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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  E$ L3 z$ z( x; l9 c' X' V
Boy Induced by Indirect Topical
6 n6 q% `2 {7 A/ k4 B7 fExposure to Testosterone& l, \1 U( a; W2 V1 e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 m: }. `2 ~3 \* i, N* xand Kenneth R. Rettig, MD1
6 W0 _' ]7 ?& }  b( T. q9 ?) n5 |Clinical Pediatrics0 y+ {" ~. z, p( `, a6 R& h3 ^" B
Volume 46 Number 6
0 C5 D8 h+ w2 I" kJuly 2007 540-5433 |5 k# z. u( a8 L# s4 Y/ W
© 2007 Sage Publications7 [' P9 u1 h9 R* C$ X6 G
10.1177/0009922806296651# |3 b3 h$ ]+ L$ a8 w. ?
http://clp.sagepub.com3 G% _$ P* G& \. f1 \7 T$ e3 N
hosted at5 w6 b: X  J/ F8 o5 }
http://online.sagepub.com  E/ {: q1 \) q; q# l
Precocious puberty in boys, central or peripheral,
8 m- ^  Z$ e0 O2 r& o6 k9 f" l  ^is a significant concern for physicians. Central) u7 l1 y, s4 a7 I4 _" I8 G7 ~+ ~4 J2 J
precocious puberty (CPP), which is mediated
( }7 N  N+ D' p) K: y1 \through the hypothalamic pituitary gonadal axis, has
4 W7 S7 `* C4 S! J: v1 x( f6 Aa higher incidence of organic central nervous system
9 [5 E+ n+ J3 t! Llesions in boys.1,2 Virilization in boys, as manifested
/ S4 B' d1 y' U7 `# z% K0 H; Vby enlargement of the penis, development of pubic
0 w/ E8 ?9 M6 D( e) Phair, and facial acne without enlargement of testi-
/ C1 d- m( h, f: i9 u; {6 @cles, suggests peripheral or pseudopuberty.1-3 We3 _* p- ^7 d  h6 l+ r& g) L
report a 16-month-old boy who presented with the
3 g8 ?* _: N1 A7 Senlargement of the phallus and pubic hair develop-
5 c; [) M) c; O6 D/ ument without testicular enlargement, which was due
# m3 Y5 T% `" W& Z1 m) Rto the unintentional exposure to androgen gel used by
+ m% q! L  e  c, ?- x+ N0 A, k3 x" Hthe father. The family initially concealed this infor-& A$ Y, n( b* g( Z/ @1 |
mation, resulting in an extensive work-up for this
# u1 l- K; L5 Y# s. U& V; qchild. Given the widespread and easy availability of
0 Q( V4 L/ t+ J3 C* `! Dtestosterone gel and cream, we believe this is proba-4 U2 I, J/ d* X4 O
bly more common than the rare case report in the
! O/ a  o/ l* k( w% rliterature.4
5 W# i. i4 l% R  E  i* q) O) u$ cPatient Report: P+ }( j% M5 F- k; n8 f
A 16-month-old white child was referred to the
- z( s- w# e# Y1 D" A! Cendocrine clinic by his pediatrician with the concern
' m' U/ a$ K, Xof early sexual development. His mother noticed
3 @: D3 `4 P. r1 jlight colored pubic hair development when he was
4 f8 t; n8 C! T6 }+ L1 f8 {! S8 HFrom the 1Division of Pediatric Endocrinology, 2University of
4 J& d* p% ~- P! FSouth Alabama Medical Center, Mobile, Alabama.* ?5 N6 D) |( O; u  X6 ^1 z5 D
Address correspondence to: Samar K. Bhowmick, MD, FACE,. R) g5 \% u: w( M( L
Professor of Pediatrics, University of South Alabama, College of' v; s8 d" U2 m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% _0 Q& W- n+ Q4 ^% H$ e2 ge-mail: [email protected].. q# X& I$ d5 z8 {4 S
about 6 to 7 months old, which progressively became
' v+ R0 |4 P2 Z1 jdarker. She was also concerned about the enlarge-
; Q% L! }9 e3 U$ u2 N2 A4 V) E) v& mment of his penis and frequent erections. The child4 K' j9 d  x9 G/ s1 X
was the product of a full-term normal delivery, with
8 F$ k  O# o! Q" O  w7 wa birth weight of 7 lb 14 oz, and birth length of
9 Z& M7 p% H+ c) }: c8 L/ T. r8 c20 inches. He was breast-fed throughout the first year; D! R( y* J0 q5 M0 f
of life and was still receiving breast milk along with9 F: K2 a/ ^6 t: {
solid food. He had no hospitalizations or surgery,
2 J+ W' `6 h3 F3 Rand his psychosocial and psychomotor development3 [- n8 R# k- T5 ]) L0 _. N
was age appropriate.
% h* I# b/ V' A) TThe family history was remarkable for the father,
# y6 R) ]# e+ E! }who was diagnosed with hypothyroidism at age 16,1 ]2 t) S1 |7 w+ l& r4 C
which was treated with thyroxine. The father’s
- W- A3 G, B7 `+ o( e9 F  Aheight was 6 feet, and he went through a somewhat
) E, |* o4 j: U# d" j6 Dearly puberty and had stopped growing by age 14.
1 C# R$ V  k, D& U) z% Y  AThe father denied taking any other medication. The
# c$ n3 n- w6 y' H$ Jchild’s mother was in good health. Her menarche
6 ^- j" g9 D# K, |8 {was at 11 years of age, and her height was at 5 feet/ A8 d$ D5 x; Y
5 inches. There was no other family history of pre-
. ~5 ?0 {! u: ccocious sexual development in the first-degree rela-# b# v; n1 W4 b4 l2 i7 u" U0 p
tives. There were no siblings.
