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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; \0 p) K& N% m
Boy Induced by Indirect Topical
' K* V# i, h8 A- a; RExposure to Testosterone6 N9 C" L/ C) G% M3 e+ Y3 M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( Y% M' }/ s1 a$ d
and Kenneth R. Rettig, MD13 }, ^5 e" b8 [3 c
Clinical Pediatrics
4 \4 s2 x9 z" e: j$ A. k, uVolume 46 Number 6' N" B/ ]; c  p5 U* w. P+ t
July 2007 540-543
! j+ O1 S3 g. b6 s9 X# \© 2007 Sage Publications1 Z$ V  }5 ]3 p
10.1177/0009922806296651, f/ ]. k2 S, q
http://clp.sagepub.com
( e2 B( `$ m- `- W) mhosted at2 I: |; |) @9 T4 Z6 c" I
http://online.sagepub.com% u+ N- \3 W# u6 T
Precocious puberty in boys, central or peripheral,
  j, S( r  I5 _' }is a significant concern for physicians. Central( x0 W4 u" C4 U, t
precocious puberty (CPP), which is mediated
" Q7 |! }' K# O, j- t' Gthrough the hypothalamic pituitary gonadal axis, has; @/ i3 o" W( V3 K" G& d
a higher incidence of organic central nervous system, O4 F) H& @% b+ C( S
lesions in boys.1,2 Virilization in boys, as manifested# U7 r- W4 b7 d8 n1 Y" l
by enlargement of the penis, development of pubic
' O- x3 r3 m# U: M; k  T5 L; N8 `hair, and facial acne without enlargement of testi-
) E1 V( F( a+ O! M; tcles, suggests peripheral or pseudopuberty.1-3 We
) Y! d+ s* Y7 L6 k. A+ e$ Ireport a 16-month-old boy who presented with the
9 H% Q6 ~2 {- ^  v; Qenlargement of the phallus and pubic hair develop-
1 _$ P9 O+ \2 U/ Dment without testicular enlargement, which was due# O; O( A1 a3 G! h' _  x6 A) P+ [
to the unintentional exposure to androgen gel used by
( a  R4 ?. s% C+ i/ Kthe father. The family initially concealed this infor-
# ~. D9 V1 h2 B; t: D4 f6 Q! a' dmation, resulting in an extensive work-up for this: U  N5 G) a9 U( W9 J" \5 Q
child. Given the widespread and easy availability of6 m' Y! G2 }/ ?* l
testosterone gel and cream, we believe this is proba-0 W- h- f9 `/ A" o
bly more common than the rare case report in the
% J0 u' c( T  t5 Y  y2 D0 Jliterature.4# y5 U! B; Q0 X% g
Patient Report+ I+ S4 M& i5 p5 G5 z+ i0 }
A 16-month-old white child was referred to the/ k( Q6 X1 U9 P9 P! z% r6 B+ [8 N+ u4 l3 L
endocrine clinic by his pediatrician with the concern5 ^6 e" c" g, U- X* `
of early sexual development. His mother noticed$ |! y# ~/ d9 `/ ^# Y
light colored pubic hair development when he was
, n! E, T# T4 c% I" [/ YFrom the 1Division of Pediatric Endocrinology, 2University of8 D' a) T" K8 P8 C5 K. W
South Alabama Medical Center, Mobile, Alabama.
! U  k, B' u7 @2 }7 R8 }& z* {Address correspondence to: Samar K. Bhowmick, MD, FACE,! J9 U( E; W% s1 D* q; p
Professor of Pediatrics, University of South Alabama, College of
9 D  \8 l; B$ E% B, pMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 t  [0 p8 P' l' F+ Le-mail: [email protected].6 G1 p% H8 s) V, b' y. m
about 6 to 7 months old, which progressively became
; ^8 G# J) C( n* R2 h4 ddarker. She was also concerned about the enlarge-
: M" L" _3 n! S# v5 H3 F) f* bment of his penis and frequent erections. The child
" K# q* O- |2 o6 z+ jwas the product of a full-term normal delivery, with
( M) K4 ~: L& Q  M2 ?/ ya birth weight of 7 lb 14 oz, and birth length of" S, r8 R7 p1 }
20 inches. He was breast-fed throughout the first year
- ^& I- n+ j6 k% ]1 ^, Lof life and was still receiving breast milk along with
  Z6 Y0 q+ G8 e1 y4 ?5 ]2 psolid food. He had no hospitalizations or surgery,
5 l1 W+ \) N. V. P% Kand his psychosocial and psychomotor development. l, `+ w$ w2 u. I# e6 L
was age appropriate.
8 a5 S& m3 ~1 w: H( gThe family history was remarkable for the father,' h7 @& w! R$ b/ R) J; g1 ?1 \
who was diagnosed with hypothyroidism at age 16,
- J; y% N# `, A! s5 u3 z9 {2 Nwhich was treated with thyroxine. The father’s
/ E5 B, x0 R1 ~" W  A9 iheight was 6 feet, and he went through a somewhat4 Y# f, P+ L: e4 I1 f
early puberty and had stopped growing by age 14.3 c% C' L' c2 G
The father denied taking any other medication. The
$ W0 T+ ]  U+ Pchild’s mother was in good health. Her menarche. q6 `+ a# U7 @* ]( t5 V* y5 Q! z
was at 11 years of age, and her height was at 5 feet
  I  C5 k$ A2 a3 \$ A3 V& V/ J5 inches. There was no other family history of pre-' N2 W4 [1 y/ d
cocious sexual development in the first-degree rela-
+ v/ F& R' S5 g* i. ]tives. There were no siblings.) v: ~, y  p9 `" q" s: Z, r
Physical Examination3 X  t* u! u4 k" ?7 t: A; T
The physical examination revealed a very active,
9 P# A0 a) @, F: d: U  _playful, and healthy boy. The vital signs documented
2 d  M! F0 r; @/ W. Ya blood pressure of 85/50 mm Hg, his length was
- M' w) |& n7 g6 F! Y90 cm (>97th percentile), and his weight was 14.4 kg3 R# D. z3 A2 y$ V; d; e2 c& h: m! ^
(also >97th percentile). The observed yearly growth
  d7 O' Q6 t8 c, U- k) tvelocity was 30 cm (12 inches). The examination of4 R& B% ?/ a+ X! L
the neck revealed no thyroid enlargement.5 Q  U6 k$ K. H& [' N  v
The genitourinary examination was remarkable for& l* c8 ~8 _8 a7 m% R
enlargement of the penis, with a stretched length of  T9 M% F5 l" K* m( O% F
8 cm and a width of 2 cm. The glans penis was very well6 M! ~9 T4 T8 R
developed. The pubic hair was Tanner II, mostly around
4 \5 F) i) w6 E2 ?1 G540
+ w" i% G2 y7 h3 T" `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' |4 k4 M9 D: d/ B$ ]
the base of the phallus and was dark and curled. The; g( }5 {3 T. _* U7 C
testicular volume was prepubertal at 2 mL each.
