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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
9 E$ Y9 v& J. i# g! R$ ~Boy Induced by Indirect Topical
1 u/ c+ K3 G7 B2 D% V+ O* y4 L0 LExposure to Testosterone
7 |3 X4 s' x, H4 [& ?/ QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 D' @' @, x' i1 ], ]# R
and Kenneth R. Rettig, MD1
) d) q. b. ?8 B: Y  N; ~Clinical Pediatrics; T7 F# d0 `: O6 x# u( G( Z
Volume 46 Number 6
; r* i. F4 Y' \4 |& j( bJuly 2007 540-543
) g& f+ c8 p( K© 2007 Sage Publications, n9 }5 M- S. D( A6 P3 w. n
10.1177/0009922806296651
6 l  z4 Y/ V! w# |* [http://clp.sagepub.com
# g& Z0 V8 z. o8 o' R, h& {hosted at9 ?) N+ \' B2 \
http://online.sagepub.com
( m% o5 n/ p7 L* X0 w' r) `0 tPrecocious puberty in boys, central or peripheral,
/ n) I# f# K, ?, q8 F* }" i; H* o% Cis a significant concern for physicians. Central; _6 y2 g  c6 ^% x
precocious puberty (CPP), which is mediated
/ W3 c. X3 ~6 Gthrough the hypothalamic pituitary gonadal axis, has( w% j4 Q* v# \" Z0 Z
a higher incidence of organic central nervous system3 h& c3 R8 D3 e4 U: M8 U
lesions in boys.1,2 Virilization in boys, as manifested
& U/ n: T/ n+ R) l2 u8 k, lby enlargement of the penis, development of pubic
' Z7 y3 J+ \( O+ F1 K; X8 U& thair, and facial acne without enlargement of testi-; B8 z" l. s' Y! n. B2 b* }
cles, suggests peripheral or pseudopuberty.1-3 We8 H& z5 t: q+ p1 p% {
report a 16-month-old boy who presented with the
& ~+ T. i/ H* d3 g% L% i( Menlargement of the phallus and pubic hair develop-
! ?* p7 p" B# p7 J$ @9 r! Q! ^ment without testicular enlargement, which was due
: m7 z+ Y5 }( S0 n0 \1 `0 ]to the unintentional exposure to androgen gel used by
+ i& K  G. w7 ?% l: ethe father. The family initially concealed this infor-# ^9 l- |2 p) g" ?  `3 L; l
mation, resulting in an extensive work-up for this' s  [- F$ J' T5 y8 P. D6 q
child. Given the widespread and easy availability of
* f/ H5 |0 s8 s, ytestosterone gel and cream, we believe this is proba-
. C: P! w0 \4 j7 ^# p" sbly more common than the rare case report in the8 I  G3 I& f" i. x
literature.40 K' R- R3 Z9 a7 b! Y6 M6 G* g
Patient Report" r6 p$ J4 b  k; h
A 16-month-old white child was referred to the) F' p9 \. R2 d  b3 o  o
endocrine clinic by his pediatrician with the concern0 B8 u: h9 \, T1 P6 L
of early sexual development. His mother noticed; G+ G7 }& x/ e0 i3 d/ H
light colored pubic hair development when he was3 N2 o' N0 Z7 C7 \, U2 {3 @. k
From the 1Division of Pediatric Endocrinology, 2University of, V3 Q" X* e' k+ u
South Alabama Medical Center, Mobile, Alabama.. R' h1 W1 X; f# D
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& t: q4 h5 d1 uProfessor of Pediatrics, University of South Alabama, College of
3 h8 ?9 H, f: P+ CMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( k2 O. f5 h" Z8 d, @
e-mail: [email protected].% V/ u* @" L* A  b0 D
about 6 to 7 months old, which progressively became
% s' I0 \* b( D5 }" Xdarker. She was also concerned about the enlarge-
" a, Q, @! C( @8 H4 [1 [; D& q' N2 Lment of his penis and frequent erections. The child
, o  V+ j. ]" \1 W2 u0 {+ jwas the product of a full-term normal delivery, with8 f- u6 K- ^2 o# Y* M! u7 U& p
a birth weight of 7 lb 14 oz, and birth length of+ S, ~& O  B2 l  L# `2 c( `
20 inches. He was breast-fed throughout the first year
& o" W. Y7 j. F# \of life and was still receiving breast milk along with
6 h. @8 ^6 q) z0 ]2 Osolid food. He had no hospitalizations or surgery,7 e0 C  W$ F3 A6 P7 T9 }. t
and his psychosocial and psychomotor development+ i& ~4 P* m& Y9 l: J9 _* l' i
was age appropriate.! m) e* w+ t" j, F; h' A# R  N* M$ d
The family history was remarkable for the father,
. G& }! {) p/ e* ywho was diagnosed with hypothyroidism at age 16,- ]; N; F* l- _( P) Q
which was treated with thyroxine. The father’s+ T- Y% g" V: ]" j8 K
height was 6 feet, and he went through a somewhat/ V8 H8 x% I# [. i. i
early puberty and had stopped growing by age 14.
" j. ^, z) c4 B8 q2 M: g; yThe father denied taking any other medication. The
6 ^; W/ p% g4 N* y' \6 zchild’s mother was in good health. Her menarche
( |2 W3 B- Q8 L" bwas at 11 years of age, and her height was at 5 feet& M4 v" j- t) y( }6 S$ V. }+ D
5 inches. There was no other family history of pre-3 H' ^0 |. ]7 V% \* s4 J
cocious sexual development in the first-degree rela-
6 r+ C! c$ ?: H) \- O" r% atives. There were no siblings.' c% ^# B3 ]% h% ]; `1 g  a
Physical Examination
; A6 s1 b6 a! D) \, S; L! UThe physical examination revealed a very active,
1 r9 z; |! B2 `+ C0 Wplayful, and healthy boy. The vital signs documented
# b$ b% [5 k: qa blood pressure of 85/50 mm Hg, his length was
5 ?( [9 [  I; j; J/ I2 z90 cm (>97th percentile), and his weight was 14.4 kg- }" L  q1 E* r, E. n9 A2 B3 k; U
(also >97th percentile). The observed yearly growth
# n  k. E' w6 a2 i% n) Svelocity was 30 cm (12 inches). The examination of- [$ o0 Y( k' I, f. J
the neck revealed no thyroid enlargement.1 j, Q2 B) ?+ D$ V
The genitourinary examination was remarkable for
: c8 g" L  P7 l; J1 ?/ q8 tenlargement of the penis, with a stretched length of( Z& O. y! U3 u9 c6 L/ S5 ?" Y
8 cm and a width of 2 cm. The glans penis was very well4 ]5 P: ~6 r' v: P5 k+ a
developed. The pubic hair was Tanner II, mostly around
0 D4 y" t' G5 R/ e7 [( o540
. e( h2 V# \9 T. U/ Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( ]% m) Z; D$ D3 \- W
the base of the phallus and was dark and curled. The+ h8 r1 F% O- u" v
testicular volume was prepubertal at 2 mL each.! ~8 q, [( H: C% L% k0 O
The skin was moist and smooth and somewhat5 Z/ d1 I- f6 |6 k0 R
oily. No axillary hair was noted. There were no: W3 f4 g1 s9 O5 E8 W+ Z- c* X& Q
abnormal skin pigmentations or café-au-lait spots.
