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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
- T% k2 P8 }( j$ L+ `: lBoy Induced by Indirect Topical
* d! J) `3 y8 Y9 Z3 bExposure to Testosterone! ~9 f- v- M0 R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 ~; @8 Q9 h1 Q' P7 v' W. B- eand Kenneth R. Rettig, MD12 u5 q  |8 F& _: z2 ]
Clinical Pediatrics
6 b7 N4 s$ H' mVolume 46 Number 67 X0 S- Z/ m( y. K  E0 H
July 2007 540-543# J) K  z/ F9 f; [
© 2007 Sage Publications0 X* h- d1 K  g  p2 g
10.1177/0009922806296651
0 g. Q6 D& c# C+ O+ s8 q  y' I, ]( K* thttp://clp.sagepub.com- Q3 C: o- I1 m" T3 F* f4 ^8 v/ O
hosted at
- @4 J7 }, q6 p5 [http://online.sagepub.com6 ~: P" a3 ?- w7 S$ ^7 _
Precocious puberty in boys, central or peripheral,  O9 F% g/ `; E# ~
is a significant concern for physicians. Central
4 x4 v1 }3 Z5 C& L& o" yprecocious puberty (CPP), which is mediated
3 B* c* a$ G0 e* l  }) c7 i+ Ethrough the hypothalamic pituitary gonadal axis, has
. ]7 D5 r# `/ h  Y' X$ g0 A! Q" G4 da higher incidence of organic central nervous system
2 m1 L. S4 O4 d6 I; y/ ^lesions in boys.1,2 Virilization in boys, as manifested
+ k6 v" y1 X; \by enlargement of the penis, development of pubic
: h9 U( L" \8 u4 Bhair, and facial acne without enlargement of testi-( m# A. b' G6 k" {6 a) P
cles, suggests peripheral or pseudopuberty.1-3 We
8 L$ V& l. i0 Oreport a 16-month-old boy who presented with the7 m; J- X2 F% z- Y/ t2 W# g
enlargement of the phallus and pubic hair develop-) K6 c- w: t9 U+ T% h5 }1 }, E; h7 @
ment without testicular enlargement, which was due
) k: f3 j/ k' @1 v. Fto the unintentional exposure to androgen gel used by9 r( N, q* n: |% A4 T, f( i
the father. The family initially concealed this infor-0 |$ N/ P! N$ S: l" j
mation, resulting in an extensive work-up for this
7 u- Z/ u, [" {( ~! Q& Cchild. Given the widespread and easy availability of
& a6 t) w/ F, S% wtestosterone gel and cream, we believe this is proba-
% L+ V  X: L( P3 e& X6 H5 @( Gbly more common than the rare case report in the: o& b5 Y9 S" g* i* r, S
literature.4
) J8 k. U! U; P3 D' bPatient Report
1 y5 I1 A7 \4 Q& v8 k) OA 16-month-old white child was referred to the
2 }. D3 {- d  [5 B! F! A4 t1 lendocrine clinic by his pediatrician with the concern
( p: Z, Z. `: jof early sexual development. His mother noticed* d7 y" t3 y* E- h* Z% X+ y" g& g
light colored pubic hair development when he was! I: _0 ~, ]* Y1 N, A, H3 N7 Z
From the 1Division of Pediatric Endocrinology, 2University of6 a  W( [# s5 `* P
South Alabama Medical Center, Mobile, Alabama.- h' m8 I# Z" N+ v9 U
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& a' F9 M$ I) C( H& E+ jProfessor of Pediatrics, University of South Alabama, College of9 w. A% @  U7 X- A3 e$ \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 w* g9 d5 U9 p" O3 O6 u( N# R0 ee-mail: [email protected].
2 {# p  a$ M( W3 w% \about 6 to 7 months old, which progressively became
5 q* V2 q: Z% m5 \/ C7 d- hdarker. She was also concerned about the enlarge-4 n# U4 x# u: \
ment of his penis and frequent erections. The child
9 j, q2 s! E4 U( k6 z( c; a$ F( Hwas the product of a full-term normal delivery, with) b/ Q, P0 g* d" R# g* e5 j
a birth weight of 7 lb 14 oz, and birth length of
# M" L0 \& r3 V/ n20 inches. He was breast-fed throughout the first year* o/ a0 j5 W& |  k
of life and was still receiving breast milk along with: M" L+ c* |. O) l- w
solid food. He had no hospitalizations or surgery,
5 D2 S/ V# j2 @3 G6 J7 Kand his psychosocial and psychomotor development
; S/ R. h' x0 Z7 |- Zwas age appropriate.; }2 Y! r3 q1 d8 Q, B
The family history was remarkable for the father,
# A# ~3 M8 }1 C- R& J6 o& o& wwho was diagnosed with hypothyroidism at age 16,5 C1 r4 ^$ E7 v
which was treated with thyroxine. The father’s
$ M3 R+ B" @1 B8 g: e) p  }. theight was 6 feet, and he went through a somewhat
, p0 Y/ ]& o% X8 nearly puberty and had stopped growing by age 14.
; Q/ s; h7 [% X3 s6 \The father denied taking any other medication. The* I2 {2 C* {7 P9 E, x' T' R2 a
child’s mother was in good health. Her menarche
5 t6 x) |8 y  u% B: o+ xwas at 11 years of age, and her height was at 5 feet
6 W1 @% ]! m# K  T( @4 |5 inches. There was no other family history of pre-
3 Q, A6 J$ N7 n: x0 R$ f$ Scocious sexual development in the first-degree rela-
" c* O- {; A7 \# I! Ptives. There were no siblings.* P: v: G9 |5 ?. n/ ^2 c8 X
Physical Examination% q+ o8 `$ }3 ]; [1 s7 d" J
The physical examination revealed a very active,
' j6 F8 I& P2 N( T& I4 a# |playful, and healthy boy. The vital signs documented8 g: K' v1 n4 ]4 s6 W5 C
a blood pressure of 85/50 mm Hg, his length was
9 U2 c# P* p" y90 cm (>97th percentile), and his weight was 14.4 kg4 K# z9 t' \9 }4 O
(also >97th percentile). The observed yearly growth4 i5 ^9 V" w; \1 M
velocity was 30 cm (12 inches). The examination of* R/ Y# g% l  g1 ^
the neck revealed no thyroid enlargement.' p, [% B% r) g, ~3 [( a
The genitourinary examination was remarkable for
* Y" S8 j& D- T2 Cenlargement of the penis, with a stretched length of
1 g2 g$ @0 G. o! {5 U8 cm and a width of 2 cm. The glans penis was very well
( v/ F% w2 M+ E3 W) bdeveloped. The pubic hair was Tanner II, mostly around# z0 y( c: ]: V3 D/ n, ]0 i; E
540( F7 z1 _6 L! g0 X6 l( [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 u  c8 Y6 I8 Uthe base of the phallus and was dark and curled. The  K" ^4 P( j, G: n5 d
testicular volume was prepubertal at 2 mL each.
