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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
4 i& ~% D8 ?1 w/ D" s  @# QBoy Induced by Indirect Topical! H  l7 W( V# u6 D
Exposure to Testosterone* F( p3 v, }  [1 B8 }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 W4 N/ Y1 v+ ], Q8 H8 y" M# Tand Kenneth R. Rettig, MD1" t+ d# |+ `* `# |: d, d
Clinical Pediatrics
! N$ x# @7 ^3 A) MVolume 46 Number 6/ k: L& Z: z4 n- N: ^0 [
July 2007 540-543
$ D, E" R$ H" R7 I  \© 2007 Sage Publications
+ U* o$ f% c6 e10.1177/0009922806296651
" K0 V  P: S& Ahttp://clp.sagepub.com
! ~  p. j$ ~. z9 p2 D  S# g* zhosted at; f: |$ p# v) k: c, f
http://online.sagepub.com
2 k% F' Z, N* i: W$ ^8 b/ D& `Precocious puberty in boys, central or peripheral,# l4 q3 q% L' J/ i) F
is a significant concern for physicians. Central
+ |4 Q# `/ I$ [, I: S& Rprecocious puberty (CPP), which is mediated& N% n% `: f  d
through the hypothalamic pituitary gonadal axis, has. C9 I5 P- e" a: b1 h, W2 c0 B
a higher incidence of organic central nervous system7 Q6 _  `$ X& _' d
lesions in boys.1,2 Virilization in boys, as manifested" b9 E( I) u- w6 \* N3 T
by enlargement of the penis, development of pubic
- f. n; b; e: O* e. [  Ehair, and facial acne without enlargement of testi-! k8 Q& n! [8 c7 \- U" y
cles, suggests peripheral or pseudopuberty.1-3 We' H3 H' H9 N% w) f# k; o/ \, f$ b
report a 16-month-old boy who presented with the
. ~5 p6 R3 {$ [9 j* Henlargement of the phallus and pubic hair develop-
" W: X$ o8 M  ~* [( }  Jment without testicular enlargement, which was due
1 e' g) [8 \1 ^to the unintentional exposure to androgen gel used by
2 o* q1 r" A  G+ Cthe father. The family initially concealed this infor-! b  u- @1 L7 |' l
mation, resulting in an extensive work-up for this
) s; \, J+ W, Pchild. Given the widespread and easy availability of: n' P$ C4 ^$ S* Y+ o; v3 q
testosterone gel and cream, we believe this is proba-
; c: x, v' q# ubly more common than the rare case report in the
3 R! }7 M- R- v6 s* {literature.4
; M  `& X; ]7 @+ t2 jPatient Report
3 J7 q# R3 {4 x% I, sA 16-month-old white child was referred to the; U0 u8 _* L/ v& m/ F0 B
endocrine clinic by his pediatrician with the concern
0 ^+ S; P) S' w4 S* S( Sof early sexual development. His mother noticed  c  h( r! D( A2 H* B- y1 [" y; u: [( }
light colored pubic hair development when he was5 H6 U" m; q- X( A; q' H
From the 1Division of Pediatric Endocrinology, 2University of0 d( n8 X! {2 M9 w' Z
South Alabama Medical Center, Mobile, Alabama.
+ Y( V: z5 {: g7 |6 b5 eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' {1 O  a# q* s7 \Professor of Pediatrics, University of South Alabama, College of
" @3 P. `2 N9 h/ f: U6 }( {( L" d3 {* zMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- \* F; }2 A, c" p# [6 T8 j2 o
e-mail: [email protected].
3 H. b, S) u9 `* W* x% T2 |about 6 to 7 months old, which progressively became/ `( A5 X5 S3 m
darker. She was also concerned about the enlarge-# d7 X5 s2 ?7 z: u# C) G
ment of his penis and frequent erections. The child. ~  L5 ]% ]: O1 X$ R( b% a
was the product of a full-term normal delivery, with
4 |* @& @; {3 R; f  c; I$ ba birth weight of 7 lb 14 oz, and birth length of) D, s4 l, ?. F
20 inches. He was breast-fed throughout the first year0 N# L4 {5 I- X& J9 z% T
of life and was still receiving breast milk along with* i2 ]+ Z( `0 c
solid food. He had no hospitalizations or surgery,
: l' w- H7 P! |0 [and his psychosocial and psychomotor development0 G1 G, m% y7 o. d& L
was age appropriate.
3 H4 ~3 L0 D( B3 ]; \" L: B- tThe family history was remarkable for the father,
1 X' z+ G1 y# A) T* Vwho was diagnosed with hypothyroidism at age 16,
3 J8 h) j: b. Y" _- M% ~9 u7 xwhich was treated with thyroxine. The father’s
: ~& L. T6 c1 g. _) xheight was 6 feet, and he went through a somewhat
+ t, }4 _7 }! d5 e* rearly puberty and had stopped growing by age 14.
; q0 F( a7 g9 k; l) dThe father denied taking any other medication. The6 H0 Y* x2 Z0 h
child’s mother was in good health. Her menarche
, K+ g# }6 U7 q% l- wwas at 11 years of age, and her height was at 5 feet( D4 \0 Z% `1 ^1 }
5 inches. There was no other family history of pre-
# G- M" a. _4 q5 s. p# [cocious sexual development in the first-degree rela-
8 g2 l* `# [# B. T& v, I$ @' R! X) jtives. There were no siblings.
, A# Z0 v4 A+ t7 F. sPhysical Examination
! B8 P7 R/ z& I- I& sThe physical examination revealed a very active,
! p7 f( z! z) w3 C' c7 d( iplayful, and healthy boy. The vital signs documented  ?8 w( ]5 ?7 Z
a blood pressure of 85/50 mm Hg, his length was8 l& z- E8 r: t, [8 v3 {
90 cm (>97th percentile), and his weight was 14.4 kg5 o# G. c, t+ q& {% k' R8 i
(also >97th percentile). The observed yearly growth5 ^5 k- v- u6 Q4 ~
velocity was 30 cm (12 inches). The examination of
/ K, y0 U8 }" L. B( Bthe neck revealed no thyroid enlargement.. ]6 r& o  b$ ?5 X, y0 g
The genitourinary examination was remarkable for$ n: b/ p; l/ ]7 S+ }/ p( R# n/ L
enlargement of the penis, with a stretched length of
4 i6 X. G8 ?! |& |- p8 cm and a width of 2 cm. The glans penis was very well
8 n8 I& h" p' J4 Tdeveloped. The pubic hair was Tanner II, mostly around+ X' {% S5 c! M2 b3 k7 `9 t
540
0 T+ N2 R7 |0 T; Q) Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 f) F, s. J. x+ m$ vthe base of the phallus and was dark and curled. The
" f# o$ c  R& L4 \6 [# h% X1 ttesticular volume was prepubertal at 2 mL each.