# O/ x1 S1 d9 s- I4 aThe skin was moist and smooth and somewhat" @$ |+ \" C7 c+ k4 b
oily. No axillary hair was noted. There were no& h! O- A% |) V
abnormal skin pigmentations or café-au-lait spots.
  a) q/ Q( D8 O+ F5 b! ?* D: E) aNeurologic evaluation showed deep tendon reflex 2+) V1 Q  m1 @: M# f& h9 x
bilateral and symmetrical. There was no suggestion
# T2 ^7 P) |$ O9 ~( Mof papilledema.
9 J, u0 f' |3 T& cLaboratory Evaluation+ ~6 @" j- l. O6 w, o
The bone age was consistent with 28 months by7 w* u8 r. X2 q- U, C) \8 W
using the standard of Greulich and Pyle at a chrono-; n% b: `* y6 _* z; M
logic age of 16 months (advanced).5 Chromosomal
; n! n5 D3 V! Gkaryotype was 46XY. The thyroid function test
# X9 z: {0 @/ X' vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- J, c, F9 _8 S# ^) m2 K
lating hormone level was 1.3 µIU/mL (both normal)./ d  w! u; k8 t7 [
The concentrations of serum electrolytes, blood
3 W8 ]+ ^, t5 u$ C4 }4 ]6 Zurea nitrogen, creatinine, and calcium all were# ?. E& {5 s- \/ O# x; S
within normal range for his age. The concentration
  g2 \7 q6 \  _2 c  y. ]( {) vof serum 17-hydroxyprogesterone was 16 ng/dL
, `9 d6 H- k. a2 j' X(normal, 3 to 90 ng/dL), androstenedione was 20+ s+ D6 o+ ?. b: y- ~* O. {; b
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& o+ p" R0 `8 `% c2 ~3 Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 Z& j5 ^. V% ^! e, w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! e1 i3 F  k, B' N49ng/dL), 11-desoxycortisol (specific compound S)4 y" f9 B4 U: p) F3 W5 u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% a- r' h* X. _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 X# F( ~( Z8 z9 m" Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: X- L7 G  r4 e3 cand β-human chorionic gonadotropin was less than
' v! J$ K( x$ r8 l# V/ H2 g5 mIU/mL (normal <5 mIU/mL). Serum follicular7 l' T; m4 p4 }+ s6 N: R4 F7 j
stimulating hormone and leuteinizing hormone% I$ U9 ]. f  \* a, A9 H$ \
concentrations were less than 0.05 mIU/mL( B. {- \& o* c
(prepubertal).' v! K1 z, {3 }: B
The parents were notified about the laboratory
' p2 O6 E1 U  m; x4 x  u5 iresults and were informed that all of the tests were+ I4 ^) M2 B+ G
normal except the testosterone level was high. The( y$ g7 y: H+ O+ J( Y: ^
follow-up visit was arranged within a few weeks to
) ]) e" P9 u( h6 O( I$ T4 c' kobtain testicular and abdominal sonograms; how-
( s7 l: F; P  Fever, the family did not return for 4 months.
, x; `. k) Q. B4 pPhysical examination at this time revealed that the% N  S: G3 D9 C, _
child had grown 2.5 cm in 4 months and had gained8 K2 q) m/ k' T2 t: `! Y
2 kg of weight. Physical examination remained
' ^" g$ p2 v8 K5 n/ n. |unchanged. Surprisingly, the pubic hair almost com-
& c6 v# v4 N: {pletely disappeared except for a few vellous hairs at" R8 |) _0 {% y- ^! q" Q. W
the base of the phallus. Testicular volume was still 24 J/ h9 c, E4 a* e) Z/ i5 d" F
mL, and the size of the penis remained unchanged.
8 [) ^8 i& a! X5 P) N1 lThe mother also said that the boy was no longer hav-
+ {- T& B5 e: I9 z# q* ying frequent erections.! }7 |5 u& Q# f: k9 W
Both parents were again questioned about use of
' H/ n6 g) o8 N& S$ gany ointment/creams that they may have applied to
  t* M: |4 U' m, Mthe child’s skin. This time the father admitted the9 ]( a2 }2 R- l% c3 g! g$ G& u7 l
Topical Testosterone Exposure / Bhowmick et al 5411 z) i% [  z* O8 c5 q0 ]8 ~/ u
use of testosterone gel twice daily that he was apply-9 |) n8 H+ S2 Y* \& G0 k
ing over his own shoulders, chest, and back area for8 r% a+ q  J; v! `4 A- R# y
a year. The father also revealed he was embarrassed, O7 y7 h; _3 J9 b7 K; L& Z
to disclose that he was using a testosterone gel pre-
& I2 v6 e  [  T. ?scribed by his family physician for decreased libido
: E. t8 a% j; N9 k$ Esecondary to depression.
: {% H) M& t& R$ UThe child slept in the same bed with parents.
4 ~4 h8 x  S; q# AThe father would hug the baby and hold him on his. S$ J7 H. \% G* V4 O+ t
chest for a considerable period of time, causing sig-
3 n% M9 ?: H  dnificant bare skin contact between baby and father.
- M! a+ h7 l4 l6 C& M7 h+ UThe father also admitted that after the phone call,
1 Z$ a3 m+ J+ w1 awhen he learned the testosterone level in the baby
  u* ~: l4 w7 v! Cwas high, he then read the product information
9 t8 a: b7 l6 H# ?0 \: _/ J  \$ \8 qpacket and concluded that it was most likely the rea-
  F% u9 U0 r- J3 L$ ?son for the child’s virilization. At that time, they) }; n( k  u4 p: H% T
decided to put the baby in a separate bed, and the! T: O" e( K* R+ Y( i6 ?
father was not hugging him with bare skin and had; B5 ]+ s9 {4 {  T
been using protective clothing. A repeat testosterone
9 ^% t- n9 u7 D8 w2 {test was ordered, but the family did not go to the8 m" r" s' @& ?
laboratory to obtain the test.
