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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
) S8 W- E5 x4 F1 ^Boy Induced by Indirect Topical$ ^$ ?8 f; J. o; q
Exposure to Testosterone  M) `  g5 X" i* a5 E0 Y1 f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 [7 ]# y2 U$ |( T6 ?
and Kenneth R. Rettig, MD1' O+ W6 M# V) O" E' N) K
Clinical Pediatrics
8 ?+ l& q' d# A3 HVolume 46 Number 6
% ~, l8 q- U& A& j& {2 @4 E3 lJuly 2007 540-543! ]# p+ R8 A* s, |' Q& @5 I4 b
© 2007 Sage Publications
7 L) Q( l% p& Q10.1177/0009922806296651- x3 f3 a$ Q+ w
http://clp.sagepub.com4 ], G! K3 e3 g
hosted at
% X* e6 b7 m$ C! Phttp://online.sagepub.com+ ]0 T  |2 \& Q' ~
Precocious puberty in boys, central or peripheral,1 i0 g3 W& n" ?9 J
is a significant concern for physicians. Central
  c; `  N2 v' [precocious puberty (CPP), which is mediated% _4 V5 z. H5 w+ s# ^- }8 s3 L& O4 a
through the hypothalamic pituitary gonadal axis, has6 g0 d" H% S. p4 w( X% g1 @
a higher incidence of organic central nervous system
1 M4 \# k7 i" ylesions in boys.1,2 Virilization in boys, as manifested
2 p5 l/ f* W$ iby enlargement of the penis, development of pubic5 G& Y; }1 k( X$ }5 x0 d
hair, and facial acne without enlargement of testi-1 ?6 r- t# O( t. \5 E
cles, suggests peripheral or pseudopuberty.1-3 We/ J& w2 d1 m- Q+ Y; f
report a 16-month-old boy who presented with the
) m# O3 v7 h3 f: \* k- b% ]* P- penlargement of the phallus and pubic hair develop-1 q# _4 q+ l( m
ment without testicular enlargement, which was due
9 H5 {- J# c1 Q# o# V! Vto the unintentional exposure to androgen gel used by
; Y7 f) k  C6 Q/ {6 k6 cthe father. The family initially concealed this infor-
4 F6 g- {& y  cmation, resulting in an extensive work-up for this2 K* u/ D+ i; K5 Q9 g3 t' L
child. Given the widespread and easy availability of( u& K/ K. J7 {' [) Z
testosterone gel and cream, we believe this is proba-
2 l' g4 j6 J+ f% xbly more common than the rare case report in the% N) G$ z  D$ g. I
literature.4+ a5 ]+ o! i6 L9 l* l6 ]* b/ I
Patient Report% \5 D' e; U. |' j
A 16-month-old white child was referred to the. f0 u, i: O) I5 {) O
endocrine clinic by his pediatrician with the concern
4 O6 Z! f. k1 f* p$ Aof early sexual development. His mother noticed' P1 {  w. }+ g  z
light colored pubic hair development when he was
/ Y) B+ R& \. R# f0 I' w8 d; D1 bFrom the 1Division of Pediatric Endocrinology, 2University of- e+ h& z9 x* E- \9 g4 J
South Alabama Medical Center, Mobile, Alabama.' H; E0 P1 {, R/ A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- p$ g+ n/ m2 N1 ^" xProfessor of Pediatrics, University of South Alabama, College of
  v9 a8 g2 U6 F) g9 D" ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! _4 O$ f2 H0 E0 b5 C: M
e-mail: [email protected].
/ r7 k9 m$ j1 M& yabout 6 to 7 months old, which progressively became/ l" d$ [! H3 r* V" L: m% N
darker. She was also concerned about the enlarge-
! x* ?" w: y& ^7 |ment of his penis and frequent erections. The child* o; n7 c7 a# u- Z! a! S! G( M
was the product of a full-term normal delivery, with+ h! L) Y1 W& W
a birth weight of 7 lb 14 oz, and birth length of
* A# y& I! ]5 @* H$ H) s7 i9 f' J: Z20 inches. He was breast-fed throughout the first year
- o9 B( Y8 x+ Cof life and was still receiving breast milk along with; [5 n6 b! v3 \: c7 X9 F$ q
solid food. He had no hospitalizations or surgery,0 c$ o/ c$ @. ?2 h( [
and his psychosocial and psychomotor development
3 I8 @+ q' l! q& [was age appropriate.5 Y# l5 r8 W- f. Z1 @' t2 E
The family history was remarkable for the father,% d6 y7 @% y/ l8 r
who was diagnosed with hypothyroidism at age 16,
6 \) F. T8 \2 K1 ?0 o/ [which was treated with thyroxine. The father’s
6 y7 @' h6 d; o5 [2 W, w; Mheight was 6 feet, and he went through a somewhat
  X3 B, j( \3 H' c( Qearly puberty and had stopped growing by age 14.7 a  _7 s! |& Z
The father denied taking any other medication. The
% Q6 v+ n  c) }* Mchild’s mother was in good health. Her menarche
- N& i. T: ]' P" f# Owas at 11 years of age, and her height was at 5 feet5 {& ]7 F$ ]  E
5 inches. There was no other family history of pre-. }6 E4 Z* {/ b
cocious sexual development in the first-degree rela-# _2 M3 e* q5 @: O! S
tives. There were no siblings.
% C! Z3 ?4 c: {# m/ w& \5 G: @Physical Examination
, w) _0 o- k( s! I4 }5 g7 y: _The physical examination revealed a very active,0 f5 ~8 Z% o; X8 p
playful, and healthy boy. The vital signs documented: X- E0 E$ f% m3 O" U
a blood pressure of 85/50 mm Hg, his length was8 k; h9 y1 N& v# G
90 cm (>97th percentile), and his weight was 14.4 kg6 W2 g. l) U# A$ t6 G
(also >97th percentile). The observed yearly growth
  X0 \0 N) a8 ~# [( w& R$ m. S0 Y. `, D1 Cvelocity was 30 cm (12 inches). The examination of6 T# z) I9 j3 e
the neck revealed no thyroid enlargement.
