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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% ]- l; ?0 r# G& @8 I
Boy Induced by Indirect Topical% L3 k  D+ Q! D1 |* Z/ ~3 R
Exposure to Testosterone
8 H1 c' P2 |) h( M6 ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" c! [2 O# w. L
and Kenneth R. Rettig, MD1
" m4 g9 T; ?3 N- _  x3 p8 {" [" NClinical Pediatrics
- Z: l  ~, j! b0 V6 QVolume 46 Number 6- h7 b5 ]! ?  m7 s
July 2007 540-543
* t6 Q3 Y8 H- v: j& y. u© 2007 Sage Publications
0 D' c7 G3 |, S8 K+ j10.1177/00099228062966511 U' O7 Z$ U4 m% T, A' d( B
http://clp.sagepub.com
' `; G% }8 G; o- Z, S9 ?' }- Ihosted at- \, i$ [  a+ }* T
http://online.sagepub.com  {7 S8 ?* O; I* W
Precocious puberty in boys, central or peripheral,* V/ q) L. _. T- I; y/ r
is a significant concern for physicians. Central( Q. Y. U8 k% L& _- R- _5 T% [
precocious puberty (CPP), which is mediated
  e" c9 N- V6 z! K) A6 M+ y0 Q3 wthrough the hypothalamic pituitary gonadal axis, has
8 {3 z9 C0 x; |$ q4 ma higher incidence of organic central nervous system5 c9 U6 }8 V6 d5 f/ `
lesions in boys.1,2 Virilization in boys, as manifested
" ?' G$ d! o" Mby enlargement of the penis, development of pubic: h' V7 s; i/ D6 x1 Y
hair, and facial acne without enlargement of testi-( Q! j0 {3 ?% B- o/ T
cles, suggests peripheral or pseudopuberty.1-3 We7 H( R+ D6 H& A# r, l  l- \7 X
report a 16-month-old boy who presented with the, S1 h% G! s* J
enlargement of the phallus and pubic hair develop-
' n; W0 p2 b0 ?& ~) x% l( |+ tment without testicular enlargement, which was due
5 v5 n$ \6 p7 Vto the unintentional exposure to androgen gel used by
( x! b  _. E- j* Xthe father. The family initially concealed this infor-* `2 j( ^# n# m# N4 M. R
mation, resulting in an extensive work-up for this( z% s6 ^1 E. [" s  T) \
child. Given the widespread and easy availability of0 `3 _+ L/ D2 |' r8 v8 |* `" e
testosterone gel and cream, we believe this is proba-
' F% @% Z: y: @  qbly more common than the rare case report in the
& y5 V/ B, _: k6 g- I5 R4 Pliterature.4
& L) C- Y4 z& }6 ]( K5 lPatient Report  q, a. m2 Z: @
A 16-month-old white child was referred to the4 e0 r" Z% o& j& d; e
endocrine clinic by his pediatrician with the concern' i* N4 h  J1 c
of early sexual development. His mother noticed
) Q  c9 C) t- v% vlight colored pubic hair development when he was0 {6 ?! w) f! `4 `6 m
From the 1Division of Pediatric Endocrinology, 2University of
# x9 r! @; T/ @! ]South Alabama Medical Center, Mobile, Alabama.
, k' o: j' [* b7 p  u9 LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, L# z4 T4 y& n  IProfessor of Pediatrics, University of South Alabama, College of
. n9 s) G/ D, K% Y6 lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" E  }- T) s5 G- Je-mail: [email protected].9 a! I" m( \1 m' @& u+ x  N, G
about 6 to 7 months old, which progressively became% s- r2 y' |' M/ D1 f. x
darker. She was also concerned about the enlarge-
- x# [6 \" p$ }# ~5 s. t1 Cment of his penis and frequent erections. The child. A" h$ z% v  |) E4 N% j- p
was the product of a full-term normal delivery, with
) v  `9 u5 S% c, q& |a birth weight of 7 lb 14 oz, and birth length of
# [- o2 d9 D* w, Q20 inches. He was breast-fed throughout the first year+ d8 l! Q) E: ~. c4 u
of life and was still receiving breast milk along with
% _) P# W) z* O. B1 p& {6 Psolid food. He had no hospitalizations or surgery,; ?3 Z) \8 u. Z7 {3 L
and his psychosocial and psychomotor development
( m* Q6 n, t9 g3 l# q/ f# J* ?7 Cwas age appropriate.
4 e% r. g* Y9 ]- s8 [  {7 s* I. OThe family history was remarkable for the father,
2 e* U3 Y2 W2 c) d: k6 Fwho was diagnosed with hypothyroidism at age 16,& I7 O9 j8 M. \" k+ d/ }
which was treated with thyroxine. The father’s8 T+ e: u8 w( H/ y$ y3 u
height was 6 feet, and he went through a somewhat
* r! L7 S- @) {% i5 w$ b' Oearly puberty and had stopped growing by age 14.
0 D% B7 d) ~" C2 W5 h1 k% x, `4 ]The father denied taking any other medication. The
& |( x6 v+ D: ~5 ]: v! ochild’s mother was in good health. Her menarche+ B: X- m5 r6 H. ~: ?5 E5 D4 n
was at 11 years of age, and her height was at 5 feet
" {) ^3 k+ O; [+ J1 S5 inches. There was no other family history of pre-
. K6 w' a0 \, u) t+ rcocious sexual development in the first-degree rela-8 E2 I2 _4 s& O8 y5 Y2 O4 A
tives. There were no siblings., G$ c! k. R- C5 r5 S5 D
Physical Examination' i; Z* K3 y$ S6 e
The physical examination revealed a very active,
( z0 O' E% V. y8 s" h: S* Nplayful, and healthy boy. The vital signs documented
$ G! }8 _- ]4 Da blood pressure of 85/50 mm Hg, his length was  `- P  D5 x0 S* _5 i* P
90 cm (>97th percentile), and his weight was 14.4 kg9 h- d( A6 m+ l$ s, N" V3 ]
(also >97th percentile). The observed yearly growth% Q$ J% \7 Z( v, h& B. B0 x
velocity was 30 cm (12 inches). The examination of
5 x- E8 ~" {1 zthe neck revealed no thyroid enlargement.4 G$ V! Q3 q6 p+ K6 w+ q
The genitourinary examination was remarkable for
/ o: n  ?* O4 M* W) {( N2 S1 x% Xenlargement of the penis, with a stretched length of
3 Q1 ?& Z8 I* K1 [$ z9 N  A8 {8 cm and a width of 2 cm. The glans penis was very well
- ?; M% R! T! U2 @developed. The pubic hair was Tanner II, mostly around
' t0 G) O" l( r1 r$ H. }, p540
8 ]3 Z  L" B$ fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 y, F5 }& I; W( ^
the base of the phallus and was dark and curled. The, ?/ Q0 ]8 v( n- e
testicular volume was prepubertal at 2 mL each.
