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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. ~  t9 c; S( A/ x
Boy Induced by Indirect Topical
, L* |8 }) S" r) c  mExposure to Testosterone3 N5 _$ Q* ]- v- h" R6 g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! a4 r& }8 z6 R0 g! h1 A. e3 }
and Kenneth R. Rettig, MD17 V, K1 V. C. m. M
Clinical Pediatrics! E4 B, C& N! ?0 a% I
Volume 46 Number 6$ ~; y: r% M( S* J- L) e$ U
July 2007 540-543
- |+ v! l: N( K: _, u& \© 2007 Sage Publications4 k$ z  _, y1 V; p* s  Y/ J! X
10.1177/0009922806296651, P/ J( X9 q2 r
http://clp.sagepub.com
8 f. ?0 @, X& ^1 {1 _hosted at, T9 }/ a0 Q, V2 O5 y9 P
http://online.sagepub.com+ h5 ^* O* p% T$ p# F5 o
Precocious puberty in boys, central or peripheral,
( s; s  U9 O" d% _9 v" |# kis a significant concern for physicians. Central0 w1 W/ Z" P' G# T
precocious puberty (CPP), which is mediated6 Q+ A0 x4 Z8 d7 d. C( T2 Y
through the hypothalamic pituitary gonadal axis, has
8 P. l; G* i  e% Q  `a higher incidence of organic central nervous system
7 t  ^+ n, {1 J# ?$ t- _, o, u, ulesions in boys.1,2 Virilization in boys, as manifested; c& `! w; }* ^4 w
by enlargement of the penis, development of pubic7 L1 p* G; ]/ `% r
hair, and facial acne without enlargement of testi-
; _$ k# q% X9 D. Y: c* P6 Ycles, suggests peripheral or pseudopuberty.1-3 We$ b( B+ @% L8 G( g# Q, U
report a 16-month-old boy who presented with the
& n/ J, J  M  C/ Z. g! H  Lenlargement of the phallus and pubic hair develop-
* F  A. f7 p4 m8 j- Bment without testicular enlargement, which was due0 \- z  X' E6 H9 L( ^
to the unintentional exposure to androgen gel used by2 [1 \3 j7 j/ q( _' I
the father. The family initially concealed this infor-# N$ {5 @) M- M- `& L3 c7 H
mation, resulting in an extensive work-up for this9 f+ W8 k; d. h& \6 h
child. Given the widespread and easy availability of
1 e; A& e$ z% Ntestosterone gel and cream, we believe this is proba-: Z* N4 U1 s' @5 z; L( @- P
bly more common than the rare case report in the9 [& M) V2 _/ B5 a
literature.4
1 [7 K3 c; m* S4 n0 V2 T, xPatient Report3 T6 Y; {1 x5 g3 R' ~% M
A 16-month-old white child was referred to the
. J* W  R( o: [0 R: Qendocrine clinic by his pediatrician with the concern& b; Z8 d( v$ p, N
of early sexual development. His mother noticed
- s( d; ?. R! z2 A- y' Alight colored pubic hair development when he was. f/ W* q& q, @
From the 1Division of Pediatric Endocrinology, 2University of
) D. \1 U& ~5 ]  }+ g* TSouth Alabama Medical Center, Mobile, Alabama.) j/ R8 ^; A1 L- u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% x# O: k# P; v5 wProfessor of Pediatrics, University of South Alabama, College of4 i, H& N" z0 ]  @9 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 t+ E0 ]# {) [5 x
e-mail: [email protected].' i! ?6 D0 K6 |( |; r" Q
about 6 to 7 months old, which progressively became# m( W8 I$ _5 p+ J- w
darker. She was also concerned about the enlarge-7 Z8 r# \6 S4 F: R6 U
ment of his penis and frequent erections. The child
3 s7 a9 W6 F, ?6 c: P7 O+ ^9 nwas the product of a full-term normal delivery, with
4 Y/ `( F; X4 F8 _/ s  f" Sa birth weight of 7 lb 14 oz, and birth length of: h4 S) Q- l5 Y) \, u2 s$ I
20 inches. He was breast-fed throughout the first year5 t5 ~7 v" ?& m9 U
of life and was still receiving breast milk along with
8 Q# U: }( f6 W& Bsolid food. He had no hospitalizations or surgery,
) O& {' g9 S% P8 A, A7 M7 dand his psychosocial and psychomotor development
% X/ t+ x& ^/ ewas age appropriate.8 E4 _6 M8 b  F! i4 {' g' I+ n* e6 S
The family history was remarkable for the father,5 m* q+ ^: ?  l. \. s2 f" y
who was diagnosed with hypothyroidism at age 16,
# D( b; [, P; a1 g( Hwhich was treated with thyroxine. The father’s
: R& |! E6 U5 `3 Fheight was 6 feet, and he went through a somewhat% `' w5 e: l7 y3 k9 C* a
early puberty and had stopped growing by age 14.
4 D4 J8 q, J! k1 [The father denied taking any other medication. The3 j5 G( a& C! X5 u1 o$ ?( q! G
child’s mother was in good health. Her menarche, |# {0 c8 o4 n9 O$ {/ K6 G
was at 11 years of age, and her height was at 5 feet' B) N+ l5 m8 y8 h2 h
5 inches. There was no other family history of pre-
% `8 m3 Z! ]; E) r3 n1 R0 e; `cocious sexual development in the first-degree rela-" E1 Z) A9 R3 S! M
tives. There were no siblings.
+ B% {/ E& ~- w8 t! a: lPhysical Examination- J+ x: ~  h* Q; [; q, ?
The physical examination revealed a very active,
$ A. @' x/ q6 t3 [" E2 G9 J8 wplayful, and healthy boy. The vital signs documented
5 X3 Q7 z7 L  q9 T6 _" O/ a  pa blood pressure of 85/50 mm Hg, his length was* F7 n$ C8 X" S
90 cm (>97th percentile), and his weight was 14.4 kg
& x3 w* H4 r6 @  t  ~, K(also >97th percentile). The observed yearly growth( r  ?  f1 e  v7 u. Y! C
velocity was 30 cm (12 inches). The examination of, L+ Q/ }, O% E6 r! b9 u* P* k. r
the neck revealed no thyroid enlargement.
