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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
# q: x5 v/ o9 M; R- VBoy Induced by Indirect Topical
7 c1 N  t2 r# S' RExposure to Testosterone" G9 d/ g1 d" d+ N) B; N" Y$ G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 M% f7 f) j" A0 q% n$ |" f& R# Land Kenneth R. Rettig, MD1
# P, Z8 T) W- u. {4 QClinical Pediatrics9 K9 N) E/ a3 V# D, L# Q
Volume 46 Number 6  W: l' P( U* O- x) z) A% m1 N
July 2007 540-543
6 i# P- |# f( ^© 2007 Sage Publications
5 I! `# @4 F. O) u# x; p' ?10.1177/0009922806296651; A) k( Y2 R  A; x8 X6 Y' v
http://clp.sagepub.com: G- w: _3 d- j5 M. [9 h& K3 j
hosted at
' P/ ^$ w" r$ X/ o, ^7 c) qhttp://online.sagepub.com  r7 H/ ]7 w/ X) K+ \
Precocious puberty in boys, central or peripheral,
( b$ E3 I3 q. Z  O6 F1 A/ K7 zis a significant concern for physicians. Central
4 G& N$ f( ]" m; bprecocious puberty (CPP), which is mediated# ~! \0 P5 Q6 K7 [. Q' k7 N
through the hypothalamic pituitary gonadal axis, has6 J, y5 {7 u. n5 o7 B* R3 S& i
a higher incidence of organic central nervous system' @4 f4 B1 G: U- r
lesions in boys.1,2 Virilization in boys, as manifested) j) b& w9 X, h
by enlargement of the penis, development of pubic% d. M. Z9 u& ~: _7 o
hair, and facial acne without enlargement of testi-3 c! c0 `+ _) U" T1 V5 t
cles, suggests peripheral or pseudopuberty.1-3 We
6 T/ w" G, T# |4 _$ }report a 16-month-old boy who presented with the; s" J7 d* A. W; P1 f
enlargement of the phallus and pubic hair develop-
  n# o9 N9 l; Cment without testicular enlargement, which was due, ~: v2 B9 ~7 w4 M7 @
to the unintentional exposure to androgen gel used by
" `4 ^" v& N% Ethe father. The family initially concealed this infor-
( Q7 g/ w3 b2 C7 P7 xmation, resulting in an extensive work-up for this
$ p- w9 X" _  X, V1 q4 schild. Given the widespread and easy availability of( k4 j* q" X6 V6 E
testosterone gel and cream, we believe this is proba-& S2 e5 a+ x" Q: H6 Z
bly more common than the rare case report in the
" h1 r, s# g5 ]6 q% s" H. ^; uliterature.4
/ n3 \; o- @$ }Patient Report+ Q9 Z' c- Z" i
A 16-month-old white child was referred to the1 S+ q2 M) r" R' a$ ^3 q
endocrine clinic by his pediatrician with the concern
8 v, j* O3 u* _# B  L: a7 Cof early sexual development. His mother noticed
  [6 [( c4 m1 P9 E0 \( B6 d. }1 elight colored pubic hair development when he was2 u! d2 A+ o3 K. w; [8 w) L
From the 1Division of Pediatric Endocrinology, 2University of. [( G8 ^2 F8 S6 O9 G6 J* x& j
South Alabama Medical Center, Mobile, Alabama.9 z! p$ d, M/ `
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 [9 D: |/ O8 g" }4 s6 M; y' sProfessor of Pediatrics, University of South Alabama, College of" k! s% n1 m9 }& y+ }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% B, B, R; r* g- S) L2 l
e-mail: [email protected].
8 b& x0 O8 P# I6 u# w/ A2 u* tabout 6 to 7 months old, which progressively became
' `. I  \- ]* Ddarker. She was also concerned about the enlarge-
8 M- G. M/ K2 c' e1 Y  hment of his penis and frequent erections. The child
4 p  V  h* w7 r7 Y- r4 N" Q. Nwas the product of a full-term normal delivery, with
& `; ?4 c$ s  Ca birth weight of 7 lb 14 oz, and birth length of8 y& d- Q  D- K1 ~/ e( R
20 inches. He was breast-fed throughout the first year, e! _  N( f/ g) I, a
of life and was still receiving breast milk along with
7 B3 \, O& n- D) `4 ]( N1 D1 Bsolid food. He had no hospitalizations or surgery,
: }9 [# d1 O3 `& L& K2 K& {and his psychosocial and psychomotor development4 h0 f# {0 Y, A8 z/ j. M  r
was age appropriate.
- `0 n, L' }: {2 iThe family history was remarkable for the father,0 z, E2 S# J/ p* l& V
who was diagnosed with hypothyroidism at age 16,
! W- ~( y; E2 s8 j* N$ jwhich was treated with thyroxine. The father’s! H8 C/ {8 Y+ s
height was 6 feet, and he went through a somewhat  u* i# e- o* ^, h" V
early puberty and had stopped growing by age 14./ e- U$ y% \" u5 z# p; m
The father denied taking any other medication. The
0 o" v' |9 g- c5 O* nchild’s mother was in good health. Her menarche
3 O4 i5 {* r" h: H: T6 f! `2 s+ pwas at 11 years of age, and her height was at 5 feet
) Z( ~) r% P7 ?, f" P" Z9 |5 inches. There was no other family history of pre-( T. |/ ^. I" C, C- |  V; L
cocious sexual development in the first-degree rela-+ o5 @' D0 |: G  `! b( a
tives. There were no siblings.
. g% R4 k  W1 K) U" w# v, X# vPhysical Examination1 q' {# [% l, O) r7 u6 ?
