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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: L9 D  \* G# m7 J% [- m! l
Boy Induced by Indirect Topical* e- m! R8 g1 g+ t
Exposure to Testosterone
/ U6 C! b$ {+ l. ^0 g1 _6 aSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 ?# z1 e0 H  b9 P& N9 J- v9 h% |and Kenneth R. Rettig, MD19 |( n* |/ v( i. O2 ~: \# H
Clinical Pediatrics
/ A. T% J" ]: i0 ?6 oVolume 46 Number 6! R# J( n1 B( K; R* X- N
July 2007 540-543
9 P- N4 u; E; t( R8 n3 _6 y+ v© 2007 Sage Publications
/ N4 i& o0 d: e5 T: g6 A. `6 }2 ^10.1177/0009922806296651& D5 `% }9 |) m; w, u' |/ j
http://clp.sagepub.com
/ F6 S, R- ^1 k( @! ~% j* X7 |hosted at
, m6 H5 x' E9 whttp://online.sagepub.com; k4 I/ [0 @: z8 H
Precocious puberty in boys, central or peripheral,
7 k  @' r' Q& l: O  w9 m) ~is a significant concern for physicians. Central8 R& B+ g( s) z/ O& i" [' u
precocious puberty (CPP), which is mediated
1 M7 {$ V6 c) c3 o/ Vthrough the hypothalamic pituitary gonadal axis, has) M1 W  H& z6 O9 d' S# t
a higher incidence of organic central nervous system9 x0 D: e* `/ }
lesions in boys.1,2 Virilization in boys, as manifested
2 b$ \8 F$ ^$ G& L! kby enlargement of the penis, development of pubic' L% C) N. {* v: g9 x, q8 I
hair, and facial acne without enlargement of testi-
5 [% a+ z( R4 l% ncles, suggests peripheral or pseudopuberty.1-3 We6 e$ L  S( |, C: g
report a 16-month-old boy who presented with the
8 q" n( R, Z; M/ I8 ]7 F6 X) Xenlargement of the phallus and pubic hair develop-
  M) |# j7 W3 }# P6 fment without testicular enlargement, which was due
4 D0 l3 {* K( S' K; A; S% nto the unintentional exposure to androgen gel used by
" w% n8 f8 }. a2 p* R6 pthe father. The family initially concealed this infor-
2 M& f( W! d# U/ @- }* wmation, resulting in an extensive work-up for this% b! U/ S( |) S. a7 K
child. Given the widespread and easy availability of* f* \+ T/ x  ]% v: B
testosterone gel and cream, we believe this is proba-0 @2 V4 O4 ?; S! r2 C
bly more common than the rare case report in the: m3 Z# e; I8 X8 I* O* N# T. R0 r. `
literature.4; S/ @7 @. ]/ p( V) g4 n
Patient Report
% M; H5 ?/ o; v; ?A 16-month-old white child was referred to the: w6 V. _! z6 p6 u2 |1 N! U4 n' g
endocrine clinic by his pediatrician with the concern) {- j) I& K8 k+ V( _! d9 `, e
of early sexual development. His mother noticed
& L2 ~7 F  O5 O' Nlight colored pubic hair development when he was
2 S" g2 Q2 H6 m, oFrom the 1Division of Pediatric Endocrinology, 2University of
) Z0 s, Q6 W! H4 S( p, W2 cSouth Alabama Medical Center, Mobile, Alabama.% r7 u/ y9 F9 H) j+ P
Address correspondence to: Samar K. Bhowmick, MD, FACE,' a" L1 e- s# H# j2 E
Professor of Pediatrics, University of South Alabama, College of
4 d+ T, C  C3 q4 H" a& T7 Q- }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ j1 H/ i0 o: m3 \/ s
e-mail: [email protected].9 T$ ^2 k/ `  @6 x
about 6 to 7 months old, which progressively became! g, r4 |! M8 f. K
darker. She was also concerned about the enlarge-: C# X! A" O3 z# f0 W) D
ment of his penis and frequent erections. The child
' a; ~4 ~4 S% h' g2 swas the product of a full-term normal delivery, with5 _) T  i0 K2 h8 l5 g* p, t
a birth weight of 7 lb 14 oz, and birth length of
+ Q4 `% N( n+ K3 J9 I* ^/ ?5 \20 inches. He was breast-fed throughout the first year
# ~% n2 C# H0 Sof life and was still receiving breast milk along with9 N8 k: G  h5 H  k) u( g4 P* N$ D
solid food. He had no hospitalizations or surgery,
$ b. G/ N" k) ^8 jand his psychosocial and psychomotor development
0 @- j* Z; F( k3 l1 B, k  C( ~was age appropriate.. O3 {4 x4 X+ V+ C, c6 t
The family history was remarkable for the father,! n3 l3 B4 Q9 n- u& a6 a! K/ |
who was diagnosed with hypothyroidism at age 16,, [9 ~; N$ q* l$ H3 }
which was treated with thyroxine. The father’s! F7 ^' L" K* R' _5 ?
height was 6 feet, and he went through a somewhat3 e( Y- Y& Y+ u3 D
early puberty and had stopped growing by age 14.& L; F  ?0 Z+ m8 S! I5 N- f
The father denied taking any other medication. The( G5 F3 K( G% e& T" t8 S5 a& I, w7 L
child’s mother was in good health. Her menarche' `: o+ N' y# w
was at 11 years of age, and her height was at 5 feet
4 x4 }( Y' D# y  {. |5 inches. There was no other family history of pre-
" {- s* y7 |5 I& }" ^cocious sexual development in the first-degree rela-
6 x5 a' D/ n7 s# atives. There were no siblings.
; |6 h1 N" F5 CPhysical Examination6 c# p. h: b, P( f. q
The physical examination revealed a very active,
* r% w  K" D* m. R2 i$ I6 @% g6 Gplayful, and healthy boy. The vital signs documented# y! h6 h1 C( W5 j- p  z$ X
a blood pressure of 85/50 mm Hg, his length was; c1 T, o9 ?1 ^1 v) M
90 cm (>97th percentile), and his weight was 14.4 kg
' p8 d3 q! r" v9 S* t(also >97th percentile). The observed yearly growth% x8 A  }/ x, z. [& S
velocity was 30 cm (12 inches). The examination of
8 r& N+ F* O, ?the neck revealed no thyroid enlargement.
