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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
4 C3 r" F2 |7 s% g: _; G. t! V1 aBoy Induced by Indirect Topical. _  B/ R3 L# Q: Y4 f+ R/ ?
Exposure to Testosterone$ G7 P  `, Y3 z3 q1 r2 r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% F) ~2 v, w, q* fand Kenneth R. Rettig, MD19 G# @. N2 G& ?1 ~
Clinical Pediatrics( D# q( D# ^' B% D5 F3 b; m
Volume 46 Number 6
, j  r( q( q3 P2 i( jJuly 2007 540-5433 W: M1 j2 E3 `+ y* n0 F1 o
© 2007 Sage Publications  u2 y: m) P# Y5 B7 ]7 A9 o& c
10.1177/0009922806296651
; C+ O; i2 q$ H' P8 _" x! ?7 bhttp://clp.sagepub.com
0 M5 K" @! L# k! e- J1 r6 Qhosted at
  X/ F! T8 e' Y4 [7 _http://online.sagepub.com; q9 Z+ g3 y/ V! T
Precocious puberty in boys, central or peripheral,6 P0 f/ ]$ q6 T+ j
is a significant concern for physicians. Central
' S$ u  e2 `  F2 A+ sprecocious puberty (CPP), which is mediated5 h* P0 H. S5 }$ K8 O4 F
through the hypothalamic pituitary gonadal axis, has
' _' E; u( V4 n3 q( _a higher incidence of organic central nervous system
9 m1 [! a. m6 a) j% @# Qlesions in boys.1,2 Virilization in boys, as manifested8 s$ t# _* a: |5 [! S
by enlargement of the penis, development of pubic
3 m% |$ N8 J$ h: U# Lhair, and facial acne without enlargement of testi-4 M, y9 Z- E) |8 p" @
cles, suggests peripheral or pseudopuberty.1-3 We0 d& ?. F  W7 |% r, n8 E3 \
report a 16-month-old boy who presented with the
# d0 |6 M& Z- {9 l/ T' ?enlargement of the phallus and pubic hair develop-
5 X' f! I7 ]* v* nment without testicular enlargement, which was due/ H1 L0 J4 t% m, \5 k8 `- J
to the unintentional exposure to androgen gel used by* s+ w; r3 j, A! e
the father. The family initially concealed this infor-+ i. U+ }9 w" T8 V( C8 G
mation, resulting in an extensive work-up for this1 }# U; {% ?7 V; z2 W5 t3 _6 I
child. Given the widespread and easy availability of* m: _! V  o! ?' @
testosterone gel and cream, we believe this is proba-
/ b, s) k! o/ Wbly more common than the rare case report in the; N/ T) P/ j( \
literature.4+ a  \% I7 R' K8 V# A/ q0 I
Patient Report
: @/ H6 D7 ]6 U5 l& ]A 16-month-old white child was referred to the
4 H8 Z2 T6 Q/ e" C& ~endocrine clinic by his pediatrician with the concern2 l. U! U2 V, N6 {% d- D
of early sexual development. His mother noticed
' x) I6 Q! ~1 {7 o# k" Ulight colored pubic hair development when he was
8 ]" I% }1 E8 Q7 `From the 1Division of Pediatric Endocrinology, 2University of
" T) ^# W# K3 M* J7 u- pSouth Alabama Medical Center, Mobile, Alabama.
6 A. ]/ g" i. X7 u+ xAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 s, W# |# [6 E" P; oProfessor of Pediatrics, University of South Alabama, College of
& B+ \0 @+ F$ G' K& W/ ]0 CMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 @7 l5 L  t) W0 b) f' H- S
e-mail: [email protected].: |$ X( W: k" U
about 6 to 7 months old, which progressively became; v' ]$ o& s4 Q
darker. She was also concerned about the enlarge-
" h) Q; ^3 L# W: f1 V- M& U) W: F# _5 dment of his penis and frequent erections. The child
( U4 h/ o' ^2 R; {% |2 I  gwas the product of a full-term normal delivery, with
0 x- y, M$ _# b  ya birth weight of 7 lb 14 oz, and birth length of
& }/ U( i: B8 X% `' l* a; M20 inches. He was breast-fed throughout the first year
% x  Z+ A/ t0 l9 f' {of life and was still receiving breast milk along with8 a5 o; J4 E2 P+ m& H7 L- m$ q1 g
solid food. He had no hospitalizations or surgery,0 o8 b* L( Y4 T" y& z' Q
and his psychosocial and psychomotor development0 P# S( m2 h7 r* S
was age appropriate.
$ N2 Z  }: T1 q  gThe family history was remarkable for the father,
9 ?+ {3 n  b3 n6 N( [, V+ Mwho was diagnosed with hypothyroidism at age 16,. w* P' q) b3 {
which was treated with thyroxine. The father’s6 `9 P( B/ @" B' p* R4 \. Q
height was 6 feet, and he went through a somewhat$ S/ e# |0 R" m/ R& H( r
early puberty and had stopped growing by age 14.
+ o4 [( C/ o; |$ L1 I8 l8 m8 {The father denied taking any other medication. The
  u" a8 T' F5 T" Zchild’s mother was in good health. Her menarche/ \% _9 y6 _! w7 r1 H6 k. x& f0 @) F
was at 11 years of age, and her height was at 5 feet# S6 O7 Q+ T- ]) _' R8 a1 H/ l# W- l
5 inches. There was no other family history of pre-
: J9 A" R) c( n1 k( v: g6 ccocious sexual development in the first-degree rela-
( n6 @4 B5 H" s9 htives. There were no siblings.7 ^2 T# f2 N; m! }) y* J
Physical Examination
8 [2 S4 p5 B& [! k$ s% K5 F# R! hThe physical examination revealed a very active,4 M: a) S- H2 @* Y- j3 S
playful, and healthy boy. The vital signs documented0 L: y7 N/ f# Z" W. a! h9 C
a blood pressure of 85/50 mm Hg, his length was
+ y0 s& R& h9 Q) I+ n' A! \90 cm (>97th percentile), and his weight was 14.4 kg' h  G6 E0 C5 o! `
(also >97th percentile). The observed yearly growth( u$ V, V$ L6 P+ z: X- O
velocity was 30 cm (12 inches). The examination of
6 ?  V  @! j7 k: ~/ h2 f( N. wthe neck revealed no thyroid enlargement., z' q6 C$ N: |/ n  ?7 M- ^
The genitourinary examination was remarkable for
9 q6 x8 Z: A. k' penlargement of the penis, with a stretched length of
* e9 C0 S2 F% `. l) o8 cm and a width of 2 cm. The glans penis was very well) [) `, S: ]" |  U7 z  X$ E5 ?! J
developed. The pubic hair was Tanner II, mostly around- r* K- o" }1 F) B
540) O) P3 u  ]1 i* B* y! R% S3 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. v6 p, f0 o/ d3 y- y% O$ l
the base of the phallus and was dark and curled. The
) Y- ?# N5 U' E0 I) v1 Ptesticular volume was prepubertal at 2 mL each.
