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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% l3 D: d: M4 Q2 Q
Boy Induced by Indirect Topical
! }, A+ t6 _) G/ N: U+ B) ?Exposure to Testosterone- X- y3 E2 l1 k% z4 |1 A; m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: n: U, u7 f, _" ~and Kenneth R. Rettig, MD1
! J1 h. k* {8 O. k' RClinical Pediatrics7 ?; B$ p( u; @5 }
Volume 46 Number 6
5 K1 p. S  |7 V+ p" D2 UJuly 2007 540-543
4 S, a4 s3 D% y4 h) ^8 E4 e© 2007 Sage Publications
1 r/ x: S& [5 X4 ^" r10.1177/0009922806296651
1 d' `  n4 l8 t  ]+ u# Fhttp://clp.sagepub.com) G# X, z1 _' m
hosted at! {$ ]; G4 T4 v$ D7 }$ _; s: T% y
http://online.sagepub.com
# _3 W& i8 @( m- ZPrecocious puberty in boys, central or peripheral,
" p7 V: E1 Y2 L& Q. w9 Uis a significant concern for physicians. Central6 P( i8 L% V# h6 a6 {
precocious puberty (CPP), which is mediated. P4 z9 {, [* \7 M
through the hypothalamic pituitary gonadal axis, has
1 ~) L) j* L5 f  Ya higher incidence of organic central nervous system# J+ R9 z( @7 l$ L
lesions in boys.1,2 Virilization in boys, as manifested
( o/ W) h  ~; v& e$ Tby enlargement of the penis, development of pubic
1 d, m- n( P. p+ N4 t+ ]% d7 n, _/ |hair, and facial acne without enlargement of testi-
! E& ~6 |6 ]; _( Xcles, suggests peripheral or pseudopuberty.1-3 We
# v; V' V8 ?* Kreport a 16-month-old boy who presented with the0 w8 W& c8 V% ~2 K" f( W" V/ G8 V
enlargement of the phallus and pubic hair develop-9 V! g) X+ z1 e7 L/ q' i0 R! i7 P
ment without testicular enlargement, which was due( |! k, u; f& d5 b
to the unintentional exposure to androgen gel used by
- Y  u3 K: T2 N6 v3 B. Bthe father. The family initially concealed this infor-
$ m  }' e4 m  m! }& pmation, resulting in an extensive work-up for this" e( B9 m  L" X! k  y% G
child. Given the widespread and easy availability of3 n$ X2 I! i. w7 @  [
testosterone gel and cream, we believe this is proba-% S# e4 C$ e, E* @# p/ n
bly more common than the rare case report in the/ H' ]# _) n5 l( v5 L5 k1 m
literature.4
& b% z: `5 s. |) h- }) `9 s; APatient Report0 f5 O9 n% K( j& X* l: U/ f
A 16-month-old white child was referred to the1 h! B4 Y: X& O) v$ z$ U
endocrine clinic by his pediatrician with the concern( S! e2 [" s5 }: l! j, X
of early sexual development. His mother noticed/ K* ?8 m( T( f2 w! A+ [4 J
light colored pubic hair development when he was* [6 Z! ^! D5 O" p! m1 g
From the 1Division of Pediatric Endocrinology, 2University of$ I2 a2 B/ I; ~: A6 @
South Alabama Medical Center, Mobile, Alabama.
: d3 f" [) P0 h1 P% H4 X  {Address correspondence to: Samar K. Bhowmick, MD, FACE,
# P  d( G; I7 P2 h% SProfessor of Pediatrics, University of South Alabama, College of! w6 o9 p" b) w, j6 {$ `1 `1 f7 t
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 M1 c7 c0 k& a! c" @2 j- R' N
e-mail: [email protected].
( Y, @1 r) M) ^7 }. r5 s6 ~about 6 to 7 months old, which progressively became
9 ^8 R$ P" W7 kdarker. She was also concerned about the enlarge-; N, X% [) j" Z6 ]; ?/ h
ment of his penis and frequent erections. The child
* b2 x1 M! ~- @( N* [, gwas the product of a full-term normal delivery, with
( }- o5 k- \6 ]! ]3 X3 Q9 N9 Ba birth weight of 7 lb 14 oz, and birth length of
. Y5 {0 p/ b$ C" ]$ d20 inches. He was breast-fed throughout the first year- n, a7 M, V! W
of life and was still receiving breast milk along with
- j8 T" F5 K) x  }% |/ @& y+ d+ Fsolid food. He had no hospitalizations or surgery,/ q% P2 s; w* ~2 h* v0 _
and his psychosocial and psychomotor development7 z' W  A6 J( z1 k' I( }8 C0 ?
was age appropriate.
7 A" ^& `, W: t) L1 [* OThe family history was remarkable for the father,) w& u/ T& y/ x* {
who was diagnosed with hypothyroidism at age 16,: h6 P, k2 ]) L3 K6 A$ [
which was treated with thyroxine. The father’s
3 H% ]4 i- F- D& @height was 6 feet, and he went through a somewhat8 V0 {$ N' {, g: P" y
early puberty and had stopped growing by age 14.
( j- B; i/ q# G6 ]2 z7 XThe father denied taking any other medication. The* D- o/ [; ^7 X8 ]2 ^- I  y  _
child’s mother was in good health. Her menarche: z3 T. G" z$ e% N, X  q1 i
was at 11 years of age, and her height was at 5 feet( M5 j1 v' m+ z1 i2 ?' Y1 w  n2 Q
5 inches. There was no other family history of pre-
  x% H0 x) [* ~1 V; ecocious sexual development in the first-degree rela-0 D, L' Y% O. f
tives. There were no siblings.
$ a$ O( `! B, c4 w& S$ _Physical Examination
  n/ x% @0 R+ U" L+ {1 X+ Z; L/ eThe physical examination revealed a very active," x: q! m0 E8 Y+ L; D$ a
playful, and healthy boy. The vital signs documented
: u& N; M$ e9 F- I  s% {1 na blood pressure of 85/50 mm Hg, his length was! s1 m7 H; W+ g. a
90 cm (>97th percentile), and his weight was 14.4 kg& j- B$ H! i& f
(also >97th percentile). The observed yearly growth
' q% S2 S/ h/ y! j, l( G  D/ ]velocity was 30 cm (12 inches). The examination of
0 j1 Q0 ?' |2 Ethe neck revealed no thyroid enlargement.
