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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
; H+ p' c* a9 T& MBoy Induced by Indirect Topical" M$ l: W$ M: O6 J# ~. P/ n
Exposure to Testosterone- L: e" S, {% e2 E* g, t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 F0 ]& i: B! [2 Gand Kenneth R. Rettig, MD1/ ^  H3 a' f2 u! f7 p
Clinical Pediatrics0 x6 r( U1 ^' P. i6 p
Volume 46 Number 6
2 b5 b$ ?: u8 |+ y* ZJuly 2007 540-543
+ I* o. x' T& y* T( o© 2007 Sage Publications- e! J! u3 g* x, }
10.1177/0009922806296651
' p5 j+ x$ ~( c5 ]1 {4 {http://clp.sagepub.com
5 y# s! d2 [$ Y8 ~0 Zhosted at( |. m8 A, e" R1 Z2 D1 l/ E7 B) I
http://online.sagepub.com7 ~* e: G% ]8 N+ V/ v0 r+ ?4 h
Precocious puberty in boys, central or peripheral,5 T7 m, S5 b4 u6 U; S4 X7 x; C8 U
is a significant concern for physicians. Central! M1 u! G3 Q# }% a" |: p
precocious puberty (CPP), which is mediated
% ]3 j; x$ {4 {' q' o, othrough the hypothalamic pituitary gonadal axis, has$ G% S0 y1 G; f3 ]5 s$ }) m
a higher incidence of organic central nervous system! ]& O* ~& N* L5 C# v
lesions in boys.1,2 Virilization in boys, as manifested5 n" z8 x0 z$ f2 {
by enlargement of the penis, development of pubic2 U% O: n% f' r
hair, and facial acne without enlargement of testi-
0 g( Y* @/ f8 |5 Icles, suggests peripheral or pseudopuberty.1-3 We: N* U- B, H* g6 y3 f/ f
report a 16-month-old boy who presented with the
; z- Z  L$ A) b$ @! L0 Cenlargement of the phallus and pubic hair develop-
- \" I8 F8 E- g" s7 Lment without testicular enlargement, which was due9 |6 G% a8 f. i
to the unintentional exposure to androgen gel used by" @% u! ~7 Y4 T* z
the father. The family initially concealed this infor-! c, C9 P4 T7 s7 u: l% Z: m: w$ r2 M& s
mation, resulting in an extensive work-up for this7 X: V, h+ H  t- g
child. Given the widespread and easy availability of
6 e4 ^. d" y1 |; C( qtestosterone gel and cream, we believe this is proba-
' w! S% v. j/ {& hbly more common than the rare case report in the
1 ?: Z, h% F+ Y( p4 r" Iliterature.4
7 z6 e0 o2 ?2 QPatient Report5 @; u" K4 X# [  b% f0 Q: R
A 16-month-old white child was referred to the
. g+ i" {3 d$ s( z( F. E+ vendocrine clinic by his pediatrician with the concern  x& Z+ W/ J/ E" ~
of early sexual development. His mother noticed
& ?2 C4 L+ @7 `8 l5 H! j$ llight colored pubic hair development when he was
' L/ \* Z( z. K, ~From the 1Division of Pediatric Endocrinology, 2University of
4 s! @5 ~- T- y/ sSouth Alabama Medical Center, Mobile, Alabama.; Y8 W- S+ e9 @' D  q5 ]$ B4 |; L
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 v( t4 I8 Y# R1 m9 l2 K6 S
Professor of Pediatrics, University of South Alabama, College of
5 ~  O' m7 `. I. [" m6 E1 wMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, M! V; r: M+ |$ o  Z
e-mail: [email protected].
# M+ Y' B/ D. l, F: mabout 6 to 7 months old, which progressively became
% Q+ S  n  v- }0 C3 I* Mdarker. She was also concerned about the enlarge-
$ P8 Y3 w0 Y7 m8 P0 Z  k7 D) q- T5 B; kment of his penis and frequent erections. The child: T# l& d3 ?, ~" N
was the product of a full-term normal delivery, with( R' `4 ^9 R2 F6 @9 `& t6 j. X
a birth weight of 7 lb 14 oz, and birth length of
; E7 x, {: V+ H% u1 O20 inches. He was breast-fed throughout the first year  k5 ]1 K$ S  p' Q# Z
of life and was still receiving breast milk along with
' Y5 w' \  D1 x" csolid food. He had no hospitalizations or surgery,- }5 M( T* d! F& Q! Z# U8 G, Z
and his psychosocial and psychomotor development4 k4 F# x1 _1 l3 s7 u% d1 n
was age appropriate.
) b/ q- k9 U7 k2 j+ b& n0 bThe family history was remarkable for the father,. v- o9 X  F) X: f) ~1 S- C/ x7 T0 ?
who was diagnosed with hypothyroidism at age 16,
* B' p+ @9 s& K& D4 z! v3 Qwhich was treated with thyroxine. The father’s
; Z+ _9 u# I2 j5 qheight was 6 feet, and he went through a somewhat
& ]3 @! S  j& P7 \$ @: |- rearly puberty and had stopped growing by age 14.( v/ P% {3 C! b
The father denied taking any other medication. The- d5 K% X) Y2 S- R
child’s mother was in good health. Her menarche
. Q% X. F1 s/ a( Lwas at 11 years of age, and her height was at 5 feet
- P( g2 S3 J7 c0 ]5 inches. There was no other family history of pre-# Q, o' O; T: j( V- }" l
cocious sexual development in the first-degree rela-
- @7 Z+ F! K, [" Z) mtives. There were no siblings.
' W% B: C- \% CPhysical Examination; R, w6 ~) M% T# L$ {
The physical examination revealed a very active,
& ]7 e) k# C2 _' s! M* D9 q# splayful, and healthy boy. The vital signs documented
. C' R/ ~! D" g& f* F8 |a blood pressure of 85/50 mm Hg, his length was
' M' F$ t+ s: M( z7 W- A- o90 cm (>97th percentile), and his weight was 14.4 kg
0 o1 A8 s5 A9 ^+ A; N: V; U: i8 b(also >97th percentile). The observed yearly growth
" O, L7 u4 v9 g; y; Ovelocity was 30 cm (12 inches). The examination of- r; }  @% ?3 d
the neck revealed no thyroid enlargement.8 f9 ]. a: a7 l& j6 z6 J  r" d& T
The genitourinary examination was remarkable for, L3 p+ @# p$ p% u: J
enlargement of the penis, with a stretched length of
0 a& Y9 b& ?$ v" W/ O  E2 [4 ?8 cm and a width of 2 cm. The glans penis was very well
( v$ t+ ^5 n. n* _( _  D( D* mdeveloped. The pubic hair was Tanner II, mostly around. {2 E3 ?, i. E8 X5 [+ U
5401 d/ ?" D: K; Y) ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 [' d, V% m, w7 K9 j
the base of the phallus and was dark and curled. The
" d3 |3 U8 T3 ?, Ytesticular volume was prepubertal at 2 mL each.
