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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
- k6 m8 t% J' j$ n, ]Boy Induced by Indirect Topical+ J: ^0 l+ f2 H# _' Q' f- q
Exposure to Testosterone
# m# c* f5 {- J6 d! `0 o# X6 s1 ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# ~# ^% |! @7 S0 e
and Kenneth R. Rettig, MD1
, _- d5 K+ E0 W. i6 j" M7 K, PClinical Pediatrics
0 J( P2 |; ?* F( G: |3 H% R* RVolume 46 Number 6+ u3 `. q% [0 w, D* t8 T
July 2007 540-543
  _: B( C: [# t6 p- g# Z© 2007 Sage Publications# @# B8 D3 @, W+ \: z% I, T
10.1177/0009922806296651
  c( e2 L/ z% V" ~4 j' Hhttp://clp.sagepub.com
$ g+ C9 n0 E, Fhosted at
3 B2 t7 F" t# T: \2 @http://online.sagepub.com$ G! w% L+ {3 [3 t( u  c
Precocious puberty in boys, central or peripheral,0 P' E; i6 C1 l; Z
is a significant concern for physicians. Central- P, u; y" d- O* m% f. {
precocious puberty (CPP), which is mediated
* o8 y& r9 t) d* {through the hypothalamic pituitary gonadal axis, has
! M; b2 A& s9 B; na higher incidence of organic central nervous system! F$ T, A3 H0 X6 I5 ]8 j% F
lesions in boys.1,2 Virilization in boys, as manifested/ t* X5 K6 N* }% H! W
by enlargement of the penis, development of pubic: O# O& v! }8 p# i
hair, and facial acne without enlargement of testi-- s' H% Y( T5 i8 u& [) A0 r# ~
cles, suggests peripheral or pseudopuberty.1-3 We) v5 g' D3 @& m
report a 16-month-old boy who presented with the
; i4 |  t4 D" H/ Nenlargement of the phallus and pubic hair develop-9 @# h7 A2 j& {. I
ment without testicular enlargement, which was due
0 H' w& s* U9 @( I2 [9 Bto the unintentional exposure to androgen gel used by/ [' E: H# H6 {, M9 J
the father. The family initially concealed this infor-0 j( d+ `& F% b
mation, resulting in an extensive work-up for this
7 l8 w1 U- ]% A( E2 p9 Dchild. Given the widespread and easy availability of# h+ \8 _$ u6 i. g7 ~/ {
testosterone gel and cream, we believe this is proba-0 C$ u+ Q8 c: @" v( P+ Q
bly more common than the rare case report in the6 ?1 B6 }* e# y( A
literature.48 l7 B% {+ g4 i0 H
Patient Report
5 Z$ W- R0 V5 ?8 @* uA 16-month-old white child was referred to the) S2 ^9 e: c$ C9 O2 w: Y/ @
endocrine clinic by his pediatrician with the concern( A# @4 o  o. G! E
of early sexual development. His mother noticed: c0 i, ~; h  i6 E- Z# X
light colored pubic hair development when he was+ A: f0 C0 d$ Q2 ^& K6 U$ M9 [
From the 1Division of Pediatric Endocrinology, 2University of
4 F8 `) I5 t, e' j" p9 e- vSouth Alabama Medical Center, Mobile, Alabama.
% v8 \# P! _- Q: NAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 d! y+ l0 w0 S: w) O+ h4 K6 zProfessor of Pediatrics, University of South Alabama, College of
8 e$ Z- v! T& g+ N; BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 ~( e+ p& v- {5 Q5 Ze-mail: [email protected].
9 f) a* m0 Z2 w7 u& _about 6 to 7 months old, which progressively became% }7 h. X6 M" [: o6 x
darker. She was also concerned about the enlarge-
' H) n0 y+ }) Kment of his penis and frequent erections. The child0 Y. e. ^- }9 I- P& q2 j/ E
was the product of a full-term normal delivery, with
- M0 G; k. }, h7 ga birth weight of 7 lb 14 oz, and birth length of5 o& [( e' X! X
20 inches. He was breast-fed throughout the first year
/ ~9 w7 b# W  Y; [$ Vof life and was still receiving breast milk along with
2 s- v' U" @8 y! H; ysolid food. He had no hospitalizations or surgery,- \  X) Z  u% L" j' N$ W) ]* [
and his psychosocial and psychomotor development
% J( {3 R" ?; Dwas age appropriate.
- b/ b1 \6 r9 n' gThe family history was remarkable for the father,* T7 I) Z5 I+ C: B. X7 s
who was diagnosed with hypothyroidism at age 16,
; a0 O9 I; j9 m! h1 ?which was treated with thyroxine. The father’s
% v2 s1 u2 c$ Gheight was 6 feet, and he went through a somewhat
4 h- v9 R+ b* Y& [early puberty and had stopped growing by age 14.; d) `6 m' {$ j
The father denied taking any other medication. The
1 \1 ]6 W- @0 S* c7 p5 }1 E  A( Ychild’s mother was in good health. Her menarche9 ]5 k8 \% y; \4 w3 y! X2 h
was at 11 years of age, and her height was at 5 feet
% |! k0 M  M6 F/ T: {1 V9 L( [# X0 J5 inches. There was no other family history of pre-
) o6 m+ i. s0 S" }4 z" y) e0 ]cocious sexual development in the first-degree rela-- q! [" J2 U1 f
tives. There were no siblings.
7 |* T5 i: j9 R+ J# b# gPhysical Examination
% W# {5 ^4 S; @2 l' r1 xThe physical examination revealed a very active,+ S& z) C. A: F' u& b2 t
playful, and healthy boy. The vital signs documented" G3 _- e! a% N7 H8 m
a blood pressure of 85/50 mm Hg, his length was
5 M  G* A- j2 Z7 \: A90 cm (>97th percentile), and his weight was 14.4 kg
& t2 o) p# ]4 V7 i+ E(also >97th percentile). The observed yearly growth1 L3 D+ m5 P! F/ R& O
velocity was 30 cm (12 inches). The examination of& {! j3 j3 \. p$ h( N
the neck revealed no thyroid enlargement.0 d; m# z8 \( o' p3 h
The genitourinary examination was remarkable for
+ U9 \5 M% l0 @$ N' Qenlargement of the penis, with a stretched length of
7 c" ~* f* W# r6 d  ]8 cm and a width of 2 cm. The glans penis was very well
& m* B/ {4 }% |* k1 odeveloped. The pubic hair was Tanner II, mostly around- @/ x3 D3 j5 e
540  P" O) U4 j) _2 W; r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' ]( n5 r5 Y& R# X5 othe base of the phallus and was dark and curled. The+ D( h4 }7 s0 F8 [- T  [) h$ s
testicular volume was prepubertal at 2 mL each.
