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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# `* ~* D7 x, `( I
Boy Induced by Indirect Topical& Q5 P2 m# |" l' h5 t% A5 L
Exposure to Testosterone' \4 w, }: a3 v0 m$ r, R; x
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( B2 t, W9 q$ g3 ?9 band Kenneth R. Rettig, MD1
2 z5 e  K1 ~4 k! r- [: q9 WClinical Pediatrics
. E* O9 G! Y) g/ DVolume 46 Number 6' Q" k. ~' a: |6 P& j; Z
July 2007 540-543, f! g5 w' z6 w: _+ j: k: Y
© 2007 Sage Publications8 v! U* X4 @6 }' U/ a1 b
10.1177/0009922806296651, Z  g3 e3 G0 X
http://clp.sagepub.com
+ ]3 p4 B7 O4 H3 fhosted at
. u7 Y1 v1 ]* m/ B$ `http://online.sagepub.com6 ]1 l, ^0 }7 d
Precocious puberty in boys, central or peripheral,
5 Y+ b) {% C! ais a significant concern for physicians. Central. v: A$ K6 [. z, B0 k# e3 D
precocious puberty (CPP), which is mediated7 [6 V+ p- _% D: z0 J0 n& _
through the hypothalamic pituitary gonadal axis, has
# T) @3 p7 X- n* va higher incidence of organic central nervous system2 ?; u- v9 J3 g' }
lesions in boys.1,2 Virilization in boys, as manifested
* O8 V+ x& d/ P; r( ~by enlargement of the penis, development of pubic
+ l9 N! v% w# i9 C, f5 m* {# b9 f$ Vhair, and facial acne without enlargement of testi-
& [. e$ |9 t: y4 y; _cles, suggests peripheral or pseudopuberty.1-3 We5 b! ?" x+ T  G4 J; ~- l' H
report a 16-month-old boy who presented with the
1 t: X/ G, X" a4 m5 }enlargement of the phallus and pubic hair develop-: a5 [3 m2 x# j8 b) E
ment without testicular enlargement, which was due
  s9 y" ^) X# }to the unintentional exposure to androgen gel used by" y1 }  Y2 D0 F! W: ^
the father. The family initially concealed this infor-1 v3 [6 @; w1 k
mation, resulting in an extensive work-up for this
2 E' m" _0 P; V3 Ochild. Given the widespread and easy availability of7 s* N$ l) I  r. J5 M. \
testosterone gel and cream, we believe this is proba-
( S4 T  O1 ]* S5 ?bly more common than the rare case report in the" ~9 Y. V9 Z( O8 ]- e+ Q7 D7 o. q1 V" z
literature.4  [% ]* Y( {* I9 Q7 _! p( g
Patient Report
! N$ ]" \; g/ z. B, G6 g0 D3 p$ uA 16-month-old white child was referred to the, ?' P+ H' P, K' h' k
endocrine clinic by his pediatrician with the concern* o( h3 G7 a* e4 O( Y5 Y5 t
of early sexual development. His mother noticed0 V  @5 C) Z! z0 Y
light colored pubic hair development when he was
% d4 N9 z- p& Y9 k5 IFrom the 1Division of Pediatric Endocrinology, 2University of9 |5 W2 g4 o7 O' ^" f
South Alabama Medical Center, Mobile, Alabama.+ M; Y/ G% q7 `- ~6 U$ U' C
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 @- Y0 \+ h9 @" sProfessor of Pediatrics, University of South Alabama, College of. m7 g: e1 I% N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 L) u# q  h3 n; P& @5 }9 o
e-mail: [email protected].
* S+ M+ Z8 k# }; K. W. `0 V( a" x) nabout 6 to 7 months old, which progressively became
# N3 t" f( I: B- q1 r# |' J: wdarker. She was also concerned about the enlarge-
/ S! {. w. x  S1 d1 Dment of his penis and frequent erections. The child
2 M3 m, t; n6 \3 G& Q0 ]6 Uwas the product of a full-term normal delivery, with
/ j. T2 [( d4 ~5 ]3 Q" @" u2 ia birth weight of 7 lb 14 oz, and birth length of
9 u9 q$ n0 B' f/ I! y20 inches. He was breast-fed throughout the first year0 }8 U4 E6 s' j. Q/ z
of life and was still receiving breast milk along with
& A/ l6 ~( s: E+ \% Y5 c; Ssolid food. He had no hospitalizations or surgery,
% U! D. ]" P, fand his psychosocial and psychomotor development
! _5 i' q: z0 k. Vwas age appropriate.
  A" h9 V0 W8 L7 V% \1 j7 n$ LThe family history was remarkable for the father,
/ h. e3 r" e; A/ [7 q' v5 @who was diagnosed with hypothyroidism at age 16,
; |, @) f4 Z, X/ \0 A0 ?2 h8 ]: Fwhich was treated with thyroxine. The father’s
. k, w! ^6 n8 Q+ kheight was 6 feet, and he went through a somewhat3 J3 ^) }# l2 Q1 R  J
early puberty and had stopped growing by age 14.
: e7 [( f9 Q' u, b- EThe father denied taking any other medication. The% _9 ]  [% b1 p. p$ b- Q. u
child’s mother was in good health. Her menarche& i& r2 `" _0 y
was at 11 years of age, and her height was at 5 feet
! k4 ^! e/ X" a. G/ ~% c5 inches. There was no other family history of pre-
" L6 s4 \, j* s3 [. r* c: g: Fcocious sexual development in the first-degree rela-
1 H4 p$ V+ p' K: V, Jtives. There were no siblings.: p" o1 Q0 {: i0 L  K7 F" K
Physical Examination" u. l% |1 y) t1 {* H. N, X
The physical examination revealed a very active,
+ R! H+ Q4 j! r: gplayful, and healthy boy. The vital signs documented  P3 v4 A, i6 y4 \/ S" j
a blood pressure of 85/50 mm Hg, his length was9 T8 \. V& J8 z9 H" K7 r0 c) \
90 cm (>97th percentile), and his weight was 14.4 kg+ {8 T2 W9 |2 T
(also >97th percentile). The observed yearly growth$ J9 d+ v. O) m: S9 R0 w  c1 q
velocity was 30 cm (12 inches). The examination of
- u3 Q8 s$ w5 K5 o9 s! f, @; jthe neck revealed no thyroid enlargement.' v/ J; r1 @8 Q1 z4 Y6 f. ~
The genitourinary examination was remarkable for
$ w/ a& n! G% U3 x" Fenlargement of the penis, with a stretched length of- ~! s$ \& K: t+ `$ S, r' L5 i2 _- l
8 cm and a width of 2 cm. The glans penis was very well# B  b7 `6 O( L, L
developed. The pubic hair was Tanner II, mostly around  W$ W' Z- B- E; z# f1 Z( H
540- `; D* I3 h, q+ {& Y- i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ }& j/ j) m4 G* \- bthe base of the phallus and was dark and curled. The
