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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/ A; ~$ C6 {* s% jBoy Induced by Indirect Topical
6 P3 y4 q+ @+ a% Y3 zExposure to Testosterone
) f# u- u4 a8 f4 m% I+ ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 X6 S( m# o! C
and Kenneth R. Rettig, MD1
7 Y- K5 U- U: rClinical Pediatrics- Y0 a8 J# F: f6 O+ `4 e; G  s
Volume 46 Number 6
4 C2 x9 a# _9 S2 }July 2007 540-543+ B7 }0 Z: D9 Q4 |; A
© 2007 Sage Publications6 ^9 a2 B+ k) V/ [) F5 ]
10.1177/0009922806296651: J0 M3 a0 M7 p( `. z  l  `6 ^
http://clp.sagepub.com
# M1 s) O$ n. _7 Qhosted at
- t8 |$ {. B5 p( Ihttp://online.sagepub.com
' r; W! V2 o6 }Precocious puberty in boys, central or peripheral,
# J; i) j% D1 x; v# Lis a significant concern for physicians. Central- ?3 `" p+ x" @$ Y: s  G  M
precocious puberty (CPP), which is mediated
7 R0 @, W, N: Q- a) Kthrough the hypothalamic pituitary gonadal axis, has
( I+ G6 i) @' o3 Za higher incidence of organic central nervous system
* r) k7 Y: v+ K, k' plesions in boys.1,2 Virilization in boys, as manifested+ E- e0 k6 A7 e; t& G8 U9 f
by enlargement of the penis, development of pubic
6 B0 S& V, U& X# s# a% Jhair, and facial acne without enlargement of testi-
1 z9 Q$ n; V) }& Kcles, suggests peripheral or pseudopuberty.1-3 We; {! H. x) {$ U0 X8 P
report a 16-month-old boy who presented with the, @  b. L9 g8 q( e0 v+ ~  }) T
enlargement of the phallus and pubic hair develop-+ `; d' J9 `& f# F
ment without testicular enlargement, which was due; Y6 f! l3 ~6 h# Z/ X
to the unintentional exposure to androgen gel used by
# F0 F$ o; X8 b4 E  X6 vthe father. The family initially concealed this infor-
% w- b% N# N; V$ v) Kmation, resulting in an extensive work-up for this
& c2 g! z: W0 o, L: ^" L6 wchild. Given the widespread and easy availability of
4 @# W, n  Q# k3 C8 [" D* Gtestosterone gel and cream, we believe this is proba-4 i; d( M/ |( x
bly more common than the rare case report in the, s: @0 G, o' {/ |5 K' e! R+ |
literature.4
: A4 l) O' X/ I# D; X4 z0 v! pPatient Report: P* N% V. b3 }1 W$ u" u
A 16-month-old white child was referred to the
/ p* F8 b- ~; _4 t) ~endocrine clinic by his pediatrician with the concern
2 L$ L: k2 z  q3 X3 c7 E8 ]2 y! m5 @of early sexual development. His mother noticed
6 R: E& J* ~. Clight colored pubic hair development when he was3 c: I6 f: O' P
From the 1Division of Pediatric Endocrinology, 2University of
' C( z3 C- P9 i$ Q5 f- R' C+ uSouth Alabama Medical Center, Mobile, Alabama.0 G! R5 I% M! T6 I1 A
Address correspondence to: Samar K. Bhowmick, MD, FACE,. T$ X% z  S$ h# T  S- e) q8 x9 Q0 Z4 q
Professor of Pediatrics, University of South Alabama, College of
0 E' d& N1 ]6 N2 xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' B% a0 G& H0 p6 }7 u) b1 J0 {6 s( V7 |
e-mail: [email protected].% Y  a6 @- f. c+ {5 S5 M& f5 o7 t
about 6 to 7 months old, which progressively became
& ]' Q4 V& b2 u* ]3 E3 Ndarker. She was also concerned about the enlarge-+ X* y6 {1 T% k6 Z2 B4 F! X
ment of his penis and frequent erections. The child
. o, w1 E* h. s* u9 Z0 Rwas the product of a full-term normal delivery, with
' Z: h6 s$ l# u. [+ L8 Za birth weight of 7 lb 14 oz, and birth length of! ^& V; K. V  T  K3 Q# x1 a
20 inches. He was breast-fed throughout the first year! L* \. y: \. L
of life and was still receiving breast milk along with* I( j8 k, j5 ^8 q% @0 _
solid food. He had no hospitalizations or surgery,% s+ c, [& O% o: [1 Y. @
and his psychosocial and psychomotor development
0 f) T; |9 T* M1 Q7 Rwas age appropriate.* e8 v8 s4 Y8 M. j# {
The family history was remarkable for the father,# n, `4 {& P. z! a2 |' V8 v; `8 H- j
who was diagnosed with hypothyroidism at age 16,/ B! f4 g% r* G2 ~" ^. j
which was treated with thyroxine. The father’s4 P8 u- |( ]% s% m* Y8 M
height was 6 feet, and he went through a somewhat
/ \+ i/ n. {2 ]( @- @, A1 {early puberty and had stopped growing by age 14.7 {- ^, ]6 I) r
The father denied taking any other medication. The
, L9 I0 V1 {9 W% i* }: f& w4 I9 Kchild’s mother was in good health. Her menarche+ I1 p! ~4 [6 h; L5 J
was at 11 years of age, and her height was at 5 feet' L* S4 m) \+ s7 x9 v) o+ D
5 inches. There was no other family history of pre-' h, I: q6 {2 Y
cocious sexual development in the first-degree rela-- Y7 U- j& u" S7 ~/ L
tives. There were no siblings.+ Z& z: e% ?! O4 Q' `' o
Physical Examination' x+ \" @, R3 k4 Y
The physical examination revealed a very active,
2 Z1 a$ ?1 T, S+ D! q- Cplayful, and healthy boy. The vital signs documented* w+ Z3 S9 f* M6 Q' C8 A; X$ d1 p
a blood pressure of 85/50 mm Hg, his length was; p3 t, m; o7 y, n0 v8 E5 h
90 cm (>97th percentile), and his weight was 14.4 kg; l/ o2 w+ ^  D& L' k
(also >97th percentile). The observed yearly growth% s3 D/ S+ q" D* |/ ]# B
velocity was 30 cm (12 inches). The examination of* G/ x1 b5 D5 Q  Z. W  ^
the neck revealed no thyroid enlargement.
