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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# [* }2 o$ q4 Y
Boy Induced by Indirect Topical
0 p( r; Q1 w( O/ s+ Z: t; c2 DExposure to Testosterone0 O8 }) ], m) [. P/ {' ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& e, T) w: L0 V8 o) q  P3 y7 L" ^and Kenneth R. Rettig, MD1; V0 T; S  B+ u4 Z7 ]  w
Clinical Pediatrics
! X+ m- G( Q0 A. c0 g3 zVolume 46 Number 67 t0 ^* x  F. X, f6 z) e
July 2007 540-543
3 ]" T; `( L5 u; X1 o% @7 W4 @© 2007 Sage Publications
) }2 m( l* d  O" k! J" H10.1177/0009922806296651
0 q1 r* d' r( ^  G* ]3 Ehttp://clp.sagepub.com: {+ G8 f% Y3 T7 F, w3 l3 l
hosted at* z  z) h& Z" j* g+ t1 x3 f$ K. ]* {
http://online.sagepub.com  A, x6 Y4 @/ ~8 {: h
Precocious puberty in boys, central or peripheral,2 ^! n; ?5 L: M: }* q  D$ ]& |3 L
is a significant concern for physicians. Central
8 R  [3 u( a3 C1 K0 }& Z. |precocious puberty (CPP), which is mediated4 V7 U& [( r& a* p
through the hypothalamic pituitary gonadal axis, has1 W; S( e' m( T9 W' A  a
a higher incidence of organic central nervous system
: \1 X, S# y# ^0 \. l$ Rlesions in boys.1,2 Virilization in boys, as manifested/ h. \) \& _6 I$ N* i" B# Y
by enlargement of the penis, development of pubic# `& q: r. r; H8 O: q: a, T
hair, and facial acne without enlargement of testi-
4 W# q4 f. Q) X! D2 bcles, suggests peripheral or pseudopuberty.1-3 We
1 n, R( l( B4 c/ |report a 16-month-old boy who presented with the8 V4 Z7 J0 y* K2 P* k
enlargement of the phallus and pubic hair develop-# @4 S2 x, q1 Y& J  W
ment without testicular enlargement, which was due
( ]; T# o7 U4 V' e6 v" Q% ~to the unintentional exposure to androgen gel used by* [4 n7 r1 E" J& h8 B( G
the father. The family initially concealed this infor-
3 ?1 P6 t# O5 l( Emation, resulting in an extensive work-up for this2 \  n( W. N8 S, z& A
child. Given the widespread and easy availability of! [' H) e, M0 J" a
testosterone gel and cream, we believe this is proba-
% Q) {3 L4 l1 P2 {: {4 zbly more common than the rare case report in the1 F9 m8 B* K6 Z7 H/ Q
literature.4" ?: H0 R! n8 ]3 q  K7 U- f) ~0 [* c2 ^
Patient Report
2 q9 u- u& P7 [6 \9 x# FA 16-month-old white child was referred to the7 @& e) J1 W  i8 w& A
endocrine clinic by his pediatrician with the concern
5 H/ ^# q! j# z% U1 P  P" W% Dof early sexual development. His mother noticed" c+ C' M" W( A! P) d
light colored pubic hair development when he was
$ ?! a* b  c/ a8 A: R( B! E% P+ sFrom the 1Division of Pediatric Endocrinology, 2University of+ U+ S: T, @, \+ `: h! [
South Alabama Medical Center, Mobile, Alabama.. N" e1 F$ ^( n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 F. C' P* j# eProfessor of Pediatrics, University of South Alabama, College of
8 D9 W' e4 |4 d$ \Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  A  k1 k% Q$ ^' he-mail: [email protected].
- U- _+ p- `5 Xabout 6 to 7 months old, which progressively became
- U( \# S  l  X2 A) @darker. She was also concerned about the enlarge-
0 l" Z# c+ `. K' l% ~3 Gment of his penis and frequent erections. The child. i9 h3 A8 C$ z# S
was the product of a full-term normal delivery, with5 T9 \- d4 U1 v) N
a birth weight of 7 lb 14 oz, and birth length of
* Y8 M/ ?* C  C0 R20 inches. He was breast-fed throughout the first year' Y) p/ }7 t$ ~
of life and was still receiving breast milk along with
/ J- r- y% R$ X; Gsolid food. He had no hospitalizations or surgery,
5 ?+ g0 M  s# y  E+ aand his psychosocial and psychomotor development
" v! t$ q! [. O4 g" r  \& [0 zwas age appropriate.% T' V8 Z8 D. o, a, t( ~: s
The family history was remarkable for the father,
4 C2 a1 [" @) ~. ^who was diagnosed with hypothyroidism at age 16,& F# N/ T* z& [6 X
which was treated with thyroxine. The father’s
: `( r9 z( h- cheight was 6 feet, and he went through a somewhat
) f+ e" |3 V% w! F+ _# b+ }early puberty and had stopped growing by age 14.
; u. G$ U* `2 N' x; \The father denied taking any other medication. The
1 q5 ?, z/ f: }/ w) Ychild’s mother was in good health. Her menarche. Z7 U1 w/ s! ^/ m; P4 a* s% F9 o
was at 11 years of age, and her height was at 5 feet/ k0 ]- h2 p* q) N  H
5 inches. There was no other family history of pre-
- \7 j9 o! f+ D) z% ucocious sexual development in the first-degree rela-& i7 `1 a+ R: v, r4 p9 L
tives. There were no siblings.1 m% c; d/ u' x! |
Physical Examination) O* _# b# C) ^
The physical examination revealed a very active,
' k# V4 p( t8 J3 ?2 mplayful, and healthy boy. The vital signs documented
8 S+ ]: J: j" `a blood pressure of 85/50 mm Hg, his length was
% F1 {$ w' u! S90 cm (>97th percentile), and his weight was 14.4 kg
# y. v- e( C6 _7 s% d+ U4 x(also >97th percentile). The observed yearly growth9 J9 k6 m- W" x* }
velocity was 30 cm (12 inches). The examination of
* X2 [: [/ V2 W5 D- _1 Vthe neck revealed no thyroid enlargement.
