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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-Old0 a' G1 Y+ d2 ?! ]
Boy Induced by Indirect Topical
/ S, |& p2 c5 FExposure to Testosterone
6 r" k9 x  Y& f% y1 }: QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& {5 H- `- A) H) g( xand Kenneth R. Rettig, MD1
3 s) e5 t" k( I5 Z" LClinical Pediatrics
. E6 {8 l; `  {' Q8 _. cVolume 46 Number 67 D) D) u$ b6 r  k* x9 a6 t- s
July 2007 540-5430 E/ b/ ^! R( [4 y; t5 ]) W
© 2007 Sage Publications  X% S9 Q8 c. \5 P
10.1177/0009922806296651& q. T* \3 `$ f$ p8 j8 S# p
http://clp.sagepub.com* S2 j2 i; Q2 m, b# K
hosted at
4 q* M7 c7 z& `7 G3 dhttp://online.sagepub.com
5 \" N( n/ X. Q! P/ X, _& EPrecocious puberty in boys, central or peripheral,8 w0 R) |- o8 ?6 ~% e- j3 _8 A
is a significant concern for physicians. Central8 V) O2 D9 U- F* k0 ^( p+ W& Z+ {
precocious puberty (CPP), which is mediated
. L: Z1 n2 u0 W) w3 jthrough the hypothalamic pituitary gonadal axis, has: s, @! C. p% Q* h. W
a higher incidence of organic central nervous system8 S8 {$ W& Q0 v" q$ v
lesions in boys.1,2 Virilization in boys, as manifested& i: R) Y8 }9 s# g3 |1 W
by enlargement of the penis, development of pubic
( W  Z% p: p1 K9 }' W* Lhair, and facial acne without enlargement of testi-3 S; i$ |/ K) k2 C/ q; [& ?
cles, suggests peripheral or pseudopuberty.1-3 We
: ]" p# `0 y& a0 ~report a 16-month-old boy who presented with the
; e- p' @; g: M, p0 c6 A3 _6 nenlargement of the phallus and pubic hair develop-
& {3 ~  `- z+ o" E* Mment without testicular enlargement, which was due0 s' g& S; p# ?4 E( m
to the unintentional exposure to androgen gel used by
( ?9 ~% [6 s" \2 [7 q. E" l5 Jthe father. The family initially concealed this infor-
/ z) o* m1 ?' F) ], S. w# N5 cmation, resulting in an extensive work-up for this
1 \# B9 z) H3 y  L8 {$ v, Cchild. Given the widespread and easy availability of! O8 }+ }; _5 x1 b3 B
testosterone gel and cream, we believe this is proba-
+ `+ w9 h2 e) c# Y) I* u0 |1 K, sbly more common than the rare case report in the0 l% A9 u% _; `8 {- [+ e! Q. P7 B% _; M
literature.4
) l& A) c* y, y3 bPatient Report
6 @; D2 ]% i4 Z' V( v/ {" xA 16-month-old white child was referred to the, Y* C4 P7 J" F1 |0 d, p- c- z$ }
endocrine clinic by his pediatrician with the concern1 _% u  y. g2 W( m% p
of early sexual development. His mother noticed' f! C0 G& i/ f( h
light colored pubic hair development when he was
- e0 x5 [2 X) RFrom the 1Division of Pediatric Endocrinology, 2University of( N* d7 c2 s/ h" C2 A$ P, r9 f
South Alabama Medical Center, Mobile, Alabama.! C3 w/ o  n5 e; h$ ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 ^9 m6 i  }! g) v
Professor of Pediatrics, University of South Alabama, College of: d0 q. T9 i5 X  N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ j1 N$ ?; y* O" L6 }e-mail: [email protected].
5 J* u( S7 a4 a$ Z& f8 Nabout 6 to 7 months old, which progressively became
7 c, R$ O8 E; x( Qdarker. She was also concerned about the enlarge-% ^" |7 J$ B( C
ment of his penis and frequent erections. The child0 ]. N' _7 _4 g/ j' t! e
was the product of a full-term normal delivery, with
; j4 R* J% K5 Ua birth weight of 7 lb 14 oz, and birth length of
" G; d+ y! v5 L: M20 inches. He was breast-fed throughout the first year( J6 g- d8 `- c; _0 C
of life and was still receiving breast milk along with
  x" M1 Y5 b0 csolid food. He had no hospitalizations or surgery,
( W" B/ e6 A) R# G8 c- }( \& land his psychosocial and psychomotor development/ O4 o5 }7 I6 V
was age appropriate.3 n, i: n4 u+ W: s3 R& S
The family history was remarkable for the father,8 s% j& l4 u, ]& j
who was diagnosed with hypothyroidism at age 16,
9 f; X2 u; o/ b, [# N- z/ p* _which was treated with thyroxine. The father’s
0 o8 [7 p7 b- h( Theight was 6 feet, and he went through a somewhat" f8 I+ G3 w* F8 B
early puberty and had stopped growing by age 14.
- Z* t$ z& T* g) wThe father denied taking any other medication. The
4 A8 h% z* X$ x5 E1 b3 q% echild’s mother was in good health. Her menarche) ]3 t  E, b) y1 M
was at 11 years of age, and her height was at 5 feet0 t$ @1 Y2 {9 T$ y$ D
5 inches. There was no other family history of pre-: i4 N+ i$ \% P8 A( |( C
cocious sexual development in the first-degree rela-# i6 E0 }) C1 x5 [6 O' \
tives. There were no siblings.  ?% U3 X6 g, v6 [; ?, \
Physical Examination
/ D" A- O0 B3 f- SThe physical examination revealed a very active,' X0 K$ D2 H$ j; \- L! D
playful, and healthy boy. The vital signs documented
  t  l0 I. O# d: I% Ia blood pressure of 85/50 mm Hg, his length was; v! m0 A" z3 R
90 cm (>97th percentile), and his weight was 14.4 kg: ~7 Z: y1 r7 K( L
(also >97th percentile). The observed yearly growth0 E3 G4 X) g& H. V- p- s
velocity was 30 cm (12 inches). The examination of
0 i9 m% u. W7 _5 n6 v4 m* X( rthe neck revealed no thyroid enlargement.
