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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
: Q1 h1 i, U: iBoy Induced by Indirect Topical' \* H! Z/ S3 F/ C7 u1 w# t
Exposure to Testosterone  B' ?* E' Q2 B9 D% v9 k6 ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: r) ?; V" \" _0 e! ?7 Band Kenneth R. Rettig, MD1
$ z! Y0 z8 L% r% O) U4 u- ?Clinical Pediatrics
) p/ y$ ^2 x& |3 EVolume 46 Number 6
6 {$ t# [7 _7 B2 J, g; H; bJuly 2007 540-543% d/ d5 o8 T4 ~8 t. E
© 2007 Sage Publications
+ _1 W4 D( C1 l10.1177/0009922806296651
  I& r" N- s0 Q; I' y4 r  chttp://clp.sagepub.com9 Q( }4 X  c( S5 Z
hosted at: h( O2 G+ {. e2 K5 E
http://online.sagepub.com
2 |6 d( G- w' D3 n8 K, VPrecocious puberty in boys, central or peripheral,
8 \' i5 Y) @0 `$ h9 ~is a significant concern for physicians. Central, Q/ }- H' H; Q/ p
precocious puberty (CPP), which is mediated+ Y$ p" R! T% h8 z9 }1 q4 U% P
through the hypothalamic pituitary gonadal axis, has: @$ b6 c$ p. E3 @
a higher incidence of organic central nervous system; J8 d: ]2 [8 h% _) m" \2 t! Z
lesions in boys.1,2 Virilization in boys, as manifested
+ {: X! f8 T& Fby enlargement of the penis, development of pubic
- ~, ^( h4 g4 Nhair, and facial acne without enlargement of testi-/ N3 X/ M2 c3 E, J: f
cles, suggests peripheral or pseudopuberty.1-3 We
! o4 i$ N  Z8 @7 ureport a 16-month-old boy who presented with the
6 R) O5 p, r  s/ o& e$ Denlargement of the phallus and pubic hair develop-
; _9 w9 l7 \( s% q- c+ @ment without testicular enlargement, which was due
( V% p% |2 o6 W) C$ E) S3 q' kto the unintentional exposure to androgen gel used by
0 Q$ S( x; q; |the father. The family initially concealed this infor-/ e, P5 o! C6 A
mation, resulting in an extensive work-up for this
; f. {( L; d+ achild. Given the widespread and easy availability of& A9 W- L' V* f1 \
testosterone gel and cream, we believe this is proba-& Q7 i/ V2 r" A0 R! P
bly more common than the rare case report in the0 A1 Z# t( I. @+ ?" h
literature.48 B, L0 Z7 B9 W: b+ \8 P, |
Patient Report
4 N5 {+ e* C+ {' [( GA 16-month-old white child was referred to the" e- A4 I2 O* w# F/ P
endocrine clinic by his pediatrician with the concern
+ H4 E/ B& w! p6 pof early sexual development. His mother noticed' @4 ?3 W9 _) L; l
light colored pubic hair development when he was
+ F* P5 Y9 Z- y0 }; X8 b$ c% }From the 1Division of Pediatric Endocrinology, 2University of- ^; Q) H0 b" q; J3 _: Q) |
South Alabama Medical Center, Mobile, Alabama.
3 w  {( q7 ^8 v' iAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 o! H8 ~: p  m' U' uProfessor of Pediatrics, University of South Alabama, College of% Q, w# O( e4 u% y7 g8 R, a/ c
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 Z: n/ l: c- t5 C" }7 n* \e-mail: [email protected].
  d& m& L- y2 @about 6 to 7 months old, which progressively became/ V! D  M! c2 I  f+ V6 H  j! t
darker. She was also concerned about the enlarge-% t: X7 o9 _! M5 R
ment of his penis and frequent erections. The child# y9 n. L1 }2 r* {! u2 q" X
was the product of a full-term normal delivery, with
: y, b! o+ M+ T( I/ m8 W' xa birth weight of 7 lb 14 oz, and birth length of8 a4 t0 M8 |) A! f% F
20 inches. He was breast-fed throughout the first year: K$ X2 B/ b( F* G/ j
of life and was still receiving breast milk along with
0 ]; A4 x$ i. k9 u5 k. O) Wsolid food. He had no hospitalizations or surgery,7 k' o  N. A' B+ f  ^5 {6 `
and his psychosocial and psychomotor development
3 {  ~7 f9 Y0 r' A  @7 }was age appropriate.
. J# F1 B/ U; U+ ^The family history was remarkable for the father,8 H# D+ C; l  v* e, \. ?) i
who was diagnosed with hypothyroidism at age 16,+ W- T; \  [, _' f
which was treated with thyroxine. The father’s) `+ k. }/ t* w/ ~) |! u! X
height was 6 feet, and he went through a somewhat
& v: A! ]) \% }/ X5 H6 d- Gearly puberty and had stopped growing by age 14.
% S& {9 M' F. t" s; g; o0 W$ YThe father denied taking any other medication. The
" X& k9 h/ B/ ~& Schild’s mother was in good health. Her menarche
( X0 Y1 W8 c; W7 `/ q2 P$ ]9 ?3 Zwas at 11 years of age, and her height was at 5 feet
9 p* y6 O8 s7 S$ j6 Y' _5 inches. There was no other family history of pre-
3 |) J/ Z1 T, k$ s/ Qcocious sexual development in the first-degree rela-
4 T2 z  [% r6 y* |7 E) r; }tives. There were no siblings.4 A  e- ?7 n! o% K6 }! \/ t( v
Physical Examination0 w+ G: _& `; w$ K. h
The physical examination revealed a very active,& K- C& q$ w+ Y+ b- k  P
playful, and healthy boy. The vital signs documented; I1 g6 }% ]! _- ~% c, V  ^/ I
a blood pressure of 85/50 mm Hg, his length was6 x  ], w+ s. W/ y. d9 w
90 cm (>97th percentile), and his weight was 14.4 kg+ f4 e9 a, j: `. m, W. [
(also >97th percentile). The observed yearly growth
6 r0 j4 D7 ~) u4 q2 ^velocity was 30 cm (12 inches). The examination of4 L& h0 W1 ^% e) `$ v- Z2 x( n
the neck revealed no thyroid enlargement., {' w" m  o4 I
The genitourinary examination was remarkable for
7 O; V, B- ~# }& kenlargement of the penis, with a stretched length of! x- j" g/ p: W( |  }9 J
8 cm and a width of 2 cm. The glans penis was very well& i. y9 P, }% h5 y9 j% j
developed. The pubic hair was Tanner II, mostly around0 P) g% s- s( F8 C" V
5406 y+ e4 k0 y  f6 B4 U" H% v7 s2 z' q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& @) K  k% R3 x2 ?the base of the phallus and was dark and curled. The# Z+ M; L3 q+ F, @. b
testicular volume was prepubertal at 2 mL each.
