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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
. b8 x7 K) Y  x  kBoy Induced by Indirect Topical
8 j2 \; E1 ?: B8 a* A0 a2 @& uExposure to Testosterone  P4 e0 h# B9 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ f) O5 |+ R( W( ]* ^: Land Kenneth R. Rettig, MD1" F9 d( c/ R  ^! ^2 j9 z+ j
Clinical Pediatrics: d3 X" {) |- j% E3 Z
Volume 46 Number 68 N! p" s& q- s: h2 C
July 2007 540-543
  V9 T4 ?3 `% L© 2007 Sage Publications/ ]! ^6 v' E6 |* h. W
10.1177/0009922806296651
6 X# ]0 U& L3 z* M( Bhttp://clp.sagepub.com
; B6 s! ?0 U% G- s4 Ehosted at
. }. {! J6 {! fhttp://online.sagepub.com& l6 z. [, A8 a' o% K. l$ M
Precocious puberty in boys, central or peripheral,
5 _: f0 e. A  t# u; Iis a significant concern for physicians. Central
- c& I* F& @3 b, w( ^0 N; gprecocious puberty (CPP), which is mediated3 e" Q0 b9 J& h/ X
through the hypothalamic pituitary gonadal axis, has* D# t- ]  j8 u" `; E* A- r$ X
a higher incidence of organic central nervous system
- y( k! X) X: _, v8 p# Hlesions in boys.1,2 Virilization in boys, as manifested# q3 S* g5 O" C; \
by enlargement of the penis, development of pubic2 v* E( Z! s; H: }
hair, and facial acne without enlargement of testi-. ]. J2 _' d2 C* ]* s* W( ^
cles, suggests peripheral or pseudopuberty.1-3 We
; L7 h( N& [. ~$ }report a 16-month-old boy who presented with the
$ a+ `  C' z6 Tenlargement of the phallus and pubic hair develop-3 Q$ f. Y. Z. u! g2 x
ment without testicular enlargement, which was due
3 x1 a! a" ^  k" xto the unintentional exposure to androgen gel used by, N4 x5 d5 L6 L9 c0 R
the father. The family initially concealed this infor-
8 z8 w6 {0 j1 c5 O+ d; F, |2 Zmation, resulting in an extensive work-up for this
7 w% ^$ r1 l4 v( U9 V0 x; Cchild. Given the widespread and easy availability of3 P. D% M8 X; @
testosterone gel and cream, we believe this is proba-
7 e. B* B/ T3 q$ C$ G  R7 G) kbly more common than the rare case report in the8 T' _: P0 y! l2 m
literature.44 V) Q4 G& \+ l9 ^
Patient Report$ T5 [7 j* R$ a0 X8 f( y
A 16-month-old white child was referred to the' ?3 R6 v# q7 b, O$ \
endocrine clinic by his pediatrician with the concern) X& j" T  b, h) r; r* A
of early sexual development. His mother noticed' E7 W% \2 `2 D
light colored pubic hair development when he was
- b8 l5 F3 G3 n0 M2 ?, O$ ~From the 1Division of Pediatric Endocrinology, 2University of
+ b; q0 I2 g) K# k0 n( oSouth Alabama Medical Center, Mobile, Alabama.4 L5 T. W" R3 i( t& B
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! X0 w. t( x  _! K( pProfessor of Pediatrics, University of South Alabama, College of2 e' ~5 x! h$ I0 Y7 U5 l- V2 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 L( f, ~" Q) B
e-mail: [email protected].
# t4 r/ t" j- ]- d# Nabout 6 to 7 months old, which progressively became+ B: P, J# ?$ N$ x; l* E
darker. She was also concerned about the enlarge-
5 s: _& M, [1 u/ \0 cment of his penis and frequent erections. The child( J; h& z' E" f$ |' Z2 m) Z
was the product of a full-term normal delivery, with
& m( h4 i- L" @9 V) T5 X1 W: s/ ea birth weight of 7 lb 14 oz, and birth length of
" [( h+ T! q5 h, R( @. G5 Y20 inches. He was breast-fed throughout the first year
* R: e6 i- N6 t+ zof life and was still receiving breast milk along with  B; Q, i5 S7 V+ j2 {: F! C- H/ o
solid food. He had no hospitalizations or surgery,
* [/ X& A( ^; J* {8 h; C+ x9 Rand his psychosocial and psychomotor development0 j. B- Q2 r* X) t
was age appropriate.* q2 [! [' D1 ?9 M0 A1 k! m8 D/ J2 ?. e
The family history was remarkable for the father,2 ^! ?$ F. \; U5 `2 p, F- f
who was diagnosed with hypothyroidism at age 16,: l# u- d' G  t( s  x
which was treated with thyroxine. The father’s" x5 N) o- h- v# d2 u# h- h: l
height was 6 feet, and he went through a somewhat
, d/ d: E+ V. X5 searly puberty and had stopped growing by age 14.
3 d) y/ D6 U3 [, Y0 v) }: bThe father denied taking any other medication. The# D3 y; m8 J1 s
child’s mother was in good health. Her menarche
9 a; k, P  u: F# k4 C# |was at 11 years of age, and her height was at 5 feet9 j9 a' P  L4 _# ^4 F3 F" D
5 inches. There was no other family history of pre-
) e# R+ I1 E  |( Jcocious sexual development in the first-degree rela-: `# C& B$ D* \1 Y; ^
tives. There were no siblings.
. n" j( a9 ^/ o' V+ H! _+ vPhysical Examination. Y$ k8 i2 L. g
The physical examination revealed a very active,8 y3 q8 j# ^) \* G' {
playful, and healthy boy. The vital signs documented
: v& A7 s% v+ R8 ~5 C+ Ua blood pressure of 85/50 mm Hg, his length was
4 U6 O& \) C, X6 z/ A90 cm (>97th percentile), and his weight was 14.4 kg9 C6 b0 t! s2 G: ]6 Z7 I. t
(also >97th percentile). The observed yearly growth
, I+ `' ~; M& F7 I) Dvelocity was 30 cm (12 inches). The examination of1 o, R+ i, c5 I( b* J( M0 y
the neck revealed no thyroid enlargement.
