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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
+ x7 S' ]$ Z* i* XBoy Induced by Indirect Topical
0 U4 i. }& d" v  P% fExposure to Testosterone- \( |+ N0 _. P" r5 q5 _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) p3 G  ^: p  h7 z
and Kenneth R. Rettig, MD1; p$ O- c2 X- K0 v" ?8 y- e: z" w
Clinical Pediatrics
( P; A( c3 e: y! C- c. rVolume 46 Number 6
2 W, p0 d* D' o; o" ?- h/ s: [July 2007 540-5434 T8 e  ]4 _. u: Z2 o5 Q
© 2007 Sage Publications
  y: e+ F. H% A! m1 y10.1177/0009922806296651
" x1 w+ Q6 f4 mhttp://clp.sagepub.com
7 V( M, ?5 C" u3 Mhosted at2 G  |9 E- P0 n/ q) [0 b4 v* t
http://online.sagepub.com8 f4 l( L2 ^% ~. v; V
Precocious puberty in boys, central or peripheral," h% X+ H+ t+ i* }$ g
is a significant concern for physicians. Central
) w6 e- n- B$ U! T9 R- }precocious puberty (CPP), which is mediated* c9 h; H" d. J6 n
through the hypothalamic pituitary gonadal axis, has
9 b' }+ A- a# Ha higher incidence of organic central nervous system
3 R7 ?4 e- E2 O3 \( Y# y- xlesions in boys.1,2 Virilization in boys, as manifested
+ m8 H- h/ `! D7 T, ~by enlargement of the penis, development of pubic
8 [' G% u, A, T  A% f' xhair, and facial acne without enlargement of testi-
, d8 @/ ]. q6 ~0 P/ |cles, suggests peripheral or pseudopuberty.1-3 We3 _, B% b  Y( h9 F9 R; ~0 J' p& L( Y2 B
report a 16-month-old boy who presented with the2 p8 d) w* ?/ U4 c
enlargement of the phallus and pubic hair develop-/ T' n$ V% I$ O9 o
ment without testicular enlargement, which was due
6 n4 R9 \. ]; D  `4 R+ C4 p/ Rto the unintentional exposure to androgen gel used by. O9 w2 G- p5 s6 D4 ~
the father. The family initially concealed this infor-
8 ?+ H% _# d8 P( }mation, resulting in an extensive work-up for this% Q5 P( W3 P. x) C( T7 h# B/ N% T
child. Given the widespread and easy availability of
. t1 a% r4 S  E5 ^testosterone gel and cream, we believe this is proba-
! R) V* e; ?# @4 lbly more common than the rare case report in the  Q4 F; T; _" L4 h9 v* |, |
literature.4
( A/ o+ Y: s' b6 d- BPatient Report
. J* b- R1 A; s  N' I: ^A 16-month-old white child was referred to the
7 X( P* n8 A9 r1 u5 Xendocrine clinic by his pediatrician with the concern
- O2 j, v+ X2 s3 v& Z* vof early sexual development. His mother noticed2 X2 p; @! B4 p
light colored pubic hair development when he was
: R+ w: G+ o) a4 B5 g2 H1 W# VFrom the 1Division of Pediatric Endocrinology, 2University of
/ K% N( ~; q; D6 u, b' ]  PSouth Alabama Medical Center, Mobile, Alabama.
  x5 w  n4 m8 s* J% J( fAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 Y6 T, Q6 r& r- qProfessor of Pediatrics, University of South Alabama, College of# A* c" j" h# b2 n5 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- t& g- e& U( \- o# z6 q) {& pe-mail: [email protected]., [2 _, F: d5 V( u
about 6 to 7 months old, which progressively became
" ^9 x* s3 U* ^: Z. hdarker. She was also concerned about the enlarge-( Y$ m( g  F4 ^) C
ment of his penis and frequent erections. The child# c. O7 f! I- [( C6 s
was the product of a full-term normal delivery, with
4 _9 \. Q3 e1 L+ T3 d) X9 Ha birth weight of 7 lb 14 oz, and birth length of% X+ u7 ?! V& o% g5 Z. X
20 inches. He was breast-fed throughout the first year
' Z/ Y9 Q/ d# r! e/ H8 ~of life and was still receiving breast milk along with
2 `( Y. }) b. z8 ], h6 f8 t7 {solid food. He had no hospitalizations or surgery,1 V: z5 ^+ R7 k( p5 [
and his psychosocial and psychomotor development$ f8 P" x, a  ]' E
was age appropriate." ]2 W" b4 u; a$ {: Y: F
The family history was remarkable for the father," q; M" @. Z% X' i1 v2 Y5 `
who was diagnosed with hypothyroidism at age 16,, U0 F2 K; {; l* W8 L8 T
which was treated with thyroxine. The father’s
( ^" |/ C1 x: M  S, d8 e$ E8 eheight was 6 feet, and he went through a somewhat
  L  o$ p0 @2 c& L2 l# c8 }early puberty and had stopped growing by age 14.8 Y3 R  S/ z" j" Z& n" J. S
The father denied taking any other medication. The1 e8 F. l0 l7 k# j6 p4 E
child’s mother was in good health. Her menarche; h# f/ ^1 T) o. x
was at 11 years of age, and her height was at 5 feet
' n0 m0 F, P, h/ d. Z+ j5 inches. There was no other family history of pre-
) ]' T$ S9 Q  d5 ^/ z" P, ~' ecocious sexual development in the first-degree rela-# M4 h2 O0 |5 H, O
tives. There were no siblings.7 {3 o' t) ^4 ^) Z. h  D% s
Physical Examination
* @4 h7 C" r5 m; o: EThe physical examination revealed a very active,
% x  N: m$ R7 oplayful, and healthy boy. The vital signs documented( {0 x; I4 p" P( F
a blood pressure of 85/50 mm Hg, his length was6 w$ `: k$ W2 M% \
90 cm (>97th percentile), and his weight was 14.4 kg
/ s4 h, m+ w1 b' B4 C; x(also >97th percentile). The observed yearly growth
: X  t& H3 U  ?2 c, F+ N( uvelocity was 30 cm (12 inches). The examination of
% I! r  p7 V+ T+ `. r3 \4 cthe neck revealed no thyroid enlargement.! U# P& n; c  ^0 Z4 u
The genitourinary examination was remarkable for
, g4 M( X; X% g/ K  @) K: c0 Z/ m+ [enlargement of the penis, with a stretched length of
! Z* k  E; A( q8 p1 u8 cm and a width of 2 cm. The glans penis was very well1 Z+ Z* L/ B2 O6 W1 m
developed. The pubic hair was Tanner II, mostly around
+ L. p6 `( v5 d, T( y4 C+ i# t, U/ I5404 Z4 J- m& Y! A6 f6 f$ n! z7 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 B+ H$ w0 q  w% ]
the base of the phallus and was dark and curled. The
$ x( [2 I$ A- K- F( Dtesticular volume was prepubertal at 2 mL each.% M: B: \& m2 D, J8 m- c0 f* X  Q
