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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
! v4 x2 `+ ]( x# I6 cBoy Induced by Indirect Topical/ I6 {6 D6 W; f
Exposure to Testosterone- ?9 \) k( U4 d3 L. D, A! t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& e8 O3 u4 E. \7 d) L! r/ \
and Kenneth R. Rettig, MD1
! @! f: [. c+ Z& L1 jClinical Pediatrics5 ^4 o. t$ A" J4 N+ X# ]+ B
Volume 46 Number 6& G0 J3 t$ S) @* [: h; C) l2 Y
July 2007 540-543, y* D) {# A0 @: V
© 2007 Sage Publications, ]% O$ Z: S3 f- B% ?
10.1177/0009922806296651+ @& [+ y7 U$ A9 F8 d5 w) o  o# x
http://clp.sagepub.com1 g+ F0 R2 N7 u: P4 P, R- Q8 |
hosted at5 v  Z$ h: H0 q8 }. {
http://online.sagepub.com
' ]+ B4 u; O- H  B* A$ G7 GPrecocious puberty in boys, central or peripheral,; W' n% I2 b6 g* w3 _7 |
is a significant concern for physicians. Central5 L+ b: A0 \7 O' k5 L
precocious puberty (CPP), which is mediated
! L0 C: E1 P* M2 \! m+ A4 Kthrough the hypothalamic pituitary gonadal axis, has; g- e7 v+ }& U0 ?6 Y4 E) V
a higher incidence of organic central nervous system4 V! q' ~$ y0 c1 [
lesions in boys.1,2 Virilization in boys, as manifested
9 u5 C+ j/ ?" E! W1 a! Tby enlargement of the penis, development of pubic- q6 p4 a' P  Y  X* n2 j
hair, and facial acne without enlargement of testi-
+ ]5 f, I( W% A0 @$ E$ i) acles, suggests peripheral or pseudopuberty.1-3 We* P9 b( y2 ~4 Z* S- C  Y
report a 16-month-old boy who presented with the
( g# Y0 D: \6 r1 {/ q2 p% genlargement of the phallus and pubic hair develop-5 p+ L, E, o* G5 P: T
ment without testicular enlargement, which was due' N5 F; j; T. V5 k' B
to the unintentional exposure to androgen gel used by+ C9 s8 _; l. f: z3 S
the father. The family initially concealed this infor-
9 V" s  M: v. i$ f5 h# N8 J, ~mation, resulting in an extensive work-up for this; ^4 n' d9 j" W9 V
child. Given the widespread and easy availability of
, r; I- M' c1 Q' u; K+ E% }testosterone gel and cream, we believe this is proba-
6 }; X; ]/ z/ L, c3 ebly more common than the rare case report in the4 I3 @4 J! G0 i* h$ w* }( X
literature.49 U" C0 p3 L' _0 c+ V8 j) s- t% \
Patient Report( o" H" h' V  ^/ C1 J
A 16-month-old white child was referred to the
$ h+ m6 W  S" i6 a& oendocrine clinic by his pediatrician with the concern
! v, g. r% e5 H0 f/ |% wof early sexual development. His mother noticed4 K% G6 Y) s; b' \
light colored pubic hair development when he was
2 p% i0 h3 l3 S! o) F8 ]2 VFrom the 1Division of Pediatric Endocrinology, 2University of3 D$ ~2 L8 `% @8 B/ \4 d
South Alabama Medical Center, Mobile, Alabama.
7 ~8 n" ]3 w" o, |2 D  K  D/ z; k) ]Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ O" J- V7 u- N( y- AProfessor of Pediatrics, University of South Alabama, College of& x/ V3 H; w5 s6 ?6 k5 Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% x9 d* @1 I7 ^/ `7 Me-mail: [email protected].
. t2 ~1 U" a% h8 S, J7 nabout 6 to 7 months old, which progressively became
+ X9 i0 {% v( P9 P+ X, Y) R9 D% xdarker. She was also concerned about the enlarge-
. R2 k: \. Z, v7 V, C# E% [ment of his penis and frequent erections. The child
0 Q4 P5 F7 Z5 l/ S, E( @was the product of a full-term normal delivery, with
: M9 ]2 S! b* t% l) D  O# Xa birth weight of 7 lb 14 oz, and birth length of
, T- s* J- O  J( \' m- l3 B; @20 inches. He was breast-fed throughout the first year- c0 c2 ], u7 t* o
of life and was still receiving breast milk along with
) H2 J9 c/ ?* Zsolid food. He had no hospitalizations or surgery,
# t8 n7 W4 U: x+ p( T! b' t- e7 dand his psychosocial and psychomotor development
) g5 L# o) w+ y7 m5 s3 W6 qwas age appropriate.5 ?9 {* f- N" X8 }
The family history was remarkable for the father,1 f& o, d, W# P0 Q: ~/ }( N
who was diagnosed with hypothyroidism at age 16,
* }! {- i$ d( `3 T* A4 Cwhich was treated with thyroxine. The father’s
  t8 }8 i7 F* xheight was 6 feet, and he went through a somewhat
+ [; M& T' f. ]. v* R/ _; o1 zearly puberty and had stopped growing by age 14.
# ^" x. P3 @& h' y; d5 k% |" m. LThe father denied taking any other medication. The9 i4 k. R1 Y# d1 e
child’s mother was in good health. Her menarche; g. s5 ^" X. ~9 W; n& X# M# E
was at 11 years of age, and her height was at 5 feet+ |( s- s! L# [9 L, i* Y
5 inches. There was no other family history of pre-
9 g% _# j1 }0 A& `& Fcocious sexual development in the first-degree rela-
% r9 I1 Z$ W! n9 Jtives. There were no siblings.$ `8 r$ j) F9 W$ m! F- t
Physical Examination
. M8 j9 R2 F9 L! I" P, XThe physical examination revealed a very active,2 z' c' f9 M! S6 p( C
playful, and healthy boy. The vital signs documented
- z0 z% }& c7 _$ @& Ca blood pressure of 85/50 mm Hg, his length was. {8 b6 U9 s( {7 N
90 cm (>97th percentile), and his weight was 14.4 kg
3 ]0 Y1 e4 K) |/ l) P2 A0 a4 Z(also >97th percentile). The observed yearly growth* i" f: i2 D; E+ @, @4 v3 T& I1 k
velocity was 30 cm (12 inches). The examination of
$ ?% c% n  `0 k( g3 l& j( tthe neck revealed no thyroid enlargement.; y% E, k6 J+ a; x% t: ]
The genitourinary examination was remarkable for) \/ S4 {- M- z" {: |0 K
enlargement of the penis, with a stretched length of
! z2 N, l! m# w8 d) k4 M8 cm and a width of 2 cm. The glans penis was very well
& P9 G7 }5 ^/ \: rdeveloped. The pubic hair was Tanner II, mostly around
8 r! R( D, e4 p) b9 Y+ }+ w5402 n7 u$ L0 O/ w" T5 b. {1 c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* ^9 q7 }5 g- D3 i5 E$ `the base of the phallus and was dark and curled. The$ d  T- }9 A3 T+ C
testicular volume was prepubertal at 2 mL each.- S7 G# J' A: g0 j6 E
The skin was moist and smooth and somewhat
8 J3 t! p5 F7 V- Y& K9 X( k& Foily. No axillary hair was noted. There were no1 t. T0 U! z: ^% q
abnormal skin pigmentations or café-au-lait spots.
