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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/ r" x& G6 F5 Z" r* u1 B1 `4 ^8 ?
Boy Induced by Indirect Topical
' W0 i& ]' r9 Q; OExposure to Testosterone
5 M4 U) ^. O  S1 E* l# P" tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" v; H, D$ c0 Y* b# Tand Kenneth R. Rettig, MD1+ V: O! c$ f6 p8 e3 Q$ L/ S% Y
Clinical Pediatrics9 E3 O/ X9 J! L$ Y: _" |- ~( K
Volume 46 Number 6* u: z& y3 ]% n9 w
July 2007 540-543- ?$ f3 Q  |2 q/ f' A; |
© 2007 Sage Publications: d, ^# `% B9 x" k% i8 Y% q; b
10.1177/0009922806296651
8 [  c' ~% {) S. q7 xhttp://clp.sagepub.com
/ w2 G) h  R, `hosted at
) ~, K2 |( Y3 h. f4 d) p( lhttp://online.sagepub.com
8 {8 ^$ z4 O$ s) T/ K' d( n) `* @6 rPrecocious puberty in boys, central or peripheral,) l  J/ j- \" I3 i8 z2 o% N) z
is a significant concern for physicians. Central
/ p) P: H/ }  C" {- p( x7 k, Nprecocious puberty (CPP), which is mediated
' C  X* L; \! D6 Othrough the hypothalamic pituitary gonadal axis, has
! V  @6 v: r% E1 _6 j. ea higher incidence of organic central nervous system
' x4 k5 O& z- t1 z: C5 m$ X8 p& rlesions in boys.1,2 Virilization in boys, as manifested3 B9 ]# B! H( c% b# A, c% e
by enlargement of the penis, development of pubic) |: L- `5 J3 [! s5 d
hair, and facial acne without enlargement of testi-0 l& r: [4 w$ t
cles, suggests peripheral or pseudopuberty.1-3 We; k. O) ]$ \$ o/ ^% |  L' }% q, H" ]
report a 16-month-old boy who presented with the7 x1 ^! y. y; @' \2 y
enlargement of the phallus and pubic hair develop-4 I/ n/ v# ^* t
ment without testicular enlargement, which was due
4 ~+ A5 M# T- i/ `to the unintentional exposure to androgen gel used by: R9 a' F8 Q. P0 g$ d! T
the father. The family initially concealed this infor-
4 N' ~& M$ b) U1 L4 bmation, resulting in an extensive work-up for this/ e0 z9 P7 c( R
child. Given the widespread and easy availability of1 }3 v- ^3 M7 G
testosterone gel and cream, we believe this is proba-
- M" X2 J9 q/ mbly more common than the rare case report in the
, v  h) a) l& F; b) R  A  R( ~1 [literature.4
( j( ~% K( w9 c  s0 HPatient Report
+ f$ S- j* p" W" j; S8 R: UA 16-month-old white child was referred to the
# P3 j. [& H' o0 L: [) B3 u7 r% k( Eendocrine clinic by his pediatrician with the concern. i: u- Q6 b; z3 j
of early sexual development. His mother noticed; i, v3 L2 k# [
light colored pubic hair development when he was8 H% e* W5 J$ M8 P' E6 [
From the 1Division of Pediatric Endocrinology, 2University of% m6 {/ a: f  O$ W9 b6 Y6 V4 Q/ e
South Alabama Medical Center, Mobile, Alabama.
; x4 `4 O2 g' ^+ TAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ y. f0 N: N% K
Professor of Pediatrics, University of South Alabama, College of
' x. Y# K% L6 \! H2 dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 I- F4 P4 j) D6 Ye-mail: [email protected].! H7 c" V# Y- N6 j8 B8 M5 G8 {
about 6 to 7 months old, which progressively became
+ g# p( k. B+ D6 R# V8 E( Vdarker. She was also concerned about the enlarge-
7 J- n, _  p/ y* T! b2 Sment of his penis and frequent erections. The child
. V# Q# L4 {( o% @6 \was the product of a full-term normal delivery, with
# g7 A% b4 v1 ?a birth weight of 7 lb 14 oz, and birth length of
( W6 U# Q$ W( s( l5 C; `3 Z20 inches. He was breast-fed throughout the first year
" o/ I5 M) h8 }* J8 ]of life and was still receiving breast milk along with
7 b- E4 w) u: s4 [; m& tsolid food. He had no hospitalizations or surgery,
8 m2 P3 W+ N% dand his psychosocial and psychomotor development4 t- b. W  L7 t8 j
was age appropriate.
1 ~) p" d/ {7 {; m# H5 B$ tThe family history was remarkable for the father,
5 F/ `6 Q0 Y4 M% n4 R& {who was diagnosed with hypothyroidism at age 16,7 a% O: H& Z5 q- p5 O  B
which was treated with thyroxine. The father’s
1 R# h% S, }' i4 R, ?height was 6 feet, and he went through a somewhat
& s( ^" ^, P) z# K8 c$ pearly puberty and had stopped growing by age 14.
; y9 W* l+ v; U# Q' `# c  iThe father denied taking any other medication. The
) i1 |+ P! v7 A& w% v4 echild’s mother was in good health. Her menarche
7 I" d$ Z8 K+ s* X5 h/ h: bwas at 11 years of age, and her height was at 5 feet
1 P4 V8 N8 {+ _% Z0 h5 inches. There was no other family history of pre-: b8 b9 K; ]' C7 n
cocious sexual development in the first-degree rela-; T# F  C, {! e7 ]! E3 k" [
tives. There were no siblings.# M+ h- g+ I' t( Q
Physical Examination& ~( ~3 G6 ~& w5 {7 |
The physical examination revealed a very active,/ A! k1 T1 T* N: F- o
playful, and healthy boy. The vital signs documented" Q, e  |2 m6 _
a blood pressure of 85/50 mm Hg, his length was
& g% S, c5 c3 @  V. o8 K) e90 cm (>97th percentile), and his weight was 14.4 kg
4 a9 Z7 L# Y. u* o* a9 e) S5 V(also >97th percentile). The observed yearly growth
" m) m' N7 ]0 T/ Fvelocity was 30 cm (12 inches). The examination of- Q! m$ n$ D: c- \* u. Q3 _
the neck revealed no thyroid enlargement.
