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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/ u1 L. R# c% N; B& B3 F) m; N
Boy Induced by Indirect Topical* J' N' [' A  t; e  O2 S
Exposure to Testosterone3 k& d/ k" _: o! {& S0 c6 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 ?( o/ X2 C7 T
and Kenneth R. Rettig, MD1& V$ }2 E% b# }6 f. r
Clinical Pediatrics
* }$ Z; C  H, G' v, S  _5 H, YVolume 46 Number 67 M; r# W' F7 X
July 2007 540-5433 `9 b; j/ q' i0 N& r
© 2007 Sage Publications  L6 V; N3 O# N$ A3 r
10.1177/0009922806296651/ u9 _3 e7 H  M
http://clp.sagepub.com
# [0 C: e* W) S! j* f) [0 ]5 U" xhosted at
6 T: H- x. u1 J5 X- F2 l  Z7 G, @http://online.sagepub.com
% @, G; G' \! ~* s3 y/ b8 DPrecocious puberty in boys, central or peripheral,
; l+ Y" e# k- h! _) f. N/ r9 c+ w2 `! }is a significant concern for physicians. Central# L' }5 a4 W$ Q: i* c' w5 {
precocious puberty (CPP), which is mediated
3 _; K6 B& t$ n, Uthrough the hypothalamic pituitary gonadal axis, has
- j  w. y! M' h$ c7 q' X2 m/ Ba higher incidence of organic central nervous system
- x& [* w7 R( W7 Mlesions in boys.1,2 Virilization in boys, as manifested/ ]1 R0 h+ K& J* a* J% ?
by enlargement of the penis, development of pubic' v7 E! ]4 _1 ?  }, m
hair, and facial acne without enlargement of testi-
+ |' g1 D4 l0 qcles, suggests peripheral or pseudopuberty.1-3 We
0 {8 l6 z) D- W/ a/ Treport a 16-month-old boy who presented with the
/ m: v- R$ ?. qenlargement of the phallus and pubic hair develop-
; {, J7 W( e$ j# q  K. ]3 kment without testicular enlargement, which was due, g; T0 f8 M5 Q9 c% P0 d+ e" \
to the unintentional exposure to androgen gel used by2 t% O* B& r) L
the father. The family initially concealed this infor-8 O/ ~8 ]9 \7 s3 Z& L! [: _
mation, resulting in an extensive work-up for this
( x. q7 p: @- s8 l: S& Jchild. Given the widespread and easy availability of* ]2 M; F2 z! U( W& H
testosterone gel and cream, we believe this is proba-: n' a7 J# w: k2 z& y/ M; N
bly more common than the rare case report in the; K( Q' E& O, X0 A
literature.4/ m  |5 ^3 y5 E' U
Patient Report+ k8 Y: c9 O" e0 A. c
A 16-month-old white child was referred to the! Z* b5 m+ x5 F3 B
endocrine clinic by his pediatrician with the concern
9 O8 ~9 }2 u1 U- h$ T# U8 B. q: Y- Sof early sexual development. His mother noticed
- k+ w' L" T! o# Ulight colored pubic hair development when he was
0 F& K- z$ w) [1 Y# J. \8 R; IFrom the 1Division of Pediatric Endocrinology, 2University of/ X) X3 i" r1 f! Y* [2 `
South Alabama Medical Center, Mobile, Alabama.
7 m) \7 x5 B1 @4 j+ O$ IAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 F  g( R. T: e& }% @* q  b
Professor of Pediatrics, University of South Alabama, College of( E6 I* ^. c7 Q$ b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ ^/ d7 J9 O4 `$ `
e-mail: [email protected]., c# y) B. I, w1 E- z, q
about 6 to 7 months old, which progressively became
; [4 o: |' C% T/ n( \darker. She was also concerned about the enlarge-
4 V* D; x( i; E- E; A/ N4 K) dment of his penis and frequent erections. The child; B% }* S! V# G+ Y, V0 A' \1 l
was the product of a full-term normal delivery, with. L  R4 h. Q3 C6 ]
a birth weight of 7 lb 14 oz, and birth length of
2 T9 f8 k- j5 i  E20 inches. He was breast-fed throughout the first year
. e7 s8 H( @6 V; T; L6 q8 Nof life and was still receiving breast milk along with4 m) l' t; y0 A+ f% A
solid food. He had no hospitalizations or surgery,5 Y0 J+ e. l/ J0 X5 k( {
and his psychosocial and psychomotor development
( v8 b+ J; r" Q) N0 E& U, Kwas age appropriate.
. ~6 l' k4 S. S8 kThe family history was remarkable for the father,
% h8 b* z/ z" b0 o1 P* }- W4 Bwho was diagnosed with hypothyroidism at age 16,7 _/ z* `/ i/ z$ X
which was treated with thyroxine. The father’s4 [) [, e5 {8 m- Y  B. D5 L
height was 6 feet, and he went through a somewhat) u: u" c  G9 q* c- i* [
early puberty and had stopped growing by age 14.6 t' ?0 {/ d) q8 N' b
The father denied taking any other medication. The
2 `6 U) I& E9 fchild’s mother was in good health. Her menarche" ?: N3 P8 m5 x) b$ f
was at 11 years of age, and her height was at 5 feet
  P. r! _$ \0 }& b( @) M5 inches. There was no other family history of pre-
, N* w4 F8 p/ q: Ucocious sexual development in the first-degree rela-$ K; a' R$ I5 Z3 a5 ?7 A
tives. There were no siblings.7 i, f4 n) C6 Y" }  [  d
Physical Examination9 H# `" u% S; U9 @6 A3 b# N
The physical examination revealed a very active,
- U0 r. s+ q& H) R# \/ j9 fplayful, and healthy boy. The vital signs documented
: ~! ^, h, L& P; f# V' da blood pressure of 85/50 mm Hg, his length was
- W8 C$ W6 a/ Z2 `% Y# S90 cm (>97th percentile), and his weight was 14.4 kg$ H* c/ m: G# J' d# z( K' x
(also >97th percentile). The observed yearly growth5 r- w4 Z! [/ {3 ~
velocity was 30 cm (12 inches). The examination of0 a6 |& M: ?& F! x' j7 z: ^
the neck revealed no thyroid enlargement.* b5 E; t- @9 q  @$ r( ~0 j
The genitourinary examination was remarkable for5 _% N$ Z! _' g
enlargement of the penis, with a stretched length of
0 h  N0 i. a" ]+ e2 U1 x6 E4 s8 cm and a width of 2 cm. The glans penis was very well
7 Q9 A2 k' ?! ?" ~1 Pdeveloped. The pubic hair was Tanner II, mostly around8 D6 Z6 T( c$ B# v  ^3 J5 [1 ^4 {# T
5408 a8 {2 i# v' d) b: f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ j% N0 S  O) b  a( c7 Dthe base of the phallus and was dark and curled. The
- X2 O0 h  A8 x& g5 b( n' ^4 Btesticular volume was prepubertal at 2 mL each.
