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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 M6 e0 Q7 t  e! ^8 P$ zBoy Induced by Indirect Topical( E3 G  T& O9 O7 H, |. Z8 h
Exposure to Testosterone. E' `& X% r7 O# a" ?4 R! r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  W& R1 s* l7 Y( a; e* ~and Kenneth R. Rettig, MD1
$ A  {3 A& e4 ^! ~- q& [2 ~Clinical Pediatrics( L8 V/ O( ?0 F
Volume 46 Number 6
5 }9 }+ \9 Y9 U& @) [  jJuly 2007 540-543
/ ]6 I0 x' {2 V© 2007 Sage Publications
) E/ ^0 |; ^* d5 g5 B: B10.1177/0009922806296651
7 n+ C' \! W: X. d5 o; i; J. B& n9 Jhttp://clp.sagepub.com% E+ _& y- B! e2 y1 C+ k! u- N
hosted at. T# i, k' W, d% C5 s" O: ]
http://online.sagepub.com( O( J8 M3 a  c5 H" F5 `4 \
Precocious puberty in boys, central or peripheral,
% n/ K1 i$ Y" D+ S5 U6 N& c2 k! Xis a significant concern for physicians. Central+ t* {1 C% H; f. N/ @4 n$ |
precocious puberty (CPP), which is mediated
, Y% \- @; S: Z9 f* k$ i3 @/ Tthrough the hypothalamic pituitary gonadal axis, has
. S+ a! l- B$ P, r3 va higher incidence of organic central nervous system
- B& }# r& N: f$ _1 I" ]5 Mlesions in boys.1,2 Virilization in boys, as manifested" w8 s# E) i/ `# ^
by enlargement of the penis, development of pubic
( {* g4 b( b4 }: C' _, E' lhair, and facial acne without enlargement of testi-
8 K% D8 T' f$ S% v4 M% gcles, suggests peripheral or pseudopuberty.1-3 We
' J$ V+ y, U6 zreport a 16-month-old boy who presented with the3 Y% Z" P3 e6 V0 _7 V9 h; L1 r
enlargement of the phallus and pubic hair develop-' `1 W8 L. t- @  M% s0 r% p
ment without testicular enlargement, which was due6 h9 y/ F! n2 f) h8 ^3 e
to the unintentional exposure to androgen gel used by
* z  b+ R0 H! |' y. cthe father. The family initially concealed this infor-
7 ~# R, i' A3 q: j) I( J6 |mation, resulting in an extensive work-up for this& V. I9 c4 m& z& R4 I/ `8 _
child. Given the widespread and easy availability of4 D. n. f+ g% c" c
testosterone gel and cream, we believe this is proba-7 w" h( F% U" P! `1 e* P: Y9 p/ ]
bly more common than the rare case report in the4 n  z, c, z9 F
literature.4
. K: M7 c( \1 g3 Q5 [/ q/ F5 Z0 fPatient Report
; j4 u- {1 t5 l& mA 16-month-old white child was referred to the
$ E! i5 C# T" g# Dendocrine clinic by his pediatrician with the concern
  [! ~0 H/ t& `0 f1 I5 O" Nof early sexual development. His mother noticed5 m9 N0 v2 J8 Q0 Y/ }, G4 C
light colored pubic hair development when he was; b; w1 _5 Z+ v. o' [" x4 J
From the 1Division of Pediatric Endocrinology, 2University of
. v; P+ P; A; S  FSouth Alabama Medical Center, Mobile, Alabama.
7 P, f9 ]; B7 o# C3 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,  Y9 @) l5 S$ q! G
Professor of Pediatrics, University of South Alabama, College of
' p5 H8 x- O- C2 g$ u3 U  xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! G  t& o& w  e0 R
e-mail: [email protected].: K* e: Y2 _2 h1 K! o
about 6 to 7 months old, which progressively became
% x& ?( `& y2 F# N! j9 r0 Hdarker. She was also concerned about the enlarge-( g: e0 {; @3 J8 v. Y
ment of his penis and frequent erections. The child9 f  p8 s& ^* T5 w6 ~. b
was the product of a full-term normal delivery, with
; N) l/ ^. s4 q- aa birth weight of 7 lb 14 oz, and birth length of8 L7 F; ?0 y0 \0 e, t  H% N" W
20 inches. He was breast-fed throughout the first year
, A" d9 {6 q* X: j7 fof life and was still receiving breast milk along with
* n6 q( V  a* Usolid food. He had no hospitalizations or surgery,: D+ T0 Y& ^: N( ~
and his psychosocial and psychomotor development) n1 |; C) ?/ w9 D1 {
was age appropriate.
$ f% \8 _$ j$ w9 p( h) X0 e4 T2 iThe family history was remarkable for the father,  L! v- |$ A- r1 J4 X! |4 c
who was diagnosed with hypothyroidism at age 16,+ s2 U0 Q9 ^$ @% q1 V- A; b) V& S
which was treated with thyroxine. The father’s$ a4 K# T, w0 b, t; m7 w! q
height was 6 feet, and he went through a somewhat$ Q; t; W  C5 r" Y8 n/ N: E
early puberty and had stopped growing by age 14.
, t1 W6 N9 @; s. ?The father denied taking any other medication. The  g6 N5 i* J( \/ `3 F
child’s mother was in good health. Her menarche! \* D/ n! ^+ S6 s
was at 11 years of age, and her height was at 5 feet
' J7 B' u8 D/ y: P5 inches. There was no other family history of pre-
" R: s# w5 l9 d5 w& P8 Vcocious sexual development in the first-degree rela-
3 p8 i" z1 N; |! `tives. There were no siblings.! m, a. x/ M  P
Physical Examination" R6 ?! \/ a' Y7 r1 H+ W
The physical examination revealed a very active,
+ ^4 @) F1 {: W, q: \playful, and healthy boy. The vital signs documented% f+ b! v4 |# n# n3 d
a blood pressure of 85/50 mm Hg, his length was
0 m! t9 Q1 f. o+ `# C" N; Q8 C90 cm (>97th percentile), and his weight was 14.4 kg
+ z" L4 [* b6 x  c+ K' |" z' O(also >97th percentile). The observed yearly growth
6 y7 G4 Y! z7 I! Z4 Q! Fvelocity was 30 cm (12 inches). The examination of
* J: e. N6 ?% z- ]the neck revealed no thyroid enlargement." H: t7 U5 f3 h* P: r9 t
The genitourinary examination was remarkable for
# z' c% L& b9 A" yenlargement of the penis, with a stretched length of: z7 v8 G* D! x) l4 Y
8 cm and a width of 2 cm. The glans penis was very well
- {9 r* o# `6 q& Edeveloped. The pubic hair was Tanner II, mostly around
$ g1 B( c% \0 U" y# }2 H* Y540
& p7 t& F6 R9 V2 d' V+ H6 {' F( p" ]6 xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, }5 o. A$ n2 X& A/ Y: ~: O; S
the base of the phallus and was dark and curled. The% T8 h: Z/ F$ J1 }9 L' h- l, P
testicular volume was prepubertal at 2 mL each., E8 r4 ?! z; Z1 }) _. n
The skin was moist and smooth and somewhat8 v0 _5 ^, f: P
oily. No axillary hair was noted. There were no
9 _& L8 ~: ~  }! Pabnormal skin pigmentations or café-au-lait spots.