The physical examination revealed a very active,
' q" X$ ?7 m0 [7 [, t  Jplayful, and healthy boy. The vital signs documented
( U% T& E! T. V1 {6 ga blood pressure of 85/50 mm Hg, his length was
% N7 G  z( ]* M- ~( U( q5 g4 |4 K1 D90 cm (>97th percentile), and his weight was 14.4 kg
. i1 z2 x- L8 \& q4 Q- ~; J' k! B(also >97th percentile). The observed yearly growth% X3 Y% a+ b) n, m
velocity was 30 cm (12 inches). The examination of
: o7 b% `/ X8 h6 f: r/ C+ d8 F5 T' @the neck revealed no thyroid enlargement.+ B3 [- m1 z  Y/ u: V7 J
The genitourinary examination was remarkable for4 f& n; V5 T0 i% K8 E* A( K
enlargement of the penis, with a stretched length of7 H; I: s/ k5 w) M
8 cm and a width of 2 cm. The glans penis was very well
6 a' r/ z. Q  E$ }developed. The pubic hair was Tanner II, mostly around
# S* v# F# A) n540
! n% x6 c2 i' Y# _3 ^, s% lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: T# p  P: w/ a5 J+ F
the base of the phallus and was dark and curled. The
9 n' g& }1 P+ E, h2 v. A; Ntesticular volume was prepubertal at 2 mL each.
! C9 |7 s7 ]7 e: W. _; ^0 r$ |3 SThe skin was moist and smooth and somewhat3 M; [8 H# r- B  O
oily. No axillary hair was noted. There were no9 P- v6 D& l# ?
abnormal skin pigmentations or café-au-lait spots.+ @/ Y, n: S5 B! d9 }; b
Neurologic evaluation showed deep tendon reflex 2+) X( C2 Z. P, }- \: F
bilateral and symmetrical. There was no suggestion
! q: e4 s) `* y& {of papilledema.
! M; @7 O0 p6 F% @" VLaboratory Evaluation
+ }( S0 q6 z* Y6 sThe bone age was consistent with 28 months by
# R1 [- A3 t5 @) Xusing the standard of Greulich and Pyle at a chrono-' h- n+ @6 m( E) ?+ d
logic age of 16 months (advanced).5 Chromosomal5 k  J1 \' e7 }' Z
karyotype was 46XY. The thyroid function test, r0 U( D0 ]. r6 v! ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 v- \5 v5 ^3 J& ^/ m6 y. Qlating hormone level was 1.3 µIU/mL (both normal).$ r' X# g5 S: H. F+ ~+ d- e# g
The concentrations of serum electrolytes, blood
8 S& F' Z( r" G) H$ A7 ]urea nitrogen, creatinine, and calcium all were
) E& I! ~4 X+ Bwithin normal range for his age. The concentration" }# ^- U, c' a" O8 ~$ e& C
of serum 17-hydroxyprogesterone was 16 ng/dL2 F0 [! f5 `/ x# Z
(normal, 3 to 90 ng/dL), androstenedione was 208 ]5 X+ S# `% D4 C( @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 S6 k; F3 Y' r) w) b$ F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# o" X2 c$ T' y2 Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' s! `; }7 m& M49ng/dL), 11-desoxycortisol (specific compound S)
. z2 s7 V0 q2 w1 Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ N1 L7 n  }; Q# C+ K* c. u2 Wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" ~2 Q- p+ z& ?/ n# _3 W1 ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 Z" p& e$ U& M4 V/ Gand β-human chorionic gonadotropin was less than
9 M" _: u, j$ O/ k- d5 mIU/mL (normal <5 mIU/mL). Serum follicular
% f7 I) o- z, C2 G& r3 c6 astimulating hormone and leuteinizing hormone, P# F& E$ W" S/ P; b% u/ a
concentrations were less than 0.05 mIU/mL
& z1 g/ j& v( P& d' z! X(prepubertal).$ w/ m+ `  d: s
The parents were notified about the laboratory& \5 b9 a- y- i/ U# Y% k
results and were informed that all of the tests were  I/ A2 k3 S- \1 s5 y$ P# s
normal except the testosterone level was high. The
0 s, o. d$ |9 G3 m" ~7 E4 pfollow-up visit was arranged within a few weeks to
4 w# C+ D) O& `5 ?3 u1 g: x- \obtain testicular and abdominal sonograms; how-# J* m5 U5 r5 t+ k) Y) \5 I; Y
ever, the family did not return for 4 months.5 l0 G6 c0 {) _
Physical examination at this time revealed that the0 X7 M* V" d2 x/ }8 x
child had grown 2.5 cm in 4 months and had gained4 Z4 r9 f  P7 |! ~# M& E/ `+ d4 ]
2 kg of weight. Physical examination remained
: ^8 E6 ?$ h6 S/ k5 H6 qunchanged. Surprisingly, the pubic hair almost com-/ y3 t* G  r& m1 i0 V
pletely disappeared except for a few vellous hairs at
3 E9 |# c5 x8 z5 _, b( p, t* Lthe base of the phallus. Testicular volume was still 2# S, M# ?6 Z8 E2 \# m& P1 s+ P
mL, and the size of the penis remained unchanged.* d. P# q4 {* L7 l2 d3 Z* S
The mother also said that the boy was no longer hav-7 f# c% ?2 H" k' G- y5 @
ing frequent erections.; i' v, d* Z: J# D: E
Both parents were again questioned about use of
+ Q) ^* ~! W4 J3 f* X- Jany ointment/creams that they may have applied to
, O$ o/ W5 O; [' x; ^the child’s skin. This time the father admitted the8 w7 s& o- o4 W
Topical Testosterone Exposure / Bhowmick et al 541/ D. S% `: C7 g7 V
use of testosterone gel twice daily that he was apply-
& ]9 m8 H1 J9 }' ]2 E- _% ]/ P7 S0 _& iing over his own shoulders, chest, and back area for
# l: e" a% K+ m0 ^' @2 \) Wa year. The father also revealed he was embarrassed
/ H. _4 [% o) l3 Z8 a! g6 t4 zto disclose that he was using a testosterone gel pre-$ T: r9 v9 `& N$ Z2 ^, P3 `4 O
scribed by his family physician for decreased libido
" F# r6 I$ F9 B% ~6 K4 Zsecondary to depression.! l3 B' H. E, v- N
The child slept in the same bed with parents.
" K  p5 C' c( s3 `9 DThe father would hug the baby and hold him on his
" @& ]0 m3 N8 Vchest for a considerable period of time, causing sig-/ S! j* L2 P" h2 _
nificant bare skin contact between baby and father.