5 r6 o$ L% j- ?6 ~Neurologic evaluation showed deep tendon reflex 2+
& i0 Y4 Y) }6 v3 m5 H) Q4 q) @, Obilateral and symmetrical. There was no suggestion
. Q& R- x( R3 O& f8 ~/ e0 `of papilledema.
% t+ Q5 h$ {# V$ O) Y5 dLaboratory Evaluation4 U* m' S, g9 C8 v5 w: W# t
The bone age was consistent with 28 months by
! L; W% ]# C4 L7 L7 Tusing the standard of Greulich and Pyle at a chrono-
$ ?+ v  e. i2 [. O' a* |logic age of 16 months (advanced).5 Chromosomal
( w2 W  Z' O% c  D, z, @1 Ykaryotype was 46XY. The thyroid function test
; K/ ?# R* W7 h/ [/ qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) s1 j3 U5 u1 Clating hormone level was 1.3 µIU/mL (both normal).
- H9 f  v) H: u" v6 B6 M( j( _6 @The concentrations of serum electrolytes, blood
) r# X4 p7 |. v  Eurea nitrogen, creatinine, and calcium all were9 F7 d5 L% B. u5 C' N, q
within normal range for his age. The concentration
( E' n0 ?: E. m4 U$ Zof serum 17-hydroxyprogesterone was 16 ng/dL
: N/ g+ I: A$ z# t$ I( o(normal, 3 to 90 ng/dL), androstenedione was 203 k1 K2 h' E! E9 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 f/ E2 r/ P4 o1 S: j9 [terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" A7 T6 i2 i# G! u8 @3 w, H6 x6 Fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" [8 C3 H0 w; n+ t2 ^$ r) b# P+ `49ng/dL), 11-desoxycortisol (specific compound S)* A5 v2 |7 O4 ]8 z: N1 l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( X0 [3 K1 P: U: E1 Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% x& m+ v% l2 l$ Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# r6 n& F# G* U$ H" G# z) ]and β-human chorionic gonadotropin was less than+ u! Z" o+ E' g  v) u7 H
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) ^; T: N) T+ A. {) R# wstimulating hormone and leuteinizing hormone
6 q3 s9 G1 A$ a' h3 G, econcentrations were less than 0.05 mIU/mL1 s6 h( F- v. Y$ C! g$ b+ ^) H
(prepubertal).
# ~# _# d3 R- ^The parents were notified about the laboratory
- b( c$ B$ f9 xresults and were informed that all of the tests were
' u3 H- b$ T) y+ y$ l6 Bnormal except the testosterone level was high. The
% [8 v6 Y, E' cfollow-up visit was arranged within a few weeks to+ C% r  ?# I3 _2 w9 Y9 t# o) ~
obtain testicular and abdominal sonograms; how-# J5 O4 W$ v% [, X! d: |- V
ever, the family did not return for 4 months.' o' z1 M' y1 n* |) p
Physical examination at this time revealed that the: u4 J4 t' u7 m3 e) J3 _1 g
child had grown 2.5 cm in 4 months and had gained
- d6 U! h. W+ a" N7 q, Q2 kg of weight. Physical examination remained, ?- \+ b7 T# ]
unchanged. Surprisingly, the pubic hair almost com-
- }; B% G) ]4 K$ E* r  fpletely disappeared except for a few vellous hairs at6 |. _: h: s* c
the base of the phallus. Testicular volume was still 21 b1 |7 K$ U, \2 N' M
mL, and the size of the penis remained unchanged.7 w* D' y1 E5 }6 O5 |9 b$ o7 S
The mother also said that the boy was no longer hav-
) d6 Z4 b# a/ K- L1 D) t3 |ing frequent erections.1 ~; L& i  L& z: E( m, ~0 C, V
Both parents were again questioned about use of
( i( r% m1 d( w+ Sany ointment/creams that they may have applied to, S) ?+ D" u: k4 f. z  D5 M
the child’s skin. This time the father admitted the1 v9 E: f2 w$ x
Topical Testosterone Exposure / Bhowmick et al 541
" i. j3 E& T, F0 @use of testosterone gel twice daily that he was apply-
8 I9 h7 ]3 T& f) Ming over his own shoulders, chest, and back area for/ {5 k9 V$ W6 ~1 K! W- k7 Z
a year. The father also revealed he was embarrassed3 V2 x$ R0 W! a5 G
to disclose that he was using a testosterone gel pre-8 Q: L6 [1 k$ r3 b( [/ O0 w
scribed by his family physician for decreased libido
1 s; b% c2 E; h' }# ]+ E& j& rsecondary to depression.
! n/ H! f$ k% P  ~9 C+ N0 fThe child slept in the same bed with parents.& u& Y) f) p7 S
The father would hug the baby and hold him on his* u4 S7 N# N5 E# V  Z
chest for a considerable period of time, causing sig-
: N( M7 b/ L0 I  }nificant bare skin contact between baby and father.
