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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
1 ]$ l3 {; h3 t5 C/ J9 X/ b$ aBoy Induced by Indirect Topical
  a4 S; K: V/ W1 l! IExposure to Testosterone5 G! L2 D9 S* |  c7 j* O, d7 }) `; B' {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 Y/ w/ C3 c; U# |( [; s, n
and Kenneth R. Rettig, MD1- Y) ]6 Q% I5 I7 E- q
Clinical Pediatrics
* R# }/ K" W# W8 uVolume 46 Number 6' o- ?% L' c5 H9 M
July 2007 540-543
: u5 T5 }- O& r& h( f. E$ t$ E© 2007 Sage Publications  ^( Z8 N. Z+ x! b9 }( i7 Y
10.1177/0009922806296651% G8 `: _; X. W
http://clp.sagepub.com
" X5 ?& C5 S  \0 S, b# Yhosted at
6 o, K& ~: p2 \4 [: hhttp://online.sagepub.com
3 a+ L: v( ]" |5 }9 PPrecocious puberty in boys, central or peripheral,
3 b& p% i' r; T7 b) M3 |# Yis a significant concern for physicians. Central$ N! J; m9 i; h8 Y7 J) f
precocious puberty (CPP), which is mediated& P/ Q$ X9 t, B; Y2 P, b  \" S
through the hypothalamic pituitary gonadal axis, has( V; }  ~$ c; Z7 ~! d
a higher incidence of organic central nervous system
2 |+ _  M9 L* N. g/ O2 Olesions in boys.1,2 Virilization in boys, as manifested
" c+ j2 O5 z0 @# {( @by enlargement of the penis, development of pubic+ a2 H: Q3 Q$ t* q+ w
hair, and facial acne without enlargement of testi-% j; ?  D9 g* X- S
cles, suggests peripheral or pseudopuberty.1-3 We5 ~$ L! [, l& j
report a 16-month-old boy who presented with the, a: N( c) c2 Q. J' P2 E$ M5 s
enlargement of the phallus and pubic hair develop-
6 ^5 `* M3 d5 ]; `$ N) S) Lment without testicular enlargement, which was due
# A( \/ p1 h- X9 Eto the unintentional exposure to androgen gel used by( f/ X1 @0 o' l% ]/ M
the father. The family initially concealed this infor-) d3 t* r9 \0 x# N
mation, resulting in an extensive work-up for this
; H8 [7 s1 e0 x7 x* K2 q0 Bchild. Given the widespread and easy availability of' o0 c8 Z& `5 l# P9 d
testosterone gel and cream, we believe this is proba-
6 Q. B0 V& T8 {3 J5 ibly more common than the rare case report in the
% H. _7 o3 Q5 |5 \literature.49 V/ M, |$ m" L
Patient Report
/ k- `. j9 O2 V4 c$ X* r# gA 16-month-old white child was referred to the" T! P' c1 v8 q9 S
endocrine clinic by his pediatrician with the concern
4 f: T& |8 w3 W3 N. U& A& J0 mof early sexual development. His mother noticed
- N0 q) A5 B7 E4 klight colored pubic hair development when he was& D; d0 |9 P" b- ], G4 ~% F
From the 1Division of Pediatric Endocrinology, 2University of/ o7 f% @+ [, \
South Alabama Medical Center, Mobile, Alabama./ [) u7 e. r, V% g) I: G
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# }) l* x# {* Z$ Z- IProfessor of Pediatrics, University of South Alabama, College of: b' l) A- M/ i8 r) f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 u- u: M+ z4 A$ U0 _- M
e-mail: [email protected].' I- i% M5 r/ s) ~+ v( @. Z
about 6 to 7 months old, which progressively became
5 ^' S1 O5 l) rdarker. She was also concerned about the enlarge-% y+ P# J$ \2 G& a1 W
ment of his penis and frequent erections. The child
! B( h' b% e- p" I0 V$ E7 N$ H' y0 owas the product of a full-term normal delivery, with  p4 N- |$ E& r0 l. [! b  @
a birth weight of 7 lb 14 oz, and birth length of
" S5 D/ j& U7 |/ ]; M( U20 inches. He was breast-fed throughout the first year1 S) x3 A# I0 s$ R
of life and was still receiving breast milk along with/ r' e: e3 n/ V' P" k" V0 g: k4 j
solid food. He had no hospitalizations or surgery,
3 w8 Y- y5 Q7 f0 Q. p  Rand his psychosocial and psychomotor development- \4 u7 v- Y9 N. g* M0 B
was age appropriate.1 |& D) j: S2 z+ T0 M" d0 ^
The family history was remarkable for the father,2 Z$ o7 F  m* Z9 k0 G1 e+ d
who was diagnosed with hypothyroidism at age 16,
6 E0 j* U; J0 Wwhich was treated with thyroxine. The father’s1 Y+ T# d- z( \1 x& [, d& Y
height was 6 feet, and he went through a somewhat
; J8 J) H# }) J1 F0 Pearly puberty and had stopped growing by age 14.
