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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
* n% d7 T1 U3 ~* nBoy Induced by Indirect Topical2 w, s+ L. F: ^% h( Q- }, u, K
Exposure to Testosterone6 h7 Y2 q3 Z+ O" w1 n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ v* R+ f% {. I% e& b
and Kenneth R. Rettig, MD1
. W5 ?7 p: Z+ i! K: o. ~% uClinical Pediatrics; s) Q/ \7 g! ^7 ]
Volume 46 Number 60 J3 w% w* _! m; K8 W7 @* I
July 2007 540-543
$ r- w% {/ I2 c6 c, `/ b4 h© 2007 Sage Publications7 e# i/ `* c9 L, J5 B0 K
10.1177/0009922806296651
0 {6 A7 N4 x4 z4 p) [http://clp.sagepub.com3 C$ w  R5 [7 H6 S) a
hosted at- t* _  y& `8 l' \  b/ b" l
http://online.sagepub.com
6 a! i/ O$ R7 H0 B7 M+ n. L- HPrecocious puberty in boys, central or peripheral,) n, X8 M. r( v. K0 C' }
is a significant concern for physicians. Central( k9 ^1 g7 R% C8 v1 z6 _4 B5 e  M
precocious puberty (CPP), which is mediated
  v8 p2 j" ]/ D5 E6 Q9 Mthrough the hypothalamic pituitary gonadal axis, has1 i2 G0 r/ ~+ j
a higher incidence of organic central nervous system
" _1 W  l% @$ l; ~lesions in boys.1,2 Virilization in boys, as manifested
7 E& U" Q1 _; @by enlargement of the penis, development of pubic
% D* p" E1 e9 ~* V- w$ W: Jhair, and facial acne without enlargement of testi-" `' p  O& n- t+ V, V5 ?
cles, suggests peripheral or pseudopuberty.1-3 We% h' I. ^4 Y6 o1 S, F
report a 16-month-old boy who presented with the4 S6 _& L9 Y1 N6 {
enlargement of the phallus and pubic hair develop-, m3 C0 _: |/ E$ n& O
ment without testicular enlargement, which was due; ^# Y+ e* c% R% C' J+ O1 B
to the unintentional exposure to androgen gel used by
- i0 ?$ \/ m1 S$ a' othe father. The family initially concealed this infor-, n( X$ T2 m' `$ E9 J4 g
mation, resulting in an extensive work-up for this
( `4 {5 A: C4 mchild. Given the widespread and easy availability of) H: ]1 e( J( W7 S4 C
testosterone gel and cream, we believe this is proba-3 w1 _1 Y% c8 y8 k( ~9 A' }
bly more common than the rare case report in the
' w$ k6 G6 E7 p0 q- W" yliterature.4) ?0 s- F4 l6 d, }
Patient Report% {0 o! Z, T' g) ]7 j
A 16-month-old white child was referred to the
) q! m# h7 M3 y8 n& S5 {endocrine clinic by his pediatrician with the concern- U( [  V. R1 Q# h7 L3 i, \3 J
of early sexual development. His mother noticed) s( e& Y4 p  S9 v
light colored pubic hair development when he was
3 N4 I; l: C/ c. @From the 1Division of Pediatric Endocrinology, 2University of
( c3 A- k" w5 y9 _$ PSouth Alabama Medical Center, Mobile, Alabama.
" r/ l: Y8 A' N+ {Address correspondence to: Samar K. Bhowmick, MD, FACE,3 T& V( C1 b1 H+ o
Professor of Pediatrics, University of South Alabama, College of: Q0 F0 ^* j6 }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! B; C2 b$ O3 d' \  @% p( ee-mail: [email protected].
  L: D3 o& ]1 [0 z$ labout 6 to 7 months old, which progressively became0 I9 l/ x5 J3 J% V( J1 r5 v4 }7 E8 i
darker. She was also concerned about the enlarge-4 v! D+ U9 X% V" n4 u
ment of his penis and frequent erections. The child
, q$ q. C0 U" y0 E/ Awas the product of a full-term normal delivery, with# D* E" z4 \1 d
a birth weight of 7 lb 14 oz, and birth length of
* ]$ ^1 ^; Y2 T& X" W20 inches. He was breast-fed throughout the first year+ h3 h9 N0 F9 R$ `. G: v6 A$ Z' V" Y
of life and was still receiving breast milk along with5 ^8 d% |: N$ ~2 ?) w! z" K5 B9 p6 c  X
solid food. He had no hospitalizations or surgery,! W2 o2 A! l4 ?* b
and his psychosocial and psychomotor development& ~/ @) i+ F* P6 E9 z2 E
was age appropriate.$ e" b; [: @4 ]' b2 U. G6 y
The family history was remarkable for the father,
9 A' W6 \3 V% x9 qwho was diagnosed with hypothyroidism at age 16,9 i& L+ J& o7 M; L& |* M8 O
which was treated with thyroxine. The father’s
2 g4 E% B5 K7 {3 Z9 |& g4 \height was 6 feet, and he went through a somewhat
, K- O* J8 p/ \" N/ i; Dearly puberty and had stopped growing by age 14.
7 M5 _, y6 m, ~) j; q- N) d! r6 YThe father denied taking any other medication. The$ g3 y3 V* {) u5 Z2 l& M
child’s mother was in good health. Her menarche$ R- X0 o. j6 ?" X
was at 11 years of age, and her height was at 5 feet
% Y# H# |* c  H3 @" G5 inches. There was no other family history of pre-/ [4 Q: V- q2 P
cocious sexual development in the first-degree rela-
& w) C0 A/ U& ftives. There were no siblings.+ ?  ?/ I2 F" F" s0 i
Physical Examination$ z: y6 ^: F( |5 _: f% H( V
The physical examination revealed a very active,
' u) n1 ^( F. K- G' zplayful, and healthy boy. The vital signs documented
# T6 z# F. Q9 F( X  ka blood pressure of 85/50 mm Hg, his length was4 O* O9 K+ z  v/ f
90 cm (>97th percentile), and his weight was 14.4 kg
4 c& c& w& T: U$ `(also >97th percentile). The observed yearly growth* y1 Z% B) Y; U9 I
velocity was 30 cm (12 inches). The examination of2 d4 \( n. W/ K/ Q
the neck revealed no thyroid enlargement.