The skin was moist and smooth and somewhat2 G7 ?. C0 E! T5 `( P
oily. No axillary hair was noted. There were no
# L$ p* c- e: w$ B3 x5 aabnormal skin pigmentations or café-au-lait spots.# d( Z) i4 R2 ~3 M6 p- H2 A
Neurologic evaluation showed deep tendon reflex 2+
5 R. f$ A5 |& ?bilateral and symmetrical. There was no suggestion
8 V2 ~! z5 u% e" Z* E7 Aof papilledema.
' s! z2 W. K  z1 x8 Y/ {: CLaboratory Evaluation: u+ v- `3 ?3 p& t7 h
The bone age was consistent with 28 months by
* G' f! K4 C2 B% M! K1 I1 Q6 L; nusing the standard of Greulich and Pyle at a chrono-
* Q# ?8 Q4 a, Llogic age of 16 months (advanced).5 Chromosomal
5 r+ W+ q9 A  t( Ukaryotype was 46XY. The thyroid function test
, _% W7 U2 r# _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( I) u. C- j3 C8 R; u  N) p( o. xlating hormone level was 1.3 µIU/mL (both normal).
* M1 _/ P( u+ D' c3 S; mThe concentrations of serum electrolytes, blood
- m, R3 C1 R1 J7 W% kurea nitrogen, creatinine, and calcium all were
/ _2 m. A: u9 f- J9 [2 F) a0 swithin normal range for his age. The concentration2 O' L& `3 [, V
of serum 17-hydroxyprogesterone was 16 ng/dL; W; L4 b0 v0 |5 @
(normal, 3 to 90 ng/dL), androstenedione was 20+ {6 E* |) [) v4 `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. z8 T: c( G3 G; ?  @5 s
terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 z7 i# B& G' z" J4 \; p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, A- k' {' K- g: N; v% @
49ng/dL), 11-desoxycortisol (specific compound S)
# n# ^" l! ?; `$ F$ k$ swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- i2 _  K4 x. T: T1 @( U0 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& }. R# `4 A; Y- u) w; s" @% V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# s3 J. Y2 c, l6 {8 K" v* n
and β-human chorionic gonadotropin was less than
) [1 }  x. y2 x+ {0 E3 V5 mIU/mL (normal <5 mIU/mL). Serum follicular
: K4 e* \) b9 e! z* f8 ^2 t% _) vstimulating hormone and leuteinizing hormone' M+ E' M. e, q: c) @4 s8 K
concentrations were less than 0.05 mIU/mL
7 r" w+ G; g4 h; u(prepubertal).& J8 j% N% }# b. J4 Z" K7 Q' b6 ~" Q
The parents were notified about the laboratory
2 Z* W4 c* r; p$ B; b) Iresults and were informed that all of the tests were
) c, }0 Q/ ?8 \2 jnormal except the testosterone level was high. The8 K- t3 |; U* m9 }6 T; \- F
follow-up visit was arranged within a few weeks to
. i8 @2 |# X. I, R0 `obtain testicular and abdominal sonograms; how-
  ]1 Z$ _0 C9 f5 w# m3 Mever, the family did not return for 4 months.
. l% Y+ d  o: W. aPhysical examination at this time revealed that the
  p6 Q! M' X2 v' \1 X9 \child had grown 2.5 cm in 4 months and had gained
! O, E$ _# C: ~2 kg of weight. Physical examination remained
( d: |% c$ p* q4 ~unchanged. Surprisingly, the pubic hair almost com-  m2 j- L& J" m
pletely disappeared except for a few vellous hairs at
% e; I: S1 r4 ~the base of the phallus. Testicular volume was still 2
; y* n! u0 Y4 y$ mmL, and the size of the penis remained unchanged.2 r* `# N' i6 n- p. ^% k6 U# b; L/ B
The mother also said that the boy was no longer hav-
7 B9 x+ ~; d" ^2 ~& p2 j' K. B9 cing frequent erections.4 i& _2 X4 J+ _. N6 C. \* c
Both parents were again questioned about use of
9 n; z% ^7 p; u* D, ~any ointment/creams that they may have applied to( i$ t$ {9 x& _  _) V5 Z) j
the child’s skin. This time the father admitted the- Z- R. |$ F- o& @% \3 X; q! l' G
Topical Testosterone Exposure / Bhowmick et al 541, X) x& U# G, u9 W" Q# P- N3 i. A
use of testosterone gel twice daily that he was apply-) F& [" B% u. ^: A: j
ing over his own shoulders, chest, and back area for
8 Q& t- U( C4 h  Q1 }a year. The father also revealed he was embarrassed
! r: J+ O# a/ o- h& pto disclose that he was using a testosterone gel pre-% X. Q8 x' r: o. j# P
scribed by his family physician for decreased libido
6 p& L4 u! k: C# L( ^0 w; Tsecondary to depression.
$ U# t3 K7 _8 x3 LThe child slept in the same bed with parents.
, o: l/ v( C6 f+ t) u. eThe father would hug the baby and hold him on his% b3 ~) Y1 h. d6 c* ]
chest for a considerable period of time, causing sig-
0 {6 d8 ]% R* v/ F& _& anificant bare skin contact between baby and father.8 l# x( \; A; k
The father also admitted that after the phone call,) q9 u, j) h1 [
when he learned the testosterone level in the baby
: }- X8 [# Z+ {was high, he then read the product information5 X. k6 B: r/ ]6 ~) @
packet and concluded that it was most likely the rea-
7 u8 ]% @$ c$ x  Z8 @! r! `son for the child’s virilization. At that time, they
) j; m+ V- o' Z  H# K( Z/ Ddecided to put the baby in a separate bed, and the
; \! n; O- Y, c& _, o/ ]8 g! p% kfather was not hugging him with bare skin and had
' M$ z" P7 a% Zbeen using protective clothing. A repeat testosterone( M3 I* ?; q; ]' ?; M1 c7 ?7 V8 W- X
test was ordered, but the family did not go to the2 ~  S: {6 g- {
laboratory to obtain the test.
