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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-Old5 o5 k) ^; u! O+ }2 l" h
Boy Induced by Indirect Topical
8 |$ z& D, u+ ]! }Exposure to Testosterone- ]* A/ j, R) v3 x; \6 F7 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 [( F  ]- o9 q- \6 L6 J% M( N$ J/ qand Kenneth R. Rettig, MD1
. B2 `( W4 p9 n3 N. EClinical Pediatrics7 R. l+ \4 n9 n# [
Volume 46 Number 6
8 C3 {( |2 K7 q0 j1 K1 OJuly 2007 540-543
5 U' X0 N& }  ~" L! o6 d$ D© 2007 Sage Publications
' v6 d. F4 }. w5 w+ t10.1177/0009922806296651$ m  \- M& x  L0 b9 q! |
http://clp.sagepub.com# k$ e: W) A. c+ H3 Y
hosted at( s# e  c1 i( b( ?2 P' j) F
http://online.sagepub.com9 i! I0 N* D3 h
Precocious puberty in boys, central or peripheral,
. R6 V; ]: R; l8 Gis a significant concern for physicians. Central
2 T' F- y: D  c  `7 K6 d2 }7 ?precocious puberty (CPP), which is mediated% H' [$ q  O: g1 L5 g6 ~
through the hypothalamic pituitary gonadal axis, has
, S* M" T$ a. Q) r  Ta higher incidence of organic central nervous system
. n# b( }: ~$ [: z6 D3 P; wlesions in boys.1,2 Virilization in boys, as manifested7 \2 c& ]" t2 E" ^
by enlargement of the penis, development of pubic/ S  y, |! A6 j( q, @* _( e
hair, and facial acne without enlargement of testi-# A# \% A1 Z' i! ?1 ?
cles, suggests peripheral or pseudopuberty.1-3 We% d8 S1 f) j& Q7 a5 A) z% c- v
report a 16-month-old boy who presented with the
1 @% }# R. z5 A; r7 m- P  Renlargement of the phallus and pubic hair develop-$ f" P2 n5 L% c% v0 g
ment without testicular enlargement, which was due
' K3 p' c7 _4 R* o& uto the unintentional exposure to androgen gel used by8 Z; q- c% D# N8 M& f# r
the father. The family initially concealed this infor-
. J- `- X" A5 t( v/ c! f' dmation, resulting in an extensive work-up for this
1 i- x$ F, H2 H0 F1 j  t' ?child. Given the widespread and easy availability of! L7 d* p7 J8 o
testosterone gel and cream, we believe this is proba-
0 n0 `; n, m4 e2 C/ qbly more common than the rare case report in the
- @1 `1 ?* E( C" gliterature.4
) V7 s. s! p( j$ e: h6 O  a8 QPatient Report2 w' C) H2 K: e* B0 L2 N) ?
A 16-month-old white child was referred to the
* t2 Q5 e8 R9 d; L% \8 Mendocrine clinic by his pediatrician with the concern
; j9 K5 `' p' W  U( H- wof early sexual development. His mother noticed
+ }7 P& c2 V* |$ ^  `light colored pubic hair development when he was
. e$ Q5 n3 u1 N; |3 ]$ nFrom the 1Division of Pediatric Endocrinology, 2University of
& |! |1 F6 J- XSouth Alabama Medical Center, Mobile, Alabama.
0 l; \3 x  |. Q7 f" `. Q# S2 CAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ D& x$ @# f( t7 SProfessor of Pediatrics, University of South Alabama, College of
  ]) r# Q8 w! K- qMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 \4 Z8 x2 Y  E7 ]+ be-mail: [email protected].
9 X% `  D- n8 m% u* cabout 6 to 7 months old, which progressively became$ m7 g( W. j  [5 H
darker. She was also concerned about the enlarge-
# _0 E3 h  [* q8 n$ Y& Nment of his penis and frequent erections. The child
! m0 o  f% m; H; g, P5 ewas the product of a full-term normal delivery, with( T- g7 f/ J/ G- N: |  n) ?
a birth weight of 7 lb 14 oz, and birth length of
& y1 J: d  q& F" P7 G0 @20 inches. He was breast-fed throughout the first year
7 V" X! ^2 e% T3 u4 z6 O( Gof life and was still receiving breast milk along with$ A, s$ x/ ]8 I9 \. r; d. t" U! G# J
solid food. He had no hospitalizations or surgery,3 j4 r& C" m" R$ H2 W8 x6 o
and his psychosocial and psychomotor development
+ V4 N+ P+ i$ K; ?was age appropriate.0 \; Q9 {, V# V! Z
The family history was remarkable for the father,
+ |/ }6 G  [% H1 v( twho was diagnosed with hypothyroidism at age 16,8 n& p0 x. T- F# C  h
which was treated with thyroxine. The father’s
4 D& s. t  q% `4 S) U+ b  Nheight was 6 feet, and he went through a somewhat
  ^1 y3 n" G8 o$ eearly puberty and had stopped growing by age 14.
9 {$ y; Y6 J# t& Z) {The father denied taking any other medication. The
& h' D3 K+ N3 O4 L, u! nchild’s mother was in good health. Her menarche
5 f! |" O3 ], h3 Cwas at 11 years of age, and her height was at 5 feet2 l) k1 K3 ~* g! Z1 y* U5 _. w
5 inches. There was no other family history of pre-: k+ `# _6 w+ y% B% `1 e; M0 h
cocious sexual development in the first-degree rela-
7 o2 T- Q, `* Xtives. There were no siblings.
( h! U% C7 o1 \( W7 zPhysical Examination- _# E7 u8 e. V2 f+ ?( v/ I$ [
The physical examination revealed a very active,
; D2 M7 Z/ J, O) `playful, and healthy boy. The vital signs documented
7 |0 t+ _7 J4 T2 `2 pa blood pressure of 85/50 mm Hg, his length was( H. {' N2 h! {
90 cm (>97th percentile), and his weight was 14.4 kg+ V/ D" V2 K4 h7 g$ m
(also >97th percentile). The observed yearly growth" w) w3 \4 h& T3 J; C( [
velocity was 30 cm (12 inches). The examination of
" T( y, a' D# W* k' Tthe neck revealed no thyroid enlargement.: ^/ f: a+ y" `; b9 Z- u6 }
The genitourinary examination was remarkable for
) W1 W. m3 B; G8 \+ G; D2 Zenlargement of the penis, with a stretched length of9 ]! y, |! V; q( `
8 cm and a width of 2 cm. The glans penis was very well' F' s: u& V' G+ N
developed. The pubic hair was Tanner II, mostly around0 X( E* |1 z# y% I& J$ E- o$ q3 V
540& ~9 E' ]  m. _) q1 p. q* |' A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' e- D" E) X5 l3 P" bthe base of the phallus and was dark and curled. The! u' Y) ?4 |- o& t7 S6 v; y; W
testicular volume was prepubertal at 2 mL each.
