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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, r0 d! K0 {; c* f% r
Boy Induced by Indirect Topical
* J& Y& J1 L5 h- Y" ]9 G( wExposure to Testosterone4 [' q: m$ |7 m3 K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: M# L" e0 \6 _4 O5 D) Q/ @' E' @
and Kenneth R. Rettig, MD1
& e- g, S* U4 ~( hClinical Pediatrics
% r- @  c6 `6 {8 Y2 XVolume 46 Number 6
  T) Y9 l* o  N1 b, P. `9 |July 2007 540-543
0 s% k5 I4 _  g( U2 y© 2007 Sage Publications. t7 {3 N& S7 X5 X2 {$ O# l4 T/ d' ?
10.1177/0009922806296651
3 _  O. i* N+ Z( Q$ ^http://clp.sagepub.com+ w4 l8 s! }1 T" P' C# D) R8 T$ _6 u* e5 m
hosted at
. i2 f* Z* W' r) Phttp://online.sagepub.com
' D+ N8 n( B. V. ~/ _Precocious puberty in boys, central or peripheral,# D$ |, j, B: @* a" X3 i
is a significant concern for physicians. Central* B! Y; t/ W8 v, y; _5 }0 p" T- w
precocious puberty (CPP), which is mediated
' ~$ S7 }- |$ U# P! ythrough the hypothalamic pituitary gonadal axis, has
3 X+ w3 n" [1 J. F7 h+ Va higher incidence of organic central nervous system5 n' n8 j+ ~7 L5 `' j
lesions in boys.1,2 Virilization in boys, as manifested
7 \! y( q' A5 P3 y* Pby enlargement of the penis, development of pubic4 n5 T% C! Q& Q( ^7 k  |
hair, and facial acne without enlargement of testi-
* S& S3 P# y$ w! t1 }cles, suggests peripheral or pseudopuberty.1-3 We
( k& Z) F8 N, j: z/ X2 y- Areport a 16-month-old boy who presented with the
* k. T& E$ u1 ?enlargement of the phallus and pubic hair develop-
7 ~; n" x* w- Z8 Ument without testicular enlargement, which was due- i8 ^- b+ \% E+ n9 B$ U+ ?1 c4 z
to the unintentional exposure to androgen gel used by
( r+ ?8 g& f2 Y% \9 ]3 Jthe father. The family initially concealed this infor-
5 x( T' d3 M9 H* dmation, resulting in an extensive work-up for this4 u4 g6 ]5 B( m+ ^6 ?$ k+ y& j1 q
child. Given the widespread and easy availability of
( y9 M9 m3 A1 }testosterone gel and cream, we believe this is proba-
: J7 @+ I" f9 g& B3 I0 f+ |bly more common than the rare case report in the
5 y* u" k& `8 C5 Pliterature.43 m) K' o! z1 Y0 ~$ X* o
Patient Report  O) ~' `8 x; ]; P/ B' K
A 16-month-old white child was referred to the5 N1 M# i! ?) Q; ~: e3 x% H* M
endocrine clinic by his pediatrician with the concern$ B9 W  s" o8 l, U, k
of early sexual development. His mother noticed
1 D2 B3 x/ ^4 ]. u2 U" qlight colored pubic hair development when he was% }. l$ n* N# y- Q
From the 1Division of Pediatric Endocrinology, 2University of
$ q9 ~4 o' e, t/ ]# m  D8 ^4 e; oSouth Alabama Medical Center, Mobile, Alabama.3 E) B1 k3 i% d% |  v; {9 R6 M
Address correspondence to: Samar K. Bhowmick, MD, FACE,& }- A6 c$ d: d. q- v+ d+ h3 }
Professor of Pediatrics, University of South Alabama, College of
: [' N7 o" J" c  T. e0 gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) M* e: ^6 c8 R1 X; J/ ]2 Be-mail: [email protected].( B/ t( R# X# Z  v( p: l
about 6 to 7 months old, which progressively became
" \% i9 U: A; y  f* ydarker. She was also concerned about the enlarge-1 ?, }8 d' `1 [6 m
ment of his penis and frequent erections. The child
7 _! Q& V; z# {/ T) G* o& gwas the product of a full-term normal delivery, with3 U' N' @3 O+ r4 X/ Y. \
a birth weight of 7 lb 14 oz, and birth length of
2 w$ k+ j* A* B/ n$ d20 inches. He was breast-fed throughout the first year
# d- K  a9 v) wof life and was still receiving breast milk along with
3 m! q9 q( R4 k: j! i) A9 l3 e7 j! Csolid food. He had no hospitalizations or surgery,
& K! O$ `0 h) Wand his psychosocial and psychomotor development
8 p6 Q$ B& _5 g& Nwas age appropriate.
) {- v0 d, t/ X4 bThe family history was remarkable for the father,! s& J# @8 t' ?2 G, N# |9 |& N/ z
who was diagnosed with hypothyroidism at age 16,
3 n8 P/ X. q* V( @which was treated with thyroxine. The father’s
! `6 s$ Y0 K" |' bheight was 6 feet, and he went through a somewhat" g, e' Z1 _; x! [" p0 S
early puberty and had stopped growing by age 14.% Q7 h0 m. c; V. u! H5 e
The father denied taking any other medication. The
% y+ s( `& w+ C# `& W, k. L5 H1 f" schild’s mother was in good health. Her menarche
: U  }( j, r$ a1 Q  |9 l9 nwas at 11 years of age, and her height was at 5 feet
9 X# {" {, L: [5 inches. There was no other family history of pre-
7 P: n  S: M$ H& Lcocious sexual development in the first-degree rela-
1 ~( m$ `' y" r6 |2 ]8 ntives. There were no siblings./ |+ ^/ |! X: u* r5 E* e) |
Physical Examination6 }+ n5 V: H) x
The physical examination revealed a very active," Y6 c! m+ I: `) t3 z
playful, and healthy boy. The vital signs documented
! S8 ^% n0 m3 o5 La blood pressure of 85/50 mm Hg, his length was
  l4 ?4 H, ?6 L! O* T. ^90 cm (>97th percentile), and his weight was 14.4 kg8 g0 W9 x6 E1 g1 D
(also >97th percentile). The observed yearly growth
! t7 g" B" r$ C5 }9 fvelocity was 30 cm (12 inches). The examination of
+ D8 `0 I. H; r3 ^the neck revealed no thyroid enlargement.0 t$ A; w- g( {8 W. a, C% M* D
The genitourinary examination was remarkable for, G7 O  {& A9 x+ V3 x' h
enlargement of the penis, with a stretched length of! d. E; e+ Y. l" y
8 cm and a width of 2 cm. The glans penis was very well. p% E4 h( ]; W1 S/ i' e
developed. The pubic hair was Tanner II, mostly around# f! H: M, Q( ^- S
540) E) e! ~" p8 h, z3 l; [8 k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 Y+ R& {' W5 T- U3 @9 r( q
the base of the phallus and was dark and curled. The. F. a7 d/ a* l% k7 o! X, P% V
testicular volume was prepubertal at 2 mL each.