3 W7 Q7 ?. U. c: `! ?The skin was moist and smooth and somewhat" G2 }7 A1 B! F( @7 s! x/ s1 R7 E
oily. No axillary hair was noted. There were no, [/ [# k4 W& Y: j, w- v
abnormal skin pigmentations or café-au-lait spots.. X  g% ^8 O+ N
Neurologic evaluation showed deep tendon reflex 2+0 y2 q( q# K* Z' v) M! I8 A0 d
bilateral and symmetrical. There was no suggestion& o* p! l6 r& B) H: d2 K
of papilledema.6 Z  N& N$ T- B, @2 a7 r
Laboratory Evaluation
) [: i0 d1 |/ Z5 c( `0 oThe bone age was consistent with 28 months by
  O/ A* ]+ T' J2 }using the standard of Greulich and Pyle at a chrono-
$ T8 j! L+ P: ]logic age of 16 months (advanced).5 Chromosomal
. E# {! p! _( S! wkaryotype was 46XY. The thyroid function test
. S3 W( j$ Y4 t! ?# S1 t1 {showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 P( x' h* r1 X' @7 b) s  }7 d
lating hormone level was 1.3 µIU/mL (both normal).
, U$ h/ y( F& ~" a8 h7 D' ^' r9 b: f2 }The concentrations of serum electrolytes, blood
5 j3 x; A0 e* f8 P/ ourea nitrogen, creatinine, and calcium all were- V3 i# ]3 P& u" k! R" C% O
within normal range for his age. The concentration7 }( T* j+ m/ b
of serum 17-hydroxyprogesterone was 16 ng/dL
: A. i$ q8 m# D, }/ }) G& W1 m(normal, 3 to 90 ng/dL), androstenedione was 200 Z* ~$ @# g" G
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ ~+ }" E* }8 M  r* K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 h  ?/ i* s1 kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: w0 ~/ u, |8 M0 `, Y4 V, Q) b4 |; f49ng/dL), 11-desoxycortisol (specific compound S)
' R: S. q5 [" Y+ H2 g7 m; Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ z9 ^) g9 ]3 e9 Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 l& Q' Q) ]# V0 z4 Qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 f+ `0 b) S& }8 H
and β-human chorionic gonadotropin was less than
$ W  Y" q5 r7 S/ @/ M" X+ B5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 F' X$ P) x4 D' q6 u$ E7 ^& tstimulating hormone and leuteinizing hormone
( S8 P! M# m0 pconcentrations were less than 0.05 mIU/mL7 y, Y! A' u+ @+ E7 y# I: E
(prepubertal).
: s# b! \) j3 |The parents were notified about the laboratory
, A7 I' }% y, b( P% oresults and were informed that all of the tests were$ U; f) p. M% s- z! p; w
normal except the testosterone level was high. The
+ A/ s& [& f: Z  P" y# t" Ofollow-up visit was arranged within a few weeks to* L2 t% {- X# J, |: ^( C, A
obtain testicular and abdominal sonograms; how-
9 Q! L+ m$ Z( V# j$ Cever, the family did not return for 4 months.$ M5 Q3 D0 T9 V  [: o* @
Physical examination at this time revealed that the1 c( T) x6 l4 _, v
child had grown 2.5 cm in 4 months and had gained
* h1 a8 A$ O' T& S2 L2 kg of weight. Physical examination remained
: U; L* X8 Y% S$ s5 Cunchanged. Surprisingly, the pubic hair almost com-7 C- E5 O( Y  A
pletely disappeared except for a few vellous hairs at
7 P! w7 o* z, ^( P. p! y9 V' O* Wthe base of the phallus. Testicular volume was still 2
* y) ]' ]8 x3 x2 b# o+ ~mL, and the size of the penis remained unchanged.
, {8 U& }% N5 U( M6 N" j- TThe mother also said that the boy was no longer hav-/ |  _# w* l- U0 _1 a; e0 ]* @& I
ing frequent erections.9 f" Y- }, B( a3 a3 @
Both parents were again questioned about use of
/ |4 U- f7 S( l# Tany ointment/creams that they may have applied to: s" M0 I. G5 T
the child’s skin. This time the father admitted the
: D8 {$ Q7 a' p- C+ yTopical Testosterone Exposure / Bhowmick et al 541
% U! R# ?2 b) X3 H3 w5 O3 [9 }- kuse of testosterone gel twice daily that he was apply-
6 w; d5 w3 ]6 \) Ying over his own shoulders, chest, and back area for
' N  y: D( M0 P6 f# Y. Y1 ~7 |a year. The father also revealed he was embarrassed3 M; e) B$ r0 p; P: I, u% E+ ?
to disclose that he was using a testosterone gel pre-2 z3 l9 X' U; e
scribed by his family physician for decreased libido  v4 A/ k7 P% H9 g
secondary to depression.
