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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
. j( B' y6 {. e+ G, }7 k2 n6 CBoy Induced by Indirect Topical! Y7 d+ z" V; ~3 C" t8 `) J* W
Exposure to Testosterone8 G7 o# `& T, y+ {, l/ @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  e+ v3 P4 S! `+ q' n+ r! _3 Yand Kenneth R. Rettig, MD1* l6 S  H3 Q# [0 L: b0 V
Clinical Pediatrics( x( s7 n+ X& q& x& s
Volume 46 Number 66 I, V9 P  z, B" ^* C  o4 K( s
July 2007 540-543. J, ^# R# `  l7 J% e7 V
© 2007 Sage Publications
( D+ I4 x' E# V6 t# v0 k* m10.1177/0009922806296651
  K$ I3 r0 r- Fhttp://clp.sagepub.com1 [# t" e: _- F: L* l
hosted at. c' K+ t3 d2 j# G; y" F
http://online.sagepub.com
( s: h% E# N+ g/ a7 O; j) q% _Precocious puberty in boys, central or peripheral,
: y) E+ ^) b) H, Jis a significant concern for physicians. Central
" r/ c" [2 `/ n3 t5 e6 Sprecocious puberty (CPP), which is mediated6 Z4 g/ L( q, G- E6 @9 P9 l
through the hypothalamic pituitary gonadal axis, has/ p; I3 Q- s$ E7 i
a higher incidence of organic central nervous system) r# t9 ~$ A+ j$ I1 \
lesions in boys.1,2 Virilization in boys, as manifested
8 [. g/ t4 Z! Bby enlargement of the penis, development of pubic
) U0 c" ?6 i, y) `# |+ R" r/ y- l) Whair, and facial acne without enlargement of testi-( K! w" o) w1 f
cles, suggests peripheral or pseudopuberty.1-3 We) ~8 J6 {0 I6 \! A$ l
report a 16-month-old boy who presented with the
  i; k( a; t3 a& d$ x' F1 {8 K/ |enlargement of the phallus and pubic hair develop-
; u  |8 v; l6 p# V: i( i) Tment without testicular enlargement, which was due$ Z& j& Q3 {9 E3 a0 {/ k
to the unintentional exposure to androgen gel used by
$ }! N7 C5 Q* q! ethe father. The family initially concealed this infor-
. v) n- u' n5 }% O$ \mation, resulting in an extensive work-up for this, H, e( A7 `; E, C; N2 x
child. Given the widespread and easy availability of
- N8 c* S7 d! h3 q- Ftestosterone gel and cream, we believe this is proba-1 \' P& M$ e2 `6 q' _) ~7 j( ]
bly more common than the rare case report in the$ K0 X( f6 ?3 X7 C! j% r, r( o+ m
literature.4
; b9 ]5 A- i; p3 r) Q6 pPatient Report; c2 I; \! L: C0 p
A 16-month-old white child was referred to the7 w8 f0 t7 K( R# E7 u
endocrine clinic by his pediatrician with the concern
1 r$ O, m, [/ ~1 k- l7 Zof early sexual development. His mother noticed6 C) `4 s$ D4 G
light colored pubic hair development when he was! ^; t1 p( q  g" I) e
From the 1Division of Pediatric Endocrinology, 2University of# m( U/ a) q: O4 o
South Alabama Medical Center, Mobile, Alabama.& I8 ^! n6 [, U# w* m) k7 x+ W  X. F
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! L( W# q4 A7 X- ]3 Y  j* NProfessor of Pediatrics, University of South Alabama, College of
/ J" d& A/ W9 j0 i; T2 V  a4 xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 B4 I1 ]/ t9 V( \- me-mail: [email protected]., v, r* `% n+ B5 f: J1 O2 N
about 6 to 7 months old, which progressively became
+ w: s8 i1 m9 k3 g' L1 N. ddarker. She was also concerned about the enlarge-6 N) B* V8 f+ n+ m% @- |
ment of his penis and frequent erections. The child' A: }# V6 ~: j6 A
was the product of a full-term normal delivery, with
, a) z6 N7 ?+ X- G0 Ba birth weight of 7 lb 14 oz, and birth length of
) p' x. \( R9 s7 `7 u8 W% ~20 inches. He was breast-fed throughout the first year
- [0 e; I' ^* w: n2 r/ R. _5 Iof life and was still receiving breast milk along with
% @8 }& I' s: O$ U% ksolid food. He had no hospitalizations or surgery,
0 S6 b) ?' h) G# r: band his psychosocial and psychomotor development0 e1 I, ^2 v/ m
was age appropriate.
3 `5 e: F) D! nThe family history was remarkable for the father,
& `& ]' I2 E! U* Q. g( B! K* Jwho was diagnosed with hypothyroidism at age 16,
( l, T, p1 x+ ]9 x4 g0 L( Wwhich was treated with thyroxine. The father’s
7 A  x( M1 s! J1 p) E1 iheight was 6 feet, and he went through a somewhat
/ G& S6 U/ p+ N! P2 A' zearly puberty and had stopped growing by age 14.. G& j  l* g9 z& J3 H8 s2 h' E
The father denied taking any other medication. The
6 R* b+ A& w  S5 [child’s mother was in good health. Her menarche# W& Q8 d; J% n" @
was at 11 years of age, and her height was at 5 feet4 b) _' l: S# I* X- S4 h. {- D
5 inches. There was no other family history of pre-1 Z3 l/ m+ U' \7 K$ M
cocious sexual development in the first-degree rela-! Z3 K2 W" ?0 [% ~
tives. There were no siblings.8 v* s* I8 _* F  t2 m3 J. _
Physical Examination
3 l% j7 h) p- ^The physical examination revealed a very active,$ o9 P! d- p% L8 d1 C
playful, and healthy boy. The vital signs documented' X+ [* x/ }5 J/ `) }
a blood pressure of 85/50 mm Hg, his length was
' F. ?' t. G6 ]2 q; H! }90 cm (>97th percentile), and his weight was 14.4 kg9 L; z1 @/ g% B
(also >97th percentile). The observed yearly growth' G$ a% y% ~% q6 l
velocity was 30 cm (12 inches). The examination of
7 I7 m; M6 a1 v6 g! g& Ethe neck revealed no thyroid enlargement.2 N+ w$ {3 w8 H/ U1 @, g# q: `1 B
The genitourinary examination was remarkable for
$ H1 t: K/ n# F4 T' h4 _1 Henlargement of the penis, with a stretched length of
% N7 h% J- |( t8 cm and a width of 2 cm. The glans penis was very well
$ ~4 f7 }, |1 x2 P1 `developed. The pubic hair was Tanner II, mostly around. Q+ q8 I" s3 G4 W; c8 Q; O" Q$ j; Y5 h
540
" D) w7 I/ K& T/ x  Y1 Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 V0 x, N! e  H, e/ D0 e3 M& Rthe base of the phallus and was dark and curled. The
3 u; S2 x( Y/ ]# f  itesticular volume was prepubertal at 2 mL each." L* Y( y, j1 F  ~1 E4 O7 T
The skin was moist and smooth and somewhat5 z% U; W) V  ~% w4 S) h2 \. j
oily. No axillary hair was noted. There were no
' ]% u% F/ s- o5 @: H5 b$ c$ N" Cabnormal skin pigmentations or café-au-lait spots.' M9 z2 Y9 F) I1 p) g" B
Neurologic evaluation showed deep tendon reflex 2+
. Z( r2 k& N6 ~) u6 Gbilateral and symmetrical. There was no suggestion
- P( `0 _# f8 ~0 K; L; V3 iof papilledema.
