R( nThe mother also said that the boy was no longer hav-) n" b1 M$ v0 [/ [: e  @. a
ing frequent erections.1 l  }% i. V! z, P/ h1 t
Both parents were again questioned about use of
8 e' ]. h) b/ l  b8 N# H! {6 Bany ointment/creams that they may have applied to8 r6 _+ t! {7 {9 {& g
the child’s skin. This time the father admitted the2 a6 f& I3 T8 Y; z- R3 _: i
Topical Testosterone Exposure / Bhowmick et al 541
) G! L6 ~9 l( D9 Y0 L% R! n4 K! \use of testosterone gel twice daily that he was apply-/ s. r/ Y* g* d+ L4 [1 P
ing over his own shoulders, chest, and back area for/ @2 |  l! e( N" W
a year. The father also revealed he was embarrassed4 u5 I. q. M/ u
to disclose that he was using a testosterone gel pre-
" Z# I5 F/ m0 v# H' T$ zscribed by his family physician for decreased libido
) z: U  U* C8 g# D3 K! Q% rsecondary to depression.* g0 M" {7 W* c& U
The child slept in the same bed with parents.
8 `: Q/ j/ ]# S$ i9 N0 Z# o1 kThe father would hug the baby and hold him on his
8 G4 D3 n" B) c8 o( Vchest for a considerable period of time, causing sig-0 d5 \' I: \! y, m, T5 ~5 _
nificant bare skin contact between baby and father.. V# r/ ?4 M" [6 ?+ u* p
The father also admitted that after the phone call,
/ Z6 n' s( o4 uwhen he learned the testosterone level in the baby8 N/ _2 u) n" o3 Z$ D' y
was high, he then read the product information
$ J! ]) Y/ t7 w( [packet and concluded that it was most likely the rea-
& m1 a: G7 T8 \" cson for the child’s virilization. At that time, they! q0 B  _: e2 `9 d# X# M
decided to put the baby in a separate bed, and the
2 ~  O7 b6 |) Cfather was not hugging him with bare skin and had
$ `, ^% P  H/ I. n. U! s( u, k% ubeen using protective clothing. A repeat testosterone/ }; x$ Z+ Z3 W8 I& J$ e
test was ordered, but the family did not go to the
4 b$ Y' t) q* Nlaboratory to obtain the test.
7 Z* O, ^2 S: K. b3 KDiscussion- N8 F4 G4 g4 o4 m
Precocious puberty in boys is defined as secondary. O$ t) u2 ~8 O, v1 Z0 D" A! c
sexual development before 9 years of age.1,47 B8 ~. `& a8 T: \. ^% f" E0 N
Precocious puberty is termed as central (true) when8 P+ \2 }  ]+ |& x
it is caused by the premature activation of hypo-# R, s& ^' h% B3 O/ b8 Q$ X
thalamic pituitary gonadal axis. CPP is more com-8 v( ]2 G3 y$ S8 ~
mon in girls than in boys.1,3 Most boys with CPP$ U1 M7 _# n6 K  t' U
may have a central nervous system lesion that is) n; D1 e5 R% o
responsible for the early activation of the hypothal-7 I! ]2 y0 t! Z/ X4 G1 e( G
amic pituitary gonadal axis.1-3 Thus, greater empha-
. }) e! J. H3 m0 w/ _3 M: usis has been given to neuroradiologic imaging in
" H) D8 }6 Z  _9 P: M9 E  dboys with precocious puberty. In addition to viril-. ^6 E7 k$ o6 `/ g6 C4 B
ization, the clinical hallmark of CPP is the symmet-; R! ], w: r! g, b& P9 J# S
rical testicular growth secondary to stimulation by
% b1 f* x* W3 P1 Sgonadotropins.1,3* _: L! A, a  p7 I* c/ G; X
Gonadotropin-independent peripheral preco-9 y7 b. {; b6 e5 K
cious puberty in boys also results from inappropriate
) Z" T. Q3 p- g0 V+ D2 ]androgenic stimulation from either endogenous or
" l8 j, @' v3 }6 Z" X6 B& u: oexogenous sources, nonpituitary gonadotropin stim-; g/ h+ K3 z2 u- V
ulation, and rare activating mutations.3 Virilizing" O1 M: R) W% q6 e  @- r8 [( Z
congenital adrenal hyperplasia producing excessive( Z9 _$ i2 X7 F! g
adrenal androgens is a common cause of precocious0 W3 P1 G, ~# d
puberty in boys.3,45 r6 c  n. ]" ]5 D+ Q1 [
The most common form of congenital adrenal8 T: L. I. o( a3 B
