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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-Old2 _8 R! X2 _# r8 K$ J/ M5 Y- ?
Boy Induced by Indirect Topical
' F5 P; X, b0 u6 gExposure to Testosterone5 b" h' m7 ~  w  q/ h$ X+ ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 W: i, _8 h* W* K) ?3 W9 e
and Kenneth R. Rettig, MD1
3 l) z  ], S' u# A6 P; {Clinical Pediatrics; }/ E% P1 Q8 H; g% T& R2 l! ?
Volume 46 Number 6
. `. M+ r( @" X( b- XJuly 2007 540-543
1 _8 D/ |& r$ g. y* L6 }1 R$ D© 2007 Sage Publications
- n; q6 J7 {, t0 J10.1177/0009922806296651" A# D8 M7 x! O, p3 l
http://clp.sagepub.com
4 f  Y3 A3 `7 Y2 p0 H" Qhosted at
% L9 v* p( ]; ?% A/ T# Q, f( hhttp://online.sagepub.com$ A$ J. c4 @" H! A$ h
Precocious puberty in boys, central or peripheral,) b' b0 U* n8 J) K. g
is a significant concern for physicians. Central. p) B# Q+ R0 r( |% m
precocious puberty (CPP), which is mediated. E) z/ O/ `$ R% z
through the hypothalamic pituitary gonadal axis, has
+ T( G# G/ P; p- |a higher incidence of organic central nervous system
7 ~; F2 E1 K3 K1 {# m& _0 nlesions in boys.1,2 Virilization in boys, as manifested; |5 X& Z; m5 _6 `4 c  c  @- M7 u
by enlargement of the penis, development of pubic3 v& q6 f4 F. c: H
hair, and facial acne without enlargement of testi-
5 D9 g; y, Z8 q+ E/ S: x; Q; bcles, suggests peripheral or pseudopuberty.1-3 We
/ f0 O* F! X$ k3 k; [report a 16-month-old boy who presented with the
% K8 y% W. t- _# g/ Xenlargement of the phallus and pubic hair develop-' p) a0 z3 i6 {- J/ Z
ment without testicular enlargement, which was due
' X2 u6 d; Y* J! Fto the unintentional exposure to androgen gel used by
- Y  a' }; ]2 M1 zthe father. The family initially concealed this infor-
' I2 [4 O* P% a1 ^! r2 K7 z) Omation, resulting in an extensive work-up for this1 M4 J& f0 Y( `0 i9 c
child. Given the widespread and easy availability of9 V0 \9 ^- C' e. g5 T) {
testosterone gel and cream, we believe this is proba-
2 ?2 s# j/ m/ |bly more common than the rare case report in the
8 l7 M. V: P5 Lliterature.4
4 t9 F3 h; |' ^! i6 ~Patient Report
1 X5 E8 q( ~& p+ [! x7 z: ~7 o. wA 16-month-old white child was referred to the
& D. i+ s6 c. v$ _8 J2 aendocrine clinic by his pediatrician with the concern5 P5 B5 `9 H2 ^5 ~4 c
of early sexual development. His mother noticed/ J: d- g0 w: F; m: [
light colored pubic hair development when he was5 Q& E, j9 O$ ?
From the 1Division of Pediatric Endocrinology, 2University of+ e" u5 f* Y7 G  P& g2 W0 a( U2 i
South Alabama Medical Center, Mobile, Alabama.1 u0 h! e+ X6 J1 h5 Y6 `
Address correspondence to: Samar K. Bhowmick, MD, FACE,- |- c, |" N6 s9 K/ ]- ~: }
Professor of Pediatrics, University of South Alabama, College of
: C, ]$ d, K& ^; @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. n. ?8 H% \, j/ D0 g, ]
e-mail: [email protected].- j1 T) E1 x+ |9 x4 D+ m
about 6 to 7 months old, which progressively became8 {  x/ Z2 \% B
darker. She was also concerned about the enlarge-
: k% {8 c$ }6 W; E( a1 Rment of his penis and frequent erections. The child
$ F4 q* G( Z/ P8 |4 P1 t7 [2 mwas the product of a full-term normal delivery, with. Q5 r8 F# S3 v3 o' F& ^
a birth weight of 7 lb 14 oz, and birth length of5 ^3 U* h. |+ E; s& n! S/ d; ^
20 inches. He was breast-fed throughout the first year
0 o3 n6 K. f+ F7 Hof life and was still receiving breast milk along with
7 T3 Q8 M. N! e- Asolid food. He had no hospitalizations or surgery,
& e- V+ J7 s4 U/ @and his psychosocial and psychomotor development
; X. i2 f; m! f  p( P) u& h  f, P4 rwas age appropriate.- [5 Y& }% B  [
The family history was remarkable for the father,- K6 _0 X7 s: a7 H$ e. p
who was diagnosed with hypothyroidism at age 16,
4 A' l2 z: c5 Cwhich was treated with thyroxine. The father’s' j- g+ a& o" q0 l, B5 k
height was 6 feet, and he went through a somewhat' v8 a/ f- ]1 I' a
early puberty and had stopped growing by age 14.* v  o& A# e/ O2 ^4 U, u
The father denied taking any other medication. The6 @, x% w1 F+ p; U- g
child’s mother was in good health. Her menarche# C: t' g4 I4 q* G' V
was at 11 years of age, and her height was at 5 feet
# C' b% H0 N- M5 inches. There was no other family history of pre-1 e* l% k6 l+ V( {9 y( ]
cocious sexual development in the first-degree rela-& J9 R) T0 w. e- b  l1 F
tives. There were no siblings.+ H2 v8 N4 _# d% O3 D( ~
Physical Examination/ S  q% O5 J6 ]) ~6 v# `2 T+ k
The physical examination revealed a very active,0 E7 K% z" l/ B' R
playful, and healthy boy. The vital signs documented
* ?. S4 H% C1 f& J) R2 M( g; y* Ma blood pressure of 85/50 mm Hg, his length was