, n! W4 f) }6 i+ T- a* s" ]Laboratory Evaluation: y  k) l7 ~" @+ ^" y- ^7 h
The bone age was consistent with 28 months by
6 t5 G  p. D, j7 u; P1 busing the standard of Greulich and Pyle at a chrono-+ s" t8 e5 v' [7 }. l8 e& r
logic age of 16 months (advanced).5 Chromosomal
* w- {1 V6 a' rkaryotype was 46XY. The thyroid function test. u& k5 w5 g. {! ^# D( H7 M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
' R" ]  ]. @! M$ q: b1 alating hormone level was 1.3 µIU/mL (both normal)./ @/ [+ \: F2 _: U8 y. T) A+ c* o
The concentrations of serum electrolytes, blood, [8 S: L* R! _' e
urea nitrogen, creatinine, and calcium all were' ?" a1 {/ r. k  {
within normal range for his age. The concentration  N1 b; H( x8 l5 i! w
of serum 17-hydroxyprogesterone was 16 ng/dL/ p  m6 a5 w* W7 g1 l2 `9 ^
(normal, 3 to 90 ng/dL), androstenedione was 20
% S8 ?: Z; G+ @, sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 ^& U5 E3 f9 r2 Y% ~
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 K- b& V+ Y4 A" Q- N2 Z$ k" I( e
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" q. }+ ~# B& {# b; n$ |49ng/dL), 11-desoxycortisol (specific compound S)& @3 [4 _5 N4 m% m  x  H
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 v) {! [. h5 X) h% b4 H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 q3 d0 N& \) u' Qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% g) Y+ ~$ m7 ?. b0 P7 qand β-human chorionic gonadotropin was less than7 R* b7 u3 F& `! X, q
5 mIU/mL (normal <5 mIU/mL). Serum follicular% |1 p4 s( K+ i1 c+ v
stimulating hormone and leuteinizing hormone9 k# ]2 R0 _1 a7 o) R* b
concentrations were less than 0.05 mIU/mL
" Q/ B9 n; Z/ y* W; F' o" `(prepubertal).
" o) d/ h: b7 D; w/ t/ `! EThe parents were notified about the laboratory
: n: r6 B/ m9 e- c) I  m% @results and were informed that all of the tests were
4 j5 Y8 v0 Y( o" a& c# z# l9 unormal except the testosterone level was high. The
+ y9 H# @$ u/ k: s6 k& e0 T6 L2 ]follow-up visit was arranged within a few weeks to
: q! K4 q& ^: k) gobtain testicular and abdominal sonograms; how-
; |7 T3 {  Y- a! C: gever, the family did not return for 4 months.
1 p. b8 y+ _. \) v% ^  SPhysical examination at this time revealed that the
$ T# f# V, j# y3 jchild had grown 2.5 cm in 4 months and had gained
0 t" S5 B+ H& N4 Y4 ^+ \" w& m2 kg of weight. Physical examination remained% a0 e; V$ m; j# r# T) i' E% F
unchanged. Surprisingly, the pubic hair almost com-3 m+ }6 t3 `" |* ~1 P; ~  ^- N
pletely disappeared except for a few vellous hairs at! U' }( V+ y, O
the base of the phallus. Testicular volume was still 24 m# t1 r3 n! a. W
mL, and the size of the penis remained unchanged.
, {# ?) T" p) b, C7 J1 tThe mother also said that the boy was no longer hav-2 T: T! S: h. I. h, f& i% @
ing frequent erections.4 G8 j3 W" ]" d' ^$ r
Both parents were again questioned about use of' H/ k( o  ]4 i7 ^4 W- I
any ointment/creams that they may have applied to5 E, M/ R( N9 `2 R) J3 f% Z8 D
the child’s skin. This time the father admitted the! l& c) U1 s8 B. f1 o3 F" {' u
Topical Testosterone Exposure / Bhowmick et al 541
1 {; e. E. J. V, ~+ J4 xuse of testosterone gel twice daily that he was apply-
# s( ^  L6 k2 F9 |ing over his own shoulders, chest, and back area for
- K6 G/ s& a  r  Aa year. The father also revealed he was embarrassed1 n: g- d' e- O
to disclose that he was using a testosterone gel pre-4 p! R; E0 e5 H
scribed by his family physician for decreased libido4 l8 W2 y" H. E
secondary to depression.
. ?6 W# X/ {" Q. R# f! s5 qThe child slept in the same bed with parents.
1 e8 i$ M/ }" F; j0 t0 gThe father would hug the baby and hold him on his' ^( O0 i6 n6 N
chest for a considerable period of time, causing sig-
- P" Y5 S3 o) D4 Tnificant bare skin contact between baby and father.
