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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
' t# d: I, U! g) Q8 v3 ^/ cBoy Induced by Indirect Topical
! k. t5 V/ ^9 L% oExposure to Testosterone1 `% s$ {5 @5 W0 K1 s+ o0 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ F6 t' c6 ~/ `0 Q1 L4 x1 Kand Kenneth R. Rettig, MD1
$ o7 W0 G. X% r7 @Clinical Pediatrics
: Q( R0 P8 ?! c  u& ~# x6 cVolume 46 Number 6+ J* N- a- q: Y3 r4 n
July 2007 540-5437 D6 F- O! r  z- H6 r. l# l& R
© 2007 Sage Publications+ {" r0 j8 P4 L* n+ X
10.1177/0009922806296651
3 }; _4 y& E; Z) f, }http://clp.sagepub.com' B# l5 U$ i; |2 X( ?/ T$ C
hosted at
- F3 x, Q1 N; H8 Mhttp://online.sagepub.com; T5 o. G6 d$ u6 }" D' ~- _/ P2 F: h
Precocious puberty in boys, central or peripheral,2 l, B7 I/ E/ A" p3 G1 s. L2 b; B
is a significant concern for physicians. Central
) q2 }$ ~* s, D! m. C  A# Bprecocious puberty (CPP), which is mediated
- S; t3 t9 t  P2 Y" Jthrough the hypothalamic pituitary gonadal axis, has% p' q/ {% _; D7 V7 ]
a higher incidence of organic central nervous system) V3 O% E5 l0 |
lesions in boys.1,2 Virilization in boys, as manifested8 L, V; C, ^* |% e* }+ M+ [8 B
by enlargement of the penis, development of pubic
' t+ n$ ]; J2 Hhair, and facial acne without enlargement of testi-
9 K! e+ [9 @9 \1 _( o1 Lcles, suggests peripheral or pseudopuberty.1-3 We" o3 s9 U1 K4 P# x! ?
report a 16-month-old boy who presented with the
% O' `0 j  ]3 `; y& x* g. u  f( N% Penlargement of the phallus and pubic hair develop-' N% t* Y+ o. @- Z& q
ment without testicular enlargement, which was due
, W" v* {7 C; v& l7 s$ t) \to the unintentional exposure to androgen gel used by
' K. p0 V( p1 `9 V+ {the father. The family initially concealed this infor-
+ H4 \, a: Y4 |) O  P% @mation, resulting in an extensive work-up for this
! P" Y- U( t1 @/ Z6 }7 e8 \1 d7 bchild. Given the widespread and easy availability of  f. N+ g" M1 H7 {  I7 c. D
testosterone gel and cream, we believe this is proba-" b( r3 i# D. l) n" y
bly more common than the rare case report in the
4 Y5 {5 v' n( d& C/ n& _& \/ |literature.4
$ S' B3 I) S, i5 u/ TPatient Report8 v8 V; e0 Y2 y8 n5 }% y
A 16-month-old white child was referred to the
2 a9 A+ {. c& x1 ^" I' wendocrine clinic by his pediatrician with the concern
2 {' q4 ~% K8 x# t% h) Hof early sexual development. His mother noticed
# m: h7 u- y) ]# U0 {' L5 xlight colored pubic hair development when he was
, V0 I% G6 s' h, h# P0 @; qFrom the 1Division of Pediatric Endocrinology, 2University of
+ Y' d7 E$ C! A. x) d4 w5 l2 nSouth Alabama Medical Center, Mobile, Alabama.
3 @' g+ j+ P# v2 BAddress correspondence to: Samar K. Bhowmick, MD, FACE,* o9 _2 P/ n' C2 F! @& l: `: X
Professor of Pediatrics, University of South Alabama, College of5 i9 `4 c, {4 Y8 U5 O; i0 V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# V0 |% |3 y. w/ u) Ne-mail: [email protected].& A6 [) g; B: e* B* O
about 6 to 7 months old, which progressively became
/ x0 G; B4 C4 \) i) p" Adarker. She was also concerned about the enlarge-$ c1 s; a4 s5 V0 `
ment of his penis and frequent erections. The child1 c  C3 z0 q8 d* I- N1 D# H, G
was the product of a full-term normal delivery, with! [4 Z0 v4 z( a; d/ B
a birth weight of 7 lb 14 oz, and birth length of  Q( y0 K, D' f" Q
20 inches. He was breast-fed throughout the first year
$ C( ~4 D+ u/ M9 O% u5 I5 aof life and was still receiving breast milk along with
$ j; M3 H  q9 ?' U& v8 P4 z7 Vsolid food. He had no hospitalizations or surgery,
" B8 R* P4 V. @9 C1 @. Sand his psychosocial and psychomotor development5 d7 w: z) \+ m+ t9 r: L) u! l  V
was age appropriate.
5 s7 c. m: {6 u7 CThe family history was remarkable for the father,
' W1 e3 S' p& z0 B' G/ pwho was diagnosed with hypothyroidism at age 16,
" j. Z5 k  L" s  ~3 _1 ~which was treated with thyroxine. The father’s
5 i7 X( U# O. R. P% O9 Fheight was 6 feet, and he went through a somewhat+ d  [! ^3 l- Q; D% M
early puberty and had stopped growing by age 14.! l' B) Y! V) T7 z. C" k
The father denied taking any other medication. The
- [# c* a0 C6 d1 Dchild’s mother was in good health. Her menarche! Z, F* [2 v5 o$ k$ _% F! V
was at 11 years of age, and her height was at 5 feet
. Z$ K7 V' c' \: G, H: d3 V! n5 inches. There was no other family history of pre-
) q/ _2 j+ N1 h" Dcocious sexual development in the first-degree rela-' e8 p0 U# U: d' F- H
tives. There were no siblings.