. ^. _' J& J: ^( BDiscussion4 S: K" D* k# y% D0 E. U. O
Precocious puberty in boys is defined as secondary7 Q: ?% [! e! Q2 V) h5 b9 f
sexual development before 9 years of age.1,41 f2 A, J# N  v9 F0 `* E0 j9 S
Precocious puberty is termed as central (true) when6 s6 A0 e$ F+ @& J$ U& R! Z+ ?: f
it is caused by the premature activation of hypo-! ^; W) {0 d' N' ~
thalamic pituitary gonadal axis. CPP is more com-1 D/ k% l7 b: p' q
mon in girls than in boys.1,3 Most boys with CPP
3 j+ u$ g" O2 z7 ]. o( B5 i/ Gmay have a central nervous system lesion that is  c! D; c1 d5 d- Q  Q7 @
responsible for the early activation of the hypothal-  v8 k. N2 ]: d& Z. I
amic pituitary gonadal axis.1-3 Thus, greater empha-0 s- X& g( _; F! h, E; J
sis has been given to neuroradiologic imaging in3 p1 T0 J% F; A
boys with precocious puberty. In addition to viril-
, l. V2 P4 f+ ]! A7 D! ]. X3 gization, the clinical hallmark of CPP is the symmet-: ~9 J6 n# m. `1 a- {5 M0 D$ \: X
rical testicular growth secondary to stimulation by
) x, d' S$ Z- o) t" ^- Egonadotropins.1,33 d8 I- d* _4 ?9 {
Gonadotropin-independent peripheral preco-
( h  {4 U* [" s+ }cious puberty in boys also results from inappropriate! _. k' e6 _8 W! ]. x1 n
androgenic stimulation from either endogenous or& G) x" Z& A" x7 Q1 h8 _
exogenous sources, nonpituitary gonadotropin stim-& I. F' k0 P$ y& [4 s* b7 v
ulation, and rare activating mutations.3 Virilizing6 u! z/ H6 M7 y, g; _! S) K
congenital adrenal hyperplasia producing excessive9 [; s  e7 |) F& O& ?) l) K; s6 o
adrenal androgens is a common cause of precocious
" s) z3 R* v6 _% qpuberty in boys.3,4
9 ?; \; o4 [4 \The most common form of congenital adrenal8 B3 W' n3 ?7 S1 L
hyperplasia is the 21-hydroxylase enzyme deficiency.
) v. Q' F2 ?$ P. T2 wThe 11-β hydroxylase deficiency may also result in* p/ y# J! j+ v; z' F1 a
excessive adrenal androgen production, and rarely,2 ?$ K" [" v. p; _7 ^
an adrenal tumor may also cause adrenal androgen
2 J4 W1 V  {0 Eexcess.1,33 A  z4 x# Y( z: D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ p0 \8 l1 r4 h% d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- o. b& w+ i* a- aA unique entity of male-limited gonadotropin-
2 n' j4 }. M3 y. Aindependent precocious puberty, which is also known* @3 R% F/ \% a+ d
as testotoxicosis, may cause precocious puberty at a
1 ~, f  Z$ U: V& p( B4 w+ mvery young age. The physical findings in these boys
+ i* D* s) d( a$ g& T# U  Vwith this disorder are full pubertal development,5 |/ g. f4 J0 x, j; I5 k
including bilateral testicular growth, similar to boys
5 c# i: c( k. D% d/ S3 {with CPP. The gonadotropin levels in this disorder9 r3 h# m1 d5 C( F) d
are suppressed to prepubertal levels and do not show
* s) ?+ C( ]6 P+ `pubertal response of gonadotropin after gonadotropin-8 o+ D9 J. {* }, z* E- Z
releasing hormone stimulation. This is a sex-linked
# I4 c( D2 v% |autosomal dominant disorder that affects only
* X4 X9 Z' S7 [males; therefore, other male members of the family
; ~2 Y$ l5 w" H6 k1 w" imay have similar precocious puberty.3! X/ \0 v# R  c" X0 M
In our patient, physical examination was incon-
8 m! I3 m" z: c0 Q6 A" rsistent with true precocious puberty since his testi-
9 Z8 {2 u0 y9 n# Vcles were prepubertal in size. However, testotoxicosis# w  l% H  Z' G9 U" V# B0 u
was in the differential diagnosis because his father
9 T% p: I" P' bstarted puberty somewhat early, and occasionally,& V3 X, B5 Q5 V8 {
testicular enlargement is not that evident in the
0 W7 ?( h/ @1 k$ T; Y3 _beginning of this process.1 In the absence of a neg-
" [  }8 @+ W2 p% X# J4 fative initial history of androgen exposure, our
" b6 D1 I+ R7 D' [+ v  Mbiggest concern was virilizing adrenal hyperplasia,& _# A9 A0 Z) m! e
either 21-hydroxylase deficiency or 11-β hydroxylase
9 c' o7 o2 M3 H2 G7 Udeficiency. Those diagnoses were excluded by find-
/ L+ K/ O) ~3 |+ b" Ling the normal level of adrenal steroids.
' m; S. s! x; Z1 S. [  sThe diagnosis of exogenous androgens was strongly
( J1 ~1 Y2 p' i( H0 d, ksuspected in a follow-up visit after 4 months because
' a; c# H+ W% C2 e6 P! w( Dthe physical examination revealed the complete disap-! F1 U3 S, _& W, [7 {
pearance of pubic hair, normal growth velocity, and
4 d% _$ h+ I; j9 e5 odecreased erections. The father admitted using a testos-2 i+ x) o2 |* b
terone gel, which he concealed at first visit. He was
; v: y5 v% ?7 k* Husing it rather frequently, twice a day. The Physicians’
8 P) G  N/ [' i) y: F  ]Desk Reference, or package insert of this product, gel or
$ Q+ ?3 p7 ^7 E6 N: _% {& ucream, cautions about dermal testosterone transfer to, l4 c. z; Q' ^1 h/ f+ P3 @
unprotected females through direct skin exposure.1 q3 i3 b% J2 L: T0 n$ g
Serum testosterone level was found to be 2 times the
" D, m1 d( K& J% \. j/ B+ pbaseline value in those females who were exposed to
; F1 X% u6 W: c5 o, o% B& E! veven 15 minutes of direct skin contact with their male
' q. V+ {4 l1 ppartners.6 However, when a shirt covered the applica-4 S+ V. N- f7 U6 j% O# l% S2 r/ h* \
tion site, this testosterone transfer was prevented.
