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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
$ u9 d$ a- M  t6 L& a8 P5 rBoy Induced by Indirect Topical
1 }" s5 R: s9 ?: N7 o' SExposure to Testosterone
8 X$ x( U. }4 N2 ^6 v. |8 Q, USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ b( t6 Y% y2 F1 T8 T, D$ }- n- ?: iand Kenneth R. Rettig, MD12 y! D0 ?! R; b* R( Q8 F
Clinical Pediatrics
, ]$ K# J  W$ i0 ?7 [0 IVolume 46 Number 66 K( d9 g  t+ H5 s1 E9 U& O) h% m, }. H
July 2007 540-543; {, j9 |1 N. U/ _6 U% w
© 2007 Sage Publications, T. O& |2 }* C# n, L
10.1177/0009922806296651, w, V! \, j$ n) U! z* N
http://clp.sagepub.com
$ X0 [8 P8 A, ~hosted at" Y! f+ Q, b5 }; y2 x9 V8 p4 d
http://online.sagepub.com5 p9 j  v* k: T  Q; ^3 P2 [
Precocious puberty in boys, central or peripheral,
' g7 W$ I7 f- `" S( Gis a significant concern for physicians. Central/ V: O# r7 ]6 H" j
precocious puberty (CPP), which is mediated2 n9 p& [- g+ Z0 \
through the hypothalamic pituitary gonadal axis, has: O, P8 e; e: i( k5 z0 \
a higher incidence of organic central nervous system
& I& t% U. l2 R1 a3 o: \- r, Tlesions in boys.1,2 Virilization in boys, as manifested
# ^0 m/ i7 k6 |) I$ P6 G: ]1 M" L" fby enlargement of the penis, development of pubic
5 i' U3 S6 f! \- ?hair, and facial acne without enlargement of testi-
: J$ D( `' F: gcles, suggests peripheral or pseudopuberty.1-3 We
0 L% u- T$ I9 d1 G9 {report a 16-month-old boy who presented with the1 P+ q; U- ?! H$ j! W2 k1 B" l
enlargement of the phallus and pubic hair develop-
3 W4 S6 k7 M. m- W" f( fment without testicular enlargement, which was due( w# p* w' Y1 e. n* x  e, l0 ]
to the unintentional exposure to androgen gel used by
5 @  L& u( t4 P: F1 O3 J$ Uthe father. The family initially concealed this infor-1 O! c$ w& i" Z
mation, resulting in an extensive work-up for this( ~- B$ R1 b3 T. f2 P: g0 k  x
child. Given the widespread and easy availability of
. E* ~5 @  F1 C6 d. x3 r: ktestosterone gel and cream, we believe this is proba-
! w$ i! Z% T. O" V, Y- {1 Obly more common than the rare case report in the
' o2 W0 o- u( C3 [6 x( f" K! Z! Iliterature.4' `, u! ^5 c: k2 X- N- X+ `
Patient Report
  D' [1 f! k. O1 f1 B+ D( BA 16-month-old white child was referred to the
" F8 O" U( ^1 ^endocrine clinic by his pediatrician with the concern3 W3 W' R: z5 X6 Y. b1 z
of early sexual development. His mother noticed
7 A9 e4 M/ J  Z( }6 a* a2 mlight colored pubic hair development when he was; B8 E5 I: b' p3 P9 h7 K
From the 1Division of Pediatric Endocrinology, 2University of
, t# O7 t3 C: @! VSouth Alabama Medical Center, Mobile, Alabama.1 X& o: Z) [2 i$ N" A5 m4 x2 t/ y: d+ Y' [
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& L& e$ d+ ~7 E: ?. `/ @0 ?& s$ M' FProfessor of Pediatrics, University of South Alabama, College of) w* ^# q; W4 a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' |$ I: `" x3 p5 T0 }7 D
e-mail: [email protected].2 X) \# J( b9 t5 U- V* I
about 6 to 7 months old, which progressively became
8 w0 P6 \6 {  |! |: [2 tdarker. She was also concerned about the enlarge-
3 g+ l" a- I! p% ?7 i$ [% oment of his penis and frequent erections. The child0 w8 x, w" n1 D, k. b% L0 H
was the product of a full-term normal delivery, with
$ c) N! ~; N! ~4 va birth weight of 7 lb 14 oz, and birth length of" t& M- H9 {0 |
20 inches. He was breast-fed throughout the first year/ }- X8 e) e" Y* e! `
of life and was still receiving breast milk along with
5 k0 u& e. f( G2 L5 wsolid food. He had no hospitalizations or surgery,
$ B$ D: l5 s0 c$ D6 L0 fand his psychosocial and psychomotor development. J( l8 o8 f# _/ F, X5 }+ {5 R% D
was age appropriate./ a5 I7 \1 A7 W' I8 B& K
The family history was remarkable for the father,
5 W& O8 W( v6 Y5 B, f0 `who was diagnosed with hypothyroidism at age 16,! h3 S1 o* H! U+ m8 [/ e
which was treated with thyroxine. The father’s
9 z+ M" [- H* l' x3 N- R+ B4 Zheight was 6 feet, and he went through a somewhat1 z/ L. ?# T" M/ x! t# P8 R1 s5 A7 _( u
early puberty and had stopped growing by age 14.' _  W/ y! q* E5 Q$ _8 Q- i# s
The father denied taking any other medication. The+ n- Q6 L- V; N6 t8 F
child’s mother was in good health. Her menarche* P% N; P8 @  ~* @
was at 11 years of age, and her height was at 5 feet/ X$ A& W" c, d- s
5 inches. There was no other family history of pre-
, w( L3 N$ z; b  N1 z, acocious sexual development in the first-degree rela-' t. o1 h- {* ^# @7 {
tives. There were no siblings.
- z, \5 _8 l5 k0 NPhysical Examination3 G7 E! k9 l$ f* m
The physical examination revealed a very active,
6 k4 ?3 T1 i" {: Fplayful, and healthy boy. The vital signs documented" e- O+ w+ l! }* R+ [
a blood pressure of 85/50 mm Hg, his length was
, W" X9 C( ]3 H7 ]90 cm (>97th percentile), and his weight was 14.4 kg
. S' R3 o# u$ i) l1 y: p0 H# [(also >97th percentile). The observed yearly growth
! ]; L/ G; y0 X( I7 F3 C9 uvelocity was 30 cm (12 inches). The examination of1 u9 g$ y3 A  ^+ Q
the neck revealed no thyroid enlargement.3 _- O) ^# @6 ?
