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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
5 A+ A, r( [* k) [! }& |  eBoy Induced by Indirect Topical
! R, e" p) o' YExposure to Testosterone) B; ]1 x- I2 p+ H
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 E2 e# @0 o& F  d! Vand Kenneth R. Rettig, MD1
0 h7 j& p: X) I3 f; P! J- v& tClinical Pediatrics
  M" ?( }  R4 Q- MVolume 46 Number 6
1 a  \" o9 d1 }. hJuly 2007 540-543
! ?+ b8 q3 o$ ?! s© 2007 Sage Publications8 ?2 f' u. ?# }
10.1177/0009922806296651
, L+ s9 s) [2 Thttp://clp.sagepub.com
8 f" a4 v& X; g8 ihosted at
: F( L* E, t* V8 }4 V" F# ahttp://online.sagepub.com6 ^8 F/ n- q/ ~
Precocious puberty in boys, central or peripheral,' O( O( O) d3 T% b
is a significant concern for physicians. Central: u3 g; U$ M; w
precocious puberty (CPP), which is mediated$ R7 u; X+ ~4 ]
through the hypothalamic pituitary gonadal axis, has
) a% I& f1 h) G; _+ C0 Ma higher incidence of organic central nervous system. @: S: J& X' F3 `' G
lesions in boys.1,2 Virilization in boys, as manifested
7 {3 J8 F1 V& q! oby enlargement of the penis, development of pubic
1 f% h" d2 t4 t, @& nhair, and facial acne without enlargement of testi-
" J+ P; M# Q( n/ x2 W4 q! Ycles, suggests peripheral or pseudopuberty.1-3 We
* v) T' }- o7 J; ~2 h5 b! T, e# zreport a 16-month-old boy who presented with the0 g6 h7 O, F2 M/ t7 T- i( d# C
enlargement of the phallus and pubic hair develop-
- ]: x( E3 I  X, Rment without testicular enlargement, which was due, q4 r  i1 b" K: Z+ ~- }5 ]( s! s
to the unintentional exposure to androgen gel used by; D! U! u2 c' D( i
the father. The family initially concealed this infor-' E1 ^& q8 ~+ O6 I) G" g: D- O5 S
mation, resulting in an extensive work-up for this
- ]3 `9 P9 V0 i+ I& Cchild. Given the widespread and easy availability of
1 w; u1 I, v& o9 c" ftestosterone gel and cream, we believe this is proba-! f5 g& a: I4 w' j& T( p6 u
bly more common than the rare case report in the
+ O, q3 f3 P3 S* @9 u! \literature.4
! i1 P7 N# e  vPatient Report8 N: R& t0 I( V* q6 ]" N/ T
A 16-month-old white child was referred to the/ F$ q. @' }, C" E# X
endocrine clinic by his pediatrician with the concern% h; n8 _1 f% c. ]0 ~# j+ B
of early sexual development. His mother noticed
0 n, _) H- r% J3 }! U/ q- s" Olight colored pubic hair development when he was7 |8 q! E7 ]! S( |4 ]5 ~6 Z( M1 N
From the 1Division of Pediatric Endocrinology, 2University of
% }* a6 ?* @) t! F# SSouth Alabama Medical Center, Mobile, Alabama.
( ~5 d8 }3 V5 c9 B4 F0 g! nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
6 K% c  E9 N  y8 G' J. _Professor of Pediatrics, University of South Alabama, College of
! x& x' n$ S, O- _- EMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 S2 o' k: y  X1 Ke-mail: [email protected].9 A' e( X0 r+ z3 m8 D/ b7 b1 @* v2 u
about 6 to 7 months old, which progressively became
0 a9 {/ ^3 T: idarker. She was also concerned about the enlarge-
0 x3 @( L% X! w# y* U7 Z9 b: l3 Sment of his penis and frequent erections. The child
" K3 h+ K% k- k6 R% rwas the product of a full-term normal delivery, with
6 j/ l7 M. s" m5 I! e3 Va birth weight of 7 lb 14 oz, and birth length of
& I* O* _# O5 g( |# {) e8 Q2 N20 inches. He was breast-fed throughout the first year
- o- x3 M6 H% ~2 n. N3 Mof life and was still receiving breast milk along with
" C8 I+ T7 o  o% J2 ?3 r* Tsolid food. He had no hospitalizations or surgery,& a; K3 q0 W9 _) H: Q9 E
and his psychosocial and psychomotor development
: C( M- ^' P  u2 d# n. M! T; I3 awas age appropriate./ E( R" Q2 u6 N8 S" n
The family history was remarkable for the father,$ q; s5 K' V" s5 \+ q2 G
who was diagnosed with hypothyroidism at age 16,! S: Q$ U! L% M; q( ?2 A
which was treated with thyroxine. The father’s: h) g$ b8 N, J) T$ {# }
height was 6 feet, and he went through a somewhat$ p* z4 L7 t! a
early puberty and had stopped growing by age 14.
# d3 n; D+ |4 c7 |4 w7 F- }The father denied taking any other medication. The
3 Y0 c# |1 B7 rchild’s mother was in good health. Her menarche
" v* L9 B3 W& Y( k. Nwas at 11 years of age, and her height was at 5 feet
1 F8 y! L( ^1 S5 inches. There was no other family history of pre-
; d$ v6 p+ J- ]cocious sexual development in the first-degree rela-! r9 X7 }- f) d4 a5 G
tives. There were no siblings.
& b7 B0 ?' m4 z% zPhysical Examination
0 ~/ [9 `( Y8 H2 V! IThe physical examination revealed a very active,
' @$ T4 r' `$ ]0 x! Bplayful, and healthy boy. The vital signs documented0 s) w0 Y5 c: I( q
a blood pressure of 85/50 mm Hg, his length was
9 G. g3 H4 ]" Q3 u4 f& ^) u- G90 cm (>97th percentile), and his weight was 14.4 kg
; i; T+ Z+ r& H1 k: s* `(also >97th percentile). The observed yearly growth2 [% u+ l: a9 q, d  w
velocity was 30 cm (12 inches). The examination of
* p4 g5 E6 q' q2 M$ R8 [; X2 Gthe neck revealed no thyroid enlargement.' e. p- S$ t. W0 l
The genitourinary examination was remarkable for$ q( v4 G3 o, p6 t
enlargement of the penis, with a stretched length of" O1 @& t7 m: k, C  b4 w
8 cm and a width of 2 cm. The glans penis was very well7 `9 f# ?2 d2 ^' e
developed. The pubic hair was Tanner II, mostly around; I: m/ ^: `- D, m! R0 N* C% L
540) y/ c9 G1 C. g- ~$ h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 @6 M: C5 _6 f" I5 i
the base of the phallus and was dark and curled. The& k  K" f' C  \
testicular volume was prepubertal at 2 mL each.
