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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* Y; \1 x9 d; b/ w3 @8 @; S
Boy Induced by Indirect Topical
% N4 ]  O  ~+ ~6 n0 ~) r$ N* OExposure to Testosterone
/ W$ H$ O/ W9 V% w1 BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 g" A$ }6 k! J9 band Kenneth R. Rettig, MD1) a. J  I( @% o7 \
Clinical Pediatrics  l" m1 {9 S! S3 p- s- |6 @* s; ~1 Z
Volume 46 Number 6
: P: Z3 m9 f' t# X- g$ OJuly 2007 540-543
% X) F# G8 J- \% h4 w! n0 N, |© 2007 Sage Publications! w/ P. G) v; ~  ?( Z
10.1177/00099228062966518 X7 |% C- h4 i
http://clp.sagepub.com
. d: |/ _' y4 T8 f9 A5 dhosted at
) y& [* k. w4 ^& i" N7 [& g* Phttp://online.sagepub.com5 X9 I9 \6 {. K- T$ M# ^  f
Precocious puberty in boys, central or peripheral,
' m& \, b! ?& z+ n; }6 T& f8 Pis a significant concern for physicians. Central
$ m3 E$ d  a" Sprecocious puberty (CPP), which is mediated
. V; b) G/ s+ q5 Kthrough the hypothalamic pituitary gonadal axis, has4 l1 k2 E. R/ f; Z8 Q
a higher incidence of organic central nervous system) p1 Y) M" T$ m7 s$ t
lesions in boys.1,2 Virilization in boys, as manifested
# X  _. @8 L3 j) X& `4 `by enlargement of the penis, development of pubic
, b" W" O; l! @) A; L6 \) F# ehair, and facial acne without enlargement of testi-
% B- t+ y# `! k$ `1 r8 x. ]cles, suggests peripheral or pseudopuberty.1-3 We
1 i* i: [$ T, L  |report a 16-month-old boy who presented with the: d' L3 H- T( I
enlargement of the phallus and pubic hair develop-
( C/ ?3 I1 O) G6 X  z4 @ment without testicular enlargement, which was due
4 |- W0 l3 g2 n2 \+ h$ w# Nto the unintentional exposure to androgen gel used by7 ?9 C  I3 ^: \$ k
the father. The family initially concealed this infor-
, A' X& t; |8 R( H/ V- H- T; y8 |* kmation, resulting in an extensive work-up for this( {7 z; S9 ~5 R; d% K
child. Given the widespread and easy availability of
, m' l& n' y( q0 e( {$ Itestosterone gel and cream, we believe this is proba-0 r9 O  Q/ ?) L# X
bly more common than the rare case report in the" W- }" d) M0 j7 ~2 J% x. i; t
literature.4
% s. T# l& @/ \0 M  KPatient Report
5 E7 z4 Q% _1 ~$ y$ D) V" VA 16-month-old white child was referred to the
+ `, ?1 e. U; Kendocrine clinic by his pediatrician with the concern
) |) r2 K  f6 X7 ]8 i* Vof early sexual development. His mother noticed7 o5 q& Q! w- ]9 s1 m, h) G
light colored pubic hair development when he was
! D! j1 C8 r) P2 i- xFrom the 1Division of Pediatric Endocrinology, 2University of
' u+ y3 h) J3 q. S# }South Alabama Medical Center, Mobile, Alabama.( m9 e4 o  F$ \5 ]! [' f6 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,! w9 b! W+ p  M( d
Professor of Pediatrics, University of South Alabama, College of7 d# @/ J* A, j  h- Y% ~: A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 ]/ t) i. ?% s! G% me-mail: [email protected]." p. d* x; U; K0 _$ I* H
about 6 to 7 months old, which progressively became) V+ W( ^* ~7 A, {8 J( ]( j8 O# @
darker. She was also concerned about the enlarge-+ X! l) v" ^. z& U5 T
ment of his penis and frequent erections. The child
# U; N7 A. u7 m5 uwas the product of a full-term normal delivery, with
9 G% @* t1 H% Ka birth weight of 7 lb 14 oz, and birth length of
9 u! y& e( O& z0 A$ m* ?/ X% ~2 P20 inches. He was breast-fed throughout the first year
) a3 q- w: @" `6 Gof life and was still receiving breast milk along with
% ~8 I2 J8 R) {" l: `solid food. He had no hospitalizations or surgery,
- S5 j, M+ q6 H3 z& ]' I& Pand his psychosocial and psychomotor development
4 Q6 w- p2 j2 l0 G  c7 Hwas age appropriate.
6 g! [( U. D0 p; B& N8 r6 d: uThe family history was remarkable for the father,
& {" \- r& k! x, ywho was diagnosed with hypothyroidism at age 16,
+ Y9 N4 [/ M% o% C. i# x4 `$ Iwhich was treated with thyroxine. The father’s
$ Y1 L5 r) y) h& Cheight was 6 feet, and he went through a somewhat
! ~& b1 ?" q2 r5 h* e: zearly puberty and had stopped growing by age 14.. l) c0 y  T2 Q" `( {
The father denied taking any other medication. The
1 ^% [! ]' T. G" P. ]% K) I  I7 Tchild’s mother was in good health. Her menarche0 X0 r5 m/ U& x* V3 W! l
was at 11 years of age, and her height was at 5 feet
& @: t) ?" `+ S. N+ t, h+ f4 D5 inches. There was no other family history of pre-; j/ ]4 X- v" o/ }- l9 Z! n
cocious sexual development in the first-degree rela-
0 v% ~  H/ C( Z9 t. ?tives. There were no siblings.
