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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) u$ s; H$ u; ?5 j9 }" s
Boy Induced by Indirect Topical; j4 v% l# X8 J$ L$ ]( |
Exposure to Testosterone
( H6 G# b) E! j4 N  _- ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! F8 @, Q1 s* a6 B" o
and Kenneth R. Rettig, MD14 |" U" b: j+ g5 {8 Z3 Y; ^% a
Clinical Pediatrics
2 \5 B5 n* R5 W8 {, ?0 _. ?Volume 46 Number 6
8 f4 X, t% b2 t& W/ A; HJuly 2007 540-543! l9 a  I' |% M
© 2007 Sage Publications* B: f. Y0 ^; x& `5 t2 ^
10.1177/0009922806296651- ?+ V2 x2 n+ d' ]2 _
http://clp.sagepub.com- |7 D( r2 Q$ t6 ?& u( A0 v
hosted at4 |- l4 Y! K0 t$ a9 h% `
http://online.sagepub.com
5 B8 z& d/ U. @. F3 e7 n3 }Precocious puberty in boys, central or peripheral,. Q& D, l9 o/ ~
is a significant concern for physicians. Central9 C3 r9 I* G) L% c) V+ ]1 T( V" E1 X
precocious puberty (CPP), which is mediated
4 e* J/ e7 y, o9 W4 Q3 V. [1 Y. gthrough the hypothalamic pituitary gonadal axis, has
2 Z# f9 q) ]. ?3 k& O2 [5 Wa higher incidence of organic central nervous system: x! P: B) Z1 O0 k3 P: e/ @& O
lesions in boys.1,2 Virilization in boys, as manifested# a9 R) a) B7 H0 Y3 l& K# ^# [
by enlargement of the penis, development of pubic
( Z  m3 I3 I# g. [9 ihair, and facial acne without enlargement of testi-
) e# M8 C2 S1 R) mcles, suggests peripheral or pseudopuberty.1-3 We
. C2 _  x& `7 c: ]/ ?5 Treport a 16-month-old boy who presented with the
$ {) [- o% R( k! J! tenlargement of the phallus and pubic hair develop-
4 x, X; c0 x2 F1 S' C$ Pment without testicular enlargement, which was due' a9 V+ S" @6 @7 \6 E. i
to the unintentional exposure to androgen gel used by/ a' m" m. _+ C7 Q$ x6 T
the father. The family initially concealed this infor-' l$ ]. Q" _- A: a# y( |7 N
mation, resulting in an extensive work-up for this
9 u3 P5 x4 B' r3 M4 \) ^  ?3 achild. Given the widespread and easy availability of/ d6 |6 F4 a" n4 [7 Q, r/ P
testosterone gel and cream, we believe this is proba-/ u! W/ [9 g" {3 [: J* h
bly more common than the rare case report in the: a% C1 P0 p, Z0 ^8 W9 r0 w
literature.4
$ _7 S' p  P* C3 SPatient Report- `0 a. D1 ~2 F* H5 C: _5 a) k
A 16-month-old white child was referred to the
/ c& c5 t  @4 i/ L* Jendocrine clinic by his pediatrician with the concern/ d% s( Y8 C+ s8 H
of early sexual development. His mother noticed. J8 w! r, J5 |1 |
light colored pubic hair development when he was
8 ]- \+ X6 @& kFrom the 1Division of Pediatric Endocrinology, 2University of$ i  J+ o8 ^  D$ J- M
South Alabama Medical Center, Mobile, Alabama.
( a2 ]2 c! o3 I' R+ a2 ?8 o: SAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, Z0 m. m5 }( U) B0 yProfessor of Pediatrics, University of South Alabama, College of9 n; T! P6 K8 O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 X7 T4 |0 v% W. g6 s" F+ c+ P1 i, me-mail: [email protected].9 b3 @+ H. a, ^5 N
about 6 to 7 months old, which progressively became
4 V& X7 F6 S1 idarker. She was also concerned about the enlarge-; b" V6 g- K( D. Z. }; M% P
ment of his penis and frequent erections. The child$ ]" j8 q4 q2 @2 N3 y$ C
was the product of a full-term normal delivery, with
2 ^* t  s: k8 r' n3 y( ]a birth weight of 7 lb 14 oz, and birth length of' W! C, V5 H0 @+ J7 i
20 inches. He was breast-fed throughout the first year* [& X/ C- b9 G! {
of life and was still receiving breast milk along with
% ?) A4 @# f; rsolid food. He had no hospitalizations or surgery,7 E1 {6 m% {/ C+ W$ D
and his psychosocial and psychomotor development
0 `' |) v9 V6 A+ y- Mwas age appropriate.! I. Y: b6 M; \* G! U
The family history was remarkable for the father,
) P2 r6 b3 q- f& |$ n) J9 pwho was diagnosed with hypothyroidism at age 16,
+ q* A3 g1 m& r9 v7 Nwhich was treated with thyroxine. The father’s
$ s8 m: V) C5 K) Vheight was 6 feet, and he went through a somewhat
( D. B4 x0 _, Q, Zearly puberty and had stopped growing by age 14.
9 l( N! q0 X9 K# ~, O+ v5 ^) U5 qThe father denied taking any other medication. The$ k$ V" B1 w! f! J' a6 y3 V