2 X9 h. R* I2 H* ZThe father also admitted that after the phone call,
) t1 x) b1 }' b% Uwhen he learned the testosterone level in the baby
" E  g% f9 O0 L7 h# C, E' Jwas high, he then read the product information
+ K! Q5 k" i- r. J: M7 [5 Spacket and concluded that it was most likely the rea-
8 g& @7 c2 F, b9 A+ b6 ?8 ]son for the child’s virilization. At that time, they
) s2 `( [  }3 `$ I3 L+ Z# Ndecided to put the baby in a separate bed, and the
  a' I  G$ X2 Z2 w4 [/ d8 ?# y# y; }father was not hugging him with bare skin and had* F' D" T& L4 E9 l
been using protective clothing. A repeat testosterone. O  p( V% z: _8 b0 X$ s
test was ordered, but the family did not go to the
1 @) T& N' s9 C' ?, {laboratory to obtain the test.1 q7 T% u+ z- ]/ \! s( g/ O3 c
Discussion% l$ l7 @  a/ v2 ]7 Z3 r
Precocious puberty in boys is defined as secondary' |! b( i9 F3 O7 |& ~
sexual development before 9 years of age.1,4
: |$ I/ H: S! K$ _- A& P8 P* T6 dPrecocious puberty is termed as central (true) when$ c) D) n1 s% T8 V6 i
it is caused by the premature activation of hypo-- C% }3 V0 B* Z# G3 K9 U
thalamic pituitary gonadal axis. CPP is more com-
; J- ~5 D3 w; _  r4 a  pmon in girls than in boys.1,3 Most boys with CPP
5 O5 R  o8 t9 n5 Imay have a central nervous system lesion that is
" e/ ]$ w# s/ g! ?/ Yresponsible for the early activation of the hypothal-
; D5 u" T  M" Xamic pituitary gonadal axis.1-3 Thus, greater empha-
) o, V2 v) v% Qsis has been given to neuroradiologic imaging in/ Y* v& g8 y8 t1 d# S" _. X
boys with precocious puberty. In addition to viril-/ S# O0 e9 I' U. q; N
ization, the clinical hallmark of CPP is the symmet-! \) p0 T, P' |) |
rical testicular growth secondary to stimulation by
8 |& I# z. U* O  L; t; Lgonadotropins.1,3
) s! d$ l* y# d! v3 [. wGonadotropin-independent peripheral preco-" Z" p. p4 P3 r
cious puberty in boys also results from inappropriate) t! H: B; m; ^
androgenic stimulation from either endogenous or
' H2 G* s% m1 }6 C& K& Uexogenous sources, nonpituitary gonadotropin stim-
! a9 O! I% V1 N% n* r6 wulation, and rare activating mutations.3 Virilizing
7 i2 |: p$ A. y5 M* l+ Z1 Q; e5 t7 m! Tcongenital adrenal hyperplasia producing excessive) Z, f$ O; S) M$ J3 H5 M# I' Z# b: V+ t
adrenal androgens is a common cause of precocious$ R+ k  Y! }7 _( i$ B+ [
puberty in boys.3,4
! F4 }& T+ E2 z% O# _1 XThe most common form of congenital adrenal# l1 D- Z1 Y1 H$ t% v& G
hyperplasia is the 21-hydroxylase enzyme deficiency.0 n* d" z- ^( ]6 P" l3 Z
The 11-β hydroxylase deficiency may also result in
& }2 x9 w+ z& I6 K/ r0 zexcessive adrenal androgen production, and rarely,+ O% V! @. M, T4 u" `( R. ?% Y
an adrenal tumor may also cause adrenal androgen- J/ j* [* g6 b% K* T: o% n
excess.1,34 m" N. j7 t1 _) l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; A$ B3 ^: K! P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( a! V4 h( B" H- n2 I
A unique entity of male-limited gonadotropin-
3 t5 ~6 m8 A7 t3 I4 \independent precocious puberty, which is also known. [# L# V  d( v
as testotoxicosis, may cause precocious puberty at a
, v( D7 L5 p2 k9 nvery young age. The physical findings in these boys
! n' N) J0 C5 r/ Fwith this disorder are full pubertal development,7 U( J. x, d' I& E$ M- l
including bilateral testicular growth, similar to boys
( r; K) O! ^# L# e! Pwith CPP. The gonadotropin levels in this disorder
+ H( Q' j! A  c+ e5 Sare suppressed to prepubertal levels and do not show1 t9 q3 \6 W; g2 o) S+ g' w! m3 |  H8 N
pubertal response of gonadotropin after gonadotropin-. o' M3 a2 k. Q+ U
releasing hormone stimulation. This is a sex-linked
+ [- _9 w7 M7 B- Pautosomal dominant disorder that affects only. l2 @6 f' i. x' ?' {
males; therefore, other male members of the family# e0 ^( E0 \: n. f( w
may have similar precocious puberty.3
1 @; G5 a0 {3 J2 c9 uIn our patient, physical examination was incon-
* i5 }- T5 x4 k. l! Vsistent with true precocious puberty since his testi-3 m2 B3 M0 T/ \% s  B7 J
cles were prepubertal in size. However, testotoxicosis
' O) C8 j+ j; P6 @was in the differential diagnosis because his father0 _( `" p8 W% R% K4 `
started puberty somewhat early, and occasionally,+ _2 t2 l2 `0 ^& W% V$ w- W
testicular enlargement is not that evident in the
' o0 e4 Q( {' [2 ^- Dbeginning of this process.1 In the absence of a neg-
+ B, j( d& p# Dative initial history of androgen exposure, our( K; R0 c& x+ E1 E/ N" Z
biggest concern was virilizing adrenal hyperplasia,
' ]* M/ G, e8 F' ieither 21-hydroxylase deficiency or 11-β hydroxylase; o8 F6 M( Z  b7 w
deficiency. Those diagnoses were excluded by find-
9 f; U. f% {( z7 s/ F5 X! e( {ing the normal level of adrenal steroids.. D* ~7 p- h7 F; ]" b/ [1 z
The diagnosis of exogenous androgens was strongly" E, n$ j$ U5 S6 T4 U7 o
suspected in a follow-up visit after 4 months because4 }1 [# `$ `# K4 c& S
the physical examination revealed the complete disap-
. l7 }9 x- Z8 i- L6 h/ i8 hpearance of pubic hair, normal growth velocity, and
4 b% W! J6 }/ u6 D% L3 v% r- v" @decreased erections. The father admitted using a testos-
$ S. Z& u* p' \( e! l+ Kterone gel, which he concealed at first visit. He was
. o2 R, u" ~+ K( U7 b4 vusing it rather frequently, twice a day. The Physicians’6 m, |7 W9 c$ Q3 f4 r
Desk Reference, or package insert of this product, gel or4 C8 u4 p/ |# c- W- x" C( g4 X
cream, cautions about dermal testosterone transfer to
# n4 @: K& c, x( \% U& eunprotected females through direct skin exposure.
( c) m% k& g3 c8 c" rSerum testosterone level was found to be 2 times the4 E2 q; ]) S0 g8 G! Z0 m$ A2 @
baseline value in those females who were exposed to
9 Z5 P( c; z' heven 15 minutes of direct skin contact with their male
" f' O, x9 w7 r& `; X3 @partners.6 However, when a shirt covered the applica-
8 d( \; v6 k" J  _tion site, this testosterone transfer was prevented.