" ]* |+ O1 ?% w) R. dThe skin was moist and smooth and somewhat7 }$ w2 N& [, W4 I8 m3 S
oily. No axillary hair was noted. There were no6 K' l+ \& y* j* t' x7 k
abnormal skin pigmentations or café-au-lait spots.
) P3 N) S1 z9 n' P) C& sNeurologic evaluation showed deep tendon reflex 2+; l0 Q% ^! g; }3 f) z
bilateral and symmetrical. There was no suggestion
+ J# t/ H& g" i4 @/ Vof papilledema.) l; G. u1 U* @- S: [  }$ H
Laboratory Evaluation
; g: H4 F' x) ^2 i' k8 T+ LThe bone age was consistent with 28 months by
& U, m7 [1 j0 Y7 Q/ @! n3 n/ L. }using the standard of Greulich and Pyle at a chrono-! W0 e2 v7 K! E2 y6 Q* U
logic age of 16 months (advanced).5 Chromosomal9 S. `$ O8 F2 W
karyotype was 46XY. The thyroid function test
" _! ?# O" H1 a: }3 D* \9 lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 a7 B" H: }; P# k9 r* m. D
lating hormone level was 1.3 µIU/mL (both normal).; x! G) r/ e' n5 B' [. m/ m& o9 s
The concentrations of serum electrolytes, blood
8 z/ B- B, k  w% W2 T" k+ }; kurea nitrogen, creatinine, and calcium all were  _2 E; C8 Z' {/ R) [& M
within normal range for his age. The concentration5 T1 w, b& R% }5 |. G8 I
of serum 17-hydroxyprogesterone was 16 ng/dL3 b0 u/ Y4 {3 J+ t7 M- m
(normal, 3 to 90 ng/dL), androstenedione was 20
% c4 T# g! ~9 N2 _& B8 Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( K: w! r% e& ~, w* I/ xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 r' ]( E0 s9 T; p5 O: xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 P# O) _' W% @0 N& ?5 a$ h49ng/dL), 11-desoxycortisol (specific compound S)8 ?  g& z( o% I% V) `- B5 X0 z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" z) p5 X, o2 X7 c* n! dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ _* X, e& X" Z6 r& N9 p5 ]testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& ]' c3 Q- _2 _' |* \
and β-human chorionic gonadotropin was less than3 W/ j' ]& a7 @3 ]/ C- N
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 D" r0 k) {, u1 H* cstimulating hormone and leuteinizing hormone% u: l" \+ D) O, Z. n2 u
concentrations were less than 0.05 mIU/mL
" ^" ~: F& k" D, z: d, [3 s0 E! b(prepubertal).
! g$ R4 ]6 U( M/ H. |$ fThe parents were notified about the laboratory2 X5 M; N3 s! Q: z# D' V
results and were informed that all of the tests were+ P3 H$ M$ _1 u3 b
normal except the testosterone level was high. The
6 p# h4 D  J: L5 f" E, P$ Hfollow-up visit was arranged within a few weeks to7 N# P" O, {$ `9 a% K1 a* j7 v
obtain testicular and abdominal sonograms; how-
4 L+ ~5 l, o7 Q* pever, the family did not return for 4 months./ m8 S! p0 W' |' g" H  }, Y
Physical examination at this time revealed that the* o; t- I5 {9 {8 B! |" v: a
child had grown 2.5 cm in 4 months and had gained
4 y9 _- u7 E, w( t2 kg of weight. Physical examination remained
0 X  {: ~; v: x) runchanged. Surprisingly, the pubic hair almost com-' O& B2 D) s7 X
pletely disappeared except for a few vellous hairs at- q9 M- z: N1 X, s
the base of the phallus. Testicular volume was still 22 q& ?. V/ B& q
mL, and the size of the penis remained unchanged.
# z3 C. R* v' _% R) N  kThe mother also said that the boy was no longer hav-( X, @  F' S5 s7 V
ing frequent erections.
( B& Z& d5 r* O" FBoth parents were again questioned about use of
( w' ]: t8 j0 R% o  N; |3 f/ O0 f$ Yany ointment/creams that they may have applied to& w. g' `8 C6 P) \( G; E1 P3 \
the child’s skin. This time the father admitted the
0 s& d" n7 K/ x' hTopical Testosterone Exposure / Bhowmick et al 541
9 G* K: J" F2 h$ \0 X$ O/ Kuse of testosterone gel twice daily that he was apply-
& ~, b4 V- `# P9 N3 ^9 Sing over his own shoulders, chest, and back area for
/ j+ A2 F+ w& x+ U8 Ua year. The father also revealed he was embarrassed# B4 o6 x7 o0 \" r9 J$ Z3 `: P* f
to disclose that he was using a testosterone gel pre-; u  _7 h$ M& \+ c, Q/ `, N
scribed by his family physician for decreased libido
" a4 ?' r/ w' i9 Hsecondary to depression.$ b( ]& v7 F) `% n  I" r% S5 P
The child slept in the same bed with parents.