) l( O* o  b% {/ h, M( nNeurologic evaluation showed deep tendon reflex 2+. a  E/ S8 N: h" ^  Q% k  C
bilateral and symmetrical. There was no suggestion
2 J  }3 x* }  Oof papilledema.5 U3 S( m. W# ], s7 I/ [
Laboratory Evaluation
3 Z" B, q' O8 `: ?6 L' lThe bone age was consistent with 28 months by
# k2 c; o3 i# q* c! fusing the standard of Greulich and Pyle at a chrono-
3 s$ O: V) V) t  ylogic age of 16 months (advanced).5 Chromosomal9 o6 E! _# l2 ^8 e4 s( B) ]& |
karyotype was 46XY. The thyroid function test* h1 j( f: x4 Q: c+ i0 z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ h: U' h3 n# N- F# Y9 ]/ W' K
lating hormone level was 1.3 µIU/mL (both normal).! C) Z! b" y8 y
The concentrations of serum electrolytes, blood
* {! R$ m7 b6 w/ ?1 Murea nitrogen, creatinine, and calcium all were
7 q4 r( K: e* t, Uwithin normal range for his age. The concentration( @2 M% S$ F! n' W7 j* f2 T
of serum 17-hydroxyprogesterone was 16 ng/dL8 S5 M3 w+ P; q1 A
(normal, 3 to 90 ng/dL), androstenedione was 208 h2 [+ v9 U! M+ K& a# a& Q2 V& v; E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- ?" b. g( ]9 I# s% H! ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( d1 f5 [; U: C: cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
, Z8 w  i. N# @! Z9 Y  h3 Y49ng/dL), 11-desoxycortisol (specific compound S)
; [4 n) o2 P. ]8 a' P  mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ h" x0 e5 c8 R/ c' L) u0 Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 B! G5 C4 }2 p( |6 @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 c& L2 S: F# S/ T1 h) |and β-human chorionic gonadotropin was less than
, e8 U( r! O3 U2 `9 G3 Y$ Y. n* ?0 R5 mIU/mL (normal <5 mIU/mL). Serum follicular& T8 k, `2 c" l* o; X0 b
stimulating hormone and leuteinizing hormone% s/ X  f; z/ @$ m
concentrations were less than 0.05 mIU/mL0 @1 L" W% o# ^- e
(prepubertal).
' N; y& t; C9 u# ~$ EThe parents were notified about the laboratory
# b5 S  O, b  o9 zresults and were informed that all of the tests were
3 P% m. g2 }# z- l* X! Hnormal except the testosterone level was high. The4 I% W! D% g6 _0 S: s/ A: Y/ ~6 t
follow-up visit was arranged within a few weeks to
! E$ s7 Z9 {+ r+ R/ C6 X. B4 n1 W8 Wobtain testicular and abdominal sonograms; how-. N* o6 U: o! j. T" ?
ever, the family did not return for 4 months.' T7 }' }$ J# I2 J' t# E+ m/ w
Physical examination at this time revealed that the% c) j' U: f3 j
child had grown 2.5 cm in 4 months and had gained8 ~: H; {/ h0 h0 Z# |
2 kg of weight. Physical examination remained
( U$ a& V9 U2 R4 Y! funchanged. Surprisingly, the pubic hair almost com-
; ^( r2 U& f  s7 npletely disappeared except for a few vellous hairs at
8 V. {3 ?! p3 E! W' T) M7 [' othe base of the phallus. Testicular volume was still 2
+ J* u" D# Z% imL, and the size of the penis remained unchanged.  _  A; q$ W9 I; i
The mother also said that the boy was no longer hav-
3 E: ]" c. v/ V' p  g3 Ring frequent erections.) m; Y7 X1 g7 x/ w% D8 j
Both parents were again questioned about use of( l6 \* p1 o1 |8 C
any ointment/creams that they may have applied to- I: r! B! I4 Z9 b
the child’s skin. This time the father admitted the
9 h) W) G7 Y+ L+ q; oTopical Testosterone Exposure / Bhowmick et al 541, D" k6 S$ N0 i& H: h: X
use of testosterone gel twice daily that he was apply-
( H% Z& Y$ Y& ]! A0 }ing over his own shoulders, chest, and back area for
- e! V8 Q' p1 P' h$ b) ca year. The father also revealed he was embarrassed
: d& F1 `+ t. yto disclose that he was using a testosterone gel pre-
9 y8 _; J) ~) _/ A% p0 bscribed by his family physician for decreased libido% A1 D( u, Z, G8 l& R$ P8 T4 q
secondary to depression.
; r6 e) p1 {/ ~* UThe child slept in the same bed with parents.) N; l1 p9 e. \# w2 K
The father would hug the baby and hold him on his6 I+ o$ D+ r. l: D% r6 k
chest for a considerable period of time, causing sig-4 ]5 k6 P# E. y) J) G
nificant bare skin contact between baby and father.
