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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-Old7 z3 e' i0 @4 i* n: Q$ t0 z
Boy Induced by Indirect Topical
$ `2 c( I. U& S1 ~Exposure to Testosterone
/ T" E7 Q* d5 w6 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 E& `! O! c9 x$ t# n, n
and Kenneth R. Rettig, MD1
, _9 ^% s; }  Z, K+ Z3 |& L2 uClinical Pediatrics
2 T. ]1 [4 e* v: K, eVolume 46 Number 6
/ |/ z( N2 @2 N3 nJuly 2007 540-543/ I6 [5 H4 p' u! }4 v) a
© 2007 Sage Publications6 Y* \# v& s/ I" t) P5 q
10.1177/0009922806296651
  Z4 s7 p0 t  s2 mhttp://clp.sagepub.com
, U8 v4 [) r. Ghosted at
/ x  N% n' Y, `/ j, T2 D- j) u* ehttp://online.sagepub.com
5 i' ]  c3 K2 D/ @Precocious puberty in boys, central or peripheral,
0 V6 c# Z3 \4 Bis a significant concern for physicians. Central0 B9 u8 t8 P. n; X
precocious puberty (CPP), which is mediated1 }2 k$ [5 i8 B2 l" K8 N9 h
through the hypothalamic pituitary gonadal axis, has  l( }5 Z% j0 w
a higher incidence of organic central nervous system
6 d/ t' B) V1 Z. P9 J; [. olesions in boys.1,2 Virilization in boys, as manifested. X* Q: G4 l0 x9 f, f
by enlargement of the penis, development of pubic: c3 m9 c% P( d" Q3 ~+ y" M
hair, and facial acne without enlargement of testi-
  ]$ L5 Z8 i4 y8 Y1 dcles, suggests peripheral or pseudopuberty.1-3 We
  ?- V6 k7 P' Kreport a 16-month-old boy who presented with the
  k9 c: @9 r. denlargement of the phallus and pubic hair develop-
% `; s8 h5 Z8 Z/ d" }- G9 @ment without testicular enlargement, which was due
6 o9 a6 f* s# P3 I: t6 n- V" Ito the unintentional exposure to androgen gel used by  c- f7 [* V) I8 a, R; T* s. L
the father. The family initially concealed this infor-/ ?2 h' J0 `2 E3 b
mation, resulting in an extensive work-up for this9 c- d* V* R6 l
child. Given the widespread and easy availability of
4 S' [0 @! x% d* V3 D( {1 Z$ |  Utestosterone gel and cream, we believe this is proba-
- X. [7 F% s; C: U1 d% n2 ^bly more common than the rare case report in the
5 \: X1 u% w' nliterature.4
9 ?1 S9 y/ g/ B3 Z# jPatient Report
5 p4 N8 d3 P9 dA 16-month-old white child was referred to the# }3 @  P0 s' g0 C
endocrine clinic by his pediatrician with the concern
- q( s: j1 x7 F* o2 ]of early sexual development. His mother noticed4 _5 h& H0 k' C
light colored pubic hair development when he was
2 k$ `6 j. u. m# Y$ A" uFrom the 1Division of Pediatric Endocrinology, 2University of3 Y# V' q  E2 R% l! }% E6 h
South Alabama Medical Center, Mobile, Alabama.4 H+ }: Z9 C4 x+ F" W) M
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 W& \* N& t' N* E% z8 a/ w8 c  Z8 I
Professor of Pediatrics, University of South Alabama, College of* L* x, k( g, C9 S  L8 R
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ L7 ~- I5 e! w2 W
e-mail: [email protected].$ B& d% B0 I  J* y: @
about 6 to 7 months old, which progressively became& v1 z( ]+ Y4 M5 b7 ]* n
darker. She was also concerned about the enlarge-
0 j; f3 _& @4 R( ement of his penis and frequent erections. The child
( e- `' i* r0 p6 ]" z- E9 I. M. G" y# awas the product of a full-term normal delivery, with
# L. s) x1 `" N% e% fa birth weight of 7 lb 14 oz, and birth length of, O1 }/ }7 p  U. j# Q. W0 i
20 inches. He was breast-fed throughout the first year
0 n# ]: N5 H; ?8 gof life and was still receiving breast milk along with
6 D$ X; h( F) }5 g5 wsolid food. He had no hospitalizations or surgery,
  O9 a1 b5 K2 @and his psychosocial and psychomotor development$ [7 Q" F7 S+ W* L) F
was age appropriate.) B  |; I. L5 J6 q- o4 d# m
The family history was remarkable for the father,
# O1 E& r( m9 J- r: Xwho was diagnosed with hypothyroidism at age 16,, S/ v0 L# T1 F% E& `) l. x6 d
which was treated with thyroxine. The father’s& n5 }1 T2 P" ~
height was 6 feet, and he went through a somewhat
+ g# F# I4 v, |3 b# Xearly puberty and had stopped growing by age 14.
/ t# `$ t# H% ]The father denied taking any other medication. The( ?, a4 ^% n! F& |6 @& V3 N. J4 V
child’s mother was in good health. Her menarche& o- P) _  l) U/ k. b+ ~
was at 11 years of age, and her height was at 5 feet; p" ~, ^# s9 V3 r0 _" R
5 inches. There was no other family history of pre-
8 [3 r6 R" c- n1 B/ Dcocious sexual development in the first-degree rela-
8 L  L+ A$ U1 vtives. There were no siblings.# o- W% \9 J* I
Physical Examination
0 R1 ^1 ^, j* W2 gThe physical examination revealed a very active,9 s' Q$ h; h6 N0 y
playful, and healthy boy. The vital signs documented* c2 C' U. }! K2 u6 G2 A+ j9 T8 L
a blood pressure of 85/50 mm Hg, his length was+ P  `; X5 |9 ^8 t* U9 g6 o) t
90 cm (>97th percentile), and his weight was 14.4 kg
/ I! |  u% u& K( i% H/ w% `(also >97th percentile). The observed yearly growth
! T$ Z+ F8 Z, g/ X4 \velocity was 30 cm (12 inches). The examination of
. B) k: A& [) B9 T" k! y! othe neck revealed no thyroid enlargement.
