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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
4 {# S+ F6 \/ NBoy Induced by Indirect Topical! C2 Z" \  ]9 D" W! X/ S5 r
Exposure to Testosterone( [. @7 C# t# U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- i1 @+ Y2 g* h
and Kenneth R. Rettig, MD1
+ D1 X: F1 p8 }6 l( CClinical Pediatrics3 ~+ c& F6 X: f. e
Volume 46 Number 6) e: U$ K) F/ ]. d2 h
July 2007 540-543- ^+ J1 t8 e/ W& m8 Q
© 2007 Sage Publications4 ?3 @3 S1 J) q  g. u: j4 F
10.1177/0009922806296651
8 }  Z# O9 U% b+ j3 Mhttp://clp.sagepub.com: B' F: {5 o9 y9 Q5 X( [5 c( \* c
hosted at( [8 W: V, T: A/ {5 {) S
http://online.sagepub.com: i4 e& c6 Z5 w$ v9 N
Precocious puberty in boys, central or peripheral,5 n, l) Z9 @3 R0 d# `! X
is a significant concern for physicians. Central
. t5 [, e' r- N3 }; wprecocious puberty (CPP), which is mediated
* i9 A% [+ k# ethrough the hypothalamic pituitary gonadal axis, has0 ]7 }. j2 O8 |/ r# c) p" C, I# ?
a higher incidence of organic central nervous system
8 x: a+ ?* ]# u+ u, W9 zlesions in boys.1,2 Virilization in boys, as manifested' i3 [5 k8 l% b$ M) I2 j: c6 i3 W4 j
by enlargement of the penis, development of pubic
' ^5 a5 _8 e3 a8 Mhair, and facial acne without enlargement of testi-
- r% f5 V" |+ Z4 kcles, suggests peripheral or pseudopuberty.1-3 We
+ Q, y/ z7 k% K7 u% Ereport a 16-month-old boy who presented with the
9 S- E  K$ x6 O, q+ venlargement of the phallus and pubic hair develop-( a; t$ g* N" H4 ?6 O# l# B& j: k
ment without testicular enlargement, which was due; b  l; F( Q; j: H6 Q* |
to the unintentional exposure to androgen gel used by/ N& \$ J0 ^1 Q9 Q% V1 o
the father. The family initially concealed this infor-6 f$ ?2 l8 \" \: T! N& M7 t
mation, resulting in an extensive work-up for this# ]% C! Z  @# _( P
child. Given the widespread and easy availability of* G0 z5 m* f  H! F  M- c1 M
testosterone gel and cream, we believe this is proba-: F6 |; V5 @; V9 o5 H1 ]  j
bly more common than the rare case report in the  J6 W9 X! o- }. F% o* y6 P
literature.4
" K' Q+ e( \3 e) a! b/ OPatient Report
8 F( s& N$ `4 D: v# X) [A 16-month-old white child was referred to the
/ l, ^1 ^/ ~% F; _7 C5 W2 \- pendocrine clinic by his pediatrician with the concern) n' j& N2 W- g# b1 N0 d0 L
of early sexual development. His mother noticed6 G" u$ Y! `& [5 c. h1 g9 s' p6 g
light colored pubic hair development when he was$ }+ C! s% ]3 n7 Y0 q" v9 u
From the 1Division of Pediatric Endocrinology, 2University of
; k5 H) O) h( s! K" h% m4 mSouth Alabama Medical Center, Mobile, Alabama.3 U1 Z( k/ O' ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,! ~; q/ t6 S5 F( o/ O- p
Professor of Pediatrics, University of South Alabama, College of0 Y6 f5 Q* ]& c. e6 S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 B& O+ K6 x7 \
e-mail: [email protected]., h' a9 h2 |* y2 J9 \! V/ m
about 6 to 7 months old, which progressively became
& k2 e( b% z( b8 sdarker. She was also concerned about the enlarge-2 {4 G: l1 \( ~, I1 X
ment of his penis and frequent erections. The child
6 c+ l' \3 d: I$ ?was the product of a full-term normal delivery, with; R0 [. [4 w! v, H9 t* S
a birth weight of 7 lb 14 oz, and birth length of
' S$ T$ \2 ?6 m# l; u20 inches. He was breast-fed throughout the first year$ b! R; i& o* g1 o) s
of life and was still receiving breast milk along with
1 E1 E. E6 A8 Nsolid food. He had no hospitalizations or surgery,
7 ~: @0 r- i) z8 }! ^% m' @5 Iand his psychosocial and psychomotor development
: ]! E- h0 z, ]8 N& nwas age appropriate.9 L1 S. i  c5 ^2 L9 k
The family history was remarkable for the father,8 L% B  I0 Q8 F: c
who was diagnosed with hypothyroidism at age 16,6 U0 J5 t# D2 k# B- x8 Q9 z, o
which was treated with thyroxine. The father’s6 `  J8 q) y  `2 y5 x7 ^% M1 ^
height was 6 feet, and he went through a somewhat# a; d, M' x! y4 D" \% k: M
early puberty and had stopped growing by age 14.8 I* v7 K  ^: A7 @: {) K9 [
The father denied taking any other medication. The
$ g& O& P( h) K$ v& @4 wchild’s mother was in good health. Her menarche- @0 q& A5 O4 f- W
was at 11 years of age, and her height was at 5 feet5 }9 A- j; ^; d7 S/ t
5 inches. There was no other family history of pre-
3 X* q% Y( H4 }% e* g0 U$ H, ]3 J7 qcocious sexual development in the first-degree rela-# p- f0 U! _) O6 O; C2 b: _
tives. There were no siblings.' r, S6 h" Y3 p& l2 b$ a: A
Physical Examination! X. e) p$ Q0 v: G7 G! W
The physical examination revealed a very active,# i( s" e! @; H# ]9 H1 X& |
playful, and healthy boy. The vital signs documented: U1 a5 C$ \; @
a blood pressure of 85/50 mm Hg, his length was  R" b% Y" }0 f' h- n; B) r
90 cm (>97th percentile), and his weight was 14.4 kg4 T. Z* e! e* K* _
(also >97th percentile). The observed yearly growth) C* s5 M+ p, `" w
velocity was 30 cm (12 inches). The examination of
/ }4 ]) A( j2 ^6 @6 o+ X! b, Pthe neck revealed no thyroid enlargement.
