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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
- R( j- {! Q2 P& R# oBoy Induced by Indirect Topical
' A6 z- u+ U! L9 [Exposure to Testosterone
9 z+ _; R  A: F6 E5 i' k8 R2 @# c* `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! R9 S( U$ H- `5 ]' \4 ]and Kenneth R. Rettig, MD1
) [: \# L5 j" K" ]Clinical Pediatrics
% I! H2 Q6 v# H9 ?Volume 46 Number 6! j3 F( o9 j& d
July 2007 540-543
" Q9 r9 b  Z3 Z+ B© 2007 Sage Publications
. Y+ h. H8 E* C% d' l' T- \10.1177/0009922806296651
8 Z+ N0 l  l& M1 @2 C- D& b! ehttp://clp.sagepub.com. A7 z1 O( A' P% s1 F6 e& K
hosted at
4 O+ t- \, m, g( I+ w  a  Dhttp://online.sagepub.com
: D/ ?; p7 r2 a+ G! A7 HPrecocious puberty in boys, central or peripheral,
3 U* `1 P( f4 _; H2 x  k/ ?is a significant concern for physicians. Central
" G; Y# V3 K* q3 m" F' Kprecocious puberty (CPP), which is mediated2 F- d; i8 t1 m& ]  ?3 t  e1 ?" |
through the hypothalamic pituitary gonadal axis, has
0 W: w) X% }; ~8 ~2 Q3 S' r# Ha higher incidence of organic central nervous system$ }9 b" H1 b, ~; ?- e" f
lesions in boys.1,2 Virilization in boys, as manifested
' u+ {6 g% `8 xby enlargement of the penis, development of pubic
$ [3 _- k! g* Hhair, and facial acne without enlargement of testi-* }5 _1 n% O$ T; _
cles, suggests peripheral or pseudopuberty.1-3 We7 C2 p% j& \( {0 Z3 ]6 Z9 Y
report a 16-month-old boy who presented with the
/ \8 u; Q! N5 P3 H$ Benlargement of the phallus and pubic hair develop-
/ ^6 ^# J  y6 [; T8 E+ E' s5 Wment without testicular enlargement, which was due
3 U/ q- s/ _7 R$ T! ato the unintentional exposure to androgen gel used by5 V/ n5 ?) [6 c1 \. d
the father. The family initially concealed this infor-
7 w- b% v4 v5 ]6 Jmation, resulting in an extensive work-up for this& [  i% E& ]2 e2 {4 p/ G
child. Given the widespread and easy availability of
9 U! w* l/ `) B! s* l$ d2 htestosterone gel and cream, we believe this is proba-' _& F; a8 W* [: Q8 e
bly more common than the rare case report in the- P8 {$ e' J6 I; @
literature.4, ?$ C# {, |* g- N9 E
Patient Report$ a) ?. X9 [. v$ b
A 16-month-old white child was referred to the! M: \+ S. b, y* C
endocrine clinic by his pediatrician with the concern
) V- m& @* |/ k! Q/ G# y, K0 _of early sexual development. His mother noticed, K: w) ^9 d) c5 F; I0 L
light colored pubic hair development when he was
$ c9 O3 }/ K: s8 ?From the 1Division of Pediatric Endocrinology, 2University of
2 l3 u5 [) n: ~& s1 q* h& j' X6 X5 u. HSouth Alabama Medical Center, Mobile, Alabama.6 }; }4 X5 Y5 j4 `
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 v9 F& P. r: o+ G) k- M
Professor of Pediatrics, University of South Alabama, College of
% d9 @% \0 n* D" ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  w( o5 t9 v8 z2 z6 |% e9 B+ Ke-mail: [email protected].5 W' t- Z; X; w8 ?
about 6 to 7 months old, which progressively became( M% @/ `; ?, ]$ K6 Q$ H1 C
darker. She was also concerned about the enlarge-
3 |+ b  O! A5 lment of his penis and frequent erections. The child
6 O. j3 n* s- i# n8 J$ K0 {was the product of a full-term normal delivery, with
& N& t: a: P& R5 Ka birth weight of 7 lb 14 oz, and birth length of
. F2 c' m+ g; U  q* X20 inches. He was breast-fed throughout the first year" a$ A* H  {6 w, Z
of life and was still receiving breast milk along with
; s5 ^. s* T) w/ u" H9 |- Q# \solid food. He had no hospitalizations or surgery,$ W( \$ o  I8 \  A' Q6 ]# Z1 S
and his psychosocial and psychomotor development# f2 X% T7 l( {; v, p
was age appropriate.
) S" v5 Y8 F. [& n/ WThe family history was remarkable for the father,) ~2 t7 k' T, n' \4 @( p
who was diagnosed with hypothyroidism at age 16,
4 d* ~9 s' ^8 b( p5 Q+ Lwhich was treated with thyroxine. The father’s, q" N7 }; f3 ]
height was 6 feet, and he went through a somewhat
: @, M$ d8 C6 E9 U. ]  O' R2 Hearly puberty and had stopped growing by age 14.! C, u3 _" I8 m* C- I3 g
The father denied taking any other medication. The/ U/ c: B% ?1 L' Z- X! ]3 x( L! V
child’s mother was in good health. Her menarche
8 F& z1 K' ]1 O* V8 twas at 11 years of age, and her height was at 5 feet# Z! n' H5 C6 J
5 inches. There was no other family history of pre-
# {2 F, s  d/ J5 B) b% {1 Fcocious sexual development in the first-degree rela-
' w0 P' T3 y- X; @7 B* j- o  Ctives. There were no siblings.  ^, J2 J7 G: T# R( s
Physical Examination2 w/ o4 g# n9 T/ h" [
The physical examination revealed a very active,
: c; h$ @  H! g3 eplayful, and healthy boy. The vital signs documented. K1 [8 q& `! q) J( }
a blood pressure of 85/50 mm Hg, his length was
) X% Q0 ]5 F0 J2 c* v90 cm (>97th percentile), and his weight was 14.4 kg
7 V! G$ b( x1 F% d- I(also >97th percentile). The observed yearly growth
7 ?7 n6 j2 U: X7 Mvelocity was 30 cm (12 inches). The examination of2 t: k, m/ z; P$ ]+ a. z
the neck revealed no thyroid enlargement.6 E- y; }8 C" C3 D( x/ P% q5 h
The genitourinary examination was remarkable for
2 `* c3 c" [# O$ B# wenlargement of the penis, with a stretched length of
( g' K/ J# h( K8 cm and a width of 2 cm. The glans penis was very well
, t& _- r" z) E- O& f( Q7 fdeveloped. The pubic hair was Tanner II, mostly around) d% o: t/ W8 b& B
540- o' x  E, g( L, H* o  z0 a  w6 ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; B9 v" u; ^4 c, ?the base of the phallus and was dark and curled. The
% C2 N2 c3 b' Y" y0 p9 {8 c) J9 `6 ytesticular volume was prepubertal at 2 mL each.
