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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
3 i) z' U* W. u1 U% p; c3 DBoy Induced by Indirect Topical6 _, [$ u9 m' u, T( l0 S
Exposure to Testosterone3 A% M4 k+ v1 G( Z5 ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' M9 j$ q4 S1 |/ ]! t4 `7 i8 k
and Kenneth R. Rettig, MD1" u& A: h) ~1 W1 L# g
Clinical Pediatrics9 s% e: ~7 q7 O1 @& C. B
Volume 46 Number 6
) ~% q/ v# j4 h" u6 NJuly 2007 540-543  `7 Z& e( v' j  S2 K
© 2007 Sage Publications
# p. x& u$ G: A6 e9 \10.1177/0009922806296651
) P' p+ d' C" X4 ~/ yhttp://clp.sagepub.com" s) x) T/ b# r3 }
hosted at
6 `4 c. Z4 O  o  Q) Z9 ehttp://online.sagepub.com
9 U8 N- J% W" x$ r  p: j' E- aPrecocious puberty in boys, central or peripheral,
8 p2 T: l9 F; S- z4 ais a significant concern for physicians. Central
& ^! t# V! C7 t% Q9 Vprecocious puberty (CPP), which is mediated; l! c+ H: c1 O: s& C, E
through the hypothalamic pituitary gonadal axis, has
9 p7 s# g- ~, ~: Ya higher incidence of organic central nervous system
  E+ f1 K8 ]+ z8 u9 z: N9 V8 n: Qlesions in boys.1,2 Virilization in boys, as manifested2 i3 n5 e! h2 f' y. v
by enlargement of the penis, development of pubic# e' h/ ~$ w0 u! F5 V
hair, and facial acne without enlargement of testi-
1 U- _, O  [- \+ j6 jcles, suggests peripheral or pseudopuberty.1-3 We: p% @3 Z" c/ J
report a 16-month-old boy who presented with the
) G1 X- X5 u+ H, H. \% n7 Q/ oenlargement of the phallus and pubic hair develop-9 J+ {5 V$ C' w' B
ment without testicular enlargement, which was due4 y4 ?% S- }3 y1 S: c8 c
to the unintentional exposure to androgen gel used by4 a) T+ _: Z, j/ M8 [% f1 m
the father. The family initially concealed this infor-
! D# J/ S' K4 I+ [* pmation, resulting in an extensive work-up for this& X7 c0 _. Q  s" C; D
child. Given the widespread and easy availability of
) K. F; I, \3 _& v; stestosterone gel and cream, we believe this is proba-
5 D% T) {: F( \( ~bly more common than the rare case report in the
$ c+ |! ~' @" b% wliterature.4
' o# p) C1 @  f# K* V  p' T- h* FPatient Report; d' a- m1 M: F( Y# J& c
A 16-month-old white child was referred to the
6 v9 \3 e1 z; l- [5 Y. l& Cendocrine clinic by his pediatrician with the concern
. E7 k* Z. O) K  H1 _of early sexual development. His mother noticed& k) x. ~4 h. p: G# N6 F
light colored pubic hair development when he was: Z, U+ g' p" D  K4 d
From the 1Division of Pediatric Endocrinology, 2University of
% j6 A, t6 F) V4 V3 h# w9 lSouth Alabama Medical Center, Mobile, Alabama.$ a  B9 S, @4 P* X- y  p
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" `; U4 q8 G3 Q# K; @Professor of Pediatrics, University of South Alabama, College of, ]9 A- H- E3 A# D/ B4 H& ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" Y1 j2 j- E( R! I/ B/ Z2 G
e-mail: [email protected].
- b  u$ m, r4 Labout 6 to 7 months old, which progressively became" E0 F0 a; ^5 m1 B: p* K
darker. She was also concerned about the enlarge-+ L2 L6 ?1 @, v0 p$ V2 ^
ment of his penis and frequent erections. The child% H9 \1 o% ]: D1 n1 m9 h
was the product of a full-term normal delivery, with, C5 C/ @; _, ]
a birth weight of 7 lb 14 oz, and birth length of% G* k! i/ _5 S3 @. t
20 inches. He was breast-fed throughout the first year
3 ]' g) _, l4 s- Y. O: a1 m1 Aof life and was still receiving breast milk along with6 L, Q. W: F) s& g
solid food. He had no hospitalizations or surgery,& E. ?" M  x, I* C
and his psychosocial and psychomotor development
4 d/ O# y1 _0 \0 r( V5 ^5 j# Lwas age appropriate.
8 Y; k- R6 X6 {9 u1 `- _. iThe family history was remarkable for the father,
1 c: c$ p6 r7 R# Hwho was diagnosed with hypothyroidism at age 16,
9 w/ Q( K- D0 l: Y) jwhich was treated with thyroxine. The father’s" ~! {- x& @" ?2 g1 ^- W
height was 6 feet, and he went through a somewhat
# S2 C& S6 Y0 `! s( Cearly puberty and had stopped growing by age 14./ O; l" [, K" W7 I0 u+ q6 y
The father denied taking any other medication. The9 J, ~3 ^/ C! o. H  t
child’s mother was in good health. Her menarche
, g1 C4 B8 T- nwas at 11 years of age, and her height was at 5 feet
5 \" ~6 M( P9 d' S! i5 inches. There was no other family history of pre-( [4 V4 H- p7 l6 a# B9 G$ g+ v
cocious sexual development in the first-degree rela-
3 {4 ^& w; W! r& s3 @7 y! z& Atives. There were no siblings.- N0 v. z0 W( k* @  N' D! e: ^* ~
Physical Examination
- w) D! O$ g$ Y" C, y0 I! gThe physical examination revealed a very active,
- r8 D% b$ E: ]$ I# lplayful, and healthy boy. The vital signs documented
, Q4 a9 L8 F* i/ Na blood pressure of 85/50 mm Hg, his length was2 V( v7 v) s  p" z. U+ f. r9 D( E
90 cm (>97th percentile), and his weight was 14.4 kg: M6 O+ J7 v) G. `* |
(also >97th percentile). The observed yearly growth+ @# N/ B' _# ~, G, r
velocity was 30 cm (12 inches). The examination of
& N* l. Q! \2 ]6 lthe neck revealed no thyroid enlargement.