0 o- I3 C' a1 z$ S0 w/ Y( k6 ?: UThe genitourinary examination was remarkable for* G4 z/ d" d* y. i! e$ J3 d
enlargement of the penis, with a stretched length of" C; i) H$ ?" i- Z6 e3 p7 H  {, g
8 cm and a width of 2 cm. The glans penis was very well
9 w4 J4 u! H; K, a& rdeveloped. The pubic hair was Tanner II, mostly around5 |- V, V$ H1 b, G, E
540
* [: }& T" a* `' I2 g) nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 T2 a; L. P+ c6 Z
the base of the phallus and was dark and curled. The* f) j* d* p' _7 K6 r* [# v, t
testicular volume was prepubertal at 2 mL each., @' J. i; h/ Y9 N( H
The skin was moist and smooth and somewhat
& x8 @6 w7 m4 K+ f9 G4 T* woily. No axillary hair was noted. There were no
' B6 R$ T3 r- W( r1 ]& ?* Qabnormal skin pigmentations or café-au-lait spots.
+ Q$ _9 o0 q( H- x- D4 h! M, M% RNeurologic evaluation showed deep tendon reflex 2+
  {3 X/ S/ P) w* S6 Hbilateral and symmetrical. There was no suggestion
# V" C# U5 b+ x- F, A% M' ^$ J$ _. Iof papilledema.
* W0 d! Y* @/ P# I9 a; c1 iLaboratory Evaluation# }! v- I# z( {+ H" b# I
The bone age was consistent with 28 months by
$ }, p5 W6 G2 H1 O5 i+ j! Xusing the standard of Greulich and Pyle at a chrono-" O6 N, s2 Q! I# i
logic age of 16 months (advanced).5 Chromosomal' V+ _/ P' _- G: |* w3 K% }
karyotype was 46XY. The thyroid function test
( h: _' e4 O& r& N9 [showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 i+ t- ^* P; a7 @, h9 t
lating hormone level was 1.3 µIU/mL (both normal).4 l8 x! `. m! y1 w: P7 N/ j
The concentrations of serum electrolytes, blood
4 T* W, N/ ]9 @, n! R+ K- gurea nitrogen, creatinine, and calcium all were
- ~, K8 c4 Z4 r" e9 h, f2 cwithin normal range for his age. The concentration; o0 U9 p" H) W; R/ g# ]' x
of serum 17-hydroxyprogesterone was 16 ng/dL4 g6 j. O$ F9 w# @
(normal, 3 to 90 ng/dL), androstenedione was 20
5 K' s0 n# D4 ]6 ^* Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& S% E( D& @# ?3 H, N) _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 P4 _) t4 p! A; cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to- @; l! {. I4 s! B$ L
49ng/dL), 11-desoxycortisol (specific compound S); X- D7 G( D9 l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 }7 U7 ~! c: L% R/ [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  u8 m. |) d2 _- t$ \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 z+ s% A8 [5 ]" E* V& Gand β-human chorionic gonadotropin was less than, `9 C5 D/ J% @8 p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; B$ @# L. w) a8 M& o. lstimulating hormone and leuteinizing hormone
8 M5 z! K, q# fconcentrations were less than 0.05 mIU/mL% y/ ]' T% {& C8 N9 S, o! i
(prepubertal).; X5 z" C4 B5 E$ h
The parents were notified about the laboratory
0 [8 r& \, v6 Rresults and were informed that all of the tests were0 x: }- I4 M. M" v/ v. U5 M
normal except the testosterone level was high. The
& t- e5 {) m/ k1 O8 \& T0 T; Q# Qfollow-up visit was arranged within a few weeks to
! F. ^  ]5 [9 f3 Nobtain testicular and abdominal sonograms; how-
, k4 ]9 k" {7 Tever, the family did not return for 4 months.
- d4 u5 j/ J& A+ {- e* ZPhysical examination at this time revealed that the
6 l+ N, e& h. s* uchild had grown 2.5 cm in 4 months and had gained1 Z" I2 t. [( ~+ D1 l$ C8 l- o
2 kg of weight. Physical examination remained0 h/ C) W8 I7 j& y2 {$ u
unchanged. Surprisingly, the pubic hair almost com-$ w1 X1 i' D9 H4 F/ ?" w" J# I
pletely disappeared except for a few vellous hairs at5 R6 m8 p9 w* K* K7 t1 E/ ~3 z2 ]
the base of the phallus. Testicular volume was still 2, R4 L6 a4 B; \/ i# d( ]/ W
mL, and the size of the penis remained unchanged." j/ S$ l' r  t- {7 X
The mother also said that the boy was no longer hav-9 J& ^3 w/ k$ u. T
ing frequent erections.
" K: t, Y/ T' K  \, _+ T' uBoth parents were again questioned about use of
+ m+ |: {$ H% {( M: J& M, R5 sany ointment/creams that they may have applied to$ S4 {5 |( @! Z' N. b
the child’s skin. This time the father admitted the$ i: V6 p6 w$ G; p7 q
Topical Testosterone Exposure / Bhowmick et al 541- E$ _# v% n' Y% k
use of testosterone gel twice daily that he was apply-
6 L7 s/ S0 L6 K! ^- ~/ ~( `ing over his own shoulders, chest, and back area for
1 D/ d; Q/ v" F" }a year. The father also revealed he was embarrassed# D( o/ F. R: Q- k1 b& f
to disclose that he was using a testosterone gel pre-8 U4 `0 _. d$ _6 C- I9 k
scribed by his family physician for decreased libido, M7 m" r, o% d
secondary to depression.9 @: f( t1 S7 x  r4 Q2 [/ Z
The child slept in the same bed with parents.
9 N4 o# e2 w) B/ s, lThe father would hug the baby and hold him on his
% i/ r" ?$ Q4 U. A: ichest for a considerable period of time, causing sig-
( E4 G2 \8 V' s. v3 p2 }nificant bare skin contact between baby and father.