$ R3 C( h9 v0 j; CThe skin was moist and smooth and somewhat6 C" n( Q. y, a# X( _# r1 w; l
oily. No axillary hair was noted. There were no
+ A5 A1 j6 m6 ^2 pabnormal skin pigmentations or café-au-lait spots." j6 X; {: U1 K" m: ?9 ?# X  c
Neurologic evaluation showed deep tendon reflex 2+
! ^+ _- P$ r& b" q# F" vbilateral and symmetrical. There was no suggestion- j' G. C2 l( K& @2 _+ J$ v5 _9 v
of papilledema.
! g, f8 _6 f2 v( V3 c: W/ LLaboratory Evaluation6 z: }7 J* c: v3 d$ E2 H
The bone age was consistent with 28 months by
2 l* W- [/ y/ d$ ]using the standard of Greulich and Pyle at a chrono-
% A/ S1 {2 j& Ylogic age of 16 months (advanced).5 Chromosomal
2 {: J& f, z# k6 Tkaryotype was 46XY. The thyroid function test' [- `# q" D" ^1 ], i/ Z( g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 G& L9 l: u2 ^! B
lating hormone level was 1.3 µIU/mL (both normal).$ K# b& h+ R* Y) F' I
The concentrations of serum electrolytes, blood
' l" |3 J$ e: q( i# |9 A9 y1 X- Nurea nitrogen, creatinine, and calcium all were
/ @' A- g3 g! G0 t! A) v' dwithin normal range for his age. The concentration& Q% {$ E! V4 O0 I
of serum 17-hydroxyprogesterone was 16 ng/dL9 x/ J; s/ n1 v$ e! L5 [7 ~& [
(normal, 3 to 90 ng/dL), androstenedione was 20% i( t. Y8 \" f) J7 u5 {# Q4 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% E! O2 j7 u7 zterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: C4 C5 A: R+ L7 `- H% Y4 J' R( M: }desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 B0 ^6 n( m, ?+ ]- i
49ng/dL), 11-desoxycortisol (specific compound S)$ F' J" p; F( Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 V/ Q, _1 s% r& _: rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 r, T. Z* a/ r: M$ U+ ?+ D; S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 J( @5 ]7 B' m! r, s  Q
and β-human chorionic gonadotropin was less than
0 S6 ^& l* X- }5 mIU/mL (normal <5 mIU/mL). Serum follicular
' T3 z8 F, E- Gstimulating hormone and leuteinizing hormone
# ^9 a7 q; f- _% l! b; H* S  I. lconcentrations were less than 0.05 mIU/mL/ U6 k' M  p5 o' Y6 n" E# i
(prepubertal).
" \- h  C& P- Q+ U- PThe parents were notified about the laboratory
& g3 j: \: T( v1 }0 N7 }results and were informed that all of the tests were
2 n; M* K( Z$ r3 snormal except the testosterone level was high. The: Y# Q3 O( Q& w2 r$ W
follow-up visit was arranged within a few weeks to
9 |. }6 t, ]+ z5 z, \/ E) Lobtain testicular and abdominal sonograms; how-6 A, `6 |+ M* ?
ever, the family did not return for 4 months.
8 U0 M4 A0 w5 j- p: dPhysical examination at this time revealed that the( H$ F+ i$ }& T& N  z
child had grown 2.5 cm in 4 months and had gained' v1 [3 P3 B1 r
2 kg of weight. Physical examination remained
! `7 ?8 Y+ ?* u' g4 O. aunchanged. Surprisingly, the pubic hair almost com-
+ \: I9 F# h+ J- Apletely disappeared except for a few vellous hairs at$ \; K: i! I% B+ R% f. G+ S' u
the base of the phallus. Testicular volume was still 2% u" A3 E1 A: w( {" b
mL, and the size of the penis remained unchanged.) _, [4 C$ U# `8 l& }. N& Y& o
The mother also said that the boy was no longer hav-
3 t3 k; p+ x4 r3 ying frequent erections.
* q( K* j. X- TBoth parents were again questioned about use of) z4 l8 \! h9 D$ u5 M, T
any ointment/creams that they may have applied to( H% O" E7 i) j, _! z$ W
the child’s skin. This time the father admitted the, b- f4 A- [, D: b8 Z! c4 n  _: k
Topical Testosterone Exposure / Bhowmick et al 541, F. {" _) Q& h# |
use of testosterone gel twice daily that he was apply-* u: `# _! c% S/ `9 q7 m; \
ing over his own shoulders, chest, and back area for, O0 B( t) v* N  q1 Z% _# c8 i
a year. The father also revealed he was embarrassed
- X) Z9 i3 d. }: F' bto disclose that he was using a testosterone gel pre-
: ]! U" V; u& Z2 ?+ Q; p" s' Zscribed by his family physician for decreased libido. X' p5 V, B, E+ V8 _
secondary to depression.6 f) q7 o* w/ i  d6 g& ]; K$ I* j+ t
The child slept in the same bed with parents.
2 u+ [+ Z8 G& E* G1 i7 ~The father would hug the baby and hold him on his
0 q' g$ Z3 Y% C/ G% v# L$ Schest for a considerable period of time, causing sig-
( o- a6 U6 `, U, P* \nificant bare skin contact between baby and father.
$ h% f1 q2 ~7 C( M( BThe father also admitted that after the phone call,7 W1 t5 a4 S- C# c5 U
when he learned the testosterone level in the baby5 ~- v. f* N9 |9 d3 @2 o8 x  c
was high, he then read the product information7 J7 V2 M2 K2 V3 g, l7 j
packet and concluded that it was most likely the rea-: U" ~! X7 A. j# c; d4 ]; |! i
son for the child’s virilization. At that time, they! H: t, T  P% k
decided to put the baby in a separate bed, and the' O& U' e! i' S3 w7 j
father was not hugging him with bare skin and had7 @/ Q7 @9 u0 n9 y9 c5 b
been using protective clothing. A repeat testosterone
+ x) W: O9 P3 Jtest was ordered, but the family did not go to the2 V4 i% [- T9 Z+ N  E' O6 ~
laboratory to obtain the test.