* x7 ~# {8 O' j$ f8 L7 ?! zThe skin was moist and smooth and somewhat
; p# n- @! s) y, o) w  boily. No axillary hair was noted. There were no
6 l& N! m$ }& T0 J! Wabnormal skin pigmentations or café-au-lait spots.
* s+ [# E4 @( D  T& PNeurologic evaluation showed deep tendon reflex 2+0 h4 w' Z; I. c/ H
bilateral and symmetrical. There was no suggestion
4 [  Z& k4 z, V2 Kof papilledema.# R' U! F+ [# [- y& z, e- V
Laboratory Evaluation
& g' S4 L5 g0 [9 @9 n9 }The bone age was consistent with 28 months by
( m( ~) k0 B: K3 Ausing the standard of Greulich and Pyle at a chrono-
2 }% p7 r: ?2 M4 Ylogic age of 16 months (advanced).5 Chromosomal5 l9 Z$ d" w/ k, F$ U) l
karyotype was 46XY. The thyroid function test
1 h$ a+ w1 N5 n, B1 z! ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 Z1 @; y+ j6 N' }0 \
lating hormone level was 1.3 µIU/mL (both normal).
* u6 a/ X9 m, WThe concentrations of serum electrolytes, blood
& ~) a1 \1 O+ Ourea nitrogen, creatinine, and calcium all were- p! e. e8 ]4 |1 n  f' M4 m
within normal range for his age. The concentration
; M5 f# A  S  [2 c" Y  Hof serum 17-hydroxyprogesterone was 16 ng/dL" E- g5 x1 _: T; p
(normal, 3 to 90 ng/dL), androstenedione was 20
( [! x( Z; R: B" k& i2 A7 \+ rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 }+ f. R0 @9 `% v" r- wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 g7 g2 J% Y& S$ f2 X. m6 C  T/ Gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to: e( L) \$ B: L: g0 R& j
49ng/dL), 11-desoxycortisol (specific compound S)
6 N6 A5 }- H# q# L* xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% }! o4 t9 F0 W) m2 k* @" Btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ d$ b: \5 Q4 i2 P9 M# ~% Y  i% itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& Q) H5 i6 d9 ~and β-human chorionic gonadotropin was less than$ I5 A# S; W* m/ I8 n' c
5 mIU/mL (normal <5 mIU/mL). Serum follicular; K/ m" @4 F7 Y+ a
stimulating hormone and leuteinizing hormone
" h1 E$ d6 q$ `% C8 |; }concentrations were less than 0.05 mIU/mL1 a7 j% L' H, H+ X" }# x
(prepubertal).' J( f/ Z; g) Y# L
The parents were notified about the laboratory
! k/ j( i( X/ z8 \7 S# Oresults and were informed that all of the tests were
, O* ^1 U5 K  Knormal except the testosterone level was high. The
: f8 m' V6 Q2 `7 h1 Efollow-up visit was arranged within a few weeks to
+ b& [* {& f4 Z3 \1 Sobtain testicular and abdominal sonograms; how-) D" @8 l+ t+ r
ever, the family did not return for 4 months.
1 ]0 b5 c  M: b  _' iPhysical examination at this time revealed that the- Z+ O- f$ e5 g! Z/ O
child had grown 2.5 cm in 4 months and had gained) }/ @, s  _8 _/ w
2 kg of weight. Physical examination remained/ o6 B) e5 g" U/ M; g
unchanged. Surprisingly, the pubic hair almost com-
6 @+ J) z7 @' o% Tpletely disappeared except for a few vellous hairs at! f; N: z4 e8 w
the base of the phallus. Testicular volume was still 2
: ?0 u9 s  i- v% {& kmL, and the size of the penis remained unchanged.
  R3 J- L3 H/ E5 FThe mother also said that the boy was no longer hav-9 V/ ?7 Q+ P0 P4 U
ing frequent erections.& R" E4 }1 b+ e. @
Both parents were again questioned about use of
7 A/ m' k9 r; l: ?$ ?, Nany ointment/creams that they may have applied to
( p9 ]" u( K3 s/ Zthe child’s skin. This time the father admitted the
% X. w% h. _. n/ C! R$ x, L7 qTopical Testosterone Exposure / Bhowmick et al 541
- }) L+ H& a+ C6 ause of testosterone gel twice daily that he was apply-
; c- P2 y" m8 ping over his own shoulders, chest, and back area for3 o8 m' j( E+ D" l! ?  q4 j
a year. The father also revealed he was embarrassed. }" n4 c* h0 W8 Z6 G4 U
to disclose that he was using a testosterone gel pre-
. K0 \0 N4 S5 Cscribed by his family physician for decreased libido
- W% A4 @$ P1 p6 L: l- z$ qsecondary to depression.! e# }) e) a- f" m. A4 d; P
The child slept in the same bed with parents.
9 F1 H. K; {7 p; O  f0 AThe father would hug the baby and hold him on his
1 @) }5 K' f! L$ G* q2 S6 y  ychest for a considerable period of time, causing sig-