: E. i3 n; r7 T5 x& j/ G9 yThe skin was moist and smooth and somewhat7 b8 Z( M6 G5 `# y6 T7 i/ f
oily. No axillary hair was noted. There were no/ j! m! o& [6 [1 T* \  C
abnormal skin pigmentations or café-au-lait spots., r3 i: h' F7 a% A- p
Neurologic evaluation showed deep tendon reflex 2+( ]/ b- u; w" g4 w' p
bilateral and symmetrical. There was no suggestion1 ?* [* p$ j' f! |# b' o
of papilledema.0 ?! Z5 H1 g; K5 B8 H, H
Laboratory Evaluation
9 i* q9 j" o4 e3 Y! j, ~; w2 U, cThe bone age was consistent with 28 months by6 O! n8 s" \8 w
using the standard of Greulich and Pyle at a chrono-9 i9 Y" }) h5 }; G! H- u
logic age of 16 months (advanced).5 Chromosomal3 ]9 o( Y. j/ V2 B5 A
karyotype was 46XY. The thyroid function test2 y  P0 ^/ i# p7 S2 L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( K. p1 Q: o$ x' T" p
lating hormone level was 1.3 µIU/mL (both normal).. s; D( g3 q  c
The concentrations of serum electrolytes, blood
0 `0 ^" U& ]* a/ O9 q- Nurea nitrogen, creatinine, and calcium all were
* ]/ ^$ E* s- Qwithin normal range for his age. The concentration# l" B- ^1 O9 }
of serum 17-hydroxyprogesterone was 16 ng/dL2 M  B) r, x& w2 y; U) M
(normal, 3 to 90 ng/dL), androstenedione was 20
7 y0 |) j8 b$ ~+ z, [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" {. |8 A4 V- z4 Tterone was 38 ng/dL (normal, 50 to 760 ng/dL),
) u9 o& q! N) y' |1 q* vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 f( ], _1 t3 L: Y6 {% M; O, T: A
49ng/dL), 11-desoxycortisol (specific compound S)
- H8 a! \6 `. s9 b" ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 e/ {" M+ C$ Q! t1 _& l6 p/ q* S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# g% K  ^* e" K( \testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  d$ i8 T7 _$ F/ X0 hand β-human chorionic gonadotropin was less than! b5 o8 F( f+ R8 H) B4 \) u
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 U4 Q' R" i# d3 v+ ?' s1 c/ I
stimulating hormone and leuteinizing hormone# p! i) z4 U0 |3 o+ O* o
concentrations were less than 0.05 mIU/mL
! b; Z+ b1 z( X/ Y0 x: E8 y! {$ u(prepubertal).5 i5 {, Z: G/ @9 t: l1 ~
The parents were notified about the laboratory
- P- W7 j6 K( Vresults and were informed that all of the tests were
: X7 @4 b" X8 i9 ~$ gnormal except the testosterone level was high. The0 [  R1 U5 @9 C$ e
follow-up visit was arranged within a few weeks to
* {0 X! ^3 {6 m* ~$ h/ r6 oobtain testicular and abdominal sonograms; how-
, r, A: Q3 r. M0 ^- V# @* jever, the family did not return for 4 months.* R& `, }* U6 J6 s: B! M+ N
Physical examination at this time revealed that the2 h" A( O! `- u$ [8 ~4 s5 A; O) o
child had grown 2.5 cm in 4 months and had gained4 u- u0 z$ n+ o/ g
2 kg of weight. Physical examination remained9 y' i% |, v0 f" [7 w
unchanged. Surprisingly, the pubic hair almost com-, C0 R- c' B# I5 x! A0 @
pletely disappeared except for a few vellous hairs at: T% L/ F+ R. d+ Y
the base of the phallus. Testicular volume was still 2
. p6 h0 l% x9 ^* y# v5 BmL, and the size of the penis remained unchanged.
* E# ?" K! {; E1 NThe mother also said that the boy was no longer hav-
2 Z/ p( S" c& c+ I" Ging frequent erections.
! _! c' y7 v9 fBoth parents were again questioned about use of
2 h' p/ U5 [, \3 {$ c1 R- Kany ointment/creams that they may have applied to
& w- t5 q3 k- I5 w, P" t* n4 |& |the child’s skin. This time the father admitted the
; D" S. A4 D5 WTopical Testosterone Exposure / Bhowmick et al 541
3 i  q. d+ Q' ~& ~* }0 Zuse of testosterone gel twice daily that he was apply-
, i3 k3 c5 X; g* D; Fing over his own shoulders, chest, and back area for" k; x% ?" m# j3 T9 ~  f) D
a year. The father also revealed he was embarrassed( S* k7 a* {& C0 P; K% c- _9 k4 p
to disclose that he was using a testosterone gel pre-$ W) [" ~# e" }" P/ t: ~% K+ d
scribed by his family physician for decreased libido
" h( f! r& y1 x) o2 d  S/ {secondary to depression.
1 \  n( V$ g' a0 z$ @The child slept in the same bed with parents.
6 I* r) z$ I- t6 v# y2 m- A$ g+ e5 [. `The father would hug the baby and hold him on his
" R5 v. G* \( M" Mchest for a considerable period of time, causing sig-% S3 {$ S% ]4 E% N. P% a
nificant bare skin contact between baby and father.