2 a4 ?& j( ~' ~  SPhysical Examination
$ k4 H* P4 S+ q" g, l* J0 k0 QThe physical examination revealed a very active,
9 C5 ?! {# E; Dplayful, and healthy boy. The vital signs documented3 ~$ ^( U6 R9 D/ r; J: y
a blood pressure of 85/50 mm Hg, his length was
$ w" O4 R& K3 Q: D* [. s90 cm (>97th percentile), and his weight was 14.4 kg
  X& [$ H6 U; k9 a8 h1 l(also >97th percentile). The observed yearly growth
! p+ N( G" G1 ^4 B, Vvelocity was 30 cm (12 inches). The examination of
, `% N9 G, ^! E; v$ J- l' m; h6 ~$ Pthe neck revealed no thyroid enlargement.2 i+ s8 p/ b6 j7 P/ W
The genitourinary examination was remarkable for
) y; O8 p* \3 n+ m( D0 Aenlargement of the penis, with a stretched length of
- _8 c/ m6 \2 U/ {8 cm and a width of 2 cm. The glans penis was very well
0 p# h; w- Q* |8 kdeveloped. The pubic hair was Tanner II, mostly around7 ?4 D& T2 f/ O! O% p* B; h4 C0 Y/ \
5401 ?0 W. \! u# O0 g9 o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 ]$ e" L% [" j% M) O4 xthe base of the phallus and was dark and curled. The1 n- D  Q- b. N
testicular volume was prepubertal at 2 mL each.( M( L. m- g6 U2 G, @9 J. T
The skin was moist and smooth and somewhat
4 a3 z# _$ i0 F9 y7 _oily. No axillary hair was noted. There were no# C9 \" o* U+ y/ p" B/ ~- A
abnormal skin pigmentations or café-au-lait spots.
- b+ [) R; U+ O* A, b' I! e! m  KNeurologic evaluation showed deep tendon reflex 2+) ?5 _- H/ S1 v4 j0 m' B+ ^. P( x
bilateral and symmetrical. There was no suggestion9 ~1 M! \% b. U, Z. x$ e2 I
of papilledema.
% o, z3 @  A! N1 f$ q1 wLaboratory Evaluation3 @2 Z/ X4 K( ?5 i) }) a
The bone age was consistent with 28 months by
- I+ i+ w8 B6 m4 t, G. ~& i" Qusing the standard of Greulich and Pyle at a chrono-
2 Z# D, ^3 I2 l* nlogic age of 16 months (advanced).5 Chromosomal9 C$ K+ W) V/ [7 m, c* I
karyotype was 46XY. The thyroid function test8 A+ X  ?- Y, D6 q0 ^9 i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 ]3 _% C  Z9 [  S" S# E/ J& R, Q3 y9 R
lating hormone level was 1.3 µIU/mL (both normal).% ]' i% n2 o4 T1 q
The concentrations of serum electrolytes, blood
8 t# D3 ?$ p6 e3 V) T+ F9 Nurea nitrogen, creatinine, and calcium all were
4 a& A" L, ^: L6 r( d! lwithin normal range for his age. The concentration3 H1 Z$ V1 |" P$ x# s; m  e
of serum 17-hydroxyprogesterone was 16 ng/dL6 V* Q! z4 |  ~* F. L5 Z
(normal, 3 to 90 ng/dL), androstenedione was 20. r, Q% f1 c/ _$ ?/ |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: |: t% \) I5 i  jterone was 38 ng/dL (normal, 50 to 760 ng/dL),( `: S4 e6 U9 p3 ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 D5 w5 t. _% U7 ]  x
49ng/dL), 11-desoxycortisol (specific compound S)
: Q  c8 t; Y  }# i1 N: @% mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ [0 }) B# M& i: c: \/ X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 X2 ?/ t7 K3 V3 ]5 z9 l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ x% C  j8 R. q: X4 Dand β-human chorionic gonadotropin was less than5 M+ P* b7 c# ?$ F8 V! g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ r1 ~- B5 ?) h/ h! ustimulating hormone and leuteinizing hormone
  s" K3 y. m( M0 d+ v7 G( j! U9 }concentrations were less than 0.05 mIU/mL0 W0 H" k/ Y% T
(prepubertal).
6 F; c# B* H' _) n; x, O+ XThe parents were notified about the laboratory
7 |5 ?- n5 C, J/ K+ y# Mresults and were informed that all of the tests were; N+ m( S3 N% P
normal except the testosterone level was high. The
. b0 J: c9 N. h9 Vfollow-up visit was arranged within a few weeks to; _2 G, }( c4 x2 k5 ]) v- F  s' J
obtain testicular and abdominal sonograms; how-
4 Y) y$ a$ [8 \8 r3 `4 `) _ever, the family did not return for 4 months.
! H( X! z% D* M" p1 @# T8 WPhysical examination at this time revealed that the; S; q5 }' q6 P% _7 `/ c4 ]4 G
child had grown 2.5 cm in 4 months and had gained) w8 V' v5 ?# W
2 kg of weight. Physical examination remained/ n/ ~- U2 R+ y% V1 `9 X
unchanged. Surprisingly, the pubic hair almost com-0 v: h: O5 f5 Y3 ?9 j! k, Y4 O
pletely disappeared except for a few vellous hairs at8 K2 T4 y% e: m; H1 C/ T
the base of the phallus. Testicular volume was still 29 x- N, d  H- t& B9 O# ]
mL, and the size of the penis remained unchanged.
' h2 ~4 t; o. X6 w* L* |2 qThe mother also said that the boy was no longer hav-( j, Y% K3 a% N% \
ing frequent erections.
) n9 A* d- Q7 f2 s7 l5 BBoth parents were again questioned about use of$ r: c1 o: B* b0 l5 y
any ointment/creams that they may have applied to
' e/ g& r* U, {( Kthe child’s skin. This time the father admitted the
! W0 o$ T) g  wTopical Testosterone Exposure / Bhowmick et al 5418 L; ^8 K' _- a4 n$ m; W
use of testosterone gel twice daily that he was apply-# U& X' R# }. [$ h2 r7 ^
ing over his own shoulders, chest, and back area for
; l' s/ D" D( W! |3 L" Za year. The father also revealed he was embarrassed
1 y( y! ]% e$ C3 w1 \. sto disclose that he was using a testosterone gel pre-
# W) u* n$ B- I( v! i# Wscribed by his family physician for decreased libido' s1 \* m2 L( g/ J" _8 g
secondary to depression.
6 D, y, E4 j  S) v! T( b1 mThe child slept in the same bed with parents.
$ ?$ @) u! m" ~% I4 N3 a( F' ?: j$ LThe father would hug the baby and hold him on his' s& {9 m2 C" j
chest for a considerable period of time, causing sig-7 P/ F' D' }& c% t
nificant bare skin contact between baby and father.
