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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-Old3 p8 W. z8 D1 [
Boy Induced by Indirect Topical0 |, G$ {7 I& n, s6 j
Exposure to Testosterone
2 Y% }- l5 }* u8 h- BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) |& X1 Y/ l( |  o' t) Y$ oand Kenneth R. Rettig, MD17 P+ }; H* S; S% `
Clinical Pediatrics0 U5 \' G. f" n+ b1 a6 ^
Volume 46 Number 69 }* i( @( C. a3 w, E
July 2007 540-543
. r9 V  J" i) C/ M© 2007 Sage Publications
) R! i7 A  ?( n3 Y$ A! R; n10.1177/0009922806296651
, c9 W) ?. K. J) vhttp://clp.sagepub.com
' z* S; H/ M6 G3 }( P* ghosted at
$ f) ^: L9 Q0 q3 Y! ghttp://online.sagepub.com" W8 c4 Y4 N4 N5 i2 n8 _4 x
Precocious puberty in boys, central or peripheral,. M( b5 _; C. h: f/ w7 x; v
is a significant concern for physicians. Central
2 u" T3 ?8 a" e. C* @% i+ Yprecocious puberty (CPP), which is mediated% }9 b9 ]* s4 e2 h; N: e" W3 y
through the hypothalamic pituitary gonadal axis, has
* O6 A% s' v; M" u# ea higher incidence of organic central nervous system
6 v# A4 i& Q  H$ b" w! m& glesions in boys.1,2 Virilization in boys, as manifested/ @4 G" I+ I/ N" p
by enlargement of the penis, development of pubic/ f+ g, W% G8 j& J. ?- e
hair, and facial acne without enlargement of testi-0 h# a, w+ Z. G: A; S# d+ x4 F/ f
cles, suggests peripheral or pseudopuberty.1-3 We
& X% H& D! t! Q& Z0 breport a 16-month-old boy who presented with the8 f" {- r* X# j$ t% N4 K
enlargement of the phallus and pubic hair develop-
* x# a+ }9 t* i! L5 Z/ ement without testicular enlargement, which was due
; Q: d# ?! q6 B# b3 Z- `to the unintentional exposure to androgen gel used by
2 i% }" {3 L2 o8 t. Dthe father. The family initially concealed this infor-
3 T3 g3 _* J+ @. bmation, resulting in an extensive work-up for this3 Q9 E' [) G) s" A, x
child. Given the widespread and easy availability of% F+ f% z# Y/ U
testosterone gel and cream, we believe this is proba-0 c- w; Z! z2 B$ f- ?
bly more common than the rare case report in the; S. Z; U; _$ Z# a- G
literature.4
, B( B% d5 x# B, HPatient Report
) N; m( V1 C) e6 M& a3 [% hA 16-month-old white child was referred to the* h8 T( O' L0 Z5 G  C. l
endocrine clinic by his pediatrician with the concern/ R1 U/ r& b  D" z9 l9 `* j3 z
of early sexual development. His mother noticed" T8 u$ }( D) |& j
light colored pubic hair development when he was! V3 E1 _+ [8 `/ g9 |' v1 Z
From the 1Division of Pediatric Endocrinology, 2University of4 i5 `8 y" f# r0 u0 g, `
South Alabama Medical Center, Mobile, Alabama.
/ c1 L9 \% e- `& Q, n. \% XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* n, D, Q+ c( O7 s5 OProfessor of Pediatrics, University of South Alabama, College of; z+ Q. }9 Z1 @  f( }. J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, `+ C& m- c/ J. J6 \8 V
e-mail: [email protected].
. Z1 T+ R7 a) ~6 M4 Q$ h$ Uabout 6 to 7 months old, which progressively became
; g' v+ h. ?" z  q2 xdarker. She was also concerned about the enlarge-1 K' N2 I8 i0 A9 g: _( s
ment of his penis and frequent erections. The child
3 B) g+ a9 _; g6 \was the product of a full-term normal delivery, with7 m- \5 y' U- q
a birth weight of 7 lb 14 oz, and birth length of
9 m5 V. T! X# g5 j4 E: M, B20 inches. He was breast-fed throughout the first year+ x% ^4 Y+ b' Q& |
of life and was still receiving breast milk along with  Z7 V  u# y6 N5 X! Y9 {; X7 M
solid food. He had no hospitalizations or surgery,
" K) m+ f6 ]. q* C# @( j. vand his psychosocial and psychomotor development
4 _# T6 r; h( G; T7 Dwas age appropriate.% ?+ m5 @4 d% U7 K8 ?/ `. b  I' \
The family history was remarkable for the father,8 a6 E+ D) w( A$ |  }
who was diagnosed with hypothyroidism at age 16,$ j$ Q5 b  X3 ?" l6 F9 g7 p
which was treated with thyroxine. The father’s% L+ L; I2 a2 D3 u
height was 6 feet, and he went through a somewhat
6 O- U; I) B) A8 f& F$ D$ Eearly puberty and had stopped growing by age 14.
( Y0 M, c" {) h( _! q2 tThe father denied taking any other medication. The
6 W) ]5 D. n. Y& v! _8 hchild’s mother was in good health. Her menarche  a  {( P8 B, b9 {( \, H9 c0 Q
was at 11 years of age, and her height was at 5 feet
% t0 w; ~  o8 e2 V  ]' T/ y5 inches. There was no other family history of pre-( z* _2 N# L& _2 ~- |- l
cocious sexual development in the first-degree rela-" {$ A& h( y3 K$ |9 b7 ]. r$ x7 ^) h' p
tives. There were no siblings.
