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鄉下的妹子太便宜,一次四個都要了[12P]

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Sexual Precocity in a 16-Month-Old
* n; h: [, r$ p. o$ }; EBoy Induced by Indirect Topical
& x6 |. H& ?9 L4 nExposure to Testosterone2 b' D* l5 q% T, }( Q: E
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# W$ q, Z" t4 U# c* c7 g- I
and Kenneth R. Rettig, MD1/ z* b5 h! g" r) Q
Clinical Pediatrics
% x5 ?" M: Z0 [Volume 46 Number 6+ s6 G) M- e) _+ s( P7 z0 o" \
July 2007 540-543$ N# a- Q% j) g9 I  D% U" j. I
© 2007 Sage Publications
) r' l; o3 h5 F. l) F10.1177/0009922806296651
4 t9 ~- e0 W, B: hhttp://clp.sagepub.com
1 T/ ?2 ]1 Z1 v/ z6 U/ d! thosted at# W# m2 O, Z. D$ i& v. A
http://online.sagepub.com
6 s3 Y+ @% q  KPrecocious puberty in boys, central or peripheral,# W. m/ y; g' |$ R* V7 V! i
is a significant concern for physicians. Central, M; ?' v! n6 j# V" {2 y
precocious puberty (CPP), which is mediated
% J' D$ K+ [8 o7 v# hthrough the hypothalamic pituitary gonadal axis, has
0 l3 H; ~5 x! \: m& t0 K0 E% y$ Ta higher incidence of organic central nervous system
6 @8 Q( T- E7 U/ Vlesions in boys.1,2 Virilization in boys, as manifested
, c1 W3 H3 W( ]( G( eby enlargement of the penis, development of pubic3 G' ~7 U8 x9 y& l! m' E( R
hair, and facial acne without enlargement of testi-7 O, H/ e- M7 C' A% ^3 h( A7 m* \
cles, suggests peripheral or pseudopuberty.1-3 We
/ t6 U3 K# T& T3 u$ Xreport a 16-month-old boy who presented with the
! l' ]  M- p) @$ {  @* Wenlargement of the phallus and pubic hair develop-4 d& @+ x% K; _- }; F
ment without testicular enlargement, which was due
# ^2 Z5 g. @5 h  j- M+ [to the unintentional exposure to androgen gel used by8 {8 d2 B6 E# b( L' n
the father. The family initially concealed this infor-, ]9 s9 i: g" O* X
mation, resulting in an extensive work-up for this
  `5 r1 u4 b& u1 p& U  |child. Given the widespread and easy availability of. f. E% ~7 H$ Z2 X. N
testosterone gel and cream, we believe this is proba-
! j* E2 |2 z  S4 S) S! D& Z  ]bly more common than the rare case report in the7 f4 K! P* X: {/ F4 B! N3 o0 C
literature.4
  F/ s0 Q5 J/ a9 p8 b% aPatient Report8 v' s( ]& f, o$ g+ f
A 16-month-old white child was referred to the$ ?! S2 R" W* w3 p
endocrine clinic by his pediatrician with the concern
9 h, H% P3 c2 z9 S6 ^* X' Xof early sexual development. His mother noticed* o5 d$ p/ Y/ v, F
light colored pubic hair development when he was
* Q8 {7 M' q! p9 h& x) h5 Y: FFrom the 1Division of Pediatric Endocrinology, 2University of
  i9 C6 R! c6 e' `2 g( x9 \South Alabama Medical Center, Mobile, Alabama.
4 Z& d) J3 }3 K0 U$ S0 x. T: @Address correspondence to: Samar K. Bhowmick, MD, FACE,
: {: Y  }- s0 ], w" b$ l6 [. @Professor of Pediatrics, University of South Alabama, College of
# ?- g- j  M8 t6 BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: m; x; ?3 u( m- t/ P' q5 N/ ~
e-mail: [email protected].
3 m7 k! x4 U0 s2 ]- n5 `' J! Tabout 6 to 7 months old, which progressively became6 @' C2 _$ e' y8 o7 V
darker. She was also concerned about the enlarge-
5 F# n5 n# ^) |& }0 L7 ament of his penis and frequent erections. The child4 f" i: p" Y! l
was the product of a full-term normal delivery, with3 E3 {5 w, {* ^* }
a birth weight of 7 lb 14 oz, and birth length of9 w* ^0 f- d  u" v8 F0 t- d
20 inches. He was breast-fed throughout the first year4 k; e# ~& C3 T# b+ L
of life and was still receiving breast milk along with  r2 g+ J' D9 S$ H* \7 U6 o1 o, T. o
solid food. He had no hospitalizations or surgery,# B# w; K# w% Y1 Q8 Y
and his psychosocial and psychomotor development& B8 W/ x2 B) t, e+ s
was age appropriate.% G! i0 A( H6 W8 A% E
The family history was remarkable for the father,
% Z, P$ ^0 I4 `- q; V1 Lwho was diagnosed with hypothyroidism at age 16,
% O6 D- V* N) q% S2 S- qwhich was treated with thyroxine. The father’s
3 H( l* P' x6 T) Uheight was 6 feet, and he went through a somewhat
" x) W0 w$ Z' I- y+ A  h" R5 F4 searly puberty and had stopped growing by age 14.6 V4 t0 l! ]  z/ Y0 _1 B/ H
The father denied taking any other medication. The" Y, {& a% O3 {* t# j9 S5 {
child’s mother was in good health. Her menarche
9 w5 K: q6 v" X$ H$ nwas at 11 years of age, and her height was at 5 feet0 h2 a/ w. Q' ]# @. I4 L9 Y
5 inches. There was no other family history of pre-
8 W, ~5 @5 \4 J  z# ~4 ^cocious sexual development in the first-degree rela-9 f0 R( _# j% x5 x: k6 Z* K
tives. There were no siblings.* L2 X0 d1 c1 j; w! S) _3 v; g
Physical Examination  K9 k( }) }( Q$ x/ \& L$ l
The physical examination revealed a very active,
) F8 L0 `8 E) L4 j- r9 Eplayful, and healthy boy. The vital signs documented
6 L* ]  i* v8 M5 N9 S7 T5 _, A" E: qa blood pressure of 85/50 mm Hg, his length was
! W1 u! W+ o% ~! l90 cm (>97th percentile), and his weight was 14.4 kg2 l7 r6 d8 N! C4 h
(also >97th percentile). The observed yearly growth
4 R9 R" W1 \8 fvelocity was 30 cm (12 inches). The examination of
( C- h" s' G' x1 bthe neck revealed no thyroid enlargement.2 ?% X% j* n# t% E) d
The genitourinary examination was remarkable for
9 b+ l, L" p: s: X, fenlargement of the penis, with a stretched length of
- G+ V8 A4 J( t) w2 H. R) e3 \8 cm and a width of 2 cm. The glans penis was very well
+ l- {- S! a' P- t+ udeveloped. The pubic hair was Tanner II, mostly around. ?% I- P  |* N2 _7 w/ @5 Y! C- l
540
  X# u2 q6 V" O4 \1 h" h& O7 hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ P4 ~  K" q4 g
the base of the phallus and was dark and curled. The
$ C3 R! y% b5 s: R# \7 ^testicular volume was prepubertal at 2 mL each.
