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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' ?0 T8 C/ d5 x5 S5 n+ _
Boy Induced by Indirect Topical, S- R( Z6 V- T
Exposure to Testosterone
" q7 D0 s$ g6 g/ W2 HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, Y7 R/ K/ u. o  U2 ~
and Kenneth R. Rettig, MD1
/ d) y6 d3 A$ d; w* i! RClinical Pediatrics+ N$ _  o7 m& H
Volume 46 Number 6. P4 q, S, z& t; A% J' n1 A
July 2007 540-543' e8 W0 k7 x5 o& R! b
© 2007 Sage Publications: X# Y1 ~9 g2 _1 v8 O* p* n& T9 l) }
10.1177/0009922806296651
4 x* T9 ~. j* Y1 k- lhttp://clp.sagepub.com
8 B1 d6 u+ N6 x& Yhosted at, r- ~7 ?! g6 {5 K
http://online.sagepub.com
9 D) g$ r6 Z+ F& BPrecocious puberty in boys, central or peripheral,+ ^7 G% W1 x7 {# [% r/ ]8 h4 w
is a significant concern for physicians. Central
0 S4 O! @" w7 y8 r3 @1 N5 q8 ^9 a! T1 r% Uprecocious puberty (CPP), which is mediated+ q7 `+ m! O( S+ c" g
through the hypothalamic pituitary gonadal axis, has
' m7 b+ v$ [6 J' P- na higher incidence of organic central nervous system
% l' z6 S5 _( Y6 T* K9 M5 tlesions in boys.1,2 Virilization in boys, as manifested- [: Q6 G* ~( Z  U. @2 z
by enlargement of the penis, development of pubic
7 v, U3 u) {1 R: z3 Chair, and facial acne without enlargement of testi-- a! R& K5 y6 S8 P! w* T  R
cles, suggests peripheral or pseudopuberty.1-3 We6 m% W0 g$ y8 D- W- ]
report a 16-month-old boy who presented with the  N1 N% \4 D. D$ f
enlargement of the phallus and pubic hair develop-
/ T2 b, c8 ?; y. ]5 Sment without testicular enlargement, which was due
* G  D5 R! w: k; F2 _+ j) n1 ito the unintentional exposure to androgen gel used by# Z* D: K$ j2 g7 H0 ]
the father. The family initially concealed this infor-
  k  j& G3 b: `8 I, X/ bmation, resulting in an extensive work-up for this# s) n- l: _2 f  K9 u
child. Given the widespread and easy availability of2 F+ [2 d% r4 X
testosterone gel and cream, we believe this is proba-) R2 C- V) B6 o- e( h; e
bly more common than the rare case report in the2 k- w; C  x# _
literature.4
, n8 L6 p" m1 k2 G2 XPatient Report
  y# _- B& s, P+ Q# YA 16-month-old white child was referred to the
, P0 c/ l& [6 J9 }4 bendocrine clinic by his pediatrician with the concern. i; t. H& i1 \! u4 s& S  t* f1 L' y% N& R
of early sexual development. His mother noticed5 g4 @$ P/ c4 `$ [$ D5 z/ h
light colored pubic hair development when he was8 D* R( U! E- Y
From the 1Division of Pediatric Endocrinology, 2University of
) N( @4 c4 e8 n6 P) p0 v. i8 @South Alabama Medical Center, Mobile, Alabama.
, E* |( Q) E# SAddress correspondence to: Samar K. Bhowmick, MD, FACE,( F  `9 m% v+ L% h8 z& ^3 y
Professor of Pediatrics, University of South Alabama, College of5 I% d4 p2 y4 W. i" c/ {8 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' U: \  R6 H7 \& He-mail: [email protected].
  e- d8 w2 k' Y- U+ Habout 6 to 7 months old, which progressively became
; X! `6 z. x* R( I, a& Ndarker. She was also concerned about the enlarge-
( _" v2 J% A, I( j# Wment of his penis and frequent erections. The child
& S2 r. }5 K  ?was the product of a full-term normal delivery, with' o5 n, q3 v4 E) s! w. i6 i5 `, u9 F0 K
a birth weight of 7 lb 14 oz, and birth length of  M7 x) P' c" y7 _: [
20 inches. He was breast-fed throughout the first year
; w9 i, [) ?2 {' V" [' T0 Vof life and was still receiving breast milk along with7 h4 o) ^8 y5 d4 w  ?$ S
solid food. He had no hospitalizations or surgery,
: x2 Q; I+ }- F# hand his psychosocial and psychomotor development
/ F2 I) P6 _: ]( c: Gwas age appropriate.
* H2 \% \' D2 ?+ rThe family history was remarkable for the father,
) h/ Q& F4 ^& ~) L) Pwho was diagnosed with hypothyroidism at age 16,, D: K. o+ i/ [% f
which was treated with thyroxine. The father’s- B3 V: O0 ]& }) n
height was 6 feet, and he went through a somewhat2 |. }( ?( \" n  U5 x
early puberty and had stopped growing by age 14., W. w( L: \9 f( j
The father denied taking any other medication. The
8 D9 p! E9 E+ d1 ]8 Lchild’s mother was in good health. Her menarche. E" C+ a2 {2 f7 R+ h2 s
was at 11 years of age, and her height was at 5 feet
1 m0 M! l, A% L* g( w$ F* s5 m) x5 inches. There was no other family history of pre-
; }) g* H8 ]1 C/ J: Kcocious sexual development in the first-degree rela-
3 v- _2 Q6 B- itives. There were no siblings.
. r) l5 C6 y6 CPhysical Examination
0 {0 a* O0 ]9 t" J3 j3 ^The physical examination revealed a very active,
; o' j# R# l  n: M2 w. f& qplayful, and healthy boy. The vital signs documented
$ d- [+ r, Z" e' Va blood pressure of 85/50 mm Hg, his length was
, T/ b+ L  H: h8 t90 cm (>97th percentile), and his weight was 14.4 kg
) D! \" n% X7 _1 r(also >97th percentile). The observed yearly growth
. o' {2 T: }9 z. bvelocity was 30 cm (12 inches). The examination of
* `6 K' }3 m) W) l" \the neck revealed no thyroid enlargement.
