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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
" J* r1 V5 e. SBoy Induced by Indirect Topical: w; O7 f# x( ]* h- y' i# @
Exposure to Testosterone
4 ^8 s. H8 s" ?9 v4 WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ [, h. ^- S( ?) C+ y. xand Kenneth R. Rettig, MD1
& Q# `+ j" ~; g/ jClinical Pediatrics
8 \; C: v1 t. e3 U0 g* BVolume 46 Number 65 e) h: U2 Q& B7 t) d
July 2007 540-543
! H7 S; t  P% J( C6 c; H: C& P% w© 2007 Sage Publications$ B# |$ @# s3 p- V
10.1177/0009922806296651
% w4 D" L! d4 z3 S3 m9 Z8 \http://clp.sagepub.com( s$ h0 g7 @, H- u
hosted at
& Z; b) l. ^- A* P5 O! s3 Ahttp://online.sagepub.com
  y( M4 W. y5 j- H/ UPrecocious puberty in boys, central or peripheral,
# D. o, @" n' t& o, C: J& ?% F" D: [is a significant concern for physicians. Central! T3 i3 F: S6 o3 X% l1 A; Z" m
precocious puberty (CPP), which is mediated
8 E- i% w8 S8 A2 b1 \through the hypothalamic pituitary gonadal axis, has  P" r: y6 x1 z9 T# V) G5 O7 a
a higher incidence of organic central nervous system5 o% S, C- F* y9 t$ _
lesions in boys.1,2 Virilization in boys, as manifested) n1 f. J+ k$ ]* \( i& i4 g
by enlargement of the penis, development of pubic
; {! H7 u" R( ]4 o, X) nhair, and facial acne without enlargement of testi-- E! O7 m1 V9 t4 u7 a  h
cles, suggests peripheral or pseudopuberty.1-3 We+ A5 Z+ K, ]& G: P. k. l7 s
report a 16-month-old boy who presented with the
, D3 w( \% o& [1 A0 s8 b! Xenlargement of the phallus and pubic hair develop-% q' c- I& ]7 a* w
ment without testicular enlargement, which was due
1 v/ R: k+ l# r7 A  dto the unintentional exposure to androgen gel used by
* g8 C3 X# W$ d- Jthe father. The family initially concealed this infor-
. n- v( y8 Y( B4 q6 [4 bmation, resulting in an extensive work-up for this. r( I. z# N  L
child. Given the widespread and easy availability of' I. r3 O" ]9 @9 Z8 M
testosterone gel and cream, we believe this is proba-
/ ]- n1 z' x* }/ F3 b0 ?bly more common than the rare case report in the9 r0 o3 `) W* z) }9 c( p
literature.4& ^( T+ R3 W- u
Patient Report
5 ^1 p/ Q, f4 RA 16-month-old white child was referred to the, Z9 ~. F" p( q, P0 ~2 Y& q; u$ v; L6 u, \
endocrine clinic by his pediatrician with the concern
1 c2 G" H* q+ |! Kof early sexual development. His mother noticed: `$ _+ b0 S6 |2 c" ~1 D* Y' A
light colored pubic hair development when he was* {9 \2 L4 E1 e) j3 |" v
From the 1Division of Pediatric Endocrinology, 2University of- |) \& G) _8 P0 j, X% m
South Alabama Medical Center, Mobile, Alabama.2 M* {- p" \$ S' A" o- H
Address correspondence to: Samar K. Bhowmick, MD, FACE,# U, [  B( e* B# g, m
Professor of Pediatrics, University of South Alabama, College of$ x" y+ C8 G' W0 ?; H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( n  F0 ^0 N+ f% a: }
e-mail: [email protected].; w6 s6 t$ W. X" W
about 6 to 7 months old, which progressively became
! ]  @9 w8 J9 l0 }- k. Y4 H, Hdarker. She was also concerned about the enlarge-9 E/ h  I$ p7 N/ E
ment of his penis and frequent erections. The child" \+ A* X1 @$ R3 A5 w
was the product of a full-term normal delivery, with" o- |  D; [9 \7 j1 _- N9 ?- [& D
a birth weight of 7 lb 14 oz, and birth length of
& Z! t$ D0 X: F8 j' s- @20 inches. He was breast-fed throughout the first year
% d8 c4 C- \8 X6 ^' S/ m! m) o. sof life and was still receiving breast milk along with4 l7 i( `& w' f6 ?$ k! k
solid food. He had no hospitalizations or surgery,, t, `/ w* g* {
and his psychosocial and psychomotor development5 t4 A$ v$ O' M- U2 k9 j3 f+ u- l
was age appropriate.
8 G+ D- A% p! h1 JThe family history was remarkable for the father,9 Q# Q! j" g9 c: }1 ^
who was diagnosed with hypothyroidism at age 16,
3 E7 O% V8 b: Z: Q4 Ywhich was treated with thyroxine. The father’s: Z' v0 I+ j# Z. |
height was 6 feet, and he went through a somewhat1 O4 x7 L3 @8 k( t- p$ o$ n
early puberty and had stopped growing by age 14.
