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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
* }% q0 d" F& qBoy Induced by Indirect Topical, l) V' G( A/ q. e8 g4 U" d
Exposure to Testosterone& x. l; v# D- z2 q) q$ I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 j# F3 A9 k7 Q+ s  |
and Kenneth R. Rettig, MD1
4 a) j: x& b- x7 l& WClinical Pediatrics
/ Q1 s1 R' p) L5 v  S% u4 D2 O8 c0 AVolume 46 Number 6
$ Q2 y8 O1 g  I" d& ^+ p% y7 P0 J2 |July 2007 540-543
' W+ [  a1 Z4 K© 2007 Sage Publications' ]  z3 p8 o3 E/ W  z+ y2 f
10.1177/0009922806296651  Z- }0 }7 i' ~& Y
http://clp.sagepub.com
: ?0 x( e  @' ]" i* ihosted at
& U) ]2 `- Q# b% _2 g+ T/ B) Phttp://online.sagepub.com
) n) y' |- ?6 d0 R; rPrecocious puberty in boys, central or peripheral,8 {5 t$ K7 j) V& j7 o
is a significant concern for physicians. Central
# z8 r3 J: K7 ]; g2 }2 Fprecocious puberty (CPP), which is mediated
( [. Y- U9 N; e6 b2 I8 Q& c' v$ b$ I2 j1 Sthrough the hypothalamic pituitary gonadal axis, has
3 r7 X( p# E5 [  Ra higher incidence of organic central nervous system2 f- H9 p7 H' b- t3 d
lesions in boys.1,2 Virilization in boys, as manifested
7 j- \. T9 Q: @by enlargement of the penis, development of pubic- _$ q: r3 v. T# d
hair, and facial acne without enlargement of testi-$ d0 H8 D; ]. x! Q! N: I1 P: ?% M
cles, suggests peripheral or pseudopuberty.1-3 We4 \' ~% v) x. F4 t7 k
report a 16-month-old boy who presented with the' ^) r5 P# ^% B, B- h
enlargement of the phallus and pubic hair develop-
# x4 ?& ~+ i3 q" Sment without testicular enlargement, which was due
& q2 q" R. l' O( Jto the unintentional exposure to androgen gel used by% k4 |0 C( k. F
the father. The family initially concealed this infor-4 W: Z. w5 s, X) K3 w4 W
mation, resulting in an extensive work-up for this
- {6 g  [0 X1 I( a' @# k4 lchild. Given the widespread and easy availability of
( l7 ?  h3 O. {0 J% B4 |! ptestosterone gel and cream, we believe this is proba-
$ |3 S' h, `- l  _4 {bly more common than the rare case report in the( H! f% P( f. {: D2 ]0 X
literature.41 D# G/ W2 D" G# d) U
Patient Report
/ f5 t5 W% E0 yA 16-month-old white child was referred to the
- K5 ]6 }% F+ Y  }7 }) V! P& F0 r- jendocrine clinic by his pediatrician with the concern
9 j4 I& f( l/ |% u; g& O. ^of early sexual development. His mother noticed
" D. m$ T9 y& v% ulight colored pubic hair development when he was, |, F; A- A( U5 I# z+ [( J( f
From the 1Division of Pediatric Endocrinology, 2University of
! q0 G$ y0 P/ I; a0 t* x6 W& mSouth Alabama Medical Center, Mobile, Alabama.
* V! j$ k6 l+ Q! B0 y- gAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 U6 C" U" l4 e1 ?; ]
Professor of Pediatrics, University of South Alabama, College of
* z+ q6 o! g4 E5 u: _& N* W; ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- F, O* K" I. be-mail: [email protected].6 x# q! ?2 X7 |$ ^6 U" H
about 6 to 7 months old, which progressively became
: D- p9 U! X' N/ v# T% N( udarker. She was also concerned about the enlarge-' @, R( Z: b3 C1 b2 K6 u
ment of his penis and frequent erections. The child
6 _1 ?: X- \2 s8 pwas the product of a full-term normal delivery, with
9 @( L. H. m$ K, M4 D1 L) Ca birth weight of 7 lb 14 oz, and birth length of- _5 F! C% u. e! h6 L& U
20 inches. He was breast-fed throughout the first year
$ t0 Z8 w+ E% \; G) Mof life and was still receiving breast milk along with
  i- ~# u& ^! p8 X9 U& qsolid food. He had no hospitalizations or surgery,9 z: [1 I7 p& d0 @3 j5 C# G
and his psychosocial and psychomotor development
3 R  Y4 {9 i, s2 Rwas age appropriate.9 K0 D- E3 z/ |- L
The family history was remarkable for the father,4 i3 q. T% ?) D8 k1 W9 f% Z( v2 Y
who was diagnosed with hypothyroidism at age 16,
! N3 j+ [3 m) k/ A% Y$ rwhich was treated with thyroxine. The father’s
9 d/ r- i6 M. X6 m, }% J. v3 fheight was 6 feet, and he went through a somewhat
' \/ y: \6 `& U: ^" Mearly puberty and had stopped growing by age 14., v% u3 N; k" J: F$ F. |
The father denied taking any other medication. The
! c" M3 y3 t+ b7 ~child’s mother was in good health. Her menarche
" K+ b7 k, Q8 [; x# l( Q8 T; @was at 11 years of age, and her height was at 5 feet) h/ F: f6 h4 D# h( B$ T% V
5 inches. There was no other family history of pre-
6 I& q) x4 Z3 @" e. e/ l7 lcocious sexual development in the first-degree rela-
5 k" D: w) J/ K8 btives. There were no siblings.
  T6 {% x9 [0 L; H9 P5 s+ lPhysical Examination2 @$ @! f; |8 u% c* |
The physical examination revealed a very active,
* _: I5 c8 t1 n. c3 X5 kplayful, and healthy boy. The vital signs documented
7 b+ m7 b2 t8 n/ x8 `. Ta blood pressure of 85/50 mm Hg, his length was4 Z% [+ q5 P. y2 I
90 cm (>97th percentile), and his weight was 14.4 kg
, A2 Z7 i  a! j$ y5 d(also >97th percentile). The observed yearly growth9 G7 K/ z1 ]  {# N, i5 [
velocity was 30 cm (12 inches). The examination of
) I' @# F, c8 ]8 Y1 hthe neck revealed no thyroid enlargement.