+ s$ y2 F) C; s  h! Z1 s3 _Physical Examination: g; f! a, R6 ]$ ~, n( }1 J
The physical examination revealed a very active,; q8 P$ g( Y! h
playful, and healthy boy. The vital signs documented/ ?3 I: u& m: Y& J/ b' m2 O
a blood pressure of 85/50 mm Hg, his length was  Z6 j( C) f# b5 `
90 cm (>97th percentile), and his weight was 14.4 kg" T: Z: \: K0 x
(also >97th percentile). The observed yearly growth
/ H5 [% j9 n6 R0 ]7 N# }$ F! m' lvelocity was 30 cm (12 inches). The examination of
; u% r3 y% T- S/ V+ V9 [. u5 }the neck revealed no thyroid enlargement.4 x# k* Y+ K, h6 l. ], Z2 S) @
The genitourinary examination was remarkable for3 @7 O% H/ ^. {6 J2 e7 W. k
enlargement of the penis, with a stretched length of( b! J; E7 M) b4 H# M
8 cm and a width of 2 cm. The glans penis was very well* i, Q; d6 d$ ]7 g* q% `
developed. The pubic hair was Tanner II, mostly around
; \/ A/ @7 m, s7 P  H# Z, h5401 T! i4 Z1 _0 X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* T( W: R/ J5 v" Y6 O/ c4 U# K3 fthe base of the phallus and was dark and curled. The# ?/ C4 i; Y. j0 M1 V
testicular volume was prepubertal at 2 mL each.8 \- a! `" k" s% p& x
The skin was moist and smooth and somewhat3 d7 w8 j7 c0 E2 x
oily. No axillary hair was noted. There were no
5 G4 j" v# U8 t& ~$ `* @$ c: xabnormal skin pigmentations or café-au-lait spots.3 r, J1 [+ H; y9 V) K" V8 s
Neurologic evaluation showed deep tendon reflex 2+: A( \1 {3 v# w) H! W, z6 M, \+ M
bilateral and symmetrical. There was no suggestion4 y! I* @( a7 d4 G3 q7 V
of papilledema.
% S, Y$ W3 L% t) vLaboratory Evaluation
& s" Y( B% m) G4 GThe bone age was consistent with 28 months by
) N5 `9 |* S" Z3 A% d' |+ cusing the standard of Greulich and Pyle at a chrono-, P0 B. D+ i. V( V
logic age of 16 months (advanced).5 Chromosomal/ X% k: U) J2 F5 K' U
karyotype was 46XY. The thyroid function test
  L7 L9 D/ i# W: |. fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 @; I( X1 X9 N) v0 y
lating hormone level was 1.3 µIU/mL (both normal)., u$ B0 `: D/ n. M6 v& R
The concentrations of serum electrolytes, blood
! m4 W& Z8 |! Gurea nitrogen, creatinine, and calcium all were
: t7 I1 }8 H4 D' _within normal range for his age. The concentration
8 k+ ?' K/ D5 _2 e5 ]of serum 17-hydroxyprogesterone was 16 ng/dL8 l7 G4 O( ~0 w9 ^7 a
(normal, 3 to 90 ng/dL), androstenedione was 20
: H5 `* S% V8 f; `9 o0 V8 T$ M7 Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) h. d+ `% u& R' z# ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& m- a5 a' ~2 q* N+ l0 ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to' h6 l. T6 E. H
49ng/dL), 11-desoxycortisol (specific compound S)
& I3 n  G! ^: l1 |, }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- u9 x: S- I. E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. s) q& o; K, k
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 T9 k2 w/ ^. y$ [1 `
and β-human chorionic gonadotropin was less than6 f# `0 ]8 I4 ]' _
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* M& Z( z( m3 l: j1 [stimulating hormone and leuteinizing hormone
; h. J* q+ I+ @concentrations were less than 0.05 mIU/mL1 \5 F3 h' m8 N
(prepubertal)., a* t4 I6 S  r4 z, G
The parents were notified about the laboratory
/ j5 r8 C, m: v, X# H4 zresults and were informed that all of the tests were  u# V( \! p& t; L& B
normal except the testosterone level was high. The
2 n+ Y! x$ P2 b7 [# vfollow-up visit was arranged within a few weeks to, g# G7 N5 n0 A
obtain testicular and abdominal sonograms; how-, r8 M  d$ c# |! q) q# n- N/ `3 }
ever, the family did not return for 4 months.
" b9 E  J2 f7 `1 k8 ]/ B9 nPhysical examination at this time revealed that the4 L# r8 o. [9 B: z  A
child had grown 2.5 cm in 4 months and had gained& m* u6 j$ ~8 q0 [, Y
2 kg of weight. Physical examination remained
0 F$ D7 a" `7 S8 A! p, F/ ]unchanged. Surprisingly, the pubic hair almost com-
' V* i' M% R0 M  Y$ |0 Spletely disappeared except for a few vellous hairs at; o, D' k! e& F% k8 I
the base of the phallus. Testicular volume was still 2
2 j  G+ y$ y* c6 t" C' v5 y3 H. _mL, and the size of the penis remained unchanged.
3 h+ b& d% _; U! R2 ^8 @( S% SThe mother also said that the boy was no longer hav-
2 y. S& s; o) L/ w5 x9 |8 ?8 ]ing frequent erections.
, j. L7 ]- c& a: s; H6 VBoth parents were again questioned about use of: _( y8 v2 K% t( {; }
any ointment/creams that they may have applied to
2 Z0 h/ I1 z5 s9 Qthe child’s skin. This time the father admitted the8 u2 s  U! K: S- |. N
Topical Testosterone Exposure / Bhowmick et al 5419 E$ l! I. y; q; _
use of testosterone gel twice daily that he was apply-4 |! |, w* H* X
ing over his own shoulders, chest, and back area for9 \2 Q* N1 o. J5 R$ [
a year. The father also revealed he was embarrassed
( }4 g0 [& N% X" q+ cto disclose that he was using a testosterone gel pre-
$ ^8 a; n4 z0 f% }2 o  R* Yscribed by his family physician for decreased libido
) S/ r- b6 X  ?secondary to depression.# n2 k; i: t2 q! o1 w
The child slept in the same bed with parents.& A2 M0 W7 G% ]( \; A3 ~. F. q
The father would hug the baby and hold him on his6 Q/ T: Q( f/ K& T& ?7 \
chest for a considerable period of time, causing sig-$ ?* Q5 w0 C% I6 z% g, `4 C
nificant bare skin contact between baby and father.