8 l! T0 d+ t7 v! m1 r+ i1 @$ H: TThe father also admitted that after the phone call,! z. m4 F: ~$ f$ y. E
when he learned the testosterone level in the baby
: T$ x4 D8 n8 y! g! m  ]% Uwas high, he then read the product information) P  F# C* J6 h7 k8 o
packet and concluded that it was most likely the rea-
( @+ l3 T6 \' h" yson for the child’s virilization. At that time, they- S* s: u$ v& {- t" D- A: n
decided to put the baby in a separate bed, and the% n* `/ c8 G7 d; M0 T  J
father was not hugging him with bare skin and had
9 N& V- Y7 V: ^; V1 F  Zbeen using protective clothing. A repeat testosterone* s; x8 P* {3 _! {( ]5 ^
test was ordered, but the family did not go to the
8 F  J& e  N$ Y0 xlaboratory to obtain the test.
/ e4 Z6 b( t6 n. fDiscussion6 M  J9 N; C# Z- M: u. Z4 }6 I
Precocious puberty in boys is defined as secondary
+ v3 h! \& E: k' V9 Usexual development before 9 years of age.1,4" y% d: F4 i% v1 v5 Z# s
Precocious puberty is termed as central (true) when
5 w5 W! v4 f7 Dit is caused by the premature activation of hypo-: S7 m# C4 _2 k7 j( ]: B
thalamic pituitary gonadal axis. CPP is more com-  n& u5 a2 y5 \! q) z' C) l
mon in girls than in boys.1,3 Most boys with CPP
, v( v$ C$ k3 S. z7 d4 ]5 Emay have a central nervous system lesion that is. l" l# o8 f6 C4 P3 _# ~- b2 v
responsible for the early activation of the hypothal-6 U- G, \% Q0 P" U5 g  q
amic pituitary gonadal axis.1-3 Thus, greater empha-; g( p- Q' Q5 X$ ?6 ?. X
sis has been given to neuroradiologic imaging in1 r6 W. ^+ x1 S( P/ v* g
boys with precocious puberty. In addition to viril-" [! t% x& e7 ]% w8 o
ization, the clinical hallmark of CPP is the symmet-
# W, o, f6 Y8 S: nrical testicular growth secondary to stimulation by8 v6 L& M" m5 F0 p+ M- l' Q5 P* e
gonadotropins.1,32 t9 \; ^/ z( Y
Gonadotropin-independent peripheral preco-
$ k5 m3 B( [6 L& Z* I: u: b/ \1 jcious puberty in boys also results from inappropriate
2 B' {' k/ |2 |$ G+ Tandrogenic stimulation from either endogenous or% m5 @( P2 O! e3 t$ Q6 c7 g
exogenous sources, nonpituitary gonadotropin stim-& g3 ]- T" c" M( ^
ulation, and rare activating mutations.3 Virilizing
& b, ]4 {4 K* B, \6 p/ ~; V) s1 ncongenital adrenal hyperplasia producing excessive
% L& Q  j% k: o* ]( a4 _! kadrenal androgens is a common cause of precocious8 J3 ~+ A2 P) T3 T+ j
puberty in boys.3,4: c4 K: Z5 T- ~" u! Y% n/ X
The most common form of congenital adrenal
% o) w  C% X! I  h( v4 Rhyperplasia is the 21-hydroxylase enzyme deficiency.+ Q0 Q4 B/ m; k3 H# t
The 11-β hydroxylase deficiency may also result in' ]; W, ]$ k$ Q5 J# k+ O
excessive adrenal androgen production, and rarely," ]+ R$ J" \1 T* p9 z
an adrenal tumor may also cause adrenal androgen* L5 F4 v- |# v
excess.1,33 J# @, j' X* ~! I8 n5 ?$ C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 E5 U4 @# I( j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- F2 Q2 u- ?" S3 bA unique entity of male-limited gonadotropin-' s! b, |0 s" \& Z9 G9 u# E
independent precocious puberty, which is also known
  Y. t" d& ^& l4 X% e0 `as testotoxicosis, may cause precocious puberty at a
9 W* S  h# X' [1 Y% V# V& Tvery young age. The physical findings in these boys+ f$ Z; n, f* I
with this disorder are full pubertal development,
- Z4 h! e0 L4 @including bilateral testicular growth, similar to boys
( o/ ~$ Z1 ^7 ewith CPP. The gonadotropin levels in this disorder
7 Y5 K+ `5 O9 r: n8 _9 `: @are suppressed to prepubertal levels and do not show
: F$ g+ K* [$ `/ N! O7 F+ N! Opubertal response of gonadotropin after gonadotropin-# O+ E1 f$ J3 q9 S3 {# E9 Y
releasing hormone stimulation. This is a sex-linked) D% ]8 P" S9 j2 |/ c
autosomal dominant disorder that affects only
# a  H# ?. T9 |) P  r  R  n  [males; therefore, other male members of the family' N( q; G$ A" S, j. `' K4 D
may have similar precocious puberty.3
; u- h* w- J$ Q9 J4 L+ \1 @5 z3 ^- pIn our patient, physical examination was incon-
0 z8 M1 g3 m0 P9 f- Asistent with true precocious puberty since his testi-
4 ~! E. S9 P  I2 k+ x- d& zcles were prepubertal in size. However, testotoxicosis
7 `! o- V3 t4 Z5 N$ Y" Pwas in the differential diagnosis because his father
, @" n$ K( K/ ^5 s6 l, bstarted puberty somewhat early, and occasionally,6 r/ Q. R3 z5 I1 ?: k
testicular enlargement is not that evident in the
5 p8 W" e! u- V9 ?! D: kbeginning of this process.1 In the absence of a neg-
9 k. T! E( c# vative initial history of androgen exposure, our% c$ y5 f- y6 c. C6 S, q
biggest concern was virilizing adrenal hyperplasia,1 C5 p' [% L) f$ h
either 21-hydroxylase deficiency or 11-β hydroxylase) ~/ B" O7 x' X3 K
deficiency. Those diagnoses were excluded by find-& m; n+ W( C% q4 v4 u) b- a
ing the normal level of adrenal steroids.: |. l' g1 S8 {4 ^8 T7 ?0 {* z
The diagnosis of exogenous androgens was strongly
9 S  n+ d& l$ P( B9 g1 ?8 @suspected in a follow-up visit after 4 months because
) d7 B. J! {" d0 B5 g5 tthe physical examination revealed the complete disap-
& B! H3 Q$ O9 ]- d4 Kpearance of pubic hair, normal growth velocity, and
9 z) T4 M3 E& Z$ n2 ?decreased erections. The father admitted using a testos-( n$ K. l2 m, ~0 m
terone gel, which he concealed at first visit. He was- O- L% j5 x6 l2 I& u- b
using it rather frequently, twice a day. The Physicians’
" o0 `& S0 J- ADesk Reference, or package insert of this product, gel or6 ]; Z" s# p+ o, W# o. _" ?
