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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
1 u$ }: ?  P: a5 y; H  MBoy Induced by Indirect Topical- E1 y, p8 N) t0 h
Exposure to Testosterone( q' Y( Q2 w3 h: r! R3 s
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 e& [7 z7 d$ J  l% i9 K
and Kenneth R. Rettig, MD1
/ E1 t' H8 b9 B2 F7 L) W" iClinical Pediatrics9 ?$ V0 ]- c" R6 I; `
Volume 46 Number 6
5 T0 S8 |4 J' A2 AJuly 2007 540-5433 h6 U& u/ F# m# o
© 2007 Sage Publications% y8 F" p  Q4 C
10.1177/0009922806296651
! c! h& V' Z0 T  l7 ^# g9 Chttp://clp.sagepub.com- `! N! i3 ~! d' X
hosted at
- ]. n8 C% Z; qhttp://online.sagepub.com
0 ~  l+ p: ?. h; FPrecocious puberty in boys, central or peripheral,
4 Y3 c& m+ T+ U# Kis a significant concern for physicians. Central
/ M8 q7 ~3 ^% \5 zprecocious puberty (CPP), which is mediated
, e) N6 G6 h2 g/ b+ Tthrough the hypothalamic pituitary gonadal axis, has
+ u6 |! ~  t% [0 Ia higher incidence of organic central nervous system
  G0 z* I" `1 {' A4 z( tlesions in boys.1,2 Virilization in boys, as manifested
$ M; l- C5 Y) [) g% Y, e( {! R( Cby enlargement of the penis, development of pubic
3 R# d- ]- L$ K* T( c* qhair, and facial acne without enlargement of testi-
8 w2 o, B. a. fcles, suggests peripheral or pseudopuberty.1-3 We
9 Y  w* q& L, A% Nreport a 16-month-old boy who presented with the
7 }$ J8 @8 A9 ^0 M" K% N8 oenlargement of the phallus and pubic hair develop-
2 S5 a+ p# D# ~# @ment without testicular enlargement, which was due: i; X! ^) ~4 U: Z0 u1 k
to the unintentional exposure to androgen gel used by2 S, Q% ^* W  L( |1 l( P
the father. The family initially concealed this infor-. O, `$ y% d8 b% N
mation, resulting in an extensive work-up for this2 E8 {' k" x( s4 k& s& q2 X' t
child. Given the widespread and easy availability of5 s+ d8 O) b/ A( e2 S: q1 H6 t
testosterone gel and cream, we believe this is proba-
, E4 ]/ b5 q+ S; w4 _9 o' ibly more common than the rare case report in the
) u0 d' G! v7 x6 lliterature.4
* b  Z! B* b: j/ X2 D; @Patient Report
3 R( Y4 c7 }" fA 16-month-old white child was referred to the+ T! ^  N+ Q& {1 \; a) O
endocrine clinic by his pediatrician with the concern
+ v$ L; b0 Z) d& |  \0 @7 gof early sexual development. His mother noticed; ~8 P6 k2 g5 L5 O
light colored pubic hair development when he was3 `6 v) V3 l1 C: p# [( X
From the 1Division of Pediatric Endocrinology, 2University of
% M$ D! Z3 z5 ^South Alabama Medical Center, Mobile, Alabama.
1 l, Q3 _0 g/ v2 }, A! _Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 G9 i. v/ v* t8 {4 r7 Z/ e# KProfessor of Pediatrics, University of South Alabama, College of9 l% J: y$ J2 b9 I# I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ W0 _  L' s6 C4 r: W4 @1 j/ ge-mail: [email protected].
# ^# Y" I# b8 M- xabout 6 to 7 months old, which progressively became
" Q# h$ W  Q, l- }5 c$ I8 {darker. She was also concerned about the enlarge-( u+ l9 }/ O2 y* O
ment of his penis and frequent erections. The child
6 [( I' @+ T0 B5 o8 a7 Vwas the product of a full-term normal delivery, with! `, t4 V, C6 k  b5 j  b" h* o* _( T
a birth weight of 7 lb 14 oz, and birth length of
1 T6 f$ }4 D& {( j( L1 @20 inches. He was breast-fed throughout the first year5 \3 p4 ^9 x6 i4 K8 j- u- @% L  i
of life and was still receiving breast milk along with
+ v. x7 ~: _) Dsolid food. He had no hospitalizations or surgery,4 @9 J8 V" d2 ^" }7 T
and his psychosocial and psychomotor development3 ~) E7 p. _! Y0 F4 b3 W
was age appropriate.. |1 B8 Y1 J2 Z% A6 Y: [
The family history was remarkable for the father,
( r! C6 x' ?$ f( F4 Twho was diagnosed with hypothyroidism at age 16,
; P; t$ r2 t8 b1 T  d2 z( ^which was treated with thyroxine. The father’s
; b& F0 B( P' a% P4 Theight was 6 feet, and he went through a somewhat
* v7 ^4 T( G2 nearly puberty and had stopped growing by age 14.
9 x1 m: b8 C9 J. A9 oThe father denied taking any other medication. The8 y6 ~7 }# g  R% ]6 \1 M- l
child’s mother was in good health. Her menarche
7 s3 j( C$ S" ~$ bwas at 11 years of age, and her height was at 5 feet7 Z3 d. U+ G/ `3 w9 `! [2 @
5 inches. There was no other family history of pre-, @0 p' t* c5 ]
cocious sexual development in the first-degree rela-3 \- U1 @7 S1 }- y
tives. There were no siblings.0 q# d) Z& W! d7 Y, x# H. S
Physical Examination
9 L6 Q: U: O8 s; E& E  mThe physical examination revealed a very active,
: k( ?! Q5 p6 S; [4 lplayful, and healthy boy. The vital signs documented5 o) n7 g% ?4 p! Y
a blood pressure of 85/50 mm Hg, his length was$ h7 L$ `" u9 k3 B
90 cm (>97th percentile), and his weight was 14.4 kg
% c( Y5 s8 n. x; h; b0 V  g) m(also >97th percentile). The observed yearly growth0 s3 X2 [3 J/ G9 S+ [/ E
velocity was 30 cm (12 inches). The examination of$ t' T  K" W# _# N/ G" y
the neck revealed no thyroid enlargement.