  A  g6 n! {( x( JThe skin was moist and smooth and somewhat$ j5 q# A% J) y+ U1 V8 X: z
oily. No axillary hair was noted. There were no
! s. D" u/ o5 V! sabnormal skin pigmentations or café-au-lait spots.! A$ c7 }& ~7 l* Z. }/ i
Neurologic evaluation showed deep tendon reflex 2+
( B6 q1 \4 q5 n$ u$ ~" ]bilateral and symmetrical. There was no suggestion
, {6 y- l3 P1 W) bof papilledema.
$ f& _7 T; I' f# w8 L+ fLaboratory Evaluation) C; M- h5 Y; L$ n. X9 H
The bone age was consistent with 28 months by: ]3 p; P: V9 T
using the standard of Greulich and Pyle at a chrono-
+ Q. D' g+ Z; ]$ \! q' _logic age of 16 months (advanced).5 Chromosomal
: d1 X- f' \1 S- e" y) Okaryotype was 46XY. The thyroid function test& G6 q% E1 D; Y0 `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% v- n. C/ }5 G( z6 ~lating hormone level was 1.3 µIU/mL (both normal).5 z4 r# d4 F7 f) g* c9 b
The concentrations of serum electrolytes, blood9 F: R. U% ^: N2 ~
urea nitrogen, creatinine, and calcium all were  a1 J: P% U2 Y& E1 S" W6 _
within normal range for his age. The concentration& Y( q" b+ h- {" P# _6 j
of serum 17-hydroxyprogesterone was 16 ng/dL
8 ^* M. J" {, c* P' V3 N(normal, 3 to 90 ng/dL), androstenedione was 20" V. q/ h( H7 v4 p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; D8 x7 ~' l, w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) x* s# @7 Q5 u- b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
  {  e* J+ `  b6 r: O+ O' Y4 r4 v49ng/dL), 11-desoxycortisol (specific compound S)
, b5 z2 u) n2 p$ p' w% [2 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 m) G' R' b9 ?% H7 V! e8 u) v" jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 h% M/ N) w2 }1 O7 B( }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; y  w$ f# A. T) u, _8 L7 ~
and β-human chorionic gonadotropin was less than
# B2 K" |; i! c5 O5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 p7 @) M* s8 U, ?stimulating hormone and leuteinizing hormone- J% Y3 b* |! J' z8 j
concentrations were less than 0.05 mIU/mL& _) Q* t0 I  {% y$ h' V, i
(prepubertal).$ k5 B3 H6 J, a( \
The parents were notified about the laboratory
: h5 f" P/ v9 Y* f* ?* dresults and were informed that all of the tests were
- S2 m, ^, u  _normal except the testosterone level was high. The
0 r, B! V. g+ T, a# ffollow-up visit was arranged within a few weeks to
+ O' v' X' `! ]obtain testicular and abdominal sonograms; how-
, q4 d: V( w* _7 Sever, the family did not return for 4 months.* d' ]; M  ^! q0 s) R
Physical examination at this time revealed that the0 R% N4 a8 j- g! ]5 _+ d
child had grown 2.5 cm in 4 months and had gained
0 B8 I/ Z' T! @; j2 kg of weight. Physical examination remained  T4 ]7 `- o7 I% W3 v
unchanged. Surprisingly, the pubic hair almost com-
6 |) U9 |; l# g: @0 zpletely disappeared except for a few vellous hairs at
. Q0 Q8 }! z  g# [/ [9 r3 _the base of the phallus. Testicular volume was still 2
, e8 D. S5 D8 a: s4 O9 c8 W* e" CmL, and the size of the penis remained unchanged.: ]* h* r5 _# s+ c
The mother also said that the boy was no longer hav-
$ S- Z% P5 P1 E+ j5 Q) Iing frequent erections.) b: d: k( P. j& j0 X0 T" e
Both parents were again questioned about use of1 `% a! h( Q% h7 L; m
any ointment/creams that they may have applied to; k, B- C0 O& D
the child’s skin. This time the father admitted the
# w: b% ^: R7 n; R- j9 nTopical Testosterone Exposure / Bhowmick et al 541/ j' G6 {  C4 x5 @0 W1 v
use of testosterone gel twice daily that he was apply-2 d: x6 Q& d2 b: G6 d2 g, L8 |
ing over his own shoulders, chest, and back area for
" \" m9 b, g; a2 p" Y  N1 B+ Ma year. The father also revealed he was embarrassed
) c8 e. ~$ v9 ]to disclose that he was using a testosterone gel pre-' c7 p! E. o5 w
scribed by his family physician for decreased libido
* G  X: M6 o4 ^( p3 rsecondary to depression.
$ J5 m6 A, d: ^& \) r8 `  s- @The child slept in the same bed with parents.
, ~9 J* y2 o- F  eThe father would hug the baby and hold him on his; L+ ]$ _! S. u; Q0 S
chest for a considerable period of time, causing sig-
7 C7 ~9 ^$ a  j9 _nificant bare skin contact between baby and father.
$ y" Q/ d$ m& D& pThe father also admitted that after the phone call,
- P1 I- R( K1 I! F$ t  V7 }when he learned the testosterone level in the baby1 T( V' s0 p1 H
was high, he then read the product information3 {7 x( z0 g& ]; H0 r: e% a
packet and concluded that it was most likely the rea-1 t! B4 U8 r. v* A* {/ R! @9 K
son for the child’s virilization. At that time, they1 W) q, }; V8 z9 Y4 f
decided to put the baby in a separate bed, and the
+ X$ t9 O# {( G6 N8 K9 w6 ]father was not hugging him with bare skin and had( l2 s; ?( A$ }* H5 z7 }
been using protective clothing. A repeat testosterone
# j" B: p6 m3 r. y* ytest was ordered, but the family did not go to the
! H0 H$ u+ r: J' ~# a* dlaboratory to obtain the test.
