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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
& @$ Y* w! @6 |# ~. {9 p/ RBoy Induced by Indirect Topical- B' j" ^1 U: i( k3 Z( ]9 o
Exposure to Testosterone/ S- V0 [! f9 _& d  v) v3 \) {9 U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! b- E" G" k  K( g6 ]) wand Kenneth R. Rettig, MD1
0 G& Y4 e- `5 V3 ]Clinical Pediatrics5 H  E1 S( Z) C6 ], G
Volume 46 Number 6
0 B* v  V9 i, J) P6 W+ S8 H6 UJuly 2007 540-543
, w, R1 W. d# Y; t+ q- R© 2007 Sage Publications- R% H! Z6 Y. [5 }- T( u2 \
10.1177/0009922806296651
2 C- U( s; R! e8 q$ d# [3 t$ Khttp://clp.sagepub.com" c/ T& v. o7 g! E" g' t( C
hosted at4 f3 `/ n3 {& k4 u( P$ @' ?
http://online.sagepub.com
1 ]" ]* h: p1 Z3 r4 k/ HPrecocious puberty in boys, central or peripheral,
& B/ G" C2 r  H8 u7 C. D, u& lis a significant concern for physicians. Central
! U3 e0 z% G/ z$ ?precocious puberty (CPP), which is mediated6 g8 z  ^: {, A% o) T
through the hypothalamic pituitary gonadal axis, has8 o2 t% }+ s# P% F7 j9 q
a higher incidence of organic central nervous system
  M4 d! ]0 `* P$ k) M1 D! Plesions in boys.1,2 Virilization in boys, as manifested
5 d& F, L3 T7 c  g# Oby enlargement of the penis, development of pubic
6 M" l: {4 O. Jhair, and facial acne without enlargement of testi-
. I) t: ~: Y9 ?cles, suggests peripheral or pseudopuberty.1-3 We
, K  t8 V" W0 ureport a 16-month-old boy who presented with the  W9 _2 r8 E  K: I+ H
enlargement of the phallus and pubic hair develop-
4 m" \; e, ^- q! P9 wment without testicular enlargement, which was due
- u$ l/ Z6 s% u% ]to the unintentional exposure to androgen gel used by6 t" a1 L+ L3 T5 f! O. s) @
the father. The family initially concealed this infor-
, L' g3 m# e: Q9 i* _. Nmation, resulting in an extensive work-up for this
! w( u! Q! q! nchild. Given the widespread and easy availability of+ t4 P0 ~9 m6 F. n( G
testosterone gel and cream, we believe this is proba-
. i5 h. }7 q/ m" _, Q5 ]" zbly more common than the rare case report in the
  c/ j4 ]& P5 E6 ?: Kliterature.41 D& X' Q- I0 {7 r5 }
Patient Report
& e' N( r' M, }' [' M+ e  \  IA 16-month-old white child was referred to the
* C; R/ G6 Y/ r9 Q' Y( bendocrine clinic by his pediatrician with the concern
* z1 [$ J; N+ z! Y) dof early sexual development. His mother noticed4 U( m* y4 F+ A2 N; ?
light colored pubic hair development when he was! n" O" |# g2 }% O: j0 z
From the 1Division of Pediatric Endocrinology, 2University of& w6 g( \& u, t! ~
South Alabama Medical Center, Mobile, Alabama.
  p6 O! A0 E# J( K# D/ c7 L6 \, YAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 j$ E% X. `+ X% r7 P+ b! `5 SProfessor of Pediatrics, University of South Alabama, College of
3 x- l% B! U$ W* P: eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) f: g: c- U/ x9 {9 Q2 ee-mail: [email protected].2 u; K1 B1 \' K/ r
about 6 to 7 months old, which progressively became
! T9 p/ j" ?  H8 F4 F7 udarker. She was also concerned about the enlarge-) D4 u) v- w+ L, E) K0 z
ment of his penis and frequent erections. The child
4 c+ f( ~. Y" [7 C; I# L$ ?4 ]' T1 nwas the product of a full-term normal delivery, with
2 F2 v  t& R6 q! [- k: i) ua birth weight of 7 lb 14 oz, and birth length of
. M# s$ C! X" z2 U5 G  ?20 inches. He was breast-fed throughout the first year
# Q$ i5 F0 I5 W# rof life and was still receiving breast milk along with
& Y4 i& W5 Y  |! fsolid food. He had no hospitalizations or surgery,
- }6 H3 K: C4 H& D, }2 Nand his psychosocial and psychomotor development
% W' _/ Y' x' r5 H4 C) r' Xwas age appropriate.$ ?" m$ r% F" q' d7 h: ~! j9 v9 ~
The family history was remarkable for the father,! k) t' f$ J/ z& f  D
who was diagnosed with hypothyroidism at age 16,8 b+ P! _2 W* P, o; P
which was treated with thyroxine. The father’s' E3 ^4 C; v/ Y, }/ G
height was 6 feet, and he went through a somewhat
7 P9 E8 U; o" j% F- ^$ Zearly puberty and had stopped growing by age 14.. j; e  g3 l- i1 M/ T) m
The father denied taking any other medication. The0 n2 [5 a" B8 U1 k; r
child’s mother was in good health. Her menarche; s0 J. |; c& F- f5 N+ ~- B2 ?; c
was at 11 years of age, and her height was at 5 feet
$ O, z5 E2 V7 \: j5 inches. There was no other family history of pre-
8 C/ Z- ?8 p% O' n' ~cocious sexual development in the first-degree rela-$ {7 d+ n/ e, w7 H
tives. There were no siblings.