The genitourinary examination was remarkable for5 b, B$ n9 c: T1 S$ J9 O) Q
enlargement of the penis, with a stretched length of
* D3 ]! ?5 _- ^+ j8 cm and a width of 2 cm. The glans penis was very well
2 \% m6 i/ g' J! F' J4 qdeveloped. The pubic hair was Tanner II, mostly around
/ v( h( T& H% m5 }" H5406 b& I' u, x. I7 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% B  a& N$ d. l( u  R" [the base of the phallus and was dark and curled. The- ~1 I2 K+ \" p7 V! y# N
testicular volume was prepubertal at 2 mL each.
4 D' E* b: Z8 U0 RThe skin was moist and smooth and somewhat1 A- {& X" A! I! j) m, A
oily. No axillary hair was noted. There were no6 r1 E# H$ K* W* {
abnormal skin pigmentations or café-au-lait spots.$ l! O& U: r. o% {$ W% l( S* @, Y
Neurologic evaluation showed deep tendon reflex 2+
1 m+ g% T6 P! `3 y% tbilateral and symmetrical. There was no suggestion
: {( O8 K( V8 o, wof papilledema.
/ D0 I  K+ m2 [9 R3 y( G3 aLaboratory Evaluation
! R3 R  ?& l0 m. E$ qThe bone age was consistent with 28 months by/ x. q9 R$ H+ V. C1 ?, I3 o" H
using the standard of Greulich and Pyle at a chrono-4 ~& _  W% R# j7 H3 W) C
logic age of 16 months (advanced).5 Chromosomal1 E7 [1 s3 G$ |7 d/ R
karyotype was 46XY. The thyroid function test. W5 Z2 k) X" C% |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! h7 S* M0 P. z/ k8 ~- i1 h0 v
lating hormone level was 1.3 µIU/mL (both normal).
) w9 d- c8 i: d1 y# n7 r: oThe concentrations of serum electrolytes, blood) I1 K% P( [% n) N) R% R
urea nitrogen, creatinine, and calcium all were# T  s, ^; h* P7 Q; p
within normal range for his age. The concentration
) h9 A5 Q& w; E7 Kof serum 17-hydroxyprogesterone was 16 ng/dL7 C3 s  S& g& ?! e
(normal, 3 to 90 ng/dL), androstenedione was 20
/ u* E7 n$ Y  R$ P0 j( R. tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 K# {6 G7 }6 T; u- N  X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 A1 ?( F. d4 v  G% `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( {7 G  Z) Z: ~0 i8 Z9 W8 U4 O
49ng/dL), 11-desoxycortisol (specific compound S)0 z3 h! N! ~# D5 t( c" }' v5 Y# |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 [0 B4 K! v/ xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 g$ F( l* P+ d8 |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),  B4 r8 G: S( a  a9 B
and β-human chorionic gonadotropin was less than' V3 c$ ?5 F+ A
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 [' A/ T0 U# a* s% Z4 }
stimulating hormone and leuteinizing hormone
! G: h+ S0 j* b7 Yconcentrations were less than 0.05 mIU/mL9 w" P2 z/ {$ N8 N3 ?! o5 L9 A
(prepubertal).
1 j* B: |  ~) ^. \/ k) U- y# UThe parents were notified about the laboratory
6 S' W& I1 {3 g, \: s/ H! {) xresults and were informed that all of the tests were9 ?! E' f: C# B
normal except the testosterone level was high. The
. W) u$ R. }% O. }/ w$ N% kfollow-up visit was arranged within a few weeks to
, l  z; Q: _2 S$ Dobtain testicular and abdominal sonograms; how-, M" Y  q# U) s+ B, H" U
ever, the family did not return for 4 months.
8 j' e5 [- h7 o% `5 lPhysical examination at this time revealed that the
6 R. F" s! s: O* r9 K3 Bchild had grown 2.5 cm in 4 months and had gained
8 v! }$ o5 Q9 w+ y2 kg of weight. Physical examination remained2 |$ c' U- t1 D$ r) u  A
unchanged. Surprisingly, the pubic hair almost com-, _7 N4 O. H6 Q1 |% U, T1 X, o
pletely disappeared except for a few vellous hairs at
# i$ Z7 r: v9 S2 U1 e8 n: tthe base of the phallus. Testicular volume was still 2
3 x: W: u, S8 W) [  [mL, and the size of the penis remained unchanged.9 M3 L  a4 j) J) D# u$ x; r# n
The mother also said that the boy was no longer hav-; ^* }% f& ~/ F% X% k  y
ing frequent erections.: b7 Q  h0 ?0 D7 ]* N, w8 ^# B% u
Both parents were again questioned about use of% n1 T% w0 @+ W: t9 P* n
any ointment/creams that they may have applied to1 S) X; E% h& t- h, h
the child’s skin. This time the father admitted the
/ E8 A; M$ S7 Y5 |8 ]Topical Testosterone Exposure / Bhowmick et al 541
! t' H3 ]: J& L. I- m1 |use of testosterone gel twice daily that he was apply-7 G# g8 Z5 N* |: p" X7 o
ing over his own shoulders, chest, and back area for  y6 n& s! G& u3 o0 s, @4 F* q
a year. The father also revealed he was embarrassed
( U& h( D% }. z5 T4 b" y; q. Qto disclose that he was using a testosterone gel pre-
9 q5 S, P$ t* _- p# {$ rscribed by his family physician for decreased libido4 U( a8 x# M) h& ^. M' U* N
secondary to depression.