hyperplasia is the 21-hydroxylase enzyme deficiency.' g. w% e: L* f& J" @" J, Y
The 11-β hydroxylase deficiency may also result in1 y9 O, ?" \2 _; s
excessive adrenal androgen production, and rarely,
9 ?* ^3 }) {4 X5 ?" t4 @an adrenal tumor may also cause adrenal androgen' G) O* A% m# Y+ K
excess.1,33 c: Q) L/ e4 I* f$ Q1 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ n$ f- p! [% C- `+ k  n9 o542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 {' C* Z- s+ d
A unique entity of male-limited gonadotropin-
5 r6 Q# \( f* u" E  ]9 X4 e5 Jindependent precocious puberty, which is also known& W( \& c4 e+ f, q7 N5 |
as testotoxicosis, may cause precocious puberty at a- F8 b7 N5 [+ W, m, h
very young age. The physical findings in these boys
  q7 |( F) j- i+ R7 iwith this disorder are full pubertal development,
0 _2 f  [" q3 f6 a4 `, J) ?including bilateral testicular growth, similar to boys
6 w! n# x6 L& Hwith CPP. The gonadotropin levels in this disorder2 P9 O9 T3 E% ^8 P+ y( N  c
are suppressed to prepubertal levels and do not show  R& e$ J# z9 F0 t# _/ ?' b
pubertal response of gonadotropin after gonadotropin-
0 }3 \8 t1 u& |( X7 a" ~+ @6 H4 W6 {releasing hormone stimulation. This is a sex-linked; e$ {- g% a5 {  U
autosomal dominant disorder that affects only( {; |5 k! y8 o5 ~' s& |6 n) p# A! r/ z
males; therefore, other male members of the family
2 }8 f$ E, R/ H% k. u* S. [6 smay have similar precocious puberty.34 u0 ^/ N, F& Z: {' x
In our patient, physical examination was incon-
2 h. ~% D2 N/ Ysistent with true precocious puberty since his testi-! S, A" n* {* l& V+ e
cles were prepubertal in size. However, testotoxicosis# d. i. u+ W0 n( n: x7 b+ n+ P
was in the differential diagnosis because his father- I& F/ ]; @$ |) n6 g7 E. M" n. Z
started puberty somewhat early, and occasionally,
/ f/ F) Y* y: O. Q' O7 n+ itesticular enlargement is not that evident in the
' i2 ]* n: P/ G- {* }beginning of this process.1 In the absence of a neg-
' J5 M7 F4 `8 Y6 ^" mative initial history of androgen exposure, our( [/ s6 g8 M0 y8 ]: l- }% m
biggest concern was virilizing adrenal hyperplasia,
( M6 J/ y9 B# L6 {9 Reither 21-hydroxylase deficiency or 11-β hydroxylase
5 u/ a. L7 g: t4 kdeficiency. Those diagnoses were excluded by find-
% c( o2 U  f8 i# c& S& O3 X+ `ing the normal level of adrenal steroids.
8 N1 O& n% n  l) M4 S. }- F9 u0 KThe diagnosis of exogenous androgens was strongly5 D% l, E. ~, D' R
suspected in a follow-up visit after 4 months because/ j, o! _' R9 m2 B" v6 C
the physical examination revealed the complete disap-4 L/ t% r3 e5 ^7 U! p" z7 |
pearance of pubic hair, normal growth velocity, and1 f4 p- l: R' U; `' t! D
decreased erections. The father admitted using a testos-9 V8 b; C9 {' G0 ]* S$ J& x
terone gel, which he concealed at first visit. He was
! J* `! t6 m- h; Vusing it rather frequently, twice a day. The Physicians’# t' R4 i3 F( a" [# B
Desk Reference, or package insert of this product, gel or3 u0 E- ^; A# B) @6 R5 C8 Q2 k
cream, cautions about dermal testosterone transfer to: u8 H) E: K$ y4 J+ B7 X
unprotected females through direct skin exposure.
# p$ {4 h- l# G* w7 O" M* jSerum testosterone level was found to be 2 times the5 z" F8 H3 H1 ?$ y
baseline value in those females who were exposed to) C% h8 v+ l* i  v3 \3 f
even 15 minutes of direct skin contact with their male
' z- n; [* ~1 r' epartners.6 However, when a shirt covered the applica-7 b. A" e* ?7 `" H) s
tion site, this testosterone transfer was prevented.
