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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* z: C' [- e0 c# x- j
Boy Induced by Indirect Topical
& t& a9 \& K+ k4 A7 t: MExposure to Testosterone! L- _9 |. [9 c  q1 p( G% \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! F- T& g# `7 E+ h5 X& \and Kenneth R. Rettig, MD1- W. y9 a/ @2 p
Clinical Pediatrics
" u0 U' ^* {6 R* r6 S/ m0 |: nVolume 46 Number 67 w3 {0 T5 H! Q! a1 Y0 f
July 2007 540-543% |4 Z: t7 ^* Q9 u. Z* Y8 r  A" v
© 2007 Sage Publications$ K, i2 l  q) T# Q8 x  ]
10.1177/0009922806296651
+ ^% q9 B# s4 `! nhttp://clp.sagepub.com
* `0 c6 D1 Y' ~- c+ ?hosted at
# E7 J) C% Y/ O7 ~http://online.sagepub.com& a' W6 ]) T: N% g7 g- t& M/ b
Precocious puberty in boys, central or peripheral,
8 J, l) I/ n* Y% g$ @0 c+ Kis a significant concern for physicians. Central% \7 _' [" F9 X  r8 H
precocious puberty (CPP), which is mediated
( Y1 x: o$ v+ j- X  S8 e4 \+ ythrough the hypothalamic pituitary gonadal axis, has9 o0 `$ e  M& ?: [" t# \& r
a higher incidence of organic central nervous system$ v' ~" a2 l0 r- Q
lesions in boys.1,2 Virilization in boys, as manifested
% j( i7 `/ _0 f7 [9 c1 X4 {1 dby enlargement of the penis, development of pubic$ c3 Q7 M$ q% X' F$ t
hair, and facial acne without enlargement of testi-
5 _) V) A" Y6 P( }' b6 L& D; A& @4 Dcles, suggests peripheral or pseudopuberty.1-3 We
) i' m1 Z; ~8 E# h0 preport a 16-month-old boy who presented with the
4 C9 g) O( X- F! Fenlargement of the phallus and pubic hair develop-  i5 X1 A3 A" Y6 p1 D
ment without testicular enlargement, which was due1 L( ~0 T% B# [; S& _% N7 |
to the unintentional exposure to androgen gel used by
' s, C$ `% G, C3 b! [  ythe father. The family initially concealed this infor-  |: {9 z8 {( ^/ V' W) ?8 y
mation, resulting in an extensive work-up for this
( K5 q% G" C. j" wchild. Given the widespread and easy availability of
/ b  i  D2 S4 g8 O, n/ p6 ]testosterone gel and cream, we believe this is proba-" y+ ^& x1 ^  Z3 k6 Z
bly more common than the rare case report in the* B( z8 N3 Z* P- m
literature.4
- n; \5 ?/ |! qPatient Report6 ]6 s, D' a) Y' L2 D
A 16-month-old white child was referred to the
! m# T: X5 V7 r2 `- B5 Rendocrine clinic by his pediatrician with the concern8 p$ F& a1 {8 V' w- h
of early sexual development. His mother noticed3 j7 ]5 A# X3 W1 ]
light colored pubic hair development when he was7 C3 {( \+ P0 t
From the 1Division of Pediatric Endocrinology, 2University of1 @! w0 K$ w0 N) L& ^; N9 l
South Alabama Medical Center, Mobile, Alabama.
$ V. e4 ^: q4 R* z  Y$ `* c6 zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 J: H2 i3 v# b6 o7 [6 S* HProfessor of Pediatrics, University of South Alabama, College of. q" P: Q; k; {1 }& {! A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 j5 o) ~# n2 v' A+ g2 o9 ie-mail: [email protected].' v: n5 T0 b# S/ G2 c0 i6 ?
about 6 to 7 months old, which progressively became( M/ O8 h; Q' b; [8 y: d1 [
darker. She was also concerned about the enlarge-
' B7 O  T$ O" S0 tment of his penis and frequent erections. The child
; ~' I( Q0 F2 |# ^8 |4 _was the product of a full-term normal delivery, with' c- e7 I' z& }2 E$ k
a birth weight of 7 lb 14 oz, and birth length of8 u% m% _, j  @
20 inches. He was breast-fed throughout the first year3 w6 [% A; r& e$ E
of life and was still receiving breast milk along with
& w; u% _4 X. Rsolid food. He had no hospitalizations or surgery,
9 W: Y/ U! r. M  \( {and his psychosocial and psychomotor development' Z- H+ b7 @8 M8 l: x: V
was age appropriate.' k+ ]/ I  W) H7 E2 P' S; k6 p# q+ ?
The family history was remarkable for the father,
8 Z$ a2 j& C4 |% owho was diagnosed with hypothyroidism at age 16,+ c+ z  g# c3 o. l+ K- H2 ^; J8 ?) X
which was treated with thyroxine. The father’s
+ T. M. h- y/ W1 @0 Bheight was 6 feet, and he went through a somewhat
; C" A8 }$ t) T/ I( g9 nearly puberty and had stopped growing by age 14.
& L9 g# q7 J4 D& H# PThe father denied taking any other medication. The
- O' T+ M% B9 I0 X% Hchild’s mother was in good health. Her menarche( T! i8 J2 p# f  L/ L( _
was at 11 years of age, and her height was at 5 feet
/ K& I6 {$ {; y1 K5 }4 F# k5 U5 inches. There was no other family history of pre-, P" M" y" M( G' q& D
cocious sexual development in the first-degree rela-$ Z' R1 a( |# O6 z  a, X
tives. There were no siblings.
