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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) m2 p1 ?% d( ^8 U* _! J
Boy Induced by Indirect Topical
5 ]: l- m9 _7 G/ ~) a" p* fExposure to Testosterone
, F9 S/ E; d% E" z0 d9 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% M1 V! y: z$ V( _: [# o! O  P
and Kenneth R. Rettig, MD14 }0 N# r4 Y6 u
Clinical Pediatrics
0 ?" g0 o! o; ]) i, w- X2 LVolume 46 Number 6. {# `3 d- I7 N- E' _: Q
July 2007 540-543
; M1 \% X8 E. I  U2 ]© 2007 Sage Publications
+ T9 P  t9 G" `10.1177/0009922806296651
. f3 i) Z$ u  q4 c5 X9 m; Chttp://clp.sagepub.com0 C, ~6 x& S1 b* T
hosted at
9 i. Q8 T/ Z7 Z# Z3 G: X1 Nhttp://online.sagepub.com" F: L) a0 P+ w2 T: F0 D' L8 ^8 A
Precocious puberty in boys, central or peripheral,
4 R& ?2 U- A7 u- u) A5 Mis a significant concern for physicians. Central: P$ z; K4 h8 s9 P3 }$ I: L4 `3 `" N
precocious puberty (CPP), which is mediated
7 V# Y* U* m4 wthrough the hypothalamic pituitary gonadal axis, has! Q* `5 h( w; n
a higher incidence of organic central nervous system
+ U# \5 j* P% mlesions in boys.1,2 Virilization in boys, as manifested
6 U5 E2 p1 s: d/ E# Q" Q; k5 jby enlargement of the penis, development of pubic
* h) M3 w3 @/ B! s0 r& v) nhair, and facial acne without enlargement of testi-# `) q7 c; j8 E( N6 p. J- C
cles, suggests peripheral or pseudopuberty.1-3 We
8 F. g" m+ r6 i4 f6 J- W+ \" yreport a 16-month-old boy who presented with the- P% f. U  c: Y* s. v
enlargement of the phallus and pubic hair develop-
# z  l: u6 A( Mment without testicular enlargement, which was due7 K/ @8 S; i( r4 l( N4 y
to the unintentional exposure to androgen gel used by
: T2 m: z! k& a) \* Gthe father. The family initially concealed this infor-, i/ p- p' {9 |  R# W9 Z
mation, resulting in an extensive work-up for this" Z; e) n' [. t" E5 t
child. Given the widespread and easy availability of% X5 S+ j# |/ @" s5 f7 {
testosterone gel and cream, we believe this is proba-
9 M; l/ |; }) \& E! bbly more common than the rare case report in the
" }+ v1 q8 Q8 K# @literature.4
9 Q4 l# H, B) D2 @" {$ mPatient Report% k5 F5 ?* F, {9 H, {- F0 b8 K9 U/ j
A 16-month-old white child was referred to the+ D2 L- L' m( D7 j" _3 x
endocrine clinic by his pediatrician with the concern
# `) D; c& E, C8 M' u* e/ Kof early sexual development. His mother noticed
# I1 L  Y6 n1 I3 r2 _- `& Ylight colored pubic hair development when he was
  t" ^: ]( f* a- A. ?- m2 gFrom the 1Division of Pediatric Endocrinology, 2University of! }- U: d4 y9 J) I0 F
South Alabama Medical Center, Mobile, Alabama.  p; f$ V( J" W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ I" d3 B/ V0 d  L2 e% L/ tProfessor of Pediatrics, University of South Alabama, College of
! O" B) A, m. o- tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 Z8 ^0 d# r6 q3 h: N6 V" P
e-mail: [email protected].
0 p2 o+ W) V5 }7 {1 V" [& Qabout 6 to 7 months old, which progressively became
2 C3 A. I. S9 ~+ Q# z1 ^2 Adarker. She was also concerned about the enlarge-5 ~$ V% Z) S5 Q4 B
ment of his penis and frequent erections. The child
3 V! V8 \/ B" ~  `0 Twas the product of a full-term normal delivery, with# j3 E7 P' P8 |
a birth weight of 7 lb 14 oz, and birth length of; {, v) S* F  T
20 inches. He was breast-fed throughout the first year% C0 Y- {: \# E) C
of life and was still receiving breast milk along with- k" z1 Q* o: _
solid food. He had no hospitalizations or surgery,, x8 y8 c1 l( V2 |- s% V* l( B
and his psychosocial and psychomotor development# q. M; E1 L# g1 m8 G, k, Q" Y, X
was age appropriate.
( [& ]# U! |; @5 fThe family history was remarkable for the father,
3 _' e8 q# z$ w7 b# c# Lwho was diagnosed with hypothyroidism at age 16,
3 D! {$ J- Y# t$ Iwhich was treated with thyroxine. The father’s0 t- B  q0 j! W
height was 6 feet, and he went through a somewhat
" E4 L: q4 C! f- [4 Uearly puberty and had stopped growing by age 14.& p, t* s1 B2 I$ b; Q) g- a/ u
The father denied taking any other medication. The
9 k$ l: p8 `. ~( zchild’s mother was in good health. Her menarche
5 N# T4 f5 j6 }was at 11 years of age, and her height was at 5 feet! N- G5 y) U1 s
5 inches. There was no other family history of pre-
  V# G1 t8 Q0 o4 mcocious sexual development in the first-degree rela-; x8 ?8 N3 g8 A4 q* W& B& D
tives. There were no siblings.( D7 P6 S) \# W+ F
Physical Examination
# l/ K# n% P' G* L  H# ]7 ^The physical examination revealed a very active,0 Q/ |. r  L8 K2 f% w
playful, and healthy boy. The vital signs documented/ e  ?# q. A% C5 Q3 Z
a blood pressure of 85/50 mm Hg, his length was" J) Z1 J# B5 ~( I3 I5 J9 Q* L" C
90 cm (>97th percentile), and his weight was 14.4 kg
0 @" w, a  u2 T$ K. D& W* w(also >97th percentile). The observed yearly growth1 {% |1 z, L6 B8 H+ M$ z
velocity was 30 cm (12 inches). The examination of
, l' m9 `6 m  ithe neck revealed no thyroid enlargement.$ G& n$ B; {; G+ q  I! S. ~
The genitourinary examination was remarkable for1 W7 M0 a( f. W
enlargement of the penis, with a stretched length of! S: R' Z' d, W; O
8 cm and a width of 2 cm. The glans penis was very well+ ^" U# f( z+ W/ z2 h2 j
developed. The pubic hair was Tanner II, mostly around
8 V: T6 _& o# y& k0 z3 U540, d2 m& G" R' l7 o/ G% F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 B# v5 `; T3 k$ R5 f1 [* G
the base of the phallus and was dark and curled. The; _: _7 i4 W. T' l& r9 m
testicular volume was prepubertal at 2 mL each./ ]7 `! I! E2 s6 }
The skin was moist and smooth and somewhat
. D1 U1 N7 g! @" c3 J! }oily. No axillary hair was noted. There were no
7 S+ I/ u6 W! `1 e* jabnormal skin pigmentations or café-au-lait spots." t' H& M6 D; S2 h7 V% {9 ^9 J( @
Neurologic evaluation showed deep tendon reflex 2+
- L; x3 L7 m# Z( D* R4 @, O* t1 Rbilateral and symmetrical. There was no suggestion1 j0 l. ]6 K( c# c$ o* t
of papilledema.