. A5 g: w* @# |The skin was moist and smooth and somewhat
( U% e* F! X/ v8 k1 koily. No axillary hair was noted. There were no
% x+ p& H7 @+ v  m! b( Habnormal skin pigmentations or café-au-lait spots.
" P" `  y/ r. k* ANeurologic evaluation showed deep tendon reflex 2+! Z+ r7 w' d- _& d
bilateral and symmetrical. There was no suggestion# K' ~8 |( I9 \  w) B5 X, D" u
of papilledema.
  k3 W3 J2 ]# S1 S4 ILaboratory Evaluation$ A+ E/ {/ ^& j
The bone age was consistent with 28 months by
1 P7 C9 o8 ?: s" [5 g5 Ausing the standard of Greulich and Pyle at a chrono-
4 `1 p/ r# Q/ |logic age of 16 months (advanced).5 Chromosomal0 Q+ X, j7 K9 {3 `4 t
karyotype was 46XY. The thyroid function test! Y, l1 Z6 b7 s: |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ s4 v) |6 c7 p8 K7 p( z6 z
lating hormone level was 1.3 µIU/mL (both normal).) Z/ c, B. V( w* `: D& S
The concentrations of serum electrolytes, blood
8 e3 q. C; k. j1 `! Burea nitrogen, creatinine, and calcium all were
: P8 ~- `( {* J. n9 [within normal range for his age. The concentration
% |; z! a7 n  S1 @of serum 17-hydroxyprogesterone was 16 ng/dL. J; Z' f" g5 G3 M
(normal, 3 to 90 ng/dL), androstenedione was 20
/ c, T! \+ L4 _; a: w* L3 ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 `" C8 @$ |- Y- y/ j' ?, A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 [' H# B1 Y3 ~, ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 c/ j* {( l- j0 k3 ?& @: v  |* P
49ng/dL), 11-desoxycortisol (specific compound S)) A% t) _/ w; w& s1 s  u3 R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! f7 v1 P3 R/ M& s- r' S( D, ?" h2 R3 ^
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% R3 I; l& @; t/ S% E- T
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 @. U5 k8 E0 X8 n
and β-human chorionic gonadotropin was less than
! i. g" v& d) \' \  K5 mIU/mL (normal <5 mIU/mL). Serum follicular4 m2 o0 i% m8 ], D" X
stimulating hormone and leuteinizing hormone
4 \' {0 b9 }, C( q  z, @concentrations were less than 0.05 mIU/mL
3 h- y) n' G9 Z) n. K(prepubertal).- H/ j' B* l  R
The parents were notified about the laboratory
/ R* n+ J3 V- u0 Sresults and were informed that all of the tests were
" a7 m9 M, h; j7 n7 h) m  @normal except the testosterone level was high. The
, V  L8 m$ u3 R4 `5 xfollow-up visit was arranged within a few weeks to
5 h( P- M! H, N  Q( }# Bobtain testicular and abdominal sonograms; how-
/ N& ~" u% y9 z7 uever, the family did not return for 4 months.
* ~$ }. f3 L# V+ hPhysical examination at this time revealed that the
; W9 N1 q1 g6 q6 y  k1 K3 Xchild had grown 2.5 cm in 4 months and had gained) G. _2 ?1 p2 q& W+ E: b
2 kg of weight. Physical examination remained0 T  f3 V* k3 K
unchanged. Surprisingly, the pubic hair almost com-
: }. b8 f5 }, G- @* X7 o0 `pletely disappeared except for a few vellous hairs at
. I& G& C2 F. b3 A& Athe base of the phallus. Testicular volume was still 20 i8 H; S9 r" J( k; W7 @& d* ]
mL, and the size of the penis remained unchanged.
( z" E0 N$ D+ A1 B) U5 SThe mother also said that the boy was no longer hav-, ~% [1 F5 b6 D3 ^5 n
ing frequent erections.+ [' b) b8 v& a0 z/ E
Both parents were again questioned about use of: U0 K% V, G- ]; o, c' Z8 z, L
any ointment/creams that they may have applied to- `& T1 T) Y& d! A6 g% D) @) N
the child’s skin. This time the father admitted the
& g1 T% {5 ^; O8 |9 k0 A( C+ iTopical Testosterone Exposure / Bhowmick et al 541
6 {) O& @3 o  Q' s; ]use of testosterone gel twice daily that he was apply-
' i- n5 m+ P/ K, ~8 Bing over his own shoulders, chest, and back area for2 m1 \* Q  {% v
a year. The father also revealed he was embarrassed0 v, \; K# z! K1 x6 l6 {
to disclose that he was using a testosterone gel pre-; @+ E. z+ {' m9 |
scribed by his family physician for decreased libido
4 k  u, V0 p% h# L* k% {secondary to depression.2 }9 a/ B. y/ @
The child slept in the same bed with parents.
2 i/ j- x, z) r' d" I. BThe father would hug the baby and hold him on his
* X7 p8 _; i9 n5 J6 g0 a; Xchest for a considerable period of time, causing sig-/ y0 ], j; e8 F! j/ V
nificant bare skin contact between baby and father.
