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鄉下的妹子太便宜,一次四個都要了[12P]

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Sexual Precocity in a 16-Month-Old$ _9 u& `: p- b: q8 [
Boy Induced by Indirect Topical
3 w5 R6 ^# }4 H+ DExposure to Testosterone% V( ^6 }* G' ~2 H; z0 W. H
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 Y5 u2 Q$ g, S; u2 B: vand Kenneth R. Rettig, MD16 W6 |  Y3 g. y1 O/ g! b5 b. f7 T3 v
Clinical Pediatrics
; K: d% T, K7 p& P/ u* f$ aVolume 46 Number 63 V* {+ ~8 a) T3 p! [( {( V7 w
July 2007 540-5436 u; v1 }+ L: k  `
© 2007 Sage Publications6 W9 u8 M0 D5 }7 Z
10.1177/0009922806296651
. L( E. w- a, U6 w* _+ Zhttp://clp.sagepub.com+ k8 r' c* k% h: x9 b
hosted at
) k% e" @5 ?: Z# K: o" n  V7 Y0 Mhttp://online.sagepub.com5 p2 I! x7 h2 Q" t
Precocious puberty in boys, central or peripheral,
1 {. ]1 ~: g, F9 G) cis a significant concern for physicians. Central
1 b5 Y9 d. i5 b9 Y' J+ Kprecocious puberty (CPP), which is mediated
, `6 D0 i. ]% n5 Dthrough the hypothalamic pituitary gonadal axis, has8 J. O6 G4 V$ h; }4 M4 c2 I
a higher incidence of organic central nervous system/ q4 m5 s4 n3 w' Y6 s0 B6 R
lesions in boys.1,2 Virilization in boys, as manifested
) l# {% f2 H7 _- R! i8 ]7 u$ lby enlargement of the penis, development of pubic
/ w; Q" n5 e. p& P* ]* N% |. H' Hhair, and facial acne without enlargement of testi-
: t9 M4 m- E4 O  \3 f* W% dcles, suggests peripheral or pseudopuberty.1-3 We
: n+ B/ W7 ^1 b( oreport a 16-month-old boy who presented with the
, x4 O8 S3 S, Z* P# Jenlargement of the phallus and pubic hair develop-
  F" k/ b, m0 S* t  l/ F( h: [$ Tment without testicular enlargement, which was due9 z1 e9 }/ l* G) ~/ D1 E( y
to the unintentional exposure to androgen gel used by
0 D0 U1 s9 m& k) T/ xthe father. The family initially concealed this infor-9 ?' }* `; F  X4 l2 Y  y# T: w
mation, resulting in an extensive work-up for this. y$ E* f1 L' h/ N1 i1 q" e3 T
child. Given the widespread and easy availability of
# T8 C8 r0 e; {7 ntestosterone gel and cream, we believe this is proba-
# _/ b0 |- S: g* |4 Obly more common than the rare case report in the
9 M7 U( T* l6 |& F( ~, M. Sliterature.4
& a% E8 [2 n8 c) y5 LPatient Report5 Z3 F6 d" W0 U: }
A 16-month-old white child was referred to the1 P: X. `0 ^; [6 q3 i! \# p
endocrine clinic by his pediatrician with the concern, v/ {7 C! b* d4 Q* x. b
of early sexual development. His mother noticed6 i7 n+ q) g1 a/ p% ~
light colored pubic hair development when he was$ i) H, Z, H6 D  c: c$ e" y7 u
From the 1Division of Pediatric Endocrinology, 2University of
% ^/ T6 Z& Q" h# ]# M" uSouth Alabama Medical Center, Mobile, Alabama.
& L& L* s, W" G6 ~" D+ ]: M! HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 B$ B4 `; V4 r' DProfessor of Pediatrics, University of South Alabama, College of
& U5 c  k, e7 w9 Q$ o$ JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; P/ \- b7 t; J& e  o, P2 c1 Ye-mail: [email protected].5 N9 M. a9 V8 V2 q( A: k
about 6 to 7 months old, which progressively became
7 }; k" t3 Q2 L; @  _darker. She was also concerned about the enlarge-
/ S1 Z2 g$ Z5 e7 v% j$ `ment of his penis and frequent erections. The child
1 l$ n1 o( z5 j/ Z* Q5 A, l" G6 Fwas the product of a full-term normal delivery, with- }6 L! z# S5 o% w# \) K5 \
a birth weight of 7 lb 14 oz, and birth length of4 f; c& T" y. w/ F
20 inches. He was breast-fed throughout the first year
9 {; }/ S  N9 _8 iof life and was still receiving breast milk along with" Z; w3 d/ e7 b4 ]' |% c5 O/ u
solid food. He had no hospitalizations or surgery,5 J" U7 x  r  N: I8 Z% O
and his psychosocial and psychomotor development9 |+ k& ~5 e0 T5 c. Q
was age appropriate.& S) P, j7 ~, E7 t3 Y9 X5 p6 S  ~! c
The family history was remarkable for the father,5 `% X2 N! D4 ]( p6 X$ l
who was diagnosed with hypothyroidism at age 16,
& `) r+ H& I- Twhich was treated with thyroxine. The father’s
! |/ s7 Q3 c* L$ A& kheight was 6 feet, and he went through a somewhat
- F. W4 }$ U$ k; y& Vearly puberty and had stopped growing by age 14.
; B, \& |; R7 |The father denied taking any other medication. The, n( ?; j* l) ]- ~
child’s mother was in good health. Her menarche' [( [" B7 U2 {" s. k& O
was at 11 years of age, and her height was at 5 feet# x; ?, Y8 @& L( L7 Y% o/ y
5 inches. There was no other family history of pre-, p" Z9 ]$ H7 n$ _! f& E$ G" c
cocious sexual development in the first-degree rela-
2 y! h: K8 b' l2 Y3 [tives. There were no siblings.
4 z6 |$ b3 H! Z+ Q+ q" T  XPhysical Examination
' n* o( B' @) P/ p4 v: DThe physical examination revealed a very active,: K8 P& B- i) [1 r- [
playful, and healthy boy. The vital signs documented
, @) r" ?* p5 i4 u$ X, W' q% m  Za blood pressure of 85/50 mm Hg, his length was8 `( ]. W; E; k3 a- R
90 cm (>97th percentile), and his weight was 14.4 kg
/ j  e0 c1 k, |- J! Z; U- {(also >97th percentile). The observed yearly growth
( a$ |" a5 _( w" v7 ^6 evelocity was 30 cm (12 inches). The examination of, L8 ^$ M0 |+ _* P' U$ t
the neck revealed no thyroid enlargement.