* D+ v' ~! g: `9 e" jThe genitourinary examination was remarkable for
" C& e# R  K, f9 M: senlargement of the penis, with a stretched length of, Q: h) o  S- J* M7 Q5 B
8 cm and a width of 2 cm. The glans penis was very well
& a! h4 `+ h* `/ q7 kdeveloped. The pubic hair was Tanner II, mostly around
$ U+ d. \; e, E/ w4 [7 U5405 w- {* T3 q0 x5 t+ D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) h6 G$ D- T0 H+ T% m' |# Rthe base of the phallus and was dark and curled. The- M% Z: u& C. h7 M5 _4 c
testicular volume was prepubertal at 2 mL each.6 F% N9 P' O: K  r% H* K/ M9 P
The skin was moist and smooth and somewhat5 B/ I& l4 Z3 P  F1 ^$ Y. w
oily. No axillary hair was noted. There were no
  S4 p/ u) E2 {) c% r" Habnormal skin pigmentations or café-au-lait spots.+ P, }% V: \, @
Neurologic evaluation showed deep tendon reflex 2+3 s, L' z2 b$ ?
bilateral and symmetrical. There was no suggestion, j+ G% K% q4 A: U( b
of papilledema.
$ z- @6 w6 i1 GLaboratory Evaluation
. J9 u: K+ `# r' A1 kThe bone age was consistent with 28 months by
7 X* O9 o1 ~/ ousing the standard of Greulich and Pyle at a chrono-
* o8 B1 [0 |; L3 Alogic age of 16 months (advanced).5 Chromosomal
! W" _* x! P9 A2 j$ {7 Dkaryotype was 46XY. The thyroid function test0 V" X) F) w, m6 |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 \: x+ M( |# Q1 p3 F8 |" X
lating hormone level was 1.3 µIU/mL (both normal).9 l; r0 d$ g3 t% ^
The concentrations of serum electrolytes, blood' h! u8 k) K0 e
urea nitrogen, creatinine, and calcium all were0 g. E& M) P( K% Q2 N4 r8 u
within normal range for his age. The concentration
8 U% `1 V+ j5 ^2 o6 ~8 ^2 t. S1 V7 {5 l* Wof serum 17-hydroxyprogesterone was 16 ng/dL
* u; c6 N$ l2 m8 h(normal, 3 to 90 ng/dL), androstenedione was 20! \& r7 x7 S. l8 `, m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: A) J* F) b( t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* B. Z$ G7 s; Q! r3 t
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* @2 ^' U. c3 \# p
49ng/dL), 11-desoxycortisol (specific compound S); p7 |! b* I- ?; U8 v
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: G! x2 {+ j) g' m" v/ s8 }4 e' h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' ]$ r& X9 G5 _, b8 z
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, ^8 `9 j8 Z: X% \  Rand β-human chorionic gonadotropin was less than
; x  h* k0 y- K% N* ?7 J! l5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 T( a% F! `& a5 f4 O9 Qstimulating hormone and leuteinizing hormone# n1 z+ F3 o* K' K. q9 B# q. h
concentrations were less than 0.05 mIU/mL
+ C4 u; ~( d7 n& T7 {(prepubertal).' I' z* x) Z: n
The parents were notified about the laboratory
: g. k8 h, o" z, m: C* @' N. Sresults and were informed that all of the tests were+ B2 ~+ a% S, w
normal except the testosterone level was high. The
) o" z6 I& z8 X$ _6 F0 _& c# `follow-up visit was arranged within a few weeks to
' P" G+ S/ d+ w2 n7 j) k8 Gobtain testicular and abdominal sonograms; how-
2 [8 O. Y! S9 [! a; }4 h. }ever, the family did not return for 4 months.
- h' O3 \, S9 I6 P! p- S- qPhysical examination at this time revealed that the
8 q! z( d9 H7 E8 T8 c7 \child had grown 2.5 cm in 4 months and had gained1 r7 T! Z9 K: C& U6 f
2 kg of weight. Physical examination remained- |- |) x6 d# z& H
unchanged. Surprisingly, the pubic hair almost com-
* d8 p, \) Z' Z. ]2 Apletely disappeared except for a few vellous hairs at
, N, Y4 Q. O5 Y% o, Fthe base of the phallus. Testicular volume was still 2  I6 T8 z3 I& x$ }
mL, and the size of the penis remained unchanged.2 g5 Z- N/ G7 j$ y- C- {$ x
The mother also said that the boy was no longer hav-
6 M7 |3 ?( i+ C) r$ Z1 King frequent erections.9 O; Y$ T, h, h& O5 r
Both parents were again questioned about use of3 s, Y* |* r. ~7 v) r; s* j
any ointment/creams that they may have applied to  }1 i) Q4 b& [" t8 I9 W9 L; l
the child’s skin. This time the father admitted the
2 E$ ?/ U7 p/ N" S+ C  NTopical Testosterone Exposure / Bhowmick et al 541
4 W/ ?. c% I' `* J/ Muse of testosterone gel twice daily that he was apply-
- C% y! \( \( h& x0 n6 d, Fing over his own shoulders, chest, and back area for
! c  k2 m9 u& C7 R3 Y: U( u3 M' i. Ma year. The father also revealed he was embarrassed) v6 x2 s3 S  U
to disclose that he was using a testosterone gel pre-
% J) f0 O+ c  _) p: n* t4 L4 y3 Xscribed by his family physician for decreased libido
( S( m0 r  Q3 \% W2 Qsecondary to depression.: x) R( w+ T: x/ T7 q* M; B- L
The child slept in the same bed with parents.