. Q. R/ v, a  _5 P8 e2 d0 r. w% U2 sThe father denied taking any other medication. The' h0 @. Y/ m2 Z
child’s mother was in good health. Her menarche
" [; h% n+ X9 R. Fwas at 11 years of age, and her height was at 5 feet
" o& b1 @7 e1 _5 _. K, g, ]5 inches. There was no other family history of pre-3 h9 {9 Q. }3 h, n2 q* O/ A
cocious sexual development in the first-degree rela-
( C% `2 e8 Q5 a* ^$ Wtives. There were no siblings.- S8 t$ E: P% n. `- q# ^
Physical Examination
! \% r+ f# q* ?The physical examination revealed a very active,4 g& B# y7 i$ l6 b
playful, and healthy boy. The vital signs documented/ Y! l& T- {9 J: r1 c; x
a blood pressure of 85/50 mm Hg, his length was
) @6 O) x& Q0 I* t  r90 cm (>97th percentile), and his weight was 14.4 kg6 L- }6 G( Z' M' E: E9 d% I
(also >97th percentile). The observed yearly growth# \( ~# s, X' R/ }9 M
velocity was 30 cm (12 inches). The examination of" k) D/ j: ~% \3 k% C
the neck revealed no thyroid enlargement./ k# q( e; b* [. m$ N
The genitourinary examination was remarkable for
- m. N5 C- C/ O) `: v6 Fenlargement of the penis, with a stretched length of) |: e4 e# b6 `3 k' Q
8 cm and a width of 2 cm. The glans penis was very well
" \! g$ ^( K+ V. C" ~developed. The pubic hair was Tanner II, mostly around
; V% R2 B$ g3 X* z" F- h540
( u4 f* i4 |/ N# [# H2 hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 X, \1 n) e9 Mthe base of the phallus and was dark and curled. The
: b1 ]- \1 B$ L- _5 V7 q$ z7 X' ~testicular volume was prepubertal at 2 mL each.  U, F+ o( [" z) x
The skin was moist and smooth and somewhat  F& c0 x5 ~2 O
oily. No axillary hair was noted. There were no
) s# X+ i4 D$ k$ o+ W# oabnormal skin pigmentations or café-au-lait spots.) H" R3 H4 M0 Z8 i- k" Y
Neurologic evaluation showed deep tendon reflex 2+3 n6 V  W- y8 m/ Y0 ~8 P( N
bilateral and symmetrical. There was no suggestion
. |5 w- N- F+ M) Eof papilledema.* ~  s) @4 g/ F. E$ w
Laboratory Evaluation! l& e1 Q9 u& M' L
The bone age was consistent with 28 months by
) b# b; m, c4 N+ o5 e4 ?' Yusing the standard of Greulich and Pyle at a chrono-+ P$ C* U- c& t* G4 Q2 l8 }! ~
logic age of 16 months (advanced).5 Chromosomal. s( t9 v2 d2 f/ Q1 b
karyotype was 46XY. The thyroid function test* W' U. ]* Z6 Y7 B1 T" I! J8 ~- j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 ~4 B- c/ B. O6 \: h5 t# d
lating hormone level was 1.3 µIU/mL (both normal).$ m  S" r3 l2 d# P; r$ \
The concentrations of serum electrolytes, blood
7 {9 X, ^3 u& w" G9 U  durea nitrogen, creatinine, and calcium all were) p2 Q$ N8 L% l- }5 H
within normal range for his age. The concentration4 P' i8 l/ P# a7 n9 ^) P
of serum 17-hydroxyprogesterone was 16 ng/dL1 s" a/ U7 t8 o- t2 q
(normal, 3 to 90 ng/dL), androstenedione was 20
- s1 x2 \+ L2 G" ?( Q, D4 G* D1 Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 Q/ n, G1 j# Qterone was 38 ng/dL (normal, 50 to 760 ng/dL),' L" ?0 F' P1 e9 Q2 ?) ]- w, [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 B# N4 b% f5 Z9 ?6 u49ng/dL), 11-desoxycortisol (specific compound S)2 X1 e% Z7 F' |9 B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ T! }! y0 z& u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( o2 ~- \0 F0 b
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),: Q: h5 N0 `$ ^+ P
and β-human chorionic gonadotropin was less than
% ^4 t" O$ r, ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
! S: x: O' W# q0 Tstimulating hormone and leuteinizing hormone
! G9 i% T' {6 S% J& Mconcentrations were less than 0.05 mIU/mL
. m1 J9 z7 J5 e5 o0 y(prepubertal).
1 B- D# f  |6 w& f- e- {( y( y1 mThe parents were notified about the laboratory
2 q: b9 P  V: a- R$ d1 @results and were informed that all of the tests were  H4 U0 Q) D6 u0 W) q8 R, r
normal except the testosterone level was high. The  |" V0 `) |4 x0 e
follow-up visit was arranged within a few weeks to
/ h1 v( e0 v( L7 n6 I' ^$ ]obtain testicular and abdominal sonograms; how-
0 U2 h" }% s4 f& F6 @' A9 x( V0 t8 never, the family did not return for 4 months.
9 m7 B3 |; p- U. q3 |$ pPhysical examination at this time revealed that the. C2 Z/ Z+ J7 l1 h1 F
child had grown 2.5 cm in 4 months and had gained% Q9 u0 X# `5 B/ F5 Y7 O
2 kg of weight. Physical examination remained* ?( N7 S" W6 F' \+ \/ W# S
unchanged. Surprisingly, the pubic hair almost com-7 l3 v' Z5 L' E
pletely disappeared except for a few vellous hairs at/ @" q8 z3 O' N. S) ]( Y9 f# G
the base of the phallus. Testicular volume was still 20 r1 R$ i! O+ s; l6 z
mL, and the size of the penis remained unchanged.
& E5 G2 [, s" k0 Q' V) x6 sThe mother also said that the boy was no longer hav-7 @3 u# R% M5 g
ing frequent erections.- x" b  F: k. N1 g* X, ?( O
Both parents were again questioned about use of
" @( @% G% F9 {- J% ~any ointment/creams that they may have applied to
" L2 E! J/ z7 g1 s* n: R, |- Gthe child’s skin. This time the father admitted the
. ~- w, E' b6 d  F8 A. |Topical Testosterone Exposure / Bhowmick et al 541
& |. e9 O- S; Ruse of testosterone gel twice daily that he was apply-, r- @" W+ f" L: C! V  Q
ing over his own shoulders, chest, and back area for
4 P: I. a1 H) F7 ^8 ]+ j! I. aa year. The father also revealed he was embarrassed2 G- [3 T3 ?/ p0 Y6 X
to disclose that he was using a testosterone gel pre-
' {% p  m) z& y, ^scribed by his family physician for decreased libido+ Q; \# ~* |9 o4 S
secondary to depression.5 T8 O1 i3 C. v9 V/ ^
The child slept in the same bed with parents.9 @7 J4 T4 ?' @6 h5 C8 H
The father would hug the baby and hold him on his
$ o) E* u. x+ |, ], kchest for a considerable period of time, causing sig-* ]0 N. J' n2 E7 \4 Y
nificant bare skin contact between baby and father.5 w/ O  @; w( c0 ^$ K& g- G% n
The father also admitted that after the phone call,
$ K9 {- M1 ~% ywhen he learned the testosterone level in the baby
  c) o7 r- h2 t3 Hwas high, he then read the product information
8 }( f, r2 u, k+ _packet and concluded that it was most likely the rea-
, r$ [! d) o9 oson for the child’s virilization. At that time, they2 n* ~  G9 I* ^8 S2 r) C# k