* [3 N' p7 t9 \, l# L3 r' h( vOur patient’s testosterone level was 60 ng/mL,) V1 B  F( e6 ]- f; h8 A
which was clearly high. Some studies suggest that% W; d+ x. Z" n) K. B/ M
dermal conversion of testosterone to dihydrotestos-
4 j5 z* _5 r7 f: D, z" _terone, which is a more potent metabolite, is more
( }  q8 d  Z5 v- _) d  A+ c( Nactive in young children exposed to testosterone
1 L- I. M2 Q0 v8 vexogenously7; however, we did not measure a dihy-
- f. _8 h% k8 ^9 e5 ~drotestosterone level in our patient. In addition to6 }3 V: z0 C! [# M
virilization, exposure to exogenous testosterone in
9 u  z1 A* Z! f4 L  Uchildren results in an increase in growth velocity and
! f' P7 b! t& h; H' iadvanced bone age, as seen in our patient." a8 o, J4 }4 A/ v% h+ c
The long-term effect of androgen exposure during
7 J/ A& m8 t# F# f& l+ Gearly childhood on pubertal development and final# x+ R# P: o- x' p4 z/ w' |
adult height are not fully known and always remain3 `( K, Q0 [% u' W4 F) C
a concern. Children treated with short-term testos-, Y  t2 P% Z: _6 k; E
terone injection or topical androgen may exhibit some7 g# \' c7 c; Q$ P
acceleration of the skeletal maturation; however, after
& |( D7 S9 i! ~9 f6 U4 acessation of treatment, the rate of bone maturation: S  b# ^1 ]! W1 D1 |
decelerates and gradually returns to normal.8,9) e' q0 ?! _' R: v$ Y( N" `: K8 L. F' ?
There are conflicting reports and controversy& b/ @) }# l5 P5 ~9 }$ I' K
over the effect of early androgen exposure on adult; D7 y7 R$ i7 d1 Z6 y0 M2 V
penile length.10,11 Some reports suggest subnormal- O" P) z2 V+ @$ D- l3 {
adult penile length, apparently because of downreg-
. Q6 y/ D! U9 b6 K- u( m. X  Julation of androgen receptor number.10,12 However,
9 Q2 c4 G2 n7 O; n/ uSutherland et al13 did not find a correlation between- J1 D8 F- ~( E+ P' x5 a
childhood testosterone exposure and reduced adult: U; h" S/ M7 O7 z8 [2 w7 s. V
penile length in clinical studies.2 N2 ?6 R' C2 D2 l+ ]
Nonetheless, we do not believe our patient is
5 V) w& m3 e2 o) M- J! W6 T) Agoing to experience any of the untoward effects from1 S0 F  J% B; [/ Z3 k9 u
testosterone exposure as mentioned earlier because
+ [! Q& U! x5 T" l( othe exposure was not for a prolonged period of time.
. u1 @3 Y' \+ E0 f3 M) Q5 d: DAlthough the bone age was advanced at the time of
2 T" J! r9 Q5 Y1 C, gdiagnosis, the child had a normal growth velocity at0 I- C7 ^. l. I0 W7 C7 b
the follow-up visit. It is hoped that his final adult
. f5 z+ X* g( j1 _* e7 ~height will not be affected.1 s" d) J# F0 A6 @! g+ d- h
Although rarely reported, the widespread avail-) Q5 e( {' f$ L0 L. [
ability of androgen products in our society may6 v6 v, M! W+ _; @3 L2 w9 E( r* c
indeed cause more virilization in male or female; _% Z7 Q! J" T3 t8 `
children than one would realize. Exposure to andro-
- E0 ^9 F, e% Z% }' \, S* \gen products must be considered and specific ques-, b+ y4 R$ X4 f2 J2 T* c* e
tioning about the use of a testosterone product or2 N7 S0 {% {+ P6 ~0 A
gel should be asked of the family members during
, _$ `; w- B$ h/ jthe evaluation of any children who present with vir-, d! {" j( T0 H) e( m% T6 a
ilization or peripheral precocious puberty. The diag-$ I& s" e8 x& o- ~9 y" d
nosis can be established by just a few tests and by# u* |  L: M& `5 e. ]) b
appropriate history. The inability to obtain such a
( p% ?3 D7 I+ K: i  J0 H$ vhistory, or failure to ask the specific questions, may
' w1 @1 V/ X7 c* ^8 c& s, mresult in extensive, unnecessary, and expensive
. P& O; [7 b8 g9 ^investigation. The primary care physician should be' [( c2 `9 Y; i; i7 F4 u: |
aware of this fact, because most of these children
# O  [$ r" U4 ~" Fmay initially present in their practice. The Physicians’9 M/ J0 U- n; H
Desk Reference and package insert should also put a% j% _' a. V/ N$ \
warning about the virilizing effect on a male or
" U4 j9 x+ w* P* f5 U: d8 afemale child who might come in contact with some-
1 B- I0 B  B( wone using any of these products.  |4 I5 {6 @; D  i
References: v& S; K1 ?+ \
1. Styne DM. The testes: disorder of sexual differentiation% X) e# b; u8 \" i
and puberty in the male. In: Sperling MA, ed. Pediatric
  X4 ^7 s) Z. CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. g8 w( D: J  t3 h: E* x1 Q2002: 565-628.( L+ r- t' v# A$ v4 L$ D! ]3 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! X1 [2 h! ~( m% I2 Q+ y& [
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 D$ ^) e8 u. |5 |. w3 `Boy Induced by Indirect Topical2 Z$ p8 r. [# Y% _; E# I
Exposure to Testosterone% g0 K! M. U1 p7 e4 i9 y% E1 Q7 b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# S0 P& k: O7 q8 Nand Kenneth R. Rettig, MD1% }3 F- \3 E0 C- x
Clinical Pediatrics" j/ `4 G2 c' D4 X
Volume 46 Number 6' z2 p$ I2 B1 f! S' M: S) |' W
July 2007 540-543
& O& s' l# s4 v  T; j© 2007 Sage Publications
6 H+ h8 T, y( ]* t10.1177/0009922806296651
3 f4 b0 i) e' F/ ohttp://clp.sagepub.com6 N& z+ M5 M- [5 n8 o) l
hosted at' E9 {( u: ]& X1 G: z$ y) t
http://online.sagepub.com
6 R1 z# j1 j( |4 h- EPrecocious puberty in boys, central or peripheral,1 L4 c3 ]; X8 x& F1 A4 m% G
is a significant concern for physicians. Central
/ X) g; x6 j/ X  z! Q% @8 xprecocious puberty (CPP), which is mediated5 d  e! P, \- n' ~