) |& m2 |( x( T7 E1 O3 U+ ZPhysical Examination
1 }9 l: ^3 m5 c" ~% [- ^0 Z- [The physical examination revealed a very active,
) `% X3 [3 J- Kplayful, and healthy boy. The vital signs documented8 v, r, W5 g. t. s! ^
a blood pressure of 85/50 mm Hg, his length was* @- Q6 l" s0 o  I& d/ L
90 cm (>97th percentile), and his weight was 14.4 kg* d4 R& a2 J" J
(also >97th percentile). The observed yearly growth
% ?0 F% E) M: n- Gvelocity was 30 cm (12 inches). The examination of7 A2 a4 T4 ?4 E1 I" c2 d5 H
the neck revealed no thyroid enlargement.3 Y$ E! _! F* |$ Y' a$ x
The genitourinary examination was remarkable for
; X+ q$ N& ~% Y; }, ienlargement of the penis, with a stretched length of, m  c- y4 o8 u+ M! Y
8 cm and a width of 2 cm. The glans penis was very well- A' G6 D& A' U; q3 X7 O
developed. The pubic hair was Tanner II, mostly around; w$ a, u3 d  a* L" j0 q# ^
540
6 v. C3 j7 W0 r" kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 O5 {# w* Y0 P2 h9 I
the base of the phallus and was dark and curled. The$ Z# V/ _7 l7 t0 Y" {! O; C9 ^
testicular volume was prepubertal at 2 mL each.
$ ]- @0 K: P4 ZThe skin was moist and smooth and somewhat3 B0 j" {$ a0 [; _6 ?) s! v
oily. No axillary hair was noted. There were no
3 E  F# w7 @/ ~. G! b$ I2 ]: |abnormal skin pigmentations or café-au-lait spots.* m0 M  s( {  e
Neurologic evaluation showed deep tendon reflex 2+# f4 E+ L- I7 {
bilateral and symmetrical. There was no suggestion
# h* P) S3 _# d$ z2 aof papilledema.
3 y" D3 u9 E9 p  M) DLaboratory Evaluation: d' M$ Y' W- G/ _" A) f# {
The bone age was consistent with 28 months by# ?, R4 |/ A/ s0 S
using the standard of Greulich and Pyle at a chrono-, D8 `* d; A8 Q9 l6 h( ]$ w/ E
logic age of 16 months (advanced).5 Chromosomal
8 J( e/ @, L% x" k2 nkaryotype was 46XY. The thyroid function test
; a& z: B; f! t! g# xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-0 W0 E- T2 `. T# x
lating hormone level was 1.3 µIU/mL (both normal).2 m- D. s$ ]; T: k
The concentrations of serum electrolytes, blood6 ~4 w: ^2 I" u  g& q/ i
urea nitrogen, creatinine, and calcium all were3 w5 D, H6 ~- c3 e& u. k( s
within normal range for his age. The concentration8 s8 F9 y; W+ ~8 r
of serum 17-hydroxyprogesterone was 16 ng/dL* m; x3 F$ w) a- [+ B& X
(normal, 3 to 90 ng/dL), androstenedione was 20" J( k) R3 @" b- W' O5 W3 W* F
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. a( p+ V* L* s& D' rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' ?# n' P; E& R& ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ A9 z* s  P; p- `- R, p3 M
49ng/dL), 11-desoxycortisol (specific compound S)
2 f1 F. G- {* N8 \was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ t6 Z$ t% w  S0 d  z( a% i) @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ X+ ]  ?9 B+ x. Y- _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ V& Z( Z. j# G0 r, Q
and β-human chorionic gonadotropin was less than2 Y, J* g- i! g, H
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 U% y2 q3 q  u, D5 V0 i- P
stimulating hormone and leuteinizing hormone( ~) y* M" X; C1 O
concentrations were less than 0.05 mIU/mL
" \$ L3 Y0 c4 a) n3 t(prepubertal).
% v/ K( |+ A  ~/ i9 H  wThe parents were notified about the laboratory3 m8 S! ~9 L: G, T. V
results and were informed that all of the tests were4 k+ Z' _0 p4 y( f! v5 g
normal except the testosterone level was high. The- [2 }1 Z( n, Q" b" s
follow-up visit was arranged within a few weeks to+ ^' z8 E2 ^* I5 N. p( l5 N* _
obtain testicular and abdominal sonograms; how-6 P; N& c7 n; P6 J
ever, the family did not return for 4 months.& ?2 c' W4 e! Q5 Q, r
Physical examination at this time revealed that the
, l1 |  h# M+ m+ P0 j& k/ l6 gchild had grown 2.5 cm in 4 months and had gained5 v) Q9 v# S, G9 {' _! p9 h, }
2 kg of weight. Physical examination remained
! a$ [1 a7 I1 [5 T% Punchanged. Surprisingly, the pubic hair almost com-$ f4 Y' {3 a* B- l( z
pletely disappeared except for a few vellous hairs at
& U/ \' V2 B' q6 U. ~the base of the phallus. Testicular volume was still 24 l* E" [6 p7 Y8 v
mL, and the size of the penis remained unchanged.; q# ~4 h# Q1 B; p
The mother also said that the boy was no longer hav-
0 o) ^  X8 M0 ^ing frequent erections.2 F  ]# ~4 ~7 m
Both parents were again questioned about use of
$ W' q( Y! s  ^( \any ointment/creams that they may have applied to4 |2 i) J" C1 R
the child’s skin. This time the father admitted the
1 d" s# o/ j* o  DTopical Testosterone Exposure / Bhowmick et al 541
3 n4 n3 A* t, [9 |' R4 quse of testosterone gel twice daily that he was apply-: }0 S& d, @6 S  h) x! i
ing over his own shoulders, chest, and back area for  R* a$ h' Z0 A% l+ R
a year. The father also revealed he was embarrassed! v' x" ^5 n9 B1 u3 T4 P
to disclose that he was using a testosterone gel pre-
  S; p5 @; g' O. m+ E, u/ `scribed by his family physician for decreased libido6 I+ s. ?$ r' c$ A; m
secondary to depression.