. ~5 }. v/ {6 B% h; o& tThe father also admitted that after the phone call,1 b) |7 c/ C+ s# s0 h4 I( R% }
when he learned the testosterone level in the baby# I" c% T% c% d$ g+ }
was high, he then read the product information8 g1 |, `" V, e. d
packet and concluded that it was most likely the rea-+ f7 S* P0 N+ K
son for the child’s virilization. At that time, they' f$ L9 K0 R. J
decided to put the baby in a separate bed, and the
0 y- a( y2 ?$ C1 k2 O: Lfather was not hugging him with bare skin and had
' Q9 j/ Y* Z/ ^0 {, R" Lbeen using protective clothing. A repeat testosterone+ i* m6 _/ L( i5 ~
test was ordered, but the family did not go to the+ g7 R" D# ^: C5 s# w
laboratory to obtain the test.- w3 \0 i) ]# B1 m( U
Discussion3 g$ Q3 ?& g6 J4 v( @3 Z
Precocious puberty in boys is defined as secondary
- q8 j+ x2 h1 L! lsexual development before 9 years of age.1,4
- r0 a6 _% Z* ~9 {9 pPrecocious puberty is termed as central (true) when
+ b; r* x' y- v5 o% B) tit is caused by the premature activation of hypo-
" [% q! A% `& s+ Kthalamic pituitary gonadal axis. CPP is more com-: G& h; ^! I8 F) J
mon in girls than in boys.1,3 Most boys with CPP) ]7 _0 H  m! D
may have a central nervous system lesion that is
1 ~: U1 a- M- z, V0 ^responsible for the early activation of the hypothal-
& a+ y8 K4 G" L. s% v& {* i1 \amic pituitary gonadal axis.1-3 Thus, greater empha-2 e3 N, s. Q# @6 O# p7 d' Q  f
sis has been given to neuroradiologic imaging in
2 l7 u/ o3 p5 b, e( D3 V8 yboys with precocious puberty. In addition to viril-
; z1 A# [- W9 t3 r; xization, the clinical hallmark of CPP is the symmet-
$ S. s$ J: y2 ?% S( I- r3 Hrical testicular growth secondary to stimulation by
' N' U! j" j+ rgonadotropins.1,3
/ @" t# h/ k" y( f6 Q, k, Z' v- TGonadotropin-independent peripheral preco-
3 j0 u# h6 C4 S% o7 }* tcious puberty in boys also results from inappropriate$ c( f; h# [; ?3 Z0 U
androgenic stimulation from either endogenous or
) f! r4 Q6 v9 E% s  `& Lexogenous sources, nonpituitary gonadotropin stim-3 {* l# |. l0 K+ C0 M
ulation, and rare activating mutations.3 Virilizing# s$ P6 f: H9 \/ g
congenital adrenal hyperplasia producing excessive- _- p+ h0 y! T' b7 @. r9 j) }
adrenal androgens is a common cause of precocious
8 d( ^6 [8 |1 O* L' ?puberty in boys.3,4
+ E4 b5 A, L1 a* D3 VThe most common form of congenital adrenal" a, O4 G4 _: X
hyperplasia is the 21-hydroxylase enzyme deficiency.
; B" I7 i, m2 MThe 11-β hydroxylase deficiency may also result in
! t# }) x+ o; b7 Sexcessive adrenal androgen production, and rarely,
) H" {6 c5 W- c2 H: Han adrenal tumor may also cause adrenal androgen# A/ i, @7 H* W3 h0 q  c
excess.1,3- q, P. ~' i2 j  N* J! z+ }9 p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* X. d  R6 c; i" M$ K$ ?542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ v7 M" c, X& B5 }A unique entity of male-limited gonadotropin-# ?  t- o8 W8 `3 w* _
independent precocious puberty, which is also known$ u1 D1 W1 y; t$ E2 K- G' p
as testotoxicosis, may cause precocious puberty at a
) ?3 d% q% A% O+ _6 O  C: A3 h9 A  svery young age. The physical findings in these boys
- Z( T; U; i8 T) y: fwith this disorder are full pubertal development,1 v! E% T, ~5 R  A; j
including bilateral testicular growth, similar to boys9 b! U# }! `2 Q# p
with CPP. The gonadotropin levels in this disorder
. v4 Z  D, A5 C1 p. p" G! p# Aare suppressed to prepubertal levels and do not show# [8 L( u- ^) W8 t5 y2 g. I
pubertal response of gonadotropin after gonadotropin-
& o) [2 U) h- |' |. ?+ P( Kreleasing hormone stimulation. This is a sex-linked' T& b5 _4 t5 g" D# o8 A3 |
autosomal dominant disorder that affects only
5 W3 D( {! U- @, f& W9 dmales; therefore, other male members of the family
2 V9 l2 ]# f- B9 ?may have similar precocious puberty.3
/ l" r8 l& z. T4 y) Y' _: [  pIn our patient, physical examination was incon-7 d' T1 E( ?2 x# k
sistent with true precocious puberty since his testi-# r! ?/ _; x) z
cles were prepubertal in size. However, testotoxicosis
/ m* H4 \3 V8 V' }! {+ Owas in the differential diagnosis because his father
* F; V$ z+ l$ F0 ^5 w1 Sstarted puberty somewhat early, and occasionally,
3 c, ^2 Z3 N4 h$ u( Ftesticular enlargement is not that evident in the& m$ ?, J1 i6 J* ?3 A& H& ~. t. M. z/ h
beginning of this process.1 In the absence of a neg-
6 P# j3 A! \  J3 t" u) ^ative initial history of androgen exposure, our+ q. m: N$ e4 C. M0 e5 o
biggest concern was virilizing adrenal hyperplasia,
: ]+ D7 N* g& ~" O. s3 keither 21-hydroxylase deficiency or 11-β hydroxylase
) b7 L* H  m% {4 i" I# K8 Z# Qdeficiency. Those diagnoses were excluded by find-
' Y! Z) K- }$ xing the normal level of adrenal steroids.
8 @* k" `8 u8 j& |7 E3 ], H/ {1 [" EThe diagnosis of exogenous androgens was strongly
. F7 Z, h5 P# m' V- ~suspected in a follow-up visit after 4 months because; E6 N$ E, p8 E8 u
the physical examination revealed the complete disap-' o8 {) Y% W" G2 [( U3 s  D
pearance of pubic hair, normal growth velocity, and9 c; M7 C! c0 U1 a2 y7 E
decreased erections. The father admitted using a testos-( h, a  Z5 c+ ^( t1 n
terone gel, which he concealed at first visit. He was+ q3 O- E  ]" H. \# m' f1 D' J
using it rather frequently, twice a day. The Physicians’
& S& q5 M3 d+ b$ \# ?Desk Reference, or package insert of this product, gel or$ ^7 g0 O0 O" Q9 W' {' ~% L2 y
cream, cautions about dermal testosterone transfer to3 j( ~/ y1 W) Q
unprotected females through direct skin exposure.
