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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
( \3 k+ q; G) }  d$ L! ^* aBoy Induced by Indirect Topical
/ ?, {' m" f% h! O0 _( ~' c: n1 gExposure to Testosterone& z" o+ O' w% T% c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 D& I9 v$ m$ q2 ?and Kenneth R. Rettig, MD1
5 P) @4 D  w/ m3 mClinical Pediatrics# ~9 Y- |% a- [7 [' R
Volume 46 Number 6
# e" A0 P; M; k1 K( gJuly 2007 540-543
6 Z6 C# e3 t) Z3 S  f  U© 2007 Sage Publications
: N# I' e* i4 e& F# V10.1177/0009922806296651% j+ S  S5 \  f& P9 q
http://clp.sagepub.com6 j  E  r/ E" x) T+ U4 \# U. I) S! Y; K
hosted at
$ t4 g/ s8 |/ H. ehttp://online.sagepub.com
# K- U. O/ |2 y7 [! nPrecocious puberty in boys, central or peripheral,  {5 l4 o; [6 U4 ]5 e& [' Y
is a significant concern for physicians. Central
! N3 U7 L, C3 P& ]6 Kprecocious puberty (CPP), which is mediated
3 o+ _) H& p1 w& N! ?through the hypothalamic pituitary gonadal axis, has- q+ _& w" N# v5 ^+ X
a higher incidence of organic central nervous system$ C% ~$ ~. R7 t" v
lesions in boys.1,2 Virilization in boys, as manifested
- i3 k* ?3 j- L8 m* I5 m7 q: x0 Hby enlargement of the penis, development of pubic
5 s) g9 Y6 }$ V# Hhair, and facial acne without enlargement of testi-
/ I, S2 ]5 C6 }& @cles, suggests peripheral or pseudopuberty.1-3 We4 h4 u+ z" L2 U
report a 16-month-old boy who presented with the/ [6 [( q0 j9 g1 A+ f- J
enlargement of the phallus and pubic hair develop-
6 \5 D, T9 K$ V% bment without testicular enlargement, which was due
) O: W% m0 B' }) _& @: R& w9 yto the unintentional exposure to androgen gel used by
- b" S& P6 q8 d2 T) p( h- @/ fthe father. The family initially concealed this infor-
$ r) ]; H8 e, vmation, resulting in an extensive work-up for this: p  r2 E8 \* s
child. Given the widespread and easy availability of) W9 I+ q7 V/ I5 M
testosterone gel and cream, we believe this is proba-
6 ^2 n3 C$ }  b  B! c9 m9 fbly more common than the rare case report in the, L" @# P& V: S- W" J1 O- J2 Y2 Y
literature.48 T! H7 i( ^7 n" P1 g! I: y  t$ d
Patient Report
$ u3 L) q" q* VA 16-month-old white child was referred to the5 k1 H6 k0 y( b* ?9 ]0 d$ v2 O
endocrine clinic by his pediatrician with the concern, N& @# Y8 u  I) U
of early sexual development. His mother noticed4 E+ z! B0 @  S9 O! U
light colored pubic hair development when he was7 [. r$ T8 O7 k3 @: x: y9 c
From the 1Division of Pediatric Endocrinology, 2University of3 y- L" z9 e. v5 K- x, W/ j( {
South Alabama Medical Center, Mobile, Alabama.2 }) O  d' u# _
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ ?' @) o* Q/ W$ Q' C; @8 s
Professor of Pediatrics, University of South Alabama, College of" W7 S$ j6 W3 R
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' B1 E1 a  R1 y3 G, D3 V# l" ce-mail: [email protected].* n. L8 |6 A& n; Y! R  B
about 6 to 7 months old, which progressively became
7 v! f) @3 O5 h5 {5 b3 edarker. She was also concerned about the enlarge-  }3 Z/ I! ?+ y
ment of his penis and frequent erections. The child3 R! j6 |$ ]+ h$ Y; F1 ~, d# a8 }& P
was the product of a full-term normal delivery, with! J4 a  F$ L+ Z8 ~; x, l
a birth weight of 7 lb 14 oz, and birth length of
. j! A% l$ Q3 X  t' O( E20 inches. He was breast-fed throughout the first year1 I7 f/ Q' O3 q* a3 Z. x$ J
of life and was still receiving breast milk along with
3 w( |2 L2 u7 g+ O9 E' ?' Y; Hsolid food. He had no hospitalizations or surgery,- d, |2 b7 c4 Z, v/ G
and his psychosocial and psychomotor development, ]1 n5 E2 \: t6 o
was age appropriate.
4 r' a' @' Z: g6 DThe family history was remarkable for the father,9 V& R  d. s( {4 e. `# a6 q; E
who was diagnosed with hypothyroidism at age 16,
3 ~8 i3 H* r, N9 b. h9 Xwhich was treated with thyroxine. The father’s
6 s! @! |# l  C/ xheight was 6 feet, and he went through a somewhat
7 B+ G" b/ B7 hearly puberty and had stopped growing by age 14.
- b$ e% c0 ~- Z" ]$ oThe father denied taking any other medication. The
) `& H9 B2 B. P+ N4 Ychild’s mother was in good health. Her menarche
% b* d3 G* T( X$ m! H: G) q1 Owas at 11 years of age, and her height was at 5 feet
: r' q) O. E/ c, S. \/ l5 inches. There was no other family history of pre-3 @: k' H) w" }' u8 R
cocious sexual development in the first-degree rela-: k6 z7 X2 z; `4 [
tives. There were no siblings.. b; {/ A7 W9 n$ w  C5 y
Physical Examination
' N6 U/ K# F$ {3 i" O/ HThe physical examination revealed a very active,, v, b# m" p& t" Y- {* N
playful, and healthy boy. The vital signs documented; i3 y# ?; K% ?& [) d+ F+ y& v
a blood pressure of 85/50 mm Hg, his length was
3 \2 x$ N( z1 C5 g! @' h90 cm (>97th percentile), and his weight was 14.4 kg5 p1 L0 ~+ b8 `# W% t
(also >97th percentile). The observed yearly growth0 F3 L' D3 p; G8 b, t/ ]" w
velocity was 30 cm (12 inches). The examination of
7 h$ q6 g8 j! d1 T9 rthe neck revealed no thyroid enlargement.