0 B9 N# I0 ~, }* U: B4 dThe genitourinary examination was remarkable for  B5 ]3 f* a+ f) P2 P' }
enlargement of the penis, with a stretched length of0 k% Z- n- }( s4 e1 x1 R$ g
8 cm and a width of 2 cm. The glans penis was very well5 D: W  p6 O# M+ [( T4 m: H& [
developed. The pubic hair was Tanner II, mostly around
" {$ E) Q' {( p  H3 B2 o6 z540% O- G" M: s3 ^) e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  W- ^* g* `" _( C) ?# O
the base of the phallus and was dark and curled. The/ s7 s) G9 n, B, B8 h6 |
testicular volume was prepubertal at 2 mL each.) ?! j) U) Z& r0 ^( N7 B9 u& m) d
The skin was moist and smooth and somewhat8 p" Z. h7 }& ?: `1 x
oily. No axillary hair was noted. There were no. V5 I& a8 A5 O  H$ j2 f; W7 A
abnormal skin pigmentations or café-au-lait spots.9 u/ K% b/ F- L0 K% w3 o
Neurologic evaluation showed deep tendon reflex 2+5 j3 f' M! g: ~2 c6 i, ^
bilateral and symmetrical. There was no suggestion. X' g7 N$ T9 E/ o
of papilledema.
; Z7 F7 A! e2 b+ b- A7 ^Laboratory Evaluation
2 t: j* p  D+ _9 ?1 }* {. l' PThe bone age was consistent with 28 months by5 D( A6 S) ~/ S# a
using the standard of Greulich and Pyle at a chrono-* }: W) i) u; W6 }
logic age of 16 months (advanced).5 Chromosomal
5 ]/ Z- }* a% z+ x1 ?0 Rkaryotype was 46XY. The thyroid function test
  F# P, w5 J1 X- x* zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-; {3 F# _* n5 N( m' ]
lating hormone level was 1.3 µIU/mL (both normal).6 g/ Q; h3 K# h; s
The concentrations of serum electrolytes, blood
5 l2 N% _- `  Q( |& |5 @5 aurea nitrogen, creatinine, and calcium all were
' [- M7 Z9 T( [4 Gwithin normal range for his age. The concentration. [' y  O- k. q! n
of serum 17-hydroxyprogesterone was 16 ng/dL9 L) d! Y; u. z! z" ^" C1 J
(normal, 3 to 90 ng/dL), androstenedione was 20
3 W3 {# O) q, D% ?9 u: Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ {+ w' g. t  d; Gterone was 38 ng/dL (normal, 50 to 760 ng/dL),) N  e7 H! R' G, B" m
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- e* ~, q9 S3 p, X1 M; n49ng/dL), 11-desoxycortisol (specific compound S)! _; U" P/ s% V6 m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ h/ i  q0 q, T3 D( `% {; b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 [% f1 G3 b( r4 V/ s! M2 ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( f% `+ [% R: H! M/ e" ?$ _/ Rand β-human chorionic gonadotropin was less than
3 f- [8 u0 o+ d4 d9 r- }' F) q5 mIU/mL (normal <5 mIU/mL). Serum follicular/ G. y2 [, z, C
stimulating hormone and leuteinizing hormone
% O2 ~1 @1 j, D: H3 B; D% t4 l$ Rconcentrations were less than 0.05 mIU/mL; M' ?) `3 T: D0 h. J3 _
(prepubertal).
4 i4 _7 ~4 k2 J: o4 e( l) }The parents were notified about the laboratory7 U4 m/ M2 Z  O* T
results and were informed that all of the tests were2 C. y9 V  K$ `* j1 n
normal except the testosterone level was high. The1 w$ ~9 I4 b* L, r  p
follow-up visit was arranged within a few weeks to
: D% Z/ q: f2 N1 Lobtain testicular and abdominal sonograms; how-5 _% ]! p; V* _/ x* Y/ E0 ]8 Y! `
ever, the family did not return for 4 months.1 J2 t$ q) g( F; e% R7 z: m$ L4 D
Physical examination at this time revealed that the
' A- [4 F# g( U( K1 X  Achild had grown 2.5 cm in 4 months and had gained
% G7 m9 C( G! m# M$ t2 kg of weight. Physical examination remained/ n( @5 G# y% ~5 B3 F+ S6 f
unchanged. Surprisingly, the pubic hair almost com-( o0 S+ G- v: z" P2 N0 n
pletely disappeared except for a few vellous hairs at
, m) t4 |- {5 h4 B7 ~7 G; Sthe base of the phallus. Testicular volume was still 2
- H+ b( d4 z+ _" h6 ~mL, and the size of the penis remained unchanged.- [4 m$ s4 S3 _  p
The mother also said that the boy was no longer hav-
6 c3 S% U; w7 a0 S+ ]ing frequent erections.) Q( @" ^9 }. x
Both parents were again questioned about use of5 f$ C! t  e% M9 u  I  s# K/ t
any ointment/creams that they may have applied to* ]$ K3 H& G" L6 J, I3 F# D2 [
the child’s skin. This time the father admitted the5 J) }! K5 D7 \( r! I8 Y' q( v8 b) ^
Topical Testosterone Exposure / Bhowmick et al 541; V/ g6 `' q8 C7 l4 r" I2 {# Y
use of testosterone gel twice daily that he was apply-5 o; R  h( E+ J; k, w$ O) t1 F
ing over his own shoulders, chest, and back area for7 U* ]3 L" J/ a% T
a year. The father also revealed he was embarrassed
$ M/ m$ ^; C- U! {7 f: S  mto disclose that he was using a testosterone gel pre-+ T+ x  ]* ~: z! C7 U" I' \
scribed by his family physician for decreased libido
5 o; w  v9 H, q" S. {8 e( |6 ysecondary to depression.; G1 u. x; ^' G1 ^$ i. V5 M9 X
The child slept in the same bed with parents.) z9 i$ d' B7 c9 V# h: u( ^
The father would hug the baby and hold him on his9 A( l. E3 P; `# `4 ?8 O7 b( O. F, g
chest for a considerable period of time, causing sig-( B* [7 W/ S, D: h
nificant bare skin contact between baby and father.  K& x! g3 q) _
The father also admitted that after the phone call,  y+ C0 m, \8 V- P: l4 R
when he learned the testosterone level in the baby* H6 ~( d! A- n. |
was high, he then read the product information
! B8 z7 q8 b& R' T1 l# hpacket and concluded that it was most likely the rea-8 U  J/ E. }) [0 H& h! v: K
