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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: h1 Y- l$ `0 U( E4 |( E/ t' ~
Boy Induced by Indirect Topical
( q# [6 n$ T0 H" e- `  @Exposure to Testosterone
- X  i# s% ?2 B+ p* v$ oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. @& t; Z7 I' F" z  v) T$ O1 Y
and Kenneth R. Rettig, MD1
2 v) B' N) E; w8 W+ W% FClinical Pediatrics
6 `9 N3 i4 R4 kVolume 46 Number 6
  g  `/ R6 O8 Y- u  ^4 W4 Y7 nJuly 2007 540-543
9 T# C8 H8 z: E© 2007 Sage Publications
- f' w" T" u5 g1 ~10.1177/00099228062966511 e6 ?  s; [7 \' W7 `9 d5 |
http://clp.sagepub.com+ [9 i6 A! C- \% T
hosted at
( |" y: {( k5 Ehttp://online.sagepub.com
% m/ q5 e* F7 NPrecocious puberty in boys, central or peripheral,
3 }' s# d! x5 ?( d1 R7 sis a significant concern for physicians. Central* B/ @$ w7 B$ v. g
precocious puberty (CPP), which is mediated
# p2 R% R6 f: D7 Kthrough the hypothalamic pituitary gonadal axis, has
6 v, F- _4 |, J- O% p# m4 x( b* O1 Ea higher incidence of organic central nervous system0 v( X2 e& M! ]7 v
lesions in boys.1,2 Virilization in boys, as manifested6 T! Y8 O7 Q2 D& ]
by enlargement of the penis, development of pubic
1 D) M9 s% w" J9 S) u/ Ahair, and facial acne without enlargement of testi-. t- z" Y9 t6 d# f# ?1 v1 Y2 d
cles, suggests peripheral or pseudopuberty.1-3 We1 B. s6 O7 c9 f$ i4 V
report a 16-month-old boy who presented with the
0 d5 x' `: z! f7 menlargement of the phallus and pubic hair develop-
# I4 S; Q# d- v" A# D$ X0 Yment without testicular enlargement, which was due
  @1 E$ }* H, K& Lto the unintentional exposure to androgen gel used by
5 z- `. Z5 s1 t7 c& tthe father. The family initially concealed this infor-
+ F; Z: d4 H0 G2 Wmation, resulting in an extensive work-up for this: n# H6 I- @! Q- W  h
child. Given the widespread and easy availability of! N* G1 h/ N7 S  n& d
testosterone gel and cream, we believe this is proba-
5 Q) z( p; O" X7 k! h7 ^bly more common than the rare case report in the
  |& s/ o. @* r# y1 g+ W# P6 y0 {: zliterature.4
7 C' R& S' D9 ]1 \. SPatient Report
, {  X+ M6 z& S9 \9 ^/ rA 16-month-old white child was referred to the  c' M8 O8 d' N9 q) j8 L( S
endocrine clinic by his pediatrician with the concern
9 X% t5 k3 R* b2 oof early sexual development. His mother noticed
9 h% _0 ]1 A5 {  F% ^( i; m9 K7 {7 \light colored pubic hair development when he was
& i: d6 R' K4 D' m$ pFrom the 1Division of Pediatric Endocrinology, 2University of
4 R7 m! ~# s! B6 j: P7 j9 tSouth Alabama Medical Center, Mobile, Alabama.
! w; P/ e. ~6 Q) g- _1 V$ L3 kAddress correspondence to: Samar K. Bhowmick, MD, FACE,- k' G; g) r: [/ [" H; K/ L. c
Professor of Pediatrics, University of South Alabama, College of  c8 g; g7 _7 D5 e3 m, n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 T9 u: x. [) x" G7 C4 Q2 |* Z% Oe-mail: [email protected].: h. v5 D2 X" v8 U0 b
about 6 to 7 months old, which progressively became) ?" D; g6 z8 ?- F7 t
darker. She was also concerned about the enlarge-
; D' l' h2 p. ?4 {3 Y6 ^+ nment of his penis and frequent erections. The child/ ~( M- ~( O$ q5 T4 }
was the product of a full-term normal delivery, with0 Z7 r8 a: X2 p1 a$ Y# M* p' X' n* ^
a birth weight of 7 lb 14 oz, and birth length of9 [: L5 B$ f& D
20 inches. He was breast-fed throughout the first year
6 R- `. z5 n; o& P* g" rof life and was still receiving breast milk along with
$ S+ Y/ i2 B3 _" K0 Q- K4 Jsolid food. He had no hospitalizations or surgery,
/ j# K( L+ M# w6 Dand his psychosocial and psychomotor development
: ]" j4 a' p4 B3 y+ Swas age appropriate., R6 ~/ Y9 p% C5 D
The family history was remarkable for the father,
) u, T7 m* G; z9 ~9 D8 Owho was diagnosed with hypothyroidism at age 16,
* f$ {7 T* A( n/ Owhich was treated with thyroxine. The father’s7 z# H* K1 [# o4 y7 h: ]! q5 z
height was 6 feet, and he went through a somewhat* r9 M8 [* B% n' F
early puberty and had stopped growing by age 14.
2 p4 d0 i& x" g2 I0 {9 gThe father denied taking any other medication. The
! f/ T' E* i3 B* i2 Fchild’s mother was in good health. Her menarche
( _# [4 e. }2 l3 P9 A* J; ]was at 11 years of age, and her height was at 5 feet
6 i1 `5 }! z& `; K. f# P+ z# w$ [5 inches. There was no other family history of pre-2 ?$ ]- t  `2 \8 Q1 e9 M5 k
cocious sexual development in the first-degree rela-( z5 t' Z) J4 M! ?
tives. There were no siblings.  s$ r  `; g2 ^; J$ v3 [$ U
Physical Examination* c% `# c0 W9 ]7 [' o1 z. A) D
The physical examination revealed a very active,
3 I7 L& H1 _" E* |0 f) Z$ R% kplayful, and healthy boy. The vital signs documented
- R% z- b& w+ g6 l0 p& Ua blood pressure of 85/50 mm Hg, his length was) Q# I" G) p5 q: q
90 cm (>97th percentile), and his weight was 14.4 kg
" k# ~3 _2 K0 [2 o& g8 u$ ~(also >97th percentile). The observed yearly growth
8 r( Y" f5 D) D, N- S" F7 I2 ~velocity was 30 cm (12 inches). The examination of- C4 C0 f+ X; W) y8 G! A+ d
the neck revealed no thyroid enlargement.