5 W3 ^- m2 {3 {2 j: c8 Ftesticular volume was prepubertal at 2 mL each.
. b8 ]* c! J+ @* r# A% F% VThe skin was moist and smooth and somewhat
8 K0 Y" P) S/ W4 x# L/ `" Uoily. No axillary hair was noted. There were no5 p3 e3 m! D/ W& u
abnormal skin pigmentations or café-au-lait spots.. p! S7 Q' n& {' E
Neurologic evaluation showed deep tendon reflex 2+5 A1 @4 d: _! o+ A' G. r
bilateral and symmetrical. There was no suggestion( Y4 V; }2 M! C+ {9 l
of papilledema.
) e3 U1 F3 u1 c' ]Laboratory Evaluation
) t7 p  J% c0 U9 F. zThe bone age was consistent with 28 months by$ R1 ^  ^+ G9 U& G6 l& V
using the standard of Greulich and Pyle at a chrono-
: s+ O: P9 f' u: D( ?0 s  w: m) tlogic age of 16 months (advanced).5 Chromosomal
* k0 J5 f* {" ~# F, l. [4 nkaryotype was 46XY. The thyroid function test) P+ L- L/ g! |& ]" c" F. t  |2 {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ Q) z! X$ M% l( H
lating hormone level was 1.3 µIU/mL (both normal).3 Q3 J2 [) x  d) D. ^9 v
The concentrations of serum electrolytes, blood& `& @$ ]" o' ~" S1 E
urea nitrogen, creatinine, and calcium all were& ]+ a( T6 @5 A9 Q" t# V3 P: O
within normal range for his age. The concentration+ b4 ^% h. w; g) |# Z* u
of serum 17-hydroxyprogesterone was 16 ng/dL* h/ o5 u( P, ^7 j: a5 C
(normal, 3 to 90 ng/dL), androstenedione was 20( K: {" \4 Q; ]$ P6 ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* c- n/ \0 A. ^) S4 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; m$ l- J) ?) W. Q0 ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 p/ c6 O4 P9 Q0 W
49ng/dL), 11-desoxycortisol (specific compound S)3 R  C6 r6 X2 f, g% U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% D$ ~4 u) C8 ^' H$ d7 K& a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 }' K  F4 u4 d" D& N6 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, m) Q+ L4 z- U
and β-human chorionic gonadotropin was less than$ Q' S& n2 q, ~
5 mIU/mL (normal <5 mIU/mL). Serum follicular) ]6 n; Q, ?1 l' S7 R% j
stimulating hormone and leuteinizing hormone
- W  X2 i0 m1 {, u5 ]concentrations were less than 0.05 mIU/mL
+ O% K+ y4 d  Z! e- f(prepubertal).
& R) H  B+ L' [9 P% mThe parents were notified about the laboratory
' h0 u+ K# j. presults and were informed that all of the tests were9 t- q  G* _- V# ]' h$ F& u; O% d
normal except the testosterone level was high. The. p9 a; `+ S( X# n4 L+ o
follow-up visit was arranged within a few weeks to
. [4 n& V' a& |obtain testicular and abdominal sonograms; how-7 M- E7 K6 _3 R
ever, the family did not return for 4 months.
, Z3 O9 D/ V; m! zPhysical examination at this time revealed that the4 ~& T  \( v+ x+ W7 Q
child had grown 2.5 cm in 4 months and had gained, K  C% X0 F- I/ \  t
2 kg of weight. Physical examination remained
  Q7 R. i" b5 Q( N. E+ d- z% lunchanged. Surprisingly, the pubic hair almost com-! O) H/ {  R- f! H0 A5 q  K/ u! p+ H
pletely disappeared except for a few vellous hairs at
$ p( J" l0 e! Rthe base of the phallus. Testicular volume was still 28 D3 |" J# D  y- p  D
mL, and the size of the penis remained unchanged.& m( @2 D8 A$ l7 c
The mother also said that the boy was no longer hav-
  i/ c3 ?0 C7 ~& H; B: U% K2 z5 ]1 }ing frequent erections.
) a8 Q; w  c; b  j1 ABoth parents were again questioned about use of. s- z* R' ]/ }8 ]7 F, z
any ointment/creams that they may have applied to! [3 X+ P9 }+ \. m  e
the child’s skin. This time the father admitted the0 [; u0 C. W4 Z+ b
Topical Testosterone Exposure / Bhowmick et al 541
' g* Q% A  g. G$ g: X& z2 yuse of testosterone gel twice daily that he was apply-3 s. r4 }/ M& Z5 Y; X6 U. O
ing over his own shoulders, chest, and back area for
- \& o( R6 N* Z; da year. The father also revealed he was embarrassed
7 T1 J2 H- Y1 bto disclose that he was using a testosterone gel pre-6 v5 t1 P5 \: l
scribed by his family physician for decreased libido' k, Y) q+ w- _! F5 B/ y
secondary to depression.% o. C7 U/ L- `4 Z" Z- i' ]
The child slept in the same bed with parents.
- L* ~1 W( E) V8 P3 sThe father would hug the baby and hold him on his1 P4 d5 E& @  J; K1 d' }4 ~
chest for a considerable period of time, causing sig-
4 ?( ?4 H' @8 r# K+ Wnificant bare skin contact between baby and father.