8 z+ i' `, B. ^The genitourinary examination was remarkable for
! J: n/ B: F5 A+ W! H9 Qenlargement of the penis, with a stretched length of
# ~' @6 @2 s$ d4 T8 cm and a width of 2 cm. The glans penis was very well
4 e8 j: s6 k; d: w0 Kdeveloped. The pubic hair was Tanner II, mostly around
2 Z% I: f9 }/ c& t8 t$ C5402 ]$ J" |. A# F1 n9 b* ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) Q' J- m, ^3 B# Z4 ^the base of the phallus and was dark and curled. The5 a" O; ^) z; I8 v# F
testicular volume was prepubertal at 2 mL each.
: f0 j  j3 `3 T4 |/ |The skin was moist and smooth and somewhat
) m( W" e) X, V2 T. Uoily. No axillary hair was noted. There were no
8 \" v) m! M9 b; |' Eabnormal skin pigmentations or café-au-lait spots.. O1 O% p3 w, V  F. b
Neurologic evaluation showed deep tendon reflex 2+) B) X, K( o+ I! N) A1 W9 m+ t9 u
bilateral and symmetrical. There was no suggestion
- z- k) b/ ^) J$ P7 U& e! Wof papilledema.' W. |1 K( L- m0 B, J  F5 F1 J9 u
Laboratory Evaluation
3 m. C1 m6 h4 ]7 QThe bone age was consistent with 28 months by2 I( q1 S) A7 `) e; d1 C7 }
using the standard of Greulich and Pyle at a chrono-9 ^  b+ I/ h& [4 _
logic age of 16 months (advanced).5 Chromosomal2 z, r! Z: w9 g, m$ s2 w
karyotype was 46XY. The thyroid function test; a8 U3 V% j6 V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 |8 ?6 w' p  f1 \& u( X3 wlating hormone level was 1.3 µIU/mL (both normal).
2 b. Q8 R; u4 @* iThe concentrations of serum electrolytes, blood
1 m8 ?- M0 n4 d3 furea nitrogen, creatinine, and calcium all were7 H/ l1 o$ T$ D; j4 W- S
within normal range for his age. The concentration- I- e& x) R( y6 T. C
of serum 17-hydroxyprogesterone was 16 ng/dL
0 p/ E2 c* X" @+ Q5 M  G(normal, 3 to 90 ng/dL), androstenedione was 209 N& C& P6 x- v# p( }) L
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 a. Y1 r, h* Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
. ]/ k, M: i% _3 ?& Rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; Y8 \+ {3 Y6 E% j* Y1 J
49ng/dL), 11-desoxycortisol (specific compound S)9 B$ F/ R, V1 Z. ]: \8 M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 Z  u6 j2 J% z$ l% stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) R: l3 D% g9 w! Btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 `7 u  L2 t, G" r9 C8 t# T
and β-human chorionic gonadotropin was less than
6 W  o$ m2 w6 [9 B1 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular% N" j) r0 n# V7 {7 ^! [# h
stimulating hormone and leuteinizing hormone
$ x' W  v+ I( o( W- {concentrations were less than 0.05 mIU/mL
! i$ }# k5 }  W/ [6 p(prepubertal).
0 t3 k$ U. T! H* v' Q  x6 ~& MThe parents were notified about the laboratory
: _) i9 y2 {: Y0 t- Z0 Lresults and were informed that all of the tests were2 X% d# f& H8 @$ N3 {5 c/ b* N* s
normal except the testosterone level was high. The
% B/ k) \+ R+ t0 o( t  i( K9 [% H7 ffollow-up visit was arranged within a few weeks to* Z3 s( s3 q6 @. B4 i) g
obtain testicular and abdominal sonograms; how-( t4 V4 x0 f2 ?7 ?* L# ~; ]+ f& r
ever, the family did not return for 4 months.7 _; D* Q  B' ^$ |* Y/ J6 v9 e
Physical examination at this time revealed that the
/ ]; E3 t9 v" K; u8 u$ {( U5 zchild had grown 2.5 cm in 4 months and had gained7 z% Z# @! |, j) O# S+ Z: j( j" s
2 kg of weight. Physical examination remained; d3 v  p  l' h$ L! y) m" I
unchanged. Surprisingly, the pubic hair almost com-7 O8 A3 @! N( U, x4 w
pletely disappeared except for a few vellous hairs at
$ x7 i( r+ c, D* r# S1 Gthe base of the phallus. Testicular volume was still 2% P" [( v" S) G  l
mL, and the size of the penis remained unchanged.
( N" i" I  V7 A2 vThe mother also said that the boy was no longer hav-, i1 a8 z' E: _6 ?
ing frequent erections.
2 |2 k! F& q( q3 g3 v! |0 JBoth parents were again questioned about use of
, f1 o$ ?5 P9 h! ^4 D0 N* ?( bany ointment/creams that they may have applied to0 C: u* U$ W  ~( M6 W2 r
the child’s skin. This time the father admitted the
5 I0 c* z4 o* y/ o: ZTopical Testosterone Exposure / Bhowmick et al 541
& \+ c# A$ k# `; r) C3 S. r* muse of testosterone gel twice daily that he was apply-
* _3 D: e6 o( W2 b$ ]ing over his own shoulders, chest, and back area for
$ T4 k4 K% Y2 `. ia year. The father also revealed he was embarrassed
0 y/ ^& a5 L* C, @) Z! |to disclose that he was using a testosterone gel pre-
7 o3 W4 p( r2 d* X( Q! c, ascribed by his family physician for decreased libido" x8 Z+ X; K$ `% K
secondary to depression.
. q. P  \$ q( y1 M; \The child slept in the same bed with parents.
% ]; C/ x7 }' I+ DThe father would hug the baby and hold him on his" X. e- {  b) B" l7 D2 X  Z
chest for a considerable period of time, causing sig-) S: x6 L. v1 c, u1 N
nificant bare skin contact between baby and father.