9 P  M# F* h5 q; J/ i  E# G0 M6 M6 LThe genitourinary examination was remarkable for
. I+ I; {* W2 Q9 [3 v; i! o3 m9 |* C5 qenlargement of the penis, with a stretched length of$ q- a& h0 D8 p& s
8 cm and a width of 2 cm. The glans penis was very well, g7 P5 G7 c6 q
developed. The pubic hair was Tanner II, mostly around3 e) k4 O6 B) r: W% T  C+ u# @0 {
540
5 A1 H( D! V$ x# eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 @+ e. L& c0 p& E6 V+ c1 gthe base of the phallus and was dark and curled. The7 \; N% }0 ~4 k0 h1 i
testicular volume was prepubertal at 2 mL each.
. l* z/ j' M! e) ?$ U2 i0 ?# BThe skin was moist and smooth and somewhat+ T" ]) u9 I1 `5 L
oily. No axillary hair was noted. There were no; I/ H* n" F% t8 Y! X! [
abnormal skin pigmentations or café-au-lait spots.
+ F# n4 Y% v6 k2 q. MNeurologic evaluation showed deep tendon reflex 2+
/ ~& m/ [0 T$ Obilateral and symmetrical. There was no suggestion; x5 k4 L) [! Y1 u8 }
of papilledema.
' N9 f; \4 ]8 ]9 ]Laboratory Evaluation( M( e3 V& N8 j  f3 e5 A! @
The bone age was consistent with 28 months by
; j: s+ R; f# A8 ~using the standard of Greulich and Pyle at a chrono-
% m9 d0 d4 ?' h+ S' Z( m3 ^1 klogic age of 16 months (advanced).5 Chromosomal1 E! z. C' |* a# k: x0 O) u7 u) ?
karyotype was 46XY. The thyroid function test. ~% `8 U6 E3 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 ]% f6 A" g/ c6 K, N* d! c7 R
lating hormone level was 1.3 µIU/mL (both normal).
( Q( C: B' D; h" U8 j# kThe concentrations of serum electrolytes, blood; P7 Q7 E; n- A: @" N) t
urea nitrogen, creatinine, and calcium all were1 D* ?( O$ H. V  M5 Z  ?* _3 A
within normal range for his age. The concentration
# q( C8 y; |+ b* y$ D/ Rof serum 17-hydroxyprogesterone was 16 ng/dL- ^, [. f% Y+ A& O% R" w/ Y
(normal, 3 to 90 ng/dL), androstenedione was 20
$ p9 F8 j; f; H8 t5 e3 C, png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* d3 r3 `  d  Q9 _5 w+ {1 ]terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( _" J, y. u: J9 ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to- H3 r: E# J9 a0 \7 M
49ng/dL), 11-desoxycortisol (specific compound S)
4 x5 F1 h9 R$ j. q" vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 I" s7 j8 {, vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* l* D' `, P6 d: z+ Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. I6 O& _! y# J$ X7 H
and β-human chorionic gonadotropin was less than
# [8 r5 R2 d$ ^5 mIU/mL (normal <5 mIU/mL). Serum follicular6 M1 @% ^2 a4 H7 ]: c
stimulating hormone and leuteinizing hormone8 h( q' p# c6 r; G3 \# G+ n5 y+ `
concentrations were less than 0.05 mIU/mL
+ D' c; T! w( V; ^" W3 G(prepubertal)., e2 \4 K# l" c/ F/ R$ ^
The parents were notified about the laboratory% Q' Z! h: c7 G: E7 h
results and were informed that all of the tests were0 E! l& V$ t3 B* v
normal except the testosterone level was high. The
3 _  g7 O! S9 F' jfollow-up visit was arranged within a few weeks to/ `& u: ]- e4 l+ x: I4 F8 B' a
obtain testicular and abdominal sonograms; how-8 s6 f$ v. C4 m4 n
ever, the family did not return for 4 months.1 @1 |9 o2 ^& Y8 C4 P% R4 K( @4 ?! h
Physical examination at this time revealed that the
6 B+ S+ _( s" i: @$ t6 Tchild had grown 2.5 cm in 4 months and had gained
3 |  K3 T+ W7 B) s7 n# x* v2 kg of weight. Physical examination remained
! v# C/ s4 i9 r: P( k( N# lunchanged. Surprisingly, the pubic hair almost com-. ?. J4 ?2 k. O/ M) D
pletely disappeared except for a few vellous hairs at
& a" R; K4 x; W6 k. qthe base of the phallus. Testicular volume was still 2
* K, G, {3 o7 A$ k3 O3 h3 lmL, and the size of the penis remained unchanged.
: {( o9 ^" n! [' x; KThe mother also said that the boy was no longer hav-
, B8 }6 L! p, Ying frequent erections.
( W* K& X) u- W% x+ C0 A% UBoth parents were again questioned about use of5 |' e# O8 ~  E" ~
any ointment/creams that they may have applied to
; E4 a0 q# b7 p: |3 ]( m8 Fthe child’s skin. This time the father admitted the" M3 _4 F  ^8 z1 S3 [; N
Topical Testosterone Exposure / Bhowmick et al 541" q0 U% N1 Z  n9 h2 [, k
use of testosterone gel twice daily that he was apply-- A( f2 r1 s$ J9 u& a
ing over his own shoulders, chest, and back area for
; c; Q5 p+ k: S8 @) g4 f$ la year. The father also revealed he was embarrassed
, }7 p% l: K! k( f& C0 Pto disclose that he was using a testosterone gel pre-& ^: U; A7 ^1 W- ?8 U5 l% s
scribed by his family physician for decreased libido$ v' g4 b# P& ^. `# H+ l+ Q& x
secondary to depression.
8 t+ g1 o* F9 ~The child slept in the same bed with parents.
. Z" Y( G, Z. Y3 |0 aThe father would hug the baby and hold him on his
% c; G' \& c0 e( achest for a considerable period of time, causing sig-
0 ]( E( u/ o0 X( Z1 H5 `8 unificant bare skin contact between baby and father.
