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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-Old9 K5 U8 C: B$ C6 b* k
Boy Induced by Indirect Topical+ h7 m0 m% O4 g' M3 c) B
Exposure to Testosterone
( g2 O3 }! x6 G- E% pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( r8 q% z# u$ R' B. j
and Kenneth R. Rettig, MD1" E$ e/ J* ]; L( N
Clinical Pediatrics$ o4 i  Q8 j5 Z' R5 H! F
Volume 46 Number 6
! t! f$ |% A3 P# eJuly 2007 540-543) ?" ~/ Z3 }: d
© 2007 Sage Publications
- o% a1 s9 `5 r" j$ X3 ]10.1177/0009922806296651
$ e  `2 i4 F& l% W& Hhttp://clp.sagepub.com1 N0 c' e0 j0 A
hosted at* W2 }+ j* V& v/ d7 y. v0 Y4 h
http://online.sagepub.com
# {2 S0 A6 z0 u  g" t. I- j* T7 `Precocious puberty in boys, central or peripheral,
( z& {7 |' r, H2 Nis a significant concern for physicians. Central% w( G# t7 K1 i5 v  P; a# h3 L
precocious puberty (CPP), which is mediated
* V8 P* C4 e! i7 Q. w+ q5 O. P% ?through the hypothalamic pituitary gonadal axis, has
/ c3 x+ V* y. @a higher incidence of organic central nervous system6 `& ]# M0 `; y! V
lesions in boys.1,2 Virilization in boys, as manifested( W* X; M1 Q* w# X8 A
by enlargement of the penis, development of pubic
! s4 V. D1 n5 o1 V' fhair, and facial acne without enlargement of testi-
/ ?) R9 S0 v0 p( A/ o& jcles, suggests peripheral or pseudopuberty.1-3 We
; q; j1 m3 k0 Mreport a 16-month-old boy who presented with the
/ ]  ~7 q( w( r% t+ j& i, renlargement of the phallus and pubic hair develop-; N0 {" }3 `. g* e) w' E
ment without testicular enlargement, which was due) `* t2 v" a0 B3 D. d) K9 z
to the unintentional exposure to androgen gel used by! O, f! g! @- z' Y% }! m
the father. The family initially concealed this infor-
6 A4 U7 e5 N5 _( Z# |mation, resulting in an extensive work-up for this
) ?/ f9 N& |; s. Kchild. Given the widespread and easy availability of
! w6 [) ]" N* P1 T; S" [testosterone gel and cream, we believe this is proba-
' h+ G" h4 U$ L- R. G; O$ @6 V, Gbly more common than the rare case report in the7 y- @* t1 o' k% r( o3 ^
literature.40 c! p: i( |6 @- z9 G8 I7 L
Patient Report  H- s/ A  f+ K
A 16-month-old white child was referred to the/ e3 D7 Y; ?8 L# f; y- G7 s
endocrine clinic by his pediatrician with the concern- s$ Y) V9 i2 W' L+ u
of early sexual development. His mother noticed
$ t. z8 @/ k4 b. Alight colored pubic hair development when he was5 F5 t; S  `3 b! Z3 O2 V: C: e: s
From the 1Division of Pediatric Endocrinology, 2University of
1 P5 I$ H4 @! g7 K3 O5 ], s# XSouth Alabama Medical Center, Mobile, Alabama.- D1 p2 z, e! I' r* m$ c3 u" y+ M& B
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 l- ?% P  d4 X4 pProfessor of Pediatrics, University of South Alabama, College of2 k* P1 ?0 |: G) K/ G; M, S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 X: x8 A/ l7 S( p; l. l( q
e-mail: [email protected].! K! L, l* _( w
about 6 to 7 months old, which progressively became
2 A+ H. W' R: ~; o# l( D# Ndarker. She was also concerned about the enlarge-
  e$ J# g' f. @ment of his penis and frequent erections. The child/ G% z( V' ]5 [' t+ d( z# ]; h9 m4 E; P
was the product of a full-term normal delivery, with, s$ B0 |, b0 ]/ T4 o3 B6 D3 h+ q- ~# @
a birth weight of 7 lb 14 oz, and birth length of
0 \5 K4 z( C% ?# X% u' g: J20 inches. He was breast-fed throughout the first year
( M9 G+ m6 m* k) G1 \3 Oof life and was still receiving breast milk along with
% w  @1 x7 B" L3 N# ?8 a5 C: R: w( Asolid food. He had no hospitalizations or surgery,
4 h. M4 k# |1 Z  nand his psychosocial and psychomotor development1 U0 I0 }; s3 D
was age appropriate.
" f* v# ]2 g/ f& i5 rThe family history was remarkable for the father,
, R% E2 G  ]3 t+ ]: J" ]who was diagnosed with hypothyroidism at age 16,
% {& D; Q% u5 \4 Cwhich was treated with thyroxine. The father’s
6 B" s( O2 d% A# K' ?2 `height was 6 feet, and he went through a somewhat2 B- e+ i/ p4 k0 V4 i! j& K
early puberty and had stopped growing by age 14.; ^  R1 a  t; q
The father denied taking any other medication. The8 O! H% W; z) x& M# v
child’s mother was in good health. Her menarche
: Q8 z" z6 L9 E2 A1 Y) j+ j# @. ]was at 11 years of age, and her height was at 5 feet+ A' z# ~! w" S
5 inches. There was no other family history of pre-
1 m: r! z% ~6 n4 k& t# e/ _cocious sexual development in the first-degree rela-
! W7 b, N0 Y$ z/ E1 O8 atives. There were no siblings.0 j! t9 i2 S, u5 |  V# K) p1 v1 A
Physical Examination* [, X; o* b, ~5 J3 w* `
The physical examination revealed a very active,
8 t6 B' @1 x7 E1 g. fplayful, and healthy boy. The vital signs documented) }8 h% T6 u6 G/ Z' U' j$ p6 P3 y
a blood pressure of 85/50 mm Hg, his length was+ }$ m! C, l4 _- t; A
90 cm (>97th percentile), and his weight was 14.4 kg7 b; G/ e7 i' d) ?' A& p  q
(also >97th percentile). The observed yearly growth
8 W/ n+ Y! @9 l7 zvelocity was 30 cm (12 inches). The examination of
0 Q/ {. n% S% i1 v, A, a2 ~the neck revealed no thyroid enlargement.
2 q" v& Z7 A- @* w# o0 l) Y, bThe genitourinary examination was remarkable for
; m0 J( f0 w4 X. denlargement of the penis, with a stretched length of- r# E/ u% a) b  e
8 cm and a width of 2 cm. The glans penis was very well
) |6 g/ d1 v5 Wdeveloped. The pubic hair was Tanner II, mostly around5 p0 e1 s$ n0 f" D, K
5407 u6 D& {0 Y8 D6 |$ f- _3 I  P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) X. x, `2 O) R& xthe base of the phallus and was dark and curled. The
, A9 x9 r& U! j* p0 Gtesticular volume was prepubertal at 2 mL each.