, B. ^1 u2 U, T7 X$ AThe father would hug the baby and hold him on his/ f5 a4 U) @/ Y) R. A& t6 ?
chest for a considerable period of time, causing sig-
) c0 u( k3 ^4 w" k1 e, jnificant bare skin contact between baby and father.- ^0 S; T' R+ V* U: t
The father also admitted that after the phone call,0 b9 w+ q. L% J( H
when he learned the testosterone level in the baby
8 b2 N  h( C2 y/ S  x" a. owas high, he then read the product information
. L4 ~: W8 C' i4 ?* n( j" f. fpacket and concluded that it was most likely the rea-
% f9 g; N; u9 L' {, Qson for the child’s virilization. At that time, they# x# t5 o/ H) n' p% |
decided to put the baby in a separate bed, and the2 |, E+ |; Q! Z0 \& b# u- M) x
father was not hugging him with bare skin and had
. \) E- m# p* S; ~6 Ubeen using protective clothing. A repeat testosterone
: _* f% M* C- C6 v1 ]7 s# Xtest was ordered, but the family did not go to the
: S" _0 @  U: \) Blaboratory to obtain the test.! O4 R8 R8 I- C, r. _. D( R
Discussion
$ q) B1 P( S) |( b0 aPrecocious puberty in boys is defined as secondary; k0 t, N5 |. q& H3 F
sexual development before 9 years of age.1,4
% {. i. u' D2 H8 ?! S4 [8 z! n) ^Precocious puberty is termed as central (true) when" T0 T# N$ `6 u+ H5 [4 u% e
it is caused by the premature activation of hypo-0 S5 A  n( E$ P$ r6 q( A& D/ ^' i
thalamic pituitary gonadal axis. CPP is more com-
/ V$ d# t+ Q( Kmon in girls than in boys.1,3 Most boys with CPP; b; j# U1 M, \- _7 \7 g1 p
may have a central nervous system lesion that is9 j, p# Y( i2 b7 J/ v
responsible for the early activation of the hypothal-& o! o) Q& `. b* f
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 V! ?. e. h* T7 Y. ^/ R  ?- Gsis has been given to neuroradiologic imaging in
. p1 |- E- l) `7 S. X% pboys with precocious puberty. In addition to viril-
. S; Y6 n% z8 |  E, p: }# ]ization, the clinical hallmark of CPP is the symmet-- q* p" x9 C  h2 m& N
rical testicular growth secondary to stimulation by  L  }4 y2 x8 F8 t
gonadotropins.1,3
) N; S# r/ }) Z8 d7 L/ ^Gonadotropin-independent peripheral preco-/ k1 z! t& O" e1 ]9 [6 X
cious puberty in boys also results from inappropriate
$ j9 C" P/ ^7 |0 q: xandrogenic stimulation from either endogenous or% w8 J8 }# l. [; B- T8 i2 `
exogenous sources, nonpituitary gonadotropin stim-
% U; n  K3 |4 s7 Sulation, and rare activating mutations.3 Virilizing
+ W5 H: [3 K' r2 h  _( ^9 vcongenital adrenal hyperplasia producing excessive$ A$ Y( [, T7 Y* @, D
adrenal androgens is a common cause of precocious
" L7 P  |5 G# @% I! f6 |puberty in boys.3,4
0 ?: F! v8 X7 a1 O# ~& T; cThe most common form of congenital adrenal- E7 a! q; l. g
hyperplasia is the 21-hydroxylase enzyme deficiency./ y; y$ w7 O/ H/ A- u" |  Z* w/ r$ V
The 11-β hydroxylase deficiency may also result in
: q, v/ m) d9 l+ ?: ]excessive adrenal androgen production, and rarely,
. @" K; Q" G) ^1 g9 K# c* e) Oan adrenal tumor may also cause adrenal androgen
& B4 f) w* b  i3 {" Fexcess.1,3
- Y! q! |/ ~$ ~; p" J( Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 h6 n  n! N. z7 \4 d. R& k( U9 N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! U! J7 T( t' m2 _6 u# a+ V
A unique entity of male-limited gonadotropin-
; g& \, p8 W2 M2 Lindependent precocious puberty, which is also known, k1 O7 m% I# p( L! k
as testotoxicosis, may cause precocious puberty at a
9 r, o+ a; A* @5 ]very young age. The physical findings in these boys
! [/ ]# j% E2 F2 ~0 t7 s+ S: M" swith this disorder are full pubertal development,/ V& N* O% k) T
including bilateral testicular growth, similar to boys/ S9 ]1 }: b8 J
with CPP. The gonadotropin levels in this disorder6 Y; f: F0 q; l( |! i
are suppressed to prepubertal levels and do not show
( O# K5 z3 t% V/ C! \% \* mpubertal response of gonadotropin after gonadotropin-* A& A2 H# S- J! K3 I8 p  Q1 o
releasing hormone stimulation. This is a sex-linked
8 s$ p3 Y# S5 J6 F! P" ^autosomal dominant disorder that affects only
, f3 o0 ?( z, P" zmales; therefore, other male members of the family
. r; i& E' J) |* }% S* B- l' a; I+ Kmay have similar precocious puberty.3
4 D7 }( u7 U  h! V- E1 V6 `+ `In our patient, physical examination was incon-# x9 k5 p( B2 x$ U  H
sistent with true precocious puberty since his testi-' Z5 J9 r6 ?. Z2 p* d
cles were prepubertal in size. However, testotoxicosis
) w0 D4 }/ k9 ~7 Y& }2 i: owas in the differential diagnosis because his father* a3 g! x4 g" g$ y5 b2 K
started puberty somewhat early, and occasionally," J* N1 ~* Z% r  e' w
testicular enlargement is not that evident in the
, N0 @3 @- ^- I! A/ v2 V- ~- Wbeginning of this process.1 In the absence of a neg-
1 C: S% S0 Z3 m% G- c( u4 E7 cative initial history of androgen exposure, our
7 {& z+ B% r, M/ b" z, z+ s! Abiggest concern was virilizing adrenal hyperplasia,. Y/ w- X/ a2 N
either 21-hydroxylase deficiency or 11-β hydroxylase5 _+ n! [! E# t4 B
deficiency. Those diagnoses were excluded by find-
3 f$ C$ I3 a% i0 l4 xing the normal level of adrenal steroids.- C: i4 R! Y- `  M
The diagnosis of exogenous androgens was strongly) x! Q6 y6 o0 V% @
suspected in a follow-up visit after 4 months because
1 n( P% l  M6 r3 Q+ k- Kthe physical examination revealed the complete disap-
8 p. T- L; ^2 y$ h! dpearance of pubic hair, normal growth velocity, and
& k4 [" _# g2 V+ p/ udecreased erections. The father admitted using a testos-; o. p. p* ]! s
terone gel, which he concealed at first visit. He was
: E# V8 K" t8 O3 a: n( uusing it rather frequently, twice a day. The Physicians’( X/ I4 P4 o8 c) N
Desk Reference, or package insert of this product, gel or: I) b  Q' z8 ^2 H: ]! h& `$ D6 `
cream, cautions about dermal testosterone transfer to
1 m! D% s# w0 gunprotected females through direct skin exposure.