7 Z, Q) B! k" _6 a! f# X8 Z- n3 f/ HThe skin was moist and smooth and somewhat
: u4 p) Q, v% h; }, x; \) \oily. No axillary hair was noted. There were no
. T- K( l3 n( t& I& M9 L# mabnormal skin pigmentations or café-au-lait spots., D2 Z% a1 K, q) i8 Q. Q# C) ~* K, J
Neurologic evaluation showed deep tendon reflex 2+
# ?6 J- ~. J$ T0 T9 b0 hbilateral and symmetrical. There was no suggestion5 A3 g3 u6 q4 U: a, ^; Y
of papilledema.
! U" I' t8 N; A& K: P  R1 cLaboratory Evaluation) Y; y& R4 {; `) t1 S3 a9 `6 ]
The bone age was consistent with 28 months by
) I8 a: W1 E: Q. J- tusing the standard of Greulich and Pyle at a chrono-$ C, D% `1 I' v  D) x: U
logic age of 16 months (advanced).5 Chromosomal4 c8 ]. |, R- M( G( u
karyotype was 46XY. The thyroid function test
$ K9 v5 r3 m& @9 T5 Ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 D% ]4 Y8 R  ?# klating hormone level was 1.3 µIU/mL (both normal).
: Y( }3 _' ^2 ^  YThe concentrations of serum electrolytes, blood
5 ^) Q. Q: x9 {8 murea nitrogen, creatinine, and calcium all were; H( {4 j7 L/ A3 G3 M1 x
within normal range for his age. The concentration
, I5 y4 A6 i* E  Q3 Vof serum 17-hydroxyprogesterone was 16 ng/dL
7 V, s. X% \/ X( R(normal, 3 to 90 ng/dL), androstenedione was 20
3 p+ O+ d' k' \ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. l* r, \" `, {: K( L
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," }, _9 ]8 A) J) M% v: T3 F  B$ T) l% Z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( K3 Z* H9 j5 ~) M) U49ng/dL), 11-desoxycortisol (specific compound S)
4 F" O# _9 {8 i3 K: r* a) [5 O6 u' \was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. d, d7 c5 k0 Q; {0 I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( {, _0 J. s& ^- P7 @1 o, u8 t+ atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, b0 U. ?( J! A, ]# L$ m" ~
and β-human chorionic gonadotropin was less than- C1 \3 Q6 T/ {0 Q1 Y- f
5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 w2 w+ c4 ]# g5 k+ `( Lstimulating hormone and leuteinizing hormone
4 p# c* O5 ]& E' ?3 }% `concentrations were less than 0.05 mIU/mL
, s/ Y9 B' F* S" U* M5 q' s(prepubertal)., h7 B! \) c9 w
The parents were notified about the laboratory
/ p: u  V8 p" c8 e+ t5 Q0 B' Presults and were informed that all of the tests were
. Z' X& |0 u2 S1 w( X* G' pnormal except the testosterone level was high. The
: W* d6 i. F* s! g7 `) L! `. pfollow-up visit was arranged within a few weeks to& }1 b- Q( Q+ ^0 D7 ?# z* ?
obtain testicular and abdominal sonograms; how-" U7 ?4 N% `0 r0 w/ J1 C3 K6 x
ever, the family did not return for 4 months.
8 m; s+ [$ }6 p( s; Y7 P$ OPhysical examination at this time revealed that the9 P& A9 `  z3 Z. w, ~
child had grown 2.5 cm in 4 months and had gained# g, Q6 e! i6 n' w
2 kg of weight. Physical examination remained5 T  L4 `) r  z3 h5 @
unchanged. Surprisingly, the pubic hair almost com-
, s+ x2 h1 ?/ ^! t; [! Ppletely disappeared except for a few vellous hairs at9 D3 q, Q: s# Q" L/ s
the base of the phallus. Testicular volume was still 2
- R; X. O9 N7 ~) [' ~8 PmL, and the size of the penis remained unchanged.
8 W2 j7 L& t/ Q' B) KThe mother also said that the boy was no longer hav-
  ?$ @" t- l0 f" Z- N( z0 a' l$ Wing frequent erections.  V. W( {# E* [0 o) u) d. Y
Both parents were again questioned about use of
% A: B8 X. u1 [- |any ointment/creams that they may have applied to3 R! v  F/ t$ j' x- F
the child’s skin. This time the father admitted the/ X$ S3 w2 T" \+ c- y
Topical Testosterone Exposure / Bhowmick et al 541+ k% w2 w% z5 O! _' f) I; ~
use of testosterone gel twice daily that he was apply-3 `" m/ ^) r: l# a. Z4 q8 K
ing over his own shoulders, chest, and back area for
" a  }  w% y) J/ y& aa year. The father also revealed he was embarrassed
7 K  I* u# B6 y; Ito disclose that he was using a testosterone gel pre-
) i( j% ?: i* r: ?8 cscribed by his family physician for decreased libido
% t7 W# G+ T  I4 o/ k' H& Wsecondary to depression.5 T% F6 k9 s" [/ v
The child slept in the same bed with parents.
" `: y' e8 Q  M( ^' |2 m0 M3 n; ZThe father would hug the baby and hold him on his
3 j, v% X+ `3 j+ rchest for a considerable period of time, causing sig-
$ q4 v" @( p% B: N8 X' w+ inificant bare skin contact between baby and father.