; s, \& a. {' N) vPhysical Examination
: s( G2 h/ [+ J9 Z2 x  jThe physical examination revealed a very active,
4 w1 a& k& \1 Nplayful, and healthy boy. The vital signs documented" e9 q; O0 |3 U1 U0 ~' |, j
a blood pressure of 85/50 mm Hg, his length was
1 B! y0 K2 c, r( L, E* q90 cm (>97th percentile), and his weight was 14.4 kg
- }2 ?/ f' n0 L% F% I(also >97th percentile). The observed yearly growth
1 \9 }- K7 g7 F, w, Dvelocity was 30 cm (12 inches). The examination of! U( a4 s0 p& D. w: i  Y
the neck revealed no thyroid enlargement.# r4 I, V+ r& E% f# P" _% Z
The genitourinary examination was remarkable for4 S; J  N$ v. z9 W2 x- _
enlargement of the penis, with a stretched length of0 J: m, w" f* {2 y  v  D, W% A' |
8 cm and a width of 2 cm. The glans penis was very well% A: n2 O9 S% _" K
developed. The pubic hair was Tanner II, mostly around
- n! I+ D1 U9 P- q/ c% ^9 J& ?; L540: {; Y+ E$ P# x' H" V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' v. g! P0 k9 R, X$ H. H
the base of the phallus and was dark and curled. The
. x! {1 {# p) n+ @testicular volume was prepubertal at 2 mL each.
7 J, Y: r- [% p; ~The skin was moist and smooth and somewhat+ M' f' m$ @7 e0 U
oily. No axillary hair was noted. There were no
) B/ `8 _+ L" M( b/ o* T8 fabnormal skin pigmentations or café-au-lait spots." @' F$ e- u* l
Neurologic evaluation showed deep tendon reflex 2+
- t7 D1 Z% z# I  U2 Xbilateral and symmetrical. There was no suggestion
1 d& e$ V/ Y* i7 ~+ mof papilledema.* M" G0 q8 f3 n$ Z
Laboratory Evaluation$ i2 g$ O  M$ N; e
The bone age was consistent with 28 months by
3 G7 @  W# {1 @1 d* [5 s+ k7 Cusing the standard of Greulich and Pyle at a chrono-
" k; ]* \1 n1 |/ T7 C" M5 g7 y+ [logic age of 16 months (advanced).5 Chromosomal5 E. `4 b5 r1 l
karyotype was 46XY. The thyroid function test
1 I* u5 ~! \& W! hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- c6 g) y, a, A1 l' {lating hormone level was 1.3 µIU/mL (both normal).0 N  y1 _0 Y' C' Z8 Z
The concentrations of serum electrolytes, blood  a: I; W* O. V3 }
urea nitrogen, creatinine, and calcium all were$ F) i5 U; `, O' x- Y9 a0 X
within normal range for his age. The concentration6 v" j2 m8 I# R$ ^
of serum 17-hydroxyprogesterone was 16 ng/dL! f! B, f" h1 M1 a  l
(normal, 3 to 90 ng/dL), androstenedione was 20
8 Z! O! r+ U' N2 w/ C6 {0 Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) v, |! N' h/ F$ V$ j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( z2 W- {. O7 L2 j5 w9 E  S) v$ [desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 y, \* |3 z1 R4 O49ng/dL), 11-desoxycortisol (specific compound S)
  S  {! P- m& h2 ]was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, A+ i2 Y1 \" R8 vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 ~5 _: a  R6 t: r1 H5 v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 l; x* c) [$ e5 ]2 R1 C# J
and β-human chorionic gonadotropin was less than; Y! R; b! r9 a
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 ~$ e' s8 R9 Ustimulating hormone and leuteinizing hormone
  N' G3 s) @3 [. @+ Vconcentrations were less than 0.05 mIU/mL$ K0 m% ?$ r+ j9 H. i; O  }# k
(prepubertal).
/ V; `+ O% T% Q3 r9 eThe parents were notified about the laboratory
( I+ q0 i8 e! @/ H7 q4 dresults and were informed that all of the tests were# I# I$ k# p# t. }* a1 F
normal except the testosterone level was high. The; N1 g( a1 @$ c
follow-up visit was arranged within a few weeks to
2 P& x2 ?8 o  i1 [" Dobtain testicular and abdominal sonograms; how-+ V' W* p8 A7 S) C+ n) {  u
ever, the family did not return for 4 months.
2 J8 ]4 D' U4 Q7 sPhysical examination at this time revealed that the
& W+ U. H# k( i3 [8 z4 Ichild had grown 2.5 cm in 4 months and had gained
7 D$ c5 j0 S+ x( Z& ]. g) g2 kg of weight. Physical examination remained8 ?9 D  O! W! s: t( @3 ~
unchanged. Surprisingly, the pubic hair almost com-
. r3 _, N$ j1 H1 apletely disappeared except for a few vellous hairs at% \1 `9 R* U: j# Z2 c% Y
the base of the phallus. Testicular volume was still 23 F  H# q9 x: x6 T
mL, and the size of the penis remained unchanged.7 `& |; t# o7 e$ f2 W
The mother also said that the boy was no longer hav-
+ B( ]7 I6 ~8 k  i$ H2 ?0 d1 Y. b4 uing frequent erections.; s& @. C# b2 p, f
Both parents were again questioned about use of  m5 j, s  S! {5 P9 ?: G5 y
any ointment/creams that they may have applied to% i+ v6 g- _* S2 w0 S) ]5 R
the child’s skin. This time the father admitted the
/ I  \2 g0 m1 u( v( {Topical Testosterone Exposure / Bhowmick et al 541% ]3 v# y" Q/ ^. L# e
use of testosterone gel twice daily that he was apply-2 z" E9 c0 B+ d" L, i0 g- _
ing over his own shoulders, chest, and back area for# I# `! L8 e; L4 W$ h
a year. The father also revealed he was embarrassed
6 C  H: q& ~( rto disclose that he was using a testosterone gel pre-4 |/ R% E) u4 b: g$ N+ f+ h: d8 \
scribed by his family physician for decreased libido
4 j- |  W) j! T; G+ O8 u- Usecondary to depression.
$ `( u, h& S- A' `2 i$ {2 _1 `The child slept in the same bed with parents.3 H4 H3 U0 [  n6 w5 e! w' L! ?