, _+ O! Z6 U2 T/ c, gDiscussion. E# {: x- Z" @( J' ^4 m3 N
Precocious puberty in boys is defined as secondary+ m! Y7 Q. w/ b' m$ g+ i$ `% ^
sexual development before 9 years of age.1,43 L" J( O) Z3 H0 \
Precocious puberty is termed as central (true) when
1 B4 y( g( B1 v, O5 L: G) a+ bit is caused by the premature activation of hypo-
( I4 m" P- v  Z" U( S! ithalamic pituitary gonadal axis. CPP is more com-* W& |0 N! V3 y& b- F+ e
mon in girls than in boys.1,3 Most boys with CPP+ ?# t+ g; a8 K0 k) O
may have a central nervous system lesion that is
* f" F0 L$ [: u. aresponsible for the early activation of the hypothal-
' G+ H; f, o! L0 V7 E) J4 s( Y, p" Iamic pituitary gonadal axis.1-3 Thus, greater empha-
. \$ [  @( B) vsis has been given to neuroradiologic imaging in4 j4 q$ e% I5 Q# J6 U
boys with precocious puberty. In addition to viril-
& o0 p4 J1 o+ f7 E7 B. Iization, the clinical hallmark of CPP is the symmet-- _' w( O6 I) C7 J# j+ t/ q
rical testicular growth secondary to stimulation by/ M9 e; {: p4 b
gonadotropins.1,3
) {$ S" b2 g+ B2 iGonadotropin-independent peripheral preco-
; U! _2 y8 W6 q  |" ucious puberty in boys also results from inappropriate
- V1 ~& u7 [# M' o2 ]androgenic stimulation from either endogenous or
5 T6 h* u$ m, S  T/ Fexogenous sources, nonpituitary gonadotropin stim-
& J* V% Z7 j7 w7 I% V9 J1 u4 hulation, and rare activating mutations.3 Virilizing
1 e3 X* q' o2 J1 \8 J9 |7 mcongenital adrenal hyperplasia producing excessive) z2 _% _7 A2 l1 }
adrenal androgens is a common cause of precocious! c5 q' }4 f$ I' C  }
puberty in boys.3,4
" a# p3 M' W" j. E3 V/ @& q7 QThe most common form of congenital adrenal
' h6 c) }" L$ nhyperplasia is the 21-hydroxylase enzyme deficiency.5 {* B4 \1 K: v- p# x7 j4 v
The 11-β hydroxylase deficiency may also result in
2 w8 o# C( v7 dexcessive adrenal androgen production, and rarely,* m) P) K8 ^+ q3 y! K0 R- c
an adrenal tumor may also cause adrenal androgen7 @: D7 X2 H7 A" \* o6 Q, i& g
excess.1,3
; a$ d* {' J% a  m- p8 w' Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 J0 {; O1 v! e% ]: V* k542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# J, f! S$ c8 M% b; R
A unique entity of male-limited gonadotropin-* |5 G4 N2 J* d! A' A
independent precocious puberty, which is also known( e  G  X) U. J% n+ k
as testotoxicosis, may cause precocious puberty at a
2 P# `9 T3 Z& Y9 a8 ?7 M$ @very young age. The physical findings in these boys' b# ^  Q( |3 `5 Y
with this disorder are full pubertal development,5 h# J( c! i$ Y4 J+ K1 H9 c9 k5 T
including bilateral testicular growth, similar to boys
5 f' o( o" y/ Bwith CPP. The gonadotropin levels in this disorder
! \) l4 Y4 X5 \are suppressed to prepubertal levels and do not show
9 q3 Z1 ^- p3 Fpubertal response of gonadotropin after gonadotropin-
8 }3 A' S% D8 G) @/ C& z3 hreleasing hormone stimulation. This is a sex-linked
* W0 Y$ k& @3 [9 e( q$ |% O. xautosomal dominant disorder that affects only1 r% I( ~' S* M& ^
males; therefore, other male members of the family
0 }: l+ S! i& H1 emay have similar precocious puberty.3
) P) ]5 a# G5 g8 c4 V  YIn our patient, physical examination was incon-- H  g1 }9 j5 R5 D& ^
sistent with true precocious puberty since his testi-
/ c! \, ]1 f% k" Scles were prepubertal in size. However, testotoxicosis
, c# y# H4 a# c% o  Fwas in the differential diagnosis because his father3 w; q# t5 X3 ~- D0 P
started puberty somewhat early, and occasionally,2 n1 O, \4 W9 p6 \. w
testicular enlargement is not that evident in the
* P; M0 D& i: K0 P5 U. E) Xbeginning of this process.1 In the absence of a neg-
' Z# o; N+ o$ `9 x5 U* V0 Eative initial history of androgen exposure, our; Q" Z  g# [. ?/ g) n, \
biggest concern was virilizing adrenal hyperplasia,% T6 l& J! n2 B# ?" P4 F5 I
either 21-hydroxylase deficiency or 11-β hydroxylase$ `% r- W8 L( G5 m, z5 o* Z
deficiency. Those diagnoses were excluded by find-& }' M, h3 e# _  B. c
ing the normal level of adrenal steroids.
- T1 O) K* f1 cThe diagnosis of exogenous androgens was strongly
5 p% B& _/ K4 Q, W& P$ zsuspected in a follow-up visit after 4 months because
" D/ [  ^1 L# X1 @9 H' G& tthe physical examination revealed the complete disap-$ Z  e; F+ w1 B9 ~9 s5 B; P
pearance of pubic hair, normal growth velocity, and
  _- T# t! |, I! u# p1 R5 p5 Fdecreased erections. The father admitted using a testos-+ k( v3 l  z* ~7 M2 j  i
terone gel, which he concealed at first visit. He was
; e2 |1 F6 ^. _7 P' zusing it rather frequently, twice a day. The Physicians’
' k+ t1 C/ P% BDesk Reference, or package insert of this product, gel or
* U# {- f1 k/ v) {9 g+ ncream, cautions about dermal testosterone transfer to4 b, t. J2 ^, a
unprotected females through direct skin exposure.8 G1 S/ ^& g- L4 @( q: [
Serum testosterone level was found to be 2 times the
9 L7 \3 i2 M! s9 j, S; Lbaseline value in those females who were exposed to% J& k/ {+ A  [& g; \& d+ g  u
even 15 minutes of direct skin contact with their male8 I* s7 C' O. ~
partners.6 However, when a shirt covered the applica-
& U0 h2 s4 h6 w5 d# Ktion site, this testosterone transfer was prevented.
