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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 l/ P1 d  ^2 SBoy Induced by Indirect Topical
3 p5 i5 D: r6 i/ t3 A2 W" l" O; ^Exposure to Testosterone1 v5 q& O* m, X9 |7 J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) Q$ t" y6 G- G9 q9 d
and Kenneth R. Rettig, MD1
4 B7 n4 X4 d3 l5 nClinical Pediatrics) N- o; b4 B7 E! E2 B
Volume 46 Number 6, v, B" e/ }8 A' f
July 2007 540-5433 O  ]2 \5 S! e$ @1 J4 M
© 2007 Sage Publications# a2 d6 C" C7 x5 p
10.1177/0009922806296651. s7 v0 T+ \+ x! n" [8 K
http://clp.sagepub.com- r- E* A: {; }! s6 S6 {1 @
hosted at
. v1 [0 f! y9 i; _http://online.sagepub.com
& f1 Z6 h- E# N2 t! `$ {Precocious puberty in boys, central or peripheral,8 @5 y: I/ n+ {3 j2 B* s
is a significant concern for physicians. Central2 H* a6 c* N3 X- o
precocious puberty (CPP), which is mediated9 D6 H1 D) O% p& d% n
through the hypothalamic pituitary gonadal axis, has
2 L: H9 L. M! ra higher incidence of organic central nervous system! C7 ~; N6 J3 V" i: F% c- Q
lesions in boys.1,2 Virilization in boys, as manifested2 n- [& b5 T3 z0 d" W) {
by enlargement of the penis, development of pubic8 f1 q" S2 U  X
hair, and facial acne without enlargement of testi-( `# J) n  ?! s9 L1 K+ K  @5 }
cles, suggests peripheral or pseudopuberty.1-3 We. B9 a6 @: B  _
report a 16-month-old boy who presented with the& P! `" z% P5 ?* N
enlargement of the phallus and pubic hair develop-
% J) Y" q7 W5 x* [  Bment without testicular enlargement, which was due9 J( k5 v/ ?$ U9 p
to the unintentional exposure to androgen gel used by  N5 e; M. E: b5 }5 D
the father. The family initially concealed this infor-
6 |& l7 p3 ~2 o8 L8 S; jmation, resulting in an extensive work-up for this7 c; k: E2 Y! k
child. Given the widespread and easy availability of6 P$ T/ M- K6 I0 |% O" `
testosterone gel and cream, we believe this is proba-
: G& r2 R/ D) |5 o2 W% t! g( g+ obly more common than the rare case report in the6 h: g. w# \  E$ k: C$ U
literature.4! ?  R- C, c+ S3 I) i
Patient Report
& L- ~4 Q3 P8 v, KA 16-month-old white child was referred to the. |, z0 V/ h8 P
endocrine clinic by his pediatrician with the concern) ], L* B$ N' a$ o# t: s
of early sexual development. His mother noticed, j2 a# ^% N+ o% v1 l/ O
light colored pubic hair development when he was
' a( E+ \8 x5 EFrom the 1Division of Pediatric Endocrinology, 2University of
! S+ Q0 V; f1 }/ zSouth Alabama Medical Center, Mobile, Alabama.
; R  a6 x' m! ^8 vAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 m% L1 L* U. u: kProfessor of Pediatrics, University of South Alabama, College of
' X3 p9 ^, f2 ?/ F6 tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) F* o- A& \/ L9 m
e-mail: [email protected].
" ]. F+ o; b! a# g  \) O2 rabout 6 to 7 months old, which progressively became/ G+ p( z; @* t0 ]! L  i
darker. She was also concerned about the enlarge-
/ \3 {* O5 H8 Z5 a, R# Vment of his penis and frequent erections. The child  W/ x6 [+ y6 U+ v. e2 s6 W
was the product of a full-term normal delivery, with
# s: ]+ l: }$ ?5 e" g6 _! Ca birth weight of 7 lb 14 oz, and birth length of
* K+ i: [8 P$ q1 a20 inches. He was breast-fed throughout the first year7 a& s$ a; s6 \2 v2 H0 y
of life and was still receiving breast milk along with
0 V0 ?0 Y8 Y$ N& c! ]' L2 ~4 psolid food. He had no hospitalizations or surgery,6 Y9 m) M" t# X8 D% z
and his psychosocial and psychomotor development1 A- Q3 g. E- g- l: H& @) m
was age appropriate.- S7 {( e' ?: K8 Z8 b' @
The family history was remarkable for the father,8 B/ [# G3 y- G- v$ s8 `
who was diagnosed with hypothyroidism at age 16,
5 w5 f+ D: a& ^which was treated with thyroxine. The father’s4 I" y& J' b8 f2 q
height was 6 feet, and he went through a somewhat" k* G5 a. Z/ e& _- v4 ^
early puberty and had stopped growing by age 14.% ^$ g& S! p4 N+ m4 m3 I. L
The father denied taking any other medication. The) h5 p# B* O) L4 j% d6 B
child’s mother was in good health. Her menarche) R8 m! E* I) x
was at 11 years of age, and her height was at 5 feet) H/ K. t0 z+ C
5 inches. There was no other family history of pre-
% h9 p* S0 F5 R4 b; j0 g8 n8 j0 w1 L! Fcocious sexual development in the first-degree rela-
4 o' x' w+ @. N3 K% w! Qtives. There were no siblings.3 H, f- v  W5 q8 p" m6 ~0 Y
Physical Examination; G( ]6 T+ A# b$ a
The physical examination revealed a very active,/ R, s7 W9 V# @' U7 e$ N  v
playful, and healthy boy. The vital signs documented7 l6 ]5 t+ E9 ?9 y. ^& w3 u4 N4 U
a blood pressure of 85/50 mm Hg, his length was  T- P. B- C) f0 g" n: g
90 cm (>97th percentile), and his weight was 14.4 kg
( J( V0 S. N! o6 q; z(also >97th percentile). The observed yearly growth
) h- [4 o/ I3 P- Vvelocity was 30 cm (12 inches). The examination of
* r  i$ `( r8 `0 A) _4 xthe neck revealed no thyroid enlargement.& s8 _5 Z6 `# N  @7 d2 u& Z
The genitourinary examination was remarkable for
& T! W" s. k6 [1 m8 jenlargement of the penis, with a stretched length of; k3 z' B4 U9 d* r" |$ i/ B0 J+ ?
