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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
0 H% Z, G  T9 o+ `* X0 eBoy Induced by Indirect Topical* B( ?; v* v; Y
Exposure to Testosterone
: i! o$ N3 k2 PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ ?" D: g6 Y6 Q& @
and Kenneth R. Rettig, MD1* G: x, @$ m8 a$ j+ h* O; {
Clinical Pediatrics
* j5 L6 k$ @. T: c% HVolume 46 Number 6
: i, O: U0 W) i6 k: q5 e% AJuly 2007 540-543
6 Z0 l. i# Q8 [1 i  P© 2007 Sage Publications# r) e& e7 {4 Q, ?
10.1177/0009922806296651
+ P) {" h/ Y3 K/ S0 khttp://clp.sagepub.com
1 L8 `! l& I2 m- l: ]hosted at
6 U' d5 u6 X8 S5 m$ B0 L( khttp://online.sagepub.com
5 B9 C$ a1 z( p% BPrecocious puberty in boys, central or peripheral,: u4 j" v0 I8 ~# T
is a significant concern for physicians. Central
% [: c: I1 |2 ~4 u) w, pprecocious puberty (CPP), which is mediated5 B$ V! u2 {/ V3 I
through the hypothalamic pituitary gonadal axis, has
- G- q% p8 V& ha higher incidence of organic central nervous system
) c; N( @9 _2 g3 Ulesions in boys.1,2 Virilization in boys, as manifested
* w* f# U/ [6 o2 F- K9 F" wby enlargement of the penis, development of pubic
" m  w! {) ]& X8 P4 Chair, and facial acne without enlargement of testi-
! {+ {4 r6 x+ k3 |! P- |3 vcles, suggests peripheral or pseudopuberty.1-3 We7 V( [6 v( U5 `( I  }, [
report a 16-month-old boy who presented with the
4 M# |- P7 ^. `7 w' ^" senlargement of the phallus and pubic hair develop-
6 j" A/ G. U4 ^. `' ?/ yment without testicular enlargement, which was due, r" {+ N/ W' o7 m1 t) h/ u! Y8 j$ h
to the unintentional exposure to androgen gel used by# D( |8 i/ O2 A6 N" g& L" b
the father. The family initially concealed this infor-
# t8 X( O3 Y# P) e3 A  X6 c% F. v8 Vmation, resulting in an extensive work-up for this
# y0 z; S; C- s; }$ c, ^) o% Schild. Given the widespread and easy availability of  T" B' h$ c1 V6 C! b
testosterone gel and cream, we believe this is proba-% ^4 P5 D; H7 r: @0 z
bly more common than the rare case report in the
" c7 k8 _- x4 ?/ q/ xliterature.4* Y/ _6 v3 q1 T- S' o7 {
Patient Report
( L; g" H0 A! p* FA 16-month-old white child was referred to the
9 ~' T, y( i# i% jendocrine clinic by his pediatrician with the concern
3 X! _* U% {/ }of early sexual development. His mother noticed. U3 n5 w7 b& o, ?5 d8 V$ F2 L
light colored pubic hair development when he was) f" e/ Q) R. Y; d: I, B+ ]
From the 1Division of Pediatric Endocrinology, 2University of% n* c0 W- W1 j* N# G
South Alabama Medical Center, Mobile, Alabama.
% o# Z) X6 g; t/ bAddress correspondence to: Samar K. Bhowmick, MD, FACE,; |3 q. ?3 Y* l2 F
Professor of Pediatrics, University of South Alabama, College of7 b7 z  S) G, g3 x- e/ B" c1 N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( {& d, `; L. H; k) j7 O. `
e-mail: [email protected].9 f- V7 n0 T# u; C/ ]
about 6 to 7 months old, which progressively became
4 U# P6 B' O: s. y, V; i: [darker. She was also concerned about the enlarge-
3 O& a( t% o5 ~7 [1 u0 ]ment of his penis and frequent erections. The child
1 f( Z8 I, F$ |% e. Wwas the product of a full-term normal delivery, with
0 Y- {: E+ P# p  S- m0 E! Ha birth weight of 7 lb 14 oz, and birth length of; [: Q. ?- ^* _9 L8 z' \9 Y: {
20 inches. He was breast-fed throughout the first year
$ d" x6 \; `5 I& x" N5 Nof life and was still receiving breast milk along with( Z7 ]  S& G+ c8 h! @+ t7 p3 e
solid food. He had no hospitalizations or surgery,) U6 Y; k! t" F" Z" k, Z1 ^3 r+ Z. U
and his psychosocial and psychomotor development& k0 x) y: n9 m8 \3 f
was age appropriate.: ]% e4 o4 D( o# f/ E% O# L
The family history was remarkable for the father,
) v2 W% f9 }: ~7 i5 C- hwho was diagnosed with hypothyroidism at age 16,
# k6 e2 W8 D, c  Twhich was treated with thyroxine. The father’s
6 d! O1 c2 P  q( N7 Q) sheight was 6 feet, and he went through a somewhat! i+ `5 B, O$ B) d
early puberty and had stopped growing by age 14.
, U0 s9 J0 q( j- h6 L7 L$ W+ CThe father denied taking any other medication. The5 B( C( y/ V- }0 S; ~# x1 {. q
child’s mother was in good health. Her menarche
7 c% d# [' o) i6 zwas at 11 years of age, and her height was at 5 feet& ?# Q+ E  F. b" Y
5 inches. There was no other family history of pre-0 O% F" F( _- c0 j- P) K
cocious sexual development in the first-degree rela-. n% s! `" s0 Z
tives. There were no siblings.
  N6 a& V- Y: N& P2 x& P0 \7 zPhysical Examination
& n6 L: {$ T& z" V  q$ N- O* DThe physical examination revealed a very active,
$ n" u. ^; m0 ^+ Z* Xplayful, and healthy boy. The vital signs documented* I' q! s' J; C* p2 V) d% ^
a blood pressure of 85/50 mm Hg, his length was! w" l9 \+ F* a7 r: g1 C
90 cm (>97th percentile), and his weight was 14.4 kg2 d9 a/ K' \, U
(also >97th percentile). The observed yearly growth/ d. X) |0 ?2 F# W1 T5 C
velocity was 30 cm (12 inches). The examination of
' T0 ^. [3 Y( _2 Nthe neck revealed no thyroid enlargement.