: ]( U3 h2 a4 X  H. F0 q' OThe genitourinary examination was remarkable for
  w3 T7 j# _3 C: Senlargement of the penis, with a stretched length of8 K* ?) |; w- E+ T! a
8 cm and a width of 2 cm. The glans penis was very well
& C# e. j0 O! Xdeveloped. The pubic hair was Tanner II, mostly around
# o6 L/ w! a5 ?% I( H7 h, W% U5401 `. m) |+ d5 X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 R4 U9 W8 ?+ ^( r0 vthe base of the phallus and was dark and curled. The
2 `& j9 ?: I+ g: wtesticular volume was prepubertal at 2 mL each.
2 X0 Q5 p4 r9 ?. n6 q; \- t7 yThe skin was moist and smooth and somewhat8 K* r9 X: g4 w
oily. No axillary hair was noted. There were no9 C% R3 g/ j) D  O: m) }& l$ ^9 Y
abnormal skin pigmentations or café-au-lait spots.
) C) Q, C2 n$ F4 |. kNeurologic evaluation showed deep tendon reflex 2+/ T' Y' q# S5 P1 W" m
bilateral and symmetrical. There was no suggestion8 F) G1 m* Y2 D0 b, {
of papilledema.+ e4 M4 C7 K% H( ]0 q( e' |
Laboratory Evaluation
& v) L  I- l6 N7 a3 K8 tThe bone age was consistent with 28 months by
  ?. k+ K: \$ Y) g* P2 \using the standard of Greulich and Pyle at a chrono-
; R+ ]/ x8 N8 Nlogic age of 16 months (advanced).5 Chromosomal
, C& ?4 {. N) m! U1 q  @5 ckaryotype was 46XY. The thyroid function test# f" I/ z( N! ^, _& n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( H6 t' q) X6 q/ Q; g3 `# V3 {- slating hormone level was 1.3 µIU/mL (both normal).
' ]+ w- F8 V' j9 OThe concentrations of serum electrolytes, blood
) l8 E" b/ }( f6 S; w9 x+ Ourea nitrogen, creatinine, and calcium all were
" i1 }: H2 B9 l( A" rwithin normal range for his age. The concentration7 k* _/ {. Z7 b
of serum 17-hydroxyprogesterone was 16 ng/dL
6 D4 t% v) `( R, b(normal, 3 to 90 ng/dL), androstenedione was 207 i. ^/ o7 w4 S: R( r( A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) f: I2 M7 ~1 G+ m8 W/ _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 s8 v: _8 D. |$ Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 L& ~2 c5 Z: A: N$ h49ng/dL), 11-desoxycortisol (specific compound S)
/ k7 \5 s+ w8 a: l1 N$ }. u" S/ mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: ?, k* ]8 g( d8 Z, P4 jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# |% C) B4 |- }0 K- g8 btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. a, t& f, g; ]! ~
and β-human chorionic gonadotropin was less than
3 X1 z& u8 @2 ]" d( z' w5 mIU/mL (normal <5 mIU/mL). Serum follicular) l# O7 r/ ]; T, y; e, J: L! m. ?
stimulating hormone and leuteinizing hormone
5 v: H' u! r2 R( `" t9 z- d+ _7 |concentrations were less than 0.05 mIU/mL
$ t/ [5 o# q6 }% o(prepubertal).
# F" L% ~$ e3 XThe parents were notified about the laboratory
7 I/ {9 ?5 X/ |, ?7 ]& K& y6 s2 i+ eresults and were informed that all of the tests were. q7 {3 X+ Q& K/ r/ o
normal except the testosterone level was high. The$ I( G# j" w% ~: H5 m9 a5 S6 g6 e- m5 t
follow-up visit was arranged within a few weeks to
# o+ w9 ^1 M2 R: f0 m5 ?; o  D! L6 cobtain testicular and abdominal sonograms; how-4 y4 g, |! A1 }  H, Q, o" A
ever, the family did not return for 4 months.' c/ C( H$ i- H
Physical examination at this time revealed that the: S3 q# w( n. I5 Y* u
child had grown 2.5 cm in 4 months and had gained
+ k2 `) k; I; g8 h( e# O2 kg of weight. Physical examination remained/ V5 R% N+ }7 g4 x1 |# v
unchanged. Surprisingly, the pubic hair almost com-' j$ g, b5 A. [
pletely disappeared except for a few vellous hairs at# C, r( \: \3 u: Y& k$ R8 `
the base of the phallus. Testicular volume was still 2
  U7 ~% q2 i3 H: X- imL, and the size of the penis remained unchanged.
  p7 F' q& W7 E' S# c% s! wThe mother also said that the boy was no longer hav-
1 f' u+ B: s. K6 Y* Ging frequent erections.