# A( }' q2 I0 _% ynificant bare skin contact between baby and father.
" E( d/ ^3 e1 l2 e6 ]$ N! j# f- @$ HThe father also admitted that after the phone call,0 w% ?  \. z1 B
when he learned the testosterone level in the baby
) G1 ~! {1 `+ \. ^) `9 ~" r% {was high, he then read the product information
; Y( y! u  }- `  ]; N( bpacket and concluded that it was most likely the rea-
, q) M# L; r( ]$ G" q4 Pson for the child’s virilization. At that time, they
( O+ Q* j0 B8 ]& H* ?; D* H+ Z# zdecided to put the baby in a separate bed, and the6 ~3 z! C1 s: k3 Z! I% l3 Z
father was not hugging him with bare skin and had$ ~  I# s! J+ L5 F/ X
been using protective clothing. A repeat testosterone
3 N5 |4 |# D# ?6 q+ A1 Vtest was ordered, but the family did not go to the
+ W5 ?0 [4 K  o1 }# zlaboratory to obtain the test.$ ?; }' Y( P% y( j/ A# A
Discussion
2 ~/ a& u8 ^3 X! h5 }7 y- aPrecocious puberty in boys is defined as secondary! c9 x; J  P' Z& j
sexual development before 9 years of age.1,4- z( _  n) k) V. D1 H5 h
Precocious puberty is termed as central (true) when; v" L0 O0 w, a; |# W" p  w- W
it is caused by the premature activation of hypo-
3 g8 |1 I" [! K3 m4 Qthalamic pituitary gonadal axis. CPP is more com-
8 i0 k! r! d; Bmon in girls than in boys.1,3 Most boys with CPP
& r4 A8 l/ t1 U+ D* r3 `may have a central nervous system lesion that is
: c7 A7 ]* c; V) d9 dresponsible for the early activation of the hypothal-
7 e7 X; b# Y8 ?' P( c4 l( lamic pituitary gonadal axis.1-3 Thus, greater empha-: C: Q/ O6 U, v7 L* \7 a( U8 l
sis has been given to neuroradiologic imaging in* U4 t% u8 R2 f/ G# `* O1 c
boys with precocious puberty. In addition to viril-6 l% o2 N% Z# t0 ~
ization, the clinical hallmark of CPP is the symmet-
4 p) T; T' u( \rical testicular growth secondary to stimulation by
' u, n5 o4 C: X7 t1 m; jgonadotropins.1,3
3 G) v3 y, I2 Z  A; |: bGonadotropin-independent peripheral preco-- x7 h3 F4 `; b2 D* j- T# l/ j
cious puberty in boys also results from inappropriate
, _4 y% w* M- b7 Landrogenic stimulation from either endogenous or
5 h+ T( I- d! t; R" T& K7 [& iexogenous sources, nonpituitary gonadotropin stim-- S0 G5 I: a1 }: S. h* x) r8 ]& A" @
ulation, and rare activating mutations.3 Virilizing0 {: X6 |' M" O; J2 ~
congenital adrenal hyperplasia producing excessive
& B1 V, Z" i1 P" h& W! Uadrenal androgens is a common cause of precocious
& i4 ?! q3 P: Q( U, t9 npuberty in boys.3,4/ ^7 ]) A: Z) ]) {3 h  f7 b
The most common form of congenital adrenal
3 h1 B. ~1 V: f  w7 B3 L$ {hyperplasia is the 21-hydroxylase enzyme deficiency.
/ w8 [5 f# W; @3 Z1 YThe 11-β hydroxylase deficiency may also result in
" a5 S( p* Z/ }  R3 wexcessive adrenal androgen production, and rarely,
/ P4 ~0 S2 ?7 l/ V# V' ~an adrenal tumor may also cause adrenal androgen$ D  \) Z3 l/ C
excess.1,3( A% @& W* B. R3 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  {8 d* H( n7 Y' L  W9 y& Z- s" ^# c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& |6 L8 }) }% M+ ?/ _A unique entity of male-limited gonadotropin-
! V9 O3 S! F6 T5 b& gindependent precocious puberty, which is also known
( ~  ^% @) L0 Q( V" i5 vas testotoxicosis, may cause precocious puberty at a
) T8 v* d4 S0 F' \. L9 O- H" zvery young age. The physical findings in these boys
0 m. y3 }/ O/ [% E! t9 D5 w% U/ Ewith this disorder are full pubertal development,0 K# m3 P2 ^! D, }+ D2 O
including bilateral testicular growth, similar to boys
& ~! J& j5 r! h0 |with CPP. The gonadotropin levels in this disorder
- y; \) a7 Z7 i1 mare suppressed to prepubertal levels and do not show
5 b% Z' `* |1 v! J* opubertal response of gonadotropin after gonadotropin-9 [# c# J  [+ N1 X- m
releasing hormone stimulation. This is a sex-linked. V& D! u' r1 |8 Z+ ?. d3 U# K
autosomal dominant disorder that affects only
; `$ E. |) W  L# j7 F' Imales; therefore, other male members of the family
% o0 x4 m& s: R9 ?, Wmay have similar precocious puberty.3: C+ U1 B2 r$ w' ]# F& o: F/ H8 k& l: q
In our patient, physical examination was incon-% |% |( Z, k  a6 r+ p
sistent with true precocious puberty since his testi-
9 {1 {# @  l2 Scles were prepubertal in size. However, testotoxicosis1 Z  v9 u9 v! }1 i0 d
was in the differential diagnosis because his father
: m9 v3 K% \+ V$ y  Mstarted puberty somewhat early, and occasionally,
' p2 k6 J0 V4 J9 k& A6 a1 t9 Itesticular enlargement is not that evident in the: n* @  W& a( `7 G' t6 Y
beginning of this process.1 In the absence of a neg-
$ |$ O2 u8 f2 }$ y3 J2 lative initial history of androgen exposure, our/ J" h. v4 ], q7 F5 w
biggest concern was virilizing adrenal hyperplasia," s4 H' J; |, B0 V! ^9 |5 ?
either 21-hydroxylase deficiency or 11-β hydroxylase" [; _6 T9 o7 G" G; ]. a1 \2 Y) k3 ^
deficiency. Those diagnoses were excluded by find-
2 R( U0 U# B4 c  ]ing the normal level of adrenal steroids.
* o2 B1 ]- X- `8 sThe diagnosis of exogenous androgens was strongly# Y4 C3 s: S& k, ]/ v7 @; h
suspected in a follow-up visit after 4 months because' @$ c/ j3 {: w7 q, Z7 ?
the physical examination revealed the complete disap-
7 Q, |/ t: t! b( G4 ~& K9 x! l! hpearance of pubic hair, normal growth velocity, and
( w/ ?, h6 W+ k1 y6 udecreased erections. The father admitted using a testos-
( P, r, T. {0 s& B# Pterone gel, which he concealed at first visit. He was( U& U& ]- R7 F7 H. T: R
using it rather frequently, twice a day. The Physicians’7 }* ^, t* q2 f5 \( m. S
Desk Reference, or package insert of this product, gel or3 G. i  f' D9 K7 i
cream, cautions about dermal testosterone transfer to- n) r. M% c5 L+ `
unprotected females through direct skin exposure.