# Y7 D5 \: a3 n/ f$ A* ~. e( lThe genitourinary examination was remarkable for: a( a/ j) p6 v, h( b6 z6 a
enlargement of the penis, with a stretched length of
; f& u2 G2 |8 a8 cm and a width of 2 cm. The glans penis was very well1 q9 T% `' \: V
developed. The pubic hair was Tanner II, mostly around
, z5 }# V/ n3 @" I540
7 h4 z7 \1 Y2 bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. F0 ~1 i! T: Q2 S: |- ^the base of the phallus and was dark and curled. The0 T' l8 M3 X! b7 U9 Y; B
testicular volume was prepubertal at 2 mL each.
5 Q. a. k9 {/ P! }3 |" z/ vThe skin was moist and smooth and somewhat1 Z- @$ h  f! n  w4 Q% b5 L
oily. No axillary hair was noted. There were no
) T+ ]5 b: i/ n" Pabnormal skin pigmentations or café-au-lait spots.
, V7 o, b' w; ONeurologic evaluation showed deep tendon reflex 2+1 r9 y0 V3 v( g: a0 u
bilateral and symmetrical. There was no suggestion
% J  f. q, @  G0 m+ t9 Y# {of papilledema./ F+ N2 J. H& L1 E
Laboratory Evaluation
& Q( c- c7 J9 CThe bone age was consistent with 28 months by8 n, p+ l- D; E! w' Y
using the standard of Greulich and Pyle at a chrono-
. V5 g: T3 Q2 x% B% ~; D4 ^4 nlogic age of 16 months (advanced).5 Chromosomal; \! v! z' {$ p7 }+ {. W
karyotype was 46XY. The thyroid function test
0 g% A3 P* f( R8 d, _2 }showed a free T4 of 1.69 ng/dL, and thyroid stimu-# O$ _0 b4 X* m1 `  o9 R
lating hormone level was 1.3 µIU/mL (both normal).
3 R& b* X1 C" _( H1 i" `. |  pThe concentrations of serum electrolytes, blood, ^: M- C* B# P: E+ S0 E
urea nitrogen, creatinine, and calcium all were1 y( e+ X; q) D9 d8 r
within normal range for his age. The concentration
) ~* ^. {$ ?0 R  J( m! i( Z$ xof serum 17-hydroxyprogesterone was 16 ng/dL; `7 e+ e) G; K1 T1 C5 V4 W
(normal, 3 to 90 ng/dL), androstenedione was 20
6 y' i# o8 @( Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 E  J2 [$ D" N0 S" p: J0 M/ j* G4 k, G6 N
terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ H* P; I) l$ w' w; L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 {6 I4 n& O6 b, h
49ng/dL), 11-desoxycortisol (specific compound S)
# K* w/ |) X) A+ b, F1 Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 U' T0 C& b, O4 Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 ~4 f( O4 g3 _' D  vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 U! f1 f- x* P$ p/ B0 _& E
and β-human chorionic gonadotropin was less than2 Z( F4 @( k7 \  j
5 mIU/mL (normal <5 mIU/mL). Serum follicular: C9 o7 V! i6 k' @$ F
stimulating hormone and leuteinizing hormone
$ g$ A8 f) U% }) \* R# d4 Rconcentrations were less than 0.05 mIU/mL
4 L' M$ |4 p% k7 r+ p(prepubertal).$ f7 s4 ?* O, I; A2 u
The parents were notified about the laboratory( a1 `3 z8 S; z
results and were informed that all of the tests were
3 Z: U' Z$ t2 b( H2 c" V9 K# Znormal except the testosterone level was high. The
' p% P. U# S8 D& Z9 gfollow-up visit was arranged within a few weeks to% Y$ A2 \7 o2 Q2 P# H7 D) `
obtain testicular and abdominal sonograms; how-- h( r/ _9 N* Y6 R& ?4 v  z  E
ever, the family did not return for 4 months.
( m; j! I, p/ U5 U7 i3 M* nPhysical examination at this time revealed that the3 E. L4 W( q1 M
child had grown 2.5 cm in 4 months and had gained: _0 S! U! U, S! b! e5 {
2 kg of weight. Physical examination remained
4 D4 o# F- H( o0 _- j" @unchanged. Surprisingly, the pubic hair almost com-# e; S8 H( t7 W8 W" a6 V5 }6 [) ~/ g
pletely disappeared except for a few vellous hairs at
% w& ^5 P/ s1 e* G7 j( Tthe base of the phallus. Testicular volume was still 2: c9 i( d8 T2 j3 X$ b: P
mL, and the size of the penis remained unchanged.
. |# [' |1 Y( y! i, z. ?: NThe mother also said that the boy was no longer hav-
1 j: j7 p" v/ C6 h8 iing frequent erections.8 e8 P9 [- [( b. a
Both parents were again questioned about use of9 H' T5 }1 j$ C  P8 k6 i
any ointment/creams that they may have applied to
6 t, m: u; Q+ }2 Qthe child’s skin. This time the father admitted the
4 r; H' J& C& MTopical Testosterone Exposure / Bhowmick et al 541
; e: p& H, ?$ p7 L; f' ?% U1 duse of testosterone gel twice daily that he was apply-
, Q, f8 K! @0 I% Ring over his own shoulders, chest, and back area for
  _/ w5 w, e2 F$ K' D; Ia year. The father also revealed he was embarrassed. U* X9 o3 a; G) `
to disclose that he was using a testosterone gel pre-
! F8 d# F* P5 c5 F/ N5 Mscribed by his family physician for decreased libido$ C$ X7 C2 B& j! o% q0 k) G7 B1 |/ H! J
secondary to depression.
' @9 g' s( B3 D6 P3 }. k* QThe child slept in the same bed with parents.
" m& J  u0 a- i" ^( b5 R2 OThe father would hug the baby and hold him on his
& S' \, `! X; r- P: w+ _1 s. dchest for a considerable period of time, causing sig-
$ f  X; \* N6 D5 Nnificant bare skin contact between baby and father.' G  O. ~% O3 Q0 ^* s2 k7 r- Q) Q
The father also admitted that after the phone call,/ n$ ]" D" \1 s+ m9 g6 ]
when he learned the testosterone level in the baby9 s6 F/ m; G! y, o
was high, he then read the product information
/ n7 i: b5 \1 [, x& Q! B& Q, y3 {packet and concluded that it was most likely the rea-4 m7 h4 f/ f/ W1 U
son for the child’s virilization. At that time, they
, O# q) m4 }% @( A' O8 @( wdecided to put the baby in a separate bed, and the
! q! U  W+ k* s1 @+ mfather was not hugging him with bare skin and had
. A( ~+ A$ e: E. p: g" ?( g* Xbeen using protective clothing. A repeat testosterone
. U, h- d' s, f: q! F4 R3 Qtest was ordered, but the family did not go to the
  e7 ~) r2 l/ f" M* vlaboratory to obtain the test.