) }& R: t( Q! jThe skin was moist and smooth and somewhat9 c4 N0 |- C; G# v" Q# u7 B
oily. No axillary hair was noted. There were no
8 }$ B3 e- h; C- ^1 fabnormal skin pigmentations or café-au-lait spots.
+ A+ M6 m% `$ G1 \& CNeurologic evaluation showed deep tendon reflex 2+
& z$ {7 h6 i0 R. Kbilateral and symmetrical. There was no suggestion
: x( p" `# @6 z4 r% m* bof papilledema.
1 l/ T/ m$ i4 |' R/ ILaboratory Evaluation
$ ?- P3 {: ]/ O3 f" {The bone age was consistent with 28 months by5 ~, R% x8 [) _* L% U
using the standard of Greulich and Pyle at a chrono-
. g( o1 X: h. x9 jlogic age of 16 months (advanced).5 Chromosomal
3 _  \2 K. p/ e0 V/ S5 f2 B+ I  Bkaryotype was 46XY. The thyroid function test; t  j; U: M8 o# j5 v8 Q5 v6 o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% W( l2 |4 }$ K2 E% Glating hormone level was 1.3 µIU/mL (both normal).
4 a$ {0 A9 z" U$ m% S6 j2 r. T: o0 xThe concentrations of serum electrolytes, blood
* H0 V) c, j! |2 }/ Vurea nitrogen, creatinine, and calcium all were+ g6 ~3 x( k8 |
within normal range for his age. The concentration
$ ?" r9 \0 V6 F  n+ w5 m# ]of serum 17-hydroxyprogesterone was 16 ng/dL* t$ s  q# m4 Q& U/ h' }
(normal, 3 to 90 ng/dL), androstenedione was 201 ?( j+ e! Q+ i0 p* A5 x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 s% k+ E7 I' ^. |4 V5 ?1 rterone was 38 ng/dL (normal, 50 to 760 ng/dL),% D5 K. z5 Z( \% z! S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ P5 C1 J% t% f% c5 D/ W
49ng/dL), 11-desoxycortisol (specific compound S)% N6 A( b8 N7 H( I# w/ B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 Q/ Q. i! g8 A% Y4 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* b  S" q7 x; t  `! g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) @2 \1 r- I3 z: b- r% S/ i/ Sand β-human chorionic gonadotropin was less than& a* T& }0 n& w" u4 P3 x
5 mIU/mL (normal <5 mIU/mL). Serum follicular* a; K% Y+ u: Z
stimulating hormone and leuteinizing hormone
$ L6 R  h6 E. oconcentrations were less than 0.05 mIU/mL
% \* W/ F" m3 r4 q6 F+ U; b$ B(prepubertal).) r* x7 @0 \, @, ?
The parents were notified about the laboratory, E9 {$ r+ \, Y
results and were informed that all of the tests were4 N* O8 f, M; f# H! ~
normal except the testosterone level was high. The9 W1 F! w2 I' u9 u
follow-up visit was arranged within a few weeks to
2 X, Q2 B4 [$ |7 Lobtain testicular and abdominal sonograms; how-
: ?: w6 B; z! ^/ L' Lever, the family did not return for 4 months.
& f% i) C7 }# Z( jPhysical examination at this time revealed that the
8 i7 p) w. n+ s7 [child had grown 2.5 cm in 4 months and had gained6 H' {3 S4 V2 C7 q
2 kg of weight. Physical examination remained- q+ |3 m% o# h2 E7 p/ u0 L! e
unchanged. Surprisingly, the pubic hair almost com-3 g' a1 d2 g6 O' X; j. p
pletely disappeared except for a few vellous hairs at, u. Y# _7 `. o/ `1 k, w
the base of the phallus. Testicular volume was still 2
. e/ r& }# }6 e* |+ n5 P2 ImL, and the size of the penis remained unchanged.. X3 b3 A0 C1 }; S, I2 G1 C8 s- K
The mother also said that the boy was no longer hav-, u: V: _- Q: ^7 U0 N
ing frequent erections.0 O, A& ~( O4 n8 @% w5 ]
Both parents were again questioned about use of
2 P/ s$ }0 ^. _/ M* G& Vany ointment/creams that they may have applied to
/ T5 ?) N5 f% x: q( C; j- N, Zthe child’s skin. This time the father admitted the
6 z# s2 ^/ a$ c+ B% Z$ A" [Topical Testosterone Exposure / Bhowmick et al 541
% Q. L0 j0 r' f5 P( \2 b0 ?4 ]- Ause of testosterone gel twice daily that he was apply-: m5 [. r$ M% J, z/ e' Y4 z5 T
ing over his own shoulders, chest, and back area for+ o! d  m8 S' H6 t: ?
a year. The father also revealed he was embarrassed$ V, [0 `2 J# L
to disclose that he was using a testosterone gel pre-% r" |9 Y) @: t7 P" i
scribed by his family physician for decreased libido) ~; P# ?, g' ]/ ^6 d0 S
secondary to depression.+ W; G0 j. x: ^& r! T, e  W
The child slept in the same bed with parents.