son for the child’s virilization. At that time, they# [" ~1 J- D" O. J  Q
decided to put the baby in a separate bed, and the$ T" f* O% {, d" }+ t
father was not hugging him with bare skin and had! t6 v1 L* a4 _% @$ k6 B
been using protective clothing. A repeat testosterone3 h4 U" j) r7 B+ C! m
test was ordered, but the family did not go to the
6 }& [: D4 \; e7 K+ |  i  H) Qlaboratory to obtain the test.* [( V" K" f9 h) d
Discussion
3 C7 y% `  }5 z2 [. M0 L8 kPrecocious puberty in boys is defined as secondary) \8 Y: I0 j4 G; y
sexual development before 9 years of age.1,4
/ M( z+ c: N6 O9 q! `Precocious puberty is termed as central (true) when
8 D. N3 N; F; V- ~8 z6 C1 ]" [it is caused by the premature activation of hypo-" e- Y4 B7 W. v$ ?$ R, P5 v6 ?  H: l
thalamic pituitary gonadal axis. CPP is more com-
0 Z* g4 F. G7 J2 r5 cmon in girls than in boys.1,3 Most boys with CPP4 l( [) f) W/ t- O
may have a central nervous system lesion that is8 q# i+ ~! }+ ~% v8 ^6 K/ g
responsible for the early activation of the hypothal-
5 y. J4 s4 \* F' l7 E. Eamic pituitary gonadal axis.1-3 Thus, greater empha-
  M& _7 g1 C1 m  V8 |4 ssis has been given to neuroradiologic imaging in2 k7 u! O. F! M7 h% u* S, T
boys with precocious puberty. In addition to viril-5 ?( M+ }: q4 I/ ^; y  W/ ^
ization, the clinical hallmark of CPP is the symmet-( [4 o: m5 a) t6 q8 M! I4 O! a% Z
rical testicular growth secondary to stimulation by0 g* c4 A  U8 v1 k7 _* ~
gonadotropins.1,3% C. ~: B5 b- \5 o
Gonadotropin-independent peripheral preco-8 l3 n* Y: u& q* c- O+ m
cious puberty in boys also results from inappropriate
: }( K3 v% w& landrogenic stimulation from either endogenous or
* e; W! w* p- \8 P4 [* L8 aexogenous sources, nonpituitary gonadotropin stim-
0 r5 x; P  b/ G+ f5 d/ q  `" Pulation, and rare activating mutations.3 Virilizing! c9 T$ r( `! F4 Z, Z
congenital adrenal hyperplasia producing excessive5 l4 x" o) Y4 [) {. ?
adrenal androgens is a common cause of precocious8 D- t7 h8 N  @% j% ~4 b- [
puberty in boys.3,4. y7 u0 w+ t, J: a# T
The most common form of congenital adrenal
7 R+ v" G/ l5 Q* j* r/ a7 ?hyperplasia is the 21-hydroxylase enzyme deficiency.+ }, ^3 N7 K% Y6 x7 r! @' I
The 11-β hydroxylase deficiency may also result in
) p. o( h7 s8 `2 A4 K4 Aexcessive adrenal androgen production, and rarely,  ^, _9 g. V) @$ _: R
an adrenal tumor may also cause adrenal androgen3 {$ Y8 [6 Q6 f1 o  y& o
excess.1,3# `/ |4 A. R0 D8 f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 a2 y* q5 p( V1 B. q  t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 J2 _% G& t) G+ N7 wA unique entity of male-limited gonadotropin-
' v7 q. C$ O$ X$ {* aindependent precocious puberty, which is also known9 U6 ~/ V, H/ e" H2 W/ C7 l; }* o6 V( z
as testotoxicosis, may cause precocious puberty at a. M  z5 Y' Z& {" g3 y9 b
very young age. The physical findings in these boys
0 o( F0 j/ l) e) s" b- R: _with this disorder are full pubertal development,
; v3 @) \$ T+ j2 aincluding bilateral testicular growth, similar to boys
' {  B9 o& W7 N' a0 }! Uwith CPP. The gonadotropin levels in this disorder$ F9 S$ z- ]( d4 q
are suppressed to prepubertal levels and do not show3 I  m. R/ v' C
pubertal response of gonadotropin after gonadotropin-4 B$ h; Q# k) g8 v/ ~
releasing hormone stimulation. This is a sex-linked
7 [4 ]# M2 T# rautosomal dominant disorder that affects only
* x* `2 P7 ]1 c$ l7 N6 ]males; therefore, other male members of the family
' g$ ~& o/ w" A( s. T, nmay have similar precocious puberty.3
& J- n6 m- I6 m5 dIn our patient, physical examination was incon-
7 T, J9 v% ]" T& K4 f6 ^. msistent with true precocious puberty since his testi-
4 n! ]7 n$ D$ H+ P) d, kcles were prepubertal in size. However, testotoxicosis) R/ H( }5 M% o0 x2 w
was in the differential diagnosis because his father  V. N. ]9 |! _; Z4 M
started puberty somewhat early, and occasionally,
$ n5 y9 z8 t# i+ }% {, Ftesticular enlargement is not that evident in the& m$ p  q* J. M' _+ O( ~- X' ~
beginning of this process.1 In the absence of a neg-# I: `7 \5 c- o, j
ative initial history of androgen exposure, our
& @( N7 {3 {: M. P7 w; s6 bbiggest concern was virilizing adrenal hyperplasia,
& q; m4 S9 V2 r: L2 A' d. G. t5 J2 T; Reither 21-hydroxylase deficiency or 11-β hydroxylase( z+ e$ `; h9 }
deficiency. Those diagnoses were excluded by find-
7 x+ z6 Y& Y0 @: a$ b: ying the normal level of adrenal steroids.& F" \, S# L3 y
The diagnosis of exogenous androgens was strongly
; T5 F' X& [. o1 ^' msuspected in a follow-up visit after 4 months because: w5 `6 K& D4 `
the physical examination revealed the complete disap-
- E% u$ Y/ G% M) q+ P" Y8 y6 dpearance of pubic hair, normal growth velocity, and+ t5 |' y: N- C4 L
decreased erections. The father admitted using a testos-
" P4 T; ^" g3 A3 t# X+ dterone gel, which he concealed at first visit. He was
7 K6 h- i' t6 D) ?using it rather frequently, twice a day. The Physicians’
& v$ f+ r9 b1 P2 m) \$ y5 t9 QDesk Reference, or package insert of this product, gel or: i) d% W6 x! Y5 {
cream, cautions about dermal testosterone transfer to" A5 o8 ^  E3 Q/ s" X7 B  Y& h
unprotected females through direct skin exposure.
