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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: f1 z4 {/ k! k6 h; J+ Y& M
Boy Induced by Indirect Topical# K- j6 L/ m9 n3 k
Exposure to Testosterone7 V/ C/ ]7 h2 I6 ~9 }0 ]! H
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 @5 E% E* ]0 N' S7 b
and Kenneth R. Rettig, MD1/ F- y* h" V: g5 Y7 I) N5 U
Clinical Pediatrics
" v6 g4 l, U( m5 N/ xVolume 46 Number 6
5 x( ]' ?4 |/ JJuly 2007 540-5432 N+ d- o5 H" T2 M
© 2007 Sage Publications
- B+ H6 _# F6 `' P7 |: s10.1177/0009922806296651$ c3 L2 ?) \, d) q2 _* G4 S
http://clp.sagepub.com9 ~7 y& s4 e# }# a1 G  a- c+ |
hosted at8 t) [7 q5 s' Y9 L+ j8 t
http://online.sagepub.com
7 [- k5 Y8 e3 n& f# Z: `; UPrecocious puberty in boys, central or peripheral,
5 H8 J5 c, V9 t# O" w4 s5 L* h! d' zis a significant concern for physicians. Central
& w! F/ g* m4 @precocious puberty (CPP), which is mediated
* f. ~% T( d5 K5 x1 a7 q6 Pthrough the hypothalamic pituitary gonadal axis, has
7 Z1 c9 [( C2 ]! Fa higher incidence of organic central nervous system
6 e' ^% R' x# H& H& m* Mlesions in boys.1,2 Virilization in boys, as manifested
3 }$ @) j0 N# l2 J3 [+ O+ m8 k$ ^$ lby enlargement of the penis, development of pubic/ n8 l! H! G- \* y5 N
hair, and facial acne without enlargement of testi-0 L4 Z* a, S0 Y7 y" Y& F3 ^
cles, suggests peripheral or pseudopuberty.1-3 We' q* f; g4 Z+ d5 K% I& f& Y- p
report a 16-month-old boy who presented with the
: A1 z- b, s& `% N# nenlargement of the phallus and pubic hair develop-% q! y9 r! c0 k$ n
ment without testicular enlargement, which was due
8 C& A. d( L/ x% \* c  ]to the unintentional exposure to androgen gel used by
. n4 P* \8 M9 c; b' F2 s( Mthe father. The family initially concealed this infor-8 R1 f  _# V& S* e- G  l0 H) P0 x) L
mation, resulting in an extensive work-up for this6 u& g- D0 @2 u% a+ n4 S' i; U+ ^+ N
child. Given the widespread and easy availability of! S. I6 a2 ]3 n  |! `
testosterone gel and cream, we believe this is proba-
/ g! l5 e5 K. H  J9 C" Nbly more common than the rare case report in the! w1 Y; b$ e* M  {
literature.44 J: p. C- Z$ ~2 M% \
Patient Report) |" l" R8 g$ j. o) U2 d
A 16-month-old white child was referred to the! _" E  n. l7 E+ L3 l: i
endocrine clinic by his pediatrician with the concern
+ @! B6 |7 }8 d1 g* ?) V0 K9 \of early sexual development. His mother noticed
. Y* o: b4 A% i% r- Blight colored pubic hair development when he was. _! u4 n4 R2 ^( u) q/ D6 c
From the 1Division of Pediatric Endocrinology, 2University of) Q3 v0 E- ?: ~& Q! x" p5 G
South Alabama Medical Center, Mobile, Alabama.0 d8 X9 u/ [, {+ P& B2 H7 d( q3 L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 N- O/ }3 t; u6 t2 ^Professor of Pediatrics, University of South Alabama, College of- [. b, X/ F1 B  d8 C+ V7 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* C$ {: {5 e- V4 ~; }e-mail: [email protected].; u% a8 x* M' S* m
about 6 to 7 months old, which progressively became3 q( f( |6 T0 V* w
darker. She was also concerned about the enlarge-6 X  l! ?( [4 [+ x3 G* l$ b8 O7 V
ment of his penis and frequent erections. The child9 n3 m, b2 A' R% k& M
was the product of a full-term normal delivery, with( ]$ l+ n" O' O" t
a birth weight of 7 lb 14 oz, and birth length of' _4 F" h. {  o0 T
20 inches. He was breast-fed throughout the first year
( T: @6 @8 d0 A' r1 Wof life and was still receiving breast milk along with
) G- Q- O: [, ^' B4 X# _3 L, M/ ]3 Ksolid food. He had no hospitalizations or surgery,
) V0 [9 m; w. [/ w: Z. E- gand his psychosocial and psychomotor development6 V! S! p' J( X. p" Z0 N
was age appropriate.
- I1 }1 j4 L/ I" qThe family history was remarkable for the father,
$ B0 e, }  M( S' L, [who was diagnosed with hypothyroidism at age 16,
# i' S$ _# q4 B- a5 g2 v. [, Swhich was treated with thyroxine. The father’s
8 _7 B* H' X0 I2 `7 Z$ e: kheight was 6 feet, and he went through a somewhat- F' ?8 m8 ?; C" u
early puberty and had stopped growing by age 14.$ r( P) C3 o4 p8 P
The father denied taking any other medication. The
  m) y; ^8 o0 _child’s mother was in good health. Her menarche0 c( d" p+ y0 P' V" J1 B9 @; |
was at 11 years of age, and her height was at 5 feet
) {4 Q1 f1 W* }* ^' e5 inches. There was no other family history of pre-
$ \# m' U5 t/ Qcocious sexual development in the first-degree rela-
- f: K- }: r, htives. There were no siblings.
* y/ A! ?3 d0 l5 k: H, M" z; kPhysical Examination
: n3 d9 F1 g3 _The physical examination revealed a very active,
- V# g6 y' D" qplayful, and healthy boy. The vital signs documented
* D5 [& ~! f  a7 _1 \a blood pressure of 85/50 mm Hg, his length was0 {1 ]7 ?' D: `+ A
90 cm (>97th percentile), and his weight was 14.4 kg, Z, Y4 m" m2 }
(also >97th percentile). The observed yearly growth) A  {( O0 d# p" p
velocity was 30 cm (12 inches). The examination of
; ^" I6 N& W/ P+ E7 Dthe neck revealed no thyroid enlargement.