) t! L- ^( _/ |- K3 e! VThe skin was moist and smooth and somewhat
6 k) Z' U1 R3 @& g7 [oily. No axillary hair was noted. There were no
$ Y& ^1 O. V" {5 B% \8 G0 Qabnormal skin pigmentations or café-au-lait spots.; Y( L5 j4 Q- u
Neurologic evaluation showed deep tendon reflex 2+
$ _) T& U' d: Abilateral and symmetrical. There was no suggestion( B* x; A' y: n
of papilledema.
% j$ E% w6 f3 o/ q: u* PLaboratory Evaluation
# h* i/ g% m( `. |( {The bone age was consistent with 28 months by& y8 I  G# Z  T
using the standard of Greulich and Pyle at a chrono-
. D( g& A+ W9 C/ G8 Q( rlogic age of 16 months (advanced).5 Chromosomal2 k1 I6 y4 S4 r  q. }) {7 B' C6 c2 B
karyotype was 46XY. The thyroid function test
7 `+ A  _8 a/ g& U+ b! I; i( I9 vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-2 m5 n: Z& {, _4 M3 T
lating hormone level was 1.3 µIU/mL (both normal).
' T! ?0 i7 `% {: [* @/ ~The concentrations of serum electrolytes, blood6 S4 H2 ?) Z0 Z  ]
urea nitrogen, creatinine, and calcium all were4 ?+ P& O$ q* S& l7 |8 `1 b  v
within normal range for his age. The concentration/ p( j4 `& q# ?4 f6 ?
of serum 17-hydroxyprogesterone was 16 ng/dL
; w' _5 X+ {. l; p; a' D# A( P(normal, 3 to 90 ng/dL), androstenedione was 20* U) t9 p0 A1 R' Q& x3 q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ ^- ?. J: I3 J" O0 X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& J" f. [4 d) S- M% n. H! ]
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- T. T. R9 {2 q, A1 u2 Z1 i6 l' j49ng/dL), 11-desoxycortisol (specific compound S)
. Z: e  L9 P$ }1 j' kwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) }* J" x- D3 g# D" i8 f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* ]5 i4 I+ H# N1 N: V/ J8 b% H6 N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 C: i. X2 R% n4 [- |and β-human chorionic gonadotropin was less than6 F( }" q( ?* d; p6 |
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ A$ B, M4 m9 ]* g! k7 T8 Kstimulating hormone and leuteinizing hormone
$ f) ]  w% F; N5 s1 }& @1 A+ Yconcentrations were less than 0.05 mIU/mL
. E, v9 {( m# P& [$ j(prepubertal).( i7 o; Q$ t3 X8 I
The parents were notified about the laboratory/ c% v8 x4 [; D" y- B
results and were informed that all of the tests were
7 @, N4 o) N; v; Xnormal except the testosterone level was high. The
( c# |. d. R1 \. Zfollow-up visit was arranged within a few weeks to' R4 X- C& n. `- ~, o
obtain testicular and abdominal sonograms; how-
. e2 i' }0 a% V; ~ever, the family did not return for 4 months.
8 z& L+ j5 i" g  o. G! a& PPhysical examination at this time revealed that the
/ c5 \8 I* L+ I; g) q6 lchild had grown 2.5 cm in 4 months and had gained
4 b2 Z$ k0 Z7 Y6 }% A' u1 Z1 s  [3 I2 kg of weight. Physical examination remained
8 g/ k% t* C9 z' X2 m2 nunchanged. Surprisingly, the pubic hair almost com-( e* C8 s- @( g) r$ }7 p& C
pletely disappeared except for a few vellous hairs at
$ E! L' Z" Y7 C" ithe base of the phallus. Testicular volume was still 2
4 M1 Y& g) V+ V8 D. A( M1 jmL, and the size of the penis remained unchanged.8 [; z6 Q: k6 e4 y' W# M! l' G" _
The mother also said that the boy was no longer hav-0 w- ?/ F, u5 J; h. N1 c
ing frequent erections.
) g8 M6 z7 i& ]Both parents were again questioned about use of9 [9 ~4 ^# Y+ S; j( U. P
any ointment/creams that they may have applied to& V- |* X" D0 R9 z. V# f
the child’s skin. This time the father admitted the
- _- t% S+ N& rTopical Testosterone Exposure / Bhowmick et al 541/ k4 h# L! w6 q2 F1 O5 U
use of testosterone gel twice daily that he was apply-
7 l0 n. u$ o* T9 U: ^ing over his own shoulders, chest, and back area for
( y6 N! E* |0 X) Ra year. The father also revealed he was embarrassed1 ]( P6 z. x( `5 J! G8 e+ ?7 N$ V
to disclose that he was using a testosterone gel pre-6 H+ m' o# ?3 |" v
scribed by his family physician for decreased libido8 s( j" m( l% F
secondary to depression.
8 e. l9 ?7 |7 qThe child slept in the same bed with parents.& O% O; E0 I% ?
The father would hug the baby and hold him on his
6 n/ k- ^1 z, P1 W  W8 }% N) bchest for a considerable period of time, causing sig-
' F1 y  c, w% L% n  Anificant bare skin contact between baby and father.