3 f- W$ `8 k! GThe genitourinary examination was remarkable for5 I  b( ~8 J1 _1 y3 o
enlargement of the penis, with a stretched length of& j9 {3 Z" U' |' h% r, [
8 cm and a width of 2 cm. The glans penis was very well) S2 s1 ^6 E' C) e
developed. The pubic hair was Tanner II, mostly around' v4 c4 s& }" @6 s, ^
540
/ }$ B: `6 c) R7 A- oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. z- j8 g, W6 X/ @: ~. P# t$ ethe base of the phallus and was dark and curled. The+ X' S3 y* G8 W
testicular volume was prepubertal at 2 mL each.
4 I4 e( M* k2 h( d, v3 b: m1 BThe skin was moist and smooth and somewhat
- v3 M; a: h" Z/ c; aoily. No axillary hair was noted. There were no
" S  A8 f6 \; _4 `abnormal skin pigmentations or café-au-lait spots.* F9 ^/ C" @+ ^$ Y4 g' W$ Z
Neurologic evaluation showed deep tendon reflex 2+: c/ N; `# G$ i; }" A! ~" s* B( n# v
bilateral and symmetrical. There was no suggestion
. X# n( s- a- i( y8 q$ X$ c. W) sof papilledema., \( l( F' M. f' {3 m
Laboratory Evaluation( t/ R" x! t& @' Q' g
The bone age was consistent with 28 months by& y. v) `, Y, c5 d; U- I3 z
using the standard of Greulich and Pyle at a chrono-" I# H% A( t1 y( `' ~
logic age of 16 months (advanced).5 Chromosomal9 q' y' J0 u4 M
karyotype was 46XY. The thyroid function test5 \2 t8 O  W0 b; ]  ^+ [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" h; y* S, ^- S( Z1 K8 }9 Alating hormone level was 1.3 µIU/mL (both normal).2 C) n9 p/ k- ~# a! H( ~
The concentrations of serum electrolytes, blood' A8 _+ {: G: h. p
urea nitrogen, creatinine, and calcium all were
( r7 I3 u! G. `) @! lwithin normal range for his age. The concentration
. D2 K9 b3 \( K' `' yof serum 17-hydroxyprogesterone was 16 ng/dL
# C2 _8 A/ R: P+ T* Y(normal, 3 to 90 ng/dL), androstenedione was 20$ M5 ?  Z1 M+ K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' p! Z7 x0 S. J6 dterone was 38 ng/dL (normal, 50 to 760 ng/dL),, Q2 {) G$ r. S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. {% @0 b, c1 c! A& a5 q5 s/ P: x49ng/dL), 11-desoxycortisol (specific compound S)* z6 y/ b( `" ^+ ^6 s; F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' ]* @! V+ D, x+ [9 Z$ Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ L) u% m4 E8 P; Z$ X6 l" v, _1 Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ ^8 I# [* A* c: V. R. [: a
and β-human chorionic gonadotropin was less than: L5 s- E9 z" ]9 M) q; I
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 k. n& C: j+ J4 _# z' c7 r& [
stimulating hormone and leuteinizing hormone( ?0 j2 P3 M9 ~8 U0 \1 q+ G
concentrations were less than 0.05 mIU/mL  O# \/ q# t3 r
(prepubertal).6 u; z! r/ F+ M8 D7 Q
The parents were notified about the laboratory
! f( B' R6 X  F: Gresults and were informed that all of the tests were
1 r+ Z& ]* R, f" a( snormal except the testosterone level was high. The
/ d+ a$ }  e, [, I- M2 dfollow-up visit was arranged within a few weeks to6 b  N) O  q/ X, d, b& Z. I
obtain testicular and abdominal sonograms; how-
4 _4 }6 ?8 ~( Z) @2 Mever, the family did not return for 4 months.) d0 S& v* I. U; V9 M
Physical examination at this time revealed that the
: w3 f0 i6 K3 k' A, ]# I5 b4 v# Pchild had grown 2.5 cm in 4 months and had gained0 ~* G. P- g: J+ N! b
2 kg of weight. Physical examination remained
: ?; M6 I7 x2 K9 M" R  Q- Y' d; ]. }. xunchanged. Surprisingly, the pubic hair almost com-
2 e* A  d5 d" \& G( opletely disappeared except for a few vellous hairs at9 V) N6 [1 d* Q9 o2 s
the base of the phallus. Testicular volume was still 2
( W5 C! S# H0 ^% XmL, and the size of the penis remained unchanged.5 z1 h" E  v; I/ P" Y
The mother also said that the boy was no longer hav-
' j6 D* I7 Q- n5 N/ I* I# Ging frequent erections.9 s; t3 M2 X" J$ ?1 n. e! [$ y$ i  E7 a
Both parents were again questioned about use of
% y2 ~, n7 i: q) y3 p6 J$ f& Pany ointment/creams that they may have applied to
1 I/ n% w1 i* O: A4 ?/ a  l1 Zthe child’s skin. This time the father admitted the
: u8 T9 {, j- d# O) s. M! f! e: L6 uTopical Testosterone Exposure / Bhowmick et al 5417 W4 g& I- C) A; f" ^- r. S/ `
use of testosterone gel twice daily that he was apply-
  x- R3 [% Z  M7 P( ?2 _ing over his own shoulders, chest, and back area for
3 R, B8 R0 J* z3 I: Ia year. The father also revealed he was embarrassed
7 Y' p3 v8 H  V8 b# zto disclose that he was using a testosterone gel pre-
% g) M7 z3 P+ e7 [! Xscribed by his family physician for decreased libido
' S3 [! t1 Z2 _9 T3 D% S4 U6 h; ?, ]secondary to depression.6 [* Z. D' B5 D+ z( q9 T
The child slept in the same bed with parents.
3 u( d7 S" h0 P( DThe father would hug the baby and hold him on his
* z3 h) N8 ?: C  a3 kchest for a considerable period of time, causing sig-& X# b) l- Z$ Q& b4 }  H8 n3 p
nificant bare skin contact between baby and father.
