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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-Old3 x0 h& n! H- B" l
Boy Induced by Indirect Topical
) T$ x8 i* B/ ^2 E3 v8 p* p1 ZExposure to Testosterone5 R/ j  K; l; |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 `6 b/ N. U; f" e$ d3 Wand Kenneth R. Rettig, MD1
" V, Z$ d0 O, w- M0 AClinical Pediatrics
6 r& B2 b& Y( o+ c' BVolume 46 Number 6. n, @/ a) ~' N1 T5 `2 h, G: ^
July 2007 540-543' u# T' X( n# ^- v0 {. Y0 y
© 2007 Sage Publications
7 ]- f/ ?: c& j7 s& R10.1177/0009922806296651
) z# \6 Y$ r& l6 A9 Nhttp://clp.sagepub.com5 \0 J: @5 ]1 P  t
hosted at7 B/ o( ~1 f  e! n3 j# B$ X( v& o& K
http://online.sagepub.com
& b* A7 ]# ~6 }5 L. JPrecocious puberty in boys, central or peripheral,* K! n* H$ ~1 E! {' F0 t
is a significant concern for physicians. Central$ Z; ~  s4 K. D5 R: G. i1 D6 {
precocious puberty (CPP), which is mediated
2 u! d6 \8 h5 T8 Q, W" {+ Dthrough the hypothalamic pituitary gonadal axis, has% K4 E7 Y5 |4 O1 s4 d, N
a higher incidence of organic central nervous system: g1 l: w& a$ w3 D) D
lesions in boys.1,2 Virilization in boys, as manifested1 H% G) O4 P1 @: _3 ], z1 R
by enlargement of the penis, development of pubic
# K! P! r) ~+ L8 ~! v* r, d( rhair, and facial acne without enlargement of testi-, [* P- t; B# X9 @
cles, suggests peripheral or pseudopuberty.1-3 We  p' y- o7 e# H" J; x% `" _
report a 16-month-old boy who presented with the
6 O$ M6 \, q/ A/ ~/ k1 t* ?  n8 G' o6 Menlargement of the phallus and pubic hair develop-  Y! ]" U) O, E' l( G- s  C
ment without testicular enlargement, which was due9 y$ }: S0 h9 r. n, X0 a
to the unintentional exposure to androgen gel used by4 W5 c' h( h% }
the father. The family initially concealed this infor-
+ _$ n% T4 X4 @, U% cmation, resulting in an extensive work-up for this% u& o* O6 {# w" E9 ]: v) P- n3 h
child. Given the widespread and easy availability of
7 r# n9 J4 l# ?  O* i2 wtestosterone gel and cream, we believe this is proba-- V/ r" O: M8 _
bly more common than the rare case report in the! M3 o- e4 y7 ~7 I. M! l" K8 E5 l6 [
literature.4$ s( t+ Q: b! y) B; M/ d/ k. L+ I
Patient Report
' C2 O" ?# U7 X+ Y6 c7 Y8 {& tA 16-month-old white child was referred to the
5 S- U. O6 A8 o% P& Nendocrine clinic by his pediatrician with the concern9 \$ w# {4 `; V$ i$ X  i
of early sexual development. His mother noticed5 c% I( ]; K+ s) Z! Y
light colored pubic hair development when he was
4 h( C6 G/ c2 F. K$ v2 wFrom the 1Division of Pediatric Endocrinology, 2University of8 Q$ r8 [! k! D. |
South Alabama Medical Center, Mobile, Alabama.
  J7 `3 ]0 j+ B2 J$ wAddress correspondence to: Samar K. Bhowmick, MD, FACE,# o' B# v+ c3 Z8 Y' }+ h
Professor of Pediatrics, University of South Alabama, College of
+ p- N2 K0 K* GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 y: Z0 i. ]8 {+ Ge-mail: [email protected].2 z4 \8 A% T" s4 Y" U; X0 r! U
about 6 to 7 months old, which progressively became
1 {$ t& |5 n# Hdarker. She was also concerned about the enlarge-
1 H+ M& f: f6 oment of his penis and frequent erections. The child2 `0 g. V2 c1 J; L
was the product of a full-term normal delivery, with
7 ~" T8 M2 M3 Y; q* U" [' _a birth weight of 7 lb 14 oz, and birth length of& W3 ?( P4 E# j3 n
20 inches. He was breast-fed throughout the first year
* O; K! _7 ]. [1 u7 o' U5 qof life and was still receiving breast milk along with
1 _( n$ ]  {& z# a2 w* ?/ wsolid food. He had no hospitalizations or surgery,3 z) p' z5 @5 N- T
and his psychosocial and psychomotor development
. d& C2 U; ^& I1 Gwas age appropriate.
+ K; |; p" @1 q. bThe family history was remarkable for the father,: ^5 K3 U% ~( e! v: v: U
who was diagnosed with hypothyroidism at age 16,
9 {, U. N% @8 J( C; g# i; Nwhich was treated with thyroxine. The father’s
( f* A  j& u% i5 o6 x' xheight was 6 feet, and he went through a somewhat
/ l, M7 a/ a0 f. aearly puberty and had stopped growing by age 14.6 U/ I4 T! V) }
The father denied taking any other medication. The
  P4 K+ u- Z$ G' u7 jchild’s mother was in good health. Her menarche3 n$ g8 Z, ?) ?6 E2 I) Z4 E
was at 11 years of age, and her height was at 5 feet- F* f. p7 z8 T4 `2 ?' h, R; Y' k
5 inches. There was no other family history of pre-
. Z3 y' B/ T9 M( ococious sexual development in the first-degree rela-; s' U  Z+ V. M. X6 v7 {" {& B
tives. There were no siblings.
5 R! t2 a7 z7 G. `7 G0 y  F$ Q! vPhysical Examination3 g4 x) u& p2 `. c: n7 i) i5 D
The physical examination revealed a very active,5 ?  F, E6 h+ f2 J
playful, and healthy boy. The vital signs documented' Z, E3 ]1 j: w+ h0 |0 R
a blood pressure of 85/50 mm Hg, his length was
. ?( N9 w2 m. v4 J: P90 cm (>97th percentile), and his weight was 14.4 kg2 n+ n* A, I$ s9 K- u
(also >97th percentile). The observed yearly growth. h! G" c; j" i( W, p$ s
velocity was 30 cm (12 inches). The examination of- x7 s6 l0 L8 X
the neck revealed no thyroid enlargement.