4 `4 A: B. R+ R- ^: B* lThe genitourinary examination was remarkable for
3 s# C1 B6 V+ s; O, m8 fenlargement of the penis, with a stretched length of0 Z: T. p- v2 j# b; j; \
8 cm and a width of 2 cm. The glans penis was very well( N& `* R' I+ ]& ~, g, E. m! p
developed. The pubic hair was Tanner II, mostly around' N5 F4 k0 l* r
540' D1 Q9 k9 U( Q0 ^% t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 f+ u. P: S; P8 _7 t2 v- V& X% ]
the base of the phallus and was dark and curled. The
2 U2 f  f7 X7 E; |testicular volume was prepubertal at 2 mL each.
( M/ \9 B: x! A/ O2 YThe skin was moist and smooth and somewhat* Z7 o& [  {# b! G5 y1 v% J! l9 h
oily. No axillary hair was noted. There were no
% y8 @5 }* P- y" m' O7 ^3 {& [5 Wabnormal skin pigmentations or café-au-lait spots.
' s  J! U2 }4 e, P6 ANeurologic evaluation showed deep tendon reflex 2+
4 [% @2 n) t5 u# d' obilateral and symmetrical. There was no suggestion
0 H& j, k" d6 j5 y# Kof papilledema.
! m# z7 a4 n$ u* k0 ]Laboratory Evaluation2 ~* W- @4 L8 [- J, s# m3 u8 m
The bone age was consistent with 28 months by
+ w. o9 B8 x/ U' vusing the standard of Greulich and Pyle at a chrono-* g  w( }6 G% R3 b
logic age of 16 months (advanced).5 Chromosomal" l6 y) y; e( ~& ~/ P$ U
karyotype was 46XY. The thyroid function test. Y6 }5 x* {4 a# [; e
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* B1 m/ j# t: C1 L# n
lating hormone level was 1.3 µIU/mL (both normal).
0 f# r0 x% d. \/ ~$ [The concentrations of serum electrolytes, blood
  m- n$ v2 v: Aurea nitrogen, creatinine, and calcium all were. B6 E. v+ I. l- S
within normal range for his age. The concentration5 k( p* @: B# [4 ?3 n% g
of serum 17-hydroxyprogesterone was 16 ng/dL9 \0 a$ \1 O& n% ?# A
(normal, 3 to 90 ng/dL), androstenedione was 207 s0 u; _/ U6 M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 i% K# v) S7 p& D( cterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 ^' p7 T, Y% ~* T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- T; v0 D" x7 t" B49ng/dL), 11-desoxycortisol (specific compound S)! e8 D) Z: ~. d: x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: }% n9 q. i0 @- Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ A2 N% X) j, o8 d3 ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* J3 ^- H3 P" q& Z4 g: Tand β-human chorionic gonadotropin was less than
4 e0 c/ |. L/ e% ^1 x5 mIU/mL (normal <5 mIU/mL). Serum follicular
( A1 v2 N2 ?+ _+ K; L4 I: \6 xstimulating hormone and leuteinizing hormone) F" H% }% e! x% K
concentrations were less than 0.05 mIU/mL
5 v3 X# E/ ]6 e$ p/ e(prepubertal).
3 ~1 v7 r+ }3 \7 UThe parents were notified about the laboratory9 C0 T+ s2 W' C
results and were informed that all of the tests were' C1 g% g" }9 F$ i' I+ K  d7 Z
normal except the testosterone level was high. The. Z% T" ^+ h: R# j3 X/ Z8 F: ^
follow-up visit was arranged within a few weeks to
6 @2 [$ q2 r3 n8 J. r  Nobtain testicular and abdominal sonograms; how-
1 M+ X& A7 b2 z2 R, pever, the family did not return for 4 months.$ P: `% x/ g& R; c
Physical examination at this time revealed that the
( p7 G5 e3 p. U& }5 s9 E: t0 c/ kchild had grown 2.5 cm in 4 months and had gained
, Y( U( d+ P5 {9 y2 kg of weight. Physical examination remained0 n4 b% Q0 a; T8 Q$ x8 z
unchanged. Surprisingly, the pubic hair almost com-" e. N' @! {* P1 d' u
pletely disappeared except for a few vellous hairs at6 a; G% g+ e4 u4 i. I
the base of the phallus. Testicular volume was still 2. m) S; O) u' s4 E" H& l
mL, and the size of the penis remained unchanged.
2 v0 O* K) m$ p9 ^& q( ?The mother also said that the boy was no longer hav-
& q- K; `$ i! ?" [6 d$ }- Ring frequent erections.
7 l* j9 z; @4 m! u6 \9 QBoth parents were again questioned about use of, v0 G2 X: p' B' h% [% Y
any ointment/creams that they may have applied to: d% C$ g" w9 B; A+ p* h
the child’s skin. This time the father admitted the1 l- U$ f, Z- H) G/ r/ F& u
Topical Testosterone Exposure / Bhowmick et al 5417 R2 V: x* b) E' D
use of testosterone gel twice daily that he was apply-
9 F& g2 p8 d" b( x8 oing over his own shoulders, chest, and back area for
6 c) c& |/ U! q0 w' [" }" va year. The father also revealed he was embarrassed
/ q& v% Z' ?3 o2 _to disclose that he was using a testosterone gel pre-
! O$ O: |- \) ~/ P0 n& `( d! uscribed by his family physician for decreased libido' A: C& _; x+ n& o4 {6 }
secondary to depression.
: `6 I$ G, h( y, HThe child slept in the same bed with parents.
2 K  `& c$ O( aThe father would hug the baby and hold him on his
# z! q- [, b: ^. K$ u9 Rchest for a considerable period of time, causing sig-+ A5 g  Y& J. `+ q$ Q
nificant bare skin contact between baby and father.
