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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
- R3 K8 A; @) h" W2 ^$ k9 e- Z* wBoy Induced by Indirect Topical/ T. o8 d1 L. R- ~$ T; t: \
Exposure to Testosterone
3 }, h% V: {0 B( J0 ^! |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  V* {9 @1 ]5 Hand Kenneth R. Rettig, MD1
7 t4 G* B4 i4 J  Y9 n* m7 lClinical Pediatrics/ P, T' }/ Q% K* C
Volume 46 Number 6, v7 \: I' @1 P! Y% Q- W8 I
July 2007 540-543
5 Q$ {6 D! f4 ]9 y+ \/ g% e© 2007 Sage Publications
3 A7 p- }2 L2 B% A) B" O10.1177/0009922806296651
% g2 H' k( r* q' j4 W9 zhttp://clp.sagepub.com
3 F; J* U. ?" X4 X0 }4 Qhosted at
7 p1 S: P1 y5 t% `' H+ Whttp://online.sagepub.com
/ c. I5 @. q3 OPrecocious puberty in boys, central or peripheral,! u  a9 ]% V1 k
is a significant concern for physicians. Central% q7 D8 O9 h: a0 p9 Q+ `0 r
precocious puberty (CPP), which is mediated
: _, ~5 V7 V; z7 C; U# i! C! Hthrough the hypothalamic pituitary gonadal axis, has
. ]# P) M2 p9 ma higher incidence of organic central nervous system! a7 N' r& B: c$ @- _1 v7 Z
lesions in boys.1,2 Virilization in boys, as manifested6 V8 u: o- @. Q7 h- p: B
by enlargement of the penis, development of pubic+ C( h! N5 V, z; u% U- |
hair, and facial acne without enlargement of testi-: \& y3 W7 f0 U$ ?8 H- q  n
cles, suggests peripheral or pseudopuberty.1-3 We
- i- v' N# @" O# e+ Y3 `: r9 E. Kreport a 16-month-old boy who presented with the
0 u) L! b8 S6 z9 h* Aenlargement of the phallus and pubic hair develop-4 t- H' \$ t8 M% F3 R/ U
ment without testicular enlargement, which was due
  v8 \$ t2 B  l) C7 Pto the unintentional exposure to androgen gel used by
1 {( X8 @1 Z' a; I. V- S( f: D4 |the father. The family initially concealed this infor-
7 l, b& E! |& T5 e& Omation, resulting in an extensive work-up for this5 A. R1 \6 [4 s) C/ t2 y
child. Given the widespread and easy availability of
+ u. M; f8 x5 C" Z. V6 ktestosterone gel and cream, we believe this is proba-* u/ \3 A/ |6 k* Q# {% P0 {
bly more common than the rare case report in the8 _' @! e2 P. v" Y  V) v& ^
literature.4" t0 @9 b; v6 C
Patient Report: F, b5 l2 i) B0 q
A 16-month-old white child was referred to the1 P7 O/ v1 K' j! l+ C
endocrine clinic by his pediatrician with the concern# i) ]2 w; J2 p7 \  l
of early sexual development. His mother noticed& L1 x) w/ \2 p' i
light colored pubic hair development when he was5 M& }5 ^* f: a: l* `& m! H
From the 1Division of Pediatric Endocrinology, 2University of
  L& a" l9 [+ c$ cSouth Alabama Medical Center, Mobile, Alabama.
0 |0 I! T# O) s* ^, GAddress correspondence to: Samar K. Bhowmick, MD, FACE,& |+ z4 T& y7 x3 z# c- [5 |
Professor of Pediatrics, University of South Alabama, College of8 I! a" @3 {- u& {- J" a8 L7 }; E. _; p
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 H3 p# N  S6 w# Ue-mail: [email protected].
6 R7 @+ d, |& f% Sabout 6 to 7 months old, which progressively became
6 ]  u* E! L( zdarker. She was also concerned about the enlarge-+ A6 @: R% l; P- d
ment of his penis and frequent erections. The child* X* |& S% U7 J
was the product of a full-term normal delivery, with
8 F# i  B8 P2 s7 V& E! E+ Ga birth weight of 7 lb 14 oz, and birth length of
, b1 e2 J+ u5 L% ^$ H) R4 H20 inches. He was breast-fed throughout the first year! Z3 k( }9 g" {8 N
of life and was still receiving breast milk along with
$ _$ a. G8 P& r% ^solid food. He had no hospitalizations or surgery,: i( v% H5 R) h+ L- ]+ V0 j( A
and his psychosocial and psychomotor development8 M( ^% a9 K* q
was age appropriate.
7 ?: ]) W( }9 TThe family history was remarkable for the father,
  Q% ?4 P+ R9 f% Awho was diagnosed with hypothyroidism at age 16,; P0 T7 U+ X) p/ {, Y: q
which was treated with thyroxine. The father’s
' q/ @& l% o! Mheight was 6 feet, and he went through a somewhat
" y( D. B* Z: B. ^0 y/ U$ Dearly puberty and had stopped growing by age 14.
5 a2 U/ O( h' M; m5 f3 qThe father denied taking any other medication. The  U! O8 p1 B" K% ?" Y5 T& C3 Y
child’s mother was in good health. Her menarche3 M, M  z! F2 \8 \
was at 11 years of age, and her height was at 5 feet" V  j( H* o- r$ R( C" i
5 inches. There was no other family history of pre-5 v# f" y5 Z$ B. t3 _
cocious sexual development in the first-degree rela-' N" C4 K" C3 K- f
tives. There were no siblings.* e- W$ v$ @2 A% P4 ]7 H& Q9 o5 u
Physical Examination
3 G4 s& e  B$ X7 sThe physical examination revealed a very active,
0 M1 Q2 M) I0 r8 m7 m+ `playful, and healthy boy. The vital signs documented+ G$ N# `/ v+ d; m  I
a blood pressure of 85/50 mm Hg, his length was
% e8 l6 k8 A1 }" }90 cm (>97th percentile), and his weight was 14.4 kg
0 h8 u. j" i$ g  R" S. P(also >97th percentile). The observed yearly growth6 n4 c- l* J0 ?: b. o6 o# D) [
velocity was 30 cm (12 inches). The examination of
& \8 \! }9 ?6 x; |. Bthe neck revealed no thyroid enlargement.