0 o* K4 d2 @0 M  o* GThe child slept in the same bed with parents.9 B  }. t5 S$ A$ l  W" E
The father would hug the baby and hold him on his
" ^' R) w& s8 x% p1 _chest for a considerable period of time, causing sig-
5 q. w) N; Z& G& r4 Hnificant bare skin contact between baby and father.: c6 S: b. u; b+ C- D
The father also admitted that after the phone call,
: J7 ?: N7 o. d4 d4 ywhen he learned the testosterone level in the baby  U$ q: h2 O/ ?2 f
was high, he then read the product information
4 `7 j% L( \' ypacket and concluded that it was most likely the rea-
. L6 r$ t! S- D. Y" z7 E  L! @son for the child’s virilization. At that time, they
' d& u; v1 o! T( y1 q4 Hdecided to put the baby in a separate bed, and the) @" F! U1 b8 H7 O5 S
father was not hugging him with bare skin and had
0 O- F- e/ V2 z& Y( dbeen using protective clothing. A repeat testosterone
8 _0 J  `; ]% l5 V, }test was ordered, but the family did not go to the$ u1 q5 }" t6 g7 [; }
laboratory to obtain the test.# G5 X2 D+ x1 ?% I* w' A
Discussion
( n5 o+ u% y4 UPrecocious puberty in boys is defined as secondary
! d" C' A8 C* L) H: psexual development before 9 years of age.1,4( E) `( O' \6 Y- h3 k1 A- B3 p  e
Precocious puberty is termed as central (true) when. k# }) B" G, T) a: r7 V8 `" P' \$ w
it is caused by the premature activation of hypo-) c6 [/ O) w! s" \# d  O6 _
thalamic pituitary gonadal axis. CPP is more com-! S& r. g8 F' ?) {" p4 f6 e
mon in girls than in boys.1,3 Most boys with CPP8 l" u! B3 g! a9 h' ]
may have a central nervous system lesion that is. `( I  B# d" M' t& O. w4 X
responsible for the early activation of the hypothal-. w( H! g2 f# M  I1 M4 Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
- s- O4 H4 s, C  T& D1 z9 |sis has been given to neuroradiologic imaging in. H8 a) L3 O4 r. f& O5 Y
boys with precocious puberty. In addition to viril-
. t0 G& d6 {$ `ization, the clinical hallmark of CPP is the symmet-5 o% [% u: _3 h. `
rical testicular growth secondary to stimulation by7 @( E+ \: [' ^
gonadotropins.1,3
8 w+ a( r7 b/ h1 l. h1 tGonadotropin-independent peripheral preco-1 p8 B" ?" @2 }, C3 a
cious puberty in boys also results from inappropriate/ X4 }; W9 T5 f
androgenic stimulation from either endogenous or
9 T% r1 o% L, ~0 _exogenous sources, nonpituitary gonadotropin stim-4 {9 a% M/ h( e- f8 q1 F5 `
ulation, and rare activating mutations.3 Virilizing
! @' B' Z  o, k  Y5 s2 B- m# ?+ jcongenital adrenal hyperplasia producing excessive5 N' B$ I" D% F7 Z$ s" M* `( H) F4 @
adrenal androgens is a common cause of precocious
2 K" \0 i0 B5 B) |puberty in boys.3,47 z) u4 a6 L7 ^- H) N
The most common form of congenital adrenal) V4 K) O( Q, Y9 t1 H
hyperplasia is the 21-hydroxylase enzyme deficiency.- L) q+ ^7 b) u
The 11-β hydroxylase deficiency may also result in
# E6 F# \2 O4 N4 Q( Z) ^( I' E: @3 hexcessive adrenal androgen production, and rarely,/ T3 e8 O5 o: t8 K& v
an adrenal tumor may also cause adrenal androgen
/ P$ @6 Q# s$ h( rexcess.1,3
' S/ F* R9 M8 Z9 @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* f5 x$ ^4 F0 X( R% B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 `" k8 W+ s# U. \7 c: \4 eA unique entity of male-limited gonadotropin-
% Z6 S& _( I# x4 q% E8 N* S) pindependent precocious puberty, which is also known/ O$ K/ \- h/ T% n( q0 N
as testotoxicosis, may cause precocious puberty at a  F( ^/ h5 H' T8 x( |  p
very young age. The physical findings in these boys& @' E2 g: a8 ?0 a- Z
with this disorder are full pubertal development,
; R7 _" T* i, e# A7 [7 qincluding bilateral testicular growth, similar to boys; P" _9 S! I: o& `; g: \; m
with CPP. The gonadotropin levels in this disorder  J- M* k$ J; C7 E- i
are suppressed to prepubertal levels and do not show
+ D, g# F; D' \: @6 opubertal response of gonadotropin after gonadotropin-9 O8 s" t' g7 t/ j
releasing hormone stimulation. This is a sex-linked  O0 d, L0 j- n8 C9 ]
autosomal dominant disorder that affects only
) V0 a6 [# c5 k; D. S3 u7 A: m1 o3 j) \males; therefore, other male members of the family
. E7 x5 r$ x! {3 S  p/ Kmay have similar precocious puberty.3: Z. q3 q5 M: u( {' U& h2 x
In our patient, physical examination was incon-
7 o- ?. I/ \  W* ^( `sistent with true precocious puberty since his testi-4 c0 y7 q" q, Z3 t5 `6 o) ^* m
cles were prepubertal in size. However, testotoxicosis
. H$ X' ]1 H9 c& ]was in the differential diagnosis because his father
  i" ~; {8 W, C" S% {started puberty somewhat early, and occasionally,% f( x2 r8 J8 s1 z3 G, e. e* A
testicular enlargement is not that evident in the
+ j2 e) b5 ?5 j" k* Q/ w9 Cbeginning of this process.1 In the absence of a neg-6 q% N7 B- n' V7 p
ative initial history of androgen exposure, our4 L2 z# @3 E/ A
biggest concern was virilizing adrenal hyperplasia,5 v3 ]0 \' ?9 ~; m! E& S$ h: w
either 21-hydroxylase deficiency or 11-β hydroxylase
% b$ }& ?5 z& q6 X, kdeficiency. Those diagnoses were excluded by find-
2 m; t. }9 e1 U  king the normal level of adrenal steroids.