% z" d5 q  C4 D" eThe father also admitted that after the phone call,$ y5 Y5 q9 @0 _1 ]' o0 a1 x) |
when he learned the testosterone level in the baby$ S" p) g0 n1 }1 M
was high, he then read the product information
0 ]) r1 ?6 j! h: Gpacket and concluded that it was most likely the rea-3 B" }' p# y- {, X) p
son for the child’s virilization. At that time, they
9 F7 _" K" W4 Hdecided to put the baby in a separate bed, and the
1 ~* I& w8 a# e1 Y7 k, ?5 Y- s( Ofather was not hugging him with bare skin and had& R1 p  b$ X* N6 U6 v+ u( b
been using protective clothing. A repeat testosterone1 b: R1 k  \7 V. k/ h0 ]1 l
test was ordered, but the family did not go to the
. Y! s/ V2 E; C# X: f% J' l4 Xlaboratory to obtain the test.1 s  O2 Z( K$ O% U( }
Discussion& o& c- B3 ?7 L: A" o+ v) v
Precocious puberty in boys is defined as secondary
% s& v, k2 X: ~7 O& @3 N  esexual development before 9 years of age.1,42 W6 ]" \7 s% D
Precocious puberty is termed as central (true) when2 v/ t6 e1 [+ U
it is caused by the premature activation of hypo-$ O4 u2 R& N0 t& P" q. F7 E
thalamic pituitary gonadal axis. CPP is more com-+ Y: s; n4 s7 d
mon in girls than in boys.1,3 Most boys with CPP
2 {( N- G- n  f$ k: b1 O/ o, gmay have a central nervous system lesion that is4 z- C, A4 ~$ n: f
responsible for the early activation of the hypothal-. x% t' L9 b' h( @) L4 {( E6 |+ i
amic pituitary gonadal axis.1-3 Thus, greater empha-
; _8 ]# S. K5 M5 ]sis has been given to neuroradiologic imaging in  l; K; j& M4 w. T5 z2 G& k
boys with precocious puberty. In addition to viril-
! ~4 a- @( s4 q7 Y! O1 eization, the clinical hallmark of CPP is the symmet-* h/ A8 i7 i1 B  M# t; e( b4 N
rical testicular growth secondary to stimulation by& x5 `* `4 ?* i5 V
gonadotropins.1,3( |6 S; U$ L2 i
Gonadotropin-independent peripheral preco-; _7 N+ c( I+ k- V5 F$ l- f
cious puberty in boys also results from inappropriate
7 c4 d" ?/ P- X! s& w% Iandrogenic stimulation from either endogenous or
" ]2 ^+ m* q8 X. U3 G. s0 H# Iexogenous sources, nonpituitary gonadotropin stim-  l( W. r7 a% T, j0 N! ~
ulation, and rare activating mutations.3 Virilizing& b* S0 P  ?$ Y# X, V- ^
congenital adrenal hyperplasia producing excessive4 q3 F) t0 K! K. y+ W
adrenal androgens is a common cause of precocious5 H7 @! o( M- d/ x( g
puberty in boys.3,4
+ B& h" n) U8 \1 hThe most common form of congenital adrenal
8 Z+ V6 B7 _  [( L5 ehyperplasia is the 21-hydroxylase enzyme deficiency." ?7 E* W. s" |5 N+ B$ A
The 11-β hydroxylase deficiency may also result in! e( i! v' }! R5 w3 E8 P  r, W
excessive adrenal androgen production, and rarely,
( j8 E% J# {+ I5 \an adrenal tumor may also cause adrenal androgen4 m' l- p1 O) [; f
excess.1,3! m" j+ V+ g3 K6 |, R+ J$ k7 X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  v% B: B& A! |( s
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 S- t* i$ N8 _. o7 z5 K8 v
A unique entity of male-limited gonadotropin-
, E" a! u: y3 L- _: uindependent precocious puberty, which is also known! c7 C, E, ~5 |8 K0 i' x
as testotoxicosis, may cause precocious puberty at a
4 I: r7 [( i# j/ Yvery young age. The physical findings in these boys
! }$ |  f8 m: t: e7 K! Jwith this disorder are full pubertal development,
( }/ ~2 v3 S- ^, v+ Xincluding bilateral testicular growth, similar to boys
! l- ~+ O5 s! a3 N( rwith CPP. The gonadotropin levels in this disorder/ O* X7 V/ ]( D+ X! F
are suppressed to prepubertal levels and do not show) s) m& y4 `% X0 R6 g/ p
pubertal response of gonadotropin after gonadotropin-
3 X! d6 P8 O* dreleasing hormone stimulation. This is a sex-linked2 @$ f% G% A( a; ~( _% E
autosomal dominant disorder that affects only/ [! K/ z2 l0 K5 b5 n  U9 A- U
males; therefore, other male members of the family! ]$ K5 g- n) l1 ?
may have similar precocious puberty.33 V7 Z$ h3 h0 t- ]; t* R1 W
In our patient, physical examination was incon-- g  ^5 Q" @" \9 _, w- l+ S
sistent with true precocious puberty since his testi-
7 q& }# f+ M' L; O- G6 s4 zcles were prepubertal in size. However, testotoxicosis0 G& k, `7 b8 N' _: f! V
was in the differential diagnosis because his father
9 s; s! r1 y$ o! h$ ?started puberty somewhat early, and occasionally,
5 L( F- p6 I+ O9 ~, S1 Y9 Qtesticular enlargement is not that evident in the
  `; o6 U8 N2 C" _. Abeginning of this process.1 In the absence of a neg-
) [2 C( R# r- N2 G8 ~ative initial history of androgen exposure, our3 t, ~* T& x5 h+ {$ x3 \! r8 s
biggest concern was virilizing adrenal hyperplasia,
$ b9 [6 \9 \* ~; reither 21-hydroxylase deficiency or 11-β hydroxylase" i& b$ U5 f$ Q' C/ z8 T4 |
deficiency. Those diagnoses were excluded by find-: `" C3 T/ N- D3 w
ing the normal level of adrenal steroids.
7 U- B6 s# O: R4 b/ Q+ LThe diagnosis of exogenous androgens was strongly
2 G/ u) a2 ~- Bsuspected in a follow-up visit after 4 months because- W5 ~8 m' U! T: C
the physical examination revealed the complete disap-
2 p5 z1 E& m3 T' N6 n& Upearance of pubic hair, normal growth velocity, and
8 T( O3 F  V& K  T& wdecreased erections. The father admitted using a testos-- q2 I* s3 c; [. N9 {( T
terone gel, which he concealed at first visit. He was3 S5 a2 M+ K6 A! Q# F5 ?$ {5 }2 ^
using it rather frequently, twice a day. The Physicians’
! X# W3 C) T& e  c* H" zDesk Reference, or package insert of this product, gel or
# x% N, B  u7 W8 A4 q- t' ~cream, cautions about dermal testosterone transfer to
- V! r; u( {1 S6 w8 t# y8 b6 {$ T! {unprotected females through direct skin exposure.