through the hypothalamic pituitary gonadal axis, has3 c, J8 E) O3 @- ^* ]$ j
a higher incidence of organic central nervous system
7 F- I5 a+ N# U5 ^7 y' P8 }lesions in boys.1,2 Virilization in boys, as manifested
+ ?( [5 F5 e' i6 A# _: bby enlargement of the penis, development of pubic
0 C- d3 h& p; x2 ?hair, and facial acne without enlargement of testi-
  n; g5 ^1 b6 o! acles, suggests peripheral or pseudopuberty.1-3 We
* [9 p( m8 Y( }2 ^- l* freport a 16-month-old boy who presented with the
7 L; K3 ?; W" r+ G' |7 `enlargement of the phallus and pubic hair develop-7 o8 N+ o: c$ l9 v: x" ?
ment without testicular enlargement, which was due
# `4 ^' v9 l. y* w- Kto the unintentional exposure to androgen gel used by
- X5 {3 E& g( A- C0 v: I5 h% _0 Vthe father. The family initially concealed this infor-* Z" M; J2 u+ V+ d
mation, resulting in an extensive work-up for this: k3 V+ `! c+ {7 q- a# c) l# ~9 B- u
child. Given the widespread and easy availability of/ ?: \+ ^6 s- F  v
testosterone gel and cream, we believe this is proba-
" Z6 ?2 y+ s% R5 b+ o+ @bly more common than the rare case report in the
) B# C$ ~0 _! y- Wliterature.4
' G0 S7 H1 ]  L1 QPatient Report+ `# ~( K* R/ b
A 16-month-old white child was referred to the
+ D) o# k1 Y/ t# kendocrine clinic by his pediatrician with the concern( f4 R9 M6 U3 c6 m# i) ?) [
of early sexual development. His mother noticed
, N# O* @0 D" B: n; r7 Hlight colored pubic hair development when he was; b( e; B* b; X  C3 f( W. b2 Y% ^
From the 1Division of Pediatric Endocrinology, 2University of
: P9 u) k  v) w& e% O0 {  G+ oSouth Alabama Medical Center, Mobile, Alabama.
+ e& k7 }* V, w" @; L% t  p# aAddress correspondence to: Samar K. Bhowmick, MD, FACE,& T8 a8 U/ a8 _- P# H
Professor of Pediatrics, University of South Alabama, College of
& T% j4 O& N) OMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  b9 j5 n, r9 z# X/ ]7 E
e-mail: [email protected].
# N5 {  c7 [0 u- n" k( kabout 6 to 7 months old, which progressively became7 h/ v5 L" _- B8 |. @6 C3 _
darker. She was also concerned about the enlarge-
1 s/ c$ m- K: R0 s5 Hment of his penis and frequent erections. The child4 P$ T+ Z7 c- T5 q6 f; a
was the product of a full-term normal delivery, with9 A4 M8 T+ K; S! I3 l8 J
a birth weight of 7 lb 14 oz, and birth length of
% ~( n$ ~* `* m7 l! O6 {- L/ a20 inches. He was breast-fed throughout the first year
- f$ m, G" P& [: F( Z; hof life and was still receiving breast milk along with' Y' s6 A! Z4 A! |
solid food. He had no hospitalizations or surgery,
* F+ q( Y- l6 Hand his psychosocial and psychomotor development
) m/ E# g3 Q5 X& |# twas age appropriate.+ q. Y  t2 S& |3 l9 R  u3 g
The family history was remarkable for the father,! ^4 P. {2 |/ b
who was diagnosed with hypothyroidism at age 16,
1 g5 W0 V/ Q; V2 w6 }( Ewhich was treated with thyroxine. The father’s0 f4 B! ^0 Y1 w5 N- f) ?
height was 6 feet, and he went through a somewhat# j) N$ R! S6 u* q% S# V) V
early puberty and had stopped growing by age 14.8 T" `3 ~/ x) c  O) ^
The father denied taking any other medication. The" b5 }  f% b) X5 C1 z* a3 a
child’s mother was in good health. Her menarche# k) P  F# \4 O3 O" F8 J
was at 11 years of age, and her height was at 5 feet0 G8 S1 V! H- ?8 B$ e# J( s
5 inches. There was no other family history of pre-7 C. ^1 @% E3 w
cocious sexual development in the first-degree rela-' a) x/ p! W, i, a3 _6 [: C% d1 Y
tives. There were no siblings.
* p: l0 x) W. _# ?% sPhysical Examination
, e6 D3 `4 W, l: g% R, B$ lThe physical examination revealed a very active,* V0 s5 x  }) |3 E
playful, and healthy boy. The vital signs documented
1 U: x; w1 G3 Z' q" U0 pa blood pressure of 85/50 mm Hg, his length was8 x0 C3 _0 E9 ]! |7 l
90 cm (>97th percentile), and his weight was 14.4 kg
1 a" _5 `* h. w9 }7 u; l(also >97th percentile). The observed yearly growth: K# y+ @! f; d- h1 i6 y8 a* y
velocity was 30 cm (12 inches). The examination of4 A/ B" D2 c+ n
the neck revealed no thyroid enlargement.# u2 l6 v: }7 c# {9 ]
The genitourinary examination was remarkable for
6 d! x, G7 l. v  w& j3 }enlargement of the penis, with a stretched length of& B. u& K; f' `& d
8 cm and a width of 2 cm. The glans penis was very well" p& I$ C" M4 A% u* y6 e2 s" _
developed. The pubic hair was Tanner II, mostly around  M( j& E! J+ U; L8 g
540
0 w; d. z  W9 x) l# Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. p' j8 s& E, J/ |9 A) ~% M
the base of the phallus and was dark and curled. The) B9 f) L4 Y7 D6 c8 J2 I6 S$ W
testicular volume was prepubertal at 2 mL each.
