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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
( Z3 }% ~; T# n- _. CBoy Induced by Indirect Topical
: c$ B0 k! o4 G' A5 p* U$ P# l0 {Exposure to Testosterone
/ ]0 X, B) z6 \. ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 a; B! v* b7 w1 \. Vand Kenneth R. Rettig, MD1
# i0 ?+ j" T: l7 B$ d( l  kClinical Pediatrics
) v" M: M' ^' ]( [  UVolume 46 Number 6
7 q% ~" |  S7 V8 g# f/ e8 k1 `July 2007 540-5438 I, I' i  a& m/ N  L8 j8 d' _
© 2007 Sage Publications
) Q1 {7 `6 m; O+ d) C, q/ f10.1177/0009922806296651
/ L4 G3 t7 Y; w, _http://clp.sagepub.com- I9 f/ i* b9 Y3 v+ i4 O& b0 Y
hosted at8 o1 c3 s6 A6 p7 E
http://online.sagepub.com
$ o. `$ T8 q4 E' ^' y. [. b9 j4 cPrecocious puberty in boys, central or peripheral,4 e3 _* ]: |4 l; }$ u1 F* S
is a significant concern for physicians. Central
7 _/ l6 x! \$ c$ o1 Z4 h! o, D2 eprecocious puberty (CPP), which is mediated  I( w8 |3 k4 _3 y  c& N. }8 o
through the hypothalamic pituitary gonadal axis, has
$ u; r7 D/ {9 _5 u7 ha higher incidence of organic central nervous system  y8 x/ J* `) k! f6 Q* g0 \% ^
lesions in boys.1,2 Virilization in boys, as manifested
" L* z/ y3 E% Q  m( bby enlargement of the penis, development of pubic# D3 x4 [) R7 R/ v# Z  C
hair, and facial acne without enlargement of testi-
' a6 n9 c( `6 C5 icles, suggests peripheral or pseudopuberty.1-3 We
* |. k+ r0 t: @: e/ Sreport a 16-month-old boy who presented with the
& }& X$ D% |- t. z- \! @. Yenlargement of the phallus and pubic hair develop-; f9 {9 B! k( Y$ S
ment without testicular enlargement, which was due. M8 R# _1 `# l1 M: y, \! ]
to the unintentional exposure to androgen gel used by
0 ]% Z: D; W& }/ y6 ~* `the father. The family initially concealed this infor-
5 V+ d9 q. ~" M* {mation, resulting in an extensive work-up for this) ]/ Z6 f8 G1 W$ q/ L0 N
child. Given the widespread and easy availability of$ S5 ~8 i9 `. _* T' [
testosterone gel and cream, we believe this is proba-
2 E; x2 s. ~! M( Ubly more common than the rare case report in the
& X6 `6 b/ l- H$ A( Y; o' |literature.4
& V' R- T; c  B4 yPatient Report
* |) [/ M! s, m- bA 16-month-old white child was referred to the6 I4 \  s- N- z9 N( z" p7 Y
endocrine clinic by his pediatrician with the concern
" P$ Q+ q2 T6 f! aof early sexual development. His mother noticed1 P0 y9 e; P0 L- C! \8 j" l$ S5 F
light colored pubic hair development when he was
4 y- V: d+ U3 s$ x4 ~From the 1Division of Pediatric Endocrinology, 2University of
3 v0 L+ m: ~+ W, h. C% G) T- iSouth Alabama Medical Center, Mobile, Alabama.% {/ @( n0 q0 |' s* p# p4 G# E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 D9 l# s& J' r  AProfessor of Pediatrics, University of South Alabama, College of3 v8 b3 A: v! P" f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 s3 }. h/ f1 re-mail: [email protected].
2 J! b: ~7 N4 T% x# Fabout 6 to 7 months old, which progressively became
$ v3 H8 e9 f3 b% A; Y) |$ ddarker. She was also concerned about the enlarge-
, ^( _! V# Q3 e+ Yment of his penis and frequent erections. The child& c0 P- n4 B* i3 t$ q4 z- J+ j9 u9 L
was the product of a full-term normal delivery, with
# p6 x2 \" T) l: sa birth weight of 7 lb 14 oz, and birth length of
8 g( g2 p; {# G" ]3 z1 v6 n0 o20 inches. He was breast-fed throughout the first year3 y" \+ B* {& T. M
of life and was still receiving breast milk along with
+ k9 q, @4 ]( W/ j  Dsolid food. He had no hospitalizations or surgery,
$ ]. P1 A$ b6 O* Uand his psychosocial and psychomotor development
! c' ~* E' n' x& B% M3 `was age appropriate.
6 I2 r; z$ D# R' t3 XThe family history was remarkable for the father,
" M3 o  |3 G  C: M& h  }who was diagnosed with hypothyroidism at age 16,
8 ?- l2 F7 S3 e4 I( X; h8 h% _2 awhich was treated with thyroxine. The father’s3 P. K' y4 b4 F8 m) P! y
height was 6 feet, and he went through a somewhat
# y1 I+ h; p6 k2 h5 m7 dearly puberty and had stopped growing by age 14.2 g- Y9 \; O8 `% s+ o$ s. l
The father denied taking any other medication. The
9 a' N# U* y4 {! I! M" |1 V9 bchild’s mother was in good health. Her menarche
- A% _& v! _" Iwas at 11 years of age, and her height was at 5 feet
& v* n. d8 ~( r/ k! ^3 Y5 inches. There was no other family history of pre-
$ P* |) ^9 I! ]: V2 O8 e$ Zcocious sexual development in the first-degree rela-# E) E8 U' A8 b' W* K5 Q
tives. There were no siblings.
% X4 r, Y' Z# l, IPhysical Examination, [* r; T* E2 J* Q$ L
The physical examination revealed a very active,
/ W" c" a8 }6 [2 w0 `3 W- Splayful, and healthy boy. The vital signs documented
. F# d1 T& _$ T# F, {+ ]a blood pressure of 85/50 mm Hg, his length was
( \* \/ m7 d5 x& V$ B+ _90 cm (>97th percentile), and his weight was 14.4 kg
: L" Q: P7 ^. \3 G( b' X(also >97th percentile). The observed yearly growth  K- S3 O7 X) V6 l
velocity was 30 cm (12 inches). The examination of
, p+ j- |6 q" X0 [3 v/ p0 `. Mthe neck revealed no thyroid enlargement.