0 C! A0 u9 W  w8 iThe father also admitted that after the phone call,
5 T7 B/ X7 L4 l& a0 M0 Ewhen he learned the testosterone level in the baby
3 j, M" x' m4 H  Nwas high, he then read the product information, Y0 j# E& X, l
packet and concluded that it was most likely the rea-3 t3 n9 S2 K9 D5 a
son for the child’s virilization. At that time, they  Z! M- c7 U( v& {  L
decided to put the baby in a separate bed, and the: q' s/ x) t. }" l8 t; L
father was not hugging him with bare skin and had/ U# d, F! H6 C0 C5 M; {) K* e
been using protective clothing. A repeat testosterone
# `4 ~! S& |' i3 Y2 Atest was ordered, but the family did not go to the
2 P7 U& c: d3 z0 B' f) rlaboratory to obtain the test.2 d4 M9 T- g( m4 q* Y0 m/ M. g: w
Discussion; {: c3 W* I; W) b6 v, B9 g
Precocious puberty in boys is defined as secondary
8 P* W1 W3 E6 W. ksexual development before 9 years of age.1,44 K& W$ V6 N! Z$ u' b
Precocious puberty is termed as central (true) when; G; M: {- a% e/ x* l" I
it is caused by the premature activation of hypo-
+ v# ]. }) y+ v" othalamic pituitary gonadal axis. CPP is more com-
8 _9 @- R0 P( C) [- Y2 R  R$ d" omon in girls than in boys.1,3 Most boys with CPP
7 q; O- K! X+ t& A% nmay have a central nervous system lesion that is
7 E. y- G  w4 h$ N0 N+ G" \/ uresponsible for the early activation of the hypothal-
  O# D8 v/ m& L8 hamic pituitary gonadal axis.1-3 Thus, greater empha-
7 F) s" o* ^  M! o6 rsis has been given to neuroradiologic imaging in# j, r( I) J2 k
boys with precocious puberty. In addition to viril-- q* C, b9 n3 t& `) k; _" e
ization, the clinical hallmark of CPP is the symmet-
$ X, Y# V! n+ ]: e+ t3 q3 Crical testicular growth secondary to stimulation by
8 G# z8 l3 b  L8 C! z, u5 O8 O9 @6 tgonadotropins.1,33 s5 F3 O& h+ [: o  v
Gonadotropin-independent peripheral preco-
  s, R- s( r2 ^0 V! r* f# R# Q, G6 vcious puberty in boys also results from inappropriate5 b/ e" L: m  Q$ N0 B7 ?
androgenic stimulation from either endogenous or; `9 z1 @) e1 T, }& n' {; B
exogenous sources, nonpituitary gonadotropin stim-
% Q5 r8 @9 l! k& e" p+ l7 zulation, and rare activating mutations.3 Virilizing
9 B3 y. _3 P; k9 r  M8 Ccongenital adrenal hyperplasia producing excessive
+ k: T  U  R5 z8 }7 jadrenal androgens is a common cause of precocious
5 c& t% V% T( B% I. f  D7 wpuberty in boys.3,4) y; F5 I9 {9 q7 ]
The most common form of congenital adrenal" b% H8 _: t- r: r# [$ o
hyperplasia is the 21-hydroxylase enzyme deficiency.5 A4 T- W0 o1 E  N9 r
The 11-β hydroxylase deficiency may also result in* f: w5 ]. H# K- \" |, Q
excessive adrenal androgen production, and rarely,
( l. Y0 X1 O1 ~0 @. f4 ian adrenal tumor may also cause adrenal androgen! `" j) v- u8 u4 a
excess.1,3
/ T( m$ w; D: E; uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 u# f* j5 j' c8 x( o4 r
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- E1 T2 l6 P& t/ f$ o% P& h, ?4 W
A unique entity of male-limited gonadotropin-
4 x4 ^8 e' m: {" X5 yindependent precocious puberty, which is also known
3 w) [: M" X/ ?as testotoxicosis, may cause precocious puberty at a
4 L% a5 J# g+ X: f; \' m) h3 ?very young age. The physical findings in these boys& U. _3 I: X/ J- Q
with this disorder are full pubertal development,' e% g  d4 Y! G+ q+ p  c' F
including bilateral testicular growth, similar to boys
2 K1 ?# Y$ l. W3 Zwith CPP. The gonadotropin levels in this disorder
* g8 h* j3 c1 l4 Care suppressed to prepubertal levels and do not show
" O/ f8 d0 [4 Hpubertal response of gonadotropin after gonadotropin-6 L) m! T# I2 y3 c8 T: n# R1 K
releasing hormone stimulation. This is a sex-linked7 F, u' j/ ]+ o# Z) O% z$ |
autosomal dominant disorder that affects only
( L9 v& [: z( `) ~4 o) V8 @* |" \males; therefore, other male members of the family9 x" r4 o6 k4 }$ ^$ d
may have similar precocious puberty.3) @9 N8 @4 }. |0 |) z1 L, c/ I% R5 r
In our patient, physical examination was incon-) T0 V# Q( I5 m' n
sistent with true precocious puberty since his testi-
1 }1 \1 C* X; Ycles were prepubertal in size. However, testotoxicosis
; Y3 x$ [* b' ywas in the differential diagnosis because his father
/ }8 e8 {# y7 F/ d6 o! |* istarted puberty somewhat early, and occasionally,& a- c' b* r8 a: E3 s
testicular enlargement is not that evident in the
+ f3 e# f2 m4 hbeginning of this process.1 In the absence of a neg-
) P3 j/ y+ ?; t, Q" i, {- aative initial history of androgen exposure, our( G0 h& k& M: e) w) o
biggest concern was virilizing adrenal hyperplasia,
0 Y# `: r8 c, Heither 21-hydroxylase deficiency or 11-β hydroxylase
& M( ^3 r" x. s/ n* hdeficiency. Those diagnoses were excluded by find-( I+ s' ?& T  _
ing the normal level of adrenal steroids.( o# v. g& n1 J) f9 b" Q, r' b  F
The diagnosis of exogenous androgens was strongly5 }' O$ X. ^, q# ~
suspected in a follow-up visit after 4 months because
& G% w6 u# l. J! Kthe physical examination revealed the complete disap-
5 ^) n7 X$ v& \7 T8 {2 E" Xpearance of pubic hair, normal growth velocity, and# F5 M1 X) U/ G( e4 y3 O9 F
decreased erections. The father admitted using a testos-
' J3 e) S" f' u2 f8 H  {# eterone gel, which he concealed at first visit. He was+ c" [  p' I+ D
using it rather frequently, twice a day. The Physicians’
+ K  U' ?' u: I) e; T: FDesk Reference, or package insert of this product, gel or9 H/ o- {3 x) m- @% R
cream, cautions about dermal testosterone transfer to
4 ?$ R( a& x& Funprotected females through direct skin exposure.
