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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
  U: [) M$ g: U2 T0 x6 x6 ^Boy Induced by Indirect Topical  y1 E3 h1 Y. a! {
Exposure to Testosterone
& n' E, f2 Y0 @" J# v1 OSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ K7 J6 J9 n/ fand Kenneth R. Rettig, MD1, q7 Q+ d. q5 C4 [$ \$ Q
Clinical Pediatrics
& M" [  m/ Q1 m4 Z# ^1 PVolume 46 Number 6
  R- t7 _  w9 T1 DJuly 2007 540-543% H, x/ j0 h, A$ a
© 2007 Sage Publications6 [6 v. y2 U0 c* S2 Y
10.1177/0009922806296651" Q+ R9 B$ Z' w1 O6 X( A
http://clp.sagepub.com
* {2 }' s4 t9 ^- c% X! F$ {hosted at
4 ]7 o8 w% o9 Xhttp://online.sagepub.com
. m' D7 h% \- j7 X( w$ DPrecocious puberty in boys, central or peripheral,8 ^, d! [$ }6 v- J
is a significant concern for physicians. Central' h1 {% p4 u5 E
precocious puberty (CPP), which is mediated/ G  w4 c; [# i& }
through the hypothalamic pituitary gonadal axis, has
' c$ P3 E' r" P4 K6 r$ g7 D* J% k) Aa higher incidence of organic central nervous system) w! E5 i; V; k5 y1 s  f
lesions in boys.1,2 Virilization in boys, as manifested2 M! F$ W  \9 K6 l: j9 A
by enlargement of the penis, development of pubic
% c) B9 Z4 d+ I, o) }- M4 Ahair, and facial acne without enlargement of testi-( S$ g& j, F' V
cles, suggests peripheral or pseudopuberty.1-3 We/ N$ S% _1 x) M; \, u
report a 16-month-old boy who presented with the- F5 y* N# X6 R, e- @: b, I9 n6 t3 l" ^0 E
enlargement of the phallus and pubic hair develop-
+ F9 h3 [% p, ?) i' Fment without testicular enlargement, which was due
1 x) a: {# `$ h+ Q! D6 bto the unintentional exposure to androgen gel used by
4 i" F8 k# Y3 t- F4 ]the father. The family initially concealed this infor-$ B6 P( V. r4 A
mation, resulting in an extensive work-up for this
, i# v( Y& c: ichild. Given the widespread and easy availability of/ k8 y7 J" t' {8 a. M- u: Q1 k" M
testosterone gel and cream, we believe this is proba-" I+ Y5 F4 \/ m4 K7 u) S, S7 _
bly more common than the rare case report in the# s. J6 c  _3 s5 t' O& x# ?2 u
literature.4
0 V! [$ i0 Z8 d$ j# |Patient Report, [; ?/ u. g% }, N; a
A 16-month-old white child was referred to the
4 O7 x. q3 f# @" e8 R$ Lendocrine clinic by his pediatrician with the concern
/ }: a3 u) C, ?8 {- J1 Dof early sexual development. His mother noticed
2 r- V9 s( T$ _6 j+ I# p; t; glight colored pubic hair development when he was5 P- Y% j4 V( }% x1 O) X
From the 1Division of Pediatric Endocrinology, 2University of
7 }. Q2 \* }" D" w" |9 ~8 BSouth Alabama Medical Center, Mobile, Alabama.
2 @: m  G. S  _* Z4 v5 fAddress correspondence to: Samar K. Bhowmick, MD, FACE,* I$ {- m5 ]" J1 V) K0 w5 k2 J, w
Professor of Pediatrics, University of South Alabama, College of5 d9 t0 Z8 c$ V: m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) b2 ?1 r" V1 O- K
e-mail: [email protected].
* l9 o/ R5 v1 B* p7 B; F- Rabout 6 to 7 months old, which progressively became* M6 x4 w1 g6 C( |  u2 j2 m* ?
darker. She was also concerned about the enlarge-
% e1 |+ H, O8 M! T( W, P& v! Wment of his penis and frequent erections. The child
* R& H! z; F: K: gwas the product of a full-term normal delivery, with
1 p9 q. K# P/ C& ^: W2 fa birth weight of 7 lb 14 oz, and birth length of
8 m9 \0 `' F, L+ ~2 B20 inches. He was breast-fed throughout the first year
$ [; s  @( @$ Y2 W* C$ ^9 N9 ^* \of life and was still receiving breast milk along with0 v( N) d6 Y  Y
solid food. He had no hospitalizations or surgery,& r* P: f' \. s& N  B/ |: e
and his psychosocial and psychomotor development- @7 T# o8 i0 [
was age appropriate.- d1 o$ A$ \0 N4 j. Q: g) V" K
The family history was remarkable for the father,. `' F) N8 I% O3 A4 G, g
who was diagnosed with hypothyroidism at age 16,
5 O# a. q# T  M. I4 S* J2 ywhich was treated with thyroxine. The father’s
6 Z, y5 K. Y) U9 G+ C3 bheight was 6 feet, and he went through a somewhat7 k8 R8 v" P: @; k6 a
early puberty and had stopped growing by age 14.1 P- u; A) |  B" m; t
The father denied taking any other medication. The
. V2 U& J* g# W( cchild’s mother was in good health. Her menarche
; q9 u( c9 E6 c7 e7 Nwas at 11 years of age, and her height was at 5 feet
9 E$ z& ~  H- F1 H# l+ U7 l5 inches. There was no other family history of pre-
  s! j3 n2 |8 F5 K2 y9 P7 scocious sexual development in the first-degree rela-
0 H! }+ `' f) F3 y/ I. Z/ }tives. There were no siblings.' N+ R( D# }* u+ _' a2 T
Physical Examination
# J5 u7 C% F' l; S) D7 DThe physical examination revealed a very active,- \  j* ^$ M1 z1 n. p6 c) l9 M
playful, and healthy boy. The vital signs documented
4 U, o0 G) n6 U. g7 sa blood pressure of 85/50 mm Hg, his length was4 b' \. e, X6 r7 c" C
90 cm (>97th percentile), and his weight was 14.4 kg
1 m7 v3 r$ P; n(also >97th percentile). The observed yearly growth2 M9 ]5 C6 s6 M* S/ a$ V% K
velocity was 30 cm (12 inches). The examination of) m  c9 |& J+ H
the neck revealed no thyroid enlargement.
