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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( y5 w  p6 I4 W) ^1 ?
Boy Induced by Indirect Topical
: |7 P4 I* h; ~+ O, V& M, AExposure to Testosterone
9 e( J- A: m, c* ~# n8 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 u, b0 z- Z* ~, P  {! B4 Iand Kenneth R. Rettig, MD16 I( o  B+ C& X# \; x. v) y, K5 G
Clinical Pediatrics
# W' w7 g+ ?- u* E" N. ZVolume 46 Number 6
# o+ Q2 e; u* C4 c9 w, a$ _' }% r( qJuly 2007 540-543. b$ k: V8 i8 v3 A% S( z" I
© 2007 Sage Publications# s( L2 l1 c6 z$ A2 x
10.1177/0009922806296651: ~& ~' B0 a# z& e% O5 _
http://clp.sagepub.com; v" H+ b; |& A8 f; }
hosted at3 _0 s# ^% [+ b% e2 L7 z
http://online.sagepub.com
: ^) A0 o1 K- G  {' ^Precocious puberty in boys, central or peripheral,
0 S' G2 Z" |; {  g" [" Ais a significant concern for physicians. Central
! r/ j) p) i5 c9 ~) d2 f1 yprecocious puberty (CPP), which is mediated
) S+ y) x( p9 t0 M) Y1 rthrough the hypothalamic pituitary gonadal axis, has
( V  c1 L" e: @5 F$ E2 Q8 wa higher incidence of organic central nervous system
1 v0 l6 o7 m: f9 F5 c7 R: ylesions in boys.1,2 Virilization in boys, as manifested' `& t) u  x* t( I0 H  _
by enlargement of the penis, development of pubic9 v. a0 E! O" w
hair, and facial acne without enlargement of testi-
: E0 u9 {4 m- |: y# ?# Ecles, suggests peripheral or pseudopuberty.1-3 We
% @: W/ d+ v3 F3 V0 B9 n7 ]report a 16-month-old boy who presented with the, A" J+ z+ V' ^' I# n. l5 q
enlargement of the phallus and pubic hair develop-
6 {5 [, D, P5 ~2 g7 p0 wment without testicular enlargement, which was due
) }" x6 I! ?) R& g) ito the unintentional exposure to androgen gel used by
: G2 S2 Q! K: V; ithe father. The family initially concealed this infor-/ |! r, h5 O- h
mation, resulting in an extensive work-up for this9 K0 I8 T: i1 J; V) y
child. Given the widespread and easy availability of3 i( O. b6 S) l* Z, r, k
testosterone gel and cream, we believe this is proba-, `# s; \  F( M: M. C; S6 P4 S! s
bly more common than the rare case report in the
7 a4 X& }  m2 Z6 I- jliterature.4, [  B8 R/ a7 b) ^0 G
Patient Report0 _# p0 l, @8 d! D$ j
A 16-month-old white child was referred to the+ i: c  |9 o7 N# F- j
endocrine clinic by his pediatrician with the concern
3 a) K1 t/ v; R8 _7 R+ ~' sof early sexual development. His mother noticed
. |' `, L4 i$ W( z8 m/ j6 Mlight colored pubic hair development when he was
8 Z2 g6 i9 i) [+ Y0 E+ W6 f) }0 QFrom the 1Division of Pediatric Endocrinology, 2University of4 p7 e' \/ V8 [
South Alabama Medical Center, Mobile, Alabama.2 }. b- w( g+ _4 u& q
Address correspondence to: Samar K. Bhowmick, MD, FACE,* B; I6 R) l( M0 P; x
Professor of Pediatrics, University of South Alabama, College of3 A8 V5 ?  ]4 A, x0 }2 y3 |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 ^3 s5 |7 e6 e/ E& b
e-mail: [email protected].
7 t! B1 L% u1 i+ A1 T1 Habout 6 to 7 months old, which progressively became& X: v* s; Z% J3 r& x  L* g; f3 n
darker. She was also concerned about the enlarge-: f  j( U4 D' U. ]
ment of his penis and frequent erections. The child
% c, H: ~3 @# @% h0 }$ U' Twas the product of a full-term normal delivery, with; s! g% ^  ^$ s# v  m
a birth weight of 7 lb 14 oz, and birth length of! z  K" R( [2 n5 Z# \! \( y% A
20 inches. He was breast-fed throughout the first year
% J8 f9 \0 l* Wof life and was still receiving breast milk along with% @7 |$ D, k; t6 F. i  L( [
solid food. He had no hospitalizations or surgery,
, ?; x/ h0 Z$ o! p  W. x2 wand his psychosocial and psychomotor development- ~' y# c% w7 ?1 E4 ^4 m+ E
was age appropriate.
) _$ `4 r: i4 C( `The family history was remarkable for the father,
) N. i) l) Q9 Q# `who was diagnosed with hypothyroidism at age 16,% |& P0 g# p2 V( Q+ O
which was treated with thyroxine. The father’s) ?, L2 }! a! J) ^' J0 A$ F  x
height was 6 feet, and he went through a somewhat0 @+ k; R- k1 h1 ?. T
early puberty and had stopped growing by age 14.3 f) E9 e# m4 _8 {4 [
The father denied taking any other medication. The$ G! ~! B' i( P0 q1 \, @1 K
child’s mother was in good health. Her menarche
* Z/ H' A/ b, o) b4 |was at 11 years of age, and her height was at 5 feet% |' E4 Q- m* \5 _' ]
5 inches. There was no other family history of pre-
8 ]0 B1 [0 X& ]1 O9 d4 O( Jcocious sexual development in the first-degree rela-
: G& t8 C# d( f" l/ Wtives. There were no siblings.- Z6 S; ?  j5 w& P1 F% P9 e* Y
Physical Examination5 H- x: b5 {0 O5 }% l1 H6 D9 t: K
The physical examination revealed a very active,
4 m) _4 y- N. m2 m4 k; @& x0 C# }playful, and healthy boy. The vital signs documented: \+ q, v4 T1 W! ]! E& F1 f2 z
a blood pressure of 85/50 mm Hg, his length was
. T7 z; ~% x8 b90 cm (>97th percentile), and his weight was 14.4 kg8 @+ r/ F# G7 L5 x$ g2 Q; e/ U
(also >97th percentile). The observed yearly growth) Y; ~& Z' g  C! h7 q3 K
velocity was 30 cm (12 inches). The examination of
$ y- ?1 f2 z" w) f, Vthe neck revealed no thyroid enlargement.+ x. S  T6 c7 Q+ L7 [# z! T  e
The genitourinary examination was remarkable for% e( p% g5 ^5 ^8 k! E
enlargement of the penis, with a stretched length of8 U- E3 {' t( i. w
8 cm and a width of 2 cm. The glans penis was very well
( s5 j( t) o  s+ Z7 \. ^- Z7 cdeveloped. The pubic hair was Tanner II, mostly around+ P( v" O3 i) O% I0 X
540
+ Q2 @8 C2 W+ Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, t, l" |% T1 I7 |% D- B* B/ ^
the base of the phallus and was dark and curled. The
% i) R" h) f$ @$ {testicular volume was prepubertal at 2 mL each.