5 O- j" v$ H* A7 nOur patient’s testosterone level was 60 ng/mL,9 z1 l% l& x* l4 n3 \" x) W; f& W
which was clearly high. Some studies suggest that' A, y( i0 A7 f" R
dermal conversion of testosterone to dihydrotestos-  B- F9 _; L3 S: L. a
terone, which is a more potent metabolite, is more5 q- X' D  O. D; d7 C! \; x
active in young children exposed to testosterone
( z: Y8 ~1 X% X6 x0 @% iexogenously7; however, we did not measure a dihy-
" _3 C( v: e. I& K6 idrotestosterone level in our patient. In addition to8 O9 H; Q3 B, [# C& C  i5 Y% ?
virilization, exposure to exogenous testosterone in" u( B  ^5 E% Z( }7 K; E9 p
children results in an increase in growth velocity and/ U' U+ E+ O) X( B' y, K
advanced bone age, as seen in our patient.
3 G5 r& p& ^- ]) HThe long-term effect of androgen exposure during
( E0 v" x" j1 m# cearly childhood on pubertal development and final
) F9 J3 s) Q2 _5 y2 [; J  W( [adult height are not fully known and always remain
* m4 T' F8 f4 `0 Q) z8 U/ P* H/ Ja concern. Children treated with short-term testos-
% Q% A& C0 w9 E* T7 w3 ?5 qterone injection or topical androgen may exhibit some
- W0 \$ k. o6 m( L; p* Jacceleration of the skeletal maturation; however, after3 h: _) ^4 @* ^& z/ W; g1 p! r% Y% c, g
cessation of treatment, the rate of bone maturation
, y2 ]  t  d! p/ ~) s& r  m: p# adecelerates and gradually returns to normal.8,9
/ z$ I- i2 r* E" H8 |8 |There are conflicting reports and controversy
% P& o7 p1 R/ ?over the effect of early androgen exposure on adult
; j6 S- L8 W: E6 ?* \/ E0 b* spenile length.10,11 Some reports suggest subnormal  C4 Q! [4 ]3 c% S  Z- }+ \3 @7 Z
adult penile length, apparently because of downreg-
$ n' f% i* s6 L+ n0 lulation of androgen receptor number.10,12 However,
( }& X: z/ J. V: _& _. zSutherland et al13 did not find a correlation between
1 |/ g9 o- u: U5 A* schildhood testosterone exposure and reduced adult
( `4 Z; m  s3 R$ T5 V$ fpenile length in clinical studies.
; P' Y* y/ O, z! U) ONonetheless, we do not believe our patient is& _8 `5 m1 N0 @* O1 B
going to experience any of the untoward effects from$ A1 |4 r" Y$ Q/ j* ]7 G7 s
testosterone exposure as mentioned earlier because
% h! ]9 |7 G) v- |# athe exposure was not for a prolonged period of time.$ r' I; W" P' j6 _
Although the bone age was advanced at the time of- t4 Z, V/ N! j
diagnosis, the child had a normal growth velocity at
9 N9 V5 z0 u- {( }+ gthe follow-up visit. It is hoped that his final adult
9 d# \8 A4 F$ ~# o, oheight will not be affected.& _1 H* M9 K4 E, `: a; |2 V, v
Although rarely reported, the widespread avail-
' E3 w+ g* {: y' {) c% D9 Oability of androgen products in our society may
% Y3 W! Z( c7 @9 D3 Iindeed cause more virilization in male or female
3 d( Z2 ^, |! b) v: i; Cchildren than one would realize. Exposure to andro-; Z. Y/ V6 O$ d  Q3 d3 V( x
gen products must be considered and specific ques-
+ Q8 `4 F& J% ptioning about the use of a testosterone product or% t" k6 ^+ @; `. y9 M4 V( H0 c
gel should be asked of the family members during6 G; s" T8 |5 v$ e
the evaluation of any children who present with vir-
4 v! @8 J; W7 Q4 j  D' K( M2 V' Eilization or peripheral precocious puberty. The diag-
, R7 _( q' r- Hnosis can be established by just a few tests and by1 y) q  K; x+ x; D. z
appropriate history. The inability to obtain such a
. I0 Z1 ^: x2 Q' F( I9 shistory, or failure to ask the specific questions, may
4 m) E3 y, g$ J* `: J6 g& C; Xresult in extensive, unnecessary, and expensive
4 u6 |7 r7 Z' p% }- kinvestigation. The primary care physician should be+ @% P4 P5 t8 b: r9 Q+ B" C
aware of this fact, because most of these children' B; b, [9 y' M
may initially present in their practice. The Physicians’" T0 f) e! u4 T; m) L  |0 H2 o) o
Desk Reference and package insert should also put a' S& f! @6 s4 I+ \/ N0 m/ @" y
warning about the virilizing effect on a male or
7 n1 P" o7 }9 i8 h1 X" zfemale child who might come in contact with some-
( p* J/ d( Y0 z- `- k5 Z' Kone using any of these products.
1 y, S& W8 E/ d7 r4 W! v, oReferences6 `" I2 S2 i, t2 d
1. Styne DM. The testes: disorder of sexual differentiation$ J* Q( F- e' W8 C" P  n
and puberty in the male. In: Sperling MA, ed. Pediatric
6 p4 W3 z7 N" U' ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: V: l- L7 W, M! ]1 j( y0 b; g2 Q
2002: 565-628.
