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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-Old3 K- s( I. X$ x7 _! Z0 G
Boy Induced by Indirect Topical, ~* ]1 K1 O. x/ i8 j
Exposure to Testosterone
+ s. u. J$ p2 ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ Y7 u, |2 E( w3 d* ?$ H! Tand Kenneth R. Rettig, MD12 t: g5 z3 M! ~* l) X
Clinical Pediatrics6 k3 z* D/ O* r7 _( X
Volume 46 Number 6
  `' E1 W: n0 l) eJuly 2007 540-543
% z( m1 T6 ~6 r9 x8 x: ]© 2007 Sage Publications, ?9 G; G+ x* X: L1 H! }
10.1177/0009922806296651
4 W" Y, j- X. a  J+ W% k6 shttp://clp.sagepub.com
1 `" v& S. `4 Ihosted at
# \& Y  g1 H2 d$ E1 xhttp://online.sagepub.com
! @8 P' D/ h! T/ T7 M! ]Precocious puberty in boys, central or peripheral,, C" {; r+ v# F( g, C) _
is a significant concern for physicians. Central) V  {8 T+ @- o& T" ?
precocious puberty (CPP), which is mediated
1 i+ G* d# Y+ f7 x8 lthrough the hypothalamic pituitary gonadal axis, has
- E0 Z! `8 _0 I- Aa higher incidence of organic central nervous system; D4 Y; ]4 `+ N4 X! [) \% M3 o
lesions in boys.1,2 Virilization in boys, as manifested
$ m& E( r% a% z4 Aby enlargement of the penis, development of pubic! A8 H: V) e( y- ^, h
hair, and facial acne without enlargement of testi-. G) g. y9 L( Y4 b8 y
cles, suggests peripheral or pseudopuberty.1-3 We
+ O( _) ~* b& Q# N# k9 Y2 Sreport a 16-month-old boy who presented with the
! G$ r6 A) }0 X+ Eenlargement of the phallus and pubic hair develop-
( O5 g# t; \: J$ H. ]; T) A7 cment without testicular enlargement, which was due
6 g8 S3 i& O9 ]" `( u; ito the unintentional exposure to androgen gel used by
% [1 }; S' t; Q( z# U/ Qthe father. The family initially concealed this infor-
1 b+ }( e. K8 b4 ?/ Umation, resulting in an extensive work-up for this( E3 r. z  O; A, }+ R
child. Given the widespread and easy availability of9 ]6 R1 E8 O& G) m+ w4 n
testosterone gel and cream, we believe this is proba-8 k9 G+ m$ F# k3 m6 K# t
bly more common than the rare case report in the
2 {3 N$ q3 s* R/ M6 V8 Qliterature.4" L4 \* ?8 p  R! o
Patient Report
* @6 Q* ]' {8 uA 16-month-old white child was referred to the
6 K' V1 ^8 H9 j$ x9 t& Zendocrine clinic by his pediatrician with the concern3 x8 E+ Z0 m6 m: B/ v) H6 ], C
of early sexual development. His mother noticed
3 n8 v- _( v) ^4 I$ C- o5 Jlight colored pubic hair development when he was
9 J. }2 J) z' i7 ~$ a* V' jFrom the 1Division of Pediatric Endocrinology, 2University of
! S9 `, \& w) n1 q4 dSouth Alabama Medical Center, Mobile, Alabama.+ v; i5 w5 A8 u3 I* g( l) {1 b
Address correspondence to: Samar K. Bhowmick, MD, FACE,% S/ }9 \8 F" o0 C+ F1 j$ O( D
Professor of Pediatrics, University of South Alabama, College of
9 v1 q8 q( `2 c/ j  F9 F- _! E: GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* x8 u$ O$ f5 {2 [! @0 O1 t
e-mail: [email protected].! h2 `, B2 U5 A# z9 v/ I8 ^* i
about 6 to 7 months old, which progressively became. X. v7 u2 |) V4 y, o
darker. She was also concerned about the enlarge-
/ |' i/ }: p: }1 }8 K3 zment of his penis and frequent erections. The child% F9 t5 I7 i& C' Y* \8 @& ]
was the product of a full-term normal delivery, with: H) b( \9 r/ R: j6 l
a birth weight of 7 lb 14 oz, and birth length of
. e4 V1 s6 y; e2 h- W5 \4 f20 inches. He was breast-fed throughout the first year
# G8 V$ _3 ]( a( [" Zof life and was still receiving breast milk along with
2 h% ~5 Q  T) E' s3 |solid food. He had no hospitalizations or surgery,9 E, Y4 S1 {4 M9 L3 _
and his psychosocial and psychomotor development  V/ c% C  g# H8 H4 w
was age appropriate.
  K5 X4 j. m# M5 _( {4 k% hThe family history was remarkable for the father,
7 u% L3 y  P: Kwho was diagnosed with hypothyroidism at age 16,; d3 `$ \# X: f& F3 @
which was treated with thyroxine. The father’s
! S$ X' R+ t2 H: b2 d0 Vheight was 6 feet, and he went through a somewhat* q6 H& s3 r! `) z5 W5 @: s: U3 A7 l
early puberty and had stopped growing by age 14.
7 W7 ]& N9 u9 q. CThe father denied taking any other medication. The
" l, i5 ^/ A( Lchild’s mother was in good health. Her menarche
, I/ n! }1 b, A9 J6 Jwas at 11 years of age, and her height was at 5 feet
9 h7 ~, a! x7 M1 E; ~2 f( Z0 g5 inches. There was no other family history of pre-
6 t, S! f2 N2 N3 }# Ococious sexual development in the first-degree rela-3 G2 X4 B$ b( c- }# k4 I6 q* f7 G
tives. There were no siblings.8 I3 @- z& P- ~$ m" M
Physical Examination
( g% \4 N: p' Y" S9 v- g' {The physical examination revealed a very active,$ l6 J# [. I9 |! h) a
playful, and healthy boy. The vital signs documented2 V+ D! @7 D1 _9 i6 g0 A
a blood pressure of 85/50 mm Hg, his length was
" P" D4 n0 J2 N90 cm (>97th percentile), and his weight was 14.4 kg
) ?. k$ B/ W) W7 Q5 B; b(also >97th percentile). The observed yearly growth
) V5 @) W  X+ R1 ^" ?, |0 pvelocity was 30 cm (12 inches). The examination of# F3 x$ s$ o2 L  ^% ~! ^, \
the neck revealed no thyroid enlargement.: s' w" P$ R$ P; V* A5 Q' y+ ~
The genitourinary examination was remarkable for
3 U6 C* T$ E; Eenlargement of the penis, with a stretched length of# [' w, G; V/ W9 ~3 s1 _" ]
8 cm and a width of 2 cm. The glans penis was very well
3 Q" ^! y9 r* B1 s; }! c* `developed. The pubic hair was Tanner II, mostly around
( n9 J& n9 b$ h2 P# |* C- u6 o540
! H/ {- Q" O/ _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 B+ D# F$ y. {2 l' Q1 \/ zthe base of the phallus and was dark and curled. The
' t* Y5 E' J- O6 }testicular volume was prepubertal at 2 mL each.