" Y/ G+ P1 L0 y  W; p/ wLaboratory Evaluation  {; k7 |6 P+ Q1 m2 \; ]" ]
The bone age was consistent with 28 months by
( K$ O; }! L- ]7 J/ jusing the standard of Greulich and Pyle at a chrono-( t1 ^% v3 i4 h3 H1 e
logic age of 16 months (advanced).5 Chromosomal
( o" c" U! ?; o' N1 c# Wkaryotype was 46XY. The thyroid function test6 d; r: o, ]& n2 p* O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 f% }6 D% C5 l0 e  klating hormone level was 1.3 µIU/mL (both normal).
; D- g' q0 b/ Y/ n) xThe concentrations of serum electrolytes, blood
8 Z6 S' e% {% U6 O/ d0 J* h7 _urea nitrogen, creatinine, and calcium all were) p8 d$ |; [# }0 \8 P
within normal range for his age. The concentration
; ]8 j3 i& {2 m, s4 R& a( tof serum 17-hydroxyprogesterone was 16 ng/dL
# ~3 J+ D6 `+ ~9 c! [(normal, 3 to 90 ng/dL), androstenedione was 20- N' t4 [- w5 I: V  R1 ?# I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 g* D7 `9 A: w: nterone was 38 ng/dL (normal, 50 to 760 ng/dL),' |, X) u* G6 c+ G* O, j) q: [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to  I. k0 t+ u1 F. I5 b
49ng/dL), 11-desoxycortisol (specific compound S); k. l. p/ L3 N0 R& Y2 W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" |& \' S4 v2 n9 y4 J9 k. J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ V# E9 D, {/ q7 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 N- s/ g( [2 o+ L+ ^  p$ v; O+ V
and β-human chorionic gonadotropin was less than% C# [8 `: }% V( Q/ I
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 M9 x, G; ?+ d2 F: Q+ q* X
stimulating hormone and leuteinizing hormone4 y" R0 r* r8 \6 y
concentrations were less than 0.05 mIU/mL
' C* ?- T% H" S4 A4 x# U9 ~1 g(prepubertal).
- k  _( ^4 ~/ q# F0 fThe parents were notified about the laboratory
$ ?5 w$ p& `3 iresults and were informed that all of the tests were. [# X( x4 p2 I. i
normal except the testosterone level was high. The
* T+ x+ E9 o8 w+ s* o0 P0 V0 Vfollow-up visit was arranged within a few weeks to
4 y3 p6 q; q, `$ Q) l8 wobtain testicular and abdominal sonograms; how-
# T- k: u* v( f' ~1 V0 [, `& Kever, the family did not return for 4 months./ h* J: o. d+ z  R5 {2 C! h
Physical examination at this time revealed that the# a  @. B3 Y% ?) O
child had grown 2.5 cm in 4 months and had gained
1 s4 c& K7 v9 S: \' D7 o0 o; S2 kg of weight. Physical examination remained
+ K% f: O8 E$ w. M; ^/ u) cunchanged. Surprisingly, the pubic hair almost com-* Y: j7 {% f3 s  c
pletely disappeared except for a few vellous hairs at
8 c' z' [% P) T8 e. ythe base of the phallus. Testicular volume was still 29 [8 j7 w$ w: X, o0 P) I
mL, and the size of the penis remained unchanged.2 |4 `# ^; Q, ^- C% N' y
The mother also said that the boy was no longer hav-
; |0 J0 Y: r' f* g( p! t/ Z& qing frequent erections.) Z1 l% j! }! }. c2 P# ]1 v9 K
Both parents were again questioned about use of9 I6 @  n, R' l) A0 i
any ointment/creams that they may have applied to
8 Y  O2 @! B# K/ ?: ^( Dthe child’s skin. This time the father admitted the
% ?: V( D4 H* D1 d' z8 F6 J! gTopical Testosterone Exposure / Bhowmick et al 541
8 ~1 i; X8 ]3 t5 I% Tuse of testosterone gel twice daily that he was apply-
* l# D6 F2 R$ U7 ?) W, J5 u1 }ing over his own shoulders, chest, and back area for) n3 o; A. S- B2 }5 A7 L# t1 ]/ ]' g4 J
a year. The father also revealed he was embarrassed( ?, R& C; h/ [! K. ^% u+ u* u! J
to disclose that he was using a testosterone gel pre-
! s4 c- D4 g; B! lscribed by his family physician for decreased libido" x+ M, `' r5 s* Q' t, g; w( p5 H
secondary to depression.
! a. n4 g3 \" r. l3 p) RThe child slept in the same bed with parents.
4 h7 A5 K% K; k% FThe father would hug the baby and hold him on his" \9 X# N7 E0 N$ U: g
chest for a considerable period of time, causing sig-8 a2 Y/ P& Z) M- t4 M( \+ v8 Q
nificant bare skin contact between baby and father.
