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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
  W+ {9 e9 h" b/ h" {) ABoy Induced by Indirect Topical
, m8 }- l" d$ D1 a' HExposure to Testosterone
; E1 }: g% T9 _) {2 w' E% P& JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  ]/ f* r1 D4 h/ Y3 z. M0 z
and Kenneth R. Rettig, MD1
# p9 B+ V- [/ j1 B, KClinical Pediatrics4 x  A3 k; M, D4 J3 {4 S1 Z$ x
Volume 46 Number 6
" E1 E* u4 h/ o" E5 s3 xJuly 2007 540-5439 n" x3 O3 j; W7 V5 l, x
© 2007 Sage Publications! W  K/ J& ]7 K0 ]  X8 E
10.1177/0009922806296651. l( }- r- G4 e9 g
http://clp.sagepub.com
3 E* S  i* O* _7 ]hosted at, v, }- ]6 H- Y, O7 }# T7 E$ A
http://online.sagepub.com9 ?+ x5 [7 }* n
Precocious puberty in boys, central or peripheral,
) _2 P3 {8 W/ \is a significant concern for physicians. Central% l6 p1 j3 r" G% t# C: U
precocious puberty (CPP), which is mediated% @1 m. H# q- ]/ j4 L
through the hypothalamic pituitary gonadal axis, has
1 h; }( C! l7 Y# f& ^1 ga higher incidence of organic central nervous system
: e6 g+ ~6 ^! x/ I- b7 Hlesions in boys.1,2 Virilization in boys, as manifested, z! ?& `) p4 x& X5 [. a# m7 Y
by enlargement of the penis, development of pubic' _! m- d- m/ E; a
hair, and facial acne without enlargement of testi-' Q* \! w2 E( s9 j" T. x
cles, suggests peripheral or pseudopuberty.1-3 We
, f, D+ s! Y1 Q8 G+ Qreport a 16-month-old boy who presented with the
2 d0 _" q+ a. Y  g. \enlargement of the phallus and pubic hair develop-
' H/ P7 E  M( H; w7 I4 ^& Nment without testicular enlargement, which was due
1 b0 J0 w8 }% y) ]. S: mto the unintentional exposure to androgen gel used by% D( h3 z- z' a9 @% T+ S
the father. The family initially concealed this infor-
6 o  s  o& `$ J; ]+ l6 ?mation, resulting in an extensive work-up for this
4 f4 p/ D& Q2 P' E( `! kchild. Given the widespread and easy availability of7 k3 ?; z, J3 {0 [2 y, |( S5 g
testosterone gel and cream, we believe this is proba-
/ @3 B, c5 {' C5 I1 gbly more common than the rare case report in the
9 I4 B; y1 g; g+ T! U: u: lliterature.4. I' B/ F& ]% I' M4 }; p' X% e
Patient Report
+ M9 `, P& p& cA 16-month-old white child was referred to the4 T9 I' u1 c- }! C7 @
endocrine clinic by his pediatrician with the concern8 V% F2 l* B7 K6 y( }7 u/ t& z0 Q
of early sexual development. His mother noticed
0 B( M$ ~5 `; v  g3 y& E0 jlight colored pubic hair development when he was
$ n% C+ d, J; ~From the 1Division of Pediatric Endocrinology, 2University of
! y8 e& G2 o- Z2 zSouth Alabama Medical Center, Mobile, Alabama.
" z7 i( }5 r7 DAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, M/ @1 w) F% ZProfessor of Pediatrics, University of South Alabama, College of
" j. T9 y* O9 }, h) a! qMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ U) I! M/ l! j0 x( k8 Z* z
e-mail: [email protected].1 y" e4 q# `4 S% n) e" a! A
about 6 to 7 months old, which progressively became0 z3 b9 q/ f9 l3 X4 a, S- p
darker. She was also concerned about the enlarge-
1 C! M7 `4 r0 X" ument of his penis and frequent erections. The child
& D/ ?4 D' ^, vwas the product of a full-term normal delivery, with2 g. ^0 h8 d- E) D( L* q9 g
a birth weight of 7 lb 14 oz, and birth length of
$ [4 z3 s+ P- R% |% E20 inches. He was breast-fed throughout the first year- B* T5 H" G0 l- o+ d6 u
of life and was still receiving breast milk along with, V  |; T& o/ N1 F$ u
solid food. He had no hospitalizations or surgery,2 O! S2 i9 q0 i/ x  ^" `6 D
and his psychosocial and psychomotor development" C& ~- I- a# m
was age appropriate.5 D( L$ q$ [: ^/ T( ^. u+ w
The family history was remarkable for the father,
; ?3 B& x% K3 W# P6 Z9 b4 m; }+ Y  {who was diagnosed with hypothyroidism at age 16,9 p- b, V. K3 ^7 ~3 B
which was treated with thyroxine. The father’s
) i! x1 D$ t/ Uheight was 6 feet, and he went through a somewhat6 W4 J( o( P7 t6 \
early puberty and had stopped growing by age 14., C0 m. R7 V4 {- {
The father denied taking any other medication. The. e: I) j' v2 O% B) Q
child’s mother was in good health. Her menarche
: T6 z" W* i. Twas at 11 years of age, and her height was at 5 feet8 X5 O! y( x6 I% X
5 inches. There was no other family history of pre-6 h0 w0 I2 b2 B( v; o& s) b. ?
cocious sexual development in the first-degree rela-; ~; N/ u# m( n5 i; m- q
tives. There were no siblings.2 P; G; J( H( X, N0 w& \
Physical Examination* ?/ r8 K& L. b2 H8 p
The physical examination revealed a very active,
! h  s/ A6 S' t. r) Jplayful, and healthy boy. The vital signs documented
" _) z7 Z7 B$ E! c$ c: la blood pressure of 85/50 mm Hg, his length was
) \7 K, C; m; {  ~90 cm (>97th percentile), and his weight was 14.4 kg5 O- {& O: E: \8 L3 k0 s
(also >97th percentile). The observed yearly growth! z4 x) [0 T3 Y( h1 S/ w3 J+ q
velocity was 30 cm (12 inches). The examination of
3 K3 M7 \! \% ~the neck revealed no thyroid enlargement.
- R- ]& ^  a8 G: g3 C3 v% TThe genitourinary examination was remarkable for
! @9 l1 W  Q: {" `enlargement of the penis, with a stretched length of1 O# r3 I* t$ B1 l0 f0 u1 j
8 cm and a width of 2 cm. The glans penis was very well9 D2 T3 i7 k- V: h
developed. The pubic hair was Tanner II, mostly around, r- p( U( H) ?( u( _- _
540
! F/ P' I" B" d7 w% [. Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. S& y) r2 J5 q# Sthe base of the phallus and was dark and curled. The
. D% S- P. J& i4 Y3 I; Utesticular volume was prepubertal at 2 mL each.