child’s mother was in good health. Her menarche, P% n/ `: F& t2 r9 i
was at 11 years of age, and her height was at 5 feet: u- ^$ d5 s% H
5 inches. There was no other family history of pre-0 E2 Z/ s9 `# A" M0 O& \
cocious sexual development in the first-degree rela-
# e. T! G( B% ?4 d+ |8 ytives. There were no siblings.
* x, e! j0 M# u. i! R: [Physical Examination7 l+ j* F1 P; G+ `( @' k# x
The physical examination revealed a very active,! J4 g2 X, t; E4 D: v
playful, and healthy boy. The vital signs documented# b# ^7 x5 N) |
a blood pressure of 85/50 mm Hg, his length was& m# x7 M- j( ^5 r
90 cm (>97th percentile), and his weight was 14.4 kg$ K6 X; x- `1 O. |/ m
(also >97th percentile). The observed yearly growth5 S1 E2 B/ O/ W- \
velocity was 30 cm (12 inches). The examination of2 y; M, e' ?# t# A8 L& m
the neck revealed no thyroid enlargement.% @: Z6 Q9 g: e2 Q( [. i" k$ M
The genitourinary examination was remarkable for
9 |* \3 w  _+ q1 C9 E! _enlargement of the penis, with a stretched length of
7 E: l, U, z& D' |- \8 cm and a width of 2 cm. The glans penis was very well7 Q* b* h0 i/ X3 G* `
developed. The pubic hair was Tanner II, mostly around
0 L& D. a7 l  C" g& ]540
$ E4 {% P- ~& `# Q- cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 {, v7 H0 K2 V) {
the base of the phallus and was dark and curled. The, a. Y( {: D8 ~/ v- Q* Q
testicular volume was prepubertal at 2 mL each.) o; \9 M2 ^: ~* ^/ v! U
The skin was moist and smooth and somewhat
4 F2 o1 [  o( H3 Hoily. No axillary hair was noted. There were no3 W+ a$ f! ]3 w+ R
abnormal skin pigmentations or café-au-lait spots.
# n* [5 n2 A$ k- w8 K0 P; vNeurologic evaluation showed deep tendon reflex 2+
/ i% q! \+ }6 h3 Q+ H4 |$ abilateral and symmetrical. There was no suggestion
; X2 h+ h/ ^3 \! q( q3 Bof papilledema.7 l- N% y2 I; d) B+ n
Laboratory Evaluation! W- V/ X6 M' Z: W3 S2 ^
The bone age was consistent with 28 months by
% z% @+ ]2 z1 p5 y7 ]$ \* K" nusing the standard of Greulich and Pyle at a chrono-
7 t* P1 z# ]( rlogic age of 16 months (advanced).5 Chromosomal: f; U4 C  C9 n. F0 q4 f
karyotype was 46XY. The thyroid function test) ^/ e: M9 O  y. W- |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' O* u- V' q7 k1 N9 F
lating hormone level was 1.3 µIU/mL (both normal).
) X8 D+ u4 O! qThe concentrations of serum electrolytes, blood$ S1 g3 f. b, {: d# c& X3 L0 v
urea nitrogen, creatinine, and calcium all were' H. @; m( @( V' u) i
within normal range for his age. The concentration/ f$ ]% m$ a4 @) n2 u
of serum 17-hydroxyprogesterone was 16 ng/dL& X  ~, H- o% @  L$ v! o
(normal, 3 to 90 ng/dL), androstenedione was 20
* b  u* [  a& N3 y' C7 {) ]. Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 |+ w. O9 v" ^8 q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 a" a, l$ W0 D& h: E: J
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 T4 H2 {2 f6 L% M5 a1 Y
49ng/dL), 11-desoxycortisol (specific compound S)+ ?0 n6 n. N! J/ W; w; P
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- l1 y) D* V1 N5 j  `7 y1 Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 X2 ]4 k2 B* }3 }7 K4 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) i' d' [; s4 k" b
and β-human chorionic gonadotropin was less than
2 A' F2 V  Y1 s/ R8 j; J5 mIU/mL (normal <5 mIU/mL). Serum follicular
: [/ L! p" `4 g* s" h3 K/ ~) }' qstimulating hormone and leuteinizing hormone
- m4 B3 F+ T  J3 k! S0 wconcentrations were less than 0.05 mIU/mL
  S- {/ b- }5 N4 n(prepubertal).* v! n7 _6 g7 J8 {/ C& m
The parents were notified about the laboratory
- h$ w& [. B7 j" p6 F3 j: z6 o( e  Jresults and were informed that all of the tests were
. H7 Z$ G; R* h2 M, I: Z; unormal except the testosterone level was high. The' T% L5 n2 X6 U0 o0 \. @
follow-up visit was arranged within a few weeks to9 ~! v/ _6 h! G5 W. m8 n, v
obtain testicular and abdominal sonograms; how-
  P" u% \# ]  a, S% |6 Iever, the family did not return for 4 months.2 K' I- i1 @" {7 O8 c
Physical examination at this time revealed that the
& _+ e7 J: o9 \. Y4 X$ W' ychild had grown 2.5 cm in 4 months and had gained
$ i' r0 z  y% E. l& E5 u2 kg of weight. Physical examination remained
4 ^! o' ]! H. h& Junchanged. Surprisingly, the pubic hair almost com-
; h* N5 b7 p, ipletely disappeared except for a few vellous hairs at
" t& g1 @3 \8 v& J$ o# @* [the base of the phallus. Testicular volume was still 27 \' x& j* P, k/ A. \3 f# \+ C
mL, and the size of the penis remained unchanged.) y, R! e% u, Y
The mother also said that the boy was no longer hav-
- C& P8 `1 g+ j  Y9 f. Q/ f( zing frequent erections.9 f2 q0 V$ p% K) @" h7 v7 N
Both parents were again questioned about use of
( u* f% O2 Q+ `0 ~7 Z/ R7 `any ointment/creams that they may have applied to% H0 T5 M& S( I2 u1 K2 C' J
the child’s skin. This time the father admitted the% K  ^5 }/ C# ?5 t
Topical Testosterone Exposure / Bhowmick et al 541$ _: F8 ]+ Q* {' g. p
use of testosterone gel twice daily that he was apply-
8 e7 s9 [# l8 m+ _: v) K6 ring over his own shoulders, chest, and back area for
  h% a3 p) U  C5 B2 [& }a year. The father also revealed he was embarrassed4 o- G3 ]6 Z2 y6 Q" }$ |" I
to disclose that he was using a testosterone gel pre-8 w+ _7 z1 Q: `7 J' I
scribed by his family physician for decreased libido3 C1 m4 s4 B6 k/ T& G5 L
secondary to depression.
6 n' p: U$ e/ {( J+ j7 M2 QThe child slept in the same bed with parents.