, Z' V* B8 }% `1 c* XThe father also admitted that after the phone call,7 Q- I4 ~! \2 {
when he learned the testosterone level in the baby
% N7 g% q' v& C* k% Uwas high, he then read the product information9 D! y. D. C# p" z/ e
packet and concluded that it was most likely the rea-* }" k) t* v' F0 {
son for the child’s virilization. At that time, they9 @; q7 [# {4 O
decided to put the baby in a separate bed, and the
9 ^: S, d8 I* u1 l; D* O$ Ffather was not hugging him with bare skin and had
7 K; s" J" ]$ U# D; Tbeen using protective clothing. A repeat testosterone! A2 M& I/ K5 C' N. P, o1 j* {
test was ordered, but the family did not go to the1 a" J% `* p/ d; r3 t% {6 L7 ~
laboratory to obtain the test.
4 D  `& i; V: a  K# |+ S; uDiscussion
5 l$ A3 n! I9 |Precocious puberty in boys is defined as secondary
8 \+ R5 p2 g8 W6 W: Esexual development before 9 years of age.1,4
. w3 y+ S# z) p/ K( X3 MPrecocious puberty is termed as central (true) when
! s) F. S+ C6 x( z- Wit is caused by the premature activation of hypo-9 z3 K: S2 C/ s0 o' p
thalamic pituitary gonadal axis. CPP is more com-0 H! ^2 G' ]4 q5 z2 b  I: ]
mon in girls than in boys.1,3 Most boys with CPP4 d: Y' |( ]& z$ M. X2 g! p
may have a central nervous system lesion that is
: r  Z  _! M6 u5 H. \1 r( \responsible for the early activation of the hypothal-+ i* o. P  g" r! Y
amic pituitary gonadal axis.1-3 Thus, greater empha-* X3 o' j) {/ i
sis has been given to neuroradiologic imaging in: }4 j4 F3 i+ F5 `2 Y
boys with precocious puberty. In addition to viril-2 ~- R5 L  b3 Z) Q
ization, the clinical hallmark of CPP is the symmet-1 c6 A( f: e& P* ^
rical testicular growth secondary to stimulation by1 I; S1 i3 l+ g& S: m
gonadotropins.1,33 |# ^7 e- S! Q6 o+ e$ U" P7 s
Gonadotropin-independent peripheral preco-
4 o- n; x) Z6 ]( v  z+ P' p+ f% _* ^cious puberty in boys also results from inappropriate% J: |& Q9 q8 b* T5 D* \
androgenic stimulation from either endogenous or
* @) `+ w5 y. X5 m, i9 g8 yexogenous sources, nonpituitary gonadotropin stim-1 ]7 z! W5 R' \" r) v
ulation, and rare activating mutations.3 Virilizing2 d1 @  Y! u" D# s+ b* z
congenital adrenal hyperplasia producing excessive1 }' s% p+ y7 E" V: L
adrenal androgens is a common cause of precocious
8 r8 z6 O2 I/ B' @. h" [puberty in boys.3,4
8 d0 `4 j! n5 c' m- c1 ^  @4 OThe most common form of congenital adrenal
+ Z7 s; M0 o" Z2 [6 qhyperplasia is the 21-hydroxylase enzyme deficiency.! k& I3 p5 N1 V/ J  F
The 11-β hydroxylase deficiency may also result in
0 `3 `5 b) u$ oexcessive adrenal androgen production, and rarely,
1 v; |4 R; k0 }8 `9 @( @: r+ }an adrenal tumor may also cause adrenal androgen0 {" p; l5 l+ M
excess.1,3# E) D! }3 o  d/ R. Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 h- K- R3 Y4 B+ {4 H542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 {) ~8 o# O! m/ m3 V& u  r
A unique entity of male-limited gonadotropin-
+ m4 P8 h0 V$ d2 pindependent precocious puberty, which is also known
5 y, c9 B' H# j4 X/ m: A( [( j2 ras testotoxicosis, may cause precocious puberty at a
. M0 h8 {8 M# Q; _* Nvery young age. The physical findings in these boys
7 ], u  p  S, H4 p1 G- Xwith this disorder are full pubertal development,
  b2 E* n$ f' F7 D: r3 P$ nincluding bilateral testicular growth, similar to boys$ t4 T" A: o, W) H+ [' G! _, o( ]
with CPP. The gonadotropin levels in this disorder
- X3 t9 m, C: V; c* e1 r2 V+ n. v' a; sare suppressed to prepubertal levels and do not show
0 e3 Z3 t3 \& ^: E/ spubertal response of gonadotropin after gonadotropin-
( l- X2 I6 T5 }! |releasing hormone stimulation. This is a sex-linked9 c! U# C+ c+ X" U3 x5 z
autosomal dominant disorder that affects only
$ D3 D3 U& I% ?males; therefore, other male members of the family
: H2 a" X% F& S3 n6 Amay have similar precocious puberty.3: I+ S% |% e# g3 i
In our patient, physical examination was incon-
, ^3 `; I/ t' w5 S  |3 Xsistent with true precocious puberty since his testi-8 A# f" S5 j) _
cles were prepubertal in size. However, testotoxicosis
* W' d; O8 h  k9 r% Xwas in the differential diagnosis because his father! t! r. d, b* @( Y# d, N
started puberty somewhat early, and occasionally,6 G) H$ I8 C1 p
testicular enlargement is not that evident in the
% \+ ?5 W1 W8 Qbeginning of this process.1 In the absence of a neg-( _" a2 r1 r  R3 {# x
ative initial history of androgen exposure, our+ }8 A+ t5 V# Z7 D5 d
biggest concern was virilizing adrenal hyperplasia,1 e( L4 J) w8 e; [" j
either 21-hydroxylase deficiency or 11-β hydroxylase
; U6 q/ o' v& q2 J3 \5 ideficiency. Those diagnoses were excluded by find-
! }% @7 W( b' F7 v; m6 M4 ping the normal level of adrenal steroids.