, `: b5 z8 K: b$ M- Z: s9 gOur patient’s testosterone level was 60 ng/mL,1 g; \9 g. ]+ U* w7 K+ Y
which was clearly high. Some studies suggest that
! u4 {. u# \3 L6 A0 N% {dermal conversion of testosterone to dihydrotestos-; m* p& L: L$ q& ]( N2 P
terone, which is a more potent metabolite, is more
" z8 R& y+ |" j+ y  V7 u8 f; oactive in young children exposed to testosterone) T+ u0 x( \# S( T! a( k, L& M* ^
exogenously7; however, we did not measure a dihy-
/ ?0 B$ V! k0 l4 rdrotestosterone level in our patient. In addition to5 }0 ^# T( i+ h4 K+ _3 t
virilization, exposure to exogenous testosterone in
* j( r4 f; u1 M* ^6 q* qchildren results in an increase in growth velocity and0 k8 Q. w$ S# K# [  a
advanced bone age, as seen in our patient.
9 K5 [. q5 U+ a! g% I7 @# t6 j0 hThe long-term effect of androgen exposure during1 j9 H( ^$ F) [  Z$ O
early childhood on pubertal development and final
! w* a5 H- x& G: iadult height are not fully known and always remain' ?7 K& n# R( K* s/ n( Q
a concern. Children treated with short-term testos-# y& N+ C& P4 M( ]
terone injection or topical androgen may exhibit some
& F3 S, D; U& f. wacceleration of the skeletal maturation; however, after
, g) N+ ^; k# pcessation of treatment, the rate of bone maturation
# u6 C) ]1 x2 f1 B# h4 Adecelerates and gradually returns to normal.8,9, C! K4 ?; U' n& b/ i) R0 w
There are conflicting reports and controversy
0 B( |1 P* e8 C+ h7 V1 dover the effect of early androgen exposure on adult
+ u, `8 ^! g+ N( mpenile length.10,11 Some reports suggest subnormal
* t6 P% i2 P: \9 X; radult penile length, apparently because of downreg-& `* C5 W4 D9 l- K9 `4 U& p
ulation of androgen receptor number.10,12 However,2 d2 p: E4 j# F+ T) K
Sutherland et al13 did not find a correlation between
# M& d/ L; b; ichildhood testosterone exposure and reduced adult
7 M2 K, R. d/ C5 O$ d; j# {penile length in clinical studies.
* b: s& D1 I6 j' T9 E% h% k* R: E7 j: CNonetheless, we do not believe our patient is- z" ?5 W5 \- v; k, c2 g) u% P6 z
going to experience any of the untoward effects from  @- M# g1 F: a+ u7 D% b
testosterone exposure as mentioned earlier because" K( e& u( m+ L1 P$ q
the exposure was not for a prolonged period of time.
- f+ |& H- w8 D% f; U' HAlthough the bone age was advanced at the time of4 I! @+ G1 r7 ?9 w; h/ O
diagnosis, the child had a normal growth velocity at5 f+ M" \; [- h& b* y, S5 o) K
the follow-up visit. It is hoped that his final adult  k1 B6 h* M" I6 o: U& [
height will not be affected.' ]2 a' H% N- B/ [
Although rarely reported, the widespread avail-/ K' w" U9 F% d* e/ o2 }6 k
ability of androgen products in our society may% |2 Q" M$ e; U5 n, \3 c+ `
indeed cause more virilization in male or female, q/ ?3 l: A: h! ^# [' R+ u$ f- [
children than one would realize. Exposure to andro-
8 G" X8 Z. c  j+ H/ zgen products must be considered and specific ques-4 q" {6 ~6 q5 `' D% c+ m
tioning about the use of a testosterone product or  H7 a- I( e1 R7 Z& v6 @% w
gel should be asked of the family members during1 v6 A% k8 }. A* ]" y
the evaluation of any children who present with vir-2 y7 G& Q9 k' J# ?' q/ x8 M# _; Z
ilization or peripheral precocious puberty. The diag-
' k; d7 w' A" Inosis can be established by just a few tests and by
' a9 x- C- T( C. K' ^appropriate history. The inability to obtain such a" F' D* m8 y' d+ x1 z* _6 @
history, or failure to ask the specific questions, may
3 {# {/ Z: S) z2 u) Q  kresult in extensive, unnecessary, and expensive) B2 i1 P& \- a6 ?
