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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' ~1 D, _; k# l' g3 ]9 z7 d
Boy Induced by Indirect Topical; c5 ^2 l7 ^3 h9 F: ?; i
Exposure to Testosterone
" |% C( V1 ^- KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 Q! a8 c+ _- `
and Kenneth R. Rettig, MD1
( k  K% F0 c& M7 ~$ yClinical Pediatrics1 f. d4 `8 j  r5 S
Volume 46 Number 64 k2 e6 Z+ M9 h  {; {9 {
July 2007 540-5432 b0 J: D4 ?+ A2 e
© 2007 Sage Publications4 W9 \. W6 }9 W9 m8 D' B2 @. i0 G
10.1177/0009922806296651! E0 a; h" S3 Q& n1 J3 H2 {
http://clp.sagepub.com% c/ f% q  w6 b9 h* U
hosted at
( d( I$ x6 W* s3 M! P8 dhttp://online.sagepub.com
  ~9 Y! T8 S& E3 F1 ?0 yPrecocious puberty in boys, central or peripheral,
$ P0 n# _9 y  e! |& Z$ \" lis a significant concern for physicians. Central
8 q5 d0 S7 s# gprecocious puberty (CPP), which is mediated4 R8 W4 b) Y: v
through the hypothalamic pituitary gonadal axis, has! E( B0 c) F- c/ ?( u' O
a higher incidence of organic central nervous system
5 P. P, R" Z- slesions in boys.1,2 Virilization in boys, as manifested7 q" ]( I( G1 i) A; k
by enlargement of the penis, development of pubic
* {4 k" n/ l% u" w7 [hair, and facial acne without enlargement of testi-
: {; V% Q& S. V. @' W7 Hcles, suggests peripheral or pseudopuberty.1-3 We- t. C* z; X8 j
report a 16-month-old boy who presented with the0 h$ Q( ]8 s$ L2 Z6 y& l- _
enlargement of the phallus and pubic hair develop-
, h' C) d3 N$ {- B6 h# ]ment without testicular enlargement, which was due
4 b+ \1 {& `+ w9 Xto the unintentional exposure to androgen gel used by
: ^0 u$ j1 R" o: Ithe father. The family initially concealed this infor-- M4 z4 W" _1 W( a0 V8 [
mation, resulting in an extensive work-up for this
8 P6 T& b" }$ B/ o" B" p* K* Tchild. Given the widespread and easy availability of. `5 `, u* [1 ?& w! |4 {
testosterone gel and cream, we believe this is proba-( F9 ]' m$ ~! z& N7 P
bly more common than the rare case report in the$ R: }% y  Y" H7 w4 u
literature.4
# i1 e' e% V) Y" M) a* @Patient Report
3 N! h5 |, t! a6 ^% GA 16-month-old white child was referred to the
# ~+ S7 Q5 k) Y+ D; ~. eendocrine clinic by his pediatrician with the concern
( [; W6 j5 T: F( oof early sexual development. His mother noticed) T/ W0 w0 |5 q5 q3 J/ r4 h: v5 j
light colored pubic hair development when he was
4 k+ L# c9 j5 J  NFrom the 1Division of Pediatric Endocrinology, 2University of
, E! m$ U$ {0 D+ B. @1 q* ISouth Alabama Medical Center, Mobile, Alabama.% B2 g$ i/ E* T+ E# M( j
Address correspondence to: Samar K. Bhowmick, MD, FACE,. X" N# C, u8 s. x. T1 X
Professor of Pediatrics, University of South Alabama, College of
, ^; p4 }& \/ K8 h8 r+ Z" a0 iMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 B# G! V0 c3 E5 K/ V& r
e-mail: [email protected].: ?+ s6 M9 c7 G
about 6 to 7 months old, which progressively became
1 m9 R: ?8 X) c/ Jdarker. She was also concerned about the enlarge-
' {- m4 M( `7 M2 c0 d( k3 `% L/ Ument of his penis and frequent erections. The child+ v( U6 ^; q  t" H) Y/ K0 w6 X
was the product of a full-term normal delivery, with, u4 W! D+ S8 u6 }8 V
a birth weight of 7 lb 14 oz, and birth length of
3 c2 J1 \' k$ S( Y2 N4 c. F8 v' }! T20 inches. He was breast-fed throughout the first year
/ H' }+ V6 f* w: R8 d, @of life and was still receiving breast milk along with) U3 z1 `/ O/ D
solid food. He had no hospitalizations or surgery,
0 `" @$ H( u$ W4 j# xand his psychosocial and psychomotor development
3 }) t+ _* F5 [2 `" H9 P* _) swas age appropriate.  T) N# k9 }% E2 W
The family history was remarkable for the father,* M. ~+ ~1 L! w& ~, g* S, e
who was diagnosed with hypothyroidism at age 16,) v% l2 e( s- x( z
which was treated with thyroxine. The father’s: z: Q* I* K: x0 x/ ]
height was 6 feet, and he went through a somewhat8 w  K* V2 B1 g& b# ^
early puberty and had stopped growing by age 14.
$ [8 N/ O8 o5 ZThe father denied taking any other medication. The
1 M4 F# M+ d$ E2 Y: ~child’s mother was in good health. Her menarche$ V8 o  D% |0 q( `! M$ {
was at 11 years of age, and her height was at 5 feet) N1 K8 V/ ^$ V
5 inches. There was no other family history of pre-  R6 H; d& u. `  U9 v3 V0 M0 j0 n, |
cocious sexual development in the first-degree rela-3 q  T( j' H0 ~, A5 W0 }
tives. There were no siblings.
1 R$ K0 G( M; X( bPhysical Examination
- w% C+ S" Y4 v4 ]The physical examination revealed a very active,
$ e, z2 w' e, E3 B. V% b5 x+ Dplayful, and healthy boy. The vital signs documented9 L1 j+ D5 c! G# K. J
a blood pressure of 85/50 mm Hg, his length was
' v. T4 }, I# Y( a5 o; L& e& m6 R90 cm (>97th percentile), and his weight was 14.4 kg
1 n, m* u0 _* q(also >97th percentile). The observed yearly growth
8 r0 a4 h% E& U! X: |3 nvelocity was 30 cm (12 inches). The examination of) q9 e  q. X9 T8 Q) ]2 \8 P( O5 F
the neck revealed no thyroid enlargement.
