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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-Old6 y# Y) `' k% v; A) V# b
Boy Induced by Indirect Topical0 A/ \, P; U" P: Y$ ?" r7 W
Exposure to Testosterone
* F3 s" K. ^% zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. X; y, d8 c; u
and Kenneth R. Rettig, MD1, I& P4 n3 x7 r% `8 K3 b& e
Clinical Pediatrics7 K1 q) [, f8 L
Volume 46 Number 6% B+ V2 {" n/ s1 D
July 2007 540-543
$ {) p- E2 J0 T© 2007 Sage Publications5 b& S' _0 ~0 \8 k. h
10.1177/00099228062966518 H, I  Q6 O: Z* z6 R
http://clp.sagepub.com
; B0 q! L- R1 [3 M! C$ H5 ohosted at3 b; j* e& _9 W
http://online.sagepub.com
0 Y9 ?7 B5 ~9 P2 K9 T0 G1 ^4 w& VPrecocious puberty in boys, central or peripheral,# }! `8 A% G& `" p: P8 g* ~4 i
is a significant concern for physicians. Central
8 S. B. I( `! W2 hprecocious puberty (CPP), which is mediated6 o& U" B: f- S+ T1 f3 o2 ?& @' q
through the hypothalamic pituitary gonadal axis, has
$ P1 f* U8 z* M) o9 v2 j( qa higher incidence of organic central nervous system. G; `6 U, |, o( f# l' c8 [* K9 o) \) o
lesions in boys.1,2 Virilization in boys, as manifested* I, v4 X+ a% d# |
by enlargement of the penis, development of pubic
$ I: h" v: Y, U$ C( a0 e- jhair, and facial acne without enlargement of testi-! \& S" t3 O" r6 l$ t
cles, suggests peripheral or pseudopuberty.1-3 We0 k7 M' ?3 j/ o& B. K- Y
report a 16-month-old boy who presented with the4 Q1 M. }- J$ h
enlargement of the phallus and pubic hair develop-, [7 X% U' w4 z8 J7 U6 C: w
ment without testicular enlargement, which was due+ ~6 `$ h' @/ ], g
to the unintentional exposure to androgen gel used by
# q4 R: m6 S; s, {( ?the father. The family initially concealed this infor-+ r8 z8 Q' k: b: Z. s  I
mation, resulting in an extensive work-up for this7 o7 d- @+ H$ k& ~, ]! S7 ~
child. Given the widespread and easy availability of
  c# a8 V3 R# X9 `$ Htestosterone gel and cream, we believe this is proba-* q- y# Y9 C3 q- l& J* {& W  B
bly more common than the rare case report in the
7 U) P  ]$ {4 j: l( M! W6 ]0 W' Yliterature.4
8 K. {* i. q6 T. VPatient Report
! ?  \0 \& T5 ~) ^0 NA 16-month-old white child was referred to the" w- t$ R, X* E0 p9 O/ v
endocrine clinic by his pediatrician with the concern! |! ^% m7 ]2 n; k9 N2 m% Q
of early sexual development. His mother noticed
4 D% U3 S7 X3 F/ u7 U9 g# Z; blight colored pubic hair development when he was
# S3 [# e3 l2 Z, q9 \; u0 a) qFrom the 1Division of Pediatric Endocrinology, 2University of- y0 L. k3 a7 v) s
South Alabama Medical Center, Mobile, Alabama.8 o8 T7 j; T& {* y; c: E2 q
Address correspondence to: Samar K. Bhowmick, MD, FACE,  ?) m# F5 N9 v0 |; E
Professor of Pediatrics, University of South Alabama, College of' r- I0 {: H2 V5 `" s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 R! g. c* i& e7 Y( v3 y; |) E
e-mail: [email protected].
; g- `- Y5 p3 o; kabout 6 to 7 months old, which progressively became" `8 C$ T, q: L  F+ K- I' R8 }0 C
darker. She was also concerned about the enlarge-7 J' s8 F- C. T' @8 o5 ]
ment of his penis and frequent erections. The child* a3 E: X, c2 m. a
was the product of a full-term normal delivery, with7 d$ x. B# Y  U+ |; h# b
a birth weight of 7 lb 14 oz, and birth length of0 m' T; W. x2 x. d7 E
20 inches. He was breast-fed throughout the first year
/ F1 B+ t3 j# Q7 s2 {2 Fof life and was still receiving breast milk along with
- ]* I: O% }9 ksolid food. He had no hospitalizations or surgery,! X1 m: z' @% _4 F! M- k& t
and his psychosocial and psychomotor development
9 V* x4 z; }! L* ]5 `was age appropriate.0 S, R  I  g& Y" a
The family history was remarkable for the father,. J$ D& u+ o3 I! W' I* z
who was diagnosed with hypothyroidism at age 16,1 N6 a6 o: a% h
which was treated with thyroxine. The father’s
' u% @4 R3 P3 c2 T* `; _  f3 z7 z" Sheight was 6 feet, and he went through a somewhat
& T5 R0 m  y7 z( g* qearly puberty and had stopped growing by age 14.  v' ~9 @8 |( E' H0 H/ A# |" @: B
The father denied taking any other medication. The6 O, u8 O3 [( B. E
child’s mother was in good health. Her menarche; n6 ?9 |3 k" e5 ]4 @
was at 11 years of age, and her height was at 5 feet' A( I6 v4 U) N' C  S9 R
5 inches. There was no other family history of pre-
3 V" _% s& K) Y2 m( j' ~cocious sexual development in the first-degree rela-; S# l2 |1 |9 g0 M9 _
tives. There were no siblings.( Y6 j  E+ q, b* j0 V' W! X
Physical Examination
5 [6 M2 P$ D, `0 O' w' C( lThe physical examination revealed a very active,
, ~" F! Y7 G4 j1 Oplayful, and healthy boy. The vital signs documented
0 I; X; |4 h* z* m0 sa blood pressure of 85/50 mm Hg, his length was
2 S5 Z) Q1 {" N; O0 Z/ ?90 cm (>97th percentile), and his weight was 14.4 kg( x+ r- p1 B5 J! L9 A, N) a
(also >97th percentile). The observed yearly growth
1 B6 Z8 q( x( U" l& @* A2 vvelocity was 30 cm (12 inches). The examination of
+ J3 N' _) g) p1 athe neck revealed no thyroid enlargement.# @' h5 R% W& C" \- y- W) K
The genitourinary examination was remarkable for& u1 b1 s+ J6 h7 ]' o
enlargement of the penis, with a stretched length of& T+ d+ \- I1 b- _# Y/ `" c6 l
8 cm and a width of 2 cm. The glans penis was very well
+ I" w0 i2 l0 L* \developed. The pubic hair was Tanner II, mostly around7 H5 H# _1 `$ H, j; n! m
540
/ B# i2 O; v% B. j7 Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' N  B" a( j+ [8 j' G
the base of the phallus and was dark and curled. The* J2 m! h6 W( X* v
testicular volume was prepubertal at 2 mL each.1 I2 T/ l  ]: D8 Z
The skin was moist and smooth and somewhat
/ {9 s& ~. G( D$ _) F4 ooily. No axillary hair was noted. There were no$ c  s+ a- n- P& f9 C& L3 l
abnormal skin pigmentations or café-au-lait spots.