6 W+ S9 \# |! f# uThe genitourinary examination was remarkable for4 Q' e% z6 U% j3 {# }8 ~* R3 I* ~
enlargement of the penis, with a stretched length of0 e1 o, j  H7 b$ q4 R$ g0 X0 T5 D
8 cm and a width of 2 cm. The glans penis was very well, O) B( k7 r  F  f
developed. The pubic hair was Tanner II, mostly around
% D, @; `$ ]3 Z" {* L540  s2 p1 E6 h% T0 l4 \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 M# n( T  H% F3 ]. r5 R( h. C
the base of the phallus and was dark and curled. The
8 v2 e, T6 }& W8 F4 P8 s+ J0 rtesticular volume was prepubertal at 2 mL each.9 v5 w- d! ?' G: ?
The skin was moist and smooth and somewhat% c/ a& F4 J$ S" [$ F# [) @! H
oily. No axillary hair was noted. There were no
% F) a% L# n0 z% s8 J; r* ]" wabnormal skin pigmentations or café-au-lait spots.
  m, A& D3 Z) J1 TNeurologic evaluation showed deep tendon reflex 2+* B& {- R5 ^2 I0 o* v
bilateral and symmetrical. There was no suggestion" z' b6 Y4 P% _' g5 j% ]& f6 u
of papilledema.  C  r- W; r0 ~/ m! \7 h0 F% G
Laboratory Evaluation& I6 q; c1 n  V& U0 [
The bone age was consistent with 28 months by" ]. d% ~8 [8 l2 A' t2 d' Z: Y1 A, h
using the standard of Greulich and Pyle at a chrono-
" Y) `: s' l# W# W0 ^- slogic age of 16 months (advanced).5 Chromosomal' X: F. h' M; L$ l" O7 @
karyotype was 46XY. The thyroid function test
' `7 l' r" g% m/ Y' W, `3 Xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) ~0 |) w: v- |. q
lating hormone level was 1.3 µIU/mL (both normal).5 i% u' p" z& J* m' ?! E
The concentrations of serum electrolytes, blood2 T; }& q, f6 j
urea nitrogen, creatinine, and calcium all were" f. {8 S- g* }+ n4 q; J/ s! ]
within normal range for his age. The concentration
& g, E+ X( J5 j" y. Jof serum 17-hydroxyprogesterone was 16 ng/dL
4 ]9 x* F; d0 p" Q1 `' x8 m7 i(normal, 3 to 90 ng/dL), androstenedione was 20. H1 c/ J& K% Y2 b  ?, v' M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( c% ?: {. L$ Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),3 ?) A& c% M* L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' O3 }1 A6 S+ }
49ng/dL), 11-desoxycortisol (specific compound S)
( [; y+ B/ T5 iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' ]" E1 J( Y5 `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' [4 q, P. m: K: Q, L& ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ V% B6 Z- b5 c, J& yand β-human chorionic gonadotropin was less than1 o# \) h+ M2 q8 M) C7 O7 Z$ B9 A  O
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; c) L7 d" b( Ystimulating hormone and leuteinizing hormone
' n5 ^, N  S( Y' |concentrations were less than 0.05 mIU/mL
7 y+ n: J' M% u% _+ C6 W0 R* b(prepubertal).& w( Y) z( b  |( T' h$ U: }2 g
The parents were notified about the laboratory, [5 u! _8 G$ e  [
results and were informed that all of the tests were
) I6 l  l# }, ^3 F( Q0 y- ?/ z& A7 w4 Dnormal except the testosterone level was high. The0 T6 n; I( l) F( @% t7 T% Z
follow-up visit was arranged within a few weeks to9 a2 g* c  d. p; |
obtain testicular and abdominal sonograms; how-0 c2 ]4 q$ U5 @' K
ever, the family did not return for 4 months.& P9 b4 ]2 m: ~1 Z/ Y4 j
Physical examination at this time revealed that the0 X4 `- g. {+ {' d8 W- q
child had grown 2.5 cm in 4 months and had gained- `" t9 N, g' P) o9 x
2 kg of weight. Physical examination remained
+ j2 t- s: p# e. K: v0 Zunchanged. Surprisingly, the pubic hair almost com-8 R: {$ N' b7 r! r& }) D
pletely disappeared except for a few vellous hairs at
/ x3 b9 @; d* j2 c' Vthe base of the phallus. Testicular volume was still 2$ G: f3 E. u+ B- I# b3 h
mL, and the size of the penis remained unchanged.7 k' U: E$ r3 C! y8 R6 u# i$ M
The mother also said that the boy was no longer hav-
; m& s3 r8 i4 z- c" hing frequent erections., ~, c8 C, Z9 i+ u4 k) q
Both parents were again questioned about use of
  D2 E& d. {! J) f! {1 n6 O4 Vany ointment/creams that they may have applied to8 l4 Q& q3 {0 o  v
the child’s skin. This time the father admitted the
& S. Q0 _8 ^9 D$ uTopical Testosterone Exposure / Bhowmick et al 541
2 J- X# G/ I0 l& Xuse of testosterone gel twice daily that he was apply-
, R8 M7 J* b& S1 fing over his own shoulders, chest, and back area for
2 R0 {  W% e# j0 wa year. The father also revealed he was embarrassed
* q, i  B; ^3 ]& T$ Kto disclose that he was using a testosterone gel pre-: V$ s' c2 w  u4 x
scribed by his family physician for decreased libido+ L; n( [; g0 \( Z
secondary to depression.  i7 v0 f3 I5 S4 y/ U- S# b2 G
The child slept in the same bed with parents.: Y9 z/ D# T2 `* D
The father would hug the baby and hold him on his
  ?9 ?* _+ b- Q" g* Gchest for a considerable period of time, causing sig-3 r: z- B8 T5 X. Q: [% x3 b
nificant bare skin contact between baby and father.