7 D0 U& ~: P/ D) Q) k6 BDiscussion
+ \" @3 |0 `" V# ~Precocious puberty in boys is defined as secondary( }0 b# n1 @5 l$ T- ?- _8 u
sexual development before 9 years of age.1,4
* o' o# |- _7 p% k7 b; iPrecocious puberty is termed as central (true) when% Y; Z) k3 M) y3 I$ Y
it is caused by the premature activation of hypo-0 X* B* D. S; e, A8 c
thalamic pituitary gonadal axis. CPP is more com-
9 q5 b: m7 ]2 Y3 o5 d; @- x! {' Q0 }mon in girls than in boys.1,3 Most boys with CPP) {- U% G/ }1 r+ R
may have a central nervous system lesion that is0 q3 ~8 x5 N' a) n' f
responsible for the early activation of the hypothal-
: W* S; f$ |. i+ oamic pituitary gonadal axis.1-3 Thus, greater empha-
5 A" H4 Q* G* d! M' ksis has been given to neuroradiologic imaging in# X7 J: W& |( _2 O
boys with precocious puberty. In addition to viril-6 ^6 F/ @% x1 b8 A1 Z( A
ization, the clinical hallmark of CPP is the symmet-; H: p8 \- R4 O. m
rical testicular growth secondary to stimulation by) W( T) I  g* M7 V
gonadotropins.1,3
+ P1 H# }6 \7 B1 D0 p! yGonadotropin-independent peripheral preco-! K3 f/ U/ }7 H% L$ ~
cious puberty in boys also results from inappropriate
8 n: U' D4 P( r$ A! Oandrogenic stimulation from either endogenous or0 z; a0 j, b- u
exogenous sources, nonpituitary gonadotropin stim-) `. G8 `4 i, x9 o
ulation, and rare activating mutations.3 Virilizing
9 P1 P4 x4 V9 P. d: c1 p$ [congenital adrenal hyperplasia producing excessive
2 Q* g9 `: {; J& Xadrenal androgens is a common cause of precocious
& N4 |) X, w0 p  Z- vpuberty in boys.3,4
  R3 H/ \5 W. B/ D' ?1 ^The most common form of congenital adrenal
6 m7 ?3 Z7 i# Mhyperplasia is the 21-hydroxylase enzyme deficiency.
6 m" k3 B) R* |+ z+ B% Z8 pThe 11-β hydroxylase deficiency may also result in8 d2 ]+ `5 V+ n) [
excessive adrenal androgen production, and rarely,1 [- I9 g$ [8 i8 E) U6 U- W" |
an adrenal tumor may also cause adrenal androgen3 C4 B: B( [/ w
excess.1,36 n  E. G( b4 `# y+ F8 M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- T- A  |9 e% B/ P% ~  t
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 m$ w3 {8 V! g; ]
A unique entity of male-limited gonadotropin-- r) E. w; `' ]7 @; J5 z" z% C
independent precocious puberty, which is also known& K. M# Z! P9 q' {2 c/ |! W3 x
as testotoxicosis, may cause precocious puberty at a
1 u- J( Y; S+ a- W4 Overy young age. The physical findings in these boys
6 ]$ s3 G7 N% u7 C/ R# X2 x+ fwith this disorder are full pubertal development,9 C# G' L  D- E' q8 _
including bilateral testicular growth, similar to boys
6 o3 ~, S3 @/ _  M: Z7 Swith CPP. The gonadotropin levels in this disorder
7 \& o# B/ H4 Rare suppressed to prepubertal levels and do not show
" ?1 Y4 |- l' K5 `, [& y7 Hpubertal response of gonadotropin after gonadotropin-
  Y1 \/ S% K+ G& D# ]  b! `releasing hormone stimulation. This is a sex-linked# t- Z( Q/ S& }7 s3 _
autosomal dominant disorder that affects only0 ?' a4 M& [; R
males; therefore, other male members of the family
" [5 W3 r% B6 Lmay have similar precocious puberty.39 _  @; F5 I  C8 B- f3 |5 y8 a! U
In our patient, physical examination was incon-
0 o+ R1 w% @/ e8 A) |$ `) {' O  Fsistent with true precocious puberty since his testi-2 D* E* h* p8 e2 E- E6 u
cles were prepubertal in size. However, testotoxicosis
: Z  \' c4 K1 a# k/ |( Rwas in the differential diagnosis because his father- a- K# j& W% W' n
started puberty somewhat early, and occasionally,* M1 M2 p9 b0 g4 T
testicular enlargement is not that evident in the
5 x5 h/ I  p5 obeginning of this process.1 In the absence of a neg-
% W/ Z- o; m7 [+ n3 c/ }ative initial history of androgen exposure, our# o9 ?) v( [' Z6 i* E
biggest concern was virilizing adrenal hyperplasia,
2 p; g3 T- C3 I  ?+ u$ eeither 21-hydroxylase deficiency or 11-β hydroxylase
' P# r1 u9 O. B4 k$ `4 n* ~deficiency. Those diagnoses were excluded by find-
2 B% u$ D+ C( l0 O! u7 d& xing the normal level of adrenal steroids.
1 q  f1 q- h% F0 o9 o. QThe diagnosis of exogenous androgens was strongly
8 F% X7 d  m! fsuspected in a follow-up visit after 4 months because+ x, U& R# n! o, H
the physical examination revealed the complete disap-
! e8 s! V0 e2 K% ]pearance of pubic hair, normal growth velocity, and
% z$ d( p5 y/ {7 m: Z* Q5 Xdecreased erections. The father admitted using a testos-
: y+ d$ i: i9 j9 x. ]  uterone gel, which he concealed at first visit. He was4 }! V% a! i( I5 l( [2 O" O
using it rather frequently, twice a day. The Physicians’+ ^8 h" p- x- X3 }, ^
Desk Reference, or package insert of this product, gel or6 d( M, C# u* t5 C& G
cream, cautions about dermal testosterone transfer to
0 s' f' i7 ?, r8 X3 {$ runprotected females through direct skin exposure.