. Q9 B3 m' k- D3 `# wThe genitourinary examination was remarkable for
) N% S! H& R9 Venlargement of the penis, with a stretched length of' @; o8 Q1 r5 p* n' s6 l
8 cm and a width of 2 cm. The glans penis was very well, @; y4 E! |8 Y; v
developed. The pubic hair was Tanner II, mostly around
$ D: d9 ^# ~1 s) c5 \540& z: W  B! n. D* K. D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% m* T) C1 [+ G+ j
the base of the phallus and was dark and curled. The) m* i0 {) Z; ^* O
testicular volume was prepubertal at 2 mL each.
/ C/ }# f- z$ z) wThe skin was moist and smooth and somewhat
- n/ e, _  T9 V& Q; Aoily. No axillary hair was noted. There were no) S9 t, d: X( ~& ^; y8 s& H% @
abnormal skin pigmentations or café-au-lait spots.
6 Q! P1 s  I% H0 n+ ~5 BNeurologic evaluation showed deep tendon reflex 2+
( E, Q: P$ [- c1 i/ o. h% m1 K  Ubilateral and symmetrical. There was no suggestion
2 O2 H/ d2 V5 \6 k; g/ Nof papilledema.. N; }, Y! o/ _* K7 R
Laboratory Evaluation% W/ {$ t# b( l% L8 k" `
The bone age was consistent with 28 months by, s; ~9 @1 e5 ?, Z% t
using the standard of Greulich and Pyle at a chrono-
% ?$ k  G8 ]& O! clogic age of 16 months (advanced).5 Chromosomal
: \, R8 N: }# P0 ~9 C, A" x) G/ ~karyotype was 46XY. The thyroid function test4 A" b, ?2 I, X! L3 J% i4 V; I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: z- I3 t5 O- M9 qlating hormone level was 1.3 µIU/mL (both normal).' [7 Z& A6 x9 Q. |& ^' [3 I) S) v) g
The concentrations of serum electrolytes, blood8 A# \* X7 r( l" p. t
urea nitrogen, creatinine, and calcium all were
: X/ Z) A/ ^0 G( t4 cwithin normal range for his age. The concentration, }& S9 d, b% K7 e" I6 P
of serum 17-hydroxyprogesterone was 16 ng/dL- H/ n2 N8 B9 _' Q! H  d* w
(normal, 3 to 90 ng/dL), androstenedione was 20
: F" |. \7 N' P7 U. ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ X; m( s( q7 W. ?. V* Z) u8 R1 C; p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ o+ L8 @- ?' W/ z! g. [, L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* j4 @& v6 {" ~
49ng/dL), 11-desoxycortisol (specific compound S)- @; t1 j$ A% s% L8 y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 r- N% }. Q& X  w' Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! M  @- W' ?* htestosterone was 60 ng/dL (normal <3 to 10 ng/dL)," _1 `8 u1 E8 G
and β-human chorionic gonadotropin was less than2 M5 Q5 |9 u& [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! O! X2 C, c6 dstimulating hormone and leuteinizing hormone
) C0 k: M; `9 |+ L& R/ X* e5 D* kconcentrations were less than 0.05 mIU/mL
) h/ h0 d9 v, d& y/ @) ~4 J(prepubertal)./ ~* g% v7 a9 R. v
The parents were notified about the laboratory2 a& e# |, Q* T( c: h1 @
results and were informed that all of the tests were
! r1 y) |% Y+ u& a9 {4 Mnormal except the testosterone level was high. The
) h( v% d  Y2 F$ v/ i7 ~follow-up visit was arranged within a few weeks to
) t3 r  ?3 d/ C# m6 ?: d/ G- Zobtain testicular and abdominal sonograms; how-+ K9 b' I; o- j) P; ]$ j
ever, the family did not return for 4 months.4 }3 w: b* V; q, |* f9 o( s
Physical examination at this time revealed that the0 ~& B  e. H/ K" N
child had grown 2.5 cm in 4 months and had gained
" J0 W5 q9 [9 j6 w* O& c+ b/ U5 j/ R0 @2 kg of weight. Physical examination remained
8 |. f% Y7 _" K: junchanged. Surprisingly, the pubic hair almost com-
; B! I  M3 m: F) `pletely disappeared except for a few vellous hairs at
1 ]" E/ X0 q4 B* U% Ythe base of the phallus. Testicular volume was still 2- E* K5 W( d8 a" Y# T) U
mL, and the size of the penis remained unchanged.7 U' R4 r2 D# @$ x7 \
The mother also said that the boy was no longer hav-
: o6 M! K0 E+ |$ P) G$ Zing frequent erections.
0 c) b. N: Z0 e0 ?" j& xBoth parents were again questioned about use of1 C6 c/ H* f4 k/ p4 X" N9 w
any ointment/creams that they may have applied to
( Y. e7 r% M) D9 Uthe child’s skin. This time the father admitted the
% T. Y3 q8 K, K. nTopical Testosterone Exposure / Bhowmick et al 541* P! J# @: Q0 R! J& O2 k' k
use of testosterone gel twice daily that he was apply-4 m& ?7 F1 ]: l* a- q2 [- |
ing over his own shoulders, chest, and back area for
( C! J; ]4 h/ s5 b* _a year. The father also revealed he was embarrassed
; F6 |! y% K! F; F/ o: ^8 cto disclose that he was using a testosterone gel pre-
3 r4 B0 |6 Q1 `1 S. @- cscribed by his family physician for decreased libido
" B' t% G. F4 A* ysecondary to depression.
" h  ?2 X9 E0 PThe child slept in the same bed with parents.
( ~! o$ l! i9 q  ^The father would hug the baby and hold him on his7 }9 g5 z( q, I5 a
chest for a considerable period of time, causing sig-
% S3 B/ m( U' v  C& gnificant bare skin contact between baby and father.
