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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
! D1 @1 w& a8 R" c; @Boy Induced by Indirect Topical
: x8 x6 M) l" B( _1 QExposure to Testosterone4 }" Z! M4 H2 }& G- Z! A& [7 M  M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 e+ C0 W* F* j0 X' C) band Kenneth R. Rettig, MD1* t; m; E0 b) E, |
Clinical Pediatrics
: C/ K( ]) _3 W9 VVolume 46 Number 6
" R; e1 I. u' Q1 WJuly 2007 540-543
# z' O/ v& D/ a9 ?+ R© 2007 Sage Publications
% s1 P, y9 a4 L5 x: w3 d2 |8 q+ E10.1177/0009922806296651% U% m8 N& h- `" u/ t
http://clp.sagepub.com- f' Q  w) q% p. o  o, x3 n0 {
hosted at
/ j0 x3 t5 E) r8 ^http://online.sagepub.com
) `: o& A0 b; ePrecocious puberty in boys, central or peripheral,
6 b1 a) b7 ^6 J: O7 Ois a significant concern for physicians. Central
' @5 m1 y7 @1 J: y  _+ ~0 wprecocious puberty (CPP), which is mediated
7 [% b! |; A* y: n% K, ]through the hypothalamic pituitary gonadal axis, has
  D9 z; Y& ?% m* e; Wa higher incidence of organic central nervous system
& e9 R' A( ?0 G* T5 slesions in boys.1,2 Virilization in boys, as manifested" U8 [8 N! E% t: J  t$ g3 \
by enlargement of the penis, development of pubic
0 K) u# e6 D1 X5 ]; S( mhair, and facial acne without enlargement of testi-6 o5 C" `6 a4 x. N& n
cles, suggests peripheral or pseudopuberty.1-3 We: i% |, m" P& E1 r- K+ ]1 r: u
report a 16-month-old boy who presented with the
" v! K  f8 }( ~; u- kenlargement of the phallus and pubic hair develop-" @8 g  Q# X# a. G$ p: B
ment without testicular enlargement, which was due% T. x8 F1 y! R/ D: ~3 f
to the unintentional exposure to androgen gel used by# |  k: Z: u, R1 A+ f! D
the father. The family initially concealed this infor-
! K9 S' f  b: `) I6 z- M* `mation, resulting in an extensive work-up for this
/ s! b7 N' K6 d' z' e+ [child. Given the widespread and easy availability of! x" _# {2 X1 [7 z& w
testosterone gel and cream, we believe this is proba-: w, K5 q. ]: M3 z  v  i
bly more common than the rare case report in the0 m& k# H; F9 ^# A5 P
literature.4- P3 w7 o, g6 i: E/ h0 S/ f
Patient Report
6 |0 g1 N5 C6 o2 fA 16-month-old white child was referred to the3 f0 [% y2 d4 i5 Y0 i; [) V
endocrine clinic by his pediatrician with the concern
1 e! W9 o. m# u1 w, F0 R; lof early sexual development. His mother noticed
; V$ Z- I3 ]9 K! F# n4 u: |light colored pubic hair development when he was
- }, h5 N- m5 j6 @% LFrom the 1Division of Pediatric Endocrinology, 2University of* n* I) B7 v4 i- ?
South Alabama Medical Center, Mobile, Alabama.3 H% X* D! A! a
Address correspondence to: Samar K. Bhowmick, MD, FACE,& U; P3 L. l& N3 O! j( m9 o& D! z
Professor of Pediatrics, University of South Alabama, College of! X$ d% \, _, f1 P1 U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ O; A1 N' }3 J* q% D0 y$ d
e-mail: [email protected].
4 p; ]8 [( Z7 |3 H0 Aabout 6 to 7 months old, which progressively became
3 q- v& R6 G% x$ ?5 p& Mdarker. She was also concerned about the enlarge-3 k. t; i  n: z2 }1 v
ment of his penis and frequent erections. The child
; Y! f! U) G9 M- b8 Q2 R: ]( Wwas the product of a full-term normal delivery, with
# G8 J) Q5 \; b# o  c! N: ca birth weight of 7 lb 14 oz, and birth length of. ^7 W" ], I9 m9 s: D
20 inches. He was breast-fed throughout the first year
+ r3 B6 h3 D6 m( Oof life and was still receiving breast milk along with
& r$ }4 V5 C$ ^' e# f5 }8 J! ssolid food. He had no hospitalizations or surgery,. O- @/ }4 d+ l$ Z
and his psychosocial and psychomotor development1 M3 R% a1 R+ w1 L: E
was age appropriate.# v8 T  q- W3 d! |
The family history was remarkable for the father,
( c4 U" w/ k: }/ {2 i2 t2 Z& uwho was diagnosed with hypothyroidism at age 16,* D& j1 H1 d; ?
which was treated with thyroxine. The father’s
$ U( p; b+ V: J: theight was 6 feet, and he went through a somewhat3 L, n" w* Q" B; F  C
early puberty and had stopped growing by age 14.
/ N0 G/ ^( x/ uThe father denied taking any other medication. The
2 q! b- }! X/ b1 ]. u2 ?1 y; cchild’s mother was in good health. Her menarche
2 B5 t; N2 s; f: s) zwas at 11 years of age, and her height was at 5 feet
2 ^  B5 ?/ ~5 i. b/ `. s& H0 X6 V: v7 K& n5 inches. There was no other family history of pre-5 A: P/ ?$ H+ K
cocious sexual development in the first-degree rela-
5 T, L' D, Y2 p5 H$ K: [tives. There were no siblings.: C+ {' h. c2 H5 |. V
Physical Examination% J2 [: M' z" F9 m' o% z( C1 D
The physical examination revealed a very active,; X' V3 o0 @) x" J' I# B& J
playful, and healthy boy. The vital signs documented
/ h9 f, L% M7 x2 k! e- c, ~a blood pressure of 85/50 mm Hg, his length was) J' h) }; Q1 c. T* P8 n7 ?" |
90 cm (>97th percentile), and his weight was 14.4 kg& |$ b: a1 R. s' @$ B. U& d, m: H5 V
(also >97th percentile). The observed yearly growth1 I7 \. R  M& G* R
velocity was 30 cm (12 inches). The examination of/ f2 A; s3 V; `4 o8 D- o# Q- E! S
the neck revealed no thyroid enlargement.! b. s" e0 k+ ]8 ~3 \
The genitourinary examination was remarkable for
+ I: l4 ~: D* y  R1 Cenlargement of the penis, with a stretched length of; {- B! z. F  z- ~# A/ l  T
8 cm and a width of 2 cm. The glans penis was very well4 {7 M$ V5 I5 }- n& |
developed. The pubic hair was Tanner II, mostly around
7 t- Q# }* X: ?$ ]7 @8 |3 u540
8 T: X( I/ d' l6 `; j. Q4 k; yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( j" k. ^5 ]3 J( A3 k
the base of the phallus and was dark and curled. The
, K" g8 i2 E& htesticular volume was prepubertal at 2 mL each.- K3 {9 b4 Y$ H! a
The skin was moist and smooth and somewhat
9 f6 i4 w: S0 I6 n. M- q2 g! y2 D2 uoily. No axillary hair was noted. There were no
! F3 q# d$ p4 @8 Y6 C; Xabnormal skin pigmentations or café-au-lait spots.