: c1 o# ?& O) X4 P; QThe skin was moist and smooth and somewhat
. T$ B! _+ X9 X* g0 N: z9 goily. No axillary hair was noted. There were no
! q+ ?4 {* ]* n& o2 H/ Eabnormal skin pigmentations or café-au-lait spots.; o4 i6 B; |/ O1 ?# U
Neurologic evaluation showed deep tendon reflex 2+
& M5 l! o4 I* K! K. n# H  Mbilateral and symmetrical. There was no suggestion! ^9 ^& c' Y! }
of papilledema." V) Y. J8 _" M3 }
Laboratory Evaluation
. g* ~) q& v" l& r7 rThe bone age was consistent with 28 months by
1 S0 M; a1 {4 {0 c! [using the standard of Greulich and Pyle at a chrono-$ n' o5 F8 p5 x3 ?% O
logic age of 16 months (advanced).5 Chromosomal
/ I  s; M; Q/ c/ wkaryotype was 46XY. The thyroid function test
7 R& Z' [4 {0 C2 rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- m7 D; V6 ^! |+ ]4 c+ \
lating hormone level was 1.3 µIU/mL (both normal).
* C5 J" H  S5 M" P+ H2 S) H1 |9 H2 @8 QThe concentrations of serum electrolytes, blood0 Z* M' Y4 {6 V4 G/ M, h
urea nitrogen, creatinine, and calcium all were
) m0 I4 u5 g" j2 N' gwithin normal range for his age. The concentration, P! C0 X6 r4 l  a1 a
of serum 17-hydroxyprogesterone was 16 ng/dL
+ n1 J! x/ w- C0 ~; l(normal, 3 to 90 ng/dL), androstenedione was 20
1 C! G$ Z( G0 n6 c- nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: K+ Q- v9 h" a" k; C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 Q0 Y( l* N% v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ P1 W  {) @! T# ]
49ng/dL), 11-desoxycortisol (specific compound S)
; [' t; {& y3 w' U7 @4 |/ ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ t0 e3 x0 t% s) e8 T  Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. F5 R( Z/ h$ p" c! J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! W0 f, _6 W& j3 |8 U. F
and β-human chorionic gonadotropin was less than  U8 o  i- H% h' H
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 _3 Z4 C& f' jstimulating hormone and leuteinizing hormone
9 ]1 U5 h- j9 Z4 F6 {+ Z! }concentrations were less than 0.05 mIU/mL. e9 R* {* X# t+ u; l$ @
(prepubertal).
3 s7 N: v; \( [5 s/ \The parents were notified about the laboratory' T% |5 o$ j8 A$ U
results and were informed that all of the tests were
) S% t8 `# \! k9 z& N. [normal except the testosterone level was high. The; P/ x( w% {# x/ W
follow-up visit was arranged within a few weeks to8 u* k/ o0 c  I: V* Q) Q
obtain testicular and abdominal sonograms; how-& v6 R( W! u2 p! ?
ever, the family did not return for 4 months.- u/ s4 [2 r8 y7 |7 p
Physical examination at this time revealed that the" m" o2 X8 A( A' }" ?0 _
child had grown 2.5 cm in 4 months and had gained8 G& [* d. X; ?( t2 g$ T
2 kg of weight. Physical examination remained& F) g0 @0 R$ ]8 O, P. Z3 x* P
unchanged. Surprisingly, the pubic hair almost com-
- b% @4 V* n0 n$ t. N: lpletely disappeared except for a few vellous hairs at
2 K5 S, i  Q+ ^the base of the phallus. Testicular volume was still 2
9 f+ B3 i5 ^) l3 J& U% bmL, and the size of the penis remained unchanged.+ U, c6 s# N3 s6 M! d
The mother also said that the boy was no longer hav-
  n3 M8 g% }$ U% _ing frequent erections.
& l. T* m: ]7 S' ^Both parents were again questioned about use of
$ j) t  L# U9 c9 O2 m. i. {1 many ointment/creams that they may have applied to9 c# H2 e- T; _$ }0 m
the child’s skin. This time the father admitted the
2 F2 s+ `/ B6 ]1 l5 H, U: lTopical Testosterone Exposure / Bhowmick et al 541
8 u- M) E; t2 e: M5 w, O8 y+ Iuse of testosterone gel twice daily that he was apply-, c7 g) f/ `0 D- C4 M
ing over his own shoulders, chest, and back area for
" \# O# Q- N2 x9 ^  c" Ma year. The father also revealed he was embarrassed' W. p) `" |6 D* G% _" a; ^
to disclose that he was using a testosterone gel pre-' V- _. f4 m7 {
scribed by his family physician for decreased libido
0 q% B  g  R) }2 Q( Zsecondary to depression.
( ~3 e( f$ x' a2 g# kThe child slept in the same bed with parents./ h4 r) U6 L$ i, T- d5 Q1 W
The father would hug the baby and hold him on his
3 o1 f4 U# t: a, [0 Nchest for a considerable period of time, causing sig-; e3 W6 v4 m) h) Z' R; N
nificant bare skin contact between baby and father.) }+ h5 B+ V; s3 q
The father also admitted that after the phone call,
  R' ^& ^$ o, H5 Cwhen he learned the testosterone level in the baby) j6 T5 o8 r4 p- f& m, z
was high, he then read the product information6 f  G5 u: x& j' W5 z
packet and concluded that it was most likely the rea-
, q  w. D9 B. L$ K' T8 lson for the child’s virilization. At that time, they, x3 o( u$ ~& a, p
decided to put the baby in a separate bed, and the! E. k* d! a; }9 k
father was not hugging him with bare skin and had
! t) b! e0 G0 ]; gbeen using protective clothing. A repeat testosterone
4 J5 i$ U' ]% l/ ?. j2 a" Atest was ordered, but the family did not go to the
/ D# A: `) w" ~5 Klaboratory to obtain the test.