$ M( s( K- l3 r- @* hThe genitourinary examination was remarkable for
4 Y8 w& I2 x- g0 c' cenlargement of the penis, with a stretched length of6 x. p8 k, o+ `# i6 ^
8 cm and a width of 2 cm. The glans penis was very well
% ~2 n6 F+ M! Rdeveloped. The pubic hair was Tanner II, mostly around
/ l( D( x. j$ k540: A9 \1 m- b; q1 |8 Y! U' S' q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; f3 k; C" `) g- u8 r3 P! ]" G
the base of the phallus and was dark and curled. The
" _! Q3 x/ Y" L; ]8 n) l" R4 rtesticular volume was prepubertal at 2 mL each.$ d! p6 n: K' S" V
The skin was moist and smooth and somewhat# |. m, H3 K: e( ~& s& N: R
oily. No axillary hair was noted. There were no
7 z- D/ j6 }* F( W% qabnormal skin pigmentations or café-au-lait spots.
; n3 u' p- V6 J: x- s2 s$ ?) RNeurologic evaluation showed deep tendon reflex 2+
8 \: B% \  U% [- Gbilateral and symmetrical. There was no suggestion: k9 ~8 Z7 p7 ~" P6 B+ G7 V
of papilledema.2 h- Y: f9 s' V8 n9 ~; |' Z
Laboratory Evaluation( O/ v2 q, W% Z, Y8 Q% @3 y
The bone age was consistent with 28 months by
9 g6 O$ N$ S! o1 @using the standard of Greulich and Pyle at a chrono-
- N' Q/ @# Q( h8 b) D$ L& alogic age of 16 months (advanced).5 Chromosomal
: D6 z- I" d6 u3 U) Q2 I% ?karyotype was 46XY. The thyroid function test4 |3 a- e7 l& R: {1 z# ]1 l
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 O3 N) B, \4 V! Xlating hormone level was 1.3 µIU/mL (both normal).
4 N2 T/ u8 {( uThe concentrations of serum electrolytes, blood9 e* V' S( O. ]; `3 r
urea nitrogen, creatinine, and calcium all were4 A; _  {; |5 L  R3 Y. U
within normal range for his age. The concentration
4 R4 d3 u/ r" @8 E$ Eof serum 17-hydroxyprogesterone was 16 ng/dL- O1 r) I- x, M& _" o, o- Y
(normal, 3 to 90 ng/dL), androstenedione was 20
  Y8 K( T0 b  J8 `5 V* J3 G/ wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 x8 \% K8 X9 U3 g" A- U+ rterone was 38 ng/dL (normal, 50 to 760 ng/dL),) p1 M! k: f5 c: Q7 S+ T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to) E: ^+ |  X( H5 [6 o: z# f) ^$ I6 X
49ng/dL), 11-desoxycortisol (specific compound S)+ A; l- A+ H1 f8 ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, O6 M5 z( i. C8 Q+ u3 Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 n. r, `+ x( U5 n& H8 f* m& H# ^! H9 Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' a( V) d& `/ M) q) d# O* X' @
and β-human chorionic gonadotropin was less than
9 [% p1 u5 i% S5 mIU/mL (normal <5 mIU/mL). Serum follicular4 {# V; M  s$ C/ B6 {+ d4 }+ N3 M0 O* u
stimulating hormone and leuteinizing hormone
: }3 S# h4 u$ J" K, lconcentrations were less than 0.05 mIU/mL: c  D+ l; m" f, k8 Y. ?: v& E$ Q
(prepubertal).
6 h, k! j! }" p( k, D8 B) F8 pThe parents were notified about the laboratory
' h% [/ p7 C. C- rresults and were informed that all of the tests were
. e6 p$ a5 X; {! F- h/ xnormal except the testosterone level was high. The
3 v& K% n; C) F# H- Sfollow-up visit was arranged within a few weeks to
3 t& d3 p1 R# S( d/ jobtain testicular and abdominal sonograms; how-0 V! m. g* V" J. I& W# k. K# L
ever, the family did not return for 4 months.
1 c4 E8 V  E1 K& m9 V0 F1 K* _Physical examination at this time revealed that the, y9 T* O6 O+ h7 V' Y
child had grown 2.5 cm in 4 months and had gained
# e1 ^9 z5 z! n$ O0 U  v+ R2 kg of weight. Physical examination remained" U. ?! |0 y7 d
unchanged. Surprisingly, the pubic hair almost com-; ^% y4 Q/ n* l. [, G6 b
pletely disappeared except for a few vellous hairs at( y! V+ A: o0 T' b; W
the base of the phallus. Testicular volume was still 2
/ j* d! X9 C& h1 [mL, and the size of the penis remained unchanged.
4 [+ E+ c0 \& a" a  ZThe mother also said that the boy was no longer hav-7 j/ g4 f% q, V5 W6 u# a# {
ing frequent erections.
3 V% ]4 R& y$ n( w. R! }: A* HBoth parents were again questioned about use of
" J7 a4 J+ j7 p& E/ e9 p6 k( cany ointment/creams that they may have applied to
6 E# l1 E, U" y7 h9 ?the child’s skin. This time the father admitted the% \, p/ T+ K7 i5 [+ t8 X$ ?, N
Topical Testosterone Exposure / Bhowmick et al 5414 m# n8 x! @" i+ B+ }+ ]2 Y5 Q
use of testosterone gel twice daily that he was apply-
( `# u- F( w% m: aing over his own shoulders, chest, and back area for, \- G! T* ^  x0 F. ?
a year. The father also revealed he was embarrassed) f: A, x& f* e3 T' k
to disclose that he was using a testosterone gel pre-/ H) Q2 P; r( N. K: n
scribed by his family physician for decreased libido
' l2 w6 K& q/ a" i' jsecondary to depression.0 {* B* o( ?" o9 @
The child slept in the same bed with parents." C: D7 g0 w! a3 D+ n$ ^( o
The father would hug the baby and hold him on his
. F0 B0 h# o( r2 I: fchest for a considerable period of time, causing sig-% o6 j) ^# R- P. _
nificant bare skin contact between baby and father.& z2 s( n% k/ J) A4 B. n
The father also admitted that after the phone call,
9 _5 d- ~; G3 Z8 Z7 rwhen he learned the testosterone level in the baby$ _4 S) e  l1 _
was high, he then read the product information% k  Y* H( x2 X
packet and concluded that it was most likely the rea-
2 a9 p; \, z/ W9 C. ?1 lson for the child’s virilization. At that time, they
% a2 V4 [: n5 Tdecided to put the baby in a separate bed, and the' n$ }6 i2 u5 J% m" f# u
father was not hugging him with bare skin and had( E2 D, v; T: K* F; G/ }' B
been using protective clothing. A repeat testosterone
8 H- _0 ~, ?3 i- d% @$ z" c6 Ctest was ordered, but the family did not go to the
. R7 T; Z/ b3 M6 ilaboratory to obtain the test.