4 e% v" m* R+ _Physical Examination
( y$ r) u) y; r+ lThe physical examination revealed a very active,/ r( X2 Z3 ~8 K. g9 |  [
playful, and healthy boy. The vital signs documented
8 S: Y5 p- J' b. g; w) `- {a blood pressure of 85/50 mm Hg, his length was
! {: O, q9 k) [9 r8 I90 cm (>97th percentile), and his weight was 14.4 kg
" H4 b. L: s3 H) I8 D' E(also >97th percentile). The observed yearly growth
: ?  S3 ]5 h! }* Tvelocity was 30 cm (12 inches). The examination of
5 q9 k: m  U; Ythe neck revealed no thyroid enlargement.% L* V' ]: S5 o2 i
The genitourinary examination was remarkable for
9 t/ v% `  P, y7 c- b% ^enlargement of the penis, with a stretched length of2 p6 @4 y* B& }0 |
8 cm and a width of 2 cm. The glans penis was very well
1 R& \( z5 i( Z( ddeveloped. The pubic hair was Tanner II, mostly around4 Z, ~% a% J& Z0 I
540  a7 K3 s8 c8 I* t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ U8 M+ P5 b; R7 H7 ~
the base of the phallus and was dark and curled. The7 l0 R: D: D/ Z
testicular volume was prepubertal at 2 mL each.+ l% X1 v4 \% _* T% ^0 C! [0 ]
The skin was moist and smooth and somewhat8 T, y, J! X2 g; a
oily. No axillary hair was noted. There were no5 M5 v! a7 y) o; u
abnormal skin pigmentations or café-au-lait spots.+ B, n) ~  ]5 z  h
Neurologic evaluation showed deep tendon reflex 2+
, L% U0 y6 [" N/ K6 nbilateral and symmetrical. There was no suggestion
/ m4 }# G: w3 y( A3 d' D9 iof papilledema.
: m: x$ B& X! S" A( k1 {) gLaboratory Evaluation
9 B9 d2 k, s3 F- O  ]8 v$ F. pThe bone age was consistent with 28 months by
  [5 H! x/ T' U% Jusing the standard of Greulich and Pyle at a chrono-9 \9 }7 e9 n5 _* S9 x+ q' M# h# E; h
logic age of 16 months (advanced).5 Chromosomal
- C, S5 u& g' V% K: D/ p; m# h2 xkaryotype was 46XY. The thyroid function test+ J6 V0 {' x5 K7 {  b7 }7 F- x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ d8 t9 @+ O3 Q0 L
lating hormone level was 1.3 µIU/mL (both normal).
- I0 t! C" }( w+ K$ T. [- O, EThe concentrations of serum electrolytes, blood
6 H9 L6 Z! v: b1 ~- eurea nitrogen, creatinine, and calcium all were
6 Q; d0 E6 Y9 h6 V* N; I% Rwithin normal range for his age. The concentration( E; }) I/ n' H
of serum 17-hydroxyprogesterone was 16 ng/dL9 ~" @' b1 Y: Q' L
(normal, 3 to 90 ng/dL), androstenedione was 20
7 U  `1 p$ [; [( v- hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& p+ R2 W! B2 i- Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 f5 h% _' F5 I- q5 K1 [* ?0 Fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to  S+ Y# g" D! H- R  w& V
49ng/dL), 11-desoxycortisol (specific compound S)
/ ?, {. k3 ~' F3 p" v" s4 q( gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! }3 G8 S1 g; \  s* y$ Etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ Z& B. p: y0 N/ D, S8 ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 c0 q! v" X! P! A8 j5 \
and β-human chorionic gonadotropin was less than6 s- V9 k& h$ J7 i4 k# c$ O
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# {! L. |$ P, ustimulating hormone and leuteinizing hormone0 S; Q+ X0 I! M4 h: y
concentrations were less than 0.05 mIU/mL9 ?- N# x* M/ J1 N8 u& r! s# a
(prepubertal).$ [) r1 f9 v) t, ^  j3 s
The parents were notified about the laboratory
. U* u/ K. X2 B2 e& Xresults and were informed that all of the tests were2 H' \# W7 r1 a+ {9 _
normal except the testosterone level was high. The+ D( S5 k/ d. x7 |
follow-up visit was arranged within a few weeks to' G# Q( {$ h- p3 W* k8 a  B' Z7 n
obtain testicular and abdominal sonograms; how-
: h5 m% E/ h; ?8 V. T. sever, the family did not return for 4 months.
, I3 z5 \6 Z/ K- xPhysical examination at this time revealed that the
% ^8 F! P/ e. B) Hchild had grown 2.5 cm in 4 months and had gained
2 g$ I9 \$ p$ o4 D5 h. r, W9 D2 kg of weight. Physical examination remained
- t9 \( }+ O+ p5 Q. {% i. Hunchanged. Surprisingly, the pubic hair almost com-
* T3 N: n7 [4 t* u& S! _5 H1 Vpletely disappeared except for a few vellous hairs at& E1 o1 d$ G+ W/ J3 O
the base of the phallus. Testicular volume was still 2
  ]- D1 F& W8 c4 r* t3 rmL, and the size of the penis remained unchanged.
- e6 ^8 E4 J9 z& W; TThe mother also said that the boy was no longer hav-
2 q; n& z$ u+ H8 p" K! j$ A4 D# V, oing frequent erections.5 R: D% z' F8 ~7 r/ A$ o
Both parents were again questioned about use of
' P, L! v6 B+ [8 k* p! Dany ointment/creams that they may have applied to
' y, l6 Z/ n9 `* `( \the child’s skin. This time the father admitted the
# A# ^' r" C% d1 Q3 e, c2 ATopical Testosterone Exposure / Bhowmick et al 541
7 Q% Y8 w# q+ O- |& [1 r  muse of testosterone gel twice daily that he was apply-+ z# Y6 F7 B- R8 P6 \9 b$ R
ing over his own shoulders, chest, and back area for# @6 V1 `4 T3 ^( z) J
a year. The father also revealed he was embarrassed
! O0 I$ R! d6 @8 ?: ?" Nto disclose that he was using a testosterone gel pre-" Z2 O2 u7 g* `) h, z
scribed by his family physician for decreased libido9 P# I3 R2 G: p
secondary to depression.
4 i0 f# O: U2 E5 f; `: HThe child slept in the same bed with parents.
- h& c! t, B9 L7 R% z* @The father would hug the baby and hold him on his5 J' [  G( y# n+ L! J- O& {
chest for a considerable period of time, causing sig-. r% A. h8 P6 W1 r. a- B, L) d. x8 V
nificant bare skin contact between baby and father.