8 cm and a width of 2 cm. The glans penis was very well3 r0 P, X# b: l7 A4 N
developed. The pubic hair was Tanner II, mostly around
% Z8 U6 z# u# q5405 `/ X" q' X' l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ ^9 u/ b+ b. F( j! d6 @/ \9 ^the base of the phallus and was dark and curled. The
6 T0 D# U. ^9 S+ j9 g' Atesticular volume was prepubertal at 2 mL each.
& Y& ]/ s% o& p9 ~The skin was moist and smooth and somewhat
2 t7 {5 j, j4 Koily. No axillary hair was noted. There were no
- E! c, H4 T) Y6 S8 ^: \' P3 ~abnormal skin pigmentations or café-au-lait spots.& [6 C' Z& ~: \% \# e- ?( b
Neurologic evaluation showed deep tendon reflex 2+
9 N8 E& q0 z- e/ [: I* Dbilateral and symmetrical. There was no suggestion
& B% U5 h& b4 c, r' A: {of papilledema., m2 q& D  ?: O9 \- K+ ]
Laboratory Evaluation! u( z' K! t3 O! h$ C
The bone age was consistent with 28 months by
5 z; A) _7 ~( r( @using the standard of Greulich and Pyle at a chrono-( j3 s0 v7 ?5 @8 Z$ u% O& A5 W
logic age of 16 months (advanced).5 Chromosomal
7 l9 y" ]+ @  Z$ ^3 m, ckaryotype was 46XY. The thyroid function test# G+ D% F8 I: A/ n& P0 @% x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 ?6 b% c. p+ L5 tlating hormone level was 1.3 µIU/mL (both normal).
/ ~; f7 }9 Q( h. _The concentrations of serum electrolytes, blood
0 g9 r3 l; N! Y  x: Vurea nitrogen, creatinine, and calcium all were
# ~3 k% v, K# w7 l- L( M$ }4 Dwithin normal range for his age. The concentration& u0 a$ B. K% L! G
of serum 17-hydroxyprogesterone was 16 ng/dL
' i8 V, q6 c! ]8 Z(normal, 3 to 90 ng/dL), androstenedione was 20# r7 a4 K  p# {/ _: u1 S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# u4 Y+ s" y/ c5 S2 ?1 Mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 ]$ V, W2 e2 x" edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 c+ ~3 e; F' V& w5 d- {- d' S5 L49ng/dL), 11-desoxycortisol (specific compound S). V/ S8 \. o9 D/ y' \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 |* T0 }% S( }4 M0 C) D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 g8 U  W. |0 w7 D( wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  s% d5 |: H% Eand β-human chorionic gonadotropin was less than
/ W6 c! w) m% u4 w5 ]- N5 mIU/mL (normal <5 mIU/mL). Serum follicular! C* A. \) q* i9 Z
stimulating hormone and leuteinizing hormone$ p/ L: _) b' A! `7 D1 ^; Q+ y
concentrations were less than 0.05 mIU/mL
7 d7 z, Y! M$ M' f(prepubertal).
! ]- _, v# M5 V- Z6 n" @The parents were notified about the laboratory
# m- L5 Z; e& w1 A& u6 k  v) uresults and were informed that all of the tests were
1 w  J" u& X  k% snormal except the testosterone level was high. The
" ^2 Z3 k) L( M* M6 m, u' ?follow-up visit was arranged within a few weeks to6 \& d  ]) Y% R: {, C
obtain testicular and abdominal sonograms; how-3 X6 ?% }2 R- G
ever, the family did not return for 4 months.8 _/ o4 Y* X0 C5 y6 f5 U+ Y" ?4 [
Physical examination at this time revealed that the
' ~- t+ r! k9 W) Q- ]& e" [child had grown 2.5 cm in 4 months and had gained
+ @- i2 A( u# x7 p& a4 k9 t- R2 kg of weight. Physical examination remained2 `& W& Y' w9 d( d
unchanged. Surprisingly, the pubic hair almost com-! K" A: q7 ]+ J* O1 p: X
pletely disappeared except for a few vellous hairs at  _0 B2 n6 u  A' t3 Y. ^$ j
the base of the phallus. Testicular volume was still 2
5 B' g; S  {! q1 XmL, and the size of the penis remained unchanged.. H+ o" ?! a# x: R. n+ f# Q
The mother also said that the boy was no longer hav-
6 R% e, I; e* a$ fing frequent erections.6 P/ V: k+ |, @* O4 o
Both parents were again questioned about use of
5 E# S1 [! F9 O5 C; ^9 m% o% many ointment/creams that they may have applied to3 ^  M' X6 k& v9 a: T" V, U: ]1 t
the child’s skin. This time the father admitted the* q  X+ v1 S, S' s
Topical Testosterone Exposure / Bhowmick et al 5414 u2 u& z7 b: S6 \/ S% C
use of testosterone gel twice daily that he was apply-4 g! _6 l' y) m/ W; }* [$ r
ing over his own shoulders, chest, and back area for) n9 ~$ N4 t, X
a year. The father also revealed he was embarrassed. H. w: Y6 k: q8 D! p1 X
to disclose that he was using a testosterone gel pre-/ w- t5 ^  O& g$ E
scribed by his family physician for decreased libido0 v6 M2 W! M2 }
secondary to depression.; Q; m1 O# k% M' {5 k
The child slept in the same bed with parents.# r" I9 Z2 t" r( k6 I1 B
The father would hug the baby and hold him on his8 H) u8 d, `- n2 X
chest for a considerable period of time, causing sig-$ p, Y; S& h* h9 O: S
nificant bare skin contact between baby and father.