3 A$ j7 O/ _( @" R* L- H2 w0 C$ lThe genitourinary examination was remarkable for
7 T# [! z/ E6 i: S; `+ m% L) W: wenlargement of the penis, with a stretched length of9 ^9 q3 n  a8 u) `' u
8 cm and a width of 2 cm. The glans penis was very well
  B: P# T9 \% P5 P9 [developed. The pubic hair was Tanner II, mostly around
$ H- |8 T; y( o6 D8 k# X540, q5 ?& M- E: T! ^, U% V+ {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  c5 u6 l9 S& ^3 kthe base of the phallus and was dark and curled. The9 N3 ^8 {& X# O1 {( O* Q
testicular volume was prepubertal at 2 mL each.
) @, f+ p7 s7 S" ZThe skin was moist and smooth and somewhat
# x2 |: B& K( E  Uoily. No axillary hair was noted. There were no
2 p# U; T. w2 A4 c" Q( W  }. m% _5 sabnormal skin pigmentations or café-au-lait spots.
+ `/ E5 U2 K0 v# c3 P- iNeurologic evaluation showed deep tendon reflex 2+' y9 a! y! L( W4 ~& B3 N& p& L
bilateral and symmetrical. There was no suggestion
3 |! @* ?5 ^: c, @of papilledema.) b" Z" n) z+ r( M2 _9 G9 O. b
Laboratory Evaluation
+ C! r6 I9 z/ Z& s3 X& L2 g& nThe bone age was consistent with 28 months by
5 Z/ i( t! ~- Wusing the standard of Greulich and Pyle at a chrono-
( x; l" h- g) zlogic age of 16 months (advanced).5 Chromosomal& k9 o2 W5 U0 M8 D
karyotype was 46XY. The thyroid function test
- K6 A3 Y& ]/ \5 E  ~* `' `5 }2 m$ Oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
" f! y! f& O; d/ Hlating hormone level was 1.3 µIU/mL (both normal).
1 R1 J+ _( E5 T7 k! g8 |, r, }The concentrations of serum electrolytes, blood
+ H8 V5 i; ]7 j$ Y5 j  {urea nitrogen, creatinine, and calcium all were7 Z; h7 l: _0 C/ i4 L, [* a9 j
within normal range for his age. The concentration  ^/ Q0 h$ D) Q: e% w
of serum 17-hydroxyprogesterone was 16 ng/dL" t7 P* Z! x: _* y! [9 ^
(normal, 3 to 90 ng/dL), androstenedione was 20
' ?+ d8 W- e3 S* c  a; bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& f/ i. D$ ]! d. A2 Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% X* z6 _3 w3 }3 K2 Y) Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 {# z. J* w* O% [  ]! c0 e7 p3 b0 L49ng/dL), 11-desoxycortisol (specific compound S)
% e) f. O. r; C/ p9 |2 }9 y  Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" x- W$ k6 Z1 _! U  e& h- V% g/ V
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 B) `2 D9 e# f/ h
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 m! K) E+ z7 n% D; }and β-human chorionic gonadotropin was less than) E; ]- U/ _0 H
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ r* c& t' {0 wstimulating hormone and leuteinizing hormone' `( f  m% d9 m' |( R0 I/ l
concentrations were less than 0.05 mIU/mL
# J4 T2 b; l9 C2 j8 _1 O! @6 A& O(prepubertal).2 d5 g2 Q  P. [
The parents were notified about the laboratory
2 T0 M5 m8 {8 X, {/ p* X' sresults and were informed that all of the tests were
4 j. \. a* v* _" c! y$ o- t- o( ]normal except the testosterone level was high. The+ m) @* B% C. I* z4 \
follow-up visit was arranged within a few weeks to: x+ i" q4 Q2 {
obtain testicular and abdominal sonograms; how-+ p2 p, g+ s  [/ b/ ]% w
ever, the family did not return for 4 months.6 I, C# R, x# ^# D+ }+ M
Physical examination at this time revealed that the0 I5 t% Y3 D3 X6 F
child had grown 2.5 cm in 4 months and had gained
3 Z$ j8 H  W+ \* `9 ]2 O2 kg of weight. Physical examination remained
. b! z& e# Z) }& k, \unchanged. Surprisingly, the pubic hair almost com-% C# s5 g1 i( v$ O0 Y5 c/ j
pletely disappeared except for a few vellous hairs at
. w1 h) a0 P. B, J2 r% [, l! Pthe base of the phallus. Testicular volume was still 2
0 ]- h, b  c" |1 @0 YmL, and the size of the penis remained unchanged.; q# f5 [' j1 b" Z
The mother also said that the boy was no longer hav-
0 r7 n1 R6 x6 E# _' ^. zing frequent erections.! I; S/ q4 _2 g$ Z) [% z& {5 c1 I- r
Both parents were again questioned about use of* t; V- s9 l) \5 e2 W
any ointment/creams that they may have applied to
- i: o2 S6 l/ j; {3 X4 o4 j# gthe child’s skin. This time the father admitted the! B& Y; H/ W' y6 Y0 _3 M
Topical Testosterone Exposure / Bhowmick et al 541
7 u5 K# A* ]1 E; Q# C  t& r; ^  Quse of testosterone gel twice daily that he was apply-* v$ i: v% ~8 R
ing over his own shoulders, chest, and back area for5 N. m# \( u- z
a year. The father also revealed he was embarrassed  T0 ~$ [$ O2 ]4 _9 e, Y3 S6 F
to disclose that he was using a testosterone gel pre-! O- |& Q* j9 v- a& r: `& S
scribed by his family physician for decreased libido% G' J6 p6 g: m; h
secondary to depression.
# j7 M: w6 {+ E6 G7 lThe child slept in the same bed with parents.
& |6 ]7 A5 Q% t% X9 FThe father would hug the baby and hold him on his) ^" q1 T' q8 K8 y3 m
chest for a considerable period of time, causing sig-* Y1 B! `) n* x" R1 B7 q! @# o
nificant bare skin contact between baby and father.
