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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
4 g" F! M" H5 h+ }* MBoy Induced by Indirect Topical# e2 J: E6 Q5 I5 K) b) z
Exposure to Testosterone7 ?/ }( j" o4 i4 @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' G- [6 R2 i6 b3 [& Q4 E' r) Q8 |and Kenneth R. Rettig, MD1
0 x. T9 J& ]8 `) j( aClinical Pediatrics* k1 v+ l7 g; B: y1 i5 y! V0 f. X* `
Volume 46 Number 6
4 y0 \, O/ l3 wJuly 2007 540-543( H* _" T( p3 h. E. w
© 2007 Sage Publications, n! C, [& d$ G0 k, l
10.1177/0009922806296651' K6 \0 ]% D, i  k4 J
http://clp.sagepub.com$ D! i* m% W3 ~9 p8 v, m# [! j
hosted at
* Y8 M' D9 s5 c' h$ A6 e9 ihttp://online.sagepub.com" t0 k2 [7 @3 R3 v1 [* L( n3 p
Precocious puberty in boys, central or peripheral,  A. q) Q7 R% [6 d, v. |: u# p
is a significant concern for physicians. Central
5 F5 g: n9 _1 F" Q; aprecocious puberty (CPP), which is mediated
$ Y" W/ x" D: X9 ~7 o% pthrough the hypothalamic pituitary gonadal axis, has
: m6 Q' F; ~" S2 N; T% ba higher incidence of organic central nervous system
5 J# R$ ?/ }" F' Y+ ^. v4 c5 Llesions in boys.1,2 Virilization in boys, as manifested
3 @9 ?# U6 c% D$ e- x& aby enlargement of the penis, development of pubic
( `* a( T& A" k3 q; m  L% Shair, and facial acne without enlargement of testi-
4 F7 F- J" `+ g! Y4 G* Ncles, suggests peripheral or pseudopuberty.1-3 We! r# {: [* u* x& @6 n% m
report a 16-month-old boy who presented with the7 z0 z0 t1 }: N1 ]
enlargement of the phallus and pubic hair develop-
0 w( o& G& O6 C" W% j# [9 r' Z- tment without testicular enlargement, which was due7 a, k3 X8 i+ L( R9 W
to the unintentional exposure to androgen gel used by; V# @& E3 {# L; K
the father. The family initially concealed this infor-& S  ?- m: F7 B+ K
mation, resulting in an extensive work-up for this
+ Q; T/ o( A* h! O" Y: C2 x( Echild. Given the widespread and easy availability of
# S' P2 J6 U* d+ \testosterone gel and cream, we believe this is proba-) K# _8 _- s; N7 p
bly more common than the rare case report in the
" X# N1 ?' e, `3 q& mliterature.4
1 K0 [: _( ]' e9 W0 s  n" uPatient Report6 G4 H8 k1 ?# `, Z
A 16-month-old white child was referred to the
. ?8 L3 ~8 |% S' i+ Uendocrine clinic by his pediatrician with the concern
) a! w- U% }( p6 T3 Rof early sexual development. His mother noticed/ x4 a5 h/ G% T, v; E
light colored pubic hair development when he was5 V; ]; W, m# G# M9 c
From the 1Division of Pediatric Endocrinology, 2University of
# v0 Q0 B0 b# e% QSouth Alabama Medical Center, Mobile, Alabama.. s* A! p' N! G; S1 }, y2 [
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" K0 H6 o& z7 V5 TProfessor of Pediatrics, University of South Alabama, College of
$ V& w; w6 i& }  s9 i7 w* AMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 v% V8 V8 s( le-mail: [email protected].
# V& h+ x+ G% B3 xabout 6 to 7 months old, which progressively became: A+ }, D% s. i+ f4 _0 c; B
darker. She was also concerned about the enlarge-
( @! a' W* \) s$ _3 rment of his penis and frequent erections. The child
. v; M/ M# h; r3 `( E6 C+ D$ U8 Kwas the product of a full-term normal delivery, with9 ?6 ^) M) i' o0 }
a birth weight of 7 lb 14 oz, and birth length of
  q( X7 i6 r8 H/ T2 l20 inches. He was breast-fed throughout the first year  q. t5 F- @' v" p# l. V# T
of life and was still receiving breast milk along with- Y7 g- ?' z: H( k9 A
solid food. He had no hospitalizations or surgery,& o% r; Q1 |) N
and his psychosocial and psychomotor development
+ Q% ]- B1 w& u. s/ C9 Swas age appropriate.
& {" K( t1 ^1 J( g$ T7 }" J6 F, SThe family history was remarkable for the father,) X" k2 `" O+ j; b9 z% w
who was diagnosed with hypothyroidism at age 16,
' X+ @, H, J  V) \% q& f8 d, O# t1 ewhich was treated with thyroxine. The father’s, \; P/ [2 j2 f
height was 6 feet, and he went through a somewhat
! V2 R. {$ D' Z" C" k# Qearly puberty and had stopped growing by age 14.
6 \$ x0 W7 o2 y6 x. |The father denied taking any other medication. The
% o0 ~  x) P, l! D3 O; J) m2 L+ ochild’s mother was in good health. Her menarche
5 a9 T# j# q$ ]! C# d$ qwas at 11 years of age, and her height was at 5 feet+ O  r0 }' E( S4 \% J
5 inches. There was no other family history of pre-8 N2 P% }4 M) w6 M0 @" W4 T
cocious sexual development in the first-degree rela-
" v" l% l4 q0 y% o' I( J* J3 G3 jtives. There were no siblings.
' j2 l7 }; E4 @' E8 H7 }. S3 \Physical Examination
) ^) D6 s! N, cThe physical examination revealed a very active,
  F$ {% n* |4 l0 d! W! I5 q8 ^playful, and healthy boy. The vital signs documented8 |& Y1 @8 j3 T7 i% U
a blood pressure of 85/50 mm Hg, his length was
7 C$ d" W5 @2 L6 G- |& X+ A90 cm (>97th percentile), and his weight was 14.4 kg
/ U7 }, U  h4 A) F(also >97th percentile). The observed yearly growth% h) r. |9 e/ O5 \
velocity was 30 cm (12 inches). The examination of2 z7 Z* N' A2 _" q
the neck revealed no thyroid enlargement.