# c* z* o1 k. M4 b- k7 hThe father also admitted that after the phone call,
" G0 j" G+ d: a, K* |) k' kwhen he learned the testosterone level in the baby
* ~5 v" S9 z2 s8 v8 ywas high, he then read the product information( i. K8 \- w) f+ r# ]
packet and concluded that it was most likely the rea-4 H9 Z& `& Q$ v- J$ z2 Q4 K" K
son for the child’s virilization. At that time, they" a( y6 ^5 v1 R
decided to put the baby in a separate bed, and the% J6 i( Z, f; m# m
father was not hugging him with bare skin and had, E9 x; r' A6 [2 `) E/ s6 ]
been using protective clothing. A repeat testosterone
) }. K. d- m" h$ ?7 |test was ordered, but the family did not go to the- g( c# {7 w/ n4 \
laboratory to obtain the test.9 h! W$ ?: _' [+ w% A3 \
Discussion
* N) S/ h6 A4 p2 f* M2 QPrecocious puberty in boys is defined as secondary  Y1 B" E1 l8 S& _5 z9 B; j
sexual development before 9 years of age.1,41 \/ O2 _6 A) ?6 _
Precocious puberty is termed as central (true) when
8 g( G- N2 r3 J6 [4 ^4 zit is caused by the premature activation of hypo-, k$ R# m8 e) O+ _
thalamic pituitary gonadal axis. CPP is more com-
8 _# _9 z. Y8 l( `! [- u8 m4 u3 n. nmon in girls than in boys.1,3 Most boys with CPP
& A; k+ x' |* T4 |! _3 }) omay have a central nervous system lesion that is
4 p" J* w: J6 e. k. S$ k0 D/ }responsible for the early activation of the hypothal-
5 y" `. T2 b! q1 r( I5 ~" m" vamic pituitary gonadal axis.1-3 Thus, greater empha-! @" M: t7 K. q; C3 C
sis has been given to neuroradiologic imaging in8 X7 z+ e6 V+ ?7 i* x
boys with precocious puberty. In addition to viril-
- k! k, Y( C' f2 @- O! u8 F- o. U, Yization, the clinical hallmark of CPP is the symmet-
6 b" L% K6 K$ V4 m( w9 ~2 l9 vrical testicular growth secondary to stimulation by3 r$ Y$ l4 Q: s  e
gonadotropins.1,3
+ P* e; t) R) V6 I9 O2 n( VGonadotropin-independent peripheral preco-$ q1 L$ T! M5 {) w$ o" E$ S5 O
cious puberty in boys also results from inappropriate
! k) C! C: }; i( M5 Eandrogenic stimulation from either endogenous or# O0 E+ \8 ], |' s. y
exogenous sources, nonpituitary gonadotropin stim-
$ E; m9 V* t( S: e# B3 L2 C8 {ulation, and rare activating mutations.3 Virilizing, ]7 F; }3 C/ E8 N
congenital adrenal hyperplasia producing excessive4 m! W$ T; `/ D, G. f: a+ i
adrenal androgens is a common cause of precocious
6 A/ l8 e: ~3 I. [9 ^# gpuberty in boys.3,4
8 }2 E1 ]) ?5 e9 l8 y- |+ T  M! @1 ~The most common form of congenital adrenal
; K. e8 K$ t* Q& Ihyperplasia is the 21-hydroxylase enzyme deficiency.4 w1 S9 I- O( w( Q' Q
The 11-β hydroxylase deficiency may also result in
! j, W. y3 X! z8 ^" [# iexcessive adrenal androgen production, and rarely,
  A- ~! H2 P$ P* M  ^* L# ~% W3 Jan adrenal tumor may also cause adrenal androgen7 e9 m' d' C. Q4 u) a1 Q
excess.1,3$ \7 W0 Z* R2 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( L1 n1 K; I: r. q542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 k. F0 I" s7 F+ G/ ], O8 S
A unique entity of male-limited gonadotropin-! ]/ C, I0 f, B; U* {8 t
independent precocious puberty, which is also known
9 d, A. c; I2 Y6 @+ p/ W3 @as testotoxicosis, may cause precocious puberty at a( [1 U0 J7 `1 Q! q/ m3 Z( s& D' `
very young age. The physical findings in these boys
* F+ d, o/ _% ~7 Lwith this disorder are full pubertal development,5 K) X; H2 m- k  B" r9 C, d9 }
including bilateral testicular growth, similar to boys
9 E8 G. v/ n: e& D4 Iwith CPP. The gonadotropin levels in this disorder
! T. T0 x0 E# Q( ?* a/ P, dare suppressed to prepubertal levels and do not show# q& `  }  b3 f. g4 l# u
pubertal response of gonadotropin after gonadotropin-
2 l2 M: X5 `, xreleasing hormone stimulation. This is a sex-linked8 y6 t# X( ^; @% q( e" i
autosomal dominant disorder that affects only( L1 l! |# T% J. a) w2 K) b, J
males; therefore, other male members of the family  Q, [" X' _" P
may have similar precocious puberty.3
  I# u" f, J/ Q/ C$ FIn our patient, physical examination was incon-
) v9 S% D; W3 g( L: Asistent with true precocious puberty since his testi-
/ F$ q6 E% l3 W- S2 K8 L( qcles were prepubertal in size. However, testotoxicosis' i. W% t, P0 v& Y
was in the differential diagnosis because his father
- }" b0 y* q8 M) e# zstarted puberty somewhat early, and occasionally,
$ O) |0 t. d- l, T* j' {* ]" Otesticular enlargement is not that evident in the  Z, Q; s3 J) }* X0 W) j
beginning of this process.1 In the absence of a neg-
  J" d* o6 S. {% R! P; Rative initial history of androgen exposure, our+ a9 s6 T+ S7 [" Y+ E
biggest concern was virilizing adrenal hyperplasia,) l6 ]! ?6 ~. I' F
either 21-hydroxylase deficiency or 11-β hydroxylase
0 A/ c. L& C4 v( G9 n' c% ldeficiency. Those diagnoses were excluded by find-' k; s4 c- y3 H+ @4 l5 s0 C5 Z
ing the normal level of adrenal steroids.* Z* @  H; O4 T) f8 [
The diagnosis of exogenous androgens was strongly6 m" \' v+ e  q
suspected in a follow-up visit after 4 months because
/ `8 G/ \- a7 u: Ythe physical examination revealed the complete disap-
* p- g! Z, Z9 U2 B3 }" Lpearance of pubic hair, normal growth velocity, and
/ d0 G1 n- u  P4 p7 j, a& idecreased erections. The father admitted using a testos-0 r& s) a9 S9 {# ~1 R9 ~* k
