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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$ O2 j) \9 X. `& n' c
Boy Induced by Indirect Topical
3 @/ a" {6 q( a0 l+ ]% J$ ?Exposure to Testosterone* g; k. J- X0 R) Z, |7 c' U1 W' F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. t! C2 @6 N* m% [. q2 ]$ |and Kenneth R. Rettig, MD1* d0 Z6 J, W1 U4 _" ?9 r1 G
Clinical Pediatrics7 T' h7 J1 w; W; T" Q
Volume 46 Number 6
: Y5 |3 Z! c0 T+ Q- AJuly 2007 540-543) J/ `/ g/ t% Z6 P
© 2007 Sage Publications8 ~( C6 E9 B2 \3 I
10.1177/0009922806296651
$ R2 a* u: ]# P) R: ghttp://clp.sagepub.com
: S+ m9 M& D3 E. J/ M9 d! \; x1 thosted at' e0 F& v7 x7 S
http://online.sagepub.com
# i+ G* X6 }5 f3 g, V4 {4 zPrecocious puberty in boys, central or peripheral,
- h: o5 m# q, {4 |is a significant concern for physicians. Central
2 L0 |3 g- W4 L* m& Gprecocious puberty (CPP), which is mediated
& z* O2 H; t, Q1 Z# t) @0 Athrough the hypothalamic pituitary gonadal axis, has
# A) Z7 q5 q. f5 t: Ia higher incidence of organic central nervous system
- Q# X: m  ~4 ~8 f0 glesions in boys.1,2 Virilization in boys, as manifested
& W" @5 G. R; u- V9 r& xby enlargement of the penis, development of pubic) d2 N. ?  I/ T& Q4 \! t6 @
hair, and facial acne without enlargement of testi-
& M9 v! ?5 Q. T8 F6 @7 ocles, suggests peripheral or pseudopuberty.1-3 We  z( `7 A1 y8 s; H) y( `
report a 16-month-old boy who presented with the9 `' _' P2 a3 r  B  U" x
enlargement of the phallus and pubic hair develop-4 u6 b! h% v! ~% ?9 t: e% z, M2 c$ R+ Q
ment without testicular enlargement, which was due9 C' U. C6 t9 y8 y  a- K
to the unintentional exposure to androgen gel used by( a  U9 x& o+ i4 D) U
the father. The family initially concealed this infor-
6 [2 T" J* Q- c1 l8 `0 R- c: bmation, resulting in an extensive work-up for this7 K/ L: Z* W, ]0 i
child. Given the widespread and easy availability of& C2 g$ r6 S# S% A4 T
testosterone gel and cream, we believe this is proba-
! b2 i3 a: ~- L) Wbly more common than the rare case report in the
- f8 g: B* R" e8 I% Aliterature.4; P7 s" n; _! {1 ]0 C1 V! i7 w& P
Patient Report
4 @+ m# K" l6 C# U7 R  h. HA 16-month-old white child was referred to the* y% }5 A7 E) u. w
endocrine clinic by his pediatrician with the concern3 z, S3 \. u; q* ~4 m: J  f8 Z* i
of early sexual development. His mother noticed$ P9 ]& Z0 q6 R: s- K
light colored pubic hair development when he was6 ]' n* I# x% ~
From the 1Division of Pediatric Endocrinology, 2University of$ o* H3 V! m/ x/ Y% h7 N. Q
South Alabama Medical Center, Mobile, Alabama./ I8 `. y8 r/ r: D5 m. q
Address correspondence to: Samar K. Bhowmick, MD, FACE,, `  y& K! i4 i/ _
Professor of Pediatrics, University of South Alabama, College of
$ P9 a1 h5 W- w; K% gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& E2 _4 n% b" y# C! c) V- H. y2 xe-mail: [email protected].
! L: g& G2 s4 Q: Y: U( B0 Wabout 6 to 7 months old, which progressively became
6 ]. E9 d2 q2 ~+ o) V0 O4 ^1 gdarker. She was also concerned about the enlarge-- L9 ^, T8 ?" [4 i
ment of his penis and frequent erections. The child/ V; W, Z4 X& ^2 Z3 y$ X) K
was the product of a full-term normal delivery, with1 W; R6 F5 n; ~! k0 F
a birth weight of 7 lb 14 oz, and birth length of7 ^# ~  O$ S6 P1 B+ T; D9 g
20 inches. He was breast-fed throughout the first year: x$ Z2 _' u* c8 R
of life and was still receiving breast milk along with
4 i" O6 y8 Y! `( A0 dsolid food. He had no hospitalizations or surgery,
6 l( n' N( z& G+ @( Z6 g$ sand his psychosocial and psychomotor development
. L% u! q! P% Q: Uwas age appropriate.' R5 M  H; I4 i6 z$ B
The family history was remarkable for the father,1 r2 h+ x8 m8 R, J- K7 n9 {
who was diagnosed with hypothyroidism at age 16,
# x2 _+ ?  U8 R3 r) Owhich was treated with thyroxine. The father’s3 x8 V) F, ?3 E
height was 6 feet, and he went through a somewhat
+ [+ p8 d; A! v: rearly puberty and had stopped growing by age 14.6 x) T* t/ m1 v" M
The father denied taking any other medication. The1 n! b0 z( @/ R! c5 w( b
child’s mother was in good health. Her menarche
8 ^+ B8 D8 ^/ _. n9 p# w+ vwas at 11 years of age, and her height was at 5 feet
9 b- N& }6 g1 @; R5 inches. There was no other family history of pre-6 i$ X  P/ \, g! v3 b$ {
cocious sexual development in the first-degree rela-
. s6 U8 ~6 u" Rtives. There were no siblings.
  t: }1 A0 b8 P# Y$ e9 pPhysical Examination; L, r, _$ }* c6 ~. M+ z6 x
The physical examination revealed a very active,
5 ], U; d! E6 }playful, and healthy boy. The vital signs documented
& x' ~5 K$ r/ |( V6 F, Ma blood pressure of 85/50 mm Hg, his length was0 a. X& G+ R% S3 H
90 cm (>97th percentile), and his weight was 14.4 kg, a1 `( a. k" p) C6 t
(also >97th percentile). The observed yearly growth* x0 v; S3 @; ]& N6 c" I
velocity was 30 cm (12 inches). The examination of, _1 `" \% G: E! o% ?2 T+ g; q
the neck revealed no thyroid enlargement.