# z# i; A! V$ z1 _0 ~3 MThe genitourinary examination was remarkable for- v! c: V9 W$ i  p; w( }
enlargement of the penis, with a stretched length of/ J: Z; s) v+ q8 t+ i
8 cm and a width of 2 cm. The glans penis was very well
; i+ }1 a* O9 Y. S5 t. |developed. The pubic hair was Tanner II, mostly around4 n* g0 a) _% k7 L1 y. p- k& }
540
. e1 x/ E" q% n) J# U  l/ F- @" W4 kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 ^" Z, `" ^& h0 S1 f6 @
the base of the phallus and was dark and curled. The$ E' B9 l  A9 n8 e  _
testicular volume was prepubertal at 2 mL each.
4 l# U6 T$ w* S6 O2 a: \The skin was moist and smooth and somewhat6 t4 b7 b5 Q* K* D! o9 i
oily. No axillary hair was noted. There were no
: x* f, F$ m/ ]; wabnormal skin pigmentations or café-au-lait spots.
4 E0 q# u0 x% T9 b8 JNeurologic evaluation showed deep tendon reflex 2+0 e) j, f& a! e
bilateral and symmetrical. There was no suggestion1 R& U3 r) N, ^: I" t7 M4 a, o
of papilledema.2 i! h5 A) G& `" e- ?. h0 O/ a( v
Laboratory Evaluation; h8 v: J! V" E% a; U! q  D: }& b
The bone age was consistent with 28 months by4 X" ]2 Z& n2 z2 ]
using the standard of Greulich and Pyle at a chrono-4 }1 ?! R4 b3 v% s
logic age of 16 months (advanced).5 Chromosomal) }! u/ @* p1 v6 {
karyotype was 46XY. The thyroid function test
6 a# ]! O9 s$ zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-/ }- E( b& d9 R0 o8 Q1 j- G
lating hormone level was 1.3 µIU/mL (both normal).
1 j2 A: S$ L% }3 N9 t1 u6 O0 tThe concentrations of serum electrolytes, blood
* g% I" D1 q  _2 N7 }5 @* v! \urea nitrogen, creatinine, and calcium all were
$ V( J$ ~6 F  E9 V/ y' Nwithin normal range for his age. The concentration& p. s% u8 J4 K4 f  j. r
of serum 17-hydroxyprogesterone was 16 ng/dL7 U5 y9 H1 N: H9 f
(normal, 3 to 90 ng/dL), androstenedione was 20
6 Y3 S$ L8 i, d; U0 u/ cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 d5 q8 u' n6 i6 ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ N# N) F  Q: O1 y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 L( z& k* j8 R( e49ng/dL), 11-desoxycortisol (specific compound S)
5 c" J6 o6 D# mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 J% [# S1 A* c6 [- \8 T
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& I/ p" T  L- E+ }  ]8 B* Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& s' Z8 W* e+ n" ]) ^) k9 y
and β-human chorionic gonadotropin was less than
, X, E: ?# b0 V9 t- j4 d. W0 r: v5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ V" n9 D' E3 ]: Bstimulating hormone and leuteinizing hormone
' v5 u0 x! y' }2 h8 J( Gconcentrations were less than 0.05 mIU/mL
) Q5 N) e# l; ]" {2 x) p(prepubertal).
& P$ O# W% W) a+ Z9 yThe parents were notified about the laboratory
: C3 V! }8 Q) m7 l9 yresults and were informed that all of the tests were
! m! U/ n3 }' y# n1 e5 p$ unormal except the testosterone level was high. The
5 W6 C6 N' ~1 M' C  ]% ifollow-up visit was arranged within a few weeks to
7 b& _& j, k( [obtain testicular and abdominal sonograms; how-6 t) b. C( t" }. ~
ever, the family did not return for 4 months.
. ?& i$ ~2 O- W! H8 pPhysical examination at this time revealed that the
: D8 V- y# u4 F1 I) h9 ?: Vchild had grown 2.5 cm in 4 months and had gained; c2 ?- q; G2 m8 L  n# U6 Z
2 kg of weight. Physical examination remained
0 F" i6 _8 D' D6 W1 c7 P3 junchanged. Surprisingly, the pubic hair almost com-/ B! O: @4 X+ i- K( l
pletely disappeared except for a few vellous hairs at; @* t. g( n6 C( [! ?
the base of the phallus. Testicular volume was still 2
3 N- n+ a" Y# f- N1 E- JmL, and the size of the penis remained unchanged.
( ]6 P' f7 u# ZThe mother also said that the boy was no longer hav-: q3 {& k4 k- \. b0 `" L0 M7 ^  R
ing frequent erections.
3 U1 o: y& R$ @/ ~: dBoth parents were again questioned about use of+ [6 P1 o7 A  M9 B2 M) s
any ointment/creams that they may have applied to6 e4 R+ Q. M) A/ g2 @
the child’s skin. This time the father admitted the, K5 r" Y( L/ u! A, l! q
Topical Testosterone Exposure / Bhowmick et al 541
/ z" S% z0 M2 S. j* y1 r$ l, muse of testosterone gel twice daily that he was apply-
) r8 W8 Z' ]( e! ving over his own shoulders, chest, and back area for9 a4 p7 K" L4 B( _- |& @& t
a year. The father also revealed he was embarrassed) n( Y+ |& y# [/ j: _7 T& K& J4 t
to disclose that he was using a testosterone gel pre-$ ~  o: d# g# k; j! O7 _, v- L
scribed by his family physician for decreased libido
7 _/ t: p: J" [3 b) Asecondary to depression.# w; k4 `2 g3 R' P8 I+ w
The child slept in the same bed with parents.
) i3 i& ]' P2 ]. yThe father would hug the baby and hold him on his- B# c& a" }" O) o# a: i
chest for a considerable period of time, causing sig-
* j5 V# z( S8 q+ Rnificant bare skin contact between baby and father.