, {" l: T9 A, W( B/ k3 V3 MThe father would hug the baby and hold him on his
; _2 Q- V" {' [+ ~chest for a considerable period of time, causing sig-- I; b, j+ J: X# h' d3 Y0 u
nificant bare skin contact between baby and father.( j* N( o9 }% U+ U. x7 |
The father also admitted that after the phone call,
( X& }. Y: _2 l0 Y* |" Owhen he learned the testosterone level in the baby4 p: T2 _8 s; y! ~! W* o
was high, he then read the product information, h7 N4 U4 ~0 [- E% t8 C( z3 W
packet and concluded that it was most likely the rea-
; z7 A7 X5 H2 a" `. M( q6 Ason for the child’s virilization. At that time, they6 I8 [6 z& y: M3 }) B" Y
decided to put the baby in a separate bed, and the
! G" C: z2 b" ofather was not hugging him with bare skin and had
3 ]0 I' l3 s1 o, abeen using protective clothing. A repeat testosterone7 ^; ]8 h( [" l; T8 d5 k
test was ordered, but the family did not go to the  ^" T2 Z- ~8 ]
laboratory to obtain the test.6 P& C! x4 ?  X; i4 @
Discussion
% g; |$ C( M; M: |  s4 bPrecocious puberty in boys is defined as secondary
; N2 U  X: Z' Q8 a* Fsexual development before 9 years of age.1,4
3 S/ k4 z9 s  w% ?1 p  pPrecocious puberty is termed as central (true) when
6 \! ~* G3 Q5 tit is caused by the premature activation of hypo-' ^# |# V- s/ p! f1 V
thalamic pituitary gonadal axis. CPP is more com-! ?% {8 P+ M6 F( K
mon in girls than in boys.1,3 Most boys with CPP: Q. `) h% S3 q& }, y' @
may have a central nervous system lesion that is- E8 M, m, o( K; F$ y* Y! G$ \
responsible for the early activation of the hypothal-
7 t  {* C/ m7 G7 Qamic pituitary gonadal axis.1-3 Thus, greater empha-
8 |% t, l$ y9 b4 c/ Csis has been given to neuroradiologic imaging in% _/ x; A: g; w7 e7 Y& y0 e* ^
boys with precocious puberty. In addition to viril-, s* b& U0 n* g" m( N
ization, the clinical hallmark of CPP is the symmet-. R& l* z, ~6 }9 I( n
rical testicular growth secondary to stimulation by- _% L) s4 u1 l
gonadotropins.1,3$ x5 n" n( H8 y9 B; Y
Gonadotropin-independent peripheral preco-# A* O2 i( @4 O! E: I
cious puberty in boys also results from inappropriate; Z/ l& u9 Q" V3 g
androgenic stimulation from either endogenous or9 S* b# i" _. I
exogenous sources, nonpituitary gonadotropin stim-
4 R; ^) x9 w& Y/ X' [/ B$ L7 o& julation, and rare activating mutations.3 Virilizing. |7 `) ?# \- C0 f
congenital adrenal hyperplasia producing excessive
6 @- P& {8 F" F1 `adrenal androgens is a common cause of precocious1 e# k; o" {$ r; }+ f& f3 r/ @
puberty in boys.3,4
+ `. C: }) N3 ?; p4 m5 k5 `# PThe most common form of congenital adrenal
1 `  H9 E% N, V  u. P; vhyperplasia is the 21-hydroxylase enzyme deficiency.
4 {: D9 Z* b* ?! e5 Z6 \6 OThe 11-β hydroxylase deficiency may also result in6 h( T5 R2 t/ a( j- T
excessive adrenal androgen production, and rarely,# e& q/ e; ]. p! ~% C
an adrenal tumor may also cause adrenal androgen
. G% R9 L* k, ?5 K( |+ @excess.1,33 d$ ]7 [# N% I  g& \+ |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. r5 M8 k: F2 R' n% |3 l$ f0 u. C4 N542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; U) m. z4 _3 f7 Q6 |9 c$ yA unique entity of male-limited gonadotropin-
$ X; f, Y$ U. iindependent precocious puberty, which is also known# s$ ~/ G2 P! M
as testotoxicosis, may cause precocious puberty at a
+ I3 Q( M4 X2 a. {; g  F; ~very young age. The physical findings in these boys
( i& B$ }; C4 e) B, Iwith this disorder are full pubertal development,* q0 _+ j7 |. _7 a
including bilateral testicular growth, similar to boys& O! a) Z, j& o
with CPP. The gonadotropin levels in this disorder
) i3 `- H) j6 S, A# Pare suppressed to prepubertal levels and do not show
3 o& K# |, M& ?' Spubertal response of gonadotropin after gonadotropin-
4 a3 ^1 R/ {% k6 ]% y; e0 g5 ]$ d% w5 m& Areleasing hormone stimulation. This is a sex-linked
* ?% T+ b9 f; R' N  lautosomal dominant disorder that affects only
. i" g: ~, {+ P. B4 `6 {males; therefore, other male members of the family
7 ]& u; n- O" n6 q# imay have similar precocious puberty.3
/ I- x* w5 p# SIn our patient, physical examination was incon-8 o; {/ k+ f0 P) {9 ^' b
sistent with true precocious puberty since his testi-( g% }9 f! ~. z2 X- R7 L) ^
cles were prepubertal in size. However, testotoxicosis
& e) c  m+ T0 }9 gwas in the differential diagnosis because his father$ E/ m0 e  e' r9 U
started puberty somewhat early, and occasionally,. U; l" [6 Z9 B& M
testicular enlargement is not that evident in the* ~. c/ N# ?" L, [
beginning of this process.1 In the absence of a neg-
, ^) T7 _2 c& L! u" e( [ative initial history of androgen exposure, our
& H* [+ a9 q! ]; F6 B2 A0 Ubiggest concern was virilizing adrenal hyperplasia,
9 N8 S- i) L6 F- O3 F, [either 21-hydroxylase deficiency or 11-β hydroxylase
0 e! s; r4 T* W% m  b- Adeficiency. Those diagnoses were excluded by find-' }% c% X- U+ [; O: ]5 c: T
ing the normal level of adrenal steroids.
0 T' e, e1 Z! u* _The diagnosis of exogenous androgens was strongly% D$ J; h( X( K% K6 {
suspected in a follow-up visit after 4 months because/ V) x, t3 t3 Z. W
the physical examination revealed the complete disap-! t# R' w6 t$ V$ e/ D- E
pearance of pubic hair, normal growth velocity, and2 e) {8 w; q! h% |& r3 G( R
decreased erections. The father admitted using a testos-: G' T- U! @" n
terone gel, which he concealed at first visit. He was; G% H) G8 I, Q1 S* v
using it rather frequently, twice a day. The Physicians’6 j+ H7 p% `' W5 ^" U: g7 J
Desk Reference, or package insert of this product, gel or  X; W: f! k9 j' c4 I) y
cream, cautions about dermal testosterone transfer to6 K$ m5 ]) E/ X5 }; N
unprotected females through direct skin exposure.
