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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
/ D# f1 v; a  T# O/ e$ `Boy Induced by Indirect Topical& j* f: S: y" {- I/ b5 A2 ~% |
Exposure to Testosterone
* N6 j, ^6 H" N: W1 GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. q, R' w7 M; i1 n8 `& H& q$ j8 J2 fand Kenneth R. Rettig, MD1
. j) Z" t/ e3 EClinical Pediatrics1 ~: D1 `8 j. g2 I) J" @
Volume 46 Number 6+ t' m1 g: M1 M2 |3 c
July 2007 540-5437 L+ D2 E4 S/ Y- ~
© 2007 Sage Publications
* r+ C1 s8 c) q" V* ~10.1177/0009922806296651
: m5 p" @- m" O( Xhttp://clp.sagepub.com, _4 A6 D1 W- x" j* i) ^+ }
hosted at' `6 Q7 v5 {" T
http://online.sagepub.com- o1 h% P3 `. i" R
Precocious puberty in boys, central or peripheral,+ [8 q! \& m- i
is a significant concern for physicians. Central; D  f3 F  n2 S0 |- m
precocious puberty (CPP), which is mediated& n' L# ~" F9 m4 o/ W
through the hypothalamic pituitary gonadal axis, has
) P  [5 ?, [$ s# l* Q+ h' Ca higher incidence of organic central nervous system$ f: U5 k1 X3 s7 |0 b: ~5 |2 u
lesions in boys.1,2 Virilization in boys, as manifested
' X" v; X# @3 _6 t+ k( hby enlargement of the penis, development of pubic0 w, a  t8 E" c7 N9 `
hair, and facial acne without enlargement of testi-0 Y( e1 p( V1 J# b
cles, suggests peripheral or pseudopuberty.1-3 We
: c2 ^2 {) j5 Z; G# v- b( }' greport a 16-month-old boy who presented with the
* R2 x, z# M; Lenlargement of the phallus and pubic hair develop-1 \3 Q3 V# L$ V5 t: A4 e8 G& w2 T, {
ment without testicular enlargement, which was due
% j, p4 M% N5 i8 O# Q  w  hto the unintentional exposure to androgen gel used by
1 k* q4 t- }9 h# O6 F5 x# _$ k; f$ n! f( Fthe father. The family initially concealed this infor-  i; H' D  s5 T( e
mation, resulting in an extensive work-up for this9 g: q5 e. M: T7 ?! {+ f2 g
child. Given the widespread and easy availability of
: [7 i. ^/ ?) c& s" o9 i- otestosterone gel and cream, we believe this is proba-
( V) V  p. \! R0 ubly more common than the rare case report in the
3 N! a1 K& `1 T4 |literature.4' f! t0 v  k  T9 w
Patient Report( B" G$ P% e$ e; q8 l
A 16-month-old white child was referred to the
" c( O6 m( K1 L9 B9 K4 d" rendocrine clinic by his pediatrician with the concern
9 T/ u( R% s1 q9 f0 \, Kof early sexual development. His mother noticed
0 H5 Q9 C% I$ Ylight colored pubic hair development when he was
  C  x1 P& J0 \; T$ M2 h& D9 JFrom the 1Division of Pediatric Endocrinology, 2University of
( t+ c3 R* j* P. oSouth Alabama Medical Center, Mobile, Alabama./ m& u* Y2 h- H3 n4 C( O
Address correspondence to: Samar K. Bhowmick, MD, FACE,! }- x' c: I4 G
Professor of Pediatrics, University of South Alabama, College of
1 W7 d3 |) Z# NMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 k6 ~' p$ S: m$ w+ N  C& o
e-mail: [email protected].8 |; V; _$ d" b7 n/ c* C* d9 ?& G
about 6 to 7 months old, which progressively became% V; _# W0 {& a) A7 b
darker. She was also concerned about the enlarge-
# v- b2 a' i$ A. r, Cment of his penis and frequent erections. The child9 Q  [* N. k4 Q
was the product of a full-term normal delivery, with
/ g6 l8 {) \* A% V* za birth weight of 7 lb 14 oz, and birth length of
/ \" B' w9 n) G9 W4 G20 inches. He was breast-fed throughout the first year; y7 T* M. ?3 g6 }# k
of life and was still receiving breast milk along with  A8 R1 H$ ~, C- o/ U0 F
solid food. He had no hospitalizations or surgery,
5 U2 Q, {4 E( U/ Eand his psychosocial and psychomotor development
) p/ r; J0 p- k$ p% nwas age appropriate.5 s, n4 m3 X+ ~) `" j# \5 U
The family history was remarkable for the father,
( |( I0 C: E3 \: L2 Z  A0 ^4 Hwho was diagnosed with hypothyroidism at age 16,% C% e* Q$ u1 X! j4 p
which was treated with thyroxine. The father’s* i/ N* X8 X" @9 i
height was 6 feet, and he went through a somewhat, b6 E8 I  \1 X/ j
early puberty and had stopped growing by age 14.4 O& O$ I4 b' v& B7 P
The father denied taking any other medication. The
7 X( u( E) t! e2 G. schild’s mother was in good health. Her menarche
* |$ \- g: N% s. s- {was at 11 years of age, and her height was at 5 feet
- x4 \; l! ?( R5 inches. There was no other family history of pre-! D0 Y7 z$ v* M  O; {
cocious sexual development in the first-degree rela-
' C6 B% F( @9 U, K1 J0 C: btives. There were no siblings.