terone gel, which he concealed at first visit. He was7 H- E  t$ Y, a  g
using it rather frequently, twice a day. The Physicians’4 ^) V5 i6 P: {! V( m0 }$ h! P
Desk Reference, or package insert of this product, gel or- D+ x' x( T) C* [* @+ Y
cream, cautions about dermal testosterone transfer to
- e; E2 T' S" N5 f! B/ yunprotected females through direct skin exposure.- d1 O. u4 A+ y8 o/ {- j% ]5 D! [
Serum testosterone level was found to be 2 times the
) F4 D% ]8 X1 N( n7 j- |# ubaseline value in those females who were exposed to) k" \9 B* `5 C
even 15 minutes of direct skin contact with their male
/ L7 j2 ]3 E0 M# Jpartners.6 However, when a shirt covered the applica-2 V  T( a9 e  e) Y
tion site, this testosterone transfer was prevented.: b; {" M5 W/ i/ X8 B( R3 @! x
Our patient’s testosterone level was 60 ng/mL,
7 G' {  z0 j6 b1 {5 ^% H  X; P1 L2 uwhich was clearly high. Some studies suggest that& f/ ^/ w  W( D  B* D
dermal conversion of testosterone to dihydrotestos-
6 `  Z! B. T5 W% @6 g& @terone, which is a more potent metabolite, is more
9 f5 N% ?' w; T0 @4 Z0 Tactive in young children exposed to testosterone" ]8 h/ Q  u6 }- h' D
exogenously7; however, we did not measure a dihy-# ^5 f8 o. l1 q
drotestosterone level in our patient. In addition to
1 y1 ~& E2 `) [/ M( n* v* f  N2 f. Fvirilization, exposure to exogenous testosterone in- s2 a. b) F) B) R
children results in an increase in growth velocity and: ~# {2 r: m* Z1 [( z7 b
advanced bone age, as seen in our patient.( k7 U# i2 [. l. ~1 d$ A  e0 Q
The long-term effect of androgen exposure during, s+ ^- j9 W( O
early childhood on pubertal development and final
& Z+ s' S* f0 iadult height are not fully known and always remain
1 a4 V0 n% e, m( m3 F1 oa concern. Children treated with short-term testos-
. k3 \5 W3 R- t& R/ h( {6 I. F' E: qterone injection or topical androgen may exhibit some0 U, G3 o5 C! {% s6 Q1 q9 X
acceleration of the skeletal maturation; however, after% M& O! X. Z. D0 c- X# q
cessation of treatment, the rate of bone maturation
: [3 L3 T1 @6 Qdecelerates and gradually returns to normal.8,9; Q  B$ C! Q' W* G1 }" Z7 j
There are conflicting reports and controversy
4 P$ q4 [0 h4 u9 h; {0 }over the effect of early androgen exposure on adult' k$ u; {9 f  M* U% d5 u0 j
penile length.10,11 Some reports suggest subnormal
% `# H# J' O# [+ f+ Y6 w! Qadult penile length, apparently because of downreg-
- i/ ^) P$ p( Q& e& c5 Bulation of androgen receptor number.10,12 However,* x) s* r( [$ B
Sutherland et al13 did not find a correlation between' a+ l2 m. w  w3 P* [
childhood testosterone exposure and reduced adult2 F+ c4 r& m& |. L
penile length in clinical studies.
7 A4 q0 f- ^! n8 X- P- y, S* I* ^Nonetheless, we do not believe our patient is; ^9 i% C2 C& Z" E& k6 P& s; K
going to experience any of the untoward effects from  `. t7 b3 Y$ x9 Z' X
testosterone exposure as mentioned earlier because$ e" m3 L( n) ]$ D2 u+ i
the exposure was not for a prolonged period of time.
  Z* q$ r& L8 Z; C% u& zAlthough the bone age was advanced at the time of0 }+ ^" S7 }" L/ ^$ s
diagnosis, the child had a normal growth velocity at, X" r5 ~/ C9 r% ?5 \
the follow-up visit. It is hoped that his final adult
  L$ f  E2 ]8 \height will not be affected.
* K" |) X' A& I; Y7 V9 h( t  A+ vAlthough rarely reported, the widespread avail-
: T: w* z; M- v3 L. ?  Tability of androgen products in our society may
  N8 U( o" a3 J5 l' Iindeed cause more virilization in male or female
7 m4 C% L" h2 b9 rchildren than one would realize. Exposure to andro-
/ X1 Q$ {; ]0 k( m, egen products must be considered and specific ques-+ h  {8 ~5 J2 ]3 \5 v8 P- c8 P
tioning about the use of a testosterone product or
1 b) X: H) ?% s/ ~) ^3 ~- @& ngel should be asked of the family members during0 W. o# K2 `2 I7 O7 Y
the evaluation of any children who present with vir-
$ F9 P% l$ u  r& ~ilization or peripheral precocious puberty. The diag-  ^$ g, a- z! J8 Y. F$ M2 D
nosis can be established by just a few tests and by6 E: G; L' g, X) {6 S2 q% |" i
appropriate history. The inability to obtain such a
* S- `$ M1 s# B6 k" Ahistory, or failure to ask the specific questions, may% m* c. I3 Q, r4 J( w
result in extensive, unnecessary, and expensive! S: h2 k5 E+ w* b# P9 {1 @
investigation. The primary care physician should be
% R+ D- A& c' j7 B$ a4 {+ F0 kaware of this fact, because most of these children$ E7 F+ I6 y2 t" @6 N& F
may initially present in their practice. The Physicians’
2 I9 \& `6 L8 R# L) }; c3 d+ t8 `( eDesk Reference and package insert should also put a) `; s! R/ m  m0 q" O8 }
warning about the virilizing effect on a male or
7 s# ~1 D/ _6 l: s/ ~1 C2 Nfemale child who might come in contact with some-: z' N  A" e2 s5 D
one using any of these products.
4 ~* g3 _8 R, e' B$ \6 V0 GReferences
; @8 l( f0 d" u+ n% E( O7 F1. Styne DM. The testes: disorder of sexual differentiation7 x9 b. o/ B7 K" ]
and puberty in the male. In: Sperling MA, ed. Pediatric
& q, ]: [" }) w5 E" |9 ]1 ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" k6 E- J3 y4 o; Q/ a6 ]. D7 o
2002: 565-628.
