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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
/ M( P; \& Q. E, n. d+ P% y* {Boy Induced by Indirect Topical; k, Q8 g) B% [
Exposure to Testosterone
+ G" z! Z2 m! L! |2 P, X; S4 Y, MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 f! z7 \* \3 |) r
and Kenneth R. Rettig, MD16 X3 k, H6 |, d" ^5 ]2 b, [
Clinical Pediatrics
0 u( I) a& u9 R4 E& A) MVolume 46 Number 6
9 O2 e5 [8 U) O6 D2 q6 SJuly 2007 540-543( N& s2 a) y4 @! ~5 e
© 2007 Sage Publications+ ^" ]' i/ q# k# f" ~# H
10.1177/0009922806296651
/ W3 O+ R( C# B- ihttp://clp.sagepub.com9 K/ |0 }8 B. b# i0 _) s# c5 s
hosted at
* z) F' _7 j7 U1 p( {http://online.sagepub.com0 p  J# }, `# C8 j$ S
Precocious puberty in boys, central or peripheral,9 C6 M, D- k$ S
is a significant concern for physicians. Central! P  S6 D* P* u/ c( p
precocious puberty (CPP), which is mediated& m! P, u4 E4 p, ?$ i' u
through the hypothalamic pituitary gonadal axis, has% B+ o8 ~3 R: w/ U+ V9 }7 s7 a1 a
a higher incidence of organic central nervous system
! ?! H" |  C+ a" k7 qlesions in boys.1,2 Virilization in boys, as manifested
2 F8 p; d  H2 s9 G! H$ [by enlargement of the penis, development of pubic
0 \/ g% Z5 e6 W) Q; Uhair, and facial acne without enlargement of testi-( z) g! r! s. H2 l8 ~0 `6 m7 b
cles, suggests peripheral or pseudopuberty.1-3 We
8 o4 I9 E, U/ O, R6 X& |report a 16-month-old boy who presented with the
; [/ V/ D( z, I0 K# N5 R, V  E4 Fenlargement of the phallus and pubic hair develop-
% e+ ^, ~' k; q1 kment without testicular enlargement, which was due7 `: |- `. q) v. g% q$ [+ S. r3 Q
to the unintentional exposure to androgen gel used by
- I% o8 W+ |" x7 H5 T7 kthe father. The family initially concealed this infor-% ?) @+ H' U& M& T4 q5 C
mation, resulting in an extensive work-up for this7 @, Q& p) b( ?& N
child. Given the widespread and easy availability of
+ Z( g' c# V+ x  K* }, @testosterone gel and cream, we believe this is proba-& [; r, e: D$ F! a7 h
bly more common than the rare case report in the
5 j  t) }- F( f  O4 aliterature.4
% ]9 n% d3 P( U4 t4 ?# l$ F  H6 B, iPatient Report
9 j# y3 Q5 m8 A* vA 16-month-old white child was referred to the  ?" {$ C: z# R' l4 f8 J4 t
endocrine clinic by his pediatrician with the concern% K0 j% N) T0 g. e
of early sexual development. His mother noticed0 j/ ?& z' j2 |: i
light colored pubic hair development when he was, f: x5 u, X* c; z5 h  u" W6 {/ A, `9 |
From the 1Division of Pediatric Endocrinology, 2University of7 C5 W* X, i1 ?9 Q$ ]9 m! R! J
South Alabama Medical Center, Mobile, Alabama.* w/ |4 z/ r% w. C0 v
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 L. O+ ?8 K4 B, s% ]/ GProfessor of Pediatrics, University of South Alabama, College of2 c  [, f5 n: A1 e+ v" N0 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& U* J: z* K/ f8 Y6 E0 Oe-mail: [email protected]., @/ i4 N( }& ]7 s: v; {
about 6 to 7 months old, which progressively became: h8 Y- \' I. |" E0 @. s7 i
darker. She was also concerned about the enlarge-& v% p' Y( [& ]- `, W
ment of his penis and frequent erections. The child+ H) F3 b- a* o1 N1 V' {& ]
was the product of a full-term normal delivery, with
2 C; O; g' S! Oa birth weight of 7 lb 14 oz, and birth length of
2 y8 l: q5 q8 z4 B( V$ B20 inches. He was breast-fed throughout the first year
4 E' f& r0 V! \5 j. r# @% s. ^of life and was still receiving breast milk along with
* O& P  I4 |8 t: }solid food. He had no hospitalizations or surgery,
7 A( S3 k" v+ t% ~3 j; X. D1 pand his psychosocial and psychomotor development
9 f$ ~* F! j# g) H) l2 m. }0 C- ~3 hwas age appropriate.3 Z/ ?' o$ E3 o  V0 n
The family history was remarkable for the father,( w( h5 W- c1 d9 r0 Q% H3 {7 d
who was diagnosed with hypothyroidism at age 16,
+ h8 u# k' e3 \# A9 |& `9 rwhich was treated with thyroxine. The father’s# O1 M# ^, _- L
height was 6 feet, and he went through a somewhat
1 H5 R$ _$ i+ p6 t+ r3 O. Dearly puberty and had stopped growing by age 14.
& |  _8 D6 [0 SThe father denied taking any other medication. The
/ @/ X" T( f/ H3 M) mchild’s mother was in good health. Her menarche
9 l) C0 T& l, g* ~4 mwas at 11 years of age, and her height was at 5 feet5 v9 m5 {; V; {0 [# B" F& W7 F* Z1 c
5 inches. There was no other family history of pre-. v# ^& ~: `1 T( m, ?3 C. o
cocious sexual development in the first-degree rela-
- t7 M$ M9 `2 t; e0 z2 D; y) Etives. There were no siblings.+ Z1 \7 e0 z- Z2 |( F# h
Physical Examination
; a; j% j' N9 J: a$ t/ h$ bThe physical examination revealed a very active,# [2 m! q$ _& |6 p
playful, and healthy boy. The vital signs documented$ Z8 A' i- x, c* [
a blood pressure of 85/50 mm Hg, his length was- W" r+ u8 P" u6 [- \
90 cm (>97th percentile), and his weight was 14.4 kg6 V$ ~2 t# q: }8 f  d) ]) e
(also >97th percentile). The observed yearly growth1 _0 q8 D4 [5 |1 \2 f) H4 X% H6 Z