cream, cautions about dermal testosterone transfer to
# `9 t$ x/ a0 @1 a, h2 R$ zunprotected females through direct skin exposure.7 }, D+ T* }9 R/ D
Serum testosterone level was found to be 2 times the
9 c* C  }! W7 ]+ Fbaseline value in those females who were exposed to
; h+ J* }9 G, ^9 @- geven 15 minutes of direct skin contact with their male
; {! |3 g" o, b) i- \( }5 @. l0 jpartners.6 However, when a shirt covered the applica-
& O1 V8 Z, }: h" Qtion site, this testosterone transfer was prevented.
" N) E! L: D9 m# qOur patient’s testosterone level was 60 ng/mL,
( P, M9 q1 X) }7 nwhich was clearly high. Some studies suggest that% _0 X' {( Y' O! {
dermal conversion of testosterone to dihydrotestos-% L; m$ S4 }" n
terone, which is a more potent metabolite, is more2 y9 @# B# [  @6 U
active in young children exposed to testosterone0 Q4 _/ R- d% p
exogenously7; however, we did not measure a dihy-
7 U! X0 G- O0 Ldrotestosterone level in our patient. In addition to
: l/ A5 e) S( c8 C. q% dvirilization, exposure to exogenous testosterone in
+ q( L" M; G7 F% @children results in an increase in growth velocity and/ r5 ?# ~  E2 }/ ~( w
advanced bone age, as seen in our patient.
8 }$ d* N' m0 i# p, J4 PThe long-term effect of androgen exposure during
+ R' S3 D5 f% u" Qearly childhood on pubertal development and final
, g- J: E; W1 oadult height are not fully known and always remain
% V9 M& ?5 B1 F" L" Na concern. Children treated with short-term testos-" Z, e) f: W8 g7 W- T; r9 u7 p" I
terone injection or topical androgen may exhibit some; t  q: _" Y1 Q! B, @
acceleration of the skeletal maturation; however, after  p7 @7 ?, U5 S, o! w2 ?7 [
cessation of treatment, the rate of bone maturation7 V: i5 {& d; ^# J) _
decelerates and gradually returns to normal.8,9
  N9 x# S" `  H4 P3 L8 aThere are conflicting reports and controversy0 Z; T9 }, r4 I! @8 R9 y
over the effect of early androgen exposure on adult
% ]6 [1 U: j6 o* Hpenile length.10,11 Some reports suggest subnormal0 L1 @, y' ^5 y! J+ w
adult penile length, apparently because of downreg-
! \7 u6 E3 x3 r* t5 {8 d2 f* Z# Julation of androgen receptor number.10,12 However,8 m. n% S( \2 a* K4 C, Q# C
Sutherland et al13 did not find a correlation between
- J: R/ Q, O! u- T) A. z& b8 ychildhood testosterone exposure and reduced adult
9 g9 v* ?/ x. |; ]penile length in clinical studies.
( K5 \, H! Q# [5 A. x2 I, qNonetheless, we do not believe our patient is$ t. h! j+ l2 m: g: Q9 w' u. u: {
going to experience any of the untoward effects from, r1 S- Z, R8 C/ o- V7 W8 h
testosterone exposure as mentioned earlier because
5 D- u9 T( T8 `9 F2 }" Rthe exposure was not for a prolonged period of time.
- G/ x0 ], G! ^" pAlthough the bone age was advanced at the time of5 Z0 m, S2 E4 H% ~- h
diagnosis, the child had a normal growth velocity at9 B" l6 K1 C- ^! a, _$ p- J
the follow-up visit. It is hoped that his final adult
( ^1 |; y) ]; n1 ]2 z4 D- Aheight will not be affected.
" `7 d+ `& _- d7 c3 N" C% JAlthough rarely reported, the widespread avail-
0 T6 k# m( F; w* K0 Iability of androgen products in our society may
! o, J* [6 W0 Z" }: [; gindeed cause more virilization in male or female
: S" v. P7 Q$ J3 P3 x1 vchildren than one would realize. Exposure to andro-' ^+ h& S/ \0 D" Q  Q7 b
gen products must be considered and specific ques-
) J3 v8 o" W5 b6 Z' ~7 E& `tioning about the use of a testosterone product or
# j9 s/ K5 `0 k! g- igel should be asked of the family members during* {0 N9 I8 {3 w5 N
the evaluation of any children who present with vir-( I- v- t8 ?( x. I( l4 A) K
ilization or peripheral precocious puberty. The diag-0 f& y* Z/ O+ _; g' x: D
nosis can be established by just a few tests and by: B# ?4 M" o: z& b
appropriate history. The inability to obtain such a3 G; r8 y( \4 z9 g- g; c
history, or failure to ask the specific questions, may" t3 R: {# l5 ~6 d: p
result in extensive, unnecessary, and expensive# ]1 L0 M% c; w
investigation. The primary care physician should be
7 U& A3 h2 D% Aaware of this fact, because most of these children
7 C. ~6 t% K* |1 o! t) ^may initially present in their practice. The Physicians’
! Y3 y' i3 E, @Desk Reference and package insert should also put a
/ O# @) V  i& {9 X3 K9 Awarning about the virilizing effect on a male or
0 w. [6 {+ W1 Q4 D% h: g" @female child who might come in contact with some-