% o7 R, f$ H- ^) \, c: qSerum testosterone level was found to be 2 times the
3 M2 j  R4 l: S) q( |baseline value in those females who were exposed to
) L$ W7 g( q, |. i: yeven 15 minutes of direct skin contact with their male
8 i- O: Q2 u# i+ l, u  ~partners.6 However, when a shirt covered the applica-
7 \. P" v- B# c6 e8 ~  r5 _tion site, this testosterone transfer was prevented.# P  |; S  x( T: u  d* {
Our patient’s testosterone level was 60 ng/mL,
0 a9 ]6 P# O" x: f( b: ?which was clearly high. Some studies suggest that
+ ?# z3 n$ T8 Q; s: ndermal conversion of testosterone to dihydrotestos-+ _( L" d* P5 P' W- O1 x/ W4 F
terone, which is a more potent metabolite, is more1 h: Q) I2 J& \; D
active in young children exposed to testosterone7 m7 }. `+ R' j( B* B. o
exogenously7; however, we did not measure a dihy-6 D5 e, y! P1 X9 K
drotestosterone level in our patient. In addition to# M) q2 g$ r0 Y. m, ]- o) ?+ L
virilization, exposure to exogenous testosterone in
/ K. [& d* K' \: hchildren results in an increase in growth velocity and
% C: @& _6 I( Q8 x* m5 A+ Zadvanced bone age, as seen in our patient.* q1 Q5 {* E* e* y
The long-term effect of androgen exposure during$ X% [( O% m0 w2 d
early childhood on pubertal development and final
) D# X% I, Q; V0 t# Ladult height are not fully known and always remain
; x/ G" I. M' t5 S& B$ c& w3 n% ]a concern. Children treated with short-term testos-3 v2 j4 |  j" r% a) ^
terone injection or topical androgen may exhibit some, G. q: w: A( P
acceleration of the skeletal maturation; however, after# F% y% v, C9 e/ C
cessation of treatment, the rate of bone maturation
0 _" h7 m- G# j2 l& N- V1 wdecelerates and gradually returns to normal.8,9
+ c& T% A1 k( P& h+ R9 }3 gThere are conflicting reports and controversy. C; |' A7 K+ h4 d) n" w* X8 ?6 a
over the effect of early androgen exposure on adult
" ^- s6 v- o* |5 h! D7 Wpenile length.10,11 Some reports suggest subnormal
5 ^5 N. d# B% U7 K5 N! R4 Aadult penile length, apparently because of downreg-
! y  c' W$ Q4 ]$ a" z* x  f, Pulation of androgen receptor number.10,12 However," ]0 q- w0 e" D! F5 f+ U. Z
Sutherland et al13 did not find a correlation between
0 F) k5 U0 C3 Q. Zchildhood testosterone exposure and reduced adult
- E, N1 e0 w" T. {: c' U: D2 Mpenile length in clinical studies.
/ q1 B$ P' \: c4 {Nonetheless, we do not believe our patient is
+ n1 H# f* I  G2 |) ^+ f7 ggoing to experience any of the untoward effects from
* M% K. X+ |! P; vtestosterone exposure as mentioned earlier because9 `- R6 ~5 z' {: v7 S
the exposure was not for a prolonged period of time.5 j5 c  v, k, t! ?
Although the bone age was advanced at the time of
& G% U! U: N' [+ H8 Rdiagnosis, the child had a normal growth velocity at
  I( t0 v& E4 _0 C  C+ nthe follow-up visit. It is hoped that his final adult  d/ k, @5 D* p& Y' X4 G3 f
height will not be affected.5 j6 w4 S( k4 h- z! P, X1 n
Although rarely reported, the widespread avail-
8 h/ P& @; a! iability of androgen products in our society may4 u0 N( Z0 w4 l0 X6 g) k: e. P
indeed cause more virilization in male or female
6 k7 `! i* J$ V6 Gchildren than one would realize. Exposure to andro-5 }" @( d$ O, T# a2 Q& S  z
gen products must be considered and specific ques-
! J* I6 }2 s8 y+ Y4 ctioning about the use of a testosterone product or
" J: ^; R" c$ r) s2 U! L+ y6 ]gel should be asked of the family members during
5 _* k' b2 K( S' J" e; P* M0 c% _the evaluation of any children who present with vir-4 J. L8 B  _) v2 Z9 ^
ilization or peripheral precocious puberty. The diag-
6 E4 U. z  ?  Lnosis can be established by just a few tests and by
1 Y# k4 G8 g0 q/ U2 J! Xappropriate history. The inability to obtain such a( ]/ L& X+ ^4 s* q& ^% f) ~
history, or failure to ask the specific questions, may
6 N8 ?' S* l$ X' `+ i. Dresult in extensive, unnecessary, and expensive
9 Y9 `7 I0 `( J( t7 X: U3 t( ^* Qinvestigation. The primary care physician should be
9 `6 D5 u) ?6 J  R. T( Aaware of this fact, because most of these children
! h4 F' l6 U$ Q7 X  G  zmay initially present in their practice. The Physicians’  J6 {( K) J9 @
Desk Reference and package insert should also put a4 H* [) P$ ?1 s2 ~9 `, j
warning about the virilizing effect on a male or
: s" W; X, W2 v$ kfemale child who might come in contact with some-; j$ p; _8 }' @
one using any of these products.: O- b5 d+ c+ e9 p1 _
References9 G6 Y. o% Q2 v9 h8 {4 P
1. Styne DM. The testes: disorder of sexual differentiation9 [9 a# c) ?- Z; Y: ~
and puberty in the male. In: Sperling MA, ed. Pediatric6 z2 c/ ]5 P; j/ S6 h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 X+ G) B; l4 r' b& b2002: 565-628.