! q! O: ^) \' W  E6 E8 LThe father also admitted that after the phone call,: g0 j2 P+ i; s. o
when he learned the testosterone level in the baby
2 c  P8 H/ x7 k! \4 q5 @( S* Fwas high, he then read the product information8 n! p' A- v/ u% [" G1 f" N1 m
packet and concluded that it was most likely the rea-
3 ?1 F7 V1 t) A5 j8 {son for the child’s virilization. At that time, they6 d% i$ A  I+ E* S
decided to put the baby in a separate bed, and the% s' L3 F) M5 S3 F" s
father was not hugging him with bare skin and had
, y- H$ ~3 u" d3 W1 _5 f1 Dbeen using protective clothing. A repeat testosterone* T" d+ T" T! _  P4 E$ B
test was ordered, but the family did not go to the" t* R5 P: ~% O/ d
laboratory to obtain the test./ ?1 g6 w/ `! D
Discussion  `" A2 A' M* ]; \; v
Precocious puberty in boys is defined as secondary0 I5 W- w$ U5 e) N2 s# Y
sexual development before 9 years of age.1,4
1 k2 V% P) m7 g' jPrecocious puberty is termed as central (true) when; q0 r/ P( u  a3 ^: S0 p
it is caused by the premature activation of hypo-) _+ e1 _( A1 g0 U* R
thalamic pituitary gonadal axis. CPP is more com-; s$ B5 o; X+ _& ~5 T/ Y
mon in girls than in boys.1,3 Most boys with CPP, `4 z5 z6 }. \& g! q8 h. N2 `
may have a central nervous system lesion that is
1 x/ H. `+ f" P! x- Iresponsible for the early activation of the hypothal-
7 L4 P; ?  c. H) O3 oamic pituitary gonadal axis.1-3 Thus, greater empha-
. R1 f* X5 s. k# Y- q/ ~" _sis has been given to neuroradiologic imaging in
. {5 \  w1 ^' y6 g3 pboys with precocious puberty. In addition to viril-
# U. a% c3 N) y; S( gization, the clinical hallmark of CPP is the symmet-' y5 K: \  P) C$ R9 r
rical testicular growth secondary to stimulation by
% `0 w( d  E9 m, Cgonadotropins.1,3
: _3 @3 O) Y4 I' `/ Z! pGonadotropin-independent peripheral preco-
. L0 U, Z" i1 |& ~2 r0 [cious puberty in boys also results from inappropriate" s: k. f; A% Y  C& Y
androgenic stimulation from either endogenous or% k# v" f7 E# F3 s& t9 H
exogenous sources, nonpituitary gonadotropin stim-
9 X6 N0 {( M) pulation, and rare activating mutations.3 Virilizing
/ V! z5 E% u+ w/ {$ j$ F; ]' Dcongenital adrenal hyperplasia producing excessive! w* K( {& i/ ~" c# d
adrenal androgens is a common cause of precocious; f+ g( P+ K. r3 U3 J; I
puberty in boys.3,4- x$ S3 ^: s% F: c3 q6 J& x' i
The most common form of congenital adrenal  _1 C( K, b) V! {
hyperplasia is the 21-hydroxylase enzyme deficiency.
  x! J+ U3 |, V: J- j, U2 BThe 11-β hydroxylase deficiency may also result in
* ^; Z6 J$ J% ^+ _0 g4 N& lexcessive adrenal androgen production, and rarely,7 R: u, t" D6 d8 p1 e0 C3 l3 f8 @8 [
an adrenal tumor may also cause adrenal androgen! q  v# a8 [9 y# L3 N3 w5 [
excess.1,3
* V- H( P4 [3 n' Z, Z2 ~5 I, Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- j! f& {. `0 Y) v
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 P. G1 M1 h, e1 r* NA unique entity of male-limited gonadotropin-
% l2 ]3 \* R5 B' s6 V* T) v& \! bindependent precocious puberty, which is also known
6 `( [8 c( r8 d6 i6 Q+ y  C4 xas testotoxicosis, may cause precocious puberty at a( f0 I& q4 ~, j0 r4 p
very young age. The physical findings in these boys) o9 g3 w' J8 a( K2 N) P
with this disorder are full pubertal development,* Z7 x4 z4 L3 S. [3 O
including bilateral testicular growth, similar to boys
. W" z/ H) w7 {& w5 ~+ dwith CPP. The gonadotropin levels in this disorder3 u. ]( F0 s& j1 X7 E
are suppressed to prepubertal levels and do not show
- J; g7 `: p4 G/ w1 Y0 B1 cpubertal response of gonadotropin after gonadotropin-( ~/ ]9 G6 \7 x, |
releasing hormone stimulation. This is a sex-linked
' o* T! ]+ H8 c; O/ K5 t9 x# fautosomal dominant disorder that affects only
' i+ V9 x1 V+ u" C9 Lmales; therefore, other male members of the family
* R/ A7 y+ ?# M" |may have similar precocious puberty.3
6 g# x0 t+ P# B) r9 O# D9 V( R2 HIn our patient, physical examination was incon-" }$ ~$ Q/ C5 I* A/ a
sistent with true precocious puberty since his testi-2 c6 ?. E: C$ j" }' u- S  o
cles were prepubertal in size. However, testotoxicosis
" U/ ~% F0 H) l- ^% \  t9 s. Uwas in the differential diagnosis because his father3 o; M4 N9 ^, e! x9 R
started puberty somewhat early, and occasionally,, U: W% v9 X- H
testicular enlargement is not that evident in the
7 Y1 g0 t$ d6 k2 ~* G* bbeginning of this process.1 In the absence of a neg-
& M: I  _) T  p( B' t) Eative initial history of androgen exposure, our
& e- m# U* {* m- k& ?; jbiggest concern was virilizing adrenal hyperplasia,
9 `4 O1 }4 b1 J% k4 ]2 ~7 E- Jeither 21-hydroxylase deficiency or 11-β hydroxylase
* m4 @' k( N! f9 |9 R( Xdeficiency. Those diagnoses were excluded by find-
( g+ _- G/ G6 m7 _( P' n& wing the normal level of adrenal steroids." [/ ]! b8 J: E
The diagnosis of exogenous androgens was strongly
" n4 s2 F+ c6 q) }! Asuspected in a follow-up visit after 4 months because
* }  o3 w8 z: k+ W3 v+ B4 e' E7 Uthe physical examination revealed the complete disap-* E. i" ]" U1 T
pearance of pubic hair, normal growth velocity, and; b/ m3 ~7 s8 Z
decreased erections. The father admitted using a testos-3 U1 B0 C- m: ?: w) U
terone gel, which he concealed at first visit. He was! Q- e3 \# O9 B9 F) M  v
using it rather frequently, twice a day. The Physicians’
) Z9 U" k2 ^( [7 J( {+ KDesk Reference, or package insert of this product, gel or; A) M* s  b: O( t5 l  r  s# q
cream, cautions about dermal testosterone transfer to
* L$ a0 m9 z0 |$ zunprotected females through direct skin exposure.