0 j* g5 Y  T/ {( K+ qThe skin was moist and smooth and somewhat
" x7 g5 U# ]1 [0 poily. No axillary hair was noted. There were no
6 f# r  a" e( _abnormal skin pigmentations or café-au-lait spots.4 T2 L- Y; a" D1 @; W7 R
Neurologic evaluation showed deep tendon reflex 2+9 r' z% W0 z8 A6 y9 l+ V/ R3 u7 v% A
bilateral and symmetrical. There was no suggestion+ ~) ]: Q6 `' c& c$ X) V
of papilledema.2 F5 c' J% k, p, N
Laboratory Evaluation
+ \% x' H- `3 n& a( k% D5 eThe bone age was consistent with 28 months by6 t1 {* V; e" L$ Z! i3 C
using the standard of Greulich and Pyle at a chrono-& E2 P& t4 U0 a, m% n+ T
logic age of 16 months (advanced).5 Chromosomal* y( j& U! U- b
karyotype was 46XY. The thyroid function test& c8 O8 G# |/ J" u& k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. a: u4 [$ ~0 \
lating hormone level was 1.3 µIU/mL (both normal).
3 u7 J- I, w% n1 aThe concentrations of serum electrolytes, blood
# w* }' U. c, I" m3 z8 aurea nitrogen, creatinine, and calcium all were
8 @- m: H4 M) K. L7 zwithin normal range for his age. The concentration
& |6 ~2 B9 H  \: b0 o# O. Rof serum 17-hydroxyprogesterone was 16 ng/dL: }- q* h, |+ f: Y2 R) \
(normal, 3 to 90 ng/dL), androstenedione was 20
" H% b, ^& Q) s2 `4 qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 v' X( l0 g! c
terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 i9 b! m( V5 J5 h% Z. c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' v+ q. ^7 k! f! w
49ng/dL), 11-desoxycortisol (specific compound S)
- V: m) x' J5 @/ w* O7 y9 ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ {3 b& U( g! b" c
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 Q, W% s9 j" I: x& z8 V. j9 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) N9 m6 |+ O3 h
and β-human chorionic gonadotropin was less than! f) G+ s8 F* O- s0 y" @% p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& X7 P, A2 D) Q5 s* Y7 z- h6 ~5 \stimulating hormone and leuteinizing hormone
6 H# v. L% X1 [- ?concentrations were less than 0.05 mIU/mL% h8 K& N+ G' o/ |9 X3 X
(prepubertal).4 G+ M' j( H3 y0 o) O0 J
The parents were notified about the laboratory9 k$ g. Y7 v; L3 _4 E$ |
results and were informed that all of the tests were' R8 z1 W; D" l6 q; c! C3 \
normal except the testosterone level was high. The
9 t* L# k: O8 E- v; dfollow-up visit was arranged within a few weeks to
. I2 J$ ~0 {' i% c- g$ g. bobtain testicular and abdominal sonograms; how-& T4 J: J; K4 C; m6 D8 Q3 n0 x
ever, the family did not return for 4 months.
  |! m. \( d# q& ^6 i0 i" O- {7 C9 @Physical examination at this time revealed that the- q, h9 z+ K' p7 X
child had grown 2.5 cm in 4 months and had gained1 x4 R: ^4 N  |- f8 i
2 kg of weight. Physical examination remained
; O# D& |8 |: n, v/ l3 P( Wunchanged. Surprisingly, the pubic hair almost com-
* s0 h: f: D( Epletely disappeared except for a few vellous hairs at  n: J  t8 \* I9 |8 p( @
the base of the phallus. Testicular volume was still 2
) y+ P% W% t: J9 s7 x9 ]. }- UmL, and the size of the penis remained unchanged.
6 X$ M! K! Z! S, M, m8 `  T% x& qThe mother also said that the boy was no longer hav-
9 I# Y3 n4 Y/ g: f9 U  ging frequent erections.6 B4 g( O" g% Y7 }; h6 X
Both parents were again questioned about use of6 N* @/ F# _/ n1 t. k  J( H& v
any ointment/creams that they may have applied to
" ]  R5 L  u/ N" lthe child’s skin. This time the father admitted the
/ B: K' V5 u, V5 N6 }. _7 gTopical Testosterone Exposure / Bhowmick et al 541
2 W1 ?. w: o( ?) v: X; f1 Fuse of testosterone gel twice daily that he was apply-8 W* c' U( y4 @$ C5 ]+ M; {$ l
ing over his own shoulders, chest, and back area for
- Y/ W# A7 r+ a& \; ja year. The father also revealed he was embarrassed
) E, k' n0 N! F# S: pto disclose that he was using a testosterone gel pre-
# y# B5 L" a, S6 z1 t9 xscribed by his family physician for decreased libido5 u' b# ^4 t, D, R, n/ r6 c& J
secondary to depression.) ~+ c2 R6 K; i, k( \" @
The child slept in the same bed with parents.
2 _* u* {5 P! l, T5 D, yThe father would hug the baby and hold him on his0 h* T3 W7 I$ f
chest for a considerable period of time, causing sig-$ Q2 y0 M& o/ g# S! C' }
nificant bare skin contact between baby and father.+ t$ m# G8 J1 m7 ]& g/ _) ?) L  b/ k
The father also admitted that after the phone call,
9 x/ p4 D% j. w; F/ t- `5 c. _when he learned the testosterone level in the baby
. j$ Y- o/ f8 d2 b' [was high, he then read the product information
6 s, u$ G$ g& |7 gpacket and concluded that it was most likely the rea-
& i. f5 h; V: I2 H7 k# u* Bson for the child’s virilization. At that time, they
3 r: O+ f; v0 X1 Z  p, Bdecided to put the baby in a separate bed, and the
  ]2 L$ }- [3 e# h" w- sfather was not hugging him with bare skin and had; X  |! k, T$ Y5 K3 r' ?; Q
been using protective clothing. A repeat testosterone
* F, D5 }) k$ r/ D3 {0 |test was ordered, but the family did not go to the' F, s3 I' q: F* z. p- S1 W  f
laboratory to obtain the test.