, |$ N& h; q: h& mDiscussion6 E, f! q  V8 {! N
Precocious puberty in boys is defined as secondary
/ j1 @2 y3 ^+ Vsexual development before 9 years of age.1,4" g  Y4 n/ J5 i0 P: L' ]
Precocious puberty is termed as central (true) when5 V* l: T' k  r$ C
it is caused by the premature activation of hypo-+ a4 c9 W7 J- [( V
thalamic pituitary gonadal axis. CPP is more com-, c0 l5 Q& n( ^2 R: E, U+ \8 R
mon in girls than in boys.1,3 Most boys with CPP  K2 k9 {  }( A: m7 q
may have a central nervous system lesion that is
; g! e1 J( V$ j* f% \/ N1 B0 Eresponsible for the early activation of the hypothal-
4 ?, ?# A/ @7 q/ yamic pituitary gonadal axis.1-3 Thus, greater empha-
  \- X  M5 U! t* p; d3 E8 q4 D$ }+ o+ [sis has been given to neuroradiologic imaging in: q# h7 P! K) X5 {7 N6 ?+ k
boys with precocious puberty. In addition to viril-
2 e/ o+ t. D/ j  F7 |( tization, the clinical hallmark of CPP is the symmet-0 U9 Q. M/ j" ^6 j. S& U. ~
rical testicular growth secondary to stimulation by+ M/ }7 {1 M' V' O! l% l
gonadotropins.1,3
6 R& X2 G# B: w. v' aGonadotropin-independent peripheral preco-6 W! K) {' a9 Y* K, c6 E
cious puberty in boys also results from inappropriate
# w$ M8 `/ Q- A  Y0 Gandrogenic stimulation from either endogenous or9 D# N) F( n! S" |: p; a: y
exogenous sources, nonpituitary gonadotropin stim-6 @- r# p) H) b" A  q* @5 {
ulation, and rare activating mutations.3 Virilizing& w1 T% y; G5 {, T1 y- P
congenital adrenal hyperplasia producing excessive4 J1 f$ c# U$ r  H+ [; S; ]: {$ q) g# x
adrenal androgens is a common cause of precocious+ j9 i! e$ u) s9 B" ^8 _9 p
puberty in boys.3,4) W/ x8 e; v" ]9 H. i  |+ m( D- v
The most common form of congenital adrenal
* z  D2 Q! P/ q3 ?, M$ ohyperplasia is the 21-hydroxylase enzyme deficiency.2 S+ ~, I9 b1 ~  R4 k6 s
The 11-β hydroxylase deficiency may also result in
" }9 S1 [, S% z* T2 o+ y. \excessive adrenal androgen production, and rarely,
' _! g+ v  f8 v5 ban adrenal tumor may also cause adrenal androgen
1 T. i! A% I( ^/ h' Wexcess.1,3, L- T# F) U( f. w; h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! r' f$ o) Q" ^542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 {5 b  Y4 V+ \1 [( }( b* w
A unique entity of male-limited gonadotropin-- B: Z0 x$ d; Y8 [9 s2 u7 N
independent precocious puberty, which is also known
& G  r0 `+ U! s7 ?6 B* ias testotoxicosis, may cause precocious puberty at a, s5 ^+ o% l% |* C1 V; ^
very young age. The physical findings in these boys5 z6 c; H2 P# j/ S' w
with this disorder are full pubertal development,
8 p# F$ F( {- s" s7 Fincluding bilateral testicular growth, similar to boys
! |# ]# H$ a7 U; b: Twith CPP. The gonadotropin levels in this disorder
) d$ a7 s; K3 [  T8 f2 {are suppressed to prepubertal levels and do not show
" A! W9 ^9 X: l* J* A# rpubertal response of gonadotropin after gonadotropin-
& W2 I- O9 Y( y2 mreleasing hormone stimulation. This is a sex-linked& H) d# m3 a5 B  w
autosomal dominant disorder that affects only
  E4 m1 o; y3 R/ L) }% Wmales; therefore, other male members of the family
- g2 {! y( b- g1 }may have similar precocious puberty.3
, g) Z  ^. j  a: N7 B6 mIn our patient, physical examination was incon-
$ a- D6 w, f5 msistent with true precocious puberty since his testi-% m  z+ U8 s3 g' C9 A
cles were prepubertal in size. However, testotoxicosis
+ u' k) l8 ?! O3 w6 R1 Uwas in the differential diagnosis because his father
9 _& H/ i4 N, e  ostarted puberty somewhat early, and occasionally," C( T3 X% y% F" k0 j
testicular enlargement is not that evident in the
% ~; ~6 Y6 y' P2 Cbeginning of this process.1 In the absence of a neg-
% L' f4 q2 B5 a0 N+ oative initial history of androgen exposure, our7 {- K* N1 p  ^! u. j
biggest concern was virilizing adrenal hyperplasia,
, A- y, `& h) }! w; e) w, ieither 21-hydroxylase deficiency or 11-β hydroxylase
0 H9 V# l/ a0 i* n' G+ G) }deficiency. Those diagnoses were excluded by find-
6 p( S& F: n6 sing the normal level of adrenal steroids.& V# o: m: k% r1 E- A8 t: s. C) S
The diagnosis of exogenous androgens was strongly
3 |9 o' `6 x3 Z; Isuspected in a follow-up visit after 4 months because0 R' g/ j  j& d8 [+ K
the physical examination revealed the complete disap-
& p, P+ J, c2 Y6 }pearance of pubic hair, normal growth velocity, and7 k8 [2 m' x" L8 I  S
decreased erections. The father admitted using a testos-
9 \: V# B3 l) o6 Jterone gel, which he concealed at first visit. He was4 V. c7 Q+ V+ m+ n& F. O
using it rather frequently, twice a day. The Physicians’& f1 L1 q, F8 f* d2 G
Desk Reference, or package insert of this product, gel or
4 s; D- v; H& G8 Tcream, cautions about dermal testosterone transfer to# Q8 P. [" |, z; H
unprotected females through direct skin exposure.