! G/ g7 x" }0 bNeurologic evaluation showed deep tendon reflex 2+9 D5 ^, w5 D, C- f, ?
bilateral and symmetrical. There was no suggestion* v& q& W0 W+ C8 M4 J& d
of papilledema.% _. o7 ^% c/ w  W$ U5 w
Laboratory Evaluation
& z) _% Z. M& B6 q. VThe bone age was consistent with 28 months by
: u' Y. n, a. {9 I2 a$ ]/ \  [using the standard of Greulich and Pyle at a chrono-' c8 \/ [& }+ S- P+ H; S
logic age of 16 months (advanced).5 Chromosomal! W6 ?) K& n3 K3 B- O8 K
karyotype was 46XY. The thyroid function test
  F; |/ t! F, P* B5 Eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, H3 C( t& M+ l8 t
lating hormone level was 1.3 µIU/mL (both normal).2 A7 y6 _5 C, V/ `0 L" N
The concentrations of serum electrolytes, blood
$ C  p6 Z5 W  S+ k- b3 j7 [+ Qurea nitrogen, creatinine, and calcium all were" z( E$ G0 N, o9 x' ~0 p: n2 y
within normal range for his age. The concentration  [+ O0 ]$ H5 m. f6 s& d  q. J& W
of serum 17-hydroxyprogesterone was 16 ng/dL
, B7 H8 K9 [; ~(normal, 3 to 90 ng/dL), androstenedione was 20
5 G" k6 d0 N% X5 a# G, e+ Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 X. z- z" j* X' u) lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 X" \) R/ V7 h; X" i' tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 y1 p2 x& q0 a( B: V49ng/dL), 11-desoxycortisol (specific compound S)' m; l- ?. K) U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! ^. E# _; N/ [1 z5 Y& L  u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: L2 ]) f, ^- u  u% x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# G/ H0 W7 N9 Y; `
and β-human chorionic gonadotropin was less than
( [! z8 m8 [0 S5 I1 F2 e+ k5 mIU/mL (normal <5 mIU/mL). Serum follicular
; E8 p$ w" \) r% u$ qstimulating hormone and leuteinizing hormone% }9 W8 A$ u% d- q8 Z; C8 T: ~9 v% k
concentrations were less than 0.05 mIU/mL
% I% Y- l/ s) d- r! D& J(prepubertal).$ W, H' D: \0 G1 T% w0 _
The parents were notified about the laboratory
% G. z( T* V4 O0 g/ z& I8 _1 zresults and were informed that all of the tests were" T. H+ o3 S5 U
normal except the testosterone level was high. The. R+ R. d) W( p1 `: Z* i3 i, M
follow-up visit was arranged within a few weeks to7 u, B# H8 I% [1 V
obtain testicular and abdominal sonograms; how-2 z) F$ K. C  M; I' L
ever, the family did not return for 4 months.6 n5 G! F9 r# I" x$ ?( ?
Physical examination at this time revealed that the
2 v& l9 l* J* h; X& t  _# gchild had grown 2.5 cm in 4 months and had gained% X/ d5 W- c: p1 }* ~1 ^
2 kg of weight. Physical examination remained# c$ h- t, |( l/ B" I
unchanged. Surprisingly, the pubic hair almost com-
3 {+ A0 h; p, M6 Mpletely disappeared except for a few vellous hairs at
3 a# m) `6 G2 Z, T7 i! `/ L  Vthe base of the phallus. Testicular volume was still 2/ o3 m$ d& G6 @
mL, and the size of the penis remained unchanged.
5 F- a( p# R8 Y( c, F, zThe mother also said that the boy was no longer hav-
6 V! N% h- G/ D& ]' Y  P6 Qing frequent erections.# a4 l& q5 w! D1 B' W
Both parents were again questioned about use of
: i# x7 M; s# \any ointment/creams that they may have applied to
  Y9 L& ~( J5 O6 b) Z8 t8 A# S1 M0 Cthe child’s skin. This time the father admitted the
' @) H8 G: C8 Y( h+ U5 T' n$ G* V: nTopical Testosterone Exposure / Bhowmick et al 541. z2 c4 g( g/ |7 h% h
use of testosterone gel twice daily that he was apply-
4 R7 s( z/ k' n) Hing over his own shoulders, chest, and back area for) g5 l) N/ ~- k+ M
a year. The father also revealed he was embarrassed
- z6 l$ e& q1 G2 uto disclose that he was using a testosterone gel pre-9 x* W5 F  S+ U2 y9 X* j/ u( g
scribed by his family physician for decreased libido
$ G# D0 a6 H- R, t# z6 B( D2 v( \- psecondary to depression.
1 ]3 u, F3 y6 r1 U/ |6 n/ YThe child slept in the same bed with parents.