& s. g2 C* l& U0 {% C$ o2 z, jThe father would hug the baby and hold him on his# x1 ~7 j' K5 S) a
chest for a considerable period of time, causing sig-% }4 X0 }* O" m5 J2 Y5 D
nificant bare skin contact between baby and father.5 f+ v4 l: m+ ^0 k; p; ~" T
The father also admitted that after the phone call,, n/ `9 G: x1 V5 l, I  S
when he learned the testosterone level in the baby
# z; g* E& U) y3 r. ewas high, he then read the product information* N" ]' ^; f" }" Q1 h" k
packet and concluded that it was most likely the rea-
9 m$ U  Z: d7 \$ d3 m4 l# Z. Gson for the child’s virilization. At that time, they5 i$ ?+ m+ T6 R% W! A+ f9 {
decided to put the baby in a separate bed, and the
" Z& m$ a% h4 D. Ofather was not hugging him with bare skin and had1 H9 A+ P& N$ p4 }5 o
been using protective clothing. A repeat testosterone7 G3 ]! U' O4 ~6 ~
test was ordered, but the family did not go to the
8 O' G% h! O* F; D; z& Olaboratory to obtain the test.8 C( U" G2 S) O) s+ C) C1 ^
Discussion* w! O9 P) N. j- F1 ?$ x
Precocious puberty in boys is defined as secondary$ A& u' Y4 d3 o. [) S6 t
sexual development before 9 years of age.1,4) d9 t. E! Q) Z7 E
Precocious puberty is termed as central (true) when$ R8 G/ j7 @6 M+ r& Y% W
it is caused by the premature activation of hypo-
( Z. w; I! E* t! J8 z2 xthalamic pituitary gonadal axis. CPP is more com-/ \  L2 y0 {! n  }! l
mon in girls than in boys.1,3 Most boys with CPP) s" {! F$ v8 f" ^5 b# r
may have a central nervous system lesion that is
* t, \1 \( F- f% c( A$ p$ {responsible for the early activation of the hypothal-
" }5 T. L. `/ ^" J: o2 P5 bamic pituitary gonadal axis.1-3 Thus, greater empha-
/ N8 D! q" U3 m, a3 Gsis has been given to neuroradiologic imaging in, ]  b0 S# W. @
boys with precocious puberty. In addition to viril-7 I, a6 K! d7 K. q( d1 b
ization, the clinical hallmark of CPP is the symmet-
6 H+ y' ]2 \. m# J* Erical testicular growth secondary to stimulation by
, {+ S, H8 o3 e; X2 a- D  rgonadotropins.1,3
1 w7 C3 s1 w2 N* R& k' x! o! rGonadotropin-independent peripheral preco-
( u) ]# m/ U8 N% @cious puberty in boys also results from inappropriate
) _4 E7 i& N( v4 I# @androgenic stimulation from either endogenous or" r& e0 s* }- e; z' u5 I+ F
exogenous sources, nonpituitary gonadotropin stim-3 T1 @% t' V) ~0 i; m4 c
ulation, and rare activating mutations.3 Virilizing
8 w0 L# x6 r: F% B8 f' j% E' Mcongenital adrenal hyperplasia producing excessive
0 J) a$ I' j8 u8 [adrenal androgens is a common cause of precocious/ K7 [+ t+ I: j5 U0 _3 @- Y
puberty in boys.3,4% V8 H# k) R, S0 I; ~0 ]) n* U% N) K
The most common form of congenital adrenal, o5 ~! l9 e; D
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ K! E' M9 [4 QThe 11-β hydroxylase deficiency may also result in8 M# }, e) v3 q) ^, c9 D* B
excessive adrenal androgen production, and rarely,
! j# R! z6 m, [) @/ Zan adrenal tumor may also cause adrenal androgen# j, ^* q. y- S. g$ Y1 O# M. ^
excess.1,3$ Y/ D1 T' k5 @/ G/ J+ w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- q3 u9 \) o: a5 k! R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, Y' d7 ^% t1 j" ^  I7 {( @5 h- ~
A unique entity of male-limited gonadotropin-4 B7 s: u, f! F6 ^7 k( _4 f* P
independent precocious puberty, which is also known/ Z( ]% o2 p4 M) Y7 l
as testotoxicosis, may cause precocious puberty at a
' P1 d1 M% `1 Z/ w1 ^very young age. The physical findings in these boys- }/ W0 b; m$ a
with this disorder are full pubertal development,
' ?( [( N* N, @& u, {including bilateral testicular growth, similar to boys* V  {7 u* J/ M) @- [
with CPP. The gonadotropin levels in this disorder% _! z! L& b4 y: [
are suppressed to prepubertal levels and do not show/ u# K$ ]' y% F/ ~- d. _
pubertal response of gonadotropin after gonadotropin-
( ^+ {  j( W- o+ h1 b/ Lreleasing hormone stimulation. This is a sex-linked
) y' p. s" f4 T' m6 z! K5 iautosomal dominant disorder that affects only" b9 p3 q; z/ K' a; g3 f7 r" ~! }9 F
males; therefore, other male members of the family/ y$ J7 c8 A, i8 R6 m
may have similar precocious puberty.3
/ v+ [  S' @* [  n  [# {; xIn our patient, physical examination was incon-& l' @4 X5 D& c, W$ _& X3 a
sistent with true precocious puberty since his testi-6 w- z, ~- r9 S3 A/ a. z* c, L' p& }
cles were prepubertal in size. However, testotoxicosis+ u4 c6 h7 o0 ]- p
was in the differential diagnosis because his father
9 d  Y' h# M0 ]# c" Sstarted puberty somewhat early, and occasionally,
0 x% Q7 p9 g9 F2 `- O0 utesticular enlargement is not that evident in the* Y: Y& H/ L3 v  g
beginning of this process.1 In the absence of a neg-7 y& P- D; X- h/ e0 [8 `0 S* R
ative initial history of androgen exposure, our# J) D2 y, \5 q( V1 |* n
biggest concern was virilizing adrenal hyperplasia,
7 ^! ?! n/ P- H( |+ b7 o4 S/ X' Veither 21-hydroxylase deficiency or 11-β hydroxylase
" z% ~2 v1 S3 y  H' zdeficiency. Those diagnoses were excluded by find-* N: A8 L* I. M6 l& d
ing the normal level of adrenal steroids.