% A# o$ c) h8 L$ WThe genitourinary examination was remarkable for
) S  j8 M+ K, p/ d: Xenlargement of the penis, with a stretched length of# e- S4 Q/ r" u1 |. C
8 cm and a width of 2 cm. The glans penis was very well! m# E0 ^# v* E' b
developed. The pubic hair was Tanner II, mostly around
/ d; I* t: Z- o4 ^: e( K" M540
6 x; \* P5 |" Pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 E# s. Q% F' y# k
the base of the phallus and was dark and curled. The! _5 Q1 Z" Q, F! U1 M* T! e+ A9 D
testicular volume was prepubertal at 2 mL each.
3 l2 X4 L' F4 V6 D1 N* qThe skin was moist and smooth and somewhat
( n+ U5 Z+ G$ yoily. No axillary hair was noted. There were no
6 x0 k! g. ]7 [+ k% D* ]) Pabnormal skin pigmentations or café-au-lait spots.
( M( w! }2 n* V: y, XNeurologic evaluation showed deep tendon reflex 2+
: I* J& i1 j) X1 B" zbilateral and symmetrical. There was no suggestion
8 L; [+ O( n& Y" l$ P) \of papilledema.
9 I% F* d; ]' \0 `& }& K2 \. _2 zLaboratory Evaluation" n; ~6 J, X- N, v4 ]. t
The bone age was consistent with 28 months by( n" B; e1 H+ S$ c" k
using the standard of Greulich and Pyle at a chrono-
  o: A, u$ t! }# H  Qlogic age of 16 months (advanced).5 Chromosomal3 _. h1 ]7 k4 T% u
karyotype was 46XY. The thyroid function test$ Y' q/ m6 E. n8 {/ L% t' D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ g. J7 y9 ?2 m- s, J  jlating hormone level was 1.3 µIU/mL (both normal).
# D$ X9 X, x3 |% O4 dThe concentrations of serum electrolytes, blood5 d; z) w# `: Q( s  q# [
urea nitrogen, creatinine, and calcium all were
$ j! O- q3 d# {5 v2 i) D4 cwithin normal range for his age. The concentration
0 S$ u4 Z7 @" S' i& @4 f% Iof serum 17-hydroxyprogesterone was 16 ng/dL
( N7 W2 ]4 t+ T+ B) u5 {(normal, 3 to 90 ng/dL), androstenedione was 20  H) A, W1 ]3 }' j9 [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ k5 e. j; ?2 L& X' Hterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 e& e+ W$ p% y+ u" J" D% y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 o- d# j3 T; n& T8 H  o  B( r% W7 T49ng/dL), 11-desoxycortisol (specific compound S)! ~( H* [9 L( j4 f) w( g* i
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! \0 b7 ?9 e  K" jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; d$ f6 u: G1 M. ]% ?$ S! |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 N0 a3 }9 d) n; {/ |7 Y! l" B
and β-human chorionic gonadotropin was less than
9 Z9 {$ k% G  \- ^+ W, ?5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 D9 G# r2 N; G& c; T1 Pstimulating hormone and leuteinizing hormone0 o2 Q, D. q& ~6 x. a% y
concentrations were less than 0.05 mIU/mL  J. V  x: u; }
(prepubertal).5 V3 |& K3 z: V3 I$ y
The parents were notified about the laboratory  k, r3 ?& W3 g& _$ @& Z
results and were informed that all of the tests were, ^- f. D2 S7 l4 L
normal except the testosterone level was high. The
1 X+ V% K; B% e5 W" qfollow-up visit was arranged within a few weeks to$ k1 x0 Z7 K2 \2 t9 R) A( l( t
obtain testicular and abdominal sonograms; how-! M: n8 x3 U8 o' E! F5 s5 g- `$ O
ever, the family did not return for 4 months.6 V# l2 B7 x8 |- r1 g
Physical examination at this time revealed that the
1 n( o9 c- i$ q& G, Bchild had grown 2.5 cm in 4 months and had gained1 {: ~/ y& z8 b
2 kg of weight. Physical examination remained
$ k; S* [) i# l! G# G+ Yunchanged. Surprisingly, the pubic hair almost com-
$ N  C% n8 F. e+ a+ A4 ppletely disappeared except for a few vellous hairs at
5 B/ e: V) _3 ^* Zthe base of the phallus. Testicular volume was still 2
! C) o) h1 R* |6 v, V& LmL, and the size of the penis remained unchanged.+ e# ?4 G8 K6 e
The mother also said that the boy was no longer hav-
/ {& U: x* L# a3 L: Ding frequent erections.
5 `  v. H5 A# UBoth parents were again questioned about use of
( Z/ j6 L3 I  O  L/ M3 ^, Many ointment/creams that they may have applied to
" ^1 Z3 Z) H  f; Jthe child’s skin. This time the father admitted the
' @$ L( Y/ t9 d: OTopical Testosterone Exposure / Bhowmick et al 5410 @- `& V7 \5 a' Y; r& V3 g
use of testosterone gel twice daily that he was apply-
# X3 C4 ~; |3 Ling over his own shoulders, chest, and back area for
( `7 l. Y* |( d' t: Da year. The father also revealed he was embarrassed* G1 |) K4 L7 H
to disclose that he was using a testosterone gel pre-* E" U9 g4 q: e" [* T/ g
scribed by his family physician for decreased libido' p1 F5 R3 s  k( F0 D
secondary to depression.
4 g9 E6 ?, g( g  i, w8 {$ ^' y# YThe child slept in the same bed with parents.
; M  f5 Q! @3 _! |. p% a/ f0 GThe father would hug the baby and hold him on his* q( D9 K! d& Z& s: _1 U! X
chest for a considerable period of time, causing sig-3 u" O! ^0 o4 v0 Y! [1 Q. {# X
nificant bare skin contact between baby and father.