6 a! S$ |; L  ?( D" fNeurologic evaluation showed deep tendon reflex 2+' T" x7 X- L% T6 j; k4 u: _
bilateral and symmetrical. There was no suggestion
9 s, X8 G5 c! _" P, S4 qof papilledema.
3 r6 C9 A# [2 G6 BLaboratory Evaluation% w' a1 }5 z4 p  m, E. r
The bone age was consistent with 28 months by8 f# m: a2 M* a0 N0 ^# t0 p1 l( J
using the standard of Greulich and Pyle at a chrono-
$ P. d4 d6 Q/ W2 blogic age of 16 months (advanced).5 Chromosomal
% m# F0 C0 n0 ^5 ]  T  okaryotype was 46XY. The thyroid function test
" @0 L# X; Z' k; H. r0 f$ _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) i' ^+ P5 i0 P% jlating hormone level was 1.3 µIU/mL (both normal).
8 b+ j" [' S# V: Z, i. nThe concentrations of serum electrolytes, blood
; L; R' i  t7 N- Xurea nitrogen, creatinine, and calcium all were
; I" q) Q# e8 |+ }within normal range for his age. The concentration7 Z" D9 H! G' k7 p
of serum 17-hydroxyprogesterone was 16 ng/dL! S6 t/ E+ E& r
(normal, 3 to 90 ng/dL), androstenedione was 20
8 g: i9 z4 E; gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- P, i/ u4 `! b9 v9 S$ h+ W
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ E4 S4 J' {  l: Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 t' J: A# L" h8 L1 j2 u3 @1 e
49ng/dL), 11-desoxycortisol (specific compound S)
8 _0 g; L, r3 T7 N- Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* }" R" E6 j6 V, z3 i0 [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 l# [% [' ]2 r- U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) u2 k' K% A6 \) U5 c/ Zand β-human chorionic gonadotropin was less than
& m* L- M( p9 _# y5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 g. t0 W: C+ W, ]6 b: P! gstimulating hormone and leuteinizing hormone
* N1 |& S, n, w& y8 A5 ?concentrations were less than 0.05 mIU/mL
% s; b% c) ?4 w; k- R! L0 ~& o(prepubertal).
0 N: R+ E' x& q: P  TThe parents were notified about the laboratory0 a2 ?1 l) c+ J! ^1 {( E
results and were informed that all of the tests were* `" C% f+ C9 ^2 I% P( ?+ v9 T
normal except the testosterone level was high. The
" |3 c6 m2 V- n. D) `follow-up visit was arranged within a few weeks to
8 }! [$ l0 X6 S$ fobtain testicular and abdominal sonograms; how-
0 I2 K" E! B" _+ O) Qever, the family did not return for 4 months.
0 b- H% d& D- m& dPhysical examination at this time revealed that the4 y) z4 {' }0 w8 ^
child had grown 2.5 cm in 4 months and had gained5 q* w- g7 S+ G0 }4 n! v
2 kg of weight. Physical examination remained) q$ _: d" Z( N! ^
unchanged. Surprisingly, the pubic hair almost com-
; V2 r* ]9 ]7 P4 {2 apletely disappeared except for a few vellous hairs at
% r% w" s) `4 O9 Uthe base of the phallus. Testicular volume was still 2: H6 z# f( v8 c
mL, and the size of the penis remained unchanged.2 j% X  O3 E) f( P+ a$ u
The mother also said that the boy was no longer hav-$ v: R5 K: s4 T
ing frequent erections.
6 C7 ]3 \1 w) K1 F, d+ C6 [Both parents were again questioned about use of% s1 c  h0 a2 H! l& S& O/ @
any ointment/creams that they may have applied to, E' ~, K8 |* U' d: c
the child’s skin. This time the father admitted the2 K  {1 q/ o- h2 X' f
Topical Testosterone Exposure / Bhowmick et al 541
. W& G8 `$ ~  E) nuse of testosterone gel twice daily that he was apply-
" t0 |3 {& p# G7 J. E! Ving over his own shoulders, chest, and back area for: l' n# |* T. ~) \: }4 S+ x
a year. The father also revealed he was embarrassed
$ O4 l/ x; u# mto disclose that he was using a testosterone gel pre-
8 J5 x6 ?* X9 @3 J1 ?; [  Vscribed by his family physician for decreased libido, c! J" {1 M2 {' A6 V8 m$ k
secondary to depression.
$ _5 Q: k7 }# sThe child slept in the same bed with parents.
( I0 l( a2 c. G' w" Z% RThe father would hug the baby and hold him on his2 h$ a+ e  _' Z
chest for a considerable period of time, causing sig-7 N8 q# s& {. c4 e
nificant bare skin contact between baby and father.# P  W4 r9 o+ O# h8 t
The father also admitted that after the phone call,  Z6 |' n2 w* b0 y9 u
when he learned the testosterone level in the baby; @. A6 J) }" X) u
was high, he then read the product information
, V% v$ b$ t1 W, I3 opacket and concluded that it was most likely the rea-
1 l* v5 o2 n7 G0 ]: Zson for the child’s virilization. At that time, they
" @% u" t3 e) f* `* ^decided to put the baby in a separate bed, and the& v6 L, g8 I0 D% c2 L
father was not hugging him with bare skin and had
/ g3 V0 p7 Y5 Z4 ^7 _been using protective clothing. A repeat testosterone
  d, m( c: z, J* J/ c" ltest was ordered, but the family did not go to the  M; {% U1 t) q+ T' j* `
laboratory to obtain the test.