7 m$ T6 ~- j+ t' e8 o, t( ~Serum testosterone level was found to be 2 times the
) p2 e  F% m0 h( Z  o" Wbaseline value in those females who were exposed to2 z0 a% O" h& s" b1 W/ D0 {
even 15 minutes of direct skin contact with their male+ \* E! W6 `( @# T8 M
partners.6 However, when a shirt covered the applica-
: i8 j7 I+ @- b2 vtion site, this testosterone transfer was prevented.- Z7 H7 _- y! v2 h6 u
Our patient’s testosterone level was 60 ng/mL,, Y3 z1 d! c4 d, L
which was clearly high. Some studies suggest that, V" N4 b) l* z+ b
dermal conversion of testosterone to dihydrotestos-7 u7 x/ F$ Q4 C  K
terone, which is a more potent metabolite, is more1 R1 j1 C. \, ^$ E
active in young children exposed to testosterone) G7 ?  l! T/ s4 m( @0 ^4 R
exogenously7; however, we did not measure a dihy-
9 T9 a6 x% F% ]  h4 N$ L( y" f7 p0 Bdrotestosterone level in our patient. In addition to$ }+ c! k' o/ R4 @" A" [1 e
virilization, exposure to exogenous testosterone in5 I. l0 V1 h5 M4 ^  Y
children results in an increase in growth velocity and
8 _) G0 @' S" i9 j9 l0 Vadvanced bone age, as seen in our patient." s( _8 b7 j7 n0 M" c) `- {: I
The long-term effect of androgen exposure during
. n5 `/ ^! h0 S. A6 ~' ?early childhood on pubertal development and final3 Y& m$ |: G8 {
adult height are not fully known and always remain
! C2 E5 t* B& Xa concern. Children treated with short-term testos-: _9 r- D* T. J( \9 T; f8 z
terone injection or topical androgen may exhibit some
% {! w: v  r9 R( W. o3 H! l3 o1 Cacceleration of the skeletal maturation; however, after& n6 C) g! S/ x1 j3 ^: o
cessation of treatment, the rate of bone maturation( h! T% B# v) d3 e8 F
decelerates and gradually returns to normal.8,94 R! ?7 o) G" }8 h5 o
There are conflicting reports and controversy
$ @3 t, x( p: ]: w. r! }over the effect of early androgen exposure on adult
2 e' G1 G% b' u9 v6 _; k: r3 [! npenile length.10,11 Some reports suggest subnormal
+ v. }" k; G. oadult penile length, apparently because of downreg-) v0 ^0 i2 u1 M* {  ~
ulation of androgen receptor number.10,12 However,+ }, Q2 ^+ b# u' \# v
Sutherland et al13 did not find a correlation between) d1 F' T8 e. u% u
childhood testosterone exposure and reduced adult
; T1 k$ }0 }' ^0 Rpenile length in clinical studies.) [  G! Q. |5 G# ]2 o4 T& M
Nonetheless, we do not believe our patient is0 V- a: s. t9 a6 q
going to experience any of the untoward effects from
# h9 `2 H- ?" z3 L* |testosterone exposure as mentioned earlier because2 o* i, ]& `+ F+ x7 W7 w  o, B
the exposure was not for a prolonged period of time.
3 q% X) {: |$ S5 Y- W& UAlthough the bone age was advanced at the time of
) _7 O8 h& R, w8 C3 e; |diagnosis, the child had a normal growth velocity at
! l1 S3 p1 \# {- G: zthe follow-up visit. It is hoped that his final adult2 m& {2 L! X: D6 M' [$ A: T7 e
height will not be affected.
/ E) t8 o6 B( `; y, ZAlthough rarely reported, the widespread avail-
. H; Q0 ^  ^& Wability of androgen products in our society may
3 Q4 H" {2 U& V7 n' P1 Z+ C5 o7 `6 h" Q: vindeed cause more virilization in male or female
. c3 z% Q+ T3 ]. J$ b6 S9 _children than one would realize. Exposure to andro-4 ~- Y; ]1 B: ?+ ^5 _  G% h. G
gen products must be considered and specific ques-
5 E8 A8 z6 B* `) Z9 P9 J% {/ Ptioning about the use of a testosterone product or$ p, N; h& H. Z; W# R1 h
gel should be asked of the family members during
4 v. X9 l, \4 k6 I0 k6 J# \the evaluation of any children who present with vir-- V  I8 S4 B( i6 r# k' n" N
ilization or peripheral precocious puberty. The diag-
6 \$ u8 _, k- n7 ?( E6 Vnosis can be established by just a few tests and by/ \* F3 A' C$ T: [8 P! Y
appropriate history. The inability to obtain such a7 }' B: m! m8 b
history, or failure to ask the specific questions, may3 I. ^+ C( f5 R3 \
result in extensive, unnecessary, and expensive
+ b# B5 I, K( l( M- F6 binvestigation. The primary care physician should be
4 m" o+ N& F$ D6 jaware of this fact, because most of these children
* P$ N' I( H4 ~6 \7 R2 z, @may initially present in their practice. The Physicians’
3 v% {/ H! o3 N0 W% E' h2 Q" eDesk Reference and package insert should also put a# R8 u1 J: w+ d) k1 C0 Y4 K
warning about the virilizing effect on a male or
6 p$ L. l, P# l6 i5 `( rfemale child who might come in contact with some-( \* q+ W3 b6 p4 R5 a
one using any of these products.3 N0 q, l5 l: F- u
References' T; g6 }" l6 }$ ^4 J- f$ u9 D
1. Styne DM. The testes: disorder of sexual differentiation( |4 t. N) F$ ?: O5 }! a
and puberty in the male. In: Sperling MA, ed. Pediatric
0 i$ T, Z  @. z* v" xEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 m& y- A6 a7 Y" A( `2002: 565-628.