% Y1 B' R% X5 R0 |. cDiscussion% ^1 S1 G5 M8 W- n, [; ~& `2 ~
Precocious puberty in boys is defined as secondary9 k: H1 q0 B: S% s* d- C  ]
sexual development before 9 years of age.1,4
/ K# q* m: j9 J9 EPrecocious puberty is termed as central (true) when6 v+ @9 X7 y! W' k
it is caused by the premature activation of hypo-: _) I  t. W6 Z
thalamic pituitary gonadal axis. CPP is more com-. V# f: F5 J+ A
mon in girls than in boys.1,3 Most boys with CPP1 D  x: f+ h! r1 L
may have a central nervous system lesion that is( h8 m$ q/ F3 Y- I9 l( a' S1 V7 [4 ?
responsible for the early activation of the hypothal-
0 D& _2 c# C1 \2 n( E  c6 S) |3 namic pituitary gonadal axis.1-3 Thus, greater empha-! x  x# A0 k  P- W
sis has been given to neuroradiologic imaging in2 P' c0 b6 _6 h$ u  z: A
boys with precocious puberty. In addition to viril-/ a5 x' d# R% f% F
ization, the clinical hallmark of CPP is the symmet-
* j' x& U  X1 U/ F# Crical testicular growth secondary to stimulation by3 D8 d# q4 W8 r* U* [+ j0 B  C
gonadotropins.1,3
# C' }& E$ ]5 d( ~Gonadotropin-independent peripheral preco-/ i$ l& O9 }; r4 q+ e8 l3 I
cious puberty in boys also results from inappropriate
0 z4 D3 W9 j! Dandrogenic stimulation from either endogenous or) l# D5 ?2 A6 n! w+ r2 H
exogenous sources, nonpituitary gonadotropin stim-
! r( Z. b9 t3 Xulation, and rare activating mutations.3 Virilizing
( W( ~% G) W$ }! Y$ Xcongenital adrenal hyperplasia producing excessive
2 J, v4 U, Q  W. d7 radrenal androgens is a common cause of precocious
4 j; _# _6 B+ \puberty in boys.3,4) i# M) O4 u) h( @1 L( ?8 A  X9 `
The most common form of congenital adrenal* o  B4 K# }* y5 F+ r" L
hyperplasia is the 21-hydroxylase enzyme deficiency.6 N3 {6 a/ v5 I" ]- V
The 11-β hydroxylase deficiency may also result in4 n0 W1 \# a" U: L; c
excessive adrenal androgen production, and rarely,
7 N6 T/ Z6 Y6 y/ u  C9 Z8 aan adrenal tumor may also cause adrenal androgen4 S3 P0 F  H1 j
excess.1,3, Q9 s$ @) F& {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ F& v' t* e) ^; E4 Z) Q/ R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- h* t! A8 H1 Z. i+ D0 L0 z+ TA unique entity of male-limited gonadotropin-
# c: U% ]% m  |# Rindependent precocious puberty, which is also known% @% p, Q1 s9 A$ R! J
as testotoxicosis, may cause precocious puberty at a0 n& y# W" O( Y: H8 C* l9 B
very young age. The physical findings in these boys
: J7 }* M5 `* s9 N# [4 Wwith this disorder are full pubertal development,2 G# a) l" p! X
including bilateral testicular growth, similar to boys
* o4 h  J% [4 V8 }" _% t; Owith CPP. The gonadotropin levels in this disorder' N, }; }9 d4 k! N: _  c$ g) }
are suppressed to prepubertal levels and do not show
; Y6 e3 K  ~* R$ z9 J& \- Z# bpubertal response of gonadotropin after gonadotropin-
' P+ f3 y2 r5 P* _( G& L6 {- K0 V( U3 }releasing hormone stimulation. This is a sex-linked4 p. U# q3 [1 v2 Z2 G7 [7 A
autosomal dominant disorder that affects only. Z. M6 Y; Q: I
males; therefore, other male members of the family
' c( ^  z0 h) T' q/ o+ l% ?may have similar precocious puberty.3/ D/ K3 d( ]) R& u* y
In our patient, physical examination was incon-
8 `! i  c* H9 c' |sistent with true precocious puberty since his testi-" E( b# l9 I' D' L+ j4 u
cles were prepubertal in size. However, testotoxicosis
2 V* D4 Y( q  S* t0 F0 vwas in the differential diagnosis because his father6 n" m  [7 |: k
started puberty somewhat early, and occasionally,# \1 V( Y* D3 [5 T
testicular enlargement is not that evident in the
' b9 I- n1 y+ G: fbeginning of this process.1 In the absence of a neg-
  j* k* ^  b0 B" Wative initial history of androgen exposure, our
" u; q4 _4 s8 Ybiggest concern was virilizing adrenal hyperplasia,
$ D7 |( y$ ?- X* Neither 21-hydroxylase deficiency or 11-β hydroxylase9 I- m- |6 x0 t& e0 W, t
deficiency. Those diagnoses were excluded by find-
9 M: a2 W$ _. ]2 b6 x" Wing the normal level of adrenal steroids.- g9 r6 w# ]( Y& B
The diagnosis of exogenous androgens was strongly
: C( r& H: o6 k( ]suspected in a follow-up visit after 4 months because
% i* n% l/ F8 ^7 ^the physical examination revealed the complete disap-7 w! w* h# c% j$ S+ r% A/ L& ^/ m
pearance of pubic hair, normal growth velocity, and- Y! L/ @) ?0 ]
decreased erections. The father admitted using a testos-
) `3 @+ X0 t" x' n( v$ tterone gel, which he concealed at first visit. He was* R5 E; b: \; e% p
using it rather frequently, twice a day. The Physicians’' g/ M' Y4 G& }& @( j$ J% y
Desk Reference, or package insert of this product, gel or+ f  c3 m; i9 f7 n( a
cream, cautions about dermal testosterone transfer to
0 p5 |; }$ n) R5 V" ?: Punprotected females through direct skin exposure.