1 |2 f# u/ g9 ~The father also admitted that after the phone call,
1 e- r1 E# }, m& owhen he learned the testosterone level in the baby3 S6 h3 ~, r; G" p
was high, he then read the product information$ q1 Y% \8 ?! z7 Z3 a1 Q% k( R
packet and concluded that it was most likely the rea-
& _8 V0 H$ B6 h' d. T) B& Pson for the child’s virilization. At that time, they4 v6 y4 z9 _6 Z7 S) Y8 }' Z
decided to put the baby in a separate bed, and the0 \$ \" ~! ?  C# e& q
father was not hugging him with bare skin and had
5 E# E9 I2 F4 Z5 w5 i! D7 e3 qbeen using protective clothing. A repeat testosterone6 F' ]4 w- y1 Y# n9 t  A7 V
test was ordered, but the family did not go to the
# {* I6 [& J! Z; u2 z& g" M* x, ?laboratory to obtain the test.
6 M. H# T6 a' VDiscussion
6 ?; P+ x8 u5 ?' Y# V) M$ ^Precocious puberty in boys is defined as secondary0 y) A( B6 d. f+ e4 n
sexual development before 9 years of age.1,4
# ]% a5 Q1 c9 U  A& W3 S! ~Precocious puberty is termed as central (true) when  C6 f1 i7 X& _8 q+ q6 S
it is caused by the premature activation of hypo-
- g) M' Q! C; L  x, ythalamic pituitary gonadal axis. CPP is more com-. R1 p, Z+ p% T- e5 I" |
mon in girls than in boys.1,3 Most boys with CPP; r+ J0 ^: _9 o2 A
may have a central nervous system lesion that is
) ]8 F/ D0 z6 i- q( }& @- [5 Lresponsible for the early activation of the hypothal-
1 G1 f2 B" A0 L4 S. D- p5 u4 V+ Camic pituitary gonadal axis.1-3 Thus, greater empha-
1 F  W( r% O- p: d5 lsis has been given to neuroradiologic imaging in+ _. H. o. j8 n$ f, h, U8 B
boys with precocious puberty. In addition to viril-& `- i+ w3 H- Y
ization, the clinical hallmark of CPP is the symmet-
9 i! s0 X( V7 \6 h5 rrical testicular growth secondary to stimulation by  ?; h+ f* c0 Y, A, i! b
gonadotropins.1,3
' Y# @9 J& _  u1 a7 p# G+ m$ }Gonadotropin-independent peripheral preco-
# {: W% |) u# fcious puberty in boys also results from inappropriate
0 @4 v0 p2 G9 V5 r8 a- Jandrogenic stimulation from either endogenous or- A, ~' k% U& P
exogenous sources, nonpituitary gonadotropin stim-3 ^/ X) ?4 [' t8 s, V6 o4 y
ulation, and rare activating mutations.3 Virilizing
, ?4 Y: N6 [4 d' E  u1 Q* y, Xcongenital adrenal hyperplasia producing excessive. W/ Y6 Q, t" g1 [' S0 u/ L
adrenal androgens is a common cause of precocious
* u/ P4 B+ i" y; k* {puberty in boys.3,4
6 R4 o! I9 F+ o/ JThe most common form of congenital adrenal2 T) L  a5 d- j% u$ ^- T2 P" u; ]
hyperplasia is the 21-hydroxylase enzyme deficiency.
% s+ F9 S) y: Y) ^) g: H" u" U, sThe 11-β hydroxylase deficiency may also result in' ~0 h, G, Y3 O/ a- l
excessive adrenal androgen production, and rarely,
' |' J* S2 h! O8 g9 yan adrenal tumor may also cause adrenal androgen
4 R- p2 C2 r4 ]9 `- _* \excess.1,3
9 {1 U& U9 W2 b3 ~1 ]& @& Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 }+ ~) w3 O, |$ w- r# U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' A5 m5 E/ ^- ^A unique entity of male-limited gonadotropin-& F) q! r+ W7 y3 n8 J
independent precocious puberty, which is also known1 N) v" p" s7 b
as testotoxicosis, may cause precocious puberty at a
* M$ C8 `" l6 ~5 x" Cvery young age. The physical findings in these boys
; L6 Z0 _) L# T  [9 g# Qwith this disorder are full pubertal development,4 c! q& b) g  ~, M0 ^
including bilateral testicular growth, similar to boys
4 ]7 k- u6 ]0 y+ Xwith CPP. The gonadotropin levels in this disorder
7 b( r$ Z0 M/ r; B6 V9 Rare suppressed to prepubertal levels and do not show* I% [0 a6 Y0 Y* v7 a3 E: I
pubertal response of gonadotropin after gonadotropin-
* L% g: e  e4 Ereleasing hormone stimulation. This is a sex-linked
6 M0 Y- I7 @/ Qautosomal dominant disorder that affects only! |) o2 Z; Q, d
males; therefore, other male members of the family: z( \! C6 e$ Y0 A  L; ?/ o
may have similar precocious puberty.3; O- Y4 m+ A0 ^/ Q
In our patient, physical examination was incon-1 Q: Y: D& R1 t1 l# D
sistent with true precocious puberty since his testi-
) d8 y" B/ ]4 p5 [- s/ A7 b: a& j0 xcles were prepubertal in size. However, testotoxicosis
# N% D) A/ f- `was in the differential diagnosis because his father7 H1 q, Q8 j+ v7 R' h
started puberty somewhat early, and occasionally,
7 D* a( k2 l6 R% e; `. i5 ^testicular enlargement is not that evident in the
9 S' @, E$ b1 \beginning of this process.1 In the absence of a neg-9 j9 E5 t" h* E" y3 M7 Q5 s9 Q- J7 m
ative initial history of androgen exposure, our2 w0 p  p. `5 }5 z+ G% z
biggest concern was virilizing adrenal hyperplasia,
" M! d4 U- e# Veither 21-hydroxylase deficiency or 11-β hydroxylase
( {5 D0 ?) f& A- I( k$ V2 u% ]- Ndeficiency. Those diagnoses were excluded by find-
) T  Z& v3 R$ R$ T$ Ging the normal level of adrenal steroids.