/ {' L0 N- o; T) R) Y; d) r4 pNeurologic evaluation showed deep tendon reflex 2+5 J$ d* l. |# V5 x
bilateral and symmetrical. There was no suggestion( _4 s. X$ p$ E0 p
of papilledema.- v; l5 F- j! T$ F2 X
Laboratory Evaluation
# I! a  O' D$ H: `: r& }* w# SThe bone age was consistent with 28 months by" C& i3 B& Y1 G6 s- |4 D
using the standard of Greulich and Pyle at a chrono-
$ s2 g' r$ m. ^+ W6 j1 v+ \" dlogic age of 16 months (advanced).5 Chromosomal: x: i! I, Y& ?' ?. ^
karyotype was 46XY. The thyroid function test# g5 z' B( n# _+ m& q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' X$ \- Q6 `/ `0 S2 y* n) o! I* d/ O
lating hormone level was 1.3 µIU/mL (both normal).% v/ E+ {" y8 {9 J
The concentrations of serum electrolytes, blood
! p0 Q5 Z! R. kurea nitrogen, creatinine, and calcium all were
- f( u* w/ d2 J! n$ G) m9 owithin normal range for his age. The concentration
& Q) @$ z8 L4 \of serum 17-hydroxyprogesterone was 16 ng/dL
  w/ W" ~5 y8 F! N$ R5 _+ Y5 Z7 w(normal, 3 to 90 ng/dL), androstenedione was 20
) f$ h8 G% V" q* h. r" l$ z0 rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 ^- T. O0 ]( _* l5 o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
  Q- ]9 y9 z. bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 f7 m9 c: M+ q2 s  w& n1 J49ng/dL), 11-desoxycortisol (specific compound S)
  a8 m% I7 ~4 ]$ gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 J# h0 P" r) ]1 r8 c2 U$ v: P4 l4 y4 J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" I) `5 O  Y3 W) G3 G1 }+ j' O% M' g6 M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 ]% c5 }% f4 S1 I) i* Y4 e% P; Rand β-human chorionic gonadotropin was less than& U* d6 N9 I% }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  j+ a5 T, @# X! W9 I1 @, _stimulating hormone and leuteinizing hormone
3 B7 R  i) p) t: S1 S; N/ Pconcentrations were less than 0.05 mIU/mL
( c! `3 J; Y4 J$ b/ H$ X(prepubertal).
- F1 T9 _6 w1 A5 G( TThe parents were notified about the laboratory
8 m8 ]# C1 l7 i& F6 Yresults and were informed that all of the tests were3 [' ?; j. K0 n. j  M& ]) B
normal except the testosterone level was high. The
- U% T5 i6 ~8 H5 J) ifollow-up visit was arranged within a few weeks to) V, H/ S' s) D
obtain testicular and abdominal sonograms; how-
2 ~- r3 E+ \2 e6 aever, the family did not return for 4 months., U% |5 d; M+ E
Physical examination at this time revealed that the& o* D* w: ]1 V/ R! j# I: @/ h
child had grown 2.5 cm in 4 months and had gained
' P- D. V0 m. {2 kg of weight. Physical examination remained: p& X  a/ |) R0 t" N( e# g
unchanged. Surprisingly, the pubic hair almost com-- z4 e  a9 T4 }5 G6 E0 {
pletely disappeared except for a few vellous hairs at2 b/ S0 b% v8 i; P/ b
the base of the phallus. Testicular volume was still 2  i) e  s+ D8 h* {) M
mL, and the size of the penis remained unchanged.
0 k7 V1 s6 l$ E, u- h3 @& P6 n, rThe mother also said that the boy was no longer hav-
8 v: O  ^- _0 Wing frequent erections.
5 T5 I* U0 m% p! U' H1 @Both parents were again questioned about use of
8 @1 w9 v2 A5 v/ R! O  L) Bany ointment/creams that they may have applied to
( ]+ f; F; h+ k$ V9 Bthe child’s skin. This time the father admitted the" z$ {- W. u* J5 Q1 v
Topical Testosterone Exposure / Bhowmick et al 541- Z2 x  s1 [5 I' Q( h5 D
use of testosterone gel twice daily that he was apply-
: k' e6 z, e* n; X; Ving over his own shoulders, chest, and back area for
: E1 n- O7 M0 b& X9 ]a year. The father also revealed he was embarrassed
5 F- v' K( }  j  _% X. b( Z3 rto disclose that he was using a testosterone gel pre-
, t/ G  x2 z  Q; V# }% T# Nscribed by his family physician for decreased libido
! q2 D! U/ H8 X" Y1 dsecondary to depression.# w! Z0 B' j2 ^
The child slept in the same bed with parents.& T6 O4 E" s' n/ f3 D! y" P
The father would hug the baby and hold him on his
/ `) R; A& ^8 @$ R/ qchest for a considerable period of time, causing sig-2 z! E- p# {# P( D& {% ?
nificant bare skin contact between baby and father.