velocity was 30 cm (12 inches). The examination of2 D9 b; K( i* n" N% A
the neck revealed no thyroid enlargement.7 N& v& R7 E/ v- R
The genitourinary examination was remarkable for
+ Z, n4 m% h3 h# {) Xenlargement of the penis, with a stretched length of
7 ~  S/ Z7 S6 g( K8 cm and a width of 2 cm. The glans penis was very well
" `  `+ S# f. d+ ndeveloped. The pubic hair was Tanner II, mostly around
; r: ~8 J3 o$ e5 ~540
1 S; N0 b( x5 o4 A) c, V2 R4 v( }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# d% o# g4 G3 v* c. H
the base of the phallus and was dark and curled. The
3 U1 f& K8 N$ q4 \0 f$ o' x3 Ctesticular volume was prepubertal at 2 mL each.
1 l  ^" t+ C% e! _7 m1 }The skin was moist and smooth and somewhat
3 o. ^8 }3 v$ z% Coily. No axillary hair was noted. There were no
% X# T, V: J+ ^. R( Jabnormal skin pigmentations or café-au-lait spots.
- K% \/ S% t, K7 XNeurologic evaluation showed deep tendon reflex 2+
. M8 T+ V! n+ k0 R; Ebilateral and symmetrical. There was no suggestion. ~9 j9 D+ I3 S6 l9 A2 r4 F
of papilledema.
4 ^" R3 |) }0 a" w/ q1 SLaboratory Evaluation
  T! ?9 ]  {' |  p& F) ~" h+ |The bone age was consistent with 28 months by; n$ U( ~. c+ T0 J+ z
using the standard of Greulich and Pyle at a chrono-
0 E% i% e0 ?6 ]( |% x  wlogic age of 16 months (advanced).5 Chromosomal' J( C/ s5 j9 @# x6 M0 w
karyotype was 46XY. The thyroid function test
! o& [3 f/ N  W  J  Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-  o* `% V% @- b* v" E3 U/ ~
lating hormone level was 1.3 µIU/mL (both normal).
6 Y! X" x  q( f( lThe concentrations of serum electrolytes, blood
% ^% K0 Q. ?- e! C9 ]urea nitrogen, creatinine, and calcium all were
: a( J; w0 b: r+ f. T/ p! O* vwithin normal range for his age. The concentration
: t5 _: g/ Z% u) N* F$ Yof serum 17-hydroxyprogesterone was 16 ng/dL( W! y/ ^8 g! z
(normal, 3 to 90 ng/dL), androstenedione was 20" a6 N" z9 o6 x; H% N7 V! d
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 s$ ~2 i% s& I9 m$ L; Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ W& J6 q% u0 g) Pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. x$ s& j, a, e$ q# l% r" U3 J
49ng/dL), 11-desoxycortisol (specific compound S)$ m, F' o/ w5 G8 ^  s
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 l% \# z% {% c4 L8 _$ A% c7 a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; S* c) v7 Q1 R5 l; a% O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 W, q2 T5 y7 i5 {( h$ W! [
and β-human chorionic gonadotropin was less than
5 B$ `# T: C. r' Y' t2 x1 D! F5 mIU/mL (normal <5 mIU/mL). Serum follicular3 l# z7 j/ y. t- ~9 C
stimulating hormone and leuteinizing hormone5 y& }9 Q$ p8 k- S/ n1 o- ~& j' k
concentrations were less than 0.05 mIU/mL1 T4 v) N4 ?9 x" B; C7 o$ `
(prepubertal).# }& v+ f/ C) K2 I
The parents were notified about the laboratory" H4 }& V$ P" R1 O; H  k4 {) v
results and were informed that all of the tests were3 O7 ?2 C0 n8 f7 j
normal except the testosterone level was high. The
* v; }) ]3 v. E" hfollow-up visit was arranged within a few weeks to
. ^, D9 R! V5 v8 l& Vobtain testicular and abdominal sonograms; how-- b' B. |9 `0 i3 a& E. A! y
ever, the family did not return for 4 months.
9 f; |4 |6 h- ^, C. PPhysical examination at this time revealed that the. A& R9 C/ N+ j2 L5 H6 n% O0 @
child had grown 2.5 cm in 4 months and had gained
2 ]1 u6 o: \3 G2 kg of weight. Physical examination remained! A8 m. s1 P  ]0 Q
unchanged. Surprisingly, the pubic hair almost com-) H9 Y$ q0 |8 S: y" O
pletely disappeared except for a few vellous hairs at
. d/ @+ d; I6 }7 Cthe base of the phallus. Testicular volume was still 26 V; U9 ~7 b: P  S) g4 ~. l
mL, and the size of the penis remained unchanged.
. Z* S# U7 \$ V: R  J/ oThe mother also said that the boy was no longer hav-
1 X9 Q8 h$ A( e8 ?# K0 T1 }# Hing frequent erections.
, J, H% i3 U* m3 t# F  j6 wBoth parents were again questioned about use of" x2 T* i$ t& h2 x, z+ a
any ointment/creams that they may have applied to+ O6 G, b" p* \( A- @# T
the child’s skin. This time the father admitted the4 v3 c! L: `* i
Topical Testosterone Exposure / Bhowmick et al 541( y" v# `; h$ i1 g& K
use of testosterone gel twice daily that he was apply-9 s6 t7 z0 \) a9 U
ing over his own shoulders, chest, and back area for
; q) f4 M" T, v1 V4 K+ K9 ca year. The father also revealed he was embarrassed
/ z" X) H* I6 |, Jto disclose that he was using a testosterone gel pre-, S8 D, k& ?) b  U# q* r) K
scribed by his family physician for decreased libido
7 v5 r% J+ v8 R, {; L! C5 |secondary to depression.; `  I9 S8 o5 Z2 ?: v
The child slept in the same bed with parents.