decided to put the baby in a separate bed, and the
/ M& e) B3 N; Q! H& rfather was not hugging him with bare skin and had
- r& Q6 M$ Y; n7 Sbeen using protective clothing. A repeat testosterone
0 @& [- b4 H1 u* mtest was ordered, but the family did not go to the
4 J, g$ J. B, \5 E* L5 Claboratory to obtain the test.
' v2 k* E" L5 ?7 PDiscussion
* R5 S* S/ H4 B1 M' |2 ^$ mPrecocious puberty in boys is defined as secondary
3 E; o! h2 c* p, Bsexual development before 9 years of age.1,4+ m! f% p  E6 }$ ]
Precocious puberty is termed as central (true) when& r; d# ~9 \. {& z5 Z
it is caused by the premature activation of hypo-% ]- ^2 ^. M. u
thalamic pituitary gonadal axis. CPP is more com-
/ S! W: i0 K; n1 tmon in girls than in boys.1,3 Most boys with CPP' d& a' b. D8 h
may have a central nervous system lesion that is7 r3 f/ Z7 y4 z$ o  X1 V
responsible for the early activation of the hypothal-
- b; Y+ ^4 l! P- m8 w+ K, Famic pituitary gonadal axis.1-3 Thus, greater empha-
2 c, R$ c3 }7 g6 b6 v$ c! nsis has been given to neuroradiologic imaging in
& f6 c' a8 G* i; x; Sboys with precocious puberty. In addition to viril-' k8 t, L# k6 W
ization, the clinical hallmark of CPP is the symmet-
9 S' m/ L0 }0 E7 T/ @3 G& x, [$ ], I- A  Rrical testicular growth secondary to stimulation by
# S4 g3 C/ ^" @2 e+ ngonadotropins.1,3+ q' T; T9 z" ]) y+ }/ }% T: V
Gonadotropin-independent peripheral preco-. x" d! [* M  u( z
cious puberty in boys also results from inappropriate
7 E$ B- W- w9 P0 h% s; G' u* i1 Dandrogenic stimulation from either endogenous or2 s2 {: P8 n" J4 Q! U: P* T9 l
exogenous sources, nonpituitary gonadotropin stim-
) M& _+ [$ k, L4 ^ulation, and rare activating mutations.3 Virilizing8 x( J. P5 l6 [
congenital adrenal hyperplasia producing excessive
) @7 p% t+ ~0 d/ T, Tadrenal androgens is a common cause of precocious
3 V+ p" D7 [1 c1 W2 Tpuberty in boys.3,45 q1 {1 S# v. a/ H
The most common form of congenital adrenal
, }* T6 e1 A/ t; y6 _hyperplasia is the 21-hydroxylase enzyme deficiency.
8 c4 {9 h; K0 x2 r  }6 }6 Z1 y5 OThe 11-β hydroxylase deficiency may also result in/ e% _& ^, Y9 ~4 \
excessive adrenal androgen production, and rarely,, l) A0 K% F3 ~' L
an adrenal tumor may also cause adrenal androgen* J9 V9 U5 k9 Q3 W/ C! t
excess.1,3
& ~$ l6 W' `0 p9 P. [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 y& K, N, t2 l) [' q& L/ R542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 E1 o, A; r2 h8 y- c5 P0 ]/ @1 B
A unique entity of male-limited gonadotropin-  W; o0 F) u! U) R* Y, t/ }3 d
independent precocious puberty, which is also known1 t" T6 T7 c0 [& Q1 W
as testotoxicosis, may cause precocious puberty at a
  E! N) ]6 c) ^7 w% }7 Zvery young age. The physical findings in these boys, H# p( b: K( p1 R
with this disorder are full pubertal development,
5 w$ M2 a+ w( b2 uincluding bilateral testicular growth, similar to boys' t0 `$ f3 T- K: Q5 M' W4 D
with CPP. The gonadotropin levels in this disorder
7 o& C# {% ?( a0 `. ~% c3 n+ s: I5 Care suppressed to prepubertal levels and do not show$ ]9 R7 D, z7 t+ U3 e3 G
pubertal response of gonadotropin after gonadotropin-
6 r" Q0 c6 z6 P# x4 b& Y& v7 creleasing hormone stimulation. This is a sex-linked
) v; S% F5 A$ ^4 r! A( U/ Qautosomal dominant disorder that affects only+ C( H+ d" c3 r# x& G6 z
males; therefore, other male members of the family
' P8 C! J3 j2 m% _may have similar precocious puberty.3  a9 F. z/ @8 L* ~4 ^) D! s
In our patient, physical examination was incon-3 j( X9 a7 h3 H- v* K1 C% [# }
sistent with true precocious puberty since his testi-" k6 j4 M& X/ i# t" P' `
cles were prepubertal in size. However, testotoxicosis
: K/ @1 Z  \0 j# W5 V7 C9 ^. Jwas in the differential diagnosis because his father
$ B+ {) J# J( y: g% Z" Kstarted puberty somewhat early, and occasionally,
2 ~! R9 B/ g: O) c% U+ rtesticular enlargement is not that evident in the
# h& A, j0 A2 y7 q# D2 Sbeginning of this process.1 In the absence of a neg-
3 g; ]# O/ E& p1 T9 J2 n5 yative initial history of androgen exposure, our, q$ M9 f( w* }/ z. h3 e
biggest concern was virilizing adrenal hyperplasia,% A. p" q2 {4 M$ u& v, k& Y
either 21-hydroxylase deficiency or 11-β hydroxylase$ m1 {$ W9 e' L6 j5 f6 ]
deficiency. Those diagnoses were excluded by find-' A5 }, t- Y, ^$ P
ing the normal level of adrenal steroids.6 F) g) l6 O! E7 X: ~  T5 X
The diagnosis of exogenous androgens was strongly2 Z  l) _) F# s! Z0 U2 [9 b4 q
suspected in a follow-up visit after 4 months because( I7 k, k8 B+ h, j, [
the physical examination revealed the complete disap-
+ V2 |/ S$ I& T' J3 {+ _; ^8 A/ Npearance of pubic hair, normal growth velocity, and
2 A  p8 ]( d/ |8 B) }& ~decreased erections. The father admitted using a testos-
4 g8 h9 S3 b2 O. fterone gel, which he concealed at first visit. He was
( t  j. S* c  @using it rather frequently, twice a day. The Physicians’# A2 Q! x$ i' n$ J- z2 |3 Z
Desk Reference, or package insert of this product, gel or% k& y9 K2 S- f0 {0 e
cream, cautions about dermal testosterone transfer to
* u' u2 ]% h( Q7 t" b! a( X( ~( Hunprotected females through direct skin exposure.5 `( A6 f0 B- m) K
Serum testosterone level was found to be 2 times the8 H! e8 Y! @# P6 e, u# v. Z+ _
baseline value in those females who were exposed to
& D3 g: K+ |! J' N) |even 15 minutes of direct skin contact with their male9 M" E* J% H/ L$ w
partners.6 However, when a shirt covered the applica-" f1 z! o( a% R
tion site, this testosterone transfer was prevented.