- S+ r- P# p5 y4 s- iSerum testosterone level was found to be 2 times the
& l: W3 C4 ]* m; ~baseline value in those females who were exposed to
! M* P4 [! k- aeven 15 minutes of direct skin contact with their male6 o/ T4 S" e1 D0 M1 m1 x0 ~: k+ g
partners.6 However, when a shirt covered the applica-
* I  p5 y  D% O" K8 d+ {tion site, this testosterone transfer was prevented.. `# F0 f1 b$ c8 j3 V
Our patient’s testosterone level was 60 ng/mL,
( h& N, P( n6 c' N% ~- q+ Mwhich was clearly high. Some studies suggest that' ^4 V6 s5 }, y" S! i" d' S# @
dermal conversion of testosterone to dihydrotestos-* @# s% |! X7 T: H$ A
terone, which is a more potent metabolite, is more
# D1 r" Q4 H! G5 k& z- {, k' hactive in young children exposed to testosterone
% T, U; @  y; iexogenously7; however, we did not measure a dihy-3 j8 A. [6 B7 E! \9 y' z6 q# g- P
drotestosterone level in our patient. In addition to
' V6 u7 j/ _" lvirilization, exposure to exogenous testosterone in. W% [: Z2 u+ S8 W2 m4 K3 N
children results in an increase in growth velocity and
. @2 p6 n/ v( ~% C- j8 e! {advanced bone age, as seen in our patient.$ f  Q; H0 W& X* D! E* v" k
The long-term effect of androgen exposure during3 V5 V2 V- _2 r* f! ^9 E; y" C
early childhood on pubertal development and final/ B$ z! V" }) S9 l8 E; H
adult height are not fully known and always remain
7 p+ a4 x" R0 L" o6 L6 Qa concern. Children treated with short-term testos-5 n. s8 n4 y1 b( w& [. M4 N
terone injection or topical androgen may exhibit some
. N. B! z& H% s/ pacceleration of the skeletal maturation; however, after
8 m( k9 X: B) w( Y, k# ocessation of treatment, the rate of bone maturation
5 R: l& D$ D% P! E1 cdecelerates and gradually returns to normal.8,9
( J' h0 e' ~5 q4 W5 @3 L$ I( uThere are conflicting reports and controversy
6 b0 G6 }7 W1 B$ m* p3 H9 A3 B1 Vover the effect of early androgen exposure on adult
) y7 t7 h' V5 I3 z0 }% D# `; ~penile length.10,11 Some reports suggest subnormal, ?! D5 ~1 c. ?7 g
adult penile length, apparently because of downreg-  A" v0 f" A1 v6 @2 v
ulation of androgen receptor number.10,12 However,7 S0 J& H8 k5 _% s5 e  _
Sutherland et al13 did not find a correlation between' w: F) i3 L( Q) N
childhood testosterone exposure and reduced adult
- ~3 J0 c5 D/ u# Y; R- Y( e9 Rpenile length in clinical studies.- f. B9 Q  Q2 n
Nonetheless, we do not believe our patient is
) x* e/ y/ k+ l  [9 a3 ^going to experience any of the untoward effects from! i8 ?+ V: q8 i$ t6 I
testosterone exposure as mentioned earlier because
. u0 n+ e* u  q3 ?% x/ Z# vthe exposure was not for a prolonged period of time.
* A$ Z1 Z7 a# rAlthough the bone age was advanced at the time of
/ `: m* Q! J: Y  V# z0 Udiagnosis, the child had a normal growth velocity at
6 }$ e* @0 E8 g* R, D* kthe follow-up visit. It is hoped that his final adult2 V) ]0 a" w  ~4 g8 l* I
height will not be affected.
( K: e* x0 G# E: E  i& fAlthough rarely reported, the widespread avail-1 f6 R9 i" F$ f9 j4 H- v  b: y
ability of androgen products in our society may* x7 Z3 _, `4 U( s- d
indeed cause more virilization in male or female
% X- `+ F  I+ Y5 }4 Vchildren than one would realize. Exposure to andro-
! j9 L9 K2 y! S/ b/ p! p7 Xgen products must be considered and specific ques-  Q9 L& M' q0 i& ~% J
tioning about the use of a testosterone product or
9 `5 l" d. F/ J, cgel should be asked of the family members during& t% w5 _5 m  ]; J
the evaluation of any children who present with vir-, l3 I2 }+ Z1 K, \
ilization or peripheral precocious puberty. The diag-
) |& T- A. Y* R% Y4 Gnosis can be established by just a few tests and by
3 b* n' a( h. Vappropriate history. The inability to obtain such a
- ?* d3 c7 i) Thistory, or failure to ask the specific questions, may  P7 t$ m- |4 }9 ^- o+ Z  _
result in extensive, unnecessary, and expensive
$ a& L2 y. g1 n* \investigation. The primary care physician should be
5 w' `# u: X0 caware of this fact, because most of these children
8 J. R: e6 }0 [% d6 W- V8 Imay initially present in their practice. The Physicians’
. a! t  L& D0 ?( ?. sDesk Reference and package insert should also put a
# }* G3 c2 q) Y$ \, w8 V2 _: o3 Vwarning about the virilizing effect on a male or7 ]$ V" ]- G* L) ~- e) M+ i' s
female child who might come in contact with some-! T4 i) O' D7 U; R, g
one using any of these products.2 r: t) f% V' z7 {) [% d
References, L7 Q' F) M( q& {
1. Styne DM. The testes: disorder of sexual differentiation
* J' s3 o& ^- t3 f- d/ zand puberty in the male. In: Sperling MA, ed. Pediatric
1 j8 X' j# X& C+ [) E/ p3 `Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! w! a; a# L5 b% m' b7 }% W  M& p2002: 565-628.! k& Y3 N# B4 i/ ]) N" S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- M8 i/ U2 P! o/ N$ kpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& y) U. H2 f! B7 N$ C) c7 Z" HBoy Induced by Indirect Topical. H  D$ X" t5 m5 e- Y6 s
Exposure to Testosterone
0 a, Q2 i1 y% \% `8 r) V. pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 u, K6 p0 u4 B$ m1 \# w2 U$ Jand Kenneth R. Rettig, MD1