8 B4 ~# V* Y- BThe genitourinary examination was remarkable for6 I1 C: G; u1 @1 B3 L! }9 u
enlargement of the penis, with a stretched length of
* n4 d9 g% k4 G  P7 I5 {$ f8 cm and a width of 2 cm. The glans penis was very well, }) ]+ F: k- A% f; l/ F8 K. X- E
developed. The pubic hair was Tanner II, mostly around8 H9 ^! D7 t  r8 ?
540
7 W, H( @# J" `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 H5 |3 V+ `9 D, T! A" E
the base of the phallus and was dark and curled. The
; w" h9 h' m" I; ftesticular volume was prepubertal at 2 mL each.
' H2 q' L( n. K" ~. oThe skin was moist and smooth and somewhat
1 U. s) V6 B5 z+ _: boily. No axillary hair was noted. There were no: y, E/ g; V3 K' P$ Y& }1 m
abnormal skin pigmentations or café-au-lait spots.
+ q8 u2 q5 m$ x' W, T) H( @Neurologic evaluation showed deep tendon reflex 2+# m  K7 W9 r, n$ \5 D
bilateral and symmetrical. There was no suggestion! \" p8 y6 z! C& i8 N
of papilledema.
6 T$ B  K& ?* k; ~! YLaboratory Evaluation
9 I/ y6 J% o( `4 SThe bone age was consistent with 28 months by
8 F" {* F' M! _+ N4 ?using the standard of Greulich and Pyle at a chrono-
/ U/ g9 m* w0 X% p5 S0 glogic age of 16 months (advanced).5 Chromosomal1 _0 V2 n% e+ v
karyotype was 46XY. The thyroid function test. P" R5 S6 s$ z( ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. J: u* ~! w0 P- Q! ^lating hormone level was 1.3 µIU/mL (both normal).
7 A7 Y# q9 h% T( }$ \/ ]The concentrations of serum electrolytes, blood
( [! I8 Z6 f' n$ Aurea nitrogen, creatinine, and calcium all were+ y' c* b8 @0 q+ t
within normal range for his age. The concentration
5 l5 ?0 r; ?, I6 F+ Kof serum 17-hydroxyprogesterone was 16 ng/dL/ b' n5 y, S* ]1 n. F8 w! Y
(normal, 3 to 90 ng/dL), androstenedione was 20$ ?$ p3 b6 A# H6 s& S" D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; R0 J% G( |1 b* M* G' d3 P
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 C! t$ `' g" g7 M$ C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! J6 w8 ~+ ]' v  C49ng/dL), 11-desoxycortisol (specific compound S)
1 L+ O/ k2 [0 C% |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* T+ q4 V9 L* ]9 {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& q4 ?& ?" b' }1 A9 O( Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ u0 o0 u0 n" u2 N: \5 i
and β-human chorionic gonadotropin was less than$ J$ F/ G, I$ b% S& s- U! K" A
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 p, y' v+ W* ?+ O3 ]* K' w" F
stimulating hormone and leuteinizing hormone
' O) V0 ?3 Z2 z% j+ W* R3 x. a( Q8 aconcentrations were less than 0.05 mIU/mL
( H+ ?/ `' R" g; L(prepubertal).* ~/ x7 g. b* r
The parents were notified about the laboratory# Y6 X. s; O5 T
results and were informed that all of the tests were
6 x+ e( w3 c/ b4 Z. t8 S7 vnormal except the testosterone level was high. The6 |# |; e5 U* P4 A3 \$ k
follow-up visit was arranged within a few weeks to
4 h, w" h9 R4 Uobtain testicular and abdominal sonograms; how-9 f& s- Q: u4 D, F& C
ever, the family did not return for 4 months.+ q: s' F: F' T' V  M' A
Physical examination at this time revealed that the
) w. U9 ~, Q2 Ochild had grown 2.5 cm in 4 months and had gained
: Y3 }! U5 O8 v3 S- @8 y/ l" ]2 kg of weight. Physical examination remained+ V. j. v' M- t5 K, P/ Z2 {
unchanged. Surprisingly, the pubic hair almost com-  _# b/ J4 H5 G/ D; t+ |7 z
pletely disappeared except for a few vellous hairs at
8 W* G2 W0 }: t) L' fthe base of the phallus. Testicular volume was still 2
4 O% R5 q" n: y" M3 m/ C" ymL, and the size of the penis remained unchanged.- e. q! q# O) T+ y
The mother also said that the boy was no longer hav-) s" w& X& o* H! F! o0 R5 f& D
ing frequent erections.
6 s6 ]' X% b# g4 dBoth parents were again questioned about use of
# Q; i$ a+ H) m. zany ointment/creams that they may have applied to- y2 u% T4 b8 p$ e0 Y
the child’s skin. This time the father admitted the$ q% x/ x# \2 v" `* _1 c
Topical Testosterone Exposure / Bhowmick et al 541
7 _) `$ u& p$ T7 i# g) duse of testosterone gel twice daily that he was apply-1 t/ d2 P2 y0 {' f
ing over his own shoulders, chest, and back area for8 v' u/ z. S6 H, R9 |- r, l
a year. The father also revealed he was embarrassed
" r& D9 @2 _9 a1 e: l' Uto disclose that he was using a testosterone gel pre-7 G) N1 `7 K, U2 j% c- \
scribed by his family physician for decreased libido: x2 S6 p5 Q3 W* c8 i" V; f
secondary to depression.
  A3 Q) T. M# S" Z5 ~+ @The child slept in the same bed with parents.
1 V* b6 V1 r3 l; ]/ aThe father would hug the baby and hold him on his1 f7 g: h( w* M( [/ f: |
chest for a considerable period of time, causing sig-# e4 N; f/ y3 ?) h# V) V, ^/ m7 j
nificant bare skin contact between baby and father.
