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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
9 [0 Z4 A# u& ?2 ?Boy Induced by Indirect Topical# m- v5 n& f7 f; W
Exposure to Testosterone
6 M4 W! v. z# SSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& S5 i0 r+ Q. }and Kenneth R. Rettig, MD1
- X$ Q2 x6 i* W  v+ vClinical Pediatrics2 Q+ x* P2 [  F$ F6 f! i
Volume 46 Number 6' \2 a( y% @- _
July 2007 540-5436 m0 E2 m( g- M  z
© 2007 Sage Publications
& k7 i6 J# N' `" I* Y8 ~. p10.1177/00099228062966511 D+ J0 m; I- D+ r9 C8 y+ \# g
http://clp.sagepub.com2 w  ^1 Y) E# ^# l7 _0 j+ g# o
hosted at
" d) l& A4 _4 G- A& chttp://online.sagepub.com- O5 ~) b% M: E; i+ c$ {1 V5 G9 i
Precocious puberty in boys, central or peripheral,
. a* M, E- q7 ^( i$ j! cis a significant concern for physicians. Central
6 C, l; S7 t) k8 h0 Gprecocious puberty (CPP), which is mediated2 M; |) `4 W: x6 m+ {' a% W+ T, q
through the hypothalamic pituitary gonadal axis, has
$ {  b4 j1 q5 B* x: v/ la higher incidence of organic central nervous system
0 H9 Q" k" q9 K9 ~3 W% m% [4 tlesions in boys.1,2 Virilization in boys, as manifested
) C" J- Z7 m, Uby enlargement of the penis, development of pubic& l$ V- H7 @* N* ]3 Q
hair, and facial acne without enlargement of testi-6 l, ~9 c, v2 x9 v( [
cles, suggests peripheral or pseudopuberty.1-3 We2 z4 Y) B4 X* A- K- ]. ?9 O  {
report a 16-month-old boy who presented with the5 Y& |5 q0 Z2 R) Q% |
enlargement of the phallus and pubic hair develop-- A* D- |1 N3 k- Y( \( {
ment without testicular enlargement, which was due
4 |2 F  @, ^  J) uto the unintentional exposure to androgen gel used by
6 _6 d4 O+ }+ J% T0 @the father. The family initially concealed this infor-( e$ D& [, s8 G+ `! f
mation, resulting in an extensive work-up for this
3 \% Q  b% X) a( H4 bchild. Given the widespread and easy availability of& `; X0 C! w5 e4 _4 R7 H
testosterone gel and cream, we believe this is proba-
! k9 K% F6 g6 ]' |" }" zbly more common than the rare case report in the* e7 g1 D, Y! H/ @
literature.4
& t* r$ j* z* hPatient Report7 M# x$ X+ ~  A4 v) v2 |+ o
A 16-month-old white child was referred to the* q: e5 i" g4 k$ l4 h
endocrine clinic by his pediatrician with the concern4 P* ?, b  U- o) P5 H
of early sexual development. His mother noticed
4 b  m& k5 e5 m/ glight colored pubic hair development when he was
* v; G- I, W: g7 Y' VFrom the 1Division of Pediatric Endocrinology, 2University of
8 P% }8 `/ P2 h- I' ~South Alabama Medical Center, Mobile, Alabama.
: j$ X0 X8 K0 h1 F* `" }* BAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 w% ~' i& O) z! K: U$ f6 q: n3 gProfessor of Pediatrics, University of South Alabama, College of
( {( D  ~/ q# J1 a$ wMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 M5 }8 U6 D; B* b4 y0 \
e-mail: [email protected].! [* `$ h7 b# v7 G1 m5 v
about 6 to 7 months old, which progressively became8 [) D) M4 {8 _
darker. She was also concerned about the enlarge-" Y4 w2 z7 r% n8 G6 G
ment of his penis and frequent erections. The child
1 \9 b8 X8 E! Q" W5 j) l, fwas the product of a full-term normal delivery, with, g; M- m1 Z$ Z1 Q2 }) ]% k
a birth weight of 7 lb 14 oz, and birth length of) j( f/ h' k* c; H5 y
20 inches. He was breast-fed throughout the first year, ~8 r1 P; O& |% j" V- a( N! U
of life and was still receiving breast milk along with/ S' w) r$ T' i& T6 y9 K/ L
solid food. He had no hospitalizations or surgery,
3 h+ B' g; h$ B1 ?/ B3 F# Eand his psychosocial and psychomotor development9 F- x/ u8 I$ G/ E) s6 K- n+ _
was age appropriate./ V" l, |* n4 q0 [
The family history was remarkable for the father,
+ U& v/ n: Z. }9 A6 @8 }6 \who was diagnosed with hypothyroidism at age 16,
3 t$ _4 V. W, M& R- j# i$ {2 x, Swhich was treated with thyroxine. The father’s2 u. @! Q8 |  ~6 |6 S$ R. J
height was 6 feet, and he went through a somewhat& F$ ]: S3 x( l/ W) C6 ]9 g
early puberty and had stopped growing by age 14.% W4 H# \. g6 |. s$ w% }
The father denied taking any other medication. The
$ B5 {' t0 g: u9 Pchild’s mother was in good health. Her menarche4 Q8 U3 c9 t/ I& `" u
was at 11 years of age, and her height was at 5 feet
3 r1 v; H/ g% K  o+ F7 W5 inches. There was no other family history of pre-
! U5 g+ I7 T% C& }/ ^: {. Ococious sexual development in the first-degree rela-8 S) y5 v) D8 Y' L) O) K7 s
tives. There were no siblings.# ~7 I  }/ z* }, f/ q3 l
Physical Examination5 W! i) i! j: J
The physical examination revealed a very active,3 q; z( s  J" m
playful, and healthy boy. The vital signs documented9 j" }- }  g3 }+ I$ D! ~
a blood pressure of 85/50 mm Hg, his length was
' y2 {5 T/ o& e  _, ]+ K# J90 cm (>97th percentile), and his weight was 14.4 kg& M  z2 [9 a5 X% _' @4 G8 @# u
(also >97th percentile). The observed yearly growth
) ]" L% g* K% r  \7 gvelocity was 30 cm (12 inches). The examination of6 Y2 N% ~- Q0 t/ a
the neck revealed no thyroid enlargement.' t# o& M' d9 d, R  H
The genitourinary examination was remarkable for
' {4 Y, G6 i5 Xenlargement of the penis, with a stretched length of1 D) F2 L. z' Y* K) ?