9 I: N# c4 U0 W" [5 |The genitourinary examination was remarkable for
8 H8 R. U$ {% _7 p& S, Kenlargement of the penis, with a stretched length of
. @& A) O0 O* I8 cm and a width of 2 cm. The glans penis was very well
: x( T% l0 {8 K! t5 b  b5 ~developed. The pubic hair was Tanner II, mostly around
- z! P$ F, E' J4 ^: r4 r% S3 C- H  u540( D. U. _' f0 Z9 f" u3 \- ^3 c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* y" G( ?/ _0 `. s5 G4 j) uthe base of the phallus and was dark and curled. The
) F9 Q, `0 @2 \, R1 w+ F4 rtesticular volume was prepubertal at 2 mL each.. j+ {' C& v: _9 q- m+ _
The skin was moist and smooth and somewhat
0 W' U7 e3 Z( p% w- J5 p6 ioily. No axillary hair was noted. There were no
/ t! _2 j( F" s- G4 Sabnormal skin pigmentations or café-au-lait spots.5 J* v+ _; a# p
Neurologic evaluation showed deep tendon reflex 2+5 B) I9 y/ q& F8 B# q
bilateral and symmetrical. There was no suggestion
' a; l; S" n3 M! r7 u/ qof papilledema.0 x0 `1 F8 ~+ V$ D. Z9 d
Laboratory Evaluation
$ A+ N2 R3 ?/ WThe bone age was consistent with 28 months by
( A" b. c0 C/ Z; f& X; J$ Eusing the standard of Greulich and Pyle at a chrono-, T# D5 N- M' A, e7 G5 \" c
logic age of 16 months (advanced).5 Chromosomal* e8 s/ @% Q. a1 ]
karyotype was 46XY. The thyroid function test% P5 A, u# ?0 l: M# T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ Y7 y" \* c9 plating hormone level was 1.3 µIU/mL (both normal).' a2 }- w0 N$ g3 R7 j4 c- N/ [
The concentrations of serum electrolytes, blood
/ }4 W; O4 M9 Nurea nitrogen, creatinine, and calcium all were
4 d- D' m/ l2 n! f5 w7 V2 lwithin normal range for his age. The concentration$ {1 b. S$ Z6 I% Q
of serum 17-hydroxyprogesterone was 16 ng/dL
% O& p- }$ ]' ?& o. Q(normal, 3 to 90 ng/dL), androstenedione was 20
  c5 W, _" j1 k+ f9 s3 r2 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( k/ _6 X; G; \: E8 z; i2 R! X2 uterone was 38 ng/dL (normal, 50 to 760 ng/dL),
" t1 L- G, A% v+ i9 Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ z( p$ t9 I7 E  p) Z. r  R" [49ng/dL), 11-desoxycortisol (specific compound S)
& @5 P1 t3 j/ N6 ~9 v- awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 `8 q& @  r2 l$ g4 `+ H5 u7 @/ jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ `& l7 ~( L6 H8 e: x4 C3 y/ Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ `) P$ X/ Y* j' {0 I) l
and β-human chorionic gonadotropin was less than) c$ I+ E2 y( @$ D4 y8 K
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 c3 V0 ]# V* Fstimulating hormone and leuteinizing hormone, Y0 C6 n% |* ?" }2 n6 `- [
concentrations were less than 0.05 mIU/mL
- A+ f# j) ~5 T2 J9 i(prepubertal).
+ q" d5 K; K  p! B; ^! Y, t5 u3 uThe parents were notified about the laboratory8 Q) u% p- K! S6 z8 ~
results and were informed that all of the tests were5 _1 n$ s0 q2 k+ @
normal except the testosterone level was high. The- Y) @& o& U& A% Z" l: w
follow-up visit was arranged within a few weeks to; G: e7 \0 {+ P( U4 n% E
obtain testicular and abdominal sonograms; how-
( L$ r" r$ }, ]% v4 zever, the family did not return for 4 months.
$ V8 H: R, ?. A8 @) v' IPhysical examination at this time revealed that the
# L( r7 n) v7 I: j9 _$ _0 nchild had grown 2.5 cm in 4 months and had gained
1 L  F" @2 I0 q) p! c; P: P2 kg of weight. Physical examination remained; k) v3 m( C. x
unchanged. Surprisingly, the pubic hair almost com-
- l7 M" r" ]  j/ I% Gpletely disappeared except for a few vellous hairs at$ X+ D. L! f+ F) S/ R
the base of the phallus. Testicular volume was still 2
" H* F. O3 i( N; {$ @! OmL, and the size of the penis remained unchanged.
3 c1 f1 g" E% |7 p# c- a2 V& FThe mother also said that the boy was no longer hav-( r7 S$ j$ A1 R0 [, ]3 i8 L
ing frequent erections.
/ x% s4 q. i7 CBoth parents were again questioned about use of
6 h- X, P0 \5 X: @  tany ointment/creams that they may have applied to: ^' i" N% w- \6 N! `
the child’s skin. This time the father admitted the
( `  _+ d. Z' s+ ^. TTopical Testosterone Exposure / Bhowmick et al 541( k% v5 `  v- s2 Q
use of testosterone gel twice daily that he was apply-
! S7 U$ }- A5 R" i; j$ Z3 K  `ing over his own shoulders, chest, and back area for
  @6 m1 v) m, N# Ta year. The father also revealed he was embarrassed
* z7 I, a9 V, T( c& ]2 ^, Uto disclose that he was using a testosterone gel pre-6 }, a# c8 i  e) A; g/ Q9 C: Y2 Y
scribed by his family physician for decreased libido
$ B) D$ ]+ U' Ysecondary to depression.
. w" w( H1 V- sThe child slept in the same bed with parents.
9 f: `" o' _- g" Q1 WThe father would hug the baby and hold him on his, J' a5 c% Y# a$ b
chest for a considerable period of time, causing sig-6 p5 C, z7 I+ g3 H
nificant bare skin contact between baby and father.