+ Q) E& \* N* \% a8 E5 G6 NThe father would hug the baby and hold him on his/ s3 g1 L* P' X7 n5 t) e4 p" K& z
chest for a considerable period of time, causing sig-
0 Z- ]7 H$ E( P7 Q. n  O  xnificant bare skin contact between baby and father.
; ~/ s/ n+ J8 aThe father also admitted that after the phone call,
; N! b1 M( _8 Ywhen he learned the testosterone level in the baby
0 |8 A- c: M8 p( x  K0 H/ a7 O, dwas high, he then read the product information
% L$ _2 T. T0 g' m' Qpacket and concluded that it was most likely the rea-
0 z% K3 g( h6 n/ ?3 Hson for the child’s virilization. At that time, they
  Y# g* V5 W+ w, rdecided to put the baby in a separate bed, and the
' H4 l/ y* \7 O' M( V. D$ Sfather was not hugging him with bare skin and had
( H' p/ V$ [$ Z/ G- F( v# e" fbeen using protective clothing. A repeat testosterone
: h1 u$ b$ }! t, }8 ?6 u% Utest was ordered, but the family did not go to the2 n3 a: V  ^& x- O0 ^6 r5 e2 x4 S
laboratory to obtain the test.* F5 M6 V( P, q  U
Discussion0 E5 Y; \" p. |, ~2 l0 v
Precocious puberty in boys is defined as secondary$ H7 n& o# L2 E) Z7 J0 {
sexual development before 9 years of age.1,4
1 j5 _. O: W. o. FPrecocious puberty is termed as central (true) when2 P( k$ Y7 M/ {0 k. v7 D
it is caused by the premature activation of hypo-% z2 A* {8 W, h9 H
thalamic pituitary gonadal axis. CPP is more com-6 q0 `/ W+ {/ U( ~, Z( Y
mon in girls than in boys.1,3 Most boys with CPP
3 K! _& J; b4 e. U" e/ amay have a central nervous system lesion that is
# Q  e# _. z7 n9 Zresponsible for the early activation of the hypothal-
0 u4 G+ G+ c( {5 |& Damic pituitary gonadal axis.1-3 Thus, greater empha-
( i$ ^  b* ]; x+ H4 H" I6 isis has been given to neuroradiologic imaging in
2 e7 N3 _' _% t/ rboys with precocious puberty. In addition to viril-! L2 b3 m3 K& E: C
ization, the clinical hallmark of CPP is the symmet-
: |. }( i* |9 a0 {0 s# t  |rical testicular growth secondary to stimulation by+ p- H: ?2 X, i, M
gonadotropins.1,3
) i9 I: p2 p3 I5 k6 m$ F' cGonadotropin-independent peripheral preco-
- m( e" a  }" z" {cious puberty in boys also results from inappropriate& g4 I2 K; z- ]4 O# [$ V
androgenic stimulation from either endogenous or
7 s! p3 f2 M9 m# w; l* Z& Wexogenous sources, nonpituitary gonadotropin stim-5 T# X% ~& w. f* _; Y% b0 R0 R9 N! O
ulation, and rare activating mutations.3 Virilizing
& H! W; j) G! v$ k: ccongenital adrenal hyperplasia producing excessive
" k7 [1 o  I7 G* W9 j* K5 fadrenal androgens is a common cause of precocious" Z6 n0 l# R! l' v, a
puberty in boys.3,46 A' V5 v3 Q% h2 |( a* }& r) Y0 L
The most common form of congenital adrenal
+ L4 b2 m+ ]3 ^5 l- shyperplasia is the 21-hydroxylase enzyme deficiency.4 f! d% Z! o5 e9 {$ |4 S; a- Y
The 11-β hydroxylase deficiency may also result in4 J9 }$ E- w+ r- t; G! P! C# j
excessive adrenal androgen production, and rarely,% d7 [! T" Q# V* Z( b' i8 a9 S( n
an adrenal tumor may also cause adrenal androgen0 g7 g! i2 j% J
excess.1,3
5 p, |: O' O2 Y- z9 dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 p: w# L, j# p0 M1 J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 |" g4 |3 J- c% ?+ dA unique entity of male-limited gonadotropin-
: X3 |  Q  L, O6 a" B2 lindependent precocious puberty, which is also known
- l# |1 m, z6 O: l3 H+ E5 Has testotoxicosis, may cause precocious puberty at a
& S# P$ d6 W( D0 dvery young age. The physical findings in these boys
, p2 p+ }7 h, u8 s/ @with this disorder are full pubertal development,1 u1 |7 w4 `; \' T; h  U& l( f
including bilateral testicular growth, similar to boys
1 X* g3 a! E3 x' ^2 w& @4 swith CPP. The gonadotropin levels in this disorder
. P& I5 q8 e$ I% h4 p' B/ c9 ]are suppressed to prepubertal levels and do not show
7 u3 ~+ V3 ^+ H# X; P/ |pubertal response of gonadotropin after gonadotropin-
- k2 ?1 i  x6 x: O4 I& q! L) A$ Nreleasing hormone stimulation. This is a sex-linked
" u: `/ V1 u+ [+ Sautosomal dominant disorder that affects only; {3 T/ O( t- p# p+ m8 g" m
males; therefore, other male members of the family
9 ^3 ?, t8 ~4 q0 Qmay have similar precocious puberty.32 w0 r: D! b# ~* O& C' V% ^
In our patient, physical examination was incon-
# I4 o' M2 B3 k8 psistent with true precocious puberty since his testi-' V$ G. c; B. k; A
cles were prepubertal in size. However, testotoxicosis
" j4 U9 a9 |5 q5 {3 ~was in the differential diagnosis because his father
6 o* j- u. L  Vstarted puberty somewhat early, and occasionally,1 W" x- f- `3 V/ _$ [9 r& L
testicular enlargement is not that evident in the3 f' E$ p) ?  ?8 e. |
beginning of this process.1 In the absence of a neg-
5 {, v, @' W# ~! Eative initial history of androgen exposure, our
1 u4 _6 s0 k+ w! N2 `biggest concern was virilizing adrenal hyperplasia,
2 w& L. v8 _/ u' s3 t/ {  t9 Reither 21-hydroxylase deficiency or 11-β hydroxylase
& @# N! {+ f  m5 R4 fdeficiency. Those diagnoses were excluded by find-
6 i6 t  m4 `  D4 x, w2 oing the normal level of adrenal steroids.
