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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
" ]+ `$ A( }0 x+ C9 GBoy Induced by Indirect Topical
8 E0 V/ W: B# `+ W2 [Exposure to Testosterone
/ x: g2 U1 `3 |/ H- H% s4 S6 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# ]$ N" N, q* ^, R
and Kenneth R. Rettig, MD16 Y" H( x  `  c+ k6 r
Clinical Pediatrics
( b$ |3 K$ o- t  C2 z8 _Volume 46 Number 6- J5 g  `. _3 `& R8 u1 O
July 2007 540-543
9 ]; z1 R" u7 l* ?© 2007 Sage Publications
  T# l7 f5 v/ \: Q+ B7 z( I( V& I10.1177/00099228062966518 d+ |* d) W2 Q1 @
http://clp.sagepub.com
) L) b9 a2 U0 G% R( hhosted at
5 \) H) l; V. M' g- J2 D/ @http://online.sagepub.com
1 k4 ?1 ^8 p) ?5 g2 _0 R9 y& ~Precocious puberty in boys, central or peripheral,2 H! w' ?: ?/ c/ D. O
is a significant concern for physicians. Central
7 b9 e/ X) o0 O+ T* ^0 ]" fprecocious puberty (CPP), which is mediated, ~0 J3 }9 h5 r; g! g9 a: K
through the hypothalamic pituitary gonadal axis, has
: J' l- `8 i! `  Y& i1 na higher incidence of organic central nervous system
* d3 `+ T0 {9 x1 B* T5 Alesions in boys.1,2 Virilization in boys, as manifested2 J" r/ _$ Q- d- W, Q
by enlargement of the penis, development of pubic
, {+ J: i4 B2 [hair, and facial acne without enlargement of testi-
) j4 X7 C' ?, `. ?cles, suggests peripheral or pseudopuberty.1-3 We
. B! f. D# E; b; Y9 f! X1 d9 i2 Kreport a 16-month-old boy who presented with the
1 n+ I4 _1 @# u( i( m/ R7 _. {enlargement of the phallus and pubic hair develop-
' O9 I# p% v; m2 w& Q: s  oment without testicular enlargement, which was due7 Z9 N) I$ p( o6 J) ^/ ?: @7 N
to the unintentional exposure to androgen gel used by- }( F2 G+ H/ V  L7 Z, v$ R
the father. The family initially concealed this infor-9 r# B5 R8 Z% P2 l( l; L! P
mation, resulting in an extensive work-up for this( B( B) n. J: A! D8 h" a+ a
child. Given the widespread and easy availability of
/ O! s) @' N  j: t* {testosterone gel and cream, we believe this is proba-4 p" w, `) u+ w9 X$ J0 c
bly more common than the rare case report in the
5 n; t: ~' D% Z  hliterature.4
& c4 _8 j! W$ a3 ]* yPatient Report
) _' u3 t0 I5 N8 ~3 ^& U3 jA 16-month-old white child was referred to the
5 }4 _9 H9 M- L& P! b7 U$ k  zendocrine clinic by his pediatrician with the concern
" N/ h8 c& I: f; H) Rof early sexual development. His mother noticed4 {0 d2 R2 k/ Z. c6 X+ f7 S
light colored pubic hair development when he was) ~- B: Q" ]3 R
From the 1Division of Pediatric Endocrinology, 2University of# ^2 J2 v( U, a, P1 W
South Alabama Medical Center, Mobile, Alabama.: j2 c* P/ D" x7 e, R7 P* o3 e
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 C# a  X) c; C8 k' CProfessor of Pediatrics, University of South Alabama, College of
2 y, ~+ y  _  f, QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 K/ y3 k9 B- o& f7 F' a1 qe-mail: [email protected].
0 [+ W) ^2 p0 Q( Oabout 6 to 7 months old, which progressively became
# X6 l+ @0 r1 U" @( tdarker. She was also concerned about the enlarge-/ n) Y. D, F& s* C; F+ W
ment of his penis and frequent erections. The child+ U( c* Q7 B2 s* o% K- I% x
was the product of a full-term normal delivery, with
' L/ T9 I$ n+ xa birth weight of 7 lb 14 oz, and birth length of6 L  O: u. [9 A# r- j$ Y
20 inches. He was breast-fed throughout the first year
) Q' }1 ?& I, s; [, b9 Jof life and was still receiving breast milk along with; D2 ]3 g) v3 d6 A
solid food. He had no hospitalizations or surgery,, w+ s# f! [8 W5 D2 G8 }* \
and his psychosocial and psychomotor development9 m; g+ t, e* B3 t  I
was age appropriate.
5 u  Z* S1 G! c9 [& H- K1 JThe family history was remarkable for the father,
2 p  S# }- e1 X, g+ ]who was diagnosed with hypothyroidism at age 16,3 P3 Z0 d( N, e- k; L7 r
which was treated with thyroxine. The father’s
& {3 o5 t/ A8 sheight was 6 feet, and he went through a somewhat
- E  C8 @$ v2 ?0 e( Yearly puberty and had stopped growing by age 14.
: t# _8 I6 z& u& b3 `' x% ~3 o; AThe father denied taking any other medication. The) @; N  R3 ^7 f( k9 L  T
child’s mother was in good health. Her menarche( C) w. r6 T4 `& q- B5 ?3 L
was at 11 years of age, and her height was at 5 feet
1 l% a; Z4 _7 p/ U) F5 inches. There was no other family history of pre-
, Q7 V! b  x/ e  Y) ccocious sexual development in the first-degree rela-- ?& W7 w* i1 ?
tives. There were no siblings.: H' @* I& z/ @! p8 a, E  G: g
Physical Examination+ D; F  R) L; v
The physical examination revealed a very active,
! o: b. k3 d9 T3 F1 ^# W" [; yplayful, and healthy boy. The vital signs documented' j5 B. u3 L+ q/ R3 C7 U
a blood pressure of 85/50 mm Hg, his length was
6 l$ o* {  b$ p3 T90 cm (>97th percentile), and his weight was 14.4 kg
+ e8 p, L; d( z$ m3 |(also >97th percentile). The observed yearly growth: r( m/ y. l9 K
velocity was 30 cm (12 inches). The examination of! \2 ]5 S8 m5 Q6 X$ c: U- O
the neck revealed no thyroid enlargement.