3 W9 p, {" X" D6 X5 ZThe father also admitted that after the phone call,% @4 m" W/ v0 [" n) _
when he learned the testosterone level in the baby) q% x' v( s( e: F- |! [' @
was high, he then read the product information7 m  l, {: R% j$ I5 X3 _, }
packet and concluded that it was most likely the rea-: A7 p: c+ t9 `0 m/ D) \6 N
son for the child’s virilization. At that time, they% ]) ~8 P1 K  Q+ M: N9 q4 i
decided to put the baby in a separate bed, and the& A6 v4 t- m% n0 m% o4 t7 I
father was not hugging him with bare skin and had
. O, h! G0 ^5 h. F9 Z$ g9 fbeen using protective clothing. A repeat testosterone
5 a3 g$ w2 u1 i; a* qtest was ordered, but the family did not go to the* X) Z$ p0 _8 X3 k( G2 w% t" z( {
laboratory to obtain the test.. z  Q# k# @* A( m9 h: v' G0 U% ]
Discussion
' z8 r3 P, @! n$ y; m! z+ s% fPrecocious puberty in boys is defined as secondary) P: `$ B8 |3 Y# C3 U7 b
sexual development before 9 years of age.1,4: H4 Y& r7 ~9 M7 m2 F0 a( I# Y
Precocious puberty is termed as central (true) when6 I8 i8 M1 Z5 \6 g$ }. j/ H  _
it is caused by the premature activation of hypo-, c  U8 ^6 |# e( _& t7 A
thalamic pituitary gonadal axis. CPP is more com-" v2 W# ^( i: _: u# }
mon in girls than in boys.1,3 Most boys with CPP, b6 _0 \# O9 N# u
may have a central nervous system lesion that is
4 @6 ?7 g* E. T$ a% I, rresponsible for the early activation of the hypothal-* p" _# J9 O! z6 s( ]0 Y& P& W& f; c
amic pituitary gonadal axis.1-3 Thus, greater empha-& B* ]4 o( f+ s/ W9 ]
sis has been given to neuroradiologic imaging in& b% n, c& D' m# G1 B& G
boys with precocious puberty. In addition to viril-
* I1 l- W7 C$ D; }; hization, the clinical hallmark of CPP is the symmet-
" Q. t4 I) k* A" M9 E, \3 s5 I+ Hrical testicular growth secondary to stimulation by
+ O0 v* g  _! C2 H# Z7 C, {+ Sgonadotropins.1,3
; g/ N9 K) [/ wGonadotropin-independent peripheral preco-
% x, m  X2 J8 x* S/ a) f' N2 y  Y) w0 Jcious puberty in boys also results from inappropriate5 j; c2 Q7 g2 R( @) n. j. I
androgenic stimulation from either endogenous or3 Z, u& y% Y! q' ~( J
exogenous sources, nonpituitary gonadotropin stim-
. `9 N- Z* w6 u+ [, Fulation, and rare activating mutations.3 Virilizing
) T+ R4 d$ a$ p1 V+ R6 Rcongenital adrenal hyperplasia producing excessive
9 d9 T7 a. C$ ~' |6 j! R! w' oadrenal androgens is a common cause of precocious7 ^" ]# Q: o. y$ r/ h
puberty in boys.3,48 I, H8 h- p3 L9 P& g4 W
The most common form of congenital adrenal9 Z4 u! {4 n' R* o/ e! H5 U' N3 y0 q
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ N  v, U* ]- t$ _4 O' X& YThe 11-β hydroxylase deficiency may also result in8 _2 ?% ?; p: [' S
excessive adrenal androgen production, and rarely,
7 x( q! z9 w" B' L) M# Ian adrenal tumor may also cause adrenal androgen% _! o! ~: V* V' ~7 j$ I
excess.1,3( f* S; l. |; y; A) X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- e1 |1 q/ {8 G. z; O6 c! g' X, L8 L$ D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 @; i% t. H, B1 d6 x$ l5 |5 x8 iA unique entity of male-limited gonadotropin-+ z6 W0 d0 k# U
independent precocious puberty, which is also known6 W2 q3 R2 y! X7 J1 T
as testotoxicosis, may cause precocious puberty at a
% \1 U& h5 f1 ?8 c. n( zvery young age. The physical findings in these boys
; y" v( W0 ?& T, N) J. n% w! Iwith this disorder are full pubertal development,, C2 Z( y. n" V' y1 t
including bilateral testicular growth, similar to boys
( ]" Y, e" T8 Z$ o: E- hwith CPP. The gonadotropin levels in this disorder/ G' M; e4 L4 a, ^
are suppressed to prepubertal levels and do not show
  E* B2 _- ~2 M- S1 upubertal response of gonadotropin after gonadotropin-
3 E" g1 W: r( h1 b; V; Oreleasing hormone stimulation. This is a sex-linked
( L9 H, o6 M: p! k5 ?* N7 U+ m2 g6 qautosomal dominant disorder that affects only+ t' ~: d- H) m0 C7 C8 T
males; therefore, other male members of the family
  t5 Z1 O3 \) kmay have similar precocious puberty.3
( a2 Z$ j) I: `0 Q! b% b! _In our patient, physical examination was incon-" g! }. O6 X/ U1 q
sistent with true precocious puberty since his testi-8 f5 o' b; o4 u- Y
cles were prepubertal in size. However, testotoxicosis
/ h& Y. |& J) }* N( pwas in the differential diagnosis because his father
+ S! e$ f9 _, \: l1 z) q4 t9 Fstarted puberty somewhat early, and occasionally,% W# d; Y3 W) D/ X7 a$ B8 y- e
testicular enlargement is not that evident in the
* u( e. D/ i% l( fbeginning of this process.1 In the absence of a neg-
. ~( Q2 n+ X0 A2 Qative initial history of androgen exposure, our' [9 s/ p/ [" ?3 t& Z7 B
biggest concern was virilizing adrenal hyperplasia,
* U3 j* {6 K- p+ Meither 21-hydroxylase deficiency or 11-β hydroxylase
4 Q1 c5 s. [6 B; o; T% W4 d, ldeficiency. Those diagnoses were excluded by find-
' ]- [7 T1 _: J* j2 J8 j7 `& W8 x2 {ing the normal level of adrenal steroids.& s; R- x  |+ P4 f2 S" \/ c9 {- p
The diagnosis of exogenous androgens was strongly) h2 R) L9 A6 q- E2 a* F
suspected in a follow-up visit after 4 months because
4 A) Q* q! D' Q( O2 r. B' qthe physical examination revealed the complete disap-5 W( G1 l% F" j
pearance of pubic hair, normal growth velocity, and" h  z3 ?/ F; R  G) \0 S
decreased erections. The father admitted using a testos-% B% p. O( F+ `$ C' v" W  I
terone gel, which he concealed at first visit. He was9 t! r! }1 b) C# X
using it rather frequently, twice a day. The Physicians’) H5 }- b# v4 e4 c) e, s2 [, I
Desk Reference, or package insert of this product, gel or3 C1 X$ ~) S2 S' T
cream, cautions about dermal testosterone transfer to
* G$ p2 a2 R; s# V0 v0 g9 }unprotected females through direct skin exposure.