5 {/ v9 S' W# RThe diagnosis of exogenous androgens was strongly
5 @, E) T' F% Y' P* ?suspected in a follow-up visit after 4 months because4 e: w& q# g. ]4 j4 D
the physical examination revealed the complete disap-7 w- z7 h1 `2 w
pearance of pubic hair, normal growth velocity, and
- t2 d8 o6 L! idecreased erections. The father admitted using a testos-: b2 c! g8 c- G/ O7 _  L  u1 @
terone gel, which he concealed at first visit. He was
* F6 ]1 B# q# _0 Iusing it rather frequently, twice a day. The Physicians’
$ W7 a0 E- D: \) L1 pDesk Reference, or package insert of this product, gel or8 n& g; j0 `+ i( I. G/ \5 Y! E
cream, cautions about dermal testosterone transfer to
8 L0 v( p; D+ N! m0 q5 k7 I- Ounprotected females through direct skin exposure.
0 ]+ ~: h2 L: E# q* VSerum testosterone level was found to be 2 times the
/ Z" T2 X4 @# T4 ?1 Sbaseline value in those females who were exposed to3 h( x0 X# ~6 d9 b
even 15 minutes of direct skin contact with their male
$ m' a) X% H! @! c1 C9 Jpartners.6 However, when a shirt covered the applica-
% i2 ]5 @: H1 C; Q% u0 t/ ]tion site, this testosterone transfer was prevented.4 F# }) ]& a' ]. q& m
Our patient’s testosterone level was 60 ng/mL,
  q: Z3 }1 e, pwhich was clearly high. Some studies suggest that
* w/ q- U' K: gdermal conversion of testosterone to dihydrotestos-
9 J4 C3 l# G+ N0 Qterone, which is a more potent metabolite, is more
' z' g( {: L- u/ ~+ cactive in young children exposed to testosterone$ z, S8 {2 A, ~- o5 u- H* v
exogenously7; however, we did not measure a dihy-
4 u) ?) |4 H5 d, J/ Gdrotestosterone level in our patient. In addition to
1 L! V' W; v5 j  Ovirilization, exposure to exogenous testosterone in5 z0 ?1 B- F5 h; ?
children results in an increase in growth velocity and
( A, D, @; T9 r' V7 }0 m8 J; Nadvanced bone age, as seen in our patient.
2 m% y# \* b/ XThe long-term effect of androgen exposure during
5 ~  |' J) ~$ j8 y( F+ Z0 R, S1 d. y: iearly childhood on pubertal development and final0 Y7 \8 `% ?) Z4 u" L
adult height are not fully known and always remain
2 H3 w3 I! \  T8 d) c/ Ea concern. Children treated with short-term testos-
! X4 F* U- F4 u  r. C5 S& f& v' Kterone injection or topical androgen may exhibit some- |8 d) U+ ]( o/ g
acceleration of the skeletal maturation; however, after6 _5 h2 P4 i4 V8 ^& B: b) x
cessation of treatment, the rate of bone maturation
/ N4 _7 l3 g9 q* X7 q1 _decelerates and gradually returns to normal.8,9
- i! h; J$ ~9 y% W# `' t4 IThere are conflicting reports and controversy
7 ]) u/ \* l* ]# X! s( O. v1 H+ gover the effect of early androgen exposure on adult# f4 N9 n! B0 i7 O& ]
penile length.10,11 Some reports suggest subnormal! p! l% Q+ W* j; S! z5 D
adult penile length, apparently because of downreg-
5 i* M$ C! G( N4 vulation of androgen receptor number.10,12 However,/ f# Z; |, [5 b7 \9 B; @
Sutherland et al13 did not find a correlation between
) Q/ p. F2 j( h) }- Zchildhood testosterone exposure and reduced adult
. ~' ]  X/ K" A/ X' Q6 @! mpenile length in clinical studies.7 ]$ B, R  K( y
Nonetheless, we do not believe our patient is6 ^& h' E; Y8 ~" m% z% S
going to experience any of the untoward effects from! o" D) \' E% d9 R3 Q8 G
testosterone exposure as mentioned earlier because! w2 M+ r3 y+ e9 K- `6 o3 g% |
the exposure was not for a prolonged period of time.
4 {4 k8 p& V0 QAlthough the bone age was advanced at the time of8 E: ?# B) T7 P; {1 X
diagnosis, the child had a normal growth velocity at7 C! p+ A0 Z. b- \7 R, [
the follow-up visit. It is hoped that his final adult
/ U* {" r2 }! U, mheight will not be affected.
( m3 t$ m. s) IAlthough rarely reported, the widespread avail-
- o: w0 C* S7 a- N. n2 dability of androgen products in our society may
3 P& F: T( E3 d% Cindeed cause more virilization in male or female3 V, v3 |% E) T; a
children than one would realize. Exposure to andro-$ H5 q- d; v1 p! h7 f/ q& A
gen products must be considered and specific ques-
! g0 T- P- X3 {8 gtioning about the use of a testosterone product or
. d7 U, L7 W, a/ s* ygel should be asked of the family members during/ Z/ \2 H) v0 t0 K5 ?! y( C+ W
the evaluation of any children who present with vir-, I. `+ |+ j( x4 M) @; i
ilization or peripheral precocious puberty. The diag-
& e  s& y6 N. u2 c2 z! j- c: V; A6 Onosis can be established by just a few tests and by
1 ]% O; N- K, S1 {: A9 cappropriate history. The inability to obtain such a5 ~2 g8 X0 ~' C3 J* z6 d- R1 s1 F1 a  z
history, or failure to ask the specific questions, may
# t# S# N$ I, y! X2 fresult in extensive, unnecessary, and expensive
/ i$ Q) F1 }' A0 \/ iinvestigation. The primary care physician should be9 X6 S) m3 e0 v" H% j$ m
aware of this fact, because most of these children$ [+ K( f2 \5 S5 c
may initially present in their practice. The Physicians’
5 I, I2 u1 X$ gDesk Reference and package insert should also put a
6 {+ j# H: n5 ?& nwarning about the virilizing effect on a male or
) G: M+ J- Y: ^' C4 H/ @; Ffemale child who might come in contact with some-$ P: Z: |2 i2 w/ `
one using any of these products.7 }7 J! B: y0 \- n4 k7 c
References* [. R- V3 l1 ]9 b5 ]
1. Styne DM. The testes: disorder of sexual differentiation- |1 o+ ], N1 K* z) G( {
and puberty in the male. In: Sperling MA, ed. Pediatric5 n  t) M3 B: W) k7 I7 [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) _- N8 j6 h* B# F" M
2002: 565-628.