1 d4 H0 r3 k3 {6 {4 O5 \Serum testosterone level was found to be 2 times the
0 a# [% d$ w6 M, ebaseline value in those females who were exposed to" C; A2 r2 A3 V+ M+ c
even 15 minutes of direct skin contact with their male. }/ T, {# h% t
partners.6 However, when a shirt covered the applica-, E1 a2 [) \3 m* N4 y
tion site, this testosterone transfer was prevented.
2 C' G" \6 @2 \/ ^9 |3 jOur patient’s testosterone level was 60 ng/mL,7 w6 e2 @* x9 n5 \! B
which was clearly high. Some studies suggest that% E3 \8 Y3 h% K* ~. p3 O& B, t
dermal conversion of testosterone to dihydrotestos-
$ X/ u$ y9 a0 m0 P! Bterone, which is a more potent metabolite, is more
# Z. p) r; _' q. u, B% L4 V( gactive in young children exposed to testosterone
& l+ q/ F, M( q4 n9 uexogenously7; however, we did not measure a dihy-
. c. ^5 \4 {3 B8 y3 ?& @drotestosterone level in our patient. In addition to
/ ^) v8 G  H: gvirilization, exposure to exogenous testosterone in
8 T9 B7 B* n8 ^  j- u1 M5 echildren results in an increase in growth velocity and- }! G# P/ S* I! C$ m
advanced bone age, as seen in our patient.8 h0 K. H: a5 I5 u. t: N
The long-term effect of androgen exposure during' \4 b0 m  S' m. ~
early childhood on pubertal development and final
" [8 H+ ~' E: @6 @2 {5 Z' Oadult height are not fully known and always remain: D3 W8 [8 Z0 J
a concern. Children treated with short-term testos-' H" W0 Q3 S0 z1 e* b, f- H
terone injection or topical androgen may exhibit some
/ V! z) X2 r; i" I/ q0 L; `acceleration of the skeletal maturation; however, after
6 |8 E  _0 y" R3 s( dcessation of treatment, the rate of bone maturation
. g9 W# L1 z, K0 U- _& ndecelerates and gradually returns to normal.8,9
0 W% [! Q' f, \& Q2 P0 OThere are conflicting reports and controversy
! Q8 P+ W4 Z$ |! H7 v5 o- @, jover the effect of early androgen exposure on adult! `' P  ?2 {. o+ i
penile length.10,11 Some reports suggest subnormal
+ t% b( a+ t( K+ k) X9 m8 O5 t0 C9 Ladult penile length, apparently because of downreg-. W3 L# K6 Y0 p- n
ulation of androgen receptor number.10,12 However,9 V7 K9 G0 ]  f: R5 z! A
Sutherland et al13 did not find a correlation between
# t+ D+ B/ q( o) `4 hchildhood testosterone exposure and reduced adult" R/ g, t0 D1 d  o8 m
penile length in clinical studies.
, d) `- L" J: ?. x; nNonetheless, we do not believe our patient is
' ^5 _8 A. m. ?( L+ b/ ^$ \  Fgoing to experience any of the untoward effects from8 w* r3 I% g5 R: f! h7 Y
testosterone exposure as mentioned earlier because
" n$ g: P( r) h- W% fthe exposure was not for a prolonged period of time.
& j# b# f) ^. I9 I" p+ ZAlthough the bone age was advanced at the time of: h6 m& l* D& v6 F4 S) n
diagnosis, the child had a normal growth velocity at
6 W" p. V! a' c4 B  t' @$ u8 bthe follow-up visit. It is hoped that his final adult2 R; }* q- e. k" h7 E" d
height will not be affected.: }2 p) k! b  @% ]0 L8 u( ~
Although rarely reported, the widespread avail-" b/ ]: N+ m8 h$ o# G
ability of androgen products in our society may
( C# b& f; y# d0 p7 S( N4 cindeed cause more virilization in male or female
2 @0 f7 E* D" x, i0 q% schildren than one would realize. Exposure to andro-
" y. x) A; A* x9 s. r0 G% a9 qgen products must be considered and specific ques-
6 L: A- a8 e+ m/ ?, Ftioning about the use of a testosterone product or
0 m  _, o# a* K7 g. E# }$ a9 |% a7 W# bgel should be asked of the family members during& f4 L, A' Y& o. A4 k6 ~
the evaluation of any children who present with vir-5 ]0 ]$ K9 I; g. H3 \/ S
ilization or peripheral precocious puberty. The diag-3 L' Q9 R- _3 D0 N
nosis can be established by just a few tests and by2 O! v% H% g6 }
appropriate history. The inability to obtain such a* z  Y) @* v9 r: `
history, or failure to ask the specific questions, may
4 B5 l# R) F, l/ s2 \result in extensive, unnecessary, and expensive
! S, U1 k& U% g5 K% Zinvestigation. The primary care physician should be4 j. F- X- Y! P9 {
aware of this fact, because most of these children" h( \1 o! Q- p. |- b
may initially present in their practice. The Physicians’
0 i$ L* T& c2 O; e$ ?8 w" `$ q6 w# e' bDesk Reference and package insert should also put a
5 g  p! X, I& T7 h3 r3 ]warning about the virilizing effect on a male or
: c" F& ~; O( a+ ofemale child who might come in contact with some-5 l! T7 x' r3 K8 v3 o$ b% ~
one using any of these products.' _8 }5 j2 s+ j. N
References
! D: y0 \  L. j4 B4 b% D1. Styne DM. The testes: disorder of sexual differentiation
9 [# @% s: P6 n' }and puberty in the male. In: Sperling MA, ed. Pediatric+ d1 @( ], k0 E
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' S( O6 \/ g% s8 t+ q5 P
2002: 565-628.1 \: c- F7 c. w: R5 O8 R' ~) s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 i% j7 e/ _& n! C0 Rpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
% {, a. y3 N; g8 @5 }  H, e1 G7 XBoy Induced by Indirect Topical
  ^4 {" [6 N$ y4 g+ |Exposure to Testosterone* ~3 t+ m3 O4 Q$ m; W
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- @1 _+ |$ y8 A( Y4 X' s
and Kenneth R. Rettig, MD1: k- \9 g9 P9 d% t: O+ A  @
Clinical Pediatrics
! Z9 ~, V9 s6 S! G# A. I0 i* m# u3 jVolume 46 Number 6
