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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+ q& ^$ ^1 ^- G# V+ A
Boy Induced by Indirect Topical
9 @7 @3 i* i& X; s2 iExposure to Testosterone
7 `0 b2 I& J# D" d6 q! x2 ?  l7 \7 `: BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& g: N, l6 o$ A/ L7 G+ aand Kenneth R. Rettig, MD18 B7 I* W/ \& x+ Q
Clinical Pediatrics
3 q. j* U- q: m! z; q7 DVolume 46 Number 6
/ p( \* _4 z% r, {, jJuly 2007 540-543$ q) W0 b4 ?: b" A/ C
© 2007 Sage Publications
1 r" F3 V) Z3 t" U10.1177/0009922806296651
/ M. }/ ~0 [  b& ]http://clp.sagepub.com
" K! A4 g: g+ f5 U: Z4 whosted at
' ^; p1 Z2 p# K" W& t4 nhttp://online.sagepub.com$ @& N. i: k) ?: C# `8 z5 E
Precocious puberty in boys, central or peripheral,
  }6 d6 |- B* n/ l9 \0 Sis a significant concern for physicians. Central9 \& N! R, J8 ]
precocious puberty (CPP), which is mediated+ L  W1 p' U' @  o# y, |
through the hypothalamic pituitary gonadal axis, has
+ v. K) I1 r- F1 }1 k2 Ea higher incidence of organic central nervous system* N8 ^4 \) y5 X/ D: f: v3 A
lesions in boys.1,2 Virilization in boys, as manifested
, T" U$ o5 L) Q" R# d3 aby enlargement of the penis, development of pubic
, l* z, N7 M8 N; m9 A" _) s3 m5 Hhair, and facial acne without enlargement of testi-
: d& S- R4 y/ x- ~( ^* Tcles, suggests peripheral or pseudopuberty.1-3 We8 H$ u; z8 A" f/ `
report a 16-month-old boy who presented with the* y' t; W: e$ b* m# L* U0 U
enlargement of the phallus and pubic hair develop-; k/ Y, U( c, u$ t
ment without testicular enlargement, which was due
9 y# [6 v9 e/ A3 ]+ gto the unintentional exposure to androgen gel used by/ C+ q  y7 q, ?  q- x6 g
the father. The family initially concealed this infor-
0 Q+ \& l; V. U9 w9 \; Vmation, resulting in an extensive work-up for this7 g5 @' d% Y. s8 [6 u- x
child. Given the widespread and easy availability of8 R4 p  b( i4 p3 R) B& E/ ]
testosterone gel and cream, we believe this is proba-
, m* P6 S' y: H6 Y9 F  @bly more common than the rare case report in the
5 n: J9 M. V' G. Lliterature.4
9 K0 f* e! S# L0 dPatient Report
* |. a. X7 j( G( j5 c( eA 16-month-old white child was referred to the
  d$ u" [4 N' k5 s- [3 B' qendocrine clinic by his pediatrician with the concern2 b* d5 {! X* B
of early sexual development. His mother noticed1 P4 T3 ?! E3 [
light colored pubic hair development when he was( e  N- u, _3 J" t  Q3 U; g
From the 1Division of Pediatric Endocrinology, 2University of* Z( ]$ i* j1 _3 s8 q$ o) Z
South Alabama Medical Center, Mobile, Alabama.
0 B6 |- b6 \1 }* s& w0 \9 XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
3 @1 n& `5 I- r3 PProfessor of Pediatrics, University of South Alabama, College of9 U8 {9 @  c4 u2 i6 Z/ ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, w5 p9 V( I$ Y3 u$ H
e-mail: [email protected]./ f! h& I0 B7 r& B, S
about 6 to 7 months old, which progressively became: ?9 p. J# g) ~+ {% W! v) ?
darker. She was also concerned about the enlarge-5 E- ~5 [- e0 L2 u1 W
ment of his penis and frequent erections. The child) }) M: J( E& r8 K' `
was the product of a full-term normal delivery, with
7 A% ?9 ~- y8 `( D# }4 D6 Ea birth weight of 7 lb 14 oz, and birth length of
4 ~1 _6 {. i. T6 o+ ?20 inches. He was breast-fed throughout the first year
5 J4 O( F  l9 X. E' Xof life and was still receiving breast milk along with
7 z& t# }/ S( z; x2 Fsolid food. He had no hospitalizations or surgery,
9 d( _9 o1 r7 S' h, Eand his psychosocial and psychomotor development4 ?+ J9 ]! _" W. L
was age appropriate.
8 [4 a: C/ q! RThe family history was remarkable for the father,3 o4 f. q4 [% J/ ~' ~
who was diagnosed with hypothyroidism at age 16,
4 }* p* O) R# _( t8 N! g; B' J/ Q8 hwhich was treated with thyroxine. The father’s/ V: U) p# E/ `3 K
height was 6 feet, and he went through a somewhat
+ n% U* [% _- g1 Y" V$ Oearly puberty and had stopped growing by age 14.
! r2 Q" u) ~! E. Y0 xThe father denied taking any other medication. The
0 b) g0 ~# f5 U" z" Nchild’s mother was in good health. Her menarche5 x. R# g8 y% l
was at 11 years of age, and her height was at 5 feet
, A0 H% y! t5 @) R% x5 inches. There was no other family history of pre-
6 Z# |+ o# T6 a3 Q9 ?% z% w' M! ncocious sexual development in the first-degree rela-
1 V; p5 J4 d: n8 }tives. There were no siblings.3 b2 m4 B) ~- i! B' `( B
Physical Examination6 V' r: v$ j" @1 ]* w
The physical examination revealed a very active,
; B" z) i2 [" N- f% o$ `0 `6 jplayful, and healthy boy. The vital signs documented1 c$ G( M, y: w3 o0 x
a blood pressure of 85/50 mm Hg, his length was
( ~0 _7 q: q! j9 V+ t90 cm (>97th percentile), and his weight was 14.4 kg
( m7 r4 }* j4 [1 G4 I1 v/ N9 R(also >97th percentile). The observed yearly growth
6 s: [! b& _( n2 Svelocity was 30 cm (12 inches). The examination of
/ |  M8 H6 J& W9 |4 Bthe neck revealed no thyroid enlargement.3 I& z0 ]" ]7 ~8 a! u7 J. G; E
The genitourinary examination was remarkable for
0 w- D& O' y1 [, y$ s; Uenlargement of the penis, with a stretched length of
% E( G. |3 J& Y8 cm and a width of 2 cm. The glans penis was very well- V7 O3 d3 Y& V2 q) p# _
developed. The pubic hair was Tanner II, mostly around$ B) s/ n; i4 i5 I  k
540
, I: t# q. e3 k6 Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 ^( L, A5 |6 ]$ g
the base of the phallus and was dark and curled. The3 {) H5 `6 E7 f/ Q# {" }$ g
testicular volume was prepubertal at 2 mL each.9 ^  g( R7 d( g2 F$ ^
The skin was moist and smooth and somewhat4 W" c$ Q! e7 A7 @5 q" y: s0 U# ~9 k
oily. No axillary hair was noted. There were no& e& R4 r+ @  f: k+ K
abnormal skin pigmentations or café-au-lait spots.