1 g1 B& q& ~7 M8 DThe father also admitted that after the phone call,
. m! x& @7 k/ Swhen he learned the testosterone level in the baby1 i/ y& V& w5 r' b7 L" c) K
was high, he then read the product information7 J' S, W6 Q4 K  c% `0 S8 E' G
packet and concluded that it was most likely the rea-
2 o3 X9 i+ W- j- v4 `7 B& j- U/ Sson for the child’s virilization. At that time, they
) v7 I8 b- a% c" c, d! jdecided to put the baby in a separate bed, and the7 ?5 j! H+ X+ i  T; w9 _5 j6 i
father was not hugging him with bare skin and had
) x6 g! U$ Y2 z5 N; L& R  U7 w5 Vbeen using protective clothing. A repeat testosterone" \4 [- [4 S# ?5 \- ~  g) o
test was ordered, but the family did not go to the" J; ^: M# |6 W5 U& z2 b0 V) m. ~
laboratory to obtain the test.
, e0 C( t/ ?! ]$ V% s2 P/ uDiscussion
1 z; E# G% |/ g1 qPrecocious puberty in boys is defined as secondary1 U3 b0 `6 [; m* {0 t4 _' c
sexual development before 9 years of age.1,4
" r9 [! A* |  F2 uPrecocious puberty is termed as central (true) when
) E# w5 e8 m7 git is caused by the premature activation of hypo-
2 j5 T; ], |  S: C0 Bthalamic pituitary gonadal axis. CPP is more com-  j: {! S; ]  @$ l/ U
mon in girls than in boys.1,3 Most boys with CPP' q, _: T# d% ], y6 E  z
may have a central nervous system lesion that is" Q2 q* U! O8 N% [3 q
responsible for the early activation of the hypothal-
, t6 ?6 C  h6 A! t7 Eamic pituitary gonadal axis.1-3 Thus, greater empha-
4 G$ E& F. n/ f3 Y, J  L  y. lsis has been given to neuroradiologic imaging in
3 J! X  H7 l3 tboys with precocious puberty. In addition to viril-
) j6 @/ X3 H- D/ q+ w5 E! lization, the clinical hallmark of CPP is the symmet-/ N  @2 J# |" x
rical testicular growth secondary to stimulation by" o8 _5 k( ~6 s4 r
gonadotropins.1,3
' S. b1 h9 u9 f2 SGonadotropin-independent peripheral preco-
* o; g9 m4 @3 H. `$ `: A" Mcious puberty in boys also results from inappropriate
0 }. H% k  b" R0 q# N' Qandrogenic stimulation from either endogenous or  I! o+ O5 O0 N4 \
exogenous sources, nonpituitary gonadotropin stim-
, K* }2 c# u* d. e. `) Uulation, and rare activating mutations.3 Virilizing; |$ X* X6 ~+ e. D' M
congenital adrenal hyperplasia producing excessive) s9 I* Z5 y) Z/ r1 B4 e( }
adrenal androgens is a common cause of precocious
" }- V7 @+ L+ G4 _puberty in boys.3,4
, C6 a4 V+ L, u: }6 hThe most common form of congenital adrenal. \, Y6 ]! }2 T
hyperplasia is the 21-hydroxylase enzyme deficiency.
& o8 i: x. o3 V3 I6 v! IThe 11-β hydroxylase deficiency may also result in
9 w$ Q- g, y* F" T5 r- dexcessive adrenal androgen production, and rarely,  y8 D' ^0 H0 h) O$ }
an adrenal tumor may also cause adrenal androgen/ g7 I$ V6 D8 g% U
excess.1,32 q( q) r8 u5 r9 M3 h9 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' e* B$ ?: ?! E: W
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, M/ Q- z2 x* _7 J2 N* B
A unique entity of male-limited gonadotropin-
/ m; w/ V& ]# Findependent precocious puberty, which is also known; }2 y) b, j* X* T+ |; r: y
as testotoxicosis, may cause precocious puberty at a
2 X$ W2 s6 K# bvery young age. The physical findings in these boys2 r" N( D& |' j1 e
with this disorder are full pubertal development,' |4 R2 n9 ]7 M3 r) P+ b, x
including bilateral testicular growth, similar to boys3 B1 v: M! O* S( l& ]' w4 k
with CPP. The gonadotropin levels in this disorder5 m" b9 [. z, \( Z- @$ |9 l
are suppressed to prepubertal levels and do not show# \' ]  S( Y. z
pubertal response of gonadotropin after gonadotropin-
4 }3 U; G8 e7 [+ W9 zreleasing hormone stimulation. This is a sex-linked
% q  D4 c2 B- a. o- A1 A( ]autosomal dominant disorder that affects only
1 _2 C7 f5 G! h  K* q: o% tmales; therefore, other male members of the family3 Y3 {  `. Z7 E' O! l9 T' ~1 W
may have similar precocious puberty.3
, X. Z6 j( E1 z- ^& Q6 r  o& l( RIn our patient, physical examination was incon-, v- K. K! q0 j  B& }
sistent with true precocious puberty since his testi-7 w# c4 e1 Y. {2 P
cles were prepubertal in size. However, testotoxicosis( Y3 a9 R# q+ S: R" n+ Z
was in the differential diagnosis because his father4 ]) A( U$ N$ `
started puberty somewhat early, and occasionally,
- z1 t1 X7 @$ x0 S8 N' b, Ttesticular enlargement is not that evident in the) J/ y$ T$ p/ G. Q& {
beginning of this process.1 In the absence of a neg-$ _6 S( q! Q8 A4 p/ Z
ative initial history of androgen exposure, our4 \( K; F7 [) l3 U1 e: Q
biggest concern was virilizing adrenal hyperplasia,
- }4 I% r; _# Y- h. ]either 21-hydroxylase deficiency or 11-β hydroxylase
$ b9 ^  R. ~( r0 P( Wdeficiency. Those diagnoses were excluded by find-- V. i5 ]  S. F) U  \7 `
ing the normal level of adrenal steroids." z0 p) J9 b) z- ?3 x7 h& g
The diagnosis of exogenous androgens was strongly
" d9 H  x+ [( `+ C# {5 @suspected in a follow-up visit after 4 months because
' H) s& L0 Z0 \  ythe physical examination revealed the complete disap-
" [6 z( j1 q! W8 f1 z! l6 rpearance of pubic hair, normal growth velocity, and
- u- H6 B/ `! `' ^+ ]5 I5 ]decreased erections. The father admitted using a testos-
, r9 j+ B7 f8 L* Hterone gel, which he concealed at first visit. He was
& E/ W) e, Z3 Z+ t0 `using it rather frequently, twice a day. The Physicians’% `9 J. L* \1 i" F! U' {! i
Desk Reference, or package insert of this product, gel or
3 Y- ^7 x7 i5 }cream, cautions about dermal testosterone transfer to
/ n0 |5 V) P$ g/ ?- ?  u' f1 vunprotected females through direct skin exposure.
