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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; Y0 G/ b! s' g, M0 x! t- E
Boy Induced by Indirect Topical9 E# f0 X7 p3 ^  G
Exposure to Testosterone; _4 Q* m% Q0 t9 _# L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ B, g4 |6 u- Q4 X8 cand Kenneth R. Rettig, MD11 @, ?+ q, H& E' V* c% W" O, Z
Clinical Pediatrics. F* y+ D) I* p% t: d
Volume 46 Number 6
' f  p, f$ s3 s- {# bJuly 2007 540-5432 E) h" J6 J/ J3 K6 K
© 2007 Sage Publications) t. C+ D! x& _6 h- p6 y
10.1177/0009922806296651
, d5 ]3 G1 @' |http://clp.sagepub.com3 l4 R: O& t2 K) k& C& `
hosted at4 N" S) v- C1 y2 E7 e* W
http://online.sagepub.com
) w1 s- f5 {& R5 c9 {% n5 KPrecocious puberty in boys, central or peripheral,
; ]# h% m  M4 Gis a significant concern for physicians. Central
; w$ B1 r/ v# m7 G' [  Oprecocious puberty (CPP), which is mediated! x; s! j6 }1 v% J% b. h; d) ~' _
through the hypothalamic pituitary gonadal axis, has
5 M9 i+ R. c+ z/ Qa higher incidence of organic central nervous system
. y! F. ?  v' Xlesions in boys.1,2 Virilization in boys, as manifested
  P$ z3 _2 n! Y7 s+ Gby enlargement of the penis, development of pubic
. S/ G# q3 ?* H0 ~hair, and facial acne without enlargement of testi-: b$ J$ N& [  L& J" o
cles, suggests peripheral or pseudopuberty.1-3 We  g# ~' ]' Z' ^! v. ]
report a 16-month-old boy who presented with the- }5 F& g# ~+ K6 ~7 E
enlargement of the phallus and pubic hair develop-
! i2 a( Z. V( S' {ment without testicular enlargement, which was due+ R8 |/ ~& D( b/ o
to the unintentional exposure to androgen gel used by+ X2 q+ J; o. C5 k  u# F8 o
the father. The family initially concealed this infor-
6 P+ j0 w5 I$ C, Zmation, resulting in an extensive work-up for this
) a) }+ C) {2 `! W" L/ b& g( Ochild. Given the widespread and easy availability of# d  \* @! A5 o9 J# ]
testosterone gel and cream, we believe this is proba-
* W, q& J( w, \+ i) B0 Ably more common than the rare case report in the/ L6 T- B+ T6 s2 |; t6 e
literature.4' O& G5 \3 r! d) O
Patient Report. R, m- i" |# C; F6 {4 S$ W& I
A 16-month-old white child was referred to the/ k3 W: a2 {) O
endocrine clinic by his pediatrician with the concern, G, t2 z6 W3 Y% X
of early sexual development. His mother noticed% P# N7 Q% N: X! N3 i* a) X
light colored pubic hair development when he was
6 z6 h2 J  D0 i$ MFrom the 1Division of Pediatric Endocrinology, 2University of
9 E0 M6 _# _8 q! A, BSouth Alabama Medical Center, Mobile, Alabama.
4 |5 a& r* M' s+ K! k+ x  c9 EAddress correspondence to: Samar K. Bhowmick, MD, FACE,
9 |, q0 a  n/ u6 N- _/ \0 ]Professor of Pediatrics, University of South Alabama, College of8 `' t( T0 o! a/ ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  R6 ]) V+ ]# Re-mail: [email protected].# j. _% E4 N- i$ b+ i2 g
about 6 to 7 months old, which progressively became
/ e8 c4 U4 Y' E6 [' gdarker. She was also concerned about the enlarge-
. ^6 ~6 ^' _0 G/ {0 Y! Wment of his penis and frequent erections. The child
$ U( t9 D# X3 f$ w# C2 K9 ]+ q- n! }was the product of a full-term normal delivery, with3 J3 h7 I" [( o- t
a birth weight of 7 lb 14 oz, and birth length of+ D' @/ l! W1 ?
20 inches. He was breast-fed throughout the first year, V8 H3 Q, a+ @7 S7 Z1 i2 K
of life and was still receiving breast milk along with
% A; E1 T" x8 r* S/ Ksolid food. He had no hospitalizations or surgery,: n' W& I- `* ]- {
and his psychosocial and psychomotor development/ A% i7 K1 |+ D# ]
was age appropriate.
# U: W6 `  U9 c' z  w/ x% CThe family history was remarkable for the father,
+ }! s) w0 F- m/ Cwho was diagnosed with hypothyroidism at age 16,
  d/ R/ K& ]2 J8 }; v/ s, swhich was treated with thyroxine. The father’s8 Y3 x* w: y2 R, X! z3 V: M7 B2 ]
height was 6 feet, and he went through a somewhat
& J( d3 _$ H- m3 O; `early puberty and had stopped growing by age 14.
) z# P5 u' q, `/ N. `# O$ fThe father denied taking any other medication. The0 x0 G+ J) X. L
child’s mother was in good health. Her menarche* R" S/ J" x$ l7 X8 F
was at 11 years of age, and her height was at 5 feet4 T, V0 M% @9 s6 }- R2 j4 Q
5 inches. There was no other family history of pre-8 O. N" p; u9 T" ~
cocious sexual development in the first-degree rela-
  s9 O) @4 }( J  _1 b* htives. There were no siblings.
, `4 D% ^0 Z3 z% L; X9 i, nPhysical Examination. L/ _% K6 \* W
The physical examination revealed a very active,4 A$ J5 b# o# ]3 d* W% ^
playful, and healthy boy. The vital signs documented
/ F5 r9 G7 L4 [3 `a blood pressure of 85/50 mm Hg, his length was1 O& H" v* ]5 w5 M0 @/ R
90 cm (>97th percentile), and his weight was 14.4 kg
) U6 m% ?7 g  \3 \2 a' r, I(also >97th percentile). The observed yearly growth7 C3 \  h/ o8 \. I1 Z
velocity was 30 cm (12 inches). The examination of
* O% y0 O/ c& M9 Nthe neck revealed no thyroid enlargement.