1 K6 E; o2 n2 t& g2 `6 ~The genitourinary examination was remarkable for3 z% A' Z( R# Q4 E
enlargement of the penis, with a stretched length of
! B% ]$ v  a8 `3 M/ N8 cm and a width of 2 cm. The glans penis was very well7 v3 ~" P( ]) ]1 U
developed. The pubic hair was Tanner II, mostly around& d, S7 i4 F7 k
540
" p% y& ~% S% Q% jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( ]& r0 O0 P, \9 q6 M! s1 d7 Ythe base of the phallus and was dark and curled. The
' r, v, j* k1 F/ }/ T. A, j6 ytesticular volume was prepubertal at 2 mL each.
. b+ v, c& i9 o" bThe skin was moist and smooth and somewhat, T7 ~. T( P; w' q% k
oily. No axillary hair was noted. There were no
" x1 p! d. E* Y7 gabnormal skin pigmentations or café-au-lait spots.7 o0 f3 X- D* I9 @0 }: O
Neurologic evaluation showed deep tendon reflex 2+
5 E. L* E1 p6 {, B) K2 C! kbilateral and symmetrical. There was no suggestion
0 Z+ z; S( ^; a6 k4 Eof papilledema.
! y- C' M. N% zLaboratory Evaluation5 Y/ I9 c% K0 x$ G7 z3 n3 i8 |2 h
The bone age was consistent with 28 months by
9 N: p: @% b# {$ F0 l$ t/ K& musing the standard of Greulich and Pyle at a chrono-2 k( M) T7 ~- z7 k" _' e0 _7 e
logic age of 16 months (advanced).5 Chromosomal) i8 Z$ k0 n3 M2 r! Y. u
karyotype was 46XY. The thyroid function test: y( f! f2 `! E/ I9 J' P  i$ f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-  W* k0 A& H8 ?; }: |" s1 T! f4 n$ `
lating hormone level was 1.3 µIU/mL (both normal).
' J* u1 E  d6 }1 F% ?3 pThe concentrations of serum electrolytes, blood8 N) U2 F2 N9 N
urea nitrogen, creatinine, and calcium all were) N/ T& Z* k. G3 _
within normal range for his age. The concentration- m- ?7 S& {) U- m, r& c( B
of serum 17-hydroxyprogesterone was 16 ng/dL
7 Y$ ]5 u4 o; k(normal, 3 to 90 ng/dL), androstenedione was 20  p) h6 G" ^! V( m; L  W
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 \- |4 O( x' o  ~  wterone was 38 ng/dL (normal, 50 to 760 ng/dL),0 }8 J- Z$ f. j8 y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ }* Q$ C1 j% v1 L3 X% \2 M49ng/dL), 11-desoxycortisol (specific compound S)# c  o" q( A) f* J8 T( A9 L4 ?( d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! h, V2 s* f- R- X* d+ q6 O) r" k
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: O& b$ ?2 _/ s# v3 |: q" |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 k8 Q! u% Q8 Y) h
and β-human chorionic gonadotropin was less than
. H' B; y2 Y; I8 I$ ~2 P8 _5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ ], E8 G; ^- Q, G, ~. xstimulating hormone and leuteinizing hormone/ R  s- z. V& ]7 B7 [, c  H: e
concentrations were less than 0.05 mIU/mL
$ a- E! X7 Y4 p9 Y+ q  S(prepubertal).3 y0 l8 `/ V5 S
The parents were notified about the laboratory3 c! w, z- i$ j1 u+ @9 {
results and were informed that all of the tests were, R# x! T& U: g# A4 [
normal except the testosterone level was high. The- d2 U, g/ r* M& M- b3 Q' j
follow-up visit was arranged within a few weeks to* _3 S5 ~  g' w3 {9 J
obtain testicular and abdominal sonograms; how-8 Y+ z, g4 G, J2 {( k, x( P" w: M
ever, the family did not return for 4 months.# e% r* W. X4 r' ]; X
Physical examination at this time revealed that the, o% I& W' g7 i8 \3 C
child had grown 2.5 cm in 4 months and had gained
' Q2 k3 ^6 |: n* ^1 o) z2 kg of weight. Physical examination remained
0 C- x2 `+ \9 Y  f- `) P! nunchanged. Surprisingly, the pubic hair almost com-/ Q0 ^5 Q) T( G! k) J
pletely disappeared except for a few vellous hairs at4 _1 o% S1 z: ~' s# F9 ^: u' ~
the base of the phallus. Testicular volume was still 2
! d) K: Z. S2 O+ {. gmL, and the size of the penis remained unchanged.
* x- n& V% F7 @7 u1 LThe mother also said that the boy was no longer hav-+ f7 J0 C* I& ]/ a4 L8 Q1 t
ing frequent erections.3 k0 j- t7 }4 x
Both parents were again questioned about use of
; N) K: j! T! \3 F" B$ tany ointment/creams that they may have applied to
) {1 M" z: T2 r( h' P$ W4 v- A1 {the child’s skin. This time the father admitted the
3 E  S  ~( Q/ i- H& T& R3 o5 {Topical Testosterone Exposure / Bhowmick et al 5418 ^% v3 i. a1 ]4 g/ d' R, p
use of testosterone gel twice daily that he was apply-: p; T* B' |0 K5 y# e* E
ing over his own shoulders, chest, and back area for
) S% m  k8 c2 Z: M$ Za year. The father also revealed he was embarrassed- Z" S* {# w/ C
to disclose that he was using a testosterone gel pre-( C" D+ S: g/ E6 Z/ Q
scribed by his family physician for decreased libido& {/ X# M4 \. u- }
secondary to depression.. Q8 G. j, f$ N
The child slept in the same bed with parents.
, E% W8 h, a8 U9 HThe father would hug the baby and hold him on his; K% J8 N9 a: K; T! ^( s: F
chest for a considerable period of time, causing sig-
" K1 d$ ^/ D4 b8 k% k5 H! Z' f& N, tnificant bare skin contact between baby and father.