5 y: C# [* [4 Y& i" `; h" JThe genitourinary examination was remarkable for& a; V: {6 V2 m. ^/ Q3 J7 {
enlargement of the penis, with a stretched length of
6 i! e1 e, q' w! A) `8 cm and a width of 2 cm. The glans penis was very well
8 c9 X7 r' ]8 u4 a. e/ W" }developed. The pubic hair was Tanner II, mostly around  Q: s* p! o0 {- k- j6 g
540
+ |0 b  }. S1 a0 ~' I" Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# C: @) ]* Q; A  }the base of the phallus and was dark and curled. The
( F* u; O, K; P1 s0 Mtesticular volume was prepubertal at 2 mL each.
0 r/ }2 _/ l  {The skin was moist and smooth and somewhat
" P! ~- m/ s3 Boily. No axillary hair was noted. There were no
% b# q2 Q+ u. N" A0 U8 {5 K7 _abnormal skin pigmentations or café-au-lait spots.+ ^4 A! j6 A4 N% R3 c2 W' E
Neurologic evaluation showed deep tendon reflex 2+
' d/ a7 L% M1 ]% U2 ~bilateral and symmetrical. There was no suggestion
8 _6 \, ~& A" `; `" G; k  Dof papilledema.
+ _4 M7 h5 O5 k! RLaboratory Evaluation
1 o0 A2 }; t8 j2 X$ ?# EThe bone age was consistent with 28 months by# K. Z0 g# E) z; V4 U  l
using the standard of Greulich and Pyle at a chrono-
- H4 U+ [5 A! P* \- R" J' o6 f! M; Ulogic age of 16 months (advanced).5 Chromosomal
/ p# z/ Z" m+ f; ykaryotype was 46XY. The thyroid function test
4 @" S! `) s2 o3 a" `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" ^. E* f' `; U" }: u  z& e  K6 Dlating hormone level was 1.3 µIU/mL (both normal).7 H0 i9 l! k# ^0 D* i
The concentrations of serum electrolytes, blood
. r! q/ i4 u! C$ d* lurea nitrogen, creatinine, and calcium all were$ Z- }% Z8 y+ H) S0 k! Z
within normal range for his age. The concentration3 |4 V1 t9 f) z
of serum 17-hydroxyprogesterone was 16 ng/dL
3 a5 h+ X1 S# Z+ I(normal, 3 to 90 ng/dL), androstenedione was 20- w& r; K# l4 s' f; V' R/ R' j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 _6 L  t, ^# f. f/ Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ X- C; ]2 P; a" Q: w3 L' jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 }3 y( T" q& a1 F: F
49ng/dL), 11-desoxycortisol (specific compound S)
+ m' C  j# Z+ Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! O/ I( Y7 H5 D2 _+ P2 Q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' z0 t6 l) W# [6 n+ j/ qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" v& p. k3 D+ l" O1 n" land β-human chorionic gonadotropin was less than
1 _9 X3 f. p- B7 N# C5 mIU/mL (normal <5 mIU/mL). Serum follicular8 X3 e' ]+ u) A
stimulating hormone and leuteinizing hormone( L3 C! C" ?  V2 V( W
concentrations were less than 0.05 mIU/mL' e9 i  Z3 x) F* |) X
(prepubertal).4 g2 v) J8 M" R* j& w
The parents were notified about the laboratory" Z6 A1 p! p# i
results and were informed that all of the tests were% z9 U& G# i2 p% J0 D1 `
normal except the testosterone level was high. The
3 D1 h' D8 _) m# `& [" b( \follow-up visit was arranged within a few weeks to
/ B* x: f: i  C* A' F& g2 Aobtain testicular and abdominal sonograms; how-
" W* \: t$ X/ c+ b) `7 _1 f2 |ever, the family did not return for 4 months.$ x7 e1 z) E; _1 [+ Z
Physical examination at this time revealed that the# u8 c7 Y0 F8 l2 @& F% f& |
child had grown 2.5 cm in 4 months and had gained
  |7 h* a1 u9 R* k! ]; E2 kg of weight. Physical examination remained) R1 Q* Z: P5 Z+ M! H0 y
unchanged. Surprisingly, the pubic hair almost com-. m6 c7 P$ D* o8 F) O9 v1 l+ k' V
pletely disappeared except for a few vellous hairs at
, _/ h& Y7 ~4 O' u/ V7 tthe base of the phallus. Testicular volume was still 2  O" x- |6 d# O: M
mL, and the size of the penis remained unchanged.
6 w$ z: Z5 n! T- RThe mother also said that the boy was no longer hav-# L$ I! G0 s4 z. D
ing frequent erections.( O; d( P" ]) t9 n5 e+ O, p
Both parents were again questioned about use of
# B( u- x! J! R) ]( `; O" \7 Eany ointment/creams that they may have applied to
7 J2 p3 E/ X. E8 F  X2 fthe child’s skin. This time the father admitted the
0 E7 ?' v) i, y+ ^/ B, kTopical Testosterone Exposure / Bhowmick et al 541
6 G, K- I: w9 Fuse of testosterone gel twice daily that he was apply-! U: W1 e6 A9 u- w+ e1 ~
ing over his own shoulders, chest, and back area for. l+ ^$ f. `! b3 ?
a year. The father also revealed he was embarrassed( [# l4 R5 K! l8 P! E
to disclose that he was using a testosterone gel pre-
4 f0 }/ A# z; Z6 N  M3 nscribed by his family physician for decreased libido
* i( `8 i# K" `  B& D, m" wsecondary to depression.