7 D) ^" H* o/ B. p/ A2 j( V" ZPhysical Examination
- k' V1 R* K" uThe physical examination revealed a very active,9 i' t" S6 X) @: {$ J8 P( S
playful, and healthy boy. The vital signs documented: m9 f/ W6 u" F, L) b/ W/ u: Y
a blood pressure of 85/50 mm Hg, his length was' V) H6 C! |$ t, C
90 cm (>97th percentile), and his weight was 14.4 kg7 l3 p, s7 D) d: y5 ]
(also >97th percentile). The observed yearly growth8 S* e* q0 k" R( R5 i
velocity was 30 cm (12 inches). The examination of
/ C! w/ |- L4 S3 A! Gthe neck revealed no thyroid enlargement.1 o' ?* E6 ~/ Z
The genitourinary examination was remarkable for
! f0 w. h8 j4 f3 |5 ]$ j& Q  Jenlargement of the penis, with a stretched length of
3 P2 j1 i' f! H$ N% V4 C8 cm and a width of 2 cm. The glans penis was very well
4 i' I$ ^9 v/ Q$ M+ H: C- u9 Udeveloped. The pubic hair was Tanner II, mostly around
- e  b0 b+ {4 Y3 I540
6 _! U- {- J0 y! X8 r; Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- S  Y3 x; X7 c9 a! V* p" g
the base of the phallus and was dark and curled. The) F' i+ j( S6 z: A3 k# k
testicular volume was prepubertal at 2 mL each.* |- D  A% @+ o& W0 P- t7 X  t+ R
The skin was moist and smooth and somewhat
: [5 b1 t1 k  poily. No axillary hair was noted. There were no
$ ]# k) F$ `0 H+ |* y( Wabnormal skin pigmentations or café-au-lait spots.5 k+ R2 `1 y) Y* W
Neurologic evaluation showed deep tendon reflex 2+
, ~+ F' ^; e% D  l- I# Bbilateral and symmetrical. There was no suggestion
2 s2 Q) ?, o. t! z9 Aof papilledema.
9 U! b4 ?" c) N2 dLaboratory Evaluation; V6 J- N/ E% `. a, k- M
The bone age was consistent with 28 months by
. r0 T: M- x/ v# N+ {/ Z8 zusing the standard of Greulich and Pyle at a chrono-/ _, }4 ^7 S' @0 f* B
logic age of 16 months (advanced).5 Chromosomal5 _% N  r/ P! s! D1 M5 o! [
karyotype was 46XY. The thyroid function test
( r+ z- W- {2 p2 qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
. O5 O! P- g5 b$ x) ^" r8 ~lating hormone level was 1.3 µIU/mL (both normal)." h- y! `( D) c) D4 B/ {# {
The concentrations of serum electrolytes, blood) }; H; H$ r* S. L
urea nitrogen, creatinine, and calcium all were+ m; w$ s+ i7 E6 L/ P1 N% V% Z
within normal range for his age. The concentration' Z7 ?5 O$ j; n+ ~
of serum 17-hydroxyprogesterone was 16 ng/dL" M0 v$ B+ A! t, l9 K- ~2 Z
(normal, 3 to 90 ng/dL), androstenedione was 20# O' [# _, }# g2 `  z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% l8 r* z2 m7 S  G9 w, y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) C' G+ Q0 Q, E$ E- i9 s/ l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' P: y6 t* H2 f' l/ a) K# @49ng/dL), 11-desoxycortisol (specific compound S)3 G% i. X! K7 S) M1 E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! C! }6 C6 i6 C6 N+ a% vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& S3 i( A. Y6 L: D( ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) O' ]( c+ W0 U2 U/ `; `( u& aand β-human chorionic gonadotropin was less than
1 y1 n; J7 Q" g- |; x5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 [* |/ `1 ^* A0 ^( U, u7 N0 vstimulating hormone and leuteinizing hormone
# p$ {% h2 P/ T% `concentrations were less than 0.05 mIU/mL# j$ \1 O) Z4 m- ?' @* _
(prepubertal).
: c) \8 W- o& ~5 t: i( tThe parents were notified about the laboratory2 }7 `* D3 O7 Y+ t; g6 _3 o
results and were informed that all of the tests were
% E1 A* z' ~1 ~7 Q$ Qnormal except the testosterone level was high. The2 ^5 a5 _: ]0 W* J- f+ `# Y
follow-up visit was arranged within a few weeks to9 J; K0 w* H! e# M+ Q8 ]: h5 `
obtain testicular and abdominal sonograms; how-3 W( f. e4 b! O5 d. U+ Y8 g1 r
ever, the family did not return for 4 months.& ]2 m: H( A$ [& y+ Z2 j' G
Physical examination at this time revealed that the; k0 ?% Z8 ]+ }) ]: R$ d
child had grown 2.5 cm in 4 months and had gained
. P7 D6 F1 F4 O! h  s# e4 b2 kg of weight. Physical examination remained5 ^; A* @3 ^; u( r' @
unchanged. Surprisingly, the pubic hair almost com-6 {5 _9 I. z/ L. k: c5 a
pletely disappeared except for a few vellous hairs at
4 L; J, Y5 H' C  B3 w" G1 dthe base of the phallus. Testicular volume was still 26 q, x" B/ k: U' [, D
mL, and the size of the penis remained unchanged.
" c1 v) ~: d( M; t& d4 q! u; VThe mother also said that the boy was no longer hav-
' A" q& D& O1 ping frequent erections.0 _) a  e: }" g0 p
Both parents were again questioned about use of
/ R6 Y5 Y3 Z! E: z5 K) [any ointment/creams that they may have applied to
- x  b5 y/ K# f7 g2 c9 }/ Tthe child’s skin. This time the father admitted the+ g: R$ G& {7 {- q: R& k
Topical Testosterone Exposure / Bhowmick et al 541) Y: H4 q2 p) O6 s/ C
use of testosterone gel twice daily that he was apply-
( Q* U! p" y3 Z5 }" C6 W' Hing over his own shoulders, chest, and back area for0 ?! e  Y- ?8 p( [6 ~; |: R- p% B
a year. The father also revealed he was embarrassed1 \& l# P' c" p* Z7 d
to disclose that he was using a testosterone gel pre-0 L0 _" t) c+ v' v
scribed by his family physician for decreased libido$ l/ [# e3 V0 e9 f) Y" E/ \4 J
secondary to depression.