2 V2 ~$ l, U: DThe father also admitted that after the phone call,
( l( [- P; }) Q9 i: _* ~2 \8 t% Jwhen he learned the testosterone level in the baby
* K; ^5 @+ o" i7 ?9 a* _$ R7 f0 G# Gwas high, he then read the product information. [. h3 z4 H  l1 @
packet and concluded that it was most likely the rea-+ O3 M' \- w+ Z% K
son for the child’s virilization. At that time, they! t, h2 t  h$ G
decided to put the baby in a separate bed, and the
# |- ?" S+ J: o# mfather was not hugging him with bare skin and had
* J6 I% v+ q; m# _been using protective clothing. A repeat testosterone
/ R8 k8 C1 R2 j5 btest was ordered, but the family did not go to the
) z. t& d! P! x! t& q6 v  blaboratory to obtain the test.% G) l$ B- s: `8 R$ f
Discussion2 F. Y" E4 m5 ^# v
Precocious puberty in boys is defined as secondary% a# T+ i( ?. h1 h4 b5 \" ~3 X
sexual development before 9 years of age.1,4
& q( Q& i: `- d# V2 WPrecocious puberty is termed as central (true) when
, i  y' V9 u! ]it is caused by the premature activation of hypo-5 a" `" U7 i1 Y
thalamic pituitary gonadal axis. CPP is more com-
- k& }% K& q8 g2 O$ [mon in girls than in boys.1,3 Most boys with CPP
# R, @; ^# S: W. m  |! zmay have a central nervous system lesion that is  |1 E1 h' }8 j3 d5 I; Q
responsible for the early activation of the hypothal-
- V: C  Z2 ^  S5 {$ Lamic pituitary gonadal axis.1-3 Thus, greater empha-- E, {3 C( `; J" q" I* p- {2 D
sis has been given to neuroradiologic imaging in
1 _! e" S  f8 P6 c$ c" A" s' N# Iboys with precocious puberty. In addition to viril-
5 [+ U3 r& A8 G. S  q7 I1 sization, the clinical hallmark of CPP is the symmet-
  J+ M  V! g) O; d1 L/ Crical testicular growth secondary to stimulation by
0 L1 v- \- z. D3 R# Z4 p8 j$ _gonadotropins.1,39 H7 e5 r0 }5 Q% g! r1 |( t
Gonadotropin-independent peripheral preco-
) N, T" H& Z( \* _; o. tcious puberty in boys also results from inappropriate3 S4 k7 _) y# g  O6 b
androgenic stimulation from either endogenous or8 y7 C/ n  F  H' a' j( _& s( H8 n  x
exogenous sources, nonpituitary gonadotropin stim-2 d& X  A' n/ a- z) W
ulation, and rare activating mutations.3 Virilizing( F. H3 O+ J! K2 {+ w
congenital adrenal hyperplasia producing excessive
; Q5 J& A) e3 Nadrenal androgens is a common cause of precocious
9 |" D- ~5 ^$ C! P0 a- [puberty in boys.3,4! w' u; J- H; N( r! k0 H) t1 |
The most common form of congenital adrenal
# K/ m" A( j& _; n' V# n7 a2 W' ]hyperplasia is the 21-hydroxylase enzyme deficiency.
; P$ Y2 r9 j6 }* \The 11-β hydroxylase deficiency may also result in8 n5 p* t) O( g. s' g/ E% C8 V
excessive adrenal androgen production, and rarely,
) P6 x- \. G, B/ v. Tan adrenal tumor may also cause adrenal androgen
3 \* ]7 R1 q: Q; A5 q2 O, ~excess.1,3
3 H) M7 v! M! L, Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 M3 e/ [4 e* z9 n$ _& \9 b542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 A# x; `3 s$ |* S9 h5 i
A unique entity of male-limited gonadotropin-! v6 |# C! C! y6 ]0 b4 v
independent precocious puberty, which is also known
4 H  w# r6 V* C( f! Jas testotoxicosis, may cause precocious puberty at a4 C9 g; Z3 p& ]$ u" H
very young age. The physical findings in these boys
5 ^+ U% B) ~% Qwith this disorder are full pubertal development,3 I8 h8 f" B/ j- N( [
including bilateral testicular growth, similar to boys
, }3 P, q, g' o0 Q0 H( L% i8 {with CPP. The gonadotropin levels in this disorder5 h0 u% B# W1 _; ?
are suppressed to prepubertal levels and do not show
: ?: Y$ t6 _/ \$ D8 @& F! B; xpubertal response of gonadotropin after gonadotropin-
8 ?& T6 o6 e: U1 A$ H! Vreleasing hormone stimulation. This is a sex-linked
/ d* m* Y7 T6 r; Pautosomal dominant disorder that affects only
5 x5 h. s/ p" I* \, C& M- amales; therefore, other male members of the family
& u$ `( V0 \2 y+ v8 kmay have similar precocious puberty.3
" L6 }# S# ]  B) ?% {In our patient, physical examination was incon-: b1 ~: I0 W; K' u  S
sistent with true precocious puberty since his testi-5 j, {7 ~9 I8 `5 _
cles were prepubertal in size. However, testotoxicosis
3 M2 N% p/ e! ^was in the differential diagnosis because his father3 C* i, K5 c" t9 N8 E
started puberty somewhat early, and occasionally,
1 L9 G  ~9 y+ z% r0 jtesticular enlargement is not that evident in the# p8 G+ T$ U) c; p) Z: Y
beginning of this process.1 In the absence of a neg-7 g8 `; X: `4 @3 S2 Z( e( k5 N
ative initial history of androgen exposure, our# m' V8 g; B$ t" x& N" F3 c
biggest concern was virilizing adrenal hyperplasia,
  F8 O" T& L2 s: I- H8 a- }+ yeither 21-hydroxylase deficiency or 11-β hydroxylase0 s% y5 F$ J" a4 l! `) h
deficiency. Those diagnoses were excluded by find-6 X8 B5 q, L' C! R
ing the normal level of adrenal steroids.