, ^* I' P2 n# E6 z$ ]" WThe father also admitted that after the phone call,8 ?* f2 g( S  B
when he learned the testosterone level in the baby
% l" O% A/ J2 G( f/ b; ~% bwas high, he then read the product information: B: t" Q6 K4 k
packet and concluded that it was most likely the rea-
7 S% O/ q0 Y! u! c8 d0 x) xson for the child’s virilization. At that time, they8 w/ c+ `. a$ {$ Z2 S
decided to put the baby in a separate bed, and the1 ~+ x/ E+ m7 F+ n% w7 h, n
father was not hugging him with bare skin and had: r! u) F) F2 E; K1 u
been using protective clothing. A repeat testosterone
1 t! m8 _" P* |test was ordered, but the family did not go to the
, l! ]. i9 N3 r7 O+ {6 zlaboratory to obtain the test.
! h9 n2 H7 k! b! a, zDiscussion
( X) Z$ U% `6 G# {& y, bPrecocious puberty in boys is defined as secondary  A( g( P9 W) u, X/ R
sexual development before 9 years of age.1,4
/ c9 G; `4 M+ j( y' `8 `" E3 LPrecocious puberty is termed as central (true) when% G* j) I" I0 H0 h
it is caused by the premature activation of hypo-  u4 }' x+ W4 w  J* J2 w
thalamic pituitary gonadal axis. CPP is more com-
+ f$ ?" F8 Q3 K( @mon in girls than in boys.1,3 Most boys with CPP
/ y4 l& t) n' Hmay have a central nervous system lesion that is
# |9 u! p: p8 y* Iresponsible for the early activation of the hypothal-
# j7 L3 m1 y, D9 ~; i0 T8 x# tamic pituitary gonadal axis.1-3 Thus, greater empha-* {4 H8 I# H8 e1 Z
sis has been given to neuroradiologic imaging in
- s5 W  z0 r; s- @) B+ yboys with precocious puberty. In addition to viril-
  z" H! a6 g' ~8 ]6 w1 B8 nization, the clinical hallmark of CPP is the symmet-
: P3 J! @* X6 E/ J) p& W$ m* _rical testicular growth secondary to stimulation by  s, t7 R: L! |& `, S
gonadotropins.1,3
% w' [" X! Z( r5 c7 r+ oGonadotropin-independent peripheral preco-
; c4 s( w" h6 _0 Ecious puberty in boys also results from inappropriate
: K( J6 b7 }8 a9 {$ Y2 W4 n0 uandrogenic stimulation from either endogenous or
, M& s2 Y0 V( W. }exogenous sources, nonpituitary gonadotropin stim-
, w: q8 D0 u- dulation, and rare activating mutations.3 Virilizing: g6 A% P0 I; i/ ]
congenital adrenal hyperplasia producing excessive
0 _- ~1 D9 t+ n  m2 ladrenal androgens is a common cause of precocious6 t6 k7 F. i( }/ _  l
puberty in boys.3,4: @  m+ P/ U& g: P
The most common form of congenital adrenal
4 u  _2 R8 E% ?% W$ B% F" j; y' Q2 x) M$ Phyperplasia is the 21-hydroxylase enzyme deficiency." U' d8 N4 l1 Z5 ?9 x
The 11-β hydroxylase deficiency may also result in/ {7 o: g$ _8 ^3 [( b4 R
excessive adrenal androgen production, and rarely,& q4 c: U% u6 N" ~3 {8 c1 ^
an adrenal tumor may also cause adrenal androgen7 Z4 \- e; x+ S" j: w2 w
excess.1,3, K" {! _. b2 X7 W) \$ Y' x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% z$ `: G3 J/ A& f542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 i5 x0 K1 S- e( X6 h  r
A unique entity of male-limited gonadotropin-
9 {6 j$ U. M4 q* B2 @6 C* Sindependent precocious puberty, which is also known  _. x0 o2 a6 j- P
as testotoxicosis, may cause precocious puberty at a% N6 t% Z& x2 ~! ]: {9 I+ N: |/ a
very young age. The physical findings in these boys
, ]' }# G+ M' Iwith this disorder are full pubertal development,
2 T# a# s3 \! R0 E( s- ~- }including bilateral testicular growth, similar to boys* _- o& r6 O( s# C5 }) T' j' I
with CPP. The gonadotropin levels in this disorder1 B, P* @# D0 u; \" g0 M
are suppressed to prepubertal levels and do not show
9 }9 y2 X4 r: }; ?/ h; N% i2 a" upubertal response of gonadotropin after gonadotropin-8 s( T" ~7 |8 K0 ~  F) u, [
releasing hormone stimulation. This is a sex-linked: d: t3 l0 j7 G1 G% I
autosomal dominant disorder that affects only
8 j" j) L& ^+ y7 s) E. gmales; therefore, other male members of the family
0 O" [5 B  u! Ymay have similar precocious puberty.3
; g+ x$ p+ @! a0 XIn our patient, physical examination was incon-4 J! s* h8 G( O( y7 t+ c
sistent with true precocious puberty since his testi-
1 [% W: }+ E; Y1 o6 Acles were prepubertal in size. However, testotoxicosis$ M# ^2 L- [( y' B: {, s! o4 I
was in the differential diagnosis because his father; X3 ?8 p4 `/ e$ i7 F5 B/ o
started puberty somewhat early, and occasionally,
) X7 G  L: e0 Y* T. A6 Ztesticular enlargement is not that evident in the
. E0 ^9 d( Y4 H, {, ybeginning of this process.1 In the absence of a neg-2 r! f& @5 [1 t" n! d2 r
ative initial history of androgen exposure, our
* T) W3 e7 R' T2 O! a( C, a: z; |biggest concern was virilizing adrenal hyperplasia,
# q  d) q$ E" d7 \& H' |7 xeither 21-hydroxylase deficiency or 11-β hydroxylase! ^$ {$ F) y9 ~; V
deficiency. Those diagnoses were excluded by find-
) q5 u! u. Z3 `0 l2 o0 ging the normal level of adrenal steroids.