9 D5 P( {, |, f; ^( WThe diagnosis of exogenous androgens was strongly" H* a) ^7 o' b! W# z+ b5 v
suspected in a follow-up visit after 4 months because
* x- p1 x1 @# i1 o5 k) g6 Sthe physical examination revealed the complete disap-
  D0 j: V- ?! v+ ~pearance of pubic hair, normal growth velocity, and3 z2 Y, Q2 ^; I. J- j! Y
decreased erections. The father admitted using a testos-
; |$ b) X7 b( L6 ~% Iterone gel, which he concealed at first visit. He was: ?% t9 X  C0 v* h  n$ R/ R% `
using it rather frequently, twice a day. The Physicians’0 i/ J! z; w9 Q& Y, I/ E3 P
Desk Reference, or package insert of this product, gel or# W  G0 M3 K  Q& a( @# t% D- N/ S7 a
cream, cautions about dermal testosterone transfer to
! t  A2 Q0 p! j! }& p7 ^+ r$ Lunprotected females through direct skin exposure.$ S) @4 E8 i# j
Serum testosterone level was found to be 2 times the
4 R3 \6 v# M; ~baseline value in those females who were exposed to0 _' `5 M  l5 Z9 I
even 15 minutes of direct skin contact with their male; s7 s9 V9 C' u( ^
partners.6 However, when a shirt covered the applica-. N2 U7 K; M1 U9 G# J9 N& h
tion site, this testosterone transfer was prevented.
/ \1 S5 C& P8 h, ^* W# B0 I1 ROur patient’s testosterone level was 60 ng/mL,
( h) D  c. p: y* w  Nwhich was clearly high. Some studies suggest that+ G: P+ b5 \+ Z) q( T, T
dermal conversion of testosterone to dihydrotestos-
% ^% L1 \, f' S2 a7 {2 iterone, which is a more potent metabolite, is more* B: w# E" Y  e4 r0 z1 }# M" n
active in young children exposed to testosterone
" {7 P" j2 C2 E5 |2 Y/ _( jexogenously7; however, we did not measure a dihy-, K& X$ ^' V: Z) ~2 {( |
drotestosterone level in our patient. In addition to
) [( H$ q, O" a, ^$ J; s9 Kvirilization, exposure to exogenous testosterone in/ c' L" ^1 B* G8 Z+ w! m
children results in an increase in growth velocity and. {# G; c. m/ R, X- y! I* c% [
advanced bone age, as seen in our patient." {" X1 T4 i( b7 o
The long-term effect of androgen exposure during
8 n/ i$ q# {: B! Iearly childhood on pubertal development and final0 E0 h. a1 d8 h: i1 |+ ~6 H- B9 }1 I$ q
adult height are not fully known and always remain
7 y& A% w8 q5 y# r% k9 ka concern. Children treated with short-term testos-
. N; H' Z" i/ B& dterone injection or topical androgen may exhibit some
1 \: }5 y" T! w  f  X+ |acceleration of the skeletal maturation; however, after( }4 D! |' u! `4 ]) N& L
cessation of treatment, the rate of bone maturation
3 s; A; P: r% n" x4 ?. s  r1 ]6 x" ndecelerates and gradually returns to normal.8,9
2 ~5 U2 U1 T8 o& K7 \There are conflicting reports and controversy
4 Z$ ]) D0 \. K7 h5 I- ]over the effect of early androgen exposure on adult1 H8 _" p- v: O+ @* N" F
penile length.10,11 Some reports suggest subnormal
7 }1 s8 |2 }- e$ r( r, f3 Sadult penile length, apparently because of downreg-3 n7 f6 T5 R  |+ B
ulation of androgen receptor number.10,12 However,
1 `& ?+ g4 J+ A$ R( P( c& Z# lSutherland et al13 did not find a correlation between
) L0 R6 l/ X& dchildhood testosterone exposure and reduced adult7 S$ ?2 w- f/ [! F. \5 i
penile length in clinical studies.
/ b0 R5 G' Y: v5 i( LNonetheless, we do not believe our patient is
) J% r6 p6 U9 r) W! W+ ]# ]going to experience any of the untoward effects from% p* }5 d& k9 u7 m
testosterone exposure as mentioned earlier because% l& ~$ E4 Y, F5 q
the exposure was not for a prolonged period of time.
: n' ^) M7 ]$ d; C3 |5 ?Although the bone age was advanced at the time of7 t& v$ V! @$ ?  ]4 u) ]4 q8 C
diagnosis, the child had a normal growth velocity at
; n& x2 k/ _9 f+ Jthe follow-up visit. It is hoped that his final adult
. G  F& t6 _9 g. c' N7 hheight will not be affected.8 I% ?8 u6 |; S" l
Although rarely reported, the widespread avail-& z* s9 `& V2 i: b
ability of androgen products in our society may- v- }* g, H1 Y3 t$ z! g) ^8 i# l
indeed cause more virilization in male or female
1 x0 ~) G9 A8 m! C4 F+ bchildren than one would realize. Exposure to andro-. r5 Z0 [5 G: u) v! {
gen products must be considered and specific ques-. _0 b5 C6 Y) v3 q& E8 H* E* g" U
tioning about the use of a testosterone product or
1 B6 T+ x8 y0 {1 K+ Pgel should be asked of the family members during
) k+ ^- Y+ @: d* w" }+ V' M8 U$ Cthe evaluation of any children who present with vir-9 A+ _6 U3 F, w8 A
ilization or peripheral precocious puberty. The diag-2 z. j7 \7 D3 d3 \: v
nosis can be established by just a few tests and by* h# F' G) K/ k  o$ w* D5 n- J
appropriate history. The inability to obtain such a
4 s& p* Q$ k5 N! e% d1 v, G# G/ _history, or failure to ask the specific questions, may; J9 l8 S5 Z) y
result in extensive, unnecessary, and expensive. a: n. t9 g& v5 r- T% L
investigation. The primary care physician should be7 S% z) K; I0 p6 h9 J
aware of this fact, because most of these children6 }  E* e4 }/ Z# C
may initially present in their practice. The Physicians’
! f- C$ O; T) i& [5 n$ SDesk Reference and package insert should also put a
! S' ]9 z) u9 @warning about the virilizing effect on a male or* L$ j# s" f8 ?4 ]( E
female child who might come in contact with some-. E% V+ g& b# D( X5 d
one using any of these products.
* J  @! Z' V5 S4 k9 [- t! PReferences1 H& X" y( D- W/ p- J
1. Styne DM. The testes: disorder of sexual differentiation
- Y, w, p% j% rand puberty in the male. In: Sperling MA, ed. Pediatric+ j/ t+ G5 a7 g6 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ G0 U* e1 m# E/ H; C2002: 565-628.