: a. l/ d2 |# l+ Y: PThe father also admitted that after the phone call,
9 F+ w) I; }. kwhen he learned the testosterone level in the baby
' {% k7 E0 j8 j$ o4 \8 T- Ewas high, he then read the product information" I9 m3 Z) E& a" H
packet and concluded that it was most likely the rea-
. V* k# d3 J0 v- Ason for the child’s virilization. At that time, they( K1 T# _' |' R% z+ A8 U# U
decided to put the baby in a separate bed, and the" X6 `  ]# C# h. V1 f0 [
father was not hugging him with bare skin and had1 n* `( P5 \* V- `4 `# Y, U
been using protective clothing. A repeat testosterone
' ^# Y5 U7 r9 c* U9 S; i% stest was ordered, but the family did not go to the
3 Z# `' |. ?: W- \2 g: ^' d9 Dlaboratory to obtain the test.
$ o, F6 r3 e! j9 i  j2 R; r, `4 iDiscussion/ R2 g! \9 N1 O2 a& Y) K. L: E
Precocious puberty in boys is defined as secondary
  ^6 ?. E% n" M4 ysexual development before 9 years of age.1,4
( }6 F9 ?" p5 L8 @7 g! UPrecocious puberty is termed as central (true) when
+ s8 H  K  s) E& Jit is caused by the premature activation of hypo-
! W% C! Z  e2 qthalamic pituitary gonadal axis. CPP is more com-1 L3 Z; N5 f+ c
mon in girls than in boys.1,3 Most boys with CPP
( x+ b9 D6 m$ ^! F9 gmay have a central nervous system lesion that is. Y1 }$ }' s) p3 o
responsible for the early activation of the hypothal-% Q0 m5 f' G3 F$ q$ J- _
amic pituitary gonadal axis.1-3 Thus, greater empha-
# ^/ }9 j- ~1 Gsis has been given to neuroradiologic imaging in# ]) J9 E& V* Y  A6 z9 Z0 d4 W
boys with precocious puberty. In addition to viril-) R! x. w  o; Z8 I6 S( n6 C' b
ization, the clinical hallmark of CPP is the symmet-
2 Q( L; R  `& u- _rical testicular growth secondary to stimulation by5 [' R  C( h* g0 H$ n
gonadotropins.1,3
; \2 b$ V8 ~( t; T: V7 a$ i7 `Gonadotropin-independent peripheral preco-
1 A( e. |7 C/ U/ V1 O3 ^% lcious puberty in boys also results from inappropriate
, f& q! R' {2 l. @3 Wandrogenic stimulation from either endogenous or
# [2 E! m: F% b9 cexogenous sources, nonpituitary gonadotropin stim-
3 c3 I: n2 L! k; N! H# ]ulation, and rare activating mutations.3 Virilizing2 R- m, W) N8 j1 h, O# ?9 R
congenital adrenal hyperplasia producing excessive) v4 \+ L7 a8 p# S& X0 o
adrenal androgens is a common cause of precocious
2 |" b! c/ X0 i( a  R+ ~1 d$ [; y% Fpuberty in boys.3,4
, w. b/ r  W; G8 ~# ^2 ZThe most common form of congenital adrenal* X% Y3 k- [$ W2 F  j& `! B
hyperplasia is the 21-hydroxylase enzyme deficiency.
' L- ^0 D. i9 {. }The 11-β hydroxylase deficiency may also result in5 [) P8 _2 Z$ C5 u
excessive adrenal androgen production, and rarely,
4 I8 d1 \# f! E7 M" Can adrenal tumor may also cause adrenal androgen
; a4 N6 O5 r/ x, p6 ^) sexcess.1,3- u3 G6 ^) i( t7 p( E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& a$ G' L+ \& T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: w: d. x7 T, q8 x7 h4 UA unique entity of male-limited gonadotropin-
* \" ?2 P! z' O- d. O: \) Dindependent precocious puberty, which is also known# \' Q( I! G# W) I# d. D" x! O
as testotoxicosis, may cause precocious puberty at a
$ u) P, \7 a4 {" Uvery young age. The physical findings in these boys
. m- [! J" O) Twith this disorder are full pubertal development,
- ?7 I3 `9 Z1 @  t; {including bilateral testicular growth, similar to boys
9 n' I; ]" f. i2 S! I; t4 ~with CPP. The gonadotropin levels in this disorder4 g5 ?( g: X5 A, p5 C4 K
are suppressed to prepubertal levels and do not show9 z  S* e. N/ s, M/ k6 B
pubertal response of gonadotropin after gonadotropin-
; w6 l9 p7 [6 mreleasing hormone stimulation. This is a sex-linked
. ^+ l& o/ n4 h. M5 ^: N& Uautosomal dominant disorder that affects only$ d/ k0 X: N4 I& t( ~; c
males; therefore, other male members of the family
6 M! K* h" Q2 h1 smay have similar precocious puberty.3
9 Z+ v* _- t* Z. F# lIn our patient, physical examination was incon-
% C0 T, X5 G. `, D- D* s$ J# k8 Vsistent with true precocious puberty since his testi-
0 I; o4 e5 P' g4 T) Acles were prepubertal in size. However, testotoxicosis
( O1 Y( q8 T6 `) Twas in the differential diagnosis because his father* e/ F, y8 ?2 j3 \
started puberty somewhat early, and occasionally,
$ Z, x; t$ u0 [- L! |8 Atesticular enlargement is not that evident in the3 m6 n; E+ B, |9 p, t( w7 c4 v9 t' ?. v
beginning of this process.1 In the absence of a neg-* \! X- y* ^1 x  D
ative initial history of androgen exposure, our1 Q( d8 z6 }2 z9 a
biggest concern was virilizing adrenal hyperplasia,, N- ^: L, S4 x7 k, C
either 21-hydroxylase deficiency or 11-β hydroxylase
3 {8 m0 O+ F/ d0 C: y$ ?" Pdeficiency. Those diagnoses were excluded by find-
, b9 c1 U* D4 p! i; U6 Ding the normal level of adrenal steroids.( i1 ?+ c4 q9 V* c$ ?9 b' ^* n
The diagnosis of exogenous androgens was strongly
" c& V4 X5 W6 g4 Csuspected in a follow-up visit after 4 months because
1 ^3 m2 }* T- M- B% v8 w8 k5 `. ithe physical examination revealed the complete disap-2 O! O; U2 D& l, i# J) z' B- d  r0 B
pearance of pubic hair, normal growth velocity, and8 Q! k9 M9 w6 p" s& ?9 M- p
decreased erections. The father admitted using a testos-
& x+ Z- O9 ]% y$ s$ O6 h1 |. Kterone gel, which he concealed at first visit. He was
. n$ C% g8 r/ ^) p/ o6 [using it rather frequently, twice a day. The Physicians’