9 ~: o2 m% ~0 I8 R/ h5 TThe father also admitted that after the phone call,
+ i$ \- B, b1 r: f8 uwhen he learned the testosterone level in the baby
: ^$ s+ e5 P6 F8 }5 R9 P1 C) Dwas high, he then read the product information' S* T/ `3 ?. V
packet and concluded that it was most likely the rea-+ X3 S  V. _  e. P$ ]" m
son for the child’s virilization. At that time, they
+ `1 |& ]9 N+ o& v) o1 Bdecided to put the baby in a separate bed, and the
0 k# z$ K4 @; P1 Kfather was not hugging him with bare skin and had
! k, }/ h0 [* D4 Z& C  @* p" M% `been using protective clothing. A repeat testosterone
4 F" z( _8 D5 I2 M. [7 e; y8 X* Utest was ordered, but the family did not go to the8 h  C  r$ m9 {# v$ I" v8 A
laboratory to obtain the test.+ z# k; K& T/ Z( N$ }" n- c+ X
Discussion
, t2 ^4 C; H* s" P& aPrecocious puberty in boys is defined as secondary& B8 l, C$ ^2 E
sexual development before 9 years of age.1,4
  R6 P' }# {: \. H! e4 t( oPrecocious puberty is termed as central (true) when: B+ m/ E' }- ^. _  i
it is caused by the premature activation of hypo-
0 F+ B! I6 `0 Y6 y! Y  _) ^thalamic pituitary gonadal axis. CPP is more com-6 N5 B, M& M, ?1 m6 }
mon in girls than in boys.1,3 Most boys with CPP
& P" W5 S0 l2 T' g0 rmay have a central nervous system lesion that is
0 A7 O5 p2 E$ E2 {! Rresponsible for the early activation of the hypothal-3 @8 x, a- Z9 @. y9 ~) x7 ^6 e
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ ?- @' `( w0 I. n9 ?' Tsis has been given to neuroradiologic imaging in1 n! U$ X% B0 p/ }) w
boys with precocious puberty. In addition to viril-
: p' Y+ T+ y/ {& G7 f7 L( }- Wization, the clinical hallmark of CPP is the symmet-
& ~1 L$ T$ V- s& s& `rical testicular growth secondary to stimulation by
4 V& ^/ M) p% G6 Ggonadotropins.1,3
+ I6 v0 Q  B/ I! T8 S% vGonadotropin-independent peripheral preco-2 Y) m# w" ?0 a! E9 z
cious puberty in boys also results from inappropriate
4 Q' |7 K6 ^2 ^' F, fandrogenic stimulation from either endogenous or
. k- c1 B4 r# e. B6 pexogenous sources, nonpituitary gonadotropin stim-( }" S. d3 [1 S
ulation, and rare activating mutations.3 Virilizing, M: l3 V8 x: q) S- I/ V
congenital adrenal hyperplasia producing excessive) N1 K* n  O; e
adrenal androgens is a common cause of precocious
) M) b% r! B  Z- u6 G& \7 apuberty in boys.3,4
% k, ?, N% p* W! mThe most common form of congenital adrenal6 G* S) M' G  J6 Z5 C* |' g! N
hyperplasia is the 21-hydroxylase enzyme deficiency.) W. E- i3 }6 u# \  }
The 11-β hydroxylase deficiency may also result in3 |& ?) u, N* M5 F
excessive adrenal androgen production, and rarely,
, V/ l; Q# k, U* O2 l# A* S, A/ Ean adrenal tumor may also cause adrenal androgen: Q7 _0 F4 t+ r3 K& b6 I. w
excess.1,3) H( H: }! P, A# W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 L; r, t1 ~2 w+ `' D; |7 |, J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: N& Z; }; D8 s3 C* UA unique entity of male-limited gonadotropin-, Y3 l0 J5 H, s& \
independent precocious puberty, which is also known
+ I  }% ^1 `" T6 T5 G9 Zas testotoxicosis, may cause precocious puberty at a
0 H6 p/ n: X! u2 d$ ^very young age. The physical findings in these boys
. p. R0 I7 a$ \0 qwith this disorder are full pubertal development,
7 s# w& w' v+ E' Gincluding bilateral testicular growth, similar to boys2 u3 H" }+ I! c6 A
with CPP. The gonadotropin levels in this disorder- N% `3 J5 C2 {  j$ R
are suppressed to prepubertal levels and do not show# j4 F. q2 Q4 F8 h3 c. w+ I4 e
pubertal response of gonadotropin after gonadotropin-
! m5 L4 J7 G& z0 g, c6 Ureleasing hormone stimulation. This is a sex-linked+ e3 b  M$ x# p( Y" \# Z" P
autosomal dominant disorder that affects only9 B6 C# L) O6 g8 X/ }( M- C
males; therefore, other male members of the family8 d) J8 `- g1 w$ J2 |0 D1 N" P/ x
may have similar precocious puberty.3
8 v( _8 Z3 a  f7 zIn our patient, physical examination was incon-
8 {7 B; t6 `+ C9 N' ^% B; }sistent with true precocious puberty since his testi-2 O+ I' X( R- i+ ]' }
cles were prepubertal in size. However, testotoxicosis- O6 ^: P2 o6 {  }- S& O8 \
was in the differential diagnosis because his father$ W$ U' u& D/ d
started puberty somewhat early, and occasionally,
  a' Q" t, X( _3 p& Jtesticular enlargement is not that evident in the2 N2 Z. Y/ e) H! ~7 [1 o
beginning of this process.1 In the absence of a neg-! D5 N/ k. V# `5 X* t& R
ative initial history of androgen exposure, our
0 ^6 [( g+ m6 R! r$ M8 U" F5 ebiggest concern was virilizing adrenal hyperplasia,+ a. s( Q( u' I7 O5 W" C) l
either 21-hydroxylase deficiency or 11-β hydroxylase
4 I1 E! k$ j- Odeficiency. Those diagnoses were excluded by find-
( G6 s3 x% a" ]! O* @  ging the normal level of adrenal steroids.& i: k9 h$ m' a: a" w' g7 L
The diagnosis of exogenous androgens was strongly
/ b- W. g  b6 F. k- ssuspected in a follow-up visit after 4 months because9 |' L) u/ G+ D( I  ^- K/ a
the physical examination revealed the complete disap-" |5 L0 r* c1 j- L$ I