* K, [7 `  x: L0 I/ _- V) vDiscussion
: e& U, B  ^& p: k# H. qPrecocious puberty in boys is defined as secondary
0 k2 v! m1 u( z% G% q& ?sexual development before 9 years of age.1,4- `2 c* S: x. }  B+ C7 |
Precocious puberty is termed as central (true) when% A1 ~" g# q; e; x/ N0 Q0 W
it is caused by the premature activation of hypo-( `- B2 m' A4 ~3 }7 j( S5 W
thalamic pituitary gonadal axis. CPP is more com-
3 @0 r1 D9 R) g3 v* `mon in girls than in boys.1,3 Most boys with CPP
1 z. b5 Q* `" R# }- p' u  b) q: ^may have a central nervous system lesion that is
! [1 P' E1 Z0 z  L' E, m' Dresponsible for the early activation of the hypothal-
+ ~0 t0 O# _  @7 b9 o/ ?" [amic pituitary gonadal axis.1-3 Thus, greater empha-
' g- }) U& J% Z( }6 Wsis has been given to neuroradiologic imaging in  G+ M4 R% {; @# e' [
boys with precocious puberty. In addition to viril-
! z) M7 T' X9 S. mization, the clinical hallmark of CPP is the symmet-7 \6 O: S8 r7 k& }8 ^
rical testicular growth secondary to stimulation by0 b# D9 W: X2 I8 q: Z  [8 E, C
gonadotropins.1,3
1 H" I$ D% z8 l- G1 H5 u9 GGonadotropin-independent peripheral preco-3 h) H% C" Y4 R6 O+ ?5 `: w
cious puberty in boys also results from inappropriate
+ ^4 `+ m9 |3 r6 Uandrogenic stimulation from either endogenous or
+ v( R$ e. f# ]9 Qexogenous sources, nonpituitary gonadotropin stim-
( m* R, Y( A6 x2 tulation, and rare activating mutations.3 Virilizing* [5 ~" U: m7 y! ?7 `' r% W- X1 d& a
congenital adrenal hyperplasia producing excessive
4 r' t+ A) {4 L# w- Qadrenal androgens is a common cause of precocious
6 g: x# r" E# U( ]  X0 d1 B7 fpuberty in boys.3,49 X- T8 V$ \1 }
The most common form of congenital adrenal
. P8 k& u2 _# A& n( Qhyperplasia is the 21-hydroxylase enzyme deficiency.2 {, O' Z% y, L: x% ?: l  [- w2 I
The 11-β hydroxylase deficiency may also result in
1 W- p2 e" O+ K' b6 w2 X: s% @excessive adrenal androgen production, and rarely,! p% T8 g, e$ a$ Q
an adrenal tumor may also cause adrenal androgen
8 H( m, a% m) [5 Jexcess.1,3; Z8 L' j0 `7 ]% E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 }  Y4 l! B" x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* E- U4 @* M' b! [A unique entity of male-limited gonadotropin-6 x  ?# z, t) O9 M3 q3 o4 D
independent precocious puberty, which is also known
$ M. _# W3 f0 ?& P7 `0 sas testotoxicosis, may cause precocious puberty at a
: y3 \$ w) ], V# Rvery young age. The physical findings in these boys) Z& D  ^$ ^* k$ P
with this disorder are full pubertal development,: K6 v" \! n& A/ H: {9 M
including bilateral testicular growth, similar to boys
, t6 v8 L# X5 L5 V+ I2 w: zwith CPP. The gonadotropin levels in this disorder* e0 m8 m7 p$ E6 ?+ |. K
are suppressed to prepubertal levels and do not show$ P, S$ i. A+ O' T0 Q
pubertal response of gonadotropin after gonadotropin-
- D/ o( A9 L+ R' Yreleasing hormone stimulation. This is a sex-linked) e4 Z$ S1 A' r2 O* r# P
autosomal dominant disorder that affects only8 w" Q5 Q2 }. U1 ?5 G
males; therefore, other male members of the family
* W) I* [5 H; v8 q+ e; d3 Nmay have similar precocious puberty.3. b) k0 {" ]+ |, d- d+ I* @
In our patient, physical examination was incon-& [+ ~6 C  R* M$ i% ]% T
sistent with true precocious puberty since his testi-
% n- H8 x% d7 A  e7 Q: h) Dcles were prepubertal in size. However, testotoxicosis' ?# [+ ]0 V1 U, C5 R) S
was in the differential diagnosis because his father
; C, J/ q& Z- \  Y0 h9 @started puberty somewhat early, and occasionally,9 `/ Q# J! I5 ]
testicular enlargement is not that evident in the7 W7 ~. k/ C8 D3 y% y2 _
beginning of this process.1 In the absence of a neg-
* Z7 S( z5 h# d* F( gative initial history of androgen exposure, our6 K4 p9 Y7 z7 r- ]6 n
biggest concern was virilizing adrenal hyperplasia,  C, v, D- d9 i/ O) i) |4 S
either 21-hydroxylase deficiency or 11-β hydroxylase% A  a# l9 e2 y
deficiency. Those diagnoses were excluded by find-8 j) c2 G8 x0 s
ing the normal level of adrenal steroids.- i+ F( G% k8 ]% o- m9 w. o" F
The diagnosis of exogenous androgens was strongly# C7 U; w5 H( V$ G- i7 Q6 i7 Q0 E
suspected in a follow-up visit after 4 months because- b4 g$ n: z7 D& E) t
the physical examination revealed the complete disap-
1 L" G* _8 c- [6 L- @$ Rpearance of pubic hair, normal growth velocity, and
8 X! J# `, N0 @% H$ x' Vdecreased erections. The father admitted using a testos-( M/ b4 ]7 H% u2 q4 G
terone gel, which he concealed at first visit. He was4 l+ i# f, t; I( v
using it rather frequently, twice a day. The Physicians’
& o( R0 n; l* Y9 y" @9 @) ]Desk Reference, or package insert of this product, gel or0 c% V" \+ ^+ X1 [; s# J- h
cream, cautions about dermal testosterone transfer to+ W2 i3 [5 S6 M. Q4 [- T
unprotected females through direct skin exposure.