& J) `' o2 j2 r! L1 DThe skin was moist and smooth and somewhat
% A$ Z) H3 m3 W, @) F: Zoily. No axillary hair was noted. There were no
$ T2 ~+ \% t9 K8 W: F; v6 w& q& A% Labnormal skin pigmentations or café-au-lait spots.
9 ]8 Q% P& p5 ?$ f2 ?% O0 GNeurologic evaluation showed deep tendon reflex 2+, D. p8 {) d% _0 D. {
bilateral and symmetrical. There was no suggestion
" n- ^2 o! F- B0 _of papilledema.: a- q# T3 U2 w/ ^5 M" B: I
Laboratory Evaluation
$ u/ a8 z$ b* ]* E0 S) ~$ ?7 XThe bone age was consistent with 28 months by
$ c6 g) E% z: ~; nusing the standard of Greulich and Pyle at a chrono-
$ \( B7 Q3 w+ J$ {+ |% @/ m  ]1 Klogic age of 16 months (advanced).5 Chromosomal
, j' i, @, R+ rkaryotype was 46XY. The thyroid function test
, q3 O+ _( N1 ], O! K0 `; |8 N, s2 }showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* e, f4 R& L  b. c8 dlating hormone level was 1.3 µIU/mL (both normal).
9 Y( I" F) M$ @3 A+ p6 tThe concentrations of serum electrolytes, blood
5 i3 V1 Y) o0 _' j- ]% o. Hurea nitrogen, creatinine, and calcium all were
8 W" I) a/ z% W5 w5 }( ]within normal range for his age. The concentration$ Q9 z& Q* ~; s1 F
of serum 17-hydroxyprogesterone was 16 ng/dL4 _3 J- I0 ^" C1 @1 Q. Q4 w/ h$ U
(normal, 3 to 90 ng/dL), androstenedione was 20
3 t9 n# |& ~- \0 rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& B/ T5 t5 `  F$ B( L# Q3 G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 E' r) S! Y; G; |8 P7 n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 x2 q7 R0 y2 ~; x49ng/dL), 11-desoxycortisol (specific compound S)# ~/ x% O4 [) b# d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! g( `# O6 X1 F$ R( d. x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ a' p# Z/ \" T& j! \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),  H  H9 b' j7 y% N
and β-human chorionic gonadotropin was less than
) e  K& }. r( ^0 q1 j! D5 mIU/mL (normal <5 mIU/mL). Serum follicular2 \; _4 h3 W+ U) p3 x+ E. r" f
stimulating hormone and leuteinizing hormone
4 U& v1 q% p" s- T' z, gconcentrations were less than 0.05 mIU/mL
- l$ O1 _# [. }! M& r* A(prepubertal).
5 }/ _1 {1 ]% s; w$ t8 XThe parents were notified about the laboratory
6 W3 q6 A. ]+ P+ j/ lresults and were informed that all of the tests were
1 r) E' a8 z4 c. d2 @6 e, }( B: \normal except the testosterone level was high. The
" P- c+ b$ L6 F. g: W. sfollow-up visit was arranged within a few weeks to' r3 c8 c0 A% s
obtain testicular and abdominal sonograms; how-; z; `! m) z- q9 q' N: z/ {
ever, the family did not return for 4 months.; S7 y( |7 g8 c; B" W
Physical examination at this time revealed that the
* o2 I/ ~% w/ G9 ~child had grown 2.5 cm in 4 months and had gained" J$ t- Z/ o2 }' D- X
2 kg of weight. Physical examination remained
* @5 }- J, z6 Runchanged. Surprisingly, the pubic hair almost com-
+ f6 y2 C) W- }! Y* `! vpletely disappeared except for a few vellous hairs at' Q$ [+ X: S1 n& z3 q( E
the base of the phallus. Testicular volume was still 2* N' q6 M  Z) |0 h7 d# F* R
mL, and the size of the penis remained unchanged.6 K0 z; N: L0 {! T) ^
The mother also said that the boy was no longer hav-+ C7 u% [% O7 A
ing frequent erections.' q& G' N8 f# K) O
Both parents were again questioned about use of/ I; m- S# E" [' b
any ointment/creams that they may have applied to4 d: d8 ?+ e) O( S- l; u! {: m) ^
the child’s skin. This time the father admitted the  A* N+ Y3 M9 g9 [- M/ U/ R8 j3 N9 B- j
Topical Testosterone Exposure / Bhowmick et al 541
. p- j3 t+ R, Y4 J4 Wuse of testosterone gel twice daily that he was apply-
5 P& X  E4 r0 F, r2 O  {7 Cing over his own shoulders, chest, and back area for
( l$ n8 `# B* `, W( i) c9 K! K# ]a year. The father also revealed he was embarrassed2 w: P" s) P/ M1 `/ J, `
to disclose that he was using a testosterone gel pre-
  i# L, x9 d+ E( E5 z' hscribed by his family physician for decreased libido% i5 x! l+ k1 N! b$ W7 ?, m
secondary to depression.
9 y0 K) J1 Y* q0 E, ?/ SThe child slept in the same bed with parents.
( j! u4 _) J/ e8 a) ?7 BThe father would hug the baby and hold him on his
% h5 F% R0 g+ d  m5 Fchest for a considerable period of time, causing sig-0 E/ U' ?$ d5 D/ A
nificant bare skin contact between baby and father.# K8 T) U4 d$ o2 Z/ x* s% B( k
The father also admitted that after the phone call,' L; u0 }6 r' V9 O9 G
when he learned the testosterone level in the baby
5 Q7 j- P5 |! r4 V6 C/ Iwas high, he then read the product information
5 P; ?3 T5 o2 L) X8 Gpacket and concluded that it was most likely the rea-
0 R2 \: S8 e' Q/ ~, _son for the child’s virilization. At that time, they: }' W6 c& I* k9 Z5 `) `7 }! a
decided to put the baby in a separate bed, and the7 M5 K: }' [( J$ N( ], A! d
father was not hugging him with bare skin and had1 t! A& L  ?3 u! p  ^0 m
been using protective clothing. A repeat testosterone
2 h- e5 ]( v1 r1 Htest was ordered, but the family did not go to the
" |) w" \0 g- u% j* ]laboratory to obtain the test.