. i6 u% b* S. ^- d# @1 ]0 U: Y, fThe genitourinary examination was remarkable for
  Q3 z1 ]1 Q& C* Wenlargement of the penis, with a stretched length of9 L! W# g+ ~4 q* e3 q
8 cm and a width of 2 cm. The glans penis was very well9 r9 R/ t9 w& ^7 i- v7 i! k
developed. The pubic hair was Tanner II, mostly around7 t$ Z; M: }! G0 z2 i1 `- O5 B( }1 z
540
3 O+ f! e  l! A9 U- @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- _9 g! H2 v1 W$ a- c8 ]
the base of the phallus and was dark and curled. The
8 R+ W: m; D7 m7 X$ J& Qtesticular volume was prepubertal at 2 mL each.4 w4 V( R1 Q) G- \( B
The skin was moist and smooth and somewhat
' N& M. f) m: S1 |oily. No axillary hair was noted. There were no
% w5 l7 s" |4 o$ f% F- }abnormal skin pigmentations or café-au-lait spots.: l# B) Y  r" q4 w" m5 j
Neurologic evaluation showed deep tendon reflex 2+
  |0 k: W  |) y* ebilateral and symmetrical. There was no suggestion8 R: ~4 T9 k% W+ q) e3 S% |5 ^
of papilledema.0 Y- i7 h' C6 o. k' a" c! i
Laboratory Evaluation5 Z/ c4 Q, ~% v: @, u9 V8 k
The bone age was consistent with 28 months by
' ]# y9 J; N0 U" @% G* wusing the standard of Greulich and Pyle at a chrono-; n2 y1 N0 g% w- |- Z
logic age of 16 months (advanced).5 Chromosomal* F6 B; c; f7 ~
karyotype was 46XY. The thyroid function test
9 n# e$ V4 R1 |showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  F: i- a1 }6 l3 t6 I8 n$ Glating hormone level was 1.3 µIU/mL (both normal).
7 B% k( l5 T6 e4 gThe concentrations of serum electrolytes, blood1 P7 \) a4 d; S! b9 ^+ k
urea nitrogen, creatinine, and calcium all were* L5 U3 k( u2 Q$ i5 ?" a6 e
within normal range for his age. The concentration
1 j/ b: T$ p6 _0 C% F: Nof serum 17-hydroxyprogesterone was 16 ng/dL% o7 e$ {( S$ M" Y3 ?
(normal, 3 to 90 ng/dL), androstenedione was 20
( W! K" E# c' f5 E( e7 h) ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ t" V! `$ d# y' n  Z# v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ f! }) n% \7 W2 D! ^6 rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to! S: J0 ~- {: [5 R! z
49ng/dL), 11-desoxycortisol (specific compound S)7 @8 z, ^; [* F! g+ J* x( O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  b" v" s, f2 v7 ^+ ?0 x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; x7 A! D4 X5 j- Z. w+ _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- w1 _8 b) Z' R/ ~6 N: R* K
and β-human chorionic gonadotropin was less than4 f. f6 ?4 ~. `6 R2 m
5 mIU/mL (normal <5 mIU/mL). Serum follicular# R( W% m3 C/ I8 c
stimulating hormone and leuteinizing hormone
3 ?4 C: n& O( t3 Kconcentrations were less than 0.05 mIU/mL
" N  L$ h( E# U* ^7 p: [2 z" |1 ?6 _(prepubertal).& k) m: e8 Q8 V
The parents were notified about the laboratory. W9 _& H, |+ a5 X( A) J$ h
results and were informed that all of the tests were
8 A" A0 I6 O0 w* k% fnormal except the testosterone level was high. The' a) M5 _: Q1 ^0 X" c6 L4 Y7 f
follow-up visit was arranged within a few weeks to) o  K. m1 @$ ?- h% k8 S
obtain testicular and abdominal sonograms; how-
* n- |+ g" @7 L! K. L! ?# xever, the family did not return for 4 months.1 x% k6 G6 l; X4 \
Physical examination at this time revealed that the4 J# z9 h0 \  F
child had grown 2.5 cm in 4 months and had gained8 o) D! g( v; e
2 kg of weight. Physical examination remained# o% R6 H3 G9 @  T9 \
unchanged. Surprisingly, the pubic hair almost com-
. Y. V9 v  w$ ]& C. U  {pletely disappeared except for a few vellous hairs at
& j% z# D) n" n8 Bthe base of the phallus. Testicular volume was still 2
. ]5 _+ B* E1 ~/ D/ W7 J5 umL, and the size of the penis remained unchanged.6 e* M3 P+ q2 P  f6 @
The mother also said that the boy was no longer hav-
' M- W- M' e/ Y9 }$ ?) ^" A) z" Aing frequent erections.
& y3 x( Z- c- r9 X9 a' L2 ~; H4 g- jBoth parents were again questioned about use of" H, ~" M2 q1 d; f: @+ r" [
any ointment/creams that they may have applied to$ _/ {" ?+ c, L+ s, l% g
the child’s skin. This time the father admitted the
- ?- m3 m) i+ v/ Q; n7 I/ I! zTopical Testosterone Exposure / Bhowmick et al 541/ j% P" J; e3 w3 Z" B
use of testosterone gel twice daily that he was apply-
( t0 g+ F" L% d7 A2 {ing over his own shoulders, chest, and back area for0 ?& \+ W6 d( z, {
a year. The father also revealed he was embarrassed
5 u/ @+ R" k1 W: E) I5 bto disclose that he was using a testosterone gel pre-8 }: l7 O$ K$ q9 l8 I, ^
scribed by his family physician for decreased libido
5 @% e2 w( I, w; i+ t! {secondary to depression.% M! H; d3 v2 b% j; E5 R/ h
The child slept in the same bed with parents.0 z+ h* \0 R5 D8 e8 v) v  U8 w
The father would hug the baby and hold him on his
; E9 z6 z, v" k0 Nchest for a considerable period of time, causing sig-* `; l: w+ r$ j
nificant bare skin contact between baby and father.