3 X" t$ U6 q0 OThe genitourinary examination was remarkable for  Q) ~- A  M% l" Y5 ^
enlargement of the penis, with a stretched length of, g1 r$ v, \6 Z" ^
8 cm and a width of 2 cm. The glans penis was very well' G/ p' @* z% ]! ]
developed. The pubic hair was Tanner II, mostly around6 [/ v" i7 W" N8 [
540
3 p( u; F* ^' Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: `- C% g+ B  t, t  N
the base of the phallus and was dark and curled. The
7 |0 F; R# x5 f2 Otesticular volume was prepubertal at 2 mL each.7 A" }& B+ I0 K4 o- q2 C  ]
The skin was moist and smooth and somewhat
, d9 w. J8 \0 K5 y, q' Boily. No axillary hair was noted. There were no7 g. M! g  M  P/ |0 A* v0 P9 w+ C% U
abnormal skin pigmentations or café-au-lait spots.+ M6 W/ M2 I* Q* k% a
Neurologic evaluation showed deep tendon reflex 2+3 u( |7 @' i. N  x
bilateral and symmetrical. There was no suggestion
% }6 m1 K- {1 _% P. Jof papilledema.
3 V' z) A4 }- v; {Laboratory Evaluation
2 \3 V5 l- f1 P; o  X+ kThe bone age was consistent with 28 months by
: d/ w' V3 }7 h! R% jusing the standard of Greulich and Pyle at a chrono-% y+ q. U* |: |1 }! c% `. |7 u4 d2 q
logic age of 16 months (advanced).5 Chromosomal
: ^- D) x- i9 Mkaryotype was 46XY. The thyroid function test
+ t3 [+ G" _( ~6 oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-& U& [+ W+ I5 X8 z
lating hormone level was 1.3 µIU/mL (both normal).
# u$ o3 A; h8 w; cThe concentrations of serum electrolytes, blood
7 \6 @8 c2 r4 \urea nitrogen, creatinine, and calcium all were
. c: a1 p, M0 ]6 u. wwithin normal range for his age. The concentration
8 W; U; D. }) Z; J2 H) {* [' a; Lof serum 17-hydroxyprogesterone was 16 ng/dL
. R9 H* |6 t" v/ q' J$ ^, u# w+ K(normal, 3 to 90 ng/dL), androstenedione was 20
# ?5 e& R. o" u$ A2 h! t' l% lng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 [' W- W6 D1 i8 Q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ K- T% f5 `9 _3 {) b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- r7 j9 U/ _# i
49ng/dL), 11-desoxycortisol (specific compound S)
  ^' I. k, ]' Z+ C8 ~6 X# ~4 dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- |; k5 t( W7 M: P4 M% G9 }
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ C( P" T1 M2 D2 h! jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: f. i3 E  I4 s  u  O. |& K/ Uand β-human chorionic gonadotropin was less than+ q$ d, V$ c0 s2 g# Z. |
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% K. r' W1 Y- m3 q4 p5 p# `- estimulating hormone and leuteinizing hormone1 }2 i5 o. @( d1 q; Q; d$ y
concentrations were less than 0.05 mIU/mL
8 z5 U2 _5 s9 c# _; j* p( t& c(prepubertal).
7 X% m5 [3 P* ~& BThe parents were notified about the laboratory
% ^2 S1 N0 U: W6 `  Qresults and were informed that all of the tests were9 i$ @6 P3 D  R2 _0 g
normal except the testosterone level was high. The
$ Y4 n* T1 n5 l" |& n* b* yfollow-up visit was arranged within a few weeks to/ P' J  {* u9 t# v0 I4 t2 p, O: w6 A
obtain testicular and abdominal sonograms; how-- l! p2 c: u5 }7 ^2 m# S! C  v, Y, h' ~
ever, the family did not return for 4 months.4 U8 ?2 D, x( `; Q7 Q" n& w# X
Physical examination at this time revealed that the
4 r/ a+ l" F4 Q0 d# f: Y& N0 [child had grown 2.5 cm in 4 months and had gained! m  D* j; D5 q+ ?2 A1 |
2 kg of weight. Physical examination remained$ b3 V6 e9 y, {) l
unchanged. Surprisingly, the pubic hair almost com-
& F& w* n7 M: F* L, m# {( wpletely disappeared except for a few vellous hairs at. W% g3 b" D# x- n9 o, W. W
the base of the phallus. Testicular volume was still 2
; j/ x% U2 a1 ~; V/ lmL, and the size of the penis remained unchanged.8 w8 ~' i: x! P$ B0 V) h- ]8 u3 W' Q
The mother also said that the boy was no longer hav-
: s% @; A! f( xing frequent erections.
  B9 v3 X' i7 {  E- |: H- o8 `Both parents were again questioned about use of
  ?! J, B1 T  s) Hany ointment/creams that they may have applied to
8 Y+ |6 r  {$ ?% S  `8 _, othe child’s skin. This time the father admitted the2 a0 c, L  [; H5 ]1 `7 P
Topical Testosterone Exposure / Bhowmick et al 541* h, c' }8 r! T
use of testosterone gel twice daily that he was apply-% [; d6 o( I6 p4 L* a  C1 }8 x
ing over his own shoulders, chest, and back area for' G3 m6 p7 Q9 g
a year. The father also revealed he was embarrassed) m" B3 w% z: }  ^  Z
to disclose that he was using a testosterone gel pre-8 ~1 ^$ k' g6 F' O
scribed by his family physician for decreased libido2 R! b, X% Q# b4 W2 a$ ~3 K6 ~( q& h
secondary to depression.
( D3 S; S! q  M8 wThe child slept in the same bed with parents.; L* A9 v' W4 r  X
The father would hug the baby and hold him on his; n& x* {7 u# n3 F
chest for a considerable period of time, causing sig-- d* v( ]9 V/ |$ M- x
nificant bare skin contact between baby and father.
$ |2 y. ?# S- X5 T: K$ P, ^The father also admitted that after the phone call,
* Z3 A+ r- W$ l: r+ Y% [when he learned the testosterone level in the baby
4 e" m$ r" K; o5 [. ~& D  |+ Gwas high, he then read the product information
# V& V0 G; k/ h: _9 ]6 b; Mpacket and concluded that it was most likely the rea-, ?# k7 K" H! V) m4 K" i
son for the child’s virilization. At that time, they
3 a: A7 g3 a4 r+ h3 Cdecided to put the baby in a separate bed, and the5 \% e3 M# n3 t  c% j% d
father was not hugging him with bare skin and had
% f) A- v8 K5 [* n% m5 {6 Hbeen using protective clothing. A repeat testosterone
* _7 j2 P9 P- [4 Y& L% f* H8 Mtest was ordered, but the family did not go to the
" M1 e. J" I: T7 L: H8 i( claboratory to obtain the test.