$ E. P( {# h8 U6 Y3 H4 a4 u, fSerum testosterone level was found to be 2 times the  @% \" o! |) u& [$ A
baseline value in those females who were exposed to# w+ s. \7 b3 i. a3 g4 F
even 15 minutes of direct skin contact with their male" |! Q5 H: W1 g1 f& U4 V5 I& j
partners.6 However, when a shirt covered the applica-" B/ N% C4 ]# o: U5 r& q
tion site, this testosterone transfer was prevented.
8 ^; i4 J; r6 n& u6 F3 |Our patient’s testosterone level was 60 ng/mL,0 {  }  d$ l& `: F
which was clearly high. Some studies suggest that
# F: F* V, P# F4 k, K, T2 J8 P, odermal conversion of testosterone to dihydrotestos-1 N$ K$ h5 J' R/ z8 a, d; E
terone, which is a more potent metabolite, is more
' S4 t, J- k1 n& u' A' X7 Yactive in young children exposed to testosterone$ G* {$ T8 x& m* ~! u+ y" k9 s
exogenously7; however, we did not measure a dihy-6 W, i$ l) a0 L) q$ {5 h
drotestosterone level in our patient. In addition to
: t: M) t" @9 D8 F+ j: m5 F& Hvirilization, exposure to exogenous testosterone in3 e1 h" }1 Z/ ]( O) r
children results in an increase in growth velocity and
% g8 J4 H7 m7 l% j- A, w( Yadvanced bone age, as seen in our patient.0 J* g( q4 D% X, z4 p& L
The long-term effect of androgen exposure during8 x4 ?4 U# r' Q" R
early childhood on pubertal development and final5 U8 S3 A' X- B& _
adult height are not fully known and always remain! @) n% y" C9 c+ G
a concern. Children treated with short-term testos-7 ^& U) m8 ^  i9 Z0 h
terone injection or topical androgen may exhibit some9 F1 w0 M% h% c0 B- E6 j; f
acceleration of the skeletal maturation; however, after
* e" F$ Q: S* Dcessation of treatment, the rate of bone maturation8 o9 R3 N$ |2 {( c
decelerates and gradually returns to normal.8,9
* g/ N& h, ~4 XThere are conflicting reports and controversy
! Z# g6 ]- ]2 f* K# r( _: r! Aover the effect of early androgen exposure on adult
1 |. O' }4 N; F5 y( r) h8 X$ _penile length.10,11 Some reports suggest subnormal
' l+ e9 l6 |& q: U& u$ b) Cadult penile length, apparently because of downreg-* A. }! ^' q; _* I$ E) S6 x
ulation of androgen receptor number.10,12 However,
1 K6 q+ K5 Z2 j, n' y; q. VSutherland et al13 did not find a correlation between
; }5 t. _- Q' F- O, N) Zchildhood testosterone exposure and reduced adult
# H5 C' k) f+ L2 Vpenile length in clinical studies.7 B& t/ V: Z( o
Nonetheless, we do not believe our patient is6 z% ~- n# \! e& q  @
going to experience any of the untoward effects from& Z0 m; ]9 _$ z* r. w
testosterone exposure as mentioned earlier because, A) q1 [' Q& ?2 f& h
the exposure was not for a prolonged period of time.+ n$ g. h/ k; a9 Q
Although the bone age was advanced at the time of
0 Q8 g# H4 B6 jdiagnosis, the child had a normal growth velocity at
( O" j1 N2 e$ l* F4 `! `the follow-up visit. It is hoped that his final adult
# p+ {3 @. a8 X' q. ?) mheight will not be affected.
: t: [( V" y& Y2 L: y9 x7 J$ ?Although rarely reported, the widespread avail-/ P# N' V6 B2 B% P' T; I$ I, W& c) N
ability of androgen products in our society may* ?+ K! }* F- e5 M6 j
indeed cause more virilization in male or female0 J0 M! Z+ _, ]# Z: d
children than one would realize. Exposure to andro-; x) ~1 y+ z9 A
gen products must be considered and specific ques-' T+ I$ d/ W8 ^2 L, D9 e
tioning about the use of a testosterone product or, N) O% _7 b& \" X# o6 |7 {
gel should be asked of the family members during
6 e- D0 w2 ?1 C, C3 C% c, Tthe evaluation of any children who present with vir-& F" k+ b( Y5 G$ T
ilization or peripheral precocious puberty. The diag-. n2 S0 o, D/ e5 i
nosis can be established by just a few tests and by
9 P* l* W$ ?" z: Xappropriate history. The inability to obtain such a
% L" `) \- I, ]9 E: v% y0 hhistory, or failure to ask the specific questions, may
# x  E' A$ e9 \& Q# m0 {' B7 mresult in extensive, unnecessary, and expensive# n* H5 u8 [7 i" e* p& W7 b# \9 S
investigation. The primary care physician should be
6 J6 x) c& u1 taware of this fact, because most of these children
0 V0 M1 R/ E, e# O- Smay initially present in their practice. The Physicians’
0 I- ~6 P8 O0 {) u" f" c3 g* \2 ZDesk Reference and package insert should also put a
1 P7 p$ y9 A: |4 N. S3 b9 nwarning about the virilizing effect on a male or
+ g' k5 f1 _! y8 P* K% @female child who might come in contact with some-
  ^% E; }9 x1 K7 Done using any of these products.