5 E, W6 ^" |: ]1 dDiscussion
! p! e$ v5 r4 f/ V3 lPrecocious puberty in boys is defined as secondary
8 }3 [7 l: x$ ?4 n/ hsexual development before 9 years of age.1,49 d; o- S  h0 J5 q' P* O
Precocious puberty is termed as central (true) when
& D: `! I$ P  V# U7 Git is caused by the premature activation of hypo-- w: Q' r3 g& P  j( N) B/ }
thalamic pituitary gonadal axis. CPP is more com-
, S9 X1 n, g1 R3 q; _mon in girls than in boys.1,3 Most boys with CPP
# y: L  T( r% x: W: ?; q- Rmay have a central nervous system lesion that is
/ N6 k7 }5 W" Z( vresponsible for the early activation of the hypothal-& O: f/ Z# K  J# x7 b1 D2 }
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ z% A1 B' }$ |! }& E, Ssis has been given to neuroradiologic imaging in
# |) Z$ U3 [7 U: F0 O3 D' J* h1 ]boys with precocious puberty. In addition to viril-* P5 d5 M+ R) L, s/ l' ?
ization, the clinical hallmark of CPP is the symmet-6 F8 D8 U( C6 [9 E) `8 _  G
rical testicular growth secondary to stimulation by; _& M: f7 I2 [
gonadotropins.1,3: X7 X# r; H/ H3 F" a( i  ?
Gonadotropin-independent peripheral preco-  P. I/ J* B# L" a' G
cious puberty in boys also results from inappropriate
# S! A) Z( |2 T, B8 l0 r" C0 tandrogenic stimulation from either endogenous or( W4 V7 l  U! ]! d% w4 a& r* G
exogenous sources, nonpituitary gonadotropin stim-5 K) g* K% X) ^' {) j; f# P  @
ulation, and rare activating mutations.3 Virilizing6 I8 V6 T' }6 Y; c7 Y$ Y
congenital adrenal hyperplasia producing excessive
6 |- X, F, t* j$ X' x2 {: k- G7 xadrenal androgens is a common cause of precocious( t5 I+ b4 ~2 @0 v7 e) }
puberty in boys.3,4, Q3 h4 j$ r$ n$ ^( ]' F
The most common form of congenital adrenal
; `; s9 q# s; X2 G* r& J& ?* Rhyperplasia is the 21-hydroxylase enzyme deficiency.) y+ V5 k$ u" C1 _! p
The 11-β hydroxylase deficiency may also result in4 X! e$ ~0 z8 P: F. k% G
excessive adrenal androgen production, and rarely,
" Q& U9 H/ n$ a% @3 J8 s* {an adrenal tumor may also cause adrenal androgen. d, _+ g9 }4 G5 |
excess.1,3+ F+ t* A. u7 m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ ]( |2 O" K9 i$ A- f+ a) \, s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 Q$ E& P4 |* F1 ~5 B( D! H8 FA unique entity of male-limited gonadotropin-" _( k/ ?( K3 M+ T4 Z
independent precocious puberty, which is also known
) u/ d' m1 l: E% ~! J; L: _as testotoxicosis, may cause precocious puberty at a3 @/ _' u% [! Q+ {& ?. W  K
very young age. The physical findings in these boys$ @- r6 E( a* Y3 r1 n: X% ^
with this disorder are full pubertal development,
* M( g8 K  m7 c2 W9 z; _including bilateral testicular growth, similar to boys
3 A) A8 p$ y( `/ v$ U3 D* A/ T$ m4 L3 f$ Hwith CPP. The gonadotropin levels in this disorder
5 d) n2 S, r% M% care suppressed to prepubertal levels and do not show
  x5 ]/ L; f" l1 Y9 f+ s( gpubertal response of gonadotropin after gonadotropin-
% z  |9 `% P; O9 p- }8 treleasing hormone stimulation. This is a sex-linked$ {- o. u4 e, K% Q. e8 T. b
autosomal dominant disorder that affects only
8 y6 R+ ]1 z3 f, x$ g3 f6 \males; therefore, other male members of the family
! ~3 M* D9 _% W5 o( S* Amay have similar precocious puberty.3
- w! Y0 {$ u7 b! B+ Y( r' n2 s$ |; }In our patient, physical examination was incon-
$ y: ?4 ~/ b0 W% W0 c9 \* Lsistent with true precocious puberty since his testi-
% n, Q- }6 G3 K2 j7 E; d0 Bcles were prepubertal in size. However, testotoxicosis% G9 Y* H) |$ ?0 n. C2 a6 g, k7 Q
was in the differential diagnosis because his father" C( [8 [* J! Y8 R2 z
started puberty somewhat early, and occasionally,! l' [  ]/ Q$ x5 U
testicular enlargement is not that evident in the
9 |- ]9 A* S/ R: Cbeginning of this process.1 In the absence of a neg-
' z( ^. v; u6 ~ative initial history of androgen exposure, our
' x9 s( ?1 D0 h8 I+ q/ I" Xbiggest concern was virilizing adrenal hyperplasia,
* l* Z% Y, I2 `+ teither 21-hydroxylase deficiency or 11-β hydroxylase
7 s6 L+ T5 s9 ]deficiency. Those diagnoses were excluded by find-$ I, W) f" F$ T( I9 g9 p2 P: G
ing the normal level of adrenal steroids.