. q1 V, k2 ^. ^" }5 TThe genitourinary examination was remarkable for
# Q1 a# r+ j7 kenlargement of the penis, with a stretched length of! \2 N+ A: p# G2 V! c, z
8 cm and a width of 2 cm. The glans penis was very well
! Q* }& E- U% J: M( Vdeveloped. The pubic hair was Tanner II, mostly around
2 z& d6 u; x, {4 i540
) \) Y9 U2 m5 I6 M$ Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- j1 }& y2 a( O2 `
the base of the phallus and was dark and curled. The
/ s% E# T  H5 otesticular volume was prepubertal at 2 mL each.. X4 n1 K. Y# P# F& E& K% d
The skin was moist and smooth and somewhat7 V) N) }5 c. Q) x3 E, f9 W
oily. No axillary hair was noted. There were no
1 U6 E3 h% t1 F( uabnormal skin pigmentations or café-au-lait spots.
* v6 W" v6 d' \; ~: `- }  t  zNeurologic evaluation showed deep tendon reflex 2+" M1 L, v9 |% U. m
bilateral and symmetrical. There was no suggestion; g' Z) M5 e& N
of papilledema.7 b) A" l- P4 `. X
Laboratory Evaluation
. H3 o% Z- j" I# q/ P0 J3 NThe bone age was consistent with 28 months by
, c6 y0 z% x! s" q; zusing the standard of Greulich and Pyle at a chrono-6 ?  R) l$ b7 c, u
logic age of 16 months (advanced).5 Chromosomal
& l. J, u1 h8 c  f1 L8 dkaryotype was 46XY. The thyroid function test; @: L* O; H5 W2 E) g6 o* X% L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* b6 ^, u. f" v8 y2 }2 A; J; }
lating hormone level was 1.3 µIU/mL (both normal).# W# w/ \: I' N- J
The concentrations of serum electrolytes, blood
& o# E$ j1 M. P7 B1 L) iurea nitrogen, creatinine, and calcium all were/ [* B; y+ w; u% c3 y0 `, n8 \3 e
within normal range for his age. The concentration
. \  b3 ]5 c8 ^" l: s; Uof serum 17-hydroxyprogesterone was 16 ng/dL" ?7 \- N3 D" K! V) j
(normal, 3 to 90 ng/dL), androstenedione was 20
( x6 \  P1 D5 i8 M7 ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* |; l( O2 U" T! O* S. O1 \% xterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 F; g% \. |; G' [% X: `" y- N6 y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: G$ W* l; _6 F# x5 c! n
49ng/dL), 11-desoxycortisol (specific compound S)2 s# D1 p! K+ x& C" q" W' y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 P$ Y3 m; P# f! h) O( V% ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- p8 @1 K/ K( R7 Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( ?' W& J* y& v, j- a6 ]7 Yand β-human chorionic gonadotropin was less than
+ M3 u+ v5 ^& M9 o- ]4 ]' J7 V5 U5 mIU/mL (normal <5 mIU/mL). Serum follicular
, N. }; K6 i1 Bstimulating hormone and leuteinizing hormone
  q! U/ K# h, l# jconcentrations were less than 0.05 mIU/mL
8 _. X1 [3 \+ q) o: h4 }(prepubertal).# H/ v& c; ~3 {, i6 v4 ?. G; S
The parents were notified about the laboratory1 g" O( k" I7 C+ Z4 l: n/ @% y6 R7 U
results and were informed that all of the tests were6 q7 t) p$ c: m) r( P9 W5 H% ]6 v
normal except the testosterone level was high. The2 N. n* _5 K2 c5 f
follow-up visit was arranged within a few weeks to7 k/ c8 y$ u2 }" ]
obtain testicular and abdominal sonograms; how-
2 F; |6 h$ g$ g7 d3 [& A+ I" wever, the family did not return for 4 months.
4 ]+ V) H$ A4 b: y5 b6 D) JPhysical examination at this time revealed that the; ~1 q/ ~) ?8 c2 d6 q9 u
child had grown 2.5 cm in 4 months and had gained% F' p- L3 M8 q) v' O5 g
2 kg of weight. Physical examination remained) k  n2 J: N+ e. v
unchanged. Surprisingly, the pubic hair almost com-1 C" A/ c/ \- R* T  i1 j/ h
pletely disappeared except for a few vellous hairs at
& b- O9 J- L- P7 h+ }/ wthe base of the phallus. Testicular volume was still 2; R6 |0 W7 S% e/ S/ O
mL, and the size of the penis remained unchanged.
6 M2 ~0 U, \2 Q  U! b; ]% YThe mother also said that the boy was no longer hav-$ A7 t. U3 |) d" s+ R
ing frequent erections.
% c2 L7 F6 T- R2 F& c7 ]+ B' O2 eBoth parents were again questioned about use of+ F2 Z& R8 V2 z2 T: x
any ointment/creams that they may have applied to
2 N% }0 }, F3 c/ E& ?8 n" ethe child’s skin. This time the father admitted the$ Z3 @* _+ q3 E" ~- d
Topical Testosterone Exposure / Bhowmick et al 5419 Q; r% k+ x% t! a- ]
use of testosterone gel twice daily that he was apply-$ ]; m- O& n9 J2 Q% V
ing over his own shoulders, chest, and back area for
. A+ U( S  _* O& ]/ w% ya year. The father also revealed he was embarrassed% V! `& a- E* O$ B& F
to disclose that he was using a testosterone gel pre-
+ f! ^, [# n+ @/ `/ P7 Bscribed by his family physician for decreased libido
! i8 L- \8 h! A  Y. b8 Dsecondary to depression.9 t' f/ X" v4 U# ^. c
The child slept in the same bed with parents.% V# b7 L& w, D& m- d; X! H3 Y/ L/ C
The father would hug the baby and hold him on his4 ^4 q( f" l8 }# \
chest for a considerable period of time, causing sig-
# F" N" I% X3 nnificant bare skin contact between baby and father.6 l) _7 ]9 n4 H2 @) K
The father also admitted that after the phone call,* d/ z4 n  R$ G) e5 w6 F0 z+ G
when he learned the testosterone level in the baby8 Y7 x- @8 H& S, e
was high, he then read the product information
& L: b6 F* ?% G, j% W1 D  H! p) }packet and concluded that it was most likely the rea-
0 {1 a+ L% l# a5 Xson for the child’s virilization. At that time, they
7 h* @1 q/ F2 Z- k/ {$ O3 f1 _decided to put the baby in a separate bed, and the* U' S9 A+ W/ `8 Z9 g3 c
father was not hugging him with bare skin and had
) J6 E4 E3 V' u  J5 g7 r; e7 Kbeen using protective clothing. A repeat testosterone
% p  V. b6 Z7 M/ utest was ordered, but the family did not go to the
* \4 T! ^; t5 S0 i) v3 f3 }- ]laboratory to obtain the test.