+ f: y7 M; Q4 v# o90 cm (>97th percentile), and his weight was 14.4 kg9 ~& o& ^( E0 w3 [, p, S
(also >97th percentile). The observed yearly growth
7 L/ z  D" i6 j/ uvelocity was 30 cm (12 inches). The examination of9 j! Y2 @8 V  F6 T
the neck revealed no thyroid enlargement.! ?# P6 ?* y/ K  }. c
The genitourinary examination was remarkable for
8 n! s& H3 r4 n1 ?) @7 e. renlargement of the penis, with a stretched length of3 p8 G$ }! M7 E9 o
8 cm and a width of 2 cm. The glans penis was very well
( B' @) T* o0 s& D% N* }0 `; [& Ideveloped. The pubic hair was Tanner II, mostly around
" \# s2 }* `' t9 w. _5407 L1 _1 ^8 ]% S. Z+ ^2 T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- c9 e- h: h) v, _6 V, G+ G6 Gthe base of the phallus and was dark and curled. The( ]! U" v: C: q7 U8 z( ~
testicular volume was prepubertal at 2 mL each.0 v2 F8 q5 k7 \
The skin was moist and smooth and somewhat
6 U7 }0 J2 l" u2 a5 f: aoily. No axillary hair was noted. There were no
% c) M8 U5 x* m9 W1 S7 aabnormal skin pigmentations or café-au-lait spots.% V7 X8 S% j0 P7 a& z
Neurologic evaluation showed deep tendon reflex 2+4 r$ m$ m/ G1 q- F- F" }% s/ e) D
bilateral and symmetrical. There was no suggestion
3 \: T& ^( @3 C* i$ Qof papilledema.- r% ]4 \. [* C, R; R& q
Laboratory Evaluation+ q0 R4 L8 @3 Q6 A$ p
The bone age was consistent with 28 months by$ q& p+ D( k" l
using the standard of Greulich and Pyle at a chrono-- _# @! @$ n) ]' t. j$ i
logic age of 16 months (advanced).5 Chromosomal
8 @7 a; @: y! W: |1 ^, ukaryotype was 46XY. The thyroid function test
& J/ J  h$ ^" _! m' tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ l) E2 r. i  ?, R
lating hormone level was 1.3 µIU/mL (both normal).6 B$ b( i1 B$ X- o( d' x& G2 s: H
The concentrations of serum electrolytes, blood4 J6 T0 Z5 {' C! p( f; B- a
urea nitrogen, creatinine, and calcium all were
, H! A* x2 i+ [/ V5 N$ Swithin normal range for his age. The concentration$ r. D. h; e: F4 l
of serum 17-hydroxyprogesterone was 16 ng/dL" d3 s/ w- |9 B
(normal, 3 to 90 ng/dL), androstenedione was 20" Q* H$ }  A* Z) x# @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* }8 P9 q$ M# \* x/ E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 i2 h2 C1 `  H$ Pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to+ ]* E0 `& M. U: t
49ng/dL), 11-desoxycortisol (specific compound S)
3 i7 R# Q- r/ T' ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& p. w. G* _0 R5 h) M8 R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 h% s1 D8 G  Z. E" q; O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 k: \2 x4 w0 T! C* @
and β-human chorionic gonadotropin was less than
* d4 H# ^& a- Q- C. A" n5 mIU/mL (normal <5 mIU/mL). Serum follicular' z0 p6 Q: N( O+ ?3 k! Y
stimulating hormone and leuteinizing hormone7 Q0 T. N' J( q- e* K: n7 M1 D
concentrations were less than 0.05 mIU/mL
# [  o. `3 J1 ]. R4 p(prepubertal).' s8 w; ^0 J" M& h
The parents were notified about the laboratory0 v( \: u& R( w& k% R
results and were informed that all of the tests were
: z5 I4 F7 X; a6 I. F1 i8 a8 L! Pnormal except the testosterone level was high. The; x, J. N1 k6 U9 n% J9 w: v
follow-up visit was arranged within a few weeks to
0 F' l. E- H( J% dobtain testicular and abdominal sonograms; how-5 B1 N* X9 {' X3 m+ G
ever, the family did not return for 4 months.& a& @+ Y  o- d. F: w9 [: t
Physical examination at this time revealed that the
  s' Y. Y0 V7 e. t1 b, ~4 kchild had grown 2.5 cm in 4 months and had gained
3 {$ J! g7 d, k2 kg of weight. Physical examination remained9 C* q# A' e+ R( p3 ^! i; u' T
unchanged. Surprisingly, the pubic hair almost com-
; x9 r; s! F- p, h/ @0 cpletely disappeared except for a few vellous hairs at( B* b$ v  z, V- c' n9 N% ]0 i) ~+ r
the base of the phallus. Testicular volume was still 2& B; I/ r5 h$ r) P# o
mL, and the size of the penis remained unchanged.
1 x. C5 V, W8 R0 xThe mother also said that the boy was no longer hav-
" q8 E0 }! f5 b/ m2 ?7 T& Xing frequent erections.
, g5 {, D! C& ]Both parents were again questioned about use of
4 c% e$ X5 r, ]2 fany ointment/creams that they may have applied to
5 b  t$ }7 X% w* c  bthe child’s skin. This time the father admitted the
# t. W$ f4 B3 ^Topical Testosterone Exposure / Bhowmick et al 541
$ _$ W( F  e% \use of testosterone gel twice daily that he was apply-: C1 a! S" ]' m9 y
ing over his own shoulders, chest, and back area for
5 T, K6 k4 m! T4 r1 t. ]+ D6 ja year. The father also revealed he was embarrassed" q% s7 f: F; A9 L
to disclose that he was using a testosterone gel pre-
) `; Z2 J: G& r6 L$ _, a+ Oscribed by his family physician for decreased libido/ O+ o2 b3 u. g8 T
secondary to depression.