1 r$ ?5 a3 C( pThe diagnosis of exogenous androgens was strongly
& }6 F$ w( w& osuspected in a follow-up visit after 4 months because
7 B- l8 _, ^8 o4 u8 Q* cthe physical examination revealed the complete disap-* l: ^; x2 S9 A- d
pearance of pubic hair, normal growth velocity, and
& ?, a, y7 c6 t6 C2 O6 kdecreased erections. The father admitted using a testos-
8 b+ ]! q; S; R7 e; u. `! oterone gel, which he concealed at first visit. He was
' h% d, \1 _* U  U/ N2 {' Vusing it rather frequently, twice a day. The Physicians’
" i$ g5 K5 J% p% R- xDesk Reference, or package insert of this product, gel or. H& o, C8 H3 g: B" k
cream, cautions about dermal testosterone transfer to
/ X: s9 J3 U- K8 w% [( J, qunprotected females through direct skin exposure.
. y. X( @% t% u) [Serum testosterone level was found to be 2 times the& O+ ~$ b; x( F" n. ]
baseline value in those females who were exposed to7 }5 p% k5 e3 M
even 15 minutes of direct skin contact with their male
5 K, i2 K: \( t- D0 zpartners.6 However, when a shirt covered the applica-
/ N! @& S% I; A  S8 D$ ^5 ation site, this testosterone transfer was prevented.
: t! Y- Y' \) J" D# MOur patient’s testosterone level was 60 ng/mL,+ X& l7 D8 k$ ^9 |" E( j/ s
which was clearly high. Some studies suggest that1 \1 I" [: n- \9 W
dermal conversion of testosterone to dihydrotestos-% p2 d* ?# i" |' ^" j6 h
terone, which is a more potent metabolite, is more/ b9 ^; J6 G- S9 A9 Q1 u6 O4 A5 s
active in young children exposed to testosterone
1 Y, v' j" k, W- S, a; kexogenously7; however, we did not measure a dihy-( \6 O; T' H$ J3 G
drotestosterone level in our patient. In addition to
5 v6 O$ |! W: w) ]) \4 ~virilization, exposure to exogenous testosterone in- s$ f+ ^% ~7 |# D" f
children results in an increase in growth velocity and- |6 s& B5 C. l( L( ]% _
advanced bone age, as seen in our patient.; H3 Z* C1 t  z6 k2 k
The long-term effect of androgen exposure during6 g% H; J. g9 `
early childhood on pubertal development and final
2 |% E+ A4 z! i; p( e$ ^/ Cadult height are not fully known and always remain
6 c( n  q3 b" a3 Na concern. Children treated with short-term testos-  a0 v! B& [7 U: Q6 o" T
terone injection or topical androgen may exhibit some
+ v7 s6 W% r$ b/ O' ?; Kacceleration of the skeletal maturation; however, after! O2 j; u& K8 @: o6 a
cessation of treatment, the rate of bone maturation
' z" v! r( j5 I" c+ [5 ydecelerates and gradually returns to normal.8,9
1 P) U/ f$ Z. i$ q, k+ O6 R2 xThere are conflicting reports and controversy
4 d, t- G! W2 D# y! jover the effect of early androgen exposure on adult+ N) [! ^8 G' o5 A# h  x( Q/ A2 b
penile length.10,11 Some reports suggest subnormal
9 k2 V: m) X4 R# [adult penile length, apparently because of downreg-
# ~7 Y2 D; A0 Yulation of androgen receptor number.10,12 However,5 L" y1 Y: h% i% q
Sutherland et al13 did not find a correlation between) A" F5 @9 I2 p- l% k8 }
childhood testosterone exposure and reduced adult
; ?0 l- h& v, `, c9 Cpenile length in clinical studies.' |  e# k9 B) M9 T: F. i3 r
Nonetheless, we do not believe our patient is1 A; f; {" x& q2 \1 C+ m; z
going to experience any of the untoward effects from- ?0 G2 V5 D  v, L1 }* v* r
testosterone exposure as mentioned earlier because+ {3 j( a9 ?4 @1 {
the exposure was not for a prolonged period of time.
- W+ q0 O/ n; p1 A1 E! d7 uAlthough the bone age was advanced at the time of
3 s. u. f& {9 [* _diagnosis, the child had a normal growth velocity at
( O2 u( L6 o1 h0 Wthe follow-up visit. It is hoped that his final adult
' S# r4 {6 l; W) Iheight will not be affected.5 l& ~1 A# a# i! q
Although rarely reported, the widespread avail-
; E! }2 e( X  g' O5 j6 m# v( `ability of androgen products in our society may
$ z: n* n5 u$ g8 `indeed cause more virilization in male or female8 f! v) W' @. X9 j
children than one would realize. Exposure to andro-$ M, a8 Y1 q+ G9 n' `+ ?
gen products must be considered and specific ques-
) B. p( E0 Q8 c2 X- qtioning about the use of a testosterone product or
. C8 K- R9 R7 T  Q. `% Qgel should be asked of the family members during
" p0 {# M& }( h4 v4 L5 Z4 jthe evaluation of any children who present with vir-
( A* i0 x, y) s, y7 |2 Z* U0 |ilization or peripheral precocious puberty. The diag-
7 x0 \' D3 m: J+ w# R) R: Wnosis can be established by just a few tests and by
0 U+ g( ]7 i( z( g! v4 Tappropriate history. The inability to obtain such a
0 F# E: k! K1 _& o8 H4 jhistory, or failure to ask the specific questions, may& N( R. P& s9 y8 W2 ~) L
result in extensive, unnecessary, and expensive
, t+ X( G1 A9 X, @( X' k8 I! linvestigation. The primary care physician should be  V3 x+ ]$ n* _
aware of this fact, because most of these children( T! P9 P: w4 c2 L1 `
may initially present in their practice. The Physicians’& z& _( b! ]) V1 o
Desk Reference and package insert should also put a6 C$ v, ^% L. P- K! ]2 _# Q2 z, @
warning about the virilizing effect on a male or/ C  l0 w' m: H; E
female child who might come in contact with some-
1 y+ p* t3 \& b, V0 d3 T' \one using any of these products.