8 cm and a width of 2 cm. The glans penis was very well
5 ^- ?) p* W: O# Q$ ], o1 Mdeveloped. The pubic hair was Tanner II, mostly around1 N3 K; W6 \' w- H. c
540
# `0 Y! N! L1 _9 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 M$ X5 Q9 |7 c+ G+ rthe base of the phallus and was dark and curled. The
: D; E% l2 a2 ]# ?; g4 Dtesticular volume was prepubertal at 2 mL each.& D1 q) z5 p4 h
The skin was moist and smooth and somewhat. ?4 {; d8 i! i; z" d; S; `
oily. No axillary hair was noted. There were no* L# b, x# i' U6 s8 V
abnormal skin pigmentations or café-au-lait spots.
8 r/ Y# T: F* b3 N' G; jNeurologic evaluation showed deep tendon reflex 2+
: w8 K% ]1 Y- Q; D5 J; J8 Q- @* b, vbilateral and symmetrical. There was no suggestion
. e5 C. K# f) tof papilledema.
+ o' B  U7 Z2 l7 T7 n$ {& {Laboratory Evaluation
% }6 F* {- e; c  R* K& }4 z' mThe bone age was consistent with 28 months by
; X# x: Q# C# ^2 E/ Pusing the standard of Greulich and Pyle at a chrono-
, i  G$ O$ O- e9 g- ]) qlogic age of 16 months (advanced).5 Chromosomal% y( |  D% Y0 c6 z
karyotype was 46XY. The thyroid function test# v1 @$ U1 f0 D5 h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 L, U6 p9 H! _4 v% r8 B9 Mlating hormone level was 1.3 µIU/mL (both normal).* _9 f* p, _& \! K
The concentrations of serum electrolytes, blood& k" ]" ^7 L1 I
urea nitrogen, creatinine, and calcium all were
8 ?+ _0 I; B: _3 uwithin normal range for his age. The concentration
1 ^# ]9 ]6 J" G0 Hof serum 17-hydroxyprogesterone was 16 ng/dL8 w# `! l$ K+ G
(normal, 3 to 90 ng/dL), androstenedione was 20
7 G, Z1 @9 X8 x* sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. `' x; @5 x; P8 Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ S' L- k. J3 g- T' @  Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to& X- f, j& V- R( q3 R! W0 \( i
49ng/dL), 11-desoxycortisol (specific compound S)$ i0 e! w; q  g
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 i* [) X/ g6 Y5 e$ c& d0 B3 Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 I0 v6 D8 K7 F' y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! A+ j  E. r* d  u4 y% C' i" U, P8 Y. `
and β-human chorionic gonadotropin was less than1 @. Z6 y5 F/ \" b3 |; S: D; Y# C1 j
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 b) u+ I2 `) h, b) h) X- Y
stimulating hormone and leuteinizing hormone
! ~7 K+ D; k2 v7 O" nconcentrations were less than 0.05 mIU/mL
* y# {: U. `8 `5 A/ ]# f- U2 Z+ R6 p(prepubertal).2 h/ G- S( R& m) H. V! S# _* O: i
The parents were notified about the laboratory
/ [( K! k( y! C. H6 g2 t5 Nresults and were informed that all of the tests were0 F" [! L' F2 W* G% g# G& ]
normal except the testosterone level was high. The: D* \; n; i6 }# r1 N
follow-up visit was arranged within a few weeks to
4 R, @. R1 h% x' _obtain testicular and abdominal sonograms; how-' t, [& L* W% J) v$ K+ F
ever, the family did not return for 4 months.
! y, T! U; P  d+ Y+ WPhysical examination at this time revealed that the
* _, P1 S* J! Y3 `child had grown 2.5 cm in 4 months and had gained6 m; A2 P: n; [: U2 l) l
2 kg of weight. Physical examination remained! o7 \9 {( z. y. }% D# w1 X# c1 l
unchanged. Surprisingly, the pubic hair almost com-: i0 Q. K/ f# \% p3 ]' l
pletely disappeared except for a few vellous hairs at" T, v) u: p& T$ B1 F1 T1 F6 ?
the base of the phallus. Testicular volume was still 2) v' Y5 o3 P, W2 k
mL, and the size of the penis remained unchanged.4 e0 m, E0 `2 B0 Z% M" d' l/ @- n) Q
The mother also said that the boy was no longer hav-
0 A7 I4 d( |$ [" \4 E: Z. {ing frequent erections.2 `$ @! y+ o/ F% N7 W
Both parents were again questioned about use of& S1 g. |: r# k! D+ l
any ointment/creams that they may have applied to  n6 z* ~- Y/ z- G6 @1 [1 o
the child’s skin. This time the father admitted the
0 z" ?  N. ~  u' hTopical Testosterone Exposure / Bhowmick et al 541
& b% W- w/ p: U7 ]2 V5 euse of testosterone gel twice daily that he was apply-
/ i/ j  |! b9 g' b# e& I  n0 xing over his own shoulders, chest, and back area for' `0 Q9 E, s4 p: R" F4 }$ h
a year. The father also revealed he was embarrassed; w1 [3 K2 Z4 p3 |
to disclose that he was using a testosterone gel pre-1 @$ }) x" n. ^9 j
scribed by his family physician for decreased libido
  F* F% Y& x! Z* x4 y1 Esecondary to depression.
2 I5 o! R' h) q" H1 o- GThe child slept in the same bed with parents.8 u) j& d& _! i8 h& O
The father would hug the baby and hold him on his
$ D( I" `9 j* Ychest for a considerable period of time, causing sig-
3 p: T+ x. B: unificant bare skin contact between baby and father.& `1 F, Y) [8 R! {1 C
The father also admitted that after the phone call,4 k" F- \* i/ m+ ?  R+ L
when he learned the testosterone level in the baby
- I: E5 S1 c. X0 u; S: B+ Iwas high, he then read the product information/ L5 \% m: o  s" W' g8 P; \
packet and concluded that it was most likely the rea-
* k* Z6 c  H% Pson for the child’s virilization. At that time, they
1 F  p$ p. ?5 u7 T/ {* \decided to put the baby in a separate bed, and the
, z7 E+ {: U& Lfather was not hugging him with bare skin and had) v7 ~/ f% d- ?) |! z+ }
been using protective clothing. A repeat testosterone5 n4 o) Z9 n, N; V
test was ordered, but the family did not go to the) a! H, `. I7 I+ x6 p9 r
laboratory to obtain the test.