) I0 T# X! E5 D2 \" C0 J. w& iThe genitourinary examination was remarkable for0 i% G6 c' [7 i3 ]" O6 k0 t0 ]
enlargement of the penis, with a stretched length of  L. `' P* X, _0 A1 \$ K
8 cm and a width of 2 cm. The glans penis was very well
* `( C8 F! M* udeveloped. The pubic hair was Tanner II, mostly around
2 Q! X/ J; e( w# n- f540
2 M6 Z! v9 p6 C! q4 l8 dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 c" S0 ^$ L1 b% i/ B5 ?* |the base of the phallus and was dark and curled. The# p9 _# d2 e/ t/ v- p# x4 [
testicular volume was prepubertal at 2 mL each.+ U' v& o3 Y5 O8 \  K4 I4 E$ j2 t/ u
The skin was moist and smooth and somewhat
# R5 n( r/ h& n. I* F" xoily. No axillary hair was noted. There were no
& i5 l1 i/ G: c0 a! [2 Z7 z: A8 tabnormal skin pigmentations or café-au-lait spots.
) k; ^& u# R& F# ^7 lNeurologic evaluation showed deep tendon reflex 2+
: R& @7 @8 ~$ t  P) X, q) }+ Kbilateral and symmetrical. There was no suggestion
* a) `: S) V6 k6 J" J! P: tof papilledema.
" d7 Y( x3 D+ J" m7 ?& D- mLaboratory Evaluation" q/ }' r( I! A& \" g+ F
The bone age was consistent with 28 months by
3 U8 t0 ]$ o; U( fusing the standard of Greulich and Pyle at a chrono-9 @9 \8 C6 t# i4 l& \
logic age of 16 months (advanced).5 Chromosomal
5 ^3 y! E- \* j, T8 I4 _- O1 A. i; fkaryotype was 46XY. The thyroid function test# K2 E0 ^% t5 `5 l) M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% k% Y9 n+ P$ Q/ ]: Ulating hormone level was 1.3 µIU/mL (both normal).6 o6 N7 t: w9 k* y1 V5 T! k
The concentrations of serum electrolytes, blood
) a+ p& C9 c# Eurea nitrogen, creatinine, and calcium all were
$ t' w5 o/ w' S2 M% U1 `within normal range for his age. The concentration" c. e5 H) V0 S
of serum 17-hydroxyprogesterone was 16 ng/dL
! I# a% V/ C/ k. Q, P2 V(normal, 3 to 90 ng/dL), androstenedione was 20$ C, f8 c; T$ }1 k9 z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' k# |* y( t  O' i0 f6 Gterone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 o* v8 X( K- ]1 pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 ]+ Z/ Q- ]- E# c' r49ng/dL), 11-desoxycortisol (specific compound S)
/ T) q8 z" H1 }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 E, z# I6 Z' [, ?) d* M* dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. H7 d% e& @5 i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 X" R. A& W$ A9 G' Gand β-human chorionic gonadotropin was less than# L: C3 Z; L1 Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 a* K' H, h" d! O; a* _stimulating hormone and leuteinizing hormone
* ^9 S6 g. I1 e. M: O' N3 ?concentrations were less than 0.05 mIU/mL  W1 V0 p/ u, T2 V9 \; ~
(prepubertal).. R6 w6 b7 e* r) h2 f# }
The parents were notified about the laboratory
# Q- C. J# q# D' z+ rresults and were informed that all of the tests were
  i0 `1 p, _6 D. Xnormal except the testosterone level was high. The4 p; q; q) o! `( ?+ v4 [
follow-up visit was arranged within a few weeks to) `% l3 }; l* e2 r
obtain testicular and abdominal sonograms; how-! Y7 v0 s3 ?& P3 k( S- x4 i! b
ever, the family did not return for 4 months.
) v+ ]8 V  X$ C% W& u! }- N9 A6 bPhysical examination at this time revealed that the
9 v/ X$ F3 J9 r, D: g+ Xchild had grown 2.5 cm in 4 months and had gained
5 [8 W8 p* W9 n2 y1 I# g6 K2 kg of weight. Physical examination remained+ A. P2 Z( q# `( R; _
unchanged. Surprisingly, the pubic hair almost com-
) j- [, K, N! q( G" Mpletely disappeared except for a few vellous hairs at
/ K+ D# P+ w: l5 i5 I2 w' h  {the base of the phallus. Testicular volume was still 2
* w8 `; E' `. x) P; b4 v1 zmL, and the size of the penis remained unchanged.
7 [" L6 ?2 y7 ~# g) J1 J/ ]The mother also said that the boy was no longer hav-* v% @+ G+ Z. d7 x2 U' _
ing frequent erections.& A. X+ s$ o0 [- C
Both parents were again questioned about use of
. M  u+ E# N  W! Fany ointment/creams that they may have applied to5 r) }. y+ O$ x" m! y
the child’s skin. This time the father admitted the5 N& P2 G2 ~3 C  c  R9 k8 l
Topical Testosterone Exposure / Bhowmick et al 541
# a5 _% l# w! x. w$ x1 Huse of testosterone gel twice daily that he was apply-
0 X: c, ~% O' `/ T* uing over his own shoulders, chest, and back area for' g8 F2 O% `  b4 h8 D
a year. The father also revealed he was embarrassed
( C# F* t( m, F$ z- Cto disclose that he was using a testosterone gel pre-
' N/ V5 e( r. I% o) y  zscribed by his family physician for decreased libido" K9 e2 F/ G' I& X
secondary to depression.
' C" N2 @' K" C2 u% [0 YThe child slept in the same bed with parents.
* H/ M0 I9 X' J' zThe father would hug the baby and hold him on his
! S0 N4 S* J1 U6 ^! dchest for a considerable period of time, causing sig-3 D( g3 U2 C7 Z/ H8 }) |
nificant bare skin contact between baby and father.0 ], o0 O& x0 Z0 e! n7 M+ z6 H
The father also admitted that after the phone call,
$ q# Z2 A# {% }7 ]  k9 mwhen he learned the testosterone level in the baby% Z5 _2 w  y* O  Q" ~' I; H% s
was high, he then read the product information
0 v0 K, A# O- P/ ?: y. fpacket and concluded that it was most likely the rea-
1 P8 v- p+ [! ^8 w2 Wson for the child’s virilization. At that time, they
/ e4 }) ^' n) [5 _* gdecided to put the baby in a separate bed, and the
% z' M, H; J4 q7 O" ~8 [6 m; |father was not hugging him with bare skin and had  ^/ V' U& S6 h$ C5 p% p
been using protective clothing. A repeat testosterone) ~4 y* y- G( V0 y. s4 o9 E! ^* U
test was ordered, but the family did not go to the
* d% r! D7 ^8 O& X% l8 Ulaboratory to obtain the test.