: L& Z3 u" K1 u% P1 [- eReferences
2 F$ _5 r7 n# @5 R1. Styne DM. The testes: disorder of sexual differentiation
/ V) o4 g6 G# V4 Zand puberty in the male. In: Sperling MA, ed. Pediatric6 V! w! T( b: G3 E) j' O8 y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ V0 |* o5 _" k4 n9 [
2002: 565-628.+ @( D7 C; G# w# K7 p: Y+ U, y3 H& B: E8 {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 C0 I0 b8 P( E& H0 o# @/ a5 \
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
( C6 \1 @6 w3 `$ t0 C9 lBoy Induced by Indirect Topical  L$ X; Z% ], `" }# `
Exposure to Testosterone
& X. U6 Z4 U4 M+ C! GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ j3 b/ g7 @' }. ^% ?' Gand Kenneth R. Rettig, MD12 W# s1 @$ b: M' T/ N
Clinical Pediatrics, |* K; b9 j! }8 l
Volume 46 Number 6" P! N4 e4 y5 ?& m- C+ x2 C
July 2007 540-543$ W! Y, ^( X# C2 L0 x' R: Q
© 2007 Sage Publications) x3 c6 i! J' r2 g
10.1177/0009922806296651
- {5 m. V1 a5 }- X% V0 s! B! ^http://clp.sagepub.com
( Y% i1 X* v* Q) N; thosted at, W6 j! \0 R2 w
http://online.sagepub.com
3 x  ~, x6 a& R- p3 T8 _Precocious puberty in boys, central or peripheral,
( h2 X( B: I. qis a significant concern for physicians. Central6 s* G" l9 ?" O7 y# {3 G1 A
precocious puberty (CPP), which is mediated
# b0 x/ d/ T. n/ T  T7 fthrough the hypothalamic pituitary gonadal axis, has
' n3 O* q1 l: O+ Za higher incidence of organic central nervous system7 g! ?5 ]; n8 ?% V) m
lesions in boys.1,2 Virilization in boys, as manifested, N( o; ~8 |+ t7 Y
by enlargement of the penis, development of pubic( p! T3 D8 P* P" [# P  C
hair, and facial acne without enlargement of testi-$ r7 i0 H0 X' y7 [2 Z$ i) ]+ x( z
cles, suggests peripheral or pseudopuberty.1-3 We
5 l2 k' K/ j" ^report a 16-month-old boy who presented with the
7 n) `; n. t! h0 u) o' Oenlargement of the phallus and pubic hair develop-
; |$ Q5 {# e3 k: E. u) Pment without testicular enlargement, which was due; i$ T5 z! ~- f4 O4 q
to the unintentional exposure to androgen gel used by
% |4 H  G3 \, P# N# j8 G! ?the father. The family initially concealed this infor-8 o1 g% O0 A) R6 Q9 ^
mation, resulting in an extensive work-up for this
3 ^; K' m  t3 Kchild. Given the widespread and easy availability of
* v$ ^  z7 m/ X3 |testosterone gel and cream, we believe this is proba-6 x8 Z  d9 R3 l( O+ e9 Y+ `- K
bly more common than the rare case report in the* h) N- D1 e6 K( n  G
literature.4* Z: M- N/ T& o- R; t  ]* l0 v
Patient Report0 r3 `/ P; n3 [2 `
A 16-month-old white child was referred to the
& T% n2 U2 i3 j# C( H! `/ Iendocrine clinic by his pediatrician with the concern" U  J1 C; [( M( C. }! x
of early sexual development. His mother noticed( D6 F+ {" x. B& f6 J( C
light colored pubic hair development when he was
% D5 ?5 {& J3 Q  r. a7 EFrom the 1Division of Pediatric Endocrinology, 2University of
( Y4 e/ h5 _" E% {) e: oSouth Alabama Medical Center, Mobile, Alabama.
- N( p! f: m' Y$ {+ l! O9 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 k& X2 G6 I' e, }3 P) yProfessor of Pediatrics, University of South Alabama, College of# e8 _5 n  u0 z9 V- Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- L7 J6 B+ |* e: D1 S, ~5 ae-mail: [email protected].
" w6 B1 {% P- ^/ Y$ pabout 6 to 7 months old, which progressively became
$ H& K& _- ?( i9 D8 l3 Ndarker. She was also concerned about the enlarge-( l; @* D/ f% N! o3 X% `2 F
ment of his penis and frequent erections. The child. {* K+ m# |8 F+ P, L3 K
was the product of a full-term normal delivery, with
) [0 k1 c8 Y# A% d4 Z& ya birth weight of 7 lb 14 oz, and birth length of
: c7 R8 a! U5 D' L5 t20 inches. He was breast-fed throughout the first year7 ?" p  S/ ?4 B- S
of life and was still receiving breast milk along with
( U/ S& M- c4 ~solid food. He had no hospitalizations or surgery,
4 E# L$ u0 c7 ~# ^6 N  Band his psychosocial and psychomotor development& R$ f6 |# B, W
was age appropriate.& r6 b7 i* n1 b/ T7 d' k
The family history was remarkable for the father,
0 _( ]' e+ R  v1 K3 {  h! Jwho was diagnosed with hypothyroidism at age 16,/ ^5 r! [& p- u% B2 w
which was treated with thyroxine. The father’s
! J' J" ^* s$ \height was 6 feet, and he went through a somewhat
% E5 t2 X  j$ ^% n% m) p" Mearly puberty and had stopped growing by age 14.! d& n& W/ L' X  Z+ S
The father denied taking any other medication. The" ^6 R3 u6 V8 i5 [1 W: T
child’s mother was in good health. Her menarche
' X6 X- m* V( ?8 qwas at 11 years of age, and her height was at 5 feet; d% H3 i- i% K( z; \6 Y+ X6 t: r
5 inches. There was no other family history of pre-- Z2 d5 x% p( c$ D6 T
cocious sexual development in the first-degree rela-% R( a2 J. d6 h0 E# c
tives. There were no siblings.) D8 S. O1 t4 |! O4 ^# i3 z- v
Physical Examination
1 N$ Q% {. j; h6 \) {The physical examination revealed a very active,4 Z: i0 ~. L7 \$ U
playful, and healthy boy. The vital signs documented+ X% I% H$ R) U2 |, L
a blood pressure of 85/50 mm Hg, his length was0 U2 {. B$ Q+ x
90 cm (>97th percentile), and his weight was 14.4 kg
2 D  H  v+ r6 E: }; S(also >97th percentile). The observed yearly growth0 U: L4 B+ Q# u- }' c
velocity was 30 cm (12 inches). The examination of/ V- b- U2 ]; q+ j" \
the neck revealed no thyroid enlargement.) [) F1 B( O' s8 `5 o  x3 R9 p
The genitourinary examination was remarkable for* s) K- N% U7 W" P3 _
enlargement of the penis, with a stretched length of& `2 u- ?& T# h* J
8 cm and a width of 2 cm. The glans penis was very well  m% b8 m8 L% Y- s- @& Y
developed. The pubic hair was Tanner II, mostly around
0 ~( G. o& L5 c( t7 t8 u540" E& \- Y, W. f0 y! H8 Y% F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 q* Y' M0 {* ]6 D% _. Ethe base of the phallus and was dark and curled. The
. J: _$ t" p: K7 l" htesticular volume was prepubertal at 2 mL each./ e3 v  _6 x+ ^
The skin was moist and smooth and somewhat
: E6 x) E# u3 N# V" S) M; ^oily. No axillary hair was noted. There were no8 `6 \1 |/ k$ y$ F" \3 {4 L
abnormal skin pigmentations or café-au-lait spots.+ U$ m, Q' j; h# L
Neurologic evaluation showed deep tendon reflex 2+# v4 z! _" e  Y' J6 f6 [
bilateral and symmetrical. There was no suggestion; x& R$ A1 W; {& ^+ p' f' ^
of papilledema.