" X/ H7 Z! d0 \0 l* g0 vSerum testosterone level was found to be 2 times the9 C& U& d. w+ n  t; }
baseline value in those females who were exposed to0 Q7 g# {* x8 |3 ~* p# I$ f
even 15 minutes of direct skin contact with their male
; h3 z# |2 g' p7 [4 gpartners.6 However, when a shirt covered the applica-
" K; F& I4 a+ @; l. i3 O3 Ytion site, this testosterone transfer was prevented.
- e* R$ L; O7 y. F  f+ C/ f0 z/ E3 COur patient’s testosterone level was 60 ng/mL,: I* Y, m1 S* z# v
which was clearly high. Some studies suggest that
; c: }$ U+ b# X* B$ Hdermal conversion of testosterone to dihydrotestos-
6 ]  E: m+ x1 s( D- Y* z9 C& _terone, which is a more potent metabolite, is more
- x1 ~5 \( s' R% O) j2 ~active in young children exposed to testosterone' X( J! u) {, j* u- X
exogenously7; however, we did not measure a dihy-8 g- H' k3 [3 F' P  V
drotestosterone level in our patient. In addition to& H% x8 W& D( j6 N
virilization, exposure to exogenous testosterone in/ N6 }) C. i2 V: H# B( V
children results in an increase in growth velocity and* ~  s* ^. N; x0 B) N8 Q
advanced bone age, as seen in our patient.! ?& Y' \4 E  @8 K
The long-term effect of androgen exposure during
! b6 n5 y( b9 t* p# L& rearly childhood on pubertal development and final7 {9 c- k1 `; r% ?& F
adult height are not fully known and always remain  ?; A. p5 @& A+ c
a concern. Children treated with short-term testos-
9 E$ E% v% g3 p7 i! Pterone injection or topical androgen may exhibit some! A$ C! ~: \0 h: s; v; {) P9 Q
acceleration of the skeletal maturation; however, after4 e4 Y$ g1 K; b$ R+ g! K7 S
cessation of treatment, the rate of bone maturation+ T6 u" p. m( _# M
decelerates and gradually returns to normal.8,9
* E. `+ `6 ]0 a+ \! K2 dThere are conflicting reports and controversy6 L) [" T& L% |1 d$ E4 I
over the effect of early androgen exposure on adult8 R0 G' E( h7 X6 ]. K5 |
penile length.10,11 Some reports suggest subnormal
7 z& l7 T" t  |+ d- ladult penile length, apparently because of downreg-/ ], u+ z3 C( ~- l6 {6 F' b
ulation of androgen receptor number.10,12 However,2 ], D2 W3 H9 S9 R2 f7 u$ K5 [) K
Sutherland et al13 did not find a correlation between! i1 f1 Z0 A% X2 n
childhood testosterone exposure and reduced adult8 G8 ~' a8 F+ e. X% e
penile length in clinical studies., |2 {3 K; b$ L
Nonetheless, we do not believe our patient is
$ K1 L* E+ N& p8 r8 f6 vgoing to experience any of the untoward effects from
6 b# T4 \# t  ?5 E, ytestosterone exposure as mentioned earlier because' {& ~# a6 c3 A6 R; c
the exposure was not for a prolonged period of time.
+ w  a& ^# h, L8 vAlthough the bone age was advanced at the time of
5 S  R: |* J$ d. z1 ]diagnosis, the child had a normal growth velocity at6 `+ o2 q  g  m3 n) S: x
the follow-up visit. It is hoped that his final adult$ Y% e/ I0 x" M3 `$ Z' _6 L/ M
height will not be affected.( d" f7 v( c# v  J+ Y
Although rarely reported, the widespread avail-4 u1 `, y0 t/ g
ability of androgen products in our society may1 Y1 a& p, U$ r
indeed cause more virilization in male or female
; m* N. j: I7 s7 Ichildren than one would realize. Exposure to andro-& B, g5 b2 D8 O3 R  g5 ^
gen products must be considered and specific ques-5 R2 ?: Y, j9 }9 Q; _: t# p
tioning about the use of a testosterone product or! }5 F) k4 L  Y5 h) L* i
gel should be asked of the family members during
' Q  G& b$ P& j: I$ cthe evaluation of any children who present with vir-
1 M* h0 C" V9 L; u+ n9 Dilization or peripheral precocious puberty. The diag-
; z6 v- D9 ~& s" C7 Pnosis can be established by just a few tests and by
+ O4 M' \" [% @$ ?' Y: eappropriate history. The inability to obtain such a
+ U* g) u: T1 G; nhistory, or failure to ask the specific questions, may2 H: A/ ]+ j6 _& ^8 [, I
result in extensive, unnecessary, and expensive) ]- j1 [7 Y1 y- Q
investigation. The primary care physician should be
% |3 Z: f" s% R1 h9 c9 s1 h) u0 Iaware of this fact, because most of these children
3 N. T+ D' u2 C' c, k/ ?may initially present in their practice. The Physicians’
* U4 o' l7 \! h$ Y+ g8 X0 b/ gDesk Reference and package insert should also put a  E* ^+ x7 c1 S0 q% r5 A1 X
warning about the virilizing effect on a male or1 z/ c5 M; o! t" k6 S
female child who might come in contact with some-
0 N% q1 D) i. B& X( Z5 eone using any of these products.( z8 ?# ?9 ?8 ~- B3 c/ R5 ]. u+ [
References
8 l" \) I, O6 b1 A" d1. Styne DM. The testes: disorder of sexual differentiation
: U$ r  a9 S$ [9 Mand puberty in the male. In: Sperling MA, ed. Pediatric8 |9 A( ?+ b/ i+ w5 P
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 k& j( q7 d' ^+ ^, U6 r1 G2002: 565-628.. Y0 H- {1 O' j, O! _- d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 g+ h- l4 i+ {  a1 V5 {; gpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* J( ?' p( S! W! KBoy Induced by Indirect Topical
& Q6 e! k" B+ j; _5 O) [Exposure to Testosterone
2 e0 E! I: O0 i/ D1 m" W+ b& KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 W) T( w' Z- @1 K1 Mand Kenneth R. Rettig, MD1
6 U+ _( W" C0 R% g2 LClinical Pediatrics