3 Z- [" l1 b0 j# ^: PThe father also admitted that after the phone call,
: j- ?" X6 y" ^: t+ U+ w; @  c) O$ rwhen he learned the testosterone level in the baby
" G, S: X1 q& O3 E8 Gwas high, he then read the product information- D& T8 ?% D; E& ~% j
packet and concluded that it was most likely the rea-
+ [7 c  B+ J7 t$ z, n' ?son for the child’s virilization. At that time, they! X2 n" S5 l3 S& w  v
decided to put the baby in a separate bed, and the$ L5 O9 K! }* _4 z+ H7 m4 S
father was not hugging him with bare skin and had
- x; x. |+ x: M3 B  u# ^; pbeen using protective clothing. A repeat testosterone
: O* I" f) M- E8 Otest was ordered, but the family did not go to the
1 ^8 I3 Q1 r" m; a6 Flaboratory to obtain the test." |6 o* y) a" Q
Discussion6 K; A6 g2 F/ e+ d+ E& o
Precocious puberty in boys is defined as secondary# u/ y0 n% P* d  q& v$ L
sexual development before 9 years of age.1,4
4 e! @; w9 [9 [' B, j: BPrecocious puberty is termed as central (true) when2 o/ @0 c' w" z8 ?" ^. M
it is caused by the premature activation of hypo-* e1 j- S8 {7 X1 i/ n! e! I
thalamic pituitary gonadal axis. CPP is more com-3 z0 \7 C; h" U0 k
mon in girls than in boys.1,3 Most boys with CPP5 l% q$ s* W/ [$ d
may have a central nervous system lesion that is
& B: `, d2 {8 `4 @7 r- zresponsible for the early activation of the hypothal-% l4 B: K" l0 ?( H* J3 p* Y( z
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 h) B0 M" Y8 i/ a3 Nsis has been given to neuroradiologic imaging in
0 m5 f+ v0 t" oboys with precocious puberty. In addition to viril-0 D4 P5 h% b7 L3 s/ C$ m; d
ization, the clinical hallmark of CPP is the symmet-9 v. f3 K; M3 d+ _* r9 r; B
rical testicular growth secondary to stimulation by7 T( W9 R& `: `0 \6 N, w& f
gonadotropins.1,33 M- l* @- c8 ~2 o7 H* I+ Z+ L8 h
Gonadotropin-independent peripheral preco-2 l: @6 Y9 t9 d' J/ x: T% ^4 c0 E
cious puberty in boys also results from inappropriate  v6 E$ N: Z; g6 U
androgenic stimulation from either endogenous or4 |% N* Z0 m; z: w: r) W
exogenous sources, nonpituitary gonadotropin stim-  K8 z; B; ]2 W0 E2 h0 s" i
ulation, and rare activating mutations.3 Virilizing5 K" `! _  X3 z
congenital adrenal hyperplasia producing excessive7 j) G# M, l% \/ M$ ^7 G/ O; U/ ~; z
adrenal androgens is a common cause of precocious! y- i; A- Z  q' ^
puberty in boys.3,4: O1 ]0 x" `. o3 a6 L. m- J/ g
The most common form of congenital adrenal
9 v& O8 i! g0 ^hyperplasia is the 21-hydroxylase enzyme deficiency.' w8 M9 ?* V  w4 Q/ L1 U6 a' `
The 11-β hydroxylase deficiency may also result in! @1 d! A9 \: K: n/ a3 `
excessive adrenal androgen production, and rarely,# u2 Q* q5 O) ^3 X" ]. B
an adrenal tumor may also cause adrenal androgen
& f+ q  v+ I' w, yexcess.1,3
& u. l' ?/ J1 t- L8 ?+ gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 U$ {. H& M+ v8 o
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* B( ]* _  Y/ qA unique entity of male-limited gonadotropin-  H+ \) u( D9 X3 Y1 ?
independent precocious puberty, which is also known5 l+ H9 W  b7 x0 \  A- n" w; E$ i
as testotoxicosis, may cause precocious puberty at a
' M: R3 b2 S6 c& x- l* I  Fvery young age. The physical findings in these boys
/ Y1 g& z) W0 k; {5 q: h$ @: xwith this disorder are full pubertal development," M* B3 t& N8 H7 c
including bilateral testicular growth, similar to boys
1 j; x* N2 p3 {% `with CPP. The gonadotropin levels in this disorder5 q3 z. e6 f% S7 D* x% L! Z* w
are suppressed to prepubertal levels and do not show
& }) u# j9 z! \; ?  U: opubertal response of gonadotropin after gonadotropin-
3 @  B9 `& W) v# Preleasing hormone stimulation. This is a sex-linked
( x# R; ^8 `, @autosomal dominant disorder that affects only
( H) _: Y+ l& R. S$ J# emales; therefore, other male members of the family
$ ~) [0 ?- E6 [: T, `may have similar precocious puberty.3
" H2 ?, v- G  ~8 d+ SIn our patient, physical examination was incon-
2 {1 y. ?$ Z1 H" h' ~5 @6 v: K, ]9 Rsistent with true precocious puberty since his testi-6 G# a5 q) _& R% u5 q) n
cles were prepubertal in size. However, testotoxicosis
) ?' A6 z7 M  A, w& ?was in the differential diagnosis because his father
0 A; n; _6 @: b. ]started puberty somewhat early, and occasionally,) W- i" z& h( e9 l# y; M1 Z
testicular enlargement is not that evident in the
" q  s' I+ l; R; K0 d, E/ bbeginning of this process.1 In the absence of a neg-
  j8 ~8 X' G8 X& s8 }8 `5 d! oative initial history of androgen exposure, our
9 B& F5 D; x# l4 m! rbiggest concern was virilizing adrenal hyperplasia,3 o2 K; W- ?' S' M% }3 I
either 21-hydroxylase deficiency or 11-β hydroxylase
( ?3 i- `3 C3 Z8 e, p" Hdeficiency. Those diagnoses were excluded by find-
; e8 T$ }( M' G' k4 {! Eing the normal level of adrenal steroids.