' k$ S' q% d/ B- M) v* DThe father denied taking any other medication. The
3 z  J* r. e6 M/ a! X' V2 z4 Wchild’s mother was in good health. Her menarche
/ a+ f! B7 C9 e, l' z& u5 m# W$ xwas at 11 years of age, and her height was at 5 feet) D7 [  v( C, e0 z7 A
5 inches. There was no other family history of pre-
) |% y5 ~2 T4 b( p) ?* O# Acocious sexual development in the first-degree rela-
7 p% W: q) C/ C: f6 c6 ?6 F( otives. There were no siblings.
# C( j: \7 c6 f0 IPhysical Examination
/ ]/ x, c  d% b5 w0 l0 zThe physical examination revealed a very active,2 K5 ~5 v  L$ i, n/ }! o; t7 L: z
playful, and healthy boy. The vital signs documented
! T' `; }( L# C' Sa blood pressure of 85/50 mm Hg, his length was6 b# c" b9 u2 U( C0 F
90 cm (>97th percentile), and his weight was 14.4 kg
* F' b1 \6 R8 G6 R6 u/ V% d(also >97th percentile). The observed yearly growth: n% o$ \$ W$ W7 f) ]/ ]
velocity was 30 cm (12 inches). The examination of# `" K% @6 L" D7 O( p: z& T9 I
the neck revealed no thyroid enlargement.5 _2 t! w, P) C9 d# G4 e
The genitourinary examination was remarkable for
3 |5 K" F: _/ g; D/ Aenlargement of the penis, with a stretched length of
+ X6 ?; N$ [/ q6 x: P8 cm and a width of 2 cm. The glans penis was very well
0 T; t5 M1 B; Q1 C9 Rdeveloped. The pubic hair was Tanner II, mostly around
/ g+ r; A: R* G9 ~540
0 L7 ]6 K# Q0 r, J8 }% X& @% }6 R8 cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 Z- b! M  H" L$ u8 xthe base of the phallus and was dark and curled. The/ {3 i" u( _+ h6 S* \: E0 a, m( a$ y
testicular volume was prepubertal at 2 mL each.
6 o9 J$ Q  R; \The skin was moist and smooth and somewhat
% S- ~% {( @/ k4 Q% X- Q6 Loily. No axillary hair was noted. There were no+ G1 s+ S# k0 o5 \
abnormal skin pigmentations or café-au-lait spots.
- d" t. \2 h+ \0 W' q0 s; ~Neurologic evaluation showed deep tendon reflex 2+
( ?. S) M" j. j8 dbilateral and symmetrical. There was no suggestion: c) H8 r: V) ?+ x! p  U
of papilledema.
1 n' w* [: i) t, {8 p$ s5 {7 {Laboratory Evaluation# T6 c0 A, m) `7 X% q& M5 u! X
The bone age was consistent with 28 months by
; H- f1 y2 p/ k, Iusing the standard of Greulich and Pyle at a chrono-
" P  }, x' f9 w3 P" B! ?logic age of 16 months (advanced).5 Chromosomal" H* Z) Y2 ^7 V: W  ^
karyotype was 46XY. The thyroid function test" ?. E' C4 y" K6 @/ u8 U
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ @* r/ U6 @: }: u* W4 [' U( I8 Vlating hormone level was 1.3 µIU/mL (both normal).