. M2 d. k5 i9 H' E9 Y, }: ?- ]The father also admitted that after the phone call,% `( x" j) x( z# ?* Q( ?5 b  f" ]
when he learned the testosterone level in the baby, p1 H% Z% u2 L
was high, he then read the product information
: ~8 [, z0 D: T% t3 Z" Xpacket and concluded that it was most likely the rea-
. k3 o% s" H  Y+ _2 J1 C2 Nson for the child’s virilization. At that time, they
# v8 B  G8 ^0 J8 edecided to put the baby in a separate bed, and the
( ^- o+ z4 K' Y. U9 A1 sfather was not hugging him with bare skin and had1 w3 F6 l8 _0 v8 O+ a8 H, g( q* a
been using protective clothing. A repeat testosterone/ ^4 \! ]; \  W  E
test was ordered, but the family did not go to the
: M/ c9 v) L$ b# @laboratory to obtain the test.1 B$ w% X- w  a$ V* z% o  g/ G/ o8 p
Discussion
; h9 {. q0 H! E' gPrecocious puberty in boys is defined as secondary5 S. j: c. c* c. W
sexual development before 9 years of age.1,4
: L7 v% e& |9 s# fPrecocious puberty is termed as central (true) when
0 I3 D% d5 B4 @7 Zit is caused by the premature activation of hypo-
, k! [' _0 o# y3 L7 o3 U" kthalamic pituitary gonadal axis. CPP is more com-
2 G8 S" L5 v* j. U5 U* pmon in girls than in boys.1,3 Most boys with CPP
+ G' a2 i/ O8 tmay have a central nervous system lesion that is. Z; M* b' B1 G( ?4 Z
responsible for the early activation of the hypothal-
/ Y$ z3 X  j+ s, W% oamic pituitary gonadal axis.1-3 Thus, greater empha-- i. h7 Z( F+ n% f+ z# R+ l  Z) ~
sis has been given to neuroradiologic imaging in
0 V4 M5 u) }4 C/ g' cboys with precocious puberty. In addition to viril-  N/ K7 r0 B1 I+ r( q" z* x4 i& y
ization, the clinical hallmark of CPP is the symmet-
+ w, Q/ L7 `  A/ J' o) Rrical testicular growth secondary to stimulation by
: M" \" H6 g5 ?2 P! Ngonadotropins.1,37 K0 R1 r% _' J4 o- m
Gonadotropin-independent peripheral preco-
& i  E2 [! q9 rcious puberty in boys also results from inappropriate
+ O4 w+ p! E! Xandrogenic stimulation from either endogenous or
" Y8 W5 q  q+ f" }3 ]exogenous sources, nonpituitary gonadotropin stim-6 E# y8 J/ E% G7 h# H+ s
ulation, and rare activating mutations.3 Virilizing: C# X/ d6 O) z0 y. t' {
congenital adrenal hyperplasia producing excessive5 r9 {3 }; V- e4 {; Q
adrenal androgens is a common cause of precocious+ N! ]- k. s9 b, ?! ], Q9 M# Q1 A
puberty in boys.3,4
7 s( G% U" z1 t" z; Z* s' V: p% `The most common form of congenital adrenal
+ h7 x; h8 n4 L0 jhyperplasia is the 21-hydroxylase enzyme deficiency.
8 \6 g. t( ?5 w" `! N% OThe 11-β hydroxylase deficiency may also result in: B+ N4 |4 J% ?! Y
excessive adrenal androgen production, and rarely,
" K1 l  g6 T6 M) |0 C( Tan adrenal tumor may also cause adrenal androgen
7 D! a8 e& D3 H2 x! ~; A# lexcess.1,3
* T& \+ y7 i& ^: eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ x8 Y6 U* L: Z# y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- m- Q: O% [( ~! ~1 {# bA unique entity of male-limited gonadotropin-
: y+ z) x( z" \8 O  ]independent precocious puberty, which is also known
. c3 u* H4 \% I0 T6 M7 ]) Vas testotoxicosis, may cause precocious puberty at a% v, A1 g0 i- S- s& t, F) H
very young age. The physical findings in these boys* Z: u. e' ^& H: u+ i
with this disorder are full pubertal development,
" m/ E+ g; D! D9 q# \including bilateral testicular growth, similar to boys
5 }% z8 G8 {+ r  F4 mwith CPP. The gonadotropin levels in this disorder0 W( W1 u/ {& ^! r# \
are suppressed to prepubertal levels and do not show
. U! o+ s" i- i4 mpubertal response of gonadotropin after gonadotropin-
( j3 \4 p0 a+ }* oreleasing hormone stimulation. This is a sex-linked
! F- H0 Q4 Y$ `5 }& A4 g* uautosomal dominant disorder that affects only  P! N8 h" H+ g! T3 }2 S# V
males; therefore, other male members of the family2 u. @0 `$ V: U% O) d! x) L1 n
may have similar precocious puberty.37 x$ Z6 w1 J* j% W
In our patient, physical examination was incon-$ l( U! h3 E8 m9 v! M4 x
sistent with true precocious puberty since his testi-
, F3 P; A: s& N, @( vcles were prepubertal in size. However, testotoxicosis  j) z- T6 U3 {  v4 V
was in the differential diagnosis because his father
( f( P7 k9 M4 e5 q3 e( [5 D% S5 J% jstarted puberty somewhat early, and occasionally,
: Z. v. R# M9 B$ g; mtesticular enlargement is not that evident in the
0 ~! |; ^: y8 N% S$ d3 ibeginning of this process.1 In the absence of a neg-
9 Z/ m- g" A8 D: k7 r2 G2 Vative initial history of androgen exposure, our
9 o0 }! c$ N0 c7 M: x1 @. t6 Xbiggest concern was virilizing adrenal hyperplasia,! [# i& @& O' }: V6 E
either 21-hydroxylase deficiency or 11-β hydroxylase2 t1 B8 t0 k. }9 @- P/ {; l, s
deficiency. Those diagnoses were excluded by find-. @! b! ~6 o5 \$ L# K
ing the normal level of adrenal steroids." g0 R: P) y4 M( B" ^
The diagnosis of exogenous androgens was strongly
+ w% n# q4 }! ^# ]suspected in a follow-up visit after 4 months because
# E7 R: j3 C7 m: X0 u' dthe physical examination revealed the complete disap-
  ]7 S7 K( Z" s" }7 e5 apearance of pubic hair, normal growth velocity, and
4 j4 U$ ?# l1 j2 @decreased erections. The father admitted using a testos-& U5 C, s* j) i, I7 R9 w
terone gel, which he concealed at first visit. He was, p' Q% Z3 }8 p; G. U* o% k' {
using it rather frequently, twice a day. The Physicians’/ Q4 s) }- M; p, _4 s* t7 j
Desk Reference, or package insert of this product, gel or; f& f; ?" f; f+ f6 I
cream, cautions about dermal testosterone transfer to3 A% s. b2 D  |7 @
unprotected females through direct skin exposure.