4 a6 e, L$ a* m/ n- vThe diagnosis of exogenous androgens was strongly
* }  e# w9 N( K" ^suspected in a follow-up visit after 4 months because
/ o) p+ j3 I/ k. Pthe physical examination revealed the complete disap-
# d% s- r$ l2 y: B& hpearance of pubic hair, normal growth velocity, and
' |7 u8 {2 F& \9 F4 Y6 j2 q7 ydecreased erections. The father admitted using a testos-
& w% \* ^2 H8 N% r- Hterone gel, which he concealed at first visit. He was
5 k( g1 P  g2 ^2 R1 Q7 ^using it rather frequently, twice a day. The Physicians’
) B9 n) e; B: d$ d2 ^$ S4 q+ ^8 }Desk Reference, or package insert of this product, gel or. S& P, v, l* e9 N3 u/ l9 d
cream, cautions about dermal testosterone transfer to! [8 i/ F1 `0 l2 x
unprotected females through direct skin exposure.  r5 ?9 o9 ?) @% H8 H8 C' T
Serum testosterone level was found to be 2 times the
( I* ^/ c( H/ s: f* O8 g2 K4 ?baseline value in those females who were exposed to
6 F; P. x+ H2 j+ q- teven 15 minutes of direct skin contact with their male
& P) l* T5 T* [/ jpartners.6 However, when a shirt covered the applica-
3 x, L7 c5 C8 c. f7 Ytion site, this testosterone transfer was prevented.
1 [, K: U% f1 vOur patient’s testosterone level was 60 ng/mL,
/ k1 V4 d) _& z% ewhich was clearly high. Some studies suggest that9 d1 `% p0 X- |4 ~+ B
dermal conversion of testosterone to dihydrotestos-4 q, @. R$ n) h' R4 Q2 h
terone, which is a more potent metabolite, is more
/ A* P1 b9 Q. G; f! d+ Gactive in young children exposed to testosterone
- S% v, B1 Q; D. l0 i) S4 kexogenously7; however, we did not measure a dihy-" k% ^' M1 [9 J1 P1 s% f
drotestosterone level in our patient. In addition to
5 A- s0 A0 I& H5 S) m' x$ ~$ Dvirilization, exposure to exogenous testosterone in" C' e; ~8 @; h" M
children results in an increase in growth velocity and# w8 `& ]% v0 K- P* N
advanced bone age, as seen in our patient.* H& z% w# R5 Z/ c! B
The long-term effect of androgen exposure during! m6 n" e0 k5 J+ A
early childhood on pubertal development and final) D; x- |# ~) ^3 r
adult height are not fully known and always remain
& e' H9 z9 j( T& R# @, h) [" @# ra concern. Children treated with short-term testos-
' m6 [( A  n& j1 y* Gterone injection or topical androgen may exhibit some$ S. f4 T5 K5 P) m
acceleration of the skeletal maturation; however, after
4 K! n# F2 u) Mcessation of treatment, the rate of bone maturation- v$ v; g) O7 S" h7 h- H7 e
decelerates and gradually returns to normal.8,9
( T: ^6 C# ^) u8 }, z9 E. F. v8 l1 ^There are conflicting reports and controversy; p7 V1 l2 ?+ |  t$ l( }) R% B
over the effect of early androgen exposure on adult
) `, ~& _. L1 w0 ]) Kpenile length.10,11 Some reports suggest subnormal; I9 l. g: t6 h, ?% N% g
adult penile length, apparently because of downreg-) f+ o" B  Q1 K
ulation of androgen receptor number.10,12 However," v6 `1 ]% \5 M6 ^3 v5 f
Sutherland et al13 did not find a correlation between1 C+ T6 h/ r- m4 C
childhood testosterone exposure and reduced adult
1 {6 i' I8 D, ^! k7 W9 O; zpenile length in clinical studies.
' e7 `9 h2 v, e6 qNonetheless, we do not believe our patient is( X  k3 |+ [( }; y5 C! ~6 y( N
going to experience any of the untoward effects from
3 g% D5 @5 d, [+ R8 M+ v5 ]& Ctestosterone exposure as mentioned earlier because6 m1 ?5 ^- W( Z  p8 m3 O. x
the exposure was not for a prolonged period of time.
( H. [* h9 W. V1 a  FAlthough the bone age was advanced at the time of3 a, w1 c8 N3 _. s8 u
diagnosis, the child had a normal growth velocity at" }7 B, W7 h& M& x
the follow-up visit. It is hoped that his final adult7 M: k& l9 S, b  d. Y1 ~, t3 _8 m
height will not be affected.
- j& O& f! y4 }. S( _$ CAlthough rarely reported, the widespread avail-
7 {# i7 u) s; B# G1 s/ O: M$ iability of androgen products in our society may& Q$ t/ X% X! v
indeed cause more virilization in male or female
# f- G. M$ b) L2 fchildren than one would realize. Exposure to andro-
- X8 I. Y' _1 p3 L' Ygen products must be considered and specific ques-4 _. i* r8 k3 a' h6 K
tioning about the use of a testosterone product or
: x" a8 O: |5 bgel should be asked of the family members during: c, K5 k! H4 L: z* R/ d& `
the evaluation of any children who present with vir-
1 `* ^# G% Y0 e7 Y# xilization or peripheral precocious puberty. The diag-' [5 w& z6 g4 j& M+ B4 q
nosis can be established by just a few tests and by
! u9 f9 n& D7 u# @/ g: Happropriate history. The inability to obtain such a
* J3 v% ]" ~  G, R+ p- {history, or failure to ask the specific questions, may
& I4 @3 n/ E! f2 L/ R6 q: nresult in extensive, unnecessary, and expensive; C( j# V3 }1 Y8 R, w
investigation. The primary care physician should be+ ]- Y& |3 t: T& E
aware of this fact, because most of these children, N2 e7 g) M* e) f  X7 p, ?0 |
may initially present in their practice. The Physicians’
/ h# E$ O4 i/ c  I$ f# }Desk Reference and package insert should also put a
% g* e1 n5 J4 }- i* l8 X1 uwarning about the virilizing effect on a male or- O/ q/ I" U8 v7 ~; Q3 |# Q
female child who might come in contact with some-6 _8 \* T1 Y0 H+ X! T
one using any of these products.# n. Q4 W( {7 ]! E+ A
References6 M) w# R4 i- w0 }( H2 c
1. Styne DM. The testes: disorder of sexual differentiation
% L# R5 s1 \/ Cand puberty in the male. In: Sperling MA, ed. Pediatric: p% \9 M$ m/ w- [- c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 M( b& K, s# x, U
2002: 565-628.9 l: L4 s( w; G. @3 ]/ l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ t/ C7 [8 z% }  Q4 H0 P5 `5 Epuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
! l9 g2 R7 m4 s: D, T% _Boy Induced by Indirect Topical
% z  o, v% a5 E( N1 l, G- WExposure to Testosterone# h6 t9 g4 h! r+ I7 v; X/ C
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ G5 J& u& d) `7 E  w( J# a
and Kenneth R. Rettig, MD17 ~) x. [! `% L4 W8 P% Y
Clinical Pediatrics
# t# w( H4 e+ ^Volume 46 Number 6# P1 Z6 K% h& v1 k
July 2007 540-543
0 g/ t/ s4 m9 Q© 2007 Sage Publications
8 |, i& C3 |8 `7 N. D10.1177/0009922806296651
, x1 d4 g1 N! s' P/ hhttp://clp.sagepub.com$ _1 A; H. X# \. W5 L9 |% ]+ A$ A2 O
hosted at. w& z5 ~; x# k5 ~* v( D
http://online.sagepub.com
, d+ r7 D; C1 X$ g% |Precocious puberty in boys, central or peripheral,
6 }' R$ E; o" u1 C) A' b; {, Dis a significant concern for physicians. Central
  K5 ]) u( R& V2 J. Zprecocious puberty (CPP), which is mediated. c4 _% ^- R7 b1 G8 y6 \9 c4 ?