' S+ a. f. V7 J0 m2 x$ M% L* s! ]The genitourinary examination was remarkable for
( [- _6 d9 @/ A2 y% ]$ h) Qenlargement of the penis, with a stretched length of
* Y1 \, x4 O$ j8 cm and a width of 2 cm. The glans penis was very well
: W- @. C5 I# y9 h" ?developed. The pubic hair was Tanner II, mostly around6 f5 \; I( g/ e" h
540- n8 B- r: m9 L/ y6 S" B1 w( f7 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 j# v* X- H$ w0 G  [8 d" a0 d( d. tthe base of the phallus and was dark and curled. The
8 c& n- n% I5 c0 q9 h! }% N! C: w! \testicular volume was prepubertal at 2 mL each.
5 P, V& W" r. F8 `# {! GThe skin was moist and smooth and somewhat
) E/ \5 c3 l: Boily. No axillary hair was noted. There were no" x/ I$ t" f. u/ u
abnormal skin pigmentations or café-au-lait spots.
8 H, Z2 C: O5 |  a9 h' k( {0 }Neurologic evaluation showed deep tendon reflex 2+' K. C: J  u/ B# ~4 c
bilateral and symmetrical. There was no suggestion
1 i! B0 A, e3 t, z1 {of papilledema.! c* ?: E, s4 K
Laboratory Evaluation2 A1 }+ M6 R+ f. W+ h2 u
The bone age was consistent with 28 months by
) K% F2 A) q. {+ H/ O3 l. eusing the standard of Greulich and Pyle at a chrono-
7 |6 ^; ^3 X: `& ?+ N- g9 s# m, zlogic age of 16 months (advanced).5 Chromosomal
$ }, q1 o( g# k, Okaryotype was 46XY. The thyroid function test- j& [1 V# W6 J6 Q/ |; G8 V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" d) c3 G) W: A' ]5 j
lating hormone level was 1.3 µIU/mL (both normal).
1 T5 h6 {2 {  BThe concentrations of serum electrolytes, blood1 p2 s2 u- N9 \2 y0 Y
urea nitrogen, creatinine, and calcium all were
0 R% I$ r+ H0 Swithin normal range for his age. The concentration
% F9 V+ A1 C3 S7 x5 Pof serum 17-hydroxyprogesterone was 16 ng/dL! n4 f& Z( M$ P& a% c
(normal, 3 to 90 ng/dL), androstenedione was 206 _# t0 Z. B- N
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" G0 _' E" T) K  dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 t; f! t. }& hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to/ ^8 d% f# r  u* h
49ng/dL), 11-desoxycortisol (specific compound S)+ E/ i/ r' X  i0 |, [" N6 q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 i0 ]) k. V4 K% V( L/ C- J/ o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( w2 u* X, C/ b( O7 S( g9 J1 D  t
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' ]7 b# d  N2 b% h- n
and β-human chorionic gonadotropin was less than
$ Z" ]* Z. |% @! T! e, u1 H5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 O: |1 |/ g, Vstimulating hormone and leuteinizing hormone
% f0 c; U- ?, k5 Gconcentrations were less than 0.05 mIU/mL6 l! y$ r2 I7 A6 G: D. n/ r; v( R0 E
(prepubertal).% U+ l- k9 @  _. O! U
The parents were notified about the laboratory
. u. C0 W' v& l, C1 qresults and were informed that all of the tests were
( V7 n& F2 r$ G( ^& K) d3 D8 ?- gnormal except the testosterone level was high. The
, m( K! v3 r  e' gfollow-up visit was arranged within a few weeks to3 G1 h/ M, N' ~
obtain testicular and abdominal sonograms; how-$ O- m" s* D* w! C
ever, the family did not return for 4 months.3 |2 X$ l5 V9 ]- y+ F' ?8 h
Physical examination at this time revealed that the
- D9 [7 _, D7 M2 l; ^child had grown 2.5 cm in 4 months and had gained2 E# [9 @- E! X" D0 P- r  w
2 kg of weight. Physical examination remained
2 k0 C2 |. z! b1 eunchanged. Surprisingly, the pubic hair almost com-
% C' e+ J1 Z. P$ I2 v- Gpletely disappeared except for a few vellous hairs at
4 V6 v/ h( [. `! Y3 N  Sthe base of the phallus. Testicular volume was still 2% V; F5 H" x) B9 t3 {' v: _
mL, and the size of the penis remained unchanged.8 k7 U* o( C) k
The mother also said that the boy was no longer hav-
% k, T7 K  h3 n- h; h2 D9 d- p: Ving frequent erections.
( \- f* Y3 V, b( }Both parents were again questioned about use of
( s' d! _0 v8 t7 C2 D4 ?% z. iany ointment/creams that they may have applied to) S' G0 O7 f! ?5 e
the child’s skin. This time the father admitted the
* f$ A% i6 Y  Q$ ^6 B7 T! lTopical Testosterone Exposure / Bhowmick et al 541' K) {. Q( Z3 u% T- ?
use of testosterone gel twice daily that he was apply-
" \) L6 D/ A- A7 f/ s, e) wing over his own shoulders, chest, and back area for
. t8 @8 A. b$ E$ L5 _+ M( z( l6 Za year. The father also revealed he was embarrassed) g6 m  H1 C0 I& h
to disclose that he was using a testosterone gel pre-# K7 e& U& K; }. V. m
scribed by his family physician for decreased libido+ b9 R. N8 g* I4 n
secondary to depression.
4 O& D9 {0 I0 YThe child slept in the same bed with parents.
3 g' e/ ~! m1 PThe father would hug the baby and hold him on his( L. I! E! u3 c/ Q% U( q
chest for a considerable period of time, causing sig-/ c7 }( X. }: o9 R/ J
nificant bare skin contact between baby and father.