+ r# N1 q4 g9 {7 w) q- iSerum testosterone level was found to be 2 times the( H! @% O2 b" |$ c
baseline value in those females who were exposed to$ d, t4 }. F7 K8 ?
even 15 minutes of direct skin contact with their male% \; A, D  k' G! U' c( Z' W
partners.6 However, when a shirt covered the applica-3 q! Q  Z2 V( K. o+ r4 @
tion site, this testosterone transfer was prevented.6 g0 K# l* a; j! V' Q
Our patient’s testosterone level was 60 ng/mL,
- Q$ j7 R! T( x$ T  I% fwhich was clearly high. Some studies suggest that
/ @$ x* x& S/ P0 X# tdermal conversion of testosterone to dihydrotestos-! b- h  _5 l. C" {
terone, which is a more potent metabolite, is more
) r" n. N4 k" B- m) Q7 @2 Bactive in young children exposed to testosterone% N( Y/ m2 H& |& X+ g: t( M) G0 \
exogenously7; however, we did not measure a dihy-
9 G; s4 u: m* N9 F# ydrotestosterone level in our patient. In addition to1 N$ g& R& U3 y0 T/ u/ c
virilization, exposure to exogenous testosterone in
9 b6 S1 o" }# t: w, a  @children results in an increase in growth velocity and
/ l/ l1 H' z  \8 g4 N& Badvanced bone age, as seen in our patient.
/ I( ^  y9 m6 yThe long-term effect of androgen exposure during
- e" n8 R! S5 A/ P! |* I* H& rearly childhood on pubertal development and final# h* n* l' E: C& I1 y- o" p+ l
adult height are not fully known and always remain$ O3 @0 w. _8 V2 L- X* P
a concern. Children treated with short-term testos-
. _, S2 c/ N3 ^terone injection or topical androgen may exhibit some
; E: P1 l8 N! T% U1 W! a# A2 u! Facceleration of the skeletal maturation; however, after+ Z4 A6 u# }% u: z4 q( ~* X
cessation of treatment, the rate of bone maturation
& z$ o4 S! a, adecelerates and gradually returns to normal.8,9
( ?& _5 W% J8 H, ]; UThere are conflicting reports and controversy
4 ^+ \& z  C7 eover the effect of early androgen exposure on adult
, [. L, ~# {6 i# Vpenile length.10,11 Some reports suggest subnormal" B! {* Z" f0 s- a
adult penile length, apparently because of downreg-
. i4 d' F+ Y8 ^5 ?  uulation of androgen receptor number.10,12 However,
6 P0 \3 _. M/ g: |: _  [, H% vSutherland et al13 did not find a correlation between
- a, |7 X: D% _$ f8 V, M0 }/ \; Wchildhood testosterone exposure and reduced adult3 {/ U. Z7 Y+ ?/ ^+ _( X! t1 V
penile length in clinical studies.$ h6 S3 ~& w/ c( p4 ~3 S
Nonetheless, we do not believe our patient is
& x5 B+ R  e; {( Q5 ngoing to experience any of the untoward effects from
7 Q& W' e" G; X. `& Ltestosterone exposure as mentioned earlier because
( ]  T( z+ a1 [% z- Z9 j1 \) mthe exposure was not for a prolonged period of time.
1 A* ~8 P# m* t* `Although the bone age was advanced at the time of+ X" ^( F' ^2 u  k. L3 X) s
diagnosis, the child had a normal growth velocity at8 H( s4 n  l1 \9 E3 F5 ^
the follow-up visit. It is hoped that his final adult5 K# a. \+ M  \1 S
height will not be affected.8 ]6 O  h6 u% f& _
Although rarely reported, the widespread avail-4 k2 [# }" u& `7 O
ability of androgen products in our society may
3 e2 V4 T9 P+ c: e, R! Pindeed cause more virilization in male or female( c# k( b$ d0 F* Q% ^8 f& v
children than one would realize. Exposure to andro-
8 E: M. K, L6 ], T' J" qgen products must be considered and specific ques-. Q; s( q- v) L+ \$ X8 u
tioning about the use of a testosterone product or
+ x& D+ k$ l" T! p6 q. Z* m: Wgel should be asked of the family members during
% u# J7 Y, X, M! d! fthe evaluation of any children who present with vir-, E* o5 U3 k8 s9 p5 F7 P
ilization or peripheral precocious puberty. The diag-2 }3 h: b  G+ g; V( D5 ]
nosis can be established by just a few tests and by
9 n; V/ I' _: X6 i: J0 Y2 {; Cappropriate history. The inability to obtain such a
3 `1 U/ ~! m' z. R0 [. phistory, or failure to ask the specific questions, may
0 `# ?6 U* y* ^/ Iresult in extensive, unnecessary, and expensive
  r2 N! k, ~# }investigation. The primary care physician should be
" t- [4 e; n* N3 z+ N0 C! aaware of this fact, because most of these children/ d. }: W* p5 W% G/ `, @/ k
may initially present in their practice. The Physicians’% Z" F4 p8 q* \$ J- ~
Desk Reference and package insert should also put a8 q% a+ c* E- B0 g) ~. C
warning about the virilizing effect on a male or4 M6 `8 R9 ^0 x5 P2 i
female child who might come in contact with some-
( g- {  M, x/ O9 @" M0 @one using any of these products.