' N' c2 v& O8 VThe father also admitted that after the phone call,
% u+ k- v, f7 K1 K4 I2 g: qwhen he learned the testosterone level in the baby+ B6 B+ h% D+ a! x) J
was high, he then read the product information
4 V' O7 {7 V5 x9 Hpacket and concluded that it was most likely the rea-
4 [/ Z/ ~! \7 E# E; s: qson for the child’s virilization. At that time, they* v4 Z# l: ~2 ]
decided to put the baby in a separate bed, and the
0 @8 f# Q: N% c; Sfather was not hugging him with bare skin and had  w& E8 a& i, d. ]0 Z; \. u
been using protective clothing. A repeat testosterone0 `* z3 k2 I+ V9 q  b0 z
test was ordered, but the family did not go to the" h# r4 r, q2 K/ C# K
laboratory to obtain the test.! S6 r4 _" t* o, a8 }
Discussion
9 |. q) {, g) s9 IPrecocious puberty in boys is defined as secondary( W$ h- U6 K. v- q/ g- ~
sexual development before 9 years of age.1,4- u/ f$ H, j" {5 a8 X# N" B
Precocious puberty is termed as central (true) when9 I% N+ g  H# Y6 m5 L' |+ o3 A
it is caused by the premature activation of hypo-
5 N2 n. [8 k+ c6 s/ Fthalamic pituitary gonadal axis. CPP is more com-& m) s- B  {% v
mon in girls than in boys.1,3 Most boys with CPP
1 i2 J6 D- T  [* M. `1 T5 n5 c' gmay have a central nervous system lesion that is
* b! f2 e# G+ w/ e, M, Hresponsible for the early activation of the hypothal-
9 G; w' o! u: X6 }6 Kamic pituitary gonadal axis.1-3 Thus, greater empha-
# v, s4 o6 |: {/ j9 Msis has been given to neuroradiologic imaging in
8 F9 Z4 M, i. q- B) [( fboys with precocious puberty. In addition to viril-( G9 P: O# X, Q' S
ization, the clinical hallmark of CPP is the symmet-7 W$ h* G: F7 e* j: O4 C
rical testicular growth secondary to stimulation by
  B" \* N9 c# [" J7 o$ z9 N8 L0 Vgonadotropins.1,3$ o1 @: Y: v. J
Gonadotropin-independent peripheral preco-' m. I$ E# U/ w6 }* c; w. G
cious puberty in boys also results from inappropriate
: A; Y; r: U6 `8 Mandrogenic stimulation from either endogenous or
* G$ |5 n: ~5 \, O, texogenous sources, nonpituitary gonadotropin stim-% ]. X+ J. I2 v' ^7 |, d
ulation, and rare activating mutations.3 Virilizing& G4 O/ Y$ |( Q  W/ o% N: [8 x( S
congenital adrenal hyperplasia producing excessive1 P1 F* I0 @- H) }: ]
adrenal androgens is a common cause of precocious' m& Q) x" b- t* W
puberty in boys.3,4" s  D/ [2 F) i+ m
The most common form of congenital adrenal
4 S& q/ [5 ~, }  e2 v) dhyperplasia is the 21-hydroxylase enzyme deficiency.
( X, T. B1 h; O8 T  v* AThe 11-β hydroxylase deficiency may also result in! r) @( U2 A" p/ [! C
excessive adrenal androgen production, and rarely,
8 g( Z0 ~! S) s. O  M8 ?an adrenal tumor may also cause adrenal androgen. x, V2 M) B, Y' c
excess.1,39 \/ p% f0 A7 t/ s1 P6 L! d  B9 u. o$ q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# @0 j. D4 r( U542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 Y4 k& L! f- O7 ?* a( `4 \# l5 y
A unique entity of male-limited gonadotropin-7 _$ W7 m5 E6 f3 a3 w1 U" d
independent precocious puberty, which is also known6 `) o" j/ I& b: Y
as testotoxicosis, may cause precocious puberty at a
9 W6 U7 ?: V( h3 v4 ]very young age. The physical findings in these boys+ a- \7 \1 y$ v+ l: A" v0 U' g
with this disorder are full pubertal development,, O1 `( M% ^' O$ Y8 p( f- f# _
including bilateral testicular growth, similar to boys6 T  Y4 i$ ]! N" r& T
with CPP. The gonadotropin levels in this disorder3 a) }* E  M2 ~
are suppressed to prepubertal levels and do not show
  A7 R- h9 b3 |2 ppubertal response of gonadotropin after gonadotropin-& G. m# j& d0 l+ D
releasing hormone stimulation. This is a sex-linked
3 a2 i. m5 Q$ tautosomal dominant disorder that affects only  U' H$ \, k- m  x
males; therefore, other male members of the family2 @& @8 G3 s0 w, P: a  ~' [% Y0 B
may have similar precocious puberty.3
5 L  X1 b5 ~7 b+ T& bIn our patient, physical examination was incon-' ^* ]* a, j5 R" F( ?# a9 z9 P: m
sistent with true precocious puberty since his testi-
/ Y' @) j7 X' _+ s$ A' jcles were prepubertal in size. However, testotoxicosis
) k" r/ o) d8 U  }8 P. b5 k8 |was in the differential diagnosis because his father4 f1 _) N% w5 ^; [3 h
started puberty somewhat early, and occasionally,0 O! }! Y* f2 t# B$ j1 B4 J
testicular enlargement is not that evident in the4 |: A# @' _! R2 N3 X# T& Y9 u7 Z
beginning of this process.1 In the absence of a neg-
: X  k# D8 A& r4 u$ u) H* V" vative initial history of androgen exposure, our
! C& A3 @, q6 c( ^- xbiggest concern was virilizing adrenal hyperplasia,. J4 G- x" r* A
either 21-hydroxylase deficiency or 11-β hydroxylase% E. [$ D! f: l) A/ @8 X5 ]9 l
deficiency. Those diagnoses were excluded by find-
' R: M9 g7 K0 H# S& Ging the normal level of adrenal steroids.
