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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
* e; k" l+ i& [* |% F( o: ABoy Induced by Indirect Topical/ s- g4 K; b7 r. K
Exposure to Testosterone' }; |" s3 Q6 H) @% w1 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 c0 J# U2 S- Q2 F& c8 Z  a
and Kenneth R. Rettig, MD12 V9 Q" T# T" O
Clinical Pediatrics0 z" q9 o) m- i8 F( K2 S
Volume 46 Number 6
+ N* R. X- Y) T& h. r% }1 y4 A( S% tJuly 2007 540-543
" g3 i; j& `8 J6 X0 _* }© 2007 Sage Publications
7 X4 u. o" M4 d* g- d: S% ]* O# F10.1177/0009922806296651' G( A. E4 W9 F
http://clp.sagepub.com/ ~6 A9 I  C% B' @' U: Y4 \
hosted at
7 U2 u* \9 A6 L% s, vhttp://online.sagepub.com: S1 M  T7 K0 n+ p' F+ i. l
Precocious puberty in boys, central or peripheral,
* h9 D0 [3 |: F4 ois a significant concern for physicians. Central' a. x: p9 k9 J9 ]0 Q. E+ v
precocious puberty (CPP), which is mediated$ [2 x4 [. D; J$ ]
through the hypothalamic pituitary gonadal axis, has
5 p% ^# |0 i" P: Ma higher incidence of organic central nervous system; ?; t# d: z6 W5 S, S
lesions in boys.1,2 Virilization in boys, as manifested
: d- V5 ~) \2 J2 fby enlargement of the penis, development of pubic9 M8 g8 l% f. k! r- n
hair, and facial acne without enlargement of testi-
  h( k$ K! K  \cles, suggests peripheral or pseudopuberty.1-3 We
8 l, w2 g; h. ^* Q2 e- Ereport a 16-month-old boy who presented with the
& A% y: i, u6 G5 i6 g' y1 p3 |enlargement of the phallus and pubic hair develop-
( V- S# l3 K- X6 p3 C: @ment without testicular enlargement, which was due
+ r; o4 p- V/ ]( L8 R3 ^to the unintentional exposure to androgen gel used by9 z3 ^) p+ O- A& T4 _  G' ^
the father. The family initially concealed this infor-# B& B1 V$ {) \5 ?
mation, resulting in an extensive work-up for this8 V1 [5 W0 o. `6 Q" v7 }
child. Given the widespread and easy availability of
% m: K8 w1 f1 L9 c% p2 `testosterone gel and cream, we believe this is proba-3 A3 V; [6 m( b! Q# G- e
bly more common than the rare case report in the
9 Y- _. ^2 n& V9 C# y9 d: Aliterature.4
6 e- {7 ]4 c- \# d1 o0 G- _Patient Report# F% u7 L: {+ a
A 16-month-old white child was referred to the
$ k; y" c$ \% sendocrine clinic by his pediatrician with the concern
3 |/ T4 n! A9 R- y" v) |0 kof early sexual development. His mother noticed
& e2 O/ z& M+ n4 D- D2 i, Nlight colored pubic hair development when he was1 v7 z7 N  S$ A
From the 1Division of Pediatric Endocrinology, 2University of$ t5 {+ F! A# i& I, R# i) ^
South Alabama Medical Center, Mobile, Alabama.- @- Y; t4 _+ B9 A( ^+ o
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' `* P0 q7 ]0 t" r2 WProfessor of Pediatrics, University of South Alabama, College of
, u3 P* u; x: Y( o, cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 |( H( S5 B7 D* r; a/ E; ]+ Ie-mail: [email protected].2 I& ^; s- V2 E: b
about 6 to 7 months old, which progressively became5 A8 \3 F& v' W/ r8 b
darker. She was also concerned about the enlarge-" f& S$ i4 q. H5 i
ment of his penis and frequent erections. The child  c0 V/ a+ ~) Q3 j7 N
was the product of a full-term normal delivery, with
  F" t- v% U  w. p+ X& v3 r& Va birth weight of 7 lb 14 oz, and birth length of
) E. {5 e" r( t5 o. a+ {3 g! w20 inches. He was breast-fed throughout the first year7 m1 b  g$ E9 E. n
of life and was still receiving breast milk along with
. {6 M) D' [4 _. usolid food. He had no hospitalizations or surgery,# X) I$ e6 ?) T: i+ h$ f) O
and his psychosocial and psychomotor development) G2 Y  o, o0 Q! ]& F2 [; @2 T
was age appropriate.
2 D' x/ y' s5 aThe family history was remarkable for the father,
& ^' y* T7 d  |% wwho was diagnosed with hypothyroidism at age 16,4 ^9 k, v# p+ }% W
which was treated with thyroxine. The father’s2 V: f, S5 R% f8 ?5 j' X
height was 6 feet, and he went through a somewhat
5 f. r0 t) J. _3 Mearly puberty and had stopped growing by age 14.- f' h$ S/ i6 R5 |! H' |% H% b
The father denied taking any other medication. The
1 l5 ~' M: |9 I! u: j) f% l# xchild’s mother was in good health. Her menarche
, k, G. u  [3 |4 g8 E' Y( E6 j' Rwas at 11 years of age, and her height was at 5 feet2 n/ E3 d3 W0 T
5 inches. There was no other family history of pre-
  L% v5 \+ u. ^6 m9 k+ ^" Xcocious sexual development in the first-degree rela-
/ v- {6 h1 Q, r5 _4 otives. There were no siblings.