The father would hug the baby and hold him on his5 e4 j1 f0 |; f
chest for a considerable period of time, causing sig-2 y0 O/ I2 M" a9 K. u; S; k) }4 y
nificant bare skin contact between baby and father.+ T9 y7 M% J7 _# r/ ^" b
The father also admitted that after the phone call," M. }; r0 b+ Y0 h- I
when he learned the testosterone level in the baby) i( T' R8 f" \) ~& Q( d4 Y2 ]9 q
was high, he then read the product information
! J1 z9 a+ z7 a: N* ipacket and concluded that it was most likely the rea-
) t: V- ?  z% i2 R) C# j5 S3 Gson for the child’s virilization. At that time, they
( h$ D. d( K4 b0 Q# kdecided to put the baby in a separate bed, and the% {0 M# i; V# {
father was not hugging him with bare skin and had4 |, W  E$ r" x/ h0 }4 d9 `* O
been using protective clothing. A repeat testosterone
9 U- S. s' {# t) A! k: {" Atest was ordered, but the family did not go to the
# x5 R: Z. y! I! S' B: a! wlaboratory to obtain the test.0 n- ]& o* t; c/ V& P
Discussion
& d3 _# b. p5 k5 _# F8 rPrecocious puberty in boys is defined as secondary; u0 S; }6 |) M# G2 g
sexual development before 9 years of age.1,4, W" |9 V  v# n: k
Precocious puberty is termed as central (true) when7 c. M) g6 D6 q. Y# d
it is caused by the premature activation of hypo-
% p) f8 {; t% n. t6 nthalamic pituitary gonadal axis. CPP is more com-0 p8 ^5 X9 v  D& l" @
mon in girls than in boys.1,3 Most boys with CPP4 l: D) Q  o7 I/ g. p9 o, P
may have a central nervous system lesion that is3 _' i9 [1 ^9 u& M
responsible for the early activation of the hypothal-2 S  s) v# A$ _
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 i. m  b% m% }( rsis has been given to neuroradiologic imaging in2 J  E' }% ]2 ]: M7 V0 w
boys with precocious puberty. In addition to viril-6 B7 b8 U  H/ B9 x
ization, the clinical hallmark of CPP is the symmet-  _+ {0 e2 E& @' ^* q
rical testicular growth secondary to stimulation by
5 o  q6 C& y" [( p' B7 y/ ?6 |1 vgonadotropins.1,3
7 S' m% V: W3 p7 zGonadotropin-independent peripheral preco-' w2 ?4 R% H3 U7 V3 j; S
cious puberty in boys also results from inappropriate
8 J: M2 Y2 A: o" E* h! t5 Nandrogenic stimulation from either endogenous or
5 I. f  D3 v- {6 m% X! Z3 f8 Eexogenous sources, nonpituitary gonadotropin stim-; F( K6 n9 B6 D( S1 |& b
ulation, and rare activating mutations.3 Virilizing
7 r0 O( B) T) i2 ?% }  B1 gcongenital adrenal hyperplasia producing excessive7 f7 W! f5 P. Z3 V% S
adrenal androgens is a common cause of precocious
/ E1 L5 \; _7 e- vpuberty in boys.3,4
8 H  B6 g& c7 a* U! ^The most common form of congenital adrenal
4 t. X( H) \5 }, Y8 ~0 Y5 whyperplasia is the 21-hydroxylase enzyme deficiency.
6 X. b& g" e: V" w: }7 uThe 11-β hydroxylase deficiency may also result in- \2 n8 e$ t' l/ j) t
excessive adrenal androgen production, and rarely,7 O0 Y/ C0 _( J$ d0 ?: k4 k1 x( s" b7 n
an adrenal tumor may also cause adrenal androgen' G1 N7 B# Z3 Q- I4 w. a
excess.1,3% ~" Q7 v, r9 l1 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; C$ z0 f2 G* w! p( @* W5 N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) [" N) L- z5 m6 U
A unique entity of male-limited gonadotropin-
- B, H2 [+ _( x3 S( P9 H4 a# |independent precocious puberty, which is also known+ C+ h$ q# W# _6 [% k4 F. q( A9 ^  U
as testotoxicosis, may cause precocious puberty at a2 V) k- P" x( G/ V# E
very young age. The physical findings in these boys# E6 _/ \% K7 E
with this disorder are full pubertal development,
$ s# q" ~/ H6 C4 F9 _) f! A/ vincluding bilateral testicular growth, similar to boys( N) m  \  s, f7 ~0 t/ S  B
with CPP. The gonadotropin levels in this disorder
; I8 y0 L4 P* nare suppressed to prepubertal levels and do not show
$ x: ?0 I% N' _6 S: Jpubertal response of gonadotropin after gonadotropin-
: e( P& N3 @3 E% U: {8 w5 Lreleasing hormone stimulation. This is a sex-linked
0 H/ p! D- T! m5 Pautosomal dominant disorder that affects only
5 D, c! k$ D# `2 S" s' {! ~# |males; therefore, other male members of the family
, t6 z9 h% H$ Z$ P  B% @- f# Q# U; Wmay have similar precocious puberty.3
  r7 q% L; P6 ]* GIn our patient, physical examination was incon-* l! n' ~" t' x0 s. C" h, |) P
sistent with true precocious puberty since his testi-
. ~* n) {; w. f" Bcles were prepubertal in size. However, testotoxicosis
5 ]) W) ]1 X& r5 q% pwas in the differential diagnosis because his father" x3 r, A- M( f4 {$ U9 U2 x/ D
started puberty somewhat early, and occasionally,/ ]0 I( P+ V% D/ k8 p/ `
testicular enlargement is not that evident in the3 t+ k7 R7 s  K8 w; C4 ^
beginning of this process.1 In the absence of a neg-
7 a1 H, z( n5 \. @: N$ a; e7 Tative initial history of androgen exposure, our
# \: w9 j+ n% @+ y2 A8 j  zbiggest concern was virilizing adrenal hyperplasia,6 W3 M# ]4 q, @8 x' g9 Q
either 21-hydroxylase deficiency or 11-β hydroxylase
, M# h* J3 A& C) N+ a9 `. x9 ^deficiency. Those diagnoses were excluded by find-7 U8 l+ g3 y1 T7 L* A; N
ing the normal level of adrenal steroids.