2 J9 I# L7 N3 X3 N/ M5 }  u, \The skin was moist and smooth and somewhat- ~4 Q, {5 n# e* }: @- B' M
oily. No axillary hair was noted. There were no% D9 D4 O4 h# _- B
abnormal skin pigmentations or café-au-lait spots.% h+ s1 v1 m2 I& x! t
Neurologic evaluation showed deep tendon reflex 2+
6 e$ M+ r4 A  f- _( Gbilateral and symmetrical. There was no suggestion1 C) }6 l1 E1 D
of papilledema.5 W/ N( _3 |) O0 J/ |2 y
Laboratory Evaluation* K* ?& ?! W$ [+ `, m. X# v$ G
The bone age was consistent with 28 months by
  \% m' Y1 h# h3 P& V7 O* Susing the standard of Greulich and Pyle at a chrono-4 ^/ t6 {( z# G6 A3 \. |& {0 h$ g
logic age of 16 months (advanced).5 Chromosomal/ G8 T; {  R8 m7 A
karyotype was 46XY. The thyroid function test& @+ c9 b; u& Y( Q! |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 G' n$ W3 x2 E& e
lating hormone level was 1.3 µIU/mL (both normal).! {% p9 r3 l- r5 O3 ]- b0 \& ^+ x
The concentrations of serum electrolytes, blood! L6 G  Y) f2 w/ F% |! X! F- R
urea nitrogen, creatinine, and calcium all were
7 k% g6 L- ^4 G& D9 Rwithin normal range for his age. The concentration
5 J5 N/ ?- Y) g2 H' s* Gof serum 17-hydroxyprogesterone was 16 ng/dL+ ^; c( ^4 w; s$ k# A6 o  u0 D2 i
(normal, 3 to 90 ng/dL), androstenedione was 20& A: u0 c* A4 r8 ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 A3 N& c. [$ I8 O) Uterone was 38 ng/dL (normal, 50 to 760 ng/dL)," u4 ]! m8 o& E! l1 T$ ?+ x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 O6 B% M& b# y, q, e
49ng/dL), 11-desoxycortisol (specific compound S)
% j- b8 }5 b+ h  O) ^+ {was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% Z0 X* F! o$ T4 H2 t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" v5 S6 x$ u9 A; f# W+ ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 Z1 N+ z3 `* h/ d, U, F
and β-human chorionic gonadotropin was less than
8 U, H; M/ P& _5 mIU/mL (normal <5 mIU/mL). Serum follicular4 ?* f( W: \: ~7 \1 ^, m) a
stimulating hormone and leuteinizing hormone
' b- f0 ], Q: C) L* {! ^' N* a5 {concentrations were less than 0.05 mIU/mL/ I9 g) Z0 p& u/ [: d
(prepubertal).
4 K/ n5 p; a7 k" T6 |5 x( sThe parents were notified about the laboratory9 w% D. H/ S" v; \8 B2 P, d( `
results and were informed that all of the tests were2 J( Z4 d$ j3 L, A" t
normal except the testosterone level was high. The
2 }& Y8 O9 X3 Vfollow-up visit was arranged within a few weeks to
) M5 y; R( E* }# c9 _obtain testicular and abdominal sonograms; how-
$ F4 S7 |6 |, _7 L8 hever, the family did not return for 4 months.) E& u4 ~" [% U2 h5 K2 ?: z
Physical examination at this time revealed that the8 o* A3 {! \/ c/ O- M% H6 y  ]
child had grown 2.5 cm in 4 months and had gained: b& p/ ^; m# m5 K4 J7 `
2 kg of weight. Physical examination remained
& I) \9 z! I8 T+ E* @. Funchanged. Surprisingly, the pubic hair almost com-+ b# X6 B- S" ~# m7 L' d
pletely disappeared except for a few vellous hairs at7 ]. w6 t3 ^- I8 I1 u
the base of the phallus. Testicular volume was still 2
6 \/ N" s% b, G7 r) z0 [' J7 R, h% dmL, and the size of the penis remained unchanged.
7 e( P8 w: S" \# }1 _. FThe mother also said that the boy was no longer hav-
" \, \/ O# G+ b5 z5 xing frequent erections.+ m8 E% j4 l4 p! W
Both parents were again questioned about use of
8 h, g5 J/ U6 C) b4 ^any ointment/creams that they may have applied to
" ^5 V) y# R! X6 d0 h  tthe child’s skin. This time the father admitted the
$ X& I3 m) P$ ^: c9 p7 xTopical Testosterone Exposure / Bhowmick et al 5416 ~/ i9 d7 _$ |6 ]
use of testosterone gel twice daily that he was apply-5 ?, J7 Z9 o# B  }
ing over his own shoulders, chest, and back area for7 Q6 T7 G9 h  L
a year. The father also revealed he was embarrassed& |* R; b: \: q6 r
to disclose that he was using a testosterone gel pre-4 N( l/ N/ ~6 X7 r3 N
scribed by his family physician for decreased libido
  ]; F# g5 I/ R& {, \+ P3 s& ^secondary to depression.9 d" [2 B* N: S3 A/ ?0 w6 _
The child slept in the same bed with parents.