4 c6 w8 K# r, xThe genitourinary examination was remarkable for
( H9 p$ f3 b* F' R4 Kenlargement of the penis, with a stretched length of3 g/ g$ e+ n1 r" {8 }
8 cm and a width of 2 cm. The glans penis was very well6 ~8 S  `2 d# U* W, y5 {7 _: h5 d
developed. The pubic hair was Tanner II, mostly around( T' Y1 `/ H, J
540
! V7 y6 D4 x# H& m' [+ R. J  B! fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 c' O' z: M2 Y  V, Bthe base of the phallus and was dark and curled. The
% j8 D/ x4 G( U3 U- ftesticular volume was prepubertal at 2 mL each.. O: \0 ~: [% o# q* e; g
The skin was moist and smooth and somewhat
# Y  D, W9 H, h$ Koily. No axillary hair was noted. There were no! f1 c/ k5 [) G: b8 H
abnormal skin pigmentations or café-au-lait spots.
0 e3 u/ Y! [0 ?Neurologic evaluation showed deep tendon reflex 2+& O) F: u5 h: \6 v% P' F
bilateral and symmetrical. There was no suggestion7 l. X+ r. y$ ?, d$ K5 r- p+ d
of papilledema.
. p  R+ S$ N) l6 I# S2 C- p3 `Laboratory Evaluation
9 M9 J7 p% y! {# DThe bone age was consistent with 28 months by( n* I2 ^( l! c; ?5 y" t6 d+ o
using the standard of Greulich and Pyle at a chrono-
) F, b9 i  D* x$ A, ?& blogic age of 16 months (advanced).5 Chromosomal
! |# r5 p% T. |- Zkaryotype was 46XY. The thyroid function test7 w4 y) W0 m" E% u/ E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 P+ h* L* G8 Z4 w1 w
lating hormone level was 1.3 µIU/mL (both normal).
6 c" d; m; j8 h6 LThe concentrations of serum electrolytes, blood
/ K- L0 j+ `4 S8 r, u4 s0 {urea nitrogen, creatinine, and calcium all were
' b7 _/ u3 @$ q9 hwithin normal range for his age. The concentration& t/ q# }7 n- c" C4 \: Q$ |/ F
of serum 17-hydroxyprogesterone was 16 ng/dL
$ v9 B4 B- M) ]& c9 J' e(normal, 3 to 90 ng/dL), androstenedione was 20! n1 u, v6 P0 Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% H# H1 P4 Q% ^) D3 k# T4 S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% j4 C4 Q7 t2 d$ E. jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to! X2 z/ j+ S7 ?2 I9 {' V4 b
49ng/dL), 11-desoxycortisol (specific compound S), X  E" g8 O0 V% H8 I$ l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 r' H0 \  \4 A+ X/ G9 `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; j6 `5 x+ P$ P: V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ U2 U& o2 f$ ]- g# Kand β-human chorionic gonadotropin was less than& t5 R' X5 s! b) ^
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ p8 j# h! A) F' b! g+ T. Z( i1 I" c# f
stimulating hormone and leuteinizing hormone
. j) o0 @5 L8 |4 }concentrations were less than 0.05 mIU/mL
* u6 N5 _% U( ^) t2 q(prepubertal).
0 v4 A2 C( i& n; V7 N5 ?: I" lThe parents were notified about the laboratory
  a/ P3 Z. f2 I8 j8 k( Nresults and were informed that all of the tests were7 Y. y. n9 v% }$ U1 V% U3 b
normal except the testosterone level was high. The5 u$ w8 z5 {3 d2 R
follow-up visit was arranged within a few weeks to4 h( M2 ^8 P) y% G2 _/ r% \- C7 W
obtain testicular and abdominal sonograms; how-2 F6 r. ^" ?3 Q2 g
ever, the family did not return for 4 months.
" F1 I( b: T2 p3 m5 UPhysical examination at this time revealed that the
0 m/ T# @" S3 X9 D' Mchild had grown 2.5 cm in 4 months and had gained& a  c4 w% ~1 d/ J+ d; x- `
2 kg of weight. Physical examination remained% z7 W( B# `9 [2 }8 T
unchanged. Surprisingly, the pubic hair almost com-/ s1 ^, H* ^& j
pletely disappeared except for a few vellous hairs at' }) ]1 u0 X/ J$ C
the base of the phallus. Testicular volume was still 2
- e9 K5 X2 ~3 C4 L6 k1 B+ @0 CmL, and the size of the penis remained unchanged.
, W/ x& B' r5 k0 B( o+ pThe mother also said that the boy was no longer hav-
0 W! H4 R6 Q6 l& q) |( T- Y# x  ning frequent erections.; s0 |; T, _3 }0 u0 o
Both parents were again questioned about use of
8 S; N" P' h1 A- Yany ointment/creams that they may have applied to2 Q( i: Y' M4 z6 n. U7 u8 r
the child’s skin. This time the father admitted the- f( R' Z* @$ \4 ?) P/ {
Topical Testosterone Exposure / Bhowmick et al 541
7 ~0 w1 T+ Q8 \) V: vuse of testosterone gel twice daily that he was apply-
" o4 b% O' a3 @; |7 M# _, [! Xing over his own shoulders, chest, and back area for
$ P. L1 }) V8 M+ h" T, `) oa year. The father also revealed he was embarrassed
/ k+ D9 {6 Z7 L& `to disclose that he was using a testosterone gel pre-
* H) G8 `$ U- C. Y: }! S5 Yscribed by his family physician for decreased libido
7 Q/ B% [1 K5 q$ gsecondary to depression.' z% O8 \' [4 H& E+ g
The child slept in the same bed with parents.* {1 o2 `2 b! p* t" ?
The father would hug the baby and hold him on his
  z/ C) z5 a9 x0 }8 Y7 ]chest for a considerable period of time, causing sig-
' _/ R: ^% |8 h% Fnificant bare skin contact between baby and father.