. o5 R5 d& ]2 P! EThe genitourinary examination was remarkable for
" |- A) W! h" u$ S" Cenlargement of the penis, with a stretched length of
$ c+ p4 g5 Y1 a9 D, F2 K1 |8 cm and a width of 2 cm. The glans penis was very well& Q' o# a5 F% w( {* _1 z1 k6 G
developed. The pubic hair was Tanner II, mostly around
9 j6 r+ t1 S% [; D7 N, d540) U' c6 m& _$ B% s) _) A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, d# T8 K* z2 l, E+ Q7 H3 B
the base of the phallus and was dark and curled. The
& T/ [, z9 M  q- O' |testicular volume was prepubertal at 2 mL each.- ]3 C# j1 Z; C% {
The skin was moist and smooth and somewhat
; i3 ]% |: B. v# i% O% v% Toily. No axillary hair was noted. There were no
6 y  w4 }- T" ~6 kabnormal skin pigmentations or café-au-lait spots.
) l4 W2 \  |' w; }& E8 ONeurologic evaluation showed deep tendon reflex 2+  a& E1 r; e4 O9 d6 \
bilateral and symmetrical. There was no suggestion. t9 `0 S* \6 ]
of papilledema.
% ~) q. B+ j2 @& a; J) H' [Laboratory Evaluation
% u( [$ z% M5 {& mThe bone age was consistent with 28 months by. n) o2 b9 t+ [7 M0 o2 b( I7 B" C
using the standard of Greulich and Pyle at a chrono-
/ F% c3 t* b- W; b' p$ _logic age of 16 months (advanced).5 Chromosomal
! ^5 D! s5 H: C8 J! {) X1 s+ @karyotype was 46XY. The thyroid function test
. T. j, P! e. P) ?! V1 o7 hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
, e1 ?4 b1 ~; F8 b: S) T( Q& Jlating hormone level was 1.3 µIU/mL (both normal).; E1 `# Q8 ^+ ~' q, t- a
The concentrations of serum electrolytes, blood
( x, ]8 ^& [! M: H' ~0 Wurea nitrogen, creatinine, and calcium all were; v7 o& x, D5 |; c$ H* y5 Q
within normal range for his age. The concentration
  a' k5 y: X/ Z3 j2 Cof serum 17-hydroxyprogesterone was 16 ng/dL! d  d' f" @7 ~. `
(normal, 3 to 90 ng/dL), androstenedione was 20$ d- B' h! z4 w; s
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# a. \* x0 e! qterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 V* z+ \  }6 N" f/ h/ @( |9 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ g1 i* p" d# T, o- X9 g8 p
49ng/dL), 11-desoxycortisol (specific compound S)
6 ^2 D5 M- I! C2 r1 Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 N& ~$ L& {* Q6 V$ [5 ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 n6 L) w& ^& B5 g# Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' S' W. @% R: B% vand β-human chorionic gonadotropin was less than
4 ?: q6 g  {: M  ]& C5 mIU/mL (normal <5 mIU/mL). Serum follicular% X: z/ k& _7 A1 ]7 F8 S/ i$ w+ J
stimulating hormone and leuteinizing hormone& |0 V9 l+ P7 B
concentrations were less than 0.05 mIU/mL
$ n8 j9 p% k; F5 h(prepubertal).7 ^9 A. G- l/ a( G( h$ s4 m
The parents were notified about the laboratory
3 R+ u7 `) X! @( g: I- Rresults and were informed that all of the tests were+ D6 l" j! ?# y3 C/ o1 y
normal except the testosterone level was high. The
% w: z2 ]# q! A% `0 x4 ufollow-up visit was arranged within a few weeks to
. v4 O! |; K+ Z4 q& l1 fobtain testicular and abdominal sonograms; how-
$ t! j; G7 J8 b/ ~/ D; x4 lever, the family did not return for 4 months.# j0 V9 G9 Z4 I0 C4 f$ Z4 l* {
Physical examination at this time revealed that the
9 ]2 u9 s, D5 |( a; Schild had grown 2.5 cm in 4 months and had gained' `6 T5 j* ]0 o: M
2 kg of weight. Physical examination remained: b0 Y# T" _/ m4 j- U
unchanged. Surprisingly, the pubic hair almost com-
7 \8 _7 u& }" d. r! M& {9 Cpletely disappeared except for a few vellous hairs at, K. f" d, Q# f) \
the base of the phallus. Testicular volume was still 2
+ E8 f% x7 ^0 N' Z8 \+ _mL, and the size of the penis remained unchanged., S& ~; v: |$ p$ j: Z, K
The mother also said that the boy was no longer hav-
/ p+ i' t6 n- a: S2 W2 ]ing frequent erections.; T) g- J5 @4 x
Both parents were again questioned about use of
2 |3 b0 ?2 q0 P9 J# \any ointment/creams that they may have applied to
- {5 ]5 N( B* Ithe child’s skin. This time the father admitted the
; _% b0 r! }% B# N3 YTopical Testosterone Exposure / Bhowmick et al 5413 x5 {0 s# n* r( j
use of testosterone gel twice daily that he was apply-; q" Z# \1 ^# S+ L( y
ing over his own shoulders, chest, and back area for
6 Z8 H1 Q9 N  u+ w. wa year. The father also revealed he was embarrassed
6 N. H5 M. G- T$ Q7 b/ Rto disclose that he was using a testosterone gel pre-
* R7 z; M8 V7 @. j4 i2 I" nscribed by his family physician for decreased libido1 p: \3 S2 B% Y. k4 r8 i
secondary to depression.
$ u) h/ d- H1 t+ L: TThe child slept in the same bed with parents.8 W1 ]' N9 M$ R* M- Y
The father would hug the baby and hold him on his
$ l2 g% ?: v+ B5 V- Tchest for a considerable period of time, causing sig-
2 j* @+ S4 |  H. znificant bare skin contact between baby and father.