* z% O3 S+ R2 ~8 H7 R  j8 N2 PDiscussion
$ K1 Q# P0 w! f+ G8 B' qPrecocious puberty in boys is defined as secondary& N- k. O4 M' h! {5 u" H$ P
sexual development before 9 years of age.1,4
1 A* u* p# d, n' cPrecocious puberty is termed as central (true) when( O6 w$ F8 j7 w. ]1 S
it is caused by the premature activation of hypo-: E% K' i% \( n. h' @, `7 a
thalamic pituitary gonadal axis. CPP is more com-
* H# ~; L% g1 P8 R, Umon in girls than in boys.1,3 Most boys with CPP
% ?0 F  W) I) v2 H+ amay have a central nervous system lesion that is) |. D0 @, }% w1 G& O6 R' r
responsible for the early activation of the hypothal-
; m( V2 M7 Y6 W, ]  ], Pamic pituitary gonadal axis.1-3 Thus, greater empha-$ f, v1 a* _4 n: \+ N' Z, s
sis has been given to neuroradiologic imaging in+ ?6 k5 x* C) E! C- W& U/ _
boys with precocious puberty. In addition to viril-
0 u5 B; f' \* H, A$ Vization, the clinical hallmark of CPP is the symmet-
) l+ O6 Q  ^) f- h$ hrical testicular growth secondary to stimulation by7 L; q& ?. Z4 d' s
gonadotropins.1,30 {+ Q* ?1 C3 E! r/ |* N/ l
Gonadotropin-independent peripheral preco-
7 ~# A) {% D! C0 F. @6 x3 Rcious puberty in boys also results from inappropriate
4 y/ e4 u: [1 _  n, Randrogenic stimulation from either endogenous or
7 Z2 R' L8 i; F" o9 |4 kexogenous sources, nonpituitary gonadotropin stim-
& p0 f6 M8 J( w0 K' tulation, and rare activating mutations.3 Virilizing/ h7 s( Q, l% R2 Y1 c8 R+ P9 m& C; k
congenital adrenal hyperplasia producing excessive, |# G/ N! g! z
adrenal androgens is a common cause of precocious6 w- f$ W* ]( Q' P
puberty in boys.3,4
8 {+ E! G$ F4 }5 AThe most common form of congenital adrenal
$ j: I% E. R; l( N' P1 k; Chyperplasia is the 21-hydroxylase enzyme deficiency.1 c% E% e: a: n6 Y6 l2 S
The 11-β hydroxylase deficiency may also result in
2 C, C/ Z% o7 nexcessive adrenal androgen production, and rarely,1 `: L9 ~. Y7 @7 H: V- J; ]. ~, W
an adrenal tumor may also cause adrenal androgen
" a3 K) D) `' X2 Qexcess.1,3
" d" q/ E$ b* C( v2 G3 O: y% f4 l- Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; _" N2 q/ ~  h$ n) S8 c/ A6 D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! n  e3 j* h- B9 ?% h' o3 i
A unique entity of male-limited gonadotropin-& I( W0 b4 {% _, I8 P* q; a
independent precocious puberty, which is also known
& G/ t% J- |) i" N2 R  N. n; Las testotoxicosis, may cause precocious puberty at a
) E( P: G- E, o2 b, Gvery young age. The physical findings in these boys
( _5 F+ p. j4 K% n" C- swith this disorder are full pubertal development,; O9 c0 e3 H7 B4 F8 E- L) U
including bilateral testicular growth, similar to boys/ L5 v$ _$ ?7 y$ s! X/ k. y
with CPP. The gonadotropin levels in this disorder  m* b% x9 i6 I: q) x; Z
are suppressed to prepubertal levels and do not show9 t5 R/ Z6 J+ s4 p& s
pubertal response of gonadotropin after gonadotropin-  I/ W" F- B% S8 A7 V. _
releasing hormone stimulation. This is a sex-linked. s: e$ A, M1 I  \% a' z
autosomal dominant disorder that affects only& s0 |/ x( z; `8 b& @
males; therefore, other male members of the family
6 q* \0 x% W( F8 pmay have similar precocious puberty.3
" |- T8 @9 x' W3 s0 {; [% B0 k* mIn our patient, physical examination was incon-
0 X( i4 u' E$ {; c" X9 Tsistent with true precocious puberty since his testi-, U6 U6 P% g4 o2 q% u: o
cles were prepubertal in size. However, testotoxicosis0 C6 H* y# b$ _5 \; e) d* e: X3 F
was in the differential diagnosis because his father
4 a  y0 w* A3 W- \' v3 Ostarted puberty somewhat early, and occasionally,2 J+ k7 Y9 f/ i$ y) ?% ^  g; s  G
testicular enlargement is not that evident in the; Z9 L/ u& P6 H$ I
beginning of this process.1 In the absence of a neg-! x7 ]& j: b, r
ative initial history of androgen exposure, our0 v/ Y' g# m7 M  L2 ^
biggest concern was virilizing adrenal hyperplasia,$ P7 o8 p# x5 {
either 21-hydroxylase deficiency or 11-β hydroxylase- V7 Y- Q/ K6 J+ g; B- x
deficiency. Those diagnoses were excluded by find-
* d) S- }4 Q4 V8 i2 W2 r& Ming the normal level of adrenal steroids.( i$ @0 t# _# k
The diagnosis of exogenous androgens was strongly, N# s2 |9 C1 Y8 g& e
suspected in a follow-up visit after 4 months because
1 _7 v1 f" ^9 x( a, a' L( Z; ^the physical examination revealed the complete disap-0 R. @4 {' i% c, S
pearance of pubic hair, normal growth velocity, and
# z! _! i  V; I, l& D. b7 ldecreased erections. The father admitted using a testos-% R: K" {1 }0 R& b0 v/ a$ z
terone gel, which he concealed at first visit. He was
3 v8 M" K( K: busing it rather frequently, twice a day. The Physicians’& Z3 f; w5 E0 B
Desk Reference, or package insert of this product, gel or9 P0 Y+ Q# J7 E) I- B$ ]# W
cream, cautions about dermal testosterone transfer to* w6 \, _4 j- K& T; t1 `
unprotected females through direct skin exposure.' N! a: L, ^/ E. p5 j; Y
Serum testosterone level was found to be 2 times the
# Y+ n" g% X- Q7 vbaseline value in those females who were exposed to  d! I% @' T5 q6 |1 m% E6 x
even 15 minutes of direct skin contact with their male& Z/ v- U1 Z/ ], W4 e
partners.6 However, when a shirt covered the applica-3 k- }6 @! g; H
tion site, this testosterone transfer was prevented.