- r* E: D4 y* }$ r* n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. ~! X: S2 d' z% L
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old9 Y) A3 C9 l( ^; l
Boy Induced by Indirect Topical
5 Q: O, |& }7 U: nExposure to Testosterone
+ i+ T: W9 G5 T7 @: F1 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( Q- X: l; J* w" j$ c( g5 q6 Zand Kenneth R. Rettig, MD17 K2 p9 @6 X  @- Z1 f  k; Q! j* [2 T
Clinical Pediatrics
( C0 q8 {3 ~, V' ^! TVolume 46 Number 6' C" E' N( }2 s5 h
July 2007 540-5432 D% l, v4 f! P$ q& @% Y' {6 F
© 2007 Sage Publications4 J- |. I3 v6 X: G
10.1177/00099228062966513 \# H$ ^; u0 j; t
http://clp.sagepub.com
+ Y' g/ G3 F$ y6 i8 h/ L( E0 dhosted at0 b9 A4 J" ]! S$ @+ e1 w! d
http://online.sagepub.com
3 l% Y. L4 e( d$ h% [; @# ?Precocious puberty in boys, central or peripheral,
1 s* I; o) x1 Wis a significant concern for physicians. Central0 E' H* y9 P: Y7 J' _3 P
precocious puberty (CPP), which is mediated2 |# ?% T/ I3 G6 _
through the hypothalamic pituitary gonadal axis, has9 }# G! T* x0 C# Q
a higher incidence of organic central nervous system
  W: P' u1 A/ m0 L& X8 zlesions in boys.1,2 Virilization in boys, as manifested3 z3 i. d# J) y3 f5 w. N& d7 L6 R, B
by enlargement of the penis, development of pubic
1 u1 [1 p9 Q0 W. ~hair, and facial acne without enlargement of testi-- G- m# c9 W! t7 `/ i
cles, suggests peripheral or pseudopuberty.1-3 We
  y- a4 _, X( @: h# @7 g, a, sreport a 16-month-old boy who presented with the
" N- E! q& v1 Q: O9 Q$ V% _  Z, _* zenlargement of the phallus and pubic hair develop-
% L3 \* i4 V# t0 @ment without testicular enlargement, which was due
3 `) ]/ _' H" _( \% V) n" A5 _& E% M4 eto the unintentional exposure to androgen gel used by& Q0 T8 B# W' p
the father. The family initially concealed this infor-9 ~6 W1 X* K! l; @& [1 J9 Q
mation, resulting in an extensive work-up for this0 N. p* U; \8 J& n$ o
child. Given the widespread and easy availability of2 ^) D# ^4 Y& a
testosterone gel and cream, we believe this is proba-  [) L# u! B. _0 H8 \, [
bly more common than the rare case report in the6 _) \- E" _9 v' l- m& x
literature.4) v$ f( L1 S4 ?+ M
Patient Report
! J: R5 V; p3 o  Y1 ~A 16-month-old white child was referred to the+ A( r1 H) F- R1 {
endocrine clinic by his pediatrician with the concern! K) ]# n( q. B2 m* j; ~
of early sexual development. His mother noticed# _  @# L! _, M5 R1 ~: O4 E
light colored pubic hair development when he was
/ y% d2 i0 c: S- v& \From the 1Division of Pediatric Endocrinology, 2University of  h; Q. d; X1 ^+ \1 ?+ W
South Alabama Medical Center, Mobile, Alabama.
" _; ^6 U% ]1 m$ a6 v# ?: GAddress correspondence to: Samar K. Bhowmick, MD, FACE,
3 @( ^; ]5 j6 HProfessor of Pediatrics, University of South Alabama, College of+ |0 @+ c4 H1 c
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! h7 y6 u( M+ h" t/ Ae-mail: [email protected].
$ _; G# z6 ?. aabout 6 to 7 months old, which progressively became1 [8 D& S* M' i% O$ \4 G4 n
darker. She was also concerned about the enlarge-
( F0 h$ U0 D* e% b3 V$ e, lment of his penis and frequent erections. The child8 P/ e) N' B2 ]' L2 k" {
was the product of a full-term normal delivery, with
+ i6 W) a* l4 _- u& }7 V5 J& _/ Ua birth weight of 7 lb 14 oz, and birth length of
5 l, Z9 C/ V" B8 o20 inches. He was breast-fed throughout the first year. d; e  K0 k3 {. L
of life and was still receiving breast milk along with* R- t- x3 d8 {5 |% a1 j
solid food. He had no hospitalizations or surgery,
; X5 T" T+ T6 T+ fand his psychosocial and psychomotor development
) h+ C& G% X( d/ Fwas age appropriate.2 ]% o$ @6 D" x- b0 V
The family history was remarkable for the father," w7 b# j2 R( p
who was diagnosed with hypothyroidism at age 16,' ~" G& A$ G& I( W8 p% `
which was treated with thyroxine. The father’s
) z  Z- U& d8 B! W  oheight was 6 feet, and he went through a somewhat
: k/ X! C8 T  _2 `! P! T- @3 h7 p' vearly puberty and had stopped growing by age 14.
, Y8 X. z! k. X% z9 n1 ZThe father denied taking any other medication. The6 g0 ~3 s8 W+ i/ [; B
child’s mother was in good health. Her menarche
1 G+ M# q. h4 l1 e# kwas at 11 years of age, and her height was at 5 feet
# [, Q6 E) u& p( \5 inches. There was no other family history of pre-
! V0 B$ _/ Y/ W- \* ]) Xcocious sexual development in the first-degree rela-
9 G3 Z0 ^' B" V2 ~tives. There were no siblings.$ A5 ^) `" a* ~
Physical Examination9 Z+ B5 [  G! P% ]! S7 n
The physical examination revealed a very active,
, {2 x2 i9 Y& O4 A  Lplayful, and healthy boy. The vital signs documented8 T% a  k$ W7 y1 y& a
a blood pressure of 85/50 mm Hg, his length was' p& H5 k: C2 k
90 cm (>97th percentile), and his weight was 14.4 kg* W) o+ a7 B* ^8 i
(also >97th percentile). The observed yearly growth, ^& R! y+ N% b: F
velocity was 30 cm (12 inches). The examination of& I# K, x" t- }# L3 ^
the neck revealed no thyroid enlargement.