. a6 T+ O. D: ?$ A% e, YThe father also admitted that after the phone call,
8 v5 \5 [6 |% ]( q2 P, D3 M9 ~% nwhen he learned the testosterone level in the baby
9 a9 W3 |2 Y! |- `) ?was high, he then read the product information
( ~2 {6 M6 R1 E% ~/ Tpacket and concluded that it was most likely the rea-4 p" c+ w8 i6 K% i9 |% C2 ^3 Y
son for the child’s virilization. At that time, they
# H' E8 R4 H" `8 E  [decided to put the baby in a separate bed, and the- x( T. ~6 u( I) l
father was not hugging him with bare skin and had
0 e* \  m: s9 Q8 G2 zbeen using protective clothing. A repeat testosterone- F6 R% T1 S* ]  @- y
test was ordered, but the family did not go to the
0 m' x9 A( f5 j0 l  Flaboratory to obtain the test., }6 \  d7 F2 I& q& t: D: S' G% y
Discussion
( _6 ~/ h$ z' K3 L( fPrecocious puberty in boys is defined as secondary
! L5 m6 D% [6 D; @* s6 o4 \sexual development before 9 years of age.1,4
9 s: }( @$ j# {" W) Y1 X6 GPrecocious puberty is termed as central (true) when
% W: d+ Z3 F( u3 c  zit is caused by the premature activation of hypo-9 V% K! f7 e5 c$ R  n, {6 G
thalamic pituitary gonadal axis. CPP is more com-
1 C/ m" C. x6 ]# T  Q2 K! xmon in girls than in boys.1,3 Most boys with CPP
- s  J/ j, m$ [& o8 }8 Kmay have a central nervous system lesion that is  i( X0 O  U1 Q# H
responsible for the early activation of the hypothal-
  w7 i) q1 n9 Eamic pituitary gonadal axis.1-3 Thus, greater empha-
  t- H, z# Q6 A( y1 v' jsis has been given to neuroradiologic imaging in/ Q+ Y/ G  f* ]9 \7 M
boys with precocious puberty. In addition to viril-: k3 k$ N# M9 Z6 K- |* x3 ]
ization, the clinical hallmark of CPP is the symmet-
% J) s5 ]8 t" q2 u& Irical testicular growth secondary to stimulation by/ t9 e2 n* g' M& e3 O( V
gonadotropins.1,3
' \, M9 {; P8 v  S1 f* hGonadotropin-independent peripheral preco-1 {; K! ^% N. }
cious puberty in boys also results from inappropriate
& x+ ^3 Y% l6 c% Q4 A4 {androgenic stimulation from either endogenous or. Q- o. O% m+ r, g% b
exogenous sources, nonpituitary gonadotropin stim-2 _8 Y5 T+ h7 ~3 L3 E* A# D" X
ulation, and rare activating mutations.3 Virilizing
. u9 A- |0 m- H( M0 scongenital adrenal hyperplasia producing excessive
) q1 L1 R; S- C5 w/ q9 H+ a( Yadrenal androgens is a common cause of precocious4 O1 f$ x" R% S& f% G' {1 T: ~& Z
puberty in boys.3,4$ S! P4 M& \6 c& @) m
The most common form of congenital adrenal2 ^' j/ K: q5 J0 a+ v
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 X% O9 d1 W( x% w0 j0 o  u( aThe 11-β hydroxylase deficiency may also result in4 [8 z9 P- B" Z) [% @
excessive adrenal androgen production, and rarely,4 K: }) O) ~# v! j
an adrenal tumor may also cause adrenal androgen
% [, p  @- l, B5 `& Wexcess.1,3
, v$ Y) c1 ]7 X6 [- Q" O' xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; n8 N: v+ h& U3 [. m% f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( j$ F) R, ]3 j. d) Z  @; ], YA unique entity of male-limited gonadotropin-
  H4 q3 D4 x1 K* z8 bindependent precocious puberty, which is also known
; {! O) }& I5 K" N. O0 @0 gas testotoxicosis, may cause precocious puberty at a* T  E" h# I5 a
very young age. The physical findings in these boys  z8 D8 i0 \2 l
with this disorder are full pubertal development,
9 B! e9 \# P1 e) zincluding bilateral testicular growth, similar to boys2 Y4 Q4 F# |- m5 B& w. D( T. r
with CPP. The gonadotropin levels in this disorder
) R8 j- y! D2 [3 R& t& i+ fare suppressed to prepubertal levels and do not show& D+ g+ U9 R# ^8 y" Y
pubertal response of gonadotropin after gonadotropin-
8 R! j1 p  \8 O) V( k% f! ^0 wreleasing hormone stimulation. This is a sex-linked
7 I6 [9 K" W8 f- N9 f2 `autosomal dominant disorder that affects only
7 i7 S3 {; a" \* y2 @7 r" }- l; p- Zmales; therefore, other male members of the family8 K- z. N7 D! N9 _6 m4 w1 p2 ]
may have similar precocious puberty.3
1 m1 l% c# U+ D! f7 e2 ]( OIn our patient, physical examination was incon-* `, n5 g, O8 q
sistent with true precocious puberty since his testi-  I/ x$ B: I4 I. S) u
cles were prepubertal in size. However, testotoxicosis
$ g  i( v% j; ^was in the differential diagnosis because his father! D6 ~% j& F8 Y0 l' n. c" E
started puberty somewhat early, and occasionally,
& ~& J* Y& ?6 b; a8 F- A4 Y) atesticular enlargement is not that evident in the
# T. x  N! v. tbeginning of this process.1 In the absence of a neg-
. G9 O1 D$ _. }+ Dative initial history of androgen exposure, our3 a7 B; j2 r: P$ m/ R5 [9 {! {4 P' z
biggest concern was virilizing adrenal hyperplasia,4 O) b1 |1 {! K2 G6 h
either 21-hydroxylase deficiency or 11-β hydroxylase
0 d! O+ |0 u% Mdeficiency. Those diagnoses were excluded by find-
& r9 H7 M/ A) Sing the normal level of adrenal steroids.& e  e. F' K4 ]2 ^1 P! |: \
The diagnosis of exogenous androgens was strongly9 R3 O" [# I! ^1 ?; W  e& U
suspected in a follow-up visit after 4 months because
' b- X/ y5 W5 Bthe physical examination revealed the complete disap-
  O9 a- r& ^: O, y# Bpearance of pubic hair, normal growth velocity, and
1 ~4 \5 `2 X3 C! @) V& f7 i7 p2 j7 ndecreased erections. The father admitted using a testos-/ M+ [+ Q1 x& P  C# E2 `6 f
terone gel, which he concealed at first visit. He was
4 n( S7 g. v' H, Y& h  ?% R& rusing it rather frequently, twice a day. The Physicians’
* d: t8 j( Z  K+ \) d2 k6 W% \Desk Reference, or package insert of this product, gel or
3 x- q+ e; N9 r+ p: |& `/ Tcream, cautions about dermal testosterone transfer to6 ^) B/ H2 r. ]" D7 e$ V2 f
unprotected females through direct skin exposure.