, d5 w! Z- N9 {, U! a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% {# |5 w) {, y2 Q6 A( E; ~puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
7 p. W6 A0 u# u7 |  Y& F0 yBoy Induced by Indirect Topical( Z* O' K4 O" ]- I* W, [  c( K6 W
Exposure to Testosterone) L# g/ a. E1 t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# W4 `0 e% C2 V  A- M8 w* Dand Kenneth R. Rettig, MD1" n" w8 F8 S4 O5 j  a
Clinical Pediatrics5 t& r; v1 k9 Y3 C
Volume 46 Number 6
, ^& w  ~  H$ N! |0 y& A  j) \July 2007 540-5436 }, j7 c& B1 X& l- O- z$ e% h
© 2007 Sage Publications& w: _2 p2 B5 V+ C
10.1177/0009922806296651
2 E+ k  Y  ^' y6 i' T7 lhttp://clp.sagepub.com
+ F4 N5 ^3 ]" y! J7 Mhosted at
  S  l, i. x  f, U" M) }& t1 uhttp://online.sagepub.com
, _% }( B+ t6 N9 _/ C  DPrecocious puberty in boys, central or peripheral,
; Y, v7 M; U$ }7 Lis a significant concern for physicians. Central5 l5 G# m7 U7 i5 s& U0 c
precocious puberty (CPP), which is mediated5 x% ]5 |7 `( w1 V2 Y& I
through the hypothalamic pituitary gonadal axis, has! m9 X: `' _% ^3 u/ R+ \7 C% U
a higher incidence of organic central nervous system
# L, n  w& [) b# zlesions in boys.1,2 Virilization in boys, as manifested
6 `- V8 L7 z) o$ m+ c9 \2 n$ `by enlargement of the penis, development of pubic
9 s* {% R: X9 e. y% i* ~2 |. Z9 F9 Thair, and facial acne without enlargement of testi-5 m; _& f+ B% M- K5 l) z3 ?1 @
cles, suggests peripheral or pseudopuberty.1-3 We4 Q4 L3 Q+ W4 W2 q$ K
report a 16-month-old boy who presented with the2 S* {. e- S, I% v
enlargement of the phallus and pubic hair develop-
" E6 Q& Y) h; L0 bment without testicular enlargement, which was due1 g5 v( U* ?$ z( ~! Q
to the unintentional exposure to androgen gel used by
5 G# B; o- s' Y6 |3 P6 x' Q( xthe father. The family initially concealed this infor-% q7 g! J' ?8 u% X! Q, v; [: W5 m; z/ t
mation, resulting in an extensive work-up for this# Z, j$ X, ?. q4 ]$ G+ \. k
child. Given the widespread and easy availability of: t; v( x+ c6 e" \/ T
testosterone gel and cream, we believe this is proba-8 X+ |" Y! {0 j8 k# n& B
bly more common than the rare case report in the
. B. Y  M* b+ K2 _# Y8 |8 l8 }8 Yliterature.4
9 c4 r6 c4 J8 t1 |4 ^: XPatient Report8 Y9 k* y/ O3 V, B5 y$ z
A 16-month-old white child was referred to the
- Z+ A. z7 L; x" D+ \) Zendocrine clinic by his pediatrician with the concern
* j$ X1 H& }/ @7 {( g5 Yof early sexual development. His mother noticed/ d2 I: {! e; s% L, a( L
light colored pubic hair development when he was% h  Q7 u/ V8 s. [! o5 S  A
From the 1Division of Pediatric Endocrinology, 2University of, l; f) W/ t3 ]
South Alabama Medical Center, Mobile, Alabama.
- D! ~! U$ o1 @6 b1 f0 W/ LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 v2 o9 N" F  J$ T# n: S3 FProfessor of Pediatrics, University of South Alabama, College of+ d  @- K" l! t
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ S* h: k6 ?& a% F' Me-mail: [email protected].: n2 F  g& |; G& ]5 t1 F0 x
about 6 to 7 months old, which progressively became
) y8 Q  h8 z1 k# x% S9 F5 E; c  gdarker. She was also concerned about the enlarge-2 x. ^) W2 ^9 L7 q
ment of his penis and frequent erections. The child
3 B3 I* r0 ~3 i% Q) o+ E2 Y$ V( ^9 v. zwas the product of a full-term normal delivery, with
0 G0 _; ^3 [: N6 a. pa birth weight of 7 lb 14 oz, and birth length of
% g/ Z" I% A5 r! E2 H% m3 r20 inches. He was breast-fed throughout the first year6 |! @& T2 X* o3 u+ S
of life and was still receiving breast milk along with1 u5 T$ s8 z4 s2 @* ~; J& T
solid food. He had no hospitalizations or surgery,* a: `  C3 P7 E
and his psychosocial and psychomotor development
  a( a" I/ h, S0 d* G# jwas age appropriate.! \8 m$ c1 f* G! Z7 Y3 m
The family history was remarkable for the father,
% y' J% A; c# \& ~. o& Uwho was diagnosed with hypothyroidism at age 16,
) S. m! }7 u( |which was treated with thyroxine. The father’s
" e& v: E; p' {height was 6 feet, and he went through a somewhat- D/ P9 X$ {) ?6 Y6 W8 T
early puberty and had stopped growing by age 14.
$ o1 T+ [; N) Q4 U/ dThe father denied taking any other medication. The* [& q8 \/ A& e5 n( I6 y
child’s mother was in good health. Her menarche/ c7 ]; z- }& K; c! v
was at 11 years of age, and her height was at 5 feet
8 \" E7 k2 l/ t' E3 p# N/ x5 inches. There was no other family history of pre-- T4 O! S* n6 j, E
cocious sexual development in the first-degree rela-( o1 h( |, ?& O8 I0 F0 N
tives. There were no siblings.
$ e4 n; t0 U7 R# ?Physical Examination3 l) N; X  |; Z' D) s1 S* U
The physical examination revealed a very active,
: m7 u( v& F3 Y3 `6 u1 gplayful, and healthy boy. The vital signs documented( b$ D- ^( f; y
a blood pressure of 85/50 mm Hg, his length was
( T) J7 R5 }0 v- R1 l+ e2 t90 cm (>97th percentile), and his weight was 14.4 kg( F" O7 ]5 {' N$ l( b' d' g: Y5 ~
(also >97th percentile). The observed yearly growth5 Z4 u4 L2 ]7 j6 c6 Q
velocity was 30 cm (12 inches). The examination of3 F6 j. i. }' o  w, v3 @
the neck revealed no thyroid enlargement.