3 Z4 G. z" p: S1 p# L6 vDesk Reference, or package insert of this product, gel or0 W5 O2 Y" N1 L! u7 f+ Y
cream, cautions about dermal testosterone transfer to
0 M! S, J8 W* C, P; ?  U7 tunprotected females through direct skin exposure.
6 W4 U& N3 X) D- b" ^3 w& OSerum testosterone level was found to be 2 times the
7 Y3 }: Y" {  K  e5 X) @$ ]baseline value in those females who were exposed to
6 f1 k( g, w; a3 g, n$ weven 15 minutes of direct skin contact with their male
" B0 O# l2 C' r, v$ qpartners.6 However, when a shirt covered the applica-3 x) F1 L* i3 S
tion site, this testosterone transfer was prevented.7 N) f2 m' f0 Y1 j
Our patient’s testosterone level was 60 ng/mL,9 _. o5 x6 O# N$ }; U$ r$ V4 x
which was clearly high. Some studies suggest that
8 o4 S& Y3 I5 [) _. G4 Rdermal conversion of testosterone to dihydrotestos-
, H; h! b# ~# L/ c: u" g8 Qterone, which is a more potent metabolite, is more/ }( d/ C) ]  ?4 Y0 ~
active in young children exposed to testosterone
. s# w" W) p+ R5 K% s- ]9 g' i* lexogenously7; however, we did not measure a dihy-* ~- h* T9 \+ z0 j# n, ~
drotestosterone level in our patient. In addition to
. x0 q+ H7 [7 p. R3 f( w/ ?; `virilization, exposure to exogenous testosterone in
5 m5 a0 m  P" lchildren results in an increase in growth velocity and5 k# O; G7 A- o: \
advanced bone age, as seen in our patient.
# l8 O5 h+ S, e: c+ ?* rThe long-term effect of androgen exposure during
! k- E8 a; y9 bearly childhood on pubertal development and final
2 V# l7 O6 J" Z" Cadult height are not fully known and always remain
  W% I5 Y, T0 M: z+ R3 ?a concern. Children treated with short-term testos-
* I+ q% {% R! tterone injection or topical androgen may exhibit some2 t0 Q. }& s( m! `/ U
acceleration of the skeletal maturation; however, after
& O( g: O) z) E5 g' Fcessation of treatment, the rate of bone maturation2 i, e; m1 L0 K& B# p4 C
decelerates and gradually returns to normal.8,9% R6 I5 c  V$ y0 |
There are conflicting reports and controversy. G' Z( H2 y5 @4 Q+ R1 T' e2 D8 C
over the effect of early androgen exposure on adult
/ I# [' t- Q4 P4 Ipenile length.10,11 Some reports suggest subnormal
% O  ^1 ?; I3 M# P- i' d8 radult penile length, apparently because of downreg-5 z7 I7 p2 E8 N; M0 M
ulation of androgen receptor number.10,12 However,
: n  A$ _. [& Y+ h& N- u' j1 G9 pSutherland et al13 did not find a correlation between
: S  Q  I8 n. E7 N  e6 e. n) T- r+ d; Rchildhood testosterone exposure and reduced adult  n0 a+ \7 j! M1 |* ^
penile length in clinical studies., _7 R& p9 F' z" c. f4 K9 W% b7 {+ s
Nonetheless, we do not believe our patient is, @4 T2 }8 z! c; w# {5 ?
going to experience any of the untoward effects from7 ~& e% |0 r6 u" y0 r- w
testosterone exposure as mentioned earlier because
8 S1 W7 p) d# ?8 m9 V. i% ethe exposure was not for a prolonged period of time.3 k: `! W) C4 ~3 E5 M7 j1 P
Although the bone age was advanced at the time of
& m. _7 F& ~) j( Zdiagnosis, the child had a normal growth velocity at7 n6 h7 n  {# A5 F; [. X
the follow-up visit. It is hoped that his final adult" ~+ V. V2 u9 b* n6 c% I
height will not be affected.  Y/ q  |+ ]5 H2 W) ~
Although rarely reported, the widespread avail-
% k8 S/ q: M7 |* e+ w7 D3 H: Kability of androgen products in our society may
. U4 f9 t7 e0 }. U6 D% G+ findeed cause more virilization in male or female
% n5 `4 D$ f9 xchildren than one would realize. Exposure to andro-5 Q3 y" b5 y0 g3 Z
gen products must be considered and specific ques-0 K! e) ?6 Y5 c
tioning about the use of a testosterone product or
1 ^/ A5 b. `5 }gel should be asked of the family members during
) Z7 R5 C' e+ W6 a- Zthe evaluation of any children who present with vir-
" b0 T4 X. k+ \+ ailization or peripheral precocious puberty. The diag-
& V6 H; P/ e5 K! Q. \nosis can be established by just a few tests and by0 ]  X# K( S5 K' T" Y+ C. T+ ]" x
appropriate history. The inability to obtain such a
5 O7 A1 ^6 b7 a9 n- [, x6 @history, or failure to ask the specific questions, may
, c4 O" B2 W; m- Wresult in extensive, unnecessary, and expensive  y- m; {0 \  D; k
investigation. The primary care physician should be" x: s. }" t: P8 T/ j
aware of this fact, because most of these children( J3 m2 T4 \( Q8 h% _; n; q
may initially present in their practice. The Physicians’
3 [. x# u2 z* g1 JDesk Reference and package insert should also put a
$ I0 O* G% Y1 a( l/ b8 g$ awarning about the virilizing effect on a male or
  m% H9 F  p0 g2 `female child who might come in contact with some-
: P$ i6 {3 i; ~$ G) C! A4 \0 ^# fone using any of these products.2 P! `% A/ S) ]: ~
References# q  ~9 g9 E( w3 p6 ]( i7 H
1. Styne DM. The testes: disorder of sexual differentiation
. x3 _1 A- Q' hand puberty in the male. In: Sperling MA, ed. Pediatric
/ h; j  D* f  Z3 U+ j. k& [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ ^/ E: N! T# T8 J
2002: 565-628.