4 w" L4 P1 Q% U9 s& e2 I( Y; HThe genitourinary examination was remarkable for
+ ]+ p, D5 ^) q% l" p" Menlargement of the penis, with a stretched length of
* _& F0 W$ n  L* y, ?8 cm and a width of 2 cm. The glans penis was very well
& T, y3 K$ n) ~: e- y6 S0 d9 K& Fdeveloped. The pubic hair was Tanner II, mostly around3 D, Z) ]  C3 S' _7 [
540
/ d8 A! z; y) K# Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) M) H/ }5 L6 J! y5 T. cthe base of the phallus and was dark and curled. The8 D6 b/ j$ ~3 q  [0 T
testicular volume was prepubertal at 2 mL each." c" h" C1 h& |' t
The skin was moist and smooth and somewhat
; p3 d# F' P" Xoily. No axillary hair was noted. There were no+ L# Z0 L) v! S" y) Q1 \* ^
abnormal skin pigmentations or café-au-lait spots.
. t4 u( g  J7 V' L+ L( pNeurologic evaluation showed deep tendon reflex 2+7 G# A/ |! ^( L; D3 c
bilateral and symmetrical. There was no suggestion1 U8 r( ~! t; [% o8 x
of papilledema.
" S2 k" a* r+ V9 J( yLaboratory Evaluation
% L1 n: ~* }; M- }* _6 Q4 `. mThe bone age was consistent with 28 months by/ Q& y$ W. |. f8 l. h+ T
using the standard of Greulich and Pyle at a chrono-
" O. q& ~# c' w" g1 [" Y  t4 M7 ^logic age of 16 months (advanced).5 Chromosomal" r0 b, ~- R  z" Z. u
karyotype was 46XY. The thyroid function test
4 a( X; X: ~1 g1 Q! _5 `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, w1 H9 m8 G4 E: [3 b- Hlating hormone level was 1.3 µIU/mL (both normal).6 y' f5 @5 ~1 W! ^& V6 [% e# X
The concentrations of serum electrolytes, blood9 r' I5 I4 `6 T8 q
urea nitrogen, creatinine, and calcium all were9 w( ]$ y& p9 O5 J5 R5 L7 X
within normal range for his age. The concentration
& x3 e* b, k) w5 Aof serum 17-hydroxyprogesterone was 16 ng/dL
: s2 |& b! p% Z(normal, 3 to 90 ng/dL), androstenedione was 20
) f  w! z7 d! M, Y9 j: zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& t& q1 k; [# l4 L6 X, u! ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, m( R3 v0 L! }8 f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( o  B% n/ \( V7 G
49ng/dL), 11-desoxycortisol (specific compound S); a! r' {- ~7 }* \& K% v9 \* E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. R3 \9 r* G* ^8 ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 P/ L( l9 x% E3 N8 |1 a1 K2 I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 \8 e6 h$ R. o9 p, ?' f1 e
and β-human chorionic gonadotropin was less than6 U% A* q7 K9 r" w
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! e2 {8 r& O6 x5 r5 `; g+ x7 Qstimulating hormone and leuteinizing hormone* S- C% Y/ {! H  l! N9 ]2 |
concentrations were less than 0.05 mIU/mL
% x+ h! ~; n+ [- U  l; {; r(prepubertal).3 \: j6 r. s$ x3 J2 u' g& _
The parents were notified about the laboratory$ W/ ^* Y5 q4 N! P/ [' s
results and were informed that all of the tests were) P3 t/ {1 B- Y; i
normal except the testosterone level was high. The* @( ~* z$ f6 [: d/ j7 _& a& c
follow-up visit was arranged within a few weeks to2 }$ B$ H* X" X' D. p0 J/ @
obtain testicular and abdominal sonograms; how-7 X2 ?9 y3 W" [2 R2 a# n  E
ever, the family did not return for 4 months.. Y+ ]) a5 `! C; U
Physical examination at this time revealed that the
" T) n9 k6 G" c: F- Q4 ?child had grown 2.5 cm in 4 months and had gained- p. V% J/ D5 U3 J# n5 d& n2 g7 @
2 kg of weight. Physical examination remained; f1 f+ r9 N: @9 |, {. q
unchanged. Surprisingly, the pubic hair almost com-
% _. i6 i; [/ q. Npletely disappeared except for a few vellous hairs at
6 [% \9 K+ _# R9 f+ }the base of the phallus. Testicular volume was still 2. N& }4 I0 I* N* d: Y
mL, and the size of the penis remained unchanged.& X0 F* ^  N. j. D9 v4 ~
The mother also said that the boy was no longer hav-
1 ~' n3 K% W1 r* _- j& Zing frequent erections.# d) w& s6 w/ Q' s  v  P
Both parents were again questioned about use of! w- b7 W& e2 K; R
any ointment/creams that they may have applied to
0 y( g0 t% |' y! U/ _the child’s skin. This time the father admitted the) k9 d& _1 V3 x
Topical Testosterone Exposure / Bhowmick et al 541
# d+ o3 G! C2 R3 S- ~use of testosterone gel twice daily that he was apply-
  D* l% V) d1 W9 N; Xing over his own shoulders, chest, and back area for
- ^; S7 O% W* u0 T$ n( }, w7 Ba year. The father also revealed he was embarrassed
! B- |# Y3 E4 X+ ~' R0 Y. Vto disclose that he was using a testosterone gel pre-3 B; s4 c& P2 |! A( I8 ?
scribed by his family physician for decreased libido
% H1 ]  O& I9 Fsecondary to depression.
9 u. u6 W9 H# @# r+ XThe child slept in the same bed with parents.
6 P, c7 A5 @& U, OThe father would hug the baby and hold him on his
( _, [/ ^/ v" o9 mchest for a considerable period of time, causing sig-  q# I7 B9 B1 d1 T' N: |0 X
nificant bare skin contact between baby and father.- T1 s3 C: H9 v7 d- ?1 q6 H* a
The father also admitted that after the phone call,1 Y7 c7 q" v7 n! s8 F$ R
when he learned the testosterone level in the baby
" B7 A0 ]" u& ^! j" \  jwas high, he then read the product information+ D# t: `. E# B3 d  G
packet and concluded that it was most likely the rea-% m3 M  O% u& w4 _# I7 T7 f8 R/ s
son for the child’s virilization. At that time, they* w5 h7 K+ a' t# @
decided to put the baby in a separate bed, and the5 `% q: P$ [/ E) r
father was not hugging him with bare skin and had
8 V8 g0 w! ^- s% Cbeen using protective clothing. A repeat testosterone6 A0 T7 |5 T+ o
test was ordered, but the family did not go to the0 c) |& Q- l/ j1 f! x. @
laboratory to obtain the test.