2 E8 g7 p3 x# LOur patient’s testosterone level was 60 ng/mL,
' D/ T0 K# z/ a1 Z$ qwhich was clearly high. Some studies suggest that7 s% h" g) Q' E  E$ }
dermal conversion of testosterone to dihydrotestos-
& ~$ o' G) d5 D$ mterone, which is a more potent metabolite, is more6 @: l! M$ z% `
active in young children exposed to testosterone
# M$ D- _5 r. d& k9 H# V, ^exogenously7; however, we did not measure a dihy-
& v) B) t: w/ \7 K! ?drotestosterone level in our patient. In addition to
0 p% S1 A, N6 ]; e' x' vvirilization, exposure to exogenous testosterone in
, R) ~0 U7 R3 H' \  q: g; G! Cchildren results in an increase in growth velocity and: E% z. ~' H1 U) X/ g
advanced bone age, as seen in our patient.
7 x) U9 A( l  B0 c1 eThe long-term effect of androgen exposure during
; ?% p9 N" g! p7 n6 bearly childhood on pubertal development and final- u8 ~# A, L3 W1 _
adult height are not fully known and always remain
$ W2 s' V8 s# K( ]3 qa concern. Children treated with short-term testos-
/ P  n3 u& Z; Z% H& K3 i7 ]terone injection or topical androgen may exhibit some
% e& b- |: K+ O6 _; Q& T" }acceleration of the skeletal maturation; however, after0 z$ r7 K4 ]* g5 i2 r
cessation of treatment, the rate of bone maturation5 c2 Y# u' O. n+ l* i; U/ Y) W/ ^
decelerates and gradually returns to normal.8,9/ {7 y# n9 s+ a( P+ r/ G
There are conflicting reports and controversy
* X( |) r0 o# \1 c, Hover the effect of early androgen exposure on adult
( q" M+ E8 g4 ?5 q/ {penile length.10,11 Some reports suggest subnormal1 O4 ]) A6 J& \/ @- C
adult penile length, apparently because of downreg-
" t3 |+ w* }5 e" [3 X8 K% m- {6 ?ulation of androgen receptor number.10,12 However,
9 O6 c# `8 r: xSutherland et al13 did not find a correlation between
: T$ V' R- y) y4 E) N& @+ v; @" Lchildhood testosterone exposure and reduced adult& g. a- d' e/ Q! @! O3 s
penile length in clinical studies.) |9 c! P! G* }8 m) d0 r; c
Nonetheless, we do not believe our patient is
" p9 O) C0 c8 ~( a4 Jgoing to experience any of the untoward effects from
- k( @! N0 r7 \9 t' s; Etestosterone exposure as mentioned earlier because
; i4 Q' f2 Z, Mthe exposure was not for a prolonged period of time.# Q5 _: {* e" V$ `/ O5 u! }# i: S4 g
Although the bone age was advanced at the time of
8 p- V' [; n$ `7 `" p4 Adiagnosis, the child had a normal growth velocity at
, F0 G1 j2 [8 e/ L; dthe follow-up visit. It is hoped that his final adult  E: e  V$ u9 _1 \! F5 Q0 R
height will not be affected.* j. n! p! W4 x. |$ q2 y
Although rarely reported, the widespread avail-
$ ]2 U  M/ X$ b$ ]1 {7 gability of androgen products in our society may$ K7 O" N/ D' C
indeed cause more virilization in male or female* ^/ E% D( z. [  o+ j! q( D
children than one would realize. Exposure to andro-
/ Q9 l/ s7 [0 D" n/ [. t& n6 Ngen products must be considered and specific ques-
2 r3 h+ z- ~, @tioning about the use of a testosterone product or
- z/ Q/ X" g. a+ i6 w% d' v- cgel should be asked of the family members during" i# M6 L5 b4 \, \1 P' Y
the evaluation of any children who present with vir-% |# l( ~  n- q% h* f
ilization or peripheral precocious puberty. The diag-! w& Q( |6 R! d8 l& ~
nosis can be established by just a few tests and by
6 Y# }+ b$ J/ R' L2 e+ Q4 S! |  Rappropriate history. The inability to obtain such a; \. W/ t# m2 Q
history, or failure to ask the specific questions, may
6 w5 T& Y5 l' i" Jresult in extensive, unnecessary, and expensive) |+ O3 a( y/ N4 m. D; ?8 u  H
investigation. The primary care physician should be2 c" U( U$ A' j; J6 F& Y
aware of this fact, because most of these children
) p9 Z; Z9 ~& B. [3 G9 Tmay initially present in their practice. The Physicians’" c! s0 r: O/ r% S8 L; l
Desk Reference and package insert should also put a: f( s8 K* F  V. c7 n- z& s
warning about the virilizing effect on a male or
5 T/ E2 w  K+ V3 \  Q" x) v0 qfemale child who might come in contact with some-
/ ~1 I6 `8 G2 `5 Q( u5 v2 z1 N. sone using any of these products.5 J: R, T3 U) f5 Z, E: L- v+ v* q
References
+ V+ ]1 v! ^: }- s9 \1. Styne DM. The testes: disorder of sexual differentiation
7 Z) _/ i; M1 f, Land puberty in the male. In: Sperling MA, ed. Pediatric! J5 d5 \' M/ ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 t# m2 u% N8 H0 p! V# i* ?
