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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) ~9 a: M( W9 H! i2 g! M" ?8 y% Y
Boy Induced by Indirect Topical
- z+ j% o8 Z- ^0 z  N* [Exposure to Testosterone- j- v' K/ L# S1 a1 l6 `3 P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. L/ L9 M# q7 p8 U0 E
and Kenneth R. Rettig, MD1: M+ @1 A! [* X0 H& B3 f% _5 I
Clinical Pediatrics' q! w+ Y  Q: G# E! z
Volume 46 Number 6
% j! E* [  |- N3 I# j& W5 tJuly 2007 540-543
3 T0 U6 U* k+ }1 b$ W( V9 ]0 s( L8 z© 2007 Sage Publications& p  b( C: p1 f
10.1177/0009922806296651, p( I. C0 I4 ?
http://clp.sagepub.com
% e* i) U) t6 y. rhosted at
( M0 W8 n$ z- T+ e4 ahttp://online.sagepub.com2 y4 G( b- p! U$ p! f7 N
Precocious puberty in boys, central or peripheral,9 R1 C$ ^' X4 }7 ~
is a significant concern for physicians. Central
  K" N" e3 m) h" }9 e& \precocious puberty (CPP), which is mediated+ q- K5 n& l+ R0 l) U/ @, H6 a- ]& q
through the hypothalamic pituitary gonadal axis, has  `) ?# T% l3 u/ d5 c* q7 k
a higher incidence of organic central nervous system( N9 t) A' Y' P* W" _4 l0 y
lesions in boys.1,2 Virilization in boys, as manifested" W6 ?2 E; z2 {, i8 f7 [% o
by enlargement of the penis, development of pubic
! w3 R8 D' y/ q& Qhair, and facial acne without enlargement of testi-
7 B2 Z" {: h, s  |cles, suggests peripheral or pseudopuberty.1-3 We0 ?6 a' b, q- r; b( k& g2 e& v
report a 16-month-old boy who presented with the* R/ u8 D- _* K) e; A! q7 X5 q
enlargement of the phallus and pubic hair develop-5 \$ h' p4 Y# J- `8 U  v
ment without testicular enlargement, which was due) r7 D# V5 C+ j$ ~
to the unintentional exposure to androgen gel used by) E& c2 j0 v5 W1 h# e
the father. The family initially concealed this infor-
9 c; u2 q( q& \! o9 Hmation, resulting in an extensive work-up for this1 d+ L  J4 _$ N9 p
child. Given the widespread and easy availability of
& |4 e! r! m% O8 p: C% h1 |testosterone gel and cream, we believe this is proba-
. h3 O0 y$ i6 ?! Z) `bly more common than the rare case report in the
0 g5 Q1 g* N9 I% r9 ^literature.4( F9 `2 A) y2 ~4 K
Patient Report
  @* ~) E, J9 |. `# CA 16-month-old white child was referred to the9 m8 e: R5 y) [$ ?. a
endocrine clinic by his pediatrician with the concern7 a  J8 f' {2 Y/ X5 K% `
of early sexual development. His mother noticed" F7 Y5 X; o2 u
light colored pubic hair development when he was
) J! ]& o* j2 D6 m( y* nFrom the 1Division of Pediatric Endocrinology, 2University of
/ T( x# d$ n7 E: ESouth Alabama Medical Center, Mobile, Alabama.
6 P! f- z: }7 A: R/ ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 q' E+ y6 ?+ h1 w3 L1 kProfessor of Pediatrics, University of South Alabama, College of. L- p! k% q! ~7 `* W9 E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 J3 |# a& e! q' Z, a' b
e-mail: [email protected].
4 x8 z9 `, M8 i4 fabout 6 to 7 months old, which progressively became
# O# [8 w2 h! c& @  @& Fdarker. She was also concerned about the enlarge-6 e1 i# M! N# V/ k+ H# E/ {
ment of his penis and frequent erections. The child
: J5 Y# O% H3 r3 u, Ywas the product of a full-term normal delivery, with
+ }5 H: C  \/ {" m. x% _) }a birth weight of 7 lb 14 oz, and birth length of5 q( K1 V. c; v% z+ n
20 inches. He was breast-fed throughout the first year5 V) E0 d1 l7 E8 x/ z
of life and was still receiving breast milk along with
, x& d8 C& b; q# H  ~& G! }6 _solid food. He had no hospitalizations or surgery,; ~! j, r3 u, k3 o3 \
and his psychosocial and psychomotor development& B( Z1 K8 n3 l! |9 Z3 v
was age appropriate.
' b& A1 p2 D- H! r$ uThe family history was remarkable for the father,
! D! H% h6 O/ ~1 M3 o+ @, mwho was diagnosed with hypothyroidism at age 16,
' |: |2 ?8 I: [* `which was treated with thyroxine. The father’s8 n; r" I4 G1 p$ h
height was 6 feet, and he went through a somewhat2 r  s$ ]" O! K- O. u: O1 e, k
early puberty and had stopped growing by age 14.7 w0 g9 L  q- W3 u3 @0 d
The father denied taking any other medication. The
2 V* Z4 d/ T0 T( [6 \child’s mother was in good health. Her menarche
+ B- i' F" L: x0 F( Vwas at 11 years of age, and her height was at 5 feet7 J6 e6 D6 r* y
5 inches. There was no other family history of pre-
- c8 P' G+ y2 ccocious sexual development in the first-degree rela-
4 B1 n3 e( c2 W! l5 L/ gtives. There were no siblings.3 d4 E' u/ d% y' n# y
Physical Examination
9 |9 }' A" D) G6 i" E# k, jThe physical examination revealed a very active,
+ s- K& x' n8 _5 }( i+ K6 g2 `playful, and healthy boy. The vital signs documented
, Y% w. a# e9 z1 ja blood pressure of 85/50 mm Hg, his length was1 m& `3 V8 b$ `, s. o* [! s- s; l
90 cm (>97th percentile), and his weight was 14.4 kg" K; C/ ?1 P/ u* Q' {3 T  Z; c
(also >97th percentile). The observed yearly growth
0 R1 }3 K7 i( ?( W5 u6 f/ L; Mvelocity was 30 cm (12 inches). The examination of3 P/ W& J! k: `
the neck revealed no thyroid enlargement.