6 _6 U5 p7 W: ~9 t% lThe father also admitted that after the phone call,
. K9 F- O* p4 J- ?2 m) }when he learned the testosterone level in the baby
4 F- e( g6 W0 ]3 nwas high, he then read the product information$ o( l; [8 _* i' u- C- S1 c
packet and concluded that it was most likely the rea-0 h( a, ~' ^( ~
son for the child’s virilization. At that time, they4 |& l+ Y4 `$ g& ?3 W9 j! Z) s0 v
decided to put the baby in a separate bed, and the& E0 q  w% f# u2 V/ t
father was not hugging him with bare skin and had
/ E3 {! w4 ?) Pbeen using protective clothing. A repeat testosterone
5 ]+ c7 x. f* }3 ktest was ordered, but the family did not go to the
0 i# m- ]( G5 ?. \8 n- [( Nlaboratory to obtain the test.
) s- `  U& V" z) c; O: t" VDiscussion
$ H3 B' Z3 q9 e4 P0 l% OPrecocious puberty in boys is defined as secondary$ w9 j7 I0 @4 P9 ]' Y$ k" k
sexual development before 9 years of age.1,4
8 G: p* w8 o! @% s+ u7 NPrecocious puberty is termed as central (true) when/ C. E& |$ g2 M) ]
it is caused by the premature activation of hypo-
- z" Z/ j. x. O" q% xthalamic pituitary gonadal axis. CPP is more com-1 ^/ V2 r9 i5 M  R
mon in girls than in boys.1,3 Most boys with CPP/ d* M% t7 r( O2 I
may have a central nervous system lesion that is$ r. w" I7 r6 K) d8 I
responsible for the early activation of the hypothal-& I# p1 b+ f0 J; s8 Q. ]
amic pituitary gonadal axis.1-3 Thus, greater empha-- W% T2 J7 I. A/ D
sis has been given to neuroradiologic imaging in+ S0 l9 F" t% i0 F
boys with precocious puberty. In addition to viril-
* J2 i5 Y- b) E! Dization, the clinical hallmark of CPP is the symmet-) x/ m+ |2 y/ u5 r' n
rical testicular growth secondary to stimulation by
1 ?, L7 c" }5 G# Pgonadotropins.1,3
( ~1 b2 q  N+ |Gonadotropin-independent peripheral preco-
& H/ d8 |- x9 a6 g* Ocious puberty in boys also results from inappropriate: Z, U: Z6 K3 B8 a9 l" I  U
androgenic stimulation from either endogenous or
9 t; t  d, K$ A+ t: o/ hexogenous sources, nonpituitary gonadotropin stim-
$ J; Y' [/ N, F( p8 C6 X% aulation, and rare activating mutations.3 Virilizing
' n7 S2 Y& g5 ~2 k; }0 W2 Ccongenital adrenal hyperplasia producing excessive( P7 x2 _- h+ u* `1 z( q8 @8 D
adrenal androgens is a common cause of precocious6 D" t" t' p  `
puberty in boys.3,4
' H, A. S7 Z$ h' m/ bThe most common form of congenital adrenal& ^* I! g4 m8 f& ]5 g" o  O4 k
hyperplasia is the 21-hydroxylase enzyme deficiency.+ A( w2 E, a$ J0 N4 P+ D- w
The 11-β hydroxylase deficiency may also result in
+ [/ C9 T6 y- S0 K0 }excessive adrenal androgen production, and rarely," ?) h0 P  k4 M& y
an adrenal tumor may also cause adrenal androgen8 \" o% P* Q# q
excess.1,36 T8 W9 E3 k6 d! J/ R8 }" X( Q' t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ j) j! t! ~2 D% _542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' ?3 E1 O& y/ _% U& {9 ?- Z
A unique entity of male-limited gonadotropin-
8 n9 }! e8 X) d  J! Iindependent precocious puberty, which is also known- n2 E9 n; g, d8 V
as testotoxicosis, may cause precocious puberty at a
0 K. {! {& K  s* x; [7 Fvery young age. The physical findings in these boys; R4 F. B7 X0 a8 |. V; w: Z
with this disorder are full pubertal development,2 v, `( C" c$ ^" d* z3 z
including bilateral testicular growth, similar to boys
" V, b* Y; j1 C2 A5 lwith CPP. The gonadotropin levels in this disorder
# u; ?0 \! p" Uare suppressed to prepubertal levels and do not show
1 ?0 x* C# f& z' S) o: Kpubertal response of gonadotropin after gonadotropin-
4 `( \8 W2 E% f/ [4 Y& k! U* ?7 |0 ~releasing hormone stimulation. This is a sex-linked+ d! K% z! w: u  v% T* ?
autosomal dominant disorder that affects only
% @" c; Z% V, Dmales; therefore, other male members of the family
4 Y7 v  Y8 H$ qmay have similar precocious puberty.3
7 Z1 M" i$ h, c" u$ F8 |/ rIn our patient, physical examination was incon-; W) c9 j4 Q* e- I# X# Z
sistent with true precocious puberty since his testi-
6 s  ^  y& S; b7 gcles were prepubertal in size. However, testotoxicosis0 P5 O' H  A' S  b
was in the differential diagnosis because his father+ i0 O& E- Y+ h0 O6 V7 E
started puberty somewhat early, and occasionally,
+ [) l7 v/ L- G3 dtesticular enlargement is not that evident in the
) e/ [% s0 H6 E: _beginning of this process.1 In the absence of a neg-
$ A# k; A  o" X6 \  u- Bative initial history of androgen exposure, our: n4 T* c5 c& H. U  i& a6 _
biggest concern was virilizing adrenal hyperplasia,
, f( _# p9 }/ ^; `5 |+ Weither 21-hydroxylase deficiency or 11-β hydroxylase8 B4 N, `1 w* i8 I" A* w2 E
deficiency. Those diagnoses were excluded by find-
4 n6 w. Z6 ?& Iing the normal level of adrenal steroids.
! m& P( Y% ^9 s8 F9 BThe diagnosis of exogenous androgens was strongly
% g& ~; t% E* c7 e1 Lsuspected in a follow-up visit after 4 months because
& P& q! u& A4 _9 m0 gthe physical examination revealed the complete disap-# n! F0 ^  P, K; G
pearance of pubic hair, normal growth velocity, and
3 e! |7 D( w$ z" sdecreased erections. The father admitted using a testos-9 f8 c' a5 X% ]
terone gel, which he concealed at first visit. He was3 E  s  `6 ~2 U8 W4 a# r, ?5 a
using it rather frequently, twice a day. The Physicians’
" @* O& |$ X5 F% P# W3 hDesk Reference, or package insert of this product, gel or( y9 b2 w1 [  H* u* T' z, H. X
cream, cautions about dermal testosterone transfer to8 @4 S3 z& l' N
unprotected females through direct skin exposure.