+ i: i5 m; B2 f" O: l3 A  iReferences
4 D1 g5 b# H% R4 P1 X% x' Q& v1. Styne DM. The testes: disorder of sexual differentiation
4 j  y+ d; N# R% j. J3 aand puberty in the male. In: Sperling MA, ed. Pediatric
: [4 w  i8 j0 C6 F* ~6 hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  ~, @7 z) {* N/ G  Z2002: 565-628.+ O0 T  {0 M6 K4 C5 I/ z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ d7 D/ ^! d8 |' ]6 G5 d! u1 xpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
0 y. @7 J# @/ SBoy Induced by Indirect Topical; x" K- y  c; x, ^
Exposure to Testosterone) G/ N  _% W9 D/ I% a( `+ y: c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ V0 |+ S2 Y- l* r2 land Kenneth R. Rettig, MD1
4 H# \& n- ]5 d, |Clinical Pediatrics
" c4 ^0 p) q/ Q/ R4 m0 H7 M# DVolume 46 Number 6) m) C0 |4 C) H: H: w. L# g
July 2007 540-543
! f7 Q/ @- ?  b! P© 2007 Sage Publications
' `* X/ q$ W2 M: \2 g10.1177/0009922806296651
% v2 X, \) l' @& Q% }+ O( y% ]- p) }; `http://clp.sagepub.com
, O8 }5 B& y, {2 k. w0 N) jhosted at2 k# K# i# L) B0 [6 I
http://online.sagepub.com
1 w' C, F. d' o2 L) q5 fPrecocious puberty in boys, central or peripheral,
- R5 |* {  e  x2 d* V% ]2 xis a significant concern for physicians. Central% ?  I3 b8 }' r% \/ \! J% c
precocious puberty (CPP), which is mediated( [8 E6 l5 B1 k  O, ?; M& F- ]3 r
through the hypothalamic pituitary gonadal axis, has
  ]1 z$ ~  ]- G8 E8 A: y: m- Sa higher incidence of organic central nervous system
! [% n+ ]% C* U) O6 L* B. J/ \lesions in boys.1,2 Virilization in boys, as manifested6 c7 y2 B! z" Y
by enlargement of the penis, development of pubic: p" V  `" I. `# D  _/ @0 d
hair, and facial acne without enlargement of testi-' g# }3 W8 T$ `1 i5 B
cles, suggests peripheral or pseudopuberty.1-3 We
2 R% f0 h1 o8 o# \2 _2 |report a 16-month-old boy who presented with the+ Z! r8 v* C+ [( ^5 {' x( _& ]& Z
enlargement of the phallus and pubic hair develop-
. k$ q( ]: I& d3 q1 W, Tment without testicular enlargement, which was due! w% v6 H! Y2 z: X* A# l& W+ ?
to the unintentional exposure to androgen gel used by
6 S, l6 I' O2 [3 Xthe father. The family initially concealed this infor-
: g0 [. R5 e/ v- g- A- Fmation, resulting in an extensive work-up for this
( ~% I  c+ w3 N1 a  r/ p9 V0 |child. Given the widespread and easy availability of( l& @1 ]- }' C3 ~) U, ?! g6 o) F& m
testosterone gel and cream, we believe this is proba-' r! e2 }& m6 k
bly more common than the rare case report in the: X6 K& v" b* @4 x+ x9 ^9 j
literature.4/ d4 a( F8 j, u9 p9 x
Patient Report7 z4 a" H  X# m/ z  U
A 16-month-old white child was referred to the
5 C% W; n5 F1 C( O  Bendocrine clinic by his pediatrician with the concern
4 C3 b: l. J; w+ y7 V4 F3 [2 {of early sexual development. His mother noticed
! X% `$ u  \4 ^! Ylight colored pubic hair development when he was
) w# Z, z& E% jFrom the 1Division of Pediatric Endocrinology, 2University of$ \! k. I* K8 r9 @* G2 \
South Alabama Medical Center, Mobile, Alabama.
' F2 t% H9 l, \* VAddress correspondence to: Samar K. Bhowmick, MD, FACE,
- y, O: r4 o4 `8 r) DProfessor of Pediatrics, University of South Alabama, College of5 M+ F7 e/ X* {! y- g3 }) O+ ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, u9 e! v& R! M/ b3 C! d! V! l3 N. J
e-mail: [email protected].3 r) H; }) w8 G1 a. l8 Z; t; r
about 6 to 7 months old, which progressively became
% q7 D2 o  N% m* ^darker. She was also concerned about the enlarge-
2 M9 A3 p9 h4 T: h) b8 Vment of his penis and frequent erections. The child4 ~7 O9 W  W) z' ~1 y
was the product of a full-term normal delivery, with
* W" n( |/ i" O/ ^1 Q# R& @a birth weight of 7 lb 14 oz, and birth length of& u$ f7 U* z7 G) G
20 inches. He was breast-fed throughout the first year
* P  K: p, R: N, _+ Z0 I" u! ]8 U6 Qof life and was still receiving breast milk along with
7 o6 s) Q& e2 h, X# asolid food. He had no hospitalizations or surgery,/ h% k  I) F' ^+ T6 K
and his psychosocial and psychomotor development1 W, i9 c4 U: ~4 E
was age appropriate.- g* h3 F* f( {4 q* F0 q2 m/ B
The family history was remarkable for the father,; `8 ~; ?8 T* `3 C5 g) M
who was diagnosed with hypothyroidism at age 16,
/ M" T" V4 w2 B+ \) A0 awhich was treated with thyroxine. The father’s2 t$ N8 y) ?! s3 s; W& Q
height was 6 feet, and he went through a somewhat
7 |" R; G. i, W4 ^early puberty and had stopped growing by age 14.
# v$ X/ W! y& P7 f7 O* MThe father denied taking any other medication. The% Q' k3 W& y" v' Z
child’s mother was in good health. Her menarche
0 A3 L" r5 P1 y% E& ]was at 11 years of age, and her height was at 5 feet
& P& W# R6 P4 R5 inches. There was no other family history of pre-4 S6 X! e$ V* x2 d; T
cocious sexual development in the first-degree rela-
1 u% `1 W( h5 o3 E  ?/ ]3 Q" C+ atives. There were no siblings.
# _; T1 V; y; R5 |2 O* LPhysical Examination
; \! n6 _- Q2 MThe physical examination revealed a very active,
! S6 F# _  \2 y! D$ Oplayful, and healthy boy. The vital signs documented' ]9 c" |4 L6 Y% i9 f
a blood pressure of 85/50 mm Hg, his length was
" ], f- w( M. j/ ^5 v% l5 N6 d; C90 cm (>97th percentile), and his weight was 14.4 kg9 A& p* L7 }$ I, c- F
(also >97th percentile). The observed yearly growth
( j4 Y8 ?' i; I+ l8 W  R/ t5 mvelocity was 30 cm (12 inches). The examination of2 `7 |6 o' @  {. W+ F+ `
the neck revealed no thyroid enlargement./ h# j! O6 V) P3 D+ B) x/ M
The genitourinary examination was remarkable for( W4 Y9 Z% S# ~! p
enlargement of the penis, with a stretched length of
3 E0 c' ?. J9 a5 q& ^$ U5 s8 cm and a width of 2 cm. The glans penis was very well
, ^; K% T" n; Y8 ideveloped. The pubic hair was Tanner II, mostly around2 g" Z1 {* H" p+ y5 X
540/ v# K0 r. n, N9 z/ y' B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# n, ~3 p% P/ O- m2 qthe base of the phallus and was dark and curled. The4 I$ r) Q5 j% G( `3 P
testicular volume was prepubertal at 2 mL each.