8 A7 T( ^+ ?4 z7 c; GThe child slept in the same bed with parents.
) h# t+ Y* g# Z, a: B0 CThe father would hug the baby and hold him on his# U2 X9 {7 _+ i4 v- ]
chest for a considerable period of time, causing sig-
) P" f8 m; Q0 @9 G, O$ h' N0 T  `nificant bare skin contact between baby and father.$ P+ T& T3 ]6 a8 ]
The father also admitted that after the phone call,6 a' H* W$ C( Q! a+ N- ?4 x
when he learned the testosterone level in the baby
7 A" C* C! }5 e' Qwas high, he then read the product information8 o6 L3 f8 V* z( y$ r1 b
packet and concluded that it was most likely the rea-
7 P5 p; P) |9 N! pson for the child’s virilization. At that time, they
8 R& `, E2 A$ i) _( Kdecided to put the baby in a separate bed, and the
5 ]5 Q- h" E& T1 Pfather was not hugging him with bare skin and had
$ T, X9 i$ a. \" t7 tbeen using protective clothing. A repeat testosterone
( j  [- l7 p1 ]  D0 ]) J/ ltest was ordered, but the family did not go to the
4 b9 @( l$ e' s" Claboratory to obtain the test.* ]9 {9 c3 h3 t" w
Discussion% B  Y. X8 B4 F: ~  x' I! {5 M
Precocious puberty in boys is defined as secondary1 P. B9 I2 j, B3 l) x3 p) g
sexual development before 9 years of age.1,4& |/ z1 \% s" Z! L7 {1 ~% _
Precocious puberty is termed as central (true) when! l. ?, i6 |) G
it is caused by the premature activation of hypo-3 Q8 w% t+ |# {6 O7 G" y* B
thalamic pituitary gonadal axis. CPP is more com-
. R. D7 I( q$ }3 _- q7 N5 Ymon in girls than in boys.1,3 Most boys with CPP$ V" E* R& t2 q9 Y3 D- V# ]
may have a central nervous system lesion that is' I$ j9 N) I4 f5 o. L
responsible for the early activation of the hypothal-- T+ @# b7 M; E2 u' b* F& c
amic pituitary gonadal axis.1-3 Thus, greater empha-  F' K- Z4 F& D1 E3 z* R2 \- C3 Q
sis has been given to neuroradiologic imaging in+ @: q$ I  p/ s8 q
boys with precocious puberty. In addition to viril-
3 }) a$ i. [! A( l0 H: Y1 Jization, the clinical hallmark of CPP is the symmet-
6 e5 T& p, [: R' u- Nrical testicular growth secondary to stimulation by0 h/ O$ t: n9 m3 w' {$ g% V
gonadotropins.1,3, }8 t. F: i2 O: f& \* u8 @; C2 q
Gonadotropin-independent peripheral preco-/ f( g; F7 t# G# w1 c
cious puberty in boys also results from inappropriate! j8 m8 o' b. L! Q5 b0 v
androgenic stimulation from either endogenous or) }) \  B6 {' \1 i# B3 I
exogenous sources, nonpituitary gonadotropin stim-
8 s$ Y- a3 Q* h; y( a; Bulation, and rare activating mutations.3 Virilizing
$ H/ d' P+ g1 L5 @5 o5 U$ Bcongenital adrenal hyperplasia producing excessive
6 F# e( K( f" F2 ^  \. t% Vadrenal androgens is a common cause of precocious: @! B' {% F8 h  Q
puberty in boys.3,4. s. C, @% \/ h, U, ^+ M+ E; l
The most common form of congenital adrenal! u, h, z  j0 ]; g7 c
hyperplasia is the 21-hydroxylase enzyme deficiency.0 |, t, Z" @% Z8 C
The 11-β hydroxylase deficiency may also result in
0 B, ^4 V$ G+ d2 q# P% vexcessive adrenal androgen production, and rarely,9 a& q7 {. }, i& q* P
an adrenal tumor may also cause adrenal androgen6 e/ ^* z. \0 E; U" g
excess.1,3
6 v9 N. N# y* a$ X& _. }, O1 y$ u6 h: Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ D$ j/ |  ~- `( e, F! @
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  i' u. t& h0 S! Q
A unique entity of male-limited gonadotropin-' R  ?+ K0 J% u. T5 X7 d9 t" C
independent precocious puberty, which is also known
1 U3 S& u; Z5 b5 A+ R, pas testotoxicosis, may cause precocious puberty at a
. \+ J6 O  }- p& |3 ~5 Jvery young age. The physical findings in these boys( R( v, B) I- @7 Q
with this disorder are full pubertal development,
5 _& m1 a4 z8 U, k4 g' E. Zincluding bilateral testicular growth, similar to boys
5 G* Y( z. Q9 b; h" p$ M; swith CPP. The gonadotropin levels in this disorder* a$ b! x" H; ]: v3 d" g
are suppressed to prepubertal levels and do not show
) Y/ z+ L8 G$ X  V. I& v" ^5 xpubertal response of gonadotropin after gonadotropin-9 e/ E) M- t. }* d" g& L) L
releasing hormone stimulation. This is a sex-linked3 l) Y/ O. `; Q9 L
autosomal dominant disorder that affects only  y" _, a5 s# D1 e! `
males; therefore, other male members of the family
  g, i2 B/ O0 Z" a/ D1 Z9 xmay have similar precocious puberty.3
( _7 F, _; D. E( iIn our patient, physical examination was incon-8 w! U0 N2 v- s( j; c: @! H+ q5 h
sistent with true precocious puberty since his testi-
- u6 c- g! @2 r  K- o- H) R& ccles were prepubertal in size. However, testotoxicosis
2 \  e  W2 D' d) O4 ]# mwas in the differential diagnosis because his father
9 h6 [# F* a0 _started puberty somewhat early, and occasionally,7 k, e9 k0 l7 C# o
testicular enlargement is not that evident in the& M$ t6 Q. a+ o3 B3 \1 h4 K* d: C
beginning of this process.1 In the absence of a neg-
' r5 d1 G: ^3 R! g1 b6 uative initial history of androgen exposure, our* j* R. X% T9 R, ?% Z; Q
biggest concern was virilizing adrenal hyperplasia,
+ N  |- q3 |: N# B4 k! c% O( [; Qeither 21-hydroxylase deficiency or 11-β hydroxylase
) l7 n8 J3 g4 \; B$ f+ h' F% udeficiency. Those diagnoses were excluded by find-
9 L; ]) {* W" V- ~ing the normal level of adrenal steroids.
) U* ~4 ^. ]+ oThe diagnosis of exogenous androgens was strongly  w" L% Y% S& q; D6 H. I4 D0 j3 a
suspected in a follow-up visit after 4 months because. F0 i9 u5 M& O: Y
the physical examination revealed the complete disap-8 w* {1 H9 n$ K2 V' Y) r& v
pearance of pubic hair, normal growth velocity, and
+ Y7 |- G3 j" |7 g" n4 Xdecreased erections. The father admitted using a testos-
$ O7 ?6 B" m, z5 y7 ?1 j. Z/ w; u6 Jterone gel, which he concealed at first visit. He was
6 R/ E; g/ y0 a: `using it rather frequently, twice a day. The Physicians’. @( F. j' P9 O1 R1 ]5 M
Desk Reference, or package insert of this product, gel or& b' P4 @" e8 m1 z7 v
cream, cautions about dermal testosterone transfer to
( p; Q8 J+ B) t$ y7 Ounprotected females through direct skin exposure.