, I6 h+ Y5 M0 G0 i' B* B, D% |The skin was moist and smooth and somewhat* Y/ Z' [& m1 \+ E. b: R6 X1 N
oily. No axillary hair was noted. There were no
. f8 R5 j3 g0 D/ s8 ?abnormal skin pigmentations or café-au-lait spots.
5 S  c( J' ~. B  j8 yNeurologic evaluation showed deep tendon reflex 2+
/ [& F+ V3 T+ s( b! G0 Lbilateral and symmetrical. There was no suggestion
. F1 A9 C, @0 e9 N. nof papilledema.. X7 p5 Y0 C) e8 |! l% s
Laboratory Evaluation- k4 x2 X/ j: x' ~
The bone age was consistent with 28 months by0 S* r- z/ G% n- j
using the standard of Greulich and Pyle at a chrono-
, u$ C8 O0 ^& V: m: I1 jlogic age of 16 months (advanced).5 Chromosomal
# m$ e  t0 c- `9 C! |, }/ p; qkaryotype was 46XY. The thyroid function test8 O' ^3 H4 a+ G" @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ B9 E4 \9 {: j0 D3 {( @lating hormone level was 1.3 µIU/mL (both normal).: B2 c6 |1 f; G% q& ~: Z0 k* w9 x
The concentrations of serum electrolytes, blood
0 x6 G" v5 r+ O  t; r& _; \urea nitrogen, creatinine, and calcium all were' b' n6 B: f& n- n) E$ i# z. u
within normal range for his age. The concentration
6 n% v: o! B( U+ x' {of serum 17-hydroxyprogesterone was 16 ng/dL
# j8 N/ k& ?  _" ?(normal, 3 to 90 ng/dL), androstenedione was 20
1 c+ W* @0 ?- g& |  L' Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) Z* Y  u! i) Q* {9 I7 l$ Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& G3 U1 P7 M! A: W6 V1 r! P( adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' O* q6 @( m( n6 {% l9 Z6 M49ng/dL), 11-desoxycortisol (specific compound S)
- V) \$ K3 P2 ~" f' ]+ Y2 }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 m$ q6 S3 u* t3 ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# P; t8 m# j$ `$ J8 o; ]* Q1 Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' {; s1 a* R, F/ J
and β-human chorionic gonadotropin was less than
! y. l) }- O$ z) s5 mIU/mL (normal <5 mIU/mL). Serum follicular
* W5 L$ Z9 u/ r/ \* mstimulating hormone and leuteinizing hormone
) e( g; z2 c/ O# h& X" _" I/ [concentrations were less than 0.05 mIU/mL
3 K  @! U6 c; W6 U1 w# q(prepubertal).
( r, ^0 d3 F+ k3 `The parents were notified about the laboratory
' }1 T' s$ s5 Aresults and were informed that all of the tests were
) U% L! E& ?) v4 h! Z8 pnormal except the testosterone level was high. The& l) F. \" @  K6 A+ g
follow-up visit was arranged within a few weeks to
- E3 w: F* I# r5 p8 q; L5 ]obtain testicular and abdominal sonograms; how-5 J% Q+ |" e' {0 \
ever, the family did not return for 4 months.
' f  w8 w. c; Y& b! }Physical examination at this time revealed that the
. R- V* B/ k/ _+ xchild had grown 2.5 cm in 4 months and had gained/ Q# I& O& ~: f' D9 S( J
2 kg of weight. Physical examination remained
0 J5 }$ Y5 e$ w) t; ~- junchanged. Surprisingly, the pubic hair almost com-$ g% l2 b% q  R/ {
pletely disappeared except for a few vellous hairs at, p- {! C! \6 z8 _% ^- h5 j1 L
the base of the phallus. Testicular volume was still 29 V' w6 {) L4 V) T: b$ h
mL, and the size of the penis remained unchanged.: q/ H' W) b2 H
The mother also said that the boy was no longer hav-
6 o$ X  ^+ ^) c; l) Sing frequent erections.
% R, u0 c$ R& d* W- U/ N2 QBoth parents were again questioned about use of
- u: \+ a! s- gany ointment/creams that they may have applied to1 f8 x+ z: H$ H3 i, e8 u
the child’s skin. This time the father admitted the5 H. @8 }4 m% B- K
Topical Testosterone Exposure / Bhowmick et al 5417 c7 I$ \* R0 ?3 c  |9 Z' h/ I- k
use of testosterone gel twice daily that he was apply-" z- n% z( J4 B! r0 T% T
ing over his own shoulders, chest, and back area for6 i" ?: Z3 N6 s; [5 v. X
a year. The father also revealed he was embarrassed
( k8 H& b$ j+ X. ]+ E7 Q' eto disclose that he was using a testosterone gel pre-4 H- [9 |. m$ N