. j5 [& O+ [7 qThe genitourinary examination was remarkable for! Z$ c; P7 N7 u" L& U2 f
enlargement of the penis, with a stretched length of
, Z* K( f; ]* f8 cm and a width of 2 cm. The glans penis was very well
; U. U4 s+ {: R+ edeveloped. The pubic hair was Tanner II, mostly around' V9 D) ^/ ?0 l; c' h2 t
540' x2 V  E3 U# U' Z" Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( Y  z3 w1 y! i! x
the base of the phallus and was dark and curled. The
; T- @/ V- m0 k* D) {* `testicular volume was prepubertal at 2 mL each.- t3 V7 h. S, O$ r
The skin was moist and smooth and somewhat9 p. O" Q$ m! Q1 G+ S
oily. No axillary hair was noted. There were no
7 W4 y: L7 U1 I! C( b" w" wabnormal skin pigmentations or café-au-lait spots.
0 H2 a3 o; Q2 qNeurologic evaluation showed deep tendon reflex 2+  ]. N# Z7 ^6 g% B% x0 `3 ~
bilateral and symmetrical. There was no suggestion
: O9 w4 q' D9 C( K' V& X7 _6 A1 tof papilledema.+ f2 y9 \  Q/ `9 Y
Laboratory Evaluation; m! E; K3 V6 E' E4 e
The bone age was consistent with 28 months by
  l6 X9 ^9 q  [/ ]8 H  dusing the standard of Greulich and Pyle at a chrono-
, \: [6 s: d5 Clogic age of 16 months (advanced).5 Chromosomal- [& T" B1 u) k3 W* v- p7 m2 ~
karyotype was 46XY. The thyroid function test5 C! |6 ]+ S9 ?9 z% Z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- r; S: p/ U. N1 j; U# s3 b8 w8 Wlating hormone level was 1.3 µIU/mL (both normal).( d" ^" ?. L* G# e) l
The concentrations of serum electrolytes, blood
8 s9 N0 \2 n0 P$ V- J' J1 t) furea nitrogen, creatinine, and calcium all were
  Q; _9 ]" t+ twithin normal range for his age. The concentration
* b8 Y  R- {/ Aof serum 17-hydroxyprogesterone was 16 ng/dL( H/ y! j) W7 d% ^3 h! ?* D
(normal, 3 to 90 ng/dL), androstenedione was 20
9 q. y7 C/ q. u+ n* Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# y6 K2 [% A3 A( d5 Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),) f' e: y8 u: l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) q6 u" h' k$ W; r49ng/dL), 11-desoxycortisol (specific compound S)
' M: h% [2 K% j. u, p) Fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 H- G4 M4 Y, h! q, U* |# jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) Q5 s/ c! j& c9 r4 p2 X$ e  g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 B2 a, g" X0 \& Y4 ~. T% Zand β-human chorionic gonadotropin was less than) F. C5 Q4 N) u& r
5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 A1 `5 q/ f3 F+ L* \stimulating hormone and leuteinizing hormone
) w' Q4 M4 U* d- ~. |concentrations were less than 0.05 mIU/mL! ?7 B3 U. U0 b" V
(prepubertal).
9 U0 y" s8 Y1 o: V" g# ZThe parents were notified about the laboratory( P. u5 o* m4 S$ [5 T
results and were informed that all of the tests were4 A0 B9 d- |# g5 k2 J4 r# P
normal except the testosterone level was high. The
2 x( h( D$ O0 F& J2 s& j! Xfollow-up visit was arranged within a few weeks to
6 v! m# r) Z# m1 ~1 Oobtain testicular and abdominal sonograms; how-( j- y5 o: ~4 N, q6 K2 z; U7 z
ever, the family did not return for 4 months., ], a, x2 t+ D% A7 X
Physical examination at this time revealed that the
3 K: N) t$ n$ h4 q% Kchild had grown 2.5 cm in 4 months and had gained3 u6 A5 ?& Y' b9 y* V8 a
2 kg of weight. Physical examination remained: {, p: S0 \6 W6 W7 d( y
unchanged. Surprisingly, the pubic hair almost com-
9 }. e) {# l8 c: M4 p4 S/ j$ Qpletely disappeared except for a few vellous hairs at
  v  \2 T% c5 Qthe base of the phallus. Testicular volume was still 2
' m; N! z6 `4 l% p9 L' {mL, and the size of the penis remained unchanged.- s8 L2 D) G- i, b8 @
The mother also said that the boy was no longer hav-+ e9 R4 c3 W( k1 P; d
ing frequent erections.5 T& V- f1 @) S
Both parents were again questioned about use of4 F1 l4 `- L% s# W2 B% j
any ointment/creams that they may have applied to
& w: r+ u  ?! I+ T! ithe child’s skin. This time the father admitted the( ]: ~5 Z% o" ]8 ~6 g5 N) C
Topical Testosterone Exposure / Bhowmick et al 541
! J3 j3 p3 R: w1 K* Uuse of testosterone gel twice daily that he was apply-
9 T! o0 V6 ~/ Y: i0 A+ ting over his own shoulders, chest, and back area for5 W5 _) ~  g4 q4 o7 |4 Q4 B" |
a year. The father also revealed he was embarrassed" i% X$ R0 ?" T; l1 W- W4 x
to disclose that he was using a testosterone gel pre-
. Z: M4 @5 K/ H% E0 H# Dscribed by his family physician for decreased libido
6 w. Q+ l, O# j' x" O/ R- \: dsecondary to depression.
7 v, G2 ]* M2 i3 Q: ]The child slept in the same bed with parents.
9 t# e& f, Z; v) C; |The father would hug the baby and hold him on his
1 ]+ P9 _  e; [+ Q8 Achest for a considerable period of time, causing sig-* |% P: M; E+ S# Z) C& u% T9 r" @
nificant bare skin contact between baby and father.: Z8 q% h. g+ [: I
The father also admitted that after the phone call,
9 N' V+ O4 D7 _# wwhen he learned the testosterone level in the baby; D; j% x) M3 n6 W- m3 O
was high, he then read the product information
9 S. i- ?* D$ `2 W$ W2 Rpacket and concluded that it was most likely the rea-
  O4 H# \. B2 _; |, U9 L. k0 dson for the child’s virilization. At that time, they
- L. ~0 N. c  w% @* t  O$ Ydecided to put the baby in a separate bed, and the
1 T2 y8 H* T# t: e6 S8 J' Pfather was not hugging him with bare skin and had
0 H" E  }$ J# }0 y  e( P% pbeen using protective clothing. A repeat testosterone
& C6 E, Z, ?# |6 Y4 Utest was ordered, but the family did not go to the+ J$ A/ G1 {) b; \
laboratory to obtain the test.
