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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. m% s6 D. K1 m2 SBoy Induced by Indirect Topical
) E4 m4 ^7 c* Y( g: K6 [7 YExposure to Testosterone
) O: ^) O  f3 ]0 y$ P( NSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& F) N% {- W6 F6 Z3 T, ^* t
and Kenneth R. Rettig, MD1
) r: W; ^5 G; WClinical Pediatrics
. j5 q! W0 i2 e* _1 SVolume 46 Number 6
* F" p# A, H4 ]$ UJuly 2007 540-543# J/ b' W: M% d
© 2007 Sage Publications
( n+ }$ Y6 |! }& ?6 W4 k  k10.1177/0009922806296651+ Q2 Y/ p) v" x4 O: _5 b9 J5 t4 w1 i
http://clp.sagepub.com
7 h5 c+ X9 b3 z6 z# whosted at0 z1 v! m" X+ u1 R; n
http://online.sagepub.com7 Y, o4 N$ D* p3 G4 e0 x/ y
Precocious puberty in boys, central or peripheral,2 e% B& v% n. a  {: S
is a significant concern for physicians. Central
  h0 r! y( \8 W! Z* g- l" vprecocious puberty (CPP), which is mediated
2 }2 [7 q  z" ^0 hthrough the hypothalamic pituitary gonadal axis, has
) R# ]* T# Q% C" a; f( Qa higher incidence of organic central nervous system
/ ?. _7 X/ B1 `8 @lesions in boys.1,2 Virilization in boys, as manifested
$ {. G5 J( q' j6 G' Z. Lby enlargement of the penis, development of pubic
/ w, y5 u+ A+ `+ p1 hhair, and facial acne without enlargement of testi-
$ v" l  a* Q: b; X4 \8 S9 icles, suggests peripheral or pseudopuberty.1-3 We
4 v: ?' d# P, o' xreport a 16-month-old boy who presented with the
4 M, W! Y& d8 ?enlargement of the phallus and pubic hair develop-
. M) v7 f+ y& a# E* m9 T9 ]ment without testicular enlargement, which was due
/ S/ h! |( V& U0 P9 Mto the unintentional exposure to androgen gel used by  T( @  Z3 x, ~. M
the father. The family initially concealed this infor-0 X; \& G+ B% w3 q, m% _
mation, resulting in an extensive work-up for this; I3 u% Q  K6 Q" o3 I5 l
child. Given the widespread and easy availability of6 b+ `  U8 t( w  Y5 T0 p
testosterone gel and cream, we believe this is proba-" V6 @3 N% r2 x& d# G0 T
bly more common than the rare case report in the: q4 ^4 `' {$ X* D- [$ U: c
literature.48 _3 C" S6 b. p# o& l
Patient Report, G+ n" X& Z! }3 n
A 16-month-old white child was referred to the' m/ M3 D0 _# s6 ]6 _* x" \" B' R
endocrine clinic by his pediatrician with the concern5 y" P, w: A, k4 B1 J3 Q, M
of early sexual development. His mother noticed, z. J5 E( k& s/ f. t
light colored pubic hair development when he was) H- `9 n1 f* ^9 W8 J& S) |
From the 1Division of Pediatric Endocrinology, 2University of7 c4 ]+ o+ S; T* \$ B  _7 d2 j, f
South Alabama Medical Center, Mobile, Alabama.- u  }% `7 h: I. k
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ I. R) @+ a0 v5 fProfessor of Pediatrics, University of South Alabama, College of  Y0 A; k6 f4 T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( U, {. S: A: U; F; y$ n+ D" E
e-mail: [email protected].- D9 `& y% x) ~, C' V
about 6 to 7 months old, which progressively became  C3 u7 N% H8 W0 @( U1 p
darker. She was also concerned about the enlarge-  ?6 J: ~( ]) q! V
ment of his penis and frequent erections. The child
6 I  O* H  T$ {- k8 F9 Q2 ewas the product of a full-term normal delivery, with
1 _( h  a: [$ Da birth weight of 7 lb 14 oz, and birth length of
2 g7 R( {  ]4 ~/ q1 f+ k. y9 D4 x20 inches. He was breast-fed throughout the first year" h+ ?; j. w* B2 F  \5 O4 |
of life and was still receiving breast milk along with
! c: x& |+ R1 p) vsolid food. He had no hospitalizations or surgery,. z: J7 h4 m) Z5 j* v4 R$ G
and his psychosocial and psychomotor development( I" J7 d, L9 E. e% N
was age appropriate.
. y2 v' q6 o+ C/ m: WThe family history was remarkable for the father,4 |( z6 s, A/ n: u6 O
who was diagnosed with hypothyroidism at age 16,
# M, f) Z, U( u# n5 {2 \which was treated with thyroxine. The father’s
$ {3 F' B8 m( k- d; y- ^2 cheight was 6 feet, and he went through a somewhat0 I( j6 {8 x: ~# B
early puberty and had stopped growing by age 14.
' O# C3 i9 g, N8 ]8 t5 e  A  AThe father denied taking any other medication. The
" a( K; q% S7 U1 O( fchild’s mother was in good health. Her menarche
; e9 L4 A- F9 {9 A; D, Q- G- F  cwas at 11 years of age, and her height was at 5 feet) Y; j8 A' ?+ L2 J' N
5 inches. There was no other family history of pre-; t9 _4 d7 \) P# m9 B
cocious sexual development in the first-degree rela-
+ p  K2 j* p# s) E7 I+ G1 _tives. There were no siblings.* D; v& c& K5 U3 O. }0 t+ t( `* c
Physical Examination" w& a& n. M( h: {4 u
The physical examination revealed a very active,7 E' z) t# G2 p0 g, i1 ]
playful, and healthy boy. The vital signs documented& i5 c! }" n% F* m% p
a blood pressure of 85/50 mm Hg, his length was
2 r1 e/ d$ Q6 |9 ^. _6 L90 cm (>97th percentile), and his weight was 14.4 kg* ^9 J/ b% `" V
(also >97th percentile). The observed yearly growth
' ?1 v+ p; c" s4 o: evelocity was 30 cm (12 inches). The examination of. Z9 g# A0 k5 @* E/ y/ Q: h
the neck revealed no thyroid enlargement.