6 Q4 J. h1 v  P- u6 ^0 H) Y- ]Discussion( L7 ?! P* m9 u
Precocious puberty in boys is defined as secondary
" K, N3 b6 N) L" ^! csexual development before 9 years of age.1,4
3 M" f: a0 I1 O4 S" x# A, hPrecocious puberty is termed as central (true) when4 ~, p6 K" h' L& J! c( G
it is caused by the premature activation of hypo-
+ l$ J' a9 l+ B  Athalamic pituitary gonadal axis. CPP is more com-
) W0 [( m& a) s: }, O% a. ymon in girls than in boys.1,3 Most boys with CPP9 F* Q. o% o2 Z/ M; M
may have a central nervous system lesion that is
) Y: W  m+ ~" \/ E* z. `0 T: L' ?responsible for the early activation of the hypothal-
5 ?2 g4 n2 k2 Samic pituitary gonadal axis.1-3 Thus, greater empha-
) U5 A8 c2 |: F# c" `sis has been given to neuroradiologic imaging in
. w, ~, ^% V: ^# p6 o5 ]4 _boys with precocious puberty. In addition to viril-* K6 X# `7 ^9 I
ization, the clinical hallmark of CPP is the symmet-
% P/ W- l# K0 m0 V. `0 _* k1 M% d5 Srical testicular growth secondary to stimulation by
; ?: x8 }0 _) _2 X( h$ N* C) Rgonadotropins.1,3! O( O0 L5 p8 ?* p9 _( b' \
Gonadotropin-independent peripheral preco-
4 Y4 r& V! U" R4 v9 {1 Z+ qcious puberty in boys also results from inappropriate
) O4 V  n' G3 `, i6 dandrogenic stimulation from either endogenous or
) ~( O7 a+ J0 G& T0 x( W; U/ O- _exogenous sources, nonpituitary gonadotropin stim-
. [+ ^" T( O7 C) @0 gulation, and rare activating mutations.3 Virilizing2 t$ a" e- b% T' I- N
congenital adrenal hyperplasia producing excessive$ d& }. ^; }0 x
adrenal androgens is a common cause of precocious
9 [1 U0 c% V" A7 ~puberty in boys.3,4
$ S& Q% p. f4 f$ L, q0 x! G+ EThe most common form of congenital adrenal
% o5 q' a, t, z1 v( O2 Jhyperplasia is the 21-hydroxylase enzyme deficiency.
& x- S  w8 {4 ]7 u1 M8 ZThe 11-β hydroxylase deficiency may also result in: V5 R0 q* F# j" O; L8 u
excessive adrenal androgen production, and rarely,
- V: S( Q9 _/ B9 l/ g0 ]) Tan adrenal tumor may also cause adrenal androgen
+ i, ?( p: j% ^& I; fexcess.1,3
. ~, d% r% _! I: m4 N" dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 k# t$ u' N3 z5 f0 U+ R$ W  O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# |4 r, [. n+ `, ?, l/ x8 Z$ b
A unique entity of male-limited gonadotropin-% s6 p7 t1 i6 p- J3 [  Z
independent precocious puberty, which is also known& b6 U. n3 R; I/ R( p
as testotoxicosis, may cause precocious puberty at a! y; G' S) \5 e- A
very young age. The physical findings in these boys& ?# z2 p6 w: Z
with this disorder are full pubertal development,
9 r2 n9 Y+ ]# W! Dincluding bilateral testicular growth, similar to boys8 K4 g7 S, x4 Q" S& r
with CPP. The gonadotropin levels in this disorder
1 o/ X- Y8 ]* C6 V6 x5 ]are suppressed to prepubertal levels and do not show* j/ p' o( h+ N# d
pubertal response of gonadotropin after gonadotropin-" S4 @" H( g7 {5 ^% k- W+ w' r
releasing hormone stimulation. This is a sex-linked
8 Y, }" F9 e1 ]/ _4 r9 r+ X6 \autosomal dominant disorder that affects only, N) C: Z1 x( y- E
males; therefore, other male members of the family7 M  {0 s6 g# O; S' V- z
may have similar precocious puberty.3
& ~. e- _6 ^6 `9 rIn our patient, physical examination was incon-$ L* N" X. D" P# @: X
sistent with true precocious puberty since his testi-8 d5 h/ a% X3 B& ?# |
cles were prepubertal in size. However, testotoxicosis2 e$ p" L( C: F$ m7 @
was in the differential diagnosis because his father/ @2 n, i) u4 ~: C) a2 ~
started puberty somewhat early, and occasionally,3 U2 [& {/ `& f: V' b" f% Q
testicular enlargement is not that evident in the7 p. i- V' k+ T" _
beginning of this process.1 In the absence of a neg-9 R# n% V" ^% j4 {: e3 H  c9 t
ative initial history of androgen exposure, our( G: B$ x1 V& o* S" P7 m
biggest concern was virilizing adrenal hyperplasia,
8 F0 W0 ~) \/ meither 21-hydroxylase deficiency or 11-β hydroxylase
2 i% L# M& f/ C! ydeficiency. Those diagnoses were excluded by find-
3 c) I2 g$ ~" ]& Uing the normal level of adrenal steroids.
4 j' m  r& p* g8 ^( n& M' `0 ZThe diagnosis of exogenous androgens was strongly8 W. b) x% P& c
suspected in a follow-up visit after 4 months because
+ c; L: ]2 U+ d" `" P& Bthe physical examination revealed the complete disap-
' L; h: y" [( F2 `pearance of pubic hair, normal growth velocity, and
  Q  Y0 @: ^3 ~( [8 v! l9 \decreased erections. The father admitted using a testos-; o  C# f( o7 |! d8 l
terone gel, which he concealed at first visit. He was5 ]* j$ ?( }! t( \" w0 @9 [
using it rather frequently, twice a day. The Physicians’' N  a# M1 B/ c
Desk Reference, or package insert of this product, gel or
5 `/ k5 O' A) rcream, cautions about dermal testosterone transfer to
/ Y& r0 W; C* o  y/ [( ]; {unprotected females through direct skin exposure.