# y# r0 |) M2 m) I$ T$ bThe father also admitted that after the phone call,
, n2 @# ?- e- {% ~- ]% xwhen he learned the testosterone level in the baby. z+ I+ G; O# j1 w8 C
was high, he then read the product information
. j8 L  l$ u. w% {8 `# O) M( qpacket and concluded that it was most likely the rea-& u' F- [, J$ x7 e
son for the child’s virilization. At that time, they
% o" }; Z  @7 ydecided to put the baby in a separate bed, and the
& v* y- O$ P' {% i; [# ofather was not hugging him with bare skin and had
' r+ e- E7 ?. {3 M+ s' xbeen using protective clothing. A repeat testosterone0 G4 \: w5 P& z8 [1 K% z
test was ordered, but the family did not go to the
) |# ?0 ~, P' I# Dlaboratory to obtain the test.
2 i) B  [* v6 YDiscussion
- \2 u" d/ t; m" U& V' E3 v$ p6 TPrecocious puberty in boys is defined as secondary
! K) O: m+ s4 U6 E3 t# J. dsexual development before 9 years of age.1,42 {* b2 ~- r. S6 P% R
Precocious puberty is termed as central (true) when
! [1 U1 K; y0 U8 ^; L4 H* r* |it is caused by the premature activation of hypo-* i- {' p3 b0 v" M/ E
thalamic pituitary gonadal axis. CPP is more com-
; z7 P8 U5 I# @0 l% O6 p; \  ~" pmon in girls than in boys.1,3 Most boys with CPP( R( F  B0 O# g5 c* ~
may have a central nervous system lesion that is
( d* z, `  Y6 b9 g# I7 ~0 \responsible for the early activation of the hypothal-# Q; B6 u# _* @/ B
amic pituitary gonadal axis.1-3 Thus, greater empha-
  @5 ?: Y& M3 p) r) O  }sis has been given to neuroradiologic imaging in4 g! c6 p+ z4 k2 D4 h
boys with precocious puberty. In addition to viril-
6 W+ @5 ]* S* }" n# Nization, the clinical hallmark of CPP is the symmet-
4 r# m. Q+ b9 i+ z6 J& ^: Lrical testicular growth secondary to stimulation by
2 `( F/ X- }8 Z9 d, a$ fgonadotropins.1,3: B; w% l$ C0 ^4 y" G
Gonadotropin-independent peripheral preco-5 Z. J& l5 [$ c) V" z2 A
cious puberty in boys also results from inappropriate: ?. O2 j- U* T/ t! X' j
androgenic stimulation from either endogenous or1 s" ^8 D! D- G) s! G& M
exogenous sources, nonpituitary gonadotropin stim-3 l7 z1 @1 ?) t+ Q1 W
ulation, and rare activating mutations.3 Virilizing/ c! F3 `/ m' W/ ]& b: H# \
congenital adrenal hyperplasia producing excessive1 v( R7 D* B8 D* a2 ~
adrenal androgens is a common cause of precocious
7 x: E" F" D. R; h; i/ ipuberty in boys.3,4- \' H1 d& X. D. y2 }! J
The most common form of congenital adrenal
3 `; Z" q" f4 [( H. v! nhyperplasia is the 21-hydroxylase enzyme deficiency.
! [+ R) T  K1 r- Y) yThe 11-β hydroxylase deficiency may also result in
; Q. \; f* b# ^$ ~; O  S5 G6 ~excessive adrenal androgen production, and rarely,  w7 s8 S7 Y) `! C
an adrenal tumor may also cause adrenal androgen
/ o: a3 @4 X& E4 R" v' O+ d$ hexcess.1,3
" ?5 u& R0 }9 ~8 sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 w& f- y9 d3 P! ~: H1 T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% m6 K) e: \6 ?+ sA unique entity of male-limited gonadotropin-# N9 L4 S: b% }: H* K$ ^
independent precocious puberty, which is also known( v+ g( o; K% Q! P
as testotoxicosis, may cause precocious puberty at a3 @0 A+ z1 ^4 ?( M* ~4 ?4 ^  @
very young age. The physical findings in these boys5 ^: K- c# q; ~- j8 d/ i
with this disorder are full pubertal development,
+ q( ^  Y6 M/ V9 `8 [. Z9 ^+ u! mincluding bilateral testicular growth, similar to boys
: ~3 L2 \4 W1 I9 nwith CPP. The gonadotropin levels in this disorder  N0 h7 k. J: x* M! o: i" s
are suppressed to prepubertal levels and do not show# q* P9 O( D  P0 m8 o7 h
pubertal response of gonadotropin after gonadotropin-$ `6 e7 p: y7 a4 z
releasing hormone stimulation. This is a sex-linked
8 [! U3 |. Y+ r6 ^. d5 qautosomal dominant disorder that affects only- E( [* t3 u: G. y! R- W) b" K( S8 Y
males; therefore, other male members of the family, z1 ^; [+ R& `+ ~
may have similar precocious puberty.3
0 _5 c8 f. t2 J5 q- rIn our patient, physical examination was incon-, p+ y& o1 f4 \9 `
sistent with true precocious puberty since his testi-
% ]6 x, S# T: G8 m. Zcles were prepubertal in size. However, testotoxicosis% L, c" f2 z* y1 B  e
was in the differential diagnosis because his father
2 k- L, }. N- T+ q  m( X  z, kstarted puberty somewhat early, and occasionally,5 j% `# j. G- W8 }" C+ Q
testicular enlargement is not that evident in the
! Y0 M3 {, h3 ~beginning of this process.1 In the absence of a neg-9 v3 L# c$ G0 t6 U
ative initial history of androgen exposure, our  P' A4 n/ w8 N' B' g' S9 \% |
biggest concern was virilizing adrenal hyperplasia,7 o) h+ M6 e$ n; W" C/ _/ q, p- ?
either 21-hydroxylase deficiency or 11-β hydroxylase# p; c* O( f1 X+ C% [. y( j2 K
deficiency. Those diagnoses were excluded by find-9 y4 z( F& e, \0 _9 @" h
ing the normal level of adrenal steroids.