2002: 565-628.9 `, O' E, f, W# X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! s4 L9 {( v2 ~" L* S
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old  B6 N. L4 a, h2 P. }
Boy Induced by Indirect Topical5 T* j  E8 l1 Y) g$ d
Exposure to Testosterone
+ z1 o. n7 i# gSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* e4 [# o! C! Pand Kenneth R. Rettig, MD1# U* p# O( [. q7 d, {
Clinical Pediatrics
9 G  E5 n1 z# }2 f7 [Volume 46 Number 64 Q! ?6 i, t/ K2 b. f
July 2007 540-543& Z& _; b  g" U! B1 L
© 2007 Sage Publications
5 A! i# B. i7 I) s10.1177/0009922806296651
. g7 Z% l* A. {. |( T1 G" Z' p5 }2 Dhttp://clp.sagepub.com: u- W  m6 j! G/ r6 ~
hosted at
$ h5 I) O3 K2 `8 \3 Ohttp://online.sagepub.com
7 Q& m1 r1 S4 i3 `" a0 RPrecocious puberty in boys, central or peripheral,
2 O% p& D  T" {8 F% Y$ C7 `4 qis a significant concern for physicians. Central
: U1 {% Y, |# h  q$ D5 ?: Wprecocious puberty (CPP), which is mediated/ y, l6 k- g9 B5 x4 H- V. p& Y
through the hypothalamic pituitary gonadal axis, has3 \" V8 ]# D9 i
a higher incidence of organic central nervous system9 V! C  {# `. E9 h0 N* p
lesions in boys.1,2 Virilization in boys, as manifested
7 \  b3 t- x( ?by enlargement of the penis, development of pubic
& c  t6 a# n  a5 f2 ihair, and facial acne without enlargement of testi-3 |- R8 C: s0 y4 D# l
cles, suggests peripheral or pseudopuberty.1-3 We; s9 E% u7 K+ [
report a 16-month-old boy who presented with the$ j( Y1 h) }5 R9 W" h* a- b& J
enlargement of the phallus and pubic hair develop-
8 r7 U# K' x; s/ `+ \! E6 Vment without testicular enlargement, which was due
! F0 M( M% u8 {- t7 bto the unintentional exposure to androgen gel used by$ \! ~- [, V+ g* V* e+ r
the father. The family initially concealed this infor-6 ~; ?* F7 Z/ B' a
mation, resulting in an extensive work-up for this
- i2 Q; Z( L% ?' Achild. Given the widespread and easy availability of: a$ V- Q' Q; @( v; N  D: K$ U; \
testosterone gel and cream, we believe this is proba-: v- p0 F; b" [# }  {* s
bly more common than the rare case report in the0 O, Q& M) E3 F+ U
literature.4  {. k' i' E0 m0 n
Patient Report
' h# }* e% v' qA 16-month-old white child was referred to the- d8 c$ Q& `/ D; ?9 U
endocrine clinic by his pediatrician with the concern% p: J+ s; J$ H
of early sexual development. His mother noticed& [% A& d/ E, O& ]! ]5 q- Q
light colored pubic hair development when he was1 [; z3 f- Y  v) R5 f
From the 1Division of Pediatric Endocrinology, 2University of
  U2 X; v' h. a# KSouth Alabama Medical Center, Mobile, Alabama.2 U/ Q+ M$ g* \/ n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
  _: t) _; e1 g5 `Professor of Pediatrics, University of South Alabama, College of" K* U$ i# s. G* p
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  f& m, ?. D/ l( V0 V' z9 Ye-mail: [email protected].& Q1 m; \& ]- h: {
about 6 to 7 months old, which progressively became9 K0 i4 C7 J, _4 ?; g  ~
darker. She was also concerned about the enlarge-
- M1 r' @' ~/ r" p; P& T; Mment of his penis and frequent erections. The child
; [: Z( X7 u4 q5 G6 F; U0 p8 jwas the product of a full-term normal delivery, with" F! a/ Q& V; r& p% \3 @! f  b4 e
a birth weight of 7 lb 14 oz, and birth length of
; V& I( j7 S: V2 W; L% J0 }20 inches. He was breast-fed throughout the first year
) ]; \6 E. G5 x/ a2 V* u' jof life and was still receiving breast milk along with
; g6 j1 G: r$ P# w; E8 |/ R' e- Fsolid food. He had no hospitalizations or surgery,# ?% [3 u9 O* U& ]: f) V8 Y
and his psychosocial and psychomotor development1 b7 M' Y; c9 e1 l1 M( w9 D
was age appropriate.( x4 O& n+ G5 q/ u, K( Q
The family history was remarkable for the father,+ {- s& F0 _, y8 T/ @
who was diagnosed with hypothyroidism at age 16,
, n7 n" ^# @$ R6 hwhich was treated with thyroxine. The father’s  |' f2 f. j! c
height was 6 feet, and he went through a somewhat
! N# t1 P6 e. V0 V, ~early puberty and had stopped growing by age 14.' A& D; i' L5 t2 [3 Z( E$ b4 `$ r
The father denied taking any other medication. The; d  P* l. F& y* m4 r& y, R
child’s mother was in good health. Her menarche& ^0 Z8 g/ E( d/ Q# C
was at 11 years of age, and her height was at 5 feet
$ z, B2 _! G3 f# x+ h+ S, }5 inches. There was no other family history of pre-
2 [" u: K9 N' r7 @cocious sexual development in the first-degree rela-0 t' d; \; H# ]8 m' D2 N
tives. There were no siblings.+ D0 P% K5 T  b1 F1 ^$ T' X
Physical Examination$ U; G: K) s. h* v
The physical examination revealed a very active,- E1 L" S( i, v+ F3 B: q2 H# _
playful, and healthy boy. The vital signs documented& R; t, O- a: Q! v7 F
a blood pressure of 85/50 mm Hg, his length was' O) g8 Q% E2 M- w5 U- m8 N
90 cm (>97th percentile), and his weight was 14.4 kg* q5 M) v- d+ x( F; j0 K9 S- L
(also >97th percentile). The observed yearly growth
# v3 X* f6 A! \/ b! B+ J) kvelocity was 30 cm (12 inches). The examination of
* Y/ Z4 ~0 D5 n7 x0 Y7 J% R8 Ythe neck revealed no thyroid enlargement.- [# u+ K( o% E5 a6 y/ g' h; h
The genitourinary examination was remarkable for2 ?8 H& l( `) P
enlargement of the penis, with a stretched length of1 q: y" m% o5 ~8 Q7 M
8 cm and a width of 2 cm. The glans penis was very well) w- L2 c2 T/ g0 z! f! _) o0 o
developed. The pubic hair was Tanner II, mostly around) m. G$ ?0 `- N9 [% n( V; ^# g/ `
540, }6 i% R/ G5 u6 z6 a4 q- I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; `8 Q5 ~) O- ythe base of the phallus and was dark and curled. The$ \& \- T" U5 ^+ F1 M6 D+ H) S
testicular volume was prepubertal at 2 mL each.