" `3 o9 {) r& |% uNeurologic evaluation showed deep tendon reflex 2+/ a) S. Y0 b; u( {" L7 v
bilateral and symmetrical. There was no suggestion7 g8 I" h) P( Q: C( Y7 E
of papilledema.
- C, G9 W$ t$ Z3 f" |! c6 j( z! K7 ]Laboratory Evaluation& H4 o8 a$ A8 S" n
The bone age was consistent with 28 months by
- s0 i  f: ^8 T, F" Wusing the standard of Greulich and Pyle at a chrono-! u) T+ C- `' S* _/ o3 z: Y; g# a
logic age of 16 months (advanced).5 Chromosomal
$ Q9 R$ v: u% Z9 H9 G3 p( R7 Z1 nkaryotype was 46XY. The thyroid function test
- Y" M; _/ a8 y$ `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
& `# R6 k6 a( X" `* Hlating hormone level was 1.3 µIU/mL (both normal).
  w; {5 f1 Y! qThe concentrations of serum electrolytes, blood0 `" w8 J8 i! c: l
urea nitrogen, creatinine, and calcium all were2 v3 T2 O, ^# N& ?" p* h% d% K. b
within normal range for his age. The concentration
: @! q5 U8 [! e$ ^! I1 Cof serum 17-hydroxyprogesterone was 16 ng/dL
/ F% {6 n1 r! O5 s(normal, 3 to 90 ng/dL), androstenedione was 20
8 g& F; a  K, C7 b& o3 ~5 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ u+ q8 y5 T- wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ l5 O3 _. _1 x1 s7 G, Q/ J! O$ Idesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 P4 S6 e1 h. a+ Q+ E: a5 c49ng/dL), 11-desoxycortisol (specific compound S)
9 U# B7 A. @0 h; v! X  \6 cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! \# ~  W; ^- B0 t& a6 i: ~- mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 n0 J$ l0 L- [, Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 x+ r9 a: Y" t
and β-human chorionic gonadotropin was less than9 f% ?+ c  D7 M% D! Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" B! J% C' V& Z- u# z% G( Vstimulating hormone and leuteinizing hormone+ x# P7 M5 j! X; S
concentrations were less than 0.05 mIU/mL! B. i9 Z9 l% g* Z
(prepubertal).
3 @7 U' l, [( h$ }The parents were notified about the laboratory
9 g# J; ?7 {5 }0 L5 h/ t1 _results and were informed that all of the tests were
, h" l5 \3 ?( u- v' [3 ^6 \normal except the testosterone level was high. The
) g/ }' E' Q7 b% Ufollow-up visit was arranged within a few weeks to
5 ?- _( {1 B3 Zobtain testicular and abdominal sonograms; how-2 c* |- `. H7 a4 b. p; @. J  m) R
ever, the family did not return for 4 months.) }- t( c; I- A9 m
Physical examination at this time revealed that the
$ c+ r# r- K* r9 m5 l4 d8 ichild had grown 2.5 cm in 4 months and had gained# q, w4 Y4 p4 D3 A$ U5 v0 H" w' E
2 kg of weight. Physical examination remained0 h# m: ?: c  n/ m; V( Q
unchanged. Surprisingly, the pubic hair almost com-: K' v. j4 K! R
pletely disappeared except for a few vellous hairs at/ a3 w( p1 h& B/ e
the base of the phallus. Testicular volume was still 2# |4 w& ^# O- j
mL, and the size of the penis remained unchanged.
: o* ^+ s" K( RThe mother also said that the boy was no longer hav-
$ H  Z2 I+ o4 B) D2 Wing frequent erections.
( D0 R* d- `# |7 `* m: k/ c3 E, bBoth parents were again questioned about use of, V8 h1 x# D* [, G8 f; x
any ointment/creams that they may have applied to6 G" f) H, K( Z" v4 g+ ?* S+ z* @
the child’s skin. This time the father admitted the
8 ~( @3 L; D  n6 a* R! oTopical Testosterone Exposure / Bhowmick et al 541( U2 b5 _* L+ ^' f: v
use of testosterone gel twice daily that he was apply-
* _7 c2 `' @/ \& Z8 y5 ?( ~ing over his own shoulders, chest, and back area for
+ S8 X# Z0 k" p! \; l/ aa year. The father also revealed he was embarrassed
9 t- p9 X2 {8 W4 @  o  W  m+ ^to disclose that he was using a testosterone gel pre-% C( ?# P9 E. y8 r6 x! k1 B
scribed by his family physician for decreased libido- A# ]: W6 A6 u
secondary to depression.6 P$ ?5 D; W$ d
The child slept in the same bed with parents.
$ x. t* Q; t1 ^& z4 bThe father would hug the baby and hold him on his
0 F2 d' h- O/ Q5 gchest for a considerable period of time, causing sig-& n) ?4 X9 e  `( J9 U2 m
nificant bare skin contact between baby and father.