1 q# l& v) x5 t" E# M8 qPhysical Examination
! F8 |, I5 c# S! I" t) m9 R( iThe physical examination revealed a very active,
5 t+ Q+ B0 ]$ c. \1 U1 }' _playful, and healthy boy. The vital signs documented  s' c5 k  }2 S( H5 e
a blood pressure of 85/50 mm Hg, his length was
4 ^! D+ R& S/ W3 G' [90 cm (>97th percentile), and his weight was 14.4 kg
% d! s0 J# f. t* b(also >97th percentile). The observed yearly growth
, K1 @/ D6 [( \! Y% fvelocity was 30 cm (12 inches). The examination of
0 v+ O2 Q# b/ C7 k+ X$ ?the neck revealed no thyroid enlargement.+ t2 v# w2 \4 N: C1 [
The genitourinary examination was remarkable for; {" l, P& g& e: S( I7 h
enlargement of the penis, with a stretched length of8 v  }6 u" D8 Q$ S4 {
8 cm and a width of 2 cm. The glans penis was very well% e( ?: g0 o1 w
developed. The pubic hair was Tanner II, mostly around$ z% i- X3 h! S/ |- x
540
$ ~0 Q& I( j  L7 |8 i, Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 k5 u3 y* B. m$ M1 z2 R, a2 A0 f
the base of the phallus and was dark and curled. The
2 r6 z7 ~$ |/ ~testicular volume was prepubertal at 2 mL each.: A. i5 G4 @( b& P
The skin was moist and smooth and somewhat# x) l/ I. p2 U& G8 }0 M
oily. No axillary hair was noted. There were no
3 U0 [3 d  s5 n, j* D" mabnormal skin pigmentations or café-au-lait spots.; H" _1 V1 `5 ~* c# R
Neurologic evaluation showed deep tendon reflex 2+
* M& p; C# S7 V7 }8 e5 G1 G4 H4 Vbilateral and symmetrical. There was no suggestion
% f  y2 X. G5 F, }! R# wof papilledema.
, i% F5 q' Y2 Y* q) KLaboratory Evaluation" e! ^! C  p, _7 @1 [0 Q9 U. S
The bone age was consistent with 28 months by
8 J& x( k. c2 E/ F+ p7 a4 f2 husing the standard of Greulich and Pyle at a chrono-  E  ]& P4 d# R: G
logic age of 16 months (advanced).5 Chromosomal, p( j# u! r7 u: ?
karyotype was 46XY. The thyroid function test3 X+ z. ]1 z8 j+ E0 B; ]! h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% Z1 D3 ]1 {  u0 |lating hormone level was 1.3 µIU/mL (both normal).' x$ O! B0 q: i& }, _8 \
The concentrations of serum electrolytes, blood
( D* n: p& U3 Qurea nitrogen, creatinine, and calcium all were( N+ J9 m% g4 [
within normal range for his age. The concentration
5 _) C" f1 }& O+ b! Iof serum 17-hydroxyprogesterone was 16 ng/dL
+ F* \" s. j% T(normal, 3 to 90 ng/dL), androstenedione was 20* x' ?& W1 p8 u9 `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" D4 k. C& L6 Y7 ^& G" M* g% n$ `, Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& O4 }+ W+ z/ F/ Y9 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to  B& h) C0 @7 O' c
49ng/dL), 11-desoxycortisol (specific compound S)
- U4 e3 ?. i3 d: Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& |. }; h% P& E  I' I* x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' t& j8 E/ U8 R0 g# _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 X& A, A5 L- W; r# I$ ~3 nand β-human chorionic gonadotropin was less than' \2 t/ U! ~- o4 e- Y% d
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 J; ~* [- n* t; ]1 n9 ~5 T
stimulating hormone and leuteinizing hormone1 Q. b" Q' e, F( Q( |
concentrations were less than 0.05 mIU/mL
: s+ i2 x. Y9 m  K4 u(prepubertal).
, z. B0 q8 T# G6 A: eThe parents were notified about the laboratory
2 u) d6 L/ ]. b' H0 p* [results and were informed that all of the tests were
; M' h6 R7 \5 ]& A3 tnormal except the testosterone level was high. The. a. V( B; R1 b  A/ t7 }1 N
follow-up visit was arranged within a few weeks to0 v5 B5 b' N0 B- z. d" ]
obtain testicular and abdominal sonograms; how-
5 V! J+ Q1 G) h; p- G1 j' Cever, the family did not return for 4 months.1 s1 R3 b7 W; `
Physical examination at this time revealed that the& ]+ x! y0 D8 X/ i
child had grown 2.5 cm in 4 months and had gained5 G2 O/ G& O# P& `4 J' a- B
2 kg of weight. Physical examination remained* z9 ]' ^8 I* N/ n2 J
unchanged. Surprisingly, the pubic hair almost com-3 e7 {/ x* a! p6 j
pletely disappeared except for a few vellous hairs at
; @% M4 A: d, n7 N5 T( [the base of the phallus. Testicular volume was still 2
1 }* x5 \- W  ], l- v, Z9 ]7 TmL, and the size of the penis remained unchanged.* F8 Q( F) w: g6 _. ]
The mother also said that the boy was no longer hav-, l+ X- m7 {5 y$ W$ @
ing frequent erections.1 r- }9 c9 ?- k) o& w
Both parents were again questioned about use of6 K) s* j1 m( y1 i- O+ l0 Z, e' z
any ointment/creams that they may have applied to
2 E* I9 w6 C" B6 p8 S. `the child’s skin. This time the father admitted the
0 X/ k/ D. ^, ?0 jTopical Testosterone Exposure / Bhowmick et al 541
1 T9 R, v/ h' w8 w  E3 Luse of testosterone gel twice daily that he was apply-
% Z0 V, c; H% h* K  ling over his own shoulders, chest, and back area for: z# ?  l% W! G# m& f3 e
a year. The father also revealed he was embarrassed/ I( T; U. @7 ^- a6 C% }7 @
to disclose that he was using a testosterone gel pre-  l6 M9 g8 C+ v4 P; X7 ~, w  ~
scribed by his family physician for decreased libido7 `+ d! O+ W1 j% B+ h6 m" Y2 d
secondary to depression.& \+ c  J9 w0 u- q1 H0 E) }1 K  Q
The child slept in the same bed with parents.
0 W& y% `$ H0 h$ B1 a" o  N6 r& V, hThe father would hug the baby and hold him on his
5 D# \$ j( n8 j8 \# }' F$ xchest for a considerable period of time, causing sig-
) j8 Q1 \& h! ]7 L$ znificant bare skin contact between baby and father.