: V* \0 s  ^6 X2 B/ S. {Discussion1 {3 c  N/ K3 W* r! p7 t; w3 G
Precocious puberty in boys is defined as secondary( [- ^# H: }- X( @! `; T: k
sexual development before 9 years of age.1,4
9 Z; G% r' G% ?3 z, IPrecocious puberty is termed as central (true) when
& \0 w/ ^/ g- l* A- g9 Cit is caused by the premature activation of hypo-& ?- z. u8 ]$ v6 Z/ V, M: ?" j
thalamic pituitary gonadal axis. CPP is more com-
/ W8 J9 b, t9 e& A3 S0 D$ L' s% ]0 J. Z% Pmon in girls than in boys.1,3 Most boys with CPP
( h* l6 T! ]& t- M) s8 rmay have a central nervous system lesion that is
8 F7 R- U4 a% sresponsible for the early activation of the hypothal-& t1 w& m5 _5 V  x( l
amic pituitary gonadal axis.1-3 Thus, greater empha-1 g# Z" b+ h& W; K+ J! z
sis has been given to neuroradiologic imaging in. v) |& U' r  @8 `  X, `
boys with precocious puberty. In addition to viril-$ K; u1 Y0 N/ e! [0 i3 \9 s+ ^
ization, the clinical hallmark of CPP is the symmet-0 u( E0 Z( R, h9 e- K1 H
rical testicular growth secondary to stimulation by
* k4 N. B% a  @& C! }" `gonadotropins.1,3
, V) l# V7 f9 I) Q8 C0 o4 MGonadotropin-independent peripheral preco-
* V7 K" a' O: t) w) r- X) Hcious puberty in boys also results from inappropriate
" F3 q6 e% Q7 E, I6 ]/ m, r' xandrogenic stimulation from either endogenous or
# g- E: S4 Z: T" C2 Oexogenous sources, nonpituitary gonadotropin stim-
6 Q. X3 w7 |2 r4 q/ ^' L9 Kulation, and rare activating mutations.3 Virilizing7 C9 _/ N! [/ l& R. Z# M6 Z& i/ ]. u
congenital adrenal hyperplasia producing excessive
, l( l) e- z/ Hadrenal androgens is a common cause of precocious  k3 m- a& f' Y: S3 @3 t7 j4 l
puberty in boys.3,4
6 K$ [' \' J$ V1 E' L- P) D4 bThe most common form of congenital adrenal
& ]/ g) h  _) Z5 `hyperplasia is the 21-hydroxylase enzyme deficiency.: [1 ?- S+ d1 K1 ?
The 11-β hydroxylase deficiency may also result in; z6 B  w% A3 M
excessive adrenal androgen production, and rarely,
$ D: i$ L4 c. Z. ban adrenal tumor may also cause adrenal androgen
1 J4 L4 }5 g, t3 g, d. }excess.1,30 u% r* h- o9 i- k+ n4 @+ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ ^* M) A9 p; L7 [* _! q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; w' y) z8 a# ^( \# d
A unique entity of male-limited gonadotropin-
' B( N/ h5 m+ s$ C7 w: uindependent precocious puberty, which is also known
, L: ^6 ^3 }: R6 ^as testotoxicosis, may cause precocious puberty at a
: U4 [# n4 R( @' r% F+ G! Hvery young age. The physical findings in these boys, R0 i) @5 Y" p% ?, G' R
with this disorder are full pubertal development,; V% a9 ?, D# x* x9 H# l& p0 ^
including bilateral testicular growth, similar to boys1 i; L1 W1 q2 M) |9 m" T
with CPP. The gonadotropin levels in this disorder
4 C: C. ~. F+ e! J; |! Fare suppressed to prepubertal levels and do not show+ J3 w; a; \' ]: c) m! W
pubertal response of gonadotropin after gonadotropin-* ?. d2 |$ H$ I% Y
releasing hormone stimulation. This is a sex-linked
2 \- R8 }9 K9 Dautosomal dominant disorder that affects only
7 y4 j# U7 k# N- G' L8 Jmales; therefore, other male members of the family
- v0 j5 c, [- O3 \/ T0 v# {1 imay have similar precocious puberty.3' D3 Q' h% e; `- K3 L- Z* `
In our patient, physical examination was incon-
  @5 J1 F: O# ?; m; [sistent with true precocious puberty since his testi-
" ]4 I! ^& {# P3 ?( A2 Gcles were prepubertal in size. However, testotoxicosis
0 v- e0 a+ |) C8 rwas in the differential diagnosis because his father
5 `& G) P) r" kstarted puberty somewhat early, and occasionally,
+ e6 D& Q; [9 ]3 E  Y- @. Otesticular enlargement is not that evident in the
& N- q2 v2 [& p+ z# v& Obeginning of this process.1 In the absence of a neg-( k* w1 e1 a7 `
ative initial history of androgen exposure, our0 z( M- B+ k* K) J
biggest concern was virilizing adrenal hyperplasia,
0 S8 M7 e: w( D9 I3 beither 21-hydroxylase deficiency or 11-β hydroxylase% c' ]: U- @- n
deficiency. Those diagnoses were excluded by find-" y# o2 t! k: T3 g% N$ R8 ^; M0 f
ing the normal level of adrenal steroids.