+ x. X8 W+ B* NThe father also admitted that after the phone call,/ V$ ^3 I6 Q8 E
when he learned the testosterone level in the baby1 K" {% K7 Q: h, M" H$ c
was high, he then read the product information
: F, T6 G9 X1 }; m: h# a0 w" xpacket and concluded that it was most likely the rea-
- l% ^8 _* d6 B, O8 y3 t5 tson for the child’s virilization. At that time, they
8 J4 K* o+ y" X2 Y+ u  jdecided to put the baby in a separate bed, and the: B1 [: k2 A; T9 R# Q
father was not hugging him with bare skin and had7 t# u5 b! w8 D* s6 X( l' l$ g  d
been using protective clothing. A repeat testosterone1 ^( x7 G7 s$ h9 A
test was ordered, but the family did not go to the
% k8 }' O1 A' Vlaboratory to obtain the test.
  w  D% U; q0 U# W. Z7 F8 XDiscussion
2 o; h- O% \0 e3 I6 }Precocious puberty in boys is defined as secondary# @2 ~) w) F! t  |  G! o
sexual development before 9 years of age.1,4
6 V3 S0 }% E9 ^' Y- q6 gPrecocious puberty is termed as central (true) when; h: Y0 O# P  t6 I  y
it is caused by the premature activation of hypo-8 g6 u0 m0 w7 Z; q
thalamic pituitary gonadal axis. CPP is more com-6 I( U* X1 |* L/ A' J: [8 S# [
mon in girls than in boys.1,3 Most boys with CPP
9 m3 K8 b9 i5 P! Y1 W% D, r) b0 j: `may have a central nervous system lesion that is+ v3 q) |. m5 p3 V" h
responsible for the early activation of the hypothal-5 T' Q# S! C, a+ ^' H# A# D4 x  X
amic pituitary gonadal axis.1-3 Thus, greater empha-' F3 x& i+ T" A# I* t, T- t3 z1 w
sis has been given to neuroradiologic imaging in. b+ F( ~% `8 M
boys with precocious puberty. In addition to viril-( F: H/ r2 H" O" [2 Z
ization, the clinical hallmark of CPP is the symmet-9 {7 b9 n( T) R7 ]0 f
rical testicular growth secondary to stimulation by( c) d8 E7 H' U
gonadotropins.1,3" J# D6 Q% J8 l$ n+ }: P. [
Gonadotropin-independent peripheral preco-" y; l' b  b! A+ u6 K
cious puberty in boys also results from inappropriate
7 ]% G& x) G" c/ i. A! Iandrogenic stimulation from either endogenous or
6 n9 a, C' P1 e. @( y2 O0 p6 y5 hexogenous sources, nonpituitary gonadotropin stim-
9 |8 r# ]9 {4 n" l5 _: `. qulation, and rare activating mutations.3 Virilizing
. E, ?; {1 \1 h- d( @congenital adrenal hyperplasia producing excessive
" R8 B! c5 S( ]$ P( V( o1 |" eadrenal androgens is a common cause of precocious
1 i# R7 |, N2 O8 apuberty in boys.3,4
6 {% M5 w8 c9 M4 b: K5 AThe most common form of congenital adrenal
2 T1 L6 h3 e9 ^3 phyperplasia is the 21-hydroxylase enzyme deficiency.  ^) k3 `. \/ L1 a( K# e* E
The 11-β hydroxylase deficiency may also result in4 ^) {7 c$ ?- s! S; v. e
excessive adrenal androgen production, and rarely,
7 I1 s, ?( y" U! e& Ian adrenal tumor may also cause adrenal androgen, F. {. g9 S  u
excess.1,3
/ R; P: }3 u1 g6 `; Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 h- w; B& H, l! a/ n! s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  J4 E, g* b( t. m  B2 Q: y
A unique entity of male-limited gonadotropin-
+ }' ]9 e2 K/ K$ D: o' ^& r8 nindependent precocious puberty, which is also known
, t6 b+ U% E0 a* U6 _1 oas testotoxicosis, may cause precocious puberty at a6 R3 K5 D  q% u- W
very young age. The physical findings in these boys5 a0 S6 Y2 Z9 D. {# ~
with this disorder are full pubertal development,
$ \1 @/ D3 \; o- e! O; xincluding bilateral testicular growth, similar to boys( V" A" r$ ~* r
with CPP. The gonadotropin levels in this disorder1 F1 `7 I8 d9 I0 d5 N" H
are suppressed to prepubertal levels and do not show
/ ^0 g6 G% Z- r! I$ o; l  u, y# ?pubertal response of gonadotropin after gonadotropin-9 S! n) z# e+ ?, f" S
releasing hormone stimulation. This is a sex-linked
( b# K  C# T: l. Zautosomal dominant disorder that affects only
# u# N+ O$ T: y+ y* Xmales; therefore, other male members of the family8 d# y, C: [3 Z" E
may have similar precocious puberty.3
: b0 ]4 h# z& I( z9 kIn our patient, physical examination was incon-
. u8 _) A! b9 ]6 E4 c: Z7 |sistent with true precocious puberty since his testi-) W/ J  c( b  C% C& W
cles were prepubertal in size. However, testotoxicosis
+ {( m: M7 s3 v9 T9 Fwas in the differential diagnosis because his father
' \! Y$ e8 u0 f0 l% {% k7 E/ Lstarted puberty somewhat early, and occasionally,( w2 Z7 y, \) ^, w* D0 Y
testicular enlargement is not that evident in the7 m! k# |% O7 k8 i# x1 |% [
beginning of this process.1 In the absence of a neg-
3 _& y2 n% ]( q$ M. wative initial history of androgen exposure, our
1 k) u2 v8 n  F6 Ibiggest concern was virilizing adrenal hyperplasia,4 ^! [' f' \/ a* J
either 21-hydroxylase deficiency or 11-β hydroxylase
2 M. I. t1 j3 t- j- w" ideficiency. Those diagnoses were excluded by find-
+ l6 V2 a! q. X2 B( U3 k6 G; |2 @ing the normal level of adrenal steroids.$ B' t0 T' Z. q2 F, Y$ T
The diagnosis of exogenous androgens was strongly
) T3 ~5 x* w: V' [  Q" @8 }suspected in a follow-up visit after 4 months because7 p8 l, I  n, n( _2 z2 H
the physical examination revealed the complete disap-
4 i) u& A+ }" k6 ^$ m% s* }pearance of pubic hair, normal growth velocity, and
7 u/ V7 L" [# ^- qdecreased erections. The father admitted using a testos-
, W3 T# m: {  U$ e! |+ K& @' J/ qterone gel, which he concealed at first visit. He was: g1 Z$ c) }, F% B  Y) W
using it rather frequently, twice a day. The Physicians’
# a7 p# f# D* ~* j3 f: WDesk Reference, or package insert of this product, gel or
2 b! D) P& d8 z% f/ rcream, cautions about dermal testosterone transfer to# L" d6 ?8 A6 l1 c) d