% A2 i. {3 v8 U+ wOur patient’s testosterone level was 60 ng/mL,5 G& G: f# ?  u% W1 Y2 O" ?* ?8 U
which was clearly high. Some studies suggest that
& ^* a" Z7 B4 J/ jdermal conversion of testosterone to dihydrotestos-
- b8 v. b& k7 }7 y+ J2 y+ t4 E( Pterone, which is a more potent metabolite, is more2 T0 J0 ]. }. Y! v: f
active in young children exposed to testosterone" t7 Q8 A2 J3 _2 t. j& F8 M8 @* J
exogenously7; however, we did not measure a dihy-) p! [2 W; t1 b
drotestosterone level in our patient. In addition to
5 q6 j/ g0 H% A1 b" Jvirilization, exposure to exogenous testosterone in3 T4 A7 d! E8 y+ B2 L1 D  Z
children results in an increase in growth velocity and1 }) t# P( e- p
advanced bone age, as seen in our patient.# V; E5 z" y6 h' i  \+ N
The long-term effect of androgen exposure during( E. \% s( t2 N% ^* ^: @/ |
early childhood on pubertal development and final# R+ r% T; G9 U& f5 {, ]
adult height are not fully known and always remain! L* A+ K* E& P6 H0 Q: @5 Z
a concern. Children treated with short-term testos-% ^6 U/ \8 d& I% W, \" W: [- X; c; {
terone injection or topical androgen may exhibit some* P/ h3 P; g: A
acceleration of the skeletal maturation; however, after* |+ h5 _1 O, s0 x
cessation of treatment, the rate of bone maturation
0 f* L; }3 O7 o( q+ {' S2 ?decelerates and gradually returns to normal.8,99 e! m! _' N1 I7 o3 j' H5 \
There are conflicting reports and controversy
( K0 q, b' x2 n1 _: mover the effect of early androgen exposure on adult7 g1 ^6 r- ]: l) v: F
penile length.10,11 Some reports suggest subnormal
) T* Y5 S; `; c9 _. uadult penile length, apparently because of downreg-
0 q# \1 m! B, }. b) ?ulation of androgen receptor number.10,12 However,
. P3 {1 M' \$ @Sutherland et al13 did not find a correlation between. f7 I% N" Y  F
childhood testosterone exposure and reduced adult) h' k, Z) t# v! p0 g
penile length in clinical studies.; ]- ~3 J7 {" Q" Z4 [0 A  q9 Q
Nonetheless, we do not believe our patient is! |# y7 {, Q( }
going to experience any of the untoward effects from
0 n/ s) h9 t0 T7 o1 L$ x) gtestosterone exposure as mentioned earlier because* U8 G3 A+ o) }6 D) w. w2 E- c
the exposure was not for a prolonged period of time.
* G5 y; {* A& i0 NAlthough the bone age was advanced at the time of
% ]# Z* I2 M8 e/ k/ v2 u8 y7 Ydiagnosis, the child had a normal growth velocity at
: v  i% E/ ]  y+ s% U# t! b. N9 f  C7 Bthe follow-up visit. It is hoped that his final adult
& J( r; H9 I0 M% ]' N1 H0 iheight will not be affected.
: R) i& ^6 u( h7 ^Although rarely reported, the widespread avail-
: g9 ^; ]+ V8 [8 E# H% \ability of androgen products in our society may
4 A2 Y5 p7 K& r/ u' J& s' o- b' {6 _indeed cause more virilization in male or female# z- @7 P- ^5 c* V
children than one would realize. Exposure to andro-
, d& z4 K' @! v( c, jgen products must be considered and specific ques-( h& i! _4 c* Z) j: Y/ H
tioning about the use of a testosterone product or( Q  H9 T$ M; f$ b) v
gel should be asked of the family members during) S3 y/ ]( }  @# ~
the evaluation of any children who present with vir-* p1 w% l  ^/ Z8 x1 m- d0 ]& I
ilization or peripheral precocious puberty. The diag-0 e. _( Z, @1 p& B
nosis can be established by just a few tests and by
# ]7 Z% ?4 Z; G; |0 Vappropriate history. The inability to obtain such a- P# Q, K" ~; n
history, or failure to ask the specific questions, may
7 l- E: I1 F) Z$ }  y- hresult in extensive, unnecessary, and expensive
: e0 a3 q& r  O4 K* ninvestigation. The primary care physician should be
1 }. T: S9 D* y0 k, @" Saware of this fact, because most of these children
5 Y; `8 N' Y  {3 Smay initially present in their practice. The Physicians’9 Z# Y" Y* R0 W) K4 L
Desk Reference and package insert should also put a
  v$ C9 a) A$ \: E  S' iwarning about the virilizing effect on a male or  V! i6 P6 x1 {/ y' r7 N2 j
female child who might come in contact with some-- {2 N" {+ f* P- Y
one using any of these products.
% f" f* {. F) lReferences
( T6 s* M0 N8 r* ?1 L  l1. Styne DM. The testes: disorder of sexual differentiation3 l/ F8 }  f( n  p( O: o
and puberty in the male. In: Sperling MA, ed. Pediatric- j* \: v/ L8 V; W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 f7 U( p& {7 b3 D- z2002: 565-628.' V" x1 j* l+ n+ n. P! ]% _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 Z- @* T$ |& y3 i4 j
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: m8 b; d' _: b8 W2 E& a, z
Boy Induced by Indirect Topical
$ j5 N; b# i- l9 l, ZExposure to Testosterone
1 W% N8 `3 H' ^8 V+ N' b9 T  i; }- MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; u8 h: ]8 X9 K% `: b1 P, oand Kenneth R. Rettig, MD1# W% K% r$ H& l$ T1 Y
Clinical Pediatrics
- U- t3 k: ^3 F6 E2 x7 WVolume 46 Number 6; I# Q" g6 u) C2 \2 M9 F
July 2007 540-543
$ l, i% f6 o" u9 m% [1 O© 2007 Sage Publications# g) m% L- |2 k: ?