  D# i* o6 {& n+ MThe skin was moist and smooth and somewhat
& E& ?! D2 v- yoily. No axillary hair was noted. There were no, ^. D. P/ _% D% E( A  ?' X6 d
abnormal skin pigmentations or café-au-lait spots.
5 Z* b# q8 }5 W$ o; RNeurologic evaluation showed deep tendon reflex 2+1 ?. D( m6 g: e2 z
bilateral and symmetrical. There was no suggestion0 ]! M+ h4 q& C! @! k" V: ]
of papilledema.
. f$ {- j! M+ r" Q' n( xLaboratory Evaluation
6 [+ ?" W! O9 X+ }4 QThe bone age was consistent with 28 months by0 m" f& q, ~, U2 G4 f7 a! G
using the standard of Greulich and Pyle at a chrono-/ T5 e7 ^# B2 p5 v& `$ M4 R
logic age of 16 months (advanced).5 Chromosomal' D) [6 }. K& ?6 F; Z
karyotype was 46XY. The thyroid function test; o( o! q1 E1 l& S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 }& ]. W3 D+ a2 ?  wlating hormone level was 1.3 µIU/mL (both normal).5 _! u+ Q% \4 m) h" ]. F5 D6 L
The concentrations of serum electrolytes, blood8 O3 u5 P) p2 L
urea nitrogen, creatinine, and calcium all were* V, J6 f0 |8 `6 b4 P
within normal range for his age. The concentration; J) A( {, o2 K- X/ J& |8 _
of serum 17-hydroxyprogesterone was 16 ng/dL) l/ u4 g3 H1 m- q( F
(normal, 3 to 90 ng/dL), androstenedione was 20
1 r8 H2 k# \8 l3 _$ M7 Q- x  Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 |4 i2 k5 x2 bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; v7 e* W& @9 N9 K. B% g) @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* k/ B5 }# a  h# M3 Z5 g  s( C49ng/dL), 11-desoxycortisol (specific compound S)
5 x- w, x& c8 Z0 n0 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 t: y  G  T1 e6 v: u- Y' H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* w) p' E# A; x" K: s  V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 N; l7 Z3 }5 R' i5 c1 S
and β-human chorionic gonadotropin was less than7 ]7 b1 `! n. }' N5 O; V8 o
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 [' j2 \; ?7 T! }, r
stimulating hormone and leuteinizing hormone
7 N8 W" K: t7 sconcentrations were less than 0.05 mIU/mL
8 `* ?& j) E+ j(prepubertal).6 l0 i/ N9 F9 B5 w+ B- Y
The parents were notified about the laboratory" c9 ]- q1 b, M  q. T
results and were informed that all of the tests were3 Y1 U9 Q( N& m0 s3 ^" M: k
normal except the testosterone level was high. The! a5 E6 m$ P- X* y6 c7 x
follow-up visit was arranged within a few weeks to$ U- v! A9 ^: x3 Q
obtain testicular and abdominal sonograms; how-
6 V5 }' l. ^+ V0 [2 Yever, the family did not return for 4 months.
6 g/ R8 u0 W! }! a) MPhysical examination at this time revealed that the8 _  {' S+ A- k$ v! u* U2 c/ t8 u& r
child had grown 2.5 cm in 4 months and had gained3 W; d% m+ p) I. T4 A# ~2 Y5 i
2 kg of weight. Physical examination remained# a5 S# I$ W: Q5 e" R. F, z
unchanged. Surprisingly, the pubic hair almost com-
6 E: G* Q: W/ ?" f1 o. g) lpletely disappeared except for a few vellous hairs at( Z! `: j' N: M- t& Z
the base of the phallus. Testicular volume was still 2
% d, V2 b' {5 ~) r' |mL, and the size of the penis remained unchanged.
) F+ N; a0 p0 C3 e) U) lThe mother also said that the boy was no longer hav-8 h+ x7 Y2 s/ o$ h
ing frequent erections.
3 ~+ t) e! Q* E/ o# H! r" r: t7 g1 PBoth parents were again questioned about use of
! u. _6 g( ]  p$ J  Wany ointment/creams that they may have applied to
+ D4 l6 P: X) z/ m! |the child’s skin. This time the father admitted the
4 T7 g2 W5 M3 D9 |+ _( k' g, ETopical Testosterone Exposure / Bhowmick et al 541
7 x4 n1 y( e3 b; x' iuse of testosterone gel twice daily that he was apply-- C( h1 B) R. O0 V: t/ W
ing over his own shoulders, chest, and back area for5 N! O1 Y5 p4 h- T5 b$ j
a year. The father also revealed he was embarrassed
) h  N$ ]5 y* F4 @) ~to disclose that he was using a testosterone gel pre-5 q! d0 ~* B2 X
scribed by his family physician for decreased libido7 a$ E0 j% O2 C: L
secondary to depression.  J- ?. I& p: \1 Q) u% w. |7 s
The child slept in the same bed with parents.; D1 G1 E: Y8 P) d) y5 T
The father would hug the baby and hold him on his
+ G2 F; r( V: ichest for a considerable period of time, causing sig-
% J+ E' m0 y2 C( `" inificant bare skin contact between baby and father.