) U9 U( u' e4 X5 w0 mThe genitourinary examination was remarkable for/ l5 |' Q. {- M1 `1 w1 j4 e
enlargement of the penis, with a stretched length of
$ z7 C* y2 ^5 o/ `2 [1 `! G8 cm and a width of 2 cm. The glans penis was very well; d1 H7 l- n# S: i( l
developed. The pubic hair was Tanner II, mostly around" `( u) @' D" I$ ?
540
4 s9 p$ r. X2 ?7 M  ]5 C+ o- Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 y+ g5 z. x) L/ O' cthe base of the phallus and was dark and curled. The
, L) z$ y9 _  t9 _4 O9 R6 U, X& Wtesticular volume was prepubertal at 2 mL each." E8 X' X2 c- \
The skin was moist and smooth and somewhat
# y# K6 Y+ F% n3 Qoily. No axillary hair was noted. There were no
5 I& K3 w& Q' |" U; H+ Labnormal skin pigmentations or café-au-lait spots.
! E& L: [$ m, I* y# KNeurologic evaluation showed deep tendon reflex 2+
3 k2 a. r  {# [; [  v6 L( dbilateral and symmetrical. There was no suggestion
1 T& z0 z4 ]# F  t, b- [7 nof papilledema.( o) c% P: e) f: Q6 @
Laboratory Evaluation
8 L0 _, A) X# S6 YThe bone age was consistent with 28 months by
5 P( `' ]' e4 f2 Fusing the standard of Greulich and Pyle at a chrono-' H6 p/ l. P+ d* w8 z7 w
logic age of 16 months (advanced).5 Chromosomal
1 r6 D( a9 t% D/ K/ w: Zkaryotype was 46XY. The thyroid function test- l) o" L. V9 d5 g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: ^. R6 ]! d8 E% s# f, tlating hormone level was 1.3 µIU/mL (both normal).
4 j$ q2 c' ~9 ]& m! |0 }( g. j4 ^The concentrations of serum electrolytes, blood
- G8 `) u! b/ j* n7 jurea nitrogen, creatinine, and calcium all were
3 ~$ s$ s' x0 s. {7 {  ~4 E& Lwithin normal range for his age. The concentration
: A/ e9 {5 P+ _# r! M4 x( v" rof serum 17-hydroxyprogesterone was 16 ng/dL
3 i/ I8 m8 U/ [(normal, 3 to 90 ng/dL), androstenedione was 20
+ H5 N% V: }" [/ o: O1 png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* m2 u" E5 t7 G: K  }. o5 Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 \; J! H- N0 \; b! N4 _0 H/ Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; g; ^# M$ r2 _
49ng/dL), 11-desoxycortisol (specific compound S)% ~9 W# J1 K4 ]* c: e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, ]5 Q+ j6 J' Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 l+ O+ e0 R6 S0 e3 \& |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 h% B1 w- }. W; l. K- vand β-human chorionic gonadotropin was less than
: G4 Y6 c. ^( u2 m# v5 mIU/mL (normal <5 mIU/mL). Serum follicular) n7 w+ c( M1 r! d0 v! Z2 I
stimulating hormone and leuteinizing hormone& K& @' t. B0 T. L/ X8 [
concentrations were less than 0.05 mIU/mL& z. L' L+ W1 d& k0 ?- U
(prepubertal).
7 V) }. V/ u1 o  k/ LThe parents were notified about the laboratory
# @0 m3 l1 W$ @$ z. R. Gresults and were informed that all of the tests were  O+ A# }0 l+ c+ w% n9 V8 K- W+ G
normal except the testosterone level was high. The( a. j8 |; V3 {
follow-up visit was arranged within a few weeks to0 E$ J4 T  z4 p5 f: _; r
obtain testicular and abdominal sonograms; how-
8 p) v3 E' ^- k% E* I/ U3 never, the family did not return for 4 months.! a5 ^$ i: X9 ]+ h" G4 G# a
Physical examination at this time revealed that the6 z* P+ }! h  L
child had grown 2.5 cm in 4 months and had gained, l* w& t2 m3 Q" e) y6 w
2 kg of weight. Physical examination remained" T4 t2 Z6 P& D+ t; N% f
unchanged. Surprisingly, the pubic hair almost com-
  N7 f5 j; K8 D! t* N& H) R5 K8 ipletely disappeared except for a few vellous hairs at3 c) D7 h1 B! |
the base of the phallus. Testicular volume was still 2
: x, V( U1 [5 e3 t) GmL, and the size of the penis remained unchanged.
! l  \( b% p) z( b7 e, j7 Y) _! lThe mother also said that the boy was no longer hav-4 j) X3 `# ]# ^, R" t' `- w7 f( r
ing frequent erections.
9 k( j# Z/ i7 F4 HBoth parents were again questioned about use of6 m- P- B/ ]; [4 g3 y6 m4 P: f
any ointment/creams that they may have applied to
, U& V, n4 h  x( u/ F6 \the child’s skin. This time the father admitted the/ a0 B6 n/ k# K% M" U
Topical Testosterone Exposure / Bhowmick et al 541- E0 D  V# F& ^- ?. t( g* V8 f
use of testosterone gel twice daily that he was apply-0 E' r2 g6 i3 b: }) P
ing over his own shoulders, chest, and back area for
1 z( w% p, p6 {  n7 _5 c4 t7 ca year. The father also revealed he was embarrassed
; h; `3 I9 L$ k$ J" x7 X, Fto disclose that he was using a testosterone gel pre-% [$ F) |; d5 H, {- f
scribed by his family physician for decreased libido5 W$ E, l+ H8 E+ V( A! W
secondary to depression.
  D4 t6 h5 `$ e+ R+ E. ~3 xThe child slept in the same bed with parents.* |1 ]1 w/ Y3 |3 C! C* g$ b4 r2 U! ?
The father would hug the baby and hold him on his& w1 D5 s' t" D4 r! w' P6 [' l6 V& a
chest for a considerable period of time, causing sig-
- h) |! w7 v( vnificant bare skin contact between baby and father.