! s- o2 _+ D4 F* G* kSerum testosterone level was found to be 2 times the
' Q7 R( P- q8 Y+ ?  F) n3 jbaseline value in those females who were exposed to
: n7 g, ^2 f) peven 15 minutes of direct skin contact with their male
# X& e- Q7 Z& v8 j; L2 }  }partners.6 However, when a shirt covered the applica-# |, j! N- {% h$ C
tion site, this testosterone transfer was prevented.( \, r/ f& }: g8 P, @$ h0 J4 M% Q/ O
Our patient’s testosterone level was 60 ng/mL,2 s0 S4 O. y% r- w4 E3 W9 ]
which was clearly high. Some studies suggest that0 j0 Q- f9 Z" t. L- Q
dermal conversion of testosterone to dihydrotestos-1 J# r8 y; I" M( U! p& ~( W2 v
terone, which is a more potent metabolite, is more' F9 L$ i% `: M5 j, z6 p3 L
active in young children exposed to testosterone
5 j/ B1 W5 A) z4 W; I  Lexogenously7; however, we did not measure a dihy-
, M- E/ B5 U+ Z/ M! X- F' Q- vdrotestosterone level in our patient. In addition to
* h! O, h: Q7 ^$ K# e( E3 |virilization, exposure to exogenous testosterone in
: k. W& b2 T; _/ echildren results in an increase in growth velocity and$ d: p& j4 U/ d, _& M
advanced bone age, as seen in our patient.
+ `# y4 K1 d3 R( QThe long-term effect of androgen exposure during5 n. L8 _2 `9 z7 r6 Y
early childhood on pubertal development and final0 F6 x; v. I' _' m% m5 [9 o- y; [
adult height are not fully known and always remain6 \+ h8 i6 f/ E' R5 p( h9 |  h9 Y
a concern. Children treated with short-term testos-
% I/ l$ O4 |2 ~: Z" x" pterone injection or topical androgen may exhibit some& e5 ~6 k2 J  P
acceleration of the skeletal maturation; however, after# X- k! \" ~; p; W- j
cessation of treatment, the rate of bone maturation+ S/ B1 q# O3 b& [8 ^- W5 V
decelerates and gradually returns to normal.8,95 h. @. w) [' q9 J! a
There are conflicting reports and controversy# ~9 l. D6 o9 `4 U
over the effect of early androgen exposure on adult
  v1 W- K, X  H7 W+ Npenile length.10,11 Some reports suggest subnormal
" o) l/ S. C! C8 R7 badult penile length, apparently because of downreg-3 e0 Y, Y8 U1 g4 k8 v& |
ulation of androgen receptor number.10,12 However,) s$ i4 E; ?, H& F4 D- H7 i: m9 b
Sutherland et al13 did not find a correlation between" ^0 b' F* K. f: ]2 M8 p
childhood testosterone exposure and reduced adult
  B1 m7 g' w3 Kpenile length in clinical studies.: L  P' E3 ~, t: r4 T" |% z
Nonetheless, we do not believe our patient is
5 O) f! U8 p: U- n6 J. Jgoing to experience any of the untoward effects from9 O8 }7 O7 v, z: S. L: J3 ]
testosterone exposure as mentioned earlier because
% \$ O9 E0 M1 R7 l" \: Nthe exposure was not for a prolonged period of time.
- m: N  r2 T9 A% n) D5 AAlthough the bone age was advanced at the time of
' ]! X# z+ Y5 |/ Ldiagnosis, the child had a normal growth velocity at3 u) W0 _! u& k" [! z' d; u
the follow-up visit. It is hoped that his final adult
4 I% E# ?* Q+ H  Sheight will not be affected.! R7 H; E/ J, z# X" D  P) y
Although rarely reported, the widespread avail-
( _5 B0 y! v* Z0 j/ o3 F7 {ability of androgen products in our society may
) G5 X$ h( K6 o- u# n- gindeed cause more virilization in male or female' W0 G5 S0 n" ?0 h
children than one would realize. Exposure to andro-
% D6 _9 Q' d% L$ \& }' {* d& I( J" Xgen products must be considered and specific ques-* i/ R( S* P. q; s# j6 R2 j- H/ t
tioning about the use of a testosterone product or
$ d' `3 \/ N- B# u  m1 v; N" m' G! fgel should be asked of the family members during) t) l3 K/ s( F! }. Y, K# d% @
the evaluation of any children who present with vir-
9 f4 `. o* c; D: \& Kilization or peripheral precocious puberty. The diag-4 i4 \, f% _/ Q! g$ {" L
nosis can be established by just a few tests and by5 z% i1 J3 O& s' u! N. w; f8 z& e
appropriate history. The inability to obtain such a6 W5 O& \) i% O, s" B, ?