% g* _. U- o8 u& L' |! X0 ]6 wThe father would hug the baby and hold him on his6 @; N6 U. M- l# ]4 @
chest for a considerable period of time, causing sig-
& z* I7 k/ B. j$ \* s8 ]nificant bare skin contact between baby and father.+ [( |* [- m' O& y  o* U
The father also admitted that after the phone call,% F- b% ~2 o- b
when he learned the testosterone level in the baby
/ Q$ ^& f$ ]5 C9 l8 h# E6 xwas high, he then read the product information/ t6 e5 \" E5 j, c! g
packet and concluded that it was most likely the rea-
8 N$ O+ ?" u9 k$ w/ hson for the child’s virilization. At that time, they! m: V5 y0 O4 ]. K" l; D
decided to put the baby in a separate bed, and the1 T. D# w4 `8 m, D
father was not hugging him with bare skin and had* h- B. p, n6 _- p) L
been using protective clothing. A repeat testosterone% e/ n  s# u8 W# g! Z
test was ordered, but the family did not go to the1 R, i8 {% {0 `; s9 h$ t
laboratory to obtain the test.# i. M7 L) b' ~
Discussion
5 I/ U3 u8 B* ~Precocious puberty in boys is defined as secondary
  T: I+ S4 p' H' {7 R: }sexual development before 9 years of age.1,4/ K' Z4 |4 X/ a; f; k8 u
Precocious puberty is termed as central (true) when
+ @! M$ o2 ?0 O. Iit is caused by the premature activation of hypo-
3 Q0 Q. K" Q! C  g" t8 A- Mthalamic pituitary gonadal axis. CPP is more com-* K7 ~1 D; d* y8 _4 \2 t
mon in girls than in boys.1,3 Most boys with CPP8 ^# L( K4 V( n" Q1 {( x
may have a central nervous system lesion that is1 @* W3 y+ q+ g1 S: i8 _7 V
responsible for the early activation of the hypothal-
4 }2 }5 d; b9 V2 k. xamic pituitary gonadal axis.1-3 Thus, greater empha-
& E2 Q# Q3 M( A. G% r7 H* Lsis has been given to neuroradiologic imaging in$ ~% D; B3 N7 {4 K# i+ G1 C
boys with precocious puberty. In addition to viril-
( N3 o1 |3 Y, ?9 S- sization, the clinical hallmark of CPP is the symmet-
3 _! G; |0 d' orical testicular growth secondary to stimulation by
5 s. N! L- ]% |( ^: U) D: \% Igonadotropins.1,36 z$ b* N) b' P5 R1 }! V
Gonadotropin-independent peripheral preco-
0 a0 k( a# I; P& ^* x. Ccious puberty in boys also results from inappropriate
( Z# x4 K& }7 y0 aandrogenic stimulation from either endogenous or/ k; V: o: c6 J# b. T
exogenous sources, nonpituitary gonadotropin stim-
8 T4 z" K* `- n1 p9 s  B' Rulation, and rare activating mutations.3 Virilizing, y" a  b3 k8 y, T
congenital adrenal hyperplasia producing excessive
4 X# H/ ~9 I. W2 d- {( xadrenal androgens is a common cause of precocious. i1 O# f$ b/ T/ [1 g
puberty in boys.3,4, r( W' E6 g% ^! p% A
The most common form of congenital adrenal! B$ z2 L% ^' _3 h7 |- z7 `6 t7 S
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 w) ?8 q/ @# t4 z5 W2 R1 fThe 11-β hydroxylase deficiency may also result in8 W, t0 d& H7 s$ U5 x5 T4 m. l
excessive adrenal androgen production, and rarely,9 G9 @% O6 L6 Q* j$ n& i
an adrenal tumor may also cause adrenal androgen
! [6 F5 ?! p  e# A& `# _excess.1,3
" k$ b6 l+ A' I: \6 w* A* s0 ?- Q  }# Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( \: H! {9 M8 {1 K7 A" O0 K5 G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& j  c7 A. @" l; g7 ?. o# ?5 W9 WA unique entity of male-limited gonadotropin-6 |: n% V# T/ _: K3 z% G( V! M8 E
independent precocious puberty, which is also known
7 u6 y# V: ~$ E1 \7 Jas testotoxicosis, may cause precocious puberty at a! x5 y" k( E8 L  R
very young age. The physical findings in these boys2 n/ C2 M- x7 |0 `" [/ k' |
with this disorder are full pubertal development,0 [$ G2 V9 r) k
including bilateral testicular growth, similar to boys% @0 P2 c6 R6 z: I4 d' w
with CPP. The gonadotropin levels in this disorder9 ?" E, Z+ p/ a4 `9 G6 k! F
are suppressed to prepubertal levels and do not show
; f7 H9 a0 v* g& z2 @; R3 F0 D5 ]pubertal response of gonadotropin after gonadotropin-+ Z; t( s5 {, X& d4 \9 V/ S6 e; X
releasing hormone stimulation. This is a sex-linked" s& g( f4 h! D
autosomal dominant disorder that affects only
/ r6 u1 K1 F% \' d! l1 ?8 dmales; therefore, other male members of the family
- U+ q; P1 K, D) E1 R+ Vmay have similar precocious puberty.3) R9 C! D' C8 z' N2 Y
In our patient, physical examination was incon-) O5 c% E+ F8 n, w- w
sistent with true precocious puberty since his testi-
  v& Z9 J# o3 wcles were prepubertal in size. However, testotoxicosis
  {* d3 k* j) g, y  C, nwas in the differential diagnosis because his father3 t: s: ]( i8 Q: j, j
started puberty somewhat early, and occasionally,
! }/ N3 {6 l3 t' mtesticular enlargement is not that evident in the3 g7 w, u) A5 v% n' O
beginning of this process.1 In the absence of a neg-
6 C3 h% N" S3 p4 Q* P* J& Mative initial history of androgen exposure, our
/ X' A8 I1 g, ?, m6 H" f7 u3 g& Ubiggest concern was virilizing adrenal hyperplasia,
& x( C# {" a& H! g& e7 {; G' veither 21-hydroxylase deficiency or 11-β hydroxylase
7 s0 g# V6 O& }! N' A( J; R. h- ]deficiency. Those diagnoses were excluded by find-
7 T6 T, e/ b2 _: j* k5 r& `# sing the normal level of adrenal steroids./ t" e% O0 s1 h7 k
The diagnosis of exogenous androgens was strongly
9 p1 z5 x: B* \/ ]$ Vsuspected in a follow-up visit after 4 months because
( s6 D- V# i' A) u, V# `the physical examination revealed the complete disap-/ |. {1 R+ z1 Y- F1 L
pearance of pubic hair, normal growth velocity, and3 R& H* E- D$ b# K, x8 Q/ Y
decreased erections. The father admitted using a testos-: Q/ e. g* x2 f" C
terone gel, which he concealed at first visit. He was+ H" A$ K0 O, I( X! D
using it rather frequently, twice a day. The Physicians’+ e( c. G  Z% q, s4 o/ j" P/ ~+ R. U
Desk Reference, or package insert of this product, gel or: c  j9 I- L0 u, u! S: k
cream, cautions about dermal testosterone transfer to8 H: x5 o& y( d5 d2 x# D( S
unprotected females through direct skin exposure.6 U5 K' N: R) N* E9 q
Serum testosterone level was found to be 2 times the, p% u% L/ \+ V. g3 h6 ]* H+ O