) v1 L. U9 V* |! `4 D& `The father also admitted that after the phone call,
% S/ [+ t3 y! k+ w* I* J/ Rwhen he learned the testosterone level in the baby0 `  L5 R) d3 [3 ?! ]/ ?
was high, he then read the product information; y( e) ?/ A1 u! p* y
packet and concluded that it was most likely the rea-
4 c7 m; R' V) z( Qson for the child’s virilization. At that time, they
* z* A5 j+ B9 [8 l8 E- _2 M0 pdecided to put the baby in a separate bed, and the
/ A+ {( i4 L2 q$ K2 m( g+ dfather was not hugging him with bare skin and had3 Y+ x: ?% M7 }* H; W. ~0 c/ I
been using protective clothing. A repeat testosterone
3 W5 H( n$ Z5 W  mtest was ordered, but the family did not go to the. W" C- Z* c+ T; }' b
laboratory to obtain the test.
0 N: y, z* t8 Z6 W1 t, p5 u; |Discussion; o2 v/ t' v8 b  J8 C6 x
Precocious puberty in boys is defined as secondary
3 [" [  t8 n- ]6 }0 I2 xsexual development before 9 years of age.1,4
3 M9 R5 |, E* i9 E9 }0 uPrecocious puberty is termed as central (true) when" U/ e0 v& l) F+ ^( h$ K
it is caused by the premature activation of hypo-( G9 I5 i+ C* c( b% |  F6 s+ T
thalamic pituitary gonadal axis. CPP is more com-
  j8 g3 b6 n3 w8 |# r7 c5 qmon in girls than in boys.1,3 Most boys with CPP4 G: K" }+ [/ |9 U8 L3 J
may have a central nervous system lesion that is
8 G% ?3 t" c( G6 w$ f6 Dresponsible for the early activation of the hypothal-; u# a7 H4 ~: d4 G/ c
amic pituitary gonadal axis.1-3 Thus, greater empha-% J6 B! D4 E* n5 t3 Y& B  b
sis has been given to neuroradiologic imaging in$ [( w: W, ?7 z8 D3 J4 f! u
boys with precocious puberty. In addition to viril-
# V- s, F+ \! b( O  Eization, the clinical hallmark of CPP is the symmet-4 d( w" z4 X, v" p
rical testicular growth secondary to stimulation by
8 }! c0 t# L( Cgonadotropins.1,3
) c: r) j  j. Z' i1 f3 lGonadotropin-independent peripheral preco-
7 v( u* g0 G" k4 w  \cious puberty in boys also results from inappropriate
" z7 @$ h; ^0 E: o: c# P1 l  iandrogenic stimulation from either endogenous or
1 ?$ W& l) _8 u9 e9 y7 ~exogenous sources, nonpituitary gonadotropin stim-
$ d$ T* @: a/ q' w0 d* n+ qulation, and rare activating mutations.3 Virilizing5 M4 H# D3 M2 \" `% ^5 I! i
congenital adrenal hyperplasia producing excessive  ], Y8 B, ?  J
adrenal androgens is a common cause of precocious; x- k: t. g; u; d
puberty in boys.3,4% |  v: M9 e2 Y9 r2 O0 C. L
The most common form of congenital adrenal
% ^8 M* C. w3 C3 w" ?6 ^& f# hhyperplasia is the 21-hydroxylase enzyme deficiency.
( @; v, o9 x$ K( \% l0 QThe 11-β hydroxylase deficiency may also result in5 e* n! M6 M2 S  ]
excessive adrenal androgen production, and rarely,
4 D. K5 ]' }4 H( w4 o# }an adrenal tumor may also cause adrenal androgen$ x! F3 Y+ k/ [/ D- Z7 q* g
excess.1,34 L  J+ B3 n6 H/ k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 a5 O- e" S, v
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. T, S' k! c0 q0 GA unique entity of male-limited gonadotropin-
6 y, Y, E/ D0 }, d2 Dindependent precocious puberty, which is also known# j, G& L6 d8 y
as testotoxicosis, may cause precocious puberty at a3 t  z* [+ C$ a; l9 ^: q
very young age. The physical findings in these boys
% j5 k. v# ^! ?) {3 N5 g" Bwith this disorder are full pubertal development,
# s2 K2 e4 h8 i! s; pincluding bilateral testicular growth, similar to boys- _' ]( a% s: u3 J
with CPP. The gonadotropin levels in this disorder
& x& E/ C. z8 V  fare suppressed to prepubertal levels and do not show0 E4 ]0 z; T  e% c1 M# U- l
pubertal response of gonadotropin after gonadotropin-, \  p+ c5 M$ J( x
releasing hormone stimulation. This is a sex-linked% D" _  `3 c3 i7 Q/ m, q* j
autosomal dominant disorder that affects only
- N+ h5 U0 B( B, f4 Smales; therefore, other male members of the family$ d4 V7 k5 X' v5 _$ f
may have similar precocious puberty.3
) S4 I: r( g; J4 CIn our patient, physical examination was incon-
* J1 d- K7 _" jsistent with true precocious puberty since his testi-
! y3 f" b/ N6 {  ~7 s' h9 xcles were prepubertal in size. However, testotoxicosis$ V+ G6 j2 ~& m1 O- S- T' H9 Q5 [
was in the differential diagnosis because his father
3 g7 O+ Q0 i  ?+ H& Qstarted puberty somewhat early, and occasionally,
, y% ~+ ?1 r- t% rtesticular enlargement is not that evident in the% M1 k' F; F! r5 W; d3 g
beginning of this process.1 In the absence of a neg-/ x4 ^4 `7 ^9 G
ative initial history of androgen exposure, our9 @# T0 ]' o$ l; r' a% ^
biggest concern was virilizing adrenal hyperplasia,
! q& {9 g- g! w1 q. H: ~; Weither 21-hydroxylase deficiency or 11-β hydroxylase
2 f8 h. @4 ^% x" W; G' Bdeficiency. Those diagnoses were excluded by find-- U0 j6 G, U4 ~
ing the normal level of adrenal steroids.6 _! L2 {7 c1 y4 Q' T
The diagnosis of exogenous androgens was strongly
; T1 P; e( ^: F" Fsuspected in a follow-up visit after 4 months because. w; ~: A3 q: I7 U) w! F/ k8 W+ ?+ t$ |
the physical examination revealed the complete disap-" m" \# C. g; M6 f
pearance of pubic hair, normal growth velocity, and. Y) i) O& n0 [# }/ r# _8 R! X
decreased erections. The father admitted using a testos-  U6 C) S' W: A  ^6 S& Y! r* r
terone gel, which he concealed at first visit. He was
* U1 q* D& Q, Dusing it rather frequently, twice a day. The Physicians’& X2 D. b1 E- c$ i8 R
Desk Reference, or package insert of this product, gel or+ f7 s" G7 p2 S7 s1 y( J( h, o
cream, cautions about dermal testosterone transfer to+ I& m) t5 s. Q* E* d
unprotected females through direct skin exposure.