. Y  g8 ~( J8 Z$ A6 j& XDiscussion* X8 A4 L# T9 b& Y% i; p
Precocious puberty in boys is defined as secondary
5 f& t( \3 k% S) z( Z2 J# V, [+ Ssexual development before 9 years of age.1,4
) O1 n! Y4 H8 B0 _8 ?- g, pPrecocious puberty is termed as central (true) when
3 \7 a3 H' R0 ~. l3 @: I; n: ?it is caused by the premature activation of hypo-" x+ {9 w! L) g' N  R
thalamic pituitary gonadal axis. CPP is more com-
/ O' }. }% p; p; ~/ rmon in girls than in boys.1,3 Most boys with CPP
/ M' W+ x' A* h6 ^6 \, e; }may have a central nervous system lesion that is' I* y  x- c* M: {; t9 e0 g5 I/ e
responsible for the early activation of the hypothal-$ N3 e: C+ A- \) u6 }
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 R  t6 z- J3 f. D9 ^sis has been given to neuroradiologic imaging in
$ d1 a. u$ ]0 r) E. H- Tboys with precocious puberty. In addition to viril-) G7 y4 ?  z6 i. _/ H+ W
ization, the clinical hallmark of CPP is the symmet-
: [4 ~, x$ r! F, z7 zrical testicular growth secondary to stimulation by" m1 m9 o2 m0 ]* r; Q
gonadotropins.1,3
; {6 ?$ @2 e7 |Gonadotropin-independent peripheral preco-
5 D; p  P$ S  vcious puberty in boys also results from inappropriate
# z6 i; E! y, r2 f9 e% mandrogenic stimulation from either endogenous or- T( T) V! c6 h; z: B
exogenous sources, nonpituitary gonadotropin stim-
) ]% U* e% R! O- z1 Gulation, and rare activating mutations.3 Virilizing
" Y' y# j6 V0 t' L  Ucongenital adrenal hyperplasia producing excessive
' G- h: O7 [- ?1 Xadrenal androgens is a common cause of precocious
) u$ h* z/ D2 y1 q% ppuberty in boys.3,49 `- [9 h1 p/ ?; V2 f" ^
The most common form of congenital adrenal
+ F, D6 n) H! w8 w7 |7 I% A. lhyperplasia is the 21-hydroxylase enzyme deficiency.: d  ]0 i5 T% a/ Z* A% u, X3 e: m& p
The 11-β hydroxylase deficiency may also result in
  @; v) m- ^) V, m6 e# texcessive adrenal androgen production, and rarely,
( n& L3 G7 V5 g- H6 w' t/ C) Xan adrenal tumor may also cause adrenal androgen' A' [! |- v& P) U# K8 A) o
excess.1,3' V4 G9 b' c& G* w2 J+ E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ U1 W! U9 c) a9 g! w4 d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! P9 ^0 b) c7 T3 B
A unique entity of male-limited gonadotropin-  A+ Q" J: A, {
independent precocious puberty, which is also known
) `4 Z$ ~* E+ e4 E' X6 {" Pas testotoxicosis, may cause precocious puberty at a
2 S7 D2 h, h2 r" W8 I0 m6 mvery young age. The physical findings in these boys
7 R& p) y4 r. Awith this disorder are full pubertal development,+ e6 H' E. K* W
including bilateral testicular growth, similar to boys
; @& f% V8 `( t+ swith CPP. The gonadotropin levels in this disorder
% [- _& F: f- q( F/ i2 n$ u- F+ J  pare suppressed to prepubertal levels and do not show9 G2 w; F: G8 f/ t, }
pubertal response of gonadotropin after gonadotropin-
" \4 ^; X( O& _releasing hormone stimulation. This is a sex-linked
& N6 G) H7 R& ], \$ Kautosomal dominant disorder that affects only
& ^6 W, Q7 A) n8 k7 Emales; therefore, other male members of the family
1 ^1 ^4 G3 G4 ?% K( amay have similar precocious puberty.3
4 f  `0 P4 L8 U$ C+ nIn our patient, physical examination was incon-
! z) O) K* a6 H7 B5 b& r6 |sistent with true precocious puberty since his testi-
% n/ \+ T3 V3 @( `: M/ s$ ~cles were prepubertal in size. However, testotoxicosis8 ?: g0 M( @0 v
was in the differential diagnosis because his father
0 c. ~( ~5 l+ h6 Zstarted puberty somewhat early, and occasionally,5 V7 e3 @2 v$ \3 ^
testicular enlargement is not that evident in the: @7 r+ C( c  F' p* c* u, ~
beginning of this process.1 In the absence of a neg-& p! ^8 H: B- g* v8 H* \
ative initial history of androgen exposure, our
! F! f$ i" A, u: T! _; l( U9 i* Gbiggest concern was virilizing adrenal hyperplasia,
) j$ C: A1 {! c( u) A% reither 21-hydroxylase deficiency or 11-β hydroxylase8 Y$ I' n9 e# g' y% }. Z& T
deficiency. Those diagnoses were excluded by find-6 v) T! \2 B! [' D5 r' X' ^5 k& i
ing the normal level of adrenal steroids.
- h8 e, c! t3 a: X+ L0 Y7 s0 NThe diagnosis of exogenous androgens was strongly5 s! R' ]; }* t6 x
suspected in a follow-up visit after 4 months because! b! p/ K- H- `- I/ a( J
the physical examination revealed the complete disap-
2 g. K6 `( ^3 Z6 [2 Kpearance of pubic hair, normal growth velocity, and: @. M3 a" G5 G1 [
decreased erections. The father admitted using a testos-
% a$ S  c: M; t7 Z- K6 mterone gel, which he concealed at first visit. He was" D( n2 U, a5 T, H
using it rather frequently, twice a day. The Physicians’2 ]6 G. {6 x9 P
Desk Reference, or package insert of this product, gel or. B6 ^; ^+ r, D1 r4 |+ d6 V
cream, cautions about dermal testosterone transfer to, u7 O. J" Q% S: s6 Y- `) f7 h
unprotected females through direct skin exposure.