: \# b. L; z# F+ `% bThe father also admitted that after the phone call,
' {- B5 T/ M" W9 t% t6 ~when he learned the testosterone level in the baby6 U$ O7 p& `, x7 C7 I  h& o) e
was high, he then read the product information
0 S: S6 H2 t5 P$ c& _: opacket and concluded that it was most likely the rea-  L' V2 [( T; E+ p8 ?- Y) T9 q! v
son for the child’s virilization. At that time, they& J# }  A5 z6 G
decided to put the baby in a separate bed, and the
& l4 A$ k; e# R7 Z/ I; E( A& Ufather was not hugging him with bare skin and had
  n3 j! x3 |0 Z7 p4 r1 [been using protective clothing. A repeat testosterone
) ~* C  ]* G8 j$ R' E+ c6 u# vtest was ordered, but the family did not go to the( M- V! I3 E; ~
laboratory to obtain the test.
6 m  s9 c. y  t8 }Discussion
7 [# @  C/ w7 ]  Y' }' I9 K" _Precocious puberty in boys is defined as secondary' J- X9 [" x+ P6 i
sexual development before 9 years of age.1,41 c  o4 }# z  e3 |
Precocious puberty is termed as central (true) when
( M/ V, L+ t9 nit is caused by the premature activation of hypo-
( `/ V3 d# G( G2 t, Q# ~thalamic pituitary gonadal axis. CPP is more com-# Y2 W  i2 H3 U' V9 Q, R- h
mon in girls than in boys.1,3 Most boys with CPP
% }- ^0 R8 y( P* B; y" Imay have a central nervous system lesion that is
2 e1 f1 p  u2 r" M# |3 eresponsible for the early activation of the hypothal-
- K3 \7 w6 F* j; \amic pituitary gonadal axis.1-3 Thus, greater empha-
$ A2 a8 @4 }0 I7 ksis has been given to neuroradiologic imaging in
. t: j/ r" v8 jboys with precocious puberty. In addition to viril-6 x5 b# Y& e: M7 w
ization, the clinical hallmark of CPP is the symmet-
* R1 Z1 |! @  F" t5 Vrical testicular growth secondary to stimulation by- y6 Y: ~  h' x% ?: q0 ^" i" x
gonadotropins.1,3' ?) _+ X( Y! B: w% N
Gonadotropin-independent peripheral preco-# M8 [+ g+ b8 M: T- F7 ~
cious puberty in boys also results from inappropriate
( b% D1 d* p- l  A3 R  mandrogenic stimulation from either endogenous or
  H* \3 g( L6 `7 Q4 M$ r6 |exogenous sources, nonpituitary gonadotropin stim-( r" Q8 z6 y+ u3 B9 a& Q7 s  s
ulation, and rare activating mutations.3 Virilizing
* B: `1 e" J7 ?+ ?1 jcongenital adrenal hyperplasia producing excessive
& `, J8 M: Z5 H: J8 U+ Q3 H. madrenal androgens is a common cause of precocious
8 j9 l8 h6 x: J2 s: R9 K3 upuberty in boys.3,45 `: e' [0 I) T  L
The most common form of congenital adrenal' A5 q0 f* O. Q' q( Z# v# O
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 w: a2 _( ~- O1 R0 lThe 11-β hydroxylase deficiency may also result in
$ p7 q. J# m; L' Y' }excessive adrenal androgen production, and rarely,* I; N6 ]+ M; w% N. n
an adrenal tumor may also cause adrenal androgen
, Y' u' s- B$ n. fexcess.1,37 Z2 Q7 K& d+ w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 M; {4 ?9 l. N0 Z2 R2 W4 G  I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 K- n. G5 P: z) j) TA unique entity of male-limited gonadotropin-4 [4 u$ y$ j5 w/ d6 Z* Q
independent precocious puberty, which is also known
- j; h* z: c- @7 v. [4 j  pas testotoxicosis, may cause precocious puberty at a8 _( D0 @& e7 u5 j. e* E7 S
very young age. The physical findings in these boys
, P8 a$ [- m) }# h. i7 |, xwith this disorder are full pubertal development,
) d8 [6 c# t: v9 Y& Aincluding bilateral testicular growth, similar to boys
5 O# D6 W- b& V/ \( C& wwith CPP. The gonadotropin levels in this disorder
+ B; c( m5 V# y' D1 Nare suppressed to prepubertal levels and do not show; h) V# V4 o! j
pubertal response of gonadotropin after gonadotropin-
2 v2 k* @; _, ?1 breleasing hormone stimulation. This is a sex-linked3 P4 d" T6 b" i% {4 r% B
autosomal dominant disorder that affects only
# Y. f$ \  K1 L5 imales; therefore, other male members of the family
- _3 K# X. {4 e, Pmay have similar precocious puberty.3- j& d3 O  x3 B9 C7 Q8 k$ l1 g1 f
In our patient, physical examination was incon-  k0 V9 X5 F/ A) y" Q0 ]
sistent with true precocious puberty since his testi-9 d& M& A! E: {$ a! ?( q  {
cles were prepubertal in size. However, testotoxicosis9 a' W9 _% r; W
was in the differential diagnosis because his father. E. f  f6 n, r$ S
started puberty somewhat early, and occasionally,9 I6 ?; B& W5 T. L
testicular enlargement is not that evident in the1 a$ D# r/ _" ?3 I
beginning of this process.1 In the absence of a neg-
" v$ b. y$ |+ e4 W+ Native initial history of androgen exposure, our
! c7 l8 C1 @) V- z2 l. fbiggest concern was virilizing adrenal hyperplasia,
  B% P2 S/ q$ L3 I6 g& qeither 21-hydroxylase deficiency or 11-β hydroxylase
- ~$ p0 e" O( Y( Adeficiency. Those diagnoses were excluded by find-5 L8 _$ S4 N; B; n7 T5 D5 X- K
ing the normal level of adrenal steroids.2 H  R- w" }" T# E2 ~4 k
The diagnosis of exogenous androgens was strongly5 t2 v9 P8 W! ^4 J$ J2 {( c
suspected in a follow-up visit after 4 months because3 G. |% \% ?1 n+ S7 [: R3 ~
the physical examination revealed the complete disap-
; H% m7 i5 T8 r( b) X! A" h: Cpearance of pubic hair, normal growth velocity, and
- K- [: @: @! {" b, Kdecreased erections. The father admitted using a testos-
$ R: D' S3 c( }terone gel, which he concealed at first visit. He was
, _& h/ b) W8 z; `0 E/ q4 f( wusing it rather frequently, twice a day. The Physicians’- a! [" ]4 D+ Q/ l; E6 u
Desk Reference, or package insert of this product, gel or+ v4 n9 x- R  ^$ k( [
cream, cautions about dermal testosterone transfer to5 O4 A% ~4 j: x6 D/ e( H
unprotected females through direct skin exposure.4 z9 S! w' O; ]# Y
Serum testosterone level was found to be 2 times the1 ^3 Y& \) k0 `( x: c1 @
baseline value in those females who were exposed to
! k5 U" X6 y8 ^4 n/ jeven 15 minutes of direct skin contact with their male
: C% |1 l+ i, P  b& z$ ]1 xpartners.6 However, when a shirt covered the applica-
$ H$ y5 R& X6 Y5 d& |% ]tion site, this testosterone transfer was prevented.
