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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
6 _* L. ?9 c- |; \% ZBoy Induced by Indirect Topical
/ K' d. ^, k0 QExposure to Testosterone
% t4 f" D/ \. b6 t7 B# |' @Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ a  }# j- H) [% y! X" O
and Kenneth R. Rettig, MD1
6 E  Z) I1 |7 U0 q/ _Clinical Pediatrics3 a# T4 _. W4 T3 j" T: G5 x
Volume 46 Number 6
, i) b' G  T+ ^0 O6 C+ i. yJuly 2007 540-543
, c! o/ U6 V# f) z7 y7 B5 y© 2007 Sage Publications  l2 S) l& J' `& L* A( [
10.1177/0009922806296651$ r1 ]9 {4 F2 z$ W. F# u% s
http://clp.sagepub.com
) j8 n/ a% m% i( d8 E8 ?7 Ehosted at# N6 R0 f( A( L) V" `
http://online.sagepub.com
& \! v9 l: k# X6 LPrecocious puberty in boys, central or peripheral,0 g* K) U. K+ d& z
is a significant concern for physicians. Central
  y, F! M$ |1 [( R1 X) mprecocious puberty (CPP), which is mediated& p" }8 O+ L: @  R/ t/ `& I& @
through the hypothalamic pituitary gonadal axis, has
2 I$ d* d2 A: Da higher incidence of organic central nervous system
9 a3 d! n7 \4 T3 c2 P  G/ |lesions in boys.1,2 Virilization in boys, as manifested7 ^: p' R/ \- j' q: K
by enlargement of the penis, development of pubic9 h2 q; j0 J4 {8 g7 {
hair, and facial acne without enlargement of testi-
0 W& F2 w( A. v7 _# I- Q" M6 ncles, suggests peripheral or pseudopuberty.1-3 We
5 r" ~, s/ x2 f$ C% u5 Z* Kreport a 16-month-old boy who presented with the0 R1 e0 H+ w* m* M1 N  D
enlargement of the phallus and pubic hair develop-. J) E% u6 V0 _
ment without testicular enlargement, which was due9 }+ U' t8 q. Q3 D5 i) _
to the unintentional exposure to androgen gel used by
) _( h& u+ n5 u! J6 [  nthe father. The family initially concealed this infor-
, q- O% R% ~8 h5 x0 T4 R9 M! q7 Bmation, resulting in an extensive work-up for this
6 S0 ~3 c9 C2 ]: c! jchild. Given the widespread and easy availability of9 a% ~/ C  A# N& c1 k
testosterone gel and cream, we believe this is proba-+ J- R# H7 ?( X/ H
bly more common than the rare case report in the
& G1 K* K+ g% w/ d7 C4 b$ x4 Yliterature.4
' o" p  T, Y1 @) O9 }/ IPatient Report+ R) p1 D% t% {5 n& S2 ]2 ]
A 16-month-old white child was referred to the1 {) }5 F8 K9 q/ E' ~
endocrine clinic by his pediatrician with the concern5 Z6 L  @2 _( [( A0 m, ?3 ]2 {0 l
of early sexual development. His mother noticed
4 L" K, w4 o, j/ j2 c* _light colored pubic hair development when he was
! z4 ?! H0 n% d0 _( \, g& Z9 S- j4 zFrom the 1Division of Pediatric Endocrinology, 2University of$ E# k) Z8 z6 y* f) z
South Alabama Medical Center, Mobile, Alabama.
' k- D. ?6 ^6 IAddress correspondence to: Samar K. Bhowmick, MD, FACE,- F' V; e( W0 X1 C, t! R* b
Professor of Pediatrics, University of South Alabama, College of' B4 ~  G& s. ^; T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& d* I9 ?! r9 Q. w& D: p4 x9 Q! Ie-mail: [email protected].
( l3 k; ?5 K# Pabout 6 to 7 months old, which progressively became. C8 H3 e' s: w; Q0 b$ ?6 L8 w
darker. She was also concerned about the enlarge-  K* F; f; C3 F4 u4 a- x" ?7 B
ment of his penis and frequent erections. The child& |2 ^# N( g$ G8 x# p
was the product of a full-term normal delivery, with
# F% |2 P. i* C$ k6 h2 u, Ha birth weight of 7 lb 14 oz, and birth length of+ [' D& w; i( h& D, _
20 inches. He was breast-fed throughout the first year6 T: h; U; ~3 p& U' g
of life and was still receiving breast milk along with
) v; ~$ g# t! n. ~( ?( asolid food. He had no hospitalizations or surgery,% \4 ]; H( o& L& @8 B- c+ T
and his psychosocial and psychomotor development# L" r. r, x+ ?  T3 P' i4 g
was age appropriate., ~# f# r/ H, I  d
The family history was remarkable for the father,, R' P! \- i: Y0 ^* e
who was diagnosed with hypothyroidism at age 16,6 s# ~/ v( V  G' w5 h
which was treated with thyroxine. The father’s/ I9 B" q1 @0 }/ Z  X  F
height was 6 feet, and he went through a somewhat
6 \+ l2 S2 W. j& Wearly puberty and had stopped growing by age 14.+ ~/ s+ s5 x  N
The father denied taking any other medication. The
1 r# h# z( i9 m/ s( M) e; X1 _+ s9 Qchild’s mother was in good health. Her menarche) F3 j, A$ k2 Y9 d* H
was at 11 years of age, and her height was at 5 feet
0 S3 r- Q& Y/ d! K8 e: }: Z5 inches. There was no other family history of pre-
, a) l& W  V) f4 W1 t6 A- d* q: ncocious sexual development in the first-degree rela-% T. R) n' `/ i* \
tives. There were no siblings.
5 r" S$ V. t/ A  c) I6 yPhysical Examination
3 ?& X4 D+ n! |* bThe physical examination revealed a very active,/ W+ m9 X) H9 K* }6 v
playful, and healthy boy. The vital signs documented
9 \) I2 r& o( e0 Ga blood pressure of 85/50 mm Hg, his length was9 l2 U& Z- b8 R7 {& h9 x7 [8 X0 r1 D
90 cm (>97th percentile), and his weight was 14.4 kg
$ b, P  _. T0 }. Y(also >97th percentile). The observed yearly growth# C; z* V2 t8 U7 a1 \: ~
velocity was 30 cm (12 inches). The examination of
8 i8 h" g) R/ n/ n7 C. xthe neck revealed no thyroid enlargement.