/ C1 X8 t, G& g0 _Both parents were again questioned about use of# v' m9 i$ @6 h# G; y
any ointment/creams that they may have applied to
" I& P. V+ F$ o! H# `6 Kthe child’s skin. This time the father admitted the
6 X8 V. U' [/ w4 \+ S/ fTopical Testosterone Exposure / Bhowmick et al 541
) P* M2 _2 O  b# Z' [( t% Ause of testosterone gel twice daily that he was apply-
5 E) ~) I5 _6 _+ ^, R2 Ning over his own shoulders, chest, and back area for) v( D+ a' J& k1 b% O
a year. The father also revealed he was embarrassed
% j, v  n5 J' u$ }! q+ Mto disclose that he was using a testosterone gel pre-% M; T% R! Y0 Y2 Y5 E3 E
scribed by his family physician for decreased libido
0 M) q' }6 x$ y9 d- Csecondary to depression., T2 O! U' j/ x  U
The child slept in the same bed with parents., [/ @9 E1 F1 U, {) R! x- W
The father would hug the baby and hold him on his
8 h. @, J- q) i/ g) nchest for a considerable period of time, causing sig-0 _5 q" f/ P+ q$ w3 O6 {
nificant bare skin contact between baby and father." w# T* S7 T, `2 V# w" W
The father also admitted that after the phone call,
5 t5 Z( N) X2 }! pwhen he learned the testosterone level in the baby0 L1 g0 l( t- K4 E- x; N
was high, he then read the product information
7 _8 I1 y" V  g5 K$ Kpacket and concluded that it was most likely the rea-% g% z7 R& V! t! A) D  }
son for the child’s virilization. At that time, they
. n  C* i% @3 P" |8 ]decided to put the baby in a separate bed, and the
0 x; F8 [: |; V6 T2 V+ Z) qfather was not hugging him with bare skin and had
/ F8 H( C: a$ Ubeen using protective clothing. A repeat testosterone9 L0 p* h! m8 {$ t8 y: m# {0 A
test was ordered, but the family did not go to the
; ^: {1 _4 u/ ylaboratory to obtain the test.4 z! J- f; n( w5 j
Discussion
1 E* \, L( U" V8 j9 Z- m* p- c; QPrecocious puberty in boys is defined as secondary+ l* a2 O* ^# p4 S* J
sexual development before 9 years of age.1,4
4 V7 v- r( H/ c, p6 i8 f7 g3 KPrecocious puberty is termed as central (true) when
' c3 y' ?; D9 }; t; l+ Iit is caused by the premature activation of hypo-/ `8 b; n( }6 T" D
thalamic pituitary gonadal axis. CPP is more com-
# T2 E8 [/ I) L% }mon in girls than in boys.1,3 Most boys with CPP
% W, A) B9 c/ |: c7 D6 u$ Cmay have a central nervous system lesion that is1 p+ ^& O, ^! ]
responsible for the early activation of the hypothal-
, s1 q! w6 b, j# ~; kamic pituitary gonadal axis.1-3 Thus, greater empha-
7 Q8 P5 {4 r5 csis has been given to neuroradiologic imaging in
$ X& A1 D8 o, l& tboys with precocious puberty. In addition to viril-
' h7 Q; V4 N2 m+ i3 A0 s3 Hization, the clinical hallmark of CPP is the symmet-- o# r5 }; k9 [4 K0 Y1 a7 R, z
rical testicular growth secondary to stimulation by" d, o7 {# ?& Z1 i2 W
gonadotropins.1,3
  Q) m* k, a" u9 sGonadotropin-independent peripheral preco-; u! A1 n5 m& _% H4 D! P/ w, i4 G
cious puberty in boys also results from inappropriate. R0 [' l7 u) q9 }
androgenic stimulation from either endogenous or
; q9 {1 D( a. i5 v$ g( p3 y- Gexogenous sources, nonpituitary gonadotropin stim-1 K- R7 \$ o9 O" t6 I& d1 q
ulation, and rare activating mutations.3 Virilizing: e# q, q0 v: @0 l. R( r
congenital adrenal hyperplasia producing excessive% s  e) s  h( K9 F
adrenal androgens is a common cause of precocious
* `' s3 Z& Z* @7 mpuberty in boys.3,4
! ~4 C; F) j0 t; RThe most common form of congenital adrenal5 X( r( ~0 U4 V; W, P" i- m6 f% r
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 R; R/ n# Z, G7 q+ [3 zThe 11-β hydroxylase deficiency may also result in% y8 G3 y0 ?( s; |, ]
excessive adrenal androgen production, and rarely,! P' |: d. X+ u& q
an adrenal tumor may also cause adrenal androgen& A3 X% F/ ?6 J- s0 x; T
excess.1,3
( h+ H" h' ~0 _: }9 c  e: m4 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! I7 N" I/ e, O: F
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: S- ]% ^$ w& S  c& Y( cA unique entity of male-limited gonadotropin-0 |; B) Q% T  x8 D' k$ m% ~0 d
independent precocious puberty, which is also known
) Q; m6 K4 q9 i$ Z7 Qas testotoxicosis, may cause precocious puberty at a, E  I- x4 n7 W2 H6 p' z' t
very young age. The physical findings in these boys
' g) I9 l( L5 q# q9 a& G7 pwith this disorder are full pubertal development,
% j) ?. s: \# G) Z6 F6 tincluding bilateral testicular growth, similar to boys
  N! p+ h+ i' Y2 v, u( z) Wwith CPP. The gonadotropin levels in this disorder; S% @7 P, Z, a, J  A
are suppressed to prepubertal levels and do not show) {  q- ~+ V, a0 M. p
pubertal response of gonadotropin after gonadotropin-
  C* Z: [& e+ b+ }releasing hormone stimulation. This is a sex-linked$ ~) `9 v/ \( b( g% Z/ H$ h3 ?
autosomal dominant disorder that affects only3 c. |# _# p: {4 i
males; therefore, other male members of the family
& f$ L; I5 _6 q! P0 Hmay have similar precocious puberty.3
3 O/ b* F* ?8 @+ NIn our patient, physical examination was incon-
) t% |* x0 S8 Y! vsistent with true precocious puberty since his testi-
1 W3 h+ z  q  i% @cles were prepubertal in size. However, testotoxicosis
# n1 O* c4 o% D( G! Rwas in the differential diagnosis because his father- m$ U' a* X) L) T  a7 U: [$ R
started puberty somewhat early, and occasionally,
0 @* W: e+ I7 n  D7 T9 U5 Ltesticular enlargement is not that evident in the
' Y+ Y- r  l6 j, ?, bbeginning of this process.1 In the absence of a neg-3 j5 L8 Q8 ^! X& C' O+ Z! h( L1 l& k: S
ative initial history of androgen exposure, our# @$ D1 ^( d/ q9 O
biggest concern was virilizing adrenal hyperplasia,$ H" x" O3 {: ?& e* u
either 21-hydroxylase deficiency or 11-β hydroxylase# T! m( A! _1 J( V& S- R
deficiency. Those diagnoses were excluded by find-( |/ k5 Y6 U$ `3 }
ing the normal level of adrenal steroids.$ n' ?" i0 @$ X! s1 p6 r
The diagnosis of exogenous androgens was strongly
/ p( {$ ]2 h& Z1 u  H3 }, ksuspected in a follow-up visit after 4 months because2 o' F. _0 r  Y( G: ]/ X! r, q7 a
the physical examination revealed the complete disap-
; ~% _; Z) I4 ]* G* {& Z8 |% \: x% Ipearance of pubic hair, normal growth velocity, and
$ Y+ @4 f4 U, b  B" _8 Ddecreased erections. The father admitted using a testos-
' E9 ^$ A" Z2 I% k- t6 eterone gel, which he concealed at first visit. He was! S% `* @- w& _; i, S; G" H
using it rather frequently, twice a day. The Physicians’
5 k/ x, m, K- t- MDesk Reference, or package insert of this product, gel or
4 ~7 g- O& }3 Y% j8 F" y2 M. o* jcream, cautions about dermal testosterone transfer to
0 C1 H+ ~8 A* p; v6 Q4 uunprotected females through direct skin exposure.
, H0 c+ g8 @: B% K6 ^% k: vSerum testosterone level was found to be 2 times the4 R0 r( L$ N0 f. ]6 \
baseline value in those females who were exposed to
, ~0 h7 e5 g: K- s$ l0 Qeven 15 minutes of direct skin contact with their male
, r  w. s; b4 y6 S: `' U2 ~partners.6 However, when a shirt covered the applica-( X% E. R6 w& B( P* H& V0 Y8 j5 m- V
tion site, this testosterone transfer was prevented.