/ s1 J' w" z. `7 j% {& GThe genitourinary examination was remarkable for$ [# W3 n6 c7 J
enlargement of the penis, with a stretched length of1 R! E8 R$ B2 o
8 cm and a width of 2 cm. The glans penis was very well. q5 H" k1 B" {3 `7 Y! j& I
developed. The pubic hair was Tanner II, mostly around
8 C& A( ^0 K* N- k540
" V5 f8 @$ r; vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  u7 G8 ~* e3 K# V% G* U
the base of the phallus and was dark and curled. The7 u" F3 _5 K+ A+ l
testicular volume was prepubertal at 2 mL each.2 H# d1 T, J8 s! e! x8 S
The skin was moist and smooth and somewhat
8 q+ [3 i) {& L$ T5 c1 Z' @, foily. No axillary hair was noted. There were no3 \6 X, I/ h+ a8 o9 M
abnormal skin pigmentations or café-au-lait spots.
; h4 \) Q' a9 z) J; D6 |! L1 eNeurologic evaluation showed deep tendon reflex 2+
0 [% R; `9 K& Ebilateral and symmetrical. There was no suggestion# s4 }2 {2 N" W- `9 g- r- R
of papilledema.) D9 T  `6 ^3 I' \# ~
Laboratory Evaluation5 T" H0 b% R$ F3 |" _
The bone age was consistent with 28 months by4 a! G( t* _( o3 Z2 ]& s
using the standard of Greulich and Pyle at a chrono-# e- a8 z" \& \8 z" s: v9 u! a7 L/ q' E
logic age of 16 months (advanced).5 Chromosomal/ T6 a; \  N& |; F4 k- G
karyotype was 46XY. The thyroid function test# q% _6 c1 I5 [. w" W% i+ i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 g5 i( O7 t4 J! m" v$ u. u
lating hormone level was 1.3 µIU/mL (both normal).! {- w9 k) o: W; U
The concentrations of serum electrolytes, blood  N; i" k) u7 s+ G! I6 ^. D
urea nitrogen, creatinine, and calcium all were* t" n) J  a0 F0 D  @9 J
within normal range for his age. The concentration
+ q& V2 d9 R6 K1 ?of serum 17-hydroxyprogesterone was 16 ng/dL  y# x" ]2 g8 |7 A: y0 [
(normal, 3 to 90 ng/dL), androstenedione was 205 M3 k- V# r8 O3 p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 k- B% f$ N2 O) Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),* V& F7 k2 i# }) o6 e$ d: _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* r. ?' c+ M9 }# _0 o
49ng/dL), 11-desoxycortisol (specific compound S)
3 D1 Z! P+ X+ E, [was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! z. C, \& W4 W' n) `7 j
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. c, R6 c! U# x' |! k; _/ V" Atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* E& g( w- ]% P- r* h6 q  sand β-human chorionic gonadotropin was less than
4 U$ f. q2 \  J3 Y# h) d: Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
' j% a* Z' L) Xstimulating hormone and leuteinizing hormone$ C- @4 Z  V) c% W
concentrations were less than 0.05 mIU/mL9 C+ W, e8 h, v, u3 [' ?
(prepubertal).
- v5 v! W9 q, l% [6 mThe parents were notified about the laboratory8 d8 p( ~: V$ w4 N: A/ A; Y0 s; J) e
results and were informed that all of the tests were
7 Q1 c$ D8 |: d2 mnormal except the testosterone level was high. The
# O7 H$ ^% m; z3 A9 sfollow-up visit was arranged within a few weeks to6 P; L6 @& y6 |& }
obtain testicular and abdominal sonograms; how-0 Y& C9 [* U+ q3 h# q4 v8 z
ever, the family did not return for 4 months.# r$ v" H, i% ]/ U  \( \& T) U
Physical examination at this time revealed that the9 t- A. r! z/ q' R
child had grown 2.5 cm in 4 months and had gained2 _/ X7 Q; v! f& |3 X4 Z2 j0 \
2 kg of weight. Physical examination remained
6 \$ m" P$ g5 D$ A* L% J0 Yunchanged. Surprisingly, the pubic hair almost com-7 @% G& A3 U) r4 k; W
pletely disappeared except for a few vellous hairs at; z6 Q: k3 f* Q
the base of the phallus. Testicular volume was still 2
  d: `; R8 I% I6 }+ L9 r+ c# wmL, and the size of the penis remained unchanged.  s; u7 w: W1 [; O& q
The mother also said that the boy was no longer hav-
+ G' G/ `9 H0 p; P5 w; ring frequent erections.
% g1 f) e" h$ Z& ]Both parents were again questioned about use of
, W0 h2 j0 m6 k" U: ]# Rany ointment/creams that they may have applied to
" Q1 J5 ]$ W( y% J3 Nthe child’s skin. This time the father admitted the6 n- c- C! }8 N3 M4 g
Topical Testosterone Exposure / Bhowmick et al 541; R0 u  y. A0 L! X
use of testosterone gel twice daily that he was apply-
) H" L5 b( R4 s% [ing over his own shoulders, chest, and back area for" b; w/ y1 D/ U+ G8 i7 M- R
a year. The father also revealed he was embarrassed% Y( t& h1 M5 w
to disclose that he was using a testosterone gel pre-
; V# b# Y4 ^# @6 |' z: A7 bscribed by his family physician for decreased libido
5 l* _) w8 |4 u6 Osecondary to depression./ }0 c" }" F' n
The child slept in the same bed with parents.9 M. r; }4 E. ^9 \# s
The father would hug the baby and hold him on his/ {$ _7 P/ e, b  s/ R8 N5 y
chest for a considerable period of time, causing sig-
. H1 K) G8 W& j8 w* B/ E0 Vnificant bare skin contact between baby and father.$ u$ E- n9 T/ h* T; \( y: z
The father also admitted that after the phone call,, ?* ]& X1 c6 P/ D0 ]
when he learned the testosterone level in the baby
7 g6 I7 l$ {: ^  x, s# Mwas high, he then read the product information
) m: ?( ?+ l1 C* bpacket and concluded that it was most likely the rea-; f. K" M( L/ c1 q& U: u
son for the child’s virilization. At that time, they
* r( s5 P3 I$ pdecided to put the baby in a separate bed, and the$ D2 g3 r8 S6 o' G4 H) D) X. W
father was not hugging him with bare skin and had
" E$ N: y% p/ A& cbeen using protective clothing. A repeat testosterone
7 D: N1 v2 n# r; r" z, @  htest was ordered, but the family did not go to the
5 V& e% A" {& e- [* z  e4 G% a$ claboratory to obtain the test.
/ F5 l' M- K+ H) B( b6 J9 |Discussion8 O! U7 x8 ?  ~: V' b2 M/ t1 y
Precocious puberty in boys is defined as secondary: h  R% N: o4 q( r+ X
sexual development before 9 years of age.1,49 J. ^% x' ?1 ?