& E2 d2 @2 b' W+ h6 i. K+ |& aThe genitourinary examination was remarkable for
/ T2 W7 w* C- Jenlargement of the penis, with a stretched length of/ o2 C" y" L0 N9 o3 a6 u4 @
8 cm and a width of 2 cm. The glans penis was very well1 h( {! h8 E; ^/ j3 |& Z7 R
developed. The pubic hair was Tanner II, mostly around
, J  t' C* m! h* ]5403 i0 s9 y1 B( v' G9 Y9 Q/ m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ F8 M& O$ l. P7 e( ^the base of the phallus and was dark and curled. The
* u3 d. s3 a4 }2 y4 s4 p$ ttesticular volume was prepubertal at 2 mL each.
. E4 G8 y5 [5 U# `The skin was moist and smooth and somewhat. o( _& g0 L6 Q$ x4 b; V
oily. No axillary hair was noted. There were no0 e) t: [* B# D7 F8 w/ Y  b' }# K
abnormal skin pigmentations or café-au-lait spots.
% o9 v/ |% r% X% @2 z: PNeurologic evaluation showed deep tendon reflex 2+
" t9 k% R& s1 @  z7 o; wbilateral and symmetrical. There was no suggestion2 b) r1 M5 N$ g( `  Z: s
of papilledema.7 t) T; T9 _( q* e2 e
Laboratory Evaluation* R' {& s4 V$ D; H2 T$ K
The bone age was consistent with 28 months by9 t+ n) g  X# K9 X, C0 e/ L( y# J
using the standard of Greulich and Pyle at a chrono-
% C& f+ P7 r, P4 {/ @8 \logic age of 16 months (advanced).5 Chromosomal0 m' O$ x2 f$ O. {3 p' B; ]( b& \+ h
karyotype was 46XY. The thyroid function test
" B: i) K8 `% @( [showed a free T4 of 1.69 ng/dL, and thyroid stimu-4 W) |! u* L9 Q. Q6 @$ t; c5 e
lating hormone level was 1.3 µIU/mL (both normal).. B9 c1 s8 \4 ~$ i
The concentrations of serum electrolytes, blood
8 _% d( a- [* f7 durea nitrogen, creatinine, and calcium all were- q7 e6 V/ S+ q3 w
within normal range for his age. The concentration/ }$ `5 z. r) o0 \8 @* `
of serum 17-hydroxyprogesterone was 16 ng/dL
" b( a/ }; _" c& Y7 k(normal, 3 to 90 ng/dL), androstenedione was 20+ Y; }( a0 R3 R2 D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ k! J; d) |$ Z: ^4 E2 K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ L4 V) a3 \0 p# C1 g7 Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
& \, d' g9 ^  p; q. r49ng/dL), 11-desoxycortisol (specific compound S)
" T/ r5 L8 V# W! X+ e. Jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' Q8 b4 U3 v8 u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 L- {: B' F* P  _- [' F$ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ }/ h, s+ k' `% W  Y9 d% Gand β-human chorionic gonadotropin was less than
! Z! J5 w" s9 w, X; ?5 mIU/mL (normal <5 mIU/mL). Serum follicular( J* P+ l; J4 n& Y/ ~
stimulating hormone and leuteinizing hormone
) b' R' |% _! T# m! t! @concentrations were less than 0.05 mIU/mL! L/ ^+ ]7 y8 y3 F+ ~4 H
(prepubertal).# w8 Z1 k4 q( K. k8 i: C# d- v1 `
The parents were notified about the laboratory  ^# M0 y: @- B$ i
results and were informed that all of the tests were5 L! P7 X% d2 V7 I/ R
normal except the testosterone level was high. The+ E$ i( w0 e/ w
follow-up visit was arranged within a few weeks to
2 i% u/ ~( ]% Uobtain testicular and abdominal sonograms; how-6 o- M8 j+ [, I+ e6 G* U
ever, the family did not return for 4 months.
& q6 u8 M" V4 RPhysical examination at this time revealed that the$ q, K# S; z- u$ O4 m8 E
child had grown 2.5 cm in 4 months and had gained
+ i1 n5 a/ v0 w2 kg of weight. Physical examination remained
$ d+ o* D# X8 X+ V+ `unchanged. Surprisingly, the pubic hair almost com-) P' B( p# D& d0 ?7 H1 C7 K$ b
pletely disappeared except for a few vellous hairs at( z1 ?  _" e' J5 j7 c( {8 P
the base of the phallus. Testicular volume was still 2" F* b  A# H3 }0 i# a! f3 _
mL, and the size of the penis remained unchanged.0 V8 @4 s1 b: i4 [
The mother also said that the boy was no longer hav-  v/ F5 A; X% A- Q9 v  X" I; X2 m
ing frequent erections.
5 U; Z( F3 Y; M7 W  ]8 O2 |& XBoth parents were again questioned about use of
: q5 n4 o3 J$ ]any ointment/creams that they may have applied to
; j0 ]/ W+ r3 g7 F6 Ythe child’s skin. This time the father admitted the
& \7 W2 X6 f  t# v* [3 OTopical Testosterone Exposure / Bhowmick et al 541+ N/ t, S; `1 d
use of testosterone gel twice daily that he was apply-
& A8 i1 a: S" F* `1 g6 ging over his own shoulders, chest, and back area for  \8 P3 b( }* P+ N
a year. The father also revealed he was embarrassed! h* k( S. t* u5 q( S; x
to disclose that he was using a testosterone gel pre-7 `8 _1 w1 J: E# d5 B( Q
scribed by his family physician for decreased libido
$ |, ~) k# e* \3 I; ksecondary to depression." c/ A5 R3 w/ S1 @1 G, m( S
The child slept in the same bed with parents.
( J- ^& q+ G0 u; XThe father would hug the baby and hold him on his
6 F$ y1 j, a, V' {chest for a considerable period of time, causing sig-8 W3 e+ N6 y8 }9 L1 l% y7 P4 Y- b7 i
nificant bare skin contact between baby and father.