9 e" P' u8 M2 z7 A6 ]; S- n$ `7 OSerum testosterone level was found to be 2 times the6 J, C' o5 v) d; i( q0 p: }
baseline value in those females who were exposed to
- }2 L0 s3 i# Y9 `even 15 minutes of direct skin contact with their male" S% V; Z3 H9 I5 w: ?" Z: C! n
partners.6 However, when a shirt covered the applica-0 C+ p$ f* b+ G# A6 _+ |
tion site, this testosterone transfer was prevented.# y0 z3 p( }2 B0 |* l
Our patient’s testosterone level was 60 ng/mL,
2 R6 C% z6 V+ W) \( o) Rwhich was clearly high. Some studies suggest that
$ F3 P/ H0 o) i+ Wdermal conversion of testosterone to dihydrotestos-
8 A- U6 w& h. K/ F. |" l: b/ |6 Iterone, which is a more potent metabolite, is more
8 C) {, q$ j6 ~0 Pactive in young children exposed to testosterone: `) |8 o( c; c! s8 Y
exogenously7; however, we did not measure a dihy-
/ z8 [7 x1 \; l: W; L# U" x, \drotestosterone level in our patient. In addition to- e) B5 O" t5 ]5 \# h$ f3 X
virilization, exposure to exogenous testosterone in
7 P' l/ H' ~2 u6 J& mchildren results in an increase in growth velocity and( H3 {4 |2 f9 D" V8 j3 {8 \, R* E
advanced bone age, as seen in our patient.
$ W  W# F( ~* U8 x* rThe long-term effect of androgen exposure during/ ]- U) i  t/ k# e; K& v9 q
early childhood on pubertal development and final; z& Q* A" a, i6 k9 W1 W/ p6 k# k
adult height are not fully known and always remain
- c! n5 k' ]! |5 wa concern. Children treated with short-term testos-
) K! c8 _5 [) x& ^: n6 P/ lterone injection or topical androgen may exhibit some
0 l; y% k$ Y- I! D6 Gacceleration of the skeletal maturation; however, after
5 q6 G& }* i! J' U+ g; Y' ^" ecessation of treatment, the rate of bone maturation- v! t& x9 ^: I6 S3 a
decelerates and gradually returns to normal.8,9
3 s9 O5 l5 C. ~* {$ a9 nThere are conflicting reports and controversy
) F! y9 O$ R6 }9 ?; Dover the effect of early androgen exposure on adult$ R, O( w- R7 F
penile length.10,11 Some reports suggest subnormal- }1 o# A, Y5 y1 [& A
adult penile length, apparently because of downreg-* {( K/ i9 S0 D
ulation of androgen receptor number.10,12 However,  W9 w4 ~1 n: N. E
Sutherland et al13 did not find a correlation between& r- B8 H- n4 s+ K: W
childhood testosterone exposure and reduced adult
  h% |# J, n& ?) {) \3 ppenile length in clinical studies.4 Z. ~0 q6 V/ r3 f
Nonetheless, we do not believe our patient is* m# a  X7 \) Z6 l/ R* Y$ u
going to experience any of the untoward effects from
6 C9 [) [7 f1 Q, Itestosterone exposure as mentioned earlier because
: i) {5 q2 q1 M# d( Wthe exposure was not for a prolonged period of time.5 a3 d& i/ ~& |9 m2 V, W
Although the bone age was advanced at the time of
+ O" x$ D9 x. G- x$ \* kdiagnosis, the child had a normal growth velocity at- D! X  H; U% h! V* J
the follow-up visit. It is hoped that his final adult
8 x& x2 k" N) i' ~; Yheight will not be affected.: `9 O- p' ^, L1 J3 q( h: R
Although rarely reported, the widespread avail-, b! W1 U" l4 `
ability of androgen products in our society may; R# S/ X6 Y% E7 C3 p% \
indeed cause more virilization in male or female
1 C) J: _8 o  i; U: s$ i' J& q1 |children than one would realize. Exposure to andro-
, ^. ]3 h( `7 zgen products must be considered and specific ques-; X+ e) d, T% [  e# G( c; a
tioning about the use of a testosterone product or7 h+ Y+ Z  b, o* {8 d  r3 ^
gel should be asked of the family members during
, K7 m/ G* @+ e% v0 `( ]the evaluation of any children who present with vir-
+ r/ @/ z1 M" s+ e0 L+ ~1 r8 [  l; silization or peripheral precocious puberty. The diag-
2 Z5 }  F0 Z* d( B' d3 tnosis can be established by just a few tests and by
7 ^' I5 b+ c3 h! l/ cappropriate history. The inability to obtain such a
( I( r$ t) N" k* uhistory, or failure to ask the specific questions, may) m0 a) U: z" A; r: h& l
result in extensive, unnecessary, and expensive
7 r( a8 k' Z* P7 ], J4 o' i& Winvestigation. The primary care physician should be) i6 Q8 h+ Z; D- x4 t* x+ u
aware of this fact, because most of these children- s1 t! z* L4 _. Z& `8 F( k
may initially present in their practice. The Physicians’
) t! B" W  Y" wDesk Reference and package insert should also put a
. ]1 N. _8 t1 t* N6 g: Twarning about the virilizing effect on a male or
; O9 D; x2 o2 }. P8 Tfemale child who might come in contact with some-
) `2 u, x+ l5 }one using any of these products.5 D6 K% P. |, Y; f3 f! o1 p9 \- P
References- _3 ~, S8 w% H* R- `# l. l
1. Styne DM. The testes: disorder of sexual differentiation' F2 r7 K0 T, e7 p
and puberty in the male. In: Sperling MA, ed. Pediatric
8 i5 n/ W5 _& g! Q1 xEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& {+ l, z9 \0 a) E/ P4 d# R; n2002: 565-628.2 `+ ~1 U; J8 L+ B/ j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ W( a6 C+ |. N7 o# v" J( }) a$ Ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" C0 R% O9 @! E1 {9 f' @