" i% L5 p1 [+ R0 uSerum testosterone level was found to be 2 times the' Z, o" h5 Y# B% Q
baseline value in those females who were exposed to
4 m2 \+ \8 K* }1 H: i" x3 R( r" y) T9 teven 15 minutes of direct skin contact with their male" L8 v4 d/ |* f/ P8 C8 M
partners.6 However, when a shirt covered the applica-% ?) |6 T7 }: \
tion site, this testosterone transfer was prevented." a/ S; E5 b2 ]2 |* O; }$ h
Our patient’s testosterone level was 60 ng/mL,
0 A% K6 x; \* `8 {which was clearly high. Some studies suggest that- q+ _- M! x6 n# n
dermal conversion of testosterone to dihydrotestos-: p% j) n1 y! \
terone, which is a more potent metabolite, is more$ m% g) Q* r4 i$ r- I9 M8 y  Y  O
active in young children exposed to testosterone
# _1 q9 [$ h2 ]0 t& dexogenously7; however, we did not measure a dihy-1 d* c- F  E: R) e
drotestosterone level in our patient. In addition to
, z' e. w# h3 q) P: y  n/ Avirilization, exposure to exogenous testosterone in' F4 y5 J, G! z/ D; H
children results in an increase in growth velocity and2 Y! Q$ ~# E/ |
advanced bone age, as seen in our patient." K! D% a" `) Z( M4 ?
The long-term effect of androgen exposure during
& V/ R  ^# u) E5 n7 F+ N7 t2 S! d, _early childhood on pubertal development and final: q! Q! g+ l9 G/ _. s2 }
adult height are not fully known and always remain, Y  ^, \6 Q; O- P2 t3 \. v
a concern. Children treated with short-term testos-
2 L' [0 s4 g' c2 gterone injection or topical androgen may exhibit some
: ~8 E$ }( B" _& g- Eacceleration of the skeletal maturation; however, after$ B2 e6 v, z' R, r' @4 S" R/ g
cessation of treatment, the rate of bone maturation
) E) B+ I( k+ ~3 G  A% s7 C4 V2 Ldecelerates and gradually returns to normal.8,96 m& {' {# N7 \+ H7 t" W* H
There are conflicting reports and controversy
4 C; l+ f8 ^5 Q5 c  |, [- wover the effect of early androgen exposure on adult2 h6 `& G. _+ \4 w  r: {
penile length.10,11 Some reports suggest subnormal
% ?9 N. N/ L3 C  W5 Madult penile length, apparently because of downreg-
/ t# U- B6 D( q5 g+ ?6 Bulation of androgen receptor number.10,12 However,9 o& c  U' S4 S9 U: p
Sutherland et al13 did not find a correlation between
, t. r' w" J$ M2 {- O: dchildhood testosterone exposure and reduced adult* h+ I+ _2 d) d' W7 I, \
penile length in clinical studies.
3 ?7 K! R5 r2 bNonetheless, we do not believe our patient is
! N5 [+ M# P/ I  Ogoing to experience any of the untoward effects from/ {: R! Y* }6 \, J8 L8 _+ u
testosterone exposure as mentioned earlier because
0 M  H$ D! r& Athe exposure was not for a prolonged period of time.
3 l5 [1 b% r6 Y/ V( Q- f3 \Although the bone age was advanced at the time of
0 |3 M. w+ h6 M" W$ Y) fdiagnosis, the child had a normal growth velocity at
6 }* x8 m& b7 A7 z( f# qthe follow-up visit. It is hoped that his final adult# o% i8 I- j5 f3 V/ Y' O2 Q
height will not be affected.
+ L  P/ G# N7 m6 @% x! C  E% ]Although rarely reported, the widespread avail-/ H0 H6 `  d2 f. N# w2 J: w
ability of androgen products in our society may1 c9 ?4 V/ p% z+ d' ?
indeed cause more virilization in male or female
: V6 G7 J. }! S5 U4 U$ j3 q# O! tchildren than one would realize. Exposure to andro-
7 s3 o/ Z' P! w9 b& @" e6 Fgen products must be considered and specific ques-3 \# R3 y# [) ~) _# C* C
tioning about the use of a testosterone product or
! O$ v  t  Z* J9 G1 I; igel should be asked of the family members during1 y2 L6 S6 G% h; `5 N6 o; r4 f' M
the evaluation of any children who present with vir-" I3 D. T; P4 K/ t$ e
ilization or peripheral precocious puberty. The diag-) D! l6 ]( M) @2 a9 A" k8 e
nosis can be established by just a few tests and by5 C9 W, a. X& b- Z  f
appropriate history. The inability to obtain such a
: y% |! N% s! i, k$ J- h4 i& }& hhistory, or failure to ask the specific questions, may5 a* V8 l: x) I6 x8 I5 H
result in extensive, unnecessary, and expensive; Y7 ^( z$ @# _
investigation. The primary care physician should be
* a% K* ~& g! o+ {! B* _2 iaware of this fact, because most of these children; z" e; B, ]2 `0 C* h3 d
may initially present in their practice. The Physicians’/ w7 u; p+ p+ Q# r( z5 v' ]  z* N. |
Desk Reference and package insert should also put a
( j( l3 F8 l2 ], S' {warning about the virilizing effect on a male or
- ~* D+ [* \  Rfemale child who might come in contact with some-
/ D* A- z9 F, J9 ~+ `) d# Jone using any of these products.
6 J# k7 ]) j3 D4 ]References0 ~; E! Z% o9 y9 ^6 ~' N
1. Styne DM. The testes: disorder of sexual differentiation" ]( H- f8 d( T1 E- k& }
and puberty in the male. In: Sperling MA, ed. Pediatric
2 O( E/ k: m( ~4 O$ o% C/ n  d5 g  DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* ^4 p0 E8 Y: q8 x1 b2002: 565-628.