$ a1 ~4 M, `5 I5 ~2 Q2 MThe genitourinary examination was remarkable for$ G3 L. t  j% p, w0 G  G4 k' `( M
enlargement of the penis, with a stretched length of
* e. O6 T9 N) g+ o! h% r: G- _8 cm and a width of 2 cm. The glans penis was very well+ s3 P' O/ }1 t, n' m7 A2 {
developed. The pubic hair was Tanner II, mostly around
- _5 l$ f: j2 q0 l6 k& n- U( ~5 h540
+ m: w8 G* F1 L; L0 rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 I4 Q- ^8 L( {+ g
the base of the phallus and was dark and curled. The) G! R; G1 I' @8 y+ [7 X
testicular volume was prepubertal at 2 mL each.
$ B9 c! k, H6 \" `9 Q( _% gThe skin was moist and smooth and somewhat
5 P5 O3 I, ?  Y! ~oily. No axillary hair was noted. There were no
/ _/ F: C' I: t" Nabnormal skin pigmentations or café-au-lait spots.2 k9 ~, `$ K/ d0 y- ]5 _
Neurologic evaluation showed deep tendon reflex 2+# q& ~2 N. a" ^! S- t
bilateral and symmetrical. There was no suggestion
5 S% D$ n: l9 S$ ^2 \/ U  `$ Zof papilledema.) H0 {- }& m* T# n8 R6 K, M) l. n
Laboratory Evaluation
3 R" a9 O& s' T9 }The bone age was consistent with 28 months by
6 m! j) v( T' l  ?' H( B! Susing the standard of Greulich and Pyle at a chrono-
( i8 h, h8 [2 B6 o" _, D* xlogic age of 16 months (advanced).5 Chromosomal0 M& p. z; e7 V  @
karyotype was 46XY. The thyroid function test
. ]1 y" o5 `8 Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- u  z+ ]- \4 @
lating hormone level was 1.3 µIU/mL (both normal).
; W( Y1 [% U- b/ wThe concentrations of serum electrolytes, blood  n1 @' r& M1 f. j5 q. v
urea nitrogen, creatinine, and calcium all were
. f  B1 Z" n6 B% W( m% u) Hwithin normal range for his age. The concentration6 O+ D3 \+ a% m7 x( h; G
of serum 17-hydroxyprogesterone was 16 ng/dL3 v% i" X7 V* V( A0 r
(normal, 3 to 90 ng/dL), androstenedione was 20
3 ^% W. @8 i  M, K: ^# png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. Q6 B4 f4 ?1 ~' z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 r7 o: t. g2 n( Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ p6 y# M6 _; x( m' r49ng/dL), 11-desoxycortisol (specific compound S)
* \3 G* u5 ^/ M; w1 R5 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- t; f2 W3 V- i8 w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 ?. `; l8 a( k% k; c' o. C, Atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),- O' U. C7 f# f7 E' e$ ~( d
and β-human chorionic gonadotropin was less than9 b: X$ d( M0 _/ r0 |9 Z$ ?# P
5 mIU/mL (normal <5 mIU/mL). Serum follicular, K1 @2 e& a, ?" J
stimulating hormone and leuteinizing hormone* I5 o0 N1 u7 ^& G& i$ C+ l# v4 W
concentrations were less than 0.05 mIU/mL
- J! P2 D6 f5 J(prepubertal).
" L0 S# V' j8 e  V' M4 J* }The parents were notified about the laboratory
4 k& {# y& W* F" L7 n* dresults and were informed that all of the tests were
) h$ O( P0 g' @' A& P& N6 @normal except the testosterone level was high. The7 g: ^3 a% ~5 g* `$ |# e
follow-up visit was arranged within a few weeks to
! ~  ~# b* t5 z; v- p% aobtain testicular and abdominal sonograms; how-6 Q, ]; H0 \: z4 l% G5 s  C+ K. d
ever, the family did not return for 4 months.0 f! N5 B3 Y& z2 f/ r; U
Physical examination at this time revealed that the3 _3 i  d; x* e- j4 R( N& h; a
child had grown 2.5 cm in 4 months and had gained
, r0 G% U. \2 l2 d, x2 F& M& {2 kg of weight. Physical examination remained
9 p! Z0 \5 i# Wunchanged. Surprisingly, the pubic hair almost com-
8 F+ f$ x2 K4 l) [pletely disappeared except for a few vellous hairs at
0 Y, Y; Z9 V  C4 b2 X' Jthe base of the phallus. Testicular volume was still 2
) e+ F0 _# J) c; |mL, and the size of the penis remained unchanged.( z  v# {5 h- ^/ e8 k
The mother also said that the boy was no longer hav-+ M' P& X" f+ }, t+ p
ing frequent erections.
2 E: w% j/ Y9 N, ?Both parents were again questioned about use of4 F) b1 X' i- k+ Q" A
any ointment/creams that they may have applied to
, O6 E3 n+ p- U; a5 G; pthe child’s skin. This time the father admitted the
% L: Y7 `) ?) s! ^1 pTopical Testosterone Exposure / Bhowmick et al 541$ O5 y5 f/ z# }; \# w
use of testosterone gel twice daily that he was apply-9 g0 U9 Y; k3 e- J8 W
ing over his own shoulders, chest, and back area for
- D( c0 \: d+ P  Z/ \a year. The father also revealed he was embarrassed
1 v( A. k) f: d, yto disclose that he was using a testosterone gel pre-1 F& |: r8 N7 g- ~3 D- u# O
scribed by his family physician for decreased libido
$ B1 n" j; s. n8 o* qsecondary to depression.4 r5 g  q4 n9 @$ x; O- e5 D$ \# j
The child slept in the same bed with parents.
- g# T! C6 [0 y3 RThe father would hug the baby and hold him on his
( R. U/ w9 j# K) Echest for a considerable period of time, causing sig-7 N( C5 |, I; q2 ~
nificant bare skin contact between baby and father.' n5 E9 e+ R% [& f. q( Z; n4 l3 N8 B
The father also admitted that after the phone call,  ], |) ^+ I" v% R
when he learned the testosterone level in the baby
# o& n/ P( K% o% d6 z8 Awas high, he then read the product information) }+ u0 [# S% J4 s+ e2 L( N7 V
packet and concluded that it was most likely the rea-
0 [6 n! E+ D/ r$ a! V8 Bson for the child’s virilization. At that time, they
" I! b; Q6 p; q0 _: f* |4 {3 ^! w0 {decided to put the baby in a separate bed, and the8 w( K9 m  U8 o) S$ E
father was not hugging him with bare skin and had
9 V5 x! k3 z( A$ qbeen using protective clothing. A repeat testosterone# P7 r' s: a/ A1 [. h( A
test was ordered, but the family did not go to the
; w' |$ h) _) u2 U: x1 Glaboratory to obtain the test.