history, or failure to ask the specific questions, may8 s: [5 }5 h# z6 E3 v! U4 h
result in extensive, unnecessary, and expensive4 A! D5 _8 z" f" g
investigation. The primary care physician should be* j2 B  C4 J1 O" K" k
aware of this fact, because most of these children
7 b" p; q! Z1 ~: Z" k" T0 l0 Vmay initially present in their practice. The Physicians’
6 [0 ?- E4 P. b6 @% oDesk Reference and package insert should also put a# Z" M4 B2 }5 e% J2 w5 S0 ^
warning about the virilizing effect on a male or& }8 d6 `# ~& J6 ]9 E; S* ^
female child who might come in contact with some-
/ q. \2 T% b5 k! ~7 L7 bone using any of these products.- }: J  j+ U6 Z6 F' e/ _
References
5 Y4 U2 z/ J# z1. Styne DM. The testes: disorder of sexual differentiation
6 i6 |! s! m" T- ^and puberty in the male. In: Sperling MA, ed. Pediatric  m5 K  {+ G/ L3 c: X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! |7 f/ D! P6 X& a5 J3 F1 a0 t
2002: 565-628.. U3 w% ?/ p1 I! _7 O  s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, t! A- e2 a7 ^
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
+ F# I; J0 d) ]7 DBoy Induced by Indirect Topical
) e, @  \4 D7 P( f& f8 z( IExposure to Testosterone& ]  N! p7 u* Q4 |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! B! O+ J' P0 b# z4 [
and Kenneth R. Rettig, MD1
& X- |4 d( R% K+ X% OClinical Pediatrics2 \' m, F$ z* W$ u6 e7 b( @, ~- a: j
Volume 46 Number 6( p1 W9 I6 G% h4 P) ]! ~
July 2007 540-543
$ a' @8 k+ _! A7 J3 f8 F© 2007 Sage Publications+ z' a( p& a8 Z/ j9 U) F- d
10.1177/0009922806296651( \1 K+ \" ^7 x% l& o& g, U, o5 a( b' T
http://clp.sagepub.com5 S% h4 t# g7 \, M) {
hosted at
, `/ F3 q* K9 O7 N+ R  m4 lhttp://online.sagepub.com( o" N3 @/ `( W
Precocious puberty in boys, central or peripheral,, `  g, X/ I/ h5 x, X% p" u
is a significant concern for physicians. Central: H, Q, j, _- F, Y
precocious puberty (CPP), which is mediated
; E4 U& X: R/ @9 [5 z! ithrough the hypothalamic pituitary gonadal axis, has
8 P; R' t" s( @8 t0 v; h" oa higher incidence of organic central nervous system- H# z9 F; j/ o. a
lesions in boys.1,2 Virilization in boys, as manifested7 @4 e( e7 _' F& V0 s
by enlargement of the penis, development of pubic
8 p4 ~, L0 `* Q* a) k& g3 Q, y4 _hair, and facial acne without enlargement of testi-
; {# q3 V& k. z3 q! ocles, suggests peripheral or pseudopuberty.1-3 We
! h+ ^) x/ f* k% p/ ]" j1 Preport a 16-month-old boy who presented with the
; A- j0 c' ?8 q& tenlargement of the phallus and pubic hair develop-
& ~& T3 o4 r% g: y/ ^, ?ment without testicular enlargement, which was due0 A$ o7 U% ^- }5 _5 j, j5 v8 X
to the unintentional exposure to androgen gel used by
$ C9 @5 ]  s8 O% U3 q4 S1 S! Uthe father. The family initially concealed this infor-, F9 _" \( s2 P  C1 N- N
mation, resulting in an extensive work-up for this
4 G" p$ I, \5 ?, _' {child. Given the widespread and easy availability of+ t- s. s" f( j$ z* D2 _6 C
testosterone gel and cream, we believe this is proba-
6 l: o& o6 w4 Z: I8 D0 gbly more common than the rare case report in the  I3 ~" J& a) `& K: x- {- r
literature.4
: L  q! A" }/ d/ A% V. A9 DPatient Report+ G5 m2 w" {- c( b" B
A 16-month-old white child was referred to the  y3 k5 _3 \, V5 D6 c( Y( t
endocrine clinic by his pediatrician with the concern
, F3 ~. Q! X3 s/ y* H! F' i* ^of early sexual development. His mother noticed0 i4 i1 v. W- y: }) ~& @. p
light colored pubic hair development when he was
8 d/ W2 }. r4 A# PFrom the 1Division of Pediatric Endocrinology, 2University of
$ T8 \; ^# e% Q4 B# e' E% d; o% G6 v: xSouth Alabama Medical Center, Mobile, Alabama.3 T: ]* W( U2 T# m" Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" W3 I) \/ A1 u; |! S! Q2 ?6 jProfessor of Pediatrics, University of South Alabama, College of; o$ [( E& j+ {5 g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 l5 u5 P: Q+ @$ y- }* g  c9 r' re-mail: [email protected].7 T& f; h* p& e# D: P( h
about 6 to 7 months old, which progressively became3 G! C/ Y0 Z+ W
darker. She was also concerned about the enlarge-! F- F. \# W& r
ment of his penis and frequent erections. The child. r8 U8 J8 }. u' ]5 S& e
was the product of a full-term normal delivery, with
2 z/ \5 q/ \8 B& v9 a$ `$ s; h0 X, ?a birth weight of 7 lb 14 oz, and birth length of
' l8 h) a( Q* Q! s20 inches. He was breast-fed throughout the first year9 \0 S+ W# e2 b2 @
of life and was still receiving breast milk along with# F1 H# Y* F0 f% q( ^
solid food. He had no hospitalizations or surgery,  f& p- j# I$ S& _+ R" M) h
and his psychosocial and psychomotor development
& n7 l, ?0 K3 ^0 Nwas age appropriate.
) v9 `- U" ]' s. E3 s, x& N* j1 ~The family history was remarkable for the father,
' t4 b' R* X- R- s+ ]who was diagnosed with hypothyroidism at age 16,
/ x0 W8 A7 ?' P5 Wwhich was treated with thyroxine. The father’s# Z1 X& ]% y) x0 [3 U' k7 ]9 _
height was 6 feet, and he went through a somewhat
+ |2 M: ]9 ~8 Gearly puberty and had stopped growing by age 14.
3 d. t: S- U; S. G5 dThe father denied taking any other medication. The/ y, z8 s4 W# p& \9 B! c8 x
child’s mother was in good health. Her menarche
7 O- O& `: k) S+ }+ d/ Bwas at 11 years of age, and her height was at 5 feet( B1 Z1 T2 g3 ]5 H- n
5 inches. There was no other family history of pre-
5 m( z0 j" `4 A2 r4 e+ ~cocious sexual development in the first-degree rela-
& g3 x% Z( ]4 q+ d: otives. There were no siblings.' n$ d( z4 d# i# X1 x  e$ w
Physical Examination) z: a1 N& ^+ d
The physical examination revealed a very active,
5 v' q$ i0 Y( r% A1 xplayful, and healthy boy. The vital signs documented3 c2 D7 g( f0 y+ n. k0 H
a blood pressure of 85/50 mm Hg, his length was
4 _3 [& I; a$ k$ e2 Q90 cm (>97th percentile), and his weight was 14.4 kg1 B& F+ E! L2 Q" ^9 B% s
(also >97th percentile). The observed yearly growth! N4 q8 J& p/ n" s+ d$ j
velocity was 30 cm (12 inches). The examination of$ @6 s6 f5 b& x1 E7 g1 H& [* @
the neck revealed no thyroid enlargement.! w6 H5 a# b  V0 v( A
The genitourinary examination was remarkable for% j3 [* M9 Q0 A$ K7 i! E2 Y- I$ V
enlargement of the penis, with a stretched length of# J2 U# c4 F' S7 V5 o" L
8 cm and a width of 2 cm. The glans penis was very well
7 [2 @( L: I5 d3 tdeveloped. The pubic hair was Tanner II, mostly around
! T8 j: q) k; _& }540
0 v, b! ~) Z4 A7 B* t8 C8 Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 v6 Q- a6 H  Pthe base of the phallus and was dark and curled. The
* C9 E9 G; k9 ]( Wtesticular volume was prepubertal at 2 mL each.