1 K( e+ X) C+ N2 Q: |! pThe diagnosis of exogenous androgens was strongly8 {8 T: Z5 g5 c5 t7 @: T7 M
suspected in a follow-up visit after 4 months because
) B$ U$ e3 j3 Vthe physical examination revealed the complete disap-
# z0 X" n; v4 Tpearance of pubic hair, normal growth velocity, and, O( t2 C* f7 e8 v, [
decreased erections. The father admitted using a testos-; u: D! q7 i# W3 W3 v( D3 |9 M, W( P
terone gel, which he concealed at first visit. He was
/ _7 [, J# Q3 w4 N6 Uusing it rather frequently, twice a day. The Physicians’
2 k) W9 m2 B' T& N! aDesk Reference, or package insert of this product, gel or
( z+ Q/ O" |$ U+ Jcream, cautions about dermal testosterone transfer to
/ L, K3 n, o. ?6 S  O! Dunprotected females through direct skin exposure.
4 F; h6 }& W6 e, SSerum testosterone level was found to be 2 times the2 F0 Q, I% a# c5 }# b3 @7 d
baseline value in those females who were exposed to
+ J% [& m2 r3 k, J5 Keven 15 minutes of direct skin contact with their male: w1 h2 _! i* z0 N. {
partners.6 However, when a shirt covered the applica-" J0 s* ]4 K+ c; Z. Y( ~
tion site, this testosterone transfer was prevented.: e/ X$ |0 r3 \# Q3 e9 J9 h' w
Our patient’s testosterone level was 60 ng/mL,
2 E+ ~/ ^6 |* d" Pwhich was clearly high. Some studies suggest that4 ^7 [+ m0 v, C. J0 s4 U& @
dermal conversion of testosterone to dihydrotestos-! ?0 V" P% [0 A
terone, which is a more potent metabolite, is more
6 [# {, J' p- Uactive in young children exposed to testosterone! j) g, y6 ~* Z0 Q
exogenously7; however, we did not measure a dihy-; U1 e1 ^( f5 F, J* r8 r
drotestosterone level in our patient. In addition to' o& W* t& K  W
virilization, exposure to exogenous testosterone in; T8 M: Y; u2 ?& ]' B: v* X! k  _
children results in an increase in growth velocity and- e! J7 h3 ^4 i# H9 o
advanced bone age, as seen in our patient.* [8 M4 B0 `3 ?8 U5 }7 ]
The long-term effect of androgen exposure during2 k2 y# _# [3 z7 C" v/ @) |
early childhood on pubertal development and final% `" }' V) W) m
adult height are not fully known and always remain* t) N5 W, A& G, \( d
a concern. Children treated with short-term testos-' K9 H$ [9 e3 }' q5 _/ g
terone injection or topical androgen may exhibit some. S- j, @' i0 T( u$ h' V% J
acceleration of the skeletal maturation; however, after
! I0 F- o. L4 hcessation of treatment, the rate of bone maturation
0 k1 k' F: k# V# i- X$ Idecelerates and gradually returns to normal.8,9  Y, A& G' d3 J0 i& r
There are conflicting reports and controversy
1 E- g: h  h5 v8 g4 vover the effect of early androgen exposure on adult4 ?2 H# Y" O( m7 ^( g8 J7 o6 e
penile length.10,11 Some reports suggest subnormal  n# l( ]% t! {2 ]
adult penile length, apparently because of downreg-! h8 s2 _+ O' x) c; F. ^$ u& g4 ~
ulation of androgen receptor number.10,12 However,+ t# \* G% N6 s# |/ a- k
Sutherland et al13 did not find a correlation between9 v8 H( j" U- w& T' N" e* |
childhood testosterone exposure and reduced adult, x9 m8 e) G: i/ e$ o/ f: K$ T
penile length in clinical studies.
5 r3 O) X* q$ P1 I; X- ANonetheless, we do not believe our patient is) V; A( N* C0 T: Z) A1 F
going to experience any of the untoward effects from
1 I( y: C' |9 H7 v/ d- Wtestosterone exposure as mentioned earlier because- R3 T; Y8 @2 V3 q) J! I  Y
the exposure was not for a prolonged period of time.# u3 y5 H2 e! {" }. v
Although the bone age was advanced at the time of
/ E. ~; A6 q/ p& qdiagnosis, the child had a normal growth velocity at  D& {! J' K* Q( O
the follow-up visit. It is hoped that his final adult  T) E2 J! E* X1 Z3 t
height will not be affected.
, X) y* ~$ q, Q5 Z( uAlthough rarely reported, the widespread avail-
; z7 w1 i& k( Mability of androgen products in our society may5 H, S. N' J4 u" F: u( N
indeed cause more virilization in male or female! x9 V# |' n7 Q, H0 Y
children than one would realize. Exposure to andro-4 U: Z- z# M# a& P
gen products must be considered and specific ques-
1 q1 [' a$ \' z; y8 @: [. V0 stioning about the use of a testosterone product or; o2 C% C1 L9 F3 i" a( p) T
gel should be asked of the family members during" T! M: i  i; V8 ]
the evaluation of any children who present with vir-% T/ c1 d4 d/ [: N# a
ilization or peripheral precocious puberty. The diag-
9 \- Z9 h8 q) o9 M2 \/ O; \nosis can be established by just a few tests and by6 Q6 R) C. J7 X6 s+ E
appropriate history. The inability to obtain such a
" B7 e( [1 u" O, o6 Y9 Q5 e5 ~' A0 }history, or failure to ask the specific questions, may! G8 L) [1 U& X: E$ t0 B* o. z
result in extensive, unnecessary, and expensive
0 I& c: y8 J$ v) m/ m3 M! ?investigation. The primary care physician should be
3 D: C6 G0 z: K3 |* N- N- a: eaware of this fact, because most of these children! X1 d- K8 V& E# u
may initially present in their practice. The Physicians’
4 Y, A! I! {2 s9 x6 SDesk Reference and package insert should also put a
/ }' J" g  O- y! ~* Twarning about the virilizing effect on a male or
! r$ O$ G3 i/ d+ lfemale child who might come in contact with some-: Y. X, _) z8 L