* y8 Q. }+ [/ G9 Q9 P9 U# V' t) NThe skin was moist and smooth and somewhat
1 _$ ^6 k; o+ {oily. No axillary hair was noted. There were no7 |9 Z- g- X# |2 k
abnormal skin pigmentations or café-au-lait spots.+ P* d" t- c# X& ^$ u2 `3 V$ T
Neurologic evaluation showed deep tendon reflex 2+
3 x8 \' m, r' x4 f4 Fbilateral and symmetrical. There was no suggestion% {4 R- V- \7 m$ L
of papilledema./ `. C& e5 t- G2 h% S
Laboratory Evaluation. _; z! m; {/ z& c: T3 s& F
The bone age was consistent with 28 months by; r* q1 ~" f3 }6 X5 }. R1 B
using the standard of Greulich and Pyle at a chrono-+ K6 r9 W9 `! q/ b: R
logic age of 16 months (advanced).5 Chromosomal7 W9 Y: v: x$ J' }
karyotype was 46XY. The thyroid function test( {) z4 v) A3 l) u6 E7 J8 N5 C' t5 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
; f- z2 v7 v& Y3 E' x" S% x$ Tlating hormone level was 1.3 µIU/mL (both normal)." T& d. f( d% O0 v9 e8 B( E( F
The concentrations of serum electrolytes, blood
! c9 ]+ E' L0 P- q" n! _2 o$ n! Lurea nitrogen, creatinine, and calcium all were
* r' _1 v; Y* G- o" g, Jwithin normal range for his age. The concentration
, R- s% N' P' |) u7 [1 C6 oof serum 17-hydroxyprogesterone was 16 ng/dL
6 G4 W3 T+ J0 C! i* P6 D5 r$ Q(normal, 3 to 90 ng/dL), androstenedione was 206 w& I, h* C! |& ?  S8 c% E  W' Z. y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 E8 `" J, F5 [3 Q& r+ Y/ Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 Q2 w6 l* r3 Q2 o5 Xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" Q2 Z  T/ ?# {# [4 ?4 a: @! l49ng/dL), 11-desoxycortisol (specific compound S)3 z! w! q3 N, E- u1 C: W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" H$ P% G# `- N1 M7 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% z1 g- P$ L7 o9 \testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 h/ n8 X% l% N' O1 H5 Oand β-human chorionic gonadotropin was less than8 X) _% s& z( n# u
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& P* Q: A" `; sstimulating hormone and leuteinizing hormone. L4 X+ B' T8 J
concentrations were less than 0.05 mIU/mL
. W2 M- _/ P0 _3 ](prepubertal).$ R9 f' b8 ?2 d# P0 c
The parents were notified about the laboratory, u( V6 _+ S* X1 p1 U) J
results and were informed that all of the tests were
+ ]* e. N! ^8 m4 T. }& f! fnormal except the testosterone level was high. The9 u1 N$ E9 a" O/ X" ?9 T" a0 B
follow-up visit was arranged within a few weeks to1 |6 m5 W1 E" j* P( `
obtain testicular and abdominal sonograms; how-
; C) R# o9 S6 b# ?6 ~; h" ~8 cever, the family did not return for 4 months.1 Y7 v8 a: Z8 r  A5 M5 T/ |
Physical examination at this time revealed that the
; N& C0 H: H! m5 Schild had grown 2.5 cm in 4 months and had gained3 w% z) I& j5 a$ E) H6 v) M6 E
2 kg of weight. Physical examination remained
  D; V& w' o+ r3 Nunchanged. Surprisingly, the pubic hair almost com-
. q; N% T8 `9 z. o1 E- fpletely disappeared except for a few vellous hairs at
; s" O( o0 b+ O, Dthe base of the phallus. Testicular volume was still 2. v+ P0 W) I: o# a! d5 w$ T5 H
mL, and the size of the penis remained unchanged.
  _3 ?- m' J7 y( M" dThe mother also said that the boy was no longer hav-
8 h$ w! D' F9 }ing frequent erections.
, z% h$ W7 j/ ~; T7 b6 lBoth parents were again questioned about use of
8 O0 z, @8 ?# R* V; b3 ?) G/ hany ointment/creams that they may have applied to) W. ]" Q$ |3 O5 i
the child’s skin. This time the father admitted the
5 b* r/ E1 a; C" b0 }Topical Testosterone Exposure / Bhowmick et al 541
( y+ M: h! }9 g) e+ e* k/ {, zuse of testosterone gel twice daily that he was apply-
1 ]' x' l$ Q' g0 N' i3 Y. qing over his own shoulders, chest, and back area for
) v. C8 I) X2 B% _& a/ l9 Oa year. The father also revealed he was embarrassed5 ^/ |* z) y9 H# W0 K
to disclose that he was using a testosterone gel pre-2 q) [$ g% d3 B6 P9 t$ s. ^# {" Q
scribed by his family physician for decreased libido9 H3 Q" u$ |0 T3 f5 C. V
secondary to depression.& s  F$ z3 O' z( O. y
The child slept in the same bed with parents.+ H2 p* K- z. t1 ^2 c/ G) a/ ^( k
The father would hug the baby and hold him on his3 v3 L7 Y% c+ ^
chest for a considerable period of time, causing sig-4 d/ M3 M. M5 e6 I
nificant bare skin contact between baby and father.$ B- a  W8 S7 r
The father also admitted that after the phone call,
& H% D' n5 F! W4 zwhen he learned the testosterone level in the baby
0 z4 V: L( y1 A( ?7 F6 `1 bwas high, he then read the product information1 p9 W3 z" q5 K2 h
packet and concluded that it was most likely the rea-8 c3 b5 V* [( p0 i2 B
son for the child’s virilization. At that time, they
& W+ r8 z5 B! ]2 c$ p- odecided to put the baby in a separate bed, and the/ Q% {4 g3 M7 D( a4 O; u( f4 \
father was not hugging him with bare skin and had* M% F9 I9 t0 j+ P3 ]1 \
been using protective clothing. A repeat testosterone
* K6 {* t7 Q! x! W/ R; {test was ordered, but the family did not go to the$ Y0 v  D! M. H. n
laboratory to obtain the test.