0 f; R& k  P. `% tThe father also admitted that after the phone call,0 |, @% o, l) g5 R/ W; Q& E
when he learned the testosterone level in the baby
% z9 {3 q3 e5 a+ Nwas high, he then read the product information) C4 ^" p9 S9 M4 J2 J% G
packet and concluded that it was most likely the rea-+ Y  C* M% R" q! ]7 q
son for the child’s virilization. At that time, they
" ?+ ?2 P* j0 x* h" z! Jdecided to put the baby in a separate bed, and the6 f- O+ X3 e! L' ?1 g2 F) z/ f
father was not hugging him with bare skin and had) ?  J; Q+ j( b6 H
been using protective clothing. A repeat testosterone2 I0 ~0 ~$ `: d0 _
test was ordered, but the family did not go to the9 e; R: d- x6 V. b% g0 |+ n$ J
laboratory to obtain the test.$ I& v/ e, d( W3 I' @$ [7 c
Discussion. t% C' C% r2 V% X2 F5 s4 f' y: `
Precocious puberty in boys is defined as secondary$ ]2 X; y% }; P8 {1 M* `, D
sexual development before 9 years of age.1,4
" F- A& d2 j2 f1 T2 ^Precocious puberty is termed as central (true) when
, t) h0 u& s5 E# z+ |- Dit is caused by the premature activation of hypo-
' l7 J! K  W5 k, e7 |thalamic pituitary gonadal axis. CPP is more com-8 a% W% t) \: ]+ z  }4 F* r/ m) U
mon in girls than in boys.1,3 Most boys with CPP
9 M) F7 U5 E' Z& H9 Q: L3 gmay have a central nervous system lesion that is$ P8 w; h, y) z* O% o7 h
responsible for the early activation of the hypothal-( D+ d0 h9 H0 e! H3 i3 k
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ \9 `8 }' }8 u0 Q; n4 j7 {sis has been given to neuroradiologic imaging in1 {9 B0 x; S. a2 j& e
boys with precocious puberty. In addition to viril-
$ J, o/ |$ J# L: s, jization, the clinical hallmark of CPP is the symmet-
' ?) U5 `/ V4 [$ H$ l9 P# Z) z' ~rical testicular growth secondary to stimulation by4 ]* N: c* `7 [/ K0 {& H
gonadotropins.1,3
+ R) T- R  p, S( C/ I4 aGonadotropin-independent peripheral preco-6 a: w* Z6 ^5 z/ h- l1 n
cious puberty in boys also results from inappropriate
7 Q4 L/ S) G) f9 Y1 l) U" dandrogenic stimulation from either endogenous or0 x0 d: m8 y* {# V. v4 n4 N
exogenous sources, nonpituitary gonadotropin stim-
, B: ?$ Z2 X! Z; b% _ulation, and rare activating mutations.3 Virilizing0 f1 ]' m+ \6 p$ T
congenital adrenal hyperplasia producing excessive
* T5 h. X' ~; \: K$ Iadrenal androgens is a common cause of precocious
8 k, j3 i/ X/ t5 c0 I% }  Vpuberty in boys.3,4
$ _/ P3 O7 c4 z- ~, i9 SThe most common form of congenital adrenal
! q, R/ w) G; M6 D9 Thyperplasia is the 21-hydroxylase enzyme deficiency.
0 @4 r$ c5 _) z( IThe 11-β hydroxylase deficiency may also result in) l& |9 X1 b% E- E  p  e! ~
excessive adrenal androgen production, and rarely,, L: R' i4 X/ N
an adrenal tumor may also cause adrenal androgen* [1 e& _; S9 [% C
excess.1,3/ T8 D4 [. ^) e% P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 P4 g6 ?# a  T& A4 M; Z' o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ W6 {: [1 u5 j$ B: `2 f7 {  G
A unique entity of male-limited gonadotropin-4 G0 j4 P- [( \3 e' E4 |4 k
independent precocious puberty, which is also known/ I4 e. g5 N2 G
as testotoxicosis, may cause precocious puberty at a
' b! x; z# y# N9 b$ C% `3 t4 bvery young age. The physical findings in these boys
& M) J- x& M! X: P, k% n; w8 ^with this disorder are full pubertal development,! E2 L. N# V. E, Q" n" x# h
including bilateral testicular growth, similar to boys) ?6 `% D( N( a
with CPP. The gonadotropin levels in this disorder
1 ~( p8 b( i. ^. K: Y* C7 X9 S+ E3 X- pare suppressed to prepubertal levels and do not show1 V) n* n6 n3 r5 X& }( g: O
pubertal response of gonadotropin after gonadotropin-6 u' g- ]3 K3 X! n
releasing hormone stimulation. This is a sex-linked8 F3 ?1 g0 H$ |# m5 E
autosomal dominant disorder that affects only
! [) z/ |" |" m7 T3 j  P: p- omales; therefore, other male members of the family
# \6 T" V0 d- _$ A- y: Tmay have similar precocious puberty.3
7 k# j. Z' h! N7 b( RIn our patient, physical examination was incon-
( J5 ~, B5 L' A3 \; Tsistent with true precocious puberty since his testi-! O& O8 R, Z  d: [
cles were prepubertal in size. However, testotoxicosis
+ z* [% r+ T& d- V$ Zwas in the differential diagnosis because his father: U6 q$ C2 Z, N- [+ C# |' S. k
started puberty somewhat early, and occasionally,5 J) _: _4 ?' I7 V
testicular enlargement is not that evident in the( g8 }* o/ ^5 Y1 B: u; X/ p$ w8 W0 y
beginning of this process.1 In the absence of a neg-
2 W% T. v9 x$ X2 V. }ative initial history of androgen exposure, our
4 O; x4 B4 I9 C6 Hbiggest concern was virilizing adrenal hyperplasia,
5 S$ I% |2 R' G$ P8 B5 Feither 21-hydroxylase deficiency or 11-β hydroxylase
4 c) V. Y$ k! bdeficiency. Those diagnoses were excluded by find-
# |( g, T; f. `% }ing the normal level of adrenal steroids.7 s5 j: e) X6 i: v( O* h" o" a
The diagnosis of exogenous androgens was strongly) H. R+ J! \! W2 f6 z4 y; p- I
suspected in a follow-up visit after 4 months because2 |# h; N( Q% v
the physical examination revealed the complete disap-
) T( T! j5 U% j2 b6 B! S5 cpearance of pubic hair, normal growth velocity, and  r6 L8 N" j% A& D1 [  z
decreased erections. The father admitted using a testos-
' I4 j& F9 j# Y: B( Aterone gel, which he concealed at first visit. He was
2 }8 I& [) }2 ~" `using it rather frequently, twice a day. The Physicians’
+ ?# O, r* {! f9 ^9 k) r  A; HDesk Reference, or package insert of this product, gel or/ n8 Z1 V$ X) }) }% X8 \# P/ p
cream, cautions about dermal testosterone transfer to
1 U9 T! t7 K: h1 R& Z! Cunprotected females through direct skin exposure.
; Z/ i$ |9 m5 B8 k/ s* X! \Serum testosterone level was found to be 2 times the
6 ^3 O  h6 K1 G  l* Z0 V! j- {$ rbaseline value in those females who were exposed to9 D% C$ j7 N" B/ U* [* Z2 V( P* x
even 15 minutes of direct skin contact with their male6 s2 ^/ O; v( `* Q- }
partners.6 However, when a shirt covered the applica-  K# H3 m7 h, v1 g1 C. k% \/ ~
tion site, this testosterone transfer was prevented.; M5 p$ h8 _  t& ?