8 e+ l. j% _' M4 k3 W4 N- \5 D: DThe genitourinary examination was remarkable for
/ e4 J- ]3 d9 D% X7 p+ Qenlargement of the penis, with a stretched length of
" Q; p" c0 U8 b+ U8 cm and a width of 2 cm. The glans penis was very well
. v# U! c, E6 D, Ndeveloped. The pubic hair was Tanner II, mostly around( k- D9 G7 ~7 O
540- l8 r- `, |$ o/ U$ C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 ~8 u  X# @: \/ A- R9 l+ ]the base of the phallus and was dark and curled. The
2 f/ H& |- q- [7 ^- p/ q0 x% d& Atesticular volume was prepubertal at 2 mL each.
, K  e. {9 _( f1 AThe skin was moist and smooth and somewhat, n/ }; n: [5 N
oily. No axillary hair was noted. There were no" X3 }4 O  }% I' e! |9 Z1 ]
abnormal skin pigmentations or café-au-lait spots.7 p1 d' q# @5 ]* n
Neurologic evaluation showed deep tendon reflex 2+
4 L3 F  X2 V, ibilateral and symmetrical. There was no suggestion. m1 d# r" k& }) R& G
of papilledema.( C, H8 Y  _5 u7 {: X& c0 X
Laboratory Evaluation
; A1 I3 ^* W# y# f/ E0 ?) [6 YThe bone age was consistent with 28 months by; S/ p7 v2 D, m; @! y
using the standard of Greulich and Pyle at a chrono-$ D+ n6 j: D8 ^0 N9 n4 ~
logic age of 16 months (advanced).5 Chromosomal
2 s* Q$ K) ?' ?, [% N6 ykaryotype was 46XY. The thyroid function test; a3 m) r$ P2 Y. j' s& K
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" z& f0 @6 Q9 b; ?$ C7 {3 dlating hormone level was 1.3 µIU/mL (both normal).2 _9 C7 ~: j0 d
The concentrations of serum electrolytes, blood
/ u& R, t0 q  y% H/ {urea nitrogen, creatinine, and calcium all were* `# _7 }( `. D6 q1 i
within normal range for his age. The concentration7 Y0 X( L3 D5 e9 _# t
of serum 17-hydroxyprogesterone was 16 ng/dL
* F. {" r& }! j(normal, 3 to 90 ng/dL), androstenedione was 20
$ m5 @: }- E* rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 q1 K3 }0 `5 Z- w( O: C- ]; Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),! C7 i% B% N* ^6 g+ N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ @! @1 g7 ]) X7 ?6 x" W$ J49ng/dL), 11-desoxycortisol (specific compound S)
7 t- V" d. m. M% a% Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 S) X; r! c) l# Z5 U8 b( d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. W/ g; ]' Y: c; b4 y6 ^% Z' Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 _$ S  r1 {$ q) x- r+ ~1 p8 eand β-human chorionic gonadotropin was less than0 [0 B, v5 K) M+ y7 q7 V3 M
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 J! a9 P$ {# p, W& j5 g) p. m1 ostimulating hormone and leuteinizing hormone
0 q/ {# e% a% [: rconcentrations were less than 0.05 mIU/mL9 h3 T$ A8 t; a
(prepubertal).
. r2 \" y* T/ wThe parents were notified about the laboratory. I% k  t6 n8 h& c3 e4 x& ]. Q9 \  w
results and were informed that all of the tests were
4 `; j+ a* e5 ?$ X1 Unormal except the testosterone level was high. The
" n( G5 J2 {- U/ ?; U( f( I2 @follow-up visit was arranged within a few weeks to: J( |6 T5 K+ Z$ K
obtain testicular and abdominal sonograms; how-
, d* Q% x1 V$ t% _$ i. Q1 n& F8 bever, the family did not return for 4 months.  E" Q; b& m* V$ G8 O9 Q& u
Physical examination at this time revealed that the% ], s( }5 J( [) j
child had grown 2.5 cm in 4 months and had gained- i. ^* _% F% L2 s$ G
2 kg of weight. Physical examination remained
2 J8 [4 }$ [- P$ O' Cunchanged. Surprisingly, the pubic hair almost com-  l+ w% m  |4 {  Q& N# e. L
pletely disappeared except for a few vellous hairs at/ O; U( ?+ x# r+ z2 U  s
the base of the phallus. Testicular volume was still 29 g  b$ E0 w7 |; T: Q  n
mL, and the size of the penis remained unchanged.
0 J& y4 T8 V  D; D* T; mThe mother also said that the boy was no longer hav-/ v1 O5 h  m# _1 I. L
ing frequent erections.
0 @/ v( f- W- qBoth parents were again questioned about use of
, Y7 I( M7 J( R( V& [, o5 r( ?/ eany ointment/creams that they may have applied to' \; k/ Z- C. N1 j! x
the child’s skin. This time the father admitted the9 J6 z! F0 x. t* z& a
Topical Testosterone Exposure / Bhowmick et al 541
. i, x: o5 {0 n! u7 h- G; F/ ]2 u5 yuse of testosterone gel twice daily that he was apply-
, [8 @4 o0 k7 ?/ uing over his own shoulders, chest, and back area for
# e' \- {: ]6 v4 E+ }1 g8 }a year. The father also revealed he was embarrassed
/ y! e  f1 _/ |; n+ gto disclose that he was using a testosterone gel pre-
; N8 |" C! `3 o$ O9 jscribed by his family physician for decreased libido7 R3 r# V" }3 }9 ^3 q# p2 o
secondary to depression.
- {4 J, Y# E6 ]9 G8 e* W* r3 \" KThe child slept in the same bed with parents.
/ |. Q( ]% @1 a2 TThe father would hug the baby and hold him on his
' T: m  \# y8 ^# gchest for a considerable period of time, causing sig-
) I: b% i* b7 Y* `: znificant bare skin contact between baby and father.! q6 j+ E7 S. I5 u; I# w
The father also admitted that after the phone call,
3 H2 |1 V# e, dwhen he learned the testosterone level in the baby
+ E& Q" H% W# ^. {# L7 nwas high, he then read the product information' b5 r: D  t& S# ^; f
packet and concluded that it was most likely the rea-
% k' y7 X9 \! n: S2 V) ]: Dson for the child’s virilization. At that time, they
8 N6 {9 l) \7 l7 X$ Ydecided to put the baby in a separate bed, and the
$ a- x8 C" T; h+ p  A' Pfather was not hugging him with bare skin and had
. b1 ]% m8 A* _+ v+ t- i$ V6 S/ pbeen using protective clothing. A repeat testosterone4 w& p. U- _* l+ L
test was ordered, but the family did not go to the; f1 W% |. V4 o2 T; R6 D
laboratory to obtain the test.