: b+ C0 s: U- C7 gone using any of these products.$ A0 F3 h1 v; }$ _1 e
References9 H$ J# c8 p: L* p; I+ J/ m3 a
1. Styne DM. The testes: disorder of sexual differentiation8 g# O4 K9 M9 M( Q& v3 R- m8 {, y' p* I
and puberty in the male. In: Sperling MA, ed. Pediatric
: ~6 t; _5 q8 YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; F) G0 R2 \' Y2 ^4 f, q2002: 565-628./ W8 j0 b# O. n: R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& J. r. E1 w1 x; r% }  q
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old& ~) c3 }1 D( L
Boy Induced by Indirect Topical4 w. E% F  O( Y) o& Z9 [* J8 H! z
Exposure to Testosterone6 s/ c0 [- E2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- k$ o7 U) B) u" z& [/ ]$ t  i# eand Kenneth R. Rettig, MD1
* ^# K" i! r* Z+ F  A) MClinical Pediatrics
8 v. N1 U; p6 A9 x! {# s- W5 x5 vVolume 46 Number 6
9 l+ b/ }* n7 }+ D! Z! N  ?# ^July 2007 540-543
$ I, J! X  t: @) `9 _. p© 2007 Sage Publications# K' W/ C& {' a
10.1177/0009922806296651
6 u7 ~9 J; V( D2 E( |  `7 O, Xhttp://clp.sagepub.com
! W7 U  Q* z& ?2 J" ahosted at4 |9 h( E0 }2 ]) e7 B4 w
http://online.sagepub.com
' m& y$ T% f4 i# U' D, f0 v1 jPrecocious puberty in boys, central or peripheral,$ F) p  [. C- y( }. X9 P
is a significant concern for physicians. Central
3 H4 B+ G- j1 A  m- K8 q' [precocious puberty (CPP), which is mediated
' u9 r" a$ e  z: a9 L" a; v$ Tthrough the hypothalamic pituitary gonadal axis, has5 [$ s: p2 P% ?) i: H# F$ A+ s
a higher incidence of organic central nervous system
, U9 W$ F! R9 I! d- k& ~4 `$ Nlesions in boys.1,2 Virilization in boys, as manifested
/ w; [0 Y  v& ?) u* q9 s: @by enlargement of the penis, development of pubic
  J9 V  U2 j6 s4 S% V  ehair, and facial acne without enlargement of testi-
5 f- G, o4 N0 O2 l# h  W  Q! p% |cles, suggests peripheral or pseudopuberty.1-3 We7 P; v, _+ r9 Z+ n9 r5 L- K
report a 16-month-old boy who presented with the
: m& U5 E2 Q* `  U, _/ zenlargement of the phallus and pubic hair develop-2 |  a5 ~2 A. T/ i
ment without testicular enlargement, which was due: e7 [+ O& Y. o/ n0 `- ^& l
to the unintentional exposure to androgen gel used by
: S2 P8 {, D/ Vthe father. The family initially concealed this infor-
$ b& r' T( Q$ `. v1 Rmation, resulting in an extensive work-up for this, ~  i# Q+ j% W  ^3 ]! y. S( _- l
child. Given the widespread and easy availability of( `7 h% D6 W% W- u7 Z
testosterone gel and cream, we believe this is proba-
5 g  d4 ^. h& H( vbly more common than the rare case report in the' G3 n  y  U% V4 u5 [8 T$ Y/ y
literature.49 p7 R; j: V# F2 e+ `0 t( \
Patient Report8 p) j4 _* |9 x
A 16-month-old white child was referred to the" W4 p) W' q, b& [4 @
endocrine clinic by his pediatrician with the concern
6 [- Z! ~) `, t! [  H. Zof early sexual development. His mother noticed0 m6 T+ O- \- X
light colored pubic hair development when he was( t8 S& l; n/ G# R
From the 1Division of Pediatric Endocrinology, 2University of
! c3 C! f( o% M7 n$ S9 _South Alabama Medical Center, Mobile, Alabama.
  D7 a! f" }: RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& _* Q; H3 X. R3 X# I, EProfessor of Pediatrics, University of South Alabama, College of2 {- ~8 y; k5 Q: p0 |/ e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 K2 P. X" O7 a& p4 H. `5 H
e-mail: [email protected].! p- X& P6 w' P* u8 G1 y: g: i
about 6 to 7 months old, which progressively became& h& o9 C/ a9 Z8 ?+ u+ m& n# s) q
darker. She was also concerned about the enlarge-. H2 ?, c7 t: x' T
ment of his penis and frequent erections. The child, A9 K8 m( a+ ~/ p6 X6 k4 F
was the product of a full-term normal delivery, with
0 q7 x  s8 h4 |' H; y- L: l. `a birth weight of 7 lb 14 oz, and birth length of
4 p2 S3 t* _4 h3 V5 ?20 inches. He was breast-fed throughout the first year- a8 J: H$ d; S( @+ u5 x
of life and was still receiving breast milk along with( a, H+ ?" N- B5 {& i
solid food. He had no hospitalizations or surgery,6 g, ^; M& K7 ?$ ?- H% }' w; Z
and his psychosocial and psychomotor development4 G; M% M/ o, A1 l
was age appropriate.
' Q3 g  Y2 [: s+ y0 eThe family history was remarkable for the father,3 b% ~2 j3 g1 Q0 y
who was diagnosed with hypothyroidism at age 16," S- `) _; m) r8 I  P+ g$ g) P/ Y
which was treated with thyroxine. The father’s( v# B2 A) M) V" ~4 Z
height was 6 feet, and he went through a somewhat7 x: y1 ~/ p8 x9 \( l+ n
early puberty and had stopped growing by age 14.