$ p% O! i; q7 k, R. DThe genitourinary examination was remarkable for
7 A0 f, @( `% l- M1 X5 Penlargement of the penis, with a stretched length of4 h2 [5 `/ m* B8 z
8 cm and a width of 2 cm. The glans penis was very well
& o  {% c0 c: Y6 Z5 X& Ideveloped. The pubic hair was Tanner II, mostly around
, [) U1 H( Y. ~' A$ \' Y4 ~. }540
$ ~; C* G4 c6 x$ t1 p) Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ A6 u5 d# U- \1 j9 ?4 x7 W( X' ]
the base of the phallus and was dark and curled. The; b) l& H" L; b2 T
testicular volume was prepubertal at 2 mL each.
! \2 H; f9 G# g& ?The skin was moist and smooth and somewhat8 ?8 u; X) L/ H$ C0 v( f3 j
oily. No axillary hair was noted. There were no6 G+ C+ ?* L, D4 Q
abnormal skin pigmentations or café-au-lait spots.
! S! R4 [% x. G) ZNeurologic evaluation showed deep tendon reflex 2+
, o/ D" l7 W: L$ w7 b( ?+ `2 p7 H% ?bilateral and symmetrical. There was no suggestion
0 F- ?+ _0 l* v7 aof papilledema.
% Z8 O# v2 u" G" r( [Laboratory Evaluation( [0 ^+ f6 h; A( W; a
The bone age was consistent with 28 months by
3 Y3 V1 c' `9 s7 ~' X6 G$ t1 zusing the standard of Greulich and Pyle at a chrono-5 E9 i: l" f; i4 l8 y6 u. o$ O# R) z
logic age of 16 months (advanced).5 Chromosomal0 j: J/ g; p  v9 O+ A4 A: h
karyotype was 46XY. The thyroid function test
2 Y7 N" D8 m! l0 W9 d. z) m2 ^- W* }showed a free T4 of 1.69 ng/dL, and thyroid stimu-! T0 q; C9 _) G. v
lating hormone level was 1.3 µIU/mL (both normal).
8 X& C+ J! w5 \4 N. ^- c3 B: uThe concentrations of serum electrolytes, blood$ z* s; D5 k' K7 d) {4 j, B
urea nitrogen, creatinine, and calcium all were) _) @2 c+ b* |# i' [, `) @5 u
within normal range for his age. The concentration) {; A8 _5 k* ?7 b5 ?
of serum 17-hydroxyprogesterone was 16 ng/dL( V" G! F0 |5 }+ V
(normal, 3 to 90 ng/dL), androstenedione was 208 U7 G9 R5 `; H. L5 O1 J' n( {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: e% Y( X4 a4 k" v! K) t) K: ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! Q2 \) c7 [$ r5 Y- Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
) i; R! T! `+ z: h8 ]1 o/ Q49ng/dL), 11-desoxycortisol (specific compound S)
* W" g0 E! I; b  ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" _) V0 ~- m4 S; v& rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! P) ^7 q) B! H% J. @8 J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& d- Z" Q0 m4 X& k$ g/ s
and β-human chorionic gonadotropin was less than, ^1 s/ f4 N8 W
5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ A6 j' U. `7 b5 n% Xstimulating hormone and leuteinizing hormone* E% q/ F5 O9 i' _
concentrations were less than 0.05 mIU/mL# N& O1 A6 B/ g: K0 `  g. h5 k* G
(prepubertal).
- [, R1 D; ~# t# G4 Y" M, e# kThe parents were notified about the laboratory: a. W1 o, C4 [0 Z! U) n, |# K
results and were informed that all of the tests were+ Q4 D% W7 _, x$ T* x) g5 a
normal except the testosterone level was high. The" S: Q, j8 x1 g6 A2 @; w% J8 z
follow-up visit was arranged within a few weeks to
8 D4 o: h' m& H6 @" b3 s* V, vobtain testicular and abdominal sonograms; how-
" i  W0 g6 U' u6 L+ u& g' {ever, the family did not return for 4 months.
/ P  x/ X% c$ x/ m: y! jPhysical examination at this time revealed that the
) ]' ?9 G" e$ @0 C* t. achild had grown 2.5 cm in 4 months and had gained2 k0 ~, ~" z. [
2 kg of weight. Physical examination remained
3 i& ^, w" ~- `4 E" ^2 Vunchanged. Surprisingly, the pubic hair almost com-
$ H8 f- O& j' V" U0 tpletely disappeared except for a few vellous hairs at
% \- U8 a/ w! }( G8 W9 b, othe base of the phallus. Testicular volume was still 2
% U4 }* O1 h$ }' E2 }, bmL, and the size of the penis remained unchanged.
2 H  X. q) d+ c6 NThe mother also said that the boy was no longer hav-% |' z5 r& Z, N4 D; S
ing frequent erections.0 {6 H( ?" t$ M! ?
Both parents were again questioned about use of' k* E- V4 j9 N% E: h
any ointment/creams that they may have applied to. B5 _% [% g2 ^7 h7 ~
the child’s skin. This time the father admitted the8 b4 i+ ]+ q' p0 F) {' v6 F; _
Topical Testosterone Exposure / Bhowmick et al 541' G3 G" u2 L1 ~0 E# N4 w
use of testosterone gel twice daily that he was apply-
+ H0 w5 i: \9 j9 u: o1 ]' Wing over his own shoulders, chest, and back area for( u8 {3 R1 V: Z! N5 Y0 c; ^# B: p! e
a year. The father also revealed he was embarrassed
- [1 T) G( t. dto disclose that he was using a testosterone gel pre-
2 U/ o- k- z+ W; K/ a1 L3 Escribed by his family physician for decreased libido- K; h% s/ Z( q5 j  v
secondary to depression.
