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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-Old8 R1 q, S; j( A7 R4 x
Boy Induced by Indirect Topical
: |0 ]8 k8 k: JExposure to Testosterone
7 j/ \0 H" |- e  u! RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 W7 G% y0 m+ Z: {& H1 |
and Kenneth R. Rettig, MD19 w. Z% L% h+ ?/ i
Clinical Pediatrics
7 U3 N6 ]" D/ AVolume 46 Number 6
- Y: O* ~! X' |2 w4 Q  G3 hJuly 2007 540-5439 K6 V/ G- V" s! j, {) ?
© 2007 Sage Publications; S& L) c& z, d, E0 y% Q
10.1177/00099228062966514 q- r, N  {& P# l
http://clp.sagepub.com% d/ k! w6 Y! G- n7 _& y
hosted at. m9 P/ z4 W( ^1 Q
http://online.sagepub.com
, j/ K$ M4 z. v/ Y$ b8 BPrecocious puberty in boys, central or peripheral,+ v% k( f2 w9 _+ |
is a significant concern for physicians. Central  |& U( v; i1 b5 ?+ e
precocious puberty (CPP), which is mediated1 b+ u( O, q8 W
through the hypothalamic pituitary gonadal axis, has/ }( h& g! K, S% s+ Z* B; o& K
a higher incidence of organic central nervous system( I% ]1 W2 B, q' H2 K1 A) G3 h
lesions in boys.1,2 Virilization in boys, as manifested( Y0 y5 ?5 ^* `% n9 W. T1 y& X3 G
by enlargement of the penis, development of pubic
. p, A2 q4 w: C1 Q2 w7 dhair, and facial acne without enlargement of testi-
, ]$ \3 s4 ~: ~2 F6 w, h) V7 G) Zcles, suggests peripheral or pseudopuberty.1-3 We
& s+ v9 c- ^. f& x% Ureport a 16-month-old boy who presented with the
" y2 G2 T# f5 [: Denlargement of the phallus and pubic hair develop-5 X; @. L2 S; s! x5 I0 w4 @% s
ment without testicular enlargement, which was due
; \1 A" }$ A/ W( R! }6 ]to the unintentional exposure to androgen gel used by5 E9 \. a; F5 Q& o2 j
the father. The family initially concealed this infor-
8 s  W7 q. x$ C/ c8 u$ Kmation, resulting in an extensive work-up for this
: s- |9 g8 `4 }) i; c9 echild. Given the widespread and easy availability of8 ]" @' O. h. A' K: ~" L+ T( W
testosterone gel and cream, we believe this is proba-
+ _( j  n( E) Q1 Z9 M' Ably more common than the rare case report in the
5 N* f8 _5 S1 Q0 u7 j" G& J  wliterature.4
6 V$ ~# g* }2 x; u/ Q7 i1 `2 {Patient Report
8 a' {3 ]5 W' N1 ]9 mA 16-month-old white child was referred to the1 e0 x7 r) L  X  g5 e9 |. h
endocrine clinic by his pediatrician with the concern  a7 l6 T6 @. K  D2 B
of early sexual development. His mother noticed6 O, E. h" l; p7 |$ @8 P
light colored pubic hair development when he was3 t+ ~5 ^. z, w( T! L
From the 1Division of Pediatric Endocrinology, 2University of" P3 z1 w! U1 ~4 \- l0 g
South Alabama Medical Center, Mobile, Alabama.( P' B( b# p6 l. G! q
Address correspondence to: Samar K. Bhowmick, MD, FACE,# M8 Y+ n7 {* D$ |8 J
Professor of Pediatrics, University of South Alabama, College of! o! R0 m1 Y3 o: \; |8 e' R! K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 z0 q- R* c% T2 r
e-mail: [email protected].
4 T; `# S4 z3 ~" K( L( V7 Oabout 6 to 7 months old, which progressively became
) w" k# s* [! s& E( s9 {darker. She was also concerned about the enlarge-1 i, d$ W9 w' ?
ment of his penis and frequent erections. The child
) b& {( d3 q, x! }1 pwas the product of a full-term normal delivery, with
$ n8 m' t' W; r2 m* Ka birth weight of 7 lb 14 oz, and birth length of6 T3 i9 q9 z( N
20 inches. He was breast-fed throughout the first year' s. O: v+ d8 G
of life and was still receiving breast milk along with
$ f4 ]* Z, [) w! \: ysolid food. He had no hospitalizations or surgery,( X6 n6 [5 Q1 p& H
and his psychosocial and psychomotor development
" x( I* h: J) }5 j" Qwas age appropriate.
! |& y+ R' |1 y* `& f. kThe family history was remarkable for the father,
1 w  |0 V6 Z  n, \who was diagnosed with hypothyroidism at age 16,
, e: x6 k9 u5 L0 O4 x1 Gwhich was treated with thyroxine. The father’s, @8 S: M* C* v7 E3 K$ Y
height was 6 feet, and he went through a somewhat
4 _+ f$ U  y# n6 E1 }% E: A) |  Bearly puberty and had stopped growing by age 14.4 ~+ Y0 a6 W5 D, d
The father denied taking any other medication. The
; j4 I1 {6 V. h7 t, [child’s mother was in good health. Her menarche
9 v! X& H) n" N+ J% bwas at 11 years of age, and her height was at 5 feet2 [- q; T, r! G: W
5 inches. There was no other family history of pre-
  M3 i9 X6 C% V! ?cocious sexual development in the first-degree rela-
6 @* D& L+ d- u  v. _% X+ g( utives. There were no siblings.- P1 B) O; Z  {  O, R8 o6 J6 a
Physical Examination
% l: K  Q6 D' ~# x7 m& a& J+ g( V! EThe physical examination revealed a very active,. F1 y1 S+ w3 H+ K  A6 _+ V% A
playful, and healthy boy. The vital signs documented
( j9 W7 H6 u& O! x* fa blood pressure of 85/50 mm Hg, his length was9 }) E5 U" H" s2 _
90 cm (>97th percentile), and his weight was 14.4 kg. i9 P# N, C2 x  N
(also >97th percentile). The observed yearly growth
- B; r& }3 o$ m7 M7 h& O; Qvelocity was 30 cm (12 inches). The examination of
+ b0 m  a' o+ M+ hthe neck revealed no thyroid enlargement.2 R; g, r, a  F% m
The genitourinary examination was remarkable for6 Q$ h1 f  U! P' _7 S
enlargement of the penis, with a stretched length of7 S  m% m: H8 e& u& Z2 N8 z4 f
8 cm and a width of 2 cm. The glans penis was very well4 U! t3 d2 r* A/ ], L5 p
developed. The pubic hair was Tanner II, mostly around
& ~4 A- V, t, |9 F540  ~* G0 L% F9 l: }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 i* O1 h# P' pthe base of the phallus and was dark and curled. The
0 v: ^$ `6 x5 J/ {$ v8 z' ]. X2 g! I; Ytesticular volume was prepubertal at 2 mL each.