4 W8 w7 l3 t; p! q9 }" b3 V. N  U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) h/ q& J' t5 |0 x$ j+ p5 N
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old+ d& i6 p# ], X+ h( a
Boy Induced by Indirect Topical, I% L! `% {) F% Q$ F/ T* ~* f
Exposure to Testosterone1 o3 l% K9 S6 r8 B: g# ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& s. y) E2 X* ]% }& `
and Kenneth R. Rettig, MD1' o6 I# @0 u* K4 o
Clinical Pediatrics6 y8 K" _' {& R$ S
Volume 46 Number 6& h  @& B* m1 a, g* c- X
July 2007 540-543( C6 j5 i. l  R- j0 h
© 2007 Sage Publications& h: g1 ?& r6 d  [- R+ x. `
10.1177/0009922806296651) m7 @/ E; V* C8 A' r! ]
http://clp.sagepub.com* ~; E! ]: x5 r$ N9 ?5 X+ L1 d* m
hosted at
, e: n! |5 W/ J+ n0 K4 k6 G" Ghttp://online.sagepub.com6 k1 e: o8 [" }- n, i/ g
Precocious puberty in boys, central or peripheral,
1 h: |' e3 S& l$ P/ i# Bis a significant concern for physicians. Central
9 g0 V/ B3 j9 m' Dprecocious puberty (CPP), which is mediated- p( V9 _: m# ~) Y5 Y% v
through the hypothalamic pituitary gonadal axis, has
! S$ x, F$ f$ f1 k6 U. ra higher incidence of organic central nervous system3 G& H5 h( |8 h2 A
lesions in boys.1,2 Virilization in boys, as manifested
0 O; M3 ~9 F. p) }& rby enlargement of the penis, development of pubic6 H+ v; r5 v; U* `( ?7 I6 F
hair, and facial acne without enlargement of testi-; V/ M! E$ r9 g8 t0 E
cles, suggests peripheral or pseudopuberty.1-3 We
8 r* X9 m: y6 B. _/ x2 }* N: x; treport a 16-month-old boy who presented with the
. |; D5 m' b: {enlargement of the phallus and pubic hair develop-3 N% Z0 l6 l4 c3 _/ P
ment without testicular enlargement, which was due& t' W/ \9 b+ K
to the unintentional exposure to androgen gel used by
. a& o' [9 p& J; p% o  X  m! o% dthe father. The family initially concealed this infor-8 _; L7 n  V9 {; H, l7 e
mation, resulting in an extensive work-up for this; L8 P6 g  |7 V) L* I* ?$ x
child. Given the widespread and easy availability of- l/ ^% `, t& h. a3 {* _% D7 k2 U; @
testosterone gel and cream, we believe this is proba-3 [+ u4 J% j- K7 s1 @
bly more common than the rare case report in the5 ]! ^4 z1 J* S, D; j
literature.4
( y) O- R% [4 G5 I! jPatient Report  W4 |5 Q% \5 u2 o( P$ O
A 16-month-old white child was referred to the" ^8 [0 l2 V7 I
endocrine clinic by his pediatrician with the concern) {$ P* [0 L. ?" X. R- M
of early sexual development. His mother noticed2 s" j& e+ s" `, h
light colored pubic hair development when he was! C7 x# [) e, u+ \# C- T
From the 1Division of Pediatric Endocrinology, 2University of
: j# X0 W- Q: k' a; \! @( CSouth Alabama Medical Center, Mobile, Alabama.$ l; j; ]( w0 L. e6 E5 b
Address correspondence to: Samar K. Bhowmick, MD, FACE,( p/ q% u" N  e6 B& |5 m8 V
Professor of Pediatrics, University of South Alabama, College of
5 G* {/ x4 F+ z4 s$ [% ^1 d! _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 r9 |) B/ W# |) W
e-mail: [email protected].
' w+ A/ R0 @1 |about 6 to 7 months old, which progressively became
7 h# m; k9 V1 W  x3 ~1 n6 {darker. She was also concerned about the enlarge-" Y+ R$ ]. V1 b) ~$ U/ v
ment of his penis and frequent erections. The child2 ]7 R) g: T5 |, D* d
was the product of a full-term normal delivery, with5 I0 ]( I* V- T) s' r" F2 M" l! Q
a birth weight of 7 lb 14 oz, and birth length of" K$ M; Z' M$ R. @- |* L
20 inches. He was breast-fed throughout the first year
2 w" P  h9 e/ K5 W: B4 P6 Rof life and was still receiving breast milk along with9 |) w" Y/ }3 l+ D" r$ p9 G
solid food. He had no hospitalizations or surgery,
+ f: {7 c( A3 `; [& H* Qand his psychosocial and psychomotor development$ }  m- ^4 ^1 v" L
was age appropriate.1 x, P: Q, K0 B
The family history was remarkable for the father,
0 v: g% d6 p; {; z3 y, wwho was diagnosed with hypothyroidism at age 16,
% ?; ^; X7 ^0 h* d6 awhich was treated with thyroxine. The father’s/ @3 Q0 X" P& T' H; j0 l
height was 6 feet, and he went through a somewhat
! T: b2 B6 ]# ]early puberty and had stopped growing by age 14.2 C* n6 W4 r. h1 k
The father denied taking any other medication. The4 ~1 A4 r+ p+ @- `0 o( m! g" n. \6 M
child’s mother was in good health. Her menarche
+ U; n% q9 K/ q1 Gwas at 11 years of age, and her height was at 5 feet. u7 |5 x9 c2 s4 s
5 inches. There was no other family history of pre-
3 Z2 f5 j. Y6 B, E% ]( K5 M& Wcocious sexual development in the first-degree rela-" E9 `' m9 R% M9 E$ ^, h% l" y
tives. There were no siblings.
* ^& y# \1 s( q" vPhysical Examination
$ d+ p3 O# K" L' W7 Y7 \) UThe physical examination revealed a very active,) i: t$ O% o: \0 N  w
playful, and healthy boy. The vital signs documented
9 Q! a+ M$ b( e' c/ Ua blood pressure of 85/50 mm Hg, his length was7 Y& w  S2 C: B, L5 m  @! H
90 cm (>97th percentile), and his weight was 14.4 kg
% U# B" N6 }" C7 N+ V. S5 J(also >97th percentile). The observed yearly growth
% Z) H2 E# q: d3 x4 }% B' r8 O. `velocity was 30 cm (12 inches). The examination of
1 g! h# y0 W+ s! y" b8 C3 ?# Zthe neck revealed no thyroid enlargement.* J0 N+ G. ~7 x/ |  Y! k
The genitourinary examination was remarkable for
. m) P) t' V7 K! r0 O9 H; `% xenlargement of the penis, with a stretched length of
7 {+ a( U& J  o  {. P( ^8 cm and a width of 2 cm. The glans penis was very well
7 r. m& W: P6 Sdeveloped. The pubic hair was Tanner II, mostly around
* i: H0 q! w+ Q540) L" }0 P5 S5 N* U' m& k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' m& Z3 T' w# ?. u) i% t
the base of the phallus and was dark and curled. The3 w5 l* i! C4 ^, p2 D7 e3 n
testicular volume was prepubertal at 2 mL each.