9 O! F1 M5 ~% D0 YThe child slept in the same bed with parents.
7 W6 Y7 U! R8 H6 XThe father would hug the baby and hold him on his" U0 C% X9 R7 n+ o1 v
chest for a considerable period of time, causing sig-' a6 J' r& O" |  D1 d6 X
nificant bare skin contact between baby and father.$ C6 X; k" ~# L7 n& N  |1 O
The father also admitted that after the phone call,
9 R% ?8 o$ j- R0 M; P8 y# cwhen he learned the testosterone level in the baby
/ c/ Z2 K  N, x" a% o$ }! Xwas high, he then read the product information" x) ?: H& r9 V; m
packet and concluded that it was most likely the rea-
0 [5 F' R& Z! k% j+ p! P$ }son for the child’s virilization. At that time, they9 ?) p  A: V. k! r
decided to put the baby in a separate bed, and the! V  D2 v1 s% n) g7 }! S+ L
father was not hugging him with bare skin and had
7 S/ i+ |3 T/ L+ C, `& }+ e7 k& |! nbeen using protective clothing. A repeat testosterone
6 ?; q7 r! l/ W3 V6 s# \test was ordered, but the family did not go to the! ~' g+ S; ]4 P$ ^! ^- m
laboratory to obtain the test.: b. f0 D' K9 Q3 ~$ e
Discussion- c  c* f3 B3 S( A; T
Precocious puberty in boys is defined as secondary
& s' b+ e& Y9 [4 ~sexual development before 9 years of age.1,4
: m0 p+ i/ {& q' KPrecocious puberty is termed as central (true) when6 d1 ]4 P9 _8 o- d" ?6 L
it is caused by the premature activation of hypo-
( V8 D. f' Z. \6 tthalamic pituitary gonadal axis. CPP is more com-- ^: Q9 K$ F2 J+ {
mon in girls than in boys.1,3 Most boys with CPP
) W$ h$ Q6 q7 P0 r& i9 tmay have a central nervous system lesion that is0 Z# S+ ]; x3 @2 A2 c2 ~
responsible for the early activation of the hypothal-
. f2 [+ x4 ]# T$ ~' v/ D3 n7 Hamic pituitary gonadal axis.1-3 Thus, greater empha-
1 Q: D' o. E4 {+ X5 _0 \sis has been given to neuroradiologic imaging in
& L, B" @& @/ ^9 |9 {' `& ?boys with precocious puberty. In addition to viril-1 r3 N  U, w8 l# G- v+ ~; r
ization, the clinical hallmark of CPP is the symmet-# F0 N3 k6 O# e% B. Q
rical testicular growth secondary to stimulation by
8 m% c5 a# V7 Ygonadotropins.1,3. d: H5 S& b: p  \$ y
Gonadotropin-independent peripheral preco-: V9 u8 z; h! K, t9 s. X% v, l
cious puberty in boys also results from inappropriate; }4 G% l; R8 B. w' I6 z4 [9 v- D
androgenic stimulation from either endogenous or0 t: m5 b9 n/ K! t* h' e; k
exogenous sources, nonpituitary gonadotropin stim-
0 Y( ]$ _- p% ?ulation, and rare activating mutations.3 Virilizing
+ Y) M, P5 v$ Y5 J4 K+ tcongenital adrenal hyperplasia producing excessive# ^1 L. W0 j  y
adrenal androgens is a common cause of precocious
5 ]& k! c) D# {9 kpuberty in boys.3,4* C2 F  B: s$ L3 O
The most common form of congenital adrenal8 Y) M" N0 T7 u2 Z
hyperplasia is the 21-hydroxylase enzyme deficiency.6 v: J% M3 S1 A
The 11-β hydroxylase deficiency may also result in
' g. R# ]  m/ M( C  Jexcessive adrenal androgen production, and rarely,3 q+ z0 q' X0 ~. v7 N. I# s9 ^- [  f
an adrenal tumor may also cause adrenal androgen4 n3 i3 a1 B( e, g/ _* ~% r
excess.1,3
5 U1 s1 N) S3 J2 a9 J- ]7 |" |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: `/ y& @7 j# I: s+ {! @542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( O7 m9 \3 J- ?9 b1 W7 ]3 XA unique entity of male-limited gonadotropin-
0 c" a  l0 {% h( L$ A$ iindependent precocious puberty, which is also known
1 r2 v8 r, [; T: Ras testotoxicosis, may cause precocious puberty at a
: T) N" E5 F& r& M8 ^. o7 X! a1 Overy young age. The physical findings in these boys! H. L: U3 E0 L! ]0 U
with this disorder are full pubertal development,
: G0 ?  v# V/ e7 P7 K/ ]) V- xincluding bilateral testicular growth, similar to boys
: W' V9 J5 L5 ]* M/ ]with CPP. The gonadotropin levels in this disorder
0 F" m! A/ g2 ^5 b. [0 l0 L2 Yare suppressed to prepubertal levels and do not show* [, `( b2 r+ }# _" R; k
pubertal response of gonadotropin after gonadotropin-: x, F. p- n8 d
releasing hormone stimulation. This is a sex-linked& Q- r) O, @. [, E
autosomal dominant disorder that affects only! q; z. P! a1 }$ i
males; therefore, other male members of the family
$ x5 \+ R- L4 z% ^6 f6 g6 n- Kmay have similar precocious puberty.3
& x0 l1 @# g4 d9 _4 ?/ T( V" YIn our patient, physical examination was incon-9 r# L# [% J  M1 X7 I- j8 e
sistent with true precocious puberty since his testi-2 V& ~: B, b& M) D1 ~
cles were prepubertal in size. However, testotoxicosis0 Q0 @& f0 h9 X
was in the differential diagnosis because his father8 e  q  q6 C8 I+ u0 A
started puberty somewhat early, and occasionally,& g' ]. F( ]7 V, T
testicular enlargement is not that evident in the3 S, F- I% v! _
beginning of this process.1 In the absence of a neg-5 a* \  |) c( u+ J, B* v! w; l
ative initial history of androgen exposure, our
% E  }% {- W, o, \, b. _! Nbiggest concern was virilizing adrenal hyperplasia,
$ U+ _, E2 }6 _% Deither 21-hydroxylase deficiency or 11-β hydroxylase0 P4 X: z! D: W6 }+ N3 Z
deficiency. Those diagnoses were excluded by find-5 c; A& r: y- f4 t( d3 u6 l
ing the normal level of adrenal steroids.! ^: X) w% S% P& w3 X/ T5 k% R
The diagnosis of exogenous androgens was strongly
& U1 K  c  l( {. |: xsuspected in a follow-up visit after 4 months because