+ ^1 [2 l0 L* f6 q/ IThe diagnosis of exogenous androgens was strongly+ }7 _3 B3 R! k9 H+ P
suspected in a follow-up visit after 4 months because
9 o0 U. M9 E5 d2 M* Lthe physical examination revealed the complete disap-5 h9 k8 x! X2 z# ]7 T( B: O: P
pearance of pubic hair, normal growth velocity, and
& G* C) M& c8 ^. S$ Bdecreased erections. The father admitted using a testos-
4 y% F% }/ \" t! C5 G3 j$ Fterone gel, which he concealed at first visit. He was% O0 {8 \( `$ C$ V3 e
using it rather frequently, twice a day. The Physicians’
6 U% r, b  W( r* n# F0 Z' zDesk Reference, or package insert of this product, gel or
/ t" _; t6 Q4 `cream, cautions about dermal testosterone transfer to
/ S6 H% t# T4 D: Wunprotected females through direct skin exposure.6 N1 U; O: H2 y, f3 q2 ]4 P
Serum testosterone level was found to be 2 times the
' U# U0 A" u( ~  U5 |- B# }) ]baseline value in those females who were exposed to
( |! g0 y' L+ H9 K1 B, N( }& r8 `even 15 minutes of direct skin contact with their male
: P' q# T* \& ^: u8 u( @3 |partners.6 However, when a shirt covered the applica-
9 B( _" d/ [0 e2 @/ Y; Ption site, this testosterone transfer was prevented.+ A2 N& L7 |+ A2 d
Our patient’s testosterone level was 60 ng/mL,
+ F3 O; q) r0 xwhich was clearly high. Some studies suggest that- f3 m, g  D- t0 U1 K* F' b
dermal conversion of testosterone to dihydrotestos-8 [3 `' s/ B) c7 ~
terone, which is a more potent metabolite, is more4 q0 O- Q' m9 A3 v0 ]. u
active in young children exposed to testosterone$ `8 Y+ u5 v! \9 t
exogenously7; however, we did not measure a dihy-7 ~% L2 s3 P- k
drotestosterone level in our patient. In addition to% X0 N( a% ~+ n; d
virilization, exposure to exogenous testosterone in
+ v( T5 S; Y$ D! h, ~5 X! xchildren results in an increase in growth velocity and
2 S  F% e  g5 qadvanced bone age, as seen in our patient.9 `. W0 W' Z! I* u- `
The long-term effect of androgen exposure during
3 k5 J" L) k3 L4 learly childhood on pubertal development and final, J  {4 H% q9 u0 ~! ^; J8 V
adult height are not fully known and always remain
# V7 [. Y* \' l1 f% ]a concern. Children treated with short-term testos-- z6 ~% C6 X# T: ?  \
terone injection or topical androgen may exhibit some6 E* z7 ^/ ]1 X( G3 |
acceleration of the skeletal maturation; however, after) g, m. i- L" R$ h( g) c! [1 W: h
cessation of treatment, the rate of bone maturation
) V3 ~+ s+ s. G: Adecelerates and gradually returns to normal.8,9. B6 b+ d9 I3 J8 _: `+ @# y
There are conflicting reports and controversy3 d3 V& U' e3 ]5 O
over the effect of early androgen exposure on adult
$ l# ^, G8 q3 P! q' Kpenile length.10,11 Some reports suggest subnormal
/ n: O& F9 V+ l: Q4 Zadult penile length, apparently because of downreg-' l8 N1 t& |( \/ ]0 m4 U5 z
ulation of androgen receptor number.10,12 However,
/ k. d- `% u- s, \# JSutherland et al13 did not find a correlation between
$ [: e8 t) ]$ X! rchildhood testosterone exposure and reduced adult
" i$ M# e! G1 [. k3 Zpenile length in clinical studies.* `: P% u: m1 d: l- q3 x
Nonetheless, we do not believe our patient is
( c: T, W6 M  Cgoing to experience any of the untoward effects from, M, n1 r  J' x' M) E8 s
testosterone exposure as mentioned earlier because
7 L3 x; q* r  e9 {the exposure was not for a prolonged period of time.
2 d+ l5 Q/ _1 u1 D3 @$ `Although the bone age was advanced at the time of
  t. ]4 `- v$ D) F# Qdiagnosis, the child had a normal growth velocity at
7 ?2 F0 C9 b4 v1 a: R( zthe follow-up visit. It is hoped that his final adult
! E4 p! }+ a# _4 |height will not be affected.$ p/ `5 _" T% z% [8 T
Although rarely reported, the widespread avail-
% u% J9 |/ |9 B, i1 r: }8 z% Kability of androgen products in our society may
& X9 H: _: R7 z, B, ~/ m4 Zindeed cause more virilization in male or female/ P6 {/ ^: g. x* x
children than one would realize. Exposure to andro-
. W' Q( f4 r( ~, q, K' L; jgen products must be considered and specific ques-) u$ O& J6 j3 K# D% c
tioning about the use of a testosterone product or
. }0 j' L1 a* ?; F+ Ygel should be asked of the family members during* H: a/ j2 \- }6 s# N) S
the evaluation of any children who present with vir-
  ?- m6 \" N9 B8 N& gilization or peripheral precocious puberty. The diag-% v8 J6 o; {. W" ]3 k& ^
nosis can be established by just a few tests and by
& f9 _) r, C! O9 Q  @appropriate history. The inability to obtain such a
( T0 I! J1 _* n4 z: ^history, or failure to ask the specific questions, may
) q2 l& ~: K( X1 F3 cresult in extensive, unnecessary, and expensive
4 M/ N8 R' K  d3 ~" ?" w* Sinvestigation. The primary care physician should be
$ T, z. o" ?% u1 [% l$ Z: Saware of this fact, because most of these children
' O% s2 F: @( L3 i. l- S2 t6 Z: ~may initially present in their practice. The Physicians’5 u' K4 l! L$ w3 O
Desk Reference and package insert should also put a6 C( E2 Y% ?9 W: `# |
warning about the virilizing effect on a male or
" T# B  N9 y  d8 d/ L" i3 N4 z+ Mfemale child who might come in contact with some-7 c+ [- X% Z3 i- c1 B" @7 d
one using any of these products.
5 O9 n4 h2 e. {References1 u4 r. P, c5 b3 k3 d  T1 \
1. Styne DM. The testes: disorder of sexual differentiation0 [% y# o" `& ?. v3 W
and puberty in the male. In: Sperling MA, ed. Pediatric4 r1 d4 Q3 y; p) a) X- K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# d3 l! ~8 H9 O4 o2002: 565-628.