10.1177/0009922806296651
1 w0 f* A/ g6 c; y" E5 H7 _" U' whttp://clp.sagepub.com+ N8 S  u1 ?; _9 |/ z) g6 I9 |
hosted at
' l) k' U4 W3 t" C1 J" W5 yhttp://online.sagepub.com8 K' K1 P0 G) O& b: e# S: i
Precocious puberty in boys, central or peripheral,
* R; S/ N" O9 m0 y. A5 bis a significant concern for physicians. Central9 V4 ^( [1 O4 E; D8 {
precocious puberty (CPP), which is mediated
7 d  j' d. }; g0 l9 @( a. Sthrough the hypothalamic pituitary gonadal axis, has
# R1 @3 i4 X# c( _7 q4 W3 h  D1 e0 ^! }a higher incidence of organic central nervous system
2 l; A- m1 B. k/ Klesions in boys.1,2 Virilization in boys, as manifested' A- E' g8 F9 V3 q* J  V7 Q( G# }
by enlargement of the penis, development of pubic
2 y; @9 w% @8 u* y) Qhair, and facial acne without enlargement of testi-( g( ^' [5 _# |. W$ t# A2 o4 K/ M
cles, suggests peripheral or pseudopuberty.1-3 We- }" P- g0 z: _8 R. d
report a 16-month-old boy who presented with the+ C2 Q2 v8 o5 V2 a5 s
enlargement of the phallus and pubic hair develop-$ r, I5 N: R7 x* o
ment without testicular enlargement, which was due/ q/ U9 ?6 R/ l) w" B* A* x) w
to the unintentional exposure to androgen gel used by. }: B7 |$ X! ^) g% N
the father. The family initially concealed this infor-
3 i9 f6 m& N1 |mation, resulting in an extensive work-up for this
$ }2 o0 E) a- q( Uchild. Given the widespread and easy availability of: S3 v; k" u$ ]6 d
testosterone gel and cream, we believe this is proba-4 W, O1 f  S. D" d. y4 P* f2 k% f
bly more common than the rare case report in the" B9 k" d2 N6 S+ s+ h* H
literature.4
6 t3 t1 M6 G+ a% r" lPatient Report
/ d3 y# r5 R4 c( `9 M- \A 16-month-old white child was referred to the' B4 K2 X6 W" d, S) y
endocrine clinic by his pediatrician with the concern; h. w+ ^8 L! S0 Z, L; e
of early sexual development. His mother noticed
/ m$ r9 S5 b1 U0 J& Ylight colored pubic hair development when he was/ y, E  T' e+ _' z( b8 w! I5 `; Q
From the 1Division of Pediatric Endocrinology, 2University of' _) Z% Q1 }' U( l: v
South Alabama Medical Center, Mobile, Alabama.9 Q  H& V  C1 p' @6 P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 e- b& h6 G* q  s# t5 ?0 RProfessor of Pediatrics, University of South Alabama, College of
3 m* u: ]8 ]) DMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. x+ N; Z. c3 {9 _8 `e-mail: [email protected].
* n- f5 C! @$ habout 6 to 7 months old, which progressively became
& q9 M; C# N: [% u5 x$ odarker. She was also concerned about the enlarge-
$ s& k' n6 z1 k& o3 n2 c  Yment of his penis and frequent erections. The child
8 ~( v  b6 C# Zwas the product of a full-term normal delivery, with
# }/ H- J# D; [6 Da birth weight of 7 lb 14 oz, and birth length of
1 [/ a" L" F# }# D; o20 inches. He was breast-fed throughout the first year  ]/ C% ]: Z& W" E  x5 F
of life and was still receiving breast milk along with
! k8 `% v8 M4 c( `& d7 `* gsolid food. He had no hospitalizations or surgery,
, N  Z6 ?* Y; j& w: a0 Eand his psychosocial and psychomotor development
0 R* B9 i. |  qwas age appropriate." I( Y% o  l; b
The family history was remarkable for the father,+ Z5 D( H0 Q$ T  v. q
who was diagnosed with hypothyroidism at age 16,! Y# T9 q7 w6 P7 i; j
which was treated with thyroxine. The father’s% B/ Q/ F: G% E
height was 6 feet, and he went through a somewhat
+ n$ D! H) U8 Y$ M9 Oearly puberty and had stopped growing by age 14.
' X( T* d8 W: E' c7 }The father denied taking any other medication. The
& b! f0 N8 \- F' `# ^5 \, Ychild’s mother was in good health. Her menarche
5 v1 N" D+ b0 t, Z% Ywas at 11 years of age, and her height was at 5 feet
0 i. a7 q9 S+ ]1 z- H. f5 inches. There was no other family history of pre-3 x* ^8 S+ ~/ @1 ^! T  a' ^' m# V
cocious sexual development in the first-degree rela-! H0 n. A2 v2 z7 _- z: V
tives. There were no siblings.