) B& H+ a. P0 B6 UDiscussion" J8 y0 N  ]( r8 D
Precocious puberty in boys is defined as secondary
! F# A7 q" B' H8 ?0 ?! p' asexual development before 9 years of age.1,4
$ M0 O/ V5 Z6 i! u. g/ s4 kPrecocious puberty is termed as central (true) when
+ P! M) ?: ]! s1 ~0 U# F  T( vit is caused by the premature activation of hypo-
+ Q& C9 }1 R! b; @* x) g) Tthalamic pituitary gonadal axis. CPP is more com-
$ v- o' i" Y1 m% V( ]mon in girls than in boys.1,3 Most boys with CPP3 c7 q. q/ A$ E3 ~* U: A4 V
may have a central nervous system lesion that is1 W( [7 U) m) k+ g
responsible for the early activation of the hypothal-# S, _- B1 K  Q0 G% I! m  a; u& B
amic pituitary gonadal axis.1-3 Thus, greater empha-; o+ O  b2 O) v5 J+ v& f$ D
sis has been given to neuroradiologic imaging in
0 l  l" c2 R5 K4 M9 A9 tboys with precocious puberty. In addition to viril-- v0 L( @4 o, G6 w" y
ization, the clinical hallmark of CPP is the symmet-# t. h0 v8 X) J* i+ c
rical testicular growth secondary to stimulation by
: F1 j. s& p  |& b+ kgonadotropins.1,3
6 K. n. H9 S( k) }2 l( O5 j# MGonadotropin-independent peripheral preco-
3 k& ~$ X5 Y# I: n9 |cious puberty in boys also results from inappropriate
& i0 g# R( U6 |2 o2 S8 w1 ^8 A; oandrogenic stimulation from either endogenous or7 O0 U( g1 r5 M; Z5 B
exogenous sources, nonpituitary gonadotropin stim-. @: q& a5 b1 V2 J+ @4 w. i
ulation, and rare activating mutations.3 Virilizing
- P! \- z* ~: h1 bcongenital adrenal hyperplasia producing excessive2 x* y1 f( U7 \) t- q; N
adrenal androgens is a common cause of precocious4 B7 I8 A2 \* j. _8 U: e: ?
puberty in boys.3,4
: R% O/ x$ l, z0 g. T  o% `The most common form of congenital adrenal
) f) `7 t2 ^/ N2 hhyperplasia is the 21-hydroxylase enzyme deficiency.$ ^& r3 ~; Y9 u& i8 {4 T
The 11-β hydroxylase deficiency may also result in$ f+ z6 E' Z5 {" f
excessive adrenal androgen production, and rarely,4 K9 y/ J* C3 X- U/ }
an adrenal tumor may also cause adrenal androgen
$ t) v- ?& a% j3 t, Oexcess.1,3
/ f  Q4 @" L) E. o  V6 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% G) p9 U! P: P( v6 s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- M4 u7 Q  W! P& yA unique entity of male-limited gonadotropin-
- F% f  E0 E( `/ E( I6 D9 Windependent precocious puberty, which is also known! @$ B  W$ ~4 C
as testotoxicosis, may cause precocious puberty at a
& V' D# p$ q2 ?6 Q# M) Qvery young age. The physical findings in these boys
1 z4 n  g* b7 J) X0 Fwith this disorder are full pubertal development," z" d- p* J& A# b$ J7 ]* v
including bilateral testicular growth, similar to boys
, r$ F4 A4 F: M/ H# w8 b3 p% wwith CPP. The gonadotropin levels in this disorder2 z  ^! G! y, C
are suppressed to prepubertal levels and do not show4 o# n, E" V3 Q6 u
pubertal response of gonadotropin after gonadotropin-
! e8 T9 t. {- w9 q8 D( f+ r# [9 Breleasing hormone stimulation. This is a sex-linked; p) p  n- ?# g% S8 F
autosomal dominant disorder that affects only) h$ K4 u: v& h$ H9 \- w1 _4 ?
males; therefore, other male members of the family  M1 `4 L! C8 Y+ Z
may have similar precocious puberty.35 V& H5 q5 f  I& C* W' ?9 M
In our patient, physical examination was incon-# I/ ~* t  b/ O
sistent with true precocious puberty since his testi-
( u4 [$ n( B# j% Ucles were prepubertal in size. However, testotoxicosis
" U' Z1 ?/ F8 y& [! r' twas in the differential diagnosis because his father
" w5 ?8 V4 _8 X* l; F) |, ustarted puberty somewhat early, and occasionally,
7 g' d3 E& C: I/ wtesticular enlargement is not that evident in the
1 k2 u# [: n0 f2 ~2 bbeginning of this process.1 In the absence of a neg-
# r7 @" d/ q! i  H, V, S5 {ative initial history of androgen exposure, our/ t! H! `; h. I& {  e
biggest concern was virilizing adrenal hyperplasia,3 x& K4 a. V/ B2 ?& ^/ h, h+ a
either 21-hydroxylase deficiency or 11-β hydroxylase+ f, K8 v& U) o3 C6 G: h
deficiency. Those diagnoses were excluded by find-
5 I, y. s4 s! h1 G8 bing the normal level of adrenal steroids.
  C6 |9 G: U8 s( F  pThe diagnosis of exogenous androgens was strongly  v5 y7 c- ?, i! Q! ]: x
suspected in a follow-up visit after 4 months because- \- Y' o% T- b& e
the physical examination revealed the complete disap-
' z4 D' Z$ U% @# zpearance of pubic hair, normal growth velocity, and
& i  |- J4 _: h: Cdecreased erections. The father admitted using a testos-
5 e4 |* L+ ~4 ^terone gel, which he concealed at first visit. He was  ^9 m( F9 r( p& A5 |. Q$ n! G
using it rather frequently, twice a day. The Physicians’
; n) o! z& K2 r9 \- D1 M3 K3 g  Q' aDesk Reference, or package insert of this product, gel or
! h7 O2 t/ j' E% u- Rcream, cautions about dermal testosterone transfer to, ~! Q  S9 K' E# g3 Q. d
unprotected females through direct skin exposure.  d8 S$ b1 x. p! _6 i" R5 ]
Serum testosterone level was found to be 2 times the
2 T  W1 O5 o, L" H0 r# Cbaseline value in those females who were exposed to
1 }; ]* Q2 P/ @6 L1 Feven 15 minutes of direct skin contact with their male
, |$ X& d% X) u. G  bpartners.6 However, when a shirt covered the applica-9 R4 L# L  E' Q1 W2 `( Y6 f
tion site, this testosterone transfer was prevented.