# a3 |' T& M2 m4 u5 ~9 G+ g  Y$ aThe father also admitted that after the phone call,
( f4 e. F/ \6 i8 k0 l5 Wwhen he learned the testosterone level in the baby7 c% v0 {7 \# r
was high, he then read the product information& {: t- d5 I: J; b* z
packet and concluded that it was most likely the rea-
1 m$ I  \: q7 z, ]# u4 q9 J0 N# qson for the child’s virilization. At that time, they
! i" A( h& K3 J* V( L( mdecided to put the baby in a separate bed, and the1 W" k( j  b# s5 |! ~: V# ^' |
father was not hugging him with bare skin and had- u! B) U: f5 r% |$ F- f
been using protective clothing. A repeat testosterone
4 I- r( W& Y, f- E% ?test was ordered, but the family did not go to the
! ]- d/ V% _" b# \  {& xlaboratory to obtain the test.
0 j" C: x/ D" y9 r% i# qDiscussion
- g4 u# U; z+ |Precocious puberty in boys is defined as secondary: @# w7 h. b9 U  L) [
sexual development before 9 years of age.1,4
$ V5 y% L. l# u3 z. K1 LPrecocious puberty is termed as central (true) when
0 T1 ~8 A- t1 j" W. ~) I, Ait is caused by the premature activation of hypo-
' M% j$ q5 [# E+ U: gthalamic pituitary gonadal axis. CPP is more com-
4 O( d- G8 D, Kmon in girls than in boys.1,3 Most boys with CPP( q- F6 p  J0 j0 c" v& u- N$ b
may have a central nervous system lesion that is
$ @. d/ M4 j, ]7 Presponsible for the early activation of the hypothal-- r" S9 j( C) r
amic pituitary gonadal axis.1-3 Thus, greater empha-
" F1 b5 f# |: t: j1 xsis has been given to neuroradiologic imaging in
7 V: E* S# {- H& ~8 u0 aboys with precocious puberty. In addition to viril-
! L6 x' J/ F+ \ization, the clinical hallmark of CPP is the symmet-
7 y. n% f. X/ \8 frical testicular growth secondary to stimulation by
( L. M9 k1 D0 w/ e/ e# n& J! [gonadotropins.1,3! T* M& U/ c$ C8 q6 [  i2 u5 e" U
Gonadotropin-independent peripheral preco-
3 o$ a9 }# d! e' fcious puberty in boys also results from inappropriate# v, H) X% n1 ~% B+ G
androgenic stimulation from either endogenous or
7 {" |/ ?5 {1 p4 d4 e- y' j5 D4 |exogenous sources, nonpituitary gonadotropin stim-7 C2 A; L$ S' Z! k
ulation, and rare activating mutations.3 Virilizing3 H( S+ O" y9 Q$ |
congenital adrenal hyperplasia producing excessive' F8 d5 J: q; \  o- ]- }% o
adrenal androgens is a common cause of precocious9 i: C# p* A4 e$ W' m
puberty in boys.3,4% J6 {& k) y6 z  q7 o
The most common form of congenital adrenal6 ^9 ~8 L5 C2 e. E2 y" G: e
hyperplasia is the 21-hydroxylase enzyme deficiency.4 w; {  f3 D6 E
The 11-β hydroxylase deficiency may also result in0 n9 e5 U, W1 l, C) L2 l% B# u- m2 o
excessive adrenal androgen production, and rarely,
2 O. _* ?) q0 A9 q1 k1 H  z; \an adrenal tumor may also cause adrenal androgen+ G2 _8 U0 s) Q. ^7 W& e
excess.1,3
2 u3 C. y7 |! J  v' b) c$ cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, {% U) O3 q$ R1 L/ V2 b% n542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% ]; ]3 Z+ @, T* U! O' V/ ~
A unique entity of male-limited gonadotropin-
4 X9 s3 k  s4 H8 X8 eindependent precocious puberty, which is also known
) o& P: g0 O6 g+ n* f) [0 Y. {2 e: Bas testotoxicosis, may cause precocious puberty at a0 u  F4 ?, r: i. Z  z
very young age. The physical findings in these boys
* Z2 b, y% s! ~with this disorder are full pubertal development,
- c9 T' S* [# c. g3 h; `including bilateral testicular growth, similar to boys( U! r3 i+ t8 t; G: {, K0 g: h
with CPP. The gonadotropin levels in this disorder
3 o0 G1 b( J! u5 _  q2 {are suppressed to prepubertal levels and do not show
# H6 J5 c0 U% Z+ v: Wpubertal response of gonadotropin after gonadotropin-
. Y( q9 t# p* }releasing hormone stimulation. This is a sex-linked
) O/ {: |" a' U" Wautosomal dominant disorder that affects only
! k( j- h4 r& X8 cmales; therefore, other male members of the family
. s' G( [' |2 O$ z# m, @% Bmay have similar precocious puberty.3' ?- o% l/ e6 y) M" o
In our patient, physical examination was incon-
5 P) W8 w+ I0 K/ zsistent with true precocious puberty since his testi-
& v9 e% n) v/ V5 |7 xcles were prepubertal in size. However, testotoxicosis
3 p) b$ h, e3 U, s9 Y7 Xwas in the differential diagnosis because his father4 H* D& s) @$ D& t1 h6 S
started puberty somewhat early, and occasionally,0 N# W" N% `& p- A
testicular enlargement is not that evident in the" z5 w. F5 I+ r6 Z$ v
beginning of this process.1 In the absence of a neg-
& ?( j, s- A- Mative initial history of androgen exposure, our  L: ?/ K3 c( f0 q& d; J( L* x
biggest concern was virilizing adrenal hyperplasia,
, q) g& u1 D' z7 H( h  g# Veither 21-hydroxylase deficiency or 11-β hydroxylase
5 S' H# O+ ^' r9 G& ?7 }deficiency. Those diagnoses were excluded by find-: x. t5 H' S. N8 L* \
ing the normal level of adrenal steroids.