; L( S6 R  X) O- xThe skin was moist and smooth and somewhat
& ?( R4 i& B; ?oily. No axillary hair was noted. There were no
7 y$ b: }" e2 |, pabnormal skin pigmentations or café-au-lait spots.$ h  }/ ~2 ^* E, t& i9 w: }' l0 `
Neurologic evaluation showed deep tendon reflex 2+; _$ G, W3 {; G- {
bilateral and symmetrical. There was no suggestion
5 d' a0 F' N# d2 ~# K1 `: _+ ~& {of papilledema.1 b. F! C) ^( X1 ?" u
Laboratory Evaluation% w5 K: ?! w* |& @3 m2 ^, Q) @
The bone age was consistent with 28 months by6 y: o4 a" k8 d8 e+ a
using the standard of Greulich and Pyle at a chrono-
4 Z- V8 W4 Y+ d$ c; U8 M; C7 zlogic age of 16 months (advanced).5 Chromosomal
+ v8 R# f# X9 z$ ^+ X2 s- a# `karyotype was 46XY. The thyroid function test
. w* a; _8 U$ Q$ [& h6 ~/ gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) [5 F! H- v! O2 l
lating hormone level was 1.3 µIU/mL (both normal).
( Y% x* a7 p$ @1 lThe concentrations of serum electrolytes, blood
- x1 w* P6 {; h5 w/ n* Rurea nitrogen, creatinine, and calcium all were
6 p* d: W+ \: r7 h) Owithin normal range for his age. The concentration
. V% N0 A: ?$ a8 H: H( O, b. \of serum 17-hydroxyprogesterone was 16 ng/dL
1 v" v0 w; j: W; d0 t8 I+ U(normal, 3 to 90 ng/dL), androstenedione was 20) i* k: ]- n& v
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! R4 Q! _3 Y+ h" C% Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),
# S+ n0 f. _( Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 W, c  U9 x  N% j% q4 _" d
49ng/dL), 11-desoxycortisol (specific compound S)
3 D! J0 U/ o4 Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ R0 u, [, G0 u- w4 Y+ t1 D! d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! p/ t, D- ]* J& R( g& m1 L. Btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" n. S# d  \( ]; Q$ jand β-human chorionic gonadotropin was less than
$ B- ?# [" w5 C! ]0 |4 ]' ^5 mIU/mL (normal <5 mIU/mL). Serum follicular) C. z. R* J; T1 i" I
stimulating hormone and leuteinizing hormone) E' c# w( L5 I: m) A3 Q
concentrations were less than 0.05 mIU/mL
2 \4 x  l, n/ S1 y5 N# I0 ~, h(prepubertal).1 \5 V6 ^2 b: \! |& m1 g, N
The parents were notified about the laboratory
: _8 G, l/ r- v# x4 n1 G* Eresults and were informed that all of the tests were
: `, p; @# k  S. q9 h- c1 T- Bnormal except the testosterone level was high. The
4 B3 c$ j6 d0 b6 R; @follow-up visit was arranged within a few weeks to
2 M1 I5 R0 A" wobtain testicular and abdominal sonograms; how-
0 C4 a" }5 p, r8 xever, the family did not return for 4 months.5 R( W6 d5 S0 z: E5 z7 v
Physical examination at this time revealed that the& _' N: v. [( o3 |( X( f; B
child had grown 2.5 cm in 4 months and had gained! }, w5 V$ d$ v
2 kg of weight. Physical examination remained: B1 r% N9 @3 H
unchanged. Surprisingly, the pubic hair almost com-
  p4 W1 ]/ `0 Ipletely disappeared except for a few vellous hairs at
1 @/ U) U8 U4 o: ~$ Hthe base of the phallus. Testicular volume was still 2  N" `5 O- i1 U3 m
mL, and the size of the penis remained unchanged.
- i" u. g7 {9 x; R# zThe mother also said that the boy was no longer hav-  f) ~  K% N" g. Q3 m1 }% _% m
ing frequent erections.
* p) ?! @$ J+ g  d3 fBoth parents were again questioned about use of1 @) U6 D1 s  K" N3 s
any ointment/creams that they may have applied to- L# W" \- U/ C- ^+ \) q; r3 P* B3 m
the child’s skin. This time the father admitted the
6 |8 {5 @5 a3 Y6 Q. LTopical Testosterone Exposure / Bhowmick et al 541
. L; F( _( \# {1 n) v. Buse of testosterone gel twice daily that he was apply-
- R' s" ~& L. V, i% _ing over his own shoulders, chest, and back area for) b3 T; E% _' e/ {- y) F0 D  J
a year. The father also revealed he was embarrassed$ y" y/ W. P' Q+ o1 k
to disclose that he was using a testosterone gel pre-
3 x# H: P5 ~% W2 {8 |scribed by his family physician for decreased libido; K2 ~  F1 S, f5 Q
secondary to depression.
: @/ H# l( s. J3 c# ^The child slept in the same bed with parents.& y3 ]* T+ N0 n$ g- p3 x
The father would hug the baby and hold him on his
- ?' ?9 _2 O' @5 |; r0 ochest for a considerable period of time, causing sig-9 g9 j$ T  y9 s1 ~1 {) u: Z8 A; C6 @9 p
nificant bare skin contact between baby and father.