% d+ @( `* Z0 ^4 G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 k/ b# c4 ]: L" c% I/ t9 a
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old0 a" N) \% ~$ C9 y$ ]
Boy Induced by Indirect Topical
( m/ ?5 R- x  S. C5 BExposure to Testosterone
' w- C* r* t- A+ |. iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 ~' g. K. s' ]0 C* Eand Kenneth R. Rettig, MD1
; N: R8 J' ?1 E, X1 z) k5 KClinical Pediatrics4 u! Z7 s3 |( @; d+ ~
Volume 46 Number 67 ^- Q0 A1 J8 ]
July 2007 540-543
" x% d4 d+ H" T# D* \( l© 2007 Sage Publications9 [: v# X* c* L0 W* s: k) |
10.1177/0009922806296651
' B  C6 A: I+ B- b: t5 T; lhttp://clp.sagepub.com2 Y; s2 v  ^2 e8 k$ J; D
hosted at2 |" _1 f( q9 L9 b& F! q
http://online.sagepub.com
3 e/ r2 G1 G2 G7 {7 f6 IPrecocious puberty in boys, central or peripheral,, P* S7 b( u1 v* p
is a significant concern for physicians. Central& {! n/ e. ^/ [/ s( ]
precocious puberty (CPP), which is mediated# N0 `5 {0 W- U' J/ K- [# _
through the hypothalamic pituitary gonadal axis, has
- E- T: k$ P+ I8 u( |$ P5 Aa higher incidence of organic central nervous system
3 I  j7 L* \; R7 ilesions in boys.1,2 Virilization in boys, as manifested- ?3 ]) M: A2 x1 c( ^4 t- D
by enlargement of the penis, development of pubic# C+ e* c$ G/ R+ J4 t8 W: C
hair, and facial acne without enlargement of testi-& y$ _% k/ c  F; ~9 W1 e6 P
cles, suggests peripheral or pseudopuberty.1-3 We" k7 W# J6 C$ E$ `9 l/ u: b" A
report a 16-month-old boy who presented with the
( E7 i7 s  X9 ^9 @7 _. oenlargement of the phallus and pubic hair develop-
. }, U: D7 a) _. g$ k7 g+ nment without testicular enlargement, which was due% ?/ d9 N% F& b, H
to the unintentional exposure to androgen gel used by, Q. Y2 |" I+ o+ c
the father. The family initially concealed this infor-4 i3 n- v9 u7 t. R
mation, resulting in an extensive work-up for this- W- G0 x+ Q! Q. g1 n6 n: E
child. Given the widespread and easy availability of2 [2 c" _6 y# D$ ~  P
testosterone gel and cream, we believe this is proba-
$ W. ?- k$ ]' X% k! M1 S& Z& lbly more common than the rare case report in the& V7 X/ ?' L- J/ j; M) N
literature.44 B$ P- t  _% j0 r1 S9 O! |
Patient Report4 c- h3 r; D# }9 o* ^/ k
A 16-month-old white child was referred to the
6 C9 S; Z% L7 Q. l6 F" ~+ kendocrine clinic by his pediatrician with the concern
1 @. w8 G) {9 `& u  Pof early sexual development. His mother noticed
, |" e: Q! b/ x2 ^' N) ~light colored pubic hair development when he was) Z; K/ c* H9 B5 E$ E: [* d
From the 1Division of Pediatric Endocrinology, 2University of" @- `) W$ a) U! x8 R$ n
South Alabama Medical Center, Mobile, Alabama.  b/ k! x& C1 \, ~2 P9 v5 R; t2 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 {+ n) ^% m0 h- q  cProfessor of Pediatrics, University of South Alabama, College of
- p: I$ z6 ?) Z- P* gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 a, y7 U4 [( r. a- ]/ V  W, L
e-mail: [email protected].8 k' d7 u  p! I2 ~, |
about 6 to 7 months old, which progressively became# v! x. Y( h& o0 A9 [- D
darker. She was also concerned about the enlarge-
" J9 V4 o) S  Q! j$ N  ]( r& Qment of his penis and frequent erections. The child/ B& w4 c  D  r- x; s& j
was the product of a full-term normal delivery, with4 y/ o' H0 n  t3 \0 \
a birth weight of 7 lb 14 oz, and birth length of
  f5 I2 X9 z1 _! j/ N) E5 {! |5 ^20 inches. He was breast-fed throughout the first year
6 b" _3 v+ K& z. J9 y. Iof life and was still receiving breast milk along with
# @3 W4 |1 ?, |solid food. He had no hospitalizations or surgery,
4 ?6 ^$ b! m3 b( W0 eand his psychosocial and psychomotor development
% i5 s" I+ s' e7 @; k9 `was age appropriate.
/ S; n3 D) t( h% j' G* WThe family history was remarkable for the father,
9 w3 R3 O, {6 i. _) j$ T% xwho was diagnosed with hypothyroidism at age 16,
% c8 s* y* P6 R: x! S- wwhich was treated with thyroxine. The father’s
/ @; A" o$ e* x" f& T5 o1 Uheight was 6 feet, and he went through a somewhat
9 z- b8 z% X: a2 g, M& ]4 Y2 aearly puberty and had stopped growing by age 14.
/ M) |) _) B# L9 a7 G8 b1 H+ `; KThe father denied taking any other medication. The
4 P" u- K1 H" V( b" s9 mchild’s mother was in good health. Her menarche
1 s" w$ h3 Z; |0 h5 Bwas at 11 years of age, and her height was at 5 feet* I( ^+ t: O( |! b1 p
5 inches. There was no other family history of pre-
& L( {' J! w- _& a; u# Acocious sexual development in the first-degree rela-- {+ X& {, X# {
tives. There were no siblings.: k6 z$ w7 N* s; y+ Z) {% V7 F
Physical Examination  [* Q% q# n1 I* U
The physical examination revealed a very active,
: S7 Y2 _4 P& _3 G4 H: xplayful, and healthy boy. The vital signs documented% |$ D# e# N  V4 z' \
a blood pressure of 85/50 mm Hg, his length was+ Y, ^- A! P& c  v1 Y; x$ c
90 cm (>97th percentile), and his weight was 14.4 kg
* ~! |3 M& T  i. Q! o$ e2 j& E2 m(also >97th percentile). The observed yearly growth; M% j& Y$ |: U. U4 [: S( X1 }
velocity was 30 cm (12 inches). The examination of
3 a" A4 D2 y4 j; [) b* Qthe neck revealed no thyroid enlargement.5 j1 X  v( f: Y# [2 |( j
The genitourinary examination was remarkable for/ H1 ~  d" d) _/ Q
enlargement of the penis, with a stretched length of8 ]% p4 V0 S- V0 J
8 cm and a width of 2 cm. The glans penis was very well
' L* j! U$ J) m8 D# U1 Wdeveloped. The pubic hair was Tanner II, mostly around2 [2 [" C8 t7 S" B: h5 b8 U0 _; @1 j' ~
5403 H) v5 n' X# M; `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ K- j. w4 h3 Q1 P4 S5 x
the base of the phallus and was dark and curled. The& k' a, Q0 D9 N$ r! E6 v+ v
testicular volume was prepubertal at 2 mL each.