$ K/ `, c5 q4 xThe skin was moist and smooth and somewhat
4 l; @: V! w6 W3 Z1 f) zoily. No axillary hair was noted. There were no
$ A4 Y# p+ ~6 n$ m' F$ C+ y3 }: D: F) ~, iabnormal skin pigmentations or café-au-lait spots.
8 t, \# ]6 ~: q) rNeurologic evaluation showed deep tendon reflex 2++ O+ A: f/ [) h
bilateral and symmetrical. There was no suggestion
4 S0 Q% D. v$ Q" r- n3 [; Zof papilledema.
0 O* y! C( _# l8 N+ _3 `Laboratory Evaluation4 R0 k7 l2 ]$ o9 \8 b4 |
The bone age was consistent with 28 months by! F* ?4 [3 d5 b0 _, Z8 c" t
using the standard of Greulich and Pyle at a chrono-2 \8 M* [3 _+ p0 Z, H
logic age of 16 months (advanced).5 Chromosomal
, b4 O) f) W5 l; c! A8 |, T( _karyotype was 46XY. The thyroid function test
" p$ n, G* [' D; T1 j$ ^* Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ |4 y& t' t! K7 m3 I  n& V, Blating hormone level was 1.3 µIU/mL (both normal)./ n* q3 S' T  p) Z6 ]
The concentrations of serum electrolytes, blood
7 i) P* J: U" b4 Durea nitrogen, creatinine, and calcium all were
/ s, ^! t9 g% Owithin normal range for his age. The concentration* b# y2 ?' Z0 E0 e- D
of serum 17-hydroxyprogesterone was 16 ng/dL
# Z; x1 S5 @9 P. `5 B(normal, 3 to 90 ng/dL), androstenedione was 20
# D/ p4 q' ~; P6 A: c* Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 x% Q1 M& O. r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; E. K& ^: q- H' ?7 W  U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& {6 w! \' B+ p4 Y6 L
49ng/dL), 11-desoxycortisol (specific compound S)
& [7 l9 h, D3 s: l& p3 ]+ ]. Kwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 b: \# a. ]2 Z# C: `2 l  E" S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! X. w& a2 y9 l' h% q$ ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' ]0 n5 O8 \  S6 H3 h; C. c* h
and β-human chorionic gonadotropin was less than9 ^) E7 {7 W4 {4 q6 H
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ E7 S6 y. E' x
stimulating hormone and leuteinizing hormone% {' K% ?* e- v9 H) E3 l
concentrations were less than 0.05 mIU/mL: I# s& ?2 x, ]( y8 |  y
(prepubertal).% k- y* M1 `' \9 a3 M
The parents were notified about the laboratory* x5 _# E+ |) w0 ]4 W
results and were informed that all of the tests were
" s( a! Q- L) `normal except the testosterone level was high. The
- ?# K; h; J4 F4 lfollow-up visit was arranged within a few weeks to$ |9 V+ G; {! Z( y: S' k) k
obtain testicular and abdominal sonograms; how-9 W- b" L: r. n; G
ever, the family did not return for 4 months.5 o; J8 I( y* {. [
Physical examination at this time revealed that the
6 j+ G% z4 Q. g- Achild had grown 2.5 cm in 4 months and had gained
# A2 N& O" W% V2 W9 r- m0 p5 H2 kg of weight. Physical examination remained. M+ E, {4 y! E, j0 `
unchanged. Surprisingly, the pubic hair almost com-
3 R' q6 s8 h$ y' ipletely disappeared except for a few vellous hairs at
! ?! y8 X, t1 J6 ?% |9 R) f; L+ tthe base of the phallus. Testicular volume was still 2
9 _0 _/ t$ S% ~& p/ z; v# umL, and the size of the penis remained unchanged.
7 @2 h6 @0 `/ tThe mother also said that the boy was no longer hav-
7 g6 A7 A' S( n8 w; \6 \ing frequent erections.7 K% V3 \' P- {- ^0 v$ U
Both parents were again questioned about use of! j) V4 d2 y' Y! H& l' L  A% M
any ointment/creams that they may have applied to
, J5 v# f, I$ _1 X$ uthe child’s skin. This time the father admitted the2 {2 ]$ |0 r; h; N6 z& Y* a1 O! M  a
Topical Testosterone Exposure / Bhowmick et al 541
  ?0 b; O5 m0 ^- y: nuse of testosterone gel twice daily that he was apply-
. q0 N* B$ x# D" \ing over his own shoulders, chest, and back area for/ g3 {- Y" I8 g  E$ l
a year. The father also revealed he was embarrassed
$ Z0 m" \5 y0 T. s/ tto disclose that he was using a testosterone gel pre-/ U* _, h9 _! J# z
scribed by his family physician for decreased libido# S6 S, |  b, c7 r5 x, K" s+ Z4 [
secondary to depression.
+ T6 G- l0 A5 ~$ R- gThe child slept in the same bed with parents.
" v3 z2 v) a3 A/ T7 E6 q& sThe father would hug the baby and hold him on his
% N. }% w0 V3 j! D% I3 N/ W) Vchest for a considerable period of time, causing sig-
# l. M* ?" ^# R" k6 t8 {; enificant bare skin contact between baby and father.
. }5 F& b( a% Q0 {2 z6 u$ }8 c; T, jThe father also admitted that after the phone call,( I6 ?+ C1 p7 N% J& S+ `
when he learned the testosterone level in the baby
6 |% e) J" g5 `  N6 F. zwas high, he then read the product information
9 V* c; P8 j4 k9 _. k) Qpacket and concluded that it was most likely the rea-
% P9 n. X- i% u: ison for the child’s virilization. At that time, they
" ^$ ~2 L3 Z4 odecided to put the baby in a separate bed, and the" ?* X8 n. w0 o9 ]3 g, h
father was not hugging him with bare skin and had
" ^" ~3 A' F0 e0 {+ [! Tbeen using protective clothing. A repeat testosterone
5 _  `4 y7 Z$ P* ^; v: k" p! ^test was ordered, but the family did not go to the
" j9 p+ @. O5 k6 {laboratory to obtain the test.