( @3 m8 q: Z' P9 X. z% z. n  UVolume 46 Number 6. c2 u0 J0 {" y0 T2 W
July 2007 540-543
: C0 Q: p; f# H! j/ R© 2007 Sage Publications
+ I& c0 p5 o" R9 N0 }10.1177/0009922806296651# ?! ^# U8 g$ h' x6 V
http://clp.sagepub.com
* l2 M) S5 z6 Y/ G0 p: {hosted at2 t4 Y2 d( d' O$ s% {
http://online.sagepub.com% F  k- E: O' u4 W4 C' W: F/ m- s$ y& G
Precocious puberty in boys, central or peripheral,! K' T7 a: v$ t
is a significant concern for physicians. Central3 J% |: g* ^1 L
precocious puberty (CPP), which is mediated4 S9 ^+ v; K! x7 \* ~
through the hypothalamic pituitary gonadal axis, has) j; B& M8 @3 |7 H
a higher incidence of organic central nervous system
7 r2 a6 b3 r1 G/ Blesions in boys.1,2 Virilization in boys, as manifested# x9 a& T# G+ z$ P- h+ I0 l
by enlargement of the penis, development of pubic: m8 n' k  w' N7 `% G2 K; v
hair, and facial acne without enlargement of testi-& \7 o' r$ O" x0 n# [
cles, suggests peripheral or pseudopuberty.1-3 We
: j/ U/ R4 O$ ~& Y, c& z" mreport a 16-month-old boy who presented with the4 C  o2 G2 y7 p0 v" j1 h  O% {8 l9 B6 i
enlargement of the phallus and pubic hair develop-
3 V  S( `: R, Hment without testicular enlargement, which was due
2 B5 D# ?4 G' b* D7 cto the unintentional exposure to androgen gel used by& ~% R& o/ ]/ k
the father. The family initially concealed this infor-8 ]7 Q; g  Y( ^( j0 o
mation, resulting in an extensive work-up for this9 y8 G7 F$ v0 B  M6 z
child. Given the widespread and easy availability of5 T  C! y' C. K* F$ ~. f4 C
testosterone gel and cream, we believe this is proba-  S7 r( `. ?# @1 t- ~
bly more common than the rare case report in the" }) I1 I6 `% f& A
literature.45 O' f. h! y( |& \+ c/ A2 X
Patient Report
! j' V3 E+ Z: Z- U6 _0 W. |A 16-month-old white child was referred to the+ P% t5 k5 V  T
endocrine clinic by his pediatrician with the concern: {( L: r' V8 ]  G5 c3 X+ @" k
of early sexual development. His mother noticed/ ^! S4 k" @9 z
light colored pubic hair development when he was
, H  g" z" G/ H: l% Q0 A: oFrom the 1Division of Pediatric Endocrinology, 2University of
4 T) n& n$ w9 O- g  a! G/ X/ SSouth Alabama Medical Center, Mobile, Alabama.8 ]; m9 [0 s! x
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 C  f$ ?2 a; D$ M5 z4 S4 V# s
Professor of Pediatrics, University of South Alabama, College of+ F7 J2 d3 @) E3 o! \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 l( I: A  B" N& p" h4 le-mail: [email protected].9 _- s) B. o1 m; ^3 W% D* g/ e
about 6 to 7 months old, which progressively became
5 }% Z! f$ a6 D8 ~3 ?8 H' @! Zdarker. She was also concerned about the enlarge-3 `& ^! v& w; X! A, \& J
ment of his penis and frequent erections. The child
1 Y8 E6 h/ U$ l: s' K' R: qwas the product of a full-term normal delivery, with: ~; J$ N+ R6 G
a birth weight of 7 lb 14 oz, and birth length of$ G9 X9 r2 L2 s/ v! U
20 inches. He was breast-fed throughout the first year
; p: u# _2 g9 g" J% k3 Z# Vof life and was still receiving breast milk along with
- |3 W+ O/ d% z% M9 k, lsolid food. He had no hospitalizations or surgery,
, m" `7 L  z) U! ^! X5 e' }and his psychosocial and psychomotor development
; ^% p: E' Y$ p0 y5 O, n7 t, twas age appropriate.* Y" [. B3 z' s6 S
The family history was remarkable for the father,+ J+ S2 a! n6 n( P* R% i
who was diagnosed with hypothyroidism at age 16,
* D6 {* g: y6 z7 H0 jwhich was treated with thyroxine. The father’s) S" d( a* X3 z# l( Q3 w
height was 6 feet, and he went through a somewhat2 T1 Z+ d3 n  t- _; z
early puberty and had stopped growing by age 14.
' a% R: R" m) EThe father denied taking any other medication. The9 [; [, t! J9 K4 E* I) {6 X
child’s mother was in good health. Her menarche$ N9 ]& x; o" \5 H2 ?* c6 M
was at 11 years of age, and her height was at 5 feet
$ ~8 E! I$ x; i$ @# b5 inches. There was no other family history of pre-
, R# h  f! a* g! k% X% D/ r' U' }cocious sexual development in the first-degree rela-
9 E- \) a6 `3 k" mtives. There were no siblings.
: ^( n, q$ h) _, z4 I8 g: GPhysical Examination/ @0 c0 k# `3 T" j9 T
The physical examination revealed a very active,: M* a9 U) E9 A+ l
playful, and healthy boy. The vital signs documented
, g  I4 N( @6 `, M+ y# d' P% ?9 Ba blood pressure of 85/50 mm Hg, his length was
) N- e" w1 J" O90 cm (>97th percentile), and his weight was 14.4 kg- Q/ c* y0 t1 @3 A* g' W
(also >97th percentile). The observed yearly growth4 g# i8 v' J, M! Q
velocity was 30 cm (12 inches). The examination of3 E3 O3 e; s& s9 R1 [0 ^
the neck revealed no thyroid enlargement.' ?9 c. K1 o1 `+ b! Z2 ^
The genitourinary examination was remarkable for
) D9 O- h2 g+ n* M# E7 \enlargement of the penis, with a stretched length of
9 V6 T# c1 F5 j5 ]* I. E1 j8 cm and a width of 2 cm. The glans penis was very well
& C0 r- n$ K( \( |# j% ldeveloped. The pubic hair was Tanner II, mostly around! a# T- q) a( J
540
- L8 c0 ^& A3 A, p: Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ ]3 J/ T/ e  u% L$ Q. X
the base of the phallus and was dark and curled. The+ F  k! a$ f4 }+ m8 [" P; }7 A
testicular volume was prepubertal at 2 mL each.