7 m* ~3 C/ o& AOur patient’s testosterone level was 60 ng/mL,4 f" {0 [& s& w: ^
which was clearly high. Some studies suggest that
' X& J  r( s4 P' j5 v# Bdermal conversion of testosterone to dihydrotestos-$ d- y9 b/ |$ J  J8 A( i1 @. t) ~
terone, which is a more potent metabolite, is more; B3 U$ o3 X" F& D) `9 P
active in young children exposed to testosterone5 I) B( j* r( w) N0 t" o
exogenously7; however, we did not measure a dihy-6 K. Q6 e! b5 G1 q/ e; v
drotestosterone level in our patient. In addition to
% i) @5 g* ~% D% ]# {' G2 d. L- Lvirilization, exposure to exogenous testosterone in5 Z3 _4 u- N1 E) V
children results in an increase in growth velocity and
1 a9 d1 D' E! o, ?advanced bone age, as seen in our patient.  ]- M' ^$ Q9 B. \1 o
The long-term effect of androgen exposure during
! T# O: a1 _; x2 d5 I1 O3 x; Nearly childhood on pubertal development and final
/ j  e/ {2 Z; {9 [. {$ radult height are not fully known and always remain
# E5 K( p5 h( i6 H; F3 ?, da concern. Children treated with short-term testos-
9 O6 X% Z- W4 [' s$ l; r( vterone injection or topical androgen may exhibit some
# j; t3 D' `1 q/ |+ R: _( T( ]acceleration of the skeletal maturation; however, after0 r3 d/ j! y  p( ~/ Z0 x9 l1 i
cessation of treatment, the rate of bone maturation  x4 @- P% N3 N
decelerates and gradually returns to normal.8,9
* ^6 W! t$ S4 @5 e8 A! E5 A9 nThere are conflicting reports and controversy0 v& ^7 k9 \! T2 v4 D
over the effect of early androgen exposure on adult
$ q* f/ ]# Z: c9 U. n0 xpenile length.10,11 Some reports suggest subnormal% b& ?8 Y. c3 O4 N" E4 b( e
adult penile length, apparently because of downreg-
. [6 W' @( H, K$ Q# m  e9 @- M5 g, h2 Eulation of androgen receptor number.10,12 However,
( H! x6 [1 b5 L) S5 P1 O; nSutherland et al13 did not find a correlation between
1 ]( O) r! H% Z, C; Y0 a7 echildhood testosterone exposure and reduced adult
) F" h6 p; p( [$ R; Apenile length in clinical studies.$ x9 F- S5 ?, Y; W0 J, l, T! J
Nonetheless, we do not believe our patient is
, n0 ?0 B+ v8 ygoing to experience any of the untoward effects from5 R$ z- s- G" D$ j
testosterone exposure as mentioned earlier because  U, L. A: ]7 a# A
the exposure was not for a prolonged period of time.% ?, d& K0 J: g/ i/ N- N' C% o
Although the bone age was advanced at the time of
; O$ K7 @, B* S# V3 p3 [* ]0 Z* idiagnosis, the child had a normal growth velocity at
5 H* H# g; S5 ~  K6 a1 m  p! Vthe follow-up visit. It is hoped that his final adult- y& _7 N; h1 ]3 O2 ~8 X
height will not be affected.
! z5 p$ v; E( J/ f/ L( P0 ]Although rarely reported, the widespread avail-0 S6 L7 j" G" ]; _4 `
ability of androgen products in our society may. W$ W% m1 m, E2 z% N6 v/ J
indeed cause more virilization in male or female1 U2 y, c& V8 t! f$ p$ D) X8 Z- Z
children than one would realize. Exposure to andro-
: n) {8 N1 S' n, Agen products must be considered and specific ques-
/ q2 P$ ~; V1 u! ]5 ~tioning about the use of a testosterone product or5 g% p- p# I4 p+ H8 E4 q" A4 ~
gel should be asked of the family members during
4 b$ K2 |4 }% ^% T5 \the evaluation of any children who present with vir-$ j6 U. l% |9 v9 M$ V  [3 G& D8 p
ilization or peripheral precocious puberty. The diag-
3 K5 R1 p/ u$ P. J/ onosis can be established by just a few tests and by
9 q/ b8 S2 Q& Pappropriate history. The inability to obtain such a
5 H9 j9 O; m. g9 Q" `& e& ^. Yhistory, or failure to ask the specific questions, may
; d- L8 v9 K: S2 J# Mresult in extensive, unnecessary, and expensive
1 z: {4 h+ m6 \2 Uinvestigation. The primary care physician should be$ f7 t( G( `8 I4 Y
aware of this fact, because most of these children
& X/ w( ~4 K6 w, F3 j; d! Imay initially present in their practice. The Physicians’- a7 L# O# q: {5 h$ W  D$ t) W
Desk Reference and package insert should also put a6 ?* \4 Y  F* x: y- ?" n- \3 d
warning about the virilizing effect on a male or
# B, [! _5 z/ @female child who might come in contact with some-
4 w$ Q1 G0 L& Q+ d; Done using any of these products.