8 D) h9 e( o- u4 s; n. tThe diagnosis of exogenous androgens was strongly% Q) J% j. s2 v1 a9 L5 q
suspected in a follow-up visit after 4 months because
% N. \4 Q& H& w6 r$ p- Mthe physical examination revealed the complete disap-# [  V! ^( R! c* ?  U
pearance of pubic hair, normal growth velocity, and# h1 @. Y  I+ o* W9 O1 `
decreased erections. The father admitted using a testos-
) x7 [0 H+ Z! q% Sterone gel, which he concealed at first visit. He was; x* M# s: }4 V
using it rather frequently, twice a day. The Physicians’. E) g9 [6 A$ i, f
Desk Reference, or package insert of this product, gel or
6 }2 g. G9 ?" vcream, cautions about dermal testosterone transfer to% `4 ?6 F. ?, G; T& ^
unprotected females through direct skin exposure.7 n7 ~9 ~" v5 w+ B( Y4 h6 P( P# H
Serum testosterone level was found to be 2 times the# s$ `7 H1 p/ \% @# t  M# X1 ~
baseline value in those females who were exposed to
  S. p: d4 p. I% t6 W$ heven 15 minutes of direct skin contact with their male
( Y* n& m7 ]& H! y5 w( z3 C# Cpartners.6 However, when a shirt covered the applica-1 `( _2 {& Y, k" S; R1 g3 f9 I! e
tion site, this testosterone transfer was prevented." V# l- c1 n( A" w: P# |0 u
Our patient’s testosterone level was 60 ng/mL,3 i, G' b4 q" @
which was clearly high. Some studies suggest that
8 ]- G( n' x9 V' ~* Q! w0 Odermal conversion of testosterone to dihydrotestos-: v/ {5 T! ?( \. G6 z  ~
terone, which is a more potent metabolite, is more
5 [$ S9 g4 y0 g' g  \" l7 `active in young children exposed to testosterone
4 H- u/ O! K0 W! bexogenously7; however, we did not measure a dihy-/ }; F  D8 s, f
drotestosterone level in our patient. In addition to
( C$ G1 ?) T  u" @8 w/ }- Nvirilization, exposure to exogenous testosterone in
) k* X" Q; I; jchildren results in an increase in growth velocity and7 G- s+ o9 `) ]2 Q
advanced bone age, as seen in our patient.
3 a+ L( |  h" ]6 rThe long-term effect of androgen exposure during' y+ r; B2 {7 G5 l( R; q
early childhood on pubertal development and final
/ T* X) h1 v2 T- Ladult height are not fully known and always remain. g4 l' d4 ^$ N
a concern. Children treated with short-term testos-0 p. i" \; w' w. f
terone injection or topical androgen may exhibit some
2 m) O2 T: z2 X3 p1 R+ }acceleration of the skeletal maturation; however, after- k% r; E% v# N- ~' b
cessation of treatment, the rate of bone maturation
' J% y# L; S5 v# ydecelerates and gradually returns to normal.8,93 N- z$ i" v5 {; L
There are conflicting reports and controversy
1 i' c$ A, ^+ K6 m$ i+ M% vover the effect of early androgen exposure on adult
( s6 q: @6 m6 G9 ]$ tpenile length.10,11 Some reports suggest subnormal' V3 C! u0 x' M# H9 x7 L) ^
adult penile length, apparently because of downreg-
# h0 E2 I4 t6 `' [9 eulation of androgen receptor number.10,12 However,
! L2 K7 y, U  F0 }: O3 aSutherland et al13 did not find a correlation between9 @) z- @- o; s5 V" }
childhood testosterone exposure and reduced adult" N" _" ?, a3 M" t* |; j
penile length in clinical studies.
. {1 {: a& H3 ]$ k! \2 fNonetheless, we do not believe our patient is8 n  K' n  [$ H( c
going to experience any of the untoward effects from
+ G9 U$ C# w% o4 d4 Etestosterone exposure as mentioned earlier because/ T6 R, Q" ]9 @" C6 G
the exposure was not for a prolonged period of time.
% _' @7 p+ l# n* @Although the bone age was advanced at the time of3 q# b- ]" D; S0 \: `
diagnosis, the child had a normal growth velocity at, G# Y' ?3 K! P; _8 p$ x% ]: i
the follow-up visit. It is hoped that his final adult6 |/ w+ L, N7 d5 X
height will not be affected.
9 j$ t* K5 U1 D5 R8 U* E5 C, BAlthough rarely reported, the widespread avail-0 I2 e9 f$ T8 |5 p" o' r
ability of androgen products in our society may( O" |1 O9 I5 j
indeed cause more virilization in male or female  ~/ J; o' @. [% e
children than one would realize. Exposure to andro-! R) [* @, r# x8 D5 J
gen products must be considered and specific ques-
: g. Z0 E4 ?1 l/ U' u" P# Ztioning about the use of a testosterone product or2 O3 O$ C% S+ ~2 Y; I- J/ ]
gel should be asked of the family members during9 Y6 R# d4 t2 b  _1 J1 {/ J) g
the evaluation of any children who present with vir-
0 }, v! K+ I" W# @( x  b) Gilization or peripheral precocious puberty. The diag-
3 M4 p7 j$ Y! T8 Z) n- y; i4 vnosis can be established by just a few tests and by
+ s$ E5 T2 L5 y  H+ Z) O2 b" Mappropriate history. The inability to obtain such a
/ O$ J" r9 Z# Z, s# r( Ahistory, or failure to ask the specific questions, may% o- G  m. X3 m: \
result in extensive, unnecessary, and expensive
# m5 {; y. \+ o! j0 Y& I) qinvestigation. The primary care physician should be
  l$ P# g8 J0 yaware of this fact, because most of these children% T9 _! u( T6 S" y6 e
may initially present in their practice. The Physicians’
& A0 ?/ e5 j( }" EDesk Reference and package insert should also put a5 W& H. f* B6 J  a, E5 @
warning about the virilizing effect on a male or
# c$ k% a* U8 x* y+ c# \6 a2 Q- jfemale child who might come in contact with some-  l, H# Y5 P$ e) y: I
one using any of these products.