unprotected females through direct skin exposure.8 \! T* r* `8 @! E* V4 k
Serum testosterone level was found to be 2 times the, N# y3 I5 R5 ~) I5 |
baseline value in those females who were exposed to4 H$ ?$ K$ t" p0 _3 ]9 y
even 15 minutes of direct skin contact with their male: a1 D8 V- ]$ ~( S
partners.6 However, when a shirt covered the applica-
3 W. Y+ m& M9 d" Q7 gtion site, this testosterone transfer was prevented.
# n- |) x0 b1 D8 P# MOur patient’s testosterone level was 60 ng/mL,
4 d- w8 f5 }/ o/ d$ Owhich was clearly high. Some studies suggest that. u( ]& c1 P' [3 i% ]. R! n% T! v
dermal conversion of testosterone to dihydrotestos-; l1 p# u1 _4 {1 \, `* _! N
terone, which is a more potent metabolite, is more
8 N7 i. P! B' o( o$ {! j- R* G. iactive in young children exposed to testosterone: Y8 S$ x# t+ Z  g. g$ k
exogenously7; however, we did not measure a dihy-
/ \; Z+ ]7 {# g+ I9 q1 ldrotestosterone level in our patient. In addition to
' J6 j. N/ O, F1 G4 \virilization, exposure to exogenous testosterone in
" r, A' e& ]. }7 q) |children results in an increase in growth velocity and
5 G- `8 H8 U8 C! @advanced bone age, as seen in our patient.
) A1 b; `9 ?8 q& U( N5 U7 |The long-term effect of androgen exposure during
) }1 |* c0 d/ o3 Q% cearly childhood on pubertal development and final
' a* |2 l9 g4 h4 xadult height are not fully known and always remain
+ k, [% W7 z- G$ ]a concern. Children treated with short-term testos-
1 J5 @7 \) q1 _1 m/ K8 a  Z, @6 kterone injection or topical androgen may exhibit some1 H) y5 h! o! J3 j" M
acceleration of the skeletal maturation; however, after
4 ]; u! o3 d& [6 v: v  M7 ^: Hcessation of treatment, the rate of bone maturation
+ D( ^' P! ?- }( X' wdecelerates and gradually returns to normal.8,99 _- x! G: K' x5 a& {7 [7 z
There are conflicting reports and controversy
5 z3 g" e  n' V' u6 Rover the effect of early androgen exposure on adult
# R" D( {9 s' k4 bpenile length.10,11 Some reports suggest subnormal
' P# }9 ?! |; x+ `8 radult penile length, apparently because of downreg-# m6 Q4 p+ D4 T% y2 @7 z! H1 p
ulation of androgen receptor number.10,12 However,/ [* `% T* E5 r8 s, G3 N3 Y; X
Sutherland et al13 did not find a correlation between4 Y0 ~8 L$ E( k. \7 Q! r8 ]
childhood testosterone exposure and reduced adult
) U; l, Y8 ?1 v$ mpenile length in clinical studies.$ A; T$ r; j. c% @
Nonetheless, we do not believe our patient is
" o3 A8 V; I: egoing to experience any of the untoward effects from' i, Q' V, u: ~3 x& {3 C8 d! u
testosterone exposure as mentioned earlier because
+ k  Z  x* E4 u$ d# @$ ^( Y* Pthe exposure was not for a prolonged period of time.
; v/ j6 U! w9 l- v( X$ R, E# hAlthough the bone age was advanced at the time of
- H4 _! T8 o1 S5 N$ Gdiagnosis, the child had a normal growth velocity at
1 u2 ?* q  _0 z! ythe follow-up visit. It is hoped that his final adult
$ D& o/ ]2 J) n( G9 E( N+ Rheight will not be affected.
1 g& x% N8 P) K7 x7 s+ U+ RAlthough rarely reported, the widespread avail-
. _' H8 d: v% w1 Uability of androgen products in our society may
" Z8 m. Q: X. Rindeed cause more virilization in male or female6 x; [$ D) x% i& g; [: e
children than one would realize. Exposure to andro-: ]$ z- G, q% E" k( G
gen products must be considered and specific ques-
* d0 ]; w+ b  l6 [- f4 m# p* K% Ptioning about the use of a testosterone product or, d0 w) n: v( K7 u2 K
gel should be asked of the family members during
2 H/ L8 p0 {% \- h; T2 o& X2 \5 ythe evaluation of any children who present with vir-
7 @8 ~( Y6 v/ `0 ailization or peripheral precocious puberty. The diag-3 @  Y. r% B- z5 D5 w7 @2 Z
nosis can be established by just a few tests and by
8 W$ L9 c5 f' i- D% ]appropriate history. The inability to obtain such a$ ~6 Y5 i6 x' l; \# g4 ]
history, or failure to ask the specific questions, may! j! m' I) S  {; Y9 C' o
result in extensive, unnecessary, and expensive
' l$ U* o0 a4 {- |- xinvestigation. The primary care physician should be3 b. l) _$ @- ~1 g  v+ Y
aware of this fact, because most of these children
" D! S/ v( U# B3 m0 {may initially present in their practice. The Physicians’
9 i1 X8 @0 c, ^& W* S7 tDesk Reference and package insert should also put a; f+ R  @5 {9 U; P% F
warning about the virilizing effect on a male or
' {; c" b2 M) c# M) ^6 Y! Bfemale child who might come in contact with some-
3 E4 Q# l! p3 ?# Gone using any of these products., f  B& Z) d* `, _9 t
References; D  u  j7 f! |5 M
1. Styne DM. The testes: disorder of sexual differentiation
* g, `7 P# a. }) iand puberty in the male. In: Sperling MA, ed. Pediatric
6 i. n) Z4 d9 q1 w0 rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  \, ]& c7 U5 v9 i2002: 565-628.