4 o5 p4 b. H5 C/ p  T9 _0 L: m+ KDiscussion9 u9 h5 w8 w  a8 e* s; e
Precocious puberty in boys is defined as secondary
( B3 D( g% R; n+ d) wsexual development before 9 years of age.1,4  r6 z8 G4 [* n+ s
Precocious puberty is termed as central (true) when
0 S" ~/ ~( b7 L1 i: F$ K6 l- @it is caused by the premature activation of hypo-! }0 E4 Q1 w  s& h" \
thalamic pituitary gonadal axis. CPP is more com-0 \8 s) C6 C( i. L/ I) K
mon in girls than in boys.1,3 Most boys with CPP4 D. P- {4 Y9 ~: h' \
may have a central nervous system lesion that is
! C9 \: e& @0 _) A2 y2 fresponsible for the early activation of the hypothal-
0 L/ K$ k; ]$ j" c( u* Wamic pituitary gonadal axis.1-3 Thus, greater empha-- ~7 D& I8 \# N
sis has been given to neuroradiologic imaging in  A7 |0 j9 k/ |6 |: o
boys with precocious puberty. In addition to viril-1 e, d4 r% a, s1 b
ization, the clinical hallmark of CPP is the symmet-2 L# G) g% ^6 [) Y/ ?" H  S
rical testicular growth secondary to stimulation by
* A) B+ Y( ?1 v$ b+ ggonadotropins.1,34 S. h5 D8 R9 r5 N5 v
Gonadotropin-independent peripheral preco-
/ l4 c- }9 G* S/ E- ]& U* f4 wcious puberty in boys also results from inappropriate
+ Y7 l, v' f2 pandrogenic stimulation from either endogenous or1 O* X- U1 o- ?4 x. X
exogenous sources, nonpituitary gonadotropin stim-
8 H7 C* p' ]# b* vulation, and rare activating mutations.3 Virilizing0 z7 B) [' B. X1 e( C( f" T- C$ y
congenital adrenal hyperplasia producing excessive1 S" v) x9 @! z4 @: d/ c" i
adrenal androgens is a common cause of precocious
! H7 ~4 n) `- U) X7 s5 X* p8 R8 Xpuberty in boys.3,4! w6 S+ U7 t( Y5 J3 v
The most common form of congenital adrenal. E0 p, E; P4 ^- L
hyperplasia is the 21-hydroxylase enzyme deficiency.' i" {1 N$ ?+ Y  X
The 11-β hydroxylase deficiency may also result in* z+ m. K& F2 b0 }
excessive adrenal androgen production, and rarely,6 Y7 x  e: d9 l+ v7 F, S- Y
an adrenal tumor may also cause adrenal androgen
* g" M" Q( u# {  K4 D' iexcess.1,3
$ s! e; e' K  o0 l, Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. m1 k" O& j1 L( ^1 n542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 ?' U0 j: W/ Z. N
A unique entity of male-limited gonadotropin-" f, i* z7 p9 |7 u8 b
independent precocious puberty, which is also known
& i: l) V% a' P7 E1 Las testotoxicosis, may cause precocious puberty at a* {& h% ~( E" ^6 s
very young age. The physical findings in these boys2 H( f4 j% F- l: P
with this disorder are full pubertal development,+ Q7 @$ t3 C, V7 e7 j# Q% U
including bilateral testicular growth, similar to boys
- r" l2 _7 v( W$ Jwith CPP. The gonadotropin levels in this disorder
9 Q4 L' H# D9 f7 bare suppressed to prepubertal levels and do not show
% p4 h% M0 y& i6 u) Ppubertal response of gonadotropin after gonadotropin-$ b( S6 K8 z5 O. [) ~  i- z: y
releasing hormone stimulation. This is a sex-linked- Q9 z' l+ ], \2 m7 @/ J# V/ I
autosomal dominant disorder that affects only
1 e0 r, ]  h% n5 {% |males; therefore, other male members of the family5 P# K2 V- I0 P8 q
may have similar precocious puberty.3* j0 }; V/ G9 b" \0 K1 o0 O% T
In our patient, physical examination was incon-0 `7 M+ I8 G6 o$ I: ]9 G5 E+ W* m+ P9 X
sistent with true precocious puberty since his testi-8 ]! g6 R2 Z8 l/ w1 s" J0 R. m
cles were prepubertal in size. However, testotoxicosis1 `1 [0 G9 x  j2 P
was in the differential diagnosis because his father
- v. c5 h+ I0 Dstarted puberty somewhat early, and occasionally,
" {, l- T+ K+ E2 u) k2 btesticular enlargement is not that evident in the4 a+ Q0 m  T1 L  ^
beginning of this process.1 In the absence of a neg-
, S$ a9 p  }  I- eative initial history of androgen exposure, our
3 g% M& M, r* I# x* _: X' N9 Lbiggest concern was virilizing adrenal hyperplasia,! ]4 K% G5 t3 _
either 21-hydroxylase deficiency or 11-β hydroxylase
- f  X5 c0 a3 y. p6 Wdeficiency. Those diagnoses were excluded by find-1 g/ a% g- X( Y: |
ing the normal level of adrenal steroids.