investigation. The primary care physician should be  a5 y5 L/ t, i+ Q1 r/ s1 ~
aware of this fact, because most of these children' C! M' X( m5 ]1 Z& u$ S
may initially present in their practice. The Physicians’3 C4 e  W) T3 J3 b# I% K
Desk Reference and package insert should also put a- G1 h# `7 w) U* n7 V* V9 j( O) J
warning about the virilizing effect on a male or( t" u6 H( k5 l/ S, L
female child who might come in contact with some-$ f8 X: G- @; Y5 W" Z4 i& f/ c
one using any of these products.% K5 z$ T; M) K
References- t3 C( B6 d, s1 f
1. Styne DM. The testes: disorder of sexual differentiation# E* y  x1 I; x3 p2 M
and puberty in the male. In: Sperling MA, ed. Pediatric
0 c+ U$ I7 E6 q, h  z% ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 j! D- A5 K% l) m/ Q: X2 U. a
2002: 565-628.6 w: ~) e  Z6 m
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( N0 \8 e$ I8 z
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old. i+ L, a. U, f# ]) `5 y" k+ d
Boy Induced by Indirect Topical
3 t  X6 C, X$ o/ D' A# F# w% X8 bExposure to Testosterone
6 v# k1 |. \; x+ X6 t& I& Q* m7 {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 O2 D* Y  I3 g9 T  p0 X- Q+ [
and Kenneth R. Rettig, MD1
$ |/ |& G4 I0 h2 T2 j/ LClinical Pediatrics+ h; m0 D, V/ Y2 L# v! u! J
Volume 46 Number 6" ^4 v$ W, X; D( r) f
July 2007 540-543. d1 ~: z3 `. A5 v8 y+ J
© 2007 Sage Publications
8 i  L( D6 g- o7 z; E1 v5 o, p10.1177/0009922806296651
. b# j# E, m9 E. T# ohttp://clp.sagepub.com
8 ^8 g6 N+ m. \6 i8 b0 Shosted at: U" {; i, N: n! A
http://online.sagepub.com
1 L( x  q4 ^% |$ t! t& J7 B3 M, ~Precocious puberty in boys, central or peripheral,' e+ d8 w+ b* {$ Q) X7 i
is a significant concern for physicians. Central8 B! y" h0 I7 t2 i- Y( ?! r$ r* B
precocious puberty (CPP), which is mediated. z5 @; f$ g1 I7 J5 P
through the hypothalamic pituitary gonadal axis, has4 n# m5 y$ w, `1 u
a higher incidence of organic central nervous system8 d, Z( S$ k) ^! A8 \
lesions in boys.1,2 Virilization in boys, as manifested% ]9 W$ D& ]0 H0 n( G
by enlargement of the penis, development of pubic
# u4 b* q: D. s/ i- A# K  Vhair, and facial acne without enlargement of testi-7 i8 q6 e3 S: U7 x$ U" D* `
cles, suggests peripheral or pseudopuberty.1-3 We& |( I. u( @) n" R
report a 16-month-old boy who presented with the
, I  f1 m0 k$ G' H, d+ a& e" ?; {enlargement of the phallus and pubic hair develop-
0 `& G# `4 }( Y1 g2 sment without testicular enlargement, which was due
4 ^- X2 `  A- S, `. ?# k2 |0 kto the unintentional exposure to androgen gel used by
  j7 t0 R7 o9 |) f- T* I* Othe father. The family initially concealed this infor-: x4 g5 u. j3 @
mation, resulting in an extensive work-up for this
" s7 J8 M! g/ ^; {child. Given the widespread and easy availability of
# Q+ L; n9 R* S/ p* o( Atestosterone gel and cream, we believe this is proba-
# R: U/ _- L& D8 Rbly more common than the rare case report in the
* w) n2 q) A/ d& c  _; H7 Oliterature.4/ r. L+ o0 l4 f
Patient Report
1 X: h; |3 w" z2 M' _3 w' kA 16-month-old white child was referred to the! [$ f" E- Z7 \, g9 }
endocrine clinic by his pediatrician with the concern
; I  ?% y# o0 |1 u( @# y3 cof early sexual development. His mother noticed
6 J; z9 }9 ~5 F: _light colored pubic hair development when he was1 h6 J2 c$ F; x  @1 S4 M
From the 1Division of Pediatric Endocrinology, 2University of) p9 D4 N9 ]; t3 `* ^: w, a0 \( p
South Alabama Medical Center, Mobile, Alabama.& ]  z  I) Y* Z% V6 ^2 M3 D" B
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' c6 t) E) X" G" Z' e/ X1 {Professor of Pediatrics, University of South Alabama, College of  I' z7 l; B( D7 i( n0 H  l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& z5 q2 K5 a) u/ Z& R- B
e-mail: [email protected].
- I. I+ O* B- Fabout 6 to 7 months old, which progressively became
# r: Y/ W; y* w4 udarker. She was also concerned about the enlarge-7 x6 P3 w* Y: ~2 x9 v. Q
ment of his penis and frequent erections. The child! y5 z; p% w" C, {7 X5 j
was the product of a full-term normal delivery, with: a, f- q( q' A3 |! W( `
a birth weight of 7 lb 14 oz, and birth length of" q! B. ~1 I( t5 M5 K1 h
20 inches. He was breast-fed throughout the first year% y  @  n" P9 {# \9 P+ @: m
of life and was still receiving breast milk along with
3 \7 s3 c5 X5 L6 Ksolid food. He had no hospitalizations or surgery,
/ c8 `. x- z* `1 p) sand his psychosocial and psychomotor development
7 i' I) M& `" [& e5 K' b7 k6 vwas age appropriate.
* C* z! N$ e4 o7 d' a; UThe family history was remarkable for the father,
' Q8 D! e" [5 @/ J1 a" q4 ^" Ywho was diagnosed with hypothyroidism at age 16,0 h  {0 ?, p3 o9 p& c( e0 {
which was treated with thyroxine. The father’s# a- ~  B4 k% |9 Z; ]
height was 6 feet, and he went through a somewhat% p9 i' r# a+ c4 H; U( B
early puberty and had stopped growing by age 14.% K, Y; ?" I1 m# E
The father denied taking any other medication. The
5 m- I6 a6 a  }  ^1 K6 ^3 {+ K- |child’s mother was in good health. Her menarche7 t6 }6 \  r# v- B
was at 11 years of age, and her height was at 5 feet+ M/ y" Y& I* L8 A3 v  e% i4 d$ K
5 inches. There was no other family history of pre-
% J% [7 C  t& N- ~cocious sexual development in the first-degree rela-' U' A2 e% ]; Y) v3 P8 D5 l
tives. There were no siblings.
1 h) r% @. B% j: T# H7 uPhysical Examination
2 s" G' B8 |& o. l& l! VThe physical examination revealed a very active,+ W' x0 ^- C( M9 [& X
playful, and healthy boy. The vital signs documented& {3 n9 [# x6 s6 E* M2 B* W. S; }
a blood pressure of 85/50 mm Hg, his length was
% X8 x  _' o# i: H90 cm (>97th percentile), and his weight was 14.4 kg1 `1 R* A+ k: c+ b3 k- f1 M
(also >97th percentile). The observed yearly growth
- p/ J% u2 r, t' Nvelocity was 30 cm (12 inches). The examination of
. q: V* q+ A; H% q; |+ Uthe neck revealed no thyroid enlargement.
