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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
& _' P6 g2 s) kBoy Induced by Indirect Topical
  o' n& e+ T7 K) n" ~2 }8 r* eExposure to Testosterone
9 l( N4 c! l9 {: D  HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" c$ s/ K0 l; X! d) v% {and Kenneth R. Rettig, MD1: D" N- K: p9 w0 U
Clinical Pediatrics
# f: w# ?* w- l$ [  k- LVolume 46 Number 6
7 z. z1 \5 w3 _# f; f) RJuly 2007 540-543# \9 \( E0 a% g
© 2007 Sage Publications
" T, T4 N0 ~* s. i10.1177/0009922806296651
9 @. w: r* ~+ ?http://clp.sagepub.com7 A5 q( L% g" ~) p2 C6 g
hosted at
' j  p8 m- G; o2 b- Whttp://online.sagepub.com4 x, d$ b- q. a; ?! J) {. w4 [
Precocious puberty in boys, central or peripheral,2 t1 D* u) H4 t8 J' Y6 X) q
is a significant concern for physicians. Central1 |1 U/ `5 \$ K. h) f
precocious puberty (CPP), which is mediated
+ I% ?- y+ g) fthrough the hypothalamic pituitary gonadal axis, has
! m; s, S' Y( Ma higher incidence of organic central nervous system
) @# J& ?5 b* X* dlesions in boys.1,2 Virilization in boys, as manifested) I% d+ j4 R# C! C5 t$ V2 f$ _
by enlargement of the penis, development of pubic
; c& M: @% S# ^% r5 w9 b# Phair, and facial acne without enlargement of testi-
( E. L& {) F/ A3 q+ w' g7 pcles, suggests peripheral or pseudopuberty.1-3 We5 ?: R* ~; o/ W! G: k
report a 16-month-old boy who presented with the7 B# ~! o- f9 m
enlargement of the phallus and pubic hair develop-
- H4 K4 m7 Q% t! T0 x' ament without testicular enlargement, which was due
$ K+ `& T5 I' vto the unintentional exposure to androgen gel used by
6 y5 A7 a6 I  [% `) I! Z) mthe father. The family initially concealed this infor-
) I+ f' }1 @- t. E/ w8 L5 tmation, resulting in an extensive work-up for this: y- G1 \! A7 `
child. Given the widespread and easy availability of
# V& \4 F" s1 A- Y1 c8 W( wtestosterone gel and cream, we believe this is proba-
+ G. t4 C) G- k, E5 X+ obly more common than the rare case report in the
; K' V3 d4 H8 j" l  Uliterature.4
7 Q7 v0 _0 y/ v  HPatient Report% j! U5 `: _" d2 f! [4 D0 Y( V
A 16-month-old white child was referred to the8 P+ |  q) ]2 V+ w
endocrine clinic by his pediatrician with the concern
1 q( _7 f3 D+ l: D- g+ kof early sexual development. His mother noticed& u- v* G5 G2 n, l" C" l1 G4 E
light colored pubic hair development when he was
, ^( i* }# Q' M6 ?From the 1Division of Pediatric Endocrinology, 2University of
  T0 H8 E& C. h" v5 u) \# q# hSouth Alabama Medical Center, Mobile, Alabama.2 t; e5 J+ d* N
Address correspondence to: Samar K. Bhowmick, MD, FACE,, Q& Q1 K* T) g
Professor of Pediatrics, University of South Alabama, College of
4 G' V8 n8 _8 |; n0 t8 y8 gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) K+ p2 H0 L2 m- Q
e-mail: [email protected].
  |/ S- F* T& ~3 G( Mabout 6 to 7 months old, which progressively became. Q+ T* ^, f5 B9 F9 h/ k
darker. She was also concerned about the enlarge-9 _5 v) o. u. H: |6 l6 c
ment of his penis and frequent erections. The child
* y- _# X3 U- |0 H  |* m1 N8 @- Cwas the product of a full-term normal delivery, with
: b- @2 V8 W6 f$ Qa birth weight of 7 lb 14 oz, and birth length of/ F5 \7 l9 A  R( g
20 inches. He was breast-fed throughout the first year( i0 w$ W5 D4 V$ K
of life and was still receiving breast milk along with
* }5 U! r9 Q. y  k3 nsolid food. He had no hospitalizations or surgery,4 Q+ K9 E+ |6 e& _9 N% ]/ S
and his psychosocial and psychomotor development) F& ?' X. {: y1 o! I0 o. i
was age appropriate.
8 U- E, ?" ?% U$ [The family history was remarkable for the father,) {' u( L) A/ g! Y; `9 u1 M
who was diagnosed with hypothyroidism at age 16,
( P) G6 F5 `7 K* D* cwhich was treated with thyroxine. The father’s
6 q! Q+ u4 @- m3 x0 Bheight was 6 feet, and he went through a somewhat3 w. |4 T2 m* k& y( b5 O
early puberty and had stopped growing by age 14.
! x) |7 t; p1 q* e& ?+ PThe father denied taking any other medication. The
5 H5 p: l4 j9 j  c. l+ J2 R0 Q, C9 ~child’s mother was in good health. Her menarche. v0 h% i# U( m8 _4 y( n
was at 11 years of age, and her height was at 5 feet
6 i$ R  W/ x% z0 o5 inches. There was no other family history of pre-
. S6 a9 ?* S0 Y, |- Y) tcocious sexual development in the first-degree rela-& Y9 [6 D6 y7 g
tives. There were no siblings.
* J8 r+ J: o# B5 D, HPhysical Examination
' Y1 [, R9 }/ t& P- u' o: R$ \The physical examination revealed a very active,6 y9 a) G. E* f5 _  B. \9 {' y
playful, and healthy boy. The vital signs documented; u: _) `  Y" |7 K( S/ `5 R
a blood pressure of 85/50 mm Hg, his length was
) k# G% s( Q; I90 cm (>97th percentile), and his weight was 14.4 kg, C  |, L$ W& Y' n
(also >97th percentile). The observed yearly growth8 B8 v9 ?# o" ~% y9 Y  d! f, w6 F
velocity was 30 cm (12 inches). The examination of
6 Y" Q, J; u0 o6 N* T: ~the neck revealed no thyroid enlargement.0 P! W( B( g! s$ F# Z% Z
The genitourinary examination was remarkable for
0 _1 x' N+ z' t) oenlargement of the penis, with a stretched length of
( N/ ]& }) q; U9 r8 J& f8 cm and a width of 2 cm. The glans penis was very well
2 _1 @0 F$ u* w% Cdeveloped. The pubic hair was Tanner II, mostly around* c& v# h6 t) {3 q, Z2 |
540
* Q( z1 Z4 r4 `& g# X( a/ G! Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" f9 m; a, J  U+ L' X5 V/ m, u
the base of the phallus and was dark and curled. The
7 c' [$ i1 l7 C& ~0 K  Htesticular volume was prepubertal at 2 mL each.