; ^% j: }. U8 ~1 u; ?: zThe diagnosis of exogenous androgens was strongly! _+ |4 `. E6 n8 C
suspected in a follow-up visit after 4 months because
% P% F+ j3 U# @1 o+ Z; q0 L8 mthe physical examination revealed the complete disap-5 m. S# z7 G$ k( g
pearance of pubic hair, normal growth velocity, and
% a: }6 L1 l+ V% `2 c1 w# N4 H: Idecreased erections. The father admitted using a testos-9 q5 y1 a6 v& H
terone gel, which he concealed at first visit. He was% Q) |6 S# {. i3 V) ~" N
using it rather frequently, twice a day. The Physicians’
8 \$ O" E5 P- P0 TDesk Reference, or package insert of this product, gel or
4 u1 B, g* O% a$ X  \* fcream, cautions about dermal testosterone transfer to
, S9 z. _! d  m" x: |0 H8 ?unprotected females through direct skin exposure.& v9 S4 d# O0 ^0 e2 l% o. Y
Serum testosterone level was found to be 2 times the
' s4 o) M0 c5 O) o" Y9 Hbaseline value in those females who were exposed to% B0 k4 X" q/ a) ~% k
even 15 minutes of direct skin contact with their male! V+ E2 u# q! H
partners.6 However, when a shirt covered the applica-
4 v# G, L7 c6 o6 b# Ttion site, this testosterone transfer was prevented.0 h) ]1 h/ {! S1 \$ @
Our patient’s testosterone level was 60 ng/mL,
! B0 ^7 V, g% b' p2 v8 Ywhich was clearly high. Some studies suggest that
' }4 c! i* D* |. V% gdermal conversion of testosterone to dihydrotestos-, }7 m' E* P7 r# S* ?! E
terone, which is a more potent metabolite, is more
0 D) |* C: a( l) f* ~+ Mactive in young children exposed to testosterone9 ]5 M" r+ ]% Y- d& P# e
exogenously7; however, we did not measure a dihy-( t. w2 V# V3 `% P* j
drotestosterone level in our patient. In addition to& [" R3 {0 z  G
virilization, exposure to exogenous testosterone in+ f/ g& n* ]$ u! T6 L
children results in an increase in growth velocity and; B0 h# j0 J0 T! I4 ]
advanced bone age, as seen in our patient.7 c2 q9 j1 }# Y, Q, D, N. Y$ }
The long-term effect of androgen exposure during
8 c7 L! d6 J" ^$ ~- ^0 |: Jearly childhood on pubertal development and final
5 O2 M# |' m& q. M" C8 n. E! D  Qadult height are not fully known and always remain
% Q. I) v" W7 xa concern. Children treated with short-term testos-
6 K" B1 b2 Z" ]1 k7 w4 Hterone injection or topical androgen may exhibit some* H& T7 `! i: t, l; e
acceleration of the skeletal maturation; however, after
, j, ^- Q3 o1 scessation of treatment, the rate of bone maturation0 O  j$ y9 L- z" d0 i6 z
decelerates and gradually returns to normal.8,9% e( k; E6 V" t* [! k, }7 V
There are conflicting reports and controversy
6 T+ i; }( a6 Eover the effect of early androgen exposure on adult
, w+ |; D8 n# apenile length.10,11 Some reports suggest subnormal! r) |- m9 y# ^& V+ i+ _2 q
adult penile length, apparently because of downreg-
6 A' P& g) G+ P( u8 ]5 H! }0 D; Hulation of androgen receptor number.10,12 However,
, d) _  e1 k7 s  ^% _3 A/ bSutherland et al13 did not find a correlation between9 R; w2 w% A9 {; H" d# f
childhood testosterone exposure and reduced adult, @+ }0 V; J9 \4 I# K. p, E8 h0 X: A
penile length in clinical studies.
1 C, [: p2 R) I# |Nonetheless, we do not believe our patient is
1 h" [* o9 w- c; _& K/ Jgoing to experience any of the untoward effects from3 H6 U% P6 `  V2 K8 w; P$ O9 b6 M
testosterone exposure as mentioned earlier because, V. A9 f1 H: Q. H/ c
the exposure was not for a prolonged period of time.8 D$ Y- K8 j0 n7 z
Although the bone age was advanced at the time of1 T" h3 b! S" [8 I/ C1 Q
diagnosis, the child had a normal growth velocity at
& o8 E2 K' x9 |+ m8 F; i/ A" ~the follow-up visit. It is hoped that his final adult
! m( c7 w% `1 k  j+ }0 sheight will not be affected.
, b% w2 h: d; [/ y, m& }Although rarely reported, the widespread avail-" T: V7 |* q3 J- v- W
ability of androgen products in our society may8 @) k% K: G3 ]( I
indeed cause more virilization in male or female
, I! g+ S' L% R6 `5 G0 M/ Vchildren than one would realize. Exposure to andro-
7 O" D1 S- a- L& K1 Ugen products must be considered and specific ques-. A+ x  {5 t$ p3 k
tioning about the use of a testosterone product or
; [* V( X, `$ G, c9 wgel should be asked of the family members during
2 i2 Q: ?$ `! a/ ]- W: p+ F. `' ^the evaluation of any children who present with vir-
8 P0 O$ U$ p9 M4 E3 @ilization or peripheral precocious puberty. The diag-
  J2 ~" Z& o8 A  Vnosis can be established by just a few tests and by
+ w+ w: @! G( X: iappropriate history. The inability to obtain such a
8 i& x' d9 o0 H. l1 C) G$ fhistory, or failure to ask the specific questions, may. }/ W+ H; Y) R" b" I
result in extensive, unnecessary, and expensive6 ~6 K. T. {2 }# |2 X7 {& k3 y
investigation. The primary care physician should be* U) [( Z' {7 }
aware of this fact, because most of these children
. M9 j- L$ v, k! o" {# H! Emay initially present in their practice. The Physicians’7 o& m; R; I) _/ R
Desk Reference and package insert should also put a% G+ ~& K5 z; b7 \
warning about the virilizing effect on a male or
* o: t/ e$ q$ Y! Xfemale child who might come in contact with some-# l) D3 f' w  k4 ^: V3 r
one using any of these products.; D  v8 N; N" G
References/ k5 g0 A# M: M' V
1. Styne DM. The testes: disorder of sexual differentiation% w2 ?1 r" s7 \: ?0 I" T
and puberty in the male. In: Sperling MA, ed. Pediatric. B! s# _/ @' X2 m; i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 y; w8 A  y, R+ n2002: 565-628.# [8 s1 P. F& Q7 C/ n" ?9 S3 [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 ~6 O. s* W( Y* b0 npuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old1 p/ u8 ^: i2 e& _
Boy Induced by Indirect Topical
: x) C2 \/ {1 s5 G$ q! wExposure to Testosterone
. h' P0 z' }* E- V9 e: B% e8 ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! K' ^9 r9 T  q' q  eand Kenneth R. Rettig, MD1# N$ }' C7 k* ~& H9 T/ x7 @) ?