# j/ g, f; |2 y+ j; L7 uSerum testosterone level was found to be 2 times the+ C% x, h/ u& {, i+ l. S) z
baseline value in those females who were exposed to
& [2 L0 ?' z- m% t+ f* Z0 _! w7 M& `even 15 minutes of direct skin contact with their male9 Q5 v$ ]& d# V4 {
partners.6 However, when a shirt covered the applica-
8 ~& Q4 b# h, J+ F1 o4 W9 `) I/ X  I, Stion site, this testosterone transfer was prevented.
6 H3 O& [* K" eOur patient’s testosterone level was 60 ng/mL,2 Y% s3 }' M8 l
which was clearly high. Some studies suggest that$ s/ {. W# w; L! {8 H! ]0 z
dermal conversion of testosterone to dihydrotestos-
! N1 c6 k7 H7 M: lterone, which is a more potent metabolite, is more! J# b3 @6 M% o- r4 b
active in young children exposed to testosterone
  J9 ]) I" Z0 R: ?& fexogenously7; however, we did not measure a dihy-
' _# U6 V0 @8 T  Hdrotestosterone level in our patient. In addition to9 Q7 y! @2 N- D0 V  X7 W
virilization, exposure to exogenous testosterone in; Z' O$ l; D' W' R' S
children results in an increase in growth velocity and
  a1 H6 \9 _6 Zadvanced bone age, as seen in our patient.6 B) z4 ^" V$ S' u8 ]/ }  s% n- U
The long-term effect of androgen exposure during
. \+ r1 Z, \2 C, y6 ~) O4 Xearly childhood on pubertal development and final8 o2 f" P9 [) u/ R" H* F
adult height are not fully known and always remain
1 B! ^8 \+ j0 J; T6 ?a concern. Children treated with short-term testos-
+ d) i4 w% l9 y! {' P0 Kterone injection or topical androgen may exhibit some" U  B- R" h1 Q" X5 \
acceleration of the skeletal maturation; however, after* L2 c4 s0 W) ]5 Y# W# H
cessation of treatment, the rate of bone maturation
! @9 ]% @4 b. S$ b. G, ndecelerates and gradually returns to normal.8,96 F9 z0 y9 z+ W% l1 {" u/ T* U: r/ i
There are conflicting reports and controversy# D; g- R9 d$ O
over the effect of early androgen exposure on adult
. C/ J- S5 p) U4 Ipenile length.10,11 Some reports suggest subnormal2 Q( P4 }1 q4 _$ F9 V
adult penile length, apparently because of downreg-% h5 q/ W3 D/ \
ulation of androgen receptor number.10,12 However,) x! O/ G! A1 J  l
Sutherland et al13 did not find a correlation between
1 s: i  e' r( a6 rchildhood testosterone exposure and reduced adult* ]; I7 t3 e# F7 y) j
penile length in clinical studies.; s! x* a* E5 L
Nonetheless, we do not believe our patient is
; ]! _& i6 L: X( S; S+ Rgoing to experience any of the untoward effects from
9 q/ Y6 U# }3 j# Otestosterone exposure as mentioned earlier because; K. T' R2 Q, s+ j$ Z
the exposure was not for a prolonged period of time.: w# R0 w" ~, c  W7 o! ~( V- i- h" s
Although the bone age was advanced at the time of
& N* ^6 y+ t& ?. H# D* sdiagnosis, the child had a normal growth velocity at
& h9 M& W9 i& g. G9 S) hthe follow-up visit. It is hoped that his final adult
, Z/ I1 p2 y5 z( z7 }7 A! J$ T  Lheight will not be affected.2 n. t. Y8 _. r9 o/ C
Although rarely reported, the widespread avail-
' a3 z) d0 S3 y# j( S: v# Oability of androgen products in our society may3 T# Z/ _, r8 Z# P: O
indeed cause more virilization in male or female; H/ a4 ^  `; O) x$ f& p
children than one would realize. Exposure to andro-. U# E6 F1 ?  ?7 _) T+ @
gen products must be considered and specific ques-
/ b  T! [( g" xtioning about the use of a testosterone product or
6 {2 g# m; [% ~1 N; k4 ngel should be asked of the family members during
* }# I% e: r& o; }the evaluation of any children who present with vir-
# I* b$ |3 H" q) a! cilization or peripheral precocious puberty. The diag-0 p9 M! m7 l: q" H7 _& W
nosis can be established by just a few tests and by& _: B; m% s) A2 X& X# s- f
appropriate history. The inability to obtain such a
* [6 }0 o  x0 ?, f. lhistory, or failure to ask the specific questions, may
! K) U' I' x, {result in extensive, unnecessary, and expensive8 ^/ X6 N& x5 o3 u6 n# A7 p
investigation. The primary care physician should be
6 F3 U$ _; s; C. `$ N/ N% z9 Haware of this fact, because most of these children
/ G8 |& r. ?: L2 {; tmay initially present in their practice. The Physicians’) U3 ~- d  y! }7 u' d* u* m: Q
Desk Reference and package insert should also put a
% l4 _$ V3 L; a0 r2 Rwarning about the virilizing effect on a male or
9 m3 z0 \. r, A) }- P1 bfemale child who might come in contact with some-
; @4 A  n7 ~  Z/ X% A* N4 {one using any of these products.' X9 g/ [3 P* F$ X5 e
References
" C2 m( m2 I* q2 J. W1. Styne DM. The testes: disorder of sexual differentiation