; Y$ w; d* d  b% Y  Q. lThe father would hug the baby and hold him on his
0 [0 O7 X/ Q- U& Nchest for a considerable period of time, causing sig-
2 v) j( b6 a5 A5 Unificant bare skin contact between baby and father., Y( L+ ~9 Q% j) o# n
The father also admitted that after the phone call,' O" L/ ?- I2 [2 P
when he learned the testosterone level in the baby! W  L9 H" x7 Y/ e0 Q+ M
was high, he then read the product information- v' j! i! y; k
packet and concluded that it was most likely the rea-& D( r9 c; {( j5 `
son for the child’s virilization. At that time, they
, H) _( p+ N/ ndecided to put the baby in a separate bed, and the
9 c& H1 Z  B% ]$ K1 _- ^father was not hugging him with bare skin and had
3 i0 O: X& I- S, i9 ?) m4 D  j% w& ?! v! Zbeen using protective clothing. A repeat testosterone
" }) o  x7 n% C6 C% {test was ordered, but the family did not go to the
8 N! U! w' L8 t3 p- @4 Vlaboratory to obtain the test.+ f# [9 k/ l( I( w. s1 v' f/ E
Discussion2 X5 I0 A  Q! M; u/ ^
Precocious puberty in boys is defined as secondary0 i: W) p2 |, V8 A
sexual development before 9 years of age.1,4
% r  [1 \7 c7 ~# mPrecocious puberty is termed as central (true) when
! Q! |, z) y2 s* K) A% q, Vit is caused by the premature activation of hypo-
# A' i2 Q2 e/ ?+ T8 e8 b4 @8 n' Cthalamic pituitary gonadal axis. CPP is more com-
0 R# |9 q  u3 t' G7 C; pmon in girls than in boys.1,3 Most boys with CPP
! J* E" m; n- \may have a central nervous system lesion that is
. ~1 V4 R0 L+ _  f+ Fresponsible for the early activation of the hypothal-2 _; k& m/ a  f; I6 N3 D
amic pituitary gonadal axis.1-3 Thus, greater empha-9 B; p1 M/ R7 X" k  Y0 V
sis has been given to neuroradiologic imaging in0 i8 h8 c6 F" F7 n7 ^0 v
boys with precocious puberty. In addition to viril-8 F9 N) O5 m; I$ b
ization, the clinical hallmark of CPP is the symmet-, x4 G- W7 d8 l9 N8 o. h+ z
rical testicular growth secondary to stimulation by
3 V9 O( k  g( C% x, W' h" bgonadotropins.1,34 k. q/ C  T  a1 X
Gonadotropin-independent peripheral preco-- @" k$ e/ E" }7 O
cious puberty in boys also results from inappropriate; l$ F. [# w  j
androgenic stimulation from either endogenous or9 c) m4 L& U1 i% f- S8 t$ s
exogenous sources, nonpituitary gonadotropin stim-/ [/ e1 s: L: W
ulation, and rare activating mutations.3 Virilizing
* T; I' t- G! K9 K8 S, l+ `$ Rcongenital adrenal hyperplasia producing excessive/ U4 x) [" y1 h& I# C  w: f9 \  N8 R
adrenal androgens is a common cause of precocious
" y! N% Q3 V: g7 epuberty in boys.3,4. Z+ V; S7 z/ W' A& ]& x
The most common form of congenital adrenal4 }2 ~- |/ ]& I0 C
hyperplasia is the 21-hydroxylase enzyme deficiency.  a6 c4 I! a8 l; `, D% t
The 11-β hydroxylase deficiency may also result in5 [# E, x" R- @' F
excessive adrenal androgen production, and rarely,
& \- _' w( {8 j7 [an adrenal tumor may also cause adrenal androgen
+ I  `1 a6 M- l* {. W5 f1 ?excess.1,35 N" ?3 |% m  v3 W! Y/ h% c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 ~/ S  K4 D& M: j' ]/ R
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 V+ K: X! L% k' ?7 a
A unique entity of male-limited gonadotropin-" j" C6 v( `( x, U
independent precocious puberty, which is also known
+ E& r6 o" F& |# }as testotoxicosis, may cause precocious puberty at a2 _) O7 @1 p9 ^
very young age. The physical findings in these boys
2 x) d9 H3 v; f3 N$ e# X( uwith this disorder are full pubertal development,
' t& h5 [) d1 ~: i3 r1 {including bilateral testicular growth, similar to boys9 x) ?' Z/ V0 Y$ L1 A1 S- y4 Y
with CPP. The gonadotropin levels in this disorder
5 p5 @% Y' D5 H! z; Pare suppressed to prepubertal levels and do not show0 |2 s5 z  w+ }
pubertal response of gonadotropin after gonadotropin-
5 c& R# @) z" m1 g5 h5 T* kreleasing hormone stimulation. This is a sex-linked; \6 n3 h& a9 |* s6 y
autosomal dominant disorder that affects only3 U0 n! W& j$ }- l& T7 m
males; therefore, other male members of the family
  o3 `0 ^7 O7 C: A# jmay have similar precocious puberty.31 O9 F: w0 Z, [" k; I2 @
In our patient, physical examination was incon-0 X/ P- |1 M6 n& T2 U- m
sistent with true precocious puberty since his testi-4 p  d; \& x$ p. [/ [0 w- X
cles were prepubertal in size. However, testotoxicosis
3 }: i  N7 h# Q6 \9 }: Awas in the differential diagnosis because his father3 W. u' _) L- o5 F* a" t) }
started puberty somewhat early, and occasionally,% x: s% a( ~# S/ G( p( I8 c
testicular enlargement is not that evident in the
& ]" C5 f' P/ m% }: Cbeginning of this process.1 In the absence of a neg-; ^% o: T7 X+ t. `: `
ative initial history of androgen exposure, our
8 }( {& U4 ~  u0 f* ]+ Ebiggest concern was virilizing adrenal hyperplasia,: c2 _6 F- ^! ^' h0 @7 H: _
either 21-hydroxylase deficiency or 11-β hydroxylase' ^- E; R8 j1 i! e$ a0 I
deficiency. Those diagnoses were excluded by find-
5 V8 Z2 q$ J' H+ H# {9 `6 C* v4 ning the normal level of adrenal steroids.5 `2 `. S) N% h7 z/ L; z* L; y' T# R
The diagnosis of exogenous androgens was strongly
5 F, ?9 ^7 a4 G# N5 w+ Ksuspected in a follow-up visit after 4 months because
' N8 n2 d7 ^, m* Q, }+ @the physical examination revealed the complete disap-