+ w0 j# I- p( c  B& S: M/ A( NThe father also admitted that after the phone call," q3 u3 E+ x+ v6 s: t' B4 ^3 L/ b% r
when he learned the testosterone level in the baby
! n6 f3 O6 J: T" K& z( lwas high, he then read the product information6 V2 f4 T6 ~9 B" W- Y# i6 R
packet and concluded that it was most likely the rea-; o$ c" A+ h0 P- t8 u( L4 M7 h
son for the child’s virilization. At that time, they
8 S7 h( y$ k! v) S5 c1 Jdecided to put the baby in a separate bed, and the- Z- J- l- e% Y( \& }
father was not hugging him with bare skin and had. x! @3 C9 `7 m6 `# |  r6 l
been using protective clothing. A repeat testosterone
8 l0 [/ g; l! x' P5 ?2 z1 t5 mtest was ordered, but the family did not go to the
4 X& ]# F: @9 I6 E; e$ K3 ]* Vlaboratory to obtain the test.
8 ]$ Z( t- w8 o. m* s1 xDiscussion7 W) m6 |/ z& t2 R  u
Precocious puberty in boys is defined as secondary& b/ o  t, f6 \, E
sexual development before 9 years of age.1,4
0 ^! b* t" Q+ T  I: O$ B1 s" `( _Precocious puberty is termed as central (true) when
9 b+ `7 B9 q  j' _, X" s. f2 \it is caused by the premature activation of hypo-3 S- l; B1 v/ o. a6 q2 l1 ^9 R
thalamic pituitary gonadal axis. CPP is more com-
5 b& n% k# w, g, c, F# z" _0 g4 jmon in girls than in boys.1,3 Most boys with CPP  F7 z; S: s, A+ j0 I( [
may have a central nervous system lesion that is% U1 K; ~9 M' w
responsible for the early activation of the hypothal-! d4 J3 [, e0 A' I
amic pituitary gonadal axis.1-3 Thus, greater empha-
; ~( O; `/ P  K5 M" x* d0 c: y2 qsis has been given to neuroradiologic imaging in
5 _$ x& K' n* D4 \7 Nboys with precocious puberty. In addition to viril-
, v" g! G" }6 l+ s8 fization, the clinical hallmark of CPP is the symmet-
: ]; b1 ~2 T% F0 O$ t+ _rical testicular growth secondary to stimulation by' r/ n# ?+ p, U' K+ w/ [
gonadotropins.1,30 W# \$ x, P5 I5 U) p  u  d1 a  M
Gonadotropin-independent peripheral preco-
' m  ?, _0 F+ acious puberty in boys also results from inappropriate
# t) f( ?$ f! j: {& tandrogenic stimulation from either endogenous or/ F8 m, v" u4 Y( a! `5 i8 E, J
exogenous sources, nonpituitary gonadotropin stim-0 ]; r$ V) D+ l
ulation, and rare activating mutations.3 Virilizing
2 c! @9 l$ p3 `8 j5 R! _" Z7 gcongenital adrenal hyperplasia producing excessive, |& H- P. |$ n
adrenal androgens is a common cause of precocious
5 a* d4 R; x. @/ I( e& Gpuberty in boys.3,40 N. a! H  y# ?$ L8 T
The most common form of congenital adrenal# ]" d2 V" @! g
hyperplasia is the 21-hydroxylase enzyme deficiency.
) ]4 t% G% m' D( x- wThe 11-β hydroxylase deficiency may also result in( K" M5 \) T8 a
excessive adrenal androgen production, and rarely,+ x/ T3 u: ^8 @9 @7 u1 f
an adrenal tumor may also cause adrenal androgen
8 j3 @! i9 B8 F) G7 [excess.1,3
8 E& M, G+ W# p' j5 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 m' g' H- L+ C8 z" }& G- p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% b! ]2 b+ S; u! I
A unique entity of male-limited gonadotropin-, _9 W1 }2 M. O6 J9 N
independent precocious puberty, which is also known
5 ?9 w# {1 V& G, J) c/ W; {as testotoxicosis, may cause precocious puberty at a, V  P. `5 I( A9 b( @3 @8 m, C
very young age. The physical findings in these boys" m9 N& o4 I+ L
with this disorder are full pubertal development,% ]! [: ^% t1 k( i
including bilateral testicular growth, similar to boys
) n8 k5 Y# |  N+ p5 z9 Iwith CPP. The gonadotropin levels in this disorder& k' ]7 R, Q, h$ ]9 I" l) y  ]1 B
are suppressed to prepubertal levels and do not show) A! v+ }* o7 v' r
pubertal response of gonadotropin after gonadotropin-
' Y: C5 S; K7 d4 ~* g8 X+ v" Xreleasing hormone stimulation. This is a sex-linked" u1 e2 D$ g3 C7 x- ^4 q/ P- ~2 d4 y
autosomal dominant disorder that affects only- Z5 G1 [$ |2 U( B- y) _- z
males; therefore, other male members of the family* j& a1 f9 U0 F$ i; }( }
may have similar precocious puberty.3$ d/ e# Q, ?  _" z3 R: G
In our patient, physical examination was incon-. m3 z/ V2 D2 S9 Y9 L
sistent with true precocious puberty since his testi-: ^7 z+ q- e: N/ `% u$ W
cles were prepubertal in size. However, testotoxicosis7 S" j( j8 w) m* Y3 |
was in the differential diagnosis because his father
# r8 T& Z, v- d( V1 D2 p' i. c" w5 `; _started puberty somewhat early, and occasionally,' h' A- f/ A* Y" g
testicular enlargement is not that evident in the( Q* E: N9 B+ p& g9 @, l
beginning of this process.1 In the absence of a neg-( l# E* @+ _2 `% G) g
ative initial history of androgen exposure, our/ @5 @/ C1 g+ S5 n4 l3 |5 G/ T. v9 ?
biggest concern was virilizing adrenal hyperplasia,
/ t2 d2 b/ ?9 B9 ^either 21-hydroxylase deficiency or 11-β hydroxylase
5 }1 P. l" V: o4 B4 cdeficiency. Those diagnoses were excluded by find-
2 v5 R+ r& `* g7 ~ing the normal level of adrenal steroids.7 p' [; I3 r) l: V$ h9 n
The diagnosis of exogenous androgens was strongly- U2 r/ G# }* S0 J2 D
suspected in a follow-up visit after 4 months because, C) K1 V/ f( _% P( F7 ?
the physical examination revealed the complete disap-2 n/ B8 p) v$ g0 X3 u
pearance of pubic hair, normal growth velocity, and# Y  g) }6 R, P5 y( a
decreased erections. The father admitted using a testos-
6 H5 x# _/ U& Q0 T) h  o& Lterone gel, which he concealed at first visit. He was2 u0 U" p! D5 ~3 L
using it rather frequently, twice a day. The Physicians’1 l# f- _: G+ p3 e" g* V" M
Desk Reference, or package insert of this product, gel or* |' j5 D; v! q) l. d' g
cream, cautions about dermal testosterone transfer to3 u- N" q  T' H/ H0 q% k
unprotected females through direct skin exposure.; E" {- J1 s$ J  B7 q
Serum testosterone level was found to be 2 times the  z$ s! L0 E$ k. X
baseline value in those females who were exposed to) e, f* q2 B5 Z/ h
even 15 minutes of direct skin contact with their male3 V$ I* f; \1 I6 U0 m
partners.6 However, when a shirt covered the applica-' I2 v! r, V5 J, b" J: E
tion site, this testosterone transfer was prevented.