7 S% o, h8 G) k, I2 S' m& m$ dThe father also admitted that after the phone call,
# u: k  d, M7 d7 H; D: X5 W& xwhen he learned the testosterone level in the baby" ^! {" X7 D/ \) b2 L
was high, he then read the product information0 @+ J8 J  J5 L4 s# C
packet and concluded that it was most likely the rea-- _% `: m4 T, h: b9 L" b, s
son for the child’s virilization. At that time, they
) V# v  r: t# ~. A; u/ C$ N' V  tdecided to put the baby in a separate bed, and the/ b. A. e% L6 \+ p' h
father was not hugging him with bare skin and had5 \7 D5 z) F$ |
been using protective clothing. A repeat testosterone: a. K, K/ a6 p9 Y+ y5 c
test was ordered, but the family did not go to the
$ C7 S& |4 y9 T9 ]laboratory to obtain the test.% y  ]+ h& I7 ~; z5 b5 g7 F
Discussion! H2 a. X5 P4 M
Precocious puberty in boys is defined as secondary# Y! z8 |4 L( \* ]3 o
sexual development before 9 years of age.1,4! B& f( v) [' ~7 j
Precocious puberty is termed as central (true) when0 j% a( M5 ^7 F# R- _3 @
it is caused by the premature activation of hypo-/ i- S+ Z% T6 _5 \0 h
thalamic pituitary gonadal axis. CPP is more com-
0 t* W$ z9 ^, W2 D. O. imon in girls than in boys.1,3 Most boys with CPP
( Z; L: f- N4 w2 ^7 j# |may have a central nervous system lesion that is9 A/ J7 i6 P/ l# b* y/ E
responsible for the early activation of the hypothal-$ r8 |: @' `) x/ C
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 V( x( y/ \& @' fsis has been given to neuroradiologic imaging in
7 k2 U3 d3 m+ a+ `  ?boys with precocious puberty. In addition to viril-0 U- m5 j% x6 x6 o
ization, the clinical hallmark of CPP is the symmet-
6 D  J! X( q2 O; Trical testicular growth secondary to stimulation by( h2 M+ Y/ C( _0 \
gonadotropins.1,3* Z! Y3 O; [5 F
Gonadotropin-independent peripheral preco-
  N/ \* e! M6 G+ Fcious puberty in boys also results from inappropriate
( ^6 K' d1 o% K; z$ {* wandrogenic stimulation from either endogenous or. G. {/ O3 N1 u9 A
exogenous sources, nonpituitary gonadotropin stim-
; O' @% n  ^! l4 y4 E' a6 rulation, and rare activating mutations.3 Virilizing. _8 ]; }/ k; c7 }
congenital adrenal hyperplasia producing excessive3 x0 Q; ?5 s! a! F1 W# o
adrenal androgens is a common cause of precocious
: s5 K1 s" z% H  d2 ppuberty in boys.3,4
4 o9 o9 f. x0 E( V. YThe most common form of congenital adrenal
! h! Z3 j1 P+ C" b/ c" xhyperplasia is the 21-hydroxylase enzyme deficiency.
* U0 B  d. q( }0 Z0 b2 i( ~The 11-β hydroxylase deficiency may also result in
: L1 N5 }2 i4 T8 i1 n8 h9 |excessive adrenal androgen production, and rarely,/ a  i! _( I' w7 c  {: l
an adrenal tumor may also cause adrenal androgen+ b, t. g5 _$ n# N3 u0 H
excess.1,31 i& M( D3 R: v3 k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. |* P, @3 Z: k/ o3 T0 r542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 G1 Q9 z! O3 W
A unique entity of male-limited gonadotropin-
; h! f& n) |. M8 j0 E8 s/ _independent precocious puberty, which is also known' J/ J" W+ s* W: w
as testotoxicosis, may cause precocious puberty at a
; S/ K3 Q% s9 e& ^, J9 ?$ Kvery young age. The physical findings in these boys( Z1 I" Q! {6 m1 m
with this disorder are full pubertal development,
+ S/ I1 k: P# m, r" Z' u' bincluding bilateral testicular growth, similar to boys4 U# q" \) R( u. P0 u* Y4 k! E
with CPP. The gonadotropin levels in this disorder
& v8 Q1 _4 |4 j/ H* R  @0 v/ T% ?are suppressed to prepubertal levels and do not show! V2 ~. v: S5 x
pubertal response of gonadotropin after gonadotropin-
+ }$ f- [5 V% X4 J  ureleasing hormone stimulation. This is a sex-linked( ~) n+ I& i' V
autosomal dominant disorder that affects only. u% e3 z+ }3 E% c" z
males; therefore, other male members of the family
/ l& O5 c- E( a* G7 X% Z* j4 Lmay have similar precocious puberty.3# o" I/ q: V) j  ~1 M9 N
In our patient, physical examination was incon-6 ?: r6 {+ K" M- x! c& a/ \
sistent with true precocious puberty since his testi-
1 _) l4 d! B& {6 v, t  i! ]cles were prepubertal in size. However, testotoxicosis
: N3 f7 W$ A* O% y0 C* g9 f5 ^/ Hwas in the differential diagnosis because his father% t1 \! t8 V; d* A% _
started puberty somewhat early, and occasionally,
$ W# a3 I/ B8 O- e. K; r; r( |: Ktesticular enlargement is not that evident in the/ G7 d- o. W$ t- S+ A* ^
beginning of this process.1 In the absence of a neg-0 O! p; P1 N/ X7 x% o$ i
ative initial history of androgen exposure, our
7 n2 T4 O+ ^2 K3 X9 L: g2 _biggest concern was virilizing adrenal hyperplasia,
1 p3 b1 s! G; [# N2 \6 Veither 21-hydroxylase deficiency or 11-β hydroxylase3 o7 X. c7 b. z- C3 e
deficiency. Those diagnoses were excluded by find-
8 W" D( ?! P2 C' K, B" K* w- m- ling the normal level of adrenal steroids.5 z" ^& p8 O& q4 M& W
The diagnosis of exogenous androgens was strongly
' k5 B+ L: }3 O+ }3 f. t' [suspected in a follow-up visit after 4 months because
/ F0 ]& z. X& \. R6 Tthe physical examination revealed the complete disap-( g3 l! E8 I4 ?" q$ u
pearance of pubic hair, normal growth velocity, and: F3 \* C/ D& Q0 H4 D5 j6 t8 H. W
decreased erections. The father admitted using a testos-
$ P/ ]* d" n2 U* Y( `9 _terone gel, which he concealed at first visit. He was6 h1 [. D& i4 h( y
using it rather frequently, twice a day. The Physicians’
5 A2 z4 A8 e5 F% L4 eDesk Reference, or package insert of this product, gel or
! v6 L! l1 Q0 |; |, G4 ~0 Fcream, cautions about dermal testosterone transfer to
# d& R* I  J8 E+ junprotected females through direct skin exposure.% d8 j5 G& I6 F7 j7 x- L( X( Q
Serum testosterone level was found to be 2 times the
7 B/ Q. [  n  p: E' fbaseline value in those females who were exposed to: `4 z- i% v4 E% Q; c
even 15 minutes of direct skin contact with their male7 y# `' M" e2 b& z% ~: {* H  T
partners.6 However, when a shirt covered the applica-
! B9 e- q: t6 Z* e/ z2 Gtion site, this testosterone transfer was prevented.