Boy Induced by Indirect Topical/ E9 G6 |! Y. j4 ~8 P3 v$ x
Exposure to Testosterone0 X+ c, E3 N0 |1 ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 y; x5 H2 [0 p2 Y
and Kenneth R. Rettig, MD1
6 V! |4 e  \; m5 M' ?Clinical Pediatrics8 o7 C: _# l2 j2 ?  J5 }6 n
Volume 46 Number 6
$ V- z, U6 J$ v+ {3 u) NJuly 2007 540-543
* S7 Z" G$ k6 Z* Y© 2007 Sage Publications
. W. K) S; {% c10.1177/00099228062966518 q8 o/ j& E' U; O  M3 v
http://clp.sagepub.com
- y9 T( f8 C5 Bhosted at; m; a/ g/ r6 j0 D7 Q
http://online.sagepub.com
( t" j& c, y, `Precocious puberty in boys, central or peripheral,
% X+ B, h5 }- M+ D! k) B* Wis a significant concern for physicians. Central
: s2 L$ R/ c+ a; ?precocious puberty (CPP), which is mediated$ y& P3 t& i3 P, Z5 y5 ~# n
through the hypothalamic pituitary gonadal axis, has1 I1 z4 z3 m2 T1 `7 W" U
a higher incidence of organic central nervous system
( C7 a* \! A7 u1 H+ P% D' a, ?lesions in boys.1,2 Virilization in boys, as manifested# Z4 g& S# K2 O+ c  f4 X
by enlargement of the penis, development of pubic
- r5 u' I- t, ?  S: K7 S2 @hair, and facial acne without enlargement of testi-
6 J. w/ F  P1 _. ocles, suggests peripheral or pseudopuberty.1-3 We2 M! r/ l& A3 x4 t% t" `( E
report a 16-month-old boy who presented with the4 C' B# Y$ g5 e0 D
enlargement of the phallus and pubic hair develop-
$ d* o( H1 M+ r# G) Q- Z; Cment without testicular enlargement, which was due
+ `/ t& }$ J/ ito the unintentional exposure to androgen gel used by) ], z' Y3 B9 q0 v0 U
the father. The family initially concealed this infor-
: i5 a! Z1 Y' A+ g1 A, G. fmation, resulting in an extensive work-up for this0 R% K9 U# E6 Z/ H
child. Given the widespread and easy availability of
. H! x8 d8 \: G: g. F  r. Ftestosterone gel and cream, we believe this is proba-& `, o9 z  T4 f9 a3 r; H/ K) c' z2 V
bly more common than the rare case report in the
, N4 r2 M  f& Vliterature.4" V; |7 S" d9 l9 Y) E8 g
Patient Report" T/ o+ {/ F9 ^
A 16-month-old white child was referred to the, k) f2 [0 o2 ?$ l' g
endocrine clinic by his pediatrician with the concern
* z4 `  V& }' L- k4 Yof early sexual development. His mother noticed
! N! x- I/ E, O: E6 m; b# M, G) ~light colored pubic hair development when he was: j0 n8 f0 z0 I4 g/ j
From the 1Division of Pediatric Endocrinology, 2University of
9 j+ \7 h, ]# V7 W8 hSouth Alabama Medical Center, Mobile, Alabama.; E+ d. p, a1 O2 i- f9 i
Address correspondence to: Samar K. Bhowmick, MD, FACE,, S" s/ Y! n/ `& i# {+ D3 B
Professor of Pediatrics, University of South Alabama, College of3 y+ ~% j  m/ ?. y, {& t8 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 j' X( [+ w/ v( Qe-mail: [email protected].
4 O1 ~$ i$ j" U! j- R$ ~' F/ Babout 6 to 7 months old, which progressively became+ E9 A& l' x3 X6 E& G
darker. She was also concerned about the enlarge-: G8 e* O# K. L1 y5 e- E7 O( e
ment of his penis and frequent erections. The child
7 d# H, s& p) fwas the product of a full-term normal delivery, with
! J/ A- }0 P+ J9 B; z0 Y! G8 Va birth weight of 7 lb 14 oz, and birth length of% D- u! h. I9 B
20 inches. He was breast-fed throughout the first year
5 Z1 P. t6 f( {' h5 Rof life and was still receiving breast milk along with
, |; z; p# Z7 v' v, _6 tsolid food. He had no hospitalizations or surgery,
0 A, d3 L5 _6 K% ^" x  g' ]3 _- oand his psychosocial and psychomotor development/ D- f: U7 ]$ b* G6 B* H
was age appropriate.
; g9 u8 e6 h' G6 r# a2 s0 O. [; lThe family history was remarkable for the father,2 _% A8 l( K* Y; F, ?" K
who was diagnosed with hypothyroidism at age 16,
% z4 v- U1 V$ D" p& \1 h- kwhich was treated with thyroxine. The father’s6 {. K/ r. v, R. R
height was 6 feet, and he went through a somewhat
  S7 G# p* x' |) h9 `4 ~2 qearly puberty and had stopped growing by age 14.
) ?+ h% E2 y6 c- @. }& k: qThe father denied taking any other medication. The
- P6 g! Q# K/ v3 C$ m1 ~! C* `child’s mother was in good health. Her menarche
4 v9 J; q) j4 j5 W8 S7 bwas at 11 years of age, and her height was at 5 feet* Y8 w0 Z/ P% j+ Q
5 inches. There was no other family history of pre-
9 b: N, l/ y. I/ x1 ?; s. Qcocious sexual development in the first-degree rela-
" b5 e7 m! f7 ~/ X/ ]tives. There were no siblings.
; g  Z3 D' {4 JPhysical Examination9 G  s$ t( U7 A: W: N
The physical examination revealed a very active,
5 G' k1 j9 ]' p2 b/ Eplayful, and healthy boy. The vital signs documented2 }/ J# w& i: @2 z+ }1 M! S% @* V) g5 |
a blood pressure of 85/50 mm Hg, his length was0 h% m9 s/ L2 V' z8 F
90 cm (>97th percentile), and his weight was 14.4 kg: e; p4 K& O' }$ U0 |% W
(also >97th percentile). The observed yearly growth: U2 \  H: G2 h0 }* C
velocity was 30 cm (12 inches). The examination of
! D' d( c" y% f1 T3 @, I; ~the neck revealed no thyroid enlargement.