6 l* x4 O" w/ d7 nOur patient’s testosterone level was 60 ng/mL,
; l. {6 C" G/ b' s, Twhich was clearly high. Some studies suggest that
0 F2 _7 J& ?6 t$ |dermal conversion of testosterone to dihydrotestos-% R$ l7 z: x3 o  R( D, L
terone, which is a more potent metabolite, is more3 ?$ w$ o) N! k" t; I* y4 O
active in young children exposed to testosterone- O+ u% |( X. K3 |; a
exogenously7; however, we did not measure a dihy-% g3 F) I1 J4 e" F/ n
drotestosterone level in our patient. In addition to
1 m7 `6 X  |# w8 Tvirilization, exposure to exogenous testosterone in: `- ?* K0 x7 F8 s4 ?
children results in an increase in growth velocity and
6 b' U8 a+ ?* R8 L0 @* V3 g6 Qadvanced bone age, as seen in our patient.# t- |( g8 A1 y0 {: z
The long-term effect of androgen exposure during) |& ?' f. C. ~4 B# h: B
early childhood on pubertal development and final: {3 K: ~6 ?7 `& W
adult height are not fully known and always remain
- Z  `* `& y4 G3 Ea concern. Children treated with short-term testos-& F& Z/ ^( I  h1 J0 i
terone injection or topical androgen may exhibit some
, C, ?9 n7 Q. a. Qacceleration of the skeletal maturation; however, after* \, y, p( {" t( O
cessation of treatment, the rate of bone maturation
: g; v. h& `# D! j  v8 ndecelerates and gradually returns to normal.8,90 V+ b& ]  ?1 Q( k1 Y3 s
There are conflicting reports and controversy- R0 p# y$ g1 s$ n% N- u
over the effect of early androgen exposure on adult' n+ s1 t( _2 z( i- o7 ?
penile length.10,11 Some reports suggest subnormal
! O# O9 F! {. b$ Hadult penile length, apparently because of downreg-
. I/ d8 _9 K# H& D( aulation of androgen receptor number.10,12 However,
, B: I! b  m: t& M3 ^6 b8 Y" fSutherland et al13 did not find a correlation between0 ]6 W5 d8 w( [/ f* U* Z2 j% d0 @' K
childhood testosterone exposure and reduced adult9 f8 O8 j3 x( w8 ^. c7 p2 ^3 g2 [
penile length in clinical studies.; a1 \( k7 v0 R% P2 \( u! `4 Y
Nonetheless, we do not believe our patient is
( P6 I0 M+ V7 f: }9 p( ^$ Lgoing to experience any of the untoward effects from
1 u) D3 S7 P) L( T' F  Ptestosterone exposure as mentioned earlier because
, \! @9 w* D! g9 j! |4 x% M+ k5 mthe exposure was not for a prolonged period of time.
: J9 I& V0 O5 g/ u) pAlthough the bone age was advanced at the time of' `6 ]  E3 Q( I3 ~4 r/ ]% I8 k
diagnosis, the child had a normal growth velocity at
6 ^4 h8 _7 l3 B5 R# V- j, dthe follow-up visit. It is hoped that his final adult
7 `* y2 q# e* v+ sheight will not be affected.
# m* x$ ?, ?8 ^3 o  N9 _8 CAlthough rarely reported, the widespread avail-
; [9 ~0 w" Y( l$ nability of androgen products in our society may
7 ?8 b8 }& R9 R8 W. r. z: D  Cindeed cause more virilization in male or female  ^+ x  c0 [. o& \! O
children than one would realize. Exposure to andro-
: `0 ]/ i! i; b) x3 u6 s2 ogen products must be considered and specific ques-
& r: Q$ \/ {; R2 ctioning about the use of a testosterone product or# ]3 i, _, c. F+ |
gel should be asked of the family members during: I; i$ W8 R; g6 O
the evaluation of any children who present with vir-4 O3 z% t6 c. ]+ ^9 \
ilization or peripheral precocious puberty. The diag-
0 d" |5 Q& ^2 P( D! t0 Onosis can be established by just a few tests and by6 r) H% b% V0 ~
appropriate history. The inability to obtain such a5 T4 ~' c$ a/ |  Z, ]  l% S' H7 }
history, or failure to ask the specific questions, may2 F2 W' A9 D0 u4 ?" F; u- S! U6 V
result in extensive, unnecessary, and expensive$ O8 H5 O0 X& F
investigation. The primary care physician should be
* A, C/ W5 W/ n  `aware of this fact, because most of these children
+ C- H0 \7 Y+ Nmay initially present in their practice. The Physicians’3 m9 {( z, b) e9 G4 J# W& n
Desk Reference and package insert should also put a) [8 q' h- O6 p" ]( w# z2 ]
warning about the virilizing effect on a male or. n9 p, ]( p; {8 d2 }7 a/ ~. A2 D
female child who might come in contact with some-9 ]3 C1 `% E6 `' D, ]
one using any of these products.