2 t, s+ W* n: ^" Q7 l: BThe skin was moist and smooth and somewhat
3 a, z+ a, k8 f9 ?9 goily. No axillary hair was noted. There were no/ E& u5 A# i9 h3 ~( e! M
abnormal skin pigmentations or café-au-lait spots.
' F$ ?7 }% L( ^Neurologic evaluation showed deep tendon reflex 2+
, C3 t6 T! I. N/ W3 A7 g7 U# t- ]bilateral and symmetrical. There was no suggestion4 X0 Z- b  u/ M6 c2 G& m( @
of papilledema.+ b' l) f: V$ V3 z) Q; k2 h4 |2 V, P- n
Laboratory Evaluation+ Y, D9 {6 c( U$ ^/ t
The bone age was consistent with 28 months by+ F4 R7 v1 q% M2 a  C& i! C, a
using the standard of Greulich and Pyle at a chrono-9 C' p% R, I( w  i! N6 q# T
logic age of 16 months (advanced).5 Chromosomal$ a7 ?  I' j4 z) c, j' @; v
karyotype was 46XY. The thyroid function test
+ n. o& O/ H9 f5 U; ?6 N3 h7 R  Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 a0 M7 y3 s! d6 ^$ A/ c* G" |lating hormone level was 1.3 µIU/mL (both normal).) w. _0 h' S2 \9 U. M  {. ]
The concentrations of serum electrolytes, blood* m: |" q& L3 c1 t$ _4 J4 p6 R
urea nitrogen, creatinine, and calcium all were
# h" b2 L2 E* q* Q9 ?; w& a! m  I- n/ |within normal range for his age. The concentration
. [/ d% ]% o; |9 Rof serum 17-hydroxyprogesterone was 16 ng/dL0 H" w8 S6 g2 N7 k& i7 `
(normal, 3 to 90 ng/dL), androstenedione was 208 R6 r4 s8 M- D: a- T9 ?" p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 T" ~% k. k0 K) H& q, p) O$ b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) D# D8 R0 ^# Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to- V: h* I! e6 p! I) n- \! D8 Y( t. O
49ng/dL), 11-desoxycortisol (specific compound S)
" S( t1 y; s9 x! N8 }# C2 Q/ C  ?" Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: W- @: b3 J: e( F. otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' o2 A3 W+ }5 y7 N9 H  ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 d" ?5 l5 V5 c1 ~( W' ~+ uand β-human chorionic gonadotropin was less than: U$ X2 j0 F: ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular* |4 r# M. a5 R/ k' I. r
stimulating hormone and leuteinizing hormone
1 q( F" B1 d5 l& B! u* X' Xconcentrations were less than 0.05 mIU/mL
* I0 _, ~+ Z4 ?& w; b0 P(prepubertal).! \: I( [. }! h! T- c6 A. h4 M1 F
The parents were notified about the laboratory; D- L: Q+ W4 W2 B  ]* c; B2 m
results and were informed that all of the tests were
/ a4 ^/ \( W5 b1 o9 Jnormal except the testosterone level was high. The
6 i- l/ f9 Q" }# K: d4 v& |2 Gfollow-up visit was arranged within a few weeks to4 [2 k* n: U3 ]1 @
obtain testicular and abdominal sonograms; how-8 x0 ~# _3 i! b; q3 F, b% N$ ?. E) M
ever, the family did not return for 4 months.4 a4 M2 l+ M* D6 U, k. p6 [
Physical examination at this time revealed that the
' {3 n* D) s' j3 X6 a, @9 ]! Kchild had grown 2.5 cm in 4 months and had gained2 N5 R4 q: O* o3 J. V' j/ z: N
2 kg of weight. Physical examination remained* ^7 O# b0 e) a2 F; ?
unchanged. Surprisingly, the pubic hair almost com-
* ^, ?0 I# t- h- D3 Rpletely disappeared except for a few vellous hairs at
/ R9 |  H5 g* T  t9 ^( y" Mthe base of the phallus. Testicular volume was still 2) G# {3 n: I" B9 |
mL, and the size of the penis remained unchanged.
, j5 m+ J  k" G) O! Q2 ?5 QThe mother also said that the boy was no longer hav-
; @- q1 x) H8 H  d8 K- ming frequent erections.
- ]7 W; K6 V3 s1 ^1 X5 C$ m9 H. wBoth parents were again questioned about use of4 H6 H2 U3 K/ A0 [2 h
any ointment/creams that they may have applied to% x1 N2 k" X' Y& w& ~
the child’s skin. This time the father admitted the
% v& V: K. R1 a- E( ZTopical Testosterone Exposure / Bhowmick et al 541% y7 e6 h. R* U3 p  j% {7 ~9 r) f
use of testosterone gel twice daily that he was apply-
1 v# {  `+ \/ ^7 B7 king over his own shoulders, chest, and back area for
' [2 ~+ y" l* V. La year. The father also revealed he was embarrassed1 s3 v& K  G: b' P- B  T
to disclose that he was using a testosterone gel pre-
! q/ R$ ?! Z  I5 u3 N0 ^  vscribed by his family physician for decreased libido! V9 s1 s6 G& Q4 @3 P5 E
secondary to depression.
9 t$ ]  [; u* I% Q$ p$ wThe child slept in the same bed with parents.
- q( V6 g: D% p( L4 R+ {The father would hug the baby and hold him on his7 K* s6 V6 m: h4 t9 {; J8 q
chest for a considerable period of time, causing sig-5 f8 g8 V* b: b1 w1 r9 J7 e1 F
nificant bare skin contact between baby and father.
6 D2 }+ J& u4 K+ b/ B6 x# QThe father also admitted that after the phone call,
& X7 k% P# r, `4 N6 Owhen he learned the testosterone level in the baby* l+ v0 P+ D9 W2 b
was high, he then read the product information
# _/ E. U  s/ z7 i0 s; h* |! rpacket and concluded that it was most likely the rea-7 d3 S$ D( H, Q1 K6 H9 @
son for the child’s virilization. At that time, they
; `- L8 N" c. t  sdecided to put the baby in a separate bed, and the2 R) m, Z7 g, {5 [- Z! T
father was not hugging him with bare skin and had6 w1 w* R+ A5 i( G! @+ r
been using protective clothing. A repeat testosterone
- [& d/ i$ }1 C" d3 Jtest was ordered, but the family did not go to the
9 j/ ?6 R! I2 @' f* Tlaboratory to obtain the test.