+ N  R* F7 o, [1 ]* q* ~References
, D0 n6 U7 [* I- A1 j+ N1. Styne DM. The testes: disorder of sexual differentiation
4 h$ _9 v0 D. m: I7 b: i  `& c9 D. Xand puberty in the male. In: Sperling MA, ed. Pediatric
4 S. h$ q9 y0 Z0 i6 j6 K  Z, l/ rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" C( e8 c% S: w# q+ n4 n# u" X
2002: 565-628.7 N+ I9 k% X( V$ r' `9 P0 V+ p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 }* ]  w$ }. ^% z# hpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old% F1 @) d" ~1 p2 J9 f4 d' p
Boy Induced by Indirect Topical
0 d- [1 y& z" ]" r& P8 _Exposure to Testosterone
  B( C9 r5 J' m+ [Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ ?- t; k; M/ K, a4 E2 J
and Kenneth R. Rettig, MD1
) b  ^3 ~  U" E/ S& c; t0 \& ?& lClinical Pediatrics
# M& Y' f; \6 JVolume 46 Number 6
6 p1 ?3 l: Y+ WJuly 2007 540-543
1 ~4 e5 v% T8 Q© 2007 Sage Publications: {0 y1 W  j' y2 p* r8 Z8 w7 T  b
10.1177/0009922806296651
- h  Q) F$ W! ]/ S3 shttp://clp.sagepub.com6 s& D. ?* B: R5 ~( I( I  Y! A
hosted at) L9 @" G2 Q5 Z  a3 ~
http://online.sagepub.com
  w4 V# i( Q: y* nPrecocious puberty in boys, central or peripheral,1 m  N( l# b* w9 {. \: }; N$ _1 ^
is a significant concern for physicians. Central
, a2 v% c& D# @$ o& g1 sprecocious puberty (CPP), which is mediated
, q, T& r6 x8 p) V% a8 n+ Cthrough the hypothalamic pituitary gonadal axis, has
, M. `! ]/ t! r" X0 h3 Ia higher incidence of organic central nervous system
: s5 m+ v5 h3 f  ]6 @% v1 j  t- Tlesions in boys.1,2 Virilization in boys, as manifested9 z  W2 z1 p0 O& B1 s  C
by enlargement of the penis, development of pubic
1 F- ]+ ?* N  R* |4 jhair, and facial acne without enlargement of testi-3 R8 n* T3 m& z& a- w* f
cles, suggests peripheral or pseudopuberty.1-3 We
1 |" S$ g( `/ Q5 D3 breport a 16-month-old boy who presented with the) O- O6 W2 {3 z
enlargement of the phallus and pubic hair develop-
' ?+ D! N4 X9 i  d: F# _ment without testicular enlargement, which was due
$ o+ d0 j0 e# `% O# {to the unintentional exposure to androgen gel used by' d" |! }3 a' X3 e) T$ g) h  f8 [! t
the father. The family initially concealed this infor-/ t7 L# q+ N9 J: `
mation, resulting in an extensive work-up for this$ o; n# {0 t" v# S# l. h5 k
child. Given the widespread and easy availability of
; [. \3 ?3 L1 htestosterone gel and cream, we believe this is proba-
8 [* s* M) T- P( y. j# Nbly more common than the rare case report in the& E" ?/ p6 S6 |$ y8 q
literature.42 c& t, W! ?. p! x8 l
Patient Report; t0 ]* n0 ~- x( H. Q( a" D
A 16-month-old white child was referred to the" r, U- A) P9 b/ j; r" Q
endocrine clinic by his pediatrician with the concern& K* U; g  q4 @6 \
of early sexual development. His mother noticed( q1 @# X0 q8 [4 n3 p* |5 W7 @2 u  H4 n
light colored pubic hair development when he was
. F, r  }( ~! y; J* {5 |From the 1Division of Pediatric Endocrinology, 2University of
- m5 Q" O5 s, k6 ]5 T- X3 }/ }% DSouth Alabama Medical Center, Mobile, Alabama.
; g$ m: N, P; [# T: a, oAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 L* i  n% R5 ~! d
Professor of Pediatrics, University of South Alabama, College of
9 d% a8 [3 z( [2 T* QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: N5 ^. F0 i4 M# oe-mail: [email protected].
% B2 _/ ?- D4 M- uabout 6 to 7 months old, which progressively became
6 A8 C( T! ?* R; h8 l+ edarker. She was also concerned about the enlarge-
0 m! E/ Y; n8 V: j/ w- Iment of his penis and frequent erections. The child
* ~4 g" T; V; c: O* p/ Uwas the product of a full-term normal delivery, with; Y0 k. ?( A4 A7 ?3 g0 f5 W
a birth weight of 7 lb 14 oz, and birth length of" q) d6 h9 w0 o- s
20 inches. He was breast-fed throughout the first year; Y6 ^4 O, f+ K' m( b) m4 }
of life and was still receiving breast milk along with- `4 b. T$ }. m+ v! _
solid food. He had no hospitalizations or surgery,
9 c' ^" \. Z& ^and his psychosocial and psychomotor development) l& ^* L/ q& y! Z( _
was age appropriate.
/ y$ Q& C4 u) l5 Z7 }0 PThe family history was remarkable for the father,
8 o  Y- l3 i) Dwho was diagnosed with hypothyroidism at age 16,  m- T! P' B9 ^. S% U
which was treated with thyroxine. The father’s
1 m+ n9 {2 T+ ~( k' p7 E7 ^  V$ Xheight was 6 feet, and he went through a somewhat  c/ D# i# [! [) `
early puberty and had stopped growing by age 14.8 i+ W# v+ _& d5 J# t0 e" R6 N
The father denied taking any other medication. The
! W( j3 }8 f6 n9 _7 @/ D1 R5 bchild’s mother was in good health. Her menarche' B6 a/ n4 L8 s" N5 o8 K
was at 11 years of age, and her height was at 5 feet3 B$ h. J8 r, n
5 inches. There was no other family history of pre-
) b( \1 x" ~, F8 y. }$ `( L& Fcocious sexual development in the first-degree rela-
4 y/ w6 N0 i  N0 Vtives. There were no siblings.