/ o7 [% R- s2 i' {, k8 I3 TSerum testosterone level was found to be 2 times the1 ~' a1 C( p! y: l
baseline value in those females who were exposed to
" Q8 l3 w( g) `/ |; A# C9 i9 peven 15 minutes of direct skin contact with their male
( S; u  W  [' a& R: ]2 ]$ J0 Lpartners.6 However, when a shirt covered the applica-
, Y  H' a; Z& O5 k/ Btion site, this testosterone transfer was prevented.: m: n7 \; E  V+ a# j0 y- H
Our patient’s testosterone level was 60 ng/mL,
5 ~. V% j* |  N8 h* dwhich was clearly high. Some studies suggest that9 v+ F; W. G, j$ O
dermal conversion of testosterone to dihydrotestos-" X& k# V0 d+ r6 ~+ F" N' t+ H$ N
terone, which is a more potent metabolite, is more" T. g9 @6 A! H* ~" }$ \
active in young children exposed to testosterone  K+ [+ R$ h' a+ D
exogenously7; however, we did not measure a dihy-
: e# p5 C6 s4 C/ V. `$ Jdrotestosterone level in our patient. In addition to/ P- y5 x( n0 ^
virilization, exposure to exogenous testosterone in
# n) y3 W' o# U8 ?, jchildren results in an increase in growth velocity and
% q% a- Q* p" w1 G1 h2 H0 tadvanced bone age, as seen in our patient.
2 j9 f5 K% Q' X! [* aThe long-term effect of androgen exposure during
9 K5 j$ q0 J* Yearly childhood on pubertal development and final
" @4 i( F  Y2 y5 U7 L+ Z* Cadult height are not fully known and always remain$ ^+ b' M9 U6 h  `+ a8 v1 J, m7 z) C! U& W
a concern. Children treated with short-term testos-2 V& }8 k8 J1 o3 C
terone injection or topical androgen may exhibit some
3 L/ x# n/ `4 X) W7 }# tacceleration of the skeletal maturation; however, after, l! P9 e3 D9 n4 [! w
cessation of treatment, the rate of bone maturation
2 E7 ?  `2 q* M1 X( Y4 Qdecelerates and gradually returns to normal.8,9
5 A2 ?% u0 k, H, a- NThere are conflicting reports and controversy- `! H  H, i3 G. a, M# j6 N4 @- u- P
over the effect of early androgen exposure on adult/ U/ x. v6 A9 I  h9 N
penile length.10,11 Some reports suggest subnormal
: T/ q9 L" l2 }! Eadult penile length, apparently because of downreg-
7 p$ N3 V# o( Iulation of androgen receptor number.10,12 However,& F  b2 w$ y6 ^) K  d- d
Sutherland et al13 did not find a correlation between
6 T  L& B# \$ F# cchildhood testosterone exposure and reduced adult
2 F7 i$ d5 I4 X; H! I+ Apenile length in clinical studies.$ Z" x$ f1 C. A" i
Nonetheless, we do not believe our patient is. Q3 n* `3 s0 W3 R
going to experience any of the untoward effects from
( v! @) z3 Y9 M" _testosterone exposure as mentioned earlier because
, [& n' R7 A+ k; S4 lthe exposure was not for a prolonged period of time.
7 @6 g! Y2 V; c( I7 MAlthough the bone age was advanced at the time of
# }5 w% ]( z5 N" Pdiagnosis, the child had a normal growth velocity at: S& N1 X5 j& s
the follow-up visit. It is hoped that his final adult* z% {% O. I3 O* t1 ?3 @! J' [% _
height will not be affected.) J$ d, R0 A1 f, n) y# v
Although rarely reported, the widespread avail-0 \# H, Y* x# I3 z7 Y) B0 D8 Y
ability of androgen products in our society may
( F7 e2 v  P4 J* M$ G" q+ R" Windeed cause more virilization in male or female
. S. E6 K5 G; e' I# ?7 W$ fchildren than one would realize. Exposure to andro-) x! h* C: l4 w1 i: h  n# d5 M
gen products must be considered and specific ques-
" _. w  N1 h. Utioning about the use of a testosterone product or
5 `1 I/ R5 |$ q7 l; Q2 b' A; @2 z: Dgel should be asked of the family members during
1 v9 h  |" w& ^+ V4 j4 s% Qthe evaluation of any children who present with vir-
% ?: p' {8 T' y6 z9 D# |ilization or peripheral precocious puberty. The diag-
# \  n% `2 K) s' J0 knosis can be established by just a few tests and by  M7 X8 ]8 l- I- f% g/ q
appropriate history. The inability to obtain such a
- B/ w! d* K6 @history, or failure to ask the specific questions, may/ n1 Q  k* l) @: m. |+ p. B
result in extensive, unnecessary, and expensive( G! U$ X2 V3 U% U* o
investigation. The primary care physician should be+ X/ Q4 @$ M1 y
aware of this fact, because most of these children! e5 L- A  \& _# j
may initially present in their practice. The Physicians’* P, A' R! G1 s! _+ `. G* y- \
Desk Reference and package insert should also put a- n6 a( _& R; X6 O. i0 u9 ~
warning about the virilizing effect on a male or
3 b; L( L- i$ z. Ofemale child who might come in contact with some-
( _. @" ^5 p) W* s5 None using any of these products.