9 ]- f& `/ h) {; ~4 Q, }* WSerum testosterone level was found to be 2 times the( `, E5 q+ l- p3 X8 j( [
baseline value in those females who were exposed to6 k/ a) ?8 j0 n! o% E
even 15 minutes of direct skin contact with their male
! C) n* F  V; @6 B/ V4 Upartners.6 However, when a shirt covered the applica-
, Q4 k% l7 O3 Y" P" N& @& btion site, this testosterone transfer was prevented.% c2 p+ Z7 d6 ^( _
Our patient’s testosterone level was 60 ng/mL,
, L4 B: O1 }% S! `; Vwhich was clearly high. Some studies suggest that; [, N3 l8 e4 k+ X8 o- N
dermal conversion of testosterone to dihydrotestos-3 [, c: ]! R0 H- N6 D8 ?8 d
terone, which is a more potent metabolite, is more
% S) X7 T7 Z$ |' w7 g8 factive in young children exposed to testosterone
0 X; F6 z% ?$ `) U0 [2 i1 ?exogenously7; however, we did not measure a dihy-* ~6 l: z' s, `7 K
drotestosterone level in our patient. In addition to1 l0 P( B1 K% }7 H* i$ g+ x( f
virilization, exposure to exogenous testosterone in5 `  f( H2 s% B+ P& B
children results in an increase in growth velocity and
. L  Y" k* W, N; B6 h0 G2 tadvanced bone age, as seen in our patient.* Q0 |. S) b6 s  ^* P5 q! x$ K4 H
The long-term effect of androgen exposure during
, p" ~  Z' {6 _1 L0 f! p2 bearly childhood on pubertal development and final
+ j0 S. ?9 _2 W" g" wadult height are not fully known and always remain
' c" z# s- L# G/ ^7 {- oa concern. Children treated with short-term testos-
, M8 h) _% G6 V4 Z4 |6 ~2 T# k# cterone injection or topical androgen may exhibit some. v$ S4 ~5 ~" Y: K
acceleration of the skeletal maturation; however, after
1 w; o9 G* Q& m6 Mcessation of treatment, the rate of bone maturation
4 r) F' }) W9 e) wdecelerates and gradually returns to normal.8,90 y9 J1 f2 U  m6 e
There are conflicting reports and controversy6 S" I& @# k) N6 w* I* N
over the effect of early androgen exposure on adult0 T' K4 [# T4 D# G9 i2 ]: O0 `
penile length.10,11 Some reports suggest subnormal
6 Q5 L5 n" m0 d# [* ^adult penile length, apparently because of downreg-
& h5 I5 G" [1 [" S$ m+ pulation of androgen receptor number.10,12 However,
" h. U; X( _2 l6 JSutherland et al13 did not find a correlation between: u1 U" G% {' b' |1 U9 Y# S
childhood testosterone exposure and reduced adult+ O' O( a5 H6 U
penile length in clinical studies.
0 o; A' X' p& z: Z7 X1 GNonetheless, we do not believe our patient is
( Y/ A" l) G  W" z' Tgoing to experience any of the untoward effects from" {  ?1 M4 L; q* `4 m5 T
testosterone exposure as mentioned earlier because
+ U) E: x3 p, C5 X2 l  dthe exposure was not for a prolonged period of time.
: V/ K* `% M0 T; W4 c9 Q8 i& Z) XAlthough the bone age was advanced at the time of! b" o+ `; {" y. O. B+ ?4 X0 e, u" t
diagnosis, the child had a normal growth velocity at
: r1 y: n! R( p) A% pthe follow-up visit. It is hoped that his final adult9 p! e5 T$ p. Z) s9 S  H& Y
height will not be affected.
3 T: t- B" Z. I, r4 I& C* JAlthough rarely reported, the widespread avail-
; d4 z  ?! Q7 E# iability of androgen products in our society may- _: c/ g6 f# N2 `2 p
indeed cause more virilization in male or female
" }2 g3 y/ J- ^" ?7 Q# M% d9 z( Schildren than one would realize. Exposure to andro-
: m$ w- k; ^' R4 f) q3 [gen products must be considered and specific ques-
- |; Y. f+ g) R$ Mtioning about the use of a testosterone product or, `2 ]/ D6 P, j" c4 U
gel should be asked of the family members during8 n  P+ |! X# l' e) P
the evaluation of any children who present with vir-* P5 j# Z0 q3 @
ilization or peripheral precocious puberty. The diag-% s" y: b/ V% q6 m( y; O8 r
nosis can be established by just a few tests and by
% U5 |5 d8 N. L1 Rappropriate history. The inability to obtain such a
4 ?9 A! D5 E$ Y/ l) d' U, c2 ^: g$ ohistory, or failure to ask the specific questions, may
5 @6 ?2 q- }! K) x' Q& F9 g2 xresult in extensive, unnecessary, and expensive# A  m# y+ H: F) r# ]& b
investigation. The primary care physician should be
# P, U6 e) U! |  \6 maware of this fact, because most of these children
- _* g! ]0 b0 X1 S# Q3 [' S& Omay initially present in their practice. The Physicians’
# @( ?* y% q7 c7 {! v1 bDesk Reference and package insert should also put a9 I" i/ w* ~/ K3 t- ^
warning about the virilizing effect on a male or
8 r1 O1 {! k& L. ^; C/ [9 Afemale child who might come in contact with some-
1 k4 y" \. X: e3 kone using any of these products., ^. w6 G" I0 b! X7 d
References
4 T7 H. n5 o$ f) L: c' f1. Styne DM. The testes: disorder of sexual differentiation
  H1 ~3 [$ O( n  Cand puberty in the male. In: Sperling MA, ed. Pediatric9 t  C) E( X6 _! U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' Z3 o* O- g9 h+ e2002: 565-628.