5 |, M' G- L1 {  n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# p7 ~( }4 L* J$ H: g  Q. v, }
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
# ~9 t  s8 m2 BBoy Induced by Indirect Topical
( u* `9 n; o7 h; V: V; a  `Exposure to Testosterone! V" D2 k* A; J7 c4 J3 s0 |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 x, ~9 j( t6 f" i
and Kenneth R. Rettig, MD1. J  H4 \! H8 _: P
Clinical Pediatrics
" D3 Y( ?8 b# F8 t1 ^0 b' f- ]5 DVolume 46 Number 6
9 o; s. G' g) m0 QJuly 2007 540-543
. d6 ^7 ~: x  m1 a: @. n+ B2 n© 2007 Sage Publications# u2 o( z5 v, a' w$ K: G
10.1177/0009922806296651
- y6 A  H0 [+ O* |: _7 ^  {) ahttp://clp.sagepub.com& e9 T$ C* f: v0 {
hosted at
# H8 @* `" s  P% {, r) Ehttp://online.sagepub.com4 J) o9 L* L+ f( W% O9 z$ J; ^: b
Precocious puberty in boys, central or peripheral,
$ u/ u7 A2 W$ a9 t+ \is a significant concern for physicians. Central1 C! w& ^4 L$ T( y$ }9 I$ ~/ E
precocious puberty (CPP), which is mediated
7 `( I1 I! e: Sthrough the hypothalamic pituitary gonadal axis, has$ r) h% e' D  Y1 o
a higher incidence of organic central nervous system
  O# |" V% k5 F5 \' T) r0 elesions in boys.1,2 Virilization in boys, as manifested* {# w' [$ M, W# W! l* C4 Z7 ^- R
by enlargement of the penis, development of pubic
; V# L% p. s' E1 `; U* \# A+ vhair, and facial acne without enlargement of testi-
+ P! Z5 N. y$ i# B/ Ccles, suggests peripheral or pseudopuberty.1-3 We* l# r7 B" H" p9 j, }, a$ O+ M" C
report a 16-month-old boy who presented with the
4 F& _. E* q* d/ Z! B7 uenlargement of the phallus and pubic hair develop-
6 k! V6 H7 O4 M: M; Kment without testicular enlargement, which was due
: P( N: }" a: L6 Cto the unintentional exposure to androgen gel used by
1 u5 n* J  Y# d9 X4 c" K; I* Kthe father. The family initially concealed this infor-
, m. G/ n9 B1 T- F4 ^mation, resulting in an extensive work-up for this8 d; h, n0 q* V$ H6 {: t# N, K
child. Given the widespread and easy availability of
* R- j' \7 q$ J$ b1 Ntestosterone gel and cream, we believe this is proba-
! {1 v2 U0 K2 [& }bly more common than the rare case report in the8 }% C) s: N; |* L. T# |/ u
literature.4
7 c1 s, M: T: I% iPatient Report
* T. z* t0 B# V6 iA 16-month-old white child was referred to the5 ^3 S2 z' T8 R$ [
endocrine clinic by his pediatrician with the concern, G# w4 m( h( P4 l6 u
of early sexual development. His mother noticed  V1 O/ G# Z$ O) z
light colored pubic hair development when he was
# o7 B  W; M1 \From the 1Division of Pediatric Endocrinology, 2University of- u5 f$ ]! `2 t6 d
South Alabama Medical Center, Mobile, Alabama.
1 a( d  y5 ~" N' k. i4 E1 x7 i3 WAddress correspondence to: Samar K. Bhowmick, MD, FACE,( F" ]) B4 W) f7 X/ Z
Professor of Pediatrics, University of South Alabama, College of1 L9 H+ b  T9 l" a2 L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* G1 m. ~, d" m$ r8 r
e-mail: [email protected].
; G& ^8 [4 ^$ X- A7 Qabout 6 to 7 months old, which progressively became$ W9 H+ y4 P1 v/ J' G
darker. She was also concerned about the enlarge-% n2 ~6 v4 `- N' z' _
ment of his penis and frequent erections. The child5 v  x8 ]; X! F$ }1 u! G
was the product of a full-term normal delivery, with$ l) s; r2 E' M9 _
a birth weight of 7 lb 14 oz, and birth length of
9 E8 w1 z  x8 F& K6 i3 x20 inches. He was breast-fed throughout the first year1 ^. ?& v5 ?( [! p, M5 J
of life and was still receiving breast milk along with( ?! @0 M3 N+ a# L/ v, n! h. Y5 W
solid food. He had no hospitalizations or surgery,* e+ ^+ h8 `" W! {: i
and his psychosocial and psychomotor development
0 Q4 x0 b8 j& M& Awas age appropriate.! t3 U8 `3 z5 M' v5 O6 [
The family history was remarkable for the father,& {* V" j8 F/ f
who was diagnosed with hypothyroidism at age 16,5 h  I7 N/ C& e/ G
which was treated with thyroxine. The father’s
* ?$ z. A- t2 f! _% c8 t3 {height was 6 feet, and he went through a somewhat
$ P( x* Q) q* \- nearly puberty and had stopped growing by age 14.( d! r# j9 U) A  {( X  c
The father denied taking any other medication. The8 b8 B2 j5 e4 V+ R, [6 M
child’s mother was in good health. Her menarche
+ b8 \1 v. b& a- pwas at 11 years of age, and her height was at 5 feet
+ f8 v1 L" r& V5 \( c2 Z8 `5 inches. There was no other family history of pre-
: z6 J( W# t3 v  J2 Vcocious sexual development in the first-degree rela-
2 }) b  U3 l( p( otives. There were no siblings.+ F$ H: r5 a3 n
Physical Examination
/ U3 W% t+ @; O7 [$ s" ?The physical examination revealed a very active,- B. r& d2 J2 \# d
playful, and healthy boy. The vital signs documented7 o7 I% [. ?8 P7 ~
a blood pressure of 85/50 mm Hg, his length was7 b0 Y1 F: t. E; z% Q4 C
90 cm (>97th percentile), and his weight was 14.4 kg
/ \! f/ |0 S# ^+ `% j' j(also >97th percentile). The observed yearly growth
0 |8 J' Z9 f7 y1 |) o2 evelocity was 30 cm (12 inches). The examination of
2 P. V9 `6 b- X1 Zthe neck revealed no thyroid enlargement.9 ]4 S/ k/ R# C: h) F9 [9 t
The genitourinary examination was remarkable for
" a& H! k* {. G  C2 o3 X! Xenlargement of the penis, with a stretched length of
, S& a. d( v, `, S$ |6 C8 cm and a width of 2 cm. The glans penis was very well
$ C( H+ S' s1 M! zdeveloped. The pubic hair was Tanner II, mostly around
; ?& H. w  {9 i9 e7 j540
" M# ^1 H' d' b  c0 j0 S5 K7 I8 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; J) i9 {& e$ D9 r. O. _
the base of the phallus and was dark and curled. The! J: g5 r& i- d( D+ Q3 g% l) z  X
testicular volume was prepubertal at 2 mL each.