. y# B3 |" O: V. gSerum testosterone level was found to be 2 times the( ]+ o  F4 l8 @
baseline value in those females who were exposed to
0 x; I; [+ M! A; C8 j/ U4 R6 [even 15 minutes of direct skin contact with their male
( H- p  I$ s* H; A" X  Z- [partners.6 However, when a shirt covered the applica-, \' b$ }) y! E. G
tion site, this testosterone transfer was prevented.
! N/ I. u4 c2 b% x# iOur patient’s testosterone level was 60 ng/mL,' Q4 b! ?9 `- F# ?! ^0 P  m
which was clearly high. Some studies suggest that
  W, [) o8 |2 r( n$ R1 tdermal conversion of testosterone to dihydrotestos-3 M9 f0 u: f7 n4 @
terone, which is a more potent metabolite, is more/ K! r2 c1 e! u, p: h
active in young children exposed to testosterone
7 H9 {  |  `4 K6 vexogenously7; however, we did not measure a dihy-: D( g2 S# z" p1 m
drotestosterone level in our patient. In addition to5 d- g, r" r3 n0 I+ T, n
virilization, exposure to exogenous testosterone in7 c% i+ m$ D! F& m% W
children results in an increase in growth velocity and& ~; c3 b: ]. a$ e$ i! |
advanced bone age, as seen in our patient.0 {- I" q: J% L& _( F
The long-term effect of androgen exposure during4 E2 y2 |5 l7 o) X
early childhood on pubertal development and final0 Y$ }; x9 f% b
adult height are not fully known and always remain
) U4 p9 b7 h4 t# na concern. Children treated with short-term testos-& q5 i' k4 I7 ]! m9 i
terone injection or topical androgen may exhibit some
. n- l# U+ w" e: W3 v, n5 A5 u% c# dacceleration of the skeletal maturation; however, after. p( J& Z/ w7 e
cessation of treatment, the rate of bone maturation
7 O7 `2 F& X6 h8 U. Q! M0 D7 c. Sdecelerates and gradually returns to normal.8,9
# [. j- A6 \6 d3 D9 R1 O: jThere are conflicting reports and controversy' {+ X, S1 k) ?- ?8 [5 E
over the effect of early androgen exposure on adult
- l7 {4 L, P5 j+ u$ u! Mpenile length.10,11 Some reports suggest subnormal$ M7 `' P, X2 g1 F; o" O  J
adult penile length, apparently because of downreg-* `# L2 h7 @( M- h" f
ulation of androgen receptor number.10,12 However,
5 n0 r, E1 g! K8 A3 lSutherland et al13 did not find a correlation between
8 }: c6 j! n- B8 P! O4 Achildhood testosterone exposure and reduced adult
$ k; z" c. d/ c8 z' |2 b- `2 dpenile length in clinical studies.
8 }: l2 f2 M1 n3 q) g4 fNonetheless, we do not believe our patient is
0 r5 F, [* b( e4 O% tgoing to experience any of the untoward effects from% o  h* v. J5 o7 J' h, t
testosterone exposure as mentioned earlier because
% @$ Z: p" Y9 ]! a, Gthe exposure was not for a prolonged period of time.
6 w) j6 f$ q. i4 k5 tAlthough the bone age was advanced at the time of
! |9 h9 ^4 _2 l5 A. cdiagnosis, the child had a normal growth velocity at$ }3 Y- n. [6 W4 J
the follow-up visit. It is hoped that his final adult3 b1 w$ Y; W4 Y/ [: w$ n
height will not be affected.; T0 I% z) e& R3 W
Although rarely reported, the widespread avail-0 X! E3 P, f- _. s1 x1 l
ability of androgen products in our society may' H8 ?, A. d% G% s
indeed cause more virilization in male or female
- w0 ?- o7 q! C% g$ I# {children than one would realize. Exposure to andro-, d- O3 x1 @  l2 o, ~3 Y- {# j
gen products must be considered and specific ques-
/ F( C0 G! F  R* ~tioning about the use of a testosterone product or& b. d1 D6 g% @% t2 U& @2 u
gel should be asked of the family members during9 q* u7 t: N0 G5 o9 ]* Y6 z- i
the evaluation of any children who present with vir-, ]6 j! o; j+ p" k
ilization or peripheral precocious puberty. The diag-
. H: t' J$ R6 F, Nnosis can be established by just a few tests and by
: X/ Q/ T% e: d& Cappropriate history. The inability to obtain such a
5 N3 P- H) {" qhistory, or failure to ask the specific questions, may
7 H: ~) R+ A5 a' nresult in extensive, unnecessary, and expensive- Y' c1 E' M4 M2 H/ B" {$ R* ^& `6 T
investigation. The primary care physician should be; t7 B6 O, G- c* j  h5 S+ B  S+ _
aware of this fact, because most of these children' m' _: _0 X7 r  G, I8 K: t, |  q
may initially present in their practice. The Physicians’
# e2 J: V- F( p" z0 J" {* J) u$ D; _& QDesk Reference and package insert should also put a' L( ?) X! Y8 p. @: g% u
warning about the virilizing effect on a male or
$ M$ f, E6 r- H, Mfemale child who might come in contact with some-
* k' n! k9 \% N) `one using any of these products.
7 q) e' @, |  N4 ^+ ]References
- m8 i  B5 a: I; u$ T* K& ?9 B1. Styne DM. The testes: disorder of sexual differentiation, w% G9 _9 H6 e. q4 B
and puberty in the male. In: Sperling MA, ed. Pediatric6 z6 t8 b# S  F+ m/ a; g% }* }( d  R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. W; s, a2 y- L' o! N( n2002: 565-628.