- P& D1 p  r* vDiscussion( R1 P- c# J( w, P! _! ~; [
Precocious puberty in boys is defined as secondary$ R' j" Q0 g  r0 b' ~3 D$ L, _
sexual development before 9 years of age.1,4& d; W( }0 }5 y6 R* S; w
Precocious puberty is termed as central (true) when( e0 w0 P  k% t) Z/ K2 C1 o
it is caused by the premature activation of hypo-
6 F& k8 p1 k/ j: ]: N0 v* kthalamic pituitary gonadal axis. CPP is more com-
, _5 Y0 e' Z- a3 Dmon in girls than in boys.1,3 Most boys with CPP' [2 g+ C" d6 z  Y- n0 m
may have a central nervous system lesion that is
# Z0 I- Y$ m0 L0 x6 P' K" ]$ `  H7 Presponsible for the early activation of the hypothal-
. ?/ I2 I6 v( i( ]amic pituitary gonadal axis.1-3 Thus, greater empha-7 r+ H4 z2 O* Q* a2 s
sis has been given to neuroradiologic imaging in
" ?2 l" d' ~/ N% c: fboys with precocious puberty. In addition to viril-1 c- ?" G2 d) D
ization, the clinical hallmark of CPP is the symmet-  A% V1 E/ z( X9 D% C6 ^0 P7 w
rical testicular growth secondary to stimulation by
8 `, I1 Q" R0 D7 mgonadotropins.1,3
/ ?1 A$ g, Y4 o  z# o0 iGonadotropin-independent peripheral preco-: O2 b8 H8 v6 q) s: w+ ^  o% N
cious puberty in boys also results from inappropriate* J, Z" w% c: T
androgenic stimulation from either endogenous or# k9 N$ Z8 T7 I: M0 Y
exogenous sources, nonpituitary gonadotropin stim-
% r$ b0 Q. S' X3 z0 ^( yulation, and rare activating mutations.3 Virilizing
( p( j* u8 l0 p. K0 Q2 ~congenital adrenal hyperplasia producing excessive
- s* A, ?7 M8 y3 I6 q* v$ xadrenal androgens is a common cause of precocious
7 w6 G" |% z$ B4 ^" S- t3 L" @* epuberty in boys.3,4
7 `( P* m& g8 c0 M+ ]2 Q$ qThe most common form of congenital adrenal
) \! `6 P6 I9 _; A% ]/ l+ Xhyperplasia is the 21-hydroxylase enzyme deficiency.
" V1 `: U; e/ CThe 11-β hydroxylase deficiency may also result in/ Q" s- y0 @5 ^- R* F2 D
excessive adrenal androgen production, and rarely,+ x  e. I- w  i8 g4 a6 i+ d$ k8 e
an adrenal tumor may also cause adrenal androgen( r* j# X6 B0 |: S1 b
excess.1,3
7 X4 I$ R# M$ `3 j7 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. \, o* A: m( W: c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- m( |& e& [% C% Q( SA unique entity of male-limited gonadotropin-
! {1 N+ O8 A) V, Cindependent precocious puberty, which is also known7 s! g# `+ x# h, q6 n0 f" l
as testotoxicosis, may cause precocious puberty at a
7 \3 k* h' _8 }' x& b2 h/ Q9 Hvery young age. The physical findings in these boys$ p& H; E' ^( M# y& {
with this disorder are full pubertal development,: C4 F/ W  ^9 D: h( c
including bilateral testicular growth, similar to boys, o1 @6 o- Q9 c) ?5 w% }( @5 c
with CPP. The gonadotropin levels in this disorder
8 S3 E; W! ^+ o2 b% P- z. Xare suppressed to prepubertal levels and do not show
4 m# S% V6 x; g' D7 Z  v& Mpubertal response of gonadotropin after gonadotropin-+ j7 c* H; k6 |! V; t( v
releasing hormone stimulation. This is a sex-linked
) l2 \! U: B1 ]6 V0 Y1 Eautosomal dominant disorder that affects only
" N! H. K& I1 z  D7 E2 _males; therefore, other male members of the family8 I) [7 \; y5 }4 `1 b
may have similar precocious puberty.36 ?4 ?3 O! n+ p8 r  z. Q  Y2 P
In our patient, physical examination was incon-
' G) E& z; A) b, }7 s5 T/ X  }6 tsistent with true precocious puberty since his testi-& ?# S* x( ~5 a" R- `1 T& G8 c
cles were prepubertal in size. However, testotoxicosis
% i" z9 G: @6 r4 {% R3 Qwas in the differential diagnosis because his father
* X9 p& k" f/ [4 b$ C3 Fstarted puberty somewhat early, and occasionally,- W1 e2 X. c& |! J2 \
testicular enlargement is not that evident in the
% t2 A0 k4 U; r4 C6 Dbeginning of this process.1 In the absence of a neg-0 R. Q$ f6 C4 c; Q6 r/ U
ative initial history of androgen exposure, our
' J1 m& {6 g; v+ y( nbiggest concern was virilizing adrenal hyperplasia,/ G+ j' q" V- I8 Z
either 21-hydroxylase deficiency or 11-β hydroxylase$ m$ _  h" E3 u; U0 K$ C
deficiency. Those diagnoses were excluded by find-; {- e1 {" Y6 e; D
ing the normal level of adrenal steroids.0 X/ t* d/ X) z6 p0 S1 {) k
The diagnosis of exogenous androgens was strongly
3 [7 L' ~1 P' H/ l8 G, Q0 i/ ^* p0 q9 rsuspected in a follow-up visit after 4 months because
5 V+ H# y, Y. y' m" I, ?+ gthe physical examination revealed the complete disap-
8 H1 S( ~4 p2 ?/ L6 k0 apearance of pubic hair, normal growth velocity, and
9 m  U* X7 S8 }; t$ y; V3 Sdecreased erections. The father admitted using a testos-: t- R' M6 j( e$ G
terone gel, which he concealed at first visit. He was
/ m- n0 F: W# W( Z1 F# l! ~2 Wusing it rather frequently, twice a day. The Physicians’
% w- B9 R5 ?- n5 [3 XDesk Reference, or package insert of this product, gel or
2 T- w0 [6 s) q( `" b0 [2 g- [1 u& Gcream, cautions about dermal testosterone transfer to
7 `) E2 w* |" M/ kunprotected females through direct skin exposure.