( H) H# i* o! `1 w# p. W" yThe father also admitted that after the phone call,
9 K  K* P/ b% T5 fwhen he learned the testosterone level in the baby, o' {7 ?+ C, ]  |* W6 w
was high, he then read the product information/ W1 g) U, |" @+ L& C
packet and concluded that it was most likely the rea-% a/ p4 @! v) T: H2 o8 D
son for the child’s virilization. At that time, they. [- A% p, I) j! a. t& }  g( F
decided to put the baby in a separate bed, and the) r, J! N4 l- |
father was not hugging him with bare skin and had7 f, u9 U0 ?  F6 S6 x1 F; J9 J
been using protective clothing. A repeat testosterone
) _* ~9 I. G( {test was ordered, but the family did not go to the
0 T8 z# E) }2 X9 l' Q# alaboratory to obtain the test.
$ h8 f- T5 L- d& h  w, `; Y8 t: bDiscussion
$ x' V8 m6 G5 ^8 D2 r( x( M/ RPrecocious puberty in boys is defined as secondary7 O' f0 Z/ m+ r1 y
sexual development before 9 years of age.1,4. m$ f' t8 O1 b$ k7 H
Precocious puberty is termed as central (true) when/ A% Z1 I3 S5 d7 F, k( f; k* h
it is caused by the premature activation of hypo-9 ?0 a  A2 @* j# F' M* x
thalamic pituitary gonadal axis. CPP is more com-8 S5 I3 ^$ {: k$ C  u4 }2 C  h7 J: T
mon in girls than in boys.1,3 Most boys with CPP, c" P! p6 D$ w) E) F5 j% v; U
may have a central nervous system lesion that is0 G' [' k/ C" B( D  n6 X" K* D  X
responsible for the early activation of the hypothal-- B5 _* [1 Z& ^" W) W0 l
amic pituitary gonadal axis.1-3 Thus, greater empha-# n$ q* f& C; g% z1 x& A+ `
sis has been given to neuroradiologic imaging in
9 \. W1 f4 y7 }boys with precocious puberty. In addition to viril-( ]  Z+ ^% R# A
ization, the clinical hallmark of CPP is the symmet-
% Y0 S* G# W- h/ @9 {rical testicular growth secondary to stimulation by* d* u6 |* u. t9 s3 l: t
gonadotropins.1,34 I+ k- s( ]+ I5 \% V6 o- |8 c; i
Gonadotropin-independent peripheral preco-
6 n/ N# ^  r# d* bcious puberty in boys also results from inappropriate
9 ^4 \# u% w& l' u* [  handrogenic stimulation from either endogenous or- j- {6 R- l" v3 y
exogenous sources, nonpituitary gonadotropin stim-
0 ?3 G  z. O, x9 ~# E  x! g/ S3 `! |ulation, and rare activating mutations.3 Virilizing+ M# [4 [; e5 d
congenital adrenal hyperplasia producing excessive& ?. {" |% O- i9 y) U4 x, N
adrenal androgens is a common cause of precocious
. o9 a4 i" ~" S$ g" p( j* Spuberty in boys.3,4( f4 F- }, g& F' m0 q& F. B( i
The most common form of congenital adrenal1 Z  [) V2 d( F7 t" J
hyperplasia is the 21-hydroxylase enzyme deficiency.% M1 M# ?4 K0 x- a
The 11-β hydroxylase deficiency may also result in
( Z+ {5 l0 s8 M, Q/ y/ h7 \excessive adrenal androgen production, and rarely,
& [  g9 Z+ A6 _7 F( k. Jan adrenal tumor may also cause adrenal androgen, D1 `' S; |+ M7 g/ }! f
excess.1,3% k0 W* V& Y, s+ q; l# e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) i5 T! w- I  a1 f" C9 `9 T. Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ ?$ K0 l# z" k, y( c( q  p
A unique entity of male-limited gonadotropin-
- V6 @9 |; u% B. M9 @independent precocious puberty, which is also known7 B" S4 c# M# O/ o  D
as testotoxicosis, may cause precocious puberty at a6 h+ t" s& k! O+ T
very young age. The physical findings in these boys8 K5 }; x6 l0 Y' n
with this disorder are full pubertal development,$ \+ \0 y! e2 G! w& Z
including bilateral testicular growth, similar to boys. r+ H, r# n4 N8 N
with CPP. The gonadotropin levels in this disorder
& m/ O7 m% g( S! \8 c; Xare suppressed to prepubertal levels and do not show
- u5 f1 p; r& i, N; opubertal response of gonadotropin after gonadotropin-
# h  f& b& k  X8 @+ V( {- ^$ j' Rreleasing hormone stimulation. This is a sex-linked+ i! n2 L) v! c: ]3 y1 W
autosomal dominant disorder that affects only$ z* Z3 S: U! I
males; therefore, other male members of the family& B8 y5 J0 m+ }" D: i
may have similar precocious puberty.3
9 j: g3 s0 C; O4 pIn our patient, physical examination was incon-
* s" H7 o3 Z( z! O, ?- v6 `6 {+ fsistent with true precocious puberty since his testi-
" A0 V8 B! N$ gcles were prepubertal in size. However, testotoxicosis4 |8 D5 h# N% Z, a) v7 R; @
was in the differential diagnosis because his father3 U( B" G8 c5 f& U+ w
started puberty somewhat early, and occasionally,
6 L4 `9 ~9 |5 l, g8 ~' d$ x# R' ?testicular enlargement is not that evident in the0 }9 s2 x: u9 M, @+ g: O
beginning of this process.1 In the absence of a neg-9 n! M% B( n: [% s! I. u
ative initial history of androgen exposure, our
$ _6 z& Y4 u9 \/ S3 T. Lbiggest concern was virilizing adrenal hyperplasia,2 }" S& d+ P5 a( c  y5 ?6 P& A4 V
either 21-hydroxylase deficiency or 11-β hydroxylase
- @4 ^) I% Z. n6 ]" _1 C7 Rdeficiency. Those diagnoses were excluded by find-% }" v& k/ N8 f( d( }
ing the normal level of adrenal steroids.