6 v4 q* f' g5 k% I1 Y. y! \Discussion6 B1 X- n- Y% [$ b1 {, o! m: }
Precocious puberty in boys is defined as secondary
/ |7 F- ?7 x) K1 m  n" U, [sexual development before 9 years of age.1,4
# X2 F: t' r0 d/ mPrecocious puberty is termed as central (true) when7 L& g1 E" K1 q% _
it is caused by the premature activation of hypo-
0 j+ v- C1 _  kthalamic pituitary gonadal axis. CPP is more com-
/ F1 w8 R, D  U$ d. c5 s  ]2 {: Bmon in girls than in boys.1,3 Most boys with CPP8 G% M0 P, G6 {# T: U: a
may have a central nervous system lesion that is$ b& e* z. w. F% K/ R/ S9 s
responsible for the early activation of the hypothal-6 X) L# Y5 S  t/ {
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 o5 f; J3 b% V- L' Gsis has been given to neuroradiologic imaging in+ M- ^( `& [# ]5 H% q9 |; Q0 c( Z: G
boys with precocious puberty. In addition to viril-& c; l$ |: L1 l0 U# X" s
ization, the clinical hallmark of CPP is the symmet-5 D1 I. c, [# y. e! T/ N
rical testicular growth secondary to stimulation by
5 [" k  k  A+ \% Z( A* pgonadotropins.1,3
8 {1 j( l" y$ |6 k$ N& {Gonadotropin-independent peripheral preco-5 n( X7 ~  y" N' ]0 C4 d
cious puberty in boys also results from inappropriate$ f, P8 J9 i! p' e. d5 ?2 i
androgenic stimulation from either endogenous or
; _( u: |: _, u7 i2 r% mexogenous sources, nonpituitary gonadotropin stim-
& u7 T& A* k2 a& W5 E" [( r6 H$ f) ]# vulation, and rare activating mutations.3 Virilizing
7 N! d+ V. K$ b* F7 U  z+ C5 ccongenital adrenal hyperplasia producing excessive) C, @" s0 \/ S7 K# x" P% K6 H
adrenal androgens is a common cause of precocious
0 L- |# D0 r. Bpuberty in boys.3,4# s6 T. C& X3 f. i$ l
The most common form of congenital adrenal
' ~2 }/ _/ q  T& W3 U( ^& c1 n% bhyperplasia is the 21-hydroxylase enzyme deficiency.5 t# A1 x- t0 C. ~
The 11-β hydroxylase deficiency may also result in; M) E2 D% [: _. {6 h$ L- V
excessive adrenal androgen production, and rarely,
* A& g. N% m7 u  E7 ean adrenal tumor may also cause adrenal androgen' c# O# j1 F5 k6 z' m' ~5 t
excess.1,3
, f* V0 W9 J1 R$ g% C6 E. \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ C! d+ a5 A! D9 `' |  `* m. @542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- P3 v& O( c8 }% \* z; lA unique entity of male-limited gonadotropin-; [2 y7 J1 e0 \% i' V# s/ t* f
independent precocious puberty, which is also known+ P0 k6 D; Q1 g5 W$ m" C8 Q$ Z9 E" k
as testotoxicosis, may cause precocious puberty at a
( r2 {+ z8 q+ `3 X0 Qvery young age. The physical findings in these boys
% n$ N; A" J  Pwith this disorder are full pubertal development,
+ X' W/ D" L8 E" j0 e$ v- Oincluding bilateral testicular growth, similar to boys8 ~- V5 D: x6 M% X
with CPP. The gonadotropin levels in this disorder
+ z, G' ^  i' k5 Y7 a$ L1 V1 D+ ]& rare suppressed to prepubertal levels and do not show
# R( u/ ?2 X' K2 l' {. {pubertal response of gonadotropin after gonadotropin-3 r7 }# V2 x/ d% b' u# [$ O
releasing hormone stimulation. This is a sex-linked' @3 R! _9 D( g3 w1 k1 P
autosomal dominant disorder that affects only7 W- z4 t7 M! ~  e, M" P
males; therefore, other male members of the family: Q+ @; M+ c# y7 m5 t
may have similar precocious puberty.3
& W6 R/ n! O) C* M4 x  [" g& dIn our patient, physical examination was incon-
- M, e# D  p" Z+ b) V& R5 l% {sistent with true precocious puberty since his testi-. M& Q3 j6 t" O
cles were prepubertal in size. However, testotoxicosis0 n7 n4 ^2 ~8 Y# {
was in the differential diagnosis because his father
6 L- s0 }* S" E6 @started puberty somewhat early, and occasionally,. \' \2 ]( ~8 Z2 y  M; |
testicular enlargement is not that evident in the
% S0 E0 n- N0 ^$ bbeginning of this process.1 In the absence of a neg-
- t. `0 K* b0 tative initial history of androgen exposure, our
1 q9 Q3 A, R: ?- j/ lbiggest concern was virilizing adrenal hyperplasia,
  K( }5 e5 k1 h( L- geither 21-hydroxylase deficiency or 11-β hydroxylase
1 \2 q$ O/ Y/ \0 `0 i4 vdeficiency. Those diagnoses were excluded by find-
5 {" H+ N7 v2 H! r2 Wing the normal level of adrenal steroids.0 O( p6 h* d- I! |0 E. q
The diagnosis of exogenous androgens was strongly
. _2 L; B" O' Bsuspected in a follow-up visit after 4 months because' c% H5 n* F: Y5 W
the physical examination revealed the complete disap-
, e2 B! G5 j; O! d2 b/ B+ s* zpearance of pubic hair, normal growth velocity, and+ z* i& M2 w2 o* f2 }
decreased erections. The father admitted using a testos-
. n  Q! j7 q, Aterone gel, which he concealed at first visit. He was* g* J4 t- s' q
using it rather frequently, twice a day. The Physicians’
% N8 R6 O' q) gDesk Reference, or package insert of this product, gel or
2 }1 N3 t! W2 }cream, cautions about dermal testosterone transfer to+ c* ?5 r2 E7 G) `& G# U/ ]
unprotected females through direct skin exposure.1 i2 h! u& F' G5 s' F& E
Serum testosterone level was found to be 2 times the% h* f, ]' k! K3 N  Y
baseline value in those females who were exposed to
, V& _  z7 a' ?2 w# Zeven 15 minutes of direct skin contact with their male
$ ?, T5 H5 R2 U; F! R( @+ y7 S9 `partners.6 However, when a shirt covered the applica-6 P$ D5 X/ |4 C
tion site, this testosterone transfer was prevented.