, Q9 O$ X2 \* Q2 ~5 pand puberty in the male. In: Sperling MA, ed. Pediatric. B. V9 D+ i9 {; S* J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 I! L) I, `! o# S2002: 565-628.( |; P+ x. p' l3 e+ ^- I' Z( M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 y3 x% \: r: t% K, F# `3 Q" @
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* F) X. V; O) XBoy Induced by Indirect Topical
1 g% W4 F4 z( x6 J  `, vExposure to Testosterone4 {; y/ K5 M& b8 T2 e; `: z9 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& z4 D* [% U$ {) H2 u* Sand Kenneth R. Rettig, MD1
4 ]$ O6 |% t8 o) PClinical Pediatrics
5 x5 ~6 p0 A. N+ G, v8 DVolume 46 Number 6" e7 N. m6 B' w' R3 L7 ]1 Z
July 2007 540-543
! c, U: a. U2 P' I: \© 2007 Sage Publications- u8 v4 q; H) ]! J0 k9 `+ A
10.1177/0009922806296651
5 v7 |8 J, i; i; R) i; z% fhttp://clp.sagepub.com$ l9 M  x* h; n4 u# t) ?& A
hosted at( z7 u" R/ q0 ]: L8 [
http://online.sagepub.com$ H  N" C6 O/ \
Precocious puberty in boys, central or peripheral,/ a6 g1 a3 _: ~: S  I0 t4 ?  @
is a significant concern for physicians. Central
7 F2 K2 \! |6 F! q- Jprecocious puberty (CPP), which is mediated
- V- {( e) C: I' Z4 y6 X) U/ kthrough the hypothalamic pituitary gonadal axis, has9 E7 Z$ M1 ?+ j6 J/ z/ j" t
a higher incidence of organic central nervous system
  X' \5 q9 |# t/ U5 V! }lesions in boys.1,2 Virilization in boys, as manifested
1 ~* c6 E1 s4 rby enlargement of the penis, development of pubic; e1 s' I! ]# L
hair, and facial acne without enlargement of testi-
) F0 J  H; u$ U$ k* R$ L: |5 ocles, suggests peripheral or pseudopuberty.1-3 We
) j" T/ ^. G, g5 I- d: r1 i3 Y% `report a 16-month-old boy who presented with the
) ^# i9 }" V8 r# i. cenlargement of the phallus and pubic hair develop-" t- m' e8 E) V. H8 K/ |: ?
ment without testicular enlargement, which was due
, A3 i. K2 y& r$ H/ Hto the unintentional exposure to androgen gel used by6 H. G9 ]' C/ ~0 h
the father. The family initially concealed this infor-
! E0 B8 h! t- I3 g# Tmation, resulting in an extensive work-up for this. \6 y$ x2 G. G; Y  Z
child. Given the widespread and easy availability of
% F" N: Q; F4 w( l5 utestosterone gel and cream, we believe this is proba-' z& |% U& ?0 x. M$ y2 H7 L
bly more common than the rare case report in the! q# N, s9 |0 {3 P( `% H. J0 ~$ D
literature.48 Y: t9 v; r/ F$ r& ~3 }- k
Patient Report" d- C) K  w/ L+ B% j/ N
A 16-month-old white child was referred to the
+ n2 \- ]8 [3 ]3 c0 w' F" b7 U! \endocrine clinic by his pediatrician with the concern
' U) g  E9 {+ l+ dof early sexual development. His mother noticed
! u$ d! C$ K6 ~; T; h; J) elight colored pubic hair development when he was- b# V8 \: B" f+ {
From the 1Division of Pediatric Endocrinology, 2University of
: t7 o: j3 ]9 @! j- A" \! QSouth Alabama Medical Center, Mobile, Alabama.6 u( z& T$ H% h* f$ R# E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% _4 F/ x. `$ k, bProfessor of Pediatrics, University of South Alabama, College of
$ y! q( o% C: h( D& lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' Y( f. p( T3 s
e-mail: [email protected].
0 o" A; @  B/ Rabout 6 to 7 months old, which progressively became7 j: {; ?6 C3 b; }1 J) w
darker. She was also concerned about the enlarge-4 p5 ]& z3 t( Z0 Q0 K4 F
ment of his penis and frequent erections. The child' b& q0 l# j: O& x
was the product of a full-term normal delivery, with" r" A+ k  W. B2 B0 ~+ v" u- r
a birth weight of 7 lb 14 oz, and birth length of) F) J7 M. h0 L3 h. h( s. ]
20 inches. He was breast-fed throughout the first year- `' F7 J& g9 S$ A% o, C
of life and was still receiving breast milk along with
. t6 u# G9 E- c2 w/ M# psolid food. He had no hospitalizations or surgery,
7 i# M8 g* b5 x; e+ ^and his psychosocial and psychomotor development. Y9 g! J  m2 h: A
was age appropriate.: v* _1 n. B" C" e; O# Q
The family history was remarkable for the father,
5 a/ ^8 W: l) Q# I" ywho was diagnosed with hypothyroidism at age 16,7 Z+ q4 r$ }: W$ I3 K
which was treated with thyroxine. The father’s
. X  H/ F3 T$ R/ s0 U( iheight was 6 feet, and he went through a somewhat9 S. A: J. ~1 W5 j8 S
early puberty and had stopped growing by age 14.2 A9 p7 v8 d& a0 `7 I/ r* r
The father denied taking any other medication. The( j& M  @* C" g4 V8 i6 ?$ \
child’s mother was in good health. Her menarche/ Y$ y3 F0 b& w0 m! O
was at 11 years of age, and her height was at 5 feet' G, z' R7 {% ~. O1 O9 Z- O9 z/ y
5 inches. There was no other family history of pre-
* ]3 _$ s, C& l5 Rcocious sexual development in the first-degree rela-3 ^9 e% c- d$ U1 [& F& K
tives. There were no siblings.