; g$ q6 m4 o& o' c3 x+ t: ~" \The diagnosis of exogenous androgens was strongly; f, N5 [) M! d0 w" s
suspected in a follow-up visit after 4 months because
9 s) P! L; Q2 F2 r2 k. h: U3 Kthe physical examination revealed the complete disap-. M" ]; J5 z1 r; P. y, ]
pearance of pubic hair, normal growth velocity, and
* ]% D8 P2 }4 u! A- `9 v) _decreased erections. The father admitted using a testos-
$ |' s0 t$ v+ @5 tterone gel, which he concealed at first visit. He was
7 ]6 o' _. Z5 l7 U1 Qusing it rather frequently, twice a day. The Physicians’' \) E: N! ~$ L! b, A
Desk Reference, or package insert of this product, gel or
3 W% s* }$ f. b  q8 R0 Hcream, cautions about dermal testosterone transfer to% [5 `) I0 [$ r0 m9 D9 }) w# e
unprotected females through direct skin exposure.% l$ C/ I/ o' G. x' A# U4 [' {
Serum testosterone level was found to be 2 times the
1 j7 V/ Q* a# W+ X" ~. ]& {baseline value in those females who were exposed to& o- [/ O' t4 H9 N
even 15 minutes of direct skin contact with their male7 w9 L& T! S  G; x4 y7 w* s
partners.6 However, when a shirt covered the applica-" F1 k6 @$ T& k5 _0 ]1 _
tion site, this testosterone transfer was prevented.8 V* q) A; f2 E
Our patient’s testosterone level was 60 ng/mL,
/ u' p; M. M( r9 b6 U* ?% gwhich was clearly high. Some studies suggest that
5 {; g  z2 F3 D% t( \, U1 g, ydermal conversion of testosterone to dihydrotestos-* S  J4 j8 v! }/ L1 N( Q( j% G# c
terone, which is a more potent metabolite, is more# _5 Q- v& O# B' w
active in young children exposed to testosterone
$ E0 E2 x3 t8 t; n& S: xexogenously7; however, we did not measure a dihy-; J+ V- q, [" C* [# F! @, D
drotestosterone level in our patient. In addition to
- ~, L. q) U* n' m4 gvirilization, exposure to exogenous testosterone in
$ w) X0 t8 I. e7 lchildren results in an increase in growth velocity and
- F  G& G3 y1 b  ]1 Yadvanced bone age, as seen in our patient.3 ?2 w2 v% o  x* e" t# t
The long-term effect of androgen exposure during& O' u. U: n' Z* l$ U- Z4 `6 H
early childhood on pubertal development and final
: L- v: G5 ~) F: S  G, kadult height are not fully known and always remain
4 r- h+ o) G! ra concern. Children treated with short-term testos-) g5 r- t' Y3 k4 p2 E8 f
terone injection or topical androgen may exhibit some) r/ H3 I8 H/ ]9 E% S2 d/ h
acceleration of the skeletal maturation; however, after% V6 {" ~7 }% E; d  Y  f0 L
cessation of treatment, the rate of bone maturation2 W( h: h9 @/ j. t0 q9 M7 |# F
decelerates and gradually returns to normal.8,9* _; V8 E! x2 g2 Q& o/ L; |- _9 R
There are conflicting reports and controversy
1 Q7 K7 C1 \4 i" R& yover the effect of early androgen exposure on adult3 F9 }4 |( Y# f4 A* W/ \! K. `$ [' f, z
penile length.10,11 Some reports suggest subnormal% ^  {" d& a6 j7 c5 W
adult penile length, apparently because of downreg-+ w4 K9 m. n4 K5 Q( `
ulation of androgen receptor number.10,12 However,! _5 h, ?5 c9 |) ?
Sutherland et al13 did not find a correlation between
& s% j% L; C# x+ N& o! R& Wchildhood testosterone exposure and reduced adult* I  \0 t4 s! _; N# s- _! d
penile length in clinical studies.
1 w* _" e/ X4 k  s. f: c! ~: u* eNonetheless, we do not believe our patient is* \4 ?' h2 ?5 S
going to experience any of the untoward effects from( k0 b6 d5 }7 N/ N
testosterone exposure as mentioned earlier because* E3 {: y& C+ x( b/ ~  \
the exposure was not for a prolonged period of time.
7 k5 D" W4 y& Z3 h) B7 eAlthough the bone age was advanced at the time of
! w0 t( H" `! K1 s2 h& F+ ydiagnosis, the child had a normal growth velocity at
8 p/ P# Q: X  C8 I% r7 ^the follow-up visit. It is hoped that his final adult
9 l& j4 A! Y, V/ c) @6 jheight will not be affected.# M2 ~* ~, H! J8 q$ T
Although rarely reported, the widespread avail-7 ~2 n8 `2 x9 w& Q5 v8 Q: r
ability of androgen products in our society may
7 s  D! s' m/ Windeed cause more virilization in male or female
. I" ~$ l7 T" O' P! e* p: X! a6 Dchildren than one would realize. Exposure to andro-- D5 h9 \) y! w5 Q
gen products must be considered and specific ques-
  W* |$ }% c" W: J& |  [, \. Ltioning about the use of a testosterone product or$ v2 n0 B  J6 G8 `- @( J
gel should be asked of the family members during% m, g! c( K/ x' m. B" U/ L4 S
the evaluation of any children who present with vir-
7 z9 A; R& D% w' h  Pilization or peripheral precocious puberty. The diag-
! H6 n# d* ?& z0 q( x6 S$ Knosis can be established by just a few tests and by
0 W' r, M0 h+ f& V: F" eappropriate history. The inability to obtain such a; v6 E. U1 c- n# {& m' O
history, or failure to ask the specific questions, may7 M( S- M$ c% x2 ?$ ?
result in extensive, unnecessary, and expensive$ O" ?9 X1 v5 g! t, b
investigation. The primary care physician should be# z( i( }0 `# j" k9 T, |
aware of this fact, because most of these children5 X! P0 f0 G+ t
may initially present in their practice. The Physicians’9 ?  {1 x0 l; @5 x$ E& m( t- A; Q' ]7 N
Desk Reference and package insert should also put a3 C  y3 K8 n4 l6 s; R! w
warning about the virilizing effect on a male or% O2 ~7 V' B" m8 S. b9 w- ~4 A; W
female child who might come in contact with some-
  t" o& z% N8 b" S' h, |( ione using any of these products.
0 z* X* Y$ V- P) D" Q, kReferences8 ]% k0 S  y7 P) \
1. Styne DM. The testes: disorder of sexual differentiation
, a) R- N. S% O* Y$ ^4 ^! `  pand puberty in the male. In: Sperling MA, ed. Pediatric4 d# n% w6 }/ }$ K0 G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! n2 H* n8 f$ C3 \$ e! q, B0 `2002: 565-628.