& a6 m) W* G8 J5 Q  VPhysical Examination
; s" F! l1 p& Q1 o( AThe physical examination revealed a very active,
) S# a) C0 H" i% `playful, and healthy boy. The vital signs documented
; b: E$ J' I9 V* Xa blood pressure of 85/50 mm Hg, his length was: A. l* x& x0 C6 V" v! j$ V0 o) ^
90 cm (>97th percentile), and his weight was 14.4 kg
0 }& U7 e! J" a# L6 x+ L) v4 H(also >97th percentile). The observed yearly growth) l2 r- P7 X, p8 M8 i* \4 X
velocity was 30 cm (12 inches). The examination of4 k, s& z% a) x: n8 u/ T
the neck revealed no thyroid enlargement.
; \' b& T: D) EThe genitourinary examination was remarkable for/ q4 g" y2 R" {1 t+ N
enlargement of the penis, with a stretched length of
: J/ S8 v. e8 s* ~6 R, P8 cm and a width of 2 cm. The glans penis was very well
+ F( h  L1 x- S5 ddeveloped. The pubic hair was Tanner II, mostly around
, [4 x! i: r; E7 o& X7 |0 p5401 @  }: x4 }, c. H8 Z3 i: v% z' i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 `4 O0 b5 ?8 u1 Z, F
the base of the phallus and was dark and curled. The1 V/ n! \8 c7 t9 E* g6 }
testicular volume was prepubertal at 2 mL each.
7 y5 n) i6 `7 G% q# z1 xThe skin was moist and smooth and somewhat
/ @0 g! R+ G$ D& I" j/ _oily. No axillary hair was noted. There were no1 R) C- J, u0 U( S5 A
abnormal skin pigmentations or café-au-lait spots.% Y1 N8 r' Q: ?5 M, F+ W9 p
Neurologic evaluation showed deep tendon reflex 2+
; B* G7 P5 O" y: B  c, {bilateral and symmetrical. There was no suggestion
; _8 i$ ^& ?8 p: Kof papilledema.% K) `, T9 Y- T; y# ^6 d
Laboratory Evaluation
3 j0 V3 d" L0 }3 `: B4 iThe bone age was consistent with 28 months by
$ ^! V5 e  Y# [; N( L' V7 z' Wusing the standard of Greulich and Pyle at a chrono-$ h/ H( `/ x* X, t1 u, c/ b7 N$ p4 d0 I
logic age of 16 months (advanced).5 Chromosomal
+ R4 K  {6 Q. w$ tkaryotype was 46XY. The thyroid function test
; E$ C' O3 g8 b7 ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 M6 F5 g7 c  D8 T
lating hormone level was 1.3 µIU/mL (both normal).8 z) N4 j% c4 [4 }+ k2 _
The concentrations of serum electrolytes, blood  }  L8 X* G4 x% J# j2 x
urea nitrogen, creatinine, and calcium all were
9 ^8 ]4 I6 S3 w2 q$ `- z0 Nwithin normal range for his age. The concentration
* ^( y4 G, I/ L# W9 ^1 G6 G, \of serum 17-hydroxyprogesterone was 16 ng/dL
& T, e* Q( h% [0 p9 q. G(normal, 3 to 90 ng/dL), androstenedione was 20
" u! Y( r$ |# y: `' j5 |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 Q6 V: Z3 \' v! E/ c, n
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 H3 M4 q3 d3 ]* G8 N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 x7 }+ f8 B- f49ng/dL), 11-desoxycortisol (specific compound S)  m2 ~7 ^# v# I& j  D/ c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 V7 O2 T2 n" G! Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: K  G" E' d4 `0 ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 M+ V2 q& h" I7 x+ x! ]- wand β-human chorionic gonadotropin was less than9 @; \+ T  n6 l- A, ]' G9 `7 K' s
5 mIU/mL (normal <5 mIU/mL). Serum follicular! D4 X# {! I- {$ t( O% o
stimulating hormone and leuteinizing hormone
" c8 l% f- W. [1 Sconcentrations were less than 0.05 mIU/mL( K& F6 {) }1 K0 _
(prepubertal).; v' ?/ t' I5 p0 s+ T
The parents were notified about the laboratory- {" P0 h' O. _/ q9 c. q
results and were informed that all of the tests were- }! t" X6 c" g" O/ |
normal except the testosterone level was high. The
7 V( [* ~. e; H$ R. o0 Rfollow-up visit was arranged within a few weeks to
* G5 ?# q! }. E" z. j5 Pobtain testicular and abdominal sonograms; how-/ y% H6 y1 R: E, q% D0 P4 [
ever, the family did not return for 4 months.