9 Q! M' t! g4 B: IThe child slept in the same bed with parents.& [; O9 {* Q3 V2 S2 @& ~/ Z
The father would hug the baby and hold him on his! ]2 A3 h0 E9 x
chest for a considerable period of time, causing sig-3 f4 o/ ?/ N5 ~
nificant bare skin contact between baby and father.. C0 F3 U! u. E& w  _7 A8 g
The father also admitted that after the phone call,
6 J" T, c7 W0 R: S; Pwhen he learned the testosterone level in the baby# E8 [/ O6 T5 r* g5 }0 K
was high, he then read the product information1 Y7 n! W8 M. U; `" @+ g
packet and concluded that it was most likely the rea-  ^) v4 j- |. m
son for the child’s virilization. At that time, they* _0 s- m6 J! H+ }8 F3 {
decided to put the baby in a separate bed, and the
% ?5 P; P/ T, v4 I( Qfather was not hugging him with bare skin and had
9 u0 G% p: Y+ {' M3 T* q- Ubeen using protective clothing. A repeat testosterone6 H' J( F+ ~6 Z. @6 K+ N3 x
test was ordered, but the family did not go to the
+ w3 F( m, f3 d1 y  Jlaboratory to obtain the test./ _* P: ?7 c5 P5 D7 {! u7 A2 n
Discussion
  s* W2 L$ v* [- m: }Precocious puberty in boys is defined as secondary: S$ }% o$ Y# s0 ^3 x! v0 m0 [) u
sexual development before 9 years of age.1,4
& ^! s3 j# J( {2 t7 ePrecocious puberty is termed as central (true) when
% k( ?, S' t. ^9 W/ R# m1 @it is caused by the premature activation of hypo-
5 v0 S# N0 b: l) b. ~thalamic pituitary gonadal axis. CPP is more com-
8 Z* R' H5 m: f& S) Rmon in girls than in boys.1,3 Most boys with CPP/ m+ u/ e# Q9 f8 z; O0 f4 [
may have a central nervous system lesion that is' R% h7 D$ G( h7 @* p% N
responsible for the early activation of the hypothal-+ _$ W' Q$ }& n) ~: x8 O4 D2 q
amic pituitary gonadal axis.1-3 Thus, greater empha-
# K$ t+ H; i8 w% O: Nsis has been given to neuroradiologic imaging in
$ u) S& f* _9 ~boys with precocious puberty. In addition to viril-
7 @/ r( ]7 r- b1 L9 P. s/ D+ T$ {ization, the clinical hallmark of CPP is the symmet-" A* ?" }; N2 a% b! L! Z% q
rical testicular growth secondary to stimulation by# w0 M* u3 m2 W# Q1 M3 i  r7 f
gonadotropins.1,3
9 @- R. L  S, i" eGonadotropin-independent peripheral preco-
* B7 l, x6 B0 {9 {& V% Q/ g2 zcious puberty in boys also results from inappropriate9 u0 A! O2 Z+ w" `# h. u0 R
androgenic stimulation from either endogenous or, e) d2 D( @' ^: }* t, y
exogenous sources, nonpituitary gonadotropin stim-  o2 x+ y) E8 K/ t9 I1 \
ulation, and rare activating mutations.3 Virilizing* z& n4 v) U3 Y1 V/ ?
congenital adrenal hyperplasia producing excessive
( t3 j9 o/ }$ P" l1 J! Ladrenal androgens is a common cause of precocious
6 s! H' y4 {: s# h: B: W* Upuberty in boys.3,41 i$ O& [) }, e# @! c/ E
The most common form of congenital adrenal
: Z& u8 j4 n0 Ohyperplasia is the 21-hydroxylase enzyme deficiency.! ^9 `$ Y  S3 u; N* b) a
The 11-β hydroxylase deficiency may also result in9 ]1 ?$ D% d! ]6 l; Y+ ]1 Z
excessive adrenal androgen production, and rarely,
6 b0 k3 k$ n5 ?6 q( C9 fan adrenal tumor may also cause adrenal androgen
7 e/ [; Z7 w& n6 t% Hexcess.1,3' e( j' u: Q% c+ U9 u) _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* a+ c7 Y1 M7 n. |" ~
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' C+ Z7 j- ]$ r1 P9 y+ S/ V
A unique entity of male-limited gonadotropin-) y- H% [! t" Y9 `) h1 C$ I; t( y
independent precocious puberty, which is also known
2 c: }9 x/ M( `7 F8 J3 U# Nas testotoxicosis, may cause precocious puberty at a( r% J8 b' A- L! }
very young age. The physical findings in these boys3 z2 k: u: }" i3 k7 i( j
with this disorder are full pubertal development,
5 a, o/ G5 o. P- V* [* |: |( ]including bilateral testicular growth, similar to boys3 M% A! P  z* x
with CPP. The gonadotropin levels in this disorder7 h# M- u- D* M6 ?) T2 e) p; N* Z
are suppressed to prepubertal levels and do not show
- z$ _* T  l; ]3 |$ ~  Q% G' W' Hpubertal response of gonadotropin after gonadotropin-
/ D. G( g5 |6 g7 Y3 Rreleasing hormone stimulation. This is a sex-linked5 r" Q7 x3 O! x8 K
autosomal dominant disorder that affects only2 l0 q# |! ^3 i- ?
males; therefore, other male members of the family
! i  |. Z6 e7 t1 x9 Dmay have similar precocious puberty.3
( W8 |7 [6 q9 Q& WIn our patient, physical examination was incon-
( c  E6 U  b- D* Qsistent with true precocious puberty since his testi-
+ B/ Z' s7 z$ ?, C  pcles were prepubertal in size. However, testotoxicosis5 g% J5 x6 p/ L8 U
was in the differential diagnosis because his father
* E) q2 ~7 k1 Z3 E! b6 Qstarted puberty somewhat early, and occasionally,
( w! q7 e8 V7 ]7 K5 B( Xtesticular enlargement is not that evident in the- U$ b* s" G- m! j
beginning of this process.1 In the absence of a neg-
7 }  R5 f* i! @0 O4 u& C* B, Gative initial history of androgen exposure, our9 M* G8 R: C9 I5 I+ O3 U: `
biggest concern was virilizing adrenal hyperplasia,
' ]/ f+ r; E( T) O4 t; \! Q8 |either 21-hydroxylase deficiency or 11-β hydroxylase
; K# T' x" e; t# `, ldeficiency. Those diagnoses were excluded by find-
7 q, u2 |3 a" Y5 ]1 n, ning the normal level of adrenal steroids.
/ n. Q3 @( d  WThe diagnosis of exogenous androgens was strongly* [$ M: a8 f' v/ ^
suspected in a follow-up visit after 4 months because7 r- r& A1 y/ J" @0 H9 X7 R+ b
the physical examination revealed the complete disap-
$ [2 R5 V1 C, p. ~pearance of pubic hair, normal growth velocity, and
$ P7 d$ T8 Z. u4 C) c# U- Hdecreased erections. The father admitted using a testos-/ M" }( y; Z5 Y0 }' E5 _) i
terone gel, which he concealed at first visit. He was
5 n& H' `+ |6 Z. T  Husing it rather frequently, twice a day. The Physicians’
8 ~5 Z8 D( Z3 D5 A! n  K- pDesk Reference, or package insert of this product, gel or
3 S: ^) H4 g" J# c6 l6 ucream, cautions about dermal testosterone transfer to7 c" l& m1 a9 w* m5 l
unprotected females through direct skin exposure.