: o9 ], d" ^' q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( b9 f( a3 {/ B9 r: ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
! e8 Q) S+ L9 u; k3 U1 J5 wBoy Induced by Indirect Topical. E& |  M9 K1 m
Exposure to Testosterone5 ~3 ^5 Z( C8 d4 J- h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ I/ l4 _1 R* o1 ?9 {and Kenneth R. Rettig, MD1* d$ a* O  E/ C2 H
Clinical Pediatrics
9 c7 _5 h" g6 K" m8 lVolume 46 Number 6
0 a  |1 F( O' ]: X2 H- h0 {July 2007 540-543
* K# c9 n; s4 Q% g$ f' B/ k. o, N© 2007 Sage Publications
9 B) N& m, x8 d( \10.1177/0009922806296651; h2 y1 _/ d8 \0 m6 q
http://clp.sagepub.com( j! J3 f8 G! F& @( J+ H
hosted at. F) ~3 p! S2 E6 X
http://online.sagepub.com
9 ]# N! l0 X6 p5 {9 `6 j1 dPrecocious puberty in boys, central or peripheral,1 S. F1 M2 T; V8 D
is a significant concern for physicians. Central
9 [. f: O( L" ]6 y( [' V. I- Pprecocious puberty (CPP), which is mediated9 f9 l) e0 z5 K  K% w
through the hypothalamic pituitary gonadal axis, has4 ~3 z: j- P- u% t+ |  v
a higher incidence of organic central nervous system0 S/ U, ?/ C# C+ f# r3 r3 c* y6 ~* v
lesions in boys.1,2 Virilization in boys, as manifested$ ?2 h0 A- [6 P% A6 T# `% j9 r
by enlargement of the penis, development of pubic
6 q0 A/ x( D$ j4 p3 G* B9 L9 w: vhair, and facial acne without enlargement of testi-
/ b& O+ Z! R( v4 Wcles, suggests peripheral or pseudopuberty.1-3 We( s& Y- \' y0 U* j  r
report a 16-month-old boy who presented with the! P" s! P. r# u; G. H- f
enlargement of the phallus and pubic hair develop-7 b4 C  i- a, _, k* u+ J: U
ment without testicular enlargement, which was due# W3 L. U4 j: }9 `
to the unintentional exposure to androgen gel used by
# r$ h4 Z" {( D/ M( Hthe father. The family initially concealed this infor-4 i; {2 q/ b" W9 c8 O+ ]
mation, resulting in an extensive work-up for this
% p- _6 T. v( zchild. Given the widespread and easy availability of
: V! U2 g: U+ h) q" I* S, Otestosterone gel and cream, we believe this is proba-
1 Z5 z1 }* E1 |3 B8 y1 I/ n! Mbly more common than the rare case report in the2 K/ F7 b( W# X0 ]6 I3 Q
literature.4; \7 L. {/ L) a4 g6 ~
Patient Report
2 F  h! o) @5 j8 B" F- p/ I' qA 16-month-old white child was referred to the: i% |$ m; ^; y$ t) b: [' H
endocrine clinic by his pediatrician with the concern; N: q. G- `8 T
of early sexual development. His mother noticed* z6 J3 |/ E0 o  K/ L* A3 Y
light colored pubic hair development when he was
) B+ P4 P$ \, N/ x- l  O, Z" f6 _5 a! G: gFrom the 1Division of Pediatric Endocrinology, 2University of
2 W' r# H9 S: ]9 V: kSouth Alabama Medical Center, Mobile, Alabama.
, n! O# s1 ~' y0 ~! XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& ]/ R3 K+ q3 v8 i7 N' {Professor of Pediatrics, University of South Alabama, College of8 ~2 Y+ x* M2 D% i( |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# z: o# M# A4 j2 a3 d: @
e-mail: [email protected].
3 [3 N0 B! X8 a/ E: n2 mabout 6 to 7 months old, which progressively became
& Y8 v) Z* ?: V+ p  Ldarker. She was also concerned about the enlarge-1 f/ W& a, V8 X/ E  F5 F+ H4 D
ment of his penis and frequent erections. The child* Y8 S: c6 `5 C$ U: X# O
was the product of a full-term normal delivery, with
' R- q% C# k- {9 xa birth weight of 7 lb 14 oz, and birth length of
/ {2 \, N3 }/ ?8 N# v20 inches. He was breast-fed throughout the first year
( v: @1 K; Q& F! Nof life and was still receiving breast milk along with
8 c) ]* J6 L6 `4 M3 ysolid food. He had no hospitalizations or surgery,
5 p4 G, n% l% \9 x7 r( R0 Oand his psychosocial and psychomotor development0 y% {7 ]# Q" }5 U, l. W; L
was age appropriate.
7 S& A( C8 M+ Y+ zThe family history was remarkable for the father,
* u* {6 F- }  S& e; Q6 Twho was diagnosed with hypothyroidism at age 16,
0 Q6 b* b6 k  awhich was treated with thyroxine. The father’s, z8 \% k( h0 }0 A7 r7 w
height was 6 feet, and he went through a somewhat- }# i6 @1 P) }3 z5 }2 B' E
early puberty and had stopped growing by age 14.
+ l( {+ ~: ?& Q3 n7 ]The father denied taking any other medication. The4 v" f# z, z+ L+ V" P, t8 d
child’s mother was in good health. Her menarche
. f: e+ F& I1 v; i# x) s( Zwas at 11 years of age, and her height was at 5 feet" z# _. L# z) c# y6 J
5 inches. There was no other family history of pre-7 a8 Y9 N$ ~5 C; J. v$ `9 h! l
cocious sexual development in the first-degree rela-) ^& g! d0 U. c3 [; y: F" U" O
tives. There were no siblings.
$ K( _+ c8 T: W+ aPhysical Examination
& j# F( D% [0 W9 f" g9 `0 i, zThe physical examination revealed a very active,
" b, m: H# P* |" }0 c, U: D& G" kplayful, and healthy boy. The vital signs documented" j: b, H: d$ [2 U- w1 N- O( p0 E
a blood pressure of 85/50 mm Hg, his length was3 z& _4 n2 b- c2 T
90 cm (>97th percentile), and his weight was 14.4 kg
+ i  k4 u9 f* u4 A/ `(also >97th percentile). The observed yearly growth
! q. W6 l  f6 ~" Gvelocity was 30 cm (12 inches). The examination of
- y$ o; X2 N4 L. nthe neck revealed no thyroid enlargement.