2 @5 X4 C/ K' |" M1 Y9 P& MThe child slept in the same bed with parents.. l2 a: S( m( u9 I/ H2 o) ?8 w& s
The father would hug the baby and hold him on his" }  S1 E9 Z$ Y  d  Z0 E, D
chest for a considerable period of time, causing sig-
4 w- ?! S9 X) i, s( b, rnificant bare skin contact between baby and father.! h+ j3 f, l3 T/ b3 n8 z6 B1 h
The father also admitted that after the phone call,
8 Q% K9 L' q/ ?% ]% Kwhen he learned the testosterone level in the baby( l$ q1 A9 s" o2 w
was high, he then read the product information; [- U* p/ R4 v! T5 Y  C
packet and concluded that it was most likely the rea-& c! v8 M! F- V' V
son for the child’s virilization. At that time, they; Y* |5 O* [5 b
decided to put the baby in a separate bed, and the6 Y6 }" p- B' e* o
father was not hugging him with bare skin and had- r: J8 B2 X+ V$ ]7 [
been using protective clothing. A repeat testosterone
  V% [2 [) Q5 ^7 L! ^8 |test was ordered, but the family did not go to the
+ n6 Y$ @6 N; ?4 d7 xlaboratory to obtain the test.+ ^% k% n  B0 N  |& H1 B
Discussion
7 @8 |$ Z5 g. t. t: uPrecocious puberty in boys is defined as secondary' L! k7 k6 E( r; D4 ]
sexual development before 9 years of age.1,4+ L& H, R2 K1 R& k
Precocious puberty is termed as central (true) when3 W. n" K' ?  E% F! n" d0 a) b* v
it is caused by the premature activation of hypo-6 p- U0 a3 M# X7 r, v
thalamic pituitary gonadal axis. CPP is more com-
( ?1 l: F9 s9 Q5 tmon in girls than in boys.1,3 Most boys with CPP0 X6 R; [4 C- _, M" h4 P
may have a central nervous system lesion that is
, H* ]$ H7 c2 {. Lresponsible for the early activation of the hypothal-
; J4 |0 b; t3 m1 Qamic pituitary gonadal axis.1-3 Thus, greater empha-
& J# e; k" r9 }5 Esis has been given to neuroradiologic imaging in
% J& }* ~0 M/ c0 kboys with precocious puberty. In addition to viril-
' F# r- ]+ n8 f4 n3 iization, the clinical hallmark of CPP is the symmet-' |, G# e/ l" j! |0 D4 _4 n) [7 ?/ @
rical testicular growth secondary to stimulation by9 {* }0 [4 v8 R
gonadotropins.1,39 e9 y9 n- T" r# ]( _+ h
Gonadotropin-independent peripheral preco-" q# r- h  u9 @5 X, Z- K: e& S1 {$ O
cious puberty in boys also results from inappropriate
. t9 `* J, s, o3 [( S' o& E  Pandrogenic stimulation from either endogenous or# I( C, n* m* p$ r5 e( k+ v# o; n' N
exogenous sources, nonpituitary gonadotropin stim-" C* W5 \9 Q/ i% j8 t7 l6 e  F
ulation, and rare activating mutations.3 Virilizing
* O0 |5 T7 L5 p6 Pcongenital adrenal hyperplasia producing excessive
2 l. \5 i$ `4 F/ N. Kadrenal androgens is a common cause of precocious. a) V8 ]: D, q8 H9 p; w+ ~
puberty in boys.3,4; i. ^( x2 S4 P. E' p7 B8 b
The most common form of congenital adrenal
% u2 {/ o7 e0 K8 mhyperplasia is the 21-hydroxylase enzyme deficiency.
1 \" o: u" p0 @4 _& W& }The 11-β hydroxylase deficiency may also result in0 T) s  G, q& S; e' A
excessive adrenal androgen production, and rarely,
- Q* y" `: f* B+ }an adrenal tumor may also cause adrenal androgen$ j8 O- \  Y* A5 Y
excess.1,3. r# r6 i3 W9 ~2 l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 r8 l4 p6 Q" b6 H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& N. Y+ V; y2 k- D
A unique entity of male-limited gonadotropin-
, G9 l- C& g* ]- C3 {independent precocious puberty, which is also known
5 f* g/ T8 S3 w7 \: Gas testotoxicosis, may cause precocious puberty at a( M. @0 r4 x9 y8 G. m1 E
very young age. The physical findings in these boys  y9 U' S9 S$ Y1 l: @% B/ r3 b
with this disorder are full pubertal development,$ o5 I- ?3 f1 ^- L' N7 P: {: |
including bilateral testicular growth, similar to boys' o6 Z6 A4 |* R% E$ J' X; i$ i
with CPP. The gonadotropin levels in this disorder
$ Y6 \: d% C" l1 [are suppressed to prepubertal levels and do not show
4 v2 S8 p; E  O6 e4 ~pubertal response of gonadotropin after gonadotropin-
2 V8 g) ]$ s7 r5 D) Creleasing hormone stimulation. This is a sex-linked
* o. R9 r: d0 G) O  Mautosomal dominant disorder that affects only# M5 v+ O9 t! A) p4 v& [8 ^
males; therefore, other male members of the family
* s& X( A8 t4 qmay have similar precocious puberty.3
$ ?4 J" F/ t- d- l& F$ JIn our patient, physical examination was incon-- X' r" X( H1 C! ^; H
sistent with true precocious puberty since his testi-; g3 {$ x+ u# N$ H- l( N! x
cles were prepubertal in size. However, testotoxicosis! W* b. V/ a4 q
was in the differential diagnosis because his father
, g$ N7 r9 {6 j5 L5 H2 Xstarted puberty somewhat early, and occasionally,6 H% L3 C5 G5 F* I
testicular enlargement is not that evident in the
2 B) R7 V+ f6 |* y7 n: r1 lbeginning of this process.1 In the absence of a neg-3 V1 ?6 M; z! O% `' r% z( X
ative initial history of androgen exposure, our
5 |* L; h. E! E  M" T5 J1 fbiggest concern was virilizing adrenal hyperplasia,
, v5 v# r% g- w- A. u" I5 qeither 21-hydroxylase deficiency or 11-β hydroxylase
+ J) w3 q) Q( ]! S: x9 [' Odeficiency. Those diagnoses were excluded by find-; D$ [2 @+ |! g
ing the normal level of adrenal steroids.