5 D, {- }" }: S4 ]' x  e* J# O; ~The father also admitted that after the phone call,. E) E2 ^  l$ W9 A' p1 r) n
when he learned the testosterone level in the baby
! Y; Y9 O1 C, W$ ?$ o9 Q2 D# twas high, he then read the product information! W7 A0 {( S- E5 l
packet and concluded that it was most likely the rea-
# c* K: P2 t9 I9 lson for the child’s virilization. At that time, they6 Y" ~5 |" O4 ~* Y0 h2 Y
decided to put the baby in a separate bed, and the( C) R9 z( N' r" y
father was not hugging him with bare skin and had% U- S3 j8 \8 |0 G, e
been using protective clothing. A repeat testosterone# B; C: H1 g/ i& {/ a2 z6 t, `$ V
test was ordered, but the family did not go to the4 o6 T3 X1 H8 N  |2 o; d& V2 l
laboratory to obtain the test.( T- \$ ~8 X4 h) M$ M  h  o
Discussion! U0 h) X" z2 b% N
Precocious puberty in boys is defined as secondary
4 ~- @* s4 W; `& y0 @sexual development before 9 years of age.1,4: J: g9 |. L3 F  k9 w, O0 t0 }
Precocious puberty is termed as central (true) when, x6 s) V& S3 g  q( Q, n6 U' b9 q) _
it is caused by the premature activation of hypo-0 W( L2 W% ]9 q- J" B
thalamic pituitary gonadal axis. CPP is more com-( f9 R" D: h0 W, H
mon in girls than in boys.1,3 Most boys with CPP# A, y) j: ?' K, `# J7 B! L( v
may have a central nervous system lesion that is- s7 s" i" ]6 f; H! v, u1 _
responsible for the early activation of the hypothal-' t6 R# X, V9 q$ n4 j% b
amic pituitary gonadal axis.1-3 Thus, greater empha-
% g) ^* o/ c3 [$ ]/ |4 W- Zsis has been given to neuroradiologic imaging in" d9 I+ d7 e4 t
boys with precocious puberty. In addition to viril-) k. A: X9 E  e$ ?5 Z- X
ization, the clinical hallmark of CPP is the symmet-0 y4 ?6 ~6 l; q$ D; S/ ^1 k, G3 p1 Y
rical testicular growth secondary to stimulation by1 \. @& E: w7 M# @: d" U
gonadotropins.1,3
% V* m4 u4 ~4 L# M1 S3 gGonadotropin-independent peripheral preco-1 M4 r/ \/ ]  L6 t! Y
cious puberty in boys also results from inappropriate
- z3 R* ?# s, b- Tandrogenic stimulation from either endogenous or
8 i+ q7 e# R: t5 c- m1 _exogenous sources, nonpituitary gonadotropin stim-4 W3 w' g2 \3 u. ^- r
ulation, and rare activating mutations.3 Virilizing
0 u9 k3 q, @+ s# o) n0 f" k; \congenital adrenal hyperplasia producing excessive' Y/ b1 s0 W' o1 o: l
adrenal androgens is a common cause of precocious
% [- d: w6 M! |: Wpuberty in boys.3,4! P( O5 G0 M+ q! d9 a
The most common form of congenital adrenal/ m7 M: G* m: O
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ ^9 h/ X( z  \, x% d# g: dThe 11-β hydroxylase deficiency may also result in) S2 \" i; [+ Q/ m
excessive adrenal androgen production, and rarely,: a% N  Q% m1 B$ Z+ L% f6 X
an adrenal tumor may also cause adrenal androgen
! H% v% Z; W6 l" Z" g8 ~3 ^; hexcess.1,38 ~( K. _2 h9 T5 m: C( f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ _9 t& e! z, C+ m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  Y2 {; y1 g% w1 W
A unique entity of male-limited gonadotropin-6 D: h9 M+ S7 X/ N* G
independent precocious puberty, which is also known) |/ T5 g* w8 E7 V6 ~$ l  m4 {
as testotoxicosis, may cause precocious puberty at a# _5 d* ~" [9 O& ?# I
very young age. The physical findings in these boys$ V2 i/ O* M' B
with this disorder are full pubertal development,
) y  O, k% W9 N1 kincluding bilateral testicular growth, similar to boys& V# O- M9 j' w. q& s9 O
with CPP. The gonadotropin levels in this disorder
; L) f: B( [; ?. Uare suppressed to prepubertal levels and do not show+ V1 U9 ^9 L. N5 a1 V
pubertal response of gonadotropin after gonadotropin-
  D6 n  Q6 F- r, p8 P0 Lreleasing hormone stimulation. This is a sex-linked
* s: _6 N; g" E7 d9 Hautosomal dominant disorder that affects only
8 W7 B! C% m& d; {males; therefore, other male members of the family
! q, b# v8 _' vmay have similar precocious puberty.3
8 ?- |0 q2 r& ^- B, A% _In our patient, physical examination was incon-
- C: t, D& S; ]8 Ksistent with true precocious puberty since his testi-* A8 g' `& q0 C# `/ U/ Q
cles were prepubertal in size. However, testotoxicosis
* V2 F7 U' n0 u6 Y- Ewas in the differential diagnosis because his father  F+ q/ ]5 l" x; t4 G+ ?! H
started puberty somewhat early, and occasionally,1 `* [+ m  Z" w: B
testicular enlargement is not that evident in the
4 [  q5 F6 b1 c$ }beginning of this process.1 In the absence of a neg-5 q: r8 v/ G9 Y0 \% k4 X/ C  \7 u& P$ D
ative initial history of androgen exposure, our: c3 P: Q( q/ L$ c- y7 F9 s1 \% [
biggest concern was virilizing adrenal hyperplasia,
2 ~/ \, H5 A0 @1 Y3 Y, o8 meither 21-hydroxylase deficiency or 11-β hydroxylase/ v1 p! v  v0 I/ C9 S
deficiency. Those diagnoses were excluded by find-( h- N* v! r1 x( V$ r: ~
ing the normal level of adrenal steroids.