Our patient’s testosterone level was 60 ng/mL,
6 Y  K$ m' m' l) Vwhich was clearly high. Some studies suggest that5 i2 ^. G2 ^, L- p: x# p
dermal conversion of testosterone to dihydrotestos-" u2 J% J9 H7 ^$ |/ e0 l
terone, which is a more potent metabolite, is more# y; Y* T8 F% M9 v; }2 b, o, ^
active in young children exposed to testosterone
& X% E6 k" j( Q+ zexogenously7; however, we did not measure a dihy-  _% w: P/ |# v' c
drotestosterone level in our patient. In addition to7 X5 T" I- E/ ]. g! ?+ b
virilization, exposure to exogenous testosterone in! O7 }$ O: p" F) b/ i" J
children results in an increase in growth velocity and
& F! B# t1 X3 e9 J( radvanced bone age, as seen in our patient.' I( \( K$ h& Y! G, V6 P0 B
The long-term effect of androgen exposure during+ m/ ~  {0 C! [1 |- P
early childhood on pubertal development and final
! H; T& y% Y4 f+ i; _adult height are not fully known and always remain
% ^: D8 f1 ~" E6 Y% N- E# H% I! ja concern. Children treated with short-term testos-1 ^: P; B: g5 S" t  I8 i- p
terone injection or topical androgen may exhibit some
" O0 W) f0 q6 M  sacceleration of the skeletal maturation; however, after
$ L/ j; |6 I! Q1 Jcessation of treatment, the rate of bone maturation
( G/ v+ l! r! w7 D5 {7 A6 x+ ^- idecelerates and gradually returns to normal.8,9
! o7 o! P* d8 C; y, VThere are conflicting reports and controversy1 p, F5 o: X9 g- V  Q
over the effect of early androgen exposure on adult
( p' q+ E! f+ R5 I8 |penile length.10,11 Some reports suggest subnormal$ a. n! `! \7 r$ _# e& d6 X
adult penile length, apparently because of downreg-
3 J# r3 O6 m+ k( Z9 M7 v4 V1 b- ]5 Iulation of androgen receptor number.10,12 However,  E! r3 L+ [$ I' x- e8 l$ I0 z
Sutherland et al13 did not find a correlation between
$ ?' v* b) v4 S% ]+ nchildhood testosterone exposure and reduced adult
+ a9 l' c: k  s. T' [penile length in clinical studies.+ p7 i4 q' i  {4 f
Nonetheless, we do not believe our patient is
; H0 c- u9 h; I4 q! |going to experience any of the untoward effects from
  m% k0 m$ T- w8 w8 }testosterone exposure as mentioned earlier because$ |4 b' B8 ^3 F% ^1 ?% b: _
the exposure was not for a prolonged period of time.
6 b! [1 D/ K9 n3 Q. KAlthough the bone age was advanced at the time of' U, E, G& J& E, |
diagnosis, the child had a normal growth velocity at
$ g4 v3 G9 w9 C0 S5 D. @the follow-up visit. It is hoped that his final adult
  ~; w4 B' W+ u: M; G( ?height will not be affected.
& P2 q- p( H3 V/ vAlthough rarely reported, the widespread avail-
; Q5 o2 x1 W5 i9 }( pability of androgen products in our society may+ z- Y+ O4 ]2 w: C
indeed cause more virilization in male or female& `% y" v. l* @% O
children than one would realize. Exposure to andro-
0 J& R1 ]2 m2 V' r. {8 ogen products must be considered and specific ques-* l' n% ~2 X: P1 _6 G5 ^- |# W! ^: m
tioning about the use of a testosterone product or2 E& ~6 {) u2 J2 Z/ h
gel should be asked of the family members during
! q9 e; k* }$ N* v- dthe evaluation of any children who present with vir-# ^9 a1 \+ t" L  S
ilization or peripheral precocious puberty. The diag-9 \* J, Z6 M: E. _) E* r
nosis can be established by just a few tests and by
* J, C: z* a& u0 b+ f( ^appropriate history. The inability to obtain such a' g9 H. O' O" K" m0 C9 [0 R
history, or failure to ask the specific questions, may) _3 p& t1 ~$ d8 Z* Q
result in extensive, unnecessary, and expensive
1 k+ X7 C0 s1 g: V9 {investigation. The primary care physician should be
$ I+ s, `' _0 e2 [: C" q* Eaware of this fact, because most of these children
6 D& W  O% u; `" d9 X7 @1 B0 O" {+ [3 dmay initially present in their practice. The Physicians’
  D* P' H1 Z5 t' p8 ]4 H( J8 J- pDesk Reference and package insert should also put a$ u( A  P4 ?! }% _8 T# F  U
warning about the virilizing effect on a male or% C8 E  h& e. V- u% F
female child who might come in contact with some-3 D4 E: G+ U# C9 R
one using any of these products.
9 v% W2 y0 s2 I7 D$ yReferences) s$ O+ ~5 p3 }
1. Styne DM. The testes: disorder of sexual differentiation
- _7 v3 ~) b6 d3 vand puberty in the male. In: Sperling MA, ed. Pediatric4 D6 f0 O1 [! s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 p. p4 S1 b" r# j  p2002: 565-628.