  z6 e5 \, A/ a% _; {! t  MThe father would hug the baby and hold him on his8 ?% I7 u1 R  J( ^7 F
chest for a considerable period of time, causing sig-
/ ]4 T6 C0 G4 x6 j! N0 s+ wnificant bare skin contact between baby and father.4 d: V2 v0 e( ]3 e
The father also admitted that after the phone call,
% E/ R+ G$ ]. U. ^  Swhen he learned the testosterone level in the baby5 L0 d% f6 G) T5 D' C
was high, he then read the product information
( G- i7 A4 ]' D& T& n/ E2 ppacket and concluded that it was most likely the rea-
" ?) Q% G' c9 S, c. F# sson for the child’s virilization. At that time, they/ r1 k, ~; C5 J6 i
decided to put the baby in a separate bed, and the. g+ D3 t. B; O# b5 ?6 E' Q
father was not hugging him with bare skin and had
0 f( m4 j/ b" k' p* }& Kbeen using protective clothing. A repeat testosterone
' E; B  k- i' D* e4 J$ A3 |# Vtest was ordered, but the family did not go to the3 h$ F' u7 V# L# i0 \
laboratory to obtain the test.+ a+ p/ |; F/ M4 }) m) a$ b3 a; r, i7 @& N
Discussion5 r: p* m, ^* W8 w: M7 l  w" E
Precocious puberty in boys is defined as secondary9 t; J' u3 q; L! h: K4 `. W
sexual development before 9 years of age.1,4
- G; ?9 U! s+ SPrecocious puberty is termed as central (true) when
/ N  G  f" A' |9 O' @7 Zit is caused by the premature activation of hypo-
( \0 Y# C% Q5 D0 n: N- X3 `2 Athalamic pituitary gonadal axis. CPP is more com-2 w, N1 W* m& ~8 r( `
mon in girls than in boys.1,3 Most boys with CPP
8 _+ ^. T# W; O* @, i3 ymay have a central nervous system lesion that is. H" n0 {" g8 q5 M7 n
responsible for the early activation of the hypothal-/ r6 C, Q5 a% R
amic pituitary gonadal axis.1-3 Thus, greater empha-
) ~/ z# _7 Y# n& H4 [sis has been given to neuroradiologic imaging in% M4 F% k1 @/ h
boys with precocious puberty. In addition to viril-4 E2 L7 n6 h, Q) W- h
ization, the clinical hallmark of CPP is the symmet-
  i: m7 Q  ?  F2 Y5 Mrical testicular growth secondary to stimulation by$ p" F# {6 a- L! h5 V
gonadotropins.1,3
. H" D& E+ l2 ?/ wGonadotropin-independent peripheral preco-
" p' t2 Q* c/ M( O) m7 d/ a$ \cious puberty in boys also results from inappropriate+ p+ h3 F% j. E. z/ j8 f
androgenic stimulation from either endogenous or% _% U6 z6 m1 l! x1 E' |
exogenous sources, nonpituitary gonadotropin stim-$ R6 Q) S4 e% P+ C: o1 C
ulation, and rare activating mutations.3 Virilizing0 c8 i/ t7 F8 m) q
congenital adrenal hyperplasia producing excessive/ e" C. s3 F- P& R3 m$ m) c- q8 Z5 h" ^
adrenal androgens is a common cause of precocious
3 t% }: B1 ?3 O$ ?4 Ypuberty in boys.3,4
$ I! Y5 |4 E* \/ f0 Q- W1 b8 `# E* @The most common form of congenital adrenal1 U! O) s9 @1 ?- F
hyperplasia is the 21-hydroxylase enzyme deficiency.& I7 M4 A* s* w% \$ [
The 11-β hydroxylase deficiency may also result in
6 G6 i3 E$ ~4 {0 [" xexcessive adrenal androgen production, and rarely,0 X" O- Q) _4 x- P7 N
an adrenal tumor may also cause adrenal androgen+ S1 ?1 x4 H+ ~* N3 r; R. [4 S
excess.1,3+ r$ U- w' f( i' O2 I8 ]5 Q4 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. r7 E7 t; I- X542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 n1 `, P* p9 z: `1 p/ C
A unique entity of male-limited gonadotropin-) F1 Q7 ?; \1 O4 U2 j3 U7 H' c
independent precocious puberty, which is also known) B  W, `8 K  p
as testotoxicosis, may cause precocious puberty at a
- f$ ]7 R/ d1 @  _+ Z. \very young age. The physical findings in these boys* [; ~! D* E8 B; H
with this disorder are full pubertal development,
* Z" K3 o6 k: v! b0 Eincluding bilateral testicular growth, similar to boys  ]0 {# ^" i. C5 d
with CPP. The gonadotropin levels in this disorder
) z0 L% }* U& i' H6 v# }+ h! ]* @are suppressed to prepubertal levels and do not show
4 }" g8 {6 P) K' vpubertal response of gonadotropin after gonadotropin-
4 u. j# o1 Y6 o# z7 breleasing hormone stimulation. This is a sex-linked) |! d; X" p3 X: k  `) B
autosomal dominant disorder that affects only9 Z6 n1 B: A% Z& e2 z+ S) c& C6 D
males; therefore, other male members of the family/ [; Y0 m% T7 Q+ b
may have similar precocious puberty.31 F* O7 z, u$ T
In our patient, physical examination was incon-% t! E! z' Y% ^0 G% t
sistent with true precocious puberty since his testi-# m. }! w, ~* P: ]+ G
cles were prepubertal in size. However, testotoxicosis, y0 p) W" Q7 r- S1 t, C
was in the differential diagnosis because his father
7 V' E% N" ^$ {- ~' W+ w6 F/ ~. ystarted puberty somewhat early, and occasionally,
9 n8 k* x5 u/ M4 [testicular enlargement is not that evident in the( h9 v9 e5 u/ z0 U4 r
beginning of this process.1 In the absence of a neg-: [& B  _, k% T& I% ]: B! f/ r  j* `
ative initial history of androgen exposure, our2 J8 _8 ~1 q8 ^0 u' q' q. d7 d9 s
biggest concern was virilizing adrenal hyperplasia,+ ?7 A( G1 l% R  T1 l
either 21-hydroxylase deficiency or 11-β hydroxylase
1 f# t' u( V$ }. y: \% s7 G) ddeficiency. Those diagnoses were excluded by find-
3 P% b2 C5 i7 F  ving the normal level of adrenal steroids.! j, a$ b2 O3 [7 o* j; [
The diagnosis of exogenous androgens was strongly& S5 Q/ V9 Q: b* L1 o3 ]6 p
suspected in a follow-up visit after 4 months because7 D* j  C* s9 Q3 F# Z: C1 f
the physical examination revealed the complete disap-. ]  A# T/ O: V+ {
pearance of pubic hair, normal growth velocity, and
1 }- e8 V/ ^$ k5 L7 Idecreased erections. The father admitted using a testos-
0 t. Z; F: m/ m% wterone gel, which he concealed at first visit. He was
+ k- M' t$ F% b& k5 Ousing it rather frequently, twice a day. The Physicians’+ N9 S9 Y: A7 t# [
Desk Reference, or package insert of this product, gel or+ y- v7 Y) @3 h. U
cream, cautions about dermal testosterone transfer to; j" N! ~  b+ z' b& e1 J) K1 |; G
unprotected females through direct skin exposure.