5 G" p3 k3 h: YDiscussion
+ |- q- H+ i: W7 w5 dPrecocious puberty in boys is defined as secondary; C& R" z) s! u
sexual development before 9 years of age.1,4
& L( k) |$ n; D# ?, ~. MPrecocious puberty is termed as central (true) when1 \; @) {  `# S* P* ^% ^
it is caused by the premature activation of hypo-
* m- n# u+ |7 Z' vthalamic pituitary gonadal axis. CPP is more com-
) u" [+ A% ^: l7 ^) D8 rmon in girls than in boys.1,3 Most boys with CPP! D2 m0 x1 S' L- M
may have a central nervous system lesion that is9 E* a7 L; ~1 n# @; u' Y8 i' r
responsible for the early activation of the hypothal-( Y( F5 r% f# ^0 X3 ?% C6 G- [1 [
amic pituitary gonadal axis.1-3 Thus, greater empha-2 x- k2 I5 ~3 z8 t
sis has been given to neuroradiologic imaging in
( V2 x+ q* k: o# ]) Bboys with precocious puberty. In addition to viril-+ O/ x/ I6 ]2 w. B
ization, the clinical hallmark of CPP is the symmet-
1 w5 _& t2 T5 p9 F: A' w" Krical testicular growth secondary to stimulation by
" l8 i3 y/ `/ S0 d! s! h1 b- kgonadotropins.1,3
) W2 V5 n- R/ H9 [2 Z& `1 \( uGonadotropin-independent peripheral preco-
$ c+ N# e5 Y. Q$ s% Z4 {cious puberty in boys also results from inappropriate
9 K/ e# d! v# q5 {androgenic stimulation from either endogenous or: [: o6 I- A. z1 J: r. {5 N
exogenous sources, nonpituitary gonadotropin stim-# p, M: T3 G  _- V% m0 T1 T
ulation, and rare activating mutations.3 Virilizing
: W5 J8 J6 U1 o6 Ycongenital adrenal hyperplasia producing excessive* \% B4 c8 h3 K$ E, C; G) q
adrenal androgens is a common cause of precocious0 U+ s7 Z$ D8 d
puberty in boys.3,4
9 i; t. \, R3 |/ jThe most common form of congenital adrenal
9 O, d6 @4 ~+ d$ E# T# i2 dhyperplasia is the 21-hydroxylase enzyme deficiency." k/ {) H3 W0 o2 _# {4 ?
The 11-β hydroxylase deficiency may also result in
' o. @7 {, ]; C$ ?+ Nexcessive adrenal androgen production, and rarely,1 R3 U4 r/ g- X9 T; U( |
an adrenal tumor may also cause adrenal androgen/ N& a# ^3 R2 K" B
excess.1,33 `- Y3 R. g9 ~0 s9 F, T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 v* `/ F5 Q+ ~! U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ @* ]' B/ ]. aA unique entity of male-limited gonadotropin-
/ o# E7 K4 f" }8 J, |# J: r4 P2 Vindependent precocious puberty, which is also known" z* C$ X+ s) {& e: I( q+ j
as testotoxicosis, may cause precocious puberty at a
# ]: z. o$ T% L" M/ g$ |very young age. The physical findings in these boys$ i7 F/ i0 P* S( }8 v/ u- A  v
with this disorder are full pubertal development,9 x# ^$ T7 J8 ^: o
including bilateral testicular growth, similar to boys
( H; F! e' H( ~) x5 [with CPP. The gonadotropin levels in this disorder" W+ n- D2 N  v6 g$ B
are suppressed to prepubertal levels and do not show& v( i% a9 p" P0 k! U
pubertal response of gonadotropin after gonadotropin-
" k: u/ Q. a2 r" z8 g; Z; X7 I- Nreleasing hormone stimulation. This is a sex-linked
$ p" s: d; o1 fautosomal dominant disorder that affects only2 x' I, |  J% F( ~0 Z5 |( W9 P/ t
males; therefore, other male members of the family
: c# L( x: g* w! i: q: g# bmay have similar precocious puberty.3
0 K& P* l! j* i: j$ hIn our patient, physical examination was incon-
; }/ U8 X) e! w  J7 Zsistent with true precocious puberty since his testi-
/ ^) h# \" o7 ^cles were prepubertal in size. However, testotoxicosis& h1 `" Z' ^4 B' ]4 M1 v
was in the differential diagnosis because his father
! W0 T4 j9 B/ M( U) G. |/ N* [" tstarted puberty somewhat early, and occasionally,
' ?3 ^4 v. c. S/ f) ftesticular enlargement is not that evident in the
  [% ]4 {4 `: p- |( R/ l3 Z, @+ mbeginning of this process.1 In the absence of a neg-" i# \5 N9 L3 {$ a
ative initial history of androgen exposure, our
8 Y; r( Z; o* c/ `0 R0 X. i# mbiggest concern was virilizing adrenal hyperplasia,! K, U( c8 w$ v! {$ \% k7 E" f0 {
either 21-hydroxylase deficiency or 11-β hydroxylase: I2 b0 o- ^5 K3 C" \; m
deficiency. Those diagnoses were excluded by find-5 a/ Y. a0 K3 K( l7 S/ c  J7 A0 U
ing the normal level of adrenal steroids.