, H' f- g0 @$ a" n6 B5 O* oThe father also admitted that after the phone call,% h9 B4 |7 \* w# t' B
when he learned the testosterone level in the baby
3 Y6 A. |! |1 gwas high, he then read the product information
. F, ^6 ^$ w2 f) z8 hpacket and concluded that it was most likely the rea-
/ i! s# a* h, R2 P* B0 bson for the child’s virilization. At that time, they
2 _! n9 n1 Z$ H/ t) C- ddecided to put the baby in a separate bed, and the/ U$ W' l. K8 @
father was not hugging him with bare skin and had
( q( ]( ]. H: |; Q7 Q) ~  r9 Obeen using protective clothing. A repeat testosterone; ?5 |/ }* V4 C
test was ordered, but the family did not go to the7 C' i3 R6 J3 Y% F7 w: T: J/ P
laboratory to obtain the test.% w5 M9 g" }! q6 t9 S' x
Discussion
- ^7 ~9 i1 @9 D" P- j. s# hPrecocious puberty in boys is defined as secondary8 Y$ \- K9 S1 r1 `( [
sexual development before 9 years of age.1,4
& d2 J, D% S9 K1 D1 _  \' E4 JPrecocious puberty is termed as central (true) when
6 s% D/ o' D0 q; Kit is caused by the premature activation of hypo-7 Z& k" }, Q* P( ~/ l
thalamic pituitary gonadal axis. CPP is more com-
. z; V( u% t- P+ Q& V4 Fmon in girls than in boys.1,3 Most boys with CPP! v5 E1 `" W& y+ l3 b
may have a central nervous system lesion that is. h# U( Z* r; M0 E
responsible for the early activation of the hypothal-) h$ f* p5 ?9 p& y  B2 b/ ~
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 x8 v  r( L) V" Zsis has been given to neuroradiologic imaging in
% s1 ?. z, m9 vboys with precocious puberty. In addition to viril-, y! P5 q$ K  h0 C/ U
ization, the clinical hallmark of CPP is the symmet-% k- z1 b6 u" d! H3 [0 b7 q# M
rical testicular growth secondary to stimulation by
9 \' v& J* s9 Y! \gonadotropins.1,3
. t# |# c$ Z  R& N; ?, V3 eGonadotropin-independent peripheral preco-
* x% l1 G5 R+ @4 J6 M6 c: `, X# [cious puberty in boys also results from inappropriate+ Q: j% h3 o3 x7 C$ o
androgenic stimulation from either endogenous or
# @3 |2 F, X+ `; `8 g2 l9 R% a' xexogenous sources, nonpituitary gonadotropin stim-
1 m& S  s) O( ?; Aulation, and rare activating mutations.3 Virilizing' r, v/ B5 m& G  S/ h
congenital adrenal hyperplasia producing excessive
2 w' D' I* F  Q0 ^! Dadrenal androgens is a common cause of precocious2 K0 S& {! x+ ]& }( _
puberty in boys.3,4
6 ~3 d( T) f5 \% @The most common form of congenital adrenal
$ p# D# w" x& i6 B$ W0 Thyperplasia is the 21-hydroxylase enzyme deficiency.
6 O" Q- L- Q3 _The 11-β hydroxylase deficiency may also result in) ?3 W- M8 ?% `2 A
excessive adrenal androgen production, and rarely,8 j1 p8 w* L$ ]  l) v/ X! X
an adrenal tumor may also cause adrenal androgen/ V1 t' @) J0 E7 K6 z
excess.1,3
  P7 m, q3 h7 ^9 _) lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. Z5 u; j4 ]5 ^1 ~6 s2 B' |/ H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 Y' I5 K. J+ O2 H" eA unique entity of male-limited gonadotropin-! U" @# k1 K& }, C  o9 q
independent precocious puberty, which is also known2 ~; @( ~! K. p4 r4 b) Z* F" o8 d
as testotoxicosis, may cause precocious puberty at a
- o# T8 S" \6 }& x7 Q/ t0 wvery young age. The physical findings in these boys5 ~4 g! s" o! S  \% X+ M' h
with this disorder are full pubertal development,+ m) m; W. X9 g, G7 P
including bilateral testicular growth, similar to boys( h: O. t) l$ |- P0 |, y
with CPP. The gonadotropin levels in this disorder: Y! T' p! J& l3 C5 j
are suppressed to prepubertal levels and do not show
) M+ V6 b2 J/ x/ N1 f9 ]) qpubertal response of gonadotropin after gonadotropin-) w' g& X% S  y' n. L* q! a9 y
releasing hormone stimulation. This is a sex-linked9 S5 j. j  B% m, J; D
autosomal dominant disorder that affects only
3 H- Y" N, X% g: H5 R$ F) H; fmales; therefore, other male members of the family9 _  [# L" g3 }1 q. {. ~+ ~
may have similar precocious puberty.3
( k. x9 y# X5 D, X" b* ZIn our patient, physical examination was incon-
9 M! N1 U# C$ W$ {$ hsistent with true precocious puberty since his testi-1 \; D+ ^: j- J& |0 w0 ?3 I1 b2 ]
cles were prepubertal in size. However, testotoxicosis
/ I0 y, X* N: Kwas in the differential diagnosis because his father
+ r; @! x$ c( ?; Vstarted puberty somewhat early, and occasionally,% l( _6 c4 O3 g% B& t. }
testicular enlargement is not that evident in the& q2 i) W( m9 _; ]- l# r( G
beginning of this process.1 In the absence of a neg-* l: |9 d1 [! n9 _7 g0 `( O
ative initial history of androgen exposure, our
$ U- {! {1 O- {8 |biggest concern was virilizing adrenal hyperplasia,5 \! m$ r1 H; [; ?9 _' ]
either 21-hydroxylase deficiency or 11-β hydroxylase
: [0 v- Q3 r. P/ F3 p/ Qdeficiency. Those diagnoses were excluded by find-* R* x7 w0 C: p* m! c( C- z7 M  f: _
ing the normal level of adrenal steroids.