, w. I# s# m* }7 O* F% ^The diagnosis of exogenous androgens was strongly/ j. Z1 B8 i2 t2 e; O  n
suspected in a follow-up visit after 4 months because
4 S& H8 H- ?: o7 Y7 Gthe physical examination revealed the complete disap-* B; ]; b9 ]) j8 P  {! S
pearance of pubic hair, normal growth velocity, and3 j/ X) |5 [' y
decreased erections. The father admitted using a testos-
# \4 R( Y2 w  N6 b& Y' iterone gel, which he concealed at first visit. He was
. n4 S, F: {7 }using it rather frequently, twice a day. The Physicians’) z+ t+ A% @& K& ^4 g9 i: G
Desk Reference, or package insert of this product, gel or1 p2 X0 ?, B  O% u
cream, cautions about dermal testosterone transfer to
! I6 D; B4 B6 ~( m( iunprotected females through direct skin exposure.- c8 Y* ~0 H# \7 T2 h
Serum testosterone level was found to be 2 times the- x. J+ a9 {2 u9 o
baseline value in those females who were exposed to7 U& e* R- P: [* ~' z6 c5 @+ `
even 15 minutes of direct skin contact with their male
7 F& g' Y4 `2 T  m) C- Y! ~partners.6 However, when a shirt covered the applica-
" T+ H- m3 D3 u. K! h7 c) Ltion site, this testosterone transfer was prevented.. U$ s/ b- w# a5 Y* [9 ?; T
Our patient’s testosterone level was 60 ng/mL," ~* A; e& r  b! d
which was clearly high. Some studies suggest that
/ y/ _2 j" M9 f7 k% o5 {+ [; R5 Fdermal conversion of testosterone to dihydrotestos-
* M9 }  _+ I0 M/ P7 ^0 _terone, which is a more potent metabolite, is more1 Z7 ~( Z8 q# Z% C* {+ ^
active in young children exposed to testosterone
7 A7 e& p  H/ H9 O" Fexogenously7; however, we did not measure a dihy-
- |3 q6 {# W7 o% X8 Ndrotestosterone level in our patient. In addition to
4 `, f4 i! B5 `- Bvirilization, exposure to exogenous testosterone in
& C# K+ C: G& ]& X" ^7 Bchildren results in an increase in growth velocity and8 g1 p% h9 q# F0 n( c# ?' h) s- a
advanced bone age, as seen in our patient./ Z) B9 J, D) W) x) C4 ?
The long-term effect of androgen exposure during
; u6 R0 R6 ?0 k* s0 J+ G* @early childhood on pubertal development and final
. p$ Y. O. W- w' gadult height are not fully known and always remain3 M( s: T3 G" }* C9 i
a concern. Children treated with short-term testos-
( F0 g* Q% i9 \7 b7 \terone injection or topical androgen may exhibit some
. k0 u* d: d3 yacceleration of the skeletal maturation; however, after+ G# W# ]5 l1 j
cessation of treatment, the rate of bone maturation7 _  B% M4 \5 z/ g; }' s# p
decelerates and gradually returns to normal.8,9
1 ?' V* Y  r' t  k5 H& YThere are conflicting reports and controversy
' J6 N" u* t& a! q$ Cover the effect of early androgen exposure on adult/ l  O. L- D. j7 N( |
penile length.10,11 Some reports suggest subnormal- \/ z' l+ C1 x
adult penile length, apparently because of downreg-
- @) Q& z- C* g4 O4 ], culation of androgen receptor number.10,12 However,
/ E7 k- Q3 x6 v4 i& RSutherland et al13 did not find a correlation between( Y" L. z$ U  K7 D) ^) J4 O
childhood testosterone exposure and reduced adult" h" X: b' k  f
penile length in clinical studies.
  m; ^9 ]2 q# z8 }Nonetheless, we do not believe our patient is
8 e0 N( P. G# qgoing to experience any of the untoward effects from2 L' o& ?+ P, s$ y' ~3 x$ U+ x
testosterone exposure as mentioned earlier because7 E+ e/ U% ~8 p' b. k3 W
the exposure was not for a prolonged period of time.
5 _+ o) u0 u  kAlthough the bone age was advanced at the time of. J( E: {2 x0 X) A
diagnosis, the child had a normal growth velocity at: S5 c0 [/ H  z8 R" |0 U
the follow-up visit. It is hoped that his final adult
+ R) ^$ h# k& r& p3 _height will not be affected.
) I4 ^' n- I9 f( RAlthough rarely reported, the widespread avail-; {4 B4 V9 f# @5 k/ G% n6 l0 r* a
ability of androgen products in our society may9 i  _8 a+ h0 A: ~
indeed cause more virilization in male or female
% [) p  q5 O8 T7 M# f+ f" J* S) qchildren than one would realize. Exposure to andro-0 A7 U8 y; |8 L3 c8 K4 j0 [
gen products must be considered and specific ques-! C2 b; c* v8 L% e/ R5 F* U
tioning about the use of a testosterone product or( C$ F1 c: y  R
gel should be asked of the family members during
( L& p/ D2 K# S# h5 C! y2 p& {' N# rthe evaluation of any children who present with vir-8 B5 C  |# l& r' ?' H( ^
ilization or peripheral precocious puberty. The diag-+ S; |  f0 K9 a& e2 d/ }3 f
nosis can be established by just a few tests and by
# h1 q7 |8 f; B  X" Y$ W" L$ nappropriate history. The inability to obtain such a
; B% ~; {, w# d$ j4 X7 F+ ?& E& Mhistory, or failure to ask the specific questions, may
/ e6 ?: w1 b+ A2 z# r* Zresult in extensive, unnecessary, and expensive; f0 @- |& S" |
investigation. The primary care physician should be7 l  g: |5 _7 ~7 V- V3 h) G
aware of this fact, because most of these children* |' U! g# w" ^* c' q- Q
may initially present in their practice. The Physicians’+ @: U: x* `3 g
Desk Reference and package insert should also put a
1 p2 I8 ^# ^$ R' @warning about the virilizing effect on a male or
) u# d$ P' ?; b% Ffemale child who might come in contact with some-3 P3 D8 F7 b0 v- v6 M( V
one using any of these products.1 E! B; A9 J7 v" \5 G" h0 X
References
  }# `$ V, I- V, \& F8 [+ `1. Styne DM. The testes: disorder of sexual differentiation