' `% \: I8 c7 c& D# W1 P5 _The skin was moist and smooth and somewhat
/ |/ b+ b/ ^  h. g* L( f2 joily. No axillary hair was noted. There were no
. s0 H' b" Q7 j( |8 l+ _% Q# Jabnormal skin pigmentations or café-au-lait spots.4 M: w6 Q& K! p' D- x
Neurologic evaluation showed deep tendon reflex 2+) E. r9 K: z* i
bilateral and symmetrical. There was no suggestion1 _: ~+ I. {" A0 O1 b/ C
of papilledema.& K4 L' }* M, M+ z( `- G9 s
Laboratory Evaluation
& ^' U" j! o" q$ B0 YThe bone age was consistent with 28 months by
( z) y/ T4 n# ~0 y3 a; C. dusing the standard of Greulich and Pyle at a chrono-
! f9 A9 a  x* m' ?6 dlogic age of 16 months (advanced).5 Chromosomal
" p7 m# v3 T9 X, t7 fkaryotype was 46XY. The thyroid function test7 s9 o: T5 ~8 v! e
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ V0 y% T1 I- R/ ]- J
lating hormone level was 1.3 µIU/mL (both normal).
& N% u7 W  Y$ g  G( q9 QThe concentrations of serum electrolytes, blood" Q* L% P& b4 g" G* |7 d
urea nitrogen, creatinine, and calcium all were
( t) Z1 a  K6 i7 ]within normal range for his age. The concentration
4 L/ w! l' }8 Lof serum 17-hydroxyprogesterone was 16 ng/dL
  C; A0 h. k6 J# n(normal, 3 to 90 ng/dL), androstenedione was 20; g6 S% H$ E3 Y9 U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ @! u  ?- x, q, T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 G7 }% E; q* r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# f6 Y+ m) N) ]& v( I
49ng/dL), 11-desoxycortisol (specific compound S)
$ C, x! {8 [; iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ I+ N2 D. P4 o. `  |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; `: O& N* Z/ f3 u8 a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 h5 F* h; N" ]) l. {and β-human chorionic gonadotropin was less than
7 q( k* D' X$ b+ I) \; O1 X, G+ q5 mIU/mL (normal <5 mIU/mL). Serum follicular$ a0 _0 I8 q8 w9 ^
stimulating hormone and leuteinizing hormone( }9 ?' \* n6 o4 }7 R' K: {
concentrations were less than 0.05 mIU/mL
, M, r1 ^9 H5 F$ r/ s(prepubertal).
9 J! }3 a/ K  b5 y7 M) _The parents were notified about the laboratory' j( X* u# }9 s. r2 _; P
results and were informed that all of the tests were
& [- h9 v3 ], n2 wnormal except the testosterone level was high. The8 P" }( v6 r# L
follow-up visit was arranged within a few weeks to& U* `4 c  X& g* C$ s) B. ~+ y. |
obtain testicular and abdominal sonograms; how-3 @4 @& F6 j( N  ~# L- g4 K. I
ever, the family did not return for 4 months.
* e, \& W& w7 u2 U/ iPhysical examination at this time revealed that the
2 {+ O9 z6 |$ D- u$ w4 echild had grown 2.5 cm in 4 months and had gained
/ d7 K' {# X# I, i* S: m2 kg of weight. Physical examination remained/ Z0 A5 c  j/ q2 I
unchanged. Surprisingly, the pubic hair almost com-
$ E$ G# v$ v# ^) ppletely disappeared except for a few vellous hairs at! `: j7 W2 E1 S- \+ M; _
the base of the phallus. Testicular volume was still 2) g, J7 B0 d' K4 j
mL, and the size of the penis remained unchanged.
& m' K) P6 z9 N& U8 r! JThe mother also said that the boy was no longer hav-0 V* S0 y# |; b, \/ e# q" U, o
ing frequent erections.
' F7 _# A! `$ F( K: G8 PBoth parents were again questioned about use of  c1 y# S3 e, g
any ointment/creams that they may have applied to- Y: m5 l3 W" T9 ?; L+ X
the child’s skin. This time the father admitted the
6 h  Q# P2 a! `) q! nTopical Testosterone Exposure / Bhowmick et al 541" q- v/ P6 y( {
use of testosterone gel twice daily that he was apply-% }; a: K6 ?& {( `3 f0 n, j) |
ing over his own shoulders, chest, and back area for
) ~, i2 {5 ^& I: Y! Pa year. The father also revealed he was embarrassed+ Y. U0 z2 y1 b1 p7 x
to disclose that he was using a testosterone gel pre-8 m+ P1 B, R. \  e  Y
scribed by his family physician for decreased libido
% d) P9 C% ]! b+ O! asecondary to depression.# ?4 e8 p1 \* d7 H2 A
The child slept in the same bed with parents.+ b4 F" Q2 D, p% q0 R
The father would hug the baby and hold him on his/ p; D4 N2 M, w9 O1 m4 l
chest for a considerable period of time, causing sig-/ A9 O; x9 C/ N8 X" A. Z
nificant bare skin contact between baby and father.