baseline value in those females who were exposed to; f0 \7 b7 K1 T4 [6 f9 s
even 15 minutes of direct skin contact with their male' F- l0 X! K5 V, J
partners.6 However, when a shirt covered the applica-
4 G2 p! i( F0 u# ~4 d* Etion site, this testosterone transfer was prevented.
8 c9 R; W8 ?) B+ ~: D) ^7 ^  e, }Our patient’s testosterone level was 60 ng/mL,
+ n9 Y% o4 E7 `2 `which was clearly high. Some studies suggest that* c6 z5 z+ C: o; ~# U: S. I
dermal conversion of testosterone to dihydrotestos-
- m6 Y) u/ j0 q  Z) kterone, which is a more potent metabolite, is more9 K7 n9 N$ A/ J8 R  D( o3 i
active in young children exposed to testosterone0 U- O4 ^% P$ G. Z' \5 D1 i" k& N
exogenously7; however, we did not measure a dihy-
, [. Q0 j: H) a8 s5 Tdrotestosterone level in our patient. In addition to/ @, a: u" J% Z: D! Z) }3 B, O
virilization, exposure to exogenous testosterone in. L& @& q4 W  r1 A& }
children results in an increase in growth velocity and9 R" H4 o# h! \1 g% A1 J
advanced bone age, as seen in our patient.% l+ u; q$ z2 g. A/ ?
The long-term effect of androgen exposure during
" a. f% [  g; m! Q  w3 Searly childhood on pubertal development and final; [8 G* ^  v( p) T0 X
adult height are not fully known and always remain
; ^; L: e: U' X/ \( w. a: G" pa concern. Children treated with short-term testos-9 D9 ?" e% U3 ~4 I# A. Z
terone injection or topical androgen may exhibit some# }$ g0 K2 m$ _! F9 u8 f
acceleration of the skeletal maturation; however, after
9 s& R8 F: [' [3 y# `; Fcessation of treatment, the rate of bone maturation
" x7 k" b+ d" G2 {decelerates and gradually returns to normal.8,9
( m& U9 }! w8 B9 aThere are conflicting reports and controversy- c( n$ F3 g5 ?' Z4 W6 y
over the effect of early androgen exposure on adult% C- E! J/ S! s" Z. N
penile length.10,11 Some reports suggest subnormal
3 n% Y$ Z2 h7 k* F4 Hadult penile length, apparently because of downreg-
6 T( K2 s7 _* b; rulation of androgen receptor number.10,12 However,9 ?& t% \' o* V3 U% k3 k: o( m. y
Sutherland et al13 did not find a correlation between
' e7 C  I# j" ?! H1 lchildhood testosterone exposure and reduced adult
* T; W7 v6 X+ x( r& u. Y. I6 ]5 o  W: upenile length in clinical studies.  V: [" t: x1 f( X0 T1 ^
Nonetheless, we do not believe our patient is
4 X" ?% V2 N9 U1 D$ v# a! h4 hgoing to experience any of the untoward effects from
: d3 S+ P4 a9 T: ytestosterone exposure as mentioned earlier because
& c4 L* A* k1 e5 S3 Vthe exposure was not for a prolonged period of time.
4 R: ~6 o6 o& @Although the bone age was advanced at the time of( E1 }6 R6 C6 y, c& C$ t# q2 v
diagnosis, the child had a normal growth velocity at
2 C, @6 F: q, dthe follow-up visit. It is hoped that his final adult1 V6 o& M( M4 L/ c% ]
height will not be affected.
! p3 g4 J& X. @$ WAlthough rarely reported, the widespread avail-4 U  \9 ]' }* l3 y& i
ability of androgen products in our society may
! |. X6 u" P% L- {2 B. F' q2 dindeed cause more virilization in male or female
  }( N! T7 ^) e- D4 T: ~( Gchildren than one would realize. Exposure to andro-5 }" Y1 u/ Q6 y' E+ t5 u0 F3 }
gen products must be considered and specific ques-
; ?2 k7 y$ {1 btioning about the use of a testosterone product or
0 p4 \, Y- B; m/ \& ~, ^gel should be asked of the family members during7 t, ^" \2 G# D4 u
the evaluation of any children who present with vir-1 [2 |5 m- n% a* Y+ f, ]
ilization or peripheral precocious puberty. The diag-
' _; X) u  y  Q3 T" mnosis can be established by just a few tests and by8 d( R  R* ~5 y) z8 k
appropriate history. The inability to obtain such a
# \' @0 g/ }. ?" @6 N/ ?history, or failure to ask the specific questions, may: u; {7 l0 a/ A' Y
result in extensive, unnecessary, and expensive
7 w$ D; G0 r' ]1 o1 a. h7 t& tinvestigation. The primary care physician should be3 v7 f, i' U/ X- l7 V. Q
aware of this fact, because most of these children
; e+ g9 e. \5 E( c5 Q$ \/ jmay initially present in their practice. The Physicians’
, n+ l" r) |& I2 K% |7 _Desk Reference and package insert should also put a
% B/ [4 c! U2 z& Rwarning about the virilizing effect on a male or+ Q  {  A, i" G) I4 M5 w$ i
female child who might come in contact with some-
$ _% X! m6 t( p1 done using any of these products./ t" q" K$ y" H) A% m9 Q" I
References
+ ^9 v8 ^( W) f4 s: C* R' \9 \- g1. Styne DM. The testes: disorder of sexual differentiation
. Q% c0 n4 Y1 uand puberty in the male. In: Sperling MA, ed. Pediatric3 J! b7 ^$ G) A, p" `+ t& J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" a* a  a4 Z8 L% @4 q& R- B
2002: 565-628.& w! S4 L5 p$ _2 t  ~1 y8 s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ ?% ?3 \4 P6 ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 w% w& u% }! x" y$ F- U; S
Boy Induced by Indirect Topical