through the hypothalamic pituitary gonadal axis, has
  B$ X1 K) E$ Y' N: M& o6 Qa higher incidence of organic central nervous system; K2 Q" Q4 p% N
lesions in boys.1,2 Virilization in boys, as manifested
1 U# B+ @0 m/ Z  x) C4 c- Jby enlargement of the penis, development of pubic3 u, N3 A5 l9 L
hair, and facial acne without enlargement of testi-
& x/ [' u: |+ p, [cles, suggests peripheral or pseudopuberty.1-3 We
# Z) P1 W& H1 m$ `5 M4 ~2 I; A  y/ Nreport a 16-month-old boy who presented with the# O+ D8 p& |, @6 b8 `7 D, ?5 D& q
enlargement of the phallus and pubic hair develop-( m) M) F% O, I5 J
ment without testicular enlargement, which was due( b( T( h" L. ^; \+ O0 r8 v# L! ^
to the unintentional exposure to androgen gel used by
$ N  M  k% q& V" g% tthe father. The family initially concealed this infor-3 s9 a  B* i( r( J) `1 w# @2 q
mation, resulting in an extensive work-up for this
! E- n% m! l& h' X& |& {+ H0 ochild. Given the widespread and easy availability of
$ g2 v' M8 y* B& h5 K/ w3 ?testosterone gel and cream, we believe this is proba-) N) L9 N" ^. t
bly more common than the rare case report in the
1 T# ]! h8 ^5 l+ \* \literature.4
6 _+ ?8 `2 B& iPatient Report
; ^8 O3 |/ R$ x! }0 A& j& l, @A 16-month-old white child was referred to the
! A* ~: O# {9 K' d; Kendocrine clinic by his pediatrician with the concern4 y) h7 _6 x" I7 G* L2 N
of early sexual development. His mother noticed& j& C8 G( g6 ^$ ~
light colored pubic hair development when he was
) r3 J; _! g5 k; S& PFrom the 1Division of Pediatric Endocrinology, 2University of
+ A0 y& b1 k, BSouth Alabama Medical Center, Mobile, Alabama.
5 J7 i# @& k/ c1 B5 e5 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. y; e" N8 s; [3 [! f" xProfessor of Pediatrics, University of South Alabama, College of2 E$ V; u/ p& d$ P/ _; C) o
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) R* m/ R) h3 f% k
e-mail: [email protected]." `* W4 R; t: ^) h' l/ X
about 6 to 7 months old, which progressively became; h+ J" o' w5 i) ?) V
darker. She was also concerned about the enlarge-
* E+ f7 \) \$ M3 i+ {ment of his penis and frequent erections. The child7 C: H  o- ?$ y4 n# u5 A9 ~3 m
was the product of a full-term normal delivery, with
* t% t2 r/ h3 S6 L6 F  ?$ t& q  ha birth weight of 7 lb 14 oz, and birth length of
9 i$ C# N8 j, v4 I20 inches. He was breast-fed throughout the first year0 C$ k2 }* }2 A5 w# o: N
of life and was still receiving breast milk along with8 C2 z$ x% H6 }0 A3 r
solid food. He had no hospitalizations or surgery,; Z7 ]; d0 P( z
and his psychosocial and psychomotor development
" z/ S  X/ K7 p* q, Dwas age appropriate.
. c  g9 b# J. m& l" VThe family history was remarkable for the father,
8 J* a8 l; M, E2 q1 }who was diagnosed with hypothyroidism at age 16,, C$ D% s* @& l# G; [% E% E
which was treated with thyroxine. The father’s. O' y% Q  E3 Q1 R' s, m7 T' i. W0 h$ S
height was 6 feet, and he went through a somewhat
) b( I3 ~) i2 u, mearly puberty and had stopped growing by age 14.' I; E! O, i3 h4 |7 p: F
The father denied taking any other medication. The
; H) E! D# t, w! o: e! X" achild’s mother was in good health. Her menarche
, n( ^' P- k8 P9 G: \% s" vwas at 11 years of age, and her height was at 5 feet8 y6 \! v/ x' F& S# R& \
5 inches. There was no other family history of pre-
8 P; r. G) I9 H% F* T$ N3 Pcocious sexual development in the first-degree rela-9 t3 Q" T. V: z8 }5 O
tives. There were no siblings." V& t. B8 M1 \& l% g
Physical Examination3 |9 s1 l5 |/ _$ _  S
The physical examination revealed a very active,  l4 M. _+ H: |$ n
playful, and healthy boy. The vital signs documented! ^& Q- T. ]6 t8 F* |
a blood pressure of 85/50 mm Hg, his length was7 y4 D# D3 j3 [% q
90 cm (>97th percentile), and his weight was 14.4 kg2 N- X9 S) O; R0 n2 o
(also >97th percentile). The observed yearly growth
" W  R3 g3 ]. Q/ h3 Wvelocity was 30 cm (12 inches). The examination of
2 J2 B9 q+ L. P+ W: Ethe neck revealed no thyroid enlargement.* n; x- J* i0 h& E
The genitourinary examination was remarkable for' }6 a9 p* H. ^6 n# B$ [0 V. I
enlargement of the penis, with a stretched length of
" c( [+ t; ^' _' [$ T8 s+ c" R  D8 cm and a width of 2 cm. The glans penis was very well  A% _- {2 H- H# m/ @( L7 E
developed. The pubic hair was Tanner II, mostly around: `* j. C' r# {0 g! g
540
; V4 K' s4 S4 w! I5 D/ Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: _# W1 Q+ }8 v& ^3 Xthe base of the phallus and was dark and curled. The" H- T9 H; T/ |9 G0 J/ v) w
testicular volume was prepubertal at 2 mL each.