6 |+ g1 T6 q* ?4 I, hDiscussion
; u' H- b: C4 oPrecocious puberty in boys is defined as secondary+ A/ ^  y" h& j8 T& O! U
sexual development before 9 years of age.1,4& }& X0 S: `# {
Precocious puberty is termed as central (true) when
0 t# w/ h" [6 M7 |! Iit is caused by the premature activation of hypo-
5 H1 N, C! e4 {thalamic pituitary gonadal axis. CPP is more com-3 `5 x0 |2 W2 K- W. U  h/ G, j
mon in girls than in boys.1,3 Most boys with CPP
3 R* h7 t" z! i& _8 h0 bmay have a central nervous system lesion that is
; \& E- p0 o/ |' Hresponsible for the early activation of the hypothal-
# o; o  R" Q; j3 s1 Samic pituitary gonadal axis.1-3 Thus, greater empha-; [$ O4 e6 C; u! l
sis has been given to neuroradiologic imaging in
/ _6 a2 u1 f3 mboys with precocious puberty. In addition to viril-
* b  I/ o1 u" U" r5 e* h( x% e) Hization, the clinical hallmark of CPP is the symmet-1 Z' I3 B; w2 k6 {
rical testicular growth secondary to stimulation by: g8 Q5 W, p4 p4 C* ^
gonadotropins.1,3& M2 E4 g; i. i0 n
Gonadotropin-independent peripheral preco-
+ q8 \: x: I) v& \cious puberty in boys also results from inappropriate, ]0 Y! P$ @+ y' Z$ r; Z/ l
androgenic stimulation from either endogenous or
* K9 u! y. p6 ]  ?exogenous sources, nonpituitary gonadotropin stim-, j$ h) c1 ?7 Y
ulation, and rare activating mutations.3 Virilizing/ Q! z5 B8 n% V
congenital adrenal hyperplasia producing excessive
% R, t1 @6 ?& f6 f0 P7 cadrenal androgens is a common cause of precocious
1 a9 s: E( D  u: Hpuberty in boys.3,4! G2 R' Z3 H2 j/ E$ U: T7 M# p
The most common form of congenital adrenal
8 a+ z6 ]7 j: L- M6 f8 chyperplasia is the 21-hydroxylase enzyme deficiency.2 b; z7 r$ F0 s3 D" ~6 c/ P( n
The 11-β hydroxylase deficiency may also result in9 L  m) r7 N; e/ n! S
excessive adrenal androgen production, and rarely,3 I" H  Y" l  i/ P4 W
an adrenal tumor may also cause adrenal androgen+ ?, d7 W, v; s, F3 M
excess.1,3# q0 w. j6 S/ ^( l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% Y5 p3 t8 P" `+ j  U
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 z; B* F/ b/ [/ `3 v% e
A unique entity of male-limited gonadotropin-
( J- w0 D' H4 z1 }7 A/ A- pindependent precocious puberty, which is also known
* C" L9 m& S* @7 X) M6 yas testotoxicosis, may cause precocious puberty at a
' g8 I0 x4 G4 X7 L: }- uvery young age. The physical findings in these boys& U- t, b; H7 y
with this disorder are full pubertal development,
: \& ?* K6 V7 H* e( t$ L, qincluding bilateral testicular growth, similar to boys! c+ i# a3 r3 l- R) J! R4 B. y
with CPP. The gonadotropin levels in this disorder- |. f, R7 x! T$ X& c
are suppressed to prepubertal levels and do not show
  C. ?* a* C' N4 kpubertal response of gonadotropin after gonadotropin-9 \. |% a) s$ d, \( {5 P, I6 N
releasing hormone stimulation. This is a sex-linked; O# c: X  B: `/ z7 _( G  l- g
autosomal dominant disorder that affects only
% K" t7 R6 H9 v5 ]7 Y6 gmales; therefore, other male members of the family% D  D' R2 i% R. V+ ]: \! D
may have similar precocious puberty.3. {* U8 Z2 h. B! s: d: d- {
In our patient, physical examination was incon-
0 ~6 w0 x( t7 H4 t; psistent with true precocious puberty since his testi-
% B: }" T1 \8 m+ P$ ucles were prepubertal in size. However, testotoxicosis
0 t0 [# l5 n/ |# K$ x$ kwas in the differential diagnosis because his father
% t9 E" I) _+ l3 L8 V( d! x, wstarted puberty somewhat early, and occasionally,
! d2 n- `$ R1 j2 f% n3 etesticular enlargement is not that evident in the" [7 f& F2 q5 v
beginning of this process.1 In the absence of a neg-
( o% o+ O9 i- ?ative initial history of androgen exposure, our& P  v8 u  A/ u9 ~) k
biggest concern was virilizing adrenal hyperplasia,
& r$ |& f2 W& ~& v: Jeither 21-hydroxylase deficiency or 11-β hydroxylase
, @! \- W7 `4 M9 s  H% mdeficiency. Those diagnoses were excluded by find-
2 z9 N0 U. |0 I" {ing the normal level of adrenal steroids.0 C- s+ o1 x# q& ?3 U/ z& k
The diagnosis of exogenous androgens was strongly
; Q/ Q5 G; F$ C7 t0 K% z/ Qsuspected in a follow-up visit after 4 months because
6 h$ ]! G" ^7 ^6 F% Q' j: ]the physical examination revealed the complete disap-
; P# _5 O6 {: P& O; n; l. F% }pearance of pubic hair, normal growth velocity, and5 h3 h3 T3 k# F5 ^2 W$ h; U+ S
decreased erections. The father admitted using a testos-2 {8 L* W7 X  V( t+ |. {6 }
terone gel, which he concealed at first visit. He was
3 A# W5 c8 q, f$ n. J/ husing it rather frequently, twice a day. The Physicians’
9 V/ h& w. y5 b# kDesk Reference, or package insert of this product, gel or
5 ?; J4 @, E) m) Tcream, cautions about dermal testosterone transfer to
( O) N$ c( o0 ]* G. tunprotected females through direct skin exposure.
