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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
0 ]  P& V5 w7 F" w' p  o7 NBoy Induced by Indirect Topical
0 R0 S8 }: f& c3 i( ^2 |Exposure to Testosterone" W% ~( E  Q+ Z' T% P* @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* {3 z7 N" y' A0 p; _1 wand Kenneth R. Rettig, MD1
, f1 ?. n8 C, }3 r( oClinical Pediatrics, f9 q4 M2 G# ?
Volume 46 Number 6
! K$ [- E  U/ R/ _  |' x0 P8 V7 c- kJuly 2007 540-543
" A; ~( Z/ ]; @/ x* F; {+ J© 2007 Sage Publications
$ {; j* T& R  ?  l! k10.1177/0009922806296651
* n, ^! _1 z" X- Z1 v+ c% Chttp://clp.sagepub.com
2 [: H* b- _/ B- h5 vhosted at
/ c- }' ^' K, t- ?) [; ?) ehttp://online.sagepub.com2 z2 T0 ~9 V" M5 k
Precocious puberty in boys, central or peripheral,! M/ j' \% e; z1 g
is a significant concern for physicians. Central
& G$ r! w; F4 J% p9 Mprecocious puberty (CPP), which is mediated
9 u- V% Q8 C) y" p. Y; Y* o) Zthrough the hypothalamic pituitary gonadal axis, has2 G- U, f' Y/ J. b) x
a higher incidence of organic central nervous system
: A3 A9 T( q/ c6 l, U0 \lesions in boys.1,2 Virilization in boys, as manifested' r: c0 s& p9 N. T2 I5 v' C3 g, ]3 C
by enlargement of the penis, development of pubic! O4 \6 o0 d. D6 v6 x+ O
hair, and facial acne without enlargement of testi-* @3 T: g  n1 \3 J. N& n' g. X$ O
cles, suggests peripheral or pseudopuberty.1-3 We- ?+ P9 ~4 u# N
report a 16-month-old boy who presented with the  Y) ]+ n. u: r9 l2 g/ A
enlargement of the phallus and pubic hair develop-8 g0 _) q8 L3 ^3 ^7 L
ment without testicular enlargement, which was due7 c5 d; L) N, T6 v
to the unintentional exposure to androgen gel used by1 V% @+ ~+ {1 P
the father. The family initially concealed this infor-$ s* V. ?( Z# Z! x9 D. w
mation, resulting in an extensive work-up for this/ ^# |' a9 i  |% T' j- r
child. Given the widespread and easy availability of  P( C6 _' _0 I/ F. N. x# C
testosterone gel and cream, we believe this is proba-
, ^9 J! c7 O6 _& G! D( w+ _bly more common than the rare case report in the
, \  f7 X1 R; g" aliterature.47 l9 i8 C0 @) f4 [9 j' Y9 [3 E8 p/ x
Patient Report* ^6 l* {+ b! h7 H( z! @
A 16-month-old white child was referred to the
1 x8 Y/ {* y' l8 {7 ~2 k# pendocrine clinic by his pediatrician with the concern5 m& O4 X7 o' k! i; ^
of early sexual development. His mother noticed
/ N0 D& y  U7 G% K( Qlight colored pubic hair development when he was# H' R* N) ]7 h5 m* N6 S4 R9 p
From the 1Division of Pediatric Endocrinology, 2University of- X/ ]# ^2 R5 m! u, g& p9 \" a
South Alabama Medical Center, Mobile, Alabama.# L* u4 M2 S. @+ e9 j
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 p+ T  i3 q1 A) U0 B9 f- R" o
Professor of Pediatrics, University of South Alabama, College of
) S/ w1 G5 F7 L+ w0 v! G/ W# W7 ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" J; i; L3 B9 b: A: g3 U9 S  x3 ae-mail: [email protected].
+ |& W& [' h3 I  @  zabout 6 to 7 months old, which progressively became
# P$ @$ l* a7 [& b, r6 w6 jdarker. She was also concerned about the enlarge-( F& G- @# x- a
ment of his penis and frequent erections. The child1 t) ~! Q$ j6 `6 x, M2 C' Z
was the product of a full-term normal delivery, with5 G& m$ k* S* A( p: [
a birth weight of 7 lb 14 oz, and birth length of" p  H( Y% V1 i: q3 s
20 inches. He was breast-fed throughout the first year9 @- r# G" w' ^/ f5 V! F
of life and was still receiving breast milk along with; f5 V- a/ L9 W/ r4 t: ~5 O
solid food. He had no hospitalizations or surgery,
# o- A+ W* N7 B" T0 t6 Xand his psychosocial and psychomotor development
4 u& O& z" N4 p! t5 Pwas age appropriate.; f$ m3 Y; b" I7 K1 h/ O
The family history was remarkable for the father,
$ U2 Z! o# V0 ]& g6 X9 D8 Y1 U4 qwho was diagnosed with hypothyroidism at age 16,  r- ]- C" w3 S1 }- z
which was treated with thyroxine. The father’s- u# g# N" @% |8 c* N
height was 6 feet, and he went through a somewhat8 `! ^2 x# H7 n; O
early puberty and had stopped growing by age 14.
- x' W6 p* x7 mThe father denied taking any other medication. The1 @  ?" J# ?9 W
child’s mother was in good health. Her menarche4 N6 H0 q1 \) [% z; `9 h
was at 11 years of age, and her height was at 5 feet
5 E( b9 j* v6 U5 inches. There was no other family history of pre-( E) [" x) b$ Z$ `+ u
cocious sexual development in the first-degree rela-
! t# S1 F, A! T% h+ Qtives. There were no siblings.! j' g9 u7 h1 ?) c% |
Physical Examination8 H5 d* s6 D; v
The physical examination revealed a very active,: G- {. n2 v* s+ B2 `
playful, and healthy boy. The vital signs documented; S" T  y! q0 B% T/ Q
a blood pressure of 85/50 mm Hg, his length was3 n7 j0 b4 Q- s2 ?