scribed by his family physician for decreased libido
3 P: X; R# p- s& ysecondary to depression.
3 o& F% [1 y$ I* U6 ^  V1 _+ ]The child slept in the same bed with parents.& T: m# k1 A4 E& L, I. M& {( q% A
The father would hug the baby and hold him on his7 N' d1 x+ p1 M6 k" o, H9 K2 e4 u
chest for a considerable period of time, causing sig-1 Y. x; L7 f1 L8 l, z9 t: _
nificant bare skin contact between baby and father.* x' o6 I5 p8 t. B9 C
The father also admitted that after the phone call,7 c: x0 ~/ ~& G6 y# P
when he learned the testosterone level in the baby
/ P1 G% T' R' D: p, Vwas high, he then read the product information
: J, i( d- I& h9 P3 m' [* ]/ Y4 E, Lpacket and concluded that it was most likely the rea-- j0 A5 \9 n- ]5 I8 X; W3 ?% `
son for the child’s virilization. At that time, they( r# d2 v2 k: S# N1 \; V# e
decided to put the baby in a separate bed, and the
. i0 q4 I2 c( [2 Xfather was not hugging him with bare skin and had
- c8 s% e9 v& r: mbeen using protective clothing. A repeat testosterone$ Z; D8 _3 o7 ]
test was ordered, but the family did not go to the
, |4 [- Z' s4 G# _/ Q1 i4 Vlaboratory to obtain the test.; E4 Y" b- P/ x) e; ^0 M0 f
Discussion
" f' b- \1 @# ?+ {: g) YPrecocious puberty in boys is defined as secondary
0 f; b2 _* s1 S% Dsexual development before 9 years of age.1,4
& B: ]; P* D" E( cPrecocious puberty is termed as central (true) when9 I+ G6 w$ Q& Z/ h
it is caused by the premature activation of hypo-* u1 V, _1 I, E
thalamic pituitary gonadal axis. CPP is more com-9 A3 v9 |& C5 Z- x  V8 u
mon in girls than in boys.1,3 Most boys with CPP+ G  }0 o) s" K' P; x5 U
may have a central nervous system lesion that is
! b+ x  N: b) }( T! Z9 uresponsible for the early activation of the hypothal-$ j. {2 Z8 v# N; b6 T  I7 S
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 F8 X! p6 q  z$ |* f- s& ~sis has been given to neuroradiologic imaging in
' z$ U; `( K6 |boys with precocious puberty. In addition to viril-" D* ?/ O2 O) r2 S! H
ization, the clinical hallmark of CPP is the symmet-. s. `% D$ B  f/ g( O
rical testicular growth secondary to stimulation by/ P( x5 p5 z! h/ k0 S  Z
gonadotropins.1,3
" @! E$ ^; U9 q( h/ t% K  yGonadotropin-independent peripheral preco-; P- _+ S; S4 ?6 l2 n
cious puberty in boys also results from inappropriate
* q8 D7 q- N/ s5 B9 {5 \2 Uandrogenic stimulation from either endogenous or
5 O. ]2 ]; `& x4 Dexogenous sources, nonpituitary gonadotropin stim-
0 U3 B5 X( I& }2 F0 O* ]& _ulation, and rare activating mutations.3 Virilizing4 R( A9 x* d% `0 _+ u. N4 y; y  C
congenital adrenal hyperplasia producing excessive/ O. F) L0 q5 X. |. A) j5 a
adrenal androgens is a common cause of precocious1 s2 }( U8 W4 k
puberty in boys.3,4& \6 V, m* W6 y$ e4 m" [9 L3 I0 X5 y
The most common form of congenital adrenal0 c. z' K5 f, j$ t8 u1 v+ _5 O
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ w0 m" @8 G+ C% H+ A4 X# @( [The 11-β hydroxylase deficiency may also result in4 w) |' I- p; z% y) G# q0 M5 \6 o
excessive adrenal androgen production, and rarely,7 L7 n( ~3 ?8 f
an adrenal tumor may also cause adrenal androgen
" O6 G6 {- v+ C7 c* o' Cexcess.1,3- I$ j- X1 B9 }& y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" C8 x& L/ v6 s3 m" n5 ]3 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& T8 j3 s; `9 Y4 h$ L1 [
A unique entity of male-limited gonadotropin-/ I3 a7 x/ X6 b* L3 t
independent precocious puberty, which is also known
! b7 K! l. t$ r& ]. x; Q* ?as testotoxicosis, may cause precocious puberty at a+ W# u# l% e) Y- E5 ?! k
very young age. The physical findings in these boys, C, z+ O6 p6 H# W9 U8 Q' L6 H
with this disorder are full pubertal development,$ h8 d' u: A' Z) z+ X. E
including bilateral testicular growth, similar to boys
) u$ F3 M7 w7 T1 @with CPP. The gonadotropin levels in this disorder3 x3 Q! I& Q) x
are suppressed to prepubertal levels and do not show8 H2 |. {: _" c/ z0 o
pubertal response of gonadotropin after gonadotropin-
1 r3 K% {% m1 i# }3 f# mreleasing hormone stimulation. This is a sex-linked" F0 D' V+ C  E) J, r) w: d
autosomal dominant disorder that affects only
) G' ]& q7 p* @( }males; therefore, other male members of the family2 I$ k& e4 k+ q3 _4 b
may have similar precocious puberty.3
- V* O' }& B0 F& r$ u- CIn our patient, physical examination was incon-' i2 E# B3 Q/ g4 R( t! V, a7 g- X) I
sistent with true precocious puberty since his testi-& V) [2 h2 w* p1 w4 Z
cles were prepubertal in size. However, testotoxicosis# R1 q, g! |$ {: s
was in the differential diagnosis because his father3 ^% i1 w; K( w# L( r% @  k' G3 D
started puberty somewhat early, and occasionally,3 V& h' D! B' R) V
testicular enlargement is not that evident in the
. R# w/ w  j$ l; H1 _  A5 g6 Pbeginning of this process.1 In the absence of a neg-- d' ^, K  Z0 w) |3 H1 U
ative initial history of androgen exposure, our
( W& H( a' {' k/ O- qbiggest concern was virilizing adrenal hyperplasia,' L% R, h% n# [8 e' I; t
either 21-hydroxylase deficiency or 11-β hydroxylase
' k7 a3 C% Y* [deficiency. Those diagnoses were excluded by find-
! C. T8 o3 Q5 w: W3 ^, u& ~  ving the normal level of adrenal steroids.- d2 V7 f  _' d5 g
The diagnosis of exogenous androgens was strongly
! G- W" v. C, X: {' Z  `1 rsuspected in a follow-up visit after 4 months because1 g8 n5 p6 E# V8 `" C# M
the physical examination revealed the complete disap-
& M9 L% {, U0 `# u! u4 ypearance of pubic hair, normal growth velocity, and
% i  r5 N: [0 {3 X3 [0 |/ pdecreased erections. The father admitted using a testos-1 {1 O+ z% l5 X6 Q8 g$ P
terone gel, which he concealed at first visit. He was& y% I3 n) G6 j- ?
using it rather frequently, twice a day. The Physicians’
) i8 l, t$ b4 |7 D# m8 _9 dDesk Reference, or package insert of this product, gel or
+ n( {! G2 N, |8 J: Bcream, cautions about dermal testosterone transfer to
  f7 M6 [/ a, d! kunprotected females through direct skin exposure.