3 V: t/ ]$ x2 U0 uDiscussion; U2 U+ _! m! ^' F' V- w: n" d
Precocious puberty in boys is defined as secondary. [0 V/ |3 V; {# I/ H0 ^  a
sexual development before 9 years of age.1,4
. `" [9 h. x3 L9 w2 u  e3 BPrecocious puberty is termed as central (true) when
1 K3 B" \9 O* k3 N1 o& eit is caused by the premature activation of hypo-! j) }! C1 O5 |1 j$ d1 c
thalamic pituitary gonadal axis. CPP is more com-
- y+ B3 T. F% q7 ~3 {mon in girls than in boys.1,3 Most boys with CPP
) T* ~3 m1 F  R2 ?3 imay have a central nervous system lesion that is* p3 n' d' J: F5 _& A
responsible for the early activation of the hypothal-
5 y9 G) ?. \6 e3 |* Pamic pituitary gonadal axis.1-3 Thus, greater empha-0 \( t# C6 t- P; B/ S
sis has been given to neuroradiologic imaging in
, ?9 i/ O; x) U# n- W9 uboys with precocious puberty. In addition to viril-* _8 K$ z# B: G: g
ization, the clinical hallmark of CPP is the symmet-
7 W' Q2 j# d7 O9 wrical testicular growth secondary to stimulation by5 w) ?% z9 x% G  E
gonadotropins.1,3- s% ^9 F- y# u/ O6 O3 }$ [" ~
Gonadotropin-independent peripheral preco-
) P  Y( L9 p5 I9 |8 V! ^$ A7 Rcious puberty in boys also results from inappropriate
/ V+ m7 l) ^: L6 F6 u: Aandrogenic stimulation from either endogenous or: U. I8 \) x1 ?! ]8 b/ L" ^/ f# Y
exogenous sources, nonpituitary gonadotropin stim-" J7 R/ t! W5 V$ }- b: B# Z/ _7 R
ulation, and rare activating mutations.3 Virilizing
- P/ k- q" }6 dcongenital adrenal hyperplasia producing excessive4 J7 S; @' _& @( s" H* ?8 R2 M
adrenal androgens is a common cause of precocious# w# Y0 O. O  q6 E
puberty in boys.3,4
/ L* }* A9 `/ q3 IThe most common form of congenital adrenal0 i  l/ h, x& m! E- `! {, L( D
hyperplasia is the 21-hydroxylase enzyme deficiency.: x+ w0 e% b! s. I
The 11-β hydroxylase deficiency may also result in2 l6 d, r1 D1 }7 o
excessive adrenal androgen production, and rarely,
& g9 r  X& K0 R0 f, Ban adrenal tumor may also cause adrenal androgen
5 v% X$ F8 n5 Y) e$ Lexcess.1,31 d3 A6 J; `- G5 [, e7 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# n+ L) h6 ^; q/ i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- K! u! s8 A/ \" m- t, s0 CA unique entity of male-limited gonadotropin-
: y$ [" V4 r1 B1 l; lindependent precocious puberty, which is also known
# z: v" U3 w5 X/ gas testotoxicosis, may cause precocious puberty at a
9 y2 _+ f1 g' S& Vvery young age. The physical findings in these boys8 k) @. d7 c3 H: z
with this disorder are full pubertal development,
; `, w8 s( \# s) V% q1 `/ |including bilateral testicular growth, similar to boys
$ o$ Z9 ]% P% B/ |with CPP. The gonadotropin levels in this disorder
5 X- N: |" _( Vare suppressed to prepubertal levels and do not show
$ G/ C4 c6 u2 `4 [3 _9 g5 ~$ qpubertal response of gonadotropin after gonadotropin-+ L  `& A& d3 a8 h6 w  i! }9 \
releasing hormone stimulation. This is a sex-linked8 d3 [" m; K- f0 S2 j* m, l
autosomal dominant disorder that affects only' `8 H9 O# n7 R7 Y* U
males; therefore, other male members of the family4 a6 {5 h# I/ A2 S+ q
may have similar precocious puberty.3
5 h$ }( @0 I; }8 NIn our patient, physical examination was incon-
9 s& Z2 S( M! x( I+ R5 T9 tsistent with true precocious puberty since his testi-# [& Y/ A8 \1 A6 B6 U5 K* `/ v
cles were prepubertal in size. However, testotoxicosis$ D6 y: _4 }, N
was in the differential diagnosis because his father
% e- q2 u; F* ^- S$ K; {7 @+ Istarted puberty somewhat early, and occasionally,. P* m. v6 b2 n7 @6 W
testicular enlargement is not that evident in the
4 J0 F2 j# b& tbeginning of this process.1 In the absence of a neg-1 \) e" H3 J6 J7 I4 k; g, v9 o  r
ative initial history of androgen exposure, our, A8 `. X: z* T+ K/ J. g, l
biggest concern was virilizing adrenal hyperplasia,$ s, O+ |1 s. A
either 21-hydroxylase deficiency or 11-β hydroxylase+ `$ y* h  n4 L, Y
deficiency. Those diagnoses were excluded by find-
9 V0 J- ~1 G7 Z% ~+ a6 n0 x9 S8 `- fing the normal level of adrenal steroids.
1 L: U& q+ X2 z$ F0 qThe diagnosis of exogenous androgens was strongly
$ g; i4 s, l' V: L' Isuspected in a follow-up visit after 4 months because
  ]# V4 y, J- X- {7 l1 y, zthe physical examination revealed the complete disap-' d) d( G6 S6 A+ `: f* C
pearance of pubic hair, normal growth velocity, and
2 I  b7 P9 X% ^1 E. B3 Ndecreased erections. The father admitted using a testos-) N) |, A3 ~# g$ i/ w* n; C6 s# {. l
terone gel, which he concealed at first visit. He was$ C1 q9 c' Z# s. \" n( Y# x
using it rather frequently, twice a day. The Physicians’- U( d3 P' U$ Y! I: v$ r( c* O( j
Desk Reference, or package insert of this product, gel or# l/ q/ A& Y) T+ d2 o" G3 [
cream, cautions about dermal testosterone transfer to- D7 H* Q. h. N& @
unprotected females through direct skin exposure.