: E. G% L/ D, M& r1 q4 k4 S' TOur patient’s testosterone level was 60 ng/mL,
- V4 s2 Q0 u6 j' w9 m- K3 _$ n1 a! jwhich was clearly high. Some studies suggest that/ e# R& P+ k2 K0 ~! x. D  ]! k
dermal conversion of testosterone to dihydrotestos-9 H7 V/ D6 A- }7 S$ M1 E& Q
terone, which is a more potent metabolite, is more# ^3 a) [8 o3 o0 N) e3 \9 [3 A
active in young children exposed to testosterone2 H, g3 \/ u1 q0 Q' P
exogenously7; however, we did not measure a dihy-2 T  T1 g# b0 E) H. C2 e% H
drotestosterone level in our patient. In addition to, s9 I6 q. Z# N/ Q7 R6 a
virilization, exposure to exogenous testosterone in
- Q- ]. }! _* W$ M, k, K( L0 rchildren results in an increase in growth velocity and4 I. r+ g" w" n& g2 d: ?2 m
advanced bone age, as seen in our patient.
  p5 @  H4 h* A2 T6 N) HThe long-term effect of androgen exposure during
8 L/ n/ p! E$ bearly childhood on pubertal development and final
9 j" M) ]" A# |7 nadult height are not fully known and always remain
" p$ `2 H  i! b' t" ia concern. Children treated with short-term testos-
) r5 L4 c# s6 r6 g! p7 ?$ yterone injection or topical androgen may exhibit some" S' ?( H8 F, s  }8 b
acceleration of the skeletal maturation; however, after
0 Z0 z0 y8 D1 b8 V6 Tcessation of treatment, the rate of bone maturation
4 o" l- v; J0 L$ s+ l2 W$ N" bdecelerates and gradually returns to normal.8,9
4 ~- Z0 J$ ^& U6 m- JThere are conflicting reports and controversy
& J9 a1 r, V6 n: Y! g. G, i' Fover the effect of early androgen exposure on adult
; @6 ^+ }# U! g& c6 c" Mpenile length.10,11 Some reports suggest subnormal
: u- v' X3 M! |4 F" _adult penile length, apparently because of downreg-0 ?9 E% c/ D* M& w2 [
ulation of androgen receptor number.10,12 However,# Y5 |) v5 ^; W6 Z; j4 T
Sutherland et al13 did not find a correlation between
, l& |. v1 S- J/ {. l: X4 schildhood testosterone exposure and reduced adult/ H, o+ L& q+ I! D% D
penile length in clinical studies.; M3 T/ o5 m- S% K2 L7 k) R+ X, V
Nonetheless, we do not believe our patient is& m; }4 m# m) [' M1 |" x% S
going to experience any of the untoward effects from
$ _5 a. t9 H! ~- R4 o- r: L4 Ktestosterone exposure as mentioned earlier because' K6 d! l: N' Q  n6 W% W
the exposure was not for a prolonged period of time.
0 Y" z! q( z' @' I" ^Although the bone age was advanced at the time of
! ~& @: R2 }9 u/ Zdiagnosis, the child had a normal growth velocity at
, j, J; c! T' b, x5 Cthe follow-up visit. It is hoped that his final adult
2 J2 r( O6 H( o7 S' h2 T; Uheight will not be affected.9 ?" T. ?: [" D& O' F9 i( O
Although rarely reported, the widespread avail-
; a$ `- k& q: `/ l" t1 nability of androgen products in our society may, ?7 ~: V+ a+ }" u& K. T
indeed cause more virilization in male or female! J$ t) @7 T; U9 R
children than one would realize. Exposure to andro-
1 w- R& R( r: Xgen products must be considered and specific ques-
* d( V2 l" j2 D# V. qtioning about the use of a testosterone product or
- V( }$ R* y$ d' q2 d. X* Rgel should be asked of the family members during
+ x* a$ i7 s0 Q! R6 Jthe evaluation of any children who present with vir-
' ~3 {) j, z0 ~# t2 H. y6 J- rilization or peripheral precocious puberty. The diag-
1 m- t% T) j  P4 Xnosis can be established by just a few tests and by
! h. p& z1 [$ w7 C; i3 uappropriate history. The inability to obtain such a
% a+ N6 ]( ?5 @) {: g0 Q+ Thistory, or failure to ask the specific questions, may9 n5 v, T; q& U1 ^* q) m6 m5 ]
result in extensive, unnecessary, and expensive
5 I! a2 \! q7 ?  x$ {- Ginvestigation. The primary care physician should be! ^2 ?) z3 Q: r9 r
aware of this fact, because most of these children: T7 ]8 D$ [# O
may initially present in their practice. The Physicians’2 x" E4 k. }" @( l7 `
Desk Reference and package insert should also put a9 Q1 G  j) V# d3 j# |. T% Q3 h* R
warning about the virilizing effect on a male or9 s3 U! G) Z) x9 W
female child who might come in contact with some-
2 C* t. U- G+ t$ j8 A7 |0 ]  {one using any of these products.
1 F! @1 R. G8 R3 ]- \# c) DReferences
& x/ B# ?+ x% I! b7 q  L1 {$ I8 R1. Styne DM. The testes: disorder of sexual differentiation( Q8 s  L+ Q& P2 r. J
and puberty in the male. In: Sperling MA, ed. Pediatric! j' M) m7 ^* B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% N7 K  {' W0 V7 Y0 {+ d2002: 565-628.7 Y$ D1 M2 t9 v+ H, H
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; R: i6 I# @. C2 e
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
4 m9 O0 C* P% v( s7 @Boy Induced by Indirect Topical
0 [/ r8 j/ H: n  ^1 V3 B( t5 g1 mExposure to Testosterone
* K, \! o3 Q! r4 c7 i1 s7 _% lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  T8 R: `+ R5 l! B0 c7 |
and Kenneth R. Rettig, MD1
3 Q, a0 v4 Y2 bClinical Pediatrics
/ e3 S& p9 N* fVolume 46 Number 61 q1 G/ @$ t& U8 P2 ]6 H% v
July 2007 540-543
7 i& \2 \1 @7 S! t© 2007 Sage Publications* j* i! C% ^* L0 i& H% n( y- n
10.1177/0009922806296651( i0 r3 T7 O( v7 `& u6 f  ?