: o3 }' X6 Z0 v1 s/ U; l; v3 `the physical examination revealed the complete disap-5 ?2 d7 W1 w. C/ k, T: t" o7 t
pearance of pubic hair, normal growth velocity, and
  k, s8 @$ o0 ldecreased erections. The father admitted using a testos-) b5 x& J1 N- n( r( o/ I4 N% b
terone gel, which he concealed at first visit. He was
; W% j: R7 A1 d4 M6 r' k" j. lusing it rather frequently, twice a day. The Physicians’
! x) N5 j6 o* ~2 Z; G3 xDesk Reference, or package insert of this product, gel or
, m. J' T- }6 o0 X3 `0 j. Rcream, cautions about dermal testosterone transfer to  u8 ?6 ]! ~7 x. y
unprotected females through direct skin exposure.- A9 J& {0 t  g, ^
Serum testosterone level was found to be 2 times the
) D: ~" H5 g. H; T3 |  q/ W- nbaseline value in those females who were exposed to, E1 U  N; W  q: z, `
even 15 minutes of direct skin contact with their male
/ F# N* R0 c: s1 lpartners.6 However, when a shirt covered the applica-. @* \3 o/ @2 {! T
tion site, this testosterone transfer was prevented.3 G) l9 k& f$ w8 c
Our patient’s testosterone level was 60 ng/mL,
/ {1 B% e" K& l3 }which was clearly high. Some studies suggest that( y+ [/ i1 H  |' R5 {/ f; M
dermal conversion of testosterone to dihydrotestos-
' y9 U  c8 B( r) d/ ^" Dterone, which is a more potent metabolite, is more+ L2 g# t% M, y; \. X
active in young children exposed to testosterone
/ f3 {* }# C. B) Y# ~$ Nexogenously7; however, we did not measure a dihy-
0 X& `4 }# P: r$ I: G" }2 [drotestosterone level in our patient. In addition to
, a* W4 \" Y7 S: l1 T0 x: Uvirilization, exposure to exogenous testosterone in
0 |/ t! ]2 r4 Wchildren results in an increase in growth velocity and
/ B  |1 h& T3 l9 K- O; Gadvanced bone age, as seen in our patient.3 ], r1 N9 b6 `/ n8 W. c/ t- ^- p
The long-term effect of androgen exposure during
- l) e' e( [  wearly childhood on pubertal development and final
9 C: W' J" @' s5 c7 F" A4 {adult height are not fully known and always remain1 Y- l% y8 g" y$ J, @! ~7 T6 C
a concern. Children treated with short-term testos-
: J6 Q; Z3 a3 z1 \+ H( q; tterone injection or topical androgen may exhibit some
( k& p9 s5 R" tacceleration of the skeletal maturation; however, after
- \& T+ x7 c: i& Pcessation of treatment, the rate of bone maturation
( c8 K1 B& d2 Y& D% C6 y9 |: ^decelerates and gradually returns to normal.8,96 d& p4 c, I( q- ]* e* h( z( _
There are conflicting reports and controversy
! T% Y' j3 V0 J; e4 Q8 z$ a7 Wover the effect of early androgen exposure on adult* v  f, L- g  s" C, p6 m
penile length.10,11 Some reports suggest subnormal# R7 V/ T& G5 C# U; l
adult penile length, apparently because of downreg-
4 y& C1 D2 I7 O0 M! |ulation of androgen receptor number.10,12 However,
* d4 ?0 c4 _; W, aSutherland et al13 did not find a correlation between0 v5 ?0 |& e" u1 J
childhood testosterone exposure and reduced adult" {' n' J9 Y9 j0 C/ i2 N$ |
penile length in clinical studies.
9 Y; f) P9 [  Y) c0 h& YNonetheless, we do not believe our patient is% `' p, i5 s4 X
going to experience any of the untoward effects from- k9 n4 q' `4 B7 i4 l% r) j
testosterone exposure as mentioned earlier because9 _9 O/ @  {  w
the exposure was not for a prolonged period of time.
  q3 V( c) R4 r8 c; kAlthough the bone age was advanced at the time of
" Q8 q/ E3 W1 I- z: y% p5 ~0 e1 x8 Zdiagnosis, the child had a normal growth velocity at  f0 r* |! C. X3 l9 X
the follow-up visit. It is hoped that his final adult
8 T$ f6 c9 e. ]0 jheight will not be affected.
9 Z" Y0 o' x6 S4 E, L" L- z, gAlthough rarely reported, the widespread avail-+ M6 \* T7 R0 T0 C
ability of androgen products in our society may  \# ^& Y) p9 W" Q# a0 N
indeed cause more virilization in male or female
8 t( ^1 T$ g/ {# t( [# ichildren than one would realize. Exposure to andro-* V, Y; ]9 c+ }, V
gen products must be considered and specific ques-
9 ~( I8 {1 j/ G- O' htioning about the use of a testosterone product or
$ H( ^! v1 }. B0 O9 agel should be asked of the family members during5 @1 G+ W4 p/ |
the evaluation of any children who present with vir-
  K$ c/ f9 N* X# vilization or peripheral precocious puberty. The diag-9 P, J2 m7 d( l1 V& `1 v0 H
nosis can be established by just a few tests and by
6 K: z% V+ F. X4 K8 ~/ o4 _appropriate history. The inability to obtain such a
. ^" L( {5 U3 Z3 whistory, or failure to ask the specific questions, may
/ @! ?1 N4 V8 _0 z$ {3 X3 wresult in extensive, unnecessary, and expensive
1 y# l$ o' Q' D; R* M! @investigation. The primary care physician should be
: [' }$ F# m& N( Z7 }) D3 ]aware of this fact, because most of these children* Y2 k+ D* b5 w
may initially present in their practice. The Physicians’8 X% w4 r9 _! I/ s& l3 z
Desk Reference and package insert should also put a2 t+ e9 d2 s1 f, ^
warning about the virilizing effect on a male or
4 I& S; L8 ?# _' ^3 B0 M- Nfemale child who might come in contact with some-
0 Y7 {9 O5 Z9 m9 ^; U$ a- k- J2 Done using any of these products.
% ]* @0 ?! P3 j, H* l- A- gReferences1 D, {* |- x1 t* O
1. Styne DM. The testes: disorder of sexual differentiation
: ~5 I( o5 E: Z- ]# Iand puberty in the male. In: Sperling MA, ed. Pediatric
/ G8 ]/ o3 r: P* G; MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 L+ O) g6 a! u& h$ k2002: 565-628.