  K4 u, R9 z/ ]" o5 ZSerum testosterone level was found to be 2 times the
, b# x) Y  Z$ k& ~baseline value in those females who were exposed to+ D) t& `( j7 w7 i) F$ S0 h% O
even 15 minutes of direct skin contact with their male
' H" j$ @/ M- D  i- Z3 opartners.6 However, when a shirt covered the applica-
6 U$ s0 `, S4 Ytion site, this testosterone transfer was prevented.. ?: K$ w5 F* `) ?
Our patient’s testosterone level was 60 ng/mL,
& j( Z: D2 x3 x: c4 [; lwhich was clearly high. Some studies suggest that% b& d* b" p, [# E4 P. t
dermal conversion of testosterone to dihydrotestos-
$ v, P& Z6 b: G$ O, [" O2 m5 q" }terone, which is a more potent metabolite, is more# }4 g. Y% V3 y' j
active in young children exposed to testosterone
' v/ w" P0 _- U5 k& z+ K% Rexogenously7; however, we did not measure a dihy-( V5 P& a: h8 B! Z8 W7 G
drotestosterone level in our patient. In addition to% u" s, U) H; b" D2 c9 L9 B
virilization, exposure to exogenous testosterone in
% R- x/ H$ t/ ?children results in an increase in growth velocity and
0 z3 R  ]& Z" s6 Padvanced bone age, as seen in our patient.: B' _- W# g' l6 a: D
The long-term effect of androgen exposure during; ?) m1 d! X2 X- ~2 d
early childhood on pubertal development and final* l* S* J/ Q$ v5 x0 W: W# _( r
adult height are not fully known and always remain
9 z. y0 Z6 U) Wa concern. Children treated with short-term testos-" c- h! Z( ^) a2 V! g! b
terone injection or topical androgen may exhibit some
9 g3 O& b7 s6 \8 Zacceleration of the skeletal maturation; however, after5 L5 S9 ^. [/ W9 e0 |
cessation of treatment, the rate of bone maturation" H8 Q, N+ C# @2 q
decelerates and gradually returns to normal.8,9/ E4 e3 c& M0 M! `! a( B  Q
There are conflicting reports and controversy
1 C8 S& h, S- r# u. d! qover the effect of early androgen exposure on adult
* m4 I% j7 Y  g1 R$ \penile length.10,11 Some reports suggest subnormal
3 q; T& @- W+ l6 _0 Cadult penile length, apparently because of downreg-
$ U2 q9 x4 b0 g# c1 zulation of androgen receptor number.10,12 However," u0 c' L6 x# {: m) d' h! i: S  m8 n; g( L
Sutherland et al13 did not find a correlation between
  D  z3 y0 I! N" z+ ~0 g: Dchildhood testosterone exposure and reduced adult4 A, w. }7 `! `' L
penile length in clinical studies.; m5 S3 D" X$ f- Y, ^7 F4 B
Nonetheless, we do not believe our patient is
9 a6 f& g! J/ [going to experience any of the untoward effects from
( i7 D/ R# y. Y( j6 L+ K  qtestosterone exposure as mentioned earlier because3 a' O) `, A/ L+ u; @
the exposure was not for a prolonged period of time.; o: a4 R9 G" Y
Although the bone age was advanced at the time of
' W& v: p8 y' k1 P4 h" Zdiagnosis, the child had a normal growth velocity at: y& y, B) ~) _. E) d
the follow-up visit. It is hoped that his final adult2 D: z- g) ?5 ]- ~! L2 c  g
height will not be affected.9 N; J3 L1 A6 M$ t7 w7 o8 y% ?
Although rarely reported, the widespread avail-
" w$ l! W$ f4 v, ~, A3 y! dability of androgen products in our society may% F) I4 {( K3 o6 s; w
indeed cause more virilization in male or female% A  X3 E% ~; G% h( M" r
children than one would realize. Exposure to andro-- Z8 ~. F" B# K" D2 N% k
gen products must be considered and specific ques-6 h$ W, z9 @5 m" F
tioning about the use of a testosterone product or& T' ~! B6 M+ F; ]
gel should be asked of the family members during% [' o+ T# R- @- [/ a! d: C; P$ u
the evaluation of any children who present with vir-" G) Y* P* N) s1 f$ V+ f" @/ K
ilization or peripheral precocious puberty. The diag-) d/ _$ {" i# g
nosis can be established by just a few tests and by% g+ _# b1 Y* r4 H% y3 N- y. e
appropriate history. The inability to obtain such a4 H. u' m! f6 T" O" V3 u
history, or failure to ask the specific questions, may
- B' u# D7 t. tresult in extensive, unnecessary, and expensive3 m+ c" u( Z& C% \
investigation. The primary care physician should be
1 H/ ?4 B# I' [aware of this fact, because most of these children
; t" `7 K2 K  s3 {5 G" U$ vmay initially present in their practice. The Physicians’
4 j0 u: r- {) A& m; ADesk Reference and package insert should also put a
0 H/ a/ y2 ?  q( y9 P* k1 B9 J) m' Jwarning about the virilizing effect on a male or1 t# i, c) @7 }* y2 y! y" U  l
female child who might come in contact with some-* T( v& U2 |- [. a3 X
one using any of these products.