0 y5 V6 z) X& ~The diagnosis of exogenous androgens was strongly# N2 b) W$ p7 m$ y/ \; X4 t
suspected in a follow-up visit after 4 months because2 d% C, J7 {1 H2 o7 w
the physical examination revealed the complete disap-
" R$ ?3 v' D5 {! O/ Y( s5 |3 X7 Y8 fpearance of pubic hair, normal growth velocity, and
4 C- s, U- @. R# Fdecreased erections. The father admitted using a testos-- Q* O3 i& u9 h; {' Z
terone gel, which he concealed at first visit. He was7 k3 y6 H+ N9 y, ?# S7 V9 b2 N
using it rather frequently, twice a day. The Physicians’/ x) T0 R8 L6 X" Y/ l" {  J5 \7 Y
Desk Reference, or package insert of this product, gel or
! ~! X% l) N- Scream, cautions about dermal testosterone transfer to
; z+ V2 S: u* k) U2 O; J' t; ~4 D, ?: gunprotected females through direct skin exposure.. H* K( I8 z5 l6 m
Serum testosterone level was found to be 2 times the' k  j/ ~% [* Z. V
baseline value in those females who were exposed to3 A: a* A* n: k2 p
even 15 minutes of direct skin contact with their male
. \& a6 [' f6 {6 |partners.6 However, when a shirt covered the applica-7 j9 }3 }# T7 U+ o
tion site, this testosterone transfer was prevented.
# v2 F! v! E' j) c2 K$ `Our patient’s testosterone level was 60 ng/mL,
9 @  Y% u& m$ n. d/ n; M5 b) D* Iwhich was clearly high. Some studies suggest that. b  w" U  G* ^. k9 Y5 N- j  B
dermal conversion of testosterone to dihydrotestos-
# U( u1 v5 l: }& E9 qterone, which is a more potent metabolite, is more, ~2 f8 p* b8 c0 S
active in young children exposed to testosterone
4 G4 X  X, c3 y3 ^! P! C1 I2 H1 _exogenously7; however, we did not measure a dihy-- n) g4 _( l4 ~  }, p0 @( o$ V1 a
drotestosterone level in our patient. In addition to
0 v- A4 `0 [, k, P+ t* ]5 Qvirilization, exposure to exogenous testosterone in
6 w. c# }$ l4 G; gchildren results in an increase in growth velocity and7 u' q! _) B/ M6 U* H8 r2 `% G
advanced bone age, as seen in our patient.
: z1 h* ~/ s2 g' ?The long-term effect of androgen exposure during
" }3 w- N: Y3 d) F" N( D: Rearly childhood on pubertal development and final3 G4 i3 B9 m) e+ N5 C% b
adult height are not fully known and always remain1 F5 h$ _( l) K6 _  `
a concern. Children treated with short-term testos-/ i! C+ ~8 {, z, `" m
terone injection or topical androgen may exhibit some
0 `* ?; r( p% K, l+ E( l7 nacceleration of the skeletal maturation; however, after
; A9 V! }- C- u6 qcessation of treatment, the rate of bone maturation
9 d: t  H; M: k! L9 O, v. Rdecelerates and gradually returns to normal.8,94 I1 L5 A5 y- f0 k6 x6 v
There are conflicting reports and controversy
8 p$ S1 [8 V3 @4 qover the effect of early androgen exposure on adult
  p3 b6 H/ ~! k9 Xpenile length.10,11 Some reports suggest subnormal
2 d  c9 g: v* O" Z8 X# _7 hadult penile length, apparently because of downreg-! v% j+ {1 Y! C+ _  ]
ulation of androgen receptor number.10,12 However,( W6 h5 O6 e7 m+ _. F
Sutherland et al13 did not find a correlation between1 o% u) t/ j" V0 O' `
childhood testosterone exposure and reduced adult# ]) D) E+ ]- k% `. U9 P; E
penile length in clinical studies.: {5 w9 u0 J' Z
Nonetheless, we do not believe our patient is
8 U. b& X5 f* ?) [9 Ygoing to experience any of the untoward effects from
7 i( k- R+ x1 T0 stestosterone exposure as mentioned earlier because2 H& I  V' f9 k/ |* X" {8 [7 q. Q
the exposure was not for a prolonged period of time.
3 C: i" Z! |3 v+ V* dAlthough the bone age was advanced at the time of
( K6 v3 e4 C5 H. E- X) U2 ]diagnosis, the child had a normal growth velocity at* G8 J! G0 ~7 z8 H7 Q
the follow-up visit. It is hoped that his final adult9 w% \  w/ m7 A- f+ ?
height will not be affected.# D# ?9 ]1 G% d1 `) c9 Q
Although rarely reported, the widespread avail-2 d# J7 d' p6 Z6 [# _
ability of androgen products in our society may9 M, u+ ~7 r5 r# Z, S3 b1 E
indeed cause more virilization in male or female
" M1 h) H3 w. @7 d) c6 d1 ochildren than one would realize. Exposure to andro-
: h5 ~& M5 R, R( U% Q, Egen products must be considered and specific ques-( J4 q+ v2 M% f( l
tioning about the use of a testosterone product or6 p1 b/ i4 R+ j& M  i
gel should be asked of the family members during
" [8 H3 V9 f: C+ S: N% nthe evaluation of any children who present with vir-
- z  r. m( w' |ilization or peripheral precocious puberty. The diag-6 Q  u$ U( Z+ m7 a
nosis can be established by just a few tests and by
5 x4 A9 w+ M) F( u; x0 J, R7 c: Oappropriate history. The inability to obtain such a
5 C/ ]- b, K/ M  u' I( zhistory, or failure to ask the specific questions, may. p& ?$ _+ D) W
result in extensive, unnecessary, and expensive5 @% t' E$ ^+ _  |2 j
investigation. The primary care physician should be1 l4 M( @# R6 ]" z, e7 V& x
aware of this fact, because most of these children2 d9 @4 W: V7 a) O
may initially present in their practice. The Physicians’+ l# J3 {4 w" ]
Desk Reference and package insert should also put a
& k9 n7 P# i4 R: ~6 owarning about the virilizing effect on a male or. k2 [, B5 m1 |3 I: _4 j  T8 N) P
female child who might come in contact with some-2 N1 [/ ?) S$ m' Y- _, k' D& a
one using any of these products.
! K8 f( p% L) \& l; _2 eReferences
- k; c# A3 A1 G; p8 P1. Styne DM. The testes: disorder of sexual differentiation' c, j% o0 H6 p' C4 f: u3 y
and puberty in the male. In: Sperling MA, ed. Pediatric
  O8 u+ E3 y; w1 ]( Z) IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# f6 g  J. l$ _6 M4 b4 o  ]
2002: 565-628.