1 M7 ~$ n- b' d( ^3 Q% CSerum testosterone level was found to be 2 times the
9 e& q& q  h* U1 l; Obaseline value in those females who were exposed to
+ f9 t, J2 ~- H) Q$ V. K, @; ~8 keven 15 minutes of direct skin contact with their male
, {9 b8 q& G" W+ n0 cpartners.6 However, when a shirt covered the applica-( n" x, v2 Y6 r: ~" o* \' _
tion site, this testosterone transfer was prevented.
8 B) p: k5 \( F/ @4 YOur patient’s testosterone level was 60 ng/mL,
0 _% o3 [! _" m' t  |which was clearly high. Some studies suggest that6 i$ Y1 F  F: N: p5 Q6 U* \9 _  J: }8 l" b
dermal conversion of testosterone to dihydrotestos-) x  L$ ]4 K9 [9 h$ z1 I; w
terone, which is a more potent metabolite, is more5 V0 U+ k) t- t+ ?9 c- ^
active in young children exposed to testosterone
! g8 r1 N: b# \2 Q4 x' rexogenously7; however, we did not measure a dihy-
( m4 t' E- k6 k7 |( ?drotestosterone level in our patient. In addition to/ r# a  |& l9 d: e' ~
virilization, exposure to exogenous testosterone in4 H8 j$ q- g# g$ k' H( c
children results in an increase in growth velocity and0 O% z! [# s0 {% Q+ `  |
advanced bone age, as seen in our patient." ~. N& _& t1 s% C) T8 {, [
The long-term effect of androgen exposure during9 n, B# M1 k: n& a" ~& N
early childhood on pubertal development and final' F5 a9 V+ ?- F
adult height are not fully known and always remain9 ]& Y, }  v+ s- ~& k
a concern. Children treated with short-term testos-* v. D6 l3 N% h& ^% W
terone injection or topical androgen may exhibit some
9 f8 A. k7 t5 r% [+ Cacceleration of the skeletal maturation; however, after
7 u( Q9 V; v: S, o2 l8 bcessation of treatment, the rate of bone maturation
  x. u" ?& f1 S+ }) p- tdecelerates and gradually returns to normal.8,9: q* Z1 s( U7 S/ w
There are conflicting reports and controversy
& K" ?5 m$ m% Cover the effect of early androgen exposure on adult: h+ |. K) x" V% u
penile length.10,11 Some reports suggest subnormal
  b( u3 ^* p) f0 L  Uadult penile length, apparently because of downreg-
( T& k( m2 a" {2 iulation of androgen receptor number.10,12 However,
3 J+ V$ N6 i+ |2 n3 hSutherland et al13 did not find a correlation between
7 W/ N& O; `' u$ S8 Cchildhood testosterone exposure and reduced adult* Z: D9 S6 Y4 x! R
penile length in clinical studies.8 T! r/ |) \4 ]
Nonetheless, we do not believe our patient is8 y: G2 ^2 K5 j9 I$ ?  j' I5 i( J
going to experience any of the untoward effects from
, _' |0 R2 \+ X6 |/ ]+ Q) ~9 Htestosterone exposure as mentioned earlier because, ]  E  Z* }% A  G) U: W
the exposure was not for a prolonged period of time.2 `/ |' ^* T1 i" n- o( `7 w* j6 v
Although the bone age was advanced at the time of
& I: A* x: Y8 W, I* [/ zdiagnosis, the child had a normal growth velocity at
; _# A3 L9 \6 K. n! K; W3 G/ n* U# {the follow-up visit. It is hoped that his final adult9 z: }! P# k* c3 j
height will not be affected.
" u8 c8 j" H2 xAlthough rarely reported, the widespread avail-
& ~7 Q3 n" ]3 Y5 l* E  yability of androgen products in our society may+ I; U7 I, z* b
indeed cause more virilization in male or female6 j; s8 S& b- ^- O0 g& N0 E5 E
children than one would realize. Exposure to andro-
; `# P/ o8 x, `' _+ Egen products must be considered and specific ques-: ]' \6 B4 n# B  l, [+ Z7 Y  e
tioning about the use of a testosterone product or) o/ s9 @" U* q
gel should be asked of the family members during3 n* P% w, H* L$ D: C
the evaluation of any children who present with vir-/ C/ X$ K3 r3 I9 P
ilization or peripheral precocious puberty. The diag-' w. D7 @/ j# C4 c* G, T) X
nosis can be established by just a few tests and by6 ]: |0 q5 y4 f* `
appropriate history. The inability to obtain such a
6 z/ p! }3 c$ |, v6 e9 Ehistory, or failure to ask the specific questions, may
6 Y6 A: U' Q/ z) M/ hresult in extensive, unnecessary, and expensive
7 e5 g- l6 L$ }& zinvestigation. The primary care physician should be
% z8 s" r- h; n- ]1 }1 Raware of this fact, because most of these children( D) k" N' r- r% j& J
may initially present in their practice. The Physicians’
( |: d: H% y( i6 d+ l% NDesk Reference and package insert should also put a
% {6 n2 B* b2 Kwarning about the virilizing effect on a male or
7 a4 h+ R+ x1 [female child who might come in contact with some-
0 {7 v; ?2 D4 W( _- r! V$ {one using any of these products.