! D) d' l7 N  g/ C- l7 }8 Y' }The skin was moist and smooth and somewhat$ v2 H" R! o& Y- [
oily. No axillary hair was noted. There were no5 v- R* \7 v3 Y# B
abnormal skin pigmentations or café-au-lait spots.
* _; k; y2 {& J, o- FNeurologic evaluation showed deep tendon reflex 2+
4 V. X4 e" F9 |) O. v1 S( T9 \bilateral and symmetrical. There was no suggestion9 [' n2 {7 e! R
of papilledema.9 w* P% c' f( w" L& ?: {+ }/ f6 }
Laboratory Evaluation, m' w: l7 D  F/ r
The bone age was consistent with 28 months by2 l9 B# t- g, ]& o) {5 R7 W& ~. B' J
using the standard of Greulich and Pyle at a chrono-
$ h! B# g( l6 G  ^logic age of 16 months (advanced).5 Chromosomal
' M! P3 ?$ N' R3 H! X6 |karyotype was 46XY. The thyroid function test
" r0 e  D; Z) @9 o/ P9 m5 ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* ?) ?* G2 P' ulating hormone level was 1.3 µIU/mL (both normal).; N6 t( Y" U# g1 O% D/ ?
The concentrations of serum electrolytes, blood
9 o) F4 L  x4 b+ E) }urea nitrogen, creatinine, and calcium all were
4 K. b3 f5 w4 g* ywithin normal range for his age. The concentration
! [( o" c7 [  C! V6 }of serum 17-hydroxyprogesterone was 16 ng/dL
' Z/ ]9 u$ p3 b- U0 @$ o% v. s  F(normal, 3 to 90 ng/dL), androstenedione was 20) \: ^3 y5 Y1 F+ d1 a  r! t: w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. X) L1 d5 \0 E( G6 E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  m2 ~; W. q* }9 i9 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. q- L3 z* r  M" F1 z% o
49ng/dL), 11-desoxycortisol (specific compound S)
: E% x0 d+ ~1 w7 t' Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 Y+ ?- ~2 E3 F# o4 [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 b" k: g& W& m' u. {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* m4 _6 a) p) w% [9 H9 ?
and β-human chorionic gonadotropin was less than; i  C9 z  `& V# z7 b, A
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 h! G8 D, }3 O2 e' |: [stimulating hormone and leuteinizing hormone
, {2 d8 A2 X. M1 i3 o- nconcentrations were less than 0.05 mIU/mL: X5 |3 o* @) b9 Y1 j# s; ^0 l4 W
(prepubertal).
( ?1 _+ t# A8 N% ^% C) GThe parents were notified about the laboratory
- v5 |0 n. c3 G% j% H. I9 k+ vresults and were informed that all of the tests were: s8 z! U6 U1 Z/ R
normal except the testosterone level was high. The
& `, R) J: e; x( X- k+ {follow-up visit was arranged within a few weeks to: m1 H6 i/ [3 V. j% J* d( m" P. w
obtain testicular and abdominal sonograms; how-3 w% F  |3 _. p4 j" d
ever, the family did not return for 4 months.0 a; d) p1 @. F8 Z2 b8 H
Physical examination at this time revealed that the$ z% g: {; n1 [$ f% l3 A
child had grown 2.5 cm in 4 months and had gained
) ?# j5 W* I- l/ j4 \2 kg of weight. Physical examination remained
- ^3 ^( D) [+ q2 R  U' `unchanged. Surprisingly, the pubic hair almost com-; g- i; S$ I/ S: Y) I. E! s9 e
pletely disappeared except for a few vellous hairs at
! z/ r4 u7 k4 A# R, c' ]the base of the phallus. Testicular volume was still 2
$ T# s: `& X+ q' imL, and the size of the penis remained unchanged.. `9 a* U, Y- _* P5 ]
The mother also said that the boy was no longer hav-
- Q: e, u" w3 ?; P; g& [8 zing frequent erections.
3 D3 K, M! M7 Q: d; Q& s8 ~Both parents were again questioned about use of1 D2 ~* r6 z8 }0 w+ ^. I
any ointment/creams that they may have applied to+ F8 q2 W: |7 \* u7 b, G* K
the child’s skin. This time the father admitted the9 Q4 p$ d+ s6 d. Y( w9 C" l
Topical Testosterone Exposure / Bhowmick et al 541& B# ^4 j- v+ Y) P6 ]' [5 ?9 _
use of testosterone gel twice daily that he was apply-
9 q& R* t/ x+ s4 V6 h1 Ying over his own shoulders, chest, and back area for
& E) m0 g( Z# a- T1 ?3 J( `: ja year. The father also revealed he was embarrassed
+ Q  R. w' ?1 Y) _7 N6 d( Rto disclose that he was using a testosterone gel pre-
( W7 l* |+ o8 z& w$ }# |2 Nscribed by his family physician for decreased libido8 I. A) A' X. S8 j4 B4 W
secondary to depression.9 O- A( V& j% c8 f  f+ S0 V
The child slept in the same bed with parents.
. x3 ^- s4 ^* oThe father would hug the baby and hold him on his! G, j) ?/ q' |( v
chest for a considerable period of time, causing sig-: L2 q5 l7 k* o
nificant bare skin contact between baby and father.