1 a- ^5 I  i! K& |) BPhysical Examination3 a8 r) P1 L; T
The physical examination revealed a very active,5 q4 v. Y# ^7 ~
playful, and healthy boy. The vital signs documented6 S7 f( L) Q8 c& H; P' }
a blood pressure of 85/50 mm Hg, his length was) P3 l5 \! R6 \7 ^; v( O
90 cm (>97th percentile), and his weight was 14.4 kg, s9 ], U, l3 l# ]1 X
(also >97th percentile). The observed yearly growth" ]6 C3 F" v5 o
velocity was 30 cm (12 inches). The examination of
) y8 I5 z2 n4 s% L& \the neck revealed no thyroid enlargement.: A4 Z7 D* H  A6 t- ?( r
The genitourinary examination was remarkable for2 L/ V" u% g& M- \' f  ^
enlargement of the penis, with a stretched length of
' Z: R$ l4 ~! c2 d, O8 cm and a width of 2 cm. The glans penis was very well0 T/ x7 f5 w6 y" P8 b3 ^
developed. The pubic hair was Tanner II, mostly around
2 G5 }. y0 W/ A. P  \540
7 h5 H9 q7 m0 I, a7 t+ a* p1 }9 o) Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% n  C/ a0 V8 ~the base of the phallus and was dark and curled. The, W  H" |' y: g9 \5 a
testicular volume was prepubertal at 2 mL each.' V, A# f7 D7 c+ ~* e4 K* d  s
The skin was moist and smooth and somewhat
+ K9 U8 m5 D$ w" ~$ Q7 A! O1 |oily. No axillary hair was noted. There were no
! B8 D4 a$ C* b- ^abnormal skin pigmentations or café-au-lait spots.: q# q8 y& ?1 @9 u3 p. I
Neurologic evaluation showed deep tendon reflex 2+
2 q1 `% ?" l# z# ~bilateral and symmetrical. There was no suggestion
9 E; o' ?( q# J) Q0 Lof papilledema., f! ^* z- E$ M$ t
Laboratory Evaluation
0 \$ ?0 ~+ q( ]+ o- c% S* a6 tThe bone age was consistent with 28 months by. w' g( p5 A4 r' h; z, ?( @, B
using the standard of Greulich and Pyle at a chrono-
8 C0 ^' f- l! @) Zlogic age of 16 months (advanced).5 Chromosomal1 ]! y- [4 h! ?  e7 @5 W: x! `# G
karyotype was 46XY. The thyroid function test- V3 Y+ M  E! e$ h( x4 R, @$ q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% w% G1 ]0 i- [- D& H
lating hormone level was 1.3 µIU/mL (both normal).! Q0 q4 o  Y# d6 f# E( X! p
The concentrations of serum electrolytes, blood
' p( d. p9 L7 u4 q/ kurea nitrogen, creatinine, and calcium all were
9 I. Z  o2 e; D" dwithin normal range for his age. The concentration2 G. R$ K8 q9 V1 C' [
of serum 17-hydroxyprogesterone was 16 ng/dL/ }/ f- B0 P: I, n* u& r
(normal, 3 to 90 ng/dL), androstenedione was 20- b9 w6 ~! L  L4 f; f1 g) s6 @3 i( l$ Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" Z) J+ x+ w9 O0 ?+ Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),1 T' G: _8 o: `* B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. C" Z" o- {: P& t  L3 ]3 |! {
49ng/dL), 11-desoxycortisol (specific compound S)
+ k9 p2 f- q3 wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- y5 R2 `; a: g; F. h' @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 ?( {; v" S6 G! y' }/ |- h, x! `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 _; ?! h2 |2 |. J5 O
and β-human chorionic gonadotropin was less than
  v; x( A+ ^6 R5 mIU/mL (normal <5 mIU/mL). Serum follicular
- ~8 v; g# b8 `( t& T2 B  z+ Hstimulating hormone and leuteinizing hormone
5 q! h# t4 q% I! S- A1 U& Xconcentrations were less than 0.05 mIU/mL
* T2 D6 m# K  D  g' c4 M3 R(prepubertal)." j8 T# C1 J$ J, G
The parents were notified about the laboratory
) _, d5 o0 E; k% {- Presults and were informed that all of the tests were
4 U' c  g' a8 L3 nnormal except the testosterone level was high. The
% p, K2 \+ z9 [7 y) g" i' d- zfollow-up visit was arranged within a few weeks to
" s  m3 R/ |9 N# z0 Fobtain testicular and abdominal sonograms; how-8 ?% @$ t/ W. F" L8 m6 C( K
ever, the family did not return for 4 months., Y% H. E7 {* K  Y
Physical examination at this time revealed that the
' w) ^: @! h( R* w0 achild had grown 2.5 cm in 4 months and had gained) ^, B: G( ^0 o4 p# m3 X* D
2 kg of weight. Physical examination remained
, {& }% M& B& J& \6 g4 y- uunchanged. Surprisingly, the pubic hair almost com-, A% U. |3 z  @
pletely disappeared except for a few vellous hairs at, w# r# o/ z8 b# g2 P+ C
the base of the phallus. Testicular volume was still 2
5 S# ?' u! U; P5 \8 VmL, and the size of the penis remained unchanged.
, ~- N( M4 I' t. U  j0 u4 f# PThe mother also said that the boy was no longer hav-
5 Q9 \, Y: @4 |2 Eing frequent erections.
4 O1 p# z/ {9 ]6 dBoth parents were again questioned about use of
) A, \# ~, z: L6 r# t  y* iany ointment/creams that they may have applied to
" S0 ]2 S7 b- ~: o) y* a4 M$ rthe child’s skin. This time the father admitted the
3 ]; L8 A# e1 c& O. OTopical Testosterone Exposure / Bhowmick et al 541- ^: [% p! u$ u, E
use of testosterone gel twice daily that he was apply-* z( N3 d2 C: `
ing over his own shoulders, chest, and back area for1 `: C; ^7 m- ^5 m# E
a year. The father also revealed he was embarrassed, Y! Z& V. u1 k# l' M
to disclose that he was using a testosterone gel pre-( B9 H; l+ |9 K5 T' t
scribed by his family physician for decreased libido
& q. r5 t7 L' _' W! p* fsecondary to depression.
; O7 O% }0 \2 t$ RThe child slept in the same bed with parents.