# f9 u  u( y. d& |Serum testosterone level was found to be 2 times the
- @# i2 ^9 E) _/ tbaseline value in those females who were exposed to( v3 E4 p9 B: n! }* i: s( O: K2 a
even 15 minutes of direct skin contact with their male
7 \: M- J% h: ]% w# t8 `3 T$ Apartners.6 However, when a shirt covered the applica-
! j+ t$ |* H" Q) `5 Ition site, this testosterone transfer was prevented.
; R# C( `  s, M. s+ JOur patient’s testosterone level was 60 ng/mL,, Y9 y9 g, v. C' {8 L: a
which was clearly high. Some studies suggest that: j) {7 {: |- [$ e! O
dermal conversion of testosterone to dihydrotestos-; z) G  w5 G- D& P# h+ X& P
terone, which is a more potent metabolite, is more! T( K! f2 x2 j) y& @+ {/ f
active in young children exposed to testosterone5 i1 y) A& `0 d$ ^8 Z8 a# U( s7 H
exogenously7; however, we did not measure a dihy-0 y7 J2 Q  b$ Q4 i& q/ X0 A
drotestosterone level in our patient. In addition to* A0 V3 R$ x2 g# f; T! k
virilization, exposure to exogenous testosterone in( Q7 z$ A6 e7 j
children results in an increase in growth velocity and
# p; R0 z" t# dadvanced bone age, as seen in our patient.
9 A5 `2 L/ ^3 pThe long-term effect of androgen exposure during; u  n# R8 u# r$ H5 E
early childhood on pubertal development and final' |' T/ r! F0 x4 P
adult height are not fully known and always remain
) j2 }& @# V" ^2 y( H& G1 b' ya concern. Children treated with short-term testos-
6 q7 T" ^* }) |terone injection or topical androgen may exhibit some; h$ a. Y& ]1 S2 C0 ]
acceleration of the skeletal maturation; however, after: M) e# d% S9 U/ A
cessation of treatment, the rate of bone maturation
9 @& k9 {) W+ @6 }7 r; pdecelerates and gradually returns to normal.8,9; B/ @+ M0 y* H1 U* w( A1 o
There are conflicting reports and controversy/ o. ]6 _2 q) o2 O
over the effect of early androgen exposure on adult% K2 z" L; d9 k1 ]
penile length.10,11 Some reports suggest subnormal9 }! c( c$ [; ~* M, n
adult penile length, apparently because of downreg-
: N% z7 Q1 V7 |# K  Gulation of androgen receptor number.10,12 However,9 o& ]  z- U1 l3 S/ D
Sutherland et al13 did not find a correlation between- W: p- T: ^- j( o
childhood testosterone exposure and reduced adult! Q3 h, \1 F$ t% V0 Y" @4 v
penile length in clinical studies.7 m8 I+ q+ v' ^! Z
Nonetheless, we do not believe our patient is0 k3 |- x0 m) ]) w, o
going to experience any of the untoward effects from3 r" k1 t% F) m
testosterone exposure as mentioned earlier because
8 A# u1 @  P. h- m2 J% Ethe exposure was not for a prolonged period of time.
% P& C0 y; W* t; u! m+ mAlthough the bone age was advanced at the time of4 N! X+ f5 [$ T- G- Q. h! Z
diagnosis, the child had a normal growth velocity at: d0 a2 S3 c7 d! Y
the follow-up visit. It is hoped that his final adult
' m2 t. c' n+ I, F8 I, U( Aheight will not be affected.$ M( ~) p& I3 ?$ A7 A8 I
Although rarely reported, the widespread avail-
& g* b& `4 T$ y& `; zability of androgen products in our society may
0 G5 Y5 B5 u0 ]2 Tindeed cause more virilization in male or female
1 Z3 \. z9 ]5 n5 m+ Hchildren than one would realize. Exposure to andro-
3 w2 _2 E* b4 ^7 agen products must be considered and specific ques-) s% l& w3 X; z! l& J
tioning about the use of a testosterone product or
- \0 F' V8 O" [- w. Rgel should be asked of the family members during
( |8 W( A$ n. g: F# bthe evaluation of any children who present with vir-
' U* ?: d# t  I2 Filization or peripheral precocious puberty. The diag-; C+ G' Z" c6 Y4 x* b
nosis can be established by just a few tests and by
2 N7 F$ b3 K4 Zappropriate history. The inability to obtain such a4 v' ?/ f% c/ ?, o
history, or failure to ask the specific questions, may
2 r. x9 _3 s) ^" M5 y: I! gresult in extensive, unnecessary, and expensive, _) F- J  v% ]: f
investigation. The primary care physician should be
5 q7 I. C8 z# y5 s) J5 {7 Laware of this fact, because most of these children% f; o: L& D2 K7 P
may initially present in their practice. The Physicians’% y2 E5 z. {2 ~1 i, `7 N
Desk Reference and package insert should also put a
; X0 ]1 q; Z: a9 a9 Z+ `. s) Bwarning about the virilizing effect on a male or
8 o7 W: K( s) qfemale child who might come in contact with some-' K. H# V; x( H  s
one using any of these products.. K' Q6 u5 U  {  f/ ]
References" Z( k( [( i6 h) L
1. Styne DM. The testes: disorder of sexual differentiation
6 O- q* n! u* [+ C+ t" l) Nand puberty in the male. In: Sperling MA, ed. Pediatric
3 s) w. Q3 \3 {' A3 K+ k7 V, XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! h/ t+ {6 r9 n, c2002: 565-628.