  a& ?' l; t6 B7 g: bPhysical Examination
/ K/ P# Y' b( a! Z, _8 B- MThe physical examination revealed a very active,$ A7 `- |; y: T. F. K8 f
playful, and healthy boy. The vital signs documented
' j0 c9 v4 F, e; Oa blood pressure of 85/50 mm Hg, his length was5 J) ^3 X1 }9 j
90 cm (>97th percentile), and his weight was 14.4 kg
6 O4 H9 Q' o% J# |(also >97th percentile). The observed yearly growth$ D* @4 G  M3 R0 J- Y3 g8 L
velocity was 30 cm (12 inches). The examination of3 r6 N, n0 m9 P! ?% _1 u+ j% H1 z
the neck revealed no thyroid enlargement.' d3 G7 w1 E; u# B, w
The genitourinary examination was remarkable for' k/ a& z7 O7 `! W
enlargement of the penis, with a stretched length of' y2 H4 C- v5 P+ k9 K) Q3 Z' n4 c( |
8 cm and a width of 2 cm. The glans penis was very well' n- X1 p$ G7 z* v
developed. The pubic hair was Tanner II, mostly around. r$ R2 F, L( g2 r5 S/ ^, p
540! J5 Z( B% j, Q6 `; \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 L& x/ I, c: N% p9 W. C8 Rthe base of the phallus and was dark and curled. The
4 E0 S4 ~7 g$ G( l" {testicular volume was prepubertal at 2 mL each.& r6 A$ P4 J& G4 S1 Z
The skin was moist and smooth and somewhat
) e* x/ F! \0 P( f) @+ j* foily. No axillary hair was noted. There were no
* h7 a! b! e4 q9 d& [9 V7 Yabnormal skin pigmentations or café-au-lait spots.
; e+ r2 L0 n/ L. q1 I9 KNeurologic evaluation showed deep tendon reflex 2+- m/ E) J) p% d. R
bilateral and symmetrical. There was no suggestion4 Z* a! f* B. J$ W; G
of papilledema.5 [; c% X8 P+ _+ `/ _) P
Laboratory Evaluation
& m5 w( m, f3 M+ A, {The bone age was consistent with 28 months by
0 D, q8 R# o! t  u/ G& l. Cusing the standard of Greulich and Pyle at a chrono-
3 E- D2 W  D9 z; _1 y/ Glogic age of 16 months (advanced).5 Chromosomal/ H6 ]& s$ Q% S, L7 \, A
karyotype was 46XY. The thyroid function test
+ z. n. p! Y" F$ Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-6 d* }+ I# W% U; d
lating hormone level was 1.3 µIU/mL (both normal).# r6 Q6 v6 Z* C: \: P
The concentrations of serum electrolytes, blood5 V! ]6 K5 @0 S6 v% y
urea nitrogen, creatinine, and calcium all were
1 Y7 I/ q4 s8 P! ]: iwithin normal range for his age. The concentration( h2 M* \( O# `) l% p
of serum 17-hydroxyprogesterone was 16 ng/dL' ?- ?' o9 R4 B/ m: f: V
(normal, 3 to 90 ng/dL), androstenedione was 20
7 f7 V6 X# S; Z8 y1 B& V! l# U7 sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 r; ~5 F4 S/ ~+ w  l4 N# gterone was 38 ng/dL (normal, 50 to 760 ng/dL),' Q) Q; M% f; ?' @3 G$ i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 v! m! A+ h# L) a4 a& w
49ng/dL), 11-desoxycortisol (specific compound S)
8 n# w% @- n0 v4 E* qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 J! w) g* ^0 h- [4 v6 V
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ ^5 \& ]5 `6 T" U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 h$ ^) Z. Q2 Q) ~/ t* ~and β-human chorionic gonadotropin was less than
3 h8 x, P0 b" Y7 m( O5 mIU/mL (normal <5 mIU/mL). Serum follicular% l2 i/ L* q( r2 K5 T% l
stimulating hormone and leuteinizing hormone6 i" }) q! ^7 j/ H3 O
concentrations were less than 0.05 mIU/mL
  Q: t9 k. _! m. a(prepubertal).
: P7 K' |  Z) C3 r4 HThe parents were notified about the laboratory
. d* \1 j# K2 G4 x6 |" N  yresults and were informed that all of the tests were8 }! O# d4 J! Q6 u# U- Y$ |% s
normal except the testosterone level was high. The5 K" h) O* m1 F3 y
follow-up visit was arranged within a few weeks to- L4 a6 z! [. U$ Y$ ]1 [
obtain testicular and abdominal sonograms; how-) P- C4 [1 }5 T+ \
ever, the family did not return for 4 months.% @5 C& W, H) c% P
Physical examination at this time revealed that the  [5 P9 E" ]4 I& d& r
child had grown 2.5 cm in 4 months and had gained( ^+ h6 y* Q9 B' u& o
2 kg of weight. Physical examination remained% Z/ h3 z( O7 c; x. C' q! O/ M
unchanged. Surprisingly, the pubic hair almost com-
& `$ I! m. o- Z3 s' U# P; _pletely disappeared except for a few vellous hairs at4 ^5 p' ]% Y7 D& A0 G8 l  {$ X
the base of the phallus. Testicular volume was still 2
& ^' a% ^7 F2 q5 C; CmL, and the size of the penis remained unchanged.1 @8 {+ Y( K7 p& P! p
The mother also said that the boy was no longer hav-
: D# i) I# J! Y( l1 E- Q: zing frequent erections.0 K2 v7 Z  J9 O
Both parents were again questioned about use of
  ^" P9 z1 J6 X: A1 [) N) C; aany ointment/creams that they may have applied to, a& q6 A/ Y( f) T7 h6 n3 h
the child’s skin. This time the father admitted the
: w0 j; ?1 I. BTopical Testosterone Exposure / Bhowmick et al 541  i8 m! }+ ]( B+ L) W0 t' f5 [& @
use of testosterone gel twice daily that he was apply-
+ X- Z! P  D+ _ing over his own shoulders, chest, and back area for
3 s3 A' a- A+ X' h3 m$ x2 Oa year. The father also revealed he was embarrassed
3 O2 L" h0 y4 J* U$ m+ J, b4 f3 b9 Zto disclose that he was using a testosterone gel pre-& p# y8 ]& a& J, K" L- A5 b7 \$ |
scribed by his family physician for decreased libido; G0 n* P# M+ @  R, `' p4 [
secondary to depression.
' q# U/ T  f( z7 O- xThe child slept in the same bed with parents.