  N+ M4 t% M1 {Serum testosterone level was found to be 2 times the& d1 v7 x5 c5 @. T
baseline value in those females who were exposed to2 U% y; l7 f  h8 Z. U% F7 [
even 15 minutes of direct skin contact with their male
% B1 Q5 T+ U  n( z! B8 C# u( U# gpartners.6 However, when a shirt covered the applica-6 P+ I$ V1 R4 ^+ ~! y+ h# r
tion site, this testosterone transfer was prevented.& w- E. G4 s, x
Our patient’s testosterone level was 60 ng/mL,
' X5 H& l5 d6 L- v- v0 w+ ~3 Z" A7 jwhich was clearly high. Some studies suggest that( M! A: S8 M& B' \$ J
dermal conversion of testosterone to dihydrotestos-
8 R' y9 V" u" Q. e8 _terone, which is a more potent metabolite, is more7 p8 m0 w# x9 Z+ C1 M2 o
active in young children exposed to testosterone
8 R, W' X7 K: ~exogenously7; however, we did not measure a dihy-
' i7 W4 }3 }* Udrotestosterone level in our patient. In addition to
' l2 W/ D8 f- L: r% v) A7 {8 Yvirilization, exposure to exogenous testosterone in# V( H; \) \' {: B1 J
children results in an increase in growth velocity and" ~, w9 J5 l, r
advanced bone age, as seen in our patient./ a* J# @( P# ]1 P6 z; k3 F
The long-term effect of androgen exposure during
' W/ s6 v8 M, O4 ^# S. x0 |- l5 qearly childhood on pubertal development and final+ \3 j2 r6 P5 Z$ w- P$ M7 q
adult height are not fully known and always remain4 E2 e$ U9 f3 Y
a concern. Children treated with short-term testos-
! n( E; h/ U5 ^3 S$ R+ cterone injection or topical androgen may exhibit some
" ~7 s: G  W7 O" g) }, gacceleration of the skeletal maturation; however, after
4 k& b' |$ N& ]1 ~cessation of treatment, the rate of bone maturation; C( c* _5 S1 i8 S: @
decelerates and gradually returns to normal.8,97 _3 V: R, A- S0 `6 F
There are conflicting reports and controversy+ d  M" k3 I. ]/ b! Q; A' k. ^/ V
over the effect of early androgen exposure on adult- s6 g' m3 G; j) P) {- W' F0 d9 }4 ]
penile length.10,11 Some reports suggest subnormal2 E( ~+ @% ?3 r" _. s8 J7 h7 K
adult penile length, apparently because of downreg-9 M+ K% ^/ O% Z9 t
ulation of androgen receptor number.10,12 However,  u! F$ Y2 ?2 l
Sutherland et al13 did not find a correlation between$ }. Z4 q, _7 P0 I4 S
childhood testosterone exposure and reduced adult
6 L7 j3 a# M1 x# k& J4 epenile length in clinical studies.: Y3 x" B, _4 c( k0 I
Nonetheless, we do not believe our patient is
% A6 Y! h2 y* E5 j0 E+ }/ Hgoing to experience any of the untoward effects from3 C0 k3 f) H( ^0 Q( F% p/ g* ~# }9 y
testosterone exposure as mentioned earlier because
- j4 U- b# v" o3 G: y7 Othe exposure was not for a prolonged period of time.
, _# Q8 t; B+ e# L% x  FAlthough the bone age was advanced at the time of- T1 I* x9 {9 p
diagnosis, the child had a normal growth velocity at4 ]' J! g$ f* J  \$ u
the follow-up visit. It is hoped that his final adult6 y1 J0 t' c; q4 R3 r3 w/ B
height will not be affected.
4 z* b; |" B4 dAlthough rarely reported, the widespread avail-
2 s9 ]$ L# f" ^7 A4 f( i/ v1 aability of androgen products in our society may# u* f# S. G0 ?5 g- s( R
indeed cause more virilization in male or female5 _; p- V, O9 G  p: Y
children than one would realize. Exposure to andro-; _7 W7 ]; R. H3 ]: |
gen products must be considered and specific ques-, S; O, k& T$ m$ ^3 F
tioning about the use of a testosterone product or
9 x7 [3 k% m8 C/ B/ ?% K* i. [gel should be asked of the family members during
& o+ b, S& _( v6 c& kthe evaluation of any children who present with vir-4 ~7 a" X. f5 K5 a- w3 k
ilization or peripheral precocious puberty. The diag-- R. b; r( |5 p! r2 J
nosis can be established by just a few tests and by9 c/ ^! Q# h6 ~( X
appropriate history. The inability to obtain such a% a1 ~0 m: H3 Y7 R( F/ t: n
history, or failure to ask the specific questions, may4 r5 U2 A5 W4 W. v
result in extensive, unnecessary, and expensive
. M  i) F0 i: Q8 Zinvestigation. The primary care physician should be& B( [3 ?  ?7 ?0 z* X, @6 X# Y  r
aware of this fact, because most of these children
" y1 V1 a& H* X% Xmay initially present in their practice. The Physicians’/ z" c' r, {& D& w$ i: O
Desk Reference and package insert should also put a
% \  ^2 ^$ {7 }warning about the virilizing effect on a male or
! b5 _9 P$ c  ?& t0 gfemale child who might come in contact with some-
' h: @6 M% B% p/ ^one using any of these products.8 o( g0 d' O! ^6 p8 L" s
References+ L/ J: i$ ]7 K) M  `
1. Styne DM. The testes: disorder of sexual differentiation
% Y' c( Y  R: Rand puberty in the male. In: Sperling MA, ed. Pediatric
$ {- n: p; w+ CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 D0 l3 K9 W, Z8 n8 o9 `) U
2002: 565-628./ @& p0 z5 h, c# G& u1 X: S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; ]+ T1 I4 B" z. L+ ?' Hpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 j3 [8 D; e0 ?, C* c. D- Z
Boy Induced by Indirect Topical
: y' l, M, M- J% a  Y. ^0 MExposure to Testosterone3 D; n5 }; N3 W  C# W4 U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: i; h( I- l7 [3 l' @# {
and Kenneth R. Rettig, MD1
6 d$ \+ l: y( `3 a) yClinical Pediatrics* q4 y- x) h% P; a& Q, y' ]* o
Volume 46 Number 6" B, i  Q! n' _4 ?