pearance of pubic hair, normal growth velocity, and0 b0 h% I8 ]& X
decreased erections. The father admitted using a testos-: {& M/ J: o) d; z) v
terone gel, which he concealed at first visit. He was5 L+ J; K. `5 l5 b
using it rather frequently, twice a day. The Physicians’! d9 q2 z, y& ^# ]1 g
Desk Reference, or package insert of this product, gel or
+ C+ @$ @, m8 c+ P0 g& d9 acream, cautions about dermal testosterone transfer to- P2 ^' d2 e/ M; H6 |
unprotected females through direct skin exposure.. D8 y  t8 d1 U1 V1 L
Serum testosterone level was found to be 2 times the* c4 R- ]4 Q7 d" s# C3 y, n% C6 j4 ~
baseline value in those females who were exposed to
5 A0 s' r7 P; i" ?) _even 15 minutes of direct skin contact with their male6 l* x- M0 q1 b. J2 I; z0 h
partners.6 However, when a shirt covered the applica-
9 V! l) E; Y8 ztion site, this testosterone transfer was prevented.  h  Y) y$ Y, ^% a- D7 E
Our patient’s testosterone level was 60 ng/mL,3 `% \6 o% J& J1 u7 Z, n5 f
which was clearly high. Some studies suggest that6 z+ Y: @5 S0 W  x7 K9 s# g
dermal conversion of testosterone to dihydrotestos-
9 l" F/ Q& T3 Cterone, which is a more potent metabolite, is more$ `) V1 l8 v0 `4 h: Q
active in young children exposed to testosterone8 g9 a0 e7 P2 e( P) h4 i/ b0 {
exogenously7; however, we did not measure a dihy-6 V- \% F$ l' A/ B8 `4 N: L
drotestosterone level in our patient. In addition to8 L0 ~; z9 w5 H& u& I
virilization, exposure to exogenous testosterone in
5 F* _/ U9 g! K' K( s" Kchildren results in an increase in growth velocity and
: O/ e, b" K3 Q4 k8 f. iadvanced bone age, as seen in our patient./ H4 i; P5 D0 \. {4 H& L/ F
The long-term effect of androgen exposure during; }# ?, o" B4 T& i, m6 p
early childhood on pubertal development and final
5 d/ p: M3 s5 padult height are not fully known and always remain- n. H& ]& D0 V0 ~0 s0 l5 X
a concern. Children treated with short-term testos-
( ~' z3 g( X" F3 ?$ w( Pterone injection or topical androgen may exhibit some
& T8 t/ a* i: E+ ]4 g4 E" f4 Uacceleration of the skeletal maturation; however, after
. s8 O2 w; h$ ]/ c  q" O* p( }- qcessation of treatment, the rate of bone maturation
& O- u7 K5 W2 edecelerates and gradually returns to normal.8,9
: Y& \! b" M, `* a- w6 A" E/ Z8 j( WThere are conflicting reports and controversy
- F8 ?  ~2 n8 A: Vover the effect of early androgen exposure on adult- e# C8 \5 z6 v) f) u2 M$ @
penile length.10,11 Some reports suggest subnormal( q( [  N8 j: h' b4 M
adult penile length, apparently because of downreg-
3 J) q- P0 y  Z! f  z  Oulation of androgen receptor number.10,12 However,; _& I9 B1 O# }2 J1 e
Sutherland et al13 did not find a correlation between- F( y) e; Y- @* @$ Z
childhood testosterone exposure and reduced adult
% b+ J5 ?$ A' P/ o' }penile length in clinical studies.! T! ?7 F* @, a6 i" U
Nonetheless, we do not believe our patient is$ `2 b) [  y) Z! }  |* y
going to experience any of the untoward effects from' S( z( V# @! v7 V9 e
testosterone exposure as mentioned earlier because$ r) p) h1 v: R) C8 J& Z
the exposure was not for a prolonged period of time.5 ~. }' R, m' S8 Y' W  ~0 G( b: L
Although the bone age was advanced at the time of
+ [: B, i7 ~* Z. Q4 b0 _6 E* adiagnosis, the child had a normal growth velocity at) J3 s/ v; Q9 S* ?6 s: \- p7 p, G
the follow-up visit. It is hoped that his final adult
$ c& {3 e( \: d% W) L6 Y" wheight will not be affected.
$ O. Q7 |8 q6 F4 v7 F) p2 F. u- Y; J, v4 EAlthough rarely reported, the widespread avail-0 [( X1 W6 l: w, D
ability of androgen products in our society may4 ?! ?# }3 @; Y  w( ~
indeed cause more virilization in male or female9 G) [4 t0 i4 I9 R1 ]
children than one would realize. Exposure to andro-
+ M, J6 H  X+ k$ h! Wgen products must be considered and specific ques-
. w( k$ R( V' m* a- {tioning about the use of a testosterone product or
1 g  Q7 x+ w6 A7 m+ u$ igel should be asked of the family members during
, u5 n- A. \9 d, K  k* M. othe evaluation of any children who present with vir-
0 s0 k& d+ @* R. Oilization or peripheral precocious puberty. The diag-
& b( o5 ]# v- d* a8 t( xnosis can be established by just a few tests and by4 v' u" \: h5 j# m5 l
appropriate history. The inability to obtain such a# n% ?9 \' q5 i. `5 |* P( J
history, or failure to ask the specific questions, may3 x2 U1 z# a$ m2 d. ^
result in extensive, unnecessary, and expensive' V& _2 @  e3 Z) O% h, A
investigation. The primary care physician should be
8 E" U2 ~. m# z7 k1 Kaware of this fact, because most of these children
& Y* R# Y% y6 ]& e: Y$ H3 O! Gmay initially present in their practice. The Physicians’
0 d1 }8 F" q) q# @! e  SDesk Reference and package insert should also put a
% S+ y- n- r+ G- ]warning about the virilizing effect on a male or5 f- \1 N& n$ U
female child who might come in contact with some-
8 ]7 Y5 n! W! M0 @; Pone using any of these products.