90 cm (>97th percentile), and his weight was 14.4 kg
! i2 f6 n2 @8 P0 M$ h; l* f. ?3 G(also >97th percentile). The observed yearly growth, Q) J+ k6 }+ G" h% w& @  M' U
velocity was 30 cm (12 inches). The examination of
7 w3 H+ p1 n6 `1 n) `& Gthe neck revealed no thyroid enlargement.) N: L1 D3 s4 l8 I3 q" c& D: c  G6 x
The genitourinary examination was remarkable for9 E4 H) T. C' Z6 |
enlargement of the penis, with a stretched length of9 K- n+ L6 D( b& A9 k
8 cm and a width of 2 cm. The glans penis was very well6 ]0 `5 S5 o# u0 }) Y; J! M, _' v
developed. The pubic hair was Tanner II, mostly around$ `+ C' H/ Z5 t/ i( \; U
540  H; `/ y' h! a- v( F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ t* [& P8 ]. @, M& q+ m6 uthe base of the phallus and was dark and curled. The
' L  N. H* {: O& ntesticular volume was prepubertal at 2 mL each.. f. j- L4 {3 v" g+ Q' T  q
The skin was moist and smooth and somewhat# X1 [6 a/ s: D. t) l
oily. No axillary hair was noted. There were no
# F0 l" H) Z6 S& \3 zabnormal skin pigmentations or café-au-lait spots.
' l9 P( Q5 q+ ^7 Z; zNeurologic evaluation showed deep tendon reflex 2+
. P/ e2 X* ?6 Bbilateral and symmetrical. There was no suggestion( U7 _' C" B) b# A" }
of papilledema.
. A/ J* T8 N9 z8 F/ u/ ]2 jLaboratory Evaluation
) D2 W+ q2 L3 E: q, q# jThe bone age was consistent with 28 months by
; C) I0 d- ~  g$ m; W3 ~! nusing the standard of Greulich and Pyle at a chrono-
6 O. _; W% g9 K( |5 N$ hlogic age of 16 months (advanced).5 Chromosomal/ C" J. \/ ?7 P! U7 s8 w
karyotype was 46XY. The thyroid function test
, j: [  r4 d& W) Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) s& o4 m8 V3 e% z7 S5 F
lating hormone level was 1.3 µIU/mL (both normal).( [- t- F2 N6 S/ b! n9 A& d1 T
The concentrations of serum electrolytes, blood3 w7 ~, o  m* o. M0 G
urea nitrogen, creatinine, and calcium all were9 A4 [4 R& p8 }4 ?! ~9 t
within normal range for his age. The concentration" x9 m- |8 c+ y* x' j5 g- [! y8 P1 {
of serum 17-hydroxyprogesterone was 16 ng/dL. x. S* U8 D0 V* Q) E
(normal, 3 to 90 ng/dL), androstenedione was 20
3 y: z, _% `# U! n( a) K' M% qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  W* P- N* q3 O' a) C6 X& a- }( S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ m- T' J/ H! A- Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" P1 y6 D, ?* W- N
49ng/dL), 11-desoxycortisol (specific compound S)
5 z$ e; s$ f. d5 V7 W# l% d& mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# D' N# Q8 n" l0 F  Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- m6 E/ ~) c. c* |8 B6 otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* _" F1 Y% g8 [0 ^) P
and β-human chorionic gonadotropin was less than
, ~0 A' e' d4 {& `3 ]% J5 mIU/mL (normal <5 mIU/mL). Serum follicular, }/ ]; w9 A0 O( A5 e6 {
stimulating hormone and leuteinizing hormone9 R& A$ D, }* l
concentrations were less than 0.05 mIU/mL
8 j, t3 Z. Y9 F(prepubertal).7 P: s) m% d( P' K
The parents were notified about the laboratory
2 t6 e. u+ F- P; K1 ^) ^  Wresults and were informed that all of the tests were
! B" h$ O# t) q5 V1 |normal except the testosterone level was high. The% p8 a0 O; M  }- g) ^# s0 y. F6 L
follow-up visit was arranged within a few weeks to
; Q3 w4 e1 M( w2 }0 }: `obtain testicular and abdominal sonograms; how-
0 l! m2 i4 G2 j1 N& h, _" _ever, the family did not return for 4 months.
" y; O# d& S8 J2 l- [; xPhysical examination at this time revealed that the
  ^' I. F7 V: X4 q+ }child had grown 2.5 cm in 4 months and had gained' H" ]9 @5 m$ B. y0 X6 z
2 kg of weight. Physical examination remained; F, j! R) W6 s; n
unchanged. Surprisingly, the pubic hair almost com-" {) X2 T3 C9 S; [- Q0 ?
pletely disappeared except for a few vellous hairs at
: w* n& B& U2 @: x9 J. rthe base of the phallus. Testicular volume was still 2
0 Q# w7 J1 o4 x9 lmL, and the size of the penis remained unchanged.: |( x/ L% h; v2 E1 U3 H2 ]
The mother also said that the boy was no longer hav-+ C6 J, \7 L5 _$ e
ing frequent erections.
/ r) c4 P* |' I1 W+ z$ X1 P* @Both parents were again questioned about use of
8 G! U& O! ~9 m/ dany ointment/creams that they may have applied to
- J  Y% [' \  a( _the child’s skin. This time the father admitted the
  L. V9 D. T8 j9 [" ~Topical Testosterone Exposure / Bhowmick et al 541  A$ p( s8 @. z( W, N: X' k
use of testosterone gel twice daily that he was apply-* q1 R" u( t8 V  U  }
ing over his own shoulders, chest, and back area for
$ R* [) m  W3 q0 W; R/ \a year. The father also revealed he was embarrassed
+ a, H# Y; {9 H5 |: N, |4 ito disclose that he was using a testosterone gel pre-+ M4 a* n: r" N* n' |/ _
scribed by his family physician for decreased libido; M" |% d' x/ M1 `3 `  I; r& ~
secondary to depression.: Q0 c( D# W3 H: ^
The child slept in the same bed with parents.
7 {7 n" k# e$ Z* m& S4 bThe father would hug the baby and hold him on his
: G+ [# ?2 Y# F$ |( ?4 e7 |" lchest for a considerable period of time, causing sig-
# x- z: ^$ j& X3 V5 Snificant bare skin contact between baby and father.
# `& O2 p( b( }! c9 f+ w1 bThe father also admitted that after the phone call,
! U# q& _3 b& ~9 W; wwhen he learned the testosterone level in the baby8 p* Y2 ]4 ]: l0 D' f2 s* n: L
was high, he then read the product information
* i! i* v0 j7 N( c1 t0 M- vpacket and concluded that it was most likely the rea-$ V! }, _" q, Z; Z! s
son for the child’s virilization. At that time, they
9 L7 k# j8 N' ^% j7 ]decided to put the baby in a separate bed, and the0 ?# F7 l+ F# _& z4 x2 }: D5 Y
father was not hugging him with bare skin and had9 K; ^/ I0 }; D% m% h+ Z# O1 v# ~
been using protective clothing. A repeat testosterone1 U9 q2 [8 v# e8 k
test was ordered, but the family did not go to the
* l0 V5 _8 e2 D1 ^/ ~0 Slaboratory to obtain the test.