0 O7 t  w( ~! W; n$ W$ U) t( \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 d( e5 A! ~" f+ J9 C2 d" Z/ ]& Ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
# J' v/ u* J/ ?Boy Induced by Indirect Topical
7 ?. e, {: J( z- MExposure to Testosterone. c' B4 I, J! d5 N% B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* ^1 r' b, g( z2 F7 p, K+ I; Land Kenneth R. Rettig, MD1
5 a* |1 @1 M$ C% kClinical Pediatrics* i/ G  b! h* s0 {! }
Volume 46 Number 6% l7 _/ [* Y; K  D9 q7 i
July 2007 540-543
4 f. j8 i& I) _© 2007 Sage Publications6 Y& j# h  b! N/ U
10.1177/0009922806296651+ J4 p; I% S% {- a5 H. ?: }5 V& V4 G
http://clp.sagepub.com
6 n' Q5 \& Z  }  }! T- z" E7 X( Mhosted at
+ o3 _1 h0 g. x( Q8 d* \$ b; Jhttp://online.sagepub.com
" a+ M; c1 f3 M9 a9 A. o% h* MPrecocious puberty in boys, central or peripheral,
& D6 X: x! |. U7 Jis a significant concern for physicians. Central
, I  J( s; ]. T: y% j+ H) [4 Fprecocious puberty (CPP), which is mediated
' X- U. F! p& A, F4 E: Kthrough the hypothalamic pituitary gonadal axis, has
% ^2 P/ [  D1 I0 a7 f+ K- Sa higher incidence of organic central nervous system
" T/ a- D& x# Y& I2 nlesions in boys.1,2 Virilization in boys, as manifested' _5 f+ r' P' r2 g) L
by enlargement of the penis, development of pubic! I4 T9 G% j) D, x( D! G
hair, and facial acne without enlargement of testi-
& v; g! p' w8 V8 g. W7 {: acles, suggests peripheral or pseudopuberty.1-3 We
% e/ ~- t. r1 D- Y; dreport a 16-month-old boy who presented with the
1 D2 w' H0 Y) G  t4 Z, _enlargement of the phallus and pubic hair develop-
  v: R6 H. C+ |7 _ment without testicular enlargement, which was due
, b) w# \" U+ |4 ?1 M1 eto the unintentional exposure to androgen gel used by
( t& Q9 |( S& K" {the father. The family initially concealed this infor-
% [, w4 |* [. |# nmation, resulting in an extensive work-up for this
% P- M3 g( P( l0 {8 R% k6 q6 Rchild. Given the widespread and easy availability of
( B* S5 u" c7 o- M* utestosterone gel and cream, we believe this is proba-  U/ d. O3 v; c4 n. b
bly more common than the rare case report in the
3 ]" ^2 X1 D" H! f% ]literature.4) P; y& n3 n5 u3 Z, |. I1 Y3 P
Patient Report% i- A4 h  j4 k9 q8 q9 ?' {3 b
A 16-month-old white child was referred to the
/ T, }: f5 s6 ^5 rendocrine clinic by his pediatrician with the concern2 F: {: r: [/ r% b. [2 l7 F- @  d
of early sexual development. His mother noticed
) l$ O9 q  b5 S+ t' Ilight colored pubic hair development when he was
) ~+ Y; w6 _6 {! \, f( v6 M% o$ ]  ~From the 1Division of Pediatric Endocrinology, 2University of
1 P! V0 Y- n& r* jSouth Alabama Medical Center, Mobile, Alabama.4 R& p3 O/ g- n1 X. V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- C. z9 H3 n( x5 X; pProfessor of Pediatrics, University of South Alabama, College of- c! M% E) e! C; p* x  q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 E! M% w2 G9 v0 h2 D4 d) Ie-mail: [email protected].
2 j+ O* P% n, M6 jabout 6 to 7 months old, which progressively became$ G* r7 W3 Q3 C# L9 ]% d
darker. She was also concerned about the enlarge-6 b7 n" R' M2 p! W+ X' y! V5 K
ment of his penis and frequent erections. The child+ w8 W( ?4 ?/ x. v: e2 N( o% m
was the product of a full-term normal delivery, with
9 j$ x  a% i" C* j$ a( i6 T/ Ja birth weight of 7 lb 14 oz, and birth length of
2 d' @1 `1 H+ C20 inches. He was breast-fed throughout the first year
3 B- a7 _1 C+ T, g9 pof life and was still receiving breast milk along with
5 M; I9 K' S- j. f$ Vsolid food. He had no hospitalizations or surgery,
0 G3 c  c0 t6 V. _8 U0 Iand his psychosocial and psychomotor development' ~$ @$ H% f) ~0 Y1 v
was age appropriate.- Z2 ?( I& D( u& l- U
The family history was remarkable for the father,7 V7 a1 H/ k* G1 N* H2 r
who was diagnosed with hypothyroidism at age 16,1 y$ c: m/ K; F
which was treated with thyroxine. The father’s! B9 [* @- f! S  c- W
height was 6 feet, and he went through a somewhat
1 @# B' J2 P6 `" Y1 B$ Aearly puberty and had stopped growing by age 14.
( i1 b0 r. w! \: G' ~The father denied taking any other medication. The
" Q8 Q2 i" k$ B% R5 ~8 k$ Dchild’s mother was in good health. Her menarche
$ d- e% [) A6 O1 ywas at 11 years of age, and her height was at 5 feet( A. R' R- @6 v/ A  W+ W
5 inches. There was no other family history of pre-" Y7 T3 P. k0 L6 z! Z2 @' }) V
cocious sexual development in the first-degree rela-0 }+ e3 `8 D, E0 S. E. ?9 U
tives. There were no siblings.3 Y$ w1 z. y9 d+ p! s0 v  [+ @
Physical Examination  \8 T! g; b+ g& t9 U; J- z
The physical examination revealed a very active,0 v8 k( ?/ a; y# t! f
playful, and healthy boy. The vital signs documented7 \* B  a& W% ~* b! q
a blood pressure of 85/50 mm Hg, his length was  S! q2 u! B, a, @, m% d: ~
90 cm (>97th percentile), and his weight was 14.4 kg" ]' \# f" a. Z9 x2 Q
(also >97th percentile). The observed yearly growth
  Q% P# I/ `, n. I( }+ H; {! uvelocity was 30 cm (12 inches). The examination of6 O: V5 }9 L* B# \, Y
the neck revealed no thyroid enlargement., A5 U' ^" k; {* T- ?  i3 N
The genitourinary examination was remarkable for
7 l- o  E; [) b& m, U: Wenlargement of the penis, with a stretched length of9 F0 ?) v( K3 X8 `" h" x6 D% ^0 f
8 cm and a width of 2 cm. The glans penis was very well+ A7 l* k/ `. K8 L4 P, d1 ^
developed. The pubic hair was Tanner II, mostly around
/ V+ j' ?" e9 F8 `  V5404 i$ y: H' b4 z: m& d8 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. ?8 W( E% ]: l& V: `7 I0 |the base of the phallus and was dark and curled. The
! S' _" t" D- c' I, X" {( [testicular volume was prepubertal at 2 mL each.