8 x( _1 [7 V8 W: C" A& o' PThe skin was moist and smooth and somewhat4 r/ w7 Q% \1 i$ I, Q% m" I
oily. No axillary hair was noted. There were no
  n6 a  s; G3 ]2 L3 d" R! Jabnormal skin pigmentations or café-au-lait spots.
: ]3 G4 c% L- V+ i% @& TNeurologic evaluation showed deep tendon reflex 2+2 J1 l7 ^5 `8 |/ {
bilateral and symmetrical. There was no suggestion
4 j, d5 U) s# J4 Aof papilledema.
4 K% h1 _* S7 {7 I1 }* SLaboratory Evaluation
% C* f. H/ x" {; p5 VThe bone age was consistent with 28 months by; j) n. j4 L1 a& X- e, c# x
using the standard of Greulich and Pyle at a chrono-, D) P" R- n' t' h7 b$ ?% g1 Z
logic age of 16 months (advanced).5 Chromosomal4 S5 i, f4 h0 M3 Z5 L9 f2 {  k
karyotype was 46XY. The thyroid function test, |7 o" y% O7 d' M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
' R6 _3 I9 C. o! Glating hormone level was 1.3 µIU/mL (both normal).
1 p) r" o2 l5 b$ F* D+ ]5 aThe concentrations of serum electrolytes, blood, |' d8 ]' `5 `' n5 y
urea nitrogen, creatinine, and calcium all were
1 m. V# x4 d9 \- E8 pwithin normal range for his age. The concentration6 s# [" V+ R$ @: o
of serum 17-hydroxyprogesterone was 16 ng/dL
0 \$ n5 U1 ^1 j+ r" g, m(normal, 3 to 90 ng/dL), androstenedione was 204 v  l$ c/ {3 I4 }5 D, a3 O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& C9 Q9 c9 p! y+ D, D" Z9 X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),1 u! X1 g  {0 D1 O$ |  Z' H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 t* b( Y. [9 g; \
49ng/dL), 11-desoxycortisol (specific compound S)( c9 L( q, \& i, `. ?  l6 U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 j* l( w# }" u2 U4 w8 W; L; u6 @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, e2 X6 q( v1 v; M/ T$ M2 b& atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' O) u9 p, F% e
and β-human chorionic gonadotropin was less than
1 m# ?; H$ u/ o( L  e* ]- q/ E/ A5 mIU/mL (normal <5 mIU/mL). Serum follicular
. O+ |0 A4 i8 @# Q' x  vstimulating hormone and leuteinizing hormone" {3 n3 L' H! U% ~% G0 }5 Q  O
concentrations were less than 0.05 mIU/mL5 I( Z2 _+ [: Y; o) q
(prepubertal).
) k* y' _+ ?3 P- {  X% Z- UThe parents were notified about the laboratory
, x; Y" d, a2 w% t8 zresults and were informed that all of the tests were( j9 _% K% W$ n/ d
normal except the testosterone level was high. The
9 n( y9 r2 T& p; F9 p# `3 dfollow-up visit was arranged within a few weeks to
' u  o3 l) U& T" ?obtain testicular and abdominal sonograms; how-1 V8 j  P  v( o, S+ ^
ever, the family did not return for 4 months., h9 g% s. q; y& {/ S' r/ l
Physical examination at this time revealed that the( Y9 c9 ]3 a& O& t2 p0 o, |# p
child had grown 2.5 cm in 4 months and had gained8 R3 Q7 f% z# Q7 k' l2 |
2 kg of weight. Physical examination remained; d/ j' c( q" J* j" X: t$ M
unchanged. Surprisingly, the pubic hair almost com-
( m  g) A8 d1 {+ q0 Q" mpletely disappeared except for a few vellous hairs at
) T: [1 ^5 V* a6 S! othe base of the phallus. Testicular volume was still 2; H! m/ @* Z4 @+ B% t2 |! t
mL, and the size of the penis remained unchanged.* A# a/ k! H; t1 B! x
The mother also said that the boy was no longer hav-
7 Z  P  j, @, ?! j9 E6 v" J5 ping frequent erections., w& G6 P0 `8 p$ h
Both parents were again questioned about use of0 \2 z+ ?7 m* L# O  P
any ointment/creams that they may have applied to
! f  {' g! i( Q" u; _4 lthe child’s skin. This time the father admitted the
/ u  k2 E1 |& g( a9 m8 RTopical Testosterone Exposure / Bhowmick et al 541
! O% U6 z5 }+ U7 u" \( U/ M1 \2 `use of testosterone gel twice daily that he was apply-/ l. F+ L; O+ a6 Z. |! v9 D
ing over his own shoulders, chest, and back area for
6 A( _5 ]' v* I% c1 za year. The father also revealed he was embarrassed' j1 Z9 T' z7 e  \
to disclose that he was using a testosterone gel pre-
( \- O" W& o3 A  d9 pscribed by his family physician for decreased libido
$ B* P5 C5 Q: K* [3 Esecondary to depression." l7 d, z8 q5 X! F% ^7 T
The child slept in the same bed with parents.4 V2 D. A. G9 q& x/ Q6 H" |
The father would hug the baby and hold him on his8 I# j% P; i6 [# _* e+ \
chest for a considerable period of time, causing sig-3 u5 `9 g' [6 l2 H9 V' c, a
nificant bare skin contact between baby and father.