: y) B3 y/ M6 q: i) |The diagnosis of exogenous androgens was strongly$ \# b; o+ o/ G7 M3 V2 U) t
suspected in a follow-up visit after 4 months because
8 t. ?6 \3 ^9 A$ b/ P) O; f8 }the physical examination revealed the complete disap-
! ?9 Q0 e8 F3 G$ A; H- ^9 ?pearance of pubic hair, normal growth velocity, and
$ i  r+ r: E4 j9 y9 \& ~7 ~8 Gdecreased erections. The father admitted using a testos-
- F) p: F; x) r2 V7 \" Xterone gel, which he concealed at first visit. He was
2 i, o; C! i0 l  E  A# susing it rather frequently, twice a day. The Physicians’
# I5 i7 s" l" z" ?0 a! RDesk Reference, or package insert of this product, gel or5 ?3 O, _0 `. V- z0 ?
cream, cautions about dermal testosterone transfer to
& l/ l7 q# |" @0 n7 E9 zunprotected females through direct skin exposure.' S& m! c: q2 l5 F' C- @. H/ r" D- z
Serum testosterone level was found to be 2 times the; L8 g$ `) [' h8 A  U
baseline value in those females who were exposed to
  c/ V1 U9 e- o1 w) |$ Zeven 15 minutes of direct skin contact with their male& K4 _7 p! n. H( }  i  @- z
partners.6 However, when a shirt covered the applica-
. ?5 B2 M/ _7 C3 G1 G! Q0 Z3 [tion site, this testosterone transfer was prevented./ E7 m) E; o& h0 Q5 S( r
Our patient’s testosterone level was 60 ng/mL,! j* r: N' ~0 P3 O$ C* N
which was clearly high. Some studies suggest that
4 ^- v" F) P# hdermal conversion of testosterone to dihydrotestos-
  [% y) O+ t) M7 F' F0 A. bterone, which is a more potent metabolite, is more6 f7 y  k+ ~; M4 K' f( r
active in young children exposed to testosterone2 {4 n* }- i3 c
exogenously7; however, we did not measure a dihy-
, P  \/ q! x$ F6 q* V; Sdrotestosterone level in our patient. In addition to
( |+ ?( @5 H0 Y/ y: S9 [) z: Gvirilization, exposure to exogenous testosterone in
+ i& \7 b3 M, T2 B2 m5 echildren results in an increase in growth velocity and
. ~# U* o- g8 H, p% oadvanced bone age, as seen in our patient.  V2 T" I1 w. ]" Q7 ~
The long-term effect of androgen exposure during
- T" Y# F9 W0 s& d0 `( \early childhood on pubertal development and final7 I( N6 o( i2 b; O/ p
adult height are not fully known and always remain
2 G& g# Q( b: q. Ma concern. Children treated with short-term testos-4 [6 ?; B. l  I, T- `) N/ r6 x4 d% Z
terone injection or topical androgen may exhibit some
) n" `! u2 ]3 A% i! macceleration of the skeletal maturation; however, after% K; {/ K8 m; `& R$ {+ y! E
cessation of treatment, the rate of bone maturation
- ^& U* X" |: a; ?decelerates and gradually returns to normal.8,9  G# A; m0 N! Q4 f/ a0 w' Y
There are conflicting reports and controversy% A+ Y6 Q1 Z# Z
over the effect of early androgen exposure on adult' J" e3 ]* b$ v4 w9 I! m
penile length.10,11 Some reports suggest subnormal
4 n! {$ G) W/ t' Xadult penile length, apparently because of downreg-8 W8 Z# N3 m2 i& K( p# y
ulation of androgen receptor number.10,12 However,
1 ^# v3 Q1 L: I" [! j* G2 |0 z6 sSutherland et al13 did not find a correlation between' D7 I1 X' `4 {3 ]  V+ {/ Y
childhood testosterone exposure and reduced adult$ }: n4 P; L4 m/ }
penile length in clinical studies.; m/ \; _3 G' }! E' V! E* j
Nonetheless, we do not believe our patient is
( M; D8 y7 k* V- ~going to experience any of the untoward effects from
3 i* [! J0 }$ s8 q# U7 wtestosterone exposure as mentioned earlier because9 E% C* M, _2 D: }- w
the exposure was not for a prolonged period of time.
& T& h9 P9 r: z  a: A/ n8 m$ c; PAlthough the bone age was advanced at the time of2 O: k* C1 {; O6 q
diagnosis, the child had a normal growth velocity at
2 G  j6 q/ z0 b7 |, n2 Tthe follow-up visit. It is hoped that his final adult0 g4 U/ x. Y/ f) h
height will not be affected.% q; S5 ?) M/ a- o
Although rarely reported, the widespread avail-
& E' n8 ]$ Y, y& Y0 J5 W+ v0 Uability of androgen products in our society may
2 B0 t- }6 a% L. yindeed cause more virilization in male or female4 a, [, t1 x5 D9 w0 l3 A7 s
children than one would realize. Exposure to andro-
) \2 s$ C- G  e0 g8 l1 y7 t( Ugen products must be considered and specific ques-
+ y4 V; M7 m# a, U2 I; Ktioning about the use of a testosterone product or% Q2 _( s9 w9 K5 Z3 B
gel should be asked of the family members during
- l# K& ~% u8 {, w) Y' Nthe evaluation of any children who present with vir-% B  B; ~5 i% k% M6 Z
ilization or peripheral precocious puberty. The diag-
3 n# ^* \0 J" ]" Q8 o1 w/ Unosis can be established by just a few tests and by; T. t: ?6 N. Y3 @3 k( D
appropriate history. The inability to obtain such a
, e& L3 B0 [$ U+ a9 h" rhistory, or failure to ask the specific questions, may
* R- q6 W4 |& {result in extensive, unnecessary, and expensive
! X; t3 `. \& |3 uinvestigation. The primary care physician should be: c5 W" z! {3 h% g0 J+ S
aware of this fact, because most of these children
8 ?( B- W; X) g, E$ t. C$ e& P  y2 Qmay initially present in their practice. The Physicians’
4 }$ I5 S1 D% \# Y1 wDesk Reference and package insert should also put a
$ y+ R: P; ~  }9 r1 O( E: Rwarning about the virilizing effect on a male or
4 b* E2 o7 d$ t/ Q* _# \$ A% Ffemale child who might come in contact with some-" p: e7 W. F  [0 S$ [& l" V
one using any of these products.! @% K8 e% Y* p: Z+ N% a
References
; o$ h5 X3 W$ ~9 p' V, g1. Styne DM. The testes: disorder of sexual differentiation
) f% g- r+ R5 Sand puberty in the male. In: Sperling MA, ed. Pediatric) I4 R2 w' x, @4 D# K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( v( D- a$ R* X( }! B' m. L' [7 h& j2002: 565-628.  A4 c( J2 W1 j; B/ W; y  {+ S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; A8 o/ |; z. H) h3 r) D
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
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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
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

/ {. T# h* I+ c7 F9 x: R9 t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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