! S3 `9 g. ?1 r) J( ^( p7 H8 Y7 ZThe skin was moist and smooth and somewhat
/ ~& S; o3 B" w& o8 m4 Zoily. No axillary hair was noted. There were no8 h; _/ I+ \9 j2 V; w, o8 s
abnormal skin pigmentations or café-au-lait spots.& g" c0 U/ b* c2 r6 ^1 `5 |7 M
Neurologic evaluation showed deep tendon reflex 2+
0 z8 f! B, ?, p, X, S! zbilateral and symmetrical. There was no suggestion2 U( E/ g' L8 l/ k4 D  v7 W
of papilledema." t, l4 s6 W7 ~) B6 x
Laboratory Evaluation4 U3 _: f0 E) [- n* q
The bone age was consistent with 28 months by6 t0 K9 L6 G+ p0 p
using the standard of Greulich and Pyle at a chrono-
( ~2 V* K" m% d4 s8 Ilogic age of 16 months (advanced).5 Chromosomal
4 P- Q0 Z) f* C: K' l. tkaryotype was 46XY. The thyroid function test
3 H. v% m4 A$ D/ Y% Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-2 g: B" x% C- F% B% b9 f
lating hormone level was 1.3 µIU/mL (both normal).
* ]: o4 a  M  m9 l' N0 ]& M5 `The concentrations of serum electrolytes, blood
8 U0 c6 C' A- h& X; Burea nitrogen, creatinine, and calcium all were
+ ~! E- ^( E* `% B% }  i3 {within normal range for his age. The concentration2 O# F- f/ W3 Z" b8 s. t) P" @
of serum 17-hydroxyprogesterone was 16 ng/dL1 h" X2 K' q$ g1 w9 `
(normal, 3 to 90 ng/dL), androstenedione was 203 b8 _) f9 a4 R: ?. V! Y/ Y& g/ d
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" p5 j  g( }& y) @' ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),, t/ F7 ^* X9 Y. Y2 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) k* {: O' l% _& D49ng/dL), 11-desoxycortisol (specific compound S)
" K3 e2 \: h9 k6 qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' a5 U) I) v8 ~% e, N8 Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 S" F  q( ]7 c5 D/ a) R7 [2 w+ w: `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& O9 O! a) E5 W
and β-human chorionic gonadotropin was less than% C' h1 ]; X+ ]! M! ]) I- E9 x
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 b" E9 A5 X* R) w4 `" N1 ?$ cstimulating hormone and leuteinizing hormone
6 D/ G9 m" |  p0 U' T2 n7 p& vconcentrations were less than 0.05 mIU/mL# Q5 g8 v. U9 @3 ]5 K; }
(prepubertal).
. u! R& z( S1 q4 ^8 D+ VThe parents were notified about the laboratory) g* Q) |% R, L/ K  `; {
results and were informed that all of the tests were" X# `, @6 j  j" i; K) R
normal except the testosterone level was high. The) P7 a9 `4 Q/ B% {$ s+ @: v; r; {
follow-up visit was arranged within a few weeks to
& m! |( b5 w3 o! B8 s0 l5 _obtain testicular and abdominal sonograms; how-: \! w  @" U) I6 \( _
ever, the family did not return for 4 months.
8 e) Q4 z5 K) E5 Z  P+ UPhysical examination at this time revealed that the
1 M) l: Y& l, h5 ~2 [) T% @child had grown 2.5 cm in 4 months and had gained7 h+ G9 V  U4 I( u& G/ y3 s
2 kg of weight. Physical examination remained& j: P, T6 C( c6 Z7 W
unchanged. Surprisingly, the pubic hair almost com-
; I5 N* t, {4 n6 Wpletely disappeared except for a few vellous hairs at
/ r; [, e$ u$ K% `3 `! {0 w% f; pthe base of the phallus. Testicular volume was still 28 t1 P; J$ q7 I7 Q- L
mL, and the size of the penis remained unchanged.
% D1 S' K8 P! Y6 dThe mother also said that the boy was no longer hav-2 P6 V% |% ]6 H2 a: ?3 g( U9 O
ing frequent erections.
- ^5 S5 X( C: S0 N' wBoth parents were again questioned about use of( C- ]7 J$ [! X6 m, A
any ointment/creams that they may have applied to& b8 _7 S2 g3 T  ]7 X& L6 `9 p
the child’s skin. This time the father admitted the- P) _3 e' I" i1 c
Topical Testosterone Exposure / Bhowmick et al 541
; k! Q/ L7 N! g  S: w1 Juse of testosterone gel twice daily that he was apply-& N+ y2 B) B2 L0 Z3 e& U
ing over his own shoulders, chest, and back area for3 y0 U! S* j6 v
a year. The father also revealed he was embarrassed2 L- F' L3 t: V" d- {  W
to disclose that he was using a testosterone gel pre-8 K; d7 P0 n' e% `7 u' b1 h
scribed by his family physician for decreased libido
# a( r# m# G% Q* Qsecondary to depression.3 K$ W# R2 H' S5 ^+ W5 e$ v) k
The child slept in the same bed with parents.# \2 D* O2 o/ l1 I# S
The father would hug the baby and hold him on his" u. x# i/ q; y' w' G* F
chest for a considerable period of time, causing sig-. T( j- P, c5 K$ i
nificant bare skin contact between baby and father.
) b! r( ]( ~& R' ^& e& ^The father also admitted that after the phone call,1 x% D/ b( b) B
when he learned the testosterone level in the baby: }/ m% V6 o* n1 {3 ~, I( I
was high, he then read the product information
: [/ V1 y5 ]7 a4 J. u5 K4 Vpacket and concluded that it was most likely the rea-
! I( I& a5 ]  T0 qson for the child’s virilization. At that time, they
0 a* X" I3 L1 {decided to put the baby in a separate bed, and the
" R2 I, N/ `: e# ?1 a/ }  v  afather was not hugging him with bare skin and had
! J' h$ k" f$ z: \4 Y/ Qbeen using protective clothing. A repeat testosterone- Y) y$ W' j6 W' D8 W
test was ordered, but the family did not go to the) {" m8 V% x* l: c' d, H
laboratory to obtain the test.