July 2007 540-543
$ o  ]% e) {' X- m- Z# e1 o, Q: i© 2007 Sage Publications0 L1 j- O# n& M" {- b" w
10.1177/0009922806296651/ I. V0 e7 |/ }+ i; s3 V
http://clp.sagepub.com  l5 x% z* r, T( n' {
hosted at' T) o4 ?9 y2 q9 ?, i; h
http://online.sagepub.com
6 O" ^+ i( j% MPrecocious puberty in boys, central or peripheral,  @/ Y  M: R/ }7 l
is a significant concern for physicians. Central
3 G' x1 d4 S  [1 rprecocious puberty (CPP), which is mediated
: w; `; U0 J3 b2 m( `through the hypothalamic pituitary gonadal axis, has: L. C2 u; m# k! N
a higher incidence of organic central nervous system, s3 C0 E* q; o2 C  R
lesions in boys.1,2 Virilization in boys, as manifested/ Y! U2 ]4 V" x; X3 `* F& Y% y
by enlargement of the penis, development of pubic. P+ p, D) C# z" q
hair, and facial acne without enlargement of testi-
4 l& k6 Q* c. I! _# fcles, suggests peripheral or pseudopuberty.1-3 We7 m# p" f! {* W) H
report a 16-month-old boy who presented with the3 r7 g% B1 W0 Q& E9 z
enlargement of the phallus and pubic hair develop-! h, y  o9 N; @0 n- q
ment without testicular enlargement, which was due
) s- i* `( K, o+ K3 Y8 L$ o! ^to the unintentional exposure to androgen gel used by
2 G' y5 e6 a9 t7 T9 C) P# ?# E4 |% ~$ t6 vthe father. The family initially concealed this infor-
5 S6 p- A2 F1 mmation, resulting in an extensive work-up for this/ A/ S3 ?# i9 k" B, f+ \1 L
child. Given the widespread and easy availability of# X0 S8 q* X6 k, Z
testosterone gel and cream, we believe this is proba-
% f5 A  L; i1 _+ F0 `* p& n7 gbly more common than the rare case report in the
$ |' f* \- ~/ v; d2 h; Uliterature.4
2 f& p& ?6 B7 tPatient Report$ f7 h/ _; G( q
A 16-month-old white child was referred to the
/ w, o; ^5 R6 {/ t" [/ G4 U3 Qendocrine clinic by his pediatrician with the concern
( v6 i" f( ?# k2 ?. Uof early sexual development. His mother noticed
* V% g: V  h8 H7 ~light colored pubic hair development when he was8 C6 R1 k# h1 \. a  t
From the 1Division of Pediatric Endocrinology, 2University of  [7 L4 r+ z% Q  |3 r
South Alabama Medical Center, Mobile, Alabama.
1 P8 R8 K0 v8 m+ y5 O; `, aAddress correspondence to: Samar K. Bhowmick, MD, FACE,: d& b  F2 L* b, Z
Professor of Pediatrics, University of South Alabama, College of
0 A' Q. Q; M+ F( v* s; ~; }! @1 J- hMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& P4 {. j7 _- M9 Z/ J
e-mail: [email protected].
, p. ~; N% z9 W  s' v/ Qabout 6 to 7 months old, which progressively became3 S8 e, k8 e  c4 {) z
darker. She was also concerned about the enlarge-( F* e' b$ I) `/ ]" v) P7 A! g
ment of his penis and frequent erections. The child# \  H3 L7 t4 r7 g
was the product of a full-term normal delivery, with0 J  n4 M" ~! R* K4 O- t# y8 A
a birth weight of 7 lb 14 oz, and birth length of3 L7 ]0 h/ Q+ k3 `+ ^- H9 b; p9 l
20 inches. He was breast-fed throughout the first year# Q, q9 ], C9 S0 `# b
of life and was still receiving breast milk along with9 x& r: q1 p; X8 N+ Q  O
solid food. He had no hospitalizations or surgery,# E/ p; ^; `0 n  [, O1 h3 q, d
and his psychosocial and psychomotor development$ e+ g3 d* N4 F3 |/ X8 ~
was age appropriate.
$ K* U9 f6 A+ d" V/ x# _The family history was remarkable for the father,
: m: i. \7 F* T1 s' }who was diagnosed with hypothyroidism at age 16,0 X" \8 y- s5 {6 B, Z
which was treated with thyroxine. The father’s
% `# j9 {6 y6 `  Y1 D& `height was 6 feet, and he went through a somewhat4 l0 R% _5 [1 K2 ^$ M
early puberty and had stopped growing by age 14.$ e) F3 a1 ]2 Q) v, h9 s! z0 U
The father denied taking any other medication. The
$ d# f$ x3 N, j7 ]% l- qchild’s mother was in good health. Her menarche
& m. A( l/ r5 Qwas at 11 years of age, and her height was at 5 feet% s. ~5 S. K+ Q* a
5 inches. There was no other family history of pre-8 m/ W7 F/ v2 v. D9 }
cocious sexual development in the first-degree rela-
; U0 `5 y( R: r0 ktives. There were no siblings.# P- o, [# I7 d3 S
Physical Examination9 L, {# {; o9 x
The physical examination revealed a very active,! @& c$ P0 q5 J' J9 r0 t% S: F
playful, and healthy boy. The vital signs documented
. R" s: z. {9 R" ~0 Ba blood pressure of 85/50 mm Hg, his length was
/ ]; a" z& O1 L4 n! t1 k4 e90 cm (>97th percentile), and his weight was 14.4 kg
+ N5 p% g& H3 Z8 s1 X(also >97th percentile). The observed yearly growth
0 R8 x- }9 Y, F3 Z/ w$ V4 gvelocity was 30 cm (12 inches). The examination of* @$ |/ r: ]: I6 n
the neck revealed no thyroid enlargement.