* R3 N# G# {9 c& }3 a/ C: R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- v/ g/ V! _4 D. U: P/ E3 k: x- U4 b" Ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old7 j9 m+ W/ x/ J: a! s
Boy Induced by Indirect Topical" D$ j6 c/ F( x1 Q5 C6 t& P
Exposure to Testosterone
  r6 m. K- c4 W5 F! {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- d& n  r2 ?3 Nand Kenneth R. Rettig, MD1# @4 T- }* t2 [1 o: `3 L* O# c
Clinical Pediatrics
+ V! _, y/ U* X0 b( x4 AVolume 46 Number 6
3 }$ F4 K) M6 ?4 @0 ]* d  BJuly 2007 540-543  b5 K( z8 k  R
© 2007 Sage Publications
4 {; O  G/ _  Y$ v7 \5 f10.1177/0009922806296651. S& ~0 D1 G. O" T* E
http://clp.sagepub.com
: ], q( o* V% v; e% ?4 A) p. Lhosted at2 Q7 i; e- Z% W, s% v
http://online.sagepub.com
, n9 D, i- J0 C$ BPrecocious puberty in boys, central or peripheral,# j1 x5 r6 J1 r0 }: x
is a significant concern for physicians. Central; e; ]3 F  Q3 w$ M/ A, O
precocious puberty (CPP), which is mediated
/ J7 @% Q1 g! ~4 Z8 [0 L$ r, Wthrough the hypothalamic pituitary gonadal axis, has
( i; c0 R* t+ M, na higher incidence of organic central nervous system7 H! M" U( P1 O* s% P
lesions in boys.1,2 Virilization in boys, as manifested; r0 \1 d+ Z" c: S
by enlargement of the penis, development of pubic
  v/ [  a7 ]3 \( x) Q2 Q9 Yhair, and facial acne without enlargement of testi-
+ @5 R$ q$ A6 rcles, suggests peripheral or pseudopuberty.1-3 We
6 t4 @. r# ]0 A& i- ereport a 16-month-old boy who presented with the7 t* U; w4 g' O- ]& g9 X
enlargement of the phallus and pubic hair develop-+ |# C4 ]2 D) l; Q
ment without testicular enlargement, which was due# B2 O2 ?8 |( c7 K! e7 A
to the unintentional exposure to androgen gel used by4 x5 _% Y# m5 R6 o! w0 b' k1 p
the father. The family initially concealed this infor-
3 X8 \( H. _7 s5 _$ G9 w0 {3 fmation, resulting in an extensive work-up for this
* u( J9 Q, p/ y  Y( F- Tchild. Given the widespread and easy availability of4 W, m+ T  P2 ]
testosterone gel and cream, we believe this is proba-
8 c' J# f. N1 r; W7 n, O! dbly more common than the rare case report in the
5 X/ f, C+ @3 B8 P* _2 `7 Mliterature.4' K  q8 S0 m* v
Patient Report3 V* o. o4 ^" H' [
A 16-month-old white child was referred to the
* ]$ H4 k- o% w% }/ i. aendocrine clinic by his pediatrician with the concern
3 e; W2 D! J$ k( ~+ N  Lof early sexual development. His mother noticed
$ x# a/ v; c1 W  i& K& J' mlight colored pubic hair development when he was
: _' }* R( h; x; p, Z+ X) NFrom the 1Division of Pediatric Endocrinology, 2University of9 I" K8 P4 C$ t! c3 N) ?% l- b
South Alabama Medical Center, Mobile, Alabama.1 u% s' O4 l5 D2 @) v
Address correspondence to: Samar K. Bhowmick, MD, FACE,. L# B' _, U/ h, r9 ^: z, c/ v' }
Professor of Pediatrics, University of South Alabama, College of
4 X4 B5 w: B/ X9 w& RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, A: G* t) m9 k
e-mail: [email protected].7 O5 p  U8 l) ?; X* m9 o
about 6 to 7 months old, which progressively became* d- F& O7 H1 {9 v7 O/ |
darker. She was also concerned about the enlarge-7 s7 U$ R7 |" y, I
ment of his penis and frequent erections. The child# `) O9 D3 r/ G; H
was the product of a full-term normal delivery, with
% l7 f9 k. {5 w0 |! m5 I/ ]- |a birth weight of 7 lb 14 oz, and birth length of& i) \" ^9 F  I/ b
20 inches. He was breast-fed throughout the first year# M4 ]: A! Z2 a$ B; w) I: E
of life and was still receiving breast milk along with
- V& ?' M4 Z. q1 b& Ssolid food. He had no hospitalizations or surgery,5 N. V4 N/ {% [( `" D8 D: h
and his psychosocial and psychomotor development# k) m8 A& i& |- N* d, e& g
was age appropriate.. W$ t% a( s  D. N" l6 N
The family history was remarkable for the father,7 \, u4 _; o  z; E5 g8 S; B
who was diagnosed with hypothyroidism at age 16,$ x/ [2 s: v: E+ c2 v
which was treated with thyroxine. The father’s
( s' _% @) `/ b6 oheight was 6 feet, and he went through a somewhat
0 {: N. B3 L+ a, ~9 f7 l" t, Vearly puberty and had stopped growing by age 14.7 u: G; [7 q6 ]- y
The father denied taking any other medication. The
1 P$ f3 |: U- i9 H; Wchild’s mother was in good health. Her menarche" D. v: d  e: n, y) v( |
was at 11 years of age, and her height was at 5 feet7 L% o/ f" s) E  |# j" I" E5 d, e& X
5 inches. There was no other family history of pre-
) |) e% \1 G$ \/ l5 y+ Xcocious sexual development in the first-degree rela-; \, y# R( e$ E4 y2 ~9 w7 _
tives. There were no siblings.