7 G  B& m/ \! uThe skin was moist and smooth and somewhat9 m: a: y4 i8 y' w4 R
oily. No axillary hair was noted. There were no
: A/ z  V: u% Dabnormal skin pigmentations or café-au-lait spots.4 I4 F& D7 U& o5 u7 Z
Neurologic evaluation showed deep tendon reflex 2+
" Z/ w9 X* a% @% Ebilateral and symmetrical. There was no suggestion
! @; w$ a( N1 c" cof papilledema.% U. h$ H* l6 K+ h, B$ N( I( ]
Laboratory Evaluation
9 t8 O7 _. R$ b4 gThe bone age was consistent with 28 months by$ @+ l! z( \7 O& T6 o
using the standard of Greulich and Pyle at a chrono-
8 x/ ^$ A/ M: X7 ?4 qlogic age of 16 months (advanced).5 Chromosomal& ]5 C; w- q/ i' W& |4 s
karyotype was 46XY. The thyroid function test
+ ^+ p6 Z- A, X7 ~- d9 Z( Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 e+ I4 s! l, H8 c7 flating hormone level was 1.3 µIU/mL (both normal).* W  J, [( L0 L4 P' r6 R- k" V
The concentrations of serum electrolytes, blood& C# K6 Z, h7 D. D5 Q: T
urea nitrogen, creatinine, and calcium all were6 t8 G1 m  ]) Z. y7 m. y
within normal range for his age. The concentration
+ k" i, q/ G4 `4 O! p; [  u4 {of serum 17-hydroxyprogesterone was 16 ng/dL
, V7 l4 H5 h, l5 p7 g1 ]; R(normal, 3 to 90 ng/dL), androstenedione was 20* T% X( g! \% l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 t" q( n" y( B& J* E9 qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 ^8 H" J( L+ h/ qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 N3 k, R: B1 \5 v! W49ng/dL), 11-desoxycortisol (specific compound S)
8 R4 h* Q. B* t1 t( r/ ~( g  Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 V- }( L  O; `3 W" {0 L8 r) Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 t3 l; ~* d; r% f* x+ k/ V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 d6 {$ a# x( J; x7 `5 b3 ?and β-human chorionic gonadotropin was less than
$ Y$ q2 b! H+ [& K  c2 O5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 O1 O% X, t/ Z) t0 C2 sstimulating hormone and leuteinizing hormone
3 l, C6 I8 P8 D3 b* Q/ U% t) D; y8 hconcentrations were less than 0.05 mIU/mL
' E5 O4 i" l0 \(prepubertal).
" u2 _9 j3 X: c- aThe parents were notified about the laboratory
5 Q9 R" ]  s; [1 \6 cresults and were informed that all of the tests were; m/ c. ~& `7 ^
normal except the testosterone level was high. The
/ k$ ]( [$ o2 C4 r) o7 y7 ~  bfollow-up visit was arranged within a few weeks to( Z6 {2 G( }" r% R7 ?# h
obtain testicular and abdominal sonograms; how-  ~6 \7 r+ B3 B- ~0 ^6 G; E
ever, the family did not return for 4 months.
% X* x! \$ ?) T( @' O) pPhysical examination at this time revealed that the
% j5 _% X. U8 @1 t- g/ w/ c/ R0 U) fchild had grown 2.5 cm in 4 months and had gained
9 ~, ]- h9 ]/ U, U- d2 kg of weight. Physical examination remained3 m- }. M9 `, Z7 Q
unchanged. Surprisingly, the pubic hair almost com-) W, t# m8 q" X- ?+ k8 G! C
pletely disappeared except for a few vellous hairs at+ J8 G5 k, I  V! g2 l, ^3 f
the base of the phallus. Testicular volume was still 28 m# t$ O) B% ]$ u/ F* {$ @7 C1 n
mL, and the size of the penis remained unchanged./ o0 q( ^- U! d# j
The mother also said that the boy was no longer hav-6 F2 P+ M# d: t" f: H7 Y
ing frequent erections.
( ?; Z: |# S; b, c6 ^( e9 ]+ _Both parents were again questioned about use of$ _( w* i& w  Q" ?4 `. A% t# }9 l+ S5 W
any ointment/creams that they may have applied to
: N; p3 N& j6 r3 _& }( g" Cthe child’s skin. This time the father admitted the
, k7 s, k2 A3 kTopical Testosterone Exposure / Bhowmick et al 541
, k7 G7 R2 a& v! d1 Euse of testosterone gel twice daily that he was apply-
" U7 l' i- d8 _2 H) }! wing over his own shoulders, chest, and back area for$ ]6 R: L( Q. s
a year. The father also revealed he was embarrassed
8 `* @! S7 T/ B! c0 A: `to disclose that he was using a testosterone gel pre-$ W$ Q1 z% m0 t) P; Q, M0 l6 `
scribed by his family physician for decreased libido+ y& B/ a- V6 M% p, b! a
secondary to depression.1 S# K$ J$ q( W1 n$ _5 ]
The child slept in the same bed with parents.