# v) s! x3 i3 i/ RThe father also admitted that after the phone call,! @* _# c; P7 T/ T+ c
when he learned the testosterone level in the baby- D5 Q* `# V* g4 L/ i3 S* A
was high, he then read the product information' _  O1 o' ^, p! V
packet and concluded that it was most likely the rea-9 m& h/ d# Z) Y3 }' Y
son for the child’s virilization. At that time, they, k% D+ Q5 Z2 r1 L* G2 n
decided to put the baby in a separate bed, and the
/ q$ `' T1 H  U( t. ^8 W& Afather was not hugging him with bare skin and had/ e7 P* M# _1 F* F; l5 w) ~/ T' S0 k
been using protective clothing. A repeat testosterone7 X; G! Q; p& _7 r: `5 o
test was ordered, but the family did not go to the
' _8 _* J0 s% h" t, o, \laboratory to obtain the test.9 z" q1 U2 |, M2 \# X' ?- E
Discussion
# M3 K+ W5 G, S- l6 P0 m5 W" KPrecocious puberty in boys is defined as secondary
' f% U+ I+ O, C( {. r# F* p0 I# A. |sexual development before 9 years of age.1,4( I9 k" w# b$ q7 s% ]$ V3 G
Precocious puberty is termed as central (true) when
; y+ r6 R* ?8 ?it is caused by the premature activation of hypo-
5 {$ e  k% k; W- m0 Athalamic pituitary gonadal axis. CPP is more com-
; t- `: g! I- j& [mon in girls than in boys.1,3 Most boys with CPP  W# N" @, V2 E& F. W
may have a central nervous system lesion that is
& {! e. O+ y: k4 l) A7 P5 oresponsible for the early activation of the hypothal-: m; ~. N! w' M5 _
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ N$ e2 h: X0 c* o( T0 [) Psis has been given to neuroradiologic imaging in0 g! J3 O- h  O& P
boys with precocious puberty. In addition to viril-- J% [+ M7 T% `- f
ization, the clinical hallmark of CPP is the symmet-( @7 G( p% c* `4 Z
rical testicular growth secondary to stimulation by
% p% }0 x- ]3 Agonadotropins.1,38 b* M% |: V# R# ~
Gonadotropin-independent peripheral preco-% \5 F8 a2 H3 U
cious puberty in boys also results from inappropriate3 E7 P. D) L3 u
androgenic stimulation from either endogenous or
: d& j& p5 `( V+ M& h, `) texogenous sources, nonpituitary gonadotropin stim-/ |0 P  ?( U6 g3 m- m6 e
ulation, and rare activating mutations.3 Virilizing
  K4 n7 [$ l+ j$ j7 jcongenital adrenal hyperplasia producing excessive
! t6 C1 Q# h& Q& Q# p- Xadrenal androgens is a common cause of precocious+ y' k' G/ o/ x7 _
puberty in boys.3,4
3 Q# N. I$ H, u, z" L* uThe most common form of congenital adrenal- e% K$ W  e- s
hyperplasia is the 21-hydroxylase enzyme deficiency./ [1 h) M3 B; i$ W# |5 M
The 11-β hydroxylase deficiency may also result in% ~* G5 C6 C* @; {5 d7 n
excessive adrenal androgen production, and rarely,* ~9 E( @2 b( W- \
an adrenal tumor may also cause adrenal androgen: y9 L7 {  m; t* u" L
excess.1,3
! n9 x1 e! n+ X- j" y+ qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 {( x& S+ ?0 ^! Z( Q6 w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 ]8 Q- X2 V& M9 |. w; P8 yA unique entity of male-limited gonadotropin-
& r* |8 p$ x7 ~8 V& ^! I( xindependent precocious puberty, which is also known5 G- N9 Z0 }8 @: y7 s
as testotoxicosis, may cause precocious puberty at a
/ k& @# ~1 N: O! D1 {6 ^, b% Svery young age. The physical findings in these boys  {: a5 \" y3 G( R4 b
with this disorder are full pubertal development,1 E! l2 Y1 p, B* z
including bilateral testicular growth, similar to boys
4 |+ n0 R  b- V1 \( ]with CPP. The gonadotropin levels in this disorder
5 ], [( |: R; care suppressed to prepubertal levels and do not show
  }2 W" Q; b3 _5 mpubertal response of gonadotropin after gonadotropin-
9 Y; q! T3 V  Preleasing hormone stimulation. This is a sex-linked- O. V* K8 W2 A2 [4 F
autosomal dominant disorder that affects only, }0 a: A& i$ J* }
males; therefore, other male members of the family
5 m# N+ z6 i0 e/ Q  m& w& jmay have similar precocious puberty.3* X/ ]9 \& D* V6 b( T* z5 _
In our patient, physical examination was incon-* t4 k  N9 f  Q# F4 U  W
sistent with true precocious puberty since his testi-7 [  M9 i! D* o. r% o
cles were prepubertal in size. However, testotoxicosis
  |% h* k  e( v  p) A& Q$ Zwas in the differential diagnosis because his father$ }7 \* ~$ J1 z
started puberty somewhat early, and occasionally,
$ D; P$ s% ]% F+ m' L, |testicular enlargement is not that evident in the
" E) ~, H3 x! V0 j3 m2 j7 ~4 ybeginning of this process.1 In the absence of a neg-, S- D$ S5 Y; j8 R
ative initial history of androgen exposure, our
0 w( Y( d  [* wbiggest concern was virilizing adrenal hyperplasia,
; ~8 z7 c0 |" Neither 21-hydroxylase deficiency or 11-β hydroxylase
5 `3 {* z, C; ^8 m& X- [  Ndeficiency. Those diagnoses were excluded by find-
) n  P5 L( a1 \  s: y2 o8 |ing the normal level of adrenal steroids.( G/ \; R6 m+ S7 a0 R+ m4 m7 f
The diagnosis of exogenous androgens was strongly
- K; }; f2 }' g; [8 L( a4 X- d; Csuspected in a follow-up visit after 4 months because
3 w) \2 `  Z; s; Y& f% Pthe physical examination revealed the complete disap-  n5 i5 _  K9 m0 _) `+ W
pearance of pubic hair, normal growth velocity, and
& F' Q: L; }& x, W6 J! g1 k9 }decreased erections. The father admitted using a testos-$ P" R6 T3 [, z, D* U/ F: m
terone gel, which he concealed at first visit. He was8 W- g2 ~% G3 u0 J
using it rather frequently, twice a day. The Physicians’
. @$ d' A# B% s9 S4 W0 G6 I# QDesk Reference, or package insert of this product, gel or
$ h8 C! Q* K' |5 y. n4 U) w7 e' icream, cautions about dermal testosterone transfer to
! O/ w+ w  p( h$ R- Y" Munprotected females through direct skin exposure.