+ g2 z3 W/ ]& T: }Discussion! `8 A7 ~2 f' m* ~# ~2 @, k) a
Precocious puberty in boys is defined as secondary( C! y$ V0 {+ o. N
sexual development before 9 years of age.1,48 z4 y& }" J) A) G
Precocious puberty is termed as central (true) when7 _) z6 R  w  e
it is caused by the premature activation of hypo-
4 Q; p7 h! u: ]2 T5 O# |7 @6 athalamic pituitary gonadal axis. CPP is more com-
3 D5 _! r9 ?2 B! ?$ Tmon in girls than in boys.1,3 Most boys with CPP5 a. t) N* [& o1 g
may have a central nervous system lesion that is) P% }! v. G) d" X# D+ U0 l5 [1 Z
responsible for the early activation of the hypothal-! n  O3 }3 j% n1 Y" Y
amic pituitary gonadal axis.1-3 Thus, greater empha-. H0 V8 l9 P( X! U$ L0 _
sis has been given to neuroradiologic imaging in  Q4 B9 a& P! g3 C6 E! A6 I
boys with precocious puberty. In addition to viril-
; c& ~4 |+ L, j2 e9 V: Q$ Uization, the clinical hallmark of CPP is the symmet-
& M5 S, W% M8 Q2 b" N% Krical testicular growth secondary to stimulation by# R2 J% Z5 P$ J8 M# S
gonadotropins.1,3, U& B) ^/ E/ [' j" w
Gonadotropin-independent peripheral preco-0 }$ q2 o4 Z. F! |! g
cious puberty in boys also results from inappropriate3 s+ {. m7 {7 b1 c, R8 j% V# {
androgenic stimulation from either endogenous or. @' K/ I0 d$ n, {
exogenous sources, nonpituitary gonadotropin stim-% O  O5 n3 Q1 x# o. c3 B( C& Y
ulation, and rare activating mutations.3 Virilizing, G/ G  Y+ w3 E. W& F
congenital adrenal hyperplasia producing excessive) J; s: d1 T0 u) M& I
adrenal androgens is a common cause of precocious6 f& s6 B- O5 |6 ]- H$ u
puberty in boys.3,4
* F' U( t" T6 v) o9 [The most common form of congenital adrenal
# Q( m0 J- U% Z8 u- h* a! H3 rhyperplasia is the 21-hydroxylase enzyme deficiency.
3 q/ ~7 ^) G3 k- h6 OThe 11-β hydroxylase deficiency may also result in% M: Q1 v4 J% t. D7 B; D3 z9 z) O9 F
excessive adrenal androgen production, and rarely,/ b0 d5 u% O( S2 F2 p* T* ]0 s
an adrenal tumor may also cause adrenal androgen; `4 E' V/ t7 p" s
excess.1,3
* y* _+ W1 c4 v% m& v9 c& rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 ^! |1 }, O; a) A5 a! w3 U% W
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% E; T0 o1 y8 g0 q5 NA unique entity of male-limited gonadotropin-
5 c4 n! @2 i# findependent precocious puberty, which is also known; C* ~( l" N+ j6 C1 c( ?
as testotoxicosis, may cause precocious puberty at a
2 i4 ], `' d  A, W$ Kvery young age. The physical findings in these boys
- B8 f6 D5 X# A: S, ~: Awith this disorder are full pubertal development,
- H5 k0 E! D* E9 Nincluding bilateral testicular growth, similar to boys
% v2 a5 ]: U  c+ n0 ]) Owith CPP. The gonadotropin levels in this disorder3 w/ i' o7 e6 o4 I# W% l/ V
are suppressed to prepubertal levels and do not show! E3 F8 C: J# m4 i7 O  y, @! W3 g
pubertal response of gonadotropin after gonadotropin-
! ]+ b7 _& A2 treleasing hormone stimulation. This is a sex-linked
1 V* {3 M) t8 M. Q9 [autosomal dominant disorder that affects only& @3 \/ T+ w. n7 }3 I' ?# X
males; therefore, other male members of the family0 h; w) Y2 o$ L  J. \
may have similar precocious puberty.37 r# c% B2 L9 m2 w4 K
In our patient, physical examination was incon-
+ F3 [  ~. N) T* o2 k8 q7 G" usistent with true precocious puberty since his testi-
: C" [4 Y: G! m4 N2 D( Ccles were prepubertal in size. However, testotoxicosis* s: }+ N0 C5 r
was in the differential diagnosis because his father0 R+ R+ j9 P3 i1 q
started puberty somewhat early, and occasionally,& {* T/ R+ C, L- V6 m8 _: D( u
testicular enlargement is not that evident in the% s; Y. h$ Z. v5 P3 e! B
beginning of this process.1 In the absence of a neg-. A0 f3 p" X* x8 u+ B1 t5 i& D3 i
ative initial history of androgen exposure, our8 m, c, z, o0 _; Y" h. z
biggest concern was virilizing adrenal hyperplasia,
5 Q, S7 k4 F( I3 z7 u+ Deither 21-hydroxylase deficiency or 11-β hydroxylase7 V2 I0 Z; k4 P3 u) b
deficiency. Those diagnoses were excluded by find-1 P, n$ g5 o; n
ing the normal level of adrenal steroids.