5 @+ h( r' G" g9 QDiscussion: ]# B+ G$ F* D% g% g
Precocious puberty in boys is defined as secondary1 E, ~" C2 y: F) }+ V
sexual development before 9 years of age.1,42 s/ N: {+ s' V
Precocious puberty is termed as central (true) when
( M& @2 n% P# w% ~* Wit is caused by the premature activation of hypo-& O4 \& {. ?2 q
thalamic pituitary gonadal axis. CPP is more com-7 J2 ]# p( t: V7 d$ w8 v5 `
mon in girls than in boys.1,3 Most boys with CPP
; {* [# u) U3 e. ymay have a central nervous system lesion that is" m. D8 z9 }5 F% F/ j! _" h
responsible for the early activation of the hypothal-
2 _" j8 `0 O5 ^2 samic pituitary gonadal axis.1-3 Thus, greater empha-
- r6 p/ C- K* ^' n8 p, Osis has been given to neuroradiologic imaging in
* g  a& o6 f% b* dboys with precocious puberty. In addition to viril-
" [  A; e! z, z& Jization, the clinical hallmark of CPP is the symmet-
! V6 e: j# ?9 U% u$ D: urical testicular growth secondary to stimulation by6 J* u. z/ n! x
gonadotropins.1,3
! C1 m* s. w8 |$ D9 O) @3 |Gonadotropin-independent peripheral preco-4 c1 O0 u6 I2 X) J" q
cious puberty in boys also results from inappropriate! M  }0 T7 c( ~3 X! w, k9 J% ^' S' I
androgenic stimulation from either endogenous or
& b6 i; s' {7 b; Vexogenous sources, nonpituitary gonadotropin stim-) W) u) E7 |7 v$ t
ulation, and rare activating mutations.3 Virilizing
7 v( B5 x9 q0 W* V$ qcongenital adrenal hyperplasia producing excessive6 z! y) b  F; T3 t( g. ?
adrenal androgens is a common cause of precocious
! y0 ?. i2 c5 F' vpuberty in boys.3,4) a" y5 l, Q0 S1 I
The most common form of congenital adrenal! m' \  k* ]- m( \  g
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ U& J. }: b" X. |! L! O! h" ?3 u$ wThe 11-β hydroxylase deficiency may also result in+ f" U; ^  r7 @) F* I/ S' g' L1 ~5 q
excessive adrenal androgen production, and rarely,; P0 E; h3 Q: W6 p  D+ B
an adrenal tumor may also cause adrenal androgen
1 r5 {# ^9 q, P5 M3 C! ~excess.1,39 M/ G& m  r1 ]6 \  l, Y1 i3 ?7 Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ U5 V+ L& u6 E
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" P+ D3 N' z+ s+ ZA unique entity of male-limited gonadotropin-
$ U: x- y* C: b% dindependent precocious puberty, which is also known7 X9 N) V8 H; ?7 P) q
as testotoxicosis, may cause precocious puberty at a
3 H8 G0 i4 D6 `4 Dvery young age. The physical findings in these boys
. r2 ?3 r& ^" ]3 i3 {& O9 z, lwith this disorder are full pubertal development,
4 v$ G4 A5 x/ xincluding bilateral testicular growth, similar to boys
  Z3 E1 P+ N& m/ A9 iwith CPP. The gonadotropin levels in this disorder" |: L3 R+ Y, \8 D
are suppressed to prepubertal levels and do not show7 N* b, q0 d' S/ B8 X6 u7 X
pubertal response of gonadotropin after gonadotropin-, ]% q" i- _0 _
releasing hormone stimulation. This is a sex-linked
+ Y3 ^) ?2 r, R# E" ~6 yautosomal dominant disorder that affects only1 f4 I% A* _& e( {: |6 A) @
males; therefore, other male members of the family* y; Y  e# {' V1 H+ L
may have similar precocious puberty.3( a; e% s5 ~( r, r
In our patient, physical examination was incon-
# }7 b3 o. @3 h- S1 q1 k$ Z9 Usistent with true precocious puberty since his testi-
$ s6 B( |$ }3 ~% k& P: Q4 ycles were prepubertal in size. However, testotoxicosis
" C  i% W: _3 y( @5 }8 @8 xwas in the differential diagnosis because his father* E/ h% ?, u0 M: v: C3 `
started puberty somewhat early, and occasionally,0 F  f' g3 u/ P7 q! v! H
testicular enlargement is not that evident in the3 ~+ C' Y) P! O5 s% P* B
beginning of this process.1 In the absence of a neg-* |1 Q' P3 q% i$ }, a
ative initial history of androgen exposure, our
/ c0 ~/ O4 H: ^1 p$ a$ Bbiggest concern was virilizing adrenal hyperplasia,' j3 k5 j* g2 T2 w" V( b% K
either 21-hydroxylase deficiency or 11-β hydroxylase
8 [# w( z: R. R, K6 u* }# {deficiency. Those diagnoses were excluded by find-$ Y5 t* n# q7 J* m5 B, K* `
ing the normal level of adrenal steroids.9 m! W+ d- ~$ O$ [( h8 X! C. [
The diagnosis of exogenous androgens was strongly8 v( L3 u5 w/ u3 C# e
suspected in a follow-up visit after 4 months because9 V) @( R) [" t
the physical examination revealed the complete disap-; m/ p6 U, \* t" S
pearance of pubic hair, normal growth velocity, and
/ b$ o$ e, e: idecreased erections. The father admitted using a testos-
2 d7 T$ p2 s" A% H  S9 B# zterone gel, which he concealed at first visit. He was
. s( Z5 l9 ~" husing it rather frequently, twice a day. The Physicians’& \" _, c6 D4 [% J9 z0 @. i
Desk Reference, or package insert of this product, gel or
; I: T1 c: E' m6 P4 g/ W  Acream, cautions about dermal testosterone transfer to
5 }6 i- Z+ c% Bunprotected females through direct skin exposure.
