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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
$ B* u2 \" Q8 a5 OBoy Induced by Indirect Topical
) ^! @8 r7 ]$ R$ q4 N$ z3 ^Exposure to Testosterone
. G6 g0 K6 A3 m, J+ K% cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 [& B( `2 [) v; ^
and Kenneth R. Rettig, MD1
: B# s3 {" }7 q% S! `0 U1 ?Clinical Pediatrics$ j4 B2 M$ y- {6 U
Volume 46 Number 67 C  V( N0 ~9 x0 Y! k
July 2007 540-543# s6 T( ~3 j  B
© 2007 Sage Publications3 |. r$ `4 v' F$ Z# A
10.1177/0009922806296651
/ O' o% ]0 l' Jhttp://clp.sagepub.com6 W1 l0 r+ S# @  {
hosted at6 W5 q1 s2 R! i% C
http://online.sagepub.com
: Z( V' j9 R* |$ [, N6 kPrecocious puberty in boys, central or peripheral,7 Y+ E& A7 c* }8 @2 H6 ~# h+ y
is a significant concern for physicians. Central
/ {- o/ R' b9 gprecocious puberty (CPP), which is mediated- Z9 S( r  y0 c2 }; h- {/ k
through the hypothalamic pituitary gonadal axis, has
  l; j  f0 B! j8 Na higher incidence of organic central nervous system
/ ?& l0 W7 T$ zlesions in boys.1,2 Virilization in boys, as manifested
7 J* {; W! z* Q+ I3 a( c9 F- L, hby enlargement of the penis, development of pubic9 }0 Y1 J) ~; A1 R/ a2 h
hair, and facial acne without enlargement of testi-% o( s4 C$ ]0 f2 F/ @. H
cles, suggests peripheral or pseudopuberty.1-3 We
$ Q$ B# p7 [! Dreport a 16-month-old boy who presented with the
/ H$ n( L/ o+ M8 s7 Q7 d$ P) @enlargement of the phallus and pubic hair develop-
% }7 `# [; J: W7 l! V+ Fment without testicular enlargement, which was due& c/ L7 ?* }9 l8 D7 }5 @
to the unintentional exposure to androgen gel used by
( z3 ~1 x9 [1 a6 ^8 Athe father. The family initially concealed this infor-
* |5 r% Y3 a( T1 emation, resulting in an extensive work-up for this
! D& \2 q) v7 a  k( ~& u! _  Fchild. Given the widespread and easy availability of
( ~+ S4 M' r5 v, jtestosterone gel and cream, we believe this is proba-
+ W; q- u* p. }0 wbly more common than the rare case report in the% c- I, |( v1 f0 n3 U3 c. e( B4 ?
literature.4
) V+ e0 m6 D6 R' _Patient Report, c" k* V+ I6 B; [: b9 l7 u4 U
A 16-month-old white child was referred to the
) o5 D$ {  ?* o* N1 U. N% g0 Rendocrine clinic by his pediatrician with the concern
& H4 w/ X( W1 V! W8 _+ D) F7 Cof early sexual development. His mother noticed) F$ c& H# t5 {3 T0 \/ B3 Z
light colored pubic hair development when he was
3 Z/ }0 D# q; z3 mFrom the 1Division of Pediatric Endocrinology, 2University of& ?/ Z6 w8 x+ T" }
South Alabama Medical Center, Mobile, Alabama.' Q  S5 ^1 R  E6 a& ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 ?; T% R2 y1 L, L' k7 `- QProfessor of Pediatrics, University of South Alabama, College of2 A  ]1 @; W/ G/ p1 A! B) q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( S4 `1 W/ T( A1 @e-mail: [email protected].
9 x& R4 P- U& iabout 6 to 7 months old, which progressively became
9 f7 V) d: N* ~4 Ldarker. She was also concerned about the enlarge-4 v& x% _2 r4 ?! F5 [9 U6 H4 f2 j
ment of his penis and frequent erections. The child
( O9 C" S* b- r8 `, f7 Uwas the product of a full-term normal delivery, with- d; g4 C/ h$ \" `
a birth weight of 7 lb 14 oz, and birth length of; e' s$ ~3 b1 O+ O- I4 O/ `: _
20 inches. He was breast-fed throughout the first year& v+ J' n9 A( r
of life and was still receiving breast milk along with
9 U& X) E/ V5 Isolid food. He had no hospitalizations or surgery,. `, O% d- X, e# {% ~- Y
and his psychosocial and psychomotor development
! {, s/ y; x7 i& F4 |was age appropriate.
' i2 r" U, N! k/ XThe family history was remarkable for the father,
; k6 X0 g6 o- \0 owho was diagnosed with hypothyroidism at age 16,  P: T" r/ f! P
which was treated with thyroxine. The father’s
. B. F( C) ?* s, T' ^( _height was 6 feet, and he went through a somewhat; \* {2 S6 O/ }' J7 Y
early puberty and had stopped growing by age 14.
, j' V' w5 u$ z$ f  NThe father denied taking any other medication. The
! z5 Y* J, f6 jchild’s mother was in good health. Her menarche
6 q5 c& i2 }. {was at 11 years of age, and her height was at 5 feet
- o  V  H" H7 N* i7 e3 Q; a5 inches. There was no other family history of pre-$ d# m- V* p  i3 c: k  J  f' e
cocious sexual development in the first-degree rela-
+ F2 O1 X8 e6 Z" S7 stives. There were no siblings.+ F/ B) k4 e$ s2 R9 h
Physical Examination
, O$ \" V$ j5 }The physical examination revealed a very active,
! s+ O+ ?- f! ~6 u7 {4 ?playful, and healthy boy. The vital signs documented2 }. U! R* ~" `! A# j
a blood pressure of 85/50 mm Hg, his length was3 Q+ G4 h8 |6 h3 x
90 cm (>97th percentile), and his weight was 14.4 kg
6 a* K! R$ X; V% S$ N3 ]8 x# [' _0 q0 Y(also >97th percentile). The observed yearly growth+ J- @& b4 D& ?" e2 x* D
velocity was 30 cm (12 inches). The examination of" n$ M- P4 ^, p
the neck revealed no thyroid enlargement.) Y; H' h- E7 U
The genitourinary examination was remarkable for8 i! \2 Y4 F" R& c& I+ }( V& {# f
enlargement of the penis, with a stretched length of! \* P: i' d" }$ E  e) a8 ?