3 }2 c. C$ a/ }+ ?The genitourinary examination was remarkable for
$ r7 {: a* ?1 _enlargement of the penis, with a stretched length of1 T" |! A" ]' t* i# g5 m  C* V
8 cm and a width of 2 cm. The glans penis was very well2 S7 L# a! M  G  j
developed. The pubic hair was Tanner II, mostly around# k' M& t+ t3 Y+ C5 W
540, S" ?) q8 y5 p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( c/ ^) a- `. S
the base of the phallus and was dark and curled. The
1 A* W, K" E1 u4 {testicular volume was prepubertal at 2 mL each.4 u4 J. C% O3 D7 N$ ^& ~3 D
The skin was moist and smooth and somewhat& j/ E' K! e+ B9 T* X1 t0 P
oily. No axillary hair was noted. There were no4 i4 C8 C, Q$ V
abnormal skin pigmentations or café-au-lait spots.; L4 r2 f' {; Q/ J2 F- i3 ], L
Neurologic evaluation showed deep tendon reflex 2+$ F5 I. |( |4 Q$ D: {
bilateral and symmetrical. There was no suggestion
# o  O6 \  _5 X+ M' C- mof papilledema.. i7 u3 m7 M' z  ~. W3 ^
Laboratory Evaluation0 l- s7 h7 t& ~0 q* p$ K& G9 `) W  f
The bone age was consistent with 28 months by
2 U. ?; k% A6 C; p& O/ ^using the standard of Greulich and Pyle at a chrono-
& b. Z4 d* h- Ylogic age of 16 months (advanced).5 Chromosomal$ f. m" X3 g. q3 I  ?
karyotype was 46XY. The thyroid function test5 v: p- {1 U3 R% [( E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( E0 a. d  ^' {, m% D8 _lating hormone level was 1.3 µIU/mL (both normal).# }; E" I; I  a; Z. F1 [& S: t
The concentrations of serum electrolytes, blood
. ^' k& ]) K4 ourea nitrogen, creatinine, and calcium all were
5 R- z' ~/ l' M* h8 Uwithin normal range for his age. The concentration
9 S" B1 P6 h4 l$ Yof serum 17-hydroxyprogesterone was 16 ng/dL5 E% h1 F, B9 p3 o7 j' S! A
(normal, 3 to 90 ng/dL), androstenedione was 208 J2 f# }9 V6 L  W% A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) X8 R$ |6 A& qterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 \  Q8 F1 i" V  |; b' g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ s# _5 }$ _. b
49ng/dL), 11-desoxycortisol (specific compound S)/ ^# y# _3 h5 c% _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 F: i9 i- O# L2 h5 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' ^! Z5 `  Q+ N" etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 j9 E4 n  _4 |, L
and β-human chorionic gonadotropin was less than$ |. F0 O- l% }( y8 r8 d
5 mIU/mL (normal <5 mIU/mL). Serum follicular  b% [" S9 U2 d, ^' M& P
stimulating hormone and leuteinizing hormone+ J' O8 O" {6 {9 f8 O' N! l, [
concentrations were less than 0.05 mIU/mL$ W$ W8 h7 |* G, L# {9 j, t
(prepubertal).
- L) Y, c5 n" v! L3 f0 a- m7 m& QThe parents were notified about the laboratory
* k5 i* H& k3 z) r, C; M. Vresults and were informed that all of the tests were
1 Z1 k0 ~& _' Z+ v8 P! jnormal except the testosterone level was high. The/ H7 e) m0 J+ ?9 S
follow-up visit was arranged within a few weeks to
. x9 d9 v2 C' f0 H" {, Vobtain testicular and abdominal sonograms; how-
9 H% _1 T; ]$ |8 u$ u+ pever, the family did not return for 4 months.
0 e$ V# K; g7 v( Y2 X: IPhysical examination at this time revealed that the9 n6 t5 r  i5 w# `% Q) L0 v$ x: u
child had grown 2.5 cm in 4 months and had gained: z) b) A* j* r, a2 k! f
2 kg of weight. Physical examination remained3 V: `! H( i! M
unchanged. Surprisingly, the pubic hair almost com-
* `. T: w! K  @! V2 F& B- opletely disappeared except for a few vellous hairs at8 i& B3 I2 P7 l2 l
the base of the phallus. Testicular volume was still 2( M$ l, h3 ]4 y/ L) d9 \
mL, and the size of the penis remained unchanged.  O5 f$ W! e" _* ?5 w- c
The mother also said that the boy was no longer hav-
8 V6 m& A; i, ]- Z. [( J5 K. q2 ]ing frequent erections.: `, o2 I0 \$ g0 j: ~
Both parents were again questioned about use of
6 l2 D1 w1 d) A+ zany ointment/creams that they may have applied to2 r' u  y" O* z/ h/ @' b  @' E
the child’s skin. This time the father admitted the
) C- z6 E$ |! o  g: E4 zTopical Testosterone Exposure / Bhowmick et al 541
* O9 y( b! S3 Y! o( p6 F" i6 tuse of testosterone gel twice daily that he was apply-# D& C* w8 L9 n1 n/ p$ J. ~
ing over his own shoulders, chest, and back area for
, F! w: i0 |! S$ C( ?& Z1 C% R$ xa year. The father also revealed he was embarrassed
, ~9 f. ^% r2 {1 C. u" g/ hto disclose that he was using a testosterone gel pre-
: e6 A6 i5 b+ b- |7 _6 fscribed by his family physician for decreased libido5 S  |7 {# c" m0 H
secondary to depression.3 ^4 |) _! ~% U+ D; m, G
The child slept in the same bed with parents.
1 V: G  r9 A1 Q* t' q) B* G5 xThe father would hug the baby and hold him on his3 d! j7 u: F4 n: l2 T6 D4 _( u, A
chest for a considerable period of time, causing sig-$ m6 X8 n0 f) L
nificant bare skin contact between baby and father.