& a- k$ S1 A1 J' G% jThe diagnosis of exogenous androgens was strongly( q0 M: r$ j1 {! d1 ]7 E
suspected in a follow-up visit after 4 months because4 W- |: \  V! H6 q) p% [: F( i! d" Z
the physical examination revealed the complete disap-  Z* R. y( O2 S
pearance of pubic hair, normal growth velocity, and$ k1 l& K5 s) o3 P
decreased erections. The father admitted using a testos-! r2 ]5 H5 g2 A
terone gel, which he concealed at first visit. He was
! r8 [/ u5 l) i: b' ]# R/ Vusing it rather frequently, twice a day. The Physicians’
% _9 T/ C- L+ j* I& o3 O9 EDesk Reference, or package insert of this product, gel or4 M3 [+ h1 p" m0 C
cream, cautions about dermal testosterone transfer to, e% ?3 P+ @5 D3 `% n3 O
unprotected females through direct skin exposure.
, E1 s' g* N& J! f# SSerum testosterone level was found to be 2 times the
# v+ z: S9 g% ~, I6 K3 ~7 m6 Cbaseline value in those females who were exposed to. u' Z8 r6 o% V7 W) U
even 15 minutes of direct skin contact with their male# `" |2 f; h; }
partners.6 However, when a shirt covered the applica-5 B) X" c1 W, n( f  V9 X
tion site, this testosterone transfer was prevented.; |* d; x! _9 u- _' D" ?* X
Our patient’s testosterone level was 60 ng/mL,
+ {! k9 _9 a8 k3 W% Hwhich was clearly high. Some studies suggest that
0 I# Z% W4 ?) Fdermal conversion of testosterone to dihydrotestos-; N/ t  W! ^7 P( |& S, w" G: @
terone, which is a more potent metabolite, is more8 X) Q- A4 x) W
active in young children exposed to testosterone
- l, d, t* t% nexogenously7; however, we did not measure a dihy-
  }- C2 K4 z) V, m+ v# Tdrotestosterone level in our patient. In addition to
. d. I2 V1 X3 M& z: ?# E! X' ~virilization, exposure to exogenous testosterone in4 t- h3 s4 c: `0 _
children results in an increase in growth velocity and/ h' @  d7 s) m% M* l
advanced bone age, as seen in our patient.
; X# |# x, E6 pThe long-term effect of androgen exposure during) c* ], ]) n6 U3 A9 |
early childhood on pubertal development and final' b4 I% g9 p) B- s9 ~0 I- D2 G
adult height are not fully known and always remain
- Q3 h7 N- _( s8 K) l- M1 I- @% ?" e+ y% pa concern. Children treated with short-term testos-# |' l; D& Z. \: c% k; V; p: U! g( o
terone injection or topical androgen may exhibit some
* V1 t( c; ?3 D% f! J' b2 nacceleration of the skeletal maturation; however, after% M9 `4 g# y( ?+ R) G1 S
cessation of treatment, the rate of bone maturation+ S, _  h2 m" p
decelerates and gradually returns to normal.8,9
8 B, N$ J1 o7 J+ Z8 JThere are conflicting reports and controversy
; d! L& W0 q9 a7 B* w' D5 B/ Hover the effect of early androgen exposure on adult
! y% V- D+ s  E& }penile length.10,11 Some reports suggest subnormal
; `$ K0 Q. W- F1 i" y3 G# Padult penile length, apparently because of downreg-
. r' K! e2 s5 Mulation of androgen receptor number.10,12 However,
& D* X! K$ P- KSutherland et al13 did not find a correlation between. `7 W8 F9 e0 M7 M- v1 ~" a
childhood testosterone exposure and reduced adult& b! N6 M4 s! X' m+ p
penile length in clinical studies.
9 p  I4 G" M  a4 W) CNonetheless, we do not believe our patient is
; |* p8 o8 u$ k) ~; F- ]2 rgoing to experience any of the untoward effects from
) Z( G" C3 h- a1 B" l$ g* e9 {; B5 Ctestosterone exposure as mentioned earlier because- `- e5 j' Z0 f0 H! T4 v
the exposure was not for a prolonged period of time.' _# q' C1 X8 o/ Q% A$ w5 z
Although the bone age was advanced at the time of
" E1 N  k0 U$ E- m/ wdiagnosis, the child had a normal growth velocity at& B8 M. b0 d- g; o8 i
the follow-up visit. It is hoped that his final adult! G9 o% C( m4 O  e2 g- D
height will not be affected.  e; B  b0 n- N& l0 V7 m5 R
Although rarely reported, the widespread avail-- Y- x& o( g6 }
ability of androgen products in our society may
9 ?5 N5 W; [6 g3 _: Rindeed cause more virilization in male or female
) g/ t% L" V! `5 p5 U: xchildren than one would realize. Exposure to andro-
" B7 Z. y1 {  A. K* [8 T& H+ Ogen products must be considered and specific ques-! i' ~# y9 v( Z( u4 y
tioning about the use of a testosterone product or
6 e! Y) A" ~4 i+ V7 c, c" Kgel should be asked of the family members during
9 a, x( l" u) Z$ v" Ethe evaluation of any children who present with vir-
$ Y' Z5 K8 t# W# G+ N# N! yilization or peripheral precocious puberty. The diag-( {' Y' x0 d1 [/ K
nosis can be established by just a few tests and by
, L# g, J( m3 O& uappropriate history. The inability to obtain such a* s9 N9 s2 y0 V/ X" c4 h+ Y
history, or failure to ask the specific questions, may
1 `/ u0 y$ J) {/ bresult in extensive, unnecessary, and expensive
7 \4 G# X; q0 _2 ]4 G/ @investigation. The primary care physician should be3 e! d0 G; ?0 \1 B
aware of this fact, because most of these children- m7 Q1 p8 m$ N
may initially present in their practice. The Physicians’  b5 q8 q$ b. D8 g
Desk Reference and package insert should also put a
4 w3 m1 J( Z" p! j# L) Rwarning about the virilizing effect on a male or0 k5 {7 g* \0 ^3 ?5 E% m
female child who might come in contact with some-
% v. |. X+ Z8 ~! Y5 T+ |9 cone using any of these products.