8 cm and a width of 2 cm. The glans penis was very well
- ?( I; h; }  A  D# \4 o5 udeveloped. The pubic hair was Tanner II, mostly around
2 r; L8 Y$ ?  w. n1 O540) k; k% F: ^; m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; `" a: ^; u" X, c5 I4 a
the base of the phallus and was dark and curled. The* \7 ~$ p7 j1 q5 A" W: _
testicular volume was prepubertal at 2 mL each.
; b) ]- U1 v8 V; d& r. QThe skin was moist and smooth and somewhat
4 D& j, V% p: Y* Y) U2 Aoily. No axillary hair was noted. There were no
) y9 b* `: P! ~+ H* _5 E" Yabnormal skin pigmentations or café-au-lait spots.' N" O0 Q3 S1 ?' [6 A
Neurologic evaluation showed deep tendon reflex 2+' [1 r: O" d2 C, L5 s9 S2 A1 w
bilateral and symmetrical. There was no suggestion
/ f2 S: I" l* e! |$ w  t; z3 ]of papilledema., t0 A5 `- I4 t- P# P' L- V$ }
Laboratory Evaluation7 G8 P& F$ B6 A5 n' d
The bone age was consistent with 28 months by0 G( ~" @" V: y8 S# Z
using the standard of Greulich and Pyle at a chrono-
5 J9 C# G- n* ulogic age of 16 months (advanced).5 Chromosomal
( Q, C! L; P$ Z& Dkaryotype was 46XY. The thyroid function test7 p8 ~- J& x, p+ b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 Z8 a" ?# |4 t( Nlating hormone level was 1.3 µIU/mL (both normal).
9 N7 O* {- L' A3 L: @: b( cThe concentrations of serum electrolytes, blood1 M+ F- p& b$ x4 D3 N% S& n8 t
urea nitrogen, creatinine, and calcium all were- l/ s6 `+ s9 W* [7 j5 a
within normal range for his age. The concentration
" R5 z3 ]& u/ R9 `  _1 qof serum 17-hydroxyprogesterone was 16 ng/dL
$ b' Q3 s) v9 b' }" o" J9 B(normal, 3 to 90 ng/dL), androstenedione was 207 |! s" ?* I$ ^: F; }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, J( E$ y/ A' u7 c" g! H4 Y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 U# R4 `# b8 c$ l! V
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 [: E/ h+ U3 C5 ?7 _2 ^2 c  k49ng/dL), 11-desoxycortisol (specific compound S)! ^3 X9 z, M% n7 S) H& V: l+ A
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' h, B! t3 T6 X/ P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; k, F- M" P. q0 E4 ]! {" ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 X6 F2 y% D; a# V) mand β-human chorionic gonadotropin was less than
- v  C' E) d- ]$ o5 E$ }: Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 e8 N3 r% ]0 J% i4 r9 v1 mstimulating hormone and leuteinizing hormone; N6 }: m, q# y( P+ e6 M/ P# \
concentrations were less than 0.05 mIU/mL; z5 h% n7 l2 \/ e* B
(prepubertal).: ^2 G7 m& M' O
The parents were notified about the laboratory
# e8 D; ?% h- l/ I2 t1 xresults and were informed that all of the tests were
. b5 n  |5 q7 h( A0 ^3 M7 k" n1 Enormal except the testosterone level was high. The
. w9 \( |& y0 O3 D$ e6 Wfollow-up visit was arranged within a few weeks to+ [' X0 j$ U( f
obtain testicular and abdominal sonograms; how-: h% M. b$ f2 x  \
ever, the family did not return for 4 months.4 P5 _" f/ k# ~1 G; s  n$ }" G
Physical examination at this time revealed that the
* \# F& ?# ~0 I6 o3 Q- kchild had grown 2.5 cm in 4 months and had gained
4 h9 i6 {& B9 c+ I4 t, @( @2 kg of weight. Physical examination remained7 D; x& R3 N, |& P2 U- D
unchanged. Surprisingly, the pubic hair almost com-
; N; z' [  K  F$ ?' a, Zpletely disappeared except for a few vellous hairs at8 Q2 D9 p. h% K  @" a
the base of the phallus. Testicular volume was still 2. J; `4 o) p" h
mL, and the size of the penis remained unchanged.+ b: P) b( v+ Z' f2 V# S
The mother also said that the boy was no longer hav-
; W7 X3 f+ b, |2 {5 v) @2 h: `+ C. a- G* r& xing frequent erections.
7 W4 U8 ~' k. J" P  }* `% u- l/ MBoth parents were again questioned about use of
0 D) i7 T6 {+ L  fany ointment/creams that they may have applied to
$ \/ Q3 R. \$ L7 h' `the child’s skin. This time the father admitted the" G; a3 K* ^! n8 Z9 ]; {& X
Topical Testosterone Exposure / Bhowmick et al 541
, z; `) w1 ^+ y7 j) Xuse of testosterone gel twice daily that he was apply-
1 N4 G: S8 c) O- bing over his own shoulders, chest, and back area for
" V0 A+ a( @, ^a year. The father also revealed he was embarrassed0 a9 r- K3 W% S6 v1 u! b
to disclose that he was using a testosterone gel pre-
7 T* S" {- `7 j* C+ \scribed by his family physician for decreased libido
# v4 D0 U2 Z! isecondary to depression.- d/ f; Q, V5 X+ {1 c
The child slept in the same bed with parents.
9 H+ }9 B5 s; t% b4 o4 B0 CThe father would hug the baby and hold him on his
6 ^- u: w  z9 p+ m+ ?% xchest for a considerable period of time, causing sig-
. L5 X6 `, [: G, L6 _% |nificant bare skin contact between baby and father.