Precocious puberty is termed as central (true) when& M, K9 g2 Q, _, l" q7 N
it is caused by the premature activation of hypo-
. {- W. ^3 {. gthalamic pituitary gonadal axis. CPP is more com-2 Q' i' j! U7 T
mon in girls than in boys.1,3 Most boys with CPP
+ d! G. L7 v! G  E  i" d; y5 S# umay have a central nervous system lesion that is
7 n; c) |( l5 k6 R- [responsible for the early activation of the hypothal-# |( k8 i- U% Z) V! F7 P, D
amic pituitary gonadal axis.1-3 Thus, greater empha-0 \3 p! O* r2 u$ K! n) g! O
sis has been given to neuroradiologic imaging in- L% K! C( c2 y
boys with precocious puberty. In addition to viril-
1 i4 N8 Z7 l, R) |ization, the clinical hallmark of CPP is the symmet-
3 C# k7 _8 f% R8 e, {' \- Zrical testicular growth secondary to stimulation by! I7 [! d* S/ X' b% q  m7 m1 U% `
gonadotropins.1,3
- z# y! a6 N1 g) XGonadotropin-independent peripheral preco-5 i, w# ^" d! v: _
cious puberty in boys also results from inappropriate
0 M% A9 U' s; x4 |. |& K4 B9 fandrogenic stimulation from either endogenous or: o. Z( U* ~# M! [2 q. S4 Y
exogenous sources, nonpituitary gonadotropin stim-/ m& R% q( |, |) [% e; D
ulation, and rare activating mutations.3 Virilizing
: F/ h, N* @& S4 `5 L$ M3 xcongenital adrenal hyperplasia producing excessive" L+ I% v+ m7 A: X2 k6 ^0 W
adrenal androgens is a common cause of precocious9 E. x' o3 ~  S1 j4 Q
puberty in boys.3,4
( o0 x9 R1 c1 g1 e4 x/ F! UThe most common form of congenital adrenal
1 k4 {2 r$ n* s. r7 e  Q6 nhyperplasia is the 21-hydroxylase enzyme deficiency.# [5 H8 U( ^+ W2 S4 w7 H6 r& o
The 11-β hydroxylase deficiency may also result in0 n1 |- a/ Y8 m9 U
excessive adrenal androgen production, and rarely,
4 d$ h! q3 }& G  `8 l& yan adrenal tumor may also cause adrenal androgen" v& O3 }# U( j* m* L( b
excess.1,3& A/ A  Z' P" g) {* M) ]2 n6 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  o- G. }, `( M& a* e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! H6 y8 n$ }2 }3 Y7 E: E' w
A unique entity of male-limited gonadotropin-
# m4 L5 W1 K( M* lindependent precocious puberty, which is also known
2 J  S5 I0 C0 L9 K9 M2 Has testotoxicosis, may cause precocious puberty at a( q1 }! Z+ S9 n* K5 ^4 N9 F/ p
very young age. The physical findings in these boys
# p  n- d: \6 K5 @1 M( `+ vwith this disorder are full pubertal development,2 |5 M4 b( U5 E8 {; `) g5 X
including bilateral testicular growth, similar to boys
0 j+ B6 I/ o3 Ywith CPP. The gonadotropin levels in this disorder
* M- C% e+ B6 q  ~are suppressed to prepubertal levels and do not show
/ L/ j0 p4 v6 j$ G( Vpubertal response of gonadotropin after gonadotropin-1 b; `/ u9 \$ S3 r1 V+ I
releasing hormone stimulation. This is a sex-linked+ @; [- y4 O& Y6 A  F" a2 S
autosomal dominant disorder that affects only
' I0 \* g# M, D! E# Fmales; therefore, other male members of the family0 H6 |: R! v/ _" Y: f* v7 f
may have similar precocious puberty.30 r: ]; A+ B$ }8 \
In our patient, physical examination was incon-! ?$ L" Q& [3 W( }' o
sistent with true precocious puberty since his testi-4 ^& z, E. E4 R% F& u/ E, e# P3 b  N
cles were prepubertal in size. However, testotoxicosis
) l+ j& f+ i4 F1 P: M2 Twas in the differential diagnosis because his father. O# M9 A$ [( }$ g$ U
started puberty somewhat early, and occasionally,! B, W; Y/ G4 R3 {) k
testicular enlargement is not that evident in the  Q5 I% u. C% F+ o! L; O9 r! E
beginning of this process.1 In the absence of a neg-* U2 N! `5 ?; t% n& j& O# z
ative initial history of androgen exposure, our7 [( M; E+ W4 i/ D6 m7 j% }
biggest concern was virilizing adrenal hyperplasia,
( b8 X- z; E# X$ Z) ], T  zeither 21-hydroxylase deficiency or 11-β hydroxylase
$ q' R: k- s! c/ H/ E! \deficiency. Those diagnoses were excluded by find-
- P" E8 @; G% I# U6 e, l' w# Iing the normal level of adrenal steroids.* ^# K, Y( d2 W% ]& _; I2 k
The diagnosis of exogenous androgens was strongly4 x4 X3 G" X3 R2 Q! a4 s: L
suspected in a follow-up visit after 4 months because& q' d: D+ {( ]1 l* Q5 K. v/ I# v
the physical examination revealed the complete disap-
! h; @3 R. C4 _2 ?pearance of pubic hair, normal growth velocity, and
1 g% R6 H- ^  r, U/ L# |  Y/ @  Sdecreased erections. The father admitted using a testos-
& `; |1 D' \5 k9 n# U% q. ^terone gel, which he concealed at first visit. He was
! C' n1 H! k8 y! o3 Ousing it rather frequently, twice a day. The Physicians’
+ e8 Y& o  Z0 LDesk Reference, or package insert of this product, gel or
& o: M* n6 q+ G: l8 ]) Zcream, cautions about dermal testosterone transfer to
& A$ L/ d  f: N( Hunprotected females through direct skin exposure.2 d/ o* ~/ _9 {0 o
Serum testosterone level was found to be 2 times the
' ~6 G0 a  U% |baseline value in those females who were exposed to
, _  B/ ?. s5 q& A* g5 seven 15 minutes of direct skin contact with their male+ J' i$ y/ @3 p2 y" E5 ]
partners.6 However, when a shirt covered the applica-& {" W+ B: s5 r
tion site, this testosterone transfer was prevented.