: h" H% P% T* i( q& K9 ZThe concentrations of serum electrolytes, blood8 B; o: p4 b7 a
urea nitrogen, creatinine, and calcium all were
7 F" [; m2 }; L) D7 K* \within normal range for his age. The concentration
* q0 ^' x% s1 s3 P) L+ J% b, rof serum 17-hydroxyprogesterone was 16 ng/dL/ Z# N0 {) l- V/ o1 W; t. ^
(normal, 3 to 90 ng/dL), androstenedione was 20( S8 E4 y$ @! B! R+ ?3 r& C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 S8 L3 x* Q2 J% B2 {0 k! ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; F- ]* n9 @4 x6 Z2 P4 rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ e! {& U: W1 m) t3 m2 L49ng/dL), 11-desoxycortisol (specific compound S), G& ~6 z! ]" i- _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 Z8 _& K# x$ ~" o7 J7 a- D% btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: r/ `' D$ t* |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ P8 _! L+ r' M; {# ^* Z7 wand β-human chorionic gonadotropin was less than. m% ^. w0 D( S0 v; f
5 mIU/mL (normal <5 mIU/mL). Serum follicular' z3 g: [# b: L5 \0 f& K4 _. j1 \
stimulating hormone and leuteinizing hormone( h  b# @- G: H9 _0 T% A
concentrations were less than 0.05 mIU/mL  i: {- ]- w. Y+ _3 I: e6 c
(prepubertal).4 O' ?" O( N5 ]2 `( A) M/ C
The parents were notified about the laboratory6 J; D0 f8 ^6 h; _
results and were informed that all of the tests were: p8 h; {; a2 j
normal except the testosterone level was high. The
1 g  A) F- G% f) S6 ]9 [- s# Z! xfollow-up visit was arranged within a few weeks to: H' _/ \0 f( S0 D; L/ Y
obtain testicular and abdominal sonograms; how-
7 o  H' A" n5 h; ]9 J4 tever, the family did not return for 4 months.
. I3 \' w; p1 lPhysical examination at this time revealed that the
( x# h7 |7 z  Bchild had grown 2.5 cm in 4 months and had gained
! @1 R/ k# b8 p7 K5 m% j, R0 a2 kg of weight. Physical examination remained
8 U+ ]4 r5 N3 @; M+ gunchanged. Surprisingly, the pubic hair almost com-
) {3 F0 g; }% A, B0 _0 t" w" kpletely disappeared except for a few vellous hairs at- E. [7 l1 G4 b, y4 I9 A
the base of the phallus. Testicular volume was still 2: f1 J4 ~5 {& u0 `. U; i
mL, and the size of the penis remained unchanged.
+ `  b' A$ E- Z7 J( M$ h+ E4 P+ bThe mother also said that the boy was no longer hav-3 M, H& Y0 z9 l4 P/ y* P/ |7 C
ing frequent erections.7 h! E+ ~  ?6 K7 {/ c7 B& Y2 B
Both parents were again questioned about use of
0 J+ M6 n  ]& U8 Jany ointment/creams that they may have applied to
8 X& v( V; e2 a" j8 Othe child’s skin. This time the father admitted the
* s+ `5 ?, U* `. t3 zTopical Testosterone Exposure / Bhowmick et al 541
: I1 d& p6 ~; |( J& h/ vuse of testosterone gel twice daily that he was apply-! i0 p- G5 B9 Z
ing over his own shoulders, chest, and back area for
2 I3 [  _: _# B, a0 Ma year. The father also revealed he was embarrassed
. N  I1 S1 S& o" V1 jto disclose that he was using a testosterone gel pre-) G) G/ i3 J3 p5 i
scribed by his family physician for decreased libido
7 y; t, c5 @: \' `" T# ]secondary to depression.
# h$ d' `! @. Z' ?& W( @" GThe child slept in the same bed with parents.
! K* l0 Y  R' X3 V6 I5 `' tThe father would hug the baby and hold him on his
* B$ Q8 d- e8 y- ?' pchest for a considerable period of time, causing sig-
" x& k# \: y$ J: {. wnificant bare skin contact between baby and father.8 ~1 S3 j6 X' ]9 B  }; l6 M8 s
The father also admitted that after the phone call,
3 }: K7 a9 ]  z1 Q0 @when he learned the testosterone level in the baby
- Z/ u8 s  a* u3 Z$ R4 d6 owas high, he then read the product information( q& u6 W  P; B$ |0 [0 G4 _( o3 ~
packet and concluded that it was most likely the rea-0 ?, e2 m+ M1 C5 g9 x
son for the child’s virilization. At that time, they3 |& B# q  P( \5 l
decided to put the baby in a separate bed, and the
* f) j: I4 t1 b1 U* g) C5 sfather was not hugging him with bare skin and had. H. @& B1 E- j8 I1 v
been using protective clothing. A repeat testosterone
* u  b( H4 J' h% a0 X% ~7 y1 Qtest was ordered, but the family did not go to the