, C8 f+ z1 X9 F9 [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, K* K, N3 Z# F1 Vpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 H. \- i4 H# E) i
Boy Induced by Indirect Topical0 F3 ]. H6 G6 J; ~" x
Exposure to Testosterone( _6 @. }5 H" `' p( z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 m( s( y( }; `+ [$ v# F& N0 ]and Kenneth R. Rettig, MD1
) z+ ^+ Y6 @* R- K! G3 }Clinical Pediatrics
: E% Q) I/ Q# ]: z/ Y0 ?9 ]Volume 46 Number 6; z; K% v6 Z; I9 a5 m
July 2007 540-543: W- K5 o: S1 K. V
© 2007 Sage Publications1 {! b* w, g" X0 T% Y5 U
10.1177/00099228062966511 X4 O/ C* \) b9 x
http://clp.sagepub.com
6 \- i" z( |9 K  X+ M2 P% U. ^hosted at
, f" o' q$ P8 B6 }3 d4 mhttp://online.sagepub.com- E4 U! c( f3 S# Z
Precocious puberty in boys, central or peripheral,6 G6 S: J0 B' i; M* U. M( n2 r
is a significant concern for physicians. Central% g! H4 O1 K0 I( P: c* Y* ?6 n
precocious puberty (CPP), which is mediated4 [- z/ [; I: I% O( T5 q
through the hypothalamic pituitary gonadal axis, has0 m# e! g# L) Z5 N
a higher incidence of organic central nervous system7 s4 ~( F* a+ O0 b
lesions in boys.1,2 Virilization in boys, as manifested
0 |/ z3 ]0 |) p* o2 ^: W0 v% f& Pby enlargement of the penis, development of pubic6 q, X* t4 `8 e& C, F
hair, and facial acne without enlargement of testi-0 P& C8 T' A3 M' D- _, b
cles, suggests peripheral or pseudopuberty.1-3 We) }4 W& M6 Q# _4 r- g
report a 16-month-old boy who presented with the8 p! r' m$ s, t" X" n( }1 s4 X
enlargement of the phallus and pubic hair develop-2 m. q& E2 q. A' C
ment without testicular enlargement, which was due
& {# g3 a1 u- v! ^! g! v% |- vto the unintentional exposure to androgen gel used by: X* m1 w! X( @, \& i! R- a
the father. The family initially concealed this infor-  O2 x. I9 A4 h+ M
mation, resulting in an extensive work-up for this' p( m( ~% N: @& w, Y! ?  O
child. Given the widespread and easy availability of+ `! B2 O, l; f$ u& F1 \4 y  k
testosterone gel and cream, we believe this is proba-
4 v5 i) p! w) U/ d# J0 qbly more common than the rare case report in the
4 E3 p2 x: I: n* bliterature.4# X  P% t7 h5 [2 l7 I7 ]
Patient Report$ J/ N: o" H+ b+ M$ o9 h" g
A 16-month-old white child was referred to the" G& K& l; Z3 H( {9 l, V: {
endocrine clinic by his pediatrician with the concern" d5 G( }6 }1 P& q3 u
of early sexual development. His mother noticed, h2 f. g) H" X' q' j) g% u, {
light colored pubic hair development when he was
  `& Z# i4 y0 ^" R. WFrom the 1Division of Pediatric Endocrinology, 2University of
9 N% h  X+ k6 s- V  |South Alabama Medical Center, Mobile, Alabama.6 h' Q7 x; ?; X& K0 x! t
Address correspondence to: Samar K. Bhowmick, MD, FACE,
  M0 q" {7 G. \7 s! t2 MProfessor of Pediatrics, University of South Alabama, College of
: l9 a! g- q* E; i) z, K# b  wMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! I% M! F; w! H; K( U% q% o
e-mail: [email protected].
& Y# ]( Y, b8 o6 labout 6 to 7 months old, which progressively became4 C6 B3 s; Q5 M4 y6 w" M% H) `* Q
darker. She was also concerned about the enlarge-
' T' c/ [1 a. L& ~ment of his penis and frequent erections. The child
8 z( G+ [$ R7 r- uwas the product of a full-term normal delivery, with
2 X, [* g$ f- V* b" c: |+ g) Y/ aa birth weight of 7 lb 14 oz, and birth length of
8 K! l* o  @0 V# _% ~! j7 _20 inches. He was breast-fed throughout the first year
5 r! p: F  m4 O0 M1 P/ {. `of life and was still receiving breast milk along with8 b8 Q% G' u6 `& t# x
solid food. He had no hospitalizations or surgery,# O/ ]4 ?: w4 q7 G
and his psychosocial and psychomotor development5 k& }7 k: V8 b4 B4 P1 N/ T/ G4 X
was age appropriate.7 c( u6 f5 C! [  ]3 |
The family history was remarkable for the father,
6 N0 s# U1 f1 T  rwho was diagnosed with hypothyroidism at age 16,
( {6 d: m) t/ [8 k3 swhich was treated with thyroxine. The father’s1 O6 Q2 C6 z8 K9 O& D8 T9 I) M0 Y
height was 6 feet, and he went through a somewhat
4 V" b: E$ v" U& t; Q- ^& H1 E: }$ b2 |early puberty and had stopped growing by age 14.0 b6 [! G# l6 D# R2 s; t( Q
The father denied taking any other medication. The
6 O+ P7 A  S" B! r% ?# qchild’s mother was in good health. Her menarche
  @3 {6 ]: ?( t) f3 q9 F- Q5 jwas at 11 years of age, and her height was at 5 feet
: F, M' O# S, R: n/ o5 inches. There was no other family history of pre-9 C/ h) z: V8 ]  |- N
cocious sexual development in the first-degree rela-8 g8 G6 A/ d5 z7 n
tives. There were no siblings.