8 |- M# Q0 z1 s7 N- lThe father also admitted that after the phone call,1 ]$ G4 F2 s; S4 s
when he learned the testosterone level in the baby; }, y# l: h# h/ M# p9 Z8 K# ?
was high, he then read the product information
" S: Q+ c* s* qpacket and concluded that it was most likely the rea-! t5 r% o5 \3 I9 i
son for the child’s virilization. At that time, they4 B+ L5 _# u2 H: j/ t. h
decided to put the baby in a separate bed, and the
) ?& h  w+ t9 r2 Z, ufather was not hugging him with bare skin and had" \2 r" H* M3 _7 D6 Z% T& \
been using protective clothing. A repeat testosterone, c% l8 Z  V+ I( S" g, z
test was ordered, but the family did not go to the  ?! B0 g% R3 x' N$ J( V
laboratory to obtain the test.  \! x3 k6 M& O8 b2 `
Discussion
6 S- I+ k8 L8 H1 ?# r4 J9 xPrecocious puberty in boys is defined as secondary4 A5 _1 r. n, n/ x$ \3 }1 S/ C- |1 V
sexual development before 9 years of age.1,4
: {  k' T: Y( ?9 `& x# oPrecocious puberty is termed as central (true) when* |8 b* G& V+ n9 c% y% e
it is caused by the premature activation of hypo-
& `0 j- V" K, j; p7 |; F, jthalamic pituitary gonadal axis. CPP is more com-& G3 k9 C2 W' q6 u; W/ u
mon in girls than in boys.1,3 Most boys with CPP3 O2 ?2 d" F/ T% }
may have a central nervous system lesion that is
' b& a- `+ a' C: Qresponsible for the early activation of the hypothal-
- ^& ^8 S0 v3 J: ]+ ?amic pituitary gonadal axis.1-3 Thus, greater empha-5 Y6 ~# t+ X7 R6 C6 e
sis has been given to neuroradiologic imaging in4 f3 f! ]) u0 ]' d
boys with precocious puberty. In addition to viril-6 H- u3 @% w5 T! a8 q
ization, the clinical hallmark of CPP is the symmet-/ v* D; ~* U& ~1 G; U3 Z
rical testicular growth secondary to stimulation by, a, q: z  s) k' o. E
gonadotropins.1,3
8 ^4 v' x( y2 U6 E& AGonadotropin-independent peripheral preco-
) x5 i6 F. u0 |$ A% G2 `" l; J2 tcious puberty in boys also results from inappropriate; @3 G6 H6 X6 |, @
androgenic stimulation from either endogenous or; \& @3 O5 p+ t/ K8 L$ a7 c) p
exogenous sources, nonpituitary gonadotropin stim-' X. f8 _- l+ `- K$ U( K
ulation, and rare activating mutations.3 Virilizing( T2 _( F3 @1 W+ k: k
congenital adrenal hyperplasia producing excessive4 G' S( L- H4 n2 H4 }+ {) ~
adrenal androgens is a common cause of precocious2 P  H# v; G) w; f  q9 l/ M
puberty in boys.3,4
) ?+ _9 y; [: ~, L, Z0 rThe most common form of congenital adrenal& `  t1 x8 A5 c3 A- k- Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
, e5 r1 q8 E8 d# tThe 11-β hydroxylase deficiency may also result in5 `2 J% h& j$ z5 }; z$ O
excessive adrenal androgen production, and rarely,
+ @) |+ b* [2 Gan adrenal tumor may also cause adrenal androgen
. G0 f6 U, w' H( ^5 vexcess.1,35 t8 }# j4 h6 D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& O2 c2 I* m3 s7 W* W542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 X. S1 M+ L; v4 N
A unique entity of male-limited gonadotropin-8 {5 [; r# a- G" e+ O
independent precocious puberty, which is also known
" {; O* {9 a" q: }. vas testotoxicosis, may cause precocious puberty at a
7 K! s# w& z* |) K3 Dvery young age. The physical findings in these boys5 O" \1 ?* f) H, Y5 i1 O$ r! j+ V/ U
with this disorder are full pubertal development,$ c* T+ s- ]1 A
including bilateral testicular growth, similar to boys
" Q4 ~% M- j1 Pwith CPP. The gonadotropin levels in this disorder
6 ]6 @+ j* E- Z, zare suppressed to prepubertal levels and do not show
+ {5 V9 s9 b7 h/ I5 g6 x) }$ zpubertal response of gonadotropin after gonadotropin-
/ ]. D2 f3 k7 w7 lreleasing hormone stimulation. This is a sex-linked1 A# P. Q- K; L: w* N
autosomal dominant disorder that affects only9 f$ u/ ?# L9 W: x+ q
males; therefore, other male members of the family  G3 v7 I' E0 G4 G9 w0 ]! M
may have similar precocious puberty.3
/ M3 ~$ {0 g* f- g9 u4 LIn our patient, physical examination was incon-; J; ]7 C1 j6 W7 U
sistent with true precocious puberty since his testi-
) R9 l2 F% k' }; X. f9 Y  rcles were prepubertal in size. However, testotoxicosis
2 i* v  W. I5 l% ?/ F  Z6 G. Jwas in the differential diagnosis because his father
( |( Y9 P$ H6 y+ M7 Q& mstarted puberty somewhat early, and occasionally,
1 F& e2 q0 H' r& {( ttesticular enlargement is not that evident in the+ Q' Y$ a5 v' Y8 R
beginning of this process.1 In the absence of a neg-. W; Q8 u0 r) I, v
ative initial history of androgen exposure, our8 J, j' K8 ?7 M; g: x: E  I: \
biggest concern was virilizing adrenal hyperplasia,3 i$ `! V4 W  h' s* F
either 21-hydroxylase deficiency or 11-β hydroxylase
3 t; E. R* D- Edeficiency. Those diagnoses were excluded by find-( _, H. T9 n; z7 K4 t
ing the normal level of adrenal steroids., M  z$ E; Y0 a; u  W; l
The diagnosis of exogenous androgens was strongly3 g8 X/ E% Q5 v
suspected in a follow-up visit after 4 months because
' x- |4 r+ \+ lthe physical examination revealed the complete disap-% e5 p& l+ K2 L# Y+ t% X  `" H, |2 N
pearance of pubic hair, normal growth velocity, and
1 y/ s4 L. O" Ddecreased erections. The father admitted using a testos-
: w2 p- S5 r2 b+ p& y) T6 j$ @terone gel, which he concealed at first visit. He was
7 q4 u' Q: k) R8 R! ~using it rather frequently, twice a day. The Physicians’
' q  O: y# {, }$ L3 B( r: UDesk Reference, or package insert of this product, gel or
6 D% }" L/ f- _! E$ u1 z: Pcream, cautions about dermal testosterone transfer to
- ^: q+ H) u* U; n4 Y- h; i, yunprotected females through direct skin exposure.