. S9 X0 B( a# HThe diagnosis of exogenous androgens was strongly
: h* q& |: i" C5 o) Nsuspected in a follow-up visit after 4 months because' ]3 _, f6 x2 k1 @
the physical examination revealed the complete disap-
& U8 s: C  G( D# Dpearance of pubic hair, normal growth velocity, and6 y8 R( j5 u# ?$ E7 r) ~& J
decreased erections. The father admitted using a testos-! w; ]/ Z' c+ d' t( F& i+ E0 d
terone gel, which he concealed at first visit. He was
0 e" g+ h( m; C! J& g& W/ j8 fusing it rather frequently, twice a day. The Physicians’
2 t+ h+ V" ]) y. g* _# t/ J6 J5 dDesk Reference, or package insert of this product, gel or
; z4 L& x  Q' f9 C4 u' ccream, cautions about dermal testosterone transfer to
+ H0 C3 e# C! K! v5 D! U; ^unprotected females through direct skin exposure.0 Z' t( m& [5 j! v
Serum testosterone level was found to be 2 times the1 C4 w/ `: \/ m" X3 y
baseline value in those females who were exposed to
( B+ X% `# \8 r& F9 \' }even 15 minutes of direct skin contact with their male
% Z5 ~9 q+ p2 N3 u6 T+ L3 Tpartners.6 However, when a shirt covered the applica-
9 H3 t/ z. ^7 j! Ation site, this testosterone transfer was prevented.$ |0 n% F8 N  p/ o) I) U$ y- F
Our patient’s testosterone level was 60 ng/mL,+ m5 E0 Z' k  \, ]0 I5 v
which was clearly high. Some studies suggest that- `3 }1 r+ b5 o3 o' D
dermal conversion of testosterone to dihydrotestos-
) a5 Q: V5 L: dterone, which is a more potent metabolite, is more- A6 E; _$ `' U3 n( ]' d' T8 k0 L+ @
active in young children exposed to testosterone
" _4 r6 ?4 F6 c% _6 Qexogenously7; however, we did not measure a dihy-2 H: e' E! g  g/ H4 s: v
drotestosterone level in our patient. In addition to- B! J! k: ^/ u& G5 {- }; U
virilization, exposure to exogenous testosterone in
1 a" e' }1 J% \/ Cchildren results in an increase in growth velocity and: d% `! Q5 w4 j' p# N
advanced bone age, as seen in our patient.$ ?. G9 `( E) A
The long-term effect of androgen exposure during
  E# g( U" _- k) I8 }" t! Fearly childhood on pubertal development and final
# Y& d) N$ K; B: h( jadult height are not fully known and always remain
9 d8 K' P9 [5 J2 A$ {& U9 ia concern. Children treated with short-term testos-
4 s2 }: Y, _8 W2 z' _; }' pterone injection or topical androgen may exhibit some4 S+ P# _1 }! J" d; N+ N
acceleration of the skeletal maturation; however, after
# H  u2 c, {" k; n1 rcessation of treatment, the rate of bone maturation8 I* [3 Z) x# o4 `+ W9 [7 X. H
decelerates and gradually returns to normal.8,9
" e, O* G+ h; R: J4 w: PThere are conflicting reports and controversy
" f9 p4 R) d1 W/ ^8 gover the effect of early androgen exposure on adult$ R7 S3 c7 l4 b+ |
penile length.10,11 Some reports suggest subnormal8 e# Q' ?) H( m# h/ z( Y! x
adult penile length, apparently because of downreg-
( a" n$ Z2 f( ]& v" ~ulation of androgen receptor number.10,12 However,+ F+ ^" f5 R3 l% p; v: h
Sutherland et al13 did not find a correlation between& S+ S3 W1 b% ~
childhood testosterone exposure and reduced adult# ]% R8 R7 u9 V6 d$ v5 M
penile length in clinical studies.
4 B/ t' w9 U) }  A" |7 pNonetheless, we do not believe our patient is
- q, V4 _" b" I, T4 f/ Ogoing to experience any of the untoward effects from
& k2 b2 f7 c0 y5 |- D/ C) j* \% Gtestosterone exposure as mentioned earlier because
2 v& |4 \: S. M& v* G0 s3 R" [! h% ethe exposure was not for a prolonged period of time.- _6 m1 o4 R% c
Although the bone age was advanced at the time of/ H1 [. B! ~* ]" h+ t# r
diagnosis, the child had a normal growth velocity at
6 s2 e& k% i: u3 F+ p# ^  m$ Mthe follow-up visit. It is hoped that his final adult
: @6 P* G) ^9 h! |6 Rheight will not be affected.' }$ V( j' L# L4 J$ ~7 ?2 y6 R
Although rarely reported, the widespread avail-
, @' s" d- d) p- ~" K8 L! sability of androgen products in our society may' Y  A5 G  v6 G2 k
indeed cause more virilization in male or female7 r, V# y) D! L/ B6 a  Y! c5 V
children than one would realize. Exposure to andro-, `6 r7 q5 n) z0 \2 A' k) k
gen products must be considered and specific ques-
9 M9 X# A( d+ [+ G! }tioning about the use of a testosterone product or0 d' j, X6 C3 ]! i# H
gel should be asked of the family members during
% D( P7 J9 A' |5 C( z# qthe evaluation of any children who present with vir-# K* {% \9 g" A0 w) P
ilization or peripheral precocious puberty. The diag-
  w6 M% q7 y8 A9 D: Mnosis can be established by just a few tests and by
/ ?/ T) _/ M2 X3 b) ?& [; xappropriate history. The inability to obtain such a3 x9 T& x5 x  ^
history, or failure to ask the specific questions, may- O8 T; c8 _, Y6 |% `7 T
result in extensive, unnecessary, and expensive2 q, R" H! k* ~+ r: C5 f6 F0 O
investigation. The primary care physician should be
1 u, J8 O. T& ^; Zaware of this fact, because most of these children/ [0 x; g9 l8 y) a
may initially present in their practice. The Physicians’
; f9 j4 k# o# t: e5 ^. n. PDesk Reference and package insert should also put a% C9 ^7 \3 V: s, n
warning about the virilizing effect on a male or
# `; Q4 X9 ?! ?  R4 Lfemale child who might come in contact with some-
  Q6 N( v' {3 |  Sone using any of these products.