, N6 d7 V. O3 q' l- _" QThe father also admitted that after the phone call,- d9 w( E8 l/ b$ c1 b  D; @
when he learned the testosterone level in the baby& s* l! ^8 _3 W1 p( _' j+ R5 ], B
was high, he then read the product information
0 v1 r" W( y7 H; U' w1 W5 ppacket and concluded that it was most likely the rea-9 F/ K! b8 H9 ]; N6 f& i% n
son for the child’s virilization. At that time, they( H# [; H8 k: A+ B
decided to put the baby in a separate bed, and the6 B7 m6 N! a% _5 Z- h. W1 p9 w
father was not hugging him with bare skin and had
2 j# _% w" o6 }been using protective clothing. A repeat testosterone
! i( I, k) m0 E4 E1 B. v# mtest was ordered, but the family did not go to the
: ]+ R) R1 y- Vlaboratory to obtain the test.% x# i! z' c! i2 K) g! x+ y
Discussion* e) f$ z  l% n8 v6 ]. w
Precocious puberty in boys is defined as secondary
' Q8 z3 ]( N2 V9 y  ~sexual development before 9 years of age.1,4
) X5 X$ t' _+ l) ZPrecocious puberty is termed as central (true) when
) C$ Y" d. G! I7 oit is caused by the premature activation of hypo-
$ R9 N8 D$ t! o2 Z3 j5 K+ [thalamic pituitary gonadal axis. CPP is more com-& ~( J+ E/ G! S# @3 r
mon in girls than in boys.1,3 Most boys with CPP
  i+ d% @9 q0 s1 P( f- ~5 S& |0 Hmay have a central nervous system lesion that is
' j2 [. J4 ^5 _8 @responsible for the early activation of the hypothal-
% R! T' ~( u6 A8 `# Iamic pituitary gonadal axis.1-3 Thus, greater empha-7 S- Q, F9 r0 p0 I* W, s  S3 T
sis has been given to neuroradiologic imaging in
8 e; X$ q  u; j* Pboys with precocious puberty. In addition to viril-
/ p! m- j1 Q. p" C+ C, vization, the clinical hallmark of CPP is the symmet-
( G' G4 X9 c8 T- Wrical testicular growth secondary to stimulation by: t: J4 h( [1 x  S
gonadotropins.1,3) j6 t2 z  b: ]1 i' ?. s7 `; q
Gonadotropin-independent peripheral preco-
3 n* r$ h! ^8 H; N8 ~8 Mcious puberty in boys also results from inappropriate" L, T/ E( n7 |5 A+ _
androgenic stimulation from either endogenous or
. J! K1 {. m; e% Oexogenous sources, nonpituitary gonadotropin stim-
3 X8 p& n4 m3 h2 wulation, and rare activating mutations.3 Virilizing
; R8 o7 }) E$ w5 O/ M7 Ycongenital adrenal hyperplasia producing excessive8 @) F, J& R! z. ?' c2 K4 v
adrenal androgens is a common cause of precocious
. D8 v7 @! f* d8 wpuberty in boys.3,4# y0 K) b' F% c% I
The most common form of congenital adrenal, l, R0 r, L! m' n$ K' w/ ~
hyperplasia is the 21-hydroxylase enzyme deficiency.
) c# f1 F+ }. A/ YThe 11-β hydroxylase deficiency may also result in
* N* i( f# |/ V, Y/ q6 c& gexcessive adrenal androgen production, and rarely,% |* G: Q+ b( M. Y9 {1 }" S$ K8 V
an adrenal tumor may also cause adrenal androgen
4 x) _- t. v1 h: N+ I( h2 Fexcess.1,3+ U' n5 ]1 O+ R1 n5 M+ s. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" k4 q8 z% z6 n$ M* i3 m8 T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ p9 ~/ u2 d6 M) @A unique entity of male-limited gonadotropin-( B5 ?# e/ V6 y! C; P7 R! x
independent precocious puberty, which is also known
, i8 a. d) j& s0 Oas testotoxicosis, may cause precocious puberty at a
" _; ]0 V$ C) Wvery young age. The physical findings in these boys5 n8 I  f; i* ?2 a4 h8 c  q. q
with this disorder are full pubertal development,9 y2 m- x& i2 z% [: i& y
including bilateral testicular growth, similar to boys2 ?3 s5 x+ q8 l$ r
with CPP. The gonadotropin levels in this disorder
. V" F0 k) x+ J$ p0 S6 ]are suppressed to prepubertal levels and do not show
& N. f4 {( Y( R. [1 P7 gpubertal response of gonadotropin after gonadotropin-
4 O' M- x8 I% z+ R: @releasing hormone stimulation. This is a sex-linked
4 j& Q, @  J2 F1 ^autosomal dominant disorder that affects only
; [, F4 M( u8 t+ Tmales; therefore, other male members of the family
0 t; ~/ s" h+ |! ]6 r9 omay have similar precocious puberty.3
  C' ?; z% S6 }* Q& ?  }In our patient, physical examination was incon-2 @" y* i1 j2 q0 l" l
sistent with true precocious puberty since his testi-6 e& t; ^+ r* D
cles were prepubertal in size. However, testotoxicosis4 d7 K2 c) o5 y0 k& X0 v9 h' e5 }
was in the differential diagnosis because his father3 t, j) L. R" X6 s
started puberty somewhat early, and occasionally,, p. v/ Q  f0 R
testicular enlargement is not that evident in the! K5 T8 j8 v% ]5 d9 g  A% ~2 q
beginning of this process.1 In the absence of a neg-4 q, M' \9 V4 l) c
ative initial history of androgen exposure, our
0 ~0 R7 b1 Q4 Abiggest concern was virilizing adrenal hyperplasia,
2 o( W9 |$ z; u) C. F$ keither 21-hydroxylase deficiency or 11-β hydroxylase5 ]1 R/ R) j8 _4 j9 E
deficiency. Those diagnoses were excluded by find-- g5 t& Z  O! z  e  z6 p
ing the normal level of adrenal steroids.
' D! S* E* n7 Z$ D2 HThe diagnosis of exogenous androgens was strongly) d5 B  G1 J2 R# b2 E& {8 Y
suspected in a follow-up visit after 4 months because* P7 [( i/ ^+ s* Z0 [
the physical examination revealed the complete disap-
/ S4 m5 T8 H* k% J: Ipearance of pubic hair, normal growth velocity, and
% t0 o; ~( `1 gdecreased erections. The father admitted using a testos-2 i- J1 L. e* n; O) y
terone gel, which he concealed at first visit. He was
3 ?; Z- E( k; susing it rather frequently, twice a day. The Physicians’
- o! q' H+ t# o9 ?! w( WDesk Reference, or package insert of this product, gel or* j; K3 C/ e2 |" }/ w+ i! a7 l% j
cream, cautions about dermal testosterone transfer to4 D+ B+ g" e% A3 n4 [) S" v: h
unprotected females through direct skin exposure.