$ M1 Q  F  T/ M- `6 ^! O) YSerum testosterone level was found to be 2 times the
+ d; X, g& X+ j. bbaseline value in those females who were exposed to" S1 U" s/ |; I# A* s! u
even 15 minutes of direct skin contact with their male
- m, a% L9 h. Q# l/ A$ M) Spartners.6 However, when a shirt covered the applica-
: o8 K$ j( x- J8 Btion site, this testosterone transfer was prevented.7 ~8 E! L6 P3 Q% F1 ~( p
Our patient’s testosterone level was 60 ng/mL,, i- h" l: ^6 s) q0 H
which was clearly high. Some studies suggest that
' g) t4 c2 J7 T. b. {' h& adermal conversion of testosterone to dihydrotestos-9 p, c$ |5 p4 R* l
terone, which is a more potent metabolite, is more1 l" W" O2 \8 V
active in young children exposed to testosterone$ O# n) L( t0 k# O, b+ i7 K( a
exogenously7; however, we did not measure a dihy-) k8 _4 l% i+ C* K! ]: r! h
drotestosterone level in our patient. In addition to
7 a9 U0 S: c1 K2 uvirilization, exposure to exogenous testosterone in
: c$ z6 b! x+ A  A( W/ ?1 u% ^children results in an increase in growth velocity and
% G: C7 H. o  `6 wadvanced bone age, as seen in our patient.
0 m' P& T% N% y' l' JThe long-term effect of androgen exposure during
5 L! w1 k. G) ]9 }early childhood on pubertal development and final
! b  k  [! Z6 V" `* R+ Q7 Ladult height are not fully known and always remain
! Q( w8 {" l& @6 k$ F1 u9 w% Da concern. Children treated with short-term testos-5 I* k6 m: j& |  r7 J; m
terone injection or topical androgen may exhibit some0 f  `' H( r& e; p+ `
acceleration of the skeletal maturation; however, after, I; m! h5 X8 B4 L
cessation of treatment, the rate of bone maturation3 h9 J4 m% {* q( N1 M
decelerates and gradually returns to normal.8,9
2 c! ?9 ~# s/ l, \" eThere are conflicting reports and controversy
/ A6 U5 k* |1 t5 n+ ~9 qover the effect of early androgen exposure on adult3 ?# s0 Q1 t& d( t$ B, w0 z
penile length.10,11 Some reports suggest subnormal0 M0 S% R. C. ?3 O/ z& d
adult penile length, apparently because of downreg-: ?5 i  r4 E( q
ulation of androgen receptor number.10,12 However,
- W$ A; ~( ~3 ESutherland et al13 did not find a correlation between* g* j5 S  p( R0 q
childhood testosterone exposure and reduced adult
( m  a) @. U) [penile length in clinical studies.9 c" _# \* e3 u- }& M# h: s- F
Nonetheless, we do not believe our patient is
* ~  z5 h" @* J- [0 Rgoing to experience any of the untoward effects from
, c6 s& r4 I7 O/ w  Ntestosterone exposure as mentioned earlier because
! v) ?1 F3 b( g9 j. G5 s) Q- @the exposure was not for a prolonged period of time.  A6 J$ g9 @# }0 ~+ w
Although the bone age was advanced at the time of3 ]7 b  v4 l6 T* c" m) @
diagnosis, the child had a normal growth velocity at; @, r* o# T! |4 [
the follow-up visit. It is hoped that his final adult
5 o1 y5 b: z  Dheight will not be affected.
: p5 K6 h; B* a# iAlthough rarely reported, the widespread avail-+ N9 P' C) R* W* u! i6 J
ability of androgen products in our society may
8 ^$ C- \! i0 r4 @) }8 V) s' M, Dindeed cause more virilization in male or female
, j1 l6 K5 x) K! w: ?" M+ Lchildren than one would realize. Exposure to andro-4 t7 C5 M( a, d& I
gen products must be considered and specific ques-
  u, h8 i" W3 ttioning about the use of a testosterone product or, J, W: S4 y) _# \$ r( M
gel should be asked of the family members during
4 F; n5 m" T* E" Xthe evaluation of any children who present with vir-
6 H/ s  b7 r4 F  nilization or peripheral precocious puberty. The diag-9 U* W; @! l: o5 ^; g
nosis can be established by just a few tests and by& S' F: x1 G* p7 ?
appropriate history. The inability to obtain such a
8 `; x' E  F+ ~history, or failure to ask the specific questions, may3 H" F1 U1 u7 X' k6 m. C; {7 v
result in extensive, unnecessary, and expensive1 ]5 F, ]0 u3 u' P2 m6 o2 _4 M
investigation. The primary care physician should be1 Z9 A! C* [6 r9 W2 z
aware of this fact, because most of these children/ Y0 @1 [( q5 w2 \& x& V. c
may initially present in their practice. The Physicians’  l- r0 W8 O/ K( D
Desk Reference and package insert should also put a
: I" E6 h2 i$ O5 p) g0 _warning about the virilizing effect on a male or
" t8 D0 y1 J1 |. Q/ t4 m. Hfemale child who might come in contact with some-# ]3 G) ~4 G; e2 [1 c
one using any of these products.