* c5 h7 T! q% hReferences
% ?4 i# D" d3 {& \8 ]1. Styne DM. The testes: disorder of sexual differentiation7 x$ p( [# ]# }. J, O! r5 [- }
and puberty in the male. In: Sperling MA, ed. Pediatric
8 C# A* n7 r$ eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 U0 F3 v1 n" Y* L- @
2002: 565-628.- U" g; d3 e( t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 _/ ~# K4 J, l) V6 V. L% V' jpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old8 M8 U! X, v% y- s) q
Boy Induced by Indirect Topical
5 C: r/ P, H$ ]- QExposure to Testosterone
: T% @/ B7 n7 w4 n+ Q1 cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 h$ F# P- c+ }, n( }6 U6 ^' n
and Kenneth R. Rettig, MD1- p: O4 O0 V. L8 B8 r
Clinical Pediatrics- t- \  I& Z0 i1 S6 J
Volume 46 Number 6/ Y+ U% K, R3 j2 U* i
July 2007 540-543
- o" E# h* r) O5 {  }© 2007 Sage Publications) Q+ M  t9 V9 j5 q. ^
10.1177/0009922806296651
& h& [; o7 y2 S" I4 n& xhttp://clp.sagepub.com
/ ]  V$ N4 `" @3 Q; Xhosted at
# q( S0 }9 e  g. f8 G2 R+ s/ hhttp://online.sagepub.com
, D% ~/ z7 R! _8 q* ?Precocious puberty in boys, central or peripheral,
/ X# E3 ~" c, mis a significant concern for physicians. Central
2 j' X% ]0 K5 C9 J5 S% S' \2 M* Nprecocious puberty (CPP), which is mediated9 ?1 ~# K8 A7 i" |1 N
through the hypothalamic pituitary gonadal axis, has' X4 E- N# v# x; d2 X
a higher incidence of organic central nervous system, r* [, D. I' H- ^
lesions in boys.1,2 Virilization in boys, as manifested  T  ?7 a8 u& T& f7 r7 j
by enlargement of the penis, development of pubic7 x  ]2 |/ j4 i, u' X& q
hair, and facial acne without enlargement of testi-4 b5 m6 @0 D+ a+ x& v
cles, suggests peripheral or pseudopuberty.1-3 We9 f( e8 J  j; W* _9 n& [
report a 16-month-old boy who presented with the8 N) J' y: D( ?4 p
enlargement of the phallus and pubic hair develop-
) Z/ ?/ Y( V2 D3 H( P1 R$ |ment without testicular enlargement, which was due
' I" ^( F! x/ V! Rto the unintentional exposure to androgen gel used by
- O: y$ g& C: \" z2 bthe father. The family initially concealed this infor-
7 a- T$ [( i* mmation, resulting in an extensive work-up for this5 _& a7 F  D! P0 h
child. Given the widespread and easy availability of
' m% F3 H5 a1 z: @2 p3 dtestosterone gel and cream, we believe this is proba-
% g4 S4 ~4 ~2 j- z# E3 _! @; K: ebly more common than the rare case report in the
2 Y7 w, H9 g& r2 p) G8 p3 e! Dliterature.4' H. n7 d' B7 R. k; c  }! G
Patient Report, X4 F, h) g  O% F* |0 e
A 16-month-old white child was referred to the* x& i: @: @$ |7 U
endocrine clinic by his pediatrician with the concern) q& m8 y" a1 m( ^: D
of early sexual development. His mother noticed
' z- Y/ }; Z- m8 L0 Olight colored pubic hair development when he was
6 R" E$ b# }) j/ m* \# m# b1 x; K4 sFrom the 1Division of Pediatric Endocrinology, 2University of
& f6 c/ e+ Y  _: X- m& U7 y. XSouth Alabama Medical Center, Mobile, Alabama.+ W' W; T, H) Y& r8 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,! }; _, |8 V/ [3 C. M
Professor of Pediatrics, University of South Alabama, College of7 {4 V1 H! Q6 {5 X" `0 Q4 k5 k
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 G! V) t( S" {. j; be-mail: [email protected].  u9 k: E; b2 c; m+ V) A
about 6 to 7 months old, which progressively became4 |$ P% l6 `+ l! b2 ]. J5 ~; r8 N
darker. She was also concerned about the enlarge-
) z7 R4 q% h1 R$ sment of his penis and frequent erections. The child5 P4 Q$ T8 A0 z1 ^
was the product of a full-term normal delivery, with5 K" }) e$ g& Q! B0 c
a birth weight of 7 lb 14 oz, and birth length of
  d- }. k- W% Y9 E- `20 inches. He was breast-fed throughout the first year
' F3 }  m4 L( X2 iof life and was still receiving breast milk along with1 A. q  s" P& S
solid food. He had no hospitalizations or surgery,
3 W* T5 S/ D/ f2 H, h4 Vand his psychosocial and psychomotor development
, U6 F" O% Q0 N, I; B2 H: G" Kwas age appropriate.! {+ P4 I9 J: r5 K" N
The family history was remarkable for the father,
  U5 C: b: t- b) vwho was diagnosed with hypothyroidism at age 16,  H4 F2 a6 a* O7 a  H  s
which was treated with thyroxine. The father’s/ W. R1 {6 b9 S( m& V
height was 6 feet, and he went through a somewhat2 O) ?3 [  L2 f/ d
early puberty and had stopped growing by age 14.* u9 V* L+ E9 f9 l& d3 Z8 ]
The father denied taking any other medication. The" K7 J0 n2 K- C. _2 q& Z
child’s mother was in good health. Her menarche
. E  v3 n- |! u& O, Rwas at 11 years of age, and her height was at 5 feet7 u/ z: _1 x5 c0 d
5 inches. There was no other family history of pre-
; N7 B% R' @4 \# E- ]cocious sexual development in the first-degree rela-
* Q9 D7 q' |; d: atives. There were no siblings.
" k" z2 E# l# gPhysical Examination
/ Z. {2 W7 m  p7 {! k) R3 SThe physical examination revealed a very active,. P2 u+ z8 I; p$ y& L
playful, and healthy boy. The vital signs documented5 B; \$ X) w, _: `" i
a blood pressure of 85/50 mm Hg, his length was
- D! Y. Y/ {6 s1 i, O90 cm (>97th percentile), and his weight was 14.4 kg
; n8 x5 G: t, A! Q( x(also >97th percentile). The observed yearly growth# f% Y6 \% D* ?+ q3 Z, T5 s
velocity was 30 cm (12 inches). The examination of
  R% @, L. C1 kthe neck revealed no thyroid enlargement.0 z4 W6 J: ]% c+ B! L- e0 ?