, b- s) X' R/ t$ ^/ v: U* P/ mSerum testosterone level was found to be 2 times the7 F  O0 {6 J4 |' _6 |' q
baseline value in those females who were exposed to. }4 S8 b' V5 i" ?# }
even 15 minutes of direct skin contact with their male0 [+ ?; N0 ?' n& A
partners.6 However, when a shirt covered the applica-
& k4 }" N! T! Jtion site, this testosterone transfer was prevented.4 x  N% {" g/ t# G3 r3 X: S/ t
Our patient’s testosterone level was 60 ng/mL,( T9 z8 l4 G& b& x
which was clearly high. Some studies suggest that
. N* @5 S1 T! J2 vdermal conversion of testosterone to dihydrotestos-; N+ d  \# l2 \4 u# [+ Q* \
terone, which is a more potent metabolite, is more
2 F8 R1 W; r9 {' u4 M+ gactive in young children exposed to testosterone
4 h5 @. U( l; d, z2 @exogenously7; however, we did not measure a dihy-  S* `- M0 S# x5 m1 u9 P/ h4 z$ N
drotestosterone level in our patient. In addition to. y; @/ m. _: l. U, ]+ \1 u" h" l
virilization, exposure to exogenous testosterone in
# h/ h; w7 J4 P5 U- Xchildren results in an increase in growth velocity and
. @3 h! P3 H/ U- Aadvanced bone age, as seen in our patient.
0 ]' T4 G" C9 A! h5 ~" n9 DThe long-term effect of androgen exposure during
" ], ~% Y  \+ c3 x  a9 zearly childhood on pubertal development and final- U1 D; U" @& Q. I/ }6 A: H0 w
adult height are not fully known and always remain6 o# J5 U9 h5 C; i
a concern. Children treated with short-term testos-
! h3 \- D' z; |7 F1 m0 s! @terone injection or topical androgen may exhibit some: l3 `# K- i4 _5 a1 H7 v
acceleration of the skeletal maturation; however, after& L* ~4 u7 F7 |4 ?5 S  m( Z
cessation of treatment, the rate of bone maturation
7 k8 W9 n* J5 kdecelerates and gradually returns to normal.8,9/ @+ Q) T5 }" {5 \. S1 p% L- F
There are conflicting reports and controversy, K; {- M# P3 D6 @2 p4 T# c
over the effect of early androgen exposure on adult2 m' a% B0 @: B; c
penile length.10,11 Some reports suggest subnormal5 i* N# g& S) J# a& J
adult penile length, apparently because of downreg-
& f* s9 D2 \( p3 Qulation of androgen receptor number.10,12 However,; F0 d- `' i4 k" O
Sutherland et al13 did not find a correlation between
! k  `/ u# c! E5 J( {1 Cchildhood testosterone exposure and reduced adult
% X0 R9 h% m2 |4 |- rpenile length in clinical studies.
, H& x: z/ c; C& T7 a5 qNonetheless, we do not believe our patient is
) M+ }0 s# D+ e3 w& Ggoing to experience any of the untoward effects from' x% I  z0 w- D
testosterone exposure as mentioned earlier because( e  t  d! R& W7 ~  M
the exposure was not for a prolonged period of time.
2 ~. e) e% [: tAlthough the bone age was advanced at the time of
1 p/ u7 ?4 }+ N: L3 t/ m0 gdiagnosis, the child had a normal growth velocity at; U. @  W( N3 E" T) X4 \' K& T$ Q. O
the follow-up visit. It is hoped that his final adult
! ^( t9 |. |: _, kheight will not be affected.6 i! z5 w0 ~$ p# M. W" G) j
Although rarely reported, the widespread avail-7 {# R- U9 w1 M. f0 C
ability of androgen products in our society may6 u" W& L3 |3 `+ W' ~
indeed cause more virilization in male or female' c9 Q7 e. t; K7 ^/ a9 d! O
children than one would realize. Exposure to andro-) w; g- }, g9 V& [+ c: z
gen products must be considered and specific ques-
) V) J5 V7 Y1 `# i# h+ e8 k2 Ctioning about the use of a testosterone product or
, B# u3 A; C, D( S+ \- c& R; Qgel should be asked of the family members during
2 N4 P. O( |0 {the evaluation of any children who present with vir-
4 s% Z# Z4 H$ Qilization or peripheral precocious puberty. The diag-, P. ^. i. Z9 j* T
nosis can be established by just a few tests and by
/ K+ C0 G( s# I) P- Dappropriate history. The inability to obtain such a2 B3 i7 \% P7 Z/ Q% A0 s- ?) r
history, or failure to ask the specific questions, may
" b0 E: _+ Z* zresult in extensive, unnecessary, and expensive) R& f8 `- C3 k9 f
investigation. The primary care physician should be
- d- k( y0 Z8 Raware of this fact, because most of these children- F7 Y  G, P2 {
may initially present in their practice. The Physicians’7 X3 c; b; _, z, l, A; \2 s* v
Desk Reference and package insert should also put a
' Q9 D2 E% F  p: fwarning about the virilizing effect on a male or% G  y+ _+ j2 s! D: B! q
female child who might come in contact with some-
  p4 K2 a2 z' |one using any of these products.
' }! T: R6 T9 u2 q  V: PReferences
# [; g% b: T3 F) H: Z1. Styne DM. The testes: disorder of sexual differentiation' `, a" u4 ^4 L% f7 I! ?: f; i
and puberty in the male. In: Sperling MA, ed. Pediatric
0 C2 v- L6 F7 l5 k% I! R' MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& J2 G9 |% O  R% r! d, @
2002: 565-628.