9 I& I3 L0 t/ {' E2 }: x$ B4 LThe child slept in the same bed with parents./ k' K3 x5 b( U0 N
The father would hug the baby and hold him on his
5 F; W' r0 ~8 i4 I( bchest for a considerable period of time, causing sig-$ B  f% ]0 g- _
nificant bare skin contact between baby and father.& M/ R& F* d' E
The father also admitted that after the phone call,
, p% s! t2 d% e- Ywhen he learned the testosterone level in the baby0 R3 [. x* |; x: k5 ~
was high, he then read the product information: t# E% L  G) G
packet and concluded that it was most likely the rea-
2 L5 `# {4 n1 J6 e. {4 `son for the child’s virilization. At that time, they
4 k1 A# M. k' gdecided to put the baby in a separate bed, and the* j. X, U9 q: w% d. h7 [# ]( e6 k9 M: D
father was not hugging him with bare skin and had
# t7 n$ H* w5 q! q. a% ~% N0 a, @been using protective clothing. A repeat testosterone3 B' z- Z. M2 Z; [% H8 K
test was ordered, but the family did not go to the
% R. A) Y+ {! c, R4 F4 X4 G5 G. ~laboratory to obtain the test.: g: B# k; D5 k
Discussion) b% t3 G% ?( k) r) c- J
Precocious puberty in boys is defined as secondary3 G9 c& t5 G- X! ]" x5 b' Q
sexual development before 9 years of age.1,4# C3 D2 u! s1 p
Precocious puberty is termed as central (true) when
( b4 P0 F+ |) l) x' git is caused by the premature activation of hypo-
6 K1 u" ~5 q. |6 F9 f6 tthalamic pituitary gonadal axis. CPP is more com-
1 W8 B: C3 E; ?+ j) }mon in girls than in boys.1,3 Most boys with CPP
: `, S* R/ q5 `! l2 G: O) mmay have a central nervous system lesion that is6 C7 t$ m0 e  f* D) m
responsible for the early activation of the hypothal-
$ j. `( i5 p+ U6 S+ V, |amic pituitary gonadal axis.1-3 Thus, greater empha-
& V' c2 `' r/ ]* g3 o! c$ i# }sis has been given to neuroradiologic imaging in
/ p8 H. d4 t) @  e3 Y7 X$ [boys with precocious puberty. In addition to viril-+ \. x- s. I# \' h9 m; `
ization, the clinical hallmark of CPP is the symmet-3 `6 @" N  s, I' D! S# R% M
rical testicular growth secondary to stimulation by
" x$ t0 j8 s/ kgonadotropins.1,3
& R1 Z) G0 q# {, cGonadotropin-independent peripheral preco-6 W! `; E* f9 B% U$ b% b
cious puberty in boys also results from inappropriate/ r( e6 L( s6 O0 c) v* N
androgenic stimulation from either endogenous or& i& A& C, i' O. P* \6 E; C1 @
exogenous sources, nonpituitary gonadotropin stim-1 ]8 i. ]" O# W4 s: g1 g
ulation, and rare activating mutations.3 Virilizing
& _/ y$ m7 t0 s+ j( c2 P7 Lcongenital adrenal hyperplasia producing excessive5 u$ ~+ W! g$ H
adrenal androgens is a common cause of precocious0 r; d4 c9 U8 @1 D: e$ M' z
puberty in boys.3,40 [; n9 J6 g: R
The most common form of congenital adrenal4 x7 L, k' M4 c4 S6 g
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 n. ^8 z( H5 {The 11-β hydroxylase deficiency may also result in
6 c& \8 d' g9 u5 x! J% Aexcessive adrenal androgen production, and rarely,) a1 u: [- h, s9 z$ O
an adrenal tumor may also cause adrenal androgen6 u9 K3 i4 b3 J1 G+ h! L/ a; y* G# W- u
excess.1,35 q0 q9 T2 ?2 e; e+ {4 A/ c4 A8 o5 v: D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% t1 c  J+ G2 J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" ~% I# }: y6 F
A unique entity of male-limited gonadotropin-
0 K# P6 ~5 Q" t$ Windependent precocious puberty, which is also known
0 l% ?* s& @1 k3 jas testotoxicosis, may cause precocious puberty at a8 o& f+ C, h8 B! H) b  H$ Q" o
very young age. The physical findings in these boys# s/ K- c- C) Q( I  j; O8 Q! C* \. w
with this disorder are full pubertal development,- l  T/ n( a& g# M) e) v7 Q
including bilateral testicular growth, similar to boys
0 h( s8 A/ F0 ?, |  e; }1 Iwith CPP. The gonadotropin levels in this disorder. f! ?" G' [* h2 d9 j
are suppressed to prepubertal levels and do not show
  B3 v, Y+ p  ^% [1 Z. i3 p, O/ lpubertal response of gonadotropin after gonadotropin-- {5 f9 h9 {( E* ]2 q' y; s1 V
releasing hormone stimulation. This is a sex-linked) p8 |! s8 K7 U% }3 k* ^$ _- l6 B
autosomal dominant disorder that affects only
/ `7 N" B3 ]+ W) ]males; therefore, other male members of the family; ]2 O, b1 a' S$ s
may have similar precocious puberty.3
' P3 l! b3 U9 n8 O2 U0 g5 Q; \In our patient, physical examination was incon-
5 G, l$ N: V9 E- t9 I, |! C& Nsistent with true precocious puberty since his testi-0 N+ P3 G/ I' S! J8 e
cles were prepubertal in size. However, testotoxicosis4 J- _: e9 u9 g; W9 a4 n
was in the differential diagnosis because his father
7 I+ J5 Q* v9 `2 S* ]( g/ ^6 [7 Ostarted puberty somewhat early, and occasionally,! a, r8 I9 }) C* I
testicular enlargement is not that evident in the
5 I6 t. U" Y6 Wbeginning of this process.1 In the absence of a neg-1 S) j, H7 ^- c# O1 `, T9 N2 q$ W& ^; b
ative initial history of androgen exposure, our; i9 h" d, [. a0 A, w7 i1 _
biggest concern was virilizing adrenal hyperplasia,
! L% {+ G4 w% l& F* K1 O+ ieither 21-hydroxylase deficiency or 11-β hydroxylase
& M, @* x, ~7 a' ?deficiency. Those diagnoses were excluded by find-
& `% M+ I- t) y  s5 j4 O! u( Iing the normal level of adrenal steroids.4 u6 v* F8 h$ S# }2 l
The diagnosis of exogenous androgens was strongly
2 ^  e# q. \) G$ V* Rsuspected in a follow-up visit after 4 months because
8 |1 V6 S0 n0 T6 z- V: j: vthe physical examination revealed the complete disap-" T* T& y( S& W, A
pearance of pubic hair, normal growth velocity, and( K5 R1 b  Q6 H+ }4 g
decreased erections. The father admitted using a testos-
% m2 w+ r( g3 [terone gel, which he concealed at first visit. He was- a# L2 K! B% c. P' x+ c% p/ {
using it rather frequently, twice a day. The Physicians’
. k$ G: Y3 Z* L. N, h4 k1 iDesk Reference, or package insert of this product, gel or% r: E5 |$ m& @
cream, cautions about dermal testosterone transfer to
: U$ d0 }1 V7 c) Z* m) _unprotected females through direct skin exposure.: w4 u  j( i4 z9 x( G# z3 G- {
Serum testosterone level was found to be 2 times the
5 j+ [  p* _2 S5 g3 _baseline value in those females who were exposed to
# S" b5 W; m0 }2 A9 Z; N! N; Beven 15 minutes of direct skin contact with their male9 V* H% d/ W6 H
partners.6 However, when a shirt covered the applica-
+ }4 h7 y5 X, ^, S1 B5 b# ?tion site, this testosterone transfer was prevented.