: ^0 X/ R9 j3 v$ a- z  E: X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, f5 x# i8 z- I4 y8 P
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old. U* ?' W7 _! {( e8 ?! o, Q
Boy Induced by Indirect Topical
5 D% d+ X5 B: X# V$ u: x+ |Exposure to Testosterone2 y7 z* h/ [" C: _( g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 S3 K- r& q; }0 E: A- ]
and Kenneth R. Rettig, MD1
. i- c, Y3 Q0 X( [# }  Z) n0 Z% cClinical Pediatrics! e/ ]: C2 w, @. I. i
Volume 46 Number 6) T7 U* ?& {0 b1 k
July 2007 540-543
1 D2 c! h+ r5 d% f( K© 2007 Sage Publications
# d9 t- g, P1 E( z+ F  {10.1177/00099228062966511 A6 B/ s' @0 |2 h1 _3 j4 m
http://clp.sagepub.com
- K( F5 Z7 w1 H& [hosted at2 d+ k9 h6 y0 K9 Z' B
http://online.sagepub.com
, l) m2 L5 u1 p" xPrecocious puberty in boys, central or peripheral,# {0 U* t9 F+ D8 r$ _3 L) w
is a significant concern for physicians. Central
! p2 ]' [# `" W9 p# g- b9 h3 ]precocious puberty (CPP), which is mediated
1 A8 C9 Q# M  o% Cthrough the hypothalamic pituitary gonadal axis, has
: ^2 L4 S) N' V5 `3 n/ u) G% fa higher incidence of organic central nervous system5 f1 w2 u# t6 ~. F
lesions in boys.1,2 Virilization in boys, as manifested
3 Q" @% E; x) X' B% {  \; Xby enlargement of the penis, development of pubic; T  |+ E  g: O6 M2 E/ g* _
hair, and facial acne without enlargement of testi-
- o7 b7 G7 W* m5 u8 ~' ycles, suggests peripheral or pseudopuberty.1-3 We+ T! r) b8 S0 i% S) \( \' X* e7 X
report a 16-month-old boy who presented with the; X& g9 s) B: _7 s
enlargement of the phallus and pubic hair develop-
- d, W; s& k- L  ?6 W' Kment without testicular enlargement, which was due
( L2 W/ v# z1 i4 J) B0 E5 L$ f, Lto the unintentional exposure to androgen gel used by' K, h/ V! l/ p$ o' T" L9 w* e3 \
the father. The family initially concealed this infor-4 ?1 C$ S+ |  f4 `( }# A
mation, resulting in an extensive work-up for this) A; @! k# j7 e6 B$ J" E
child. Given the widespread and easy availability of
. ^: l2 g% j  R2 v2 e! u. `testosterone gel and cream, we believe this is proba-3 X% D* S) |& V6 d) U( P
bly more common than the rare case report in the
& E& J( t+ I6 A' T) K) W! Q3 c) G7 Bliterature.4+ C" B  p0 h& j% `- T( {7 U# u7 n
Patient Report
- m! y! P7 N6 u" mA 16-month-old white child was referred to the
1 }9 |6 s8 T* r9 J- c% M9 m) uendocrine clinic by his pediatrician with the concern7 B' w' I; Z; L0 F- d. |
of early sexual development. His mother noticed
/ f: H$ Q6 U+ E# @0 w( N2 Xlight colored pubic hair development when he was
0 `" w, J4 E, {4 m  G8 f, bFrom the 1Division of Pediatric Endocrinology, 2University of  j# [, x$ J/ Y
South Alabama Medical Center, Mobile, Alabama.
0 W* |0 I7 ^5 Z4 d% M  e8 AAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& @8 \0 }0 @0 u9 z* b. lProfessor of Pediatrics, University of South Alabama, College of. K  A: o: t7 H: |* P( n, L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ t& k0 \# _: c$ {e-mail: [email protected].% D4 v, ~: n% p
about 6 to 7 months old, which progressively became
% X3 d8 V+ X+ n( ^, Idarker. She was also concerned about the enlarge-
* P0 u0 X; w9 @# d# ^  L! [ment of his penis and frequent erections. The child+ A( K- m7 u3 i3 t
was the product of a full-term normal delivery, with/ i2 w2 x2 y1 M/ H( L  f+ k' r
a birth weight of 7 lb 14 oz, and birth length of
! N# L6 f6 q, \$ F9 S) a20 inches. He was breast-fed throughout the first year4 j+ Q9 O) f' B5 k
of life and was still receiving breast milk along with
/ f& k+ x% f8 u: f- Usolid food. He had no hospitalizations or surgery,; A: s/ J' [0 K) K" p3 U# `
and his psychosocial and psychomotor development, @7 s. ^+ q, I# G# ^. ~0 _2 g
was age appropriate.+ }) P7 ]6 e1 ^5 a
The family history was remarkable for the father,7 Z5 g1 c8 |  y8 |9 n
who was diagnosed with hypothyroidism at age 16,! ?: @4 o* c  j3 L
which was treated with thyroxine. The father’s
# \! |2 B9 h- U* {) p# y5 k" Oheight was 6 feet, and he went through a somewhat! r0 {. F; b2 V, ]
early puberty and had stopped growing by age 14.# |, G( O, e, l2 t
The father denied taking any other medication. The
+ [3 S( g8 v/ \( j2 A! dchild’s mother was in good health. Her menarche" N7 m. r. P  r2 k1 B  ~* d: ?
was at 11 years of age, and her height was at 5 feet, f( o! t( ]' e* F
5 inches. There was no other family history of pre-
# s+ B( P9 |& Pcocious sexual development in the first-degree rela-" _' {6 p  i+ `+ @. l( t
tives. There were no siblings.
& G7 @0 X6 ~$ v/ x1 P7 OPhysical Examination" s8 N# I5 v6 p' n! G9 ?
The physical examination revealed a very active,# q6 z" b2 N7 @, `0 a/ h& A
playful, and healthy boy. The vital signs documented
6 u+ m' J6 C% R8 b$ J6 \a blood pressure of 85/50 mm Hg, his length was
% U/ j8 I: Y4 L( w90 cm (>97th percentile), and his weight was 14.4 kg" V# w/ K+ P4 {" D9 z9 R+ ]/ E0 E
(also >97th percentile). The observed yearly growth% I, k8 V) j+ z, Q  y! p7 ]% A( n
velocity was 30 cm (12 inches). The examination of
0 h  f. N2 [/ R; t+ jthe neck revealed no thyroid enlargement.# o: q) }, }4 z  f
The genitourinary examination was remarkable for
3 ~. y; W1 v7 Q# e" U) Zenlargement of the penis, with a stretched length of
% B; Y2 V- O% m- e8 cm and a width of 2 cm. The glans penis was very well1 S' u: H& d$ T/ `. f( B, p" F
developed. The pubic hair was Tanner II, mostly around; G* s! Q9 P' r. y& p6 y
540$ {$ Z3 v6 s' s8 k, F( d3 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 N: k# B& Y0 n' Q* t3 n2 p
the base of the phallus and was dark and curled. The
% D( t. X4 a% Q: u* ]$ ~testicular volume was prepubertal at 2 mL each.