! P' P. s' }' z. ^' JThe father denied taking any other medication. The
/ g7 {* ^, w6 m% j2 @child’s mother was in good health. Her menarche
- Z2 j/ z% A7 Hwas at 11 years of age, and her height was at 5 feet
4 X' l: }! C2 g# F# e  t  v' t, m5 inches. There was no other family history of pre-. W# ]+ g7 d6 P: l7 o
cocious sexual development in the first-degree rela-
% D& P1 A, r. F5 ntives. There were no siblings.4 b0 Y! u" ?+ l# T
Physical Examination
: e* p& K. E% e; D6 ~0 Y8 h3 rThe physical examination revealed a very active,# u! V3 i- R* u( }. H
playful, and healthy boy. The vital signs documented
& \0 _, w& q+ I% la blood pressure of 85/50 mm Hg, his length was2 |, S9 d$ U! A) S* ]
90 cm (>97th percentile), and his weight was 14.4 kg6 _/ M& @  @- e# g
(also >97th percentile). The observed yearly growth+ f! [5 s8 T- j+ B; F
velocity was 30 cm (12 inches). The examination of' d/ z- S! |5 x- h
the neck revealed no thyroid enlargement.2 B2 D+ W' K, v5 v
The genitourinary examination was remarkable for
+ ^7 ], D5 p2 w! q$ ]. `enlargement of the penis, with a stretched length of* M3 ~! W, `* P
8 cm and a width of 2 cm. The glans penis was very well
% H& ]  ^2 h+ |! k5 Bdeveloped. The pubic hair was Tanner II, mostly around
- z0 I( M) P5 w( V4 y: F$ e540  N* E; t0 g" i/ E6 Z" h' E/ B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 ?7 {' V6 A: j- n$ `
the base of the phallus and was dark and curled. The7 t: G0 O$ g6 f3 Y. U
testicular volume was prepubertal at 2 mL each., x. L" P$ D2 @
The skin was moist and smooth and somewhat  x4 w0 N6 j/ L
oily. No axillary hair was noted. There were no/ h4 G$ X7 _* A
abnormal skin pigmentations or café-au-lait spots.: `+ N( A! O0 ?- G
Neurologic evaluation showed deep tendon reflex 2+
, j& n* o; u* k3 X; tbilateral and symmetrical. There was no suggestion4 L: k2 D0 o: A- K: }" i6 u9 b9 y! I
of papilledema.0 L2 }; U3 {  M  t! y
Laboratory Evaluation$ ?; z9 o% V' F4 o, r4 X. _5 i7 j
The bone age was consistent with 28 months by
; q3 i; [, \; I* [! ]  Dusing the standard of Greulich and Pyle at a chrono-
& ?9 [% }5 j* Plogic age of 16 months (advanced).5 Chromosomal
7 u; D1 R, G, Q+ ?  Pkaryotype was 46XY. The thyroid function test
: T+ D" H! G8 |$ Ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 J% u% Q. H& |: `  ?* V
lating hormone level was 1.3 µIU/mL (both normal).; A; u0 B7 z( t$ i! F
The concentrations of serum electrolytes, blood3 k' ?" l7 w4 u4 Z0 D8 k
urea nitrogen, creatinine, and calcium all were
* z* N# g( F, @within normal range for his age. The concentration, ^! o& }7 U' J% @2 }
of serum 17-hydroxyprogesterone was 16 ng/dL
2 o8 _$ h7 _" t. R8 a(normal, 3 to 90 ng/dL), androstenedione was 20+ [$ Y" ?7 }  h& q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 ?/ m' E$ ^( _" W- J9 V! R8 t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& ~/ I" U! d4 B! A* I6 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 |0 z3 w- M' [49ng/dL), 11-desoxycortisol (specific compound S)
2 x1 c; U- H" `! _" g' `5 Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  f* c0 F% J( |1 V( }  }
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: V. W( h/ o! |  P' i: i5 {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( c! d) f, F  j1 E  Xand β-human chorionic gonadotropin was less than
' {- U( Y1 h/ p. ?. Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
% K" n0 M' K  A# s6 G4 J, p7 Ystimulating hormone and leuteinizing hormone
) A# j: v2 n+ @% y# P1 B: C# fconcentrations were less than 0.05 mIU/mL+ z3 ?9 D6 t- C% w1 R- g4 u
(prepubertal).
  K0 _9 x4 y6 K$ i- b7 MThe parents were notified about the laboratory' J, K3 o6 H5 v' h0 I; {- n! l
results and were informed that all of the tests were
' u/ m2 S' W$ T6 ~* w' D2 C/ M; lnormal except the testosterone level was high. The
# U6 I4 F% O, F5 Nfollow-up visit was arranged within a few weeks to0 s2 w$ X1 D2 S# G2 Q; @
obtain testicular and abdominal sonograms; how-2 g8 U! N) s3 i' Z6 D
ever, the family did not return for 4 months.
; L, P5 t3 q# U& z0 |Physical examination at this time revealed that the' S+ A; y9 m* c3 _. }1 v: r9 Q
child had grown 2.5 cm in 4 months and had gained2 t7 P1 _$ |9 W# ?3 W
2 kg of weight. Physical examination remained6 G6 `: t! j6 B, L! h* c
unchanged. Surprisingly, the pubic hair almost com-
% L8 l8 o% a5 e# a( fpletely disappeared except for a few vellous hairs at
2 Y6 m5 ]5 h- Xthe base of the phallus. Testicular volume was still 2" n" C1 `2 S3 \8 t, H
mL, and the size of the penis remained unchanged.1 d: X8 F2 \; ?0 ]4 R
The mother also said that the boy was no longer hav-: O2 R1 H4 J# }+ _+ P$ N9 l
ing frequent erections.
8 b% g* r7 V- ~# g3 u4 O5 UBoth parents were again questioned about use of2 L* O+ B1 j+ _; @4 j6 h) m
any ointment/creams that they may have applied to
. v/ o$ N  ?% s; e4 E7 z# Q2 ?+ o6 lthe child’s skin. This time the father admitted the. G$ z# c; d! [+ W6 ?8 b
Topical Testosterone Exposure / Bhowmick et al 541
  q- r7 p% j0 ?% S4 E: K: Ouse of testosterone gel twice daily that he was apply-) e3 @5 j3 a4 T- E
ing over his own shoulders, chest, and back area for1 r3 F5 \8 q; d
a year. The father also revealed he was embarrassed, \& I1 u+ B; y+ L& ?
to disclose that he was using a testosterone gel pre-/ A7 _% |7 V! ]4 C/ I+ G
scribed by his family physician for decreased libido
4 {3 J3 M* t) Qsecondary to depression." @- {0 i6 Z7 D! r5 A# W) Q
The child slept in the same bed with parents.
4 y3 v" @6 O- u" Z6 |% GThe father would hug the baby and hold him on his
! ]& ~" d0 L/ V7 F0 b* h' u. N; c$ _: Schest for a considerable period of time, causing sig-
& V% k: C6 T1 w; Gnificant bare skin contact between baby and father.: A" O% `* ~9 S
The father also admitted that after the phone call,
& O: m6 B& D- \" k3 Y8 \: R$ h& ]when he learned the testosterone level in the baby5 i2 R, ~6 B% ?+ S- ^6 z4 y
was high, he then read the product information
$ h, ?2 {* W5 e0 ?# x2 p7 v) upacket and concluded that it was most likely the rea-
: W) `+ R. Z0 K0 _son for the child’s virilization. At that time, they
: k  i, R3 w) D' b; i4 pdecided to put the baby in a separate bed, and the
7 h  h$ A  d# {- e+ r# mfather was not hugging him with bare skin and had3 \# x- _. {. o  ?% u% q
been using protective clothing. A repeat testosterone
; Y4 \; S! l  ^test was ordered, but the family did not go to the4 ]) x# W( x2 ~( K) D
laboratory to obtain the test.