8 M2 ?- y2 d- S2 r0 k* KSerum testosterone level was found to be 2 times the
: r6 t7 g: U7 r4 rbaseline value in those females who were exposed to
4 k1 X) [/ ?/ r* b2 weven 15 minutes of direct skin contact with their male
, z3 m' _; f1 m8 h2 Epartners.6 However, when a shirt covered the applica-
. m7 i  d0 S% e; R, N- `1 otion site, this testosterone transfer was prevented.
* D; Y4 Q% {, }2 [( qOur patient’s testosterone level was 60 ng/mL,$ _3 C, C' |% C+ x+ Z
which was clearly high. Some studies suggest that
) ~, J( W+ R, Odermal conversion of testosterone to dihydrotestos-
+ B: k0 `% X$ b, R# p6 O) Gterone, which is a more potent metabolite, is more
- b. D7 K. z$ Mactive in young children exposed to testosterone
9 ]( K1 k" F; j; F+ q3 texogenously7; however, we did not measure a dihy-
1 {2 z9 p% Z% [6 l- Hdrotestosterone level in our patient. In addition to0 ]1 m( D4 ]- g" N6 ]) g) z
virilization, exposure to exogenous testosterone in; R0 @! }$ b4 q* q) _+ R" N( ^3 y
children results in an increase in growth velocity and
" x2 Y1 J1 m( [3 [( Z+ S  dadvanced bone age, as seen in our patient.  t& r) |: H; {  m7 n9 ^! S( q
The long-term effect of androgen exposure during
/ J) Z. E" Y8 Y  Z- `early childhood on pubertal development and final
" |1 ]# q8 i" Y) w" z9 F7 oadult height are not fully known and always remain
4 H1 x: l8 j2 E1 V' j# O' h4 Sa concern. Children treated with short-term testos-
+ j. U3 T" H1 ^3 X; F# M' }terone injection or topical androgen may exhibit some
$ m5 `* l' I, U* Xacceleration of the skeletal maturation; however, after7 N3 @$ q# I! c; C
cessation of treatment, the rate of bone maturation! F# _8 y" B9 J. u
decelerates and gradually returns to normal.8,91 R+ I' O. z% j5 h2 q; T
There are conflicting reports and controversy% M" W, s# f- g# ?& l" I: n0 s6 L
over the effect of early androgen exposure on adult5 o2 O7 R4 z1 ?" S$ }3 c
penile length.10,11 Some reports suggest subnormal; e! }% O# f; L! s. n
adult penile length, apparently because of downreg-2 A( I' B7 E: M3 d7 \' U% {
ulation of androgen receptor number.10,12 However,* H; |! z" S1 |  {3 P' p8 J* ]0 z
Sutherland et al13 did not find a correlation between. C2 ]' g" m( Z$ i( r/ P0 R
childhood testosterone exposure and reduced adult) K# q# C+ d- ?5 M* ~: K* p1 R
penile length in clinical studies.# p5 U, n9 l2 h0 h! S
Nonetheless, we do not believe our patient is
8 Z- {2 k! y; Ngoing to experience any of the untoward effects from1 n! G1 w4 }9 U+ N
testosterone exposure as mentioned earlier because% \7 ]& Q% |! `, y& t" Q+ w- t
the exposure was not for a prolonged period of time.5 S  K4 Y/ S+ U+ |9 l" F2 W/ h; o
Although the bone age was advanced at the time of' I+ ]4 p$ t% k
diagnosis, the child had a normal growth velocity at8 U+ Z- g8 T- N- _, w$ y
the follow-up visit. It is hoped that his final adult% y6 h1 {( {: M! @  S
height will not be affected.6 l, K7 ]+ ~5 h* ~, p% X- M1 x
Although rarely reported, the widespread avail-  Q; ~- i- D+ Z1 ^* P
ability of androgen products in our society may8 V% ]# s' [- ]$ C$ i6 N4 i2 F
indeed cause more virilization in male or female
  e$ N; i8 \; S0 w, |children than one would realize. Exposure to andro-
5 P( G5 d+ U  J, `gen products must be considered and specific ques-5 U2 j- ]# {& B9 A& ^% Z  F0 X
tioning about the use of a testosterone product or
  x4 ]7 z. ^% ?( T% Y2 _- Sgel should be asked of the family members during
$ t0 }5 a1 x6 P5 q6 }the evaluation of any children who present with vir-
- j; o5 O- n" jilization or peripheral precocious puberty. The diag-
' _# F3 m; Z' Inosis can be established by just a few tests and by$ ]" `& M, v+ c" L
appropriate history. The inability to obtain such a
1 ]1 H9 z5 E* Vhistory, or failure to ask the specific questions, may
$ a, @% F% n& L3 N( n. ^' S4 Oresult in extensive, unnecessary, and expensive, j7 y" o% ~' z. X& C+ x
investigation. The primary care physician should be" }8 S2 q6 x$ K& v; [; R/ ?