6 \- Z( }! I5 F8 aThe diagnosis of exogenous androgens was strongly$ C7 b$ \2 ]" g
suspected in a follow-up visit after 4 months because4 K( c2 J( f6 v" D0 W- s/ i
the physical examination revealed the complete disap-6 Y: j* m/ b" e, S
pearance of pubic hair, normal growth velocity, and4 y  L1 I" w2 L% s7 J; D
decreased erections. The father admitted using a testos-
0 ^, v: }2 g- Pterone gel, which he concealed at first visit. He was% W2 b8 k- @9 c/ q& Q6 ?0 n
using it rather frequently, twice a day. The Physicians’
- m. @% G, p5 v4 r+ {. G; R! J/ P5 dDesk Reference, or package insert of this product, gel or# J& C1 h& w- B& {5 r1 a) P7 V
cream, cautions about dermal testosterone transfer to
) ~) A1 b9 m) d5 p# Xunprotected females through direct skin exposure.. P4 @# r# A2 z2 k
Serum testosterone level was found to be 2 times the
9 Z& e1 J& F/ H* ]- D% zbaseline value in those females who were exposed to) ^5 q' y  F% ]& \
even 15 minutes of direct skin contact with their male
1 K' ^5 K: b- a, A2 m* t4 W7 K! apartners.6 However, when a shirt covered the applica-
0 \# ]: B' R2 y( n3 Jtion site, this testosterone transfer was prevented.
5 A( O- _" d, N( u: _3 bOur patient’s testosterone level was 60 ng/mL,3 p  x# B. Y' u; Y8 }0 s9 x
which was clearly high. Some studies suggest that
; O  |  b6 S1 `2 P; |0 h9 ]dermal conversion of testosterone to dihydrotestos-
, z: ?. K  x, Vterone, which is a more potent metabolite, is more9 _/ t  ]2 k  U& F! M2 W
active in young children exposed to testosterone
! p5 n% B0 p! |" Cexogenously7; however, we did not measure a dihy-5 @0 B, V5 n7 o% ^
drotestosterone level in our patient. In addition to; S; i" r) C' {9 T
virilization, exposure to exogenous testosterone in2 T( ~5 F1 {9 }% O0 d% `" @+ m: }
children results in an increase in growth velocity and
- n8 p* b+ u& i* ?4 a% Y6 nadvanced bone age, as seen in our patient.8 ^# c9 M# u. E4 U' y
The long-term effect of androgen exposure during
3 S* w2 E! f+ b4 I  J) iearly childhood on pubertal development and final1 z1 k  s( ^2 }4 |0 I
adult height are not fully known and always remain! x0 x( i# ^) \. W/ u5 C; h
a concern. Children treated with short-term testos-8 V9 Q* H  ?9 \' _
terone injection or topical androgen may exhibit some8 o4 ^+ g% I- B( N( G2 f
acceleration of the skeletal maturation; however, after  \1 v: E/ p- s- M
cessation of treatment, the rate of bone maturation& h4 Z' T) Q$ S/ k* o8 W
decelerates and gradually returns to normal.8,9$ ?2 R( h8 R& o$ a$ Y
There are conflicting reports and controversy2 `* {) k5 N3 v" R0 y0 D
over the effect of early androgen exposure on adult
5 v4 U$ v9 s4 x" f* r( Xpenile length.10,11 Some reports suggest subnormal. S. X' E$ y0 ~7 L$ \) x
adult penile length, apparently because of downreg-7 Y8 o- o2 \; @4 X: u8 M( l. Y
ulation of androgen receptor number.10,12 However,
: D& K5 ^3 G  Y' d& vSutherland et al13 did not find a correlation between  W" |0 X5 N+ G* W* b! P+ D
childhood testosterone exposure and reduced adult, X1 \$ t7 E  @: K
penile length in clinical studies.
, n. O* n1 D! oNonetheless, we do not believe our patient is, k4 c, L" b& T8 |+ ^
going to experience any of the untoward effects from
* B; Q9 R, r# p% G, C6 a( |- Itestosterone exposure as mentioned earlier because4 P; }% e6 q0 D1 ~% m
the exposure was not for a prolonged period of time.( Q; R! D, X2 p. a. s+ k. B' m8 l
Although the bone age was advanced at the time of
) W0 Z- E  `5 j) Vdiagnosis, the child had a normal growth velocity at
% B$ r( Z/ R9 }: g2 g! Dthe follow-up visit. It is hoped that his final adult4 x! d, Z  i7 y0 ^  s" h, f
height will not be affected.5 k: f- E: D( X( P' k$ a8 k6 E
Although rarely reported, the widespread avail-
% _/ M1 x6 n0 O$ N3 s6 rability of androgen products in our society may7 p# F+ k8 d2 F" d/ i& g9 d
indeed cause more virilization in male or female
2 [* \! r* N0 i- h- P0 c3 jchildren than one would realize. Exposure to andro-+ d* |% R" b) Y5 H
gen products must be considered and specific ques-8 \1 V1 _& n9 q* m7 e: T7 k4 [+ f3 b
tioning about the use of a testosterone product or5 \) B. J& u9 u( T# I4 @
gel should be asked of the family members during
+ G' {3 T; Q6 ~' xthe evaluation of any children who present with vir-
5 v& R: c' u( D  ]6 L2 qilization or peripheral precocious puberty. The diag-' q6 q' E0 D0 L# X  g: ]
nosis can be established by just a few tests and by
* o* v9 c+ Y8 d, [6 yappropriate history. The inability to obtain such a0 [, I. X& I, J' W
history, or failure to ask the specific questions, may
1 r- [( u: M! i* r- J% h1 F6 N% d! Uresult in extensive, unnecessary, and expensive
7 d% k4 ~2 v" Y) l. B$ s! [8 h1 Zinvestigation. The primary care physician should be
5 f% ?# U4 k8 ?' _9 I/ B5 }aware of this fact, because most of these children8 Z- k& m. e6 O) s) R
may initially present in their practice. The Physicians’
. o0 D! l" ~1 b, M1 ?+ S% eDesk Reference and package insert should also put a; X- l. K6 u1 d" v3 |  Y
warning about the virilizing effect on a male or
7 c, }# d$ ]$ w3 g  E+ t5 }" e$ [female child who might come in contact with some-
6 l. X2 ~3 b- f- Fone using any of these products.* ~+ h4 u* H+ [
References
" }( `. w4 t3 u  i1 W3 b+ d0 ?1. Styne DM. The testes: disorder of sexual differentiation
) l8 v8 C; f4 K. I, s8 ~. D  I4 S: Vand puberty in the male. In: Sperling MA, ed. Pediatric
" k/ u) ^$ R8 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; g" s  p% g: p3 c
2002: 565-628.