0 T; o) V) c. D9 zSerum testosterone level was found to be 2 times the- i/ v( U7 `4 i
baseline value in those females who were exposed to( l" a; B& X' M6 ]  d
even 15 minutes of direct skin contact with their male
. u5 D2 D$ |! j+ i2 }% epartners.6 However, when a shirt covered the applica-4 G# O5 k0 Y, W- e+ P! X
tion site, this testosterone transfer was prevented.
% }) H, K7 i6 I( HOur patient’s testosterone level was 60 ng/mL,$ E: u' c/ L, a& Z8 V
which was clearly high. Some studies suggest that
- q8 i' y: ]; ~% b. i/ Q1 S. A2 Idermal conversion of testosterone to dihydrotestos-+ M: F1 J# r/ G7 h! G7 I4 e8 [
terone, which is a more potent metabolite, is more
' @! j$ {2 F8 bactive in young children exposed to testosterone: l+ n, l; B2 S. G+ F4 x; O
exogenously7; however, we did not measure a dihy-
; p4 i' \. i1 t2 _% T  Qdrotestosterone level in our patient. In addition to
* N+ s$ ~+ @& O" l3 _8 nvirilization, exposure to exogenous testosterone in
: e3 S- a; D' f" i5 f+ P2 nchildren results in an increase in growth velocity and
$ Z3 D$ y* Q5 L( G8 ?& e. ^) I5 ?8 jadvanced bone age, as seen in our patient.
+ V7 A" t, X7 TThe long-term effect of androgen exposure during. R- Z- |& E$ R0 y: @. x
early childhood on pubertal development and final3 b4 P) Y& _. k* `( i
adult height are not fully known and always remain! S8 a# p+ n  P% z7 L. P" I
a concern. Children treated with short-term testos-1 H; O  n, t/ s2 i; B: X
terone injection or topical androgen may exhibit some
$ d7 _4 y/ N7 E1 }2 x, q; r: P- qacceleration of the skeletal maturation; however, after8 L6 ^$ i- I0 h) Q. b
cessation of treatment, the rate of bone maturation
8 N' z/ z6 V. C& }" N! bdecelerates and gradually returns to normal.8,9& w" b- B! W1 J6 s  c" c
There are conflicting reports and controversy
' I" Z8 z. S# d2 F! B. e9 t3 K9 L& Mover the effect of early androgen exposure on adult
% W" k! b1 B* |# C; X2 I' {7 gpenile length.10,11 Some reports suggest subnormal, e) u0 Z9 [. A; U% Y
adult penile length, apparently because of downreg-+ p' j  `2 V, G/ T8 \9 i
ulation of androgen receptor number.10,12 However,
$ C- D7 Q) D! L+ R) o) g3 p5 WSutherland et al13 did not find a correlation between6 A3 |) o/ I% D: A1 J8 w; C
childhood testosterone exposure and reduced adult
' l; m7 y3 k6 d& \penile length in clinical studies.
; D$ s- u( b. R+ u7 INonetheless, we do not believe our patient is
9 z- q1 x+ G  N- b, U3 @3 Y( Cgoing to experience any of the untoward effects from
- P! N9 g- K6 Ztestosterone exposure as mentioned earlier because
$ n8 D+ e/ P7 E* J% W% bthe exposure was not for a prolonged period of time.
7 M  z& C. Y2 x' I; eAlthough the bone age was advanced at the time of
3 W% L7 _# S6 S, R6 C. Bdiagnosis, the child had a normal growth velocity at" e% O& n$ [/ k
the follow-up visit. It is hoped that his final adult$ E; l1 ]! w/ F( g, w* H
height will not be affected.& J# Z' y6 L9 Q8 Q  u$ D& J
Although rarely reported, the widespread avail-7 ]' J/ B( G4 e
ability of androgen products in our society may
& _% F* Q- ?7 Jindeed cause more virilization in male or female
! P0 i9 A+ x! n% Hchildren than one would realize. Exposure to andro-  C5 H, t3 h+ ~$ k' P
gen products must be considered and specific ques-
% ^5 P# b9 N+ }, ^3 l' ~9 [0 ktioning about the use of a testosterone product or, m4 O; U+ C* k6 W
gel should be asked of the family members during% r) V" e' L& [! _9 I! V
the evaluation of any children who present with vir-3 _( n: i) M1 _' b5 d+ B  a
ilization or peripheral precocious puberty. The diag-7 M+ H" H& Y4 W
nosis can be established by just a few tests and by
* Q5 o/ L9 }7 a2 Xappropriate history. The inability to obtain such a# {* {) Z5 c, \% t4 U, I/ Z
history, or failure to ask the specific questions, may
* J4 Y0 e' n0 F' g8 yresult in extensive, unnecessary, and expensive+ Y1 h8 F, m4 a0 u/ F
investigation. The primary care physician should be% \8 o. N$ R* d& m' i* q
aware of this fact, because most of these children
* ~) s" N! Q( S% h0 I! b) ?may initially present in their practice. The Physicians’1 t# U; Z& L% S% r; ]
Desk Reference and package insert should also put a
/ X1 h7 G7 S3 D1 k& @warning about the virilizing effect on a male or
  h, s4 H1 ?' ^. O0 Tfemale child who might come in contact with some-
# [& x' W; I5 g0 vone using any of these products.( V. A% Z$ o' j9 q
References# g; e; G0 h9 f2 R% \; w5 t
1. Styne DM. The testes: disorder of sexual differentiation
& W0 W1 z1 T) q3 k% rand puberty in the male. In: Sperling MA, ed. Pediatric
- p2 z3 f9 l- p, T+ gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 d7 {8 T  K7 v2002: 565-628.6 Y4 T) J/ n+ H, {+ i
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- D/ g3 s/ H1 V, apuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ b) K' C- I# K% b7 O, KBoy Induced by Indirect Topical- d: J8 H8 ]' b9 J, ^
Exposure to Testosterone
( R" \, D( _0 X/ B3 C- A; x# l4 `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% F% D' h+ S5 O; eand Kenneth R. Rettig, MD1
% D5 C0 {/ B  U5 }0 G1 C% |) ?9 dClinical Pediatrics