/ o/ w6 L. u; X7 j  ]The father would hug the baby and hold him on his
) x& v* [! z4 Wchest for a considerable period of time, causing sig-9 a' Y( K1 z4 @( w. |$ S  z+ `7 M
nificant bare skin contact between baby and father.+ K& V- \# u5 M% J! X) d
The father also admitted that after the phone call,
+ \1 j7 k2 r& p5 r) E2 S) h3 |% Kwhen he learned the testosterone level in the baby
& H$ D2 _" e3 Uwas high, he then read the product information
. `9 \( ?. H* W2 o! Bpacket and concluded that it was most likely the rea-+ r( ~% K0 y' U9 E
son for the child’s virilization. At that time, they/ K: ?% y; f1 H
decided to put the baby in a separate bed, and the
- t+ }0 B+ O% ]4 m, G6 k/ T9 s7 {% a" nfather was not hugging him with bare skin and had. z& m# D  e# H+ j3 b8 m$ `/ U
been using protective clothing. A repeat testosterone5 i5 x% g# F5 B. S5 c
test was ordered, but the family did not go to the# X/ g! |- q2 f
laboratory to obtain the test.! D) x# @5 G! s& t& N3 k  w
Discussion
# N4 h2 Q( u" X  c, k1 P8 ?4 CPrecocious puberty in boys is defined as secondary
6 t- G# q9 t) K. e# s8 Esexual development before 9 years of age.1,4! C3 v: @( X* @: c9 ?5 I! T0 n& B
Precocious puberty is termed as central (true) when
! u6 l: W0 w! i4 \# Fit is caused by the premature activation of hypo-
! C* Q: q& ?8 N" G5 K5 Zthalamic pituitary gonadal axis. CPP is more com-' R3 n/ c0 x" Z3 Y& S
mon in girls than in boys.1,3 Most boys with CPP
9 P7 U. A8 W! L. r- {6 x0 bmay have a central nervous system lesion that is4 D3 E& G4 L, j/ w" s! a/ R7 k( d
responsible for the early activation of the hypothal-
- k# ^; O& ]% U. N* Z+ u3 m. qamic pituitary gonadal axis.1-3 Thus, greater empha-9 }" y$ [4 S) f/ B7 q6 m
sis has been given to neuroradiologic imaging in
; e  Q+ j5 H& ?$ fboys with precocious puberty. In addition to viril-& T5 c* {. t/ d: ~0 U
ization, the clinical hallmark of CPP is the symmet-
4 E3 v& o0 R+ g7 j! }$ krical testicular growth secondary to stimulation by
# \- n5 n8 z: x2 Rgonadotropins.1,37 k( _5 X/ \+ T4 t# D
Gonadotropin-independent peripheral preco-
8 ]$ ]' s/ ^! S, |( n& j3 Qcious puberty in boys also results from inappropriate
( l2 m) S  {! c( n1 zandrogenic stimulation from either endogenous or, L- i: w: S& p
exogenous sources, nonpituitary gonadotropin stim-
3 ~$ J( P# _4 h. J/ z7 `% ]ulation, and rare activating mutations.3 Virilizing' S9 T+ X" k- A; ~6 Z; a
congenital adrenal hyperplasia producing excessive# x9 P( _6 X! q# E5 h9 l4 Q2 s8 F
adrenal androgens is a common cause of precocious% j3 ^$ |& C" B' }7 }6 c( ?
puberty in boys.3,4- A5 S% B5 b: \# h9 @2 L# r* P
The most common form of congenital adrenal
/ A0 l4 L! N, c7 Whyperplasia is the 21-hydroxylase enzyme deficiency.
" x" r& t& {, x9 L# k: h. ~- l- }The 11-β hydroxylase deficiency may also result in
- [; D9 v, z0 G3 P0 X: Rexcessive adrenal androgen production, and rarely,
0 e1 [7 D6 P% l) J1 E# E! `an adrenal tumor may also cause adrenal androgen$ \9 m5 I6 L% a" E# p9 i0 O
excess.1,3
/ P! t# l3 J, e9 q8 kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  b1 I% F7 x. K3 Z( O+ L1 w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ b  V  X- T: R7 Q- o6 y
A unique entity of male-limited gonadotropin-$ p7 R4 a5 E) b; V
independent precocious puberty, which is also known
( V1 E4 j  F2 a3 s  ~# Bas testotoxicosis, may cause precocious puberty at a; a# H! f+ i3 y' F" z; j! z
very young age. The physical findings in these boys" _/ J/ m$ w; m% h
with this disorder are full pubertal development,$ `* N/ ]5 c5 Y. i" h
including bilateral testicular growth, similar to boys' m- q% r2 [. H# M
with CPP. The gonadotropin levels in this disorder
9 M. ^( e+ [3 x, Q8 mare suppressed to prepubertal levels and do not show
4 r3 z7 b/ j6 P0 x9 p- L0 Vpubertal response of gonadotropin after gonadotropin-
5 f7 P3 h6 l) i% {" R0 U; \releasing hormone stimulation. This is a sex-linked
; b+ X/ i8 _2 I8 x$ C1 Z7 Z' b* s4 wautosomal dominant disorder that affects only) J# m! _1 M3 q' ]0 k( C) f) O' ^% X
males; therefore, other male members of the family
- S7 L5 \/ B4 E5 z% |1 r8 }+ g2 qmay have similar precocious puberty.3
; o" x2 L- v, f" [In our patient, physical examination was incon-2 Q* _# H1 X1 Z9 F2 W. B* S
sistent with true precocious puberty since his testi-4 q* R, j( n- n/ G
cles were prepubertal in size. However, testotoxicosis4 i  L! s9 f% Q. s! _! B* J
was in the differential diagnosis because his father! p1 f) i7 @* y( @
started puberty somewhat early, and occasionally,! {" A* F$ i3 T4 ~# b  n
testicular enlargement is not that evident in the) L; H3 {  G, R, x, f
beginning of this process.1 In the absence of a neg-
; Y6 F$ J# r  _, _" Sative initial history of androgen exposure, our7 u9 t, N  S" X8 n& e0 g
biggest concern was virilizing adrenal hyperplasia,7 p0 Y7 _1 C( J
either 21-hydroxylase deficiency or 11-β hydroxylase  o: `9 O5 F* e2 |$ A% N
deficiency. Those diagnoses were excluded by find-3 m- v' W8 F/ O: K' n. B& h2 K$ ]# `
ing the normal level of adrenal steroids.+ e& v1 P' v! N5 M; S+ p& L* f
The diagnosis of exogenous androgens was strongly, m3 ]% S* w' m2 c  [( N
suspected in a follow-up visit after 4 months because3 z4 k' L6 o+ d5 _: B- K
the physical examination revealed the complete disap-; J1 C% L$ t2 C" A8 j
pearance of pubic hair, normal growth velocity, and
2 D4 I4 M/ J1 O, h: ]0 idecreased erections. The father admitted using a testos-