+ X, I1 n8 w3 T; v- d% ZOur patient’s testosterone level was 60 ng/mL,/ A9 E2 \  r) F* y! f4 P
which was clearly high. Some studies suggest that
$ ~" r$ w; t6 k& ^% K4 e1 Sdermal conversion of testosterone to dihydrotestos-# J, y" b" Y& a' E3 X
terone, which is a more potent metabolite, is more0 M. {4 N: ?7 J, @6 d; l
active in young children exposed to testosterone
6 o: c  L0 Y. _5 L: u1 l! @# aexogenously7; however, we did not measure a dihy-
, B2 ~2 x5 Q. t  s$ Q6 Zdrotestosterone level in our patient. In addition to
* Z$ w; T9 G- K0 `virilization, exposure to exogenous testosterone in4 E( T; w: m, Z. r
children results in an increase in growth velocity and: H7 \7 @7 T; @, }6 ^
advanced bone age, as seen in our patient.9 |, \! `/ z  ~9 q8 w) u/ \
The long-term effect of androgen exposure during6 \0 \% j0 t6 }2 d. B
early childhood on pubertal development and final# D8 R! I# H, @' Z% ?) p9 o/ P
adult height are not fully known and always remain$ s0 s" O% d* Z/ D' J, h' P& |
a concern. Children treated with short-term testos-
* w5 e; E0 F% {4 S1 Pterone injection or topical androgen may exhibit some
1 X: n6 z- w: W5 N3 D# Lacceleration of the skeletal maturation; however, after4 l4 E* S( d# q! z" q
cessation of treatment, the rate of bone maturation
( n, n% {1 b) ldecelerates and gradually returns to normal.8,91 A, c+ {6 g7 Y5 G+ w
There are conflicting reports and controversy
- y7 {" Z, G5 B1 t5 q0 i1 hover the effect of early androgen exposure on adult
) ]$ T* N6 K. J# {3 N( f, Tpenile length.10,11 Some reports suggest subnormal. }1 U' R7 a8 a) y8 X( [
adult penile length, apparently because of downreg-! U- G+ }# j  s2 \, {
ulation of androgen receptor number.10,12 However,
! y0 w9 z3 G2 {& \/ W' p# nSutherland et al13 did not find a correlation between# z2 E" a& g9 M% s0 l. v3 y
childhood testosterone exposure and reduced adult, B" @! Z; X& j' F& e# H( ]
penile length in clinical studies.
- W5 b+ l0 g5 t- cNonetheless, we do not believe our patient is7 j+ _, d( X9 {4 b* F% F
going to experience any of the untoward effects from% f9 F1 f3 |9 e1 r1 a5 I0 R
testosterone exposure as mentioned earlier because
- `& l& I+ J; P& a. j0 cthe exposure was not for a prolonged period of time.9 e8 G8 m1 C* A5 N+ Q& ^
Although the bone age was advanced at the time of
. v( s8 f$ B4 Y' Odiagnosis, the child had a normal growth velocity at+ @5 A9 R0 L3 V0 v/ o
the follow-up visit. It is hoped that his final adult
6 W+ [! T/ V$ K1 `) o4 ^height will not be affected.: ]4 B' f( X5 B. n4 }
Although rarely reported, the widespread avail-
3 E- {. v  h6 }ability of androgen products in our society may5 y2 F; p3 b0 N
indeed cause more virilization in male or female
! \1 f  K. z# L3 ychildren than one would realize. Exposure to andro-
( _, E( j3 ]* u) L/ N( }gen products must be considered and specific ques-/ h; x( |3 T) ?9 X5 O5 o
tioning about the use of a testosterone product or
3 B& f' d+ D9 S2 y/ V; Agel should be asked of the family members during
% c7 h5 O' `  Z) v4 Z4 X) O) othe evaluation of any children who present with vir-2 Z9 |$ s5 }% w
ilization or peripheral precocious puberty. The diag-8 Z; Z* v5 `, r9 t5 O9 T2 _
nosis can be established by just a few tests and by  z1 G$ y; \! a
appropriate history. The inability to obtain such a
' E/ x; x( ?, e0 k' mhistory, or failure to ask the specific questions, may
. W' x4 L/ m+ ~( _8 kresult in extensive, unnecessary, and expensive: I+ j/ ~& N1 b" D
investigation. The primary care physician should be+ h. s# |9 U3 Z- R
aware of this fact, because most of these children
$ g0 I; B6 V+ A" s. P% y2 ymay initially present in their practice. The Physicians’
+ N, ^! k( _. w( h5 l: \1 g4 ZDesk Reference and package insert should also put a0 T, ~. h6 k( ?4 A1 |
warning about the virilizing effect on a male or6 S) x+ \3 t( ]' H: F) n; x
female child who might come in contact with some-
" w" F. @  ^# k8 I6 gone using any of these products./ e. G1 ~' _% ^% c
References6 V: E7 p' w# H3 m" i' |
1. Styne DM. The testes: disorder of sexual differentiation/ k6 i0 o0 {9 f" f
and puberty in the male. In: Sperling MA, ed. Pediatric
/ d" W1 A& A2 _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- Q0 Q+ t! i  k8 S5 w! m5 B( U6 u4 v. |
2002: 565-628.