; k$ P& |6 ?  W' k* K7 }0 N  D" |Volume 46 Number 6
4 _1 L2 _1 s# N$ M: Q2 d0 w) hJuly 2007 540-5433 P$ `1 s. V) O
© 2007 Sage Publications3 `0 \& f2 H, r" v$ J+ ]! L! J1 Q
10.1177/0009922806296651
' d# V3 D! `! u3 |' p8 ?4 Ahttp://clp.sagepub.com
$ W* [1 E4 b% Q& z& S& }: Nhosted at7 q) C& H4 E: X/ [' f  k
http://online.sagepub.com
( I1 S- _, r6 f$ N, KPrecocious puberty in boys, central or peripheral,
/ t# n6 l+ {3 |is a significant concern for physicians. Central1 D- ]- w) F2 i
precocious puberty (CPP), which is mediated
/ D0 v3 D3 f- [- t- l( b+ Dthrough the hypothalamic pituitary gonadal axis, has
3 i# b1 }  g3 g/ D! f4 D) Z5 ma higher incidence of organic central nervous system
/ b' Q# `- n& M$ J/ Clesions in boys.1,2 Virilization in boys, as manifested
, K: [  U' |0 a% t2 _$ F( Zby enlargement of the penis, development of pubic
4 j1 ?, P4 U+ c2 l( `  lhair, and facial acne without enlargement of testi-1 l0 h& h; Q4 ?5 `4 N
cles, suggests peripheral or pseudopuberty.1-3 We7 c2 j; M7 m: u" H. g/ p
report a 16-month-old boy who presented with the
8 h* v5 B; f5 h. Yenlargement of the phallus and pubic hair develop-" y+ y! v* p# C8 X' Z
ment without testicular enlargement, which was due3 s6 ~) P2 F5 v9 V% @
to the unintentional exposure to androgen gel used by* {8 [8 n7 |8 m
the father. The family initially concealed this infor-" T% f7 i& @7 {6 n
mation, resulting in an extensive work-up for this
' i. ?3 {' M: q1 Qchild. Given the widespread and easy availability of* X4 R, a" d1 |9 S2 W6 Z; ?
testosterone gel and cream, we believe this is proba-
$ k" b! y5 m) j/ U! J" bbly more common than the rare case report in the2 v" Q% z2 u$ s/ D$ i3 z9 w
literature.4( ^: j2 m* U, O
Patient Report, B2 k, W) }. D: f$ a
A 16-month-old white child was referred to the5 J8 Z$ Q! N; [* x# Q- n
endocrine clinic by his pediatrician with the concern
, W& @) P5 T8 _8 b5 y8 M' Qof early sexual development. His mother noticed
  r) ~2 R  L+ k# h- l6 Mlight colored pubic hair development when he was
0 D/ z4 d' {/ fFrom the 1Division of Pediatric Endocrinology, 2University of+ `1 B1 ]; J! Z  ]& Z1 Z6 p) Q- g
South Alabama Medical Center, Mobile, Alabama.
! Q, C9 s, Q6 t6 tAddress correspondence to: Samar K. Bhowmick, MD, FACE,
9 m8 |! H- V! PProfessor of Pediatrics, University of South Alabama, College of
4 p& T& |5 w" n1 O8 k" f0 yMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 e1 r9 b; M+ R. r/ E/ Y% o
e-mail: [email protected].
; T" a" \, R" c# O+ gabout 6 to 7 months old, which progressively became) C$ |. p8 q3 n- s1 [
darker. She was also concerned about the enlarge-/ U' ^& j& j& y1 U0 J* e: O
ment of his penis and frequent erections. The child
- c/ G* @! _+ N. q9 j' d* q& j9 ~was the product of a full-term normal delivery, with  a) i  G" S# R1 A
a birth weight of 7 lb 14 oz, and birth length of
" w' w: k3 e4 {: a20 inches. He was breast-fed throughout the first year
, }4 f" ]* u) sof life and was still receiving breast milk along with
( m, I; E$ v' [4 R, R6 O+ |. [solid food. He had no hospitalizations or surgery,
" f8 w' `/ c8 m; ~8 @" dand his psychosocial and psychomotor development& n2 I. d  m' U8 M$ c) l
was age appropriate.
5 ]# \# C) y% c$ E* {2 bThe family history was remarkable for the father,
% O' H6 n* d, I( S8 \: ]who was diagnosed with hypothyroidism at age 16,; p) u: a2 Z$ J
which was treated with thyroxine. The father’s3 [8 X# Y$ O& a" @
height was 6 feet, and he went through a somewhat3 w! h: d% p4 [; K; t. K& p! x
early puberty and had stopped growing by age 14.; [7 x" s7 Q  w
The father denied taking any other medication. The
# ?8 {- q# Z: Z/ w4 ^child’s mother was in good health. Her menarche
6 G! P9 `4 i8 U2 qwas at 11 years of age, and her height was at 5 feet
. e5 T1 |+ A, t  m0 t5 inches. There was no other family history of pre-# G1 b, ^" Y: N: e+ y8 ?2 a6 L
cocious sexual development in the first-degree rela-
. t3 F# V) T6 ~% J( @, Ytives. There were no siblings.
! m% }: G8 b0 |. w( ?* a) hPhysical Examination
+ x- i  V/ F0 G( B1 NThe physical examination revealed a very active,
" e/ N# G. e; u9 o+ K% N! fplayful, and healthy boy. The vital signs documented
2 h6 x3 N6 x: m* b2 v, M3 W: Za blood pressure of 85/50 mm Hg, his length was
0 e; o0 t( \1 w9 H" D9 Y; P90 cm (>97th percentile), and his weight was 14.4 kg
: o7 t) q/ M, @(also >97th percentile). The observed yearly growth
6 N- O7 D2 h+ G+ ?' \4 cvelocity was 30 cm (12 inches). The examination of. k; X7 b0 |) H
the neck revealed no thyroid enlargement.: D* c! r4 J4 X( K
The genitourinary examination was remarkable for
( i/ I0 E/ X8 }: `1 Xenlargement of the penis, with a stretched length of
8 r7 R" _* k$ L( E( a9 Z8 cm and a width of 2 cm. The glans penis was very well: T/ f- t9 N7 _' l8 q/ j; ^
developed. The pubic hair was Tanner II, mostly around
  k% w) d8 i  H3 s. W, [3 i( H5403 s3 m5 l5 n2 f4 e# G5 S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, _& Y/ m# s2 Z0 K/ [0 zthe base of the phallus and was dark and curled. The! ^& G; y' |3 I! \7 k  j/ W
testicular volume was prepubertal at 2 mL each.