. |( z& v4 U6 o/ }The genitourinary examination was remarkable for
( K* N" \3 N7 n2 R8 X. h4 Fenlargement of the penis, with a stretched length of' A; z% n) Q% T" ]
8 cm and a width of 2 cm. The glans penis was very well/ _( B! L+ Y1 m  N5 y; U/ a0 h- H; k8 q
developed. The pubic hair was Tanner II, mostly around/ n0 ]7 s- h& H$ O; _/ t2 q
5408 d# |2 X+ w% l7 s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* x/ l2 x, p' N& }- [% Athe base of the phallus and was dark and curled. The
2 w3 p+ U" t0 q. i4 dtesticular volume was prepubertal at 2 mL each.
8 a. u* `+ Y/ k2 L9 _The skin was moist and smooth and somewhat
8 X8 q; X. m2 ?1 y: |oily. No axillary hair was noted. There were no6 i7 a6 r. R) L" J
abnormal skin pigmentations or café-au-lait spots.
/ H/ C- L( T6 fNeurologic evaluation showed deep tendon reflex 2+
  s+ `$ D6 P/ k8 s' b6 ?: q5 Jbilateral and symmetrical. There was no suggestion
) g4 \9 E0 n1 @: F2 d" V4 kof papilledema.
9 z9 @  @' f' t- K8 z. M9 [Laboratory Evaluation
  P( G, f9 }" Y/ Q5 XThe bone age was consistent with 28 months by
: F& d! J4 w' x" _using the standard of Greulich and Pyle at a chrono-
) G! `3 y/ I; x: J* g7 Rlogic age of 16 months (advanced).5 Chromosomal
/ }, x  X8 }/ M* j- A- pkaryotype was 46XY. The thyroid function test, T1 K: G: x$ u7 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ f  m4 A, K: g0 V, [0 f  A
lating hormone level was 1.3 µIU/mL (both normal).
* ?3 A7 m+ D1 z" GThe concentrations of serum electrolytes, blood0 j5 O: c& S# |5 i
urea nitrogen, creatinine, and calcium all were0 o1 _( E8 ^* R1 ~8 t
within normal range for his age. The concentration
  h) R' W$ N; i+ {( ?of serum 17-hydroxyprogesterone was 16 ng/dL. ^3 T' G# w* D& c2 B( I( a
(normal, 3 to 90 ng/dL), androstenedione was 20
: Q: e/ Q* o. d7 D7 O* X7 Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ B& z* B) x& V. {8 Q3 O  Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 O2 z; A- Q1 w; k1 ?( U  {' Q; k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 x7 Q1 l, l  K/ K* s- z
49ng/dL), 11-desoxycortisol (specific compound S)
0 w9 `; a! Q; r3 Q) m  n4 Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. i; |( l3 `2 X$ H& L% X. V+ Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! ~4 j% b& i" u3 E3 h
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; Z, y" D6 Q/ f
and β-human chorionic gonadotropin was less than
# {; k( V/ t4 |0 ?: \5 j3 a5 mIU/mL (normal <5 mIU/mL). Serum follicular8 d9 U- L( |! w# W+ k
stimulating hormone and leuteinizing hormone
5 k& O* R; W, P- Y: H2 nconcentrations were less than 0.05 mIU/mL
6 ^$ V; c3 N+ u$ r0 t$ }(prepubertal).
( B, b& c. B3 Z' wThe parents were notified about the laboratory
$ K; u' V4 A; U9 u+ |4 eresults and were informed that all of the tests were( l4 H! U% ?  z
normal except the testosterone level was high. The1 H1 f- ?$ y9 c
follow-up visit was arranged within a few weeks to) `. \$ Q, v& O/ y  @
obtain testicular and abdominal sonograms; how-
; |( |" n; s" x% L5 f, lever, the family did not return for 4 months.
" N. e8 D& i7 A( v- TPhysical examination at this time revealed that the' c3 T6 p, h5 @5 F4 G3 y5 Y0 |) [% B
child had grown 2.5 cm in 4 months and had gained; x% l* Y- v7 Y( M* w( M# f$ y7 \4 D
2 kg of weight. Physical examination remained6 i7 ~5 C8 {6 Q' O, [
unchanged. Surprisingly, the pubic hair almost com-
) e6 _& v: j7 Epletely disappeared except for a few vellous hairs at
" ^% |( E/ {! b* Zthe base of the phallus. Testicular volume was still 28 T4 h+ j  B4 ]3 U* u2 E
mL, and the size of the penis remained unchanged.8 g- B  d: k  P% Y4 n: s# w8 [
The mother also said that the boy was no longer hav-( ^$ V3 ?6 u' o+ A, J
ing frequent erections.
. ~( f: D% ^$ l/ s8 X9 L) ~Both parents were again questioned about use of6 N$ x* P, ~8 D3 h/ R# \/ z
any ointment/creams that they may have applied to/ p/ X  \0 r' w6 ?0 k2 w! L" i
the child’s skin. This time the father admitted the* }* y6 l/ e/ P9 \; }
Topical Testosterone Exposure / Bhowmick et al 541
; L3 g% V! q& r2 U% ?- Q/ Luse of testosterone gel twice daily that he was apply-9 S$ H6 }6 [  S5 V5 f
ing over his own shoulders, chest, and back area for
$ J( V& m4 j7 \a year. The father also revealed he was embarrassed) o/ M2 ~/ T5 {, V$ A3 z8 n: ?
to disclose that he was using a testosterone gel pre-
. `, k  O8 ]2 o% A4 w7 Gscribed by his family physician for decreased libido
) Y# R& _1 V: U. B. |' t0 K8 dsecondary to depression., S& {( `% S* A
The child slept in the same bed with parents.
7 n; K, e3 M4 l$ @' o9 @) j- ]" `The father would hug the baby and hold him on his& _7 S, I/ W( {( }) \9 t
chest for a considerable period of time, causing sig-  c9 O, ^4 {, V3 G/ w. K1 X5 _
nificant bare skin contact between baby and father.