5 `' _5 U5 ?1 D* `9 WThe diagnosis of exogenous androgens was strongly* l+ j' M# b$ m/ k6 I
suspected in a follow-up visit after 4 months because
8 P) }" t/ E; U' ~# rthe physical examination revealed the complete disap-7 @7 t! Z; a, H" k/ ?. L
pearance of pubic hair, normal growth velocity, and8 _  x+ J4 a4 N" _& c/ a" W! C
decreased erections. The father admitted using a testos-
; \6 n+ y- t. B- rterone gel, which he concealed at first visit. He was
. q6 L0 z/ T% u1 f, l) fusing it rather frequently, twice a day. The Physicians’2 P; Q0 K" ?2 A6 d" A5 R7 a# T
Desk Reference, or package insert of this product, gel or, ?# n8 n, H  ~# a/ ?: @6 n
cream, cautions about dermal testosterone transfer to
7 h7 E4 y  V0 Gunprotected females through direct skin exposure.! ^% b+ f% U/ q1 s
Serum testosterone level was found to be 2 times the0 v& }8 u  w7 ?# G
baseline value in those females who were exposed to
& o( ]; r1 F$ t* b, V: u2 Seven 15 minutes of direct skin contact with their male- O2 c0 x+ K8 {  ?
partners.6 However, when a shirt covered the applica-
' |+ g2 Q7 s0 ~2 b4 Q4 ]+ [) }& dtion site, this testosterone transfer was prevented.
: c3 B, H' e& k$ j) Y0 ^% }- h5 JOur patient’s testosterone level was 60 ng/mL,
3 I. v& x4 l) y& O$ H; rwhich was clearly high. Some studies suggest that
; @! Z( c* c8 x5 W: X" Gdermal conversion of testosterone to dihydrotestos-
* m& N/ o0 S+ e! z9 Z) W9 ^# Gterone, which is a more potent metabolite, is more
5 k- ?* _7 ]5 M( Y' Dactive in young children exposed to testosterone' g" P' o/ ~0 Z7 H/ m
exogenously7; however, we did not measure a dihy-6 o, \" \8 {9 s6 [% j
drotestosterone level in our patient. In addition to
9 M# P- R/ v) O+ kvirilization, exposure to exogenous testosterone in
* [8 Q3 r* D! ~$ O) {; schildren results in an increase in growth velocity and
' ]: s* U0 k* R* M% z6 ladvanced bone age, as seen in our patient.5 f2 e2 s/ n, E  }: o+ E6 }  U
The long-term effect of androgen exposure during$ \/ D. @2 r9 z% h/ |
early childhood on pubertal development and final2 `1 I8 L0 ?: u8 I5 y
adult height are not fully known and always remain% j9 Z/ v! B2 i3 B7 |
a concern. Children treated with short-term testos-
+ z( ~6 [' N: v$ R( Dterone injection or topical androgen may exhibit some, B6 g  v, X$ K
acceleration of the skeletal maturation; however, after
9 i" R$ o+ L+ T& o; w. ccessation of treatment, the rate of bone maturation& x$ Z" A8 a5 |- I7 `7 p& x1 w
decelerates and gradually returns to normal.8,9( A& [9 K6 W5 r' V4 g
There are conflicting reports and controversy
1 W( `; T9 q0 \$ e# V5 E: H7 [over the effect of early androgen exposure on adult5 G2 d# T. {6 {
penile length.10,11 Some reports suggest subnormal
! ?3 W" ^/ T% i( ]9 Q! F& wadult penile length, apparently because of downreg-: p% o$ s3 U; D/ ?, j
ulation of androgen receptor number.10,12 However,
# a3 }5 N0 E9 L5 O/ N( f+ qSutherland et al13 did not find a correlation between- e' z9 ]$ Q6 q# I7 J1 P
childhood testosterone exposure and reduced adult* d9 k9 w% h5 d5 g& q8 h( O) l
penile length in clinical studies.) h) d! L2 q( Q) [, Q
Nonetheless, we do not believe our patient is
: U4 \  L% g* @' ygoing to experience any of the untoward effects from. W9 S! o6 ~1 f7 Z
testosterone exposure as mentioned earlier because- C* H& S7 I' z& ?2 [  {
the exposure was not for a prolonged period of time.- R" L& B: R$ s; r  z% ~
Although the bone age was advanced at the time of
% t* s# G7 s6 M5 m, f, M: Z/ z) q' S6 Mdiagnosis, the child had a normal growth velocity at
/ C# O8 c% h0 S  [9 }8 C* Athe follow-up visit. It is hoped that his final adult
; X: A1 B1 p/ Z# Eheight will not be affected.5 V) V7 V9 p& G$ @; g9 [2 ?; |9 x, K
Although rarely reported, the widespread avail-
! T$ {* H  g. l, U! z8 j1 Fability of androgen products in our society may* x7 f* i; s" z" t4 K$ k
indeed cause more virilization in male or female
* w; ~3 d0 U) h* @' s: v+ _2 jchildren than one would realize. Exposure to andro-- t& x! j: P) I4 h( [# ~
gen products must be considered and specific ques-* J4 s& G4 a! t! y
tioning about the use of a testosterone product or
$ r. \( H5 V* ]gel should be asked of the family members during
' `+ t7 @( F5 n4 ?) N3 d$ [: @6 Mthe evaluation of any children who present with vir-! o1 m& f+ m! N- l& i9 K1 A8 K. I
ilization or peripheral precocious puberty. The diag-
8 _3 G" A0 x9 b5 e, Hnosis can be established by just a few tests and by
. q3 N, ~" e. ?  c0 O) K$ _* H1 \! dappropriate history. The inability to obtain such a/ F! n. z4 v5 _( Y. Y+ L
history, or failure to ask the specific questions, may
$ n6 m! J* A! Z, Tresult in extensive, unnecessary, and expensive
5 A4 S# s% B2 v6 u. Dinvestigation. The primary care physician should be+ Y9 l7 Z1 v% y, K) t' D# g; Z( y- M
aware of this fact, because most of these children* J% @; l" G; v- G+ ^1 d
may initially present in their practice. The Physicians’
" b1 W. I1 S% FDesk Reference and package insert should also put a5 g  o0 _9 b6 z: |$ H$ }9 v, ?
warning about the virilizing effect on a male or$ I* J4 F6 N3 c" o7 m% a: R
female child who might come in contact with some-: ]8 Y' k8 ^9 k
one using any of these products.3 v2 x; L3 y1 S2 j  L( h
References
& V  L# r3 F' l6 }% B1. Styne DM. The testes: disorder of sexual differentiation
& y# }# G$ L! B! ]  F4 R- mand puberty in the male. In: Sperling MA, ed. Pediatric
$ C4 Q% w0 t4 v1 FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 }4 V' y, S' _; P) b7 M5 f
2002: 565-628.