" p  M2 l* X4 h: F  e. s/ MThe diagnosis of exogenous androgens was strongly1 F$ c$ O" q8 ]: F% V  }0 C1 ]
suspected in a follow-up visit after 4 months because
' V7 T' N' ~% C2 A& X/ t8 dthe physical examination revealed the complete disap-
1 _. {" b$ q/ P# c& w# N: J* jpearance of pubic hair, normal growth velocity, and/ M. G* {6 v+ m' z5 \' C5 f& z
decreased erections. The father admitted using a testos-
  }' Y+ v+ V3 X$ ]terone gel, which he concealed at first visit. He was% f8 C: H+ u7 f+ T" r4 Q+ v
using it rather frequently, twice a day. The Physicians’
9 u8 Q, k/ @- w: MDesk Reference, or package insert of this product, gel or. K/ B+ L) S. i7 l# [0 r
cream, cautions about dermal testosterone transfer to; h/ Z: k4 V5 Q. _. a5 C/ Z
unprotected females through direct skin exposure., H% [, ]- E! R. m- |' C
Serum testosterone level was found to be 2 times the  n1 _3 @5 w& H# Y( G
baseline value in those females who were exposed to
) B$ e/ J$ c& K( \3 F$ leven 15 minutes of direct skin contact with their male! z. F5 [; M: Q3 h9 q9 j: u
partners.6 However, when a shirt covered the applica-0 z, V- |3 ^6 S' D; q
tion site, this testosterone transfer was prevented.( X4 T4 _  D# M, F* Q: W
Our patient’s testosterone level was 60 ng/mL,
' F7 m# u1 T$ x7 q8 l( n- Pwhich was clearly high. Some studies suggest that
6 @, p; g# a5 {* `2 cdermal conversion of testosterone to dihydrotestos-
3 k: v; z5 y! D7 v* f$ ^2 o1 ?terone, which is a more potent metabolite, is more6 q. Y2 h3 F: i7 B# K
active in young children exposed to testosterone" C0 J- }9 a' i  n3 P6 q
exogenously7; however, we did not measure a dihy-* p* P6 @+ o- `  w" ]
drotestosterone level in our patient. In addition to
" V" c! }/ ^5 |4 N3 D  wvirilization, exposure to exogenous testosterone in
' x$ c6 ~) O2 d1 |children results in an increase in growth velocity and7 c! f4 ?( X, d# P4 G4 A- y' e
advanced bone age, as seen in our patient.
5 U# A* M5 R* ]1 Z+ AThe long-term effect of androgen exposure during# A3 u; X, V  R5 U
early childhood on pubertal development and final6 A* f6 Q8 S! Y& T7 G
adult height are not fully known and always remain5 y! g0 F6 R0 c! @7 ]4 ~* k
a concern. Children treated with short-term testos-: l, q3 G9 v$ r& v1 m0 B
terone injection or topical androgen may exhibit some
/ J; F6 _' _; A* H+ Y0 M8 nacceleration of the skeletal maturation; however, after1 F' g" |$ W: z
cessation of treatment, the rate of bone maturation
; H9 v: Z; ^+ ~, E5 i. n+ edecelerates and gradually returns to normal.8,9# ^) I$ P( v9 x
There are conflicting reports and controversy
. n: e3 d% R2 t0 _5 B. vover the effect of early androgen exposure on adult, X9 Y" _3 c2 Q; v4 z' k
penile length.10,11 Some reports suggest subnormal
5 ~: }6 w3 D8 j6 C0 O! y) U/ @1 D& Nadult penile length, apparently because of downreg-) e7 \8 [2 W- u3 N) y  e$ W2 y
ulation of androgen receptor number.10,12 However,
5 B2 V( C, A6 R6 tSutherland et al13 did not find a correlation between% C# S0 _7 B9 G4 o* ^% ~! _
childhood testosterone exposure and reduced adult# ~& a+ h; t7 \: b! r
penile length in clinical studies.7 H! r& B  ~  |2 C/ J4 f
Nonetheless, we do not believe our patient is
" k: j3 J" ?+ A) i7 V' X5 dgoing to experience any of the untoward effects from" t) m2 L. B- ~
testosterone exposure as mentioned earlier because+ w+ @+ r5 ?$ O+ U) ~5 C4 S
the exposure was not for a prolonged period of time.
8 X& r! m1 ~& x8 X/ ]( p+ TAlthough the bone age was advanced at the time of
( p8 R$ G% v: `$ i# j  z  adiagnosis, the child had a normal growth velocity at, r/ F+ L6 l7 i1 N% n% r
the follow-up visit. It is hoped that his final adult
' ]5 P8 @) G& |% P; z1 }, sheight will not be affected.$ H, n! M8 n- R8 f
Although rarely reported, the widespread avail-/ _- `, A9 p  j+ _( ]) V
ability of androgen products in our society may
) T6 |; @* J( L, \8 s( E$ ?indeed cause more virilization in male or female/ s) ]: i6 l% M5 k
children than one would realize. Exposure to andro-0 s; w' t5 J3 P& i4 @
gen products must be considered and specific ques-
7 ^: Z+ S; B) ationing about the use of a testosterone product or
5 w5 {. F* A% Z4 j% C  k& {: r: Q/ wgel should be asked of the family members during  q# h& K% j) v* C# F
the evaluation of any children who present with vir-8 x: A6 |& W+ Q4 J2 D6 y
ilization or peripheral precocious puberty. The diag-( n3 v8 o5 Q& [, B1 V/ ~! I
nosis can be established by just a few tests and by
& Y! k) D0 V4 Y# Gappropriate history. The inability to obtain such a* i* r4 {; t( x& Z
history, or failure to ask the specific questions, may
+ G3 O" \* M$ |; Wresult in extensive, unnecessary, and expensive
; H& b; n# z/ u6 zinvestigation. The primary care physician should be, s8 c2 g2 @2 }
aware of this fact, because most of these children# M/ d8 K7 K& p, M6 r; C) P
may initially present in their practice. The Physicians’8 A* ~: X% l" H' @
Desk Reference and package insert should also put a