9 l: K6 P5 {& n, p7 h, sThe father also admitted that after the phone call,$ D: I+ I( A4 N: D
when he learned the testosterone level in the baby3 O; P  ?% ~& E/ `, U( Z" Y
was high, he then read the product information
# i4 n; p0 @$ _packet and concluded that it was most likely the rea-1 q9 r" A7 a1 r9 Y8 e: L
son for the child’s virilization. At that time, they7 r; O8 m2 M* {- D; Y. i
decided to put the baby in a separate bed, and the& s) C0 l- K% g
father was not hugging him with bare skin and had
+ t# `* M, H" b7 t' y# ]- kbeen using protective clothing. A repeat testosterone
. s. U, b. ^' ^  {6 L0 ~0 W- H3 jtest was ordered, but the family did not go to the# c) q  Q6 g/ r$ Z6 i- g( s' b
laboratory to obtain the test.
3 ?  ^5 e9 U  }1 }: `$ V; ~4 UDiscussion
2 r( t, y, _& Q2 e1 FPrecocious puberty in boys is defined as secondary& }6 L7 N* }6 B+ g5 x% X8 [7 V" z  R
sexual development before 9 years of age.1,4
/ c8 K, b9 M. q1 m7 }3 nPrecocious puberty is termed as central (true) when" `* o6 g4 d8 t3 c4 i
it is caused by the premature activation of hypo-7 R+ n; J, D" d  W( s
thalamic pituitary gonadal axis. CPP is more com-
# {" t) g3 c. V! d2 G# kmon in girls than in boys.1,3 Most boys with CPP3 v  q5 j9 q! K& e: U! a
may have a central nervous system lesion that is
8 y5 K- _# V7 Z: f, y2 G- Y9 [) Hresponsible for the early activation of the hypothal-
: R3 }0 x' }" i% h: C. [+ m; kamic pituitary gonadal axis.1-3 Thus, greater empha-
8 C; G$ |/ h% ]: G2 @sis has been given to neuroradiologic imaging in- P9 m+ Y, G( ?8 {7 L
boys with precocious puberty. In addition to viril-
9 m/ u  I) B7 i* C& Bization, the clinical hallmark of CPP is the symmet-& e6 E+ q4 A) S4 V
rical testicular growth secondary to stimulation by
, Q, V  W7 B& X9 _) a( O# ?gonadotropins.1,3
: a! I8 ~! `( HGonadotropin-independent peripheral preco-  Y: b/ [* @* G$ ]4 W/ B
cious puberty in boys also results from inappropriate* U' q9 [' f- E6 W
androgenic stimulation from either endogenous or
7 b+ v" r9 e. f- t; R( M$ ?) Rexogenous sources, nonpituitary gonadotropin stim-
4 I9 h. _9 C  ^( ^2 s2 iulation, and rare activating mutations.3 Virilizing
  ]  H3 @5 N' \+ Ccongenital adrenal hyperplasia producing excessive
8 G) ?! G6 c: Badrenal androgens is a common cause of precocious* f! S" [0 c% @( q
puberty in boys.3,4! {' W' h0 ~* e" q, r. S# b, @
The most common form of congenital adrenal, ^- q+ e4 b( V. n
hyperplasia is the 21-hydroxylase enzyme deficiency.+ H# d: J8 z) H, }0 `- b
The 11-β hydroxylase deficiency may also result in
' E: }! Z0 b5 Fexcessive adrenal androgen production, and rarely,3 x. P. o3 Q3 ?- n$ V8 o. b; m
an adrenal tumor may also cause adrenal androgen
. c9 P6 \- h$ k! nexcess.1,3! a( Z1 G5 e- R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! t5 V! h1 s9 s. y2 p* S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 ?2 \& |  L$ y+ q! W$ \3 ZA unique entity of male-limited gonadotropin-, o' ^. M7 e, [  a
independent precocious puberty, which is also known
7 q1 f' z4 L; ^0 [$ b" was testotoxicosis, may cause precocious puberty at a
4 e/ o/ }' J  M) ^very young age. The physical findings in these boys8 x  N' m+ M' a6 F& z" ~- @
with this disorder are full pubertal development,1 N. ~. R6 m! `, h
including bilateral testicular growth, similar to boys
6 E* g, h  b3 r2 d: l9 ywith CPP. The gonadotropin levels in this disorder
$ W4 I% f8 W) _. w0 pare suppressed to prepubertal levels and do not show$ r% [4 n" X' u, N1 u+ i9 \. S
pubertal response of gonadotropin after gonadotropin-
0 v  ~; _3 R/ Y8 Wreleasing hormone stimulation. This is a sex-linked  K' u) c* ?' X4 Q, e
autosomal dominant disorder that affects only- J, q' y; V5 N0 m+ R" \
males; therefore, other male members of the family3 q$ j8 D$ }9 F
may have similar precocious puberty.3& c3 _  [2 ?% R: b, ^
In our patient, physical examination was incon-
, C7 [4 ]- |* W) z4 W1 F  {' ?/ ~sistent with true precocious puberty since his testi-4 [3 }+ M# V6 c
cles were prepubertal in size. However, testotoxicosis
7 |% J- e+ E, M* h( h7 dwas in the differential diagnosis because his father
. Z4 T6 S6 c  n$ y7 W3 i6 Qstarted puberty somewhat early, and occasionally,' V/ s3 g9 n" o( G, Q; l
testicular enlargement is not that evident in the% J# G3 H' n) Y& Q; S' K+ A
beginning of this process.1 In the absence of a neg-
6 u& W; p1 D+ Q2 X# m. J. x; kative initial history of androgen exposure, our  V$ z& `& J' S/ T+ \
biggest concern was virilizing adrenal hyperplasia,
% m0 D4 t) Q' g  e2 m  c# ^either 21-hydroxylase deficiency or 11-β hydroxylase
- [4 i% ^0 c: zdeficiency. Those diagnoses were excluded by find-
% \3 q/ K; G7 I8 d9 L8 h7 Bing the normal level of adrenal steroids.9 \: l" g) r  Y: D" f: @
The diagnosis of exogenous androgens was strongly
) R2 u2 g- \( t: H6 {' Ysuspected in a follow-up visit after 4 months because
% S4 K$ N* N$ y) wthe physical examination revealed the complete disap-
! G6 j+ _. @- ]& U- apearance of pubic hair, normal growth velocity, and. v- @1 ^* |, X  F
decreased erections. The father admitted using a testos-
* q2 c/ i2 s( e$ B- Mterone gel, which he concealed at first visit. He was
. L3 V. l  J6 T' R$ q3 d- vusing it rather frequently, twice a day. The Physicians’
. I/ d6 ?# [5 T" \7 tDesk Reference, or package insert of this product, gel or
' y# g/ G* ?2 f! z3 }% Lcream, cautions about dermal testosterone transfer to
1 e& ]: o8 n% T. Ounprotected females through direct skin exposure.5 a4 \' O  |* F3 H* m  h9 O7 X& O
Serum testosterone level was found to be 2 times the5 {5 p. q6 C& G
baseline value in those females who were exposed to
% R% h3 ^' F. b" \) I4 e- w; }even 15 minutes of direct skin contact with their male
! ^$ [( w; l5 b; d; Epartners.6 However, when a shirt covered the applica-
; j+ [1 C$ Z% z; Stion site, this testosterone transfer was prevented.