7 x( m1 \6 y7 o) a7 l+ oReferences0 K( m/ u% P2 J0 r
1. Styne DM. The testes: disorder of sexual differentiation
8 D, ^$ l* o( o7 O+ S/ G' Wand puberty in the male. In: Sperling MA, ed. Pediatric
% @5 j. A) E. \8 ?9 e) q6 pEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 k3 s6 Y, s; H: \  j
2002: 565-628.' q; H; v6 t2 ]" X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 Z' U" v' R4 N- H: f/ A* i5 f, Spuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: i9 R+ b6 ~$ f( ]
Boy Induced by Indirect Topical
9 G2 @5 g' l9 N9 ~( RExposure to Testosterone0 }$ Z( }' l7 X1 {0 G8 ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ A; \- u1 s( B& m  U3 N9 _' o& ^and Kenneth R. Rettig, MD1  i  C0 M6 G9 ]+ j! w# |* B1 J
Clinical Pediatrics
2 ]: s  _' r, Q" Q/ xVolume 46 Number 61 g. B6 n) \; ]/ O; D8 ~
July 2007 540-543
- ~2 O+ X" G$ s2 b/ r( W7 R; i© 2007 Sage Publications! u) X) q, v% E
10.1177/0009922806296651$ N. o* T- Z* A0 x2 }
http://clp.sagepub.com1 G! k# L2 E$ Y
hosted at" q4 F( \# y9 A5 g
http://online.sagepub.com
6 y7 h4 i. I! ]2 N7 e7 k* ePrecocious puberty in boys, central or peripheral,) o3 s' H; F  D) T4 m
is a significant concern for physicians. Central
$ @% u3 T* j: F1 I  p0 Aprecocious puberty (CPP), which is mediated8 M9 e, d, T3 W9 M! _" A
through the hypothalamic pituitary gonadal axis, has
8 j: B0 i4 P4 g% G2 G" R' Qa higher incidence of organic central nervous system' p* A6 h7 \/ I
lesions in boys.1,2 Virilization in boys, as manifested& P; M( D1 q3 [& W. `3 f
by enlargement of the penis, development of pubic. X; R9 V' B6 {9 h
hair, and facial acne without enlargement of testi-- T, y) m( @7 X
cles, suggests peripheral or pseudopuberty.1-3 We* S/ a- P: {) D1 O5 @. i7 {7 j
report a 16-month-old boy who presented with the
* Q/ _, A& F2 L6 n) i2 g+ e. Henlargement of the phallus and pubic hair develop-4 m, c3 v7 a: N% |3 s9 E
ment without testicular enlargement, which was due9 G( L7 a5 e% `2 `# a. V% }8 e& |
to the unintentional exposure to androgen gel used by
, \6 |1 |; o  U5 ?: m# A' mthe father. The family initially concealed this infor-! a7 G% P3 g4 K+ d
mation, resulting in an extensive work-up for this
7 z" R8 _( q# M" Y3 x' {child. Given the widespread and easy availability of3 \; V" e3 V% u& L% D
testosterone gel and cream, we believe this is proba-0 n, s/ J& Q* r  p9 w' k
bly more common than the rare case report in the. w2 Z+ ?: U, _  B! A. z- H
literature.49 E$ J& x2 I1 i. C/ z
Patient Report$ @( R3 B5 ?% h, L! Q
A 16-month-old white child was referred to the
. T8 q' z# C; r; dendocrine clinic by his pediatrician with the concern
$ I# D5 v1 e2 k8 ]( L6 ^of early sexual development. His mother noticed; M" I8 E; c% U& o5 J
light colored pubic hair development when he was
( ^7 z. k3 c* k( \* s6 J) vFrom the 1Division of Pediatric Endocrinology, 2University of
' c* Z9 {/ e' ?& |; [+ nSouth Alabama Medical Center, Mobile, Alabama.  r# S' @1 ?. G* K6 s
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 H& g% X1 q* ]
Professor of Pediatrics, University of South Alabama, College of
6 N% x3 d' P5 Z: _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  Z7 K' k9 ~! e" x. @2 Le-mail: [email protected]./ `1 F! \; N; r3 w+ g
about 6 to 7 months old, which progressively became" @2 A( t, V4 N! U* ~' m5 Q' I: L
darker. She was also concerned about the enlarge-- f0 F! I) D. x2 R+ A
ment of his penis and frequent erections. The child7 t3 J0 [/ X  h$ d" C0 l- b. w
was the product of a full-term normal delivery, with# p6 q7 F3 `( j7 H2 b
a birth weight of 7 lb 14 oz, and birth length of7 K1 ~: Y4 x# Z$ ~& y9 S( t
20 inches. He was breast-fed throughout the first year6 ~! M# B" e; m/ _2 y: E/ H" k
of life and was still receiving breast milk along with- _; K3 p9 p5 P4 q; a+ s/ @
solid food. He had no hospitalizations or surgery,
" q$ _- K9 b3 S9 u5 Y. n; I7 Wand his psychosocial and psychomotor development% _: f$ ?3 F1 A" ^
was age appropriate.
5 V% x2 P6 _9 S( u$ g; ?$ u+ A+ UThe family history was remarkable for the father,7 L  d! C; c; |' S- r
who was diagnosed with hypothyroidism at age 16,# z7 l8 m. e* Y: U( F, K
which was treated with thyroxine. The father’s
# P' l2 j; l/ C4 _height was 6 feet, and he went through a somewhat$ x& l  k' U! v( A
early puberty and had stopped growing by age 14.: i* g; }: q/ d2 C) i( ^
The father denied taking any other medication. The  u0 `6 [+ C( ^6 p8 d- r
child’s mother was in good health. Her menarche
- z: h0 j$ ~+ G: gwas at 11 years of age, and her height was at 5 feet
9 Q( q: p+ c6 M, r/ w6 O5 inches. There was no other family history of pre-
( T6 l. O9 [" H" `1 `cocious sexual development in the first-degree rela-" W- Z& G$ @1 {
tives. There were no siblings.% E/ d' A1 C. v/ o* ?* S
Physical Examination  N; A- ]# j2 V
The physical examination revealed a very active,/ o$ b+ z) T  u% ^5 r1 ?' k$ F
playful, and healthy boy. The vital signs documented4 o/ ~" u' i' y7 {& @) l
a blood pressure of 85/50 mm Hg, his length was
/ s! G9 Z' ~2 d9 m- e- N/ ?5 \# Q; S) D90 cm (>97th percentile), and his weight was 14.4 kg
8 B/ y. @) Z1 v3 O(also >97th percentile). The observed yearly growth; S! `, f1 {, r( @9 r
velocity was 30 cm (12 inches). The examination of
+ B+ M- {8 x! L6 U5 V, ~the neck revealed no thyroid enlargement.! `7 ^( W6 m" s. d6 |1 e
The genitourinary examination was remarkable for
& t+ s6 w* r! x6 x. V) v: renlargement of the penis, with a stretched length of; s" f' ~% J6 Q) i0 [
8 cm and a width of 2 cm. The glans penis was very well
. G! S" U4 k7 o# L8 v/ o0 w- pdeveloped. The pubic hair was Tanner II, mostly around
3 P! Y; ?! G. F540
, r; q% n9 o' J; \" oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. k4 b1 `: A; W8 S, P
the base of the phallus and was dark and curled. The5 M7 \$ p: [* m" I7 p3 \
testicular volume was prepubertal at 2 mL each.