0 g) l  O1 T: |References! N/ ]5 O1 ]2 a" {
1. Styne DM. The testes: disorder of sexual differentiation
/ E# z9 q; U  w" p+ |" Land puberty in the male. In: Sperling MA, ed. Pediatric
2 k/ \+ X4 L( K3 |+ BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# A5 M$ |: s0 T
2002: 565-628.3 j7 w3 W( G0 n' P3 q: d1 k
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ ]0 A3 O9 Q7 y7 k9 l  R
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
. ~" _; W' T' D" r) I, vBoy Induced by Indirect Topical
3 J9 b% p7 g$ p" D" Z  lExposure to Testosterone
# e& L4 e$ X- Q. p4 B  ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* ^, n  \( O$ w6 \5 n1 s: {6 vand Kenneth R. Rettig, MD1% M( \: w( S& {' t
Clinical Pediatrics5 ~: s, c. H1 \0 ~7 k1 g7 k0 d
Volume 46 Number 6+ C7 f" q6 ]  `, r7 N
July 2007 540-543# `5 E7 t2 c0 O- o3 D
© 2007 Sage Publications" o5 I1 n( h( n8 E( r6 ]: |
10.1177/0009922806296651
: X  A1 n% M1 B( c) Ghttp://clp.sagepub.com9 f  R. y2 K8 v# h
hosted at
9 R: @* y# i2 ^/ }* R3 Shttp://online.sagepub.com/ X. o- l# e+ ~
Precocious puberty in boys, central or peripheral,1 Q( m+ ]: r$ S1 S0 D0 k# y- f- W- e
is a significant concern for physicians. Central
! {3 `- X: }- r% tprecocious puberty (CPP), which is mediated; _5 \6 s; i) P; v! U
through the hypothalamic pituitary gonadal axis, has( P1 E$ `- Q. ~5 p, g4 T9 k) k
a higher incidence of organic central nervous system% i2 ?9 P3 ?$ q" V( D) r  {
lesions in boys.1,2 Virilization in boys, as manifested8 ~* ?$ f0 k" ?) p( B! d
by enlargement of the penis, development of pubic
3 I5 T* }% r; e) q" z5 X8 R( Thair, and facial acne without enlargement of testi-! ]8 A) O7 x  d
cles, suggests peripheral or pseudopuberty.1-3 We
# A) z5 l7 v: w! P! C4 Qreport a 16-month-old boy who presented with the0 F6 k5 d/ M6 B( ^- Z/ R
enlargement of the phallus and pubic hair develop-
: c) a" t- U6 ?! a6 J7 k+ D# z4 h; E6 {ment without testicular enlargement, which was due  Y9 E- c1 Q* \8 B
to the unintentional exposure to androgen gel used by
  E7 @& i' G* sthe father. The family initially concealed this infor-" U  T0 b  n! n  Z0 Z+ H) W
mation, resulting in an extensive work-up for this6 ~1 c- n! k0 n; i
child. Given the widespread and easy availability of
( A1 N4 a- _2 H# n* Qtestosterone gel and cream, we believe this is proba-
  M! B. ?4 s$ e' H; ibly more common than the rare case report in the
6 E2 V. N) K2 G+ pliterature.4
/ G2 \9 g# y0 Z: L0 U* t2 BPatient Report5 d7 b7 t; @6 G! Q% f8 [3 T3 ?
A 16-month-old white child was referred to the
8 {! @% u8 e; ^$ x# vendocrine clinic by his pediatrician with the concern3 e! h! T5 F! P
of early sexual development. His mother noticed6 X6 D: P# z; @" f
light colored pubic hair development when he was3 V/ S. e+ u4 v, o) ?
From the 1Division of Pediatric Endocrinology, 2University of* U# Q: q, X5 Q! w3 e8 Z4 A
South Alabama Medical Center, Mobile, Alabama.4 I7 D2 d% W' I+ L' T( E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" z9 ?+ L' p4 _5 B: H/ hProfessor of Pediatrics, University of South Alabama, College of5 {" h' O# A7 u+ d/ w+ @1 T) V( y7 [
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& V4 [4 w1 V( u" U# Ee-mail: [email protected].
# b# V4 `+ a; V  c- @about 6 to 7 months old, which progressively became0 V3 g0 U4 f1 L: i6 \0 @: ?
darker. She was also concerned about the enlarge-
0 E! h. z2 O! {6 B) qment of his penis and frequent erections. The child1 ]- C0 a! W9 b$ Z8 P& j8 V7 |
was the product of a full-term normal delivery, with! b0 U3 P9 `" M
a birth weight of 7 lb 14 oz, and birth length of; C# I# S: |+ S9 {$ l
20 inches. He was breast-fed throughout the first year
$ D+ ^: O) G! `9 h$ }, X6 @* vof life and was still receiving breast milk along with! k# \5 W; c  ~' z7 \
solid food. He had no hospitalizations or surgery,
, V8 c: m, o% u4 u# I. ]and his psychosocial and psychomotor development
' t, W- W4 A" D8 \+ Wwas age appropriate.
$ H" p9 ?9 U, w- E' NThe family history was remarkable for the father,
6 k8 `4 {5 |" D. d, q/ \who was diagnosed with hypothyroidism at age 16,
2 L4 z1 d" P1 J, ^4 Hwhich was treated with thyroxine. The father’s
8 m, m; |$ D5 Jheight was 6 feet, and he went through a somewhat
$ @9 C" S8 z6 N5 Qearly puberty and had stopped growing by age 14." p% v9 j/ k5 D0 J" c
The father denied taking any other medication. The- P" E. C. K0 t" v5 K
child’s mother was in good health. Her menarche" ^5 ?; s; y- }4 `5 q
was at 11 years of age, and her height was at 5 feet
* }, c& }; T# e" h2 V# w5 inches. There was no other family history of pre-& M! Z, |3 I8 [
cocious sexual development in the first-degree rela-  G' \4 t3 R5 E) q+ ^9 a
tives. There were no siblings.
9 {6 u, C5 Q1 R/ jPhysical Examination
' k' P6 B& O/ ?The physical examination revealed a very active,( O/ i& I9 D, T, A3 l
playful, and healthy boy. The vital signs documented, K- _7 u" B% B5 s7 n
a blood pressure of 85/50 mm Hg, his length was
  I" t: S- a3 x  E: O* H- O90 cm (>97th percentile), and his weight was 14.4 kg$ Z: |9 U4 _* ^# Q: c
(also >97th percentile). The observed yearly growth: }$ H/ w' b" J9 `
velocity was 30 cm (12 inches). The examination of
$ a! ~/ O& b' {9 e0 d! athe neck revealed no thyroid enlargement.