: E9 W/ v, q# a/ T5 P) HOur patient’s testosterone level was 60 ng/mL,
) Z6 q! y5 u9 c# v( X# }9 `( a8 I& Ewhich was clearly high. Some studies suggest that3 v! ~. N- _/ l: `
dermal conversion of testosterone to dihydrotestos-
$ Y. p+ W5 ^" d; P' A/ Yterone, which is a more potent metabolite, is more
% [! [$ |# b0 R. T. x/ dactive in young children exposed to testosterone+ G3 L' S1 d8 O" W- ?
exogenously7; however, we did not measure a dihy-
7 k1 W$ S8 X. k; N% ydrotestosterone level in our patient. In addition to& X1 T8 w: Y  }- a3 B+ g, Z
virilization, exposure to exogenous testosterone in( k" K- Q1 M8 v4 j* P) F7 K3 c
children results in an increase in growth velocity and
6 K: J+ g) Y7 ]4 a9 Q$ \% oadvanced bone age, as seen in our patient.
# i9 P5 R6 o1 X8 r4 h2 gThe long-term effect of androgen exposure during
( ^. f  D7 t& H$ y9 d- s" |3 `early childhood on pubertal development and final
$ O& Z0 d: T# T4 n) zadult height are not fully known and always remain8 }4 B, S  x( V/ b% V
a concern. Children treated with short-term testos-- c: |6 M7 W+ z7 |8 q
terone injection or topical androgen may exhibit some
+ r) w* z" s, P" s; Q/ G* b5 lacceleration of the skeletal maturation; however, after) ?$ B( H" i2 x5 _: W% ?4 I) H3 f$ L
cessation of treatment, the rate of bone maturation5 \1 v5 }: p0 S- w0 k4 X& h# D
decelerates and gradually returns to normal.8,9
: U, G, i, b0 G2 SThere are conflicting reports and controversy
* X  W5 h) \6 X9 E* bover the effect of early androgen exposure on adult
8 F3 g4 S& a5 U! Q& Hpenile length.10,11 Some reports suggest subnormal6 D6 Z) r. O! h/ _. m5 U
adult penile length, apparently because of downreg-4 ~+ a0 s6 E9 l4 r, K7 p
ulation of androgen receptor number.10,12 However,0 Z6 _4 I, W0 O
Sutherland et al13 did not find a correlation between) m9 H, {: V& W, k* X; V, ~
childhood testosterone exposure and reduced adult
$ v' C) h- D6 d+ h4 q8 F; B7 _penile length in clinical studies.
( G. m0 m/ d" r5 n9 H. dNonetheless, we do not believe our patient is
& a) `* V$ I3 P, I' u  J1 ]going to experience any of the untoward effects from
7 b4 e! [, e7 j$ V$ {testosterone exposure as mentioned earlier because
8 r' ]9 L6 y9 Tthe exposure was not for a prolonged period of time.
+ d6 u' q: J4 I. ZAlthough the bone age was advanced at the time of
# ^, O( C" u* I. G( n" Ddiagnosis, the child had a normal growth velocity at3 ~3 I) H' |+ O9 P
the follow-up visit. It is hoped that his final adult
: x' M. C4 X3 Oheight will not be affected.
* Q, ^! c: p# }5 pAlthough rarely reported, the widespread avail-. [. j& Z' V+ k4 r) y
ability of androgen products in our society may8 p6 q1 P! O. c
indeed cause more virilization in male or female
8 T+ d) y5 I2 Schildren than one would realize. Exposure to andro-2 ~; Z" n; q8 h$ v
gen products must be considered and specific ques-
4 a- p% J1 K. C5 D7 f; P- Ctioning about the use of a testosterone product or
$ i1 {- I. ?! E2 E  q9 zgel should be asked of the family members during+ l% X3 L8 m# K
the evaluation of any children who present with vir-
5 x* C3 ~* t7 p* o$ eilization or peripheral precocious puberty. The diag-5 M+ N2 ~  g/ g8 t. p; j& e. F! n
nosis can be established by just a few tests and by8 P: X4 C$ B* M/ ~4 w" P% ~
appropriate history. The inability to obtain such a
6 k9 p  s, R0 I6 P7 |7 h* _history, or failure to ask the specific questions, may
( r' J5 v# |: u2 T% fresult in extensive, unnecessary, and expensive# q( a8 x; q) n5 x( U" l1 q6 _9 y
investigation. The primary care physician should be; r' F8 w; L+ R, n8 U
aware of this fact, because most of these children. l9 @/ R9 o/ Q7 T( G. \
may initially present in their practice. The Physicians’4 X4 L' N8 Z# {- u5 m3 g* I
Desk Reference and package insert should also put a1 f  h& f" x) H2 ?3 o
warning about the virilizing effect on a male or! N! e) Q" F, c
female child who might come in contact with some-; o. o: U4 Q9 d# p1 Q) F: d8 b
one using any of these products.4 o1 f7 |6 P! ^7 Y: ^
References
) C% A8 Y/ f$ A5 X, R6 W1. Styne DM. The testes: disorder of sexual differentiation. O/ j5 w3 I5 X( @
and puberty in the male. In: Sperling MA, ed. Pediatric
9 ~' P$ A+ r. V2 JEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ R( `" T0 D+ i
2002: 565-628.