0 p8 A2 Z! I6 P9 H) I% e* oThe skin was moist and smooth and somewhat
& e' I( i" [% `3 C2 l! Doily. No axillary hair was noted. There were no/ A6 R! q$ D, j3 x: J0 l
abnormal skin pigmentations or café-au-lait spots.
' c& B% Q/ w2 [4 Q! r9 E. |% BNeurologic evaluation showed deep tendon reflex 2+
) N. r. E; I$ T7 P: Xbilateral and symmetrical. There was no suggestion
, b) P3 O% u) Lof papilledema.9 W9 D3 _: i7 D% A  G9 l% T
Laboratory Evaluation" l! n3 l2 O3 g: a7 n; k, k* h
The bone age was consistent with 28 months by  C8 b9 x' f  Q) c1 u
using the standard of Greulich and Pyle at a chrono-
* O' A; `: Y1 ~2 H( glogic age of 16 months (advanced).5 Chromosomal
7 E6 y) @& R/ wkaryotype was 46XY. The thyroid function test# e2 t. i7 T: A0 F' i6 S( U2 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 P4 V  a  e2 S$ k9 [) y2 M
lating hormone level was 1.3 µIU/mL (both normal).
% Q' _' a* a9 ^' r. Y5 {" [The concentrations of serum electrolytes, blood
2 k) L# W: M) i+ w  g: f9 Aurea nitrogen, creatinine, and calcium all were, G8 W: m- ~+ @0 b3 v* }( t" \# z
within normal range for his age. The concentration
! [4 `) }5 j, c: v/ B: Hof serum 17-hydroxyprogesterone was 16 ng/dL1 C; o" j7 w* u! Y% S
(normal, 3 to 90 ng/dL), androstenedione was 20
4 M; w5 V) I4 ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 W# m4 d4 A, o# L. h9 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 p- t2 M% i0 d/ i5 b* a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 o; k- u$ F3 H" A' x" \3 t2 ~
49ng/dL), 11-desoxycortisol (specific compound S)4 L( R& j. V3 f/ ~+ z& L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 a( G2 k+ _' Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) r/ e& u, A) @% C( s& D# {9 h) Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ @  b' i6 s9 d/ V/ |1 x/ r7 g
and β-human chorionic gonadotropin was less than, @/ f! G3 L1 \; Y% }4 ?: i, p+ T
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- m4 o/ e: K8 @1 @& I: estimulating hormone and leuteinizing hormone
; M$ G8 D, v6 l; H. g  Oconcentrations were less than 0.05 mIU/mL. W/ t  j! ]8 _5 O
(prepubertal).
+ T! o1 ], y8 J* A$ f/ ?The parents were notified about the laboratory
- }* J/ M; t  h8 q2 oresults and were informed that all of the tests were
+ r6 D# P& w. Z! h/ Tnormal except the testosterone level was high. The
4 c/ W8 H- D: l0 d) H" ifollow-up visit was arranged within a few weeks to
* c# U, Q4 W( k$ a. Y5 Eobtain testicular and abdominal sonograms; how-$ Q, \5 Q: s6 ]( J7 M" w8 {
ever, the family did not return for 4 months.! Y5 Z- |% A) ]# f" A
Physical examination at this time revealed that the
' I5 _- f' |7 F- j' schild had grown 2.5 cm in 4 months and had gained, s& k; t- f% Z  X. P& f+ I
2 kg of weight. Physical examination remained# T8 |3 f$ e$ ^/ K
unchanged. Surprisingly, the pubic hair almost com-
: \; Q+ |! P0 I; \. ^# p/ Jpletely disappeared except for a few vellous hairs at$ x4 ?( w# c. U# o0 s1 z3 g
the base of the phallus. Testicular volume was still 2
, j5 z. B5 f  ?! `* W! G3 bmL, and the size of the penis remained unchanged.
, N0 `, w# k3 \- cThe mother also said that the boy was no longer hav-: p7 X- A8 F! ]  V- c
ing frequent erections., M6 l3 @: g4 F' k" q* v9 w
Both parents were again questioned about use of
. K: T/ o# a9 z8 g5 h4 r8 N/ oany ointment/creams that they may have applied to
7 I) b+ l3 e2 N. tthe child’s skin. This time the father admitted the2 S( |5 ?2 H3 L0 h# n$ Q
Topical Testosterone Exposure / Bhowmick et al 541
; V! K, G! _+ nuse of testosterone gel twice daily that he was apply-+ L! n. r& {' ?* U2 K2 z- k
ing over his own shoulders, chest, and back area for
* e) m5 B, X4 G2 Y8 I! Ra year. The father also revealed he was embarrassed
% N4 G: C/ F0 d# lto disclose that he was using a testosterone gel pre-# B. u' F1 \( Q/ ?
scribed by his family physician for decreased libido( X( h# Z  }1 }" m* B, N2 l
secondary to depression.
, ]  E! k9 T) w8 eThe child slept in the same bed with parents.
; P! d0 G9 a+ l$ c* s2 R  TThe father would hug the baby and hold him on his
1 {7 x$ f0 H7 I* D: pchest for a considerable period of time, causing sig-
% h4 r8 ]) R# A7 t5 Xnificant bare skin contact between baby and father.