* c$ }7 B/ x$ U" MSerum testosterone level was found to be 2 times the
+ J3 i  a7 a9 t* N  obaseline value in those females who were exposed to/ w$ P7 \; B; o; ~. W- R
even 15 minutes of direct skin contact with their male
6 W2 [+ G- w) y" Dpartners.6 However, when a shirt covered the applica-
7 ?8 N* d" y8 `% m- ?tion site, this testosterone transfer was prevented.4 l  j) t& d! E0 a. A: F
Our patient’s testosterone level was 60 ng/mL,8 V& [! V* Y* T, M4 `' F8 j
which was clearly high. Some studies suggest that! ?( u8 L- ]( D6 s% K  P) T# f
dermal conversion of testosterone to dihydrotestos-
4 G2 A% }0 m3 z7 V0 Jterone, which is a more potent metabolite, is more: A& I; q; G% _* E7 `' b
active in young children exposed to testosterone
, |+ l  ]- B. J) Cexogenously7; however, we did not measure a dihy-8 Z: a+ @* ]! o+ M: }/ C
drotestosterone level in our patient. In addition to
4 M. f, _' P5 hvirilization, exposure to exogenous testosterone in
' q) n% d8 r& S* C( u# Qchildren results in an increase in growth velocity and
9 E# o# _# ]8 V4 v* c1 U, l  F5 o- w/ `advanced bone age, as seen in our patient.
6 f/ I. e- C. o; h6 ^: _* r" \) fThe long-term effect of androgen exposure during
( `8 F) j0 b$ N" @' uearly childhood on pubertal development and final
" n8 K9 ?1 A+ I6 O0 e! radult height are not fully known and always remain
1 s- Y$ A' f" W9 T6 Y  N2 p, }- ua concern. Children treated with short-term testos-1 S. a6 \! e* G# P. I% _
terone injection or topical androgen may exhibit some
+ n5 f0 ~0 r$ g# l6 f& tacceleration of the skeletal maturation; however, after
8 i. w3 Y' H9 ecessation of treatment, the rate of bone maturation
2 T/ d5 y/ o6 k+ g0 B* t/ mdecelerates and gradually returns to normal.8,9
% D" z( N" M$ H) c) zThere are conflicting reports and controversy* s/ D- k  H2 T$ I5 o6 f/ r
over the effect of early androgen exposure on adult: R4 _0 R* f" ^
penile length.10,11 Some reports suggest subnormal
# w# x: u4 P# E' a3 P' @5 J1 Zadult penile length, apparently because of downreg-5 ^1 Z% m+ @# R  }) B8 l
ulation of androgen receptor number.10,12 However,8 S! T( @; C$ o) D0 ~
Sutherland et al13 did not find a correlation between
) S. k8 K8 c; ~  [' l; S$ Ochildhood testosterone exposure and reduced adult
$ k8 h: Q4 ^: \penile length in clinical studies.
  P4 T# `6 j; v5 `Nonetheless, we do not believe our patient is
. j; B) F6 L8 n- X8 Y1 d* O/ Vgoing to experience any of the untoward effects from6 `( Z2 l( K, `4 c5 A! _1 Q
testosterone exposure as mentioned earlier because
1 n0 r0 g" [- @' H6 ]! N) H0 qthe exposure was not for a prolonged period of time.
% C$ i! A" v. P7 g1 |4 t' CAlthough the bone age was advanced at the time of# {. i* s' S, ?2 T: P! S
diagnosis, the child had a normal growth velocity at
& y, r3 O& F% X1 |# w$ W( m/ @the follow-up visit. It is hoped that his final adult
# [& |$ s! g; _& L; B, o8 Y1 Iheight will not be affected.
7 \9 @8 X& f; ^, x7 m( K' V5 Y1 X1 QAlthough rarely reported, the widespread avail-
$ J: K/ u" |2 e/ L$ s* S2 iability of androgen products in our society may
& p5 `7 T* p/ o$ J! C9 zindeed cause more virilization in male or female
! F+ |5 J" [/ D) Y# u, lchildren than one would realize. Exposure to andro-
  `$ ]0 C0 H7 u) M4 |gen products must be considered and specific ques-( F' ?$ Z9 ?- O; v/ U
tioning about the use of a testosterone product or& H% \2 l' C9 N: L* O" q
gel should be asked of the family members during
3 J9 C# T  c7 \the evaluation of any children who present with vir-5 K) J) P9 R6 @! O
ilization or peripheral precocious puberty. The diag-( O' {9 q7 J+ w: X4 v- ]8 ^
nosis can be established by just a few tests and by
  ]) X! O/ f9 G! F3 G0 iappropriate history. The inability to obtain such a
9 ~. P2 D3 N+ x6 G3 Uhistory, or failure to ask the specific questions, may
2 g8 P# f* j6 E3 ~2 M0 hresult in extensive, unnecessary, and expensive2 h. B: h7 s: \. z% n& B' L
investigation. The primary care physician should be7 {0 P, C" r+ S- c' E
aware of this fact, because most of these children+ P( l( e4 L9 Y& g$ U# |5 ~
may initially present in their practice. The Physicians’
. W) g# s. @$ E, w  d0 C& |Desk Reference and package insert should also put a  v/ h9 Y( @3 `
warning about the virilizing effect on a male or$ P9 @; Y, B" C# ^
female child who might come in contact with some-  ?+ X" q( W3 E  X! {
one using any of these products.