http://clp.sagepub.com0 e2 x7 ~/ a2 }+ L
hosted at. z, o9 Q- c) Q8 v
http://online.sagepub.com
6 Q* [1 r; R$ g4 y) M4 vPrecocious puberty in boys, central or peripheral,
" R2 T  x- g# W( J1 ]is a significant concern for physicians. Central
8 i' `- p4 M6 y, S" Q# Z9 }precocious puberty (CPP), which is mediated
) D/ z4 D1 f) J# n* z8 zthrough the hypothalamic pituitary gonadal axis, has
1 t- l" J/ z6 {a higher incidence of organic central nervous system3 v  k$ o" F. b' G5 ~* o) r6 X
lesions in boys.1,2 Virilization in boys, as manifested$ j" w7 ^- j/ e3 d8 R
by enlargement of the penis, development of pubic- c1 W. ?$ e( {7 e0 s. N% |
hair, and facial acne without enlargement of testi-7 Q* v, e0 N" c5 I" U
cles, suggests peripheral or pseudopuberty.1-3 We- A& A6 Z/ h" P$ z$ R3 q
report a 16-month-old boy who presented with the( A: |  K* I6 o: F) I
enlargement of the phallus and pubic hair develop-
+ {$ k' e5 F( C3 p! Lment without testicular enlargement, which was due' I2 I+ s8 _1 b% H) F
to the unintentional exposure to androgen gel used by
2 r) y* ~* {# p0 hthe father. The family initially concealed this infor-$ d9 [, I2 `' K
mation, resulting in an extensive work-up for this  D5 X' n+ h3 h# E' K% w* l- \
child. Given the widespread and easy availability of% o  Q6 g, `: S% W- q/ ~
testosterone gel and cream, we believe this is proba-& [& o$ S3 F: e9 }0 v
bly more common than the rare case report in the
% a0 h- r' V8 J! b2 \7 Uliterature.4) ]9 X, e8 s" p9 \" D$ ]4 E
Patient Report2 U0 p( e2 m& h; q6 M
A 16-month-old white child was referred to the
2 e" B: L2 w2 n2 Tendocrine clinic by his pediatrician with the concern$ B' F" s0 H+ _! C; m
of early sexual development. His mother noticed3 `3 _5 Y3 s; x" ^
light colored pubic hair development when he was
% W3 \# f* x) o3 T$ `From the 1Division of Pediatric Endocrinology, 2University of
3 n/ W/ l; Y0 z4 @South Alabama Medical Center, Mobile, Alabama.
9 T: G. W) X' O  R. VAddress correspondence to: Samar K. Bhowmick, MD, FACE,2 ?  w% U1 h! y5 q/ t6 D" ~
Professor of Pediatrics, University of South Alabama, College of
4 f8 I$ G" y' kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 c0 z3 M' A" v2 F
e-mail: [email protected].: P6 u" P9 Z. F' O# S
about 6 to 7 months old, which progressively became
2 l. F) K3 C8 T6 d7 T! ~darker. She was also concerned about the enlarge-
* d" Z% D, e$ @! ament of his penis and frequent erections. The child  E% f2 G- O# w  H0 t% o$ H
was the product of a full-term normal delivery, with7 b$ x! M# |" V  Y6 |: F
a birth weight of 7 lb 14 oz, and birth length of
  G% ^. `8 ]  p+ h1 Y20 inches. He was breast-fed throughout the first year
: u/ l; \  V( I" j, Mof life and was still receiving breast milk along with  y2 I' c8 ]8 {6 L. i8 ^3 \
solid food. He had no hospitalizations or surgery,
3 P' S9 i9 y, C1 fand his psychosocial and psychomotor development) h# j8 F8 @5 _/ K5 E8 _, \# U
was age appropriate.2 N5 R/ {7 |- X+ s( D5 {
The family history was remarkable for the father,% Z' ~) T6 s9 H4 X
who was diagnosed with hypothyroidism at age 16,
, A/ A( b, w/ i( R- |! I4 bwhich was treated with thyroxine. The father’s
  w: ]8 Q6 g* \1 j* Mheight was 6 feet, and he went through a somewhat
' J2 P+ Z! C0 @# A1 }& learly puberty and had stopped growing by age 14.
# V8 h6 @+ C' uThe father denied taking any other medication. The
+ t1 Q; A; Q; |; L7 Wchild’s mother was in good health. Her menarche
: B- I' }4 N6 u$ o" n0 a9 H  P3 fwas at 11 years of age, and her height was at 5 feet- N& N% L- W2 Q9 j4 K4 \: a
5 inches. There was no other family history of pre-
' X. q  Q, }) V+ O8 ~5 ococious sexual development in the first-degree rela-0 Z# D- E" K+ S8 }/ h( q; O- T
tives. There were no siblings.
  g; Y, x& @; V: ]Physical Examination* y  P# G' b, Z5 I; m/ Y! r2 ?
The physical examination revealed a very active,
; u, s% Z+ W( s0 H. b8 @& Eplayful, and healthy boy. The vital signs documented
4 A3 z" O8 k, k  ja blood pressure of 85/50 mm Hg, his length was
. t# R9 E& }& {1 Q! a8 b2 n90 cm (>97th percentile), and his weight was 14.4 kg
3 t- F6 K0 @, K# q1 R9 J6 v; _(also >97th percentile). The observed yearly growth8 v9 {! @$ g$ M% d
velocity was 30 cm (12 inches). The examination of
+ \3 [) n9 J, P. Z" kthe neck revealed no thyroid enlargement.& O0 b8 O3 z( x8 _2 [3 Y. U! S" P, T% T
The genitourinary examination was remarkable for; g3 g) V, B, `8 ~$ Q+ E0 w9 u" \
enlargement of the penis, with a stretched length of  \0 [9 Z+ A& a( k$ \; `
8 cm and a width of 2 cm. The glans penis was very well: ~. O1 V% a; O! ]6 c, c
developed. The pubic hair was Tanner II, mostly around: I% D7 N5 l7 {* L4 w
540
* D. R: J- d. E& B5 A' B( kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ l! U. [# G2 |% l7 \0 q8 W
the base of the phallus and was dark and curled. The
9 k: X/ E& n1 u0 u2 Ptesticular volume was prepubertal at 2 mL each.- L3 r; B  c+ ^! h+ S
The skin was moist and smooth and somewhat: O3 W# _# @* Y# i9 d) `
oily. No axillary hair was noted. There were no0 ?+ N  ], _* v; j9 D
abnormal skin pigmentations or café-au-lait spots.