4 l$ i3 ?9 F' F( aThe father also admitted that after the phone call,
" V# `$ z2 ?6 a9 E3 Y- S! dwhen he learned the testosterone level in the baby
1 D+ n/ z+ c- V9 Q" _was high, he then read the product information
3 j7 M& m% ?5 i+ b  }packet and concluded that it was most likely the rea-7 |5 L( p! I) k- A' N; a. e3 v
son for the child’s virilization. At that time, they
0 Q0 W  s4 m; M6 l3 z' w8 Ndecided to put the baby in a separate bed, and the
) U  W+ b, b% I( cfather was not hugging him with bare skin and had
' h. ^4 o5 Z5 q  _! ubeen using protective clothing. A repeat testosterone
9 j7 k3 `: K; }, N6 T9 ^4 Xtest was ordered, but the family did not go to the
6 K! r8 \5 ^8 R7 _9 @laboratory to obtain the test.2 x. t2 r* l/ m: S5 B
Discussion7 E' R( C* A# q! j4 c  h/ e5 P
Precocious puberty in boys is defined as secondary9 ?  z' q. ~* ]
sexual development before 9 years of age.1,4
6 C$ j4 [% ?9 m5 a0 \Precocious puberty is termed as central (true) when
+ z0 H, K7 t- E$ A% C9 X* s. git is caused by the premature activation of hypo-
+ f1 n6 k6 }) b9 |$ w) Zthalamic pituitary gonadal axis. CPP is more com-
$ S  b0 o$ Z* O( n% N, zmon in girls than in boys.1,3 Most boys with CPP( s  X  Q* L+ y
may have a central nervous system lesion that is% D! r- N9 k1 h6 h9 U' K: y
responsible for the early activation of the hypothal-
9 n) j- Z7 o1 e1 F. I/ p6 Yamic pituitary gonadal axis.1-3 Thus, greater empha-
% W! O2 D8 r2 }. [) lsis has been given to neuroradiologic imaging in! I3 ^) e1 R6 v2 P
boys with precocious puberty. In addition to viril-
( c! v- I) k$ ~; h% X' u% Jization, the clinical hallmark of CPP is the symmet-  t" q' x( I% Y  h* b/ q( \$ j
rical testicular growth secondary to stimulation by- R" B. X8 v/ }0 W' ?6 `) a
gonadotropins.1,3
& Y* T4 V. e' [$ W& ~( F# AGonadotropin-independent peripheral preco-& H& B, B/ h+ p( {
cious puberty in boys also results from inappropriate& F7 I8 y$ C9 d6 ^' d; o- l
androgenic stimulation from either endogenous or  ]3 g' I" ?5 d' [# T2 n
exogenous sources, nonpituitary gonadotropin stim-2 f3 d" o& P) [
ulation, and rare activating mutations.3 Virilizing0 z2 l8 ]; G+ M
congenital adrenal hyperplasia producing excessive4 L' m/ ]; I( f" z4 r5 Y
adrenal androgens is a common cause of precocious
& U# G3 y9 u$ C0 ~6 n: Bpuberty in boys.3,4
/ R( o  \  i1 [2 T; I- Q3 iThe most common form of congenital adrenal, i( n8 f- c3 @+ _7 d
hyperplasia is the 21-hydroxylase enzyme deficiency.
# w. A. X+ u  Z- p3 ^: `" S4 KThe 11-β hydroxylase deficiency may also result in2 s% }' g8 x% r% o" t
excessive adrenal androgen production, and rarely,$ t1 U  c& Z0 D
an adrenal tumor may also cause adrenal androgen* ^: n. H( s* N" F8 e) Y+ V
excess.1,3
+ z! u" p# W8 r( O8 y5 v! _/ Q2 E4 qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- V% v$ `2 x! S0 e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" C/ h& o' c$ Y
A unique entity of male-limited gonadotropin-
( k6 T: K, b: c, findependent precocious puberty, which is also known' A, f2 a% k  _0 N( H
as testotoxicosis, may cause precocious puberty at a% h  O, v7 b# I5 B
very young age. The physical findings in these boys
* j3 [& w+ b: g, Dwith this disorder are full pubertal development,
: l9 m! Q/ {7 L7 [: a' zincluding bilateral testicular growth, similar to boys
3 v0 D& ]  p6 v9 T1 a; twith CPP. The gonadotropin levels in this disorder% D9 m; G8 u. [3 ?* W; n
are suppressed to prepubertal levels and do not show
9 \8 a$ U6 w& H0 kpubertal response of gonadotropin after gonadotropin-
! l; J' a1 s! Sreleasing hormone stimulation. This is a sex-linked
: F& y1 l, e3 Q* _# q; e$ n" Oautosomal dominant disorder that affects only  d5 C) s2 B3 i
males; therefore, other male members of the family2 X: ]2 T, S0 h  ]6 Q
may have similar precocious puberty.3! V" G' M0 C3 n! h5 [
In our patient, physical examination was incon-
' K+ s' R5 r( o) I  ?/ hsistent with true precocious puberty since his testi-2 c. V5 j8 a( {2 U7 @# }
cles were prepubertal in size. However, testotoxicosis. s% B- u9 [* N8 d4 d' d
was in the differential diagnosis because his father7 ~' M7 l7 E7 x
started puberty somewhat early, and occasionally,
: l( `1 R3 t) E3 Ntesticular enlargement is not that evident in the
' d7 U: y  n3 kbeginning of this process.1 In the absence of a neg-
" Z: u! I8 y1 lative initial history of androgen exposure, our
8 \. e9 }  Y. y0 ~biggest concern was virilizing adrenal hyperplasia,/ q' M! B7 A% t1 I  C) |
either 21-hydroxylase deficiency or 11-β hydroxylase
' h) ^5 ]$ [1 V  F9 mdeficiency. Those diagnoses were excluded by find-
0 L, p# S! m: U1 Y. K  iing the normal level of adrenal steroids.$ Y- \' ^- S/ u5 H+ ~& T7 C! H- [
The diagnosis of exogenous androgens was strongly
3 Q7 A+ D% w, I% k2 ?) S! lsuspected in a follow-up visit after 4 months because! O) H8 V8 L" g
the physical examination revealed the complete disap-' A/ Y/ b. {. N$ f" `9 L& L
pearance of pubic hair, normal growth velocity, and
1 h2 f- O" L$ @decreased erections. The father admitted using a testos-( u7 B9 [4 I0 R/ t4 e
terone gel, which he concealed at first visit. He was9 f8 Q( {4 a6 K+ E# y& S
using it rather frequently, twice a day. The Physicians’( P' {2 G  W3 [# C4 l* ]$ Z/ A
Desk Reference, or package insert of this product, gel or/ M* D  E6 \0 D! K7 o+ |
cream, cautions about dermal testosterone transfer to
& J" U; h* A- p6 R: L% I9 m3 Punprotected females through direct skin exposure.