& t5 P- G8 A7 K' b9 f$ H, N  z: dand puberty in the male. In: Sperling MA, ed. Pediatric/ k( }$ }  U$ A$ P8 ~- @5 g
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" ]1 {7 T2 x; V" ^8 B
2002: 565-628.; \9 ~# S: L4 v' a5 q" _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( o; A. Y) d  C, ]% Ppuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old/ z! T$ T3 j/ d
Boy Induced by Indirect Topical( H8 G% t% C1 _! J9 ?5 _5 l
Exposure to Testosterone: V2 \9 z. m2 t8 P6 Q9 h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 z% _+ e. N( v, [  q4 jand Kenneth R. Rettig, MD1& R9 |9 Z# J' ]. v% X) U1 U& T
Clinical Pediatrics
$ Y2 T( Z3 X' y+ k' I+ T* GVolume 46 Number 6! t# p  T& D1 e/ |( ?8 G
July 2007 540-543
9 q* ]7 u& P" ]5 S0 A© 2007 Sage Publications; b: w) _8 A7 \1 Z3 r6 b
10.1177/0009922806296651
9 R+ F; ]" H* J; O+ Whttp://clp.sagepub.com" H1 L/ }( |% D8 ~1 p( y3 e
hosted at
/ T' F, _# g1 b5 Q  r$ M$ F. Y2 h0 bhttp://online.sagepub.com( G3 K; u  x' X- u; W
Precocious puberty in boys, central or peripheral,
1 _* J5 t) d! K9 f& I. Xis a significant concern for physicians. Central
- g- }6 n$ a! T8 cprecocious puberty (CPP), which is mediated
( d/ U  k0 n2 z$ J) Zthrough the hypothalamic pituitary gonadal axis, has
7 c$ _( h+ v3 S$ C# ?5 [  @a higher incidence of organic central nervous system
, e; \4 ^% W& n% Xlesions in boys.1,2 Virilization in boys, as manifested. X% g" R8 X! B' p
by enlargement of the penis, development of pubic
' L) y3 q3 {, i# Y' xhair, and facial acne without enlargement of testi-1 u: u; v# q% u  L' Q. K
cles, suggests peripheral or pseudopuberty.1-3 We0 v6 v0 _5 m' `& x
report a 16-month-old boy who presented with the
7 ~/ y3 E5 P2 |  `- wenlargement of the phallus and pubic hair develop-. U) v' o9 F. L; V  B
ment without testicular enlargement, which was due! ?3 N4 f/ u5 P; l: z6 r. \3 Y% z! |
to the unintentional exposure to androgen gel used by
4 k+ ?- Z9 s2 x0 [5 Ythe father. The family initially concealed this infor-1 `% c# t; |8 l+ r5 `( d
mation, resulting in an extensive work-up for this
9 |# b$ Z; c! ?/ q2 L$ C6 \child. Given the widespread and easy availability of) _7 L7 w. ~6 J! o& o
testosterone gel and cream, we believe this is proba-0 v$ u/ o- ?( _9 l, B
bly more common than the rare case report in the
! [" `, |( _% }) Vliterature.4
# H& W& Q" M# V" JPatient Report
6 T5 v' N9 ?- I! M, d6 V+ ~A 16-month-old white child was referred to the/ Y6 n9 _+ ^( u0 H
endocrine clinic by his pediatrician with the concern5 U+ W/ U6 b- T+ m
of early sexual development. His mother noticed" n# A: Y; R# R, A# }* Q7 Y( K
light colored pubic hair development when he was
4 J3 e) n5 g5 U, s# BFrom the 1Division of Pediatric Endocrinology, 2University of, p9 ^% k0 n% \
South Alabama Medical Center, Mobile, Alabama.8 X  S: a9 {( ^7 f" @4 F
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. K. W9 }* [8 _( ]# P7 `Professor of Pediatrics, University of South Alabama, College of0 D3 H* a2 _3 V2 w: H" v( ]( w6 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: c: d9 R$ s; d$ t* q0 p5 p% B0 t7 A+ d
e-mail: [email protected].
& ?- b' d7 h' _+ D( Wabout 6 to 7 months old, which progressively became! ]1 q) Q" d8 U2 F7 o, L
darker. She was also concerned about the enlarge-
) O  x0 n6 U& h6 k( x$ _ment of his penis and frequent erections. The child- R* @# e2 i# u% a% _
was the product of a full-term normal delivery, with
. ?( p9 s% t% M  h- R) Z' Oa birth weight of 7 lb 14 oz, and birth length of6 r, U6 x1 S* [! j/ O) L5 L( S$ L
20 inches. He was breast-fed throughout the first year) A  S: m. s- p$ M7 @8 S/ [7 z
of life and was still receiving breast milk along with
/ t/ L% k3 _, ~9 v4 x# T* h; N' {solid food. He had no hospitalizations or surgery,
5 i4 z! L) Y9 Q9 _2 Iand his psychosocial and psychomotor development
/ |8 a6 a- G: I8 s5 {1 v9 ?was age appropriate.
, I; j3 Z' I: g) o% F$ ~The family history was remarkable for the father,
7 M7 ?* K! {# G& Kwho was diagnosed with hypothyroidism at age 16,& `" L- z6 t5 p9 P) d1 z
which was treated with thyroxine. The father’s3 l8 X( y! L6 h
height was 6 feet, and he went through a somewhat9 \& |% M7 a5 X6 N% m0 k$ y
early puberty and had stopped growing by age 14.6 [1 I  h. f& E; a3 T9 \- u8 ?
The father denied taking any other medication. The" x- m' t9 \' z
child’s mother was in good health. Her menarche
4 \7 b2 i) R/ z2 rwas at 11 years of age, and her height was at 5 feet+ F, a, \( ~, D1 P
5 inches. There was no other family history of pre-7 E% j/ _2 n: J  L0 N
cocious sexual development in the first-degree rela-8 ?& i& Y0 k6 P$ G
tives. There were no siblings.
* W8 B# c7 y2 w/ Y& K4 \7 g3 aPhysical Examination7 n$ G; w  n/ M, D, `* `7 \6 \9 |- J3 ]
The physical examination revealed a very active,
( R) S- ^# F, _; [6 n# y# ~playful, and healthy boy. The vital signs documented
% f- A) P0 V  E* Ba blood pressure of 85/50 mm Hg, his length was( w2 r* \& s* r3 X
90 cm (>97th percentile), and his weight was 14.4 kg
4 x3 z# n3 I) I# s+ d# ^(also >97th percentile). The observed yearly growth3 f' ^) h2 M: y! S
velocity was 30 cm (12 inches). The examination of
4 x; [0 S: {3 ^1 P9 Mthe neck revealed no thyroid enlargement.