8 X4 g/ V9 U+ ^0 PPhysical Examination
" ]) k3 R+ r) Z8 lThe physical examination revealed a very active,) r1 N, O/ b0 ]/ ?0 f6 n0 a
playful, and healthy boy. The vital signs documented  w3 g$ s, |" ?4 H) a. ?/ o; Y! v
a blood pressure of 85/50 mm Hg, his length was3 p. B6 ?: s5 C% ~1 d, k$ {
90 cm (>97th percentile), and his weight was 14.4 kg
2 s- E0 F) N4 K+ Y3 d  T(also >97th percentile). The observed yearly growth) y- o9 @9 R$ M! K
velocity was 30 cm (12 inches). The examination of
1 a0 I: Q  t. b, l) u9 R. M& q& \- sthe neck revealed no thyroid enlargement.6 j, J* ?1 O, e% M' q" ?  [# B, H* g
The genitourinary examination was remarkable for
( }5 S& v( y/ Q* |* N7 \enlargement of the penis, with a stretched length of
$ E6 @5 R- }, ^6 }8 cm and a width of 2 cm. The glans penis was very well
) @" i' U: _" X3 h+ L- K4 H/ l, Jdeveloped. The pubic hair was Tanner II, mostly around7 J1 T# w! Q- E4 R9 ?' t: Y
540
$ Y, C' `: V0 b+ wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. F7 R: X: u2 o' p- N, |
the base of the phallus and was dark and curled. The
+ k& ?) A7 U* |8 utesticular volume was prepubertal at 2 mL each.' \- u6 r8 _4 {
The skin was moist and smooth and somewhat9 d6 I! w: Y0 F2 _3 n" V) L
oily. No axillary hair was noted. There were no
% x6 s& E5 d/ I* P# [% G( Xabnormal skin pigmentations or café-au-lait spots.
9 B# c) S& U: z9 wNeurologic evaluation showed deep tendon reflex 2+
7 i) k) W8 v& O7 N) ~7 ^bilateral and symmetrical. There was no suggestion
, z9 c. A9 w1 Vof papilledema.
5 u0 M$ V& `0 D1 t- S+ a8 fLaboratory Evaluation5 g; T9 @! |5 e# r3 V5 t; \
The bone age was consistent with 28 months by
. e% l/ `. c  y' U7 H) v4 p( Zusing the standard of Greulich and Pyle at a chrono-: s2 a) i9 d9 x+ j! N
logic age of 16 months (advanced).5 Chromosomal! T, m, p- H/ Q7 K
karyotype was 46XY. The thyroid function test
8 f+ j& `# l& d- G3 d6 e+ Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( q8 F5 h+ ~0 Klating hormone level was 1.3 µIU/mL (both normal).
4 R0 t2 Z4 D) t2 e8 L( x) }( mThe concentrations of serum electrolytes, blood1 Z1 T8 d  _, H7 v
urea nitrogen, creatinine, and calcium all were
0 H/ r  w$ j7 z. Zwithin normal range for his age. The concentration
6 C0 l8 [' n* ^& Jof serum 17-hydroxyprogesterone was 16 ng/dL
! x0 h6 `3 W8 |5 |- d0 `+ f(normal, 3 to 90 ng/dL), androstenedione was 20
  e% N8 ~1 L( u2 I. V5 B/ P* |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 m  P) ]- s, }% D6 e$ D; [
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! Y2 }- D' ~% \' m0 u+ V- C. q1 Bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ K" Q  J& r! |2 }49ng/dL), 11-desoxycortisol (specific compound S)
+ f5 S; o  B" A& X) [+ Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: b' I1 E- m% Z+ n& g1 w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 O1 P4 ]2 e# ^5 p0 k# v1 `7 M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 j) P% k. y" ?
and β-human chorionic gonadotropin was less than
0 u+ u  }& N" t$ y5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 a' o* Z8 E- x* E. `2 T9 k% estimulating hormone and leuteinizing hormone
2 j6 c+ E3 A2 M  a; U8 Fconcentrations were less than 0.05 mIU/mL
" M$ x9 F$ p; {. r3 F# Z& b(prepubertal).
* ?: u. ?3 K- X& W1 r# n4 {; uThe parents were notified about the laboratory
( S+ Z  H4 D( g. g2 Hresults and were informed that all of the tests were
7 s' E" {" n4 R* g7 K- F% \) wnormal except the testosterone level was high. The
0 f; w5 Q6 }$ Z* j/ tfollow-up visit was arranged within a few weeks to( v- y; M3 V1 V% z' x
obtain testicular and abdominal sonograms; how-
2 C4 A: b+ Q; R1 n: c" r  ]# lever, the family did not return for 4 months.( k" r6 U+ ~& T: \  P
Physical examination at this time revealed that the" z) j' V5 M- U1 q2 Z
child had grown 2.5 cm in 4 months and had gained- ~2 Y  {& R  ]) f" l
2 kg of weight. Physical examination remained2 K  P) J/ |, z; ]. r
unchanged. Surprisingly, the pubic hair almost com-7 y# U; f1 K8 V
pletely disappeared except for a few vellous hairs at( K  P5 _  X) g4 \5 q+ ?% B- _2 c
the base of the phallus. Testicular volume was still 2! t) R0 ^* ]; @  {2 P$ i
mL, and the size of the penis remained unchanged." Y! d/ S, G5 {9 X/ H2 M: m
The mother also said that the boy was no longer hav-1 ?" i4 M! d* d" D
ing frequent erections.  b0 n  M9 E( h; ]
Both parents were again questioned about use of" W# U' X1 A2 l  ^
any ointment/creams that they may have applied to
2 P9 h0 o5 @2 ^3 O, X0 D. wthe child’s skin. This time the father admitted the
4 C5 M1 M7 R9 G9 B4 T; kTopical Testosterone Exposure / Bhowmick et al 541* Z* |$ f% D$ d0 |+ Q
use of testosterone gel twice daily that he was apply-3 w7 I& Z# E8 Q, m5 Z2 x& z- O
ing over his own shoulders, chest, and back area for
( ]* e, |( o0 a# xa year. The father also revealed he was embarrassed/ }$ v6 k7 d; }& _3 \
to disclose that he was using a testosterone gel pre-5 s- |' i: e% k0 F
scribed by his family physician for decreased libido8 E! m) f/ @/ h
secondary to depression.! r! `. u5 ]: O% o- [% V* |' n! u6 G& u$ s
The child slept in the same bed with parents.6 a6 C0 o) x; N) k) s
The father would hug the baby and hold him on his! L( R0 P2 h2 v7 E
chest for a considerable period of time, causing sig-
6 f4 L  [5 i3 \! |/ A0 Vnificant bare skin contact between baby and father.6 P" W" ^" ]  ?* I4 b1 O7 R
The father also admitted that after the phone call,  s$ f: Z5 E! d  P) j3 R7 n
when he learned the testosterone level in the baby2 s, Q5 P8 ~2 X5 ?1 Q/ U
was high, he then read the product information" }* v' C7 _$ w, w3 z# B# w. u
packet and concluded that it was most likely the rea-