4 x6 N7 g0 T" f& C7 @" g9 c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 \% l+ |# l# l
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
. G, h* c# T, _' h' s: e7 oBoy Induced by Indirect Topical
1 B) N' b' N2 h* oExposure to Testosterone* l" Y7 r% t- m( c: x: X$ @9 }! @: e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 m& L* v) [( f& [- V4 s( }$ Kand Kenneth R. Rettig, MD1
* u) n" {7 T0 ~# Y# pClinical Pediatrics* i% B4 M" S* |% y
Volume 46 Number 6
9 M9 b( {) o  d0 c9 ^0 ^2 ]1 \9 XJuly 2007 540-543: q: v  b! t4 F# H
© 2007 Sage Publications, F1 d' B2 Y9 m* E3 c! ~
10.1177/0009922806296651+ E5 f- ^! \9 v
http://clp.sagepub.com
/ V# t" o1 {  X% Whosted at
0 a) k. ^! ?, Z- G8 s4 T: b5 ahttp://online.sagepub.com
" ]# j! }; ^% J  qPrecocious puberty in boys, central or peripheral,
# g3 S$ k7 Z. D0 F. S* x9 Kis a significant concern for physicians. Central
; a4 |+ j( }: f; K2 e# X! L0 Zprecocious puberty (CPP), which is mediated
% b' Z0 h: w& M& K2 K$ B# Pthrough the hypothalamic pituitary gonadal axis, has
! R9 y$ i+ J# ]2 R! Oa higher incidence of organic central nervous system, |  k4 i; j  ^
lesions in boys.1,2 Virilization in boys, as manifested0 t# j( }5 C, A) U! a9 |" Q
by enlargement of the penis, development of pubic: [( q0 {/ Y7 U) V/ Q3 O; L
hair, and facial acne without enlargement of testi-
* H0 ~' C$ B- H! Wcles, suggests peripheral or pseudopuberty.1-3 We9 l9 b3 T, P2 O$ Y; M) h7 n
report a 16-month-old boy who presented with the( E3 D; {8 g# d  G& }% Y
enlargement of the phallus and pubic hair develop-7 H, G$ Y) k1 ?% s
ment without testicular enlargement, which was due
1 Q1 c! b' @4 [! Mto the unintentional exposure to androgen gel used by
: G; F2 V6 ~$ _/ I- d1 Ethe father. The family initially concealed this infor-
, Q: b0 e3 h0 h8 X: z! smation, resulting in an extensive work-up for this
' l0 R/ u! T! _4 K- U: bchild. Given the widespread and easy availability of
- T2 g, u7 W6 [1 Atestosterone gel and cream, we believe this is proba-3 ~# Z4 m* v' t7 r; Z6 `  K
bly more common than the rare case report in the
* z- U2 h8 ]9 u7 o2 Y6 r: u* J. _literature.4# d* |# ?& r" f  }8 S  A/ p
Patient Report  N# n/ E3 s9 G3 P
A 16-month-old white child was referred to the' W7 L6 N; M/ B6 w7 E
endocrine clinic by his pediatrician with the concern
0 f5 i, \- C% o  Fof early sexual development. His mother noticed
, t1 m+ e- h! X2 P3 S; E! s, Clight colored pubic hair development when he was
% X8 x+ r, T) e0 v, u2 XFrom the 1Division of Pediatric Endocrinology, 2University of1 w$ p- @4 Q  q
South Alabama Medical Center, Mobile, Alabama." T" J5 k2 [1 L" {1 Q
Address correspondence to: Samar K. Bhowmick, MD, FACE,# y3 p: z  n4 c9 _2 ]) p' O/ |8 f2 q
Professor of Pediatrics, University of South Alabama, College of
+ [3 v# r2 x; MMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% t! Q7 J% o% `% y' L; ]
e-mail: [email protected].) u, V) {! x* i8 B
about 6 to 7 months old, which progressively became  j4 Q; _( N* C
darker. She was also concerned about the enlarge-4 X. m9 [5 M* ]3 F$ h' T
ment of his penis and frequent erections. The child
8 f0 t6 i/ R4 {9 m6 C6 T/ Mwas the product of a full-term normal delivery, with
, l1 J: M- m  G5 Oa birth weight of 7 lb 14 oz, and birth length of
* ^( H) ]. K4 v4 {; Y20 inches. He was breast-fed throughout the first year
) b6 I; Z0 g% |' Lof life and was still receiving breast milk along with2 j8 H* t/ X* d- O1 F
solid food. He had no hospitalizations or surgery,. K5 E! X6 l' [3 Z" G; v
and his psychosocial and psychomotor development9 P, F- i  B6 N+ |, i
was age appropriate.0 ~* K2 m4 M8 ]
The family history was remarkable for the father,
- Q: j. ?. z2 ?4 P1 fwho was diagnosed with hypothyroidism at age 16,. S: D+ S' E* c
which was treated with thyroxine. The father’s
, F: J. K0 F6 I2 H* \7 Sheight was 6 feet, and he went through a somewhat
# L- M& |; L1 R  P5 iearly puberty and had stopped growing by age 14.
9 S0 [1 S2 ?4 L# U1 jThe father denied taking any other medication. The
5 h. _  T9 U7 a3 s( O( k. V  \child’s mother was in good health. Her menarche7 ~  [( J! _: c: L
was at 11 years of age, and her height was at 5 feet- K7 [2 u. N/ u& `
5 inches. There was no other family history of pre-
$ d* F) @  Z. U. I$ f& K  Jcocious sexual development in the first-degree rela-
6 i1 j- }' n- b% \- Q% a6 Atives. There were no siblings.  Y4 c, y2 Y3 v* o% w
Physical Examination; H0 b9 t5 J, `, z8 a
The physical examination revealed a very active,! m/ D9 N: d$ H! }7 D
playful, and healthy boy. The vital signs documented! K% z8 D: m  J! S, P) ]
a blood pressure of 85/50 mm Hg, his length was/ @, v7 X) E% ]8 a( Y$ S1 h/ h
90 cm (>97th percentile), and his weight was 14.4 kg
( i# X6 N$ j! v/ w0 B5 \(also >97th percentile). The observed yearly growth
+ S0 X1 h9 e0 K* f, nvelocity was 30 cm (12 inches). The examination of: S/ L! u9 i/ [
the neck revealed no thyroid enlargement.