# a8 e% S) d5 j* m& [The father would hug the baby and hold him on his
, y! ^2 y0 h, F; p* _chest for a considerable period of time, causing sig-) M5 ?" Z0 a  u, P5 ~1 q% m
nificant bare skin contact between baby and father.: M* m& X5 _- D
The father also admitted that after the phone call,% d; n1 w2 T5 J: _1 M  {* J! N
when he learned the testosterone level in the baby  x8 C* {4 _! X7 M+ t# k5 M# f
was high, he then read the product information
' [, ~- K3 t( l$ d* epacket and concluded that it was most likely the rea-6 }, C1 @5 |" x7 q
son for the child’s virilization. At that time, they$ d: i! y6 m; ~
decided to put the baby in a separate bed, and the
& C3 X1 l8 n* j7 a2 v- mfather was not hugging him with bare skin and had5 z0 \3 y/ [9 E1 D5 s" k
been using protective clothing. A repeat testosterone
/ k7 i) K  \; n8 s9 _+ z; r% C% otest was ordered, but the family did not go to the
5 S0 [2 Z: \* f  G. A1 @9 @laboratory to obtain the test.) r2 b( ?5 r& t. b6 X
Discussion
8 v7 a7 q& Z+ j+ ~Precocious puberty in boys is defined as secondary
" N8 j: |5 w/ Q. F- \+ Qsexual development before 9 years of age.1,4
( Z! j& \6 }+ L+ ^Precocious puberty is termed as central (true) when
6 i- ]1 X# R  Nit is caused by the premature activation of hypo-6 @% P1 F* x% ?( B9 h: q
thalamic pituitary gonadal axis. CPP is more com-
- @6 L  a4 X2 ymon in girls than in boys.1,3 Most boys with CPP
2 }- B- s3 {# A7 emay have a central nervous system lesion that is* @- f$ L! V2 s: X
responsible for the early activation of the hypothal-
1 R7 a2 y6 Z# b3 wamic pituitary gonadal axis.1-3 Thus, greater empha-. h0 k! E" u- m
sis has been given to neuroradiologic imaging in$ Y/ N% B$ u) Q$ U7 m/ a! C+ j
boys with precocious puberty. In addition to viril-9 ~7 {- y1 Y, P0 I/ G; W
ization, the clinical hallmark of CPP is the symmet-! ~! x7 q! `# D" R
rical testicular growth secondary to stimulation by: }; c- S$ F# a0 J5 ?( v! _. B" ~
gonadotropins.1,3# b0 u; L4 f  _/ l$ v+ N" l
Gonadotropin-independent peripheral preco-; j. E! u, f$ I7 I& x8 \  K' q3 r
cious puberty in boys also results from inappropriate
! {- s/ k" g2 C$ tandrogenic stimulation from either endogenous or
: y3 n! n& I3 fexogenous sources, nonpituitary gonadotropin stim-$ S3 }' P8 h3 K1 T+ z
ulation, and rare activating mutations.3 Virilizing) x. [- c  @& j& c+ t; x
congenital adrenal hyperplasia producing excessive6 K# U( u6 }, e4 X" j  }5 ]# P
adrenal androgens is a common cause of precocious2 M5 V( c+ Q# b' p1 d/ ]8 Y
puberty in boys.3,4
) I* D% ~$ G8 W$ n8 }0 }5 ?8 HThe most common form of congenital adrenal$ \! n* m* `/ A3 d8 \
hyperplasia is the 21-hydroxylase enzyme deficiency.7 {0 p& q' E) i8 [3 r0 T5 r: P3 A) h
The 11-β hydroxylase deficiency may also result in1 h% X) b5 Y) u8 [
excessive adrenal androgen production, and rarely,
4 u2 M1 {* `' ian adrenal tumor may also cause adrenal androgen9 u% @$ d: s  e0 s0 ?; D# M3 |
excess.1,3+ S/ Q% s) `* A& @& c2 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  h5 I+ m% R  v  r! j) P0 J542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 X! D9 n) }* A6 Y3 A7 ^+ E
A unique entity of male-limited gonadotropin-8 ^' W5 T: T, J  C+ r& G# z- C6 P% x
independent precocious puberty, which is also known
( A' n+ T6 G& V% Zas testotoxicosis, may cause precocious puberty at a
' o" s4 M) T. Svery young age. The physical findings in these boys
8 V3 i+ q$ j( v+ R/ I& I+ ^' P" Xwith this disorder are full pubertal development,
% a1 M( R" W; s# t  A! P6 P/ T5 Pincluding bilateral testicular growth, similar to boys7 J; g1 j2 ~. T  l& D
with CPP. The gonadotropin levels in this disorder! O- e3 L5 C2 {/ o2 [/ Q
are suppressed to prepubertal levels and do not show0 C! E, a" T/ w
pubertal response of gonadotropin after gonadotropin-
/ L% x# p5 j/ j3 t8 Vreleasing hormone stimulation. This is a sex-linked
& e# }! v" [1 t# sautosomal dominant disorder that affects only
" e; U1 [& B/ c4 m, {males; therefore, other male members of the family
5 ^, F# P0 i7 O9 p; Q* Rmay have similar precocious puberty.3  p+ _9 h- Y- h- X0 [( u
In our patient, physical examination was incon-
' S# P0 g/ P) ?: Z/ I1 i7 k4 I/ Jsistent with true precocious puberty since his testi-0 J& l! }4 ?2 B! ~6 ^) j2 u
cles were prepubertal in size. However, testotoxicosis; v2 N# C/ J+ Y/ O3 J
was in the differential diagnosis because his father* L' J2 ~9 p+ N6 V  @. w
started puberty somewhat early, and occasionally,, z4 F& S' D" X; V3 p# I2 \0 Z' R
testicular enlargement is not that evident in the
! D7 \- s* I* W8 m% O( ubeginning of this process.1 In the absence of a neg-
& l! |, v1 O3 [" y9 M: Gative initial history of androgen exposure, our& s3 G' Y8 e- ?8 G, a+ C: C) H) K
biggest concern was virilizing adrenal hyperplasia,+ w( ?& z/ i% q3 j: T
either 21-hydroxylase deficiency or 11-β hydroxylase) L8 u9 q( t8 n
deficiency. Those diagnoses were excluded by find-9 F/ `0 H4 v2 ]6 U# ~( g
ing the normal level of adrenal steroids.) c) R6 {5 v0 ~
The diagnosis of exogenous androgens was strongly! S  ~) [) |1 Y! v' k% o
suspected in a follow-up visit after 4 months because) D, b+ }9 n6 {: j, X$ m
the physical examination revealed the complete disap-3 _: E! C+ P$ {3 J
pearance of pubic hair, normal growth velocity, and
9 ?8 T. X# L6 u  e( A. [2 D+ B3 bdecreased erections. The father admitted using a testos-' n& r1 `, \6 N5 R
terone gel, which he concealed at first visit. He was
) `2 h& O) J7 b' g5 |, P* Gusing it rather frequently, twice a day. The Physicians’
$ }2 @- w3 O7 m) i% xDesk Reference, or package insert of this product, gel or" C" `$ z$ D# o
cream, cautions about dermal testosterone transfer to# F: k3 A7 N( v
unprotected females through direct skin exposure.* o$ r% I/ }* E  `. A& w  s) D
Serum testosterone level was found to be 2 times the
- ~1 I7 P. _' Xbaseline value in those females who were exposed to
! i, t' h8 g& `- S! H% Ueven 15 minutes of direct skin contact with their male! D  O, l5 m9 n8 [, \2 o! b* z: V
partners.6 However, when a shirt covered the applica-5 Z% @% L, l' A3 F0 q7 c2 X
tion site, this testosterone transfer was prevented.