" q( E$ N. ?" U7 J0 ]2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' [- n$ R9 n8 E+ rpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" Z# M0 @( X, y1 b9 Q0 o
Boy Induced by Indirect Topical
- m! E0 ]8 [) q8 G+ v5 c- V1 zExposure to Testosterone  `& H3 ^0 \) c3 Q* x% W
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* M3 S* d- a' W0 L  aand Kenneth R. Rettig, MD19 A7 L& }6 F/ k2 b4 a
Clinical Pediatrics0 i* Z8 b; [( n- l- t1 w
Volume 46 Number 6
+ I7 Z+ a0 ^* P; v3 Y# m5 d# rJuly 2007 540-543- \) X# _) i1 c' R
© 2007 Sage Publications
" T( O  ~7 n2 V2 m10.1177/0009922806296651* `& ]1 ]( S9 q# Y5 L3 N  I; h- |
http://clp.sagepub.com
# |& Y. X: P( f7 K, Hhosted at! _2 T, s5 b) K7 ~
http://online.sagepub.com
% k8 q* H+ C1 k* h5 dPrecocious puberty in boys, central or peripheral,
" L+ U5 Q" u3 j+ c. }, V+ bis a significant concern for physicians. Central) ^) w" u/ H) }8 {" B& u$ ~
precocious puberty (CPP), which is mediated# ~: E+ j3 @; X7 h5 @5 `' a% v( e
through the hypothalamic pituitary gonadal axis, has. ]/ _1 O8 @1 b, q+ t) _  _0 u
a higher incidence of organic central nervous system
; X: Z. y; B# n8 llesions in boys.1,2 Virilization in boys, as manifested
2 U6 I3 y: Y7 J3 i- Kby enlargement of the penis, development of pubic
: r9 E# `* Z, w/ w5 {% S7 uhair, and facial acne without enlargement of testi-8 A. M0 f/ R+ z7 }
cles, suggests peripheral or pseudopuberty.1-3 We+ `" k  E! \/ Z: L
report a 16-month-old boy who presented with the
$ I. P1 K: J  n* c  c% c/ ~enlargement of the phallus and pubic hair develop-; Q; R) R/ L9 ~' U% I* H
ment without testicular enlargement, which was due1 [8 j) D7 G3 K
to the unintentional exposure to androgen gel used by
+ J( r  ^0 w+ a1 n) `the father. The family initially concealed this infor-! P9 o0 ]0 L# S2 j' s  ^
mation, resulting in an extensive work-up for this1 C9 x% X% u, y1 [  a9 B
child. Given the widespread and easy availability of
1 `0 {+ p* R8 Ktestosterone gel and cream, we believe this is proba-3 W% u9 p% _4 X0 w! u" j
bly more common than the rare case report in the; D, o( g$ ?( j  `0 L
literature.4. @# d' E4 Y2 t! ^
Patient Report
3 f; W9 l& M8 \3 C; |2 w/ RA 16-month-old white child was referred to the
/ e* [: G/ m. |: b* @endocrine clinic by his pediatrician with the concern, j& t3 p3 \3 \
of early sexual development. His mother noticed1 D" [" f; ]0 N& h  b
light colored pubic hair development when he was
/ \! q5 K/ v$ o& {3 x% v: |5 i* CFrom the 1Division of Pediatric Endocrinology, 2University of2 h) r5 U5 J& Y. z8 H. `9 L8 |
South Alabama Medical Center, Mobile, Alabama.
8 Z% J4 ^! U" @; iAddress correspondence to: Samar K. Bhowmick, MD, FACE,, x; C- M- F/ v1 V( k- }) ^
Professor of Pediatrics, University of South Alabama, College of1 D0 Y9 `: c5 C4 D! L% O* y2 }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- r1 h' R7 J+ T0 c, @9 Ze-mail: [email protected].
  Y4 o! _! g% F: E; d9 R$ uabout 6 to 7 months old, which progressively became
. H) D& Q" N4 o, N9 L+ T! y) Jdarker. She was also concerned about the enlarge-' K: E' H+ ]7 w- R& \/ M1 Z+ @
ment of his penis and frequent erections. The child
/ [$ f" D" Z, w5 d, H6 twas the product of a full-term normal delivery, with
8 j5 g0 _' B; Y: [6 D8 n" Z3 z, da birth weight of 7 lb 14 oz, and birth length of% Q* v( I! l( M1 G
20 inches. He was breast-fed throughout the first year+ s- C0 k. u0 B4 e( B/ O  A
of life and was still receiving breast milk along with4 E4 c+ H6 r' x6 E, q0 E
solid food. He had no hospitalizations or surgery,+ ~% l( \# V1 `0 N1 g" G
and his psychosocial and psychomotor development
5 S: q) `3 @/ a, B' s  cwas age appropriate.) y& N4 |+ p3 G5 B) b' h/ Y0 t
The family history was remarkable for the father,; r2 a8 ]5 P1 _2 Q8 ?  M
who was diagnosed with hypothyroidism at age 16,
' T' ~4 l7 c0 B" ^9 w5 Lwhich was treated with thyroxine. The father’s
( h# ~8 M* W3 z' m! Qheight was 6 feet, and he went through a somewhat
8 m/ I0 K' l1 {! P& x. ]/ |. hearly puberty and had stopped growing by age 14.
4 W5 L6 r: N% V& y$ A9 tThe father denied taking any other medication. The
$ ?9 I* B0 V% l4 {: Vchild’s mother was in good health. Her menarche
. a' Z, X: `7 y, iwas at 11 years of age, and her height was at 5 feet
: t; J! S, w/ A% V% r' D7 T; [5 inches. There was no other family history of pre-; p9 P+ q4 q' c: d% ~
cocious sexual development in the first-degree rela-
% D: Y( ^6 W" b. [* f. m& Mtives. There were no siblings.3 e+ }" ~; A# n( G" U: ^
Physical Examination5 S, m/ D; J5 \/ A. b1 a
The physical examination revealed a very active,
7 i0 K0 T1 D; [! u+ f$ Zplayful, and healthy boy. The vital signs documented
: `1 f' c% B# S9 Ra blood pressure of 85/50 mm Hg, his length was8 ]( B7 y+ {- r5 j; [4 ~
90 cm (>97th percentile), and his weight was 14.4 kg3 n! O- }1 K( {( E" ^0 }, B( \4 p
(also >97th percentile). The observed yearly growth$ @2 ^' R! k/ D- a5 ?
velocity was 30 cm (12 inches). The examination of
- D. L" k& ?& Hthe neck revealed no thyroid enlargement.