Clinical Pediatrics
" t7 |0 `4 B& Y% D- mVolume 46 Number 6( R3 p5 p) C1 a) f% s" w
July 2007 540-5431 @  S& D1 G9 p" n7 x
© 2007 Sage Publications+ p5 A7 I$ v: M4 m, c3 D9 ]. H0 S1 Y
10.1177/0009922806296651
: p- [# d: [; W& A8 Z% L' x8 t9 Whttp://clp.sagepub.com- d$ o" e4 v$ ?7 ^
hosted at
2 a' h+ o% \: l4 F2 uhttp://online.sagepub.com& m2 S, ?. D. N  I/ K- {/ l
Precocious puberty in boys, central or peripheral,% I- m" c4 j# B" @( f5 w
is a significant concern for physicians. Central
& J( Q5 C. M, p& y  s% n% X5 zprecocious puberty (CPP), which is mediated9 G" L+ W7 N' f4 T. N; k
through the hypothalamic pituitary gonadal axis, has2 f7 k; `( S" f: T8 p5 i1 Y9 T5 j
a higher incidence of organic central nervous system
' J* }: N9 |5 y2 alesions in boys.1,2 Virilization in boys, as manifested
- B& `5 X. W% _% Z: H2 aby enlargement of the penis, development of pubic
/ L) I$ `" ?% t  O% ghair, and facial acne without enlargement of testi-
- I$ a7 o2 Q; q2 dcles, suggests peripheral or pseudopuberty.1-3 We% J+ y' Q% q( i) }3 V
report a 16-month-old boy who presented with the
! {# @! S  d& \9 J6 F/ \, F6 jenlargement of the phallus and pubic hair develop-$ r( H% o5 g$ I9 ]
ment without testicular enlargement, which was due& N  B. b) D1 [- R# P9 j
to the unintentional exposure to androgen gel used by$ n" l9 {6 F5 X: {3 z: X3 L
the father. The family initially concealed this infor-
4 C* \- \1 G" j  \8 Pmation, resulting in an extensive work-up for this
5 l/ H, a5 h! s& Jchild. Given the widespread and easy availability of
. i5 o$ V7 a4 I" Xtestosterone gel and cream, we believe this is proba-5 \8 ?* O/ g# ~$ V7 w1 o' y! {5 ~
bly more common than the rare case report in the" b8 r  D3 e# n) z
literature.4, b5 j0 R: T  t& K  X4 n
Patient Report
; g; M/ \9 m6 R2 `5 h7 v+ mA 16-month-old white child was referred to the
  N, z# h# ?# e; |% t+ ~endocrine clinic by his pediatrician with the concern
% }0 ^5 J) N: k& K/ L  S# \of early sexual development. His mother noticed# x, k5 I* }, b7 q' ~: a" E
light colored pubic hair development when he was
* y' O! G, _! I  s5 lFrom the 1Division of Pediatric Endocrinology, 2University of; N  |3 H- O  Y1 I* b& b4 O
South Alabama Medical Center, Mobile, Alabama.' X3 [; ?! V1 d0 [0 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* X: Q) r  z. a# sProfessor of Pediatrics, University of South Alabama, College of
( `3 K) d: F: m- E% k& oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" u! ~, g- y8 e8 u: ~
e-mail: [email protected].) _- I: t. r/ i
about 6 to 7 months old, which progressively became- R3 x! z/ {# F( e7 U* e& s
darker. She was also concerned about the enlarge-
0 W% B5 M9 t, `" I) o  Pment of his penis and frequent erections. The child
6 y7 F; J# ^3 b* l  W5 zwas the product of a full-term normal delivery, with
& J* B- g' R( j( ]+ E) }a birth weight of 7 lb 14 oz, and birth length of
4 t& d- C, Z' W' h20 inches. He was breast-fed throughout the first year# `; {. z. j# y& _. J( p9 q/ {
of life and was still receiving breast milk along with$ n0 g  s1 q) W8 M7 F4 g6 O9 \
solid food. He had no hospitalizations or surgery,
/ ~1 r& S) C( F: fand his psychosocial and psychomotor development' r, B0 W/ H+ P0 S8 E
was age appropriate.
" L* w0 {  x' o4 R$ E" M+ Q+ gThe family history was remarkable for the father,, l! D/ H: t' L
who was diagnosed with hypothyroidism at age 16,6 j! P8 N0 m0 R
which was treated with thyroxine. The father’s
( u6 r9 ~  Z' K7 d- ]. K+ P6 ~+ Pheight was 6 feet, and he went through a somewhat8 k8 u: v. u2 q1 |2 y
early puberty and had stopped growing by age 14., U0 Z* i' k7 t* N( [8 S
The father denied taking any other medication. The- ^2 Z+ |# u* C( M$ s: H" `( n
child’s mother was in good health. Her menarche7 H# o1 Y: b- z! j# W! |9 e& j
was at 11 years of age, and her height was at 5 feet
+ K$ R7 E7 ^  [1 G5 inches. There was no other family history of pre-" Q" w" g1 t/ r/ R7 _& ~1 W6 x
cocious sexual development in the first-degree rela-) \' D8 J1 u1 M& B! {" X% v
tives. There were no siblings.