& m. n. Y! e* H3 \* d6 hThe skin was moist and smooth and somewhat
- Z; U1 m0 o* w; xoily. No axillary hair was noted. There were no
3 B0 o1 V4 m, s3 z8 O& oabnormal skin pigmentations or café-au-lait spots.
4 x1 B" a3 @* }- S$ n4 |, KNeurologic evaluation showed deep tendon reflex 2+
% ^: {, f6 W, `9 C0 L, Lbilateral and symmetrical. There was no suggestion; ], w6 x$ K, ]% H- R
of papilledema.
: ]  B$ S  l0 n8 \, l7 {Laboratory Evaluation4 B; L5 S: ^# n* ~% p) V
The bone age was consistent with 28 months by1 d" v0 z4 h' s' ]$ `
using the standard of Greulich and Pyle at a chrono-) h, j4 q9 `0 l  M; T# B
logic age of 16 months (advanced).5 Chromosomal
' _% g3 H+ U. R3 s4 ~0 qkaryotype was 46XY. The thyroid function test
) e3 B% ~- `+ w; yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 P, J$ l8 T" e  J3 w% {lating hormone level was 1.3 µIU/mL (both normal).
6 X, [1 V+ Y8 IThe concentrations of serum electrolytes, blood
) v, n( u7 e, L) L, Xurea nitrogen, creatinine, and calcium all were
5 I: A8 ~) l3 Q3 V  j& o5 ewithin normal range for his age. The concentration
, d6 B5 S4 H. Q; [of serum 17-hydroxyprogesterone was 16 ng/dL4 u4 {) y# r' _# T, n3 i; d
(normal, 3 to 90 ng/dL), androstenedione was 20- n% O& ?& d5 ?& d! b
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 z8 b3 ?) |8 b2 ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),, x1 M5 E: q& X) x9 c* ~
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 O# Q; n1 U% s8 W- N, ]) y& z( A49ng/dL), 11-desoxycortisol (specific compound S)
% R9 y; T* d! F8 R! u3 c  e- f# C9 wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, r+ E2 J" c. L$ W( D1 f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 f& b3 v+ Y$ M) |& Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 h) M7 ?; \6 x( y; q  ?
and β-human chorionic gonadotropin was less than
* W/ U+ j: p& m- _' i7 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
! F$ j3 x' M- e8 L( g) cstimulating hormone and leuteinizing hormone+ Q, O1 K1 y8 Q* k( {4 y3 S
concentrations were less than 0.05 mIU/mL
$ M# L5 f. g, Q1 {8 p8 w: Z1 E(prepubertal).9 }, m5 `- I+ c1 Q) t, C
The parents were notified about the laboratory
, s8 N% T; V; Mresults and were informed that all of the tests were
- \* J  _! R; w. O+ snormal except the testosterone level was high. The
7 o+ T3 n- F9 P7 K+ ]follow-up visit was arranged within a few weeks to
3 n3 R; z7 x* ?/ ?# L$ wobtain testicular and abdominal sonograms; how-+ E9 ]/ h3 M) Q# c/ R; x
ever, the family did not return for 4 months.8 \+ M' V* O! X5 H# [" e
Physical examination at this time revealed that the
4 p/ u6 g/ P  V' G0 {0 X* Z( Pchild had grown 2.5 cm in 4 months and had gained
" ^5 F, {0 w& \0 Y8 K2 kg of weight. Physical examination remained  r' ?( m8 w' L7 M, ~: Y  K9 }
unchanged. Surprisingly, the pubic hair almost com-' G: h+ C$ |+ z7 B; W2 {! n
pletely disappeared except for a few vellous hairs at
5 M. c3 d& a: w7 Kthe base of the phallus. Testicular volume was still 2
/ @' E' I  y" A$ RmL, and the size of the penis remained unchanged.% ]+ L  J7 p( G8 ]# R4 J
The mother also said that the boy was no longer hav-) K+ O+ T- y5 ]5 X) C( _4 ^( J" h
ing frequent erections.5 m; |3 A  _2 Z" ^: L. A2 S
Both parents were again questioned about use of
% H3 s/ [* Q/ A7 `* {  _/ Nany ointment/creams that they may have applied to
% m5 ?7 A5 [7 C8 nthe child’s skin. This time the father admitted the* M- S" H6 s/ f0 Y- ]
Topical Testosterone Exposure / Bhowmick et al 541
8 l1 O: \+ y) E9 uuse of testosterone gel twice daily that he was apply-. D; ]0 O2 |; P* b1 W- J* z3 x
ing over his own shoulders, chest, and back area for
' [2 W/ e% i2 c6 M0 ea year. The father also revealed he was embarrassed
9 C/ q- j" C. P7 \3 Uto disclose that he was using a testosterone gel pre-
9 z6 K1 k2 T$ ^0 s2 u# u6 v1 k* cscribed by his family physician for decreased libido+ [4 @- o2 t7 H7 V
secondary to depression.2 F" D% x' p' A- ^4 G
The child slept in the same bed with parents.9 J6 Q; M: N2 J
The father would hug the baby and hold him on his7 C( _9 Z: @4 j8 A0 O
chest for a considerable period of time, causing sig-) B# `/ K" V* R) e  u0 y' S2 j# y" E
nificant bare skin contact between baby and father.! F' n" ~- w2 |( v; |/ J. @/ h; Q
The father also admitted that after the phone call,
: ~. c4 ?" l* N* gwhen he learned the testosterone level in the baby
. o. V. _; x9 ?' H7 I2 |! wwas high, he then read the product information
1 U9 R" D! U% f! ypacket and concluded that it was most likely the rea-+ p& ^% X6 X) }" Q
son for the child’s virilization. At that time, they
- _  I* ]! Y0 y  J2 ?9 [decided to put the baby in a separate bed, and the
/ v( ~4 x* n2 w- m1 q* {# ifather was not hugging him with bare skin and had
7 f) Q  B$ B# i3 t7 e3 f; G* V( u' abeen using protective clothing. A repeat testosterone