  D& ]- a* M) _) E: ^The child slept in the same bed with parents.- R- x6 y) G/ X/ E1 j
The father would hug the baby and hold him on his
) m" }6 ~, ?$ Z2 o- jchest for a considerable period of time, causing sig-4 o0 _% h* ]# [9 e7 m6 ?0 l
nificant bare skin contact between baby and father.: t. O/ U  u( [4 H% d" R
The father also admitted that after the phone call,
0 Q* t5 k  S4 C- q' lwhen he learned the testosterone level in the baby/ @( L5 P' A( X/ p% Z1 H4 v
was high, he then read the product information' P8 c# E% M( v# t2 c" U$ f& o/ t
packet and concluded that it was most likely the rea-
& Y- q% z) Y9 N) c# lson for the child’s virilization. At that time, they
0 v5 _# |$ a0 q# D9 n. xdecided to put the baby in a separate bed, and the
. ]& r; f% j) K: i& @father was not hugging him with bare skin and had( f! K8 U# U  ]
been using protective clothing. A repeat testosterone1 y' ~/ v0 e. ~. d8 i& L
test was ordered, but the family did not go to the
$ [# B. W2 ?, vlaboratory to obtain the test.! ?$ c1 R5 J" y. X3 d
Discussion
' C, e. |  q5 Z1 {5 VPrecocious puberty in boys is defined as secondary
4 y; Y5 Y5 Q% d9 T4 }/ u  \sexual development before 9 years of age.1,49 k6 c/ S; ]% e. b4 O8 x9 u
Precocious puberty is termed as central (true) when3 X  I8 p7 e3 @' h
it is caused by the premature activation of hypo-
2 T* @3 V0 t- G/ {thalamic pituitary gonadal axis. CPP is more com-/ ]3 }4 L3 L$ H3 J7 t6 G. E% ^
mon in girls than in boys.1,3 Most boys with CPP8 e8 V1 b2 |1 @6 X$ W& N
may have a central nervous system lesion that is
7 ~* N- G+ N/ T0 d6 x' sresponsible for the early activation of the hypothal-
* `% O5 Q% w/ V' v$ [amic pituitary gonadal axis.1-3 Thus, greater empha-
8 u' c5 |9 F5 A, ?: h; ]' B2 hsis has been given to neuroradiologic imaging in
* h3 N  c5 b8 `boys with precocious puberty. In addition to viril-
/ t& d& [* i1 C" n: f* b! dization, the clinical hallmark of CPP is the symmet-
+ l. e; H& I$ erical testicular growth secondary to stimulation by
# v$ M3 I; K& x( b/ ]gonadotropins.1,3
( q8 b9 W0 I; w4 |4 G. X8 ^Gonadotropin-independent peripheral preco-+ w& u7 R' I1 r% i3 w1 P# ]
cious puberty in boys also results from inappropriate
  Z) G" k0 I7 l; Qandrogenic stimulation from either endogenous or
& ^6 _  p6 w8 b4 \exogenous sources, nonpituitary gonadotropin stim-
' x% @; a% D8 i3 q! bulation, and rare activating mutations.3 Virilizing, L: G- g7 X/ e+ i0 X
congenital adrenal hyperplasia producing excessive
6 |0 X  }" F, Fadrenal androgens is a common cause of precocious
) \( ^0 L" ]4 [+ Q9 j7 z& zpuberty in boys.3,49 H! M* e, |1 v+ W4 c' F
The most common form of congenital adrenal
+ h( ~3 m  F: N$ j; hhyperplasia is the 21-hydroxylase enzyme deficiency.
5 B: Q& v8 Z' o6 {- bThe 11-β hydroxylase deficiency may also result in
1 h2 t/ J* H" e& wexcessive adrenal androgen production, and rarely,
# S  a$ e$ E! [7 Kan adrenal tumor may also cause adrenal androgen
; {3 K2 c. M; x" L' ]9 m7 }excess.1,3
& N1 z9 ~8 m' d7 u7 ^; B3 Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 s4 U8 a( ?, h7 W7 C& N3 D& a542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# ^2 v1 ?3 E2 F2 R  L; v
A unique entity of male-limited gonadotropin-
* n; i* @. a0 q  B& vindependent precocious puberty, which is also known
: t" H, ], s! d5 d# w% P8 _$ ~as testotoxicosis, may cause precocious puberty at a
2 Y" i2 z: ~- H% F5 cvery young age. The physical findings in these boys
5 C3 _0 I6 z, s2 g3 B8 v1 b; z, Ywith this disorder are full pubertal development,
, b0 `. z6 n7 A* u0 N% Y& ]including bilateral testicular growth, similar to boys7 m7 G$ y% ^; Z: _
with CPP. The gonadotropin levels in this disorder- I; G: I- e8 o/ i0 a0 @9 n
are suppressed to prepubertal levels and do not show: t- J4 A( v& g
pubertal response of gonadotropin after gonadotropin-6 \7 i. O. V' K1 t
releasing hormone stimulation. This is a sex-linked
, f9 F3 f! p' cautosomal dominant disorder that affects only
# b1 C3 z  U; [9 h& i8 b+ _- X; R8 Bmales; therefore, other male members of the family6 W  R$ q2 I# \* n4 f' D
may have similar precocious puberty.3
/ o" V* m8 V, h" _2 C2 Z2 Z: cIn our patient, physical examination was incon-
: P% g) D% N- o2 H! _- Dsistent with true precocious puberty since his testi-
' V- o8 W% Q6 }7 v3 acles were prepubertal in size. However, testotoxicosis
5 [/ `0 u8 E! Jwas in the differential diagnosis because his father- I) C& n% i0 Q2 R1 b9 u, l$ o
started puberty somewhat early, and occasionally,
$ r* v. m! G. W/ Utesticular enlargement is not that evident in the
  D# w5 s" W3 R( A# \beginning of this process.1 In the absence of a neg-* o! S, z2 M7 f" x
ative initial history of androgen exposure, our
) E4 T; F2 d* _5 t! Hbiggest concern was virilizing adrenal hyperplasia,
8 W, H6 S' b, d' Z7 h# Meither 21-hydroxylase deficiency or 11-β hydroxylase
  P0 N  c$ y4 \' Ddeficiency. Those diagnoses were excluded by find-
% s9 m0 ?2 M2 T9 m3 [: cing the normal level of adrenal steroids.- {5 S9 B% j! Q  a
The diagnosis of exogenous androgens was strongly
! ^% J. @- I( Q+ `# ksuspected in a follow-up visit after 4 months because' e5 _0 M5 {  E8 T6 m% M
the physical examination revealed the complete disap-
7 M- Y# ?, J- J- {pearance of pubic hair, normal growth velocity, and
5 c1 d( s3 e# E3 b% `/ J+ Rdecreased erections. The father admitted using a testos-8 M0 L0 T4 a# S' O0 u: X
terone gel, which he concealed at first visit. He was, \) U$ e7 ]) z$ d: r
using it rather frequently, twice a day. The Physicians’# T2 v; Y8 L  h8 N: A+ I, E" L
Desk Reference, or package insert of this product, gel or4 y; t6 r/ O; N* Z" M) {# [' h
cream, cautions about dermal testosterone transfer to
# i. I$ f% z% X% P7 y9 Tunprotected females through direct skin exposure.- D6 v- G% H+ Q9 d' F; Q+ \
Serum testosterone level was found to be 2 times the
7 h) \3 \9 ^/ W$ `baseline value in those females who were exposed to
0 _3 J/ I, N( |0 ~even 15 minutes of direct skin contact with their male' H2 N3 o0 H, V1 p0 X& o% D
partners.6 However, when a shirt covered the applica-" j; D' R3 a4 T' L
tion site, this testosterone transfer was prevented.  v) I6 v, a' I
Our patient’s testosterone level was 60 ng/mL,
# K, @1 F: V2 M# \+ Dwhich was clearly high. Some studies suggest that
3 e- w' K1 Z9 G% f& g; n4 r5 t& Pdermal conversion of testosterone to dihydrotestos-1 Z1 i! x9 g0 L
terone, which is a more potent metabolite, is more
7 b; v5 [* m# }2 o- Tactive in young children exposed to testosterone+ C" O% R; z  m1 W
exogenously7; however, we did not measure a dihy-
* T7 x3 P* P5 Odrotestosterone level in our patient. In addition to5 C. ~2 q8 t$ c' _3 V( E& r; Q
virilization, exposure to exogenous testosterone in! ^4 g8 m) Z6 H- K7 A* P1 K
children results in an increase in growth velocity and5 A; ~) G6 s/ o7 l- U+ B
advanced bone age, as seen in our patient.