6 ]6 @4 X0 e2 W& Z' V9 U) jThe father also admitted that after the phone call,- B2 k) c/ U' b5 J& w
when he learned the testosterone level in the baby; j. [! t, {# j
was high, he then read the product information
/ I; C/ x1 h! T& s6 G( Ypacket and concluded that it was most likely the rea-) {" n& O2 F$ W8 y6 l+ x
son for the child’s virilization. At that time, they5 R8 W  ^4 D* j- q5 a- U4 K
decided to put the baby in a separate bed, and the
$ {$ S! Z0 y+ S! Jfather was not hugging him with bare skin and had& r" o' P3 [: W
been using protective clothing. A repeat testosterone5 O- I6 o9 e! I; e: I
test was ordered, but the family did not go to the
4 s) h" |: i3 o+ k6 ^laboratory to obtain the test.
9 O; H' A. K1 Q$ O6 RDiscussion5 A' Q1 B: H* {0 ^* |
Precocious puberty in boys is defined as secondary
- v$ R; R4 z: O8 M+ N1 psexual development before 9 years of age.1,4
# R. P: M; ]1 L2 @: M* KPrecocious puberty is termed as central (true) when
8 N& l, a- k: p, G$ i3 U" Dit is caused by the premature activation of hypo-
4 U) i3 C5 w6 H" A) a) a0 x, Mthalamic pituitary gonadal axis. CPP is more com-
$ C6 W7 ]" G( H/ `' V" q2 gmon in girls than in boys.1,3 Most boys with CPP5 e; \7 O3 l! u" M
may have a central nervous system lesion that is2 ~) `5 p, o0 o1 a  @+ g
responsible for the early activation of the hypothal-, q9 c8 X  V7 O; R3 b5 U
amic pituitary gonadal axis.1-3 Thus, greater empha-
4 E5 `/ t- p/ v% ]sis has been given to neuroradiologic imaging in% s0 \3 [' r0 ^  F
boys with precocious puberty. In addition to viril-
- [- U' V2 ?& L+ Z6 Tization, the clinical hallmark of CPP is the symmet-
' \6 ]- A: l' X! }  X  D# c/ Prical testicular growth secondary to stimulation by, L. ]0 e% O# F4 G8 H9 ]
gonadotropins.1,3# S- V0 x8 A7 G; n. B3 E0 D, Q
Gonadotropin-independent peripheral preco-
% ?4 Q7 {4 V" O& S; m1 k( zcious puberty in boys also results from inappropriate* J' v, [0 f. ]- b& X
androgenic stimulation from either endogenous or
, ~2 u5 ~" b( R; f7 O4 lexogenous sources, nonpituitary gonadotropin stim-! G: s4 u$ \: V5 a
ulation, and rare activating mutations.3 Virilizing
, {3 H: K  m( d" t8 v7 Mcongenital adrenal hyperplasia producing excessive
, t3 f( r- N5 q5 E# kadrenal androgens is a common cause of precocious
: H$ N9 ?" I* z" l( Z1 Vpuberty in boys.3,4
  M; [. \8 d* ~& w0 v# BThe most common form of congenital adrenal
) ?6 k2 Z/ t1 p* g' g% p7 |- k9 lhyperplasia is the 21-hydroxylase enzyme deficiency.
6 c) U) A7 h1 @! `, Y6 p8 VThe 11-β hydroxylase deficiency may also result in
: `. u# l7 I3 d9 ]excessive adrenal androgen production, and rarely,/ R- G" L) P9 v
an adrenal tumor may also cause adrenal androgen" J% u3 v7 U: ?: S1 |
excess.1,3
+ `4 w5 U) [: k7 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 [6 ?8 |( n7 V+ K4 q* ?7 C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) y6 [2 _5 _! {0 d, X5 F
A unique entity of male-limited gonadotropin-$ T9 s  N* m* B" o0 @$ a& Y8 R
independent precocious puberty, which is also known
$ u5 p6 e+ _; L8 Xas testotoxicosis, may cause precocious puberty at a
. m# ]! ]) i3 G% \, mvery young age. The physical findings in these boys* o  S3 x+ R. _; J) `% E' D) z
with this disorder are full pubertal development,
. F# u/ B2 J8 q  j2 |including bilateral testicular growth, similar to boys: j1 P, P2 F* u0 @  V
with CPP. The gonadotropin levels in this disorder
- Z* _4 o9 R2 tare suppressed to prepubertal levels and do not show
5 v6 h( i: L6 ipubertal response of gonadotropin after gonadotropin-! U2 s& E6 {9 B/ q
releasing hormone stimulation. This is a sex-linked  _$ S! S4 z7 I0 S( v
autosomal dominant disorder that affects only
$ d- d; R: U6 T7 M, A$ A0 Ymales; therefore, other male members of the family
3 P" b! t  t' Tmay have similar precocious puberty.3
- m: \/ S- m# j3 wIn our patient, physical examination was incon-. ~: |+ k$ @/ x, I' H1 v
sistent with true precocious puberty since his testi-
: L1 M& A$ N' r- N1 xcles were prepubertal in size. However, testotoxicosis# c  q: ?: D. c6 X7 K9 V
was in the differential diagnosis because his father/ Z8 H# \; t! _! T7 p9 q
started puberty somewhat early, and occasionally,  v$ O4 |! m( c+ `' V, A$ e
testicular enlargement is not that evident in the5 ]4 ?0 v! i1 x8 ]/ |+ B
beginning of this process.1 In the absence of a neg-1 E5 ^* j3 z& O! Q/ J- `
ative initial history of androgen exposure, our0 \* r' E; t( M+ W* I. n
biggest concern was virilizing adrenal hyperplasia,; `: S) H! T6 i4 N- B0 Z: u# J# T9 d
either 21-hydroxylase deficiency or 11-β hydroxylase
5 u% j* `% ]! X. G8 m; t' Ydeficiency. Those diagnoses were excluded by find-# K5 e. N1 D! T4 a2 v- g7 B
ing the normal level of adrenal steroids.; H2 I/ x. s+ @  m  k; x5 h
The diagnosis of exogenous androgens was strongly  T( J* _& \6 e7 J! \! S  s* {9 o
suspected in a follow-up visit after 4 months because
( l% `- v2 @$ a- z4 J, rthe physical examination revealed the complete disap-
& u' S9 {7 `0 p3 upearance of pubic hair, normal growth velocity, and
. {% @0 d9 e) b: idecreased erections. The father admitted using a testos-
! _5 k9 h. i$ Sterone gel, which he concealed at first visit. He was
' C& p; Q% ^, V5 L: j% ?( p  ]! Husing it rather frequently, twice a day. The Physicians’, N4 r' ^; `  g$ N, |
Desk Reference, or package insert of this product, gel or
& k) U) I0 m7 j0 ^+ [& l7 Lcream, cautions about dermal testosterone transfer to  L5 }5 c6 b% H1 |, h: c2 ]* l
unprotected females through direct skin exposure.