( ]) N3 W! |6 RThe diagnosis of exogenous androgens was strongly: l  w' q9 Q, X
suspected in a follow-up visit after 4 months because  a0 M& }/ X( T$ E) {! y5 S
the physical examination revealed the complete disap-: m2 C; z3 @1 M8 A
pearance of pubic hair, normal growth velocity, and
; b7 `7 ^+ L; Tdecreased erections. The father admitted using a testos-7 d6 m! Z  d1 H" J- U3 p9 Y6 F
terone gel, which he concealed at first visit. He was* e3 k& `5 @6 j& C" [8 ~$ z6 i
using it rather frequently, twice a day. The Physicians’
: Z: T6 k! j" fDesk Reference, or package insert of this product, gel or
3 O$ V  J! |8 Y+ S: `5 _; f+ Lcream, cautions about dermal testosterone transfer to% }5 c: a: d$ N5 y$ P, \
unprotected females through direct skin exposure.- t6 i/ u7 r/ G& ?* G( H
Serum testosterone level was found to be 2 times the5 O( @; g% F1 c0 f8 S2 V
baseline value in those females who were exposed to
: A" Q/ ]: q3 [, v* r" P" m9 heven 15 minutes of direct skin contact with their male
% X* Z, H+ Y. \9 vpartners.6 However, when a shirt covered the applica-; T4 D2 z/ F3 j3 W
tion site, this testosterone transfer was prevented.7 b7 Z" P; T4 C& M# F/ F9 x
Our patient’s testosterone level was 60 ng/mL,
3 b# Q$ E9 ^2 V# ~* w6 x3 _8 uwhich was clearly high. Some studies suggest that
: E  H  ]; q+ mdermal conversion of testosterone to dihydrotestos-. D. d; e" T( }. F/ a0 n
terone, which is a more potent metabolite, is more
, |" V) Z+ ]3 B4 K/ |active in young children exposed to testosterone0 a1 {5 h* R6 x+ i
exogenously7; however, we did not measure a dihy-
) y  W; B% x5 U; x, t* N# S9 O- Adrotestosterone level in our patient. In addition to
) D% J: o  j; X# kvirilization, exposure to exogenous testosterone in9 ?0 t' |! e( C7 s" d1 Z
children results in an increase in growth velocity and
7 t) ?( [9 n& q8 w( ^1 `advanced bone age, as seen in our patient.3 t3 i$ T# J! j
The long-term effect of androgen exposure during6 q) x- b) u0 K0 H1 v
early childhood on pubertal development and final
! v4 }  R2 ]$ Y( J" i. @2 I. _adult height are not fully known and always remain4 w  G- j4 c( P) \
a concern. Children treated with short-term testos-; }8 Y2 R% w  o1 ]2 d
terone injection or topical androgen may exhibit some/ C" P8 M6 Q3 A. g3 d
acceleration of the skeletal maturation; however, after
  {* V/ `$ G# @0 A* jcessation of treatment, the rate of bone maturation
) D1 w  [5 i( gdecelerates and gradually returns to normal.8,9
  e* E, c& R1 w" RThere are conflicting reports and controversy
8 J) B$ y, n+ k+ Nover the effect of early androgen exposure on adult
" B  D' [# A  Q! qpenile length.10,11 Some reports suggest subnormal
" s' R5 C, b% @/ M' c; oadult penile length, apparently because of downreg-
0 _2 p# N1 Z- d8 U' g9 ]. culation of androgen receptor number.10,12 However,: n, e4 r& E' H3 `( O
Sutherland et al13 did not find a correlation between" _* Q+ o1 j2 J2 K! B2 S
childhood testosterone exposure and reduced adult0 D; s5 G9 x6 _% w
penile length in clinical studies.
8 E7 f% W3 t( FNonetheless, we do not believe our patient is
$ o6 o7 ^- R) B& x2 Q$ o; W: z' ggoing to experience any of the untoward effects from4 H! j5 o+ V/ z! N8 a! F, I
testosterone exposure as mentioned earlier because
! f: G, t0 [4 A2 {- S0 K6 Vthe exposure was not for a prolonged period of time.
  G, U4 q- ?& n( O' F7 w0 R4 W' ~0 q9 E8 \Although the bone age was advanced at the time of
' P" }% {0 z: s+ X& E) rdiagnosis, the child had a normal growth velocity at" o" Q8 [& X* p* h4 h! q8 q
the follow-up visit. It is hoped that his final adult
% l. N) H5 o- Y: j9 |height will not be affected.' j: w$ X5 ?4 p" K8 `& E
Although rarely reported, the widespread avail-
& U2 h# }! c# l; L% }' a3 @# E$ d: eability of androgen products in our society may5 Z; d4 i3 q* u# k# I* V, `
indeed cause more virilization in male or female9 i' V' ]8 O( c0 e7 f- C& A
children than one would realize. Exposure to andro-
3 x0 F* q# S+ Q2 t) {6 {0 F, pgen products must be considered and specific ques-
# a, U' p* Y# wtioning about the use of a testosterone product or- N* e* V9 c5 k" X& C
gel should be asked of the family members during
5 n+ b7 R; s" L% r8 R8 nthe evaluation of any children who present with vir-6 u) h/ Z0 i6 S* I1 x
ilization or peripheral precocious puberty. The diag-; n# I6 C4 [  O) `. j  I0 t9 w
nosis can be established by just a few tests and by; w0 ^+ n5 n  ^8 f& ^2 a5 E+ c; v0 @
appropriate history. The inability to obtain such a7 [. Y0 R3 H* P6 T/ Y# A
history, or failure to ask the specific questions, may$ q/ a: `% D, E% U$ L( o
result in extensive, unnecessary, and expensive0 ]! D+ l+ e- _# ]7 }9 e
investigation. The primary care physician should be+ `8 X; j8 R/ A2 `( H" R/ h  V2 q
aware of this fact, because most of these children4 V  U) T0 W" c" M. A& P7 z' X
may initially present in their practice. The Physicians’8 e9 p7 J; n. h/ Z4 w& H# W
Desk Reference and package insert should also put a0 b! i) q3 E) Z1 A: `
warning about the virilizing effect on a male or# @  j. h( X- Z$ w% d
female child who might come in contact with some-) a$ o: C$ O6 x) I) e- j. \+ s: k
one using any of these products.! @) N" r3 t7 i
References# c/ L+ y. b" U" m