, x- |3 E$ U- e: u) \9 Y" K! z3 V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- b/ ?1 v- D7 f+ m) @
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old! A3 T0 X6 J. K, u# f
Boy Induced by Indirect Topical9 x& S8 j$ u  O0 Q
Exposure to Testosterone& h( J% K- {/ w* D6 U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. s1 G. h3 w% f& L5 S  Aand Kenneth R. Rettig, MD1
6 q+ N1 [! }  ]7 ~Clinical Pediatrics, ^' L% d2 h2 y! |3 ]
Volume 46 Number 6. S) {" f6 ?; X' N! F. }; j& X/ ]
July 2007 540-5433 s; o9 c+ L  F6 }, [- N. }+ L3 ]
© 2007 Sage Publications7 V! B3 ]* Q, D: p" D9 c1 v* E: Q
10.1177/0009922806296651' ?1 e) v' p) m
http://clp.sagepub.com$ V% u1 g4 g! Y9 V3 N( Z% k  h! m
hosted at
6 @+ d2 K) [* khttp://online.sagepub.com
( r/ F( K9 g# e9 T5 `9 [/ N  hPrecocious puberty in boys, central or peripheral,2 q( x6 H' Q% E
is a significant concern for physicians. Central4 ]  ]: K# ?9 z& F
precocious puberty (CPP), which is mediated9 L" R# |( A' d
through the hypothalamic pituitary gonadal axis, has6 a7 o0 d; ^1 }' ^; `3 I
a higher incidence of organic central nervous system
3 h" W3 l+ f+ Y3 X8 B3 F9 mlesions in boys.1,2 Virilization in boys, as manifested4 q/ ^& K6 _$ T5 A
by enlargement of the penis, development of pubic# M; y" z/ M$ f9 K: u  v( U7 u3 J, @
hair, and facial acne without enlargement of testi-) \0 J& q  E0 }# l6 ~% ?
cles, suggests peripheral or pseudopuberty.1-3 We
+ u, \; Q# g8 X& R0 v4 N# {, J, ^report a 16-month-old boy who presented with the6 b- Y4 d! b  _9 v# R3 u
enlargement of the phallus and pubic hair develop-2 Q3 p* y( Q$ C5 T- f
ment without testicular enlargement, which was due3 ?" e% P  n" e; ]5 ~
to the unintentional exposure to androgen gel used by2 ~  f3 I/ o: `- S7 y
the father. The family initially concealed this infor-
/ n8 [+ g* \. U# q- }mation, resulting in an extensive work-up for this
! N/ y: W  R9 T% c9 echild. Given the widespread and easy availability of' I8 m0 A! }2 t  h9 T
testosterone gel and cream, we believe this is proba-
- ~) t0 _* X+ h5 f, u5 f! }; n/ Pbly more common than the rare case report in the
# x- R- w" T' ]( m$ f" E1 }. `literature.4
" _" _# u! K1 C! ]+ dPatient Report
# t' b2 O! E) tA 16-month-old white child was referred to the, |  X$ ?# s" W8 i6 Y
endocrine clinic by his pediatrician with the concern/ w7 N# V2 L' v0 F; ~
of early sexual development. His mother noticed: v. w1 ]* S6 D: A/ X9 T
light colored pubic hair development when he was
" m" x, O. t+ L% F; K/ e, K. b: xFrom the 1Division of Pediatric Endocrinology, 2University of
( k7 u# _$ H& l/ Q" }! u6 ?South Alabama Medical Center, Mobile, Alabama.1 n4 r8 y8 N9 f. a, O8 G
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; b/ V0 e% g% ZProfessor of Pediatrics, University of South Alabama, College of% U3 j0 L7 q3 l  B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 ?8 O# ]5 V% t5 h$ f' {2 \3 l8 C
e-mail: [email protected].4 N. ^; ~. l3 D# @; z
about 6 to 7 months old, which progressively became0 Z9 }! e3 q' G3 a1 }% w9 r
darker. She was also concerned about the enlarge-
1 L9 i0 A) G; ]ment of his penis and frequent erections. The child
, F- e6 @/ R! d. Qwas the product of a full-term normal delivery, with/ R, W3 K: m( S& K
a birth weight of 7 lb 14 oz, and birth length of- K$ O- F+ F/ ?( @) \) Y2 Y" l' P
20 inches. He was breast-fed throughout the first year7 }/ x* V+ p; d1 a- B: k$ T. F4 q5 i
of life and was still receiving breast milk along with
5 t. m' \2 P/ usolid food. He had no hospitalizations or surgery,7 g7 O* A- {$ _2 X& m3 C
and his psychosocial and psychomotor development$ j; J/ B/ ?$ a3 A$ Y' Z8 D8 {
was age appropriate.
! |  u6 G6 @  SThe family history was remarkable for the father,
8 S- U) Z1 i1 _: y7 Fwho was diagnosed with hypothyroidism at age 16,& u+ N' j. o" `
which was treated with thyroxine. The father’s
  R7 `( L5 x: |height was 6 feet, and he went through a somewhat
! b9 x8 @3 K2 _5 K+ i' Qearly puberty and had stopped growing by age 14.+ }2 u. m# \! c) Q
The father denied taking any other medication. The) B: ~+ p' Y  ^' A# C  Z6 V
child’s mother was in good health. Her menarche8 `7 ~2 G* f7 q9 u# D
was at 11 years of age, and her height was at 5 feet2 j) m7 i( h5 ]6 g. e. x- V
5 inches. There was no other family history of pre-
( a: R3 y5 q2 A% icocious sexual development in the first-degree rela-. G1 H5 H/ L5 N
tives. There were no siblings.9 r& }7 T! A: Q% }2 `+ `6 l
Physical Examination
5 W" U! x5 z* `- f) J4 ^The physical examination revealed a very active,! p! [& P; s. h3 G" E$ p
playful, and healthy boy. The vital signs documented
. R' }3 Q8 `( ?8 P1 R2 Q* D9 i% m( m& Oa blood pressure of 85/50 mm Hg, his length was9 `8 x( e+ O! `: P; |6 D9 y
90 cm (>97th percentile), and his weight was 14.4 kg  N+ m0 k8 J3 p4 z' G1 `5 v; p
(also >97th percentile). The observed yearly growth! S/ h% E/ |0 T% N
velocity was 30 cm (12 inches). The examination of7 p/ p) ~. X2 n# Q' O7 Y% g
the neck revealed no thyroid enlargement.
  m! x7 v3 m' K. b9 k- sThe genitourinary examination was remarkable for
/ K. s5 A: f) J$ I5 e7 Z" y! venlargement of the penis, with a stretched length of% r8 k" V8 P: G9 v
8 cm and a width of 2 cm. The glans penis was very well1 [. d1 V2 `6 i
developed. The pubic hair was Tanner II, mostly around
' Q1 D5 ]  E0 R+ q: m! x" I540  w& e2 k) T% x5 F1 I4 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! ^% y& [: D, M" dthe base of the phallus and was dark and curled. The
! ^7 q& r  B, vtesticular volume was prepubertal at 2 mL each.5 O7 S/ Z! r# K1 D
The skin was moist and smooth and somewhat' n: L: s- q. E2 g6 y$ k
oily. No axillary hair was noted. There were no% N* h, @1 _9 D- N1 G
abnormal skin pigmentations or café-au-lait spots.