8 O2 G  [4 q( j7 D1 s7 q5 ]. N2 m; UThe diagnosis of exogenous androgens was strongly7 t. f  o7 p1 e$ g9 t0 N+ q% t' R$ w
suspected in a follow-up visit after 4 months because
- Y! p7 O3 n7 z/ a4 Dthe physical examination revealed the complete disap-
- ^$ s, b6 L4 l; |( B1 ypearance of pubic hair, normal growth velocity, and) H' M, T. \) S7 n4 g* v
decreased erections. The father admitted using a testos-
. Y9 A8 o9 x# P& Yterone gel, which he concealed at first visit. He was
" \6 ^: g* D' Cusing it rather frequently, twice a day. The Physicians’
  o* g& J6 a/ I- jDesk Reference, or package insert of this product, gel or( M# C! s' h2 N
cream, cautions about dermal testosterone transfer to
& K9 L+ K# D/ [/ x; e2 ~2 junprotected females through direct skin exposure.; _+ \. @4 c3 `
Serum testosterone level was found to be 2 times the
9 j+ {9 o: x9 w& Pbaseline value in those females who were exposed to! u; R9 T4 S$ O# @$ Z
even 15 minutes of direct skin contact with their male
+ b6 U: x2 ?9 ~( Npartners.6 However, when a shirt covered the applica-( l1 e2 z! }! i# e/ U
tion site, this testosterone transfer was prevented.6 R% L+ h, I0 I  \2 t4 ]* ]
Our patient’s testosterone level was 60 ng/mL,5 d# |" z3 h7 f+ E! n
which was clearly high. Some studies suggest that
# B  q1 U0 D9 }  ~. bdermal conversion of testosterone to dihydrotestos-
# \" a3 U- U# {* p* R4 Z$ d$ h; Zterone, which is a more potent metabolite, is more
/ U5 ~4 s6 v' o# hactive in young children exposed to testosterone( l) a! ^2 k2 i- u5 J% _
exogenously7; however, we did not measure a dihy-
$ \3 q- M6 d( Kdrotestosterone level in our patient. In addition to- v" X' |) Y9 v% Q8 A' P  c. H
virilization, exposure to exogenous testosterone in, ~9 U( J- T# G% t3 \  @2 [% F
children results in an increase in growth velocity and
: g; t8 S# ?$ Q+ z4 F: o" fadvanced bone age, as seen in our patient.
# X* D' w) `3 [8 X! xThe long-term effect of androgen exposure during" T& Y2 I+ s: x% o: S: n/ T
early childhood on pubertal development and final; a& j& O& U' e
adult height are not fully known and always remain' K& j6 M9 i' w1 O
a concern. Children treated with short-term testos-% A6 |1 w3 _; n
terone injection or topical androgen may exhibit some
$ E. r8 Y5 L4 P3 X7 o2 Gacceleration of the skeletal maturation; however, after! Y! @& l' o& s0 f; T1 a
cessation of treatment, the rate of bone maturation' o+ q( q' p9 N( P' D7 N
decelerates and gradually returns to normal.8,9) j3 s6 Q( C! a7 \9 o: J" B
There are conflicting reports and controversy  k- Z4 Z, k4 P( J
over the effect of early androgen exposure on adult8 A# F- B9 y, w1 r' |
penile length.10,11 Some reports suggest subnormal* ^3 r5 @" @: n/ `( `
adult penile length, apparently because of downreg-
/ {" U+ W! D: c) pulation of androgen receptor number.10,12 However,
" S& n& `. a# k# }( q9 d9 C. lSutherland et al13 did not find a correlation between: P' c% g; B9 r
childhood testosterone exposure and reduced adult
5 P8 I6 a8 \, _& H) F, e9 kpenile length in clinical studies.- u4 w6 z, |7 h
Nonetheless, we do not believe our patient is
  i. x5 }5 t% y  i3 C4 L5 u% t# dgoing to experience any of the untoward effects from
& ]( D  }4 K5 Y  V/ j; `) \% Ztestosterone exposure as mentioned earlier because
7 T7 j# H1 y# m$ }5 b3 f  D% d4 T* Uthe exposure was not for a prolonged period of time.
. `7 ^. K! i: p  @& WAlthough the bone age was advanced at the time of
6 N3 \: a) E9 p/ ?6 Wdiagnosis, the child had a normal growth velocity at
, }* J; h/ r  |( k4 ~8 x$ lthe follow-up visit. It is hoped that his final adult
6 W1 E+ {4 [4 w5 L0 T; f8 ]# @% \height will not be affected.' z" _1 q7 H+ b% N; U; [( Z* K
Although rarely reported, the widespread avail-
% {! h! ]( G. R& }- }8 D) hability of androgen products in our society may
) U0 j7 J+ S( N- o4 e+ Jindeed cause more virilization in male or female
) \( n/ u+ {! U/ P/ ichildren than one would realize. Exposure to andro-/ r+ w2 b1 j6 H/ Y$ G
gen products must be considered and specific ques-
# i5 e0 e1 @/ b% S* `tioning about the use of a testosterone product or3 o3 Y! L% c7 i, A8 a. m) L
gel should be asked of the family members during
/ {4 B' @/ t4 J/ y4 j6 Sthe evaluation of any children who present with vir-# `! }# D8 A- w7 f4 R
ilization or peripheral precocious puberty. The diag-
! b1 S. t: \6 F* c4 Dnosis can be established by just a few tests and by; Y5 D. i+ L5 t  l
appropriate history. The inability to obtain such a! s1 z+ \# V" h' b$ j
history, or failure to ask the specific questions, may
- d- U( }; Z: Cresult in extensive, unnecessary, and expensive
$ M/ I. A: R( I! T! b) @investigation. The primary care physician should be
; Q$ u9 ^6 K& T1 Y. Saware of this fact, because most of these children
( F9 I4 G2 v7 h6 \0 x! lmay initially present in their practice. The Physicians’: Y8 ]# }; k& y: k; [$ r
Desk Reference and package insert should also put a, n) Z/ g1 a& L5 O. J: H9 D
warning about the virilizing effect on a male or" |- I$ m. x# R, G/ R7 |
female child who might come in contact with some-" ?- m. K" R6 u
one using any of these products.
1 F9 ?* A7 {- ]$ o6 n8 dReferences2 ^9 R" ~  ~! j4 b( K1 c
1. Styne DM. The testes: disorder of sexual differentiation
1 z' @& ?' L1 K3 W' oand puberty in the male. In: Sperling MA, ed. Pediatric9 v/ E2 u3 A9 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 T* C; m2 `3 b# i1 Q
2002: 565-628.