0 g9 @' j0 ^& ^. ^: {/ iJuly 2007 540-543+ [& Z; v4 s6 }! e8 }: |7 [
© 2007 Sage Publications* j# B# z# N; y# K3 d9 l
10.1177/00099228062966516 p$ |: b% O/ i5 }
http://clp.sagepub.com
7 _; Z( j$ ^! p; S; }hosted at2 Z6 U+ H% S0 K! u; j, O+ g
http://online.sagepub.com
6 N! U, J' |3 Y( y6 t5 WPrecocious puberty in boys, central or peripheral,2 L- x) Z4 c( c8 Y/ U/ h6 e# ]4 ]
is a significant concern for physicians. Central! c) ?8 C* r& ]( E( ^- n0 ^
precocious puberty (CPP), which is mediated6 B4 x# ^  T1 F# Y
through the hypothalamic pituitary gonadal axis, has$ P$ ]8 }& r  M; p. A& L+ ^
a higher incidence of organic central nervous system
8 k" c( l1 E/ a1 s% |# v% _lesions in boys.1,2 Virilization in boys, as manifested& }$ C, B  F  s; S0 n
by enlargement of the penis, development of pubic% d$ A' L& g7 C% b
hair, and facial acne without enlargement of testi-
2 d" b1 \- s: D' m" {: ucles, suggests peripheral or pseudopuberty.1-3 We
* C1 K- |. e4 G/ ireport a 16-month-old boy who presented with the/ Z0 ^; H- e# w: Y3 R/ P" c# {
enlargement of the phallus and pubic hair develop-  Q8 G" p; \1 u& z
ment without testicular enlargement, which was due/ v! N- ^6 k0 d; H( ^
to the unintentional exposure to androgen gel used by# p; ]+ {- V1 Y
the father. The family initially concealed this infor-! P9 e- E& Z; C4 p7 V' a
mation, resulting in an extensive work-up for this1 i( J' |5 ?+ S: G) o' ^
child. Given the widespread and easy availability of
+ ?/ {- I( {0 f+ I: {testosterone gel and cream, we believe this is proba-9 H) H9 l3 ^8 v9 w
bly more common than the rare case report in the8 V0 [# f! w6 }. y( P
literature.4; F8 m' A( @' _3 U' Z
Patient Report" ^4 Z/ u6 o' Z# q8 `4 s: y' m* b
A 16-month-old white child was referred to the
7 w: Y7 s! k, ^& S: w- _  k% ]1 qendocrine clinic by his pediatrician with the concern" R4 b# i; @5 a4 Z  c$ U/ w
of early sexual development. His mother noticed
* L0 `) Q6 F! J% {" g' k3 b( mlight colored pubic hair development when he was
' V7 I( E- c, J5 h' MFrom the 1Division of Pediatric Endocrinology, 2University of: r4 K& m4 F4 R; j2 L2 b3 i
South Alabama Medical Center, Mobile, Alabama.
7 N- {; I% I' Z0 T3 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
  |, c1 I" O. n4 d, b2 g# wProfessor of Pediatrics, University of South Alabama, College of
) r6 V9 f- z  B: nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# n- y5 @: K. i6 @% O- r
e-mail: [email protected].- V8 D8 F! c$ y* F0 p+ {1 b, @
about 6 to 7 months old, which progressively became% k. D, f& u* L- j: ^
darker. She was also concerned about the enlarge-
+ X+ u; j6 ]- @! f/ m; j. ~ment of his penis and frequent erections. The child
: e+ g: b( p+ X9 B8 l" L9 wwas the product of a full-term normal delivery, with
) X6 E. t' O/ }8 c% E3 c' @a birth weight of 7 lb 14 oz, and birth length of% z* U; v6 k9 J- b2 X. i
20 inches. He was breast-fed throughout the first year7 Y! L$ ]4 B6 Z$ {. s6 |$ k5 K
of life and was still receiving breast milk along with
( x; ~! q5 l2 `' q9 wsolid food. He had no hospitalizations or surgery,! p# o6 t4 K% i+ y/ c
and his psychosocial and psychomotor development
( }6 [. K9 \2 m1 s2 Bwas age appropriate.: [! D, J2 O) _
The family history was remarkable for the father,
% n. d$ ]; ^4 I% zwho was diagnosed with hypothyroidism at age 16,
5 J/ Y' `, c! v  j! r( ?which was treated with thyroxine. The father’s
4 q4 C6 m& W9 P8 R' b! lheight was 6 feet, and he went through a somewhat( _* \+ _; C4 w* ~% s$ k
early puberty and had stopped growing by age 14.' `( {* j$ m; g/ ]- o
The father denied taking any other medication. The
$ q8 v8 E' z0 i, G  G$ Schild’s mother was in good health. Her menarche: Q7 t: Y3 J  H0 K* N" P
was at 11 years of age, and her height was at 5 feet
" W& V# h! d  u$ C5 inches. There was no other family history of pre-; ?! _! h7 Y7 o  V8 T* t5 X; V9 K
cocious sexual development in the first-degree rela-4 H$ [/ i1 G$ `& Z: n4 R% \
tives. There were no siblings.
( D& r3 b4 Q. }, p/ k0 r7 ~: xPhysical Examination
) r" d8 [8 ~+ r$ C9 Q6 U6 d( N3 xThe physical examination revealed a very active,
  U5 B# o1 C& a/ G4 Q" G% vplayful, and healthy boy. The vital signs documented7 b% t* Q8 t) h' w
a blood pressure of 85/50 mm Hg, his length was
. a0 U/ p* D0 p4 t& ~) F4 K90 cm (>97th percentile), and his weight was 14.4 kg
# E3 G2 N0 H9 j3 ^  k(also >97th percentile). The observed yearly growth# D5 g# X( {3 w# O1 x, C3 J: @
velocity was 30 cm (12 inches). The examination of. O6 |( e% @- b7 f( D7 _% }  u
the neck revealed no thyroid enlargement.8 T/ f* G1 o6 x, b, E# w5 p
The genitourinary examination was remarkable for$ V3 d4 a. a/ C* C, Y4 f# Y0 F/ t
enlargement of the penis, with a stretched length of
" j% K+ W( r9 v, ~/ ?! W8 cm and a width of 2 cm. The glans penis was very well
2 c  V( x% M! [3 W% @developed. The pubic hair was Tanner II, mostly around  |$ @6 u7 m$ o4 N2 _- d
540
4 q8 J  x6 s* J! q* M: O( \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 u. d, g% M- P1 m- D8 {the base of the phallus and was dark and curled. The" g# j5 Y+ h) g+ @) ]0 v. Z
testicular volume was prepubertal at 2 mL each.