* p, J/ w* K  Y' p* fOur patient’s testosterone level was 60 ng/mL,
/ l! T! y0 O) ^$ qwhich was clearly high. Some studies suggest that5 M; A8 M) U+ n; H0 W1 [
dermal conversion of testosterone to dihydrotestos-7 X! r# X1 L  x- B
terone, which is a more potent metabolite, is more
3 g# \5 ~. E% G, U$ mactive in young children exposed to testosterone
( u3 A) z8 s$ k; |. q( ^exogenously7; however, we did not measure a dihy-9 [( n* p3 {5 X9 G5 V  W* F! Y9 @
drotestosterone level in our patient. In addition to
* I% v2 A4 z3 Y# m5 U) p% Gvirilization, exposure to exogenous testosterone in
/ k8 L$ q! q9 I: z) x2 p4 P& wchildren results in an increase in growth velocity and. h% o4 S- n- x) v/ q
advanced bone age, as seen in our patient.5 b" R! b% ~0 a# r  k- g2 z% ^/ w
The long-term effect of androgen exposure during
1 C+ t" d4 k* b/ C6 j& Kearly childhood on pubertal development and final
1 L% d$ d" ?: I9 F1 u( ^adult height are not fully known and always remain
! d& W: ]5 C3 ^: o' Ba concern. Children treated with short-term testos-
( M' w; C. [( H3 {% T* ~0 kterone injection or topical androgen may exhibit some
. u4 _) W3 y1 N# q, p6 R& Pacceleration of the skeletal maturation; however, after& ?- c0 A% N1 }+ n% N( R
cessation of treatment, the rate of bone maturation% r1 t( a6 X. F; D6 e5 c
decelerates and gradually returns to normal.8,9, z. o( z0 F$ s9 g+ h
There are conflicting reports and controversy) k, e' \4 b9 @  f% O; s
over the effect of early androgen exposure on adult
1 V* p0 Q2 e* m/ H8 z' Z: {: wpenile length.10,11 Some reports suggest subnormal, U. \) d; e- y5 G& ]1 v5 W" U
adult penile length, apparently because of downreg-
3 |3 }0 ]; I' y0 K9 m% d. z$ tulation of androgen receptor number.10,12 However,
. \3 W! H4 C2 Y8 `& eSutherland et al13 did not find a correlation between
2 C; E- S1 o) lchildhood testosterone exposure and reduced adult
7 O9 {' w0 C9 _$ P& spenile length in clinical studies.
/ A6 e% M+ w" t1 ^: @7 ]% ~; T( XNonetheless, we do not believe our patient is
, o$ r# }6 y/ j: M. ~6 ?0 Y: Rgoing to experience any of the untoward effects from6 H2 Y% h! Y: U% G
testosterone exposure as mentioned earlier because
" e) z7 `; b2 m' z1 N$ Kthe exposure was not for a prolonged period of time.
; Y1 u5 z- Y( O+ X" N9 S; `Although the bone age was advanced at the time of$ E2 G6 P5 y3 u: R* i7 `' L
diagnosis, the child had a normal growth velocity at
! ^+ ~* H) q0 p  Z0 c) t+ Kthe follow-up visit. It is hoped that his final adult
9 A! _% j' x0 K, b- k1 iheight will not be affected.' n0 Q% v" R% G7 i3 T! j
Although rarely reported, the widespread avail-5 C  G5 M; ?$ Q% G, x' Q, \
ability of androgen products in our society may
6 q% b! q+ u( N" Kindeed cause more virilization in male or female! l) J+ H9 Q; v- q, v( x% g9 b& \
children than one would realize. Exposure to andro-/ }- w4 I# C3 U5 @
gen products must be considered and specific ques-! S# I  Y. U6 ~2 F: W& ]: F
tioning about the use of a testosterone product or4 R5 W7 c* W% g& q+ _9 ^
gel should be asked of the family members during, p' ?4 T& Y3 G' @+ G2 [
the evaluation of any children who present with vir-
7 g7 v. X; S4 Q  ?, _% \+ L; xilization or peripheral precocious puberty. The diag-, K4 a1 e9 x5 k$ g' l+ Y
nosis can be established by just a few tests and by
* h1 }' F& Z* N, k, b0 o$ u; Mappropriate history. The inability to obtain such a
: c: Z2 i* i2 Y! z$ G7 {history, or failure to ask the specific questions, may
5 [3 `7 L7 K: {; [& Nresult in extensive, unnecessary, and expensive" s5 H1 p7 v+ G* ~: z7 C
investigation. The primary care physician should be
5 i9 A  q" ?& i% {* u6 ]; k+ Jaware of this fact, because most of these children
4 u" L2 L+ |0 u3 w( Wmay initially present in their practice. The Physicians’# q, G& U* }/ L' {2 i
Desk Reference and package insert should also put a
4 J1 ^' c) c4 X6 H1 ^1 ?; T; Q4 h, wwarning about the virilizing effect on a male or
; d. |% [8 f! I5 x1 }9 O; E  s' ~female child who might come in contact with some-
7 w2 T( U2 K2 j2 U1 E% vone using any of these products.