2 k- W! A0 z/ s' O- ^, IThe father also admitted that after the phone call,2 Y' L: w" V' e
when he learned the testosterone level in the baby
3 @0 q. y' i5 m+ l+ bwas high, he then read the product information
9 j0 |# @( j8 V* g+ H8 I% Kpacket and concluded that it was most likely the rea-# u# V  W7 G& O3 ?
son for the child’s virilization. At that time, they
! V/ ^  I+ l; g' d6 z3 \decided to put the baby in a separate bed, and the0 R& `8 d% x- @  K: D8 [
father was not hugging him with bare skin and had
; _. ]" e- y- Wbeen using protective clothing. A repeat testosterone7 y4 k+ g' B; ]5 p2 |' }
test was ordered, but the family did not go to the5 h3 h# ~! J+ u
laboratory to obtain the test.
+ u- M1 X+ Z" g- o2 W: v7 pDiscussion/ N8 H  t! _; g! X
Precocious puberty in boys is defined as secondary
. }) ]) O( H7 m5 e  }sexual development before 9 years of age.1,4
, r7 M0 J/ |+ B4 Q' [8 r3 l! JPrecocious puberty is termed as central (true) when
5 f7 Z' g! R" B3 t+ U7 \, n0 iit is caused by the premature activation of hypo-0 S; [8 z0 H. Q  g) p9 L6 @
thalamic pituitary gonadal axis. CPP is more com-# y# W5 w% S* B2 o: Z  R; {7 H$ ^
mon in girls than in boys.1,3 Most boys with CPP
; d- }" k; H1 C* z& nmay have a central nervous system lesion that is
. h# Z4 D# r8 A7 e! n. ~responsible for the early activation of the hypothal-6 w6 ^' {% v8 {7 v
amic pituitary gonadal axis.1-3 Thus, greater empha-' B5 V$ ~" Y# c7 S: ]* o7 q
sis has been given to neuroradiologic imaging in) |% \) O/ f# N  c
boys with precocious puberty. In addition to viril-
+ K8 f0 F7 g+ H5 C$ f$ b, oization, the clinical hallmark of CPP is the symmet-* B: ]& p- ]* M8 x6 M4 C/ p
rical testicular growth secondary to stimulation by
* e  p. x8 |* @+ @  |gonadotropins.1,3  \  ?  \6 u/ U' d  ~* x' o, {
Gonadotropin-independent peripheral preco-" i' h  O0 P3 M3 k- Y3 b6 X
cious puberty in boys also results from inappropriate
$ s4 I: H2 E' J7 Yandrogenic stimulation from either endogenous or
! p; I- c- |- K: y7 Bexogenous sources, nonpituitary gonadotropin stim-- _2 x) K, n3 R) f# h: m
ulation, and rare activating mutations.3 Virilizing
; _; z6 K& V1 ^/ l) Q! F9 x# Kcongenital adrenal hyperplasia producing excessive
1 E* b8 O0 F0 w1 Iadrenal androgens is a common cause of precocious* ?: `; ]& M' M3 f% c1 M! ?, T
puberty in boys.3,4' A% B" K0 s6 g  G) h: i3 r3 F: p
The most common form of congenital adrenal+ ^8 C+ s$ _. X! K
hyperplasia is the 21-hydroxylase enzyme deficiency.; s$ L: d3 F- m: m
The 11-β hydroxylase deficiency may also result in  C% w3 {2 q: @8 y" N: s/ a6 x! n
excessive adrenal androgen production, and rarely,/ ^7 J: x. O, {6 U
an adrenal tumor may also cause adrenal androgen
6 M5 B5 S  _5 X% ~4 R8 Q" @/ J1 Bexcess.1,3! C4 |) o; g  l& @7 ?6 x5 B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ g5 ~$ E8 e1 J- e  N0 G- u1 B: S$ W
542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 w9 \' |. q' V6 G
A unique entity of male-limited gonadotropin-6 p# s! I& \& k
independent precocious puberty, which is also known
" @9 s3 N8 ]6 h9 g; z+ b' Das testotoxicosis, may cause precocious puberty at a- n& m, ~) J/ u9 F' d" z1 J0 k
very young age. The physical findings in these boys
. z& m# v% e+ h2 O! \with this disorder are full pubertal development,
: q( r/ Z& \; ?: B' V3 O6 Iincluding bilateral testicular growth, similar to boys
" D. E2 C# C  @$ X' S& @' _with CPP. The gonadotropin levels in this disorder4 |1 j; y, J5 W) b
are suppressed to prepubertal levels and do not show) \( }3 X2 O* C# n
pubertal response of gonadotropin after gonadotropin-
7 {6 s0 K5 i1 c+ `/ }$ q6 Mreleasing hormone stimulation. This is a sex-linked
$ Q, Y, O* r; dautosomal dominant disorder that affects only" ~9 |2 n, ^; s  N3 }
males; therefore, other male members of the family
) S3 S" i1 Q+ J" o, fmay have similar precocious puberty.3% C) B; r1 @+ K5 q; F
In our patient, physical examination was incon-9 A% K+ j% q6 @$ X5 r' S3 g
sistent with true precocious puberty since his testi-$ H+ ^& y% n, s  i
cles were prepubertal in size. However, testotoxicosis$ H, x9 p7 V# k
was in the differential diagnosis because his father* ^8 x8 t( Y7 \9 J
started puberty somewhat early, and occasionally,* O2 T. X8 a: `& z# N
testicular enlargement is not that evident in the& u! H6 }. L* }# B' r
beginning of this process.1 In the absence of a neg-8 L& w: ~7 `, t8 N. |7 o$ _) T, {# R0 r
ative initial history of androgen exposure, our# ~2 ^5 p( L: g1 k5 K3 q1 [# ~
biggest concern was virilizing adrenal hyperplasia,+ V8 P, r. M/ T! K
either 21-hydroxylase deficiency or 11-β hydroxylase" p! ^2 {  B' L3 s0 K6 I
deficiency. Those diagnoses were excluded by find-+ O) ^/ ]1 U4 g
ing the normal level of adrenal steroids.4 J: r3 n; j% n7 o
The diagnosis of exogenous androgens was strongly- q, n: }! q7 p
suspected in a follow-up visit after 4 months because
0 d9 w* @& B& T4 T; @the physical examination revealed the complete disap-( T$ R1 S' b$ A- h+ A) n* I5 h
pearance of pubic hair, normal growth velocity, and- G$ p8 Q7 Y+ n+ ^. `! H: Y