8 i5 x/ Q; ~& n7 D6 d& ISerum testosterone level was found to be 2 times the+ K: l- }* U) r1 f( f
baseline value in those females who were exposed to
! C5 p: m- H: e6 x  xeven 15 minutes of direct skin contact with their male
# ?) E  H! e) j2 N/ W! @partners.6 However, when a shirt covered the applica-7 f8 U+ L3 E. V
tion site, this testosterone transfer was prevented.
8 ^3 x* s( g% [Our patient’s testosterone level was 60 ng/mL,# B" @! a1 B+ r: E% g
which was clearly high. Some studies suggest that0 s: Q. a5 Z. v; A# K
dermal conversion of testosterone to dihydrotestos-
5 I# \( I* _, Fterone, which is a more potent metabolite, is more/ F0 k, d4 ^0 i6 s5 }1 g
active in young children exposed to testosterone
- r7 \- g  g" d3 R* kexogenously7; however, we did not measure a dihy-8 {6 A1 S  X+ v3 C1 S& `$ r
drotestosterone level in our patient. In addition to
: ^3 F/ V+ _3 V( Kvirilization, exposure to exogenous testosterone in) C# g' K# a& \; \" s6 E
children results in an increase in growth velocity and
) H! z; D: ]2 Y% Wadvanced bone age, as seen in our patient.
# |) u  S5 O' z, d& O. pThe long-term effect of androgen exposure during% r/ h! H. }" P: L
early childhood on pubertal development and final1 Z6 }' R8 M+ s, w
adult height are not fully known and always remain: K3 J* u  L$ d9 Q
a concern. Children treated with short-term testos-
5 g" g* y# A3 S0 [! wterone injection or topical androgen may exhibit some  D. V0 g  b8 h2 B
acceleration of the skeletal maturation; however, after
9 m4 L+ e5 @7 _5 ~) k5 ]: ^cessation of treatment, the rate of bone maturation2 d! G; E  B  b+ c7 E) f
decelerates and gradually returns to normal.8,9
( L6 V# C6 z2 S# B& b" o- n2 i2 z5 fThere are conflicting reports and controversy
/ O2 Z1 d5 v) v. r& ]) Kover the effect of early androgen exposure on adult
8 u) v- s  e1 C' {, m+ e+ F- Mpenile length.10,11 Some reports suggest subnormal
8 t* K8 j4 O2 e; w* E( Zadult penile length, apparently because of downreg-, ?4 b! D$ J9 m4 B- n/ Y
ulation of androgen receptor number.10,12 However,
( n$ Q. b5 M# t; Q* v# o, d6 J0 \Sutherland et al13 did not find a correlation between  d3 J0 J2 ^& Y- m5 d1 d5 h6 i+ ]
childhood testosterone exposure and reduced adult
! z6 r& G) ?7 G) ipenile length in clinical studies.
, q! v/ [' P2 k4 c5 l( kNonetheless, we do not believe our patient is2 u- D* z: S* f1 \  U. M) ^  c
going to experience any of the untoward effects from
) R: X2 l3 g1 u. _; t; `testosterone exposure as mentioned earlier because
4 q0 X4 @5 v) p! Tthe exposure was not for a prolonged period of time.
& S! w3 P; ?# O# f  yAlthough the bone age was advanced at the time of0 Y8 |- T8 b  ]" R
diagnosis, the child had a normal growth velocity at+ h( [4 D) j) k5 E* f8 j
the follow-up visit. It is hoped that his final adult
% M% ~* c/ y" Q* \8 uheight will not be affected.
) F  F& c' p1 W' |Although rarely reported, the widespread avail-& m$ g  ^3 k& F; ]" s% B! O
ability of androgen products in our society may
* b# `. m* Z" C! kindeed cause more virilization in male or female8 W% a# }1 @, q; \' ?0 R" E2 W/ S
children than one would realize. Exposure to andro-% a6 T! _4 `# z* D4 y9 T6 `
gen products must be considered and specific ques-$ x1 e; j/ `3 S! R* t
tioning about the use of a testosterone product or5 j; X6 @  d" I4 E4 E' m
gel should be asked of the family members during
4 x! s7 I9 n" J: nthe evaluation of any children who present with vir-8 k9 U/ [0 N5 V% k9 K" {, F8 D. X: {2 N
ilization or peripheral precocious puberty. The diag-
( @. B( D" Y, i+ j# c# I; ^, i; fnosis can be established by just a few tests and by1 s2 i. |% u1 m, ]
appropriate history. The inability to obtain such a
% t3 \! ]9 n! Mhistory, or failure to ask the specific questions, may
2 }  I; ^4 k- K( I: {2 Y- Aresult in extensive, unnecessary, and expensive4 `) v3 H  Z2 b" n& U! g
investigation. The primary care physician should be
2 z- p  {9 `  G! Faware of this fact, because most of these children
+ j4 B6 |3 W, c/ W2 u1 t7 Nmay initially present in their practice. The Physicians’% u$ W7 K6 D* G9 k; P7 ?+ h" X
Desk Reference and package insert should also put a9 Q3 y1 {- v# S* I
warning about the virilizing effect on a male or) Q0 ]1 G' B9 t' u. r
female child who might come in contact with some-9 ?; X  J0 X0 b" B
one using any of these products.6 d6 N0 Q8 }5 G' a$ G9 a8 {# T
References
& G1 C! R; j3 i; X( |- A1. Styne DM. The testes: disorder of sexual differentiation
* v0 w2 D7 p. ^+ z; l. ]5 F# ?and puberty in the male. In: Sperling MA, ed. Pediatric
4 V7 t8 w* o/ C( ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: S7 L1 f9 T4 k% N
2002: 565-628.