' H: h8 A  R) |' ^' L8 c& KSerum testosterone level was found to be 2 times the
# J6 J5 y3 m7 O2 T8 Zbaseline value in those females who were exposed to2 q) I; X) c! W+ M1 W% {
even 15 minutes of direct skin contact with their male
* ^4 x0 L" z8 ]partners.6 However, when a shirt covered the applica-
( G& a9 c' A8 p2 ~3 }tion site, this testosterone transfer was prevented.
+ w  [4 h: {+ ?3 s7 JOur patient’s testosterone level was 60 ng/mL," b8 M6 e3 M+ f: L2 ^5 y  b3 r
which was clearly high. Some studies suggest that
5 N+ t2 t: Q; \dermal conversion of testosterone to dihydrotestos-
0 h+ a4 q( E8 v. kterone, which is a more potent metabolite, is more4 t) Q' s3 K# r1 u; U
active in young children exposed to testosterone0 D! _% y  N' a! Y+ u3 p
exogenously7; however, we did not measure a dihy-, f0 k( R1 r1 e0 t: T% A: o
drotestosterone level in our patient. In addition to
& Q  v7 j' n+ g/ ]  y: F8 x) R" y1 |virilization, exposure to exogenous testosterone in
9 @; S0 V( Y9 v  H! k! l0 Dchildren results in an increase in growth velocity and
6 ]; k5 M. N0 N6 {, wadvanced bone age, as seen in our patient.
& j  @$ K- B: t' M! G9 J9 U8 NThe long-term effect of androgen exposure during
) W# f  a8 T: \; jearly childhood on pubertal development and final6 H: V2 G4 s4 n  e% p( {( u
adult height are not fully known and always remain7 y2 V. V7 U7 n; T
a concern. Children treated with short-term testos-- D  b; }2 M% b# t- n: O' l' A
terone injection or topical androgen may exhibit some
- Q1 x. {- ^3 T* _8 gacceleration of the skeletal maturation; however, after
1 H. E+ ~8 Z9 `4 e( Dcessation of treatment, the rate of bone maturation
: x3 k. @0 X6 kdecelerates and gradually returns to normal.8,9
2 t$ {, X0 h* J& n, mThere are conflicting reports and controversy4 u2 W. I' I2 d' w
over the effect of early androgen exposure on adult
" F. W# z9 b3 ]+ `* |* W; @1 Spenile length.10,11 Some reports suggest subnormal
+ N% ^5 i; l' A# W9 @8 cadult penile length, apparently because of downreg-
4 U4 t9 O. X0 a; p% s" culation of androgen receptor number.10,12 However,
8 ]( }* n3 T- R! ~9 R! B7 M: [Sutherland et al13 did not find a correlation between0 I5 i- s6 Q8 S4 U0 B0 l5 I. J+ Y
childhood testosterone exposure and reduced adult$ V1 ]% R. |  {1 y1 r: [
penile length in clinical studies.
+ l+ ^" g8 W, u% X( E9 W: [% C; jNonetheless, we do not believe our patient is* t8 @( e6 P' O( V/ G
going to experience any of the untoward effects from+ U% ~, I! t7 A8 \+ b$ Y) h
testosterone exposure as mentioned earlier because
5 g. R- S& v# dthe exposure was not for a prolonged period of time.
! l5 T1 Y+ R& d' G0 H6 _/ vAlthough the bone age was advanced at the time of
; S% B" g" P' q' x$ @. @% p* @diagnosis, the child had a normal growth velocity at
, I- Z9 h; b3 O# S7 s% bthe follow-up visit. It is hoped that his final adult4 Z  P) y& o3 e% u/ l; L0 s
height will not be affected.* {; ]2 B+ x7 e
Although rarely reported, the widespread avail-
! b9 ?( W/ n2 }! q6 d8 G4 y! k: S) Zability of androgen products in our society may
& ~: S- B. |& m+ z8 r5 Mindeed cause more virilization in male or female
7 M9 b) }  s0 i! o( Uchildren than one would realize. Exposure to andro-1 b8 Q+ K, u3 n
gen products must be considered and specific ques-
4 r& K8 j+ G' U, utioning about the use of a testosterone product or
+ ^. u: J# X0 h1 u2 Wgel should be asked of the family members during
0 ]% X2 t9 f" |$ E& Dthe evaluation of any children who present with vir-) y) `0 Q. G5 @; V* C* x0 I% c
ilization or peripheral precocious puberty. The diag-) y/ H" ~* R* J) |4 ~7 `9 y
nosis can be established by just a few tests and by. A  X% u% g+ q  T
appropriate history. The inability to obtain such a
& _/ ~3 P* R% A! g# X. }history, or failure to ask the specific questions, may
9 K- I. k. i* s! s) iresult in extensive, unnecessary, and expensive& Q. v3 I' [+ X9 u# ]
investigation. The primary care physician should be$ G% {/ M% U  b) Y" N
aware of this fact, because most of these children
% O7 ]& B$ P9 }( o2 F) \. ^may initially present in their practice. The Physicians’
0 M: F  J& b1 K* X/ M$ ?Desk Reference and package insert should also put a
8 }5 J/ J! k' u0 D3 j  Lwarning about the virilizing effect on a male or
8 N7 ^7 h5 [( m* F0 Xfemale child who might come in contact with some-! G/ Z$ I4 _  }7 }# l. o
one using any of these products.4 x5 P3 f' l/ x6 B
References
* d; }$ I" q6 h. l3 {' Z1. Styne DM. The testes: disorder of sexual differentiation
0 S/ k( S8 f) C4 O7 w; Sand puberty in the male. In: Sperling MA, ed. Pediatric
9 T  v" K9 V3 E2 ]" t) R4 JEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. c' Z; F8 u5 a; d
2002: 565-628.