; ~5 P$ n$ ]+ j8 F9 q8 G! I6 ILaboratory Evaluation
2 c8 w1 F3 B% DThe bone age was consistent with 28 months by
. p; `7 S* i, E. V! z! z" uusing the standard of Greulich and Pyle at a chrono-; }" g2 j  M& O# n4 J7 t/ D
logic age of 16 months (advanced).5 Chromosomal
' S9 Z  K0 V+ P2 h5 gkaryotype was 46XY. The thyroid function test
" s4 \. t4 o, [showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 Y5 P& W. ?, \* }  T# b' R
lating hormone level was 1.3 µIU/mL (both normal).
! E" d' a  h# p  rThe concentrations of serum electrolytes, blood. {/ R$ N5 t" b/ P5 B
urea nitrogen, creatinine, and calcium all were" I; G; b4 H+ ~! G
within normal range for his age. The concentration
: m! [/ }: N! w- nof serum 17-hydroxyprogesterone was 16 ng/dL. F  t4 W3 a  S9 F5 D' J8 Z
(normal, 3 to 90 ng/dL), androstenedione was 20
& H' m+ m$ S& k. l' ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' @# ~; Y9 K. e1 X' y* @/ I  M; V& Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ W2 V3 s: ]& @+ c! D2 O2 P* sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
% e6 Q/ `- t; ^- N4 T49ng/dL), 11-desoxycortisol (specific compound S)
$ i0 I' ]8 D' R' |, x/ w: Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' A1 F* g5 r2 j5 {7 [: b+ ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 H7 R- I6 R0 s/ `* d" i9 _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* Y7 ~$ O& h# N$ W8 Yand β-human chorionic gonadotropin was less than7 r3 J4 q/ X2 y5 E- ]6 f* f
5 mIU/mL (normal <5 mIU/mL). Serum follicular; b* {+ H+ }. @, T# N
stimulating hormone and leuteinizing hormone
/ @( g4 }8 q' j# v8 |0 Oconcentrations were less than 0.05 mIU/mL
: o; Z6 t4 a0 K(prepubertal).
5 a$ Q* E" T1 l; y( h0 LThe parents were notified about the laboratory; L% O/ k' T/ L& X6 p" Q% A4 p% x
results and were informed that all of the tests were, O$ U: ~. h  X
normal except the testosterone level was high. The" t# c% T9 A9 Z, }$ `, w) B
follow-up visit was arranged within a few weeks to
3 [4 l* G( d1 B) K/ b" Gobtain testicular and abdominal sonograms; how-
& y. B; t) i$ b. O* Y+ Fever, the family did not return for 4 months.
% n7 q' f9 J1 W* lPhysical examination at this time revealed that the
0 o% @0 [" i9 ]0 Lchild had grown 2.5 cm in 4 months and had gained% X/ w( O7 s0 y* t& A2 P- t" L
2 kg of weight. Physical examination remained
  C0 k7 a0 i0 F% ^$ {% vunchanged. Surprisingly, the pubic hair almost com-
! l0 n' q. s, D: |! b' ^3 B( Ypletely disappeared except for a few vellous hairs at4 G4 ~4 _5 [# L3 @: q0 u
the base of the phallus. Testicular volume was still 2% _  ^. Q7 [1 Z7 t
mL, and the size of the penis remained unchanged.
8 @2 v1 s: u2 G  T% NThe mother also said that the boy was no longer hav-
, t& E9 H0 m: xing frequent erections.
0 }! ^0 P, u5 UBoth parents were again questioned about use of
5 |2 j3 i7 ?* @0 g" t. `0 e& l6 Jany ointment/creams that they may have applied to$ K0 K* P1 D2 r9 t. E1 R6 \
the child’s skin. This time the father admitted the
% i- H% C% w4 J3 VTopical Testosterone Exposure / Bhowmick et al 541
6 r/ @2 f; W9 m% Iuse of testosterone gel twice daily that he was apply-! M+ [: j1 Q. r  V$ C" I
ing over his own shoulders, chest, and back area for" z0 {$ R* ?5 M
a year. The father also revealed he was embarrassed( h# b. n5 i1 N; U
to disclose that he was using a testosterone gel pre-: e6 F! k+ W* E
scribed by his family physician for decreased libido
' g; A* g6 V; k, b; ysecondary to depression.
0 {4 s0 t4 B: H( j9 h8 x0 y  hThe child slept in the same bed with parents., ]( X! B7 A: ?, j$ @# Q
The father would hug the baby and hold him on his# X' l6 M3 Q: t, Y% y* F
chest for a considerable period of time, causing sig-  j2 d  k# U! r1 N7 n1 I5 Z
nificant bare skin contact between baby and father., E. `& V0 Y5 ]! q5 n5 ]
The father also admitted that after the phone call,; Q3 k2 c7 h" C1 @$ H  h6 b
when he learned the testosterone level in the baby
- K: m4 k7 |! q$ O+ H( `- E6 |. Lwas high, he then read the product information6 _3 }3 x  e! c' }: H
packet and concluded that it was most likely the rea-9 r& b8 c/ c% ?, z% _- Q  C
son for the child’s virilization. At that time, they8 i! ~" ]- X( e4 T* e
decided to put the baby in a separate bed, and the
/ N( \* ~9 F5 e" S. v2 B& a# E! a/ kfather was not hugging him with bare skin and had* Y9 s4 S$ l2 ~$ [! w3 M5 h# ?
been using protective clothing. A repeat testosterone
% }. u! K8 `0 U6 K% J3 Qtest was ordered, but the family did not go to the; u$ e. K* ~' s; q" X% Y
laboratory to obtain the test.