; R. |6 N! W( }% n0 J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. E& u9 \( t% k$ Ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" g$ s9 \( Y4 v& G. A$ |
Boy Induced by Indirect Topical
% ]) ]3 R: O4 g: ]6 ^Exposure to Testosterone$ `/ `! ]  R+ Y/ z/ Y% h) ?2 T
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! N) F+ Q  ^$ i: w6 }  f8 dand Kenneth R. Rettig, MD1
! [/ X# W! Z2 A! L6 U0 g; g2 fClinical Pediatrics  e7 K+ o7 h& C7 N( D" l7 V" i
Volume 46 Number 66 Z0 n* p1 Y# L) O! t
July 2007 540-543; i, W( Q& |) z1 m8 r9 h
© 2007 Sage Publications
9 P' X) a& o2 o9 h) i% h2 U10.1177/0009922806296651: I1 e' V7 L2 X+ H. n
http://clp.sagepub.com* Z" R  i1 a" W, ~7 {
hosted at
+ D) @& f. x. Ahttp://online.sagepub.com
2 g$ i, x* t- x/ R8 FPrecocious puberty in boys, central or peripheral,! K8 {4 @' Q9 d9 t4 M( C! Z
is a significant concern for physicians. Central7 X+ l7 L7 H1 _+ y: S3 t& z
precocious puberty (CPP), which is mediated  n3 T7 @8 u% a5 S$ m; D
through the hypothalamic pituitary gonadal axis, has
( Y' d! B! _* ~. \: N# ?5 v+ ]6 xa higher incidence of organic central nervous system8 T# }' \7 w- j7 {
lesions in boys.1,2 Virilization in boys, as manifested4 r4 [  T2 [. |+ g. ^
by enlargement of the penis, development of pubic
4 I& s! G' K+ ]% L& `1 Ohair, and facial acne without enlargement of testi-
/ C, K! g- |, z- F' j; s2 Ycles, suggests peripheral or pseudopuberty.1-3 We+ s3 ~* H( _  s0 V
report a 16-month-old boy who presented with the
) D" S. `+ |$ F( Menlargement of the phallus and pubic hair develop-
) R2 N$ |0 z% v' ^8 Z3 [ment without testicular enlargement, which was due
- c) p% w7 C5 a4 B4 tto the unintentional exposure to androgen gel used by5 v5 n" j, M( Y
the father. The family initially concealed this infor-: I4 Z  O0 x6 ~& y/ u
mation, resulting in an extensive work-up for this
+ e1 Y  I' F: B* Nchild. Given the widespread and easy availability of7 A0 C% }* z8 F2 }; H7 d' _
testosterone gel and cream, we believe this is proba-
  L; T8 v- Y1 [0 g( W' L4 N, t1 @bly more common than the rare case report in the8 Y3 a' X4 |% ^
literature.4
0 S) ~9 K& N! C  X6 b, |+ b( mPatient Report2 p3 z) o5 t3 H/ z# w& {% i1 ~$ B8 m
A 16-month-old white child was referred to the4 K3 f; K* a- ^4 A% _
endocrine clinic by his pediatrician with the concern- {$ h( }# c' |: {0 Q4 U9 w4 [/ O
of early sexual development. His mother noticed2 P9 H4 q6 X& e- S+ \5 \# E* w# ~$ ?
light colored pubic hair development when he was
! |8 A* H# V  G# k/ F) u9 o+ [From the 1Division of Pediatric Endocrinology, 2University of* H1 K5 N* @8 }: {% x9 E
South Alabama Medical Center, Mobile, Alabama.
' f, @" ~; ]1 PAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 T" E4 W! P( ]3 J' ?) u# [% K* M6 Q1 yProfessor of Pediatrics, University of South Alabama, College of% P# m- K' M" ?8 @; \3 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! |* T0 `! }3 s9 E/ R" be-mail: [email protected].) Y, U7 ]2 o+ ?4 q
about 6 to 7 months old, which progressively became
; l) S; q. Y$ o; T! y' udarker. She was also concerned about the enlarge-1 a0 F: \" m( J# M
ment of his penis and frequent erections. The child) \' a+ z. i3 ^; n' I2 N
was the product of a full-term normal delivery, with) |% @5 |8 ]- c/ L
a birth weight of 7 lb 14 oz, and birth length of
0 `+ n" B5 K& K/ z$ Y; ]20 inches. He was breast-fed throughout the first year" |2 v; z3 M8 s- Y' C
of life and was still receiving breast milk along with
) C% Z( R6 W5 [# lsolid food. He had no hospitalizations or surgery,4 _1 s5 K8 h2 I! N! ?
and his psychosocial and psychomotor development/ g. k: K2 x7 v, s; ^5 X! J+ v
was age appropriate.) c3 U" D* i5 R, K6 M6 T! m; N  m
The family history was remarkable for the father,
3 z1 d& ^( ~* Q: a$ |1 u7 y6 swho was diagnosed with hypothyroidism at age 16,
1 P& a# U" W) t5 Fwhich was treated with thyroxine. The father’s
$ Z5 v" k; K" t% aheight was 6 feet, and he went through a somewhat
$ S7 o# M9 B/ K! Aearly puberty and had stopped growing by age 14.
* Z$ r0 u9 b: a7 JThe father denied taking any other medication. The
8 ?/ p& ^/ _+ H) I, r% A( }- A  jchild’s mother was in good health. Her menarche
! S& Y- N& ]+ u( F/ l, B  kwas at 11 years of age, and her height was at 5 feet9 B5 z7 U! r+ c: ]) H/ x% T9 a
5 inches. There was no other family history of pre-
, l8 b) M0 }% E' a* ecocious sexual development in the first-degree rela-* r: u( X, J  A% N+ [: \' n
tives. There were no siblings.+ b+ [! i8 \$ l
Physical Examination
$ `, q. v6 o' E; C* IThe physical examination revealed a very active,
7 l; `4 Z% e3 @5 X" v) Rplayful, and healthy boy. The vital signs documented
, C1 P" M& T% W2 z4 n) La blood pressure of 85/50 mm Hg, his length was; a' }8 M4 M- |7 c0 s) N. E
90 cm (>97th percentile), and his weight was 14.4 kg3 T& N1 H- ?# a! i# W( u
(also >97th percentile). The observed yearly growth
0 K" y" x# F3 G) D, V9 q3 g1 g: a6 fvelocity was 30 cm (12 inches). The examination of; C& \& ~6 H' d, }
the neck revealed no thyroid enlargement.