2 k6 [  E, \% ^2 L7 F& ~* n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 p% T4 |4 D) r& o, T
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) ^- e, C6 }/ X. a! z2 ]
Boy Induced by Indirect Topical
) k9 e. q6 u, ^Exposure to Testosterone: E, x4 h4 V) r' n9 @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ w5 D9 D: w* E3 T' N# _- w) b( {
and Kenneth R. Rettig, MD1
3 ]& O. v- i) U7 _; m& v  }Clinical Pediatrics0 m/ w; g. Z6 U5 {; x1 c
Volume 46 Number 6
: A- {: E; k) c8 dJuly 2007 540-543! @9 R+ _$ j! ]2 p; m) W- R9 a
© 2007 Sage Publications7 \8 A, Y, k0 H  U
10.1177/00099228062966517 Z; P2 B9 h( P* a; |
http://clp.sagepub.com( b2 ^1 K/ q/ b/ w+ Q
hosted at
0 ^! h: u# h1 p: O+ |3 r+ shttp://online.sagepub.com  m" e; W+ f$ u0 _3 o
Precocious puberty in boys, central or peripheral," f; F5 w- l4 ]9 ?
is a significant concern for physicians. Central
$ `& a- ]" k6 M# _( }" \" gprecocious puberty (CPP), which is mediated
6 Q% K6 T" W$ i1 s* Y; Cthrough the hypothalamic pituitary gonadal axis, has
9 s3 h  r8 @* [9 Y' Xa higher incidence of organic central nervous system  d, \% p, Y0 c0 V8 ?
lesions in boys.1,2 Virilization in boys, as manifested+ c7 ~2 D0 i0 V7 f# G$ \2 D
by enlargement of the penis, development of pubic6 J+ p( d' k  U7 O
hair, and facial acne without enlargement of testi-
  H- X/ r- O" p' z, z* Wcles, suggests peripheral or pseudopuberty.1-3 We: U4 \2 M( b" _  _, ^1 V: J; H
report a 16-month-old boy who presented with the
0 [2 h+ U* W6 m. Z1 n  H7 y' b# Eenlargement of the phallus and pubic hair develop-
3 R& s3 K7 o8 a! O& h7 s+ w& `; }ment without testicular enlargement, which was due) b# W+ s' }- A
to the unintentional exposure to androgen gel used by1 z5 m1 ^( {9 b. Z: G+ E
the father. The family initially concealed this infor-% l6 C4 \- t. O7 F+ N2 |
mation, resulting in an extensive work-up for this
' `8 x& ~9 W( x0 u- I  nchild. Given the widespread and easy availability of
. e" M7 A. ]. i( M/ n* ~( a$ ptestosterone gel and cream, we believe this is proba-7 U8 S. h& C) [' }- p' O2 ]
bly more common than the rare case report in the
2 O( f% i7 w9 b. `literature.4( ^& s, E& z% y. u  q3 ?) q
Patient Report1 }: ?0 M9 `8 Z& j- }! A
A 16-month-old white child was referred to the
* r1 M8 [2 U1 f& Mendocrine clinic by his pediatrician with the concern
/ e) W0 f- E+ Oof early sexual development. His mother noticed1 k; b( }) d2 Q
light colored pubic hair development when he was
6 Q/ s0 |# h6 U% @& j& lFrom the 1Division of Pediatric Endocrinology, 2University of
7 T  u1 P0 `3 R; C" l8 uSouth Alabama Medical Center, Mobile, Alabama.
! u& K8 C% i4 R  v) o9 }Address correspondence to: Samar K. Bhowmick, MD, FACE,
) @  Q6 _6 ^7 Q. e0 QProfessor of Pediatrics, University of South Alabama, College of! n% R  k# ]" D7 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 K4 F% ?" q; \2 K( s
e-mail: [email protected].
( O$ I8 B4 ~' w8 Iabout 6 to 7 months old, which progressively became; M/ O, j( F: o4 Z
darker. She was also concerned about the enlarge-# D- ~+ ^  H5 Z$ E. T0 ?
ment of his penis and frequent erections. The child  k# `8 C% n/ F$ k# a) C: n
was the product of a full-term normal delivery, with+ W6 Y' g. }* L" B- |
a birth weight of 7 lb 14 oz, and birth length of
( N7 [0 l1 p8 ]& Y1 e' p20 inches. He was breast-fed throughout the first year
5 ]/ R! s) M. C' a3 [# Zof life and was still receiving breast milk along with' j  o, k+ W% y1 I1 b
solid food. He had no hospitalizations or surgery,! V6 j6 h: E! E
and his psychosocial and psychomotor development
# b, v3 `- x' z, O+ X' C3 s7 K/ Swas age appropriate.) }- C& n6 r, [1 ^+ D! i
The family history was remarkable for the father,0 A7 q0 x/ m1 o6 M. D) n5 h
who was diagnosed with hypothyroidism at age 16,
; i. r9 f. j4 C- t1 H/ j6 f: S. Ewhich was treated with thyroxine. The father’s
; d8 a* n% a$ L% {height was 6 feet, and he went through a somewhat
- ~& F4 z: v2 ~2 z1 A" bearly puberty and had stopped growing by age 14.9 Z* p6 P' |- V) s3 X; c8 g
The father denied taking any other medication. The) ^2 e6 T4 P: t& ^5 W5 z
child’s mother was in good health. Her menarche
4 ?1 ]+ C, f  b: [8 \2 twas at 11 years of age, and her height was at 5 feet0 o( H5 o& j2 R4 ?, G
5 inches. There was no other family history of pre-" r) g/ a7 d# {
cocious sexual development in the first-degree rela-( ]. h1 L* y# \4 I9 D
tives. There were no siblings.