% t9 K# o9 o9 ]) i$ i9 f$ KReferences- R, l* j- G) C' j
1. Styne DM. The testes: disorder of sexual differentiation. `- S# i0 w7 B( V8 G
and puberty in the male. In: Sperling MA, ed. Pediatric
1 |* [8 R! o" {+ MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 c- P$ {' f( M2002: 565-628.: \& G( a+ C' `+ ^$ S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  X( R" g( X  G- O
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 J. L6 E( e2 xBoy Induced by Indirect Topical
6 F6 b  W# x" I+ X- nExposure to Testosterone
/ {- p5 c. w2 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ @( X" I# }" ^  [* }( Qand Kenneth R. Rettig, MD1, K6 J$ X" n, k( S% l
Clinical Pediatrics
( l& j, f' {. v, h1 }Volume 46 Number 6
% G( Y$ s* F6 pJuly 2007 540-543% S. K3 W, ^5 x) V# B# K# p+ R: o
© 2007 Sage Publications
4 C& d9 F0 t4 ~10.1177/00099228062966519 a( w% q1 e) ?* y* J
http://clp.sagepub.com( Z% B% A2 |: c& w* S
hosted at
4 M- ?0 O- {4 G0 \0 t, Q" rhttp://online.sagepub.com& A0 g2 Q. W8 i3 N7 i
Precocious puberty in boys, central or peripheral,. K" y7 v8 J! J  A1 j7 n" S
is a significant concern for physicians. Central
5 Q2 c$ k$ X9 |* o$ V- U4 V- qprecocious puberty (CPP), which is mediated
3 S- V5 {: ~' h7 W& sthrough the hypothalamic pituitary gonadal axis, has
6 ?8 k, ^; L+ Oa higher incidence of organic central nervous system
$ v: h' ~; t. [9 klesions in boys.1,2 Virilization in boys, as manifested
5 E/ E; V% F! r4 r. {by enlargement of the penis, development of pubic; u7 }+ D/ S, j& K2 C
hair, and facial acne without enlargement of testi-
  o8 [! C1 D' S$ W+ S; hcles, suggests peripheral or pseudopuberty.1-3 We
9 b- @  H: f6 p+ H+ L( e3 @9 G7 Greport a 16-month-old boy who presented with the
. \9 ~1 d+ f6 p, Y6 ~4 w3 z7 [enlargement of the phallus and pubic hair develop-
1 d+ q' \. B( K( x7 q" G- R  W* Iment without testicular enlargement, which was due; R7 G. C% k( P; c! [
to the unintentional exposure to androgen gel used by) b) E' v% O% v  w( M/ J
the father. The family initially concealed this infor-6 w$ I: u  A6 P) \' J* z: l
mation, resulting in an extensive work-up for this! ?8 t- a  Z' ^
child. Given the widespread and easy availability of
$ K$ d- }6 O" }3 @testosterone gel and cream, we believe this is proba-# F/ ^6 l5 N5 q+ N) U- L% p# P1 g! g
bly more common than the rare case report in the  J  s$ m( V+ Y& Y
literature.41 S! b! q8 T4 e5 e  x& c
Patient Report0 S0 @0 F% ~% t$ A
A 16-month-old white child was referred to the; z8 G( K5 ?" |' j5 y. L
endocrine clinic by his pediatrician with the concern
" p5 r6 E7 d  |. x7 s" \, P& nof early sexual development. His mother noticed
# y  c6 B1 Z* B7 i' z  |5 ]light colored pubic hair development when he was/ n0 X5 X3 c$ {$ h# S* u9 O" ?- I
From the 1Division of Pediatric Endocrinology, 2University of
% s$ N! x8 R! Z/ L1 XSouth Alabama Medical Center, Mobile, Alabama.
+ j( x* T% `9 A& Q3 e; JAddress correspondence to: Samar K. Bhowmick, MD, FACE,7 d/ c; o* j% ?9 V/ }
Professor of Pediatrics, University of South Alabama, College of2 d# B! V& S+ `7 q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# |% t; [* c5 y( W0 I( M. q
e-mail: [email protected].- u( h3 l$ G& O
about 6 to 7 months old, which progressively became/ C. e2 q" `' }# L, f' c
darker. She was also concerned about the enlarge-
, |5 ]/ F0 D( f& U8 oment of his penis and frequent erections. The child
: a( a, p) V2 gwas the product of a full-term normal delivery, with' O, n8 R/ G% @) t# C8 _/ C
a birth weight of 7 lb 14 oz, and birth length of3 r; P( m- ]4 j, i
20 inches. He was breast-fed throughout the first year% z# i* {6 m* z7 K7 z7 z# _
of life and was still receiving breast milk along with
) S- E, }. O( ?6 d1 r2 s. Psolid food. He had no hospitalizations or surgery,
* X9 ^$ M" g% jand his psychosocial and psychomotor development" o  H9 B0 ?/ P) ]
was age appropriate.& }. g6 o% L  T: M, o0 o
The family history was remarkable for the father,5 {3 @& U2 T; ~/ A
who was diagnosed with hypothyroidism at age 16," s9 G' g$ s+ G7 q. c
which was treated with thyroxine. The father’s: m; |0 g/ V+ A$ ?# Q. R
height was 6 feet, and he went through a somewhat6 {9 Q; g; L# g( M8 ?8 I& ]/ _5 n
early puberty and had stopped growing by age 14.' ?7 b9 ~/ Y% M/ C( k
The father denied taking any other medication. The
! q' V6 y$ W" `) W- {" Y( ^child’s mother was in good health. Her menarche& ^/ F) {% O2 j4 I& r, _
was at 11 years of age, and her height was at 5 feet* S: ?- q$ t" W; U% s2 Z
5 inches. There was no other family history of pre-
9 }9 b+ s" }+ `+ gcocious sexual development in the first-degree rela-
2 Y; }. P1 F3 [: Btives. There were no siblings.
: p0 }7 a( X$ f8 y7 i3 d( xPhysical Examination& ]/ i* H6 r! H( g2 q8 x" B2 l0 g
The physical examination revealed a very active,. z4 [) |1 U) ^; B3 o" L  H
playful, and healthy boy. The vital signs documented
+ S/ R1 B6 E6 A+ ia blood pressure of 85/50 mm Hg, his length was- q* B* R, W; A; x" N
90 cm (>97th percentile), and his weight was 14.4 kg* c! ?! w* t) \+ u' I& c: F- O
(also >97th percentile). The observed yearly growth
. i) K6 s" \: Jvelocity was 30 cm (12 inches). The examination of
- P& [' t9 I7 u) j$ Qthe neck revealed no thyroid enlargement.