; h1 u. W1 _; ^6 k" wReferences
) w0 a. I: o* T+ s& a  f* O1. Styne DM. The testes: disorder of sexual differentiation
$ R8 ?- L4 C+ G! n* o9 h! @1 band puberty in the male. In: Sperling MA, ed. Pediatric
) d' ?6 z% g# x# U; ]" W* aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 R. V' O7 x+ I1 I2002: 565-628.& w8 r) [/ b' T' \6 m& G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 z0 |+ R' `' }& D
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 V& L% S+ Y7 Y. p: g
Boy Induced by Indirect Topical
. h& R" g1 f/ y6 J7 l* {Exposure to Testosterone
$ h4 x' j* O, b# s, QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. i. g- r! Q" D8 n0 Wand Kenneth R. Rettig, MD1
! N. n6 o$ x8 [1 sClinical Pediatrics+ O4 J6 p) E' l- R* s* K. K/ O
Volume 46 Number 6  y6 k/ F: [' \' g$ F
July 2007 540-543
5 T2 \! v0 }  Q3 W5 |' G, {© 2007 Sage Publications$ \. x, b7 ], {& k1 q
10.1177/0009922806296651" c2 Q: x3 c. x9 n3 p
http://clp.sagepub.com
& V. D/ c) W: Y' r$ Y4 j6 Vhosted at
/ o; B7 o5 U2 }0 ?7 b* V# lhttp://online.sagepub.com
8 E3 m# {2 w. H8 w7 o) L3 _4 ~Precocious puberty in boys, central or peripheral,
# _& b3 H# w$ Bis a significant concern for physicians. Central
/ A. U1 h& j1 `% P9 r4 o( x& O: yprecocious puberty (CPP), which is mediated
  A% A& n# Q- E( s' m5 N, tthrough the hypothalamic pituitary gonadal axis, has
9 q# a) ?$ x- l, c3 Ca higher incidence of organic central nervous system0 R! Z9 t6 a+ z9 t
lesions in boys.1,2 Virilization in boys, as manifested
7 F6 c6 d# Q3 \( Z# K6 Fby enlargement of the penis, development of pubic1 H+ V# C. D0 w" @3 a4 a# ?3 K
hair, and facial acne without enlargement of testi-
1 Y* i4 j/ Z6 m9 m8 e' P8 Bcles, suggests peripheral or pseudopuberty.1-3 We0 J  A0 W5 I; J# O
report a 16-month-old boy who presented with the
" g* x$ _9 k+ t2 J+ _! oenlargement of the phallus and pubic hair develop-
; ]7 _2 x4 l+ q" u; sment without testicular enlargement, which was due
1 D5 D+ S( S( C0 hto the unintentional exposure to androgen gel used by0 Q( l) e  F8 P, x: e
the father. The family initially concealed this infor-
0 `: q# p! j0 e( C3 pmation, resulting in an extensive work-up for this( p9 B: }1 e# L8 a  T3 y  r% z% c
child. Given the widespread and easy availability of* x" [# y7 T  `% o7 z- K& B
testosterone gel and cream, we believe this is proba-7 e4 D1 n3 p6 @# h& @
bly more common than the rare case report in the
* o6 Y) j! M& c/ gliterature.4
2 [% b1 ?' Y3 p% `* t& Z% DPatient Report
" c9 C* i; X9 U( w1 t" {A 16-month-old white child was referred to the0 u) d+ p! d& ]) ~- `' ^5 ?/ z/ x4 t
endocrine clinic by his pediatrician with the concern
* K: [% D1 n, u4 Xof early sexual development. His mother noticed5 P( B# Y% g) b  A& n
light colored pubic hair development when he was
- q7 _5 A( E6 QFrom the 1Division of Pediatric Endocrinology, 2University of
& b/ O' c3 q9 o* k1 \7 ySouth Alabama Medical Center, Mobile, Alabama.
( A0 \( a+ }1 o  c& [9 E; }, ?3 iAddress correspondence to: Samar K. Bhowmick, MD, FACE,) D! W8 H8 |# c3 i! y" |4 ]0 N
Professor of Pediatrics, University of South Alabama, College of" B6 \. M( U9 _& W  ^1 g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' |( S8 M+ q9 }8 P/ ]" J  E3 qe-mail: [email protected].
2 o9 C) C; S0 V" [1 t8 cabout 6 to 7 months old, which progressively became: O+ r8 @4 k0 T
darker. She was also concerned about the enlarge-
# `1 z; x  P/ V% Q' P6 Ement of his penis and frequent erections. The child. C( L; s0 e/ B: x7 w+ K) y
was the product of a full-term normal delivery, with1 d9 P( s- B) J! ?/ g
a birth weight of 7 lb 14 oz, and birth length of- h% V& W4 f$ c6 o
20 inches. He was breast-fed throughout the first year4 N0 a. t: r8 a; r( ?/ ~4 q8 ~
of life and was still receiving breast milk along with
) m1 p+ `  c3 O* msolid food. He had no hospitalizations or surgery,0 Z7 k  {  V: ?9 l( M/ G# g" H
and his psychosocial and psychomotor development: S' `& ]7 A' T; D
was age appropriate.9 S; Q" Q. J3 I  m
The family history was remarkable for the father,
' \% i6 X- }) K/ Y' \who was diagnosed with hypothyroidism at age 16,3 n9 A) m7 T' w6 _3 X
which was treated with thyroxine. The father’s
1 u+ x; x: ], x& V7 Uheight was 6 feet, and he went through a somewhat8 e6 c/ [8 Y9 d4 M- v2 F
early puberty and had stopped growing by age 14.3 n. w. J' w5 I0 l$ l
The father denied taking any other medication. The
2 I  T5 m$ F) M5 A' kchild’s mother was in good health. Her menarche* r1 X! `9 e5 t
was at 11 years of age, and her height was at 5 feet$ m) Z6 J9 B$ W; Y2 ~8 W2 \* A
5 inches. There was no other family history of pre-5 L. ]8 f$ X! W+ Z' {3 }/ U
cocious sexual development in the first-degree rela-& T6 Y- p: \5 w2 A% W2 Z
tives. There were no siblings.