) ^  I3 U1 n8 f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" R0 m; a! c3 ^# u/ K
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old# ~8 u- g4 [- H; y
Boy Induced by Indirect Topical( V2 }  U( Q: Q' o/ C
Exposure to Testosterone
4 i3 E, t" V1 ]" ~3 D' d# q! |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 @5 F. I6 T  b9 n" Z. B
and Kenneth R. Rettig, MD1
( J0 O1 T( L, B( j) @+ }3 UClinical Pediatrics
7 h- ^" X1 c5 z$ E5 ?$ Q& jVolume 46 Number 6( X' Z3 Z: a8 i4 j" Z
July 2007 540-543& J4 }- o! y# s9 a, i5 Y0 W) s
© 2007 Sage Publications4 g  _/ W3 j  g; C
10.1177/0009922806296651
0 J9 Y9 C& z0 G) Ghttp://clp.sagepub.com
' q. T$ D6 W* rhosted at* y& e; H  N+ a/ V- E& m
http://online.sagepub.com
+ g+ j/ ^3 s7 t3 d0 S# M" w2 WPrecocious puberty in boys, central or peripheral,
0 \4 e1 B' j) z2 W( ]! _7 K2 g7 L& Z3 uis a significant concern for physicians. Central
) Y. s- \3 t9 b3 ]0 R( f  j: y7 X) Fprecocious puberty (CPP), which is mediated4 H8 e* M. \* v4 l, V; K. e
through the hypothalamic pituitary gonadal axis, has* @  W4 J+ F, t, B' Z5 b: b- {2 D
a higher incidence of organic central nervous system, E' w( f: B/ ^, M5 Y
lesions in boys.1,2 Virilization in boys, as manifested
" ~& @5 i, ]6 k, N7 Q, P. rby enlargement of the penis, development of pubic
1 X* Z* Q2 L# s9 B, ^4 k" Shair, and facial acne without enlargement of testi-6 s( J" ~+ Q+ d! A/ t$ p7 H
cles, suggests peripheral or pseudopuberty.1-3 We
% z8 {1 U6 O1 [: g2 z, kreport a 16-month-old boy who presented with the3 Z3 @; h; t3 H" r
enlargement of the phallus and pubic hair develop-
5 q+ s' Q2 `9 ]ment without testicular enlargement, which was due
  ?  X3 x" c7 k$ z6 @+ Qto the unintentional exposure to androgen gel used by
' Z! _' [4 S% [the father. The family initially concealed this infor-
, Q3 b8 u# y3 m1 O0 Z& lmation, resulting in an extensive work-up for this% R( e8 x  M" V" b/ M2 b* U. i
child. Given the widespread and easy availability of. z2 S& P3 p6 g$ {9 J) f
testosterone gel and cream, we believe this is proba-2 {6 p  B* `8 x* v. K9 I" k
bly more common than the rare case report in the- K0 V/ n5 M1 g( m3 E) t; W, R
literature.4
" @/ B0 ?% H8 a' x6 d  vPatient Report' a& h7 o+ e1 s3 e
A 16-month-old white child was referred to the% j: v! T# d, h
endocrine clinic by his pediatrician with the concern
; V/ k0 [4 R! V' Gof early sexual development. His mother noticed
2 {( d* W' d8 B1 _) Q/ m+ m6 h' jlight colored pubic hair development when he was
1 v/ R2 O. v( {& x6 d& @/ m2 G5 pFrom the 1Division of Pediatric Endocrinology, 2University of
, L0 ^# r( z; i3 t0 D0 S' rSouth Alabama Medical Center, Mobile, Alabama.
: E# d6 z4 l# L9 ^( eAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 y- q6 |9 {- q
Professor of Pediatrics, University of South Alabama, College of
% b/ P, I. Y$ C) I/ p3 X8 \7 A+ c2 T2 tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 o2 u! d; V8 a) a  I6 _1 _e-mail: [email protected].
5 P/ ?4 F! A" z& a6 M* h3 Iabout 6 to 7 months old, which progressively became
! v$ v7 O. m8 Q  I4 G$ W1 r# hdarker. She was also concerned about the enlarge-3 {2 q" `3 T2 l8 V  L
ment of his penis and frequent erections. The child
1 ]5 l5 A( Q7 d: V8 O5 Mwas the product of a full-term normal delivery, with  s$ F0 x$ K: c* x* r, D1 w* e
a birth weight of 7 lb 14 oz, and birth length of3 V- {. \6 q0 T  p/ Z& i/ G3 ]
20 inches. He was breast-fed throughout the first year- j! y0 @/ u! K9 O
of life and was still receiving breast milk along with, q; K1 t7 p# @" [: s
solid food. He had no hospitalizations or surgery,( A0 {# n1 }7 [& d- O' c
and his psychosocial and psychomotor development0 O1 U8 q, p2 d" R$ p; d9 T" `
was age appropriate.
9 j' _9 Z! y+ Y/ T8 bThe family history was remarkable for the father,
  K* E, Q; h" d+ e7 dwho was diagnosed with hypothyroidism at age 16,
  {$ I# y& D; K) I2 Owhich was treated with thyroxine. The father’s/ p+ s3 c5 y% |! K
height was 6 feet, and he went through a somewhat
- k& N: i) V+ D5 Nearly puberty and had stopped growing by age 14.. H2 ]; S1 w; K( `  p4 N6 N
The father denied taking any other medication. The
9 C2 a  k" f* M$ O' ^2 M8 ichild’s mother was in good health. Her menarche, V- p8 V/ `; q0 P  ?8 P/ O
was at 11 years of age, and her height was at 5 feet: h' k1 _5 c7 j0 d# Y: n
5 inches. There was no other family history of pre-' V1 X) X1 G4 N+ X
cocious sexual development in the first-degree rela-( h' W; w! y1 P, a& f# v. H$ }- m
tives. There were no siblings.
2 c, V; |! _  ]4 UPhysical Examination% d% e4 M* C0 Y& b/ v, E8 a& ^
The physical examination revealed a very active,3 k6 p2 v& i- E
playful, and healthy boy. The vital signs documented' A1 X' \2 f! p9 B  x& k9 f
a blood pressure of 85/50 mm Hg, his length was
1 D2 m5 t- U1 l$ }/ H90 cm (>97th percentile), and his weight was 14.4 kg
8 {4 G8 X: b, q6 K0 S6 S(also >97th percentile). The observed yearly growth7 \! o! j( A/ S% [  e
velocity was 30 cm (12 inches). The examination of
* a( ]9 S/ b, x# R/ U  Bthe neck revealed no thyroid enlargement.