" w$ H" t" w) g. t7 u0 `2 K+ }Serum testosterone level was found to be 2 times the
; c9 z9 |; r4 H/ K7 ^7 Hbaseline value in those females who were exposed to8 v8 ^: [& H% Y' D% h
even 15 minutes of direct skin contact with their male
/ O, w2 V* s, Z. Tpartners.6 However, when a shirt covered the applica-/ D* c- h$ d0 M6 M" r
tion site, this testosterone transfer was prevented.
" {5 o0 ?% r" h8 p, iOur patient’s testosterone level was 60 ng/mL,
! A5 O# r% B+ E; ?which was clearly high. Some studies suggest that0 d5 \( M% ~7 W& o$ E- ^0 I) e& N
dermal conversion of testosterone to dihydrotestos-; u) T% [# w* ?: {7 V. H
terone, which is a more potent metabolite, is more
% h2 f$ i' D  e: f, \4 @) cactive in young children exposed to testosterone
: n/ H' F( }( O0 K# X# j0 o" Z8 sexogenously7; however, we did not measure a dihy-2 ~) |  y% S% q! i
drotestosterone level in our patient. In addition to, @' k2 E6 n- w( ]( u& g# F
virilization, exposure to exogenous testosterone in
8 E7 o' u- \3 i2 u" {7 schildren results in an increase in growth velocity and
! B' a4 a: D4 u% X2 uadvanced bone age, as seen in our patient.
* f# e* J. Q5 z+ E8 r& m" Q  O- TThe long-term effect of androgen exposure during+ Y+ l( }" Y" _7 u* \" e/ @7 ~, V
early childhood on pubertal development and final
% b( Q4 `$ E* m4 E7 zadult height are not fully known and always remain" k7 W' b- S' S' x" ?7 F' E% z
a concern. Children treated with short-term testos-
  Y/ Y3 l6 Z# R3 ]terone injection or topical androgen may exhibit some+ z3 f6 j! W+ J3 w$ N% v. J) y
acceleration of the skeletal maturation; however, after; L8 O+ `( B& O: }6 p4 H
cessation of treatment, the rate of bone maturation" f) Z1 B5 c, R8 A) C, K! s- a( E
decelerates and gradually returns to normal.8,9! h1 X- ~2 J" g) a, I
There are conflicting reports and controversy
. f  z! w5 R# P' n9 a# I% Sover the effect of early androgen exposure on adult& E$ B6 n9 \7 F6 w
penile length.10,11 Some reports suggest subnormal. ~2 R3 [" V, ?/ O" Z, ]
adult penile length, apparently because of downreg-5 _( w% I( V  v7 a7 N5 g
ulation of androgen receptor number.10,12 However,
0 X- P7 d5 n# P! j( k9 ^Sutherland et al13 did not find a correlation between: Q3 m& s3 \# n5 l
childhood testosterone exposure and reduced adult
6 W: n; H+ \& }% f. i, npenile length in clinical studies.2 G% r1 g' F) Q9 h; r: U* g
Nonetheless, we do not believe our patient is
7 ?# a( Z) q- L  y+ `! Lgoing to experience any of the untoward effects from7 ?4 m3 p$ h! V+ D% X4 ~
testosterone exposure as mentioned earlier because
: G/ E& a* B6 y" ]$ [( Zthe exposure was not for a prolonged period of time.( k/ r( e6 d6 l% |( @5 s
Although the bone age was advanced at the time of3 \% F# [1 d: S8 h+ T4 n% r3 _
diagnosis, the child had a normal growth velocity at
0 q" y' B* J1 Lthe follow-up visit. It is hoped that his final adult3 F' C# k6 i  Z# z" J
height will not be affected.
) M$ a* ~# P, F" U4 J. F8 RAlthough rarely reported, the widespread avail-
8 L" J" J7 u/ e9 p; sability of androgen products in our society may' O+ L8 \/ a8 p  ?: t9 U3 v1 E& {1 {
indeed cause more virilization in male or female3 n7 |1 D2 @+ `, s! z
children than one would realize. Exposure to andro-
8 }: V2 R" V4 W; ?) cgen products must be considered and specific ques-
# w- D: j. ]! r& A2 l, \2 p7 I" L0 |tioning about the use of a testosterone product or
0 j! e8 y& O" F, S: d: k5 N) Sgel should be asked of the family members during
! u% v2 Z( |) {the evaluation of any children who present with vir-
' g7 U5 h+ C$ p9 g8 O8 R- k# Zilization or peripheral precocious puberty. The diag-) e& k- M3 {: n% P0 S  Z: r4 w+ h' v
nosis can be established by just a few tests and by& _% N; p5 j2 J
appropriate history. The inability to obtain such a
! h( `4 ]+ g& m, f, F- d" ]history, or failure to ask the specific questions, may; t5 c# `$ A6 [) X1 Q9 N! a
result in extensive, unnecessary, and expensive* T6 y" v7 o' x
investigation. The primary care physician should be/ f- w: b/ s9 T$ l, ]% F3 q# I  D
aware of this fact, because most of these children$ s+ k5 l. e' u
may initially present in their practice. The Physicians’/ {" t0 R) k" [2 }
Desk Reference and package insert should also put a, r2 d3 @4 [8 H3 D
warning about the virilizing effect on a male or
$ u% ^) q- x4 i& Gfemale child who might come in contact with some-# B/ v5 L1 M. F
one using any of these products.