) f$ X2 o- a& B% l& rOur patient’s testosterone level was 60 ng/mL,& l+ Q* [: P8 \5 J4 c
which was clearly high. Some studies suggest that
' k8 i( Y" J- u, e; Udermal conversion of testosterone to dihydrotestos-
% U  ^) H$ j1 u  H2 A+ Dterone, which is a more potent metabolite, is more! a  p# j& b; s* L  p$ b7 T" J3 I
active in young children exposed to testosterone
$ P: w9 s. i* X% m8 pexogenously7; however, we did not measure a dihy-
7 t! a7 B6 B3 U. ?. A* ydrotestosterone level in our patient. In addition to
3 R5 P1 B5 A. g6 j; R. R0 b! kvirilization, exposure to exogenous testosterone in5 d9 a  \4 M2 B
children results in an increase in growth velocity and
) ?9 x* H$ a. |) m* Oadvanced bone age, as seen in our patient.6 q3 ^' B5 F' H  o
The long-term effect of androgen exposure during
, s/ H( X& ^4 |$ o9 xearly childhood on pubertal development and final! M/ W. B5 ^1 c2 T0 m0 Y: N: }; R
adult height are not fully known and always remain
* m; p7 ^0 i7 J) E% X1 y0 {0 G  ]a concern. Children treated with short-term testos-' l  N% Z; p) b, c  G! L+ N
terone injection or topical androgen may exhibit some
) N& y1 Y0 z: W- k* f) L1 |  F7 |acceleration of the skeletal maturation; however, after0 n  b4 ?: b/ g: {9 D0 ^7 `
cessation of treatment, the rate of bone maturation
# o9 k4 f* U7 I6 ?decelerates and gradually returns to normal.8,9
1 c& `. x& G7 o$ I( HThere are conflicting reports and controversy
$ s1 y+ \' R+ u0 gover the effect of early androgen exposure on adult7 T' j! n3 h% e6 i  V1 L1 t
penile length.10,11 Some reports suggest subnormal0 A# Q/ @% `- ^4 f9 A$ i
adult penile length, apparently because of downreg-
0 e+ `: W# }; J) J/ g# C/ e# Nulation of androgen receptor number.10,12 However,( z) t7 c' K$ J4 ?
Sutherland et al13 did not find a correlation between
* m3 `9 }9 u, V- `3 Nchildhood testosterone exposure and reduced adult. D4 t7 T- d# ]) z9 w
penile length in clinical studies.
) z6 L4 Z$ c( q* d& |! r/ mNonetheless, we do not believe our patient is$ F5 T$ c9 u9 a5 i+ m* j" D2 _
going to experience any of the untoward effects from
2 j) p: S8 n* w" g4 i1 k: ?4 @testosterone exposure as mentioned earlier because5 A& K, L1 S3 J
the exposure was not for a prolonged period of time.: K7 `! |: h% n+ l& f; m
Although the bone age was advanced at the time of- q( t" X4 a% A5 w0 v5 |  {
diagnosis, the child had a normal growth velocity at
( `0 `  N4 |9 A: W( V* n3 u+ cthe follow-up visit. It is hoped that his final adult
. F7 X( i5 l  t: Z( y) Z& k% q0 X8 }. mheight will not be affected.
7 q5 E7 z, i/ f  Q4 h1 a& tAlthough rarely reported, the widespread avail-. b5 }5 A. x& i
ability of androgen products in our society may, Q; N6 |. M8 `1 l' ~) `4 q# f
indeed cause more virilization in male or female& }& F) {0 x2 |6 ~4 b' L( A
children than one would realize. Exposure to andro-4 Z. J- J' v. A$ `
gen products must be considered and specific ques-9 h/ Q& t- `/ N( Q! j5 a5 B5 f9 j
tioning about the use of a testosterone product or$ h* ~; J9 B7 O% K5 c2 q
gel should be asked of the family members during  s' [8 P/ J' d/ }8 t( W7 y
the evaluation of any children who present with vir-  [+ x# p( b9 k7 m  G
ilization or peripheral precocious puberty. The diag-! e6 q4 W; r$ s5 E9 c
nosis can be established by just a few tests and by2 ~  Y9 u$ v6 m7 K1 ?# n
appropriate history. The inability to obtain such a5 [& z& `; X' \* R! b0 K
history, or failure to ask the specific questions, may
5 c$ |8 D  r% ]9 |$ D) ~! Rresult in extensive, unnecessary, and expensive$ B2 v8 P8 {/ m7 e
investigation. The primary care physician should be
0 R+ b3 l0 Z/ \( r9 Y/ E- [. Haware of this fact, because most of these children4 _( S, T/ W- a' n, `1 \2 `! D
may initially present in their practice. The Physicians’
+ U' ~' k( s0 I- ^- mDesk Reference and package insert should also put a
0 e3 U" u  a- K* t, [% Xwarning about the virilizing effect on a male or
9 p' N4 B) a4 u* }" _female child who might come in contact with some-& v7 c) D5 s- [: E" k2 @, O
one using any of these products.0 w! N8 W: d8 n4 ^0 }
References
1 ~1 r$ x" Z4 r  |' P, y. _% Z1. Styne DM. The testes: disorder of sexual differentiation
, }/ f6 [% K0 aand puberty in the male. In: Sperling MA, ed. Pediatric5 c, @' E3 R$ N+ x9 O0 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 b+ \9 i; U4 `/ \0 {& r( I2002: 565-628." B0 M- {$ T( ]4 f: Y. v