$ J! W! u& A0 y6 D, x3 \/ c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 P- ]. N$ x2 V, b+ a4 Bpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
. b2 R( [# I9 O3 B) wBoy Induced by Indirect Topical1 T' y: L- e9 o6 R2 X, J
Exposure to Testosterone
- [4 E3 t; ~5 NSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! y% w2 I5 z3 J# H: iand Kenneth R. Rettig, MD1( ]& J. v( @4 G( g9 W% ~& \$ c
Clinical Pediatrics* p- o4 E+ U6 _- A' V
Volume 46 Number 60 @- y) C9 x5 j; S& ]
July 2007 540-543# E0 q5 x9 m$ x; w3 |  @, J
© 2007 Sage Publications7 `  s6 I# D5 g9 o  O6 A0 ]9 b
10.1177/0009922806296651
: X0 Q" O8 z$ n/ thttp://clp.sagepub.com: [" F) a. d( h! D
hosted at4 j8 D3 \1 O* d. o& Q% I, n. w( X
http://online.sagepub.com, Q/ e) p' z9 D" v5 i2 `
Precocious puberty in boys, central or peripheral,8 Y# P# Y2 d) l# U8 r, Y
is a significant concern for physicians. Central
* l$ P/ y4 h# t+ nprecocious puberty (CPP), which is mediated6 A& E8 m8 ~0 K
through the hypothalamic pituitary gonadal axis, has* a, w# O0 ~3 X& W( O
a higher incidence of organic central nervous system
! p- v' y6 K- P6 o% {- Vlesions in boys.1,2 Virilization in boys, as manifested6 c8 T1 n2 Z; C6 ~- P5 s5 @' E. V
by enlargement of the penis, development of pubic! d$ q$ w1 ~( C5 t* P
hair, and facial acne without enlargement of testi-
; M8 O" h! R4 l+ N8 Xcles, suggests peripheral or pseudopuberty.1-3 We4 A5 n5 d3 W" E7 E1 M$ V2 |
report a 16-month-old boy who presented with the
6 E# _9 V' R: D5 u/ w0 }! Henlargement of the phallus and pubic hair develop-
  H5 @; ^, C* X$ Hment without testicular enlargement, which was due* B  W" k2 G' n, z3 K4 `; o
to the unintentional exposure to androgen gel used by
8 ]3 p$ d% W, P2 p6 Othe father. The family initially concealed this infor-
  h6 P5 ~. e9 e0 @mation, resulting in an extensive work-up for this' \9 p" c2 @* p, o$ K
child. Given the widespread and easy availability of" C8 r8 @! _8 w; N- V
testosterone gel and cream, we believe this is proba-3 O' J4 s! X9 E% h5 f1 n, ]2 b6 E
bly more common than the rare case report in the
$ ?5 p$ v+ o9 E" q' q4 Pliterature.4
% C! _1 B' V2 n/ @! ?% kPatient Report
5 y. d/ P4 B" c' c+ YA 16-month-old white child was referred to the. i  m% k" e' Z0 J
endocrine clinic by his pediatrician with the concern7 A, J& F, V& H% [4 q9 v7 ~  @
of early sexual development. His mother noticed
: c3 }7 M+ b5 P' I* nlight colored pubic hair development when he was& H9 ~- M4 A/ g  R" ~5 v
From the 1Division of Pediatric Endocrinology, 2University of; J; X- I, |# V- a; H& S/ @
South Alabama Medical Center, Mobile, Alabama.* i3 G0 U2 s& K7 n
Address correspondence to: Samar K. Bhowmick, MD, FACE,* s. ?0 b0 `2 P
Professor of Pediatrics, University of South Alabama, College of
4 o# U! ]2 j- v0 v8 M2 SMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 s5 Z/ h7 S" C. a
e-mail: [email protected].
+ c$ X, K% R% N7 Q! oabout 6 to 7 months old, which progressively became! P8 N5 C4 A1 F" M
darker. She was also concerned about the enlarge-
& [4 z; t. |- Y. z& Q2 xment of his penis and frequent erections. The child& D# K0 s9 _- N8 w
was the product of a full-term normal delivery, with- B( P0 M! h' P9 B- T0 n7 t: l# T
a birth weight of 7 lb 14 oz, and birth length of
/ \4 b2 ^5 B( q. O$ I1 o20 inches. He was breast-fed throughout the first year. m- s- g; C/ Z, t' y8 W
of life and was still receiving breast milk along with! y, w7 a  m0 V$ M& W  @' A0 `
solid food. He had no hospitalizations or surgery,* m9 o5 O% f: A+ l" r, _
and his psychosocial and psychomotor development
$ L$ v  k1 Z% P4 l2 J# @  iwas age appropriate.
0 @7 F& n  A1 C0 UThe family history was remarkable for the father," \) ~" a; g5 B# l) ?
who was diagnosed with hypothyroidism at age 16,
0 ^; P: A$ K- k5 ewhich was treated with thyroxine. The father’s1 a8 I7 D& s# l1 t6 D6 U! G/ i* g
height was 6 feet, and he went through a somewhat
9 z: l! A4 m! {( y( Oearly puberty and had stopped growing by age 14.
- |* W+ N) B. d! hThe father denied taking any other medication. The
+ p/ I! t$ G/ ~6 wchild’s mother was in good health. Her menarche
  G) x+ U+ W( u4 e; b+ Kwas at 11 years of age, and her height was at 5 feet
: r/ j3 b( O6 ]. x1 t, h# N5 inches. There was no other family history of pre-/ p( R  f+ h) f" ?+ B# a+ O
cocious sexual development in the first-degree rela-
3 q9 N( k5 s" R" `tives. There were no siblings.
" S3 K- v6 n, f. A8 W: h& BPhysical Examination
: r$ R$ f7 i2 |& ~  t: ]/ WThe physical examination revealed a very active,
/ C; w* p9 C7 Q* Kplayful, and healthy boy. The vital signs documented
. F6 Z( P; n; b) h: j& Qa blood pressure of 85/50 mm Hg, his length was2 i7 b5 f6 j4 q" v
90 cm (>97th percentile), and his weight was 14.4 kg
3 a8 o# k2 O; h$ F) _3 i" g: v(also >97th percentile). The observed yearly growth
9 Y/ P; Y% y% B) o! Avelocity was 30 cm (12 inches). The examination of; y& n1 p, ?) R  `) f3 R( ~* d$ }5 Q
the neck revealed no thyroid enlargement.