) |) K7 v$ Q/ q5 i% AThe skin was moist and smooth and somewhat
$ }* r/ R4 }! b# R' poily. No axillary hair was noted. There were no. I, y8 _' `9 `0 L1 s1 w' m' V; b
abnormal skin pigmentations or café-au-lait spots.$ u9 k2 H& u" f3 v% L
Neurologic evaluation showed deep tendon reflex 2+
4 R; d9 ~% y' lbilateral and symmetrical. There was no suggestion
  z7 M( ]7 @( j5 `- S; Vof papilledema.
, v: y: r  F# X  h, ZLaboratory Evaluation
7 |/ e" p, z# C  W+ e3 aThe bone age was consistent with 28 months by
( ^  p" n' x  ?$ |( m  \* q9 q; yusing the standard of Greulich and Pyle at a chrono-9 U8 d& s/ E( \+ v" c% x
logic age of 16 months (advanced).5 Chromosomal
9 I  G* x1 I% l  U# ~. O& f8 [karyotype was 46XY. The thyroid function test
- L' ]- N$ b5 v$ Ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 b5 R3 Y! U: M9 D8 L
lating hormone level was 1.3 µIU/mL (both normal).
" k! y( J/ d# n& o, l+ Q! q$ hThe concentrations of serum electrolytes, blood$ e' h- i# v1 m3 e* J) z
urea nitrogen, creatinine, and calcium all were
7 r7 ?  @+ t+ @: C3 z# Lwithin normal range for his age. The concentration  e* O9 m1 q0 `. j( \$ Q" m
of serum 17-hydroxyprogesterone was 16 ng/dL
% O% ?' T* {  d. z3 K7 q(normal, 3 to 90 ng/dL), androstenedione was 20
& F7 }: @8 M; {4 Y3 Z- `, gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  P' y4 V; x/ H, E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, F3 g0 s8 D; h  _0 l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; o: X  J& e2 C; ?4 L. {4 a8 M49ng/dL), 11-desoxycortisol (specific compound S)6 i; w2 c4 a' x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# ~, C' [( j3 \$ k! W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 E" N! p* T7 |- R& x* O- m
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) t, d' c  y/ k; e; ^
and β-human chorionic gonadotropin was less than
5 {3 f: c' q5 F7 N5 mIU/mL (normal <5 mIU/mL). Serum follicular
* y# j  f7 @8 u+ `+ i$ a- Ostimulating hormone and leuteinizing hormone
1 N! g' x& f4 l9 l5 T/ y/ K; ^concentrations were less than 0.05 mIU/mL
8 U# ?# U% `. C( }(prepubertal).
. H, i% V) B& E' ^The parents were notified about the laboratory$ r0 F9 k& g. X+ X
results and were informed that all of the tests were! O- R8 I* R  C7 l3 ?* ]
normal except the testosterone level was high. The
* H% [! ?0 p2 [" d0 pfollow-up visit was arranged within a few weeks to
$ `% R1 u7 v4 \0 z& |" S( tobtain testicular and abdominal sonograms; how-* c. ]" F! u5 U+ a: w
ever, the family did not return for 4 months.
4 P3 }2 Q6 O' N7 c& k0 rPhysical examination at this time revealed that the+ r( F9 q( J3 J, W7 b
child had grown 2.5 cm in 4 months and had gained3 ^* p6 m, C/ k5 j. {. E3 h/ v
2 kg of weight. Physical examination remained: S; m. P2 v- {. L4 C
unchanged. Surprisingly, the pubic hair almost com-; [8 O( t% A( X
pletely disappeared except for a few vellous hairs at
) B2 @. Q+ g6 C, c# ]) y& A. kthe base of the phallus. Testicular volume was still 2
+ W' k) T( e' F0 ^3 S& d5 F" i" @, }mL, and the size of the penis remained unchanged.# g! N1 j8 ^5 n
The mother also said that the boy was no longer hav-8 m. T2 h% x9 G, A, h  q( V
ing frequent erections.
: g: ]( c& z6 J4 eBoth parents were again questioned about use of
& I$ V! b( ?0 U- y  l, Nany ointment/creams that they may have applied to
  @& K4 `8 S2 v- [0 @the child’s skin. This time the father admitted the
; z1 Q" l7 h, u' x& CTopical Testosterone Exposure / Bhowmick et al 541
1 I9 _& X9 {  Z, a8 D6 o+ iuse of testosterone gel twice daily that he was apply-
. s/ y" J% s: d. Y/ zing over his own shoulders, chest, and back area for
1 E4 R0 ^; y% ]& K1 s1 y# F/ Ma year. The father also revealed he was embarrassed/ \  h$ J: l# _& E% `
to disclose that he was using a testosterone gel pre-7 J8 n- Z- ]) `  f; O* f
scribed by his family physician for decreased libido
  O+ ]% L  j& j6 J/ M: V3 g* ssecondary to depression.! X- O$ L& S  u; {2 ^* E3 x
The child slept in the same bed with parents.
# l. [2 L- s5 ~The father would hug the baby and hold him on his
4 X% s& X9 |& b, K3 gchest for a considerable period of time, causing sig-
1 k  O6 E% ~2 N0 [+ B' Lnificant bare skin contact between baby and father.
0 s6 k4 O  A: f5 Y0 X  [) u! r0 j1 jThe father also admitted that after the phone call,+ c2 I. H) q+ t) l0 q  d
when he learned the testosterone level in the baby
5 j5 `6 ^3 v2 D$ [% v$ c( w* Gwas high, he then read the product information/ U. \9 q2 l' g& K+ n) S* T* F4 p
packet and concluded that it was most likely the rea-1 q2 R' |1 l: ?  E3 s2 j
son for the child’s virilization. At that time, they. C1 F) A- w# S, _! ]# j
decided to put the baby in a separate bed, and the& q, b& J. i4 W
father was not hugging him with bare skin and had
& e5 U# n  R9 }  b. n/ Gbeen using protective clothing. A repeat testosterone
& T! Y/ A+ m, t0 Ctest was ordered, but the family did not go to the
( O3 c0 B1 i! B& l0 b) v8 d0 ^laboratory to obtain the test.