4 ^0 X, L& E! D# ^) A3 o; P) yThe skin was moist and smooth and somewhat  s# n0 X) D$ H
oily. No axillary hair was noted. There were no+ u% @# O5 ^2 U) @( }
abnormal skin pigmentations or café-au-lait spots.& W4 z7 R' e! p% D9 X
Neurologic evaluation showed deep tendon reflex 2+
8 W) t" w/ t7 @) |( ~/ Pbilateral and symmetrical. There was no suggestion
; ]1 ]5 U1 M  B7 J1 X+ pof papilledema.
0 I4 O. ^& @5 a+ [1 ~Laboratory Evaluation
% w# c  z, O( N7 IThe bone age was consistent with 28 months by6 a. c3 S( R3 f+ ^9 b& h
using the standard of Greulich and Pyle at a chrono-- A7 B6 P% F% Y3 V* p8 M/ b+ [
logic age of 16 months (advanced).5 Chromosomal
; d. |1 S" f4 L1 R0 \, b8 tkaryotype was 46XY. The thyroid function test
; M/ _! D: Y! @5 I0 gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 H+ o6 E$ T/ b9 W, _
lating hormone level was 1.3 µIU/mL (both normal).
+ I9 Z4 n* u/ O/ A" P( p. n" CThe concentrations of serum electrolytes, blood
! @* r  j9 U- U' ~  Furea nitrogen, creatinine, and calcium all were
1 O7 ~# G0 x; n9 W* qwithin normal range for his age. The concentration' J# n/ q! T" m3 ^+ D0 n& G4 U
of serum 17-hydroxyprogesterone was 16 ng/dL
! A" w7 x, g5 e6 H( w' Z(normal, 3 to 90 ng/dL), androstenedione was 20
2 T  d* Z5 l+ E4 ^1 W  j* Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 [% B5 S1 c: ^0 [  iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- u8 y- Y, }  Z* T2 O. Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ [: u; D8 N2 C. a) l0 `& |7 r49ng/dL), 11-desoxycortisol (specific compound S)
; E" S, r2 `& q3 |+ b5 Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; y. A$ f/ T: d# Y/ `' jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 r& a0 `2 H# i8 w2 x3 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 ?6 e  b) F4 a! K& X& U  D. b8 Z4 g
and β-human chorionic gonadotropin was less than
; d7 |$ V: x' p5 `5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 R) C" I/ M6 }2 astimulating hormone and leuteinizing hormone, i. c- S2 c" @0 {- w. q
concentrations were less than 0.05 mIU/mL) c* u- ~" I3 |" ]" K
(prepubertal).! M( l7 E% y! k) R0 Q* a) \1 K
The parents were notified about the laboratory
  j# U3 `& f  b' `3 ]7 _results and were informed that all of the tests were  M  s' @1 ~  W/ ~" {  t! _( _
normal except the testosterone level was high. The
, j& U. \0 X2 Efollow-up visit was arranged within a few weeks to' q/ ^$ L1 z$ L6 I" \0 X/ E# d( K4 t0 w
obtain testicular and abdominal sonograms; how-
% ~7 W+ {. `3 \6 R4 m9 Wever, the family did not return for 4 months.' w0 n1 ^5 }: p; w' L
Physical examination at this time revealed that the6 P$ Y: s6 D8 c( k' F" k' B
child had grown 2.5 cm in 4 months and had gained
+ a8 E1 B4 P! v2 kg of weight. Physical examination remained% F7 {2 [$ ?& z, Y% Y
unchanged. Surprisingly, the pubic hair almost com-
- i2 @# y6 `1 _pletely disappeared except for a few vellous hairs at
% R% o7 P, d. t# k6 mthe base of the phallus. Testicular volume was still 2
( Z; Y0 f% _& A6 @3 n* bmL, and the size of the penis remained unchanged.
5 U+ ~1 b# ^$ U1 G8 Q7 E0 P9 KThe mother also said that the boy was no longer hav-
% o/ e6 K" c' W* `  ying frequent erections.: h% j. M& a1 [- a
Both parents were again questioned about use of  W- R. `+ k. y% |/ `
any ointment/creams that they may have applied to! f* S+ V3 i! h
the child’s skin. This time the father admitted the! @3 l+ l* P: Q  p5 x
Topical Testosterone Exposure / Bhowmick et al 541
) i" J" e1 h* A4 S) J8 b2 h( m& x% wuse of testosterone gel twice daily that he was apply-
: q1 `! P/ _5 ], ring over his own shoulders, chest, and back area for
4 [/ S' W, v1 I4 p+ u/ I) Aa year. The father also revealed he was embarrassed1 \8 r  r0 d: S" D: B% Z1 w
to disclose that he was using a testosterone gel pre-, c6 s: R  O4 J% k1 _5 R& @
scribed by his family physician for decreased libido
* `* H* _6 U9 s9 J, Fsecondary to depression.
$ ?: z+ J" F! C$ X# r) _The child slept in the same bed with parents.# J# _# u- |5 k! ]1 H
The father would hug the baby and hold him on his/ x) F- n- Y/ }& `  g
chest for a considerable period of time, causing sig-1 z* B% ^  H- N! k
nificant bare skin contact between baby and father.0 Z: L2 |6 ]% {3 S" P/ P" F1 L
The father also admitted that after the phone call,/ y8 Q: s  C1 v5 Y- A! T# }9 M
when he learned the testosterone level in the baby! d& }& d. S$ [
was high, he then read the product information( ?4 R: g% b. U' G. [0 M- C
packet and concluded that it was most likely the rea-
  V  d' I1 S# s* Q9 q( q" \8 o: }, Gson for the child’s virilization. At that time, they
6 u' G6 Q( A0 L" ~2 wdecided to put the baby in a separate bed, and the3 Z4 Y# M, D# F% U
father was not hugging him with bare skin and had' m7 N# N3 G/ s' V4 x! Y
been using protective clothing. A repeat testosterone( d8 n8 @' @1 e1 B8 p3 o7 C% L1 L
test was ordered, but the family did not go to the
0 ~) Z5 v- t: O7 m+ llaboratory to obtain the test.