$ E& ^. e5 K1 m0 s$ O. |Serum testosterone level was found to be 2 times the7 r* L/ J" \7 Z# H# Q  C$ ?
baseline value in those females who were exposed to0 d; I7 i* ], `8 J0 ~- l  O1 _% ]
even 15 minutes of direct skin contact with their male1 J$ ~& a* ~, U* U. a5 `
partners.6 However, when a shirt covered the applica-4 k4 _3 Z3 h4 S) _, A
tion site, this testosterone transfer was prevented.
- W, P4 L1 z( O! W9 MOur patient’s testosterone level was 60 ng/mL,. }$ C; u9 @& ?. b, q1 r+ r
which was clearly high. Some studies suggest that, ]7 p3 J9 q: {; O. z' u4 \
dermal conversion of testosterone to dihydrotestos-& y3 v: X+ {3 I% j4 ^' e
terone, which is a more potent metabolite, is more
& s; R* x' h1 }active in young children exposed to testosterone- X3 U: q8 V6 C& Z
exogenously7; however, we did not measure a dihy-
* C2 T3 ~8 P, Hdrotestosterone level in our patient. In addition to+ n; k5 A& k  o( n5 A& ^# e+ p
virilization, exposure to exogenous testosterone in; V4 z/ x7 O  T& d- A/ r
children results in an increase in growth velocity and$ P+ r9 F6 U8 l: J- y: q. O
advanced bone age, as seen in our patient.- ^3 Z* r/ g1 \( l4 P
The long-term effect of androgen exposure during( M9 j) @% B0 P+ Q; a9 d3 l+ W4 o
early childhood on pubertal development and final8 {; l; l- s6 A% N9 d& K6 ~+ \3 l
adult height are not fully known and always remain- p3 c' D* q: Q* Z& z5 V$ Y/ ^# r6 o
a concern. Children treated with short-term testos-, Z, H9 @/ ?: }3 Q1 V5 J
terone injection or topical androgen may exhibit some2 B" p: E7 z, v5 x5 i
acceleration of the skeletal maturation; however, after/ L+ t. [/ K) C3 ?2 l' A
cessation of treatment, the rate of bone maturation
3 W/ U4 {7 M, R- m' R2 Ndecelerates and gradually returns to normal.8,9
0 G8 |: _3 q" v0 g/ C2 w$ PThere are conflicting reports and controversy- l6 p, ]% K; Y
over the effect of early androgen exposure on adult; ?3 ?' o- l& S
penile length.10,11 Some reports suggest subnormal
/ [9 L: S# ^3 u, S; V: gadult penile length, apparently because of downreg-* N# m/ V  \+ k9 H5 x: N
ulation of androgen receptor number.10,12 However,
, b( x* {7 Z. t; v  [Sutherland et al13 did not find a correlation between
5 l/ j# X9 y$ o  A+ i- xchildhood testosterone exposure and reduced adult8 I  t) m! _, B2 a# N; X
penile length in clinical studies.0 X- u% y+ g9 Z/ B) Q) d6 n& Y
Nonetheless, we do not believe our patient is
- F) }! {) D3 w( Q4 Xgoing to experience any of the untoward effects from- R& Y+ |) b: o
testosterone exposure as mentioned earlier because
/ c+ N% Z; Q9 g. Y6 t' tthe exposure was not for a prolonged period of time.
; T' D' ?8 {; c8 ]9 M# e" f: fAlthough the bone age was advanced at the time of
( x, O! X* v0 ~3 Adiagnosis, the child had a normal growth velocity at0 q: e( _( u, l5 X- ?- D' M
the follow-up visit. It is hoped that his final adult0 I( h8 D9 v6 q
height will not be affected.
. V8 L; K. U, S1 }Although rarely reported, the widespread avail-
7 o4 n% Y6 T% H. v: a# V$ ^! n4 Fability of androgen products in our society may
$ H* Q  h6 u; s5 x5 Pindeed cause more virilization in male or female* z- U! }- y$ K; @' f' y
children than one would realize. Exposure to andro-7 W- b9 Y4 Q5 e
gen products must be considered and specific ques-
' h( k1 y. J4 C2 t% M* {tioning about the use of a testosterone product or# z' @3 s8 [0 O/ E- ?6 S
gel should be asked of the family members during
3 P! @9 F3 p' m9 ~the evaluation of any children who present with vir-* h! r1 i0 K( R7 ^! O; y
ilization or peripheral precocious puberty. The diag-& q) ^; p+ b# U* \
nosis can be established by just a few tests and by
: u, h& {2 V* ^2 t# }/ Happropriate history. The inability to obtain such a! h" R: E, j! g9 s9 M
history, or failure to ask the specific questions, may
9 o) M* ?. d7 Y4 R: j4 L* k8 t- {) t& jresult in extensive, unnecessary, and expensive* U" y- r( n5 L
investigation. The primary care physician should be
8 }5 N4 Q; l0 [, N6 `aware of this fact, because most of these children
" \+ P/ S6 Y5 G  T4 M  s( n2 i8 emay initially present in their practice. The Physicians’
2 s/ |2 S0 ?$ @1 mDesk Reference and package insert should also put a( k! G7 U. u7 q4 S. E5 D
warning about the virilizing effect on a male or  Q/ E  m3 K4 t" i* \: w
female child who might come in contact with some-* w$ K" @2 w# `6 s) O
one using any of these products.