; M# E9 F9 w& y; d: O& cExposure to Testosterone
$ I" S+ Z9 z8 c7 h  S1 D$ ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ c) w* d$ k! G' m  tand Kenneth R. Rettig, MD1* B' e4 a( a3 }' {9 Q4 y% g
Clinical Pediatrics$ y0 P; y1 N+ k" N+ [& I' q8 K+ w
Volume 46 Number 6
* S3 ]( l# x* `. ^' j; eJuly 2007 540-543
; ?+ e8 c) |2 a' H1 h8 A' k+ Q- U( w! J© 2007 Sage Publications
0 j$ `3 R6 l6 m/ S* K10.1177/0009922806296651/ b) {6 |/ H! J
http://clp.sagepub.com
( i7 W4 P8 I8 D% F* V* [hosted at6 B& O, T: G/ ^8 I& F. l! C
http://online.sagepub.com+ E9 s% V+ F; r# p
Precocious puberty in boys, central or peripheral,
0 n4 U$ o! y7 L( B+ cis a significant concern for physicians. Central2 I0 Z* z8 k1 F: }
precocious puberty (CPP), which is mediated
* |$ v$ ]3 h" L: O2 Gthrough the hypothalamic pituitary gonadal axis, has( J2 M5 p, |  r7 q4 ~
a higher incidence of organic central nervous system
/ m: }5 B: X" I+ r4 `% mlesions in boys.1,2 Virilization in boys, as manifested
1 a  v: m+ X8 `by enlargement of the penis, development of pubic
2 b$ ~2 R3 _  d8 Z$ N$ ~( dhair, and facial acne without enlargement of testi-
9 D; }5 O( L. L. Gcles, suggests peripheral or pseudopuberty.1-3 We0 b; K, E  |! {' I
report a 16-month-old boy who presented with the
7 p7 o4 D" p$ g( [7 v9 jenlargement of the phallus and pubic hair develop-
6 |6 F1 b/ t8 ^4 X+ Rment without testicular enlargement, which was due
. B/ M$ E% c. x, o" h8 u% h4 yto the unintentional exposure to androgen gel used by4 w$ v# t, v) a! M5 m# w4 _# A! r
the father. The family initially concealed this infor-
! b. O* g/ S2 x6 ]mation, resulting in an extensive work-up for this
- \+ t9 K: I9 y; t9 Y* r1 y5 Schild. Given the widespread and easy availability of
2 b3 Z+ q$ e- `# Ktestosterone gel and cream, we believe this is proba-
! D1 p) A9 X% l" ]  d1 gbly more common than the rare case report in the
+ p( l9 w! b: a4 S2 h! B+ {literature.4
/ u" q1 I0 K+ L$ }9 I5 _, `Patient Report# G7 X* @) {& u3 @; i; e5 k1 I
A 16-month-old white child was referred to the
; p6 i( |& E1 D6 Aendocrine clinic by his pediatrician with the concern4 @9 V8 `; }1 u$ x( v9 o8 p
of early sexual development. His mother noticed
6 J7 B9 A, G, m" l' \( H7 s6 zlight colored pubic hair development when he was4 p- u$ I7 U/ N; o
From the 1Division of Pediatric Endocrinology, 2University of) D9 ?/ a8 y: y0 g
South Alabama Medical Center, Mobile, Alabama.5 H5 I4 i5 r: l' c& B0 |! J
Address correspondence to: Samar K. Bhowmick, MD, FACE,0 V% c2 c' v+ Y6 a8 b- t9 W( Q
Professor of Pediatrics, University of South Alabama, College of
( z* O5 Y6 Q# a6 A1 P+ VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 y2 A) @) [" E. ue-mail: [email protected].
! B* x& N: L" m6 D3 Babout 6 to 7 months old, which progressively became
4 R- [4 t" F! y: Fdarker. She was also concerned about the enlarge-
. G& E& u! U: s. B8 g% ament of his penis and frequent erections. The child
7 d$ d, [4 ]  T9 }1 Hwas the product of a full-term normal delivery, with0 v+ s4 t5 ?5 r3 O+ c7 L, Q" V
a birth weight of 7 lb 14 oz, and birth length of
% {2 R1 Y$ H* z* o20 inches. He was breast-fed throughout the first year$ X' u  N' ^" M' P3 K2 k, _
of life and was still receiving breast milk along with
) y' I( L! i: Q/ b  o/ Bsolid food. He had no hospitalizations or surgery,; l5 ]: D$ l* l0 w( `
and his psychosocial and psychomotor development
- g$ d; t/ o5 t9 dwas age appropriate.  `( U, U! f: s. P
The family history was remarkable for the father,5 Y2 d% T/ G# P& \9 B$ Z+ z
who was diagnosed with hypothyroidism at age 16,
- [$ }4 _) F) T- Lwhich was treated with thyroxine. The father’s1 Z% E/ L9 x1 [" V/ ], c$ i+ a/ y
height was 6 feet, and he went through a somewhat
( F2 S) b0 T2 o( n* R# O8 n  uearly puberty and had stopped growing by age 14.5 ~$ b) _% X0 k
The father denied taking any other medication. The
- P7 N' i  w3 u4 [# L, |- j3 Vchild’s mother was in good health. Her menarche7 ?& V4 R- q- \
was at 11 years of age, and her height was at 5 feet" X3 k. {3 o/ x3 ?4 j
5 inches. There was no other family history of pre-
$ j' @% H. N, a* f; ncocious sexual development in the first-degree rela-
, i0 O/ B, d7 g; N0 d6 ttives. There were no siblings.
1 n- c2 {" ]6 q6 ]5 ?! KPhysical Examination( D% ~& n8 Z+ |( q. V7 h1 z
The physical examination revealed a very active,4 L0 l* ?$ r# j
playful, and healthy boy. The vital signs documented
1 E+ r" d2 b/ |( {a blood pressure of 85/50 mm Hg, his length was
# V; T( |. U& E9 X# P3 @90 cm (>97th percentile), and his weight was 14.4 kg, W7 B0 ?: A" C- d3 K
(also >97th percentile). The observed yearly growth
/ i, ?' `. z" J; P" ?: Vvelocity was 30 cm (12 inches). The examination of
. Q3 f3 l9 Z1 w  }2 h( @9 p# sthe neck revealed no thyroid enlargement.