  G' R! f0 ]7 ~& s+ i% a* E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: j- l* c5 a0 ^7 ], O5 z8 B
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
6 o1 X5 ]: x. H* fBoy Induced by Indirect Topical, r, i" K. ~5 D# u3 A
Exposure to Testosterone3 \! \/ Y6 P5 I  q2 u# \# t2 d# Z2 J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 _2 e' [4 P1 kand Kenneth R. Rettig, MD1
' F  T$ I  w/ _& d9 SClinical Pediatrics
+ w6 S9 w" H* }3 G8 Y, L, F% cVolume 46 Number 6
- Z% r. }9 F8 ]+ T* @4 fJuly 2007 540-543
0 a- k$ `+ B$ j& W1 r* b, m9 D© 2007 Sage Publications
; _8 ]: E) G! G( b10.1177/00099228062966516 C' }1 x) R& Q( Z
http://clp.sagepub.com$ w8 `8 Y! z' B5 \6 C
hosted at! A0 f6 Z: o) c( U6 h
http://online.sagepub.com
6 t  u1 n  A+ u* KPrecocious puberty in boys, central or peripheral,5 c  h0 L% P6 Z6 ?
is a significant concern for physicians. Central& c2 P- X$ L3 H9 q- Y3 l" S
precocious puberty (CPP), which is mediated+ K% W: S% S4 P+ N5 u2 A2 ?
through the hypothalamic pituitary gonadal axis, has  s8 u- p" `' P$ L! Z
a higher incidence of organic central nervous system
2 z, T+ x( ]7 N! |% l4 J& rlesions in boys.1,2 Virilization in boys, as manifested7 V* @3 T% R! |+ p3 U. E" V6 O0 {
by enlargement of the penis, development of pubic: ~1 q* P6 k9 ^7 G
hair, and facial acne without enlargement of testi-
8 c; l- i9 A( c' Z0 m9 B* jcles, suggests peripheral or pseudopuberty.1-3 We. I8 G8 _6 o0 K8 d! \! O/ L& C
report a 16-month-old boy who presented with the
4 |, D! F; y1 n' }" y( I* i' nenlargement of the phallus and pubic hair develop-; E: Y3 N' b1 F4 R$ v2 H5 V
ment without testicular enlargement, which was due
5 F6 J" f1 |& Pto the unintentional exposure to androgen gel used by
4 S8 U6 W9 E1 E) c& D3 {4 e6 l7 cthe father. The family initially concealed this infor-  x  n# j3 u) t1 [
mation, resulting in an extensive work-up for this
3 Z% l/ S& X* j8 Fchild. Given the widespread and easy availability of1 t; y: Z$ \/ k7 B& {* L
testosterone gel and cream, we believe this is proba-1 w: p$ C( ~3 r  T0 Y, Y, {  W
bly more common than the rare case report in the8 m: ]2 ^6 Q0 v
literature.4
0 Z. e, T& ~+ x) ]Patient Report, F; b& K1 `2 V8 A2 _
A 16-month-old white child was referred to the
& i8 g+ J( r" Z) k  m8 s6 m0 i' ?endocrine clinic by his pediatrician with the concern1 {3 L- |/ O/ n% |4 e( G
of early sexual development. His mother noticed
, }) G4 v$ X9 rlight colored pubic hair development when he was
. ?% p% ^6 u# e) h1 LFrom the 1Division of Pediatric Endocrinology, 2University of/ ?: O3 U" z% E% `
South Alabama Medical Center, Mobile, Alabama.% X; I* y. J2 i! a5 `3 X
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: W1 u6 I: z( U9 V2 uProfessor of Pediatrics, University of South Alabama, College of
" o7 g+ C6 a2 j( {9 X5 ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 q2 ~8 S* ^4 V- t3 x9 E
e-mail: [email protected].
- `/ ]: }2 {" n( Pabout 6 to 7 months old, which progressively became1 ~" {, A, H, e* w6 P
darker. She was also concerned about the enlarge-
! g, h2 ^0 k2 C$ C: y7 M; `, [# }ment of his penis and frequent erections. The child
& I' E: \' t1 n! v( k/ V% k2 zwas the product of a full-term normal delivery, with
) s: z" |  T7 M/ oa birth weight of 7 lb 14 oz, and birth length of
9 C( g6 _6 k! P3 b% X& e20 inches. He was breast-fed throughout the first year
, E3 h' h( W6 f3 R) U& Dof life and was still receiving breast milk along with1 R( O5 d! O" i+ [4 N; m6 Z# Y$ I
solid food. He had no hospitalizations or surgery,
, k* x  f! r' Z# ~; Q! K2 Kand his psychosocial and psychomotor development3 F1 [( @: D5 b2 ?" Z+ z
was age appropriate.  `8 N% r0 }; U  V; v  Z
The family history was remarkable for the father,  s. v3 j; H; F6 ]3 c) \! O4 h
who was diagnosed with hypothyroidism at age 16,
. \4 ]$ }3 l. ^) }" A& swhich was treated with thyroxine. The father’s( z+ W" J  @  v$ m6 v- m) j+ o
height was 6 feet, and he went through a somewhat" g" n- D  J- e6 x
early puberty and had stopped growing by age 14.& L" o1 ?) }* d0 \* Y( h
The father denied taking any other medication. The
$ m& u' r& s# b. q) {child’s mother was in good health. Her menarche1 x3 g" z  C* h. j, i9 ~% o2 ]
was at 11 years of age, and her height was at 5 feet
2 l/ r4 H% [# R6 ?+ y+ _5 inches. There was no other family history of pre-
3 x( y. E& m" B! a2 }cocious sexual development in the first-degree rela-
$ B; i; O7 R. W9 O+ U8 q& i2 C* U  y" utives. There were no siblings.) e; o  S0 v* n5 D- n! G
Physical Examination
# [$ y$ |7 k% \% j( XThe physical examination revealed a very active,
3 S4 Q! Z  a& o1 Z. W1 \7 qplayful, and healthy boy. The vital signs documented3 m( l' v, o5 X; [1 N& _! W
a blood pressure of 85/50 mm Hg, his length was5 |% e1 z8 q( H  t# K! S, R! r
90 cm (>97th percentile), and his weight was 14.4 kg
5 K" G' x9 o" O; X. A(also >97th percentile). The observed yearly growth" v# h% C4 s! Y$ h8 c2 x( Z1 p7 Q
velocity was 30 cm (12 inches). The examination of
# Z/ ?9 {9 K0 fthe neck revealed no thyroid enlargement./ [* ?9 a0 ~7 B4 s
The genitourinary examination was remarkable for( [- C9 f1 w! c, W
enlargement of the penis, with a stretched length of
/ g$ _( q6 ]& j" \; K, V. |8 cm and a width of 2 cm. The glans penis was very well9 W3 f% V, T0 y/ Y' k
developed. The pubic hair was Tanner II, mostly around
9 @# a3 V7 n: v5407 t% v" j$ h* M6 |9 @# D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! i5 q8 E  x7 r! Qthe base of the phallus and was dark and curled. The
, x' ~+ |( z$ n; A. c+ F9 mtesticular volume was prepubertal at 2 mL each./ b& f# B$ D/ g' q" B! f# A
The skin was moist and smooth and somewhat2 K$ R# ]- ~+ l. K3 _4 R, |
oily. No axillary hair was noted. There were no) T( k6 R8 D: g9 g' m( q
abnormal skin pigmentations or café-au-lait spots.7 S( q4 Y4 S: E3 d/ H+ q
Neurologic evaluation showed deep tendon reflex 2+8 v! ?3 W9 E/ u- V6 n$ t
bilateral and symmetrical. There was no suggestion1 C" P4 j" E% C! G: u. u
of papilledema.