2 ^7 w/ V: h4 J8 r( D  iPhysical Examination
! }6 U  v+ r5 ~. U4 I# kThe physical examination revealed a very active,; Q) e8 S9 |" ^
playful, and healthy boy. The vital signs documented0 ^3 Z  B8 Y9 c% u# B6 u" F" p2 G
a blood pressure of 85/50 mm Hg, his length was( Q8 ^  F  p- {# b" ?" x
90 cm (>97th percentile), and his weight was 14.4 kg- s1 r$ Y9 A* N
(also >97th percentile). The observed yearly growth
+ O. {: V( ^1 o5 J8 ?6 ^( X* rvelocity was 30 cm (12 inches). The examination of0 U+ }  F# w: v; |2 U5 i( R
the neck revealed no thyroid enlargement.. [- [& Q0 k  j4 ^
The genitourinary examination was remarkable for+ j  s# S+ q1 T3 [9 c) h4 Y
enlargement of the penis, with a stretched length of
: n7 Y9 R% w( `* n3 F6 X8 cm and a width of 2 cm. The glans penis was very well
3 Z0 P% Y; \! }& V3 S- S! Hdeveloped. The pubic hair was Tanner II, mostly around
- n% ~; h* M3 L1 }5 x7 k5400 Q0 r! T2 c7 o3 m0 C) w3 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' `1 M9 U5 b0 e  R  @& Z, w
the base of the phallus and was dark and curled. The2 Y* L) b3 W& g% l& ]* x( A
testicular volume was prepubertal at 2 mL each.& z* i# o& Q1 _* R2 C# U% I
The skin was moist and smooth and somewhat8 Z" X$ c- V7 r5 x6 h3 g
oily. No axillary hair was noted. There were no0 ~" B" k# B8 T' |, M& H
abnormal skin pigmentations or café-au-lait spots.
$ {3 l7 U5 G3 w) cNeurologic evaluation showed deep tendon reflex 2+
* T* g; T9 q9 h1 G6 ?" gbilateral and symmetrical. There was no suggestion
1 c! ~: |/ o5 g9 @5 o  yof papilledema.
& D' {  ^- y" ^# B, r$ W3 W4 \+ BLaboratory Evaluation
' Z2 h. [6 `" u+ [The bone age was consistent with 28 months by
: Q+ F) @7 t, z- E& G  D, t* Y/ eusing the standard of Greulich and Pyle at a chrono-$ ~3 O, `  ?) {) F
logic age of 16 months (advanced).5 Chromosomal) e6 S5 r7 K8 q/ l6 j
karyotype was 46XY. The thyroid function test
4 v7 S3 B0 \7 U6 g! |! yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ ^+ J9 D. Q+ w! y  s9 P+ _  Flating hormone level was 1.3 µIU/mL (both normal).
, p! L- P$ p: m  ?The concentrations of serum electrolytes, blood
% m+ Y( _4 T9 Kurea nitrogen, creatinine, and calcium all were
( _" v5 M. f3 o  H% Rwithin normal range for his age. The concentration
1 q8 |/ Q0 U* J2 a" z+ gof serum 17-hydroxyprogesterone was 16 ng/dL
9 s: ?" l: k4 s' m, u% t! W% h(normal, 3 to 90 ng/dL), androstenedione was 206 m- z5 X* s% R1 |7 r) }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  ~# o  E) D1 G! x1 u2 Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ g2 E- N) i% s1 l; x$ W8 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 |& C2 B. m! p. ^49ng/dL), 11-desoxycortisol (specific compound S)
( u3 n# ]) s& Y& n1 i8 |6 [9 Z& c% hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 i6 Z' x" E1 v# h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) H, }/ r4 Z) Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 P6 F) n0 x2 L
and β-human chorionic gonadotropin was less than& C( i5 q( B: r. u( P
5 mIU/mL (normal <5 mIU/mL). Serum follicular: i$ D% N* ]$ A% Y
stimulating hormone and leuteinizing hormone8 m0 ?3 H0 j+ ?# c4 k9 y
concentrations were less than 0.05 mIU/mL; M3 u# z% x1 l, V. R+ T) u
(prepubertal).
7 B8 m. m* v! eThe parents were notified about the laboratory/ ^  W" L- _1 k& B
results and were informed that all of the tests were
& r1 ~/ d& M, b3 C, ]0 b3 n. \) c; Nnormal except the testosterone level was high. The
0 Q9 o& c% b1 Hfollow-up visit was arranged within a few weeks to
7 M/ ?! x' Y! L. _obtain testicular and abdominal sonograms; how-
9 t( J6 j5 @& Qever, the family did not return for 4 months.
& ~, e4 _; \% T9 A3 \! wPhysical examination at this time revealed that the
, _' K% s# m( O4 w4 g" W( cchild had grown 2.5 cm in 4 months and had gained- O/ g. V9 s4 {  @
2 kg of weight. Physical examination remained- T& f: U' Q- S6 V& h: X8 F
unchanged. Surprisingly, the pubic hair almost com-, b) ^; g! Z8 p! U8 W  x
pletely disappeared except for a few vellous hairs at3 i* H2 J# z3 ?* F
the base of the phallus. Testicular volume was still 2
; J6 X" S: g1 zmL, and the size of the penis remained unchanged.
9 L; R5 e/ f7 M3 W( s; [, a  rThe mother also said that the boy was no longer hav-( u4 o+ O. x+ |% D- s
ing frequent erections.
- j9 F" ]8 }5 y3 f+ o' BBoth parents were again questioned about use of1 s/ I. I5 ~4 S& u1 Q$ Q# F
any ointment/creams that they may have applied to
0 b6 v% x- `/ W8 g* ethe child’s skin. This time the father admitted the1 u3 F5 e( K: V+ ^. I) d
Topical Testosterone Exposure / Bhowmick et al 5416 v" q! k# V, I" I
use of testosterone gel twice daily that he was apply-, v2 w) _  k" E1 x, T# K1 n
ing over his own shoulders, chest, and back area for. \, l  f5 {) `& b# ^0 V- P
a year. The father also revealed he was embarrassed
/ {) S8 e+ m* Y( _: d, uto disclose that he was using a testosterone gel pre-8 p( R) ^& |7 H$ U$ r  o
scribed by his family physician for decreased libido
9 {5 b% ]+ p1 jsecondary to depression.
- ?6 |: l2 }& A& o7 v7 rThe child slept in the same bed with parents.! B0 s9 J  M+ v$ ~2 k9 i
The father would hug the baby and hold him on his
5 h6 _! U( ?3 n1 Wchest for a considerable period of time, causing sig-. J8 c( D1 w! O* P+ L0 H! }1 f0 V
nificant bare skin contact between baby and father.