7 c5 Y" K$ `/ n5 \  UThe genitourinary examination was remarkable for& l! l6 c$ `' A$ q, G' u" e1 G
enlargement of the penis, with a stretched length of: f% \! {5 _2 B4 V
8 cm and a width of 2 cm. The glans penis was very well
! W3 y$ m  g' v: \* Odeveloped. The pubic hair was Tanner II, mostly around( L8 f# W2 ^0 X: W3 I! @4 L7 i
540
( c- K4 Q- l5 E0 r. O! D# D) b0 Q$ lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" W/ g' x* {! m5 xthe base of the phallus and was dark and curled. The2 B5 `* w. X- O( G$ t
testicular volume was prepubertal at 2 mL each.* k% T" v+ _% H4 C  a  C. j" B( l
The skin was moist and smooth and somewhat* ]5 Y; g3 c: w# c7 h# H
oily. No axillary hair was noted. There were no
$ @6 ^4 V8 s2 Z, n. rabnormal skin pigmentations or café-au-lait spots.
2 P( _5 T! _; Q. YNeurologic evaluation showed deep tendon reflex 2+
- {, D6 C7 R/ n, U4 ubilateral and symmetrical. There was no suggestion
& }8 A- I- P+ tof papilledema.! j8 H. i+ j: {5 ^
Laboratory Evaluation! t& s* c7 p3 R  b
The bone age was consistent with 28 months by
! l) r( Z3 p- a$ N! D( @( tusing the standard of Greulich and Pyle at a chrono-5 l) v7 h) b" D9 o% R+ S9 j7 k* N7 o
logic age of 16 months (advanced).5 Chromosomal) x3 x) s+ ^5 e8 U2 W# t' c6 R
karyotype was 46XY. The thyroid function test6 h" n' C* G) X( n3 |' \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& v3 i6 l+ u+ s( k
lating hormone level was 1.3 µIU/mL (both normal).
5 v. U8 q/ t! I% g) G3 v1 JThe concentrations of serum electrolytes, blood9 X3 n5 T! [: n; n3 f1 U# p
urea nitrogen, creatinine, and calcium all were( e: D! N, x  x9 z
within normal range for his age. The concentration. X) Q5 A1 H: |) B4 m1 o: _7 W
of serum 17-hydroxyprogesterone was 16 ng/dL  k" }/ C- g9 J  @+ A0 h
(normal, 3 to 90 ng/dL), androstenedione was 205 z5 O# Y8 W( ]3 s5 t- K) r, \
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- d. [( i, [  oterone was 38 ng/dL (normal, 50 to 760 ng/dL),+ ^. ]3 |7 n1 K# b/ K2 }. |7 G, b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 y' `. z: z* q9 `) K  T& D% n# ^5 S
49ng/dL), 11-desoxycortisol (specific compound S)
& ^* g- O- b! ?$ ?2 H8 ]' Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 v9 \( R8 X2 x/ v( E. ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! v; m* o8 j# z# E. H" g- r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( K. v# Y/ H- l! W. p! g
and β-human chorionic gonadotropin was less than9 P4 a; W2 m; @  k
5 mIU/mL (normal <5 mIU/mL). Serum follicular* o, h/ f6 @8 \. O8 R
stimulating hormone and leuteinizing hormone2 J# [# Z1 E' X3 ?1 M" w, L- W
concentrations were less than 0.05 mIU/mL
4 n3 a' d, ~! }- Z9 P" D$ p; H$ Z/ r(prepubertal).# T* z# v- M' i+ `2 r
The parents were notified about the laboratory
) w) o& i1 T! G! \. \results and were informed that all of the tests were2 m% L/ p! S) T2 M
normal except the testosterone level was high. The7 K1 h. a# q8 B. b
follow-up visit was arranged within a few weeks to
+ H$ F  a2 t% V: i! Uobtain testicular and abdominal sonograms; how-& n" z' S: Z* p& G) T
ever, the family did not return for 4 months." o& E1 ^1 w$ B# B
Physical examination at this time revealed that the- n; l' R& @. Y
child had grown 2.5 cm in 4 months and had gained. z5 ]1 B2 C- y
2 kg of weight. Physical examination remained4 \/ B5 I2 z; ]0 X3 p
unchanged. Surprisingly, the pubic hair almost com-- n, A, r* a* b+ p, k
pletely disappeared except for a few vellous hairs at
2 ]4 t( `  O3 |; ?6 h- Sthe base of the phallus. Testicular volume was still 2
: N- u+ k2 d) K, p+ lmL, and the size of the penis remained unchanged.0 ]- J& a$ g7 M, F' C8 `' V
The mother also said that the boy was no longer hav-
* L* k, n! S$ G$ uing frequent erections.
3 h0 \) v/ U) ^$ x- l3 SBoth parents were again questioned about use of
# V3 p* z2 d8 ^any ointment/creams that they may have applied to
% d5 y' \. f: K0 d) Cthe child’s skin. This time the father admitted the
8 F7 m( H3 i9 M8 i6 B" x6 L: O. T4 DTopical Testosterone Exposure / Bhowmick et al 541) R3 U% w) K+ V! e  m4 Y( e2 x6 A
use of testosterone gel twice daily that he was apply-% F6 `  T9 ^6 ~7 J
ing over his own shoulders, chest, and back area for# x/ Y: c( B+ P' U5 D- V8 [: Y
a year. The father also revealed he was embarrassed
' B/ |& b7 D- m) ?. {to disclose that he was using a testosterone gel pre-
% O  U, o: _: Yscribed by his family physician for decreased libido
( g( S3 q+ \) Dsecondary to depression.