+ R9 H: q, A$ J$ {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ Y1 D0 G, p- D  s2 o/ i! L5 P
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old& n6 J9 f7 J# |. B0 x8 ^
Boy Induced by Indirect Topical, V& b+ w" c4 \, D+ Q0 N) p0 L2 |
Exposure to Testosterone3 g7 f; F. s: F' G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 Q2 s; I) z7 ^& `$ K# U2 O' x
and Kenneth R. Rettig, MD1/ J; J1 O/ ?# t8 s" j
Clinical Pediatrics
, x3 z- G+ t& b3 |% U; tVolume 46 Number 6# q& Q6 C4 J9 i" ~$ Y; q
July 2007 540-543+ w  D5 W9 G5 B8 o1 n
© 2007 Sage Publications
& ~+ o! \  S3 V# K0 I10.1177/0009922806296651
2 R+ U# p" A" K7 t* w& a3 C3 hhttp://clp.sagepub.com
$ T: O# `) P" o' ~) ^hosted at: [5 S, E+ t9 {! |5 @0 I% p
http://online.sagepub.com6 I; B8 N7 v- O% H: \8 k$ m
Precocious puberty in boys, central or peripheral,2 m& R+ f7 Z' d& ^- \
is a significant concern for physicians. Central
6 S3 _3 v) C4 @& [8 B) M/ iprecocious puberty (CPP), which is mediated
5 _% [% C& T( s, \through the hypothalamic pituitary gonadal axis, has# X; I: n6 u6 `7 r1 `+ z  I
a higher incidence of organic central nervous system4 h! _1 @9 c; ~' W  C" A
lesions in boys.1,2 Virilization in boys, as manifested
& x/ q1 }1 W% k% B& r; Hby enlargement of the penis, development of pubic( G( x% @, J, z9 Z5 B
hair, and facial acne without enlargement of testi-
8 D, T7 h' W3 scles, suggests peripheral or pseudopuberty.1-3 We
- s5 L4 D4 v5 N+ [; _+ Areport a 16-month-old boy who presented with the
3 C4 @6 K1 c# t4 ~2 s$ x3 Senlargement of the phallus and pubic hair develop-
% z+ p% a% s. @# C4 y6 C' Ement without testicular enlargement, which was due
! o8 }2 B$ ^# i) Z9 j% Cto the unintentional exposure to androgen gel used by
7 r+ e5 `, o4 uthe father. The family initially concealed this infor-2 W& f+ K, u, H
mation, resulting in an extensive work-up for this
) D/ B+ B! m. L: e) F2 j$ P5 rchild. Given the widespread and easy availability of- z- _! s& \4 b0 L# C: G7 W
testosterone gel and cream, we believe this is proba-
# S- k* Q9 H& Fbly more common than the rare case report in the
5 w( u! d- F( M8 W9 J$ l( ]; yliterature.4
. v' `/ Q! A  P. |& \& D. aPatient Report' s: \$ r# m# a% l7 F
A 16-month-old white child was referred to the; H6 e- X8 h  X
endocrine clinic by his pediatrician with the concern
: @+ H) j* ?% i% H4 s% Oof early sexual development. His mother noticed
, x4 D8 ^3 I' {8 }light colored pubic hair development when he was
% h* x6 A5 R. U1 r; S: f4 fFrom the 1Division of Pediatric Endocrinology, 2University of
6 |( U7 _5 d1 }7 b( B  dSouth Alabama Medical Center, Mobile, Alabama./ s8 {3 a$ O% ]; G% Q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
3 e! e: K0 _0 A2 }1 u  _Professor of Pediatrics, University of South Alabama, College of
/ J0 x7 s- @* g% u1 xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* m) G8 P% N7 H% L
e-mail: [email protected].2 W7 ?, F  H3 P8 t. l
about 6 to 7 months old, which progressively became
5 B4 k* {0 j6 }; n: z: Y& Xdarker. She was also concerned about the enlarge-
3 @) N1 ?+ Z+ |2 q& t  F, ]7 H) Cment of his penis and frequent erections. The child* ~" Z2 g; d: ?
was the product of a full-term normal delivery, with
/ g2 y) j9 Z6 K, L4 C* C. J4 Q7 Oa birth weight of 7 lb 14 oz, and birth length of' w2 j$ }3 c8 g# ^) w- z
20 inches. He was breast-fed throughout the first year! R/ |9 x3 l+ f
of life and was still receiving breast milk along with
" q' o  F  L* Usolid food. He had no hospitalizations or surgery,
0 |/ Y. B8 S! \7 i/ l# x% ?5 aand his psychosocial and psychomotor development  i! C" i3 F% Z4 F8 U
was age appropriate.
) c4 W0 F8 O1 o  V, f: ^' xThe family history was remarkable for the father,
9 ?* k. D  @2 `6 ^. Kwho was diagnosed with hypothyroidism at age 16,
1 M, ^# r1 U7 ^8 lwhich was treated with thyroxine. The father’s
! ]8 J9 ?4 n. e3 T% B, G& Uheight was 6 feet, and he went through a somewhat
8 ^4 g; M# i) G- M8 e4 ^1 E6 searly puberty and had stopped growing by age 14.
% K$ O! N6 x4 NThe father denied taking any other medication. The
8 @  S% r7 U: i2 K" V, N2 S' Rchild’s mother was in good health. Her menarche
8 C' g4 ^: ?9 N+ R7 q8 _0 ^was at 11 years of age, and her height was at 5 feet
( m! V/ C$ `) q- T- z( d5 inches. There was no other family history of pre-# r3 c4 A1 u3 ^1 Z$ A  s
cocious sexual development in the first-degree rela-. r) ?8 D( w/ {- R  j7 {" e
tives. There were no siblings.: E8 k7 w2 V; d0 V; [8 ^
Physical Examination. w3 W  Y: H; v' B8 E" J& d- j
The physical examination revealed a very active,& y) C$ t% t, ^4 k8 X, b
playful, and healthy boy. The vital signs documented
, M$ g8 a7 q; T9 Z2 Fa blood pressure of 85/50 mm Hg, his length was
! E- E0 f6 s2 [. `7 Y9 X90 cm (>97th percentile), and his weight was 14.4 kg+ f8 k) F. @2 @* Z( R6 H6 z1 y
(also >97th percentile). The observed yearly growth# u! K$ f& q8 |% E; u/ a
velocity was 30 cm (12 inches). The examination of0 v9 s+ z+ l0 \
the neck revealed no thyroid enlargement.