9 _6 A" N& M: v  Z3 C; l! J* Pwarning about the virilizing effect on a male or
% F+ X8 l7 c/ Z) e' o- b% D6 mfemale child who might come in contact with some-
  I& x. O; J, M$ |$ P& `one using any of these products.1 C4 ?1 ?8 Q' ?8 a0 b3 @- L/ `, a
References
7 Z7 ]4 x& E' @1. Styne DM. The testes: disorder of sexual differentiation* B: a4 K3 l$ M" F+ w7 \$ r
and puberty in the male. In: Sperling MA, ed. Pediatric
% W9 M; @! ]  m3 X. @, N5 o; r. T: zEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ D" o( s9 `0 I/ T9 ~
2002: 565-628.  ?; [( h5 ?4 N8 d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ A% i0 ^, V& |: e! ]. |; Zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
0 F. l& s7 m/ p, ~Boy Induced by Indirect Topical
$ `3 e% i9 ]( WExposure to Testosterone
. `( V; O; e& ?Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 k# d3 W9 i0 g8 C: H- V
and Kenneth R. Rettig, MD10 ~  ?' y2 I$ q
Clinical Pediatrics
$ y6 \1 U+ H( g& y2 cVolume 46 Number 6
' u. @/ p3 Z+ `' I. ^' |4 f- @July 2007 540-543
4 }. Z2 b; @) i# G© 2007 Sage Publications
& c6 ]& N+ c$ c1 {3 _5 R10.1177/0009922806296651/ \( U3 n0 Z6 {) ?" m6 r/ V
http://clp.sagepub.com4 t/ ]- m% A) @7 S' s5 Z+ ^
hosted at
4 {, u/ ?/ v0 q2 c/ x1 E3 whttp://online.sagepub.com
1 T9 S' a  v: @( `) NPrecocious puberty in boys, central or peripheral,/ N: h8 \, l5 f' Q  S9 Q
is a significant concern for physicians. Central
, u4 O( B$ k5 u, P# R5 {precocious puberty (CPP), which is mediated
2 C  k- Q4 b' M/ Dthrough the hypothalamic pituitary gonadal axis, has; m4 X4 m0 T* t4 I! L  i
a higher incidence of organic central nervous system/ }+ V' a9 P( Y! M& h
lesions in boys.1,2 Virilization in boys, as manifested1 t: f) Z& r! f) a! s4 t
by enlargement of the penis, development of pubic* C0 Z5 ~- O/ ~6 k
hair, and facial acne without enlargement of testi-) _- Y3 g, q; q# H' P
cles, suggests peripheral or pseudopuberty.1-3 We2 o1 d  g. N  R6 m: [
report a 16-month-old boy who presented with the% X( \. B9 Z5 Z3 ~
enlargement of the phallus and pubic hair develop-6 I& i. P  b) A/ x8 t  s
ment without testicular enlargement, which was due+ G9 @& P$ K/ w  J" U% r
to the unintentional exposure to androgen gel used by  L+ C& U- @" R2 I7 t! v3 H
the father. The family initially concealed this infor-
2 Q9 D: R9 T/ @$ m4 y/ i& ~# H1 ymation, resulting in an extensive work-up for this
+ e; t4 e% Y+ Nchild. Given the widespread and easy availability of" C. J. W7 I7 [: n2 \7 `. V
testosterone gel and cream, we believe this is proba-! I, T, C" a+ k
bly more common than the rare case report in the6 d+ |. A- p8 \2 F4 v& [
literature.4
2 w! y* T' L; W$ \/ f/ W/ U6 OPatient Report
+ Z- _5 _$ D; }$ S  _A 16-month-old white child was referred to the: x6 f, |8 t: K% e) S
endocrine clinic by his pediatrician with the concern
' V" \+ H. i1 B. l5 l: y8 u+ g( Xof early sexual development. His mother noticed
/ t0 V1 G3 t& X7 k( P0 w- J1 Rlight colored pubic hair development when he was+ p7 v2 I' `1 M( c3 J# g5 y2 J
From the 1Division of Pediatric Endocrinology, 2University of$ D5 L4 M9 e% f% d& n
South Alabama Medical Center, Mobile, Alabama.
$ A0 I/ Y; }# m4 y* MAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; _; v) S6 X0 Z& X% j2 A( wProfessor of Pediatrics, University of South Alabama, College of
2 X0 u- T- `9 N: A6 D( eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 z( _5 X! t' Z- L! v  te-mail: [email protected].3 j8 W: p1 t& G8 A# H
about 6 to 7 months old, which progressively became2 {9 I: c) ?: q1 s8 v
darker. She was also concerned about the enlarge-9 O  b% t! X& n9 o: g3 }( V! n
ment of his penis and frequent erections. The child
: |, {5 b- f; I& swas the product of a full-term normal delivery, with
' P9 B& O" [* m* s) l# W! j# j( ma birth weight of 7 lb 14 oz, and birth length of
# E5 C, _$ E0 ^' H8 B: f20 inches. He was breast-fed throughout the first year
) x$ B2 I+ C& O5 w' Dof life and was still receiving breast milk along with7 h( {' O- y0 j# W( l
solid food. He had no hospitalizations or surgery,
$ Y8 d1 i# A4 P( \/ @and his psychosocial and psychomotor development
4 O3 ^3 j( @4 h& E+ [! L; I: ~was age appropriate.
8 U9 j( n( ]+ u. F- @4 `The family history was remarkable for the father,+ ~# I6 F! q% d( o4 p2 G- `
who was diagnosed with hypothyroidism at age 16,; N# @2 y! b8 l* Y. T
which was treated with thyroxine. The father’s% l+ q% k8 ^, d. ^+ H. c
height was 6 feet, and he went through a somewhat: a/ y/ t- p2 Q& [) q
early puberty and had stopped growing by age 14.
% H! D, I4 |/ q% YThe father denied taking any other medication. The
0 `& ^) k$ t  T0 q% `/ Zchild’s mother was in good health. Her menarche
! F# R# ~# q5 xwas at 11 years of age, and her height was at 5 feet& v: Q8 k9 g2 e7 z+ G' ^1 z) c7 T
5 inches. There was no other family history of pre-
( W  Q: N! d2 x6 }6 y! ]+ wcocious sexual development in the first-degree rela-
1 y9 \7 J' t. f1 W$ `. {tives. There were no siblings.