6 i! W! d% u( X5 H8 iReferences
$ E9 R) x1 G# a4 E1. Styne DM. The testes: disorder of sexual differentiation
6 `. R& p2 F; s5 R6 xand puberty in the male. In: Sperling MA, ed. Pediatric
. [" i3 v9 _( |$ e6 HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! A2 n9 X4 C* h, o; _6 T* e
2002: 565-628.1 a) E, @1 s8 E: ?3 B9 K) W# m2 u
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 P) ~: m0 F6 F- u) @puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old- c6 R/ f6 _1 C5 X& k, q& m
Boy Induced by Indirect Topical
2 R- Z  P- j0 L1 rExposure to Testosterone
: Q+ L4 @6 n7 B# iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  c- w/ M! |$ I8 ^/ I2 A
and Kenneth R. Rettig, MD10 }, s3 a3 u  d# }  p
Clinical Pediatrics
3 J- |: d' l% @Volume 46 Number 6* C; H% y* M- F9 ]: [
July 2007 540-543
" u: x( q. `. R4 E7 o© 2007 Sage Publications; E+ R6 C9 C! P  D$ |; T% t7 h: H" `
10.1177/0009922806296651, @( H- o8 _$ z, k! S0 H4 M
http://clp.sagepub.com' G3 {; ?" e8 y4 S3 ?# |. q
hosted at
: e( f- K& w0 Uhttp://online.sagepub.com
  c; p* s$ y2 F3 ?  xPrecocious puberty in boys, central or peripheral,
( e1 F' {3 W6 P. b# q* ^' \is a significant concern for physicians. Central4 m& b9 I4 E9 k/ K/ F7 \
precocious puberty (CPP), which is mediated
# n9 N0 F3 B; T. q2 ?through the hypothalamic pituitary gonadal axis, has2 j5 J) J# G1 K' {
a higher incidence of organic central nervous system
0 p2 _$ D# }% W3 O. Ylesions in boys.1,2 Virilization in boys, as manifested% J  U3 @% K4 d5 s
by enlargement of the penis, development of pubic
/ F1 d$ h2 n. r+ chair, and facial acne without enlargement of testi-/ ]7 g8 N! D0 M/ ?" N4 j
cles, suggests peripheral or pseudopuberty.1-3 We
7 @$ V# }' p2 V5 B9 z7 Hreport a 16-month-old boy who presented with the# H, k' g# M* L' {
enlargement of the phallus and pubic hair develop-5 }. |" N3 g& M
ment without testicular enlargement, which was due/ U8 o# e3 q- K& K; T- }
to the unintentional exposure to androgen gel used by
- g7 X5 ~* n' O2 \8 nthe father. The family initially concealed this infor-! M* I: }3 @# k) ~4 T. |2 i
mation, resulting in an extensive work-up for this/ ~' s4 a" {% E  Y! V% D0 g; q) q
child. Given the widespread and easy availability of
2 C+ y! W/ v, c+ }  P: ~% Btestosterone gel and cream, we believe this is proba-3 y9 ~  D- ^! o  j
bly more common than the rare case report in the. w# Q0 j5 D+ p! b$ m1 r
literature.45 {0 {7 `# @+ G( q2 q
Patient Report8 S& V1 m/ V7 K" W' S
A 16-month-old white child was referred to the: U% b# H. K, ]" m6 V4 g
endocrine clinic by his pediatrician with the concern9 I6 i( x% t4 H2 l3 Q. t
of early sexual development. His mother noticed
5 A2 m; Q/ S2 P! V. T# J% elight colored pubic hair development when he was
- @8 s; \2 H" g/ J6 q! x# hFrom the 1Division of Pediatric Endocrinology, 2University of8 j) y* m& w) B: F% p1 ~$ ~+ A
South Alabama Medical Center, Mobile, Alabama.% z& D8 Q7 K4 ~, l; p7 `
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ e* |- o/ h7 ZProfessor of Pediatrics, University of South Alabama, College of2 b* O% q) v7 ]! }: A6 G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. B. {, i) X. j7 U3 Z. e) b5 {! Je-mail: [email protected]./ A# n. d  M7 M$ I( \: i! l
about 6 to 7 months old, which progressively became9 \5 x! X6 ]9 e3 S
darker. She was also concerned about the enlarge-
' @. Z0 r4 G0 Z6 ]8 s" f. Bment of his penis and frequent erections. The child/ h/ y) l. x' l8 t: X8 ~7 ^
was the product of a full-term normal delivery, with7 C- P' ?3 _& H" |9 {
a birth weight of 7 lb 14 oz, and birth length of
+ q3 P) O7 d+ I1 \# P* N20 inches. He was breast-fed throughout the first year2 e% a. F1 s! T: ^
of life and was still receiving breast milk along with3 ?+ L, c* X1 ?& G( }
solid food. He had no hospitalizations or surgery,
& a" t; e7 X! U! a- ^9 Uand his psychosocial and psychomotor development' F! q$ ~/ C5 I. X) r% T( t
was age appropriate.. w7 I& v- ]2 e; i9 ^% f$ I
The family history was remarkable for the father,' |' a& o4 D4 l# U; m
who was diagnosed with hypothyroidism at age 16,
( w# n" S' V. p- x5 n5 A0 Qwhich was treated with thyroxine. The father’s, a0 O' I; ^: d8 u
height was 6 feet, and he went through a somewhat
- x, P1 I9 x' S1 W$ d1 z4 d! N( B" Q  uearly puberty and had stopped growing by age 14.6 q* n9 _1 S( B& @9 y  J, ]
The father denied taking any other medication. The
4 ?0 y/ A# n+ n# K0 mchild’s mother was in good health. Her menarche
) \, x1 {8 G$ E. h8 |was at 11 years of age, and her height was at 5 feet
. L! g6 T  v2 D# N. A5 inches. There was no other family history of pre-3 ~$ A/ m: N6 Q% V- l
cocious sexual development in the first-degree rela-) q# y+ E. I' ~$ z! h; }0 ^) w
tives. There were no siblings.5 s; \- v9 f+ a$ ~
Physical Examination4 d$ ^  p+ [! J. F
The physical examination revealed a very active,& H+ ~  ]* u, @3 s
playful, and healthy boy. The vital signs documented
' L' g2 N8 Q" P; g6 u3 D' O2 |9 Na blood pressure of 85/50 mm Hg, his length was
/ i2 P  p# _: L5 [2 v. u90 cm (>97th percentile), and his weight was 14.4 kg+ W0 m0 Q# Y4 a8 f
(also >97th percentile). The observed yearly growth
" N0 O! y2 G' \  Z+ n9 Wvelocity was 30 cm (12 inches). The examination of
* Y2 L: F( f7 Y, j4 Pthe neck revealed no thyroid enlargement.7 l0 y8 L, E# X$ c, d
The genitourinary examination was remarkable for3 \2 ~' y/ |' ~4 S5 A! s
enlargement of the penis, with a stretched length of7 F1 [# m( |% P7 Z( k1 h
8 cm and a width of 2 cm. The glans penis was very well2 ]. c( v! R# y: R: ?3 P& b$ }
developed. The pubic hair was Tanner II, mostly around% J+ Q; }) y0 B
540
  b" x5 U. ?0 `' ^, Q" \. Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 g& g; d0 g! G; o& z' L$ R, ?the base of the phallus and was dark and curled. The
' V' F/ C4 L1 [7 E% ?5 Qtesticular volume was prepubertal at 2 mL each.$ c% r- j# r& ?% ^! b# P
The skin was moist and smooth and somewhat% M5 E& S0 p  s- t. Z# j
oily. No axillary hair was noted. There were no
& \1 G# S( |; W6 y  babnormal skin pigmentations or café-au-lait spots.