; {  L8 j  w, }2 CPhysical Examination
1 a4 K, ?6 |, W7 u1 M* j% tThe physical examination revealed a very active,
1 J6 ]) R) y' x/ z0 `, qplayful, and healthy boy. The vital signs documented
! E4 F' Q' j; T. Z3 R+ Ca blood pressure of 85/50 mm Hg, his length was
) X/ v; w& |/ h1 r1 _% j. [8 q90 cm (>97th percentile), and his weight was 14.4 kg3 O/ g: W1 M7 N! I! T( w( I0 h' y
(also >97th percentile). The observed yearly growth
. @) `' V# j( B! Dvelocity was 30 cm (12 inches). The examination of1 Q: }' S9 x/ i4 I
the neck revealed no thyroid enlargement.( Y' }3 Z) q+ n* m$ C/ x* C% i
The genitourinary examination was remarkable for" U8 ]; A, H4 H& |5 o/ q) t; X
enlargement of the penis, with a stretched length of
! U$ w: `, l$ s0 P  j4 X. c8 cm and a width of 2 cm. The glans penis was very well
* d8 a, h. }& Y: Q! f$ U' q3 `) ^% c9 Sdeveloped. The pubic hair was Tanner II, mostly around
: r* g$ [% O4 g! v, M5 _540- ]% s6 L% k: F; e, ]$ f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. D3 g7 [6 y3 G; ~+ ithe base of the phallus and was dark and curled. The
  `7 \8 [7 p/ [+ }+ utesticular volume was prepubertal at 2 mL each.0 Y# n' ?- X; Z2 L% K) D, z0 ?0 z
The skin was moist and smooth and somewhat
; v' U$ t( ^+ G4 v6 U# O' xoily. No axillary hair was noted. There were no
5 b; m1 E( N8 L' sabnormal skin pigmentations or café-au-lait spots.5 q6 c$ A+ v6 h1 q
Neurologic evaluation showed deep tendon reflex 2+
9 g% [3 c# L$ {bilateral and symmetrical. There was no suggestion8 h: e+ C4 c% G9 I. f$ R5 K, u
of papilledema.
, N0 K% C6 |" `/ l% x# u, }Laboratory Evaluation- R* M4 P9 s0 y# Q. U7 d
The bone age was consistent with 28 months by
6 _; |& e* [' G) L/ kusing the standard of Greulich and Pyle at a chrono-1 e# a+ F" \- d8 A. O; V  M
logic age of 16 months (advanced).5 Chromosomal- h- P7 I0 B" h: b1 f4 {, }
karyotype was 46XY. The thyroid function test
' }1 Q- l( W- Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 g. q7 z- ~9 |  u# Vlating hormone level was 1.3 µIU/mL (both normal).# l( t8 A7 Q0 i
The concentrations of serum electrolytes, blood
8 w3 @. m* c- l% Nurea nitrogen, creatinine, and calcium all were" Y4 @* m' [9 S" [2 m' j
within normal range for his age. The concentration
$ x9 C9 {" u8 n' T9 P2 n" ?8 b' Wof serum 17-hydroxyprogesterone was 16 ng/dL: A. p) _, M# W0 U; ?5 b
(normal, 3 to 90 ng/dL), androstenedione was 20
5 ?) T/ s! t' Y3 I; Z& ]+ `. Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' L, y4 {* H4 K) O% S0 X( ~. Iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 i. i; H! z: F, i4 r5 @6 g# ^9 Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ O) K: A' _2 o" }4 A  H+ e/ i
49ng/dL), 11-desoxycortisol (specific compound S)
; Y% f6 F- l, Z4 U- G& f( wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: M' ^# G9 l  i' E4 X+ `2 ltisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 c9 v) p! C; H* E$ htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) R" V8 J' V( M4 E# |5 ^# E4 r* N
and β-human chorionic gonadotropin was less than, _: e5 [- O/ W& g* s% P
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% @$ S- _  A4 D3 t; s' astimulating hormone and leuteinizing hormone: p$ f" h, u- o
concentrations were less than 0.05 mIU/mL
$ {$ j0 ?$ A' G8 x" ~7 `& \  a- }7 w(prepubertal).6 u/ X& [. r/ `. g- G# V0 M& `& x) m
The parents were notified about the laboratory! _/ [" _6 E$ `
results and were informed that all of the tests were( r" S  E4 M" b. {. X
normal except the testosterone level was high. The/ s; s9 R/ w* J
follow-up visit was arranged within a few weeks to- o5 I5 ~) {* J3 T4 B9 \
obtain testicular and abdominal sonograms; how-
, y6 ~# f: D) b5 x; d. k: uever, the family did not return for 4 months.
8 L* Y% f& p9 [0 N: h) {; \, uPhysical examination at this time revealed that the" e* t  e  F1 L4 E* w
child had grown 2.5 cm in 4 months and had gained
, S' i0 b! c1 X) J2 kg of weight. Physical examination remained
, l1 |3 X, e. U$ }unchanged. Surprisingly, the pubic hair almost com-/ n7 l- G( j; l7 R" M
pletely disappeared except for a few vellous hairs at: r0 N5 m7 T' ?
the base of the phallus. Testicular volume was still 2. F, Q( t& h% H9 f* [, R
mL, and the size of the penis remained unchanged.
5 Q' t- E% m! d% s# q" FThe mother also said that the boy was no longer hav-3 ?3 L3 p5 K1 ^. m1 L
ing frequent erections.
" B$ W, f: u5 [9 A& wBoth parents were again questioned about use of
/ p' _; r; m) t: j% x: i3 F7 }any ointment/creams that they may have applied to
; ]4 l9 v4 [/ P( ~& d) jthe child’s skin. This time the father admitted the
6 A/ r  @: x! r( Y& YTopical Testosterone Exposure / Bhowmick et al 541$ _) t1 s1 y5 e% \$ U/ Z+ p3 a
use of testosterone gel twice daily that he was apply-* X# z( |+ J5 F% d/ v) Z% d( w
ing over his own shoulders, chest, and back area for$ q, H% H) g4 B4 O" t( u
a year. The father also revealed he was embarrassed
1 |* k' m$ a( X; E$ wto disclose that he was using a testosterone gel pre-: h9 @9 z7 E' e3 @
scribed by his family physician for decreased libido
- s! O: {; \% r  ]+ jsecondary to depression." ^- o' j; Y0 Z2 x6 a6 l* R2 z
The child slept in the same bed with parents.