' q) m0 I! x+ A# oOur patient’s testosterone level was 60 ng/mL,$ X6 x9 l$ i: J& P! F: o/ [
which was clearly high. Some studies suggest that
, z/ e; q/ l; |& ddermal conversion of testosterone to dihydrotestos-
' w) S1 G7 B1 P, D5 Hterone, which is a more potent metabolite, is more, d" D" K/ V: I: J2 J, a  V8 r! }$ w
active in young children exposed to testosterone1 E  h* W4 D' d- S. X6 W; d
exogenously7; however, we did not measure a dihy-# R( f% a( D$ i0 ?
drotestosterone level in our patient. In addition to
; f8 ?! k) s8 j9 i! Evirilization, exposure to exogenous testosterone in
- ]* e' _3 J! M$ Q  m4 K2 \children results in an increase in growth velocity and
9 ^  ~, K) _/ }- _6 _, V, h4 |advanced bone age, as seen in our patient.( g# B& `7 o6 @( u
The long-term effect of androgen exposure during
2 h- ^  {* M: O' l* m& \. |early childhood on pubertal development and final: C: f  u( r/ g4 Q  h0 K$ o
adult height are not fully known and always remain( Q4 M; m3 t: C" U) j
a concern. Children treated with short-term testos-2 l& E- C" ]( ^+ D* l
terone injection or topical androgen may exhibit some  c& Y/ U% Y$ ~4 E: N( [  j0 S. C1 R
acceleration of the skeletal maturation; however, after
6 s2 ?; c6 v' B5 ^) Acessation of treatment, the rate of bone maturation
1 ^5 }0 B) h( ?decelerates and gradually returns to normal.8,9
, g" p- p4 ~+ C4 a! L" TThere are conflicting reports and controversy
0 m) V& f) g" V! Gover the effect of early androgen exposure on adult8 a3 A0 ^, x, t9 O! B" j) w0 v/ g, K
penile length.10,11 Some reports suggest subnormal
! N, l3 }9 }/ ladult penile length, apparently because of downreg-
% Q' @' S/ d! g  R) Kulation of androgen receptor number.10,12 However,& [8 B. G3 P" s+ o: b
Sutherland et al13 did not find a correlation between8 O  v  m* r, H' M3 B
childhood testosterone exposure and reduced adult, y# Y1 ~' s& R  [
penile length in clinical studies.3 M  r% D- x: X3 U" p3 [/ n0 P' ]* ]
Nonetheless, we do not believe our patient is0 l7 X1 n! c2 G
going to experience any of the untoward effects from6 ~( T1 n9 p6 g8 g; V
testosterone exposure as mentioned earlier because& ^" R) N# i8 t" H+ b$ i
the exposure was not for a prolonged period of time.
; g& h- f) l4 e# k' MAlthough the bone age was advanced at the time of
, m: p* e' }& A( D* t: idiagnosis, the child had a normal growth velocity at
/ N! C3 D5 G9 E" Tthe follow-up visit. It is hoped that his final adult
8 ~. C2 \' w) ^) K5 O0 Z3 F1 `height will not be affected.9 p9 u* N& |+ N! ?! {2 l
Although rarely reported, the widespread avail-) I) g4 J8 ?% j7 R7 ~
ability of androgen products in our society may) u: ~$ {3 P8 p! [
indeed cause more virilization in male or female. }" S. ^1 \/ N( h% C" z
children than one would realize. Exposure to andro-: h4 x1 }# L6 f- q
gen products must be considered and specific ques-
' W! F( B7 A1 M' P8 Qtioning about the use of a testosterone product or
1 i9 @4 ?8 p  f" Jgel should be asked of the family members during4 Q! G$ [- M6 R) [+ X  n/ \
the evaluation of any children who present with vir-
; C) R" x# `- p( j8 I. P( Silization or peripheral precocious puberty. The diag-4 o/ w+ g) ?, I  q2 d* m
nosis can be established by just a few tests and by% B: w' H4 D6 b1 h: w+ ]5 r7 [
appropriate history. The inability to obtain such a
3 I0 A7 t# `2 v3 o) }history, or failure to ask the specific questions, may* |$ `( b4 G5 ^# S9 w7 l
result in extensive, unnecessary, and expensive- {# ?4 x! b. h2 @) v5 W
investigation. The primary care physician should be
) A' d& F$ @0 S4 _' Zaware of this fact, because most of these children
7 u  \: T4 I3 o; j' @6 umay initially present in their practice. The Physicians’& \3 u- U- o% b! p9 F) j" Z
Desk Reference and package insert should also put a1 [6 [' Z' C0 Z& G+ v5 v/ I
warning about the virilizing effect on a male or
* k+ S/ H- ]8 q, j3 d4 dfemale child who might come in contact with some-9 a4 D: H. ]( I0 T
one using any of these products.