0 ?- C$ z' m0 O* }Serum testosterone level was found to be 2 times the
& [9 {* z5 R2 o7 {baseline value in those females who were exposed to
" f3 F( I1 `% t' veven 15 minutes of direct skin contact with their male
$ k* L! _: _0 s$ z  |partners.6 However, when a shirt covered the applica-2 H* a& {3 v' ~% B  M6 t
tion site, this testosterone transfer was prevented.
9 `! f# D5 \7 |1 H# l3 v  Z/ \Our patient’s testosterone level was 60 ng/mL,
4 }  d6 J; I8 A- V5 F8 L; Awhich was clearly high. Some studies suggest that
: E' F4 ]4 ]# S' I4 P0 @dermal conversion of testosterone to dihydrotestos-0 X6 ~* C* C* D/ x- s- ^
terone, which is a more potent metabolite, is more$ o9 [' \, G. c' O) b- ^* O9 B
active in young children exposed to testosterone
% W; |: Z5 \9 Texogenously7; however, we did not measure a dihy-/ W1 q+ [& Q/ q: v$ k" s4 r) ]2 ?
drotestosterone level in our patient. In addition to; C' I2 e- Z0 Y
virilization, exposure to exogenous testosterone in) I# i+ l" r# M* E
children results in an increase in growth velocity and& K* A$ T9 h8 s
advanced bone age, as seen in our patient.
% n! b& k+ m; IThe long-term effect of androgen exposure during: k& k8 m/ ]/ [) d3 z# I. p
early childhood on pubertal development and final6 D7 G1 A% M/ t$ g
adult height are not fully known and always remain
$ s8 i% C1 C3 b2 s. |$ i' Ma concern. Children treated with short-term testos-5 Q: W! ]! H- g
terone injection or topical androgen may exhibit some
. n; u4 S% K3 o; zacceleration of the skeletal maturation; however, after
! ^6 u, x- H. w2 C1 g6 ?8 k5 m+ Zcessation of treatment, the rate of bone maturation
% v. h; N$ w  ]9 K/ w2 Vdecelerates and gradually returns to normal.8,92 _- g- H. X; ?  [! E
There are conflicting reports and controversy3 s+ P1 I  [2 V  \9 b/ g8 u
over the effect of early androgen exposure on adult
- Q) a8 p. W) R& A7 Ipenile length.10,11 Some reports suggest subnormal9 o% ?8 }# S2 l  P( T4 w
adult penile length, apparently because of downreg-& z7 `" ]3 P/ u, g% w
ulation of androgen receptor number.10,12 However,
; U4 E. \$ H1 {* eSutherland et al13 did not find a correlation between
& b$ x+ v- s6 n9 zchildhood testosterone exposure and reduced adult
" W- s, V, N+ N9 Bpenile length in clinical studies.) T" H' t9 R( j. ^* b
Nonetheless, we do not believe our patient is
& ]/ j4 V/ R) Jgoing to experience any of the untoward effects from( O& m! b& w* X. j2 N$ S
testosterone exposure as mentioned earlier because
" \, t$ ^2 c% v/ ], P6 mthe exposure was not for a prolonged period of time.  w" j( o+ E. B/ n
Although the bone age was advanced at the time of
& r$ u( |& \. H- B! y8 Y, a0 c4 \) _diagnosis, the child had a normal growth velocity at, X" M3 q6 s3 R: G. W% J
the follow-up visit. It is hoped that his final adult. \$ Z4 S+ i9 Q0 H
height will not be affected.7 v$ h3 ]9 m1 N/ t& C' b
Although rarely reported, the widespread avail-
; r4 E5 e- P$ G1 vability of androgen products in our society may
) b6 y9 U4 d2 z* X# C: W2 u2 ]2 ~indeed cause more virilization in male or female
5 {1 ]9 N' G3 Z( Z6 ~8 hchildren than one would realize. Exposure to andro-9 ]8 Z1 ?, t/ ]  z) R
gen products must be considered and specific ques-7 ~8 f0 E5 E( Y' ]& ]# k* d: o, j
tioning about the use of a testosterone product or$ v$ R/ d3 E0 E; R" {
gel should be asked of the family members during  D6 S8 G" K- U" d4 T% x4 c& j3 Z" Z" _
the evaluation of any children who present with vir-% K3 t/ l. R$ D* G9 y2 b7 h  A
ilization or peripheral precocious puberty. The diag-
4 y0 D1 L# r& R& H, \nosis can be established by just a few tests and by. @5 X% H) C7 O! |9 t
appropriate history. The inability to obtain such a
' o$ R$ I: U$ Ehistory, or failure to ask the specific questions, may$ E1 `, B' V5 A7 l5 G; k
result in extensive, unnecessary, and expensive
0 W( g; b- c, [8 Yinvestigation. The primary care physician should be
% G$ y" H1 ]; H. Maware of this fact, because most of these children! t* V+ }2 A  s) o$ a0 a" O
may initially present in their practice. The Physicians’# o) D) O! R5 M
Desk Reference and package insert should also put a6 p4 h$ O: g  A7 ?3 D- l7 K+ |4 X
warning about the virilizing effect on a male or8 O1 B9 @1 ^; O) E
female child who might come in contact with some-8 ^; y6 ^5 Q+ M" }3 J0 L
one using any of these products.; k5 L$ ?/ W" E0 s* X) k
References
: R- [/ w3 e7 k0 C: Z0 e8 ~1. Styne DM. The testes: disorder of sexual differentiation
- P' L' z0 j2 D, y; h) jand puberty in the male. In: Sperling MA, ed. Pediatric3 x! M; z+ W. q; P; F
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, K( }: k5 d& k5 W3 S4 h2002: 565-628.8 I+ L; D. f# ?1 }8 @  l2 R# q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: R0 x* s2 H6 `3 X2 |puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* I+ u* L: s( H1 Z  zBoy Induced by Indirect Topical