8 a# p/ S  J1 f6 f3 XSerum testosterone level was found to be 2 times the
2 [4 s) h) e$ y- Jbaseline value in those females who were exposed to; K9 J& g2 E# K& P1 H% G( E( C
even 15 minutes of direct skin contact with their male3 p/ {2 o4 e2 t% M* p) C
partners.6 However, when a shirt covered the applica-
  d4 K7 I' u* ?- ltion site, this testosterone transfer was prevented.! L& X2 ]3 O+ }; Q0 w
Our patient’s testosterone level was 60 ng/mL,. b3 I3 l5 @& o; w7 c3 d& j
which was clearly high. Some studies suggest that
4 |/ I, g2 M. A  Idermal conversion of testosterone to dihydrotestos-
2 }3 H  _  O' C; s) Tterone, which is a more potent metabolite, is more- [5 [5 f* s+ j" [$ k6 y& ?% @
active in young children exposed to testosterone
- R2 w# E# }; K. E! Lexogenously7; however, we did not measure a dihy-' a$ t  z+ W$ ?" R& m7 Q
drotestosterone level in our patient. In addition to
/ s5 y, [( B7 _1 N/ S. ^- y2 Rvirilization, exposure to exogenous testosterone in
3 L& E; m7 O8 ?$ q4 [children results in an increase in growth velocity and
4 V7 T5 J1 S2 U( V4 ^advanced bone age, as seen in our patient.: \# u, T. n' S, }( g& t; u& e
The long-term effect of androgen exposure during
/ a$ k  F2 n# W- Learly childhood on pubertal development and final% E) y  x; {- I
adult height are not fully known and always remain
$ {2 O6 F% M( j0 E4 ~* Ia concern. Children treated with short-term testos-
0 @+ X- M; y9 N1 @% Y1 l7 O! |9 v  Tterone injection or topical androgen may exhibit some) T; s! R, X3 v) k9 Q3 r
acceleration of the skeletal maturation; however, after
2 [0 k7 l& \0 ^9 K  H/ h9 s5 X/ [cessation of treatment, the rate of bone maturation
' Q' x1 u! i7 @5 J* h5 rdecelerates and gradually returns to normal.8,9
( q# Z: s. A* r3 vThere are conflicting reports and controversy
9 {" v& d& {6 x3 k, B, \7 T% Sover the effect of early androgen exposure on adult
; G  J0 X* T; p4 g' }penile length.10,11 Some reports suggest subnormal8 S2 O1 v! ?' W- [5 a' R
adult penile length, apparently because of downreg-
4 K* ~2 M$ R* d/ s- Oulation of androgen receptor number.10,12 However,) n7 \$ B" |0 E1 \6 v" m
Sutherland et al13 did not find a correlation between
/ ~+ f, u& H2 Jchildhood testosterone exposure and reduced adult
. w1 v9 u. I, k  ^$ qpenile length in clinical studies.5 m1 W& X2 d6 K, ?8 B/ i
Nonetheless, we do not believe our patient is
7 m9 G) a' m( ]+ jgoing to experience any of the untoward effects from
4 l7 X/ @/ V2 V: H- a4 Y. Jtestosterone exposure as mentioned earlier because
5 y" i5 h3 D" g# G6 g& e" v/ e" Dthe exposure was not for a prolonged period of time.6 l) h8 L! `. b8 _9 `* V
Although the bone age was advanced at the time of
5 }& S( W: \! V" {diagnosis, the child had a normal growth velocity at: }0 c: b+ W3 F$ T  a
the follow-up visit. It is hoped that his final adult
+ w$ H, k  O, q% ?! k8 Rheight will not be affected.+ e' f- G3 |9 q, k9 o2 [5 ~
Although rarely reported, the widespread avail-% L' ]4 }8 J& X; M% V
ability of androgen products in our society may
/ q; N8 q: [& T" a8 ?indeed cause more virilization in male or female
$ X, [0 n0 }1 z* H5 v# {+ T7 q7 cchildren than one would realize. Exposure to andro-
# o7 r0 c+ Z8 g# W% p" o9 Hgen products must be considered and specific ques-
- J  i. L# }: ]1 Ytioning about the use of a testosterone product or' {  V- x7 N0 t: a9 l5 K* r
gel should be asked of the family members during4 o) C9 g! X6 l; d" P- \
the evaluation of any children who present with vir-
9 @! \& L0 Q8 b, z* K8 v0 d5 ~ilization or peripheral precocious puberty. The diag-
% w, _$ @9 l8 anosis can be established by just a few tests and by
( \# s: z. i1 y+ G7 z+ Cappropriate history. The inability to obtain such a3 h5 m# H9 b7 T7 X$ x% T8 d: i
history, or failure to ask the specific questions, may/ e# ]% q5 P, ?- T4 x+ t2 |
result in extensive, unnecessary, and expensive: ?6 }- v- Q& u" G, a, _, E
investigation. The primary care physician should be
* a5 ~" j$ Q( k. iaware of this fact, because most of these children) k' f+ I. V& g+ U* u' u7 T
may initially present in their practice. The Physicians’  w2 W0 U( o. B& m0 n6 A
Desk Reference and package insert should also put a
/ Z8 r2 {6 h4 z9 x- o, ]warning about the virilizing effect on a male or. i0 K9 `, e9 T) }, p+ B
female child who might come in contact with some-6 i6 x5 m1 ~5 `1 m& r4 ~; m
one using any of these products.
/ v2 Y# I  N6 ~1 ^+ G- _References% m2 @# G: X( W* d
1. Styne DM. The testes: disorder of sexual differentiation
. u5 ^: o* O4 S5 Qand puberty in the male. In: Sperling MA, ed. Pediatric3 Y7 }2 [. B4 O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* R5 y4 D% S  p2002: 565-628.