0 p/ l! z: g* \/ \% aThe father also admitted that after the phone call,
$ T) e+ _; U% kwhen he learned the testosterone level in the baby
! b3 A( b: y. E* L1 |( Swas high, he then read the product information+ L/ {# u$ L! M. c' }8 v
packet and concluded that it was most likely the rea-
# b0 f. P# n- b1 ]( C4 I, i9 Zson for the child’s virilization. At that time, they( B' K; N  B( g3 K. ^9 r3 D
decided to put the baby in a separate bed, and the
) x6 l( ^* [& Q" cfather was not hugging him with bare skin and had9 F' D1 v1 v2 r: x, U
been using protective clothing. A repeat testosterone! m$ l% g& @; l- K
test was ordered, but the family did not go to the/ D7 j' J, G3 O6 M* ^+ Q- X: _& v5 W
laboratory to obtain the test.
* E# u6 Q/ S1 M) \3 DDiscussion  ~' w. g7 q! H& X5 P
Precocious puberty in boys is defined as secondary9 p" }; O2 n" b/ I, E
sexual development before 9 years of age.1,4
- x. V& ?0 Q$ ^Precocious puberty is termed as central (true) when' @0 g! H& L7 P2 w% V0 v2 X2 N( \
it is caused by the premature activation of hypo-/ v6 E1 q7 K8 f
thalamic pituitary gonadal axis. CPP is more com-/ M- C1 o/ a5 ^4 H. Q& b9 q+ F& _
mon in girls than in boys.1,3 Most boys with CPP
) c- T: X' r6 k; S3 A% Gmay have a central nervous system lesion that is* ?' D; D* |$ D  K) K+ Z5 S
responsible for the early activation of the hypothal-: w( ?$ G. Y4 ]
amic pituitary gonadal axis.1-3 Thus, greater empha-
" ~* D2 i  \. Dsis has been given to neuroradiologic imaging in3 H8 u/ I& }" R4 P6 F4 @" f
boys with precocious puberty. In addition to viril-/ m7 p0 H" b% H
ization, the clinical hallmark of CPP is the symmet-
4 T7 R8 M; L* ?rical testicular growth secondary to stimulation by
8 R# Y- F# P. c. e0 A: k, x' Bgonadotropins.1,35 @, @1 K! J/ b$ H# K
Gonadotropin-independent peripheral preco-" T8 i# y" V/ e/ s
cious puberty in boys also results from inappropriate7 P  R6 o' W# u
androgenic stimulation from either endogenous or- B- Z8 g" M( W; w: g  W
exogenous sources, nonpituitary gonadotropin stim-1 R6 S; e) x: U4 h' D' m( n& r
ulation, and rare activating mutations.3 Virilizing7 y3 I3 {% j: q- a; e5 w) F- z9 y! z! r1 i
congenital adrenal hyperplasia producing excessive0 u7 ]" e: O# ~* f" b# Q
adrenal androgens is a common cause of precocious
" s1 b6 A- A6 n/ k5 B2 D5 s( n* Mpuberty in boys.3,4
- v$ p( o& p7 H! eThe most common form of congenital adrenal! r+ g' o( \2 M) f+ e
hyperplasia is the 21-hydroxylase enzyme deficiency.' Q7 f1 l/ r6 G6 F; e. A
The 11-β hydroxylase deficiency may also result in
5 f/ l. U" d/ i1 F& a+ [) ]excessive adrenal androgen production, and rarely,3 e1 z- T, t/ @1 \# e
an adrenal tumor may also cause adrenal androgen6 K& q7 r$ j( A$ u4 m. W8 I
excess.1,3
1 K# b: L2 ?4 _9 i0 tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# V, v3 T/ j, ?. f: p$ x1 ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 ^7 F2 c) y0 wA unique entity of male-limited gonadotropin-
0 l) j; A7 h0 U# ?* H8 Nindependent precocious puberty, which is also known
# h6 ^  R' p7 M4 Y  Yas testotoxicosis, may cause precocious puberty at a
% m5 P0 V& ~1 I4 b. bvery young age. The physical findings in these boys0 O+ R4 j9 z4 I
with this disorder are full pubertal development,6 @/ y: m4 h6 c0 b0 Y- c
including bilateral testicular growth, similar to boys
  B: j+ }4 M  Bwith CPP. The gonadotropin levels in this disorder: C( `# q1 |, ^, D$ N& \
are suppressed to prepubertal levels and do not show& N# i$ P. h+ ^" h6 f
pubertal response of gonadotropin after gonadotropin-6 C+ i7 Y# U( [
releasing hormone stimulation. This is a sex-linked
0 |& o3 m$ K" D  |0 M3 gautosomal dominant disorder that affects only! Q1 ]+ Q8 a8 s+ t$ t2 T
males; therefore, other male members of the family% C1 Q3 F8 o6 @* m* `
may have similar precocious puberty.35 R+ T5 r# W. @5 [7 N
In our patient, physical examination was incon-
' O# e( q! a; ~# fsistent with true precocious puberty since his testi-
  I: |9 E# I3 ]( a4 f* l$ C+ Dcles were prepubertal in size. However, testotoxicosis
7 [. u9 }8 L5 G& u6 ^was in the differential diagnosis because his father
- s, R4 u4 D0 ^, Zstarted puberty somewhat early, and occasionally,2 l: @. L7 H- `9 B; j. E: m! v
testicular enlargement is not that evident in the# e' o$ `- M2 j
beginning of this process.1 In the absence of a neg-
% z2 Q9 m! C: z, S7 b. xative initial history of androgen exposure, our
8 M6 J  i7 c! l8 _8 \1 ]- D7 T7 Ubiggest concern was virilizing adrenal hyperplasia,
; W0 O0 @+ S" p. O4 g& X$ Deither 21-hydroxylase deficiency or 11-β hydroxylase
+ p- g7 X& m1 _; [. t; g7 sdeficiency. Those diagnoses were excluded by find-
- }5 r8 o8 V1 |ing the normal level of adrenal steroids.
$ l( W6 [+ s4 V' h3 vThe diagnosis of exogenous androgens was strongly
) e! L& |9 N* J; o' }suspected in a follow-up visit after 4 months because, ^& I" ^% w2 ^! v% K3 T
the physical examination revealed the complete disap-
' l1 t+ C0 z  C' b% |4 w, Epearance of pubic hair, normal growth velocity, and
$ t8 W2 D* {" Zdecreased erections. The father admitted using a testos-
, g! C; t- I+ ]' ^9 i% |terone gel, which he concealed at first visit. He was+ E/ g4 a; ^/ _/ c' P
using it rather frequently, twice a day. The Physicians’1 Z/ h  [! o' x  Z: j& Z
Desk Reference, or package insert of this product, gel or
& r$ c+ j% |# z/ ~! Z; A$ bcream, cautions about dermal testosterone transfer to& ^$ I0 p9 D) e0 `: }
unprotected females through direct skin exposure.