+ b1 B7 x* M* UThe father also admitted that after the phone call,
' c+ |- g+ U9 N* u5 \5 Bwhen he learned the testosterone level in the baby# V5 B! y% Z2 D
was high, he then read the product information4 F+ i/ l- y5 t3 x- X
packet and concluded that it was most likely the rea-4 ?2 O* q9 C* d. n" O
son for the child’s virilization. At that time, they" q7 e; v6 {6 X# Y
decided to put the baby in a separate bed, and the. R' D4 E7 X9 {2 R# ], X; C
father was not hugging him with bare skin and had
; A/ u, w( x2 s7 W2 c# Ebeen using protective clothing. A repeat testosterone' n3 e: `8 j6 ^. e9 u
test was ordered, but the family did not go to the
  Y' A% L' g2 a0 klaboratory to obtain the test.$ |  S  L! g3 H: g
Discussion
) P+ G; f3 h9 ?& MPrecocious puberty in boys is defined as secondary
2 t5 B' O) c- ?sexual development before 9 years of age.1,4
! _  D( C0 x' f  {Precocious puberty is termed as central (true) when) c6 X# T! T* [# x) ]& L, w
it is caused by the premature activation of hypo-" c( Z4 u: K1 k. J
thalamic pituitary gonadal axis. CPP is more com-
) f3 @( v$ H* y0 m  F% [: x, pmon in girls than in boys.1,3 Most boys with CPP
6 t0 o% k1 w! y" r! pmay have a central nervous system lesion that is
& }, [1 j2 C- B' t3 `) bresponsible for the early activation of the hypothal-
- R7 F- U, i  k! U! [amic pituitary gonadal axis.1-3 Thus, greater empha-: _% V) e" _. G5 r5 L' A) C
sis has been given to neuroradiologic imaging in
- g+ G$ L  {9 yboys with precocious puberty. In addition to viril-# X  `$ x. X. q
ization, the clinical hallmark of CPP is the symmet-
) O8 ^1 ~1 z& z' f- srical testicular growth secondary to stimulation by0 a: q. H# }6 u6 H1 s) J$ r% L
gonadotropins.1,3
. O: t! m2 @  t& o7 \1 W/ w& }6 I0 wGonadotropin-independent peripheral preco-
% O# g1 f& m1 o6 |cious puberty in boys also results from inappropriate
8 ^6 O: `9 J+ Sandrogenic stimulation from either endogenous or( o1 n7 ]8 W8 B8 ^* K3 u4 a
exogenous sources, nonpituitary gonadotropin stim-2 P3 Z, X  J. C0 g
ulation, and rare activating mutations.3 Virilizing5 \& U1 C' `8 F# T% r0 _0 n. k( P
congenital adrenal hyperplasia producing excessive
* ?9 `4 G" y* i. b: ^adrenal androgens is a common cause of precocious
2 [# G+ y( j. r4 [puberty in boys.3,44 x. j' k1 |  H( W& F- Y
The most common form of congenital adrenal
7 B# x. D! T8 m' O0 @: p9 thyperplasia is the 21-hydroxylase enzyme deficiency.3 _5 _' g9 z9 `3 e: d
The 11-β hydroxylase deficiency may also result in
1 x: L0 p) S4 |! L; N$ Vexcessive adrenal androgen production, and rarely,; d0 O. }/ N* b4 t( n) v# R
an adrenal tumor may also cause adrenal androgen: ~8 S  m2 |/ p9 y$ T- V8 L
excess.1,3
( p9 ?: U& }$ {4 X& e8 fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 n4 s) A+ @; m  O/ J6 Y0 W) |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: O7 N8 C* C1 l: s) [* T4 v
A unique entity of male-limited gonadotropin-
8 O' c8 T+ B# a3 X" t) x2 I* Windependent precocious puberty, which is also known
3 A7 W/ l1 y& `& zas testotoxicosis, may cause precocious puberty at a
+ i4 P1 s; d7 C- G- u. Uvery young age. The physical findings in these boys* a: ]! B, G, J$ @2 E7 t% H) t
with this disorder are full pubertal development,+ k1 @( v! j$ }: z( N. {
including bilateral testicular growth, similar to boys
( C: a3 \$ Z; b. d- C! Jwith CPP. The gonadotropin levels in this disorder
/ Y8 u; j) i: T/ f$ e7 h" ?are suppressed to prepubertal levels and do not show; Y* r7 K9 R8 ^- w+ k
pubertal response of gonadotropin after gonadotropin-
8 H6 X! K& ^. J! R: I2 Ereleasing hormone stimulation. This is a sex-linked
; d/ l, M) U6 q2 g! H* Wautosomal dominant disorder that affects only+ w( B: W! ]1 D( s# o# B
males; therefore, other male members of the family% A. r) [: t- B1 A
may have similar precocious puberty.3
8 I" V0 I$ B! o0 JIn our patient, physical examination was incon-- C" s. X( K( U) g+ \/ q
sistent with true precocious puberty since his testi-
' ?" B  o. H; R" L$ B% Vcles were prepubertal in size. However, testotoxicosis
: Q  b$ f( b; z8 _8 ~; R4 kwas in the differential diagnosis because his father$ l1 Q8 I) `! J/ D5 d
started puberty somewhat early, and occasionally,
0 K8 u; G" T, x. x1 ~+ ~testicular enlargement is not that evident in the
( i$ ^+ F% ~" S5 Ybeginning of this process.1 In the absence of a neg-. W, y  G! D8 ~# _
ative initial history of androgen exposure, our5 g: K7 o  B/ M1 t3 {/ V( [
biggest concern was virilizing adrenal hyperplasia,
% g7 I$ D3 r. U3 t3 j" B, M& weither 21-hydroxylase deficiency or 11-β hydroxylase, s3 C( m3 e7 d# C1 ?3 n( t' k4 h" p8 m
deficiency. Those diagnoses were excluded by find-
9 t$ k5 E. q2 p! Ving the normal level of adrenal steroids.7 x( j+ E6 v; `, _1 c& z
The diagnosis of exogenous androgens was strongly
$ h" L7 k5 i3 B2 J0 zsuspected in a follow-up visit after 4 months because
/ B( n4 }: H6 K. dthe physical examination revealed the complete disap-" j6 f- L$ h- [( S( [
pearance of pubic hair, normal growth velocity, and$ @7 M# K5 b% h) K  p
decreased erections. The father admitted using a testos-
8 \" T# f  m! @9 Nterone gel, which he concealed at first visit. He was0 {7 g8 A* {) D3 T
using it rather frequently, twice a day. The Physicians’
* y. h+ h0 D  N; B# {Desk Reference, or package insert of this product, gel or1 `: T. x; g9 [1 [) D
cream, cautions about dermal testosterone transfer to
# Q: ^) S0 R! ^( G) @+ wunprotected females through direct skin exposure.
5 K; h% p" t8 [Serum testosterone level was found to be 2 times the
$ d% w% H4 g) B) \3 [5 P  zbaseline value in those females who were exposed to
' g& |! A) |/ l2 P5 F4 h8 {" neven 15 minutes of direct skin contact with their male
' g9 J3 P3 B* V. ~" O9 o, ~partners.6 However, when a shirt covered the applica-
; }) l* q" P. e9 H, ?tion site, this testosterone transfer was prevented.