( F2 g* y6 \. V) U; Y6 w/ Z0 V% q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 I+ m9 J. I  f( E$ H+ r& J. i! e" Hpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ G# b- N! ]2 ?+ tBoy Induced by Indirect Topical
& e7 K1 n. R! g4 o% d, d; HExposure to Testosterone
: p- {! f1 X$ A4 C9 z6 ?( x* {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 g( X! w. ~0 ]7 C0 }and Kenneth R. Rettig, MD1
, Y6 ?( h4 ^9 z9 N8 A1 dClinical Pediatrics2 r2 b0 M8 l/ ]5 Z' Z
Volume 46 Number 6+ M( I  R: F, L- A+ W# g: e
July 2007 540-5439 @7 d' [" j& v% N1 o
© 2007 Sage Publications# F* ?* k+ P4 \* C  E  z3 p
10.1177/0009922806296651. x6 P: }+ u4 K; k1 `
http://clp.sagepub.com
0 {: b6 K) ~0 ^- f: chosted at, c" j' E; S; d) Z* _5 ~. I
http://online.sagepub.com
; M& y4 L2 g- }Precocious puberty in boys, central or peripheral,# _" ]3 U/ t2 g6 q' E$ h
is a significant concern for physicians. Central
2 g, {% v% b* _9 y7 y! D; @9 Fprecocious puberty (CPP), which is mediated% O- ~% |5 G' ^# a/ {
through the hypothalamic pituitary gonadal axis, has
- X* D6 f6 @) j; a4 @* ta higher incidence of organic central nervous system9 A$ Z: t3 m( \
lesions in boys.1,2 Virilization in boys, as manifested: {* o8 D" c5 u5 G+ y. d1 l
by enlargement of the penis, development of pubic
+ p. c4 c) ~9 ]' t* `, a. H: b' g; Phair, and facial acne without enlargement of testi-5 o1 z5 p+ B2 l* f# c; R
cles, suggests peripheral or pseudopuberty.1-3 We
# f, h* z: u3 n" xreport a 16-month-old boy who presented with the
  m. j' P# _8 {- R' b2 T& fenlargement of the phallus and pubic hair develop-, }' X7 o3 r% h2 u
ment without testicular enlargement, which was due
$ z" h. o. t& i- k! s% Nto the unintentional exposure to androgen gel used by/ w: u. U: t' o
the father. The family initially concealed this infor-+ S8 V  O8 S! g# u
mation, resulting in an extensive work-up for this$ u  r! ^" v5 V( q2 Y' f
child. Given the widespread and easy availability of3 j3 M( {7 d- z$ K) G( h
testosterone gel and cream, we believe this is proba-8 z$ D2 Z. P$ a; {
bly more common than the rare case report in the1 u1 j  q8 S  r' ?
literature.4( U: l' F/ e' y. O
Patient Report
2 y; ]4 s* i, T6 `! n& d7 SA 16-month-old white child was referred to the
' \' a9 k& h7 G+ P" ?$ nendocrine clinic by his pediatrician with the concern
, p" r: v& R4 C+ h* O/ Gof early sexual development. His mother noticed6 w5 |1 `2 D1 q! |2 x' m
light colored pubic hair development when he was7 V# s5 J3 P# t) D. U
From the 1Division of Pediatric Endocrinology, 2University of: d9 r; H: |- Z5 O! @
South Alabama Medical Center, Mobile, Alabama.
" \# w; l! O- s% S9 S% p( Y7 aAddress correspondence to: Samar K. Bhowmick, MD, FACE,( D; h* }0 J% H7 a$ H5 T
Professor of Pediatrics, University of South Alabama, College of0 Y  c8 B% [* L9 U8 l) Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) _* F4 p; p. r* |$ v" f
e-mail: [email protected].
7 e8 K& l( _5 Labout 6 to 7 months old, which progressively became' A, ~2 A! O2 N9 A9 y. P
darker. She was also concerned about the enlarge-2 J9 y# f) e. i7 l9 p
ment of his penis and frequent erections. The child; p! b2 }1 B, r
was the product of a full-term normal delivery, with7 B1 p9 S9 S1 @. d  F' e
a birth weight of 7 lb 14 oz, and birth length of
9 T  C% @; P2 c20 inches. He was breast-fed throughout the first year
4 d" P7 _9 i. g8 J5 N% ]9 gof life and was still receiving breast milk along with
7 n8 J4 M1 v$ y) t  z# N. j6 Msolid food. He had no hospitalizations or surgery,& z' V% p9 S5 N, u
and his psychosocial and psychomotor development5 o" f0 \4 R+ U1 P! H& b
was age appropriate.1 M% A, L+ ?3 N* ]4 y& G) ?$ n
The family history was remarkable for the father,) v% v  J! x0 N: i& M0 H' u$ Q
who was diagnosed with hypothyroidism at age 16,
2 h. B3 b9 \& N+ K5 e" N: Cwhich was treated with thyroxine. The father’s  S4 ]; B% H  g, ^
height was 6 feet, and he went through a somewhat
/ G$ r( T. a; \0 Tearly puberty and had stopped growing by age 14.( x  l" w+ D& v" U3 G+ @1 o. n
The father denied taking any other medication. The
8 i+ G3 U- k5 w8 mchild’s mother was in good health. Her menarche
, c1 W& ], b) {) \2 z3 Owas at 11 years of age, and her height was at 5 feet
- N0 ^: p2 m4 K3 I- D5 inches. There was no other family history of pre-
0 y8 }! G# Z4 M) t8 X$ Ococious sexual development in the first-degree rela-
- {$ C! G$ s! b  K$ @  B' Ltives. There were no siblings.- O- Y1 q* ]3 k3 q6 J
Physical Examination* ]& M. s5 G. F$ x
The physical examination revealed a very active,( x3 J* i3 m- }! m
playful, and healthy boy. The vital signs documented& h6 k1 l$ i5 A2 L1 t
a blood pressure of 85/50 mm Hg, his length was. S" ~! @6 S4 [
90 cm (>97th percentile), and his weight was 14.4 kg( o" C9 E8 k& W7 C1 J% w
(also >97th percentile). The observed yearly growth
; T: K. B/ ~, C8 A" F2 C" avelocity was 30 cm (12 inches). The examination of; j1 N3 F0 z" f) ?% l% ^
the neck revealed no thyroid enlargement.; h( o1 B% x( D8 x! V
The genitourinary examination was remarkable for
4 ~( n! f& b3 Penlargement of the penis, with a stretched length of' ^+ k% N" {3 g, ?) B9 X+ j
8 cm and a width of 2 cm. The glans penis was very well
  g2 F1 }  I9 c* udeveloped. The pubic hair was Tanner II, mostly around
0 ], V: W' s( |% G3 v5 @540# Q7 [1 b& R5 \3 L+ x# e# s0 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 |. G- u* ?; }, z" ?
the base of the phallus and was dark and curled. The1 ]6 q, E) q* ?9 S
testicular volume was prepubertal at 2 mL each.