, J' @0 ~& \8 f" a+ F6 ]! Q2 pNeurologic evaluation showed deep tendon reflex 2+: {$ w/ D# y, l6 \( X5 s
bilateral and symmetrical. There was no suggestion2 x+ n& J* m, H; s4 U
of papilledema.$ U9 y. G9 P$ u/ ?
Laboratory Evaluation
' [4 o1 a. n( [* q& h% K' d' gThe bone age was consistent with 28 months by
' E( P. i# P$ a9 J; u5 p- Qusing the standard of Greulich and Pyle at a chrono-( C% p4 m* }* }1 C/ `+ J! P4 A
logic age of 16 months (advanced).5 Chromosomal2 z, B9 L$ q5 ~  i
karyotype was 46XY. The thyroid function test
5 y' e* {6 ]7 X) pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
' h/ E8 T, o) N) ?lating hormone level was 1.3 µIU/mL (both normal).
/ {! W" j" q" W; T! z- H# [  B/ lThe concentrations of serum electrolytes, blood
- _5 Q5 C: ?. U. H# h8 N! ~4 s* Purea nitrogen, creatinine, and calcium all were( s# z4 y' s8 S5 K& G/ X7 {& ?2 u' ^
within normal range for his age. The concentration3 m% m& o- ^5 J; F
of serum 17-hydroxyprogesterone was 16 ng/dL
/ g3 r$ r. F+ q8 z+ M(normal, 3 to 90 ng/dL), androstenedione was 204 w8 ~! ^0 s: J/ J' t4 {2 z- k; q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ t1 }5 ~7 s" v; iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 j, t, s: E8 d1 j' u4 l# p1 sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 h0 R/ v& L) q7 n49ng/dL), 11-desoxycortisol (specific compound S)
( ?$ O/ I9 y+ W% C2 K2 \- Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- z- c* [: `! Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 m+ n1 w+ h; r2 q! z: ~' j0 {, J6 v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! q2 N/ c4 F9 D+ I' {5 C6 C$ @7 |
and β-human chorionic gonadotropin was less than
) ?& a$ A0 L) V/ N' M$ T5 mIU/mL (normal <5 mIU/mL). Serum follicular6 Z+ s1 o" g( {. J; n
stimulating hormone and leuteinizing hormone
* Q  x  K+ s+ g* S. s5 U- {concentrations were less than 0.05 mIU/mL
, t2 O% H% b: w0 N$ f9 R(prepubertal).+ f# j% W0 v) ^' O2 d5 |
The parents were notified about the laboratory( }1 f* K) d5 O( c+ H; F
results and were informed that all of the tests were" y  Z" W, B: `: H/ H5 q
normal except the testosterone level was high. The
1 P, \; ~2 N7 R( E, c( Vfollow-up visit was arranged within a few weeks to; l' R; x/ l/ v
obtain testicular and abdominal sonograms; how-
/ N7 n7 r8 R  F! X, jever, the family did not return for 4 months.; T- U( ~8 k6 ~+ q8 W/ Z
Physical examination at this time revealed that the
3 R% B* q) k0 r; G5 k7 @  b9 q' u* echild had grown 2.5 cm in 4 months and had gained
+ {. ^6 i, z4 H8 z' g" k2 kg of weight. Physical examination remained3 D" y4 ^; X5 z. q& A& m
unchanged. Surprisingly, the pubic hair almost com-7 z$ R2 D% H9 {$ n
pletely disappeared except for a few vellous hairs at
1 U' d( E! R0 I2 t- k& Rthe base of the phallus. Testicular volume was still 2
' ~" O' f" s1 M- k1 F2 XmL, and the size of the penis remained unchanged.
. H; Y" w7 v1 {8 G0 t3 `The mother also said that the boy was no longer hav-
1 O& y, u5 k3 I/ U3 U* bing frequent erections./ e) D) y- h+ M' N% r" s
Both parents were again questioned about use of& M; A- c; ^" }" _1 H' @4 Z0 T
any ointment/creams that they may have applied to
  s2 J; o( c. z4 C; nthe child’s skin. This time the father admitted the
# k0 f5 D( C% j8 c$ A7 W/ m" _Topical Testosterone Exposure / Bhowmick et al 5412 d5 v& V$ `7 ?7 K6 x5 x
use of testosterone gel twice daily that he was apply-
* u; ~* z8 V& Ting over his own shoulders, chest, and back area for; z" P' g& I. W! L
a year. The father also revealed he was embarrassed/ J& Y& i& ]8 ~+ [* |
to disclose that he was using a testosterone gel pre-
( l/ q/ I, O1 F9 k5 v! Lscribed by his family physician for decreased libido
( q: ?/ k1 P' w- l3 v3 M9 T% y6 Nsecondary to depression.
' \( G/ W. L2 q2 ZThe child slept in the same bed with parents.
9 }+ F$ q0 ?" wThe father would hug the baby and hold him on his' f" w4 o  L+ @( U2 \$ J
chest for a considerable period of time, causing sig-  k: Q# f1 n: y( J! j' h& O
nificant bare skin contact between baby and father.
. X9 `+ I% n: R7 ?1 `) R6 QThe father also admitted that after the phone call,  T3 ?% H- i0 [/ c
when he learned the testosterone level in the baby
2 a' E3 C# E" W- x2 J: h( swas high, he then read the product information2 g: b1 g( ?4 V5 G" m6 h
packet and concluded that it was most likely the rea-
8 F6 u/ \$ t/ y2 A$ v& d* Rson for the child’s virilization. At that time, they* |5 R4 b8 ^* |! B
decided to put the baby in a separate bed, and the
7 j8 f" \& [. u' H# {5 C  Mfather was not hugging him with bare skin and had% o  o# J; m- T/ D$ L
been using protective clothing. A repeat testosterone# j# k6 o. O6 s9 k4 i) |- {
test was ordered, but the family did not go to the7 Q: V5 T0 x- I1 M& X
laboratory to obtain the test.