9 O8 r+ Y5 I' P' i6 [The genitourinary examination was remarkable for
+ m4 y1 {0 E+ B, I( E; m4 uenlargement of the penis, with a stretched length of
: @8 n( t( k8 m' ]* ]+ l- W. {8 cm and a width of 2 cm. The glans penis was very well1 l2 l3 S; e' v% h
developed. The pubic hair was Tanner II, mostly around$ k1 k3 t( ?) {! R4 {( v- E1 P) y
540
4 i1 \+ O0 g4 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' D. p- _( t& R8 f3 m
the base of the phallus and was dark and curled. The
9 g1 h$ N) J1 _; _testicular volume was prepubertal at 2 mL each.
3 h  d+ A9 U/ j" DThe skin was moist and smooth and somewhat
4 M. W$ ?+ n6 L- U0 }- i: R; aoily. No axillary hair was noted. There were no
; B- B4 J; H+ o3 D8 }abnormal skin pigmentations or café-au-lait spots.. y; M; a! _, [+ q0 E) n& p: M
Neurologic evaluation showed deep tendon reflex 2+
* K* ?' z# V) W1 ]( s  u0 Dbilateral and symmetrical. There was no suggestion
  T' K* d7 a; q" o$ n- Rof papilledema.
8 F) r5 m/ O0 C/ R! h8 pLaboratory Evaluation
+ v: i0 M1 a: j$ H7 X3 dThe bone age was consistent with 28 months by
& u" U4 c/ x1 w8 L1 o9 Z. t: e: Wusing the standard of Greulich and Pyle at a chrono-. ~# ?5 s& X5 w0 n/ F9 Q3 R/ E$ o: C
logic age of 16 months (advanced).5 Chromosomal+ Q. y4 R6 _5 e9 d
karyotype was 46XY. The thyroid function test$ A" z) |- J( T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" R6 ]7 m& B" B( p4 q6 [lating hormone level was 1.3 µIU/mL (both normal).. l4 G/ b$ m5 e
The concentrations of serum electrolytes, blood
6 o. `/ e4 @- [  _7 eurea nitrogen, creatinine, and calcium all were
* B2 G- O* A4 [5 E8 B  L# pwithin normal range for his age. The concentration
- B( j0 e9 g/ ]of serum 17-hydroxyprogesterone was 16 ng/dL  N5 M, U) f" `3 k% L+ a
(normal, 3 to 90 ng/dL), androstenedione was 20# Q. V/ c4 I& ?1 I5 M- v+ M4 b3 x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( X, O/ {, i) F+ u$ yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ o. C. f1 \& w5 [4 C2 I& q: {desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 r% h- y  a2 c3 e1 A. w
49ng/dL), 11-desoxycortisol (specific compound S)7 F" \1 L! u( T$ Z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, H  k4 z6 c* t- B! h- G" f5 _! ]( ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 W7 w- f" M/ R! Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' k  w! @) S  kand β-human chorionic gonadotropin was less than
5 _" w& {8 W6 d% s1 X5 mIU/mL (normal <5 mIU/mL). Serum follicular+ J/ t% [9 Q, @: Y2 i1 Z  j
stimulating hormone and leuteinizing hormone
7 F, B8 j$ a% g( M4 p! ^concentrations were less than 0.05 mIU/mL/ L* o: i3 \6 o4 L  D2 t
(prepubertal)., }* ^4 y2 q2 i! T4 m
The parents were notified about the laboratory
' M( W) G5 O, a, Z2 tresults and were informed that all of the tests were
0 d$ b+ j- g0 |# A( W5 Y8 j& Vnormal except the testosterone level was high. The
3 n) E( @9 a2 o* g% s+ v6 Kfollow-up visit was arranged within a few weeks to
7 ?! L9 i2 i& y" ]obtain testicular and abdominal sonograms; how-3 t$ {# r+ ^: S( L" D+ O$ s( Y
ever, the family did not return for 4 months.
" S+ i! X1 n8 M* D  ~6 XPhysical examination at this time revealed that the/ d4 ^( W. I7 b
child had grown 2.5 cm in 4 months and had gained' k  V3 ]7 H( m3 m( z& e
2 kg of weight. Physical examination remained- h; Q0 P) q( U  \" K
unchanged. Surprisingly, the pubic hair almost com-. P# K% S  D$ C0 ?9 k; k( |, ?
pletely disappeared except for a few vellous hairs at
  d* S# H* u/ {9 z! v7 h/ Tthe base of the phallus. Testicular volume was still 25 i( h/ ^5 N+ b
mL, and the size of the penis remained unchanged.
" |# i1 {+ u2 v) g/ Y/ h) L. {- qThe mother also said that the boy was no longer hav-# d3 ?: b2 @- @6 |9 U
ing frequent erections.
+ ]/ w* G; W/ O8 cBoth parents were again questioned about use of3 i. ^* `" q" o+ p) _
any ointment/creams that they may have applied to* N9 @! B2 _8 K' Q
the child’s skin. This time the father admitted the, y4 B! u; H* {0 V  l9 x
Topical Testosterone Exposure / Bhowmick et al 5410 X. m( P( e$ M5 ?) Z# B
use of testosterone gel twice daily that he was apply-2 {6 U' b. w) ]3 A* D# S
ing over his own shoulders, chest, and back area for0 _. g2 n( \) X1 |: I0 [
a year. The father also revealed he was embarrassed. q4 G/ D5 y; o% r$ d! s0 H0 g
to disclose that he was using a testosterone gel pre-3 P# K) p" U5 o8 U' y
scribed by his family physician for decreased libido0 m8 U/ L6 V0 x; u+ T6 S& E) Q) B
secondary to depression.! A2 v& _% \6 ]0 E2 F" @
The child slept in the same bed with parents.