% j3 K- b/ b- \4 r& s2 g/ M5 y; pThe father also admitted that after the phone call,2 P$ Q9 S. }3 f$ H4 o& ~4 @7 D* B
when he learned the testosterone level in the baby! e# S9 X7 {- I2 p4 v! K3 d( a* {
was high, he then read the product information6 @5 z/ B8 O+ |
packet and concluded that it was most likely the rea-
) q% r! w7 ~2 W& }4 T) j5 g! ^son for the child’s virilization. At that time, they; _6 M- ]/ M. S  S/ I
decided to put the baby in a separate bed, and the$ a, _# w$ u  D$ K
father was not hugging him with bare skin and had; {0 i: w: J4 E  N% l
been using protective clothing. A repeat testosterone
! m( Z6 G* Z2 g5 Z7 p& ~test was ordered, but the family did not go to the
# t9 x2 C0 L  K! x+ J2 tlaboratory to obtain the test.
- g0 D; _2 M) H) M+ p, ^Discussion
" W$ {- f4 a( F0 ?Precocious puberty in boys is defined as secondary
' D5 v/ W$ L, S' ~0 z! u& r+ b: C4 Zsexual development before 9 years of age.1,41 }0 x+ R7 C! l; {2 M+ s! F
Precocious puberty is termed as central (true) when/ f7 z2 L2 |1 s- E7 g5 B
it is caused by the premature activation of hypo-
8 I/ z6 N) Z& E- i( ?2 @thalamic pituitary gonadal axis. CPP is more com-; j" h5 D8 m8 i! G
mon in girls than in boys.1,3 Most boys with CPP0 m7 G" w1 ~$ W: [; M
may have a central nervous system lesion that is$ b" V4 M* X, g4 {; V
responsible for the early activation of the hypothal-7 p, F/ c- x7 r* ~/ r
amic pituitary gonadal axis.1-3 Thus, greater empha-/ ~% D$ ~8 `: `0 w0 d1 x$ Q
sis has been given to neuroradiologic imaging in& ~: q! A: f: ~& h4 ^4 ?; B! J& N
boys with precocious puberty. In addition to viril-
: a! N5 p/ k0 L; z5 Gization, the clinical hallmark of CPP is the symmet-
3 [2 g" F0 g- P  o4 P0 Q7 Arical testicular growth secondary to stimulation by
3 S, B: M! |' q; sgonadotropins.1,3& Y# n" z, s6 s9 N: b8 k0 P- O
Gonadotropin-independent peripheral preco-+ j5 a) z5 a- i  x
cious puberty in boys also results from inappropriate; s- _: f- Z  h  x, m
androgenic stimulation from either endogenous or
0 w' |3 h- K9 D* M8 v6 b  V& ?exogenous sources, nonpituitary gonadotropin stim-7 }( C! [$ \. [
ulation, and rare activating mutations.3 Virilizing; T# A$ v# A2 ]  Y! O, s  C
congenital adrenal hyperplasia producing excessive3 ~2 \* t  b% G$ Z( v+ K
adrenal androgens is a common cause of precocious
5 v( F8 p) T# o- x! d* k& zpuberty in boys.3,4$ y$ w. X4 q! p  ?, b2 H
The most common form of congenital adrenal  Y3 {4 Y- ]8 j/ F& F3 l; Y
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 k. W; B  e. K6 EThe 11-β hydroxylase deficiency may also result in9 ^- S( W8 |! i2 j
excessive adrenal androgen production, and rarely,/ `+ D0 r2 C3 r$ m; }5 b
an adrenal tumor may also cause adrenal androgen% L: t6 i7 w8 k8 s& X) m8 ~
excess.1,3. h# T% @' i! _# G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* o2 H8 c% {* K: S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 i: B; x' b% m3 r+ \% N+ C" a! wA unique entity of male-limited gonadotropin-* ~9 d( C. i9 u. T  ~( r; L
independent precocious puberty, which is also known
, y9 o8 x1 o4 G3 t2 w1 X0 K$ E- w. g& Bas testotoxicosis, may cause precocious puberty at a+ L& m  k8 o) l' l0 K* e7 N* d
very young age. The physical findings in these boys
0 j+ ^: k" F: ?) o( |with this disorder are full pubertal development,' L& W0 G# `8 }  }
including bilateral testicular growth, similar to boys+ E6 Y  l1 @7 d, W' _) z
with CPP. The gonadotropin levels in this disorder2 w; M6 f2 A8 c) {
are suppressed to prepubertal levels and do not show" L, ~2 C5 M2 N6 w" C
pubertal response of gonadotropin after gonadotropin-
6 B0 |- ^$ P, V. b5 B' Qreleasing hormone stimulation. This is a sex-linked
' Q. H4 A6 t! A! H6 ]" k7 c* |autosomal dominant disorder that affects only7 s+ v- i8 D* b4 c* _/ E7 E
males; therefore, other male members of the family8 P8 }: ~- E& V$ r. ?, x; D$ A' O
may have similar precocious puberty.3
& x; @4 b- X4 r5 |& VIn our patient, physical examination was incon-
/ ^5 E3 X( m" }7 ^& G; `% ksistent with true precocious puberty since his testi-/ \# ^  O+ x6 V: t
cles were prepubertal in size. However, testotoxicosis
7 S; @5 d- B1 s  S( s# C( fwas in the differential diagnosis because his father
! s# P) z( e; Astarted puberty somewhat early, and occasionally,; w5 c. Y5 |: l# }
testicular enlargement is not that evident in the
; a: ]4 F  G7 @$ Y* A+ u( ^  P  Y6 Ybeginning of this process.1 In the absence of a neg-/ h( C2 q$ C9 P5 t- `# A/ N) K
ative initial history of androgen exposure, our
1 h7 T0 u  p( M3 ]biggest concern was virilizing adrenal hyperplasia,! \6 G  w. e+ D% M% j
either 21-hydroxylase deficiency or 11-β hydroxylase
2 e6 [% `, E$ G0 P: G5 {deficiency. Those diagnoses were excluded by find-
1 _* x1 U  k# c/ ying the normal level of adrenal steroids." N, L, |' t! r- \
The diagnosis of exogenous androgens was strongly
! u' z* c6 F" L* W* T( y7 c( l! ysuspected in a follow-up visit after 4 months because" M, i; o! `" n
the physical examination revealed the complete disap-/ j: u, M( A5 o* @$ C5 U
pearance of pubic hair, normal growth velocity, and% k- t6 j( b5 p3 p
decreased erections. The father admitted using a testos-9 l4 B( _  p! S9 x
terone gel, which he concealed at first visit. He was
- L; G& S* p# `. Wusing it rather frequently, twice a day. The Physicians’
, [3 U) h$ `. r: o9 k0 x4 tDesk Reference, or package insert of this product, gel or
. |7 U7 W' a" X+ Qcream, cautions about dermal testosterone transfer to
& b5 m1 ?$ B$ z4 {6 I8 J; Xunprotected females through direct skin exposure.( ~7 k8 e" g+ o7 r% z
Serum testosterone level was found to be 2 times the
& S) y% a9 T  [* Abaseline value in those females who were exposed to$ V1 O( Y& k4 [/ p* ?