% Y" i7 D# ^* T2 }6 Z2 iSerum testosterone level was found to be 2 times the. L7 c2 P9 U. |4 ^: C/ d
baseline value in those females who were exposed to9 v. Z" q+ K8 f3 W1 @
even 15 minutes of direct skin contact with their male
% Z* ]4 l4 C7 }( c6 Spartners.6 However, when a shirt covered the applica-/ S" @* n) d( Z1 H! `# e, n
tion site, this testosterone transfer was prevented." B. |; Y# ~& x! ?! E( r! l' m  p
Our patient’s testosterone level was 60 ng/mL,
$ x1 J1 h% H' B. g" ]which was clearly high. Some studies suggest that
, M7 u- l$ n& }: |+ gdermal conversion of testosterone to dihydrotestos-) |2 X- v( N+ p5 R! K
terone, which is a more potent metabolite, is more
1 W: ~: {* x% v' x/ h4 v) Y& bactive in young children exposed to testosterone: G3 C# j- [* @+ \
exogenously7; however, we did not measure a dihy-
# y1 [2 P/ G0 u5 m' c- ], s) j. @drotestosterone level in our patient. In addition to4 b) B7 S- w, s) n. L# p
virilization, exposure to exogenous testosterone in- ?; K  P: T- L
children results in an increase in growth velocity and
3 m* Y9 I$ ?* [5 G( Radvanced bone age, as seen in our patient.
6 k* K% a$ q' S  p* oThe long-term effect of androgen exposure during
% ]1 b  Q, I2 eearly childhood on pubertal development and final4 ~7 x) L% V  [  a5 x
adult height are not fully known and always remain
& i- ^8 Q5 ~" v  |. ?' x# Na concern. Children treated with short-term testos-* `1 |  @0 s" A* H! x
terone injection or topical androgen may exhibit some
, t. b6 N7 Y& {/ Kacceleration of the skeletal maturation; however, after6 A8 @& V% Z8 a5 B1 M) _
cessation of treatment, the rate of bone maturation
. r& w/ ]4 U$ j2 wdecelerates and gradually returns to normal.8,9( h" Z* M9 u: ^
There are conflicting reports and controversy
$ k2 Y7 s- Q% W' I9 Tover the effect of early androgen exposure on adult: A4 z  Q/ |  F8 b
penile length.10,11 Some reports suggest subnormal
# b; a* x/ E6 W% |' x) L3 \# x1 r* }adult penile length, apparently because of downreg-
, m$ k2 J/ ]' Zulation of androgen receptor number.10,12 However,! D% N) M/ v$ ?; t5 L3 M
Sutherland et al13 did not find a correlation between; j' L- w; e" Q7 J+ B
childhood testosterone exposure and reduced adult
, P6 [$ \1 ~; i. }0 I  s- o! Y) K* Tpenile length in clinical studies.; _" w3 H! A* n
Nonetheless, we do not believe our patient is
0 d5 F* L. I: M% ]/ Pgoing to experience any of the untoward effects from
' [5 E% ^9 E2 l8 p% C2 ktestosterone exposure as mentioned earlier because
3 W) {, \/ m+ ^' A" ?9 u* bthe exposure was not for a prolonged period of time.1 X  o" f4 U& T$ F, L, M8 d
Although the bone age was advanced at the time of: \" M- h- Q" i! s9 A9 r. a& m
diagnosis, the child had a normal growth velocity at' `- l, T% P7 s
the follow-up visit. It is hoped that his final adult
9 P2 G( C: V' pheight will not be affected., a& z0 M2 p8 `6 J
Although rarely reported, the widespread avail-- l0 K4 v4 s: }% J0 R
ability of androgen products in our society may
# S4 W1 f( b$ z+ ?indeed cause more virilization in male or female; A! U' C& V( e0 G! \" r; r; V8 ~% t
children than one would realize. Exposure to andro-
2 E5 e: U0 F6 A# P+ s  ngen products must be considered and specific ques-
: _9 ?% j) G) k: u; g: Utioning about the use of a testosterone product or9 C' S) q, Y# _7 T( }3 ]
gel should be asked of the family members during5 B2 \" {+ s) V' w9 X
the evaluation of any children who present with vir-% ?+ e) u3 Z3 ~) D5 `
ilization or peripheral precocious puberty. The diag-* j+ z$ q0 t, l; g) z7 k) w2 Q1 L
nosis can be established by just a few tests and by3 @8 D3 s! D: ~$ g
appropriate history. The inability to obtain such a
( h2 l/ L# T- t3 ^history, or failure to ask the specific questions, may% |! x  v9 t7 p) [7 a. P
result in extensive, unnecessary, and expensive+ ^: w1 |7 G& b2 o4 [. F
investigation. The primary care physician should be9 [6 @3 [- ^- t% z8 F9 j
aware of this fact, because most of these children/ p# U/ H1 [1 K$ ~9 J6 \
may initially present in their practice. The Physicians’# a& d; V! z0 k* v: b
Desk Reference and package insert should also put a
0 ]) l3 N7 |  D/ J. vwarning about the virilizing effect on a male or3 [# x9 Z- i* G0 r0 F' }6 e; ]
female child who might come in contact with some-
/ r* b# v2 O' [' vone using any of these products.