8 u$ t* F7 u7 f+ _% A7 EThe skin was moist and smooth and somewhat3 C- w6 l# ]  ~7 ~' p' h
oily. No axillary hair was noted. There were no
  \' e2 u2 H3 `- w" habnormal skin pigmentations or café-au-lait spots.: j4 R9 J9 X9 p4 G/ o3 Z  u: l
Neurologic evaluation showed deep tendon reflex 2+3 `" b( [$ ~8 f( t7 [. e3 i
bilateral and symmetrical. There was no suggestion0 U2 k0 r  t6 |" n5 B8 Y4 [
of papilledema.* p- G7 W9 s5 g; {2 i
Laboratory Evaluation
( j& [, Z- ~/ f* H/ H3 C% mThe bone age was consistent with 28 months by* s5 D& U; A& @' z& {  H
using the standard of Greulich and Pyle at a chrono-0 P. y. ?& J" C. C
logic age of 16 months (advanced).5 Chromosomal
) H$ C4 q3 k% U- \. n+ M+ mkaryotype was 46XY. The thyroid function test% n8 q( c3 P7 s8 f* N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 }7 [+ _. B0 J' G8 t- e6 Vlating hormone level was 1.3 µIU/mL (both normal).
; y. A. P) P8 ~; u( z! qThe concentrations of serum electrolytes, blood
- f4 l3 q  q$ R! N% r0 `urea nitrogen, creatinine, and calcium all were
" D/ E0 i( ~- `within normal range for his age. The concentration
" ^/ _( E" W! J! \& w- Fof serum 17-hydroxyprogesterone was 16 ng/dL8 |4 N  @) B2 ]0 f1 s
(normal, 3 to 90 ng/dL), androstenedione was 207 E% _, G7 D) Q7 G- \
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: a# b( o9 |3 x0 V( Y% Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 H. _7 E6 s9 Y8 q/ P% _desoxycorticosterone was 4.3 ng/dL (normal, 7 to  ^, G' @* |1 b# ^& R! b
49ng/dL), 11-desoxycortisol (specific compound S)2 w0 U/ I; h) Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 i! o! V4 z0 @! ~7 H/ K* _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 z4 G" u' U2 T) u& |; W, Y. _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% C, p# T# H: O$ e3 Qand β-human chorionic gonadotropin was less than
  _) A3 M! ]8 e' R( A5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ i" E8 {. |. z* L7 V* C4 u' Pstimulating hormone and leuteinizing hormone
( c% J5 c# k& e4 D& g2 Fconcentrations were less than 0.05 mIU/mL  G8 ?- E# @4 T- z) F- X$ \
(prepubertal).
( D. T& r( F8 t/ o. k. |. lThe parents were notified about the laboratory
7 |2 G! t! A5 n* Z# s3 [% A" w" Presults and were informed that all of the tests were
5 t. ]  @/ X' F) a% @normal except the testosterone level was high. The5 S6 K8 a0 ^! a5 f
follow-up visit was arranged within a few weeks to
5 `9 U/ d$ m& {; ?3 B4 G' Aobtain testicular and abdominal sonograms; how-
# o" m; j) V5 `# V( q) `* [: }0 U( Yever, the family did not return for 4 months.
$ B2 Q* q* o& ^6 ]& A; APhysical examination at this time revealed that the' S% X, s& \2 A
child had grown 2.5 cm in 4 months and had gained
4 I  U0 T0 W1 ?& z2 kg of weight. Physical examination remained
' @( a5 w( m& f$ Runchanged. Surprisingly, the pubic hair almost com-
6 `0 |7 a8 U  O: c9 [$ k5 @$ Bpletely disappeared except for a few vellous hairs at
" Q* b1 ~5 |+ U$ T3 ithe base of the phallus. Testicular volume was still 2
# _. A6 C# T0 d3 {1 YmL, and the size of the penis remained unchanged.! q5 f/ m! c7 _( I2 e! C# a+ z
The mother also said that the boy was no longer hav-
, d0 _5 B( C! F& X  P& ring frequent erections.3 G' T/ p- i  t6 [9 D: X
Both parents were again questioned about use of
; l9 l) Y4 f# ?1 P+ W' b1 Gany ointment/creams that they may have applied to
1 v8 i- M3 n9 Jthe child’s skin. This time the father admitted the
' X" i' }8 P6 s3 y- JTopical Testosterone Exposure / Bhowmick et al 541! M8 Q% ^6 ^( F3 |* v
use of testosterone gel twice daily that he was apply-
) B3 j0 R3 {& O/ Cing over his own shoulders, chest, and back area for. A: i; h8 F$ V# L0 J
a year. The father also revealed he was embarrassed4 O0 s7 V% o3 B" ?' m2 \" S
to disclose that he was using a testosterone gel pre-
$ X6 K. P+ U% F+ C6 u: Escribed by his family physician for decreased libido2 u% r* [+ [0 k1 H5 K
secondary to depression.
# v& u  ~$ y, @& M( H, |The child slept in the same bed with parents.
3 |  E2 v9 D* b& \9 s6 JThe father would hug the baby and hold him on his
$ ~5 ^' Z5 @, o2 K2 Q9 nchest for a considerable period of time, causing sig-
/ F; f7 K1 l1 b2 cnificant bare skin contact between baby and father.