The genitourinary examination was remarkable for' J( e: f2 L- k) F  ]8 ]
enlargement of the penis, with a stretched length of1 `1 \6 K! m8 `0 P' [2 c
8 cm and a width of 2 cm. The glans penis was very well
4 U( W: i8 R" a/ w6 edeveloped. The pubic hair was Tanner II, mostly around8 ?$ w( ~) h% y5 B( j: y
540
: x1 _$ O: z6 k9 P" H8 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; X9 z# ?( t5 {the base of the phallus and was dark and curled. The2 w2 j) k( ~5 v* {
testicular volume was prepubertal at 2 mL each.
: ?/ Y- Y" j, b1 e! X1 C; ^, }* BThe skin was moist and smooth and somewhat2 Z5 B8 Y& d, Z! R' x, a# f* K+ [
oily. No axillary hair was noted. There were no
' v1 f5 R( x" m& Wabnormal skin pigmentations or café-au-lait spots.
/ K+ t8 ^0 Z' {: N8 UNeurologic evaluation showed deep tendon reflex 2+
$ d# Y$ H+ D, cbilateral and symmetrical. There was no suggestion
$ o6 u1 n& t5 z- gof papilledema.5 P4 [9 A: A. O. x7 y( n  [& P
Laboratory Evaluation$ H8 q4 U3 J8 d
The bone age was consistent with 28 months by* {/ L! U" H- j3 `- n
using the standard of Greulich and Pyle at a chrono-8 L* a. }2 R* g/ z- @1 {' H
logic age of 16 months (advanced).5 Chromosomal
$ u- L1 `  c6 {; Y$ S( K& @karyotype was 46XY. The thyroid function test) u% U, i9 L+ w! ?3 d' t1 n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) @5 @* s2 ]$ ^& b3 rlating hormone level was 1.3 µIU/mL (both normal).
- R' Y  u# m2 Y5 }The concentrations of serum electrolytes, blood  z/ ~/ T  @0 B# Y7 S# g8 G" I, s
urea nitrogen, creatinine, and calcium all were$ h9 h! ?+ d4 [( r
within normal range for his age. The concentration* E0 D0 N6 M1 v# L" q. W4 o4 I
of serum 17-hydroxyprogesterone was 16 ng/dL
8 F4 q, i9 j9 \' f. y$ C(normal, 3 to 90 ng/dL), androstenedione was 20
2 P+ R7 ~7 f( c9 T+ I5 `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: u; K6 i" j! N% P( S. qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: k3 h* W9 @$ E, G8 sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to, h* V- I$ V2 i6 x9 m
49ng/dL), 11-desoxycortisol (specific compound S)
6 e4 G  X0 _9 L1 nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" f( r3 c- C; H4 Z$ r$ V% B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 Z5 y# {) a* R
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 _2 J) E3 W. C/ g* ]* A* tand β-human chorionic gonadotropin was less than, f- Q4 q2 U$ y+ r2 O: W
5 mIU/mL (normal <5 mIU/mL). Serum follicular  I+ R- e& x" X! g' Y1 N, i' t
stimulating hormone and leuteinizing hormone+ x+ }: ?3 C1 b; L% L' {1 \
concentrations were less than 0.05 mIU/mL
0 W+ q' `7 T9 p* A; S(prepubertal).
* v+ |' e  z) g! _4 {The parents were notified about the laboratory" ^: d9 g+ n4 F4 @# j8 q6 m7 F9 S
results and were informed that all of the tests were, P2 B5 F3 n* ~
normal except the testosterone level was high. The, ?" m0 X5 B" c; k$ T
follow-up visit was arranged within a few weeks to0 z- d; w, N3 A' B0 r+ ^. H# S8 ~0 p$ }
obtain testicular and abdominal sonograms; how-
0 J% M5 Y" r4 bever, the family did not return for 4 months.
. z) U% F2 S" xPhysical examination at this time revealed that the+ N( l( g! h& c( j3 s$ \" j
child had grown 2.5 cm in 4 months and had gained, R& t5 D/ }4 A1 Y% q7 g2 U( m
2 kg of weight. Physical examination remained
$ a( D  S: Y4 }9 E" R+ j8 Q/ Vunchanged. Surprisingly, the pubic hair almost com-9 a  b& D1 ?3 B  ~+ T
pletely disappeared except for a few vellous hairs at. ^! S& n: R+ W( F% R
the base of the phallus. Testicular volume was still 23 [: K! L( S" N1 ?" s, ]5 n* k& b
mL, and the size of the penis remained unchanged.
% n+ R" s& k& X+ I% d& _The mother also said that the boy was no longer hav-. Y+ D9 w$ w0 }8 [( O
ing frequent erections., a8 w. j% W% u) h3 X- R8 `
Both parents were again questioned about use of
8 m; I0 x* ]$ x! \6 p, e" V, Zany ointment/creams that they may have applied to2 {) l; D! U- ]5 R* I4 z
the child’s skin. This time the father admitted the
. Z/ ^4 ~: a! {' A- D. ZTopical Testosterone Exposure / Bhowmick et al 541
! d; v6 a4 [4 `, V! \use of testosterone gel twice daily that he was apply-
; m2 p2 k" v- X7 s; qing over his own shoulders, chest, and back area for
6 J! i7 ^0 P$ ya year. The father also revealed he was embarrassed
3 h3 Y+ H/ f' h5 v" Oto disclose that he was using a testosterone gel pre-& D% a( V( W( k
scribed by his family physician for decreased libido
$ e  ^* P, N9 `% A# Csecondary to depression./ U- [* ]4 ?( u, c8 L7 f( L% S  |
The child slept in the same bed with parents.
8 B% n0 @- @$ Q6 u1 KThe father would hug the baby and hold him on his/ s1 X1 H9 T$ Q/ n2 z9 L9 p1 x
chest for a considerable period of time, causing sig-; H# y- m; i/ m* j& ?3 ^2 L
nificant bare skin contact between baby and father.