( u: t1 H; q+ W  R% T- z( Fson for the child’s virilization. At that time, they
2 c% h; E6 w( B( Zdecided to put the baby in a separate bed, and the
5 p& V1 I$ s- u1 u- }father was not hugging him with bare skin and had0 a- ^2 |- \; q+ U) L- i- [; }# T6 `
been using protective clothing. A repeat testosterone
$ c% ^, t: f5 O8 `test was ordered, but the family did not go to the. z4 u4 q, E7 ^  V/ _" N1 d; M
laboratory to obtain the test.. _* f! Z1 `- h5 o# J# g
Discussion* v' B. p% Q' U* R6 \5 [8 ]
Precocious puberty in boys is defined as secondary
  F, ^- `2 z2 o, ysexual development before 9 years of age.1,4& a6 z0 H4 G6 K- K! k
Precocious puberty is termed as central (true) when
9 T8 a: [3 Y1 E+ _2 \it is caused by the premature activation of hypo-) E- g% k8 z6 H. N* v
thalamic pituitary gonadal axis. CPP is more com-/ z+ B% C: l  J" i7 m9 b+ `
mon in girls than in boys.1,3 Most boys with CPP* t  o1 `+ R6 S1 o7 m
may have a central nervous system lesion that is
: O9 V) o2 j4 j! t, cresponsible for the early activation of the hypothal-
( {" ]( g7 S% p8 eamic pituitary gonadal axis.1-3 Thus, greater empha-3 s) x7 O2 _9 T+ w& t+ }' ~4 }
sis has been given to neuroradiologic imaging in% {- I4 [9 A6 I" U; X
boys with precocious puberty. In addition to viril-
7 c" Q2 I6 b  ^  x2 I& o& D$ Fization, the clinical hallmark of CPP is the symmet-5 b) l1 S! T4 \' l1 H" Y" s  R
rical testicular growth secondary to stimulation by9 ^( q! O: v: U1 v9 Q/ C
gonadotropins.1,3
5 T+ g( l& W6 X. g" p; X6 rGonadotropin-independent peripheral preco-, s& I, P# L0 B3 s% K) J6 }4 V
cious puberty in boys also results from inappropriate* [) s+ E! t% h: w& e3 h
androgenic stimulation from either endogenous or% K; d* P, I5 _& K5 j
exogenous sources, nonpituitary gonadotropin stim-
2 d5 I& R- d. f: Z/ eulation, and rare activating mutations.3 Virilizing' `- R. ^4 r6 g3 `7 H
congenital adrenal hyperplasia producing excessive& p  l- m2 |1 ~2 a. y
adrenal androgens is a common cause of precocious
: @' u2 G' p, y1 O. `9 Q$ ~puberty in boys.3,4% I) J, r1 ^0 G
The most common form of congenital adrenal
, I0 q# [$ @* _- v0 X( Nhyperplasia is the 21-hydroxylase enzyme deficiency.+ w( v9 e* D2 `
The 11-β hydroxylase deficiency may also result in
" h% w% I# d0 N; Eexcessive adrenal androgen production, and rarely,
* Y- _, K8 ~1 ian adrenal tumor may also cause adrenal androgen$ {6 q4 q; I/ }4 F( ^, \9 b$ p
excess.1,3! `1 V3 z! s6 S5 g( C+ o# M' V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 l3 J9 I5 w5 k- f) f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, C" d" T! A/ Y: uA unique entity of male-limited gonadotropin-
3 K3 d, K6 v) z) e. iindependent precocious puberty, which is also known3 F) ?+ M8 Y# U/ i( J- f) U
as testotoxicosis, may cause precocious puberty at a
# {! x0 Z1 U, X" O7 F' e; `very young age. The physical findings in these boys
9 e% F0 ^& K1 [/ g( `1 w5 A6 d4 [  ywith this disorder are full pubertal development,& {6 O- {* F2 m, l
including bilateral testicular growth, similar to boys/ K# w7 S* r5 u1 o) R8 I+ G
with CPP. The gonadotropin levels in this disorder7 y! v0 W' E/ {; W2 ]# f3 n
are suppressed to prepubertal levels and do not show+ [8 q" O4 c/ b9 G' h- n* L  J/ M) m7 \
pubertal response of gonadotropin after gonadotropin-
( J1 b0 ~& Z/ n* ]% H2 i$ c: Vreleasing hormone stimulation. This is a sex-linked; b: R; Q2 R, }& v: h, x
autosomal dominant disorder that affects only
; Z1 D: m( @! _8 C* D8 z& u/ @males; therefore, other male members of the family0 g+ R& S. B7 P$ H, T
may have similar precocious puberty.3& v& _9 W) @: q& p8 Z
In our patient, physical examination was incon-$ y4 M8 o$ ?4 a; f. i' p' @: {3 }+ \
sistent with true precocious puberty since his testi-- e. y, z! K% h% u! j2 [
cles were prepubertal in size. However, testotoxicosis
7 P+ J# O( Z& g6 M; ywas in the differential diagnosis because his father! X$ V$ K: }8 I, g: T, u, |8 h
started puberty somewhat early, and occasionally,) W* l4 n; L' v/ H2 A0 Z
testicular enlargement is not that evident in the8 R  \6 p4 x& W) Y# D& }; \' G% m
beginning of this process.1 In the absence of a neg-
" X! v! C3 d5 `( ]9 @ative initial history of androgen exposure, our* I+ A* x3 `& H+ O. ]( B( G
biggest concern was virilizing adrenal hyperplasia,
  P2 a% B% A) g2 x3 f) o9 a" M4 Peither 21-hydroxylase deficiency or 11-β hydroxylase
. t) S( h2 Z/ \- Mdeficiency. Those diagnoses were excluded by find-
+ a; R0 Z; y- R( }0 W2 k2 cing the normal level of adrenal steroids.5 R6 {* R5 X4 z$ _; q
The diagnosis of exogenous androgens was strongly
) i9 m2 v6 _& N3 ~) Msuspected in a follow-up visit after 4 months because
9 C% g5 g/ g) R. kthe physical examination revealed the complete disap-
# N2 {2 v7 i  Apearance of pubic hair, normal growth velocity, and  ]# t" @; [3 h7 ]1 [, e
decreased erections. The father admitted using a testos-
+ n% a" Y* y  ]% m6 _8 N3 _' y# rterone gel, which he concealed at first visit. He was! E; h1 \; Q" F* [% p- _
using it rather frequently, twice a day. The Physicians’
; W5 U! g# I! Q7 x3 W9 q' c( \Desk Reference, or package insert of this product, gel or. k% b' A* ^; V) I3 E: m
cream, cautions about dermal testosterone transfer to
4 O" [/ ?0 ]3 M4 j# ?9 r/ U3 g' ounprotected females through direct skin exposure.
7 T- W1 b9 W9 oSerum testosterone level was found to be 2 times the- R$ f/ M4 J8 l2 [% |% {+ v% ~
baseline value in those females who were exposed to7 T% m: E2 r, k9 F4 M
even 15 minutes of direct skin contact with their male" _& l7 ~) q* r! l
partners.6 However, when a shirt covered the applica-% f0 m0 R2 f# [4 _! L. K; |
tion site, this testosterone transfer was prevented.