- h- M2 z- u4 n  v. N' IThe diagnosis of exogenous androgens was strongly
# e/ a4 n, @, {7 {/ |suspected in a follow-up visit after 4 months because: K, y2 S* m. L+ d
the physical examination revealed the complete disap-' T( P' \) u: h- j2 s0 m2 g
pearance of pubic hair, normal growth velocity, and' g6 m7 A2 J' E$ g
decreased erections. The father admitted using a testos-, F* [% C  o- o; P
terone gel, which he concealed at first visit. He was
6 U! f0 q. m  {2 M4 n; l) D2 M- r, Yusing it rather frequently, twice a day. The Physicians’/ a6 a( i: ^! \$ ^8 S
Desk Reference, or package insert of this product, gel or
, L( P. Y3 V) u% U: jcream, cautions about dermal testosterone transfer to
7 l7 _5 T, `7 M0 O: l+ w2 Zunprotected females through direct skin exposure.: A0 O: \* o3 H+ ?( g5 Q
Serum testosterone level was found to be 2 times the  C% M% N$ A) c; r) v, ]4 [' R7 r
baseline value in those females who were exposed to& {2 t% l% d9 B
even 15 minutes of direct skin contact with their male
; w- ~/ U2 |# v7 x& B, ?partners.6 However, when a shirt covered the applica-
+ C: N6 @3 O; b1 p9 W. d7 qtion site, this testosterone transfer was prevented.( h2 u$ p' @1 J
Our patient’s testosterone level was 60 ng/mL,
) V, R* Z4 B. ^: C4 pwhich was clearly high. Some studies suggest that
$ Z" W/ A" c7 x9 \7 Bdermal conversion of testosterone to dihydrotestos-
. G8 z+ i* K/ y) y# O* d" Sterone, which is a more potent metabolite, is more8 k: \3 i, R2 s, q) k( B
active in young children exposed to testosterone
5 l6 n' T8 A7 K9 rexogenously7; however, we did not measure a dihy-
) [% B' O3 p! u; T  Q/ i- H# adrotestosterone level in our patient. In addition to
) J+ z5 F/ `' t' Bvirilization, exposure to exogenous testosterone in
( |& s0 J% l6 H' j% ?3 X8 rchildren results in an increase in growth velocity and
- X" l* d0 c$ ?0 p8 x; T- dadvanced bone age, as seen in our patient.  N0 l3 y+ P4 }% v8 J
The long-term effect of androgen exposure during
$ _8 F. H5 H" F: j! Learly childhood on pubertal development and final
: Q5 K: g) [0 Z- p1 W8 D# l; Uadult height are not fully known and always remain$ ]" t1 v  b( X! v8 t  E( U: \
a concern. Children treated with short-term testos-
5 P! ]% }4 |* e3 k% Y0 M, Wterone injection or topical androgen may exhibit some
- e* W/ n1 R8 U# Jacceleration of the skeletal maturation; however, after
8 K( B$ K6 P, \7 zcessation of treatment, the rate of bone maturation. p* p9 y$ m! G! x" I  {. u9 m
decelerates and gradually returns to normal.8,9
* J% {+ S0 G; k; k/ g  {" g7 S. r: G$ KThere are conflicting reports and controversy
4 \& q& B; [, s& j( _4 Nover the effect of early androgen exposure on adult
' A9 i0 j4 f0 ]5 dpenile length.10,11 Some reports suggest subnormal
2 m* T, j# ]- P  x) x: iadult penile length, apparently because of downreg-* h0 `1 W/ [* l0 l0 h
ulation of androgen receptor number.10,12 However,
0 e( p% F! d# n# k% _Sutherland et al13 did not find a correlation between
5 m$ N9 d- Y$ M) V, gchildhood testosterone exposure and reduced adult+ R6 m; c) T3 k: M+ B, \2 `. I. E
penile length in clinical studies.
# \( P0 {2 N4 |) I. J! N. ~" \. jNonetheless, we do not believe our patient is
3 @. G0 J7 a4 G0 K* lgoing to experience any of the untoward effects from$ z7 F8 A8 S% G- r2 ]- l. v
testosterone exposure as mentioned earlier because; J& v: D1 |* U2 R" v; w
the exposure was not for a prolonged period of time.
7 n. V0 w/ p$ V  X# MAlthough the bone age was advanced at the time of6 ^) N+ f% b# P' r8 l
diagnosis, the child had a normal growth velocity at
% D4 ^; z6 b+ A/ O0 Tthe follow-up visit. It is hoped that his final adult
  A6 P& B+ I8 t# _0 j3 `9 Mheight will not be affected.
7 X1 y4 g) w+ `Although rarely reported, the widespread avail-: z3 s, v' }* |/ h7 w
ability of androgen products in our society may
; [7 A8 p6 u0 c5 X9 G6 ^  Vindeed cause more virilization in male or female
" D" g, w+ F. s% Echildren than one would realize. Exposure to andro-. q5 A( W; i* t/ j$ n
gen products must be considered and specific ques-
/ x( M2 M/ {: a6 Ntioning about the use of a testosterone product or
" `! W7 B' O: }$ [& v  pgel should be asked of the family members during
9 g4 ?' k+ [" Q; ?0 `1 B' E1 a) Wthe evaluation of any children who present with vir-0 S7 W. X/ @2 e* A0 [" P6 @
ilization or peripheral precocious puberty. The diag-' C! c  p  a3 c6 k$ c: W& _' d
nosis can be established by just a few tests and by
, _4 w5 F/ X. u1 S  \; bappropriate history. The inability to obtain such a
' M. ^2 G  c/ Vhistory, or failure to ask the specific questions, may2 [* ?7 P6 E1 I# T8 z
result in extensive, unnecessary, and expensive
5 c; U; _9 U3 i) b! ?investigation. The primary care physician should be, j9 r( H* y* k6 Y, B% r/ w
aware of this fact, because most of these children! Q1 p' r0 a5 v; o: b; d; V
may initially present in their practice. The Physicians’$ w6 f% c* X6 V4 e
Desk Reference and package insert should also put a% s0 V0 b1 f7 O
warning about the virilizing effect on a male or
: ~- E' p  j) qfemale child who might come in contact with some-
, W8 Z7 u$ G& i9 a' J8 L# ^one using any of these products.