* B/ x) M7 h0 S  ^" KThe father also admitted that after the phone call,3 J+ ^- \1 V, V& r
when he learned the testosterone level in the baby: J* O  F( x4 I: c% Q
was high, he then read the product information
7 ~1 v3 r; n, m* H( B/ v  ^packet and concluded that it was most likely the rea-* X) H) Q3 T( t, o
son for the child’s virilization. At that time, they4 @4 \" o& H; q$ q& k2 }4 R
decided to put the baby in a separate bed, and the3 x# ?0 D9 C4 N) B" X
father was not hugging him with bare skin and had" D$ C+ Q4 k2 G9 r& y3 \
been using protective clothing. A repeat testosterone9 i8 J8 B+ \+ G7 N! J
test was ordered, but the family did not go to the& H1 @+ W8 G: T9 \
laboratory to obtain the test./ k$ o+ X  i4 d1 {& p
Discussion/ i" l5 r- H. o* z# j% L( t0 B; _
Precocious puberty in boys is defined as secondary
8 q+ l- d, P) I* H$ Gsexual development before 9 years of age.1,4
7 B! @1 E) A; `- yPrecocious puberty is termed as central (true) when
2 |" p. r' U. ?0 _it is caused by the premature activation of hypo-
$ e4 d5 A. f* B5 {, Gthalamic pituitary gonadal axis. CPP is more com-* ~4 }" ]# {& T( K
mon in girls than in boys.1,3 Most boys with CPP" [7 B$ A: U1 Q
may have a central nervous system lesion that is+ v8 y; \' W4 G5 C4 {  D
responsible for the early activation of the hypothal-' I9 {* y, ^. P  k0 i; i3 v
amic pituitary gonadal axis.1-3 Thus, greater empha-- O4 }2 X$ J: A# ]6 T& Y
sis has been given to neuroradiologic imaging in7 R3 v; H, I6 V- S! o
boys with precocious puberty. In addition to viril-: K$ X1 E) \0 f1 A; H
ization, the clinical hallmark of CPP is the symmet-! u8 ?6 i" B8 [! {& H0 r
rical testicular growth secondary to stimulation by
6 C  c  _! \0 P' R( z" n4 R8 cgonadotropins.1,3
: M$ h+ i9 M; N- a! j* }" K' m- MGonadotropin-independent peripheral preco-7 s0 ?2 f' y% f/ _0 t9 x% C
cious puberty in boys also results from inappropriate
1 \0 v$ s) `& O$ v2 m/ Yandrogenic stimulation from either endogenous or
8 [- }( v# V' T" y& Uexogenous sources, nonpituitary gonadotropin stim-+ V6 |% @9 N& ]; E* h
ulation, and rare activating mutations.3 Virilizing1 R$ W3 j) c1 w1 |/ X! }. C4 ^8 Q
congenital adrenal hyperplasia producing excessive
& E) Y1 k2 B% |% uadrenal androgens is a common cause of precocious
4 v$ w! M# [+ P' Cpuberty in boys.3,4( t) a0 |* L& a6 G3 Q
The most common form of congenital adrenal! l; J6 Q" }$ l4 |+ A
hyperplasia is the 21-hydroxylase enzyme deficiency.
% F) r9 V6 X; [The 11-β hydroxylase deficiency may also result in
+ _! ~* V; I8 E( Y: Q& yexcessive adrenal androgen production, and rarely,
  J  o* L/ T& K" han adrenal tumor may also cause adrenal androgen
! Z- i) o' s- c( Y. K' zexcess.1,3  e5 E% T! n; W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, m* }6 S( j; h3 T7 y- Z% S/ W542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! K; K5 e) u+ j9 `8 Z
A unique entity of male-limited gonadotropin-
# Q. a* _: }1 V- bindependent precocious puberty, which is also known
5 K7 {% D+ T9 K- T( z9 r6 M+ xas testotoxicosis, may cause precocious puberty at a. Y) v1 R! O# U( D2 F6 {! z0 t+ G
very young age. The physical findings in these boys! i3 b9 S) Q; K8 y9 F# E! I
with this disorder are full pubertal development,( S) b2 g# i: B+ f( [
including bilateral testicular growth, similar to boys+ D, O$ k) ]* ~9 d: e* R. i: q
with CPP. The gonadotropin levels in this disorder
$ W5 `4 i5 t/ u4 P% Q% P$ Sare suppressed to prepubertal levels and do not show3 w6 d$ w0 w* b1 V4 U" m, }
pubertal response of gonadotropin after gonadotropin-+ v1 b" {# @6 @! d7 z
releasing hormone stimulation. This is a sex-linked
5 g9 W6 ?4 C( m! B% ?  ]0 Rautosomal dominant disorder that affects only2 T2 }# Y1 T' \- A
males; therefore, other male members of the family$ e. H9 ?7 I" O9 V: Y# V
may have similar precocious puberty.3
2 j9 K" U" M$ S- OIn our patient, physical examination was incon-
8 Z- ?5 D' Z3 o* j; g) q3 [% zsistent with true precocious puberty since his testi-4 {  H2 Y" E7 o- q
cles were prepubertal in size. However, testotoxicosis- D% c3 m( Y+ T4 {8 J# B
was in the differential diagnosis because his father
* c/ X* F( m) T" x4 m& astarted puberty somewhat early, and occasionally,
# H3 R/ K" p1 F# h. Btesticular enlargement is not that evident in the9 T, Q& K  @/ }5 E- w
beginning of this process.1 In the absence of a neg-: {) T* u0 i- X# |" [% w
ative initial history of androgen exposure, our
: \6 e1 ^. P! m' Q: N: q6 Rbiggest concern was virilizing adrenal hyperplasia,- y' |5 C2 X# u3 X: }# V9 g
either 21-hydroxylase deficiency or 11-β hydroxylase
+ I  j1 u( c/ M# Z( P% ~. @deficiency. Those diagnoses were excluded by find-8 q1 d6 {, {( T
ing the normal level of adrenal steroids.  i8 o$ X5 g  b+ T. m, ?