  P2 S, w6 L4 a: n# r5 BThe genitourinary examination was remarkable for9 I5 c& D# w5 b- \  F
enlargement of the penis, with a stretched length of/ L6 r$ f( o' m, g9 j+ {) K  s
8 cm and a width of 2 cm. The glans penis was very well. h  X- f" @, U, Z  K" }5 R
developed. The pubic hair was Tanner II, mostly around
  m! r4 w8 t6 ]& o0 `9 J540$ m# Z3 }! I* X' {8 R+ H/ |' l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 {: Q. |# p% {# T9 N( [* G' F, r7 vthe base of the phallus and was dark and curled. The
! _6 \4 m9 H! X4 }4 s' K. q: Ctesticular volume was prepubertal at 2 mL each., C( s! }* \6 A5 Q4 f) v: H, V! q: o
The skin was moist and smooth and somewhat$ T4 O5 u: W2 p: X! n- z5 D5 j
oily. No axillary hair was noted. There were no
3 P+ Z% @1 o; babnormal skin pigmentations or café-au-lait spots.. `* I8 B! z9 v5 u
Neurologic evaluation showed deep tendon reflex 2+8 \) C5 I8 C0 q6 c
bilateral and symmetrical. There was no suggestion
$ B* d' V7 F+ x8 w$ I' x1 ~of papilledema.
' m7 x2 g0 K8 e* @, N3 VLaboratory Evaluation- _8 E4 p/ [" D. P  p: K
The bone age was consistent with 28 months by+ X/ u% n. R$ T: R9 z9 a
using the standard of Greulich and Pyle at a chrono-
% y; o& N, L$ s) I" `5 W- Wlogic age of 16 months (advanced).5 Chromosomal1 p' ~1 w7 Z9 X" q- B2 y* o( t
karyotype was 46XY. The thyroid function test4 E3 Z5 u; X# j0 q% b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ {+ D$ s, T& ~- V9 k$ W8 J
lating hormone level was 1.3 µIU/mL (both normal).6 _$ J" k0 ]; t9 N& [, a' ]8 ^
The concentrations of serum electrolytes, blood; j$ _4 a; a( e9 @- U- p% C2 b( _
urea nitrogen, creatinine, and calcium all were% W+ [) Y/ T% w
within normal range for his age. The concentration
0 z- _  O: @3 ?) X# B$ y8 _of serum 17-hydroxyprogesterone was 16 ng/dL" C5 _7 F. \7 b! c
(normal, 3 to 90 ng/dL), androstenedione was 20
) I$ Y" D+ Q; I  u" {/ }! s# Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 Z( n! o( W$ E1 a% O2 h* Q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),1 z. b$ P2 o- @$ K& u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. z8 K) w: }3 i49ng/dL), 11-desoxycortisol (specific compound S)$ n, j9 ^  K! e, ~" x% ^+ s
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 D* K' i* F; s) rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; c. K- U6 h& k
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; r2 V6 U/ J9 ?$ l/ @
and β-human chorionic gonadotropin was less than6 D+ y4 z0 }" N2 K& }
5 mIU/mL (normal <5 mIU/mL). Serum follicular  o. S( Q  S' Z
stimulating hormone and leuteinizing hormone
' s  U) ^- B% I( A+ H4 yconcentrations were less than 0.05 mIU/mL
1 o, Y' F  f$ t: A(prepubertal).9 s; o8 z+ l5 U8 x: e! Y
The parents were notified about the laboratory* e$ b, F/ A" e: m. r" [
results and were informed that all of the tests were
! l/ W% R" Q! c% z2 Y+ nnormal except the testosterone level was high. The
; Y( F, W, M5 O3 x( A* ~follow-up visit was arranged within a few weeks to! l& k# j) o! p% b
obtain testicular and abdominal sonograms; how-
0 Z2 y  e; {$ l! j+ v' a  ^ever, the family did not return for 4 months.; `/ T3 Q9 ^; [& ?( G. X0 t
Physical examination at this time revealed that the- Y/ I9 ]/ J1 B" J. i; C
child had grown 2.5 cm in 4 months and had gained
2 H. Z# Q6 ~! x2 kg of weight. Physical examination remained
8 u# v4 U, ]4 Z- @+ ?/ f/ xunchanged. Surprisingly, the pubic hair almost com-4 ~9 `" x1 X9 E) U- v, o
pletely disappeared except for a few vellous hairs at
' Q3 m1 b- Y. lthe base of the phallus. Testicular volume was still 2
/ m, d5 U6 a) @) i" vmL, and the size of the penis remained unchanged.# h" b& f. \/ W, v
The mother also said that the boy was no longer hav-
2 ?: p, M& I8 ling frequent erections.
9 `7 i8 f$ |3 _3 u; k) sBoth parents were again questioned about use of  Q. ^2 y1 A: q3 X. z
any ointment/creams that they may have applied to5 v7 k6 v8 T! h3 @
the child’s skin. This time the father admitted the* e8 @& a6 z- T* F) U
Topical Testosterone Exposure / Bhowmick et al 541
- M7 D+ ^8 K$ R3 R8 Vuse of testosterone gel twice daily that he was apply-
6 t% w- W" e7 P1 Y2 ?" u2 Ting over his own shoulders, chest, and back area for& H3 m/ i& F' J% X, }& H
a year. The father also revealed he was embarrassed
6 E5 p% P; o  ]to disclose that he was using a testosterone gel pre-, `  D- P2 R5 B+ v1 t  p6 C8 H- V
scribed by his family physician for decreased libido5 b) d, [: H% C: }% c8 f7 j- c
secondary to depression.
8 k( H. h8 P! b0 d; a- ~+ m1 CThe child slept in the same bed with parents.
2 {& D4 P) J4 J$ I$ B4 cThe father would hug the baby and hold him on his! F% N9 y0 T9 c
chest for a considerable period of time, causing sig-; j- b( b$ y4 ^, k  W
nificant bare skin contact between baby and father.