: c# E2 F4 m7 v! OReferences
, e7 ^$ t+ u3 p4 i! q1. Styne DM. The testes: disorder of sexual differentiation
" b' A) ]5 T& n2 f3 hand puberty in the male. In: Sperling MA, ed. Pediatric
( z8 B" ?6 y2 x' [2 r. _* ~Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' S8 _& c. t  {* |% R
2002: 565-628.8 w" n- u' S4 R0 r6 x! b: |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ l* m* E2 R7 e* Ppuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old0 Z8 w9 [- v7 L/ v7 j; H# d
Boy Induced by Indirect Topical/ m+ b+ u- Q8 b. R: }; L0 x3 T
Exposure to Testosterone- {5 A1 Y$ z: Q* G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  [5 ?9 ]! y# x0 ^and Kenneth R. Rettig, MD1
* X) B2 m! N- [1 L$ f9 s) Z% eClinical Pediatrics
3 L! \7 N7 L# rVolume 46 Number 6; D  v: y$ Z" p8 V+ h% D
July 2007 540-543
/ _! E7 l7 z: B5 e© 2007 Sage Publications
( r3 u- M& O( ^8 k1 _0 N* D2 B, r/ X10.1177/0009922806296651
3 u( S6 o# w; q3 |% K1 E4 vhttp://clp.sagepub.com: U& v( `" U0 o% ]. G
hosted at
' |, m1 ]/ W! y8 k& |8 vhttp://online.sagepub.com- ~2 |- A. }1 z
Precocious puberty in boys, central or peripheral,' J  I4 t/ V! f( G1 y' N  C
is a significant concern for physicians. Central% Z) d9 h3 ^5 Z9 M" l  {/ o. K) U5 [
precocious puberty (CPP), which is mediated
$ M7 E8 e, v* Q, V1 {6 X0 |through the hypothalamic pituitary gonadal axis, has3 A& t7 H+ Q5 S) ^+ M5 D/ }% L( H
a higher incidence of organic central nervous system
3 w" U9 {' k. Mlesions in boys.1,2 Virilization in boys, as manifested
( v4 o! l. A( w3 N4 nby enlargement of the penis, development of pubic
* L. _5 ^" `2 i- bhair, and facial acne without enlargement of testi-: R9 L4 _6 T' o1 f% p
cles, suggests peripheral or pseudopuberty.1-3 We
" q  K/ }* ~0 S% Y& C# Zreport a 16-month-old boy who presented with the
$ s4 i5 r4 v9 u, R- q1 q: c5 denlargement of the phallus and pubic hair develop-( W' C% v9 t6 T/ [6 m; S3 g1 c
ment without testicular enlargement, which was due; \9 {6 x3 q0 m: |2 g! h
to the unintentional exposure to androgen gel used by
' s4 h9 q) m8 p4 f" K* R1 Rthe father. The family initially concealed this infor-
" _6 j+ a! J& i) B! a9 D. `mation, resulting in an extensive work-up for this
  Y% p, G1 p1 E& p( G# Z  schild. Given the widespread and easy availability of5 l, w6 x9 p7 z3 @4 }; P; P- Y, K. c
testosterone gel and cream, we believe this is proba-
1 n2 c$ Z% z3 P1 v1 Obly more common than the rare case report in the: I# D& A0 ^4 [) ~9 O
literature.40 x" T: ~& e5 c' x. u
Patient Report
1 R& H( U& p  t9 o2 J! F6 ]A 16-month-old white child was referred to the
# I0 r$ b5 L; Pendocrine clinic by his pediatrician with the concern3 E* f, v$ [  h
of early sexual development. His mother noticed
3 r! C# S8 D* R6 x( j/ jlight colored pubic hair development when he was
& D. u8 e" X: d1 @' aFrom the 1Division of Pediatric Endocrinology, 2University of
4 `; o. L) U1 kSouth Alabama Medical Center, Mobile, Alabama.
, Y7 J+ K1 T# |Address correspondence to: Samar K. Bhowmick, MD, FACE,
" U" V" ~& ]8 F5 O+ {Professor of Pediatrics, University of South Alabama, College of+ k8 d; m" p0 n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 U  \# f! c% |7 @
e-mail: [email protected].
1 f9 v, }5 S+ g4 Wabout 6 to 7 months old, which progressively became
! U" S9 n( X, O2 x3 Udarker. She was also concerned about the enlarge-
1 N5 z; {2 U  v" p; oment of his penis and frequent erections. The child- ^4 t6 e9 F3 F6 S; W# c
was the product of a full-term normal delivery, with
2 C+ c: N! p' f% p7 B  ja birth weight of 7 lb 14 oz, and birth length of3 l  d) l, c& i4 C0 u  U
20 inches. He was breast-fed throughout the first year3 A0 `( V/ g& F& ~
of life and was still receiving breast milk along with$ |1 F9 f; W3 v. b7 V
solid food. He had no hospitalizations or surgery,
3 ^; [; w8 J8 H6 _and his psychosocial and psychomotor development
, v3 P2 A2 s6 P) t6 ^, b& @. K4 {2 Ewas age appropriate.
( u6 o, i, x+ cThe family history was remarkable for the father,% Y8 A8 b+ X7 w1 Z& [3 c
who was diagnosed with hypothyroidism at age 16,
0 n" J3 C, J+ b5 e  U1 \. y: Uwhich was treated with thyroxine. The father’s
; {3 N) j6 t6 N0 P$ Kheight was 6 feet, and he went through a somewhat
# d  B* @  r6 B3 E1 jearly puberty and had stopped growing by age 14.
8 O3 Y% ?2 K+ _% S1 jThe father denied taking any other medication. The
5 n2 l5 S. q" h6 b$ u, y& c+ schild’s mother was in good health. Her menarche
6 ]; v9 `3 [- R, Z- }/ o- G8 Ewas at 11 years of age, and her height was at 5 feet
% i$ w$ |9 X) X, Q0 a- u5 inches. There was no other family history of pre-" w6 M  Q. N: H  p
cocious sexual development in the first-degree rela-
0 \9 c( D2 H: J9 |tives. There were no siblings.
5 }: K. U% _  XPhysical Examination
+ s8 m+ x8 ^' j& p& T8 ?9 |The physical examination revealed a very active,9 V) |  R: h% v! L: X2 C9 ]
playful, and healthy boy. The vital signs documented! a+ X% W4 T5 V
a blood pressure of 85/50 mm Hg, his length was
9 q( o- M' [1 @* Z0 B- j3 r90 cm (>97th percentile), and his weight was 14.4 kg
. _6 L( J0 u3 w(also >97th percentile). The observed yearly growth
; n& O2 f; V. m' [) E2 X- Ivelocity was 30 cm (12 inches). The examination of
' ^% t3 e/ R/ p1 \4 w$ wthe neck revealed no thyroid enlargement.* t( J# ~  p; z1 F  M
The genitourinary examination was remarkable for% o; N$ |4 w4 ^. R, I
enlargement of the penis, with a stretched length of: |: f( G' ~& m9 a* V8 n3 q/ ~# ]
8 cm and a width of 2 cm. The glans penis was very well; T5 x$ ]* M0 V" ^# y' W6 Z7 ^
developed. The pubic hair was Tanner II, mostly around
  P- k& f3 n2 M: c540
. t3 b8 [. s0 y9 L7 K  K- Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 w- p( y$ }% K6 j4 F% H
the base of the phallus and was dark and curled. The& C) V- b. l" g1 }
testicular volume was prepubertal at 2 mL each.