* S- N. r. C1 |) r0 S$ |0 a! qClinical Pediatrics
( h5 y4 v" f# H& \, n& }" ]Volume 46 Number 6
. K2 a; s9 `2 t' T" W* L* nJuly 2007 540-543( R! N, E" r; Q6 R( k9 v
© 2007 Sage Publications
2 y9 [  C8 I5 z10.1177/00099228062966517 Q% d% J5 q# U7 Z
http://clp.sagepub.com
& {) H0 V1 Q0 k4 ?hosted at8 L3 r4 A# [+ N+ C
http://online.sagepub.com
5 K- o9 q6 F, w% h+ D9 A' HPrecocious puberty in boys, central or peripheral,! {( e# E: ~9 F# N- Z
is a significant concern for physicians. Central8 i, h8 v: r! H0 {; f! N* b6 C
precocious puberty (CPP), which is mediated  E0 b; ~- E3 \* E9 B* K) A
through the hypothalamic pituitary gonadal axis, has4 e# T, q* s- k( Z2 B6 U/ u
a higher incidence of organic central nervous system, Y. F' `; f9 l# T" |5 |
lesions in boys.1,2 Virilization in boys, as manifested
3 a7 @9 f# n, }) l! ~* R- c0 }by enlargement of the penis, development of pubic
5 i; d  M  r' ]2 D, z/ N( [hair, and facial acne without enlargement of testi-& l: r, u5 b, b( ]0 Z! b
cles, suggests peripheral or pseudopuberty.1-3 We, R% Z# o# U/ B2 V
report a 16-month-old boy who presented with the
( Y2 ~& W, N4 F) t) |* X  [& _enlargement of the phallus and pubic hair develop-( |1 f9 D' W% d' U" Y; ^1 m
ment without testicular enlargement, which was due
% g% ?4 A& k1 P  D! |+ d' T& Zto the unintentional exposure to androgen gel used by
  P* [2 e9 J' A( B: A6 sthe father. The family initially concealed this infor-
- P! l5 l1 _6 G( \: l, \mation, resulting in an extensive work-up for this# J* m1 g6 ^; x" [
child. Given the widespread and easy availability of9 ^( Y* d  n  G3 C; i. O
testosterone gel and cream, we believe this is proba-
& _# ]+ e, _: f% O, Obly more common than the rare case report in the) j& J) m) q6 l. w) h
literature.4
: h( R# G/ D/ LPatient Report% l( @& l$ e1 A9 g0 {6 {
A 16-month-old white child was referred to the- V+ V9 L5 i* _) m% G$ d: }
endocrine clinic by his pediatrician with the concern
1 B. Z( Q  ?' o/ y# {) {  w# Yof early sexual development. His mother noticed( D5 [6 w2 }4 h( \' u, b5 y  v
light colored pubic hair development when he was
9 v* D1 s* x2 C! CFrom the 1Division of Pediatric Endocrinology, 2University of
- j, u* @9 ]/ jSouth Alabama Medical Center, Mobile, Alabama.
3 G" M. [1 w+ m2 J( g, t0 w2 sAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 F6 l7 p3 ~. k) {! O/ ?# j; o% @
Professor of Pediatrics, University of South Alabama, College of5 \4 r8 D: r1 Q7 y" \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ ^# X& M! R' B  |$ v, F3 v* ?e-mail: [email protected].
( \0 |. y+ h7 B4 Z4 Habout 6 to 7 months old, which progressively became
/ h& J1 r$ s& d" _darker. She was also concerned about the enlarge-: H6 I  I' O$ I2 N9 b, B; l
ment of his penis and frequent erections. The child2 Y, y4 p8 s- o4 c: h7 J' M
was the product of a full-term normal delivery, with
1 s/ W- S0 u2 ^' w; Qa birth weight of 7 lb 14 oz, and birth length of
( Z, e! g' U9 L  L20 inches. He was breast-fed throughout the first year, N* ]" |2 ^' \: F
of life and was still receiving breast milk along with
( |! ~; F, ^/ `" Y& e; V5 ysolid food. He had no hospitalizations or surgery,
0 f+ n) w, C2 X. cand his psychosocial and psychomotor development
+ C- x" B, \" j  T" p7 `was age appropriate.' x5 o9 H) C9 w
The family history was remarkable for the father,
6 `: k: |" ]% e1 B5 Q+ ~who was diagnosed with hypothyroidism at age 16,
" }( w2 f2 O8 Q+ E. I8 Vwhich was treated with thyroxine. The father’s9 T2 ?* Q' K% Q! a
height was 6 feet, and he went through a somewhat% m  }, p/ `: X( a
early puberty and had stopped growing by age 14.1 o8 S# X0 o) ]- X
The father denied taking any other medication. The
0 _6 y* f8 {8 y. H9 wchild’s mother was in good health. Her menarche
# o5 w5 D7 s6 R* f- Owas at 11 years of age, and her height was at 5 feet' B! J2 e" X6 I
5 inches. There was no other family history of pre-# k4 A2 q' [) f( q; X4 N
cocious sexual development in the first-degree rela-
9 e% }" _$ h* Y# B8 Jtives. There were no siblings.
- J  U; m8 `5 r. U+ L4 m7 iPhysical Examination. f# l+ s. L& E( T" z4 |2 z
The physical examination revealed a very active,- P  R. ]3 u/ w5 Y5 |* p
playful, and healthy boy. The vital signs documented
( y7 a5 R0 v0 y" {a blood pressure of 85/50 mm Hg, his length was
* `/ {  N! H6 y90 cm (>97th percentile), and his weight was 14.4 kg0 V0 X4 d( z) }# I
(also >97th percentile). The observed yearly growth
1 u4 h8 E% r2 j. G7 x0 P4 Xvelocity was 30 cm (12 inches). The examination of
) ]" r0 X0 R- w. Ethe neck revealed no thyroid enlargement.' U  D1 r: V* M- H( F3 M9 g
The genitourinary examination was remarkable for
+ i  i( i( i' y- L% G1 ?enlargement of the penis, with a stretched length of: x+ @1 Z9 \+ I2 m' w% D
8 cm and a width of 2 cm. The glans penis was very well# L$ H) q1 \" m. V: A
developed. The pubic hair was Tanner II, mostly around
% i4 r! C1 W9 z: Q1 W0 m2 m' a; T540
! g4 P$ E& `5 uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. l" u3 B4 w4 ~- C3 s
the base of the phallus and was dark and curled. The. ^5 }0 a# v& l5 f3 k
testicular volume was prepubertal at 2 mL each.