( g' |; J# F8 E: x7 J& u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 Q4 L, z3 H+ bpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old- \4 L. E; z1 U0 {3 y
Boy Induced by Indirect Topical
1 P9 X2 |" u0 U& v3 l% r" aExposure to Testosterone
$ N+ d# X* }7 ~) zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* a. O* y/ B5 l7 @
and Kenneth R. Rettig, MD1
5 |% Y/ D3 h  A' v3 j( uClinical Pediatrics
/ J/ C3 e1 U, j' ~+ @Volume 46 Number 6& J" R4 \2 U$ `% P8 y5 y, I0 m# A3 i
July 2007 540-5438 E, x) c% y6 v% L# i
© 2007 Sage Publications
' F" U  `, x7 [3 Q" L- ]1 E( H10.1177/00099228062966514 L) ^# ^7 w4 M# {5 s# G& o0 q
http://clp.sagepub.com
  u* B' `- l$ P; h1 N% qhosted at+ j; {% X( K  b" m6 X
http://online.sagepub.com" p1 g9 k2 {) }* {! R
Precocious puberty in boys, central or peripheral,- i* R5 y5 r, b% v! s
is a significant concern for physicians. Central
7 o, N3 |( k$ k' h4 y/ jprecocious puberty (CPP), which is mediated2 e# w( K7 B$ S; Q' A
through the hypothalamic pituitary gonadal axis, has# U5 I9 J: K) V0 x- n5 c" T# o
a higher incidence of organic central nervous system+ `# v, i+ e! Z1 M' }- v+ P' R
lesions in boys.1,2 Virilization in boys, as manifested
# @% q1 k2 v9 C. A* A* Q- Lby enlargement of the penis, development of pubic% D  |! r0 U' v9 x5 f6 e
hair, and facial acne without enlargement of testi-; O4 N, g9 r: p( H9 r3 N/ ?/ V
cles, suggests peripheral or pseudopuberty.1-3 We
8 c7 ~" Y3 Z: rreport a 16-month-old boy who presented with the" V9 m: G- ]7 L7 K/ |: A
enlargement of the phallus and pubic hair develop-* ~6 }( W9 `, R* b  G
ment without testicular enlargement, which was due
" A# J3 Y9 S% o' jto the unintentional exposure to androgen gel used by
( V6 [& h1 C. Y4 E$ nthe father. The family initially concealed this infor-+ h% {: }2 Y8 Q6 J0 M
mation, resulting in an extensive work-up for this
% e. h$ d# z7 c! D, Mchild. Given the widespread and easy availability of
( Y" ]0 H) K7 J1 wtestosterone gel and cream, we believe this is proba-1 N6 ~  g" {6 L8 @6 S
bly more common than the rare case report in the/ S+ h; N! Y; T; ?( S0 w
literature.4
& H6 C7 ]" X8 [# `4 g# R$ oPatient Report& @3 V+ d0 i" p  j3 H
A 16-month-old white child was referred to the
; w: }! x) Z; Y9 c/ c9 s3 nendocrine clinic by his pediatrician with the concern
; _, l0 Q. O0 C. Z# h) nof early sexual development. His mother noticed+ E& F5 X1 u  T! m3 P
light colored pubic hair development when he was4 ~4 S6 X+ ]8 c
From the 1Division of Pediatric Endocrinology, 2University of# P! G1 v3 V" b2 Z+ c
South Alabama Medical Center, Mobile, Alabama.9 B1 `; L' U! m6 h
Address correspondence to: Samar K. Bhowmick, MD, FACE,
  G) A$ Y2 Z# F; U% wProfessor of Pediatrics, University of South Alabama, College of
6 J. n2 \$ Y; O4 [) LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 O, d2 o0 a% K* Be-mail: [email protected].
( D) d# W1 t* V3 @3 Z  Gabout 6 to 7 months old, which progressively became: [" d0 N% o8 [# q9 @3 o- r
darker. She was also concerned about the enlarge-4 K7 T, C& b/ w8 t. V
ment of his penis and frequent erections. The child
2 X7 ]& w2 \8 qwas the product of a full-term normal delivery, with
2 g+ L% k. R* h, J+ L* |a birth weight of 7 lb 14 oz, and birth length of6 G' c8 C$ i# U4 h) ?  `' X0 x
20 inches. He was breast-fed throughout the first year5 Y2 w  c: c3 i' [1 D* m5 E
of life and was still receiving breast milk along with
% [3 u, V$ P8 M+ x; S+ Y3 Dsolid food. He had no hospitalizations or surgery,2 N9 I' m. z& [  O
and his psychosocial and psychomotor development3 `' K6 M+ V( ~# c9 a! ^0 |. N* {
was age appropriate.
" W  h8 x2 z' x- Y+ ZThe family history was remarkable for the father,
7 Q3 l/ Z; H, S& P( N  Swho was diagnosed with hypothyroidism at age 16,
( v4 ]; q- q+ ?3 E9 s  w/ Jwhich was treated with thyroxine. The father’s
7 n) g2 ^' q5 _1 J+ kheight was 6 feet, and he went through a somewhat1 C- R1 E' p) n  I6 @1 [+ O
early puberty and had stopped growing by age 14.
& Y3 Z' ^# I+ [" @The father denied taking any other medication. The
0 n/ l/ }, S: O# R) }child’s mother was in good health. Her menarche
. c3 C8 G, d$ j2 e; f+ Vwas at 11 years of age, and her height was at 5 feet
* V# f" j$ U1 d7 l5 inches. There was no other family history of pre-6 @, M5 S0 ~. V  O
cocious sexual development in the first-degree rela-/ J9 D" j) f8 U/ l. L
tives. There were no siblings.
, M7 ]2 }* ~5 ^. ePhysical Examination
, K9 Z5 C5 f; n+ o. X2 _% |The physical examination revealed a very active,
# |3 R6 A# Z/ g6 B0 d* Z  Iplayful, and healthy boy. The vital signs documented
; b- H* |5 U& d4 y' s) fa blood pressure of 85/50 mm Hg, his length was" d/ l( ?( Q: a6 M* ^
90 cm (>97th percentile), and his weight was 14.4 kg7 C/ [! ?8 J* H' f! [/ x. a
(also >97th percentile). The observed yearly growth) |; T- Z& f9 E3 Y/ D
velocity was 30 cm (12 inches). The examination of8 N# z6 P5 f, `8 b6 f( ^8 G1 s/ \
the neck revealed no thyroid enlargement.