7 S" X0 ~  ^$ O3 }; F( A% QPhysical examination at this time revealed that the. A- h7 w2 x( I( m$ [
child had grown 2.5 cm in 4 months and had gained
0 a3 Y% {( s: Q2 kg of weight. Physical examination remained
# _- n4 A9 r0 Y0 v1 \3 K" junchanged. Surprisingly, the pubic hair almost com-& L1 X: ?4 p. x* _3 z' L' B2 f
pletely disappeared except for a few vellous hairs at; `9 H3 Z2 N- S8 _0 ], r" f4 J
the base of the phallus. Testicular volume was still 2+ T# r* B5 ]; u- d0 k1 x# r
mL, and the size of the penis remained unchanged.
9 P/ n! x, W9 R' |/ OThe mother also said that the boy was no longer hav-
5 J4 B0 ~" A+ Zing frequent erections.
4 l  z" F: c1 h; }; TBoth parents were again questioned about use of) b4 y# H- Y7 Z
any ointment/creams that they may have applied to
4 p: ?, O0 f9 }: B& cthe child’s skin. This time the father admitted the# t3 W) m5 H; v, u  w
Topical Testosterone Exposure / Bhowmick et al 541/ e- D( \7 z. \( T+ E) @, M
use of testosterone gel twice daily that he was apply-5 ]" p6 _& G, C8 O6 O2 i9 X
ing over his own shoulders, chest, and back area for
& x, R' P5 L( _  p0 }- x% na year. The father also revealed he was embarrassed$ ^9 C2 _4 z% l( ]: }5 A2 e
to disclose that he was using a testosterone gel pre-
4 [& P9 q7 h7 H) {- R" `scribed by his family physician for decreased libido! p4 P3 d* N% F1 i# r- x
secondary to depression.' l6 w7 U3 M! c8 u7 }& O* }6 F
The child slept in the same bed with parents.
) a. _4 }7 J" q4 M/ ^  H# VThe father would hug the baby and hold him on his
6 I+ d( N/ X% C& K1 R3 t# Qchest for a considerable period of time, causing sig-% [( Z; ^% w* ]- W/ @8 k) `
nificant bare skin contact between baby and father.
1 T. i0 b7 L- d$ VThe father also admitted that after the phone call,; ~- |' ~6 D3 k' k
when he learned the testosterone level in the baby$ W0 D" v6 Z) s! n+ B* E0 s4 z
was high, he then read the product information4 j3 `2 t0 R- a' z+ A+ u5 ^
packet and concluded that it was most likely the rea-. K% S2 u" l. ^/ \4 o& s
son for the child’s virilization. At that time, they
3 @* S: @% i. e+ Ddecided to put the baby in a separate bed, and the
% p) ]! i" m  S$ C3 y! k+ s: k! Bfather was not hugging him with bare skin and had; \, o9 z  z. K7 O& R
been using protective clothing. A repeat testosterone
- {. {/ m# J; G" I- S. a% Ttest was ordered, but the family did not go to the
) }" }( N% Z; A9 V9 ~0 l$ W, Tlaboratory to obtain the test.: F/ b6 W6 S+ e+ x( t( E
Discussion5 r" s0 T  {% C2 `
Precocious puberty in boys is defined as secondary
% U. e. H3 |  w9 c3 y) }sexual development before 9 years of age.1,4" [- [* i2 x6 R
Precocious puberty is termed as central (true) when
) Y  K* W' I1 y- P3 R1 Yit is caused by the premature activation of hypo-
+ c0 X1 K' n) Z2 E7 Z5 X# A3 pthalamic pituitary gonadal axis. CPP is more com-* G# l$ A, f5 A! B4 I4 n
mon in girls than in boys.1,3 Most boys with CPP' p0 s6 G- E. d& q1 t0 I1 L/ y* L
may have a central nervous system lesion that is
5 T/ D3 p6 q% D6 Oresponsible for the early activation of the hypothal-
9 E) K/ U9 Y+ H+ z; w: ?) Vamic pituitary gonadal axis.1-3 Thus, greater empha-
! v8 n8 J. u- g/ Z9 R/ h& Jsis has been given to neuroradiologic imaging in
% c: ~" c' o, r' P9 \# }4 ~/ wboys with precocious puberty. In addition to viril-8 e9 R. Z' U+ m% T  J5 X+ b! J
ization, the clinical hallmark of CPP is the symmet-
, |, j8 A3 b* b1 Erical testicular growth secondary to stimulation by
8 j! g! L2 s5 {. L3 ygonadotropins.1,37 T0 m" V# u! u% J# |6 k* v" z1 C
Gonadotropin-independent peripheral preco-6 _4 P+ l* C/ w! Z( b0 }8 v: \6 F
cious puberty in boys also results from inappropriate, b* g9 m/ i) J* t
androgenic stimulation from either endogenous or
- E( D- O" [2 ]" {0 H$ F, [5 j3 }/ aexogenous sources, nonpituitary gonadotropin stim-" E. y* G0 y6 D* @. B
ulation, and rare activating mutations.3 Virilizing  h0 o$ q& x1 t0 }1 Z
congenital adrenal hyperplasia producing excessive
3 c* @  t, i- x" \. T6 E/ ~adrenal androgens is a common cause of precocious" k! E$ S# O" z# R- q( ?