% \9 j- p- H7 p( Z1 m$ [- K& y4 oThe genitourinary examination was remarkable for* ]: `/ M5 ]4 n: X2 k8 T0 \
enlargement of the penis, with a stretched length of2 x) d$ [1 x# ]7 Z  q: ?" ~2 ~, l& k
8 cm and a width of 2 cm. The glans penis was very well
! _( I% L2 m# K) x& bdeveloped. The pubic hair was Tanner II, mostly around
2 D. g  Z' z" }& ]7 n8 ]3 L$ y7 r540
1 n- |- R  B9 v) y) iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' g" x3 [3 e3 e9 Z) P6 p  u/ Athe base of the phallus and was dark and curled. The; s) f* h* g5 `% j& e* |- L
testicular volume was prepubertal at 2 mL each.
  b+ |/ k- e7 I2 RThe skin was moist and smooth and somewhat; M7 @' ^5 F  q( c
oily. No axillary hair was noted. There were no. p! O0 _+ g. t% i% {
abnormal skin pigmentations or café-au-lait spots.
6 W& V' w3 z1 eNeurologic evaluation showed deep tendon reflex 2+
3 H+ m% C4 s$ A  t4 @6 n+ z/ bbilateral and symmetrical. There was no suggestion; u1 ~% r  Z% U0 Q' }' [
of papilledema.! }, n$ J/ o+ L5 H
Laboratory Evaluation4 g5 W. V/ q* c7 u7 Z7 w& o
The bone age was consistent with 28 months by& [- L! |# [& X7 j  i
using the standard of Greulich and Pyle at a chrono-
$ B& ]$ ~& L+ \6 _, Ulogic age of 16 months (advanced).5 Chromosomal
: J# M' k) S# \, u  k0 Akaryotype was 46XY. The thyroid function test
5 J  b, i6 |: S( q3 Wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  L* t7 J( @. y  P5 ?9 q; i) {! Jlating hormone level was 1.3 µIU/mL (both normal).
2 S2 w6 N1 Q1 h( nThe concentrations of serum electrolytes, blood
2 }8 z) m0 `, s0 B- o. G) v  lurea nitrogen, creatinine, and calcium all were2 R* c) \4 A" \& R& m, x4 r
within normal range for his age. The concentration! [1 n: }: Y. x9 g0 l" [# ]; ?
of serum 17-hydroxyprogesterone was 16 ng/dL
" z$ v7 l& I9 A# j(normal, 3 to 90 ng/dL), androstenedione was 20
5 V; W+ u/ S. _" mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 G9 @& |0 @/ D2 J2 x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. W' V1 u: B% p7 V! T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 g$ l, ]8 S8 j; L% e49ng/dL), 11-desoxycortisol (specific compound S)
; T3 I, l6 p: y6 G, ]was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" \9 w' H, l4 O( K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 R: i: ?- c* h& ?testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 W1 ]" @9 {/ d% n8 Y+ d% ~9 _
and β-human chorionic gonadotropin was less than1 s6 q; ]5 g) U+ J( i, N/ ^
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" Q& q) o; A, f9 a* k" a* Istimulating hormone and leuteinizing hormone2 C! O/ v' G! s  n
concentrations were less than 0.05 mIU/mL
7 e/ N: x" u+ L4 J2 E/ J! y+ l' e' P(prepubertal).- I6 S/ M) a: W. U
The parents were notified about the laboratory
6 L, ?6 [4 l% n2 m& P, Q( yresults and were informed that all of the tests were/ x9 @" ^+ M" t1 n9 A" b3 g% e: y
normal except the testosterone level was high. The
; z) b) `8 s' }: H' w% lfollow-up visit was arranged within a few weeks to
0 F* m5 H* k% T% f# v& u9 Xobtain testicular and abdominal sonograms; how-
2 s* T( o2 w- J& Y4 V" cever, the family did not return for 4 months.: h; H4 \$ R7 C( w  h3 y
Physical examination at this time revealed that the2 L9 M' k# g% T6 A* Q) y) A
child had grown 2.5 cm in 4 months and had gained
( U/ B0 B4 k" G2 kg of weight. Physical examination remained
  D% }2 M6 X5 V  _5 _unchanged. Surprisingly, the pubic hair almost com-. F* ]. {: ?" E: Z/ @6 ^
pletely disappeared except for a few vellous hairs at
9 B6 a& S! T3 {' u9 Lthe base of the phallus. Testicular volume was still 29 b: g  [. T$ x; B
mL, and the size of the penis remained unchanged.' [5 `2 B4 Q. K" B7 G# [
The mother also said that the boy was no longer hav-
+ X& t5 @: a; t3 Xing frequent erections.- R# I. g9 [) r% A
Both parents were again questioned about use of- d0 L7 W9 M, V& L" k2 w2 J
any ointment/creams that they may have applied to  _2 {0 U% Y- N: |. N; i6 ~
the child’s skin. This time the father admitted the
0 Q, H7 k+ B' f* f* ^" LTopical Testosterone Exposure / Bhowmick et al 541
# Z6 v9 n. E) B9 Iuse of testosterone gel twice daily that he was apply-2 {7 R" }' I, b, Q$ n- u" G
ing over his own shoulders, chest, and back area for
( ?) L2 U8 T3 k; l# E  F8 h3 _/ ya year. The father also revealed he was embarrassed
. u. v+ b( Y3 j2 ^to disclose that he was using a testosterone gel pre-4 [) [* D# J$ d2 B5 A
scribed by his family physician for decreased libido: D8 g! ~) X& s$ h1 @# r5 ?/ C
secondary to depression.
1 K! e/ N" Z$ w( ]: fThe child slept in the same bed with parents.
& k( v$ M. J* ^* g, W* aThe father would hug the baby and hold him on his  Q2 [4 e$ i8 t  S" x
chest for a considerable period of time, causing sig-
* G' U4 l3 Q* H8 M  u! _nificant bare skin contact between baby and father.
, q! z8 j- J$ d, N3 G  f6 T0 O/ O) _The father also admitted that after the phone call,% {& m# [2 u2 X- v- L
when he learned the testosterone level in the baby( h6 i# ~$ w- c) \2 C
was high, he then read the product information
3 `6 G3 w* @7 n/ p2 P" o* Wpacket and concluded that it was most likely the rea-: o9 `; y  X$ X; L) m$ j% F2 c) h
son for the child’s virilization. At that time, they- ]* y# Q8 D, q& X
decided to put the baby in a separate bed, and the
5 M* |* W. \$ Dfather was not hugging him with bare skin and had. J+ k% k* [$ S
been using protective clothing. A repeat testosterone6 O4 `$ K8 y( Y: G
test was ordered, but the family did not go to the( `5 b. O$ [8 c1 d# I) F
laboratory to obtain the test.