9 q3 p, j0 U& R  e" E. H2 BPhysical Examination( _) F& F/ O3 e7 V, ?% L7 c2 {0 f
The physical examination revealed a very active,6 s  D/ k7 x  g6 G, M' e# n
playful, and healthy boy. The vital signs documented
7 t7 e9 @$ ?" H( G; ?" |, `5 ?4 Za blood pressure of 85/50 mm Hg, his length was
$ P% c  t- H( x& y: x90 cm (>97th percentile), and his weight was 14.4 kg) N3 e5 ]& t9 J( n! [. ~# U% n+ j( s
(also >97th percentile). The observed yearly growth3 q" X7 A( x# h! r0 j! T% Y+ w
velocity was 30 cm (12 inches). The examination of
8 C* Z2 X9 ^5 Y% s7 t2 o6 D: zthe neck revealed no thyroid enlargement.
- S% b+ z3 s& q6 n: @; w: fThe genitourinary examination was remarkable for  U* n4 e4 b. W& K% Q
enlargement of the penis, with a stretched length of
! C6 F+ d8 l) K0 K8 cm and a width of 2 cm. The glans penis was very well1 }" ?2 G# Z2 n1 J
developed. The pubic hair was Tanner II, mostly around
2 n! b) Y8 F" p- D) Q5408 `3 k2 L; I0 i* x- t1 B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 f4 t; }. V" c6 H) O1 xthe base of the phallus and was dark and curled. The- F5 Q' j7 A# Y4 A& O: U: D8 {! g
testicular volume was prepubertal at 2 mL each., B; Z8 m& C5 c
The skin was moist and smooth and somewhat4 C% y5 `& y4 ]& K0 X4 n
oily. No axillary hair was noted. There were no4 K3 \8 V- [3 c# n5 k7 @& u4 I
abnormal skin pigmentations or café-au-lait spots.
* ?1 o$ i; ?; f) f! O: e) ?Neurologic evaluation showed deep tendon reflex 2+5 c, P  J* L6 x+ I/ W2 X
bilateral and symmetrical. There was no suggestion
4 j" T6 `/ o. o$ Gof papilledema.0 {  n1 b: {; L# b- z% h
Laboratory Evaluation
. _2 n3 C( x3 d6 dThe bone age was consistent with 28 months by8 `' u. s$ L9 T" S' Z) d
using the standard of Greulich and Pyle at a chrono-
7 c3 J4 u6 Y' ?logic age of 16 months (advanced).5 Chromosomal
* n9 q& a4 y3 c6 o% }+ E2 \karyotype was 46XY. The thyroid function test  }/ h/ D( ?' h/ N. A/ s. @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 G( ^2 F' S0 w3 A4 |! I+ e1 ulating hormone level was 1.3 µIU/mL (both normal).
2 V1 ~. _+ L0 i6 D# gThe concentrations of serum electrolytes, blood
3 I* @0 A' X( C# z, L$ I3 m7 turea nitrogen, creatinine, and calcium all were6 g  P( U3 c. |+ \
within normal range for his age. The concentration- o! P2 x2 v. O7 ~8 V, G
of serum 17-hydroxyprogesterone was 16 ng/dL) B" @6 h( H/ C" \- T+ q; L$ B
(normal, 3 to 90 ng/dL), androstenedione was 20
, J, [9 `2 j* W4 L3 ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ J: d8 B( s2 W0 L8 Pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ f! i+ |! v2 ]' G9 V$ vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 L8 w% j, D  c$ s) t2 [' s49ng/dL), 11-desoxycortisol (specific compound S)1 O9 b8 {+ a( ^; Y1 H) X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 B# u9 ~; D" W9 \; _: m- B/ \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; e8 D. ~& {% ]+ N6 F0 Ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 V+ N, J; `' G! \  ~# n9 rand β-human chorionic gonadotropin was less than8 w; M* |/ [1 R# I- q( J; B. u
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 D  x# q  f) y% H: C. y) M" q
stimulating hormone and leuteinizing hormone
6 m* |" T$ r9 P" X' c: j, X9 ^( Kconcentrations were less than 0.05 mIU/mL
7 P! f( O, I6 ^8 b(prepubertal).
" Q7 E% z2 ^" e. T9 oThe parents were notified about the laboratory
$ Q9 e- v1 _: X8 A1 u4 qresults and were informed that all of the tests were
% f5 V9 ^0 M: E1 I" h2 ynormal except the testosterone level was high. The: V. i% ~$ @- O4 o8 y
follow-up visit was arranged within a few weeks to
1 l1 g8 }  [5 G' h5 f8 w+ w1 O8 bobtain testicular and abdominal sonograms; how-" m- c! K* T3 E# @
ever, the family did not return for 4 months.
% }* v! l$ `) U/ N5 ?2 WPhysical examination at this time revealed that the
' {- V4 ?( ?" c( S- I* tchild had grown 2.5 cm in 4 months and had gained
& R' N: c* S7 k! t2 kg of weight. Physical examination remained
* H# m: z* c' j: F( N& ^unchanged. Surprisingly, the pubic hair almost com-
: {; d: B5 f- c. X9 ~pletely disappeared except for a few vellous hairs at$ _+ v. F2 ]6 Q; J) Q
the base of the phallus. Testicular volume was still 2
3 }! A% k, N+ ?! {5 zmL, and the size of the penis remained unchanged., q; ?% [- Z9 c$ T7 ?/ U% l
The mother also said that the boy was no longer hav-. q4 J# e& Y3 F! t- {: H
ing frequent erections.
- r& `7 G& t; y3 [% J( O- Y2 NBoth parents were again questioned about use of1 ?" x4 K" Y' E6 F# [# p2 \+ O
any ointment/creams that they may have applied to
+ B0 {8 g+ C2 b2 j  Gthe child’s skin. This time the father admitted the
( w& _/ u5 x0 _' Y4 {9 u. BTopical Testosterone Exposure / Bhowmick et al 541: M& W/ b1 t3 E* U  G2 `0 h
use of testosterone gel twice daily that he was apply-" N: r, V8 ?: h" p+ T# P
ing over his own shoulders, chest, and back area for9 S2 Z$ S7 j, J/ }
a year. The father also revealed he was embarrassed! P) _( o6 u( A) j; O
to disclose that he was using a testosterone gel pre-
3 }- B1 r7 a$ r" \+ J0 w, ?scribed by his family physician for decreased libido% g. I; R3 Q. i) ?+ \; p8 D7 q& b
secondary to depression.  n( c% r+ l0 I
The child slept in the same bed with parents.