4 Q" ~+ Z# R2 pReferences5 }; L- b3 t, z, m
1. Styne DM. The testes: disorder of sexual differentiation
& {; {: B* a1 |0 R8 }0 ^5 eand puberty in the male. In: Sperling MA, ed. Pediatric
6 X* H! @9 s* z5 F' H" bEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: l6 ]2 ~& f7 Y# O2002: 565-628.5 [9 J( {! m3 m7 @. n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 `) ?5 B; _8 p. k5 k- I
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old, @9 N! Y& D; {, O3 D
Boy Induced by Indirect Topical/ B- Y  ~, L- V- P
Exposure to Testosterone5 H6 Y: ]  f0 K# p! w7 e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 q" R! n1 F- Q7 f- D5 f+ g
and Kenneth R. Rettig, MD17 ~8 m; P8 u+ n4 U. R
Clinical Pediatrics1 \. G1 C( q0 l, E) j
Volume 46 Number 6
% S& ?! o1 ]) M! a+ rJuly 2007 540-543
) Y' {; C# z+ a5 o* ^© 2007 Sage Publications
1 L8 Y0 [$ W2 m- A  p9 y1 S10.1177/0009922806296651. ~1 w2 b4 |* c' `4 q3 n: b
http://clp.sagepub.com; v$ b3 X, ?2 E; k& K- ?
hosted at
: k+ S5 s! U* A/ o+ x2 Thttp://online.sagepub.com: p. z8 E+ s- }7 ?, d6 X5 y  M2 m1 o* @
Precocious puberty in boys, central or peripheral,: B9 K4 x9 C! t. Y
is a significant concern for physicians. Central
! C4 w+ r" O7 r, y9 {precocious puberty (CPP), which is mediated
6 P# L+ o7 h0 o3 `% y2 @# Fthrough the hypothalamic pituitary gonadal axis, has
1 @# E7 r3 N+ R8 c( z2 Fa higher incidence of organic central nervous system# x' R2 \) m, o; K, V4 n: x, h* g
lesions in boys.1,2 Virilization in boys, as manifested0 F- ?' f. p2 e, l# @
by enlargement of the penis, development of pubic
4 T) B, M& A6 p" j* o2 rhair, and facial acne without enlargement of testi-$ ]9 ~" k% M4 ]+ j4 T( ?, \  J$ x( R7 c
cles, suggests peripheral or pseudopuberty.1-3 We& V1 R" N/ k* F
report a 16-month-old boy who presented with the- I2 _6 H/ a3 G5 l
enlargement of the phallus and pubic hair develop-) R, P4 s+ e" W7 P+ ^- P
ment without testicular enlargement, which was due6 b1 f% }- d' J5 _# u
to the unintentional exposure to androgen gel used by/ K4 N3 F5 [. x# @
the father. The family initially concealed this infor-
: M4 k/ w( t% A6 \/ X$ i% Fmation, resulting in an extensive work-up for this! x+ ]! G$ }+ G1 |, |  c9 J$ ?# e9 @
child. Given the widespread and easy availability of- G: q# M+ l: b
testosterone gel and cream, we believe this is proba-& w3 n' G  b: ?! {8 d
bly more common than the rare case report in the0 H4 ]% K: f" @  D% i& [5 p
literature.4* H+ X/ m- l  l6 A' }1 Y, P
Patient Report
- X+ l* y" _, {A 16-month-old white child was referred to the
; k2 H( ~+ d- y! }5 {$ y9 H% Iendocrine clinic by his pediatrician with the concern4 ?3 n4 _# ]/ N% N
of early sexual development. His mother noticed
  E8 W& `8 m7 _' ^, hlight colored pubic hair development when he was4 d( t: ^7 o* J
From the 1Division of Pediatric Endocrinology, 2University of2 O/ P/ F" j# D& L
South Alabama Medical Center, Mobile, Alabama.
0 R3 }0 R2 I2 AAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 u: z" \6 p* EProfessor of Pediatrics, University of South Alabama, College of7 h% w/ k3 f3 k% {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* L4 y* W, _/ W) ?% j( O; Xe-mail: [email protected].1 F8 M" E; f  i0 {$ O0 J" K$ y
about 6 to 7 months old, which progressively became, G+ E: o4 _0 ^. {+ J1 s; `4 J9 {6 J
darker. She was also concerned about the enlarge-: F: v  {: B* Q/ ~8 g) p& [
ment of his penis and frequent erections. The child. n# k4 g7 e& e% F! Z8 q3 g
was the product of a full-term normal delivery, with# O/ N7 M/ x- _$ G* Y
a birth weight of 7 lb 14 oz, and birth length of
# s8 E2 {! V- h& `8 k20 inches. He was breast-fed throughout the first year
$ H5 \6 R" ~8 K  n9 B( j5 Lof life and was still receiving breast milk along with
' U" n6 \; d/ M  Y3 }solid food. He had no hospitalizations or surgery,6 A4 f3 ~4 [3 Z
and his psychosocial and psychomotor development
5 n, k# J: p3 V* p, M3 Hwas age appropriate.! i' e7 \( S0 f8 d7 I) s3 d
The family history was remarkable for the father,- ~# _5 X( A  |3 c) e) n: w8 Y
who was diagnosed with hypothyroidism at age 16,
; J/ k" b- }9 b/ V# Uwhich was treated with thyroxine. The father’s
& D4 F/ Y, y: ^height was 6 feet, and he went through a somewhat; |- d& b5 h6 u8 R% j+ u5 `" T6 i
early puberty and had stopped growing by age 14.$ A; t' n6 P+ }
The father denied taking any other medication. The
* C6 x) H% r: |' y- W( Achild’s mother was in good health. Her menarche' l4 H; i6 i8 ?' b' A6 Z
was at 11 years of age, and her height was at 5 feet
( L3 @$ G: b9 c& D! x& z" d; F1 g5 inches. There was no other family history of pre-. c( _6 g4 ?$ m# B- C3 \! u
cocious sexual development in the first-degree rela-
" c# s6 `# J2 N2 u' Z# {tives. There were no siblings.
1 }8 G& x3 K7 W  z$ C% v0 RPhysical Examination1 v- p2 n9 i* p+ ]
The physical examination revealed a very active,0 `; T3 e8 Y7 i6 S
playful, and healthy boy. The vital signs documented
: j5 a$ q6 V) n; r6 J1 La blood pressure of 85/50 mm Hg, his length was% B( x2 |; y+ l, ?: G, m
90 cm (>97th percentile), and his weight was 14.4 kg
, a7 E0 `7 e" B: o- C" w(also >97th percentile). The observed yearly growth( ~. i2 P! W7 X3 }
velocity was 30 cm (12 inches). The examination of: C5 s2 J" e5 z9 Z/ k/ h' ~
the neck revealed no thyroid enlargement.) G6 `6 h. O. e8 Y0 k5 ~
The genitourinary examination was remarkable for5 D- _, D, ]% N; d% Z+ J; E: x# S
enlargement of the penis, with a stretched length of  W' y4 w% P1 [" d( H0 _4 ]
8 cm and a width of 2 cm. The glans penis was very well
1 B7 [) N( K7 h. }developed. The pubic hair was Tanner II, mostly around
$ O) q) X  W; R5409 v1 j7 U8 k; L2 _3 Z$ ?