) ]% }6 ^% G1 M! q: F& vOur patient’s testosterone level was 60 ng/mL,
& }8 P+ l& b0 Hwhich was clearly high. Some studies suggest that
, P4 `5 J5 \7 \+ O. o/ l" f& Bdermal conversion of testosterone to dihydrotestos-
" V& G8 O' w4 ~" W) y; H- I0 k0 t; uterone, which is a more potent metabolite, is more: \/ v: l/ e. b
active in young children exposed to testosterone+ I& W* ]& u" w+ H( ^$ e! f
exogenously7; however, we did not measure a dihy-! C! z" e+ ^, y3 r
drotestosterone level in our patient. In addition to
8 A- K3 J9 P, uvirilization, exposure to exogenous testosterone in4 x7 {5 l, H7 T. V% k" c$ s/ L1 i$ |1 x
children results in an increase in growth velocity and! H$ e# H8 z3 `4 U9 a
advanced bone age, as seen in our patient.3 g) {. V) M. ?. k7 H
The long-term effect of androgen exposure during* s. @' r) P6 u6 F9 q" \
early childhood on pubertal development and final
4 x/ k3 c- h5 x: i) Q* J6 cadult height are not fully known and always remain
" i4 H# b: ^6 n; ]4 Da concern. Children treated with short-term testos-
. G  G7 r$ T9 R1 q2 G0 v8 Vterone injection or topical androgen may exhibit some
# L" g8 ~2 }( p5 T0 s# D; ~) Xacceleration of the skeletal maturation; however, after
8 b/ Z; C$ C* r0 rcessation of treatment, the rate of bone maturation3 i. k  p  x- o: m$ ?6 p
decelerates and gradually returns to normal.8,9, O5 q7 R3 S7 G7 q
There are conflicting reports and controversy
3 D; ]$ t: x+ Oover the effect of early androgen exposure on adult
9 @4 ?; w1 T% F8 U, I6 Ipenile length.10,11 Some reports suggest subnormal7 Z' F6 v0 ]9 g( |
adult penile length, apparently because of downreg-
9 c' P) y4 ]" \. {) o" C7 ^* wulation of androgen receptor number.10,12 However,
/ M) K0 ]3 Y' t- m: B. {, iSutherland et al13 did not find a correlation between& T) u2 M& e* |0 s/ ^: A
childhood testosterone exposure and reduced adult0 ]4 i: h  @% A/ L9 y9 \3 o
penile length in clinical studies.8 r7 J( x. e: M7 c
Nonetheless, we do not believe our patient is
7 o1 W/ Q! I; x' j: Pgoing to experience any of the untoward effects from
4 h, D2 K6 v& Ktestosterone exposure as mentioned earlier because
+ y* N7 ~: Y8 \the exposure was not for a prolonged period of time.
, Q; ^+ g8 j, jAlthough the bone age was advanced at the time of
- @' Y5 ?5 T! A6 q3 P3 i( Mdiagnosis, the child had a normal growth velocity at
* Z, y7 I  I9 Y8 gthe follow-up visit. It is hoped that his final adult
/ H, ?/ Y7 q7 [height will not be affected.1 A% l' e: w, ]9 A0 J
Although rarely reported, the widespread avail-2 x$ k% }/ \; s) x, D' e0 w5 ~" ^
ability of androgen products in our society may
' T& |9 z0 ]5 C( ?indeed cause more virilization in male or female
2 t3 e* M6 y- r5 k4 Ichildren than one would realize. Exposure to andro-
2 N2 U! z6 W) h$ r: ogen products must be considered and specific ques-' F7 Q% h, @, L
tioning about the use of a testosterone product or
; `. P/ K) Y5 q( Q0 u" y6 n* Sgel should be asked of the family members during  v$ X6 r6 a; X+ ]
the evaluation of any children who present with vir-
3 X7 H+ h* Q+ z7 e2 _6 \ilization or peripheral precocious puberty. The diag-
8 O/ Z+ X7 }" M) w  p, i; W" _0 Bnosis can be established by just a few tests and by1 `7 \6 f) T, U0 z
appropriate history. The inability to obtain such a
" V8 S* ]/ v* Y. r0 nhistory, or failure to ask the specific questions, may0 X1 s  W) H! o+ L2 r
result in extensive, unnecessary, and expensive
! O+ l7 N4 f' pinvestigation. The primary care physician should be
0 x0 C% ]3 Z5 O3 z3 \8 Q6 naware of this fact, because most of these children
! L2 c% L1 q! m3 ~may initially present in their practice. The Physicians’
: l* c6 A" `/ ?: U  F7 NDesk Reference and package insert should also put a
. Z/ v* V1 d- B# g$ lwarning about the virilizing effect on a male or
" B) }6 e# p7 @4 Efemale child who might come in contact with some-
3 B) G% I4 k% b2 l1 A* tone using any of these products.2 x* Z6 y6 ~. t% k
References
- t+ N# z( `+ A; k* \8 W6 Z$ i1. Styne DM. The testes: disorder of sexual differentiation
  \9 N# q) P1 ?/ fand puberty in the male. In: Sperling MA, ed. Pediatric6 V  v8 a' X4 U7 x8 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# C1 U' H4 c' p2002: 565-628.
+ n- b& X: _. e5 O# r0 U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" S- A2 F3 M& \7 [- ^
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
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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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