( z% t& b2 B+ P" F. lThe father would hug the baby and hold him on his
, f) m7 S. S# J; D8 Schest for a considerable period of time, causing sig-
# ^' ^% x% h# R4 cnificant bare skin contact between baby and father.
& i  T2 G" p  @- l0 DThe father also admitted that after the phone call,
. a. S8 U% ~2 x/ h4 P5 R" g# Wwhen he learned the testosterone level in the baby: p8 ~' S6 {1 c% {. P; {* w  H
was high, he then read the product information: ]  w* e  ~8 L. J  M& f- f+ C
packet and concluded that it was most likely the rea-
6 ]" Z" [! l: w4 j! Bson for the child’s virilization. At that time, they
3 A" }. g  M5 E' D# m, v6 mdecided to put the baby in a separate bed, and the
0 h# b5 I# E. P  x4 ^* Ofather was not hugging him with bare skin and had" Y7 a4 q* e, D
been using protective clothing. A repeat testosterone: `, n0 g8 x3 }# E; ~  l( Y6 E
test was ordered, but the family did not go to the
3 L0 W. l- t- @0 xlaboratory to obtain the test.! U9 h2 w' {1 P, @. `. [0 n0 ?) W0 T
Discussion
# \0 K1 P+ [. T/ [% Z& I5 WPrecocious puberty in boys is defined as secondary
5 }" h, I  X: H$ h. O4 v; ssexual development before 9 years of age.1,4
# y' Y( r7 E0 Q$ |9 H) HPrecocious puberty is termed as central (true) when$ V- f2 n4 ~( D. ~! E" H8 Q5 q; q9 C
it is caused by the premature activation of hypo-  V- x% I& X% _/ Y( e
thalamic pituitary gonadal axis. CPP is more com-
8 Z& f2 K# o' w4 ^. |mon in girls than in boys.1,3 Most boys with CPP
3 m' p) W; A+ B) F8 e* t1 u; fmay have a central nervous system lesion that is' |' v# I& E: W; w) E5 v
responsible for the early activation of the hypothal-
$ n% T' y  }8 s6 ]6 v8 zamic pituitary gonadal axis.1-3 Thus, greater empha-
: T9 R# _. `9 D$ lsis has been given to neuroradiologic imaging in
# ~3 E3 C  g. h  ?' tboys with precocious puberty. In addition to viril-
* {+ @7 d) f2 H8 ~ization, the clinical hallmark of CPP is the symmet-
* p4 N: s- R. [2 C. l2 B+ c8 frical testicular growth secondary to stimulation by
; B) u. M& H& R) q: p' c/ Egonadotropins.1,3
9 \7 G2 e% M) W/ S6 x% t, \Gonadotropin-independent peripheral preco-) C8 G2 w0 V" P7 p2 N9 `
cious puberty in boys also results from inappropriate' T6 x# F, j8 F& b0 X
androgenic stimulation from either endogenous or
  P8 i4 o; j- D" l% T/ p( Xexogenous sources, nonpituitary gonadotropin stim-
; D  D* \) s6 T" i  uulation, and rare activating mutations.3 Virilizing& K2 S6 l" `1 M& F3 Z# g
congenital adrenal hyperplasia producing excessive
/ E0 S, l2 m) i; O4 ^7 oadrenal androgens is a common cause of precocious
# ^; s. ?  K0 t7 e/ \puberty in boys.3,43 L9 Z/ U0 ~( F1 B
The most common form of congenital adrenal
( U$ u7 k& w9 Zhyperplasia is the 21-hydroxylase enzyme deficiency.
. c& g- Q; L% s" F* gThe 11-β hydroxylase deficiency may also result in$ [( `% `3 m; q
excessive adrenal androgen production, and rarely,, Y3 i4 ?1 H! _- k5 ?  d
an adrenal tumor may also cause adrenal androgen" o* n" W( S7 }' ?, K
excess.1,3/ |( ~3 A: I4 w8 p3 \+ s2 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& P" C  ]2 x. e6 d8 I) T  c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# e3 j; q% c, H$ o( V* [A unique entity of male-limited gonadotropin-$ u' Y4 q* c' A# Y( i& B8 V
independent precocious puberty, which is also known+ d, o; {4 |5 x# C/ @
as testotoxicosis, may cause precocious puberty at a, X  M& C' @; v
very young age. The physical findings in these boys  R" `9 n( z0 h, a
with this disorder are full pubertal development,# G# n' k% d" Y5 f, a! D1 s: B' z
including bilateral testicular growth, similar to boys
5 z1 ?. V& M  D, W" t! r' \with CPP. The gonadotropin levels in this disorder) k5 ]4 ?, F9 X1 Z- \' B
are suppressed to prepubertal levels and do not show, L8 l1 I9 [8 {6 M- F9 Z
pubertal response of gonadotropin after gonadotropin-0 q3 n4 G0 t' P
releasing hormone stimulation. This is a sex-linked
+ F" K) e6 i8 H4 s- c8 E' y. rautosomal dominant disorder that affects only
6 B3 E; P( E; H& Vmales; therefore, other male members of the family/ z( d; \$ {; d0 W8 F4 `  K
may have similar precocious puberty.3
. I* _& X7 ~# s- K6 J! O9 _9 dIn our patient, physical examination was incon-0 o( g- _( m/ y- d
sistent with true precocious puberty since his testi-
5 ^3 H. i: x$ Wcles were prepubertal in size. However, testotoxicosis) ?0 c6 g/ q. O- [
was in the differential diagnosis because his father
' ^: i) `4 K, v$ ~( h3 Tstarted puberty somewhat early, and occasionally,) A8 ^% {/ N) e, G. T- E
testicular enlargement is not that evident in the
- S* c% o, r+ a) wbeginning of this process.1 In the absence of a neg-
! Y1 h* {! |! ?- M7 u4 b; B9 J5 Aative initial history of androgen exposure, our
9 R+ f( B; o& b* g4 Sbiggest concern was virilizing adrenal hyperplasia,
$ G) ]- {# [) S# n. D  l: n7 Teither 21-hydroxylase deficiency or 11-β hydroxylase
8 ]2 ?8 B* |* P' X" m0 ddeficiency. Those diagnoses were excluded by find-
  |; q5 D4 M7 b3 I3 `6 `- qing the normal level of adrenal steroids.