( \2 T' x$ z: U# tpearance of pubic hair, normal growth velocity, and! F; `7 K( b/ p7 v% `) \* P
decreased erections. The father admitted using a testos-
6 z# p3 Y# H" v- ^terone gel, which he concealed at first visit. He was0 J, J. o2 L  C0 i9 q3 [5 H% e
using it rather frequently, twice a day. The Physicians’  n& @/ Z) Z; b: W3 |: O
Desk Reference, or package insert of this product, gel or8 m( a, X$ j- d" B. _
cream, cautions about dermal testosterone transfer to$ Q0 d- A) }  Y$ R5 k
unprotected females through direct skin exposure.# T% O& h* T4 J: j9 S- V$ B
Serum testosterone level was found to be 2 times the1 M( B: w8 T) A& X/ g
baseline value in those females who were exposed to  z% ^- w1 S8 B
even 15 minutes of direct skin contact with their male9 f; r' B& t) u2 \( Z
partners.6 However, when a shirt covered the applica-1 L5 S0 K4 S0 `# Z, Y4 f
tion site, this testosterone transfer was prevented.3 S' p# R, K+ M1 j2 h  o
Our patient’s testosterone level was 60 ng/mL,
$ {6 M9 C4 ~% J9 H) j# M4 _which was clearly high. Some studies suggest that
* D) ?& j: a4 idermal conversion of testosterone to dihydrotestos-
8 _( W0 K4 t/ ~' [! Tterone, which is a more potent metabolite, is more
+ \7 w4 g# p+ `5 n/ [1 ~active in young children exposed to testosterone( @, d5 B  x7 M- ~2 L! z/ q4 }, P) b# |
exogenously7; however, we did not measure a dihy-+ t$ P4 M9 |6 P0 D" p3 j0 A7 ], c7 s  s) H
drotestosterone level in our patient. In addition to( l) N/ b+ [; s' W
virilization, exposure to exogenous testosterone in
. {4 L) b( Y- Y0 M9 `2 H+ Xchildren results in an increase in growth velocity and
2 i4 d# P* C, V; h, u% ?advanced bone age, as seen in our patient.0 j: a7 e0 c+ s" a
The long-term effect of androgen exposure during
7 m0 J# Z. W9 E3 e2 v; eearly childhood on pubertal development and final
/ h1 k  A* |- z* W# Jadult height are not fully known and always remain
% P7 m6 Y3 h3 A1 Z/ |3 W; pa concern. Children treated with short-term testos-! l: W5 h6 K, Y# ~- H: j
terone injection or topical androgen may exhibit some9 {% L% K+ V# v, `0 X$ k# o+ `
acceleration of the skeletal maturation; however, after/ v; H( P  S) M# h( E, J3 }# ^9 A, D
cessation of treatment, the rate of bone maturation" {1 S! i) Z- f
decelerates and gradually returns to normal.8,9
. A% a2 z8 T* RThere are conflicting reports and controversy# K6 k* ]  U7 P# b* F
over the effect of early androgen exposure on adult) y: }; f" g  Y
penile length.10,11 Some reports suggest subnormal
1 I. S; X3 _& Cadult penile length, apparently because of downreg-
" k) L  h3 Z$ q& B% D& Fulation of androgen receptor number.10,12 However,
% ^+ r& H% P" ^; h  h9 lSutherland et al13 did not find a correlation between8 S; T4 Z. u" v
childhood testosterone exposure and reduced adult3 _( j3 i5 W  j- H  E) X
penile length in clinical studies.3 K; y  e1 m6 K! K# A8 T  c4 Z( E
Nonetheless, we do not believe our patient is* q9 t/ @; h2 \' S' u' ]+ K% u
going to experience any of the untoward effects from
- i5 @1 {2 \% E4 R% z  z7 Itestosterone exposure as mentioned earlier because  D' x/ C0 g* b  E% j
the exposure was not for a prolonged period of time.- Q" D3 I- x3 `2 ?1 D3 p  L; b
Although the bone age was advanced at the time of
. s& h0 a  Y) C3 Fdiagnosis, the child had a normal growth velocity at+ [6 p* e7 _  T- e$ s( l
the follow-up visit. It is hoped that his final adult
' E) Q& k* \4 ?. Theight will not be affected.5 H- e) O% ]$ i- a& Z
Although rarely reported, the widespread avail-
6 d* Q  R) \, s1 w( Lability of androgen products in our society may
/ m: r; T# b$ x" A6 `) a3 gindeed cause more virilization in male or female3 H) }7 n" u2 h6 p4 m
children than one would realize. Exposure to andro-% u3 s+ B* D( \) ?$ c! |
gen products must be considered and specific ques-
- g% J5 L, ~0 [' xtioning about the use of a testosterone product or
7 c. W* s, @) U0 Zgel should be asked of the family members during7 J0 t: f0 a5 e& N# V2 G
the evaluation of any children who present with vir-
7 s' |! c9 v: I, Q  h3 jilization or peripheral precocious puberty. The diag-% \% @2 u  E. e+ {
nosis can be established by just a few tests and by. ~9 @' k% n% ]6 d. \
appropriate history. The inability to obtain such a( ~# ^) O7 U# W6 ]! B- D
history, or failure to ask the specific questions, may
; C3 R% F. V/ C0 r6 Gresult in extensive, unnecessary, and expensive
! c) j; J6 g2 O8 m; Kinvestigation. The primary care physician should be
+ e" D2 D, E1 X* D; C7 ~$ iaware of this fact, because most of these children
$ [2 h" C3 i1 r. smay initially present in their practice. The Physicians’
9 K) Y5 S4 e1 Y; H8 M4 q* {2 qDesk Reference and package insert should also put a' t5 h" ?0 T" C! @0 l! ~; g
warning about the virilizing effect on a male or
# U6 `0 p" _! ffemale child who might come in contact with some-6 ~8 D$ u- \2 b+ B+ O' G. J
one using any of these products.
; i4 X8 [( [; P$ }( NReferences
6 q6 X- f0 y7 x1. Styne DM. The testes: disorder of sexual differentiation
) P7 y9 a4 ~# T# Jand puberty in the male. In: Sperling MA, ed. Pediatric, n6 N: G  @5 n6 v) U6 F, c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( a- p' n" U9 @* V3 q: r
2002: 565-628.