; t' e6 J, @, O+ v8 }9 t! ~The skin was moist and smooth and somewhat
+ Q  l  o0 l/ m1 Z- N1 ioily. No axillary hair was noted. There were no
4 a: J& j  o' i) v0 j9 {abnormal skin pigmentations or café-au-lait spots.; f( u0 d/ u" D7 n" m: ^
Neurologic evaluation showed deep tendon reflex 2+/ |4 P! Z- F+ ]$ P+ @
bilateral and symmetrical. There was no suggestion2 ?; a: W) v9 t! k& k  j" ]
of papilledema.
0 O$ m2 ]9 u9 O- t5 BLaboratory Evaluation- n( T3 Y) i0 Q  O; ?. W+ G0 d( H) y* `
The bone age was consistent with 28 months by
; T1 G) g5 S8 X( u7 N2 q7 m4 ^using the standard of Greulich and Pyle at a chrono-
0 v& w- \2 J2 N# {* |logic age of 16 months (advanced).5 Chromosomal
4 P2 u" j- H% W7 g, L3 S( {karyotype was 46XY. The thyroid function test
& W3 Q6 C: H- C( J% f( M9 x. Y% Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 u( J, ^, ^8 C3 V5 [' Mlating hormone level was 1.3 µIU/mL (both normal).
4 l( g" L4 t( n  |% b, b% m6 v+ @8 JThe concentrations of serum electrolytes, blood$ a. q! a' k+ y/ G; _% f
urea nitrogen, creatinine, and calcium all were
: _# [1 A% Q( R7 U$ q; m$ cwithin normal range for his age. The concentration) W) I, G  q4 K
of serum 17-hydroxyprogesterone was 16 ng/dL8 T( m# M. ?" h8 ^& w; Q+ @3 R
(normal, 3 to 90 ng/dL), androstenedione was 20
$ d: n9 s1 i  f- W9 r2 a! png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 Y: e4 H5 b6 t' j" i$ J
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ ?! \& H4 n, s7 \+ x! Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 @! K' `% d+ U* J3 v
49ng/dL), 11-desoxycortisol (specific compound S)" k! x/ @, n6 J4 r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( L" g9 T, _6 J2 e  @# H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& b) ~( ?4 E" c/ z$ e$ ]/ {+ x( I3 \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! u* x; J2 W' M/ L4 [
and β-human chorionic gonadotropin was less than! n4 {- V0 w0 a% R" @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" }  Z6 S( w% J) o! W  _stimulating hormone and leuteinizing hormone
; |  M! z0 _4 D( }- F( b" b/ qconcentrations were less than 0.05 mIU/mL
3 R/ e, N8 V; p# s(prepubertal).# u2 ^5 p! r5 M' e1 G7 R! U
The parents were notified about the laboratory
" A$ P5 u8 H. P( k& I& d$ ?+ B  Kresults and were informed that all of the tests were
% A: m+ T; i& A3 b% _normal except the testosterone level was high. The. g6 p* n  P9 }/ A0 A7 q
follow-up visit was arranged within a few weeks to; |1 r  f; h- k! ]1 u
obtain testicular and abdominal sonograms; how-
, n2 h+ q1 r* H" A8 f2 lever, the family did not return for 4 months.1 |- X: w/ X3 K
Physical examination at this time revealed that the+ ]- h3 S0 G8 `* P( o+ Q2 @
child had grown 2.5 cm in 4 months and had gained9 l9 c  B' D: c/ I& o
2 kg of weight. Physical examination remained( W' N+ S0 W  ?( O' G& h' J' f
unchanged. Surprisingly, the pubic hair almost com-
, Q% n, l9 Q+ Npletely disappeared except for a few vellous hairs at0 }2 ~* l1 ~% \( A& j
the base of the phallus. Testicular volume was still 2  v. ]. D' _" ?5 Y' M4 `
mL, and the size of the penis remained unchanged.
, w5 c5 f! U% T6 Y* AThe mother also said that the boy was no longer hav-- @1 f& G+ O. w6 [+ O: M/ K) m
ing frequent erections.
: e1 M0 O" v4 PBoth parents were again questioned about use of( q' b% `4 i: e# [5 J, K/ S) U
any ointment/creams that they may have applied to
4 y1 |& ^0 a( M  ^% X8 ~the child’s skin. This time the father admitted the; B! p1 T" r4 W8 D& D9 D
Topical Testosterone Exposure / Bhowmick et al 541
: |2 M* ]$ e6 c  P( b9 C0 \* A$ Wuse of testosterone gel twice daily that he was apply-3 U5 z" D# W  B% P
ing over his own shoulders, chest, and back area for
) D) a' v: P, u& E  N& Ha year. The father also revealed he was embarrassed; g; B1 j% y; _2 N! a5 U+ h
to disclose that he was using a testosterone gel pre-( B' D! r! U; X
scribed by his family physician for decreased libido
3 b5 J" M( \  r4 I+ zsecondary to depression." \6 S$ c1 j$ H5 h% Z: j2 T  H
The child slept in the same bed with parents.# t4 ?2 N% w$ I, W8 h. C* S& M
The father would hug the baby and hold him on his
8 v6 A* ~- l! h* wchest for a considerable period of time, causing sig-% G5 ~3 f/ h; R
nificant bare skin contact between baby and father.8 m: S; u' i+ |9 T4 Y% ~
The father also admitted that after the phone call,, n( B# H7 X- o% N
when he learned the testosterone level in the baby# E& C$ k; I& v4 \6 r
was high, he then read the product information5 x+ k$ d' j$ A; _/ @+ f0 u
packet and concluded that it was most likely the rea-
; P, A# L, Y+ C3 S( @6 k% M" P) o7 Rson for the child’s virilization. At that time, they
; d) G- t. P: ydecided to put the baby in a separate bed, and the! H1 u/ Y2 r, z+ R$ d9 K* M+ d0 C
father was not hugging him with bare skin and had) v, l+ g) y, N( a$ W( [
been using protective clothing. A repeat testosterone5 Z9 O, R- X# q) G( Y' \$ B
test was ordered, but the family did not go to the
" p" k$ R& \- z# Tlaboratory to obtain the test.