The diagnosis of exogenous androgens was strongly
3 s9 L* v" N$ k( @5 a) ^( Lsuspected in a follow-up visit after 4 months because
/ G. y4 K# k7 ?the physical examination revealed the complete disap-
: N6 L$ e. S/ E, Ppearance of pubic hair, normal growth velocity, and
3 U) h- ^. N3 U) kdecreased erections. The father admitted using a testos-
9 D  R2 a! x; y7 G, Y* B5 Lterone gel, which he concealed at first visit. He was
* L0 ~- _, r4 Fusing it rather frequently, twice a day. The Physicians’9 o, H4 D' C% v1 o3 }; R5 U
Desk Reference, or package insert of this product, gel or
1 ]  s. @! ~' b0 p8 c3 Jcream, cautions about dermal testosterone transfer to; o% N* l+ S/ q) Y% s7 `
unprotected females through direct skin exposure.. O* D2 ]) K, O( g8 F
Serum testosterone level was found to be 2 times the
! p9 H+ m( `6 h% dbaseline value in those females who were exposed to
" P; V# ?' P8 e# |& Ieven 15 minutes of direct skin contact with their male' U  R7 M- J' b. b
partners.6 However, when a shirt covered the applica-
  P; J( m/ T; h$ ]& ation site, this testosterone transfer was prevented.7 D4 [. Y8 @; T
Our patient’s testosterone level was 60 ng/mL,
( u' K; k3 a9 s% j3 p/ gwhich was clearly high. Some studies suggest that
9 k6 E8 V, \, X9 Xdermal conversion of testosterone to dihydrotestos-0 e) b  M' l. g: k( b: }
terone, which is a more potent metabolite, is more% m! R( C% B" d3 L- T; D
active in young children exposed to testosterone
4 {! \3 r/ j6 U5 c: iexogenously7; however, we did not measure a dihy-1 x2 c" ~, |" F1 q/ ~
drotestosterone level in our patient. In addition to
6 V4 M; b1 @% E$ C, zvirilization, exposure to exogenous testosterone in
. |( j2 \6 M6 Uchildren results in an increase in growth velocity and4 S5 u* K3 i$ S: A) Q. Y, j3 S% V
advanced bone age, as seen in our patient.
5 y% K+ Y4 q$ O# _, X" b5 JThe long-term effect of androgen exposure during
* ~- p  v& R5 Nearly childhood on pubertal development and final
" Y& ]3 n  h# B7 x! i; i+ I( _5 dadult height are not fully known and always remain
" N% z& E. r# h4 z" L# m% a  Ca concern. Children treated with short-term testos-
6 V+ |" ?5 C1 Bterone injection or topical androgen may exhibit some
  P: m" n0 t8 ?3 Y( e# p9 V7 U. pacceleration of the skeletal maturation; however, after- ~* d0 ?, z' b  Y. t. o2 n0 j; r
cessation of treatment, the rate of bone maturation
% V+ O* L) d( r. v% d1 B* D- \0 Idecelerates and gradually returns to normal.8,99 ^' y7 u: I3 K
There are conflicting reports and controversy3 N+ h: i, W# \$ Q5 g( B
over the effect of early androgen exposure on adult# C7 l& s& Y1 v  H1 m5 Z
penile length.10,11 Some reports suggest subnormal
# H- N8 P8 U# u9 o; madult penile length, apparently because of downreg-
% {& P  d4 |7 B' Q/ ^( m" a' Mulation of androgen receptor number.10,12 However,% A) q' I8 C3 f: O& z
Sutherland et al13 did not find a correlation between
9 Y( m; n8 ~6 W1 Z2 w: kchildhood testosterone exposure and reduced adult/ K* I2 ]0 ?2 V4 K0 i
penile length in clinical studies.
% X, ^1 l7 E/ B$ \3 O* lNonetheless, we do not believe our patient is! ~' T9 d7 ?% u' G. R
going to experience any of the untoward effects from! O8 L# n) v$ ?. H2 d2 ^
testosterone exposure as mentioned earlier because/ h* E" ]) `0 B" Z  H
the exposure was not for a prolonged period of time.# m- O5 x' z1 K( _; y5 @
Although the bone age was advanced at the time of
4 Q: W' @1 h, Adiagnosis, the child had a normal growth velocity at
  M7 o( x: o9 ?the follow-up visit. It is hoped that his final adult
3 l/ M3 ]+ f* @, x6 p8 Dheight will not be affected.' K" e% K5 Z4 B% g7 p8 }+ {
Although rarely reported, the widespread avail-8 I* i5 c7 V, F2 n+ S& L6 ^
ability of androgen products in our society may; f4 c5 |" S# u) j  w) F1 p
indeed cause more virilization in male or female! t2 ?- R7 e$ c
children than one would realize. Exposure to andro-
/ b# D" n9 b: F" S* dgen products must be considered and specific ques-
' @" d6 }% ^! c; c2 V- [tioning about the use of a testosterone product or
) a# \3 P6 g" j2 Kgel should be asked of the family members during. x3 n) ^8 F+ t) q* c( g: P
the evaluation of any children who present with vir-5 z  Z# m% N0 A' U. |9 c
ilization or peripheral precocious puberty. The diag-- l( ~5 m' P9 I& x4 I: Z& f( K
nosis can be established by just a few tests and by/ f3 k) z3 h% x. Z" q7 b  E
appropriate history. The inability to obtain such a2 M$ g$ ^% G  Q. x
history, or failure to ask the specific questions, may
1 }8 v$ k1 B+ F& x- H) |+ Jresult in extensive, unnecessary, and expensive0 l" g, ], Q( Q4 k+ u0 y
investigation. The primary care physician should be( f6 `$ D9 Y- H" s6 |9 r
aware of this fact, because most of these children
, _1 B$ k( p3 ~may initially present in their practice. The Physicians’
/ x, {6 h* T% G8 i) JDesk Reference and package insert should also put a
( L$ x8 A) |& ~: o; zwarning about the virilizing effect on a male or! `' k- \3 G- ~! Q2 j0 w
female child who might come in contact with some-
' b# y* |( h5 [6 T1 |  xone using any of these products.