5 D3 w9 R: P% B, G7 F$ a+ A; IThe genitourinary examination was remarkable for
4 W& j5 h3 y* Uenlargement of the penis, with a stretched length of( {! M7 ]$ `' ^" u6 [1 D- _+ ?2 l3 M
8 cm and a width of 2 cm. The glans penis was very well1 h! F, s/ _" _9 B. D  R/ p3 E. f
developed. The pubic hair was Tanner II, mostly around
" v# I6 W' g/ `. h) O540
" p. @$ ?% L4 k7 [7 w* Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' }; u: P$ U+ Y# L: J5 j0 l
the base of the phallus and was dark and curled. The
0 i  N. S/ ^% ?( D! f% dtesticular volume was prepubertal at 2 mL each.& l5 C$ m6 l& _% o  I$ L) v
The skin was moist and smooth and somewhat
2 Q' C5 _: L* ooily. No axillary hair was noted. There were no
/ ~- G( F3 O/ G) [/ Q% iabnormal skin pigmentations or café-au-lait spots.! ^% J8 M$ I2 C
Neurologic evaluation showed deep tendon reflex 2+. X: F- @$ z9 `2 Z  G
bilateral and symmetrical. There was no suggestion
- s6 ?1 B& Q5 [3 ^# {; pof papilledema.# l) Z; P; }& F8 K% p8 s
Laboratory Evaluation
! \: Y. S3 I* KThe bone age was consistent with 28 months by
- P6 P" z# ]9 D1 \2 ~" r" zusing the standard of Greulich and Pyle at a chrono-
! D5 k8 S6 B/ E, f% @9 Elogic age of 16 months (advanced).5 Chromosomal
6 A5 }- D, \/ d1 z; _8 `* n. S; xkaryotype was 46XY. The thyroid function test
, ~* \( @, d9 F9 lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 C, ~" E5 T2 J- g' e* w+ F
lating hormone level was 1.3 µIU/mL (both normal).* i  X4 \9 h8 V3 o* f1 Y
The concentrations of serum electrolytes, blood6 }& |$ O) {( c  j0 v; Z
urea nitrogen, creatinine, and calcium all were
  ~: t; s- l1 W5 ^& U/ Ewithin normal range for his age. The concentration3 m1 |9 F' ^4 P4 O
of serum 17-hydroxyprogesterone was 16 ng/dL  {" R7 ?" H! T; A6 X1 t
(normal, 3 to 90 ng/dL), androstenedione was 20
" E5 d1 J9 n" L. l8 L# V! d" ~. Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! S6 i0 z, L- _# g$ C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( {( G8 \8 m4 x1 M* m& edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  h; m! P% `! y1 C) L49ng/dL), 11-desoxycortisol (specific compound S)
* Y5 w6 u) D6 [1 H4 j3 ~& iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 J4 q  j* N1 I9 u" x( ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! f2 ]' B1 b- n2 z  Y/ [' [' Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),: r& H! k7 y* ?7 k8 n' k
and β-human chorionic gonadotropin was less than/ O& _5 R1 P6 v* N" J' M! r
5 mIU/mL (normal <5 mIU/mL). Serum follicular/ K- t/ Y- v) E
stimulating hormone and leuteinizing hormone
+ Q" `6 c. [! yconcentrations were less than 0.05 mIU/mL
1 F4 U3 R3 r( X" i# ]0 O% f(prepubertal).+ `7 s# c3 S% Y" E6 e# o  z
The parents were notified about the laboratory" ?/ m. {+ y& p# j* a- M
results and were informed that all of the tests were" ^# H. H3 L' W  g
normal except the testosterone level was high. The
/ O) d& t2 j2 D6 ?( p" ifollow-up visit was arranged within a few weeks to- R2 L" D3 O2 l) m! \4 u+ `
obtain testicular and abdominal sonograms; how-
! V& y9 O5 Q1 D0 N7 a: vever, the family did not return for 4 months.9 f6 C$ P( b5 g9 V6 l
Physical examination at this time revealed that the+ X. d+ c; \# h& h6 x, g+ C
child had grown 2.5 cm in 4 months and had gained: l* r: k) d# T
2 kg of weight. Physical examination remained
: x6 y! |: D& S- Y, nunchanged. Surprisingly, the pubic hair almost com-
* T2 B) [8 `4 n% _7 \  Kpletely disappeared except for a few vellous hairs at; h! G7 [" R% S) L, b
the base of the phallus. Testicular volume was still 2
1 M8 B/ M$ G) u# J# \mL, and the size of the penis remained unchanged.8 q( T/ j+ v3 E0 t/ g3 x1 K
The mother also said that the boy was no longer hav-
. S: c. `$ Y+ h. cing frequent erections.
$ h  M9 x7 [& dBoth parents were again questioned about use of
3 \" m6 }' ?( J# Sany ointment/creams that they may have applied to9 i! k7 M; }) t' x
the child’s skin. This time the father admitted the
' E! `' [/ l0 h2 a/ c  KTopical Testosterone Exposure / Bhowmick et al 541
7 G, X; {; I% m: Uuse of testosterone gel twice daily that he was apply-
4 N" a. T; u. {4 U8 ping over his own shoulders, chest, and back area for
& g) W: t1 {( m2 ?6 L4 ca year. The father also revealed he was embarrassed
  F$ c! r4 j+ o, }2 _' P! A( bto disclose that he was using a testosterone gel pre-" v' C  x+ \% P8 {
scribed by his family physician for decreased libido& @4 I6 r+ f! z/ M
secondary to depression.
. x  }* L4 w- @1 i' C2 `The child slept in the same bed with parents.- w# ]- W. M# t  W* F& Y9 O  K
The father would hug the baby and hold him on his
$ D7 t! V1 M( d9 Q7 }/ ~" Z3 ?chest for a considerable period of time, causing sig-3 S2 M* \. O- @& \8 z" Z
nificant bare skin contact between baby and father.+ Z6 a, I) G2 L# Q8 ~% I
The father also admitted that after the phone call,
, a; i( D6 Z8 Z: F4 t9 S8 e- p& Nwhen he learned the testosterone level in the baby- z9 u) @1 Y) Z; @& S+ x
was high, he then read the product information
. |* n; h  E; f/ q% e+ M3 |# rpacket and concluded that it was most likely the rea-
5 v2 u; v1 N( e$ u) Y8 `( ^son for the child’s virilization. At that time, they: D/ `# Q+ a; E3 r! }# U
decided to put the baby in a separate bed, and the8 M/ Q$ `! K6 O2 B0 v8 C
father was not hugging him with bare skin and had
0 ~% A2 ~& n& X: a1 v( z! xbeen using protective clothing. A repeat testosterone- k: O& i4 D/ p+ o' r; Y. o
test was ordered, but the family did not go to the
& L& N5 h( d, D& Glaboratory to obtain the test.