# h* |' H# |" }7 o4 D; nDiscussion6 M' _7 l0 y8 z- z! L: t0 ~. r
Precocious puberty in boys is defined as secondary
8 R8 z4 D- J. j$ w% W/ csexual development before 9 years of age.1,4+ H; n' l; d' F6 X# Y# e
Precocious puberty is termed as central (true) when
3 S/ S4 F6 Y6 s! f$ {7 ~it is caused by the premature activation of hypo-
# U7 x; a  a: {thalamic pituitary gonadal axis. CPP is more com-
( Y0 B% f! n1 z( Fmon in girls than in boys.1,3 Most boys with CPP' ^5 u8 O8 R- h/ N
may have a central nervous system lesion that is
' z- t& _& }# l" [$ Presponsible for the early activation of the hypothal-2 a. u- m0 p' f" z% X7 _
amic pituitary gonadal axis.1-3 Thus, greater empha-
# f+ B4 f' n1 t( Y2 x$ {" Q3 s1 _' ~sis has been given to neuroradiologic imaging in5 g8 g( E+ j5 Q& O3 N
boys with precocious puberty. In addition to viril-
2 n5 }4 m2 W9 T* I; S( F, c5 {ization, the clinical hallmark of CPP is the symmet-
4 y5 R; {, V2 U9 srical testicular growth secondary to stimulation by
7 @% x" H: g# p% {$ i) C7 w7 ~gonadotropins.1,3
5 F, P" I& w( c* N. CGonadotropin-independent peripheral preco-
0 G4 z3 u3 u$ `: J8 ^cious puberty in boys also results from inappropriate: U  A+ F" S/ t: L0 M- W- M
androgenic stimulation from either endogenous or
" T) Z. B; b: w# D# Lexogenous sources, nonpituitary gonadotropin stim-
) b: F% Y5 D! {- {: U% S/ P- t8 zulation, and rare activating mutations.3 Virilizing8 `$ o% p0 i; o
congenital adrenal hyperplasia producing excessive
1 r. z! |" o1 Nadrenal androgens is a common cause of precocious
/ n: c: P" a1 ~! e. dpuberty in boys.3,4
: u" ]) q1 G- a1 |/ L7 eThe most common form of congenital adrenal
) n  f  l  x- C7 o9 chyperplasia is the 21-hydroxylase enzyme deficiency.7 ~! K8 ~* t. p( y: q+ H* M
The 11-β hydroxylase deficiency may also result in- [/ P, A3 h0 O3 r" g
excessive adrenal androgen production, and rarely,
) i4 y4 I0 d. v. B) m, {5 ?6 m. Y9 aan adrenal tumor may also cause adrenal androgen
4 I; l( d6 N% J* K0 I& x. ~excess.1,3: i$ f1 z+ p. y/ S( S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 o+ t( ^8 `4 R542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% L$ _" a- i5 D1 A% V3 ]A unique entity of male-limited gonadotropin-
' ]9 f$ h$ f% g* [) q, d  H; a: z' |independent precocious puberty, which is also known0 S- h' M9 u+ F2 k
as testotoxicosis, may cause precocious puberty at a
$ h, n- b& d9 x0 ?very young age. The physical findings in these boys0 ^( @6 C; f. l7 a( v
with this disorder are full pubertal development," O" U1 q; L  B% q6 q
including bilateral testicular growth, similar to boys4 w, J  y% e. B" `9 P
with CPP. The gonadotropin levels in this disorder
: A: E& s; j: Q2 f. R9 `are suppressed to prepubertal levels and do not show2 J- ]$ l' d- j0 C, u
pubertal response of gonadotropin after gonadotropin-
7 J& T' `# a. m9 Sreleasing hormone stimulation. This is a sex-linked
! z- L& ?) z$ F/ `autosomal dominant disorder that affects only4 m" q! T( a2 N
males; therefore, other male members of the family
* S3 G/ w8 p$ }8 l- i; [may have similar precocious puberty.3
" B" u2 F1 K" V. h( V, ~In our patient, physical examination was incon-: n. t' G8 y# J' j$ S" l6 J
sistent with true precocious puberty since his testi-6 ^# R+ }9 `% F# t
cles were prepubertal in size. However, testotoxicosis7 d! V6 F: _. r2 d6 r, f/ j6 j
was in the differential diagnosis because his father% O: e0 n# E* G  ]# I7 k
started puberty somewhat early, and occasionally,
, E! O" g$ ?9 c( l2 a; Ftesticular enlargement is not that evident in the
3 h& q$ ~2 w: }! G& U, C, f$ h7 gbeginning of this process.1 In the absence of a neg-
; n3 z- e$ J' |9 w1 Z$ M- ]ative initial history of androgen exposure, our
8 y# _. y' R+ ^' _, ?biggest concern was virilizing adrenal hyperplasia,
+ w8 I& W# \2 Xeither 21-hydroxylase deficiency or 11-β hydroxylase6 K6 B3 ^6 `' F" h, P% F, G! B
deficiency. Those diagnoses were excluded by find-
: c+ X0 y* ^- y2 t2 Ting the normal level of adrenal steroids.4 ~" s/ B9 u1 e/ B
The diagnosis of exogenous androgens was strongly$ F$ b# o" \8 S% K& F( k
suspected in a follow-up visit after 4 months because
4 m6 _1 X' C9 B! b0 Pthe physical examination revealed the complete disap-
" n/ s- G1 b- A' m4 W6 k( d/ q  cpearance of pubic hair, normal growth velocity, and
8 S8 h9 B( l/ C( m: f3 bdecreased erections. The father admitted using a testos-
( d( M& g6 \7 O$ {) J; @terone gel, which he concealed at first visit. He was. l  |* L& b9 k0 a: k7 W" X; ~3 K
using it rather frequently, twice a day. The Physicians’
9 `) A9 K! E+ m6 gDesk Reference, or package insert of this product, gel or) P3 A; W$ x: b" j& T
cream, cautions about dermal testosterone transfer to1 \9 m2 `3 ]" J. n/ _$ P. W# u0 |
unprotected females through direct skin exposure.  W+ y% L2 n5 ~7 Q  j$ I! R
Serum testosterone level was found to be 2 times the1 h5 h; U  U) t: N( G4 ^, }
baseline value in those females who were exposed to% l  j, B: V+ U7 Q2 \/ |
even 15 minutes of direct skin contact with their male
" S1 ]8 ?9 F/ \# B2 E9 opartners.6 However, when a shirt covered the applica-
8 @+ R' o: |* g* m( G/ A5 Mtion site, this testosterone transfer was prevented.