8 n3 M" O% G# |The diagnosis of exogenous androgens was strongly/ E: X5 z6 W( ]: ]7 _6 R; ~
suspected in a follow-up visit after 4 months because
! \" [) Y2 G0 p4 Ethe physical examination revealed the complete disap-
2 Y5 A- \: q4 b) @% @7 Opearance of pubic hair, normal growth velocity, and; o+ {* ~- a8 x% V  C
decreased erections. The father admitted using a testos-& Q. l, ~) X# I. h3 U
terone gel, which he concealed at first visit. He was/ l/ y9 b6 K7 u" K/ v
using it rather frequently, twice a day. The Physicians’) ~! q  d6 R2 E4 F( k6 r7 r4 U
Desk Reference, or package insert of this product, gel or% U! I1 Z  z* t
cream, cautions about dermal testosterone transfer to* r2 j- Q, |% _) V3 @: b. h
unprotected females through direct skin exposure.6 i- E& m2 H3 f: ]* [6 g
Serum testosterone level was found to be 2 times the
! E  C4 {' ~. O' y& {3 n" Ybaseline value in those females who were exposed to
+ g$ }) B* y2 y6 c  `9 yeven 15 minutes of direct skin contact with their male0 c9 x5 l# M; {+ X$ S5 f
partners.6 However, when a shirt covered the applica-4 |9 |4 b! ]9 U% w
tion site, this testosterone transfer was prevented.
5 X! i5 }7 d  o+ j: V. ]& z4 `% cOur patient’s testosterone level was 60 ng/mL,
( d9 O+ Z$ m. P2 x; S$ Dwhich was clearly high. Some studies suggest that
1 F. d, n. C/ P* U: ^+ _dermal conversion of testosterone to dihydrotestos-" ]( E# ^& ?/ y2 R( q
terone, which is a more potent metabolite, is more0 H3 m- N% h9 B: ?# e+ F; w
active in young children exposed to testosterone
$ c- m0 ^* i  u9 I! jexogenously7; however, we did not measure a dihy-
! P! u/ j( S: t) s9 wdrotestosterone level in our patient. In addition to
2 N' e% ?. M2 B& X5 f& S) M- |virilization, exposure to exogenous testosterone in9 V0 d) q  k" ~4 W1 i* L' l' l
children results in an increase in growth velocity and- ]5 E; t- z9 {# t2 g  S
advanced bone age, as seen in our patient.6 d* v3 y1 L$ {! F) E* K# _
The long-term effect of androgen exposure during" L8 h' K. p4 K
early childhood on pubertal development and final" O/ c$ c$ g) T
adult height are not fully known and always remain1 K& v; K4 c4 O  n4 o. ^
a concern. Children treated with short-term testos-
4 |* i) k2 [% Z: a: |9 t7 qterone injection or topical androgen may exhibit some, V- [8 A; L6 P1 i5 G
acceleration of the skeletal maturation; however, after
4 x% c8 e  q% h- c; r, z; Mcessation of treatment, the rate of bone maturation/ e. Z/ H  o3 r* o9 a
decelerates and gradually returns to normal.8,9, R3 M% g8 _, q
There are conflicting reports and controversy
7 B) ?+ u% M' q* ^: tover the effect of early androgen exposure on adult
! ?# E; r8 Y6 I; ?/ f- [, }( Ppenile length.10,11 Some reports suggest subnormal& N6 [8 M, g8 H/ w
adult penile length, apparently because of downreg-
$ R! t2 ?+ u7 C! Aulation of androgen receptor number.10,12 However," M- i0 f! ^6 M4 C
Sutherland et al13 did not find a correlation between/ t# \7 V$ Y8 n
childhood testosterone exposure and reduced adult: ^5 @: i+ B6 J. n  P
penile length in clinical studies.
5 m0 w# I% w2 c9 F# {Nonetheless, we do not believe our patient is
9 F9 v( u$ t$ |8 e! Jgoing to experience any of the untoward effects from
+ q* B3 C1 o4 Q. j. A+ `! Y( Z% ptestosterone exposure as mentioned earlier because
( z3 v% b; o5 r/ r3 l0 L* Gthe exposure was not for a prolonged period of time.  E1 u2 J9 @* m- }( I
Although the bone age was advanced at the time of
  s6 e7 u: u# \6 V3 ?diagnosis, the child had a normal growth velocity at$ a% Y3 J0 p9 [2 V4 l/ C
the follow-up visit. It is hoped that his final adult. e$ E7 t8 l# \8 v2 C6 b
height will not be affected.
5 X/ A0 J" w8 Z  s( w8 I8 v9 P# bAlthough rarely reported, the widespread avail-
6 ]+ E! B( X$ n, D0 aability of androgen products in our society may
/ _% c) ]# @5 A4 `4 iindeed cause more virilization in male or female
' h, W- X6 [$ \- t; l) p$ [; {children than one would realize. Exposure to andro-$ V7 |2 p5 |7 o) L! d; H9 f% \8 ^  F
gen products must be considered and specific ques-0 b1 f" {5 U/ W2 Q8 D6 w/ R
tioning about the use of a testosterone product or+ e+ @4 u0 P: y
gel should be asked of the family members during2 T% i( {0 `- _2 ^$ C# x# ^3 Q% o
the evaluation of any children who present with vir-
+ F  y2 U* }6 E: Y  ailization or peripheral precocious puberty. The diag-
, a% z( n3 _+ ]# Onosis can be established by just a few tests and by: r, t! r  H% {3 X' W
appropriate history. The inability to obtain such a
; y' _) w% F3 t7 p7 X/ ihistory, or failure to ask the specific questions, may% ~+ o' n2 j* |0 v6 q
result in extensive, unnecessary, and expensive
* b, O* H- d: n( d7 Ninvestigation. The primary care physician should be
: v& G( a" Z; F! n, Raware of this fact, because most of these children3 t# V; q2 t# R8 O, j4 k9 y
may initially present in their practice. The Physicians’
( i9 C% T  m: `/ B  J0 lDesk Reference and package insert should also put a
% B; y+ _4 W" I2 x8 {, Jwarning about the virilizing effect on a male or
# [2 }! A; d+ u: [6 M' Qfemale child who might come in contact with some-
8 [: E1 `) d4 d4 Y3 b2 tone using any of these products.
  y% l& M: t/ Z! }7 q7 F. n; IReferences* U5 r8 S  M( e- c- j
1. Styne DM. The testes: disorder of sexual differentiation
, R: P* l! i3 oand puberty in the male. In: Sperling MA, ed. Pediatric3 t+ w: {! n; j. n/ }
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 R3 U) O! p6 H0 W8 e! c
2002: 565-628.
4 h, `6 N& {! f( t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& X' m# @1 y+ N# ^! }0 g: Fpuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

) @' u" V5 [% `( R1 s% v" d- u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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