( ~( f+ c" G& r+ qSerum testosterone level was found to be 2 times the8 N$ r% J- g* J; U$ q) M2 N7 ?
baseline value in those females who were exposed to
& ?# W/ o8 A3 G5 w. y' X3 Meven 15 minutes of direct skin contact with their male
0 g6 p5 ~' R9 q1 k! D) `  Spartners.6 However, when a shirt covered the applica-
( n! _; E3 H" ^5 mtion site, this testosterone transfer was prevented.' Z1 f9 r% v7 C# ^# k
Our patient’s testosterone level was 60 ng/mL,
3 q& i8 |! ?# Twhich was clearly high. Some studies suggest that
% k8 E6 K" \1 o9 o; tdermal conversion of testosterone to dihydrotestos-8 B# K4 _' v. g6 O9 h
terone, which is a more potent metabolite, is more* q' b' _0 K3 S- W9 \3 V) p: u) q
active in young children exposed to testosterone' L& R6 h' t# u
exogenously7; however, we did not measure a dihy-
( N7 z  B; M5 G! S% }+ G$ J% o+ h, R$ rdrotestosterone level in our patient. In addition to
0 k7 h* d8 h  u" ~! O1 ~- {virilization, exposure to exogenous testosterone in' a2 G. T* g& F9 }  }* b) a
children results in an increase in growth velocity and$ _0 A4 ]2 U( n* v( h6 I
advanced bone age, as seen in our patient.
3 v0 N: d: y' N- hThe long-term effect of androgen exposure during+ \5 ]% P9 M8 Q: a: r, t
early childhood on pubertal development and final
7 Q' I+ I8 q" J" t/ Dadult height are not fully known and always remain; B& ?' j! N2 Q, ~# f  p
a concern. Children treated with short-term testos-  O9 C) ]4 Y5 L- ^5 e" @/ G
terone injection or topical androgen may exhibit some
8 m+ P5 o% l  tacceleration of the skeletal maturation; however, after
( A% q& z! d# N" Dcessation of treatment, the rate of bone maturation
3 @+ W+ U5 r0 \: i9 e( v, mdecelerates and gradually returns to normal.8,9
: Q5 e3 i3 t( K4 m2 P" `There are conflicting reports and controversy! Q+ I* l: U+ ]* a& m) }! S4 u9 ^% \
over the effect of early androgen exposure on adult9 F/ \2 a/ N9 N4 _1 L$ d
penile length.10,11 Some reports suggest subnormal! @0 X: Q+ S0 U# N6 D6 ^
adult penile length, apparently because of downreg-# b3 ]8 o, h" E( |  x, S
ulation of androgen receptor number.10,12 However,
7 R  F! @+ a. J& l: @. ZSutherland et al13 did not find a correlation between9 ]) j% N, J9 o) l5 j0 l; n
childhood testosterone exposure and reduced adult
, c6 @! R# I. |penile length in clinical studies.4 U. C, M# e) U5 z
Nonetheless, we do not believe our patient is
. w) w  q1 k/ ogoing to experience any of the untoward effects from: v1 l8 u3 s; n5 t6 q
testosterone exposure as mentioned earlier because
' w: D8 c0 Y1 D! Zthe exposure was not for a prolonged period of time.
! s+ Y9 A0 V) gAlthough the bone age was advanced at the time of
8 L+ `+ M, V: rdiagnosis, the child had a normal growth velocity at! {, a9 p% h9 ]( d! ~" s: w0 P
the follow-up visit. It is hoped that his final adult
% m# f( S( v' G9 E# N) v& T8 Dheight will not be affected.
% R: `% k6 O$ A5 v7 b+ gAlthough rarely reported, the widespread avail-
, e. D2 K8 V: s9 U2 ~ability of androgen products in our society may
" E% }( W& G& l$ D, d0 i; |indeed cause more virilization in male or female" ?( d6 h* V1 T1 U0 S
children than one would realize. Exposure to andro-
& q, e, ?; u" ~* ]% {gen products must be considered and specific ques-8 ~. [5 I8 T2 N& U; {
tioning about the use of a testosterone product or
% b. K3 {6 K. w: [- W3 Q" S3 tgel should be asked of the family members during
9 J' s# X- R% bthe evaluation of any children who present with vir-3 X1 |: L8 r' V! O  B
ilization or peripheral precocious puberty. The diag-. a0 n/ p% i6 J/ \& d! V
nosis can be established by just a few tests and by+ D  g% m% ^6 p, {
appropriate history. The inability to obtain such a5 c1 {, X6 \( \* T, y- A" Z
history, or failure to ask the specific questions, may" {6 z' l# T- R! r$ q. r. P
result in extensive, unnecessary, and expensive
9 k2 V" ^2 M+ N0 S- Y. @investigation. The primary care physician should be
) P9 w( T- Y0 H1 y* T" Aaware of this fact, because most of these children
+ [# C: J3 D4 [1 s" Imay initially present in their practice. The Physicians’
# f) @0 w* C& i4 X9 Y! b5 L! wDesk Reference and package insert should also put a" W- s' O5 ^4 s+ ~! c
warning about the virilizing effect on a male or2 B4 L4 S% G9 x
female child who might come in contact with some-6 I( y- R/ z1 K. x0 k
one using any of these products.6 z* [2 Y9 Z; \. ]5 ?( e2 B: y8 D8 S
References
; j+ f" W% B( }& c0 t1. Styne DM. The testes: disorder of sexual differentiation
3 X0 Q  f2 `0 L  x, \8 l5 S: eand puberty in the male. In: Sperling MA, ed. Pediatric) M+ {) ~1 |2 a3 }7 F4 ]+ Y) {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" O+ ~# \6 {/ h- `2002: 565-628.0 F6 ?  O2 y( x6 R1 Q0 J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 q" I2 J/ _( G0 ~1 s1 R- ]
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