$ s3 T; u- R  W* mReferences" A$ i6 x) ~3 S- X
1. Styne DM. The testes: disorder of sexual differentiation1 b/ o+ D8 ]6 ]% R5 r* c
and puberty in the male. In: Sperling MA, ed. Pediatric
  q1 C1 G+ p  j; p4 _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 A3 t; x6 w9 N0 Q  Q2002: 565-628.0 T( P5 G* }" Q) ~5 r" }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! \; x& u3 Z1 M& f
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
- d" H" R, A7 _! y$ s: LBoy Induced by Indirect Topical
; r" v4 j! @! U' c0 o+ r6 `Exposure to Testosterone
4 \! O* e1 m% WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  t1 u/ s! c( N" K
and Kenneth R. Rettig, MD1
4 w, _' K8 E& G5 ^3 UClinical Pediatrics$ O6 m0 e8 i' l/ {  f6 D3 a
Volume 46 Number 6
4 [, D) D+ M% s* N% K& ]* GJuly 2007 540-543; X& }- i% m  T; g( a
© 2007 Sage Publications
2 v  A5 j' n9 q% y9 D7 Z0 i3 B1 h10.1177/0009922806296651
6 @1 ?5 N1 G( f( f5 thttp://clp.sagepub.com
4 L0 X4 f! u4 H' ~: Whosted at# M5 n0 R) D, v' @
http://online.sagepub.com
5 Z( ]2 s) W7 m' ^0 V( ]( XPrecocious puberty in boys, central or peripheral,6 o6 H$ C; N2 _# O
is a significant concern for physicians. Central
1 P4 }$ j; l& [( I3 @$ ^  m6 C& ]precocious puberty (CPP), which is mediated
# |. Y8 |4 N0 lthrough the hypothalamic pituitary gonadal axis, has2 u0 X7 ~% m# ?1 J
a higher incidence of organic central nervous system- M# B. J5 K' k- |/ k- R+ ~
lesions in boys.1,2 Virilization in boys, as manifested8 ^# R/ d# y0 B2 _
by enlargement of the penis, development of pubic
0 O! T! a! a+ v" qhair, and facial acne without enlargement of testi-
1 a9 u" |7 @3 p$ a9 Z6 ?cles, suggests peripheral or pseudopuberty.1-3 We7 s3 a' a/ I8 h4 `( p
report a 16-month-old boy who presented with the0 ?2 k  I1 O, ^7 b7 E
enlargement of the phallus and pubic hair develop-
) O- C4 \0 Y! k. J( ~7 @$ Jment without testicular enlargement, which was due  \1 T7 Q; j, P
to the unintentional exposure to androgen gel used by" \+ J/ p5 W& F5 ~+ E: a0 ]% s
the father. The family initially concealed this infor-+ O7 k7 l0 e6 l5 Z$ g0 M* ]
mation, resulting in an extensive work-up for this/ o5 y" I1 n* u* Q: u
child. Given the widespread and easy availability of* s% ^" ]; M2 h" {( B
testosterone gel and cream, we believe this is proba-. V+ a# d+ {7 V+ u; g/ L9 e2 \" E0 w
bly more common than the rare case report in the" A5 d( ~1 L# Z% f: F8 c  @
literature.4
1 X- X& p" r0 X" r8 MPatient Report. G: Y+ {  b8 ^# ?- }: l
A 16-month-old white child was referred to the
+ {+ t  @' A5 ]( I/ nendocrine clinic by his pediatrician with the concern
/ c, V( F% v9 _( B' Bof early sexual development. His mother noticed& J3 J( J) e5 [8 e, Z3 C* Y: c
light colored pubic hair development when he was
: |( J& w1 C$ s9 R/ K" v$ Y1 ~0 BFrom the 1Division of Pediatric Endocrinology, 2University of
% d4 G& U* Y4 S  H3 ?* cSouth Alabama Medical Center, Mobile, Alabama.# i, y  R0 i9 [( @
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ ^' Z( C1 t& C. \Professor of Pediatrics, University of South Alabama, College of3 g6 m( d+ D( o. O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! }2 W! Q( o) c' V3 A
e-mail: [email protected].
& u+ n+ _% j6 d4 q+ a& n7 Fabout 6 to 7 months old, which progressively became  i: T) n1 t  y! u( ^" |
darker. She was also concerned about the enlarge-1 f7 y6 w% g& Y# D6 N$ \0 d: E& u; v
ment of his penis and frequent erections. The child
/ N$ n) ?$ s; y$ Y- q/ x5 ywas the product of a full-term normal delivery, with- S, \. l# E% F2 g* h* g, B3 O
a birth weight of 7 lb 14 oz, and birth length of
. F9 s/ l. O0 r) j+ k20 inches. He was breast-fed throughout the first year$ F6 W/ u) s8 v" {/ I" y
of life and was still receiving breast milk along with, ]4 {2 t+ ~3 o( }) l! Z1 [% u
solid food. He had no hospitalizations or surgery,
# Q6 K9 x( K: h) m9 E6 {and his psychosocial and psychomotor development
3 X9 T3 c% r0 H4 ]4 Ywas age appropriate.+ o) M: B1 N$ K6 ^. D
The family history was remarkable for the father,
( C' n; y" y6 P! wwho was diagnosed with hypothyroidism at age 16,
  H( p6 b0 r3 g  ywhich was treated with thyroxine. The father’s
+ ?* m7 }3 O0 G9 D" g# Fheight was 6 feet, and he went through a somewhat
! U& r6 J! \3 searly puberty and had stopped growing by age 14.. d( ?/ p3 }, `* Y4 d, ~2 G
The father denied taking any other medication. The4 P) S# a2 v6 G% R1 t) T  |
child’s mother was in good health. Her menarche( K" b% [7 N; `9 N& k2 B
was at 11 years of age, and her height was at 5 feet3 ^" M, h. O- v+ T+ U
5 inches. There was no other family history of pre-+ N* d; S" `5 A0 V/ O
cocious sexual development in the first-degree rela-2 |. g& N# M- |) g. h" _
tives. There were no siblings.! ^6 N' P& {- }# _, r$ |/ E$ P' p
Physical Examination
$ [( V( d6 @2 b. D" F: B% `The physical examination revealed a very active,
/ g3 j7 A* U( V; i% V/ yplayful, and healthy boy. The vital signs documented5 t" L% S$ q; V6 I
a blood pressure of 85/50 mm Hg, his length was
# L3 d; O4 A* _. ?90 cm (>97th percentile), and his weight was 14.4 kg
' m3 U/ ]1 g  u1 }' u* u6 Y(also >97th percentile). The observed yearly growth
" v. {1 w* B/ ]9 f9 A2 xvelocity was 30 cm (12 inches). The examination of$ H# }1 A, u/ m" i5 y3 E
the neck revealed no thyroid enlargement." G$ D9 m1 t. a3 b2 a
The genitourinary examination was remarkable for( Z# _+ b* F$ ]0 z* b
enlargement of the penis, with a stretched length of% ^, _4 C9 U1 Z* z% }3 g8 v) N
8 cm and a width of 2 cm. The glans penis was very well
( t4 g  G! _  c8 C1 D1 W& x4 M: Vdeveloped. The pubic hair was Tanner II, mostly around9 m6 w, `- U3 I3 W( X# t, E
540
" E# ^8 p" {$ f7 _6 V6 x6 Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! `/ M! b! Y  t) M  e
the base of the phallus and was dark and curled. The- V, n3 E% j' v% R2 }
testicular volume was prepubertal at 2 mL each.