7 X+ z& c5 m- V9 N+ gOur patient’s testosterone level was 60 ng/mL,5 {) n8 f$ W- T
which was clearly high. Some studies suggest that1 i3 d8 g" g; ^, {5 ]. p* P! p5 ~
dermal conversion of testosterone to dihydrotestos-
  K9 ]5 W# o4 K7 E) bterone, which is a more potent metabolite, is more
7 A9 w, f( a; G: R6 P7 P$ g$ ^active in young children exposed to testosterone
8 o/ A  D/ M' V) Kexogenously7; however, we did not measure a dihy-* o+ d* b8 U, V9 m( j) G
drotestosterone level in our patient. In addition to. D2 }2 V2 `: D: z. c) o6 p
virilization, exposure to exogenous testosterone in( H7 q) G8 s4 L$ i( t3 x8 T6 p
children results in an increase in growth velocity and. n' W$ w9 u% n( Y$ M7 ^
advanced bone age, as seen in our patient.
, Q7 A4 C! J  ?3 J5 m! W- f. Z) ]The long-term effect of androgen exposure during6 |8 F; }) L* k) m' o  \
early childhood on pubertal development and final
1 Q9 T5 H, T9 v* [/ L9 J  Z  @adult height are not fully known and always remain
. ]( V% A* x8 {" a% z" @- ^, sa concern. Children treated with short-term testos-
; y& e! r( `' hterone injection or topical androgen may exhibit some
, c4 Q# B' a+ k* p2 t% V0 Tacceleration of the skeletal maturation; however, after" _1 N% Z3 ]+ i
cessation of treatment, the rate of bone maturation
5 r6 v  [2 t) h( w4 U* I/ pdecelerates and gradually returns to normal.8,92 h4 A! U  J2 |1 [- r% J  K0 o4 c- q
There are conflicting reports and controversy8 A7 X4 O& u# a) C) A, c
over the effect of early androgen exposure on adult8 ~+ ^2 p; o, u% e
penile length.10,11 Some reports suggest subnormal# x0 E- x5 j6 P6 v
adult penile length, apparently because of downreg-
+ ?9 W- w& Q( qulation of androgen receptor number.10,12 However,- V0 i+ `* i5 `' x+ Z3 h
Sutherland et al13 did not find a correlation between: J- w6 t$ l: q# i  |& I: C
childhood testosterone exposure and reduced adult
' a3 x/ L+ r9 F) S! T  x7 X5 Rpenile length in clinical studies.9 K% L2 b. l& {! |! j# z
Nonetheless, we do not believe our patient is% z9 h  O$ O7 @; N& e, J0 m
going to experience any of the untoward effects from
3 w1 A2 [- `9 W; K4 m- utestosterone exposure as mentioned earlier because) m7 ~- h4 }( \* N0 S
the exposure was not for a prolonged period of time.
6 Z3 Q2 K% u2 l  K/ jAlthough the bone age was advanced at the time of
" q! {  [9 V' `, F7 l7 Wdiagnosis, the child had a normal growth velocity at
$ J( A& I, H0 ^" bthe follow-up visit. It is hoped that his final adult/ d; b2 M# u. v# h+ Z
height will not be affected.
5 q# O0 Z" U; t( V9 L+ YAlthough rarely reported, the widespread avail-& k. B/ q! {8 N# D1 ~' v
ability of androgen products in our society may
& f$ {; ?0 c6 [2 b! e2 pindeed cause more virilization in male or female
. h& d0 c( v/ C& _* Gchildren than one would realize. Exposure to andro-3 G9 G5 P# X0 t( l; u4 ~. o
gen products must be considered and specific ques-
" F+ M/ l4 [( Ftioning about the use of a testosterone product or
& k: u3 H6 X5 b8 [& C0 o+ Egel should be asked of the family members during
- z+ X2 G, D7 l. z) c' Athe evaluation of any children who present with vir-
, h6 J8 T2 ]# q0 V8 Lilization or peripheral precocious puberty. The diag-
) \; P# _6 q1 B) H" Qnosis can be established by just a few tests and by2 z) L8 }+ a: K( Z/ `/ q0 h
appropriate history. The inability to obtain such a# c; i9 w1 k% E: }! f, g
history, or failure to ask the specific questions, may
8 p6 M  C  b. M, hresult in extensive, unnecessary, and expensive4 K' S( R* k# a0 O( b5 \/ q
investigation. The primary care physician should be
9 A, \7 K& S1 T9 [, W* p9 `aware of this fact, because most of these children
7 t( }. L5 c( _$ L, vmay initially present in their practice. The Physicians’, U# u) T# r7 N( N4 ?$ v
Desk Reference and package insert should also put a" N" X) k. S* G. W" P2 Z
warning about the virilizing effect on a male or
" m; k2 ^5 ^* ?7 ?7 qfemale child who might come in contact with some-+ G1 H9 D: ?2 X3 r  Q# ?