4 f' R) s8 Z  L8 d6 i+ g. Z. S* F4 \Neurologic evaluation showed deep tendon reflex 2+
+ T5 x- M9 C6 v* Bbilateral and symmetrical. There was no suggestion
5 ?, Q* y$ S5 y. zof papilledema./ a2 l6 k: c& `1 J- L" i
Laboratory Evaluation! f0 o( Z" o( H( t
The bone age was consistent with 28 months by1 l7 C4 t4 M2 n: R4 T' q( t* L
using the standard of Greulich and Pyle at a chrono-
$ @3 Z  C- o- `# q; x4 s. O6 ^' llogic age of 16 months (advanced).5 Chromosomal1 e4 U, l+ j: A/ f- t
karyotype was 46XY. The thyroid function test# V/ P2 R! o! w* E/ L1 y2 f: L) J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ R1 o6 w8 _2 U/ ulating hormone level was 1.3 µIU/mL (both normal).
3 W6 h' D  o& y% _% c' u5 EThe concentrations of serum electrolytes, blood# r4 A$ w+ Y* H
urea nitrogen, creatinine, and calcium all were
. @* b9 |+ v5 A( @within normal range for his age. The concentration( u) e- b. j3 l
of serum 17-hydroxyprogesterone was 16 ng/dL/ R! B6 w2 b% S0 D) I
(normal, 3 to 90 ng/dL), androstenedione was 20- I. u) n1 V6 Y. ^" L6 H3 |+ {* |% x3 u
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ ]  S. F# G9 u. u1 p0 m! d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, ?5 U0 b7 o+ f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( Z5 r0 n" O* o
49ng/dL), 11-desoxycortisol (specific compound S)
! Q/ n9 Z0 `0 E* G6 }1 ~# Dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 ?- t! ^. C, I/ P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% a2 y; ~$ `* o, F- ~8 ~# x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 b! G8 n9 g" ~6 Qand β-human chorionic gonadotropin was less than
% s: t4 I1 v' z: E) r5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 O# A, e* H# {6 r, @stimulating hormone and leuteinizing hormone/ f* l: C: X3 r- Q
concentrations were less than 0.05 mIU/mL
% e) l6 ?5 r. n/ X! T(prepubertal).
7 U: E' V/ E: i4 L' UThe parents were notified about the laboratory. s% T) \5 r5 ^
results and were informed that all of the tests were5 R6 K/ A2 V( p* D- I$ N
normal except the testosterone level was high. The
; e- K8 A, {6 K5 {follow-up visit was arranged within a few weeks to
) T  F8 k, j. c1 Y: ?: ~' _' v6 Sobtain testicular and abdominal sonograms; how-) j/ p- S; L9 e/ E) r5 z# ~4 c( ?
ever, the family did not return for 4 months.
, _  H% l. c9 ^9 V# V- F' [+ lPhysical examination at this time revealed that the* c7 s  E* }, O6 _
child had grown 2.5 cm in 4 months and had gained$ a3 F& I4 b- {( T4 [
2 kg of weight. Physical examination remained
; ^$ r# p5 v7 \3 ]! L% D. Eunchanged. Surprisingly, the pubic hair almost com-
) f$ E6 [" H- i( |- k) Z, b6 ]pletely disappeared except for a few vellous hairs at
' d# r6 w$ U6 Q, a: F' g! }: S3 xthe base of the phallus. Testicular volume was still 25 ?0 v) c$ F9 K: P3 r! `* p  E) |" j
mL, and the size of the penis remained unchanged.
  a# r1 N+ K! j  LThe mother also said that the boy was no longer hav-
5 r1 ^  P1 t: ?# u4 j: oing frequent erections.$ F4 X8 ~+ N& \" l- \/ {; `
Both parents were again questioned about use of- W; q5 R5 A/ k
any ointment/creams that they may have applied to
% D& p4 U6 B- F7 {the child’s skin. This time the father admitted the
' l1 c; W  o) HTopical Testosterone Exposure / Bhowmick et al 541
) y. f& z, x; W! N# E& t* }. uuse of testosterone gel twice daily that he was apply-
% F: |( N) ~+ u# F7 y) Y$ L6 King over his own shoulders, chest, and back area for* O, X+ d/ N# M
a year. The father also revealed he was embarrassed1 n. r6 s/ @8 H) k0 \* B
to disclose that he was using a testosterone gel pre-
/ U, \$ {* E9 ~' Yscribed by his family physician for decreased libido9 w( X& `4 _' X2 z
secondary to depression.