5 G' j! _5 s' T- U% j0 gSerum testosterone level was found to be 2 times the
5 c' H1 T( w: p$ Ibaseline value in those females who were exposed to; y+ U, J+ x9 K2 b/ _
even 15 minutes of direct skin contact with their male+ Z" o3 s  D% V1 l% Q% a" }" F- R0 i
partners.6 However, when a shirt covered the applica-
) v( m% Z1 u3 Mtion site, this testosterone transfer was prevented.. k3 e2 M8 S! R) f
Our patient’s testosterone level was 60 ng/mL,; I1 b) Q2 w$ S; ^  r; A9 E9 u% ], A
which was clearly high. Some studies suggest that
5 P! f! i- \0 E6 a7 mdermal conversion of testosterone to dihydrotestos-+ d* }/ k" d% }8 i
terone, which is a more potent metabolite, is more  K# A  q- F( `' _
active in young children exposed to testosterone! g; o- `4 B1 ?. y
exogenously7; however, we did not measure a dihy-
1 s6 M) _' Z; G, t$ _. Kdrotestosterone level in our patient. In addition to; V$ a4 a6 g/ V9 F8 |
virilization, exposure to exogenous testosterone in7 r, \; B" O+ ?) o3 C
children results in an increase in growth velocity and% U3 X+ @0 O% J' M
advanced bone age, as seen in our patient.  z& ^/ T# e; [; g1 \# X/ F
The long-term effect of androgen exposure during
3 D! a7 w5 E) \. N# Searly childhood on pubertal development and final7 v% _& H- D9 b6 }* z
adult height are not fully known and always remain
" o8 L! u. J# a: o6 Ja concern. Children treated with short-term testos-- [( x- X7 d( v+ j
terone injection or topical androgen may exhibit some
# Z& U4 e* ~; A) [6 Pacceleration of the skeletal maturation; however, after
- o7 r2 `# C  Z4 Y# R0 w; Kcessation of treatment, the rate of bone maturation7 J2 v( Z( [% P2 ?
decelerates and gradually returns to normal.8,9
! x; g- U' f# k' k8 a( dThere are conflicting reports and controversy2 D2 {/ r; s+ x. u$ M# v& E
over the effect of early androgen exposure on adult9 W& z2 X. b9 ]& r
penile length.10,11 Some reports suggest subnormal3 \0 z( t7 w# ]9 I3 J
adult penile length, apparently because of downreg-
  k; M4 R( j* a6 culation of androgen receptor number.10,12 However,
) [8 L7 C; \6 J  L7 N0 B& f# dSutherland et al13 did not find a correlation between8 m% z3 |* O5 G6 ~% d% @
childhood testosterone exposure and reduced adult/ G' n! z; G7 |. \
penile length in clinical studies.
: i% G$ J3 W( l4 T4 J$ U1 {Nonetheless, we do not believe our patient is
$ {! }$ a7 B1 u& Vgoing to experience any of the untoward effects from- W3 ~) Y& j% _( e0 S3 `) d3 C
testosterone exposure as mentioned earlier because
0 o7 H0 N  ]; J! r% Nthe exposure was not for a prolonged period of time.
+ g4 l1 v& D! ~3 ?5 x! n4 K3 t6 ZAlthough the bone age was advanced at the time of
- T5 }/ O9 p$ m; z. B. Adiagnosis, the child had a normal growth velocity at
# i. a8 l. l5 E% r, c8 cthe follow-up visit. It is hoped that his final adult# t3 f; S" V7 {; Z! J: X
height will not be affected.  U) e' J: [& `4 ~4 {
Although rarely reported, the widespread avail-; a3 B, |8 F( G7 ?! ^" @
ability of androgen products in our society may
* @! x8 p, ^. C$ v) hindeed cause more virilization in male or female$ [* @2 h) Q# y" c! }* N
children than one would realize. Exposure to andro-7 S( r1 H- w) I& ^, F
gen products must be considered and specific ques-6 a1 I$ |+ f% r1 D0 Q$ x3 Y
tioning about the use of a testosterone product or
6 v/ `/ L6 f) u, e" T; n( Y$ |gel should be asked of the family members during- {' Y" V/ [5 z2 k- }5 ]) ^3 }. o
the evaluation of any children who present with vir-# i, k* V7 K4 a* Z
ilization or peripheral precocious puberty. The diag-
% E  B$ V& M+ |6 Onosis can be established by just a few tests and by. |2 ~& q! y! b" }* |7 H& w, [
appropriate history. The inability to obtain such a' h* N% y3 T; C/ P4 m9 {
history, or failure to ask the specific questions, may
, |4 a8 l0 {1 v2 aresult in extensive, unnecessary, and expensive6 ?# @9 K9 b) w6 |; r* {) {6 ]
investigation. The primary care physician should be. m" s% y7 A5 \0 W) `! N
aware of this fact, because most of these children
$ M. {. e% U$ u; J' f! k+ bmay initially present in their practice. The Physicians’& p' [' y% l/ U) T0 X4 Z. p! z
Desk Reference and package insert should also put a
6 u9 ~9 q0 A7 {# j6 n4 ywarning about the virilizing effect on a male or8 L* q; f( _, I. M6 d5 K5 ^/ G' F
female child who might come in contact with some-
. T/ f' ?  ~! p+ b" d, Fone using any of these products." T, ~+ ^! b3 A
References
1 L1 A7 U( a4 d: V7 q1. Styne DM. The testes: disorder of sexual differentiation
0 Z! r! f) T; a  C9 E9 o' Eand puberty in the male. In: Sperling MA, ed. Pediatric
, S5 }  F; C: ^2 {0 C( wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 s+ _% i( Y6 ~+ m& i5 h2002: 565-628.