one using any of these products.7 E1 t% y' f! H1 l
References3 e5 E  }- M* [8 m6 u
1. Styne DM. The testes: disorder of sexual differentiation
; T4 w4 l8 M4 Y4 cand puberty in the male. In: Sperling MA, ed. Pediatric7 }! V0 i+ D+ H& C2 f; A0 O/ L" k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 ]! B  L$ h. o3 c6 U+ N( l2002: 565-628.& D* U) j! D4 F$ [: R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' Q* W1 ~3 _/ v9 |, Tpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) k) k/ @- ?7 s. h8 Q  ~
Boy Induced by Indirect Topical) f8 B4 @$ |* a1 g+ N% M: a
Exposure to Testosterone5 o: r) Q) Z, G; X, S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 u& k/ {. Q+ x8 r9 N. E- v
and Kenneth R. Rettig, MD11 s& U& O; g- p
Clinical Pediatrics  ~8 Z8 G: f  \8 z% P
Volume 46 Number 6
. v& C$ S' j4 K1 IJuly 2007 540-5430 F0 `2 j. D2 p5 W
© 2007 Sage Publications  u$ \1 j: i" E& C/ F
10.1177/0009922806296651
- G) ^1 P. \0 Ohttp://clp.sagepub.com
  O2 q# w9 q; H6 {2 V0 mhosted at3 D, p+ A. b: `/ J$ D* W: X
http://online.sagepub.com
9 a7 T) ]; Y) p9 CPrecocious puberty in boys, central or peripheral,2 f. ?& C8 m1 U& t5 M
is a significant concern for physicians. Central
9 }9 r/ E- E% j0 T8 B6 Pprecocious puberty (CPP), which is mediated  @4 U5 ~9 I+ i" W! J4 x
through the hypothalamic pituitary gonadal axis, has
# B' g& t: Q. b' l' fa higher incidence of organic central nervous system
0 [/ j! b" a$ |1 {) i+ d/ ulesions in boys.1,2 Virilization in boys, as manifested
7 Y: W5 K3 n* o' T! A- X% e+ zby enlargement of the penis, development of pubic
9 H# x& K# N+ J% o6 K* qhair, and facial acne without enlargement of testi-
3 w2 F% G: @" E( X- {6 Fcles, suggests peripheral or pseudopuberty.1-3 We, z. M3 ^5 q) u+ e+ N7 M
report a 16-month-old boy who presented with the* t0 }1 u) Z* u# l* j
enlargement of the phallus and pubic hair develop-$ U: _6 [  k1 f3 f) Z- h/ p
ment without testicular enlargement, which was due6 W9 K& J( J2 d* o0 R
to the unintentional exposure to androgen gel used by! K! n. v+ p3 t
the father. The family initially concealed this infor-
0 g/ N6 K8 K3 t0 K, ?6 O9 Bmation, resulting in an extensive work-up for this& X9 \9 k& _9 `' r0 ?7 p
child. Given the widespread and easy availability of6 O8 ]. Y9 F& t6 [7 C# I
testosterone gel and cream, we believe this is proba-
! h. Y. G& S1 S0 gbly more common than the rare case report in the+ w- T, g$ H. `& O- c+ X* t
literature.49 M5 K6 U0 I6 [& F
Patient Report
, x* l9 y5 ]8 M, i* C" r( \$ @A 16-month-old white child was referred to the' Q: l9 c" K9 L$ Y5 T; t# a# J
endocrine clinic by his pediatrician with the concern
( t4 V3 U4 @3 A$ }. z! ~of early sexual development. His mother noticed
# I6 [" b% {7 M4 I5 v* q- v/ nlight colored pubic hair development when he was
. M/ e( K4 f: nFrom the 1Division of Pediatric Endocrinology, 2University of7 V1 u8 {) P' u- L2 s
South Alabama Medical Center, Mobile, Alabama.! A' _  Q+ A- R2 k$ u; w
Address correspondence to: Samar K. Bhowmick, MD, FACE,: d( w, `- i, }, }( c. u
Professor of Pediatrics, University of South Alabama, College of+ |) ]& ^# ^1 T* ?/ ?0 t8 [
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% d+ ]& W% C! Y& w' T  Te-mail: [email protected].
0 e5 N7 S5 _4 p/ u0 ~. O! M$ pabout 6 to 7 months old, which progressively became
: m6 R! W9 i; u% O- `# Ndarker. She was also concerned about the enlarge-
- _+ ]8 {# i9 F8 s" Cment of his penis and frequent erections. The child
6 z. y9 ~6 n/ J3 ]* y- c; x- [was the product of a full-term normal delivery, with
5 [# \4 ^! B: j4 d: F8 c; Ma birth weight of 7 lb 14 oz, and birth length of+ y- V# b7 p7 t3 ~0 U% E3 l% Z6 t
20 inches. He was breast-fed throughout the first year
0 c& {1 ~4 G2 |6 Aof life and was still receiving breast milk along with
/ C3 x8 ?! w, [, W1 c* Vsolid food. He had no hospitalizations or surgery,9 i6 t) \4 @- e6 U* J+ M* C
and his psychosocial and psychomotor development" Q- T5 ~5 `2 ^# D) k1 j" K: H  Y0 m
was age appropriate.8 G& J- r2 ]3 d- A0 [
The family history was remarkable for the father,
( P/ y" m3 W* h( ]( Twho was diagnosed with hypothyroidism at age 16,( B) C* E/ M8 S9 ]" ?5 |* I5 k; O
which was treated with thyroxine. The father’s$ z* \, Y3 j5 l5 p  m7 l0 y
height was 6 feet, and he went through a somewhat6 R/ ]6 I2 ?3 u. q3 h5 l
early puberty and had stopped growing by age 14.& @5 H+ v  W% h  N6 @
The father denied taking any other medication. The
: A8 J$ P% C# M) b) w& Rchild’s mother was in good health. Her menarche8 J* x  F, S9 |- l# s
was at 11 years of age, and her height was at 5 feet+ V' Z3 x* g1 ^
5 inches. There was no other family history of pre-8 L6 e- i; ]# v: s0 L! E
cocious sexual development in the first-degree rela-
0 @! f- T7 w& Z1 V0 ^tives. There were no siblings.