, ?& w; k1 G1 xThe father also admitted that after the phone call,
3 _' F( v) Z- Z# Ywhen he learned the testosterone level in the baby: T1 h3 v# _  ]
was high, he then read the product information
1 Z& L. p) `( u% c3 I& npacket and concluded that it was most likely the rea-- b- F0 r' P3 w# `% [
son for the child’s virilization. At that time, they
$ Z, ~% w( k0 f& o/ s" j5 o+ \decided to put the baby in a separate bed, and the, j' @4 m! i1 S( ~# x
father was not hugging him with bare skin and had& L6 n" p+ u* p. ~% \
been using protective clothing. A repeat testosterone
1 O0 ?0 {6 ?/ l7 {/ xtest was ordered, but the family did not go to the0 p, E7 Y2 I9 o) l9 D" J3 H
laboratory to obtain the test.5 h: j8 W5 ]! a$ H0 H6 @4 e1 n& R
Discussion
1 X6 j- l+ L* D1 ]( wPrecocious puberty in boys is defined as secondary0 ]+ h& p! X( h) g0 a- z
sexual development before 9 years of age.1,43 v: m) t. k5 e. M
Precocious puberty is termed as central (true) when5 Z. D  W' ?/ K  @: M5 p
it is caused by the premature activation of hypo-  N& `" b: Q7 g) x, p! G* T" k
thalamic pituitary gonadal axis. CPP is more com-
$ A& `4 @& W& t$ V% Ymon in girls than in boys.1,3 Most boys with CPP
: P9 q, z9 k' I2 amay have a central nervous system lesion that is
, j, H6 i( g+ G0 Gresponsible for the early activation of the hypothal-
5 j# b1 ~( a4 X$ E* {amic pituitary gonadal axis.1-3 Thus, greater empha-2 ], N4 J/ d0 x' G. X3 E
sis has been given to neuroradiologic imaging in. r* @) f9 @: n: Z( @9 j
boys with precocious puberty. In addition to viril-/ o3 z4 O3 o/ ]( }5 @7 w
ization, the clinical hallmark of CPP is the symmet-
. H1 S2 |; \2 f8 w  y$ |rical testicular growth secondary to stimulation by. C$ ?5 `5 [& ~7 X/ y; R6 y& X5 Q
gonadotropins.1,3! j2 J5 o$ q! ~( }  B, J3 Y, s" u
Gonadotropin-independent peripheral preco-
! N2 r' V! m9 z0 |! e) dcious puberty in boys also results from inappropriate! U+ E5 A' F; e! F8 C
androgenic stimulation from either endogenous or9 v% z* @/ y) ]3 G. ]2 Z( X* B4 s
exogenous sources, nonpituitary gonadotropin stim-3 R8 `/ S8 b/ B0 T
ulation, and rare activating mutations.3 Virilizing% m7 O5 J% u+ k. F2 ^( I
congenital adrenal hyperplasia producing excessive
/ z8 m" e, x7 n- Ladrenal androgens is a common cause of precocious$ o  i/ L/ X" r* O$ P' w
puberty in boys.3,4
+ M. D; B/ B1 l% p- M5 D2 }5 a* V: P( yThe most common form of congenital adrenal% Z4 u) ~0 W& U. ^7 @6 K  C
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ R) H; d% V3 d6 [6 o! {; M6 LThe 11-β hydroxylase deficiency may also result in, @$ r3 i9 c1 q+ n$ K7 y0 `
excessive adrenal androgen production, and rarely,
& A1 F/ i, H+ C) San adrenal tumor may also cause adrenal androgen. b  x3 _% d! ]# c3 v) S, S
excess.1,39 s  _! ?( h7 _4 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# \% Q2 c- ^) ^' \- a542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 a9 k2 H9 k7 b; O9 q0 L: v3 z  ?0 q0 qA unique entity of male-limited gonadotropin-2 w+ {3 i5 ~. V7 o  g5 H
independent precocious puberty, which is also known
4 z6 [5 }+ ?2 ]  {as testotoxicosis, may cause precocious puberty at a0 b1 L1 h; _7 T( A7 Y' k
very young age. The physical findings in these boys! [  f7 i2 t5 U+ Q% M1 \& n
with this disorder are full pubertal development,
) c+ p2 C4 f: {$ o* |including bilateral testicular growth, similar to boys  L, z% u9 P8 s) K4 i
with CPP. The gonadotropin levels in this disorder
, S; \% C5 o0 ^. Oare suppressed to prepubertal levels and do not show
0 ^# {$ [" K' Zpubertal response of gonadotropin after gonadotropin-; h2 x' h0 [& ~8 Q: {
releasing hormone stimulation. This is a sex-linked
, f# Q& b' h7 }; `% k( hautosomal dominant disorder that affects only
  a6 Y6 L8 ~, s# zmales; therefore, other male members of the family
5 A2 p0 A" F/ C: E4 kmay have similar precocious puberty.3: Q6 C; I/ `, s4 O
In our patient, physical examination was incon-
# ]! h- L7 @5 V+ O1 Ysistent with true precocious puberty since his testi-
* j2 Y/ V7 I8 u5 Xcles were prepubertal in size. However, testotoxicosis* [* N9 X; K' {
was in the differential diagnosis because his father7 V; Y7 k' g9 m; i9 K
started puberty somewhat early, and occasionally,9 X9 O& O0 R0 X! |) N' ?" ?& M4 x
testicular enlargement is not that evident in the" [% M+ b0 L: K" H; G( o2 u
beginning of this process.1 In the absence of a neg-
/ V1 G) }# {5 Qative initial history of androgen exposure, our
. @  T5 N0 h7 Mbiggest concern was virilizing adrenal hyperplasia,
* h$ v0 R3 ]) ?3 Qeither 21-hydroxylase deficiency or 11-β hydroxylase
& H# t# N9 j. s+ g" Z* S$ vdeficiency. Those diagnoses were excluded by find-1 C& {. n* u; ^3 |* b
ing the normal level of adrenal steroids." `, v9 K9 x8 z- n
The diagnosis of exogenous androgens was strongly7 P! y4 r; R% y7 s) }
suspected in a follow-up visit after 4 months because+ Y  t' o  N# e5 d6 q
the physical examination revealed the complete disap-0 `; n7 I$ K' A( K* Y9 ]6 y
pearance of pubic hair, normal growth velocity, and5 E, E/ j( g' Y) E6 l: |
decreased erections. The father admitted using a testos-
" z! T' X- u5 i1 E( Vterone gel, which he concealed at first visit. He was
  G5 U0 ~0 g6 Z' n; u* Dusing it rather frequently, twice a day. The Physicians’" k4 S# W; L* |- m
Desk Reference, or package insert of this product, gel or
" Q& F5 c5 ^. i0 C9 t$ {# ncream, cautions about dermal testosterone transfer to
  i( I+ r% `$ x( Eunprotected females through direct skin exposure.! q; z3 S: t3 h! f! E6 b
Serum testosterone level was found to be 2 times the
/ @, x- R3 s* I5 V9 ebaseline value in those females who were exposed to
- X8 K; C4 Z1 q; s0 Z" Neven 15 minutes of direct skin contact with their male
# Q0 v  L# P: [# w# _: F. {8 hpartners.6 However, when a shirt covered the applica-
* x& n2 M/ |$ p$ Mtion site, this testosterone transfer was prevented.