' c% w& y7 B; v$ T+ i& i; F$ NThe father also admitted that after the phone call," M; K5 y5 I3 ]3 x
when he learned the testosterone level in the baby
9 p8 V& W# [9 h  A) Dwas high, he then read the product information! O$ z8 u9 ~9 N; G
packet and concluded that it was most likely the rea-
; _% t0 I  w" H7 O: [8 vson for the child’s virilization. At that time, they
5 \) B% e3 {! T( ?+ r0 j/ ], bdecided to put the baby in a separate bed, and the3 m( F; ^/ c! _" @- p& {' P
father was not hugging him with bare skin and had6 b8 t. @+ ]+ k! L
been using protective clothing. A repeat testosterone" P3 _- C+ y2 I* X+ O
test was ordered, but the family did not go to the5 N% |+ h- V6 ]. V/ `
laboratory to obtain the test.4 t* U( P5 I$ p/ ~
Discussion) ?* j7 p. b' E7 Z9 q1 g  y
Precocious puberty in boys is defined as secondary
. c; |9 z* C' b9 jsexual development before 9 years of age.1,4
$ ?3 @1 b2 @) c2 ^; LPrecocious puberty is termed as central (true) when
# _/ k* i# o3 Q) j- rit is caused by the premature activation of hypo-
) Q- i" _2 |3 O- Lthalamic pituitary gonadal axis. CPP is more com-; W) ^, F! [$ S, L1 E7 t& s
mon in girls than in boys.1,3 Most boys with CPP0 _3 N  P, o. g* s9 S
may have a central nervous system lesion that is
, x/ T5 q! e, v' L% Qresponsible for the early activation of the hypothal-
) X7 B9 L% s* |' l3 g* L3 tamic pituitary gonadal axis.1-3 Thus, greater empha-
, j2 h$ F0 \+ ?( bsis has been given to neuroradiologic imaging in* m7 C. b9 a. {' O: b' q% V
boys with precocious puberty. In addition to viril-
$ u: q' c, y( N: M% |9 ?ization, the clinical hallmark of CPP is the symmet-
4 U# ?; |7 _9 A' {7 }9 Rrical testicular growth secondary to stimulation by0 b4 `2 L2 S1 w3 Z
gonadotropins.1,3
2 N" H) m, E& |Gonadotropin-independent peripheral preco-
8 x' l2 c6 W( A$ Mcious puberty in boys also results from inappropriate, F4 X' t3 m( t2 b- w1 S
androgenic stimulation from either endogenous or
) `- x/ K, B, yexogenous sources, nonpituitary gonadotropin stim-3 F* s4 A& y  @; B4 H
ulation, and rare activating mutations.3 Virilizing
2 j1 q7 G! d9 S6 I% D8 pcongenital adrenal hyperplasia producing excessive
, `4 F% ~* ~  w. F+ ]4 ~/ oadrenal androgens is a common cause of precocious" f/ v" g2 }. S: ~+ ?7 R
puberty in boys.3,4
5 R2 Y: `- T- |+ N& Z& `; N1 e0 oThe most common form of congenital adrenal
  M: B: Q7 }; A/ Thyperplasia is the 21-hydroxylase enzyme deficiency.
8 N9 Q4 X; H. [  Z/ J" \The 11-β hydroxylase deficiency may also result in7 B4 o$ P0 Z! t( ~$ n& C0 f. d8 r
excessive adrenal androgen production, and rarely,  g5 C: G$ z6 M% ^
an adrenal tumor may also cause adrenal androgen" x/ s& j' j9 i2 g" }$ i6 A
excess.1,3
' m  n/ h2 e2 |6 [1 v" j8 `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 J8 d4 W3 T4 \, s0 i: I/ S0 _' T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. D3 U# i  i8 H0 ]- }6 h# }
A unique entity of male-limited gonadotropin-
8 u* P+ N( X. b& vindependent precocious puberty, which is also known) y2 K4 q0 k4 ~
as testotoxicosis, may cause precocious puberty at a
! L: H; n! T8 e6 d' R; rvery young age. The physical findings in these boys+ A( |% u) R) W* M5 S1 m
with this disorder are full pubertal development,3 f1 F* v+ m8 P, d
including bilateral testicular growth, similar to boys
/ y& X4 M" {6 o  h5 Lwith CPP. The gonadotropin levels in this disorder
( y+ N2 S8 D: v0 I; x0 D" ]are suppressed to prepubertal levels and do not show
2 a; e; s  j  X0 r# O% L, ^- Y% Ipubertal response of gonadotropin after gonadotropin-
3 D4 k* T; M% l8 jreleasing hormone stimulation. This is a sex-linked
9 k0 I0 H5 n- W* @" Lautosomal dominant disorder that affects only
( d5 j6 S$ D9 [: ^. o" r- E, Qmales; therefore, other male members of the family
+ R  V9 O0 m% ]( |may have similar precocious puberty.3
5 ~# c8 L7 d  Z* b5 h0 \In our patient, physical examination was incon-7 M# _7 j1 s3 O  S- n5 u
sistent with true precocious puberty since his testi-' g9 C+ z" g4 d
cles were prepubertal in size. However, testotoxicosis
- e% |( f3 x$ V0 W; xwas in the differential diagnosis because his father
/ ]. I0 i+ N" m/ _9 Astarted puberty somewhat early, and occasionally,
, h" H' Q; ^  L5 E+ [testicular enlargement is not that evident in the
; v- e1 U- I( @  H7 v4 }beginning of this process.1 In the absence of a neg-
, B! V: ~& o# v4 M7 mative initial history of androgen exposure, our
, F: p$ B0 m: q& U& r, [* `9 D6 Vbiggest concern was virilizing adrenal hyperplasia,5 V* \, f; S% f. z8 a
either 21-hydroxylase deficiency or 11-β hydroxylase
& `7 q8 S: [& N. \deficiency. Those diagnoses were excluded by find-$ E. g0 B' @8 b- k3 @2 @
ing the normal level of adrenal steroids.$ n2 [  I; l9 V/ Z
The diagnosis of exogenous androgens was strongly
; D6 r1 P8 [2 osuspected in a follow-up visit after 4 months because! {) e  z8 {/ [) `
the physical examination revealed the complete disap-
( ?  u4 M8 F4 Q& n2 T, epearance of pubic hair, normal growth velocity, and( L7 s2 d5 g9 _3 ?+ M" R8 ]
decreased erections. The father admitted using a testos-
& `( J, p' I1 ~5 V$ W! k0 {' \9 dterone gel, which he concealed at first visit. He was
, L/ `$ h: j" N3 }using it rather frequently, twice a day. The Physicians’2 A0 T8 s9 b8 E, T4 H4 F
Desk Reference, or package insert of this product, gel or
% F6 s4 n, n% b( h; d; r; S, `' jcream, cautions about dermal testosterone transfer to
7 c8 ?. V' w. a% t: f* E2 B  V0 Wunprotected females through direct skin exposure.