9 E5 W) W4 U$ e" A. c, _  B! k: zThe child slept in the same bed with parents.* T5 l# H! u- u! o5 J
The father would hug the baby and hold him on his% E$ n! A$ v- H' I& K% h/ E0 V$ _
chest for a considerable period of time, causing sig-
# U' y0 a5 ]$ Y1 o$ Onificant bare skin contact between baby and father.1 [+ Y; H( ]" W4 N2 `* Y# H3 z$ K
The father also admitted that after the phone call,0 Y1 t" t: y9 K5 \- }6 M
when he learned the testosterone level in the baby1 l8 r) \/ [- w" R0 y' g
was high, he then read the product information& c( h# M7 b: f/ T# H
packet and concluded that it was most likely the rea-
% G" n' g6 k0 wson for the child’s virilization. At that time, they8 @1 l' x8 r+ t& J
decided to put the baby in a separate bed, and the" z$ Q  F: y$ R
father was not hugging him with bare skin and had4 V3 \  V  k! ^7 k
been using protective clothing. A repeat testosterone
. b+ J& A. F( t& W, C1 Ytest was ordered, but the family did not go to the
0 R  \/ |9 ?( C/ s9 }* a. qlaboratory to obtain the test.
6 i7 L5 c! \8 r( z' \5 z7 l; P9 UDiscussion% \. y5 o. Q  J8 }
Precocious puberty in boys is defined as secondary' @5 b! ~2 m2 d3 _; Q2 z: i# Q
sexual development before 9 years of age.1,4
- g7 g3 Y& n5 v$ _5 lPrecocious puberty is termed as central (true) when
: [% }' q" }9 `it is caused by the premature activation of hypo-/ a& J! k( _8 q
thalamic pituitary gonadal axis. CPP is more com-# x* W0 j8 M3 ?/ S
mon in girls than in boys.1,3 Most boys with CPP. U5 M( H- ^  a7 g- T0 G" Z0 s3 d# N
may have a central nervous system lesion that is+ r" A' y  F: e2 S2 ~
responsible for the early activation of the hypothal-
8 R% V! i& d8 u6 c; z) damic pituitary gonadal axis.1-3 Thus, greater empha-
0 y9 a- j3 c* B  Lsis has been given to neuroradiologic imaging in
3 n; B3 ?- ^$ y/ Wboys with precocious puberty. In addition to viril-
3 R& \2 Z+ ?7 S1 Xization, the clinical hallmark of CPP is the symmet-
( Z! S  V/ p: K8 a: c* H. o/ z1 t" I& drical testicular growth secondary to stimulation by
) l+ W. t( [0 L1 n* j: ~, Lgonadotropins.1,3
2 j2 u1 z; X+ y6 h0 jGonadotropin-independent peripheral preco-
0 o2 t6 s" e8 D1 Gcious puberty in boys also results from inappropriate
$ k4 d; e+ i# O$ p% Mandrogenic stimulation from either endogenous or
$ Y, P3 ?$ r0 d) j, zexogenous sources, nonpituitary gonadotropin stim-) \3 @3 T0 C( U( Z% s. Z  e3 ^+ d
ulation, and rare activating mutations.3 Virilizing
3 O5 ^9 E  B( u& `congenital adrenal hyperplasia producing excessive
% X: x- m) p. B# `$ a) xadrenal androgens is a common cause of precocious, @8 T0 [4 z) V# `& i
puberty in boys.3,4
2 `$ J& R1 }0 D. p8 f. BThe most common form of congenital adrenal
# r4 r- ?  t5 khyperplasia is the 21-hydroxylase enzyme deficiency.
5 ~% Z4 U. m0 \2 k$ VThe 11-β hydroxylase deficiency may also result in
! |6 j6 R0 B- L5 Z) b( oexcessive adrenal androgen production, and rarely,
. a6 [$ ~' a9 Z! p- A! d( `- t/ h) Ean adrenal tumor may also cause adrenal androgen
' m! N% r2 u0 Q8 \8 q( g1 Mexcess.1,3
* d  \" n+ L% d' V5 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 t5 h* d) a7 x: z9 n542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 w: d- |* G+ t, [0 GA unique entity of male-limited gonadotropin-4 r# Y( P: `6 O2 q/ h
independent precocious puberty, which is also known# `: W7 Z7 t& m- E' H  c: A
as testotoxicosis, may cause precocious puberty at a
& p  u0 d% g; T/ |very young age. The physical findings in these boys
! ^+ L7 y1 Q2 [* Owith this disorder are full pubertal development,
& a. U* u) o: D' h& Z( }4 p' rincluding bilateral testicular growth, similar to boys
, u1 _$ k3 n: x+ `" Ywith CPP. The gonadotropin levels in this disorder
+ `& M" K. R8 h' E8 D- c5 g5 uare suppressed to prepubertal levels and do not show
" [+ w% T$ ?& a: R& T; z: m8 Dpubertal response of gonadotropin after gonadotropin-7 `% K* S; {* v' e$ z9 T* o
releasing hormone stimulation. This is a sex-linked2 x: E; _0 {; C# R3 B1 F
autosomal dominant disorder that affects only
# T' ^% c7 c% \( hmales; therefore, other male members of the family
% g# ^. h% e2 p9 ~1 v- wmay have similar precocious puberty.3
1 V; C5 _) M- r0 sIn our patient, physical examination was incon-
5 h7 P% B3 o$ J' X  f: Ssistent with true precocious puberty since his testi-4 c  f; t" b1 q/ \: O8 V
cles were prepubertal in size. However, testotoxicosis
/ f. n6 W* I, g7 L% Fwas in the differential diagnosis because his father2 F: g& f0 S; o7 Z) }$ U( q3 c
started puberty somewhat early, and occasionally,
5 f( W5 d2 R" F: S: Utesticular enlargement is not that evident in the
5 k0 }7 K# P8 r; i) d7 Cbeginning of this process.1 In the absence of a neg-
6 e4 c- q+ o2 o- Tative initial history of androgen exposure, our# C  m- `* k# e
biggest concern was virilizing adrenal hyperplasia,; e: ?2 I8 S8 r( M
either 21-hydroxylase deficiency or 11-β hydroxylase9 a+ J4 Z& i! t! D
deficiency. Those diagnoses were excluded by find-
1 o) P7 q3 r6 V' ~2 E2 Cing the normal level of adrenal steroids.+ \, [' k. Q6 G! l' L
The diagnosis of exogenous androgens was strongly
. A0 |7 G( W2 Q- T* c- d! ssuspected in a follow-up visit after 4 months because; v  B* Y5 J9 B' \- A9 G( N
the physical examination revealed the complete disap-
" {* K7 ~" H+ I" Q- `pearance of pubic hair, normal growth velocity, and& Y4 S4 e# P9 u
decreased erections. The father admitted using a testos-
7 i, w. B) t* Cterone gel, which he concealed at first visit. He was
* H' B/ ?0 k/ B7 }using it rather frequently, twice a day. The Physicians’
/ p6 G& {  l( L- QDesk Reference, or package insert of this product, gel or* X4 v; V! @: Z8 s5 A  f5 J
cream, cautions about dermal testosterone transfer to
# ?. {6 Z* y3 _unprotected females through direct skin exposure.
( b* `. a8 V, p6 TSerum testosterone level was found to be 2 times the
: ]0 p- {: s% m( J" D+ ~baseline value in those females who were exposed to
/ E$ [) E- b; K: N% |" Weven 15 minutes of direct skin contact with their male' v* n& A0 J0 s; R
partners.6 However, when a shirt covered the applica-1 ~, N, Z; f5 f* \9 o0 f8 V
tion site, this testosterone transfer was prevented.