1 h" \* y0 H& Z* Y0 @* H4 @The father would hug the baby and hold him on his8 J. h  }7 F- b
chest for a considerable period of time, causing sig-
) O) f+ a! ]' ]/ f" qnificant bare skin contact between baby and father.' r6 C/ h1 U7 x) e9 p6 a; j
The father also admitted that after the phone call,
- l+ t* [; i9 q4 k+ U$ f; bwhen he learned the testosterone level in the baby# W: \6 T# O8 |# g
was high, he then read the product information% Q) ~5 r4 a1 p3 I' \2 j
packet and concluded that it was most likely the rea-
) @+ x& j+ I3 J/ Json for the child’s virilization. At that time, they& y/ G+ m% s" [
decided to put the baby in a separate bed, and the/ o% i2 W5 ^. m; _8 p( X2 Y# T
father was not hugging him with bare skin and had. {. w, |% W" c7 x$ i8 ]
been using protective clothing. A repeat testosterone0 j- w5 ^" j5 ]) }
test was ordered, but the family did not go to the
7 Y0 u2 }4 x0 e" `9 alaboratory to obtain the test.
' Z2 V& J/ T* R# o7 V% I* `6 jDiscussion' Q- ]: f4 f1 A* @0 q
Precocious puberty in boys is defined as secondary
7 O0 ^7 u: P: O  Wsexual development before 9 years of age.1,4  ^  X  c3 H6 k* ]' f( W
Precocious puberty is termed as central (true) when0 Y/ V9 [& Z; j3 `
it is caused by the premature activation of hypo-
: P7 [$ W+ T- I; j+ @; f" [& Bthalamic pituitary gonadal axis. CPP is more com-* U. j6 ?4 F1 }2 y( J
mon in girls than in boys.1,3 Most boys with CPP
& f0 e. q3 F; B# C8 O+ e# @) q' }may have a central nervous system lesion that is" z* L$ h: l4 A/ ?/ [
responsible for the early activation of the hypothal-/ m9 @* H. k5 A: u- ~) h, H
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 e- U3 g' d4 v  ~5 j: hsis has been given to neuroradiologic imaging in
2 S" o& j% ]3 T$ v  Fboys with precocious puberty. In addition to viril-! `  B6 m# d; u1 b* ]3 h
ization, the clinical hallmark of CPP is the symmet-$ ^; u% y1 g- ]
rical testicular growth secondary to stimulation by
  X' Y- H0 v5 s/ Rgonadotropins.1,30 z+ F3 m, e. x4 h* H/ ]
Gonadotropin-independent peripheral preco-
$ `5 T; w" a' h! Kcious puberty in boys also results from inappropriate
$ ]' X! b8 M- K/ C1 R7 Tandrogenic stimulation from either endogenous or% |1 V- X) r/ _" u% g) X5 Z
exogenous sources, nonpituitary gonadotropin stim-
5 `+ o; K! [6 D4 |ulation, and rare activating mutations.3 Virilizing
7 Q  p! i7 F7 {, j/ s* j2 qcongenital adrenal hyperplasia producing excessive
3 J7 d8 }/ Z+ G$ a; R/ Xadrenal androgens is a common cause of precocious
0 K8 ^' }3 O$ ]$ l8 opuberty in boys.3,4
3 N- h0 X; \9 _6 H7 OThe most common form of congenital adrenal% E6 m6 v: F5 b0 F. e* s
hyperplasia is the 21-hydroxylase enzyme deficiency.3 C( ~6 Z& g; Z( U8 S
The 11-β hydroxylase deficiency may also result in
3 k8 b8 c+ q; W) Z% Wexcessive adrenal androgen production, and rarely,
1 e$ u) O! F" v" Qan adrenal tumor may also cause adrenal androgen4 S2 o) S' i) \
excess.1,3
  y8 n9 \6 E) y7 O7 y4 c2 uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. b' H0 K3 h' W+ e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. `: Z4 `" O7 o0 A* R
A unique entity of male-limited gonadotropin-
+ y. S; R; ]8 y* ]independent precocious puberty, which is also known' U( k. a: I% A$ N" Y
as testotoxicosis, may cause precocious puberty at a1 E+ U7 n. f" v* }* P7 W
very young age. The physical findings in these boys
1 q: o0 h' e0 E  e' v8 Bwith this disorder are full pubertal development,
. y2 `8 j2 j- z* nincluding bilateral testicular growth, similar to boys
5 R! c5 `- r! Qwith CPP. The gonadotropin levels in this disorder9 O, ]6 H* s- H4 e! c
are suppressed to prepubertal levels and do not show
' g# `- e1 D1 P, ~7 Gpubertal response of gonadotropin after gonadotropin-
+ j# _' ^+ L* z$ n( F. R6 j" t$ ?releasing hormone stimulation. This is a sex-linked) V$ U; W/ a( S0 S! l
autosomal dominant disorder that affects only2 p2 h+ C  [% X0 ~6 Q& |+ W
males; therefore, other male members of the family0 m# ~" G  D* S7 l' [, g# i1 q
may have similar precocious puberty.39 H) X# H% S) g3 L1 ~# b! i
In our patient, physical examination was incon-. R/ w$ _) Q, S' b
sistent with true precocious puberty since his testi-
0 c" Y( ?1 _' Q+ C/ S1 [& Ccles were prepubertal in size. However, testotoxicosis( n: _% I3 a$ j4 Y$ _
was in the differential diagnosis because his father- q( |# q7 z1 y% Y3 }7 M2 }
started puberty somewhat early, and occasionally,% H, N: M4 W1 x) n5 Y6 j0 J% A
testicular enlargement is not that evident in the! T9 J0 e  p: A, X; c; |* K
beginning of this process.1 In the absence of a neg-8 c5 k. C) _7 t& S! l4 b, t
ative initial history of androgen exposure, our! u( j( i$ e3 J# d% }
biggest concern was virilizing adrenal hyperplasia,8 e7 J  T, T4 q& R" q$ C
either 21-hydroxylase deficiency or 11-β hydroxylase" K- U+ W! Y7 L1 g. |- H
deficiency. Those diagnoses were excluded by find-  _$ V" z1 i0 t0 S5 \0 u: ^
ing the normal level of adrenal steroids.. C& z( F4 S8 ], _* I9 ~
The diagnosis of exogenous androgens was strongly  g  X# {  P; F1 k1 |8 K9 a$ Q% K
suspected in a follow-up visit after 4 months because
0 z; l1 m9 N: g, athe physical examination revealed the complete disap-, @4 z5 r& y3 g- ?5 S2 i2 x' Y, T
pearance of pubic hair, normal growth velocity, and1 s1 j1 E! {5 d$ t
decreased erections. The father admitted using a testos-
/ u$ r9 |! o; R8 j' Fterone gel, which he concealed at first visit. He was
. N/ A9 ]# q2 j# _using it rather frequently, twice a day. The Physicians’
; e/ u7 ?* f" w' I$ A. DDesk Reference, or package insert of this product, gel or& P1 d) X4 X/ M; o. N8 Z; h
cream, cautions about dermal testosterone transfer to
% H8 y" V0 }  t2 b. W6 b" Uunprotected females through direct skin exposure.! O0 f5 A* ~! x
Serum testosterone level was found to be 2 times the; m9 I/ W$ J* Q: ?7 Z! H' D2 d7 C
baseline value in those females who were exposed to
) [) v+ \7 `" c" U; v- M" Geven 15 minutes of direct skin contact with their male
! U) w) K) E# n3 D0 S4 v. _/ vpartners.6 However, when a shirt covered the applica-
' \; r. G: g* ?) P5 a; X, Ttion site, this testosterone transfer was prevented.