. I2 U4 \8 L8 _The long-term effect of androgen exposure during* U' E2 w. d0 P
early childhood on pubertal development and final! S. L  i/ C* x8 N' N; b" @
adult height are not fully known and always remain- ~. ]0 M. ]" v: s6 f. {; o
a concern. Children treated with short-term testos-
+ H/ V# u6 d+ ~. `terone injection or topical androgen may exhibit some
7 Z+ n9 z5 [+ O+ T& B* @acceleration of the skeletal maturation; however, after
# |0 I& b: h/ r2 X& Z( icessation of treatment, the rate of bone maturation
" j. e( F0 u. O. Q* |decelerates and gradually returns to normal.8,9( d" X5 |; b$ k0 L- z. k* ?: W
There are conflicting reports and controversy
$ J: T' h# m( [% h$ Z& e! Z) Oover the effect of early androgen exposure on adult# B" G* ~0 e/ g. J
penile length.10,11 Some reports suggest subnormal5 H3 b: O+ o0 S9 J
adult penile length, apparently because of downreg-
& |# A: b* D9 o2 Hulation of androgen receptor number.10,12 However,7 s" u$ d% M* e. n) n/ F
Sutherland et al13 did not find a correlation between/ z% Y7 t) ~! V  v0 E
childhood testosterone exposure and reduced adult- W7 B% Y4 q9 G1 l2 l
penile length in clinical studies./ W; ^5 x; k3 P- G2 W! y  A
Nonetheless, we do not believe our patient is
, H1 Z, |2 z( B3 y6 fgoing to experience any of the untoward effects from
0 d3 V9 f  }( [. |testosterone exposure as mentioned earlier because
! q* ^) D: ]$ I  B& b! v* e! r5 Hthe exposure was not for a prolonged period of time.
% z) R# l( u7 \' eAlthough the bone age was advanced at the time of" E- k5 `: R* `, Y6 b  j
diagnosis, the child had a normal growth velocity at
* K, k1 k' D+ C1 i$ B# Dthe follow-up visit. It is hoped that his final adult
/ g$ z* `* ]# H; }height will not be affected.5 z* T/ M, A2 l0 X) w: k
Although rarely reported, the widespread avail-8 z6 I& ~& S1 _9 ?6 K
ability of androgen products in our society may
7 }9 B1 i6 ^1 w' `& Pindeed cause more virilization in male or female
2 G2 U7 e, O9 u: tchildren than one would realize. Exposure to andro-# Y' ~1 W  P( b& j
gen products must be considered and specific ques-% z% Q% E. d2 Y5 k6 A* h& `' i0 X
tioning about the use of a testosterone product or7 R! a# X3 d6 O
gel should be asked of the family members during
  i( B4 o) D" P; u, t3 ~the evaluation of any children who present with vir-5 U3 k4 D" F& g. Z
ilization or peripheral precocious puberty. The diag-+ p& e) B' R5 R( e, d4 B
nosis can be established by just a few tests and by! Z6 H- U3 W* k. F* E
appropriate history. The inability to obtain such a+ S. L% H$ ~8 B5 n7 v
history, or failure to ask the specific questions, may
! g+ e# @+ g& C& }% G8 nresult in extensive, unnecessary, and expensive9 j& [) e! V* a' Y
investigation. The primary care physician should be  K' W' t. U% p5 A
aware of this fact, because most of these children
  q8 d  I  K4 i) W7 Jmay initially present in their practice. The Physicians’
& K$ A" h9 \: x& V2 X% _6 }3 z% ~Desk Reference and package insert should also put a# |4 ]4 ]* ^( B9 @! s' c
warning about the virilizing effect on a male or
" y; I: n) k( gfemale child who might come in contact with some-9 m& u  ], y& {! R
one using any of these products.
0 D8 @! l8 @6 cReferences& {0 ~" t3 S. j9 z1 @; d
1. Styne DM. The testes: disorder of sexual differentiation
+ O' S& b" N* G- X  n2 ?. qand puberty in the male. In: Sperling MA, ed. Pediatric- ~, n( z4 c: h% _8 O! P4 q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 Y/ n/ m/ V. o8 Q; Q+ f
2002: 565-628.