, L& ~$ g  `" S4 dReferences2 p, M1 d9 C: t5 ?/ Y8 L8 _
1. Styne DM. The testes: disorder of sexual differentiation
. R4 \2 _* D6 ]0 C3 j2 zand puberty in the male. In: Sperling MA, ed. Pediatric5 J$ u8 w. c9 I
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. O/ |. D; a0 g- x) U# |, \2002: 565-628.6 L% C' v* j! E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 C8 Y7 u/ l9 ?" Y; H1 X. Epuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: c/ N% H- ~' t. i/ }  y0 A% l
Boy Induced by Indirect Topical
/ i: s0 |- K' z% cExposure to Testosterone# e$ g/ o* n. C7 E' B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: V$ \" s% n, `3 G
and Kenneth R. Rettig, MD1
4 U1 p0 y6 T  n- }8 YClinical Pediatrics1 w5 B# I0 t0 g( w
Volume 46 Number 6
# k: k" o( P+ v5 G/ o+ KJuly 2007 540-543
1 @5 q0 t8 L' e- J© 2007 Sage Publications& ?! O( ?7 b4 y/ \! k
10.1177/0009922806296651
% e! i9 h$ p1 r5 m) a& O+ |. U$ Ohttp://clp.sagepub.com
4 z* X$ C, k0 I3 U+ t; _& B. Z) @: n; Thosted at
! }1 J! W, t$ thttp://online.sagepub.com5 U- g9 f1 @; f+ \3 a1 K( Q
Precocious puberty in boys, central or peripheral,
, T0 T8 s  W" _is a significant concern for physicians. Central
% P9 ^# t- F$ U7 y' F0 ?precocious puberty (CPP), which is mediated
9 q" U: T2 V' P3 Bthrough the hypothalamic pituitary gonadal axis, has
. F& p: Z7 t4 F' n, v2 Y5 _, N. Y8 Ka higher incidence of organic central nervous system
8 d% r: p8 N& i& P4 wlesions in boys.1,2 Virilization in boys, as manifested6 h3 v9 R/ Z0 ?, @# p3 f
by enlargement of the penis, development of pubic& F8 J) ~8 c/ I: i' ^) e6 _. v3 D
hair, and facial acne without enlargement of testi-' a* u" a2 _( z9 E- B
cles, suggests peripheral or pseudopuberty.1-3 We
9 W2 k1 g0 d# _# _$ X! x5 ?+ ^9 Zreport a 16-month-old boy who presented with the* W8 C$ A) |2 S. _5 f+ T
enlargement of the phallus and pubic hair develop-1 J3 y( ~( r2 j2 p, s% ?
ment without testicular enlargement, which was due3 Y; }% C, c) Z/ L; O
to the unintentional exposure to androgen gel used by0 y, W0 K; I8 X1 v! V2 \: n7 }
the father. The family initially concealed this infor-2 q8 M/ W! U! T( w% x# {2 ~" n6 W
mation, resulting in an extensive work-up for this% o" i0 S* i" {( H/ u
child. Given the widespread and easy availability of/ V; P# P% m$ D0 C' ]+ D
testosterone gel and cream, we believe this is proba-. ~) M, W# v$ N: M  X# [9 G: _
bly more common than the rare case report in the
1 m1 U% g. r1 mliterature.4
" |3 A$ w1 Q2 V4 m& nPatient Report3 O9 {0 Y- G& |3 k3 o* I6 o9 l
A 16-month-old white child was referred to the9 {  E% h+ I9 q* O
endocrine clinic by his pediatrician with the concern
4 s9 p& m( ~& Rof early sexual development. His mother noticed
5 K' B+ Q* d* Slight colored pubic hair development when he was
  [6 Y- i- U: o. e4 |5 R$ V+ vFrom the 1Division of Pediatric Endocrinology, 2University of' m2 r7 L( ]  O* m8 K& d# {5 x
South Alabama Medical Center, Mobile, Alabama.
/ p+ o1 v  o+ p& c9 `2 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* b, r. M+ b: B6 |Professor of Pediatrics, University of South Alabama, College of# U, |$ {1 m- y! T9 [
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" B8 [: k# v  ^7 }6 _
e-mail: [email protected].. [3 W( b# j* q' K$ |) z+ l
about 6 to 7 months old, which progressively became1 C- J- L% Z* K8 u0 O
darker. She was also concerned about the enlarge-
6 b& X* q, U) J+ E6 `) Fment of his penis and frequent erections. The child. K" |  X' |' q  y7 T! c
was the product of a full-term normal delivery, with
) J9 x- U& F7 \# H! h% Xa birth weight of 7 lb 14 oz, and birth length of" a4 ~; I7 c. m; y/ L  r
20 inches. He was breast-fed throughout the first year4 ^; M. D( D6 I9 r6 J
of life and was still receiving breast milk along with: v7 P  x$ f. C. J' c
solid food. He had no hospitalizations or surgery,
2 k/ r4 l  Q8 _. \1 l" I6 s9 @3 `and his psychosocial and psychomotor development, C4 i3 N$ H( S" g: J* y* q
was age appropriate.
9 Z( V' _+ g( lThe family history was remarkable for the father,9 \: _: h5 ], p* Y9 A3 y& I
who was diagnosed with hypothyroidism at age 16,  {3 y! U8 y! a. l; O; \( I
which was treated with thyroxine. The father’s
) U5 F% j- {7 U) e: W0 Q# z" aheight was 6 feet, and he went through a somewhat
+ S' I. ~/ g0 a( N7 yearly puberty and had stopped growing by age 14.
& j* ^0 X* X7 b- C- |; z" G0 w6 VThe father denied taking any other medication. The6 a, S  b' {3 ~3 J8 b6 K, t& }
child’s mother was in good health. Her menarche
0 ?0 N. D' j' d1 I8 Vwas at 11 years of age, and her height was at 5 feet) A, l9 F0 K" T: R3 g
5 inches. There was no other family history of pre-
. d3 m7 _2 J4 _cocious sexual development in the first-degree rela-2 a; s# Z* N( _: _# D# g7 A
tives. There were no siblings.8 k) X  e! O# w  f
Physical Examination
! F$ t4 I, Y  a! C8 Z6 R( NThe physical examination revealed a very active,& k( u2 b' {+ x* M
playful, and healthy boy. The vital signs documented0 F, I- a% m0 d" D" v' `( K
a blood pressure of 85/50 mm Hg, his length was, B2 y) g- v( I' o- k6 L/ w
90 cm (>97th percentile), and his weight was 14.4 kg
9 a+ M* f( \0 g" C! n, y6 J(also >97th percentile). The observed yearly growth2 v5 H0 ]5 t- }  s1 ^3 b9 g
velocity was 30 cm (12 inches). The examination of2 m) f) x9 F8 T
the neck revealed no thyroid enlargement.& n0 L, `$ y2 L$ V# l7 ~% p
The genitourinary examination was remarkable for. g$ Q) c  b3 ~* }3 p0 T) f5 h
enlargement of the penis, with a stretched length of/ h" a# e+ ?' I5 ^( ]
8 cm and a width of 2 cm. The glans penis was very well2 {3 N; \7 i6 F4 x
developed. The pubic hair was Tanner II, mostly around7 O( G( R# u# I- e# Y/ K  _: f
540; r8 `- W% J$ C% K' B3 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& I( m. a2 \1 [. [# h
the base of the phallus and was dark and curled. The
7 Y$ [2 E1 q# C  M" F6 u2 N8 H$ W6 Btesticular volume was prepubertal at 2 mL each.( ?2 T: \0 R7 |* E4 U$ _7 R
The skin was moist and smooth and somewhat! M  h9 M# C: E: b
oily. No axillary hair was noted. There were no
8 n; I( U6 ?: \  @" U0 vabnormal skin pigmentations or café-au-lait spots.