( L0 s1 i! K! k1 C+ xDiscussion) s( G* u" g" Q
Precocious puberty in boys is defined as secondary. A' Z6 _" X& D: m! n, h
sexual development before 9 years of age.1,4
  A0 r/ O: h+ q. U" aPrecocious puberty is termed as central (true) when1 H) F/ i% ?( ]2 |6 N+ Y% @
it is caused by the premature activation of hypo-7 _3 X- G2 D7 z; N, t
thalamic pituitary gonadal axis. CPP is more com-* ^* b1 }6 y) P# M0 R
mon in girls than in boys.1,3 Most boys with CPP2 _9 G4 _& j* H* Y1 T8 u
may have a central nervous system lesion that is& k" E( ^# ~$ \0 Z* `: W
responsible for the early activation of the hypothal-5 N  l& a- r: K& O
amic pituitary gonadal axis.1-3 Thus, greater empha-
. I6 s5 I; A; u  \! |$ B' l% Asis has been given to neuroradiologic imaging in
. K7 K* z( C, L4 R, ~, d6 }4 K8 ?boys with precocious puberty. In addition to viril-
* L" Q6 \- \5 B$ {- u$ B: |ization, the clinical hallmark of CPP is the symmet-4 F! ~% E/ N4 L0 p5 b. \8 M9 Y
rical testicular growth secondary to stimulation by5 e/ ]# k3 C2 L6 G  J. _
gonadotropins.1,3
5 b+ k6 q" S/ F5 D  vGonadotropin-independent peripheral preco-
$ U+ g( O& ~8 K$ Icious puberty in boys also results from inappropriate
1 j: L4 D; q* F& O1 U* g8 F+ _) \androgenic stimulation from either endogenous or
  o! T' E9 Y/ f! D/ Y! ~  xexogenous sources, nonpituitary gonadotropin stim-0 C3 u  w$ _* p( ^6 M1 s, k/ U" F
ulation, and rare activating mutations.3 Virilizing
& g; j* z4 s! L! N# ucongenital adrenal hyperplasia producing excessive, g/ J. i6 t" W; S
adrenal androgens is a common cause of precocious
1 G) C5 }- _9 m; k* E" d% Fpuberty in boys.3,4
. w9 e: C0 I$ qThe most common form of congenital adrenal
# N/ T) K9 C7 a' |" D* lhyperplasia is the 21-hydroxylase enzyme deficiency.
! n; j' ]6 q- r' t' hThe 11-β hydroxylase deficiency may also result in4 F& g* S6 ~% }6 [- L7 |
excessive adrenal androgen production, and rarely,: d: t( |' {+ r3 E) [0 ?
an adrenal tumor may also cause adrenal androgen
0 |  I( P. r) D* |! v" f! xexcess.1,3
; }6 M( M9 g% E/ x9 c; T/ q. Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" j/ p- r* b$ O! W- u/ K5 G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) J' u  h( z% s* T  b
A unique entity of male-limited gonadotropin-) M' h/ `/ T' N: t; h" ^4 K% w! S
independent precocious puberty, which is also known
$ ^) X: l9 Y8 |2 O4 U2 o8 c; Q' J+ \2 x! nas testotoxicosis, may cause precocious puberty at a) Q# D4 P8 O% w" C1 ]. h+ N6 {6 t
very young age. The physical findings in these boys9 O, ]5 C, e$ ?0 y- D/ ~& y% D
with this disorder are full pubertal development,# h! a, v; N" F$ T" _
including bilateral testicular growth, similar to boys1 }, {0 r* u2 h* ?
with CPP. The gonadotropin levels in this disorder+ L  d- C* G6 M* c' I8 N1 |
are suppressed to prepubertal levels and do not show
0 l. m7 n( _4 M" I. E& xpubertal response of gonadotropin after gonadotropin-
/ T7 e5 e( E# T( nreleasing hormone stimulation. This is a sex-linked$ d" q0 g9 G: K& a& u1 Z
autosomal dominant disorder that affects only6 U+ c- w7 H/ b$ o4 t9 ^
males; therefore, other male members of the family) [" g" U; j/ a: ?3 D
may have similar precocious puberty.3/ L) b; l6 b7 O( ?6 ]% I
In our patient, physical examination was incon-
" a4 M/ p' [$ t4 n  bsistent with true precocious puberty since his testi-/ W! s9 }% H3 g$ t" D
cles were prepubertal in size. However, testotoxicosis
8 x( y. t6 @+ G' e8 j" z/ zwas in the differential diagnosis because his father
0 @( r0 @2 C9 A7 Pstarted puberty somewhat early, and occasionally,6 H$ M/ T- z5 U, {
testicular enlargement is not that evident in the
& x; T6 e/ x. I0 g5 D# M3 k: Jbeginning of this process.1 In the absence of a neg-
1 h, K. c8 l7 e7 C* ^/ ^' Zative initial history of androgen exposure, our
0 p$ }$ S6 D1 D! ^. sbiggest concern was virilizing adrenal hyperplasia,
/ s8 q. G  j0 ?5 e% L  i  l/ geither 21-hydroxylase deficiency or 11-β hydroxylase
6 e( U% b' F! }' Z* B$ |deficiency. Those diagnoses were excluded by find-. B% g! t7 U/ N- y! _4 q
ing the normal level of adrenal steroids." U3 L+ u) z" c7 }! q* |4 E
The diagnosis of exogenous androgens was strongly/ p) U) c+ ~( T
suspected in a follow-up visit after 4 months because: j) _% E4 w+ l7 [9 t% M+ ~7 C
the physical examination revealed the complete disap-
3 q6 ]% a$ e" W" p3 C$ _pearance of pubic hair, normal growth velocity, and& q. N# B" M: Y6 }( i
decreased erections. The father admitted using a testos-4 T1 q8 A4 P2 _$ f
terone gel, which he concealed at first visit. He was7 m& E/ B2 q1 ^/ ~  W9 u( ^0 i- a
using it rather frequently, twice a day. The Physicians’
, f8 M6 M6 z1 u9 V% E8 G! Y2 M/ jDesk Reference, or package insert of this product, gel or1 m9 o: e" |( }/ q/ h* V
cream, cautions about dermal testosterone transfer to
% H- _9 \4 W! `! D8 ~unprotected females through direct skin exposure.( P' f& i0 S! _/ v+ _+ z6 r
Serum testosterone level was found to be 2 times the  F& W% \/ q# Y; O) k* S+ c
baseline value in those females who were exposed to5 z. b8 f+ X/ J9 y( ]
even 15 minutes of direct skin contact with their male5 ]( L5 @4 V% z0 _
partners.6 However, when a shirt covered the applica-
8 J: W/ W2 d# x& J* i, Jtion site, this testosterone transfer was prevented.2 A6 f3 T7 u% s
Our patient’s testosterone level was 60 ng/mL,
9 M  V% T2 x$ `# Rwhich was clearly high. Some studies suggest that- F9 B  h# f* v
dermal conversion of testosterone to dihydrotestos-
+ P+ f  W8 _: ~+ L2 Iterone, which is a more potent metabolite, is more9 w7 u5 W6 Z; H. Q' A, q
active in young children exposed to testosterone2 N  l5 D' \5 }2 t6 Q8 x6 M
exogenously7; however, we did not measure a dihy-
3 G: D! P* Y& u1 ?7 U0 @7 hdrotestosterone level in our patient. In addition to5 i5 U) D: {6 W/ B$ c; k
virilization, exposure to exogenous testosterone in, C1 J& _$ K& q& P: r
children results in an increase in growth velocity and; Z# f) m- y8 ]) C$ Z
advanced bone age, as seen in our patient.