1 s5 u% f2 G! [* B+ h& jDiscussion4 e+ f/ z2 e+ A( Y4 k7 S
Precocious puberty in boys is defined as secondary
! h7 T5 ]+ C  r& I, c3 Tsexual development before 9 years of age.1,4* G, w6 _# r8 H1 v
Precocious puberty is termed as central (true) when
2 ^0 D' Y% C7 _" Iit is caused by the premature activation of hypo-
( L3 H8 Z; I" [; G  C, c+ Jthalamic pituitary gonadal axis. CPP is more com-! _0 f; L5 o' G3 @
mon in girls than in boys.1,3 Most boys with CPP3 c$ s7 ]! R, Q" o! Q
may have a central nervous system lesion that is: L2 j% M( i& x- _, q1 ?
responsible for the early activation of the hypothal-
- \1 p- n5 h# w5 J% q* [. Y0 ramic pituitary gonadal axis.1-3 Thus, greater empha-
1 O9 }) H, e: D$ R: S" ysis has been given to neuroradiologic imaging in
) d/ k) M7 ?2 jboys with precocious puberty. In addition to viril-- K' q7 r/ r% J- [# R/ u$ l
ization, the clinical hallmark of CPP is the symmet-) j  ^% V' C2 w$ Y
rical testicular growth secondary to stimulation by
/ u; }3 l( ^: q. A6 F# S* Cgonadotropins.1,34 y/ Y' {* w) N8 I/ D* N, j
Gonadotropin-independent peripheral preco-
' E! W& i+ l( \! ]3 k# p7 W4 ecious puberty in boys also results from inappropriate' K+ t* D7 Y0 G. C! P5 Z; I
androgenic stimulation from either endogenous or
% o+ f3 a. ^5 X: s2 `7 ?exogenous sources, nonpituitary gonadotropin stim-
3 K: B- n" i% J+ ?0 v4 J" J) t% c  wulation, and rare activating mutations.3 Virilizing2 q4 E5 H0 e: b& x$ p1 a6 x1 ~) z6 f
congenital adrenal hyperplasia producing excessive
8 J; M, v3 x4 i4 {3 ]adrenal androgens is a common cause of precocious  ]5 M) ~$ k. C7 P7 A
puberty in boys.3,4
; {, l. n: G+ V% q+ ?6 v$ IThe most common form of congenital adrenal
% c6 p0 `  X/ J. _% X/ {5 _hyperplasia is the 21-hydroxylase enzyme deficiency.: W) o9 C9 Y6 T0 C
The 11-β hydroxylase deficiency may also result in1 T$ W% u8 }! d4 Z: D
excessive adrenal androgen production, and rarely,
6 X# a" P$ t7 r' R- [$ M+ _an adrenal tumor may also cause adrenal androgen
' |1 _* l7 w' b9 t5 i% u8 t* A2 zexcess.1,33 p2 x6 q# x6 g* E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' |8 E3 Q5 ~- w% b& _! r2 ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" H# d% p' e( w! F" c# z- B
A unique entity of male-limited gonadotropin-. {0 T, K" m0 p2 R5 X
independent precocious puberty, which is also known8 V1 H; _2 [  f+ a" B$ k6 j
as testotoxicosis, may cause precocious puberty at a+ R6 P0 |+ i: b% Q( N; K
very young age. The physical findings in these boys8 v* A, L1 |( \, k% f% c; M+ h
with this disorder are full pubertal development,
% I! \  @9 I: y. G& s0 ^: Fincluding bilateral testicular growth, similar to boys8 w5 c, v) v7 \, S" _' O1 B. K
with CPP. The gonadotropin levels in this disorder, m5 g# [# [% e( F1 L6 F
are suppressed to prepubertal levels and do not show
8 H' l2 |, Y8 a" p0 L- ^7 \5 y+ @pubertal response of gonadotropin after gonadotropin-" d. j  `+ f  s4 U3 r
releasing hormone stimulation. This is a sex-linked6 D& e- r2 `: i
autosomal dominant disorder that affects only: D  ^. d7 i: Y" b% o: e4 k. N
males; therefore, other male members of the family: s. h' b: d0 j: u) A0 U5 b  p
may have similar precocious puberty.34 {1 N. \5 n+ s# c- ~
In our patient, physical examination was incon-
3 k) M- F8 a8 k2 c" A" `! _% lsistent with true precocious puberty since his testi-5 F! K0 k3 l4 D, g  ?8 y
cles were prepubertal in size. However, testotoxicosis# k, ?( y) U4 [/ i* [: W6 E# U1 Z; V
was in the differential diagnosis because his father
1 ^, ^1 G+ y! n# X' H% \; rstarted puberty somewhat early, and occasionally,2 o+ f# x2 |: Y
testicular enlargement is not that evident in the$ r( G7 V9 L% `6 I! `, @
beginning of this process.1 In the absence of a neg-( \& _- R; c9 q% j& L: c
ative initial history of androgen exposure, our
" d  B/ H7 n- {- M2 b: ~( o6 wbiggest concern was virilizing adrenal hyperplasia,
" S& a" c3 |6 u$ y6 g' oeither 21-hydroxylase deficiency or 11-β hydroxylase' P4 i( N7 b: V  U
deficiency. Those diagnoses were excluded by find-; W3 [9 _" O- W. s, H! h
ing the normal level of adrenal steroids.