3 z$ _) i7 z9 @! P4 \! Z! XSerum testosterone level was found to be 2 times the. R( E$ L: x( _* Y* r  E* ~
baseline value in those females who were exposed to3 d/ @" l8 j* S
even 15 minutes of direct skin contact with their male' \6 ^; d- B! K5 d  v
partners.6 However, when a shirt covered the applica-; a" D/ q% M  G# B
tion site, this testosterone transfer was prevented.' V8 d! |6 H" x8 Y2 ^
Our patient’s testosterone level was 60 ng/mL,
) E2 Z4 J" ]6 ]! _' j; Rwhich was clearly high. Some studies suggest that) |' j9 ^/ B4 Y9 z+ I; b
dermal conversion of testosterone to dihydrotestos-& W1 m! X- h6 x$ o
terone, which is a more potent metabolite, is more
& d# ]1 ]# ?: L4 f9 C$ Z+ t( _6 B5 ractive in young children exposed to testosterone
5 }7 X0 n$ p2 _exogenously7; however, we did not measure a dihy-
7 I6 P! Z: ?% M7 T& V7 hdrotestosterone level in our patient. In addition to
/ Z& z1 v2 z5 W. e" @1 _2 zvirilization, exposure to exogenous testosterone in
3 A# \3 y3 I: D/ d5 v- cchildren results in an increase in growth velocity and
& _, E% k( @! N5 [/ P6 R  madvanced bone age, as seen in our patient.
) Q* @' G! T$ l. tThe long-term effect of androgen exposure during
/ S# [) m5 ^% D% D6 Z& x1 {early childhood on pubertal development and final/ |* g/ {  _, q9 ?
adult height are not fully known and always remain
% Q6 ?. s( G& J5 z4 ya concern. Children treated with short-term testos-" C, C/ A4 ?$ V/ D" S
terone injection or topical androgen may exhibit some+ k" l+ o: Z) q" v: ^' \
acceleration of the skeletal maturation; however, after
2 ^+ ^. t# C. Pcessation of treatment, the rate of bone maturation1 A! H' K9 X7 J* P! g- T
decelerates and gradually returns to normal.8,9
# N: u& G) K' F6 k1 n& w6 w1 ]& ^There are conflicting reports and controversy5 Y3 [( M" _# L5 W% W
over the effect of early androgen exposure on adult
" p0 i  i0 X, rpenile length.10,11 Some reports suggest subnormal
+ X+ g0 @1 c* x" j1 uadult penile length, apparently because of downreg-$ w- b- Y+ y4 O* ^' Q( Y
ulation of androgen receptor number.10,12 However,
9 G4 y$ d9 C3 m5 p& s5 t+ J5 PSutherland et al13 did not find a correlation between; E0 n: Y4 E& o
childhood testosterone exposure and reduced adult
7 e7 I+ O( {, e8 B7 Tpenile length in clinical studies.; O2 b  S! W/ \
Nonetheless, we do not believe our patient is! A3 D8 r: G& G, |' z7 w4 c
going to experience any of the untoward effects from: n1 V5 z4 b6 R4 m. A
testosterone exposure as mentioned earlier because& H1 W5 w. p3 p- p6 @% q+ T
the exposure was not for a prolonged period of time.
, ]2 d# T7 r4 a) J6 A0 BAlthough the bone age was advanced at the time of
. V1 w* [+ j* I& S" T0 a; zdiagnosis, the child had a normal growth velocity at
% R1 l# h; l1 c" i; r4 B  X2 sthe follow-up visit. It is hoped that his final adult. {8 b/ ]9 g' x  N
height will not be affected.1 G+ I6 R1 m% \1 f6 `
Although rarely reported, the widespread avail-, _) L( [% k" r$ b
ability of androgen products in our society may* E. n) k, i  s- J- K( Q
indeed cause more virilization in male or female/ D6 V, a, V5 q( |* P% S1 \$ u
children than one would realize. Exposure to andro-# j  M/ e; ]- z0 q
gen products must be considered and specific ques-: E8 m3 g& K2 x
tioning about the use of a testosterone product or& S* O7 w3 |6 T
gel should be asked of the family members during
% ?# d$ N+ m( L) j8 }the evaluation of any children who present with vir-
/ w# n$ `6 V4 x) C( C1 wilization or peripheral precocious puberty. The diag-
/ P) e: q0 b( Dnosis can be established by just a few tests and by- N9 @. L; O$ e6 \$ l6 M
appropriate history. The inability to obtain such a
# J. j+ T4 T/ j5 r0 H% D4 Jhistory, or failure to ask the specific questions, may
6 T/ y0 O0 g0 z( c( Y8 P( Q" E9 ?result in extensive, unnecessary, and expensive
; V4 S# _! C5 L* x2 _investigation. The primary care physician should be$ D8 t6 R' p2 A
aware of this fact, because most of these children
0 ]" W, w6 N  R$ H! f% a. V; ?may initially present in their practice. The Physicians’
5 _* y! h2 O: }, e" fDesk Reference and package insert should also put a6 ~  \5 X3 b8 W2 n
warning about the virilizing effect on a male or
, u' r1 i# t, y4 dfemale child who might come in contact with some-
+ \1 H: V1 Q- j: hone using any of these products.2 i- x6 |+ o/ v( w
References$ ^( s  j9 \& Y/ X3 ^2 u, S- e
1. Styne DM. The testes: disorder of sexual differentiation
! m1 k2 Z  G& ?- @' x' c0 J, w2 rand puberty in the male. In: Sperling MA, ed. Pediatric' e7 ^9 j; \6 q& j" Q3 o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; d6 e5 q' ^0 D- k5 p
2002: 565-628.2 f* I% m) D- ~3 ~
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* f/ F. {0 O' J
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
7 t1 k) C  o$ w4 H  I  H3 xBoy Induced by Indirect Topical
, R+ N% `1 A% C. H7 K' ]Exposure to Testosterone, V/ S$ k1 s9 s# u. q+ H  Y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 s1 |# m( O8 j. ^4 y0 c" Uand Kenneth R. Rettig, MD1/ B/ ]6 z" t6 B+ K& H3 r) Y
Clinical Pediatrics
% u' G8 R/ t. H1 Y+ A. }; lVolume 46 Number 6+ l- Z# y6 D7 y3 c% i