  B; c1 H: z% f( l4 A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ Y7 D3 N& U: e) jpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old( e  i) q! M& |5 h% D
Boy Induced by Indirect Topical
# ], q; b, D( O( ]9 @Exposure to Testosterone
6 V0 m0 c3 J5 Q$ z* R3 |0 G2 JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  [8 l. q; R, J6 @and Kenneth R. Rettig, MD1
9 K, x7 ^/ m1 D' e4 I' dClinical Pediatrics
( M* f$ \# {+ ?; m5 tVolume 46 Number 6: v5 O" W6 g5 z9 E, a" g
July 2007 540-543
5 Q- J' h& L: u0 a© 2007 Sage Publications
9 o' x: e0 l; H( m10.1177/0009922806296651
9 g  g( a% W3 o/ thttp://clp.sagepub.com
$ X! ^$ Y: p: O) o# G, L! Dhosted at- A  l1 N' a( g" B$ e
http://online.sagepub.com
( c; v$ |) Z* B3 \( T2 PPrecocious puberty in boys, central or peripheral,
& a, F$ x' w! @& nis a significant concern for physicians. Central
6 G* y/ o8 Z4 r. m% Qprecocious puberty (CPP), which is mediated, Z* F5 W  d" ?# b! q4 I- g
through the hypothalamic pituitary gonadal axis, has1 ^2 A' e. [0 C* j3 v
a higher incidence of organic central nervous system
4 Z; M5 g: I# W' n  V$ Jlesions in boys.1,2 Virilization in boys, as manifested
: o& ]- ]8 f+ b" T; z- lby enlargement of the penis, development of pubic* H+ z6 @  h% w3 _+ R; |
hair, and facial acne without enlargement of testi-8 e8 o7 d7 ~. Q! `2 [, [( Z) l9 d
cles, suggests peripheral or pseudopuberty.1-3 We! y( k$ T3 Q' b" |
report a 16-month-old boy who presented with the
8 T# y4 \2 B* ^" u& `, c3 I. Jenlargement of the phallus and pubic hair develop-/ A6 k% z  f1 Q
ment without testicular enlargement, which was due
1 e+ A' w$ z: }to the unintentional exposure to androgen gel used by
& e& ^0 F2 ?( U- g3 Pthe father. The family initially concealed this infor-
* L2 I3 z1 S5 e" [* K; I+ ymation, resulting in an extensive work-up for this
8 ?. \7 Z, ?4 u: x; Z1 Lchild. Given the widespread and easy availability of9 @6 U4 o4 T8 A+ n
testosterone gel and cream, we believe this is proba-+ J) o, w( \+ B
bly more common than the rare case report in the( ]( `( n2 p! n
literature.4
0 @0 G. A- t( L" ]! YPatient Report9 |! p! e' C! D
A 16-month-old white child was referred to the4 b) _  J; R+ C% U% ~
endocrine clinic by his pediatrician with the concern
! I: a1 r) a4 e- I# z8 B4 \of early sexual development. His mother noticed
: D& G6 I2 f: B. n8 u4 S2 j! wlight colored pubic hair development when he was
9 Y6 a$ P$ d9 K2 Q) R5 Z4 CFrom the 1Division of Pediatric Endocrinology, 2University of
  J  _9 x, Y& p. \- {- l& VSouth Alabama Medical Center, Mobile, Alabama." Y: g2 _2 \1 `8 p) K9 [0 Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 x/ F" y  a, ^6 sProfessor of Pediatrics, University of South Alabama, College of
/ W& w! `* g4 y* C* B) P- n' `Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* _, R9 K% b8 G' a* J; r: ^e-mail: [email protected].7 N% Q8 W- @7 O9 a- c
about 6 to 7 months old, which progressively became) t' c) R+ c% H& o! L" |' x  S
darker. She was also concerned about the enlarge-4 n3 D7 H9 {* Y  m5 A- Y) f
ment of his penis and frequent erections. The child: [1 k) Q% s) m& w- A
was the product of a full-term normal delivery, with
0 B3 i& j  [: |6 X. ?0 p/ da birth weight of 7 lb 14 oz, and birth length of
, ?! h! _- P0 n( I. s& P/ T20 inches. He was breast-fed throughout the first year
. ^3 Y& ], ?% W. `2 D- P6 d. i5 |, Qof life and was still receiving breast milk along with
- m2 Z4 K8 V! y0 fsolid food. He had no hospitalizations or surgery,
, C5 E4 j3 ]5 [7 \9 o' T3 Aand his psychosocial and psychomotor development# U! m  J2 N* w( D9 @
was age appropriate.
6 ?! Q4 @9 I0 F; T1 kThe family history was remarkable for the father,
1 O  w, K' v+ {7 uwho was diagnosed with hypothyroidism at age 16,
/ T! ^  Y% _- rwhich was treated with thyroxine. The father’s- q% w& T. ~2 x& j  g  L& r
height was 6 feet, and he went through a somewhat/ _# j3 j8 l9 o% Z/ O) C" k8 i
early puberty and had stopped growing by age 14.
) u4 W6 z2 @& F5 FThe father denied taking any other medication. The# T" b4 p- a" B( @0 J/ i
child’s mother was in good health. Her menarche
3 i0 \) r- i3 O8 o. n6 `- {' \was at 11 years of age, and her height was at 5 feet4 O% e9 |9 c) p2 E! l: @8 y9 q2 N8 G# ^
5 inches. There was no other family history of pre-
, u% e) x* m- N) u8 dcocious sexual development in the first-degree rela-
' @9 A9 Q  V6 `/ wtives. There were no siblings.2 R9 K, i6 C3 n- N  O3 Y7 g, \
Physical Examination
: G8 t2 t5 k. s+ }1 v& T. C" FThe physical examination revealed a very active,
% v9 ?4 y9 K& ?/ K6 D: }5 aplayful, and healthy boy. The vital signs documented
  I9 O, p; h! Q+ x2 ~! qa blood pressure of 85/50 mm Hg, his length was- N% r( l. w$ [  s9 |/ n
90 cm (>97th percentile), and his weight was 14.4 kg3 _# ^9 ^9 H5 V, h( n
(also >97th percentile). The observed yearly growth% l% I9 ~) V! x1 Q/ R
velocity was 30 cm (12 inches). The examination of
% R/ @( S; N& [& J: ?0 ^the neck revealed no thyroid enlargement.