one using any of these products.. K- B5 U% ]" x5 ?+ z; a6 u
References6 Y! ^8 C0 ?. q/ m
1. Styne DM. The testes: disorder of sexual differentiation0 q& W) }/ o; Z3 ~$ G# X$ l" q
and puberty in the male. In: Sperling MA, ed. Pediatric
6 U+ r+ P8 k8 N/ F8 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 o5 N0 R0 Y' C* V2 I, ]7 q% O2002: 565-628.
! P9 j) G: c% f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 b# F$ p% E0 [9 V. `4 v( E
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
( }/ g+ q/ t3 P& }/ }6 r& fBoy Induced by Indirect Topical. G: N! ?! z6 N% w% z- p+ p% [2 X
Exposure to Testosterone
& \' D+ |: f4 ]" G' |5 }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# N& l# R5 W2 m# O# Kand Kenneth R. Rettig, MD11 b3 k, d! [$ U+ H0 h
Clinical Pediatrics
8 z  ?! {6 @  K" e4 j5 G: e. _3 cVolume 46 Number 6# H6 D- k" L& A" L
July 2007 540-5431 c. O% D$ k3 r' R
© 2007 Sage Publications* f$ [) l  r: U6 c7 `
10.1177/00099228062966511 T* V  B$ e' ?( a( s
http://clp.sagepub.com: f+ `! s1 D( W9 `# ~( s$ h
hosted at. H% W; E* c, a& l, ^' L$ x
http://online.sagepub.com$ Q0 T  a8 O, q" U( L! }
Precocious puberty in boys, central or peripheral,' a- U* O; W! g8 {0 ~6 x1 o0 }
is a significant concern for physicians. Central+ P4 K# E8 O+ L( v
precocious puberty (CPP), which is mediated
- k) o6 ]8 V4 Q) Vthrough the hypothalamic pituitary gonadal axis, has) M6 a8 e5 o: ~9 A/ o! ~
a higher incidence of organic central nervous system7 I7 R$ q( }# C9 u. m
lesions in boys.1,2 Virilization in boys, as manifested
" }0 D/ b. x; w' O+ ?" Bby enlargement of the penis, development of pubic
  s: V& a+ W% l3 Shair, and facial acne without enlargement of testi-
8 |  H$ A' q# C3 r5 U4 [cles, suggests peripheral or pseudopuberty.1-3 We
0 `1 n0 I- @+ o: a% {3 D/ Ereport a 16-month-old boy who presented with the
+ p) ]0 i5 `, F& T$ l+ aenlargement of the phallus and pubic hair develop-
+ T7 ?. @; f* gment without testicular enlargement, which was due
5 k! M: ~9 V. Tto the unintentional exposure to androgen gel used by+ e2 t; c3 _5 J& ~4 A
the father. The family initially concealed this infor-* y* Q% N3 R# R$ K
mation, resulting in an extensive work-up for this2 P. I4 U1 H  [0 o% y
child. Given the widespread and easy availability of
$ k' c  n* k& ?8 A: |testosterone gel and cream, we believe this is proba-
1 M/ O+ n! Y# Nbly more common than the rare case report in the. j/ Y, L0 I3 o/ {0 g! b! ]2 k& w
literature.4! o; _% J9 h9 t/ G9 C
Patient Report
/ L5 D: s4 \  q. s: VA 16-month-old white child was referred to the
' g/ B3 t2 U) W1 k& k% nendocrine clinic by his pediatrician with the concern
. F+ i1 h3 J6 e! c% R# Yof early sexual development. His mother noticed
$ _% \* s; S" i7 A) Wlight colored pubic hair development when he was
: d- D/ o5 f# H+ Q: xFrom the 1Division of Pediatric Endocrinology, 2University of
. `' ^" d5 \- U& `' tSouth Alabama Medical Center, Mobile, Alabama.
- Q% J: l/ \. q7 H; k$ ]Address correspondence to: Samar K. Bhowmick, MD, FACE,' _7 a& q  P& r- ^
Professor of Pediatrics, University of South Alabama, College of% L+ r/ ^# N- _$ n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 ~: @# ^, i+ G' ^: d! Ze-mail: [email protected].- f1 N! G6 s& m% A
about 6 to 7 months old, which progressively became5 U( v; ~9 N; z. [7 \* D
darker. She was also concerned about the enlarge-4 F3 Q* S- d9 S# K; C! K
ment of his penis and frequent erections. The child
/ m# k" }. Z( e  x7 k  \was the product of a full-term normal delivery, with
$ a7 l  H- w8 w. F/ u  |5 ra birth weight of 7 lb 14 oz, and birth length of& O3 g; f, n( V8 t8 d+ P
20 inches. He was breast-fed throughout the first year
( }$ Q) [! T, v, Q6 m8 Wof life and was still receiving breast milk along with
2 R% U4 N+ M5 v  Esolid food. He had no hospitalizations or surgery,
' ^! Z  U; D! t: N; Band his psychosocial and psychomotor development
( p) _: a! }1 D9 ?' d  S+ t! Fwas age appropriate.' d+ s' @( k8 w
The family history was remarkable for the father,
4 q; c; E1 n# C1 xwho was diagnosed with hypothyroidism at age 16,
; P' K- l6 Y3 Z* g. t8 t0 t& swhich was treated with thyroxine. The father’s
( a( s) u5 C. T9 w7 Qheight was 6 feet, and he went through a somewhat
' ^( J! k8 p& jearly puberty and had stopped growing by age 14.; V* l4 U& L' m% j" z
The father denied taking any other medication. The) e2 k4 v; R, F3 D; j8 K
child’s mother was in good health. Her menarche( W, m. v! J7 L8 X" A
was at 11 years of age, and her height was at 5 feet+ h& _5 ~" H9 t6 B8 Q1 A
5 inches. There was no other family history of pre-1 s+ h$ D" n4 l( Z
cocious sexual development in the first-degree rela-, g: \& {4 u" y' Y+ }
tives. There were no siblings.