decreased erections. The father admitted using a testos-
9 U; b$ A% w8 @8 G  u# H: i7 T  W  Z3 uterone gel, which he concealed at first visit. He was
  D; p9 ^( r8 zusing it rather frequently, twice a day. The Physicians’
0 j' q$ Z* D* C2 g# |Desk Reference, or package insert of this product, gel or$ ^( |0 j6 U1 X4 k9 P/ H
cream, cautions about dermal testosterone transfer to
% s- B! k  F* Z* P% e4 D, f: g& Nunprotected females through direct skin exposure.+ P. B* n, b0 X, E0 x0 w
Serum testosterone level was found to be 2 times the
# O% O% t+ j8 t7 s; ybaseline value in those females who were exposed to4 M+ f- _8 v8 x3 Z7 L" }
even 15 minutes of direct skin contact with their male4 D* z) x1 l, U; g" w2 \
partners.6 However, when a shirt covered the applica-6 i# D5 I& F/ K  N6 M
tion site, this testosterone transfer was prevented.5 S2 Z4 D  e( ]/ Y& f! M+ C
Our patient’s testosterone level was 60 ng/mL,
5 z" K1 ]. ^+ l0 swhich was clearly high. Some studies suggest that; Q, R$ f- F# r
dermal conversion of testosterone to dihydrotestos-* M2 P- Y8 M3 B0 J
terone, which is a more potent metabolite, is more
9 S. c* z6 x# @+ B/ \" aactive in young children exposed to testosterone
6 P  j0 _; ^: l1 l9 rexogenously7; however, we did not measure a dihy-
9 F* b, v6 ?& ?% x$ C* P5 fdrotestosterone level in our patient. In addition to
6 Q$ o; N- C& }1 g+ X; Svirilization, exposure to exogenous testosterone in) N, b9 ^! ?9 b+ _% _% L
children results in an increase in growth velocity and9 b1 o0 i5 k7 @: A# ^, y
advanced bone age, as seen in our patient.
) x8 s5 {0 |7 ^The long-term effect of androgen exposure during% z/ L! ~  k; H8 O; G2 u# E
early childhood on pubertal development and final
3 c  T4 K; l7 x$ c: @adult height are not fully known and always remain
& P' ^1 X- z; s$ q' Ia concern. Children treated with short-term testos-( s. r1 O/ d5 U8 z8 _2 D0 I  N
terone injection or topical androgen may exhibit some: i8 E% J( W8 p* }9 g- `# r
acceleration of the skeletal maturation; however, after
+ L; }8 k% E% @3 G; B1 q( ]cessation of treatment, the rate of bone maturation% J: w" l' z" l+ d1 u
decelerates and gradually returns to normal.8,9
3 J  C- g' s9 C% A( T  lThere are conflicting reports and controversy2 i6 s7 a" W7 L! u
over the effect of early androgen exposure on adult
: u7 I6 B; ^8 i! upenile length.10,11 Some reports suggest subnormal
( R! C. ?/ M; I% oadult penile length, apparently because of downreg-
# j0 O- u) u  [ulation of androgen receptor number.10,12 However,3 Q, C- n% k3 T/ V/ o
Sutherland et al13 did not find a correlation between+ y# }% K+ p- D
childhood testosterone exposure and reduced adult, C) g) @6 K, ~0 x. `2 r/ q
penile length in clinical studies.9 d; t& y6 k) b
Nonetheless, we do not believe our patient is9 H; V) e2 t  R# @1 X( e
going to experience any of the untoward effects from) P7 c1 {* Z6 T1 G; b" {! K" d! L) Q
testosterone exposure as mentioned earlier because
* K; s1 `1 {# D& L9 f; fthe exposure was not for a prolonged period of time.# ]7 d3 Q; Z9 l+ H) d
Although the bone age was advanced at the time of
4 u% M# b+ W5 x$ j& i/ sdiagnosis, the child had a normal growth velocity at5 i* w& v2 M! P. l/ \% i/ @
the follow-up visit. It is hoped that his final adult
0 {+ A6 _: A% Y9 a* w" Dheight will not be affected.
, ?! n5 I8 X/ k% E4 PAlthough rarely reported, the widespread avail-# k; }% w, _7 k2 A3 ^; J* D# |
ability of androgen products in our society may# X6 x9 d7 R8 h
indeed cause more virilization in male or female. K9 V% \5 ^/ N; }2 n" t
children than one would realize. Exposure to andro-
, L# Y; {8 s1 U3 ~+ h: f) Mgen products must be considered and specific ques-4 q; d8 {' E5 g. z. s, ~
tioning about the use of a testosterone product or! X1 p- W6 A8 f0 A! h) ?+ {7 t) A
gel should be asked of the family members during
# z0 n2 i1 b* o& z* Vthe evaluation of any children who present with vir-# t6 X  t% l# o. z5 d/ r* j
ilization or peripheral precocious puberty. The diag-
' Q6 ~6 V# j! Cnosis can be established by just a few tests and by
- u7 z# U  }  B+ y- U3 J/ w, tappropriate history. The inability to obtain such a6 L  t7 J% ^8 P
history, or failure to ask the specific questions, may  g. m1 W- C. p! Q: W, D
result in extensive, unnecessary, and expensive; s7 t: Y- S6 `& J' L5 y9 y! ]8 S
investigation. The primary care physician should be
! z) e, X+ C$ c+ u9 v1 u* [, Maware of this fact, because most of these children" b/ D8 r0 J7 q
may initially present in their practice. The Physicians’
( r! j1 C+ X$ F: U: n) ?0 DDesk Reference and package insert should also put a3 K9 Q" ^) p. B+ N/ g
warning about the virilizing effect on a male or$ g, \" I. e5 X, k$ ?
female child who might come in contact with some-/ @9 v9 B6 B5 I0 o( X, _% ^
one using any of these products.& P$ i7 @# G6 X& k1 m) u. `
References) [" e9 J0 |. c/ p9 w
1. Styne DM. The testes: disorder of sexual differentiation  x% x. J% o3 |
and puberty in the male. In: Sperling MA, ed. Pediatric" Q: G& P: }3 ^. `* I+ r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( l# P- I. K7 y. E$ X7 y5 m" j
2002: 565-628.