( k5 F/ ]& |+ S; e$ G# ZThe genitourinary examination was remarkable for
$ I, ?3 g: j4 o* j! A1 d+ Uenlargement of the penis, with a stretched length of
+ K( S: o! V& v8 cm and a width of 2 cm. The glans penis was very well
9 o/ w1 n/ C' ideveloped. The pubic hair was Tanner II, mostly around
4 I3 p5 L1 Y7 ?! W. X9 @: Q540
6 q* L# S& Q* F% {3 }- cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* ~1 a3 Y  T4 B. E  i9 jthe base of the phallus and was dark and curled. The
; @* H3 L$ k! I5 s8 W2 Ctesticular volume was prepubertal at 2 mL each.
& x5 x) U4 O' t6 [# t1 OThe skin was moist and smooth and somewhat
. m" H0 e- t+ J8 }2 woily. No axillary hair was noted. There were no2 @4 Y4 N3 O$ n( H+ I3 h( t
abnormal skin pigmentations or café-au-lait spots.
# K/ N6 b7 X# j" @Neurologic evaluation showed deep tendon reflex 2+. Y% p8 F, u9 o- M% [
bilateral and symmetrical. There was no suggestion
8 n1 C. M4 e; G* oof papilledema.: n3 B- G% @% F: o5 p
Laboratory Evaluation
) ]0 V# K6 n5 \The bone age was consistent with 28 months by" Z; Y/ c% Q& ~- i5 w8 V& g( q6 F
using the standard of Greulich and Pyle at a chrono-1 T: B5 G- |9 g  u; v* e2 m
logic age of 16 months (advanced).5 Chromosomal
2 D* g2 B* Z' Z( @( Mkaryotype was 46XY. The thyroid function test
3 s' R8 W, @2 A: i/ @showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 S0 v; U8 W7 c( P8 W  A! V
lating hormone level was 1.3 µIU/mL (both normal).  P% L" `  q- L# m+ A! t
The concentrations of serum electrolytes, blood: @' r. k. B4 l$ T' E/ P+ ]
urea nitrogen, creatinine, and calcium all were2 U! O+ |) G1 x' K
within normal range for his age. The concentration
* ~6 l# K3 z# G, Gof serum 17-hydroxyprogesterone was 16 ng/dL) u7 T; Y7 c* m/ C& h+ l9 k
(normal, 3 to 90 ng/dL), androstenedione was 20
! k& q  n1 y# P- p: s$ Y6 [( Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, R/ I6 n* P$ e) v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ q3 H, s- {2 ^# [desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ K" w! X0 s! P; W, m4 K
49ng/dL), 11-desoxycortisol (specific compound S), ~2 N3 c$ c% v+ `5 f" [& ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& L- \1 f7 u1 I; R  t3 stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# J* m% `( ^* R- B- e8 Y3 g# ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 J" B) p2 o6 F, Z. D
and β-human chorionic gonadotropin was less than, y% H7 R7 F8 U6 U5 h
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; w- N; o9 f) }  Z& M; Tstimulating hormone and leuteinizing hormone/ B7 }; H7 H. d( Z1 B
concentrations were less than 0.05 mIU/mL' _) b- C9 ]' \* `, t5 ~* n: o* i
(prepubertal).
0 [9 y2 D3 G) U7 t0 `4 }! rThe parents were notified about the laboratory" t+ B$ n3 ]& G( T' t( J
results and were informed that all of the tests were
- c) k5 V8 |2 o& v" ^normal except the testosterone level was high. The: i/ |- h7 z& k* x' `
follow-up visit was arranged within a few weeks to  ~/ D) I2 c! e2 e' v2 I" w/ ?' d
obtain testicular and abdominal sonograms; how-' t# k7 _9 b+ r9 H* ~) H" U' e
ever, the family did not return for 4 months.
6 I- |% W* Y9 _1 X1 tPhysical examination at this time revealed that the: M( x5 a+ _2 r) {" \
child had grown 2.5 cm in 4 months and had gained8 m% T) l! `' M- e: G3 u8 c
2 kg of weight. Physical examination remained5 j( u5 z: t# k$ l  j
unchanged. Surprisingly, the pubic hair almost com-
7 _+ b" Z/ ]4 a8 [5 F6 a# i' ]2 {9 Cpletely disappeared except for a few vellous hairs at
9 L1 z: u2 V/ x. G% R5 J, Ethe base of the phallus. Testicular volume was still 2' f2 v) j& C  g, v! Q1 u
mL, and the size of the penis remained unchanged.; `( `: j2 e% o% G) l3 q
The mother also said that the boy was no longer hav-' P* B+ C% ~% E# ?* T( c
ing frequent erections.
' ^$ d% H$ O- J. g$ ^Both parents were again questioned about use of  O6 f& P$ c! ]( h# k
any ointment/creams that they may have applied to6 c* j: M$ T8 T$ G, `
the child’s skin. This time the father admitted the9 L# Q- m' r" b( H0 w5 I
Topical Testosterone Exposure / Bhowmick et al 541! S- h1 c3 z) `' U  q- u
use of testosterone gel twice daily that he was apply-
! H# i! r9 F3 u0 ]7 W( ling over his own shoulders, chest, and back area for2 c  o% Y, m3 X
a year. The father also revealed he was embarrassed
% e7 [8 S4 H. f- w/ Vto disclose that he was using a testosterone gel pre-
. y1 Y1 B+ W% {5 y" C: a* Q7 t! L/ nscribed by his family physician for decreased libido
  V" R; ]! Q6 b( ysecondary to depression.
2 G7 R: \) p. G; f8 EThe child slept in the same bed with parents.3 a% p3 L+ @9 p! \: Q" _5 D7 a
The father would hug the baby and hold him on his
/ Z" v+ \$ ?. Vchest for a considerable period of time, causing sig-
. B8 J$ y. A$ m( Onificant bare skin contact between baby and father.