+ H2 q. j& `+ {2 hReferences
( s( b/ r: T- s% V% M1. Styne DM. The testes: disorder of sexual differentiation
; v4 E7 }4 ]2 b5 m# Q0 c3 Band puberty in the male. In: Sperling MA, ed. Pediatric
7 z9 N0 u0 w7 |3 k0 ]4 @$ uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 @4 D$ Z$ d0 r6 _
2002: 565-628.. f+ Q. |, [3 D1 R8 \( e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- S/ Q! z* \& d% ]3 W0 l! R# d
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old# v, D: U, D9 Y9 [
Boy Induced by Indirect Topical
: t* O3 u2 I9 J' j! f) C3 ]) TExposure to Testosterone# b7 O  j: Y- r+ i$ F# S( V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 F0 A7 g1 K# V( V  E
and Kenneth R. Rettig, MD1
; X8 V5 j' T4 mClinical Pediatrics& O# {7 y* ]; U! y( ^/ r3 t+ Z
Volume 46 Number 6
* F% E4 s4 j/ E$ k: \/ |July 2007 540-543$ U$ f& u8 i% n& k# n. i  A+ P
© 2007 Sage Publications/ H3 [3 \3 ^9 v, @4 n
10.1177/0009922806296651( ~9 c+ L$ \2 g9 i4 ]$ q+ X
http://clp.sagepub.com. ]0 `: A/ Z) C$ j& x5 l; k
hosted at
/ A/ k& c6 T7 T. C% [, mhttp://online.sagepub.com
! l9 G7 W4 y; J# S* }: JPrecocious puberty in boys, central or peripheral,, n, r  q" o5 K, M( [
is a significant concern for physicians. Central4 n  n4 v% {, P
precocious puberty (CPP), which is mediated- ?) O+ w2 ~) ]- e
through the hypothalamic pituitary gonadal axis, has, r8 X( l' j; u- m  l
a higher incidence of organic central nervous system
1 x, U" u0 U5 U; Z4 q8 hlesions in boys.1,2 Virilization in boys, as manifested, e& F! }+ }& w" a$ @& P/ _
by enlargement of the penis, development of pubic  {3 a% M% t) `& o- A, E( a  ?" k! C
hair, and facial acne without enlargement of testi-
3 w0 [2 S5 T3 ?, }8 i6 b: Dcles, suggests peripheral or pseudopuberty.1-3 We
! J5 J  g5 a6 R0 I" w+ Ereport a 16-month-old boy who presented with the& u1 b% K; v/ s6 I& g
enlargement of the phallus and pubic hair develop-+ a1 K; R# u+ A
ment without testicular enlargement, which was due
6 o8 d- \: n4 `" a3 P2 I3 B: R. ?to the unintentional exposure to androgen gel used by0 @# `# ^+ U3 ?5 z" o
the father. The family initially concealed this infor-
. `! M* P  D6 B/ m$ a* J( f6 v1 dmation, resulting in an extensive work-up for this
2 F- M6 J' Y. I& achild. Given the widespread and easy availability of! X0 T& G; i: x5 K& D1 K
testosterone gel and cream, we believe this is proba-
1 ~# k' m8 j, ^3 _: `bly more common than the rare case report in the
5 h; N. x4 r! I; i/ yliterature.4* a8 F6 h/ a6 ^1 J1 t: k
Patient Report/ E& k0 g5 {  }; u! g0 O
A 16-month-old white child was referred to the: |/ C( n1 \; t  w* N
endocrine clinic by his pediatrician with the concern6 z4 O( @  F, {; x9 [. {
of early sexual development. His mother noticed
6 h2 x% }) p6 i# ~* Clight colored pubic hair development when he was
; }; ^# G3 u, YFrom the 1Division of Pediatric Endocrinology, 2University of- W/ D$ g6 D6 R% _2 X0 L# a* R
South Alabama Medical Center, Mobile, Alabama.! Q) j' r; f( w9 j+ n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% I# ?: P5 \! MProfessor of Pediatrics, University of South Alabama, College of
. ]( K4 x+ ~9 t* r4 `Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 o/ S/ b. U; B& _1 Ve-mail: [email protected].; g  I3 X1 I6 r% B1 L$ |- _
about 6 to 7 months old, which progressively became% s4 \( W, o+ G! O0 r( y& S
darker. She was also concerned about the enlarge-
. j# M- H0 S7 i. G. @ment of his penis and frequent erections. The child- j$ ~  r; T2 }" B' V" @
was the product of a full-term normal delivery, with8 |& s/ R6 `3 w4 Q& f6 H
a birth weight of 7 lb 14 oz, and birth length of% D2 w" B9 l- K4 K: ?# r
20 inches. He was breast-fed throughout the first year8 w# {. O1 a, `) y
of life and was still receiving breast milk along with7 {% R8 O2 h" m8 j/ S) x# j
solid food. He had no hospitalizations or surgery,
( ]. Z$ A# y3 K. c: s$ ?  Fand his psychosocial and psychomotor development
7 f  p, n; D4 i' W* T6 L+ Twas age appropriate.7 ^: T: A3 u) s$ U
The family history was remarkable for the father,; S- D- I( t5 t4 x
who was diagnosed with hypothyroidism at age 16,
/ Q* m0 {1 W$ Nwhich was treated with thyroxine. The father’s
# A  G1 E8 O$ r9 }height was 6 feet, and he went through a somewhat" D7 \6 Y  ]+ Y1 x3 R0 U
early puberty and had stopped growing by age 14.& c7 w; ~; Y1 V+ p
The father denied taking any other medication. The7 F  y& J$ l) _! u
child’s mother was in good health. Her menarche
$ O, n: c$ i: F( q% h3 k+ A4 jwas at 11 years of age, and her height was at 5 feet
$ H) [0 O; X1 P2 y7 y7 e) c) @5 inches. There was no other family history of pre-7 n/ b5 Q6 F  A3 X$ J8 {$ s
cocious sexual development in the first-degree rela-/ e# s1 Y9 A; C4 j( I# J2 ?
tives. There were no siblings.