: |' |( ~, X; Q% V- W+ B* k" q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 z- b6 s: f3 w1 r, [" f5 {puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) \; T9 ?% W. ^# a7 l/ D
Boy Induced by Indirect Topical$ c/ A# @) W6 ~5 Y1 q2 ^" H$ a
Exposure to Testosterone
, O0 B( T' _" M# K% |4 |6 @+ qSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 E; K, N: L- F; pand Kenneth R. Rettig, MD1
$ ~) q% [2 P. h: b- }- IClinical Pediatrics+ ]0 I+ I0 A; Q8 D0 E: N% ?
Volume 46 Number 6
" o, C) W; E) ]1 C3 E3 nJuly 2007 540-543# _/ f$ L% y2 t. R
© 2007 Sage Publications9 O8 A; x# p" Y. t0 E" G
10.1177/0009922806296651
' D3 F0 M; y# s# Q- J" l4 K- Shttp://clp.sagepub.com
+ t1 y0 E6 w3 q0 X$ N! v% c( ~7 |4 Ghosted at8 T- V2 i5 e& {) M$ |
http://online.sagepub.com
& l+ c4 A; o2 i7 n- q3 [7 j  kPrecocious puberty in boys, central or peripheral,7 N- ~) y) j6 T' \
is a significant concern for physicians. Central1 P5 K. P' i1 j' G8 q# Z$ g) Y
precocious puberty (CPP), which is mediated+ \8 K4 k7 ?! |# I4 h1 o7 F
through the hypothalamic pituitary gonadal axis, has
" ]7 g2 A# h, E1 A. E4 Sa higher incidence of organic central nervous system
. |0 w1 g% d9 j. i7 n2 Llesions in boys.1,2 Virilization in boys, as manifested9 x5 F1 T' d8 N1 L4 A5 S. o6 Q
by enlargement of the penis, development of pubic3 j) d' q) M4 m* T$ P6 ]- O/ S
hair, and facial acne without enlargement of testi-
* r; X2 H, S3 }# P* ^3 Jcles, suggests peripheral or pseudopuberty.1-3 We  N% ]; w9 X. U+ U0 K* W, c
report a 16-month-old boy who presented with the  p6 z: [0 N0 I; S
enlargement of the phallus and pubic hair develop-# q9 A. Z3 ~; }' @5 P: Q
ment without testicular enlargement, which was due
2 H2 s; W5 ?& @6 Z3 x# bto the unintentional exposure to androgen gel used by
( J& G$ S; \0 A0 v" L9 @& G: U4 Lthe father. The family initially concealed this infor-
9 E! J* X) f: z% G: e+ V# ?mation, resulting in an extensive work-up for this
; g4 F) H$ L* |child. Given the widespread and easy availability of
7 \; G) U; J, a  u% Rtestosterone gel and cream, we believe this is proba-! W' }1 l" X( _7 p& }
bly more common than the rare case report in the
3 [* Q$ ~% l! i) q6 o0 }literature.4- Q  E) w7 u: j' j# r! C
Patient Report1 a8 b/ j6 A6 g# d
A 16-month-old white child was referred to the5 N1 B) |( C1 T% q6 H) @
endocrine clinic by his pediatrician with the concern: b* y9 S9 S8 _) r
of early sexual development. His mother noticed
+ G9 G& p: u! F' p- |8 klight colored pubic hair development when he was/ y& _  P- \, O9 ]
From the 1Division of Pediatric Endocrinology, 2University of
. f. o# i, Z& l& x6 vSouth Alabama Medical Center, Mobile, Alabama.' ~/ G9 k8 O$ E' A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 M, E5 Y" L# qProfessor of Pediatrics, University of South Alabama, College of
  d8 {6 E+ f" ?6 ?+ |4 DMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: T' ~9 J. p/ m8 S* `* Ce-mail: [email protected].
# x" j  U' i# O( P3 @" ~about 6 to 7 months old, which progressively became
0 O4 n" F+ ~/ ddarker. She was also concerned about the enlarge-$ i) \  z" X2 X/ @
ment of his penis and frequent erections. The child
# ~1 w7 c  I" p3 G2 L$ nwas the product of a full-term normal delivery, with
. l7 S) s% j, B- ?5 sa birth weight of 7 lb 14 oz, and birth length of
; g! G# a) q: l! [20 inches. He was breast-fed throughout the first year- |" N  D3 Q$ z- ?0 l* }
of life and was still receiving breast milk along with/ J/ l6 m% `$ E! A& E5 e! ~
solid food. He had no hospitalizations or surgery,. M" Q* d  L7 ~- ^& n5 ?
and his psychosocial and psychomotor development% ^& w( E& V0 N9 T
was age appropriate.
7 v1 J8 v8 O6 u3 j& E5 y1 S, \The family history was remarkable for the father,
) U  s6 R( f& H. K. \. |who was diagnosed with hypothyroidism at age 16,! F8 F5 r% Z4 i( x  B" K. A9 T. I
which was treated with thyroxine. The father’s' L! c' f( f  l9 H) l
height was 6 feet, and he went through a somewhat( z+ V2 Z2 r6 S$ l  Q0 |
early puberty and had stopped growing by age 14.5 g% r$ J6 q/ \
The father denied taking any other medication. The
- f  K" R4 W1 D4 c5 L7 Wchild’s mother was in good health. Her menarche. L+ K5 [  R- W, @. r) |) i) F
was at 11 years of age, and her height was at 5 feet" e8 B1 |' x% q; X& c- p
5 inches. There was no other family history of pre-5 i: q' u, P# A
cocious sexual development in the first-degree rela-
2 ?6 D% w9 i" _' htives. There were no siblings.