' ]- [) x; X( ANeurologic evaluation showed deep tendon reflex 2++ z% S$ m( I7 W  \4 C8 K
bilateral and symmetrical. There was no suggestion/ T3 l4 r" G# e( C6 J. w: _: a
of papilledema.6 p8 S* z+ h) K5 Y) ^+ h
Laboratory Evaluation
+ A: L* S  t5 O: m# b1 U( @* {, y5 pThe bone age was consistent with 28 months by
: z. R8 `  A; H. n; Tusing the standard of Greulich and Pyle at a chrono-
& f3 N' M0 C1 T; x; O6 ?5 m4 Nlogic age of 16 months (advanced).5 Chromosomal0 W2 m  v: R' y6 @* T: R' V6 R
karyotype was 46XY. The thyroid function test& j# v2 s6 q( N, a. h! J8 P. Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 _) ~* \4 u2 X
lating hormone level was 1.3 µIU/mL (both normal).
" f2 w. k) W" l$ x' f# \2 l, S5 AThe concentrations of serum electrolytes, blood  s, e; A( {5 N+ u
urea nitrogen, creatinine, and calcium all were
. u! }, u+ D: awithin normal range for his age. The concentration
2 m" Y5 k/ t  \2 l- K- vof serum 17-hydroxyprogesterone was 16 ng/dL
8 L- J; o2 k+ y, Z(normal, 3 to 90 ng/dL), androstenedione was 201 U; d+ D, H- \7 v8 t" Z: f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ U/ o5 i, C) G% i) B. d. g4 f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 \) t( n' v" D4 _6 Pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 k2 k' J* ]$ N/ c/ O8 R49ng/dL), 11-desoxycortisol (specific compound S)
9 k( X/ z; y' Q$ D' t# Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. S' R$ V0 E* J. ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 R6 q$ |) r+ I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: D1 e* G$ e( e/ z- gand β-human chorionic gonadotropin was less than
8 {" X- S7 S* S, b9 E$ f5 mIU/mL (normal <5 mIU/mL). Serum follicular
- G; ]( F6 i  E! Pstimulating hormone and leuteinizing hormone* d  ~) G& Z1 V# d" h' |) ^
concentrations were less than 0.05 mIU/mL! i1 U6 a6 w. s' g; j. g% R) M6 l
(prepubertal).
+ L' g5 `+ v3 n0 d* s4 K$ [* k5 `The parents were notified about the laboratory
" N* m) J1 o* e: N, S. Hresults and were informed that all of the tests were% {0 }+ w0 r- i4 E# g  X% M
normal except the testosterone level was high. The/ A  ~  h' s1 v$ j& K3 f
follow-up visit was arranged within a few weeks to
( I+ |6 C5 [) P! A3 F/ S. Q6 a0 w8 cobtain testicular and abdominal sonograms; how-9 X9 q' Y, K$ W: I$ d
ever, the family did not return for 4 months.( w* I- ^# h2 \) ^& q" T
Physical examination at this time revealed that the# P& ?, C/ ^( [5 r7 ^& c5 v- i
child had grown 2.5 cm in 4 months and had gained; F, }( u- @5 w8 W1 ~. @- m% M( K
2 kg of weight. Physical examination remained5 O- W0 a, e; X8 r3 B6 J
unchanged. Surprisingly, the pubic hair almost com-
% m. c$ g. g; N& G+ j  S8 ipletely disappeared except for a few vellous hairs at  ?* ]& `  Z2 }; a5 ]
the base of the phallus. Testicular volume was still 2
; U1 C+ Q( K$ i: KmL, and the size of the penis remained unchanged.  r+ T  d& K/ L3 l1 q
The mother also said that the boy was no longer hav-
& a6 J: A1 f+ }+ [% H  M& C) a0 jing frequent erections.6 N* a+ i! B2 ~' R' h' ~. p3 L& r' P
Both parents were again questioned about use of2 E% `; q" }# Z) J* x- J6 z
any ointment/creams that they may have applied to
6 }0 y: j# j  W3 R, E( e* `the child’s skin. This time the father admitted the
# r1 Y- m' s4 b. uTopical Testosterone Exposure / Bhowmick et al 541
4 _8 m- y4 p6 c7 Q" M+ puse of testosterone gel twice daily that he was apply-
8 \2 z6 H1 _/ Q/ p4 H' m7 ging over his own shoulders, chest, and back area for
1 Q4 d9 \+ v- G9 S/ {* f( ia year. The father also revealed he was embarrassed$ y1 e. l1 K7 `' C+ s5 n5 P$ h; ?
to disclose that he was using a testosterone gel pre-% Q  `( T7 [, N; J! J: _
scribed by his family physician for decreased libido# e1 O* w" f% Q% f! }' G- R. I
secondary to depression.5 a$ _6 d. k2 y, |% M% I7 f$ w8 O
The child slept in the same bed with parents.3 m% E) a7 ?4 y
The father would hug the baby and hold him on his' e' h/ l6 `8 E5 i6 t1 F! u# [
chest for a considerable period of time, causing sig-0 W4 U8 K5 C" B, p0 s# r7 `0 s5 l
nificant bare skin contact between baby and father.! k% e2 w; L. r! d0 U7 x9 @& J, @
The father also admitted that after the phone call,; ?9 Y. ^' X. N$ i  n
when he learned the testosterone level in the baby
5 ~' \# D5 J4 b+ i1 w& ^was high, he then read the product information
. {- ~5 b0 K! Z0 ~0 V+ ?packet and concluded that it was most likely the rea-
% D- [* S4 E% a3 D$ [son for the child’s virilization. At that time, they
2 q  p4 _: y1 e. Ddecided to put the baby in a separate bed, and the
0 i" w0 E; e, y/ P/ ^father was not hugging him with bare skin and had
9 \0 Y* Y7 b1 Qbeen using protective clothing. A repeat testosterone
  I) A0 }/ T7 `test was ordered, but the family did not go to the" y  q. r/ Q0 T2 q
laboratory to obtain the test.