1. Styne DM. The testes: disorder of sexual differentiation
& N8 X/ _( r2 rand puberty in the male. In: Sperling MA, ed. Pediatric& ~7 K) |% b0 [  X5 k" u: ?% i5 u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ H3 h  P0 @+ I! F* D2002: 565-628.% Z9 h. C6 \4 [, X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 Z5 ?, I8 I, N
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" ^# q( F/ E# x  UBoy Induced by Indirect Topical
, @' s' W( g4 N; \Exposure to Testosterone% {" O  ^8 E( x$ M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 T4 _1 t6 ]0 i& ~+ F& qand Kenneth R. Rettig, MD1
0 m0 y, n2 X) F9 sClinical Pediatrics% e$ e' ^2 |& t& Q- Y; }/ j3 T( \
Volume 46 Number 6- z4 e& ~, B: T1 u/ Q
July 2007 540-5431 l9 J& p0 h  g" x, ~# t
© 2007 Sage Publications( q2 L& r) }# O* Y
10.1177/0009922806296651
& D7 C6 o& g2 j. f% y$ h7 E$ Khttp://clp.sagepub.com+ Y1 j+ N$ D" p% f0 ~  e1 z
hosted at  |3 q9 c& y! K. ?5 D9 @
http://online.sagepub.com# p; O4 C1 @! ?( p* k
Precocious puberty in boys, central or peripheral,
7 o1 l, [& j) h5 Y' T/ F' h0 Ris a significant concern for physicians. Central
0 I5 [6 i: N- yprecocious puberty (CPP), which is mediated
( q  ]7 L/ q  V+ O/ Lthrough the hypothalamic pituitary gonadal axis, has, d: \7 z" Z4 ]9 K9 d
a higher incidence of organic central nervous system
' Q+ k6 c  Z( V$ f3 s0 clesions in boys.1,2 Virilization in boys, as manifested& l3 h  Z+ w0 R, {' ^6 T
by enlargement of the penis, development of pubic
1 ~" i4 y/ E! A, r) Ahair, and facial acne without enlargement of testi-
. X- N0 P* m- y9 I4 v$ ecles, suggests peripheral or pseudopuberty.1-3 We
% Z) k$ G8 H: [7 Zreport a 16-month-old boy who presented with the
: u8 @! I( o* }7 a) A; @enlargement of the phallus and pubic hair develop-. S1 O/ ]- n8 U! U0 I% o
ment without testicular enlargement, which was due( }+ c7 O: D& r2 i) U( P) l
to the unintentional exposure to androgen gel used by
" D7 ^5 X" S& q' h1 Qthe father. The family initially concealed this infor-
% r3 j, f: @* O9 W3 v. tmation, resulting in an extensive work-up for this( ~1 |( v9 o! ~. V/ K
child. Given the widespread and easy availability of2 W: e& s3 T% `0 Z# {2 ?& J$ r
testosterone gel and cream, we believe this is proba-
0 W' [1 ^5 e8 M9 {! E! v/ jbly more common than the rare case report in the
! T$ s5 O: q' W9 b# ~- A- ^+ P" jliterature.4; o* q1 Z0 p4 i: v
Patient Report
( c% h' d5 I! \& w) n5 EA 16-month-old white child was referred to the
; \& x9 x) ~, Q# I; _$ V4 r' `endocrine clinic by his pediatrician with the concern. a% A0 T: o, `3 r+ J2 ~
of early sexual development. His mother noticed0 @/ P" O0 m% i0 s. G  f
light colored pubic hair development when he was
' g- f+ Q6 u3 o, |9 m; zFrom the 1Division of Pediatric Endocrinology, 2University of) x; R4 _1 I) B1 b
South Alabama Medical Center, Mobile, Alabama.
; d1 \/ H. b; p4 j* ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
& j" a+ `7 ^* D0 Y+ j) }Professor of Pediatrics, University of South Alabama, College of
+ e+ p% o9 ~( ?4 Y# L- }# UMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# z1 c7 S5 R  e' O
e-mail: [email protected].
2 Y# [& p. \& \( d1 c0 t2 Babout 6 to 7 months old, which progressively became7 z. S4 _8 a# ?5 z
darker. She was also concerned about the enlarge-4 }6 r" j" |: V) e; s
ment of his penis and frequent erections. The child8 U7 J7 w5 ?  H( s
was the product of a full-term normal delivery, with
) ]! b: r4 ?' ka birth weight of 7 lb 14 oz, and birth length of0 s/ _4 V, I" K+ u* T5 Z
20 inches. He was breast-fed throughout the first year
9 |! }- ]! a/ ?  n- oof life and was still receiving breast milk along with
$ Y. s8 i. V7 C: f1 r2 Ssolid food. He had no hospitalizations or surgery,
: P3 U2 ^, D$ w7 K7 G4 eand his psychosocial and psychomotor development
0 R: J* n6 M3 L( ]- j8 nwas age appropriate.
* i7 K) T2 n4 O: D; IThe family history was remarkable for the father,' a% T1 i1 V" `3 w0 C
who was diagnosed with hypothyroidism at age 16,
& D4 h- |9 T6 I6 P3 {" Owhich was treated with thyroxine. The father’s
- p$ Z4 Y$ c' c- A1 s3 Aheight was 6 feet, and he went through a somewhat
/ m' u1 g+ [5 k  ?" C) k' Bearly puberty and had stopped growing by age 14.
! J  N7 h/ M+ kThe father denied taking any other medication. The6 e+ z/ d. N& x  g8 l6 |
child’s mother was in good health. Her menarche; I6 l2 ]) l9 j$ {% x. g2 E
was at 11 years of age, and her height was at 5 feet
' T9 q5 H) Y) y. G. M1 G& H5 inches. There was no other family history of pre-# l4 q$ z1 j1 K- ~( F# T) ]; d
cocious sexual development in the first-degree rela-
3 b. D6 n6 Q" Q1 D. X' Gtives. There were no siblings.: P. x) T7 k! g( y& \8 y6 c
Physical Examination, u" K& v2 q9 B
The physical examination revealed a very active,
6 Y1 J' k) A. c9 Q, o  ~playful, and healthy boy. The vital signs documented
- J5 e6 \3 |8 N# q1 q' Y0 ca blood pressure of 85/50 mm Hg, his length was
# B' R" w4 N0 Y. J90 cm (>97th percentile), and his weight was 14.4 kg
$ z: M7 J9 B) r" s(also >97th percentile). The observed yearly growth
, V" w2 z0 ^! W+ {9 D; ?velocity was 30 cm (12 inches). The examination of+ X: S; Z4 f2 b/ O7 a
the neck revealed no thyroid enlargement.