# L8 U& \) \/ v5 r+ lReferences
, i/ _1 N9 G# N3 r6 R1. Styne DM. The testes: disorder of sexual differentiation1 `! S# |- F* J9 K) P* z
and puberty in the male. In: Sperling MA, ed. Pediatric
" ^, v& z, F- E' lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. ]+ \# s( w- @" T2002: 565-628.) G1 d! \  q1 Z7 ]& b0 F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ |" l+ u1 r, u1 l
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* j2 t" e6 ^3 g; C/ w. N$ D. P
Boy Induced by Indirect Topical9 ^6 Y) Z' O. c, }8 u. n( c3 Y
Exposure to Testosterone
8 G- K5 O" O  h! k4 v; BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# e" J- K; v  a. u5 \
and Kenneth R. Rettig, MD10 z9 q: k( \# P2 h! M9 Q; E0 ]; b
Clinical Pediatrics
/ ~$ z) i: Z3 J4 u' LVolume 46 Number 6
9 ]$ K: X3 d( K' w( m; K+ bJuly 2007 540-543) l& s, p( n3 V. I0 y
© 2007 Sage Publications
! `! N2 \# h6 Z& {10.1177/0009922806296651
" \2 g! x8 T+ rhttp://clp.sagepub.com
  G9 E2 f# n' i; ihosted at
' H1 P( Q2 v" O. J) E( _! shttp://online.sagepub.com
; Q) J* N6 @2 Y5 w' F, G, IPrecocious puberty in boys, central or peripheral,
! Q% S3 a! ^* his a significant concern for physicians. Central
1 q' r# Q9 u8 Bprecocious puberty (CPP), which is mediated
/ [) H3 a7 u$ e9 ~through the hypothalamic pituitary gonadal axis, has
/ y5 w# R+ {" t3 m: oa higher incidence of organic central nervous system/ X- E  p. J. O  d# `* V; W6 C
lesions in boys.1,2 Virilization in boys, as manifested
% {% u/ ]8 r1 M+ ^. l* `* j# j1 D2 d# [( ~by enlargement of the penis, development of pubic$ Y4 J) c+ t" V
hair, and facial acne without enlargement of testi-
3 b" Q+ I( `5 D  {/ c. m8 Q4 vcles, suggests peripheral or pseudopuberty.1-3 We* ^2 g- J: q; u7 c( ^0 h
report a 16-month-old boy who presented with the  y: S5 B, ?  B+ |
enlargement of the phallus and pubic hair develop-
% G+ W3 |2 @% Gment without testicular enlargement, which was due
* q4 n6 c7 L8 R/ ~5 A, Ato the unintentional exposure to androgen gel used by
, q7 U+ F3 E3 m7 T5 i3 qthe father. The family initially concealed this infor-
+ y, q- L, V# o/ S- u+ _: kmation, resulting in an extensive work-up for this
- @3 I2 ^. |( Q4 n# r; W+ P' Bchild. Given the widespread and easy availability of0 a# l; [2 }! A& L; s- f9 g
testosterone gel and cream, we believe this is proba-
# D' ]# p5 A0 ]; m& }bly more common than the rare case report in the9 E0 ?) v( Z2 x& a4 M
literature.47 ]" i$ [& q. V+ C1 B6 K
Patient Report3 C! m! u. ^$ _  w
A 16-month-old white child was referred to the
* n8 O& S& i; K8 O2 Lendocrine clinic by his pediatrician with the concern% P0 ?* M6 q% _
of early sexual development. His mother noticed* v$ ^" k: i3 L3 V# d* `
light colored pubic hair development when he was
$ u( k) |  g) k2 p! k6 |From the 1Division of Pediatric Endocrinology, 2University of
6 R: q2 N/ N1 y, l6 tSouth Alabama Medical Center, Mobile, Alabama.
- a! h, x3 l! f0 A2 I; uAddress correspondence to: Samar K. Bhowmick, MD, FACE," l: O  j+ _$ ~6 m8 o- h- X: I6 u
Professor of Pediatrics, University of South Alabama, College of
: g. O$ Z+ K/ j( {9 N/ {Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 c% n% k% E6 C
e-mail: [email protected].3 k5 L) h; W8 h8 f( H, T2 ?% E- u
about 6 to 7 months old, which progressively became
8 O4 j/ {* Y& l; p. S6 k! x# jdarker. She was also concerned about the enlarge-
: a1 [4 Y, D$ Y7 ~5 f, Y* I( f% x% Mment of his penis and frequent erections. The child
! S7 d5 b) k& p; Awas the product of a full-term normal delivery, with$ |$ A; b2 q0 X' O
a birth weight of 7 lb 14 oz, and birth length of
/ e. f) a( s# s20 inches. He was breast-fed throughout the first year: f3 V' f. u9 @. C
of life and was still receiving breast milk along with' n6 \8 c! ]# h9 s. R
solid food. He had no hospitalizations or surgery,
/ x6 a: h' `' i1 _- |and his psychosocial and psychomotor development) {, C/ h$ n" }" V* U
was age appropriate.
8 S5 h" ^/ f, vThe family history was remarkable for the father,5 ]% B5 p) u- S& C2 K6 n# \
who was diagnosed with hypothyroidism at age 16,- Z% }; ~( D  N% m" @1 z
which was treated with thyroxine. The father’s
2 r, I- {0 D4 U3 V0 i) theight was 6 feet, and he went through a somewhat* L5 G- M+ F/ S( M3 u# x
early puberty and had stopped growing by age 14.: ~# P) O( ]8 F) V  ~5 k4 f1 I
The father denied taking any other medication. The
" N' I: C2 l4 q% n- z7 Cchild’s mother was in good health. Her menarche
& x" T( T# ?) H) B2 |) cwas at 11 years of age, and her height was at 5 feet
' K7 Y4 e: N. d8 {% {1 R9 t5 inches. There was no other family history of pre-$ m9 \# `5 I1 K$ B* P" H
cocious sexual development in the first-degree rela-& `  {: P/ y+ A6 ^
tives. There were no siblings.
8 @$ w; u2 G2 d4 \/ hPhysical Examination
0 l1 R  w' B  dThe physical examination revealed a very active,
1 g$ Y5 ~/ h& P' {% H( W" H/ w, v; Fplayful, and healthy boy. The vital signs documented
$ B# j9 c( L' Y! c. v1 g! oa blood pressure of 85/50 mm Hg, his length was& S6 m* o3 w& H; C" x$ U2 h
90 cm (>97th percentile), and his weight was 14.4 kg% C( l& R; F  J4 ?# ]
(also >97th percentile). The observed yearly growth
/ e: S; d5 r6 {4 p9 Gvelocity was 30 cm (12 inches). The examination of. F: @- L# z  n3 [
the neck revealed no thyroid enlargement.