* C) N& U$ K& [4 X; n& Q5 Z! \The skin was moist and smooth and somewhat# v2 O* ]. P9 C8 e
oily. No axillary hair was noted. There were no
/ ^9 N% `# Z: D- C, g' sabnormal skin pigmentations or café-au-lait spots.- V8 z" W% ?2 U5 \9 J( a% J& J
Neurologic evaluation showed deep tendon reflex 2+7 P8 e5 p: g9 k3 W$ }
bilateral and symmetrical. There was no suggestion5 q: [$ \+ R" n  M! z
of papilledema.% c) n! U+ B+ ?3 M# P: N% R
Laboratory Evaluation* o9 p7 y. {# [/ e! w
The bone age was consistent with 28 months by
# r8 B) ]: I& c% p8 r0 j& Susing the standard of Greulich and Pyle at a chrono-
1 y. M4 t4 Z# f, `logic age of 16 months (advanced).5 Chromosomal# Y9 g" X, U' b
karyotype was 46XY. The thyroid function test
0 I, H4 o$ A# Xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 o) |5 Q2 ~; l2 a( A/ ^) P! Hlating hormone level was 1.3 µIU/mL (both normal).* G0 g* y3 I7 k/ N- j
The concentrations of serum electrolytes, blood# g" X0 d  B4 s; V& E
urea nitrogen, creatinine, and calcium all were- A# z* n% O) V, q
within normal range for his age. The concentration4 s$ g; O# l0 F8 H: ^- e1 w
of serum 17-hydroxyprogesterone was 16 ng/dL
; G/ o5 O1 R3 k' l% G% C1 G(normal, 3 to 90 ng/dL), androstenedione was 203 B4 z$ g6 L8 e/ ?: y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ e7 i- k  c9 {% E' ], ^6 }0 Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! o6 V5 n+ e' b6 c9 `# M# R/ A( c% P2 Q( Rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 F4 n) a0 n6 [  G* @49ng/dL), 11-desoxycortisol (specific compound S): w( U! y. h9 d7 b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 b3 r5 q6 ?- i0 D% x+ Q+ @! I+ rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% r4 l" d$ U2 R& x( s4 n
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 a+ z- D& x$ \7 q
and β-human chorionic gonadotropin was less than2 w6 \# ~: o4 v# g2 P' h  p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) M, G5 N+ P+ Z! J: O- u; rstimulating hormone and leuteinizing hormone
$ E% k3 S5 B7 o4 O' `1 ]3 q# ^concentrations were less than 0.05 mIU/mL% d, ]( C- Z; g1 \$ ^
(prepubertal).
/ v- h% I& F; }9 V4 pThe parents were notified about the laboratory4 ^  c( }4 h* w& I8 S9 j! J% Q
results and were informed that all of the tests were
+ m+ y! Q9 c! ~4 l3 ~  N% M: Fnormal except the testosterone level was high. The
" M1 m" P5 w* H6 G7 Ffollow-up visit was arranged within a few weeks to% t) R9 ]0 ]/ g8 i
obtain testicular and abdominal sonograms; how-# G* s2 x  x4 B- q7 T+ H7 O: y- v
ever, the family did not return for 4 months.
) L, B. F( y! @% B0 IPhysical examination at this time revealed that the5 L4 a. I$ v! W7 s: c0 c$ Y- ~
child had grown 2.5 cm in 4 months and had gained
! Z0 i) ?6 g) Y  Y6 _2 kg of weight. Physical examination remained2 ?5 C% O+ C, e+ K6 t$ b( F
unchanged. Surprisingly, the pubic hair almost com-
- a) L' o; M, {2 J9 _- R9 wpletely disappeared except for a few vellous hairs at
( R0 g2 E7 i* G# C  U. W+ J- J* ?; A" jthe base of the phallus. Testicular volume was still 2
. b" t- l8 m5 vmL, and the size of the penis remained unchanged.% u' F, p  v. O/ m& o. C' p3 _
The mother also said that the boy was no longer hav-% J' r$ T8 g1 V$ ~
ing frequent erections.# O- N* J5 G7 y' R3 q6 p4 Z
Both parents were again questioned about use of
+ m" F% f8 y- A- J8 M) Jany ointment/creams that they may have applied to8 @$ X+ U5 J3 d/ q
the child’s skin. This time the father admitted the9 d' x, z7 F6 F; g( g, T2 Y& N
Topical Testosterone Exposure / Bhowmick et al 5418 k" W/ y" b: Z+ c5 d+ V+ H2 N( n+ ]
use of testosterone gel twice daily that he was apply-
' h8 D$ v! g& E# Sing over his own shoulders, chest, and back area for
5 L) D# _6 s$ A: ]; Ta year. The father also revealed he was embarrassed
  k2 Y7 ?% t7 o/ Rto disclose that he was using a testosterone gel pre-5 R' `( m+ W+ ^7 D" X9 j
scribed by his family physician for decreased libido
; _( Z6 c  v' ?: zsecondary to depression.
9 z/ F2 k' M$ X# ?8 I/ I1 \" A8 LThe child slept in the same bed with parents.