( ?) h+ ~7 r$ |/ `8 qThe genitourinary examination was remarkable for
$ _' _& O9 S8 Genlargement of the penis, with a stretched length of" H- P) t" E& Z" f0 W
8 cm and a width of 2 cm. The glans penis was very well5 @7 }  Q4 A4 f& `1 v1 x: t& `9 \( G
developed. The pubic hair was Tanner II, mostly around0 e! x- ]7 F- \+ R$ l; ~
540' T7 l5 c: P/ M0 B$ m1 `" Z9 a; M; q! Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 |9 i0 x6 L! v1 o
the base of the phallus and was dark and curled. The: J8 n0 L) a9 X1 _2 f
testicular volume was prepubertal at 2 mL each.
2 _' J$ M- t: ]& }The skin was moist and smooth and somewhat! ]7 j, @# \  g) i- ?2 N
oily. No axillary hair was noted. There were no1 |# C" p! v0 d2 q
abnormal skin pigmentations or café-au-lait spots.3 Y; c$ [# N) _6 o$ T( ?8 p1 ?
Neurologic evaluation showed deep tendon reflex 2+
# u0 H) C! S& a- o' }bilateral and symmetrical. There was no suggestion
3 ^* \  J6 K0 \2 A0 C5 pof papilledema.0 ^% n. G# \1 ^7 l7 h
Laboratory Evaluation
3 B9 g) ^3 R" zThe bone age was consistent with 28 months by% C7 j* ?! v& ~+ d% `  j  W3 J- t/ m( ^
using the standard of Greulich and Pyle at a chrono-6 G/ c, O( z. m6 K
logic age of 16 months (advanced).5 Chromosomal4 c5 y8 ^% j6 T: a, a: i
karyotype was 46XY. The thyroid function test
' Q; m- Y5 A  J2 O8 t; r( d: ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-  d2 d9 C. f  u2 u* X3 y
lating hormone level was 1.3 µIU/mL (both normal).
. D1 c. d/ m3 v% T; GThe concentrations of serum electrolytes, blood
0 d! ]- ?6 p6 D( |; H7 R! ]) m" Zurea nitrogen, creatinine, and calcium all were" }9 V& a, \, M9 K+ p
within normal range for his age. The concentration8 l2 G( ?" s' B0 H
of serum 17-hydroxyprogesterone was 16 ng/dL; w( z" L2 z1 s% q( [" z" J) A7 a" `
(normal, 3 to 90 ng/dL), androstenedione was 20
& j# _( e4 [! F4 C  `5 h: C# ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  `4 n/ \8 {) B7 \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 b3 `5 H! B* K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 u  P' y! n8 D  k) N8 H; ?
49ng/dL), 11-desoxycortisol (specific compound S)
; j, A* r0 u) i% g% Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 n( m" [' n1 Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 ?, b& O3 [3 g! t* \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ p7 n  J% G% T) N/ }, k$ D) ]. y
and β-human chorionic gonadotropin was less than0 i( D( b# \. p+ m4 v! s
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 j2 n6 W$ _0 I" p  hstimulating hormone and leuteinizing hormone
: M; f9 B: E. V9 xconcentrations were less than 0.05 mIU/mL- G1 C- b4 ]" e/ y7 z6 G/ v, m
(prepubertal).0 F( h6 g4 k* K1 T! {( p
The parents were notified about the laboratory
9 c0 f( f, b+ e4 \2 eresults and were informed that all of the tests were
1 x8 y6 L# ?& I2 U( H# mnormal except the testosterone level was high. The7 R5 q4 C% N* e; r( T" W
follow-up visit was arranged within a few weeks to# _! }' c% [: D; Y- }0 [
obtain testicular and abdominal sonograms; how-
* g: C0 @( E! g) ^) m* eever, the family did not return for 4 months.
2 f. o) U( N: x! g4 CPhysical examination at this time revealed that the
  x) g. o" M2 Q7 b$ d, ychild had grown 2.5 cm in 4 months and had gained
# x+ a' M9 ?, B; J2 n2 kg of weight. Physical examination remained* J0 D! u' F) M+ j$ Q* P+ Z- V
unchanged. Surprisingly, the pubic hair almost com-
  x& W( ]; I. ?3 l; Cpletely disappeared except for a few vellous hairs at7 q/ h! I7 J& C. N, u5 p' u
the base of the phallus. Testicular volume was still 26 T' `; d# y" \4 t1 [) H" k5 _! s5 d
mL, and the size of the penis remained unchanged.
9 X* l6 c4 W* X$ k/ ?0 H  O/ f# i5 IThe mother also said that the boy was no longer hav-
, K5 A; O5 ~/ M8 _. R! [ing frequent erections.4 h7 B9 L  N/ x# ?4 `- y8 S
Both parents were again questioned about use of8 I& `3 [+ _9 D" @  \3 B! G* R
any ointment/creams that they may have applied to
1 C. P7 v, R# q: Ithe child’s skin. This time the father admitted the6 v6 q" V7 p' X5 o( x
Topical Testosterone Exposure / Bhowmick et al 541( G8 S5 v8 ^  P# ]
use of testosterone gel twice daily that he was apply-/ H0 t8 x2 W' P6 g. R  A& ?* ?% W3 M
ing over his own shoulders, chest, and back area for: ]; a0 Q: ~- j4 p8 e
a year. The father also revealed he was embarrassed
' o  z$ P- r, c' W) Y/ S: r1 Xto disclose that he was using a testosterone gel pre-
/ O# ?. H6 v' D8 |scribed by his family physician for decreased libido7 x5 K+ F* M: t' o2 W. O" d  ]4 ?
secondary to depression.- c; A  T3 ^" c; `) i
The child slept in the same bed with parents.
1 ~7 ?2 w2 X$ i# Y/ {7 e, F( \The father would hug the baby and hold him on his
$ R, ~3 ]% E& e5 X' Vchest for a considerable period of time, causing sig-3 o3 ?! D- ^1 W' i5 ]
nificant bare skin contact between baby and father.