5 _1 P. u2 @- d4 s5 g" J5 xBoy Induced by Indirect Topical
, j4 m$ D8 X0 G: n' E, d& eExposure to Testosterone7 [3 X7 c0 p5 ?! K% f' K0 b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, L4 k4 C4 c. r# E6 s
and Kenneth R. Rettig, MD1
. Y) a4 Z4 i( U. g( g5 W5 xClinical Pediatrics) A3 h- w6 S# Z: f2 ?( o
Volume 46 Number 6
) w5 D+ p; ?! q8 H  j/ WJuly 2007 540-543
6 [% g% K+ {: g' n6 j© 2007 Sage Publications; T8 H3 ?) ]* i& ^2 c
10.1177/0009922806296651
( o3 F4 `: E7 s. W5 whttp://clp.sagepub.com
! ~& s1 Q/ S. j* B) Fhosted at
8 \( x4 @0 d; D1 p' m5 x, Hhttp://online.sagepub.com, g1 ~& J4 n$ g! z" F! b* n8 `
Precocious puberty in boys, central or peripheral,
. C/ O9 ^: u' p$ His a significant concern for physicians. Central  [# J0 Q& N6 S7 `7 m! Y
precocious puberty (CPP), which is mediated
4 O) b" u/ v2 ]+ M& K" Z0 v9 X9 @through the hypothalamic pituitary gonadal axis, has
3 V: d& f8 \( |" X8 Fa higher incidence of organic central nervous system+ H6 c& {" P# |, y7 ]
lesions in boys.1,2 Virilization in boys, as manifested2 F" E9 ?: q7 v5 P8 E
by enlargement of the penis, development of pubic$ ]8 X+ W# v4 x$ E' {& Q
hair, and facial acne without enlargement of testi-  s( ~, m5 o6 ~+ F) Y$ D
cles, suggests peripheral or pseudopuberty.1-3 We
) G9 _- K6 l- ]report a 16-month-old boy who presented with the
' g' I$ A# z& P% {# q6 V1 Kenlargement of the phallus and pubic hair develop-% z# C" R2 |' N3 \: n' `/ o( D
ment without testicular enlargement, which was due
2 [3 R& P7 c' a/ g- yto the unintentional exposure to androgen gel used by) L$ I0 X9 E4 m6 f
the father. The family initially concealed this infor-
; Z, }+ l# I9 T! W' A* n+ l2 {  b% Emation, resulting in an extensive work-up for this1 m, m5 Y% @( b' m( u5 r
child. Given the widespread and easy availability of  E$ d7 ^0 b; z! W
testosterone gel and cream, we believe this is proba-. Q# o( v4 Q1 e7 F  b$ o7 c
bly more common than the rare case report in the- ^: G4 M! i4 h; E' ~
literature.4% {7 X. G- A2 F& d
Patient Report* ~4 _. h, s1 C6 B* V$ \8 q# \# B$ a
A 16-month-old white child was referred to the% ~1 n  p$ o/ y7 o% H! h
endocrine clinic by his pediatrician with the concern$ c5 T- a* a8 R& }( A% ], K9 o3 W
of early sexual development. His mother noticed+ m5 O4 I% d$ l0 I4 Y4 X
light colored pubic hair development when he was- O* J0 U' Q2 \- J7 P
From the 1Division of Pediatric Endocrinology, 2University of
7 v3 q# u9 u" N1 D$ Z- c3 w" \South Alabama Medical Center, Mobile, Alabama.5 v8 Y  V/ Q* T: h% q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 J2 x: ?6 v+ U6 I2 g4 _Professor of Pediatrics, University of South Alabama, College of
7 y6 g& M3 J, b. a' u2 o" dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 Q3 B( B/ r2 {; Z+ K8 we-mail: [email protected].
. S- o9 A: k( v# Sabout 6 to 7 months old, which progressively became
& o0 s4 R; Q* [& Wdarker. She was also concerned about the enlarge-
/ ~8 I0 V# P, {& b. [ment of his penis and frequent erections. The child
+ z" `- Z; H; U( T+ Rwas the product of a full-term normal delivery, with7 U7 }" q% O7 p( x, U
a birth weight of 7 lb 14 oz, and birth length of
- H- ?3 J, W& `% \20 inches. He was breast-fed throughout the first year' r* i! r. B  ^7 V" f
of life and was still receiving breast milk along with- J. s4 H( L& `' W7 }' ^& c" g7 @1 T
solid food. He had no hospitalizations or surgery,
0 B* x4 d0 Z2 u7 [and his psychosocial and psychomotor development9 [/ ^/ j3 u! M/ S9 S2 z
was age appropriate.- H- `/ t2 L; o" X
The family history was remarkable for the father,& w) h8 N: q+ O5 H( K3 _* d
who was diagnosed with hypothyroidism at age 16,$ `. U' ~) t2 j% I% f; o5 ?' D
which was treated with thyroxine. The father’s- s# Y4 n5 j% j3 _, r
height was 6 feet, and he went through a somewhat$ t) m9 e; h7 @% \- ^1 r  j
early puberty and had stopped growing by age 14.
* @7 S# R, ?) Z6 ~1 s# s- lThe father denied taking any other medication. The" K# q5 ~/ O. h# S
child’s mother was in good health. Her menarche
: z/ a( ^  U  nwas at 11 years of age, and her height was at 5 feet* w7 g- x& y0 C; S
5 inches. There was no other family history of pre-& e3 o& E5 B7 E5 O' M! f  F& X
cocious sexual development in the first-degree rela-
& }& T4 T1 t! Gtives. There were no siblings.0 o* e, j% y9 U. g
Physical Examination5 t5 F* E' j; N3 {$ |% D9 Y
The physical examination revealed a very active,7 Z7 G; q1 |/ S) {- c" u7 f
playful, and healthy boy. The vital signs documented* L2 ?; }) w( `( s7 Q) ?+ J9 |
a blood pressure of 85/50 mm Hg, his length was
/ z7 z1 H1 m1 l90 cm (>97th percentile), and his weight was 14.4 kg
+ b& @3 `% F+ p+ ~6 f(also >97th percentile). The observed yearly growth
: S9 H8 F& k; V+ a' I0 l0 s% zvelocity was 30 cm (12 inches). The examination of% S1 O, `+ k0 b
the neck revealed no thyroid enlargement.