) }7 V- l7 |8 N# Q8 ]) kThe genitourinary examination was remarkable for
! B9 y( F6 k) B, \6 [8 v2 zenlargement of the penis, with a stretched length of
) e/ e  b2 ?; }) @/ J1 o8 cm and a width of 2 cm. The glans penis was very well
9 y. L  Z! Y7 |) v2 d! vdeveloped. The pubic hair was Tanner II, mostly around
! M% C! D# j$ V; k+ J540  V6 K* a1 x$ b  U) F% W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 |, Y. q- h$ u- V- |
the base of the phallus and was dark and curled. The: I! j3 @& V6 @! U7 {0 }
testicular volume was prepubertal at 2 mL each.
6 S& B; M, f% {1 S+ h  S9 ?, hThe skin was moist and smooth and somewhat! m: _9 o. {$ u1 D
oily. No axillary hair was noted. There were no
: e: E6 _( A& Z" M' ?/ K# cabnormal skin pigmentations or café-au-lait spots.
. h( K1 y3 ~: w" M1 T5 T2 kNeurologic evaluation showed deep tendon reflex 2+
9 `: C% h9 I$ l* N$ ubilateral and symmetrical. There was no suggestion
; c7 f7 q* S6 W* i8 Q; a9 \of papilledema.( t( C. l! E& _2 e
Laboratory Evaluation. ?+ `5 B# T, a: u- }# d
The bone age was consistent with 28 months by3 u8 ]5 K, {# d
using the standard of Greulich and Pyle at a chrono-
9 T: J# R+ \& P3 b. [! i+ S- i5 Slogic age of 16 months (advanced).5 Chromosomal; e+ ~  c& ?2 g4 z) E7 P8 F) {# h; k
karyotype was 46XY. The thyroid function test
* m# {. A2 `9 X1 y$ A; G9 M  f9 x. rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-& f" [, M& }, }0 P: P
lating hormone level was 1.3 µIU/mL (both normal).
! P1 c% ~1 N, q: x5 t, pThe concentrations of serum electrolytes, blood
* T9 ^' [: N1 {. s5 X* w' t; Uurea nitrogen, creatinine, and calcium all were
0 f9 d: w4 [& M: {; L1 O% pwithin normal range for his age. The concentration) S" _( b6 C: C9 t5 G: ]/ O
of serum 17-hydroxyprogesterone was 16 ng/dL
  ~1 `) B0 _6 R2 N+ Z; e# V(normal, 3 to 90 ng/dL), androstenedione was 20
$ n3 `9 i& k$ R7 f8 Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 j& B7 q& v( n. h1 V; _1 ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; L$ j) q& B  x% ]
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, u9 F1 t( ~  v
49ng/dL), 11-desoxycortisol (specific compound S)
3 D" N% i9 S* T: x4 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. k  @! }- L6 ~1 _5 p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: Q; Q1 i+ L4 s: i; q% V7 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 u+ X! p& y9 ?0 E2 N& e1 b) k: ~5 Cand β-human chorionic gonadotropin was less than* `& a6 q' U1 E; _, f7 t
5 mIU/mL (normal <5 mIU/mL). Serum follicular, p% d8 j) ~* w4 w5 v' E3 ^
stimulating hormone and leuteinizing hormone
- o8 a5 C+ |& C8 |8 W' rconcentrations were less than 0.05 mIU/mL
( `. `# ^! |/ c. ^2 F(prepubertal).
5 h, p% ]- |" |7 z* Q" q3 K' c$ F0 {The parents were notified about the laboratory% P% h+ Z" P: E1 P; X% r
results and were informed that all of the tests were: y- D" @2 J0 v4 H2 n) B
normal except the testosterone level was high. The* s* c1 i4 h. {) W9 L/ Z
follow-up visit was arranged within a few weeks to
4 O3 u% B+ t8 {4 f4 R7 aobtain testicular and abdominal sonograms; how-, B* D2 u( v0 M7 j- ]
ever, the family did not return for 4 months.7 C& S" l. |: z3 p0 I# v( g
Physical examination at this time revealed that the
  ^1 |1 y) p  |  Q" pchild had grown 2.5 cm in 4 months and had gained6 G1 ~1 ?% [2 z+ m. _8 V* c
2 kg of weight. Physical examination remained
- X% w; v0 [$ s0 h- f+ V5 i  l3 Gunchanged. Surprisingly, the pubic hair almost com-
1 g& s( h0 e; y# l0 Apletely disappeared except for a few vellous hairs at" }* c1 b7 l  d4 j# w1 Z/ E8 O
the base of the phallus. Testicular volume was still 2
6 B9 C/ T+ C, V3 i0 `8 q* LmL, and the size of the penis remained unchanged.' A8 b5 f1 Y' `$ I; f" @7 v7 Z" [
The mother also said that the boy was no longer hav-
# q: d% s& o2 W: Z. r- `2 x" Ting frequent erections.! n* O4 n1 @7 W; n9 ?! u
Both parents were again questioned about use of; u' |" x3 ]  ~
any ointment/creams that they may have applied to: F% @9 ]  r+ `( R4 }
the child’s skin. This time the father admitted the
" j6 O" |% F7 H, k  cTopical Testosterone Exposure / Bhowmick et al 5410 Z6 N) ^: \6 i; I
use of testosterone gel twice daily that he was apply-
$ i  r3 J- c# `  }ing over his own shoulders, chest, and back area for
: Y: S! }' P# Ya year. The father also revealed he was embarrassed! |, w0 ]4 k+ J
to disclose that he was using a testosterone gel pre-
* t7 ^3 Z" t; A8 Uscribed by his family physician for decreased libido: h1 S" B3 m/ j" i
secondary to depression.- J% u2 R" Z7 y6 N
The child slept in the same bed with parents.