1 O8 ~4 R6 i# e; N: z  ^References( t9 v% ^6 y; d. z; ^" y# Y3 F
1. Styne DM. The testes: disorder of sexual differentiation
- f+ M1 C) B5 l% p/ y8 d" j; e: Hand puberty in the male. In: Sperling MA, ed. Pediatric
  @9 x9 z. S- HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 n# F0 N( Y5 b' X
2002: 565-628.0 S5 Q/ s6 H/ D- |- P) Q1 B0 c
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( n7 M! b8 [  ^5 Dpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
7 j2 E& R9 d* V3 UBoy Induced by Indirect Topical  B9 j5 B0 ?1 u6 N
Exposure to Testosterone
. g) S! k! J1 s2 lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; S; x9 d- m3 ]6 L6 u7 tand Kenneth R. Rettig, MD1. P7 K" S% m7 x# x1 q
Clinical Pediatrics
; z  k, N* |. }5 ]Volume 46 Number 6
+ A* ?  p! ^# U, kJuly 2007 540-543
1 ]+ k3 J4 m& k2 u. L+ Y© 2007 Sage Publications0 q2 Q3 _* y0 U; A$ |* m
10.1177/00099228062966512 \, p" f5 Q3 y( i+ P
http://clp.sagepub.com) f/ ~7 x& h& b' L
hosted at* o# {$ e4 W& [- X* H; {! [1 Y) c
http://online.sagepub.com
& d; N1 G" g2 {+ WPrecocious puberty in boys, central or peripheral,9 |6 o# F( H! D  N" B3 p
is a significant concern for physicians. Central
# v' y$ ^6 U: \( r/ k# o4 S# Iprecocious puberty (CPP), which is mediated
6 f# t0 e! k2 C% F/ Kthrough the hypothalamic pituitary gonadal axis, has
2 V$ E" ]0 u( `a higher incidence of organic central nervous system9 E& B* R# j! P( _
lesions in boys.1,2 Virilization in boys, as manifested' {' W: f9 l5 a& `" C
by enlargement of the penis, development of pubic
6 h, m/ m2 P( Z, Ohair, and facial acne without enlargement of testi-
7 g4 K2 q  H+ N# c/ J2 }  Ncles, suggests peripheral or pseudopuberty.1-3 We, l1 S+ O! e0 i; C
report a 16-month-old boy who presented with the8 A3 r- t3 b2 o  u; _$ g+ `7 B9 V
enlargement of the phallus and pubic hair develop-
& d+ d, M+ }' b- o  @ment without testicular enlargement, which was due
* ^5 o/ C( g4 q- Q+ nto the unintentional exposure to androgen gel used by
0 H' W) r* [7 a6 x2 D& r2 Fthe father. The family initially concealed this infor-) {# c* \: ?/ x
mation, resulting in an extensive work-up for this
' o: Q: n2 k" W. Dchild. Given the widespread and easy availability of1 \9 z: S, k* g3 j3 g! k
testosterone gel and cream, we believe this is proba-  O1 b# V2 e- G" R
bly more common than the rare case report in the& a9 A/ y# D9 p3 Z6 M
literature.4
9 `# {! U7 C; k  f9 YPatient Report
( a' N( U% l* D; @3 ?A 16-month-old white child was referred to the8 S3 W' D, Z+ G1 q- Y% B5 q
endocrine clinic by his pediatrician with the concern) ~8 V  c' x: b" j
of early sexual development. His mother noticed
, o4 d0 {' E5 E4 Elight colored pubic hair development when he was
; u/ D& v2 S) Z" b. I4 `From the 1Division of Pediatric Endocrinology, 2University of$ K! o$ g* F7 L" K" H+ d
South Alabama Medical Center, Mobile, Alabama.
+ t, ^3 f: T+ r5 n6 `/ p1 V# VAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 L$ e# ]8 U! O: G8 ^% x
Professor of Pediatrics, University of South Alabama, College of% g* d- X7 i) {. T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; j5 \) D  M! k
e-mail: [email protected].- U2 d3 I8 H6 M$ h# `9 T- q$ A# F  a; f
about 6 to 7 months old, which progressively became
2 ^: a, G- o4 C  I# hdarker. She was also concerned about the enlarge-
1 Y% b( r+ x" ]* y# y' fment of his penis and frequent erections. The child
- P0 ]2 T: h5 T) j/ hwas the product of a full-term normal delivery, with
! z1 t3 H* Y$ H- `8 l4 x' b" {& aa birth weight of 7 lb 14 oz, and birth length of
; g$ ]5 d4 M5 ?% W1 I3 z2 ~20 inches. He was breast-fed throughout the first year2 S" c: ?+ e4 [& X1 r' t, w3 M: r- l
of life and was still receiving breast milk along with
+ ]( X7 i( H; k! X+ s) Tsolid food. He had no hospitalizations or surgery,
& r7 u. |/ a0 band his psychosocial and psychomotor development
. r1 J8 ?8 H. N# mwas age appropriate.. a8 q. l9 L6 x8 o/ H( j9 x6 {
The family history was remarkable for the father,* z5 _! {$ p; C2 [& C# C3 `
who was diagnosed with hypothyroidism at age 16,
$ J8 i" _( i1 P' m/ o# ?2 _& ^( e% owhich was treated with thyroxine. The father’s
- `7 G: m0 `) ?0 a7 x3 d7 |height was 6 feet, and he went through a somewhat% h7 P- E; ~7 D/ h" N
early puberty and had stopped growing by age 14.
3 `8 e' K3 ~8 p" v7 lThe father denied taking any other medication. The
  `! s! M4 [# M& ]0 Ochild’s mother was in good health. Her menarche
9 U/ z% |" a. F3 `* ]( kwas at 11 years of age, and her height was at 5 feet
* K1 f- z7 q2 N' U5 inches. There was no other family history of pre-
8 c4 J& u$ B2 T$ Z: n, I5 Bcocious sexual development in the first-degree rela-
9 J5 o5 }4 L! `" Htives. There were no siblings.- j' Q& p) B; \6 {
Physical Examination- E4 @9 C1 h, \$ r& b' Z0 ~# c
The physical examination revealed a very active,
3 G  p" g7 I, d' E' v# b; V0 tplayful, and healthy boy. The vital signs documented- {  z% ^% ^! ?& G
a blood pressure of 85/50 mm Hg, his length was
& H$ d9 S* _5 r1 H( v2 U90 cm (>97th percentile), and his weight was 14.4 kg
1 n/ N: `  S" [/ |, q' _3 a(also >97th percentile). The observed yearly growth
4 y5 }5 {) w& b6 xvelocity was 30 cm (12 inches). The examination of9 }0 l( @. A4 C
the neck revealed no thyroid enlargement.6 J5 J! a7 a" E* @$ e4 _
The genitourinary examination was remarkable for+ ?8 L- \: f; y7 B1 \
enlargement of the penis, with a stretched length of
. ^3 T6 A& Q/ s/ b7 @, R+ q  F8 cm and a width of 2 cm. The glans penis was very well
1 ^: C' S6 J5 s; t8 fdeveloped. The pubic hair was Tanner II, mostly around
( `) s9 t" m3 s* e540
  n8 o% C/ g2 r  h, W3 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  E4 y  n! |" c$ k% ~6 u
the base of the phallus and was dark and curled. The
) g( S( y5 Z7 Ltesticular volume was prepubertal at 2 mL each.. n" A+ P' ^7 I
The skin was moist and smooth and somewhat
( [1 C$ |4 X9 e. m3 _7 S& ?0 zoily. No axillary hair was noted. There were no
- I3 c$ F; G6 }) V& Eabnormal skin pigmentations or café-au-lait spots.