aware of this fact, because most of these children9 c; [9 O7 V2 h1 c
may initially present in their practice. The Physicians’) V. ^' O+ K# X4 h2 o% d
Desk Reference and package insert should also put a9 b# D9 R& v% C
warning about the virilizing effect on a male or; c2 d/ d9 T7 m4 L7 R
female child who might come in contact with some-
7 F/ R( t' a" y% u* y: }one using any of these products.
) U% a/ Q6 G: q3 j6 KReferences
- }& K% z% ]( S* y1. Styne DM. The testes: disorder of sexual differentiation
1 \5 u3 m( b2 W8 W: N0 ^; wand puberty in the male. In: Sperling MA, ed. Pediatric
' W( I$ {) ]2 s) f6 s$ `Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ C" P8 v1 G1 l' X6 J* D! h9 T2002: 565-628.7 ]/ k# L- K$ d; ]* _, I7 R* n5 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- e( P& c0 Z$ {puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" n! e$ b; s- D$ Q9 F) b5 UBoy Induced by Indirect Topical4 h+ H$ C) t: K4 \* K5 j
Exposure to Testosterone8 L8 Y  O$ k3 {3 {& i/ f& W, S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 l2 |8 O- h" E- H, q3 O2 u$ I# b
and Kenneth R. Rettig, MD1
0 S( H* P4 A* a. S! bClinical Pediatrics: R1 W' B# y0 H9 z
Volume 46 Number 6
; w( `) B  V5 D/ ]July 2007 540-5435 p0 H' x9 M" l. @
© 2007 Sage Publications, @4 E) D0 }* P3 w) s& D, y
10.1177/0009922806296651
: q! v3 q3 R  ^& n4 L8 O! b" a2 U' m+ Phttp://clp.sagepub.com
  \, ?- G7 j6 p' thosted at- O: x, s. p1 G; t  C4 z! u
http://online.sagepub.com
* r. d$ q# y+ _5 \% d9 P, ^Precocious puberty in boys, central or peripheral,
( F( m8 x6 Y3 Y) }0 C" |3 zis a significant concern for physicians. Central" u) r) |" M9 ]9 j9 F- v
precocious puberty (CPP), which is mediated
1 A9 e5 B3 a. t5 Y) v3 ?& ithrough the hypothalamic pituitary gonadal axis, has
& k5 G8 P. v, u' g, P0 p" n% Wa higher incidence of organic central nervous system
9 e  t3 g. X2 d; ]lesions in boys.1,2 Virilization in boys, as manifested
0 ]7 S' _3 E+ q( Q1 h2 m  r% vby enlargement of the penis, development of pubic
" s! D! Q9 Z, {5 R$ V7 g5 r7 Ehair, and facial acne without enlargement of testi-
- Y6 L8 e6 P% t# w) i$ V" C7 {cles, suggests peripheral or pseudopuberty.1-3 We
* W0 g; X7 N( U" N0 d$ qreport a 16-month-old boy who presented with the' a: ~; S7 b3 @
enlargement of the phallus and pubic hair develop-4 L9 v1 k3 p: R( `- U
ment without testicular enlargement, which was due4 j7 W6 H) X) Q# o. ]/ M2 C
to the unintentional exposure to androgen gel used by7 R* ?; X+ K; ?
the father. The family initially concealed this infor-
, ~4 Z" \9 r8 bmation, resulting in an extensive work-up for this
9 I3 R$ J: b- N- j% c  uchild. Given the widespread and easy availability of
% @, \6 {) j- J  o; \. A  Q6 Wtestosterone gel and cream, we believe this is proba-
8 \8 P+ _4 p0 [& l( vbly more common than the rare case report in the
) g( a/ F1 P; k5 M) Y& |+ eliterature.4
( u( i+ ?2 t5 @& \% yPatient Report
( R0 u/ E6 B3 V8 ]$ _5 K. e6 IA 16-month-old white child was referred to the3 M' w( ^$ i% D
endocrine clinic by his pediatrician with the concern0 @" {; H% v& ~8 |$ S
of early sexual development. His mother noticed
& s3 k+ p$ D2 t) p7 }8 H: Blight colored pubic hair development when he was
# \7 n) W" k6 @$ @2 w) V" zFrom the 1Division of Pediatric Endocrinology, 2University of# z, q5 p0 R% u0 y
South Alabama Medical Center, Mobile, Alabama.
; t0 \1 h- s5 mAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. d% S# U; x8 `+ @* V0 |Professor of Pediatrics, University of South Alabama, College of% C! B) o+ N7 |0 d1 r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# A1 z6 C% x* M
e-mail: [email protected].- _1 M! W; T9 u
about 6 to 7 months old, which progressively became3 [5 V' a& e1 T0 B
darker. She was also concerned about the enlarge-
7 c7 s1 N/ V% Lment of his penis and frequent erections. The child
( h2 M1 N" O, z4 l: Q! {was the product of a full-term normal delivery, with* Z/ U9 e: C6 M; o
a birth weight of 7 lb 14 oz, and birth length of
4 Y* f- v8 ?  b7 o1 r20 inches. He was breast-fed throughout the first year
1 [& s1 D) w2 _/ q; kof life and was still receiving breast milk along with
+ z5 u+ h+ g) O6 v% ksolid food. He had no hospitalizations or surgery,
- h$ M' R5 e; l, E8 n6 _" Gand his psychosocial and psychomotor development
+ O$ V9 g" o8 d0 J8 \# c  Zwas age appropriate.
! W, U/ X1 Y- k' J  x5 k1 ]4 S5 f# ~The family history was remarkable for the father,6 C' I# r9 i/ X0 a7 [  P, l7 q
who was diagnosed with hypothyroidism at age 16,# x  {3 s* U$ }/ r2 m
which was treated with thyroxine. The father’s
* [, A6 O3 r4 eheight was 6 feet, and he went through a somewhat! C  p! E! q6 M$ q
early puberty and had stopped growing by age 14.
# j* }9 W; a. b& h4 CThe father denied taking any other medication. The
1 ?4 F' x. M- f! nchild’s mother was in good health. Her menarche/ a! g* I' w" g! D+ Q" J; z5 N4 `
was at 11 years of age, and her height was at 5 feet
/ c2 j' l1 [! g7 |  v4 n7 _5 O5 inches. There was no other family history of pre-
# @# I+ X: ?' g% t. S& |' `6 I. p. Dcocious sexual development in the first-degree rela-* s, d' M* r$ D& J, {" R
tives. There were no siblings.- J! ^1 h3 M5 `: |' c
Physical Examination" g/ K7 V" `) _' y* U1 l
The physical examination revealed a very active,
- t& I' G! V4 W+ _. Vplayful, and healthy boy. The vital signs documented
) p* z2 t. U7 k$ Ca blood pressure of 85/50 mm Hg, his length was+ u! U! ?9 }0 u- \
90 cm (>97th percentile), and his weight was 14.4 kg
& P& q' |6 `/ z) N/ d(also >97th percentile). The observed yearly growth
" X& L4 f9 o# E) evelocity was 30 cm (12 inches). The examination of
& ~6 n. \6 E: P% Qthe neck revealed no thyroid enlargement.* d, ?9 Y/ b8 n( o* I
The genitourinary examination was remarkable for
3 Q9 s3 Q  d% V, f% Lenlargement of the penis, with a stretched length of& B' U+ I. Q- Z/ F
8 cm and a width of 2 cm. The glans penis was very well
& _) E& a8 U) ddeveloped. The pubic hair was Tanner II, mostly around5 ?, v6 B. R/ E, S7 `+ I# [9 U+ ?