/ C+ k! F1 V4 j0 W, R6 q" X' sDiscussion- e* y6 f5 T  k; |
Precocious puberty in boys is defined as secondary9 M5 K# f1 |& i4 H% ]. m
sexual development before 9 years of age.1,4
. f5 `3 l0 `) U2 |4 jPrecocious puberty is termed as central (true) when) R) ]1 o1 [' t( V
it is caused by the premature activation of hypo-0 k( B9 m5 }" w2 ]  B! |: {7 D2 K/ f
thalamic pituitary gonadal axis. CPP is more com-
8 P8 \: }3 `  F% g; Cmon in girls than in boys.1,3 Most boys with CPP
. @" ?! c; C& f: p1 g" d4 ]7 O* a4 pmay have a central nervous system lesion that is
% e9 Q: B- _, I7 _" mresponsible for the early activation of the hypothal-2 \2 M, E6 f2 B& }6 K, h
amic pituitary gonadal axis.1-3 Thus, greater empha-5 Z, d2 Z$ _" l* h4 L4 l2 s! ~8 m6 r
sis has been given to neuroradiologic imaging in
; \( E3 t8 Q1 J+ |& Aboys with precocious puberty. In addition to viril-
. C) z/ ^- b) ]$ a3 k9 t+ ~/ zization, the clinical hallmark of CPP is the symmet-
0 S2 Z- E" J6 I3 s. hrical testicular growth secondary to stimulation by. W& E8 ]% s8 s5 k& p
gonadotropins.1,3! V" P% @( v8 a* b: L4 D
Gonadotropin-independent peripheral preco-, A6 W+ F  J$ z: y1 C) z8 ?
cious puberty in boys also results from inappropriate# Q4 V9 y% Y- [3 X$ c' Z) v2 E
androgenic stimulation from either endogenous or
3 _7 M: g- R5 s: Zexogenous sources, nonpituitary gonadotropin stim-# J+ R7 ?" {( l
ulation, and rare activating mutations.3 Virilizing& Y6 W4 L* j; L1 K0 ]) t( A, G2 I( S
congenital adrenal hyperplasia producing excessive& @* ?( L6 U$ [
adrenal androgens is a common cause of precocious8 w4 y$ u0 V/ s4 B/ Z4 z# c$ @
puberty in boys.3,4
  r  `1 ], @& K: K2 a% dThe most common form of congenital adrenal# g1 J. Z) n8 n1 _: R0 l1 u- _% r0 u( t/ V
hyperplasia is the 21-hydroxylase enzyme deficiency.1 m6 z4 q; l5 L2 e+ V* B. n/ S
The 11-β hydroxylase deficiency may also result in0 e7 b6 M4 R7 f3 G
excessive adrenal androgen production, and rarely,
  X8 u9 N: U' ?* i, c3 _an adrenal tumor may also cause adrenal androgen6 Y$ K" m" ~/ Y' ~6 }, C
excess.1,3
" Z; s. a6 l" J1 T; D' P: {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ f# ?4 ~  v$ K7 p. i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( L# u0 o2 a% K/ B/ mA unique entity of male-limited gonadotropin-
( ], l* C1 u$ S! a" }1 `3 @7 S& N% bindependent precocious puberty, which is also known6 o) h- M$ ?: Y; P  F/ A% L( L
as testotoxicosis, may cause precocious puberty at a
. v9 k: ?+ v1 v9 t- [0 bvery young age. The physical findings in these boys0 N$ J9 V- a/ K- n; l
with this disorder are full pubertal development,% \' P" L) w- L5 r2 |9 Z
including bilateral testicular growth, similar to boys
! e8 i$ M7 F% u$ l" S4 x" Awith CPP. The gonadotropin levels in this disorder
/ L$ H( x* D2 h3 o6 Rare suppressed to prepubertal levels and do not show6 t) @9 u0 p1 N4 N: q: j+ _
pubertal response of gonadotropin after gonadotropin-
1 o2 a8 @: Z( k) n; @) |2 vreleasing hormone stimulation. This is a sex-linked9 m. T* T- H% J& \( k2 X
autosomal dominant disorder that affects only6 |% h' [$ r6 R/ d, B/ P
males; therefore, other male members of the family
4 k1 J+ F1 }- nmay have similar precocious puberty.3$ V. d$ L9 D2 M/ a( E  [* F) Q
In our patient, physical examination was incon-
7 L+ B5 \# o- Bsistent with true precocious puberty since his testi-
2 f& T. \9 s5 R% {3 V+ N' j  Scles were prepubertal in size. However, testotoxicosis
: |( R+ o  C. l4 S& r8 @0 ^' Bwas in the differential diagnosis because his father
; l6 j% X8 X8 vstarted puberty somewhat early, and occasionally,0 L4 K/ u6 S2 \  [& W' P
testicular enlargement is not that evident in the) U: I' t0 L5 ?, ]' `
beginning of this process.1 In the absence of a neg-' ^5 l0 `% k% y# h6 g0 x" t
ative initial history of androgen exposure, our1 w2 _& L" }* p. {8 U
biggest concern was virilizing adrenal hyperplasia,
; D3 |5 x0 M/ \9 D% p' r* `either 21-hydroxylase deficiency or 11-β hydroxylase
! L4 y' V* _5 g1 r% i% ?  p* Edeficiency. Those diagnoses were excluded by find-7 K) t8 L- c( k3 g! ~
ing the normal level of adrenal steroids.( v* C$ W0 Y1 G6 w) j; @
The diagnosis of exogenous androgens was strongly
+ n& X5 J7 K% s, b" B5 t5 W; Tsuspected in a follow-up visit after 4 months because$ W; _4 F5 ^- f0 O; ]' K+ r
the physical examination revealed the complete disap-# g" {) R8 N5 ^4 \1 t
pearance of pubic hair, normal growth velocity, and- Z1 v7 T5 q( _3 u0 h
decreased erections. The father admitted using a testos-/ R" m5 U: [% m% Y
terone gel, which he concealed at first visit. He was
) F2 b0 c8 z6 Z1 E3 {using it rather frequently, twice a day. The Physicians’
% V! w* M3 V5 z3 s  ?, s* P: W" T& eDesk Reference, or package insert of this product, gel or. H' g6 V( P- Y, @
cream, cautions about dermal testosterone transfer to& O  ?7 N) M8 h( k& C% z
unprotected females through direct skin exposure.