6 g) u( `+ P+ b# h- C2 c7 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! b1 O6 a$ n, E4 l; [puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; ?3 n- O" n, G5 R  N1 O
Boy Induced by Indirect Topical0 R. z% p" C, s* Y2 K" c
Exposure to Testosterone$ \7 K8 ], K0 l5 _/ Y4 A! v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; t5 F: J& `7 J8 u4 |and Kenneth R. Rettig, MD1
) ^, O$ Z* a6 k3 p5 O5 M1 IClinical Pediatrics
( K2 W6 x. B; _# w( @Volume 46 Number 64 R' X9 @5 s4 z$ [; O3 \% a
July 2007 540-543* G" l6 G; {: }* A/ A( ~
© 2007 Sage Publications
* E# G' W( T/ a$ N. T) ?" S10.1177/0009922806296651
% |7 v0 T. \$ w4 C* c' ~3 \http://clp.sagepub.com
% K( T  N9 E; ^hosted at
  Q& E! u3 Z" khttp://online.sagepub.com
( D6 E$ r: s! i6 y8 T( g( N" U0 jPrecocious puberty in boys, central or peripheral,
) i/ x5 N( V7 J$ _# K( Tis a significant concern for physicians. Central! g$ n, F" b6 K
precocious puberty (CPP), which is mediated
/ x  M3 \1 _3 \( X4 Z9 |; [) kthrough the hypothalamic pituitary gonadal axis, has
' m5 U$ m% j9 [3 @. U" l# Ra higher incidence of organic central nervous system" u% Z( j8 Y4 d6 U0 V8 l' n% z7 q, P; g
lesions in boys.1,2 Virilization in boys, as manifested# V+ A$ E' F$ N9 q; u
by enlargement of the penis, development of pubic
) w8 i# d/ ]2 ?3 e4 J7 ]7 G" c5 M+ Jhair, and facial acne without enlargement of testi-
4 U) u% z- j: u/ a" q' ?1 ucles, suggests peripheral or pseudopuberty.1-3 We
6 i8 K1 c* h( O8 B4 areport a 16-month-old boy who presented with the- A7 M5 s: @% T6 I
enlargement of the phallus and pubic hair develop-
9 [6 P' n  p& mment without testicular enlargement, which was due
% }) N! {, E' x: a8 U( Ato the unintentional exposure to androgen gel used by, o0 ]4 X. L, [7 Y
the father. The family initially concealed this infor-
$ q$ i$ C7 j0 E1 v" `# r' Gmation, resulting in an extensive work-up for this7 Z8 k; L/ ]  [) }4 V( E5 [
child. Given the widespread and easy availability of
* a7 Q/ N1 W8 @& H- Ntestosterone gel and cream, we believe this is proba-  H  r5 H  S5 Q. r( c
bly more common than the rare case report in the$ E4 n3 R; B: W& a
literature.4
$ }5 T% h) {9 A# f7 U' Q/ ?Patient Report
0 e! j5 U) n( N1 E# D) Z0 ~A 16-month-old white child was referred to the
. L1 k. x* ]6 _  Z, H. kendocrine clinic by his pediatrician with the concern
9 Q5 v, Y# G+ g1 q2 F" xof early sexual development. His mother noticed
5 T9 J% o7 Z( i5 j+ Hlight colored pubic hair development when he was
4 A9 O' {3 M+ o7 p- E" LFrom the 1Division of Pediatric Endocrinology, 2University of
; d8 t$ d* ]9 R* n* I, `7 @7 `South Alabama Medical Center, Mobile, Alabama.
; Y* x% Z/ S* X- V+ M+ n; m! s5 }Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 a' H2 `; b1 X" F/ T: zProfessor of Pediatrics, University of South Alabama, College of
3 l5 n1 Z' j3 h5 C9 K" r2 T/ bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& Y3 `7 }7 a3 }. Z. _# Ue-mail: [email protected].
+ ]( l% b" Y6 vabout 6 to 7 months old, which progressively became8 Z8 c1 p+ O$ H5 f
darker. She was also concerned about the enlarge-
) d4 i/ C' G# Fment of his penis and frequent erections. The child( L* K1 g! w. |. I0 N4 e
was the product of a full-term normal delivery, with
% n4 {- @1 ~- h& b2 na birth weight of 7 lb 14 oz, and birth length of: q; U6 y( q$ R
20 inches. He was breast-fed throughout the first year
7 m9 x' b2 d+ e% `! q8 u  fof life and was still receiving breast milk along with
4 d- U/ D. F) z& y0 Fsolid food. He had no hospitalizations or surgery,2 X* w3 [5 o& ?, F! f* P& P
and his psychosocial and psychomotor development7 w0 I$ D' z0 D
was age appropriate." ?! H- Q# ^# J) ~( Z* G
The family history was remarkable for the father,
; z; I7 \- l# d# Xwho was diagnosed with hypothyroidism at age 16,
& c' p" L0 s- \( ^1 Fwhich was treated with thyroxine. The father’s
5 L, Y2 w) ?' v+ D5 ]( oheight was 6 feet, and he went through a somewhat6 J/ h$ k2 v7 z! ^" v/ p1 s
early puberty and had stopped growing by age 14.
0 c2 z9 i2 t8 u1 _5 k  }4 g% LThe father denied taking any other medication. The( e1 y( j% g- P8 m  B
child’s mother was in good health. Her menarche; A& Y$ l6 j, g: S* ^% `4 ^; S6 x8 a0 ?! c
was at 11 years of age, and her height was at 5 feet
( @  U& i. L0 m, `5 inches. There was no other family history of pre-
0 c5 W- \9 x7 r% Icocious sexual development in the first-degree rela-5 i9 q6 M1 i' W0 p0 h2 G: M1 @# r! u2 f
tives. There were no siblings.! X9 @3 o3 X  e# {: @" B! N
Physical Examination/ G- I( R8 S; S
The physical examination revealed a very active,
7 O6 C. |3 o4 S4 u/ Dplayful, and healthy boy. The vital signs documented
3 W, O2 A0 X) X( a- @) c; O8 da blood pressure of 85/50 mm Hg, his length was
- b6 w6 u4 f+ Y% p90 cm (>97th percentile), and his weight was 14.4 kg
+ r: S; z: U# ?+ ?' Q, `+ W(also >97th percentile). The observed yearly growth: \2 J$ x# G8 D  L
velocity was 30 cm (12 inches). The examination of
9 s% _9 Y! [7 |; j8 e! }5 Vthe neck revealed no thyroid enlargement.