6 I; G6 K; ?2 J$ O0 k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' w* P1 p6 x1 T5 j1 A2 cpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
9 \2 \/ Q+ h0 S- x' }Boy Induced by Indirect Topical
) K: t. j( I5 a, zExposure to Testosterone
  L" O' ~$ ]* a- h3 m2 r, ~- j2 MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 }- d8 M! u0 e+ T0 l7 F
and Kenneth R. Rettig, MD1
, U3 X' Y  K+ G3 K( nClinical Pediatrics
, k9 T+ @" b; r( n" C/ NVolume 46 Number 6
$ C) a9 |- ^7 z: vJuly 2007 540-543
- h( {2 o2 J$ v- ^& ?© 2007 Sage Publications
8 A  Y7 l0 F/ D' x6 P10.1177/0009922806296651
7 W+ n% `0 _7 n: `& c4 x' g# bhttp://clp.sagepub.com3 }4 L6 Y% `4 r
hosted at
* H) ^, y% _$ [* B1 g4 w4 }http://online.sagepub.com7 s& c1 d. ^3 D- }" v6 E6 m
Precocious puberty in boys, central or peripheral,
+ T0 Z- z- T# F! c0 ]& d8 }is a significant concern for physicians. Central
0 Q) s. g% D; c# `( iprecocious puberty (CPP), which is mediated  o, H# n5 S# f, K( ~: l
through the hypothalamic pituitary gonadal axis, has
& f) ]+ i& s6 {% Fa higher incidence of organic central nervous system2 ~( p! E0 c1 D" P/ Z
lesions in boys.1,2 Virilization in boys, as manifested) d+ k( s4 t- }  Y+ p
by enlargement of the penis, development of pubic
. P( p* g$ S+ u: @( `hair, and facial acne without enlargement of testi-0 ~, C+ r# {( y
cles, suggests peripheral or pseudopuberty.1-3 We0 q9 V$ w2 e( \# s+ H+ A+ u
report a 16-month-old boy who presented with the
  B, O  o2 V# {/ v' e9 Zenlargement of the phallus and pubic hair develop-
  s3 N: x- _1 D. C1 t% V4 Cment without testicular enlargement, which was due
) i) [, w; R! V/ K7 Lto the unintentional exposure to androgen gel used by" Y* O8 r' f* V2 C
the father. The family initially concealed this infor-  e. a2 ?% n9 a$ U. i" @0 k7 ]
mation, resulting in an extensive work-up for this
; ]* Q; y( t/ B  bchild. Given the widespread and easy availability of# ^& F8 `; L6 H
testosterone gel and cream, we believe this is proba-
9 B6 B3 X; S7 I1 o9 \: s  Sbly more common than the rare case report in the
5 j+ g( T: u8 e& n6 D. h. p8 N0 i) Hliterature.4# x+ v/ K2 F* P, i) ?' T
Patient Report
' K. P+ F% H+ U$ @2 t, iA 16-month-old white child was referred to the
% [3 _' i4 F. @4 q7 O# ]# d8 w) J+ @endocrine clinic by his pediatrician with the concern# O' t/ ~8 a* W; P2 T; e* D$ r
of early sexual development. His mother noticed
3 E( S0 L9 J: t3 v8 p. H2 ?light colored pubic hair development when he was2 T/ @- V# k& s1 E1 u
From the 1Division of Pediatric Endocrinology, 2University of5 c7 A7 [4 S) x
South Alabama Medical Center, Mobile, Alabama.
0 C* ~" E# f. [! J' U4 qAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 T, L& @7 D. Q
Professor of Pediatrics, University of South Alabama, College of9 E$ K' U; {& x1 u' t
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& |+ c+ |3 Y5 O- c  N* T
e-mail: [email protected].
* M8 r6 x5 p) Q6 H- g6 _about 6 to 7 months old, which progressively became
# C- Y( f1 \7 q# cdarker. She was also concerned about the enlarge-
% ~  h7 R( y& h8 A5 Jment of his penis and frequent erections. The child
* m, p, W, E9 y# U# w; E8 C' uwas the product of a full-term normal delivery, with
% A) U9 j8 g! G4 M8 \a birth weight of 7 lb 14 oz, and birth length of+ S/ ~7 q! r0 T
20 inches. He was breast-fed throughout the first year
* r$ G# V0 x" d# F7 k* V. T6 uof life and was still receiving breast milk along with
9 e. I5 X/ l+ e8 C0 j) Bsolid food. He had no hospitalizations or surgery,
+ u8 A: y/ f* E8 k$ ?8 X5 w1 band his psychosocial and psychomotor development
  }+ d* e+ ]& D+ D6 J" C5 i0 owas age appropriate.
0 [2 S0 J2 v) c( r6 uThe family history was remarkable for the father,
" L& N) _$ s- T% Y9 ~) wwho was diagnosed with hypothyroidism at age 16,
- |* Z) H! ~* s" owhich was treated with thyroxine. The father’s
" T& s& L4 G; k! Oheight was 6 feet, and he went through a somewhat
% Y6 ~9 A) K, K6 b  F; nearly puberty and had stopped growing by age 14.
5 e7 \1 s: _, h- v. }6 W. I; K) bThe father denied taking any other medication. The9 `. S% n  ^* O! h
child’s mother was in good health. Her menarche
$ ~" ?1 T2 l+ g/ }. o0 Q! I7 Awas at 11 years of age, and her height was at 5 feet
& o+ ?: L  D$ E$ E- V5 inches. There was no other family history of pre-
6 h. W8 |. m2 L! xcocious sexual development in the first-degree rela-
  ^# l& A5 n- ~( Q! m1 |tives. There were no siblings.
, t" U3 i4 W+ W. s0 }Physical Examination
& c/ u% e8 p8 M9 LThe physical examination revealed a very active,+ M! H0 O$ R2 F
playful, and healthy boy. The vital signs documented
3 Z& G/ k! B# y" q1 Ka blood pressure of 85/50 mm Hg, his length was
+ _' c2 B" \! \0 q0 j* [90 cm (>97th percentile), and his weight was 14.4 kg- w6 R* M  H4 ^& q8 Y) w- B
(also >97th percentile). The observed yearly growth: h" w% n# Y) U7 ^) ?
velocity was 30 cm (12 inches). The examination of1 K" @9 ^9 c/ j. B. F# J' x
the neck revealed no thyroid enlargement.