6 k: q7 y2 n, b/ jThe skin was moist and smooth and somewhat
) v5 t7 R  e) x  {# y6 ^! coily. No axillary hair was noted. There were no: [  |, ^5 I* U3 K2 E
abnormal skin pigmentations or café-au-lait spots., X+ F+ x2 W% n0 n7 a( I1 ^
Neurologic evaluation showed deep tendon reflex 2+) b  x  [6 g/ G
bilateral and symmetrical. There was no suggestion  G& R7 c( s( W6 u- R
of papilledema.3 }0 c" R- ^9 S9 @$ U# M
Laboratory Evaluation
: V7 C7 \! j7 k2 p9 bThe bone age was consistent with 28 months by
; O7 h& A" Y9 t1 G" {using the standard of Greulich and Pyle at a chrono-
( i) O' [' m$ P* J0 x' U; N+ Alogic age of 16 months (advanced).5 Chromosomal- w4 O% H! F1 C1 r' O: f+ \$ G% D
karyotype was 46XY. The thyroid function test
9 }4 O) R% D* T/ E, p' Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ e7 o9 f$ `0 ^/ b+ `( t- Q/ c! M
lating hormone level was 1.3 µIU/mL (both normal).3 O" E! `$ y3 h% s2 D  q
The concentrations of serum electrolytes, blood
& j3 M0 C) c$ h: ^9 _urea nitrogen, creatinine, and calcium all were& |' ^6 u9 ~; r2 i
within normal range for his age. The concentration
4 x4 B6 ?, R- Y& L# _- }. Nof serum 17-hydroxyprogesterone was 16 ng/dL3 d7 X- H/ S. M5 j9 m" @
(normal, 3 to 90 ng/dL), androstenedione was 20
) f& J1 a7 i" tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 X, x* |  t, M1 a9 C6 r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! F* j9 ?: A% y0 y" ]3 ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to
% ~6 d# ?7 p. \; I3 t1 G5 h# p49ng/dL), 11-desoxycortisol (specific compound S)
  m9 n- E5 u4 y8 K9 b/ V  `+ y( ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) ?$ j6 x4 O3 o/ X7 ~1 Z( S+ p0 U1 Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' _, u$ {$ H7 t/ {1 H* D# k/ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 _4 ]$ m- w% O% d* s+ H# mand β-human chorionic gonadotropin was less than
! s( B. S# ~( w! h* j9 n; D/ T5 mIU/mL (normal <5 mIU/mL). Serum follicular
. L/ H1 j1 b+ K) e7 Ostimulating hormone and leuteinizing hormone
9 ?2 T6 f+ Y! Qconcentrations were less than 0.05 mIU/mL
  H0 a, s" _7 @' x(prepubertal).
/ v) `7 n6 j( o; H2 y+ FThe parents were notified about the laboratory
8 e- M2 F6 I5 o8 q1 }results and were informed that all of the tests were
* _, v  |/ ~) Z& S: ], ?! unormal except the testosterone level was high. The4 a/ K$ Y* S8 c! N% J( r
follow-up visit was arranged within a few weeks to4 g% ~- S& [3 O7 N: o% e( H( F" o" h) X
obtain testicular and abdominal sonograms; how-
9 O1 V0 {5 @4 ^# yever, the family did not return for 4 months.: B( J3 o# }$ f1 g3 d) p
Physical examination at this time revealed that the; k% G1 h" Y; Z  u# S
child had grown 2.5 cm in 4 months and had gained
0 a6 W8 Y5 A, `( `2 kg of weight. Physical examination remained
+ X' @# d; E2 m1 funchanged. Surprisingly, the pubic hair almost com-2 A3 k6 Z' v3 v$ R* X# Y# x
pletely disappeared except for a few vellous hairs at
4 N' x. `( e# x0 W, }the base of the phallus. Testicular volume was still 2
6 G* B% z9 K8 \" Q3 OmL, and the size of the penis remained unchanged.5 v- |7 j" N7 k' }4 j/ X3 i9 M- c
The mother also said that the boy was no longer hav-
' \2 l, U" K+ u. h6 king frequent erections.
* |) r, g+ l# {" T- A( ]Both parents were again questioned about use of2 V3 J5 T6 O+ l+ ]5 ?
any ointment/creams that they may have applied to, _" ^' m/ n7 G# E. j3 t/ q" O
the child’s skin. This time the father admitted the
9 ~) a( y/ P* X4 |4 n/ g( ^' t* }Topical Testosterone Exposure / Bhowmick et al 541
6 C+ i' z6 {* Fuse of testosterone gel twice daily that he was apply-! g7 G6 f! x4 a" G+ ~' a: R) J  D- W
ing over his own shoulders, chest, and back area for/ _6 |1 M9 U9 Q) s' J1 W) p
a year. The father also revealed he was embarrassed
$ r* i' o1 G1 _/ K7 {) rto disclose that he was using a testosterone gel pre-
, h6 ]# Y2 G+ ?2 @4 _5 P1 fscribed by his family physician for decreased libido. i8 P1 f; o, e
secondary to depression.
1 ^+ z  d! A8 {- h9 dThe child slept in the same bed with parents.
% t) }/ \- B' X7 u* [- lThe father would hug the baby and hold him on his
3 r* B3 a# [( P1 m( S7 ~) {chest for a considerable period of time, causing sig-" \& j5 u: d" E0 N' b
nificant bare skin contact between baby and father.