, ~6 y1 J; N: F4 R# q) E6 U. eNeurologic evaluation showed deep tendon reflex 2+
7 K4 b: v- P+ b/ L5 fbilateral and symmetrical. There was no suggestion6 N6 g3 ]9 X/ Z0 Q* z/ X
of papilledema.
1 n2 W! j& v6 K; @1 {/ S5 wLaboratory Evaluation* v, g/ b/ ^& S
The bone age was consistent with 28 months by4 v  \) f' T" }* h% j! @! z
using the standard of Greulich and Pyle at a chrono-
8 \# J8 E" _, O$ ?1 Elogic age of 16 months (advanced).5 Chromosomal
1 ]* }' x9 u( m/ s2 h! R+ l; Skaryotype was 46XY. The thyroid function test
# L% N+ S' b" Q/ x$ O9 K# ]8 Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-  d, m. L- M& e$ U6 s
lating hormone level was 1.3 µIU/mL (both normal).
3 R& s$ N( }# a1 oThe concentrations of serum electrolytes, blood$ h9 G( d3 ?$ r
urea nitrogen, creatinine, and calcium all were
/ J4 r+ z$ D- s9 k3 nwithin normal range for his age. The concentration
" a* j; w+ Z, v# Zof serum 17-hydroxyprogesterone was 16 ng/dL
6 Y6 R# D# b9 |% E(normal, 3 to 90 ng/dL), androstenedione was 20" C4 A! {0 r: I. l" K4 Y8 P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! v6 b$ @' E% j: O6 a; ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 V, W2 o: e* G; R" p  A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 H$ S" T, H; Q: ~2 I) y49ng/dL), 11-desoxycortisol (specific compound S)
  b- `! P7 r% {- bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 h" ~8 L; l' K$ H, Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! _! j& S  R+ ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 S3 w) m7 ]- C& h: Zand β-human chorionic gonadotropin was less than
1 `: o8 u/ o. W9 Y5 mIU/mL (normal <5 mIU/mL). Serum follicular
) Q0 }+ g  G1 Y. a8 Mstimulating hormone and leuteinizing hormone# J" y3 Y4 l+ h; C* u
concentrations were less than 0.05 mIU/mL! |5 P* M# l* v" Q! R6 c: I! G+ ?
(prepubertal)., X4 k5 }* S+ o1 R
The parents were notified about the laboratory3 U" @' X  a; h& G( x  Y( n
results and were informed that all of the tests were
, k) e. Y, O' ^- k* n0 F5 r8 e: R6 jnormal except the testosterone level was high. The8 }" W8 e5 r  F! _/ |! U3 X
follow-up visit was arranged within a few weeks to
2 f+ ]" G9 J, H: u# mobtain testicular and abdominal sonograms; how-% }& G8 X* o: T" ^. e
ever, the family did not return for 4 months.
8 \6 u& {  z; B' H' v- XPhysical examination at this time revealed that the
0 ~8 ]/ x0 |& a* G: [6 x4 r) a" ]! zchild had grown 2.5 cm in 4 months and had gained: Y$ p; Y/ Z+ a( \+ `
2 kg of weight. Physical examination remained4 Z/ A+ Q0 k3 `& m4 m1 r
unchanged. Surprisingly, the pubic hair almost com-& J* E( p* I; t+ W1 Z
pletely disappeared except for a few vellous hairs at) j  |/ Y5 T5 D7 j  s/ t% ?
the base of the phallus. Testicular volume was still 2
0 k" ~/ U2 U9 S% n! {& d- d8 |mL, and the size of the penis remained unchanged.
( O7 A" Z  E; q7 F5 iThe mother also said that the boy was no longer hav-
# S! [& n+ @  b, Aing frequent erections.
9 L, ^1 E$ O8 f" |  A; t$ R. _Both parents were again questioned about use of
, u# K1 E9 |5 `% U5 k1 R4 J, Xany ointment/creams that they may have applied to
( |# g; l- i6 V) {1 Athe child’s skin. This time the father admitted the
8 x& u( R( q* i9 e9 KTopical Testosterone Exposure / Bhowmick et al 541
! n$ H& ~; Z" T. w' k, {. suse of testosterone gel twice daily that he was apply-$ e. n/ `) Q# q0 a
ing over his own shoulders, chest, and back area for
; L8 W" U/ X4 s9 H8 ]a year. The father also revealed he was embarrassed
" W& J7 A8 x; _4 d- ?6 |to disclose that he was using a testosterone gel pre-
% Q3 {" D  U/ Iscribed by his family physician for decreased libido
: w7 Y7 J- X+ N' k9 Psecondary to depression." n2 _2 e( v9 g3 d/ R9 x, e
The child slept in the same bed with parents.
' s6 t( N5 [, C3 k8 z! WThe father would hug the baby and hold him on his
5 S2 G& b" V, Nchest for a considerable period of time, causing sig-
- a7 W2 r7 K( u% ^; D" B# I3 X+ j* ?nificant bare skin contact between baby and father.
. ]6 y$ k! U: `; pThe father also admitted that after the phone call,' k8 P0 V6 ^5 n/ {
when he learned the testosterone level in the baby
) ^8 V0 I: M2 B* i9 g( wwas high, he then read the product information
0 x* F& F: ~$ P$ h  `( l1 Epacket and concluded that it was most likely the rea-
4 h; l6 Q5 z8 r1 ^9 l/ dson for the child’s virilization. At that time, they+ `* R" V2 l: J
decided to put the baby in a separate bed, and the; q3 s# A) F% t
father was not hugging him with bare skin and had
' o9 [* r0 Q( b' Y0 xbeen using protective clothing. A repeat testosterone
3 @, H$ r& K" M% Gtest was ordered, but the family did not go to the
& u# B6 k* M# A8 ?$ p9 ?laboratory to obtain the test.