. e# q2 R8 ]& S; E6 s8 ?% r; SOur patient’s testosterone level was 60 ng/mL,& u' Y! f. j* L3 V# ]9 \
which was clearly high. Some studies suggest that+ u( U5 H, k6 N! S% h8 d- A+ S
dermal conversion of testosterone to dihydrotestos-
" B: p0 b7 s; K+ B4 ?terone, which is a more potent metabolite, is more
" f0 K/ O1 R" d; Mactive in young children exposed to testosterone) [) o) D7 ^% V: g# G
exogenously7; however, we did not measure a dihy-7 f0 f( M+ ?% I) f
drotestosterone level in our patient. In addition to
4 [3 P* G; v7 bvirilization, exposure to exogenous testosterone in
1 |8 u5 t; j* ?' _3 ~- d" Mchildren results in an increase in growth velocity and, |, P9 N1 a1 b# g0 X
advanced bone age, as seen in our patient.3 F0 F& b' b) @& `$ A( s$ @' n9 f
The long-term effect of androgen exposure during4 z( A, y$ g! M
early childhood on pubertal development and final
, P6 ~2 y( X! u1 _, h, Jadult height are not fully known and always remain& K. Q5 i+ r; r+ `3 F- I
a concern. Children treated with short-term testos-
% X# x  a* A. v! A9 ?- sterone injection or topical androgen may exhibit some! x+ \) s1 S: M' y" G
acceleration of the skeletal maturation; however, after
  m: V+ Z6 m5 S/ N" t' o  Rcessation of treatment, the rate of bone maturation
( d% @7 v# Q9 z+ pdecelerates and gradually returns to normal.8,9
- p6 {1 i# W9 rThere are conflicting reports and controversy$ S0 Q- V8 x9 J% w5 a, }
over the effect of early androgen exposure on adult3 J2 X% D( |7 x" w
penile length.10,11 Some reports suggest subnormal
, P( X' s9 `0 M7 S+ [, W+ Xadult penile length, apparently because of downreg-4 I& w# F+ v& Z
ulation of androgen receptor number.10,12 However,
& D8 L% j" s% ^' @& VSutherland et al13 did not find a correlation between
; B" F5 e2 z) m! w: k- Echildhood testosterone exposure and reduced adult" R9 Y. [) N. F, H# i, S
penile length in clinical studies.
1 X. j( S! n' Q" @4 G9 kNonetheless, we do not believe our patient is( D3 F/ o3 {; k6 N3 R. H
going to experience any of the untoward effects from
. z5 K8 c3 a& @9 m2 y1 Ptestosterone exposure as mentioned earlier because
" R+ ~' j7 \) J$ v# Q0 Cthe exposure was not for a prolonged period of time.# D! L- c) n4 H  K" }9 L
Although the bone age was advanced at the time of
  R6 C7 e- f0 b! Y5 Idiagnosis, the child had a normal growth velocity at* X- N' c$ i8 Z- l
the follow-up visit. It is hoped that his final adult
3 \1 h+ S% ~- t# S- }height will not be affected.5 ^' e3 g+ n! x1 J8 g) H
Although rarely reported, the widespread avail-
2 q+ r+ f& B  f7 {ability of androgen products in our society may& }4 v- ?, p/ Y
indeed cause more virilization in male or female. B1 Y/ s5 _1 y. L5 j$ k! e2 a9 w
children than one would realize. Exposure to andro-
! {: g8 r, H/ g7 W; e3 cgen products must be considered and specific ques-2 O& s1 p8 V7 V" L! P2 Y4 c2 }  r9 g
tioning about the use of a testosterone product or5 P8 u5 j, b) S( |+ ~9 V6 m
gel should be asked of the family members during
, S2 t/ d) a* }the evaluation of any children who present with vir-. y0 x8 z# A4 B2 O
ilization or peripheral precocious puberty. The diag-. F! E: b! j. K5 m& H/ n
nosis can be established by just a few tests and by
* D4 A$ o" B) z% U' Jappropriate history. The inability to obtain such a4 P+ Z0 c" J" o1 I( {7 j
history, or failure to ask the specific questions, may. q. |8 \+ Z# |5 K' @. J' n, X
result in extensive, unnecessary, and expensive
$ M+ H  [$ i4 O2 M' Z4 g  _+ kinvestigation. The primary care physician should be  P0 S8 C, N/ D# Y* K4 ]
aware of this fact, because most of these children7 z2 W: p3 r8 L7 I$ @2 r, ^
may initially present in their practice. The Physicians’1 \' \" j6 d+ ~$ b3 }
Desk Reference and package insert should also put a: _$ x; ]0 o1 d* a4 {) j
warning about the virilizing effect on a male or: W! D! O; a7 p" n
female child who might come in contact with some-. r9 V6 w& [% G0 ~( t
one using any of these products.# v6 c- |5 h& [
References
9 p) Q' v9 P: k. u. n! C1. Styne DM. The testes: disorder of sexual differentiation
/ E; }! ?5 u' `3 u: N  kand puberty in the male. In: Sperling MA, ed. Pediatric
* _7 r/ V- W6 F" [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  d# V8 A* M- r2 M
2002: 565-628.