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the base of the phallus and was dark and curled. The: H, }% O7 i4 F7 e* ]4 s8 W
testicular volume was prepubertal at 2 mL each.
' i8 R" C( u& }: BThe skin was moist and smooth and somewhat9 \  ]8 G  u& }+ w' O; h
oily. No axillary hair was noted. There were no. a& Y$ `/ z: R0 r. W3 I$ j- a
abnormal skin pigmentations or café-au-lait spots.
2 O  `7 w+ X) R: ~& KNeurologic evaluation showed deep tendon reflex 2+3 ~% K1 L; h# s' g0 p- C2 `1 A
bilateral and symmetrical. There was no suggestion' O: c0 d, |8 R$ l1 d" o
of papilledema., w, P: c% F( c' c$ p# z# H
Laboratory Evaluation9 S, W+ d2 w# [; t2 y$ E- e" ~
The bone age was consistent with 28 months by* B; V/ k' Y; f$ l' t6 D. ~
using the standard of Greulich and Pyle at a chrono-
) P( R2 @; R( f: }) w0 Llogic age of 16 months (advanced).5 Chromosomal, ~+ k4 J& K- O) A4 J2 [
karyotype was 46XY. The thyroid function test
) f. v3 D* y: }# yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- a, }! U: M: k! t
lating hormone level was 1.3 µIU/mL (both normal).
: M# y- k( W6 z0 e1 U1 v0 _9 w* SThe concentrations of serum electrolytes, blood
% W& ?6 X$ \7 a* d3 ?5 V# Purea nitrogen, creatinine, and calcium all were
& g5 I4 a; |# @8 y7 V' b& \8 k$ Swithin normal range for his age. The concentration
, r8 B7 m2 W& Z* M' qof serum 17-hydroxyprogesterone was 16 ng/dL9 W, T+ ~/ Z3 c" m/ g. q
(normal, 3 to 90 ng/dL), androstenedione was 209 G0 a; x$ p# T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 d' Q! G) S1 Y& v+ m9 ?, _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 N! R  _0 x9 x1 Q/ Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ {: c4 s1 T6 o" _/ C$ X4 C49ng/dL), 11-desoxycortisol (specific compound S)* j# a, w" K7 {7 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 K, L# H" Q, Q" C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% ~5 c* H0 }( ]- J! r( }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& Y* c6 \. \+ J7 W
and β-human chorionic gonadotropin was less than
  n  G/ N( K  U' F: I1 x5 mIU/mL (normal <5 mIU/mL). Serum follicular
- ?1 d( Z# B7 J4 T, H8 ostimulating hormone and leuteinizing hormone* k" w$ H9 {$ ?5 d  A; W9 p( m
concentrations were less than 0.05 mIU/mL* @4 V. U* x- X
(prepubertal).
, i, {, h" ]" h3 ^The parents were notified about the laboratory
! G5 h  W  B) F+ y5 x+ gresults and were informed that all of the tests were( a; r# b& _( G  ^* q2 D3 b
normal except the testosterone level was high. The
& T6 B1 a1 A! hfollow-up visit was arranged within a few weeks to+ c4 A/ }( t: Y, F+ [+ P
obtain testicular and abdominal sonograms; how-
* G! W% Z5 c. n6 b" D& yever, the family did not return for 4 months.
$ w1 u) x0 l8 Z. h" `" vPhysical examination at this time revealed that the
) y( A  Q4 X( d8 Z) Z* t& g) q0 dchild had grown 2.5 cm in 4 months and had gained
" y4 F( x' u" G& Z6 @2 kg of weight. Physical examination remained
) S7 A) M3 f" F# S/ Runchanged. Surprisingly, the pubic hair almost com-
, D6 r) v, k! B0 @pletely disappeared except for a few vellous hairs at+ M! Q  a1 _7 w% O) q3 B8 `
the base of the phallus. Testicular volume was still 2: v9 X- C2 @1 t' n& Z$ t
mL, and the size of the penis remained unchanged.$ e* }; e% h( H8 t- M& ^
The mother also said that the boy was no longer hav-- B" C! M9 e' p  ~# s
ing frequent erections.$ F2 G7 Y0 L3 \  O
Both parents were again questioned about use of; t! o2 H6 I. n/ H# \9 b
any ointment/creams that they may have applied to
' R& L8 n  ^9 C0 E/ n# ?6 {% Dthe child’s skin. This time the father admitted the9 A- P6 v/ }3 h, z  H9 o8 X7 Y' n1 s, O
Topical Testosterone Exposure / Bhowmick et al 541
# ^# u. O  |/ [* @0 z4 luse of testosterone gel twice daily that he was apply-$ M# y5 h& K; m6 S
ing over his own shoulders, chest, and back area for
6 g8 L5 v2 X+ r* C4 V: Ka year. The father also revealed he was embarrassed& `1 w; k: h! }* |
to disclose that he was using a testosterone gel pre-/ n- V' V1 E0 z( S% X. k
scribed by his family physician for decreased libido
7 C& ~. ]2 j" X" J+ \+ csecondary to depression.+ {$ K, v1 ?2 t  l) z1 ?2 b4 i# ?
The child slept in the same bed with parents.% s( O  Z: }0 k
The father would hug the baby and hold him on his# x1 {& {$ \/ u6 f+ {' ?
chest for a considerable period of time, causing sig-% b% J9 ~0 ?) h; ^* z
nificant bare skin contact between baby and father.