6 w+ y& {  j& cPhysical Examination
/ ?0 ?' q( e4 A% o$ SThe physical examination revealed a very active,) \8 W$ i5 f- r' P7 D" ]3 ^5 f
playful, and healthy boy. The vital signs documented7 ?9 p% ]- X& k! |9 l
a blood pressure of 85/50 mm Hg, his length was, l( U) g& g! M+ d5 T1 P
90 cm (>97th percentile), and his weight was 14.4 kg/ d. O* m/ X7 a) i
(also >97th percentile). The observed yearly growth9 j2 b$ e, a* e$ Y
velocity was 30 cm (12 inches). The examination of
# R" m/ u# G+ C% r/ ^the neck revealed no thyroid enlargement.. @# r* X# s  Q" a4 f9 b6 q
The genitourinary examination was remarkable for
( `8 C! |- G) B* ~1 S0 Q9 denlargement of the penis, with a stretched length of
3 k& b* f, Q/ W* Z' _8 cm and a width of 2 cm. The glans penis was very well
1 D6 h% j4 K6 G  C) Hdeveloped. The pubic hair was Tanner II, mostly around* _/ I( Q  _( ^
540% z# G6 e. ?* f" C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ ]' s4 I. @/ e( |% R8 q' Othe base of the phallus and was dark and curled. The
  p; d9 X! o9 b1 A: v" ytesticular volume was prepubertal at 2 mL each.* Y5 @7 l1 w8 A! P
The skin was moist and smooth and somewhat' O  {+ a- Z- N6 A
oily. No axillary hair was noted. There were no" r6 x, [# `' {5 H! D! s  P; l. j/ t
abnormal skin pigmentations or café-au-lait spots.
% k1 F+ {2 U4 x% @Neurologic evaluation showed deep tendon reflex 2+$ r. h" |$ Z* o, t, x; ]% X4 N: y. h
bilateral and symmetrical. There was no suggestion
8 V: `0 f! J% b; I) d- J. o& xof papilledema.
! A( S& [9 @' n" bLaboratory Evaluation8 P0 p* X2 s% ?' Q6 u) u
The bone age was consistent with 28 months by* I: @7 x4 }6 O1 F0 Q
using the standard of Greulich and Pyle at a chrono-" Z+ ]- x% m% @# L- w
logic age of 16 months (advanced).5 Chromosomal
! `% r. c+ v$ N$ n+ J' w" X- _4 }karyotype was 46XY. The thyroid function test
7 T! w; C5 Y6 f; F1 J5 S" mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, [; ?) `1 H$ ~' G5 `
lating hormone level was 1.3 µIU/mL (both normal).
" {& _, O3 D  }9 oThe concentrations of serum electrolytes, blood& J/ z6 r+ f. I1 Q4 j9 [) X& B# V: P
urea nitrogen, creatinine, and calcium all were. Z( F" A- r$ I0 \) o
within normal range for his age. The concentration; \2 }' B0 V/ y5 T8 H" g' s
of serum 17-hydroxyprogesterone was 16 ng/dL" d/ d; B- h4 q$ H8 j1 {
(normal, 3 to 90 ng/dL), androstenedione was 206 Z9 D9 E  |) ^2 S, [+ S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) L% o! a+ n/ |* Q6 b3 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, ~& U8 b2 [- a! C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ q) @: f5 n  Q; X5 F49ng/dL), 11-desoxycortisol (specific compound S)
, x- X! j6 {* v) Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 N5 k+ c7 D# _: B! ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! D. u$ o" ^! m/ V- X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ k8 @) d- `3 t9 N0 h$ h
and β-human chorionic gonadotropin was less than4 U. z/ w) V5 `( I, B0 {% }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 \+ H/ S. B. G4 j" _  zstimulating hormone and leuteinizing hormone
, W2 L3 }/ Z* gconcentrations were less than 0.05 mIU/mL
- t1 z+ r& C  L3 x5 N(prepubertal).; M% m: Q- p4 F* y3 f
The parents were notified about the laboratory
3 |- y8 }8 H) gresults and were informed that all of the tests were. Y4 V  P) a5 W' U
normal except the testosterone level was high. The
( I  P2 l; ]: M& B/ U+ ]follow-up visit was arranged within a few weeks to
6 W+ F% c5 i% \1 b" K/ w. gobtain testicular and abdominal sonograms; how-
5 {3 s0 X* P1 u- P& m% Pever, the family did not return for 4 months.
' z, b) p0 g% m0 j0 p: cPhysical examination at this time revealed that the3 Z, p9 c; L& y' L" h  U
child had grown 2.5 cm in 4 months and had gained
5 V) [+ \& `+ Y  P5 C9 N2 kg of weight. Physical examination remained
' G5 K0 G, F3 C1 ?unchanged. Surprisingly, the pubic hair almost com-
3 b+ I: z, Y4 `" ]% spletely disappeared except for a few vellous hairs at7 j& y, _8 Y. ]& L2 C3 [- C
the base of the phallus. Testicular volume was still 2! V* o! c8 l# G7 S
mL, and the size of the penis remained unchanged.: \2 o2 n+ ]+ ]/ ^! R
The mother also said that the boy was no longer hav-% |, J! W3 |* ^) o# ^3 v
ing frequent erections.
. c* d! f; {# G* g2 b5 E+ sBoth parents were again questioned about use of, J) g% L: W. u+ x' X# ?
any ointment/creams that they may have applied to: C0 h8 p; A5 k- o% ^3 i0 i
the child’s skin. This time the father admitted the+ c- Y/ H" G; t. p0 Z0 ^
Topical Testosterone Exposure / Bhowmick et al 541
; B/ H) n; W" R! \0 Zuse of testosterone gel twice daily that he was apply-
) K. w4 f4 I9 r3 m  Ging over his own shoulders, chest, and back area for: ]3 \$ m! Y. j, H' N
a year. The father also revealed he was embarrassed  e3 {3 Z) g6 z
to disclose that he was using a testosterone gel pre-
& ?% o# t) w! d1 {7 A" pscribed by his family physician for decreased libido2 u5 h0 S, G0 I6 z( [$ _
secondary to depression.% |8 ]2 x' H4 c
The child slept in the same bed with parents.7 P0 L1 O$ U( B4 O0 r
The father would hug the baby and hold him on his
) v: @$ Q! K1 R9 Vchest for a considerable period of time, causing sig-
! a9 n# F; d+ U1 Gnificant bare skin contact between baby and father.