+ u  H7 y" K5 m2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 U, {' G0 X: N' F5 w% y: ^/ {0 r, H
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old. L$ e; P  P" ~* f
Boy Induced by Indirect Topical6 j% |& n+ O  o0 G8 z5 `
Exposure to Testosterone
* j/ b! I* _0 f4 d5 sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: h' X1 K; C- eand Kenneth R. Rettig, MD1
# J( u2 r) U$ v' ]4 S4 B! qClinical Pediatrics6 A, E* i! ~7 ^; o7 b! o
Volume 46 Number 6
4 D, Q! G: j# M" s' qJuly 2007 540-5430 W* R  M' V( o& |, }. j
© 2007 Sage Publications
4 R8 v. a; K3 m* I8 U10.1177/0009922806296651
7 ?. l& ?! [2 P! `http://clp.sagepub.com$ n, @0 y( d$ K
hosted at- r0 i) X$ i# L; T; _
http://online.sagepub.com: Y' C8 E. C# D7 l$ o- f
Precocious puberty in boys, central or peripheral,
% Z" W9 i  ?9 {+ }6 ?/ s5 ois a significant concern for physicians. Central' i4 ]* Q3 n) b# ?9 S
precocious puberty (CPP), which is mediated$ }* t' X2 {& x( G
through the hypothalamic pituitary gonadal axis, has4 T8 V& Z* _) u! y" M
a higher incidence of organic central nervous system
- r9 A6 X) I( M3 m4 l  K! mlesions in boys.1,2 Virilization in boys, as manifested
- x: @- o; ?5 o" F+ p4 Hby enlargement of the penis, development of pubic
0 A4 {' E) [" h. ]% L4 y, h4 u, ^" chair, and facial acne without enlargement of testi-
" p: y! Z# G) B8 \cles, suggests peripheral or pseudopuberty.1-3 We& |5 i1 w% O+ F8 U7 S5 R( Z, s! M
report a 16-month-old boy who presented with the" z) h1 h/ }8 n$ Z1 M) g
enlargement of the phallus and pubic hair develop-) b3 ?4 f8 Y6 m: }
ment without testicular enlargement, which was due
: e! D" r3 T  U4 L  Lto the unintentional exposure to androgen gel used by0 ?1 ]2 K6 _/ W* z6 T6 d5 ^$ f
the father. The family initially concealed this infor-0 s% B0 D0 t: N
mation, resulting in an extensive work-up for this
+ M+ m" d' ~0 C, r3 Nchild. Given the widespread and easy availability of" b! x8 K' q/ K5 W
testosterone gel and cream, we believe this is proba-8 o  l( q2 `. w  b: K6 R
bly more common than the rare case report in the9 g% ]* R/ q# I9 i! Y
literature.45 g; Q# q& W# H# ~3 v8 W
Patient Report
3 Z4 F! c2 t* P& lA 16-month-old white child was referred to the! D' m$ @3 t/ `/ f( C2 f3 {8 w
endocrine clinic by his pediatrician with the concern
: a- ?# b: ^' F5 z% P( x) iof early sexual development. His mother noticed7 h0 i. i3 U8 j3 W
light colored pubic hair development when he was
) |; ~* r5 Q% A# cFrom the 1Division of Pediatric Endocrinology, 2University of
, ]8 D9 x1 w5 M, o- w# LSouth Alabama Medical Center, Mobile, Alabama.
0 W; m, {* Z  N8 P. q* D* ~5 F- OAddress correspondence to: Samar K. Bhowmick, MD, FACE,. ^2 F: u" ~. i1 G
Professor of Pediatrics, University of South Alabama, College of
9 k1 Q, r  L6 V6 H3 _' BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 k: i" z" `9 r- Y6 re-mail: [email protected].
# H' W* w6 F( cabout 6 to 7 months old, which progressively became
& v9 s: z) Q( u9 ndarker. She was also concerned about the enlarge-
+ m( V" Q) S1 N3 S# ^4 E+ D3 Jment of his penis and frequent erections. The child
1 g+ z, K! ?! C. _% D) {' O* Bwas the product of a full-term normal delivery, with6 w5 h/ U7 c+ O. x$ d  u, T
a birth weight of 7 lb 14 oz, and birth length of
0 [( X# O+ ?9 B& e, G4 \; L20 inches. He was breast-fed throughout the first year
( k) Q4 |0 U: A- J4 \" |of life and was still receiving breast milk along with
% p# |7 G: }6 p7 vsolid food. He had no hospitalizations or surgery,$ ?9 v( }: \- w3 q
and his psychosocial and psychomotor development* w4 ?, Y6 v  N+ [
was age appropriate.8 G0 K% @" W0 O' v7 l& ?
The family history was remarkable for the father,
" ~/ z  v5 E' L6 b' {who was diagnosed with hypothyroidism at age 16,! p6 B1 y' |; a; |1 F! l
which was treated with thyroxine. The father’s
) M, y- a0 k; k6 G& Iheight was 6 feet, and he went through a somewhat
% e/ a2 Y/ z; iearly puberty and had stopped growing by age 14.6 T$ g0 a. C8 W& r) p
The father denied taking any other medication. The& U. _# `. I' w- y3 y3 O
child’s mother was in good health. Her menarche
8 C- g! ^1 G, i9 S2 `was at 11 years of age, and her height was at 5 feet- d9 u& k5 u- b8 q  o& r
5 inches. There was no other family history of pre-# X  x' k; A' l0 y
cocious sexual development in the first-degree rela-5 l5 Q# _; N, t4 e  _4 \' N
tives. There were no siblings.
) y( Y2 b) Q& v# V1 {3 xPhysical Examination' y5 e- H, D% [% O' k% @9 I
The physical examination revealed a very active,
! X5 Z. ~% P( U" _8 G$ ?playful, and healthy boy. The vital signs documented
# F' [* S3 \7 @' xa blood pressure of 85/50 mm Hg, his length was+ w2 I/ `$ |" @# K) D; I3 F
90 cm (>97th percentile), and his weight was 14.4 kg9 b+ \% R' K9 {
(also >97th percentile). The observed yearly growth
( z( s" s; ]% z0 e+ W. ovelocity was 30 cm (12 inches). The examination of
+ V- ^3 U* n4 ?, Y; _- z; {) Rthe neck revealed no thyroid enlargement.2 C0 K0 v6 U4 p; {
The genitourinary examination was remarkable for
) V4 ^% h4 u% [& J7 W! x4 b# ~enlargement of the penis, with a stretched length of
" Q* Z( V% f% v/ z; f. p8 cm and a width of 2 cm. The glans penis was very well# \! N4 C1 g* P- K3 i) G3 Q- m- ?+ x
developed. The pubic hair was Tanner II, mostly around- \# S& K. E0 ~( i) h9 n
540
6 A( j' P* h# M  y, J7 Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 b1 f/ x$ T. g
the base of the phallus and was dark and curled. The
2 z/ z! z; D  b4 mtesticular volume was prepubertal at 2 mL each.