; t6 v. x! J6 y, ~& l+ XPhysical Examination& N. `5 ?4 o' I: l
The physical examination revealed a very active,
9 _  i: k- {' ]; @; i1 hplayful, and healthy boy. The vital signs documented$ y& g4 h; [7 W+ h, Z
a blood pressure of 85/50 mm Hg, his length was" w$ c1 R. }5 ?$ e0 j) o+ @: x
90 cm (>97th percentile), and his weight was 14.4 kg
0 }: W4 q8 M2 @" Y! u# [  o9 B(also >97th percentile). The observed yearly growth
7 f' E4 ?5 w" K; Fvelocity was 30 cm (12 inches). The examination of! g- i0 d  u7 Z
the neck revealed no thyroid enlargement.8 t. H; l: F8 i/ F3 c
The genitourinary examination was remarkable for
4 Q! d6 N0 G; t' c3 _; `. N: Genlargement of the penis, with a stretched length of$ E3 }& S  K' e2 t/ h2 `5 A
8 cm and a width of 2 cm. The glans penis was very well
$ V6 B( o, ]  j6 Q  sdeveloped. The pubic hair was Tanner II, mostly around! \5 F1 \- \( @0 z
540
" r3 P' f+ Z6 m. ]. p2 l9 lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 Q3 w& P9 M- I+ n  T
the base of the phallus and was dark and curled. The8 q( J* f: J  W6 h8 {5 T# O
testicular volume was prepubertal at 2 mL each.' `+ q8 s' y: e6 M5 p) l, H8 C
The skin was moist and smooth and somewhat
. g) A' I% c4 Loily. No axillary hair was noted. There were no
3 W* Q* B1 s0 ?% p" F! G4 Tabnormal skin pigmentations or café-au-lait spots.
% K# K6 L' ~$ Q4 K3 G4 p& j# U3 }Neurologic evaluation showed deep tendon reflex 2+
0 v+ z% e$ B* j! ]: Tbilateral and symmetrical. There was no suggestion- Q8 q8 W4 x& t) C! R: h% V
of papilledema.4 V2 x6 {" C+ y9 h: E: q
Laboratory Evaluation
. ^; |2 O6 e" C* m3 l9 ~, U& IThe bone age was consistent with 28 months by+ J( O2 i$ A1 v8 O& g2 s" ?
using the standard of Greulich and Pyle at a chrono-
: p# h: C0 n, F) x! D! |! N- mlogic age of 16 months (advanced).5 Chromosomal2 X+ ]! D, w0 b( k, j1 t+ J
karyotype was 46XY. The thyroid function test8 [. Q8 T8 q3 Q5 a$ B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 W- G6 n: p: i8 v6 h
lating hormone level was 1.3 µIU/mL (both normal).* u( U$ D% [! g) g
The concentrations of serum electrolytes, blood
$ A" F# T7 j' Q  J4 o6 surea nitrogen, creatinine, and calcium all were5 X) U0 M/ @! d; u( t
within normal range for his age. The concentration
- B8 V4 ]0 m4 o$ C' q2 P0 aof serum 17-hydroxyprogesterone was 16 ng/dL0 X1 ]9 \' q, R9 c" \/ _* ^
(normal, 3 to 90 ng/dL), androstenedione was 20
6 @9 \9 }! c9 y! cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* ?. n" l, J( R4 Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 p) o2 t7 m- \) s* Q" N" f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 o  k; C& X4 ^, B) j49ng/dL), 11-desoxycortisol (specific compound S)
5 n; \* W# g6 {9 ^7 P; bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 G+ o& |! h5 l" {' Ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) z2 s8 G+ m7 q8 N# C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 p; U! p: Z" e/ D4 M) [
and β-human chorionic gonadotropin was less than
4 f* K" r6 z+ ~: X& _5 X0 o5 n5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 t% `' A# N) |& Gstimulating hormone and leuteinizing hormone* u- L# I  r9 `( ^, V
concentrations were less than 0.05 mIU/mL* x# S0 `& |2 I- H; `% f% G! W  j
(prepubertal).- U1 h* R  D# l0 e* U. D( O; g
The parents were notified about the laboratory: z9 w. w" \& i* Z
results and were informed that all of the tests were0 U+ z6 E7 w. c; z: K' `! E
normal except the testosterone level was high. The5 P0 W' d$ p, K
follow-up visit was arranged within a few weeks to
+ B, b% h5 E- ~3 r& [4 s0 f" t! Oobtain testicular and abdominal sonograms; how-# Y6 a/ ~- l) X3 K% P0 l
ever, the family did not return for 4 months.
4 m, R5 @+ C& i, k+ ~, t# t, CPhysical examination at this time revealed that the+ O" j2 ?2 D( x& P
child had grown 2.5 cm in 4 months and had gained/ M( C  \; q4 S: [& v
2 kg of weight. Physical examination remained
$ r2 H; b* Y  punchanged. Surprisingly, the pubic hair almost com-
& x$ g2 I2 C) B) Ypletely disappeared except for a few vellous hairs at7 P# ~: T1 |2 U# I) {
the base of the phallus. Testicular volume was still 2
2 C/ u8 r0 T; R% x# l! `mL, and the size of the penis remained unchanged.0 r" m# h) v* Z* q
The mother also said that the boy was no longer hav-0 x7 ^: E" f" B9 _- x
ing frequent erections.
2 _$ J1 {2 t# n( zBoth parents were again questioned about use of: a( F, b, o; m) z2 A5 d- [* h
any ointment/creams that they may have applied to- p  e* j" H8 k: v0 t0 m3 O
the child’s skin. This time the father admitted the
( m# z4 N+ Q% A$ N  `) eTopical Testosterone Exposure / Bhowmick et al 541
0 j, ]$ {2 d7 l' G) @8 Yuse of testosterone gel twice daily that he was apply-" n0 m# r: l" q" {$ S1 v
ing over his own shoulders, chest, and back area for+ |; E: [$ I, I3 G" o8 \" W1 T9 w) p( \
a year. The father also revealed he was embarrassed4 b+ z& Q& H7 f: Y
to disclose that he was using a testosterone gel pre-
# R- T3 W( R! K& P4 o4 c! `3 Yscribed by his family physician for decreased libido0 I) y" X. P  X
secondary to depression.. |4 L- k2 ~( ?+ c, i7 X0 |
The child slept in the same bed with parents.3 B1 _* p1 E* B4 ^8 q
The father would hug the baby and hold him on his
: `8 W( }; z2 f7 ?7 dchest for a considerable period of time, causing sig-
& {% x. U+ o" u+ F5 d$ Y. h- anificant bare skin contact between baby and father.. J$ A9 N; F" l* w# G/ x
The father also admitted that after the phone call,
% x1 x2 d* E* g3 g( N/ |( x9 n+ twhen he learned the testosterone level in the baby8 r! S) K+ h. [. y0 c9 q
was high, he then read the product information# R# u  I4 t( V  ?& u6 ^) T: O
packet and concluded that it was most likely the rea-# f: c$ W4 K4 k9 |9 a
son for the child’s virilization. At that time, they
/ y7 W& E# s( |  Z5 Y" H, Kdecided to put the baby in a separate bed, and the/ C3 t+ {5 k7 W( U8 Q
father was not hugging him with bare skin and had  }+ }" V$ p$ @" T: {: f
been using protective clothing. A repeat testosterone
" @, G2 k  d' a( m3 G/ Etest was ordered, but the family did not go to the
4 [1 Z' h8 n( t0 llaboratory to obtain the test.