. O# m. O1 U- }2 t/ t6 _1 D" SOur patient’s testosterone level was 60 ng/mL,
3 O7 v1 _5 G" A$ g  e% t4 ^1 {3 Z! Dwhich was clearly high. Some studies suggest that
- D" X$ m' ^/ R. p2 S3 Pdermal conversion of testosterone to dihydrotestos-3 D2 k3 o0 n. v$ z  n5 c' k& f
terone, which is a more potent metabolite, is more' N" ^5 B4 k" c1 ?
active in young children exposed to testosterone( j4 R" S: w* v" ~
exogenously7; however, we did not measure a dihy-
7 x  p* m( e) t  B  Rdrotestosterone level in our patient. In addition to
/ _3 X; a5 S3 k+ I- y4 \! x, U5 z6 vvirilization, exposure to exogenous testosterone in6 U1 m  y& s1 M
children results in an increase in growth velocity and
; i3 k$ P- Q9 R( W. X+ Badvanced bone age, as seen in our patient.: m" Y! |3 W" I5 c
The long-term effect of androgen exposure during
5 K8 C. ?: x0 M2 X3 m7 z$ searly childhood on pubertal development and final
5 b' V  `# {5 m' A; s! e8 E4 radult height are not fully known and always remain7 N1 p! W' r6 H
a concern. Children treated with short-term testos-
6 B, C; i# G; }6 L! A4 {& Pterone injection or topical androgen may exhibit some! T/ G7 b5 D& I
acceleration of the skeletal maturation; however, after
. V' K; r' h8 v1 Q- Gcessation of treatment, the rate of bone maturation
6 |  m3 |- Z/ p, W$ n" Z) udecelerates and gradually returns to normal.8,97 R9 v, @! S/ b/ c/ [5 |2 c
There are conflicting reports and controversy
/ ^4 M  `% h( {, W& h" g  {- wover the effect of early androgen exposure on adult
: {0 F8 x; ?+ o) vpenile length.10,11 Some reports suggest subnormal
& h* N3 |5 U1 k) U  K1 [; U7 a  yadult penile length, apparently because of downreg-
; i( m# M/ L; _' Culation of androgen receptor number.10,12 However,1 W' ~0 D4 ?- ~) b
Sutherland et al13 did not find a correlation between
' b0 c) @+ R" Q/ Ychildhood testosterone exposure and reduced adult
% h  E' r, T& W$ p# Kpenile length in clinical studies.
$ ]& H/ k' v, ]" @2 ~Nonetheless, we do not believe our patient is
' J( Z6 g. Z* b* V+ W9 B% c2 ogoing to experience any of the untoward effects from) e# K/ ], P0 K& }, y. O' b& r
testosterone exposure as mentioned earlier because7 U- L/ k- Z' i( P: B' D7 l% W7 z
the exposure was not for a prolonged period of time." \. Z( Y0 B, ?" [0 h. |. }
Although the bone age was advanced at the time of
* [5 }0 Z; M/ \diagnosis, the child had a normal growth velocity at
6 R& [  n# x4 m- O4 lthe follow-up visit. It is hoped that his final adult* d& S# M+ `) N4 k8 A) O; Q7 r+ I% j
height will not be affected.
: U- t9 x' p5 @Although rarely reported, the widespread avail-6 X. f6 T, r( a) C
ability of androgen products in our society may
# J1 S1 b8 i4 e/ C& _6 {4 xindeed cause more virilization in male or female
* O# k3 \  g. K/ k4 Cchildren than one would realize. Exposure to andro-9 ~  F" D! m+ I( @2 _' N# s2 s/ N4 T9 N
gen products must be considered and specific ques-
) j) ~0 K! T( X& _. u, [& n+ Etioning about the use of a testosterone product or' H, Q# ]0 m% G
gel should be asked of the family members during& V0 H7 ?+ M" B. W# T; K! d1 A
the evaluation of any children who present with vir-
8 d3 S) l4 j8 Q, s$ D% \ilization or peripheral precocious puberty. The diag-
$ F( |. f/ \0 B" ], T: d( n6 P  `5 H( Cnosis can be established by just a few tests and by
# _' F3 Z! h9 L4 m- s$ |# @7 Tappropriate history. The inability to obtain such a
4 p$ a; Y) f2 M; K3 X3 bhistory, or failure to ask the specific questions, may3 n% ^8 E# m; h; s
result in extensive, unnecessary, and expensive- s! }7 a4 p/ L7 j0 x' ~
investigation. The primary care physician should be) U0 m( G2 ^1 ^' N6 Q5 c
aware of this fact, because most of these children' E5 E$ p. a: T0 v
may initially present in their practice. The Physicians’
5 X1 ?7 E4 i' t% _/ ^+ NDesk Reference and package insert should also put a: i! }4 i8 r1 k: K) G
warning about the virilizing effect on a male or
! l- o# ]3 I8 a. X) Mfemale child who might come in contact with some-/ K- J! C: j/ ?; H) Y
one using any of these products.2 l, R' N4 U' b* w& U9 a$ h
References
+ E% |0 |; J; l7 u1. Styne DM. The testes: disorder of sexual differentiation2 }; ~$ `8 X9 Q. p) m: k7 r
and puberty in the male. In: Sperling MA, ed. Pediatric6 U4 w4 [6 ~( a
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 a* i0 |& }# z* i2 ^4 A! `4 q2002: 565-628.
8 f8 ^# ~$ @1 E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. ~! Y8 h* p/ ?