6 h" R/ G2 m+ a2 q+ G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 T2 y! |7 r. f: y" W$ B
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old! `7 h7 X7 _5 J2 |" Z
Boy Induced by Indirect Topical- z  J1 {" C. {0 ?! b$ W
Exposure to Testosterone/ m6 K7 r1 z8 D% U  b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# }- A* o# I4 T2 C7 l0 P
and Kenneth R. Rettig, MD1
5 d. z% L7 n) V- YClinical Pediatrics( ~$ u* v4 ~+ y. b* W: u
Volume 46 Number 6
5 I& Z/ q" J3 R! r3 Q+ a. v! `July 2007 540-543# I4 I, {$ A+ L3 T9 w
© 2007 Sage Publications& b) F/ A( q1 k+ o5 j9 S
10.1177/0009922806296651" C% i/ ]4 t' e2 D
http://clp.sagepub.com
" G! U/ F  v( ~& k2 u+ C3 v# T: ]hosted at
6 Z$ T% Z# ?* zhttp://online.sagepub.com7 s; d: E( u% t
Precocious puberty in boys, central or peripheral,% I7 O% M. Q$ }8 _# L: \# [3 G- f
is a significant concern for physicians. Central, ]9 R% |5 r, t( I; B
precocious puberty (CPP), which is mediated
& |: W% Z9 ^2 X. B  J) f+ F4 athrough the hypothalamic pituitary gonadal axis, has
' p6 Y/ d6 C2 Y5 Pa higher incidence of organic central nervous system
  g; u! R3 z7 i: Z  slesions in boys.1,2 Virilization in boys, as manifested/ ^- |$ _* F$ g- i% U, L. [9 u
by enlargement of the penis, development of pubic
; _; E- O- {( f* }" M- I& ?hair, and facial acne without enlargement of testi-
8 b0 H( f4 v) Ycles, suggests peripheral or pseudopuberty.1-3 We8 e& `6 n' x2 o' V0 b
report a 16-month-old boy who presented with the1 `4 t6 c# |4 J. f2 [4 o6 ]: B1 D
enlargement of the phallus and pubic hair develop-/ \! w% F+ }9 {( l: e
ment without testicular enlargement, which was due) D- P: t) x6 `- v* e$ ]
to the unintentional exposure to androgen gel used by
; `/ }0 G* U# a* T, Rthe father. The family initially concealed this infor-
* p8 \' v& ^; r6 Kmation, resulting in an extensive work-up for this; \, x. c+ \0 @' v6 X  p* @
child. Given the widespread and easy availability of$ w8 H& ^4 {' L% [8 n( o  p# o2 I
testosterone gel and cream, we believe this is proba-/ D" J( |1 x  b1 \" t
bly more common than the rare case report in the! J! Y9 T0 ?7 H9 o' f
literature.4- g6 l7 m7 K6 N% u% I
Patient Report5 t& Y& f" ~3 N9 M1 o
A 16-month-old white child was referred to the
. }2 g2 ]$ y3 K1 K/ W- tendocrine clinic by his pediatrician with the concern% E( R! q$ a9 x! U0 E
of early sexual development. His mother noticed/ ]  t4 E# a7 M) A  p! E8 }
light colored pubic hair development when he was
: W7 v' G; D. sFrom the 1Division of Pediatric Endocrinology, 2University of
8 [+ Z1 t5 i8 w# ~+ R7 CSouth Alabama Medical Center, Mobile, Alabama.
5 i! k6 g% @, W" r1 J3 G# cAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: g. Q  \3 |# y) w- o& EProfessor of Pediatrics, University of South Alabama, College of
. n6 \* \7 e- }0 r2 @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 i' G' B0 e; O+ u2 c$ Ve-mail: [email protected].4 j" W5 o2 `/ C# k6 d: K) g
about 6 to 7 months old, which progressively became# v& Q; g/ d0 i( H$ Y" }% L0 u
darker. She was also concerned about the enlarge-
* d% T: W) C) \ment of his penis and frequent erections. The child  h+ E  A; n( \/ l; F9 B0 H& E$ K
was the product of a full-term normal delivery, with; D, r" r4 s6 L2 o5 i
a birth weight of 7 lb 14 oz, and birth length of5 _+ w! }) E6 s1 A6 r7 [
20 inches. He was breast-fed throughout the first year) t, b( Q: Y& ^* n
of life and was still receiving breast milk along with* ~: b) O: Z- n8 l. K7 O
solid food. He had no hospitalizations or surgery,& P' R" f& [. t" J0 o2 V) [, H
and his psychosocial and psychomotor development! t- Z% l3 D& P. B: U
was age appropriate.
- F1 }) }6 F3 tThe family history was remarkable for the father,$ o5 G* Z9 _/ d1 y5 f8 ?
who was diagnosed with hypothyroidism at age 16,
! L4 [" |+ Z4 C9 y8 Wwhich was treated with thyroxine. The father’s: I' f. U: g7 w  _0 a  w* C
height was 6 feet, and he went through a somewhat, i0 Q4 [9 r  g3 _1 p. W& S
early puberty and had stopped growing by age 14.
! _: s+ v5 v% aThe father denied taking any other medication. The! }6 r4 U8 R8 J7 X# p& r( {- A: i
child’s mother was in good health. Her menarche
" o8 ~0 N! X- V5 bwas at 11 years of age, and her height was at 5 feet) e6 S/ D6 s5 l6 j* U, C, y
5 inches. There was no other family history of pre-+ m4 l1 g: T3 q/ P) v- [
cocious sexual development in the first-degree rela-
/ N; J$ F$ j, t' o7 ^tives. There were no siblings.
% p3 J( O, x% }7 d) @: f% KPhysical Examination* {+ d$ N- N1 ~0 `! ?% g$ O# N
The physical examination revealed a very active,' X$ `8 H6 W% a3 r. X
playful, and healthy boy. The vital signs documented9 o6 o3 y8 M/ `  H- l
a blood pressure of 85/50 mm Hg, his length was
( o# }3 F9 k# b4 N+ c90 cm (>97th percentile), and his weight was 14.4 kg9 ^; c1 R: }, h: f0 Q
(also >97th percentile). The observed yearly growth6 Q( R' E2 _) e9 i
velocity was 30 cm (12 inches). The examination of
, q* d  V* o0 Othe neck revealed no thyroid enlargement.