( I( N# F: \$ C. ^) d* w1 MThe skin was moist and smooth and somewhat
) _; {! p- Z6 }9 B' Foily. No axillary hair was noted. There were no+ E4 }& {$ z8 |  P  Q: m0 a- t
abnormal skin pigmentations or café-au-lait spots.+ k' L7 n7 a" K6 |, y/ I- Q
Neurologic evaluation showed deep tendon reflex 2+
8 R5 w" q- A% P! Jbilateral and symmetrical. There was no suggestion
" i% L0 ]- n, q( g$ x0 Jof papilledema.
7 F% P  A4 }% L$ n( S5 eLaboratory Evaluation* \; _3 Q& [. [8 H7 U$ ]& W
The bone age was consistent with 28 months by
. V) I$ I- ]8 c' X1 n# uusing the standard of Greulich and Pyle at a chrono-; A5 a4 O5 V6 X7 m! B: E# L8 T" ]' ]
logic age of 16 months (advanced).5 Chromosomal, |$ ~7 F" U  d- d2 h/ Y; n* S4 Y
karyotype was 46XY. The thyroid function test) `$ G; t3 y0 {* Y* y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& s) Y( A; ^4 `" m
lating hormone level was 1.3 µIU/mL (both normal).
9 Q+ P2 J% ^# G2 F* DThe concentrations of serum electrolytes, blood; E" z7 @8 Q8 I% r2 I, r# J; k
urea nitrogen, creatinine, and calcium all were7 x( {' U2 K0 t0 w% u, e9 c7 v$ c/ r
within normal range for his age. The concentration8 I+ m+ G% |6 D$ E$ @* A; x4 K9 R
of serum 17-hydroxyprogesterone was 16 ng/dL
0 ?" [3 O8 w7 \( @9 S8 o" ^(normal, 3 to 90 ng/dL), androstenedione was 20
) l  `- P+ l0 p0 Nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& g; u2 \  v. e% y7 w/ u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, f% k# W) e. k3 [1 r8 y! u7 B2 ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( y& i' j2 d3 I, {5 D8 x49ng/dL), 11-desoxycortisol (specific compound S)
; {# q8 p; k8 T3 Y9 M3 fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; l; E8 x1 S% }, w8 v- z; @. P: k7 s' u! B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& G9 P& F  _$ h- X* b3 ?; I' B* U" gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* o# P5 ]5 \: h& Z
and β-human chorionic gonadotropin was less than
, S/ a0 V% c, @. s3 ~. z$ v5 mIU/mL (normal <5 mIU/mL). Serum follicular
# v3 b% E0 ]) d) A! B6 l7 d6 Gstimulating hormone and leuteinizing hormone
/ L' B5 t/ r+ }0 y4 Pconcentrations were less than 0.05 mIU/mL3 E7 b* N4 q; y1 ?+ {: G6 q
(prepubertal).0 B! o7 @2 k- n( Y/ g" _% Y% |
The parents were notified about the laboratory& F- r5 j6 S) r8 S  [* a
results and were informed that all of the tests were
6 t" I/ z( c  g) Q5 _normal except the testosterone level was high. The' W6 v( H( ?5 S
follow-up visit was arranged within a few weeks to  p  z( g4 q2 K! z, I; {; K6 \
obtain testicular and abdominal sonograms; how-
/ k9 Q* t: j# @  Oever, the family did not return for 4 months.
9 r/ x$ }: M- L# W9 J+ s' tPhysical examination at this time revealed that the& y8 p6 H. q# r8 e0 ]& Z$ X
child had grown 2.5 cm in 4 months and had gained  B3 Y% X; y! x- m/ J$ w: d8 L
2 kg of weight. Physical examination remained, M4 e# _6 U8 V' t
unchanged. Surprisingly, the pubic hair almost com-" H) k% k2 e8 G( ^& v  I& p
pletely disappeared except for a few vellous hairs at
/ l7 u4 ?( h- C" u# G$ s/ Cthe base of the phallus. Testicular volume was still 2
" U$ Y( H: e6 i1 ]4 L2 ^mL, and the size of the penis remained unchanged./ {0 C: G- s- p, Q: U, C
The mother also said that the boy was no longer hav-. k1 U8 n* z& {3 z  j- @
ing frequent erections.
1 U6 B5 l, s  tBoth parents were again questioned about use of
$ W' `8 B: X" k5 f2 T& b7 Oany ointment/creams that they may have applied to
8 Q( ?% n. V* s8 a/ E$ H/ C* c3 othe child’s skin. This time the father admitted the
8 f) y( ?$ z  ]/ uTopical Testosterone Exposure / Bhowmick et al 541
5 p. D6 Q5 I% s+ h. ~2 Fuse of testosterone gel twice daily that he was apply-- E* o& v" B& z( l% f  u5 s
ing over his own shoulders, chest, and back area for
7 _2 m- u# Z) b/ q! C% c2 ka year. The father also revealed he was embarrassed
- u* M+ ?# ~6 C3 }$ o+ ]to disclose that he was using a testosterone gel pre-' z+ i5 N0 T& h" d, f: `6 `
scribed by his family physician for decreased libido
3 }3 a% j1 l: X" v9 `. W2 zsecondary to depression.