& y8 Y( a6 t8 E* {+ EThe genitourinary examination was remarkable for
2 _+ t; @1 M# n! penlargement of the penis, with a stretched length of
4 r+ n5 P) t7 {  z$ ~5 X# M+ G8 cm and a width of 2 cm. The glans penis was very well
$ y# S- K/ |" Pdeveloped. The pubic hair was Tanner II, mostly around
; Q: }$ H- I; K540
4 O. ^( b3 [! U. B% Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 K- V9 }. A: E  z6 y0 B7 xthe base of the phallus and was dark and curled. The
  a. s; l& K) Ftesticular volume was prepubertal at 2 mL each.
* I! `. E$ t1 H9 J# EThe skin was moist and smooth and somewhat% m6 r! z! H, G/ y0 q9 |
oily. No axillary hair was noted. There were no
8 N! C/ a3 M  Y, Gabnormal skin pigmentations or café-au-lait spots.
' B9 U& W1 X' Q3 W/ p* lNeurologic evaluation showed deep tendon reflex 2+
2 w$ L) y$ U2 U: s- w3 \+ bbilateral and symmetrical. There was no suggestion: h7 c, g1 A: r
of papilledema.
8 [, m( r) m& f+ y: D' ULaboratory Evaluation! q, l7 t6 v+ q, g! V( Q; V& z
The bone age was consistent with 28 months by$ r) M: m, B$ w' i
using the standard of Greulich and Pyle at a chrono-
: W7 E+ o  y9 ?. E9 z9 a/ I" S) Xlogic age of 16 months (advanced).5 Chromosomal
: _6 ]) y8 u7 F" r( c0 x) w. gkaryotype was 46XY. The thyroid function test7 x3 R0 w$ u8 Z7 s) \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& [9 G; b. L( w. P# ~" k
lating hormone level was 1.3 µIU/mL (both normal).4 ?2 m: C- s3 ?5 K3 @. S$ g- J
The concentrations of serum electrolytes, blood- v4 `" h, W( F: M* }
urea nitrogen, creatinine, and calcium all were
6 n0 w/ c, P( n3 I& Q' Cwithin normal range for his age. The concentration
/ c+ n# D; h! N2 Wof serum 17-hydroxyprogesterone was 16 ng/dL( P& C6 e- S$ u/ u+ w4 X
(normal, 3 to 90 ng/dL), androstenedione was 20  Y+ K4 k. v$ j5 V; M. a' F
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% C" H3 ?$ _# G; O4 o0 G- ~0 j' rterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 S7 C0 N5 G: @7 B; S3 V
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) H: f$ |6 u- |" [; m9 W49ng/dL), 11-desoxycortisol (specific compound S)
( J5 s$ ?6 w' o% e2 A3 I* Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, k) B7 A& D" o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! t8 @, q; V4 \% T9 A  \% l' K8 q' Atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 C( u; b/ J- j; ^and β-human chorionic gonadotropin was less than
; ?6 {8 }8 j; w5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 O7 M" C; S  ?2 g1 y; h- Ystimulating hormone and leuteinizing hormone) _4 B2 y) R% U/ a4 V, X
concentrations were less than 0.05 mIU/mL$ l4 y* i0 P* ?
(prepubertal).( p  t8 ?! h( w9 Q# K' ~9 Y( y
The parents were notified about the laboratory( p! A+ x. E' q! N5 S
results and were informed that all of the tests were
1 a& n4 H) V7 e. F6 xnormal except the testosterone level was high. The
$ Y/ W8 e8 m( k% }/ f# A0 m9 jfollow-up visit was arranged within a few weeks to
" e- P* @9 A8 Z  e( I, @; Bobtain testicular and abdominal sonograms; how-* E2 }( T. Y& I$ @! q* q# v6 y
ever, the family did not return for 4 months.$ D% I9 b) ^- |, @+ B+ H% b
Physical examination at this time revealed that the
$ F% S2 r2 O# r* Y! q3 h3 ?child had grown 2.5 cm in 4 months and had gained
+ I; ]% Q, U5 l" G$ l' z0 `9 {# e2 kg of weight. Physical examination remained. q3 G) G. O* P" e( L! {
unchanged. Surprisingly, the pubic hair almost com-
  d/ }, x  T2 T/ h9 _5 `pletely disappeared except for a few vellous hairs at) D) O3 s2 l* N0 H
the base of the phallus. Testicular volume was still 2. o  F" N& g& Q  ^: B) Z5 g
mL, and the size of the penis remained unchanged.
% A4 u0 v4 T2 M' U* _( Z# NThe mother also said that the boy was no longer hav-
3 W9 I/ ~! N8 Fing frequent erections.
! K7 `& k. r6 w# H0 M  m* |Both parents were again questioned about use of
3 E3 B& R) f, e" C8 Iany ointment/creams that they may have applied to
2 _! `/ o/ f4 P; ?0 Athe child’s skin. This time the father admitted the
# ^. y% Q4 K$ w2 c$ _* X. tTopical Testosterone Exposure / Bhowmick et al 541
$ _0 M9 T2 e! J& Buse of testosterone gel twice daily that he was apply-
  Q/ Q+ \# V; v0 c. King over his own shoulders, chest, and back area for! c5 L/ C( O- p
a year. The father also revealed he was embarrassed
6 T* T8 [+ H+ Q0 C& Q0 _to disclose that he was using a testosterone gel pre-
  f6 p- w4 P; D# b2 Rscribed by his family physician for decreased libido
1 @- p3 K- }5 _: msecondary to depression.
' `: ]! r5 L+ U6 [6 p5 f1 n3 f! eThe child slept in the same bed with parents.
% G- h- g; _. \; ^The father would hug the baby and hold him on his, L' c. l1 F( I" A# t/ H6 p! [
chest for a considerable period of time, causing sig-
+ K! t- k* Z& D2 k% J! Enificant bare skin contact between baby and father.