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& [9 I' u6 [* [* E" E' J& X. ]/ \
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
3 |( \9 C) i2 LBoy Induced by Indirect Topical
5 e6 u. o! T6 R0 Z- X& r/ H! T# {Exposure to Testosterone
3 V  }4 ?' B6 U! SSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' R0 W5 ^, W: \! q( d* U  p* Q. Tand Kenneth R. Rettig, MD1
2 M/ j% t' \" |$ \7 O. l; eClinical Pediatrics. c3 Q) L8 g$ b2 x
Volume 46 Number 6
9 T7 U6 P1 s" A) o% d3 J+ FJuly 2007 540-543
. U( m5 }; ]# I+ P0 h8 U© 2007 Sage Publications# `8 W. t! Q6 E9 @' G& S
10.1177/0009922806296651+ W" c$ a0 R9 Z
http://clp.sagepub.com
2 I4 c+ M/ r1 @1 |( dhosted at
# u4 N2 z. T9 T. r( Fhttp://online.sagepub.com
. G; s2 e* U- ^/ S) {( DPrecocious puberty in boys, central or peripheral,
; `1 Q  x% I- _& lis a significant concern for physicians. Central+ {5 Y# N' B9 O! f
precocious puberty (CPP), which is mediated* N& a- O7 a2 P6 T2 c
through the hypothalamic pituitary gonadal axis, has" m& B0 k, |+ T& a
a higher incidence of organic central nervous system0 J' e$ I2 Q7 `0 r; q
lesions in boys.1,2 Virilization in boys, as manifested4 I, u/ P( U! ~7 [( b1 i
by enlargement of the penis, development of pubic3 ?: b: k7 }  w+ k& s) W8 W9 }4 R* v
hair, and facial acne without enlargement of testi-$ z! ?# [- D: h5 Y0 `+ l7 J
cles, suggests peripheral or pseudopuberty.1-3 We
) X8 r3 k) o  f: U0 Z$ ]% r, rreport a 16-month-old boy who presented with the
7 K6 x" H2 m' ]! _, I% T# Aenlargement of the phallus and pubic hair develop-
" L, l) G( v0 D. o+ g! h% Vment without testicular enlargement, which was due
+ N6 t: T. l7 {) R8 {+ {. Bto the unintentional exposure to androgen gel used by6 Q5 L6 A0 B  o" {4 z. p- n2 U
the father. The family initially concealed this infor-
2 N( T+ _" k8 w6 Mmation, resulting in an extensive work-up for this, f! @% _* l" R$ j" B
child. Given the widespread and easy availability of
$ U, D, m8 r  d: c; `! u, n- o( ~* ~5 ^" rtestosterone gel and cream, we believe this is proba-
/ p& p) h7 D! _0 Gbly more common than the rare case report in the
$ k: `5 P# G  m# |* Kliterature.4" V1 `! v, L! I# J" @
Patient Report
& q8 n! z. u3 K6 JA 16-month-old white child was referred to the
* p5 z- K) M: Q9 P/ L3 t/ Zendocrine clinic by his pediatrician with the concern
/ d3 a' H  f7 [8 Y& g9 uof early sexual development. His mother noticed
' V+ j6 `) ?2 M3 Olight colored pubic hair development when he was
/ d! ~. i1 R8 XFrom the 1Division of Pediatric Endocrinology, 2University of5 n* U, O* M* t1 I8 [
South Alabama Medical Center, Mobile, Alabama.  _! C. F6 Q/ W" J" H
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ w8 T4 w  i) J! D
Professor of Pediatrics, University of South Alabama, College of
9 o, _& o8 T4 t3 f8 yMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, C4 A4 ?% e3 P
e-mail: [email protected].
- [7 g0 d- W! Y7 X( kabout 6 to 7 months old, which progressively became  q0 J, g/ v0 m* n
darker. She was also concerned about the enlarge-
) M" z! {! }6 W% g" Kment of his penis and frequent erections. The child
9 x( B+ B& ^; K) ?! L2 ~+ {) M1 Z$ qwas the product of a full-term normal delivery, with' a4 b$ i1 p& K% h9 o9 a8 m# F
a birth weight of 7 lb 14 oz, and birth length of
8 w% i7 U; \0 e" T7 D( E. I20 inches. He was breast-fed throughout the first year; A. C' r5 f7 F9 c
of life and was still receiving breast milk along with
- ]" H0 \, o2 ?  V" m; r' {solid food. He had no hospitalizations or surgery,
7 o! |6 z% r1 aand his psychosocial and psychomotor development
; B- X8 n; \9 |& O5 ^was age appropriate.
0 C4 i  G* l7 l5 }- F: }The family history was remarkable for the father,- w, L6 i5 N: s% O/ E  H% p
who was diagnosed with hypothyroidism at age 16,
1 S  h+ y1 C) m, bwhich was treated with thyroxine. The father’s4 S" b- t- W1 A* f2 [4 R
height was 6 feet, and he went through a somewhat
8 w* z0 w" N: z* w0 h; I+ h6 vearly puberty and had stopped growing by age 14.
" I9 V+ X+ J3 S' }1 P" fThe father denied taking any other medication. The" ?( h/ `& e8 D' @, D6 q. b7 |
child’s mother was in good health. Her menarche, g) S- ?4 z3 w" t7 Y( z
was at 11 years of age, and her height was at 5 feet# w/ H. |+ D- w6 A2 m+ d
5 inches. There was no other family history of pre-
0 h+ J9 j; P; R) T  ]  r' l, ccocious sexual development in the first-degree rela-
/ l' Q8 M& U5 y- y0 F5 Ntives. There were no siblings.