* Z( a5 C5 V6 {. R: V3 Z- jReferences
( z5 T, J  ?3 L0 a1. Styne DM. The testes: disorder of sexual differentiation4 q# A) I5 R( {  l
and puberty in the male. In: Sperling MA, ed. Pediatric0 z2 K5 N2 T, G+ K/ D) r7 w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ g6 {5 P% S& u7 X5 I2002: 565-628.( c3 W* ]) u" d  x+ d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ u0 @! i4 E& |! q
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old1 d+ H6 c  ?5 `/ }# t3 u3 b+ v
Boy Induced by Indirect Topical  Z5 B, C: {) r3 }8 \
Exposure to Testosterone. O2 Z5 O% e/ Y- f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* s* g. z5 H& y) Q0 r
and Kenneth R. Rettig, MD17 V. I( G3 ]7 r( P: T8 e
Clinical Pediatrics- S1 H* H; F2 D( v( @1 B
Volume 46 Number 6$ E/ ^4 Z4 q/ E" Q5 S! y
July 2007 540-543
: T# H( g* Z4 E" e+ T$ r+ c© 2007 Sage Publications
# M$ F9 W/ l" ^10.1177/0009922806296651( H3 P0 G" K1 W* q+ u
http://clp.sagepub.com
' E4 o  k: N* `1 C( F0 Zhosted at9 J1 C3 V' q6 S0 k' }" \5 i
http://online.sagepub.com
# V! ~; u% z- c% q' mPrecocious puberty in boys, central or peripheral,
- n  M, o( X( W3 e7 N6 u5 yis a significant concern for physicians. Central; K, p' v) @; K# f$ y' c. G1 k4 ]+ E
precocious puberty (CPP), which is mediated
/ J) G" ^) r/ b( }$ }through the hypothalamic pituitary gonadal axis, has
1 R1 v) J8 t  z# va higher incidence of organic central nervous system0 c* I( ~1 s* g8 a7 O* `
lesions in boys.1,2 Virilization in boys, as manifested
9 }! |7 P9 z- U8 i$ Hby enlargement of the penis, development of pubic( o9 a: z* l" B8 L$ N, V2 `2 Y
hair, and facial acne without enlargement of testi-$ B- I; Z$ g7 D0 H7 Y
cles, suggests peripheral or pseudopuberty.1-3 We0 I" V6 h0 B) t2 W' U% x
report a 16-month-old boy who presented with the. M$ Y  I- M  D- H  Y- t
enlargement of the phallus and pubic hair develop-% @8 t. H. x2 t5 ^0 \, O; |/ t
ment without testicular enlargement, which was due( q  ^9 ~& l1 v! \; `9 t: l
to the unintentional exposure to androgen gel used by6 a! J5 e2 ?; m, R2 M
the father. The family initially concealed this infor-. i4 ?  C* z" o! k8 s& P' |, X! |
mation, resulting in an extensive work-up for this
7 {' o4 c$ M0 Q) E, zchild. Given the widespread and easy availability of
' b4 M9 O6 U- f: w) ]0 Wtestosterone gel and cream, we believe this is proba-1 ]+ m- n  b! N: u
bly more common than the rare case report in the
" Q8 R. V& B  c: b) pliterature.4
6 \+ o: C( Q9 B& APatient Report0 R- A' r# s- M" C( }6 W
A 16-month-old white child was referred to the2 H# l7 A8 j1 c, i# u( P+ B
endocrine clinic by his pediatrician with the concern/ O3 t6 m) ~5 ~- ]: o' {* b# o
of early sexual development. His mother noticed
, _$ A  h' V2 H* C7 n7 ilight colored pubic hair development when he was
5 ~$ U; v2 Z" f" R7 W4 [, w' vFrom the 1Division of Pediatric Endocrinology, 2University of2 e, |4 k- n& T7 u8 H
South Alabama Medical Center, Mobile, Alabama.
7 u  A& {0 N" }! z* CAddress correspondence to: Samar K. Bhowmick, MD, FACE,
! \% f4 I2 B1 W% Z" C6 ^Professor of Pediatrics, University of South Alabama, College of
. Y) e6 {; s9 M$ i1 a: eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) m% x1 S# O$ L+ W& v: [
e-mail: [email protected].! C$ D+ |7 V' P
about 6 to 7 months old, which progressively became/ N% l7 d1 `; l* [. }' m  D
darker. She was also concerned about the enlarge-8 s# n! S) z6 U  r3 r1 m; n% l
ment of his penis and frequent erections. The child3 f5 z) v. S2 a4 {, i; \# m, V
was the product of a full-term normal delivery, with$ w" N+ n5 ~1 o. y
a birth weight of 7 lb 14 oz, and birth length of
# U* K; I1 ^! y20 inches. He was breast-fed throughout the first year6 N  _' H! Y  o; E) y' ^; x+ f6 W
of life and was still receiving breast milk along with
4 k. K/ d6 H5 F7 d0 {' usolid food. He had no hospitalizations or surgery,* w$ i" s# _/ R8 T4 R
and his psychosocial and psychomotor development+ o' _- M( W; V# z% ~
was age appropriate.
# C6 u+ ~/ l. l# }, T# mThe family history was remarkable for the father,
' K; [4 u: M$ E& Qwho was diagnosed with hypothyroidism at age 16,) |% \3 }# [1 Y
which was treated with thyroxine. The father’s
& S7 K" U5 _  Z2 @3 Kheight was 6 feet, and he went through a somewhat( C% y6 I- s1 q" f8 m
early puberty and had stopped growing by age 14., H$ \1 ^4 [  Z0 ?) C
The father denied taking any other medication. The
4 Q& a. I; X4 F% n6 A, E+ N7 schild’s mother was in good health. Her menarche: y8 ?( b3 B+ W; i" L
was at 11 years of age, and her height was at 5 feet
9 [$ ]) x+ {% _) H' R! [. K5 inches. There was no other family history of pre-
! _* F! O- B9 h7 ncocious sexual development in the first-degree rela-
9 ?" W% c' x! O0 ]# f5 z9 C) N2 htives. There were no siblings.3 r1 m; S5 Q3 E' Q- u; h4 G1 f
Physical Examination
/ W4 o4 e& j7 G! _' LThe physical examination revealed a very active,) o; T' ]2 V* i
playful, and healthy boy. The vital signs documented$ ]6 r3 G. ?7 k
a blood pressure of 85/50 mm Hg, his length was
0 s' ?+ |. C3 {2 `  G90 cm (>97th percentile), and his weight was 14.4 kg
9 P+ N6 @% y. G7 O/ `(also >97th percentile). The observed yearly growth
  p- e; v3 _) rvelocity was 30 cm (12 inches). The examination of
: P6 m! j1 j5 z: ^the neck revealed no thyroid enlargement.- L& i' u' [$ ~
The genitourinary examination was remarkable for3 @3 i3 ~% |6 I+ N( a* S
enlargement of the penis, with a stretched length of2 M& x$ k; i. w/ @6 f( a  k
8 cm and a width of 2 cm. The glans penis was very well/ Q9 W! Q0 J; A# i8 A
developed. The pubic hair was Tanner II, mostly around
4 F$ P. ?8 G0 I" m) {. S540
* w  {6 Y) C) F7 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% P+ C% m; h. w/ j" T3 qthe base of the phallus and was dark and curled. The
7 c- R2 v; z/ ^8 g0 R- V0 i+ j7 Rtesticular volume was prepubertal at 2 mL each.