) q$ E" W0 W: J/ `: n3 l2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 v0 z+ t  m: I" l8 F) j
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
3 e7 j% {# I3 n1 B2 E' \) \* jBoy Induced by Indirect Topical
6 Q# X! r% ]3 Z" p: M( l6 oExposure to Testosterone/ h9 o$ `& H& O. ]- ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* |' Q3 e. P$ m. `and Kenneth R. Rettig, MD1
" R6 n9 T$ c# ?+ x  m/ F' J2 xClinical Pediatrics8 E0 G# a, o. \, q( @# q5 j
Volume 46 Number 6$ g6 ?8 J4 z) X* B3 k
July 2007 540-543
6 R5 [# e3 [, j  z/ f/ T3 m, `2 s© 2007 Sage Publications- J5 E% V6 q! z% n
10.1177/0009922806296651" C7 z) J* m2 p% B: G9 X
http://clp.sagepub.com
$ w! I" d5 P% A0 T$ Y( l3 w4 n# Shosted at! m0 V& P7 p! j6 r
http://online.sagepub.com: c/ n+ Y' g' P! @' x3 ]# m7 `
Precocious puberty in boys, central or peripheral,
# \- }! d. B" j4 ~; {is a significant concern for physicians. Central
2 U  D. M. ?2 z3 E% wprecocious puberty (CPP), which is mediated% S5 D1 o; m3 b9 E6 ~) ~) }# l: D
through the hypothalamic pituitary gonadal axis, has8 \6 [: u0 m' i/ h
a higher incidence of organic central nervous system
. c( w- C' B1 N# S+ e: ~3 rlesions in boys.1,2 Virilization in boys, as manifested
+ m* f) u0 E9 z! Aby enlargement of the penis, development of pubic
0 c  X, x/ z4 d6 @hair, and facial acne without enlargement of testi-
/ ^, a: A+ @  v0 _1 F6 i* xcles, suggests peripheral or pseudopuberty.1-3 We
; @* Z' p( r) ?- t4 H# Z' a  d. b4 breport a 16-month-old boy who presented with the
" Y- v' V+ F! Venlargement of the phallus and pubic hair develop-
  S5 m* ]# w1 {: [0 Jment without testicular enlargement, which was due
! t% u/ q* y: X6 O/ q  a3 Cto the unintentional exposure to androgen gel used by* }" X, S# T) r
the father. The family initially concealed this infor-/ ^% ]6 H& _+ I, b. g9 J0 `
mation, resulting in an extensive work-up for this
4 a" m0 e' t- `7 A) i) Achild. Given the widespread and easy availability of
) i! y1 f% N' J: btestosterone gel and cream, we believe this is proba-
: j( v  G( n% ~  z2 `; Gbly more common than the rare case report in the9 v/ v% b2 n, F
literature.4
6 P0 T) h5 ~1 F$ D- Y! ?% |Patient Report
9 B$ o6 {6 e! ?5 uA 16-month-old white child was referred to the- m- a' a, r! I) _) J: r9 S& J
endocrine clinic by his pediatrician with the concern2 _- g& e8 `. u% q4 ^$ v
of early sexual development. His mother noticed7 w# Q; n# _: u
light colored pubic hair development when he was$ Y/ [7 V, F( n. K
From the 1Division of Pediatric Endocrinology, 2University of
. Z. l  N% Q/ B1 rSouth Alabama Medical Center, Mobile, Alabama.! ~: A$ o8 f  W4 O3 i
Address correspondence to: Samar K. Bhowmick, MD, FACE,
) y* M! q! i' q1 _/ hProfessor of Pediatrics, University of South Alabama, College of. Y$ t  r5 y3 p8 ~2 K$ Z, {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- F* N' h- X# l% N, o- P$ [* \
e-mail: [email protected].
& L! D- `% O" W8 y' @) fabout 6 to 7 months old, which progressively became
6 q+ Z9 y/ {# C0 r7 ~darker. She was also concerned about the enlarge-& [, o$ N8 I1 Z" B6 K: D* j" s: B
ment of his penis and frequent erections. The child- H/ T8 r% _- s0 j# y. g4 J
was the product of a full-term normal delivery, with
* M0 q  b+ e9 K! O8 Ca birth weight of 7 lb 14 oz, and birth length of6 k8 l' W! B! x! k0 X, q% p
20 inches. He was breast-fed throughout the first year% S" l( x) g/ g) w% w& k
of life and was still receiving breast milk along with
6 b/ F% K& {: d  usolid food. He had no hospitalizations or surgery,/ f5 I# \% }" r' B8 E
and his psychosocial and psychomotor development% n5 q% ]- i: t- Y0 C7 J$ o! w
was age appropriate.
2 Q: _( g% P( \The family history was remarkable for the father,. T7 m2 ^5 |" I( ^
who was diagnosed with hypothyroidism at age 16,
, {! e8 |9 o$ C2 J9 \  Twhich was treated with thyroxine. The father’s
/ I7 |+ M* k, E4 Q3 Kheight was 6 feet, and he went through a somewhat
/ F# m( k9 p/ Z( T% p$ g) B  [early puberty and had stopped growing by age 14.
& K9 }  l! k" q9 D/ ?4 D; ]- SThe father denied taking any other medication. The
% e; X% d2 |- f- n) [child’s mother was in good health. Her menarche
6 b9 N- y) v1 s6 J. k6 C) _was at 11 years of age, and her height was at 5 feet5 b% n- i7 `; y- a* V: g
5 inches. There was no other family history of pre-
: B  D1 [4 }6 c: _" s! Y7 f  |cocious sexual development in the first-degree rela-& T1 I) C2 t3 J$ g6 m
tives. There were no siblings., V! W: h# X9 Y% A/ K# B$ \6 A
Physical Examination( h, b0 c6 @1 e4 J2 I
The physical examination revealed a very active,
. n/ ?' a" x! C0 f9 \playful, and healthy boy. The vital signs documented
0 ~) j9 m/ r' e# }5 ha blood pressure of 85/50 mm Hg, his length was) a3 K0 O: I6 O* X$ W+ C
90 cm (>97th percentile), and his weight was 14.4 kg
5 [7 b& m- }$ u" d0 A7 |(also >97th percentile). The observed yearly growth" C  h! J* h" u0 ~9 G$ y
velocity was 30 cm (12 inches). The examination of- G1 B1 ]7 a. |2 c; c1 x
the neck revealed no thyroid enlargement.