) l' U* @1 X/ s) I' z. s5 O/ WThe genitourinary examination was remarkable for% q$ e2 @$ ?+ u6 v! ]4 K
enlargement of the penis, with a stretched length of
0 E+ ?5 i" Q4 o, s. u% c$ @8 cm and a width of 2 cm. The glans penis was very well
) w; Y6 J" c2 [( {developed. The pubic hair was Tanner II, mostly around) U) z/ \- d, u7 @8 j
540
* ^: M. |. D' [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& ^  v( w) t9 `9 M5 q/ I/ Kthe base of the phallus and was dark and curled. The
* f; L; X% u. M6 R3 |3 |testicular volume was prepubertal at 2 mL each.3 g4 q  b- C8 ?+ z  r
The skin was moist and smooth and somewhat
. a9 [. R) J  D* Yoily. No axillary hair was noted. There were no) t9 ^- t; |4 @
abnormal skin pigmentations or café-au-lait spots.9 i/ n! H8 `+ k. Q4 D/ x4 W
Neurologic evaluation showed deep tendon reflex 2+4 a! J% y! g; I7 c0 l- X7 ]* F. M% Y7 P
bilateral and symmetrical. There was no suggestion5 ^3 ~7 v; G, @* T' P
of papilledema.4 S0 f- `' F' o8 Q, I" O/ x5 n; l
Laboratory Evaluation
. ^5 u5 n0 z  EThe bone age was consistent with 28 months by6 N- D9 r* A* A; |. o8 U
using the standard of Greulich and Pyle at a chrono-2 [/ ]& u+ K% R# Q3 y+ z; @% M& y
logic age of 16 months (advanced).5 Chromosomal
# {! O' j# H2 D7 ?1 U# Ukaryotype was 46XY. The thyroid function test3 V' o2 S" r9 P) ~" k, y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-  M: x, b; |% B& B
lating hormone level was 1.3 µIU/mL (both normal).
- c5 E+ }- F* ^5 ~The concentrations of serum electrolytes, blood
% |8 W, F$ F/ _1 ^urea nitrogen, creatinine, and calcium all were: W" h6 a4 ^# V' @+ a
within normal range for his age. The concentration6 Z7 z  s1 W# P9 x2 {: H! i7 h$ f$ a
of serum 17-hydroxyprogesterone was 16 ng/dL* _- p, g4 }1 P8 M" Y* H. ~
(normal, 3 to 90 ng/dL), androstenedione was 20: a- ]! t7 a0 P/ h5 n8 u, f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  x- o$ V# |) i; q, y. X9 ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ W8 H# }- [9 E! d1 e/ @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 W" \' T: F- W9 c1 h' a
49ng/dL), 11-desoxycortisol (specific compound S)
' ~  ?1 U' T& O) F3 [9 m% q- uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: m  R5 p: N7 P( O( ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# Q1 ^8 j7 @/ l4 Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ i) ~  q* M3 z+ Zand β-human chorionic gonadotropin was less than7 H6 ?) S* i. w  X, D
5 mIU/mL (normal <5 mIU/mL). Serum follicular% d# O1 e8 o  ]* s5 _
stimulating hormone and leuteinizing hormone
( Z% H6 J; y" L" ^6 }concentrations were less than 0.05 mIU/mL
: _+ e) E7 }% e; r9 ?, ^4 ~  r(prepubertal).
: ^2 Z9 S1 P! c- O0 p$ h) a7 r8 y1 |7 TThe parents were notified about the laboratory' o) X7 G2 A  Z3 ^
results and were informed that all of the tests were
" V) _3 _  O* A, \normal except the testosterone level was high. The! @( ^% \1 Y$ x; ]: {. ~
follow-up visit was arranged within a few weeks to: R  {) I- I  t0 @
obtain testicular and abdominal sonograms; how-- M4 Z% i( N4 W. G7 T' g0 K+ F
ever, the family did not return for 4 months.7 E- R/ L8 a3 x
Physical examination at this time revealed that the
( @4 k% n" H( {) Qchild had grown 2.5 cm in 4 months and had gained
1 b! b; d$ L8 ^) Y4 N1 K) k0 B2 kg of weight. Physical examination remained
  A. Y* q1 o, w8 i* D4 Tunchanged. Surprisingly, the pubic hair almost com-
8 D5 F2 v/ `# ?" ppletely disappeared except for a few vellous hairs at2 d3 M, w' A0 i5 r
the base of the phallus. Testicular volume was still 2% R" n* i- V  `, s( N5 M* [
mL, and the size of the penis remained unchanged.1 u  B( T& ]; K; P0 w$ q& O/ w
The mother also said that the boy was no longer hav-
, N$ a- J8 w! C# z/ n3 n  {9 g5 hing frequent erections.2 X: W7 h/ a% y: M2 z4 D8 ^" {
Both parents were again questioned about use of
$ V/ h- @& r; K( G% a* S0 Y" vany ointment/creams that they may have applied to
1 l% d: E3 p, o" `the child’s skin. This time the father admitted the
3 y6 P5 n& Y+ NTopical Testosterone Exposure / Bhowmick et al 541
7 O6 l0 R( R  \- t9 E" wuse of testosterone gel twice daily that he was apply-: @% e) j: t" [% {" k
ing over his own shoulders, chest, and back area for
1 v- U3 L* U# t5 p# Sa year. The father also revealed he was embarrassed9 |) r: {; f( Z9 V( m9 M
to disclose that he was using a testosterone gel pre-4 ~7 {8 `/ j& g0 V7 W
scribed by his family physician for decreased libido
8 J; s: H4 {. H+ z* K& ^secondary to depression.1 x6 P7 B* N2 ]. g
The child slept in the same bed with parents.
. j# E. k8 A. H4 `3 K1 V8 LThe father would hug the baby and hold him on his# D4 l$ \/ ?& P/ I% r3 k6 S4 F, y
chest for a considerable period of time, causing sig-% N7 k8 {7 H: i$ G% P7 |! d! j
nificant bare skin contact between baby and father." k0 y! j1 L& x) f7 |3 a
The father also admitted that after the phone call,+ e& w3 O$ C" e1 `( q
when he learned the testosterone level in the baby
% e" R* g' _4 @" Swas high, he then read the product information4 g+ x  r1 I  W6 B4 p# i  F3 T
packet and concluded that it was most likely the rea-
. x* V/ X9 v; L. E( m/ }# a$ c8 [0 kson for the child’s virilization. At that time, they0 Q; z  g0 {" H) z0 R
decided to put the baby in a separate bed, and the8 x2 i& s. |& E  Z, v5 i
father was not hugging him with bare skin and had
1 S$ c  i5 p/ D% vbeen using protective clothing. A repeat testosterone
* J$ R" c/ l% [3 ?8 W) ]% Q; Atest was ordered, but the family did not go to the. n; h0 Q9 f9 m7 J; C
laboratory to obtain the test.