: p2 p: w" B5 tThe genitourinary examination was remarkable for
1 O) J4 e: k: `/ m( r/ ~2 benlargement of the penis, with a stretched length of) H# p1 T) T' ^
8 cm and a width of 2 cm. The glans penis was very well
6 j) @5 a* m4 f: Ddeveloped. The pubic hair was Tanner II, mostly around
! G% F3 s4 O8 P540
# i5 e. |/ c. J8 [% Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ X2 H  a) {% d, S1 V
the base of the phallus and was dark and curled. The
( I: }' P0 x7 N- m: |  Q6 _testicular volume was prepubertal at 2 mL each.
7 I+ D9 N. o( t) g' y0 y- p1 IThe skin was moist and smooth and somewhat
9 @0 B) @  A. aoily. No axillary hair was noted. There were no6 J! ^* I; S0 Z/ h
abnormal skin pigmentations or café-au-lait spots.
! |4 L; U# h! c1 P9 ^/ x. qNeurologic evaluation showed deep tendon reflex 2+: B7 N) F% z  W. q2 B  W' v
bilateral and symmetrical. There was no suggestion6 p5 |( ^; N6 j, N$ e* a3 n
of papilledema.
8 |+ j) x1 J! _/ LLaboratory Evaluation
% W. A, m# o0 m' Z4 W, R- ?  aThe bone age was consistent with 28 months by
, l, M& ~+ H: r4 U4 B7 Gusing the standard of Greulich and Pyle at a chrono-
4 s0 J4 o2 m1 o- Wlogic age of 16 months (advanced).5 Chromosomal
" |% q- H  J% i) G  U0 Hkaryotype was 46XY. The thyroid function test( B1 P  m0 x; K* ^, \! ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" a& y6 q7 j5 c9 q: k) Y
lating hormone level was 1.3 µIU/mL (both normal).
' r3 J2 b" ]' q7 }, }The concentrations of serum electrolytes, blood, n2 Z: i7 M  R7 ~$ s$ }/ \
urea nitrogen, creatinine, and calcium all were
/ v8 Q! G; |+ a; c+ pwithin normal range for his age. The concentration. g& q/ C% }6 o6 l" J, o. j
of serum 17-hydroxyprogesterone was 16 ng/dL+ u8 C/ V  g# x: }) e
(normal, 3 to 90 ng/dL), androstenedione was 20
0 D6 b. t8 y7 U( g1 ?! Ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% N% s1 s. r: u9 y: J2 L6 K+ I, E0 g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# J4 ?2 t% C1 Q) x+ J- x* fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
, d# X4 u5 g) b: Z" c( D' C; L49ng/dL), 11-desoxycortisol (specific compound S)- B4 S) O+ S+ ~, v( r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- x. r" `& n) l" ]0 Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ V, S2 }: [1 f% @6 r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 _$ j2 ?1 A1 {6 l% C9 {7 A( F& q
and β-human chorionic gonadotropin was less than. O9 J  z; V6 l1 I
5 mIU/mL (normal <5 mIU/mL). Serum follicular, |% H/ o$ ]; a! N$ s; c; P
stimulating hormone and leuteinizing hormone
0 a$ l" p! `' jconcentrations were less than 0.05 mIU/mL) b7 [4 D1 b/ C
(prepubertal).
+ {8 v1 }+ ?! K5 TThe parents were notified about the laboratory
1 o0 J2 \$ [/ w) ]results and were informed that all of the tests were
+ j! r/ r; C" ^7 x$ Cnormal except the testosterone level was high. The% y& A8 o& S/ S: G/ ?% B
follow-up visit was arranged within a few weeks to1 @) p& ^8 ^- T) v3 @% R
obtain testicular and abdominal sonograms; how-# w: m) X: X2 a+ m6 T
ever, the family did not return for 4 months.
2 z2 c6 }0 X+ }: y" A& S6 hPhysical examination at this time revealed that the, p/ ?( V. H$ H. p/ ?
child had grown 2.5 cm in 4 months and had gained
# C7 i; ~9 f: Z5 }2 kg of weight. Physical examination remained5 d2 {2 t4 J8 Z
unchanged. Surprisingly, the pubic hair almost com-
9 M9 \8 `# N8 E, Upletely disappeared except for a few vellous hairs at
1 g5 `; t: T) Z7 |8 h) mthe base of the phallus. Testicular volume was still 2; ]! M4 p$ T8 U  R- p9 N8 f
mL, and the size of the penis remained unchanged.8 V3 B) S6 d; a* D6 b( U; Q; {" T, L
The mother also said that the boy was no longer hav-
( y3 Y7 B: P0 F- Y: Y3 p* Ving frequent erections.
. y) s+ {1 u& _) u+ A1 n* }5 p% {Both parents were again questioned about use of
8 S- n! J/ L% C% ^any ointment/creams that they may have applied to
2 B7 o3 s$ K' t7 X$ ?2 |6 ^" }the child’s skin. This time the father admitted the. E  J! x  ?. ]; e
Topical Testosterone Exposure / Bhowmick et al 541
" o8 Q! X6 N  v. v: |use of testosterone gel twice daily that he was apply-
" t) D: d8 ~" G, Bing over his own shoulders, chest, and back area for3 d7 z* k, F  ?0 I, ]+ l* m
a year. The father also revealed he was embarrassed+ g6 s: w8 o4 Q1 ?
to disclose that he was using a testosterone gel pre-* e- H- O4 A9 j( }0 R. ^; z& O
scribed by his family physician for decreased libido
" T' P( h4 q& Q3 R$ {- Osecondary to depression.
% M& e1 U  d% R& CThe child slept in the same bed with parents.
+ f+ H8 @, w' f8 W: EThe father would hug the baby and hold him on his
" Z8 g6 u7 @2 Y; a$ ^/ ?+ M7 Uchest for a considerable period of time, causing sig-
( x. }# o* p* z# [' b: d/ P8 M0 Unificant bare skin contact between baby and father.