9 |* M7 M& H) @& AExposure to Testosterone
  A6 j/ k  }8 b0 Q3 m9 P6 _6 r9 I* YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! \, K1 H1 Z5 @0 c: u  ^
and Kenneth R. Rettig, MD1
% M! d& H0 t- R3 T( BClinical Pediatrics
; }! A1 M( T& AVolume 46 Number 6
6 `9 D- h; l; U% ^7 I$ y$ RJuly 2007 540-543" r: n4 ~$ E+ y2 ]$ K5 X
© 2007 Sage Publications' K* u7 J: a& N4 k2 Y2 ~/ C
10.1177/0009922806296651# \8 {7 V  @6 s0 `7 J  @
http://clp.sagepub.com. p& N% f5 p; X6 N7 |
hosted at
' j9 f8 |7 l; L3 Z& @! B  p7 `; i0 F+ zhttp://online.sagepub.com
6 A, b: J3 c5 U+ I" APrecocious puberty in boys, central or peripheral,: ~% o( G: D3 \' c2 u( O
is a significant concern for physicians. Central
; D: y, d4 P' o, D) {, Pprecocious puberty (CPP), which is mediated9 d* [8 d; \" A2 w! A
through the hypothalamic pituitary gonadal axis, has
2 H' X( B# k$ `9 @% x6 U; L' Sa higher incidence of organic central nervous system  D1 F8 g2 @/ e! ^* k
lesions in boys.1,2 Virilization in boys, as manifested
: J4 I/ v# y1 s; A$ @8 p* f4 rby enlargement of the penis, development of pubic
, P' Q: Y6 g, D6 q( a' uhair, and facial acne without enlargement of testi-$ Y* t" p- x1 D8 t" d. e0 e
cles, suggests peripheral or pseudopuberty.1-3 We( S8 g: n2 q# [, O( [: A
report a 16-month-old boy who presented with the2 v7 Q, u- s/ q) F4 q
enlargement of the phallus and pubic hair develop-
! v3 ^: {, p- n! N5 F5 _ment without testicular enlargement, which was due
. z2 Z. c$ p# C  U) @to the unintentional exposure to androgen gel used by
; d+ V0 x! H/ |4 T0 I* r2 Hthe father. The family initially concealed this infor-
: l# ]0 C1 x' o2 U5 `# }mation, resulting in an extensive work-up for this% v7 t5 B4 D5 W3 h& f
child. Given the widespread and easy availability of6 q4 t) a4 l6 i0 s% N" [; c
testosterone gel and cream, we believe this is proba-
; u2 ]/ z+ x9 G2 e! W# Lbly more common than the rare case report in the
  j4 s2 }* o& x- e$ k: f0 pliterature.47 K" e( a0 j, s: C5 L1 M
Patient Report
, D* c0 b  y' a4 IA 16-month-old white child was referred to the9 }( m0 m. G6 k& U( L# @: G
endocrine clinic by his pediatrician with the concern1 U9 }8 D; j! D4 D+ S. G' W4 T
of early sexual development. His mother noticed
* G" l' A8 t. ?/ S6 ]8 f2 ~light colored pubic hair development when he was5 E8 Z' E: s7 S" G0 K& f: {
From the 1Division of Pediatric Endocrinology, 2University of
7 ^+ X6 b8 `. S- z. ~South Alabama Medical Center, Mobile, Alabama.
. |! k" n9 b! T4 f% o9 bAddress correspondence to: Samar K. Bhowmick, MD, FACE,; v/ C+ [" \- v& k; q4 g) r; g
Professor of Pediatrics, University of South Alabama, College of+ b5 ^* h6 h6 Q( T% \4 U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( a: s1 \! ?  a/ j& G2 r$ V3 K: V& Y
e-mail: [email protected].
/ s# a! q3 g6 m' c* wabout 6 to 7 months old, which progressively became/ J+ _, u3 p: U4 Q
darker. She was also concerned about the enlarge-6 W. G5 E& f) Y0 ^, ?4 }
ment of his penis and frequent erections. The child
: D6 E+ U, u1 l& twas the product of a full-term normal delivery, with: y1 D" ^3 b4 h1 S
a birth weight of 7 lb 14 oz, and birth length of6 x" Q2 G$ {1 d% d
20 inches. He was breast-fed throughout the first year2 U/ ~. Z, N7 ?% Q3 S
of life and was still receiving breast milk along with
8 w! [( ^7 t- q, Z/ ~1 N6 @solid food. He had no hospitalizations or surgery,
6 G% C, c$ r0 ^$ C. y- a3 rand his psychosocial and psychomotor development
/ r: m! u8 {* D6 v! W3 Z6 v7 Wwas age appropriate.! }! @$ U8 y7 g
The family history was remarkable for the father,
0 [8 Q" ~# K: _3 rwho was diagnosed with hypothyroidism at age 16,1 C" D0 l6 d2 }( g) M- a( H7 K
which was treated with thyroxine. The father’s
+ _% W5 `: i4 A3 X9 B9 dheight was 6 feet, and he went through a somewhat
" V9 u* M0 {' W" cearly puberty and had stopped growing by age 14.
$ |; L9 N" H/ U8 k; g( Z; O& K' u' KThe father denied taking any other medication. The. T5 Q9 _7 t: h
child’s mother was in good health. Her menarche
8 n! M6 A( |1 U: d  wwas at 11 years of age, and her height was at 5 feet
: S1 N5 t! k$ j, c5 inches. There was no other family history of pre-
4 N' M0 ~- p. \cocious sexual development in the first-degree rela-
8 \9 J& k5 g) B3 F/ N) }tives. There were no siblings./ `  F* m. t* M) Z' b0 w
Physical Examination. [( p* l/ Q. \+ k8 Q
The physical examination revealed a very active,- b, ~0 y4 P9 G( m! G
playful, and healthy boy. The vital signs documented
7 `6 ^) y/ q! K' q" a5 Y1 }$ ~6 ha blood pressure of 85/50 mm Hg, his length was
% q* v" \4 ~8 X, @/ D- f- U90 cm (>97th percentile), and his weight was 14.4 kg
2 B: o4 W% @7 z$ }(also >97th percentile). The observed yearly growth2 V- ~- B# ]  l* v$ S/ X) J
velocity was 30 cm (12 inches). The examination of; W: n/ m$ s+ l2 c0 H
the neck revealed no thyroid enlargement.