( M% ]! x2 p1 u; k: n4 b% DThe genitourinary examination was remarkable for
. {0 S2 C8 A! j" d8 d6 @: l8 ]! denlargement of the penis, with a stretched length of
! q, z1 E' z5 J+ M9 G8 cm and a width of 2 cm. The glans penis was very well5 S$ u$ m9 q7 y! ]
developed. The pubic hair was Tanner II, mostly around
1 M% q' H# ]. M# C. O540( ?0 Q  P, F0 J! _2 q" F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) o1 {5 M3 l2 i* W$ L
the base of the phallus and was dark and curled. The
2 D7 q# o. W% C: G, H  Vtesticular volume was prepubertal at 2 mL each.+ [8 A9 @6 V, O* W1 A8 \. g
The skin was moist and smooth and somewhat
! r: b' G  W/ I& x/ u' o/ doily. No axillary hair was noted. There were no
1 l- e# g: g- l5 t: Eabnormal skin pigmentations or café-au-lait spots.8 G% P# C2 V/ R8 v
Neurologic evaluation showed deep tendon reflex 2+7 x& C$ ~0 C3 N1 C- C: g
bilateral and symmetrical. There was no suggestion: u8 I  f& w  P' T
of papilledema.* Z6 O+ o8 {( U! g
Laboratory Evaluation
  a( X& f& @* e7 j$ F' uThe bone age was consistent with 28 months by+ O! p5 j2 m1 v/ ^
using the standard of Greulich and Pyle at a chrono-* R/ z- F2 q5 ~# h+ w$ E# k& \
logic age of 16 months (advanced).5 Chromosomal
) ~9 N5 O% J% N+ ?0 ukaryotype was 46XY. The thyroid function test1 C+ m) \& H: A/ ?
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- k. t5 T, f- L
lating hormone level was 1.3 µIU/mL (both normal).
- \$ }- @4 e5 Z5 wThe concentrations of serum electrolytes, blood
1 ~1 u5 i# n4 S3 j/ m5 u9 vurea nitrogen, creatinine, and calcium all were
7 K3 T) E- T: {within normal range for his age. The concentration( ~& }, {9 H; ?$ i2 ?1 s# l! I( A3 z! f
of serum 17-hydroxyprogesterone was 16 ng/dL) i& ?) o( z( H0 b, z, X
(normal, 3 to 90 ng/dL), androstenedione was 20* t  Q2 M8 E) r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 y2 c5 ?/ C& W' K6 D: Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) `. D6 @: A& u; Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: x$ M/ r% o% L+ l5 f49ng/dL), 11-desoxycortisol (specific compound S)
( |% ?  G0 H, X5 w! h  Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 E! T; k' l, F: ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% o1 ?9 T7 |/ T8 C9 ]( Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 b8 M2 I5 g; o. {and β-human chorionic gonadotropin was less than' P( H6 x9 P% q" q9 I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 C2 T7 F2 X- C8 L; t& ystimulating hormone and leuteinizing hormone1 W0 D! ^2 W9 _, f
concentrations were less than 0.05 mIU/mL) W# o9 r9 q5 n1 G( K6 Y% @2 t, E% f
(prepubertal).
0 J% x% |2 N9 f  W/ `The parents were notified about the laboratory* l# Y" R% Q2 _
results and were informed that all of the tests were
1 K; i# {2 e; _& }* wnormal except the testosterone level was high. The
! D6 r# d* P3 q( |9 k) x0 \/ t4 {6 tfollow-up visit was arranged within a few weeks to
" W9 I3 Y. a: qobtain testicular and abdominal sonograms; how-
- `( Z8 w1 {6 g- V3 C3 {ever, the family did not return for 4 months.  _! P& ?, _, P- h2 P* F
Physical examination at this time revealed that the
; `9 k: F  Z. c: w; b! achild had grown 2.5 cm in 4 months and had gained
/ [( L6 b2 o$ i' I; z2 kg of weight. Physical examination remained
# z+ y6 X2 ]4 k0 N/ l# runchanged. Surprisingly, the pubic hair almost com-
! D% H9 R# F7 A1 Bpletely disappeared except for a few vellous hairs at2 @: J. v* w" A8 s+ d
the base of the phallus. Testicular volume was still 2
8 [: F+ J5 B6 FmL, and the size of the penis remained unchanged.