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old, Q/ h( H) `$ V8 K- v
Boy Induced by Indirect Topical# ]% R- k+ b+ R- v8 K, k# P$ _
Exposure to Testosterone
: C# p* X( H" B- T  q) PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, m9 |6 Y. H& ?0 ]2 |' q5 f
and Kenneth R. Rettig, MD1
8 I0 k4 K! E$ h2 E: O8 E- d. e6 BClinical Pediatrics7 x0 p( z: F4 f. @* ^' k% f
Volume 46 Number 6/ Y/ U3 Q' w, ^4 x4 p* H
July 2007 540-543
, V" N& E) k9 h3 j* B9 u6 g7 C: f© 2007 Sage Publications4 D% B/ n, _: ]( r! V! Z% [
10.1177/0009922806296651  M" E! y+ Q7 C1 l! o' l
http://clp.sagepub.com
* Y$ |' m" p) _) s8 M1 y4 chosted at! T6 q( `( L2 A* N7 E. [) o! g
http://online.sagepub.com, y1 \' J: P- a+ c, E0 C! [
Precocious puberty in boys, central or peripheral,9 w/ R' e* X- Y, z: M9 F
is a significant concern for physicians. Central
! E/ e% [: d" p  e  }2 j6 X/ [precocious puberty (CPP), which is mediated
9 o3 W$ @5 I5 b9 F% [1 K- T; gthrough the hypothalamic pituitary gonadal axis, has
2 ^# z3 F; B( w6 T0 R7 z2 n' Ca higher incidence of organic central nervous system; R- d4 e. V- R4 ^: k! }
lesions in boys.1,2 Virilization in boys, as manifested! P/ V, H* S0 p; n) ^1 ?  `6 |7 ^
by enlargement of the penis, development of pubic
( m7 [1 U, h$ q& Z8 e  whair, and facial acne without enlargement of testi-7 ]# Z1 p% [. u( E1 R. _" n
cles, suggests peripheral or pseudopuberty.1-3 We
+ I" h+ l# d6 `- y" qreport a 16-month-old boy who presented with the  N1 I+ l! u. _3 x) V' I
enlargement of the phallus and pubic hair develop-+ Q! n% z! G# }% O: d  C
ment without testicular enlargement, which was due/ E. R9 J5 o9 `2 r7 }% Q0 G& F
to the unintentional exposure to androgen gel used by
: V/ J& r. D- }) y; D; `the father. The family initially concealed this infor-8 ^, y4 [/ H1 ~7 l, S3 A" R- {
mation, resulting in an extensive work-up for this3 J* h. S$ z. W. j. \: {: k. y
child. Given the widespread and easy availability of
; p$ G) T" i: mtestosterone gel and cream, we believe this is proba-
& j* [4 m, ]9 @/ z( |bly more common than the rare case report in the
; \" c' J! c! W( p, `literature.4
) P7 y5 [2 c0 E3 W# o. v1 QPatient Report
4 x% h2 Q( h8 d5 R; \) [A 16-month-old white child was referred to the
2 @/ ^- ^+ T( |( t1 Xendocrine clinic by his pediatrician with the concern" m9 w" b3 f. i  _6 Z6 p
of early sexual development. His mother noticed) F3 f! x7 U8 W5 w% z# I
light colored pubic hair development when he was3 g% s. F* D6 B- y/ T$ {
From the 1Division of Pediatric Endocrinology, 2University of  r- x4 n  D; o, F) ^
South Alabama Medical Center, Mobile, Alabama.
2 p+ W! s6 r8 e- d9 a& x0 zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 f! G0 o( ?- ]" J/ L: E' n9 N3 ?Professor of Pediatrics, University of South Alabama, College of0 @9 U# ?! X" X: _; ^1 Y' f+ e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ U( y, {- N, a2 A9 Ye-mail: [email protected].# k7 U% s9 N3 j$ `# d2 ?4 h, q
about 6 to 7 months old, which progressively became6 V9 f  ?6 W8 E1 d. [
darker. She was also concerned about the enlarge-
; Z, D0 d) f; a6 n' N8 tment of his penis and frequent erections. The child8 J0 C  }9 G* O! a% U. Z1 F$ B& |
was the product of a full-term normal delivery, with% n0 f9 {# A, T# g1 x
a birth weight of 7 lb 14 oz, and birth length of
4 K- @0 B* `2 b: E- z20 inches. He was breast-fed throughout the first year5 ]3 S$ m& T! Y6 H: [1 k2 Q/ E+ g! \
of life and was still receiving breast milk along with
  c# T  E4 y2 L4 H/ [solid food. He had no hospitalizations or surgery,# t6 Q  E) |9 w9 G# f& b6 `. [) g
and his psychosocial and psychomotor development
% d9 r9 v; Y  F! D0 J& @1 Xwas age appropriate.$ r, v8 T" z; P# R" g- [
The family history was remarkable for the father,
) I- w) S, i, M' }: M  Z' g/ v& Ywho was diagnosed with hypothyroidism at age 16,/ E3 M/ X" P, C/ l2 \
which was treated with thyroxine. The father’s6 K+ s7 K& ~& \- v. W, H5 r5 v
height was 6 feet, and he went through a somewhat3 h' R: B7 s4 r. {2 T# T2 U1 [
early puberty and had stopped growing by age 14.( X/ F$ u2 a; E1 o* q4 S
The father denied taking any other medication. The$ T7 h/ W. n" D7 G
child’s mother was in good health. Her menarche
2 |- |. H$ Q* L/ s" g( S# Q( b. k$ jwas at 11 years of age, and her height was at 5 feet7 @* t4 `' @8 |
5 inches. There was no other family history of pre-" n* F- d/ O% j
cocious sexual development in the first-degree rela-
3 d$ {8 E1 l; ~& F/ u9 J% K) M1 Mtives. There were no siblings.