- w9 v8 f7 b* \$ v9 @2 H2 vThe father also admitted that after the phone call,
" M2 d/ }0 s5 b3 ^when he learned the testosterone level in the baby4 h2 N# q8 M8 m9 [- g# m
was high, he then read the product information
7 f3 F+ c) {8 t; P0 _1 cpacket and concluded that it was most likely the rea-8 X; @0 q  S! f1 L# \7 ^
son for the child’s virilization. At that time, they5 f& K" D3 P1 [# v5 T
decided to put the baby in a separate bed, and the
& x, J  E$ F/ R! r1 Qfather was not hugging him with bare skin and had/ V8 @! Q" v& _8 Y4 i
been using protective clothing. A repeat testosterone
# T& K, o6 P: O. I+ dtest was ordered, but the family did not go to the
1 J: a1 ^& u3 n$ x/ Claboratory to obtain the test.
% r1 d9 C3 i( U8 ]  F1 C( `" VDiscussion
9 f. ~& l5 l' g* d5 ]- X. _Precocious puberty in boys is defined as secondary: @; O4 j% I1 n6 r  t0 l
sexual development before 9 years of age.1,45 h: a- T- d# l9 K' c
Precocious puberty is termed as central (true) when4 O" Q( x1 r3 l  J. z
it is caused by the premature activation of hypo-
- u0 L1 K  y- K: vthalamic pituitary gonadal axis. CPP is more com-, P8 {4 x0 U, B  t; J  m+ n/ I& K
mon in girls than in boys.1,3 Most boys with CPP
5 b3 l' a( b, j# u4 Zmay have a central nervous system lesion that is; E7 d+ I/ a* d$ P  v/ R
responsible for the early activation of the hypothal-9 ~: l7 D8 h# ]8 {! S
amic pituitary gonadal axis.1-3 Thus, greater empha-5 d  o" {) K5 W% q- l8 G
sis has been given to neuroradiologic imaging in
9 S( o# V" N: z, m1 n  a: m& Fboys with precocious puberty. In addition to viril-
: D" C9 [: @* K6 \6 l8 d+ t- h2 z0 Pization, the clinical hallmark of CPP is the symmet-
5 {4 h5 l& O0 ?; ?rical testicular growth secondary to stimulation by
7 f/ K4 _) G9 f) d0 k& z  O! Lgonadotropins.1,3
7 [5 `8 m/ U+ g1 z0 b( g8 pGonadotropin-independent peripheral preco-2 V* r. g( P' E, F9 U9 C8 V6 s
cious puberty in boys also results from inappropriate6 t$ {* Q3 j1 Q/ b
androgenic stimulation from either endogenous or
/ q/ z* J3 J6 {2 {4 }5 Nexogenous sources, nonpituitary gonadotropin stim-
# Q  T  T6 d4 w7 Yulation, and rare activating mutations.3 Virilizing
5 Q' ^9 h5 \1 ycongenital adrenal hyperplasia producing excessive
; i+ U) l1 ~! A% j* N/ z/ U: vadrenal androgens is a common cause of precocious9 g% m( u4 E1 ]3 i* [
puberty in boys.3,4
( o7 z/ ?# [# {) T" `4 tThe most common form of congenital adrenal/ u" }+ A: ^) Q  u# c! {7 n4 T
hyperplasia is the 21-hydroxylase enzyme deficiency.
6 h  \* ^9 b' w. n( D5 d' e" WThe 11-β hydroxylase deficiency may also result in$ ~, ^, G/ p3 P
excessive adrenal androgen production, and rarely,
0 f! q) I1 |' A" r! M# Jan adrenal tumor may also cause adrenal androgen/ f/ R5 s1 Y1 a/ z& G$ M3 ?
excess.1,3
6 F1 }  t, H+ o  @1 n6 G; q0 G* T. p  Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, y/ N. o: {( q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; Q' {+ p9 N% @3 Y" y+ P! O, k2 F
A unique entity of male-limited gonadotropin-
' |2 J& T' a( s% I0 W" L: b* ?5 Y5 sindependent precocious puberty, which is also known
2 M' q9 d- a# v$ E# Tas testotoxicosis, may cause precocious puberty at a. W. r; u7 O2 d; N# L, C4 i# \
very young age. The physical findings in these boys
* n9 T, T- k5 b7 P# H4 a& Ywith this disorder are full pubertal development,
9 E5 W, ~7 X6 J  s9 K, y/ H8 d* }including bilateral testicular growth, similar to boys' z( T  C- x) B$ ~
with CPP. The gonadotropin levels in this disorder6 E# J( d' M; B' P: ], D3 t
are suppressed to prepubertal levels and do not show. J# \/ a1 Y' C$ _4 q9 R/ g
pubertal response of gonadotropin after gonadotropin-
1 J+ l1 ?* o6 M/ g. g2 G% l) Zreleasing hormone stimulation. This is a sex-linked$ ]1 E5 P5 r7 e$ y6 D
autosomal dominant disorder that affects only
" Y% g: K$ d" I7 F: H5 w$ J# pmales; therefore, other male members of the family' X5 [; X6 v9 k" g
may have similar precocious puberty.3
* N3 h/ I. {0 Y7 \In our patient, physical examination was incon-
$ R- ~) ?- R7 i$ ysistent with true precocious puberty since his testi-
9 b5 \0 q' q! Ncles were prepubertal in size. However, testotoxicosis3 k; ~, o4 N( _. ~2 Z
was in the differential diagnosis because his father" p, [- t9 L, ~2 Y& w
started puberty somewhat early, and occasionally,
1 B) l+ o" l" R: ftesticular enlargement is not that evident in the" B2 ]  y( R2 i' S; l# N
beginning of this process.1 In the absence of a neg-
, u; h3 ]) v5 w+ g; l9 m5 Dative initial history of androgen exposure, our
6 p+ m$ z4 ^& o8 d' d2 V8 mbiggest concern was virilizing adrenal hyperplasia,
7 _' P- x- v& |% Jeither 21-hydroxylase deficiency or 11-β hydroxylase0 a( _9 h& d) ^6 _
deficiency. Those diagnoses were excluded by find-3 g& [7 L0 C. y" M9 ]* q! h* h
ing the normal level of adrenal steroids.
6 C1 M0 {3 C" y$ T7 e; ^The diagnosis of exogenous androgens was strongly
. z7 I2 ~7 M7 s9 |suspected in a follow-up visit after 4 months because: W0 @. F( ]: X0 i; ]$ `
the physical examination revealed the complete disap-
0 I+ \- Y. Z1 G8 `! dpearance of pubic hair, normal growth velocity, and7 ^8 s7 g, ?0 `$ d& C
decreased erections. The father admitted using a testos-4 e( L7 \! K0 x
terone gel, which he concealed at first visit. He was  O5 }: H0 b( i
using it rather frequently, twice a day. The Physicians’
4 \0 O% O( O, I8 U. O# p# lDesk Reference, or package insert of this product, gel or
! @7 X! f+ @4 s4 ~: ?% }; \3 tcream, cautions about dermal testosterone transfer to
. v: }- T3 d& I  s0 Vunprotected females through direct skin exposure.