" H  q9 d6 D  @$ mReferences- ^3 V2 f5 \" i; x: z# j
1. Styne DM. The testes: disorder of sexual differentiation
! a2 |/ D) q- Q0 X2 u4 _! qand puberty in the male. In: Sperling MA, ed. Pediatric
& v' |6 |  B: \Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 H& \& n1 s. [+ _. w9 R
2002: 565-628., p4 S. q, |# i1 M7 ^' ~0 g
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 b+ T+ j! t) y$ [8 Ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
6 }8 S5 A0 o2 N7 F, v0 dBoy Induced by Indirect Topical
& @6 X) ]: Q2 c# n* R  fExposure to Testosterone" |' {& S9 y9 e4 X: j) f/ z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; b* b% o( v3 G7 f) e) R1 pand Kenneth R. Rettig, MD1
3 r( H( c7 q3 [" P! NClinical Pediatrics
- G$ ?- J# T4 fVolume 46 Number 64 J7 g/ u; u  G
July 2007 540-5435 J# Y( U3 z' L1 O4 u" Z, A
© 2007 Sage Publications
% M) G  V% u0 k, Q6 x8 s! t" Q' Y10.1177/0009922806296651
) P8 x! m, ~$ f% Y! Vhttp://clp.sagepub.com
! p6 N1 @" w  h7 mhosted at
, F: N. \0 A4 d6 q  ^http://online.sagepub.com
7 H1 d: ?! ?5 z6 W; {) Q  kPrecocious puberty in boys, central or peripheral,) [8 g' L' c$ X: `. D! L7 i7 \! ?
is a significant concern for physicians. Central
$ g/ X* Z. {( k8 [6 sprecocious puberty (CPP), which is mediated
5 x7 ]# ^, k) ythrough the hypothalamic pituitary gonadal axis, has1 T* Q" s4 j2 T2 P7 o
a higher incidence of organic central nervous system
$ [/ Y* }$ v. K! nlesions in boys.1,2 Virilization in boys, as manifested
( }2 E0 F* N* y2 x& Mby enlargement of the penis, development of pubic% W2 p; {! h3 z! n! B) r3 t
hair, and facial acne without enlargement of testi-. K# g' m+ l& ^, ^. u
cles, suggests peripheral or pseudopuberty.1-3 We' s. y3 v( [- S. h3 K8 [0 ]
report a 16-month-old boy who presented with the
- J. N, D# T6 z, Y! p7 ?) @4 Z- Henlargement of the phallus and pubic hair develop-
" V. e0 J4 |9 P, j' z9 k# Kment without testicular enlargement, which was due
! I1 s8 H9 x- @+ `4 v! eto the unintentional exposure to androgen gel used by- S; K9 e$ R" D2 ?& Q
the father. The family initially concealed this infor-. |+ G6 a+ s1 v4 e+ B
mation, resulting in an extensive work-up for this
8 r" N. H9 o! {3 T7 a" N3 Echild. Given the widespread and easy availability of  C- _( H9 ~6 U$ `1 P) c5 D
testosterone gel and cream, we believe this is proba-2 ]- d6 Q* c1 i/ c
bly more common than the rare case report in the. m! d0 G% e- g+ P
literature.48 t9 o; k8 q3 r
Patient Report1 }9 r/ y9 h8 e( j
A 16-month-old white child was referred to the: B+ s8 ?: b, Y2 ]8 n# _
endocrine clinic by his pediatrician with the concern( Q1 H8 D0 G" t* W8 Y" |
of early sexual development. His mother noticed
# q: H+ A% N  U- B4 A% Mlight colored pubic hair development when he was
% j9 F1 y7 J/ Y+ C5 \+ Q: c0 k3 fFrom the 1Division of Pediatric Endocrinology, 2University of
6 J3 d! o# Y* X( d) }5 D, @+ b8 V( sSouth Alabama Medical Center, Mobile, Alabama.1 |  M, f! h& C. Z* f; R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! U; {, J4 Q4 w! U# K" ^1 ZProfessor of Pediatrics, University of South Alabama, College of4 I2 B! c# ]6 n, ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 d9 M: T. s) Fe-mail: [email protected].
) G4 V/ n& ?9 V8 C: l) qabout 6 to 7 months old, which progressively became" |, R6 @0 I/ v/ Y* Y. Q
darker. She was also concerned about the enlarge-" K7 z+ W$ ?: |  c% Z
ment of his penis and frequent erections. The child
4 t8 p+ t7 K& E4 Hwas the product of a full-term normal delivery, with
; h8 m* V/ y, Ja birth weight of 7 lb 14 oz, and birth length of: ~  I! U, \' M* w
20 inches. He was breast-fed throughout the first year4 }+ o  X8 {* f" c
of life and was still receiving breast milk along with
. k9 h1 v- C$ d2 R+ |+ Fsolid food. He had no hospitalizations or surgery,3 I9 O" @8 `& f' p( E% q% R; b: m" l' L
and his psychosocial and psychomotor development
; V1 s8 g% @* t1 m& S: @was age appropriate.
2 S8 v2 t! O7 sThe family history was remarkable for the father,
9 q0 Y! T3 }4 ~- ^8 X& o+ a4 ywho was diagnosed with hypothyroidism at age 16,( {0 w9 O( D  `; P
which was treated with thyroxine. The father’s" _3 w$ v8 t6 ~1 f
height was 6 feet, and he went through a somewhat
5 F, S& ~2 j, F. H* `early puberty and had stopped growing by age 14.4 |+ t& s+ ]! T/ N" P# b
The father denied taking any other medication. The) n3 C2 X( `; R1 h
child’s mother was in good health. Her menarche
9 Q7 `: y+ H, D$ ?- \# A2 {was at 11 years of age, and her height was at 5 feet( ^! x! z1 {$ I' F0 X
5 inches. There was no other family history of pre-
3 [* E4 d  _6 n. |$ s4 L6 e5 y. mcocious sexual development in the first-degree rela-
0 X  k& W( M$ ftives. There were no siblings.$ o" Q, u  C$ ^3 m
Physical Examination
; v  {( o1 D5 M, L# e9 S% e7 Y' mThe physical examination revealed a very active,8 y$ ^; i' o" A; L) c! W" |1 i/ @* l
playful, and healthy boy. The vital signs documented" h% _( o; G$ m, B
a blood pressure of 85/50 mm Hg, his length was
4 ~4 b' ]3 S1 S8 Y+ f90 cm (>97th percentile), and his weight was 14.4 kg  |" Y" ]  e7 ^" ~/ ~4 z( J
(also >97th percentile). The observed yearly growth
3 k% c0 o5 S. Avelocity was 30 cm (12 inches). The examination of
2 G! z$ \( I! R# F3 H- y! ^the neck revealed no thyroid enlargement.1 e; C# U+ U$ m2 C- s$ h
The genitourinary examination was remarkable for2 Y2 K0 g. e& p2 Q+ U* N
enlargement of the penis, with a stretched length of3 P* E+ @, m7 y) m4 u! f) s
8 cm and a width of 2 cm. The glans penis was very well) Q9 W# }! l( Q& p2 V& g  \
developed. The pubic hair was Tanner II, mostly around1 v. y- m+ ^. B5 I8 V5 c
540" O6 F) `0 W% B' O# I9 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 E" b: O! y' }the base of the phallus and was dark and curled. The% }  x6 P5 k9 J% M2 ^- I# @, G- _
testicular volume was prepubertal at 2 mL each.