: w, x) f% _3 tReferences3 d% S5 ]* E- L$ A/ P
1. Styne DM. The testes: disorder of sexual differentiation: ^2 a9 x$ }# K2 m
and puberty in the male. In: Sperling MA, ed. Pediatric
: f( ?) M# Z. m) n  a4 n7 KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; y3 j; x9 t9 N8 R+ [# B) c
2002: 565-628.$ F* }7 ]5 f1 a% M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 N* `  n: K' c- ~. Y+ J, |3 Opuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ `: w6 a/ R! M) `) W: Y- _Boy Induced by Indirect Topical! {( L5 O7 v9 _1 ^# @. ]
Exposure to Testosterone
- P& ^2 W! j/ f7 Z, OSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- @& ~4 g; P6 K* i
and Kenneth R. Rettig, MD10 t& Z4 b2 g& w) G6 `
Clinical Pediatrics8 A3 w5 `4 g% Q% I
Volume 46 Number 69 K/ u3 H) c6 Y( k
July 2007 540-543% o+ k5 ~, j; g6 P. b1 v
© 2007 Sage Publications4 C, }' E% t1 u) T9 i( D
10.1177/0009922806296651
: P3 E5 z8 J& \* F; y- ~  ^http://clp.sagepub.com
4 P7 K8 G( k$ n$ phosted at0 [2 U, T& Z# J( r, s4 P$ k1 W
http://online.sagepub.com
/ i+ y+ U! [' CPrecocious puberty in boys, central or peripheral,
" e4 t* L% o* G# Iis a significant concern for physicians. Central
4 g  m# |, S& q: P" K1 C6 hprecocious puberty (CPP), which is mediated
9 R$ I* L9 X3 V/ J6 ]! g" [# Tthrough the hypothalamic pituitary gonadal axis, has2 b. |1 \) W2 S7 ]/ o7 ]
a higher incidence of organic central nervous system" w8 x2 A$ q+ U; H: Z! {
lesions in boys.1,2 Virilization in boys, as manifested
+ s3 V! p; t3 Q; M0 l, }3 {by enlargement of the penis, development of pubic: v3 @  F. ?7 X+ S0 K7 G9 |. @! E! m
hair, and facial acne without enlargement of testi-  L- x/ C( N+ p' w- C4 H3 \
cles, suggests peripheral or pseudopuberty.1-3 We
3 ^! K  Z4 x0 N! E/ M( Creport a 16-month-old boy who presented with the
9 `; }+ ?0 @: y' W  i7 Zenlargement of the phallus and pubic hair develop-6 @8 o' X6 o" t, _8 z# Z4 s; k+ n3 F
ment without testicular enlargement, which was due6 R, W! `1 a6 E- ~, c2 \# t
to the unintentional exposure to androgen gel used by
4 c. ~7 j' I, K* q7 W, o2 ithe father. The family initially concealed this infor-$ Q9 G4 _% O  K: q  E# y9 O
mation, resulting in an extensive work-up for this7 q0 A" q) F! F0 k( I' \( @
child. Given the widespread and easy availability of& ~. d, c5 y* z7 n
testosterone gel and cream, we believe this is proba-" h5 E, [: i6 R+ D7 ^
bly more common than the rare case report in the
% [: J9 S  b1 y5 k. a( W( c& r7 n/ mliterature.4
5 o, [1 M, D1 T9 p. }Patient Report& f* s2 X5 h3 k- U) u& {
A 16-month-old white child was referred to the/ W2 M, ~2 U$ k* d9 E
endocrine clinic by his pediatrician with the concern
) q, F7 l# W& \+ ?# R7 f5 k: @+ Cof early sexual development. His mother noticed0 K! h; Z% D9 N5 Q. x/ M' ~3 i3 `
light colored pubic hair development when he was
  Q( E9 _* e2 l5 mFrom the 1Division of Pediatric Endocrinology, 2University of$ b7 x/ t4 l$ |5 q3 l8 h# l
South Alabama Medical Center, Mobile, Alabama.! H1 _$ I( U; x0 G9 H
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 v' a+ L. u: ^9 p6 nProfessor of Pediatrics, University of South Alabama, College of
. D' s# I+ U, E* K8 r! TMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 D- M9 ~, Y* e; z  g0 m
e-mail: [email protected].
/ n5 f: ]$ u8 y. P& V* ^about 6 to 7 months old, which progressively became
) Z, e1 `) l. X% ydarker. She was also concerned about the enlarge-
* Q- D! T* l0 Q; {% _) ument of his penis and frequent erections. The child4 X% x# F* c2 O( l  z2 a
was the product of a full-term normal delivery, with
: F0 s5 U. {6 z& Y6 d$ X2 \a birth weight of 7 lb 14 oz, and birth length of) \. I8 z( q! l& Z' N
20 inches. He was breast-fed throughout the first year. K2 S8 [# P" `& |9 f6 E
of life and was still receiving breast milk along with0 `, d7 k+ u0 h5 X
solid food. He had no hospitalizations or surgery,
5 h, Z& Q; e. p4 O2 d8 T8 u% `and his psychosocial and psychomotor development% J- z* u! M  t+ o+ o. S- @# \
was age appropriate.% v9 _4 g; \1 {2 _
The family history was remarkable for the father,; g1 F+ u. B7 b" X: R1 T
who was diagnosed with hypothyroidism at age 16,& H$ d% h5 v2 Q
which was treated with thyroxine. The father’s
' g+ v: z* f( H6 W, |height was 6 feet, and he went through a somewhat
$ g' Z" d6 ?9 z: Mearly puberty and had stopped growing by age 14.1 z$ b1 s( T- m( E
The father denied taking any other medication. The
1 ^$ i/ i* A5 x* achild’s mother was in good health. Her menarche: Y: E7 R5 C  D, p7 y
was at 11 years of age, and her height was at 5 feet
/ O& r/ Z6 w0 ?) Q9 `# T; R5 inches. There was no other family history of pre-
: f0 G! H! W8 s# K9 U' _* ecocious sexual development in the first-degree rela-
& G/ w6 V2 z2 s7 J3 ttives. There were no siblings.
! w, ?3 G0 f' |Physical Examination
4 E. J. o" f! ]2 M0 W; _/ lThe physical examination revealed a very active,
7 `# W5 Q3 d0 }2 d2 T# H, Oplayful, and healthy boy. The vital signs documented
+ p5 m0 L* u$ k& ia blood pressure of 85/50 mm Hg, his length was1 X1 P; N" G0 V) [1 ^
90 cm (>97th percentile), and his weight was 14.4 kg' g) {! I+ J0 F' @  |0 l* j
(also >97th percentile). The observed yearly growth# I' b3 }  ^6 f) }3 t  @2 X
velocity was 30 cm (12 inches). The examination of, x0 M( u9 e: j! W! D2 u7 p
the neck revealed no thyroid enlargement.