6 t7 ?+ n! b+ V  s/ A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 I; i1 A' D- I, Q. O5 t
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 x! S+ R0 P3 n' D5 o
Boy Induced by Indirect Topical
$ ~: R; G5 W9 j! V% HExposure to Testosterone
8 k; H" @! \4 y0 k$ d1 FSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( V7 V7 g" C5 t
and Kenneth R. Rettig, MD1  j  h- Y' y5 m6 v8 o
Clinical Pediatrics: W9 `8 f# r9 k* d
Volume 46 Number 6
' j+ h4 s$ V0 @+ S! }5 w. h' MJuly 2007 540-543& o1 J' V* j8 J4 v% f
© 2007 Sage Publications) x0 x0 g- a: }% p' N5 l
10.1177/0009922806296651
7 b: u3 M* n; n5 F5 b1 Vhttp://clp.sagepub.com- v% f( g9 h: I& M" F! W' O( R
hosted at" z3 y; S7 J7 o: `
http://online.sagepub.com3 V6 [5 [- f5 v7 }& \2 v) n- l: N: A
Precocious puberty in boys, central or peripheral,  I" z4 c$ v7 |. f: q* L; Q
is a significant concern for physicians. Central( P. s9 P+ Y5 b+ e7 Y- P4 r, f8 C
precocious puberty (CPP), which is mediated+ _- Q0 X, \! Y# {! X" A
through the hypothalamic pituitary gonadal axis, has' Y. `5 J. L. b$ A
a higher incidence of organic central nervous system$ P9 {* M4 K5 [3 V; t6 F' }) g
lesions in boys.1,2 Virilization in boys, as manifested) J- y* I; ~- z6 H' d
by enlargement of the penis, development of pubic
# c- K  z( A8 Ghair, and facial acne without enlargement of testi-
# ~1 Z3 D9 C3 ]' X5 e* vcles, suggests peripheral or pseudopuberty.1-3 We' d$ W+ L1 |4 E  j7 N" n
report a 16-month-old boy who presented with the7 J8 h5 q6 N/ |+ E5 c. H
enlargement of the phallus and pubic hair develop-/ `! C% G9 Z  h# f
ment without testicular enlargement, which was due* x0 q) H/ q, F% e4 m* g6 k
to the unintentional exposure to androgen gel used by0 T$ k+ k% C7 _  A9 j5 E
the father. The family initially concealed this infor-' ]' l  H, P, l' Y
mation, resulting in an extensive work-up for this* e, d$ H$ M3 ~1 Z! I
child. Given the widespread and easy availability of
- a  p7 f4 g8 |" n7 O* H; M4 C6 jtestosterone gel and cream, we believe this is proba-' Z7 M+ |' T: P1 Y& O9 S
bly more common than the rare case report in the
7 U6 o0 M% }0 ]/ T) kliterature.4
; s. s$ B, i4 f8 x2 R8 hPatient Report: k* d1 @9 f1 Z
A 16-month-old white child was referred to the  _- U) X! v2 J4 s% I, u/ g
endocrine clinic by his pediatrician with the concern( ?6 n3 y5 |& w2 J* \+ B8 J( q
of early sexual development. His mother noticed
* W, `& k$ g4 l2 C4 Vlight colored pubic hair development when he was- O8 l+ @4 J7 L# a
From the 1Division of Pediatric Endocrinology, 2University of$ Q% n0 w$ |3 L' `) ?# |, L
South Alabama Medical Center, Mobile, Alabama.
; Z5 A, ]$ I& s& d! V$ g! oAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 e: F6 D+ ]% }9 N1 J
Professor of Pediatrics, University of South Alabama, College of& A- `6 Z& T1 ~1 R4 z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) g# S4 ^1 _) |+ Y  Ie-mail: [email protected]." R4 p: e% ~/ |+ l% N4 K! W5 z
about 6 to 7 months old, which progressively became
: g; I5 X4 y7 w0 i0 |darker. She was also concerned about the enlarge-; n4 A+ x# i. }5 i* P% m9 j
ment of his penis and frequent erections. The child
& Y7 ]) n+ Z' swas the product of a full-term normal delivery, with6 C( Z! P$ {. Y
a birth weight of 7 lb 14 oz, and birth length of* @2 z1 c- @+ }" @  G$ p# a
20 inches. He was breast-fed throughout the first year; l0 f% t( f) V% f. d3 A1 m  ?
of life and was still receiving breast milk along with
  G4 d2 {3 E, Zsolid food. He had no hospitalizations or surgery,
# S3 y4 w$ |+ Y7 ^, H  Z* Mand his psychosocial and psychomotor development
) `2 V+ G' w6 Iwas age appropriate.8 o' y+ g5 [# N1 d
The family history was remarkable for the father,2 U" W4 r! D- d8 n4 E
who was diagnosed with hypothyroidism at age 16,
% i4 `6 I& u! a) Dwhich was treated with thyroxine. The father’s: U5 L. j8 b* y' B9 u4 j
height was 6 feet, and he went through a somewhat' o9 k0 P' g4 z
early puberty and had stopped growing by age 14.; [" A" t9 J9 F
The father denied taking any other medication. The5 e) I& G8 a* C% P& `, O
child’s mother was in good health. Her menarche  ?  @8 F3 n4 H/ N* t4 a3 q
was at 11 years of age, and her height was at 5 feet# Y4 R. y) L. |4 a
5 inches. There was no other family history of pre-
, n  ~' F7 a1 J% \! ^' Zcocious sexual development in the first-degree rela-
; d* I( A% [7 l4 f3 W! J3 ?tives. There were no siblings.* b* J$ C( I& q% d
Physical Examination$ C+ [& [5 l: p- T& y. v+ g' T
The physical examination revealed a very active,
* v7 a9 J$ v$ r- K* l4 b1 jplayful, and healthy boy. The vital signs documented
; s$ w1 m* h. }/ Ba blood pressure of 85/50 mm Hg, his length was
0 c7 n" Y) H6 k) ?+ C9 Z3 v90 cm (>97th percentile), and his weight was 14.4 kg
% [6 X4 @/ b( H% Y5 B/ s. F(also >97th percentile). The observed yearly growth' ]! R( f* R, }! z% }8 Z
velocity was 30 cm (12 inches). The examination of
/ z/ P1 R8 T' N9 \$ mthe neck revealed no thyroid enlargement.