3 U" N3 f% s) S7 s4 Z8 I: T7 U3 A% ~Our patient’s testosterone level was 60 ng/mL,( p" F3 [# y# I5 \( W3 x% |
which was clearly high. Some studies suggest that7 c6 ~& M4 r1 g/ Y; K3 h" x" \
dermal conversion of testosterone to dihydrotestos-" B9 \- v/ ~' C5 t8 f0 M
terone, which is a more potent metabolite, is more: m' G: g. a3 Y. T+ g! y
active in young children exposed to testosterone- ~$ C) m; B* p& i1 Z" }/ D
exogenously7; however, we did not measure a dihy-
$ N  d% Y) L8 V! d, bdrotestosterone level in our patient. In addition to
! @4 i  o( x4 J1 {virilization, exposure to exogenous testosterone in
5 ^1 |2 C4 X7 d, g& gchildren results in an increase in growth velocity and0 ~3 _/ N2 O4 C; j5 D
advanced bone age, as seen in our patient.
9 X* X) ~, n! B& n8 r; [" E$ \The long-term effect of androgen exposure during) m! w9 P6 _/ v
early childhood on pubertal development and final
9 V7 _: I4 Y$ ^2 E, z# e6 Dadult height are not fully known and always remain
  j! {/ V: d; ?4 h7 @! t0 l& ha concern. Children treated with short-term testos-( v0 J" J$ I+ J: X" ]7 C1 \
terone injection or topical androgen may exhibit some  S6 }5 Z) P; Q& b
acceleration of the skeletal maturation; however, after# E! ?7 D) w4 {6 ^- g0 z
cessation of treatment, the rate of bone maturation3 w2 H  ^$ Y- l$ c
decelerates and gradually returns to normal.8,9
6 _2 m0 T2 x0 hThere are conflicting reports and controversy
1 f( h; I' p6 G& j5 W$ uover the effect of early androgen exposure on adult
9 Q7 m# G4 J) @  N# R1 Kpenile length.10,11 Some reports suggest subnormal6 i' f5 b' E# B9 f3 f$ Y' p, y
adult penile length, apparently because of downreg-5 X4 s( i+ T% a
ulation of androgen receptor number.10,12 However,5 }  y4 ^; p$ b
Sutherland et al13 did not find a correlation between! ]1 X9 r; @  e
childhood testosterone exposure and reduced adult* r, _' h1 D: G3 [4 J0 h
penile length in clinical studies.  Z$ o5 |$ i+ n) X  |$ O
Nonetheless, we do not believe our patient is
3 C- G- N, P8 ]3 E/ Tgoing to experience any of the untoward effects from4 k8 B$ V+ B" ?3 F' }( V
testosterone exposure as mentioned earlier because, F* w/ C7 \: n, _. P
the exposure was not for a prolonged period of time.7 ]/ X) E# J3 ~5 f4 k
Although the bone age was advanced at the time of
- z! }1 {' O" `7 n' t8 b/ X3 b/ J2 v! jdiagnosis, the child had a normal growth velocity at/ I' {$ e, i+ m
the follow-up visit. It is hoped that his final adult( S. t/ h, @7 m) K: n
height will not be affected.
" l9 Q& K4 W8 pAlthough rarely reported, the widespread avail-) N0 j0 m5 z3 O) f6 [1 Z5 s+ o& m6 _
ability of androgen products in our society may8 f) a0 O; j8 z; L) a
indeed cause more virilization in male or female1 I6 t" ^) U/ G
children than one would realize. Exposure to andro-
! f7 Z* k: k- T+ y4 r$ v/ e0 agen products must be considered and specific ques-) j& l- `+ [' R# J
tioning about the use of a testosterone product or
1 y/ H- F7 m* r. c- M' pgel should be asked of the family members during6 D2 W' v% N) k$ h- f- }
the evaluation of any children who present with vir-. y7 N' C6 c8 Q5 @' D
ilization or peripheral precocious puberty. The diag-
$ F$ R$ I2 h4 C" q8 U. e9 m5 rnosis can be established by just a few tests and by- d5 p( g5 W4 S1 R& n( d7 B
appropriate history. The inability to obtain such a
/ ^. u9 y4 {3 G( P/ Thistory, or failure to ask the specific questions, may6 V9 D1 A- U/ i4 \2 ^# G$ K
result in extensive, unnecessary, and expensive5 |# ^; H. _1 U& e: e1 J% p
investigation. The primary care physician should be
2 E( H  a* U1 S2 w7 A6 saware of this fact, because most of these children! z5 r: [/ N/ G& \( m# b0 z
may initially present in their practice. The Physicians’* v; j4 L/ Y( Z% }- P# B
Desk Reference and package insert should also put a
; D. B4 \: ~2 P9 d" k/ C/ p9 rwarning about the virilizing effect on a male or9 G! a7 n. o) z
female child who might come in contact with some-  i" r  z" J1 E9 d+ S" Y
one using any of these products.
' ^- n0 ^8 K  q5 Q2 g9 C+ q. cReferences
" M/ R" R8 j, K& D" O0 ]5 x; U1. Styne DM. The testes: disorder of sexual differentiation9 e4 H$ s, G; S1 x+ Z
and puberty in the male. In: Sperling MA, ed. Pediatric0 o1 ?1 `! s' e" Y  C& P8 s7 I
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: m) F( Y/ z, s2002: 565-628.