& y& b6 [3 I; I4 d' ?9 _5 y% W! NOur patient’s testosterone level was 60 ng/mL,
2 U7 w7 F$ d( n) H" lwhich was clearly high. Some studies suggest that
6 V$ u8 f) _7 xdermal conversion of testosterone to dihydrotestos-0 d  n0 I. ]* e
terone, which is a more potent metabolite, is more
5 g0 N* G: x) H) P& P6 Iactive in young children exposed to testosterone
& P+ ]1 o) y+ kexogenously7; however, we did not measure a dihy-; G8 V3 A+ j) Z
drotestosterone level in our patient. In addition to3 @# G- o) z( I- z) y8 K1 `
virilization, exposure to exogenous testosterone in
: e4 q) J- o/ x# a7 ^  C3 wchildren results in an increase in growth velocity and
& w' |$ w& ^. tadvanced bone age, as seen in our patient.
  L7 A; ?, J. ^5 k, E( s, B; R' U6 [The long-term effect of androgen exposure during9 V. N. D/ N( x
early childhood on pubertal development and final
) l- o9 Z9 h$ b, i8 K! c, B% X; |/ Wadult height are not fully known and always remain
6 U* L% W) w8 _9 _a concern. Children treated with short-term testos-
, ]; `. ?. B' R1 }5 ^1 A4 ?terone injection or topical androgen may exhibit some  f- h, U- W) b- y; f
acceleration of the skeletal maturation; however, after; Z  g9 R' O# q  Z1 o7 E
cessation of treatment, the rate of bone maturation
+ p( p" }# k* \  v% L4 Z" Xdecelerates and gradually returns to normal.8,97 Z( c1 K+ z$ d3 g2 C; J
There are conflicting reports and controversy
- t& i) |7 s& j& [5 y' s# jover the effect of early androgen exposure on adult
" m4 |- P* v; e0 T! w5 K" U1 npenile length.10,11 Some reports suggest subnormal
$ P  k0 ?. _+ N) G( [  _adult penile length, apparently because of downreg-7 k2 I# Y6 ]% @6 p3 K5 k
ulation of androgen receptor number.10,12 However,7 A5 J7 F7 Y+ ?1 q: T( P
Sutherland et al13 did not find a correlation between
0 g( z% Z+ h" j& uchildhood testosterone exposure and reduced adult
! r, M, V* a: Q" {penile length in clinical studies.5 x, L6 o/ U$ ~, N
Nonetheless, we do not believe our patient is
8 q1 ^4 w% Z3 n. n! M4 x& ]  fgoing to experience any of the untoward effects from
8 |' c1 r. Z- X+ j6 z: X; Ytestosterone exposure as mentioned earlier because, h, |6 a7 Y" w8 D
the exposure was not for a prolonged period of time.
5 v& H4 Z9 P# IAlthough the bone age was advanced at the time of
2 ]3 X7 J) F/ V9 Z" l: V/ q" rdiagnosis, the child had a normal growth velocity at$ \) r5 X6 v8 Y6 T: Z
the follow-up visit. It is hoped that his final adult
7 T1 e4 k3 m9 }height will not be affected.
; q) a  s- P; ^  z$ cAlthough rarely reported, the widespread avail-
" g; J7 F! Z& b# y0 {ability of androgen products in our society may
0 C( Q5 s* c- aindeed cause more virilization in male or female$ {9 W% d" F& f* G
children than one would realize. Exposure to andro-
$ o8 h0 [1 _5 l# I- E% c4 wgen products must be considered and specific ques-
% U! I% w7 e  qtioning about the use of a testosterone product or4 ]9 |) t+ h. @. X7 p
gel should be asked of the family members during, K+ r! H! {/ T) X+ L% ]1 }
the evaluation of any children who present with vir-5 q+ ]9 M5 e5 o: X) e5 t& K
ilization or peripheral precocious puberty. The diag-
4 L3 L0 M; n$ bnosis can be established by just a few tests and by
/ o. \7 E; ?6 p5 ^appropriate history. The inability to obtain such a
6 \6 z6 K# |" {' v* Lhistory, or failure to ask the specific questions, may2 |) u# T: @# P/ [/ g) `0 H, B
result in extensive, unnecessary, and expensive+ V4 P, d% b- T  ?2 }
investigation. The primary care physician should be; k  o1 P$ v5 x/ ~3 |; ^
aware of this fact, because most of these children
. `. ]* c0 J! Xmay initially present in their practice. The Physicians’9 z" y& {0 K. t9 d7 M
Desk Reference and package insert should also put a- N8 j& r7 m% e- J
warning about the virilizing effect on a male or
% ]+ ], J) [# D* k, yfemale child who might come in contact with some-
6 l3 `, g5 e/ a" b; O  q6 Lone using any of these products.9 x0 u4 i7 l8 G6 P
References
5 ^3 o. E9 ]. t" s1. Styne DM. The testes: disorder of sexual differentiation# \) K6 p! B9 f* F6 X
and puberty in the male. In: Sperling MA, ed. Pediatric% V% D7 N( _( U& n, P( A; E9 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 m& C( c, i. b9 y
2002: 565-628.
6 K, W8 I4 r5 u- v1 X. q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. L- e- j. m6 ~4 a$ P; q
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
# d& H7 Z- {1 O( I9 i5 |, s
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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