3 S  o- c% k  Z% _The father also admitted that after the phone call,1 D) P6 k6 e; D# u) [
when he learned the testosterone level in the baby9 d1 c  j% J( m
was high, he then read the product information- t0 A9 A) {- {/ B' y5 L6 I
packet and concluded that it was most likely the rea-- W+ P/ e0 Y2 I  K* J
son for the child’s virilization. At that time, they
6 d  ^; z- T0 F! l4 ~: ~+ zdecided to put the baby in a separate bed, and the9 ?6 b2 ?4 J, E! q* k# }
father was not hugging him with bare skin and had
( _" l2 f; x8 q1 U/ E9 N- e  ]been using protective clothing. A repeat testosterone" B$ y0 G8 i/ I& j6 w2 O( r
test was ordered, but the family did not go to the
1 w3 P8 @1 u, _) @( j( d4 Mlaboratory to obtain the test.
4 I5 l* H7 r/ h6 zDiscussion: c/ t3 m) c4 h# x
Precocious puberty in boys is defined as secondary  Z' H0 {' F% R) c' p1 Q) x( [
sexual development before 9 years of age.1,47 ^* a2 H, J! h% r: _
Precocious puberty is termed as central (true) when7 `1 n, M: ]; q& n* B
it is caused by the premature activation of hypo-7 l8 H! F! U3 z& g
thalamic pituitary gonadal axis. CPP is more com-
' A# X% d$ V0 m/ M8 Zmon in girls than in boys.1,3 Most boys with CPP
5 _" A* ]( [. X* e' e* Fmay have a central nervous system lesion that is
9 ^3 X2 K5 j, }responsible for the early activation of the hypothal-
$ K+ G/ l1 `' e0 Y1 a; Tamic pituitary gonadal axis.1-3 Thus, greater empha-. G3 c5 u, |4 A. i! D
sis has been given to neuroradiologic imaging in
) e9 I/ }2 f4 P- R5 nboys with precocious puberty. In addition to viril-) U5 O7 s6 G1 t3 E  K( i: h0 X
ization, the clinical hallmark of CPP is the symmet-
+ p2 y  Z$ ~0 j+ j8 A. \5 Rrical testicular growth secondary to stimulation by
5 |3 ?3 t( F. H* r0 v. P" R& {gonadotropins.1,39 M& T( T8 }% X4 D
Gonadotropin-independent peripheral preco-
+ Z3 w) a( ?+ j0 V- Q( U6 Scious puberty in boys also results from inappropriate6 I% y& i$ A5 ?1 z0 D, n7 x* c
androgenic stimulation from either endogenous or: u3 |, X( U9 j1 t) e
exogenous sources, nonpituitary gonadotropin stim-
. {% Z" Z  L! T0 V. T( q0 _ulation, and rare activating mutations.3 Virilizing
3 R7 u. P, {* f. G* xcongenital adrenal hyperplasia producing excessive, x& W$ J) K0 R
adrenal androgens is a common cause of precocious
* ]. e% D6 V1 z4 d! h* Dpuberty in boys.3,4+ Y5 i4 F1 c% p# }1 N- W3 ]) P: O
The most common form of congenital adrenal
5 [( \/ J5 x! Ohyperplasia is the 21-hydroxylase enzyme deficiency.3 H' z  K3 C6 j1 J0 z" J
The 11-β hydroxylase deficiency may also result in& K0 W: G0 @& Q+ p7 l) F
excessive adrenal androgen production, and rarely,9 ?5 J5 V" E: h
an adrenal tumor may also cause adrenal androgen
  c: c5 Q9 X' qexcess.1,3
, C2 c- p; [* _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) E2 z. q( N- u' d1 c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* m# c+ }5 ?: R% w/ z, T2 s6 A
A unique entity of male-limited gonadotropin-( `& {6 T; X- G  Q
independent precocious puberty, which is also known4 M: l: r7 {3 P8 f, ^& x2 P
as testotoxicosis, may cause precocious puberty at a. |8 L. Z$ b- k) I: l* l) y  @
very young age. The physical findings in these boys
9 J0 s3 m  r/ B% w  {! p% @with this disorder are full pubertal development,
& d$ ?5 |# I1 O7 L1 u% h5 K7 oincluding bilateral testicular growth, similar to boys5 A; z6 Y7 s* j: S7 a/ `
with CPP. The gonadotropin levels in this disorder) x3 @+ L  ^' x4 z5 x! _
are suppressed to prepubertal levels and do not show& A6 f9 Y+ C  @: E  o! g; w
pubertal response of gonadotropin after gonadotropin-; `  Y9 Q$ \- R1 q& v. Z* U
releasing hormone stimulation. This is a sex-linked
) T' _. A" {2 A* \7 f6 Cautosomal dominant disorder that affects only2 N2 Y$ Z* ^. X% y
males; therefore, other male members of the family: w  A9 f- i- g' s' U% A
may have similar precocious puberty.3, X( L, ~* l* T- j
In our patient, physical examination was incon-
& `) S+ x3 \& Gsistent with true precocious puberty since his testi-
! {( _$ `$ @; u) W( G1 h" ucles were prepubertal in size. However, testotoxicosis
- E7 Z9 v& g3 J4 H& g: H: awas in the differential diagnosis because his father4 T0 x5 L) s# N# |/ I* x( ~  }
started puberty somewhat early, and occasionally,9 r+ v; [- u( D0 f
testicular enlargement is not that evident in the
+ w+ Y& x2 a6 Q( H0 i; |beginning of this process.1 In the absence of a neg-
7 M* I% ^+ H( I5 F" X$ _ative initial history of androgen exposure, our
  d, _* C: Y3 U- Sbiggest concern was virilizing adrenal hyperplasia,8 [! l9 p4 ]. v: g2 l& V$ ~
either 21-hydroxylase deficiency or 11-β hydroxylase* T9 [& f4 G" V, n1 _. C/ {! S