7 _9 B) A1 g3 n) O7 L0 |The skin was moist and smooth and somewhat
- c) b# V& i& N3 N5 _, J' Goily. No axillary hair was noted. There were no& Y9 m& j. T( V, i$ d7 r5 f2 c! n+ w
abnormal skin pigmentations or café-au-lait spots.
" {( d8 |- h# [, e; P7 NNeurologic evaluation showed deep tendon reflex 2+
( Z9 c0 _7 o& h8 ~( z3 c. kbilateral and symmetrical. There was no suggestion
% [" r! R) R, K. Mof papilledema.
7 j! p, b! t! n9 z! {/ }Laboratory Evaluation
7 o- T$ \4 I3 Y9 n0 o& m) UThe bone age was consistent with 28 months by
8 D8 a" o; w( D+ x& [using the standard of Greulich and Pyle at a chrono-  X2 Z: F1 n$ I. Z
logic age of 16 months (advanced).5 Chromosomal( F1 t) i% n! e5 P
karyotype was 46XY. The thyroid function test
  c* C; p- `, F6 t0 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 i& f, e( x9 ^0 ]+ Nlating hormone level was 1.3 µIU/mL (both normal).
, J+ M& e' v; }The concentrations of serum electrolytes, blood
3 v# Z0 g# B3 Kurea nitrogen, creatinine, and calcium all were6 n2 w5 \* N6 _( T
within normal range for his age. The concentration
) u& W  c. ~: I, M6 W# K- Fof serum 17-hydroxyprogesterone was 16 ng/dL
! X! i2 n6 E! ]) @(normal, 3 to 90 ng/dL), androstenedione was 205 _4 r* Z4 m& t" a- [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; T2 h6 D" Y5 x4 v; o; ~! f- T; aterone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 k& Y# D, e  O4 z+ l6 m9 xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ e3 M! O  J/ \7 C. G  L49ng/dL), 11-desoxycortisol (specific compound S)
# O& B% h8 N6 ]1 O* w& `8 G5 X' pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( a; S! |& S1 \  _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 V- n! O6 U( A0 R' ^4 C  u$ d' otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# B. j- s" o' N9 _* \) J* a1 Fand β-human chorionic gonadotropin was less than: d, }1 Y) K$ ], E! Y1 v
5 mIU/mL (normal <5 mIU/mL). Serum follicular
, s4 X' f. g) r' sstimulating hormone and leuteinizing hormone$ f6 s( C/ _0 o4 E/ |" B- }2 T
concentrations were less than 0.05 mIU/mL
2 b+ Z8 \6 Z5 A& G; m( l& T(prepubertal).1 Y; Z, \1 G% G# t; X( f+ t
The parents were notified about the laboratory6 a% y3 O/ ^; O& Z
results and were informed that all of the tests were
) H( a) s& n, w. V  X6 I! Nnormal except the testosterone level was high. The( ?. V8 f, O1 z& ]' _
follow-up visit was arranged within a few weeks to6 \: N/ @+ `( Q) x& N
obtain testicular and abdominal sonograms; how-
7 v; p1 g; A$ a# D% n* wever, the family did not return for 4 months.
( p# b! z# N- s! HPhysical examination at this time revealed that the
3 \* v$ C, T! b" Vchild had grown 2.5 cm in 4 months and had gained
! ?; f  P+ F2 s" X2 W3 i/ A2 kg of weight. Physical examination remained
( p( C! g) q9 e/ P8 Xunchanged. Surprisingly, the pubic hair almost com-
" E6 ]. M% J3 r/ Y* n% H9 Upletely disappeared except for a few vellous hairs at4 `0 |7 E6 M+ i/ ~  o0 q! _1 b
the base of the phallus. Testicular volume was still 2
! y4 a8 v) d( K- UmL, and the size of the penis remained unchanged.
$ h9 i8 |% j7 s- {- mThe mother also said that the boy was no longer hav-/ \4 t0 ^9 B/ E$ j3 u. p) b6 j
ing frequent erections.
9 j$ B& [" C- u$ k, @Both parents were again questioned about use of& d: p; F! D" H) J, K1 P
any ointment/creams that they may have applied to! g7 P7 Z/ H% U, B7 W" q- n
the child’s skin. This time the father admitted the$ P+ s6 b% R& h2 b+ S( S
Topical Testosterone Exposure / Bhowmick et al 5411 ^: x/ E" w; R7 [' [- @3 |# X1 F
use of testosterone gel twice daily that he was apply-
( u* _: ~" e$ n' y5 j8 Zing over his own shoulders, chest, and back area for6 f  ^# ^' a- M/ H. n
a year. The father also revealed he was embarrassed
  I) W& \' P% Y: I+ Pto disclose that he was using a testosterone gel pre-
, P1 C: v; h' ?% m4 u) |/ Hscribed by his family physician for decreased libido, u0 M/ I. D9 w1 a
secondary to depression." F! U$ A  [+ {& y/ _
The child slept in the same bed with parents.4 t* }% {+ M* r; [. i
The father would hug the baby and hold him on his
6 T9 F- S3 u  `1 ]" cchest for a considerable period of time, causing sig-$ x" M0 _3 }7 N% \* q" N7 `0 j- b
nificant bare skin contact between baby and father.0 a) U* A2 O. G: O- V/ F7 ]
The father also admitted that after the phone call,
2 ~) {8 D; \% B; s. O6 Hwhen he learned the testosterone level in the baby+ N( P7 ~- n# H7 d  v) n% @5 r
was high, he then read the product information
5 H) \3 I  _/ A7 {# ?3 spacket and concluded that it was most likely the rea-. K" v) Q+ g2 W/ n: O
son for the child’s virilization. At that time, they) L+ t6 U. a$ J: t& P1 _+ j
decided to put the baby in a separate bed, and the
6 Y; e9 t+ W9 Z5 nfather was not hugging him with bare skin and had* b: E: z  P9 {4 N/ X
been using protective clothing. A repeat testosterone
, s4 ~) o/ r4 f1 R5 Ptest was ordered, but the family did not go to the7 C* f/ I6 U8 b' P( b2 R6 D
laboratory to obtain the test.