* i+ S) n& Q. K# T2 JThe father also admitted that after the phone call," i; t4 q7 _/ @: A9 J' Z
when he learned the testosterone level in the baby  \- h' U$ @0 ~8 W" u
was high, he then read the product information
! S* I" z- a( C  q9 [! `packet and concluded that it was most likely the rea-
" W. ^& H* G4 J! C1 k- O6 Uson for the child’s virilization. At that time, they7 Z6 f0 J/ f0 `* q$ T7 G7 ], Z
decided to put the baby in a separate bed, and the- P% a4 f3 a7 `7 [
father was not hugging him with bare skin and had
" S5 j: Z+ D' A! R6 _been using protective clothing. A repeat testosterone
7 R5 H$ }$ f0 J/ Y/ {' itest was ordered, but the family did not go to the# b6 O$ r+ M  d
laboratory to obtain the test.
! X; q" Z0 ~6 H& T: P! rDiscussion
6 @. T9 e& |, ^1 [" S) APrecocious puberty in boys is defined as secondary
/ F/ R! Q) m0 p9 m  o* ~$ E3 ~sexual development before 9 years of age.1,4
: M: W" _+ [1 {% [Precocious puberty is termed as central (true) when3 I: J; @6 d' Y5 I; [# C1 ]3 l% N5 C' ^
it is caused by the premature activation of hypo-6 o6 [; w) b- S1 d, d7 \, |8 v/ S
thalamic pituitary gonadal axis. CPP is more com-
5 t7 W9 t7 b9 _) vmon in girls than in boys.1,3 Most boys with CPP( F, b5 b; ^' {2 F9 |4 ?/ e- ]
may have a central nervous system lesion that is
7 Y3 w1 h- S& w$ j1 M4 Xresponsible for the early activation of the hypothal-) a" z9 c' ^+ f: y" O+ T
amic pituitary gonadal axis.1-3 Thus, greater empha-
; M* @/ j* O1 J5 j2 e# o& Nsis has been given to neuroradiologic imaging in! o% R2 _* d3 x/ Q% Z- g
boys with precocious puberty. In addition to viril-
! V: n1 z% a2 uization, the clinical hallmark of CPP is the symmet-
; Q6 o4 a+ ^  ?6 mrical testicular growth secondary to stimulation by' h% T: R+ _7 i) Y
gonadotropins.1,31 Q* q' b% d+ L
Gonadotropin-independent peripheral preco-  z5 u" L4 B% Q, ]' N
cious puberty in boys also results from inappropriate
+ K* e6 I! h9 m5 O- I! r  a+ dandrogenic stimulation from either endogenous or
! Z9 ?, v: G+ Z! r2 _7 \exogenous sources, nonpituitary gonadotropin stim-  S. z/ ^* K- R0 m/ a
ulation, and rare activating mutations.3 Virilizing
2 p# k' l' _; ?congenital adrenal hyperplasia producing excessive
, [. i. t: n, B1 e8 qadrenal androgens is a common cause of precocious
! X8 C* U+ W5 A8 opuberty in boys.3,4
; S. }7 G+ l1 R. k7 n# vThe most common form of congenital adrenal! L  f4 d4 K1 O8 y% d
hyperplasia is the 21-hydroxylase enzyme deficiency.8 R% F; |2 z$ G6 q5 R! K
The 11-β hydroxylase deficiency may also result in% F$ Z( a# A  V$ K
excessive adrenal androgen production, and rarely,. u) g, t" v7 b. p0 ^
an adrenal tumor may also cause adrenal androgen
/ F$ P* x- M8 r, d0 g5 g# ]excess.1,3
$ l* q& Z/ l: k5 H7 V* o' fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& g% B' k& K4 g" B' W3 S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 Z3 `- d2 p; aA unique entity of male-limited gonadotropin-( B8 ^( e% {1 T2 s8 s/ u5 @% L! `% o
independent precocious puberty, which is also known% \! L- \2 \! w! {# k
as testotoxicosis, may cause precocious puberty at a! c, \3 h! q( ^% u- _/ k
very young age. The physical findings in these boys
  B$ d" T' N; F' u" Z3 i5 Gwith this disorder are full pubertal development," _; t; C/ ~* p+ v: P9 q
including bilateral testicular growth, similar to boys
  f9 c* D- ?4 T, vwith CPP. The gonadotropin levels in this disorder
; T& n: t& f/ u6 r5 R: W' V3 Xare suppressed to prepubertal levels and do not show
% K, _+ O1 J% |4 x5 epubertal response of gonadotropin after gonadotropin-
! f% ]0 {. H* x' X  h4 |releasing hormone stimulation. This is a sex-linked
$ o4 Y7 `, t3 U3 Y* Wautosomal dominant disorder that affects only) M5 M4 R( t: f. ]0 ~6 ]3 }
males; therefore, other male members of the family
# h! x$ @9 W4 rmay have similar precocious puberty.3
, a$ \1 j+ A5 \6 l3 @7 S7 gIn our patient, physical examination was incon-
8 W9 ~, n/ s4 s: Osistent with true precocious puberty since his testi-4 E% Z  o+ F! f# V) H% I
cles were prepubertal in size. However, testotoxicosis# d# W* t4 S3 D1 [
was in the differential diagnosis because his father; u/ O( B+ R/ }2 @% Y% w6 W2 X
started puberty somewhat early, and occasionally,
: k3 Z) W+ @6 E" a, z; a1 j& G2 y, ktesticular enlargement is not that evident in the
7 k  c2 Q5 @( t- g& n6 M2 abeginning of this process.1 In the absence of a neg-& s3 @+ b  ~% J7 Z  B& G2 h3 V5 |
ative initial history of androgen exposure, our# T, q7 c- s, l% u! [% |
biggest concern was virilizing adrenal hyperplasia,
' k1 O2 l( J1 J( K, _: C" [either 21-hydroxylase deficiency or 11-β hydroxylase2 |7 W* {! y. r- ?6 v
deficiency. Those diagnoses were excluded by find-
; X3 \% e& v7 [% q  }ing the normal level of adrenal steroids.