even 15 minutes of direct skin contact with their male- l7 r0 N1 p! N' L2 [5 A) }# n
partners.6 However, when a shirt covered the applica-( B: |4 ~1 j! r; B
tion site, this testosterone transfer was prevented.( }  k& T$ S$ [# r8 q
Our patient’s testosterone level was 60 ng/mL,9 K. a) w6 |) g& d% k0 _
which was clearly high. Some studies suggest that
/ y9 I6 l- }3 |dermal conversion of testosterone to dihydrotestos-3 J! T) l; }% `. x; ~+ J
terone, which is a more potent metabolite, is more: C: N) c: S* E
active in young children exposed to testosterone
! Q$ p8 }  a1 }$ A  J3 uexogenously7; however, we did not measure a dihy-) X( |& L8 t0 u3 o, _( w; n- d
drotestosterone level in our patient. In addition to
. |8 W, c2 X# }) n1 W" ivirilization, exposure to exogenous testosterone in) |9 S5 Z6 B2 i" J
children results in an increase in growth velocity and
0 p9 }  o4 H1 f9 ^8 F4 q& E$ O2 h0 gadvanced bone age, as seen in our patient.
9 a+ e7 w/ N' Y& L' ^' `' j6 VThe long-term effect of androgen exposure during+ X2 q" g& E2 O
early childhood on pubertal development and final
, O  ~$ u! L( q  P! z( Y5 dadult height are not fully known and always remain
1 N' h) ~2 c- T+ W! t& M' xa concern. Children treated with short-term testos-
2 T( H$ M2 L/ @( o7 m( o+ uterone injection or topical androgen may exhibit some
6 s8 H& N9 ?" B& f; Jacceleration of the skeletal maturation; however, after! X& U7 T4 \  Z# A- @
cessation of treatment, the rate of bone maturation% o2 N0 M. A$ Z" p" `
decelerates and gradually returns to normal.8,9  i8 g( K7 @# V! j; r# m; K& M! ?
There are conflicting reports and controversy) g% ?8 `" v5 b+ l/ B
over the effect of early androgen exposure on adult
# g" v4 f3 K  A" J+ V- O: openile length.10,11 Some reports suggest subnormal  J9 A& q" @- N, n
adult penile length, apparently because of downreg-
9 G/ H2 ^1 E, |  Dulation of androgen receptor number.10,12 However,
4 y/ ~# u7 Z& C  R: hSutherland et al13 did not find a correlation between
9 t2 X' E5 f- R" G) `6 l- p% d9 mchildhood testosterone exposure and reduced adult
$ s3 {2 G" o+ @penile length in clinical studies.7 f' X# z9 x8 S6 `- I
Nonetheless, we do not believe our patient is4 O5 a( F. C! o
going to experience any of the untoward effects from) }/ W$ a7 ~# K) C1 \! L8 y4 u
testosterone exposure as mentioned earlier because
7 _6 B% }- [- P: J: nthe exposure was not for a prolonged period of time.
9 r# I' e2 q8 v9 I( G6 FAlthough the bone age was advanced at the time of
) A1 [( h0 a  d9 H. U; ~diagnosis, the child had a normal growth velocity at4 l5 [' ]( p9 L& R' V5 H
the follow-up visit. It is hoped that his final adult0 D/ v& o4 S* ~, y- A( g2 H! u. ^
height will not be affected.( v& x/ G. q, Z. _
Although rarely reported, the widespread avail-
) E  Z+ _( B8 X( C/ Z. n8 ]ability of androgen products in our society may
9 z: n. }, B3 c1 z$ Uindeed cause more virilization in male or female
( n* g- y) D! echildren than one would realize. Exposure to andro-9 V& x: {% O" Y9 G- `( x
gen products must be considered and specific ques-5 P1 f" h7 |' S5 V
tioning about the use of a testosterone product or* j9 H, u3 _& E+ _* w5 L
gel should be asked of the family members during3 M! n. s& ?) X1 m9 h5 s
the evaluation of any children who present with vir-6 g$ I/ R6 i/ s, C2 N! |; ]' e
ilization or peripheral precocious puberty. The diag-! l5 n( z* e, D9 o& p, q
nosis can be established by just a few tests and by/ t+ h6 N) X6 G3 S8 \5 x
appropriate history. The inability to obtain such a
% T/ S! w! a$ R3 Z1 Fhistory, or failure to ask the specific questions, may
$ i/ j! b: l9 @7 oresult in extensive, unnecessary, and expensive
9 z6 ?! X2 U7 f- sinvestigation. The primary care physician should be1 N% S; _5 t3 J6 H
aware of this fact, because most of these children4 Z. w0 U* l: N3 X# [
may initially present in their practice. The Physicians’
2 f, v; a# S) dDesk Reference and package insert should also put a
5 r. l; f( u/ W( ?warning about the virilizing effect on a male or
4 x/ ?: `2 M2 w% y, U% P7 rfemale child who might come in contact with some-
( J5 C0 N8 ^& b: Q+ P0 Q1 D" W5 G! |one using any of these products.2 o: c+ X: f! f; ]
References- _3 t$ M& |! g6 r; E3 f
1. Styne DM. The testes: disorder of sexual differentiation0 N7 f" L4 N) m. w8 h+ t# {
and puberty in the male. In: Sperling MA, ed. Pediatric
* Z! j; Y( X! k4 A3 Y+ N+ t3 fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# g% T- s" Q2 v: G
2002: 565-628.
# H5 F. N% s" j0 ^2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: _6 j% @' W; n4 Jpuberty 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

4 i; R: ^0 d/ o! X8 @+ `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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