% Z# V" P9 i& a4 i, P1 ^+ FDiscussion& ~- ]/ L. _) c  I9 J3 u
Precocious puberty in boys is defined as secondary: u. C9 a" L$ s3 }9 O
sexual development before 9 years of age.1,4: M5 S7 ~1 S: z
Precocious puberty is termed as central (true) when" q( d) K( }/ ]
it is caused by the premature activation of hypo-
' u& s& n" t: T, a* v8 tthalamic pituitary gonadal axis. CPP is more com-
+ w5 g, U- {. g& |' t, Nmon in girls than in boys.1,3 Most boys with CPP
3 d2 g7 B5 p  }8 O2 nmay have a central nervous system lesion that is- c. s6 K8 P$ O5 O3 y1 z- j
responsible for the early activation of the hypothal-+ @3 g7 L$ n3 T  R$ Q$ z
amic pituitary gonadal axis.1-3 Thus, greater empha-
  O2 U! }" A  y6 Gsis has been given to neuroradiologic imaging in8 ?0 P7 O2 O( c7 p+ e' R
boys with precocious puberty. In addition to viril-, Z. v% \+ a1 G. Y9 h+ n/ ?
ization, the clinical hallmark of CPP is the symmet-$ o9 f; W5 Y4 ?; a8 u& J9 H
rical testicular growth secondary to stimulation by
7 b+ h* }* q& u( S, t+ [) |7 [4 H: ggonadotropins.1,3
( s4 f; w6 v  x  R* M/ c$ ~Gonadotropin-independent peripheral preco-
# r! `- n7 N4 N: ^cious puberty in boys also results from inappropriate- l6 Q  y1 B6 Q6 e7 h  ?4 O
androgenic stimulation from either endogenous or
' E4 G- G. T: u0 h: l6 K4 I* x8 Oexogenous sources, nonpituitary gonadotropin stim-
) c& E+ O0 w& z' u6 \! hulation, and rare activating mutations.3 Virilizing* a, ~; x$ ]0 }7 J- C, e7 b4 r) p) P
congenital adrenal hyperplasia producing excessive( v: V2 i9 J" T, `2 l& n
adrenal androgens is a common cause of precocious  J/ [% \6 _8 V# Z' ?/ G' @
puberty in boys.3,4
/ M+ l" P( i! C0 x7 b2 XThe most common form of congenital adrenal
1 K' ?1 P; ^# p" w) t- f/ ?hyperplasia is the 21-hydroxylase enzyme deficiency.1 j5 ^/ C$ O3 ]5 o) p
The 11-β hydroxylase deficiency may also result in
  Y3 o5 u, O/ p% hexcessive adrenal androgen production, and rarely,0 z: Q( k, L4 W0 X0 j
an adrenal tumor may also cause adrenal androgen
$ s' K7 i% ^, {excess.1,30 U3 f$ g% K  v5 {7 K$ c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% f1 q3 c* |) c( J/ z5 I2 A542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; @) E9 H; G) Y/ a8 E, {, z2 IA unique entity of male-limited gonadotropin-
0 K+ Z# H2 N0 p  xindependent precocious puberty, which is also known
% ^2 L. |& T& N$ R9 g4 oas testotoxicosis, may cause precocious puberty at a+ Y& w" e8 e- s* {
very young age. The physical findings in these boys/ u3 L! Q% w: i" Y5 y. Q" ^4 Z
with this disorder are full pubertal development,
2 }$ g2 U) E  D( p5 p1 ^( Xincluding bilateral testicular growth, similar to boys4 S# F- z" ]. Y& O" }: L8 [
with CPP. The gonadotropin levels in this disorder/ F0 j% }9 ]2 g5 z9 h' ^0 s
are suppressed to prepubertal levels and do not show  F5 W, S. z# M  o2 g2 f
pubertal response of gonadotropin after gonadotropin-9 Z9 C0 Q5 I- D! B8 Z2 X
releasing hormone stimulation. This is a sex-linked
- F( u( w: O+ m; _1 n8 U; Cautosomal dominant disorder that affects only9 E$ P3 R. W% W! u
males; therefore, other male members of the family
- H2 h* n6 c5 N# W; }may have similar precocious puberty.3
+ @9 J5 w0 {5 {' cIn our patient, physical examination was incon-9 d; Z9 o3 R6 U5 e1 }7 a. d- E
sistent with true precocious puberty since his testi-$ E$ t2 b' G! Q& U+ o( Z9 I
cles were prepubertal in size. However, testotoxicosis
- ^1 e; t" a$ _" Z: m8 Twas in the differential diagnosis because his father
: o  m, q- M+ r- estarted puberty somewhat early, and occasionally,5 T5 M2 d& \8 C2 A. G0 w
testicular enlargement is not that evident in the
0 q; O, i1 Y6 Qbeginning of this process.1 In the absence of a neg-* m, @3 s! r: }3 S! M% t! A! m
ative initial history of androgen exposure, our
% g9 X* c% r- m5 @6 Hbiggest concern was virilizing adrenal hyperplasia,3 ~- U  T* D& w! J' k& V
either 21-hydroxylase deficiency or 11-β hydroxylase
# ^0 }/ [( k" R2 Z7 J0 `deficiency. Those diagnoses were excluded by find-( m* U3 m9 t" H6 W. h7 ~1 l2 ~
ing the normal level of adrenal steroids.  [  N: _( ^0 y4 n
The diagnosis of exogenous androgens was strongly0 o6 D& |# E8 r: f6 x0 T# O/ V, g
suspected in a follow-up visit after 4 months because
6 i9 @' f% @3 q- @9 Sthe physical examination revealed the complete disap-" H' n- P. O9 C. E2 q' i
pearance of pubic hair, normal growth velocity, and
. ?) c5 E/ Z/ P, {. r6 f7 ?) Xdecreased erections. The father admitted using a testos-
' D% ~* T# F% E! \' qterone gel, which he concealed at first visit. He was' x! B! b3 [4 e( J- z- F& O4 w' d
using it rather frequently, twice a day. The Physicians’
1 s2 N. W! Z% S$ ^7 R0 PDesk Reference, or package insert of this product, gel or$ o/ z- b3 a. i5 U# R) J2 u
cream, cautions about dermal testosterone transfer to' x( s; R3 ?- F% Y2 u
unprotected females through direct skin exposure.' x4 `: C( x; J' a7 p, w
Serum testosterone level was found to be 2 times the
0 Z$ z' n0 @$ r' l0 ^baseline value in those females who were exposed to4 V, n4 \, f. F9 f9 ^
even 15 minutes of direct skin contact with their male
4 R: i9 V: y% [/ w% ?. Epartners.6 However, when a shirt covered the applica-0 A  V# c7 l: P. n% n* |8 |
tion site, this testosterone transfer was prevented.