6 H; }9 F/ A& v2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 \. p+ W$ \4 F& Qpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
+ ~  k7 i- H) s" u. Q, s- ZBoy Induced by Indirect Topical
4 q7 |- g$ s# B4 Y% _$ R8 ^! x2 kExposure to Testosterone2 T* K/ |8 X3 @* I; U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- {8 q; }  N2 j! T3 S' p* y5 P: [0 ^2 ^
and Kenneth R. Rettig, MD1
" I, P. X3 T: Z: S& B+ @* w, dClinical Pediatrics. ]+ @3 p  |% h: T0 E. d4 u! r
Volume 46 Number 6
. ^+ q' |0 C% V7 W0 q8 vJuly 2007 540-543
- X/ C0 s8 p. g# k/ X6 O) M* n) @5 e© 2007 Sage Publications" N$ d- g& S* u( y0 J
10.1177/0009922806296651
( r0 }- F+ i. x* e3 b* q- {http://clp.sagepub.com
8 A0 C, t) f6 b3 Whosted at9 Q# K! o& c1 {# `3 ~1 q
http://online.sagepub.com% ?+ P8 E/ R! W( @
Precocious puberty in boys, central or peripheral,4 Y4 T: d! H1 M0 w6 f8 {+ E% A
is a significant concern for physicians. Central
2 g" `2 x" \( a9 o8 ~1 mprecocious puberty (CPP), which is mediated, ^9 p7 L4 z& }) L+ z
through the hypothalamic pituitary gonadal axis, has
: l% `& l1 v/ b' Q- ra higher incidence of organic central nervous system) w" e. U, b% G: \
lesions in boys.1,2 Virilization in boys, as manifested
0 b1 e, t: k/ E( M1 Z% iby enlargement of the penis, development of pubic
! \4 i" X/ I+ ^9 n2 P5 d$ u+ ahair, and facial acne without enlargement of testi-$ C" U4 s  ]" T* B
cles, suggests peripheral or pseudopuberty.1-3 We# s# Q: D! j! `
report a 16-month-old boy who presented with the; N2 H1 G, M2 }$ H& j. Q
enlargement of the phallus and pubic hair develop-
2 J: T4 \8 O: B( _ment without testicular enlargement, which was due
5 ^5 _* D8 r/ H+ f4 `; X8 O6 Q6 Vto the unintentional exposure to androgen gel used by
5 F6 p9 R" N3 |. U% }/ k0 Vthe father. The family initially concealed this infor-
$ F5 X' j  U: W9 W7 J7 r  z# W& H9 x6 ]mation, resulting in an extensive work-up for this
" |3 t3 D6 d4 X4 t& n5 E4 uchild. Given the widespread and easy availability of/ f* @$ K# ?9 \/ V
testosterone gel and cream, we believe this is proba-& g: H6 s: s: @5 D
bly more common than the rare case report in the( f! ?- ?3 l% l% \# a4 L6 d
literature.4+ n3 C& R* L- k
Patient Report7 ]" m9 v% x. N' I, g/ m7 w
A 16-month-old white child was referred to the
. b4 d6 I7 }; j1 x& Hendocrine clinic by his pediatrician with the concern
' h$ \% m6 b# M1 q' L3 vof early sexual development. His mother noticed
5 I$ Z) Y4 B# M2 L$ Flight colored pubic hair development when he was
- a- x1 {. E$ l6 KFrom the 1Division of Pediatric Endocrinology, 2University of
/ h7 T: Y3 }  S6 W+ @/ ]) d/ ?: xSouth Alabama Medical Center, Mobile, Alabama.
! j* W7 g7 p9 s% ]+ ^$ FAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 [* T6 M* |0 n6 [- I, wProfessor of Pediatrics, University of South Alabama, College of! N1 \- A' p1 [. J( @" m# f( D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: D+ D& t3 G# Q1 W7 L) \; w) [
e-mail: [email protected].: J7 k) @3 T2 f
about 6 to 7 months old, which progressively became% t. Z' i, K. P, O! U* ^, _; \
darker. She was also concerned about the enlarge-4 \0 c1 K" I( R' B) R- l
ment of his penis and frequent erections. The child
6 j0 K# ?& k( P" m" W' T( Q; Hwas the product of a full-term normal delivery, with& G9 o. A, J$ h6 ~- h. c) M
a birth weight of 7 lb 14 oz, and birth length of( P' f7 N: D+ n+ G  v* k' l9 _
20 inches. He was breast-fed throughout the first year. d0 f* r& E5 M' {. [
of life and was still receiving breast milk along with2 J- Z8 o$ u6 }  G* z( F/ z
solid food. He had no hospitalizations or surgery,
7 Z. T8 T( |' Q$ zand his psychosocial and psychomotor development3 j3 C+ }  G+ T. S
was age appropriate.
* b. y% M3 |3 e7 |The family history was remarkable for the father,
0 G. u& k* M' A( cwho was diagnosed with hypothyroidism at age 16,' C0 F+ _3 F3 C0 m* h1 ?' z4 I
which was treated with thyroxine. The father’s
1 U$ v1 }# b! y. m; aheight was 6 feet, and he went through a somewhat8 H# n- g% g/ q, t
early puberty and had stopped growing by age 14.9 A' N7 b% N5 c/ J$ Y# }2 l/ ?! M
The father denied taking any other medication. The
8 O! E) L3 W: h! {0 t& |child’s mother was in good health. Her menarche/ [6 M% ~- Z+ G8 x- Q8 y
was at 11 years of age, and her height was at 5 feet9 Z& k6 P' n: U9 h/ g( S+ D" W
5 inches. There was no other family history of pre-) ?+ G8 D; x. [" v* h- @
cocious sexual development in the first-degree rela-3 y) h. e1 i# h- Q& B' S% ~- N
tives. There were no siblings.+ U7 n% `9 [. I8 Z9 X  z
Physical Examination$ L" f% S4 m3 o
The physical examination revealed a very active,
2 B$ g# y' \% u" B* R% X( X* eplayful, and healthy boy. The vital signs documented5 [; \- }  o7 `  |
a blood pressure of 85/50 mm Hg, his length was
9 g; t( q& O7 p) K8 X" e90 cm (>97th percentile), and his weight was 14.4 kg
% b5 l$ a9 Q0 ], }. q4 C/ Y8 [(also >97th percentile). The observed yearly growth' f$ V5 C! G* P
velocity was 30 cm (12 inches). The examination of1 q- u6 ?1 X% g! U
the neck revealed no thyroid enlargement.