" Z6 p2 g: |# y. Y; VNeurologic evaluation showed deep tendon reflex 2+6 y7 [0 d1 ]/ g& ^
bilateral and symmetrical. There was no suggestion; T* M2 n: U; w: D% M) a3 h: ^
of papilledema.( G9 g5 e- Y: b) N( G
Laboratory Evaluation
7 {: c8 K& G' q9 V' x/ ]5 |4 y8 W8 YThe bone age was consistent with 28 months by
  ]4 g9 t7 C- M. X: L. pusing the standard of Greulich and Pyle at a chrono-  {: b- L( t2 e5 a! g. R" [
logic age of 16 months (advanced).5 Chromosomal3 U  u3 y2 N5 [; J( u7 J+ |
karyotype was 46XY. The thyroid function test* l" W: u8 k- G% ]- r7 W9 i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! p! c. H( @6 l  x) h) j% m( Q
lating hormone level was 1.3 µIU/mL (both normal).3 G$ V; L5 \& h/ [
The concentrations of serum electrolytes, blood
, i, f6 ^; q3 L7 D( Jurea nitrogen, creatinine, and calcium all were
6 Y3 z/ v. e8 G& }within normal range for his age. The concentration0 _# ^, M) a! Y2 j% {! S: Y0 v
of serum 17-hydroxyprogesterone was 16 ng/dL2 ~5 E6 j6 C" c9 q; ~
(normal, 3 to 90 ng/dL), androstenedione was 20( ~3 J. @- f' G2 }" V+ u) f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- A/ |7 {* S" }- {- Q' E) {8 J
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" S7 h% ]% l, S, g' O8 `% a3 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 n$ Z" n( o% j+ C49ng/dL), 11-desoxycortisol (specific compound S)1 D& J" ?6 s* e+ P% g0 U5 L+ ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# Y0 |" }$ `8 \1 N* n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% g8 z, T( |. d4 s, q/ L; k6 c' wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 H8 d( A* x4 j2 G
and β-human chorionic gonadotropin was less than3 F9 L& T$ W* c5 @9 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% L6 J8 Y, D1 Z; G- Lstimulating hormone and leuteinizing hormone
+ b$ f) N2 |! r+ f) Yconcentrations were less than 0.05 mIU/mL0 ^% F- F. y* W
(prepubertal).2 T) H5 X  H: f% g
The parents were notified about the laboratory
: \" g" u% R9 R" a% n# `results and were informed that all of the tests were% j" a  [6 N* _
normal except the testosterone level was high. The
+ v. w8 C! I. }: t, ~' F$ K( qfollow-up visit was arranged within a few weeks to; n9 [5 |# k% A- D! Y0 ?& W
obtain testicular and abdominal sonograms; how-0 q  w1 y, z5 S( r$ ]
ever, the family did not return for 4 months.
; e6 H+ ^! ^' y0 NPhysical examination at this time revealed that the
+ H0 |6 `; F" D& p! }child had grown 2.5 cm in 4 months and had gained
  G/ |/ P% S8 O: o5 j4 U+ ^5 [. K+ G2 kg of weight. Physical examination remained
+ C# ~* T5 J9 B( ?- o1 j8 t$ eunchanged. Surprisingly, the pubic hair almost com-- ]  e  Y/ J, @
pletely disappeared except for a few vellous hairs at
  o! \/ \- J6 ]) r/ u) U' lthe base of the phallus. Testicular volume was still 2" h, V% ]  R" Y. m+ q4 V
mL, and the size of the penis remained unchanged.
0 M/ V9 a0 v7 fThe mother also said that the boy was no longer hav-
" r& u; x( t) B; Ping frequent erections.
& Q( J. q" |3 D3 f6 A1 A* `/ DBoth parents were again questioned about use of
& A% Y; ]8 |' i2 Many ointment/creams that they may have applied to$ m: [$ W# f" p* W; U8 U9 A
the child’s skin. This time the father admitted the
; W( m" N# s$ Q) _: XTopical Testosterone Exposure / Bhowmick et al 541
& n  I6 q  I  j) r; O0 Suse of testosterone gel twice daily that he was apply-4 c7 Z. P+ J" Q8 _/ O: M$ `
ing over his own shoulders, chest, and back area for; Y* U& N8 P5 ~  l% |
a year. The father also revealed he was embarrassed. G7 u8 F0 g+ X% Z) n1 V
to disclose that he was using a testosterone gel pre-
  A+ b1 S0 |( @, xscribed by his family physician for decreased libido" r% A/ ^& V7 W, M& q
secondary to depression./ g, G) H7 d8 @# W7 o+ c
The child slept in the same bed with parents.7 A0 ]4 `0 X  v1 Z" x6 ^7 S* }& S
The father would hug the baby and hold him on his
+ g; H/ @9 \1 i( k1 ychest for a considerable period of time, causing sig-, ?2 y% X. A8 l+ ~4 C3 d# t
nificant bare skin contact between baby and father.1 s; n# f; X% k, h' H2 B
The father also admitted that after the phone call,
  H3 J- _8 `; W8 \- twhen he learned the testosterone level in the baby
0 B) Z& v% s! x. n& B8 N& j2 L# _was high, he then read the product information: ?  O5 @( b8 K! P' {1 X# l
packet and concluded that it was most likely the rea-) b7 u  @/ |8 p% \6 X+ J& F
son for the child’s virilization. At that time, they
' x$ j" F; y7 P; B2 j9 K# V* Mdecided to put the baby in a separate bed, and the3 ?% P$ `; N& s1 Z) u
father was not hugging him with bare skin and had
1 B5 r' N) Z$ ?( t5 N1 dbeen using protective clothing. A repeat testosterone0 h: L$ I' G- W' j7 |4 ]/ m, D2 I/ w
test was ordered, but the family did not go to the
% K0 J1 _- t+ i  y0 n3 Wlaboratory to obtain the test.# \% \7 J( i) E- _