. v5 A. K, p, ~Discussion; B9 N$ i, ^' I7 u- r6 b
Precocious puberty in boys is defined as secondary* M( ^  N* r( C7 C& }: L
sexual development before 9 years of age.1,42 _. n$ l+ ?5 F9 {1 S
Precocious puberty is termed as central (true) when
8 v8 z) K% M" h" _it is caused by the premature activation of hypo-
+ e3 C# K5 ^$ D- Rthalamic pituitary gonadal axis. CPP is more com-
! t: E' U* L8 u1 ^. I& x: kmon in girls than in boys.1,3 Most boys with CPP5 j  ~) Q$ z8 |. C. r1 q: V' \: G
may have a central nervous system lesion that is
2 N3 r' x6 ~+ F/ a! ^5 `responsible for the early activation of the hypothal-. C5 W" h5 S; N  X2 H- c% V" x
amic pituitary gonadal axis.1-3 Thus, greater empha-; M  e, v( M0 {$ ~" t1 I
sis has been given to neuroradiologic imaging in# Z5 u" [0 d# T& g
boys with precocious puberty. In addition to viril-) I5 f  p) ?" ~6 B6 t
ization, the clinical hallmark of CPP is the symmet-. @) V, p! j8 i, X  s* w; a& n
rical testicular growth secondary to stimulation by6 O# A8 I6 W% r. P9 T* J. p
gonadotropins.1,36 r& ~, Z+ f3 Y4 U: d
Gonadotropin-independent peripheral preco-# o4 {  e- b! A  [5 [
cious puberty in boys also results from inappropriate
, p9 f, w' w+ r7 H- `; ~+ O, _* @androgenic stimulation from either endogenous or% P0 C+ h$ W7 w6 r# k
exogenous sources, nonpituitary gonadotropin stim-6 v$ ^7 x. U! \$ t# y
ulation, and rare activating mutations.3 Virilizing  A- E7 S0 D+ k) {
congenital adrenal hyperplasia producing excessive
8 E% @$ q/ E& z+ u- [- tadrenal androgens is a common cause of precocious
' ^3 |3 B; v: e4 b$ g  Epuberty in boys.3,4' F1 s+ i  \0 i, ^, L
The most common form of congenital adrenal
2 p6 Y0 ?: g" g! e1 S) H' ehyperplasia is the 21-hydroxylase enzyme deficiency.6 Z( c! e8 ^/ w/ g8 n9 m8 w; X
The 11-β hydroxylase deficiency may also result in
0 M+ ~3 i& A0 m, |7 z) X* \excessive adrenal androgen production, and rarely,' b/ N' q8 n: Z( G, Q
an adrenal tumor may also cause adrenal androgen
$ v7 v, e1 U' P# X8 oexcess.1,3
% k+ R' }" H* E) x0 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' t- h4 G" d! T7 [& c: J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 x  J& S0 \8 j: U# _/ u2 xA unique entity of male-limited gonadotropin-8 G$ [4 R- H2 _
independent precocious puberty, which is also known( ~# O8 V5 F- N5 B. G* @
as testotoxicosis, may cause precocious puberty at a# D7 Z; Y$ a; g1 A& Z. X% _
very young age. The physical findings in these boys
+ X5 s. J( B; ~6 gwith this disorder are full pubertal development,4 U: [% W' m% D! S5 @
including bilateral testicular growth, similar to boys
2 D1 D8 Z/ F. q7 O- Bwith CPP. The gonadotropin levels in this disorder4 Y* r" s; ]+ l  n* E  R; V
are suppressed to prepubertal levels and do not show
+ j$ P+ u/ H& ^pubertal response of gonadotropin after gonadotropin-( I( H) B- w% |; o: Q8 T
releasing hormone stimulation. This is a sex-linked2 K$ M% t' ?- j9 x2 g
autosomal dominant disorder that affects only
: r, a4 N# ~- N( ^6 ?males; therefore, other male members of the family( z/ h$ ?9 j1 h* r  v0 c
may have similar precocious puberty.3
8 E) \& ?7 S! x" M( N) nIn our patient, physical examination was incon-8 I. {+ M3 Q3 a- S7 F  Y
sistent with true precocious puberty since his testi-
* _, ^4 O9 f" F3 p; [, ]4 \cles were prepubertal in size. However, testotoxicosis5 W# r5 o' W% u, S
was in the differential diagnosis because his father) E& H' p/ Q+ _# c. q
started puberty somewhat early, and occasionally,; l; L: W) a- a: A
testicular enlargement is not that evident in the7 ?2 z) b& R. a# ^- m! ~
beginning of this process.1 In the absence of a neg-
& x8 ?3 H  U1 K: pative initial history of androgen exposure, our
) J5 E! U1 m1 s( Ibiggest concern was virilizing adrenal hyperplasia,) I. f; U2 v" ~! Y7 p6 x+ z
either 21-hydroxylase deficiency or 11-β hydroxylase, R: ^/ q& e' ]' x% J: V8 O) B% _' Q
deficiency. Those diagnoses were excluded by find-
- b; t9 C3 u# P( }7 sing the normal level of adrenal steroids.6 i, e9 D' P4 i2 s7 e
The diagnosis of exogenous androgens was strongly
! N* n' I9 a+ V- M; @2 vsuspected in a follow-up visit after 4 months because9 E  K* L% p! ?3 j
the physical examination revealed the complete disap-
% x: v$ [& l* S5 K/ k3 tpearance of pubic hair, normal growth velocity, and
, e9 q% x: p9 u! p+ W0 {; gdecreased erections. The father admitted using a testos-
$ ]% N; i- b+ M0 Q7 c2 Lterone gel, which he concealed at first visit. He was# ]! n* J  u; Z% b
using it rather frequently, twice a day. The Physicians’
7 j0 S1 l! [; D- d' {6 ]* B1 |4 v) IDesk Reference, or package insert of this product, gel or2 _5 b7 B" t& e" j# U
cream, cautions about dermal testosterone transfer to9 T5 C1 R6 l2 N0 A6 n
unprotected females through direct skin exposure.