/ n) V: y/ A# u) }4 V2 o+ MThe child slept in the same bed with parents." P; ^$ {5 [$ X+ }. Q; e) P4 ^
The father would hug the baby and hold him on his- r% E, d: u, F4 w. l  X* O
chest for a considerable period of time, causing sig-
# f. H, D3 Z$ s. W: }8 D* c" g8 _nificant bare skin contact between baby and father.
/ M! `, i# x/ h6 Y$ W) J# lThe father also admitted that after the phone call,) [: p' A9 w, c# \4 y" j
when he learned the testosterone level in the baby$ d: d& o* Q* }& Y7 M5 y* c
was high, he then read the product information
& s+ L9 T# Q! r. Y8 n" bpacket and concluded that it was most likely the rea-
4 |3 b$ K1 E5 bson for the child’s virilization. At that time, they
8 m4 @  V& U: h5 ^6 D" L+ o9 pdecided to put the baby in a separate bed, and the
( B7 }  o# f5 n; B  s5 p! dfather was not hugging him with bare skin and had
& q+ W+ V: @4 Sbeen using protective clothing. A repeat testosterone0 d2 E2 W( H  {
test was ordered, but the family did not go to the+ g" r: m  E$ \# ~+ k5 z2 j* e
laboratory to obtain the test.
6 c, p# M. x9 k* J2 g, nDiscussion9 ^% O6 ?! k$ }* b) D
Precocious puberty in boys is defined as secondary/ Y& g9 |$ U7 I& q4 ~4 H
sexual development before 9 years of age.1,4! t+ v9 q1 J' h; Y3 o& a
Precocious puberty is termed as central (true) when2 T( G2 S! D, L: T
it is caused by the premature activation of hypo-7 q/ Y0 h0 c! n8 I
thalamic pituitary gonadal axis. CPP is more com-* {  s+ y5 \6 I( r+ o$ a! V
mon in girls than in boys.1,3 Most boys with CPP2 z! k  U7 k3 S4 b4 f7 x
may have a central nervous system lesion that is; ?5 }' _4 F( E1 f7 @! R- h+ H
responsible for the early activation of the hypothal-" T1 ^; U" _' L2 d1 }0 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
" i, O; `+ ]2 r! v$ g6 |) csis has been given to neuroradiologic imaging in
( n/ W; p' b- ]3 T6 n! N3 l1 `boys with precocious puberty. In addition to viril-! Y$ j8 R- o  w* i6 i
ization, the clinical hallmark of CPP is the symmet-
1 Z4 A3 r2 s2 r  c/ o. F$ E" irical testicular growth secondary to stimulation by7 G+ g4 U1 D7 |5 ?% ^( W
gonadotropins.1,3
* I1 H2 \0 K' {$ X, k% PGonadotropin-independent peripheral preco-
6 w' c! {. Z* L* Z* Ycious puberty in boys also results from inappropriate$ e. }* X( x1 O2 \- {3 k$ C4 Q
androgenic stimulation from either endogenous or
" w) _( h. S0 z3 J* qexogenous sources, nonpituitary gonadotropin stim-/ J* J/ H/ B# V3 Q, U) W
ulation, and rare activating mutations.3 Virilizing0 z8 x8 D3 s$ ]0 V
congenital adrenal hyperplasia producing excessive
$ y  |) p/ M9 C) _) Nadrenal androgens is a common cause of precocious
% B1 t' s7 ]4 d  m) c, Bpuberty in boys.3,4
* B) C# ^: J3 o. UThe most common form of congenital adrenal  C3 T- Z# _$ C. a
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 q+ c# K  n+ ~; VThe 11-β hydroxylase deficiency may also result in. x% Y9 t1 `/ k( u+ M
excessive adrenal androgen production, and rarely,3 F' L; T3 W, g( A2 c7 w) l
an adrenal tumor may also cause adrenal androgen
) R6 G6 a1 t1 iexcess.1,3/ m% u2 ?9 _2 r1 x& @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 D: C5 T" H+ S$ j* [0 T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* Z* ~" z- Q: ~; X
A unique entity of male-limited gonadotropin-3 u7 X* ^! G2 u* D7 \, w* Z
independent precocious puberty, which is also known% \; S9 _4 {, p4 ?- u4 M; E
as testotoxicosis, may cause precocious puberty at a
; Z! U6 N& `* i$ ]very young age. The physical findings in these boys
0 n6 Y. i. R' ywith this disorder are full pubertal development,# h7 H/ g, |: a/ u% X
including bilateral testicular growth, similar to boys
2 x/ _. M: e* S' N1 q2 l. T( jwith CPP. The gonadotropin levels in this disorder9 \+ l& F4 V" x6 n+ V6 p
are suppressed to prepubertal levels and do not show1 E8 K( L& o0 J6 K. s7 J! ^
pubertal response of gonadotropin after gonadotropin-& ~* q( q' B* R
releasing hormone stimulation. This is a sex-linked$ ^. L5 j5 }3 @; n$ ]
autosomal dominant disorder that affects only
8 O% J  Q* O  A" U& M0 Omales; therefore, other male members of the family+ U  s) \# o: G" x! V" |
may have similar precocious puberty.3, ^( |4 o6 u! T6 V
In our patient, physical examination was incon-( `* x8 d& ?7 H# z
sistent with true precocious puberty since his testi-* M; z8 ]8 A( q
cles were prepubertal in size. However, testotoxicosis
% `8 ^9 J0 s' |was in the differential diagnosis because his father0 v7 u$ ~! a+ r. ~7 }* K
started puberty somewhat early, and occasionally,! K0 q* W0 a9 D. ~
testicular enlargement is not that evident in the
' n/ r. H0 S- E, \% p4 E: C; Tbeginning of this process.1 In the absence of a neg-
: p+ k6 a- ^2 G( }( h$ V. R% lative initial history of androgen exposure, our
2 a; P! P& a8 f0 N3 hbiggest concern was virilizing adrenal hyperplasia," M5 p  _. C- K( F% i' _
either 21-hydroxylase deficiency or 11-β hydroxylase
6 p& n" A$ t9 K( rdeficiency. Those diagnoses were excluded by find-
1 \9 @0 R2 y0 @; @/ ?ing the normal level of adrenal steroids.1 k6 k/ v6 e+ O8 u$ v
The diagnosis of exogenous androgens was strongly% g+ d/ m/ }  N. E: U* @0 d) O
suspected in a follow-up visit after 4 months because% J5 M1 W8 V$ Q: ?7 C; K9 _
the physical examination revealed the complete disap-4 x8 u& P8 i" h7 p. {/ p
pearance of pubic hair, normal growth velocity, and
1 V+ m( ]: J+ E) g' Y. Rdecreased erections. The father admitted using a testos-2 B6 C2 s7 U' A( Z5 q) G
terone gel, which he concealed at first visit. He was
9 ?" a  J  h/ x; w, d8 \using it rather frequently, twice a day. The Physicians’
8 D0 I; T& k4 g! V; D3 eDesk Reference, or package insert of this product, gel or& ~, K: X% P, e1 e- _' h
cream, cautions about dermal testosterone transfer to. J' w) }5 V; U8 \7 S7 I
unprotected females through direct skin exposure.+ k9 Z+ ~( e4 L: Y% N
Serum testosterone level was found to be 2 times the
1 w+ S: Z0 ^2 ~: G. Mbaseline value in those females who were exposed to& M* |% y# m: Z& T( h
even 15 minutes of direct skin contact with their male
# t& d4 i  J. ]2 \partners.6 However, when a shirt covered the applica-
' f- E" k" Y0 d, N. D0 Wtion site, this testosterone transfer was prevented., S; Z! @2 H; l* G) R- c- j
Our patient’s testosterone level was 60 ng/mL,
; Y- d/ b& ?# Y& I' Twhich was clearly high. Some studies suggest that
+ V5 t" o; I) n! u7 o( O% sdermal conversion of testosterone to dihydrotestos-
2 @) S9 K3 ~6 M# s0 d& iterone, which is a more potent metabolite, is more
+ w& O. @- T9 Pactive in young children exposed to testosterone  \! _+ W7 `# a8 w' x. q
exogenously7; however, we did not measure a dihy-) G* e8 }- j' R+ ?