* |2 h3 Z1 j& W8 }Our patient’s testosterone level was 60 ng/mL,9 M3 N1 ?0 n7 v, W0 U) f
which was clearly high. Some studies suggest that' |' n* g2 f+ o# I
dermal conversion of testosterone to dihydrotestos-
' h4 x7 R9 h, {- c7 ^terone, which is a more potent metabolite, is more
7 R# Z& ]4 g4 G5 t1 ractive in young children exposed to testosterone
! N; @  M: b% ^7 c! U8 wexogenously7; however, we did not measure a dihy-" a) i4 V' X; k* Y
drotestosterone level in our patient. In addition to
: c6 @* d% ]0 q# u$ {6 n( Hvirilization, exposure to exogenous testosterone in
! S- y3 a. s9 |0 Mchildren results in an increase in growth velocity and3 a" c4 F7 {! o+ C% |6 {, s
advanced bone age, as seen in our patient.. a. d2 e) k: T$ Q- t* f5 Q6 [
The long-term effect of androgen exposure during" G; i$ L9 e( s* ?" n. s5 e. A0 m
early childhood on pubertal development and final  O6 l! `6 e- `' P
adult height are not fully known and always remain; P# L- |. |% Y$ u
a concern. Children treated with short-term testos-7 L7 Y* b$ T" w/ A; I3 V- e8 s
terone injection or topical androgen may exhibit some6 ]9 a5 b& Q% H! y
acceleration of the skeletal maturation; however, after3 T4 `1 Z0 ?- @& K
cessation of treatment, the rate of bone maturation
! M4 V+ Y4 B8 K0 Cdecelerates and gradually returns to normal.8,9
( s7 {$ r3 c% X0 e) ?There are conflicting reports and controversy* F; O( ^  O; o$ l2 E/ T  T" `
over the effect of early androgen exposure on adult0 S0 l- C$ `9 ~
penile length.10,11 Some reports suggest subnormal
4 o' Y# x: t/ y5 Fadult penile length, apparently because of downreg-, ~' F" ^" [! X4 ?% N
ulation of androgen receptor number.10,12 However,) Z( V& Q5 l9 b+ G) Y
Sutherland et al13 did not find a correlation between
+ B% a$ o6 c+ i6 R" b2 J) v! t- R8 rchildhood testosterone exposure and reduced adult
. e5 u2 ~, N* h1 d! Y$ V- {' Dpenile length in clinical studies.
8 l7 i$ `7 v, |8 j) S* mNonetheless, we do not believe our patient is0 z2 A$ i  ?) `' g9 `. Q
going to experience any of the untoward effects from+ o' J& }( `9 ?. M+ @
testosterone exposure as mentioned earlier because9 x, X+ [& z6 ^$ S6 O
the exposure was not for a prolonged period of time.
3 |! ?2 w2 L0 x, V  ^$ dAlthough the bone age was advanced at the time of( G, v2 H% d% }5 D1 @+ Q: B
diagnosis, the child had a normal growth velocity at
8 H! H0 L9 M% l+ y+ R1 Tthe follow-up visit. It is hoped that his final adult
8 M6 X/ x* U7 @& I* _" X% [3 Qheight will not be affected.1 V5 M$ r  x  Y( d, T& X0 P
Although rarely reported, the widespread avail-
9 n( {3 r9 V5 g3 @5 _9 f1 Z# R$ ~) Lability of androgen products in our society may
, S' u3 ?! y. D4 }% u: Oindeed cause more virilization in male or female7 |# C' b- n7 b7 K
children than one would realize. Exposure to andro-
6 k4 g- A' |' j. Y$ Wgen products must be considered and specific ques-# S$ R) ~9 |9 v6 |1 Z
tioning about the use of a testosterone product or/ a% \) T( }! Y" D
gel should be asked of the family members during1 v" e0 u4 H* j/ z! [
the evaluation of any children who present with vir-" u7 [. \! C% \2 o# E
ilization or peripheral precocious puberty. The diag-) U8 P+ g$ u* T$ {3 r: U) C
nosis can be established by just a few tests and by
% @$ K( [  }5 n4 `, ^+ J% [appropriate history. The inability to obtain such a$ q& q( p+ `0 q9 \5 U; V
history, or failure to ask the specific questions, may- v6 B& L2 @- z  O" E; U4 K  g
result in extensive, unnecessary, and expensive
) w# |# ]) Q. o: e+ D, tinvestigation. The primary care physician should be' W+ ~% F" F1 f! X  U" {8 x
aware of this fact, because most of these children
8 O) D+ }2 \& m0 Z- h# p, X/ g- bmay initially present in their practice. The Physicians’: x% c* g; p$ P! F/ h' s4 v
Desk Reference and package insert should also put a: g* F+ ^' r  M3 c
warning about the virilizing effect on a male or( B' e/ y* A1 }7 i
female child who might come in contact with some-3 S% l, @7 {) a) Q$ S3 _  w3 z
one using any of these products.
4 E9 X# b9 ^/ D4 MReferences) X( C; V' m+ O  w: x8 |$ ?
1. Styne DM. The testes: disorder of sexual differentiation
! X9 z% r; k! f0 J3 M, wand puberty in the male. In: Sperling MA, ed. Pediatric& w6 _3 ?" s* U( ?+ {3 x/ g
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& _) Z, {1 e9 b$ }: L, |5 y5 E
2002: 565-628., f& g) N0 f% x" }" X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ H+ a5 ^* I+ R/ L
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
+ w% t+ w% x% ^3 T4 e1 c- L9 x
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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