deficiency. Those diagnoses were excluded by find-
4 N- o8 T" F" m; q% ping the normal level of adrenal steroids.
1 [& h* e; N- [) Y- mThe diagnosis of exogenous androgens was strongly/ ]; _3 X- E7 ~
suspected in a follow-up visit after 4 months because# p; K. x; ]2 Y1 D8 q) S
the physical examination revealed the complete disap-
  E0 A& b- V, l# Z  n; n  y+ T1 y. Bpearance of pubic hair, normal growth velocity, and
: B3 H* d2 E5 Wdecreased erections. The father admitted using a testos-
  x2 P  C  F: I6 Qterone gel, which he concealed at first visit. He was$ }8 b2 U" f% c. Z9 \
using it rather frequently, twice a day. The Physicians’6 D0 Y/ H" |- {) E
Desk Reference, or package insert of this product, gel or. _6 ?: d: f3 z9 A7 K1 k
cream, cautions about dermal testosterone transfer to
4 i8 L. C( a- @% xunprotected females through direct skin exposure.; O5 T- b. Z3 D
Serum testosterone level was found to be 2 times the
% Q& z1 c( H+ M+ o9 vbaseline value in those females who were exposed to( m& |: w) `' T' f) e
even 15 minutes of direct skin contact with their male7 s7 H% \& ~* e3 B, w7 ?+ z
partners.6 However, when a shirt covered the applica-8 p2 A2 x4 C0 \) ^: J, e' S
tion site, this testosterone transfer was prevented.3 @9 U" x" E5 r
Our patient’s testosterone level was 60 ng/mL,
) w/ X* @2 `6 g/ v0 Nwhich was clearly high. Some studies suggest that
7 \5 H; A3 z! E9 Pdermal conversion of testosterone to dihydrotestos-( S" w2 A; J; \
terone, which is a more potent metabolite, is more
4 P) Z( n) a# @& Factive in young children exposed to testosterone
% d1 f( `; C& g' `9 b$ oexogenously7; however, we did not measure a dihy-) Z0 S$ N' }& ^( }4 Z' K+ l3 g
drotestosterone level in our patient. In addition to/ a6 c( L; Z3 O; o
virilization, exposure to exogenous testosterone in
1 M8 ~0 Z7 V$ B8 g$ [children results in an increase in growth velocity and: E* H* z# }+ {* n9 ?3 P
advanced bone age, as seen in our patient.# N( r) A7 x  g7 X
The long-term effect of androgen exposure during! r' Z3 U) q( y/ S5 S8 H8 \" L
early childhood on pubertal development and final. i- ]4 U! Y% t% V5 [# z
adult height are not fully known and always remain
* ~1 d* ]1 Y. e: w( ya concern. Children treated with short-term testos-
3 ~6 e2 h6 a: |# u, w* M! }; ~terone injection or topical androgen may exhibit some
) n  G  u, w  }+ X4 Facceleration of the skeletal maturation; however, after
7 L/ s+ S7 x/ y1 ~* W; {% h8 Icessation of treatment, the rate of bone maturation  J+ J4 m0 n8 x0 b+ ?* @2 X
decelerates and gradually returns to normal.8,9
: ]) K6 C3 ~' h! |+ M, f; {There are conflicting reports and controversy6 U; d2 L5 Y4 O6 w0 v
over the effect of early androgen exposure on adult
+ T; K8 g$ l/ f$ ~! Ipenile length.10,11 Some reports suggest subnormal
. ?' [1 i* g. W) t" \% Hadult penile length, apparently because of downreg-
9 g) E' j8 v8 o- L! e$ A1 K' Wulation of androgen receptor number.10,12 However,) s3 o7 ^4 H0 r( G$ |: Z
Sutherland et al13 did not find a correlation between: B5 j* z6 W6 {) l% U  g, z4 l
childhood testosterone exposure and reduced adult
  S/ s1 ~" T2 X- Upenile length in clinical studies.
- C4 R0 S5 [0 ^- B3 ?0 |Nonetheless, we do not believe our patient is
  H" b( d9 w4 q8 e2 O/ _going to experience any of the untoward effects from
7 D  @9 K0 L! a, i) O0 [3 N9 otestosterone exposure as mentioned earlier because
' k, s- U% K0 z. zthe exposure was not for a prolonged period of time.
2 m6 \# A4 g! z0 N/ g6 _8 uAlthough the bone age was advanced at the time of
5 L% e  P0 V; w, P6 V. }9 }diagnosis, the child had a normal growth velocity at
2 f$ x: n) L% `) lthe follow-up visit. It is hoped that his final adult- X; n2 k! ]! B0 t# y6 C; C
height will not be affected.7 s$ Z0 ]; r6 Q5 I1 k! A) v
Although rarely reported, the widespread avail-
  a  b0 z7 Y, x) K( W3 z9 o# zability of androgen products in our society may
, |9 e% h/ d2 r+ E/ w3 q6 Vindeed cause more virilization in male or female) b& I# H  K& f  h! H5 V' {
children than one would realize. Exposure to andro-
/ G1 r4 ?2 D7 a; e0 S1 xgen products must be considered and specific ques-( y$ ~% E1 o, y- Y) G! K# G
tioning about the use of a testosterone product or
0 ~( D5 h- W$ ^. f8 {/ F, ugel should be asked of the family members during# I1 c5 ^/ c8 w' p
the evaluation of any children who present with vir-( u0 v! U- t+ i9 D- ~, W
ilization or peripheral precocious puberty. The diag-
# x" D# O9 t$ M2 Z* Q  gnosis can be established by just a few tests and by
! r4 `4 F+ L( g$ H4 f/ Wappropriate history. The inability to obtain such a4 v: B5 h9 Y* e, a( H
history, or failure to ask the specific questions, may
1 k- u6 _3 n0 k/ [result in extensive, unnecessary, and expensive/ s2 L, V# S! s
investigation. The primary care physician should be% i" B6 e1 X) k7 _
aware of this fact, because most of these children
. M; b3 p9 Y3 emay initially present in their practice. The Physicians’
) i8 f) g- Z- b* V" n3 w- @/ j! xDesk Reference and package insert should also put a
5 k' [+ K3 c3 j6 ?8 L8 W( Owarning about the virilizing effect on a male or# o1 g5 I) q; J& X
female child who might come in contact with some-1 U) W  V- I1 o  a9 P7 x9 d
one using any of these products.  e# w/ p1 [" r( Y+ G5 H
References
% w2 j4 k* R% x) Y# H6 K: z8 \1. Styne DM. The testes: disorder of sexual differentiation& W4 Y# F; k9 z
and puberty in the male. In: Sperling MA, ed. Pediatric" S& M2 Y3 T; R3 j9 ?' s+ E/ f; S
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 z: x' g7 o1 m, }8 _' S
2002: 565-628.
* w% w8 j. c6 ?. a# C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 x. Y4 T* A, l/ H4 m" mpuberty 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
( \' a- \' W4 u: V# H7 L; ]9 v% F
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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