5 C1 Y; O; B' r1 kPhysical Examination( t5 d! Z# |' l9 r* k' |
The physical examination revealed a very active,
/ A# F7 ]* e  I1 n# wplayful, and healthy boy. The vital signs documented& q7 _4 ~* S* P# P8 r
a blood pressure of 85/50 mm Hg, his length was
/ L! e/ s  A/ U90 cm (>97th percentile), and his weight was 14.4 kg
- t6 i% t9 b. C(also >97th percentile). The observed yearly growth
! U' C, c7 d, k' Lvelocity was 30 cm (12 inches). The examination of
0 m6 C9 }( w2 H- ^2 r: V6 @the neck revealed no thyroid enlargement.! M" @1 Y6 w4 E, d$ h
The genitourinary examination was remarkable for* }/ G: G1 c# u0 m! j8 I  f
enlargement of the penis, with a stretched length of
( `1 D: b& b/ e: n# x" A8 cm and a width of 2 cm. The glans penis was very well
+ |! a/ @# l0 I1 ]6 |+ cdeveloped. The pubic hair was Tanner II, mostly around0 a4 i4 M6 O% c' X$ D' C
540
& D0 W& X. O4 E2 t/ z% \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ ~, z1 \& {4 \. u) K( ~3 H* C7 q
the base of the phallus and was dark and curled. The2 ^2 G" V9 p& y8 ?2 ?4 Z
testicular volume was prepubertal at 2 mL each.6 q  a0 {( d6 `0 u/ A% }  y
The skin was moist and smooth and somewhat1 W+ P" _$ v" Y; ?$ A4 b
oily. No axillary hair was noted. There were no
# e) `, P4 C8 Z3 ]: m* oabnormal skin pigmentations or café-au-lait spots.
" a8 o( G3 o" e' k, RNeurologic evaluation showed deep tendon reflex 2+) H* G/ w: G6 }$ O
bilateral and symmetrical. There was no suggestion- }; |6 ^: I/ r5 k  V' {. N
of papilledema.
/ V" m/ d" u2 X# h1 V  DLaboratory Evaluation8 N& u- u* c5 A9 [
The bone age was consistent with 28 months by
1 [2 @- o6 O" C* L" ~! rusing the standard of Greulich and Pyle at a chrono-4 B# g+ d& A& b
logic age of 16 months (advanced).5 Chromosomal
1 K& L' N) O% K* p. s+ G( lkaryotype was 46XY. The thyroid function test! _9 g7 Z* R3 w- q6 x7 j. k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ L6 w, D2 A& Ylating hormone level was 1.3 µIU/mL (both normal).& y4 U3 K! V) V# G6 E
The concentrations of serum electrolytes, blood
: S, J# @2 u. m  Jurea nitrogen, creatinine, and calcium all were' t' ~. S5 w, J
within normal range for his age. The concentration
( d$ z3 |& y8 x& Sof serum 17-hydroxyprogesterone was 16 ng/dL
" X9 L( r) k1 m2 P* f(normal, 3 to 90 ng/dL), androstenedione was 20
0 v7 {$ v) a# E& V, B: Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 n( }: o2 E$ [5 C) w1 y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 X4 f2 o$ i$ i9 Y, R+ r! x) u! s* Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to9 N- s: P9 C6 M# y- R" N) y
49ng/dL), 11-desoxycortisol (specific compound S)
* _, @  Z( d$ z, m$ `0 f' c: owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 T$ p) Q, Z7 U' d" [1 o1 i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ M0 r' s! i$ }* O/ G+ |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 g3 u2 B3 k  ~# s% D  `* B  U
and β-human chorionic gonadotropin was less than
# d+ c! y$ c* s: ^$ \7 n7 F5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ b; \3 K) O; Estimulating hormone and leuteinizing hormone5 }' w  D  T. k' ~4 w& ^, e+ Y' D. s7 t
concentrations were less than 0.05 mIU/mL" I1 H! L: l8 q( p
(prepubertal).: Z( y5 ?" T* x. J- _
The parents were notified about the laboratory: }- a$ V/ L6 N- m4 C6 j- m% o
results and were informed that all of the tests were2 J0 V( P" L; c( N4 K8 F
normal except the testosterone level was high. The
6 S/ s* h) J7 t* |5 z3 Lfollow-up visit was arranged within a few weeks to) P0 F* A% v# Z( w) E8 c9 z
obtain testicular and abdominal sonograms; how-" B1 e* i3 k- F% v; v
ever, the family did not return for 4 months.
. D: p4 f7 }. m1 FPhysical examination at this time revealed that the( L8 [% z8 _: w+ L! s! C! s
child had grown 2.5 cm in 4 months and had gained
, h, K6 ]! J( T2 kg of weight. Physical examination remained
8 W! ]+ [5 W1 X& ]unchanged. Surprisingly, the pubic hair almost com-
1 H0 [$ E( W' c! }/ E4 wpletely disappeared except for a few vellous hairs at6 h5 X: f- y4 E2 j5 J; f8 Q2 j
the base of the phallus. Testicular volume was still 2
" [# I$ y8 t0 B  WmL, and the size of the penis remained unchanged.! k8 N5 r1 @" _  |, B$ [1 m$ Q: i
The mother also said that the boy was no longer hav-
, N5 r5 z$ J/ |; L. B. cing frequent erections.
8 \- I: B: O) K! O7 a2 U+ iBoth parents were again questioned about use of
  G1 O' B- Z1 E$ _! P. yany ointment/creams that they may have applied to. x2 o. Y  y- Q' ]
the child’s skin. This time the father admitted the. R4 j# `3 f2 c5 Z/ x! o' x/ v
Topical Testosterone Exposure / Bhowmick et al 541+ `8 A( T. r. q+ s. P+ x  ?% D+ b
use of testosterone gel twice daily that he was apply-+ }; l0 a( C- f- ?7 n7 c
ing over his own shoulders, chest, and back area for
1 q& u1 h+ \! ]  pa year. The father also revealed he was embarrassed
$ T- V% c7 S- Z; |& P5 bto disclose that he was using a testosterone gel pre-
: q0 x! U% B' w  F* k5 ?  Xscribed by his family physician for decreased libido
! ~1 E4 ^; a5 @( i; Rsecondary to depression.% T. F+ \9 z" z+ x$ P
The child slept in the same bed with parents.
) \; e. H& d! e0 JThe father would hug the baby and hold him on his
' {1 i: ^3 ~. Y! Rchest for a considerable period of time, causing sig-
4 b* s+ o! S/ r) Knificant bare skin contact between baby and father.) M. C" l! w5 W( P& d3 q
The father also admitted that after the phone call,: ~! E: `# r1 ^& d) B: L. D
when he learned the testosterone level in the baby
5 |; T8 e4 C$ v0 T6 ?" ^7 [' swas high, he then read the product information7 d8 W2 `' e, e  C9 T3 ^* x
packet and concluded that it was most likely the rea-3 A1 [: z! k! t
son for the child’s virilization. At that time, they# _; a2 R, R7 @! x: [
decided to put the baby in a separate bed, and the
, k- A" W2 v- u4 p! Afather was not hugging him with bare skin and had
" `% H7 G; r% E1 \& Tbeen using protective clothing. A repeat testosterone4 ^" J# E- P/ A: H
test was ordered, but the family did not go to the
! r5 L+ O, T4 T, Olaboratory to obtain the test.