, o1 ^, K5 q% D3 U# n& N+ v" r+ v" `The skin was moist and smooth and somewhat$ b8 z9 }9 s; F7 T4 d4 J
oily. No axillary hair was noted. There were no
8 s* f1 q0 D- ?abnormal skin pigmentations or café-au-lait spots.
" S9 }% w/ M9 ~: N) \- x$ iNeurologic evaluation showed deep tendon reflex 2+% }" k+ v; k- o
bilateral and symmetrical. There was no suggestion# L* F, c: O6 p, u% D5 q
of papilledema.
7 Z# h! y2 k' p& U% R! g- f. nLaboratory Evaluation4 W2 v) S6 N' y; ~9 S& d- t# _; H" c
The bone age was consistent with 28 months by; E9 V' T/ t' i+ d6 `! B, ^
using the standard of Greulich and Pyle at a chrono-
) a, M' V; s, ?: v5 Y: A0 }logic age of 16 months (advanced).5 Chromosomal, |% c2 G9 h5 V( Q
karyotype was 46XY. The thyroid function test; h( [4 F5 c' J$ C. I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-  [( P6 ?  Z7 I
lating hormone level was 1.3 µIU/mL (both normal).
* o3 e8 @5 X+ B5 G& x, l9 ^7 b3 `The concentrations of serum electrolytes, blood4 d2 |; N7 A. _5 i! m3 ]+ a. `
urea nitrogen, creatinine, and calcium all were, j" |+ A' S: r7 B
within normal range for his age. The concentration
4 c( f! ^: k6 t0 ?2 B3 J; vof serum 17-hydroxyprogesterone was 16 ng/dL
& A* L9 d# e% b! n2 P5 ~(normal, 3 to 90 ng/dL), androstenedione was 20
0 x1 G& `/ u) `2 a0 _3 w! \ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' O( A* ?) J4 ?7 g# D6 Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),; ^4 H+ L$ Y  g2 e
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% U9 K4 ?# I. R; K+ d49ng/dL), 11-desoxycortisol (specific compound S)
. x* i+ m+ t3 R4 ^1 |* H3 N1 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. I0 [6 O6 s+ `- r$ K/ O: J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# {; h, D: K6 [7 n; I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ B( l# R+ y9 ?6 D  R% k) @
and β-human chorionic gonadotropin was less than4 t. x9 W2 c/ F8 R4 \/ Z9 x
5 mIU/mL (normal <5 mIU/mL). Serum follicular( L& Z' [4 t1 u% l# c7 K
stimulating hormone and leuteinizing hormone6 M5 d2 t8 k4 h' {
concentrations were less than 0.05 mIU/mL# _. x  S: `, [: ]$ B) T
(prepubertal).' ?4 ^8 v# a* @
The parents were notified about the laboratory, g+ P& ~. Y) h' J% M
results and were informed that all of the tests were5 p2 T5 y# r9 P5 U% c) R
normal except the testosterone level was high. The
1 m0 }  F/ n( G  R9 ?1 f# ^9 c9 }follow-up visit was arranged within a few weeks to- @$ J, U3 G- X+ ~( I# q
obtain testicular and abdominal sonograms; how-3 ~; z; M7 v5 I. V0 z
ever, the family did not return for 4 months./ `# s( Y- V& q( |) l) j9 n- _8 c
Physical examination at this time revealed that the  q7 X! N1 r- Q+ X# i
child had grown 2.5 cm in 4 months and had gained$ ~, p& C. S' u7 B, [6 O
2 kg of weight. Physical examination remained( A# z( m( S5 x$ |# v
unchanged. Surprisingly, the pubic hair almost com-
) X! e1 Y. m1 G, n& r& g$ @0 Rpletely disappeared except for a few vellous hairs at, X; e  F. l% a$ Q4 r
the base of the phallus. Testicular volume was still 23 R' `5 D  E+ L5 N6 m3 \
mL, and the size of the penis remained unchanged.7 m3 e5 J) [: {( L
The mother also said that the boy was no longer hav-% ^, b0 Q6 W. l* h
ing frequent erections.4 c6 b- D0 v9 K* f+ n
Both parents were again questioned about use of2 W4 ]' H1 ?5 P" K% X, y
any ointment/creams that they may have applied to! T+ \# e7 x4 i. m. o
the child’s skin. This time the father admitted the
8 l  e3 d( T" \2 ^Topical Testosterone Exposure / Bhowmick et al 541  H+ R9 G7 F" P1 S2 h
use of testosterone gel twice daily that he was apply-
) `* B/ q) V! f7 y( u8 I! Ging over his own shoulders, chest, and back area for. D" \# ?9 z3 L/ J7 g
a year. The father also revealed he was embarrassed
* L2 i( E* L4 ^- j3 C- vto disclose that he was using a testosterone gel pre-
$ z7 v: |( W; S+ X+ Escribed by his family physician for decreased libido
; a" t5 R* c( ?secondary to depression.* f  l9 [& w# }. `+ r; K
The child slept in the same bed with parents.9 I1 w/ f- ]3 q0 `
The father would hug the baby and hold him on his, k; b3 r# Y4 m
chest for a considerable period of time, causing sig-% T6 h' l6 `2 I+ }; p  ]
nificant bare skin contact between baby and father.* f. U  S" r/ m2 ^" Q0 I, H+ l
The father also admitted that after the phone call,$ L4 L7 _3 z- ]# ^( K/ Y, M  Q
when he learned the testosterone level in the baby
, J7 H7 t! o% V/ E, swas high, he then read the product information& a: ~! ]  e% [