+ E8 i$ a& T# t+ @laboratory to obtain the test.$ L* D! E/ D) s7 @0 R
Discussion) `, U! r7 F' A; @# T$ I% g
Precocious puberty in boys is defined as secondary
; I) y6 f* f- _$ k( esexual development before 9 years of age.1,4) f0 G5 K# r6 T9 @& `
Precocious puberty is termed as central (true) when
( ]% P6 D0 x" ]5 N0 Z! eit is caused by the premature activation of hypo-
6 P3 X* s8 J6 Z6 H/ Z3 d) pthalamic pituitary gonadal axis. CPP is more com-- O' P0 b* B3 ?) s0 \7 [  ^; O
mon in girls than in boys.1,3 Most boys with CPP
6 W; Z/ k' w# n& `' d; _- v. mmay have a central nervous system lesion that is6 _* p1 L7 _; z1 }
responsible for the early activation of the hypothal-7 c5 W9 w6 o" R, s# A
amic pituitary gonadal axis.1-3 Thus, greater empha-! y  `+ c8 s+ f' b) n$ ]: |& ]- l
sis has been given to neuroradiologic imaging in
  E' |5 G: ~! z4 {boys with precocious puberty. In addition to viril-
: o& v; L- `7 q3 T6 d9 M0 hization, the clinical hallmark of CPP is the symmet-# J: V/ {/ G8 d$ f: D; {- T
rical testicular growth secondary to stimulation by/ D/ s: {5 G! K8 V  L, r# t. \
gonadotropins.1,38 `- w9 G9 S9 W: D) c1 Y) D
Gonadotropin-independent peripheral preco-
1 p# a' Z6 f' ~5 S* Ucious puberty in boys also results from inappropriate
* o* Y4 a7 l7 L) T' k8 qandrogenic stimulation from either endogenous or9 L8 i4 L6 A% a& k
exogenous sources, nonpituitary gonadotropin stim-# K, L+ k. C6 b+ S
ulation, and rare activating mutations.3 Virilizing
/ J( H. ]7 I  |, ?5 b: u+ Fcongenital adrenal hyperplasia producing excessive
+ w) Z; h5 q) R% gadrenal androgens is a common cause of precocious/ `4 i5 y; {/ d
puberty in boys.3,4
5 [1 G  U% z3 |. u2 F" @  ]The most common form of congenital adrenal
4 |7 m$ f* f' \0 t- u: L9 S/ ~hyperplasia is the 21-hydroxylase enzyme deficiency.( u' N) ]7 R7 e5 q/ ^- m7 A
The 11-β hydroxylase deficiency may also result in
9 u; a3 q8 z! mexcessive adrenal androgen production, and rarely," Z. ~2 V/ x1 I: P3 Z8 J. {
an adrenal tumor may also cause adrenal androgen- F- M0 M  o1 a/ r
excess.1,3
0 r; m- ]9 M" M3 u- ^. Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, \# Z' c4 M5 j" `' e  D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 P  d: `) b3 t+ c3 IA unique entity of male-limited gonadotropin-7 {  F/ B) H! k5 p
independent precocious puberty, which is also known
" Z) `: U! ~& Q5 Jas testotoxicosis, may cause precocious puberty at a
/ f0 q% r, _) f$ t$ _( Uvery young age. The physical findings in these boys; I3 B1 I! _6 u( ~$ D
with this disorder are full pubertal development,* C0 x" S6 [$ v/ k/ ?- \
including bilateral testicular growth, similar to boys
- _# C# z$ y* s" z) o5 {* \with CPP. The gonadotropin levels in this disorder
: U, G- a9 {- @  Yare suppressed to prepubertal levels and do not show# A9 g- |9 B' k5 z0 Z( V
pubertal response of gonadotropin after gonadotropin-& d$ U9 v: Z1 \7 m) T/ v
releasing hormone stimulation. This is a sex-linked
: j: Z0 G& h0 I! n& [4 Z8 @8 vautosomal dominant disorder that affects only/ L& R! b. X" {7 |! q
males; therefore, other male members of the family
  N. B% [; I' F% E0 lmay have similar precocious puberty.3
7 {' \$ x$ N* b' OIn our patient, physical examination was incon-
) f# |3 d' z) @1 Csistent with true precocious puberty since his testi-1 p! {6 x1 f6 \! p# w3 H6 L
cles were prepubertal in size. However, testotoxicosis+ V' C  ?4 B& `4 A
was in the differential diagnosis because his father: u7 s0 h" Z& U5 |5 K8 g0 ~( ?
started puberty somewhat early, and occasionally,# B( H; R) J# o) {( l
testicular enlargement is not that evident in the: z  ^/ r: @7 m: ~! m- Y
beginning of this process.1 In the absence of a neg-. P/ X! q0 w* i0 _/ j
ative initial history of androgen exposure, our
2 L) |9 W* y' ?+ u0 y, U6 H% s* Mbiggest concern was virilizing adrenal hyperplasia,5 ?; }% j8 w' W2 v3 e3 K4 c
either 21-hydroxylase deficiency or 11-β hydroxylase
0 @" v5 r" P+ A  Q! a$ D6 [; pdeficiency. Those diagnoses were excluded by find-
' e; n0 |. q4 b% |4 ]6 ]ing the normal level of adrenal steroids.