0 q# C7 V" {* _% gThe father also admitted that after the phone call,6 a( T. e0 G/ F  [5 E
when he learned the testosterone level in the baby
6 k" Z+ C0 u5 t* U7 T0 `" T( p& t1 t5 Bwas high, he then read the product information
" I/ s; u3 z0 o" D8 p- W; d+ Dpacket and concluded that it was most likely the rea-
% k# b8 Z7 b& W% [; q" J8 Z" Yson for the child’s virilization. At that time, they3 i# L. _- |' c2 X8 I: B: Q6 N
decided to put the baby in a separate bed, and the
5 P# p8 Y. P+ V+ B2 ffather was not hugging him with bare skin and had
/ H+ r) Y; S  v+ b7 l; `been using protective clothing. A repeat testosterone
9 f  B& ?  f" itest was ordered, but the family did not go to the8 {1 v9 J" Y1 `% y5 D( J# l
laboratory to obtain the test.* P% z  p; \2 C7 m3 i
Discussion- A$ B6 X: F5 j" U; S
Precocious puberty in boys is defined as secondary
% d- b6 C1 a/ X4 C; lsexual development before 9 years of age.1,4- u$ i, l4 a- V; C! y- F
Precocious puberty is termed as central (true) when
6 V3 \( i  a) A  ?it is caused by the premature activation of hypo-5 e9 l) P9 Q3 X& n& v
thalamic pituitary gonadal axis. CPP is more com-* D3 M5 p# w; j  G* w  _
mon in girls than in boys.1,3 Most boys with CPP& Z# k% }2 P# w+ ^1 {1 s
may have a central nervous system lesion that is: d4 _3 H  z1 A' t" r8 E
responsible for the early activation of the hypothal-. r. x$ g, ?% Q% E. k, O3 c
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ T/ z2 A, B/ o* E3 `0 j0 _sis has been given to neuroradiologic imaging in
4 ?( U5 C" l( Vboys with precocious puberty. In addition to viril-
  f' Y  M, |4 bization, the clinical hallmark of CPP is the symmet-+ a7 |4 C3 K' J3 V5 c$ a4 f4 o
rical testicular growth secondary to stimulation by9 K+ G1 G. `1 l' Y
gonadotropins.1,3+ ^2 I$ O# i" m$ k6 t
Gonadotropin-independent peripheral preco-
! ^* t  y- W" {8 ^' P7 Ocious puberty in boys also results from inappropriate
/ ?( |0 E- ?: W0 f: r& s% I# O# fandrogenic stimulation from either endogenous or
2 b3 I" Q8 \: a6 k' Sexogenous sources, nonpituitary gonadotropin stim-( e( u7 L5 A% H1 ?
ulation, and rare activating mutations.3 Virilizing7 T6 ]0 i) H; G1 A2 ]: n3 L- E6 l7 \
congenital adrenal hyperplasia producing excessive
6 |$ r' Q- w- B2 \" H% eadrenal androgens is a common cause of precocious
# k1 \/ I' p5 x" mpuberty in boys.3,4
9 ^" \$ X9 S( |! ^4 p/ v( n3 iThe most common form of congenital adrenal: R: w% _( W2 W* @
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ d) }6 C) [% UThe 11-β hydroxylase deficiency may also result in
0 i. w. l4 c; Aexcessive adrenal androgen production, and rarely,! v3 o+ x; ]! w( l0 Q' \5 A( q; T! T
an adrenal tumor may also cause adrenal androgen. L9 t! t1 c( ]$ F- i$ H6 a
excess.1,3
$ K, e! l% u/ m  N  Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& E% S3 q' `! }0 `8 w& m. J
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 Z9 n" w! B2 l( f/ Z) C
A unique entity of male-limited gonadotropin-* f! Z7 k3 U. c2 Z( C* G3 k* a, [% w' ~
independent precocious puberty, which is also known
' z) m9 a2 }8 R1 Uas testotoxicosis, may cause precocious puberty at a
' p8 i8 r9 p& K, D- xvery young age. The physical findings in these boys
, m  E8 |# H/ [1 }# [& O# Jwith this disorder are full pubertal development,
1 m# Q$ m- r: K, S# ~including bilateral testicular growth, similar to boys4 `9 x  H& c% c! _" z9 _
with CPP. The gonadotropin levels in this disorder
  `" y1 x# x7 `# U0 zare suppressed to prepubertal levels and do not show6 `/ f) a+ U* N
pubertal response of gonadotropin after gonadotropin-
4 n+ Y, x  D* }/ M7 Rreleasing hormone stimulation. This is a sex-linked6 {6 a0 V8 a( d: v
autosomal dominant disorder that affects only2 ?8 ^, ]8 ^7 \4 J
males; therefore, other male members of the family; A  E0 L9 V& G8 n. q7 C0 E
may have similar precocious puberty.35 B3 r4 J* r3 Q& L$ i; v
In our patient, physical examination was incon-
* r; c& N6 O! h2 hsistent with true precocious puberty since his testi-& R( K! w! ~) N! N0 M7 j8 ~
cles were prepubertal in size. However, testotoxicosis
1 s/ D* |9 J& p( Xwas in the differential diagnosis because his father
7 j% @# @5 A! o2 C! Istarted puberty somewhat early, and occasionally,
' o; W& Q  ]4 f8 G& ^# u3 b0 Vtesticular enlargement is not that evident in the
; z* u- h! l$ Q) R: [  N, p# Q# Ebeginning of this process.1 In the absence of a neg-
( j3 [3 t- _5 b# E) M) a$ b# v' Zative initial history of androgen exposure, our2 V* c, }' R$ y' p; D
biggest concern was virilizing adrenal hyperplasia,. Y5 [, s" I" N' `; @: M
either 21-hydroxylase deficiency or 11-β hydroxylase
8 a; F; p8 b- d1 Rdeficiency. Those diagnoses were excluded by find-; [% E0 d. n" m5 \' M( d
ing the normal level of adrenal steroids.  T  B6 e+ B9 s) b4 U$ M
The diagnosis of exogenous androgens was strongly
9 X, q# |4 V( G3 A4 i( Isuspected in a follow-up visit after 4 months because
' s, a. _, C& W; P- g! e% Y; ]! z) i3 othe physical examination revealed the complete disap-
5 h6 W  w9 g/ a  P" ppearance of pubic hair, normal growth velocity, and6 x; M- Y6 B( Q) K( @6 s/ v
decreased erections. The father admitted using a testos-
  j. `% k/ m  N# T3 j: y7 Wterone gel, which he concealed at first visit. He was8 O) `( m  F& ?8 c6 V6 A7 d- B5 _; ~' k
using it rather frequently, twice a day. The Physicians’+ u$ C2 l$ L( U3 q# G/ L
Desk Reference, or package insert of this product, gel or) ~* I  I6 [* j1 h
cream, cautions about dermal testosterone transfer to
% c5 h* e, d3 @  |8 g$ i) `unprotected females through direct skin exposure.