7 R; x( f/ X- Q1 E, KPhysical Examination
$ F1 W# r9 N7 i+ aThe physical examination revealed a very active,
& E% f. F( G$ g* D+ g3 xplayful, and healthy boy. The vital signs documented
+ f2 M* P2 Q, ?/ [, ]: Ya blood pressure of 85/50 mm Hg, his length was
5 I8 B  s5 A, \- I90 cm (>97th percentile), and his weight was 14.4 kg. q3 M0 l& i- j- }& t/ O
(also >97th percentile). The observed yearly growth
, A+ C& ~& w7 n0 Pvelocity was 30 cm (12 inches). The examination of5 Y3 M1 i2 i! t2 G$ R. n
the neck revealed no thyroid enlargement.* r5 B" b2 j# A$ D+ G
The genitourinary examination was remarkable for+ D. z2 Q8 {4 x( P5 Y6 k7 ~9 B( T
enlargement of the penis, with a stretched length of/ e0 E/ x! a' ]9 q0 s
8 cm and a width of 2 cm. The glans penis was very well1 l" k& r9 C3 @& _* L# h
developed. The pubic hair was Tanner II, mostly around
& X) J1 R7 I. x4 L2 L540
" q1 O5 N, ?( p8 Pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; c2 H8 {9 W* z0 {9 m1 p2 ~* f
the base of the phallus and was dark and curled. The
! d/ X" p& {9 Btesticular volume was prepubertal at 2 mL each.3 u5 T3 c6 |& A% O; B7 i
The skin was moist and smooth and somewhat
2 `* i3 R+ C' i) V: d) c" Foily. No axillary hair was noted. There were no  b9 R  g2 k* }7 o  M- S7 Y
abnormal skin pigmentations or café-au-lait spots.: P1 ?! E& J, a2 x$ g) J
Neurologic evaluation showed deep tendon reflex 2+, C! F: i+ j4 Y8 v. ]
bilateral and symmetrical. There was no suggestion( u2 n6 M1 X, u, t9 h4 i$ r- q
of papilledema.
) W' a# i; l) ^8 g" o, dLaboratory Evaluation8 y, `& C4 M* g/ y/ A' n$ R- a
The bone age was consistent with 28 months by
) ?! d) Y# x/ ~7 t8 y3 G, Qusing the standard of Greulich and Pyle at a chrono-- E) y! Q6 e3 W! W- b2 ^
logic age of 16 months (advanced).5 Chromosomal
4 Y! E; f: s) {: m1 H5 rkaryotype was 46XY. The thyroid function test
0 J* t: _4 b" Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 I' _1 W4 x# m: h8 ^lating hormone level was 1.3 µIU/mL (both normal).! A( a8 D  b0 c' q. W
The concentrations of serum electrolytes, blood
5 @" g- ~1 H5 ^5 F# \8 Aurea nitrogen, creatinine, and calcium all were
& {9 L) I3 G) ]! V- Gwithin normal range for his age. The concentration
7 p, P( @2 e! q, I* S* l$ Vof serum 17-hydroxyprogesterone was 16 ng/dL
3 m  a( ]3 D& u  c(normal, 3 to 90 ng/dL), androstenedione was 20( H4 ^0 b2 g; ?3 c/ a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 x* c# t9 j) g6 {7 g" Z( I6 G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 T! y  M5 {* x" odesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 {+ W1 _* l# u6 `$ t
49ng/dL), 11-desoxycortisol (specific compound S)
( @* B7 L3 J0 s: @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 M9 s' U; _' Y8 ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. l/ y5 |$ W/ |; N. O: ^$ h: h* |) ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# a+ G: ]2 r) a4 u
and β-human chorionic gonadotropin was less than+ p% S9 j8 c6 W  Y" O% K- x1 e, a
5 mIU/mL (normal <5 mIU/mL). Serum follicular0 [- Z7 m2 f6 h
stimulating hormone and leuteinizing hormone0 ^8 Q2 J, W; L$ J+ \, m
concentrations were less than 0.05 mIU/mL; d$ C  y8 S4 i5 _- m/ O7 ~
(prepubertal).+ @* X8 A3 E0 u$ ?
The parents were notified about the laboratory# L6 x  b3 ^" k, ~7 i( g7 J% S2 Q
results and were informed that all of the tests were
% r- }0 ?: F5 Y! `5 Inormal except the testosterone level was high. The- B  U0 S# C! E$ c* {
follow-up visit was arranged within a few weeks to
4 k4 s6 e( Q8 r: Q1 x6 Uobtain testicular and abdominal sonograms; how-) o! \* ]$ j1 E2 N
ever, the family did not return for 4 months.; u- e" t% i7 |$ T
Physical examination at this time revealed that the
! q+ e% t; V/ m2 ~& i( Gchild had grown 2.5 cm in 4 months and had gained) f4 h! W: d& g7 a; ?, N
2 kg of weight. Physical examination remained
! t) {* D: A7 F% \5 Qunchanged. Surprisingly, the pubic hair almost com-- i9 X4 S* d# g/ s1 t+ X
pletely disappeared except for a few vellous hairs at% ~3 G. D3 E2 u1 i0 |
the base of the phallus. Testicular volume was still 2
6 y6 ?2 Z9 ], q- W( d. [mL, and the size of the penis remained unchanged.2 L! ?1 ^: p0 t8 n. ~5 R: e3 q( Z
The mother also said that the boy was no longer hav-
* k6 ]8 Q6 C" P: Oing frequent erections.( x  \" z) _) f) i- s" o8 ~) m5 e
Both parents were again questioned about use of
0 o* v( d, F- }% j% cany ointment/creams that they may have applied to% ^, b% f& H2 p" h
the child’s skin. This time the father admitted the! U0 ~4 B! h, x. G* d9 a
Topical Testosterone Exposure / Bhowmick et al 541
; f( ]) j5 g2 N  g1 F# _use of testosterone gel twice daily that he was apply-
8 T  m4 n0 O4 L: I4 Bing over his own shoulders, chest, and back area for+ Z' o+ S1 [0 \! n$ b' O# j
a year. The father also revealed he was embarrassed: Y& W1 E+ V* m
to disclose that he was using a testosterone gel pre-
) |0 M; _% R' h/ z2 n1 ascribed by his family physician for decreased libido
0 I( S; S( A% O( esecondary to depression.
6 Y. l( z7 |! QThe child slept in the same bed with parents.% `* z7 ~, m' S- k2 f2 i
The father would hug the baby and hold him on his
0 j) X8 Z0 W  f8 C+ t# |  Schest for a considerable period of time, causing sig-
# n9 ?' G6 T$ G" A( `& x3 J: S" Cnificant bare skin contact between baby and father.
! n& n  g- V, L& `- {5 b9 ^( YThe father also admitted that after the phone call,( r( Q) w8 p8 j$ G/ x
when he learned the testosterone level in the baby
) b4 B( G# B7 ^5 b$ J* Lwas high, he then read the product information
6 T. J: b3 h1 P: Y  ipacket and concluded that it was most likely the rea-
/ t. S: R; q- p5 N7 K, A9 B3 L& Y/ ^son for the child’s virilization. At that time, they
- Y4 r+ M+ r' i+ M( T5 pdecided to put the baby in a separate bed, and the% @# N3 a; n7 K' w0 z
father was not hugging him with bare skin and had
  V6 b* U+ Z, \5 g1 tbeen using protective clothing. A repeat testosterone
% k- j1 K# A/ btest was ordered, but the family did not go to the4 A" k7 _1 O7 T7 q# L" f- A
laboratory to obtain the test.