+ I( U7 ]0 f6 s. O; `  mThe skin was moist and smooth and somewhat* W9 r* D/ j5 U  Y& M4 ]- Y
oily. No axillary hair was noted. There were no1 ~! _/ j% I* O/ p+ ?1 {& N
abnormal skin pigmentations or café-au-lait spots.
. r* @/ ?! k# j- WNeurologic evaluation showed deep tendon reflex 2+
* H- |, \+ g6 fbilateral and symmetrical. There was no suggestion
3 G: H$ G; L: c6 s' }+ p0 Uof papilledema.
0 l( ~& t! n- ]) F) R2 V7 N. E% nLaboratory Evaluation
7 n/ D- r: W- q. N% k: k# g$ m! bThe bone age was consistent with 28 months by3 E$ G7 @9 l7 _. {+ o! }
using the standard of Greulich and Pyle at a chrono-  W8 {1 T  s. ~$ e( Q3 d6 F5 s
logic age of 16 months (advanced).5 Chromosomal5 L0 J" A, T  b/ W6 s# n9 s
karyotype was 46XY. The thyroid function test
9 y. x/ P4 t3 {7 y" F; V3 Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 L% k; h; p+ q1 J( n/ B8 @
lating hormone level was 1.3 µIU/mL (both normal).
  ~3 F) z/ R/ j4 Y7 ^The concentrations of serum electrolytes, blood0 A. R6 P5 F/ }
urea nitrogen, creatinine, and calcium all were
1 \2 ]3 c  v! x3 K( f& Ewithin normal range for his age. The concentration
5 _0 {2 c+ _4 A* z% J2 s  d4 ~of serum 17-hydroxyprogesterone was 16 ng/dL: _. b" x5 K7 s/ @
(normal, 3 to 90 ng/dL), androstenedione was 209 E1 j7 y# d. m% ^  X! t. {# }  F6 P3 P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, T4 J! M" ~- T2 j; x  O' g5 L
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 ^% |5 [1 ?; n& W+ e* m/ L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; F. c; d  l; p5 }9 x% F% T& }  H6 F
49ng/dL), 11-desoxycortisol (specific compound S)3 n6 u0 `( ]+ m  u) O' f
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* `% ^. \' v* j. ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  f9 z0 b& W8 H2 U4 \8 p9 v4 I1 k( Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 X& j/ j3 l( a$ p" z& `. x% e
and β-human chorionic gonadotropin was less than
- E( K+ \  J: w4 }, y& l5 mIU/mL (normal <5 mIU/mL). Serum follicular
, o, z8 O" ]6 ]1 N3 [, Wstimulating hormone and leuteinizing hormone; o4 }: P0 I2 Y6 I( N, x
concentrations were less than 0.05 mIU/mL
9 W7 u" v  X' t& `* n(prepubertal).. J9 M/ a: F5 y% U; `% v/ O& O
The parents were notified about the laboratory9 z, {; w( F6 m% _/ y
results and were informed that all of the tests were/ D) A& D$ _& V/ b
normal except the testosterone level was high. The
3 `- w* W  Z2 U" o$ c( ffollow-up visit was arranged within a few weeks to! q) F$ p2 @) {7 a
obtain testicular and abdominal sonograms; how-+ N3 x9 f6 S# L
ever, the family did not return for 4 months.
! ^( M4 V8 q7 |6 E7 [* hPhysical examination at this time revealed that the' z9 e0 g7 d( u! w& I1 {
child had grown 2.5 cm in 4 months and had gained
$ F0 Y, P( ^$ ~3 L( O2 kg of weight. Physical examination remained1 g0 s! e9 A- b8 X
unchanged. Surprisingly, the pubic hair almost com-; a8 H9 ?3 i* J8 L# o9 d# i7 ^. o
pletely disappeared except for a few vellous hairs at
/ l% z* a/ U$ e: f! S' pthe base of the phallus. Testicular volume was still 2# N8 s% q4 ^" s; s1 F- H
mL, and the size of the penis remained unchanged.
+ I9 L! c: N* K" w! R! w9 VThe mother also said that the boy was no longer hav-
, U+ N$ S) b, h2 ting frequent erections.
5 l% h+ s* t4 X. A: aBoth parents were again questioned about use of
  ?7 Q2 O2 }  r0 iany ointment/creams that they may have applied to' T! B( V+ R; p) m  `: [2 o6 F, p
the child’s skin. This time the father admitted the
% f! K( ?; V1 G4 \; z; F( V9 k+ I2 iTopical Testosterone Exposure / Bhowmick et al 5417 E- I* Q4 j# |
use of testosterone gel twice daily that he was apply-
, P8 E, `, e( w4 King over his own shoulders, chest, and back area for- A& R+ j! Z5 m
a year. The father also revealed he was embarrassed
2 {8 }6 m8 J  e& I/ u/ W; F- Dto disclose that he was using a testosterone gel pre-8 |% d( J! w4 B+ g+ O+ c
scribed by his family physician for decreased libido
9 r7 ^8 v* e0 b" E6 fsecondary to depression.& F$ D' g, q8 j2 t+ w2 T
The child slept in the same bed with parents.
1 Z4 D* u& ]5 p  f& [% e+ ?The father would hug the baby and hold him on his6 {' r- i) H' D0 ?: S$ G
chest for a considerable period of time, causing sig-2 I0 y0 x. g5 D& g
nificant bare skin contact between baby and father.