) T/ E4 b: Q0 d1 PDiscussion
0 [1 x# t2 ~7 G; u5 n: U! Q* aPrecocious puberty in boys is defined as secondary
6 A; G  ~4 Y; N! B) ~sexual development before 9 years of age.1,4; C  X: V& [5 `0 l4 r% M
Precocious puberty is termed as central (true) when2 }; D. r9 E2 u" k+ P) A( h
it is caused by the premature activation of hypo-
1 a# O1 f9 i& p, m0 Xthalamic pituitary gonadal axis. CPP is more com-
& r, N$ q/ E0 ?% r* Rmon in girls than in boys.1,3 Most boys with CPP
, A7 X, P% D4 B0 imay have a central nervous system lesion that is  B* T" _1 W, b6 T
responsible for the early activation of the hypothal-
5 I) K! u% Y+ I- Camic pituitary gonadal axis.1-3 Thus, greater empha-
6 U+ c" T5 ^/ c- O! Dsis has been given to neuroradiologic imaging in  l6 {0 o5 N# O: s) x0 m
boys with precocious puberty. In addition to viril-
6 z, f! [2 G+ uization, the clinical hallmark of CPP is the symmet-
9 ~% |1 n# U; v+ u- ?2 Z7 yrical testicular growth secondary to stimulation by
6 [2 j: {3 p5 A) I& L& u- e7 sgonadotropins.1,3
: L) Z, h$ r8 W2 ~$ pGonadotropin-independent peripheral preco-3 }8 \1 o. s& B* e
cious puberty in boys also results from inappropriate$ i% u- m- t# N  {1 n/ n
androgenic stimulation from either endogenous or
4 B5 z7 O. D$ Hexogenous sources, nonpituitary gonadotropin stim-
% ]) x8 [) r% K, D! w4 t  julation, and rare activating mutations.3 Virilizing5 A7 w& m& v0 B5 F& Y& F
congenital adrenal hyperplasia producing excessive
! z! p9 L" e, Z+ C8 ^! w1 uadrenal androgens is a common cause of precocious
/ g- X2 s& h7 R# ]& Xpuberty in boys.3,40 e+ G1 @, _- J5 V+ ^& A
The most common form of congenital adrenal) p. Q! O$ [& L# d2 n5 N( J
hyperplasia is the 21-hydroxylase enzyme deficiency./ ]! E, m  R& ~0 V0 K
The 11-β hydroxylase deficiency may also result in
1 c, u# _. t" f0 j/ K+ ]9 T! Dexcessive adrenal androgen production, and rarely,( U# i3 |; c2 Q3 Y0 f& |! F
an adrenal tumor may also cause adrenal androgen* @- d9 v& r% J' ?" o
excess.1,3$ r& y, o: Y+ v4 p# y* D- a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' j4 s0 V6 }( p' F: y& R5 M3 L542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 S2 `: M: o6 }7 H7 b5 |& s8 ~+ z
A unique entity of male-limited gonadotropin-& l* U2 y" D3 {4 r& i
independent precocious puberty, which is also known# k8 N; g7 {# ^/ i* R3 z3 P' V
as testotoxicosis, may cause precocious puberty at a
" ?  v; ~. G4 o1 b2 ~very young age. The physical findings in these boys" i2 G9 l4 T9 y  a* b7 Q9 [5 J  g8 w5 j
with this disorder are full pubertal development,
( V9 i! i- g+ i1 F0 {including bilateral testicular growth, similar to boys
  Q+ X, V& p  l& l1 \4 [9 lwith CPP. The gonadotropin levels in this disorder( K6 J' e7 y; T# a  n0 Y( c0 C+ w
are suppressed to prepubertal levels and do not show8 F0 @, U% ]; p  i
pubertal response of gonadotropin after gonadotropin-
9 C; l  e1 D8 C; Preleasing hormone stimulation. This is a sex-linked
' N) k9 N: F6 t( ~* qautosomal dominant disorder that affects only
  S" w5 z: k. K, o  N3 r/ ?2 cmales; therefore, other male members of the family
+ z7 l8 C( o0 q9 kmay have similar precocious puberty.3/ g/ q' U1 E& q; ^5 x) Z6 W
In our patient, physical examination was incon-
. m6 r" ]7 ^" P2 _4 h. U* `sistent with true precocious puberty since his testi-& Z3 i$ y$ n# Z  G7 w
cles were prepubertal in size. However, testotoxicosis
: J& E0 _; u3 P2 ^8 b2 B0 pwas in the differential diagnosis because his father2 p. n- @9 S( V8 N2 w% P2 b' u
started puberty somewhat early, and occasionally,! S* a" m9 M: {7 C
testicular enlargement is not that evident in the5 L$ G4 n  v5 {
beginning of this process.1 In the absence of a neg-
8 ?2 f" m( K2 O3 q7 sative initial history of androgen exposure, our
2 D& z9 ~+ p1 e9 Lbiggest concern was virilizing adrenal hyperplasia,
& s3 E: m- a+ p: l# T) u0 y, m' w8 L8 Seither 21-hydroxylase deficiency or 11-β hydroxylase
$ @* B3 |( d% @1 v! wdeficiency. Those diagnoses were excluded by find-/ H' w' Y- B$ s' O& `8 ?- D
ing the normal level of adrenal steroids.' \( L3 l1 V5 ~9 X  h8 a4 ~2 z
The diagnosis of exogenous androgens was strongly
) q/ l2 `/ g3 e) S4 P: Zsuspected in a follow-up visit after 4 months because/ P! @; y9 o- \* L8 A# `# ^
the physical examination revealed the complete disap-5 A; x# f" S, K9 ?1 a
pearance of pubic hair, normal growth velocity, and
* K3 f( l: z  _. Q' x3 d6 {! [decreased erections. The father admitted using a testos-( K/ l: o9 I9 Z0 f& e9 B
terone gel, which he concealed at first visit. He was0 t( d9 P% h5 Z& I
using it rather frequently, twice a day. The Physicians’4 K" l1 x+ A/ n' M% z! M4 W
Desk Reference, or package insert of this product, gel or( k3 g) @; l7 w( i7 D
cream, cautions about dermal testosterone transfer to
# I7 F- l1 B  punprotected females through direct skin exposure.3 m3 M. s  Q) `9 z
Serum testosterone level was found to be 2 times the