7 q, W- |6 j) Q2 [: e& l1 B; `Discussion
/ i. o: B+ w8 u, w3 U5 h2 kPrecocious puberty in boys is defined as secondary2 g6 W0 b3 y; t5 x/ V
sexual development before 9 years of age.1,4
0 U% @- R) z4 Z" {Precocious puberty is termed as central (true) when: Q- T" w5 P) n' X" c* n. e7 P( R
it is caused by the premature activation of hypo-( a" o/ b; D6 j) J- X
thalamic pituitary gonadal axis. CPP is more com-
' z6 {, `$ ~, e! V3 z: d0 Jmon in girls than in boys.1,3 Most boys with CPP
# i+ M: z3 y+ A9 {- xmay have a central nervous system lesion that is
4 D. q. v; [: P# Rresponsible for the early activation of the hypothal-+ z$ R4 \- L4 R
amic pituitary gonadal axis.1-3 Thus, greater empha-: m  _& D! q$ ?/ l! a' i  n
sis has been given to neuroradiologic imaging in: Q+ b: ~; m; D
boys with precocious puberty. In addition to viril-, }. X, ]/ B7 l( T, l
ization, the clinical hallmark of CPP is the symmet-8 h3 {: r; e! {
rical testicular growth secondary to stimulation by( `3 s" O8 L/ n' _
gonadotropins.1,3
: O4 \4 q) o" l2 {1 g! y1 [Gonadotropin-independent peripheral preco-" l3 _, a; A6 k6 q
cious puberty in boys also results from inappropriate0 m; e8 X7 d) C: |; N" O2 W" C
androgenic stimulation from either endogenous or! a5 a$ D1 G4 a6 K3 a( J+ [
exogenous sources, nonpituitary gonadotropin stim-/ {) w3 s+ ^( x0 x/ }0 z
ulation, and rare activating mutations.3 Virilizing  i- Q3 F0 H+ s% S" r. R
congenital adrenal hyperplasia producing excessive
0 @" T/ a' {# o% T! t6 S5 D- Yadrenal androgens is a common cause of precocious
- i5 i) G+ K5 x: O. Wpuberty in boys.3,4
. |, M% Y8 W% L# @7 UThe most common form of congenital adrenal$ I7 ^" P( m, \0 I4 v4 B
hyperplasia is the 21-hydroxylase enzyme deficiency.
* f2 g+ Z" x& [% g' ]The 11-β hydroxylase deficiency may also result in! j* P5 m- j3 k# U0 Z& e
excessive adrenal androgen production, and rarely,
4 }$ L; D- ^" O0 C5 \an adrenal tumor may also cause adrenal androgen8 Y- {* S  s1 O3 S2 |' y! I$ ]$ R
excess.1,3
3 v9 _. K2 W0 x+ }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; ?2 w7 N8 y/ v: k  \& z; X542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, b* i6 Y5 _: _! ^" M* J( oA unique entity of male-limited gonadotropin-& k+ g& R: R. e% X2 ]
independent precocious puberty, which is also known
+ h  z7 W+ A9 e9 `, Has testotoxicosis, may cause precocious puberty at a7 U9 k( Q# A2 B) I; _0 q) u
very young age. The physical findings in these boys7 q7 c9 r% V: ]7 S
with this disorder are full pubertal development,
, Q9 C, G3 O7 D' K# rincluding bilateral testicular growth, similar to boys
$ y3 b+ V/ a' ewith CPP. The gonadotropin levels in this disorder
; `- d5 _& ^, m- Tare suppressed to prepubertal levels and do not show
" z; h4 v$ J2 `4 }! `; r- Vpubertal response of gonadotropin after gonadotropin-( L, P, N9 U/ w6 Q
releasing hormone stimulation. This is a sex-linked+ _+ o& G6 F- k) Z0 ]# u; c' O
autosomal dominant disorder that affects only1 g. D8 G1 t1 B6 m9 L: u
males; therefore, other male members of the family
: V; g- o- ~$ h6 }) qmay have similar precocious puberty.3
# [. S* b8 d3 y' sIn our patient, physical examination was incon-6 m5 p9 M6 \( v+ ?% H1 l) l* B& s' h
sistent with true precocious puberty since his testi-
2 m3 T9 C: S. P6 O! bcles were prepubertal in size. However, testotoxicosis* o- m7 S' I8 z  _
was in the differential diagnosis because his father
, L( k% C$ O0 q; c- b! f( hstarted puberty somewhat early, and occasionally,( v( l, B2 g& @( \5 |+ o. v' z# w
testicular enlargement is not that evident in the' M$ B: F% o) Y: @# p; F2 f" K
beginning of this process.1 In the absence of a neg-
$ s) u5 E/ I8 s3 v! M& e- g' C1 V2 }; uative initial history of androgen exposure, our
, m1 q) }% Y+ @5 `+ W" q4 jbiggest concern was virilizing adrenal hyperplasia,
/ |+ M5 R' M, Z1 y4 P2 keither 21-hydroxylase deficiency or 11-β hydroxylase
- [$ a7 F; R+ V9 Pdeficiency. Those diagnoses were excluded by find-& O0 N6 j- R! t) c
ing the normal level of adrenal steroids.7 B2 V5 k, v! {6 z! N
The diagnosis of exogenous androgens was strongly
9 ], D7 a- ^2 k& O) Psuspected in a follow-up visit after 4 months because, S8 Y9 G: _! j' W/ }
the physical examination revealed the complete disap-
0 q/ _2 z4 n3 m  spearance of pubic hair, normal growth velocity, and: y* i0 k, T8 _
decreased erections. The father admitted using a testos-
  F0 a: D1 K. qterone gel, which he concealed at first visit. He was
6 x/ J( ~5 A7 L/ P. z  Lusing it rather frequently, twice a day. The Physicians’
7 r8 q$ g) T2 |Desk Reference, or package insert of this product, gel or
1 z0 e5 F' b2 B  Q, Lcream, cautions about dermal testosterone transfer to
5 x0 F* W! F2 b2 D$ e4 kunprotected females through direct skin exposure.' g; [  b  O/ w
Serum testosterone level was found to be 2 times the
. |8 N9 k$ f9 e) Mbaseline value in those females who were exposed to
. Z4 o% W4 A! p! Y7 veven 15 minutes of direct skin contact with their male! b6 ~7 A' p" u6 w) R& @- g) ^- n2 J
partners.6 However, when a shirt covered the applica-) f! I1 D& k* T( E: I+ ^) z
tion site, this testosterone transfer was prevented.