3 [, |: Y% B/ P3 z2 NPhysical Examination
# o# V: s6 d+ o9 \2 t( bThe physical examination revealed a very active,
5 G- {7 D+ `3 j( c2 d; ]playful, and healthy boy. The vital signs documented
3 _+ n4 x; g7 ka blood pressure of 85/50 mm Hg, his length was0 z2 ?7 V7 p+ u) C
90 cm (>97th percentile), and his weight was 14.4 kg2 `* F+ t. F4 ]7 _$ U1 z7 J) _
(also >97th percentile). The observed yearly growth/ V$ |- o& w1 P$ d, F
velocity was 30 cm (12 inches). The examination of
/ w7 g- ~& y6 a# P, Hthe neck revealed no thyroid enlargement.9 U* J& _4 ~8 p% R9 m/ _
The genitourinary examination was remarkable for, m1 U9 ~+ \: t2 f2 q
enlargement of the penis, with a stretched length of
' }( z. c7 a# Z- D- Z1 x% k4 _! k8 d8 cm and a width of 2 cm. The glans penis was very well! a: s8 t  S1 C$ Y5 \& _: g
developed. The pubic hair was Tanner II, mostly around
% T9 A. b( X8 r  P% m) G# }9 {540
+ L* j4 H. L) a; aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 N0 ^# o6 T* I. X) l
the base of the phallus and was dark and curled. The
* ?& f8 ]3 R' xtesticular volume was prepubertal at 2 mL each.3 s% N2 H) k) t% g4 q! k
The skin was moist and smooth and somewhat: Q4 r0 x" R* s4 w( Q
oily. No axillary hair was noted. There were no
  i9 x; |: Z/ T( |. n6 |abnormal skin pigmentations or café-au-lait spots.2 O% u! R8 X/ A: K0 `: X
Neurologic evaluation showed deep tendon reflex 2+9 x5 k( r% y$ m8 {0 z. p
bilateral and symmetrical. There was no suggestion# S4 x6 M9 H" u
of papilledema.
( T2 v' s- J( d! a, S8 f9 `5 FLaboratory Evaluation# h& i# ?, k. a6 W
The bone age was consistent with 28 months by$ d- G/ N$ ^% j$ J8 J% f
using the standard of Greulich and Pyle at a chrono-
5 U; a( p9 a& k* O. f  y( [5 c9 ~logic age of 16 months (advanced).5 Chromosomal
1 F6 h2 E( x: P1 f- xkaryotype was 46XY. The thyroid function test
/ ~: c# l+ x  e2 m* O. \0 tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 I* _' v0 w/ `3 b% O! A
lating hormone level was 1.3 µIU/mL (both normal).7 V* t1 u9 h7 }# `
The concentrations of serum electrolytes, blood
7 m/ j4 T" y; P# T: Z) ]' N5 q. Nurea nitrogen, creatinine, and calcium all were5 J% I3 K# s7 m+ D+ m: U
within normal range for his age. The concentration
3 }* J- v4 [6 s8 w6 I6 r, Q& qof serum 17-hydroxyprogesterone was 16 ng/dL6 i( x1 T5 p  Z3 {3 R  L
(normal, 3 to 90 ng/dL), androstenedione was 20! j9 r4 @1 R+ Y: {2 \4 j& n8 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. I; E1 ^0 x( P. s/ Q, S/ Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 i" d: j( ^1 v+ e8 jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
, G5 b5 m9 A$ O49ng/dL), 11-desoxycortisol (specific compound S)1 @, M+ G8 I% }& M1 S: d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 r" P: k$ J# p; ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, `# v( I1 g, q. s. _testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 p. R0 \3 }2 @6 \2 y- mand β-human chorionic gonadotropin was less than  Z" G/ @$ O+ R) N' F
5 mIU/mL (normal <5 mIU/mL). Serum follicular. J1 u4 S8 |, V9 v/ Q4 h
stimulating hormone and leuteinizing hormone! i" Q1 H/ [; j6 Y1 S
concentrations were less than 0.05 mIU/mL
+ B, u' l; a) F, [( G(prepubertal).
4 V0 t+ `9 O& u: N+ z1 `- ^The parents were notified about the laboratory
) X* Q4 b+ g) _, p9 q. x9 Wresults and were informed that all of the tests were
, K7 y. _$ u! {. Vnormal except the testosterone level was high. The0 q3 x; v5 i8 ~6 g4 p: Z) I  }
follow-up visit was arranged within a few weeks to! i. O) r4 O2 u! ~1 ^! p
obtain testicular and abdominal sonograms; how-. ~- K5 `! v8 Z" N# ~7 _
ever, the family did not return for 4 months.
3 l% b* _* z# Q) S" ^- z- PPhysical examination at this time revealed that the
# [: |. c1 U; L3 Gchild had grown 2.5 cm in 4 months and had gained6 I0 o) j/ M. M3 H. o: G
2 kg of weight. Physical examination remained/ I6 P2 Z- v1 h( i* z9 Q7 J
unchanged. Surprisingly, the pubic hair almost com-
8 C5 ?3 D% l. Ipletely disappeared except for a few vellous hairs at' x) _7 u" K$ J0 G" _
the base of the phallus. Testicular volume was still 2  |- c& \. {; }8 W
mL, and the size of the penis remained unchanged.
9 a9 P. B1 R9 LThe mother also said that the boy was no longer hav-
% ^; K$ N( Y+ J" t4 c. N& ]ing frequent erections.
* @, N0 Z5 N# q! X4 aBoth parents were again questioned about use of
1 ^& t; \) Y  q, Y) v/ Zany ointment/creams that they may have applied to8 B+ N: d) G3 H" M5 L; z$ V: Y5 a
the child’s skin. This time the father admitted the6 ]' l: f/ G! l5 }- e+ b5 Q/ R
Topical Testosterone Exposure / Bhowmick et al 541
/ P7 ?1 t/ u* Q7 quse of testosterone gel twice daily that he was apply-6 c5 E# ]  V' }
ing over his own shoulders, chest, and back area for2 |# k7 S, b! I9 T/ q$ z7 O! Y
a year. The father also revealed he was embarrassed
! {7 |# p6 d- l+ Mto disclose that he was using a testosterone gel pre-
4 E* E9 |! J% }9 y2 Oscribed by his family physician for decreased libido
) \+ F) [' v4 B6 p& Q8 f6 [secondary to depression.' L' {# ]$ {0 Z! w
The child slept in the same bed with parents.
: y% T4 P! `' ~+ I# u/ MThe father would hug the baby and hold him on his
/ I7 A0 Y5 {# W* Z& n! Tchest for a considerable period of time, causing sig-1 ]. `/ G7 c: T7 {% w9 ]
nificant bare skin contact between baby and father.