' ~$ B9 H, W, u% wDiscussion" u) v" g1 o  [" q, V9 U1 n
Precocious puberty in boys is defined as secondary
( ]3 F6 S, A+ d0 hsexual development before 9 years of age.1,47 V( z5 P/ S$ M- U
Precocious puberty is termed as central (true) when
% N2 F0 r, v1 o1 r0 X* @; pit is caused by the premature activation of hypo-
' ]' @4 H# a* [1 Vthalamic pituitary gonadal axis. CPP is more com-8 _$ m( x: Y9 m; t) G
mon in girls than in boys.1,3 Most boys with CPP. d4 w/ G( W! ~% e- y0 ^" k
may have a central nervous system lesion that is+ F+ I) o7 p0 B. X5 x& g% e
responsible for the early activation of the hypothal-
0 E7 U- D/ D0 }amic pituitary gonadal axis.1-3 Thus, greater empha-
" y% e' e2 M2 ~sis has been given to neuroradiologic imaging in1 D+ ?. Q$ w, `4 G0 F  r: O
boys with precocious puberty. In addition to viril-
/ ]) F8 {$ D: _) V0 `ization, the clinical hallmark of CPP is the symmet-# ?9 g' S, ~% n" M2 o; f7 t' ^
rical testicular growth secondary to stimulation by
4 |1 m  b: H$ d" }4 k% m/ h7 Kgonadotropins.1,3
6 ?) R' J) Y6 a. y7 H. Y/ jGonadotropin-independent peripheral preco-0 j" W0 K2 B; u0 A
cious puberty in boys also results from inappropriate% P3 }7 @8 _3 T& S1 V
androgenic stimulation from either endogenous or0 o% F* H" a& L7 L: x
exogenous sources, nonpituitary gonadotropin stim-
% P* P3 ]3 U( S  h5 X0 U; H, ]ulation, and rare activating mutations.3 Virilizing1 ^; e& q9 `+ a! c8 X8 A. A1 V
congenital adrenal hyperplasia producing excessive
) C6 v$ x, w2 i) _4 k* ~adrenal androgens is a common cause of precocious
4 o  P% W1 F" m$ y: N! ?puberty in boys.3,47 O8 _2 [4 P$ Q3 c/ w7 N4 G
The most common form of congenital adrenal, _# l, y; E$ c6 }4 \- r
hyperplasia is the 21-hydroxylase enzyme deficiency.
) o+ [9 I! T) N: f: L8 CThe 11-β hydroxylase deficiency may also result in
  S6 Q2 m5 A. Z9 U! jexcessive adrenal androgen production, and rarely,% {0 M6 ^1 w) F) f% f% l6 m5 w* C
an adrenal tumor may also cause adrenal androgen
3 w7 Q" c1 I* N5 t# G" ]) b0 Nexcess.1,3
, \. H* O3 I0 \& lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' q" _2 p4 C5 ]4 S6 {" U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
  y" [* m! K$ I8 E3 rA unique entity of male-limited gonadotropin-
/ V- J+ V5 d& E& H; a7 v+ k3 Tindependent precocious puberty, which is also known
& B# W5 G+ r9 |$ Y  b" i: Uas testotoxicosis, may cause precocious puberty at a' _% \5 T$ g4 G7 ~. F; |! u
very young age. The physical findings in these boys8 P+ O! a) Z* O' G1 K* t! B# H
with this disorder are full pubertal development,
2 x2 O  U6 w5 x0 D* n2 f* e( [including bilateral testicular growth, similar to boys
0 g3 c: L5 T& e; y$ v1 W7 Hwith CPP. The gonadotropin levels in this disorder
; ~1 J' `3 a6 h8 Jare suppressed to prepubertal levels and do not show
( n. p- a% e: X3 ^* k9 [: t$ A9 F& spubertal response of gonadotropin after gonadotropin-
- P) b' v0 y6 Q, g1 Kreleasing hormone stimulation. This is a sex-linked
& t' \/ N& G7 @; B/ I4 Sautosomal dominant disorder that affects only
4 _; t1 E% f/ W. t# r# Z- I6 G7 |males; therefore, other male members of the family3 H; O3 |  |' R' S
may have similar precocious puberty.3
" s& l$ }1 }7 O9 n/ {* n+ YIn our patient, physical examination was incon-( n' j# Q2 G5 k" O+ F1 N% l* G; z
sistent with true precocious puberty since his testi-- M3 w2 ~/ ?1 |3 |8 s8 ~( J
cles were prepubertal in size. However, testotoxicosis) N5 i7 x1 j1 j/ U: R
was in the differential diagnosis because his father
9 F- f. \. q( A+ u" tstarted puberty somewhat early, and occasionally,
6 v; v7 S& }- E% S: z$ ^4 X1 Rtesticular enlargement is not that evident in the4 ]( G* ?9 Z2 k7 P" t# W6 S3 x; j8 w
beginning of this process.1 In the absence of a neg-3 C& K1 [& F% N0 I) {: S! b
ative initial history of androgen exposure, our
& {  S7 J) m9 bbiggest concern was virilizing adrenal hyperplasia,! }% }) ^3 U. D$ V# P! |: n$ u$ I+ A6 O
either 21-hydroxylase deficiency or 11-β hydroxylase
! d2 Q% D& s6 y& U  ideficiency. Those diagnoses were excluded by find-
9 T# d, d( P+ s8 Ning the normal level of adrenal steroids.0 }( @/ `5 P* T  H& Y4 }
The diagnosis of exogenous androgens was strongly3 b2 n/ \( e5 [
suspected in a follow-up visit after 4 months because5 w1 I: W6 S+ E9 ]: _" D* I
the physical examination revealed the complete disap-$ J% E0 `& i# a$ b
pearance of pubic hair, normal growth velocity, and
2 A/ N, D- w. \7 ?( adecreased erections. The father admitted using a testos-9 g1 D1 |8 [) o9 p6 z
terone gel, which he concealed at first visit. He was, O4 H. P5 Q& a) |
using it rather frequently, twice a day. The Physicians’
  d+ N$ x+ z! W& X8 ]. ^9 c; BDesk Reference, or package insert of this product, gel or) O: Q$ ^: J/ ?" w$ t/ f  O% z8 n
cream, cautions about dermal testosterone transfer to# d: [) L( Y1 T- i) C
unprotected females through direct skin exposure.