) ?3 z* [2 I6 d; [& g2 B7 W! y+ lThe father also admitted that after the phone call,
! D) C5 k" ?' n) v: a. l$ `when he learned the testosterone level in the baby
: A7 _% C* x/ E, Fwas high, he then read the product information8 e* n+ A9 `: h3 a. L- Z5 y2 C+ w- Q8 @
packet and concluded that it was most likely the rea-5 h1 @' _0 n1 f, H8 Y1 w& u% V% s
son for the child’s virilization. At that time, they
, h0 Q  C$ m1 l% Bdecided to put the baby in a separate bed, and the% R) j! w5 G% L4 z- x& A
father was not hugging him with bare skin and had- i/ S& `" D  {. K
been using protective clothing. A repeat testosterone
% ^. [( V! l$ Q, I# p6 P, b6 ptest was ordered, but the family did not go to the
" a2 o/ u- w2 x! T* A" alaboratory to obtain the test." Q" C" L' w6 I' w; O  z
Discussion& Y; ]# j) ^: X: n, H" i6 ~
Precocious puberty in boys is defined as secondary$ w' `- R7 ~3 w# o+ w
sexual development before 9 years of age.1,4* o$ w. D1 f. Z- M2 P
Precocious puberty is termed as central (true) when
% S2 h0 |. ?4 j$ L, x3 w# _it is caused by the premature activation of hypo-
' Z" F) [8 a" m+ N* c" D2 x: Ythalamic pituitary gonadal axis. CPP is more com-
: n: Z8 A+ a8 E% B- umon in girls than in boys.1,3 Most boys with CPP
3 H  J' y: g, K2 a1 z) h& v% |may have a central nervous system lesion that is
: q) {9 s+ p0 c' ]responsible for the early activation of the hypothal-
4 W( B1 U1 h- U% @$ G9 x: Camic pituitary gonadal axis.1-3 Thus, greater empha-8 [& U) {& X0 S: T, _/ t
sis has been given to neuroradiologic imaging in
% ?" Z* {! L- \( @0 zboys with precocious puberty. In addition to viril-# T! _+ P& Q( N1 W3 U6 }5 ~' C
ization, the clinical hallmark of CPP is the symmet-
0 E7 i/ S7 |2 ]: s" J, X4 vrical testicular growth secondary to stimulation by
4 A0 `+ y7 x0 dgonadotropins.1,3) v/ J) [; z) ?: o; ]* K; V7 W! z/ K
Gonadotropin-independent peripheral preco-/ u6 d' n+ x/ \( A9 p5 i
cious puberty in boys also results from inappropriate
4 K9 q1 m, ~9 I* \androgenic stimulation from either endogenous or0 r4 Q  T  ~6 ^  x- A: m2 C
exogenous sources, nonpituitary gonadotropin stim-
2 b/ `3 v9 |, I6 Q/ zulation, and rare activating mutations.3 Virilizing
9 a' h: K5 ^9 N9 ]" l1 G+ P% Zcongenital adrenal hyperplasia producing excessive
: m2 U* ]6 `! w" s7 s+ }5 G- wadrenal androgens is a common cause of precocious
, X) L6 t* T0 `2 {" y5 k. rpuberty in boys.3,4( \7 B7 O2 q# m3 h6 w/ `9 v& d
The most common form of congenital adrenal
; V" i. r0 s( ~1 B  y' F8 Dhyperplasia is the 21-hydroxylase enzyme deficiency.
* R5 x; I9 D( o. HThe 11-β hydroxylase deficiency may also result in0 {& v1 y8 b+ a' G: v
excessive adrenal androgen production, and rarely,
1 s  h9 Q3 H$ Dan adrenal tumor may also cause adrenal androgen3 j: e7 Q2 Z' p* z& o
excess.1,32 {* j$ M2 C6 T( v/ [9 S4 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* z* v, ?1 I5 t. v, i. X542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ x! L: f6 ^8 ^/ \A unique entity of male-limited gonadotropin-3 o0 T/ C9 K+ p/ W4 ~9 U
independent precocious puberty, which is also known" M. ?( C3 ^3 a  L% ]& }  h; l
as testotoxicosis, may cause precocious puberty at a* p4 z3 X7 a! B
very young age. The physical findings in these boys
% n* A" [6 B4 e" T4 Nwith this disorder are full pubertal development,
* H9 U% x2 p1 Z* aincluding bilateral testicular growth, similar to boys0 {" W. N' _7 r0 A$ i
with CPP. The gonadotropin levels in this disorder( _4 e1 x7 ~4 A$ \
are suppressed to prepubertal levels and do not show
. b7 i% J& ]- Jpubertal response of gonadotropin after gonadotropin-
4 y, [. z6 l9 ]4 `+ y& Zreleasing hormone stimulation. This is a sex-linked
' x# _. Q. \0 X3 A' e- n* E1 N$ u; iautosomal dominant disorder that affects only
# N. P# g6 b5 U# ~1 mmales; therefore, other male members of the family/ ~. w. {" a* u# G
may have similar precocious puberty.3
  c1 ?6 w7 o8 MIn our patient, physical examination was incon-
( y/ h& @4 K) y, k. R, b: \/ Usistent with true precocious puberty since his testi-/ `  G% l( ]; i
cles were prepubertal in size. However, testotoxicosis2 N" p* X( d, |' y! B5 i
was in the differential diagnosis because his father
! J1 Z  F; o4 ~/ M# m' Z0 jstarted puberty somewhat early, and occasionally,
2 g$ A0 R+ f  I  ~testicular enlargement is not that evident in the
# x0 U$ j! c, u* b4 o/ G- {5 dbeginning of this process.1 In the absence of a neg-$ a5 }# z1 y( s: j" {. j5 p8 G
ative initial history of androgen exposure, our
' o- y2 \' R, d2 s4 X! vbiggest concern was virilizing adrenal hyperplasia,
" C; k) e% j3 [: X* S! leither 21-hydroxylase deficiency or 11-β hydroxylase
( |$ I5 p' \+ s  wdeficiency. Those diagnoses were excluded by find-2 L& F$ y+ u6 _+ t6 G
ing the normal level of adrenal steroids.# ^3 d, x2 X* W$ y) l
The diagnosis of exogenous androgens was strongly
& b  w- _% K7 ysuspected in a follow-up visit after 4 months because7 Y2 w. D+ w! `' k8 @1 l" q
the physical examination revealed the complete disap-
( R6 m. ]  Y1 E; i$ F: Npearance of pubic hair, normal growth velocity, and3 j! ~6 k2 U# H
decreased erections. The father admitted using a testos-5 r) D- N/ ?4 X+ y* @
terone gel, which he concealed at first visit. He was8 l+ S' E# X* F+ U
using it rather frequently, twice a day. The Physicians’
6 y3 w' v$ z7 o+ @: ~, rDesk Reference, or package insert of this product, gel or
( r7 R' s. j1 g. [+ g8 V0 R% F  J4 ?cream, cautions about dermal testosterone transfer to: L2 Z* h' N" L) r+ Y9 r
unprotected females through direct skin exposure.( O% k9 Y# R. T4 B# t
Serum testosterone level was found to be 2 times the
7 y" f6 j  Q4 _2 b( H8 }baseline value in those females who were exposed to
% [7 X" G: u( V8 O; Jeven 15 minutes of direct skin contact with their male
' T# `+ r. ?+ ppartners.6 However, when a shirt covered the applica-
: r& ^& Q* G/ ?! m9 ktion site, this testosterone transfer was prevented.