% Q6 c* H( N8 ~% yOur patient’s testosterone level was 60 ng/mL,
; }+ ]# w2 m2 |# l9 e8 S- ^% Bwhich was clearly high. Some studies suggest that; ]) W5 ?; [. y5 ]  L8 m
dermal conversion of testosterone to dihydrotestos-/ u% ?2 r; p) Z1 p
terone, which is a more potent metabolite, is more4 L3 K; i: F$ O" C9 I. [* h! s
active in young children exposed to testosterone
6 o$ _1 J; I, n3 u+ xexogenously7; however, we did not measure a dihy-
# m# f" s% ~5 E. tdrotestosterone level in our patient. In addition to5 ]/ G( {9 h  O, \- L- ^
virilization, exposure to exogenous testosterone in9 W  J. ~: U0 c" H" D
children results in an increase in growth velocity and
; _/ P5 m: I( k0 i- Qadvanced bone age, as seen in our patient.
  h- q3 Y1 S- j5 ?The long-term effect of androgen exposure during
) \7 ~' B, T- `2 s; z" P) @* ]early childhood on pubertal development and final
4 g) T' B6 s' X. h. Tadult height are not fully known and always remain; T+ J0 f/ V1 m& V2 q
a concern. Children treated with short-term testos-! e4 @, ]" }! L9 k
terone injection or topical androgen may exhibit some
& G7 m8 n( I+ F+ f4 n( e# zacceleration of the skeletal maturation; however, after
, h' j% J& K8 }1 @- k3 R( D7 dcessation of treatment, the rate of bone maturation( Y; w7 A9 f# x" z5 N
decelerates and gradually returns to normal.8,9: `8 S1 g- f3 j/ a: @! g
There are conflicting reports and controversy& m- l( @+ X; `% Z* B, g0 T! Z( C
over the effect of early androgen exposure on adult7 v& k* a8 \* @/ w
penile length.10,11 Some reports suggest subnormal
/ K( @  y* F8 _2 w5 \5 _5 Gadult penile length, apparently because of downreg-0 {  l6 |) Y  P, ~. i9 l& W
ulation of androgen receptor number.10,12 However,
4 l6 e4 j# G+ O3 Q! R1 ?& PSutherland et al13 did not find a correlation between
, f0 }# O0 ~* I% x* f, \childhood testosterone exposure and reduced adult) ^) Y% `/ Z$ ~/ S
penile length in clinical studies.0 q3 y& O. g0 [/ @/ Q: d: {! h
Nonetheless, we do not believe our patient is3 m# E: S8 N, m' g4 m1 i0 t
going to experience any of the untoward effects from
  b7 V$ H9 w. ~% ktestosterone exposure as mentioned earlier because0 K: a. [! T9 z7 U/ F9 l- Y, M
the exposure was not for a prolonged period of time.+ ?7 h1 @0 m: c7 j& Z# Z6 v5 f
Although the bone age was advanced at the time of. T. L! J  O- o
diagnosis, the child had a normal growth velocity at; U, [# B3 x2 u/ p  f; {' F6 ^
the follow-up visit. It is hoped that his final adult$ G) ^' a% s' s8 [( B0 X
height will not be affected.7 U. i( K7 [0 M# p  d, e. u2 W2 ?
Although rarely reported, the widespread avail-* N% O4 J+ I" K) I
ability of androgen products in our society may
( O) @' C$ J7 J) X7 Y( qindeed cause more virilization in male or female. ~" j! c  \0 u. N+ X) |
children than one would realize. Exposure to andro-5 k3 R; c6 Y0 P% H6 p
gen products must be considered and specific ques-1 h" q3 K; x5 [: u1 q. ?  d
tioning about the use of a testosterone product or9 t# P& P6 o0 F& P5 [  r. g
gel should be asked of the family members during
* ?5 T9 a( o2 N5 D/ Fthe evaluation of any children who present with vir-
7 A4 f/ ^+ i' d4 T# v! Q5 Q$ oilization or peripheral precocious puberty. The diag-
5 n. |7 P9 d8 Wnosis can be established by just a few tests and by4 z6 ^% W8 x1 s6 i9 A6 [
appropriate history. The inability to obtain such a
6 e( X. d1 a4 A5 q% G5 V4 H$ @history, or failure to ask the specific questions, may
! l2 K8 A. K9 ^( ?% [1 i% g, L5 Qresult in extensive, unnecessary, and expensive
' ]% ]  p0 y  ]/ L' iinvestigation. The primary care physician should be3 t+ Z- }/ u8 K' }+ o0 q6 \: G
aware of this fact, because most of these children5 C+ h: g3 ^* }
may initially present in their practice. The Physicians’" S! K# G9 P( i' K$ G# C' b% [5 Q
Desk Reference and package insert should also put a
  e* q( z2 d' M& e9 h$ ?warning about the virilizing effect on a male or$ E8 Q' h* W2 |+ S% L/ A& y9 N/ A- \
female child who might come in contact with some-
- o5 f: r4 L' E# pone using any of these products.$ \% ~+ w4 X, ^. M8 ?, Q
References( e' N. l2 u% i
1. Styne DM. The testes: disorder of sexual differentiation
. a: u; k2 s9 I0 N6 s0 }8 W0 {and puberty in the male. In: Sperling MA, ed. Pediatric
; d; }3 j' A8 ]9 cEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 o  c: a' b# J* J
2002: 565-628.
( f- D% Q) `; m5 t  H1 z. q5 x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  Y* K- \' J, J3 s" n0 spuberty in children with tumours of the suprasellar pineal
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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
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
9 D/ G- k- ^6 E; M
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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