) u6 B. d8 X3 H; `5 bReferences
5 E0 D% M4 w1 [9 R1 @1. Styne DM. The testes: disorder of sexual differentiation" X% `5 L* I& j/ u, V) A
and puberty in the male. In: Sperling MA, ed. Pediatric) q$ \' e2 e; w+ Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( j0 w$ P6 c* F0 F
2002: 565-628.3 f  r+ k% H; M" c/ p5 f" ?& ~
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; M/ q! g5 w  Z0 h# ^) i2 t. fpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
% E! d7 Z, y# s$ ]# t. B+ ~0 SBoy Induced by Indirect Topical
8 w* O9 ?) ^$ D3 sExposure to Testosterone
  k$ Y: `2 g' U1 V+ @/ bSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 r+ ]; _% H0 X/ x7 D
and Kenneth R. Rettig, MD11 u6 ^: j* s/ P. T: n
Clinical Pediatrics( v5 `; X2 p0 s% e, O+ w: Q
Volume 46 Number 6
! o# ^8 g+ d$ ?6 S, [! y; VJuly 2007 540-543
" t7 g$ L& ^( s9 \/ b© 2007 Sage Publications
& `- O8 g% r; S" S$ k* T) t( {10.1177/0009922806296651
: L1 D% U* G. j  v! ~4 Zhttp://clp.sagepub.com  Y9 k& @" m/ X7 ]# l! o8 H  P: G
hosted at
' F/ B& _0 U" d8 t. Lhttp://online.sagepub.com  F1 R: Y2 ]0 T4 q' x
Precocious puberty in boys, central or peripheral,
/ p* w: u2 ^* bis a significant concern for physicians. Central
1 ~) Q) I. k  r) V$ V. O7 Y" wprecocious puberty (CPP), which is mediated
* L" c5 u1 D$ ]. m- t8 R5 l# c2 u9 |through the hypothalamic pituitary gonadal axis, has
: u* W3 ?9 A8 s$ }- _6 na higher incidence of organic central nervous system% `- U  i- y' K7 B3 I7 S$ }& e
lesions in boys.1,2 Virilization in boys, as manifested
7 Y  ?+ P! w# S8 d  [2 d7 f# J5 A2 ?by enlargement of the penis, development of pubic7 v3 |6 a1 A  ?4 b( I1 Y
hair, and facial acne without enlargement of testi-
9 @7 h% t% |) y4 h+ v& t% P- u0 Z# u3 pcles, suggests peripheral or pseudopuberty.1-3 We
6 j$ G, p% B: X. Jreport a 16-month-old boy who presented with the$ G" E: d9 J% X
enlargement of the phallus and pubic hair develop-+ a, s  A9 A" F, t7 m# u, R
ment without testicular enlargement, which was due
' N, ]- m0 D. j8 ^/ `to the unintentional exposure to androgen gel used by
" G9 G  O7 M; a6 `/ Jthe father. The family initially concealed this infor-+ S( k& [' ?+ f
mation, resulting in an extensive work-up for this
: w' M. Z% W  @# c0 xchild. Given the widespread and easy availability of& F: U& ]- Z) [
testosterone gel and cream, we believe this is proba-4 L; }6 X0 l) z, M
bly more common than the rare case report in the
* i+ O$ P" N4 O# P$ I4 T8 cliterature.4
) m/ c( s, R- c% X' ~Patient Report8 U3 ]3 w2 }( O* r& s
A 16-month-old white child was referred to the
+ J5 S2 S( N: C% ^* kendocrine clinic by his pediatrician with the concern7 ^% Y7 H6 k) W6 A6 _, i
of early sexual development. His mother noticed
2 t6 Y0 l* {8 E3 k8 T8 Olight colored pubic hair development when he was+ H( \3 C9 d. ]& b
From the 1Division of Pediatric Endocrinology, 2University of
: s/ t, U+ j: ?7 \" }South Alabama Medical Center, Mobile, Alabama.) V* W3 Q; L( A& A4 P# k. V) l
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- n; I5 |8 h* dProfessor of Pediatrics, University of South Alabama, College of% b6 ?. {* ]* z1 H" O, O5 I* |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 K" V2 ^9 L' _; a2 k/ u& v' u( D
e-mail: [email protected].
% ^5 q9 O7 X+ \- M+ j6 C9 }5 t1 Wabout 6 to 7 months old, which progressively became
8 @: X- `7 d" h# Ldarker. She was also concerned about the enlarge-9 P; _7 g" M) S8 ?6 r
ment of his penis and frequent erections. The child% a; G7 Z% Z3 B2 M! j1 Z
was the product of a full-term normal delivery, with* d! d6 M' P' y! m
a birth weight of 7 lb 14 oz, and birth length of5 }% S7 X% T% [: ?' V1 I% I, i
20 inches. He was breast-fed throughout the first year
4 I4 v7 ?9 V  f7 ]0 w3 E2 b- \of life and was still receiving breast milk along with
/ V6 l5 Q+ b  q+ N6 @4 w* wsolid food. He had no hospitalizations or surgery,  j5 X7 V; b# _1 E2 P$ B# [
and his psychosocial and psychomotor development
. I( n' x3 s3 B" s. n; ~5 q% xwas age appropriate.
% K  z" @8 E( O% AThe family history was remarkable for the father,1 {8 Q5 T. g/ a5 a3 Z
who was diagnosed with hypothyroidism at age 16,
# J- |4 N7 X- @' \which was treated with thyroxine. The father’s
8 _) k' S- ?' _' W* `height was 6 feet, and he went through a somewhat
5 [; ?2 @" C. J$ d, \- I; ]early puberty and had stopped growing by age 14.. q7 n- M; |/ w
The father denied taking any other medication. The
, ?+ \$ E" t0 T7 G  M& Tchild’s mother was in good health. Her menarche. U# q3 D/ x7 k! a2 w
was at 11 years of age, and her height was at 5 feet. k8 _1 W( V6 N% y4 C& c8 Y1 s2 S
5 inches. There was no other family history of pre-* g0 Z. C& q1 {" n7 c; x$ z
cocious sexual development in the first-degree rela-& B7 x: J7 b8 K/ _4 o
tives. There were no siblings.; h% c* o" r3 a, K- U0 F7 y
Physical Examination4 ]9 A' V6 D" v  z/ m
The physical examination revealed a very active,- E8 s( r3 P4 _7 _7 b0 d2 |- p
playful, and healthy boy. The vital signs documented+ D7 O9 j" k2 ]" l3 e
a blood pressure of 85/50 mm Hg, his length was
, D# {/ }: E% X9 P9 H$ @5 k, q90 cm (>97th percentile), and his weight was 14.4 kg1 _9 H/ R, d" a% Q# K