" R' z7 t+ e0 W3 l; dDiscussion
) {: Y) R- W0 R2 q9 {! {Precocious puberty in boys is defined as secondary+ e% \$ U& o3 i  ^) m, e6 }$ t( y8 k
sexual development before 9 years of age.1,4) u) _$ A0 n: K( L
Precocious puberty is termed as central (true) when- J% f9 N. N+ r' Q
it is caused by the premature activation of hypo-4 v3 l" u  |% g$ i; [  Y% ~
thalamic pituitary gonadal axis. CPP is more com-3 o+ V% d& s/ w
mon in girls than in boys.1,3 Most boys with CPP
1 Y6 Z: K) e0 z  h! g" ^* lmay have a central nervous system lesion that is- E& g# V  q& V1 v3 ?5 X9 v8 X* D
responsible for the early activation of the hypothal-
2 ]3 p/ ^& ?7 `. yamic pituitary gonadal axis.1-3 Thus, greater empha-
: Y  Q, F' A# Y  zsis has been given to neuroradiologic imaging in
. X: p$ k1 o) q6 wboys with precocious puberty. In addition to viril-7 K% c8 W1 I+ A: s2 L
ization, the clinical hallmark of CPP is the symmet-; y  @7 V1 e/ m
rical testicular growth secondary to stimulation by
. v2 b  z  z& w! agonadotropins.1,3
2 }0 I$ b0 ^% M7 l2 {+ wGonadotropin-independent peripheral preco-
! Q5 i9 \3 @: Z/ O' _" u. Scious puberty in boys also results from inappropriate$ _; G4 n8 G6 s
androgenic stimulation from either endogenous or$ \  P1 ?" x2 F, ?' [* b" Q4 ~4 {
exogenous sources, nonpituitary gonadotropin stim-
9 A5 }' ^( ~+ m; Q* n# mulation, and rare activating mutations.3 Virilizing
; `! Q) j: U! Y9 Xcongenital adrenal hyperplasia producing excessive& H" i3 @8 E5 X& s( H/ m: c' G! F
adrenal androgens is a common cause of precocious
% V" w: U# L4 k; M) j8 Apuberty in boys.3,48 W1 [" f" P3 W  Q: X4 f# j/ h
The most common form of congenital adrenal
! E! m& ]" d5 I# }7 shyperplasia is the 21-hydroxylase enzyme deficiency.
5 m2 c" V. M# C4 R7 hThe 11-β hydroxylase deficiency may also result in
7 J) C. w/ Z- B* L, f& fexcessive adrenal androgen production, and rarely,3 }3 [! Q1 z: z
an adrenal tumor may also cause adrenal androgen
* s- v( k/ ?6 _7 l  mexcess.1,3- a; B* J0 l0 \  I5 ?9 n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ L" u: @& s' B5 h$ j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 H- H( Y7 Z+ x5 p. NA unique entity of male-limited gonadotropin-
, c0 x( Q& ^7 Y8 _' xindependent precocious puberty, which is also known
# C- ]- s0 ?& s% x# sas testotoxicosis, may cause precocious puberty at a
/ Z: I) z6 G$ x6 ^' U! [very young age. The physical findings in these boys
1 b, I: G' n, x$ k& H- Wwith this disorder are full pubertal development,
- q: e! {" q6 m# `, I+ @% H8 r8 pincluding bilateral testicular growth, similar to boys
  ]( A. [) t' Ewith CPP. The gonadotropin levels in this disorder
( G* Y% }& I& ?: r* Sare suppressed to prepubertal levels and do not show
) v- a4 w4 `4 R0 Cpubertal response of gonadotropin after gonadotropin-
* d) w9 l2 G: ]  s( h5 creleasing hormone stimulation. This is a sex-linked
- j) N+ Q8 q- s3 p- \' ]# R  iautosomal dominant disorder that affects only+ [8 \- D0 Z' f$ P4 \  h9 s$ z' }
males; therefore, other male members of the family2 ~/ j+ V( U9 f6 d' o" ~
may have similar precocious puberty.3
) |9 o# a* b1 V  L% k. NIn our patient, physical examination was incon-$ x5 u0 N# g  F
sistent with true precocious puberty since his testi-& k+ Y' [: ?5 m
cles were prepubertal in size. However, testotoxicosis
8 z6 C/ ^2 F" g) \* I) Q+ [5 cwas in the differential diagnosis because his father7 L4 l* q6 n" V/ o+ N8 {; z. Q
started puberty somewhat early, and occasionally,
  w4 f6 P" r' i* dtesticular enlargement is not that evident in the
) r3 G+ j& a; z0 M: d! abeginning of this process.1 In the absence of a neg-
6 \5 b/ K$ Y( i% o+ a8 aative initial history of androgen exposure, our: r7 ?8 R4 Q: ^. j5 o( h& i
biggest concern was virilizing adrenal hyperplasia,# `. e5 L- c# |
either 21-hydroxylase deficiency or 11-β hydroxylase
" ]+ S3 \/ T9 y' W" d, W$ l  Qdeficiency. Those diagnoses were excluded by find-
1 s. K; q4 t8 E7 zing the normal level of adrenal steroids.