0 C4 z3 z$ J* D/ M5 B; ^The father also admitted that after the phone call,+ n% ?! ^8 ~/ j: s$ w# s
when he learned the testosterone level in the baby
2 y  m+ H5 ~& M5 F+ ^/ uwas high, he then read the product information
* z( ?  E. O% C2 ^% ~packet and concluded that it was most likely the rea-
. c$ V: \$ z. h$ x+ kson for the child’s virilization. At that time, they
* s4 s" j+ Z, ^6 Ndecided to put the baby in a separate bed, and the9 J! I( Z8 _; \1 r+ B
father was not hugging him with bare skin and had1 F0 N; N: i% L3 z  P$ D: p# q/ S6 u" G
been using protective clothing. A repeat testosterone: u; D1 \1 B8 H7 r5 c2 P1 n, R
test was ordered, but the family did not go to the
. x2 w5 b. n/ N2 G) M$ a# s8 _2 b8 Llaboratory to obtain the test.
6 ^. O- F1 a' w9 y: F1 gDiscussion
2 m. B% s( h4 c. c% ?Precocious puberty in boys is defined as secondary( B) w3 P) s- q7 |* t( R: F
sexual development before 9 years of age.1,4
) p7 X) e# h) y5 ePrecocious puberty is termed as central (true) when
& G: s& R+ Q9 l4 D6 ~it is caused by the premature activation of hypo-0 k& b, q" h+ |( T; v
thalamic pituitary gonadal axis. CPP is more com-( `9 W& @- t2 R# s2 E, W* s+ V$ P. i
mon in girls than in boys.1,3 Most boys with CPP+ p5 n$ d; ]+ p" C( P
may have a central nervous system lesion that is3 ^" P( ?5 G3 N# }, b4 l2 u* G
responsible for the early activation of the hypothal-
% s- g4 b: {+ _( o3 e. P6 qamic pituitary gonadal axis.1-3 Thus, greater empha-
) j5 E6 D- ^7 N' u$ x: x* Wsis has been given to neuroradiologic imaging in  L9 \* U0 n5 O5 o6 ?
boys with precocious puberty. In addition to viril-3 f5 y+ R1 g) L; p
ization, the clinical hallmark of CPP is the symmet-3 j7 U/ C4 H( C! u* C1 G# @5 F
rical testicular growth secondary to stimulation by) A# B! w3 {4 U$ S
gonadotropins.1,3
( G6 H! U0 C9 H# R6 qGonadotropin-independent peripheral preco-
8 R8 D: O- P: Gcious puberty in boys also results from inappropriate
* H$ i, c1 B& L1 v1 e: ^7 fandrogenic stimulation from either endogenous or' j5 P. e+ {% t, Z4 q: K/ p
exogenous sources, nonpituitary gonadotropin stim-
( s5 x( b% W& d0 d3 e9 H, y: kulation, and rare activating mutations.3 Virilizing
6 b% l2 c8 [! z, vcongenital adrenal hyperplasia producing excessive
. @5 A9 s" g6 Q+ U7 E. i! ~+ ladrenal androgens is a common cause of precocious
( V8 j* M- ~  {9 b% cpuberty in boys.3,4+ q$ g7 @  E5 G5 D) q
The most common form of congenital adrenal
7 R; w  G. }9 G- i7 p& ]) Ahyperplasia is the 21-hydroxylase enzyme deficiency.
$ W  i) n' T( QThe 11-β hydroxylase deficiency may also result in
% U4 d) u4 Y% T# T& Iexcessive adrenal androgen production, and rarely,' _5 ^+ X9 B: ^& f% w
an adrenal tumor may also cause adrenal androgen: A& c+ N4 ~) d% R5 M
excess.1,38 t/ a% S  o5 Z2 y6 k" U  h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' r2 d- \% \7 _8 p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ i9 t8 x* y2 f) cA unique entity of male-limited gonadotropin-
) C8 J) _$ |: G; y3 R/ @0 hindependent precocious puberty, which is also known8 ?2 z/ }  E0 h
as testotoxicosis, may cause precocious puberty at a& n* Z# C) v; q- c' r
very young age. The physical findings in these boys& x& E4 A/ _2 T- [' i' X
with this disorder are full pubertal development,0 \; N, s4 Q( w  I. j# \5 P& \5 b# h
including bilateral testicular growth, similar to boys
, R4 s' l+ G3 ^0 \  A9 u4 ?with CPP. The gonadotropin levels in this disorder9 u" n3 U3 A( |# p- k+ [- U* A* u. ]
are suppressed to prepubertal levels and do not show8 _( k; d( c  _$ U
pubertal response of gonadotropin after gonadotropin-
, M! F& E6 s9 F1 W9 d: Vreleasing hormone stimulation. This is a sex-linked, _# }& I* L) d* z' e% V# D- C) B4 g/ Q
autosomal dominant disorder that affects only& u3 m7 [7 z$ S% j! {
males; therefore, other male members of the family; c6 y0 }% F9 w- e7 {0 y& b, d
may have similar precocious puberty.3* z6 B9 C1 f9 m0 g9 @' V" k7 [6 @; H
In our patient, physical examination was incon-
  n6 A; n4 M' _0 |sistent with true precocious puberty since his testi-
; l- s$ ]2 _1 _1 J9 d6 scles were prepubertal in size. However, testotoxicosis0 Z7 a7 x! w9 G& U" F8 B6 D
was in the differential diagnosis because his father/ n9 t! O1 o% P& k
started puberty somewhat early, and occasionally,9 n5 h4 @9 a; `# B1 D$ [& m
testicular enlargement is not that evident in the% c. c5 s1 g! [( F
beginning of this process.1 In the absence of a neg-
! g; C' v* y, h5 lative initial history of androgen exposure, our' n! f; A" d9 G) d% ?
biggest concern was virilizing adrenal hyperplasia,
- N; j* x' v1 e5 k; g' Ueither 21-hydroxylase deficiency or 11-β hydroxylase! g/ g* m9 a& L% T. N
deficiency. Those diagnoses were excluded by find-4 E! Q5 ?/ C9 I) ~. H  v
ing the normal level of adrenal steroids.