: j3 V7 {7 L# D: s* P) T' ZThe skin was moist and smooth and somewhat
4 u7 `- {/ |, d& c0 |2 o( O2 [! poily. No axillary hair was noted. There were no
9 I, s+ Q- |( D; {2 j2 Wabnormal skin pigmentations or café-au-lait spots.
) d  J4 y4 ~  nNeurologic evaluation showed deep tendon reflex 2+
4 D: \+ g  G& b: {bilateral and symmetrical. There was no suggestion
7 D: N: X9 W, h/ L  k! N, A/ wof papilledema.
' u( J* J8 n, s/ x; _$ GLaboratory Evaluation
6 w$ z$ T( b3 F- X3 ~; HThe bone age was consistent with 28 months by6 L: R/ U6 Z4 n8 t6 A
using the standard of Greulich and Pyle at a chrono-
6 B, q! ?) d4 w. X0 C+ _logic age of 16 months (advanced).5 Chromosomal
7 |7 ]9 V  \8 z6 u9 }karyotype was 46XY. The thyroid function test: [. f) X* J4 O, G! ^% J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# [& d: h( \% C6 E: r  s9 Qlating hormone level was 1.3 µIU/mL (both normal).
. W+ X- W& t% [& `  HThe concentrations of serum electrolytes, blood
! D* I$ A/ P3 W) w4 V1 }% _urea nitrogen, creatinine, and calcium all were0 ?; \* M8 Z& x" E% @) z
within normal range for his age. The concentration2 i0 N; R5 |; b8 `8 y
of serum 17-hydroxyprogesterone was 16 ng/dL: _2 k6 C- s4 |: y( n7 M
(normal, 3 to 90 ng/dL), androstenedione was 20
9 ~; [3 S2 ~, Z9 U( K3 K2 F7 u  ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ f5 V2 q  j5 D; i. x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 i9 _3 K& e) @$ P3 k- |, p" g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- w) J: O" A+ {  f7 U( L# B49ng/dL), 11-desoxycortisol (specific compound S)
) E' n/ h, U' T5 M3 \/ Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 Q8 w+ f8 [- a7 u' z5 d  J% h6 x2 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 C3 ]& a3 [4 Q) vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ }8 ]7 w  e& [4 p6 Qand β-human chorionic gonadotropin was less than! M( y0 g9 q# t/ `
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" _/ L, M" x4 R; l! b0 I. L3 Xstimulating hormone and leuteinizing hormone
7 I  g" @8 y2 S- N6 T' y2 Tconcentrations were less than 0.05 mIU/mL* X% C9 C7 c3 P2 p. J
(prepubertal).
7 w! y+ _# q9 V* F, M$ EThe parents were notified about the laboratory+ F6 m4 \- }7 {- R8 _! y
results and were informed that all of the tests were) _8 ~7 V. G$ |. S% W4 D( s
normal except the testosterone level was high. The
, R( }& h" }" a# M1 nfollow-up visit was arranged within a few weeks to
, ^# Z) n& S4 u7 D  P0 qobtain testicular and abdominal sonograms; how-
* \5 b, N/ _3 f  x' v3 Pever, the family did not return for 4 months.$ Q6 C6 D4 q6 z6 u
Physical examination at this time revealed that the$ O3 T% c, q, }' @
child had grown 2.5 cm in 4 months and had gained, W/ I# ]9 P8 e+ }% [7 @4 J9 q
2 kg of weight. Physical examination remained
& v- n# F4 i' w" tunchanged. Surprisingly, the pubic hair almost com-3 `. g- w  o/ B# l
pletely disappeared except for a few vellous hairs at3 i$ e+ i% u- I1 Q! _6 G, O% S
the base of the phallus. Testicular volume was still 2. d- }' `7 t" m
mL, and the size of the penis remained unchanged.! L8 B7 C) Y2 h6 [7 o' W* N8 j
The mother also said that the boy was no longer hav-  w! S* u7 q0 l, q, s. S5 v  b
ing frequent erections.0 n. n5 f( S4 w3 G) `, r8 r6 D
Both parents were again questioned about use of$ D* \: _% @7 S. }  l0 m# o$ L( K7 {
any ointment/creams that they may have applied to- E" [8 F5 ~3 j2 f  R. M% ?, `: A' {
the child’s skin. This time the father admitted the8 N5 B  T3 _" `* N4 D( ]' b7 {3 u/ J
Topical Testosterone Exposure / Bhowmick et al 541
) q# O( W1 |: M* L! {use of testosterone gel twice daily that he was apply-  l9 g& x8 U% E8 u
ing over his own shoulders, chest, and back area for
$ f  r/ I0 Q5 H! [0 ]6 h) i7 da year. The father also revealed he was embarrassed  B  B  ]) F' L
to disclose that he was using a testosterone gel pre-5 N0 u( H* c) K2 t. ~
scribed by his family physician for decreased libido
3 ~& p2 A+ X1 h. S8 h7 X& {% Ksecondary to depression.
! z, ?4 \1 M9 z. J8 u7 r$ n+ NThe child slept in the same bed with parents.