# G4 t6 w  X- T9 V# _! kSerum testosterone level was found to be 2 times the: t- ?  P+ p1 `( d
baseline value in those females who were exposed to6 e# y7 E# V: z. X' B; @! Z
even 15 minutes of direct skin contact with their male( e' B2 e0 M4 C
partners.6 However, when a shirt covered the applica-% r* l, ^5 s* C+ Q% z0 f
tion site, this testosterone transfer was prevented.  ~2 H  E! T3 J: l. W6 Y. \+ @
Our patient’s testosterone level was 60 ng/mL,
* x5 i- _, N  r0 ^6 f1 k: z8 ewhich was clearly high. Some studies suggest that
) z# W5 A' E  z8 Q, jdermal conversion of testosterone to dihydrotestos-
5 E9 \) b( z+ [6 f; X" p  U2 _terone, which is a more potent metabolite, is more( H/ u- b7 k- }2 t+ y6 a
active in young children exposed to testosterone1 A1 k4 l/ k) G
exogenously7; however, we did not measure a dihy-
0 ^% r( W, v" \* ~drotestosterone level in our patient. In addition to
6 e5 V  C" q2 a! A: vvirilization, exposure to exogenous testosterone in
" S- Q$ G9 ?- H( t8 k# z/ D$ Ychildren results in an increase in growth velocity and
$ P0 e* Q0 E) {0 Madvanced bone age, as seen in our patient.$ m6 [, f* ^3 L2 W- S( t+ W+ u
The long-term effect of androgen exposure during# `/ S5 Z2 ~8 c4 }4 R- ]
early childhood on pubertal development and final
$ ], a1 o6 B' ]' A9 J, Oadult height are not fully known and always remain! _% _5 C- u7 Z; V+ R  W7 }5 k
a concern. Children treated with short-term testos-
' D' b% d1 A' E, ^8 l2 u; C* \terone injection or topical androgen may exhibit some
- q+ H" ]0 c( y, C9 k: _2 sacceleration of the skeletal maturation; however, after# i, l& G# O" K- i/ a- ?
cessation of treatment, the rate of bone maturation4 T# e2 c9 l# \* ?/ s& u
decelerates and gradually returns to normal.8,9
( T5 F7 U5 c/ P0 o! p- A8 [# AThere are conflicting reports and controversy
0 l$ I3 o) Q5 S$ \over the effect of early androgen exposure on adult# x% g+ v5 U- [6 t( ?
penile length.10,11 Some reports suggest subnormal
! U, J2 W! i3 L( j* xadult penile length, apparently because of downreg-. m- c. T5 h: p, j/ B- D2 o8 S
ulation of androgen receptor number.10,12 However,3 y! i0 _7 y( c3 h
Sutherland et al13 did not find a correlation between
; i- H& ~1 g9 L  ?- Z+ nchildhood testosterone exposure and reduced adult$ [9 |! e1 |9 c7 i) p/ l& e2 G
penile length in clinical studies.
% S, R' E+ h8 f/ K4 c6 WNonetheless, we do not believe our patient is% J2 [. `7 t/ a0 A7 ^+ S
going to experience any of the untoward effects from
$ E' A' S( N1 A/ A+ X; z+ ~testosterone exposure as mentioned earlier because: s/ y5 a/ {6 ^
the exposure was not for a prolonged period of time.* E7 L5 I# t  M
Although the bone age was advanced at the time of
! t/ ]1 ~, g8 X6 ^, G, hdiagnosis, the child had a normal growth velocity at' E- z2 T- ^, k" P2 D) u% v
the follow-up visit. It is hoped that his final adult
6 H( E" q; T, `* l* _height will not be affected.$ y( r8 s4 O; I$ I! ^
Although rarely reported, the widespread avail-4 w6 D) R6 h# H; I0 _: N% b3 [1 i
ability of androgen products in our society may
. l- \8 H2 L8 Kindeed cause more virilization in male or female
* o0 @9 X8 l, o5 }5 tchildren than one would realize. Exposure to andro-
/ v" T+ {$ _: Sgen products must be considered and specific ques-* X1 [2 `* f6 l/ J# I1 q
tioning about the use of a testosterone product or# Q$ J, A0 q% x
gel should be asked of the family members during
* _% [' l. B" Gthe evaluation of any children who present with vir-! S* F* D* m  @2 a5 @& ]+ H
ilization or peripheral precocious puberty. The diag-
# r: Y  o) w6 L$ W! @/ ~nosis can be established by just a few tests and by
/ q0 ^% g' S$ _3 O& F/ Wappropriate history. The inability to obtain such a
3 _* B0 c. p/ t: G9 h: O9 w% Mhistory, or failure to ask the specific questions, may; k$ l1 {: \, o: w& k2 m1 a
result in extensive, unnecessary, and expensive
! m, q) w9 Y0 K8 h' v$ d. Xinvestigation. The primary care physician should be3 Y7 ]' J0 h- |3 H* g" \
aware of this fact, because most of these children9 N* j% n& K. h9 y9 k5 @, u
may initially present in their practice. The Physicians’
4 M. \. f  E  k9 pDesk Reference and package insert should also put a
, z; ~" R! b0 R& V6 xwarning about the virilizing effect on a male or
) F3 E9 E. f! v) Jfemale child who might come in contact with some-4 l2 ~2 }" z3 @# R+ |/ _& V- G& p
one using any of these products.
9 R9 w0 k% Q% |4 V' v* ~References1 ?8 a3 U& `9 t  v# @$ l
1. Styne DM. The testes: disorder of sexual differentiation) z/ Z8 x' a8 G
and puberty in the male. In: Sperling MA, ed. Pediatric; y: p7 P* |- G) P/ l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 z' D. i2 L; I0 _+ [0 @
2002: 565-628.3 j' Z8 M- C0 I$ ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: K% M3 `* T0 F3 U9 C- b. F! J
puberty in children with tumours of the suprasellar pineal
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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
( W. _! ]# a* ?5 w1 T' u
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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