+ e4 q8 n  E6 f4 _; \  wThe genitourinary examination was remarkable for
2 P/ E8 c6 U! J" N& Z4 n( Y% V7 Jenlargement of the penis, with a stretched length of" D) O4 F. @4 m) P: _+ n. l8 U
8 cm and a width of 2 cm. The glans penis was very well0 X3 H# d; Q/ ~( u+ |3 I
developed. The pubic hair was Tanner II, mostly around
* y, B; }% ?. V540
3 Q6 v! s# c! D" N  |2 N/ W5 G; Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! l7 O5 O, U; X0 g5 othe base of the phallus and was dark and curled. The, S7 g0 a* B5 P& ?1 R% T
testicular volume was prepubertal at 2 mL each.
; x4 ~4 l, Q  _The skin was moist and smooth and somewhat) G/ N" c: e* Q/ C& r
oily. No axillary hair was noted. There were no
. Q* A5 _# I. Q1 l2 q2 rabnormal skin pigmentations or café-au-lait spots.8 `! @- H% E+ m! I) P
Neurologic evaluation showed deep tendon reflex 2+
; a$ w" X3 L6 t/ xbilateral and symmetrical. There was no suggestion
: N! W+ f0 c' [$ f5 Jof papilledema.
% \4 M: S0 Y4 s- s& GLaboratory Evaluation1 o1 f/ A* }1 _
The bone age was consistent with 28 months by
3 V' R# ?# v. V6 ?+ Busing the standard of Greulich and Pyle at a chrono-  k2 P* K4 L1 g2 l/ P4 ?/ Q. ^
logic age of 16 months (advanced).5 Chromosomal& u* K% D5 P0 \7 ^5 s, p' G
karyotype was 46XY. The thyroid function test' d- t3 n6 R8 Y( j6 b- N3 k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! E2 s  i7 @8 W0 F. Q4 H
lating hormone level was 1.3 µIU/mL (both normal).# z- P  S$ V4 _/ W+ N# {: u1 n9 T
The concentrations of serum electrolytes, blood2 g( @/ _( Z8 i9 W& Z' Z7 [& F
urea nitrogen, creatinine, and calcium all were0 A2 z! x2 n, ?) {; L
within normal range for his age. The concentration
0 c$ k& w$ a1 e/ [- Wof serum 17-hydroxyprogesterone was 16 ng/dL
' w. ?9 w4 S* X8 k(normal, 3 to 90 ng/dL), androstenedione was 206 ~& q9 s. O9 q0 R, c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( N, t/ U  G1 Z# Y/ ]* _terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 s2 e6 N8 E2 J2 l+ t" G: v( t
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 Q6 _* n& O% l7 |
49ng/dL), 11-desoxycortisol (specific compound S)! x- k5 `2 C# f- n3 s7 l7 L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 R3 \- ?) y  [: F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ A+ f& h  M( b; H) ]6 Qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& N1 h! A* B' A$ h5 k; V* u
and β-human chorionic gonadotropin was less than
" ~0 x$ E, ^6 V, f3 v1 O; X$ |5 mIU/mL (normal <5 mIU/mL). Serum follicular+ ]2 F; N" @0 W! @
stimulating hormone and leuteinizing hormone
: \  x+ n3 `6 I4 `concentrations were less than 0.05 mIU/mL8 r- m6 u3 n' ?$ C  J2 e* T
(prepubertal).
8 O4 ^5 q" V- H: }) I% Y$ J4 GThe parents were notified about the laboratory
0 x' ~1 U, j$ V9 C5 Y+ Wresults and were informed that all of the tests were
# c9 N1 t. n( x! T3 y; p0 Pnormal except the testosterone level was high. The6 v) c5 R, k# y, z
follow-up visit was arranged within a few weeks to7 d: t2 s% p4 c* \! x5 x
obtain testicular and abdominal sonograms; how-9 m% w% |3 x8 l6 ?  m
ever, the family did not return for 4 months.
- r# z4 k4 r4 n9 V2 s7 oPhysical examination at this time revealed that the4 R) L6 a9 n# d* n  s/ M+ [
child had grown 2.5 cm in 4 months and had gained
2 i( U; @# T4 m/ e3 B2 kg of weight. Physical examination remained
$ S9 I, ~. V  E% runchanged. Surprisingly, the pubic hair almost com-
/ r' S2 I0 q1 L/ N% Z, e0 [& Cpletely disappeared except for a few vellous hairs at9 n: Z, K$ T1 |( k4 n
the base of the phallus. Testicular volume was still 20 e; j" N& `) E7 `( ?3 e6 t9 Z
mL, and the size of the penis remained unchanged.
! a+ H* }5 W, c, P  a( CThe mother also said that the boy was no longer hav-
# L* a) H! U4 H/ ~6 ting frequent erections.. G2 S' k1 w; |6 |" O* {- B
Both parents were again questioned about use of- {4 s  i6 p# g5 q: b" d; f$ b# W; e) G
any ointment/creams that they may have applied to  W6 h1 Q: J  L+ v# p; O
the child’s skin. This time the father admitted the
: _3 t( ?2 f3 S9 S7 K+ t$ E5 KTopical Testosterone Exposure / Bhowmick et al 541
/ a5 x* _' S% ]  yuse of testosterone gel twice daily that he was apply-
2 f# ^1 u. d& Y+ ~; U, \ing over his own shoulders, chest, and back area for
- ?; d% r$ o8 F1 M6 Fa year. The father also revealed he was embarrassed
+ |  O( j- t2 y' d6 \to disclose that he was using a testosterone gel pre-: R3 q: X" S  c) w- C) X, V
scribed by his family physician for decreased libido3 y& E& H! w& h. X2 G5 L0 \
secondary to depression.% b/ S9 ^% h- w! q+ c% [7 P# s
The child slept in the same bed with parents./ l) c- a) R7 r6 ^$ L; C
The father would hug the baby and hold him on his, V( u) @5 |/ f' w  y) T* ^0 C. b# N
chest for a considerable period of time, causing sig-2 _% N9 P5 D# {) m& x* N0 [" K
nificant bare skin contact between baby and father.* c( }( L7 w4 Z, V
The father also admitted that after the phone call,
+ H  j$ W# q: \when he learned the testosterone level in the baby$ P# m" U6 @2 k4 r# z2 }) q
was high, he then read the product information( G; K( ~& d! r6 g# t2 V
packet and concluded that it was most likely the rea-" K- L' {& K5 W9 d6 A
son for the child’s virilization. At that time, they
) Y$ K. o; ]9 {2 d6 y. q; L/ ]decided to put the baby in a separate bed, and the& e2 `+ J3 z5 Y5 Y$ E1 a5 y
father was not hugging him with bare skin and had
9 v+ S& u$ _& q1 d4 bbeen using protective clothing. A repeat testosterone6 P9 H6 C7 g7 E; v: r( q! Q
test was ordered, but the family did not go to the
8 f) h) ]- h% C5 a$ y% T, Z7 olaboratory to obtain the test.