$ G7 x$ S( S' C  _, L! c5 `The genitourinary examination was remarkable for) k; R( i) M* B8 Z+ `2 K
enlargement of the penis, with a stretched length of
- {" v1 j) ~* y2 v7 W! ?8 cm and a width of 2 cm. The glans penis was very well
: x" c( W8 `6 u/ ydeveloped. The pubic hair was Tanner II, mostly around
( M3 b3 r# k: j$ ]- X. [, Y540
2 B( {# I5 h! f3 Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) U5 V) i8 i) w' O
the base of the phallus and was dark and curled. The; P- A  z- T" C3 C  D; P8 [
testicular volume was prepubertal at 2 mL each., ^. w% t( l. B- V7 v/ p2 {
The skin was moist and smooth and somewhat! d! F: |) j7 |4 o, Y2 J- N
oily. No axillary hair was noted. There were no# k) Y* s% f  R: q) \! f
abnormal skin pigmentations or café-au-lait spots.
, t% \8 s  Q9 i' e9 P6 qNeurologic evaluation showed deep tendon reflex 2+
8 T  M7 g$ q# o' I: e; Tbilateral and symmetrical. There was no suggestion
4 @( Y" S* I. P; M4 l) iof papilledema.- M8 u# C5 ?/ o5 w( {! L
Laboratory Evaluation; b- a6 V. L9 s) n! J0 Z
The bone age was consistent with 28 months by, {; p; h7 p1 j
using the standard of Greulich and Pyle at a chrono-
" f( g8 t8 N% u8 o( vlogic age of 16 months (advanced).5 Chromosomal$ U, _6 i$ g( V* Q
karyotype was 46XY. The thyroid function test
6 I+ U" z6 I& @: V$ [4 Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  p: H8 Z% u8 S3 z$ o3 @% J: G% ylating hormone level was 1.3 µIU/mL (both normal).$ K7 A5 ^* V! u: I; j& }1 {
The concentrations of serum electrolytes, blood  h' [+ e# H+ O' {+ J6 }8 }
urea nitrogen, creatinine, and calcium all were3 ~* _& g$ ]! G$ [& r
within normal range for his age. The concentration0 m( k9 N. D8 ?$ Q5 R3 ?
of serum 17-hydroxyprogesterone was 16 ng/dL
. Z' H3 t& [5 p  N7 j5 z( w; ?# b(normal, 3 to 90 ng/dL), androstenedione was 20
' f7 R7 p1 N; e6 R) Z6 J: dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 F  l2 `3 y' h) h( G+ X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. j" w: U2 P5 O
desoxycorticosterone was 4.3 ng/dL (normal, 7 to% z" H' Y! ]8 U: R
49ng/dL), 11-desoxycortisol (specific compound S)
$ ?" K- R0 P0 D3 {was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 e$ J+ |* V' M0 Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 T. o& e/ ?7 x4 _" b9 ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' k0 u/ C7 |" U* ^/ tand β-human chorionic gonadotropin was less than
. f3 f: A5 P4 `: L5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 d8 V! ?7 G  y% O- q* N$ zstimulating hormone and leuteinizing hormone
2 a5 S1 j' d+ |concentrations were less than 0.05 mIU/mL
7 R+ f; A$ W+ g) m2 ^(prepubertal).
/ p3 Q; z9 b% `( }- f, U1 zThe parents were notified about the laboratory
3 q# j: Z7 @# p! U. a( M7 v) K  p2 qresults and were informed that all of the tests were7 A& X, a' N4 R( [2 L1 Y- `' E) R1 j
normal except the testosterone level was high. The4 ?0 A% a1 e" W7 K
follow-up visit was arranged within a few weeks to
; H/ H+ t3 R- l% Q  O0 M1 hobtain testicular and abdominal sonograms; how-& x$ ]) |8 L1 t2 }
ever, the family did not return for 4 months.
, \: G1 R% R* }% U+ o8 k5 QPhysical examination at this time revealed that the
+ _. ?2 }5 ?$ \8 S" C8 _( M% j" mchild had grown 2.5 cm in 4 months and had gained" X# \5 h3 T; g. T: r
2 kg of weight. Physical examination remained! x7 D8 }% r3 h3 P; c$ M2 P# H8 j
unchanged. Surprisingly, the pubic hair almost com-
# b# u$ ]0 A% npletely disappeared except for a few vellous hairs at0 K1 E" J/ `8 o: L! m6 z
the base of the phallus. Testicular volume was still 2. u9 H% U  L" [/ Y
mL, and the size of the penis remained unchanged.
. m/ s) y, h" G0 z: n6 ZThe mother also said that the boy was no longer hav-
' e3 ^. d& ?* [3 V* X, y1 Jing frequent erections.1 s& m3 X8 Z' l1 b
Both parents were again questioned about use of$ Q6 ?, ^- Q7 h! V* @3 e
any ointment/creams that they may have applied to3 M, c2 h, |  D2 ~5 I
the child’s skin. This time the father admitted the/ }/ |+ ^( ^# U8 F5 l6 x
Topical Testosterone Exposure / Bhowmick et al 541
0 g6 P/ i' G( Ouse of testosterone gel twice daily that he was apply-! t4 l9 b0 G( ?' y. h% L7 I) j% H
ing over his own shoulders, chest, and back area for6 F( z2 |+ s+ L0 i/ Z/ H
a year. The father also revealed he was embarrassed% e! ~4 e" {( ]% v. L: Q( z9 a
to disclose that he was using a testosterone gel pre-
% y2 H7 b7 e8 }; |8 x; Q/ Lscribed by his family physician for decreased libido! H% e1 e( \0 F3 n5 `
secondary to depression.
2 w5 J( I9 {& ^; o& e( l. fThe child slept in the same bed with parents.
7 c9 [7 B! Y+ RThe father would hug the baby and hold him on his
0 Q) U0 j' K1 R4 b0 U  echest for a considerable period of time, causing sig-
4 a. i7 c# m* u$ O; {* gnificant bare skin contact between baby and father.