  `  R. m1 U  IPhysical Examination9 r% @0 M& V# f. L$ T
The physical examination revealed a very active,
) H% L7 B5 v+ |7 ]) Rplayful, and healthy boy. The vital signs documented; ~+ B, N* P3 c
a blood pressure of 85/50 mm Hg, his length was
8 C" Q1 s( K6 T( ?+ ?90 cm (>97th percentile), and his weight was 14.4 kg
/ D, i3 v0 J" x* z* l(also >97th percentile). The observed yearly growth6 {- f& [2 u1 \
velocity was 30 cm (12 inches). The examination of( j$ X3 C) T( {- j1 ^1 C8 q
the neck revealed no thyroid enlargement.) k: c, v" l: X, X
The genitourinary examination was remarkable for
6 ?  ?! |2 ~. B4 \9 ienlargement of the penis, with a stretched length of
6 d  x9 j) y( W* p1 ^: Z4 B8 cm and a width of 2 cm. The glans penis was very well4 ], W+ ]0 P* A/ ^
developed. The pubic hair was Tanner II, mostly around0 M! Y8 p" N7 y; k: P0 Z
5402 t* m3 S$ `, u: U4 f+ B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 J3 a2 k2 u$ b" _5 mthe base of the phallus and was dark and curled. The
* [* a1 G) R, @6 C  ktesticular volume was prepubertal at 2 mL each.# h0 D* k$ t) G; R
The skin was moist and smooth and somewhat
$ _% |0 ~! z5 z5 D0 n7 joily. No axillary hair was noted. There were no
  O0 G3 u6 Y8 \, G, b. @8 P- Y' gabnormal skin pigmentations or café-au-lait spots.
1 R) v! z  b3 E( UNeurologic evaluation showed deep tendon reflex 2+( S2 ^9 o  Q2 k# R% [7 p/ n2 p
bilateral and symmetrical. There was no suggestion
+ g8 X& h9 s, r5 eof papilledema." N0 E9 L: z& @2 E" g
Laboratory Evaluation
0 i* o; B  R# d4 \+ ~# SThe bone age was consistent with 28 months by8 A0 W; @8 \* H" h( G: e
using the standard of Greulich and Pyle at a chrono-* v5 e) O& m. |6 a
logic age of 16 months (advanced).5 Chromosomal; R+ a, P6 y$ ~% H6 V
karyotype was 46XY. The thyroid function test- i7 g8 z- f) s- ~7 g3 \/ o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# a- M3 p9 i, e0 o7 s; Z) R* H
lating hormone level was 1.3 µIU/mL (both normal).6 ~9 D; m! u( }$ i7 z0 f# {
The concentrations of serum electrolytes, blood0 R% ^% m4 S. I, C. ~7 q
urea nitrogen, creatinine, and calcium all were
! N- Z8 }$ o" Y. M! `' Ewithin normal range for his age. The concentration
+ S% I- e/ r; ]9 qof serum 17-hydroxyprogesterone was 16 ng/dL4 F2 t% _- O& M
(normal, 3 to 90 ng/dL), androstenedione was 209 d5 C( g9 M3 Z  N. K1 x1 h* Y  I% u
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( B; s0 o( t% S# nterone was 38 ng/dL (normal, 50 to 760 ng/dL),( ]$ N. F/ a( ~  ~
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# j: x& Q0 S7 o) N6 D: S* ~
49ng/dL), 11-desoxycortisol (specific compound S)) U6 |# P. V9 M9 }# f) P' T- z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# m1 f+ p% e7 y. S" Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: `9 r! }) R3 w, J7 o3 Z$ jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- e9 ?' e% u6 U( g2 iand β-human chorionic gonadotropin was less than
. w" i* O2 ]0 v1 A5 mIU/mL (normal <5 mIU/mL). Serum follicular4 s' C( b( b( v
stimulating hormone and leuteinizing hormone
( e# l6 ]8 w$ s, V. mconcentrations were less than 0.05 mIU/mL1 a, Y' Y; w* p  s. G
(prepubertal).
9 v- |. O9 B  WThe parents were notified about the laboratory1 T  |4 [* I* {8 m( _" t; |: m
results and were informed that all of the tests were3 o+ m% G2 o+ Z0 Q% I- X
normal except the testosterone level was high. The0 _% q) r; A; d- x7 `% H
follow-up visit was arranged within a few weeks to
7 l0 p4 O- i& R1 E6 Sobtain testicular and abdominal sonograms; how-
- c6 f; o& X6 q9 o1 U9 \; ?+ i! iever, the family did not return for 4 months.
8 h7 j$ g+ W8 M" wPhysical examination at this time revealed that the! ?8 }7 V2 c8 y. @. h" t
child had grown 2.5 cm in 4 months and had gained2 x% R" ?! S2 `; m
2 kg of weight. Physical examination remained, }0 L( f  o* @' g' r, f
unchanged. Surprisingly, the pubic hair almost com-
0 p0 h, _. p1 ~5 i, Dpletely disappeared except for a few vellous hairs at9 ~1 n, z- M* Q6 W, H4 J$ b7 E
the base of the phallus. Testicular volume was still 2
9 _* s- i' n, A0 U7 XmL, and the size of the penis remained unchanged.* l! d5 e/ h' r9 p
The mother also said that the boy was no longer hav-0 l. B: F! l4 q/ Y0 R# V1 ~+ k
ing frequent erections.
3 z' {" U9 ]* Y; lBoth parents were again questioned about use of
7 H5 B! P, ?& }: a2 P0 rany ointment/creams that they may have applied to
- q' Q/ u% E; W9 x. Cthe child’s skin. This time the father admitted the
4 }& ~( e6 X( E/ ?. ITopical Testosterone Exposure / Bhowmick et al 541& r0 ^" j9 l7 v* `$ Q# k
use of testosterone gel twice daily that he was apply-
' N' f" X6 X9 `7 Q# V; g: cing over his own shoulders, chest, and back area for2 q6 c7 g# A/ t+ ]4 j7 V2 w! S! y' O
a year. The father also revealed he was embarrassed0 Y! n4 l; N8 X2 a  m
to disclose that he was using a testosterone gel pre-
; p2 u. n9 o5 u, E3 e$ K5 R: _% f) q$ tscribed by his family physician for decreased libido
5 T- `( v4 M) L' Osecondary to depression.6 R$ w# N* C: R: I4 C. `& v
The child slept in the same bed with parents.1 D2 P+ f. R$ z1 h$ }" [: u4 ~6 Y8 W
The father would hug the baby and hold him on his
& p0 v, B  r; u" u) Wchest for a considerable period of time, causing sig-8 L! n, v8 y/ T
nificant bare skin contact between baby and father.