puberty in boys.3,4
+ I- G5 X( q, m* ]1 pThe most common form of congenital adrenal$ P1 f2 V3 p- Y9 x' R' h
hyperplasia is the 21-hydroxylase enzyme deficiency.. K9 k! \  J* `
The 11-β hydroxylase deficiency may also result in
& i$ }9 j: Y% Eexcessive adrenal androgen production, and rarely,1 G' B& j( A' Z
an adrenal tumor may also cause adrenal androgen5 T8 f& D9 _5 J3 d5 @7 r
excess.1,3" z* m5 s9 C; r  w7 q/ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 r* ?0 m1 E: u6 I  D! S% j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 y0 P. U  ]& n% {' K  VA unique entity of male-limited gonadotropin-: l. p1 A* x0 s
independent precocious puberty, which is also known
$ Y1 N$ ^9 D7 }7 B% kas testotoxicosis, may cause precocious puberty at a
7 L3 R0 v- M3 K5 P, @6 u4 Qvery young age. The physical findings in these boys: R3 M/ a0 [1 w, w4 h& y8 }+ F
with this disorder are full pubertal development,
- y& a2 @8 ~( Aincluding bilateral testicular growth, similar to boys
/ [# ^" N+ t. m9 Owith CPP. The gonadotropin levels in this disorder
2 o* b5 Y6 V% v0 Nare suppressed to prepubertal levels and do not show" s" u9 i, e4 [+ @9 h
pubertal response of gonadotropin after gonadotropin-
0 b1 P1 j. |4 u2 |0 `9 }releasing hormone stimulation. This is a sex-linked/ P: o" v) P, q7 u) g0 k) d4 H6 v
autosomal dominant disorder that affects only
$ c3 U5 q( J& V- @5 K1 y3 i* tmales; therefore, other male members of the family
/ W6 H! ?2 G( r" }may have similar precocious puberty.3: x8 ?8 P4 Y; {  Z: G
In our patient, physical examination was incon-0 y) q( L* z/ J0 ^4 T
sistent with true precocious puberty since his testi-/ ^" C3 J1 f# I( a9 q/ C; t
cles were prepubertal in size. However, testotoxicosis: i2 X' P+ _1 B# B! Z  X
was in the differential diagnosis because his father
8 x3 d1 c$ x1 o, M6 bstarted puberty somewhat early, and occasionally,! j/ L) \4 O" \$ l7 X$ B
testicular enlargement is not that evident in the
4 X8 C' d. R& L- O3 @beginning of this process.1 In the absence of a neg-
$ b' U' V. [  d7 ^; [& a2 zative initial history of androgen exposure, our
5 E! A2 S: B6 c" R( p- R8 K+ zbiggest concern was virilizing adrenal hyperplasia,
, r; Q+ e% e! S3 keither 21-hydroxylase deficiency or 11-β hydroxylase# Q% l6 V% A( @$ j, `! R+ J
deficiency. Those diagnoses were excluded by find-
/ C6 ]: v4 ?# E$ q0 W( wing the normal level of adrenal steroids.
* O, r6 e5 J/ e: sThe diagnosis of exogenous androgens was strongly
4 q  f0 X1 ^% x1 Wsuspected in a follow-up visit after 4 months because
  U/ `! v* X- H0 Q% ]# [& ~the physical examination revealed the complete disap-
( o6 c7 @1 |, A# kpearance of pubic hair, normal growth velocity, and' n/ H4 [( @9 O" C1 k( ^, O  M
decreased erections. The father admitted using a testos-
- f8 ~8 Y- U- [- j1 J6 Oterone gel, which he concealed at first visit. He was, c( X) N5 s) t
using it rather frequently, twice a day. The Physicians’
9 \: g0 D1 R- N( \+ Q. rDesk Reference, or package insert of this product, gel or
- F7 W2 n9 b5 ?! P& D9 qcream, cautions about dermal testosterone transfer to
0 @' L6 g+ t% W4 B! d$ X6 bunprotected females through direct skin exposure.2 y8 ^3 K- k" |# @0 R4 C
Serum testosterone level was found to be 2 times the
3 N9 ^# E& T6 T2 `: v, ~9 |* T  [) x* ^baseline value in those females who were exposed to6 y4 @: X0 x# X* K
even 15 minutes of direct skin contact with their male
  ]$ L' X& @5 `2 u! ?0 opartners.6 However, when a shirt covered the applica-
/ R8 r2 ]3 v" V# n0 Jtion site, this testosterone transfer was prevented.7 Z8 V2 G" m+ C, k* M8 `, m
Our patient’s testosterone level was 60 ng/mL," ?9 g; ?; @5 c5 M; C
which was clearly high. Some studies suggest that
/ z' B# L; }( b% |; y6 Q7 Wdermal conversion of testosterone to dihydrotestos-* k4 u- q7 B2 i3 R' ^5 H/ E
terone, which is a more potent metabolite, is more" r7 G% i1 h# @7 R# A
active in young children exposed to testosterone' v$ S4 Z2 V: J+ ?