drotestosterone level in our patient. In addition to: J3 A( q' U2 a% a  ^" ~) w
virilization, exposure to exogenous testosterone in8 `6 u; O7 Y8 h- T3 U+ @+ J
children results in an increase in growth velocity and5 a( j, D* L& K/ A$ K/ D
advanced bone age, as seen in our patient.
( ~% d! I/ o; R, pThe long-term effect of androgen exposure during2 P: y" Y: b7 Y* k5 J% J5 ~0 K
early childhood on pubertal development and final9 k) G4 [1 `5 D" V5 b7 b
adult height are not fully known and always remain+ p$ U4 W) Q. i# |: M
a concern. Children treated with short-term testos-( z3 e8 {. ?! `7 r
terone injection or topical androgen may exhibit some$ T4 }; Z- w3 E. t, [8 x- l
acceleration of the skeletal maturation; however, after
- |( L6 ?+ D+ }cessation of treatment, the rate of bone maturation
6 w6 a' e' j. n3 `decelerates and gradually returns to normal.8,9
: l7 m3 O- c+ ?1 dThere are conflicting reports and controversy* o4 g! t/ F, M5 ^
over the effect of early androgen exposure on adult
0 @2 o6 _$ u' Q0 }+ _! ^6 Epenile length.10,11 Some reports suggest subnormal4 K# L$ e" B& B( D1 i! n
adult penile length, apparently because of downreg-+ E: ~5 r$ ]8 |0 u
ulation of androgen receptor number.10,12 However,6 @3 |: l: E/ q: G  j1 P0 H
Sutherland et al13 did not find a correlation between; O. U6 z7 q; \& U  Y* a9 F
childhood testosterone exposure and reduced adult
3 l0 a5 k+ A9 c. g( Fpenile length in clinical studies.& ?& [  O& ~7 ]8 N+ S' [4 e
Nonetheless, we do not believe our patient is9 c: Y) C0 ~6 s7 b. c* W
going to experience any of the untoward effects from1 [" O4 }* I1 Z
testosterone exposure as mentioned earlier because( W! U% z  ~$ d) u; {
the exposure was not for a prolonged period of time.
# b% g% @1 b: l9 d& r; [' e5 ?Although the bone age was advanced at the time of, ?$ n- R0 Y7 V+ v# T
diagnosis, the child had a normal growth velocity at' J) h8 D& y' ^: ]% {
the follow-up visit. It is hoped that his final adult1 r, x* g- f. V
height will not be affected.
$ Y4 o( l) O) C: ^4 dAlthough rarely reported, the widespread avail-" ~) u  @+ v$ M2 S! Q
ability of androgen products in our society may; X! `5 C$ n% ]6 R3 y
indeed cause more virilization in male or female' [& C+ g" q  D  o6 X: D4 u
children than one would realize. Exposure to andro-
) K0 n" H) b& q2 Wgen products must be considered and specific ques-
# I: P# x9 A% y- wtioning about the use of a testosterone product or
( t4 P/ b+ C1 C' _gel should be asked of the family members during# r. O  S& l$ B4 ^/ N; q. {; ~
the evaluation of any children who present with vir-  x0 C- k) n4 l" p6 C8 T  p
ilization or peripheral precocious puberty. The diag-' t  k# K/ }7 H0 H7 Z: u
nosis can be established by just a few tests and by
# v! Q  o4 `/ n$ Y& k# F! Z$ wappropriate history. The inability to obtain such a) r6 i' O0 w1 K) j- D# ?" R0 t- [# {
history, or failure to ask the specific questions, may, P  i) x3 Y1 ^( l4 x9 T8 P
result in extensive, unnecessary, and expensive
: F* _- J9 g- e9 d; L0 ^4 l4 finvestigation. The primary care physician should be
2 T0 X0 r3 X5 aaware of this fact, because most of these children1 u/ w( D; d1 D' _
may initially present in their practice. The Physicians’* t3 p; V# d& ^0 Q+ G7 {3 u
Desk Reference and package insert should also put a
& ]( J+ \  m8 w2 N: H( R- hwarning about the virilizing effect on a male or( `( z/ }. x6 W
female child who might come in contact with some-
* r- v; S% a% O" J) Lone using any of these products.
& b, T1 w6 @$ ?# R6 o0 JReferences$ R7 g4 R! F% u7 ^
1. Styne DM. The testes: disorder of sexual differentiation
9 C+ y/ s6 }; w, p( t. iand puberty in the male. In: Sperling MA, ed. Pediatric
8 j0 K8 h, f: X  }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 A' u0 Z. a5 `* a% _4 W2002: 565-628.$ E  R) `; z, M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ E( s( X0 G0 `8 S3 k
puberty 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

# Q# E0 r  R* U! k0 b. |3 r! T4 V2 \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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