4 J* [0 t$ G( C) _' CThe father also admitted that after the phone call,9 u2 f- A4 f3 H; B# J
when he learned the testosterone level in the baby
0 J( o: A' V3 }" Mwas high, he then read the product information0 @& e2 j2 p0 e8 F3 K
packet and concluded that it was most likely the rea-2 q! Z0 J2 p* ?" q
son for the child’s virilization. At that time, they
  I& w3 d* t* I  q# ^decided to put the baby in a separate bed, and the
, M) @- W' J$ g8 }+ gfather was not hugging him with bare skin and had
9 i0 W, T: j% M5 c- S. @: C) Xbeen using protective clothing. A repeat testosterone
: G% @- O/ s( C  Wtest was ordered, but the family did not go to the# H: L8 A2 h3 ?9 g' v$ L  ]
laboratory to obtain the test.1 c4 m' M% U6 L* r
Discussion) e) m- Y2 N+ ~  z( i9 r
Precocious puberty in boys is defined as secondary
" o6 O' B3 K* s! Usexual development before 9 years of age.1,4
0 w3 X! z8 u  x1 t, i/ D: Z8 APrecocious puberty is termed as central (true) when& H& Q  c+ I9 K. J9 ]2 g
it is caused by the premature activation of hypo-) W( `) F2 |+ ~% H& n6 D+ J
thalamic pituitary gonadal axis. CPP is more com-
& S9 C, r/ B( z7 U9 T0 T5 f8 D! ?& Tmon in girls than in boys.1,3 Most boys with CPP
; ]$ |; j, ?; U+ I: ]7 V/ `may have a central nervous system lesion that is9 v6 o* j* U- p. ]$ W
responsible for the early activation of the hypothal-3 H$ L% l6 B, Z8 Q4 K
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ Q# K# P+ K5 @$ Ysis has been given to neuroradiologic imaging in
7 e+ x- Z( ]2 g) e8 tboys with precocious puberty. In addition to viril-0 s( {+ a& P! S
ization, the clinical hallmark of CPP is the symmet-5 b/ f: }3 B5 Y5 d( M* h5 u) z
rical testicular growth secondary to stimulation by) F9 |: N! v; O+ @
gonadotropins.1,3( o# ]2 q  x6 Y6 K7 @5 k5 [
Gonadotropin-independent peripheral preco-
, n) Z4 r5 W# [5 ~3 I, Zcious puberty in boys also results from inappropriate
+ S3 k; L9 I1 U+ ~androgenic stimulation from either endogenous or* Z$ E2 Y  ]( b- a9 g
exogenous sources, nonpituitary gonadotropin stim-$ f$ \4 O8 R0 H4 b# Q# g
ulation, and rare activating mutations.3 Virilizing
5 q7 R/ O, ~9 dcongenital adrenal hyperplasia producing excessive
$ W! O' V& X8 Ladrenal androgens is a common cause of precocious. S% G% z# h( l
puberty in boys.3,4
8 z( G$ W" k! F  x# LThe most common form of congenital adrenal) i5 M) g- z. Z" I! t
hyperplasia is the 21-hydroxylase enzyme deficiency.4 \4 p" \! z. c  R. i4 i+ q
The 11-β hydroxylase deficiency may also result in
2 S  u& t3 y' p( W$ K! T! qexcessive adrenal androgen production, and rarely,
) |* U2 z! C+ ]; E$ Q7 gan adrenal tumor may also cause adrenal androgen
# X: Z9 ?' h: L' Y  }* t  f( u" s% ?, Rexcess.1,3. f; p+ U: x+ E1 k  k/ i' l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- E% y: f* R' i* X. d& Y, L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 ~; w# H* s' A. d9 D( SA unique entity of male-limited gonadotropin-' H4 [: X: L9 R% X
independent precocious puberty, which is also known
. l& v% O: d& T* x+ ^as testotoxicosis, may cause precocious puberty at a
; _$ Y3 E  P3 t  F" z* q& ?very young age. The physical findings in these boys
# d  @' |: h" K5 B; Ywith this disorder are full pubertal development,
& ]! f  M6 m1 n# b! ~: t; T  w8 [6 t' dincluding bilateral testicular growth, similar to boys
- }; r% p9 h" L7 ]! ^with CPP. The gonadotropin levels in this disorder
" N! a3 {" J- m( Y. tare suppressed to prepubertal levels and do not show% f" U, G) \4 m/ L) \5 D, _1 M) Q
pubertal response of gonadotropin after gonadotropin-
* `4 l& d/ G0 Q$ f6 w  Rreleasing hormone stimulation. This is a sex-linked% F/ [8 L2 \. V# {
autosomal dominant disorder that affects only
9 X( y6 V- o! ]( X% p- m7 _males; therefore, other male members of the family* {  w5 a: Z! R8 j- R7 p
may have similar precocious puberty.3( v- P* u" y" L) u5 q. ?( `
In our patient, physical examination was incon-) g% `& n* S- ~  b
sistent with true precocious puberty since his testi-
) y; _) ^, R" \cles were prepubertal in size. However, testotoxicosis
4 `+ \  Y+ x- i/ c- O0 t4 }was in the differential diagnosis because his father
1 w  ]  n# a2 t. K: xstarted puberty somewhat early, and occasionally,8 I" ^# |1 _& ?5 t
testicular enlargement is not that evident in the3 q# y6 X# q5 Y( e; [9 d. g( p8 ]' U
beginning of this process.1 In the absence of a neg-" q8 V) z+ h3 V" A
ative initial history of androgen exposure, our4 v* Q* L" Y' i+ S4 D8 _. I
biggest concern was virilizing adrenal hyperplasia,. B3 b* w" G3 p( r! @- w; |
either 21-hydroxylase deficiency or 11-β hydroxylase6 g/ @" G2 a6 A1 _  C' u. X
deficiency. Those diagnoses were excluded by find-4 i5 c; A2 S; d  u) Q3 h" w2 v
ing the normal level of adrenal steroids./ K0 L+ C* {5 V4 H
The diagnosis of exogenous androgens was strongly$ q3 d" @0 |, ]  k5 c8 O. `7 |" l
suspected in a follow-up visit after 4 months because
; Y( c& Z6 M9 o. v2 ^3 d: rthe physical examination revealed the complete disap-" j% I8 U& ^: w0 A0 P& ~
pearance of pubic hair, normal growth velocity, and
8 ?3 U7 ^. m' g/ G9 ~  |decreased erections. The father admitted using a testos-
) {, v2 I, w1 Wterone gel, which he concealed at first visit. He was
3 H# e8 f  E; wusing it rather frequently, twice a day. The Physicians’. P) i, |6 y7 i
Desk Reference, or package insert of this product, gel or
9 a9 B% c$ Y3 L+ c# D& }cream, cautions about dermal testosterone transfer to. D8 ~# D+ z  Y% k% }
unprotected females through direct skin exposure.% w. F4 V6 b! H. D7 k
Serum testosterone level was found to be 2 times the6 |- v% G9 U6 D8 b& v/ q( u
baseline value in those females who were exposed to" x0 b7 m$ L8 S, P
even 15 minutes of direct skin contact with their male
4 L& f& A! W. s! P3 hpartners.6 However, when a shirt covered the applica-* j6 o0 e: _, s0 Q1 Z
tion site, this testosterone transfer was prevented.+ B2 q# S. u+ i7 y8 F. |5 A
Our patient’s testosterone level was 60 ng/mL,6 K. }6 s0 A2 @8 R
which was clearly high. Some studies suggest that
4 f, c6 U0 ?6 i* G$ J8 fdermal conversion of testosterone to dihydrotestos-
. b! a4 |8 c9 `9 p& A! Z4 bterone, which is a more potent metabolite, is more" M7 h4 C3 Z% a1 x! y/ \
active in young children exposed to testosterone, W/ o4 \. Q! u4 ?7 o! L/ E+ N! X, I
exogenously7; however, we did not measure a dihy-
: s1 Y; P% o& ^  J1 v% t+ t. Cdrotestosterone level in our patient. In addition to
/ k; m! I7 ^) U% X& {virilization, exposure to exogenous testosterone in
% p/ ?  x/ \$ C1 M! k" Y7 ichildren results in an increase in growth velocity and# c; Y0 J, f$ w# R( C% u. L# u
advanced bone age, as seen in our patient.