& ^$ y8 M8 K2 JThe genitourinary examination was remarkable for% Y3 e. X: ]9 _% \; y  D
enlargement of the penis, with a stretched length of
- B4 r) n7 U) h: ?6 d8 cm and a width of 2 cm. The glans penis was very well: f4 D" H% {' n; y, B
developed. The pubic hair was Tanner II, mostly around
2 w' v/ U% W( m* N540# t, `. d# L: N6 L% e# k# d1 U5 T0 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  f  X( z. L7 d8 sthe base of the phallus and was dark and curled. The2 Z. {5 g7 N: Z. |0 s! L2 C4 c
testicular volume was prepubertal at 2 mL each.0 U4 p- P2 T0 l% E! p
The skin was moist and smooth and somewhat
5 b4 s$ X3 [/ I4 v6 r4 G, m' ^oily. No axillary hair was noted. There were no. }0 M. n) g! W, N& c7 J
abnormal skin pigmentations or café-au-lait spots.
, s- O6 s9 g( A& V/ s* C& k% ANeurologic evaluation showed deep tendon reflex 2+8 s/ g+ b  v4 _; K. t
bilateral and symmetrical. There was no suggestion
! L% u+ A2 p: T. }of papilledema.4 S% Y, H- c- y
Laboratory Evaluation% D' m  J* z- \; L3 O4 ]
The bone age was consistent with 28 months by& F( U, x* L3 O% [7 [! q
using the standard of Greulich and Pyle at a chrono-1 ^2 p6 O) R4 `: g2 a0 n
logic age of 16 months (advanced).5 Chromosomal7 r6 y0 }6 x+ ?
karyotype was 46XY. The thyroid function test9 w6 Z7 W+ F% S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ E4 \/ b% r7 p% G
lating hormone level was 1.3 µIU/mL (both normal).
( {, B2 S$ z% j- y0 B( r! ]The concentrations of serum electrolytes, blood, b9 R6 J  ^* V+ D/ r, E
urea nitrogen, creatinine, and calcium all were
$ v& u% f4 P) y' F5 cwithin normal range for his age. The concentration
" Y  ~, j& ~% uof serum 17-hydroxyprogesterone was 16 ng/dL8 K- F: o2 Z  d5 _1 x# q9 w
(normal, 3 to 90 ng/dL), androstenedione was 20
) V1 s7 \" z/ e' ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 s. D7 c. C$ nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 d( {6 Y8 G2 s4 C. w" y4 [, k# edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
* a2 c9 ]- Q; K& S* V; o49ng/dL), 11-desoxycortisol (specific compound S)5 Q+ b) z* F1 F6 N4 v4 n* [% b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 u! A1 d' L; b: N) C2 m" c1 Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  |; s* e3 r! Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# E; V8 ~. h: |5 Q) w
and β-human chorionic gonadotropin was less than8 B2 r4 W% B( b, S
5 mIU/mL (normal <5 mIU/mL). Serum follicular& I8 t( F+ I* u7 `( d, _+ `
stimulating hormone and leuteinizing hormone0 Y- G2 g0 ~/ K
concentrations were less than 0.05 mIU/mL/ q2 F# w/ ^$ _% J
(prepubertal).
+ U( d* w7 o" A4 I" ]8 kThe parents were notified about the laboratory; R. m! b/ g4 o6 S  A
results and were informed that all of the tests were& U- g% g, p3 a& C
normal except the testosterone level was high. The! ^! m2 X& ]5 d% o
follow-up visit was arranged within a few weeks to
$ m+ M( W' u, @. T% W0 U% aobtain testicular and abdominal sonograms; how-* W* e  J1 f2 z% l9 r, N
ever, the family did not return for 4 months.
3 @; h4 _( O4 s2 `2 A! g1 lPhysical examination at this time revealed that the3 n. F4 O# K3 H+ f2 k5 A
child had grown 2.5 cm in 4 months and had gained# M0 y2 R! t, ?- D7 D$ ?
2 kg of weight. Physical examination remained
' r' h1 k8 I; m* Q( Hunchanged. Surprisingly, the pubic hair almost com-
! V/ c7 y. y- Q6 P" Fpletely disappeared except for a few vellous hairs at# W$ o3 ~/ E1 L- m+ ^
the base of the phallus. Testicular volume was still 2; }2 K; R! w8 I. b/ c: y( P$ l
mL, and the size of the penis remained unchanged.0 x" ]$ I* G& I4 @0 _: F& x
The mother also said that the boy was no longer hav-
- `$ M, _$ e# K+ ], Qing frequent erections.
. m* r( p' ]. y" h3 M) D! ~Both parents were again questioned about use of0 V* B: y; n1 s
any ointment/creams that they may have applied to% K. m) n3 h) f
the child’s skin. This time the father admitted the6 b! n; P4 O+ T# {4 d' w- `
Topical Testosterone Exposure / Bhowmick et al 5415 M0 ~# H$ R% n! h1 n* w
use of testosterone gel twice daily that he was apply-/ C9 W6 I# [* A* z& s/ v% w
ing over his own shoulders, chest, and back area for
+ [& r" _  {2 ta year. The father also revealed he was embarrassed0 X6 c+ u9 q3 W; C
to disclose that he was using a testosterone gel pre-
' X3 ?3 V& ^6 _3 f/ sscribed by his family physician for decreased libido
% [+ v4 p/ d" ^0 [9 D( `  Esecondary to depression.
" c3 O, {9 w: t/ KThe child slept in the same bed with parents.
' l0 B: S; ^' J3 [1 \4 JThe father would hug the baby and hold him on his6 ]" W5 a& C. e% d5 X/ n* H" ~
chest for a considerable period of time, causing sig-. ?) u7 `; v, Z
nificant bare skin contact between baby and father.