( W' _, z$ h* h; H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- b- q9 p- {2 @- x& n4 h; P# C$ bpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) B5 `2 P$ L  l- r2 V: G( q, Y
Boy Induced by Indirect Topical
4 @" V* F; x3 \5 g4 dExposure to Testosterone+ A6 z& M3 r' J1 R3 b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ N' e8 \; a7 |& land Kenneth R. Rettig, MD1
3 @$ V% L$ w9 ]) U, y- @, WClinical Pediatrics
3 ?/ e$ z( N! B# Z# O! F- g, V; sVolume 46 Number 66 B  B4 D: S" R) d& _
July 2007 540-543; ^- J, q: Y# t$ ^/ q( p8 k, t" f
© 2007 Sage Publications
1 T9 C0 t/ G+ n' l; {, o4 v10.1177/0009922806296651
, V) @9 q+ s  d- ~( ], G# s9 Chttp://clp.sagepub.com
* i+ Q+ M8 \; {" Dhosted at
; Z. Y% f& M( _0 o, m# B7 Y6 _http://online.sagepub.com
# U4 T- k8 E1 w4 r) |( VPrecocious puberty in boys, central or peripheral,# H4 _9 N% S8 @; Y' u. \
is a significant concern for physicians. Central
0 O. U- i2 g1 _% `$ j0 _precocious puberty (CPP), which is mediated
5 s  {  E* m* P0 T# c4 x, Cthrough the hypothalamic pituitary gonadal axis, has
4 l* y- ^6 H: E5 Q: Ta higher incidence of organic central nervous system& N) w# \2 Y8 U: a2 L' C
lesions in boys.1,2 Virilization in boys, as manifested
. ^. a$ O5 `3 y8 l3 K& Bby enlargement of the penis, development of pubic
/ Q1 L5 o0 P8 u& k* Q9 [7 }, Bhair, and facial acne without enlargement of testi-
0 ]7 h$ {% |6 u  ?  m1 rcles, suggests peripheral or pseudopuberty.1-3 We
. b% k( R( J* ~report a 16-month-old boy who presented with the
4 F! `8 _! D2 |7 _2 j0 Nenlargement of the phallus and pubic hair develop-- W: p8 f0 d6 z/ a; R5 k
ment without testicular enlargement, which was due- C9 |7 D7 k; N2 f! u- b  @8 `1 T
to the unintentional exposure to androgen gel used by% u; D3 }# D- B1 z6 X
the father. The family initially concealed this infor-* k/ y7 P8 m0 w' h, ~3 H# K
mation, resulting in an extensive work-up for this
3 w- l& _% i8 `child. Given the widespread and easy availability of- x3 R& s) f- J, C% O
testosterone gel and cream, we believe this is proba-
5 M# O2 Z3 m' S" d$ c# H: Dbly more common than the rare case report in the: {+ ]5 `- j$ L7 _+ u. H4 M( G
literature.4
/ z" x- z* `5 [- X. z* }; W3 cPatient Report
! {: `" g( |# m; p* B7 j% y; `A 16-month-old white child was referred to the4 T8 p$ D  q% i& _6 N) V" O
endocrine clinic by his pediatrician with the concern
' F  P1 H! f2 @$ _+ ]4 M  aof early sexual development. His mother noticed$ M% L' b! o8 v! M6 E: G
light colored pubic hair development when he was
6 D1 q% Z1 K0 D2 QFrom the 1Division of Pediatric Endocrinology, 2University of
8 }6 l: E/ j, _South Alabama Medical Center, Mobile, Alabama.: r* j- k' L' R5 L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( m2 I, b$ f0 F2 bProfessor of Pediatrics, University of South Alabama, College of
  _3 C: A+ L' p) c: m6 p+ K# dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& j, I. Z( B3 T# u. A4 me-mail: [email protected].! I7 o. j+ T# U3 a% C7 c
about 6 to 7 months old, which progressively became
! A5 m! E  r5 D7 L# G4 J( kdarker. She was also concerned about the enlarge-0 y9 e& a. Y! i1 s) z+ c' X7 S7 d
ment of his penis and frequent erections. The child
6 i- U4 |8 ?6 x+ ~, A5 E& i. kwas the product of a full-term normal delivery, with
5 ^; `" c& P* D5 h1 w1 ?% qa birth weight of 7 lb 14 oz, and birth length of
/ q2 c+ Y, c1 R20 inches. He was breast-fed throughout the first year3 E' k8 g2 Z- v& f; t
of life and was still receiving breast milk along with) a; }/ z# P! a8 J& r# F9 R
solid food. He had no hospitalizations or surgery,( d7 J0 i' [& Q; k) I- P0 x
and his psychosocial and psychomotor development
% K, l+ i% v, |was age appropriate.& H8 q+ ]9 ]8 c
The family history was remarkable for the father,
) U( w& g* J6 E$ n! N) l6 ewho was diagnosed with hypothyroidism at age 16,) j$ X6 x: G7 p8 @; [9 A1 I0 H- c: Z
which was treated with thyroxine. The father’s- H+ S% R1 J$ E( J
height was 6 feet, and he went through a somewhat
/ R( x) ]' x3 m4 pearly puberty and had stopped growing by age 14.
' [: @% F* B$ z/ @' dThe father denied taking any other medication. The
8 _* r( G) S; rchild’s mother was in good health. Her menarche
( W; Q* e$ P4 l1 n7 l* }( Owas at 11 years of age, and her height was at 5 feet6 X1 X4 x& H0 e
5 inches. There was no other family history of pre-
! J9 g, V6 ]( H+ c0 u" A/ e( Lcocious sexual development in the first-degree rela-9 G! f' |) c1 v! Y4 C
tives. There were no siblings.
0 h$ {4 D. v1 EPhysical Examination
+ n% _7 \; d2 m, h1 K3 j, f- qThe physical examination revealed a very active,3 T0 b4 M3 p4 h6 J# N9 w9 N
playful, and healthy boy. The vital signs documented
: x* H$ ^- a! q5 @a blood pressure of 85/50 mm Hg, his length was
  u: u2 \* [, z5 ?90 cm (>97th percentile), and his weight was 14.4 kg9 ]6 M& z) |2 C
(also >97th percentile). The observed yearly growth
, C! l3 Q7 M. ^velocity was 30 cm (12 inches). The examination of) F- W; n/ _! Y+ Z$ q2 C3 W
the neck revealed no thyroid enlargement.