(also >97th percentile). The observed yearly growth
! b1 p9 [6 v; |9 \+ I- Nvelocity was 30 cm (12 inches). The examination of
8 X* P7 [& Z# a, @- Wthe neck revealed no thyroid enlargement.
6 o, p$ d- l2 rThe genitourinary examination was remarkable for
4 `) J8 A4 f8 Z+ ~  q7 benlargement of the penis, with a stretched length of  O5 h  L& G" X$ A. l) T) {
8 cm and a width of 2 cm. The glans penis was very well
+ V6 c, O) K$ v; w% I8 Gdeveloped. The pubic hair was Tanner II, mostly around6 u4 P7 `( h4 R. i  F* a: `
540
0 E& R# p6 ~% [$ Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ r" o* I0 w$ }0 e0 T
the base of the phallus and was dark and curled. The
$ _; u2 p6 \0 S9 Ltesticular volume was prepubertal at 2 mL each.9 P. E7 C& A2 C. q
The skin was moist and smooth and somewhat/ m: S1 z4 k" V
oily. No axillary hair was noted. There were no* k: I* {) t# a  R7 C
abnormal skin pigmentations or café-au-lait spots., e/ j5 s( y2 `$ T
Neurologic evaluation showed deep tendon reflex 2+
. B1 M/ t: r+ _. e1 xbilateral and symmetrical. There was no suggestion
4 P& {6 A& f, @, Q) f1 ^1 d% [1 _0 j; F* `% ?of papilledema.
  T4 D9 {5 f* ?  c1 w& ~Laboratory Evaluation
0 P6 P" S% n8 UThe bone age was consistent with 28 months by
& o; t2 `- ]5 A- X3 U( P+ husing the standard of Greulich and Pyle at a chrono-
' _6 ?: a; E( r8 ^logic age of 16 months (advanced).5 Chromosomal0 V2 J) W( k$ S0 U6 u
karyotype was 46XY. The thyroid function test$ w/ @4 T9 k+ j$ }- l* C
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 I  V8 D5 Z5 m$ }* y0 L
lating hormone level was 1.3 µIU/mL (both normal).
  T3 ~9 ~9 @4 r; j2 iThe concentrations of serum electrolytes, blood
! P/ T+ W" `2 V3 _2 T" X7 Yurea nitrogen, creatinine, and calcium all were
( \7 y: e: Y4 [( ^within normal range for his age. The concentration
, r; W* k* F( j" y9 |# ^of serum 17-hydroxyprogesterone was 16 ng/dL
7 k$ r+ z- k  b* O(normal, 3 to 90 ng/dL), androstenedione was 20* t2 {# z4 W3 c! _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! w+ b3 X) D( T9 _) K2 j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 O6 f( T3 [* ~( zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 y6 K) q2 {3 C: B+ @1 B. O49ng/dL), 11-desoxycortisol (specific compound S)
  a* o& c0 I6 n5 G' \" Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! Q& }9 Q9 Q; |7 l
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  C7 s- z" M- |' W' j6 g' S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 \# W' [/ P) q8 N3 M/ o
and β-human chorionic gonadotropin was less than
5 O! s7 v* t7 w& K* e4 s  J4 D5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 y6 w; `# `  j- S$ |stimulating hormone and leuteinizing hormone
) W# O0 ~7 m4 M) |concentrations were less than 0.05 mIU/mL
  H4 L7 n: z" [(prepubertal).
& a. l4 f! }4 uThe parents were notified about the laboratory
, ~3 X2 F; S2 F; sresults and were informed that all of the tests were
2 }# L1 j9 E: h4 P: u- j2 u4 @; Lnormal except the testosterone level was high. The6 F) c$ x" G! l5 F) h
follow-up visit was arranged within a few weeks to
! G; D5 o' Y! xobtain testicular and abdominal sonograms; how-3 v; @  J% _/ A1 _% U
ever, the family did not return for 4 months.2 ]+ u/ y& E+ U8 b' z0 `
Physical examination at this time revealed that the+ j9 w5 [' m. |3 x1 \
child had grown 2.5 cm in 4 months and had gained! i3 |" A; h* v" l- o
2 kg of weight. Physical examination remained
. k+ H4 A. S2 x' U  @3 `6 ounchanged. Surprisingly, the pubic hair almost com-) o. f# m! H% ?4 b
pletely disappeared except for a few vellous hairs at" _" P6 A* x$ ?. I1 `7 P; T
the base of the phallus. Testicular volume was still 20 N+ ^0 b/ i9 j% K/ d
mL, and the size of the penis remained unchanged.2 }6 U# ?, s8 T3 M
The mother also said that the boy was no longer hav-
" b  A( @& H1 F0 o0 Eing frequent erections.2 K( E5 \2 N2 c; I7 y4 ?+ J
Both parents were again questioned about use of
+ y$ Z) _! W5 U" E5 Jany ointment/creams that they may have applied to
, i2 e# ^3 B$ A7 m5 Wthe child’s skin. This time the father admitted the6 u; w: q  E! ?
Topical Testosterone Exposure / Bhowmick et al 541& h3 v7 j: _$ G$ O, o
use of testosterone gel twice daily that he was apply-
- t; h" P) h3 {6 jing over his own shoulders, chest, and back area for6 z* W4 o# b# {
a year. The father also revealed he was embarrassed3 A7 l: ?1 j5 d  T
to disclose that he was using a testosterone gel pre-, w* i3 m( d% j- ~% ?+ s+ S: y3 e
scribed by his family physician for decreased libido
, |$ Q0 u; X" D5 z/ ~  tsecondary to depression." j+ k! s9 Q% C6 P
The child slept in the same bed with parents.
- q8 D. A4 {/ |' k1 ?The father would hug the baby and hold him on his1 c1 x. L8 V4 i
chest for a considerable period of time, causing sig-
  _$ e8 X; H2 `& t- `, A2 K4 pnificant bare skin contact between baby and father.& @" T( Y+ p2 C4 l( ~+ {1 x9 l! x
The father also admitted that after the phone call,2 @; v1 p$ e* I
when he learned the testosterone level in the baby
  v- M/ ]6 N1 o& Hwas high, he then read the product information
/ n; [0 m' }0 V, ^" q+ V- _packet and concluded that it was most likely the rea-4 l- k: a( b( D" T% Q+ o/ U8 n
son for the child’s virilization. At that time, they
5 l5 M$ y2 z( ]2 Y1 e/ [decided to put the baby in a separate bed, and the
% M- f% d+ l$ p. o/ {father was not hugging him with bare skin and had
  S( z) Y$ B! k# Qbeen using protective clothing. A repeat testosterone$ @. h8 |5 e# p4 m' f' K# h* m
test was ordered, but the family did not go to the
9 f# Y. X+ q# X2 T3 hlaboratory to obtain the test.