/ h8 f  K2 V, }  j  d& |Physical Examination
0 H, O7 J% g$ @, k  cThe physical examination revealed a very active,( I  c# Y  v$ r/ t/ u3 Z
playful, and healthy boy. The vital signs documented1 ]/ N: W( |/ J5 S; n
a blood pressure of 85/50 mm Hg, his length was
0 \" @  c: |, |" W% e90 cm (>97th percentile), and his weight was 14.4 kg
  I, ~" \" [4 F8 V, P7 C(also >97th percentile). The observed yearly growth' l. D: I& `: E. e
velocity was 30 cm (12 inches). The examination of
. y8 {6 M) M7 f' b3 s2 [the neck revealed no thyroid enlargement.7 W" D# R2 ]/ G7 [
The genitourinary examination was remarkable for% l  R$ o6 R  h+ O# V0 S1 W8 Z' {' g
enlargement of the penis, with a stretched length of& G: w. F) @/ w  m1 t; Y, D
8 cm and a width of 2 cm. The glans penis was very well
- x$ \9 l/ u* U8 ]/ |  @7 udeveloped. The pubic hair was Tanner II, mostly around. S6 ?9 k+ B' A" E% `
540
3 u* \6 n: J- W) j  Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 q: M0 o8 o& `7 N$ Dthe base of the phallus and was dark and curled. The2 U2 t4 P& a" C. r+ G* d% A
testicular volume was prepubertal at 2 mL each.1 a5 l+ c5 x. u" O' k8 X7 v" X
The skin was moist and smooth and somewhat
' m7 ?8 r- X$ toily. No axillary hair was noted. There were no$ `  ^& }1 d) Z7 e2 o: W
abnormal skin pigmentations or café-au-lait spots.5 q- q* w* S5 y0 B+ F
Neurologic evaluation showed deep tendon reflex 2+
' o' K# A0 q+ X% f3 v& K) t1 ?bilateral and symmetrical. There was no suggestion9 V7 i' L1 Y# v4 `* \1 B7 z
of papilledema.4 w4 l) \) D- [+ B. o6 Q
Laboratory Evaluation/ l( K3 K$ V' `+ C7 I
The bone age was consistent with 28 months by
$ H$ V& G4 y- f# O1 wusing the standard of Greulich and Pyle at a chrono-' `- n8 u1 B' t% u5 ^6 V# `& {
logic age of 16 months (advanced).5 Chromosomal  z! J3 j, m+ V4 }) d. B+ u
karyotype was 46XY. The thyroid function test! U/ q" I+ m! P4 e/ X) Y( o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: k- ^8 _, n/ Y; Ilating hormone level was 1.3 µIU/mL (both normal).$ Z: p* A" q! r
The concentrations of serum electrolytes, blood
- r; R3 ?  g3 _# vurea nitrogen, creatinine, and calcium all were; x6 r) G' T7 Z8 ?
within normal range for his age. The concentration3 a4 j9 ], I6 d; L
of serum 17-hydroxyprogesterone was 16 ng/dL
' [' r2 [* l$ [(normal, 3 to 90 ng/dL), androstenedione was 207 P5 S1 u+ U3 F
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 Q" c+ h5 Y" B! C2 ^3 M! C3 _, `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
: C' X& {$ B9 \" N2 |3 P2 u/ edesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ r: Z' S! t7 N4 W4 T* ^( E
49ng/dL), 11-desoxycortisol (specific compound S)# X; m# W. K3 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 g! N& t+ N/ t4 i  i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# Q" D2 f5 Y- h! vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),! |4 s* V6 u1 F, J/ o, X4 j
and β-human chorionic gonadotropin was less than) {, o8 T; i9 d3 O4 x1 |
5 mIU/mL (normal <5 mIU/mL). Serum follicular! t( }2 P5 j& l# @1 ~# A9 a
stimulating hormone and leuteinizing hormone& b7 Z! j. l! i" n! f$ K
concentrations were less than 0.05 mIU/mL
+ }6 T- @0 p: v(prepubertal).
1 U- f( r- r, \1 t7 hThe parents were notified about the laboratory- q& }) l" C: L) l/ ]: [
results and were informed that all of the tests were( S; u1 }/ L  D$ b$ Z
normal except the testosterone level was high. The' U; I  k2 c! q/ W# Z
follow-up visit was arranged within a few weeks to
% ?9 v% @+ Z$ g' M- c* a9 Jobtain testicular and abdominal sonograms; how-7 s& ]& `# g# l8 X) G
ever, the family did not return for 4 months.
% N  K. g( d  u* k3 l0 r% ?+ S% K( {9 nPhysical examination at this time revealed that the6 A( c: R& `/ t! v. o7 l! n
child had grown 2.5 cm in 4 months and had gained
: E1 |3 y3 R' V" h0 o' p5 L( R2 kg of weight. Physical examination remained
; v) U* b2 }( a; s3 N$ F9 ~7 }unchanged. Surprisingly, the pubic hair almost com-8 O7 q1 }( T$ t& e* _  O) }
pletely disappeared except for a few vellous hairs at2 G1 g7 ~$ j7 J; X! t! `
the base of the phallus. Testicular volume was still 2% o6 o+ w1 B8 z2 }& V- n* e0 X
mL, and the size of the penis remained unchanged.& i) L3 K6 |- q0 ^  @7 o0 k
The mother also said that the boy was no longer hav-
7 L; [- H8 \8 Sing frequent erections.6 l! S. K! P3 z' h
Both parents were again questioned about use of1 Q- u. g% n. y; d
any ointment/creams that they may have applied to
' E' t4 \' K6 z, U, Q$ R& ^the child’s skin. This time the father admitted the
* T: Y! B0 x( S1 f4 v# x9 PTopical Testosterone Exposure / Bhowmick et al 541
5 Z1 n  B( a: d! T5 b# Ouse of testosterone gel twice daily that he was apply-4 \  G6 K0 u0 ^
ing over his own shoulders, chest, and back area for( K) }7 C) u- G4 D4 w" V
a year. The father also revealed he was embarrassed5 @& \$ b) c$ M  z- x
to disclose that he was using a testosterone gel pre-& B# X( Q* x0 G/ y
scribed by his family physician for decreased libido7 J% Y7 L) I7 G3 J/ ~! E+ M( C
secondary to depression.
) C5 E7 @+ ]1 b$ t" h6 O! {- xThe child slept in the same bed with parents.
, H! H% x: X- j+ v# q1 d6 \2 g9 PThe father would hug the baby and hold him on his
% ~1 Q  b5 u3 G3 x* m/ d' gchest for a considerable period of time, causing sig-& z4 M6 J) ^  M& J
nificant bare skin contact between baby and father.