- ~# E' Y* J0 z* t: NThe father also admitted that after the phone call,+ _: o/ I: n9 b
when he learned the testosterone level in the baby! u! [5 L2 |) O( n' o
was high, he then read the product information
) o( x. o8 `/ @. a5 s, E# B* \packet and concluded that it was most likely the rea-
- O$ ]7 Y; k( ^  O7 Uson for the child’s virilization. At that time, they7 _; q! Y1 ~! {, E, S
decided to put the baby in a separate bed, and the
# n5 p4 A, l. s* E; }  Kfather was not hugging him with bare skin and had" B& @! u& M: ^
been using protective clothing. A repeat testosterone1 k/ W" h- U5 u" C
test was ordered, but the family did not go to the. J* T, @& z% k4 L
laboratory to obtain the test.( [  |9 D0 K6 a* |. t) b
Discussion! s- q) X& i2 o: N& A& O; R3 N
Precocious puberty in boys is defined as secondary
% Y1 z& ], b$ J& Xsexual development before 9 years of age.1,4
# F. ?. N% q: F) [0 k) f/ W  jPrecocious puberty is termed as central (true) when2 B- C# w* y5 L/ S: J( X
it is caused by the premature activation of hypo-/ }1 e' [, f, a: F
thalamic pituitary gonadal axis. CPP is more com-
% e  j1 W8 g4 y: K$ o; h; o' R" F, Wmon in girls than in boys.1,3 Most boys with CPP
2 ~  D$ y: C: ~9 C7 a( p$ pmay have a central nervous system lesion that is
$ N  p  _3 G; m; O6 jresponsible for the early activation of the hypothal-
& C! D$ [$ g, R: O2 uamic pituitary gonadal axis.1-3 Thus, greater empha-
6 |7 k' G5 R; H) ]4 Asis has been given to neuroradiologic imaging in
! Q; a- Z9 {! U6 l) C' C- p2 G* Iboys with precocious puberty. In addition to viril-3 d! {" X% K6 M0 b( K; ~# f/ @; D
ization, the clinical hallmark of CPP is the symmet-2 Q7 \5 b/ q4 t; W! j( l2 S- r: S9 b
rical testicular growth secondary to stimulation by
% Z5 ]9 a& }7 ], Q, W* p0 J; Ogonadotropins.1,3# E: I- n- P1 r$ p8 w7 @
Gonadotropin-independent peripheral preco-
4 y/ R1 W7 K& G; j! i* hcious puberty in boys also results from inappropriate
* e8 c% v0 K2 z. X: vandrogenic stimulation from either endogenous or
5 [% j( k" n: B# k6 q6 U, G5 _exogenous sources, nonpituitary gonadotropin stim-
) H+ u/ \& o0 \0 j' I8 C- iulation, and rare activating mutations.3 Virilizing
2 V5 ]% {4 H2 e7 j, U5 lcongenital adrenal hyperplasia producing excessive
+ [  g( \# g7 |4 N& C( u, h! ^3 _adrenal androgens is a common cause of precocious
" B# B1 T' B; J0 o( opuberty in boys.3,4; Y3 k$ t* Y5 _" i- F( \
The most common form of congenital adrenal
0 v3 S- t) ~2 B7 j0 P7 E% e: whyperplasia is the 21-hydroxylase enzyme deficiency.1 J1 H2 }3 l! n! F# w) W9 w
The 11-β hydroxylase deficiency may also result in8 v, H- S$ H1 A' [! Q
excessive adrenal androgen production, and rarely,+ z. w; ^1 ~: ?" F/ Q
an adrenal tumor may also cause adrenal androgen
( S2 z; y" d. ~; f: `  Jexcess.1,3  h6 W6 I7 h6 Y7 s- t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* @9 }& b  F7 g& N4 O+ x542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 M. u4 Q: F& |
A unique entity of male-limited gonadotropin-, l. _4 ?! O% s, a$ z
independent precocious puberty, which is also known) j4 o% R, v! c" k% f; ?. L5 m
as testotoxicosis, may cause precocious puberty at a3 h: }( R3 a% L* O/ N3 A
very young age. The physical findings in these boys. t# N+ {3 H0 b6 T
with this disorder are full pubertal development,7 W; o: V. r  c$ r! D; l, {" ]2 ]
including bilateral testicular growth, similar to boys
2 c2 ?: u) E& @  r+ jwith CPP. The gonadotropin levels in this disorder
& O5 h, l2 w- Aare suppressed to prepubertal levels and do not show" L# r5 f3 w' B! U+ _" Z; B& X" M0 P
pubertal response of gonadotropin after gonadotropin-8 I) f4 @* Y- n! b" F
releasing hormone stimulation. This is a sex-linked9 Z% s+ k6 ?; X# x0 f5 ?
autosomal dominant disorder that affects only
+ ]4 P4 b0 S! [9 o3 n  L$ w1 Lmales; therefore, other male members of the family4 p- _7 _0 h5 z
may have similar precocious puberty.3. \6 P0 H3 G$ f/ T- W1 T5 X  N
In our patient, physical examination was incon-
" g! L$ A- J/ W. S& A* h% tsistent with true precocious puberty since his testi-/ F, C' T4 V5 I
cles were prepubertal in size. However, testotoxicosis
6 ~; J; p2 t# l+ f2 k* D  Uwas in the differential diagnosis because his father7 u% e$ M7 |+ N) F
started puberty somewhat early, and occasionally,
+ l+ R# i! S  A" Y4 O$ y6 ^testicular enlargement is not that evident in the+ h8 [3 @7 X& J5 ~
beginning of this process.1 In the absence of a neg-; t& j7 d( m% e$ R% y
ative initial history of androgen exposure, our
9 B" Z+ T+ b1 U: Xbiggest concern was virilizing adrenal hyperplasia,9 M* }! m! {$ k9 J+ D6 i
either 21-hydroxylase deficiency or 11-β hydroxylase: }' m! Z7 l7 f" z! \) [3 B
deficiency. Those diagnoses were excluded by find-0 C; e& p) @, J0 w
ing the normal level of adrenal steroids.% W6 H" q, F6 G1 J/ ]7 h. N
The diagnosis of exogenous androgens was strongly
6 _! \; E" n) v/ ^suspected in a follow-up visit after 4 months because8 f1 q7 n2 H4 p5 q. @
the physical examination revealed the complete disap-
  c" J. b+ |7 v! Apearance of pubic hair, normal growth velocity, and6 P# w( {" ?  A7 o3 e" b
decreased erections. The father admitted using a testos-
  V4 Y# v$ f3 sterone gel, which he concealed at first visit. He was
* T' G4 |3 t9 R2 L. Jusing it rather frequently, twice a day. The Physicians’
( p: o! E  E# a& x  H' G, Z7 h4 Q) WDesk Reference, or package insert of this product, gel or
! h5 W. s2 {: E. Kcream, cautions about dermal testosterone transfer to" f) e, Y5 ~& K0 M) n1 ]' G
unprotected females through direct skin exposure.. `* s" Z' n) f2 w. E2 |# [# B$ }
Serum testosterone level was found to be 2 times the# `8 S( y+ n, c; r9 u4 O; }; M
baseline value in those females who were exposed to
* x$ h+ Y' ]& ?  aeven 15 minutes of direct skin contact with their male
* M) d2 ?* `3 J1 z8 ]* npartners.6 However, when a shirt covered the applica-
* K! O: W3 `" d& x& z7 o* ntion site, this testosterone transfer was prevented.  d% |) K5 J4 Q8 K* }; {
Our patient’s testosterone level was 60 ng/mL,
. w+ }$ Q5 l2 g. w8 D" E6 q/ f$ Dwhich was clearly high. Some studies suggest that' p4 }" o1 E7 k
dermal conversion of testosterone to dihydrotestos-
6 Z/ `( r/ e" K8 ?2 _* Hterone, which is a more potent metabolite, is more2 F! J7 X, T/ i
active in young children exposed to testosterone
7 N( M4 _- a* R5 Uexogenously7; however, we did not measure a dihy-; x0 z- m. _. x5 r% B  D
drotestosterone level in our patient. In addition to
' _9 c7 X* x( ]6 x' n4 v/ ^) l3 ^virilization, exposure to exogenous testosterone in% }4 @5 o* u: z* Q  c6 `
children results in an increase in growth velocity and
/ v+ C9 b0 J5 F1 M3 [! M- j# k. ]advanced bone age, as seen in our patient.