% ?7 C7 ]5 d: F$ o; l5 d" kThe genitourinary examination was remarkable for3 V9 S: m4 J/ U! n
enlargement of the penis, with a stretched length of
# b3 o3 w8 A/ d+ K1 N  ^/ ^8 cm and a width of 2 cm. The glans penis was very well
- g+ J6 m0 a# x0 p. T8 n3 Cdeveloped. The pubic hair was Tanner II, mostly around
5 T' d3 g7 `+ |! y4 G6 J  R9 E540
, p. z& Y6 U& J8 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; r+ {: d6 K1 @1 Q1 |$ pthe base of the phallus and was dark and curled. The$ @7 g. R6 v9 ~( b1 |: G1 |
testicular volume was prepubertal at 2 mL each.
6 J- T6 E3 i) g3 HThe skin was moist and smooth and somewhat( P8 L" e/ a1 W, I' y
oily. No axillary hair was noted. There were no
* o  ?; S. c, [5 [( n" s* Z+ D; Y; F" w/ Jabnormal skin pigmentations or café-au-lait spots.
* l4 y5 ~/ T9 cNeurologic evaluation showed deep tendon reflex 2+4 Q6 I9 `7 {* [
bilateral and symmetrical. There was no suggestion
6 c( @5 P- B) T" M6 D5 u% lof papilledema.
& |7 `. O& O' \0 |# y7 u+ x9 i" qLaboratory Evaluation( m" J* k3 o# @+ e. a( b+ u0 A& E5 H
The bone age was consistent with 28 months by
/ T2 t( Y( |# f7 gusing the standard of Greulich and Pyle at a chrono-
1 v, S( H, r9 D) D2 A0 Ylogic age of 16 months (advanced).5 Chromosomal! D7 y! g9 G5 |$ R
karyotype was 46XY. The thyroid function test" w; u% v6 x9 _5 O( y2 z+ x- L( ~, r
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 n+ w# }1 x" ilating hormone level was 1.3 µIU/mL (both normal).
0 y- ]2 C$ K4 Y3 ?/ d; LThe concentrations of serum electrolytes, blood  }# @% x7 e/ K1 _# M8 x; J4 i* u, {2 G& R
urea nitrogen, creatinine, and calcium all were& d; A4 k2 `# r6 A$ B
within normal range for his age. The concentration
; P# \3 E+ O( u4 I) Sof serum 17-hydroxyprogesterone was 16 ng/dL  W% V' N! A. d1 H5 B
(normal, 3 to 90 ng/dL), androstenedione was 20
1 o" d- W, i2 T1 E! \4 U% Y; ~& Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% o) v* x  C) Z) _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% y7 ^1 @6 A# A6 m' I: F7 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 ^$ z: y: T* D6 b: ]49ng/dL), 11-desoxycortisol (specific compound S)7 ^) S* o- `- ~& a8 V& C
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  D' z2 F% E/ e, i6 t% }
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# v( I- I" [( \- N: y# L1 ~; F
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 B5 p! `+ C% j- ^and β-human chorionic gonadotropin was less than
) v1 G7 n& b) I9 T! d& @6 P5 mIU/mL (normal <5 mIU/mL). Serum follicular& X! R& I. R3 J: [
stimulating hormone and leuteinizing hormone+ P/ t! E! ?* e
concentrations were less than 0.05 mIU/mL
! g, R( {8 X+ _. M& R( x) u% L(prepubertal).6 P8 H7 ^. b, ?8 r8 |1 P
The parents were notified about the laboratory3 t0 h  i" c- u4 n/ z$ \$ D6 {) w* X
results and were informed that all of the tests were
  A6 z' h  `0 q' D: }; mnormal except the testosterone level was high. The, o4 N8 x- a% x) A  L, g
follow-up visit was arranged within a few weeks to3 R# d7 R: G' ^% s% @
obtain testicular and abdominal sonograms; how-
2 r0 |$ k6 p5 Rever, the family did not return for 4 months.& `! c1 d* K' w% q0 ]
Physical examination at this time revealed that the3 ?# [+ z5 l) H2 @% d3 m
child had grown 2.5 cm in 4 months and had gained% Z) S% I. Q" D5 f/ p: B
2 kg of weight. Physical examination remained/ K5 m, ?" `' m0 j
unchanged. Surprisingly, the pubic hair almost com-$ s' k& I& w+ f% `; z
pletely disappeared except for a few vellous hairs at* R# N' `* T, z8 k" a
the base of the phallus. Testicular volume was still 2. @* W$ k& Z' p
mL, and the size of the penis remained unchanged.
$ `" X- [) G  `2 o; S1 m4 mThe mother also said that the boy was no longer hav-1 w4 Z4 F* ~) c  r# R& N
ing frequent erections./ Y3 ^5 F. f$ z1 Z
Both parents were again questioned about use of
% t. ], }: ]/ A, s4 n& Zany ointment/creams that they may have applied to+ u7 y0 X3 Q* ^9 q. y: C8 E7 j. v2 i
the child’s skin. This time the father admitted the
% n) d8 V9 r2 pTopical Testosterone Exposure / Bhowmick et al 541% H8 p$ M0 v2 m
use of testosterone gel twice daily that he was apply-/ \, o$ M/ o/ H( r
ing over his own shoulders, chest, and back area for
2 P" ]% E; ~& H% I3 c7 T5 ka year. The father also revealed he was embarrassed
7 M: b" O. H) x& Yto disclose that he was using a testosterone gel pre-/ y) y6 \- G' i
scribed by his family physician for decreased libido$ V) M( A4 j2 N  B
secondary to depression.
# x4 ^( B. p1 `% c) M# c( GThe child slept in the same bed with parents.
( T8 r. W) t4 F, N1 ]The father would hug the baby and hold him on his
: ~7 H; ^" k! C+ o1 ^9 P! j6 O9 h! i* h  jchest for a considerable period of time, causing sig-* _7 k- k; J8 ]9 @; O& E6 \! O4 X
nificant bare skin contact between baby and father.