3 K, ?2 B* ^! I# E  ]7 r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ `2 i- W$ d% f  {; P9 h7 l
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old' H( @' e, `+ ], t( K! \
Boy Induced by Indirect Topical
( B5 n, M4 f7 N: \& V; DExposure to Testosterone
" X4 V7 F* W% f$ |8 q* g& XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, B$ K- o7 M7 m. n7 _+ F5 W
and Kenneth R. Rettig, MD12 J+ W, _  s4 j0 `3 z
Clinical Pediatrics9 x3 Z+ J  Q% O
Volume 46 Number 6
% A0 D3 ]# d) d. C% G% G& eJuly 2007 540-5430 ?( [$ x" w9 u" x5 V( g8 |
© 2007 Sage Publications
; u6 [4 w0 g5 U3 `0 C6 \10.1177/0009922806296651* y* N5 |5 v; P' x9 z
http://clp.sagepub.com+ ^' s0 s! j9 P
hosted at
9 ?1 t, p% j/ \2 }* k7 {: Xhttp://online.sagepub.com* Y, V6 L2 F( d( B4 d- y
Precocious puberty in boys, central or peripheral,4 e% R+ a7 @6 N5 k8 @: _$ ^0 b
is a significant concern for physicians. Central
5 N9 x5 U1 @5 q5 z" Wprecocious puberty (CPP), which is mediated) [- A; s+ S1 H+ T9 r: S' |" l
through the hypothalamic pituitary gonadal axis, has. c+ Y& ~. c  ~+ E4 X1 g7 e
a higher incidence of organic central nervous system
. K) w2 n$ k" A+ l; @lesions in boys.1,2 Virilization in boys, as manifested
6 |2 D: Q9 ~! W. wby enlargement of the penis, development of pubic6 L6 S4 t( H- W6 ?7 g8 ~
hair, and facial acne without enlargement of testi-# P$ G0 H- X/ J  ~% O2 K
cles, suggests peripheral or pseudopuberty.1-3 We
* d2 u" f' u2 c9 `6 Yreport a 16-month-old boy who presented with the; ^. z4 H% v0 k7 H) D
enlargement of the phallus and pubic hair develop-
0 f/ \0 O' ^) t; F  a6 N1 Dment without testicular enlargement, which was due
5 e7 h# P5 N7 g1 k# d  X2 j( lto the unintentional exposure to androgen gel used by. N2 e3 ~# B+ c0 c* S! P; V
the father. The family initially concealed this infor-- l* }7 t/ }1 e% m
mation, resulting in an extensive work-up for this
& ~) n7 X7 T! x& U, ochild. Given the widespread and easy availability of6 }, `' B8 M% @- Y
testosterone gel and cream, we believe this is proba-* i4 p: W) C2 L& ?+ d: e6 z1 [
bly more common than the rare case report in the
5 n; s1 M! J) t+ m5 Dliterature.4" e6 @1 [0 g7 P$ n
Patient Report
0 T3 ~& a2 u4 g' q5 NA 16-month-old white child was referred to the
: ~' I; Y8 k  ^  @& H2 I2 [' fendocrine clinic by his pediatrician with the concern
" C( S% Z0 J4 v! fof early sexual development. His mother noticed
. o* g4 P- {& }6 C6 Y2 w/ x. M0 ulight colored pubic hair development when he was
7 r! p( D) Q1 J* ?. f! OFrom the 1Division of Pediatric Endocrinology, 2University of- Y5 D; ^; \6 P* W5 [1 }! a3 j
South Alabama Medical Center, Mobile, Alabama.' ~+ M; ?4 E7 B0 }) g: L0 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,& y( K7 ^1 a6 h
Professor of Pediatrics, University of South Alabama, College of+ s! i' X1 D% N7 ?* X, d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- n7 Y' Y+ c+ _8 `# Ne-mail: [email protected].* z" g; Y6 _9 B; |$ u! M; L
about 6 to 7 months old, which progressively became' J. R  Q; q% ~# I. O5 {
darker. She was also concerned about the enlarge-; M2 x& Y: q, t" a+ |* h8 `
ment of his penis and frequent erections. The child
: [0 U& Y1 g0 x3 ewas the product of a full-term normal delivery, with
, b' T% \: }* S* ?) c! L# Oa birth weight of 7 lb 14 oz, and birth length of( z3 ~3 {! Q* R1 j0 x" ]
20 inches. He was breast-fed throughout the first year) x6 z4 }! P% N" o$ b
of life and was still receiving breast milk along with
+ \9 `3 {9 y2 n+ Lsolid food. He had no hospitalizations or surgery,
1 Y9 O# @  Y# C% eand his psychosocial and psychomotor development
/ m- f' a5 r' S- C- B) x3 Bwas age appropriate.) `, z# a1 G  t: W; S9 r
The family history was remarkable for the father,$ S3 x9 S% \1 C' H( l$ _# b
who was diagnosed with hypothyroidism at age 16,/ t  y5 v: k" I. j
which was treated with thyroxine. The father’s. g. q+ v& W( L4 ~+ i- @! `% `
height was 6 feet, and he went through a somewhat$ i+ v# @( |( f: T( q+ i! t
early puberty and had stopped growing by age 14.
/ {% i! a1 i6 f/ S( |% bThe father denied taking any other medication. The5 V5 N5 j& n) Z; d- t* M
child’s mother was in good health. Her menarche
0 Y1 [/ L* t9 T4 e/ Z0 P( `5 V. Nwas at 11 years of age, and her height was at 5 feet
$ K( t% w" R# X9 |5 inches. There was no other family history of pre-- i# B+ H" P7 P+ \3 q
cocious sexual development in the first-degree rela-- Y& E' E2 i4 c1 v4 I- g! W
tives. There were no siblings.
+ E2 F( Z9 ]8 q3 f+ u9 c4 }# R! m" j2 JPhysical Examination6 i( o7 ]1 a; R  G
The physical examination revealed a very active,7 `6 D' c8 x" a' F  X
playful, and healthy boy. The vital signs documented
  k3 `# j' `# c* Ga blood pressure of 85/50 mm Hg, his length was
- }+ h5 f0 M! i/ ?90 cm (>97th percentile), and his weight was 14.4 kg
: \" d  ^3 q' K1 z' \/ u0 a(also >97th percentile). The observed yearly growth
+ h4 v* A$ ~$ L+ g9 l, n+ R* lvelocity was 30 cm (12 inches). The examination of
) d/ O1 F: N. M( G" Y3 ?* Cthe neck revealed no thyroid enlargement.