+ d7 M0 L# d' P' S. e! b5 eThe father would hug the baby and hold him on his
6 E  J1 E; ?. D) H9 k# K# Y% ]chest for a considerable period of time, causing sig-
- _0 t2 I- l5 }* Onificant bare skin contact between baby and father.0 g: E; S# }. n! z+ r
The father also admitted that after the phone call," W- \' |  o5 N/ I4 B( m
when he learned the testosterone level in the baby
; T2 r' e6 Q$ H5 Dwas high, he then read the product information
! @! H  b3 j8 S6 j& R% Fpacket and concluded that it was most likely the rea-
" I' \' S! W% s3 Qson for the child’s virilization. At that time, they0 Z- X7 w6 w( Z
decided to put the baby in a separate bed, and the2 ~4 J) w9 Y2 q* a
father was not hugging him with bare skin and had
+ ~3 X8 y# |" K, G9 U- ^& Ubeen using protective clothing. A repeat testosterone
' Y* S4 u1 D1 V5 |3 g9 atest was ordered, but the family did not go to the
" {! i8 M  z/ G4 Nlaboratory to obtain the test.
  [# P$ n0 {" Q7 |4 k% d! f  ]Discussion$ A. p; t6 T% j/ l9 Y* |
Precocious puberty in boys is defined as secondary
# e+ n& o" e4 w, [/ A4 {0 k4 {2 Wsexual development before 9 years of age.1,4
: I0 h$ k5 T1 i/ |# x5 EPrecocious puberty is termed as central (true) when* X7 Q. A1 a; ]: B1 L+ h! ]+ P
it is caused by the premature activation of hypo-
: c8 d: j2 {0 J7 Z5 {8 _; N4 Pthalamic pituitary gonadal axis. CPP is more com-
2 n* x8 C( A' \5 u6 S9 tmon in girls than in boys.1,3 Most boys with CPP
; ^& S: ?- `8 z$ x+ Y4 smay have a central nervous system lesion that is
& @" k6 e: C/ b: Fresponsible for the early activation of the hypothal-' R* B8 B+ K% q' @; w5 ^
amic pituitary gonadal axis.1-3 Thus, greater empha-# F+ t+ Q  |7 T; A* s
sis has been given to neuroradiologic imaging in& v9 Q9 r1 J, x# ~  X! N: P' e2 b
boys with precocious puberty. In addition to viril-
+ F5 K/ ~6 d( a( n1 Q1 ?# z8 c  zization, the clinical hallmark of CPP is the symmet-
( Y/ H5 Y. y7 zrical testicular growth secondary to stimulation by
' e& E1 t+ M+ N8 a, X8 Egonadotropins.1,3$ [, H% P6 O+ C5 x6 [) R
Gonadotropin-independent peripheral preco-! J6 O; p- @+ e7 K
cious puberty in boys also results from inappropriate
! _1 E  G7 h7 z, N2 Uandrogenic stimulation from either endogenous or! h7 W$ |& j& f+ E# `
exogenous sources, nonpituitary gonadotropin stim-
# k- M. y/ C4 @. dulation, and rare activating mutations.3 Virilizing
( w) C8 a3 K$ tcongenital adrenal hyperplasia producing excessive+ p% j% l3 w- H3 p( o7 q
adrenal androgens is a common cause of precocious% q  h0 M' z! ?6 t- {
puberty in boys.3,4: z1 G1 i' B6 M
The most common form of congenital adrenal8 q* c; K) v6 G6 |/ K5 \6 L; Z: L
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ W  f/ p" l3 A) w+ BThe 11-β hydroxylase deficiency may also result in
% k1 @$ S" L0 `8 k) uexcessive adrenal androgen production, and rarely,
% ^- ^5 G, u$ t3 E" g- Can adrenal tumor may also cause adrenal androgen
& ]) s7 E8 y) eexcess.1,3
5 R6 _# d1 A( O0 O% G4 ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- a# c/ z# f1 m! R. X' b) G542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ m8 a  E3 R+ Z5 g
A unique entity of male-limited gonadotropin-
/ _0 `5 v2 ^% _independent precocious puberty, which is also known6 K: x: m9 O5 Y" ^
as testotoxicosis, may cause precocious puberty at a
1 v2 f  J4 e" [" k5 t! _very young age. The physical findings in these boys
, {4 I1 |* C; Z  P! b7 t9 Kwith this disorder are full pubertal development,
, U7 T9 S& M! \. e# z7 E" o; Xincluding bilateral testicular growth, similar to boys
5 e# S7 G7 D3 I8 \' hwith CPP. The gonadotropin levels in this disorder' h" D# `! I  E0 F- g
are suppressed to prepubertal levels and do not show5 a" W7 B' A2 o, V- V
pubertal response of gonadotropin after gonadotropin-/ P5 h6 y+ a6 ^8 i* b1 W! U: W% k
releasing hormone stimulation. This is a sex-linked
, ]2 Q7 b3 Q- q; ?* j; Pautosomal dominant disorder that affects only
6 {# p9 Y3 P) Q, |$ n5 `* ymales; therefore, other male members of the family& L; k( }: R2 O# m% n. {4 C" e
may have similar precocious puberty.3
. R+ Q1 o5 W3 W3 O* \' h3 bIn our patient, physical examination was incon-& l- E4 J5 J; k% J& ]# r' _- E
sistent with true precocious puberty since his testi-
8 K2 o$ L8 }8 h" l; R. Ocles were prepubertal in size. However, testotoxicosis6 z3 x9 W2 [! [9 O+ d1 @+ A
was in the differential diagnosis because his father: a3 d& K& Q: D7 R
started puberty somewhat early, and occasionally,
. h7 \! y0 Z1 U) @! w, `1 ktesticular enlargement is not that evident in the
  H# G( O, ?1 P2 h. ~' Gbeginning of this process.1 In the absence of a neg-# [! L$ O) S9 Q
ative initial history of androgen exposure, our4 b! u8 b' y1 R6 b. V" }
biggest concern was virilizing adrenal hyperplasia,$ {2 @9 w+ S8 d  j
either 21-hydroxylase deficiency or 11-β hydroxylase
+ S  W6 z- z3 u+ D! R, o! @0 ddeficiency. Those diagnoses were excluded by find-+ m) j" ]' I) ?% x% a
ing the normal level of adrenal steroids.
, P+ k: [( e" ^0 ], q8 K6 b! rThe diagnosis of exogenous androgens was strongly( q3 _6 Z' y* |0 r  U+ |
suspected in a follow-up visit after 4 months because. W- s9 R# ?$ W* p
the physical examination revealed the complete disap-
2 w! I# @; d! L2 {$ epearance of pubic hair, normal growth velocity, and
% S0 Y9 j. k/ D" Pdecreased erections. The father admitted using a testos-1 I/ B9 ?6 @2 P5 O: ?
terone gel, which he concealed at first visit. He was
, d0 B/ x) ]2 a  W1 Nusing it rather frequently, twice a day. The Physicians’
& p' s) p& o6 b7 m1 _Desk Reference, or package insert of this product, gel or8 V4 t4 U& N; U$ A
cream, cautions about dermal testosterone transfer to
; J: l( n9 P, r6 ?2 Junprotected females through direct skin exposure.