. [% z. a, N3 S: S' j- wThe father would hug the baby and hold him on his1 J8 C7 n& |! i6 H) x
chest for a considerable period of time, causing sig-
1 J6 T( k6 }3 H% n2 f0 e/ Knificant bare skin contact between baby and father.. A5 F4 J% h; e' E; D% U
The father also admitted that after the phone call,! g( V8 [: \8 s9 b, k' V  p
when he learned the testosterone level in the baby
8 A8 Z( t, ?( n2 w( U# S1 H$ B5 V6 bwas high, he then read the product information
, }3 P! f* h' l* r4 o7 hpacket and concluded that it was most likely the rea-4 a4 M, a3 t0 K' O
son for the child’s virilization. At that time, they
/ }6 P4 K9 {$ s" \  p- Gdecided to put the baby in a separate bed, and the5 ~; Q: e! B9 a7 A' a8 }! K2 _
father was not hugging him with bare skin and had
, Q- z, H8 b% Z# k& [; B3 Bbeen using protective clothing. A repeat testosterone
/ K+ n+ D0 m0 a+ q1 ?test was ordered, but the family did not go to the
6 y$ k) v" h7 g9 {: l% llaboratory to obtain the test.& i6 V; A5 L6 q$ G# w2 W+ {
Discussion
) J1 z5 \: e. ?4 r- }Precocious puberty in boys is defined as secondary0 W' K6 B' N4 [
sexual development before 9 years of age.1,4
/ }- v' @0 e* v3 S) N( m7 k4 UPrecocious puberty is termed as central (true) when
5 ]7 F4 M: q6 w* P% |: [it is caused by the premature activation of hypo-& h2 C9 D/ F; J: o  K/ A
thalamic pituitary gonadal axis. CPP is more com-3 M  t  d) @4 u! [
mon in girls than in boys.1,3 Most boys with CPP
6 K5 d4 O& ~: Tmay have a central nervous system lesion that is
8 a0 N( R& W$ m' hresponsible for the early activation of the hypothal-4 [) F& u. Q& q* l
amic pituitary gonadal axis.1-3 Thus, greater empha-
& `) z' h$ b5 ~sis has been given to neuroradiologic imaging in
8 j2 X* s1 Q1 a* R) b4 u( {boys with precocious puberty. In addition to viril-
" \% d, P' N$ H! d, Kization, the clinical hallmark of CPP is the symmet-3 X+ t0 B9 J5 C: c9 V" s
rical testicular growth secondary to stimulation by
( I1 ~9 C8 z3 Q6 G6 Y' {0 rgonadotropins.1,3
  J0 ^/ l/ e( W9 }* c+ lGonadotropin-independent peripheral preco-9 {/ E7 @% M( F% K7 b
cious puberty in boys also results from inappropriate( p/ S. r3 f; g5 S$ f5 c7 _- W$ e
androgenic stimulation from either endogenous or
1 @2 W0 Y) t8 }exogenous sources, nonpituitary gonadotropin stim-
& b0 m7 c# L; b2 @# G: {: g$ vulation, and rare activating mutations.3 Virilizing
! d  m4 i3 g) P1 U- a: t* Mcongenital adrenal hyperplasia producing excessive
: [+ c$ l, g2 t/ Gadrenal androgens is a common cause of precocious7 y9 v$ O' x- P9 L
puberty in boys.3,49 Y8 q( H1 t% i& r
The most common form of congenital adrenal, E" s/ r: L6 {3 \
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 l5 P) X5 S1 L, q# kThe 11-β hydroxylase deficiency may also result in
. G: [# Z3 q5 \4 b: Uexcessive adrenal androgen production, and rarely,
4 B$ R: X9 u0 D+ f* b/ Ean adrenal tumor may also cause adrenal androgen
7 p5 d' q4 f- J* Z% @- e9 iexcess.1,3* V6 c& V: W& i2 s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 ?9 V) T: Q" p! [3 b. }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, X+ e1 Q2 E: |( BA unique entity of male-limited gonadotropin-$ F. H9 h4 z9 v- u
independent precocious puberty, which is also known( b' M3 ^+ q6 A+ Z2 z: U8 l
as testotoxicosis, may cause precocious puberty at a
! K5 Q+ t+ j3 Q$ ~& Q# _8 cvery young age. The physical findings in these boys
6 G( w* T8 [& Qwith this disorder are full pubertal development,5 ]& L0 M' ~( C9 g, p
including bilateral testicular growth, similar to boys
: J0 A3 E* F& w+ jwith CPP. The gonadotropin levels in this disorder! s7 K+ v/ A' m0 b! J( J2 d4 F
are suppressed to prepubertal levels and do not show& P# |* T% k' Y4 k$ O* e7 r6 G1 s
pubertal response of gonadotropin after gonadotropin-6 T  z; B4 {8 r$ t
releasing hormone stimulation. This is a sex-linked  R3 X& v8 s( e+ J5 a/ W: F, b# N. I
autosomal dominant disorder that affects only
8 T' s6 d2 D( Y+ Nmales; therefore, other male members of the family) u: e5 j$ ?, o- [" V6 P
may have similar precocious puberty.3
8 g, \8 r3 j! n% i+ P7 _- jIn our patient, physical examination was incon-0 u5 n, _& B: b* I
sistent with true precocious puberty since his testi-( {/ P% Y. j5 }5 K! p
cles were prepubertal in size. However, testotoxicosis
4 B$ s# m/ N" R, v4 Ywas in the differential diagnosis because his father
/ G3 ?' j# l0 L9 E4 J  i9 astarted puberty somewhat early, and occasionally,% e/ W# c& z& l" Q3 B% r: W
testicular enlargement is not that evident in the* c! \; V8 ^+ n7 }# h& F- j5 l% H
beginning of this process.1 In the absence of a neg-
# Y; p4 L7 P3 m9 dative initial history of androgen exposure, our% j2 |: }8 c& J7 |" S
biggest concern was virilizing adrenal hyperplasia,
% o, M1 |% F8 C7 `: E4 u- Geither 21-hydroxylase deficiency or 11-β hydroxylase
' N- V! G! C7 E+ ~0 ^! ^deficiency. Those diagnoses were excluded by find-
; M$ I! j6 j) A5 D4 e! w4 l' e7 p7 ding the normal level of adrenal steroids.