( o& A2 Q) q9 r# g% r! B$ [/ ]Laboratory Evaluation! E3 t( A- a3 p% z* [5 O) c( P
The bone age was consistent with 28 months by
7 B( g4 U5 i9 ^) Jusing the standard of Greulich and Pyle at a chrono-1 t: r& D1 j' X4 d+ x# R* F
logic age of 16 months (advanced).5 Chromosomal
% m. g% j& k9 r5 Kkaryotype was 46XY. The thyroid function test+ p' |  p$ x+ D- ^/ J. i+ d) r+ I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 S) u$ B  a2 A/ z6 m' ?; Alating hormone level was 1.3 µIU/mL (both normal).
6 d4 C8 n- W( {The concentrations of serum electrolytes, blood
, a8 v6 L$ Y0 f4 t/ C( {6 H; \urea nitrogen, creatinine, and calcium all were4 |5 A2 a& K8 Z
within normal range for his age. The concentration+ T. y, I2 I  G# Q. Q: k
of serum 17-hydroxyprogesterone was 16 ng/dL
' B' E+ ^' h* t9 G(normal, 3 to 90 ng/dL), androstenedione was 200 w( q* e. y9 C' `( i
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ l' S( U7 E2 f! o/ b: p- e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) t  t3 n9 {0 r: r: x! j: R
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 Z4 s$ v! x% ~; p  d8 k
49ng/dL), 11-desoxycortisol (specific compound S): o/ R/ ]9 H9 ]: x6 v
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' Z- H' t# r& o# \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ z1 G- N6 v9 A# k' h6 v9 y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( U! [1 }9 j8 j& N% r$ y- ^" M* {2 uand β-human chorionic gonadotropin was less than" _& W2 v, z* \# e) ~5 A, H
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ J7 T( R) h# _+ L! y, M
stimulating hormone and leuteinizing hormone
6 I" _$ Y# u+ Iconcentrations were less than 0.05 mIU/mL
6 ]; v& Z. H5 @(prepubertal).* v, W7 ~5 R  H6 R- R. A& z8 u9 b
The parents were notified about the laboratory
; ?& w+ S2 O) @- @* R, Fresults and were informed that all of the tests were* j6 p. k) H. c: N7 u& b( J
normal except the testosterone level was high. The
: \+ S$ ^' j1 m* |% f  n* r4 ffollow-up visit was arranged within a few weeks to* m' ^6 \. B+ a$ O! u0 m# W( S
obtain testicular and abdominal sonograms; how-
5 Q3 Z' S3 U( _. I5 P: Mever, the family did not return for 4 months.
1 O. ~: k' l4 \! JPhysical examination at this time revealed that the
5 \9 D& M0 s4 d" tchild had grown 2.5 cm in 4 months and had gained. F4 I( G4 T4 b1 }
2 kg of weight. Physical examination remained3 D/ b  a& m: ^6 \/ _# D
unchanged. Surprisingly, the pubic hair almost com-
9 K: k/ k4 p/ i' y3 B* }; ?6 L5 bpletely disappeared except for a few vellous hairs at
; M- i  I, q# Kthe base of the phallus. Testicular volume was still 28 ^/ x6 \2 w3 \9 ^6 g0 B8 ?- k
mL, and the size of the penis remained unchanged.: e! c8 k3 l/ t; g+ f  I
The mother also said that the boy was no longer hav-4 x3 y+ K& N# ~+ ~1 Q6 T! P" S
ing frequent erections., J6 e% t* B$ q! l6 q3 d# ?/ o
Both parents were again questioned about use of! v8 R& {! d  l
any ointment/creams that they may have applied to9 {, C. C- }& f0 Y
the child’s skin. This time the father admitted the
: ^7 q5 [- m% Z5 e+ P! nTopical Testosterone Exposure / Bhowmick et al 541
1 J4 U# e- z4 d7 n+ `3 E3 {* ^. juse of testosterone gel twice daily that he was apply-" t4 v4 E0 O( _/ c
ing over his own shoulders, chest, and back area for& z. U6 C9 }7 z- `* x
a year. The father also revealed he was embarrassed
' n, S/ O' X  a6 ?" @to disclose that he was using a testosterone gel pre-
7 ^6 H& d& T3 o* y, V- }( \scribed by his family physician for decreased libido
( `6 O& M$ [7 B- U8 ^7 g7 xsecondary to depression.6 T, [* M. [; r9 q4 r
The child slept in the same bed with parents./ L" ^% n  [' O
The father would hug the baby and hold him on his
  X- J7 Z+ _% {chest for a considerable period of time, causing sig-
2 z6 ^- g/ Y( i! \5 \+ }! ~8 onificant bare skin contact between baby and father.