5 Q9 o4 x. p6 c$ P0 G) g# C" LThe father also admitted that after the phone call,# d$ B' M5 e! i: x4 ]7 i; }
when he learned the testosterone level in the baby) C" h' j5 b) t2 o; m0 D4 Y" c
was high, he then read the product information
7 N; z( E( X! U7 d: j5 Z) P+ l1 R# @packet and concluded that it was most likely the rea-; E; w* x# G! r0 b! V
son for the child’s virilization. At that time, they! w$ d& X- b' ^1 D% L) k3 V5 {1 P4 |
decided to put the baby in a separate bed, and the6 w! b# m9 h4 S1 ?8 M7 |
father was not hugging him with bare skin and had
0 g8 B5 l: E# l. cbeen using protective clothing. A repeat testosterone& [! x  A3 @3 Z, g0 ^
test was ordered, but the family did not go to the/ R3 ?0 W- G) D8 C- Z
laboratory to obtain the test.
) g3 S  D$ K; C8 u, v. O5 K; K8 mDiscussion
+ ]6 S# j3 O8 N' |; E* RPrecocious puberty in boys is defined as secondary5 h$ C' W7 G/ B; K
sexual development before 9 years of age.1,4
/ }+ w2 _7 w! D5 Y( rPrecocious puberty is termed as central (true) when
: m+ I( |0 ^' V% _5 {it is caused by the premature activation of hypo-- t5 b4 G) x( N+ G2 }2 C, n
thalamic pituitary gonadal axis. CPP is more com-! t, ~: h% E1 i+ |1 N
mon in girls than in boys.1,3 Most boys with CPP
! E& \/ y& M  \8 L8 p& }may have a central nervous system lesion that is
& R9 v# b/ ?0 s+ E. vresponsible for the early activation of the hypothal-5 P7 _8 t1 ~0 I5 F* w" T1 k
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 D( f- g1 D; a' u) p3 m* ?sis has been given to neuroradiologic imaging in
9 {( h8 d+ c4 qboys with precocious puberty. In addition to viril-
. V# U6 {; s( h1 s2 g' pization, the clinical hallmark of CPP is the symmet-
8 g* W. n7 F) w  V2 _/ Arical testicular growth secondary to stimulation by+ S  Y' E) t. y/ n+ Q
gonadotropins.1,3! z: u& {* J9 Y. l; E( i9 _6 ]
Gonadotropin-independent peripheral preco-
* @& C" W6 `* I0 k" |cious puberty in boys also results from inappropriate
* o! N& C  h. Y4 R3 e1 ?androgenic stimulation from either endogenous or. ^9 y& R5 j$ r  c( K( O$ V8 p
exogenous sources, nonpituitary gonadotropin stim-
! F% H& H1 S# |* O  zulation, and rare activating mutations.3 Virilizing9 N: o' C& h4 z7 W9 {+ o  E* K
congenital adrenal hyperplasia producing excessive, p. v$ N( T) I( _4 p8 G2 R9 g2 p
adrenal androgens is a common cause of precocious
0 ]- X& @( q+ L6 rpuberty in boys.3,4
( z# |$ k% @% f; X! j; Q. TThe most common form of congenital adrenal
! V" A% {- f% s2 E; I- i3 M$ n- }hyperplasia is the 21-hydroxylase enzyme deficiency.8 R+ D0 ^7 _9 `& Z$ w6 K
The 11-β hydroxylase deficiency may also result in
8 h% T6 w4 m: c9 B. |3 s. k8 Lexcessive adrenal androgen production, and rarely,: L9 J, ^6 e3 }0 e3 x5 T! B
an adrenal tumor may also cause adrenal androgen: _& y- q1 C) M/ g- f, N1 y* @* X
excess.1,3; r- b' r' L7 z" j/ J  f& p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* H$ R" _2 j/ W' M# g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. U2 [2 v$ H) Y7 @* ~8 v
A unique entity of male-limited gonadotropin-, k# J3 W9 d  M: q+ z! R6 K4 t6 K- i: \
independent precocious puberty, which is also known" \' Z6 P2 o4 W7 S; e# B+ c1 R
as testotoxicosis, may cause precocious puberty at a* z6 E; M, r+ Z( R+ s$ j
very young age. The physical findings in these boys
$ U9 [5 X" j! V& P2 U: Mwith this disorder are full pubertal development,3 G. T0 t3 ]8 a0 r
including bilateral testicular growth, similar to boys0 @! Z5 V) k- J% y/ P
with CPP. The gonadotropin levels in this disorder+ B& d' F, _( Q' L$ ~
are suppressed to prepubertal levels and do not show
, A7 S) i2 U0 v9 i/ T6 b7 K+ xpubertal response of gonadotropin after gonadotropin-; u, B! {. D1 h7 d
releasing hormone stimulation. This is a sex-linked
3 K% ]; m+ D8 O) f+ q* ?autosomal dominant disorder that affects only
0 S) }1 h" }) a# Jmales; therefore, other male members of the family: G# H0 l7 ?5 o7 `6 m/ c( S
may have similar precocious puberty.30 m0 H$ m& Z, L% u$ H
In our patient, physical examination was incon-1 y2 v7 e; c1 ?% w& H  \5 }: S
sistent with true precocious puberty since his testi-% ~) u3 y- V0 o
cles were prepubertal in size. However, testotoxicosis
: R* |& N5 b$ b7 {9 dwas in the differential diagnosis because his father
; X: k# Y6 K' |0 t* qstarted puberty somewhat early, and occasionally,
4 h$ h3 M' H! O2 D5 h$ r3 Xtesticular enlargement is not that evident in the- @$ i0 l0 V: y( _  {: L6 k
beginning of this process.1 In the absence of a neg-8 A$ A# S! B+ j5 N6 I( N7 p  |
ative initial history of androgen exposure, our
+ D3 r: u" e3 E  T' w0 `biggest concern was virilizing adrenal hyperplasia,
; Z* }( m/ k3 p9 ]5 F# jeither 21-hydroxylase deficiency or 11-β hydroxylase9 u5 y4 L$ _* {0 y
deficiency. Those diagnoses were excluded by find-/ A$ R0 L- m1 J. x. o$ @
ing the normal level of adrenal steroids.9 J( }# I9 T: _- @% i
The diagnosis of exogenous androgens was strongly
4 W# f+ j1 a* ?/ E$ i6 Ssuspected in a follow-up visit after 4 months because
( S% b& }' B* m: V/ dthe physical examination revealed the complete disap-0 _; K/ M- z3 j# y9 K
pearance of pubic hair, normal growth velocity, and: B6 l9 G4 U1 i0 a
decreased erections. The father admitted using a testos-: g  p0 r. @' u5 ^2 C2 b
terone gel, which he concealed at first visit. He was1 H; x/ ]2 N9 {* D; ^; l! b
using it rather frequently, twice a day. The Physicians’! K- v0 C2 P2 W
Desk Reference, or package insert of this product, gel or( s. [. X3 u( _% u* ^' b4 Y
cream, cautions about dermal testosterone transfer to
' r5 N) C( W  Q' ~unprotected females through direct skin exposure.