" D$ |+ ~( P0 mThe genitourinary examination was remarkable for6 P  \! l9 P% u$ \
enlargement of the penis, with a stretched length of
* ~9 E& w. X1 R3 S, |# V: B8 cm and a width of 2 cm. The glans penis was very well
  t- m0 G+ b5 N+ n! [, Vdeveloped. The pubic hair was Tanner II, mostly around
% N% B- W5 ?0 r& j% g/ T& W/ J540# x. C7 H! S. c  r* {! w9 K( Y$ b2 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 M; V9 Y# S% E1 x% K6 ithe base of the phallus and was dark and curled. The" Y9 A% O3 [& p
testicular volume was prepubertal at 2 mL each.* U% o4 Q! [" o1 A; I8 y% }; p
The skin was moist and smooth and somewhat
$ Q& C  p# d6 b" noily. No axillary hair was noted. There were no5 l* }) {7 I. B6 m$ J+ \
abnormal skin pigmentations or café-au-lait spots.
# W' N' R2 A8 k; s  uNeurologic evaluation showed deep tendon reflex 2+
3 s( w6 R- S6 @' ~2 ^, K3 `bilateral and symmetrical. There was no suggestion
, P" \4 l5 v5 X6 N, }$ Vof papilledema.
: u7 e( R: E' D7 }9 [Laboratory Evaluation
1 n# d9 Z) U  J" l) t' NThe bone age was consistent with 28 months by
- ?1 v2 p! b! j9 Yusing the standard of Greulich and Pyle at a chrono-3 i) R& i4 u2 N
logic age of 16 months (advanced).5 Chromosomal0 j1 [* t4 U& W- G
karyotype was 46XY. The thyroid function test
2 L7 B2 ^/ R7 h4 ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 e3 @- b! {) \, @& g8 alating hormone level was 1.3 µIU/mL (both normal).6 J4 E9 s! x9 R8 Y: s! [
The concentrations of serum electrolytes, blood
1 o  m+ c( m) d6 f3 o1 A% e( j: `urea nitrogen, creatinine, and calcium all were' R8 K  `! X0 D) _( ?
within normal range for his age. The concentration# c" H7 h5 c& b! H8 f+ C
of serum 17-hydroxyprogesterone was 16 ng/dL
1 h5 p! z( ?0 B, S% ^(normal, 3 to 90 ng/dL), androstenedione was 200 c% J. ?5 h( _/ B) i; _9 Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 ~' \# ~0 }) r* @4 c! A/ S6 {
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 ?- B9 Q  J9 x7 t$ O5 N5 `$ Bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
* P! b4 K6 |2 _2 o49ng/dL), 11-desoxycortisol (specific compound S)  f  ?' o& f4 H5 K( Y  Y2 J8 V
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: r  d2 Y( m. M9 @$ Q' n8 D9 T- J& ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* S( j: `0 P5 h( v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% W& [5 Q- ?- E& C' U' A
and β-human chorionic gonadotropin was less than
: p/ X% g5 a: a3 E+ s( m5 mIU/mL (normal <5 mIU/mL). Serum follicular
, ]8 F! p* ?  }  y* Z$ Zstimulating hormone and leuteinizing hormone
! u+ n6 v9 h8 t2 Fconcentrations were less than 0.05 mIU/mL
& }0 K: q# r4 l  Z(prepubertal).
, ^! w. B. w/ |/ dThe parents were notified about the laboratory& P8 d5 Q& S8 {3 N* b) }/ p# X
results and were informed that all of the tests were$ Z: \* q3 o5 ]6 F7 k& L: F
normal except the testosterone level was high. The6 `  W( A- Y( J6 d3 I
follow-up visit was arranged within a few weeks to
3 w) d* n* E0 u/ @3 |' |obtain testicular and abdominal sonograms; how-. @5 ^" g% Y% @. J/ R1 p
ever, the family did not return for 4 months.
- N& T/ r# H) X% J& k5 }Physical examination at this time revealed that the5 E- M: C/ b5 E7 a7 M
child had grown 2.5 cm in 4 months and had gained1 O% l2 o2 K8 b+ ^9 p) D; V
2 kg of weight. Physical examination remained
% N/ j% ~: m! ?! I0 e4 I& @unchanged. Surprisingly, the pubic hair almost com-0 R+ e) m0 R, e9 M  s
pletely disappeared except for a few vellous hairs at
# y% d4 V  A0 G/ o9 ~the base of the phallus. Testicular volume was still 2
1 D. S, x; K7 _4 j- Q/ _mL, and the size of the penis remained unchanged.9 D1 J! o) d5 ]' r. {
The mother also said that the boy was no longer hav-# P9 |% b, N% Y1 J5 i
ing frequent erections.' ~( c# v: @- }+ D, S
Both parents were again questioned about use of. H( e8 h" s$ |. @" {% t
any ointment/creams that they may have applied to0 ?% q/ U* }5 T' a; \: H% q
the child’s skin. This time the father admitted the
/ }! y8 ?) x) l8 _; e7 D& l' k9 [Topical Testosterone Exposure / Bhowmick et al 541
; U9 T  Q, f3 O2 ?) guse of testosterone gel twice daily that he was apply-
$ d! g, w( H5 X0 k& g/ Qing over his own shoulders, chest, and back area for* ^( P7 w" a* P9 ^( j+ V
a year. The father also revealed he was embarrassed5 d: z& }( x& g+ g: p
to disclose that he was using a testosterone gel pre-+ b/ s1 a! G* \2 O
scribed by his family physician for decreased libido
4 l% \- }" S6 Q9 J/ Fsecondary to depression.! m1 x0 Y* H! U+ P; Z
The child slept in the same bed with parents.
& v8 B. @' V7 C2 @$ r! @The father would hug the baby and hold him on his
0 C. I/ @. T2 h4 Tchest for a considerable period of time, causing sig-
! r" Y" e, w" _, `7 F! m* x7 ?* @nificant bare skin contact between baby and father.