Discussion" S% W1 U/ i% n2 J! k4 q
Precocious puberty in boys is defined as secondary: q: j3 L! u0 `- X1 o: L1 E
sexual development before 9 years of age.1,4$ h% E* m& J1 m4 {8 y( `( ]' _! c
Precocious puberty is termed as central (true) when
7 o7 B" Z4 c3 Z/ w+ G5 }8 Tit is caused by the premature activation of hypo-
1 \7 d+ ~. T* X# Qthalamic pituitary gonadal axis. CPP is more com-. r% s0 `) E2 O* A  D
mon in girls than in boys.1,3 Most boys with CPP
/ @2 _/ G4 Q: s4 s& {4 gmay have a central nervous system lesion that is7 \" c- e+ p5 W1 q7 C0 C
responsible for the early activation of the hypothal-
6 a9 q- F/ z# @, Z8 I, u: W3 `amic pituitary gonadal axis.1-3 Thus, greater empha-' K. ]3 G0 }7 g5 |( l
sis has been given to neuroradiologic imaging in! {1 v0 b3 O- w
boys with precocious puberty. In addition to viril-: k/ V0 J8 k# I8 f( J
ization, the clinical hallmark of CPP is the symmet-
( m5 t' Z/ V- F7 z3 x' S- arical testicular growth secondary to stimulation by
* W# {: I- g2 x% U# \gonadotropins.1,3* K1 O( T9 O% H& s9 [& I& _( b
Gonadotropin-independent peripheral preco-
7 {- Z1 {3 `% q0 Bcious puberty in boys also results from inappropriate
1 s# t( s; Q* V8 Y: w; J2 I" Q0 @androgenic stimulation from either endogenous or0 e! h$ A4 M# ^& z1 U; r2 f
exogenous sources, nonpituitary gonadotropin stim-
" M8 t0 v4 k8 o/ r9 ~ulation, and rare activating mutations.3 Virilizing
" v  m+ x) E# S) S2 ]( D0 {% Bcongenital adrenal hyperplasia producing excessive9 B1 I. X; R. K/ c3 j3 d+ F% I9 K
adrenal androgens is a common cause of precocious
; d( G- L5 F* Z9 F; Bpuberty in boys.3,4& \& c7 b: r! q" }/ j( G" o2 Z! G
The most common form of congenital adrenal% ?! r4 S" I) N  U) {
hyperplasia is the 21-hydroxylase enzyme deficiency.+ g3 ^% k. g) a1 M8 g, g/ u
The 11-β hydroxylase deficiency may also result in0 l* E7 z- w! S6 B: W% x
excessive adrenal androgen production, and rarely,/ ?& t$ s* D) s% Q6 ~
an adrenal tumor may also cause adrenal androgen
0 G& d4 {5 P9 z8 i# x. ]" Jexcess.1,33 `2 o) ~( K. C3 x' c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, ]3 l1 x4 A* y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ [2 u: `- X1 k+ T2 Q- O6 x3 RA unique entity of male-limited gonadotropin-
$ X! c/ j" _* r) ~independent precocious puberty, which is also known* N- |3 t9 G& [; j1 H4 [0 u
as testotoxicosis, may cause precocious puberty at a
3 }- O6 P! C+ G7 kvery young age. The physical findings in these boys
) V# T" r2 y2 O* Jwith this disorder are full pubertal development,6 a9 N" }& }4 W2 x2 C0 N
including bilateral testicular growth, similar to boys: N; X1 T) Q' m# ~
with CPP. The gonadotropin levels in this disorder
; L8 i! Y$ B% v& N& Z- ^0 [; C- care suppressed to prepubertal levels and do not show
, G& r" Y! }/ d: Cpubertal response of gonadotropin after gonadotropin-5 n8 X2 p8 F1 G; L6 j
releasing hormone stimulation. This is a sex-linked
! k7 P+ C: g; T& y4 e) q9 B, `6 b% X7 Rautosomal dominant disorder that affects only
) q+ v; |  Z+ }. T" |males; therefore, other male members of the family0 K* A3 v* `' F1 l: A9 J* P" v
may have similar precocious puberty.3! B% K2 J2 x7 F
In our patient, physical examination was incon-
, K" n5 u" V2 U, V0 X9 Dsistent with true precocious puberty since his testi-1 v0 E/ t5 _/ o$ T4 X
cles were prepubertal in size. However, testotoxicosis: m. S+ m( V7 U5 A. I- r6 e" }* {7 r
was in the differential diagnosis because his father: p0 V! n7 U6 q+ D
started puberty somewhat early, and occasionally,5 Z, C  s  y0 t. F
testicular enlargement is not that evident in the
; B9 _/ Z/ ]0 K7 T7 r. Fbeginning of this process.1 In the absence of a neg-. E; I: S; h6 H/ U, m% v$ e
ative initial history of androgen exposure, our1 U: P6 @; F' i. G$ B7 W
biggest concern was virilizing adrenal hyperplasia,- n' v; n& ]/ c
either 21-hydroxylase deficiency or 11-β hydroxylase
4 E+ r- V( w+ h4 J3 t& Gdeficiency. Those diagnoses were excluded by find-4 z6 k2 d: X$ t, @+ z$ w4 i
ing the normal level of adrenal steroids.
9 G' |/ d0 Q/ z7 u7 K- [4 m1 }, Z; ?The diagnosis of exogenous androgens was strongly
1 K8 u* V6 ?# Q- U( Z$ x- wsuspected in a follow-up visit after 4 months because4 A! k9 ^/ U- }
the physical examination revealed the complete disap-
1 F9 E, J! n! \5 {6 Rpearance of pubic hair, normal growth velocity, and. f" y. u  P' g* ^, B0 D
decreased erections. The father admitted using a testos-
# ~" B0 H) |# w* T& o  hterone gel, which he concealed at first visit. He was
6 X7 E+ S4 k& kusing it rather frequently, twice a day. The Physicians’
4 [! T/ t2 e" Q- U# i' ^0 o) s5 N5 f# ^Desk Reference, or package insert of this product, gel or" h( a/ [1 j7 v2 w
cream, cautions about dermal testosterone transfer to$ }' o  I1 g6 B% H; I
unprotected females through direct skin exposure.