$ J$ J( H% |( n/ B. ~Discussion5 t5 j/ r5 q& d- `* e0 H0 W
Precocious puberty in boys is defined as secondary
7 q  [5 E$ ~- m: _2 y' Y! S# X3 Wsexual development before 9 years of age.1,4
9 p/ O& V1 H# H. r4 d  ?) ?Precocious puberty is termed as central (true) when' J6 Y" N% T" k% }1 E' O
it is caused by the premature activation of hypo-
$ H7 s7 U1 j: rthalamic pituitary gonadal axis. CPP is more com-7 t+ ~# C( S  J
mon in girls than in boys.1,3 Most boys with CPP) r0 _$ \$ g. V
may have a central nervous system lesion that is
4 h: E/ Q. C! U- }responsible for the early activation of the hypothal-, a, b( |/ H+ N' K+ T+ d) `
amic pituitary gonadal axis.1-3 Thus, greater empha-9 p  y9 z0 B: q' z6 K
sis has been given to neuroradiologic imaging in
# ]! d. x$ M( m* D" i- d( a) oboys with precocious puberty. In addition to viril-/ i0 ^7 V6 j+ ^1 [% _
ization, the clinical hallmark of CPP is the symmet-% A0 x- [, t! O, j& y/ I
rical testicular growth secondary to stimulation by
$ U- ~4 d, ^2 ^5 i' j! xgonadotropins.1,3' U5 J: z$ Q( G
Gonadotropin-independent peripheral preco-$ x. M1 v5 [. A- n
cious puberty in boys also results from inappropriate
# {+ B& {8 n1 U. J: _) Bandrogenic stimulation from either endogenous or& G* d0 f6 ?5 I& e& O
exogenous sources, nonpituitary gonadotropin stim-( |7 C* z+ m$ R) b/ K: [6 @+ E, v
ulation, and rare activating mutations.3 Virilizing4 Z# C  Q, T( Z3 R5 w: K
congenital adrenal hyperplasia producing excessive
( G  ?: Z) Z# |) D/ K/ cadrenal androgens is a common cause of precocious
6 S2 l7 o, z3 o5 ^puberty in boys.3,4
% ?# ?( D3 A# U% bThe most common form of congenital adrenal
0 |+ R: N7 H$ t$ f+ Rhyperplasia is the 21-hydroxylase enzyme deficiency.  @7 j% ]3 j8 V& y- O
The 11-β hydroxylase deficiency may also result in
; o  ~) ]2 {- Yexcessive adrenal androgen production, and rarely,& B5 L, |% k7 R4 n: x2 v( `4 l
an adrenal tumor may also cause adrenal androgen( |  e. v0 o& W8 E* L8 a' t
excess.1,3- [9 n. d& ^! n; J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& {: u1 O/ h% ]" c! X) `5 ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! P- j# A4 Y$ X; AA unique entity of male-limited gonadotropin-
% ~/ U! G$ ~# D2 @independent precocious puberty, which is also known: u1 V. E  r' |  W2 X# b
as testotoxicosis, may cause precocious puberty at a
0 j8 J4 ^; H( s8 F* [8 @/ x+ k( dvery young age. The physical findings in these boys; O3 v+ n0 ^3 K, b2 n
with this disorder are full pubertal development,
7 m* S4 T4 v4 ~( |including bilateral testicular growth, similar to boys) l  N) x* L! W6 `; e3 E7 i
with CPP. The gonadotropin levels in this disorder9 B1 F; F6 F+ _; c" Y; b; U
are suppressed to prepubertal levels and do not show: O7 ^8 ~2 C- Z( b; i
pubertal response of gonadotropin after gonadotropin-
$ ^* B8 @8 z% o* W* W; creleasing hormone stimulation. This is a sex-linked
3 T! r8 ]# C$ |  ~9 `  |, ^autosomal dominant disorder that affects only7 r& g( Z* i& F* A+ [
males; therefore, other male members of the family
+ N$ c# h& Y& p3 c6 emay have similar precocious puberty.3
, f3 }# P9 b, F4 F/ ]1 ^5 A* AIn our patient, physical examination was incon-: m, }: X, s6 ]6 L1 q9 |" H
sistent with true precocious puberty since his testi-! k3 [9 _# u* f0 O
cles were prepubertal in size. However, testotoxicosis
, J  ~6 K# F- ^) h8 b  {& Uwas in the differential diagnosis because his father
1 b3 H( R+ `3 {" k/ T, mstarted puberty somewhat early, and occasionally,7 m" q) o! e5 G& s3 [2 {
testicular enlargement is not that evident in the9 Z. i8 x& }2 l6 X4 W
beginning of this process.1 In the absence of a neg-4 {. J0 o& K1 m+ ^8 ]: E1 n/ [
ative initial history of androgen exposure, our
' T3 K  ~7 r5 [& s4 U% Fbiggest concern was virilizing adrenal hyperplasia,
) Q/ _, \8 |# R! }0 heither 21-hydroxylase deficiency or 11-β hydroxylase) U" t+ H. E; w
deficiency. Those diagnoses were excluded by find-5 z# a6 D" r9 B$ ?' X( n6 k
ing the normal level of adrenal steroids.8 o. w& j1 M5 C" _, E% i
The diagnosis of exogenous androgens was strongly  z$ B3 E& X2 o& T
suspected in a follow-up visit after 4 months because  `; ^: X! V' Z/ `; x3 u0 H' g+ A
the physical examination revealed the complete disap-* B+ A7 m' {+ M: _
pearance of pubic hair, normal growth velocity, and
) T& B1 ]$ q; s9 w" Ndecreased erections. The father admitted using a testos-  T% M3 U& o6 g! ^  K
terone gel, which he concealed at first visit. He was
( t1 l  W. g) V/ |using it rather frequently, twice a day. The Physicians’
  [( {/ q8 a. I8 O" V! A4 Y5 Y1 f8 K* hDesk Reference, or package insert of this product, gel or+ ~2 b, j% g; L& T' r1 ~# [
cream, cautions about dermal testosterone transfer to
9 a6 t  L& Z1 d9 J) c( B5 V+ Punprotected females through direct skin exposure.