) C# O( [" g4 B) zPhysical Examination! T. y6 \9 |8 o3 C/ q. f1 P; \
The physical examination revealed a very active,& T& H) ^. u! g+ W+ d! H
playful, and healthy boy. The vital signs documented
% U0 B  X8 K2 Za blood pressure of 85/50 mm Hg, his length was0 }4 O& m  ]! ]1 T
90 cm (>97th percentile), and his weight was 14.4 kg
( v  J" k& O% d# S9 w# |) G9 J- S(also >97th percentile). The observed yearly growth
: |# m, e/ [: o# d. ~( Qvelocity was 30 cm (12 inches). The examination of( [9 e% A6 H3 i  {2 X- U, u
the neck revealed no thyroid enlargement.4 A8 i8 }* F* `5 n5 F
The genitourinary examination was remarkable for
& Y, J. n3 [; C7 y- d$ n- Fenlargement of the penis, with a stretched length of
5 b7 }; O  R6 g- Q8 cm and a width of 2 cm. The glans penis was very well! Q( L) c+ i4 `  }8 O
developed. The pubic hair was Tanner II, mostly around
' r6 d5 i) x, G3 j9 o2 f540
) u6 w' l. K+ P% J* s5 E4 Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" y# Y6 e. Q( j& x4 J
the base of the phallus and was dark and curled. The
' o: w. L. h+ d+ p# L+ s! Utesticular volume was prepubertal at 2 mL each.
0 I3 |; W. }. ^The skin was moist and smooth and somewhat
0 j' E0 ~% r+ Y2 r+ Hoily. No axillary hair was noted. There were no8 m! l% p; W5 x2 ^0 L. T5 r
abnormal skin pigmentations or café-au-lait spots.& S, X7 O1 K: V5 ~! ^
Neurologic evaluation showed deep tendon reflex 2+: u. h+ Q6 _* F+ C  H: n
bilateral and symmetrical. There was no suggestion
  g0 g8 N3 J6 M5 G$ O, l9 Tof papilledema.; [' W0 G! ?7 n) H. ?5 X+ |0 n
Laboratory Evaluation
! g! P) }6 I; J. K: _0 E. QThe bone age was consistent with 28 months by, Y2 e: a# F% A8 d
using the standard of Greulich and Pyle at a chrono-. [4 x3 ]3 O. \  V. Q) S
logic age of 16 months (advanced).5 Chromosomal
% q% ~9 y7 i9 D1 P5 mkaryotype was 46XY. The thyroid function test& T0 p0 N. z  k+ k( n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ n4 O" `+ D- J2 _' M0 S- rlating hormone level was 1.3 µIU/mL (both normal).$ h- e; m8 D; X. L; t; b
The concentrations of serum electrolytes, blood
1 m5 }5 D  I/ wurea nitrogen, creatinine, and calcium all were
" o3 _, v: T$ }within normal range for his age. The concentration
% F  L- a# C  f9 ~of serum 17-hydroxyprogesterone was 16 ng/dL, E$ [* F0 e& s, N
(normal, 3 to 90 ng/dL), androstenedione was 207 m4 o' b* F2 q3 S8 P8 A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! O2 Y' e2 i8 m' Y' U4 [; f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, c" ?3 ?6 G1 k! m* _; rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to# [5 U% v. b2 J- p4 V9 f
49ng/dL), 11-desoxycortisol (specific compound S)/ B( G( C0 f2 o/ t: B# s
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 `# U$ Y  j0 D1 u! R/ w# F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 y$ U" h9 c; o4 G8 p! Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( K: J- V& @) i& F0 \and β-human chorionic gonadotropin was less than
- G, W4 v( s8 m: Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 y/ @; C: L0 ~) `: Ustimulating hormone and leuteinizing hormone/ o$ j0 ?% ?% `0 q) ?2 a
concentrations were less than 0.05 mIU/mL
* G- f- O% {1 g; N+ E(prepubertal).  O$ |4 ?9 u: J3 U& d  C: {
The parents were notified about the laboratory
+ r: p- U$ O( B" {9 kresults and were informed that all of the tests were1 T& |: A" r2 G3 H0 E& r' x
normal except the testosterone level was high. The  u" s( }% f  ]+ D+ b3 p3 ~: ]
follow-up visit was arranged within a few weeks to
7 ~. A" A2 m. a' \obtain testicular and abdominal sonograms; how-9 S4 C. `  U0 H1 U1 f8 N5 \3 ^0 C
ever, the family did not return for 4 months.; }" U: X3 x6 Z. f, M. ?. x% p, V0 L
Physical examination at this time revealed that the4 d5 L  N6 D/ Z  F( {3 E
child had grown 2.5 cm in 4 months and had gained
5 F0 Y& j6 z/ \7 y2 kg of weight. Physical examination remained
! e2 g: R( h) o1 G7 |unchanged. Surprisingly, the pubic hair almost com-3 @2 ~& t, t( q) j
pletely disappeared except for a few vellous hairs at. Q$ \; j. y6 f: `% @& T
the base of the phallus. Testicular volume was still 26 {! r% M# b: _. a7 _2 L2 T0 A
mL, and the size of the penis remained unchanged.8 Y. W! S6 x& `) z
The mother also said that the boy was no longer hav-* z) r$ c7 c  H. K5 o! ?
ing frequent erections.
0 ?+ u- t+ l3 y3 t( ^  n% xBoth parents were again questioned about use of
$ I3 v) @' q' Z$ Iany ointment/creams that they may have applied to
4 S1 L- o; }4 |1 N$ |( Z6 h# ~the child’s skin. This time the father admitted the9 G0 E" H- U: r! x6 x3 a
Topical Testosterone Exposure / Bhowmick et al 541; P& _, D; J. H4 `% a+ W" G/ |
use of testosterone gel twice daily that he was apply-" t. X6 U6 [2 s, v1 G+ r6 |8 N/ V* B
ing over his own shoulders, chest, and back area for; m$ z$ P' U6 Q1 M) f1 S
a year. The father also revealed he was embarrassed8 E6 G6 r4 Z% g
to disclose that he was using a testosterone gel pre-
) k. w% ]+ r2 L. w7 Uscribed by his family physician for decreased libido
6 n+ A: U! j' a  G8 f+ b* h  Xsecondary to depression.5 \, D" I/ D( U- d+ d
The child slept in the same bed with parents.$ L8 K  J1 l- B' `) Q4 H
The father would hug the baby and hold him on his3 e' J/ w7 I8 R# G" z- P' l$ s
chest for a considerable period of time, causing sig-5 C  ]8 e. h! V0 L% d$ U
nificant bare skin contact between baby and father.