; X4 m0 ^0 K  x% b7 V; tDiscussion
; j& R& i/ Y: c0 D0 o5 }Precocious puberty in boys is defined as secondary7 W! S; {! m( u" D) m  L; B
sexual development before 9 years of age.1,4
0 z9 ]) }0 s$ m: P+ c1 _Precocious puberty is termed as central (true) when! g) a3 T( V7 h0 k. t6 K
it is caused by the premature activation of hypo-" q. _# |. p" h* s4 W
thalamic pituitary gonadal axis. CPP is more com-6 I0 h, ^/ l! Z" p$ y2 U
mon in girls than in boys.1,3 Most boys with CPP
' z  z# h9 N* w+ f9 z) z- `may have a central nervous system lesion that is/ h0 G2 W. r  u; J, F
responsible for the early activation of the hypothal-- @1 J. x4 w9 }' D8 n* \
amic pituitary gonadal axis.1-3 Thus, greater empha-
* m& Y- \& o5 P0 k3 `sis has been given to neuroradiologic imaging in. g) f  x9 L9 G, v# V# u3 V7 ]
boys with precocious puberty. In addition to viril-; ]6 [; X6 z3 q4 a8 r* h
ization, the clinical hallmark of CPP is the symmet-
$ V: u" a9 `2 h$ m! g$ jrical testicular growth secondary to stimulation by
% b4 k( _  C+ N; S2 l2 r0 jgonadotropins.1,32 q" [# R  ^- d  {! c# |
Gonadotropin-independent peripheral preco-
+ H- e( Y) g* q+ x. kcious puberty in boys also results from inappropriate& L# W0 K1 Z* S) \; Q2 w2 F
androgenic stimulation from either endogenous or
( l" Q/ Q. e* vexogenous sources, nonpituitary gonadotropin stim-+ Q; u* X) K- S* x. j0 S1 U& M2 m
ulation, and rare activating mutations.3 Virilizing
3 x, O# U! \3 X9 dcongenital adrenal hyperplasia producing excessive' Z8 Y) C+ i, S9 k7 n) O. r# Q1 N
adrenal androgens is a common cause of precocious; ~; x1 O! T1 r2 \0 ^* p" X
puberty in boys.3,4
% D1 k- N; C  a2 |, K7 S& m! t. pThe most common form of congenital adrenal5 G9 u$ m- x0 l9 ?8 M# ^& d
hyperplasia is the 21-hydroxylase enzyme deficiency.* C7 e" K% H, C# f- e; v% D
The 11-β hydroxylase deficiency may also result in: w) z/ _$ t6 F; g
excessive adrenal androgen production, and rarely,
9 f! X' m% T, y5 Ran adrenal tumor may also cause adrenal androgen
! a: ~  d# g" p6 u6 yexcess.1,33 [! L- j7 C3 M& Z: `1 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ d, J0 H/ }( B# ?5 V% |" J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 a8 T, f8 x7 c6 {( TA unique entity of male-limited gonadotropin-
5 K: W1 l0 S, N, windependent precocious puberty, which is also known7 S) N/ V  t  [" u
as testotoxicosis, may cause precocious puberty at a
; H8 h1 \8 J% S2 m1 C6 N3 k& U  Gvery young age. The physical findings in these boys, H  s0 ~3 c+ [# i; }  m
with this disorder are full pubertal development,
' E8 G9 N: V$ K9 {- b$ ~( uincluding bilateral testicular growth, similar to boys9 a! M' p, S1 o% r
with CPP. The gonadotropin levels in this disorder
7 H. W# q9 ?% Q" C% }are suppressed to prepubertal levels and do not show) |- C# n3 n2 K- k$ t. P
pubertal response of gonadotropin after gonadotropin-" g4 K( K- L7 Q( N- B( C
releasing hormone stimulation. This is a sex-linked" Q/ W3 z6 U# o
autosomal dominant disorder that affects only! \' [& W, d: B1 U2 M4 P  x
males; therefore, other male members of the family( J4 ]# e  H" y
may have similar precocious puberty.39 }6 c/ J/ g7 ?; h/ @
In our patient, physical examination was incon-) i3 F1 i7 p/ N( p2 f* `
sistent with true precocious puberty since his testi-" c# f! {! `+ y# X; `7 o( z
cles were prepubertal in size. However, testotoxicosis
: y- s1 @; ~. ?$ e! l3 rwas in the differential diagnosis because his father! u; E& g8 O% z
started puberty somewhat early, and occasionally,0 W$ _  M# a5 Q# {9 X
testicular enlargement is not that evident in the
8 J( ~* }, R1 f" o' `! _' l; C0 nbeginning of this process.1 In the absence of a neg-- B$ L  ~# G4 s9 y. n* M
ative initial history of androgen exposure, our
+ w; j2 _7 P! a2 z7 Dbiggest concern was virilizing adrenal hyperplasia,+ j# |1 y# A0 s- N3 \5 M4 k
either 21-hydroxylase deficiency or 11-β hydroxylase/ Y) k& i) t1 i+ h) x
deficiency. Those diagnoses were excluded by find-5 G1 s" u5 `8 g6 {* ~- R- D
ing the normal level of adrenal steroids.
  N2 G' b, \. v8 C! {3 Q3 ]( pThe diagnosis of exogenous androgens was strongly$ o# \, D9 @$ \# d5 d( X
suspected in a follow-up visit after 4 months because
' c( h4 w6 F2 a& rthe physical examination revealed the complete disap-. D3 i: Z3 b6 d
pearance of pubic hair, normal growth velocity, and2 T* h7 E8 g- P5 |; ^
decreased erections. The father admitted using a testos-8 v5 e' v5 J- E! G$ t0 D9 n8 g
terone gel, which he concealed at first visit. He was0 @& D: q% Z, ]) W. g$ a
using it rather frequently, twice a day. The Physicians’- a8 s$ a/ k, f, E) z9 K+ @& D
Desk Reference, or package insert of this product, gel or
( d7 v* l6 F: m7 ncream, cautions about dermal testosterone transfer to) x0 m# f3 Y; E$ v: w' x9 D
unprotected females through direct skin exposure.