July 2007 540-543
& C* G7 ^8 E6 h© 2007 Sage Publications
, c4 Q. S4 g) N) h10.1177/0009922806296651
+ x) |6 B" k; @http://clp.sagepub.com
0 |( J% t: X2 P$ y$ ]$ |. ^7 ]8 Shosted at* T0 H9 C( l$ X" w) P2 X$ P
http://online.sagepub.com
6 ^: L7 E! i( i# t1 J9 N" uPrecocious puberty in boys, central or peripheral,2 U4 d# w; |+ x' K4 ]3 f
is a significant concern for physicians. Central
0 M1 |+ ~' j9 A3 P0 K, X- yprecocious puberty (CPP), which is mediated6 d0 ?: T0 X* S# G* o; a
through the hypothalamic pituitary gonadal axis, has
& ?. O6 [% c* B0 T1 C& |$ fa higher incidence of organic central nervous system9 x+ {4 I( V$ i- Q9 x
lesions in boys.1,2 Virilization in boys, as manifested
$ Q  n- D  P6 u6 o; O" cby enlargement of the penis, development of pubic+ E4 e2 O0 r0 h) E: X) {& Q" |
hair, and facial acne without enlargement of testi-$ H" J9 s) v8 S0 p# p
cles, suggests peripheral or pseudopuberty.1-3 We
/ V7 _, b" j# |! _5 v) ~- }report a 16-month-old boy who presented with the
* r+ p9 v( Q! p7 q6 eenlargement of the phallus and pubic hair develop-  \+ Y: b( H: q/ T0 r8 }
ment without testicular enlargement, which was due" S- w3 d* x% b* o% R3 ~
to the unintentional exposure to androgen gel used by1 x  _$ N) a6 c* E+ D1 W/ ^
the father. The family initially concealed this infor-
8 v& h0 w9 L  N9 l+ g6 |mation, resulting in an extensive work-up for this; U7 q3 `! T) f9 ?7 d8 ^: Y
child. Given the widespread and easy availability of
0 M% x3 }# u" h2 K! }" X& utestosterone gel and cream, we believe this is proba-! O1 C( B! z7 t4 p
bly more common than the rare case report in the
' M' U% T5 i' _# j; Oliterature.4$ f( K4 v% {% ~) }7 M9 [7 ]
Patient Report$ C: U2 i$ E" z7 f$ Z% Q0 M% @# v" H
A 16-month-old white child was referred to the$ G% R3 f1 S6 \
endocrine clinic by his pediatrician with the concern* n3 M& V7 Z0 R( j
of early sexual development. His mother noticed/ C% \6 X3 p$ x( n0 J2 {
light colored pubic hair development when he was* ]2 Z) W6 p' G" y% G# k
From the 1Division of Pediatric Endocrinology, 2University of
0 a4 A! L3 B  G1 Z, I% v+ ySouth Alabama Medical Center, Mobile, Alabama./ P2 d7 X$ y5 x: |8 W' C5 b6 |
Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 U0 G1 c! w" H1 z+ S+ BProfessor of Pediatrics, University of South Alabama, College of
. d1 F0 m8 y0 l) HMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* T5 T0 o* a9 O( S& O; o0 i
e-mail: [email protected].
" y+ U0 x( q: z( j8 Vabout 6 to 7 months old, which progressively became
" ^# ]! j( o% T1 R  P1 |/ udarker. She was also concerned about the enlarge-
" \" F) c/ K: n9 M& Q6 P. qment of his penis and frequent erections. The child
0 y& C, \% I, }- M7 }* t, f% @was the product of a full-term normal delivery, with
% M$ n9 l3 \5 ~  U/ `& oa birth weight of 7 lb 14 oz, and birth length of7 g1 w6 d7 h; P: X  \. K
20 inches. He was breast-fed throughout the first year; b7 H6 ?0 M+ n' K
of life and was still receiving breast milk along with
- Q! O+ |6 W5 h1 Qsolid food. He had no hospitalizations or surgery,
, {1 l; `: W1 b+ F6 B0 S7 Z" band his psychosocial and psychomotor development% C( J5 }9 E: Q1 c6 H: E- `
was age appropriate.
5 Q$ z/ K+ P+ D3 VThe family history was remarkable for the father,# z; `2 _" }1 C5 j' f+ m
who was diagnosed with hypothyroidism at age 16,
: Z& N# n1 Y+ q* S  c8 S$ o; Vwhich was treated with thyroxine. The father’s0 }- D) x' o! _6 ]
height was 6 feet, and he went through a somewhat
, o! ]2 ?% Z" g  B* J% y" d2 Jearly puberty and had stopped growing by age 14.6 w% g: w/ O2 H$ `3 y, @; I
The father denied taking any other medication. The. G0 o9 r& @) B+ s+ p1 o. A6 _0 h
child’s mother was in good health. Her menarche  O5 H7 O0 s  f- D9 W4 \5 e, u
was at 11 years of age, and her height was at 5 feet' ~& R: S$ g& j3 I
5 inches. There was no other family history of pre-2 L4 i1 _! w& d1 b: M3 U& Q4 C
cocious sexual development in the first-degree rela-" ?' z) \+ o# v0 \0 i: R
tives. There were no siblings.! x; Y5 \* o3 }1 |# E( u4 p
Physical Examination
  y% h- l  d+ m0 F0 iThe physical examination revealed a very active,0 u2 ?0 n4 I' [! e7 [) Y' Z
playful, and healthy boy. The vital signs documented
# P: b+ D4 @2 u- t+ B5 Na blood pressure of 85/50 mm Hg, his length was
9 @2 }! c2 A+ S7 Z" E90 cm (>97th percentile), and his weight was 14.4 kg1 j$ A6 r5 j  j1 v% I
(also >97th percentile). The observed yearly growth
2 \5 m9 @/ g) T1 qvelocity was 30 cm (12 inches). The examination of
6 T& P0 B  S" ?9 o5 s+ S+ Nthe neck revealed no thyroid enlargement.
3 E" j! P9 Q, v0 C0 i$ QThe genitourinary examination was remarkable for" I6 k0 q1 U+ c5 O7 s" l0 ]' v/ a
enlargement of the penis, with a stretched length of
7 r: Y) n, e; f- `; z; ^8 cm and a width of 2 cm. The glans penis was very well
  _+ z' ^1 R6 E: P. }" f# z9 edeveloped. The pubic hair was Tanner II, mostly around5 q# T/ c) w3 \
5408 u( z& d# X% m7 W+ w0 K2 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, ]2 @+ K2 Q* w6 gthe base of the phallus and was dark and curled. The7 l, Y9 D+ b, Q5 [
testicular volume was prepubertal at 2 mL each.