7 H% ?+ D2 K: z' O6 p( g! k3 T3 |Discussion% `* M( U' m9 w) a$ J9 y/ s, E( h
Precocious puberty in boys is defined as secondary: l" R5 R& `  D  d4 |3 B
sexual development before 9 years of age.1,42 k+ ^+ T' I1 c. @! k: @- L* i- s* M
Precocious puberty is termed as central (true) when
/ c* t7 j' m% B& [$ Nit is caused by the premature activation of hypo-# {- W' \# ~# F
thalamic pituitary gonadal axis. CPP is more com-3 R% M+ K  d$ S2 b
mon in girls than in boys.1,3 Most boys with CPP3 e2 h9 E2 w- A; O5 Z8 V) B
may have a central nervous system lesion that is
8 x! o: u2 b) W$ Bresponsible for the early activation of the hypothal-
" }/ m! `/ \( E/ a: P8 X8 I; o" F1 famic pituitary gonadal axis.1-3 Thus, greater empha-" p3 x! n* }, H/ M
sis has been given to neuroradiologic imaging in# e! V' }" ~1 X+ y/ f/ z
boys with precocious puberty. In addition to viril-3 @4 H# z0 o9 P3 s" L
ization, the clinical hallmark of CPP is the symmet-8 T7 d# g8 H1 g) N6 v9 Q
rical testicular growth secondary to stimulation by  o% j4 n1 Q+ W
gonadotropins.1,3* r* D7 k0 q9 l. K% _
Gonadotropin-independent peripheral preco-3 o, D1 o4 Y) z4 p0 Z9 Z
cious puberty in boys also results from inappropriate- X9 C0 q9 ^0 j. w" n; T8 B
androgenic stimulation from either endogenous or
' l+ V1 E3 s) b% l4 x* Hexogenous sources, nonpituitary gonadotropin stim-
5 Q7 S9 v* Y) \  rulation, and rare activating mutations.3 Virilizing" I; y# k" Z4 W7 _
congenital adrenal hyperplasia producing excessive8 r+ O) \1 v0 w) E( j# F
adrenal androgens is a common cause of precocious
7 n2 e0 W- q" P. X. l& E8 Qpuberty in boys.3,4
" p2 J2 q5 T3 k5 U2 [; e* UThe most common form of congenital adrenal
% R& i+ L& X' H4 ?- ^8 d. Jhyperplasia is the 21-hydroxylase enzyme deficiency.: K9 Z2 V3 k" @% L
The 11-β hydroxylase deficiency may also result in- r' f% p9 a" m7 E% N1 m0 |
excessive adrenal androgen production, and rarely,! g; x. A1 u6 s$ ]( d
an adrenal tumor may also cause adrenal androgen1 t" ~2 _( o  n
excess.1,3- Q. X. W1 F% H4 F) O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 E! t+ Y" G. s/ M4 i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! u; m' k  L( g* [+ K! `0 `; v
A unique entity of male-limited gonadotropin-
/ Q2 i- [+ u4 ]independent precocious puberty, which is also known7 o( p+ Y) U& @* M  w, z
as testotoxicosis, may cause precocious puberty at a5 F  Q) _; c( M( U9 U  V; E
very young age. The physical findings in these boys7 N" }. j( H. [
with this disorder are full pubertal development,
0 ^6 S: l* T* H3 j% hincluding bilateral testicular growth, similar to boys- t0 `5 [; `$ g  O
with CPP. The gonadotropin levels in this disorder
' w) }" h  I3 w5 z" D8 dare suppressed to prepubertal levels and do not show: y: w3 b! P# m* I, m, b" `# @( Y# h
pubertal response of gonadotropin after gonadotropin-/ k# l: M! \' g
releasing hormone stimulation. This is a sex-linked
# U3 X0 i; e4 d: K! @0 J( Lautosomal dominant disorder that affects only
8 I1 V: B# i8 h- a1 Tmales; therefore, other male members of the family
- h- w, ?' M3 {- g0 a2 v9 Q/ R  Imay have similar precocious puberty.34 ~* b& ~# J) I
In our patient, physical examination was incon-
' U( x2 }7 V8 ?4 U2 |' J- xsistent with true precocious puberty since his testi-4 D! }' h6 D4 [
cles were prepubertal in size. However, testotoxicosis; S' C8 C% y" Y
was in the differential diagnosis because his father
( |9 l( O8 s2 }3 d& qstarted puberty somewhat early, and occasionally,5 P6 V7 J" E  T$ z0 G2 D
testicular enlargement is not that evident in the6 d% d/ [% b3 ?; A  |" K: ?0 P
beginning of this process.1 In the absence of a neg-0 d/ o* H( J' f* S
ative initial history of androgen exposure, our0 I4 N) w2 k+ m* [, ~: L6 x! P
biggest concern was virilizing adrenal hyperplasia,
  s7 ?. j2 W4 @9 [2 z( ieither 21-hydroxylase deficiency or 11-β hydroxylase+ o; {; n' t# j- c5 n7 |" }8 P
deficiency. Those diagnoses were excluded by find-
- e! D! c8 I4 C! Oing the normal level of adrenal steroids.; C. r$ r- x+ ?: r9 y
The diagnosis of exogenous androgens was strongly
+ E  e' c4 S8 v6 z; Qsuspected in a follow-up visit after 4 months because" O, f5 n4 E# {, T' h
the physical examination revealed the complete disap-0 F" }: D2 _1 [  H+ G: M/ s
pearance of pubic hair, normal growth velocity, and
. ~( t1 L2 j- r6 W. h4 Ydecreased erections. The father admitted using a testos-
2 j. y6 @$ h/ x- Z, Tterone gel, which he concealed at first visit. He was
3 l1 V' i5 E) {0 ?/ [2 v7 V2 musing it rather frequently, twice a day. The Physicians’# M& |& x5 u* F# z! p
Desk Reference, or package insert of this product, gel or, q% h5 J3 a3 |, [
cream, cautions about dermal testosterone transfer to/ q2 m7 o, _) Y
unprotected females through direct skin exposure.- h0 Z5 B* b+ p' U1 s5 z7 b
Serum testosterone level was found to be 2 times the+ q  P* {2 S6 l2 L
baseline value in those females who were exposed to4 @5 A( [( A% z4 _! {5 q4 `, `
even 15 minutes of direct skin contact with their male
/ ?' J- N& Q; I* dpartners.6 However, when a shirt covered the applica-8 g& c0 q7 Q% E0 p; s
tion site, this testosterone transfer was prevented.