" x  R% ~2 A* }+ U4 j" iThe father also admitted that after the phone call,, ~: ?/ t5 _$ b* g, B- n1 a
when he learned the testosterone level in the baby
9 T7 G0 H- }2 j6 h3 ~. \( Iwas high, he then read the product information
  Z8 i: f$ U  h7 K( t0 q7 ypacket and concluded that it was most likely the rea-
$ T: r* k- P3 a! d5 C9 Sson for the child’s virilization. At that time, they2 k0 |* l0 T% u: R: ^2 m, R
decided to put the baby in a separate bed, and the
* s. h$ `9 B5 `9 D, i. }" u! ~: cfather was not hugging him with bare skin and had
( A- |- R" z( h& x$ N# Cbeen using protective clothing. A repeat testosterone. z1 O3 S! M. A4 L0 P2 d  q+ w
test was ordered, but the family did not go to the
, K) |9 J* P( T& tlaboratory to obtain the test.$ u! A2 D% e5 `: K# `5 |+ h* R1 k
Discussion2 A) o- C8 K+ T  L& }# y
Precocious puberty in boys is defined as secondary
  E/ k6 C5 t2 }+ lsexual development before 9 years of age.1,4
4 i8 _1 e* a& ?Precocious puberty is termed as central (true) when2 M% w% O+ i  Q7 j' B3 P
it is caused by the premature activation of hypo-
) R% K- n# O5 |& B& Vthalamic pituitary gonadal axis. CPP is more com-
7 ^5 G3 `* E! |& F5 x( A( j* t, Ymon in girls than in boys.1,3 Most boys with CPP" K( Q; v& s* X1 l1 `: ^
may have a central nervous system lesion that is
. I7 k$ E, C/ X  Y  B1 xresponsible for the early activation of the hypothal-  \, _+ d% \1 n' |7 j7 h  u+ E
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 ?9 y* \6 s& T/ @7 j( nsis has been given to neuroradiologic imaging in4 h) s; k% B$ }
boys with precocious puberty. In addition to viril-" h. x7 f3 {% k& ~  {
ization, the clinical hallmark of CPP is the symmet-
& t9 Z6 h; T8 f1 F, t8 C* s5 n. irical testicular growth secondary to stimulation by  k( Y7 h" n2 V
gonadotropins.1,3& v/ [7 H& E* [
Gonadotropin-independent peripheral preco-
$ ]. T1 W4 X" C  u, s' q5 ~2 P  J; n/ rcious puberty in boys also results from inappropriate$ I. Y& e% M$ `! l3 u4 L
androgenic stimulation from either endogenous or
7 K# M. |, m( A0 k: C5 texogenous sources, nonpituitary gonadotropin stim-# A; l9 t! c9 R" Y: h; ]
ulation, and rare activating mutations.3 Virilizing
/ d! A2 j4 M4 Q# H3 F- b# k7 F% Vcongenital adrenal hyperplasia producing excessive
1 M, a) E8 q; k6 D4 L" A! k) B* Y% kadrenal androgens is a common cause of precocious/ |) h$ _* c; |0 B
puberty in boys.3,41 S9 O3 _2 r& Y. ^6 z) B
The most common form of congenital adrenal
$ l, q. H8 R/ E3 [5 S; Whyperplasia is the 21-hydroxylase enzyme deficiency.. j" ]& t' C( G5 M
The 11-β hydroxylase deficiency may also result in
  o* N! q$ e8 n; L" P' y. f5 L' {excessive adrenal androgen production, and rarely,7 U' b& u7 g+ X  f
an adrenal tumor may also cause adrenal androgen. ~; `- w9 x, P  G, m1 E2 k
excess.1,3
/ N+ l' K& J7 W& `/ wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 B5 Z7 i1 p* [' j+ o: c
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) y* O* v) b8 {: v
A unique entity of male-limited gonadotropin-
, n0 O! X! N, V6 ?0 D+ v  Qindependent precocious puberty, which is also known
4 H( Q: v  q* W0 J! nas testotoxicosis, may cause precocious puberty at a4 r* a* c( K& {- ]6 \- H, w9 w
very young age. The physical findings in these boys8 O' u2 n4 E' H6 G( a% B$ [0 U  v) z; ]
with this disorder are full pubertal development,/ F5 z% S& A6 X2 n* P$ S
including bilateral testicular growth, similar to boys* V' I# ]: k! r7 c- ~/ |5 i
with CPP. The gonadotropin levels in this disorder# y$ g, `4 V& F$ j5 ^' s; v  W
are suppressed to prepubertal levels and do not show$ o1 c  y; O7 z
pubertal response of gonadotropin after gonadotropin-  z6 B7 V# G; ^
releasing hormone stimulation. This is a sex-linked
8 n% T" z9 ^2 X2 n8 l* W+ lautosomal dominant disorder that affects only
$ |1 h" L  I: y* R7 G- L4 V9 b) Gmales; therefore, other male members of the family
- x2 M9 D1 z" vmay have similar precocious puberty.3% t& W, Z% Y0 h3 S9 h9 x5 d
In our patient, physical examination was incon-# q2 ]/ i" p, ~- s8 v
sistent with true precocious puberty since his testi-
5 y. B/ q# S2 T) l; S& l% l7 p0 W! icles were prepubertal in size. However, testotoxicosis7 |! H- H, J. t& m) Z
was in the differential diagnosis because his father
/ S* B. Z1 p. w# r4 lstarted puberty somewhat early, and occasionally,
' b1 ?. C! c8 P" ~$ \' T3 L! }testicular enlargement is not that evident in the9 J! b  o# j! S  J
beginning of this process.1 In the absence of a neg-
+ x8 a+ i0 ^6 a0 c) U5 B. eative initial history of androgen exposure, our
! i5 D$ R6 @, T) ]1 [+ i# Ibiggest concern was virilizing adrenal hyperplasia,
8 Y) h# l2 P; Aeither 21-hydroxylase deficiency or 11-β hydroxylase
/ _, h4 T1 F" r! c! }5 G9 {2 p6 Odeficiency. Those diagnoses were excluded by find-
+ n+ x1 @# _3 i6 K7 }% ting the normal level of adrenal steroids.