6 p: @, W% @0 z1 @. pThe father also admitted that after the phone call,6 m: ?9 C1 P+ ~- m5 i$ b/ T9 I0 @; C, u/ H
when he learned the testosterone level in the baby
2 l2 _; B# `! f* F1 |was high, he then read the product information
. |4 C& B# E% Npacket and concluded that it was most likely the rea-! x8 ~7 F' H/ R9 ^: A% h5 w
son for the child’s virilization. At that time, they
( }4 j7 S' C" A- i6 C- O. Sdecided to put the baby in a separate bed, and the
& m2 Y: b  r1 w# G$ d' b, X+ Q* _father was not hugging him with bare skin and had
; r) z, F) c+ R8 E2 {1 K+ ]been using protective clothing. A repeat testosterone
& ~, b& f1 a9 n' `test was ordered, but the family did not go to the: X' R3 V  T% C. G/ m
laboratory to obtain the test.8 [, b; v9 y# f
Discussion
- y& a/ I' [6 k( [$ A3 [Precocious puberty in boys is defined as secondary
: q3 V: I. x* x" x6 ^1 x0 E- B7 Msexual development before 9 years of age.1,40 }8 q3 V7 a9 W* u0 f) ]# }6 v
Precocious puberty is termed as central (true) when2 |. n" U# ?! g4 [* X6 S
it is caused by the premature activation of hypo-& B2 B, D! R/ X4 V6 o6 V) j
thalamic pituitary gonadal axis. CPP is more com-
3 z( ^# @1 Q; o$ Y3 fmon in girls than in boys.1,3 Most boys with CPP
- P/ w+ M" S( F5 zmay have a central nervous system lesion that is+ @6 p4 G7 P3 P' U' d9 i
responsible for the early activation of the hypothal-
+ C5 F% |; K: X$ Tamic pituitary gonadal axis.1-3 Thus, greater empha-
- g. C* w) p* {/ `* T  {sis has been given to neuroradiologic imaging in; O7 `6 ]- ~" I
boys with precocious puberty. In addition to viril-
' p# f- T; g. J0 {: H8 l5 Mization, the clinical hallmark of CPP is the symmet-* M7 p3 S/ E" E$ D( l5 w# x
rical testicular growth secondary to stimulation by
+ X0 ?! b. B. d; V3 I4 B) Xgonadotropins.1,3; k7 A; |4 V, o9 R) K7 o  J
Gonadotropin-independent peripheral preco-8 k& s2 R9 M0 y& ~% n4 a" ~
cious puberty in boys also results from inappropriate
3 V3 |# p6 c# x( o: N: i9 |2 G7 Iandrogenic stimulation from either endogenous or
/ k% t: b+ y3 Y; q# l2 d3 eexogenous sources, nonpituitary gonadotropin stim-6 g6 @# `8 Q+ q# ?8 q# B% C2 Y
ulation, and rare activating mutations.3 Virilizing4 s9 m; A. ?" p; d/ B6 _1 j* _/ @
congenital adrenal hyperplasia producing excessive
% a! i$ l/ e: N; Q- C& P2 F( Padrenal androgens is a common cause of precocious8 j- M0 G3 d' m8 B( p
puberty in boys.3,4
; \* h$ s: B3 @& [' x% `7 cThe most common form of congenital adrenal
0 x8 i" D( W) \, Hhyperplasia is the 21-hydroxylase enzyme deficiency.
; c6 G- ~5 h5 mThe 11-β hydroxylase deficiency may also result in
% }& ?/ E! T+ [1 i9 _0 ]* fexcessive adrenal androgen production, and rarely,
- |# x! R1 p& g6 ^an adrenal tumor may also cause adrenal androgen
* R) Z5 n& [; Q( o4 D0 X; c5 L. rexcess.1,3
- @* g! z' w: T( {2 Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; s7 n9 C) U! j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 }6 W* {9 O$ ]  X6 B  J( RA unique entity of male-limited gonadotropin-
% e1 J: b7 Y: v8 D. K" w5 C1 R& aindependent precocious puberty, which is also known, n2 j! x  |+ n/ B5 B
as testotoxicosis, may cause precocious puberty at a
& l" s3 `% Z) R) F6 G. W0 |very young age. The physical findings in these boys
9 S* G# e7 n" U; @2 @/ gwith this disorder are full pubertal development,) z6 Q: Q& v% J1 V/ K
including bilateral testicular growth, similar to boys( N$ y) ~6 S% E, o, p& I
with CPP. The gonadotropin levels in this disorder
0 X# b2 s3 M* X' Kare suppressed to prepubertal levels and do not show
; s& B$ ^9 h6 \6 Z/ @# [. r1 d1 Kpubertal response of gonadotropin after gonadotropin-
  X8 @& ~( l* ^! freleasing hormone stimulation. This is a sex-linked# v( o# M. f6 t) l- z# U7 h
autosomal dominant disorder that affects only
4 k- \7 o% E$ V3 I8 _; [4 mmales; therefore, other male members of the family
1 B) ~$ \& b  A4 h; {may have similar precocious puberty.3
8 X6 j$ x; b! F) a$ i  {" E* h6 MIn our patient, physical examination was incon-
# B" |( V6 }4 d; B! k. w1 hsistent with true precocious puberty since his testi-  s* S/ f4 p5 m0 R2 Q$ t! [2 H: h
cles were prepubertal in size. However, testotoxicosis
$ `0 a+ R0 Z9 l! Iwas in the differential diagnosis because his father) V3 p% x: a  \: _9 E7 L
started puberty somewhat early, and occasionally,
7 v0 v2 x  @) M" H8 C/ _* ftesticular enlargement is not that evident in the* G4 r* V8 ?7 W9 f. i( Y7 y
beginning of this process.1 In the absence of a neg-, `* t3 ^1 `  T' z& y9 g
ative initial history of androgen exposure, our/ x: L# O$ n- R; N9 G. `* F9 W
biggest concern was virilizing adrenal hyperplasia,2 C! V% i8 J" {1 o4 {1 p5 f- S  _
either 21-hydroxylase deficiency or 11-β hydroxylase9 L1 ?1 L/ `& F1 E7 K* T" x1 i
deficiency. Those diagnoses were excluded by find-9 U( N, F$ e0 s2 I- S2 s
ing the normal level of adrenal steroids.
: K( t; M2 P& T) \1 d  pThe diagnosis of exogenous androgens was strongly/ w) p: m/ Q6 |* ^$ z+ j2 B7 t
suspected in a follow-up visit after 4 months because3 o0 a2 g3 ]. q4 V) x0 ^% Z
the physical examination revealed the complete disap-: a' }/ D1 L( s3 c8 g
pearance of pubic hair, normal growth velocity, and7 n( h9 D) ~4 n( C9 m- x, z, c8 k
decreased erections. The father admitted using a testos-" c9 _4 B5 Z4 f% _
terone gel, which he concealed at first visit. He was! z" i8 Q0 O' ]! M' J
using it rather frequently, twice a day. The Physicians’8 a: }. I2 R! [- \; F% w
Desk Reference, or package insert of this product, gel or
  T3 {: Q+ O5 `* Jcream, cautions about dermal testosterone transfer to
( A' M2 f+ K! k% j. E' Dunprotected females through direct skin exposure.