( U3 B$ D7 @9 d# i$ uThe genitourinary examination was remarkable for9 o+ H9 ^3 _3 A
enlargement of the penis, with a stretched length of
5 h% w1 i$ |/ T6 ^" E8 cm and a width of 2 cm. The glans penis was very well
$ i! m8 A, b/ B, ndeveloped. The pubic hair was Tanner II, mostly around
' L0 Y; H+ p0 x; [/ K& B. {540
1 j7 W2 I& }8 w; d' r1 Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 f( A0 ?3 p8 e1 U- ^
the base of the phallus and was dark and curled. The
3 Q6 v/ x8 T% ^4 H4 H/ ptesticular volume was prepubertal at 2 mL each.
+ \3 n. y/ \9 B- }% \The skin was moist and smooth and somewhat& A$ Q/ G& @. c% R7 u6 e6 K
oily. No axillary hair was noted. There were no
( q$ h6 D' T. S4 Rabnormal skin pigmentations or café-au-lait spots.- C6 C/ t6 p% @  b$ B; ?
Neurologic evaluation showed deep tendon reflex 2+3 U( {5 E+ X2 I7 L
bilateral and symmetrical. There was no suggestion
, b! D! B$ S6 I: Uof papilledema.
2 s6 F* M, }0 yLaboratory Evaluation0 ?" A) V5 ?( Y: t5 R* W6 y# ?& T
The bone age was consistent with 28 months by+ l/ _  l7 C" a; u1 k1 ?; b) t
using the standard of Greulich and Pyle at a chrono-: Z. W: C# T6 l7 V2 q7 O9 y
logic age of 16 months (advanced).5 Chromosomal
  T% D) o% H- n3 m# U5 |; ~karyotype was 46XY. The thyroid function test6 D- _3 A8 V& H4 ^4 W! J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! G/ b5 }5 f) _9 u; d/ f+ Q
lating hormone level was 1.3 µIU/mL (both normal)." W+ C0 q2 V4 ?' e9 w4 E9 F
The concentrations of serum electrolytes, blood
) y0 x1 Y$ ?! [* u7 purea nitrogen, creatinine, and calcium all were8 t5 M) ~2 o/ G- O  n3 C# M
within normal range for his age. The concentration
( ^/ P4 L: y6 R6 F" qof serum 17-hydroxyprogesterone was 16 ng/dL
. f* d" H1 r' ^* i) p(normal, 3 to 90 ng/dL), androstenedione was 20% X7 [" y; a+ `; y* ~; |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 x1 y  Z# V* u5 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ s/ d2 @& l/ b6 `9 s8 o& q% kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 i9 U! q: D9 N" J0 D! a( E
49ng/dL), 11-desoxycortisol (specific compound S)+ ~" f0 P7 T; `6 e# s5 @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 c: P. ?. a7 W; L; a+ M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% y% A% Y9 Q0 \  G  x2 a6 |, }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& E- w& [  g' P, S8 Y
and β-human chorionic gonadotropin was less than
1 {8 ^2 P* S  ~0 ~1 m! ~5 mIU/mL (normal <5 mIU/mL). Serum follicular. s9 E7 r2 y% x$ h% f
stimulating hormone and leuteinizing hormone6 s$ E0 \2 w+ S! o1 f. X7 a
concentrations were less than 0.05 mIU/mL
3 ]6 I6 x( P- ^8 W2 [/ Y(prepubertal)./ G" V  Z& w8 @$ y  q! c
The parents were notified about the laboratory
' `$ W5 l- ]; P% Wresults and were informed that all of the tests were$ T$ t$ g5 b: Z
normal except the testosterone level was high. The$ e  S7 \  D' s% z6 p+ R& M( p$ }
follow-up visit was arranged within a few weeks to8 \* B8 z! k8 K
obtain testicular and abdominal sonograms; how-! }* G7 V' b* N/ u0 M7 l
ever, the family did not return for 4 months.
6 I( h+ s- j. @5 |Physical examination at this time revealed that the
# k! j3 O4 S% R, c, _child had grown 2.5 cm in 4 months and had gained
1 s& }) H% |$ \* S. Y, v' H, x1 u2 kg of weight. Physical examination remained" ?6 v  @9 C( U& F* x
unchanged. Surprisingly, the pubic hair almost com-
2 r/ j- H  P/ _& F; ?# Kpletely disappeared except for a few vellous hairs at
, ?" ]: R2 M2 J% L' v  q' t  h0 g* Pthe base of the phallus. Testicular volume was still 2' Q9 l/ G2 ^) K. z1 n) R
mL, and the size of the penis remained unchanged.
% ^* o- }, {$ VThe mother also said that the boy was no longer hav-
$ O+ C5 S9 m" h% N. }7 x3 t+ xing frequent erections.
. o# [& H6 O: R( oBoth parents were again questioned about use of5 t# z9 U2 t9 W# U8 J
any ointment/creams that they may have applied to
" H" e* E, N  {' [. U) r$ gthe child’s skin. This time the father admitted the
4 ?' Q' I8 z3 w% Q9 L+ qTopical Testosterone Exposure / Bhowmick et al 541/ X8 ~2 \  y! N& Y
use of testosterone gel twice daily that he was apply-
. `1 B6 J3 G: oing over his own shoulders, chest, and back area for0 s: s; ~3 `, ]2 ^3 N& C
a year. The father also revealed he was embarrassed4 S5 H' }: p4 ^) R1 @$ s; s- o
to disclose that he was using a testosterone gel pre-% i' r8 m  q" y" U2 }! f
scribed by his family physician for decreased libido
' U) ~- K) h2 ^1 K0 }; ]5 [secondary to depression.3 I) H7 p3 q+ F* Z, _% m  E
The child slept in the same bed with parents.
( l8 m8 R( l4 b- X# ?$ q  `! yThe father would hug the baby and hold him on his, d' E8 r9 w1 L* g, x, n6 }
chest for a considerable period of time, causing sig-
2 G* ^4 n0 m3 @5 N* |( \nificant bare skin contact between baby and father." l9 J) p% e  i+ i+ r
The father also admitted that after the phone call,
9 h* g  J' S. ~9 V( i! Nwhen he learned the testosterone level in the baby/ |  g5 p) J- x5 O
was high, he then read the product information( K. v2 y$ C' p! s6 u4 w5 k! F
packet and concluded that it was most likely the rea-, r! v" K6 L7 {1 P
son for the child’s virilization. At that time, they, v# K8 \, k( f( z$ v2 ^
decided to put the baby in a separate bed, and the
4 g, D! b9 y: {% D& nfather was not hugging him with bare skin and had. y# S5 S' n2 n% v. `/ }% _
been using protective clothing. A repeat testosterone. k: G% _" [& X' D8 b' \
test was ordered, but the family did not go to the2 A3 J; z9 `( p6 u5 T
laboratory to obtain the test.