3 i& }3 P' i. V( Y: WDiscussion9 B6 a$ K( W& ~' k, `! T, [0 z
Precocious puberty in boys is defined as secondary
+ o$ H- _5 k. z: m( Lsexual development before 9 years of age.1,4
9 {: u% a; k0 D; }: L- Q( lPrecocious puberty is termed as central (true) when
/ Y# I/ J# q( d- a, J* L* g* ^it is caused by the premature activation of hypo-
% r% f' L0 j$ |/ y" T; d1 Z7 Vthalamic pituitary gonadal axis. CPP is more com-
; l% D! b. V8 I# xmon in girls than in boys.1,3 Most boys with CPP+ q! m/ L, B" F3 s+ V6 Y  y
may have a central nervous system lesion that is( z% Q" e$ L( v! V* o, F( `
responsible for the early activation of the hypothal-
. \- H# O3 P3 A1 W' H6 F% aamic pituitary gonadal axis.1-3 Thus, greater empha-
8 W1 E! k* L, c7 _# dsis has been given to neuroradiologic imaging in6 n+ G. k  `8 T. `+ \
boys with precocious puberty. In addition to viril-3 t" j" l/ H7 _* ~8 K" h
ization, the clinical hallmark of CPP is the symmet-4 u" ]! z. y; g7 h, X! ?% v
rical testicular growth secondary to stimulation by
) M) s* _" f# Ngonadotropins.1,3' q9 }9 A+ v4 ^6 X# R5 v1 H1 O* ~! G. n
Gonadotropin-independent peripheral preco-
, h  V, E; F) Jcious puberty in boys also results from inappropriate
8 N# s5 B6 d8 O8 }; T! ?$ dandrogenic stimulation from either endogenous or
# x9 g7 Q- t4 o) O% Yexogenous sources, nonpituitary gonadotropin stim-% \! F# _" O# a' Y
ulation, and rare activating mutations.3 Virilizing
% t' ^- y3 U: m* j5 Xcongenital adrenal hyperplasia producing excessive; c! X4 h( i, v+ r9 s
adrenal androgens is a common cause of precocious' X+ h: M$ E, J8 y+ O6 ^" B0 q
puberty in boys.3,4' n( C5 K/ c: T6 D0 F! Y4 k- r3 u3 A
The most common form of congenital adrenal
* W3 P/ ?" b- g" ?" E' ~2 `hyperplasia is the 21-hydroxylase enzyme deficiency.
7 d  E+ B# o0 FThe 11-β hydroxylase deficiency may also result in( L! e4 m4 H- @- _
excessive adrenal androgen production, and rarely,
" W+ Y2 L3 C6 ~- van adrenal tumor may also cause adrenal androgen! G8 m- W$ x  `: O
excess.1,3
5 h3 D: i' @3 p2 y  i# `8 X9 G& Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 |5 |2 W9 K& d" ?; S1 m* N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 r8 r6 o* @9 @% h" e+ y- MA unique entity of male-limited gonadotropin-
4 q9 g; L7 @. D& t0 |- rindependent precocious puberty, which is also known
6 n# b; h+ Q8 B  `; nas testotoxicosis, may cause precocious puberty at a
0 `+ `1 ~* `* s8 `3 c  F3 d6 qvery young age. The physical findings in these boys2 W  }2 b1 x# d/ x
with this disorder are full pubertal development,4 H* m  q% s3 o  ?& D: f# k7 I: E/ }
including bilateral testicular growth, similar to boys) m1 N$ H  h! a6 {! O) }4 B) o. Q
with CPP. The gonadotropin levels in this disorder( E; }$ o; w2 u" W1 j
are suppressed to prepubertal levels and do not show5 K. {" C4 N6 ^: A
pubertal response of gonadotropin after gonadotropin-: H1 G0 \. ?  m) _7 k( E
releasing hormone stimulation. This is a sex-linked
& B, i% z) r3 [9 u3 _autosomal dominant disorder that affects only
# _. e- V9 w2 N9 u- U7 amales; therefore, other male members of the family
8 n! i# x: Y! X+ A$ J$ pmay have similar precocious puberty.3: J, n7 o1 a. k! ^
In our patient, physical examination was incon-
1 t5 Y6 l' I. X- n1 L, E6 usistent with true precocious puberty since his testi-
6 I  w2 M1 d2 w+ r3 pcles were prepubertal in size. However, testotoxicosis7 y% V" l; `, o6 }4 L+ u
was in the differential diagnosis because his father: [6 m3 o$ [+ v# x; V7 q
started puberty somewhat early, and occasionally,' K1 U% @1 R' m! M7 [( v% y
testicular enlargement is not that evident in the
+ R& j8 X5 f) S7 P& A: \; pbeginning of this process.1 In the absence of a neg-! i/ y2 M0 U. X& I9 ^& t( p
ative initial history of androgen exposure, our' H, b+ h/ P$ |7 U7 \# u# t
biggest concern was virilizing adrenal hyperplasia,
& i" `1 X1 u6 W1 q4 D) |; S% I, Peither 21-hydroxylase deficiency or 11-β hydroxylase" j+ q3 W6 S: B0 ~8 N
deficiency. Those diagnoses were excluded by find-
* q, X# b$ {2 t% t# }ing the normal level of adrenal steroids.* @6 j7 u2 I6 p* w9 H  N2 o
The diagnosis of exogenous androgens was strongly
* k. d: x! O) g, esuspected in a follow-up visit after 4 months because* ]' L% r# N  c
the physical examination revealed the complete disap-
- f% f$ |/ C+ T% [: G, Epearance of pubic hair, normal growth velocity, and
2 m& v9 q2 P. Q8 [decreased erections. The father admitted using a testos-
( L2 G! `" s0 G1 R2 j0 Cterone gel, which he concealed at first visit. He was
3 C% \, K' R" i) U4 Y: dusing it rather frequently, twice a day. The Physicians’
; Z8 U2 v# a) o7 L$ t+ YDesk Reference, or package insert of this product, gel or0 ^% L) G+ I2 C& e* t5 R- z- ~* q
cream, cautions about dermal testosterone transfer to
9 C2 i+ \! w$ X/ t  Junprotected females through direct skin exposure.4 e5 r7 _5 X$ y( B) ]
Serum testosterone level was found to be 2 times the  Q$ Y& |7 V) h: d
baseline value in those females who were exposed to0 B4 A* R& a+ ~: e. m
even 15 minutes of direct skin contact with their male. G5 W1 K) [) A3 ]8 P# L
partners.6 However, when a shirt covered the applica-" F; x( s# X( z' V& T" d
tion site, this testosterone transfer was prevented.  f6 r/ H- S! c
Our patient’s testosterone level was 60 ng/mL,7 M# P' q# n! t/ ?3 I1 x* n
which was clearly high. Some studies suggest that! h; S$ _8 p  c$ ?' `3 ?