; i. [1 e& M5 lThe genitourinary examination was remarkable for
2 C7 `9 ]! P/ e, jenlargement of the penis, with a stretched length of
. }) r: W! N* x9 i. c8 cm and a width of 2 cm. The glans penis was very well
  v  s0 L& L/ I: }  `developed. The pubic hair was Tanner II, mostly around
5 A, _5 ?' d9 E% N' y* Y( [540' x* c- c5 V5 u- I: t; \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 @- ^% ]  {: Q3 t- f6 r' wthe base of the phallus and was dark and curled. The
; f# Q, R0 B2 z5 P; R2 [5 stesticular volume was prepubertal at 2 mL each.8 {, ~' T% {; i7 F2 O) s( I+ A  X
The skin was moist and smooth and somewhat- l0 q; X/ e2 a: g5 K$ \1 P! X
oily. No axillary hair was noted. There were no
' \4 }8 N- P& ^- H1 x1 fabnormal skin pigmentations or café-au-lait spots.2 [. W/ V2 O3 q3 a( M3 W- ?' d# F
Neurologic evaluation showed deep tendon reflex 2+0 ~& d& u# p4 ~
bilateral and symmetrical. There was no suggestion
& N. T5 F/ U3 Sof papilledema.
* S( c( y# ], _) N; GLaboratory Evaluation4 _/ F* j, T+ N; e8 I3 Y
The bone age was consistent with 28 months by
! b( P  t% ~7 y' s8 H. eusing the standard of Greulich and Pyle at a chrono-
, i' D+ @3 s0 h2 ]' `logic age of 16 months (advanced).5 Chromosomal
, x, `5 f/ b$ Mkaryotype was 46XY. The thyroid function test
; g5 G9 j( R0 ~! Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, \7 i8 b0 s! P) W; R) C
lating hormone level was 1.3 µIU/mL (both normal).
, y2 C" h$ M1 V. v; p  q0 TThe concentrations of serum electrolytes, blood
4 [) t' l$ g5 \' N* k* Lurea nitrogen, creatinine, and calcium all were
2 [: g  t- [" y0 M  a" X8 Q; rwithin normal range for his age. The concentration: W! e( G( q& R$ f
of serum 17-hydroxyprogesterone was 16 ng/dL
/ o  x4 l3 G; D. H, ?$ j(normal, 3 to 90 ng/dL), androstenedione was 20
( ~, {2 I: N+ sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- a' \1 ]6 c" q, l% M; k; Z0 u" y0 nterone was 38 ng/dL (normal, 50 to 760 ng/dL),& w- I* a0 G6 t. A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" T+ \5 O* J# f/ {) `
49ng/dL), 11-desoxycortisol (specific compound S), n6 A% H( @- ^7 T% m# f, M) h4 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ N9 l) [" g  f. Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 D8 x) D# K4 O/ h: h0 ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% Y. K6 X0 i! {( b' ~and β-human chorionic gonadotropin was less than
& W  \, t9 F% M- b5 mIU/mL (normal <5 mIU/mL). Serum follicular
) K' Z8 U4 E+ ]/ v6 H0 K/ A7 h" Sstimulating hormone and leuteinizing hormone
( F1 K6 H3 |5 }2 F) A( z) Hconcentrations were less than 0.05 mIU/mL5 o& j$ {+ |- D* y( i# g
(prepubertal).
* {3 z. }, |- ?8 U: NThe parents were notified about the laboratory
& q* O6 m+ F" c# d% presults and were informed that all of the tests were
7 |: ]( m! F+ t# H8 ^& [6 Dnormal except the testosterone level was high. The* U0 }& r2 P" w3 f6 |( l( b2 O
follow-up visit was arranged within a few weeks to
) z- h, ]. O& W, g2 k' k  oobtain testicular and abdominal sonograms; how-
: G# U* H: }8 E" Pever, the family did not return for 4 months.
( @' p! a5 m% M2 rPhysical examination at this time revealed that the& P9 R" h: H  l; \4 }" k* }
child had grown 2.5 cm in 4 months and had gained, v. X$ ?. |/ @: O7 G
2 kg of weight. Physical examination remained
0 w" U$ A6 r3 z; r4 [unchanged. Surprisingly, the pubic hair almost com-
* j: Y* y4 Z8 S6 H" b2 Apletely disappeared except for a few vellous hairs at
8 {: c$ B+ x% athe base of the phallus. Testicular volume was still 2( _) U' b" P7 _8 u- S& K8 o
mL, and the size of the penis remained unchanged.
$ O5 i0 t$ I; Z4 @) z1 pThe mother also said that the boy was no longer hav-% d- }8 r, _9 D' ~
ing frequent erections.  Z! a+ ~- |; t" r( b! F/ j
Both parents were again questioned about use of
! d1 ]- n# s5 v! G: q$ Gany ointment/creams that they may have applied to
+ I$ g: ]( T! Q1 d5 }* F4 s- dthe child’s skin. This time the father admitted the% x1 b$ j! p* L
Topical Testosterone Exposure / Bhowmick et al 541# J) P) l. ~! q# E, g. s2 n( ]
use of testosterone gel twice daily that he was apply-
' m6 Z% j+ x# Q$ [ing over his own shoulders, chest, and back area for
- K' {+ D* W1 X4 Na year. The father also revealed he was embarrassed4 k, c3 I7 D! u
to disclose that he was using a testosterone gel pre-$ y5 `; H. m$ m. @  K" l9 J6 q  ^* H
scribed by his family physician for decreased libido+ ]* m$ V2 y1 b' d( B! t& `8 l1 a
secondary to depression.
( ]" E, a* \' a6 H5 j8 E* LThe child slept in the same bed with parents.. a/ z6 w7 ~5 P, i3 l3 R
The father would hug the baby and hold him on his
! A7 V$ c* o5 d0 l1 a) J7 R, ochest for a considerable period of time, causing sig-
0 ?1 S) _# |. r# u3 \5 Xnificant bare skin contact between baby and father.