  [: u5 U$ U9 ?The father would hug the baby and hold him on his* q& R- S5 ^2 ~' G
chest for a considerable period of time, causing sig-
7 K) C5 D+ B1 _9 Lnificant bare skin contact between baby and father.4 A+ o8 Z2 y* X/ S) V& Y' B
The father also admitted that after the phone call,
2 ^4 {# W! q7 Gwhen he learned the testosterone level in the baby" Y" T- ], k- Z( ?/ O
was high, he then read the product information
5 I/ I2 V# u3 t1 h4 S$ b2 fpacket and concluded that it was most likely the rea-9 Y) W" ^7 |8 S0 {6 r
son for the child’s virilization. At that time, they0 u( _7 C, o! z9 \+ l" B+ B- A
decided to put the baby in a separate bed, and the
9 l; ^. `7 U# X3 _* c% S! W- Y8 j4 qfather was not hugging him with bare skin and had; [9 J' b6 r  z( n6 N4 `
been using protective clothing. A repeat testosterone
6 G! O6 i0 z  Y! j) ttest was ordered, but the family did not go to the
$ R  S/ Y6 S, q9 `! h' ilaboratory to obtain the test.+ t, G  f1 ?, I8 z' H1 |) h
Discussion
5 U0 a. d2 _. M' E: y! [" vPrecocious puberty in boys is defined as secondary/ t2 \; G0 d* _6 X
sexual development before 9 years of age.1,47 p( ~5 y+ p' }8 V; I
Precocious puberty is termed as central (true) when6 b, Z% h" h3 Q, e
it is caused by the premature activation of hypo-
5 T8 F4 ]# j; @6 y4 h* qthalamic pituitary gonadal axis. CPP is more com-
! s  T# V. b# Fmon in girls than in boys.1,3 Most boys with CPP* h3 I) }4 k4 ~" A8 D7 s) M8 X: B6 K
may have a central nervous system lesion that is
! U' m0 _0 Z* M& _- G9 Yresponsible for the early activation of the hypothal-+ ^; a! q$ `8 ]1 t8 @% x% z
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ L3 z$ V2 ^! w# }  R4 asis has been given to neuroradiologic imaging in& J; h$ Y. ~9 x' {1 Z  J, S* \* [* e) K
boys with precocious puberty. In addition to viril-
4 x& O+ T1 E( v3 V( S1 k/ iization, the clinical hallmark of CPP is the symmet-
$ J3 J& X& i8 Y# l4 v+ erical testicular growth secondary to stimulation by$ i3 M( D6 g! M
gonadotropins.1,30 `  l# Y5 c  q  D- y+ m
Gonadotropin-independent peripheral preco-1 L$ E( y4 a* X* \6 W
cious puberty in boys also results from inappropriate
! d7 {' Z8 A& g( @) eandrogenic stimulation from either endogenous or3 ?+ Q8 s. _# G* l) |2 N2 s
exogenous sources, nonpituitary gonadotropin stim-9 x: z* {* ~* y8 g$ |! a3 `/ D! ~1 {) @
ulation, and rare activating mutations.3 Virilizing. C; i6 O5 S+ d9 g. T0 J
congenital adrenal hyperplasia producing excessive' ~/ {. d7 J, H# F/ a; J+ w. H
adrenal androgens is a common cause of precocious
% Z, U" L7 o0 @9 Epuberty in boys.3,4
7 J4 ~# b" Y, s; y: t9 ^0 UThe most common form of congenital adrenal
1 Z# X$ l' Z6 I3 s, m: L4 Qhyperplasia is the 21-hydroxylase enzyme deficiency.
& C5 e. l$ W2 n9 [- O9 YThe 11-β hydroxylase deficiency may also result in
+ ~" A+ i  s( ?1 qexcessive adrenal androgen production, and rarely,6 [6 ^5 p4 ?9 D; P7 @, _
an adrenal tumor may also cause adrenal androgen& i" b# ~/ ~, O
excess.1,37 P; @4 q- _# E9 b* f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 e* [1 t% j, F+ D0 x" G! g2 j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ Z$ t2 x. e# r7 q7 BA unique entity of male-limited gonadotropin-
; F  ?* S# z- M  i1 ^$ K- Mindependent precocious puberty, which is also known& m2 _3 _+ R: u8 b5 F
as testotoxicosis, may cause precocious puberty at a" G# I- k' y9 o2 A, e
very young age. The physical findings in these boys
) Q% Q) S' T4 U5 ^& ^/ q) Nwith this disorder are full pubertal development,
, Z! Y0 V) [2 y! f* Eincluding bilateral testicular growth, similar to boys! q6 S/ W- B6 v! c- y! [
with CPP. The gonadotropin levels in this disorder
1 Y% J' b7 ?1 j% [# _7 g+ ^are suppressed to prepubertal levels and do not show
/ k; c4 S8 J2 O8 Ypubertal response of gonadotropin after gonadotropin-# t+ t7 N8 k: R; |
releasing hormone stimulation. This is a sex-linked
1 F3 R4 c2 ~" T7 `/ b9 `' K7 cautosomal dominant disorder that affects only' D+ J5 m8 T/ B& e5 D5 n
males; therefore, other male members of the family/ g8 i) {7 I3 S1 o
may have similar precocious puberty.3
0 a; n0 a9 Q& k( CIn our patient, physical examination was incon-
* n. g7 S* y7 w- l( s& msistent with true precocious puberty since his testi-
% v; i2 m' S" Acles were prepubertal in size. However, testotoxicosis
; C  \6 ?  S$ X! {) Rwas in the differential diagnosis because his father/ b& A! L$ A4 v$ e' o
started puberty somewhat early, and occasionally,3 ^5 {  o- l, o
testicular enlargement is not that evident in the, w1 \' x9 }* L- P+ O5 O
beginning of this process.1 In the absence of a neg-8 O. w- J+ g4 ~2 X" x. m, s
ative initial history of androgen exposure, our( L! L7 m8 K8 {( }4 M% n% A
biggest concern was virilizing adrenal hyperplasia,
5 e: N! [4 e- T. f! d* deither 21-hydroxylase deficiency or 11-β hydroxylase# Y2 I8 _5 F7 ]* T3 y" Z* ]
deficiency. Those diagnoses were excluded by find-2 U/ C2 @2 S) m5 J
ing the normal level of adrenal steroids.