( e4 \; F7 y# g3 t+ X# wThe father also admitted that after the phone call,
4 d- Y# _: T  P7 v( M8 iwhen he learned the testosterone level in the baby
2 b3 C. I/ `, J) lwas high, he then read the product information
) y  o' l/ @! L2 q4 J+ Zpacket and concluded that it was most likely the rea-
0 g. ?$ w/ f. D4 }son for the child’s virilization. At that time, they
/ S. j5 X: p- I9 Ndecided to put the baby in a separate bed, and the
* O, L6 M4 J$ O2 [/ ufather was not hugging him with bare skin and had
/ T5 S( w6 K! B8 E6 x. s) H2 mbeen using protective clothing. A repeat testosterone. F. ?. f& o+ f1 B3 Z, J2 G+ X# A6 q
test was ordered, but the family did not go to the
- x7 _2 Y8 m( B) ~! Vlaboratory to obtain the test.
! P3 ^/ P2 d3 N& t1 S: g: xDiscussion
4 Y' B+ k; N0 [2 `  t. iPrecocious puberty in boys is defined as secondary
5 |, Y; c1 F! d2 lsexual development before 9 years of age.1,4
& T8 X% ~5 M' b1 hPrecocious puberty is termed as central (true) when0 Z. a4 R* g: y6 G
it is caused by the premature activation of hypo-
3 \2 s2 ~! [6 X$ {2 F0 tthalamic pituitary gonadal axis. CPP is more com-9 o7 s" b! S; N% v- b
mon in girls than in boys.1,3 Most boys with CPP
! E3 W- o9 B! rmay have a central nervous system lesion that is: T& a. H$ \0 {6 p# e6 ]
responsible for the early activation of the hypothal-
+ {* l& ]& T7 x/ {; U) ^5 Damic pituitary gonadal axis.1-3 Thus, greater empha-
, m+ K9 M1 k* s( psis has been given to neuroradiologic imaging in* A& q  b5 m% V) [7 V4 e% h
boys with precocious puberty. In addition to viril-% I# c1 }2 t2 T7 N* i' `/ z; i9 V
ization, the clinical hallmark of CPP is the symmet-1 m# I7 M& p  P0 X3 i( S; P
rical testicular growth secondary to stimulation by. {) D& \8 Z8 Q5 `: }5 J/ c9 _
gonadotropins.1,3# |% c* D4 G1 B' B) C
Gonadotropin-independent peripheral preco-0 B& [+ }$ P% C
cious puberty in boys also results from inappropriate4 H# E( L4 ?9 |
androgenic stimulation from either endogenous or; X2 r7 y% Q& v! m! i1 C% `
exogenous sources, nonpituitary gonadotropin stim-
0 f6 Z: }5 g2 lulation, and rare activating mutations.3 Virilizing/ |0 T% M9 F% `. b
congenital adrenal hyperplasia producing excessive
  F6 s& {0 |1 ?; F, V0 oadrenal androgens is a common cause of precocious
0 t0 W7 H( i4 @# @  Gpuberty in boys.3,4
& {& ]+ ?/ u7 jThe most common form of congenital adrenal
9 G4 F, X8 k! Rhyperplasia is the 21-hydroxylase enzyme deficiency.! u; c9 Q- o- J8 Q* d. n
The 11-β hydroxylase deficiency may also result in
8 ^) _: Y0 Q9 |+ d/ _$ Z3 p6 vexcessive adrenal androgen production, and rarely,
+ q0 ?& q$ c8 l2 S& p! Oan adrenal tumor may also cause adrenal androgen$ }( H% G: e  U& n% ^$ b
excess.1,30 a  r, d0 v" |. c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 b4 h8 p% r2 v; z% \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- {0 A; ?+ i0 T
A unique entity of male-limited gonadotropin-
( f  K( T% f# b9 ?4 dindependent precocious puberty, which is also known; v2 J9 M. [& c% B$ q
as testotoxicosis, may cause precocious puberty at a
$ V+ P! ]+ F: k4 S' overy young age. The physical findings in these boys
4 k6 M" c8 A7 r" `$ \with this disorder are full pubertal development,8 `9 d  b+ L4 w: P3 E
including bilateral testicular growth, similar to boys: O& [6 O6 O; S0 }+ z; H. l
with CPP. The gonadotropin levels in this disorder- Q  E, u2 U+ ^$ Z5 I
are suppressed to prepubertal levels and do not show! d2 J% K/ [3 N9 }& x$ M# c
pubertal response of gonadotropin after gonadotropin-6 T' \) J. `( h( k" e7 q! @
releasing hormone stimulation. This is a sex-linked
' Q' C* T  @4 dautosomal dominant disorder that affects only
5 N1 [& S7 T5 W5 p, I# I. C7 Wmales; therefore, other male members of the family
" |: t% b0 ^2 J6 S5 L5 M% F5 r* |may have similar precocious puberty.3
$ v# d8 G' g! r" }In our patient, physical examination was incon-
) H  g3 q; r! m+ D* Csistent with true precocious puberty since his testi-' p6 `4 I# T' t* K# k3 o4 f
cles were prepubertal in size. However, testotoxicosis
7 q# g  j0 ~" z. L: T  W9 J1 l" {was in the differential diagnosis because his father# K9 D0 ]! S' w9 a9 S" \
started puberty somewhat early, and occasionally,( a& f- Q* C2 ^, r/ m2 D
testicular enlargement is not that evident in the
* u# Q" s( M8 P, w! a6 ubeginning of this process.1 In the absence of a neg-5 k1 a7 w% V# s
ative initial history of androgen exposure, our3 |. G9 U; {5 A
biggest concern was virilizing adrenal hyperplasia,0 N, `4 \/ z" P8 \/ A9 P% |( v
either 21-hydroxylase deficiency or 11-β hydroxylase! q" t, S* D/ e2 x# N1 Y$ j6 N: `