9 f/ O0 V- Z3 k3 }! z( lReferences
' z' G7 q8 {! g+ ?3 w4 ^1. Styne DM. The testes: disorder of sexual differentiation
+ ]6 y! N( v& n( q; s0 Mand puberty in the male. In: Sperling MA, ed. Pediatric
) @% G7 ~3 q: X- V& q6 q' J$ fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ G* [  u) m! n+ R% P* f
2002: 565-628.# r! u8 P, u& q  W9 e+ ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 q3 Q0 x- ?, C" H4 R
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
+ Y# U3 a9 t- i& g  hBoy Induced by Indirect Topical. b8 V+ g$ z$ L# Z. x2 a# o9 t. Y
Exposure to Testosterone, M$ P) H; ]1 O
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% Y& q! i' {% q! d4 Z) G# Q
and Kenneth R. Rettig, MD1' _0 C9 O% e$ v, Z, h* Q
Clinical Pediatrics6 n; L7 w+ Y6 }" Z( g
Volume 46 Number 6, x$ d: Y& ]0 k8 w3 h. C/ V
July 2007 540-543
2 c0 \% @3 H$ [; J+ H1 B/ {) |, Y/ z© 2007 Sage Publications
& a' ~7 @; B7 r2 e10.1177/0009922806296651
1 g4 O% U; @8 |- S0 B% \/ zhttp://clp.sagepub.com1 V" h. g; C- N5 S5 x
hosted at0 ^6 f! P& t7 {: o3 [2 X6 P( v6 J
http://online.sagepub.com
8 k! ^+ H' L; e" l" I' PPrecocious puberty in boys, central or peripheral,, A: p2 X# y4 Y1 `; t2 t$ q5 C
is a significant concern for physicians. Central( X& l) Q( B8 G' p1 Z: Q
precocious puberty (CPP), which is mediated8 u: c1 M( e2 G
through the hypothalamic pituitary gonadal axis, has# C8 H" J" @' Y. _, N" F% w
a higher incidence of organic central nervous system' m. |' t8 t5 o) s9 @
lesions in boys.1,2 Virilization in boys, as manifested
' ?5 b- ~/ z1 G1 L; Xby enlargement of the penis, development of pubic+ Q% R* l- ~+ y  q; v3 i
hair, and facial acne without enlargement of testi-
( [4 c, Z: ^. o5 E5 ]: mcles, suggests peripheral or pseudopuberty.1-3 We, e0 K) F- l. ^+ p3 j3 o( v, N& N. ~
report a 16-month-old boy who presented with the, X, l: k( M4 Z& d# z
enlargement of the phallus and pubic hair develop-
7 M! B9 X5 B$ i, R! g: Gment without testicular enlargement, which was due
  J  g( f* k% }to the unintentional exposure to androgen gel used by- s& F7 k3 g( h
the father. The family initially concealed this infor-
1 Y4 H/ O* B# n- ?0 Lmation, resulting in an extensive work-up for this- R! y3 z' H7 z' }  i
child. Given the widespread and easy availability of
' X+ g, T) L5 u+ o) t. dtestosterone gel and cream, we believe this is proba-7 O* m4 C. {" w
bly more common than the rare case report in the3 A' A6 y" a0 \  p
literature.4/ ~# H- {, a) b0 q) B
Patient Report. u2 n$ E2 ?; n
A 16-month-old white child was referred to the. U3 a1 ?- B' b; W. Y3 c0 f3 j/ p
endocrine clinic by his pediatrician with the concern
0 j. J1 r0 Q2 K3 o* fof early sexual development. His mother noticed3 ~6 H! ^2 C; `, e
light colored pubic hair development when he was% m) A6 B. R8 y( l
From the 1Division of Pediatric Endocrinology, 2University of
5 ?' h9 O- t& V# q3 T+ s8 G, lSouth Alabama Medical Center, Mobile, Alabama.  E$ \# d! Q$ P* |; X
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 {; }  B4 z* [+ G' n
Professor of Pediatrics, University of South Alabama, College of
7 O+ x2 O8 v7 O; V- ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 }' v3 X* ~5 Q: G% w: ^( }
e-mail: [email protected].0 x; ~! W( V* x
about 6 to 7 months old, which progressively became+ Q3 {' @, j' w% o. |+ l
darker. She was also concerned about the enlarge-
" c3 n+ z7 P3 _8 {3 Pment of his penis and frequent erections. The child
8 u$ {( n7 y0 e$ z1 O, Uwas the product of a full-term normal delivery, with
% P0 W0 ^" t: [: fa birth weight of 7 lb 14 oz, and birth length of
" s9 g: H0 I& W2 N% O+ S* W20 inches. He was breast-fed throughout the first year
/ }# K: G+ C% s# X, p9 T# p1 }of life and was still receiving breast milk along with
6 d8 U1 \4 ]: m; S0 u# csolid food. He had no hospitalizations or surgery,5 a5 d( f2 v9 }
and his psychosocial and psychomotor development
  |: D1 ^4 n* k, W* M3 D: Nwas age appropriate.: g. c' v, }$ r$ o% h
The family history was remarkable for the father,
* z7 X/ J4 j+ S5 ^% Z/ T# dwho was diagnosed with hypothyroidism at age 16,. m& P! `9 v* |, B, J' p
which was treated with thyroxine. The father’s
# }5 h! _' a/ m. W- R  hheight was 6 feet, and he went through a somewhat" ~8 Y! p7 O0 [+ t; N
early puberty and had stopped growing by age 14.
7 _) c" J3 [' T) rThe father denied taking any other medication. The: W7 J0 T$ b2 b% M  L8 N
child’s mother was in good health. Her menarche
8 x' O; B" \1 ]  {+ X- h9 nwas at 11 years of age, and her height was at 5 feet4 f3 S8 ?* p6 ]: ?! }* o
5 inches. There was no other family history of pre-$ o5 u3 A: V* O- h$ I8 N
cocious sexual development in the first-degree rela-4 _* O4 t, A: n# x: V
tives. There were no siblings.. B, U- e; V+ V9 A4 [
Physical Examination
" {; [8 V) P: H$ k3 z" a: XThe physical examination revealed a very active,, R, @( d* }8 ^% ?4 I- w
playful, and healthy boy. The vital signs documented! e( ]/ D# Q4 _
a blood pressure of 85/50 mm Hg, his length was
$ L# E% v, k, q, K/ L90 cm (>97th percentile), and his weight was 14.4 kg! Y5 D$ m1 b- J* B3 Z
(also >97th percentile). The observed yearly growth" d5 g/ ?5 F: l% {6 q
velocity was 30 cm (12 inches). The examination of
  L% t9 y" O3 ?# c1 ~4 `the neck revealed no thyroid enlargement./ Y6 \8 O( a2 F! C/ q8 J
The genitourinary examination was remarkable for
# g5 ?' A$ h! |: h- W9 g/ W& Yenlargement of the penis, with a stretched length of  j( B$ j" e7 Q  t7 {5 R! K8 L
8 cm and a width of 2 cm. The glans penis was very well& e1 P' c+ R; @! G) @) H# h0 [
developed. The pubic hair was Tanner II, mostly around
6 V) h3 o" i* ~540# M% g& m/ d* m- Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% |& ~% X- H0 h: a% F% m6 L7 W# ?
the base of the phallus and was dark and curled. The
3 t# k7 `* q/ s+ ~! J. f3 Ytesticular volume was prepubertal at 2 mL each.