6 ]0 T2 A: g, X" O. I' \+ \The father also admitted that after the phone call,
% q" ]0 }, X) m3 Fwhen he learned the testosterone level in the baby
# R9 T( @+ ]7 z( \: _( @was high, he then read the product information
0 Z% Q& ]+ C( A& \1 `5 Mpacket and concluded that it was most likely the rea-
- m  w' `2 H; zson for the child’s virilization. At that time, they3 o8 X8 O* @" ?# x! I, F
decided to put the baby in a separate bed, and the
, {# ]$ d. F- ]& V& y+ Rfather was not hugging him with bare skin and had/ k$ T! c# G+ s7 y7 o- ?& F
been using protective clothing. A repeat testosterone
- {& }# u/ U* J* xtest was ordered, but the family did not go to the4 [$ \, E0 C' G, E: `$ ^  b% v0 Z% g
laboratory to obtain the test.3 e5 X2 T6 u6 J4 G
Discussion
, ~; m+ i  O3 U. OPrecocious puberty in boys is defined as secondary$ W* }$ D! A+ b8 T5 \3 W
sexual development before 9 years of age.1,4
: e; K3 a4 I* c4 I. K- w8 s4 zPrecocious puberty is termed as central (true) when
' |# T4 g& g, vit is caused by the premature activation of hypo-9 O2 B; |+ j1 K$ |9 h, a
thalamic pituitary gonadal axis. CPP is more com-
! m  a9 @8 O, Rmon in girls than in boys.1,3 Most boys with CPP
  ~% }) e! |  b% [% b0 i) Xmay have a central nervous system lesion that is
9 n( `4 z' D& p% a+ e$ I/ Eresponsible for the early activation of the hypothal-
2 e" J! b5 K7 D  R9 jamic pituitary gonadal axis.1-3 Thus, greater empha-8 ~  [0 y& m: ~" }  O
sis has been given to neuroradiologic imaging in
! Z7 W% y/ i' O! W/ Y6 fboys with precocious puberty. In addition to viril-
' P0 t+ _' F  i- R) ?# S( V7 uization, the clinical hallmark of CPP is the symmet-3 o; M  r' p, i0 e
rical testicular growth secondary to stimulation by: V6 B5 q2 i- u, O
gonadotropins.1,3
9 e" e3 P$ u# r9 jGonadotropin-independent peripheral preco-
+ e+ c/ u( _* ^6 L7 `cious puberty in boys also results from inappropriate
: _- w: a6 n$ G& ]5 B. [androgenic stimulation from either endogenous or1 N6 y1 ]' C% ^, \7 z
exogenous sources, nonpituitary gonadotropin stim-
/ P. ?! }" T( J0 tulation, and rare activating mutations.3 Virilizing
6 G2 A* G0 {+ o0 i- U4 jcongenital adrenal hyperplasia producing excessive& i+ {  b( s( Z; }! M, X
adrenal androgens is a common cause of precocious; ^9 G) P, i5 \. q. [" @" B! X8 s
puberty in boys.3,4; Q3 i8 e7 w5 S! }( S9 Y/ o
The most common form of congenital adrenal6 S# X! H2 V  }5 ?% w, H
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ B5 Z+ L. v% [! w( b+ tThe 11-β hydroxylase deficiency may also result in
' s! C: m  |: D. iexcessive adrenal androgen production, and rarely,$ u5 U0 j: {% L6 X! c1 d' L$ _* y
an adrenal tumor may also cause adrenal androgen. e% A- E3 J5 j& s
excess.1,3. a- {2 a: ?/ t, F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) R2 W+ L0 h6 d5 G% D1 ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 E. V! [3 U& H/ r9 a9 v% P& F
A unique entity of male-limited gonadotropin-5 a* Y0 S* u9 u) }0 M  V
independent precocious puberty, which is also known9 @( T5 b, v  x6 P
as testotoxicosis, may cause precocious puberty at a3 u; x2 X0 R4 p" c
very young age. The physical findings in these boys1 D  P; N# p" y9 b
with this disorder are full pubertal development,
. x4 {9 ^, n! r$ b& e, R* cincluding bilateral testicular growth, similar to boys( D, ^9 K, c8 ]9 ^# ]
with CPP. The gonadotropin levels in this disorder
7 S+ t! W4 a6 C4 q( \4 L, `- gare suppressed to prepubertal levels and do not show: k% I( r/ y' ]6 ]0 z
pubertal response of gonadotropin after gonadotropin-/ U* \. L( D, s3 U, g
releasing hormone stimulation. This is a sex-linked
* b6 f. o* E( ?8 h3 x$ T# sautosomal dominant disorder that affects only! ?/ \+ C$ F# c, t; ]. I- ^* J3 |# r
males; therefore, other male members of the family
) |0 c& X. o, R+ nmay have similar precocious puberty.3+ K4 [4 a) r! q- r
In our patient, physical examination was incon-+ ~2 V) a8 x( I
sistent with true precocious puberty since his testi-
8 P. e& ?: B0 }* tcles were prepubertal in size. However, testotoxicosis% u* |3 E/ O# V3 t" \5 P2 e
was in the differential diagnosis because his father
7 x4 V; q# E- L, u4 l+ \started puberty somewhat early, and occasionally,
' d+ Q! d9 ?/ b- `+ {testicular enlargement is not that evident in the8 r* n5 P  q! c! C% J) P
beginning of this process.1 In the absence of a neg-
+ M! w0 p! }8 g& s' Iative initial history of androgen exposure, our
  j2 x# ~0 ]2 G  U( j# Vbiggest concern was virilizing adrenal hyperplasia,
# E/ k. l9 z# N' n! yeither 21-hydroxylase deficiency or 11-β hydroxylase5 w, h. m( o9 T7 j4 E: W5 q
deficiency. Those diagnoses were excluded by find-: b4 E7 Y+ W+ K2 s5 W! n% [
ing the normal level of adrenal steroids.6 q# O$ N) ?$ g
The diagnosis of exogenous androgens was strongly
. v8 v7 j5 _9 ?, u* ksuspected in a follow-up visit after 4 months because0 |8 E+ n& _7 A' c8 a
the physical examination revealed the complete disap-
, x3 F+ |, O8 f" I' B% T& xpearance of pubic hair, normal growth velocity, and6 Y# J( H& B" E2 ]* D4 u* c
decreased erections. The father admitted using a testos-
- e2 a5 z) @5 q- X7 }2 Oterone gel, which he concealed at first visit. He was7 {) g, [( @3 g1 o! I
using it rather frequently, twice a day. The Physicians’
0 `2 k- Q' o0 f. _. p4 _! B5 mDesk Reference, or package insert of this product, gel or: S9 v$ L, g9 s/ ?) ^+ `3 e
cream, cautions about dermal testosterone transfer to
" q- E2 c" ~- L1 }0 w$ R' e1 cunprotected females through direct skin exposure.! j0 W5 Z6 `; @8 o, A3 ]2 d
Serum testosterone level was found to be 2 times the
8 h$ h4 P" C$ h9 D3 Mbaseline value in those females who were exposed to
8 _4 H: V! v2 ]; ^7 Q) K# I/ aeven 15 minutes of direct skin contact with their male
% x$ [0 u. d' T& G6 ]) a( Ipartners.6 However, when a shirt covered the applica-; K* q& J) r! d3 P
tion site, this testosterone transfer was prevented.