+ a7 o- o' t1 p. N9 d: m, eThe genitourinary examination was remarkable for# ~$ G* r( o7 j4 g+ J% c  S8 L
enlargement of the penis, with a stretched length of
5 I  I% Z, b: p) V5 f+ D2 V8 cm and a width of 2 cm. The glans penis was very well
! D; G9 T) I& u* s+ sdeveloped. The pubic hair was Tanner II, mostly around! `3 e* I4 o6 S8 l0 X* x
5405 X; b5 u9 R' {2 E2 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 u3 [1 S& G; M$ n' ]: \6 Rthe base of the phallus and was dark and curled. The
4 s9 L- o1 F# L% o* k3 I" a2 ttesticular volume was prepubertal at 2 mL each.) O& x* a: ^& O1 X3 V- E
The skin was moist and smooth and somewhat
" H8 T$ j% r0 d8 e$ y, q8 Foily. No axillary hair was noted. There were no+ @' I. G$ b+ s! ~% s7 o  ^
abnormal skin pigmentations or café-au-lait spots.% p) u% P- q* d+ e2 w( O" a& R
Neurologic evaluation showed deep tendon reflex 2++ W( C: b; B" o& ?2 I
bilateral and symmetrical. There was no suggestion
, F2 z4 r/ I" a( Y1 M( vof papilledema.
9 ~1 N+ J4 a$ a6 t6 v$ H2 \Laboratory Evaluation7 a/ T' Q" f0 R) J' n+ b
The bone age was consistent with 28 months by# k& o0 x8 [* a. M, `. c/ K
using the standard of Greulich and Pyle at a chrono-( G4 d7 K" z$ h' d5 G
logic age of 16 months (advanced).5 Chromosomal
3 i$ r; W% K, ^" m; kkaryotype was 46XY. The thyroid function test& d1 k/ Q/ r) V9 |; @! g3 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. W6 l' g0 F: B: o) |' U+ k; @8 X
lating hormone level was 1.3 µIU/mL (both normal).
6 r- i3 v2 _: p/ t% x. R" E) lThe concentrations of serum electrolytes, blood
- p, F0 [% |; w: b2 durea nitrogen, creatinine, and calcium all were
+ S+ R$ I, Z4 ^& p, uwithin normal range for his age. The concentration3 V0 M  [" A' q
of serum 17-hydroxyprogesterone was 16 ng/dL
+ d* v, g7 b  D$ d(normal, 3 to 90 ng/dL), androstenedione was 202 |. J0 O5 s; ^- G9 x% j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! Z9 {  u# l" y# {- }5 g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ @* _# d  k5 U% T7 c6 ~6 p$ Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" O( a7 l; @0 u2 a7 D7 ~  \
49ng/dL), 11-desoxycortisol (specific compound S)5 y1 [1 |! |9 I- }! n6 [- l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 e" r% ~7 @: }$ ^* I# \7 u& `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; f# G- E# T0 m9 \( xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: i6 O/ `* d4 P9 h8 \and β-human chorionic gonadotropin was less than3 B  c7 A1 z# u( p, Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 j, E1 b* x) a7 m/ F- ~2 l5 rstimulating hormone and leuteinizing hormone
- g! \" K6 ^$ Z$ sconcentrations were less than 0.05 mIU/mL0 K9 G; Y- M% y: X( v
(prepubertal).. F- \# a6 k# S8 F6 C9 C7 F3 k0 r
The parents were notified about the laboratory( @* |1 q# ^* T. j3 U
results and were informed that all of the tests were9 @7 \1 I' W# B# J4 S
normal except the testosterone level was high. The/ Z% C1 G* q5 L/ B: Y
follow-up visit was arranged within a few weeks to" ^, M% p; B( ^4 a5 U( ]
obtain testicular and abdominal sonograms; how-
# M1 o3 B% n( Q2 jever, the family did not return for 4 months.+ k) t$ ~' m: ^+ \
Physical examination at this time revealed that the
: K' D% B$ d2 lchild had grown 2.5 cm in 4 months and had gained  Z! `# Q+ C: w* s$ H
2 kg of weight. Physical examination remained( h! P! b! [0 x, H  I% X
unchanged. Surprisingly, the pubic hair almost com-
5 |# e& P( {5 G, X" i. [; Zpletely disappeared except for a few vellous hairs at( G( H' ~2 s1 G
the base of the phallus. Testicular volume was still 2
2 @. u# q5 p. e7 L* B+ o5 zmL, and the size of the penis remained unchanged.
" k$ X' Y& c+ K2 }) a1 C  MThe mother also said that the boy was no longer hav-
: @9 E$ c" p8 c. K5 |ing frequent erections.. i: O2 c2 v9 `+ A& A3 J' ]. s
Both parents were again questioned about use of! t, D, v# ~- \0 I# t
any ointment/creams that they may have applied to/ S  \0 J& w5 W' G
the child’s skin. This time the father admitted the$ W: u$ s* c) e8 R* D
Topical Testosterone Exposure / Bhowmick et al 541' s  {& J7 q, R# I  r
use of testosterone gel twice daily that he was apply-
, ^6 H' O. N$ zing over his own shoulders, chest, and back area for3 L2 Z* G- k' A7 u$ R9 t
a year. The father also revealed he was embarrassed
. ~! {6 G! Y1 ~to disclose that he was using a testosterone gel pre-
, w& \, N3 @. f& F2 iscribed by his family physician for decreased libido9 @3 [! G! v2 V% T6 O; o9 o9 O
secondary to depression.
$ x; a& O! }1 o" P3 u- t. UThe child slept in the same bed with parents.
% |) I; X. ~8 d" o+ a7 HThe father would hug the baby and hold him on his& X5 A/ a  M& N
chest for a considerable period of time, causing sig-+ K% z: j1 ?! |9 {
nificant bare skin contact between baby and father.
: |! k* B* I5 R' ]0 T8 vThe father also admitted that after the phone call,& ^+ ^! R# g; [& b
when he learned the testosterone level in the baby
7 K# d" q: Q7 m6 j5 Q% s  C* lwas high, he then read the product information
2 R0 g: f& d* l* q9 W: ^7 n- Q! Vpacket and concluded that it was most likely the rea-: X$ [4 B$ H& p* ^2 I
son for the child’s virilization. At that time, they" _9 E- H1 x- V
decided to put the baby in a separate bed, and the; ]* E- r6 ^5 q( f5 D7 y
father was not hugging him with bare skin and had
5 m0 j/ u7 N4 U- L8 y5 }been using protective clothing. A repeat testosterone5 K' c' e4 ?8 O" r& ~1 O
test was ordered, but the family did not go to the  x4 R5 E4 z) z9 H
laboratory to obtain the test.