+ i% m/ r: u( q( Q5 lThe father also admitted that after the phone call,
* M: [  ^& B7 S$ B% [, Hwhen he learned the testosterone level in the baby3 a: r+ S, u. z4 v6 i' o
was high, he then read the product information
! d0 E. M: k& r% U8 F+ \0 |packet and concluded that it was most likely the rea-% X' o+ a) l& U* l
son for the child’s virilization. At that time, they, B9 g5 r5 a  i" {- m4 n
decided to put the baby in a separate bed, and the
, r& V1 z- f- W. q/ p* Y( Afather was not hugging him with bare skin and had9 c/ [; m0 r  |1 x) h3 K9 W/ v2 o2 H
been using protective clothing. A repeat testosterone
7 M7 |% ?4 u- g( E1 o+ D  ?test was ordered, but the family did not go to the
- h5 ^4 t% b+ _5 C2 ~7 n5 Hlaboratory to obtain the test.! m: ~9 H4 N+ A4 t9 o& u- d
Discussion
' @1 z" s) J9 o9 H; o1 G4 @Precocious puberty in boys is defined as secondary# R5 s5 \& ~! p
sexual development before 9 years of age.1,4
4 |' x6 O$ ~1 p* w4 `- f( IPrecocious puberty is termed as central (true) when) q; ]2 T: x( `+ x' x9 E# W
it is caused by the premature activation of hypo-
3 n/ H- p6 ^6 Nthalamic pituitary gonadal axis. CPP is more com-1 F6 m" A2 d8 `# `5 r8 v: a) I
mon in girls than in boys.1,3 Most boys with CPP2 b( M4 L6 C. V) ^8 e2 a# S
may have a central nervous system lesion that is
2 O" Y6 t- R9 x5 h- l2 Q& t& f1 Xresponsible for the early activation of the hypothal-
  u" h1 y8 H: z4 }4 h7 Aamic pituitary gonadal axis.1-3 Thus, greater empha-
' I9 D& e: y- Xsis has been given to neuroradiologic imaging in% ~" e: B. X1 S& n: v
boys with precocious puberty. In addition to viril-
  d' M' e7 V8 K, g0 Wization, the clinical hallmark of CPP is the symmet-3 W8 Z& e* z' O. L
rical testicular growth secondary to stimulation by* _2 Z  {+ f$ E. K
gonadotropins.1,3
' [( K+ H7 Y& B6 LGonadotropin-independent peripheral preco-, o9 Q( Q! D+ _- Z: ]' d: w
cious puberty in boys also results from inappropriate
" |# ]' K7 r1 Bandrogenic stimulation from either endogenous or
2 ^2 ^" t5 X) E9 k9 yexogenous sources, nonpituitary gonadotropin stim-
  `# G$ c- X( aulation, and rare activating mutations.3 Virilizing" k8 ]* e1 v) X
congenital adrenal hyperplasia producing excessive
3 ^0 Y7 @6 N# H5 ]adrenal androgens is a common cause of precocious
1 j9 C$ l, ]9 {- {% Y% ?puberty in boys.3,4
  ^( d* C- V0 G( R4 `' @0 B1 t$ sThe most common form of congenital adrenal
+ k, A! d1 t( f  h' y  \1 z; g" m5 \4 phyperplasia is the 21-hydroxylase enzyme deficiency." T* C1 p' Z. D) K5 _
The 11-β hydroxylase deficiency may also result in  d! p3 t! P& h2 C5 z2 T( z
excessive adrenal androgen production, and rarely,
8 n2 R5 U6 v! D# Z& z; san adrenal tumor may also cause adrenal androgen: `4 ], @1 a( V% l, c
excess.1,3. U3 `0 [, L6 H- p' Z3 @5 q& I8 w3 A* d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 L7 T3 m7 e1 I% J6 g/ }/ \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 `% _- }: t1 p7 G  v1 G2 L7 B! x5 sA unique entity of male-limited gonadotropin-/ H9 n: S9 a- ]0 F' X2 n3 ]
independent precocious puberty, which is also known4 N9 V- ^* ?. _4 g) c8 m  h
as testotoxicosis, may cause precocious puberty at a
; p" N9 m5 ~+ l; k) X  g* d: dvery young age. The physical findings in these boys9 Y& j- G, X( z9 E/ J  {
with this disorder are full pubertal development,! h& E- V! O+ W. u# r
including bilateral testicular growth, similar to boys9 T5 o3 z5 S$ H' I' d
with CPP. The gonadotropin levels in this disorder- o; Y! c8 K/ N! x5 |+ y
are suppressed to prepubertal levels and do not show
+ o& U' R% E! y" Rpubertal response of gonadotropin after gonadotropin-
$ C) L: q9 z) O/ A; Sreleasing hormone stimulation. This is a sex-linked
' h, e# ^9 W, Xautosomal dominant disorder that affects only; V+ o* E* K. I) i& h
males; therefore, other male members of the family
3 c) N7 }9 v! o! t) G( umay have similar precocious puberty.3
: I, [1 J4 r2 e8 I1 K+ DIn our patient, physical examination was incon-7 B& \7 [: }# A/ H; |9 ?
sistent with true precocious puberty since his testi-  w( C$ ^5 c8 _) W
cles were prepubertal in size. However, testotoxicosis
4 w# A- m- r0 b- {was in the differential diagnosis because his father/ Y2 ~* G0 v: g+ e# p& S: r
started puberty somewhat early, and occasionally,+ u( g' _+ p, k% `& [3 L6 ~
testicular enlargement is not that evident in the3 o7 K) t# {, ^
beginning of this process.1 In the absence of a neg-. d2 X& H4 S7 j+ y( {$ n
ative initial history of androgen exposure, our
0 o! K! f, N% L; Z- L3 }biggest concern was virilizing adrenal hyperplasia,5 D7 u2 X2 b- K: s7 w
either 21-hydroxylase deficiency or 11-β hydroxylase
5 V, L- V: U6 u1 y( {deficiency. Those diagnoses were excluded by find-
% y! L; T$ U* v7 u$ h; P9 wing the normal level of adrenal steroids.5 g$ P6 p$ G/ H, Z6 F9 B
The diagnosis of exogenous androgens was strongly
8 e" S" c  ?- o0 v/ k# j" U# Dsuspected in a follow-up visit after 4 months because: ^1 T( c# L8 `9 `
the physical examination revealed the complete disap-; P6 f  Y8 C  @. c( p# o: O
pearance of pubic hair, normal growth velocity, and; E, l8 R1 W" y$ q! K) f/ X
decreased erections. The father admitted using a testos-
' ?  p' d* z  x! J! }5 b! l# Sterone gel, which he concealed at first visit. He was
9 q) ~3 g9 s3 p. kusing it rather frequently, twice a day. The Physicians’, ?- d8 h, i2 F7 D6 N
Desk Reference, or package insert of this product, gel or
1 G" M! ?! w, r7 P; jcream, cautions about dermal testosterone transfer to
  X/ y8 i% V/ K& K8 U' p8 a7 ?- v/ u* munprotected females through direct skin exposure.