% E' g0 L1 j# E( {+ z; FThe child slept in the same bed with parents.4 ~7 P" I# P+ }  H0 C* J
The father would hug the baby and hold him on his
- Q. y7 c% n: |+ pchest for a considerable period of time, causing sig-2 O/ x: L9 P7 m& l5 Q- R7 B
nificant bare skin contact between baby and father.# s; P" s& X5 g. @
The father also admitted that after the phone call,: w2 C. r% M$ B* ^8 a* [  Q
when he learned the testosterone level in the baby( V. E6 V6 ^* b: z0 v
was high, he then read the product information* @. |1 b$ S1 h
packet and concluded that it was most likely the rea-7 R) \( Y5 F1 z/ s2 A
son for the child’s virilization. At that time, they2 q& d( w" S4 H
decided to put the baby in a separate bed, and the. m  e: z  ^* n# y: M2 a
father was not hugging him with bare skin and had& G1 z9 a$ G$ h0 o6 O
been using protective clothing. A repeat testosterone# j% ~+ [" ]. A7 Q+ A
test was ordered, but the family did not go to the
4 \. W/ r: `6 b% j5 c8 m, flaboratory to obtain the test.
4 v0 K7 ~" o0 N) U( @Discussion! ?7 ~0 ~& `+ d" g. O  C
Precocious puberty in boys is defined as secondary
# \  E5 F; g# n: _1 U' |sexual development before 9 years of age.1,4
1 m5 v: B# R' T; g, Q! @; Z, zPrecocious puberty is termed as central (true) when9 F  j4 Y- r4 l# z0 h9 f+ p) F
it is caused by the premature activation of hypo-4 e3 L$ a( @( ^3 M4 R! u7 \
thalamic pituitary gonadal axis. CPP is more com-8 f+ N& q  o3 I; @8 l
mon in girls than in boys.1,3 Most boys with CPP5 P, w+ p0 n2 t
may have a central nervous system lesion that is- ?* {, y$ I' Y$ J; z' r
responsible for the early activation of the hypothal-2 e1 J- H! q$ S( S
amic pituitary gonadal axis.1-3 Thus, greater empha-6 Y: V7 D8 ]0 c
sis has been given to neuroradiologic imaging in
: ], J% G6 T0 m1 [- gboys with precocious puberty. In addition to viril-
7 d  A8 p0 f& \) }( Lization, the clinical hallmark of CPP is the symmet-
! l" D2 D7 I2 Brical testicular growth secondary to stimulation by
2 ?" V$ ]$ K* t/ g" \) Ngonadotropins.1,3
  C2 K$ j/ ^, K. ]5 r! k7 jGonadotropin-independent peripheral preco-
+ I) j+ A& h$ k# wcious puberty in boys also results from inappropriate( L& m1 P4 _1 o9 d4 [& F
androgenic stimulation from either endogenous or9 h1 ?+ u. v7 s% g9 W
exogenous sources, nonpituitary gonadotropin stim-
& [/ t8 j/ \8 ?0 m2 Julation, and rare activating mutations.3 Virilizing7 g. z2 B6 E2 x
congenital adrenal hyperplasia producing excessive
! s' W; z6 T+ n. i" Radrenal androgens is a common cause of precocious* a( d' d2 _' h2 m$ N3 j* D' P: A
puberty in boys.3,4
2 S7 J" S/ m* @8 ~: s" _2 K- [The most common form of congenital adrenal
$ p2 o  e, O. _6 {hyperplasia is the 21-hydroxylase enzyme deficiency.+ S, N$ Z3 X0 H' }9 D
The 11-β hydroxylase deficiency may also result in
* {% y# N( [9 a% p7 \( A7 Bexcessive adrenal androgen production, and rarely,
9 w5 ]' \: `6 ~an adrenal tumor may also cause adrenal androgen+ @% T+ e; _- k  c) n3 \& O
excess.1,3
2 o7 K/ h  a0 ~9 u8 }5 b5 Y. t( b4 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 t, @  ~+ \7 U7 [* W
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 b1 S: k- _3 O
A unique entity of male-limited gonadotropin-, y/ u1 y( r# f# z4 @* o2 s
independent precocious puberty, which is also known) y% G! T/ J4 I$ {; S% _$ U/ @$ [8 S
as testotoxicosis, may cause precocious puberty at a
) {, |+ ?4 N( A* {" z% s5 S- Hvery young age. The physical findings in these boys+ P8 l* a2 U) L% B% A4 o
with this disorder are full pubertal development,- U% T2 `4 d  t# x# _3 g7 R
including bilateral testicular growth, similar to boys
8 Y3 n0 \( p. S) L; Pwith CPP. The gonadotropin levels in this disorder
5 J- P) ^- t- B/ {0 Fare suppressed to prepubertal levels and do not show9 u: p) W: w! S9 H$ v6 n
pubertal response of gonadotropin after gonadotropin-
  _8 P9 k) ^0 f6 {releasing hormone stimulation. This is a sex-linked$ q* z& p& s( w9 N
autosomal dominant disorder that affects only
4 B+ a0 [% Q6 x* y9 v, nmales; therefore, other male members of the family
0 z- Y! @) ?1 c9 V, l* Jmay have similar precocious puberty.3
2 T6 v7 G1 s, l1 A0 ~& ZIn our patient, physical examination was incon-
& C& o3 O" {2 s* q: b" J! gsistent with true precocious puberty since his testi-
. H3 |0 |2 J2 E8 E, m- ~. I( Kcles were prepubertal in size. However, testotoxicosis7 E2 W9 W% E- E/ G; N8 D
was in the differential diagnosis because his father) V0 j5 Y/ M  k/ G
started puberty somewhat early, and occasionally,0 G* d- m( z5 c( _  n
testicular enlargement is not that evident in the& X6 e  V( o! x: y1 y5 C9 p% Q
beginning of this process.1 In the absence of a neg-
1 \7 g1 K( p. _6 F: @ative initial history of androgen exposure, our
: g1 b. r  Y" Y( B4 v: ~$ Lbiggest concern was virilizing adrenal hyperplasia,
- K- n! k$ n* oeither 21-hydroxylase deficiency or 11-β hydroxylase# G5 O! ]# K4 i
deficiency. Those diagnoses were excluded by find-4 v7 N. G7 X. }  {; l: ^
ing the normal level of adrenal steroids.