7 L2 C/ T0 B9 |  c: P: dThe father also admitted that after the phone call,
. |. h: }3 W- H3 p8 uwhen he learned the testosterone level in the baby
1 ^, s0 I7 c  ~  _3 Z- awas high, he then read the product information; `, A1 [* f6 Y" H1 B# f  x, I
packet and concluded that it was most likely the rea-
. A% g' M& u* h& G5 h7 b" ^son for the child’s virilization. At that time, they+ C% Y- W0 v. I' z1 z
decided to put the baby in a separate bed, and the) ~9 j5 o5 D: c/ w1 Z
father was not hugging him with bare skin and had( h; i/ d# N0 A
been using protective clothing. A repeat testosterone
- ]+ n9 p' W8 b+ H7 G$ wtest was ordered, but the family did not go to the) f$ H8 J* p/ y- z7 Z1 \
laboratory to obtain the test.
% b( p% N7 j2 r- ZDiscussion
( Z. ?% o7 f: ~Precocious puberty in boys is defined as secondary
: I; R/ c- d0 n$ k6 S. msexual development before 9 years of age.1,4
+ `8 V# T0 m6 ^+ X; }: {Precocious puberty is termed as central (true) when
% }/ ^" I* f" N) Git is caused by the premature activation of hypo-
2 u, h- F8 N3 }, L. C" A$ o) Athalamic pituitary gonadal axis. CPP is more com-% X0 W+ c+ a; B" V7 W
mon in girls than in boys.1,3 Most boys with CPP/ r- D" _8 r/ \7 ?7 E& {
may have a central nervous system lesion that is( j4 g+ e' I  N- A4 i; u; T/ @
responsible for the early activation of the hypothal-
( ]- |9 s+ }' c2 {+ Z6 O/ wamic pituitary gonadal axis.1-3 Thus, greater empha-; u" C" `) V. h1 f1 G5 f
sis has been given to neuroradiologic imaging in; Y' [* P% e8 s
boys with precocious puberty. In addition to viril-( l9 y* |# ~: u0 d
ization, the clinical hallmark of CPP is the symmet-9 h5 D" K' G) n: e( C
rical testicular growth secondary to stimulation by
* Q; b" \' H- n) I6 h6 w1 Vgonadotropins.1,3- P  U, d/ H4 R& V0 p2 w' L( R  y
Gonadotropin-independent peripheral preco-; {  o) X: b7 b( J7 A9 F/ j
cious puberty in boys also results from inappropriate
5 B7 x+ z! B, b! qandrogenic stimulation from either endogenous or# c2 b+ ~5 P/ ^9 x# G: o
exogenous sources, nonpituitary gonadotropin stim-
8 m' D8 s; p, R: }6 \- mulation, and rare activating mutations.3 Virilizing
4 [$ Z' {3 Q; p" S  econgenital adrenal hyperplasia producing excessive
- G* J& @! G! A# iadrenal androgens is a common cause of precocious+ X! E9 ?! n' g7 ~8 Y' t
puberty in boys.3,4+ C: Z" T6 Q% x, c- q7 U# U" m
The most common form of congenital adrenal
+ j! C8 q) z3 H* n8 n! v7 G2 xhyperplasia is the 21-hydroxylase enzyme deficiency.
+ h# ]; \+ [/ d  T! ?2 w. QThe 11-β hydroxylase deficiency may also result in
( }& |% u) u: C" p' M+ \+ lexcessive adrenal androgen production, and rarely,! C: k/ I0 {4 U( i  v8 H
an adrenal tumor may also cause adrenal androgen; K3 h0 V2 e+ C# [6 ]+ j" @: |
excess.1,3! Z. I; z" K+ G+ R4 S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  F9 N4 g4 Y) K: J  H8 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 d. Z" ~' J7 k0 ^4 \, c
A unique entity of male-limited gonadotropin-+ H! p9 v# u& Z! ?; H
independent precocious puberty, which is also known
" U4 Y% \  \; S3 l9 s3 ?as testotoxicosis, may cause precocious puberty at a
9 @7 e0 o% f. {; D; L6 I; G  a! mvery young age. The physical findings in these boys' J6 N! M$ V/ M, }- G& @# |* L) s
with this disorder are full pubertal development,' `1 I0 \8 f- N; K# F% i
including bilateral testicular growth, similar to boys
& q5 W3 U9 w" mwith CPP. The gonadotropin levels in this disorder# k5 h" J7 O& V" p' D
are suppressed to prepubertal levels and do not show
6 m* }) o8 n: T! h* ipubertal response of gonadotropin after gonadotropin-
* t  k, n; Z9 x* |releasing hormone stimulation. This is a sex-linked
& b: E1 r2 a1 u! C/ z6 w% vautosomal dominant disorder that affects only
- \' K) Q- `7 [) wmales; therefore, other male members of the family/ T- M! ]: w- c7 i. M# t
may have similar precocious puberty.3
2 u) D/ o, l4 G+ R8 ?In our patient, physical examination was incon-  ?+ Y. B& ?: F, e+ Q
sistent with true precocious puberty since his testi-% n: U% @* H- j- B" S9 G
cles were prepubertal in size. However, testotoxicosis
( L" E6 j( k. H) b5 }: o9 {was in the differential diagnosis because his father
) S" y* V5 B# [2 h, Bstarted puberty somewhat early, and occasionally,
8 }9 B4 V" _% j; s1 ~# D+ ntesticular enlargement is not that evident in the
7 i. ]1 B# W5 ubeginning of this process.1 In the absence of a neg-! O& j% Q3 f9 ?& `, I  v) }
ative initial history of androgen exposure, our& S/ s7 ]/ a& z3 @) q7 [9 X# l
biggest concern was virilizing adrenal hyperplasia,
/ u/ y! k+ v0 [9 u$ h8 beither 21-hydroxylase deficiency or 11-β hydroxylase
  E, z8 f9 G) o+ ddeficiency. Those diagnoses were excluded by find-
0 V  D  }( f! r% F7 z: ting the normal level of adrenal steroids./ o: f! L  `) d2 A- `# U
The diagnosis of exogenous androgens was strongly
+ J9 f% A6 r. o6 C$ ususpected in a follow-up visit after 4 months because- a3 X1 p) I! w: a! F4 y
the physical examination revealed the complete disap-
. R5 G% k: S$ e/ Xpearance of pubic hair, normal growth velocity, and5 x( q5 ]2 c9 M  X2 t
decreased erections. The father admitted using a testos-8 ]8 x" S4 X" a8 t
terone gel, which he concealed at first visit. He was& ^2 D4 D4 g, `+ `4 T. l4 Z: [
using it rather frequently, twice a day. The Physicians’