8 z1 l/ h5 W" a5 L- l  U9 `The diagnosis of exogenous androgens was strongly
2 M" {2 \2 E' i" }1 g: L; ?suspected in a follow-up visit after 4 months because) H& \8 v( D8 ?
the physical examination revealed the complete disap-
5 [; V) |8 C( p  x. x3 ypearance of pubic hair, normal growth velocity, and$ v. }! x# o+ Z
decreased erections. The father admitted using a testos-& w- x& \# w3 Z
terone gel, which he concealed at first visit. He was- m( W5 ]9 }$ Z+ H
using it rather frequently, twice a day. The Physicians’
, n  V1 W; a- E# g1 dDesk Reference, or package insert of this product, gel or" h8 k" i# f3 L  F. \+ w' v
cream, cautions about dermal testosterone transfer to
* F6 p. E  K, w* U3 Sunprotected females through direct skin exposure.5 z6 m. \" [, K. N$ q/ y; Z) K: S/ `
Serum testosterone level was found to be 2 times the
) [. n$ Z4 |2 \: ^2 V/ l* h- x4 zbaseline value in those females who were exposed to
/ E0 D+ W$ C- p3 [3 M5 C' g3 Z' F* reven 15 minutes of direct skin contact with their male8 T8 T1 M+ ^" h' N6 v9 h0 ^
partners.6 However, when a shirt covered the applica-( R9 Y. I6 Q  Y, d$ \
tion site, this testosterone transfer was prevented.0 n; B  X5 W1 d+ k
Our patient’s testosterone level was 60 ng/mL,- J6 m- V; G1 ]5 A
which was clearly high. Some studies suggest that' |6 Q6 B  h8 q- A! T, }
dermal conversion of testosterone to dihydrotestos-* d4 X* e$ V6 I/ v
terone, which is a more potent metabolite, is more
5 y& X. t/ ?& [+ X% h; y7 ~active in young children exposed to testosterone
3 B2 b) q* i. a' C- m" P) B( }exogenously7; however, we did not measure a dihy-
0 ~3 G7 R( Q1 h' Idrotestosterone level in our patient. In addition to7 m$ w% H" M' V2 l- Y. V
virilization, exposure to exogenous testosterone in; S2 ?" L- g# k1 V  ]) U) ?0 r
children results in an increase in growth velocity and
+ U% P4 x: X  \) V' @4 jadvanced bone age, as seen in our patient.
8 x7 o2 z8 K5 Q+ d! XThe long-term effect of androgen exposure during7 \9 u' R/ ^7 K: g8 c$ E
early childhood on pubertal development and final+ {0 e5 e8 q7 \2 O
adult height are not fully known and always remain
( B! U- Q1 S3 R2 La concern. Children treated with short-term testos-8 q7 Z0 a& K+ }
terone injection or topical androgen may exhibit some. v* O" {4 f8 [" o' F
acceleration of the skeletal maturation; however, after
& o) ?8 s) c7 |cessation of treatment, the rate of bone maturation
' I* S6 }+ k" ?7 Q6 X; Pdecelerates and gradually returns to normal.8,9" }$ y0 |% d7 j8 x  O( K) Y6 k
There are conflicting reports and controversy4 t& v& S4 B5 `- H: B" P4 a
over the effect of early androgen exposure on adult7 ~9 h; T# [2 e* \% K9 r1 q
penile length.10,11 Some reports suggest subnormal
  _2 G9 e# p1 ?6 u: Z7 qadult penile length, apparently because of downreg-0 F4 H4 V9 r% }4 p/ c
ulation of androgen receptor number.10,12 However,
( p( S% E) b% L/ H/ o' [" HSutherland et al13 did not find a correlation between
. s% t4 [5 o5 N3 L- T/ f+ d- ?childhood testosterone exposure and reduced adult
, ?- _' U8 b4 ?# {7 r) M+ A. Mpenile length in clinical studies.  n  F+ r( b5 R! e3 q# x+ {# J
Nonetheless, we do not believe our patient is
  ]( K3 h, U) T# D: Sgoing to experience any of the untoward effects from: l8 d) G6 E# z* F( r7 o! d* C
testosterone exposure as mentioned earlier because
( a( ~  {& T. w! M. }# ?5 |' ]the exposure was not for a prolonged period of time.
9 R# k9 c& _2 B1 |1 D# _Although the bone age was advanced at the time of$ `! j/ w1 M: S: K& x
diagnosis, the child had a normal growth velocity at) t0 n6 _. l# b1 ?% \
the follow-up visit. It is hoped that his final adult+ }2 s7 k8 U+ n. I3 L
height will not be affected.
8 F: K& A7 p9 @1 v. fAlthough rarely reported, the widespread avail-. F7 p! C+ Y" `: Z, T
ability of androgen products in our society may- ]( D, q: y& n, N5 N
indeed cause more virilization in male or female1 N. e* n  g% q, L
children than one would realize. Exposure to andro-9 G) D1 p% m5 l
gen products must be considered and specific ques-9 B6 y( S5 u  ?( W# `" |! O
tioning about the use of a testosterone product or. M7 e& G' `- Z# D: e, N% ~4 G  q
gel should be asked of the family members during  J3 C  H: m4 s' h
the evaluation of any children who present with vir-
- Q8 ~# D5 i; R2 Z& H9 m+ zilization or peripheral precocious puberty. The diag-9 Y* e8 M2 Q8 q
nosis can be established by just a few tests and by! g6 B: @  j; _6 L
appropriate history. The inability to obtain such a
0 W& X, S' i9 |0 Shistory, or failure to ask the specific questions, may; \; _, r' Y& w7 [7 o
result in extensive, unnecessary, and expensive8 j) L8 H5 d  X5 Q( D( n
investigation. The primary care physician should be8 e0 s% [& P. V
aware of this fact, because most of these children
9 ~) _+ @. d# ]may initially present in their practice. The Physicians’
7 l0 [- ~! ?0 y6 c( CDesk Reference and package insert should also put a: V* Y! i& V9 u; L
warning about the virilizing effect on a male or9 M6 x$ ~. h" D* f
female child who might come in contact with some-4 z8 g. r  u9 P4 A
one using any of these products.
& G7 O1 [1 Z: b; J  L6 ^2 N# R. o1 qReferences- Z$ M% F/ {, [6 o
1. Styne DM. The testes: disorder of sexual differentiation5 E+ A9 I# U9 e2 z
and puberty in the male. In: Sperling MA, ed. Pediatric5 ?2 w" |- y4 a6 w: O7 U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! \; p% I. R: h; r" m! J4 N, ~
2002: 565-628.* J! m2 X$ P2 {  b- I8 k* G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# |  w1 h+ N" i) R" r
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
5 a: Q% p( t& v9 w/ @
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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