$ z9 s4 m5 r+ W  F. mThe long-term effect of androgen exposure during
( j) @+ j: `) {) Y# S- v* s) ~early childhood on pubertal development and final
& {+ h7 j! P$ P* k" i) `) z0 j1 A) Qadult height are not fully known and always remain9 o4 q* n- B3 n' \: d# |
a concern. Children treated with short-term testos-
8 c3 Y3 d. e1 y  [9 r" Z) ]$ N& U5 Oterone injection or topical androgen may exhibit some$ F5 {* G; o2 H9 F& L" G+ V
acceleration of the skeletal maturation; however, after: f& I2 \" p' ?0 ]: r' d0 p+ A! _
cessation of treatment, the rate of bone maturation
/ E4 M) C% A! ~! w: t/ W4 m# y- @decelerates and gradually returns to normal.8,9+ E0 C8 T8 M* j, h3 n7 z& R
There are conflicting reports and controversy2 g1 X# v( a3 A- U5 |1 B
over the effect of early androgen exposure on adult
) L0 B* G% G7 M8 }  r- n$ o! G! wpenile length.10,11 Some reports suggest subnormal
7 l+ P6 {, ]  x$ iadult penile length, apparently because of downreg-
/ C2 \# L5 H: I8 p5 C7 A$ i1 dulation of androgen receptor number.10,12 However,0 N. N  L  S# q6 \5 y$ ?. N
Sutherland et al13 did not find a correlation between4 P8 y) t5 S. B0 a
childhood testosterone exposure and reduced adult
( Z( C; R1 B! N8 u" C" Zpenile length in clinical studies.( P4 L) e/ h' }+ C9 R: d
Nonetheless, we do not believe our patient is6 W; B) R$ \5 j( q: x8 d( u5 J, h
going to experience any of the untoward effects from
+ V. D* g! h8 i. u) ~testosterone exposure as mentioned earlier because
" B- j" Y, ^) y7 c( M/ jthe exposure was not for a prolonged period of time.
/ {  F+ t3 Y' t9 G8 M9 UAlthough the bone age was advanced at the time of' q# X) d3 _& e( a; q8 K" E& R$ t4 c( Z
diagnosis, the child had a normal growth velocity at
+ v3 |: ^$ k4 p2 J/ gthe follow-up visit. It is hoped that his final adult
: k& j( _/ G. M" N: Vheight will not be affected.2 z* Q1 Q% w3 }8 Z  x
Although rarely reported, the widespread avail-
2 `7 ^4 }  T/ N! e9 yability of androgen products in our society may
* |" G7 Z/ k, h7 f) Nindeed cause more virilization in male or female
. ^$ i: u% w( q4 K) Mchildren than one would realize. Exposure to andro-# G; P; _' {- _0 D: C
gen products must be considered and specific ques-& h' w4 d& z2 T& z* o# V
tioning about the use of a testosterone product or
0 @9 K7 v1 C' _6 fgel should be asked of the family members during# Z  K2 I7 U, N, E. @
the evaluation of any children who present with vir-0 D* N; m- Z0 S3 N: b
ilization or peripheral precocious puberty. The diag-
& I7 r: j% [6 unosis can be established by just a few tests and by' t. k4 `5 B5 ?$ D( M1 m
appropriate history. The inability to obtain such a
9 t8 f: t8 `7 ]) |history, or failure to ask the specific questions, may
! c4 o! r& ]; Q7 r" ^" U4 }result in extensive, unnecessary, and expensive
) r5 {- G/ I% k# I) rinvestigation. The primary care physician should be; W, v+ g( P2 a) i/ O/ I5 i7 h
aware of this fact, because most of these children
+ Y) y9 j% T3 c/ ?, N5 f' h8 w# imay initially present in their practice. The Physicians’$ o, G3 X' U9 Y& ~( f6 b: W
Desk Reference and package insert should also put a+ Z$ V  @# N4 w5 l; @. A% `1 n
warning about the virilizing effect on a male or) n: H% {# j0 t$ R2 O
female child who might come in contact with some-
+ a$ s" a$ U$ z! c: v2 J8 rone using any of these products.
4 n( N: o1 Y+ G0 q6 AReferences
; B" f4 \: A/ K: w5 H: b. p8 M1. Styne DM. The testes: disorder of sexual differentiation
* ?5 D  U, [0 H0 v2 ~6 I- vand puberty in the male. In: Sperling MA, ed. Pediatric
: r) ?+ V3 j9 u" j7 GEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 A- z5 k% K7 @" F9 Y0 g2002: 565-628." c/ e0 D3 C4 w- H/ a; ^! ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- H: d; T) v2 R+ S7 o2 N$ d
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
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
3 u- u8 P* g! F0 q8 r/ n/ K0 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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