/ O# Z' F% U9 c4 ADesk Reference, or package insert of this product, gel or
, t3 }, P# e" l) N2 _cream, cautions about dermal testosterone transfer to
7 |" k9 X3 x# N2 w. Nunprotected females through direct skin exposure.% p- s# J1 w& b# t3 @8 Z  O
Serum testosterone level was found to be 2 times the( z( f* d4 B& u
baseline value in those females who were exposed to
) |4 A3 N7 J. leven 15 minutes of direct skin contact with their male
/ q$ y; M0 s' |- E* w5 W8 Q1 m- n' Spartners.6 However, when a shirt covered the applica-5 I$ d( _- w% B! J
tion site, this testosterone transfer was prevented.# g2 b& \9 q3 d- B# p
Our patient’s testosterone level was 60 ng/mL,
# g( i) z5 ~3 b* a/ ]/ iwhich was clearly high. Some studies suggest that
, N$ `- y5 A) M4 adermal conversion of testosterone to dihydrotestos-
; w% h- w/ a: n4 oterone, which is a more potent metabolite, is more
+ q+ D0 L( |# l8 Eactive in young children exposed to testosterone9 W  T# E9 J, I- z% F! H8 V( Q/ S
exogenously7; however, we did not measure a dihy-2 v/ X' m( D+ K0 S1 A5 q( E$ r
drotestosterone level in our patient. In addition to9 p3 C$ ]2 |- a3 `
virilization, exposure to exogenous testosterone in
' S5 L$ l0 |9 m' ~2 ~9 K! vchildren results in an increase in growth velocity and
0 B/ v- O) h; P1 w- A: sadvanced bone age, as seen in our patient.: ^  b7 G) C# j2 W, h+ [
The long-term effect of androgen exposure during
1 H7 m+ x/ q- x% c7 V5 ^early childhood on pubertal development and final
' K4 U2 L8 j! m! ?/ u! Y! Jadult height are not fully known and always remain
# Q! J- F. i' a, Na concern. Children treated with short-term testos-
# v2 Z2 L* q: a! m5 bterone injection or topical androgen may exhibit some
1 x2 U: @1 z  ~* Dacceleration of the skeletal maturation; however, after
# N  J/ ]# ^7 _. W! U. icessation of treatment, the rate of bone maturation
0 x3 q) g' g7 a  I$ wdecelerates and gradually returns to normal.8,9
8 C6 F7 r) w/ B, T) i3 H% cThere are conflicting reports and controversy) |( g8 i% D7 a
over the effect of early androgen exposure on adult
/ e+ F! i+ N' Zpenile length.10,11 Some reports suggest subnormal
# Z2 m- r, Z9 e6 Y! M& I- w, Q+ a+ r3 hadult penile length, apparently because of downreg-
/ X, G7 b$ G1 E8 T& f0 z6 Uulation of androgen receptor number.10,12 However,
9 r+ ^) f, f1 `& C9 S' U4 [Sutherland et al13 did not find a correlation between) o0 |, t3 F. A! _8 k' B
childhood testosterone exposure and reduced adult% l' V" f9 \: X! W$ y- @
penile length in clinical studies.' l. y8 {2 ~6 A2 S% g3 S
Nonetheless, we do not believe our patient is  Q; f/ f. G  g4 m# D5 S2 G
going to experience any of the untoward effects from! H6 l7 Z7 a3 D' C) g9 g& C
testosterone exposure as mentioned earlier because
# \. k% {# {' othe exposure was not for a prolonged period of time.
4 w0 k, v! v! h0 o+ o# `2 JAlthough the bone age was advanced at the time of
! P8 h/ o& G4 e% Q; u7 r/ e$ Wdiagnosis, the child had a normal growth velocity at8 b7 P% D4 B, ]6 H+ p/ U2 C
the follow-up visit. It is hoped that his final adult7 ^' o6 _# w& A: t& A; Q; N! X
height will not be affected.& Z3 V! [' r# m0 o
Although rarely reported, the widespread avail-) z; J; K8 g  O. d2 h) G
ability of androgen products in our society may. _! c; K; v& D/ K4 ]7 O: K( Z
indeed cause more virilization in male or female5 ]# Z. @5 k6 |7 P& `
children than one would realize. Exposure to andro-
; W, R" X! E) j. xgen products must be considered and specific ques-& X1 k' @  p0 x; j: V
tioning about the use of a testosterone product or# T" }/ D: s* @, ?: K
gel should be asked of the family members during$ y; j1 I2 l& Z% u# @) \
the evaluation of any children who present with vir-
) S, |% @8 _) y9 E# iilization or peripheral precocious puberty. The diag-
/ Y; w% h! i/ t6 z: w/ l3 N; snosis can be established by just a few tests and by
( z% P  G; h. v2 Tappropriate history. The inability to obtain such a
& ]& J" ~: T9 }* M3 f4 m5 Hhistory, or failure to ask the specific questions, may
- F* }$ H0 M- O5 Oresult in extensive, unnecessary, and expensive, j. e& O5 y$ |2 R* O/ R
investigation. The primary care physician should be
. }# Y3 d# I5 r5 P( j# N; uaware of this fact, because most of these children' D" n' _) J8 a; ?- r
may initially present in their practice. The Physicians’- F' R# S# p$ x* N  ~5 f9 j5 W
Desk Reference and package insert should also put a
% Y' m6 B2 C4 B5 Swarning about the virilizing effect on a male or
1 d4 S! \3 \: j. \/ |( ^7 w# ^# bfemale child who might come in contact with some-
: ]& U& r3 P3 T6 @6 a% o$ y, p, H2 ione using any of these products.( r# }  D, k! K9 k
References7 z% p. J- n. w
1. Styne DM. The testes: disorder of sexual differentiation
% V. `% j) {. H4 zand puberty in the male. In: Sperling MA, ed. Pediatric
. R- K# d# V4 N( i) rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- i" f* l9 s+ c4 }8 p# O
2002: 565-628.7 ^" d/ k2 m2 @9 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 r9 `7 n: l/ y2 H+ }- j7 R, {# J4 l: \
puberty 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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
: ^# _) U" H  L
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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