3 R% i+ _7 k. Y% T! }" BOur patient’s testosterone level was 60 ng/mL,# |! |1 e5 r3 _( V( C; f; h
which was clearly high. Some studies suggest that
2 t2 D* y( o& J6 t& \" _dermal conversion of testosterone to dihydrotestos-7 ~& k' f' @: k2 [
terone, which is a more potent metabolite, is more
* z* T1 s% f3 J  W  V; r8 P6 Q" ~active in young children exposed to testosterone5 y4 H! s3 B0 n) g2 z0 S/ O6 W, _5 u
exogenously7; however, we did not measure a dihy-2 g- T- A" z. Z' B# U
drotestosterone level in our patient. In addition to! D- i# t( @5 z7 {: k9 \1 i
virilization, exposure to exogenous testosterone in
$ }( {$ r7 i% |children results in an increase in growth velocity and
1 T0 D( d  s/ p. ]advanced bone age, as seen in our patient.
* R8 }; d2 Z5 |) l" C4 L* I0 WThe long-term effect of androgen exposure during
. T  }' I0 U4 zearly childhood on pubertal development and final
$ p1 h8 {" n& iadult height are not fully known and always remain  T" J4 G) j# t
a concern. Children treated with short-term testos-
1 `5 z! W! ], xterone injection or topical androgen may exhibit some: Q0 q7 ^9 ]% z/ T7 l8 ]1 |
acceleration of the skeletal maturation; however, after
  b, o4 j6 i& `cessation of treatment, the rate of bone maturation
# B3 M6 f# L/ s' z# X+ b; s6 M, idecelerates and gradually returns to normal.8,95 u& E' ~. G# f  D! |
There are conflicting reports and controversy
7 q. \( j7 s( x7 W+ Bover the effect of early androgen exposure on adult
3 w& C; G+ e- O% k, Xpenile length.10,11 Some reports suggest subnormal
0 d/ s) G+ _2 N) O  Z, A$ l# }adult penile length, apparently because of downreg-
$ |6 U, \1 h/ ?  n8 v8 n4 P" |" Lulation of androgen receptor number.10,12 However,
! W# p' [  Q5 ^+ d- a1 b: jSutherland et al13 did not find a correlation between1 q! o* Y, m5 Y5 c) k
childhood testosterone exposure and reduced adult8 H) ?! R) @; }: _& K$ t3 u
penile length in clinical studies.) E0 _8 f5 t8 `0 y6 |/ @) p
Nonetheless, we do not believe our patient is
7 [4 N0 A5 A9 ~- k9 wgoing to experience any of the untoward effects from" F% V2 R- [$ H3 S: P3 s( t
testosterone exposure as mentioned earlier because
. n3 X1 Y5 q0 s# _the exposure was not for a prolonged period of time.
# v0 P9 Z" _8 O3 u  X' HAlthough the bone age was advanced at the time of+ U- z& ?) c2 ]0 v: g) ~
diagnosis, the child had a normal growth velocity at
7 o  K% T* M. Z9 d1 h/ ?( v  F, Dthe follow-up visit. It is hoped that his final adult
5 J+ K) ~7 M1 j; x9 Jheight will not be affected.
: ~' I: G; i  |! f5 D( E2 yAlthough rarely reported, the widespread avail-% |7 A; q9 a7 R0 u. C. O. g7 n% l  f
ability of androgen products in our society may
0 Z( m$ R0 x4 Hindeed cause more virilization in male or female
2 u0 U# }0 j' |4 ]children than one would realize. Exposure to andro-* d5 i; p  G2 v( z
gen products must be considered and specific ques-8 L# Q0 a1 F2 \* S; w
tioning about the use of a testosterone product or8 M/ L  K* v( }$ H) ^, @5 R9 t
gel should be asked of the family members during/ C  f5 G0 _$ o
the evaluation of any children who present with vir-
/ I6 N5 G1 l) x, I( L6 Jilization or peripheral precocious puberty. The diag-2 v5 K& o+ k4 U
nosis can be established by just a few tests and by& l# Q  V# u( o; A
appropriate history. The inability to obtain such a
$ y0 n  o) f$ d- B' nhistory, or failure to ask the specific questions, may1 l" z; q1 ^! w  ]$ r
result in extensive, unnecessary, and expensive5 `% V# \1 V  X) P/ R
investigation. The primary care physician should be4 s0 M$ g& ^' F0 E2 @3 l# w9 W
aware of this fact, because most of these children4 Y, l) P" u/ ^$ n
may initially present in their practice. The Physicians’
9 o2 X; \% j; h! ~. o+ L4 uDesk Reference and package insert should also put a
& s! u$ o$ J$ o7 X* r' ewarning about the virilizing effect on a male or
+ ?* Y8 @& \4 nfemale child who might come in contact with some-- U8 n0 v: C1 @& }% a4 ^. J
one using any of these products.
3 a" w' O* r" b- {9 C7 j+ c$ j% i: aReferences* g# c  F" T3 H- w0 {( ]
1. Styne DM. The testes: disorder of sexual differentiation
2 x% Y4 Q- x# o% X. R3 band puberty in the male. In: Sperling MA, ed. Pediatric
% A6 n! G5 G1 PEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 m' S+ G; t6 V" J- V2002: 565-628.