; T' q+ q: J7 _6 g% c! VDiscussion
6 W1 K& O* ?9 b6 k2 U& o% PPrecocious puberty in boys is defined as secondary: u/ n* g( m/ I8 F) {& N
sexual development before 9 years of age.1,4
1 s3 T; y- h$ b+ F/ ~4 ~& UPrecocious puberty is termed as central (true) when
; z3 u  G7 p- ~* Mit is caused by the premature activation of hypo-8 f! A2 w$ C5 n- w2 v8 C( M' ~6 k
thalamic pituitary gonadal axis. CPP is more com-
; a  @! F! v0 xmon in girls than in boys.1,3 Most boys with CPP8 n! Z6 L$ n# Y: l0 z
may have a central nervous system lesion that is
+ u# Y' I- n! o9 jresponsible for the early activation of the hypothal-
4 V7 S& H- }* H2 pamic pituitary gonadal axis.1-3 Thus, greater empha-/ o' V% Q9 t4 J6 O, D3 a% ~8 B4 g3 o
sis has been given to neuroradiologic imaging in
, c+ U5 D7 I0 t; y3 }boys with precocious puberty. In addition to viril-
+ \% D% |0 [( X* S7 E/ Q! t  sization, the clinical hallmark of CPP is the symmet-
+ Q6 p: I9 _1 Q9 d; ^1 Urical testicular growth secondary to stimulation by3 [4 z1 j# n4 l+ d" i+ }
gonadotropins.1,3: _/ \" p) Q6 U6 l
Gonadotropin-independent peripheral preco-4 B- M# I0 Z2 R3 h- D
cious puberty in boys also results from inappropriate
% ?) L9 y2 T" Z3 vandrogenic stimulation from either endogenous or
6 v! E: J: _" m$ vexogenous sources, nonpituitary gonadotropin stim-
: i# b3 r; o% vulation, and rare activating mutations.3 Virilizing1 q$ I7 f& [6 E* w& c% Z$ d& \9 [% s
congenital adrenal hyperplasia producing excessive
( s" \9 j8 i8 [" l8 j( n8 i, yadrenal androgens is a common cause of precocious
9 Q2 j' F- N4 }$ ], S8 O! z- @puberty in boys.3,4
' s5 G% t8 U& p; gThe most common form of congenital adrenal
, P% ^. U( v5 r  c. }' ehyperplasia is the 21-hydroxylase enzyme deficiency.; o- |. V8 A  w' A4 v
The 11-β hydroxylase deficiency may also result in5 G: h* _/ b% m: b$ \9 ^2 s" q( n
excessive adrenal androgen production, and rarely,
: v6 g; Z" N. P9 Qan adrenal tumor may also cause adrenal androgen2 V! V5 F) T9 N+ n8 t
excess.1,3; b* H2 m: a* A1 s7 A, j$ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# i2 @" E; u; ]7 m/ M' q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ `  |. M  m; D# y6 ^, C
A unique entity of male-limited gonadotropin-* C, Q! y' O" A) h% L4 y0 Z, T' O0 V- |
independent precocious puberty, which is also known0 t& P5 A0 \! A- D  R
as testotoxicosis, may cause precocious puberty at a
" F! E7 E; Q1 U3 j# s, c$ Gvery young age. The physical findings in these boys
8 I) ~' B8 Z* x; G& x/ F' J2 }with this disorder are full pubertal development,, k5 B% F2 r( F. c* s$ D* ^
including bilateral testicular growth, similar to boys9 D4 N' J9 @6 U; U# F
with CPP. The gonadotropin levels in this disorder+ Z' {: h( O8 s. w5 k3 j
are suppressed to prepubertal levels and do not show. w" Q- V% K% m) h
pubertal response of gonadotropin after gonadotropin-5 d: A( x& i- j1 g
releasing hormone stimulation. This is a sex-linked3 @! L) ]7 v: l( q
autosomal dominant disorder that affects only( s! y: E! j2 ]8 A7 y! Z
males; therefore, other male members of the family5 z. W/ \( Z6 |( `2 F
may have similar precocious puberty.3
. D* o: }! c2 |: D( T2 ^In our patient, physical examination was incon-" M6 ]# j4 L5 Q3 n
sistent with true precocious puberty since his testi-; j; D2 @$ ]2 b3 N
cles were prepubertal in size. However, testotoxicosis
0 f. Q$ |8 |. N& w4 h1 z+ g: ]was in the differential diagnosis because his father2 Y# V: c) s9 m8 N- C; u
started puberty somewhat early, and occasionally,/ R  e1 x( q8 [: H& u" \# v0 v
testicular enlargement is not that evident in the
2 R, \' O1 d* o' obeginning of this process.1 In the absence of a neg-+ z3 Y5 i' f1 y. l
ative initial history of androgen exposure, our6 U" s2 O1 O+ Z$ L) A" D  }
biggest concern was virilizing adrenal hyperplasia,7 c5 B4 ], O1 f* P
either 21-hydroxylase deficiency or 11-β hydroxylase
  l! ^, }" |% m3 Ldeficiency. Those diagnoses were excluded by find-
9 {) O' k7 e8 m- ]ing the normal level of adrenal steroids.
0 Z" |* |+ P" nThe diagnosis of exogenous androgens was strongly& B# U+ {% K  H5 F
suspected in a follow-up visit after 4 months because6 D6 `1 t" \; v) x! ]$ E5 J
the physical examination revealed the complete disap-& R  ~$ g- g6 q, n
pearance of pubic hair, normal growth velocity, and! O& r* |! [& E, a( u
decreased erections. The father admitted using a testos-+ @5 {, K1 f/ Q$ J3 f
terone gel, which he concealed at first visit. He was0 n0 z! h5 c1 F( P" I  S
using it rather frequently, twice a day. The Physicians’
  v5 P4 Q6 Z3 @" W+ i1 M: VDesk Reference, or package insert of this product, gel or  Q! }- q" m9 a$ R
cream, cautions about dermal testosterone transfer to
' r8 S2 a- L1 w5 c1 h1 }0 junprotected females through direct skin exposure.