, ]( m: l" v# t' ?6 S" O/ Q" S5 dThe genitourinary examination was remarkable for# z0 K% j0 m! W$ a
enlargement of the penis, with a stretched length of8 W% x+ P0 x. ^
8 cm and a width of 2 cm. The glans penis was very well
9 d8 ]3 R5 q$ s7 \* s9 rdeveloped. The pubic hair was Tanner II, mostly around) }, {$ p; ], ^1 q/ ]
5402 ~" o' [4 j  z5 |1 R5 \9 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 j3 o0 V) v5 ^, f% W4 g% X4 k9 |6 E
the base of the phallus and was dark and curled. The* `1 G. w7 K' G
testicular volume was prepubertal at 2 mL each.
% u/ x# h( p% }; W3 ^7 h: GThe skin was moist and smooth and somewhat" f- j# o, i- T! F) b
oily. No axillary hair was noted. There were no' v) ^- i# d5 I# Z% G
abnormal skin pigmentations or café-au-lait spots.4 [6 M+ M! M4 n; @* U) w
Neurologic evaluation showed deep tendon reflex 2+
3 t, T0 L- p5 D; U' @7 zbilateral and symmetrical. There was no suggestion8 m  R! ?( A1 q7 _  O
of papilledema.
) D# B$ }: I- _Laboratory Evaluation/ i  m# c/ S' @# f! y0 O! O2 J
The bone age was consistent with 28 months by- A8 S+ k  z0 L, J
using the standard of Greulich and Pyle at a chrono-
7 U+ h5 K  B% C1 P! Ylogic age of 16 months (advanced).5 Chromosomal
$ A. K# n5 Y7 lkaryotype was 46XY. The thyroid function test
& T$ j0 c; }+ @6 X+ T2 R) M: Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-( ?: W$ `. x0 J1 C5 J9 Z% e
lating hormone level was 1.3 µIU/mL (both normal).; s7 ~& U) X: X8 ]# L% M- x" h
The concentrations of serum electrolytes, blood
9 N' M7 K- R! Z) U/ Jurea nitrogen, creatinine, and calcium all were7 o4 [/ {6 r& S8 b2 p- ]& N
within normal range for his age. The concentration
1 m, V/ ^' D+ g6 L9 R# Nof serum 17-hydroxyprogesterone was 16 ng/dL
$ k& t0 T# c8 P& c(normal, 3 to 90 ng/dL), androstenedione was 20
' z- T0 _3 c% e7 Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 t* Z# B$ e7 r* gterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 b, H! f' S  \desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 x( h; S' p" A/ U" h# B49ng/dL), 11-desoxycortisol (specific compound S)
) _$ H* [- x5 l/ j4 F2 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 |8 N$ y) d# z2 M3 a( A: @9 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  f$ _6 V$ s1 G( vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 {! h% i/ ?  dand β-human chorionic gonadotropin was less than
) [( M+ @# Z# Z/ T2 X5 ]; L7 l5 mIU/mL (normal <5 mIU/mL). Serum follicular) r5 u; V3 r5 h" h( C- |1 Z
stimulating hormone and leuteinizing hormone
# O' G1 `: z- {  s; Q4 rconcentrations were less than 0.05 mIU/mL
# ~) G+ O' n3 g$ s8 D. [(prepubertal)." [) O& R  e* O) Q
The parents were notified about the laboratory
5 C2 r( e! Z* E' D7 _7 l4 Aresults and were informed that all of the tests were
+ O; h! N( I& X$ u3 K: @7 N. @  B% I7 `normal except the testosterone level was high. The, j+ k; C5 t' s
follow-up visit was arranged within a few weeks to; i* Q0 G  p8 g8 o  K
obtain testicular and abdominal sonograms; how-
( Q8 f7 y1 k; _- v' v3 Tever, the family did not return for 4 months.
9 U4 H  h- n9 ZPhysical examination at this time revealed that the5 u5 Y& f9 g4 f3 B/ O: [
child had grown 2.5 cm in 4 months and had gained
' r7 {7 L& S- j% y  {9 C  _2 kg of weight. Physical examination remained+ L) \* b9 i$ A! S, P/ q+ M1 J/ R
unchanged. Surprisingly, the pubic hair almost com-
& c2 I" x9 I; R. B7 m( {pletely disappeared except for a few vellous hairs at
3 Q' R4 V7 P. {, v& \+ }the base of the phallus. Testicular volume was still 2/ @( k) E, h6 u9 a7 ]; F+ f
mL, and the size of the penis remained unchanged.% t; f1 N& K6 j( a/ v% m; A
The mother also said that the boy was no longer hav-
7 Q; v% H% m3 T: I3 Ving frequent erections.: u4 N4 P  n3 Z$ n% D  _! t
Both parents were again questioned about use of
2 R6 s: t. `3 Q. B  {any ointment/creams that they may have applied to
. W( j; C4 M: b3 h- n% uthe child’s skin. This time the father admitted the
2 ]$ @! }( r7 ^9 ~Topical Testosterone Exposure / Bhowmick et al 541
! k, g  N6 U7 b" ~6 iuse of testosterone gel twice daily that he was apply-
, P$ a7 A! B' v% Z9 ring over his own shoulders, chest, and back area for
4 v# F% u. ^" b* }. oa year. The father also revealed he was embarrassed
! q& @$ h0 R- I! U- w; |to disclose that he was using a testosterone gel pre-. m) [% ]. ~+ U6 I/ y' `  I3 m
scribed by his family physician for decreased libido
- N4 ~! a8 _! D8 y0 ]" osecondary to depression.0 K  T5 J; T8 T. y
The child slept in the same bed with parents.$ K+ k; L1 b7 o5 Y6 n# M
The father would hug the baby and hold him on his, q$ M) D% f+ L/ E! s; d1 g" B2 N
chest for a considerable period of time, causing sig-6 }7 ^, W0 \- {& B7 q
nificant bare skin contact between baby and father.