+ h& Q* m  G  Y7 S5 zThe genitourinary examination was remarkable for3 t/ c. n* c2 |- O- @4 H
enlargement of the penis, with a stretched length of# _' C9 R4 I" D) l3 r
8 cm and a width of 2 cm. The glans penis was very well3 u- w2 b) b8 S  ]0 l! ]* W
developed. The pubic hair was Tanner II, mostly around" S* K3 _/ G( h8 `2 M$ j
540
( x$ }2 d: @) G1 N+ f0 X/ uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' v' a+ |% T; h
the base of the phallus and was dark and curled. The
5 s, r5 a. L& W" C7 p1 \! k, {  htesticular volume was prepubertal at 2 mL each.  O: r- x  b4 {6 Z- q" U
The skin was moist and smooth and somewhat
5 [0 T  i# |1 T3 K  f3 j) Joily. No axillary hair was noted. There were no4 ^8 S" s" {1 j  v" i
abnormal skin pigmentations or café-au-lait spots.
# A! h$ ~, x! e& Z+ d% H% RNeurologic evaluation showed deep tendon reflex 2+
; W) }1 D* a5 L6 _: t) m; qbilateral and symmetrical. There was no suggestion
8 |* X! _% T$ _' ?% U, `9 Lof papilledema.: ~  X4 v* |3 T1 x. p
Laboratory Evaluation) a7 S# i5 w2 n1 i
The bone age was consistent with 28 months by
( q: U. D/ `" Q' Zusing the standard of Greulich and Pyle at a chrono-) ~* Q2 L, Z  |9 F
logic age of 16 months (advanced).5 Chromosomal' L4 [, T$ t! l) C# [% j
karyotype was 46XY. The thyroid function test. Z$ x- H) z0 Q9 }% [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% s) `. v  D; Q0 R- q
lating hormone level was 1.3 µIU/mL (both normal).: R3 B& l9 P+ [% o: N
The concentrations of serum electrolytes, blood
  t7 r: w4 l. u; u0 O. r, gurea nitrogen, creatinine, and calcium all were3 H8 ~# `0 p. s5 E; H. _4 G9 M5 \/ O
within normal range for his age. The concentration# T9 d* g. ~9 z) r8 a7 E# X
of serum 17-hydroxyprogesterone was 16 ng/dL2 N4 b' q7 S# b! {
(normal, 3 to 90 ng/dL), androstenedione was 20
% x; a' f0 ~9 L/ {# c, {* eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, N: q8 `& n. M; pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 K% Z) O" V- A* e. S8 T7 Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
- W7 q5 H3 j' r, d. z. T49ng/dL), 11-desoxycortisol (specific compound S)
& s( K, h0 a: V5 T  Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 v. m1 e5 Z% u1 t; @0 v6 |* Z( gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! p" g/ K2 S- F! j1 G+ c4 F7 h  m& Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),: k9 A  z/ d+ ?6 F. j2 v
and β-human chorionic gonadotropin was less than
( U' }& c8 X5 v/ ?; j5 mIU/mL (normal <5 mIU/mL). Serum follicular/ x" Q, r, g8 K$ f! e) _7 W$ S! p  W
stimulating hormone and leuteinizing hormone
0 t, f: Y% D& n2 k0 A9 \- Uconcentrations were less than 0.05 mIU/mL
& L5 u; }( r) v' ~5 l" ](prepubertal).
& H/ B. O+ L+ f* XThe parents were notified about the laboratory
0 n* O2 Z* {+ ^) u9 T/ yresults and were informed that all of the tests were
& }/ y- J" t- t2 E- p+ `6 v* q9 J- Hnormal except the testosterone level was high. The
2 x/ ?" P8 \9 P, Vfollow-up visit was arranged within a few weeks to6 ?4 X9 i- A. A7 l% i0 U
obtain testicular and abdominal sonograms; how-1 Q7 n  N7 c/ z! `( A3 m, V
ever, the family did not return for 4 months.9 I3 P! H' A( V* N, k
Physical examination at this time revealed that the  _0 w( ]8 R4 P6 V4 _: _. N
child had grown 2.5 cm in 4 months and had gained7 T0 T$ _6 \" ~/ `
2 kg of weight. Physical examination remained
. Z* T. d: I0 d# ?3 M- M* Zunchanged. Surprisingly, the pubic hair almost com-
" b/ o% W8 M9 U0 j$ fpletely disappeared except for a few vellous hairs at6 A2 t* _- D; {/ w' S6 _  g
the base of the phallus. Testicular volume was still 2
/ \4 }, H* i, ^2 {4 mmL, and the size of the penis remained unchanged.
. m" ^0 e* ^" ~* H& RThe mother also said that the boy was no longer hav-6 U* p; ]- u# g$ j, O/ H
ing frequent erections." n9 J+ j9 I0 a0 E
Both parents were again questioned about use of
2 H; ^% z$ ?% G4 F% [6 j# E9 j4 W* xany ointment/creams that they may have applied to- H. H% \- s2 l: {
the child’s skin. This time the father admitted the
5 h( ]+ j) k4 a- C' F( g& d7 z  T: W9 wTopical Testosterone Exposure / Bhowmick et al 541' A' |) O9 n+ E  k" F
use of testosterone gel twice daily that he was apply-" g0 X$ a; d4 q& L& U1 T
ing over his own shoulders, chest, and back area for
" x5 b; C. o- e7 w' Ha year. The father also revealed he was embarrassed0 r/ g. Q  _" K% e/ U8 e* F
to disclose that he was using a testosterone gel pre-8 T5 H8 n/ [& |* N
scribed by his family physician for decreased libido
2 n; X  d& S8 Q4 a8 @( Wsecondary to depression.
5 c1 y/ h! _8 X! G. A6 Z7 N" o4 GThe child slept in the same bed with parents.8 L% |$ z. \7 m+ \
The father would hug the baby and hold him on his
& p$ b! f& ]9 Vchest for a considerable period of time, causing sig-" K6 S% W* C4 q* l7 f7 D! h
nificant bare skin contact between baby and father.! I2 a  Y# K' {9 e9 m4 e
The father also admitted that after the phone call,
+ d8 c( t7 Q0 x& Owhen he learned the testosterone level in the baby
$ v0 C0 x/ q: t, d2 i7 W7 ]was high, he then read the product information
' Q. r; M+ @# [) Wpacket and concluded that it was most likely the rea-3 K  b) A% b) W
son for the child’s virilization. At that time, they8 h+ c0 b4 q5 C
decided to put the baby in a separate bed, and the) t9 V% I9 m. \
father was not hugging him with bare skin and had
* \2 ]  W# t+ H( Z0 Dbeen using protective clothing. A repeat testosterone( B$ U4 Y, I; w  R, w' e
test was ordered, but the family did not go to the8 U5 k% X* s5 }% y
laboratory to obtain the test.