2 r" t5 Y, a4 I0 C; l* K; v, P( Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 c) L% G5 t& {/ y
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old9 K8 ^2 Q" c8 ~% D& a  Y$ G- {$ I
Boy Induced by Indirect Topical
5 o; F2 e" w" H8 uExposure to Testosterone
% T2 Y0 j2 m6 n1 S5 ^5 G6 |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* s7 M1 K# i6 c8 y+ U
and Kenneth R. Rettig, MD10 `/ }. I/ ~8 w4 F) ?* w/ ^
Clinical Pediatrics( w6 h) Y; e9 I/ D; c) A
Volume 46 Number 6* j0 k# m6 d: ?: ~# @9 Y# x
July 2007 540-543  h; T6 K4 L# I! F4 L) m
© 2007 Sage Publications! ^$ F9 r5 Z0 Q
10.1177/0009922806296651
4 a0 Z' S" I! A5 T3 c7 J, |http://clp.sagepub.com$ T! Y! s$ j/ S% l2 v
hosted at
* g! x$ j8 \! j9 y2 d: A& Ohttp://online.sagepub.com
1 v/ O) Q# a+ k) BPrecocious puberty in boys, central or peripheral,
" Y0 G: O2 u  u: M% ris a significant concern for physicians. Central
  t. h( o- Q! h7 j7 Q+ Iprecocious puberty (CPP), which is mediated
3 }( V1 G' ?2 D( E! A/ E1 C9 hthrough the hypothalamic pituitary gonadal axis, has
- Y' a  m3 t. M0 n/ L! ^a higher incidence of organic central nervous system
1 O) ?* q" i' }, Hlesions in boys.1,2 Virilization in boys, as manifested
& M) M+ k1 H% @# Z) ~% dby enlargement of the penis, development of pubic
3 k% [8 U# F# H  o  h- r8 c1 uhair, and facial acne without enlargement of testi-* E# a# d6 h% d' R- r
cles, suggests peripheral or pseudopuberty.1-3 We1 I$ X' e8 G, t
report a 16-month-old boy who presented with the
) z2 U) z, c7 v" ~9 I, fenlargement of the phallus and pubic hair develop-! X8 b4 S% b6 Z- c0 E
ment without testicular enlargement, which was due
& F' M$ n1 N1 {3 y  `1 u5 W, O! r, gto the unintentional exposure to androgen gel used by) }8 n' O* z- T# T+ w$ {
the father. The family initially concealed this infor-  m" ^' M4 R/ x& B# o3 X# ~
mation, resulting in an extensive work-up for this0 W- v9 z  l% C
child. Given the widespread and easy availability of
/ y7 c6 [& M! u3 L( Wtestosterone gel and cream, we believe this is proba-
; k5 r+ }! b2 _* U& G4 `bly more common than the rare case report in the! S2 ?% F# o# }+ U& k
literature.4
- o# Z" K5 A" N; {Patient Report+ @' O6 l5 G5 W! E% s& R7 U
A 16-month-old white child was referred to the
% d8 }8 P) s# }" `# B( \7 Uendocrine clinic by his pediatrician with the concern! S/ X% h! m( F7 q% F1 I
of early sexual development. His mother noticed
0 f  X- r: a$ n6 G: d. mlight colored pubic hair development when he was4 v& u* ^- b' R8 r8 l5 C2 W
From the 1Division of Pediatric Endocrinology, 2University of
0 F, ]( B7 K4 X' Q1 ?+ n4 o! OSouth Alabama Medical Center, Mobile, Alabama.8 t. H; ^7 L* A1 j. M
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( G- F% `2 {- L  m- l! LProfessor of Pediatrics, University of South Alabama, College of$ {5 K: x) W; ^3 l* D# P
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ ~. e! b, i' Y8 \1 \. ?+ f( ~" e
e-mail: [email protected].( \; l5 t1 f( S, w+ G( n+ h
about 6 to 7 months old, which progressively became
! F- T3 J/ I# ^darker. She was also concerned about the enlarge-
4 C. G/ {. |  B' _9 ?/ X# Ument of his penis and frequent erections. The child
6 X2 q/ X( f  d. c5 U- Fwas the product of a full-term normal delivery, with# r' Y6 @8 m7 i4 d  d3 {. b
a birth weight of 7 lb 14 oz, and birth length of
( _3 b8 c! Q4 e. E2 N1 \7 m5 _20 inches. He was breast-fed throughout the first year# j6 c" g4 T9 u3 L* k- C
of life and was still receiving breast milk along with6 J5 W5 d; j. H8 V" }+ k: ~
solid food. He had no hospitalizations or surgery,. g3 R; ?& h! J8 B. D9 o
and his psychosocial and psychomotor development
9 b  {% c5 ~6 X2 @/ t$ t* z$ Ywas age appropriate.8 j4 W; z) G1 Y2 F  q- ^
The family history was remarkable for the father,
' i0 v6 l) v( L- {who was diagnosed with hypothyroidism at age 16,
# c. h# H+ ~( Pwhich was treated with thyroxine. The father’s
) l& z. F+ P6 w; Q9 s# w) Gheight was 6 feet, and he went through a somewhat
1 K4 T& d% U7 e% {* m, vearly puberty and had stopped growing by age 14.
5 P# `4 `7 u% W$ x6 o' x# _The father denied taking any other medication. The3 j$ Y2 F3 _" E6 u5 b9 D; h
child’s mother was in good health. Her menarche- S' }7 ]+ M. ]. F4 f' P
was at 11 years of age, and her height was at 5 feet5 N3 G  f0 x  I, B7 P$ s8 O" l2 N
5 inches. There was no other family history of pre-
0 Z  a8 b7 f7 v# n7 s8 G6 d+ g! kcocious sexual development in the first-degree rela-
% o  T5 m3 L8 J* |tives. There were no siblings.; `  c& R, x% K: c# [% E
Physical Examination0 B6 O$ U! S/ Y$ \, u0 N7 _# J' q
The physical examination revealed a very active,% Z6 m* y  z/ t; q% }6 N+ A
playful, and healthy boy. The vital signs documented
! Y# }* Z8 l+ G/ c4 R/ Ka blood pressure of 85/50 mm Hg, his length was/ {. b- o) n2 r2 H
90 cm (>97th percentile), and his weight was 14.4 kg& ]7 t9 }8 U/ E# N8 r( h
(also >97th percentile). The observed yearly growth$ u4 s/ }) R, j- u" m) s1 u* Y
velocity was 30 cm (12 inches). The examination of
( N: D! I0 P+ a2 {/ ?- x" g: X. ~9 Wthe neck revealed no thyroid enlargement.