: M" I- _$ Z. O* sThe genitourinary examination was remarkable for
7 e4 W( C/ U! xenlargement of the penis, with a stretched length of# Q% }/ b2 H9 C
8 cm and a width of 2 cm. The glans penis was very well
! f& Z5 @5 b1 f- G' X* ldeveloped. The pubic hair was Tanner II, mostly around
2 l# ]& y! ~: I2 z" L540
$ j8 Q0 ]4 O- \3 |6 |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ], y- \/ |8 U
the base of the phallus and was dark and curled. The& C0 J# F# M! w, u( L8 ?
testicular volume was prepubertal at 2 mL each.
7 g2 d: Y7 F. l- Z4 eThe skin was moist and smooth and somewhat( A; r8 H3 K3 d) w
oily. No axillary hair was noted. There were no
% X2 v0 ~% ?# q3 [; V( X4 Pabnormal skin pigmentations or café-au-lait spots.
$ w  o% K: a; H  eNeurologic evaluation showed deep tendon reflex 2+& b* y7 m; H8 _" G. E8 y
bilateral and symmetrical. There was no suggestion
1 `- r2 N/ ^; |5 W! k  wof papilledema.
( k3 X* y5 \4 o& \) U& zLaboratory Evaluation+ A2 R. E5 R# t0 X8 q8 N" k
The bone age was consistent with 28 months by9 C! k8 V# |5 ~9 T! Z
using the standard of Greulich and Pyle at a chrono-0 R0 `7 b8 V8 j- ~
logic age of 16 months (advanced).5 Chromosomal& a2 [! F, q2 X5 H) s- T
karyotype was 46XY. The thyroid function test, d) g; L7 h5 ?2 o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
& k+ {" L0 e7 c" ?1 D! p/ T# I) f) Ilating hormone level was 1.3 µIU/mL (both normal).
& {! N( r" {; d2 X7 Z5 |7 Z, bThe concentrations of serum electrolytes, blood& G! U1 p( I/ ?: K' P$ ]2 j+ _2 Q
urea nitrogen, creatinine, and calcium all were
+ v3 f$ v* A) G5 s6 R; H! @. G4 Vwithin normal range for his age. The concentration5 ]) B% z- |2 z! P' Q
of serum 17-hydroxyprogesterone was 16 ng/dL. p8 _$ j6 I- [; ~* U( |4 i
(normal, 3 to 90 ng/dL), androstenedione was 20
+ a( K/ m6 G4 @9 E6 A+ ?3 Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( X4 }6 n  M" O1 E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 q; R$ z6 z* `, E# T0 A& r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ _5 j& _& e* S0 b
49ng/dL), 11-desoxycortisol (specific compound S)" \* l6 |. H* z! v/ g
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 E" Z, {# A$ V0 t) @1 Vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 M2 c/ w; q. F3 ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 I9 ^, K( m$ Nand β-human chorionic gonadotropin was less than" C1 j+ [+ \0 Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular
' [( ^6 U3 Y1 {# s8 Zstimulating hormone and leuteinizing hormone
5 K/ D( e& D7 Aconcentrations were less than 0.05 mIU/mL
  y4 u! v4 O7 X/ \1 Q+ }(prepubertal).
4 z0 w2 z' z3 o8 e& D) f5 K$ z+ MThe parents were notified about the laboratory* L/ }. L0 r& }7 s. q$ e2 M! R
results and were informed that all of the tests were6 t1 Y" @9 ]% s; N6 w
normal except the testosterone level was high. The4 w; k2 v6 J/ N! e6 k
follow-up visit was arranged within a few weeks to
  N! W9 h0 k# n' D4 i- ^5 N0 pobtain testicular and abdominal sonograms; how-
  M& N1 H; K2 g2 Rever, the family did not return for 4 months.
0 B, ^% E$ V( GPhysical examination at this time revealed that the
  e( K7 y: r9 mchild had grown 2.5 cm in 4 months and had gained9 D  U/ u5 X' c% x- F
2 kg of weight. Physical examination remained5 X2 b5 P* |* @% |2 {9 d0 n
unchanged. Surprisingly, the pubic hair almost com-3 ]( K/ p+ ~3 n
pletely disappeared except for a few vellous hairs at
* |& l! ~5 x+ o1 @' @the base of the phallus. Testicular volume was still 2- K! i- I3 ?6 d7 |0 l& O- H4 U& B
mL, and the size of the penis remained unchanged.* g" ]. u6 _" \# ~; ~
The mother also said that the boy was no longer hav-
1 l$ H0 i% a& ^1 Eing frequent erections.
- A* t. B, e( E/ t- qBoth parents were again questioned about use of3 n) F8 W8 E9 g# }: b
any ointment/creams that they may have applied to4 X4 |1 ^3 x7 Q! S' m0 Q
the child’s skin. This time the father admitted the
4 l+ z. ^+ m% W8 P$ p  c* U$ A1 x$ JTopical Testosterone Exposure / Bhowmick et al 541
7 p2 ?3 b1 x/ i- P* Cuse of testosterone gel twice daily that he was apply-" O3 R+ I* J& g9 t0 K, a5 i
ing over his own shoulders, chest, and back area for1 W  M8 j  |& r2 k/ d: K6 n5 `
a year. The father also revealed he was embarrassed
. m" |0 {2 \" j  S2 H* K+ p6 a  |to disclose that he was using a testosterone gel pre-+ F/ F! ^' i( Y6 `
scribed by his family physician for decreased libido
9 i0 f1 R# _7 L4 [" ~$ d5 T* wsecondary to depression.
+ G; H+ y" b" PThe child slept in the same bed with parents.
0 ^2 x1 S% M; g2 C% VThe father would hug the baby and hold him on his
& t" `: {2 Q& F5 }chest for a considerable period of time, causing sig-
' z2 u, |. {6 enificant bare skin contact between baby and father.