5 F/ `( S) H% a# H( ^5 mThe mother also said that the boy was no longer hav-
1 x4 [5 @) g$ [ing frequent erections.1 S! g  R' p: e. W* J2 r6 r, a
Both parents were again questioned about use of
0 F7 T/ U) C5 }9 a9 Jany ointment/creams that they may have applied to
5 \; \8 h3 e% J2 j+ g- Sthe child’s skin. This time the father admitted the
" u# n: C$ e9 p( ATopical Testosterone Exposure / Bhowmick et al 541" X6 s4 y) w0 W; @
use of testosterone gel twice daily that he was apply-9 B+ D7 F1 C2 h8 |7 J# p% A2 M
ing over his own shoulders, chest, and back area for
( x$ J% i0 N) ]a year. The father also revealed he was embarrassed
+ p, m6 d: F3 O  W% [to disclose that he was using a testosterone gel pre-* x$ P( _; h" p4 P) d
scribed by his family physician for decreased libido
& {" x, F& }0 }secondary to depression." i( F, o; A1 p* K! s; G2 q
The child slept in the same bed with parents.7 q2 D+ w: W. ^+ }/ X1 ]
The father would hug the baby and hold him on his
0 O6 E  T  G9 e9 Ichest for a considerable period of time, causing sig-
$ L6 V0 X; L1 ~* Y& \$ ~nificant bare skin contact between baby and father.1 L- Q4 N2 k: r8 \5 H6 W8 J7 w
The father also admitted that after the phone call,, z& j# D! k7 I# l+ x  \
when he learned the testosterone level in the baby. e7 R: n# \5 }/ M2 r, y
was high, he then read the product information
. u& i+ I4 f8 ?8 O( [! {/ Hpacket and concluded that it was most likely the rea-
6 U7 r6 O7 Y, _6 ?+ tson for the child’s virilization. At that time, they" Y5 L3 W  i7 ~% w
decided to put the baby in a separate bed, and the
: S! T" ~2 g, ufather was not hugging him with bare skin and had
# }2 Z- q# v* L: }2 }% ]0 Jbeen using protective clothing. A repeat testosterone5 k7 ]# E0 w8 K
test was ordered, but the family did not go to the
4 H' x: t$ Z0 N* f& llaboratory to obtain the test.* f% N6 a8 \/ f4 j. Q4 P& n) _# l& u/ u
Discussion
  q" H3 X1 v4 uPrecocious puberty in boys is defined as secondary
- E# E5 {( J6 S5 f  Ysexual development before 9 years of age.1,4
3 B7 I( Q+ G7 V; g8 rPrecocious puberty is termed as central (true) when
7 n/ ]" V' b7 H. E8 ]$ o# \it is caused by the premature activation of hypo-/ H3 c7 X1 F% L& j8 O
thalamic pituitary gonadal axis. CPP is more com-
  C& y0 f% K5 r4 p2 A4 smon in girls than in boys.1,3 Most boys with CPP
6 f' _, X' a2 x( |$ Cmay have a central nervous system lesion that is* t1 u8 A" W+ p
responsible for the early activation of the hypothal-' }/ Z6 m( _( P. H
amic pituitary gonadal axis.1-3 Thus, greater empha-: m% L6 L1 V0 Y4 e
sis has been given to neuroradiologic imaging in' Q, s8 U* y5 {, }
boys with precocious puberty. In addition to viril-2 u. u, F7 E# q6 W6 _7 ]# V3 R
ization, the clinical hallmark of CPP is the symmet-
5 `, Y3 j2 A8 O; V; k6 `rical testicular growth secondary to stimulation by! q) ]# d9 Y2 N4 x' S
gonadotropins.1,3- G2 K" F) r! e# F& }5 e1 G. ~; J% ?
Gonadotropin-independent peripheral preco-
! |& h- z- q: [- w) t! kcious puberty in boys also results from inappropriate' c" t5 H; o( e/ V  N, h4 P
androgenic stimulation from either endogenous or
/ Z" d2 @  p. q0 e* lexogenous sources, nonpituitary gonadotropin stim-& {/ D9 ~! }6 S' ?% m  y9 B. \
ulation, and rare activating mutations.3 Virilizing+ G: m1 M8 H4 N: T
congenital adrenal hyperplasia producing excessive
9 N; s4 V, w1 a0 A. Z7 |7 Q7 Eadrenal androgens is a common cause of precocious
7 G6 q6 n  v. d, U1 rpuberty in boys.3,46 t- H* n5 t) T! u8 ]1 b
The most common form of congenital adrenal
8 u1 s% F  Z/ Y- W' j9 B' z$ {hyperplasia is the 21-hydroxylase enzyme deficiency.
5 R- w2 w7 e' ]& ZThe 11-β hydroxylase deficiency may also result in
4 l: \5 _# X9 i( Sexcessive adrenal androgen production, and rarely,* W* T5 J5 I3 p
an adrenal tumor may also cause adrenal androgen
" u; |% d* M- f+ {" x( Nexcess.1,3% |$ ?5 c7 {6 K0 _7 m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 c6 {5 p) l8 ?/ ?" T% i* p542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 |9 ^" }4 v+ R1 N6 O" y, z; F/ g! ^  k
A unique entity of male-limited gonadotropin-! U; t( }" }3 S3 X
independent precocious puberty, which is also known. A# u& x4 R* V
as testotoxicosis, may cause precocious puberty at a
; T; G2 G  f8 K( L0 V! s9 Y! Vvery young age. The physical findings in these boys% L! Y$ ^+ g- r
with this disorder are full pubertal development,
. _' K/ A; G/ L+ f  Jincluding bilateral testicular growth, similar to boys
$ {9 t# W( r, _' s/ C+ m+ J  pwith CPP. The gonadotropin levels in this disorder
8 \1 [/ i  l3 Z( H3 jare suppressed to prepubertal levels and do not show1 W' w3 x( x3 y
pubertal response of gonadotropin after gonadotropin-8 d, y+ L4 k. |: I* y
releasing hormone stimulation. This is a sex-linked- }* ^1 ~+ R  l, N3 L( S* h! X! @& P
autosomal dominant disorder that affects only: z  I  C5 y. S/ Z
males; therefore, other male members of the family" U. a( K2 j, |. z8 |
may have similar precocious puberty.34 R3 f. |7 \1 s. E: o
In our patient, physical examination was incon-6 O/ A3 _2 k, h& i( i( g
sistent with true precocious puberty since his testi-
2 ~/ x) t$ b# O8 m! q) k  mcles were prepubertal in size. However, testotoxicosis
' |9 h1 v' s) A/ awas in the differential diagnosis because his father
& {0 \, f. p% u1 t2 Dstarted puberty somewhat early, and occasionally,
' C  U' U% d7 R( J% U2 Dtesticular enlargement is not that evident in the4 G3 r$ t9 u) w& |) W% ^$ B% _
beginning of this process.1 In the absence of a neg-% g9 E9 o- W" V" G' ~
ative initial history of androgen exposure, our
8 |* C+ Y, `. R8 s2 R3 z: Ebiggest concern was virilizing adrenal hyperplasia,, p+ c/ g. ~  j- m  @9 s3 ~
either 21-hydroxylase deficiency or 11-β hydroxylase
! F9 Z6 N" Y% H0 ]+ D9 ?deficiency. Those diagnoses were excluded by find-
+ I7 Z& W* @% l# K( @9 a) C' ying the normal level of adrenal steroids.4 r6 Q# Q- X* p5 v8 W
The diagnosis of exogenous androgens was strongly. p7 {% O9 r% f7 b3 L
suspected in a follow-up visit after 4 months because# `  [# D; z5 i, J( {
the physical examination revealed the complete disap-
) T$ g% o  F4 e5 v- [pearance of pubic hair, normal growth velocity, and* p8 ]6 z! L4 E& \1 ]! r1 t
decreased erections. The father admitted using a testos-
  b9 ~: B0 f: o6 h$ W* \- rterone gel, which he concealed at first visit. He was  T# v3 c9 G% ^, T! x) E0 V4 [
using it rather frequently, twice a day. The Physicians’; z6 n/ E0 Q+ S9 h( Z0 T# e
Desk Reference, or package insert of this product, gel or
0 B7 u4 n  f( ?4 gcream, cautions about dermal testosterone transfer to* W. I. `% n9 x, ^
unprotected females through direct skin exposure.