9 t" A- U6 O2 @% x( ?The diagnosis of exogenous androgens was strongly+ b- J; d# `! ?% \! C
suspected in a follow-up visit after 4 months because
) y( W, F& d; W) hthe physical examination revealed the complete disap-
& b9 |# S; N- }' o! d) t1 W& qpearance of pubic hair, normal growth velocity, and3 a, m5 {) [$ C9 t1 Y7 C
decreased erections. The father admitted using a testos-7 ^& }5 e( U0 D' b* s6 G$ R
terone gel, which he concealed at first visit. He was  a' z0 P. \( |; g2 v1 ]
using it rather frequently, twice a day. The Physicians’3 t1 R* H/ Q& \, ?' Z# v
Desk Reference, or package insert of this product, gel or
% d- e' {) C* A. u8 T) u( \cream, cautions about dermal testosterone transfer to
1 }/ N8 w8 a  Z1 d6 M1 Z+ Munprotected females through direct skin exposure.* g" o( e  D$ B! @& @) @( f8 F
Serum testosterone level was found to be 2 times the
0 d0 P" \: [* p; V0 i# Gbaseline value in those females who were exposed to
8 H9 L9 _; W6 Feven 15 minutes of direct skin contact with their male# ^( M/ O+ Y( I( q6 H; J/ r
partners.6 However, when a shirt covered the applica-1 t4 i9 K! |  j0 y9 j1 I! [& T
tion site, this testosterone transfer was prevented.
$ O8 f& b! N! y% @Our patient’s testosterone level was 60 ng/mL,- y. M+ I0 d! m8 B0 i- f) y
which was clearly high. Some studies suggest that  T. x, b2 a) g3 _% ]) _( F" G
dermal conversion of testosterone to dihydrotestos-
1 p* A5 x  e* H& \terone, which is a more potent metabolite, is more# R6 d1 H3 ^: O, Y- [
active in young children exposed to testosterone" D7 n& v+ ^+ z$ M0 u3 Q* N* K
exogenously7; however, we did not measure a dihy-0 {. R, T% l" n1 V0 T
drotestosterone level in our patient. In addition to; F. [5 z$ S& p" c5 g
virilization, exposure to exogenous testosterone in, s1 R3 x, j! P: d% z0 k) o
children results in an increase in growth velocity and7 y/ N; F$ Y. P* D
advanced bone age, as seen in our patient.
7 P$ M, ^, ~% d2 n" PThe long-term effect of androgen exposure during
- p. m% q$ P7 A# @1 H" wearly childhood on pubertal development and final
$ W' y  j. j2 K$ radult height are not fully known and always remain9 o) U% o  o7 [/ L$ _' |7 G
a concern. Children treated with short-term testos-
$ p& B0 W0 O+ F5 O% l' o: _terone injection or topical androgen may exhibit some3 e: q$ ~( a* m. u; A5 M# L% K. H
acceleration of the skeletal maturation; however, after3 J% C# P  _0 Q+ X, `2 M# F
cessation of treatment, the rate of bone maturation7 L0 j+ X1 D) B/ i8 k0 x
decelerates and gradually returns to normal.8,9/ w" \& n/ j8 V8 m5 T! e
There are conflicting reports and controversy& g, L# Q( J$ _5 i# ?
over the effect of early androgen exposure on adult
& M% \) R1 d) x9 A* ?& A+ Jpenile length.10,11 Some reports suggest subnormal: a* t1 W" R* P: E4 m
adult penile length, apparently because of downreg-4 B) o0 A$ K2 d. P: T# L
ulation of androgen receptor number.10,12 However,
( a- e, K8 Z0 z+ m- @; i8 r% tSutherland et al13 did not find a correlation between
: F( Z& d7 U2 r: P( i! T6 w# Achildhood testosterone exposure and reduced adult
8 C1 @  e) b2 ]) U0 epenile length in clinical studies.0 [* `9 f8 I2 T
Nonetheless, we do not believe our patient is- y- @2 `8 G, u3 R
going to experience any of the untoward effects from5 u. M0 _, s7 T
testosterone exposure as mentioned earlier because" G, [( q6 i# F/ f
the exposure was not for a prolonged period of time.! ^2 i4 U+ a9 W+ o
Although the bone age was advanced at the time of
$ q2 n" G* G* W* Ydiagnosis, the child had a normal growth velocity at" [2 P# a7 V; L, r2 b1 }/ R7 G
the follow-up visit. It is hoped that his final adult
8 ]. j6 ~3 H: B7 C- q7 p+ Sheight will not be affected.  g+ {* Z6 W0 R
Although rarely reported, the widespread avail-
6 @9 ^- s! P" X$ b& W# f' Xability of androgen products in our society may* p9 f/ p: e& `1 |" ^- _
indeed cause more virilization in male or female
& _- K( {- Z0 O( {1 qchildren than one would realize. Exposure to andro-
% N! S" S) ?( Q! Z- \8 hgen products must be considered and specific ques-8 @" A# t# L9 l$ [5 _
tioning about the use of a testosterone product or
" }% [4 l3 X% [7 Mgel should be asked of the family members during" H7 E0 ]3 e' K5 x! g8 q
the evaluation of any children who present with vir-- r2 u" U0 G! h( J- Y/ E3 K" q
ilization or peripheral precocious puberty. The diag-* Z( E; a+ U4 E9 Y  H( v6 B
nosis can be established by just a few tests and by2 H; w- @: L( V$ R0 Y
appropriate history. The inability to obtain such a" E; g  M' S8 H2 b. I* o$ V' K
history, or failure to ask the specific questions, may
/ }4 T8 B1 Y: O; |& R! ?6 \result in extensive, unnecessary, and expensive
3 G) G8 A6 k7 a" n5 j) I  Dinvestigation. The primary care physician should be$ p' L" |/ ~, S  O* y  l' j+ F; z. r
aware of this fact, because most of these children
& f7 t' A+ s. P- Kmay initially present in their practice. The Physicians’
, T7 d$ C8 W$ k3 Z" J. z" ADesk Reference and package insert should also put a$ l7 U2 g; X6 C, [/ |* b
warning about the virilizing effect on a male or7 A( X0 j7 Z) O3 x9 f! g
female child who might come in contact with some-% L4 _+ A: x- C: B( W1 l" T3 O2 x3 d
one using any of these products.
2 r; c+ @$ }" u8 @References1 s" ?* R/ b' L4 H/ Q5 [
1. Styne DM. The testes: disorder of sexual differentiation8 I8 \# t: S6 }3 l6 y
and puberty in the male. In: Sperling MA, ed. Pediatric
) o! x& [! n, NEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- L% u( z2 [7 ~0 D; `% y2002: 565-628.+ g3 g! X# `) G; ?+ e2 J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' b- u! e' d1 v+ P- [
puberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
7 d5 Z/ M  {7 U2 g; R0 y0 Y% \
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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