' X, C" r! |6 f- X4 r' \Physical Examination. x0 ?  ]2 l' i, L) {0 q  l
The physical examination revealed a very active,8 G7 S' `3 V/ I) O
playful, and healthy boy. The vital signs documented( u/ `4 Q: k# ~) m
a blood pressure of 85/50 mm Hg, his length was
- \: d! D& R6 X8 b90 cm (>97th percentile), and his weight was 14.4 kg" r' ]5 c  R1 o; V. C! v
(also >97th percentile). The observed yearly growth
9 t3 |: r0 X0 b$ Y4 xvelocity was 30 cm (12 inches). The examination of
, f! a+ H! L* \6 q7 \the neck revealed no thyroid enlargement.& T$ E+ u% ~# y
The genitourinary examination was remarkable for
4 o, ]4 `6 ~! ?- X% Y3 [, lenlargement of the penis, with a stretched length of
  Z0 T9 K! |. _3 f8 cm and a width of 2 cm. The glans penis was very well; S' [8 R+ y  K- E
developed. The pubic hair was Tanner II, mostly around
* G  ^) l5 M2 T7 `2 J540
, F, h9 }, M$ w9 p1 l6 ?- [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" @. a/ k* W. L0 ~
the base of the phallus and was dark and curled. The
. k2 u/ q: P( {0 Btesticular volume was prepubertal at 2 mL each.* B4 b, d/ m' P
The skin was moist and smooth and somewhat' r; g. v( p. T' o2 \
oily. No axillary hair was noted. There were no3 c  B4 O) H" l. i  @2 j5 N
abnormal skin pigmentations or café-au-lait spots.2 h* e3 F8 r* G: T) M
Neurologic evaluation showed deep tendon reflex 2+
- ^/ z. x# k/ U9 M/ o5 o$ l0 Zbilateral and symmetrical. There was no suggestion
" n7 `) o1 ^3 g$ zof papilledema.; ?3 K/ {# r% V. k
Laboratory Evaluation( l8 d1 W. J, n& V# H
The bone age was consistent with 28 months by
3 X0 c- b# g, z0 H8 h+ Wusing the standard of Greulich and Pyle at a chrono-" H3 Q( _& D6 _& d4 E( d
logic age of 16 months (advanced).5 Chromosomal
, n3 X$ y% _' n. ?4 ?+ q) vkaryotype was 46XY. The thyroid function test7 W5 ?, f5 {# x/ n" B: j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. }: i5 V4 ^4 T6 A" X/ Hlating hormone level was 1.3 µIU/mL (both normal).
* I2 k' C3 ^) RThe concentrations of serum electrolytes, blood+ E* f2 G0 T' B7 J# K- ^1 P7 w
urea nitrogen, creatinine, and calcium all were
* r( o# f3 y- R5 Nwithin normal range for his age. The concentration
: @0 B) T, w0 aof serum 17-hydroxyprogesterone was 16 ng/dL/ Q+ [# O& Q/ k% k
(normal, 3 to 90 ng/dL), androstenedione was 20
+ O" M) n) h( t/ ]" @* @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 t+ {. R; y  {
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 C  Q' Y( b% V; E1 ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  z& o! D! ]0 Y4 W1 @, X: Y49ng/dL), 11-desoxycortisol (specific compound S). r5 \. j% B  D' ]% b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: |0 O- A+ n/ l( D* q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% O5 L/ r, s4 ^1 ~5 Wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 o3 E; B! ]5 T( N& z7 aand β-human chorionic gonadotropin was less than; w/ l& W$ W4 u2 C. U7 }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
' l0 y, P" j4 b( b6 c1 C' `9 n; E  w! Estimulating hormone and leuteinizing hormone: c; o& J* M& y% W
concentrations were less than 0.05 mIU/mL2 ]+ ?5 R) `) \8 _
(prepubertal).5 H. S0 P/ O' d1 l$ v
The parents were notified about the laboratory
9 x: _; j' t0 S9 Nresults and were informed that all of the tests were  x" g. z* m0 v& r  g+ H* K2 j
normal except the testosterone level was high. The0 d/ R2 k# i' \( j6 \
follow-up visit was arranged within a few weeks to5 D7 ]  \8 C9 w
obtain testicular and abdominal sonograms; how-. g+ ~& o3 u1 ~, A8 A' e# q, J) y7 s
ever, the family did not return for 4 months.3 J# a  P% P% D( k3 e. }
Physical examination at this time revealed that the1 i9 G, @( ^; l0 b
child had grown 2.5 cm in 4 months and had gained# M2 I: O2 l9 [
2 kg of weight. Physical examination remained
5 J; J8 o, z$ ^& ^( Junchanged. Surprisingly, the pubic hair almost com-: D! H' W! D" [/ [7 j, u
pletely disappeared except for a few vellous hairs at
, D; g- l' r" y! j# o, ~/ @the base of the phallus. Testicular volume was still 2, k2 T' H. f$ E( B" K7 e5 j) _
mL, and the size of the penis remained unchanged.
' I3 L5 C# R- ^& c0 T  E: MThe mother also said that the boy was no longer hav-. @' q5 C$ C: d) k
ing frequent erections.0 |, H- d1 u" l& e; Y
Both parents were again questioned about use of
2 ^4 ~5 C( f6 O4 G& N0 `; Vany ointment/creams that they may have applied to
9 Q, c" ]6 O# A6 O8 Z3 a, M9 O' I: Xthe child’s skin. This time the father admitted the# c; \+ h, j* w; W6 V
Topical Testosterone Exposure / Bhowmick et al 541. u: z6 l9 V5 ]  Y% W6 c
use of testosterone gel twice daily that he was apply-
. l0 o( P( U  f; Zing over his own shoulders, chest, and back area for& c( @; X/ Q9 U) ~3 O) A# A
a year. The father also revealed he was embarrassed
$ r' T! D* ?% o9 K  _; z7 r1 ^to disclose that he was using a testosterone gel pre-
+ _# W% N* G! u2 Xscribed by his family physician for decreased libido/ n$ r) x! W" w4 y3 t! I9 V
secondary to depression.
  N) ^" I5 K7 q: @. N* |The child slept in the same bed with parents.
6 |2 y( I" g9 @* `5 D7 ^3 GThe father would hug the baby and hold him on his
6 e2 n# l( O3 rchest for a considerable period of time, causing sig-, u6 R$ A" ^& N: G# A+ B
nificant bare skin contact between baby and father.