deficiency. Those diagnoses were excluded by find-
8 I$ V( g, ^3 z: @6 Ding the normal level of adrenal steroids.
0 ?" v8 D  }+ DThe diagnosis of exogenous androgens was strongly
6 {1 g6 v! o, k8 q9 W0 b, s' V2 c5 Esuspected in a follow-up visit after 4 months because
4 B  W* |" b6 O4 Y4 pthe physical examination revealed the complete disap-
3 ]. j9 {& w1 y% D1 o7 u- ]pearance of pubic hair, normal growth velocity, and
1 a) X5 Z* g: U: adecreased erections. The father admitted using a testos-" y9 h2 r1 ]9 r4 V# f: q2 J
terone gel, which he concealed at first visit. He was
. ^3 ]- A# ^* G9 pusing it rather frequently, twice a day. The Physicians’( P6 z3 Z8 D+ j) c/ \; R0 W4 Y
Desk Reference, or package insert of this product, gel or2 t8 ]6 I) b. g/ ^$ U% N% t1 |
cream, cautions about dermal testosterone transfer to
/ _) k! {6 ^* B5 V7 r& R! B* Eunprotected females through direct skin exposure.) r% X' T/ V+ e! h+ c+ m
Serum testosterone level was found to be 2 times the
& z, \" k- W  t- x2 h3 B' ~baseline value in those females who were exposed to
* i- }; f+ g0 b' F# Q% m$ Qeven 15 minutes of direct skin contact with their male
0 X0 F5 H! a% R" B5 Zpartners.6 However, when a shirt covered the applica-+ b# q( R+ e" g  ^6 z
tion site, this testosterone transfer was prevented.
/ R( L3 g+ s4 ZOur patient’s testosterone level was 60 ng/mL,
' j' f  k# P- J9 s2 {9 l+ u- b7 Bwhich was clearly high. Some studies suggest that
* O% ?* ^% `: O+ ]  R+ W) K2 Tdermal conversion of testosterone to dihydrotestos-: q' A3 {# b! M# S1 V
terone, which is a more potent metabolite, is more" V% Y9 i+ _4 o: ?
active in young children exposed to testosterone& q! J0 N: S# H" \! T: n: X; I
exogenously7; however, we did not measure a dihy-
4 G( v- X$ N6 T! ^" r/ rdrotestosterone level in our patient. In addition to
* {/ n) {' O5 k5 G* _, ]  \virilization, exposure to exogenous testosterone in
9 k& d1 Y% o  ]3 [3 cchildren results in an increase in growth velocity and' v* j; \! H+ F  H9 V, m! w, c) z
advanced bone age, as seen in our patient.
& u# ^: c. y: N1 y$ t* iThe long-term effect of androgen exposure during- R( ]  y  ?( r0 X; r
early childhood on pubertal development and final
  N0 T3 B8 @' F+ radult height are not fully known and always remain
) B$ o: p7 i$ W  |a concern. Children treated with short-term testos-
, ?; `$ Z" |5 S; ^7 r4 p& oterone injection or topical androgen may exhibit some
: K( D. p9 P3 T6 ?4 |- L5 Jacceleration of the skeletal maturation; however, after
) m- n5 R3 G( g4 K: ]( V; h! Qcessation of treatment, the rate of bone maturation6 b2 Y1 Q, \  s  U
decelerates and gradually returns to normal.8,9
3 o( J, |4 ^% Q! IThere are conflicting reports and controversy* F) k5 U' G" d& a, E
over the effect of early androgen exposure on adult2 g; T( U/ k- A
penile length.10,11 Some reports suggest subnormal
. R1 t# m0 n* O5 R; U* e, T3 d5 x2 nadult penile length, apparently because of downreg-
  V: h6 o8 T& q8 V$ fulation of androgen receptor number.10,12 However,
0 G4 f- E: g" y+ E! `9 GSutherland et al13 did not find a correlation between
; f# _4 {- L, ~9 Dchildhood testosterone exposure and reduced adult
+ {' t; o8 h) |1 E( F5 ]+ Spenile length in clinical studies.$ E4 z. h$ ]4 L8 Q
Nonetheless, we do not believe our patient is. @: z; G) ~2 q: V, p
going to experience any of the untoward effects from
  n( N- ~5 `$ f: Q4 htestosterone exposure as mentioned earlier because# T* @" v1 d7 [) R
the exposure was not for a prolonged period of time.! H% x8 W+ Y3 \: D1 \
Although the bone age was advanced at the time of
3 }3 i( `% O$ j/ B1 ?- J1 s, ^" ydiagnosis, the child had a normal growth velocity at) L( u3 {5 V/ [/ s# \* [
the follow-up visit. It is hoped that his final adult
& b2 k6 D( J6 H& k. N/ }+ `! yheight will not be affected.2 }2 y8 ?; O! a0 y* V0 L: i0 _
Although rarely reported, the widespread avail-& E! c- d& v9 V
ability of androgen products in our society may* F& L7 r' |- R/ H
indeed cause more virilization in male or female, y0 c6 N1 T( B# J4 M
children than one would realize. Exposure to andro-0 w& h" y0 G8 O. @
gen products must be considered and specific ques-! r# w- _. O" m$ D4 P: w
tioning about the use of a testosterone product or# ~9 j3 c+ K$ I
gel should be asked of the family members during. C) [5 q! `1 x2 \! w/ Y
the evaluation of any children who present with vir-
; i  s' ?2 ~; j& P* o- Nilization or peripheral precocious puberty. The diag-
* I: ?& u2 o; R5 E) _/ V; Inosis can be established by just a few tests and by$ v% \. W0 u. l. l
appropriate history. The inability to obtain such a7 h% j8 c, X: z' v
history, or failure to ask the specific questions, may5 {' D3 |6 P* G
result in extensive, unnecessary, and expensive
. L  _" E% s" Q, N( [investigation. The primary care physician should be
! @/ S' N# \, M% n7 Kaware of this fact, because most of these children* _* `* n5 L: O7 l& t, H
may initially present in their practice. The Physicians’* v# C# a/ `& Y" G4 V( T5 U
Desk Reference and package insert should also put a/ s3 }$ O2 D. T/ h/ R$ G
warning about the virilizing effect on a male or
+ H0 X) q) k, t3 Bfemale child who might come in contact with some-) Y! q) s$ A0 u' a4 x
one using any of these products.. \  X7 Y# @% z# O/ I
References
7 s+ q+ L  U" F7 p! D8 H, P1. Styne DM. The testes: disorder of sexual differentiation( g; s4 j1 o2 x9 E
and puberty in the male. In: Sperling MA, ed. Pediatric
2 O. q4 \/ j8 fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" [% ?! W- M8 b8 x1 W: i# }2002: 565-628.& K* [8 ?2 V6 m
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; o' V% w( v8 B3 v/ Q1 vpuberty 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
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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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