$ k% o) T# L4 H. {4 P; uThe genitourinary examination was remarkable for
/ `& N" f" C& Q4 m4 o  Q2 T) @enlargement of the penis, with a stretched length of* P& ~, y% A1 f+ _% Q" _
8 cm and a width of 2 cm. The glans penis was very well, Y* `9 }! d. i7 \' l% N. s
developed. The pubic hair was Tanner II, mostly around2 Y7 x& ]4 ~* V, ^
540
+ ~4 I( W* k- oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 m$ R+ B4 R; L
the base of the phallus and was dark and curled. The
. q! K5 q0 S+ L: h$ [1 xtesticular volume was prepubertal at 2 mL each.) |' l9 \; ?2 n0 z
The skin was moist and smooth and somewhat& w; o- ^9 j6 K
oily. No axillary hair was noted. There were no' g) W1 }4 h" `. K
abnormal skin pigmentations or café-au-lait spots.
2 f) G/ {4 A4 D  i' {: J! UNeurologic evaluation showed deep tendon reflex 2+
  q. I; \4 g7 P5 `! x& c) gbilateral and symmetrical. There was no suggestion% m1 Q( a' E6 C
of papilledema.) x% K; Q0 h# F8 S
Laboratory Evaluation
: b8 T9 L6 W' nThe bone age was consistent with 28 months by2 F0 W: s! {3 j" ?* ?5 Z- [
using the standard of Greulich and Pyle at a chrono-$ A# a) S" w2 E% M$ M7 a: M
logic age of 16 months (advanced).5 Chromosomal
7 k( n. _) w/ F( jkaryotype was 46XY. The thyroid function test0 U& J* S9 y* @5 [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ J5 C6 T4 k- B) o8 S8 j
lating hormone level was 1.3 µIU/mL (both normal).
3 I+ q" z# J8 g$ ~The concentrations of serum electrolytes, blood
( E- ^% |6 |9 J& o* Burea nitrogen, creatinine, and calcium all were$ H1 c- f6 n% ]- s" _- A
within normal range for his age. The concentration+ z; ^$ Q, l! Y
of serum 17-hydroxyprogesterone was 16 ng/dL
! ]) {$ \" I4 n* ^: a2 S4 Y) O(normal, 3 to 90 ng/dL), androstenedione was 207 g, I' q9 v# W/ f& U9 d
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ [" j! i+ r7 y: y
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," I4 O% W( a/ ~  z* E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ g  [3 {/ C& {6 a3 g
49ng/dL), 11-desoxycortisol (specific compound S)
) X7 }! _$ p; A  N: N6 lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- _% c8 B. u" u/ Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: ?/ w$ }3 K) p% n
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 N$ }6 i1 \3 R4 R; \3 ?and β-human chorionic gonadotropin was less than
3 W) Z1 o6 {2 t5 mIU/mL (normal <5 mIU/mL). Serum follicular
: [2 m- T# }7 |. F" o2 [6 b5 Q/ c9 u" Jstimulating hormone and leuteinizing hormone
  ]. I4 T( L* a* lconcentrations were less than 0.05 mIU/mL
3 B4 }% `# F* Q0 w0 M(prepubertal).' O* O3 Z) N* _; u6 v; [& T7 x
The parents were notified about the laboratory3 g8 X( [+ F( k* h: E& [
results and were informed that all of the tests were
; ^9 F2 l; I, m8 ], @normal except the testosterone level was high. The& o; q, \/ ?# ?6 X; o) h- f; p, L
follow-up visit was arranged within a few weeks to
% F) ]: z/ n& E7 Z* t9 _) H2 B( f7 robtain testicular and abdominal sonograms; how-
6 M9 K# k" N( H# r% {ever, the family did not return for 4 months.4 ~0 ~. [: ]7 L0 A7 R2 ]3 S: W; L
Physical examination at this time revealed that the4 V/ U0 E4 d/ H" c% ~, }" L
child had grown 2.5 cm in 4 months and had gained4 u8 E! ]0 b5 |0 B. r" w
2 kg of weight. Physical examination remained
) l  `( h4 n5 |6 Junchanged. Surprisingly, the pubic hair almost com-
& k- n( o9 l5 \. Q. spletely disappeared except for a few vellous hairs at- a, m3 @) H1 {& S
the base of the phallus. Testicular volume was still 25 `: o7 E+ p+ m7 |6 K4 z
mL, and the size of the penis remained unchanged.+ b* }  I: C/ q1 q
The mother also said that the boy was no longer hav-2 K+ x7 |. n$ Q% ]- K9 X* ?+ M
ing frequent erections.
, G) |5 K" t/ ~$ x1 v! Z; W7 D8 KBoth parents were again questioned about use of
, b+ c$ X% D3 G9 lany ointment/creams that they may have applied to7 i5 p4 k# Y# j$ C* J8 W6 K3 y
the child’s skin. This time the father admitted the
* v0 L9 `9 D. H) g, L9 LTopical Testosterone Exposure / Bhowmick et al 541! z/ X- d( J# O& k9 W0 J
use of testosterone gel twice daily that he was apply-
/ f5 s/ w" B* D. ming over his own shoulders, chest, and back area for) @6 d1 o5 q/ ?; K8 b: g6 J
a year. The father also revealed he was embarrassed4 c" S. d% G( O' f! d5 A* Y
to disclose that he was using a testosterone gel pre-# r1 x, I9 z) y1 s/ J$ i
scribed by his family physician for decreased libido: C$ E' ~2 ~7 X8 R$ [# a% Z
secondary to depression./ z6 H% t* @; ]4 H% s! L
The child slept in the same bed with parents.6 Z: j3 \2 R9 M# H( \" W) p
The father would hug the baby and hold him on his
3 }1 f7 V1 {3 mchest for a considerable period of time, causing sig-
: l; \3 V& N' `nificant bare skin contact between baby and father.+ `9 @$ Z8 q2 I; _8 e3 F6 r" o
The father also admitted that after the phone call,
, Q% q# ~7 ]6 \8 F( T0 i8 q% Bwhen he learned the testosterone level in the baby( j4 N! {6 M) ?6 ], s6 }' v
was high, he then read the product information% X, G$ N" v# x5 w8 e
packet and concluded that it was most likely the rea-
3 e% v% ^  j. O& d1 }7 U& F' Xson for the child’s virilization. At that time, they4 I# _( P3 t1 X
decided to put the baby in a separate bed, and the4 S3 k% w8 c2 p2 }
father was not hugging him with bare skin and had6 N: T% [9 f8 g5 L- O* `$ ~" j
been using protective clothing. A repeat testosterone
  i' ?, s4 ~/ H6 Z: otest was ordered, but the family did not go to the
* t" E+ E2 I+ F$ e# elaboratory to obtain the test.