; Z# d5 q5 w8 U* oDiscussion
2 ?& {/ |/ J: L5 mPrecocious puberty in boys is defined as secondary
0 r/ S' F( k6 c* E$ K9 |- @sexual development before 9 years of age.1,4
6 d( l2 C) Z/ V+ s  |0 v! tPrecocious puberty is termed as central (true) when  ~5 k( q; K, T
it is caused by the premature activation of hypo-
9 \$ {* V8 |& b' ^  Z8 n* M5 \% c# {thalamic pituitary gonadal axis. CPP is more com-
4 V  ?# u* ^! K  k6 v3 q- g7 amon in girls than in boys.1,3 Most boys with CPP
8 p4 _5 _1 X# A7 Z, s! p) ^may have a central nervous system lesion that is/ i7 m* O% Y. p! o1 }! U6 n. p
responsible for the early activation of the hypothal-5 g! h- E  j# F0 A9 r; m6 s# ?6 g
amic pituitary gonadal axis.1-3 Thus, greater empha-+ z- K& r8 X5 ]( U0 C) v
sis has been given to neuroradiologic imaging in. d- b" n) [# E- a" i' y+ c: {: K
boys with precocious puberty. In addition to viril-: T5 G3 S( F7 I
ization, the clinical hallmark of CPP is the symmet-% b, K/ o* W7 A+ p
rical testicular growth secondary to stimulation by
' `- U" o2 P) ?gonadotropins.1,3" s9 X8 T2 P" m; [0 l, v$ e
Gonadotropin-independent peripheral preco-1 z. X; Y& c. t% X: O0 C
cious puberty in boys also results from inappropriate& |1 r( v, i! _; m; U" O, v
androgenic stimulation from either endogenous or. Q$ `3 Y0 ]/ w* f! y8 A
exogenous sources, nonpituitary gonadotropin stim-8 o0 p5 h. D9 _' x% b4 O
ulation, and rare activating mutations.3 Virilizing/ I1 b. O4 @8 L$ c$ S- o, a4 G
congenital adrenal hyperplasia producing excessive
& m/ Y7 M1 j+ S' o% Y1 h0 Madrenal androgens is a common cause of precocious" A( X* A3 S7 \* G
puberty in boys.3,4# R' e& [9 Q; C; K  z
The most common form of congenital adrenal) f0 O3 R  m' b6 ~
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ Y$ D/ W8 [8 H4 yThe 11-β hydroxylase deficiency may also result in' g  m7 a, i  f: ]
excessive adrenal androgen production, and rarely,
# ^; n1 Q2 X6 F" ean adrenal tumor may also cause adrenal androgen
7 m  @4 H. o* z* `3 hexcess.1,33 \9 i/ Z; D- V7 K& z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* d. T  @8 g3 ^7 x7 t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% O8 m" M6 u) D+ Q7 Y9 y6 j; J
A unique entity of male-limited gonadotropin-# ~* A( p4 y0 I7 g( p- z8 }
independent precocious puberty, which is also known4 K3 w9 B4 n4 }6 P1 |" Q; f* O
as testotoxicosis, may cause precocious puberty at a
2 }" U2 t5 X5 G6 o7 mvery young age. The physical findings in these boys
- z) P7 A9 {1 }- Z2 g/ O$ [with this disorder are full pubertal development,  `/ [" s$ r; C* f
including bilateral testicular growth, similar to boys, B% k) C8 S# s( R
with CPP. The gonadotropin levels in this disorder5 o0 H, g1 r  t4 }& }; A; Z  T
are suppressed to prepubertal levels and do not show1 c1 l: M) a2 D1 s# k
pubertal response of gonadotropin after gonadotropin-
* j2 m( |$ ?1 k9 |2 creleasing hormone stimulation. This is a sex-linked) X- R+ A+ ^! J8 z7 I2 D. ^
autosomal dominant disorder that affects only6 M% X# y0 A/ s) G) Z$ `% E: _
males; therefore, other male members of the family
1 O  O' D" W  M+ Pmay have similar precocious puberty.3: ^: ?- w$ Q" L/ L6 x& [0 K& g
In our patient, physical examination was incon-4 v" w  H' q3 ]7 O+ `: M$ ~9 {
sistent with true precocious puberty since his testi-
, E$ Z  e/ P1 U+ n% V# i7 Ccles were prepubertal in size. However, testotoxicosis1 D8 D- l# i7 |  W/ C( h
was in the differential diagnosis because his father
0 I& n) D6 _" P, b  A% Tstarted puberty somewhat early, and occasionally,9 x8 W& z. K  U' L
testicular enlargement is not that evident in the) p$ u) r5 H% |" A- z
beginning of this process.1 In the absence of a neg-
! M; D6 C0 p$ M$ ?ative initial history of androgen exposure, our, X' o( r: Q' }- t* B/ V
biggest concern was virilizing adrenal hyperplasia,
% Y" o4 P" I2 H, Oeither 21-hydroxylase deficiency or 11-β hydroxylase
- ^. p0 @) k+ a7 X4 D5 f, wdeficiency. Those diagnoses were excluded by find-3 x4 f1 d4 s+ ~- A" `! M
ing the normal level of adrenal steroids.5 s7 Z9 @1 A9 a' ?$ d) I
The diagnosis of exogenous androgens was strongly
, t( P7 H- F( N8 k9 v! l9 |suspected in a follow-up visit after 4 months because
5 O3 h/ i; ]( |* l5 j+ Wthe physical examination revealed the complete disap-
1 e8 r' K# m/ E# e+ D$ Rpearance of pubic hair, normal growth velocity, and9 R2 K( X$ s, e: W( V# c$ S' {+ |
decreased erections. The father admitted using a testos-
9 O( F5 w# s, d# p* Tterone gel, which he concealed at first visit. He was
& z; _# V. z* o4 _' Yusing it rather frequently, twice a day. The Physicians’& y  y, j* z( t0 H
Desk Reference, or package insert of this product, gel or
5 M2 u( N! n) F8 ycream, cautions about dermal testosterone transfer to
+ H7 D% M  n3 v, P7 sunprotected females through direct skin exposure.