. l  z; d) ]5 R6 i; x/ SThe diagnosis of exogenous androgens was strongly
% S0 L, L8 _- A0 d% |9 Lsuspected in a follow-up visit after 4 months because
' b. l" f5 U3 Z, Mthe physical examination revealed the complete disap-# e$ |) K$ C& Z# C/ T+ O: l  ^. G
pearance of pubic hair, normal growth velocity, and) V' X% x5 K8 r2 d
decreased erections. The father admitted using a testos-' `. o# E5 H8 s) x) R5 Y6 c
terone gel, which he concealed at first visit. He was6 s) j4 \' N- D2 f+ D
using it rather frequently, twice a day. The Physicians’6 r0 W- @7 d3 J( K: q7 Q
Desk Reference, or package insert of this product, gel or! G. \& o1 H: u4 Q( @
cream, cautions about dermal testosterone transfer to& ?& S& j* h; N
unprotected females through direct skin exposure.- i6 _  F% R. v/ y# P
Serum testosterone level was found to be 2 times the
) t  z  R. w4 G2 A  I8 Q" Xbaseline value in those females who were exposed to7 N0 h* b& K3 d& ~  B6 n2 l1 L7 o
even 15 minutes of direct skin contact with their male
! Y- `8 @# V/ l$ N/ k8 v. r( [% r6 epartners.6 However, when a shirt covered the applica-
! n3 i( ]! D/ w2 U; w. ition site, this testosterone transfer was prevented.. g2 Q9 M; B8 o0 Q3 z
Our patient’s testosterone level was 60 ng/mL,
, k2 v4 ]. p( F- _which was clearly high. Some studies suggest that- D2 {7 M" t2 j4 W$ R& i) X
dermal conversion of testosterone to dihydrotestos-" j7 k4 m$ |, v% l( ]1 _
terone, which is a more potent metabolite, is more% {' y$ I" o% A# ?7 F# ?
active in young children exposed to testosterone
$ D; N' c4 v: G8 u0 j& Texogenously7; however, we did not measure a dihy-2 M/ E, C' e: Z; W8 v) ]8 c: j
drotestosterone level in our patient. In addition to
5 C! [  I, z, @# @: {, \/ Rvirilization, exposure to exogenous testosterone in
, f0 `8 \$ O) _. m7 ?( J9 O8 W- q5 w/ Pchildren results in an increase in growth velocity and
# _0 q( b* R; D* x5 Dadvanced bone age, as seen in our patient.5 n; W5 P5 {8 I, t3 Y
The long-term effect of androgen exposure during
3 M3 C$ u4 k; s# ]3 V! dearly childhood on pubertal development and final- g1 n& }/ ~! f' S
adult height are not fully known and always remain
% `0 @! y: U# \a concern. Children treated with short-term testos-# o: ?  K4 m4 N
terone injection or topical androgen may exhibit some
0 b) D( i! P. W$ c4 N% lacceleration of the skeletal maturation; however, after7 ~- S& F2 k; Y+ W
cessation of treatment, the rate of bone maturation7 E* f3 z$ j, V$ N6 I, Q  S
decelerates and gradually returns to normal.8,9; x! t, m' C' Q( Z6 \5 y, L  g
There are conflicting reports and controversy9 |; \9 C) y& C% p8 O
over the effect of early androgen exposure on adult; F: f2 N& h7 o+ i7 k7 a
penile length.10,11 Some reports suggest subnormal
5 s2 q8 O' S4 v( Y5 x$ \% J( d, ladult penile length, apparently because of downreg-" d! c) H5 [$ [: _9 O( f
ulation of androgen receptor number.10,12 However,4 m: j7 `3 h! G% l% S
Sutherland et al13 did not find a correlation between5 O) r" p7 u' q  m; U# L
childhood testosterone exposure and reduced adult; p: z& R- K  W4 V$ _
penile length in clinical studies., h9 R3 ?9 L# Y4 I0 \, ?" p
Nonetheless, we do not believe our patient is* H+ ?" c8 C4 A  u2 ]5 f
going to experience any of the untoward effects from
* `, \( I( w. r. m! o+ g6 ]2 p0 ~testosterone exposure as mentioned earlier because. {. Z9 T. ~: D: B0 ^& u% t
the exposure was not for a prolonged period of time.
1 Z; J3 g& q' m1 M3 a/ i. c# M! ZAlthough the bone age was advanced at the time of! d$ k9 M6 q$ I4 e0 L
diagnosis, the child had a normal growth velocity at1 c5 z4 T  A. @/ d/ o% W; @" E
the follow-up visit. It is hoped that his final adult" }% c( ^* m. U  ]
height will not be affected.
* p5 V/ P  ?6 H% EAlthough rarely reported, the widespread avail-
* J8 ?( c' ~. t5 l. f% m5 ?& jability of androgen products in our society may
$ G! o( c5 j2 j  j, L" hindeed cause more virilization in male or female/ b) d& H  l' j/ y7 R4 |  ]5 n
children than one would realize. Exposure to andro-% W  l: j4 \3 O1 g2 Y) q1 i6 z
gen products must be considered and specific ques-
7 n, F0 H* k3 h; v4 Gtioning about the use of a testosterone product or
" m8 |# o! ~) U! n9 tgel should be asked of the family members during
- P6 A# ]9 @7 f- O  b: Zthe evaluation of any children who present with vir-+ X, G' \% i$ Q9 O0 k
ilization or peripheral precocious puberty. The diag-  N# z8 d5 l1 F' o
nosis can be established by just a few tests and by
# _# \0 V$ a9 Pappropriate history. The inability to obtain such a
& n$ k4 }$ z$ T" O4 T) Whistory, or failure to ask the specific questions, may& [- c+ N, z! E: ?) D7 j
result in extensive, unnecessary, and expensive5 C! K  n  U/ `/ v5 w5 a, m
investigation. The primary care physician should be- d% b( j. v4 l# T  f
aware of this fact, because most of these children) k2 }0 J# Q7 P3 M# m3 M; H
may initially present in their practice. The Physicians’
4 _* t7 z6 H) n3 k, |Desk Reference and package insert should also put a
, v  n7 D( \1 n$ w8 Z0 b; u# nwarning about the virilizing effect on a male or
8 p* t, I( g% m% Yfemale child who might come in contact with some-
7 k6 l+ k7 K6 None using any of these products.
5 Q) v3 q7 q3 x2 d" @! u6 sReferences
9 |: x6 |; w7 E7 e1 H1. Styne DM. The testes: disorder of sexual differentiation9 a6 J" P. D0 R& l8 ?
and puberty in the male. In: Sperling MA, ed. Pediatric! I3 i! I6 i# `0 k# K2 D
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( u. `7 i* V, O7 @9 O+ u
2002: 565-628.+ e1 j3 N& G( T* N6 M0 D4 F4 ]/ J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* f/ K: a5 k% t; [; V+ Bpuberty 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
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

  V1 ?' |7 P6 U精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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