6 J2 `6 `) A8 k; X# P; B) eDiscussion# O4 i# F2 M. ?7 O& g% c; Y3 b
Precocious puberty in boys is defined as secondary
- K& E) g6 A+ @" L  \1 Q8 Ksexual development before 9 years of age.1,4: P( X' U  A3 p0 F5 F
Precocious puberty is termed as central (true) when4 a  D/ n8 H- K# U7 Q4 H6 I
it is caused by the premature activation of hypo-
  G1 @2 C' j" y: `- e! Bthalamic pituitary gonadal axis. CPP is more com-6 g" i$ v9 \5 R+ ~0 j3 V% V
mon in girls than in boys.1,3 Most boys with CPP! q- ?9 t; e% k7 v
may have a central nervous system lesion that is
* j# V6 ~, {: ^0 `responsible for the early activation of the hypothal-
7 Y  L- d' p* @5 }amic pituitary gonadal axis.1-3 Thus, greater empha-
  C0 P4 R6 _- P$ d0 f+ hsis has been given to neuroradiologic imaging in
. l" g: }5 `$ C4 I8 v$ yboys with precocious puberty. In addition to viril-
9 M  {$ `& k. v7 ]ization, the clinical hallmark of CPP is the symmet-3 M; `7 z; E7 B3 E8 y. q% f- z
rical testicular growth secondary to stimulation by
! V9 x& Y" N( r+ Igonadotropins.1,3
) ^. Z# k9 h- s) d9 y* eGonadotropin-independent peripheral preco-* [/ ?1 s! P# ?, l  R. U
cious puberty in boys also results from inappropriate
1 R8 ~  r4 Y8 B+ t" yandrogenic stimulation from either endogenous or
. q2 l7 B. ]4 e; g2 r; oexogenous sources, nonpituitary gonadotropin stim-" _4 }9 L- z: H$ S& o
ulation, and rare activating mutations.3 Virilizing
! ?0 W6 W! {' Dcongenital adrenal hyperplasia producing excessive% `3 r+ `( _6 s2 C, J) ~+ l) b: Q
adrenal androgens is a common cause of precocious
/ ]% y! N5 \3 P5 v# j9 A2 ]puberty in boys.3,4
$ Z) v* @0 v8 WThe most common form of congenital adrenal
3 |, ~9 k: L6 Ahyperplasia is the 21-hydroxylase enzyme deficiency.
" a  x/ [7 V1 D! @- q0 u7 `The 11-β hydroxylase deficiency may also result in
( ?! x0 f6 E7 R6 ~4 `+ g8 Oexcessive adrenal androgen production, and rarely,( p, E7 [, Q3 m0 f+ r7 _8 z6 i# l
an adrenal tumor may also cause adrenal androgen
: r2 y+ K' S! m+ n: F2 N, eexcess.1,3
6 U% W( ^% _) R' Y  P- Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! B5 h9 Y2 w8 F- _( T( k& B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ ?2 l4 A3 o- H! ^, f# n% s( @: `
A unique entity of male-limited gonadotropin-& S) [: @' m" v
independent precocious puberty, which is also known
1 \" j+ B# |# p0 Q0 \5 B: p& Sas testotoxicosis, may cause precocious puberty at a, K3 i. c( |( J- m& a
very young age. The physical findings in these boys7 I& j' `4 J5 R  B
with this disorder are full pubertal development,
  k/ Y4 a7 u7 p) B' Y" D$ Oincluding bilateral testicular growth, similar to boys+ T" ?0 G: M' l8 F0 K9 f
with CPP. The gonadotropin levels in this disorder
9 I  H. b+ z* s4 M9 V6 Eare suppressed to prepubertal levels and do not show
3 [8 T$ R4 e1 }# Opubertal response of gonadotropin after gonadotropin-
( x+ {: }4 ~8 L% o; P5 c# h5 m  Oreleasing hormone stimulation. This is a sex-linked2 R" ~$ q7 [5 ^- m, _5 s
autosomal dominant disorder that affects only
4 u* w/ ?9 u) ]" i7 Bmales; therefore, other male members of the family
/ p/ ]8 W! F" @- M/ Y4 jmay have similar precocious puberty.3$ K0 ?9 v5 O6 F3 S
In our patient, physical examination was incon-
& N" l* p0 Y- r/ Ksistent with true precocious puberty since his testi-
* I  j6 ^+ A* P/ t- B- Q1 acles were prepubertal in size. However, testotoxicosis
8 Q0 `; D, j+ q# u. D/ Mwas in the differential diagnosis because his father
& T8 U6 b* F( I+ j! G6 ?started puberty somewhat early, and occasionally,9 Y! c  x& j3 h0 B
testicular enlargement is not that evident in the  }  d, H4 v& [/ ~
beginning of this process.1 In the absence of a neg-
* O6 c3 d6 l' o* v* Sative initial history of androgen exposure, our" F+ P1 _( t* M5 S  i" D/ ^
biggest concern was virilizing adrenal hyperplasia,* A' F- J6 j% O, v
either 21-hydroxylase deficiency or 11-β hydroxylase: E! L. W6 f1 N9 l
deficiency. Those diagnoses were excluded by find-: U1 t- ~, _' R' ~- l; S5 z
ing the normal level of adrenal steroids.