. V, I* J0 E9 t% v, YSerum testosterone level was found to be 2 times the0 P$ _! j9 q. p. [5 J
baseline value in those females who were exposed to  h5 ~2 t& E, h
even 15 minutes of direct skin contact with their male
- |3 S+ R$ \' S, |- i0 F/ S5 lpartners.6 However, when a shirt covered the applica-3 w/ g  j2 a1 k% l- F) o: y2 v
tion site, this testosterone transfer was prevented.
2 |' q* c& v  T/ H; d! GOur patient’s testosterone level was 60 ng/mL,* g/ @2 c# v+ I0 m# d
which was clearly high. Some studies suggest that
+ v' p& t; j5 F# X  }9 ^3 jdermal conversion of testosterone to dihydrotestos-
& J' T  o) i7 _. s% W- O$ mterone, which is a more potent metabolite, is more
& g5 t& O% w# cactive in young children exposed to testosterone  `" R7 I: r- O# X
exogenously7; however, we did not measure a dihy-) q+ Z& L0 p) g- a
drotestosterone level in our patient. In addition to. Y* K( E# \* j
virilization, exposure to exogenous testosterone in
4 M" d1 W2 d8 Z6 k- ochildren results in an increase in growth velocity and& y& A% _: M  z; `; C! J* ^" k
advanced bone age, as seen in our patient.
& h' j; f+ o4 H1 P" fThe long-term effect of androgen exposure during* f4 e% d, R! e' {, z
early childhood on pubertal development and final$ h) A5 x4 B$ Y
adult height are not fully known and always remain6 V: t; k6 N1 m! z0 U
a concern. Children treated with short-term testos-
) p6 Q& i7 T6 z/ `2 }6 Iterone injection or topical androgen may exhibit some! i4 f( Y" l' k4 }. ~' k
acceleration of the skeletal maturation; however, after" R6 U) Y1 r2 G! I. S/ X8 e
cessation of treatment, the rate of bone maturation
# U2 ?6 s& J. N: B  g* gdecelerates and gradually returns to normal.8,9  Z* T- K$ R) e+ g$ _9 h) t- X
There are conflicting reports and controversy+ p8 ?* e' W2 ^
over the effect of early androgen exposure on adult
! A3 o0 E1 ^5 Q+ Zpenile length.10,11 Some reports suggest subnormal8 [* c1 C" ]: z' E, ]4 e
adult penile length, apparently because of downreg-  z  O; O0 j) @/ N
ulation of androgen receptor number.10,12 However,
5 q& ~! m3 a' p% qSutherland et al13 did not find a correlation between$ i; [% ]! x6 e% W
childhood testosterone exposure and reduced adult+ c* y$ z6 B$ A0 g! s3 B/ \; t
penile length in clinical studies.+ y7 I; _$ _9 F
Nonetheless, we do not believe our patient is. t# G5 ?% \, }; ?' S( y/ k6 [& E  `+ D
going to experience any of the untoward effects from
: _9 B' I* G# I3 K" H" m% a6 ltestosterone exposure as mentioned earlier because
- W2 U# g7 e3 q, Wthe exposure was not for a prolonged period of time.
5 D6 y$ A+ l8 x8 QAlthough the bone age was advanced at the time of
: ^! |! p) d9 ]6 p& Ediagnosis, the child had a normal growth velocity at& ^* M8 O, ?$ U8 x; m! L
the follow-up visit. It is hoped that his final adult
9 Q6 S- M, U8 Zheight will not be affected.; c7 |7 Y' }' X7 ^1 t- t& n
Although rarely reported, the widespread avail-
4 J+ w2 y2 I, o  Lability of androgen products in our society may) ]9 Q4 o/ }2 A0 Y2 h
indeed cause more virilization in male or female
8 Q; l5 z2 j( E' r/ p* cchildren than one would realize. Exposure to andro-
% Z( z$ W; Y6 v) Agen products must be considered and specific ques-
3 B/ ^3 X( i. V7 r3 vtioning about the use of a testosterone product or0 |# ^6 _  P' S5 W" |: _
gel should be asked of the family members during
, r2 @  T3 W: \+ B  @1 o, x1 ^the evaluation of any children who present with vir-
( N5 ^  l+ {9 d9 I- f! kilization or peripheral precocious puberty. The diag-8 C3 g0 w6 I( d% U
nosis can be established by just a few tests and by
1 t5 @/ [. [- M3 Dappropriate history. The inability to obtain such a
2 I! ?* H0 X" A" u2 a7 }3 @1 C% a; X1 Fhistory, or failure to ask the specific questions, may
' S* H/ Y; ]/ U- N% Wresult in extensive, unnecessary, and expensive: W; F: y. ]; E) X4 _
investigation. The primary care physician should be1 v; V9 J2 L6 z& i3 I" t8 `
aware of this fact, because most of these children4 ~2 B* m* B5 V; g9 t; I
may initially present in their practice. The Physicians’
6 B/ q- Q! M0 BDesk Reference and package insert should also put a: O) ]0 _) U& A! Z+ R" v$ Y
warning about the virilizing effect on a male or
2 L' C/ P0 W3 {0 `1 j8 @9 ~female child who might come in contact with some-
9 h5 X- n% p, M! i( Y9 L7 \; [$ n# mone using any of these products.# |" V+ X: M  E% ?
References7 ?3 ^2 _# a' d7 G! j
1. Styne DM. The testes: disorder of sexual differentiation
7 L$ ]) V  i. x0 k% x; land puberty in the male. In: Sperling MA, ed. Pediatric  q8 r* w) |8 D) a* ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# t' r! o6 U5 r- p3 y6 C% ?2002: 565-628.
" D) B4 Q2 N+ t. R  j2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) V2 k+ o, [3 m& i+ H& x
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

+ I; k+ u9 U- a  a  D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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