$ t- j. L3 H; r4 w% r6 jDiscussion5 u5 T6 k2 R8 M4 b9 ]4 x" N
Precocious puberty in boys is defined as secondary
$ g, Q6 T) \- O: Rsexual development before 9 years of age.1,4! b! k" P( i% F0 b0 l1 p
Precocious puberty is termed as central (true) when: A( e6 Q; g$ s: @' K1 n
it is caused by the premature activation of hypo-/ \+ d) i2 C/ D+ Y
thalamic pituitary gonadal axis. CPP is more com-* `% I1 O+ z- t" L: K: x
mon in girls than in boys.1,3 Most boys with CPP/ Q( d' ~/ o; u4 [. N1 y% G: E3 b
may have a central nervous system lesion that is
' M0 M% U& c  l' l' |responsible for the early activation of the hypothal-. u+ h7 I8 F, ?0 ~( x
amic pituitary gonadal axis.1-3 Thus, greater empha-3 z9 g# w% U! k2 V
sis has been given to neuroradiologic imaging in
! c' [5 I3 e9 Pboys with precocious puberty. In addition to viril-/ Y" |- Z1 @1 N7 h6 z
ization, the clinical hallmark of CPP is the symmet-% ?  y$ p) x( o9 w* k
rical testicular growth secondary to stimulation by( S# F/ d% V. h0 c7 @, }: t4 A
gonadotropins.1,3
2 Q- A$ H" Q/ v  W! E# T+ }; u0 ?Gonadotropin-independent peripheral preco-
$ S% ~" s9 i4 q# T1 Q) L4 }cious puberty in boys also results from inappropriate: L4 j4 U; `  q! s
androgenic stimulation from either endogenous or+ {; B7 Q0 E/ B$ c8 R8 b
exogenous sources, nonpituitary gonadotropin stim-2 p' U, I: B  |3 Y& x
ulation, and rare activating mutations.3 Virilizing
. i, ^( R5 v8 m* x' ?8 ]2 Xcongenital adrenal hyperplasia producing excessive
" e  H* S5 V& g# C% G6 Iadrenal androgens is a common cause of precocious
! v: t  O& v4 ^/ m: Upuberty in boys.3,4, \, r& ~: \1 G& g' A" i7 O' [+ \
The most common form of congenital adrenal9 K! O( L) a1 o3 r; [. Y
hyperplasia is the 21-hydroxylase enzyme deficiency.
% g5 M& p  N0 L. o( _7 D& aThe 11-β hydroxylase deficiency may also result in. r2 r+ r* b& a! r
excessive adrenal androgen production, and rarely,
# h) d7 w0 @1 D  `an adrenal tumor may also cause adrenal androgen2 c+ T) T9 N6 i  L+ K
excess.1,3
3 ?# {: ~) ^" r7 z# {( Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) ~+ P) C4 I, v  a4 w6 }" ~7 M7 Z542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 y: |/ a2 C; Z: C1 q
A unique entity of male-limited gonadotropin-
+ g- ~* P7 D4 P$ c8 @5 K# B& ~9 gindependent precocious puberty, which is also known, f" D. \( ?! s
as testotoxicosis, may cause precocious puberty at a' S2 t1 v0 S3 |# R% A/ s
very young age. The physical findings in these boys
' D1 Y, G( d5 H! B6 Cwith this disorder are full pubertal development,9 D1 [0 C8 k* ]4 @3 H% }( m  [
including bilateral testicular growth, similar to boys
) ~# q# P! w+ Q8 ~$ Twith CPP. The gonadotropin levels in this disorder# Z0 X$ O& t% m
are suppressed to prepubertal levels and do not show
; O  |$ ]: G& B" dpubertal response of gonadotropin after gonadotropin-+ d* n2 b/ F6 C4 o3 U
releasing hormone stimulation. This is a sex-linked
$ W$ s5 q2 i+ h  q, T8 x4 W1 \autosomal dominant disorder that affects only$ I9 Z8 @$ @) S0 ?
males; therefore, other male members of the family
8 r* F* d8 t; L4 |7 p9 S0 dmay have similar precocious puberty.34 s: h4 r8 l0 I7 k7 s9 ~
In our patient, physical examination was incon-
! X; B$ `( Y! p9 k# isistent with true precocious puberty since his testi-* Y. v7 H( z: I: [9 g
cles were prepubertal in size. However, testotoxicosis
- c- J! Z' T& Owas in the differential diagnosis because his father
- X! d2 \3 }1 Rstarted puberty somewhat early, and occasionally,9 i. e( z. V: E) O
testicular enlargement is not that evident in the3 s6 e% g. ~. K% D. S
beginning of this process.1 In the absence of a neg-' R8 Z9 `2 D8 w
ative initial history of androgen exposure, our
  O" M2 A0 j9 ~, ^  c$ ?9 n3 Gbiggest concern was virilizing adrenal hyperplasia,
9 n) M; E9 u: ~6 {0 H) deither 21-hydroxylase deficiency or 11-β hydroxylase5 _# C0 m3 y+ C: `) l& y1 l- x7 M
deficiency. Those diagnoses were excluded by find-0 r- e8 C4 g% g1 Z- n8 A" B2 J% w
ing the normal level of adrenal steroids.
/ d& @( B$ M4 x, D' E3 W1 u+ V# Z- EThe diagnosis of exogenous androgens was strongly  |8 S0 M  ~- q4 A
suspected in a follow-up visit after 4 months because
$ D7 r  A$ Z' W; r# f: mthe physical examination revealed the complete disap-' w$ \6 i7 q& ~  x
pearance of pubic hair, normal growth velocity, and
% F: F' H+ S( u, w3 wdecreased erections. The father admitted using a testos-
8 l: _1 ?* g; q) S, U+ tterone gel, which he concealed at first visit. He was
: J+ ?- \. c' t, u2 uusing it rather frequently, twice a day. The Physicians’
6 P, C) @/ w2 R$ k! a6 LDesk Reference, or package insert of this product, gel or
7 _- T' }, p1 K& l& p0 u9 fcream, cautions about dermal testosterone transfer to
8 i. D' u% {; T4 G( i. z5 H6 uunprotected females through direct skin exposure.