. K+ j! M. h- ?  k0 c5 s  N& yThe skin was moist and smooth and somewhat  k8 O8 G8 G5 @) l' o
oily. No axillary hair was noted. There were no$ K7 g* {- D' k; L2 j) n9 s9 f% ~& G' e
abnormal skin pigmentations or café-au-lait spots.* O8 R# ]4 R' K' h+ _2 t
Neurologic evaluation showed deep tendon reflex 2+
' g5 j; t2 G9 J# gbilateral and symmetrical. There was no suggestion
5 ]! m0 `9 A) Y4 k' G* U9 [9 u4 M' lof papilledema.: K8 E; t; |: c8 u5 T! N
Laboratory Evaluation
2 i( i9 m* Z/ V, vThe bone age was consistent with 28 months by
4 ~( q- R0 {9 Dusing the standard of Greulich and Pyle at a chrono-
! i) y/ D6 O6 `# T, V& z- llogic age of 16 months (advanced).5 Chromosomal6 z1 Z( `6 C* Q& g
karyotype was 46XY. The thyroid function test
  A  a, d" L- x) ]  o$ tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-& d/ M+ [1 U8 Z2 i  Z  @7 U4 I
lating hormone level was 1.3 µIU/mL (both normal).
1 }# f1 c! j3 ^9 oThe concentrations of serum electrolytes, blood
  D4 L- @2 A$ Z) g& `4 _) E# aurea nitrogen, creatinine, and calcium all were2 V" Z+ _4 @( W. c/ E  K
within normal range for his age. The concentration  c4 z3 {) U( a+ g
of serum 17-hydroxyprogesterone was 16 ng/dL
- S  [7 G* |. \" j4 Z# A(normal, 3 to 90 ng/dL), androstenedione was 208 _7 E4 t* J5 q: l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 A  u7 [8 t! M3 i3 P, Q+ vterone was 38 ng/dL (normal, 50 to 760 ng/dL)," S; v  \. P) i+ W1 Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' E  L/ I8 b" M+ s3 p5 I+ m/ Q* k9 X/ l* _
49ng/dL), 11-desoxycortisol (specific compound S)% u1 h4 F* }7 Q. c2 R$ ]3 h
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. e2 O2 k7 y' w* c# e4 K; O. Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 Z7 H$ e, B5 v- j# C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 D& _4 z  {! X/ I$ a$ M  Qand β-human chorionic gonadotropin was less than
& ~9 w( p+ O' [5 mIU/mL (normal <5 mIU/mL). Serum follicular
* c8 n$ ]' j* S0 g$ h1 l9 Estimulating hormone and leuteinizing hormone1 H9 w! N3 D0 h! u9 G% A5 Z
concentrations were less than 0.05 mIU/mL" F% g* o* `% \
(prepubertal).) o9 x: O5 ?' t
The parents were notified about the laboratory
# F) i/ n. V4 h# jresults and were informed that all of the tests were
! i/ v0 J3 B* `3 c7 r0 Znormal except the testosterone level was high. The
5 `8 k3 {7 ^! I  [8 gfollow-up visit was arranged within a few weeks to$ E1 M. H2 ~% c1 F
obtain testicular and abdominal sonograms; how-3 ^/ @8 y7 E( X" U
ever, the family did not return for 4 months.) J$ g1 r- b6 j, t  Y9 H. X/ f
Physical examination at this time revealed that the
+ Y1 ?" V0 F% ]9 Zchild had grown 2.5 cm in 4 months and had gained
  S, {- u  z. s; w3 L+ R& ]% Q2 M! E2 kg of weight. Physical examination remained! q2 e" s4 u& l! l+ r$ x4 n2 M
unchanged. Surprisingly, the pubic hair almost com-3 l1 J( ~; Z+ H
pletely disappeared except for a few vellous hairs at
: |: m( ]5 V+ E" T% p3 Z$ Vthe base of the phallus. Testicular volume was still 24 _& A0 m1 v  o3 U$ {
mL, and the size of the penis remained unchanged.
& h; I- l; `0 b7 ]% \9 iThe mother also said that the boy was no longer hav-' s) ~3 K" [+ |* z& n# p
ing frequent erections.! L, j9 k: b$ H- ~* R9 x# u
Both parents were again questioned about use of3 ]1 P* n1 h7 I& n4 u( y* d2 K
any ointment/creams that they may have applied to
5 G7 w, C, ?- s) Bthe child’s skin. This time the father admitted the0 _# {8 m# E. ?( O  f# B
Topical Testosterone Exposure / Bhowmick et al 541
" ]' O( U8 k# @" x* H+ Ause of testosterone gel twice daily that he was apply-: ?. g* l& i$ q( b% b
ing over his own shoulders, chest, and back area for
% Q/ V  \/ D, h- w; G4 la year. The father also revealed he was embarrassed
! e3 S5 |0 Q, lto disclose that he was using a testosterone gel pre-
. j" V- t5 P7 b1 l; L- J* Ascribed by his family physician for decreased libido
2 U9 c3 F1 N% v6 H9 Dsecondary to depression.
) R" q; }: V( W1 e" e+ g+ L9 RThe child slept in the same bed with parents., E/ s7 _" \  [1 V3 P
The father would hug the baby and hold him on his5 w( X3 ]- X! B
chest for a considerable period of time, causing sig-0 A; X4 E4 a0 g/ M
nificant bare skin contact between baby and father.3 ?) [' f" i/ `( ^. G* r5 x
The father also admitted that after the phone call,
* ]* I2 s/ x4 p0 kwhen he learned the testosterone level in the baby
  D+ ]/ D# k, k3 Z- A% {4 |- l: Vwas high, he then read the product information
5 z! q5 W; _6 P$ N1 Rpacket and concluded that it was most likely the rea-
; Z- M7 Z! g' ^$ `son for the child’s virilization. At that time, they
. f4 C% i( w2 adecided to put the baby in a separate bed, and the
6 H0 k# |3 z1 a6 Z3 F9 Ffather was not hugging him with bare skin and had
7 ~, m& {- T* l) {  n8 Wbeen using protective clothing. A repeat testosterone
/ K8 _  C% }- b! ~* G+ m6 F. ~! Ptest was ordered, but the family did not go to the- D' [4 j$ n6 E& P; e! `5 T+ I
laboratory to obtain the test.