( z% g& `( Q+ y6 C2 q" d- F7 UDiscussion
! w& H) F* W/ {2 UPrecocious puberty in boys is defined as secondary
+ W/ C; D5 Q  usexual development before 9 years of age.1,4' w) M. d8 W4 |5 o1 R
Precocious puberty is termed as central (true) when/ O: Q( V% j0 E$ P! D$ A  T: ?
it is caused by the premature activation of hypo-
9 E& q/ d8 Q9 @8 othalamic pituitary gonadal axis. CPP is more com-9 }& ]* F, f7 \, W6 u2 Q2 A. |
mon in girls than in boys.1,3 Most boys with CPP
* G* ]6 i4 g) U/ |6 Vmay have a central nervous system lesion that is
- J& G# k/ v. F5 U( u" Z- _responsible for the early activation of the hypothal-
. U2 r" v7 N1 Q. s  [4 j* Yamic pituitary gonadal axis.1-3 Thus, greater empha-
% a: D( I( U- Y; {sis has been given to neuroradiologic imaging in
  p2 N: u( c* v. zboys with precocious puberty. In addition to viril-
5 O7 F( P, _! n! Z+ c+ m7 H0 oization, the clinical hallmark of CPP is the symmet-5 ~0 B9 l1 Y# n* C2 g
rical testicular growth secondary to stimulation by; A& Q  P7 r  {6 E$ z/ g! H
gonadotropins.1,3
' o" u* w$ @+ G6 x' ]) @Gonadotropin-independent peripheral preco-
3 W7 b" d9 Q  F+ D* Pcious puberty in boys also results from inappropriate
/ ^6 G* {% t) R/ s. z/ `  E$ O! w* candrogenic stimulation from either endogenous or( a: ~( d& B/ p, y( a# K
exogenous sources, nonpituitary gonadotropin stim-, Y; A1 f8 F9 w2 b/ k% z' ]' M% f2 E
ulation, and rare activating mutations.3 Virilizing
# l, U! d; N& s6 ^2 y5 jcongenital adrenal hyperplasia producing excessive2 ~0 f) Z0 q* _# s! E! F, i* E
adrenal androgens is a common cause of precocious
8 M4 g, B6 ]; D+ H& Zpuberty in boys.3,4/ H& z' T2 P4 E) u4 G7 j
The most common form of congenital adrenal1 b9 [4 W  X0 |7 x9 `& e7 M# _
hyperplasia is the 21-hydroxylase enzyme deficiency.# B& e4 Z! ~" I; c, O- D
The 11-β hydroxylase deficiency may also result in$ L* m$ C1 r8 q: [
excessive adrenal androgen production, and rarely,
$ I" W% d* R# Z8 M# x/ t# c% C1 Qan adrenal tumor may also cause adrenal androgen
' S7 U& h3 N6 \, t5 [/ V1 y7 `/ b+ eexcess.1,3% |% E+ }1 M; E; v. Z) c" A' r) [* a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. {1 p3 d( d9 M3 H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& w& H- C; j/ I' @9 L$ FA unique entity of male-limited gonadotropin-6 H% a9 `$ Z7 r- E$ i% R9 |+ ^$ P
independent precocious puberty, which is also known: D. `2 ^6 |3 ?. |' p! c+ K! Q5 u  G
as testotoxicosis, may cause precocious puberty at a
6 R7 Y9 Q+ {# {very young age. The physical findings in these boys- H* ?( y# f9 U
with this disorder are full pubertal development,
4 R& K( t7 x+ m; Q* aincluding bilateral testicular growth, similar to boys
2 L  T' u/ ]/ z  C1 \with CPP. The gonadotropin levels in this disorder* D- E/ V* n1 N2 n- I8 x
are suppressed to prepubertal levels and do not show  E( C+ R# J1 O5 x. x
pubertal response of gonadotropin after gonadotropin-/ O0 [) Q% P( L. @6 T5 p3 n
releasing hormone stimulation. This is a sex-linked
' n7 v% @5 C7 Aautosomal dominant disorder that affects only! ^" j8 H/ u% I+ P9 i9 X
males; therefore, other male members of the family
( `! [0 i9 `+ k) mmay have similar precocious puberty.3% R, L3 d9 I- ~3 |
In our patient, physical examination was incon-, a4 O% u8 d1 m: l
sistent with true precocious puberty since his testi-
3 G: u  X& t4 x  h) M+ O; T$ {# fcles were prepubertal in size. However, testotoxicosis
$ C) {! F! I7 j% @was in the differential diagnosis because his father
+ |. ?4 ^0 A7 I& x2 U. T! qstarted puberty somewhat early, and occasionally,
+ R% @3 ?, _  B9 a* l5 u4 ntesticular enlargement is not that evident in the5 k* ]# @! e+ V+ M3 {
beginning of this process.1 In the absence of a neg-
9 T/ h" k" ~6 A4 native initial history of androgen exposure, our
! |4 ~8 U% E7 o/ p8 dbiggest concern was virilizing adrenal hyperplasia,
; K. c- z6 V( k0 K, x% b& s& oeither 21-hydroxylase deficiency or 11-β hydroxylase5 g3 e! P' r3 H6 I5 l
deficiency. Those diagnoses were excluded by find-' F( Z& Z4 I; r5 Y  a% t8 k' P
ing the normal level of adrenal steroids.
  e7 s+ i/ }, v& h; dThe diagnosis of exogenous androgens was strongly
4 |& ^1 O2 }, Ssuspected in a follow-up visit after 4 months because" l% @1 `  N+ D
the physical examination revealed the complete disap-& K; D  M% |* i# P
pearance of pubic hair, normal growth velocity, and
) U! m& ^6 G- Ldecreased erections. The father admitted using a testos-
. g' x* S/ {/ l5 W/ t- \" aterone gel, which he concealed at first visit. He was
3 N7 H% Y. ]% G8 E7 |: |4 `8 Pusing it rather frequently, twice a day. The Physicians’
7 h0 y& \1 w2 D- R3 U2 y7 K0 ?Desk Reference, or package insert of this product, gel or
! g" r& u8 \2 B7 ]5 C9 [cream, cautions about dermal testosterone transfer to( z5 i0 F; P  S# C) b
unprotected females through direct skin exposure.4 |$ }* j  s8 d1 E. \7 X* N! J) Z
Serum testosterone level was found to be 2 times the
' q1 e0 W- X5 Y  ^7 n; Wbaseline value in those females who were exposed to2 u+ E- w) h- K9 m7 G
even 15 minutes of direct skin contact with their male+ u& ~+ a# @! B( U# G+ `
partners.6 However, when a shirt covered the applica-
" B7 `& [) G3 w; Z$ g  {# Ftion site, this testosterone transfer was prevented.