# q1 o) E- H7 E- B4 QDiscussion" d, R- h/ J6 v/ C
Precocious puberty in boys is defined as secondary4 S- R. X% N/ ~
sexual development before 9 years of age.1,4
  C4 Q2 n; ?( G2 b' l. i2 r. S6 qPrecocious puberty is termed as central (true) when7 }. I3 Y. {! j- s5 y
it is caused by the premature activation of hypo-0 A& p+ a0 f+ [+ K: K, g
thalamic pituitary gonadal axis. CPP is more com-7 f+ q6 m1 c6 ~2 y
mon in girls than in boys.1,3 Most boys with CPP; g1 X, P, D. U3 X
may have a central nervous system lesion that is
% h  e3 m$ l/ x; `responsible for the early activation of the hypothal-
7 ?+ ~  O" Y% H( }amic pituitary gonadal axis.1-3 Thus, greater empha-
8 E/ R- ~# k; k5 T5 O, Z# Z% A$ [sis has been given to neuroradiologic imaging in
2 b" e# Q3 C: u; Xboys with precocious puberty. In addition to viril-
. U: T- S4 i  L& r0 z2 W6 \ization, the clinical hallmark of CPP is the symmet-
; H* Z0 R5 ~% {rical testicular growth secondary to stimulation by* m4 E' l6 t" S$ M8 ?
gonadotropins.1,3/ |! m- P3 F3 ^* B% g
Gonadotropin-independent peripheral preco-
- U+ F' q1 D+ g7 N$ O: W5 D8 f" pcious puberty in boys also results from inappropriate
* {: d6 I: _+ J8 Landrogenic stimulation from either endogenous or
1 r4 O! h6 M7 O9 ]- x/ sexogenous sources, nonpituitary gonadotropin stim-" ]7 s, t8 H8 ?  u
ulation, and rare activating mutations.3 Virilizing
% t& D  ~  H; |; F$ |% I8 ~8 T4 }+ bcongenital adrenal hyperplasia producing excessive4 E; _4 Y7 B$ M" q4 O9 o: A$ ]) S
adrenal androgens is a common cause of precocious6 K2 u  r  d3 E% ?7 \
puberty in boys.3,4: ]8 o. a  e3 n; Q& v  `$ C1 N+ D
The most common form of congenital adrenal
+ B0 E4 M2 s* [2 Y  V( n4 [hyperplasia is the 21-hydroxylase enzyme deficiency.
, [, y5 v0 n6 m' |* [The 11-β hydroxylase deficiency may also result in9 I! }# Z% }; T1 f
excessive adrenal androgen production, and rarely,) M2 n  j; l4 F1 Z7 E
an adrenal tumor may also cause adrenal androgen
# z  l. g0 ?+ z! b% z( Rexcess.1,33 K/ b4 L3 ~, n' R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 u+ G& C1 z2 o6 J5 A% m542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 Z5 p2 M- L! f4 |- z; k
A unique entity of male-limited gonadotropin-
3 K( [; Z! F) e! x/ t0 A0 Yindependent precocious puberty, which is also known
: u6 ~5 r( `3 Las testotoxicosis, may cause precocious puberty at a8 B7 Q& d7 j# e9 ?
very young age. The physical findings in these boys
5 F: M6 J$ R! m0 dwith this disorder are full pubertal development,2 Z! l" o" l. u' O  ~1 W
including bilateral testicular growth, similar to boys* R( b. E2 O& P5 A# C2 t3 w0 X- P
with CPP. The gonadotropin levels in this disorder1 X7 V5 A! [7 y" `+ B
are suppressed to prepubertal levels and do not show7 y' U' }- ]$ p& D1 i
pubertal response of gonadotropin after gonadotropin-% t( v4 u. d, S/ X3 ^
releasing hormone stimulation. This is a sex-linked3 M  k: W9 Y  b. V* r  a
autosomal dominant disorder that affects only
) s+ J8 U6 N7 n, vmales; therefore, other male members of the family
( N3 H: B' [$ B. Jmay have similar precocious puberty.38 k9 `' T; w/ g- o8 I( q2 j) R
In our patient, physical examination was incon-
# B$ ]7 p* L. H/ ]% y: hsistent with true precocious puberty since his testi-. Z7 r( s" V, F
cles were prepubertal in size. However, testotoxicosis
- V( \/ ~. g0 P$ R" fwas in the differential diagnosis because his father
5 V4 Y: |. v7 xstarted puberty somewhat early, and occasionally,- W2 V% C( m5 u' a6 |: l9 a& Y; d
testicular enlargement is not that evident in the
4 a. E  i6 A! j4 Z' \beginning of this process.1 In the absence of a neg-
1 X7 |  H4 I$ q8 fative initial history of androgen exposure, our0 s7 x& ^, ]6 Z1 ]) E- |
biggest concern was virilizing adrenal hyperplasia," x/ @  K5 W' H: H1 _" _
either 21-hydroxylase deficiency or 11-β hydroxylase
1 a/ ~- x9 Z2 Q3 kdeficiency. Those diagnoses were excluded by find-1 z9 E# x9 M' b$ G
ing the normal level of adrenal steroids.