8 Y  d0 O( M. @0 u. w  o$ gThe genitourinary examination was remarkable for+ C7 L; C+ ^" ?- r; m
enlargement of the penis, with a stretched length of! K: U# Y  `4 N2 ~2 \
8 cm and a width of 2 cm. The glans penis was very well% W& s& V, i/ F  M8 Q& U6 D
developed. The pubic hair was Tanner II, mostly around. q' [) c) `/ O- p" M$ T
540
+ B0 b8 I  ]; S9 u" G% H& [" aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! Y# t. O/ P( b6 m( g* n
the base of the phallus and was dark and curled. The7 F3 X% Y" a1 P* R8 X( g- g: r. z
testicular volume was prepubertal at 2 mL each.
6 w1 |8 a5 E# e9 r: v5 Y6 v' l  ~The skin was moist and smooth and somewhat
3 n4 ?  Z. k7 ?: s+ c5 I8 a! P5 Voily. No axillary hair was noted. There were no+ a9 L! `; g, J* i
abnormal skin pigmentations or café-au-lait spots.
: m4 Z  E# \( B1 u, q+ N$ E: INeurologic evaluation showed deep tendon reflex 2+& ^. S" v$ [% c) o
bilateral and symmetrical. There was no suggestion
/ ?3 B% q# j, aof papilledema.
4 T' Z$ s3 T) n( u# B8 _Laboratory Evaluation) @" F$ H5 q, q( b, a
The bone age was consistent with 28 months by
5 _3 Y% ^/ @2 Q  d3 dusing the standard of Greulich and Pyle at a chrono-5 e& w' ]/ B& H3 ?. x. @. ?# U
logic age of 16 months (advanced).5 Chromosomal
1 F0 G6 H) o6 c5 h. w' O  Dkaryotype was 46XY. The thyroid function test) k& G0 q  K6 D/ \6 r# g" s
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" d. {: F1 b; I. v' {! E0 plating hormone level was 1.3 µIU/mL (both normal).
2 s  t( y4 z$ O! i4 }, mThe concentrations of serum electrolytes, blood9 l  ?& I' f( M5 y/ b
urea nitrogen, creatinine, and calcium all were& J/ s. g! y. l: F# z+ P
within normal range for his age. The concentration5 `0 f  ^& u( r, v2 d& W# U
of serum 17-hydroxyprogesterone was 16 ng/dL
! K: q, ?4 k- ]. x: p' D: j(normal, 3 to 90 ng/dL), androstenedione was 20
. X. _; W; @+ m" E) \. y/ Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& Z. ?% X$ O9 Z1 ?5 I! dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
. _* K3 c% d  q% o2 R6 C; E/ u. }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 t# i7 l1 c% s49ng/dL), 11-desoxycortisol (specific compound S)
2 Y' F# g; a7 I2 Owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* {# L( a& {  b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 N: q" v: v8 g9 h1 ?9 P, Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ j0 w  y; l" j3 t/ U  X. xand β-human chorionic gonadotropin was less than
2 p- `  }) X/ m  w5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 d9 X! X% m$ N( Z  L' k+ ^% s$ l9 xstimulating hormone and leuteinizing hormone
. B: I6 H7 m% f& ^- w: `) A$ Uconcentrations were less than 0.05 mIU/mL
1 Q" m& }( I& h/ [4 X8 {- c0 k(prepubertal).
, Q4 f! x! b% S/ f; `0 rThe parents were notified about the laboratory
  g" ?7 w# F9 |+ M( ~0 yresults and were informed that all of the tests were$ p& z% {& }, Q9 Q3 {
normal except the testosterone level was high. The
) P' O; `( i( K( Y: n  K2 m# u/ nfollow-up visit was arranged within a few weeks to
/ W' X7 @  E! G" j; Vobtain testicular and abdominal sonograms; how-
# V; A# n( _: g) t) [! ~8 J( A7 F- qever, the family did not return for 4 months.
0 l/ v' N5 X( g, r2 x' m& g; gPhysical examination at this time revealed that the
% _5 I1 K# E5 \. m- S; N8 L; uchild had grown 2.5 cm in 4 months and had gained
. P' y8 y5 R9 ^; P" ^2 kg of weight. Physical examination remained
3 X& T% ]$ e" m+ E4 bunchanged. Surprisingly, the pubic hair almost com-
8 ?# ~0 P9 H$ {% |+ Q( upletely disappeared except for a few vellous hairs at8 U. c! I' x& N6 U# R
the base of the phallus. Testicular volume was still 29 M4 z' c: n: F; \/ ?# y/ [0 E
mL, and the size of the penis remained unchanged.
  }2 C2 f9 C& |% `: d8 n, g: AThe mother also said that the boy was no longer hav-! `* m6 S. M( v  j* R$ N
ing frequent erections.
$ i2 i2 Z" k0 w+ ?3 E$ v7 vBoth parents were again questioned about use of5 F8 w) U9 ]0 x8 }
any ointment/creams that they may have applied to
  L+ z  u: o" ]& @: {; r6 gthe child’s skin. This time the father admitted the
- }0 T8 x: T0 }/ Y8 E5 B9 iTopical Testosterone Exposure / Bhowmick et al 541
( I8 y7 J% m& J3 Y0 k' P* [4 \" y. Iuse of testosterone gel twice daily that he was apply-
# ?  ^; S/ t8 F( R8 U& O! G+ Ring over his own shoulders, chest, and back area for* ^1 U$ a8 {" p
a year. The father also revealed he was embarrassed2 J! B; o" \6 M# u4 X
to disclose that he was using a testosterone gel pre-
" z7 W) }& K7 q( dscribed by his family physician for decreased libido
* k. y+ t. y( tsecondary to depression.$ h  v: x  t7 h" F- F0 V9 f5 i0 ~
The child slept in the same bed with parents.5 T! X5 \- p* z( z
The father would hug the baby and hold him on his
1 n" K. b4 i& k/ Achest for a considerable period of time, causing sig-" e3 ?/ H# y" M4 Q6 O; u& r
nificant bare skin contact between baby and father.. b) N0 W5 m) Q$ |
The father also admitted that after the phone call,
. g- U% R5 C  `when he learned the testosterone level in the baby
( \, v$ |; y! q" e: wwas high, he then read the product information+ W# ^1 k1 F: T# q- z1 G: v
packet and concluded that it was most likely the rea-
: w9 b' \% N% G/ u2 B* [son for the child’s virilization. At that time, they7 T& j8 {' \2 x' [
decided to put the baby in a separate bed, and the  O7 m, O* r; R
father was not hugging him with bare skin and had
4 c: }( T+ s" J- T2 wbeen using protective clothing. A repeat testosterone
6 D" N% J; x) v( [4 N% [test was ordered, but the family did not go to the' G: ]! ?, `* g0 \
laboratory to obtain the test., M, u' y8 u$ ?$ ?