9 S( O* l: n# L5 D* I& p# eThe diagnosis of exogenous androgens was strongly
8 a! P, N" L5 U9 f- {- Ususpected in a follow-up visit after 4 months because9 E2 u# K" p7 H% O
the physical examination revealed the complete disap-1 q6 w  r7 P! V: n8 O
pearance of pubic hair, normal growth velocity, and( t/ W* ]5 {) Y
decreased erections. The father admitted using a testos-8 o" @% D/ X) _' i: Y) e  x
terone gel, which he concealed at first visit. He was
% O5 ~$ o  q8 g# b3 _0 Wusing it rather frequently, twice a day. The Physicians’
+ s. a- V) a1 I. L( E  O1 v: [Desk Reference, or package insert of this product, gel or
% w$ A8 z* F8 q# ycream, cautions about dermal testosterone transfer to
9 ]$ b- |" _' |/ aunprotected females through direct skin exposure." B& p) |; m8 `! M4 L
Serum testosterone level was found to be 2 times the
5 f( v6 U6 H1 T- l" J. lbaseline value in those females who were exposed to2 e2 ^' z- N8 k, @8 X
even 15 minutes of direct skin contact with their male, @% ^9 D" Q% \! `( G' s/ q
partners.6 However, when a shirt covered the applica-
  H  _4 P) g: ztion site, this testosterone transfer was prevented.  ]6 z. Y6 `9 X9 H
Our patient’s testosterone level was 60 ng/mL,) c* b( h! M! a; c+ U) ^, c
which was clearly high. Some studies suggest that
0 Q+ W2 }9 @& m- J) s6 N0 @" _5 Qdermal conversion of testosterone to dihydrotestos-
. ?% B& e8 \9 `" `2 Q7 yterone, which is a more potent metabolite, is more9 c  _  }( L0 X
active in young children exposed to testosterone
& }) m, W) p' `% E: W& Kexogenously7; however, we did not measure a dihy-
$ o& E3 e) C; u* b, s% J5 xdrotestosterone level in our patient. In addition to
; f* [( X# v8 d8 S- q" ~virilization, exposure to exogenous testosterone in
, F+ H) d- ?0 I4 r3 u. Xchildren results in an increase in growth velocity and
( x# ~. }* g) `# Uadvanced bone age, as seen in our patient.
9 y! I: G5 Z7 B$ O+ T6 `* oThe long-term effect of androgen exposure during7 F9 x+ X; V5 a! {
early childhood on pubertal development and final
) h. b3 V, b& m! Iadult height are not fully known and always remain
  |  S/ ]8 g+ f* ya concern. Children treated with short-term testos-. F' F; }. `7 ~6 f4 E7 j
terone injection or topical androgen may exhibit some
% n) F8 H' Q2 A# ]3 \2 e  kacceleration of the skeletal maturation; however, after
& q% H7 Q& z( R* b9 Vcessation of treatment, the rate of bone maturation
, o, `4 r! e- h# Z, I9 bdecelerates and gradually returns to normal.8,9
. V" J: {; X/ S' M5 d0 wThere are conflicting reports and controversy9 c+ Y1 t, I/ Q! ^4 J
over the effect of early androgen exposure on adult4 Z9 k& f8 g) w4 j9 |" [! o
penile length.10,11 Some reports suggest subnormal
5 n5 a' b* d% _0 zadult penile length, apparently because of downreg-  A. ~) j) q& j. H0 G
ulation of androgen receptor number.10,12 However,
: h6 p7 g" G0 ]9 wSutherland et al13 did not find a correlation between
+ G, K5 C) o7 w/ i% D; Echildhood testosterone exposure and reduced adult
9 _# Z/ \: a: y+ lpenile length in clinical studies.
5 U/ o( a+ `3 |# v! `Nonetheless, we do not believe our patient is# Q8 N; K7 X) R
going to experience any of the untoward effects from
8 y! K. n. D7 Z+ D: k# mtestosterone exposure as mentioned earlier because1 c" d5 P5 M; x
the exposure was not for a prolonged period of time.
. H, I: j7 R! TAlthough the bone age was advanced at the time of
% [4 D9 c: U9 u. rdiagnosis, the child had a normal growth velocity at
8 M8 H8 i8 j' _+ Pthe follow-up visit. It is hoped that his final adult# b0 U3 b7 l' m
height will not be affected.
- P0 r8 ~* t' F) X/ H- b! l* fAlthough rarely reported, the widespread avail-
7 p; D, H1 q2 r% jability of androgen products in our society may
- z' F. T( V  {! findeed cause more virilization in male or female" I; G/ d4 ~9 u2 I1 f
children than one would realize. Exposure to andro-
: U7 b) ?6 Y) _" A' qgen products must be considered and specific ques-
$ @4 S+ X( r1 I; y. [2 w! x. a( ytioning about the use of a testosterone product or6 T# \' O% ^6 f) @' D
gel should be asked of the family members during# ]+ D4 n% |! i# n: ~7 ^& v
the evaluation of any children who present with vir-
0 u3 y7 N6 ~5 Nilization or peripheral precocious puberty. The diag-3 o2 b. ?0 G4 {% X3 H
nosis can be established by just a few tests and by
4 l+ G# e3 g1 g' e7 yappropriate history. The inability to obtain such a
- o4 ]2 Z5 h6 g' Yhistory, or failure to ask the specific questions, may
: j& i, ~  X& X2 K4 y  A) gresult in extensive, unnecessary, and expensive6 h* Y4 V9 R; d% |/ X" i; r. P: E
investigation. The primary care physician should be
: |" n+ W4 _) @2 U. Taware of this fact, because most of these children9 U0 N3 d! p9 f
may initially present in their practice. The Physicians’; l( A  o$ H( n  o+ R) G* f
Desk Reference and package insert should also put a
: ]4 q# |8 N8 T2 a% A0 v+ e$ kwarning about the virilizing effect on a male or8 Y9 `$ T/ G$ f, |0 O8 J+ Q& k
female child who might come in contact with some-+ r; k& \8 k; l+ ~
one using any of these products.
. x2 A* U1 o/ a7 d# v% uReferences2 D- f: s7 V; a3 }  k1 n
1. Styne DM. The testes: disorder of sexual differentiation
! O) E: u9 v5 r! M( kand puberty in the male. In: Sperling MA, ed. Pediatric
; E/ p1 q& }! _9 S# ^5 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 t% I5 c: O( N' F1 i, ~: Q
2002: 565-628.
- `8 k% Q% J3 n( N# b# I5 Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 ?" v! F! r3 i* ~0 G
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!
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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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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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