. R6 n/ j+ T% [! J1 oThe father would hug the baby and hold him on his% u1 _; ~+ N0 M* T# P% g, C
chest for a considerable period of time, causing sig-0 A, g: V& q( w# u  B1 Y
nificant bare skin contact between baby and father.
  u0 y& Y( z  ]. d* F1 PThe father also admitted that after the phone call,
) _  l" ~" Y: I" f6 twhen he learned the testosterone level in the baby+ Z. G1 V- {# k5 `% W5 N
was high, he then read the product information1 M2 Z! \  c$ ]% \) Y
packet and concluded that it was most likely the rea-
( o5 ]1 H! r3 |' V& B, Uson for the child’s virilization. At that time, they5 t% S9 l5 Z, O8 q; F
decided to put the baby in a separate bed, and the
6 m7 s: P! w' {9 ^* x1 l0 X% Lfather was not hugging him with bare skin and had: u; [  m' P, n% e
been using protective clothing. A repeat testosterone
  }4 }0 Q3 O  k' q$ |test was ordered, but the family did not go to the3 O4 ]2 F5 N+ t4 Z& }- v$ ~* ?
laboratory to obtain the test.
  d/ N6 i, N& u" L, ]! jDiscussion
9 \5 j( K' p( E- ^Precocious puberty in boys is defined as secondary$ c  f! S) e  }* O" @
sexual development before 9 years of age.1,4, A, q! B# J2 z4 A* q
Precocious puberty is termed as central (true) when# e! s. |* ^2 c( L4 F) w) ?! u
it is caused by the premature activation of hypo-5 E. T! B1 A2 j& u' i2 Q
thalamic pituitary gonadal axis. CPP is more com-
# N4 S! k; \5 Z" M! d! W% F3 @mon in girls than in boys.1,3 Most boys with CPP9 E- g& \* |( ?& t0 W% Q" j
may have a central nervous system lesion that is
' g; |) G2 w7 T  Q6 I& m, Iresponsible for the early activation of the hypothal-
  s  v" B8 k; w3 ^; L; U$ Y* o4 ~5 uamic pituitary gonadal axis.1-3 Thus, greater empha-
. _9 l0 V4 J# L4 B1 k! Esis has been given to neuroradiologic imaging in; e4 h% Z8 D) ~3 N
boys with precocious puberty. In addition to viril-1 }+ A7 o/ b& X- E
ization, the clinical hallmark of CPP is the symmet-% a4 x; `0 o  g3 ~1 y
rical testicular growth secondary to stimulation by7 Y6 e+ e  F$ Z& F, i
gonadotropins.1,3
9 l3 a8 \) j+ z+ \' ~+ rGonadotropin-independent peripheral preco-
, o$ d9 @$ L4 v6 K4 t1 zcious puberty in boys also results from inappropriate
7 M# M$ j+ p/ r4 ~/ Sandrogenic stimulation from either endogenous or
: s  q# u: _( f7 Texogenous sources, nonpituitary gonadotropin stim-- ?( B/ V4 H% J" @) c! Z
ulation, and rare activating mutations.3 Virilizing; }& T0 c: s8 u+ B5 {3 X
congenital adrenal hyperplasia producing excessive
. K- r, y  |4 Q" q3 ^adrenal androgens is a common cause of precocious
2 ?0 @7 Z3 k( q) n* Spuberty in boys.3,42 p3 c$ T( _/ F# V: }1 T
The most common form of congenital adrenal( B. R! c7 Z2 x0 W+ G
hyperplasia is the 21-hydroxylase enzyme deficiency.
! u3 ~* U5 ^; L4 aThe 11-β hydroxylase deficiency may also result in9 h+ }. H: K+ D+ V3 u6 n$ y: U2 |
excessive adrenal androgen production, and rarely,2 _" t& E. D! s& O7 L
an adrenal tumor may also cause adrenal androgen
. G0 I0 I, O* k; Bexcess.1,3
* e0 S* i/ e; O7 m  Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 J0 W6 G9 b, p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" q  i9 S, Q" A+ ]9 c/ n1 E
A unique entity of male-limited gonadotropin-
" ~3 q+ `( L' c8 findependent precocious puberty, which is also known
8 E  `/ O2 ]) Y# n5 s  Fas testotoxicosis, may cause precocious puberty at a1 v' p# e) t$ f) j, V: C4 {5 G6 m! U
very young age. The physical findings in these boys
9 A" B" A: ?3 n  r1 S/ h9 iwith this disorder are full pubertal development,
2 f& N6 K- k6 P7 w& Vincluding bilateral testicular growth, similar to boys
* M5 Y0 J* i$ ~: u! K7 o* dwith CPP. The gonadotropin levels in this disorder
' r' B% z: l! L5 lare suppressed to prepubertal levels and do not show( o) C) `, e9 l0 i! S8 R" r
pubertal response of gonadotropin after gonadotropin-
1 c3 @: _! T& q, Q- ^' w1 Vreleasing hormone stimulation. This is a sex-linked: t4 P, n+ a) i2 A. u; M6 O  s$ T
autosomal dominant disorder that affects only
7 v, d: _  a0 T* C* u8 h9 Mmales; therefore, other male members of the family
5 d, f7 |7 x$ P6 d3 r" L1 ]may have similar precocious puberty.3! r6 Z& ^' ~% }$ H
In our patient, physical examination was incon-
3 K3 D6 m" P. m, \, |sistent with true precocious puberty since his testi-* t0 s* S1 s' K
cles were prepubertal in size. However, testotoxicosis4 Y# c- T6 s0 K: C( Y9 E0 w
was in the differential diagnosis because his father
8 A% k: O% _: E& pstarted puberty somewhat early, and occasionally,
; v: l4 e3 I, m0 ttesticular enlargement is not that evident in the0 U  m: _0 ~: V; J" T! r
beginning of this process.1 In the absence of a neg-
' Y/ u7 {) w: ^) b8 o% [% Bative initial history of androgen exposure, our
, c& ]% S# D& T2 [4 a. y6 ebiggest concern was virilizing adrenal hyperplasia,2 T" [7 M: [( ?( H; t/ {1 s& D+ D& F
either 21-hydroxylase deficiency or 11-β hydroxylase+ \7 D: D% B; n+ e# B$ Z4 |
deficiency. Those diagnoses were excluded by find-7 Q) f* c% x- A
ing the normal level of adrenal steroids.
- G: u. t! j9 u0 z& _The diagnosis of exogenous androgens was strongly- ~' ]* Y5 ]3 E9 D9 Q: z- H
suspected in a follow-up visit after 4 months because; W8 b$ r1 |+ N/ t% I
the physical examination revealed the complete disap-4 t4 N* C& e/ x
pearance of pubic hair, normal growth velocity, and" P6 }' U3 {7 O: l, [2 o) q
decreased erections. The father admitted using a testos-
! X5 d1 C2 p0 f# f: \  b0 O9 y" Y9 pterone gel, which he concealed at first visit. He was
9 x7 o  g" P) t) Fusing it rather frequently, twice a day. The Physicians’
, e# O: W8 p/ t- \$ bDesk Reference, or package insert of this product, gel or2 K2 s( A( l0 n
cream, cautions about dermal testosterone transfer to0 Z! o- L3 s  d7 L: q0 c- E5 L1 W
unprotected females through direct skin exposure.