; }7 `& y. X& ~- C+ BSerum testosterone level was found to be 2 times the
% T  O/ @- \* J( [baseline value in those females who were exposed to
& J2 v1 _; o8 K5 W+ qeven 15 minutes of direct skin contact with their male
# r( J/ g" W* t$ Y( I+ ~partners.6 However, when a shirt covered the applica-
$ Z' _/ w" V  c6 T' P7 z9 ption site, this testosterone transfer was prevented.6 i6 L" e' y. H' K
Our patient’s testosterone level was 60 ng/mL,& C) C: i. c: n6 v& U
which was clearly high. Some studies suggest that
, o8 J* W  j/ w7 N% ^* w4 zdermal conversion of testosterone to dihydrotestos-& s; V7 S* E6 S0 @
terone, which is a more potent metabolite, is more* w! s& P3 W, O- J1 s- w3 J. j
active in young children exposed to testosterone/ V7 ^) c" k" v: f4 ~1 j
exogenously7; however, we did not measure a dihy-, U1 p& _) J8 r  Q" ]4 i: Z/ T# R8 P
drotestosterone level in our patient. In addition to; W7 x/ K; E/ C8 n2 q& u
virilization, exposure to exogenous testosterone in
/ J3 v5 P- ^! ~* q0 W" R: ?children results in an increase in growth velocity and* V, n( W& q4 s+ d
advanced bone age, as seen in our patient.! u$ r  Y+ c) i
The long-term effect of androgen exposure during/ t7 j7 A: R( K
early childhood on pubertal development and final
# B& N2 o$ q2 yadult height are not fully known and always remain. v7 ^& @) F1 Z, b4 [( E- q
a concern. Children treated with short-term testos-
+ c+ x7 o) n5 W" Wterone injection or topical androgen may exhibit some
1 P, m7 g9 P( B/ U4 I  N  qacceleration of the skeletal maturation; however, after, Y( [  E+ R6 [# ~5 Q7 m9 W3 ?
cessation of treatment, the rate of bone maturation
/ N4 {- \7 I1 R% O! Kdecelerates and gradually returns to normal.8,9
" x  c5 w( h  A, v3 U* @) xThere are conflicting reports and controversy
; V9 `9 D2 z" o3 yover the effect of early androgen exposure on adult
* L2 w! Y. X- I/ t& R4 N  Bpenile length.10,11 Some reports suggest subnormal5 \3 f. _$ |9 ~+ K. O; L
adult penile length, apparently because of downreg-
/ K! B' ~& ]) g, pulation of androgen receptor number.10,12 However,
' a2 M( m5 p9 ESutherland et al13 did not find a correlation between  m7 T: n* U7 k$ _4 P  R* f1 w
childhood testosterone exposure and reduced adult! v6 H6 D, \6 |* {3 I* P
penile length in clinical studies.6 z+ Y; F' V, G. T# J2 e* K5 ]
Nonetheless, we do not believe our patient is
' U7 e9 N- |9 j, Agoing to experience any of the untoward effects from
8 l3 X3 O/ n) Y3 p+ K7 Utestosterone exposure as mentioned earlier because; T5 u. G$ H/ }' v  v8 z5 W
the exposure was not for a prolonged period of time., b* m' d1 i+ f9 t' T4 K" T: J
Although the bone age was advanced at the time of
# ~) p7 q; n! V% d9 ^diagnosis, the child had a normal growth velocity at
; L( Q: c3 P( T9 ~0 p4 Cthe follow-up visit. It is hoped that his final adult
) F3 {0 v" f5 y; s' b' Cheight will not be affected.
; f) V* k# u9 m+ FAlthough rarely reported, the widespread avail-
5 i5 b  p' x/ q+ p7 u/ z# Jability of androgen products in our society may. F6 K* ~6 B& a6 y1 j' S
indeed cause more virilization in male or female- O3 ~" [- O: `
children than one would realize. Exposure to andro-
% V. Z" f% D7 z- }gen products must be considered and specific ques-: f$ b- ^% @$ \* C" j
tioning about the use of a testosterone product or
) E1 p& r8 @" A% ]gel should be asked of the family members during* O" U' Q' L9 P) c9 W: ~
the evaluation of any children who present with vir-$ q' Z. C. c8 b, e  A/ N9 q& g- p
ilization or peripheral precocious puberty. The diag-
( @+ q0 y! S& z% S; [2 X3 Onosis can be established by just a few tests and by, b6 }, C, G4 M' S
appropriate history. The inability to obtain such a
, [  L' G% I% m9 B+ ?- j0 qhistory, or failure to ask the specific questions, may6 ~( V: U# V, g. C& B; S9 }
result in extensive, unnecessary, and expensive$ C6 E& T" t/ F7 U' [  d
investigation. The primary care physician should be
, t, s1 Z: I4 i. N$ Paware of this fact, because most of these children
8 Z" q$ @; h9 P8 u2 g" kmay initially present in their practice. The Physicians’0 R# }. e  n  `+ H/ R! k
Desk Reference and package insert should also put a
/ x2 x; h: K/ Y! ^' i* G% _/ rwarning about the virilizing effect on a male or+ a7 G4 @$ t8 z1 W3 o% z
female child who might come in contact with some-' N/ J5 r' A  Z& C. i- @" z
one using any of these products.* W/ O% g. `+ k
References3 y6 _/ |# ?7 e6 i
1. Styne DM. The testes: disorder of sexual differentiation
7 \# i1 a) w( Q( \8 U. E4 Wand puberty in the male. In: Sperling MA, ed. Pediatric
" w2 h( M! k+ H" S* ~$ P) {; S0 EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ y2 B! Y0 e! X- V# I2 A2 T2002: 565-628.$ \# B$ H& ~6 Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 N+ o$ z) f# g6 c. b5 ipuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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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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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