, G/ v& z, r) r0 NThe father also admitted that after the phone call,7 t5 `& X" z& e
when he learned the testosterone level in the baby
" N/ k( [' E. I' k' [+ G" Kwas high, he then read the product information7 k3 k0 j( d) P! v. O* n
packet and concluded that it was most likely the rea-
0 x  A# u- e* K% _son for the child’s virilization. At that time, they
9 h8 k: @4 L* T) Hdecided to put the baby in a separate bed, and the
0 w. P! t" R7 _7 [6 o+ m) Bfather was not hugging him with bare skin and had3 ~9 i1 z1 D& w5 x: R
been using protective clothing. A repeat testosterone# B' r! _, \5 d+ S: |# E3 d
test was ordered, but the family did not go to the6 E# g" h6 G1 F& H) j* k
laboratory to obtain the test.
  g0 T( |" m- O; w0 Q6 k2 L$ yDiscussion- C( b) x/ F5 \$ `' l1 L
Precocious puberty in boys is defined as secondary
8 X" ]- ?6 y& g) |! l' isexual development before 9 years of age.1,4
2 c# T* ~  W1 w) dPrecocious puberty is termed as central (true) when
# B" E. c9 W' b  }it is caused by the premature activation of hypo-8 k7 o  S% O$ x# \  s
thalamic pituitary gonadal axis. CPP is more com-7 ?3 t& Z8 _/ {3 h0 ~0 P4 \' i, R" S0 q
mon in girls than in boys.1,3 Most boys with CPP2 u' X8 S0 y) o' F( E) n  d
may have a central nervous system lesion that is( Y  Z. d! M) Y6 I- s  K5 n' C! ?
responsible for the early activation of the hypothal-1 s: A. e0 }# `' g4 t% W7 ~
amic pituitary gonadal axis.1-3 Thus, greater empha-' k! E  n8 v+ P$ c3 V
sis has been given to neuroradiologic imaging in" u* [/ g5 N" s. m  ]+ T: A2 l
boys with precocious puberty. In addition to viril-9 F6 W+ ?: [# E  s1 t( P* B
ization, the clinical hallmark of CPP is the symmet-# f% R% A2 z/ Q+ m7 ^- }; d
rical testicular growth secondary to stimulation by
5 C  k8 B8 ]% X  v( u" k7 Xgonadotropins.1,3  a  r" K7 D$ Q  C0 E4 t; \
Gonadotropin-independent peripheral preco-$ F' L0 V# h" ]* y* U3 ]
cious puberty in boys also results from inappropriate' N* b7 s$ j  A+ Y! Q7 K% Y
androgenic stimulation from either endogenous or
. Q' P: {% A. w" R* G1 |. _exogenous sources, nonpituitary gonadotropin stim-; B5 |6 K% ~( e0 Q9 ]# R- c& U
ulation, and rare activating mutations.3 Virilizing
! m- D2 C* ~. T* P* xcongenital adrenal hyperplasia producing excessive
% y" v) g; X% M, c2 ]8 Q* Qadrenal androgens is a common cause of precocious5 H+ u- S- e* X, w4 ?+ w& E
puberty in boys.3,4& a) C1 q, W# ]$ l
The most common form of congenital adrenal
; s, s$ L7 |5 i" nhyperplasia is the 21-hydroxylase enzyme deficiency.
: k& U  d$ D4 h6 b- A9 vThe 11-β hydroxylase deficiency may also result in
3 Q1 d8 ^3 E2 X2 p! T7 Zexcessive adrenal androgen production, and rarely,
; K4 B5 i# l1 W+ [3 \9 @2 n7 i: zan adrenal tumor may also cause adrenal androgen, K8 N9 P. p! i% P8 n
excess.1,3
1 c/ O& N5 |8 sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 G  E! |& }, F5 X7 z) m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 T1 ^6 i6 q& M4 [- B  K2 \A unique entity of male-limited gonadotropin-
% Y* P* _2 b: N) K9 l1 B# uindependent precocious puberty, which is also known
2 J# q  u: Y- `as testotoxicosis, may cause precocious puberty at a" a5 L/ U; t4 f* T* R& m+ i) Y
very young age. The physical findings in these boys
4 v1 k' @* L5 t$ ~5 Rwith this disorder are full pubertal development,; ]5 `. J0 }0 w% V
including bilateral testicular growth, similar to boys
% h& _0 H3 c" }1 M, `with CPP. The gonadotropin levels in this disorder
: x6 C  _; o" F" }/ E# Rare suppressed to prepubertal levels and do not show
( B3 a( N% D/ Vpubertal response of gonadotropin after gonadotropin-
9 p+ I: g6 f* e" hreleasing hormone stimulation. This is a sex-linked
7 d7 i, R7 w1 Uautosomal dominant disorder that affects only: N6 U- M7 I) v8 l
males; therefore, other male members of the family
. @4 m1 M7 n, H& d9 j9 Emay have similar precocious puberty.3
4 C, D7 s( W4 A# |0 }In our patient, physical examination was incon-5 f; A3 C. [6 D  ~  p6 M
sistent with true precocious puberty since his testi-' E5 M$ X, d; z
cles were prepubertal in size. However, testotoxicosis5 q- M" P1 @/ ]
was in the differential diagnosis because his father4 n# j( S* X. H7 \+ T: ]! }
started puberty somewhat early, and occasionally,9 x6 W  K" G! N: h' @7 a
testicular enlargement is not that evident in the
4 }& _9 a; A# ?3 k/ j* r  Jbeginning of this process.1 In the absence of a neg-
1 l* v+ Y5 `3 e4 Z) _7 j8 L: uative initial history of androgen exposure, our) d- ^! y! x# x8 Q: P
biggest concern was virilizing adrenal hyperplasia,
: k$ p# f7 y* U. ~+ S9 ]% h5 [either 21-hydroxylase deficiency or 11-β hydroxylase
3 A. C0 H7 x, }9 H0 S8 x# L8 B) {  `deficiency. Those diagnoses were excluded by find-
* h: c4 u: ^/ v9 d- Hing the normal level of adrenal steroids.
" u+ E; n. d- CThe diagnosis of exogenous androgens was strongly6 y6 `, M/ |# C, ]  j: p3 j
suspected in a follow-up visit after 4 months because
% P% P; Q8 K6 O7 zthe physical examination revealed the complete disap-8 Q9 B2 t  c. b+ y, |6 G
pearance of pubic hair, normal growth velocity, and
5 C( y- t9 U  Y) T5 ~decreased erections. The father admitted using a testos-
& D0 `* J) w7 L  D( S2 l' f% Eterone gel, which he concealed at first visit. He was5 T6 U) x7 |. W9 d3 _) s
using it rather frequently, twice a day. The Physicians’7 V8 M. s. d" o6 R4 [* v: j+ C$ ~
Desk Reference, or package insert of this product, gel or1 K0 F; L6 \. H: d8 x
cream, cautions about dermal testosterone transfer to" k! x/ b" ~1 m: V# ]
unprotected females through direct skin exposure.