! q) i1 o! S* bThe skin was moist and smooth and somewhat+ [' p, H* O: p& s
oily. No axillary hair was noted. There were no% @! L6 P( j& |4 x5 Y$ w; {# o
abnormal skin pigmentations or café-au-lait spots.
# S7 Z. I) t8 f' D# }Neurologic evaluation showed deep tendon reflex 2+. O% I, t1 Y6 q- l4 c9 U/ t
bilateral and symmetrical. There was no suggestion) [. P- i, O/ K0 K: M) q0 ^9 j
of papilledema.
9 @  i: L7 n- `  L5 r/ @Laboratory Evaluation
. e! U- L& _- G% {The bone age was consistent with 28 months by
, L& P( N& n* E0 musing the standard of Greulich and Pyle at a chrono-
  `: Y( P7 f# V/ o! [logic age of 16 months (advanced).5 Chromosomal
, e+ p6 p5 K' Z; Q7 f) ^2 l& w1 J" ]karyotype was 46XY. The thyroid function test3 d" u0 x  V5 E% d1 F! h! h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 Q" {& e% N+ o. L2 }; klating hormone level was 1.3 µIU/mL (both normal).
6 D3 ~- O( M; n& Y# xThe concentrations of serum electrolytes, blood
8 j- ?# [  c( i9 G' ?7 K6 O: i* j- o1 Vurea nitrogen, creatinine, and calcium all were
6 a) e+ K# O, m: Pwithin normal range for his age. The concentration2 Q: x4 A9 n' F- K
of serum 17-hydroxyprogesterone was 16 ng/dL
$ s2 j3 a, g9 k, Z; H! E(normal, 3 to 90 ng/dL), androstenedione was 206 I+ U% l  f  k8 }4 B9 @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 z; v$ \5 z% F- v& Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% |" o4 ^) R6 \% sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 y0 b0 F6 L8 v49ng/dL), 11-desoxycortisol (specific compound S)1 ?# H7 q; I, s+ o3 c. G
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, p7 ~' ]* M- t" ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ S4 A# H% Y0 W( s: ]; R( [1 N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) k! b- k7 r4 S& E1 Y5 c
and β-human chorionic gonadotropin was less than0 V7 L: |3 ^+ t. j8 M; C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 ]4 ~' J8 O2 Q  g9 Lstimulating hormone and leuteinizing hormone
; B( U" I' ]: Rconcentrations were less than 0.05 mIU/mL  U) ?+ M1 m) f+ D  k8 G
(prepubertal).: `- x6 x) F1 z$ F# o# l
The parents were notified about the laboratory* Y$ b- Q' O) \. c8 f8 \9 o6 L
results and were informed that all of the tests were
2 t% ]/ Q- }# b4 _! v( X; Bnormal except the testosterone level was high. The( T3 s' K6 U  B% E
follow-up visit was arranged within a few weeks to0 v3 X9 ~# ^  Q% n; A, F3 g
obtain testicular and abdominal sonograms; how-
" A1 `2 N. j. x/ R( J- A! Lever, the family did not return for 4 months.
. n# o, }. X' y) JPhysical examination at this time revealed that the
1 e1 W% B7 o& k: @1 Q% p% @child had grown 2.5 cm in 4 months and had gained* g: r+ G: T; {9 g  K0 S* ]- `( }& @
2 kg of weight. Physical examination remained8 ^0 [5 k+ K0 S9 P1 M1 n
unchanged. Surprisingly, the pubic hair almost com-: ~9 G* ^# q) l
pletely disappeared except for a few vellous hairs at
9 ^, M' }9 k& O9 _5 ~the base of the phallus. Testicular volume was still 2+ U: Y# m% P7 |0 g1 l
mL, and the size of the penis remained unchanged.0 r% R; i" b" G$ @7 ^7 j: K/ C
The mother also said that the boy was no longer hav-- F% z5 k) [, T# z( p
ing frequent erections.
" C7 y2 A3 h8 R8 pBoth parents were again questioned about use of
: M  ^: L6 ]& ~' g3 B! a+ @any ointment/creams that they may have applied to
- L) K+ Y  i' a: m7 a9 K: bthe child’s skin. This time the father admitted the
0 O+ U" v1 a! YTopical Testosterone Exposure / Bhowmick et al 541
; a9 j1 j* t. E, R% s3 c* {use of testosterone gel twice daily that he was apply-
3 b6 x; n" o  v  e' q( Eing over his own shoulders, chest, and back area for
4 ^0 t1 x. s4 G8 U+ ]2 Y7 Qa year. The father also revealed he was embarrassed
* X$ m0 U1 X+ b+ `2 xto disclose that he was using a testosterone gel pre-: L" N+ }& l7 J* L3 L) q
scribed by his family physician for decreased libido# s; P; w- r2 }  S9 C+ ^3 R
secondary to depression.
1 ]7 c- K8 d% CThe child slept in the same bed with parents.
* Y' @0 N! O2 J0 \( T- EThe father would hug the baby and hold him on his) c/ p3 B/ U6 s
chest for a considerable period of time, causing sig-8 [8 t1 o' ^! S5 v& n# F" @
nificant bare skin contact between baby and father.
( l5 x4 O" E. B: P+ R, T8 MThe father also admitted that after the phone call,
& o& I4 X, n7 k+ u9 U8 vwhen he learned the testosterone level in the baby
& H% ?) ^' o' D# P. F6 Swas high, he then read the product information3 J# R. b# B# V' i4 l
packet and concluded that it was most likely the rea-% v- E" @3 A" \
son for the child’s virilization. At that time, they
$ G& ]# r. V" _# Fdecided to put the baby in a separate bed, and the
  j2 `: `6 |" d( s7 |4 Cfather was not hugging him with bare skin and had: `' v4 m" S) W$ U
been using protective clothing. A repeat testosterone
1 J8 a" x. f& x) q$ p& m8 ftest was ordered, but the family did not go to the& b; U6 l6 J4 w0 k; M0 \
laboratory to obtain the test.