  _# W, q7 j4 R! xThe father also admitted that after the phone call,
' i& \( S, @, bwhen he learned the testosterone level in the baby% K# j: X- d& ~2 a5 R
was high, he then read the product information
+ y  X9 a7 a, A/ A' n0 Zpacket and concluded that it was most likely the rea-( g  j+ O/ w2 l: n
son for the child’s virilization. At that time, they( ?1 V. ?7 R% P1 _
decided to put the baby in a separate bed, and the
# O& O# y4 g1 W$ g4 u/ m% {father was not hugging him with bare skin and had
! n) g7 A  m; O) C# rbeen using protective clothing. A repeat testosterone
  Y6 J& ], O& o2 \7 f. L# _test was ordered, but the family did not go to the
+ U5 c. v+ R* Mlaboratory to obtain the test., P( M4 |7 `  N* y3 P. b9 z
Discussion
7 P+ {0 S. _3 C$ f; i% mPrecocious puberty in boys is defined as secondary
) c0 |& p& t9 [) e! M8 L+ L3 m( {2 asexual development before 9 years of age.1,4* @4 v4 n8 N  n6 ?/ J
Precocious puberty is termed as central (true) when# d; \" ?$ ]/ V& G
it is caused by the premature activation of hypo-' S" [) U1 r2 f- p: _! y; h$ e2 K
thalamic pituitary gonadal axis. CPP is more com-+ u" D# O. l+ e$ j8 u
mon in girls than in boys.1,3 Most boys with CPP# z3 B; a& v0 S/ l2 M
may have a central nervous system lesion that is; @* x/ w/ ?8 h9 e: O7 G7 g
responsible for the early activation of the hypothal-1 O8 }" ~4 ]5 n4 F* e
amic pituitary gonadal axis.1-3 Thus, greater empha-( F4 P+ E8 B6 S/ ?) b1 u, V
sis has been given to neuroradiologic imaging in, U" L4 |$ j1 z7 K5 u
boys with precocious puberty. In addition to viril-0 X+ I4 }' L, D7 {. e' v: C
ization, the clinical hallmark of CPP is the symmet-) s* D, S. a; \/ l
rical testicular growth secondary to stimulation by
7 o# u$ }/ L4 L. ^gonadotropins.1,34 o: Y, S0 h9 n3 @, B+ `
Gonadotropin-independent peripheral preco-. ^! X" `" K* N5 l  h
cious puberty in boys also results from inappropriate
) f* B, I- J4 R1 b5 mandrogenic stimulation from either endogenous or
7 u5 M/ B- l1 B& _exogenous sources, nonpituitary gonadotropin stim-4 L0 j' q* [9 s2 V" h
ulation, and rare activating mutations.3 Virilizing" \0 S3 |0 @8 O8 W  }& o
congenital adrenal hyperplasia producing excessive
/ U8 u# _) E1 W# C1 nadrenal androgens is a common cause of precocious0 u5 M$ g- V+ j) I: O) {
puberty in boys.3,4
# C1 m$ s7 I& T  w' ~The most common form of congenital adrenal
# ?( E6 l: W8 _* j" W9 ]hyperplasia is the 21-hydroxylase enzyme deficiency.
7 d. Z0 t. x9 [9 [/ nThe 11-β hydroxylase deficiency may also result in; @  `' q/ T: G7 N% f5 z. B
excessive adrenal androgen production, and rarely,* A4 t5 ]$ m! x$ \+ L3 b
an adrenal tumor may also cause adrenal androgen
; y& Q% \; I- K& Mexcess.1,3
; s- B$ _" l* W, ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. m. C. V; j; f1 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 H$ j; }) w5 NA unique entity of male-limited gonadotropin-# d9 n7 c3 h$ `0 \6 M" e7 ~
independent precocious puberty, which is also known+ |7 V7 G; B8 }) n* Q
as testotoxicosis, may cause precocious puberty at a
& E  Z/ u, r- G# M+ P0 U% nvery young age. The physical findings in these boys
3 T: K6 Z! d( j7 m% }* Q8 Dwith this disorder are full pubertal development," ~7 A$ ~( H3 H+ \8 O
including bilateral testicular growth, similar to boys( A: [0 Q/ t* V6 D% ]
with CPP. The gonadotropin levels in this disorder( Y9 j( |; R: o* o" s
are suppressed to prepubertal levels and do not show
! `& s- Q2 T$ R' ]# l8 cpubertal response of gonadotropin after gonadotropin-+ ^9 |! i4 M: s% v1 U4 s5 F! l5 @) y$ l- d
releasing hormone stimulation. This is a sex-linked$ u6 g9 V: ~. p1 W
autosomal dominant disorder that affects only
+ h8 q4 g6 i0 t0 v% c# J: umales; therefore, other male members of the family& L. ~3 G2 K/ F0 u! r! F
may have similar precocious puberty.3
/ s/ \4 h3 U: y; z/ OIn our patient, physical examination was incon-! U. g6 S" f, [- n6 u# W  J/ E( o
sistent with true precocious puberty since his testi-
& V# V; }! A" c/ F/ Pcles were prepubertal in size. However, testotoxicosis
# P( k! f) ]0 k8 ]+ lwas in the differential diagnosis because his father
6 C4 a6 B. R6 z5 c! ?6 a* hstarted puberty somewhat early, and occasionally,
; Q! a, ^) x6 g; ?( m3 otesticular enlargement is not that evident in the0 H6 I: W1 d3 a/ ~- @# l
beginning of this process.1 In the absence of a neg-
- a: r0 Y/ P9 V- Z, F1 R: f( Wative initial history of androgen exposure, our
7 V7 x* k/ F/ t4 K6 qbiggest concern was virilizing adrenal hyperplasia,
  `. a9 R6 M: z" H; seither 21-hydroxylase deficiency or 11-β hydroxylase. h2 I# O4 {- O0 T& `! [
deficiency. Those diagnoses were excluded by find-8 m+ X/ F$ _9 y7 p' n8 }
ing the normal level of adrenal steroids.
6 ?' D6 l& p) y. n$ p: [7 l8 mThe diagnosis of exogenous androgens was strongly8 n% g& g. b) u% Z' p& F8 D! M2 I
suspected in a follow-up visit after 4 months because
+ r/ d; j: ]. p$ u0 ~9 Dthe physical examination revealed the complete disap-4 A3 D# B% T7 a# {$ U% t0 b/ \. i. w
pearance of pubic hair, normal growth velocity, and
& t3 O5 r: d7 Ddecreased erections. The father admitted using a testos-
; a8 u$ C0 j0 i' K6 Nterone gel, which he concealed at first visit. He was
5 }8 E' [1 [' Tusing it rather frequently, twice a day. The Physicians’
' m; P  d; _' W9 P- T  p3 [Desk Reference, or package insert of this product, gel or' Y  t2 i& M4 s. ]4 _
cream, cautions about dermal testosterone transfer to7 l& y) a1 k& x! B3 g
unprotected females through direct skin exposure.