. v9 X/ g) H4 B: b( s3 XThe genitourinary examination was remarkable for
, p# Q( g3 m* l2 y. n9 qenlargement of the penis, with a stretched length of
0 w! c: F: o, P( q- Y4 C0 T" \2 t8 cm and a width of 2 cm. The glans penis was very well5 ?7 k+ G7 V2 w( c1 `
developed. The pubic hair was Tanner II, mostly around8 |/ M* z) T8 M8 C2 A( o  W# N
540& @5 A  E7 F  b' C. {! p  y" `
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the base of the phallus and was dark and curled. The) d6 u# m2 K" E3 r+ v
testicular volume was prepubertal at 2 mL each.
4 j0 N' B9 ^- I- o6 v) }$ iThe skin was moist and smooth and somewhat9 y! e4 J# R* `6 o3 T
oily. No axillary hair was noted. There were no% Q' E' W! N( T0 s4 r
abnormal skin pigmentations or café-au-lait spots.
$ F% S& ^* |6 }# C. n4 o! ANeurologic evaluation showed deep tendon reflex 2+
9 ]1 s, c0 c" ~: {# zbilateral and symmetrical. There was no suggestion
7 @7 h5 L$ J6 d, V% Vof papilledema.; P* j1 Z5 R. K( n2 C/ J! }2 t
Laboratory Evaluation
4 ~/ H7 _$ |: S% q9 f+ S3 BThe bone age was consistent with 28 months by
/ l# z- S( {4 ], n3 V% T! p: z1 Husing the standard of Greulich and Pyle at a chrono-9 Q+ T8 ?; k0 |" d* |; w. d+ m6 K
logic age of 16 months (advanced).5 Chromosomal# r4 b, }) v; [) k# E/ f8 X, t0 z
karyotype was 46XY. The thyroid function test4 z# d9 ^+ L0 L7 N, s# t3 u1 m3 [7 j( E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 Y' z2 w) h, d- ?# i. @lating hormone level was 1.3 µIU/mL (both normal).
) H7 V6 J6 |4 ]The concentrations of serum electrolytes, blood
9 G# H5 K- l' I4 v4 Turea nitrogen, creatinine, and calcium all were
2 X9 X' T! X7 }7 Q! i  f' Qwithin normal range for his age. The concentration6 O& x* }: c  Q: U# [. S5 H
of serum 17-hydroxyprogesterone was 16 ng/dL
0 c3 i2 n9 {; S(normal, 3 to 90 ng/dL), androstenedione was 20
. }6 G6 I7 p# X* Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 Y. ~1 G  W5 I( x* nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: K, a7 v/ J% {" x9 Gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 O5 B; A" a, v% }( s
49ng/dL), 11-desoxycortisol (specific compound S)7 K6 ~; U) s+ g& o- [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 u  t# q4 k/ ~# t8 B% f0 [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; i1 S$ b  a9 A! A
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( R; b) ~, L" M% N3 C5 d8 Vand β-human chorionic gonadotropin was less than; r& y& n0 o0 y2 a
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 Y! R4 i( q0 |" E
stimulating hormone and leuteinizing hormone
2 {& ]' x/ j' h" A* L4 ?concentrations were less than 0.05 mIU/mL+ y: K$ i1 Z) H
(prepubertal).# e2 P, x0 G  [6 A# |& m3 P; c
The parents were notified about the laboratory4 f6 u1 r" X3 `- |
results and were informed that all of the tests were
# J: @" {% [! V8 O: H  N1 W4 r$ [( ]normal except the testosterone level was high. The, j- U' y3 n3 h0 a
follow-up visit was arranged within a few weeks to
: @8 f1 V+ F) `+ [5 _' [obtain testicular and abdominal sonograms; how-
' q- k. N* J, P. X9 N# y+ V& Aever, the family did not return for 4 months.
* b8 ^; @8 H! X* lPhysical examination at this time revealed that the3 H5 P4 \" y" p! W6 }- Q4 w
child had grown 2.5 cm in 4 months and had gained
% B4 A% ?) m4 }; S, X3 E2 kg of weight. Physical examination remained3 X( j; ^: O4 R. ^. a% z8 ^
unchanged. Surprisingly, the pubic hair almost com-* r0 l$ F0 a/ _2 |" K: H: _: x
pletely disappeared except for a few vellous hairs at- r& o+ j8 [) g( d
the base of the phallus. Testicular volume was still 25 s1 J( @5 @8 P+ ]( E- `1 `
mL, and the size of the penis remained unchanged.
0 c1 X4 [- T( }3 HThe mother also said that the boy was no longer hav-8 Z: X0 P# {( B4 Y, g8 i8 b" \, W9 b& S
ing frequent erections.; y9 [" ^; f" V- ?
Both parents were again questioned about use of
0 L# c2 W9 G4 u: V; g& qany ointment/creams that they may have applied to3 U+ H' ]7 F& U+ l/ k9 K- R
the child’s skin. This time the father admitted the
3 [8 j/ Y; G5 j: h& q: mTopical Testosterone Exposure / Bhowmick et al 541
) H9 G8 s* V' }! V; {( tuse of testosterone gel twice daily that he was apply-. }. a9 f7 J, u) ]% f% [% K" _& \
ing over his own shoulders, chest, and back area for/ _3 p. X: ~6 T* @
a year. The father also revealed he was embarrassed9 \. V$ \; y9 L5 ?9 H, V* R: j1 W
to disclose that he was using a testosterone gel pre-
3 M1 ^9 _' ~: }: G( q, `5 @scribed by his family physician for decreased libido4 B7 W6 j1 d' O# T3 k
secondary to depression.5 u# c6 M7 O' O- F! H7 t6 U
The child slept in the same bed with parents.
/ `4 `4 g7 M8 a9 V+ v5 m+ T7 KThe father would hug the baby and hold him on his
3 W# e& P- E9 D0 ]) D- X2 gchest for a considerable period of time, causing sig-
  g& n3 O8 u8 y7 s' Xnificant bare skin contact between baby and father.
) P. y: P9 g- o  }( K5 wThe father also admitted that after the phone call,
/ w/ \# v( U5 D7 u* X1 ywhen he learned the testosterone level in the baby, V- p0 z  O5 S( {( S  r, D
was high, he then read the product information- H6 c0 ]$ y- P$ F$ V+ [$ |
packet and concluded that it was most likely the rea-
' K3 U  i$ Q  u" q1 Gson for the child’s virilization. At that time, they  s5 T) U, h. y' K6 V) L8 a/ F: J
decided to put the baby in a separate bed, and the6 @/ E0 M0 }1 B# I) m
father was not hugging him with bare skin and had6 [; Z6 N0 M1 q. J2 u; Z6 N! J6 o0 U9 @
been using protective clothing. A repeat testosterone4 [* C+ J; }' [6 g
test was ordered, but the family did not go to the3 c; r% v) _' B$ a) V
laboratory to obtain the test.