3 N: m4 m, [) Aterone gel, which he concealed at first visit. He was
( @2 L5 m* N1 Y* G  h4 `) wusing it rather frequently, twice a day. The Physicians’- [1 C8 z0 u- j$ B# O- t, D
Desk Reference, or package insert of this product, gel or- a5 _; o4 X, L
cream, cautions about dermal testosterone transfer to
8 f- E5 h( q; Q6 R- w" H9 dunprotected females through direct skin exposure.8 h- [& P9 n* p1 \: d9 w
Serum testosterone level was found to be 2 times the
- I: q% ]5 V. r; ^baseline value in those females who were exposed to
1 m! Q$ R/ v4 [; W9 Zeven 15 minutes of direct skin contact with their male
# j" S/ B$ `" B* z4 f5 t( Mpartners.6 However, when a shirt covered the applica-
1 @: ~: k, l1 O9 J) a% Ption site, this testosterone transfer was prevented.6 C5 M# ?3 Z1 |# O6 [- q! p
Our patient’s testosterone level was 60 ng/mL,9 p8 k$ s( c% l4 t+ o2 z
which was clearly high. Some studies suggest that7 g' |, _0 k! o4 V. B
dermal conversion of testosterone to dihydrotestos-
! k  J# J, Q+ h' tterone, which is a more potent metabolite, is more/ f1 |' }, R8 x) _0 r! l6 O& S$ L# U
active in young children exposed to testosterone# T$ Y9 u, I, D3 o8 C. p5 D
exogenously7; however, we did not measure a dihy-! P1 ^0 G. ^. u" K
drotestosterone level in our patient. In addition to( }3 j# h! \! q: m
virilization, exposure to exogenous testosterone in
* e; k: e1 |- ]; c: u) Rchildren results in an increase in growth velocity and
9 [! L' ]! l3 n& e  i1 k: ^  Qadvanced bone age, as seen in our patient.& Q+ p  A) C7 ~- V. Z1 _- w
The long-term effect of androgen exposure during
7 R% {, u% f, \1 m  z3 wearly childhood on pubertal development and final* j8 X6 H3 d! U' B5 O% }
adult height are not fully known and always remain% d" w5 R) G( G, g7 K1 d! S
a concern. Children treated with short-term testos-6 R/ X6 }) w& P, t* K! {) V
terone injection or topical androgen may exhibit some
1 T, d! s3 j0 f* M. e2 nacceleration of the skeletal maturation; however, after: d) E- R' W9 C0 ^# ?
cessation of treatment, the rate of bone maturation2 Q' F6 H) ]( i5 d* \
decelerates and gradually returns to normal.8,9
0 I4 {- ^4 T0 V* `7 T3 JThere are conflicting reports and controversy
# j4 d7 [2 x, K+ h5 v' b+ @over the effect of early androgen exposure on adult
% D) q* Y- e+ ~8 I" Fpenile length.10,11 Some reports suggest subnormal
3 s' @( \, W/ G! N' |adult penile length, apparently because of downreg-3 W7 \9 I2 z" N+ I! \; F4 L. M7 r
ulation of androgen receptor number.10,12 However,
) X4 s3 m" y, ]# {Sutherland et al13 did not find a correlation between
- d% K9 X( y: \' j+ t8 |. }childhood testosterone exposure and reduced adult& F" s8 d2 e4 h3 B- ^9 r
penile length in clinical studies.
+ a0 n6 G. S1 L! [/ SNonetheless, we do not believe our patient is
& v$ ~0 j6 b- Z0 B2 w: I; Ngoing to experience any of the untoward effects from- l7 Q; G, I9 n, m8 Y4 D
testosterone exposure as mentioned earlier because- [' ?6 t. \2 K- `+ n$ M. _
the exposure was not for a prolonged period of time.$ U5 [& m6 h1 Z9 {1 S! X! ]0 J
Although the bone age was advanced at the time of% F1 x7 ]: a- M# x$ m8 h2 Z
diagnosis, the child had a normal growth velocity at
  L4 ?# o4 R  s1 Hthe follow-up visit. It is hoped that his final adult
. ^  v+ b5 _# j* J7 D" P* Hheight will not be affected.! R7 v7 e# G+ y( Z, l$ I
Although rarely reported, the widespread avail-
& v) a2 ?; r; _: M% a# j9 L% }; [ability of androgen products in our society may6 s7 ?# l6 g6 q$ ?" J& ?5 v
indeed cause more virilization in male or female7 C# H  y' a7 `2 t  g- K" {1 v
children than one would realize. Exposure to andro-
. n: m0 d8 h4 l; Zgen products must be considered and specific ques-3 i- o& ~9 u2 z& W/ M: `- G
tioning about the use of a testosterone product or8 w3 v8 K/ N( b  w" x6 L. R4 X
gel should be asked of the family members during/ S3 c* O: A7 D* i! r+ R* q
the evaluation of any children who present with vir-
! p6 X; I9 q7 m( T4 |. Ailization or peripheral precocious puberty. The diag-
+ Q" Q; x. n1 w9 wnosis can be established by just a few tests and by4 I( O) g% p0 `# y
appropriate history. The inability to obtain such a$ a& I, M; K, T# \
history, or failure to ask the specific questions, may9 m0 i; M! P. `3 p/ l
result in extensive, unnecessary, and expensive8 H$ _: V4 T" n
investigation. The primary care physician should be
0 H" X! ^# {0 ^7 V5 c5 jaware of this fact, because most of these children
! q8 @8 A2 J  H( [' {may initially present in their practice. The Physicians’
2 r9 q( ~% {4 ]  RDesk Reference and package insert should also put a* _/ j% ]  U3 S4 a5 L/ |. @& c
warning about the virilizing effect on a male or; v4 K  B2 m7 G# C
female child who might come in contact with some-
+ `3 E$ B& J) [4 A/ _* @9 t) \one using any of these products.: R6 W" U5 T% G
References
4 O% j% K8 M# C: w% I1. Styne DM. The testes: disorder of sexual differentiation
1 l0 ^2 b( ]9 C' K8 yand puberty in the male. In: Sperling MA, ed. Pediatric' V- N' [4 M! m  r1 j" [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! u- w. q0 _; Z8 ?* E
2002: 565-628.
, L5 {9 l/ U. K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, R$ `1 u3 V- ]( {
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
+ f9 p% }. ?* k6 W  C8 A
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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