2 ~6 k+ ?0 j' N0 g* h/ sDiscussion
, ~( y1 `0 \) JPrecocious puberty in boys is defined as secondary
4 E" f6 |# L4 Tsexual development before 9 years of age.1,4" u0 @% l: M3 X1 S. g' y/ }, t
Precocious puberty is termed as central (true) when
0 S" t3 J% O& p- y. ?% {* Qit is caused by the premature activation of hypo-
* v7 R0 B% S  u: e3 x( x' Lthalamic pituitary gonadal axis. CPP is more com-
% O& M, b  F& g6 I8 _7 ~mon in girls than in boys.1,3 Most boys with CPP
6 {0 N1 ~# p" {" {$ B( t; G: gmay have a central nervous system lesion that is( l; B: A0 F9 Q6 f7 z" W5 j$ P+ i
responsible for the early activation of the hypothal-) c  n; }4 X2 B- I% B
amic pituitary gonadal axis.1-3 Thus, greater empha-
- ^5 p0 J9 d( U8 gsis has been given to neuroradiologic imaging in5 x6 M* E" R+ K! |& \
boys with precocious puberty. In addition to viril-) d8 u% l9 Q8 D5 |6 P$ J; T
ization, the clinical hallmark of CPP is the symmet-! O7 Q2 Z# O" l& }/ v( H* @" I
rical testicular growth secondary to stimulation by; H) ~6 g6 G( H
gonadotropins.1,3  u) W$ x6 N! i( }# F+ u
Gonadotropin-independent peripheral preco-
5 J2 J. I: I3 G! Zcious puberty in boys also results from inappropriate8 ^) V' _! [% V3 w  w
androgenic stimulation from either endogenous or
9 B/ E% j& ?* k" ~exogenous sources, nonpituitary gonadotropin stim-( G" w7 S- M! C6 E) O0 ?
ulation, and rare activating mutations.3 Virilizing; i, {; X' x2 {; w2 v
congenital adrenal hyperplasia producing excessive+ m" }# s6 m3 x0 j
adrenal androgens is a common cause of precocious$ E- K; y0 S. U4 `9 \: p1 @
puberty in boys.3,4' r/ A% l* k( W* ^: B9 L" t
The most common form of congenital adrenal
3 Q8 Z, O; Z' C) Fhyperplasia is the 21-hydroxylase enzyme deficiency.: U: a: q- _: t( h
The 11-β hydroxylase deficiency may also result in
: h; ~5 C  r, M  H# @, Y- s& Sexcessive adrenal androgen production, and rarely,
& ?2 i8 `, Z) t; j! Fan adrenal tumor may also cause adrenal androgen
* z, M# V0 ]. Jexcess.1,3  X7 ?! W; k& u& ]" j/ d) b- G" N' o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 O( B: K) t' @, u# L3 W; D+ `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( p: d6 S+ \! j4 C: ?9 G1 r& ?+ ]
A unique entity of male-limited gonadotropin-
7 u: O+ W0 p& v, ^; L4 Iindependent precocious puberty, which is also known0 o; P' u9 t  p# M- c
as testotoxicosis, may cause precocious puberty at a( u6 T8 H3 ]1 d  k2 X5 n6 R( g
very young age. The physical findings in these boys; w9 Z0 K$ A9 k# ~( M' A- x/ w; Q
with this disorder are full pubertal development,
. n" p/ t* z9 X! D( s5 o5 zincluding bilateral testicular growth, similar to boys" ?/ G! `9 _- h( @4 M5 N% U" ]
with CPP. The gonadotropin levels in this disorder
, m. u& x# p/ Rare suppressed to prepubertal levels and do not show
( C, |  |% |5 M( ^: f+ F$ @pubertal response of gonadotropin after gonadotropin-
1 T& b$ n2 k$ Q2 J/ x, F( ], zreleasing hormone stimulation. This is a sex-linked: V1 q$ j3 S' j0 ]8 _
autosomal dominant disorder that affects only
. G' j2 P9 I) N4 z% Umales; therefore, other male members of the family
5 l% _) s5 d4 ?/ d7 Kmay have similar precocious puberty.3& u( S( }: P; g4 Y5 J# G% p
In our patient, physical examination was incon-" b8 j" S4 P/ `9 ^' s7 r; f
sistent with true precocious puberty since his testi-) \. \9 {1 _4 m& V
cles were prepubertal in size. However, testotoxicosis
4 v' v. x# M/ ewas in the differential diagnosis because his father4 f! H. z: o2 m2 r
started puberty somewhat early, and occasionally,
& k2 ?/ F  ?  u% u$ q3 ~testicular enlargement is not that evident in the9 D" f( k% g4 _# e0 {  l
beginning of this process.1 In the absence of a neg-$ G7 \/ d- B' _  Z9 q. O2 ]& `/ _
ative initial history of androgen exposure, our# \: R9 u' d1 U( \
biggest concern was virilizing adrenal hyperplasia,
6 @8 Y7 h3 B- W4 ]/ aeither 21-hydroxylase deficiency or 11-β hydroxylase, I9 l) \9 o+ Q4 `3 A9 T4 ]  K
deficiency. Those diagnoses were excluded by find-
) z5 k# ~- M5 B% K9 _' A+ E- `ing the normal level of adrenal steroids.
* t, n! v& v+ Q& Q  `3 i7 ^The diagnosis of exogenous androgens was strongly  d: h6 q& O; j
suspected in a follow-up visit after 4 months because! M  ]4 a1 G4 s8 r
the physical examination revealed the complete disap-
/ k% W$ U- C' b, M: ppearance of pubic hair, normal growth velocity, and: u, Z, b: Z& f: H0 ]  X' N, Q5 k
decreased erections. The father admitted using a testos-
% k  B, Q  C5 S5 a! b- w1 bterone gel, which he concealed at first visit. He was
2 V: A5 o6 A  r+ _( w# p1 Qusing it rather frequently, twice a day. The Physicians’. T1 S' L* {: S/ p) a; b9 h3 C
Desk Reference, or package insert of this product, gel or+ X6 \+ i/ P+ [; ^  L' H( z- j
cream, cautions about dermal testosterone transfer to1 H' C1 @% h: P7 |
unprotected females through direct skin exposure.