- L6 f* w* s, N# ^Serum testosterone level was found to be 2 times the, U! Y" ^. c0 D( |+ \! S. Z
baseline value in those females who were exposed to
1 ~( X' T# G1 L& Leven 15 minutes of direct skin contact with their male8 e& R2 Q0 Q/ I$ T
partners.6 However, when a shirt covered the applica-
2 ?4 Q$ m" j0 M/ b" u7 ztion site, this testosterone transfer was prevented.$ [" Z* D: W: @4 L" I/ I, L. [
Our patient’s testosterone level was 60 ng/mL,$ W! T" f; \/ s# t( K/ E( d8 I  S, i
which was clearly high. Some studies suggest that
0 J5 b3 V6 z1 S" p; Fdermal conversion of testosterone to dihydrotestos-4 d9 g8 s+ S( L9 z0 m
terone, which is a more potent metabolite, is more3 ^7 d; B1 D" `
active in young children exposed to testosterone
& O" w: a% H/ A3 B; d! [) Pexogenously7; however, we did not measure a dihy-
4 T- y1 {% ~0 s0 z8 z2 S' b) Ldrotestosterone level in our patient. In addition to
9 o+ i+ O! b0 G! d. V8 Z9 z5 ?virilization, exposure to exogenous testosterone in& o9 r6 m$ n$ `
children results in an increase in growth velocity and
1 E. a2 Y$ ]( x! Z7 D) [3 W! Wadvanced bone age, as seen in our patient.$ H$ J/ S2 E6 _1 n/ P3 [$ t
The long-term effect of androgen exposure during
' N  d, b! d' t, U/ oearly childhood on pubertal development and final- |9 K  x* O% M% S
adult height are not fully known and always remain3 G; b$ k4 j" E; S4 o
a concern. Children treated with short-term testos-) G  \& F% b# p- |
terone injection or topical androgen may exhibit some0 _! p0 G1 s$ }, @/ _. ^4 o, H  D' v+ o
acceleration of the skeletal maturation; however, after
  i* C6 Z4 T1 T0 N% N8 Gcessation of treatment, the rate of bone maturation4 z7 R9 s! G* O- z/ p
decelerates and gradually returns to normal.8,9" s6 `; d  O" N4 P& E, U
There are conflicting reports and controversy
6 |; u( }$ f' `4 ]1 x( g3 D% vover the effect of early androgen exposure on adult( X& O; w, M$ e
penile length.10,11 Some reports suggest subnormal
3 v+ D* Y# V+ y$ }; ?; Radult penile length, apparently because of downreg-  o2 \' B" h- ?+ F2 X6 H0 Z3 G9 {
ulation of androgen receptor number.10,12 However,, f% h6 p* A# f0 H, k
Sutherland et al13 did not find a correlation between
& f' l4 I$ b, r9 Z6 X; X3 V0 fchildhood testosterone exposure and reduced adult
. P. O3 H& K/ T1 \7 B% k* m8 Apenile length in clinical studies.# p) G' j7 k! C0 w4 ]
Nonetheless, we do not believe our patient is
5 H6 c4 a0 A: |, x, F( @: X( P4 ]going to experience any of the untoward effects from" L8 N# r! s3 }4 U
testosterone exposure as mentioned earlier because; }: W: ]. v! [7 H! B8 K
the exposure was not for a prolonged period of time.2 \  y: g" O* @1 V) @' P( B9 T
Although the bone age was advanced at the time of. s. D7 {6 X; K& `
diagnosis, the child had a normal growth velocity at: i7 \- {7 w( m' x; m* u
the follow-up visit. It is hoped that his final adult
/ I# u0 R2 J2 [1 cheight will not be affected.
% K4 \; F) Z  ^4 P, pAlthough rarely reported, the widespread avail-
" T) o5 v( N. N7 U& fability of androgen products in our society may
; ?3 q, r8 T3 J4 V4 e8 cindeed cause more virilization in male or female& K2 A/ K& t- V( y  G0 ~( ^$ t
children than one would realize. Exposure to andro-0 K, k  L+ A; j) q% i: N9 @
gen products must be considered and specific ques-
$ M7 L2 O; W- A: ltioning about the use of a testosterone product or2 D% H/ J9 y, T3 l, n& U- k
gel should be asked of the family members during$ X5 d- u- n( L4 }# q/ b8 W4 m
the evaluation of any children who present with vir-5 h$ y9 z- e5 B$ {( f8 Z& o4 A8 ]& |, B
ilization or peripheral precocious puberty. The diag-
: k3 _; E5 U- M) H9 znosis can be established by just a few tests and by
% g3 G4 C. Y- R  |  R1 Pappropriate history. The inability to obtain such a
" m( }! o, L0 @$ ]history, or failure to ask the specific questions, may
1 @8 w' \  Y; {, s6 x6 B4 Mresult in extensive, unnecessary, and expensive0 N& B( I, |; M6 [1 N7 s
investigation. The primary care physician should be
" f7 g( w8 a% F) t1 yaware of this fact, because most of these children
/ a/ _( [3 J7 @, a- C- mmay initially present in their practice. The Physicians’. b) |' r, O( }* x( h5 B. P: i0 U
Desk Reference and package insert should also put a' p& K, b' g+ b, g+ U, ~9 H8 q8 }
warning about the virilizing effect on a male or" k. N# G4 q* ^0 y4 g
female child who might come in contact with some-
, V: O3 e% R1 i( z' vone using any of these products.
- y! e( [/ i9 g- O; t" D* l# B0 ?( BReferences- k) E* b9 ?4 I
1. Styne DM. The testes: disorder of sexual differentiation' y* Y/ s' U' j' \1 z' O! {& w
and puberty in the male. In: Sperling MA, ed. Pediatric% h) s% y7 b" \' p3 Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 X) j9 C  N$ l/ O7 b2002: 565-628.
. M% v3 S6 T2 Z: h1 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% b6 v& [) o9 C/ \" x: j5 X" y
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
* K* q$ i0 j& r' H. |% R+ S
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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