) L7 d( a: N+ ?2 _Serum testosterone level was found to be 2 times the
/ W9 C: o& c8 x* _6 Rbaseline value in those females who were exposed to& E% o! F$ q* i, S% x
even 15 minutes of direct skin contact with their male2 P# |' B5 c% Q! l" j( Y: U
partners.6 However, when a shirt covered the applica-
+ f6 ^% T4 z* N# S' B+ @7 ktion site, this testosterone transfer was prevented.( \# S' Z) m; W+ s9 b$ O
Our patient’s testosterone level was 60 ng/mL,
/ S) I: e6 u1 N* Bwhich was clearly high. Some studies suggest that
5 k3 x9 ?9 I6 ^: s( ^- Ldermal conversion of testosterone to dihydrotestos-
* z0 P# W: h7 w; R, u0 q) [terone, which is a more potent metabolite, is more
8 n# `- {. S  a4 p0 X9 m% Mactive in young children exposed to testosterone
# c0 a1 q) @/ r* xexogenously7; however, we did not measure a dihy-6 P1 e5 F$ J8 D0 ]8 A
drotestosterone level in our patient. In addition to
' |4 N  b8 N6 ?% k- Nvirilization, exposure to exogenous testosterone in  @/ v8 X+ D/ x$ i9 h
children results in an increase in growth velocity and
& F9 k: J" v8 J5 l: j$ Uadvanced bone age, as seen in our patient.# `  p$ S! I1 v. _, B: ?# ~
The long-term effect of androgen exposure during
# H' x- C+ I: V6 j. Dearly childhood on pubertal development and final
4 G. G( D, h5 o" b6 @: d5 K, ladult height are not fully known and always remain% I4 E8 |4 U7 j" _8 E
a concern. Children treated with short-term testos-
+ T6 C4 z+ O, C. P& {+ gterone injection or topical androgen may exhibit some
1 a6 U: G. O  }: [. Facceleration of the skeletal maturation; however, after
0 Y/ M# w# g! a' w2 q- T4 rcessation of treatment, the rate of bone maturation
4 ~1 a( p. I/ T+ f4 Ddecelerates and gradually returns to normal.8,9% p2 y5 W, F& v/ \1 j" U* m/ F6 C
There are conflicting reports and controversy  Z0 p+ R  Z, [4 _
over the effect of early androgen exposure on adult1 I! D$ ?) N$ V$ Q' V
penile length.10,11 Some reports suggest subnormal9 Z4 b, W( j# E4 l3 b+ N7 {
adult penile length, apparently because of downreg-
9 X/ F" U* u1 p1 Y2 p$ n2 i" rulation of androgen receptor number.10,12 However,& M- L4 J; k( G6 U, t" d0 t7 l% ^
Sutherland et al13 did not find a correlation between
% w8 l  h. ^) p& L3 _; Rchildhood testosterone exposure and reduced adult
( o+ n' r- G: D, h# b- ~" K% upenile length in clinical studies.
6 \# e- E$ z3 l, w8 D: _2 dNonetheless, we do not believe our patient is: c' s) W! S2 _6 K3 ]. V8 E
going to experience any of the untoward effects from* \, C6 j. W, ]8 V1 Z" z
testosterone exposure as mentioned earlier because: e! Z/ i3 Q' c
the exposure was not for a prolonged period of time.# x7 J; w/ p  M5 J2 v- d
Although the bone age was advanced at the time of
* b9 g+ ^5 f$ D+ ~" C2 o; z* {diagnosis, the child had a normal growth velocity at3 j0 L/ P& v$ S" y% y
the follow-up visit. It is hoped that his final adult
  x7 q' q) H  }" Gheight will not be affected.
. K! b$ {: p' O1 h- uAlthough rarely reported, the widespread avail-
- @* j2 b5 G4 h- q$ @5 M8 Q. v. Wability of androgen products in our society may+ I+ f7 w' W( |1 g
indeed cause more virilization in male or female: [4 N% z$ q- X
children than one would realize. Exposure to andro-: ?2 Q, z2 T! w* }7 ~6 T% ^  E
gen products must be considered and specific ques-
( i% p2 g8 |1 Rtioning about the use of a testosterone product or
! L# k+ c' D* `: K0 pgel should be asked of the family members during
& Q7 Q' [! @4 ?+ Kthe evaluation of any children who present with vir-$ Z3 {  \( \9 g* Y7 b
ilization or peripheral precocious puberty. The diag-; n- I1 x6 F- e! k* J8 E
nosis can be established by just a few tests and by
% R+ R4 n8 r8 uappropriate history. The inability to obtain such a
& v. p. |6 o4 E' ?8 F" thistory, or failure to ask the specific questions, may
1 p% }) q" B" I) L+ A3 gresult in extensive, unnecessary, and expensive3 n5 h/ K' z# ~5 f
investigation. The primary care physician should be% Z2 t# s" e0 T) q& T/ V/ Y5 ~
aware of this fact, because most of these children
! J* D( L! G7 Q0 ^! A9 r* cmay initially present in their practice. The Physicians’" v6 v4 U/ _+ G! x
Desk Reference and package insert should also put a
7 I  Z1 E4 w- pwarning about the virilizing effect on a male or+ \! Q$ y2 q! W3 O4 f
female child who might come in contact with some-
9 \# a. U5 o4 o  {one using any of these products.
$ Y% L) z3 e' A; f) ?! vReferences$ Y# Z( O" Z- c; E. L7 N$ @) L
1. Styne DM. The testes: disorder of sexual differentiation
+ ~) p  A+ Y- `6 M) {: O( v* Band puberty in the male. In: Sperling MA, ed. Pediatric% U* w7 q& l* \; C( k9 c7 ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) n$ B) y6 p8 H6 w2002: 565-628.
' f1 N3 p0 t- Z" I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 r7 ^+ a0 V4 O2 D% X) Q. Q  }puberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
6 b: M$ H6 J1 Q' G% O6 j
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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