- d" J& {0 t) aThe diagnosis of exogenous androgens was strongly  G3 A& I" n' c1 A
suspected in a follow-up visit after 4 months because
% a) [7 w( E' R. Othe physical examination revealed the complete disap-
1 F5 E) V5 d( U) F$ bpearance of pubic hair, normal growth velocity, and3 V% w6 e3 U2 W$ w, ]2 O
decreased erections. The father admitted using a testos-. E# W! P5 U3 ^$ U4 ~
terone gel, which he concealed at first visit. He was  j/ a7 U: w: C0 `! D+ ^# R
using it rather frequently, twice a day. The Physicians’
' K0 s0 T1 i1 O8 g$ |% B6 Q3 ~Desk Reference, or package insert of this product, gel or$ a6 K" J* @2 l  c  F: w8 O1 ~
cream, cautions about dermal testosterone transfer to
4 F4 \# ]  S9 U' m+ i; r2 G  cunprotected females through direct skin exposure.
+ @. A" m" `4 h/ `2 `# T9 rSerum testosterone level was found to be 2 times the, w- F5 F! i, V4 ]- E: r
baseline value in those females who were exposed to/ B: @% S9 b" |" b6 w" y! D
even 15 minutes of direct skin contact with their male
: e) Q: I. A- \( E$ {; F/ ]/ lpartners.6 However, when a shirt covered the applica-
6 {6 b, f; J7 k) W" [% h* P8 e6 Stion site, this testosterone transfer was prevented.
4 O; Z% a  j& ~) dOur patient’s testosterone level was 60 ng/mL,
+ x/ P! X1 L' d' \9 R5 Q3 ?which was clearly high. Some studies suggest that
3 s- l0 q$ d6 Y1 kdermal conversion of testosterone to dihydrotestos-
  @2 E) Q; w5 d9 H% E! N: Q4 Wterone, which is a more potent metabolite, is more2 J/ O' t5 \8 s2 {7 x% ^1 V( }0 r" ^
active in young children exposed to testosterone
/ I+ C) \1 S& z; O: j+ ^exogenously7; however, we did not measure a dihy-6 C7 l. r3 A% i- h8 T2 C
drotestosterone level in our patient. In addition to& {$ V0 j& X0 M6 S  A% q
virilization, exposure to exogenous testosterone in
% ?2 L- \, m( N* }/ v3 `children results in an increase in growth velocity and
3 Z8 w8 n7 ]1 x: M- k' \/ Madvanced bone age, as seen in our patient.4 }; a: [6 b0 _& ?4 e! D* v! ^: U
The long-term effect of androgen exposure during
! j) a$ H0 i# tearly childhood on pubertal development and final
/ Y0 A8 Y' x% }( eadult height are not fully known and always remain0 l7 B. N& A2 _+ X  e
a concern. Children treated with short-term testos-# I6 O5 S/ p; Y
terone injection or topical androgen may exhibit some: Y+ x5 J: c- L
acceleration of the skeletal maturation; however, after- X6 G4 Y/ S2 F
cessation of treatment, the rate of bone maturation6 P! c. T" @, `, a$ _7 ?1 H
decelerates and gradually returns to normal.8,9
9 c9 r+ ]2 w) d: I# gThere are conflicting reports and controversy
# V/ X* A1 K: T: R# D3 n$ c7 V# Jover the effect of early androgen exposure on adult9 c: S( f  D3 T) v2 ^; E# k
penile length.10,11 Some reports suggest subnormal
7 d% \+ b. V( V! V& L6 Ladult penile length, apparently because of downreg-
: ?% H3 V, n8 f( j& julation of androgen receptor number.10,12 However,
8 z* \7 o1 @" j5 nSutherland et al13 did not find a correlation between( H" Q5 s* h! G% v1 e8 ^
childhood testosterone exposure and reduced adult
- _0 P* `. x; T0 @penile length in clinical studies.
- Q1 `# B! q  M, ~Nonetheless, we do not believe our patient is
! B. j" o5 C& X% fgoing to experience any of the untoward effects from
- u1 N" m& h* l1 k. `; Dtestosterone exposure as mentioned earlier because
: r( h% n$ \9 j7 ^8 pthe exposure was not for a prolonged period of time.1 r) u4 I) [0 ]/ @
Although the bone age was advanced at the time of
, Z/ C5 j8 C, ]diagnosis, the child had a normal growth velocity at4 x0 X4 N4 B* V0 d, Z
the follow-up visit. It is hoped that his final adult0 Z/ m/ Q' T+ I7 |1 F( [. m6 ^' _/ N
height will not be affected.2 l3 X1 J! [, j1 p" K* l3 a
Although rarely reported, the widespread avail-7 m- u3 Z6 f8 L, Q4 R+ H1 R
ability of androgen products in our society may
' n+ B& r: y$ B3 m3 K$ q% \" }) lindeed cause more virilization in male or female; _3 {7 \0 f* P# u" E: \2 a
children than one would realize. Exposure to andro-6 X  X( m# t2 L* B' \9 n) c6 m
gen products must be considered and specific ques-' _) M3 _6 Q7 _
tioning about the use of a testosterone product or
4 z+ q, h% T& K) E* u& Lgel should be asked of the family members during8 x% s" q# t) b
the evaluation of any children who present with vir-
% n% `1 X1 s6 ~5 Oilization or peripheral precocious puberty. The diag-
% C5 x$ H* \) ]) ~nosis can be established by just a few tests and by( I9 t; l% \% [! j. I" M% x
appropriate history. The inability to obtain such a
* ?4 W8 m2 J% U1 Q4 `history, or failure to ask the specific questions, may. k3 d5 d2 a7 F" E6 N9 q
result in extensive, unnecessary, and expensive
! X/ L' h: w6 }investigation. The primary care physician should be
6 W- p3 S* d) r# }, F. Y  l4 faware of this fact, because most of these children6 q1 _0 G- V2 z0 b. p: w
may initially present in their practice. The Physicians’
/ Z7 d& o0 T9 m" \% nDesk Reference and package insert should also put a
: i* G% n) k/ O- m& qwarning about the virilizing effect on a male or
/ J7 m( `6 R9 ?6 Jfemale child who might come in contact with some-
) a3 w+ E; I5 b" V- j* v" Oone using any of these products.% p  k4 c9 M- v( D6 p
References& h) Z- k7 [  N7 r* M+ {, v) P
1. Styne DM. The testes: disorder of sexual differentiation
) W3 `3 x8 y9 h, ~  D0 J/ ^, Kand puberty in the male. In: Sperling MA, ed. Pediatric
1 A; |. S% }6 S5 KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- b+ p7 \: j- I2 k9 g2002: 565-628.: z: |2 Q# v7 p6 D! J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! p) C# v* G' l8 lpuberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

5 q, m& `. _9 b7 u' B! E; t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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