& y0 c# z% g4 c, p- dThe father also admitted that after the phone call,
  Y- L" e% R/ {/ y% v# kwhen he learned the testosterone level in the baby. s$ h; J5 n0 E3 V+ [, o
was high, he then read the product information9 a' n; a* m$ z, ]1 A+ O
packet and concluded that it was most likely the rea-! B. {( t6 g. F, c8 |
son for the child’s virilization. At that time, they+ g5 n( r, f& X, I
decided to put the baby in a separate bed, and the& s6 ~5 Q! N. B+ B
father was not hugging him with bare skin and had6 H- n7 ]0 i3 q+ L# e
been using protective clothing. A repeat testosterone5 f" q, N7 P" V1 C: p
test was ordered, but the family did not go to the$ f( O  H  \( S9 a1 z
laboratory to obtain the test.& y7 G0 n7 g, b& g
Discussion! q2 F  p7 F$ ^2 Z
Precocious puberty in boys is defined as secondary& K7 [1 L8 M# p2 V
sexual development before 9 years of age.1,4; t, ]& U' C* a
Precocious puberty is termed as central (true) when
8 E; g5 E: T( [$ k3 Zit is caused by the premature activation of hypo-: H- L. {0 D/ d8 p' Q* o, A
thalamic pituitary gonadal axis. CPP is more com-/ a5 Z4 p3 v' V, w3 t
mon in girls than in boys.1,3 Most boys with CPP7 f/ b# i: D- _  D" D1 c% W( A
may have a central nervous system lesion that is
' A, V" ^" {. Z* o+ Q; sresponsible for the early activation of the hypothal-* q. q; x+ Z- a0 u; `
amic pituitary gonadal axis.1-3 Thus, greater empha-. v- S/ W# }- G; D0 B+ E
sis has been given to neuroradiologic imaging in
  Q% d8 \  I4 h! n2 K$ V& M0 e4 Aboys with precocious puberty. In addition to viril-
7 G, O2 u% b# f, Z. ~2 Y2 jization, the clinical hallmark of CPP is the symmet-
2 J2 v: L2 d, Q5 W1 Jrical testicular growth secondary to stimulation by
. ~2 H9 m1 ]+ C/ Ngonadotropins.1,3" h5 n/ B2 p$ E4 R
Gonadotropin-independent peripheral preco-" Q' f8 l: [5 e
cious puberty in boys also results from inappropriate- ~1 n* d) }/ ^* f/ o7 x
androgenic stimulation from either endogenous or* p$ p5 F4 A8 U$ b3 T3 h
exogenous sources, nonpituitary gonadotropin stim-1 T5 z! u7 k2 w
ulation, and rare activating mutations.3 Virilizing
3 i+ @! A, ?4 o5 {8 T7 a- x% wcongenital adrenal hyperplasia producing excessive0 w5 [2 x& a- M  b7 G' o
adrenal androgens is a common cause of precocious% ]+ b" c+ E4 }; h. D
puberty in boys.3,47 o" w. d! \# t1 K! X3 ?- D
The most common form of congenital adrenal
) {% A& @5 _- A; ^2 ?hyperplasia is the 21-hydroxylase enzyme deficiency.8 b5 Z: c1 a0 A5 G* i, |4 x
The 11-β hydroxylase deficiency may also result in
" E1 `+ [9 S* D# H1 Cexcessive adrenal androgen production, and rarely,  ?4 T/ z( a/ j8 S) C
an adrenal tumor may also cause adrenal androgen
2 x8 U! [. J) c; Z3 iexcess.1,3; N, _* p' u! f$ G2 E" i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 s2 L6 s+ j5 v3 w542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 f: }6 B9 k+ i9 u5 `- T' _% v
A unique entity of male-limited gonadotropin-
! ?* g& @; t$ ?3 H5 cindependent precocious puberty, which is also known3 q, Y9 X; I8 u; z
as testotoxicosis, may cause precocious puberty at a' y$ o5 U4 N/ {# S2 q6 [
very young age. The physical findings in these boys
9 R5 K& @1 Z% _0 Qwith this disorder are full pubertal development,1 I& K( D1 w  V
including bilateral testicular growth, similar to boys
$ _% R7 K3 l( J( [9 ]with CPP. The gonadotropin levels in this disorder
9 c/ @2 k+ v* F3 G. c- R$ a8 ~are suppressed to prepubertal levels and do not show( _5 k( [; `- m1 C$ n
pubertal response of gonadotropin after gonadotropin-
  t8 p4 @0 Z& G* xreleasing hormone stimulation. This is a sex-linked
5 |+ G  g1 u1 E4 {2 {" G- Zautosomal dominant disorder that affects only9 }0 b1 f. \. M! Y6 Q
males; therefore, other male members of the family
: |' b0 l6 B7 \may have similar precocious puberty.3
# X: {$ T2 g$ {+ s) TIn our patient, physical examination was incon-- L, _8 Z! W) F; ?! B1 g3 R! E$ s
sistent with true precocious puberty since his testi-
/ p1 l7 J! J9 p4 ~* g- [cles were prepubertal in size. However, testotoxicosis
: Y+ b5 D) X' g& m! U0 ewas in the differential diagnosis because his father
' q# \% H) g* O9 lstarted puberty somewhat early, and occasionally,
/ r/ B3 S* ]1 j0 Ctesticular enlargement is not that evident in the
/ x& P- y: ]2 @- Pbeginning of this process.1 In the absence of a neg-' y' n' t8 c- n& q0 p
ative initial history of androgen exposure, our4 l" I! D6 Z: F: T% @) [; J
biggest concern was virilizing adrenal hyperplasia,0 d! J. O+ H! K/ ]2 K
either 21-hydroxylase deficiency or 11-β hydroxylase' e5 V( k4 `: @0 |( I/ w; T
deficiency. Those diagnoses were excluded by find-3 E. H- }1 E$ Z
ing the normal level of adrenal steroids.