; h/ o0 a# R( Q7 c. n7 o3 x: C' JThe skin was moist and smooth and somewhat
' a% p, w; r# ]6 eoily. No axillary hair was noted. There were no% P. b( g( M! T2 q- W) C8 X, H
abnormal skin pigmentations or café-au-lait spots., C$ @: ?* [1 I5 L0 i; D7 @
Neurologic evaluation showed deep tendon reflex 2+
0 h( B1 l9 {% _3 n+ _" C( [, ]bilateral and symmetrical. There was no suggestion; H/ f( V, [1 U6 Y' |( B
of papilledema.
5 l+ u7 |; j* R4 C5 C+ N8 [4 DLaboratory Evaluation
+ S1 a- B$ L; C: zThe bone age was consistent with 28 months by) ]* U( p+ d* Q1 R
using the standard of Greulich and Pyle at a chrono-# I+ e, M3 N! Z' A3 I) a1 {' Z
logic age of 16 months (advanced).5 Chromosomal: C. V$ Y$ z! a! o9 T' G
karyotype was 46XY. The thyroid function test
$ Z( t! C2 T( Z4 Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% w6 M" ~# R% f6 z9 c  P+ V  i
lating hormone level was 1.3 µIU/mL (both normal).
% Q  E8 z) n: J* ?! J$ G" SThe concentrations of serum electrolytes, blood
. J* v5 i2 y: o( V9 O* L) C  t% hurea nitrogen, creatinine, and calcium all were$ W3 R5 }' C. R0 k, T4 z
within normal range for his age. The concentration# \# \# l5 j0 a+ u0 k$ f
of serum 17-hydroxyprogesterone was 16 ng/dL
; ]/ Q  F* R+ e  R; Y(normal, 3 to 90 ng/dL), androstenedione was 20# T6 R  X7 l" U4 A$ E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- s: Z, k% W. L9 I1 e4 \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ ]# y# v% q( c* m. d4 n2 M2 O. fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 [7 {+ `2 J6 j* ^
49ng/dL), 11-desoxycortisol (specific compound S)
% J/ A8 P0 e( `3 I3 X4 qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ P. _8 I4 v* E; s' Ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 ?  B/ F; a  Z$ m% h- [- u
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! I9 c3 S& g" J1 d) Z3 t5 N: ?
and β-human chorionic gonadotropin was less than
+ b% t" b8 A! D! F4 z; H5 mIU/mL (normal <5 mIU/mL). Serum follicular3 U# T) E  c  F$ w% G+ ~6 [
stimulating hormone and leuteinizing hormone
( l& }0 ^% ?" V3 A# T% \" r+ Q$ Fconcentrations were less than 0.05 mIU/mL7 p' e. M5 g7 \9 A
(prepubertal).
" d  k. z% N1 v) G+ O' ^The parents were notified about the laboratory9 `: N0 l1 v# G: i& Y
results and were informed that all of the tests were9 r% y+ ?+ I& ~6 l3 T( ^
normal except the testosterone level was high. The( f6 Y2 ?, I& |! R0 v  |0 Z
follow-up visit was arranged within a few weeks to  \- l( m. }# N6 h- @$ t6 S$ D
obtain testicular and abdominal sonograms; how-
& j+ L! a! r9 V2 I% }7 Z6 Sever, the family did not return for 4 months.& K- a9 V# j+ \) {
Physical examination at this time revealed that the% |5 t" I  t9 X+ i
child had grown 2.5 cm in 4 months and had gained4 y0 c* k0 N' E4 T! K
2 kg of weight. Physical examination remained
# }" Z  U) e8 B) ^% y, Gunchanged. Surprisingly, the pubic hair almost com-  {- o$ D6 E: T: {7 v" t, a5 \) y0 ]
pletely disappeared except for a few vellous hairs at
0 O4 Y& w/ C" L- E0 Othe base of the phallus. Testicular volume was still 25 S2 K$ R/ X4 |( b2 @
mL, and the size of the penis remained unchanged.
2 y( j! f& y+ c! u; Q1 qThe mother also said that the boy was no longer hav-( ^5 T* {$ d5 u  k& W8 [  f/ r
ing frequent erections.
+ t! ~' T! i# m2 u" CBoth parents were again questioned about use of  @8 `, r# P2 M: z1 s
any ointment/creams that they may have applied to
( i8 c$ w; }4 T; U$ I. S) |" ~# D2 _the child’s skin. This time the father admitted the, V6 Z) k3 x" ]1 w! U" k
Topical Testosterone Exposure / Bhowmick et al 541$ J5 I& r3 p8 ]+ q+ p/ g7 M4 U
use of testosterone gel twice daily that he was apply-
/ v- j$ I. k7 T( V3 Z# m4 Hing over his own shoulders, chest, and back area for! o; ~' J; H$ K/ B, C
a year. The father also revealed he was embarrassed; m1 R" L6 l, B( h: l- @$ x
to disclose that he was using a testosterone gel pre-" [+ F- j# L8 W/ D
scribed by his family physician for decreased libido
" `+ A8 O4 i& ]' i4 Z# l+ lsecondary to depression.
8 m$ o8 @2 H! i" P9 X8 {$ MThe child slept in the same bed with parents., H( I- F9 S( D& H7 }  R
The father would hug the baby and hold him on his3 \/ B' q$ `  i
chest for a considerable period of time, causing sig-: |3 u4 M9 B# U* t7 t5 v3 k: u( O
nificant bare skin contact between baby and father.