: _0 g, ^5 l1 [% m+ O9 D! wThe father also admitted that after the phone call,6 P3 f5 y0 N; v7 L$ R% e
when he learned the testosterone level in the baby
9 U) G+ e; n2 d. X8 nwas high, he then read the product information
. T, i- c6 _1 b3 x/ Lpacket and concluded that it was most likely the rea-
3 p& w* l# p# D, |son for the child’s virilization. At that time, they
: l* ?0 e) B) l& Q. H5 O$ kdecided to put the baby in a separate bed, and the' [- @% F9 _3 w* y7 d0 x' p) ]; w& N
father was not hugging him with bare skin and had* f& r3 c  ?# P) |0 q
been using protective clothing. A repeat testosterone6 d$ p. k1 n: \7 C8 x
test was ordered, but the family did not go to the6 B7 Q  \# R% w/ r- I* `2 B
laboratory to obtain the test.
* B' [- f" ]9 }- X/ ZDiscussion/ E! S( q$ Q, Y% Z; s* A. _) `3 z
Precocious puberty in boys is defined as secondary, ?8 s5 _$ d; |1 U
sexual development before 9 years of age.1,4: |. u# u. A& \% p# F$ _% L# a
Precocious puberty is termed as central (true) when* Y& e) ~, p4 m# c, x) x
it is caused by the premature activation of hypo-
1 c+ ?( Q) o& |3 ?; uthalamic pituitary gonadal axis. CPP is more com-
: B& K& {- u  y4 p( D* }/ Y# C; u8 f9 dmon in girls than in boys.1,3 Most boys with CPP
& m/ Y9 _' _& _# E' J2 |: zmay have a central nervous system lesion that is* L! O' V) O  t% [3 h6 J
responsible for the early activation of the hypothal-
  z, d; p3 Q+ m$ B6 E" X( B6 r+ oamic pituitary gonadal axis.1-3 Thus, greater empha-
8 X$ v! A! e  m3 W, x+ Wsis has been given to neuroradiologic imaging in! h* I8 Y5 E; F5 D
boys with precocious puberty. In addition to viril-
% h% [5 W$ g; T9 w1 K# c% pization, the clinical hallmark of CPP is the symmet-
, k8 s. w; F+ x0 n) |# trical testicular growth secondary to stimulation by7 g+ y$ x. j5 e4 X3 R- |& k
gonadotropins.1,39 c6 u! h0 A4 t  Z! D" u; a: p" T; s
Gonadotropin-independent peripheral preco-; n- T9 k5 {) W! y, m% h5 a" Q4 Y
cious puberty in boys also results from inappropriate
4 g) e/ {1 A: y* h" C1 q( P% G1 C/ \" _androgenic stimulation from either endogenous or
) P- c, K, a+ y# k. g) o6 D* d* kexogenous sources, nonpituitary gonadotropin stim-+ h% ~4 w+ U( v; U. s' S: Q7 U
ulation, and rare activating mutations.3 Virilizing
) p; t9 V# `+ G: t& L9 {5 B& Econgenital adrenal hyperplasia producing excessive
# m- G" M2 P+ L# wadrenal androgens is a common cause of precocious
& F+ V5 ?1 e7 n/ w& u4 @  i9 apuberty in boys.3,4
! Z, s; I/ J0 Y# A5 HThe most common form of congenital adrenal
9 K; Y8 H) ^' \! o1 [hyperplasia is the 21-hydroxylase enzyme deficiency.6 V6 U" q; B: t6 [" A4 Y
The 11-β hydroxylase deficiency may also result in
, ?' b0 x0 {$ T( k$ Fexcessive adrenal androgen production, and rarely,/ j1 k1 K4 l/ k9 ?4 G) d
an adrenal tumor may also cause adrenal androgen
$ q, B' i% P/ |# W- s$ Xexcess.1,36 Y3 r! j) ^: j7 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  u7 @4 b+ k$ |( Q9 ^: g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 i  q- G+ T  P5 j, zA unique entity of male-limited gonadotropin-: \1 w0 E, k6 i. V
independent precocious puberty, which is also known$ T9 g1 r/ M5 R
as testotoxicosis, may cause precocious puberty at a
1 i7 e' h+ u: Pvery young age. The physical findings in these boys
/ N6 H9 F& l* W% w2 J1 W2 t) wwith this disorder are full pubertal development,
0 p& ~- G5 L5 V" Q1 n, Kincluding bilateral testicular growth, similar to boys( R1 X; j; l" C) V- P
with CPP. The gonadotropin levels in this disorder" E. @0 U7 b! G& g% W
are suppressed to prepubertal levels and do not show# y0 z" S, S* m3 l5 T5 b
pubertal response of gonadotropin after gonadotropin-( I! I! k3 \* m' H% `4 A7 T
releasing hormone stimulation. This is a sex-linked
2 J- A9 u- ^9 o% u( o" {0 ]autosomal dominant disorder that affects only& Q2 D4 H* ?5 E# {
males; therefore, other male members of the family
* Q8 q1 h* }% F5 f6 F4 \may have similar precocious puberty.3# I8 O- b) }* Y/ ^. d# U
In our patient, physical examination was incon-
: u' u* x! {/ _+ o6 w- Ysistent with true precocious puberty since his testi-
- @  @3 D2 ]* U; Dcles were prepubertal in size. However, testotoxicosis7 E  Y7 ^5 [( Y1 z3 W
was in the differential diagnosis because his father) x' x9 K  N& O  a
started puberty somewhat early, and occasionally,/ `8 I0 r. W2 f* H! p4 @9 |/ |. c3 P
testicular enlargement is not that evident in the- T5 e+ s( o* l: q6 K+ w  V
beginning of this process.1 In the absence of a neg-5 V  ~  f4 x& j! p# ^2 j7 i
ative initial history of androgen exposure, our
5 S) V: q, @5 q2 p5 l* O; ?* ^" qbiggest concern was virilizing adrenal hyperplasia,
$ b4 n8 D! ?; E& }( ?- ^either 21-hydroxylase deficiency or 11-β hydroxylase9 a1 Y1 B1 ]4 M5 ]
deficiency. Those diagnoses were excluded by find-
. g# C. b8 b" Y! O8 _ing the normal level of adrenal steroids.4 E1 a  z" F- z. I4 t; o! T' L5 t
The diagnosis of exogenous androgens was strongly5 h$ B  p# u" k( `
suspected in a follow-up visit after 4 months because
* v! k1 b, g; M# f) L' ~! cthe physical examination revealed the complete disap-
: r; r0 v6 R( v& B% l: g+ Xpearance of pubic hair, normal growth velocity, and6 M" g& d3 `$ i9 D: g
decreased erections. The father admitted using a testos-
' Q$ u3 j; u: E# Dterone gel, which he concealed at first visit. He was
% ^  R) {8 V: D3 rusing it rather frequently, twice a day. The Physicians’
" p6 J9 K0 g7 sDesk Reference, or package insert of this product, gel or* y4 p# |) {8 ~8 y0 [+ r4 c8 a
cream, cautions about dermal testosterone transfer to
& _  @( S" d& c) v# Aunprotected females through direct skin exposure.