% J6 P& ^) g! ]Serum testosterone level was found to be 2 times the  l8 K" B* Y5 F/ D/ b! x+ j
baseline value in those females who were exposed to' ^$ R9 Y  Y0 E* A
even 15 minutes of direct skin contact with their male: N1 h* f4 i- P& {" o! Y$ ^1 j. K8 d# O
partners.6 However, when a shirt covered the applica-
, j8 |# K' i, ], X  a" g$ ition site, this testosterone transfer was prevented.& N1 y' f1 e0 R, I( [
Our patient’s testosterone level was 60 ng/mL,
3 @: d8 c0 U2 g: J! Xwhich was clearly high. Some studies suggest that( f9 y6 s$ `8 j0 H: Q( [
dermal conversion of testosterone to dihydrotestos-
" F/ S2 i" Z2 F1 f( \) {terone, which is a more potent metabolite, is more5 q  {) O; E) Z" W! {
active in young children exposed to testosterone& K( H/ Z4 D! V6 e2 p0 T& O
exogenously7; however, we did not measure a dihy-
* j0 D, {- A8 ]$ |+ odrotestosterone level in our patient. In addition to7 \% h* u! y. |/ j
virilization, exposure to exogenous testosterone in, @9 t  u: x) s$ k  |1 T- f
children results in an increase in growth velocity and
' |, D  g/ A) y) t* Aadvanced bone age, as seen in our patient.! U* P# d3 U8 k
The long-term effect of androgen exposure during
# i/ K6 r$ V4 V1 x+ b7 learly childhood on pubertal development and final- `+ c1 s! |/ l2 x. n5 U
adult height are not fully known and always remain# y3 {9 }& P1 t' y. f. b# _$ {
a concern. Children treated with short-term testos-9 f, M+ T, B5 H3 u2 ?
terone injection or topical androgen may exhibit some
  j- f- i+ P$ _7 r: ]! U9 j5 A, zacceleration of the skeletal maturation; however, after" Z' a6 w8 u/ Z- T  P3 s
cessation of treatment, the rate of bone maturation
5 T" @. w  I( v0 d- e" udecelerates and gradually returns to normal.8,9
6 |& F' b* x, l5 e% C" E7 `There are conflicting reports and controversy
8 c3 D( [1 F2 n& W+ x# sover the effect of early androgen exposure on adult, {# C/ `5 P9 {1 J; p7 W
penile length.10,11 Some reports suggest subnormal
! j' Z, ?0 X# X0 Eadult penile length, apparently because of downreg-
% g  [4 ~* p8 S% p: x2 qulation of androgen receptor number.10,12 However,
8 i' M% I5 U5 @4 ySutherland et al13 did not find a correlation between& O% l3 t# R. }. z
childhood testosterone exposure and reduced adult4 n& {" e6 u# m. G
penile length in clinical studies.2 y, B; W' `  s% i8 d( A
Nonetheless, we do not believe our patient is4 O3 s; H% o( \: F% \
going to experience any of the untoward effects from8 c, q2 b% R4 p. k
testosterone exposure as mentioned earlier because$ `, o* r, D$ w) l$ z& }
the exposure was not for a prolonged period of time.- x8 }/ `  S1 v* W  l& i
Although the bone age was advanced at the time of
* Q6 B2 V8 S, g3 Adiagnosis, the child had a normal growth velocity at4 x& g" l; C% |
the follow-up visit. It is hoped that his final adult
$ m5 e4 o* C4 h7 g) Nheight will not be affected.$ `) U/ t7 Y3 |8 z* y0 C! h( ?
Although rarely reported, the widespread avail-' J' a& e1 {5 y. O
ability of androgen products in our society may' U9 N( y" o/ H" L
indeed cause more virilization in male or female
8 U: G8 H% s+ l: `0 d" U" Xchildren than one would realize. Exposure to andro-/ I& |/ j/ \( d- K+ n
gen products must be considered and specific ques-
% W: u6 b$ v! `8 E( E" R! }. q: o4 mtioning about the use of a testosterone product or
* z4 @! R; M  f& V, u) r+ U1 Q& ugel should be asked of the family members during
  |  ~' E# v0 b- R4 J& C7 Gthe evaluation of any children who present with vir-" P5 e6 w& k. X* Y
ilization or peripheral precocious puberty. The diag-. a! ~0 V; {0 Y6 h
nosis can be established by just a few tests and by
8 u* P) P" o, p2 i, rappropriate history. The inability to obtain such a8 ^7 c" L' l3 |- ?" {" c
history, or failure to ask the specific questions, may' r; t0 Q$ w7 f
result in extensive, unnecessary, and expensive
8 b$ `' U+ n) ~3 Y. dinvestigation. The primary care physician should be9 `" i' p0 q- ^! q6 I
aware of this fact, because most of these children
+ b/ B" \$ T$ I9 `may initially present in their practice. The Physicians’$ p* r& p8 j2 L8 Y/ [% x: u( T
Desk Reference and package insert should also put a& `. ^+ A# E9 Y5 w1 l3 A
warning about the virilizing effect on a male or4 l0 k% D- V0 W5 I
female child who might come in contact with some-
) z# r3 T5 a; I7 c2 u" v3 @& oone using any of these products.' D% f6 D. m8 F- G/ C
References
( _6 j; E) M0 z1. Styne DM. The testes: disorder of sexual differentiation
/ c; M& X% N0 t2 C, Tand puberty in the male. In: Sperling MA, ed. Pediatric8 |  c$ K" S5 S. y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( b" ?! `1 _0 ]) W
2002: 565-628.1 z) g% n- T  a/ u# b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 D* H& R" C, ~puberty in children with tumours of the suprasellar pineal
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女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
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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

7 C! e) F) F$ ?* f- ^+ x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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