: w" D7 ?+ Q4 X: s( K3 ^+ A! zOur patient’s testosterone level was 60 ng/mL,
! N2 a6 P  U3 x$ h% Xwhich was clearly high. Some studies suggest that5 \! q9 a' e+ [) `0 V9 c' x6 x1 m2 N
dermal conversion of testosterone to dihydrotestos-
" I0 i; n" ~8 y$ nterone, which is a more potent metabolite, is more
; B+ d. l- @$ }  z  Cactive in young children exposed to testosterone4 J2 A& d7 z! c! ?7 a9 g/ b
exogenously7; however, we did not measure a dihy-
; S& [7 c5 P1 H" A; }- jdrotestosterone level in our patient. In addition to
% [3 w7 B. C0 hvirilization, exposure to exogenous testosterone in
4 c2 C9 ?& E& Ochildren results in an increase in growth velocity and+ v6 L5 i8 k! C
advanced bone age, as seen in our patient.
7 ]5 p6 I* m- D6 tThe long-term effect of androgen exposure during0 t+ Z' f( e5 k
early childhood on pubertal development and final/ O/ i# {/ V% L% D
adult height are not fully known and always remain; V8 N/ ^+ F4 W6 d* j) k
a concern. Children treated with short-term testos-
; K/ N* Q9 F. f! J/ K5 gterone injection or topical androgen may exhibit some4 _' F  v2 P6 a
acceleration of the skeletal maturation; however, after+ e% X5 b" N* t
cessation of treatment, the rate of bone maturation2 x9 X$ Z7 u5 w# R* }" s  u
decelerates and gradually returns to normal.8,90 Z8 a4 y" i  \+ Q; d5 D* ~
There are conflicting reports and controversy; Z$ l& N7 p7 Q3 N1 k9 S& Y
over the effect of early androgen exposure on adult
7 t8 p- y7 O& T8 _penile length.10,11 Some reports suggest subnormal
1 ^5 m/ K- V' d' d: Cadult penile length, apparently because of downreg-% D2 f% E' Z' `8 p
ulation of androgen receptor number.10,12 However,
- I: J+ `8 T' tSutherland et al13 did not find a correlation between& A8 F) M" m7 {! l5 l8 Q
childhood testosterone exposure and reduced adult
( S7 z: t: G  z: v: Npenile length in clinical studies.9 t% n& Y: \. O/ W1 R& W! B' J
Nonetheless, we do not believe our patient is& e9 c& J* y% C2 C* l9 L1 m2 h
going to experience any of the untoward effects from
( U8 ^' y: Z* H: Ptestosterone exposure as mentioned earlier because+ n0 `% i4 J+ z+ I" _. d
the exposure was not for a prolonged period of time.
" R* P  u' @* d1 h5 A& YAlthough the bone age was advanced at the time of
) U5 S* e, d) y8 \diagnosis, the child had a normal growth velocity at# a0 V9 j; ?) w1 ^7 l* b+ ~
the follow-up visit. It is hoped that his final adult
! f; R6 c1 c1 n4 K" g+ @height will not be affected.* l& D' |: \  }1 |2 D
Although rarely reported, the widespread avail-: @4 Y' `: \" Q; l0 \
ability of androgen products in our society may
* g4 |& [$ F) r/ s) L" A, p1 |indeed cause more virilization in male or female& S. W, B$ ^' P# a# L" D' J9 n
children than one would realize. Exposure to andro-0 t; q- C2 n% G$ s1 V: t
gen products must be considered and specific ques-
8 n4 Z! |! D( ntioning about the use of a testosterone product or5 D7 o9 {8 X. k9 T7 v; ~
gel should be asked of the family members during
8 Y4 f! O# L" g- q3 S$ K! |$ L: i- Tthe evaluation of any children who present with vir-
+ c+ p: N) K# `  x) z) Yilization or peripheral precocious puberty. The diag-
( ~1 U; ^  {. a& \0 U' G7 [5 hnosis can be established by just a few tests and by
. l3 B7 @6 u. L6 x3 g+ Cappropriate history. The inability to obtain such a, q' N* D3 ?' R- T/ y
history, or failure to ask the specific questions, may
% M" i" L: f# |( k" tresult in extensive, unnecessary, and expensive5 p- a  E& Y7 Q8 E9 V, B3 `' P  L
investigation. The primary care physician should be) T6 @  {4 @) |9 ?* V; t8 m7 a
aware of this fact, because most of these children3 J# s8 m! g# z3 H- Z! c
may initially present in their practice. The Physicians’
) u" G0 G1 I9 p. }Desk Reference and package insert should also put a
( q! Z8 x! X5 X" ^warning about the virilizing effect on a male or
3 l/ s- z- g( {- w5 b; w  Tfemale child who might come in contact with some-
1 G6 ?) S* g* M) O( e3 @one using any of these products./ p) Y1 r9 ^3 M
References
5 |4 v( c2 S7 L1. Styne DM. The testes: disorder of sexual differentiation
) ^; M6 S4 a0 Q4 {) P' X; Aand puberty in the male. In: Sperling MA, ed. Pediatric
0 Z7 ?* \3 Y0 l8 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 Z) X& e! r* \6 a2002: 565-628.
7 \; a0 X: I1 N. W% J! S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ |3 x2 m9 B5 I9 e  T+ J5 l, q
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
& J4 r2 R& c, L! m
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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