! g# ~9 x! G+ {; q# SSerum testosterone level was found to be 2 times the# C; P% i! y* N! d1 `( q% b7 L8 a
baseline value in those females who were exposed to& l: Y; f. N* D1 \2 z
even 15 minutes of direct skin contact with their male
" }, \8 X& w( F1 d9 Z% m5 zpartners.6 However, when a shirt covered the applica-, |# U( @, y- a  D* Q: M" ]% ~/ k
tion site, this testosterone transfer was prevented.; i' X& R  X* S& @- L" m
Our patient’s testosterone level was 60 ng/mL,
1 Q) G% k$ C0 [" a# s  Qwhich was clearly high. Some studies suggest that
+ c- ~. S2 D' P% \, @0 l. n( u7 qdermal conversion of testosterone to dihydrotestos-$ i( D) y1 y3 |
terone, which is a more potent metabolite, is more
$ L8 ~! ^) t: }% Kactive in young children exposed to testosterone
* Y! d4 z8 v% f& |+ m+ `exogenously7; however, we did not measure a dihy-6 h5 b& m6 t1 q' E% z# v0 V1 d
drotestosterone level in our patient. In addition to
8 C- ~4 u& O% \! c* vvirilization, exposure to exogenous testosterone in
" t& a" V5 u* G/ g5 V, G- cchildren results in an increase in growth velocity and/ m  l( p  a  s* }2 D9 E( N; V# x
advanced bone age, as seen in our patient.
) X( d7 o/ O" n5 i  hThe long-term effect of androgen exposure during
9 y5 [/ w; @3 Learly childhood on pubertal development and final# }4 f' T& b0 F# i: K4 e# {: G
adult height are not fully known and always remain' _# @6 L6 H- c' h
a concern. Children treated with short-term testos-6 B  O& J0 e  L7 ^! j0 N" a
terone injection or topical androgen may exhibit some, U) w0 Y/ M: L
acceleration of the skeletal maturation; however, after0 c7 ]: [  u( E* }; L3 Q# h
cessation of treatment, the rate of bone maturation; [  u( C; r' ?: y
decelerates and gradually returns to normal.8,9
0 e: N: D+ E3 s% }There are conflicting reports and controversy. {9 L8 C( k$ H% i( b" y0 c
over the effect of early androgen exposure on adult% d$ ~0 I0 T1 J4 B
penile length.10,11 Some reports suggest subnormal1 [4 Y& y( x8 R
adult penile length, apparently because of downreg-
* S( }0 y! x1 C5 F# o1 R  mulation of androgen receptor number.10,12 However,+ O1 y# I9 C9 o! B2 @: e
Sutherland et al13 did not find a correlation between  H2 x: R$ g0 G( \, R4 T3 h
childhood testosterone exposure and reduced adult
9 L& x% k3 o. Y$ Q9 ^" W, ~penile length in clinical studies.( U" ]' ^7 h- h
Nonetheless, we do not believe our patient is
* W) h; [5 R1 m( }- _going to experience any of the untoward effects from
8 C; Y$ K: p: |8 [0 U8 v, ^testosterone exposure as mentioned earlier because6 S: h1 N: R. W2 H" E; s
the exposure was not for a prolonged period of time.6 g( B2 q0 e# {" m, C
Although the bone age was advanced at the time of6 X4 S/ x% `% A! W' v$ c, N! R- i6 d
diagnosis, the child had a normal growth velocity at- P4 `5 m) Z/ x7 B9 r
the follow-up visit. It is hoped that his final adult
8 B& d7 y7 a- I' i7 \height will not be affected.
4 u7 e1 `2 @' a' b5 Y4 W. [5 MAlthough rarely reported, the widespread avail-
) f, Q: t1 A$ F+ b, bability of androgen products in our society may: u5 |* ^/ F: L9 P, B
indeed cause more virilization in male or female
: [; O) P$ P4 o; l# D+ ~% p4 i# A5 [children than one would realize. Exposure to andro-
* E! t4 L: I, m8 z5 dgen products must be considered and specific ques-
' R* O1 J+ n: x; y% q4 f" l; c2 {tioning about the use of a testosterone product or8 ^* ]7 R0 C2 y3 }
gel should be asked of the family members during
8 i4 o! j. I7 K3 i8 W( Kthe evaluation of any children who present with vir-7 l( x! n/ i# |
ilization or peripheral precocious puberty. The diag-/ g. W0 V( J! h
nosis can be established by just a few tests and by
; @! R, c3 f; R+ t) Happropriate history. The inability to obtain such a" e6 V& r* h0 e. e
history, or failure to ask the specific questions, may
0 `; {# C0 o% l; `: D1 }result in extensive, unnecessary, and expensive
3 M8 V0 `4 O# N7 N- a" Linvestigation. The primary care physician should be0 C1 d1 \9 h4 c
aware of this fact, because most of these children$ p( y; a# X2 B: o+ ^. `' ]
may initially present in their practice. The Physicians’1 r: U2 j. @+ W0 K# Z
Desk Reference and package insert should also put a3 H- D2 N, \6 ^: M0 b0 t& G
warning about the virilizing effect on a male or
9 w. R# j; g! ^female child who might come in contact with some-
: k/ K' x3 S0 X. f. a0 Zone using any of these products.
5 @, ^# O; F. ?References. v% ~4 f1 ~( F4 O5 }( e
1. Styne DM. The testes: disorder of sexual differentiation
) e! J( L4 q) ~$ l/ B. r/ Rand puberty in the male. In: Sperling MA, ed. Pediatric- }: c8 x' t0 k% h* C2 i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 P. L) M$ o" D- g* R, `+ K  q2002: 565-628.1 }4 ?$ [, [9 C- R* f$ n$ k- U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 k4 J0 S1 U6 d5 s3 R: \puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
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
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

5 a5 d3 y* w" k" ]( {; K9 |4 V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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