! [" Y4 Y# O- g8 S- |; ZDiscussion/ ]3 H5 l2 c6 ^( N( W3 w4 D
Precocious puberty in boys is defined as secondary1 k4 Y% T7 F! M2 _, @* }# w
sexual development before 9 years of age.1,4
4 k" E" ?% Q# A* S3 ]Precocious puberty is termed as central (true) when
4 c- c5 ]8 Q( }- j) k$ tit is caused by the premature activation of hypo-
6 s: b, y4 A8 }" A# _2 _2 rthalamic pituitary gonadal axis. CPP is more com-! f8 j$ U- e8 B' a' C
mon in girls than in boys.1,3 Most boys with CPP+ d  Y' W5 O7 \
may have a central nervous system lesion that is, z3 k( q+ {# B3 `
responsible for the early activation of the hypothal-
3 w6 q5 w0 {0 j. d; B# Jamic pituitary gonadal axis.1-3 Thus, greater empha-
- ?# L- v( X0 w' N$ v+ [sis has been given to neuroradiologic imaging in# Y0 S7 q% G0 h  b- Q
boys with precocious puberty. In addition to viril-
* ]8 Y# I1 @( N+ Y# ?+ Yization, the clinical hallmark of CPP is the symmet-1 k. g' ~- R- {& e% T1 z; ^
rical testicular growth secondary to stimulation by, D0 `) u1 [, ?
gonadotropins.1,3/ e! Y5 l! m  C6 t7 x& p9 O4 x7 w
Gonadotropin-independent peripheral preco-
2 ?7 o7 e! j- mcious puberty in boys also results from inappropriate; s1 e& _& {; L" d
androgenic stimulation from either endogenous or
- D, k) E1 a/ {7 X* U7 a# pexogenous sources, nonpituitary gonadotropin stim-
  b  b+ T/ U2 m& j8 nulation, and rare activating mutations.3 Virilizing5 N$ Z  y9 s; P  j7 d6 h! Q/ [$ q
congenital adrenal hyperplasia producing excessive
1 Y% S* {4 k% F  ~: k& R/ wadrenal androgens is a common cause of precocious5 f8 `% ]. p4 S& E
puberty in boys.3,4  _- E: X! Y, d, ?2 z  T4 N. p
The most common form of congenital adrenal
1 g* x9 W) q; N0 phyperplasia is the 21-hydroxylase enzyme deficiency.! P: n7 W3 @# V% F. t! \
The 11-β hydroxylase deficiency may also result in- m7 W. t0 k& z
excessive adrenal androgen production, and rarely,5 D  l8 G3 Y* P) P" {( _
an adrenal tumor may also cause adrenal androgen# K( X( m" B7 R% H& W: D7 |
excess.1,3
* h; v1 ~& T" c3 S) Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! F( j, ?3 n2 j" k4 o
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. t: B$ m- `9 l# O" ^. I9 W3 Q
A unique entity of male-limited gonadotropin-
! `: V9 `( ~2 R# cindependent precocious puberty, which is also known
* G, b: D3 @% t  Y* e4 ras testotoxicosis, may cause precocious puberty at a8 M& o1 i) Z! K& B( ?, v4 n7 f
very young age. The physical findings in these boys; S7 L3 F0 B3 m, a/ F
with this disorder are full pubertal development,
6 |8 P* a& K$ t) k% U; a5 K. |including bilateral testicular growth, similar to boys
: p2 X6 C. d" b( ]with CPP. The gonadotropin levels in this disorder/ N. a# m. |$ H7 g' E
are suppressed to prepubertal levels and do not show
% R2 W2 k$ {" R+ m6 I0 Cpubertal response of gonadotropin after gonadotropin-
! f1 W. A( c1 ]8 v. @% n" ereleasing hormone stimulation. This is a sex-linked) B$ M1 k2 K, }1 T+ {6 G
autosomal dominant disorder that affects only$ ~# g% Q4 X) \& }6 I+ Q
males; therefore, other male members of the family
$ b' j' J8 W9 P" Umay have similar precocious puberty.3
$ r" s' i" p* r/ p9 S1 pIn our patient, physical examination was incon-
! y/ w1 R. e6 I# k  l( Esistent with true precocious puberty since his testi-
+ [% @5 z& f% \4 y) l3 V2 Bcles were prepubertal in size. However, testotoxicosis
- O- }- v% @7 Q6 ]% ~4 c" q% Kwas in the differential diagnosis because his father: x8 i! g7 }" b3 U* S# i
started puberty somewhat early, and occasionally,3 B5 m, G" @1 }$ L! z3 p
testicular enlargement is not that evident in the
& I* f9 I% E* t! H1 ?! _- Sbeginning of this process.1 In the absence of a neg-
) o. W/ G3 Y8 d% s$ N# T: r2 sative initial history of androgen exposure, our. l" y. |- q7 q' G; f) n9 N
biggest concern was virilizing adrenal hyperplasia,
. G* k8 j, n: {& d( r! Weither 21-hydroxylase deficiency or 11-β hydroxylase
/ \- ]9 z7 j; ]' Adeficiency. Those diagnoses were excluded by find-
4 g: q% k# |' oing the normal level of adrenal steroids.
. x( ~  X* n5 {* N/ D0 [6 [The diagnosis of exogenous androgens was strongly
6 l! A6 T$ H% `suspected in a follow-up visit after 4 months because
$ U& r" @8 X' @- q- ]0 sthe physical examination revealed the complete disap-
) S7 S5 L# O+ j8 E6 A3 g2 ?/ L: Mpearance of pubic hair, normal growth velocity, and
9 I, j, ^1 j! w. ydecreased erections. The father admitted using a testos-/ S8 ?; S6 |7 n& D5 |
terone gel, which he concealed at first visit. He was
: x" T, c1 |2 @# h: q5 b5 susing it rather frequently, twice a day. The Physicians’' E$ ^6 S" y9 A8 M2 T6 q$ M- o7 ?9 {
Desk Reference, or package insert of this product, gel or2 x/ b) I; f, U% N
cream, cautions about dermal testosterone transfer to
  C5 T7 j2 h$ s( w4 I1 d2 Iunprotected females through direct skin exposure.