8 B! |7 B1 X( s8 c3 K5 g* jDiscussion
5 F+ a$ }/ T- U; Y" Q2 H2 v- xPrecocious puberty in boys is defined as secondary
: [: k7 ?( c, Dsexual development before 9 years of age.1,41 C( Z* k: F1 F
Precocious puberty is termed as central (true) when; c0 g7 e0 i8 r/ y% @
it is caused by the premature activation of hypo-5 w* `+ |# [5 L5 V& J' K8 }- m
thalamic pituitary gonadal axis. CPP is more com-
" {( e) {8 L3 Z3 Umon in girls than in boys.1,3 Most boys with CPP
' e6 [4 k% W: b( n- A" x2 L1 I7 fmay have a central nervous system lesion that is3 n0 ^. g8 C5 j0 r+ m6 W
responsible for the early activation of the hypothal-
5 |. i' V0 I* f. a5 z, e+ q( L& @amic pituitary gonadal axis.1-3 Thus, greater empha-
" t2 i  d6 Q7 D9 ssis has been given to neuroradiologic imaging in8 z- P0 ~: R( {9 A% `
boys with precocious puberty. In addition to viril-+ g; v. H, r& G- ?
ization, the clinical hallmark of CPP is the symmet-: c* d- L. B+ B) `* {: U$ s# B7 d
rical testicular growth secondary to stimulation by- P( }/ w9 F6 _" ^8 J. ^
gonadotropins.1,3
! V3 H9 k, C. j8 g0 VGonadotropin-independent peripheral preco-3 A+ S7 q+ @  |& W% n
cious puberty in boys also results from inappropriate
+ Q. E& ~7 d2 [; {1 V8 A( Kandrogenic stimulation from either endogenous or5 e/ N9 V& d! T3 E% T5 W4 V; _. z
exogenous sources, nonpituitary gonadotropin stim-& r% m; ~" ]: k# S9 n, c4 |
ulation, and rare activating mutations.3 Virilizing
& `- Y1 y% b- L+ m, k+ `7 Gcongenital adrenal hyperplasia producing excessive
- ~* D9 t% _4 C+ }7 t& s3 ?adrenal androgens is a common cause of precocious
8 ^' N) x! \- x1 Npuberty in boys.3,4
5 U# q8 c) e2 o7 K- Y3 s7 L$ J" {* XThe most common form of congenital adrenal5 @* Q; [3 k2 @2 |& E# e# K
hyperplasia is the 21-hydroxylase enzyme deficiency., W& I6 q( \1 A0 R. B; Q* [# b
The 11-β hydroxylase deficiency may also result in
- v% c/ X4 U; p. ~' M: kexcessive adrenal androgen production, and rarely,
( r& E  X- }1 E* z) l3 K# O' Gan adrenal tumor may also cause adrenal androgen
$ W1 K' Q( [* w3 K3 D; Hexcess.1,35 ]9 {3 K2 a0 n8 b" K+ o. ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% H# i' T. ]$ P7 i. d- W
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 w+ Y) ]8 ]: _7 F
A unique entity of male-limited gonadotropin-
" O4 Q+ s' h" _# d( r+ J, gindependent precocious puberty, which is also known
" z5 _7 x  m# f% `8 aas testotoxicosis, may cause precocious puberty at a# @! f4 p7 [' M
very young age. The physical findings in these boys, e2 ~. m9 z/ {, A% T
with this disorder are full pubertal development,
5 J; a$ s" _3 x+ M( U' yincluding bilateral testicular growth, similar to boys! C# z7 X9 Z. J( l  b
with CPP. The gonadotropin levels in this disorder9 @$ Z7 s" z$ D. ?6 ^
are suppressed to prepubertal levels and do not show
, h; Z! |% C% [: `pubertal response of gonadotropin after gonadotropin-4 o% J! `9 F0 h6 {; Q4 V1 v$ J
releasing hormone stimulation. This is a sex-linked7 R, e) O" d( t3 r1 Y. n7 T
autosomal dominant disorder that affects only! s% k. E8 j0 ?: d8 E9 u
males; therefore, other male members of the family2 ^0 _  o. ~" l- W; Q  T
may have similar precocious puberty.3& C: [1 g" K9 N- R& h0 g
In our patient, physical examination was incon-# J* I* E5 N) H9 I! T6 R# Y- w
sistent with true precocious puberty since his testi-
1 H1 Z! }5 a8 i, \cles were prepubertal in size. However, testotoxicosis
  M9 \# w9 e- Q6 w4 O  Cwas in the differential diagnosis because his father
7 Y! B. N$ M) V; k4 y# f4 N) Q; tstarted puberty somewhat early, and occasionally,1 W' D4 Y$ G; b: A
testicular enlargement is not that evident in the7 ]; o, n0 n. I2 I* h: q$ R
beginning of this process.1 In the absence of a neg-8 W& ^# q5 y; \2 i
ative initial history of androgen exposure, our# ]1 B" C/ W* z4 M3 L
biggest concern was virilizing adrenal hyperplasia,
6 @% z4 D  Z5 V# I/ |either 21-hydroxylase deficiency or 11-β hydroxylase' {+ d" T4 B7 I% t1 Q
deficiency. Those diagnoses were excluded by find-
( o' s" e$ P$ e! _  jing the normal level of adrenal steroids.5 f( O* D6 _# G( M0 r$ g- q1 M
The diagnosis of exogenous androgens was strongly
+ e% y1 A( t/ H8 l# e7 K3 X+ {suspected in a follow-up visit after 4 months because- v! J, r* j3 g" V2 }' n* v! I
the physical examination revealed the complete disap-
8 N% k  G3 V5 `6 K- Gpearance of pubic hair, normal growth velocity, and
6 o+ U; X  W+ G( Vdecreased erections. The father admitted using a testos-
% U5 X, z$ b7 @+ eterone gel, which he concealed at first visit. He was9 Y. l+ G( T! w
using it rather frequently, twice a day. The Physicians’6 ]3 y; b+ r+ j, b% [, n
Desk Reference, or package insert of this product, gel or4 \5 P. W, s2 }5 E
cream, cautions about dermal testosterone transfer to! s0 C" J: J8 W' y3 f$ ~% i
unprotected females through direct skin exposure.