. p+ u& ~- h# a8 W6 KDiscussion- S" x, o6 S9 J. M
Precocious puberty in boys is defined as secondary
2 @0 T/ x; V) j3 o) gsexual development before 9 years of age.1,4
6 ]2 Y! }' v7 s6 `7 |! JPrecocious puberty is termed as central (true) when
- w7 Q* W1 h$ N/ dit is caused by the premature activation of hypo-8 m& D. B1 _& A  l  N9 y
thalamic pituitary gonadal axis. CPP is more com-. k% \! \, p# O4 \1 S) e7 L( S4 Q9 F
mon in girls than in boys.1,3 Most boys with CPP
/ w; _9 X3 E% M" n" |may have a central nervous system lesion that is
& O( ^2 p: a* f+ tresponsible for the early activation of the hypothal-
6 e  i+ z+ C2 t6 u4 p8 w9 K% g! mamic pituitary gonadal axis.1-3 Thus, greater empha-6 J) C! X6 r. o: k
sis has been given to neuroradiologic imaging in! L- D+ D# M3 |8 e- B
boys with precocious puberty. In addition to viril-
; E% o; G" U, d5 ?; ^' q9 J! xization, the clinical hallmark of CPP is the symmet-# L3 A. m2 s( ^4 q' q, l& f) |1 k
rical testicular growth secondary to stimulation by. Z, f' a: f% o! T
gonadotropins.1,3& k* B* ?' y6 u% \/ E3 |) ^3 q8 {
Gonadotropin-independent peripheral preco-
& p$ c, R. Q  a6 C* X* {5 s5 Q6 ucious puberty in boys also results from inappropriate
% a- W# f+ B. {1 }androgenic stimulation from either endogenous or! k. f4 N2 Q0 F& _- U
exogenous sources, nonpituitary gonadotropin stim-+ K) t8 o6 K9 D6 I5 p# [
ulation, and rare activating mutations.3 Virilizing$ i# [: \7 P6 Z1 G5 t! `
congenital adrenal hyperplasia producing excessive
3 R! C0 N2 J9 o/ |6 U& Kadrenal androgens is a common cause of precocious% ^  e, y, ~6 ]2 C* v5 X' O
puberty in boys.3,4
; a# d3 w: G3 n9 QThe most common form of congenital adrenal
9 ^. `, Q! Y9 fhyperplasia is the 21-hydroxylase enzyme deficiency.- R. r0 e; D& }/ `4 e" }; f
The 11-β hydroxylase deficiency may also result in
0 m; E0 E; a, l$ c  Qexcessive adrenal androgen production, and rarely,6 g" m0 C% R- {% u0 x# a) G3 K
an adrenal tumor may also cause adrenal androgen- C+ }8 q4 c' e& O
excess.1,32 c, o3 l0 ^  V, C3 e7 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 @1 ~. l* i; q) W: Q4 A
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& Q- t3 O5 ^/ r4 `' ^9 q1 }! g
A unique entity of male-limited gonadotropin-4 }% N- v% ]4 C7 G" t: Y
independent precocious puberty, which is also known
) ^- f' [! X% A: Vas testotoxicosis, may cause precocious puberty at a
2 E5 k% {& E( J6 z* c+ Hvery young age. The physical findings in these boys
# e& D! j$ g+ ^; L9 owith this disorder are full pubertal development,
2 v7 o3 [& }, V* ?3 y6 k; Nincluding bilateral testicular growth, similar to boys- ], q3 L  d8 ]; u
with CPP. The gonadotropin levels in this disorder
: I* u2 m) z! Z9 D5 n5 R0 q* {6 kare suppressed to prepubertal levels and do not show' `2 H4 `% x5 S& d7 V) p3 T: C
pubertal response of gonadotropin after gonadotropin-
/ t2 I7 R0 U3 areleasing hormone stimulation. This is a sex-linked) G2 Q1 S. I0 x2 _: e3 {; z
autosomal dominant disorder that affects only
% `  O: N! N& f9 T9 B; c3 U3 R( @males; therefore, other male members of the family9 `8 o& G% @% ~9 J0 q, o
may have similar precocious puberty.3
  d% K- k; v- [% i+ ]( PIn our patient, physical examination was incon-$ Z3 `  [  |2 t8 x- G
sistent with true precocious puberty since his testi-
/ |- J4 M3 Y) O' d. icles were prepubertal in size. However, testotoxicosis
& ?" S( t8 L% H: h2 ]was in the differential diagnosis because his father
; o- ?3 C3 ?5 n0 Lstarted puberty somewhat early, and occasionally,
4 ?* O0 q8 J% \testicular enlargement is not that evident in the4 q# a/ l7 `1 Q3 h* T& {
beginning of this process.1 In the absence of a neg-) v1 w! ~2 h6 Y
ative initial history of androgen exposure, our
$ A- G( P$ C7 _% |: V( ^# ?' Qbiggest concern was virilizing adrenal hyperplasia,+ I5 q  Y: B- C$ |
either 21-hydroxylase deficiency or 11-β hydroxylase
% M; l4 e2 p4 k8 t1 x4 A; vdeficiency. Those diagnoses were excluded by find-! E0 P. ]* |* L0 p2 i- _
ing the normal level of adrenal steroids.