- T: ~2 s8 F, tThe diagnosis of exogenous androgens was strongly6 r5 }/ h4 J4 T9 B" N  l' {/ X& ?
suspected in a follow-up visit after 4 months because
% j  D9 g0 ?2 J' V0 V% q# nthe physical examination revealed the complete disap-+ z6 ~% m* a; N: t7 s0 p
pearance of pubic hair, normal growth velocity, and9 r0 N7 w1 R& t
decreased erections. The father admitted using a testos-
& C( d: F0 o( F1 wterone gel, which he concealed at first visit. He was; X1 z# e! Q( N0 E: U
using it rather frequently, twice a day. The Physicians’
3 R$ d( M8 e" H; Q! f% FDesk Reference, or package insert of this product, gel or/ O2 S9 G6 L" r. b3 m6 b! G% b2 a
cream, cautions about dermal testosterone transfer to! o+ O. A1 C/ o: c- ^' e4 k4 }
unprotected females through direct skin exposure.0 ?2 V9 E  _- e5 k
Serum testosterone level was found to be 2 times the/ D/ u6 e7 L) H- m
baseline value in those females who were exposed to8 q- i7 }$ V0 `  B" C; Q
even 15 minutes of direct skin contact with their male
0 T! n3 Y9 V/ t  ^# M4 lpartners.6 However, when a shirt covered the applica-
( W8 v6 \- Z' r( t& O# {tion site, this testosterone transfer was prevented.
/ d  u9 t: I: U9 E6 D% P  f% T- MOur patient’s testosterone level was 60 ng/mL,
" ^9 T2 a: Z& ]" v+ [8 Jwhich was clearly high. Some studies suggest that& N4 l$ ^9 ^" ]* @+ F
dermal conversion of testosterone to dihydrotestos-7 y; w0 x, }0 S
terone, which is a more potent metabolite, is more1 X0 H: H; d* [4 R  ^' Y& [: {) T
active in young children exposed to testosterone& V* {1 `/ {. j. B
exogenously7; however, we did not measure a dihy-
; S; v4 {* T' e( T+ y5 F3 y8 L- Ydrotestosterone level in our patient. In addition to
5 ~' |: K; {" N4 t3 qvirilization, exposure to exogenous testosterone in( ^( e4 H9 r1 e: a% u
children results in an increase in growth velocity and- ^; F* I; G9 ?6 J$ c
advanced bone age, as seen in our patient.0 V' H$ ]- C* m0 D) k9 @) \8 X
The long-term effect of androgen exposure during3 Y6 r# K5 l3 K
early childhood on pubertal development and final
# m! S9 ?" R/ N& x, B* Qadult height are not fully known and always remain$ Z8 `9 u8 ]. R+ M% @
a concern. Children treated with short-term testos-- t# m5 O3 l3 D. C" V; w$ w
terone injection or topical androgen may exhibit some2 T# v/ e  [, L' r
acceleration of the skeletal maturation; however, after
( a4 n/ i4 i0 O) `" c" h6 x" Jcessation of treatment, the rate of bone maturation
$ I& D4 v5 r; E2 s+ a  W# Ddecelerates and gradually returns to normal.8,99 \0 f1 d3 O6 _
There are conflicting reports and controversy$ w% P! d4 g+ R% n2 ~: G
over the effect of early androgen exposure on adult1 P$ R/ d8 W; B$ k
penile length.10,11 Some reports suggest subnormal
3 Y/ c: T5 ?3 ^" D- radult penile length, apparently because of downreg-0 e. i/ Q& i  `! S  ~
ulation of androgen receptor number.10,12 However,
: F6 l0 r7 s. j8 kSutherland et al13 did not find a correlation between0 R7 r) }: g0 p( f
childhood testosterone exposure and reduced adult7 B; [8 q3 P3 y1 h
penile length in clinical studies.
8 M( F& J8 p! RNonetheless, we do not believe our patient is
: I+ j$ `7 n* A- f6 Dgoing to experience any of the untoward effects from' s9 z8 F8 n. C$ r, O& p. v
testosterone exposure as mentioned earlier because
$ W' U' P* W* Dthe exposure was not for a prolonged period of time.3 [$ U( B" V- S% U5 Z
Although the bone age was advanced at the time of
$ c* W$ n* M/ E* t' ddiagnosis, the child had a normal growth velocity at; n5 j' E) @( ^" g  J
the follow-up visit. It is hoped that his final adult
! ~, _$ ?2 N& Bheight will not be affected.# x( D; d0 P3 v7 _
Although rarely reported, the widespread avail-! j( @+ l, k+ Z* s* }0 t
ability of androgen products in our society may
# ^  f2 p2 g! g; V* b& I7 N/ Kindeed cause more virilization in male or female
' _/ ?& V+ [4 r( G8 a% t7 Uchildren than one would realize. Exposure to andro-
6 O0 F6 N/ u6 M( T& _  Ugen products must be considered and specific ques-: n. n$ S5 a# J* i- g1 [- j
tioning about the use of a testosterone product or% w+ g5 }! |; R4 H6 ], T& V
gel should be asked of the family members during' n- r, x% U. r$ H  m$ v
the evaluation of any children who present with vir-# Y' S1 \7 ?' u# L7 G( g
ilization or peripheral precocious puberty. The diag-
5 Z: b3 S3 @4 A7 w, r" tnosis can be established by just a few tests and by
6 R. ^9 K8 j' K4 ~8 j! u& l" [appropriate history. The inability to obtain such a
* b: h6 z' {2 c1 r( x. l' dhistory, or failure to ask the specific questions, may9 P, E1 \5 F8 M
result in extensive, unnecessary, and expensive
7 u) [' X, c2 T. binvestigation. The primary care physician should be! R" r+ q/ |1 ~6 a6 U8 G& m0 W
aware of this fact, because most of these children
' Q# L  Z) v+ D; S' {may initially present in their practice. The Physicians’# J' V/ [' X) H1 e
Desk Reference and package insert should also put a
$ @2 ]' b' }7 X0 p+ k4 ewarning about the virilizing effect on a male or1 g) [% `: h, G1 k% G
female child who might come in contact with some-- I4 f1 Z# o! F6 \6 P1 a
one using any of these products.8 j9 g5 ~" x. Z) n0 u
References+ X) l5 \' ^4 A8 e# e$ x; @9 C2 v
1. Styne DM. The testes: disorder of sexual differentiation
" ^: ~% K, V3 D; l+ y, Eand puberty in the male. In: Sperling MA, ed. Pediatric
$ u) u. f; U' v$ kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( ~8 W4 L4 {- ~6 r! }' Z, p8 Y2002: 565-628.; O# H9 Q& D! h) ^* K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 Z0 ]) \3 V' Q, `7 p' a  {
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
; Y+ U, o! V) ?# ~1 L* Q
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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