* D* p+ {" l9 o0 J9 P; j" e5 E/ [! T7 fThe genitourinary examination was remarkable for' z: ~/ E6 \- {
enlargement of the penis, with a stretched length of
9 u/ _# p6 F9 [6 ^3 H- d( E- E8 cm and a width of 2 cm. The glans penis was very well
  O0 ^% E& p% @5 O6 h6 bdeveloped. The pubic hair was Tanner II, mostly around- T. R9 b; V/ q
540
' i' Q& v% ^( Z. P, A! o) nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ P; n" j& ?2 _, d. m% [7 \the base of the phallus and was dark and curled. The; K1 m0 I7 u* y) F" |  Q. F' Y# M
testicular volume was prepubertal at 2 mL each.; @% p/ x, K' h8 T
The skin was moist and smooth and somewhat
6 A6 r7 e& O7 woily. No axillary hair was noted. There were no
) ~) F+ K# }1 h. P& K! D! Q  Eabnormal skin pigmentations or café-au-lait spots.
- m8 V- g, U' U# F0 B0 _Neurologic evaluation showed deep tendon reflex 2+* m' O4 b& C! C$ r9 Z. \9 x
bilateral and symmetrical. There was no suggestion
6 U5 [9 E1 |* jof papilledema.2 g( r* p. h7 _; \6 X
Laboratory Evaluation1 K" n2 |) O5 ?3 ?- y6 e
The bone age was consistent with 28 months by
1 U' c4 p# I% s9 P7 b/ e( {using the standard of Greulich and Pyle at a chrono-
2 l4 y8 q3 r- ologic age of 16 months (advanced).5 Chromosomal7 @3 b% T) k0 o+ w/ ^9 y2 X
karyotype was 46XY. The thyroid function test
! F, S: e# |9 a, X- u$ mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-2 `! b0 ?# v3 w- m( v
lating hormone level was 1.3 µIU/mL (both normal).' {% d, O0 a0 ?, {) [
The concentrations of serum electrolytes, blood
' U& R2 m' R. I8 I7 furea nitrogen, creatinine, and calcium all were1 o( R, o( v4 @* _; m& w8 L
within normal range for his age. The concentration' `6 K) S8 i) x9 c, v/ o" l5 r+ G5 x
of serum 17-hydroxyprogesterone was 16 ng/dL
: j6 v1 o( r. z- C: z' T(normal, 3 to 90 ng/dL), androstenedione was 20  \5 S8 Z/ S! G' R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) v% x" e$ @! [+ X! k% h; d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 b/ {# Y/ @0 q5 C: wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! A) y: m, t' I49ng/dL), 11-desoxycortisol (specific compound S); F% i  t/ z% a" p8 J4 v$ E- {. h
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, k9 T1 o* b! g, ~- q0 R! }+ ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 U. Y. P4 z# v4 t- P, C' Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& s2 ]* Z8 H5 {# |& R% v+ \& @2 Mand β-human chorionic gonadotropin was less than
) e8 {& Z; }  u) o5 mIU/mL (normal <5 mIU/mL). Serum follicular
% P; f% ^& l, P4 r9 Estimulating hormone and leuteinizing hormone
2 n. Y, H/ R7 |: }concentrations were less than 0.05 mIU/mL3 b3 q. c( t6 a( f+ a
(prepubertal).& ]( g# T4 o1 W9 t4 L
The parents were notified about the laboratory
. f& H" |0 [. i4 Dresults and were informed that all of the tests were
) Q; p* @( R& {! L8 p' jnormal except the testosterone level was high. The# |4 a% l* P, {  u8 C) ?
follow-up visit was arranged within a few weeks to; Y' d" d# a% r# {, S, A
obtain testicular and abdominal sonograms; how-
, K. P" G5 I" ]0 y0 W1 Mever, the family did not return for 4 months.; v* f# S/ P, d( G! d, x. D
Physical examination at this time revealed that the
6 g' ^4 ]4 q* K- Y1 K% `child had grown 2.5 cm in 4 months and had gained
( J) j* `' |' e' X9 I* N) a2 kg of weight. Physical examination remained5 r' w* {4 i" k. H2 N
unchanged. Surprisingly, the pubic hair almost com-5 t, w- ]4 u0 R: z# |) @: ~6 J
pletely disappeared except for a few vellous hairs at
8 ~# n5 ~- U2 z5 r, pthe base of the phallus. Testicular volume was still 2
2 e# \! C8 I& wmL, and the size of the penis remained unchanged.4 L. p) X, D" ?4 ^9 l! O! {
The mother also said that the boy was no longer hav-% o& A4 F! o* e# {, V
ing frequent erections.$ w2 f+ O5 O$ ~6 h# B6 J4 _; x
Both parents were again questioned about use of$ S: w5 V7 ^- |' E: V1 p
any ointment/creams that they may have applied to0 j" l+ \" O/ N$ n6 Z* F  `0 b
the child’s skin. This time the father admitted the
$ x2 }' |# A. ^7 |Topical Testosterone Exposure / Bhowmick et al 541
) K- |! v2 |, o0 [& muse of testosterone gel twice daily that he was apply-" v0 O( G5 v4 j% @* T/ h0 {
ing over his own shoulders, chest, and back area for
( P/ ]- T& d! Q9 |8 ua year. The father also revealed he was embarrassed- Y# W1 k2 N! a+ V
to disclose that he was using a testosterone gel pre-
& t! R: l$ l& J0 ?$ T# `scribed by his family physician for decreased libido; k! }+ e% s  A6 r, b9 E2 }3 y
secondary to depression.
( D, K: g$ N6 O+ t5 i. gThe child slept in the same bed with parents.
5 i( Q0 s; g) P9 PThe father would hug the baby and hold him on his4 }# X' a( o- A, [1 h: H
chest for a considerable period of time, causing sig-0 e: X9 p% y3 a# a  A- u" X
nificant bare skin contact between baby and father.
3 X; P! t$ q  u2 T# I+ m8 rThe father also admitted that after the phone call,
8 }. d' h( D' _5 I# P5 ], d4 wwhen he learned the testosterone level in the baby4 y$ W( C* J) v
was high, he then read the product information
' S* g: X7 ~1 r. i+ `packet and concluded that it was most likely the rea-
! q$ i3 F6 K2 M0 m9 @( Xson for the child’s virilization. At that time, they
6 F7 z6 {$ _4 q4 f7 _% V: k8 sdecided to put the baby in a separate bed, and the
3 K& A' n9 O! d) @father was not hugging him with bare skin and had8 z; S  @* Z: j
been using protective clothing. A repeat testosterone
8 D/ N& Z# f" Y- B+ I# m& Itest was ordered, but the family did not go to the
' v: x; ]) Y$ i  s( T/ N4 I6 klaboratory to obtain the test.