, A- q# y1 F7 \/ }! R; aThe father also admitted that after the phone call,
# B8 E) f' Z, w5 Z) U! f3 cwhen he learned the testosterone level in the baby/ M9 w& Q0 c# I! b& o* b
was high, he then read the product information/ F# m: [' ~% R# Y$ O( K: a' `( n
packet and concluded that it was most likely the rea-9 E5 z: j( ?, I9 i) S) K: p7 f
son for the child’s virilization. At that time, they
! C- U: v1 M2 idecided to put the baby in a separate bed, and the
4 X, m2 L* f2 }( Gfather was not hugging him with bare skin and had+ q+ i, A9 b3 n5 `: Y3 x
been using protective clothing. A repeat testosterone0 b' e4 O. W9 c7 x) B' g  `
test was ordered, but the family did not go to the) T/ q; H" k' E0 U$ Y& R
laboratory to obtain the test.
4 x% U: y# v  B. _0 `& f- QDiscussion9 f4 o. j: p* ~; O' E7 y8 Y1 T
Precocious puberty in boys is defined as secondary5 V6 X# v/ n3 d$ ~9 @
sexual development before 9 years of age.1,4
( |/ `7 ?& M% G% ?Precocious puberty is termed as central (true) when; Z( Q0 N7 z2 V' M) x1 e
it is caused by the premature activation of hypo-
% C: `* B1 q7 i& rthalamic pituitary gonadal axis. CPP is more com-
& C4 G2 |6 o; b/ @- Amon in girls than in boys.1,3 Most boys with CPP1 b/ X$ X4 p6 o5 o/ B
may have a central nervous system lesion that is: |9 ]7 H) O! B& c6 L4 W
responsible for the early activation of the hypothal-
! V- F# ?$ Y3 l. V. yamic pituitary gonadal axis.1-3 Thus, greater empha-
# t* c. X, X) w% O" f' W# asis has been given to neuroradiologic imaging in! v. ~+ e' T- Q' Y0 N% j( }  I
boys with precocious puberty. In addition to viril-
. f; \' I$ n( n% Tization, the clinical hallmark of CPP is the symmet-% S% Z# z( y1 {
rical testicular growth secondary to stimulation by, c+ g7 a3 O: i3 F7 |# v! H- @
gonadotropins.1,30 L: p$ H8 Q3 P7 I5 `
Gonadotropin-independent peripheral preco-
+ l$ z% d( ]  J2 p. Pcious puberty in boys also results from inappropriate6 X1 i+ ]! L" V2 Z3 O
androgenic stimulation from either endogenous or4 L/ N# v8 ~0 w2 i4 b* H
exogenous sources, nonpituitary gonadotropin stim-
. o: U$ x; z/ [% K1 @ulation, and rare activating mutations.3 Virilizing
. e3 Q7 G/ W) Y7 |- V/ D  Acongenital adrenal hyperplasia producing excessive/ {7 _+ G$ q" J3 [% w1 @2 I
adrenal androgens is a common cause of precocious
- l8 G) M4 G+ D0 R9 s# g0 qpuberty in boys.3,4
7 J& D7 x4 }; `  v8 WThe most common form of congenital adrenal
$ H6 u2 y* O5 G. lhyperplasia is the 21-hydroxylase enzyme deficiency.
- x  x$ [$ N4 aThe 11-β hydroxylase deficiency may also result in. k: b; z$ q+ C& ]
excessive adrenal androgen production, and rarely,2 N1 i% f  E$ d% i7 ~
an adrenal tumor may also cause adrenal androgen
/ Z& O3 [; d; Dexcess.1,3
( ~2 I5 }5 s1 _0 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& O% e& L6 K, t2 U- n" G2 s7 |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# k3 X' Z  k/ g0 T7 wA unique entity of male-limited gonadotropin-
, Z. q2 t) J8 d7 iindependent precocious puberty, which is also known& I6 p* @  x  w; L
as testotoxicosis, may cause precocious puberty at a
* o$ Z9 |" [- A* C4 ~1 S5 l! H, Bvery young age. The physical findings in these boys
( N7 _8 y& J# {4 N# H. i* P; hwith this disorder are full pubertal development,
& Y& d7 O$ _' H6 X! C: ^/ t" Oincluding bilateral testicular growth, similar to boys
0 i* I1 T' C% H8 a2 Dwith CPP. The gonadotropin levels in this disorder2 n- S5 W0 E4 B
are suppressed to prepubertal levels and do not show8 \' Y  T$ d% R1 L+ a8 o
pubertal response of gonadotropin after gonadotropin-! d+ l, X+ u0 W; X( n
releasing hormone stimulation. This is a sex-linked
6 u/ |& k% P' O6 Y) c- ?4 gautosomal dominant disorder that affects only
  K1 E, S$ Y4 `& a: omales; therefore, other male members of the family
2 h' s3 ]" E3 l6 M2 }' `may have similar precocious puberty.3- V# e0 D' K# v+ `% ~, Z. l5 t
In our patient, physical examination was incon-. a. \! @& I# H+ K6 Y3 r( N
sistent with true precocious puberty since his testi-- V" [, Z9 l7 P$ N0 g- r
cles were prepubertal in size. However, testotoxicosis6 z0 v" f$ N# D: S6 A) ~# \6 |
was in the differential diagnosis because his father
- f7 k& Q' \2 pstarted puberty somewhat early, and occasionally,
: u- \1 n9 I0 ttesticular enlargement is not that evident in the7 x3 t! P- S0 q
beginning of this process.1 In the absence of a neg-& ]7 Y  b/ e. c) g
ative initial history of androgen exposure, our) B/ E* g6 v5 W) U1 Y+ W: ?  B
biggest concern was virilizing adrenal hyperplasia,
( M: P- z3 {7 a6 k6 Veither 21-hydroxylase deficiency or 11-β hydroxylase' Q; z3 b! J6 b# n
deficiency. Those diagnoses were excluded by find-8 R, ]0 a( Y- R2 Y3 `% `
ing the normal level of adrenal steroids.
8 H& _  ^5 d3 P) k4 [. ~. W2 B0 eThe diagnosis of exogenous androgens was strongly
8 H0 p, x# r% G8 D0 J# wsuspected in a follow-up visit after 4 months because
/ \" v2 L$ w* |4 C. m+ Uthe physical examination revealed the complete disap-
# f& z& E$ z; tpearance of pubic hair, normal growth velocity, and7 e8 T1 E! L$ Q/ Y* @9 ^
decreased erections. The father admitted using a testos-$ K1 _  g  o" _8 Q1 m
terone gel, which he concealed at first visit. He was
- f; \: L# t- y& k  u: g* x- qusing it rather frequently, twice a day. The Physicians’0 n( ]: b3 a2 \# v) U* b8 ]
Desk Reference, or package insert of this product, gel or- O# D4 t& |# H# U7 D/ f
cream, cautions about dermal testosterone transfer to# v4 y: ^9 V- S: H5 F
unprotected females through direct skin exposure.