! d4 v6 n7 x# G9 x- cSerum testosterone level was found to be 2 times the
+ j( f' `* A1 n6 g$ M1 |' wbaseline value in those females who were exposed to. B# ?4 w/ j+ Z) j# l
even 15 minutes of direct skin contact with their male
* ~9 R% b- a' l8 y0 xpartners.6 However, when a shirt covered the applica-3 k) b# Z- k( `2 z8 d$ q6 x* c
tion site, this testosterone transfer was prevented.
5 d1 h) C5 i# J+ M& mOur patient’s testosterone level was 60 ng/mL,
8 ^; u; |2 {0 A/ {which was clearly high. Some studies suggest that
( O8 h. G2 Q- U5 {! Ddermal conversion of testosterone to dihydrotestos-
  e" o5 \0 Z2 ~9 X+ P1 Bterone, which is a more potent metabolite, is more
4 z) d6 B, M! S% }* s- I* Xactive in young children exposed to testosterone1 z. C  p5 w0 c7 ]/ Y' J9 [3 h* U
exogenously7; however, we did not measure a dihy-
8 R0 k9 s1 m8 K/ c: W4 {drotestosterone level in our patient. In addition to5 p, v2 G0 L6 M& B( e
virilization, exposure to exogenous testosterone in
( S- S1 c" V; G- {0 S$ Q! n6 Dchildren results in an increase in growth velocity and
2 |3 S' W0 ~3 Z6 G2 W/ S+ @advanced bone age, as seen in our patient.  h. V% q3 M7 C# E6 \/ S. c4 k( v
The long-term effect of androgen exposure during& I3 o8 b$ m& J  \$ J
early childhood on pubertal development and final
" h- N2 {$ g* q, aadult height are not fully known and always remain0 C3 ]0 B; q/ a
a concern. Children treated with short-term testos-" c( e# q2 q$ v+ y9 m1 d5 D4 c
terone injection or topical androgen may exhibit some
$ F% G$ Q3 Y( ]7 T* g) z, `# macceleration of the skeletal maturation; however, after
' Z7 V( U" H/ Dcessation of treatment, the rate of bone maturation
) x8 `* c2 J. C! a: c8 L7 ?decelerates and gradually returns to normal.8,9
  {6 R" B! k  S! y1 gThere are conflicting reports and controversy: x( z2 j% |$ V% p
over the effect of early androgen exposure on adult( D1 _; x9 T$ `* X, L& [+ |* L: e
penile length.10,11 Some reports suggest subnormal
: P  r1 w/ v- n: x: Qadult penile length, apparently because of downreg-
* P% l/ l' U- D7 s5 sulation of androgen receptor number.10,12 However,. }& A; ]2 n, V1 Q5 i
Sutherland et al13 did not find a correlation between
' t- o3 Y7 S4 k1 E3 ?8 {4 Qchildhood testosterone exposure and reduced adult/ D  R' [7 }# Z
penile length in clinical studies.3 ?9 t; }; Q( V! Q  J6 y0 ?
Nonetheless, we do not believe our patient is
  f7 a" B% E, _7 o* U5 igoing to experience any of the untoward effects from
1 E$ Z% q# D/ [: D3 u+ ^+ u1 B& t* itestosterone exposure as mentioned earlier because# u) `" V- l; @7 N" {
the exposure was not for a prolonged period of time.6 ~" w/ r+ k$ W- b
Although the bone age was advanced at the time of1 J/ q7 h5 I6 ?6 M
diagnosis, the child had a normal growth velocity at
  o$ ^9 q/ i' S) `# ~. m, Tthe follow-up visit. It is hoped that his final adult
/ p; ^  D! y* s5 j$ i$ Fheight will not be affected.1 C, Y, x0 E* ~+ f' [
Although rarely reported, the widespread avail-
, Y% G: R/ @6 J* _' n: |ability of androgen products in our society may" I& a6 j/ y$ Y* ]
indeed cause more virilization in male or female
5 f3 a+ b7 n% _) @children than one would realize. Exposure to andro-6 z  q; B' b/ V& P" K
gen products must be considered and specific ques-7 u7 I, _4 B" K+ u( W9 o: X. _5 q
tioning about the use of a testosterone product or
+ h6 A- F: i4 e$ e1 Hgel should be asked of the family members during
) X& y! b/ Z% v  Athe evaluation of any children who present with vir-
) o1 Y5 Q" T7 |  _# u) N6 p% Y# Iilization or peripheral precocious puberty. The diag-1 c  z4 L6 Q4 g( o+ a! k
nosis can be established by just a few tests and by( ]( d& J$ `8 E% r
appropriate history. The inability to obtain such a
! S4 a+ P8 c  d0 m2 Xhistory, or failure to ask the specific questions, may+ A3 _6 G4 d+ m: G1 I
result in extensive, unnecessary, and expensive
# X1 a$ @( K3 Iinvestigation. The primary care physician should be
. S, w* T# @' Xaware of this fact, because most of these children: C4 c) X( K+ d( v# l8 V( t
may initially present in their practice. The Physicians’9 q( _5 c) I. H9 h2 j$ L5 m
Desk Reference and package insert should also put a; w( x5 _3 _9 C6 g. A" c; R
warning about the virilizing effect on a male or
0 x8 ^. ]1 E9 P6 k5 t5 _( Yfemale child who might come in contact with some-2 X" c( `+ d9 ?$ M& O1 O( Q+ h
one using any of these products.  G- c. r+ M" i, x
References
4 `' h- T  D. K1. Styne DM. The testes: disorder of sexual differentiation% x& ~. M# K/ i2 W1 I
and puberty in the male. In: Sperling MA, ed. Pediatric
6 [) X9 I/ z+ K$ B% B& y; z# b8 a5 fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ H2 t% ]0 u& C
2002: 565-628.
8 c. I0 u+ ]- A, s8 q3 I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, {- v& A' s1 @( ]* Ypuberty 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

% b5 |5 t( o% y0 H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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