540+ P: W3 x  c( X" ^( n- b1 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 d8 l+ e. v. mthe base of the phallus and was dark and curled. The3 m+ N' Z" L0 }$ r& e$ M
testicular volume was prepubertal at 2 mL each.: L$ f. S! A# t0 J& N
The skin was moist and smooth and somewhat
- T9 x+ }6 e. Q, H5 d" {oily. No axillary hair was noted. There were no: |" C) s" F1 c9 Z$ ]7 U, I
abnormal skin pigmentations or café-au-lait spots.% Z! P1 g) P! t% c% M
Neurologic evaluation showed deep tendon reflex 2+
0 t! f! d' i! K7 X) Ibilateral and symmetrical. There was no suggestion
6 O# X8 G, l* ?9 n" h. S1 R) Uof papilledema.& `8 h0 J4 u) N8 b
Laboratory Evaluation
4 V  [; J& ?+ x9 mThe bone age was consistent with 28 months by
$ O$ R; x; s$ o4 d' r# T- Pusing the standard of Greulich and Pyle at a chrono-6 f! C3 C, c4 Q- T5 O- B
logic age of 16 months (advanced).5 Chromosomal- |7 b1 S6 _' h) a1 Y! m1 O% Q
karyotype was 46XY. The thyroid function test, L* E  z& ~/ N- ^* P6 A& f& g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) u5 I& d$ V% ^lating hormone level was 1.3 µIU/mL (both normal).4 H, r9 N. B0 s0 n. ~4 y9 }- ]
The concentrations of serum electrolytes, blood! i3 C& [+ L+ O2 z" m
urea nitrogen, creatinine, and calcium all were+ e$ l( n5 I# S
within normal range for his age. The concentration  f" F  l3 {* h7 e
of serum 17-hydroxyprogesterone was 16 ng/dL3 r# K- `* J! P0 }7 U) o# x
(normal, 3 to 90 ng/dL), androstenedione was 20
7 l/ M1 l- S" s* _# [5 x7 W' zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; ^$ U; C- N+ b. t  ~
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; e) q) P) G7 N4 K+ odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ C; z+ I& {$ F- x; k; ^5 S- L49ng/dL), 11-desoxycortisol (specific compound S)$ `! r- I) a/ @+ Y4 h, _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 S: E- x$ j. o! V
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 R( d/ ~- p6 O" D2 Q7 B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, r0 ?$ u" O& |9 h5 S0 dand β-human chorionic gonadotropin was less than. Q! R9 G$ t7 I7 d! y/ F
5 mIU/mL (normal <5 mIU/mL). Serum follicular/ Q3 s4 s6 D* n+ O
stimulating hormone and leuteinizing hormone
4 o; G- A& D1 Qconcentrations were less than 0.05 mIU/mL
5 L# T0 f2 z6 X% I$ X/ `& }(prepubertal).
. A3 J) u1 [  EThe parents were notified about the laboratory
0 ?, y( i& }! k. Z; tresults and were informed that all of the tests were
9 c- J9 F4 H+ Znormal except the testosterone level was high. The
" g3 a/ S2 |5 yfollow-up visit was arranged within a few weeks to
0 k" Z5 P8 u# n; h/ `# yobtain testicular and abdominal sonograms; how-
$ B% V: T( i5 N! dever, the family did not return for 4 months.
: k) `( W- X4 t  \4 BPhysical examination at this time revealed that the2 `/ D4 Q" ~- j8 D
child had grown 2.5 cm in 4 months and had gained, N5 t1 V% f; P% v
2 kg of weight. Physical examination remained
# V1 G8 U' H! T( H& c5 Iunchanged. Surprisingly, the pubic hair almost com-- o, p  S9 H: K9 `
pletely disappeared except for a few vellous hairs at% H& b& \  U: y$ R
the base of the phallus. Testicular volume was still 2
# k( }! e1 R& L' z/ t! B) NmL, and the size of the penis remained unchanged.
, G1 p/ v1 l( q5 n& ]9 H3 w# q) mThe mother also said that the boy was no longer hav-
; z, ^. o* i1 H  Bing frequent erections.
9 k$ f$ A! O* P' a3 X/ ]Both parents were again questioned about use of
! w0 m$ \5 k% p# T2 I# A% ?any ointment/creams that they may have applied to
; e0 P$ S" w7 x# t% Ithe child’s skin. This time the father admitted the) l/ c. I( S7 Y( \3 M4 v
Topical Testosterone Exposure / Bhowmick et al 541+ I$ i% F0 E% ~% o6 P; f' R
use of testosterone gel twice daily that he was apply-' a: t: S2 @# h# ?
ing over his own shoulders, chest, and back area for* M) [5 I" Z7 b# I/ A" s
a year. The father also revealed he was embarrassed
, |: r! B9 i3 x, U3 eto disclose that he was using a testosterone gel pre-# n" d  N. Q* {  \
scribed by his family physician for decreased libido% U( z4 B- q9 b1 n% v
secondary to depression.% K0 N3 o/ O$ ~% a1 L8 k
The child slept in the same bed with parents.