5 z  s5 v* X3 G6 ?' COur patient’s testosterone level was 60 ng/mL,
! j( _. c5 d1 _. |) xwhich was clearly high. Some studies suggest that* _$ M  R1 h- ~6 S3 |! ~
dermal conversion of testosterone to dihydrotestos-
) n7 j! ]) P% g# t9 }0 lterone, which is a more potent metabolite, is more/ _' ?+ K3 N+ \
active in young children exposed to testosterone
" g* k5 _* |0 uexogenously7; however, we did not measure a dihy-
4 c4 q( O! r  P% W$ ~) f0 }% m2 ddrotestosterone level in our patient. In addition to( }* |: o% }& [
virilization, exposure to exogenous testosterone in4 Z$ T+ w  j# B& \" h
children results in an increase in growth velocity and4 F% F0 O; t" Q0 {
advanced bone age, as seen in our patient.
! X, p  P9 z9 A$ Z# G2 Y. f  J9 A5 C+ OThe long-term effect of androgen exposure during
4 X: ]- `$ B1 D2 s! B  Yearly childhood on pubertal development and final' U3 y* @- Z& C9 v. B7 y8 w
adult height are not fully known and always remain: U; r: Q8 v" Q5 N2 g
a concern. Children treated with short-term testos-6 E7 k/ P# n0 G  Q
terone injection or topical androgen may exhibit some
* c. l  v0 c  v; k' M# x! hacceleration of the skeletal maturation; however, after" F8 O. V4 i: J1 N( O2 I- w
cessation of treatment, the rate of bone maturation/ o8 r+ ~1 l/ d: v
decelerates and gradually returns to normal.8,9
3 U" F/ r5 o/ Y2 |9 {9 f/ vThere are conflicting reports and controversy+ N+ s4 d& s  t, y
over the effect of early androgen exposure on adult5 T7 ]& ~$ L! Y; I, c; ?7 U, r
penile length.10,11 Some reports suggest subnormal7 P7 P8 F0 z" r. V# M1 _
adult penile length, apparently because of downreg-) {5 x1 C" U8 j/ @9 J+ H
ulation of androgen receptor number.10,12 However,
$ ?7 B  f+ h1 Z7 JSutherland et al13 did not find a correlation between& c: T3 [3 X  \% Y: `
childhood testosterone exposure and reduced adult: t# Y* ]" @0 O! N7 J5 f+ U$ ~6 O
penile length in clinical studies.* w/ f% R# k4 q4 j/ Y8 L% }
Nonetheless, we do not believe our patient is, l' |4 X0 J0 S& L9 B
going to experience any of the untoward effects from
. F! p3 S2 m# ^) @5 l# |' etestosterone exposure as mentioned earlier because. i4 @/ o3 E6 J! {# {7 ?
the exposure was not for a prolonged period of time.; k* h4 L( B  c+ X7 I
Although the bone age was advanced at the time of
8 ^/ b% L. M3 ?; O/ Zdiagnosis, the child had a normal growth velocity at
$ m4 ~" @3 ~2 s& ~; @% J7 Z. ?) Wthe follow-up visit. It is hoped that his final adult
/ ?/ g' A+ p" L* W& [$ i9 J" f, aheight will not be affected.
8 z, F1 S- ^# \Although rarely reported, the widespread avail-
6 v% R- h5 t$ U9 A4 ?& f" xability of androgen products in our society may3 U; X5 a5 X- V5 A9 }
indeed cause more virilization in male or female
1 d( c+ P, r6 Q8 ~children than one would realize. Exposure to andro-5 P2 d2 f, U2 n3 \
gen products must be considered and specific ques-
# x5 f: T% y3 ?+ z+ z' Ptioning about the use of a testosterone product or
" ?( ^$ y5 `/ I$ M$ }) ^) x/ T  f# Lgel should be asked of the family members during5 k. @; k, z- ^+ m) _
the evaluation of any children who present with vir-: A. t$ p0 u# O; n1 W/ \
ilization or peripheral precocious puberty. The diag-
$ ^( L6 {3 o3 t% l  Unosis can be established by just a few tests and by
  P+ @0 Y) u7 l. _appropriate history. The inability to obtain such a
' T$ S  _+ r0 R$ j6 P+ Nhistory, or failure to ask the specific questions, may7 v+ v1 ]* n9 N2 X& W
result in extensive, unnecessary, and expensive9 [. E* o$ e* }1 S8 m( b
investigation. The primary care physician should be
" D  d/ G5 q& O0 o+ q1 iaware of this fact, because most of these children7 j" Y0 d0 P8 `
may initially present in their practice. The Physicians’; C1 d( w2 m6 G& L/ i' ^9 @& p
Desk Reference and package insert should also put a6 z8 M0 W0 r3 ?; O8 p* m
warning about the virilizing effect on a male or
4 C. n! x' q6 O/ D, Pfemale child who might come in contact with some-: h" e: Z' t, E$ B9 \. k
one using any of these products.- z" R. H5 N8 N5 b
References" c4 ], Z1 q7 F: b. `" M
1. Styne DM. The testes: disorder of sexual differentiation- ]# v6 V6 e% a
and puberty in the male. In: Sperling MA, ed. Pediatric
2 `" I5 b4 _$ }* \: {& YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 X1 G  F) A9 w# `& S! x5 [2002: 565-628.
- T6 @4 J+ f6 J  q# D( z, l+ k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* }6 }/ F+ X6 R% s. ?0 L1 L
puberty in children with tumours of the suprasellar pineal
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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

# n5 g$ M6 f. @1 ^% X* v% h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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