7 N0 a5 ]4 v. u9 ODiscussion
# l9 d; U, P: r0 ^Precocious puberty in boys is defined as secondary8 B6 f, H$ I8 }; i4 o' t+ n, }
sexual development before 9 years of age.1,4
7 i# S) E/ R7 a! T$ rPrecocious puberty is termed as central (true) when
6 q- C; k! R+ L- x! ~; bit is caused by the premature activation of hypo-4 V1 @: A2 K& @" o, l+ a: |1 Q
thalamic pituitary gonadal axis. CPP is more com-
' ]* {2 y( w+ z) g) r9 C$ G$ s8 a+ U$ vmon in girls than in boys.1,3 Most boys with CPP/ F& R  t  T. A$ l$ ?
may have a central nervous system lesion that is5 h" n9 B, J1 Z0 j! f
responsible for the early activation of the hypothal-( U: _2 q4 p1 X3 ]1 v$ H
amic pituitary gonadal axis.1-3 Thus, greater empha-
; ^  W. i) K/ O0 p0 @/ I  B$ D/ H8 Lsis has been given to neuroradiologic imaging in) S) C; r/ W. L; {6 n
boys with precocious puberty. In addition to viril-
; ~. X/ z! n/ l/ uization, the clinical hallmark of CPP is the symmet-, {  M3 N( G+ M& ^# R, Y' p6 r3 E
rical testicular growth secondary to stimulation by
. O0 P! X1 f; ~gonadotropins.1,3; a2 [# N$ G2 L5 y7 H* K9 M
Gonadotropin-independent peripheral preco-
6 ?8 b: y* `4 V: {4 w% wcious puberty in boys also results from inappropriate
$ f) N9 v6 ~* X3 O: i) c, |$ Q% P' jandrogenic stimulation from either endogenous or
& D- C9 Y& p6 S/ K" K# rexogenous sources, nonpituitary gonadotropin stim-
4 r9 X8 `2 X& D0 [7 d# Bulation, and rare activating mutations.3 Virilizing; a1 ?) t- o! c5 a/ B
congenital adrenal hyperplasia producing excessive; k$ h1 u9 J8 @- E
adrenal androgens is a common cause of precocious
; B( M8 c/ h0 Q& q! }7 `  C2 Ypuberty in boys.3,4$ y% O# _% Z; m: ~! o* E
The most common form of congenital adrenal
/ m( R1 X3 a/ o! J# u3 w7 _9 Yhyperplasia is the 21-hydroxylase enzyme deficiency.
' a& ^) T) k& k0 _2 {The 11-β hydroxylase deficiency may also result in
  L/ E% d& o3 lexcessive adrenal androgen production, and rarely,# E. }. F* c: }+ w4 w8 S
an adrenal tumor may also cause adrenal androgen
( _6 K  i+ e) K* ~. o( L  Iexcess.1,3
2 H# w" [  _" {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( a, g' t( Z, _% |1 S9 \( s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, s5 I8 C' B; c
A unique entity of male-limited gonadotropin-
' g7 j7 `$ N5 J( H+ M5 U/ Eindependent precocious puberty, which is also known
3 Y8 J: p' |4 b, o' v% h7 R5 x( @as testotoxicosis, may cause precocious puberty at a
2 m1 W$ N  j* P6 xvery young age. The physical findings in these boys& Z7 @, a6 B! _% @) _. u
with this disorder are full pubertal development,
& y. I9 D* q4 u/ L7 {- l+ hincluding bilateral testicular growth, similar to boys$ Q5 g% e' [0 k% ^% w5 e& [7 A" I9 p$ c
with CPP. The gonadotropin levels in this disorder- J6 h6 n+ m7 r$ A+ l
are suppressed to prepubertal levels and do not show7 K- P# F- r! h9 B# G
pubertal response of gonadotropin after gonadotropin-& [% P% B9 a- u. i+ j2 {
releasing hormone stimulation. This is a sex-linked
4 `5 H1 V) p6 P" r4 L  lautosomal dominant disorder that affects only' I$ Z* S, W  _$ j0 X
males; therefore, other male members of the family
' ~( O& M0 g, F% U9 z; nmay have similar precocious puberty.36 i& e, O$ m* n$ J4 E- z* H2 I
In our patient, physical examination was incon-
. g0 Q' P0 _- f, f. Q: Fsistent with true precocious puberty since his testi-# A$ j7 `: w. R0 E( b1 g, @0 y7 p
cles were prepubertal in size. However, testotoxicosis
' g7 n: W& F7 o5 l0 f/ Xwas in the differential diagnosis because his father
$ c* H/ {1 G# b" \started puberty somewhat early, and occasionally,; D% b. _+ q4 C- D6 ^
testicular enlargement is not that evident in the
3 q+ e# ~8 A/ j# cbeginning of this process.1 In the absence of a neg-
$ B, D& o( ]) R- x" a1 e" F6 lative initial history of androgen exposure, our
: }$ c6 D' j# L# v/ S. Mbiggest concern was virilizing adrenal hyperplasia,2 b& Y4 q  B. n( a; {! p, h" c6 f
either 21-hydroxylase deficiency or 11-β hydroxylase
7 X* w4 T8 U2 }1 Cdeficiency. Those diagnoses were excluded by find-
. b$ J1 c# F  x  K. s: Qing the normal level of adrenal steroids.
5 M, b7 ~  N+ h. e9 y8 t! Q' {1 N5 NThe diagnosis of exogenous androgens was strongly# M! J7 }; R+ [! x; O& Q
suspected in a follow-up visit after 4 months because
6 [0 Q3 n; X1 E8 ^! Gthe physical examination revealed the complete disap-
+ {0 W: m: o4 z8 }- Q, Ypearance of pubic hair, normal growth velocity, and
$ s! J+ B; q( K  C: T' ?decreased erections. The father admitted using a testos-
9 M! E/ N* f% aterone gel, which he concealed at first visit. He was& p. f; \4 a. O" D2 R
using it rather frequently, twice a day. The Physicians’2 J- w1 @/ H5 V  j4 ]2 G+ f/ ~
Desk Reference, or package insert of this product, gel or$ K6 F0 F" Q+ J3 o( _
cream, cautions about dermal testosterone transfer to
/ ]" P( i$ s* N- W. M7 `unprotected females through direct skin exposure.