( w& l% `* k4 Z/ BThe father also admitted that after the phone call,/ y0 Z$ O8 U2 z8 ~
when he learned the testosterone level in the baby4 ^# ~5 X8 X* t' C
was high, he then read the product information
7 G8 J9 n- x8 k7 O( z8 R$ k; s6 _packet and concluded that it was most likely the rea-) X( z3 f$ M$ ?0 l! G( J
son for the child’s virilization. At that time, they
$ l$ z% H9 m2 P$ M& k/ Y, n; ldecided to put the baby in a separate bed, and the
: t4 ^: l# c% g( h( nfather was not hugging him with bare skin and had
6 j2 @2 Q& P; \+ Ebeen using protective clothing. A repeat testosterone: J+ X2 u- m4 {$ ^- @0 Z
test was ordered, but the family did not go to the
4 k. r+ u/ H4 a; jlaboratory to obtain the test.6 @  r; S; Y) P- L% k4 K& T! y
Discussion
" I1 v& n9 G' L7 v+ VPrecocious puberty in boys is defined as secondary
' e% Q3 A+ U' @sexual development before 9 years of age.1,4% U  u) o9 v8 w, V5 l, Y
Precocious puberty is termed as central (true) when! O. T: A1 d( w5 G, E" m2 Z' k
it is caused by the premature activation of hypo-* v- m! s2 X8 s) Z* O( c
thalamic pituitary gonadal axis. CPP is more com-
7 B1 d- A; }* }+ F+ zmon in girls than in boys.1,3 Most boys with CPP
, |: ?, G1 u5 E" qmay have a central nervous system lesion that is1 u! q+ f( i% j8 e3 ?, X: b6 Y
responsible for the early activation of the hypothal-
" a+ @3 @, W3 A( t/ }amic pituitary gonadal axis.1-3 Thus, greater empha-
+ M, s$ T% F# C( Q. ?* w6 |% dsis has been given to neuroradiologic imaging in
; s+ e+ `2 b2 K  ^1 Vboys with precocious puberty. In addition to viril-
& q0 c* H  h( T8 E& ^" e2 yization, the clinical hallmark of CPP is the symmet-
1 q6 q4 J; A) Trical testicular growth secondary to stimulation by8 M$ m8 h6 T4 q8 h! k$ Q. D
gonadotropins.1,38 b+ O" k* U. e! D+ a6 F) D- C
Gonadotropin-independent peripheral preco-; Y# N0 t8 k- p0 v' e; s5 d2 A8 `
cious puberty in boys also results from inappropriate+ E1 L, S/ D& ]0 i) _
androgenic stimulation from either endogenous or
  q9 C" M& `3 K+ M7 U5 Yexogenous sources, nonpituitary gonadotropin stim-# e3 u8 Z4 o, F- h7 v/ |/ l
ulation, and rare activating mutations.3 Virilizing9 t! ?8 \5 f7 n8 T4 R9 ^- y
congenital adrenal hyperplasia producing excessive
' a; y1 R( _2 k. Y) V8 Iadrenal androgens is a common cause of precocious
# p. o4 O1 z: D  Dpuberty in boys.3,4
8 O; J* F: @& j: cThe most common form of congenital adrenal$ _' W: q3 G: ]( d% P4 ?
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 K& ~* z2 E" n6 [4 A% iThe 11-β hydroxylase deficiency may also result in
5 Q1 [& \( C5 X# _( H- ]) _excessive adrenal androgen production, and rarely,( _: O, Y2 _9 ^, H
an adrenal tumor may also cause adrenal androgen
3 K" c' @3 H5 |+ @excess.1,3$ u& }# b. y. n+ t, o# V/ x+ _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ S0 u- D' \& A2 L  a- C% ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ C6 |/ N& ?4 l/ @, G5 M* e9 ^A unique entity of male-limited gonadotropin-" n, ?# J. N2 s+ N0 R! Q
independent precocious puberty, which is also known' v3 J$ o. ?2 R
as testotoxicosis, may cause precocious puberty at a' D' n3 a0 E( w! ?3 K: n
very young age. The physical findings in these boys
7 m. X9 O% e$ `: k( W; h0 O- ~; ^with this disorder are full pubertal development,7 M- i! f) P- L& y& I
including bilateral testicular growth, similar to boys
: C5 S- e1 F. f% i  gwith CPP. The gonadotropin levels in this disorder
' N! e; y" I) s  J* Mare suppressed to prepubertal levels and do not show. E+ U6 E1 G: c+ A
pubertal response of gonadotropin after gonadotropin-3 ]% w0 l  T  I" }$ T
releasing hormone stimulation. This is a sex-linked
9 R* Z, Y& B9 M, Z" Cautosomal dominant disorder that affects only
, _) s6 q/ c, [+ J: D$ t, [males; therefore, other male members of the family- b# ?4 W6 g' u4 q% x
may have similar precocious puberty.3
$ U2 a6 F6 H. t: A' iIn our patient, physical examination was incon-: \9 Q! n" i7 _/ `
sistent with true precocious puberty since his testi-$ v) ]$ {0 k0 `
cles were prepubertal in size. However, testotoxicosis9 b4 D% Q; ]( ^7 K  Q
was in the differential diagnosis because his father1 b( c) J) v% C; Z7 `) Q, e
started puberty somewhat early, and occasionally,3 M- `; H; e, G7 X, I) @+ e
testicular enlargement is not that evident in the* @: G  O  I/ o9 w7 |" E/ ~  B% ^
beginning of this process.1 In the absence of a neg-
& H' k/ V/ J+ g, a3 C" @- Lative initial history of androgen exposure, our- y' n* Y- @) p  {# H: N4 I
biggest concern was virilizing adrenal hyperplasia,5 N4 [: v! ]: I; K
either 21-hydroxylase deficiency or 11-β hydroxylase; s& p+ C& P0 Y
deficiency. Those diagnoses were excluded by find-
. A  N, b. ~: y$ f. H$ j3 zing the normal level of adrenal steroids.6 ]  o% ]3 ^* z4 F/ e: u  t3 ?
The diagnosis of exogenous androgens was strongly1 ~( R0 j2 o% L4 T# G
suspected in a follow-up visit after 4 months because8 x9 d* s. Q6 o9 d- \/ F
the physical examination revealed the complete disap-. Y  N/ L+ m- g7 z* i; _
pearance of pubic hair, normal growth velocity, and
* E2 B& A& N. E6 l- l3 e2 m3 Bdecreased erections. The father admitted using a testos-
% n" J; u. r( E( V& Nterone gel, which he concealed at first visit. He was. o1 `  }, z- H5 ?
using it rather frequently, twice a day. The Physicians’
! m; f3 g% ]( U) h% ~5 V! q( FDesk Reference, or package insert of this product, gel or
% w2 K" K9 {: T+ w' }cream, cautions about dermal testosterone transfer to
; b, U3 G4 Y" p% ^1 D6 E! u# Bunprotected females through direct skin exposure.