; }! ?/ x2 N7 i) t/ T9 }+ J* w0 bSerum testosterone level was found to be 2 times the: E+ I/ m# X2 q: l: @, t  a, U
baseline value in those females who were exposed to7 W* J' A. @/ y& K1 ?/ ]. S. d' D
even 15 minutes of direct skin contact with their male) x( [3 s# `) t9 F
partners.6 However, when a shirt covered the applica-
, x8 i" W  {! H% t& jtion site, this testosterone transfer was prevented.
4 N/ I+ y# ^. `# J! O) fOur patient’s testosterone level was 60 ng/mL,7 {/ o( [, C; V. Q- s, u
which was clearly high. Some studies suggest that( K, Q( V7 e  r8 R! S
dermal conversion of testosterone to dihydrotestos-
  W8 G" l3 E0 l; P% ^terone, which is a more potent metabolite, is more
0 T4 j" }3 y, q* \& |- hactive in young children exposed to testosterone( W- g& ?: {3 w/ s+ J! i) D
exogenously7; however, we did not measure a dihy-
3 o8 k8 W1 ^) u! Bdrotestosterone level in our patient. In addition to- \9 f+ y# F4 k, K' _' N: ~
virilization, exposure to exogenous testosterone in
3 @. A" I5 |* P3 ~children results in an increase in growth velocity and* j! i$ z  ?" n2 K0 h0 o0 t
advanced bone age, as seen in our patient.( {0 J) ^7 a. M2 L
The long-term effect of androgen exposure during
3 a  P+ E; F3 Q/ U) e* Q* {- pearly childhood on pubertal development and final# e1 x" a+ a: y' L
adult height are not fully known and always remain
9 }. w$ x' _, `- B# n& E! Za concern. Children treated with short-term testos-
# w( B% C( V' x. C3 c0 e3 sterone injection or topical androgen may exhibit some
7 @1 @! E; H3 K/ Z1 y1 X0 Wacceleration of the skeletal maturation; however, after
0 Z# P( E, ~# t' ecessation of treatment, the rate of bone maturation
; \% X+ [; D! q5 I5 pdecelerates and gradually returns to normal.8,9
) v% [$ Y6 I! t1 Q: n' b- c* eThere are conflicting reports and controversy! v4 f- c$ `+ c  {# h, T8 B6 a
over the effect of early androgen exposure on adult
/ U1 ~. ~2 h, w1 wpenile length.10,11 Some reports suggest subnormal4 b+ L6 z3 c7 d3 U, U- P
adult penile length, apparently because of downreg-! [" u% E7 M, @1 L5 q$ v2 A
ulation of androgen receptor number.10,12 However,3 H2 o. B3 r; K
Sutherland et al13 did not find a correlation between) ^) {  X4 {# r6 k& h& z: a; _
childhood testosterone exposure and reduced adult
- j9 V3 u) A: n+ mpenile length in clinical studies.
/ Q2 h5 Y' j0 O2 z, PNonetheless, we do not believe our patient is
# x4 p7 \+ }) d9 e% Bgoing to experience any of the untoward effects from( h2 r( }9 U; @1 D, r
testosterone exposure as mentioned earlier because, X' s: ]! J3 [5 c
the exposure was not for a prolonged period of time.) H/ u- _3 i1 X1 _' G2 ?. v# P1 B
Although the bone age was advanced at the time of- _# E, e* w0 |8 h  y& t
diagnosis, the child had a normal growth velocity at& p1 K) W7 e4 r, c- l
the follow-up visit. It is hoped that his final adult
  l- C& k& R+ I6 @: v3 ^height will not be affected.  p: a( \0 J" ]& f6 j+ g
Although rarely reported, the widespread avail-% \- L+ l* c8 P, o5 [# u* K9 `0 ~
ability of androgen products in our society may
3 i" h, Z5 K) F; {* U1 vindeed cause more virilization in male or female
/ k2 _. i: W. |. x. ^, _& @children than one would realize. Exposure to andro-
' _/ x" l* O$ ^% s6 @8 bgen products must be considered and specific ques-: d0 ]9 s; U1 r
tioning about the use of a testosterone product or8 s9 U2 R0 H3 v" r
gel should be asked of the family members during' J0 X# G( |# p& o8 d# _
the evaluation of any children who present with vir-
% L: C5 |. D" T' @ilization or peripheral precocious puberty. The diag-* k' ^/ U0 `0 a. L# q, W1 Q
nosis can be established by just a few tests and by
5 `' \" {( D6 Q8 w9 o5 Cappropriate history. The inability to obtain such a3 `# O' @0 M3 L7 x- Z
history, or failure to ask the specific questions, may) {1 L, s- T" l
result in extensive, unnecessary, and expensive
1 K* n8 G1 q; t2 Y- ninvestigation. The primary care physician should be
. I8 J% P' p1 g# q: z- taware of this fact, because most of these children
/ D; I8 {; c% n4 r% V! z" Hmay initially present in their practice. The Physicians’
: d/ H- k" Y8 [$ W/ DDesk Reference and package insert should also put a
" o4 G/ X2 a- U& g. pwarning about the virilizing effect on a male or
. n5 {; n/ X3 V0 ~5 Ifemale child who might come in contact with some-2 d% |* ~8 h6 h
one using any of these products.
( }3 Q* z, v. ?' P. cReferences
/ I  w' O# G4 R7 x' u# g! F6 H. t0 H1. Styne DM. The testes: disorder of sexual differentiation
2 M/ i: s) d& T' a# A: K3 F' w3 Dand puberty in the male. In: Sperling MA, ed. Pediatric
3 B: ?9 \0 ~  H! aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 e; X! y5 J" X2 E& o( z( Z' ~* g
2002: 565-628.; s$ f4 L# q5 U, {8 g
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% M/ [) m' [% N6 }9 Z
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

) r6 Y5 m/ I! M' Y4 b& I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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