( ~7 K( m- H  H/ q/ kThe diagnosis of exogenous androgens was strongly' ]. q  H" Y9 t$ I0 V/ c
suspected in a follow-up visit after 4 months because
% |' A; h4 F; u5 n+ V: Fthe physical examination revealed the complete disap-
; t$ c; W* C  bpearance of pubic hair, normal growth velocity, and
2 N+ h% ]4 T( ^: W- pdecreased erections. The father admitted using a testos-& \9 c6 k  l& j" i2 k8 Q
terone gel, which he concealed at first visit. He was
4 {  o) Q3 _" M$ f& [  @& Z  iusing it rather frequently, twice a day. The Physicians’
  y( V. r# S% J% \5 `4 wDesk Reference, or package insert of this product, gel or
. ?/ x) R9 |  g; D( c# p( ncream, cautions about dermal testosterone transfer to! [9 n# d" s$ ~* `3 `8 a# x
unprotected females through direct skin exposure.* w2 i% @* X- }  k
Serum testosterone level was found to be 2 times the+ h9 B" V: o8 X) K2 d/ r
baseline value in those females who were exposed to. A0 N' F' O! ]" k
even 15 minutes of direct skin contact with their male) [. O2 M# _  ?" t9 Q% F2 k& k
partners.6 However, when a shirt covered the applica-
; ]1 m, o* q' x% J6 ation site, this testosterone transfer was prevented.
1 ~! y7 x4 D8 R! a% y+ `; yOur patient’s testosterone level was 60 ng/mL,
) h; Y/ G3 U$ p8 C  x8 a3 Iwhich was clearly high. Some studies suggest that& Q3 _. \4 b. U- n! X
dermal conversion of testosterone to dihydrotestos-% I4 a- ]0 J% B5 Y2 @
terone, which is a more potent metabolite, is more
) C: X" R- \; s& s! dactive in young children exposed to testosterone7 h" v/ K  S5 w; C3 D+ n
exogenously7; however, we did not measure a dihy-
1 e1 J9 f' o2 _8 o6 ]drotestosterone level in our patient. In addition to, v0 j  i  C' N0 j
virilization, exposure to exogenous testosterone in
- E" c' R, ^- n* W) A8 |children results in an increase in growth velocity and9 U2 u% e2 c. m% s; K( S
advanced bone age, as seen in our patient.( `$ H' Q/ U5 V9 O6 V6 }+ M! z
The long-term effect of androgen exposure during" g$ S  _+ E: C% N9 {6 o& H
early childhood on pubertal development and final
: b1 a% g3 a* Oadult height are not fully known and always remain5 k) a( d, t7 w$ b
a concern. Children treated with short-term testos-. D* Q% j# d0 l# i- @+ W' V. \1 n
terone injection or topical androgen may exhibit some
( x9 C( g8 X# M( r( Gacceleration of the skeletal maturation; however, after5 `' h+ Y7 |* r
cessation of treatment, the rate of bone maturation/ F% U! Y. g6 W) s  ^
decelerates and gradually returns to normal.8,9# G6 Z6 b' j* q& S
There are conflicting reports and controversy. A7 V! B" Y7 x( }1 J
over the effect of early androgen exposure on adult: I' a8 V" W( I! L  E
penile length.10,11 Some reports suggest subnormal
( |$ B, s7 |8 C4 b1 badult penile length, apparently because of downreg-( Y( s; L0 d0 e( ?( j$ Q
ulation of androgen receptor number.10,12 However,
+ b& Y$ w6 \  T* t+ J7 p4 ]  ^& G% C# sSutherland et al13 did not find a correlation between
7 b( B# P" f2 C! ~# c0 [8 jchildhood testosterone exposure and reduced adult
+ @3 L0 v% t" h& y* C* spenile length in clinical studies.6 T$ ^0 ?: k5 D) a/ V* W5 i5 k5 U
Nonetheless, we do not believe our patient is
- B, o5 |  s! M  _, \going to experience any of the untoward effects from
& o* w- |( L, \/ u/ O: Gtestosterone exposure as mentioned earlier because
! x# C2 W% N  t4 _/ h6 j- @1 C7 Dthe exposure was not for a prolonged period of time.
, j/ \! x$ P/ T: ?/ C# e& CAlthough the bone age was advanced at the time of
* x3 U$ W8 _: R: C6 z% Gdiagnosis, the child had a normal growth velocity at
4 Z) e' Q0 p9 i4 s4 Z) I' s( t7 gthe follow-up visit. It is hoped that his final adult
6 H0 M- ]3 J& C, a# A" Eheight will not be affected., T; R0 l8 Q, J# m8 a: F
Although rarely reported, the widespread avail-
4 T, D2 v" J6 O( r& v7 aability of androgen products in our society may7 Z& }  U' Z9 m: B( g/ \, {9 U' A
indeed cause more virilization in male or female9 X6 a  |1 r0 D/ W% ~6 x
children than one would realize. Exposure to andro-) N' a4 M: C4 ~; l( p
gen products must be considered and specific ques-- X( r$ T$ r* }) s9 S
tioning about the use of a testosterone product or
' O6 d, {. d0 ?/ P$ R( D/ |gel should be asked of the family members during" o' u2 H/ T' N5 Q& y3 p
the evaluation of any children who present with vir-- r- s3 I+ G# l% W: U; q/ S7 M: f
ilization or peripheral precocious puberty. The diag-8 f- K7 P$ n3 G- z  f+ ]$ r! n
nosis can be established by just a few tests and by8 T1 I7 m0 ~- ?" Q) g0 |0 m( o
appropriate history. The inability to obtain such a  Z/ l1 W' z# q; B" f$ B* r. @
history, or failure to ask the specific questions, may
  k: k* g: J6 k% D% @/ Bresult in extensive, unnecessary, and expensive
7 C1 S; b( W  ?9 q, m$ U4 n: b5 F" D( ~investigation. The primary care physician should be
! M1 K7 a$ S2 D4 s' laware of this fact, because most of these children1 n' G  H# B2 b3 K* l
may initially present in their practice. The Physicians’
( V; {0 h( {1 n) ZDesk Reference and package insert should also put a8 x9 p4 O$ c8 M0 V+ ^# n
warning about the virilizing effect on a male or  @7 O- s; G! r5 r7 R, u- q! f' M
female child who might come in contact with some-
) I5 n5 l: c+ f" o8 eone using any of these products.) V" i& j5 t) R
References" {  B$ x) N4 h
1. Styne DM. The testes: disorder of sexual differentiation; Z+ j  W- T  X& O: R) P
and puberty in the male. In: Sperling MA, ed. Pediatric7 B4 Q5 I3 a! @$ R& j
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 U$ l. S4 T2 O2002: 565-628.
+ L. D; b9 Q1 ?, }% P( q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. k1 O6 |! P) J5 c, b& u& o1 Xpuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

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發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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