$ z1 [5 {" g' \! O/ NDiscussion% c; k2 R6 q0 x$ o; Y6 E
Precocious puberty in boys is defined as secondary. D- @/ X9 S0 Y7 _( k9 B
sexual development before 9 years of age.1,4! C0 H( |5 T9 r- g- P
Precocious puberty is termed as central (true) when
2 t) c* ], o2 z% L: s; t: tit is caused by the premature activation of hypo-! Z4 i4 r$ q; w* S
thalamic pituitary gonadal axis. CPP is more com-
( O. d0 @( f' D' p7 b( m; }mon in girls than in boys.1,3 Most boys with CPP
- Q) p) P( e0 s6 a) d& ]' Ymay have a central nervous system lesion that is
0 t. P4 }, }5 g- A" |responsible for the early activation of the hypothal-
' a% C# ~$ ^% W9 }amic pituitary gonadal axis.1-3 Thus, greater empha-6 i: S7 @8 d% B$ b$ v$ ?
sis has been given to neuroradiologic imaging in
9 m8 S! Y& K; rboys with precocious puberty. In addition to viril-
) m% }' L; [* |! r! a& rization, the clinical hallmark of CPP is the symmet-+ u; O' x# o. I0 q1 w9 w: C
rical testicular growth secondary to stimulation by; h/ o; ?; g# o: V0 U7 L
gonadotropins.1,3. ^% n0 R6 ?* Z& s' {2 a. |
Gonadotropin-independent peripheral preco-
& V# p: g; `; a7 Z8 T1 }cious puberty in boys also results from inappropriate
3 D, A7 |" u# L3 K9 yandrogenic stimulation from either endogenous or
- W* C5 F( l. F6 L# M  yexogenous sources, nonpituitary gonadotropin stim-3 _" t! n0 h% N" I; E8 V
ulation, and rare activating mutations.3 Virilizing
; }3 ~7 h7 F6 \7 Lcongenital adrenal hyperplasia producing excessive. X! v1 K5 A( l
adrenal androgens is a common cause of precocious
% b8 u" Z/ \! p! [, o- B/ hpuberty in boys.3,49 @. s; l. y; l+ o
The most common form of congenital adrenal$ a" D. y0 f5 r$ ]6 M4 G  O
hyperplasia is the 21-hydroxylase enzyme deficiency.: \  x/ a+ h# L% G( E
The 11-β hydroxylase deficiency may also result in
+ U: F* b9 C' b; r. U- d' ]excessive adrenal androgen production, and rarely,9 r6 P) k" n7 Q4 ?! g4 w6 V6 D4 l
an adrenal tumor may also cause adrenal androgen: j& _' }' T2 s' h8 M9 {
excess.1,37 P/ p' Q. w9 _; Y) u! f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 V8 V6 _+ N6 q
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 G9 _, D+ L6 j; Z: `" j$ [3 M
A unique entity of male-limited gonadotropin-
1 `7 z7 T) b4 x9 N+ ]9 @independent precocious puberty, which is also known
$ `9 u* y+ q7 b  m# vas testotoxicosis, may cause precocious puberty at a/ O3 H* a' t* _9 L9 X& s
very young age. The physical findings in these boys
) L6 L7 j/ _7 G- Y& }with this disorder are full pubertal development,
$ j' B5 T3 d0 V5 kincluding bilateral testicular growth, similar to boys
8 Y' B+ D/ O) Uwith CPP. The gonadotropin levels in this disorder1 d. l! L5 x6 d+ o* W9 O
are suppressed to prepubertal levels and do not show
6 S# ]/ I+ {+ `8 O; N, V$ S" G# ^$ dpubertal response of gonadotropin after gonadotropin-. e  N& i% F& Z) c  R- V1 X
releasing hormone stimulation. This is a sex-linked
( Q7 m7 H4 C1 p" t7 Rautosomal dominant disorder that affects only
' {4 _2 \; R' h- g! M1 Ymales; therefore, other male members of the family: M# h/ E. z  t" U( W. ~5 h
may have similar precocious puberty.36 W0 M, D, X5 G" i8 q5 S: J- q* h
In our patient, physical examination was incon-
) P$ H4 \1 _' d% L' Tsistent with true precocious puberty since his testi-
2 J" i3 N* k7 m3 _cles were prepubertal in size. However, testotoxicosis
4 M' F1 J1 P& L3 f# Hwas in the differential diagnosis because his father1 n8 Z: k- X! g3 S
started puberty somewhat early, and occasionally,% x+ l* u2 v! ]6 O+ K1 `
testicular enlargement is not that evident in the9 ~# m" J* x# B: H& v
beginning of this process.1 In the absence of a neg-$ d% J, H: l; T$ B- b" g5 w
ative initial history of androgen exposure, our
: A2 q& G6 u( ~" U! ^0 P  Bbiggest concern was virilizing adrenal hyperplasia,
! w" z) O- w7 r! h# U+ L% Meither 21-hydroxylase deficiency or 11-β hydroxylase: q: C5 i. E9 \4 v' E! @
deficiency. Those diagnoses were excluded by find-( g. Y9 m3 y) y
ing the normal level of adrenal steroids.) W& P* {6 I- |! j% ~* f* j, J1 d
The diagnosis of exogenous androgens was strongly
. {/ p9 u* W6 x2 T, Q3 Ysuspected in a follow-up visit after 4 months because
( T$ A" E$ N9 N. _5 K4 pthe physical examination revealed the complete disap-
, B& \# s1 ?' C% m: kpearance of pubic hair, normal growth velocity, and
- W3 R/ v$ J! N: D* y  s7 }' v% kdecreased erections. The father admitted using a testos-
: p6 G1 X2 n6 u" G7 Aterone gel, which he concealed at first visit. He was
9 `2 v  a3 h  J4 s7 j+ g+ z$ eusing it rather frequently, twice a day. The Physicians’" e0 S! F9 S6 {5 T! i0 |0 v% s# B9 G
Desk Reference, or package insert of this product, gel or
5 i7 e& Z, N( ?( b2 c+ Pcream, cautions about dermal testosterone transfer to
8 g& x2 H, F0 W! d2 Runprotected females through direct skin exposure.