Discussion/ m9 r6 l3 N7 \/ j8 M7 c2 [6 }
Precocious puberty in boys is defined as secondary
* f" t$ a# W& |& @* o5 j" Z5 r2 Usexual development before 9 years of age.1,4
7 F) `2 Z( R2 J) }: [Precocious puberty is termed as central (true) when9 a1 S' d: u) _$ F. j
it is caused by the premature activation of hypo-" ?/ o# v! k7 g9 g
thalamic pituitary gonadal axis. CPP is more com-
8 X8 T& {3 v  j+ jmon in girls than in boys.1,3 Most boys with CPP9 a/ I& d4 r3 ]2 B
may have a central nervous system lesion that is' o  K9 P! s( f5 ~' S# P/ `0 L% ?
responsible for the early activation of the hypothal-& ]' |0 ~# W+ H5 f7 F' i8 o0 i6 e6 {
amic pituitary gonadal axis.1-3 Thus, greater empha-9 T' `3 ?6 k  z, \9 }
sis has been given to neuroradiologic imaging in+ x+ w. s$ @. f; p) K: G9 Q. n& N5 H
boys with precocious puberty. In addition to viril-4 L* D8 ]8 V- t, @8 k
ization, the clinical hallmark of CPP is the symmet-; g* v. X) u9 A/ w) }+ B" K6 F0 c
rical testicular growth secondary to stimulation by$ w9 B( O& G& u) g2 [
gonadotropins.1,3
4 B' g1 s# S) E8 a% TGonadotropin-independent peripheral preco-
+ u+ r" e: d* A# w; y0 P8 p, rcious puberty in boys also results from inappropriate7 C) x& i+ b; j, @7 i
androgenic stimulation from either endogenous or
3 c( B; }' q1 Z& h$ Z- j) F$ Jexogenous sources, nonpituitary gonadotropin stim-( G( T1 N% I0 k- j8 y
ulation, and rare activating mutations.3 Virilizing
0 T' M6 S* u% kcongenital adrenal hyperplasia producing excessive, n( s' Q3 c; J' e$ `
adrenal androgens is a common cause of precocious% D' ?2 n3 k4 E" N; p  e2 ~8 E7 _+ E- x
puberty in boys.3,4
! ]' x2 ~8 M/ NThe most common form of congenital adrenal
6 Q( U4 z  L; _# Yhyperplasia is the 21-hydroxylase enzyme deficiency.. i9 u% }! b* E" ?1 Z4 Y- y
The 11-β hydroxylase deficiency may also result in( H$ m6 O3 _5 l
excessive adrenal androgen production, and rarely,$ y' R; t8 W$ M! Q: J$ e1 t3 i
an adrenal tumor may also cause adrenal androgen6 ~1 a8 L5 W( [) a# }
excess.1,3
/ Y: K! M. w+ O0 u( n" K5 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 k* x$ G1 K& }0 Z' h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% Z) {2 c+ q' M6 U9 F: f9 l. iA unique entity of male-limited gonadotropin-7 T/ J4 v) }" s# t7 Q. J" a( S* J
independent precocious puberty, which is also known
" I+ \$ d7 z( O; N5 k; gas testotoxicosis, may cause precocious puberty at a
5 h6 B* n2 o. W1 uvery young age. The physical findings in these boys
) O3 J) V; b6 P) c1 Twith this disorder are full pubertal development,
, |9 _! |* R+ J7 l' Gincluding bilateral testicular growth, similar to boys
( r7 s- Y! K8 B) ewith CPP. The gonadotropin levels in this disorder
: [2 m6 i3 J4 |are suppressed to prepubertal levels and do not show
" h8 j; a- B- \: t  a' ~pubertal response of gonadotropin after gonadotropin-0 t! J* [4 D0 o( N0 G+ M( P) G( M
releasing hormone stimulation. This is a sex-linked
3 g/ m; `7 F& k9 f7 \autosomal dominant disorder that affects only
0 Z# F  z5 r: r. m  P# T) omales; therefore, other male members of the family
1 E' i, N' {8 O+ umay have similar precocious puberty.3
: D- `/ l  G, V. `6 U# D! AIn our patient, physical examination was incon-6 M0 ~5 R9 I! M( s* x
sistent with true precocious puberty since his testi-  e( `4 l: Q0 I. }0 r
cles were prepubertal in size. However, testotoxicosis/ S1 |4 J8 }) z- P4 W( f
was in the differential diagnosis because his father
! z  O+ J( B- ?; j0 w* K) U# vstarted puberty somewhat early, and occasionally,
6 I  \: [4 f+ Y% @( M0 V% l8 C8 ~testicular enlargement is not that evident in the5 p4 I/ Z  B: I% }1 @6 Q3 y% I' |
beginning of this process.1 In the absence of a neg-; {0 P! s- h" B# H+ @2 {/ p0 l
ative initial history of androgen exposure, our5 ~/ |6 T$ N% c5 L1 H! Q0 Q* P
biggest concern was virilizing adrenal hyperplasia,* B* g/ C7 @2 s& O2 ~# n( H# i5 E
either 21-hydroxylase deficiency or 11-β hydroxylase
  l- Y+ D+ ~  Y' N1 ^, n8 ^deficiency. Those diagnoses were excluded by find-
4 k* O# @, r% u* l, sing the normal level of adrenal steroids.