1 m! L  ^3 u, d, H) L1 z$ _The father also admitted that after the phone call,
: M# [& G# o! [# x; i( wwhen he learned the testosterone level in the baby5 |7 h* q+ a' V" |5 Z0 j
was high, he then read the product information
/ `4 m7 M; s8 hpacket and concluded that it was most likely the rea-- t7 E& p: t! [7 B5 S, [1 f2 r( d) s9 F
son for the child’s virilization. At that time, they
# s) ]* l/ Q: b9 kdecided to put the baby in a separate bed, and the, E9 X% {" [5 s5 @
father was not hugging him with bare skin and had
- _7 l/ T+ J8 F) X: k. q5 o* Abeen using protective clothing. A repeat testosterone2 o- F: a9 w# p) G0 C4 l
test was ordered, but the family did not go to the) U) {3 g( n/ a9 k! e6 I& P. p, R
laboratory to obtain the test.7 u+ L$ d& [" Z. A2 q5 d3 [2 w0 J
Discussion
# d) U" b: w5 zPrecocious puberty in boys is defined as secondary
+ m- h  x3 n3 ?, {sexual development before 9 years of age.1,4
: |: s" F. c; E; I/ l" @Precocious puberty is termed as central (true) when
$ o, p8 U1 z9 N. [6 E: `# ^it is caused by the premature activation of hypo-9 A7 g$ p* B" [# m( j
thalamic pituitary gonadal axis. CPP is more com-
# s0 v* M* R( v+ F9 r) a( R# ]- ^" amon in girls than in boys.1,3 Most boys with CPP
  B; M3 V' u8 j# P# L9 Y% d" c# [may have a central nervous system lesion that is) A; m( L+ l7 N! h1 y% l/ X; R6 |
responsible for the early activation of the hypothal-$ c: ]- G* o" J' g" {9 m
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ V( M7 h( X: q& L2 ?, ~( r" gsis has been given to neuroradiologic imaging in" j. ~4 A4 K& c# X0 T
boys with precocious puberty. In addition to viril-
/ {5 x3 ~) n) `. t/ \ization, the clinical hallmark of CPP is the symmet-" g2 S. i; k2 L) q9 |$ }9 I
rical testicular growth secondary to stimulation by
0 `2 b2 Z' M) ~2 g& g% A$ Vgonadotropins.1,38 n5 ~* L* W- v9 J
Gonadotropin-independent peripheral preco-
  z5 S, }, M% M0 F4 f6 S. ]cious puberty in boys also results from inappropriate
2 P  J7 |1 s7 jandrogenic stimulation from either endogenous or
( z0 ?: e9 K) a+ c7 i! O8 H* c% qexogenous sources, nonpituitary gonadotropin stim-) V6 h. f  O$ Q3 z, K5 V
ulation, and rare activating mutations.3 Virilizing, K' t; O+ |8 u# j! a( w, O
congenital adrenal hyperplasia producing excessive
3 I4 x3 U: k2 J2 |adrenal androgens is a common cause of precocious
3 x, C7 O# v: ^: `0 t6 J& h/ hpuberty in boys.3,4$ G8 [- f! j6 {3 z! P: G
The most common form of congenital adrenal& I8 L. @7 o/ l: G7 j6 ?$ t6 j
hyperplasia is the 21-hydroxylase enzyme deficiency.1 P- u" R/ U( F- N. A% ?
The 11-β hydroxylase deficiency may also result in
1 @: [3 r  a* f9 {1 a. W: C& Yexcessive adrenal androgen production, and rarely,( m3 Z6 C0 u' r1 O1 C' `. I
an adrenal tumor may also cause adrenal androgen
" P9 J% D7 b# y: w) G0 @, iexcess.1,3! A- z2 W/ {! |  O" I8 l  i, f+ q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 q" j- d7 j8 J$ q3 y5 k- L8 D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: Q1 l8 c, F  t1 T& A; F4 YA unique entity of male-limited gonadotropin-
" o" G8 s; {8 Vindependent precocious puberty, which is also known
9 N1 c! |! b- q' |( y3 Cas testotoxicosis, may cause precocious puberty at a7 L# D; K! `& m
very young age. The physical findings in these boys; e9 X" E* T' U7 g4 d& b
with this disorder are full pubertal development,4 P0 ~2 V" J2 J% v
including bilateral testicular growth, similar to boys
' x& N+ v6 o3 ?with CPP. The gonadotropin levels in this disorder  i6 |0 s( ^" |$ w7 x
are suppressed to prepubertal levels and do not show
' W( v# ~0 N( G* @4 ~7 r1 A1 dpubertal response of gonadotropin after gonadotropin-
( Z3 h- {2 R0 t( ~) P: l7 Creleasing hormone stimulation. This is a sex-linked
1 m' ~9 x5 F2 F  [# N: Yautosomal dominant disorder that affects only
: Z/ ^4 W" n4 ?: b, r5 imales; therefore, other male members of the family
' w) m0 [& Q2 `1 ]  r) c5 Q9 Zmay have similar precocious puberty.3
6 J' p& A( A6 [! `1 aIn our patient, physical examination was incon-% {. a. G  w- n/ b
sistent with true precocious puberty since his testi-$ H+ s$ b. S2 \1 p' U9 w
cles were prepubertal in size. However, testotoxicosis, s% y; K/ e2 N5 }' m* [8 @
was in the differential diagnosis because his father1 e9 V+ k4 o9 [* r7 o7 S
started puberty somewhat early, and occasionally,
" r+ e+ S0 k. D* a! etesticular enlargement is not that evident in the
" j4 g! b! Y9 z1 @7 Rbeginning of this process.1 In the absence of a neg-
0 Z! }# {" b3 @/ C7 Qative initial history of androgen exposure, our
1 D- w# w5 e; b" ]) h1 F# Obiggest concern was virilizing adrenal hyperplasia,
' S7 e/ r$ O  W, e; v3 L4 y. weither 21-hydroxylase deficiency or 11-β hydroxylase
9 E; Y! S& S* Wdeficiency. Those diagnoses were excluded by find-
- L/ Y0 L1 g: ding the normal level of adrenal steroids.4 z7 H% `. D  s6 |* p
The diagnosis of exogenous androgens was strongly
( H8 r0 h* O& o: h2 R9 }suspected in a follow-up visit after 4 months because) C: [' A3 l" h
the physical examination revealed the complete disap-
% u6 S7 Z0 s2 B) tpearance of pubic hair, normal growth velocity, and
; H& e4 O: b' [! [* Rdecreased erections. The father admitted using a testos-
9 V9 j/ N- |4 t! O: {5 Kterone gel, which he concealed at first visit. He was
, K+ ~8 P7 h6 Z' xusing it rather frequently, twice a day. The Physicians’