- X) i" Z3 p1 G  _4 s5 BDiscussion
7 X# E5 X  g1 D, Z, }  m: SPrecocious puberty in boys is defined as secondary
0 W8 d2 ?+ Y# A2 H( D# w  B8 `- u  vsexual development before 9 years of age.1,4  X  u* P  u; `- E% p* d
Precocious puberty is termed as central (true) when( E) E, ]1 X" `/ L1 x
it is caused by the premature activation of hypo-
' M/ \! T" j, `- S9 k. Hthalamic pituitary gonadal axis. CPP is more com-
7 G. W: d9 t% Nmon in girls than in boys.1,3 Most boys with CPP
/ o/ }! Z! D$ vmay have a central nervous system lesion that is
2 W4 M* l0 x# c$ ^8 y+ Zresponsible for the early activation of the hypothal-
& P5 i- B3 R8 j3 ?: L" ^% Damic pituitary gonadal axis.1-3 Thus, greater empha-
% J$ D% ]3 [( E, t& _sis has been given to neuroradiologic imaging in
2 R+ |* R3 _& u5 ?boys with precocious puberty. In addition to viril-
1 a6 B8 J1 A5 z% i; g6 i- Zization, the clinical hallmark of CPP is the symmet-
+ W# q+ a- L) Q2 Srical testicular growth secondary to stimulation by" ]3 i; F6 T  U7 K' j, P8 \3 J  o
gonadotropins.1,35 j$ e  U' @  ~9 S) d$ u
Gonadotropin-independent peripheral preco-  L) f2 e* u% t1 |6 v6 {( Z/ |
cious puberty in boys also results from inappropriate
$ l8 r" i) m9 K1 Fandrogenic stimulation from either endogenous or
% ~& h8 b4 S1 o% `exogenous sources, nonpituitary gonadotropin stim-+ U0 H% [3 i6 \8 e/ a8 C- G
ulation, and rare activating mutations.3 Virilizing" |* l; P2 G; G9 k+ F- {' E9 Z
congenital adrenal hyperplasia producing excessive
4 e9 b3 g7 X5 G8 @* n, t+ a) ~adrenal androgens is a common cause of precocious
+ G7 W4 ]7 l! r8 _! opuberty in boys.3,48 D: Q- f' q7 G% z2 ~: Y0 j; V' b
The most common form of congenital adrenal4 _! t; }  X, N: }& y
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 v" `5 E2 {/ _) n8 C( aThe 11-β hydroxylase deficiency may also result in( n' R. @/ W7 S* `  Y* |4 M
excessive adrenal androgen production, and rarely,9 B0 q2 u! h( J& G" g+ i' D
an adrenal tumor may also cause adrenal androgen
9 L- A% e2 U8 w4 m6 l8 \! Cexcess.1,3
) n) i' |7 ~# h' o7 q1 U# e- s  _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 {; q* M1 X8 T# W" d( @8 p0 {542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 c9 V# ]+ E9 q" x+ MA unique entity of male-limited gonadotropin-
; Q# s% C- U3 D+ i: F: mindependent precocious puberty, which is also known
6 I- S2 h$ \$ g$ R, was testotoxicosis, may cause precocious puberty at a" h2 `9 N: |( s9 y) J
very young age. The physical findings in these boys
; f4 {/ \. r& Z" O8 J7 q9 `with this disorder are full pubertal development,/ H) H! I8 t, ?& ~' n+ c! |
including bilateral testicular growth, similar to boys
8 p& A8 z- C  fwith CPP. The gonadotropin levels in this disorder
/ R& A0 ?( r: C6 u1 Eare suppressed to prepubertal levels and do not show
3 m* b0 T$ ^' h  ~# Apubertal response of gonadotropin after gonadotropin-+ E- f7 z" ?, {
releasing hormone stimulation. This is a sex-linked# x9 `) ~: v3 J4 Q0 H
autosomal dominant disorder that affects only! x: q+ G, u  U4 V5 W& i! y/ t
males; therefore, other male members of the family
6 f) }: t# `7 O: h# z6 omay have similar precocious puberty.3& Y% g+ Q1 K6 C8 B( x
In our patient, physical examination was incon-
) G; |' V9 y, G5 F5 O3 G9 C# wsistent with true precocious puberty since his testi-
+ k. s) N! {; d5 c* v6 a) [cles were prepubertal in size. However, testotoxicosis2 H$ q: d0 r/ B: m" `" J4 p. b
was in the differential diagnosis because his father( _. C" \' @; N& A; _( ]6 c% d
started puberty somewhat early, and occasionally,
* }5 p: ^  \5 i' {' ?) e+ \testicular enlargement is not that evident in the
0 C% l( ]' A( w' a; a& @/ Kbeginning of this process.1 In the absence of a neg-
0 m2 ?' y9 A- d1 B3 e" Rative initial history of androgen exposure, our( E1 `! k# i4 a' |) s
biggest concern was virilizing adrenal hyperplasia,
) z# e. z$ C7 k# }either 21-hydroxylase deficiency or 11-β hydroxylase
0 l2 m! L) a1 E6 K2 a" ~/ X8 [deficiency. Those diagnoses were excluded by find-
/ w9 x$ H( A; i6 n- F% F+ ~! Ming the normal level of adrenal steroids.