! l5 u6 z0 Y- l* _8 {9 W; O) s; x2 `( hThe father also admitted that after the phone call,
" t5 w  @, E2 p+ ~; P3 lwhen he learned the testosterone level in the baby
/ S" i: h- D5 ?2 U8 u# Zwas high, he then read the product information0 e& p$ R; t% F8 P) w9 T
packet and concluded that it was most likely the rea-
$ o% R& \1 n2 e9 |- x, I- P. wson for the child’s virilization. At that time, they
0 z: v% J8 x. V! ^" [. A; N4 bdecided to put the baby in a separate bed, and the
# ]7 b- y3 F: X. w( d% S8 k1 [father was not hugging him with bare skin and had
1 h& L6 _" E4 t- Pbeen using protective clothing. A repeat testosterone
2 z; ^/ i1 {6 vtest was ordered, but the family did not go to the7 Z5 n3 N0 _$ l( H. F
laboratory to obtain the test.+ Y) }. h3 Y- d* E, M
Discussion: k+ g& V! {6 B3 a" B& s
Precocious puberty in boys is defined as secondary- U+ z  H3 b: G& W% M
sexual development before 9 years of age.1,4
- g' q5 d# h  s( TPrecocious puberty is termed as central (true) when
* d0 |) ?1 {9 n* xit is caused by the premature activation of hypo-* _  s; ]4 C) n- y' {
thalamic pituitary gonadal axis. CPP is more com-6 g" r5 l  Q$ i4 D
mon in girls than in boys.1,3 Most boys with CPP; Z  z' r9 c: r1 m7 D% s
may have a central nervous system lesion that is+ J9 C9 q# d9 x9 L
responsible for the early activation of the hypothal-5 J) l* x/ E/ ?& F8 Y6 q( ]
amic pituitary gonadal axis.1-3 Thus, greater empha-5 X1 S  r9 U. w2 p
sis has been given to neuroradiologic imaging in3 u5 L- k$ g# U
boys with precocious puberty. In addition to viril-
) [; z5 X' [% C/ ?ization, the clinical hallmark of CPP is the symmet-3 J0 E1 W1 `2 o" V: J
rical testicular growth secondary to stimulation by
+ O% |, x" j2 e) pgonadotropins.1,3/ S( S$ G5 ^2 a; I/ o5 D# `) T
Gonadotropin-independent peripheral preco-
. E6 Z/ J% G" p; Lcious puberty in boys also results from inappropriate# i, ]) r& d! w1 \$ L9 i
androgenic stimulation from either endogenous or
( W& S2 F7 H8 g2 F( nexogenous sources, nonpituitary gonadotropin stim-4 M; P- Y6 R6 m- e; m  R$ E
ulation, and rare activating mutations.3 Virilizing, b1 k% K/ ]4 T" W# Z2 {. g
congenital adrenal hyperplasia producing excessive" Y; u3 M9 R; V4 m/ D4 O
adrenal androgens is a common cause of precocious& N/ O8 R. ]1 R! W7 Q: i' P/ a
puberty in boys.3,43 n2 V! R6 W5 V7 u. i4 l( B
The most common form of congenital adrenal
/ C/ u( ~& g- k0 g+ _hyperplasia is the 21-hydroxylase enzyme deficiency.; \9 ^1 M0 r6 n
The 11-β hydroxylase deficiency may also result in+ k0 V) J- x$ D( n/ I3 U" {
excessive adrenal androgen production, and rarely,7 G$ G3 B" O) s5 G
an adrenal tumor may also cause adrenal androgen5 y5 y( }# {& S, p8 u7 F+ J. h) `
excess.1,39 F. n9 W) c' H) K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ B& x- n0 R8 }542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 I$ \7 J* u+ J' d7 d! K! w; z% h
A unique entity of male-limited gonadotropin-( {6 S+ @8 N7 q8 }
independent precocious puberty, which is also known, Y+ g( s2 Y/ K. A3 t
as testotoxicosis, may cause precocious puberty at a: g3 Z6 ]7 F/ Z5 g
very young age. The physical findings in these boys0 f* U( V4 x4 T, a9 _6 a# c: [  Z
with this disorder are full pubertal development,  ^0 H, g# M! }" {+ m
including bilateral testicular growth, similar to boys
6 o6 a- `: X$ G1 Qwith CPP. The gonadotropin levels in this disorder! g  J# Y3 `, s3 W$ E, B  ?/ [
are suppressed to prepubertal levels and do not show% u1 p2 T! Q+ o' x
pubertal response of gonadotropin after gonadotropin-% C6 [) ^4 U* p7 x
releasing hormone stimulation. This is a sex-linked1 m% y. G5 w# [' r! ]. O5 Y5 F
autosomal dominant disorder that affects only0 L* T$ |) K6 g, `4 Q
males; therefore, other male members of the family
- [! x& U( P+ y8 ~/ }/ g: L4 [may have similar precocious puberty.3( E, l  Q, i: z' j9 I
In our patient, physical examination was incon-# t4 W- v3 ]" Q
sistent with true precocious puberty since his testi-
$ L2 G0 N; x) F4 ncles were prepubertal in size. However, testotoxicosis
) }  k' Z/ h3 x" d& q+ r, Ywas in the differential diagnosis because his father
1 `( D( K# [3 q$ p7 r; Sstarted puberty somewhat early, and occasionally,3 U$ N5 e  f: V& J
testicular enlargement is not that evident in the
1 R3 v. b7 W6 N( xbeginning of this process.1 In the absence of a neg-
' u7 f6 G" T  h1 s% H3 J7 g( S- x$ Y6 Aative initial history of androgen exposure, our  W2 {! ^/ K: s  X% r/ j8 x8 z
biggest concern was virilizing adrenal hyperplasia,4 {  C; v: E  K4 H. G! [' H
either 21-hydroxylase deficiency or 11-β hydroxylase* u  k- U" c( ]9 k  g
deficiency. Those diagnoses were excluded by find-
+ K/ _  k# B& I# N4 o7 J, aing the normal level of adrenal steroids.( z) y* _9 \$ D% r( h0 f/ `& e$ R
The diagnosis of exogenous androgens was strongly- h0 B/ A! F/ R5 a  W8 ^
suspected in a follow-up visit after 4 months because
+ u3 @+ a& ^% H  m2 u% _/ ^4 Xthe physical examination revealed the complete disap-
( y* V% T2 g5 C* k& _; dpearance of pubic hair, normal growth velocity, and
) m# ]: ?5 b4 G! _decreased erections. The father admitted using a testos-6 u4 ]# b% V8 X$ I3 |
terone gel, which he concealed at first visit. He was5 \1 k, h1 Q1 }
using it rather frequently, twice a day. The Physicians’
2 A$ x& D( w+ R3 P  LDesk Reference, or package insert of this product, gel or
1 f) R7 |) V* r+ L2 H9 ?" z* h- }8 rcream, cautions about dermal testosterone transfer to
; Y- s; `2 Y1 Y5 b* e8 hunprotected females through direct skin exposure.