7 Y( W4 z# z& Y& e, M4 GThe father would hug the baby and hold him on his, R- n9 h- i/ Y7 H; j+ N
chest for a considerable period of time, causing sig-4 B5 Z2 h9 g" d! N
nificant bare skin contact between baby and father." M( ?: T/ t' {/ i
The father also admitted that after the phone call,# `/ ~, _! y! U4 p% V
when he learned the testosterone level in the baby% \  u% v' Z0 t5 v' x3 v* B! J4 w
was high, he then read the product information
: t# `0 K4 D! L( p; H( g3 bpacket and concluded that it was most likely the rea-/ a( c( L" ?5 O5 l" o
son for the child’s virilization. At that time, they) }8 V1 U; y- i+ o( q' |
decided to put the baby in a separate bed, and the
6 x6 r" Z8 k8 F$ y! x/ ffather was not hugging him with bare skin and had5 Q; c/ X7 z( L0 f2 j$ R
been using protective clothing. A repeat testosterone) Z. d/ t4 D( X0 \, r5 G- n
test was ordered, but the family did not go to the+ L7 D* q2 K. j6 h9 _2 O2 \
laboratory to obtain the test.. Q. O4 S$ K# r0 k% z4 e
Discussion6 R7 I, W& c7 ^6 I! H2 L8 n2 V) F+ L
Precocious puberty in boys is defined as secondary5 I' t/ h1 T/ E& W1 }6 A' Y3 P  G  _
sexual development before 9 years of age.1,4
9 [( [* C& S- G5 ?0 h9 kPrecocious puberty is termed as central (true) when. S9 l4 w9 W$ m, Q
it is caused by the premature activation of hypo-2 \9 m+ }1 S( T+ }1 |9 D7 C
thalamic pituitary gonadal axis. CPP is more com-
" p& {2 H( a$ W' @2 y- ~5 J6 f! dmon in girls than in boys.1,3 Most boys with CPP
! V0 x& c2 u- g; \may have a central nervous system lesion that is; x3 j$ f; a  R4 k
responsible for the early activation of the hypothal-% `7 s5 q! Q4 k2 S% b  Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
# J  x7 n: i/ \" H; p+ p0 t2 ysis has been given to neuroradiologic imaging in& D6 {9 R1 X; ?7 h% f7 k2 u
boys with precocious puberty. In addition to viril-; i* u- ], j$ R  d
ization, the clinical hallmark of CPP is the symmet-( u7 l2 i6 U4 a  D/ q7 G- W
rical testicular growth secondary to stimulation by
5 l% i$ T; f1 V2 R8 k& V: ggonadotropins.1,3
7 h9 ]) o- \3 G. cGonadotropin-independent peripheral preco-2 R: L- h' V. m) q4 F0 k
cious puberty in boys also results from inappropriate7 E1 b8 L0 V- ?: |& Q
androgenic stimulation from either endogenous or
( O) w1 `% h2 Z7 Yexogenous sources, nonpituitary gonadotropin stim-
4 @) P+ w5 ^0 T6 I' Yulation, and rare activating mutations.3 Virilizing! E# j2 n* {$ Q8 E& k- c, @
congenital adrenal hyperplasia producing excessive( H# Y6 s8 e, `
adrenal androgens is a common cause of precocious
$ H/ G+ o$ P0 G  t5 Rpuberty in boys.3,4
0 c- \8 M1 F0 M# h1 cThe most common form of congenital adrenal- p' }8 p6 a0 s/ d7 O6 o1 _$ p( h3 c
hyperplasia is the 21-hydroxylase enzyme deficiency.  p; G7 u% {2 a3 w; R
The 11-β hydroxylase deficiency may also result in- h/ s: Y/ q2 z- j: u. \2 D5 O* E7 Q
excessive adrenal androgen production, and rarely,
& T  y7 y7 d* D8 z3 t+ v3 `5 M# X1 Ean adrenal tumor may also cause adrenal androgen! W+ v# T; y& L) ?; l
excess.1,36 T0 G- r4 w7 [/ ]3 w8 |" p' x, d& j) |: {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: G7 m/ @5 \* w542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ x2 e7 U5 n2 n7 x4 `A unique entity of male-limited gonadotropin-
) o- T% W! c% Sindependent precocious puberty, which is also known
5 Z% F) }: y4 Yas testotoxicosis, may cause precocious puberty at a
* U/ o6 ^" N) |- J( _4 e" Hvery young age. The physical findings in these boys+ D$ E1 k* Q7 ^
with this disorder are full pubertal development,# m: [. R. [3 c6 z" j0 b3 S
including bilateral testicular growth, similar to boys+ k: k+ ]4 a9 D8 z5 X- s: W
with CPP. The gonadotropin levels in this disorder+ m9 K+ l# @% F  o* a9 B& s
are suppressed to prepubertal levels and do not show8 w7 r' O# i! O4 {' z/ f3 S
pubertal response of gonadotropin after gonadotropin-
, T8 _4 V! p8 u# r$ _releasing hormone stimulation. This is a sex-linked( ]" i* G. W$ a1 @' y* l
autosomal dominant disorder that affects only
" @, Q+ s: L& a' h+ o+ ]males; therefore, other male members of the family. T6 r' M" V, @/ P
may have similar precocious puberty.3
  t; b: n2 z3 J2 `+ {In our patient, physical examination was incon-
: ^0 e( c2 H% Psistent with true precocious puberty since his testi-( s/ S; ^1 I. Y8 W
cles were prepubertal in size. However, testotoxicosis
  {) ?! w* G4 w- }was in the differential diagnosis because his father  J: F1 P. J/ v( b7 p5 }
started puberty somewhat early, and occasionally,' q+ {# b& y6 W  v
testicular enlargement is not that evident in the0 e/ p0 c0 Q* [/ `8 F
beginning of this process.1 In the absence of a neg-# n$ v5 Z' y8 d3 o2 K( F
ative initial history of androgen exposure, our
* g$ }4 m9 x2 b- D/ q; Bbiggest concern was virilizing adrenal hyperplasia,/ ^$ D) m1 B' J" ?1 j. ^9 H
either 21-hydroxylase deficiency or 11-β hydroxylase; W4 `5 v3 n9 A# f  x" H
deficiency. Those diagnoses were excluded by find-9 j8 r# z# v/ Q+ K* {
ing the normal level of adrenal steroids.% n0 m7 @% F, x* }; m
The diagnosis of exogenous androgens was strongly% A- w2 J/ Y' o9 w( Z9 p
suspected in a follow-up visit after 4 months because6 |( i+ _# _4 a+ }3 M
the physical examination revealed the complete disap-" R- u4 [( o+ a  |) w8 L
pearance of pubic hair, normal growth velocity, and
" o! N# h# Z$ S& D$ udecreased erections. The father admitted using a testos-. Y5 `' b* J/ t0 s* n: Y
terone gel, which he concealed at first visit. He was6 j, j, M+ r4 Z. M( ~# E
using it rather frequently, twice a day. The Physicians’
1 W4 q: T3 S2 D0 XDesk Reference, or package insert of this product, gel or
9 |, X$ V9 R! J# y9 E& H- ocream, cautions about dermal testosterone transfer to  N. e- B- f& n9 e  G
unprotected females through direct skin exposure.