, T& A2 n4 ?- FThe genitourinary examination was remarkable for
. c  o" c; I0 v+ T( g; K! e7 U/ {enlargement of the penis, with a stretched length of
1 ~( ~5 w% I, x8 cm and a width of 2 cm. The glans penis was very well0 T& T/ D. [: D& `2 m
developed. The pubic hair was Tanner II, mostly around0 S8 y* v) }" M/ l7 k
5400 q1 x) m1 h  t2 I+ U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 `' C% N. \! ]7 gthe base of the phallus and was dark and curled. The( j. I6 |7 t  h; {4 V6 e- o4 k6 x" F
testicular volume was prepubertal at 2 mL each.
5 Z9 Q+ V! ]; G+ X. a" E; ]The skin was moist and smooth and somewhat9 a5 x$ F4 p3 X9 Z+ f
oily. No axillary hair was noted. There were no
6 Y; s; j' D3 N& |abnormal skin pigmentations or café-au-lait spots.3 l: W) {8 k# [4 s+ y. R
Neurologic evaluation showed deep tendon reflex 2+
& o! I3 r2 l& ?8 N5 Jbilateral and symmetrical. There was no suggestion9 m4 ]0 l( y$ K2 o$ I& l% K
of papilledema.4 R. v( v( ~, k0 x+ B
Laboratory Evaluation
, j5 G) U! _  jThe bone age was consistent with 28 months by
) E. z! m" ^- zusing the standard of Greulich and Pyle at a chrono-
. |4 y+ e3 k1 I' [0 z9 mlogic age of 16 months (advanced).5 Chromosomal8 f  v* M; m) a. C  @: w
karyotype was 46XY. The thyroid function test9 j3 j3 y4 [! L+ z; b' q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& z& Z' f; U/ s1 T; V: K$ v) V( E9 ?
lating hormone level was 1.3 µIU/mL (both normal).# n; K1 J5 }6 d6 N: a! r' i  w
The concentrations of serum electrolytes, blood
* N9 n, Z7 S, L- x+ N0 ~urea nitrogen, creatinine, and calcium all were( Q4 p" E# ?; p" ^
within normal range for his age. The concentration' g2 s$ y4 H2 W) Z5 `
of serum 17-hydroxyprogesterone was 16 ng/dL
( g& o  e: U0 M' k% e# A(normal, 3 to 90 ng/dL), androstenedione was 20$ A7 b% m" G* f/ ^! ]$ S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" q5 E$ S: H1 l/ _! k9 z  O% @6 oterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 g" v9 e. Z% m, C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" H9 ?1 d: @) c% n7 N
49ng/dL), 11-desoxycortisol (specific compound S): w$ d; n! @& q! [  M# L' n
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# X; t6 m, a. ^) w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 G% s6 S) K( _/ E* H
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* Q& w8 T0 C! @. V% a2 p" wand β-human chorionic gonadotropin was less than
) b7 X; l" p% \6 j1 H5 R5 mIU/mL (normal <5 mIU/mL). Serum follicular6 Y$ I; q3 K! t7 Q( D
stimulating hormone and leuteinizing hormone" L1 A7 D" w- Q
concentrations were less than 0.05 mIU/mL; z8 x1 J+ w0 N+ w5 m: _+ R) r
(prepubertal).' H% p9 b/ z/ o5 o
The parents were notified about the laboratory
$ T) H. \4 C; h5 a5 _- ~results and were informed that all of the tests were
* ?- ~6 |4 J1 o; h. z' Ynormal except the testosterone level was high. The; d) w$ r  H/ }7 k0 n1 D" N" _4 A
follow-up visit was arranged within a few weeks to6 z7 E0 t( O% A9 y! O4 x
obtain testicular and abdominal sonograms; how-. d" O  l4 q/ ~* C+ U+ d5 ]
ever, the family did not return for 4 months.. E$ Y# k+ l# U2 @5 x
Physical examination at this time revealed that the8 d" H4 V& k% s7 O% q' t; f' Z
child had grown 2.5 cm in 4 months and had gained
- ]/ R5 J3 \& ~6 X  h6 g! Y2 kg of weight. Physical examination remained& f: b- K5 D8 L
unchanged. Surprisingly, the pubic hair almost com-
  g) X& k9 \* ~, s; dpletely disappeared except for a few vellous hairs at
4 O& |) e( h) R. _( Nthe base of the phallus. Testicular volume was still 23 m# U4 d5 j; q. D
mL, and the size of the penis remained unchanged.
8 n8 ^. W2 o1 _, V1 G2 I9 c: ZThe mother also said that the boy was no longer hav-
& \# L$ ]* x# @' Ling frequent erections.
' G; e9 \- `% ?! g$ m  {Both parents were again questioned about use of
! O( j6 z4 Y' u4 Y4 y9 gany ointment/creams that they may have applied to
( \+ w) w$ T9 b8 lthe child’s skin. This time the father admitted the. Z4 M: n2 q, l  `- R
Topical Testosterone Exposure / Bhowmick et al 541
# \# ~- r- k3 fuse of testosterone gel twice daily that he was apply-
2 r/ k' @6 K( z! c. Y5 H# Z* ling over his own shoulders, chest, and back area for. i" h* S) x9 s5 n* x' k6 j+ W; t
a year. The father also revealed he was embarrassed
+ i& B  E2 k6 g8 P9 ]. f  Kto disclose that he was using a testosterone gel pre-
3 d1 j& c1 V. q: k' Z2 {scribed by his family physician for decreased libido9 E1 L0 J2 a9 v9 @
secondary to depression.
; d7 r" I0 i. ]. \4 l1 l- S' l7 VThe child slept in the same bed with parents.
: g# G" T2 o1 N9 }. d- s; K! WThe father would hug the baby and hold him on his* s1 R  t. J2 f
chest for a considerable period of time, causing sig-! w2 P! s+ G2 O% }# G. X
nificant bare skin contact between baby and father.