7 x( ~! G* r4 eThe long-term effect of androgen exposure during
: g/ g8 u' k) y, Gearly childhood on pubertal development and final
, L1 |3 H: ]+ q* Kadult height are not fully known and always remain
& O7 [5 w  d8 b0 Ia concern. Children treated with short-term testos-
- Z$ L% |+ Z$ I2 Kterone injection or topical androgen may exhibit some, w$ `7 V% A* R0 o
acceleration of the skeletal maturation; however, after
1 u0 H$ X4 o, E7 Mcessation of treatment, the rate of bone maturation
% C2 n6 q: N% `* w3 v! G0 Zdecelerates and gradually returns to normal.8,97 }* i, @8 D! X( Q9 {' E2 S
There are conflicting reports and controversy
9 G, F1 T  H) G6 t6 X2 a" F, ^, Zover the effect of early androgen exposure on adult
% @  z6 W* n$ D/ ~  g2 X% Wpenile length.10,11 Some reports suggest subnormal5 \$ y- O. o6 D( h5 {! A
adult penile length, apparently because of downreg-" l0 J' \, g! s! I$ ~) @$ ~9 ~
ulation of androgen receptor number.10,12 However,
! a) U  d) {  r' u% O* zSutherland et al13 did not find a correlation between
8 @# p$ S& A( r$ e/ t5 F- tchildhood testosterone exposure and reduced adult* a- R6 {+ x. h0 m; z
penile length in clinical studies.
7 L7 G, k- X# w! TNonetheless, we do not believe our patient is
- P) b' g! U5 M- s' ggoing to experience any of the untoward effects from) N+ c+ Y, p& m! y5 o" A0 P
testosterone exposure as mentioned earlier because% ~3 g: U2 v7 S4 O
the exposure was not for a prolonged period of time.7 L4 l. e! p; ^8 s9 {& K2 O
Although the bone age was advanced at the time of  |- f+ T7 i7 z# }
diagnosis, the child had a normal growth velocity at
# R; z  X( C8 L- g7 K5 c: vthe follow-up visit. It is hoped that his final adult0 ]$ A, |% M% w  A9 f$ }2 I* ?
height will not be affected.. a) l% K5 d. [3 \8 p. U3 Q" L
Although rarely reported, the widespread avail-) u0 j. ]% w7 F
ability of androgen products in our society may; d7 J# j8 u% @- N/ V# D2 u% K' U
indeed cause more virilization in male or female
" R+ y. f3 d- n; `2 w2 ~+ w) Rchildren than one would realize. Exposure to andro-! K( \: V$ J6 F9 G; {( _& l
gen products must be considered and specific ques-2 G& U# `$ ]9 O, J+ F: x/ g
tioning about the use of a testosterone product or( y. m9 p' r* Q; E
gel should be asked of the family members during
! L# x) v) E0 ~) bthe evaluation of any children who present with vir-) f7 U5 b2 S- n3 p' q6 R
ilization or peripheral precocious puberty. The diag-; z1 f9 Y" u) F$ ?- J
nosis can be established by just a few tests and by* V0 q+ v- p5 B% c
appropriate history. The inability to obtain such a! u3 e# A$ A+ `+ F, P
history, or failure to ask the specific questions, may4 u& b- z. b: B1 @, e
result in extensive, unnecessary, and expensive& g' w7 @; H! S+ O2 P- l0 H" `
investigation. The primary care physician should be3 n' ^% z# f/ P' H, ~. ^5 @8 p) q
aware of this fact, because most of these children! S$ Y  P" E1 D+ O2 @; a1 K. g
may initially present in their practice. The Physicians’
& u: F3 G8 x$ o+ X& H# ?0 V# S# }Desk Reference and package insert should also put a9 G: K6 w7 F8 q& q# p4 c( S
warning about the virilizing effect on a male or
! E% Z+ K( W! ufemale child who might come in contact with some-+ Y. W! E9 U+ Z( q8 h6 g
one using any of these products.
3 ], v8 ?( c, Q9 s, `9 _References
6 o2 G! J. K; t! F9 v1. Styne DM. The testes: disorder of sexual differentiation, g  ~7 A, B/ G, `! f
and puberty in the male. In: Sperling MA, ed. Pediatric
" e! ^" V& J7 K7 B/ R' pEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% a+ i$ E& s6 B( \: a
2002: 565-628.! I4 j# {* Y5 D/ U% X) s* A. [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& n$ V6 T# g+ N5 npuberty 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

& i, L: |  O' F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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