/ y  O8 C$ R0 lSerum testosterone level was found to be 2 times the6 E/ Q# h/ w2 S. N& [2 n# |# z
baseline value in those females who were exposed to8 _8 E8 \' W8 U( b
even 15 minutes of direct skin contact with their male3 `- k7 Z( H1 t# y# g: y4 m% `5 q
partners.6 However, when a shirt covered the applica-
1 v8 D( V) s5 {1 A! I1 }4 ]! ztion site, this testosterone transfer was prevented.
4 s0 X" I" O7 a- ^2 mOur patient’s testosterone level was 60 ng/mL,% ]5 S9 n% e* P. Y2 D/ P1 i
which was clearly high. Some studies suggest that6 Y$ c( @9 I( Q0 P/ _( Q& @3 Q
dermal conversion of testosterone to dihydrotestos-
+ S/ X' E# |' j$ x  M% Tterone, which is a more potent metabolite, is more
) a( Y: ?: ~$ f- \3 ?active in young children exposed to testosterone0 p% t" w9 m! J" \
exogenously7; however, we did not measure a dihy-% s2 @1 v; i( H6 p7 a: k
drotestosterone level in our patient. In addition to
& R: x2 [. c* K9 {$ m7 o4 i8 wvirilization, exposure to exogenous testosterone in
" j6 b+ H1 f4 n+ E+ a6 achildren results in an increase in growth velocity and
9 |1 q: R' k; V4 L0 P7 Ladvanced bone age, as seen in our patient.0 E9 a$ ]! l5 J6 F9 l" z
The long-term effect of androgen exposure during
% `9 r$ T: m5 L8 qearly childhood on pubertal development and final! y6 ^# A' T  j: p# N
adult height are not fully known and always remain
7 G% I2 G/ m: Qa concern. Children treated with short-term testos-
* F. L+ {! C1 K8 L5 Eterone injection or topical androgen may exhibit some4 q& R% c  F2 c6 g2 K" l' O
acceleration of the skeletal maturation; however, after
2 B$ A/ i4 j% b' |) z, p: x/ d6 ncessation of treatment, the rate of bone maturation
& K' i; A, n! F/ ~3 l7 r; Jdecelerates and gradually returns to normal.8,9
2 F% Q' j& r" L) H8 B( [7 Z# n: kThere are conflicting reports and controversy/ D7 ^* X  ]- ?* o/ S
over the effect of early androgen exposure on adult
" d7 \  _; r$ s: l! Ypenile length.10,11 Some reports suggest subnormal3 ]5 F! w, W% u5 ~2 n
adult penile length, apparently because of downreg-
2 W: b* Y  r  H% Zulation of androgen receptor number.10,12 However,
0 V. g( P5 W+ Y- ?2 gSutherland et al13 did not find a correlation between: T: F. y) h2 o. e' O4 K6 s1 r; j
childhood testosterone exposure and reduced adult$ B5 q/ b! A8 w: I
penile length in clinical studies.
" t9 L4 f% Q' Q) q8 g1 h* E2 i" sNonetheless, we do not believe our patient is' t% V3 @* u% h1 \
going to experience any of the untoward effects from
3 y% z3 s; O+ G# O3 e( \& Q9 Ztestosterone exposure as mentioned earlier because. U0 X5 Y; L, b- t
the exposure was not for a prolonged period of time.
5 R. a& z$ b% g  R! e2 N: PAlthough the bone age was advanced at the time of: G" V3 ~, o% }" J( S
diagnosis, the child had a normal growth velocity at
$ x# Y: \) T- b3 D& b8 Sthe follow-up visit. It is hoped that his final adult
+ K0 u0 t' ~* p1 I3 cheight will not be affected.
- C6 n7 f; E5 _# r0 G4 IAlthough rarely reported, the widespread avail-
3 i8 S9 a% Q6 a/ E# R3 Mability of androgen products in our society may/ i9 H: |. `( y
indeed cause more virilization in male or female0 c0 e$ K) @7 d0 o& [
children than one would realize. Exposure to andro-0 }( }* x% a8 t- S, d
gen products must be considered and specific ques-8 x4 ~8 R% ]5 G$ k4 \
tioning about the use of a testosterone product or
( i/ H: d$ R+ h: F- X+ F3 G/ Bgel should be asked of the family members during
5 r# K2 s' o8 |the evaluation of any children who present with vir-! g' C: I0 V) `6 |
ilization or peripheral precocious puberty. The diag-: m0 e6 ]2 L, ?6 P8 s2 y! p& I' E
nosis can be established by just a few tests and by
. S/ C5 ?  I# I/ `! I6 n0 O& {appropriate history. The inability to obtain such a: i8 \* b8 G% ]1 x  `6 b, y" m8 R: ^
history, or failure to ask the specific questions, may  m& h* z; i( e# h' {
result in extensive, unnecessary, and expensive
& M/ S0 x. S/ _5 kinvestigation. The primary care physician should be
" \" n2 u! x8 q& t9 [aware of this fact, because most of these children5 J$ @3 U5 o8 f: t2 q! Q
may initially present in their practice. The Physicians’) b% f) U+ S/ A: o
Desk Reference and package insert should also put a* @# n* t7 c, U- A! f- C
warning about the virilizing effect on a male or
+ ~+ d8 ?$ O/ E! Q' Lfemale child who might come in contact with some-
9 J) P$ N8 G( [; G& n# Gone using any of these products.
: L  ?8 z9 |. s% ~2 g! W, f! MReferences
2 D* L8 v5 ?- _1 H+ x6 t: h( I1. Styne DM. The testes: disorder of sexual differentiation- V. ^/ v; ?/ C  Z
and puberty in the male. In: Sperling MA, ed. Pediatric
1 X1 x7 c" K, QEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: [: d( J$ c: Q2 |7 Y# u
2002: 565-628.4 I# z/ g8 ^' R3 }9 u  p$ f, P
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 w) B- C/ e) S
puberty 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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
; }" C/ Q' d$ ~, G( [* ?. f# B. q" 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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