2 F3 x" K: q$ l: ]' ^Our patient’s testosterone level was 60 ng/mL,
- e2 `5 F) s/ t; P* ~8 wwhich was clearly high. Some studies suggest that; q& ^1 e) u& Q  n2 v
dermal conversion of testosterone to dihydrotestos-
5 k! t/ u  k  g4 n6 Hterone, which is a more potent metabolite, is more
0 }$ c4 g& ?9 f- }/ ?+ y( f4 L2 Yactive in young children exposed to testosterone) a$ Z/ w$ x* N, a% v/ |
exogenously7; however, we did not measure a dihy-0 ]6 `4 `% J' f- u! A/ m% U. L
drotestosterone level in our patient. In addition to; w' D5 q: r) m
virilization, exposure to exogenous testosterone in% m7 O9 g5 s6 `! A7 j! W, Y
children results in an increase in growth velocity and
& B1 C! u# T: V2 A4 fadvanced bone age, as seen in our patient.; P; J3 p: O# R  [: r  N3 @
The long-term effect of androgen exposure during  D( j$ N# N. R4 B
early childhood on pubertal development and final* N& }! ~  s  u
adult height are not fully known and always remain
, T! U7 e0 U7 _0 Z% L' |a concern. Children treated with short-term testos-0 J7 o/ N& }/ X1 i
terone injection or topical androgen may exhibit some# B" s, C% k  l7 {
acceleration of the skeletal maturation; however, after, q& o# f' z/ H- d& K( A* J9 n5 p' [
cessation of treatment, the rate of bone maturation% j1 H! L3 j4 C8 f) Z
decelerates and gradually returns to normal.8,9
+ }) }( y' Q5 ]7 ?There are conflicting reports and controversy7 a4 u' h7 Q( W% ^8 _
over the effect of early androgen exposure on adult# F' n4 d& M- t1 E3 e. ?7 i
penile length.10,11 Some reports suggest subnormal
/ @' E3 o* Z* I- uadult penile length, apparently because of downreg-
+ |/ B" k$ o9 g1 l* l, {# V: lulation of androgen receptor number.10,12 However,& Y" \3 ]9 U$ N1 W6 X9 {+ {2 C! |
Sutherland et al13 did not find a correlation between9 O6 B$ p; B; Y0 c3 Y6 F
childhood testosterone exposure and reduced adult/ O$ _/ j7 C9 n' c+ y& Y! x
penile length in clinical studies.
; ]2 }6 ^: l, z( c4 v2 ], INonetheless, we do not believe our patient is' E& z9 E$ \. j' U* y3 p5 N6 l
going to experience any of the untoward effects from% N7 C6 z  I7 }
testosterone exposure as mentioned earlier because* J1 n2 M7 d4 O+ S% p2 f
the exposure was not for a prolonged period of time.  `, d- Q4 r" n. }; \7 h
Although the bone age was advanced at the time of) }2 k$ a# n9 d3 J3 f0 E2 j; L4 M; t
diagnosis, the child had a normal growth velocity at  E+ G+ r2 p+ C- u7 z8 K
the follow-up visit. It is hoped that his final adult
0 h% D; p4 z! D8 Bheight will not be affected.) Y' ]5 I! b/ p) l" ~3 j
Although rarely reported, the widespread avail-
& c( K' i; E+ N$ dability of androgen products in our society may
4 y7 b6 s) ?" S/ lindeed cause more virilization in male or female- O& U, F2 \+ b  \$ J
children than one would realize. Exposure to andro-" v8 n' {, T8 |+ p: O+ A$ [$ \
gen products must be considered and specific ques-
7 T. F! j. e/ h1 Wtioning about the use of a testosterone product or
' b0 S5 p* c9 p1 f  o  Egel should be asked of the family members during; ^7 R; Y# R. L6 {/ b+ E! z+ r
the evaluation of any children who present with vir-9 u5 ^% ?9 R. n( h% ~. v
ilization or peripheral precocious puberty. The diag-6 f( s* y4 @% i; V" W3 b
nosis can be established by just a few tests and by
2 D$ [( i* w, |0 d$ C$ wappropriate history. The inability to obtain such a
# }# `# W) c& |9 Thistory, or failure to ask the specific questions, may
0 ^1 W4 q" k% f( }' v% B1 Fresult in extensive, unnecessary, and expensive' j) S( m% o# q9 ~9 @5 x9 z
investigation. The primary care physician should be) C+ b) w5 L) F) x. ?/ X/ Q; D
aware of this fact, because most of these children
! [8 j2 Z- V0 e7 i: ^- b2 w  ~may initially present in their practice. The Physicians’2 N9 W) N' d2 b- b
Desk Reference and package insert should also put a) O" k5 J) n' E6 C; f1 n
warning about the virilizing effect on a male or! Q, S; ^* t5 l: y3 F
female child who might come in contact with some-+ I5 {' S& K+ F% B1 y6 E% p6 v
one using any of these products.4 K9 ^0 B. f- b! z9 E7 d
References
3 m0 Z  L" k% b7 x/ u: @$ p1. Styne DM. The testes: disorder of sexual differentiation
$ X7 Z! t# G4 n- r" Xand puberty in the male. In: Sperling MA, ed. Pediatric( i; ?6 B. E) _+ o! `! H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, G0 X: V* U3 Q, \; S2002: 565-628.2 N9 A/ Y7 M! _2 K& F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! r9 U3 b* U, H4 \" S& A' G, Y5 ]
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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

1 {2 s9 B( `, ~0 p. Z/ L8 d8 {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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