0 y- w; F1 q: DThe father also admitted that after the phone call,3 ^( \5 c. X0 ]' e4 s, ]' u
when he learned the testosterone level in the baby- }* }7 j6 [2 y5 y
was high, he then read the product information7 d6 k* D0 i+ l( Q/ o
packet and concluded that it was most likely the rea-
1 c; M, \4 D0 hson for the child’s virilization. At that time, they
6 L3 Q* h/ r  m1 Y# |" I: {9 Udecided to put the baby in a separate bed, and the- p; G) K: P" H& l% u# Z# M
father was not hugging him with bare skin and had
7 O" t7 V% ]0 Nbeen using protective clothing. A repeat testosterone
5 n! t, _% b: K7 m' }9 J; Htest was ordered, but the family did not go to the
+ C  B# X+ u, C' y8 claboratory to obtain the test.: J! c9 @8 S; ]# W
Discussion& k6 ~3 V6 N+ r4 ?$ r  u  P, J
Precocious puberty in boys is defined as secondary
# i' h6 ?' D7 X6 _, v6 }" g* Bsexual development before 9 years of age.1,4
0 D+ B7 |- y4 ^! d5 M  Z- ?Precocious puberty is termed as central (true) when& j! |6 A; l8 \' U# n+ k5 T7 w
it is caused by the premature activation of hypo-
% p0 I$ ]6 U9 Y7 [! k0 L+ Lthalamic pituitary gonadal axis. CPP is more com-
' n- p/ W: v( p7 D# {7 y; x( Amon in girls than in boys.1,3 Most boys with CPP
3 Z$ K$ U, \- Y, jmay have a central nervous system lesion that is$ k" J) d. k3 s
responsible for the early activation of the hypothal-: Y& j4 l* C: L  m
amic pituitary gonadal axis.1-3 Thus, greater empha-, e4 f7 h( d8 J8 d# o. `
sis has been given to neuroradiologic imaging in; k" f) o5 x! h
boys with precocious puberty. In addition to viril-: V! [' E3 s$ C' C2 M
ization, the clinical hallmark of CPP is the symmet-
  B7 {  P7 p$ I" {: c. orical testicular growth secondary to stimulation by
- g' q3 b+ R1 l( p/ n4 y  _gonadotropins.1,3
- t9 O. o" r) j; {Gonadotropin-independent peripheral preco-
1 R1 ]* d" l4 L# Ecious puberty in boys also results from inappropriate- W$ M2 [, y) X3 X
androgenic stimulation from either endogenous or! W# Y' x" T$ m, N! i2 j/ s( w& z
exogenous sources, nonpituitary gonadotropin stim-3 _. d* P2 E: B5 x: ^& R
ulation, and rare activating mutations.3 Virilizing
% `+ ]" |6 _( U/ M3 N! ycongenital adrenal hyperplasia producing excessive; y. l# ]. E% h* `9 ]& z
adrenal androgens is a common cause of precocious
4 V6 C- d5 ~- b/ }puberty in boys.3,41 ?& u" @. M4 B) d: O8 R2 H
The most common form of congenital adrenal; l3 N7 U2 B" Z" x) d
hyperplasia is the 21-hydroxylase enzyme deficiency.
# g4 R5 Y& _7 g% y2 q$ pThe 11-β hydroxylase deficiency may also result in
& h- k( m0 U: H& I! texcessive adrenal androgen production, and rarely,: w1 R: l# b9 q4 ?1 ?
an adrenal tumor may also cause adrenal androgen/ _! t0 p6 Y2 z. J+ L
excess.1,3
/ l  s' a, a& h' }8 Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ ^# i5 n0 q3 h. T! N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, p- v  l# Q3 ^  Y# P* \A unique entity of male-limited gonadotropin-
2 e: ^; J+ B; t8 m/ P$ |9 hindependent precocious puberty, which is also known2 t& ~7 n5 X+ S1 z" l) ^
as testotoxicosis, may cause precocious puberty at a: L1 ^% j. X3 F/ h: A
very young age. The physical findings in these boys
# K! S+ a3 }! w! m% U3 ?with this disorder are full pubertal development,. w) [; f. Y5 [% R* E' [, n4 f
including bilateral testicular growth, similar to boys& U' p; \4 a6 n
with CPP. The gonadotropin levels in this disorder
/ ?$ {" _. d* H/ p4 h. W8 a3 `; Sare suppressed to prepubertal levels and do not show6 A% M) R7 U$ {/ u1 [, c
pubertal response of gonadotropin after gonadotropin-
% L; `5 C( i! dreleasing hormone stimulation. This is a sex-linked
1 G3 L. ~2 ^8 r$ {/ fautosomal dominant disorder that affects only
+ W! O8 O7 S/ Y* i5 t( ymales; therefore, other male members of the family# o( ?4 s6 `, O3 r
may have similar precocious puberty.3
; v, O' u+ i/ n& c- T3 R% o$ PIn our patient, physical examination was incon-
. I/ M- M0 K5 Fsistent with true precocious puberty since his testi-; q, s3 P( Q; m! u! P& f
cles were prepubertal in size. However, testotoxicosis1 i; V1 s4 m( H
was in the differential diagnosis because his father
4 s' ?9 z2 \& W: I5 }0 ^started puberty somewhat early, and occasionally,6 \% C0 H6 w; h3 L
testicular enlargement is not that evident in the
) Y% K, g/ f7 M' k( U$ ybeginning of this process.1 In the absence of a neg-/ ]( k7 s  u4 L! a8 y
ative initial history of androgen exposure, our
% C+ Q! o% t$ H, t+ Obiggest concern was virilizing adrenal hyperplasia,
: \: A( j# C3 ^9 q; ]" u* leither 21-hydroxylase deficiency or 11-β hydroxylase' ?: {7 e  R, l
deficiency. Those diagnoses were excluded by find-3 a% Y$ ~# T6 Q4 _
ing the normal level of adrenal steroids.  ~7 E5 n( E! \3 ?' D
The diagnosis of exogenous androgens was strongly
! r. B$ [! R9 h- _suspected in a follow-up visit after 4 months because2 z1 Z) C( r: A- U' E5 v% v
the physical examination revealed the complete disap-
+ F% ^- k2 F6 H  npearance of pubic hair, normal growth velocity, and! p5 Y- w% c1 S
decreased erections. The father admitted using a testos-6 k% W. Q0 s% n" _' ^" e$ O
terone gel, which he concealed at first visit. He was
. y. w7 W. K1 p: r+ n, Musing it rather frequently, twice a day. The Physicians’; i8 H6 V7 F/ o
Desk Reference, or package insert of this product, gel or
2 d3 g5 z, S+ A2 q4 z1 }cream, cautions about dermal testosterone transfer to
& C- E1 Y5 b* Z" D& Sunprotected females through direct skin exposure.