4 Y; ^7 L. k3 d3 y6 p$ ^The father also admitted that after the phone call,% x9 ?2 m0 Z" p/ X) M
when he learned the testosterone level in the baby5 y2 t5 d" J5 I1 ~; U  T! ^& }
was high, he then read the product information
2 ~" q' j0 k2 ~  K5 b5 Vpacket and concluded that it was most likely the rea-4 m! o( f6 t; J3 \8 L  ]4 W5 v
son for the child’s virilization. At that time, they1 ]( ^4 f5 O3 L
decided to put the baby in a separate bed, and the
# @7 T/ ]$ F& O8 }7 ffather was not hugging him with bare skin and had, ~# T8 c( o9 m3 h# ^( {! v
been using protective clothing. A repeat testosterone+ T6 H. m, p2 Y" ]: {3 R5 ]7 j
test was ordered, but the family did not go to the
: x% u5 h0 q% _% Q( k& B2 blaboratory to obtain the test.% a) X0 \5 Q; D- ~! K
Discussion' L* A5 q$ n' M3 M
Precocious puberty in boys is defined as secondary
6 z8 _' Q5 L) v# p. hsexual development before 9 years of age.1,4
# [/ y# R# G# O9 a& @, v+ [Precocious puberty is termed as central (true) when8 \# z# s: v. C$ o+ _) \! ?
it is caused by the premature activation of hypo-# A, A! Y& S: j+ K" d
thalamic pituitary gonadal axis. CPP is more com-
& k& }; a4 N$ ?( q7 ]$ O- p' Cmon in girls than in boys.1,3 Most boys with CPP
, I8 ^" ^0 E" g: R! g% V% M6 P0 D0 smay have a central nervous system lesion that is% w. }* \2 R8 }2 j" i' s, {
responsible for the early activation of the hypothal-
2 q; V& C' c! h, \1 jamic pituitary gonadal axis.1-3 Thus, greater empha-& z/ ^4 r4 `" g0 X* e' a
sis has been given to neuroradiologic imaging in
# O, h! l  g# {( N% iboys with precocious puberty. In addition to viril-# @( o; a) R6 i, x. l* b
ization, the clinical hallmark of CPP is the symmet-
# U" H! ?% p) c" Q- e& N  N: O0 yrical testicular growth secondary to stimulation by8 _0 D1 y0 o' C9 b
gonadotropins.1,3# i" i; w$ V0 T! n4 V. l- w9 U
Gonadotropin-independent peripheral preco-" G. G6 S1 Q/ u1 O
cious puberty in boys also results from inappropriate
1 W  O, [% q$ y! L' w; Q0 Aandrogenic stimulation from either endogenous or2 Z* h+ X) ]- c/ K% k: d
exogenous sources, nonpituitary gonadotropin stim-- i: B" b$ B4 D- {$ l- p, ]) h  u1 n
ulation, and rare activating mutations.3 Virilizing
8 W- K) }: d( R! R* scongenital adrenal hyperplasia producing excessive
# A# c) f8 s1 n! c5 ?adrenal androgens is a common cause of precocious9 `# K" U5 c7 J' h/ y4 y
puberty in boys.3,4
; ]4 T8 ]8 F/ M1 ^The most common form of congenital adrenal
% y2 O4 G/ ~# O4 L/ U9 @hyperplasia is the 21-hydroxylase enzyme deficiency.
& |, A2 J# `! w6 vThe 11-β hydroxylase deficiency may also result in
# }9 d6 X5 O6 W( }7 v, u1 [excessive adrenal androgen production, and rarely,% D2 }3 p! U/ v- Y( G. V& E
an adrenal tumor may also cause adrenal androgen4 c. s# j  T$ P. U4 n6 g% k1 s/ w
excess.1,3
9 i5 k9 Q$ R6 T0 ?4 Z# ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# s: C8 A. |9 l$ f$ B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; l; l) Q6 `; v$ A, hA unique entity of male-limited gonadotropin-
( q" P4 i- b5 q- b! z7 F( B2 Z2 Iindependent precocious puberty, which is also known
$ k# M. K- I! t- eas testotoxicosis, may cause precocious puberty at a
0 g2 t5 B% r: E0 p  x& c- J4 wvery young age. The physical findings in these boys& t$ V5 {3 d6 k+ w
with this disorder are full pubertal development,7 K0 g( k% v* L
including bilateral testicular growth, similar to boys+ G7 ?# Z) Y3 q* }
with CPP. The gonadotropin levels in this disorder% b; c8 e8 k, r: r7 A0 Z9 ~
are suppressed to prepubertal levels and do not show
3 Q! z& O" B4 B3 b( `0 ?pubertal response of gonadotropin after gonadotropin-
5 A  z+ F* G5 N/ ?" b$ o5 wreleasing hormone stimulation. This is a sex-linked. I6 \; L' L, G, O8 {
autosomal dominant disorder that affects only4 v1 U% Y1 _3 S6 u# ~8 q
males; therefore, other male members of the family
* D4 m/ @' \. m; Amay have similar precocious puberty.38 H3 s2 P2 _/ o  ?# n
In our patient, physical examination was incon-& _, d% E9 r2 _1 K
sistent with true precocious puberty since his testi-# P, J+ _) s# ]' b; E3 O. L
cles were prepubertal in size. However, testotoxicosis
0 N7 V' H0 \# u% x' l3 g' Nwas in the differential diagnosis because his father+ c. i4 d4 v3 p9 z; L% q( f4 N; T+ a
started puberty somewhat early, and occasionally,
2 p7 R* {  @1 }( F! L5 xtesticular enlargement is not that evident in the0 C& \+ M# R: _
beginning of this process.1 In the absence of a neg-3 f2 [1 a% O" X  I) H5 [5 c% O
ative initial history of androgen exposure, our0 i) u) u* {' }( t/ `0 G* i
biggest concern was virilizing adrenal hyperplasia,
2 {+ m* _& c( k& d- f( [8 j9 d# J0 Ueither 21-hydroxylase deficiency or 11-β hydroxylase& L7 U# T0 \* d, F& V
deficiency. Those diagnoses were excluded by find-, N' F- C5 I% i) s9 Q
ing the normal level of adrenal steroids." e: H) g* X; @' ^7 o
The diagnosis of exogenous androgens was strongly
2 ^0 x. e- K- P2 bsuspected in a follow-up visit after 4 months because3 r, I4 S. \* H" Y% |1 }3 j
the physical examination revealed the complete disap-
+ |6 J9 B/ A$ X- _* Y- ~3 y0 `pearance of pubic hair, normal growth velocity, and" y* @$ }) O  s. ~
decreased erections. The father admitted using a testos-
/ B2 U8 d3 {5 [1 mterone gel, which he concealed at first visit. He was
( h: N: m/ T9 a* Fusing it rather frequently, twice a day. The Physicians’
( @8 O8 h" v, |' rDesk Reference, or package insert of this product, gel or. U8 t9 {/ r0 b9 X1 y! d
cream, cautions about dermal testosterone transfer to, I  N/ [  ^# c3 C) u0 ?, ^
unprotected females through direct skin exposure.2 A3 N* X4 I- N& b/ |, j4 c. @0 a/ F3 E
Serum testosterone level was found to be 2 times the- B! \9 o" D: K- ~+ z1 S
baseline value in those females who were exposed to4 `& |; ^( R* y& M: I- ~
even 15 minutes of direct skin contact with their male! `3 n: [5 V7 I, l1 g3 o  |
partners.6 However, when a shirt covered the applica-& C8 L/ ]0 z& X; |% Z, w# M
tion site, this testosterone transfer was prevented.