7 B$ r* E! j3 u/ {Our patient’s testosterone level was 60 ng/mL,
# W5 A- e4 U5 Q) A! D! z6 a! Cwhich was clearly high. Some studies suggest that% t3 B6 a* m. j  T
dermal conversion of testosterone to dihydrotestos-/ ^0 M: C6 x3 o0 ]$ ~1 w" {& f
terone, which is a more potent metabolite, is more
5 J: q# j! v/ X1 nactive in young children exposed to testosterone
% V# J: Z5 F7 i" h: ]exogenously7; however, we did not measure a dihy-
9 {; f( x* D% u# u% l3 Sdrotestosterone level in our patient. In addition to
) ^6 |* _  b3 @% L4 s* o* `& nvirilization, exposure to exogenous testosterone in
. G. y- m$ |3 i5 B0 ychildren results in an increase in growth velocity and' _3 z9 n; Y- l; |% N
advanced bone age, as seen in our patient.
3 b6 z& ^4 [  b2 q8 o) wThe long-term effect of androgen exposure during
9 V4 q+ c- c$ r- ?early childhood on pubertal development and final9 l/ q& c9 ^7 R) J2 v( R6 `
adult height are not fully known and always remain
8 L6 n& d+ K9 T- |- ga concern. Children treated with short-term testos-, m7 {* R- ^, U, J6 Y% Y2 H
terone injection or topical androgen may exhibit some7 C6 C& ^" o/ Z6 A- j0 T# T$ b
acceleration of the skeletal maturation; however, after" S! g. N; _. d, z2 ^" W
cessation of treatment, the rate of bone maturation
$ n2 g7 Q' M" jdecelerates and gradually returns to normal.8,9" j6 S/ ?+ o4 U- o7 F6 _  W7 {
There are conflicting reports and controversy
. O7 o+ T" v8 b- _' X; oover the effect of early androgen exposure on adult! E) T" t9 V/ t. T! J
penile length.10,11 Some reports suggest subnormal
9 O- J1 i! y& N, B# b6 }0 padult penile length, apparently because of downreg-8 W. Q/ O4 I# b5 B' H+ C) b
ulation of androgen receptor number.10,12 However,
" y8 s& v0 V) X3 WSutherland et al13 did not find a correlation between
" c' V" \' T2 ^* ~childhood testosterone exposure and reduced adult8 T! E# {6 U+ Z9 `: W" S1 `
penile length in clinical studies." T' C2 l  ?5 ^- G! x
Nonetheless, we do not believe our patient is
) i" z% I* ?* \  wgoing to experience any of the untoward effects from  W0 F% Y7 Q. `7 m4 m
testosterone exposure as mentioned earlier because
) _% N' `) L; p8 D; `5 r' Z' d' u: E/ Qthe exposure was not for a prolonged period of time.
; c5 V8 ]& H8 O( r' v; jAlthough the bone age was advanced at the time of
$ P8 V+ ~+ x$ _) K6 @diagnosis, the child had a normal growth velocity at  l( E8 \& b3 g# G  H
the follow-up visit. It is hoped that his final adult
1 n% |  ~$ C5 k' a( B' Nheight will not be affected.; z4 y0 V' j: Q/ A4 {
Although rarely reported, the widespread avail-
; n4 r0 h& y+ k9 w6 ^ability of androgen products in our society may
8 p  l3 n* ^) }9 R! eindeed cause more virilization in male or female( D0 x5 I5 ^0 [
children than one would realize. Exposure to andro-
& |; b" ~$ L3 L1 Vgen products must be considered and specific ques-: R, ]/ L  k" I" h
tioning about the use of a testosterone product or/ W; r8 i2 O4 m" }7 G$ q
gel should be asked of the family members during  s& d$ U. Q3 q# F. \# V
the evaluation of any children who present with vir-
0 [8 q) I) e* T$ a/ J* |& ]ilization or peripheral precocious puberty. The diag-
9 M; {& R6 {) v7 a' M% V# N' X6 Bnosis can be established by just a few tests and by; x, {; m7 [0 ~% }3 M1 X& K4 ^
appropriate history. The inability to obtain such a
5 k1 V+ D- s7 w2 Shistory, or failure to ask the specific questions, may5 F! Y4 o- s* X8 q) P5 b
result in extensive, unnecessary, and expensive0 D# y; o/ k! c& Z; l* D
investigation. The primary care physician should be
  R0 i2 r& ]" Vaware of this fact, because most of these children! ^8 c8 M) D7 C
may initially present in their practice. The Physicians’/ W' a" U9 r; d! o
Desk Reference and package insert should also put a
- K- _' `- L4 @) Swarning about the virilizing effect on a male or
8 o0 y! K5 H8 h8 o" t& S+ a: \female child who might come in contact with some-/ Z! B" |; A8 E/ k$ B; y$ t
one using any of these products.- k6 r+ ^9 y% g2 P( Y8 ^
References; A( t0 ]. p& A+ k
1. Styne DM. The testes: disorder of sexual differentiation
3 S  G5 B/ m9 a3 m" M# qand puberty in the male. In: Sperling MA, ed. Pediatric' c' ?9 ~6 a3 F) i; Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% h- b! C. a7 u" V" A& v2002: 565-628.  Q* Y& t# z1 T) r' [  A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' ?5 r/ [$ e/ y* q& _. S$ e) \
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
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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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