$ c; Q4 H3 L* S% tThe father would hug the baby and hold him on his
, L9 w- v1 `& E& W, ~$ _0 Achest for a considerable period of time, causing sig-
6 I) g8 c. h3 o# K6 m$ T. [nificant bare skin contact between baby and father.
& R3 T7 P. _8 V. DThe father also admitted that after the phone call,
. v' {4 c: z! Q2 R! x7 S/ J& ?when he learned the testosterone level in the baby
! ]& T, q; Z4 }, nwas high, he then read the product information
" {( j; j- g, R" t" u' R- _7 @% Npacket and concluded that it was most likely the rea-
7 s  ?# s. V; Lson for the child’s virilization. At that time, they, u7 ]3 G" ?) g) _) l7 V8 m
decided to put the baby in a separate bed, and the6 v  {7 }- L) {6 z
father was not hugging him with bare skin and had9 w) w8 x+ F# M: d& U6 H
been using protective clothing. A repeat testosterone9 T& L# [$ D' N7 D5 M
test was ordered, but the family did not go to the# Z" c2 q* L+ C  N
laboratory to obtain the test.& T. a4 h* X! h, \  d, {- y7 l: V
Discussion3 R9 U2 B+ \$ S  \5 W
Precocious puberty in boys is defined as secondary
1 q. u" g& q& b- t4 v" Fsexual development before 9 years of age.1,4; t1 ~6 W9 T2 \% ]8 f: p9 _# n2 s
Precocious puberty is termed as central (true) when/ j8 k7 ]/ c2 ]- |0 r& ^  X8 n5 m
it is caused by the premature activation of hypo-2 G  \0 n8 B1 d3 V- H7 x. I
thalamic pituitary gonadal axis. CPP is more com-
8 ^  X# F+ o' N; Cmon in girls than in boys.1,3 Most boys with CPP3 s, v) B# |4 F3 Y/ |
may have a central nervous system lesion that is
+ V5 H3 g6 A" h' Q  u' R6 c9 hresponsible for the early activation of the hypothal-* _) x0 ~5 H5 B# C
amic pituitary gonadal axis.1-3 Thus, greater empha-# W8 c! p! b# r8 X( c1 ?# c  U% Z' h
sis has been given to neuroradiologic imaging in2 o8 [' W! ?# B; i3 [
boys with precocious puberty. In addition to viril-; `4 }7 d$ S$ g6 W, _+ {6 T( Q
ization, the clinical hallmark of CPP is the symmet-
  Y* s: Y  J3 ~' i' Rrical testicular growth secondary to stimulation by9 R' C: o' q( `
gonadotropins.1,3' C6 {3 ]. {+ K/ d' z% p6 W
Gonadotropin-independent peripheral preco-
3 `1 a4 t# l' T9 S) Ncious puberty in boys also results from inappropriate! \7 k& U6 v  L
androgenic stimulation from either endogenous or6 b6 }6 i" L: q' E  w2 N! G9 A& ~
exogenous sources, nonpituitary gonadotropin stim-$ k8 L8 f+ v9 R; \: u
ulation, and rare activating mutations.3 Virilizing! x" b- U9 N8 a7 H
congenital adrenal hyperplasia producing excessive
* Q( B% _3 f1 z8 m4 D# N- wadrenal androgens is a common cause of precocious
2 ~" {8 l' X; O8 g6 Jpuberty in boys.3,4
6 a; L2 i0 \' R7 z/ K) x0 V. x; {The most common form of congenital adrenal
$ I8 _6 g: ]3 c/ G/ O6 ?hyperplasia is the 21-hydroxylase enzyme deficiency.- Z% a& @9 C, k$ s* h. Q
The 11-β hydroxylase deficiency may also result in
" d9 E; M5 h; O( n& s9 ?& Xexcessive adrenal androgen production, and rarely,
5 x6 `$ w' z! @an adrenal tumor may also cause adrenal androgen0 P' L* r; x7 O8 q( [$ ]& o) n
excess.1,3
) h* u* K+ C$ D% ^! L9 Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: m% D) N7 m& I( X1 k
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' G  S' x% A" g9 b5 sA unique entity of male-limited gonadotropin-. B9 F; R# d6 R8 z' G- w1 o
independent precocious puberty, which is also known
: i6 i: u$ x1 q8 Aas testotoxicosis, may cause precocious puberty at a& Z& j! ~! z* b) G1 U* S( ?
very young age. The physical findings in these boys3 g0 G/ k/ O( h0 O8 q1 a" f
with this disorder are full pubertal development,+ W7 g4 B+ d2 h/ a3 c$ v7 Y
including bilateral testicular growth, similar to boys
5 j6 m/ T& z  `with CPP. The gonadotropin levels in this disorder
- {' |- f; u7 |" I$ bare suppressed to prepubertal levels and do not show
) e- U! _  p# O" C. fpubertal response of gonadotropin after gonadotropin-; K: b7 X$ c3 l4 d9 }2 ^
releasing hormone stimulation. This is a sex-linked! g8 V$ M$ E0 @. l# c
autosomal dominant disorder that affects only
' q/ H; g# }4 [" a- G/ Umales; therefore, other male members of the family6 c- w7 t' d) e7 t/ J
may have similar precocious puberty.3$ m: ]) f4 ~3 y9 q! Z
In our patient, physical examination was incon-
! A' d' _0 r2 Msistent with true precocious puberty since his testi-
& s% t, h4 o. f& \% E( u$ E( Icles were prepubertal in size. However, testotoxicosis
; ~9 R4 k* \+ h; a, A* s& R# ~; Kwas in the differential diagnosis because his father
* S0 c2 W3 u/ ]- M  pstarted puberty somewhat early, and occasionally,
( I" b! h* i1 U" ntesticular enlargement is not that evident in the
% \1 d2 ]7 N& m0 a+ Mbeginning of this process.1 In the absence of a neg-; A! H+ s( A! }# w7 l+ ^
ative initial history of androgen exposure, our, B0 B  U; F: k+ S; {9 i
biggest concern was virilizing adrenal hyperplasia,1 H0 O2 _& h# D
either 21-hydroxylase deficiency or 11-β hydroxylase  J- P. Y+ _" Z9 M/ i+ X
deficiency. Those diagnoses were excluded by find-6 w( z( i8 `# J" V/ @5 a
ing the normal level of adrenal steroids.