! S8 D$ e- v3 |$ y2 q% GThe father also admitted that after the phone call,
1 a$ q4 @) T3 D$ D6 kwhen he learned the testosterone level in the baby
0 h- @% u7 R. o6 K* r2 swas high, he then read the product information
; O4 t0 }; {% ?, V7 W2 M8 bpacket and concluded that it was most likely the rea-$ G8 L+ i4 g4 h( N# t% |
son for the child’s virilization. At that time, they) t( w! m' y. ]' L# `4 L: Q) t
decided to put the baby in a separate bed, and the- n8 s( _* A" m; m1 \1 [
father was not hugging him with bare skin and had0 a7 l& m; C% @$ v0 I
been using protective clothing. A repeat testosterone
/ g; M" t: P6 C& S3 rtest was ordered, but the family did not go to the
4 q. ?. ^/ f0 p! V' v) Olaboratory to obtain the test.
! k1 Q. |2 o3 X/ f- d5 ]% N" rDiscussion
; {8 T: K  `; E/ a' m; i  ^0 u. Y  CPrecocious puberty in boys is defined as secondary
1 x8 w+ [( V2 Z* }. F9 ?sexual development before 9 years of age.1,4
2 q' r6 J; W9 Z8 x0 c$ g7 d7 XPrecocious puberty is termed as central (true) when
% [' k+ V6 x2 [5 F8 Z6 Eit is caused by the premature activation of hypo-
! J3 v6 N- b& e' qthalamic pituitary gonadal axis. CPP is more com-
7 h! [! F; B2 C! umon in girls than in boys.1,3 Most boys with CPP
+ {  A/ E2 P+ t/ Z9 r( Emay have a central nervous system lesion that is- q7 d9 w2 s3 [# p2 h
responsible for the early activation of the hypothal-" b3 |) W0 I# b/ I# s. d9 e
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 p" B2 X6 w5 `; c" |# qsis has been given to neuroradiologic imaging in
6 n; ^% {6 k& }  [( y+ A$ Z& I9 f& B3 Cboys with precocious puberty. In addition to viril-
' H1 C% z4 f7 \3 _& h, J  |ization, the clinical hallmark of CPP is the symmet-
3 x% a, D' N6 @+ f# V( O7 X; \rical testicular growth secondary to stimulation by
$ {7 M" n; B- U5 Mgonadotropins.1,3
- \- a& N1 _8 q7 ]8 L2 WGonadotropin-independent peripheral preco-: N' B7 \4 u% j7 `
cious puberty in boys also results from inappropriate
/ X' n5 g" e! _4 Handrogenic stimulation from either endogenous or
: M5 ^, G. r1 cexogenous sources, nonpituitary gonadotropin stim-6 o* L( o: f0 n
ulation, and rare activating mutations.3 Virilizing
- X+ J7 }; X! I! R* [! K: Q" ?congenital adrenal hyperplasia producing excessive
8 W& R3 |) c8 u5 W9 U- x& i' Badrenal androgens is a common cause of precocious! V3 C5 {9 M4 z8 m8 {5 E% |/ \
puberty in boys.3,4- t% o3 p4 w$ E8 v/ t, m* f4 \& _) R8 w
The most common form of congenital adrenal, H: b4 A* q  Q7 [: E2 m
hyperplasia is the 21-hydroxylase enzyme deficiency.7 \: Q* g* D( m# \2 P/ n- i
The 11-β hydroxylase deficiency may also result in: p( x& ?$ B  y- r- Z
excessive adrenal androgen production, and rarely,
# b" a3 j3 w' j  Z( e( Ian adrenal tumor may also cause adrenal androgen
* L4 W. w0 A0 W0 J$ yexcess.1,3$ P1 v( i+ m2 F  _: n- ~/ \! d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ n+ p7 k% z* e  F' i542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 `1 K+ W* s# M- S' ]+ Y/ f/ S4 @
A unique entity of male-limited gonadotropin-6 t4 a3 [. M( S, ^, \
independent precocious puberty, which is also known
; Q+ |  v3 ^" `- k$ _* w1 S- jas testotoxicosis, may cause precocious puberty at a
5 b1 n1 d% f1 ?8 c+ zvery young age. The physical findings in these boys" a3 w* V; X4 F& C/ p* |
with this disorder are full pubertal development,
1 ~) Y& U5 Q3 d- Y$ Sincluding bilateral testicular growth, similar to boys& B( C* E+ W" A8 o! p" s4 a8 Y- @
with CPP. The gonadotropin levels in this disorder  K" ~+ z* h1 [0 P2 P: k6 r
are suppressed to prepubertal levels and do not show  e+ p: ?2 J- k3 k9 i
pubertal response of gonadotropin after gonadotropin-4 N! p; i) C; l6 ~0 \. z0 w+ ~
releasing hormone stimulation. This is a sex-linked! F1 ], W: ^9 V5 S0 c2 Z
autosomal dominant disorder that affects only
4 n7 ?$ T; j" omales; therefore, other male members of the family
' u7 [! R/ K) A: xmay have similar precocious puberty.3; J$ ~7 t8 o& n" M' P8 A( S
In our patient, physical examination was incon-
, V7 P9 V; v8 G! L* T% H8 ^5 bsistent with true precocious puberty since his testi-
9 r  x' K# e: ^: a4 Hcles were prepubertal in size. However, testotoxicosis
3 D1 A( V& ]! i( i0 m# {was in the differential diagnosis because his father
7 Y; G# v: I7 M# \3 Cstarted puberty somewhat early, and occasionally,
/ g$ e" N: w+ p# t! R9 Otesticular enlargement is not that evident in the
3 H# X- D. n! h& S* Ubeginning of this process.1 In the absence of a neg-9 s/ c0 `9 ]1 T3 |$ f
ative initial history of androgen exposure, our) M4 g4 A9 U/ y' K) T
biggest concern was virilizing adrenal hyperplasia,
- ?) ]: l: f, l. _0 B3 Qeither 21-hydroxylase deficiency or 11-β hydroxylase$ V# l; k0 p' B, R/ a2 D
deficiency. Those diagnoses were excluded by find-0 I, u9 a! c2 \3 y$ U
ing the normal level of adrenal steroids.
' x$ D" F4 s% ]The diagnosis of exogenous androgens was strongly
3 S; {. U  K2 R6 ^9 n1 c. ksuspected in a follow-up visit after 4 months because; j* Z+ s2 `( p( t- m
the physical examination revealed the complete disap-5 u# B- I6 b% E# L& M  a( {1 ]
pearance of pubic hair, normal growth velocity, and" f* d1 u/ L1 T; q* B5 \/ @& r+ I
decreased erections. The father admitted using a testos-8 F/ f7 T1 z& d9 o
terone gel, which he concealed at first visit. He was% `/ [- ^7 t( G& P8 u( R: |
using it rather frequently, twice a day. The Physicians’
4 t5 r& j3 q1 ~3 }$ C' nDesk Reference, or package insert of this product, gel or
5 u" q# o" q$ \, E' [; H* Zcream, cautions about dermal testosterone transfer to2 v5 A4 y+ s* H0 Q( K$ e( R
unprotected females through direct skin exposure.