; p; U3 c6 d8 ]7 n- |0 }# z' ESerum testosterone level was found to be 2 times the* Y/ z# u, Y: r% D9 \" \
baseline value in those females who were exposed to6 Z1 X7 J& q  E  N* R5 ^
even 15 minutes of direct skin contact with their male8 K. W. I# m& u" s
partners.6 However, when a shirt covered the applica-# j: w" ^" d) g
tion site, this testosterone transfer was prevented.
4 p) n2 f6 W2 p. m- `3 HOur patient’s testosterone level was 60 ng/mL,
8 N# X6 U! f4 g, P$ swhich was clearly high. Some studies suggest that) g; u5 J' R( J. M3 m" X$ \
dermal conversion of testosterone to dihydrotestos-
& p2 |1 s! Q/ i9 k; Y9 ^terone, which is a more potent metabolite, is more
" F9 G3 u/ x) L  w7 {3 h! ]active in young children exposed to testosterone- D9 Z9 g% ^" i* h' e
exogenously7; however, we did not measure a dihy-
) V; g, @3 I) p( Ddrotestosterone level in our patient. In addition to
6 U% R* Y4 ^1 z8 T- s  U" |virilization, exposure to exogenous testosterone in
+ E4 d; _0 k, [. D* L' `children results in an increase in growth velocity and
- F9 T0 y/ ~8 H3 n! S2 \advanced bone age, as seen in our patient.
, u& T$ P( z* `4 M" e% X# k" UThe long-term effect of androgen exposure during. e( ]/ G& F, g5 ^4 P  Y1 A8 i
early childhood on pubertal development and final
+ c1 P3 Y. ?$ ?, ]+ u! v' Dadult height are not fully known and always remain
: V# z% b; k4 _1 w7 aa concern. Children treated with short-term testos-% u* H9 ^; C" V; r" c) [
terone injection or topical androgen may exhibit some. i9 S# z6 }$ U2 h
acceleration of the skeletal maturation; however, after( [0 b0 y, T$ d8 v( t2 ^
cessation of treatment, the rate of bone maturation
5 z" O$ ?% A6 V, ?  T) b( M' Wdecelerates and gradually returns to normal.8,9, g/ V" C3 G# D) a) S; \
There are conflicting reports and controversy  w/ T; v! w  ?8 x' e
over the effect of early androgen exposure on adult
2 e( a' |% J6 O- Z% }penile length.10,11 Some reports suggest subnormal
" F& R  K" b5 ?$ Y' H8 Dadult penile length, apparently because of downreg-! U4 d( X8 ^* }8 U
ulation of androgen receptor number.10,12 However,- x7 \% S2 K% ~5 M5 w' [  B) x
Sutherland et al13 did not find a correlation between1 b. V0 Q, P8 T5 D
childhood testosterone exposure and reduced adult$ ?) Y  k  T; f/ N
penile length in clinical studies.
2 |, y; T) @* Q- O& f. uNonetheless, we do not believe our patient is/ m* K3 d8 _% Z# H. `4 I' a
going to experience any of the untoward effects from0 h" ^5 b  B) t+ i; M" _
testosterone exposure as mentioned earlier because7 R7 |: }. E" J" c
the exposure was not for a prolonged period of time.  q2 E" Z3 p" s
Although the bone age was advanced at the time of) a+ M5 L, I" j& Q9 B  Z5 z
diagnosis, the child had a normal growth velocity at
/ E, s9 [$ k( N* Xthe follow-up visit. It is hoped that his final adult; g1 ^; V, _/ L6 U# W
height will not be affected.
& ]7 T6 Z9 t/ n2 |Although rarely reported, the widespread avail-
2 o6 w' B+ }" S4 zability of androgen products in our society may, p" t+ P2 e, N/ r' g4 Y7 k$ Q
indeed cause more virilization in male or female. i* W; R7 d! ^( j& g, b* y8 [
children than one would realize. Exposure to andro-7 X/ n0 _% _4 ?$ f* O
gen products must be considered and specific ques-6 x( E; X* Y6 h0 L/ h9 o
tioning about the use of a testosterone product or, S9 l, S' Z" |8 u8 I( H
gel should be asked of the family members during
1 k& |# D& I2 \4 F( N1 k' m0 {2 Athe evaluation of any children who present with vir-& S) X( J5 D) ^1 f; ]
ilization or peripheral precocious puberty. The diag-3 [, S0 L) B: I
nosis can be established by just a few tests and by  T3 s1 }' j1 L: r! k7 P- T: L8 k& h
appropriate history. The inability to obtain such a; o/ ^% {2 D. p$ N# g
history, or failure to ask the specific questions, may4 g9 L- u! l* C7 Z  a$ S
result in extensive, unnecessary, and expensive
! J+ i/ P5 v2 z) d7 l. N) }$ M2 oinvestigation. The primary care physician should be
  G7 F9 i3 S% v1 c- Baware of this fact, because most of these children" `6 ]" y7 I8 x
may initially present in their practice. The Physicians’3 Z) ^+ x0 Q- J5 }
Desk Reference and package insert should also put a/ ]( X  w" r! Q5 G1 ?/ U, T
warning about the virilizing effect on a male or: P% f8 h, z0 Z" Q; b
female child who might come in contact with some-  B9 ^* j- D; D4 a5 n5 W
one using any of these products.# g0 [) ?  ~5 L
References. i6 B4 N# H, j# ~3 d( q
1. Styne DM. The testes: disorder of sexual differentiation
6 V- s. j, b( t* T  f5 P; p2 j; |and puberty in the male. In: Sperling MA, ed. Pediatric9 p* B6 P* Z; ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 |, z/ D1 x; K1 @3 a$ R. _
2002: 565-628.8 I3 U6 ^- k/ i& c0 M  \! b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 P! _# y6 w; fpuberty 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

4 y! E& A. @* w2 v8 h8 X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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