exogenously7; however, we did not measure a dihy-! e! v8 _6 W& \+ r1 e) h
drotestosterone level in our patient. In addition to7 C  }8 w: \) W/ r; Y
virilization, exposure to exogenous testosterone in% E7 I6 a7 Q6 ~2 S7 V8 j
children results in an increase in growth velocity and
6 h# P, s1 ?& }advanced bone age, as seen in our patient.1 x/ L, G* u$ r( a6 ?6 z! B6 E
The long-term effect of androgen exposure during% }" C& f8 ~/ T0 C
early childhood on pubertal development and final: S  K+ m! @" @' P: S
adult height are not fully known and always remain
; {) t$ c. H% B; I$ Xa concern. Children treated with short-term testos-. {! f+ }0 n9 W" \$ E
terone injection or topical androgen may exhibit some- S0 l& z7 f8 A4 i& y+ @, u0 C" m
acceleration of the skeletal maturation; however, after
1 y( h* X& \1 M, icessation of treatment, the rate of bone maturation/ n. @$ f% v1 A( a# C
decelerates and gradually returns to normal.8,98 R9 H1 E8 R' V
There are conflicting reports and controversy
1 X$ Z! x6 V! Q& f; b$ gover the effect of early androgen exposure on adult* v0 X/ K3 g; {
penile length.10,11 Some reports suggest subnormal
, N4 F: F. d; }/ ^5 Z; N3 c/ Dadult penile length, apparently because of downreg-
+ H* o/ ^  E) l8 {ulation of androgen receptor number.10,12 However,
  M! I, i7 x  O/ K4 b8 \8 D, a7 iSutherland et al13 did not find a correlation between/ A. B4 v7 i  R+ X
childhood testosterone exposure and reduced adult
, _9 C' y; h; spenile length in clinical studies./ n8 j% T( R& e+ f0 e
Nonetheless, we do not believe our patient is
' o; a4 p. @- S- ?going to experience any of the untoward effects from0 u+ f' a  [+ z6 u) w5 I
testosterone exposure as mentioned earlier because9 h3 ^1 r+ o! g% C  }" x. U" B
the exposure was not for a prolonged period of time.
5 R# _, a9 G9 f* q, _! ?' {Although the bone age was advanced at the time of
7 |4 d$ d" q9 n( bdiagnosis, the child had a normal growth velocity at
, v! |* W) d1 \4 vthe follow-up visit. It is hoped that his final adult
9 y1 _- ]) {; Fheight will not be affected., `9 R6 \9 ?. _9 q% p
Although rarely reported, the widespread avail-* C! B+ z# h4 G4 |
ability of androgen products in our society may# }* z! [& c. q2 E* s" a6 T
indeed cause more virilization in male or female5 O6 S' A6 e+ W( }6 j/ I6 @0 L6 E
children than one would realize. Exposure to andro-
* ?! w" a8 {: A$ _gen products must be considered and specific ques-
$ n  ^( x$ M" P5 Ktioning about the use of a testosterone product or+ o3 V& C! K, L+ n7 @4 ~
gel should be asked of the family members during
! D: {  u/ i8 U' x; }the evaluation of any children who present with vir-$ C# |+ R) [1 T9 e) _
ilization or peripheral precocious puberty. The diag-
+ T( r; D9 e$ Znosis can be established by just a few tests and by
3 Q7 H% N; ~4 t3 Dappropriate history. The inability to obtain such a6 ]0 O* x6 a( S4 c1 w9 ~  \) o
history, or failure to ask the specific questions, may/ o7 M1 Z- ]( e5 Q6 ~$ Z! v
result in extensive, unnecessary, and expensive
9 B0 a- _7 `* w9 T3 K5 [& einvestigation. The primary care physician should be
9 m0 u: `9 j" C) i9 E% _8 b# a; }aware of this fact, because most of these children
# D# |" F* J9 {' f- a' fmay initially present in their practice. The Physicians’/ {) u, X" a4 r0 s9 m+ `
Desk Reference and package insert should also put a& P9 I5 k: S; n1 k( B
warning about the virilizing effect on a male or7 B/ H6 \6 v9 c; h$ `  B  B- o: B
female child who might come in contact with some-
: N( Y1 k. R% x* a. K" x# A6 Pone using any of these products.
7 ^+ _  K* R0 p' KReferences
7 @+ u* K6 i. P+ ?8 Z$ |* T1. Styne DM. The testes: disorder of sexual differentiation
: A5 }; z7 T% Q% v, B8 l5 sand puberty in the male. In: Sperling MA, ed. Pediatric
8 M, I8 U1 o. Z9 ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, ^) q+ w9 }* G: n0 \
2002: 565-628.
/ `" b/ D/ L1 n3 ?9 a/ j$ I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& v$ Z) |7 p8 Q$ F0 t5 Cpuberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
0 l) w- K2 H8 W$ Z( H: g  I3 `
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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