1 B- ?* Q. N8 {- r: Y/ ~The genitourinary examination was remarkable for+ B- Z% _" o: m; a
enlargement of the penis, with a stretched length of
- {1 F' X" I: ?/ }" a4 a$ n& k; u8 cm and a width of 2 cm. The glans penis was very well) v8 {2 W/ o3 `
developed. The pubic hair was Tanner II, mostly around0 ^& X: ?, ?. V. @) R1 P; J
540/ O% _7 @  U% [% S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, Z. x/ i. ~$ @3 ^4 V2 u% N; C: ^
the base of the phallus and was dark and curled. The7 m, n2 u# I- r2 U; a# T, @
testicular volume was prepubertal at 2 mL each.
" v! q% i/ a( Z  h8 m4 DThe skin was moist and smooth and somewhat1 e) O$ w' N) v, r( h
oily. No axillary hair was noted. There were no4 o9 b7 ]/ U: h
abnormal skin pigmentations or café-au-lait spots.9 k* Q4 k# C; f& H
Neurologic evaluation showed deep tendon reflex 2+! {; P0 F. s; Z% d
bilateral and symmetrical. There was no suggestion
; D* @4 T5 D/ `9 @of papilledema.9 ~7 Z" }) J* e* ~% @% q4 ?% ^" U1 w
Laboratory Evaluation$ U+ s# g. x# [' p
The bone age was consistent with 28 months by
. ^1 Z6 }4 h- q) m& Dusing the standard of Greulich and Pyle at a chrono-' m" p* D( x. S; W
logic age of 16 months (advanced).5 Chromosomal8 B0 b+ d) H. r  C( ~9 i  @
karyotype was 46XY. The thyroid function test
# a+ c5 X% k' {showed a free T4 of 1.69 ng/dL, and thyroid stimu-# ]' _, h7 P9 L
lating hormone level was 1.3 µIU/mL (both normal).* j& h- F5 `6 f
The concentrations of serum electrolytes, blood
- P5 J3 H4 T& l  eurea nitrogen, creatinine, and calcium all were2 `3 C# @9 k8 A- v1 b
within normal range for his age. The concentration6 I4 M+ J/ t) |8 Q9 l: ^
of serum 17-hydroxyprogesterone was 16 ng/dL6 i1 g: I5 v1 v
(normal, 3 to 90 ng/dL), androstenedione was 20
: N5 g+ J$ c4 L9 ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% M+ t7 O2 F) W! G6 T" t+ `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. G9 f  q! H7 x. X
desoxycorticosterone was 4.3 ng/dL (normal, 7 to! t" S# D( b: U4 o( e, V
49ng/dL), 11-desoxycortisol (specific compound S). m& E* g% t" W& ]) H$ d; R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! A1 i, p3 C6 Y4 a, z4 P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; M9 w4 v3 l* q+ W8 m
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" d1 C( t7 Z, T; O# \and β-human chorionic gonadotropin was less than
  W# c- |) }& S3 u. d1 d5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ E. u; F+ {6 Rstimulating hormone and leuteinizing hormone3 t; m5 e( [" U  G8 i5 Y7 k
concentrations were less than 0.05 mIU/mL1 P) i8 _* s) J
(prepubertal).& L0 k' u: L' K6 G9 h* a9 `1 B# {
The parents were notified about the laboratory7 ?- `  n) ]+ P
results and were informed that all of the tests were
# x! y/ e% W( W) n& dnormal except the testosterone level was high. The
8 C* p  \7 Y0 Y% X/ W% J! M1 ?follow-up visit was arranged within a few weeks to
9 m7 v0 M3 s! x# I0 g9 I3 bobtain testicular and abdominal sonograms; how-" p) {5 e6 |& X4 W
ever, the family did not return for 4 months.3 w6 |9 R( U2 _/ |
Physical examination at this time revealed that the
' k7 z* I7 X# w  z4 s% Uchild had grown 2.5 cm in 4 months and had gained; H. `6 K# X) m: ?" @
2 kg of weight. Physical examination remained
% a& T& P) Q6 p0 \+ N4 y9 S0 Dunchanged. Surprisingly, the pubic hair almost com-/ x- b( l- c, L/ c2 M3 A
pletely disappeared except for a few vellous hairs at
! w3 n5 t, {- ~7 [% Bthe base of the phallus. Testicular volume was still 28 N+ n. w+ B* u: r, E" h
mL, and the size of the penis remained unchanged.
  J! i4 d$ H) g5 J3 i8 p) f6 rThe mother also said that the boy was no longer hav-
4 E; ~0 o6 e5 \- B8 Y- @8 [0 }ing frequent erections.: f1 _  w! U+ Q9 m/ P
Both parents were again questioned about use of
* [8 O9 B* f) Y$ @1 q4 \' @8 E; kany ointment/creams that they may have applied to( v+ c$ q1 ?* o. e
the child’s skin. This time the father admitted the
' f" j9 t/ _" J/ _  }( F) l* XTopical Testosterone Exposure / Bhowmick et al 541# E2 ^$ W9 Z( B
use of testosterone gel twice daily that he was apply-
8 l- B7 |7 @+ s) }) ]/ O3 \ing over his own shoulders, chest, and back area for
6 P% V& w6 i- ma year. The father also revealed he was embarrassed) G% Q" G# x" ~) i: q+ [/ T  j
to disclose that he was using a testosterone gel pre-! D: I; O7 b' Q9 Q& S; L4 k5 N
scribed by his family physician for decreased libido
8 L: K! Z/ g5 O' s6 q1 V/ B, Hsecondary to depression.( z, A8 W  B7 l0 r
The child slept in the same bed with parents.
' g$ L; Y  i7 T9 t/ U9 y4 Y& @0 qThe father would hug the baby and hold him on his
, e0 d8 t# Y+ hchest for a considerable period of time, causing sig-
) i5 W) c1 U4 ^/ D* Qnificant bare skin contact between baby and father.
' ?6 d" v$ C" J' GThe father also admitted that after the phone call,
( F, y& H4 Q4 e- h4 v: Vwhen he learned the testosterone level in the baby
; O% d# A- Y4 h; |5 W! _was high, he then read the product information
( p5 T1 b- o3 C0 i% s% rpacket and concluded that it was most likely the rea-
3 J6 i8 I$ R! W! G) a1 m6 Dson for the child’s virilization. At that time, they
# d7 j* P4 i/ D: x3 y& T7 hdecided to put the baby in a separate bed, and the
- o, Z! B& U/ }$ F# rfather was not hugging him with bare skin and had
# W3 r2 F* Z2 j  Pbeen using protective clothing. A repeat testosterone
  Y& f3 r7 |1 e( ]test was ordered, but the family did not go to the) @* t! `! l( b0 g1 G: D3 N
laboratory to obtain the test.