3 t1 C0 m" s: H+ j4 [# iThe diagnosis of exogenous androgens was strongly
- a( `9 ?2 Y  p) j# e+ bsuspected in a follow-up visit after 4 months because
. Y2 [6 Y/ G3 b1 F" S% r9 D9 Dthe physical examination revealed the complete disap-  P/ B: x" x$ {" R9 n
pearance of pubic hair, normal growth velocity, and
7 i1 X4 E* _* a3 jdecreased erections. The father admitted using a testos-% p% \1 ~9 I/ R% L
terone gel, which he concealed at first visit. He was- T4 U' P9 w9 d* c7 U: W$ D  c
using it rather frequently, twice a day. The Physicians’
# k- ~: m. R) s% K8 A' ]9 MDesk Reference, or package insert of this product, gel or  K+ s+ _6 G8 L: A
cream, cautions about dermal testosterone transfer to
6 K  m: g% [$ aunprotected females through direct skin exposure.
% p7 S' F0 \6 ?+ Y) ^3 iSerum testosterone level was found to be 2 times the" C* Z: s- F3 {# E+ l8 T
baseline value in those females who were exposed to' N4 [9 |5 ]- o: C8 i
even 15 minutes of direct skin contact with their male
5 n8 ^$ f6 s3 bpartners.6 However, when a shirt covered the applica-
, R: \9 H, U/ H* @8 R) Ktion site, this testosterone transfer was prevented.
& v( }9 ?6 t+ F6 C8 m5 K/ aOur patient’s testosterone level was 60 ng/mL,
! X4 D# U* }7 G3 Q! v7 h4 K& G% ywhich was clearly high. Some studies suggest that: M$ w( t8 {. T' U4 A& _2 [+ _
dermal conversion of testosterone to dihydrotestos-# ~+ x7 A# s7 A9 S
terone, which is a more potent metabolite, is more
0 [$ c  b: f! v* ~! z5 Xactive in young children exposed to testosterone
# l3 F4 w5 Y' d: A3 v5 C* Fexogenously7; however, we did not measure a dihy-
/ }6 F/ O- l: odrotestosterone level in our patient. In addition to7 d6 A: ^. L& K. L
virilization, exposure to exogenous testosterone in7 {4 l2 j0 }2 I! R5 [* t% O9 ]+ n
children results in an increase in growth velocity and
$ Y9 w& X  t! G( V3 t, jadvanced bone age, as seen in our patient.& q' N: y; h% K. u
The long-term effect of androgen exposure during
9 q5 H, N" W+ W% d, l0 Cearly childhood on pubertal development and final- v/ i' x" ^8 ~: V: p
adult height are not fully known and always remain
: m6 {$ U$ ?& [  U: X# ]a concern. Children treated with short-term testos-& K$ h% W/ m- I4 U3 B
terone injection or topical androgen may exhibit some' w: Z0 M- C9 {
acceleration of the skeletal maturation; however, after0 G7 O6 G3 D/ y* c# O% ]3 g
cessation of treatment, the rate of bone maturation) h, I3 e0 m) y: k$ K" ^( g9 r% C
decelerates and gradually returns to normal.8,9
, y' u3 n7 ~1 w# d  n6 C- fThere are conflicting reports and controversy% y6 T4 i( k5 B1 P1 @
over the effect of early androgen exposure on adult
/ @& S# A( V" i) `penile length.10,11 Some reports suggest subnormal* d5 Y; y- E& \% X9 f  [
adult penile length, apparently because of downreg-
! P$ X" L6 m/ r1 A$ ^, S+ iulation of androgen receptor number.10,12 However,
5 F, L) }  @3 r8 F. b4 cSutherland et al13 did not find a correlation between
9 b- z3 U2 x0 n1 X" }childhood testosterone exposure and reduced adult; \& [/ F$ R2 x3 @& P
penile length in clinical studies.. W, Y8 S( p" _
Nonetheless, we do not believe our patient is
$ t* G9 J& L' {/ ?- Hgoing to experience any of the untoward effects from3 \; w. F9 p9 x5 d
testosterone exposure as mentioned earlier because/ @5 P6 t- d+ `
the exposure was not for a prolonged period of time.( u9 e* E8 l+ _3 g1 Y3 @4 p
Although the bone age was advanced at the time of
+ t6 E$ R7 `: }$ i/ g9 ]) ?diagnosis, the child had a normal growth velocity at4 E) Y0 b8 z: `7 [8 a
the follow-up visit. It is hoped that his final adult( u1 j$ ]0 F4 G) u3 c# O
height will not be affected.
* B4 v" ?9 q% l1 ?Although rarely reported, the widespread avail-
' g0 U0 c+ i: k& _) z! m% v, Lability of androgen products in our society may( B1 f* E+ _/ O" M0 S3 Y: c
indeed cause more virilization in male or female* Z% Q# s* m5 c( S8 E
children than one would realize. Exposure to andro-
$ \9 Y0 [$ i, _& xgen products must be considered and specific ques-; K" l$ I% F: d: `7 C/ c
tioning about the use of a testosterone product or" A1 d5 [- x2 o6 Z
gel should be asked of the family members during
( m2 Q: C0 A( M9 Y( Uthe evaluation of any children who present with vir-
) I- @" W. [9 Z, I# e8 [1 n* T# xilization or peripheral precocious puberty. The diag-
( Z! l+ [8 e# a; Nnosis can be established by just a few tests and by
9 U: x% ^, z0 ~  L2 Z. _appropriate history. The inability to obtain such a
% B5 {% {! s* U( Rhistory, or failure to ask the specific questions, may* `' i- O; ]1 ?# }) S
result in extensive, unnecessary, and expensive
! |5 X; {# P4 r# Binvestigation. The primary care physician should be
6 [0 X* \' f# _) |: ^- O) A% a/ N+ }aware of this fact, because most of these children
: Q3 z: y5 a( A( l& _: }may initially present in their practice. The Physicians’
6 Y- \% C% W9 B% c9 K: cDesk Reference and package insert should also put a
9 {6 n3 i1 d) i* N# zwarning about the virilizing effect on a male or: S: w0 E0 V+ O" C' f% X/ c# v
female child who might come in contact with some-4 K9 g% K" Z; ?1 d9 c. M/ y+ O
one using any of these products., o6 V7 {, `+ j+ @9 C- @( h
References2 o0 k9 @/ \$ ^# W2 l& y
1. Styne DM. The testes: disorder of sexual differentiation. R2 x$ X) E8 U; N# t
and puberty in the male. In: Sperling MA, ed. Pediatric
% B7 b' }& o% _( t- ^5 E  a/ ~Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 Y- U0 g0 m9 `) P7 j2002: 565-628.9 F$ R7 t8 Y% q: Z+ W3 h! q( J+ T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% T" m) L) {! k$ I4 T' u6 W
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
7 |; t$ i2 r! f1 `9 [! ]  f# N
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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