4 k* h" _! Q0 d+ W0 b9 F* xSerum testosterone level was found to be 2 times the; L# Z, f: b( t9 k4 L
baseline value in those females who were exposed to5 N) j6 @# J. g$ P
even 15 minutes of direct skin contact with their male
5 K' e" \0 d0 g  @partners.6 However, when a shirt covered the applica-/ B: v* Q/ j, N+ G$ c
tion site, this testosterone transfer was prevented.+ x2 A) N: G. d6 H0 g
Our patient’s testosterone level was 60 ng/mL,
% d. h  \/ L+ N# A# ewhich was clearly high. Some studies suggest that
& A' B( q& o) z" I! s" t8 a. hdermal conversion of testosterone to dihydrotestos-
& w( k$ n$ C6 m" x2 w2 T# t  Gterone, which is a more potent metabolite, is more
) ~7 V( _% z/ _9 ]3 x7 gactive in young children exposed to testosterone
- v0 M) m7 D/ w9 nexogenously7; however, we did not measure a dihy-
( p. _" _; X$ x: W5 X9 ldrotestosterone level in our patient. In addition to0 w1 L4 b' ]/ x+ O0 N+ f
virilization, exposure to exogenous testosterone in% o9 R1 J! ?0 E
children results in an increase in growth velocity and( s& Q" A# T( u/ p1 D$ A
advanced bone age, as seen in our patient.! ~7 C. C5 ]: F0 w  F- K  r
The long-term effect of androgen exposure during
  T0 R$ _4 v3 O2 g2 n1 ?6 y) jearly childhood on pubertal development and final
+ I* z( d4 A/ d, O4 m; k  M# Radult height are not fully known and always remain5 r6 @# G$ _5 e7 J: v
a concern. Children treated with short-term testos-  x) p' @1 G- _
terone injection or topical androgen may exhibit some
6 g2 V' n+ b& I1 G$ jacceleration of the skeletal maturation; however, after
9 q7 i1 G. N$ m5 M4 W1 hcessation of treatment, the rate of bone maturation- O* k) E* E8 ?
decelerates and gradually returns to normal.8,95 q& g$ B. A" ^" s4 M) J# N& ^$ H/ e
There are conflicting reports and controversy
( H0 c- y5 ]8 b0 ^0 }/ ^over the effect of early androgen exposure on adult
$ w" [- z3 e  |- H6 a& o) W& [penile length.10,11 Some reports suggest subnormal! w. w- f3 z- t& U; g7 e5 s
adult penile length, apparently because of downreg-
! y" V. j6 A) M3 M+ b7 mulation of androgen receptor number.10,12 However,
* G( T% n' S" V0 k$ hSutherland et al13 did not find a correlation between2 h. @: t, m, @: g" i
childhood testosterone exposure and reduced adult
4 m' m4 \+ ~( ~5 W3 E& q# t3 Qpenile length in clinical studies.
6 w' j0 S8 p0 r  o# z% WNonetheless, we do not believe our patient is( L3 V; M& A7 ]) Z+ I6 y
going to experience any of the untoward effects from2 A: ~7 r! G2 T: L- ?
testosterone exposure as mentioned earlier because3 x: ?3 E. o7 Q* J" A
the exposure was not for a prolonged period of time.) S* J4 F1 u  ]# J, I$ O
Although the bone age was advanced at the time of9 @" j2 e' P  b% K
diagnosis, the child had a normal growth velocity at
: O1 V! B7 \) `/ {) @1 l) Vthe follow-up visit. It is hoped that his final adult
8 N" }( Z+ A  V6 b# ]/ J% r' B5 _height will not be affected.8 b# `. I5 l& j' I
Although rarely reported, the widespread avail-8 D- G9 H3 C$ Q8 w% F! B, ~
ability of androgen products in our society may2 ^3 e! X- d; P% f0 S) O
indeed cause more virilization in male or female: H$ g* }4 L3 B& I( _& `. o: X
children than one would realize. Exposure to andro-
7 f5 x0 x7 M: N0 wgen products must be considered and specific ques-
5 I. P$ O7 z. g2 wtioning about the use of a testosterone product or3 [' h8 D6 z0 n% T: a6 N
gel should be asked of the family members during
5 z6 C) N0 K$ @1 d! Y" C7 _% gthe evaluation of any children who present with vir-! `+ q6 W8 ~1 ]# ^
ilization or peripheral precocious puberty. The diag-% q6 P: ^# q  Q3 k7 ~, `5 v
nosis can be established by just a few tests and by  C4 Y- {2 r9 `5 p/ u, m8 I# u9 e
appropriate history. The inability to obtain such a
4 @# T- f( b" j; G+ u2 `  `history, or failure to ask the specific questions, may0 h# A. [! L4 j
result in extensive, unnecessary, and expensive% Y. F$ C3 ^/ h1 _' T" H, u3 U9 P
investigation. The primary care physician should be/ Y8 ^7 {' [, t! A- z9 n
aware of this fact, because most of these children8 e7 K+ P; J7 y, k7 t
may initially present in their practice. The Physicians’& P7 w2 g0 N: t" O
Desk Reference and package insert should also put a/ ^- t) H6 }* K+ I4 T
warning about the virilizing effect on a male or& z6 g+ v6 T4 S* u
female child who might come in contact with some-% S+ m9 c3 }: U, R$ Y# ]
one using any of these products.
, h. L+ e; l# CReferences% O% Z5 }1 V5 T7 O; n$ X
1. Styne DM. The testes: disorder of sexual differentiation
9 L* T8 M* L' s3 d0 I+ kand puberty in the male. In: Sperling MA, ed. Pediatric
0 f& {: _2 Y" v3 nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 q* I. s: q" G8 p7 o+ L$ Y" _
2002: 565-628.
# W% {9 w; O5 Q. D& l) C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 L  T8 u5 X3 r; M& E
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
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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
5 l2 g( O4 p, u% }
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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