, n4 q$ K, @: xSerum testosterone level was found to be 2 times the
# A3 x2 h: N1 D2 s# E' b9 A2 m1 K3 Obaseline value in those females who were exposed to+ D5 r& \# B0 M) g  Y8 R/ S! c
even 15 minutes of direct skin contact with their male1 `/ P4 ~' j2 L- o5 i" p" ]4 A
partners.6 However, when a shirt covered the applica-6 c3 f( v& V8 N" ^. c
tion site, this testosterone transfer was prevented.
  }2 Z& ?) ~' q: ^Our patient’s testosterone level was 60 ng/mL,' U, o" n- i; c3 Y( \" _8 M4 P
which was clearly high. Some studies suggest that
! T7 i, h8 ^( o' L& h& L9 k9 Z& w; \2 i6 odermal conversion of testosterone to dihydrotestos-
8 V) v9 k. h) x) l( ~& jterone, which is a more potent metabolite, is more+ k% F/ F4 {1 W- S
active in young children exposed to testosterone3 |3 p8 K' W6 h( j
exogenously7; however, we did not measure a dihy-
# c7 H- v2 t6 @/ B$ Adrotestosterone level in our patient. In addition to
, l$ b8 h9 S" f; r" T( H/ j3 f- cvirilization, exposure to exogenous testosterone in
" x) r. w8 G! Y" R9 L7 @7 Cchildren results in an increase in growth velocity and
9 C& Q3 Q4 B, _2 X3 j2 f3 Ladvanced bone age, as seen in our patient.
% `' ~9 ?0 V( q# v9 R6 N' sThe long-term effect of androgen exposure during% x; L  B9 ]! z8 ?2 N3 R: x# E
early childhood on pubertal development and final
* G$ C! ^+ y6 L- Z" \& L# badult height are not fully known and always remain
& O  Y( Q/ n/ e: ra concern. Children treated with short-term testos-
2 P, I% @. C+ I6 o" F# k+ {6 ]terone injection or topical androgen may exhibit some
+ @( o! W5 y9 Q$ J$ {" S# L2 facceleration of the skeletal maturation; however, after+ W, q! j  D/ }- t4 r& d* A
cessation of treatment, the rate of bone maturation
: f! R  W( ^, F7 p4 j1 Zdecelerates and gradually returns to normal.8,9
' U2 C1 d( c( L* a# B+ k& O& uThere are conflicting reports and controversy9 S; p& j# n6 t
over the effect of early androgen exposure on adult
. X9 l" |) m5 }7 ~: e- [+ spenile length.10,11 Some reports suggest subnormal& u+ ^4 }( P1 q& D4 c) u
adult penile length, apparently because of downreg-1 ]( x1 }' e5 Q2 e, n8 s& E% {
ulation of androgen receptor number.10,12 However,$ r) p0 Y  w( x8 e; R8 S! A
Sutherland et al13 did not find a correlation between
/ Y* p5 n  Z8 ?. K5 jchildhood testosterone exposure and reduced adult) G) Q2 I$ Q! p# e& i
penile length in clinical studies.6 L2 N1 g$ s$ I7 J: m9 S
Nonetheless, we do not believe our patient is9 @4 _- z; l- f/ \
going to experience any of the untoward effects from
$ j6 C$ p- Q$ g+ A* A# K8 |testosterone exposure as mentioned earlier because- B  x% m9 l3 Z' I
the exposure was not for a prolonged period of time.
& ]: ]- v& H5 p; u* NAlthough the bone age was advanced at the time of
- c: e  o, g) }: E% K( T: Y, Jdiagnosis, the child had a normal growth velocity at
- |& j( @- j  J; J2 a9 I+ X, Bthe follow-up visit. It is hoped that his final adult; u: J5 ^, R6 s6 K
height will not be affected.
1 i2 W8 w, {, d1 _) P& gAlthough rarely reported, the widespread avail-
/ C" U) ?! L) `. q4 L# P5 G! ~) lability of androgen products in our society may
' Y/ s9 G/ i. ]8 A: |% j. f; K! Xindeed cause more virilization in male or female
* ]# E! ^7 e6 n/ M  G% G9 ichildren than one would realize. Exposure to andro-
, G( k. ^, Z2 _$ fgen products must be considered and specific ques-  q2 X7 I$ J1 ?+ f6 x/ n/ v
tioning about the use of a testosterone product or
/ W* z' ]& C" egel should be asked of the family members during7 J: ~! B( G5 y/ T8 b
the evaluation of any children who present with vir-, |6 F3 S0 `& A* U; [
ilization or peripheral precocious puberty. The diag-$ g2 B) h+ W. r8 \2 `
nosis can be established by just a few tests and by
, y5 L- x  v0 o5 ]! s6 ~0 bappropriate history. The inability to obtain such a+ F* y& O/ B3 b: o$ u2 z
history, or failure to ask the specific questions, may$ L/ w5 j# H8 A: U1 k+ q' o6 o
result in extensive, unnecessary, and expensive
3 ?# `9 e  m  w  B9 R) vinvestigation. The primary care physician should be
" F7 J; ]8 v, _3 p) Eaware of this fact, because most of these children/ X( S' k. v* E5 t1 W( E8 k6 U: J
may initially present in their practice. The Physicians’' Q' c- Y3 g4 f% P1 O& }/ |
Desk Reference and package insert should also put a
( b% U4 @9 D# W* Pwarning about the virilizing effect on a male or
; U2 z& r% P8 a* V# f$ w" O/ B! wfemale child who might come in contact with some-9 \5 m% t1 k9 |, H( e2 y( ]: Z8 o9 N# s
one using any of these products.
: f1 i& l. k1 `0 L4 l8 tReferences; e# M8 n! q$ q6 x
1. Styne DM. The testes: disorder of sexual differentiation
. V1 }( y, E  _and puberty in the male. In: Sperling MA, ed. Pediatric9 S0 [" K! G% B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. p( O5 l& Y; S$ b5 r) |! I+ }! u
2002: 565-628.
0 }3 R/ E. R5 \# j. h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ `# F0 ^* `5 j" f( w7 l6 g" ]puberty in children with tumours of the suprasellar pineal
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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

3 v7 i* {( d( o% X% G& q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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