5 d) J6 c- M5 _3 ?9 }6 LThe diagnosis of exogenous androgens was strongly4 u) u4 d  Z; P, O0 b! R
suspected in a follow-up visit after 4 months because
  x. j( f. _- A' J" z+ k/ ~+ Fthe physical examination revealed the complete disap-( S: _' \5 c4 ^. @( y: y
pearance of pubic hair, normal growth velocity, and' v; O8 w/ g, `; @8 g7 b
decreased erections. The father admitted using a testos-3 h) f, s2 R+ X$ Y" f( w- e
terone gel, which he concealed at first visit. He was8 Q- e( l1 U8 C# W  n
using it rather frequently, twice a day. The Physicians’- M3 N9 \- j0 Z- ^, n, U. M
Desk Reference, or package insert of this product, gel or+ t. A4 l; J6 |- N& i2 ~
cream, cautions about dermal testosterone transfer to2 x+ ?  x% f( L/ Y
unprotected females through direct skin exposure.
" r/ T6 I& v! H& w% ]5 aSerum testosterone level was found to be 2 times the  e3 k5 P% C+ H4 y9 |4 m+ d
baseline value in those females who were exposed to1 {5 s! V2 I. B: y# U3 `  q* Q
even 15 minutes of direct skin contact with their male& H7 v# G0 o/ t1 a$ c
partners.6 However, when a shirt covered the applica-
4 j- R. {; E$ s. ^* D8 \$ @tion site, this testosterone transfer was prevented.0 [3 `  c" x: X5 E( e
Our patient’s testosterone level was 60 ng/mL,
: L* o8 c7 N- [% Iwhich was clearly high. Some studies suggest that& Z# ~+ z7 \% n" H7 s" C0 v
dermal conversion of testosterone to dihydrotestos-
: x2 [0 `* j5 T9 b/ }  N6 D8 Dterone, which is a more potent metabolite, is more& o$ X* J) _/ v8 A- |) _  E' I
active in young children exposed to testosterone& `: d% X: e4 P# J; a
exogenously7; however, we did not measure a dihy-0 o5 R! e. W# ]5 I) I
drotestosterone level in our patient. In addition to
% _- u8 F2 \7 t) r* @" P/ Avirilization, exposure to exogenous testosterone in( @& P0 ~5 r' k1 {- g5 B# i
children results in an increase in growth velocity and, j" s6 D2 S2 J2 x& c
advanced bone age, as seen in our patient.6 V4 m. P4 s+ F4 V  t
The long-term effect of androgen exposure during
' B" n3 P. e# D2 z# q: s6 Zearly childhood on pubertal development and final2 R+ x: u$ X1 Q0 G$ Y
adult height are not fully known and always remain
2 U, ?2 W; C" Y# ^* a$ }" Va concern. Children treated with short-term testos-
1 ]  `! X* ?( e' Q5 V6 bterone injection or topical androgen may exhibit some7 d0 ^. Z8 l1 s6 @' I# x
acceleration of the skeletal maturation; however, after5 `" U7 o' E& p+ m+ T" O/ ]
cessation of treatment, the rate of bone maturation2 d' D1 k6 C5 q& r
decelerates and gradually returns to normal.8,9
5 n  m4 c7 j, G  u& {There are conflicting reports and controversy/ L1 @: W* Y- I. O, l
over the effect of early androgen exposure on adult% ?5 k. K+ o/ @. y& r
penile length.10,11 Some reports suggest subnormal
; ?6 a$ [4 n" }* M7 \adult penile length, apparently because of downreg-1 f' Y8 F. _) i  c1 M( B7 F
ulation of androgen receptor number.10,12 However,
7 q6 u5 B! k, W5 X) d! fSutherland et al13 did not find a correlation between) B8 P0 ]" P8 B
childhood testosterone exposure and reduced adult2 u2 c3 D0 u6 L! n
penile length in clinical studies.
5 y. c3 M& |. h) c8 aNonetheless, we do not believe our patient is( B: l& U# v3 L" c9 b$ U
going to experience any of the untoward effects from
5 g. m9 F( D& H, {4 r) ?- ltestosterone exposure as mentioned earlier because
% B0 Q/ _4 n2 M' p9 k# dthe exposure was not for a prolonged period of time.
0 s  w$ b( m" \: vAlthough the bone age was advanced at the time of- [/ D- D9 I) j" B8 |1 C
diagnosis, the child had a normal growth velocity at) [* ]/ @8 O1 E7 W- F! `7 X, w
the follow-up visit. It is hoped that his final adult1 v) P, ~6 f' W" @; o: W) w
height will not be affected.
7 @, K) g( g3 F) B8 v! Z2 IAlthough rarely reported, the widespread avail-
7 I9 R; k( S0 M) aability of androgen products in our society may
$ `$ a+ _& R6 y. u% gindeed cause more virilization in male or female1 c7 n0 [+ u8 @7 K9 F
children than one would realize. Exposure to andro-
: X# e9 R9 K( n" U2 C! rgen products must be considered and specific ques-
' D4 V" H1 Z, m4 N- xtioning about the use of a testosterone product or+ a$ L& u. y  J' i, {) L3 Y' T2 u; e
gel should be asked of the family members during
4 O0 h% |0 Y$ {. I3 a) Hthe evaluation of any children who present with vir-
% J! |+ k! {' R4 i+ i, Hilization or peripheral precocious puberty. The diag-+ o7 D0 S* v! b! a
nosis can be established by just a few tests and by" b8 z# y+ a! m" {
appropriate history. The inability to obtain such a
" \: Y) X6 V$ _  Khistory, or failure to ask the specific questions, may( A, w2 w! s+ ]) W
result in extensive, unnecessary, and expensive
2 ~- x- ^  j# a$ l3 ]investigation. The primary care physician should be+ @" u; v  M) o$ b+ u& m: o
aware of this fact, because most of these children
1 ^  Q, J- ?* e, k" C: Imay initially present in their practice. The Physicians’- f- Z/ P! T8 w2 L- q) q% _
Desk Reference and package insert should also put a
9 _  @$ S4 p2 bwarning about the virilizing effect on a male or8 z6 ]% J2 d+ U/ O3 g2 t. ~
female child who might come in contact with some-
, `9 j0 `: e( |% A' b" {one using any of these products.# t  I3 G' f" l! ~: n6 |7 p6 d
References# X" ?% I6 K" K
1. Styne DM. The testes: disorder of sexual differentiation: s# ?- E8 m9 A
and puberty in the male. In: Sperling MA, ed. Pediatric
( T% ^& g/ G! F$ w$ ~, \$ NEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* T. a3 G7 U$ }" z  X2002: 565-628.$ K1 j+ @5 l! P$ S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 T: h8 t( Q* H; ppuberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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

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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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