4 U6 R: ?- P0 w* p9 GSerum testosterone level was found to be 2 times the. {% N  A/ ?4 ^9 O
baseline value in those females who were exposed to
  [7 k/ C. B! z6 B/ k: _- H  a* {even 15 minutes of direct skin contact with their male- u: U* n( h+ A9 _
partners.6 However, when a shirt covered the applica-/ W, a, D* j% e) f0 T$ y
tion site, this testosterone transfer was prevented.) N+ g+ K  k. L: }' J+ \
Our patient’s testosterone level was 60 ng/mL,
: j  K. E; a" J8 J+ |7 e: y: `which was clearly high. Some studies suggest that; M2 a0 n, {& k
dermal conversion of testosterone to dihydrotestos-& p0 {" u$ m# V# Z/ F* D/ ]
terone, which is a more potent metabolite, is more- ]" Q9 s: d) B
active in young children exposed to testosterone( r0 z+ d  c3 f9 n1 w
exogenously7; however, we did not measure a dihy-
/ k8 Y7 @5 ?& s% T2 @% o, t2 G' Sdrotestosterone level in our patient. In addition to/ o! A* d2 E3 B% Y0 N
virilization, exposure to exogenous testosterone in* O& S0 y& ^$ q; X) B: A( R# }
children results in an increase in growth velocity and3 B; |2 H* m% H
advanced bone age, as seen in our patient.
1 V! s& ?! t1 w2 S+ d% E, QThe long-term effect of androgen exposure during# ^) m2 U" N7 a( j/ C
early childhood on pubertal development and final, u( @4 f9 a: F) L' ?; e
adult height are not fully known and always remain
5 b6 J' M) z+ |0 b! j: i& y& ~" @a concern. Children treated with short-term testos-
5 k& h  Z# _0 f5 y" ]terone injection or topical androgen may exhibit some. N" Z8 f, u' W8 V( _
acceleration of the skeletal maturation; however, after% z2 I& F3 G4 v* f# l
cessation of treatment, the rate of bone maturation* n+ f: R% `* e6 j
decelerates and gradually returns to normal.8,9
: V. s2 e+ I5 P0 B4 ~There are conflicting reports and controversy
/ Y6 f1 z) k* R4 h1 ]over the effect of early androgen exposure on adult
) \' }& Z" P4 openile length.10,11 Some reports suggest subnormal. t. Z, T( {3 R3 t
adult penile length, apparently because of downreg-; O4 z$ N( i: s1 @
ulation of androgen receptor number.10,12 However,
+ f; [7 z" U+ ASutherland et al13 did not find a correlation between8 n, G/ V% ]; t& I. P
childhood testosterone exposure and reduced adult
" G9 }9 |6 |; W- h# ^" _2 w  Y( w* xpenile length in clinical studies.
7 Y: m  b- z6 ZNonetheless, we do not believe our patient is3 Q& L+ @9 F9 y0 g( _
going to experience any of the untoward effects from2 {# z# ?2 I% k# n
testosterone exposure as mentioned earlier because  F7 p# Z7 j* c9 B7 v& y# g
the exposure was not for a prolonged period of time.7 P  r- T- A! @3 N6 x" Z7 J5 e
Although the bone age was advanced at the time of
' r' n. q! Z$ H) N7 {diagnosis, the child had a normal growth velocity at
' Z! m+ `: B# A$ V3 k$ lthe follow-up visit. It is hoped that his final adult
5 j7 u: {, L$ J/ |/ M3 W$ _/ fheight will not be affected.
" O  z; ]5 p: B8 J- LAlthough rarely reported, the widespread avail-
6 h' o2 ^- p5 [& i; A) Gability of androgen products in our society may
! c  R# S$ F" c8 {& a+ D( C+ N( H4 [* Tindeed cause more virilization in male or female
& x+ `0 M7 K! [- R+ wchildren than one would realize. Exposure to andro-; C& u- I5 M8 ?4 n
gen products must be considered and specific ques-: b: D9 ]1 H1 i" ^
tioning about the use of a testosterone product or' W" \" L4 _; V, T) A  ]% H
gel should be asked of the family members during
' S$ [& U- a( X* cthe evaluation of any children who present with vir-
- y6 B# @# T" W4 }5 R' W5 M7 _ilization or peripheral precocious puberty. The diag-( {6 |1 h, A" {  A- Z
nosis can be established by just a few tests and by6 Y9 X* L1 O' C4 O* h" G% O
appropriate history. The inability to obtain such a6 Y7 ]& o$ q9 V* J2 t* X+ \
history, or failure to ask the specific questions, may
6 w2 E+ Y+ C( ~9 |result in extensive, unnecessary, and expensive9 q2 X& f6 u$ L
investigation. The primary care physician should be
% k) {1 J9 P4 laware of this fact, because most of these children
1 _, G- i) R8 R; {1 X" E4 B8 vmay initially present in their practice. The Physicians’+ Z5 _0 Y* s0 s" J$ @+ D
Desk Reference and package insert should also put a& A+ O5 o* ]2 i0 A/ j
warning about the virilizing effect on a male or  j( ?% n( O- b+ I
female child who might come in contact with some-
% ]# g; X4 W/ r; w* None using any of these products.4 m, q: F3 E% F# p1 O
References( O5 }' ?; Z% V+ q; f# Y$ Z- ~
1. Styne DM. The testes: disorder of sexual differentiation
3 j4 |! Z" ]0 l' @+ hand puberty in the male. In: Sperling MA, ed. Pediatric" G' E, w  s1 `0 p0 @5 H' x/ H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  S& ]+ A! I0 A$ x0 F) \
2002: 565-628.1 r1 f$ p, v9 _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 E0 `5 E5 R  q1 Q: O1 `
puberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
6 A4 M' M' ?- i& |8 y' g
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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