2 Q0 R- {- p1 m' l& ~) D9 r: I- P! aSerum testosterone level was found to be 2 times the
; T# B& i: H, G4 Vbaseline value in those females who were exposed to' w+ [9 a/ w+ ~& |" q
even 15 minutes of direct skin contact with their male
  e7 Y$ @* f3 s1 ?' N+ Ipartners.6 However, when a shirt covered the applica-
  W$ m, e8 w; Qtion site, this testosterone transfer was prevented.
: a+ S2 w/ S; l: L* H' o; zOur patient’s testosterone level was 60 ng/mL,
* E! L( b# p% n0 t: O* {" Zwhich was clearly high. Some studies suggest that4 t5 x8 m8 E- l7 q6 R
dermal conversion of testosterone to dihydrotestos-
5 q5 R2 ~: k3 f$ x* j% G7 rterone, which is a more potent metabolite, is more
, g0 m2 K0 w6 r( @0 _3 W0 Sactive in young children exposed to testosterone- O, z/ E2 z$ u; i& h7 H& e* p
exogenously7; however, we did not measure a dihy-2 Q% J% M+ Z: r$ d3 S7 z7 j
drotestosterone level in our patient. In addition to
- _* B7 x8 G. W' m& Avirilization, exposure to exogenous testosterone in
' M+ _, B' K% {3 U+ wchildren results in an increase in growth velocity and# h. Y9 k3 q. s: e, u$ R& L8 ?' p
advanced bone age, as seen in our patient.' m2 J- t0 A/ N. k8 a" G8 d, `. Q: H' c
The long-term effect of androgen exposure during+ p4 H; a1 x; _% w- R& H3 g  K
early childhood on pubertal development and final7 w1 s: W8 r6 D/ ^
adult height are not fully known and always remain3 W+ e  l* [% g5 W2 q) f
a concern. Children treated with short-term testos-: I; v( T1 z: ^* S. k
terone injection or topical androgen may exhibit some1 |" R: J+ F; ^! k& m( s2 g3 ~2 p& K" Q4 P
acceleration of the skeletal maturation; however, after
! R6 t5 N2 `$ j/ hcessation of treatment, the rate of bone maturation
, C5 P: v2 C6 R+ vdecelerates and gradually returns to normal.8,99 I) s& N1 w# M9 y, c' I
There are conflicting reports and controversy
) I5 }9 T! g9 _+ Mover the effect of early androgen exposure on adult
5 }; E* `) a6 ]" Upenile length.10,11 Some reports suggest subnormal
0 i% a1 J7 ^) h% t6 J0 dadult penile length, apparently because of downreg-
7 Z- J  b) O8 @ulation of androgen receptor number.10,12 However,
/ G0 c" }9 ~5 `5 x6 W6 O: b. J  S% gSutherland et al13 did not find a correlation between% [+ @) \! w3 U" B
childhood testosterone exposure and reduced adult
  d7 w! A; z6 n; \, dpenile length in clinical studies.4 a1 }2 e6 r) T1 B1 E" y
Nonetheless, we do not believe our patient is
0 u7 s1 }. _* u! rgoing to experience any of the untoward effects from! [$ m. I0 i  c7 B4 Z7 h' c7 F
testosterone exposure as mentioned earlier because
9 g( ^' P1 H: Q7 h# R0 c) Jthe exposure was not for a prolonged period of time.
  G( O( ?- _3 H; M: VAlthough the bone age was advanced at the time of: D* o6 {1 v' c1 `# q% r" M( G
diagnosis, the child had a normal growth velocity at" T5 j+ I/ J+ }7 Q+ }  N" w
the follow-up visit. It is hoped that his final adult/ f# X( q0 x1 q; X& s
height will not be affected.* H2 W: k$ W) q' Z0 f
Although rarely reported, the widespread avail-% y1 {' @9 a# t' l8 i3 }3 D
ability of androgen products in our society may
* E7 A  o5 }) y" K% t/ O7 Nindeed cause more virilization in male or female
/ k( \% q# d" m9 B8 G5 P; Nchildren than one would realize. Exposure to andro-
; {1 h  B7 I5 q. Mgen products must be considered and specific ques-; G+ O: @1 D- M; i  f3 J
tioning about the use of a testosterone product or
* d+ n# }6 u6 P. d( V' Ygel should be asked of the family members during
: I9 X! j* f' k' B- Othe evaluation of any children who present with vir-0 b; J- y5 T0 C4 C/ I) N
ilization or peripheral precocious puberty. The diag-1 V' d2 k7 q4 D8 h
nosis can be established by just a few tests and by
3 g0 |, w: d% F' i9 q7 Happropriate history. The inability to obtain such a
4 y5 R( R+ X* Yhistory, or failure to ask the specific questions, may
) ~; L5 r* b* M) O& |! Q& }+ K! Gresult in extensive, unnecessary, and expensive1 y4 M# w2 y4 }  J+ _
investigation. The primary care physician should be% i" h: M' c% c! Q7 g
aware of this fact, because most of these children. q1 V# C1 E( N
may initially present in their practice. The Physicians’- o- S3 t! G( z- P
Desk Reference and package insert should also put a1 U4 A& q/ N. n7 ?
warning about the virilizing effect on a male or
, g; x; D' N6 I( Gfemale child who might come in contact with some-3 D( ]/ x9 K! a+ R) N
one using any of these products.* s$ v" I# L6 P
References: l$ x1 \; ]: B" |3 D( \
1. Styne DM. The testes: disorder of sexual differentiation8 E7 N+ H6 b- a
and puberty in the male. In: Sperling MA, ed. Pediatric
1 V2 m1 K" Y% i" `" yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 }, ^; ~6 o9 w4 B
2002: 565-628., X7 t$ G: g/ _8 ~2 P' j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 @. s' a0 q+ J5 D2 xpuberty 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
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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
1 w! B  q6 W; X  M& W7 `# }8 g7 e
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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