( X; V- n& P: ?! t+ C/ M8 FThe diagnosis of exogenous androgens was strongly
5 n1 @  D: S7 t, n5 u. ?suspected in a follow-up visit after 4 months because
. [/ J$ @+ Z1 ?5 Dthe physical examination revealed the complete disap-) J, w" Q4 ~" X7 e7 n
pearance of pubic hair, normal growth velocity, and
' Y# k$ r) [( x7 ]8 adecreased erections. The father admitted using a testos-
, P/ `% W' Z, R3 Bterone gel, which he concealed at first visit. He was% J8 v1 L3 }, c! e
using it rather frequently, twice a day. The Physicians’
$ o( u# V$ x$ B' u2 y  w+ ZDesk Reference, or package insert of this product, gel or
* [/ `, M3 t+ @" w4 x" Y/ V( W& |- pcream, cautions about dermal testosterone transfer to
. [+ X1 c4 f# ]* x- w; H) [unprotected females through direct skin exposure.7 y  P, e: }) R8 F6 U# C
Serum testosterone level was found to be 2 times the
1 I9 h2 o# H4 y/ X9 ?- c: A* @% wbaseline value in those females who were exposed to2 A8 [! R  ^2 C& x9 B/ P7 `
even 15 minutes of direct skin contact with their male
$ A* m6 u# u2 J: C8 r3 k1 z! apartners.6 However, when a shirt covered the applica-
- \2 I$ P& B1 K! qtion site, this testosterone transfer was prevented.
8 n' N/ c" q9 b) rOur patient’s testosterone level was 60 ng/mL,
, g5 J: U$ [( `) Y0 D$ Lwhich was clearly high. Some studies suggest that- d4 g2 q1 ~- [! D( O8 ]
dermal conversion of testosterone to dihydrotestos-
8 j  g4 ?8 o8 z) k7 U1 mterone, which is a more potent metabolite, is more
3 E/ I* u- r. C5 j. i& B* aactive in young children exposed to testosterone" a* U0 R- J4 i
exogenously7; however, we did not measure a dihy-3 a! X6 {6 J2 u9 u9 D1 x
drotestosterone level in our patient. In addition to; n5 v  v5 Q1 j2 ?) \5 I/ v
virilization, exposure to exogenous testosterone in! W. J  L8 A8 f' H  s
children results in an increase in growth velocity and
/ X2 N8 G& X# ^advanced bone age, as seen in our patient.
0 [$ I+ f6 t1 hThe long-term effect of androgen exposure during
! V5 x* P: Q" B+ i8 p- ^early childhood on pubertal development and final
( D/ g- c2 V$ N: y1 l: radult height are not fully known and always remain
. z) p& a, {% K4 }a concern. Children treated with short-term testos-( R1 K  X6 K9 t7 r
terone injection or topical androgen may exhibit some
8 n& o# p; Y! U8 ]0 {% q0 vacceleration of the skeletal maturation; however, after/ h& F$ y/ a8 e# B/ X
cessation of treatment, the rate of bone maturation
$ x# N& X6 k4 s; Udecelerates and gradually returns to normal.8,9% I& I& S1 T7 `! M
There are conflicting reports and controversy
# ?( p2 [* D1 k- S* rover the effect of early androgen exposure on adult
$ `) x% `' M2 |3 N( ~# Dpenile length.10,11 Some reports suggest subnormal
& o; F, c, S! eadult penile length, apparently because of downreg-" b2 c  c- _- k- N' H, a6 v
ulation of androgen receptor number.10,12 However,
7 b7 `5 K& j* B) B1 o6 r7 TSutherland et al13 did not find a correlation between  i& l. _- h' V* n% j
childhood testosterone exposure and reduced adult
! @- Q3 Y& \3 e+ L1 Spenile length in clinical studies.
; e. d- |7 R- c1 q3 uNonetheless, we do not believe our patient is* b2 r; t/ R0 X$ I# D0 x& Q9 m
going to experience any of the untoward effects from
, ^2 M0 |! E' Btestosterone exposure as mentioned earlier because; g. v! b* @( q
the exposure was not for a prolonged period of time.
. W6 ?# V( ?1 N  nAlthough the bone age was advanced at the time of
/ V2 E9 n# J0 p, xdiagnosis, the child had a normal growth velocity at
8 j/ c' Q5 U4 D1 |( wthe follow-up visit. It is hoped that his final adult
# a* [  k$ G3 I3 L/ zheight will not be affected.
! N( h* h6 }4 I- r) ^Although rarely reported, the widespread avail-
9 u6 z6 U6 c. t( {9 j. Fability of androgen products in our society may4 u0 e8 x$ Y2 a0 j1 Q& B
indeed cause more virilization in male or female3 l* k& M+ y0 L! a( r6 ^
children than one would realize. Exposure to andro-
9 V4 \. D8 r% w; `4 qgen products must be considered and specific ques-% X4 i9 L  W! ~4 J2 g
tioning about the use of a testosterone product or
9 L7 X. `8 ^% ^% S9 I4 d9 Jgel should be asked of the family members during
+ r9 j7 ^2 W( s& n4 D0 v) Ythe evaluation of any children who present with vir-3 S; l  P8 _5 P6 Q, ~
ilization or peripheral precocious puberty. The diag-. h1 x( p- i* |" A1 t! \
nosis can be established by just a few tests and by
" [9 f8 a9 ]! c- F! X. eappropriate history. The inability to obtain such a+ s' O) G3 x- V: k
history, or failure to ask the specific questions, may2 L- D0 {' u2 k# [, P
result in extensive, unnecessary, and expensive( N  |) G, x1 G1 n8 H' [5 Q
investigation. The primary care physician should be
& K$ ?1 p+ W# G7 U5 Oaware of this fact, because most of these children! G2 ?4 \) {- c1 x8 Z" p
may initially present in their practice. The Physicians’
, j3 [4 A3 g4 K" Y; f- MDesk Reference and package insert should also put a( _. G* a, w+ V
warning about the virilizing effect on a male or6 S- y& m9 V( \" p1 P
female child who might come in contact with some-
. ?# u4 Y/ |3 s& ~2 h" M4 q, f. j$ done using any of these products.
( Q% ^+ O2 H) k3 \8 O) ^References7 o. _5 n6 b% N* p9 |6 _  ~: \
1. Styne DM. The testes: disorder of sexual differentiation
) i3 {$ d2 T" P! Y) Land puberty in the male. In: Sperling MA, ed. Pediatric
/ p3 O! c/ W0 g5 @  J+ G' LEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& R4 Z( m! O  c* o: {* g
2002: 565-628.
0 z4 S* F2 ^7 C7 C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 s" l, u/ i1 F/ \, o. ?9 \$ a/ }
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
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

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發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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