6 X, N8 n" b3 O" ^, u) X3 ]' [The skin was moist and smooth and somewhat( g' X: _4 ]. }/ x1 |& u5 q" s
oily. No axillary hair was noted. There were no6 o& A( u: V5 `; p0 I- ^+ J
abnormal skin pigmentations or café-au-lait spots.( s" G  C: I0 Y
Neurologic evaluation showed deep tendon reflex 2+
+ d% Y% l5 a$ H; ~1 L9 D/ lbilateral and symmetrical. There was no suggestion5 A' D4 c  z/ ^5 ~- k
of papilledema.
3 m, `4 y! V( l: M4 X+ h5 q7 _Laboratory Evaluation& b5 [. z! h: @) g: f( ?. Y
The bone age was consistent with 28 months by
  V0 }9 B! T7 v; M  Wusing the standard of Greulich and Pyle at a chrono-/ D9 V; ?; M. V: @7 O0 _
logic age of 16 months (advanced).5 Chromosomal/ g6 M2 h# ?1 E) H
karyotype was 46XY. The thyroid function test
$ f8 k' \# z( P. D0 dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 D7 i. [9 y% \$ I, f: j& C
lating hormone level was 1.3 µIU/mL (both normal).
) @* o3 B" q, S' e: f# I. M8 s% AThe concentrations of serum electrolytes, blood3 y1 r+ G4 x8 T2 O( @% e
urea nitrogen, creatinine, and calcium all were8 \2 i& @2 Y; S
within normal range for his age. The concentration) o4 H6 Z9 K' r. D" N
of serum 17-hydroxyprogesterone was 16 ng/dL
: z2 b  \1 ^7 q+ l, u/ h" I3 X(normal, 3 to 90 ng/dL), androstenedione was 20! h7 \: x/ H* u0 Z* }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; y( G% a  m- b+ o9 {/ p$ t% cterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, D7 p+ y: l7 Y/ u. Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" s  g: A. J8 A$ p% n
49ng/dL), 11-desoxycortisol (specific compound S)) J5 K  }( V6 Z/ h/ q" O9 T' ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 o- i" j, n( d2 E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 S% {& l$ Z: f: T/ P
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
. B. ]& I- h) H$ R- d4 Wand β-human chorionic gonadotropin was less than
; U: g& ^( X* r1 M0 D& e1 a9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular2 q# Z4 y) N; \5 P9 U4 n
stimulating hormone and leuteinizing hormone
* Q$ S  R3 \, s( ^! ]2 ]% }$ gconcentrations were less than 0.05 mIU/mL
3 o7 @/ ]6 J  B  y(prepubertal).
2 u! q2 D* U; b: `- m2 ?The parents were notified about the laboratory/ d3 G  w- Z) d% Q
results and were informed that all of the tests were; O0 K& t! w. \0 P: C
normal except the testosterone level was high. The
  l; \( n  Y: }7 T. c7 e: x4 efollow-up visit was arranged within a few weeks to/ C3 {9 F3 a$ k; x+ K$ {
obtain testicular and abdominal sonograms; how-
/ |1 ?0 K/ W7 w7 f9 F( i6 D5 O& Y7 |ever, the family did not return for 4 months.- W2 x% Q! T& `* _- X  c
Physical examination at this time revealed that the
$ M  x5 T, m% q1 K/ T4 Xchild had grown 2.5 cm in 4 months and had gained6 b0 C: M7 N) O& e
2 kg of weight. Physical examination remained
; ?6 E+ z9 {4 u3 h. H% H! nunchanged. Surprisingly, the pubic hair almost com-+ K9 }1 U: c/ Z
pletely disappeared except for a few vellous hairs at
- l- S" Q/ W  g1 ]& ithe base of the phallus. Testicular volume was still 2' o2 m9 B! X2 O9 O
mL, and the size of the penis remained unchanged.5 @2 J3 ^# d) Z/ ]- E  y  e
The mother also said that the boy was no longer hav-
% j- K% t6 [7 u9 Xing frequent erections.. e2 S2 e5 L3 f" Y/ b- s  @) a
Both parents were again questioned about use of8 I' M: E' }1 @5 W
any ointment/creams that they may have applied to: s& W0 u* `6 R1 t' E
the child’s skin. This time the father admitted the/ z1 j3 e3 ^' a( i- m8 P
Topical Testosterone Exposure / Bhowmick et al 5411 ^9 C# X& T. ~  `
use of testosterone gel twice daily that he was apply-  H- U6 a' V, {* w
ing over his own shoulders, chest, and back area for
* `, v% W) j9 e7 ]8 Ia year. The father also revealed he was embarrassed
. c  n, J' w! Q2 a: t* Vto disclose that he was using a testosterone gel pre-
5 q% c) w4 N) A- I" a8 Fscribed by his family physician for decreased libido
& T" _, M) h7 i/ ]( |' Dsecondary to depression.
+ g4 A" d# Z/ Y6 p5 BThe child slept in the same bed with parents.5 Y& b/ U" C8 Y8 o6 t- Z, ^$ N
The father would hug the baby and hold him on his
) Q% V" K# V, f* _1 Vchest for a considerable period of time, causing sig-
( y$ J( }; @$ w' Fnificant bare skin contact between baby and father.