' J  K! e" j4 ]! w6 K5 ?& l9 _test was ordered, but the family did not go to the
9 O# ~3 Z7 t: U4 w3 x* C) Plaboratory to obtain the test.
# A. x, w$ ^: L; C7 a, p6 cDiscussion
1 }" w6 q5 W5 \! ]  rPrecocious puberty in boys is defined as secondary5 m8 x$ N3 C1 d- {: }' @8 N  }
sexual development before 9 years of age.1,42 J$ E, ^3 f" {0 ?8 C1 l3 ^0 d
Precocious puberty is termed as central (true) when
7 y4 i1 t3 K# o2 ~( t$ M: \/ Xit is caused by the premature activation of hypo-
4 l8 r2 K0 p) F! u; B* Y/ othalamic pituitary gonadal axis. CPP is more com-
$ g6 n' V! G' Z, p( Qmon in girls than in boys.1,3 Most boys with CPP
8 X/ d  l9 M" tmay have a central nervous system lesion that is" ^* u, I# ]) {: b4 B
responsible for the early activation of the hypothal-# ]* n# h, b0 I  [
amic pituitary gonadal axis.1-3 Thus, greater empha-+ E  U7 s: E4 b  o
sis has been given to neuroradiologic imaging in
5 V$ o9 H2 a2 @$ m0 Y0 m5 H8 @boys with precocious puberty. In addition to viril-
, A0 X) ^* b% I$ q( hization, the clinical hallmark of CPP is the symmet-7 q# }) x/ `  I& p) j
rical testicular growth secondary to stimulation by/ Q% ]. r$ e; o: R- ?0 Y9 b6 x# \
gonadotropins.1,3. R3 {5 q0 D1 `) R% E* }" Z' S
Gonadotropin-independent peripheral preco-
* I! ^' j' x% W) dcious puberty in boys also results from inappropriate; y% n+ ?% ?6 `& i6 z
androgenic stimulation from either endogenous or
9 [  \* z0 B6 v$ y; G1 Z! yexogenous sources, nonpituitary gonadotropin stim-
/ X: n+ a: @) B9 |: t: pulation, and rare activating mutations.3 Virilizing, a4 k5 i9 N% U
congenital adrenal hyperplasia producing excessive5 n4 h  V% r, R7 g
adrenal androgens is a common cause of precocious
+ U% g3 [6 f( \* ^: }; j- T5 ppuberty in boys.3,4
: Z# R/ G: J* ?9 P+ SThe most common form of congenital adrenal) {7 {$ E0 C7 D" j+ [
hyperplasia is the 21-hydroxylase enzyme deficiency.
* e/ f. n3 j6 x2 |The 11-β hydroxylase deficiency may also result in; I4 a' b# z- S6 k2 k7 y
excessive adrenal androgen production, and rarely,
0 A: b) ^/ v$ }an adrenal tumor may also cause adrenal androgen& e! {. Q* L# i" t  O
excess.1,3" s9 W0 F& ]6 a! G; `  n  N0 E- L3 |) l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' R$ a; s0 s0 s5 |' t
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 M4 ^* e2 O/ l4 _; @+ K
A unique entity of male-limited gonadotropin-
8 `7 B$ J$ q- Aindependent precocious puberty, which is also known8 K' d: y  U7 c7 f) [, ?
as testotoxicosis, may cause precocious puberty at a
& u: l3 ~" k+ E8 N9 j9 N5 Yvery young age. The physical findings in these boys
% u/ v9 @3 R3 U0 Nwith this disorder are full pubertal development,
' H3 b4 A- W9 s( F6 T! X; r1 gincluding bilateral testicular growth, similar to boys4 G' `$ c1 j5 P
with CPP. The gonadotropin levels in this disorder
6 n0 A7 L; |8 L; Zare suppressed to prepubertal levels and do not show
" W3 X* ]& t; Y- o0 x6 opubertal response of gonadotropin after gonadotropin-
+ d% W# A& _" u% j; ireleasing hormone stimulation. This is a sex-linked; d. Z2 f9 Q2 [  V! N1 e
autosomal dominant disorder that affects only
; J, x$ {) B: t2 }* c9 Kmales; therefore, other male members of the family8 C0 d% }3 R: h8 B$ l
may have similar precocious puberty.3
2 n3 j0 o( t+ f9 E9 c& u& lIn our patient, physical examination was incon-& w+ o3 q) o4 e) i: F  Q
sistent with true precocious puberty since his testi-
7 m! V) h( B% U2 q6 L9 p# {% ]cles were prepubertal in size. However, testotoxicosis' i- i/ B+ o0 L7 E
was in the differential diagnosis because his father
" Z$ ?* {) G. ^$ ^; y. r: g7 M: g+ kstarted puberty somewhat early, and occasionally,
* I5 u& s* u$ ~* k, C9 rtesticular enlargement is not that evident in the
1 ]( O, K0 _6 h5 K2 vbeginning of this process.1 In the absence of a neg-
& B% V% ]7 J  j9 b+ e& ?ative initial history of androgen exposure, our3 D( h$ F2 g2 q! e5 K9 H0 i! V
biggest concern was virilizing adrenal hyperplasia,
  I; [+ z7 m4 L6 P: {+ Geither 21-hydroxylase deficiency or 11-β hydroxylase
- ?# O2 h% K) Z# c% i' j. Ndeficiency. Those diagnoses were excluded by find-; t) r: l% w7 C8 V% ~
ing the normal level of adrenal steroids.  v6 z7 i! |4 [4 i
The diagnosis of exogenous androgens was strongly  ]  q" n- b+ E/ A7 \
suspected in a follow-up visit after 4 months because3 T5 r; u8 B! |' v4 ~0 c: `
the physical examination revealed the complete disap-* {5 N  h8 L. X' ~* W
pearance of pubic hair, normal growth velocity, and
: d; f$ p- \, r9 G- k& k, E# _decreased erections. The father admitted using a testos-
; o. f2 D) W+ i0 j: n  N$ Oterone gel, which he concealed at first visit. He was
1 d% c' l5 Y7 l% {" ousing it rather frequently, twice a day. The Physicians’9 O- `; a. K$ ?0 b0 l6 O" Z
Desk Reference, or package insert of this product, gel or
: [2 J. x3 p- ]0 X3 ]+ d5 Y3 ?! U) ocream, cautions about dermal testosterone transfer to  y: c+ e* q' g5 a, }( W
unprotected females through direct skin exposure.0 ~( E3 O3 F% S- o* v
Serum testosterone level was found to be 2 times the
9 T8 z3 I2 d* ^& Q6 @0 _baseline value in those females who were exposed to9 k  d7 N9 y0 Z, W
even 15 minutes of direct skin contact with their male! {& V6 Q0 H, L: [7 `' D" I2 w$ a
partners.6 However, when a shirt covered the applica-
0 J$ [6 @/ r, |tion site, this testosterone transfer was prevented./ I- K1 a. \. |) L
Our patient’s testosterone level was 60 ng/mL,
8 g6 i6 M/ ~+ N2 m3 R1 Wwhich was clearly high. Some studies suggest that
9 w; R$ O# @- _0 W% O, Udermal conversion of testosterone to dihydrotestos-3 c  F  S  }7 G( d- w
terone, which is a more potent metabolite, is more+ E0 j  |  m; u$ `* ?* _6 m8 A
active in young children exposed to testosterone+ U- G8 K$ d0 t. ]
exogenously7; however, we did not measure a dihy-
5 ^& x9 z# S0 d5 f* u7 ^8 wdrotestosterone level in our patient. In addition to
1 @& Q( P0 `0 Q& yvirilization, exposure to exogenous testosterone in
; e2 }- x/ G3 I7 Z" ^4 ?# Y  [  ~2 Gchildren results in an increase in growth velocity and2 h, U" v* z' Q2 R! G$ v
advanced bone age, as seen in our patient.