" Q) x8 t5 q8 @! \2 r3 x8 sThe diagnosis of exogenous androgens was strongly- D2 L3 P  ^* ~) f5 Y" @
suspected in a follow-up visit after 4 months because* x, k+ z; f$ A. q; f, Q( B$ |
the physical examination revealed the complete disap-4 i' h) B. y/ g7 d0 K
pearance of pubic hair, normal growth velocity, and) }$ N/ O6 }+ l( o1 O% B
decreased erections. The father admitted using a testos-9 X' K8 i1 o7 T( l4 s+ q; z* V0 q
terone gel, which he concealed at first visit. He was# K( m/ x7 a8 M! X
using it rather frequently, twice a day. The Physicians’' n$ q; G$ e5 X0 g
Desk Reference, or package insert of this product, gel or
3 l' N3 ]/ U" L4 }cream, cautions about dermal testosterone transfer to9 z  }" Z. `5 m9 w3 w
unprotected females through direct skin exposure.1 h, @3 `: H1 y+ \0 W/ Q
Serum testosterone level was found to be 2 times the: U: M4 `: ^( H, e
baseline value in those females who were exposed to1 h9 r/ Z! ~  ]" x2 n! R9 w
even 15 minutes of direct skin contact with their male- }: A, n" W" ~  _% J
partners.6 However, when a shirt covered the applica-5 `& g" d$ |* ^, h2 m
tion site, this testosterone transfer was prevented." {: E  d% E1 J; E+ Z& i
Our patient’s testosterone level was 60 ng/mL,( C2 r$ ^3 i* I" l$ D
which was clearly high. Some studies suggest that; [0 ?: F7 E4 E4 F
dermal conversion of testosterone to dihydrotestos-3 R* L$ k1 ]) a! q" C( f! Z
terone, which is a more potent metabolite, is more" O( g0 a1 N; u1 d1 W7 j8 |
active in young children exposed to testosterone
" c, C" I: j" P& K3 cexogenously7; however, we did not measure a dihy-( L: w5 U) k# V- W
drotestosterone level in our patient. In addition to
" |- E% p; H8 ]! u' t3 Bvirilization, exposure to exogenous testosterone in
4 @0 q; ?. w) b, W9 Wchildren results in an increase in growth velocity and
- m0 j" k' X# L$ F' `. jadvanced bone age, as seen in our patient.# I: G, }7 \, [& e" w' _
The long-term effect of androgen exposure during
; m+ W$ Y8 z  g6 h) ]! d" l1 |early childhood on pubertal development and final7 S4 x# ]6 V% ^; v( Q& D
adult height are not fully known and always remain( u* M8 |! ~, l$ o) l* L; _0 @: z" X
a concern. Children treated with short-term testos-
. I0 Z3 d% j' @% ]- `terone injection or topical androgen may exhibit some
8 m6 W; h% i' _' Dacceleration of the skeletal maturation; however, after
' w4 i, J1 c/ R2 k7 _$ m( ~cessation of treatment, the rate of bone maturation
, v9 b6 v+ F5 w9 B7 \4 o8 adecelerates and gradually returns to normal.8,9. j4 ?- ]! D% Z/ e0 K" ]
There are conflicting reports and controversy
! l* q: ~% B. M7 t1 I4 `9 Nover the effect of early androgen exposure on adult/ T0 }# j& |+ A+ S
penile length.10,11 Some reports suggest subnormal
* C! F) j7 q8 J4 U# O9 N( Iadult penile length, apparently because of downreg-
- d) x' D- w. G$ Xulation of androgen receptor number.10,12 However,
2 e$ ]6 y9 j, ]: U9 a2 ]Sutherland et al13 did not find a correlation between7 }4 ?; _: O8 r9 g
childhood testosterone exposure and reduced adult$ }# Y. c0 Q) B3 N: \
penile length in clinical studies.
4 E) L) B# w& a! CNonetheless, we do not believe our patient is9 S. b6 }$ v( f2 l2 r
going to experience any of the untoward effects from- e" x1 e: h& `# l+ l1 [# |4 Z
testosterone exposure as mentioned earlier because, D) f" D  h; C* ], A
the exposure was not for a prolonged period of time.' `3 K1 |7 h$ q: i% ^, H- p
Although the bone age was advanced at the time of# q5 {' G% M5 i; `2 h* q
diagnosis, the child had a normal growth velocity at
4 e9 f  G& K9 \5 ^the follow-up visit. It is hoped that his final adult& }: n6 R9 G4 F. W3 {" {0 x
height will not be affected.
3 Y: M1 Y6 V$ S- bAlthough rarely reported, the widespread avail-' W$ l, n. W/ P% r$ D
ability of androgen products in our society may# i/ d3 h& t  j0 i
indeed cause more virilization in male or female9 K; O# `; P* h3 U0 E) u% F" ~4 ~* S
children than one would realize. Exposure to andro-$ s5 g% Y  M9 E2 W3 I' V
gen products must be considered and specific ques-
! M' {& S% m4 g7 L% H/ ^: Y8 k/ Etioning about the use of a testosterone product or2 |% x( ^7 K& a% F# _! Y
gel should be asked of the family members during7 c+ p9 _& {: @+ u/ A6 Z: |6 E$ S
the evaluation of any children who present with vir-0 ]: u6 U' S, n
ilization or peripheral precocious puberty. The diag-! X' v3 D( k% K/ y
nosis can be established by just a few tests and by
2 w9 N; d' h. K# a& I; C1 h! Pappropriate history. The inability to obtain such a$ A+ S! f9 m% F
history, or failure to ask the specific questions, may7 D% _9 b2 {0 p$ n' {5 s$ v
result in extensive, unnecessary, and expensive  _1 b4 ?* _% b8 R9 @2 O( i6 G
investigation. The primary care physician should be6 d+ q5 S2 {# o
aware of this fact, because most of these children
- C$ b. |6 e: ^2 V6 w+ X0 x0 {) Qmay initially present in their practice. The Physicians’6 k2 ]  x. b+ ^! _9 R" j" s2 @3 H
Desk Reference and package insert should also put a% C8 N, O3 |* X7 x0 n
warning about the virilizing effect on a male or
! L: p; w6 ^- a9 a0 v& o9 `female child who might come in contact with some-& Y. G8 ?% X! d! V
one using any of these products.+ [' @4 @* K0 p6 \- L
References( l5 H) U) I1 V( _: B" E
1. Styne DM. The testes: disorder of sexual differentiation! b4 q2 F$ p4 K" C
and puberty in the male. In: Sperling MA, ed. Pediatric; ^/ r" n/ k" y3 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 y7 c# K1 I+ u  o/ ?) h6 ]
2002: 565-628.
3 w9 ?: s+ ^9 [8 R0 U* b2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 e7 ^1 u: Y- q, x3 k. X
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

( U6 a3 ~. x5 D. v; Q. N4 D9 m/ [0 [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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