3 s/ n* p+ n/ m3 ]! y+ iThe father also admitted that after the phone call,
6 c5 P4 @6 G9 I: b! V! cwhen he learned the testosterone level in the baby9 h# A, e5 `3 \3 p# s8 r+ k, X/ H
was high, he then read the product information+ d' C1 E3 m9 l0 o
packet and concluded that it was most likely the rea-# e0 D# `% s; R3 P+ `
son for the child’s virilization. At that time, they+ @+ p* N$ _; V% x
decided to put the baby in a separate bed, and the
8 u7 ~# C" f6 e% v( y7 R% Pfather was not hugging him with bare skin and had+ a6 B  o& A4 Y0 P
been using protective clothing. A repeat testosterone, J! x& J8 p1 T5 S9 ?& y+ b( k
test was ordered, but the family did not go to the
7 I9 j3 U+ k2 p! blaboratory to obtain the test.
- H' N* t; N& ^7 oDiscussion* Y' e5 ]1 X8 J/ m
Precocious puberty in boys is defined as secondary' Q, x* F. A8 J+ r5 V
sexual development before 9 years of age.1,4' T% _7 p) G/ X$ O
Precocious puberty is termed as central (true) when& `; V5 d- B, K0 L0 D
it is caused by the premature activation of hypo-
  @9 g' d/ V, V( N0 J4 C) ?6 F; Rthalamic pituitary gonadal axis. CPP is more com-' H* F! y2 G. w# \0 E
mon in girls than in boys.1,3 Most boys with CPP
. _1 c" D$ H) f- umay have a central nervous system lesion that is# I3 z0 ]  G& _& Z- q  n  C
responsible for the early activation of the hypothal-
: y: O9 K; |) xamic pituitary gonadal axis.1-3 Thus, greater empha-
$ }4 J1 @: K! N( j$ o- ~5 hsis has been given to neuroradiologic imaging in/ A! F) y' q5 Q+ D. P" ~* w+ W6 \
boys with precocious puberty. In addition to viril-
! U2 r4 u! k7 |( p! v* n( Sization, the clinical hallmark of CPP is the symmet-
8 n1 Y7 R/ D8 e2 h. p! \  G  zrical testicular growth secondary to stimulation by
$ I' N7 U, `3 C* igonadotropins.1,3
6 Y$ ~/ M+ }- z/ F7 y# I9 b4 ^% ?Gonadotropin-independent peripheral preco-' ~, {. x+ n- s1 K
cious puberty in boys also results from inappropriate* b) M, S% p( g) s4 j* w% E
androgenic stimulation from either endogenous or2 A& c7 r% H5 j! A( U
exogenous sources, nonpituitary gonadotropin stim-
- g3 F. n! v6 t) Z, [. w5 m) \1 Sulation, and rare activating mutations.3 Virilizing/ S0 n$ f5 c" \
congenital adrenal hyperplasia producing excessive1 U2 u( K1 J& c- @8 L" p( Z6 }
adrenal androgens is a common cause of precocious
% O: e9 L0 q  b  t: _3 p- npuberty in boys.3,4
0 _9 O  d. A' UThe most common form of congenital adrenal
" q9 r3 M9 x3 y& W' Y$ }8 w, {! Thyperplasia is the 21-hydroxylase enzyme deficiency.
! `6 I/ o/ R5 \The 11-β hydroxylase deficiency may also result in9 F' N3 H; x6 [4 P9 |" ?
excessive adrenal androgen production, and rarely,/ Q7 M( J* e6 n$ y
an adrenal tumor may also cause adrenal androgen: N6 \4 m' C+ w+ @; _- l. z) U; E
excess.1,33 n+ J2 }1 \2 v' M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 C$ @# P$ P) Y0 @; C7 N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& u: z% a, V2 v' O( _. I8 e* K
A unique entity of male-limited gonadotropin-5 M3 U/ i7 C1 \$ |% P
independent precocious puberty, which is also known3 {, {, G) }8 A% n: P: E( V
as testotoxicosis, may cause precocious puberty at a
2 e7 k! j9 y) }1 rvery young age. The physical findings in these boys
8 S/ {8 J, B4 h4 P" y, G4 uwith this disorder are full pubertal development,
- W+ G  v3 E! X. e' b1 Qincluding bilateral testicular growth, similar to boys
/ N) Y/ L% z4 ^" O7 B0 dwith CPP. The gonadotropin levels in this disorder+ S  Y( h- k& N* j) n  r8 b7 J  G
are suppressed to prepubertal levels and do not show
" D  b2 c- N9 R* X  |pubertal response of gonadotropin after gonadotropin-
5 N+ A* {8 L6 t# _& wreleasing hormone stimulation. This is a sex-linked( P; o# V! ^1 |0 _8 {% L
autosomal dominant disorder that affects only
. c, z" ]6 m/ p0 x! y  ]0 S2 O; Smales; therefore, other male members of the family
% M0 {6 ]# P. Z! F& P( x/ Qmay have similar precocious puberty.3+ S- L# r. H7 i8 C. d, ~
In our patient, physical examination was incon-( Z! Y( w- w; t9 {  b* d6 v+ W
sistent with true precocious puberty since his testi-0 M# a0 _/ v. u: V; Y8 r$ g
cles were prepubertal in size. However, testotoxicosis3 J+ W- h( o* H, a. m6 n: G
was in the differential diagnosis because his father" h* z8 ?2 q$ Q% B9 I, c, i
started puberty somewhat early, and occasionally,
$ x- Z- Q9 {) U: d/ u) ^4 s5 l& Ltesticular enlargement is not that evident in the
0 p) Z' S% I- j, n/ Z  zbeginning of this process.1 In the absence of a neg-
" m5 m9 |, T1 L9 a+ c/ @; sative initial history of androgen exposure, our4 Y; d/ a/ u, Q, |4 V
biggest concern was virilizing adrenal hyperplasia," U' b7 t- G3 Z. p- V7 `
either 21-hydroxylase deficiency or 11-β hydroxylase, g: D/ S, |( c# M
deficiency. Those diagnoses were excluded by find-
, m3 ?: d% @# N+ p4 z+ C; Qing the normal level of adrenal steroids.2 S) X9 W( }' _5 N
The diagnosis of exogenous androgens was strongly
3 d7 m  H" M7 }0 Z9 n- {1 a2 jsuspected in a follow-up visit after 4 months because
1 G/ g  }4 Q  h" a( Nthe physical examination revealed the complete disap-
: n6 T# o1 }; K+ hpearance of pubic hair, normal growth velocity, and$ w7 t/ k' d/ Y- C0 _
decreased erections. The father admitted using a testos-2 R! {5 m3 v4 H5 {; Q% |
terone gel, which he concealed at first visit. He was. y8 p9 @3 \* Y/ f
using it rather frequently, twice a day. The Physicians’
$ h) Z6 P  n2 ?% J7 r7 ?Desk Reference, or package insert of this product, gel or+ }6 j$ D8 x' m* w! _4 M) S
cream, cautions about dermal testosterone transfer to. }, y" u6 z1 }) _( m6 f, @3 P
unprotected females through direct skin exposure.% R! I( r& J/ g# `* `- S: T
Serum testosterone level was found to be 2 times the
0 P' Q- [3 {' R- Q3 Z7 qbaseline value in those females who were exposed to
  J( c6 ^% N2 J) h$ {: |$ W* geven 15 minutes of direct skin contact with their male1 Q; x4 P7 p8 n" d3 }
partners.6 However, when a shirt covered the applica-/ a! E' _+ ^9 @" u% m
tion site, this testosterone transfer was prevented.