, z; D% F% v/ z% {0 j  kSerum testosterone level was found to be 2 times the4 Z5 }" i% L. X) T% o! F
baseline value in those females who were exposed to
9 ~) Y( o* c2 `$ m# A, i- @# Reven 15 minutes of direct skin contact with their male
0 z3 Q5 _  U: E, Mpartners.6 However, when a shirt covered the applica-
  m( S% G8 K2 I3 {) I( e6 rtion site, this testosterone transfer was prevented.
. W6 J+ h  a" V( p/ {+ L+ J0 a8 ]3 {Our patient’s testosterone level was 60 ng/mL,+ q, o+ T3 l% A* }6 ~' X  m
which was clearly high. Some studies suggest that
4 |; O+ S: P& Q" P0 Ydermal conversion of testosterone to dihydrotestos-
# G7 H- K* h6 J4 cterone, which is a more potent metabolite, is more
( T; V  F0 g2 b) e& a! sactive in young children exposed to testosterone
: h$ S* H2 f1 U+ F1 ]3 e  Gexogenously7; however, we did not measure a dihy-
' F( ^: c2 A0 B2 {. G7 D1 ~drotestosterone level in our patient. In addition to
* i/ p+ [4 ]# K' r* N- zvirilization, exposure to exogenous testosterone in9 o8 `( p+ n! U- A6 a; y) ]4 V
children results in an increase in growth velocity and
$ e  W. l1 R+ B* O" C$ Ladvanced bone age, as seen in our patient.
7 }  @0 l9 x  R$ D" ?! gThe long-term effect of androgen exposure during
# _; S' P$ r) F( T  Q) A" c0 Q+ d- searly childhood on pubertal development and final( V: k6 z1 s1 N: b: h0 W, ]
adult height are not fully known and always remain0 N9 l) M3 l2 J0 p
a concern. Children treated with short-term testos-5 a9 R) |0 Y( q$ r0 \* L
terone injection or topical androgen may exhibit some
! [9 }8 w1 ~2 F, c- xacceleration of the skeletal maturation; however, after# \* x7 X) m2 u* p" l7 P% _, J
cessation of treatment, the rate of bone maturation
4 A6 Q7 t( a  i& i* Y/ [! H; [# ]decelerates and gradually returns to normal.8,9
. R) k) G5 }/ s, t9 ~There are conflicting reports and controversy. e" p8 S  t+ S
over the effect of early androgen exposure on adult
. E, ]( p0 C! e. G0 Z& Xpenile length.10,11 Some reports suggest subnormal
! ^" W7 G' b$ S5 P/ v* f3 Zadult penile length, apparently because of downreg-4 W2 e! [- c/ P+ b
ulation of androgen receptor number.10,12 However,; h: R/ r5 \% a0 I: M5 u
Sutherland et al13 did not find a correlation between) ]3 {2 o3 H* J  j3 E9 }2 m
childhood testosterone exposure and reduced adult& L% z2 d/ e1 ^0 v  t9 I* M8 E
penile length in clinical studies.
3 t+ h/ {* D- b) S) d$ B/ p8 LNonetheless, we do not believe our patient is
; w' O, j3 _3 \9 \9 S/ \5 Zgoing to experience any of the untoward effects from% `& m. X* o2 W/ A! u* `$ n& N8 r
testosterone exposure as mentioned earlier because
% P! L- {  ~) Q6 K( d1 Z, fthe exposure was not for a prolonged period of time.
* l! a  I0 }: `  TAlthough the bone age was advanced at the time of( `  |* T% x* R, [
diagnosis, the child had a normal growth velocity at
5 o9 y: G$ Z# y5 }the follow-up visit. It is hoped that his final adult8 Y2 K9 ?: A% {3 A8 n
height will not be affected.
: w( z6 ~) Z9 l# a, ?# iAlthough rarely reported, the widespread avail-" s+ N0 f. b9 H, e" @8 K7 m
ability of androgen products in our society may
, N+ l. n1 ^$ G. R7 V: S% Z) pindeed cause more virilization in male or female
% K/ @- h( j. S- z% N; P, ^children than one would realize. Exposure to andro-
# N/ ]# [. e0 Mgen products must be considered and specific ques-- p9 N( Z  m5 l6 ^
tioning about the use of a testosterone product or5 a6 I0 T& [8 o4 _2 N4 a' |
gel should be asked of the family members during3 a5 u/ A; R* X3 l
the evaluation of any children who present with vir-
' o0 E2 E0 r0 i/ W1 z- Cilization or peripheral precocious puberty. The diag-
0 B8 N0 R) o3 [+ tnosis can be established by just a few tests and by( H, B- d7 R" ?+ V
appropriate history. The inability to obtain such a
! v5 ^1 E' q8 A: t" u, F3 }0 [history, or failure to ask the specific questions, may
. c+ a) T% v9 t, h( D! G5 L  Z4 G2 n8 Bresult in extensive, unnecessary, and expensive
; ]# U* @! l3 K$ {5 @6 ^: dinvestigation. The primary care physician should be
  u5 U8 f* }2 O, t3 S) W  K( maware of this fact, because most of these children
2 }" q( Q  A- J& Hmay initially present in their practice. The Physicians’0 E' b$ v* q( Y" |3 y
Desk Reference and package insert should also put a
6 P2 Y2 Y: y: ?; _1 V3 |  {warning about the virilizing effect on a male or- B5 B$ O& o# J, {3 n
female child who might come in contact with some-
, _! r6 F% G6 Pone using any of these products.$ @) H6 }+ B; T) ^5 ?
References
: i# A# }! ]1 L: [9 y1. Styne DM. The testes: disorder of sexual differentiation1 K" q0 H/ O: Q5 Y9 }; _$ U& \% d0 g* \
and puberty in the male. In: Sperling MA, ed. Pediatric
0 M7 j) V- P) a: rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& O2 v! M/ i1 ~9 H2002: 565-628.
4 b" K; X' T0 l& l0 I- S3 Z, F2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! S: v) ^, R9 d, R
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
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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
2 @) e% @1 Z& v3 \" 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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