2 ?2 g; y, C* c1 x. {7 MThe long-term effect of androgen exposure during+ f1 v/ ~+ g1 h- j+ w
early childhood on pubertal development and final+ r$ `5 n5 Y, B/ ~" W+ X
adult height are not fully known and always remain* O  M/ {: a/ h) F" g
a concern. Children treated with short-term testos-+ d5 B* G- b2 n+ z+ N8 Y
terone injection or topical androgen may exhibit some  M2 T! p* w$ v% M# s
acceleration of the skeletal maturation; however, after8 I4 S% Q; J, V( _: |
cessation of treatment, the rate of bone maturation
. [! _+ E, @! pdecelerates and gradually returns to normal.8,9
; J" p- l  R  q8 n5 l! VThere are conflicting reports and controversy5 p1 X1 b0 I/ m, _
over the effect of early androgen exposure on adult  W8 e' y7 p$ o* X7 G! I
penile length.10,11 Some reports suggest subnormal
) M! p+ c4 s$ _4 H( a3 zadult penile length, apparently because of downreg-
* U' r9 L7 Z& gulation of androgen receptor number.10,12 However,
$ y: S9 a% {& J7 h6 [6 K" bSutherland et al13 did not find a correlation between
( g- F" Z& n$ r' R. Z2 O* J5 a$ j( ?childhood testosterone exposure and reduced adult
4 o* P3 [8 A  s6 epenile length in clinical studies.
/ J/ m4 _( k3 ^Nonetheless, we do not believe our patient is; L* ]5 K6 i8 \% j) u' ^* c
going to experience any of the untoward effects from& n9 [, w9 I& C, C4 f, k+ Z1 g
testosterone exposure as mentioned earlier because
( X. f0 r" O2 z' P. R9 y# lthe exposure was not for a prolonged period of time.: U0 |5 X7 t* q; O. K  o/ {& }$ I+ d
Although the bone age was advanced at the time of
  h, {6 A% V8 K& r: J3 h$ Tdiagnosis, the child had a normal growth velocity at9 s% F  ~! l! J9 v' o% M# s6 @' h' s, W
the follow-up visit. It is hoped that his final adult, F4 Y! J. z% v- u- p# Z
height will not be affected.5 x9 w$ O. h4 v; Q( L
Although rarely reported, the widespread avail-! m* z) z% G! `  V. _& w
ability of androgen products in our society may
0 O+ W4 Q6 d7 j4 k: h2 U) @indeed cause more virilization in male or female
7 }" O- C! s2 E/ v: n4 fchildren than one would realize. Exposure to andro-& Z0 D6 I7 U7 D
gen products must be considered and specific ques-
* B5 ~& h. T; c* T; Vtioning about the use of a testosterone product or
4 t. ?1 P8 g1 w' s- x5 T5 o5 r" F: Pgel should be asked of the family members during
6 o# R4 ^6 G! Vthe evaluation of any children who present with vir-1 s: g; Z3 o3 `5 Y/ ?# b+ L
ilization or peripheral precocious puberty. The diag-
2 Y6 {, s4 D9 i0 s* H) knosis can be established by just a few tests and by% ^# B$ k2 ?1 j  n4 Y- n
appropriate history. The inability to obtain such a
! ]/ C- a; Y& D0 O# \# Ahistory, or failure to ask the specific questions, may4 Z1 L! c1 P0 ]& N, P% o
result in extensive, unnecessary, and expensive
: \2 u  L$ E4 s/ e9 Minvestigation. The primary care physician should be
: `# o! [$ X! ^+ d5 j  s  |2 zaware of this fact, because most of these children5 G# Z/ m! n. ?/ `. x# ]5 o
may initially present in their practice. The Physicians’5 l2 U: @6 V  {
Desk Reference and package insert should also put a
% c- ^" ?  @( W& Bwarning about the virilizing effect on a male or" y/ w) y+ c# P
female child who might come in contact with some-
: x: j- b7 A* @+ \- N, h: sone using any of these products.) q1 K5 o0 f/ J- Q+ w
References4 v: ]- P1 _. n$ A
1. Styne DM. The testes: disorder of sexual differentiation
' ?: P  J" t7 C/ C* m+ D0 yand puberty in the male. In: Sperling MA, ed. Pediatric
1 A7 N, f) ?1 C7 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 ]; n9 W! |) q4 x' M3 p9 r: L
2002: 565-628.
9 [$ d* f5 @" g' @  L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 ~+ a: J7 P" R7 ^% y/ q4 K% h
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
: G1 B  O# t0 M* Q/ I8 S) w
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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