4 q+ y' M: _! m2 I, ]$ p" Q' ZSerum testosterone level was found to be 2 times the4 i# i7 _. T8 c: v4 \
baseline value in those females who were exposed to% v4 B9 G% y9 r1 p$ K% [7 K
even 15 minutes of direct skin contact with their male
: {& z2 n3 A% g6 |, N9 S8 bpartners.6 However, when a shirt covered the applica-
. V1 K" @, A) ~5 r9 Ytion site, this testosterone transfer was prevented.
/ j" o" i, V. v% Y$ ?Our patient’s testosterone level was 60 ng/mL,
, U: G. f) k  b+ Y6 q6 `which was clearly high. Some studies suggest that4 k& y$ ]: x7 w! l7 g8 D
dermal conversion of testosterone to dihydrotestos-
- Y; `0 Q" C0 ]4 t# M1 c+ i( I" Pterone, which is a more potent metabolite, is more- i( L; a$ H5 A( i
active in young children exposed to testosterone5 b! ^8 b. c) K) Q( P
exogenously7; however, we did not measure a dihy-
, B/ T4 k' |' Edrotestosterone level in our patient. In addition to
) [5 \7 c2 X7 I" M  P4 o/ {virilization, exposure to exogenous testosterone in4 r+ g3 H- O+ O: }2 C
children results in an increase in growth velocity and: @3 B# R  z1 U7 d) {" ]% y
advanced bone age, as seen in our patient.3 H, P! Q' {2 e4 p$ k
The long-term effect of androgen exposure during
3 P; Z: r9 V6 cearly childhood on pubertal development and final- H) P. B# O" x9 @7 H( ?+ |8 e
adult height are not fully known and always remain
' U4 p. [; _( q! K& ]# ma concern. Children treated with short-term testos-
7 I  ?) o: B, b' X6 t8 jterone injection or topical androgen may exhibit some% ~/ m% o8 |/ |7 w
acceleration of the skeletal maturation; however, after
% w2 ?5 ]' z8 c6 T: _( O0 V8 q2 Wcessation of treatment, the rate of bone maturation6 g) r, C8 f6 s3 T
decelerates and gradually returns to normal.8,95 P, _) j& R* ]+ L6 ?
There are conflicting reports and controversy
0 A: y5 ^2 X( M# Y0 _5 L7 Rover the effect of early androgen exposure on adult0 o* i! o8 R- U  M; z2 W9 `1 U
penile length.10,11 Some reports suggest subnormal
8 f9 D0 w9 {% vadult penile length, apparently because of downreg-, `' \1 k+ f0 Y4 M8 _
ulation of androgen receptor number.10,12 However,
; _. N  ^4 q$ x& bSutherland et al13 did not find a correlation between
* X8 X1 s! C- _childhood testosterone exposure and reduced adult+ e  Q/ `0 }7 z2 q8 O
penile length in clinical studies.! d8 c! e+ s. N8 P( u
Nonetheless, we do not believe our patient is
6 e( S$ m( b( K9 tgoing to experience any of the untoward effects from$ @3 ^" u! O, ~- w# D8 v
testosterone exposure as mentioned earlier because
1 z# a3 w+ N! W: s  Fthe exposure was not for a prolonged period of time.
/ s! {8 V0 N. z; u& h6 L' ^Although the bone age was advanced at the time of1 V# h0 x, o2 B! ~& Z
diagnosis, the child had a normal growth velocity at
7 Y! t  C8 Y# fthe follow-up visit. It is hoped that his final adult- }9 r! p; N( F! T: U: C' S5 t
height will not be affected.7 }$ r. E! L# a/ [( L
Although rarely reported, the widespread avail-
5 m, L3 {# L! p+ zability of androgen products in our society may
3 F* t! `% a' s' L* Cindeed cause more virilization in male or female; y6 Z7 i7 M" W) ]+ ^* _# c7 u
children than one would realize. Exposure to andro-( u) v7 {2 m* C) m
gen products must be considered and specific ques-3 a- D# h, C. P
tioning about the use of a testosterone product or- n6 e4 b: D, E5 {5 U
gel should be asked of the family members during
3 ?" a! u. ~% r9 L; A. z5 ?7 h6 Othe evaluation of any children who present with vir-+ X0 |+ O5 j' e* X* p5 r
ilization or peripheral precocious puberty. The diag-7 C; ~1 `/ N. o- l% h
nosis can be established by just a few tests and by1 v, `0 i1 G! ]/ y  k, d
appropriate history. The inability to obtain such a
  T9 H  `7 S3 x; J% F! ahistory, or failure to ask the specific questions, may+ s" Y1 n- \- g7 l
result in extensive, unnecessary, and expensive% w% v$ u7 e1 x: \: N+ N' g
investigation. The primary care physician should be
: k% W% z# a! L# o3 V; A; Yaware of this fact, because most of these children) j+ q' j- [; s+ c- v) D* q' d
may initially present in their practice. The Physicians’/ E5 H" Q; }( {! K
Desk Reference and package insert should also put a
* _4 c# \3 A, ]" Nwarning about the virilizing effect on a male or
: l; c  ]3 @* f2 C) b. a$ Ifemale child who might come in contact with some-
7 i# p7 |$ _+ L, `# k+ B' }# t% z. Lone using any of these products.
; O# t: A7 y* F, y6 h* d; w; w3 LReferences  S. J1 k: ^9 `" F! r5 K
1. Styne DM. The testes: disorder of sexual differentiation) @: E7 d. D5 }6 v
and puberty in the male. In: Sperling MA, ed. Pediatric
8 _* ?. L. N2 H" \! J) F; QEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 M( Z$ g8 z( h+ u& d; R9 H# Y7 i2002: 565-628.
4 l0 _3 H0 J. R9 z! w0 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 Y* z3 B4 M) u, i
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

9 S& H4 o& G; q: z% 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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