: D" i: a4 |( w8 L+ U( [! ]9 f# ^; d8 cDiscussion/ u1 N. i# L0 q  I0 Y
Precocious puberty in boys is defined as secondary
& X5 [: O& I4 C: w3 S( s; W( Osexual development before 9 years of age.1,4
( M! p$ h9 L. W+ p( jPrecocious puberty is termed as central (true) when
0 w3 p* i3 A  ]5 b9 o! oit is caused by the premature activation of hypo-" k6 I) h9 Z% x* R
thalamic pituitary gonadal axis. CPP is more com-: _8 w! l; @  f0 U% c- B7 L2 a/ X
mon in girls than in boys.1,3 Most boys with CPP  _: `: H2 A/ T) ^. I
may have a central nervous system lesion that is6 G. P9 R( j* R+ ~, Q
responsible for the early activation of the hypothal-6 o  q" ]0 l3 |( ]$ J$ D
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 u7 z2 x, [4 Y$ L& ?6 j, Esis has been given to neuroradiologic imaging in
/ A+ Y" O' d, ^2 e7 _0 I: f2 lboys with precocious puberty. In addition to viril-) W: M& @6 i- n6 J5 e4 Z! k# i
ization, the clinical hallmark of CPP is the symmet-  L7 L: L* r; j$ g# P
rical testicular growth secondary to stimulation by
, _$ O( C* t% r4 {9 Q1 t3 J, egonadotropins.1,3' ~$ k  \) W4 m# g) I$ n* N* C
Gonadotropin-independent peripheral preco-3 g9 z, K+ g" K$ v/ e; f# S0 v2 A4 t
cious puberty in boys also results from inappropriate4 J3 m) I5 Y) a( ?
androgenic stimulation from either endogenous or
. ^  [! X' U! v: C& @7 t" w1 g# U" rexogenous sources, nonpituitary gonadotropin stim-
1 f% ]7 z2 U8 a0 Lulation, and rare activating mutations.3 Virilizing
; j, h, [; w# N0 s. Icongenital adrenal hyperplasia producing excessive
3 Z" B1 K3 G; x' `$ e2 ?adrenal androgens is a common cause of precocious
; d1 _: {! p" n# B' p+ [puberty in boys.3,4; s. Y  Y0 l2 Y  z5 `2 c1 E
The most common form of congenital adrenal
! f/ o: N! y0 p- U4 [hyperplasia is the 21-hydroxylase enzyme deficiency.% V- O: y) y0 U: r. s  B9 f
The 11-β hydroxylase deficiency may also result in: p+ G/ `$ U' |. P" L. n6 s
excessive adrenal androgen production, and rarely,
3 K" g& K$ L( j& w7 _an adrenal tumor may also cause adrenal androgen
: d0 Q4 O6 Y4 X+ K) e+ [3 Xexcess.1,3
* o2 v! q7 E9 Q$ m( Z  ~6 b1 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 V6 u; j* o# l( ^) w. z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 l) F' y8 k( eA unique entity of male-limited gonadotropin-
5 M  |" Z( E& T. M/ _( Gindependent precocious puberty, which is also known
  s2 _" a$ q' e1 \) H& ras testotoxicosis, may cause precocious puberty at a" D- H0 i7 h- ^4 s# a5 E0 R5 k
very young age. The physical findings in these boys
  G1 ~! r* ^2 Twith this disorder are full pubertal development,# |+ {4 M; D0 q! f" Q. {# i/ }
including bilateral testicular growth, similar to boys5 X3 |+ }* z2 o! [- T" ^
with CPP. The gonadotropin levels in this disorder
9 O4 a, k  K* A4 p+ X1 Lare suppressed to prepubertal levels and do not show
! j/ J2 i$ y* ~; j/ }8 Y) Dpubertal response of gonadotropin after gonadotropin-
$ N& f& P* R( Q  jreleasing hormone stimulation. This is a sex-linked+ s/ u0 w8 w7 e: ]# P" U
autosomal dominant disorder that affects only
) E: F3 T  d( K7 v- lmales; therefore, other male members of the family! t' O3 N% G# K2 \
may have similar precocious puberty.33 a! R) E& _' W( i  H( ?3 G9 @
In our patient, physical examination was incon-
3 u2 b) s! l/ e1 H4 {4 }1 d0 B. ^sistent with true precocious puberty since his testi-
8 H. B' n  E' d* E! x( U8 Wcles were prepubertal in size. However, testotoxicosis
6 Q4 m+ V, \! z  X* Fwas in the differential diagnosis because his father0 z' b8 Y2 z. Q  b9 z
started puberty somewhat early, and occasionally,
7 G, F; q3 [2 P. atesticular enlargement is not that evident in the5 S5 U) D% O% X' ]
beginning of this process.1 In the absence of a neg-4 J' }& z- C* T6 \3 e" `8 p
ative initial history of androgen exposure, our
: S  x6 o8 ?0 _, lbiggest concern was virilizing adrenal hyperplasia,
- k( o5 u% \5 O; D- A) J+ Zeither 21-hydroxylase deficiency or 11-β hydroxylase6 K' ?8 k6 A+ B1 Y% \- b, ~
deficiency. Those diagnoses were excluded by find-
( W0 T; ]2 u3 K) r/ Eing the normal level of adrenal steroids.% ]( N/ o& @) r( S$ y
The diagnosis of exogenous androgens was strongly
- \& r& `2 G$ y! q4 [. @$ b$ Msuspected in a follow-up visit after 4 months because' Y$ Y8 x4 \0 `) @  {3 e
the physical examination revealed the complete disap-
4 @* v9 `- D* K, ^! A& kpearance of pubic hair, normal growth velocity, and2 q5 E8 f3 \) D0 J5 j/ g
decreased erections. The father admitted using a testos-
' W0 Z0 Q/ I# S: c( e1 j& V, x% g) Pterone gel, which he concealed at first visit. He was# H6 v* ]( ^- e
using it rather frequently, twice a day. The Physicians’9 v# h  [$ K1 w# M) }& m8 m
Desk Reference, or package insert of this product, gel or
1 ?& r8 V4 y& c: O) a5 Y# e. Vcream, cautions about dermal testosterone transfer to
! ]7 i+ N1 H- W  E6 Qunprotected females through direct skin exposure.' s1 }! W9 M( ~: b. r8 h
Serum testosterone level was found to be 2 times the
* C& |$ o2 S  s* M5 X& M1 s, tbaseline value in those females who were exposed to/ S% d' O4 v7 V( _
even 15 minutes of direct skin contact with their male. Z& Z" B4 |% i. z' w- z/ A