) @- d* A& Q3 a4 D1 |+ v# [Our patient’s testosterone level was 60 ng/mL,4 r/ n: B* }& X( n
which was clearly high. Some studies suggest that
8 O5 K) }6 q0 c( w8 S( q" P( ]dermal conversion of testosterone to dihydrotestos-4 _: Z0 C2 @; I8 b1 h
terone, which is a more potent metabolite, is more
  N3 V- C7 c# D* sactive in young children exposed to testosterone6 H) N/ n# H) I' i
exogenously7; however, we did not measure a dihy-( m6 V! ?  a6 _, H0 D
drotestosterone level in our patient. In addition to7 C; _  Q. B# S+ H9 i
virilization, exposure to exogenous testosterone in
/ _( m7 V! G) v" K) ^9 R* ?children results in an increase in growth velocity and
- t# D7 B- o3 ]/ N8 N: Eadvanced bone age, as seen in our patient.. W% l! n" t2 y4 }  _5 ?4 M# t
The long-term effect of androgen exposure during+ M' l8 ^: v5 C3 _
early childhood on pubertal development and final7 k: b9 d! u, Q+ x8 I$ h0 r
adult height are not fully known and always remain
. p8 O6 f' H; b# ^/ v! ma concern. Children treated with short-term testos-& f4 W) [' z. P
terone injection or topical androgen may exhibit some
# F! h* h2 b) S1 R9 C& D/ t# @acceleration of the skeletal maturation; however, after
4 b4 x& Q- U: k# ^, Ccessation of treatment, the rate of bone maturation" I. Z$ X0 X2 j1 b# O2 E
decelerates and gradually returns to normal.8,9& k8 d& ^1 _5 B. G+ y
There are conflicting reports and controversy, A+ c9 B+ d+ c& ?
over the effect of early androgen exposure on adult
0 z9 T- ]: q7 t# ppenile length.10,11 Some reports suggest subnormal! ^& [3 W: U0 T5 O' D2 D& ^
adult penile length, apparently because of downreg-
" ~4 e+ Y* d. _0 D+ g0 {3 `; O) Uulation of androgen receptor number.10,12 However,
9 ~; r. P2 s* z5 V' TSutherland et al13 did not find a correlation between. \9 T5 Q: V( u1 d  l( _
childhood testosterone exposure and reduced adult8 t6 t) \5 Y6 F
penile length in clinical studies.: ]+ v# L( R* N% L7 Z: \) I  D
Nonetheless, we do not believe our patient is
7 n1 q6 i: U, zgoing to experience any of the untoward effects from5 a$ v3 {* |9 X9 ~* C
testosterone exposure as mentioned earlier because
0 K3 b; B% w/ d; i- W8 }6 V5 C! B- ythe exposure was not for a prolonged period of time.& s2 x) B! F" Z* W1 h
Although the bone age was advanced at the time of
& P* p! q& g' L8 pdiagnosis, the child had a normal growth velocity at. V6 c1 f+ h, e; a' p
the follow-up visit. It is hoped that his final adult
+ |+ ?! s5 B- q& N  c# k* Kheight will not be affected.  I  j9 i0 E& ^3 J# |
Although rarely reported, the widespread avail-
" o% Z; Z1 ~) A( d+ r5 T* u9 Lability of androgen products in our society may
4 A3 W7 a2 m) |  M4 `$ g0 windeed cause more virilization in male or female
8 C% M# B0 Q5 V6 g  {  K; q6 \5 T' jchildren than one would realize. Exposure to andro-
/ q$ u8 q' g6 x  E0 Vgen products must be considered and specific ques-8 X( p/ t2 S& u6 L" E- b6 w, G( q9 I: _
tioning about the use of a testosterone product or
$ Q& }) N) e6 c% agel should be asked of the family members during
* t# A  D/ v8 n, L+ Y2 R, hthe evaluation of any children who present with vir-
; W5 T/ Q# y) e  e0 j( u3 Milization or peripheral precocious puberty. The diag-- I9 B( `1 A% J7 ~
nosis can be established by just a few tests and by3 f' U3 G  L$ w6 h) B  B# `
appropriate history. The inability to obtain such a
% ?1 `$ M$ n( n) H& K5 _history, or failure to ask the specific questions, may: o; c9 ]2 f. l/ {+ Y
result in extensive, unnecessary, and expensive
. X: U9 N+ y* |3 B! g, Binvestigation. The primary care physician should be
! w: q, `# }$ R9 U2 ~7 Xaware of this fact, because most of these children0 _" `* F2 R+ s& W# E9 q) H3 K
may initially present in their practice. The Physicians’
, T! T, T. v( j* I" LDesk Reference and package insert should also put a
& w* o" |9 H4 O* X; Swarning about the virilizing effect on a male or2 |/ U) P8 ~) ~* H4 J  Q
female child who might come in contact with some-$ d) T) Q6 a; T$ A) d
one using any of these products.
+ T# q9 K% h6 k8 k! e/ m! qReferences2 \9 p1 O- n! _' d: J7 Z
1. Styne DM. The testes: disorder of sexual differentiation2 u% O' {9 W. h$ Q4 ?; n0 b
and puberty in the male. In: Sperling MA, ed. Pediatric
/ D2 Q0 S: e" zEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. A# {: T- \- q1 v. G, ^9 ?! K  |
2002: 565-628.9 x+ k& k: a7 D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* }) U7 C9 o0 I0 Cpuberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

$ b" A: T8 a9 ~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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