& }: _) {* Q" I% lSerum testosterone level was found to be 2 times the1 W+ c. c6 b/ n" Y* _
baseline value in those females who were exposed to; [( F% o  u. i2 [3 d# N' f
even 15 minutes of direct skin contact with their male7 K3 `5 _' z( n1 v1 \$ E
partners.6 However, when a shirt covered the applica-3 K+ n# T7 K; e1 q' }+ f3 \
tion site, this testosterone transfer was prevented.9 x% }5 v7 g- Z4 ^0 t5 U) u, Q1 O
Our patient’s testosterone level was 60 ng/mL,
  h; C+ ~# i9 [; b( m' [5 Pwhich was clearly high. Some studies suggest that. y9 m" O/ P% a/ G  P2 I1 d: d
dermal conversion of testosterone to dihydrotestos-8 K4 N1 p9 ]( g9 D( l
terone, which is a more potent metabolite, is more
' o# M" ~. ?8 C. L7 Dactive in young children exposed to testosterone
5 r9 d# R3 q8 O2 B/ M  Yexogenously7; however, we did not measure a dihy-
: [! P; J0 s  f8 z! J- Fdrotestosterone level in our patient. In addition to' b( r5 `! m+ o3 A4 s4 g
virilization, exposure to exogenous testosterone in
# y1 g* v& {$ P# Kchildren results in an increase in growth velocity and
! {6 H5 q3 |! [9 T  e5 gadvanced bone age, as seen in our patient.9 M9 Z* C7 N# b9 P: k
The long-term effect of androgen exposure during
6 V; o  b+ v2 S5 o- f' R7 N( {early childhood on pubertal development and final
! e$ z2 O4 Y5 O0 q" U  kadult height are not fully known and always remain
8 N0 c4 o/ U& m+ \) y& Ta concern. Children treated with short-term testos-% \  ^- j" V3 q# ^, ]6 s- ~
terone injection or topical androgen may exhibit some
4 A8 K" Z: X+ m! r9 j1 Dacceleration of the skeletal maturation; however, after
. ?$ L" X4 v( i6 Z/ ^! _0 T0 ncessation of treatment, the rate of bone maturation& E+ h1 ~" p- t1 S
decelerates and gradually returns to normal.8,95 S& P* e8 j$ s  x. @
There are conflicting reports and controversy# b$ s1 Y1 U3 P; q7 n0 Z
over the effect of early androgen exposure on adult6 I* o  Q" E; B' Z' E, |& }
penile length.10,11 Some reports suggest subnormal1 ]  a9 y% Z- W
adult penile length, apparently because of downreg-
2 e" k  u0 Z8 i5 k1 `ulation of androgen receptor number.10,12 However,/ D1 S2 g6 P, O% t8 g, x3 f
Sutherland et al13 did not find a correlation between
& Z" g# h. T( i1 @' t' Nchildhood testosterone exposure and reduced adult
0 N: {8 t4 B8 y8 F1 apenile length in clinical studies.
0 Y; l& S# J' b  s4 R0 }Nonetheless, we do not believe our patient is
- \8 s& y# e( xgoing to experience any of the untoward effects from- w( |* a4 Z) h/ _
testosterone exposure as mentioned earlier because
, I/ [  z7 [) m: y. Vthe exposure was not for a prolonged period of time.! ?! n4 x* c& t
Although the bone age was advanced at the time of
% p: X+ f, m" g9 _# v' Idiagnosis, the child had a normal growth velocity at
6 Z! z1 Z1 G; V& R3 s- X3 bthe follow-up visit. It is hoped that his final adult
7 ]1 x* n& x; f& Xheight will not be affected.( q, ?2 k9 `, Y3 y! E
Although rarely reported, the widespread avail-: o- E% E) Z" Z: B# i
ability of androgen products in our society may
+ P8 C# n4 r4 P* ^" X: E# Findeed cause more virilization in male or female3 D9 g9 w2 o* B7 r3 x! ]/ U) E4 {
children than one would realize. Exposure to andro-
8 |. S) t4 ]. L% r. R$ j" Ogen products must be considered and specific ques-- D% `+ z& u6 i3 P. g4 X2 P
tioning about the use of a testosterone product or. E$ h9 n# `" t( T3 K& z
gel should be asked of the family members during7 B  z7 y$ e; v' J9 O
the evaluation of any children who present with vir-
$ s* r/ B$ ^3 `4 U/ i  O; Filization or peripheral precocious puberty. The diag-
, p5 e# X9 Y; e9 [nosis can be established by just a few tests and by- A) f! {( N/ m$ ?* P- S! @! t( X
appropriate history. The inability to obtain such a$ {# c$ @+ g3 W+ j( P+ {
history, or failure to ask the specific questions, may7 U* r5 u. U( |4 X) e
result in extensive, unnecessary, and expensive+ r9 I1 @3 a  X' ]# m% y" G
investigation. The primary care physician should be
( f* y6 s- I: L3 L) P$ zaware of this fact, because most of these children
) h# s  `0 O6 j8 h+ C" O: umay initially present in their practice. The Physicians’8 B0 Z' M# @( [0 e' Z7 d* |
Desk Reference and package insert should also put a# V' G. e0 f0 K. y( T& G
warning about the virilizing effect on a male or
4 v. q1 h, k& Y1 B' tfemale child who might come in contact with some-( m7 O8 Q) h7 ~  ?% F5 I
one using any of these products.
$ U& i4 @% T8 g* YReferences
4 G* }1 l- C; C9 {6 O. C1. Styne DM. The testes: disorder of sexual differentiation- I* S3 x9 W8 }7 p* z5 D6 ^
and puberty in the male. In: Sperling MA, ed. Pediatric
" G: m1 }. m! Y* U/ ^& @9 nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 E8 r! G- Q; f3 B+ X' S1 r
2002: 565-628.0 ?: B& B7 M* z9 b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- y; J/ M3 n( t' X5 D* D( M& jpuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
1 t% Q# Q' d) ]2 d" ?
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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