$ |  \* `0 x+ N+ z1 rThe diagnosis of exogenous androgens was strongly7 R& R( N+ k/ b, O( W
suspected in a follow-up visit after 4 months because. U7 g; L+ B$ o' O- F; {
the physical examination revealed the complete disap-4 G. s5 s/ p6 ^! w' r5 {8 `# I
pearance of pubic hair, normal growth velocity, and+ P( s, a5 ?$ b9 V
decreased erections. The father admitted using a testos-7 i7 c: o7 t9 O7 {  v0 |
terone gel, which he concealed at first visit. He was4 j+ s3 a+ ~& x* h! y; B% H0 x
using it rather frequently, twice a day. The Physicians’
! ?. u3 n& e9 H, O) sDesk Reference, or package insert of this product, gel or, t7 X% P$ w5 \9 D' [( r7 D
cream, cautions about dermal testosterone transfer to6 Z8 T7 F+ ^2 U1 B" `
unprotected females through direct skin exposure.- `' H! z  K' v
Serum testosterone level was found to be 2 times the
0 ]/ r5 a9 }4 |4 B8 Qbaseline value in those females who were exposed to3 p  i/ X- b; X8 @
even 15 minutes of direct skin contact with their male; A. n* y' I; [/ l5 [- N
partners.6 However, when a shirt covered the applica-
+ A" b" J+ e2 O0 o, Y9 P. ction site, this testosterone transfer was prevented.; M2 T4 h# b3 m$ A& H4 Z3 ?+ t
Our patient’s testosterone level was 60 ng/mL,; W# W- b$ n+ _3 B+ J2 v
which was clearly high. Some studies suggest that
5 Z  E+ ~( Y2 P. m# U+ o5 P  \dermal conversion of testosterone to dihydrotestos-! [8 m1 m$ k; K  a- t0 y+ a
terone, which is a more potent metabolite, is more! k- z! u, c% {) q# y) g6 w0 B$ n# V
active in young children exposed to testosterone
! u2 A- J; _/ X+ x" ^( R# Eexogenously7; however, we did not measure a dihy-7 h& X% v* R7 S1 c* \5 v+ @
drotestosterone level in our patient. In addition to
3 {3 \, p6 [. [7 L( L+ Tvirilization, exposure to exogenous testosterone in! E& l* F6 F  a6 [' X8 J
children results in an increase in growth velocity and
: c( {7 s4 r; u4 x9 g% p/ sadvanced bone age, as seen in our patient.
4 H7 b% X) N8 W* ^/ u) Q2 C) VThe long-term effect of androgen exposure during$ d' S' z" P! y! J1 z
early childhood on pubertal development and final
2 ?. ?! B" w0 |% O' [adult height are not fully known and always remain
7 }- Q" A& K! a5 z; v1 {a concern. Children treated with short-term testos-2 u9 [. k2 {0 |/ ~, |% u
terone injection or topical androgen may exhibit some
8 m! p1 t% {  _6 u2 @acceleration of the skeletal maturation; however, after5 h4 g+ D' m) ]$ P
cessation of treatment, the rate of bone maturation
( i" M6 x: i6 N" I- x# {; Qdecelerates and gradually returns to normal.8,9
. u! j: h5 I9 j( }# RThere are conflicting reports and controversy" Y& L5 X4 E; @: \  R) |
over the effect of early androgen exposure on adult
. L1 w; B: G# h! }+ a1 Ypenile length.10,11 Some reports suggest subnormal( J* Q' ^: s" d0 D
adult penile length, apparently because of downreg-
7 d0 e- k: B' ]2 dulation of androgen receptor number.10,12 However,# a1 H  l/ E: J  ], w* f' s
Sutherland et al13 did not find a correlation between
$ f# M; u' o2 N' T, h- Rchildhood testosterone exposure and reduced adult% @) U6 j/ f' s& T+ |
penile length in clinical studies.  G1 @' t/ c! V$ R
Nonetheless, we do not believe our patient is/ G# K: w9 k4 X3 V
going to experience any of the untoward effects from+ ~3 o( z* I- B
testosterone exposure as mentioned earlier because
2 @  J8 |7 v$ X* ^8 x% B+ [. r! gthe exposure was not for a prolonged period of time.
0 x: p5 {( I9 b% r1 gAlthough the bone age was advanced at the time of) Z: m* N5 S/ f
diagnosis, the child had a normal growth velocity at4 U6 w' g' V6 W
the follow-up visit. It is hoped that his final adult0 p) B0 U5 i8 O& Q) }
height will not be affected.; W- P9 K/ Y# |8 a& a+ C4 g
Although rarely reported, the widespread avail-
% E( M. H1 |( J2 C$ \ability of androgen products in our society may
$ J3 I# P9 ^& t, h; _$ Tindeed cause more virilization in male or female
- k4 U. x5 {- L/ r2 g) s" B7 schildren than one would realize. Exposure to andro-
/ r0 Y: W2 P" Q8 U, rgen products must be considered and specific ques-
$ {4 _. J; {& L% ptioning about the use of a testosterone product or
% x( ]; U6 W: p" J; j8 igel should be asked of the family members during8 N; O  ~1 v( @0 q( ^+ }" i, r
the evaluation of any children who present with vir-+ d0 M: ~  \! R, E
ilization or peripheral precocious puberty. The diag-: w3 Y! A* i# Z) v9 W
nosis can be established by just a few tests and by
) S: X" O; e7 n) a5 zappropriate history. The inability to obtain such a
( w4 r9 X( T3 Y6 Q' [7 \  s" nhistory, or failure to ask the specific questions, may
9 t: Z: A" S5 v! O. Tresult in extensive, unnecessary, and expensive
  R% j; B% G0 ?, i1 P% ]investigation. The primary care physician should be4 b2 Z  f8 E/ ]: Z
aware of this fact, because most of these children; b. l4 h- G% v. Q! C
may initially present in their practice. The Physicians’. Y% [: x" i; S0 a8 U
Desk Reference and package insert should also put a! q: k- h6 {) ~; \" ~) @* X7 Q$ x% w1 m
warning about the virilizing effect on a male or
3 A  `7 {$ J6 r3 g" K- bfemale child who might come in contact with some-
1 _. a# y+ f/ a( O0 Zone using any of these products.
4 p3 [7 l2 b. w/ R. N  u. oReferences2 k; T" i/ d( ?- m* F. B  o2 C" E: d
1. Styne DM. The testes: disorder of sexual differentiation9 F; a+ `3 N: ]# C! N
and puberty in the male. In: Sperling MA, ed. Pediatric- k# T/ J/ D8 t& E5 X) c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! z, N: ]3 g2 G5 m& @- Z; i4 w
2002: 565-628.
; o3 y. X, d" h( y  p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* P1 O  W+ q( O7 L$ W
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
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
" [8 k' w/ G3 }( g0 D" `" u. O
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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