9 E$ ~5 s& u+ @5 v+ ]Our patient’s testosterone level was 60 ng/mL,7 l" h8 N' N: n) h/ i7 u
which was clearly high. Some studies suggest that
& q  V8 S) g: ?, Ddermal conversion of testosterone to dihydrotestos-
5 ?5 T; T! ]+ k" \& k" X3 ?. f4 Gterone, which is a more potent metabolite, is more! p' h1 x. N+ t, ^7 |' [2 A
active in young children exposed to testosterone
; b% T2 z  b( ^. Q2 iexogenously7; however, we did not measure a dihy-
) U5 c# J) J8 _7 ~drotestosterone level in our patient. In addition to- \$ r" p# S) ^
virilization, exposure to exogenous testosterone in
* K& Q* Q- g" w" wchildren results in an increase in growth velocity and
9 t1 v" p3 E: p5 e! Vadvanced bone age, as seen in our patient.9 z% o7 ]' L6 l. h9 D
The long-term effect of androgen exposure during
) q$ W9 h: z# F, z1 {& @) T, d  ~% i! yearly childhood on pubertal development and final4 s4 N. i+ _, J  B
adult height are not fully known and always remain
2 o" p( x; e, {- Ka concern. Children treated with short-term testos-* T' L/ C2 @/ S! y9 h% F$ a. x
terone injection or topical androgen may exhibit some! }6 l5 x4 _, B9 Z
acceleration of the skeletal maturation; however, after
3 E( y7 R% w# N  q+ b! Dcessation of treatment, the rate of bone maturation" {7 m) K' C# `2 m$ _( K: s
decelerates and gradually returns to normal.8,9
* T7 {: E4 E% e# s! p4 ZThere are conflicting reports and controversy% x6 P) W+ t* K) ]/ n" n: ]" _
over the effect of early androgen exposure on adult- e. O+ r5 f8 u
penile length.10,11 Some reports suggest subnormal5 G. d0 P( @* B
adult penile length, apparently because of downreg-
; j6 u/ y9 c7 M3 d- O4 g$ J5 Z) Yulation of androgen receptor number.10,12 However,
+ G! d7 g, v: n, D# ~6 m% [' `# `Sutherland et al13 did not find a correlation between
- `* j4 A9 g1 Z# S. I5 ^childhood testosterone exposure and reduced adult) W8 w( z2 s/ M4 x  y# E" {
penile length in clinical studies.; U9 y- p" i) h% x, M
Nonetheless, we do not believe our patient is0 s- c+ k6 F- x" I& ?9 x) X
going to experience any of the untoward effects from& A! K2 S( F3 M5 V
testosterone exposure as mentioned earlier because
- ?: ?7 v- o/ E0 m6 ?the exposure was not for a prolonged period of time., S: O" w% ^6 p! A! g% T0 c( L
Although the bone age was advanced at the time of& y& Q8 @% u3 ]  ^4 o
diagnosis, the child had a normal growth velocity at
! j& n, n- w  H$ F+ s. @3 g5 Lthe follow-up visit. It is hoped that his final adult+ J5 `7 E# I  K6 ~/ m* Y& u
height will not be affected.
) R4 p/ v! O! t( ZAlthough rarely reported, the widespread avail-7 w+ T6 \/ L% \$ z
ability of androgen products in our society may% y. \9 G6 a7 S, |6 _
indeed cause more virilization in male or female/ Y* z, {0 v& J7 c8 J6 B
children than one would realize. Exposure to andro-
: a- B& g3 ~% z; \gen products must be considered and specific ques-
. ]( R$ z% A( A/ _2 f/ K0 `tioning about the use of a testosterone product or. W- |; P! m. o7 \2 M4 x' f4 U
gel should be asked of the family members during
. |! G! T% r6 ]5 D4 Othe evaluation of any children who present with vir-
$ U0 e$ t% `* `4 p9 iilization or peripheral precocious puberty. The diag-5 ?; w, c. T6 H! r4 M) r2 t
nosis can be established by just a few tests and by* v8 k3 X: X' Z8 K3 G
appropriate history. The inability to obtain such a
7 ?% s: q6 l  H. }/ V) }. X1 chistory, or failure to ask the specific questions, may
- h/ o. B, ?- R" _! y0 Kresult in extensive, unnecessary, and expensive5 u+ v" q3 m1 M9 B' V
investigation. The primary care physician should be1 Q/ O8 L1 C7 v+ |8 @3 K
aware of this fact, because most of these children; M3 x4 o& W0 u' \2 U
may initially present in their practice. The Physicians’
) H1 [5 ?. B. H1 B* {Desk Reference and package insert should also put a* B$ }- H1 L+ Y, S; N  r! B* q
warning about the virilizing effect on a male or3 p4 L2 o' k0 i0 X  c& T$ k
female child who might come in contact with some-7 c4 n7 A( `( y  V, }/ \) q+ |
one using any of these products.
% ^9 r: k5 q5 i4 e' ]' T  OReferences
# ]1 x% Q, x+ d/ P1. Styne DM. The testes: disorder of sexual differentiation  h( e, o* \  b/ S1 F
and puberty in the male. In: Sperling MA, ed. Pediatric6 y% R& T/ b$ v- R% ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* D  D- O% k$ R$ l! U) T# J
2002: 565-628.5 @0 U/ @) n2 t4 K5 S4 l! ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 y9 ?" n& n" R( n( r! z
puberty 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
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
( L, y; f; y+ @: |! {7 f" J
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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