& V4 ]% F' C( g2 b+ D4 w, {The father also admitted that after the phone call,% e) H, D' C# @6 B
when he learned the testosterone level in the baby
$ ^, w7 X1 @% T$ ^3 kwas high, he then read the product information
/ h  W* a( G. y8 T& Wpacket and concluded that it was most likely the rea-/ j0 W9 o  M% y( U
son for the child’s virilization. At that time, they" y  h  s- g* y) U: h# S5 \
decided to put the baby in a separate bed, and the
5 L. }# B# g6 G# Rfather was not hugging him with bare skin and had, A2 n; s- i2 `/ x' [1 G% o
been using protective clothing. A repeat testosterone# Y# Q) b: q% K5 [' S2 R+ o6 m# y
test was ordered, but the family did not go to the
2 i7 h9 Q- ~+ c; x8 ?5 X7 c- |2 flaboratory to obtain the test.
" @5 M/ E7 c( l5 k$ r4 S* H  _+ gDiscussion
; [  k: Y: z$ I* n! o! SPrecocious puberty in boys is defined as secondary$ P! q* [. {- G4 ?
sexual development before 9 years of age.1,4
8 s& Z# O* ?* w: O6 ?4 v) hPrecocious puberty is termed as central (true) when, V" h0 R. [8 L( H8 P. Q
it is caused by the premature activation of hypo-
8 ?# h4 U+ A3 |9 ^- \thalamic pituitary gonadal axis. CPP is more com-
& |6 j; F3 H# C, d+ Amon in girls than in boys.1,3 Most boys with CPP
- S  e7 P8 A" ^# x3 E0 C7 Dmay have a central nervous system lesion that is7 a  L' @8 C" z
responsible for the early activation of the hypothal-
0 S1 ]) \* r( v# {6 o3 c4 \amic pituitary gonadal axis.1-3 Thus, greater empha-2 T. U5 q3 k  m0 k' n# L$ h
sis has been given to neuroradiologic imaging in! I- B/ |& {7 J6 ^( i1 i
boys with precocious puberty. In addition to viril-
( I4 K! Q) W( \ization, the clinical hallmark of CPP is the symmet-
; m6 c3 T; _8 q' irical testicular growth secondary to stimulation by
% A! i8 ?+ G1 E! M& N5 {/ r# }gonadotropins.1,3
5 r! b( d7 N+ q$ BGonadotropin-independent peripheral preco-$ c+ H  ]3 e8 `( T" s/ U( X
cious puberty in boys also results from inappropriate1 ~8 J- a4 f9 Z# e6 ?4 t( [
androgenic stimulation from either endogenous or
' W! ?! g+ I2 @) m2 b4 qexogenous sources, nonpituitary gonadotropin stim-. E# c. [* ^, V' j* J4 `
ulation, and rare activating mutations.3 Virilizing; ]7 @8 G# \, M
congenital adrenal hyperplasia producing excessive! p" Y# Q7 i* @7 d3 L
adrenal androgens is a common cause of precocious! a) b" B0 e  r. n, L5 f& U  Q) e
puberty in boys.3,4
: K2 m) F; y' a$ o3 g' X! U4 b- uThe most common form of congenital adrenal( L" }" l4 b8 |1 z( }
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ w, O) j* i2 @; z8 H9 I3 x' oThe 11-β hydroxylase deficiency may also result in# j7 B  z* w. s4 h
excessive adrenal androgen production, and rarely,
6 Q% i8 D6 r! k8 ?/ Z  ~0 ian adrenal tumor may also cause adrenal androgen
1 C8 Y, i8 p6 Eexcess.1,3$ X6 T' S* x6 V) |6 s1 u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ E8 }" j4 z/ D  p+ ]0 [
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" H6 x- d9 {9 F$ m, D+ VA unique entity of male-limited gonadotropin-& O+ V# }- z1 P% c
independent precocious puberty, which is also known
. Z. [) E6 i4 e# nas testotoxicosis, may cause precocious puberty at a3 P+ r) L9 }0 R/ u( h3 p: g5 d' k' R' j
very young age. The physical findings in these boys6 I( ]9 t+ L' i( g1 t
with this disorder are full pubertal development," [# J4 F/ O; N- R7 N# h
including bilateral testicular growth, similar to boys
3 l+ T8 M- g7 [$ e9 Hwith CPP. The gonadotropin levels in this disorder
, `1 G0 ]# F* f) {6 j; nare suppressed to prepubertal levels and do not show
$ C: B- c+ `% P$ m# N! {pubertal response of gonadotropin after gonadotropin-
5 S- B: C% G3 r  `% X& Z! b. Ureleasing hormone stimulation. This is a sex-linked$ x5 C' G' k: u! f& [( K
autosomal dominant disorder that affects only% n1 N$ m: Z  B" {" Q4 }- R
males; therefore, other male members of the family
: f4 e; |) u6 |, N7 B! Q( bmay have similar precocious puberty.36 ]1 H2 r; O- F1 a
In our patient, physical examination was incon-* O8 I* y, O+ @/ K" a6 i2 b& a
sistent with true precocious puberty since his testi-
4 b1 u$ K* T) H* x* y, ^# |cles were prepubertal in size. However, testotoxicosis
3 q# o% S- T* p! D( j1 k, v9 gwas in the differential diagnosis because his father7 U) m4 c" w2 I; O" G( W' S3 F
started puberty somewhat early, and occasionally,
' M6 z0 V( Q$ D- }testicular enlargement is not that evident in the8 v- N( Y& U* j% j1 V
beginning of this process.1 In the absence of a neg-, N4 T0 G4 Q2 S/ X  l& c
ative initial history of androgen exposure, our# W9 Z3 R, @! e1 T; ~0 n
biggest concern was virilizing adrenal hyperplasia,
9 Y! y- d1 n5 [3 \either 21-hydroxylase deficiency or 11-β hydroxylase  S( B9 t0 c) i" s
deficiency. Those diagnoses were excluded by find-3 _8 r( Z  i/ [! Y
ing the normal level of adrenal steroids.: d2 @+ M( i$ I! r+ N$ R* p4 i3 F
The diagnosis of exogenous androgens was strongly; u& v) Q$ d/ S7 s
suspected in a follow-up visit after 4 months because  p9 H7 V$ d8 R7 Z7 V
the physical examination revealed the complete disap-" m; C3 r  f$ }# [4 n  i. |
pearance of pubic hair, normal growth velocity, and
# ~* K2 u5 i- e4 Z8 ~9 e3 X( F# [& Fdecreased erections. The father admitted using a testos-7 w; [: f0 i, g; A1 d
terone gel, which he concealed at first visit. He was9 `; G) N1 t( J$ Z
using it rather frequently, twice a day. The Physicians’  p6 Q/ |9 k( v
Desk Reference, or package insert of this product, gel or; ]( g6 b; ~: e& T; ~
cream, cautions about dermal testosterone transfer to
) t; ?, a) _2 _unprotected females through direct skin exposure., @8 M- f2 _6 |9 A
Serum testosterone level was found to be 2 times the
; v: B8 C- M) _" l4 E" Jbaseline value in those females who were exposed to
2 D3 U7 T( @% Z4 ^6 leven 15 minutes of direct skin contact with their male+ d' f2 k/ v" h
partners.6 However, when a shirt covered the applica-
' L8 ^% ^( ^" _8 Y& T: S4 \tion site, this testosterone transfer was prevented.