4 F+ Z2 h; Y- P8 O* S" s" lThe diagnosis of exogenous androgens was strongly# u' k. z" V& z* x3 y9 a3 g
suspected in a follow-up visit after 4 months because! }8 W# _( I! m" i
the physical examination revealed the complete disap-
( Y' V" x  K) g% ]pearance of pubic hair, normal growth velocity, and
6 R% e  U6 j7 H- m% i6 J! ?decreased erections. The father admitted using a testos-7 F: k/ b- O% P
terone gel, which he concealed at first visit. He was
* D  Y6 E, ]1 @& dusing it rather frequently, twice a day. The Physicians’- e1 G# X+ B& L" Q
Desk Reference, or package insert of this product, gel or
0 r3 M0 x0 [& E( f" mcream, cautions about dermal testosterone transfer to: w5 D" }+ W4 v
unprotected females through direct skin exposure.! S7 e2 T5 Y5 ?4 j$ Z, |
Serum testosterone level was found to be 2 times the) v8 K, }  V& V. ^
baseline value in those females who were exposed to
+ q5 ^: d! @7 p. J2 F6 U& V2 xeven 15 minutes of direct skin contact with their male1 B" N+ J( Z9 F- }9 x0 ?& s$ a
partners.6 However, when a shirt covered the applica-4 s) T1 J# q6 w; L; r
tion site, this testosterone transfer was prevented.
" B- q- R. |: G' K8 _Our patient’s testosterone level was 60 ng/mL,
& r  M1 E- v1 t+ `" e. d% V9 P1 K0 Wwhich was clearly high. Some studies suggest that. j: `$ G3 p$ C! ]& F
dermal conversion of testosterone to dihydrotestos-3 b" b9 y; m3 y" S7 i2 M$ j4 \
terone, which is a more potent metabolite, is more( G1 U6 c$ i) c% W1 h7 U1 T* _
active in young children exposed to testosterone
" z& V2 `9 x8 c) `exogenously7; however, we did not measure a dihy-
& p& A% Z+ _# I  Adrotestosterone level in our patient. In addition to. I, d# ^2 H* U, M2 X$ w# W
virilization, exposure to exogenous testosterone in1 E2 i1 Z- c+ u; u2 o
children results in an increase in growth velocity and# Q1 p% r, F5 r" j
advanced bone age, as seen in our patient.
# G2 U1 l6 N& KThe long-term effect of androgen exposure during
9 Z) l  @1 ]: v* r# ?# U  d) V! v. Cearly childhood on pubertal development and final4 |0 b5 k5 N/ h6 Z! a( [# e& f
adult height are not fully known and always remain
( H3 D. z  P9 r1 `  fa concern. Children treated with short-term testos-$ u% |7 T3 u% j0 ^* W) \, g
terone injection or topical androgen may exhibit some
( z  w, a/ [5 O! [, [6 W9 Iacceleration of the skeletal maturation; however, after  x/ ^! g7 Z# l2 \( Y$ M! q5 `9 h6 u
cessation of treatment, the rate of bone maturation6 y5 \6 h2 n* E% |" l4 T! n( s
decelerates and gradually returns to normal.8,9
8 D, A/ I" A. ]. K9 ~+ ~" oThere are conflicting reports and controversy, T) _0 V) k- m. H& c5 m
over the effect of early androgen exposure on adult+ g, z0 ?% a# U# \
penile length.10,11 Some reports suggest subnormal  `. F5 D5 J& @6 n& i4 }0 }3 f' e* ?
adult penile length, apparently because of downreg-9 `! z$ e/ i3 w# c8 \. m) p7 Q
ulation of androgen receptor number.10,12 However,: }8 N( J# X2 X7 h+ ^
Sutherland et al13 did not find a correlation between" `* {! E. G7 z, _8 t( k* `) J2 T
childhood testosterone exposure and reduced adult! {( W8 {9 _) K$ b" }% @  a% }
penile length in clinical studies.
$ J. a4 i5 j- p, Z" a7 P5 ]/ ANonetheless, we do not believe our patient is4 g6 ~, B( _3 V- f8 X
going to experience any of the untoward effects from, g. H4 ^( G) j) E+ j, W3 r1 j
testosterone exposure as mentioned earlier because
& z! t9 u6 }4 W; _the exposure was not for a prolonged period of time.
# s7 f- d) K" Z+ n% l' r0 s0 `  {Although the bone age was advanced at the time of
6 M0 f; _' [, h* Z3 D; vdiagnosis, the child had a normal growth velocity at3 A1 \5 A% \8 i; k
the follow-up visit. It is hoped that his final adult# \3 I0 m* d4 t  k; @5 J
height will not be affected.3 R4 w- v8 P' A5 o/ j# A
Although rarely reported, the widespread avail-
$ |: u# z7 O* x) `3 f; kability of androgen products in our society may* O+ J$ H" \$ N$ X5 {" u: k
indeed cause more virilization in male or female# z2 ?% K: t7 Q% o
children than one would realize. Exposure to andro-
# [2 \) C! ?$ K+ d0 G* wgen products must be considered and specific ques-
! S/ S* y4 o% P, ptioning about the use of a testosterone product or
+ f; a: g  Q$ ]) a, e% m# i! Dgel should be asked of the family members during0 F8 J2 B+ L& i% q  J
the evaluation of any children who present with vir-- u. W5 |5 ~1 {2 Q5 Y
ilization or peripheral precocious puberty. The diag-
3 I. a5 J( i, w7 x5 l( n4 Jnosis can be established by just a few tests and by
$ R" n8 g. i2 j/ F5 y! tappropriate history. The inability to obtain such a4 S5 N( w5 \! Z9 O( b
history, or failure to ask the specific questions, may+ e7 _3 I: q/ k+ g, o
result in extensive, unnecessary, and expensive" r% @; _$ R3 a" ]% m) V' s' f
investigation. The primary care physician should be+ ^' x" w4 Q; p4 c- g: U
aware of this fact, because most of these children8 n- K7 k7 [: N, M
may initially present in their practice. The Physicians’
( e$ N: o3 y3 p" O; L9 K- e* WDesk Reference and package insert should also put a
/ }; k# J% t4 J* b3 fwarning about the virilizing effect on a male or0 k4 J* W# R( C
female child who might come in contact with some-4 }- ]% B! j- @3 l3 y
one using any of these products." f2 G; w: N8 E2 B
References: ]* K1 m# |: q' \- e
1. Styne DM. The testes: disorder of sexual differentiation
  d9 h- Z& b/ `and puberty in the male. In: Sperling MA, ed. Pediatric
$ ~* v: o  a+ g- l/ wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% p5 B1 G0 r( |9 Z9 S; W2 D0 a2002: 565-628.
' e; E* {8 {5 Y4 }2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 ^; B, P' g1 Z/ S3 Rpuberty 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
- B' V5 A" F* j% |; k/ L) w
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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