: F! l8 s. j3 N7 D. v' W% uSerum testosterone level was found to be 2 times the1 x! B6 g. F% m$ X# x9 ]
baseline value in those females who were exposed to
2 f$ W3 [& P5 |( x& ]even 15 minutes of direct skin contact with their male% V# r! \0 `% |( ^
partners.6 However, when a shirt covered the applica-* e. G+ x9 G' \9 Q) C6 E( _
tion site, this testosterone transfer was prevented.5 p2 U/ G5 i1 ~
Our patient’s testosterone level was 60 ng/mL,
4 ^0 |0 ^& S! A5 X( zwhich was clearly high. Some studies suggest that9 l9 n  r1 A4 z$ z" {0 D+ k; [
dermal conversion of testosterone to dihydrotestos-. G+ R2 F+ v7 _* S" g
terone, which is a more potent metabolite, is more( u0 y! l; {3 o; m
active in young children exposed to testosterone
4 z: O+ |$ m6 ~4 Rexogenously7; however, we did not measure a dihy-' a/ K2 L2 p+ Q: F: t6 S
drotestosterone level in our patient. In addition to
6 r5 V8 m. `# avirilization, exposure to exogenous testosterone in
. O( b- w+ f/ Z& ?( F, Bchildren results in an increase in growth velocity and% b# H/ @( @: K- F0 c
advanced bone age, as seen in our patient.
4 l+ B* a! G& q; Q0 SThe long-term effect of androgen exposure during
( V6 c5 z2 Y: W6 U! e1 H2 n, uearly childhood on pubertal development and final$ [/ ?$ h+ Z3 j% J9 W( {
adult height are not fully known and always remain8 x; }  p) |3 \" n" v
a concern. Children treated with short-term testos-  G  S& b% v5 T6 u- r
terone injection or topical androgen may exhibit some
9 V! J9 [/ ^: G9 C! {! I: ?acceleration of the skeletal maturation; however, after
% f: E$ t" T+ X; ?; D' mcessation of treatment, the rate of bone maturation
8 d, g0 A; K( G0 \+ ?decelerates and gradually returns to normal.8,9% i% p; s+ E; e1 X
There are conflicting reports and controversy0 I3 w# t) b* p
over the effect of early androgen exposure on adult( B3 \. B0 q1 j6 J4 I, A/ r
penile length.10,11 Some reports suggest subnormal7 A- d1 R2 k0 x8 y3 c% E
adult penile length, apparently because of downreg-  x* q+ R! [0 [: b/ ^1 {
ulation of androgen receptor number.10,12 However,9 c! n0 a5 L6 v5 W1 G9 ^
Sutherland et al13 did not find a correlation between1 t+ w& [# M8 d7 [9 [7 G
childhood testosterone exposure and reduced adult8 `* I8 z1 z. ^6 L$ P# E
penile length in clinical studies.
! L; S9 r% p2 aNonetheless, we do not believe our patient is  v" u+ m7 I8 p$ Z2 s
going to experience any of the untoward effects from- q: A+ t, y6 k
testosterone exposure as mentioned earlier because
1 h( S! A) k+ r) Gthe exposure was not for a prolonged period of time.
/ X+ o' S0 f. {$ CAlthough the bone age was advanced at the time of+ C: f; O( A. I% E0 @
diagnosis, the child had a normal growth velocity at& B$ D/ |7 p, x
the follow-up visit. It is hoped that his final adult( J1 A( U) D8 p' V* ~6 U; `
height will not be affected.
* ^' d9 ]! ~  @! c5 MAlthough rarely reported, the widespread avail-
% o; h  R/ M% T' U' C  Qability of androgen products in our society may, Y5 E; ]: l4 |
indeed cause more virilization in male or female, B& y% b4 V& q- @
children than one would realize. Exposure to andro-
! V6 E! ?& a$ B) O, G/ ~gen products must be considered and specific ques-- |. o+ A6 i: j% g' H1 _
tioning about the use of a testosterone product or5 @; b2 A( k  r* z- V2 ~- _
gel should be asked of the family members during# l1 ^0 O5 ~8 y  n; y9 V0 P
the evaluation of any children who present with vir-5 l7 y) c: d" s( y" K; f1 S+ e
ilization or peripheral precocious puberty. The diag-
3 M1 E$ }; k& t7 n) k) n' ]nosis can be established by just a few tests and by( J# b8 t5 }* l" i1 q% S/ V9 }: J0 j
appropriate history. The inability to obtain such a% P3 s7 n3 J4 P8 t; Q
history, or failure to ask the specific questions, may
) V1 e' \$ R/ q  q9 c; {" J( k- U$ ?6 D0 Wresult in extensive, unnecessary, and expensive( N8 Y1 \/ A; \7 U1 V1 U9 x4 W- J
investigation. The primary care physician should be
  i* y1 B# ~- l; p, L. xaware of this fact, because most of these children
$ ]) h& V# k; v! _, Q+ smay initially present in their practice. The Physicians’6 B2 q3 l8 s+ Q# [3 b# D
Desk Reference and package insert should also put a
, E! @( E0 B  m1 twarning about the virilizing effect on a male or
8 F8 W/ ?- b6 K5 `; ~' p9 ffemale child who might come in contact with some-! D& P# R6 G, z3 E8 h
one using any of these products.: ?) l" {6 o+ q) }$ F
References
7 }) Z9 D0 R) K1 O. ^- |6 I( B1. Styne DM. The testes: disorder of sexual differentiation
! l' ]! B) [% [& Uand puberty in the male. In: Sperling MA, ed. Pediatric
+ [& A8 b% j  hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 [/ P' M5 h5 \/ i- c  G2002: 565-628.- h% _- O/ z/ d) ]) M/ N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 e5 n& N5 `" s4 o" [, F  Cpuberty in children with tumours of the suprasellar pineal
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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
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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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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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