5 v3 O2 y. O0 ]" kSerum testosterone level was found to be 2 times the! P) r) }) X- R4 O6 w
baseline value in those females who were exposed to9 {! x( g6 r% F2 N* j- P
even 15 minutes of direct skin contact with their male
; T8 x: j+ S6 dpartners.6 However, when a shirt covered the applica-
  C) |! {2 o) w+ ktion site, this testosterone transfer was prevented.
5 ?* L; B! n' ~  C7 w# Q* y1 ^Our patient’s testosterone level was 60 ng/mL,
( e. l/ @0 }! v4 ewhich was clearly high. Some studies suggest that, W9 N+ h4 e1 U8 w
dermal conversion of testosterone to dihydrotestos-- |+ s  |+ S/ W7 d; s: {
terone, which is a more potent metabolite, is more
% T: S1 i* n2 e# f: K4 |active in young children exposed to testosterone2 Y  |6 M+ j' [3 B" ^6 U
exogenously7; however, we did not measure a dihy-
4 }5 U7 z& u8 @' y3 J* Fdrotestosterone level in our patient. In addition to
) v- C$ Z9 E3 _7 ?1 _virilization, exposure to exogenous testosterone in
. \7 Z1 v% ^; g+ l* Vchildren results in an increase in growth velocity and5 a! F$ U0 Q4 E3 K2 y
advanced bone age, as seen in our patient.
5 d3 n+ v1 ]0 {9 wThe long-term effect of androgen exposure during  f/ d- w% G2 N' e: _. M" R
early childhood on pubertal development and final
3 y- P# q0 n* _9 |1 |$ Cadult height are not fully known and always remain
& m7 R, y: E: W$ Ra concern. Children treated with short-term testos-
0 e: M. y9 J1 @' S& K& Iterone injection or topical androgen may exhibit some) x( ]$ @$ f3 ~# q, s
acceleration of the skeletal maturation; however, after
- r0 G1 j3 P9 \2 F0 G6 {cessation of treatment, the rate of bone maturation# a( A' D- e3 O, v% W
decelerates and gradually returns to normal.8,9* N+ K3 g; |4 i
There are conflicting reports and controversy
' l5 |4 Y: n) Q" }6 p, K% Kover the effect of early androgen exposure on adult
/ v+ `1 g# W1 P* T4 |. Upenile length.10,11 Some reports suggest subnormal
% U+ t8 N: A, J2 t  G: R9 Xadult penile length, apparently because of downreg-9 A2 Z- Q8 f9 g0 u$ F
ulation of androgen receptor number.10,12 However,
& T+ D; {' L  r/ gSutherland et al13 did not find a correlation between% K0 L% w6 a2 F  a2 l6 F: `, O
childhood testosterone exposure and reduced adult
7 t' N9 L) C/ w7 F7 Ipenile length in clinical studies.
7 X% _# ?. l5 ^2 a" _# b8 @Nonetheless, we do not believe our patient is
/ A$ X2 q8 L* t% @' Tgoing to experience any of the untoward effects from7 P4 U& c5 D' O2 a4 ^) m
testosterone exposure as mentioned earlier because" {9 h4 P5 K8 I! n8 D( d  I
the exposure was not for a prolonged period of time.
9 w, M$ o, ]: j7 s" B3 O* cAlthough the bone age was advanced at the time of) F; \( v5 H) W% z7 o) @
diagnosis, the child had a normal growth velocity at; X. R- Y/ S& m) d0 B3 P
the follow-up visit. It is hoped that his final adult4 K. g! t$ _# O1 }& u$ w, k. a
height will not be affected.
5 p" Z' G. ^6 E0 c7 \1 rAlthough rarely reported, the widespread avail-
' F. ~' B: U3 x$ i( b1 Zability of androgen products in our society may" t/ A& W7 _/ }4 u
indeed cause more virilization in male or female: v' E2 G3 K  k, `- W# s
children than one would realize. Exposure to andro-) S, p% W8 [. Q) }, ?, ]
gen products must be considered and specific ques-8 j  Y+ o4 P( D* h6 z1 i- d7 c
tioning about the use of a testosterone product or8 V" J3 H) P0 A  c6 a4 f
gel should be asked of the family members during
+ d1 u; R6 W3 P& [+ H6 b. }the evaluation of any children who present with vir-
& y+ I' D8 t& @  G8 @$ c% C5 I9 \ilization or peripheral precocious puberty. The diag-" J! ^0 p7 z1 g5 a
nosis can be established by just a few tests and by( r% @4 u3 r3 G# T% F9 _
appropriate history. The inability to obtain such a
# a* ~# {# ^1 s8 m4 b3 ?8 Ehistory, or failure to ask the specific questions, may
. @# E1 [; E" `/ n, Tresult in extensive, unnecessary, and expensive& S5 R; s' ?5 z" n/ g
investigation. The primary care physician should be; {' o; a- i5 \4 L1 Y. G. `8 u
aware of this fact, because most of these children- x/ ^' _: h2 [: w$ U$ r. I4 b% _1 ?/ Z0 F
may initially present in their practice. The Physicians’4 L, B. T' U1 `
Desk Reference and package insert should also put a
4 o# M1 v# E: U3 P: jwarning about the virilizing effect on a male or
+ X  B# ?" s9 E! {0 K  Gfemale child who might come in contact with some-
' b& r2 b; o# N$ G7 {' hone using any of these products.  A! i+ n' y8 Z; \& y
References
( O+ T+ D; h- q% N1. Styne DM. The testes: disorder of sexual differentiation
" K8 B8 G% Q& Q  ^and puberty in the male. In: Sperling MA, ed. Pediatric9 [2 A- M# n7 {- L$ y/ G8 y! @
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 w$ y6 I% T- O4 x6 D* W2002: 565-628.
- [7 M. }4 w( T4 p/ [% \6 W. A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) n, K% [6 U% @, l6 y
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
  F  s* m8 [9 p9 p+ O
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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