1 J3 o7 q: i  w' D, o4 e7 W/ SDiscussion- g4 l6 j4 H" _7 p. O5 M5 T5 q
Precocious puberty in boys is defined as secondary3 \/ P/ H* N. m4 H
sexual development before 9 years of age.1,4
5 ?. G: T! t7 _* a8 h" Z, y2 n6 dPrecocious puberty is termed as central (true) when- H4 K0 F: V( f% l2 T7 U6 ^4 p6 I
it is caused by the premature activation of hypo-
; R& y7 i6 ^3 {, }* K; Wthalamic pituitary gonadal axis. CPP is more com-
/ K# U& s% W% F1 G9 C' ^2 p8 Qmon in girls than in boys.1,3 Most boys with CPP9 G: z# M9 b5 M! Q* ~4 G
may have a central nervous system lesion that is
/ G: Z( L: U2 ?3 C2 eresponsible for the early activation of the hypothal-
, s4 d* E/ Z  W6 b* T/ Namic pituitary gonadal axis.1-3 Thus, greater empha-
+ g; d! Y) e! R5 r4 Q& \) n% Lsis has been given to neuroradiologic imaging in, K1 c/ a& n3 [( |; b, O* |* o% D6 j
boys with precocious puberty. In addition to viril-
, J) L! |& g# H( D: J$ I. E3 Dization, the clinical hallmark of CPP is the symmet-
  F5 p* F7 W6 t' z/ `rical testicular growth secondary to stimulation by  H1 S5 w  t4 y, Q9 c
gonadotropins.1,3
6 @2 C! d( U, a6 p; nGonadotropin-independent peripheral preco-
  ]* X& E7 _( O1 `2 t; B2 s/ Kcious puberty in boys also results from inappropriate+ z& e+ k4 P0 `: M5 m* g
androgenic stimulation from either endogenous or, Y6 x, C' V. ], Z
exogenous sources, nonpituitary gonadotropin stim-2 c3 u6 a5 W, a8 {6 ~# O
ulation, and rare activating mutations.3 Virilizing
2 H9 ~8 ?9 f0 B, Z2 t7 q6 r% fcongenital adrenal hyperplasia producing excessive
  \3 o, i& D4 _# nadrenal androgens is a common cause of precocious
8 q) G4 _+ |. L: Q( J/ M9 X) j# Q& W* Qpuberty in boys.3,4" `8 W+ V8 A( f6 K! w: h
The most common form of congenital adrenal6 B3 A9 g; ?% \. R, ~$ h/ @- x
hyperplasia is the 21-hydroxylase enzyme deficiency.( h% E/ X, n$ R% P& B
The 11-β hydroxylase deficiency may also result in: g. @1 D' X5 Y
excessive adrenal androgen production, and rarely,! _' K2 P) V+ q3 ?! ?
an adrenal tumor may also cause adrenal androgen
9 ]9 {3 M( _! y. Z/ G7 V$ @5 I. cexcess.1,3& L2 m; w5 I* _3 B6 M% g* t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& K. k( l  M. P' Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 r: h; J2 j. bA unique entity of male-limited gonadotropin-
, I7 [6 Q0 C: ], a- |% f( m6 f0 hindependent precocious puberty, which is also known
9 @( t( E: C5 w: Uas testotoxicosis, may cause precocious puberty at a
2 H2 L* e' N( Z- |+ l3 Vvery young age. The physical findings in these boys+ B, u7 F% j4 y) C4 K5 ?
with this disorder are full pubertal development,
+ [- u$ j. w$ @  H& {including bilateral testicular growth, similar to boys! ?% {5 [/ M, M' n5 A  q
with CPP. The gonadotropin levels in this disorder
* ?. _0 ~4 p5 f' ?4 f  }. iare suppressed to prepubertal levels and do not show" m. e5 t# ~$ L3 F
pubertal response of gonadotropin after gonadotropin-
/ j+ w2 ?5 {# p. ]4 jreleasing hormone stimulation. This is a sex-linked
! q9 [, T, e% f% E/ |1 Jautosomal dominant disorder that affects only( v& W/ E6 Q, E% h3 t- @6 O* M. Y& T. [$ E/ c
males; therefore, other male members of the family' N" s) V; x. L9 Z5 [$ e8 ?6 ?
may have similar precocious puberty.3: H6 L) k& h' Q& t9 h
In our patient, physical examination was incon-2 ]$ o# X; j/ {6 G, N* ?
sistent with true precocious puberty since his testi-
( a' I% Z! `5 q% x' o& y4 Q% Zcles were prepubertal in size. However, testotoxicosis: I8 B9 {5 Q" T4 v% Y* y4 K) s
was in the differential diagnosis because his father7 i# Y0 N- p2 \. r! a1 F
started puberty somewhat early, and occasionally,
' b7 ^0 v* d5 }0 W- O5 j' v, O3 {6 Xtesticular enlargement is not that evident in the" M8 m' F/ T# c% h+ q- u# t
beginning of this process.1 In the absence of a neg-5 G" ^- o) Q) ^% H7 J' s3 {
ative initial history of androgen exposure, our: i3 v% ~. z) @" A& {5 L
biggest concern was virilizing adrenal hyperplasia,! t  T3 F. C' R
either 21-hydroxylase deficiency or 11-β hydroxylase
( e2 }, R4 Z4 o1 q5 {deficiency. Those diagnoses were excluded by find-" \* w. M0 e; Q' o- c: {' _
ing the normal level of adrenal steroids.& V! N" h9 _. b5 W/ a
The diagnosis of exogenous androgens was strongly0 Y( G! d/ q& W' m% t
suspected in a follow-up visit after 4 months because0 y& ]5 _1 b" D" k# r* G
the physical examination revealed the complete disap-& M0 R% C: y* f; B$ _: f
pearance of pubic hair, normal growth velocity, and# `6 w- B9 |" R6 E: n: ^. c+ x* H
decreased erections. The father admitted using a testos-
# r2 W$ m: u$ A8 b% rterone gel, which he concealed at first visit. He was
& s% r; @" L1 u/ p$ c1 Ousing it rather frequently, twice a day. The Physicians’# f6 w6 q: b( H7 y- {. }
Desk Reference, or package insert of this product, gel or
& p) D' o0 Z  _4 `, M8 h# P+ Zcream, cautions about dermal testosterone transfer to
) v+ s8 S2 x! z3 N; _% i3 ?unprotected females through direct skin exposure.. d5 O& _% n3 r" v
Serum testosterone level was found to be 2 times the% Z$ K7 h0 A4 a8 s
baseline value in those females who were exposed to
  z( n1 L: I, s  z3 l2 V( V. ueven 15 minutes of direct skin contact with their male
, q0 V) i) f2 ~0 r- Ipartners.6 However, when a shirt covered the applica-4 q! F7 }7 L5 j% D% n- r/ s0 P
tion site, this testosterone transfer was prevented.