1 y, o# `5 S) {9 T. y" @7 v, wOur patient’s testosterone level was 60 ng/mL,
( P2 F( W* v# I' N0 x# X2 {which was clearly high. Some studies suggest that
, P9 J! m3 Q2 }( @" M$ Sdermal conversion of testosterone to dihydrotestos-
9 p5 i% B0 o3 N! }terone, which is a more potent metabolite, is more4 l' a1 p# ~1 u$ F9 U
active in young children exposed to testosterone
! d! l9 ?, Q5 f" \exogenously7; however, we did not measure a dihy-/ d7 z6 t# p6 b5 i* _
drotestosterone level in our patient. In addition to
; h4 p% L3 `$ gvirilization, exposure to exogenous testosterone in
) I: `" C9 F+ Dchildren results in an increase in growth velocity and
, y5 Q. h3 \. K5 i1 v+ Dadvanced bone age, as seen in our patient.: t8 D) i; j( ?; h
The long-term effect of androgen exposure during
6 C) `* n9 ]: P# Y9 t" }early childhood on pubertal development and final
: d  e* S" _; j& l! o! [9 ^" Padult height are not fully known and always remain
8 p* X0 M" n; L; w4 {: C" Fa concern. Children treated with short-term testos-
$ V, q5 V) W( ^& o- V0 ]terone injection or topical androgen may exhibit some' N; P6 o; v+ i6 D8 U2 Y" I
acceleration of the skeletal maturation; however, after
9 _/ r7 }1 E8 s; Y0 d# C, Ucessation of treatment, the rate of bone maturation
. o5 C0 l% L' i, g# b0 @: b& wdecelerates and gradually returns to normal.8,9
# [$ G7 Z9 U5 k1 W# d0 p0 VThere are conflicting reports and controversy, _/ a+ T+ D! C) {. U, a6 w
over the effect of early androgen exposure on adult
9 y% H# O) R' u0 v  k1 Dpenile length.10,11 Some reports suggest subnormal! Q0 M9 s1 S' z
adult penile length, apparently because of downreg-# R: T0 @" _5 K) X; W9 j5 e% |
ulation of androgen receptor number.10,12 However,4 [, L2 U# C7 V1 J& {+ D
Sutherland et al13 did not find a correlation between
& f- }% R1 Z# z, S: i/ H' Fchildhood testosterone exposure and reduced adult
* A0 E) l/ [+ @& N% Z  hpenile length in clinical studies.
, A* \$ j4 k) tNonetheless, we do not believe our patient is8 S8 `: ]5 P% L; S9 C6 y
going to experience any of the untoward effects from
/ W& s4 U/ h0 R" y; u% s' h3 O: Vtestosterone exposure as mentioned earlier because2 z7 q& F! r2 S/ i: n
the exposure was not for a prolonged period of time.
) o' B4 k: p- L9 C4 O8 L' G- I- @Although the bone age was advanced at the time of
2 j1 f. S" a$ S" S7 L2 g( b% t! `diagnosis, the child had a normal growth velocity at9 h! a0 P5 m$ N3 E
the follow-up visit. It is hoped that his final adult
# E( Y; Y; L4 Y* w# Uheight will not be affected.+ r4 v& ~3 \( z+ e! K, s& _
Although rarely reported, the widespread avail-
) @1 U8 I# e  y6 l, Lability of androgen products in our society may( L9 {: F/ k) d- r: q* b
indeed cause more virilization in male or female7 p, W8 J4 P& }) k# \# p) \; q$ G) u
children than one would realize. Exposure to andro-
( t; O4 o5 P! D6 B) qgen products must be considered and specific ques-; C& G/ ^8 l3 o2 u0 t9 `% ~. s
tioning about the use of a testosterone product or3 ^$ R7 Y- Z5 `% B: g
gel should be asked of the family members during
* w/ ^& e" S0 n2 ethe evaluation of any children who present with vir-: O) w, M) h7 t* r
ilization or peripheral precocious puberty. The diag-$ p1 y/ @, r) j! a$ N1 b
nosis can be established by just a few tests and by
, d( P. W: _0 Mappropriate history. The inability to obtain such a" o9 Y- J/ s" @. k& s  s: D3 n
history, or failure to ask the specific questions, may
1 k6 E2 S- y4 p) S  c' X  Hresult in extensive, unnecessary, and expensive4 c: p3 E' D- B8 A- ~6 L& r) H9 \
investigation. The primary care physician should be
% t# L4 |( l; `# w/ `aware of this fact, because most of these children
, G9 t* _, {4 E7 m: Amay initially present in their practice. The Physicians’
3 w& m3 ?7 |& _; m9 NDesk Reference and package insert should also put a  Q- C4 t0 E, P: @6 q& V* e
warning about the virilizing effect on a male or
5 a5 f: Q$ K! V5 B" ifemale child who might come in contact with some-) w2 m8 u% j# @* T
one using any of these products.
" |; q! Y3 o! @1 w. |8 l9 r, nReferences+ f. ^& S; i+ b' y
1. Styne DM. The testes: disorder of sexual differentiation/ E) a6 z( X* G' e+ m' v
and puberty in the male. In: Sperling MA, ed. Pediatric3 s4 A; d; u# P* g4 U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) z, \$ M( T8 ~/ v+ O$ ?4 H
2002: 565-628.
0 Y4 {3 z; e7 ~* H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! Y! Y4 [5 x- G
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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

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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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