- H/ Y3 G9 q/ BThe father also admitted that after the phone call,6 p: L# ]5 Y( H% I6 @7 B
when he learned the testosterone level in the baby
$ e9 e, M- j6 owas high, he then read the product information
1 ^5 K6 s* o& v; |packet and concluded that it was most likely the rea-8 }) G3 P2 T! O% I
son for the child’s virilization. At that time, they9 D. D3 j' Q: B0 \: [" D5 S
decided to put the baby in a separate bed, and the3 t/ }5 O9 S  C: L' V& k
father was not hugging him with bare skin and had' J) C, R  Y3 H% V( s
been using protective clothing. A repeat testosterone
5 `* Y% H  F( E" t7 [9 Jtest was ordered, but the family did not go to the
1 z, n$ y$ F( {4 ^laboratory to obtain the test.( ^0 G+ F: W- Y+ i6 s0 K
Discussion
$ q( h$ q* D* Z9 I0 O! uPrecocious puberty in boys is defined as secondary+ j/ [- E% s" Q1 ?+ ?) w
sexual development before 9 years of age.1,4
- [  F$ }( k$ [& J& hPrecocious puberty is termed as central (true) when
; W8 y! W# W3 E+ y; K+ Vit is caused by the premature activation of hypo-
* Q0 C9 Q0 \3 B8 r. zthalamic pituitary gonadal axis. CPP is more com-
' f' h; [& F" L% s  o3 Cmon in girls than in boys.1,3 Most boys with CPP; |- |5 Z4 i) d8 n( ]. }8 v
may have a central nervous system lesion that is3 U; Y2 \. l5 M
responsible for the early activation of the hypothal-
: d; q) U6 z7 Z' J( _: ]amic pituitary gonadal axis.1-3 Thus, greater empha-9 y5 Z, C, |% M( F& G3 N; g* C1 ^7 J+ H
sis has been given to neuroradiologic imaging in
8 J; b5 \$ ~* P" \boys with precocious puberty. In addition to viril-; M: G. g4 e4 T; {* ]
ization, the clinical hallmark of CPP is the symmet-( r' `7 w, k9 Y3 Q
rical testicular growth secondary to stimulation by* f7 ~/ `6 K1 s) x8 W
gonadotropins.1,3; a" Z# T, s  b5 Z0 [3 m
Gonadotropin-independent peripheral preco-
& I, c& ?0 m+ J6 I" G6 d3 Rcious puberty in boys also results from inappropriate
" q0 q( i. `$ v% M. n5 x) T+ bandrogenic stimulation from either endogenous or- }) K+ V- b0 p8 E/ z
exogenous sources, nonpituitary gonadotropin stim-( g- V4 u& ?$ Q( p; w# }
ulation, and rare activating mutations.3 Virilizing* p" k  i% Z& C" [3 k; o5 C$ ?8 f+ g
congenital adrenal hyperplasia producing excessive, o  t, x8 J& `7 A  M
adrenal androgens is a common cause of precocious
, s2 L6 o- A9 I; V# Bpuberty in boys.3,4" G6 R4 ^+ y& v* P) i, R+ |+ N* E
The most common form of congenital adrenal  ~+ a1 a) ]+ [/ g
hyperplasia is the 21-hydroxylase enzyme deficiency.) g+ L: R  g; `; o4 M
The 11-β hydroxylase deficiency may also result in' w, e5 \- N. j: j: V
excessive adrenal androgen production, and rarely,
  F1 _* j3 _# u& M! Q# h) Yan adrenal tumor may also cause adrenal androgen
6 Z% e$ k" p$ \; q7 i) @# nexcess.1,3
8 O1 G1 m& o# U5 d- gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( b. p5 X# C* p6 i2 F3 H% q0 _! j! g
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% [6 ?0 U4 H' c. |5 y) uA unique entity of male-limited gonadotropin-* h, s4 \/ R' Z$ `1 Z
independent precocious puberty, which is also known+ p: S" q$ D% U3 r% Y% R
as testotoxicosis, may cause precocious puberty at a$ g- Q0 X& |+ V' d
very young age. The physical findings in these boys+ z; o" O6 F/ t( r$ s* n6 b/ A
with this disorder are full pubertal development,
8 _& w/ d; l! C7 B/ d" Hincluding bilateral testicular growth, similar to boys
/ R& Z- C& i$ f9 _6 t" wwith CPP. The gonadotropin levels in this disorder" c. M: ~: l2 N$ t
are suppressed to prepubertal levels and do not show( k3 `7 w) T% D0 R  E
pubertal response of gonadotropin after gonadotropin-* H3 X8 c" E+ T8 }/ h4 i7 y
releasing hormone stimulation. This is a sex-linked! u7 u( S' t& |  q
autosomal dominant disorder that affects only1 s. T# r' s( \* ^
males; therefore, other male members of the family& _3 ~* \3 F' b
may have similar precocious puberty.3
1 e# a& f8 f2 {5 ?0 A6 w! nIn our patient, physical examination was incon-3 ]8 F) m# o* ^7 }, g) f4 v! U
sistent with true precocious puberty since his testi-
, b2 Q' ]5 R8 v+ vcles were prepubertal in size. However, testotoxicosis
* n# c, ]; i8 X1 Iwas in the differential diagnosis because his father
$ d- X  p/ N+ t1 Gstarted puberty somewhat early, and occasionally,2 o3 K- u, I* I" ~$ m
testicular enlargement is not that evident in the
" ^( d" v  B9 r1 ibeginning of this process.1 In the absence of a neg-
, d* U+ H! E1 M2 Q$ z5 cative initial history of androgen exposure, our
% S" E0 u; P  J5 k4 Ibiggest concern was virilizing adrenal hyperplasia,6 y+ X8 u/ b: X
either 21-hydroxylase deficiency or 11-β hydroxylase* W4 K% Z0 U! t. h" b& D4 [
deficiency. Those diagnoses were excluded by find-) o  n3 A' x9 u; u. d
ing the normal level of adrenal steroids.& n, B, x, f# c7 @; `, T4 J, p% C
The diagnosis of exogenous androgens was strongly
, T9 o6 T2 s9 i# m1 u8 W& M  {1 V5 }8 ]suspected in a follow-up visit after 4 months because
1 P$ k6 T) m, q: ~; Vthe physical examination revealed the complete disap-
$ F; s" D. i6 Epearance of pubic hair, normal growth velocity, and0 Z( o3 d& J2 s* a$ H  S4 [
decreased erections. The father admitted using a testos-
0 ?+ }6 j* S$ F4 N8 Qterone gel, which he concealed at first visit. He was
) b4 ?: _7 Y- E/ \$ fusing it rather frequently, twice a day. The Physicians’