& Y' f4 g6 d# Q1 |8 o7 _( l. mThe diagnosis of exogenous androgens was strongly+ u8 s# H0 s" O! P0 l1 E
suspected in a follow-up visit after 4 months because
' [; y5 k+ q; Q% m! x5 C6 Z; jthe physical examination revealed the complete disap-
7 ~8 ^; V* Q+ V( Z# `. u! A% npearance of pubic hair, normal growth velocity, and
" X$ R5 q# N; j& Cdecreased erections. The father admitted using a testos-
& Q8 v5 x1 `" {, p7 s0 \terone gel, which he concealed at first visit. He was, J1 N  [7 I8 w
using it rather frequently, twice a day. The Physicians’8 {2 J+ n; D# n- Z: ]9 P0 g
Desk Reference, or package insert of this product, gel or
, U& I* h/ D, {" i" D5 f, k0 Scream, cautions about dermal testosterone transfer to
5 j) @( J2 N& Gunprotected females through direct skin exposure.  \; \' N$ Y) S  h& o* @, ?' o7 j
Serum testosterone level was found to be 2 times the; _- \$ p9 \; y6 R
baseline value in those females who were exposed to
1 e" `$ p. h/ t8 leven 15 minutes of direct skin contact with their male
3 ~1 V' H0 e) D2 epartners.6 However, when a shirt covered the applica-9 T4 q- q, F+ L& R# M) ?' K
tion site, this testosterone transfer was prevented.
( M, q9 |. C6 f3 _% KOur patient’s testosterone level was 60 ng/mL,
3 S2 T/ k5 F8 H! l# v, c4 Mwhich was clearly high. Some studies suggest that
9 g9 h+ W* ~' u! gdermal conversion of testosterone to dihydrotestos-
. W2 V7 ?3 f) }, `2 G, s$ }* Oterone, which is a more potent metabolite, is more
, l0 a4 k% f7 m& B# h7 M: ractive in young children exposed to testosterone
- Z+ I5 ]9 k. {7 y: _& r2 @8 d" Iexogenously7; however, we did not measure a dihy-( \$ V+ M  y8 M' h- k4 R
drotestosterone level in our patient. In addition to
2 }9 b5 u$ @3 \9 C7 evirilization, exposure to exogenous testosterone in. q! G. q' }5 ^- X8 W9 R" ^+ n
children results in an increase in growth velocity and' c& B! t( H5 x
advanced bone age, as seen in our patient.
6 A+ r+ }' Y" Z' ~/ H  PThe long-term effect of androgen exposure during! f  Q3 o1 Q) {- O9 G
early childhood on pubertal development and final* o) W# v2 q* s6 s5 @9 ]
adult height are not fully known and always remain
' h; W' u. z) z2 y* \( Ma concern. Children treated with short-term testos-
* f. Z2 g; X5 U+ K+ Mterone injection or topical androgen may exhibit some
. X: k& _& a+ i$ x5 s; x  Dacceleration of the skeletal maturation; however, after
8 h0 s+ o7 }5 I6 R' U9 Ucessation of treatment, the rate of bone maturation0 v! R4 F" U/ O$ `6 p
decelerates and gradually returns to normal.8,9
$ v' R9 {# M2 f" u6 t* m  R) uThere are conflicting reports and controversy
, c5 {# B: c  `over the effect of early androgen exposure on adult0 N. S- V! N& J# O
penile length.10,11 Some reports suggest subnormal3 o' G6 x! C% g" X- G8 r2 b
adult penile length, apparently because of downreg-
" @$ |! o3 b  a9 ?8 y' H2 `ulation of androgen receptor number.10,12 However,
- U1 I  O' l: ySutherland et al13 did not find a correlation between
+ ]. e! Q' y  Hchildhood testosterone exposure and reduced adult4 ?- V7 T7 ~  G) O- B
penile length in clinical studies.  O& d9 S9 C( c4 K# L& e& T
Nonetheless, we do not believe our patient is! u) S4 F- f% s
going to experience any of the untoward effects from  K) R3 s/ {, _9 u7 K* z
testosterone exposure as mentioned earlier because! G1 \8 _9 {/ ?1 G$ c
the exposure was not for a prolonged period of time.
& x# n( p$ u" d. r& D: ^( T3 u" WAlthough the bone age was advanced at the time of3 X0 ^/ H8 V6 |) V8 k; j+ [
diagnosis, the child had a normal growth velocity at
% a+ R. O7 A$ R7 f# Mthe follow-up visit. It is hoped that his final adult9 y7 H3 t" ], ]  T' J
height will not be affected.
! g0 J, `4 ?( J- L; zAlthough rarely reported, the widespread avail-5 @0 Q0 {* Z  c) M7 I  q
ability of androgen products in our society may( K6 M: F: ~7 P& i
indeed cause more virilization in male or female+ t$ r5 V- H6 F; y/ W
children than one would realize. Exposure to andro-; ?! t( o9 \, L  X+ s, c7 K
gen products must be considered and specific ques-6 s: N0 O$ ?+ b1 Z; R& k! F
tioning about the use of a testosterone product or: O" L) l) @1 c. f, \" ^3 y3 R
gel should be asked of the family members during
, |+ a2 G9 x3 k% Othe evaluation of any children who present with vir-
( u3 r: e: m3 e3 oilization or peripheral precocious puberty. The diag-* k' a# K  W% o) I* J
nosis can be established by just a few tests and by9 X2 d+ n$ a* R% V* D( [5 q
appropriate history. The inability to obtain such a7 b* P' J1 Q% K/ q
history, or failure to ask the specific questions, may. G" p/ A6 I' t2 P' E
result in extensive, unnecessary, and expensive; U9 O2 j! j6 Q/ z* P7 A
investigation. The primary care physician should be4 ]# D. w* [1 f. p$ m
aware of this fact, because most of these children
( E* k1 c* E! ?. i1 t' }may initially present in their practice. The Physicians’9 O6 \) Q# p9 v2 D% C6 G
Desk Reference and package insert should also put a
8 j6 }/ N! @6 [" m' mwarning about the virilizing effect on a male or
2 m0 p. {( T- A/ C4 n' ~8 g) wfemale child who might come in contact with some-
" \9 X4 Z# m7 N) ~) H, mone using any of these products.
5 J; l3 g, ~6 @References! \/ ~& V9 O/ U: \5 `/ ?  c
1. Styne DM. The testes: disorder of sexual differentiation
$ J1 {' k/ y) L" u' oand puberty in the male. In: Sperling MA, ed. Pediatric  m9 d; i1 f& }8 _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" S6 B3 S# ~! ]9 D! {6 a5 O
2002: 565-628.
; A/ D' Q6 S% n0 J6 d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 h" k- V. g9 X8 ?0 {" w% J4 cpuberty in children with tumours of the suprasellar pineal
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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
* \5 `* L9 ]1 p/ g" ~2 y0 V# n0 ]
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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