7 V+ P  a: ~' w: i. \+ o/ bSerum testosterone level was found to be 2 times the
! @, k4 [+ ^+ Obaseline value in those females who were exposed to
; G! f5 ^. Z/ N6 h3 h- g: [, Qeven 15 minutes of direct skin contact with their male
/ G% \  X# J% z. r0 Z; o' Dpartners.6 However, when a shirt covered the applica-4 F2 o9 c- f7 Y6 q4 H5 \
tion site, this testosterone transfer was prevented.
6 l6 o! O  [/ j. L9 n# qOur patient’s testosterone level was 60 ng/mL,
: m0 T" ?5 s4 s- r9 @4 ~which was clearly high. Some studies suggest that
8 E# o: z+ \3 F: o1 Ydermal conversion of testosterone to dihydrotestos-
5 L& U" X' {: u) C! tterone, which is a more potent metabolite, is more% m" v+ S( }9 S4 ^# S- x- N
active in young children exposed to testosterone
' s6 F/ |# q8 Y) h8 [) Oexogenously7; however, we did not measure a dihy-
- J6 K5 r) |0 Zdrotestosterone level in our patient. In addition to2 N* J2 ?% B) k' T9 }- f
virilization, exposure to exogenous testosterone in
( C- ]3 s3 U  Y% R* i  pchildren results in an increase in growth velocity and
1 n- x0 \- W; t0 Q+ t5 |, iadvanced bone age, as seen in our patient.
# e! I6 f4 T7 T$ c; Y" SThe long-term effect of androgen exposure during2 U6 }3 U( n! c9 e7 A$ }
early childhood on pubertal development and final
3 p+ a1 ^6 p4 ]0 g' O1 d& ^adult height are not fully known and always remain
3 Y6 @4 b( g* S. H. [' Ca concern. Children treated with short-term testos-+ P7 q& h. k: D$ L2 e% d
terone injection or topical androgen may exhibit some
. }- G5 D0 A* }, B6 zacceleration of the skeletal maturation; however, after" T4 B  E! Q8 J0 t& M0 [
cessation of treatment, the rate of bone maturation
9 |1 V! i* [: q! ]. o  d5 qdecelerates and gradually returns to normal.8,9
5 @/ l7 R5 E  a9 |There are conflicting reports and controversy/ k, W0 F, [4 L' A" J
over the effect of early androgen exposure on adult
# r  x- I/ t4 Vpenile length.10,11 Some reports suggest subnormal. R1 j8 n/ `, S. F9 C( t4 |
adult penile length, apparently because of downreg-; c3 ~  {! x. _( U, H) W
ulation of androgen receptor number.10,12 However,) `/ [5 g/ \$ ^
Sutherland et al13 did not find a correlation between) B. G$ A# O  ?0 R2 }1 r6 j7 t
childhood testosterone exposure and reduced adult
: f; E1 I  F) g" F, ]1 ]penile length in clinical studies.
, i! g: _- N/ ?- |  D% eNonetheless, we do not believe our patient is
1 t& E4 F0 c, v( m& j' B+ ?going to experience any of the untoward effects from
" k& G; J& b0 u( ltestosterone exposure as mentioned earlier because1 S+ e  V$ ?' @
the exposure was not for a prolonged period of time.) s" {8 e# K/ K  U* M# a- p& I  X
Although the bone age was advanced at the time of
. a$ G& d$ d+ [3 Bdiagnosis, the child had a normal growth velocity at; U5 B) c  O% V' f2 B% a1 [9 p
the follow-up visit. It is hoped that his final adult& N! o/ K8 M) L/ B
height will not be affected.
, ^! y. x8 K! o1 P( RAlthough rarely reported, the widespread avail-- f' C" q$ ^1 ]' F/ N0 L. H
ability of androgen products in our society may
& n& @4 B: x% `. sindeed cause more virilization in male or female: L: d$ b- A7 X3 h8 ], `
children than one would realize. Exposure to andro-! o$ O! L8 J4 X  L
gen products must be considered and specific ques-
' D8 Z1 o; w2 _2 T/ n' utioning about the use of a testosterone product or
6 X2 P0 S2 S! I" t' ^. Agel should be asked of the family members during
0 i) P- g' E% n2 B' Lthe evaluation of any children who present with vir-- _# ]8 @2 H9 B5 E6 c1 p) [) N
ilization or peripheral precocious puberty. The diag-  }5 [, s, H* y$ o
nosis can be established by just a few tests and by# g2 A$ M# |0 a9 U
appropriate history. The inability to obtain such a
! i( g/ @% ]/ [: p( nhistory, or failure to ask the specific questions, may: G3 M- X8 L0 `0 |9 p
result in extensive, unnecessary, and expensive; ~5 z3 y; m/ u  ]3 ^
investigation. The primary care physician should be+ V7 p4 G4 \( v' b
aware of this fact, because most of these children
3 `+ ^4 c. T* y! A* M# ~may initially present in their practice. The Physicians’1 }+ l! x8 m! q% r! q$ g  a! w
Desk Reference and package insert should also put a
, Z1 z8 G$ ?6 u) G* `% B; |warning about the virilizing effect on a male or, W' X; K7 q4 T9 W& l4 y/ ]
female child who might come in contact with some-; k; m: e( G/ {; q
one using any of these products.
6 E+ X1 R  s: {: j, E) oReferences  u  D4 p" u0 H6 d
1. Styne DM. The testes: disorder of sexual differentiation5 s: i( j6 c+ U3 o, n! B
and puberty in the male. In: Sperling MA, ed. Pediatric6 b, o) l/ _( g" J- w- }3 l+ x1 ~) w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  s, i+ S1 \. t) F& V/ {2002: 565-628." P. _3 R+ o# Q9 }% Z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* \# z) j- T: m& ^$ S* ]% _) ipuberty 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!
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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
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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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