* t  u* ?( z# W3 |" |' iDesk Reference, or package insert of this product, gel or
# b! v4 p: M7 ucream, cautions about dermal testosterone transfer to
2 Y# {3 o) e5 Lunprotected females through direct skin exposure.7 C1 O  @0 ^, ?0 j$ b1 n
Serum testosterone level was found to be 2 times the# L& i! `# y+ m
baseline value in those females who were exposed to& Y: ~- D* L2 F+ V" {
even 15 minutes of direct skin contact with their male
# _. E6 ~% z1 Hpartners.6 However, when a shirt covered the applica-9 M( Y- F- s% X9 F) o  S4 y' [
tion site, this testosterone transfer was prevented.3 `3 S4 M- Y+ O6 A2 j* ^
Our patient’s testosterone level was 60 ng/mL,
. E; Z* K6 K* @4 swhich was clearly high. Some studies suggest that
: }, o! ~- k5 z/ Z) e% g* vdermal conversion of testosterone to dihydrotestos-, j$ ^+ N( C' k1 i( L% u+ V1 n
terone, which is a more potent metabolite, is more
* V5 @, N6 r9 g- h4 K+ c) W1 D) kactive in young children exposed to testosterone
+ V/ c5 m  Z9 l. _/ xexogenously7; however, we did not measure a dihy-
  i/ l" u7 u+ e2 ^; Q  Adrotestosterone level in our patient. In addition to
) }0 ^1 W1 \6 @) c0 l7 V' D$ i1 yvirilization, exposure to exogenous testosterone in; z7 P: E& D( ^
children results in an increase in growth velocity and
2 |2 N! P) H: o  _: uadvanced bone age, as seen in our patient.5 D7 E  b$ ?1 a. j  J" h7 K
The long-term effect of androgen exposure during
7 U3 _4 L$ }; m/ k, r- Fearly childhood on pubertal development and final
2 l) K5 I6 M. O1 o' w# Q) o1 hadult height are not fully known and always remain, Y6 C" R8 x$ O: S# H0 l
a concern. Children treated with short-term testos-: B* u5 `: h; U/ X7 |
terone injection or topical androgen may exhibit some$ [1 X' Q0 L! F% a, [& b5 E
acceleration of the skeletal maturation; however, after
8 R2 s8 ~6 B4 n8 @cessation of treatment, the rate of bone maturation3 A/ Z% _) A4 ?2 c
decelerates and gradually returns to normal.8,9
7 z% i# S6 i$ [There are conflicting reports and controversy
  Z. n9 A- A( a# F  mover the effect of early androgen exposure on adult
/ k# ]4 l4 X# ~% v1 K' x9 K) k- Lpenile length.10,11 Some reports suggest subnormal
; V0 e: ~, N  @6 ]4 b4 Hadult penile length, apparently because of downreg-( {+ ?1 k6 n$ A% N+ @, \. D
ulation of androgen receptor number.10,12 However,
2 Y$ b: r% x  ZSutherland et al13 did not find a correlation between
) W5 T2 ~* j; Y, N% Mchildhood testosterone exposure and reduced adult
9 ^' l& c. f9 ^; _7 k3 upenile length in clinical studies.( C2 w+ X# f7 }# I' S; u
Nonetheless, we do not believe our patient is
# d- }' I' P; ?going to experience any of the untoward effects from
# [1 w, J$ H2 g, ytestosterone exposure as mentioned earlier because, ~; e  \- d  F% R! w% w$ o
the exposure was not for a prolonged period of time.# c# J3 y4 M  J* R3 \6 u
Although the bone age was advanced at the time of
* ^  s5 f/ `0 D7 W# a! wdiagnosis, the child had a normal growth velocity at
9 K! P# S( ^& ?' B2 S, l2 i, Ythe follow-up visit. It is hoped that his final adult1 J  d! w" @  {/ m
height will not be affected.% N3 }: h) k$ Q" n
Although rarely reported, the widespread avail-
: _3 B+ w0 O. kability of androgen products in our society may
  Y# ^9 w# d4 C; N3 y! w- }indeed cause more virilization in male or female" r9 `; X. T' r" V. l
children than one would realize. Exposure to andro-9 J  |3 p1 x2 n/ ]" F0 x7 m7 p
gen products must be considered and specific ques-
" ?8 m$ q8 N. L* jtioning about the use of a testosterone product or
' M1 y! l8 K  Z. ~* G1 c4 l/ igel should be asked of the family members during# Z1 W0 J  T* X9 E# Z( z7 H0 D
the evaluation of any children who present with vir-$ G: ]& ~) g0 `- b$ x% z( y" d
ilization or peripheral precocious puberty. The diag-# e2 o: V0 x' Y( g2 |" |; u
nosis can be established by just a few tests and by
5 F' e. D) O1 O& {) a3 Wappropriate history. The inability to obtain such a
! }/ `( s, Z7 w: F* ~" ]( r7 f# Chistory, or failure to ask the specific questions, may
4 [6 t  C4 t7 h  G: Lresult in extensive, unnecessary, and expensive; p# ^" g  ]5 i4 `, j
investigation. The primary care physician should be
" z0 c( @, I1 P( Q! s  h( Jaware of this fact, because most of these children/ U4 ?, V4 ]4 S8 ?8 y' z
may initially present in their practice. The Physicians’
2 D- J  d& L2 A- @: ?Desk Reference and package insert should also put a
/ u8 l! f( K' Iwarning about the virilizing effect on a male or
4 M9 ?  u9 \7 ~/ T2 o0 ^. C6 g1 h% s1 Cfemale child who might come in contact with some-$ ^! H0 B" W6 G. d, O- j
one using any of these products.5 @/ F7 J* C) S! Y9 b
References) B1 \; E# m5 j0 A" E% L; [
1. Styne DM. The testes: disorder of sexual differentiation2 ~7 w6 ~; m, T9 e8 p2 n
and puberty in the male. In: Sperling MA, ed. Pediatric
& J; O% j7 i/ F0 n, X. q; u4 ~Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ e! K* o; d! m2002: 565-628.$ `. v3 G' r% d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ C/ W6 O  K$ O4 Spuberty 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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加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

' n' o4 K4 r! a" ]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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