5 ~0 X. F) _" |$ ?% oSerum testosterone level was found to be 2 times the
; A4 [" J5 o1 h# c5 w7 hbaseline value in those females who were exposed to8 k; @" v7 z' E0 b
even 15 minutes of direct skin contact with their male
- n% b6 b1 V7 L, r$ `* upartners.6 However, when a shirt covered the applica-
( S6 m( z0 X1 u1 `1 etion site, this testosterone transfer was prevented.1 X0 g# X0 u# t7 U* D' j
Our patient’s testosterone level was 60 ng/mL,
: c0 b# E- e( ewhich was clearly high. Some studies suggest that) G- ^4 V- [! I/ I. H% y0 X
dermal conversion of testosterone to dihydrotestos-
+ w7 ]( \" I# ^' Y1 m/ O  Z0 n! f3 Wterone, which is a more potent metabolite, is more1 ~; |% \: x6 v7 A* c" t$ l$ [
active in young children exposed to testosterone
0 V1 z* M. F" K+ L+ R0 Pexogenously7; however, we did not measure a dihy-1 C' G2 k4 r3 [- `. p
drotestosterone level in our patient. In addition to8 K0 V8 M6 ]/ E& s: I
virilization, exposure to exogenous testosterone in
  d: x( _; O( cchildren results in an increase in growth velocity and
' u; h# Y" c) B- M2 t% Cadvanced bone age, as seen in our patient.0 a/ t4 M' w: }; u6 o
The long-term effect of androgen exposure during4 V0 Y/ o% b, f; ~7 f9 Y* y, O
early childhood on pubertal development and final
) t$ u$ n/ i! E: Nadult height are not fully known and always remain6 Q4 D+ x+ I. j! `- f- c
a concern. Children treated with short-term testos-
6 j: m, ~% E4 Z. u1 Vterone injection or topical androgen may exhibit some+ d/ a! a4 o1 E+ F1 @- q- E$ a
acceleration of the skeletal maturation; however, after) q- U! u+ V  ~+ B8 K1 f
cessation of treatment, the rate of bone maturation
5 J& J! ^1 \+ C* Xdecelerates and gradually returns to normal.8,9! i8 L5 u  {4 [* c1 B
There are conflicting reports and controversy
. D# a# }: [) O% {' |over the effect of early androgen exposure on adult( x& ?7 c5 t. M) o1 O* F
penile length.10,11 Some reports suggest subnormal
; L0 z, b5 t" C, Q! u# _* g+ Zadult penile length, apparently because of downreg-+ m" x4 n* L0 h( X
ulation of androgen receptor number.10,12 However,
( l( T% L" g3 U. U9 r. Y) USutherland et al13 did not find a correlation between& I) {. W. j9 B. I& B
childhood testosterone exposure and reduced adult
/ ?( D% k3 n- J+ [( j+ Mpenile length in clinical studies.: ~- W& @1 ~0 ~& s0 @
Nonetheless, we do not believe our patient is
" b1 ~: q# ?& @going to experience any of the untoward effects from8 _1 w/ w6 a" C/ n
testosterone exposure as mentioned earlier because0 b4 ~; D/ O$ C/ Q) [* i
the exposure was not for a prolonged period of time.* |; {" R5 ~% q. ~3 d+ n. A! B
Although the bone age was advanced at the time of
. l9 R& `1 N: a- a, r7 M; ^diagnosis, the child had a normal growth velocity at+ k$ Z3 S8 ?( ?! ]1 }
the follow-up visit. It is hoped that his final adult* ~& Q/ t" e2 b' W7 N! F
height will not be affected.9 s% `1 B8 Y) ~4 T- b7 _
Although rarely reported, the widespread avail-
" Q! L" f* ^% u4 B6 mability of androgen products in our society may
2 `2 \: A; y7 X7 a  L3 zindeed cause more virilization in male or female
( P1 D4 L# A. k/ m' @4 achildren than one would realize. Exposure to andro-
+ [# w+ H/ K/ ^! A! v" _gen products must be considered and specific ques-
* W7 n! q5 g$ u+ b4 V# z8 }7 p) ~tioning about the use of a testosterone product or
. O& X4 n- a' [& r" L4 g9 jgel should be asked of the family members during
4 o1 `( T0 @" b% Y, y5 _the evaluation of any children who present with vir-3 s, ]. j1 h% @. r; n7 Y7 J
ilization or peripheral precocious puberty. The diag-
( p$ N1 m- }+ s6 U  Fnosis can be established by just a few tests and by
: D: n- d+ }2 Y8 |: V  m$ g1 Sappropriate history. The inability to obtain such a
9 |- T2 n; }) S, v# Q' y* H) jhistory, or failure to ask the specific questions, may
* Q, g4 w9 x$ Rresult in extensive, unnecessary, and expensive# r! ?8 n) b# e5 |) s
investigation. The primary care physician should be# Q% E; P/ C) G
aware of this fact, because most of these children0 p3 O1 U. _! B
may initially present in their practice. The Physicians’5 k0 D/ ?& h5 m+ b
Desk Reference and package insert should also put a
2 Q- U5 }& a8 g+ {* I  x; v8 xwarning about the virilizing effect on a male or
$ K" a- Y3 T2 p* O2 xfemale child who might come in contact with some-" m. h. y3 X8 p2 j- |
one using any of these products.
  _$ L6 u1 ^( r9 tReferences, W; O1 ^: s# U2 S* K$ |, K
1. Styne DM. The testes: disorder of sexual differentiation/ \' B; V+ F1 c. P5 u4 S6 I
and puberty in the male. In: Sperling MA, ed. Pediatric: k' _9 C4 A9 m% L0 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 X4 N; O/ o& o2 ^5 \2 a
2002: 565-628.
6 M1 E* \% {$ @6 ~- O2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 _" R3 T) V, q/ v/ Q2 k- N
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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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

3 K! b, l  `- f9 R' I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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