  l' U' D' p% j) ?, ~The diagnosis of exogenous androgens was strongly6 `* S1 q9 ~% b6 ]4 z
suspected in a follow-up visit after 4 months because
& ]1 a' t9 d! {( X0 U* j4 T1 ~the physical examination revealed the complete disap-' B0 L8 M! l! u
pearance of pubic hair, normal growth velocity, and
! b2 d# D6 h- D8 Udecreased erections. The father admitted using a testos-
2 G0 h, C) N' |8 M/ D! jterone gel, which he concealed at first visit. He was
8 @! w! h. f# zusing it rather frequently, twice a day. The Physicians’
! W. B$ I9 [: B9 K5 z  xDesk Reference, or package insert of this product, gel or  ]# o8 n$ x  l7 p
cream, cautions about dermal testosterone transfer to4 ^8 n! _4 P: o2 [8 w
unprotected females through direct skin exposure./ m* ?8 G" s: g+ h
Serum testosterone level was found to be 2 times the7 E- i7 ~; j( n/ c. i. y
baseline value in those females who were exposed to9 B2 @8 G7 L+ z$ Y3 x' |; w
even 15 minutes of direct skin contact with their male
8 g, h/ N( W/ \. gpartners.6 However, when a shirt covered the applica-
; {/ h* N5 ~, r( j. ltion site, this testosterone transfer was prevented.% G( N% V# R' `
Our patient’s testosterone level was 60 ng/mL,
# R  ~5 e9 C7 E6 G. R- Wwhich was clearly high. Some studies suggest that6 j: ?9 M# Q4 ?3 ]' a9 }9 q9 L3 \1 G; A
dermal conversion of testosterone to dihydrotestos-
; N) W/ B& ^# z; R, S/ q0 gterone, which is a more potent metabolite, is more- F% O) [  ?( g5 g+ l. @
active in young children exposed to testosterone" `6 c4 N2 N; K) d
exogenously7; however, we did not measure a dihy-7 X5 f) T7 p. c! S8 |) b6 [. a
drotestosterone level in our patient. In addition to
8 M2 _6 G, t+ U& |' }3 h1 L. s7 t' tvirilization, exposure to exogenous testosterone in
$ M1 R% w+ u! J8 Schildren results in an increase in growth velocity and
- L: i* W+ v' m+ y+ {) e7 a7 Badvanced bone age, as seen in our patient.
9 ^7 M1 w  O: ?5 ?9 _; h: fThe long-term effect of androgen exposure during9 Z/ [5 n, j# l) V
early childhood on pubertal development and final0 U8 f: i* Q' e5 Y
adult height are not fully known and always remain8 ~- G1 Z- K$ F( ]+ P% f0 w% d
a concern. Children treated with short-term testos-* F& V! e9 A+ T0 ?
terone injection or topical androgen may exhibit some
: d/ a) R& l3 U* P! B* Q% Facceleration of the skeletal maturation; however, after5 O1 G2 V3 d0 G: b$ \
cessation of treatment, the rate of bone maturation& S' a; S  h* V2 X3 Z
decelerates and gradually returns to normal.8,9
% [! n4 B4 j) d' z2 W( q0 r; G1 K5 j' hThere are conflicting reports and controversy
) y' n- j( b! X% y( Y7 |1 |. x" Yover the effect of early androgen exposure on adult1 M0 g/ H0 l2 a* A) Y. A
penile length.10,11 Some reports suggest subnormal, w' X, s; c( o$ P5 F: B; y
adult penile length, apparently because of downreg-2 d6 Z1 E% _- r3 }9 r: C2 u& l
ulation of androgen receptor number.10,12 However,3 D$ t3 j3 o9 e* m1 q
Sutherland et al13 did not find a correlation between
9 a+ A1 F2 j" O1 P. w+ }childhood testosterone exposure and reduced adult! [7 a) e" |% G- ], b
penile length in clinical studies.
" [$ p* T8 b+ c( M) A# s9 X6 c( rNonetheless, we do not believe our patient is
* N9 h: b% [- |$ I8 q  b- Ggoing to experience any of the untoward effects from
7 P4 s: i. W9 D' ntestosterone exposure as mentioned earlier because
( A* \8 y" v9 W9 F, \2 b! }- l- Vthe exposure was not for a prolonged period of time.
1 A+ A9 L5 c0 Y7 |; O7 _' A. JAlthough the bone age was advanced at the time of; z8 i5 ^5 {, v' \
diagnosis, the child had a normal growth velocity at
! c5 ]" ]7 }- _( e; q" Pthe follow-up visit. It is hoped that his final adult) M) t  ?: V8 T) e" F& i
height will not be affected.
8 d2 W$ x) K  G3 nAlthough rarely reported, the widespread avail-
, ?) M8 ~& }8 dability of androgen products in our society may
/ o) J: F2 q2 O3 U1 `) jindeed cause more virilization in male or female( n- W" a! Z# f7 j6 w3 \* L; M" L
children than one would realize. Exposure to andro-4 U8 ^. A1 g& N  `$ I* p' Z% M" k
gen products must be considered and specific ques-
* ~2 O5 B3 u8 a! D: A+ D0 p, H2 X( Htioning about the use of a testosterone product or. i6 K. s; r, P  h, X. O8 \
gel should be asked of the family members during
' Z. J4 K% V# k9 O1 a" q  athe evaluation of any children who present with vir-
" c, X4 h+ D$ {) n# [/ f' gilization or peripheral precocious puberty. The diag-
' B$ `% @9 b9 J3 A. Q# V# l2 K; t( ?nosis can be established by just a few tests and by" Q6 `) s6 M+ e' B$ V& E% N
appropriate history. The inability to obtain such a- B4 @" [# `* ~9 @0 A3 u
history, or failure to ask the specific questions, may
1 }: E2 r: D/ w4 r+ t" m9 xresult in extensive, unnecessary, and expensive
$ d$ h; B! ~. E9 L2 uinvestigation. The primary care physician should be
8 ~5 w4 E0 Y7 w+ haware of this fact, because most of these children8 @; A% j0 o% v  ^9 |. X0 ~* L
may initially present in their practice. The Physicians’
; O8 A/ r; C; H) }+ MDesk Reference and package insert should also put a" f5 I( m2 R' y8 p. ^% c2 V  y
warning about the virilizing effect on a male or9 A; w" W! K1 ^4 X3 D3 ]# h; k9 a
female child who might come in contact with some-
- J) k7 F, c$ c) q! R/ w4 E+ k; z0 Qone using any of these products.
3 ]$ A' `& W! I0 KReferences
1 N" Z% b& A5 J5 S+ N6 h4 |/ A1. Styne DM. The testes: disorder of sexual differentiation
% u) n* T! n6 w2 }4 @( N; Aand puberty in the male. In: Sperling MA, ed. Pediatric
* l3 \7 _" ~7 I* [  ~5 jEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; K' j" H/ w) b# f' r- i
2002: 565-628.( F" d) J( I5 i: ^. l1 u
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* g# f! U4 ?. j# X; _6 Spuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
: q2 d' Y& c1 V1 V2 x
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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