3 |2 m! G5 M4 z; s9 S9 `8 oThe long-term effect of androgen exposure during
, W" O7 u, U2 W- ~' L, R- kearly childhood on pubertal development and final1 x9 S0 V' O) L; K* [  i: P  t
adult height are not fully known and always remain4 z* `1 g7 v1 I: Y8 U. `
a concern. Children treated with short-term testos-
6 q6 `5 m! e9 G" ~terone injection or topical androgen may exhibit some
4 d! v. T, b. V% o6 H7 l1 n; lacceleration of the skeletal maturation; however, after8 R8 |/ a* F6 I/ F! `6 B8 q
cessation of treatment, the rate of bone maturation% O7 E/ u/ G; S9 A
decelerates and gradually returns to normal.8,94 I$ D) @2 Y' R" R% @) k1 g
There are conflicting reports and controversy
, \4 m( \! ~" D$ b3 V' @over the effect of early androgen exposure on adult
: Y2 \( T( F( x% }1 @6 zpenile length.10,11 Some reports suggest subnormal( k# x: n9 M, e. ~$ o
adult penile length, apparently because of downreg-9 i" @2 I0 @2 m$ Y. j- T* L8 q  O
ulation of androgen receptor number.10,12 However,& u3 e" V7 u5 ^5 a. y' t
Sutherland et al13 did not find a correlation between
- w4 U( s' `4 C8 q. G9 F' X6 ?childhood testosterone exposure and reduced adult
- ]. q  Q- T2 [8 H$ X) \# [: |penile length in clinical studies.
3 {) f7 S8 C2 L& E7 `5 W. h( hNonetheless, we do not believe our patient is
0 h. f5 R/ Y3 f4 T* ygoing to experience any of the untoward effects from
' M# I0 p( U* }) n! Rtestosterone exposure as mentioned earlier because
+ w) m1 g; t7 \3 l1 n9 w4 Athe exposure was not for a prolonged period of time.
4 m/ G# P, L( f9 P8 B: HAlthough the bone age was advanced at the time of# u4 ~+ I; N' i: o" I4 i9 e
diagnosis, the child had a normal growth velocity at
  N1 w, R& g( f0 u5 P9 D% l/ Mthe follow-up visit. It is hoped that his final adult
& X. }( d; ~! q) xheight will not be affected.
/ g" Q) H0 X$ _* j  k& CAlthough rarely reported, the widespread avail-
; ]5 |6 F& V$ t: rability of androgen products in our society may3 R; }$ i2 b' W, l
indeed cause more virilization in male or female
5 k/ o% {+ l0 w% f! _children than one would realize. Exposure to andro-) o; i3 D$ ^( s0 @! n% d0 ~
gen products must be considered and specific ques-. R. m/ A* B& V
tioning about the use of a testosterone product or
2 D( v0 R. Q" `1 }; P+ m1 Qgel should be asked of the family members during
  Q4 P' W9 n2 w! `* O, {' Othe evaluation of any children who present with vir-) x7 n3 w) ~9 k* e# ^+ g
ilization or peripheral precocious puberty. The diag-
; R% W9 e9 Q- n* n* T8 Mnosis can be established by just a few tests and by. o& \+ m8 e0 V% U+ _1 A
appropriate history. The inability to obtain such a9 T8 W9 M) W$ J/ K1 L
history, or failure to ask the specific questions, may" B2 Y7 U8 w, \0 I7 D, L
result in extensive, unnecessary, and expensive7 h8 Q& S  r3 r: ?% `
investigation. The primary care physician should be
, o3 ~9 M. ^7 m* Y( O- saware of this fact, because most of these children
6 G$ @% D0 f! \# R6 _  o+ P4 rmay initially present in their practice. The Physicians’
+ a6 s: Y4 ^2 S6 X  b6 T- `* n5 KDesk Reference and package insert should also put a# a. g2 W0 C3 O1 W" h6 i, M
warning about the virilizing effect on a male or. I+ V! h- y- s; g/ h" p8 W8 L
female child who might come in contact with some-( F  n7 u7 ~* l; i
one using any of these products.
4 e+ b' h! z/ VReferences! ]' j5 U) J" o& ]$ X0 m
1. Styne DM. The testes: disorder of sexual differentiation
9 p7 p9 M  E& F7 ]! oand puberty in the male. In: Sperling MA, ed. Pediatric/ p! i; }. N; }5 J; Z3 ~  W4 z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 g5 w( n6 b  \6 Q5 U2 v
2002: 565-628.
; @* r' o7 J9 z' I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ Z9 ]5 g- F" }' z4 r2 \& tpuberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 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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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

+ G5 B0 c) `& 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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