9 K! I" ]% ~( [3 |, VSerum testosterone level was found to be 2 times the
+ `1 f2 |0 D* U! j9 F. h# N/ v1 a  Wbaseline value in those females who were exposed to
4 {) {' I2 T/ s8 {& g, n) neven 15 minutes of direct skin contact with their male
; C. _+ O* A& p9 _partners.6 However, when a shirt covered the applica-0 r: T, C: D1 _' D# e( [7 `! G% B
tion site, this testosterone transfer was prevented.. |4 R0 c% @  d, `9 d( H. z
Our patient’s testosterone level was 60 ng/mL,3 U& z4 n6 b7 A" Z( P# T5 {/ v
which was clearly high. Some studies suggest that
* }! B) P# Y- S6 |dermal conversion of testosterone to dihydrotestos-9 w* A, Q+ n. p# M, T
terone, which is a more potent metabolite, is more
5 Q- d' x! {0 n% Y. Tactive in young children exposed to testosterone
" p$ ]2 y+ Z! V/ ]2 d8 ?2 W3 ?  wexogenously7; however, we did not measure a dihy-9 \4 t( A) c# Y" d4 K
drotestosterone level in our patient. In addition to
8 z. H$ o7 X+ r3 j0 X; r: rvirilization, exposure to exogenous testosterone in- f. o" p9 x/ g& W
children results in an increase in growth velocity and
. ~- @+ m  `: U: A# \; I' t1 l8 |advanced bone age, as seen in our patient.
7 c& w% \/ U  ]+ R, k8 m4 K' S3 XThe long-term effect of androgen exposure during: m% v8 `2 R3 c# f
early childhood on pubertal development and final& i  n3 g) L0 z2 s. d2 p
adult height are not fully known and always remain) n* s& y# B3 z, o4 ]
a concern. Children treated with short-term testos-
2 A( u/ J0 `; \terone injection or topical androgen may exhibit some
3 D  H" ~! x9 m4 M$ r* f: racceleration of the skeletal maturation; however, after# f. H7 H# Y" W: g
cessation of treatment, the rate of bone maturation
, u# ~/ h2 J! Y9 H+ [: `decelerates and gradually returns to normal.8,9
3 |& l3 N! h/ X- JThere are conflicting reports and controversy
, |  G) g( K# |# f! D8 Mover the effect of early androgen exposure on adult! z' E7 K/ n+ A
penile length.10,11 Some reports suggest subnormal, _! S; c) B' i6 p2 f
adult penile length, apparently because of downreg-+ S. }1 w; K1 e' {1 z
ulation of androgen receptor number.10,12 However,5 x& i6 t# |  P; @: D
Sutherland et al13 did not find a correlation between, m1 i# d! Y: {6 ~' W* i+ m; M
childhood testosterone exposure and reduced adult
. |+ l# p5 _# |" ?penile length in clinical studies.6 [9 a( h, F6 p
Nonetheless, we do not believe our patient is) n8 v2 g% }. A0 [9 L
going to experience any of the untoward effects from4 t/ O3 i/ n# i' |) H/ ~& l
testosterone exposure as mentioned earlier because% ^; j' |2 O% T9 c  |
the exposure was not for a prolonged period of time.
- C; v  n9 E. B& r# Y5 S+ f2 Z4 iAlthough the bone age was advanced at the time of
5 O3 e. n* r, L% ^9 v5 }4 L$ Mdiagnosis, the child had a normal growth velocity at0 L3 e/ k/ c/ f/ ]6 N: Q. t$ A
the follow-up visit. It is hoped that his final adult3 e) P& V6 J& ^, [/ S6 }! V
height will not be affected.3 R. [" }1 G# u* u
Although rarely reported, the widespread avail-
$ q( {! f% i/ f! G3 {ability of androgen products in our society may/ ^9 \4 j( E, [' N+ I4 a3 M
indeed cause more virilization in male or female
7 y6 o% J! n$ }# G1 uchildren than one would realize. Exposure to andro-
5 D( J# Z4 @7 I7 d2 C% X- }6 Zgen products must be considered and specific ques-
- B' u; B8 h3 Ctioning about the use of a testosterone product or
" X1 p8 s% O/ B, R4 @gel should be asked of the family members during
4 c# b" z* p1 ?  e* ~5 R" R: wthe evaluation of any children who present with vir-8 E: [( Y, v: t3 {6 j  z% h9 @& s
ilization or peripheral precocious puberty. The diag-3 \+ L7 w, m/ K6 }5 q: D
nosis can be established by just a few tests and by# u( {  e3 [3 x0 j4 p1 m
appropriate history. The inability to obtain such a
  y. I5 P* T7 `4 P$ Z. ~history, or failure to ask the specific questions, may
- @* o! }- G4 Z4 d4 g9 p  N, wresult in extensive, unnecessary, and expensive
  o; m8 q1 O* U, n5 f! Finvestigation. The primary care physician should be3 l% f0 \! |0 V( \
aware of this fact, because most of these children
" [3 `4 E4 H6 @( N1 n. ?may initially present in their practice. The Physicians’: k/ p! F6 Q' c) c# }
Desk Reference and package insert should also put a
- w, t- _0 r; |: Y; hwarning about the virilizing effect on a male or" |" \+ i; c  U! u' z% \4 x( p% ~
female child who might come in contact with some-
- B+ W- I) e/ }! aone using any of these products.' `  S6 x& x9 ^! |1 S
References) G4 C, p5 @' [0 r# G6 e8 i# e! N& t
1. Styne DM. The testes: disorder of sexual differentiation
+ I9 W+ O# ?. C4 H" p1 Aand puberty in the male. In: Sperling MA, ed. Pediatric7 d. I( d! C/ ?1 B" K: N8 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( Q9 @* }0 T, B; r2 L. ^2002: 565-628.  K( Y8 t7 M9 I# w
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) P$ U1 T% \$ q9 G) U. `8 n
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

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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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