& k3 R! O; F4 t7 B; M) N' ^3 sSerum testosterone level was found to be 2 times the" r5 r$ y% ?' p7 G
baseline value in those females who were exposed to
6 u, D3 A4 O4 i9 t( D; aeven 15 minutes of direct skin contact with their male
: Q3 Z# u+ x" K- j5 W% vpartners.6 However, when a shirt covered the applica-
! b) _8 Q$ n# [! B9 r) k  b: jtion site, this testosterone transfer was prevented.7 _) ^& w+ Q' q% d. h" w
Our patient’s testosterone level was 60 ng/mL,
4 e" g, {3 s( J! |which was clearly high. Some studies suggest that
! m: W/ R$ O3 a) C0 wdermal conversion of testosterone to dihydrotestos-( C! g7 B0 d; k& N! h
terone, which is a more potent metabolite, is more: j* q$ s& A, ]- e
active in young children exposed to testosterone: e3 d4 c3 ?2 ]+ q% X6 a/ n; y$ v
exogenously7; however, we did not measure a dihy-
8 \- G) B9 [$ k. f+ Pdrotestosterone level in our patient. In addition to
  H9 s9 G/ g/ q9 D5 Zvirilization, exposure to exogenous testosterone in
  W% b/ S# z/ O$ Y9 e4 C% Z, j1 zchildren results in an increase in growth velocity and
5 h6 [& R& ~/ I1 O; xadvanced bone age, as seen in our patient.' G2 N, o6 E' S7 ~; G5 n  s- s
The long-term effect of androgen exposure during' G9 w5 F* i, L
early childhood on pubertal development and final
( _: @# f* a. Y1 i, t4 k0 y5 dadult height are not fully known and always remain
# `8 E: n  i' r, L% e; _: W, j0 S8 e  qa concern. Children treated with short-term testos-
, O) y6 V. I! ~! X9 yterone injection or topical androgen may exhibit some
8 X; D. z3 O! s8 ~acceleration of the skeletal maturation; however, after
0 i0 y+ n4 W2 q! P4 l$ Acessation of treatment, the rate of bone maturation& c8 J* S2 u+ V  k
decelerates and gradually returns to normal.8,9
2 z$ b6 r. X( Y4 \There are conflicting reports and controversy
& t- }, a* u$ |over the effect of early androgen exposure on adult
4 c+ N& _% d0 ^$ Apenile length.10,11 Some reports suggest subnormal; @) B0 E  y& l5 e  [  J; p
adult penile length, apparently because of downreg-
& J# S: v: v. j. R3 l' o0 z" U/ r! d4 Xulation of androgen receptor number.10,12 However,
- t; J7 z# h$ O! O7 d$ `( ZSutherland et al13 did not find a correlation between# g0 S  `: h' L# P. G# U1 z8 V1 k' K
childhood testosterone exposure and reduced adult2 M  X# e7 G0 n
penile length in clinical studies.
$ Q- d/ V# s  I2 s/ c- }1 ^' t1 R. MNonetheless, we do not believe our patient is
& U/ [2 l- a$ V3 rgoing to experience any of the untoward effects from
0 v, b6 n* J! b" d8 Ktestosterone exposure as mentioned earlier because
& D- h: h! p+ W; M& `the exposure was not for a prolonged period of time.7 _4 O& j. y/ g" w7 f/ e8 d
Although the bone age was advanced at the time of" `, ~4 @1 C! Z8 ^+ D
diagnosis, the child had a normal growth velocity at
$ L2 s, N8 M* U- E  Pthe follow-up visit. It is hoped that his final adult/ M  F& }$ z0 H0 j
height will not be affected.
. w+ S" B9 P) G2 Z# ]6 oAlthough rarely reported, the widespread avail-
  H; d! ^, D: \: Y, m9 D+ f+ X: ?8 Rability of androgen products in our society may( l9 D" ~8 N& w$ j
indeed cause more virilization in male or female9 Y  U4 u1 z/ E2 q
children than one would realize. Exposure to andro-
% s0 O! q) \  Z/ n. Z5 Vgen products must be considered and specific ques-& j/ z& T, v, r3 _0 c6 |1 P
tioning about the use of a testosterone product or
+ f0 ]* _6 Q  K5 r# t/ ]gel should be asked of the family members during
2 a% D2 U$ }& `7 r4 T, Vthe evaluation of any children who present with vir-& j: G0 |' u. P3 J# v" P0 i
ilization or peripheral precocious puberty. The diag-
9 z" @, y* R2 D3 ynosis can be established by just a few tests and by
( p3 ]* d& }2 a* k2 D: eappropriate history. The inability to obtain such a
. `# {! T) ]* ?- rhistory, or failure to ask the specific questions, may: m, E+ C$ {1 Q
result in extensive, unnecessary, and expensive' L- j' ]4 K7 |
investigation. The primary care physician should be! k/ j. S+ c8 G0 f7 [
aware of this fact, because most of these children
! R, v+ e/ N; j, gmay initially present in their practice. The Physicians’
. i: P$ ~& _+ G- ^& hDesk Reference and package insert should also put a
7 d& h# e% M- P" r1 v2 Lwarning about the virilizing effect on a male or; m6 W* Q& w3 P% \' Y
female child who might come in contact with some-+ c" w/ m  s: k6 w
one using any of these products.3 P1 s; u$ N7 ~* x/ l: Q( t! M2 q
References7 u" S) C1 e( U: Q  L
1. Styne DM. The testes: disorder of sexual differentiation
& M2 o6 A4 }6 d1 `) eand puberty in the male. In: Sperling MA, ed. Pediatric6 a5 o! C. _( Y, f6 a
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* X  I- t2 d. ?' k
2002: 565-628.
+ M$ d# g9 p5 |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! p0 ^% {9 z+ n6 z# A
puberty in children with tumours of the suprasellar pineal
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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
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

, V& L, S/ f' b# y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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