$ v- m8 p3 X, Q" o  I5 ~. w8 wSerum testosterone level was found to be 2 times the
. _# `' U, d4 @& f* u% d  X& A3 gbaseline value in those females who were exposed to
8 }; U- Z/ U% Q# veven 15 minutes of direct skin contact with their male
3 @) M, h) `4 Y7 N, B6 ^partners.6 However, when a shirt covered the applica-- w0 E& ^- a$ E  D
tion site, this testosterone transfer was prevented.3 B0 \/ L! N% Y( x# X
Our patient’s testosterone level was 60 ng/mL,. I6 W# I+ G  H2 i0 F/ v
which was clearly high. Some studies suggest that
# W$ G0 Z$ v4 k+ [* k) U1 p0 }dermal conversion of testosterone to dihydrotestos-
6 U* J! C% e! q6 dterone, which is a more potent metabolite, is more* l+ P+ Z2 K* [5 v
active in young children exposed to testosterone
" `6 b% W% c0 A) r# ~5 Fexogenously7; however, we did not measure a dihy-
  c$ l4 t; r" r" k- m4 Gdrotestosterone level in our patient. In addition to
. E4 ~& E' U" F, K3 mvirilization, exposure to exogenous testosterone in
$ g. J, ]& }, Z1 G5 Y0 f  u/ D9 Fchildren results in an increase in growth velocity and
9 S+ y( ]( z6 c7 h0 L. Zadvanced bone age, as seen in our patient.
  u% [% p& {: t$ {( GThe long-term effect of androgen exposure during: {- `3 ~5 F, k4 w+ J
early childhood on pubertal development and final9 W: L# P: M# B" a
adult height are not fully known and always remain4 E; ^' c" l- S. u) j
a concern. Children treated with short-term testos-
/ }- c. ~1 a, E4 p, R4 r, R0 Mterone injection or topical androgen may exhibit some
4 C8 y6 X2 z9 j! bacceleration of the skeletal maturation; however, after! v& I' j. M1 N; U: u! @" T4 e
cessation of treatment, the rate of bone maturation: Q6 j9 ?$ D: h9 d' d/ l
decelerates and gradually returns to normal.8,9
, H0 d! E& w$ h7 TThere are conflicting reports and controversy
6 ^* u$ I( t! V8 Pover the effect of early androgen exposure on adult4 B3 O7 }9 i+ P
penile length.10,11 Some reports suggest subnormal
  D1 w. w1 v$ ]/ H& ^8 ?' {adult penile length, apparently because of downreg-
/ d/ C: x7 Z4 E+ Bulation of androgen receptor number.10,12 However,
. G% z$ B: f1 G  r" a6 g$ {Sutherland et al13 did not find a correlation between" Z$ K% O9 L- ~* F+ x
childhood testosterone exposure and reduced adult/ @4 [5 I8 c0 z( }/ Y
penile length in clinical studies.
2 m( ~3 l  Y# X% o9 |. g9 I4 JNonetheless, we do not believe our patient is
$ E# i) m; }2 s6 K5 J9 _! T4 ogoing to experience any of the untoward effects from
" m  C9 d! T3 Etestosterone exposure as mentioned earlier because
6 G7 z: `8 m" `. P6 n# w3 Zthe exposure was not for a prolonged period of time.) X* U4 d  f/ N; F$ @* U6 c1 J
Although the bone age was advanced at the time of+ C/ i6 V! P( y# w
diagnosis, the child had a normal growth velocity at) w! u8 r$ h& ~7 C) m4 ?
the follow-up visit. It is hoped that his final adult3 q, f' u" g/ G# ~' B
height will not be affected.
, e3 Z: d. s7 k- a) d; G  L' N# lAlthough rarely reported, the widespread avail-! I1 o3 m1 ?6 w( y" Y- v
ability of androgen products in our society may3 |8 _1 U0 x( e% M  s
indeed cause more virilization in male or female
: @( A7 }9 j( o; ]$ I8 }' w" j7 Qchildren than one would realize. Exposure to andro-9 U' _! t" ?; I' `% C: Y
gen products must be considered and specific ques-
. Y" F9 X, K/ Z3 c* f! j5 [tioning about the use of a testosterone product or0 v, D1 @% n, M& s9 H
gel should be asked of the family members during5 f/ m8 C& }' ]" q
the evaluation of any children who present with vir-
( _* }7 a( K4 S! Pilization or peripheral precocious puberty. The diag-0 _4 ]. C1 X; M% |8 p3 p
nosis can be established by just a few tests and by
$ n% }6 [6 a5 B+ U& b, P, J; happropriate history. The inability to obtain such a+ J" i. I; e9 K( `% R
history, or failure to ask the specific questions, may. ]- u, G6 W: v8 \& K! M
result in extensive, unnecessary, and expensive2 @( }( g! x+ Z( k% g+ H' F6 F0 o
investigation. The primary care physician should be
8 n- t4 N& l8 e5 a' E7 u9 z" Kaware of this fact, because most of these children# Q1 K% Q& s* L7 r6 `1 W
may initially present in their practice. The Physicians’
8 T  j. t1 V2 \( c, X6 v$ aDesk Reference and package insert should also put a1 f. ~0 |7 @  w- x! d* v
warning about the virilizing effect on a male or7 H0 \4 {: [4 J+ g
female child who might come in contact with some-1 w  C9 n1 F  }! O" b, [
one using any of these products.
/ j! k: X3 w4 ~6 u/ L; Z0 E: NReferences
3 R* S& ]) b0 B* R: S1. Styne DM. The testes: disorder of sexual differentiation. l' U! p0 F: j% w6 f* f
and puberty in the male. In: Sperling MA, ed. Pediatric
( z# \$ Z' S6 v* T7 j+ B2 u" QEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( W, J0 R" Z3 f+ y) a/ S$ f3 ^
2002: 565-628.
, p. @1 U8 l7 S. ~$ e8 s& y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; l) b3 Q& B" F2 d7 S& d2 l% y7 r: `
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

- C) j" b+ i' 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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