  N/ h& e6 w5 e, E' H! fSerum testosterone level was found to be 2 times the) K1 r1 ^% F* ^
baseline value in those females who were exposed to4 O" {( e. Y4 c! O
even 15 minutes of direct skin contact with their male6 g% C/ B* ~3 i+ a3 q6 l+ W
partners.6 However, when a shirt covered the applica-0 E" B  ^9 ?) p$ ?3 t6 _% Z
tion site, this testosterone transfer was prevented.
# D. b% t8 {) l! v, U! kOur patient’s testosterone level was 60 ng/mL,
% n' G% m5 N+ x  {8 ]which was clearly high. Some studies suggest that
, n  ?8 u* s) i6 k2 C5 \5 h- X% A. [dermal conversion of testosterone to dihydrotestos-" o- f% X* K% d" x4 J/ D' q
terone, which is a more potent metabolite, is more
1 r: V# }' p; c. `6 h1 Bactive in young children exposed to testosterone
& q7 t2 Q! z3 ~  ], r" W5 Zexogenously7; however, we did not measure a dihy-( Z& A9 ]5 Y* H7 O
drotestosterone level in our patient. In addition to
: G0 r6 z; q+ _% @virilization, exposure to exogenous testosterone in! ~0 y" x6 ]( T
children results in an increase in growth velocity and, Y7 @( c1 v& C+ i+ p
advanced bone age, as seen in our patient.
6 X1 v* o) X9 m3 K) _The long-term effect of androgen exposure during  ~. b4 {4 b4 [% C& y4 [* b4 v
early childhood on pubertal development and final2 D. E- e7 l3 J, \9 C5 \( m0 A
adult height are not fully known and always remain. }" I& h4 Q; c0 M1 ~7 @
a concern. Children treated with short-term testos-
6 [) H& O& K5 ]1 |terone injection or topical androgen may exhibit some
! x: d5 y- K/ Y% M6 `- M: `6 [acceleration of the skeletal maturation; however, after
6 e& V# ?: c: Bcessation of treatment, the rate of bone maturation
' n: g9 ^" ]* ~' @: Z. j, vdecelerates and gradually returns to normal.8,9
& s# C; ?, \, T5 [. q' HThere are conflicting reports and controversy
# W# Q  P7 `( Iover the effect of early androgen exposure on adult! n+ C1 t3 H" S8 U  ~: k9 A
penile length.10,11 Some reports suggest subnormal" D3 y9 V8 J4 r7 E5 b' E  i
adult penile length, apparently because of downreg-) |+ G6 s: I+ f' E) o% T
ulation of androgen receptor number.10,12 However,$ }  _8 v% v: u- G( W1 H
Sutherland et al13 did not find a correlation between0 C7 t7 W' c& b8 O
childhood testosterone exposure and reduced adult# [( }# Z$ `; K' W, o4 `! Q" A" E
penile length in clinical studies.
3 p8 X4 b% f7 vNonetheless, we do not believe our patient is
# w9 @7 z6 n  p) u! R/ z( y3 mgoing to experience any of the untoward effects from
7 L) `+ `  ]+ c3 h9 ?+ ntestosterone exposure as mentioned earlier because
; ?! @$ M8 {' Y5 k8 Y$ q' g! zthe exposure was not for a prolonged period of time.) i2 Q  c1 |/ J- B% H/ J
Although the bone age was advanced at the time of
2 U. Z" P/ W' W0 I; d; b& Z5 m. bdiagnosis, the child had a normal growth velocity at
4 `$ ]7 M" w* N/ q4 v6 F/ P! ?the follow-up visit. It is hoped that his final adult" i  A$ ?8 G5 P/ K. C/ u
height will not be affected.
/ u( ]: r4 }( C8 F' UAlthough rarely reported, the widespread avail-
' Q) N+ H4 u0 m5 H) y( ^. L9 z& nability of androgen products in our society may
6 J  e8 @# w; ^! z# Oindeed cause more virilization in male or female5 U2 z# |' f# I" |( a% L. t
children than one would realize. Exposure to andro-
+ |/ ?  O6 ^% {/ Y) [1 Xgen products must be considered and specific ques-( K% u4 T1 w* L6 V  z" L
tioning about the use of a testosterone product or
6 T4 W- I  c) n8 H7 O% ]gel should be asked of the family members during: `* K; s4 E! H9 R, X; k* \
the evaluation of any children who present with vir-: p* q! `6 i" P: f
ilization or peripheral precocious puberty. The diag-
1 M; W0 C5 @) b% mnosis can be established by just a few tests and by
7 r2 z5 P5 ~$ y+ G# }" l7 d3 S0 b2 nappropriate history. The inability to obtain such a
- e# a3 X( U! T: ], ~" x0 j2 ^6 dhistory, or failure to ask the specific questions, may: ^- M. M) K5 a% S
result in extensive, unnecessary, and expensive
( |/ ~2 I, e6 g# N1 v: L& Qinvestigation. The primary care physician should be
6 G. a; i4 ]4 Uaware of this fact, because most of these children, Y) b: l  J7 O/ j
may initially present in their practice. The Physicians’- X8 z6 D. \/ H/ w; ~1 a) q1 \4 I
Desk Reference and package insert should also put a
4 R0 ^& p! [& c- nwarning about the virilizing effect on a male or
4 W5 W4 C* ]! ofemale child who might come in contact with some-
1 R: o" ]) z. ^! @6 l6 Kone using any of these products.
: T0 e8 B$ B2 i: n  qReferences$ R+ r4 ?- o  i3 m* Q1 `
1. Styne DM. The testes: disorder of sexual differentiation
" n, l7 \* ~: j0 R: iand puberty in the male. In: Sperling MA, ed. Pediatric
$ `% c7 g( {) j; o, G! WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- v% M9 P! j% ~2002: 565-628.5 ]# @* `" L+ _4 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- e; l* S) d' L. Z; n# `puberty 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

8 r* R, Y7 J; W- Z: z( p* m) W1 E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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