' o" a7 L5 k$ i; zOur patient’s testosterone level was 60 ng/mL,# k7 c( {+ [! A! \
which was clearly high. Some studies suggest that8 e4 Q$ R3 C; q- Y, C
dermal conversion of testosterone to dihydrotestos-9 A' t% m! X) h% F: ^
terone, which is a more potent metabolite, is more/ W# x: n3 n. W+ w6 d0 \
active in young children exposed to testosterone
: p; ]/ E, D; _% O) }) pexogenously7; however, we did not measure a dihy-9 T* @  ?' V8 r$ {0 {/ Z8 g& h7 Z  t! r
drotestosterone level in our patient. In addition to% E/ t% x9 _; W+ x
virilization, exposure to exogenous testosterone in
9 E0 e3 v$ P! W. x. _5 `children results in an increase in growth velocity and
6 D' W/ R3 @; A% G! Z/ J5 c" Padvanced bone age, as seen in our patient.* V6 z$ b! q: R* J( i+ T# C6 j
The long-term effect of androgen exposure during
2 W6 ?8 h' M3 w% k1 P9 {) gearly childhood on pubertal development and final
+ x* t* I( v2 nadult height are not fully known and always remain# C1 s! V- K$ a, Q& w7 _+ V, W
a concern. Children treated with short-term testos-
! m2 W* ?  _! K& a1 Y+ [! J& M# R9 G# [terone injection or topical androgen may exhibit some& s% M9 p, k, x! ]" G
acceleration of the skeletal maturation; however, after
; ]- ~9 t* ?) }9 D8 I* icessation of treatment, the rate of bone maturation  ?9 I, h, J5 ~8 A9 ]
decelerates and gradually returns to normal.8,9/ G7 e! x% h8 O" _$ y
There are conflicting reports and controversy# `! ^3 l- C+ \0 y# a
over the effect of early androgen exposure on adult* b& l" E. ]9 n
penile length.10,11 Some reports suggest subnormal
' C; C7 V. n! S. n1 g; `/ ?adult penile length, apparently because of downreg-
1 b# k2 s; o- N! N5 iulation of androgen receptor number.10,12 However,
2 b* Y. n* I8 l7 b8 ASutherland et al13 did not find a correlation between
& J  L0 _) @; Cchildhood testosterone exposure and reduced adult
1 _8 c1 S  U" N* Mpenile length in clinical studies.
! H4 K+ L8 X! U) @; H( ^  FNonetheless, we do not believe our patient is
& o8 M+ ]& O! w. fgoing to experience any of the untoward effects from
0 p  [* t* S  d  U% Etestosterone exposure as mentioned earlier because
  ]% a6 l  Q8 D, ~the exposure was not for a prolonged period of time.
* Y( x* n: X7 C. r4 F& l# m6 o9 s) zAlthough the bone age was advanced at the time of& X! p6 ]! {' d3 u) q! s, y1 c
diagnosis, the child had a normal growth velocity at
1 x6 h) o' [# H! n9 T/ I) U  uthe follow-up visit. It is hoped that his final adult+ J9 F5 s0 y& c- Q: P5 d) A
height will not be affected.1 l5 _7 v! N, t8 u
Although rarely reported, the widespread avail-
2 h6 |, `% C4 C% R  T2 Q5 ?/ hability of androgen products in our society may1 p  M$ v3 l$ n
indeed cause more virilization in male or female
: ?9 [. y6 g* |  tchildren than one would realize. Exposure to andro-. o8 B3 M, C3 ^8 x$ m1 z9 q
gen products must be considered and specific ques-, n' X0 u3 t( d# n6 T, Y% X8 b
tioning about the use of a testosterone product or
$ H) ^. R% ]' T; Z( ?6 Ygel should be asked of the family members during
  h5 b5 c* T$ Fthe evaluation of any children who present with vir-; J( C* o$ }8 b5 `" m
ilization or peripheral precocious puberty. The diag-
5 y% h, e& P/ D# ~! tnosis can be established by just a few tests and by8 n% [, V4 v0 a2 V, Y/ U
appropriate history. The inability to obtain such a* p- n2 G5 }- I1 T( l3 l1 P
history, or failure to ask the specific questions, may
* X8 k) R5 j! s5 m! X" Rresult in extensive, unnecessary, and expensive
: R* e1 `4 c4 ?6 B2 {; i6 oinvestigation. The primary care physician should be' `1 Y; \1 E+ L" M
aware of this fact, because most of these children( B3 c' ^) S2 m- |) w
may initially present in their practice. The Physicians’3 y/ j- {& E3 h
Desk Reference and package insert should also put a* \; e( \6 G& j5 ~
warning about the virilizing effect on a male or; C) P1 M" x: _6 t+ k
female child who might come in contact with some-
2 B, }5 o: n/ O$ Hone using any of these products.; q+ V# j: O& {* `9 ~# b
References" d: N0 B# p) X, L  }
1. Styne DM. The testes: disorder of sexual differentiation
  T% ~! S5 r8 \' ]and puberty in the male. In: Sperling MA, ed. Pediatric; E7 g" D! N2 k  L' R$ `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: b' Q3 o, y9 z2002: 565-628.
: i' e, ~! V; c# e* }$ L& I5 `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& m7 g  Z, F6 Z( e, S+ f, ~
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
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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

5 Y7 {, T! E$ @% E0 c  e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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