- }' C* d' n) h( Z- GSerum testosterone level was found to be 2 times the; q! r$ b0 T& ~3 l
baseline value in those females who were exposed to
7 o4 @( W. N. x) t0 g9 Beven 15 minutes of direct skin contact with their male
$ R" Y5 X6 f" R  U6 ]0 h* Fpartners.6 However, when a shirt covered the applica-5 X& B) Y3 ^  U3 `6 b
tion site, this testosterone transfer was prevented.
+ \) i8 w6 `6 \Our patient’s testosterone level was 60 ng/mL,: _# r1 Y0 W% L( g5 M# j* v5 ?% w
which was clearly high. Some studies suggest that
7 Y$ U' r* `/ ?' g+ q/ Ndermal conversion of testosterone to dihydrotestos-
- d5 O2 b0 g' gterone, which is a more potent metabolite, is more
! B; y* \- u3 u  ^5 g# @( ~active in young children exposed to testosterone0 c0 B; K/ c" S0 ?& q
exogenously7; however, we did not measure a dihy-
+ a$ E0 w" i# E' d2 w% L' l9 J' e" wdrotestosterone level in our patient. In addition to
8 ^* A6 v7 {8 \5 Bvirilization, exposure to exogenous testosterone in5 P: u' Q  H8 h4 m6 W
children results in an increase in growth velocity and
# D( N) J2 C. a$ S( a4 Q+ z: aadvanced bone age, as seen in our patient.
% g! O) i: x" P! nThe long-term effect of androgen exposure during) Q( F9 O: b  e* K# }0 T
early childhood on pubertal development and final2 P( K' u- }7 h  `4 U9 T
adult height are not fully known and always remain
0 _5 r0 P5 F$ _! o8 Sa concern. Children treated with short-term testos-
! T4 q- r0 ?, {terone injection or topical androgen may exhibit some
, B$ y$ [' L( L5 i+ L( hacceleration of the skeletal maturation; however, after4 o) V4 Z$ b. W/ T1 R$ H
cessation of treatment, the rate of bone maturation0 {. b+ l# |5 Q) |, Z1 ?1 P5 y
decelerates and gradually returns to normal.8,9) F' k$ R! |% _, k
There are conflicting reports and controversy  T. s5 Q- A* u  H3 X5 z
over the effect of early androgen exposure on adult
# h( T3 k3 h, y* G( K4 e9 spenile length.10,11 Some reports suggest subnormal
+ p4 ^) A& K& K- B. N/ E9 A2 wadult penile length, apparently because of downreg-/ \7 u" i/ T; i6 O# p
ulation of androgen receptor number.10,12 However,/ E0 E: w6 R0 E1 }2 D6 l
Sutherland et al13 did not find a correlation between* f' ?6 d0 C7 j8 ?+ R
childhood testosterone exposure and reduced adult' U6 S! w# N- O+ d% O0 x3 }- ]5 V
penile length in clinical studies.- g  ^& a1 W+ M/ g8 R0 r
Nonetheless, we do not believe our patient is4 X4 A4 @" _: p( O+ D; |
going to experience any of the untoward effects from
. g) z/ G4 N0 N" t! Atestosterone exposure as mentioned earlier because) u" v2 |3 n6 G9 ?; G/ t/ D
the exposure was not for a prolonged period of time.
7 y! p! q# t) ~* q) W  W+ J4 @7 PAlthough the bone age was advanced at the time of
+ s' o8 g( J9 p9 idiagnosis, the child had a normal growth velocity at# u6 r# h; o8 G  r' n& C
the follow-up visit. It is hoped that his final adult$ y7 ~: B+ V( B2 d
height will not be affected.2 C  e( u, O4 q
Although rarely reported, the widespread avail-
: y) b; _$ i1 L3 |" yability of androgen products in our society may" b: ^4 g- X; p; D2 W$ c% b; Y
indeed cause more virilization in male or female
: h4 A6 V. u* H# l2 ~' P! zchildren than one would realize. Exposure to andro-
8 |% A( r2 U; j5 {- c. a: i# ogen products must be considered and specific ques-
& ?' y" A" z9 A# i' V0 \tioning about the use of a testosterone product or
% c7 a8 g+ _5 R8 A0 `4 s0 dgel should be asked of the family members during, E# `2 d" [+ U# r3 ?7 V
the evaluation of any children who present with vir-
% \+ G% r9 l- H/ I  uilization or peripheral precocious puberty. The diag-
& X4 q3 ^( W" X; T; M$ `! S' ynosis can be established by just a few tests and by
% p5 J1 W- n  Y* d/ A" B" ]& w! kappropriate history. The inability to obtain such a1 ~# E' o# C0 f
history, or failure to ask the specific questions, may4 R# ~- ]3 l5 ^- ]/ e. P
result in extensive, unnecessary, and expensive& q/ k. a( m0 ?6 ~" O  j
investigation. The primary care physician should be
( ?0 J' ]/ _  Z2 |' b. w% R) |aware of this fact, because most of these children+ F, I, r2 x+ u9 G3 c# g: a* ]
may initially present in their practice. The Physicians’
9 ]% w  A0 X8 O, @9 b# `Desk Reference and package insert should also put a
3 i: e' t3 i, k" ~  b) V4 ?7 [warning about the virilizing effect on a male or9 I. e: K# p. h6 J0 j0 e8 N! `
female child who might come in contact with some-6 K7 d3 f3 g4 g# h( F' @, f
one using any of these products.
6 `; E2 g* x4 S6 _References- ^5 n6 t/ T0 e
1. Styne DM. The testes: disorder of sexual differentiation6 f# H  f/ y4 r) O$ Y  t7 X
and puberty in the male. In: Sperling MA, ed. Pediatric0 N* T7 ~6 F4 U& w$ }4 G  o8 x! w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& J  p' z/ c; f+ U6 p# U) }! h  v# g
2002: 565-628.
" q3 W( ?) Y; j4 {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ g( w/ C5 z- A1 ?9 G, O6 _* _puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 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
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

/ h- M. U; P' N: Y% R% q! N. R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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