8 O1 ^7 u, P8 k- uSerum testosterone level was found to be 2 times the6 h" u$ ]1 S9 g( p
baseline value in those females who were exposed to
4 g7 w- P1 r! @: I' xeven 15 minutes of direct skin contact with their male$ E  t; G/ Z+ Z
partners.6 However, when a shirt covered the applica-
0 ?& v* X7 Y- `: C5 ^9 Rtion site, this testosterone transfer was prevented.( d0 U" G5 G; M
Our patient’s testosterone level was 60 ng/mL,
) X# x. J* n# F% V& cwhich was clearly high. Some studies suggest that; r6 p# z$ g% r+ @9 B9 H  A5 Z8 m3 E
dermal conversion of testosterone to dihydrotestos-
/ d2 `4 b4 [$ t3 u3 G3 qterone, which is a more potent metabolite, is more! |" c! W2 R" L" ?5 d' n
active in young children exposed to testosterone
) s& J4 N: _9 wexogenously7; however, we did not measure a dihy-
5 Y9 p8 Y3 i5 `4 gdrotestosterone level in our patient. In addition to% P- q: h$ [$ q3 G
virilization, exposure to exogenous testosterone in
& S; t& P8 X( A$ H! ?children results in an increase in growth velocity and
: J2 I1 f  L- U/ b# C4 radvanced bone age, as seen in our patient.
, B. U8 n0 [& k6 C0 f  d& lThe long-term effect of androgen exposure during
9 t: G  S8 W: pearly childhood on pubertal development and final
" q. j6 W: F1 I/ u& q; ~& _: B6 u! Wadult height are not fully known and always remain0 `0 Y" f, ]( s3 g
a concern. Children treated with short-term testos-% R; e' Y5 v9 G" R# B
terone injection or topical androgen may exhibit some
0 P2 m  h8 B# e6 L. W; ^acceleration of the skeletal maturation; however, after1 t9 `- U; b+ S
cessation of treatment, the rate of bone maturation
+ w0 M8 H$ S1 v& Z1 h2 x3 Bdecelerates and gradually returns to normal.8,9
. M  B8 b7 ~" X% E  V/ I# tThere are conflicting reports and controversy
: f* k' z" }5 C- Y" I: _) W- _over the effect of early androgen exposure on adult
* J  B, }2 c. c2 ?6 m! Z4 fpenile length.10,11 Some reports suggest subnormal$ f) E3 H- h/ ~0 i# c# Q- k  l
adult penile length, apparently because of downreg-
9 e0 C5 i! n# u6 x" y6 bulation of androgen receptor number.10,12 However,
; o0 |8 ?: K, T2 gSutherland et al13 did not find a correlation between' T" X% D9 ~  h
childhood testosterone exposure and reduced adult
. R, p( |; ]  K: t! Qpenile length in clinical studies.8 ]7 C; z- c3 V6 r
Nonetheless, we do not believe our patient is# p. p8 B) ^% B( c# r9 u
going to experience any of the untoward effects from9 X. W! f4 Q, `( h
testosterone exposure as mentioned earlier because" A8 h, V. i+ ~+ {
the exposure was not for a prolonged period of time.
/ Y+ i# Q/ g6 U% Z) P( n9 }Although the bone age was advanced at the time of5 S, l$ {# f; ^  }& [# }7 {/ V- u- @" E
diagnosis, the child had a normal growth velocity at' h! r  R7 J7 O& B
the follow-up visit. It is hoped that his final adult
( b, U0 y5 S" z% `$ r, Aheight will not be affected.
, I0 q" g+ R/ N* [Although rarely reported, the widespread avail-
# w2 \5 ~& {) j6 u) @" kability of androgen products in our society may
" G# ?' N: a2 W' p3 `, Hindeed cause more virilization in male or female
; Q) |, Z. R1 H" {$ U6 C6 n- lchildren than one would realize. Exposure to andro-
# D/ L7 `3 B: E& ~: Sgen products must be considered and specific ques-  ]) e3 @! d6 T* z
tioning about the use of a testosterone product or
! k' m# R2 C$ y9 ]% Hgel should be asked of the family members during
! K8 V- T" W/ ~the evaluation of any children who present with vir-/ s+ w; i3 y4 C. i% E0 E9 r* L7 a# K
ilization or peripheral precocious puberty. The diag-
2 E9 [0 D. R. i' C$ G9 Bnosis can be established by just a few tests and by
  \% K+ W# n+ ]/ r/ Yappropriate history. The inability to obtain such a6 V) j4 ^. U7 _, p
history, or failure to ask the specific questions, may; ^- Y) F2 [2 n1 f: h5 m' z. L
result in extensive, unnecessary, and expensive: K9 l- D) J/ O, _  T
investigation. The primary care physician should be
( F% o1 E7 R) C6 {3 Z3 M* L9 eaware of this fact, because most of these children
6 r: }" N& o4 p8 P+ |may initially present in their practice. The Physicians’
: X9 ^: o' _0 gDesk Reference and package insert should also put a/ C5 m2 @3 X/ a/ S/ [
warning about the virilizing effect on a male or
# v8 X, C& J/ n2 o# t+ d4 `2 L" E3 lfemale child who might come in contact with some-
: ^' d: Z" x: @- {% V. K8 M+ tone using any of these products.
: ]: N; x' U9 c; W2 [: h6 ~0 A: CReferences
2 n4 Z1 R" S+ e5 A  F" W  b% y& I1. Styne DM. The testes: disorder of sexual differentiation$ @8 J) E0 K, ?; z( i; H
and puberty in the male. In: Sperling MA, ed. Pediatric0 p- r- p% J! q5 n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ c5 A+ B, i- r3 K0 P1 j# F
2002: 565-628., T) @  ^9 K' q3 W% I" K5 {/ g* W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* U( J1 Z' P. [1 X0 P( s4 gpuberty 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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發表於 2025-1-19 02:41:05 | 顯示全部樓層

/ t9 e/ K0 M. l) Y) D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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