2 Y  {# p2 i1 X  h, ^0 mSerum testosterone level was found to be 2 times the
( T/ O7 {3 v( K) H" ^, q# \7 l# }baseline value in those females who were exposed to
! C! T& `7 l- A0 veven 15 minutes of direct skin contact with their male
: G* h' P- ]2 t0 p: p9 P" ~partners.6 However, when a shirt covered the applica-
1 C, E+ W& i8 {- ntion site, this testosterone transfer was prevented.
" Z& [7 V' h5 ~9 a% r0 H* BOur patient’s testosterone level was 60 ng/mL," F! G" o% H$ Z: k$ u
which was clearly high. Some studies suggest that" G5 g5 G/ I0 w. f! R
dermal conversion of testosterone to dihydrotestos-, k4 z0 U# j% u6 M: t
terone, which is a more potent metabolite, is more
5 e4 k! Q4 ^2 d. [) f6 G8 M- B$ Kactive in young children exposed to testosterone* \! X% h/ ?/ ]. h& ~0 w
exogenously7; however, we did not measure a dihy-
' y5 Q( d$ W/ m4 pdrotestosterone level in our patient. In addition to
+ p6 o# Y( c9 P* L% w$ jvirilization, exposure to exogenous testosterone in+ U, \5 {  U" i
children results in an increase in growth velocity and
& N! ^8 Q# n+ S  W* _* radvanced bone age, as seen in our patient.
; ~; \# d' ^- }( _The long-term effect of androgen exposure during9 ^; K" {$ P+ \, B
early childhood on pubertal development and final
" r7 t/ b' I4 {) h7 U! Ladult height are not fully known and always remain5 @; m: h  q0 r" Z$ v" E8 X
a concern. Children treated with short-term testos-/ D$ L& W' l& H( w: R
terone injection or topical androgen may exhibit some
8 U% s- c0 B# I9 v: iacceleration of the skeletal maturation; however, after& W. R3 H. o  _. m  r
cessation of treatment, the rate of bone maturation, q+ x4 o4 {8 |$ z+ W" Z3 o# S8 ^% u
decelerates and gradually returns to normal.8,9
, ]% m5 ~2 R2 k. h' j( e$ H, B' pThere are conflicting reports and controversy( c" R8 k' D; {' X+ I: i% A
over the effect of early androgen exposure on adult& s$ O- i$ Q/ c8 I, O/ j% {
penile length.10,11 Some reports suggest subnormal
5 O7 ?$ Q* ]* A! @$ a' ^% ^+ Madult penile length, apparently because of downreg-0 z/ |* S( Z9 ]8 u8 {
ulation of androgen receptor number.10,12 However,6 v+ e3 g( h3 e! _" G4 P6 w
Sutherland et al13 did not find a correlation between, P9 w; r0 y. w8 i+ I. H
childhood testosterone exposure and reduced adult" P0 r' J  e4 `6 R9 ?, |( L- Q
penile length in clinical studies.& M1 p# y5 [* Y) _# R% i
Nonetheless, we do not believe our patient is) |  r2 U* [; k( O" ?/ l
going to experience any of the untoward effects from
& `6 k) }# S- S5 t5 I9 q+ etestosterone exposure as mentioned earlier because
: ~4 H) W" ^4 j; pthe exposure was not for a prolonged period of time.
* N; r  |9 l% H! u. MAlthough the bone age was advanced at the time of6 ?# @6 ^* }2 G  l$ U6 P1 _
diagnosis, the child had a normal growth velocity at
. M* R6 e) k2 M1 {! Tthe follow-up visit. It is hoped that his final adult
  o5 ^0 l$ O( z* J+ Lheight will not be affected., l: U# U$ r; Z5 Y( ]3 l, A
Although rarely reported, the widespread avail-
: F5 t) ?+ S  J  iability of androgen products in our society may
8 |. X( @0 y7 q& h; _7 |5 x, ~indeed cause more virilization in male or female
: y5 J) _' r' M$ R8 _2 _9 a7 Bchildren than one would realize. Exposure to andro-
1 P$ S6 }9 }+ c: @9 m. H5 Igen products must be considered and specific ques-
5 Y) f" f' ?( [5 G) \tioning about the use of a testosterone product or
" Q) P) r7 F! T5 ?gel should be asked of the family members during6 s4 @( k/ C* \; T$ E
the evaluation of any children who present with vir-: X& w( ]; a/ y7 T) z: [% u
ilization or peripheral precocious puberty. The diag-+ Z2 O; N1 t, p$ g" Q' P: Q$ A
nosis can be established by just a few tests and by
' c1 X& G4 F7 oappropriate history. The inability to obtain such a4 b( h6 j* P; @, w& V& L" O+ Y
history, or failure to ask the specific questions, may/ ~+ ~' i" u' {9 v+ _
result in extensive, unnecessary, and expensive
) b, K1 f- l+ A. @investigation. The primary care physician should be
. i: P5 s% m( s9 a5 h6 Zaware of this fact, because most of these children# P$ K" p, h8 z/ V, s/ q
may initially present in their practice. The Physicians’' }6 [7 I: l9 y+ t
Desk Reference and package insert should also put a7 F: Z: }# f- C1 `6 q
warning about the virilizing effect on a male or
' d( y- M: F- `3 b, r6 F( Wfemale child who might come in contact with some-# F+ Y# J1 Y, d- I# ]
one using any of these products.( `# S) Z+ I/ \3 T& p" t( m
References
& F0 G8 Q; u" P* B6 n, u1. Styne DM. The testes: disorder of sexual differentiation8 J8 @# c" n0 Z
and puberty in the male. In: Sperling MA, ed. Pediatric" a! j+ ]2 n9 n2 Z9 `+ a! g
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 T) Q) l) A8 l4 i5 ^6 C$ J2002: 565-628.
3 R9 \  }" o: f- |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 W) j7 w% [2 A/ g# [7 [
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

# e' m& ?% F) W4 K9 F; k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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