! j. A# p0 {0 P) M. COur patient’s testosterone level was 60 ng/mL,
% p3 A6 A! @( E7 z0 I6 W5 Wwhich was clearly high. Some studies suggest that
  S) v5 h4 e/ pdermal conversion of testosterone to dihydrotestos-6 \% q! O( u7 b+ r
terone, which is a more potent metabolite, is more' Q9 D9 x- p9 e4 ~- x  r" x: V0 ^. J
active in young children exposed to testosterone
7 @* O  K( v) x/ lexogenously7; however, we did not measure a dihy-) }: l5 \/ @% |; R
drotestosterone level in our patient. In addition to
; e2 B; X' }  F7 m4 s, `virilization, exposure to exogenous testosterone in
6 j# e# B, x! J. C% s* Y& a$ Ychildren results in an increase in growth velocity and
* {$ }0 t2 }) y: ~: madvanced bone age, as seen in our patient.
. }4 g) T" q& h; UThe long-term effect of androgen exposure during
6 j3 h0 g0 O* c4 h% nearly childhood on pubertal development and final
  a, v1 S: E8 padult height are not fully known and always remain% y0 F. _6 a) N/ a& i+ t$ b
a concern. Children treated with short-term testos-
3 S0 w2 G8 @0 x1 Z5 Z- ]; Gterone injection or topical androgen may exhibit some
, ?/ H# B0 h! @acceleration of the skeletal maturation; however, after- n# a6 s/ `$ P# r9 \
cessation of treatment, the rate of bone maturation# i, y9 y8 X* I) c+ ]1 N
decelerates and gradually returns to normal.8,9" ?$ Q/ v6 o* ^  u( L
There are conflicting reports and controversy
% l' L& Z! I9 R1 `! Jover the effect of early androgen exposure on adult
; W' c' u7 z/ I% w- z2 F% V) Qpenile length.10,11 Some reports suggest subnormal' H; ]* B9 _" O- {
adult penile length, apparently because of downreg-
" \# ^8 e: ^# y  D4 q+ Y$ F) Dulation of androgen receptor number.10,12 However,
. T; {4 }* j* r& n5 k& A, q2 JSutherland et al13 did not find a correlation between
2 `3 s0 M. P1 p, k% n" l3 w5 [childhood testosterone exposure and reduced adult& ?. ^$ n- d3 c; Z
penile length in clinical studies.% x) U* Y' u" |9 o. k: N
Nonetheless, we do not believe our patient is) W& b+ p! T/ c4 ~2 c
going to experience any of the untoward effects from
4 m9 Z7 A: g3 l5 w0 V8 ztestosterone exposure as mentioned earlier because( T  G0 u/ H/ ~  T! E
the exposure was not for a prolonged period of time.
9 N: R6 \6 o) x7 W/ e" p' u$ @Although the bone age was advanced at the time of8 N: h' K2 O4 F8 q8 P
diagnosis, the child had a normal growth velocity at
2 Z% n9 l1 C  F, W! F3 vthe follow-up visit. It is hoped that his final adult
. f7 I& [4 L4 {$ K! ^4 b3 v# Theight will not be affected.
9 I4 n5 P' w$ B/ c* _0 `8 f- O- bAlthough rarely reported, the widespread avail-) p5 ~) z3 r/ C2 Z9 B0 v6 I& y
ability of androgen products in our society may
1 b- v! X+ f. Q% ^+ Z. zindeed cause more virilization in male or female- E5 X" i, `2 s3 _
children than one would realize. Exposure to andro-
9 F0 B6 B; E+ O: H$ \gen products must be considered and specific ques-
  W4 l8 Z! u3 ~0 Itioning about the use of a testosterone product or
% D5 m( {9 Y# d# K- rgel should be asked of the family members during9 y5 k/ i9 N$ C6 U& c
the evaluation of any children who present with vir-
$ z: n! V& S8 ~ilization or peripheral precocious puberty. The diag-
, d2 D: K/ p  W( ]+ C' Rnosis can be established by just a few tests and by0 B1 U: P4 ]* ]3 A+ Q# ~# y
appropriate history. The inability to obtain such a
$ @  B; Q& |* c3 Y% S" w' ahistory, or failure to ask the specific questions, may6 ?3 |; E3 u) z3 K
result in extensive, unnecessary, and expensive; p. X+ D7 C8 u' ^/ n. _* }# B
investigation. The primary care physician should be* b# P. E  f2 |4 c$ |9 A3 x
aware of this fact, because most of these children$ o( j  d' V. F5 e
may initially present in their practice. The Physicians’5 m& i( i+ m/ ?" N! L
Desk Reference and package insert should also put a8 c4 f, s( R  O% L) v$ p/ n0 m% K, i1 I
warning about the virilizing effect on a male or
$ s" w5 F) f+ s1 Y( q: ^female child who might come in contact with some-
/ J$ C  Q0 Z5 L8 y1 ^  aone using any of these products.+ t. e- @2 P9 h
References3 v" ?) F8 V5 O! }
1. Styne DM. The testes: disorder of sexual differentiation' [- F! A. U; L. G1 f4 m# I% i- W6 J
and puberty in the male. In: Sperling MA, ed. Pediatric
  }, y* h/ Y' U. R8 T% \6 L& y% H( WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 s( F( @! G* [2002: 565-628.
" p- Z/ \( [# M4 w* x" z; ~5 i# h) n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ O* P; s; F* k/ d5 {
puberty in children with tumours of the suprasellar pineal
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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
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
1 j* w* w& G. ?- k# u- o
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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