, n' m5 g: |- v8 P- |Serum testosterone level was found to be 2 times the
7 \- E! {# \: Jbaseline value in those females who were exposed to
( a& k' z! B+ G* p+ m8 H" geven 15 minutes of direct skin contact with their male
% |: O, |; {7 _1 Q$ ^partners.6 However, when a shirt covered the applica-' J; ^& j+ H) |: L5 l7 A* h) p
tion site, this testosterone transfer was prevented.
1 V$ A0 G5 K* Z0 D" z9 g5 {$ KOur patient’s testosterone level was 60 ng/mL,
, `  \) r4 C) e7 y9 f! k6 P& X" uwhich was clearly high. Some studies suggest that6 B" ]- U4 ?& I! Z" ]* y9 a
dermal conversion of testosterone to dihydrotestos-' @" l8 |: W* c' y1 Q
terone, which is a more potent metabolite, is more
& h% v8 @9 o2 b: y9 [! [- k0 {active in young children exposed to testosterone
/ J8 ?- q0 Q% F" G4 Yexogenously7; however, we did not measure a dihy-
: k2 s4 ~0 p$ k7 adrotestosterone level in our patient. In addition to
7 Q9 J" Z  T9 hvirilization, exposure to exogenous testosterone in2 k1 M, p0 u3 G: q2 F
children results in an increase in growth velocity and! ^- i& A: B% k! q* L" |' C( P6 }
advanced bone age, as seen in our patient.) ?7 }% \& D3 Z; q: ]) d% e  Q: g
The long-term effect of androgen exposure during, x& G) }" _& W! w% l2 h/ m- p
early childhood on pubertal development and final) L* j" Q: |5 x: P4 ]. A  Q% W# I( y
adult height are not fully known and always remain" K! E# p: v9 F# [
a concern. Children treated with short-term testos-* u2 K9 A- S' f% ^- h0 T; f
terone injection or topical androgen may exhibit some
& |# H3 n& G" _) a8 Racceleration of the skeletal maturation; however, after
# ^0 V: _; H+ w" [3 B5 @) Jcessation of treatment, the rate of bone maturation
$ f' q( ?+ R2 o  h3 q( b2 P& vdecelerates and gradually returns to normal.8,9' {# z: V4 ?: J$ B% y
There are conflicting reports and controversy5 ]& g1 r' k8 w3 _% O
over the effect of early androgen exposure on adult$ a6 X2 x0 }* T$ r1 v8 Z! K) @" n' w
penile length.10,11 Some reports suggest subnormal
4 K' M2 p- R2 U  A# {/ G* Yadult penile length, apparently because of downreg-
+ I' p. H  L" P) T( r7 Qulation of androgen receptor number.10,12 However,
$ x" N+ I% q- j; vSutherland et al13 did not find a correlation between! ?$ n/ \1 g1 O$ ^+ V
childhood testosterone exposure and reduced adult7 Y4 e4 Z+ V0 j( ^9 P" `
penile length in clinical studies.
, ~* p7 D- E9 x1 r9 Q  ^1 }* ~# m0 vNonetheless, we do not believe our patient is. x# N* P) k9 k9 i3 T
going to experience any of the untoward effects from
' J/ h3 D5 a5 itestosterone exposure as mentioned earlier because  v, a) s. H2 B3 c! V% k) w# W
the exposure was not for a prolonged period of time.! E# t! }  A0 I4 u
Although the bone age was advanced at the time of/ m; ~( j7 |7 _8 W: A
diagnosis, the child had a normal growth velocity at
( b* x( L# N; g8 d5 R6 l8 }! W4 tthe follow-up visit. It is hoped that his final adult% x, H) l2 B5 R. E- ]
height will not be affected.# z& q6 E* Y# P- a0 e: m+ X7 E
Although rarely reported, the widespread avail-) i& M. u+ Q3 |. ]8 ?; ^
ability of androgen products in our society may; \  X: d& i# g
indeed cause more virilization in male or female
$ [4 k/ j6 I7 |8 i. Uchildren than one would realize. Exposure to andro-# O' C* W3 p) V9 ^
gen products must be considered and specific ques-
7 z2 Z' ~: t1 s2 N  \) q2 stioning about the use of a testosterone product or/ ]+ o0 u4 l; }2 E( y
gel should be asked of the family members during
3 i6 p& h/ e$ L+ D9 z, g+ rthe evaluation of any children who present with vir-3 i  @" M1 Y: A9 v5 `/ |
ilization or peripheral precocious puberty. The diag-
$ T6 j9 H7 {+ g: O6 |nosis can be established by just a few tests and by
: {/ G4 r2 f5 O  M# O% a! vappropriate history. The inability to obtain such a8 h, e' }4 x8 u- r7 g
history, or failure to ask the specific questions, may
  @3 [# [; }( T" ^& tresult in extensive, unnecessary, and expensive
: I" ]3 R. d* e5 b4 y; Kinvestigation. The primary care physician should be
* E; }# f$ x7 l$ N7 gaware of this fact, because most of these children% d1 q) T( u. f% U( q) L
may initially present in their practice. The Physicians’6 r* g' R  n2 N/ g6 G7 c) a8 V
Desk Reference and package insert should also put a$ N! G9 Y8 H4 m% `( C) h5 p# L2 g# b
warning about the virilizing effect on a male or
9 H  i4 U5 D1 V; g9 @female child who might come in contact with some-
# M/ P9 R& N: F% {one using any of these products.
5 e, p- H/ N* _' O, X4 YReferences! A5 i* l# g- X" d7 u2 y
1. Styne DM. The testes: disorder of sexual differentiation" R! J: U1 k! Q; O! o- o1 {6 N( c9 e
and puberty in the male. In: Sperling MA, ed. Pediatric
! }! n: w7 W* @7 g+ E- ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# ]9 M: S# R- M' D9 f4 z
2002: 565-628.
6 x0 v7 E3 l: [4 N3 ~/ R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ z4 x7 D/ F. I4 _. s
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
7 o) \+ k4 E5 L6 k* H
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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