" a9 G9 C* j. C+ iSerum testosterone level was found to be 2 times the  U; z/ w. v4 q6 ?  ]7 Z
baseline value in those females who were exposed to# E) `0 G3 A3 F4 h+ w3 p- r1 O; ^
even 15 minutes of direct skin contact with their male
" K+ K9 {  W2 Jpartners.6 However, when a shirt covered the applica-5 j! d5 Q: p2 D7 s  H
tion site, this testosterone transfer was prevented.
2 S  {. t/ g2 v0 G- w) }' J7 m* \Our patient’s testosterone level was 60 ng/mL,# i6 H  c! g( A& F; n
which was clearly high. Some studies suggest that5 r9 Z2 E' ~  X& Y) w# ]% [  X
dermal conversion of testosterone to dihydrotestos-/ v8 L, \' H' @
terone, which is a more potent metabolite, is more" g1 j: U' j- Y6 a1 k7 k# P
active in young children exposed to testosterone1 W$ N4 h* a- m0 V% w& _: ], f2 C$ [
exogenously7; however, we did not measure a dihy-
, p; }8 i/ x6 Z* odrotestosterone level in our patient. In addition to8 V. |9 H" {/ u# x0 k5 c
virilization, exposure to exogenous testosterone in
( f5 ]' A: ]3 s6 H! c/ F2 E2 f0 \* Lchildren results in an increase in growth velocity and
! K3 q& a' ~) Ladvanced bone age, as seen in our patient.) I4 h. k5 I/ }# O, Z" p
The long-term effect of androgen exposure during; ^4 H# V1 _7 h5 c, G& Q
early childhood on pubertal development and final( ]7 a* z& l: g1 |- ]
adult height are not fully known and always remain
( ]0 Y& j6 s2 _# i* Z' pa concern. Children treated with short-term testos-
) d; ~% k* o  P9 u, j# ]/ pterone injection or topical androgen may exhibit some2 y) \; ]0 x8 ~" ^
acceleration of the skeletal maturation; however, after
# t, W$ F6 m8 F! a- M% z6 Ocessation of treatment, the rate of bone maturation/ I# E9 l# d3 }: J
decelerates and gradually returns to normal.8,92 F8 O3 D& l( r( B
There are conflicting reports and controversy
1 b, x5 p5 i2 z7 L6 ]1 m0 f3 @( k2 mover the effect of early androgen exposure on adult: q, H! j; V  G9 L7 F+ w0 g
penile length.10,11 Some reports suggest subnormal- S9 v' @+ g" ]3 N; m8 y$ z- h+ b
adult penile length, apparently because of downreg-
7 D  ?2 F% A7 m; [8 C% mulation of androgen receptor number.10,12 However,
0 O: l# Z3 Q1 e6 t( F" }Sutherland et al13 did not find a correlation between
2 E: B6 Z3 l/ F) ]- `childhood testosterone exposure and reduced adult
2 w5 H/ Z3 D5 N0 ~# e9 ~7 [penile length in clinical studies.; n  Z+ |% {2 R4 P3 }1 B) C0 b- s
Nonetheless, we do not believe our patient is
  a7 ?, A* y7 {7 k- Pgoing to experience any of the untoward effects from+ D# r5 j4 X4 Z. l: y8 ~: _
testosterone exposure as mentioned earlier because
( w6 e8 O0 @1 j  A" O6 \# vthe exposure was not for a prolonged period of time.
/ w; f3 `6 ?+ P+ `* h# vAlthough the bone age was advanced at the time of3 j: t. R+ }# K( B$ m
diagnosis, the child had a normal growth velocity at
) Q" e! ^/ a7 h# E: M4 L$ G) wthe follow-up visit. It is hoped that his final adult
5 D# P5 J7 a3 O; l! Q0 T2 e" mheight will not be affected.
+ T" c2 \% x1 p4 q  k9 x: z5 q2 gAlthough rarely reported, the widespread avail-
5 }. m9 T( F' tability of androgen products in our society may
" \5 _. j+ N- i: n* u4 cindeed cause more virilization in male or female
# F- O1 x: K) _& v5 ?children than one would realize. Exposure to andro-( A3 D, f' C( M. u, J, V1 Y# n6 c
gen products must be considered and specific ques-
+ g* j6 z2 n# s' ktioning about the use of a testosterone product or' m* x" f# q) R9 O7 r7 Y6 O
gel should be asked of the family members during7 g- z+ Y! ?4 E/ V- h
the evaluation of any children who present with vir-1 Q  l. ]1 X( E5 g7 O/ T; J- O6 s
ilization or peripheral precocious puberty. The diag-
- p, y, x* C5 ~- Q  X7 qnosis can be established by just a few tests and by$ L1 J. [3 e+ X& G' C9 Y' v
appropriate history. The inability to obtain such a
6 R- N: F6 d) p9 ^$ W0 F! s0 zhistory, or failure to ask the specific questions, may
8 c# c; v; [$ I2 w2 Hresult in extensive, unnecessary, and expensive, s. [9 l- b) s3 u% a5 O
investigation. The primary care physician should be
) x. q( S3 F) D9 kaware of this fact, because most of these children
3 b( @: j3 M% t8 Imay initially present in their practice. The Physicians’: N/ \: ]: u) O6 Z2 N
Desk Reference and package insert should also put a5 a0 N( V/ A2 h# n! y1 e+ x
warning about the virilizing effect on a male or
7 e0 F7 G9 [" s$ _5 lfemale child who might come in contact with some-; h8 g# {& `2 q  R1 s9 z4 K! {
one using any of these products.
9 F* o- i- P, FReferences
( G2 }4 K+ i# O5 w: |1. Styne DM. The testes: disorder of sexual differentiation) u( j, s0 X# j' U) h; V; ~' }' O9 U
and puberty in the male. In: Sperling MA, ed. Pediatric/ @. M+ D: ?/ B9 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) ~6 G4 S! t0 R8 f8 u# }
2002: 565-628.
2 X5 l7 h  t0 H" S, O: s: w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 |- G5 ], ?5 i- G9 g9 jpuberty 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
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
- i; e: ?( O7 h) L. b/ X
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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