# x7 T0 O5 }' v9 V* F' |Serum testosterone level was found to be 2 times the
' y7 c! n: A% Ibaseline value in those females who were exposed to
, ?: Z: A# b3 Feven 15 minutes of direct skin contact with their male1 j  ?- z) @0 A6 O2 ^) I# S
partners.6 However, when a shirt covered the applica-
$ T) r5 @) m  ltion site, this testosterone transfer was prevented.; ^' m& i% S9 M% w
Our patient’s testosterone level was 60 ng/mL,
' `; t2 h, K! awhich was clearly high. Some studies suggest that9 }1 d4 R, W8 p
dermal conversion of testosterone to dihydrotestos-# B' y( ~1 M2 Y9 A  ]' i) G: J
terone, which is a more potent metabolite, is more
, f, r8 k% R& D! p/ p4 factive in young children exposed to testosterone
+ u: W) C) n5 n6 N( Eexogenously7; however, we did not measure a dihy-  s6 p. S1 j: J; k* i- T
drotestosterone level in our patient. In addition to
: F7 y& y  p" L2 F9 V" |& yvirilization, exposure to exogenous testosterone in
/ E, M: F! J6 Ychildren results in an increase in growth velocity and4 B; C  L: ]  Y" \! L9 X
advanced bone age, as seen in our patient." x; k0 F; Y4 Y
The long-term effect of androgen exposure during
2 n  E. N; j8 b8 B6 u( Yearly childhood on pubertal development and final' z* f3 N/ x( E9 l% ^% g5 _
adult height are not fully known and always remain1 H2 i; {0 l4 U0 `- x
a concern. Children treated with short-term testos-8 p' K4 a+ e# x/ Q# I! n! _, H
terone injection or topical androgen may exhibit some
3 e, I4 y- y( C8 F& lacceleration of the skeletal maturation; however, after' J% x) w: o6 J' o0 J' @! J4 K
cessation of treatment, the rate of bone maturation8 O# r/ I: q# _* K" y
decelerates and gradually returns to normal.8,9& c5 y0 X# B/ _8 T
There are conflicting reports and controversy+ F5 M. b- E- N1 h; _
over the effect of early androgen exposure on adult
+ A0 \5 _8 }7 Ypenile length.10,11 Some reports suggest subnormal1 K% ]! J* E# ?9 ~
adult penile length, apparently because of downreg-
9 U, @+ y. W  {4 h! o/ X4 hulation of androgen receptor number.10,12 However,
! b; f* U9 a0 B1 {) H: SSutherland et al13 did not find a correlation between
* P  q' T' d2 `7 b& P# k9 Zchildhood testosterone exposure and reduced adult
6 s/ ~$ \: m3 O: A2 t6 apenile length in clinical studies.. F1 l+ f% I. }+ K: i4 P
Nonetheless, we do not believe our patient is
# M& d8 U% [4 C+ t* ~& xgoing to experience any of the untoward effects from
- `- K" f7 Q9 E" P8 }+ A8 P9 mtestosterone exposure as mentioned earlier because
" H& o1 R/ H# C9 H; \the exposure was not for a prolonged period of time.2 ~% ?6 H# B7 P+ c
Although the bone age was advanced at the time of1 G" y* ?) o/ u
diagnosis, the child had a normal growth velocity at
3 z: y# d* f8 E2 f) u& o/ qthe follow-up visit. It is hoped that his final adult
+ @9 F/ Q0 {; n+ |; Fheight will not be affected.
/ o1 q) j$ M6 }# ^+ g: k0 y+ g: dAlthough rarely reported, the widespread avail-2 w* r% N) ~  g  S8 O( K4 E6 \
ability of androgen products in our society may
# R4 o3 M7 G, f3 ~indeed cause more virilization in male or female
4 B% E1 \! M0 e3 I4 b" Jchildren than one would realize. Exposure to andro-9 u( M) w/ c) Q( x2 U8 }( B
gen products must be considered and specific ques-& v9 m" j' a6 y
tioning about the use of a testosterone product or
1 H( h8 H% }+ E) f5 xgel should be asked of the family members during
% {9 [6 Y; x/ E1 Q. qthe evaluation of any children who present with vir-
# q! M* Z% B* o* \2 {5 jilization or peripheral precocious puberty. The diag-1 b9 ?# a6 v" I3 e# N/ w+ s0 k
nosis can be established by just a few tests and by
$ G- O! l6 Y& ^9 P6 l& U! oappropriate history. The inability to obtain such a
5 Z4 q7 d7 `, ~  Uhistory, or failure to ask the specific questions, may
8 K/ o0 o; \: d# kresult in extensive, unnecessary, and expensive
. a% b4 a$ W# Iinvestigation. The primary care physician should be3 D1 |- i" r0 h, ?  T3 r- r
aware of this fact, because most of these children
9 f9 K5 g8 q; Q4 D5 H( z1 mmay initially present in their practice. The Physicians’
( G% n# o8 I9 @4 IDesk Reference and package insert should also put a
- }( |" O! f& A; [; l1 X  r/ twarning about the virilizing effect on a male or
% B" N' M  E/ w) Yfemale child who might come in contact with some-1 Q6 z, x' [3 V5 p: Y6 V  ]. J6 s
one using any of these products.
. x# W& T4 v% }6 n( O7 Z( X2 jReferences  L/ F1 p: `, F  C8 \
1. Styne DM. The testes: disorder of sexual differentiation
; T9 J% P" U/ Q8 gand puberty in the male. In: Sperling MA, ed. Pediatric
# M7 K) k6 j' D) K/ tEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 {# {  P, Q9 l% K2002: 565-628.1 y6 `9 E9 y# W% F& F4 }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# f9 y+ p" E! A8 `( m/ \  Npuberty in children with tumours of the suprasellar pineal
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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
; C3 {0 z. r1 U& ~1 T
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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