5 B4 p/ Y9 Y6 s8 [2 fOur patient’s testosterone level was 60 ng/mL,3 u- _3 `" D6 R7 p8 P0 `
which was clearly high. Some studies suggest that: t! G+ u% }5 _3 |8 l! c% O
dermal conversion of testosterone to dihydrotestos-
. Z* P/ e% G8 R& Z1 x- Z& [terone, which is a more potent metabolite, is more8 s, q3 t  U. H5 e  W0 X% W4 \
active in young children exposed to testosterone# ~5 H( N# N( B  @1 D4 c! `1 k
exogenously7; however, we did not measure a dihy-
! r0 b/ T/ y  T: F+ U4 ~6 _drotestosterone level in our patient. In addition to
- a* a! z& [& `2 A1 y( E0 Hvirilization, exposure to exogenous testosterone in
+ u. J1 B" f) B2 ~' Lchildren results in an increase in growth velocity and
, Z6 l$ S3 B( F* l# Q& eadvanced bone age, as seen in our patient.
6 O5 R0 k0 J) KThe long-term effect of androgen exposure during, Z' y9 n7 V1 d; b
early childhood on pubertal development and final* q) Z0 J2 \# S+ D6 ]
adult height are not fully known and always remain
7 f8 `3 D+ `9 D! h9 [a concern. Children treated with short-term testos-
" C- ?) Z! ~* F, e' X3 f: `, X) `$ nterone injection or topical androgen may exhibit some1 {* ~; C' G) T* I  N; `
acceleration of the skeletal maturation; however, after, k- G$ Z# ]: |. \1 T+ C
cessation of treatment, the rate of bone maturation
7 t  t2 \, Y; [! {3 w9 g3 s) pdecelerates and gradually returns to normal.8,9
2 S: N1 i! f3 g4 U, nThere are conflicting reports and controversy
5 I: j/ ~& x$ T# g$ j# j/ M) G: Oover the effect of early androgen exposure on adult
4 x. @  _+ _0 L% q8 h0 y; q0 I  qpenile length.10,11 Some reports suggest subnormal
& o& h6 e& L# \6 R, ?, I/ E$ ^adult penile length, apparently because of downreg-
9 Q0 n& k+ ^( W5 _0 ~ulation of androgen receptor number.10,12 However,
; q2 t4 d7 }6 E* ?Sutherland et al13 did not find a correlation between
! F# o) d, b% }! p& Uchildhood testosterone exposure and reduced adult
# u6 V; g, J: A2 w1 ~penile length in clinical studies.) \) V5 m3 X5 O% R, ]' k* }% E
Nonetheless, we do not believe our patient is
0 r& N9 G# k. D5 Z2 lgoing to experience any of the untoward effects from
0 j9 |) ^5 ]* v& t  vtestosterone exposure as mentioned earlier because9 w  C0 P7 u/ i
the exposure was not for a prolonged period of time.  p! c. h3 u2 |) T
Although the bone age was advanced at the time of
4 Z2 R, {+ t/ H, j( L; y* Ydiagnosis, the child had a normal growth velocity at
6 C; Q" W+ Y! G9 p) }the follow-up visit. It is hoped that his final adult
6 p" l3 k" H. I7 K& I' }height will not be affected.
: M4 x& U) S6 r5 {( `Although rarely reported, the widespread avail-1 M; V. x2 c+ Y- `4 b. }
ability of androgen products in our society may
* \* R* ^8 o* w2 Q# i, _- q1 m3 mindeed cause more virilization in male or female: R. `$ K# T1 p% |4 x; P+ j
children than one would realize. Exposure to andro-" d% \1 a* w" H
gen products must be considered and specific ques-
& [3 v, j0 M! W' G: a( vtioning about the use of a testosterone product or
" n- N7 _% Z5 w! |gel should be asked of the family members during
% y' q& I( M: W9 sthe evaluation of any children who present with vir-' ~0 S6 r! `% a1 p* X, V
ilization or peripheral precocious puberty. The diag-$ q* o4 z' y2 F# s) d' A
nosis can be established by just a few tests and by  t, O" d% g" z
appropriate history. The inability to obtain such a
0 m/ x1 E5 b! @! j! P) X7 R$ Yhistory, or failure to ask the specific questions, may
4 k; l, l5 ]5 qresult in extensive, unnecessary, and expensive
2 ~0 ~0 x" o% B2 Ginvestigation. The primary care physician should be5 V1 L+ u7 t( _" _( b& x* Z6 B
aware of this fact, because most of these children
. u. l& B6 A* g% q% y0 R! ymay initially present in their practice. The Physicians’  Y% U% S7 ]) |, ]
Desk Reference and package insert should also put a/ _# S9 t8 \5 D- b$ X) B" @  F
warning about the virilizing effect on a male or
* [" s. E% ^, z4 |; `' s* `female child who might come in contact with some-
) }" z/ O% \8 ^! o, b6 e5 mone using any of these products.8 p6 |7 N  q7 N7 Q/ Z
References( I6 y- w( w7 ^8 \) J7 g5 L
1. Styne DM. The testes: disorder of sexual differentiation9 Y, j" E- w3 X. o, O
and puberty in the male. In: Sperling MA, ed. Pediatric
8 F5 y/ t# t6 G$ x8 KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 V3 x1 D! J0 U2 r$ U9 j5 N2002: 565-628.
% U  _* p0 w8 y- N( B2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ f" [, B/ ?* B6 n$ x: i: I; Apuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

& \/ y; u0 c3 z/ w& K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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