" x7 m: I& W- v8 ~; g( ^$ DThe diagnosis of exogenous androgens was strongly& i5 V- R/ \( W( \/ `  W+ `5 y- D0 K
suspected in a follow-up visit after 4 months because
, t& {9 G) J8 o4 z9 Hthe physical examination revealed the complete disap-
! d# K% `; _" ppearance of pubic hair, normal growth velocity, and
; u  k$ f; \  C& }1 Hdecreased erections. The father admitted using a testos-
8 N: X% G, \" [9 ]1 V; d/ c4 Q6 Gterone gel, which he concealed at first visit. He was
& s  q' `& a4 O2 J$ h4 q+ qusing it rather frequently, twice a day. The Physicians’! W4 [: U. F, }- W9 t/ N2 R; J+ f+ J, G
Desk Reference, or package insert of this product, gel or# d& k* ]: C) u# H# H% u' i
cream, cautions about dermal testosterone transfer to
# F1 J6 i! g; u  F* Tunprotected females through direct skin exposure.8 C8 w& Z0 j. r) I$ z. e
Serum testosterone level was found to be 2 times the$ t; ?, n- S8 u
baseline value in those females who were exposed to: D# p- A4 U# `6 h8 W
even 15 minutes of direct skin contact with their male# P. h. l; g2 r1 p+ i" Z- ]* f& k2 X+ C& U
partners.6 However, when a shirt covered the applica-0 R) ~; a# m$ ~  ^( c  T
tion site, this testosterone transfer was prevented.
+ T! T6 x; k% AOur patient’s testosterone level was 60 ng/mL,# r: m* ^7 ~! C$ J( P% b
which was clearly high. Some studies suggest that% k: S* {: b; r' e3 N* M
dermal conversion of testosterone to dihydrotestos-
! h# E5 W1 @/ w5 m; ?* F; |* _terone, which is a more potent metabolite, is more3 y+ I: J3 }4 r+ j
active in young children exposed to testosterone
, |* z# k2 |3 C3 E% ~* sexogenously7; however, we did not measure a dihy-* ^$ L- ^% j5 y8 Q1 c6 n
drotestosterone level in our patient. In addition to1 a& B: ^/ g  @; ?' r7 I8 V
virilization, exposure to exogenous testosterone in/ V1 y( [( i4 Q3 Y, z1 H
children results in an increase in growth velocity and
$ a% ~, K# E0 t, [advanced bone age, as seen in our patient.6 s0 i8 J. D6 G3 I% F
The long-term effect of androgen exposure during
+ h" l- \' Z8 q7 N2 ?early childhood on pubertal development and final7 w& t  T6 K; O! k# y  g; V
adult height are not fully known and always remain
9 A9 R6 j/ X/ ]a concern. Children treated with short-term testos-
$ h2 u% k  H" V7 i* fterone injection or topical androgen may exhibit some& n8 T8 s" y# e
acceleration of the skeletal maturation; however, after
% V4 P# l' q1 H2 K' p  [cessation of treatment, the rate of bone maturation* |) N! t% U" {: Y
decelerates and gradually returns to normal.8,9; h6 Q9 T0 q2 B4 v6 Q
There are conflicting reports and controversy
( ^. z# c% S2 d$ n  `$ [4 S1 jover the effect of early androgen exposure on adult
# n0 M2 ^) r* i1 D- G$ E  G. bpenile length.10,11 Some reports suggest subnormal5 F. B5 G8 r. U+ @; R. R
adult penile length, apparently because of downreg-
; z8 q( c4 ^5 w  u& A+ |( d0 j3 bulation of androgen receptor number.10,12 However,% }  B+ `: B9 Y8 \( Y2 K, f% j, ]
Sutherland et al13 did not find a correlation between, \5 s" V; A) b# q( \
childhood testosterone exposure and reduced adult
2 `8 q6 E6 o! G6 O1 L! y! G$ m+ ppenile length in clinical studies.
  Z9 E. }, M  K# b3 yNonetheless, we do not believe our patient is
6 D3 T7 N9 f2 `  Fgoing to experience any of the untoward effects from
: c) R6 ?4 Z' K7 N4 qtestosterone exposure as mentioned earlier because
/ J) H5 ~  p" ]2 U* _7 t- ithe exposure was not for a prolonged period of time.
3 s* \$ l0 _1 c: R- r! z( C0 ]Although the bone age was advanced at the time of" ?; |3 d- V7 B% J6 c9 ?
diagnosis, the child had a normal growth velocity at
( S& x. T5 T; Z' Lthe follow-up visit. It is hoped that his final adult* C; R% s4 i, L2 s0 j; s& Z+ J
height will not be affected./ [) D7 h1 B# H. W; N9 ~
Although rarely reported, the widespread avail-
! P3 H0 |: p% O9 o3 p( X. ~0 _3 Fability of androgen products in our society may: u5 o. t* ^& x
indeed cause more virilization in male or female
3 N; z% A: F0 P8 M. i. b7 Hchildren than one would realize. Exposure to andro-
" {9 U3 u) D9 c+ I  @% Hgen products must be considered and specific ques-$ t; y# n9 h+ T0 b7 T4 h/ a9 {1 E0 n. }1 t
tioning about the use of a testosterone product or
* Z( _+ o. j5 ]6 egel should be asked of the family members during
" T3 X4 y. \8 L0 s0 othe evaluation of any children who present with vir-
4 Y" x/ U; Q  b  Vilization or peripheral precocious puberty. The diag-" W$ l3 G+ n, P. g9 o, g
nosis can be established by just a few tests and by
# R4 l* A* z, q9 [, d- t. F+ pappropriate history. The inability to obtain such a2 v  D. i3 M1 i; y
history, or failure to ask the specific questions, may
" s: r+ T! ?5 J3 X- C% {6 ?. x5 t/ Lresult in extensive, unnecessary, and expensive
0 Y. P3 ^8 ?& a! F% ^investigation. The primary care physician should be! P' d6 ]# N! B; x# B
aware of this fact, because most of these children
; U7 j! u6 U' t) c* T% p' X9 N- [may initially present in their practice. The Physicians’  J  u, N0 b2 Z
Desk Reference and package insert should also put a* j4 f$ H" N! J4 P. ~8 p3 }3 v5 v
warning about the virilizing effect on a male or4 ]; ~0 @- {' R7 v; x
female child who might come in contact with some-0 B% Z  J. K* @7 M
one using any of these products.% Y) k( @+ s& q9 ]
References8 E4 w7 D$ d8 l3 _  y
1. Styne DM. The testes: disorder of sexual differentiation
& g5 C; Q% U; v$ V% Sand puberty in the male. In: Sperling MA, ed. Pediatric
5 T4 @0 p3 S( S' z, DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ E; Y! X9 ~9 R& h8 M) `/ e
2002: 565-628.
9 M7 M* c- Q- N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, \: P. e4 H: P0 b# {" j3 Xpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
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
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

& h% u0 ]. y- C+ k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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