packet and concluded that it was most likely the rea-7 C/ k6 h: j+ J! n0 I; ~+ v0 m
son for the child’s virilization. At that time, they, S8 {7 j1 m" \8 l1 ?7 H, F
decided to put the baby in a separate bed, and the
2 ~1 l1 \1 l; v- Q6 wfather was not hugging him with bare skin and had
. \( f( O; W9 m" B0 ^7 Zbeen using protective clothing. A repeat testosterone
% V4 o/ }& |* c3 U' ttest was ordered, but the family did not go to the
% U9 D7 ?* s0 h. Z3 llaboratory to obtain the test.) v9 V6 D0 d, |% e# ~
Discussion" o2 X# Q" v! k1 x2 q
Precocious puberty in boys is defined as secondary3 a4 {; h) @) Q) x0 H# o
sexual development before 9 years of age.1,4; m; ?  ]- y0 E1 _' c/ y
Precocious puberty is termed as central (true) when
' z+ L8 b% E2 \! i, ^! Qit is caused by the premature activation of hypo-# w. q  D# d( Y: s; {
thalamic pituitary gonadal axis. CPP is more com-2 d. L! t1 i) g! p( j( Z  C1 {, s
mon in girls than in boys.1,3 Most boys with CPP" o/ Z5 @2 \* j
may have a central nervous system lesion that is
8 ]% R0 @- m6 d0 [- E3 Q$ Lresponsible for the early activation of the hypothal-4 O/ d: i: P. ], I
amic pituitary gonadal axis.1-3 Thus, greater empha-
# C0 A! i' C" i. x: csis has been given to neuroradiologic imaging in. [  r# p! C% b8 p
boys with precocious puberty. In addition to viril-6 L4 l, k! d0 x" t
ization, the clinical hallmark of CPP is the symmet-; I. v, C+ N7 L1 ?( T8 ?% e
rical testicular growth secondary to stimulation by8 T3 p* ^' G8 z6 t. T6 A
gonadotropins.1,3
# i+ [3 z1 u3 ]Gonadotropin-independent peripheral preco-
0 C6 h; u; j5 M- H8 r' V9 a1 @( Hcious puberty in boys also results from inappropriate3 l5 M5 K& b5 s& l  G* Y- Q+ H
androgenic stimulation from either endogenous or
8 R: u$ v+ J, Yexogenous sources, nonpituitary gonadotropin stim-9 d! n9 b* [, r3 c
ulation, and rare activating mutations.3 Virilizing1 l* T/ A# y* m& Y2 o# c1 r
congenital adrenal hyperplasia producing excessive$ d/ Z0 N& B( ]1 J0 W. b* U3 D
adrenal androgens is a common cause of precocious
3 N- D& P* O' K' H7 ~$ Ppuberty in boys.3,4; m: M: o4 h0 x0 a2 V) H
The most common form of congenital adrenal% |) T" X% Z+ H# O  d
hyperplasia is the 21-hydroxylase enzyme deficiency.. Z, P; Z7 E; k) l' r
The 11-β hydroxylase deficiency may also result in
2 A; L2 g: q$ }& x" {excessive adrenal androgen production, and rarely,; X* O- ]5 T% o( q8 T2 v/ r" H0 V
an adrenal tumor may also cause adrenal androgen6 O" O3 |% c! g* J# r" g+ [
excess.1,3
4 a! }6 Y) L1 B6 C8 O5 w+ Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 M& P9 m0 h+ t: c7 N( M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  P7 [8 a6 u% y
A unique entity of male-limited gonadotropin-
$ S! A) i+ c6 f2 a- Pindependent precocious puberty, which is also known9 M' s0 ~9 T" B
as testotoxicosis, may cause precocious puberty at a% `; Q7 e  \* X* I8 l1 R
very young age. The physical findings in these boys
' H$ q0 K( f2 D( _with this disorder are full pubertal development,5 \# N- I2 L9 N" c) q
including bilateral testicular growth, similar to boys
( G: {" }8 i9 E6 O$ q" C! W4 Ewith CPP. The gonadotropin levels in this disorder0 b& K& |: }- I( W9 B
are suppressed to prepubertal levels and do not show
( u# A+ o  e. R) \/ Fpubertal response of gonadotropin after gonadotropin-
! F: h) A+ Z" Q0 {+ a5 Y' c, greleasing hormone stimulation. This is a sex-linked/ {5 p% ~. R% f& s0 I8 q! u
autosomal dominant disorder that affects only# Z) N6 l- }* Q7 T% F
males; therefore, other male members of the family" j4 `8 }; x% K( M# \4 C
may have similar precocious puberty.35 D5 v7 `  h; Q( ?
In our patient, physical examination was incon-8 ]& ?7 C% ^# n! h# [
sistent with true precocious puberty since his testi-2 a' d# N, ?: c* P+ u& a
cles were prepubertal in size. However, testotoxicosis6 a- x5 d2 F6 h6 d, Y0 u
was in the differential diagnosis because his father
6 f5 F  s7 R  E) {4 ^started puberty somewhat early, and occasionally,% E! K9 A# R2 l: S$ E
testicular enlargement is not that evident in the8 `4 z( z4 m$ L' P  R1 F
beginning of this process.1 In the absence of a neg-
4 E4 |; f1 X/ N6 N/ S# @7 |ative initial history of androgen exposure, our
/ P2 f8 L% v( f' E+ t- tbiggest concern was virilizing adrenal hyperplasia,. p. n1 `& w. Q0 X# B1 j+ w
either 21-hydroxylase deficiency or 11-β hydroxylase
7 O- P* |) F0 Z: ?% P6 u' xdeficiency. Those diagnoses were excluded by find-
6 x' d5 n, U  ]  S! l0 p! y# ying the normal level of adrenal steroids.