partners.6 However, when a shirt covered the applica-
# p3 b% @/ N& `8 P5 i$ f: e" T& u+ ztion site, this testosterone transfer was prevented.
. O, X  c+ h& i4 d: f) w4 _Our patient’s testosterone level was 60 ng/mL,7 M9 `3 k. J  ?% |
which was clearly high. Some studies suggest that! O5 Y0 a4 u* A# G  s$ X2 c
dermal conversion of testosterone to dihydrotestos-. Z& w5 b- a; J9 E
terone, which is a more potent metabolite, is more. M4 u( a! I6 G
active in young children exposed to testosterone  [" A7 P* G' S0 z, c$ e& c
exogenously7; however, we did not measure a dihy-
! G; m. }/ u  F' `! X  x$ ndrotestosterone level in our patient. In addition to. ~% r* F$ q+ d( Z+ Y0 C
virilization, exposure to exogenous testosterone in
1 m7 s- |  m' _children results in an increase in growth velocity and
1 x/ V+ I3 E% Q4 t: V1 `advanced bone age, as seen in our patient.
7 o' p# [4 L7 MThe long-term effect of androgen exposure during
; K0 D( E+ U) ?- ?8 V3 Rearly childhood on pubertal development and final
7 v7 h0 R. Z* Nadult height are not fully known and always remain* I, ~) r% h1 F5 y) s4 \
a concern. Children treated with short-term testos-
& i3 q* T/ S8 V6 G+ Cterone injection or topical androgen may exhibit some/ ]8 s+ ?- b4 Y' a
acceleration of the skeletal maturation; however, after
  j* b: Y# `0 q$ _  U1 O; Kcessation of treatment, the rate of bone maturation
; J* W# J, g! D' C4 q0 hdecelerates and gradually returns to normal.8,9: d( w$ Y  S+ {2 d
There are conflicting reports and controversy* _2 [7 N; `5 ?2 M0 H8 c+ Y
over the effect of early androgen exposure on adult, @9 ]2 s. Z3 W2 ^) A* j
penile length.10,11 Some reports suggest subnormal
. e. Y5 E( S0 u& H; Wadult penile length, apparently because of downreg-
; e* k4 |" f! |# `2 Y; r+ oulation of androgen receptor number.10,12 However,! O% V8 c  d+ P- S
Sutherland et al13 did not find a correlation between! _$ x( D, R) x) n
childhood testosterone exposure and reduced adult
" v. p$ o' M  @, \3 Wpenile length in clinical studies.  a# A8 d) _3 L
Nonetheless, we do not believe our patient is
* j9 s+ K: u0 \, Mgoing to experience any of the untoward effects from
% o4 o2 {) k! n; _8 j( \& Btestosterone exposure as mentioned earlier because
7 G6 p6 l1 b; y( g3 ~4 X% b$ ethe exposure was not for a prolonged period of time.
8 \2 w& D7 p- b+ s% z5 cAlthough the bone age was advanced at the time of
# S( K3 P0 b9 {* I: Y, f' Bdiagnosis, the child had a normal growth velocity at1 i( M2 ?& c0 Y) G- w$ l8 z& N7 X
the follow-up visit. It is hoped that his final adult
2 M. F8 v  X5 j: u) G9 ~' mheight will not be affected.
! N! x  `/ F3 ]& rAlthough rarely reported, the widespread avail-) j# S3 Z8 N$ Y4 ~
ability of androgen products in our society may2 F1 u9 y6 c$ C$ m$ [
indeed cause more virilization in male or female
, E5 @) X  n* qchildren than one would realize. Exposure to andro-" T/ b1 a" e  V4 v7 e9 f% p
gen products must be considered and specific ques-5 h: v* Z) N- Z1 n8 `! X9 E* V
tioning about the use of a testosterone product or
" U/ l/ P  y- U& m+ ^gel should be asked of the family members during( J, x; o& j* a& ^1 ~
the evaluation of any children who present with vir-1 S. j! g- b7 A3 C8 u
ilization or peripheral precocious puberty. The diag-. D2 Q( ~5 Q# u! i9 G, j
nosis can be established by just a few tests and by
/ n" J- \& R9 |% o7 v0 aappropriate history. The inability to obtain such a
: _, t! }6 |# l( t- M3 `history, or failure to ask the specific questions, may
4 J' ?6 W( M# k# u) s- V/ Qresult in extensive, unnecessary, and expensive+ Y3 i5 j3 P) y$ K, x% g7 V0 y) e
investigation. The primary care physician should be
' `4 W1 ~' R( `* ^% Iaware of this fact, because most of these children
( l! s6 ^4 R+ C! Hmay initially present in their practice. The Physicians’. `% }2 m; m6 \5 G  w7 j' D. j
Desk Reference and package insert should also put a
" c/ b' x( o! ~6 pwarning about the virilizing effect on a male or0 s8 Q  n. c  G7 W8 N) E
female child who might come in contact with some-4 I$ A) }4 R  j0 N& e; N2 q
one using any of these products.
) t; d5 C  o& ~% N  gReferences  @; B3 M9 F. P
1. Styne DM. The testes: disorder of sexual differentiation
- {" P/ q' J5 F) [+ R- k8 A9 vand puberty in the male. In: Sperling MA, ed. Pediatric' ]* |+ l4 R8 Y  Y3 V( v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 [2 T7 w2 G8 Q3 ]
2002: 565-628.
2 P: d/ _' A# A& ]) B% H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. @8 O: U% b/ @5 e) B
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
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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
! C1 @$ y. r. d, n, v% |  V
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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