2 _4 m  _1 Q" G% O# e  oDesk Reference, or package insert of this product, gel or  n0 k' z' I. v$ \" r
cream, cautions about dermal testosterone transfer to( U% D  J; j# J1 O3 e: q
unprotected females through direct skin exposure.1 P& n7 D6 `/ o* V; K9 j; |
Serum testosterone level was found to be 2 times the
2 U0 K% s; N0 F) P- Xbaseline value in those females who were exposed to
0 X3 z  l( |+ A" `0 b( D% ieven 15 minutes of direct skin contact with their male
  `; t2 ~" r/ `& |7 U" h7 a5 Xpartners.6 However, when a shirt covered the applica-
8 ~, I2 _6 v8 s8 w# Y* z6 Jtion site, this testosterone transfer was prevented.1 q% X( N( j' b8 f+ H1 j$ Y
Our patient’s testosterone level was 60 ng/mL,( v% ^+ ~  f. \9 \5 z* X, O- C. N
which was clearly high. Some studies suggest that: }4 t, i( ?2 z
dermal conversion of testosterone to dihydrotestos-
2 W4 ?. u( v, f3 f* Rterone, which is a more potent metabolite, is more
/ w! L4 w! i# n  c1 A, Q4 m! zactive in young children exposed to testosterone
& ?- O; Z9 s6 o& ]9 u$ zexogenously7; however, we did not measure a dihy-! |; i3 F, g( H' b: S# V
drotestosterone level in our patient. In addition to
! I+ O2 H, g* D) Fvirilization, exposure to exogenous testosterone in
9 ?! ?7 a, r$ u; `$ z5 C( ^7 ^7 kchildren results in an increase in growth velocity and/ B' E5 N) k2 L8 w& A
advanced bone age, as seen in our patient./ V+ m  S) l5 j, d: l& @- E# `
The long-term effect of androgen exposure during. ?9 d6 \6 y/ o7 R. I
early childhood on pubertal development and final
1 C% n! n% {0 g( aadult height are not fully known and always remain
# i- q. _! C' I5 L! k. Ca concern. Children treated with short-term testos-+ E  `" r, {# }% b. }/ Y, o* V0 Q
terone injection or topical androgen may exhibit some
3 W1 h& `9 T+ q" Xacceleration of the skeletal maturation; however, after2 X. v$ L3 h3 ~0 x, N+ f0 a
cessation of treatment, the rate of bone maturation
2 G2 r9 V+ u1 |% ], z4 L  }% jdecelerates and gradually returns to normal.8,9
( U. M+ L9 l+ f0 gThere are conflicting reports and controversy" R: R. V! a- k
over the effect of early androgen exposure on adult
. Q9 Z' W' n: {penile length.10,11 Some reports suggest subnormal
1 K) ^9 \  P# n' C6 dadult penile length, apparently because of downreg-
3 O' C. b' }  Culation of androgen receptor number.10,12 However,
  i" c) q5 i+ q; w- v* z9 JSutherland et al13 did not find a correlation between# M8 Z/ ]; v: G+ V' u8 S
childhood testosterone exposure and reduced adult9 R( S  n4 d* N* \
penile length in clinical studies.
7 Y. f9 A5 l4 Q$ _( `Nonetheless, we do not believe our patient is
" X/ q  R0 R& e4 U4 p; Qgoing to experience any of the untoward effects from1 u) o$ R7 j3 ?/ V& o
testosterone exposure as mentioned earlier because1 l$ h* Q0 s. J  Z8 t( y2 D. S
the exposure was not for a prolonged period of time.: x; O6 ]2 {3 |; V% }
Although the bone age was advanced at the time of
5 h" F1 U3 v+ q  C% B4 Ddiagnosis, the child had a normal growth velocity at+ o0 a0 f/ D; S1 v; ^/ Y
the follow-up visit. It is hoped that his final adult: p# K3 A/ S2 b/ e; [7 N1 X* V0 i
height will not be affected.
% f+ Y8 i) e: l. KAlthough rarely reported, the widespread avail-
4 N0 B) Q4 F) i7 Q# {  H: i% ?ability of androgen products in our society may
. I" H' F, c6 T& t- R3 Zindeed cause more virilization in male or female/ _) _" j0 _$ x* ]" v
children than one would realize. Exposure to andro-
3 ^/ W6 F! L& \9 ^4 G0 P& `gen products must be considered and specific ques-
# E: N+ i% D  f: N6 p) ktioning about the use of a testosterone product or# C: h2 `5 X4 K$ G1 @& c; o) w
gel should be asked of the family members during0 V6 H2 p; d5 K  d! v* r
the evaluation of any children who present with vir-
9 `$ M7 W( h( Z8 l% lilization or peripheral precocious puberty. The diag-
, X7 n# S$ |8 v+ |8 @nosis can be established by just a few tests and by
5 n( j6 N" i, O0 Nappropriate history. The inability to obtain such a
; g0 ?  k8 }  n( h0 ^; [$ q* P- Khistory, or failure to ask the specific questions, may
/ Y2 [5 F8 y6 i) t9 m6 }% Qresult in extensive, unnecessary, and expensive
- f/ f4 l8 G3 n& L' Yinvestigation. The primary care physician should be
" P! S# d6 l: a: ]aware of this fact, because most of these children
: E: q% h+ s) ?! F/ E$ F5 tmay initially present in their practice. The Physicians’
; ^5 y0 S0 N) i$ [4 |7 n0 y1 i, eDesk Reference and package insert should also put a
6 m$ B# k- f! O  kwarning about the virilizing effect on a male or
5 c, A# h8 L1 W, v8 bfemale child who might come in contact with some-; W+ R7 A( u0 F, [
one using any of these products.
/ V. N1 v; ^- L  l+ I+ UReferences1 \0 w6 O, p+ T/ ?0 E4 a8 @2 t  j
1. Styne DM. The testes: disorder of sexual differentiation! ?  A  Z! P8 j) [0 t
and puberty in the male. In: Sperling MA, ed. Pediatric& @2 O$ @2 E! u9 n: V7 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; f5 ^( }7 F7 y2 u4 c! j" a- D2002: 565-628.6 e3 c4 X  J8 K4 t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* m; Z' ~! R, S
puberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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
6 A# V/ h8 f0 M: O0 f; u8 ?  C
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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