8 y, q* c* i+ L8 k( N# k. a' rbaseline value in those females who were exposed to
, N/ t* v% T0 z- D# Seven 15 minutes of direct skin contact with their male1 a  n0 [9 s5 Y, }
partners.6 However, when a shirt covered the applica-
" j  \4 v8 g4 l; F- M2 btion site, this testosterone transfer was prevented." _5 Y  Z- r' R& w  s
Our patient’s testosterone level was 60 ng/mL,. Q' G" y1 _1 [. [/ _# _% x+ A
which was clearly high. Some studies suggest that
! R" N2 D4 k. ?0 Y: r1 Vdermal conversion of testosterone to dihydrotestos-
6 E, X7 w: m, Mterone, which is a more potent metabolite, is more4 r* X7 E- g$ _7 l% C
active in young children exposed to testosterone3 \+ z" r) M$ L. K. u  r/ ]2 {: e
exogenously7; however, we did not measure a dihy-
: y) R; J$ S" ]6 g4 y* b6 X; q( C( [drotestosterone level in our patient. In addition to
1 n$ d! M7 J$ z, l  E  O: |% C* \: Kvirilization, exposure to exogenous testosterone in
8 j1 O. h) B) c( f- G; z1 Dchildren results in an increase in growth velocity and
% @# p" R4 F1 O/ Kadvanced bone age, as seen in our patient.; j; M. m* B  }# M6 Y
The long-term effect of androgen exposure during
) {( a" l* H1 ?) w6 Xearly childhood on pubertal development and final
8 v% i' Q- i9 radult height are not fully known and always remain
, {' D2 l" K( la concern. Children treated with short-term testos-1 R: o0 \# N; D2 A2 J; Q1 B
terone injection or topical androgen may exhibit some
, u0 n) X5 S4 [$ S/ b) Q/ |6 b9 _acceleration of the skeletal maturation; however, after& I( x4 a$ W6 L% i/ e1 w+ ~
cessation of treatment, the rate of bone maturation! c, _& S2 ]: C6 m. z
decelerates and gradually returns to normal.8,91 u9 }9 [0 l+ Y/ h
There are conflicting reports and controversy3 u6 {5 [9 Q- a' e+ }9 R( U
over the effect of early androgen exposure on adult
5 H" Q0 ~/ i" ]penile length.10,11 Some reports suggest subnormal2 k  g; r0 `- G+ V. w
adult penile length, apparently because of downreg-1 Y! `/ O7 Y$ J5 W
ulation of androgen receptor number.10,12 However,
6 g- w7 o, Q4 K6 P; kSutherland et al13 did not find a correlation between6 `% @' s* J" @' x6 H7 a4 P
childhood testosterone exposure and reduced adult+ v) r9 n  x* P# B6 z
penile length in clinical studies.
  z7 V7 M- x0 C- \8 a, O- oNonetheless, we do not believe our patient is$ P$ p9 {& R1 M: F# m5 ~4 g
going to experience any of the untoward effects from
$ N7 G. Y* F  I) s! Atestosterone exposure as mentioned earlier because# K  H6 T3 o& K  ~
the exposure was not for a prolonged period of time.1 B  ]* h2 H+ l; I  i# R
Although the bone age was advanced at the time of
( o  y! b) w5 L5 Ndiagnosis, the child had a normal growth velocity at+ J: c- P7 T) K7 d
the follow-up visit. It is hoped that his final adult; @5 Q$ S5 s5 U6 l5 M
height will not be affected.
5 S; ]) b6 @# Z4 l- F  mAlthough rarely reported, the widespread avail-
* ^6 ]: n# c0 Mability of androgen products in our society may
+ B: h* }( r& k2 z' Gindeed cause more virilization in male or female# e! j' O& N) Y/ s7 b  T2 _
children than one would realize. Exposure to andro-
9 ^  W- m2 h* F6 n, q6 }gen products must be considered and specific ques-- F; ^: W) M0 z8 A: X2 }# y0 w
tioning about the use of a testosterone product or
9 D) }" R- a9 r! P1 [gel should be asked of the family members during
) j4 \8 @% T1 ?' K+ D# `' H- athe evaluation of any children who present with vir-
( d, G6 l+ y) M2 ^ilization or peripheral precocious puberty. The diag-$ }: T& O3 m; Y; g% d; _
nosis can be established by just a few tests and by6 z. {3 a4 l$ \* D0 S
appropriate history. The inability to obtain such a, H9 l' _3 u+ [0 E' ?' Q
history, or failure to ask the specific questions, may) q$ `" V  n3 l. t
result in extensive, unnecessary, and expensive
8 U8 G6 I$ N6 q8 q4 n. Tinvestigation. The primary care physician should be
- b" [( y( p/ ]! G# b4 Gaware of this fact, because most of these children/ e) j* P# x# l- x# m2 t
may initially present in their practice. The Physicians’
; q; B" h0 n6 Q" g; |  [Desk Reference and package insert should also put a: g6 R! C" `/ {+ |
warning about the virilizing effect on a male or' ^: e; K, u) I2 r  _+ C
female child who might come in contact with some-! X$ B5 \$ c! U  `5 ^. g
one using any of these products.2 z0 y! ]; X3 d
References
3 B( X0 J- w/ n/ p1. Styne DM. The testes: disorder of sexual differentiation
3 S; A+ i) p" f6 `and puberty in the male. In: Sperling MA, ed. Pediatric
+ A+ e& @$ F% R' p# z1 V3 EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; h3 M' s  w5 l1 @; n1 ?2002: 565-628.
+ N' _: a% p9 N8 A* Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( ?8 L& [7 P- R  xpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

3 \& w8 [1 s" T精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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