dermal conversion of testosterone to dihydrotestos-
+ V- j  V9 X9 H* {1 t: lterone, which is a more potent metabolite, is more
9 u: N+ |5 ~+ B$ O& x& p0 ~active in young children exposed to testosterone
5 x4 b2 x5 W: d" b0 f6 [exogenously7; however, we did not measure a dihy-
6 J+ I. o& u+ s8 A- @drotestosterone level in our patient. In addition to
0 D% h; @% e# s: jvirilization, exposure to exogenous testosterone in
1 Q/ U1 `# `2 J: O* S: g8 ]children results in an increase in growth velocity and
+ ?6 F1 J" v/ Padvanced bone age, as seen in our patient.
/ L, ?/ O! U$ \The long-term effect of androgen exposure during
$ h( J* I7 P* E. X, b! y2 @* v7 q. zearly childhood on pubertal development and final
) K. w1 H2 H' @- F( \" B' [' G4 Dadult height are not fully known and always remain
5 I+ [' W1 r( Oa concern. Children treated with short-term testos-
2 L9 z+ R3 X$ h& Gterone injection or topical androgen may exhibit some+ W! O. N" a0 K- }5 P' ?8 d4 \
acceleration of the skeletal maturation; however, after3 {: @- G4 @& U
cessation of treatment, the rate of bone maturation& |- w- d+ y# c  X& _
decelerates and gradually returns to normal.8,9' t5 n; D$ Y/ Z& p. _
There are conflicting reports and controversy' h0 E9 m" I- Z& Y, p; C1 h2 }
over the effect of early androgen exposure on adult, o/ s/ e' A6 h: t
penile length.10,11 Some reports suggest subnormal
" ?) n1 m) N+ e  p% c9 ^4 Fadult penile length, apparently because of downreg-' e, e: ^; ?' w5 C6 R) n0 d
ulation of androgen receptor number.10,12 However,
4 D4 i" n6 V9 G- k5 g0 \Sutherland et al13 did not find a correlation between
) R; E' r% j* V" M) Y' h) _childhood testosterone exposure and reduced adult3 U: L  q. L" B* D4 s  ~5 F, y
penile length in clinical studies.; Z  P4 |( x* h, w
Nonetheless, we do not believe our patient is
, z  d. T, Z" I+ j. d, g9 lgoing to experience any of the untoward effects from/ X+ \( ]9 F# c7 h
testosterone exposure as mentioned earlier because
, R6 @6 R. M; [, T" s; ^; z( v" I# ?  ?the exposure was not for a prolonged period of time.
0 S3 W( H6 M+ M# C7 o: ?Although the bone age was advanced at the time of6 a. k1 Z3 J4 f6 F" E7 @; }  G
diagnosis, the child had a normal growth velocity at$ l. O4 b+ P  J3 u# S
the follow-up visit. It is hoped that his final adult& I, @7 a! O2 z1 G$ Q0 t
height will not be affected.1 J9 n5 M. o+ N2 x5 y$ {
Although rarely reported, the widespread avail-
% z& h7 D( h+ R6 h& `ability of androgen products in our society may6 b+ J6 W2 ?9 I; M  O
indeed cause more virilization in male or female+ b% r& ^  U& S% ]8 N
children than one would realize. Exposure to andro-8 @- y; U/ n) [
gen products must be considered and specific ques-
8 h# q3 A; ^- F& jtioning about the use of a testosterone product or# b. P; J+ m2 u8 h2 K8 w# \
gel should be asked of the family members during
/ m9 e& c( H; }. _6 xthe evaluation of any children who present with vir-( u3 w( `3 `6 X
ilization or peripheral precocious puberty. The diag-  c! l' I% x3 v# W3 t
nosis can be established by just a few tests and by
) V" j& |- W! k  k3 lappropriate history. The inability to obtain such a
. I3 H+ l1 a% R0 \6 rhistory, or failure to ask the specific questions, may
' u5 |6 H" ?: Y  jresult in extensive, unnecessary, and expensive
& q' x3 l% l4 O) R. b9 u9 dinvestigation. The primary care physician should be+ |/ w1 P3 P3 ^* I
aware of this fact, because most of these children2 @4 v% {4 I/ A7 F4 W" B+ D3 x
may initially present in their practice. The Physicians’8 d/ w4 a7 h# \  J
Desk Reference and package insert should also put a% D* n( W' [: }  U
warning about the virilizing effect on a male or. m# X( o& o4 H) _+ O
female child who might come in contact with some-$ w1 b1 L- B/ P
one using any of these products.
! R  P# p) ]* b: u9 j8 K: xReferences
% L. d! s8 b$ [7 Y2 D  V7 _. ?1. Styne DM. The testes: disorder of sexual differentiation4 a) P  ]0 i) O  r7 Y' L" N$ [
and puberty in the male. In: Sperling MA, ed. Pediatric
! G6 W* |6 D- jEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 r! M" p: a  M% M6 `  P
2002: 565-628." O8 t9 N# \& s' v! |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 t2 n- u% Y( s
puberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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
7 P% C. |) b0 G0 s' y. R2 H6 q% B9 a9 t
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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