- q9 D5 `; q9 G) f5 _5 R7 ~The diagnosis of exogenous androgens was strongly+ V4 Y( ^0 w+ p" b
suspected in a follow-up visit after 4 months because1 f$ O- A9 n  ]. j' J5 m( D
the physical examination revealed the complete disap-4 |( M5 _- g- Y1 N
pearance of pubic hair, normal growth velocity, and8 U8 Y% C& l7 _- f! R; n
decreased erections. The father admitted using a testos-) ^$ i4 s  A& G  O0 {- y/ T: t
terone gel, which he concealed at first visit. He was
; {9 G" N& j3 R( Y4 F% I8 Z4 }using it rather frequently, twice a day. The Physicians’
& g0 C) T8 c* n6 [8 P: G0 gDesk Reference, or package insert of this product, gel or1 z; z6 Z( D+ n* `$ g: U7 F4 o" U
cream, cautions about dermal testosterone transfer to
; v* X5 \  g$ zunprotected females through direct skin exposure.0 Z4 e* G7 \  P4 a3 B7 J3 |" ~
Serum testosterone level was found to be 2 times the( Z- S9 b1 }) u
baseline value in those females who were exposed to
, t# t  Z5 B) x2 ~/ _9 `7 q0 J- yeven 15 minutes of direct skin contact with their male4 Q5 T' w1 G& \6 J. }" ]; }
partners.6 However, when a shirt covered the applica-
  s$ D9 m" b. z. g) `0 ^7 ption site, this testosterone transfer was prevented.- z6 r( ?" b2 H- r% ~! ^8 Y0 V
Our patient’s testosterone level was 60 ng/mL,
6 x8 X8 u5 ~5 s3 V8 E7 ]which was clearly high. Some studies suggest that! R& j$ @* t2 q- ]
dermal conversion of testosterone to dihydrotestos-
+ @& G- d6 B3 N: Uterone, which is a more potent metabolite, is more# j0 M4 _$ |/ M4 z' L, ?
active in young children exposed to testosterone
$ r7 ^- U0 ~- z! B( E* H7 K, G" xexogenously7; however, we did not measure a dihy-
0 x8 e! g3 Q; \9 s5 ~" p; z! y& A4 Rdrotestosterone level in our patient. In addition to( q8 T& k1 i( \
virilization, exposure to exogenous testosterone in1 ^" K# @) D0 w2 `3 O
children results in an increase in growth velocity and( a: j1 z5 S( o' S2 q
advanced bone age, as seen in our patient.# G- m$ p5 H# ~% S  y$ v% _
The long-term effect of androgen exposure during+ S% I# M0 h7 W4 V3 a
early childhood on pubertal development and final9 O  `* I5 ?( q
adult height are not fully known and always remain
, J% K! I6 q; s# R' f- P9 o) ?a concern. Children treated with short-term testos-
* h$ e5 w- m. E( y/ n" \4 ^3 x4 [% tterone injection or topical androgen may exhibit some
3 J8 Q7 i. f& P. l4 @) racceleration of the skeletal maturation; however, after( a9 r" S9 a# }$ N
cessation of treatment, the rate of bone maturation
! p( k* c* _6 j5 g% ddecelerates and gradually returns to normal.8,9
: A3 s6 K( v: x4 g; t6 g2 @2 hThere are conflicting reports and controversy
6 S5 J0 F& Z# K2 dover the effect of early androgen exposure on adult: K$ _' {  F' J# N
penile length.10,11 Some reports suggest subnormal
5 ~, \+ }+ t2 O4 A) @% j7 uadult penile length, apparently because of downreg-
% }, @  x: N1 b- rulation of androgen receptor number.10,12 However,
* `# O, ^" `$ U9 ]1 N& |' @( P- D7 B$ bSutherland et al13 did not find a correlation between
5 I. e: `' b1 j& xchildhood testosterone exposure and reduced adult
' S( A+ l7 z" q$ y# dpenile length in clinical studies.
9 h! Q% L8 k$ r( r3 Q/ m+ e$ b! bNonetheless, we do not believe our patient is9 ^% x. P+ Q+ p2 s3 r1 n/ r
going to experience any of the untoward effects from
; x# C4 V% f' n$ I+ N3 ztestosterone exposure as mentioned earlier because
( `8 f) n' ]' [) s$ A$ othe exposure was not for a prolonged period of time.
/ E2 G7 |+ R/ O* rAlthough the bone age was advanced at the time of
) G- _  O1 I5 }0 j- |' Ndiagnosis, the child had a normal growth velocity at, D: s1 e6 v8 q  H5 P* U9 K4 b
the follow-up visit. It is hoped that his final adult5 J3 s6 G2 {& P
height will not be affected.: Q- t- G! H3 C) j0 \! }
Although rarely reported, the widespread avail-; ]& Y0 }  T" n: q5 K. J
ability of androgen products in our society may
) k, V0 K$ S( }. [; F1 ^indeed cause more virilization in male or female" G2 c% P5 L" g5 h) O! `- X; ~5 R
children than one would realize. Exposure to andro-( r8 W# r  u3 B
gen products must be considered and specific ques-; `6 D' L4 N2 ]1 g( Z' M
tioning about the use of a testosterone product or
9 u/ j6 d' _5 U" C6 v5 M, H8 N6 ^gel should be asked of the family members during( ?4 [1 H- z, l: R+ ~; j
the evaluation of any children who present with vir-) \2 j$ H  `1 [: F0 o9 _% Q9 b3 _' J
ilization or peripheral precocious puberty. The diag-- t- Y, F' j/ ^" [
nosis can be established by just a few tests and by+ i+ Z$ k2 A' I+ t; g
appropriate history. The inability to obtain such a7 A0 W. M" y  Z$ w: Y$ ~
history, or failure to ask the specific questions, may
8 {; i% `) p- G0 Z$ n, ?1 vresult in extensive, unnecessary, and expensive, ?6 H% m4 d" J3 o  y' b& q) [% l8 K
investigation. The primary care physician should be1 v  ~! \7 a$ x9 C6 A3 t/ q4 h
aware of this fact, because most of these children
% a" G( V- Q* F! {% ]" dmay initially present in their practice. The Physicians’
& v6 z: A, K! u. G/ `; r4 X! cDesk Reference and package insert should also put a
/ B/ F$ i; i+ \  w/ U% `warning about the virilizing effect on a male or) R( w2 X: j0 Z% O5 b
female child who might come in contact with some-. x( C$ ^! s& H1 Z4 |- d  s
one using any of these products.: q* O1 ^' T; e8 e8 F
References
6 j4 p# Y0 U3 v0 t( h3 L1. Styne DM. The testes: disorder of sexual differentiation5 l7 J9 c, r9 Z$ Y3 G: _. Z. ]+ X
and puberty in the male. In: Sperling MA, ed. Pediatric
. Z% d, o+ @: ]" _$ bEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. i5 H6 Q- r# N+ d2002: 565-628.) d. M9 S% @6 x5 ]! X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 E' b1 q0 r! }0 i7 K
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
0 \3 X0 P2 t, K& ~- F
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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