6 q5 j# L0 i( `Serum testosterone level was found to be 2 times the
0 N9 T7 U6 p: c6 [  }  Kbaseline value in those females who were exposed to
2 u' k; H) b$ T$ h& heven 15 minutes of direct skin contact with their male1 o/ c/ g& J5 u+ n7 v. m# k/ C
partners.6 However, when a shirt covered the applica-$ M& T3 r  A4 ~
tion site, this testosterone transfer was prevented.3 h1 N+ G: m" ~& F7 t
Our patient’s testosterone level was 60 ng/mL,: D$ M( Q/ M# c+ M3 [$ s: n
which was clearly high. Some studies suggest that
7 u7 b  g4 z. U5 udermal conversion of testosterone to dihydrotestos-
1 f5 r" T3 |2 u. l3 ~$ \+ Pterone, which is a more potent metabolite, is more6 W* |" k2 _/ J, L; P4 s4 B
active in young children exposed to testosterone
$ Q# r; N" Q6 n4 |1 V0 Xexogenously7; however, we did not measure a dihy-: E+ \0 A& \! i. l
drotestosterone level in our patient. In addition to
. a6 n3 T* i/ i0 Z8 M/ Tvirilization, exposure to exogenous testosterone in. V; I1 V) z; o: c/ q. A% y) ^- \; H/ i
children results in an increase in growth velocity and
9 h3 p2 o& P! h. Dadvanced bone age, as seen in our patient.  C6 m  v+ p7 M+ A) F& D* x  V
The long-term effect of androgen exposure during7 a$ `7 g  z0 E% Q0 K9 b7 ]* }
early childhood on pubertal development and final: ?! L% T3 h* B0 A6 V" S
adult height are not fully known and always remain
1 ?- ~- W* J3 `+ Za concern. Children treated with short-term testos-" O$ h- N+ @4 X& g
terone injection or topical androgen may exhibit some
" ~: @7 Y9 A5 ~# N3 @2 N: T8 oacceleration of the skeletal maturation; however, after
: {; j3 |5 u" o$ ocessation of treatment, the rate of bone maturation
2 m" H4 L4 p4 e5 Zdecelerates and gradually returns to normal.8,9, B4 K& D  `" S  o
There are conflicting reports and controversy
2 D% m. d& h) m3 Vover the effect of early androgen exposure on adult  F1 s( T5 s% n1 u. T+ z. b
penile length.10,11 Some reports suggest subnormal
& p/ B8 w5 [) eadult penile length, apparently because of downreg-
# D6 E& U# S+ w" z0 l5 eulation of androgen receptor number.10,12 However,
3 ?: k7 `0 V( j* [Sutherland et al13 did not find a correlation between
& |/ x9 H4 `0 I% _0 p, c9 Tchildhood testosterone exposure and reduced adult7 k+ O, u, H9 F6 v8 G' I* {
penile length in clinical studies./ A; r5 D3 C, ~! y3 K
Nonetheless, we do not believe our patient is2 A- V. P$ N" M7 o! G* }
going to experience any of the untoward effects from
8 d( |, e# f) T( ]! U5 W+ [( [testosterone exposure as mentioned earlier because
; g6 M+ g7 J. fthe exposure was not for a prolonged period of time.
2 a) \% k3 e) i# DAlthough the bone age was advanced at the time of
" Y) O/ e* y" [, N/ ediagnosis, the child had a normal growth velocity at
$ A! E- @$ F) D# t1 e3 e; r) K( D% Dthe follow-up visit. It is hoped that his final adult
/ _6 P  P. S  ]% bheight will not be affected.3 [" l" H0 L, J
Although rarely reported, the widespread avail-
) M, i0 x8 U, I! qability of androgen products in our society may
! C, D- [) K; W- l5 h* {indeed cause more virilization in male or female
5 T/ E, C& \+ b- Hchildren than one would realize. Exposure to andro-
- U) @+ Q& U0 V3 ~; \3 fgen products must be considered and specific ques-
) o5 r" M0 q1 g0 C5 E) H( etioning about the use of a testosterone product or
& A+ Y. }! [' G& ~) P, Cgel should be asked of the family members during4 V! k% t$ u$ s# ~
the evaluation of any children who present with vir-
: Y% h& A" h9 k6 _2 |& Wilization or peripheral precocious puberty. The diag-) ~9 `& I" g4 a) n0 |) l& H
nosis can be established by just a few tests and by
" _- H6 ?* o  r) Nappropriate history. The inability to obtain such a
% x% \2 Z) {4 f# f3 I- Ihistory, or failure to ask the specific questions, may
* V9 ]/ p  z% |7 n# eresult in extensive, unnecessary, and expensive
& }# J  a: n0 R0 P" h* ainvestigation. The primary care physician should be
* ~$ U) k; [& I9 J# faware of this fact, because most of these children
/ \$ l4 Z( _) l/ D/ A+ t8 c, F9 {may initially present in their practice. The Physicians’
% u( K& {  @2 o( b; h3 S$ \3 SDesk Reference and package insert should also put a
9 T4 e! ^* \: n6 Lwarning about the virilizing effect on a male or5 A( k: Q6 A+ h: C3 g" N* c6 p( p3 a. h
female child who might come in contact with some-6 \* T/ Q6 x4 t
one using any of these products.
8 x5 E7 z3 r- w1 e! C: ]$ KReferences3 s- ~+ ^. W% X! R! [0 t0 M
1. Styne DM. The testes: disorder of sexual differentiation
% A& ~* \; E$ z( r2 f( j5 |- ^and puberty in the male. In: Sperling MA, ed. Pediatric
" E/ j# o0 {: B9 c  \0 u9 u! @5 @5 WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 Z5 K) w4 l* f7 \/ ]4 B7 g6 Z1 ]
2002: 565-628.2 h, A8 u0 A. E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& M9 v$ Q& d  H: ~# Kpuberty in children with tumours of the suprasellar pineal
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女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
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精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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