& B& K" z6 H# D( o; x  n! yThe diagnosis of exogenous androgens was strongly  R0 R6 e9 ], Z7 x1 S" i
suspected in a follow-up visit after 4 months because
" p: ^1 f6 }) ]0 N7 z9 Gthe physical examination revealed the complete disap-$ b- c, x6 I/ O! u9 q7 R: ~
pearance of pubic hair, normal growth velocity, and
- F0 t. A9 K  X) ~decreased erections. The father admitted using a testos-% C2 N3 z0 w6 l# v  r
terone gel, which he concealed at first visit. He was* c5 v  y2 e2 y# N; u
using it rather frequently, twice a day. The Physicians’
+ I' q8 s' q* N% V9 sDesk Reference, or package insert of this product, gel or: _1 b: r$ o/ f; D% p
cream, cautions about dermal testosterone transfer to, T( r( M# t5 \1 |, [+ S& k5 B$ _
unprotected females through direct skin exposure.. U3 ?* o4 t- c/ \: l+ L2 k
Serum testosterone level was found to be 2 times the2 t: k, Q' r$ ~! y( ^( _7 z2 X) [
baseline value in those females who were exposed to0 z" D8 h' W% _/ {& K  @
even 15 minutes of direct skin contact with their male
# y% e. T' M) e5 i/ s2 M3 y' ~partners.6 However, when a shirt covered the applica-
( o8 e7 M7 @6 h: z3 P- ]6 Vtion site, this testosterone transfer was prevented.
) t5 W0 j+ t+ P5 z5 G" U2 eOur patient’s testosterone level was 60 ng/mL,: J0 b1 m4 }  a4 a
which was clearly high. Some studies suggest that$ R- |% z1 A8 F% _( u
dermal conversion of testosterone to dihydrotestos-
7 B1 ]% @" G7 C3 mterone, which is a more potent metabolite, is more
, f, X) M1 j% ^5 M( \* Zactive in young children exposed to testosterone
' s: J% U) r: ?/ ^6 fexogenously7; however, we did not measure a dihy-
+ X9 `, G7 I, ~2 Adrotestosterone level in our patient. In addition to% m, \" [% i% j+ [: W2 d% q
virilization, exposure to exogenous testosterone in9 `% h" E3 i; V$ W
children results in an increase in growth velocity and
9 t& V+ @3 M' U8 gadvanced bone age, as seen in our patient.
( d  T: P& M0 z3 ~2 MThe long-term effect of androgen exposure during
2 F: C) |' ?2 W+ |$ O7 Y5 k4 rearly childhood on pubertal development and final
. d* a+ t) z2 M0 ~adult height are not fully known and always remain
# ?5 j& `$ y$ e3 h9 S- c  h; Ua concern. Children treated with short-term testos-- g4 u' e6 A4 t, P" w
terone injection or topical androgen may exhibit some
, i+ i( D% {  Q& k' Wacceleration of the skeletal maturation; however, after5 B) {1 \/ q# t+ M
cessation of treatment, the rate of bone maturation
4 \: j& k4 r: K$ i5 i- Tdecelerates and gradually returns to normal.8,94 ~6 W: I2 W/ h& L0 C% r& A$ t
There are conflicting reports and controversy5 c6 W4 h* {6 l' h/ `1 T
over the effect of early androgen exposure on adult! Z! r$ y2 f4 L" T, j- n
penile length.10,11 Some reports suggest subnormal4 T. a  u4 S( G7 u/ y) u
adult penile length, apparently because of downreg-
' i4 s9 s! K6 \* m! zulation of androgen receptor number.10,12 However,
- m2 @; b) H$ G- @. s0 NSutherland et al13 did not find a correlation between+ w: g+ s  t7 x7 `" z
childhood testosterone exposure and reduced adult* Z' _; n9 ?+ P% C, d) V
penile length in clinical studies.# l2 o8 b$ }/ Y9 Z
Nonetheless, we do not believe our patient is
- @0 i# J9 F5 u0 Egoing to experience any of the untoward effects from
- _# \# f- A$ O0 w  ~- Ltestosterone exposure as mentioned earlier because
; k6 f  S( M: H; e+ Qthe exposure was not for a prolonged period of time.
) A' Z( d) j7 ~: _; |0 `Although the bone age was advanced at the time of
' I$ Y! ?: B6 V7 t5 Y! v# ndiagnosis, the child had a normal growth velocity at, V# O1 }% h4 f
the follow-up visit. It is hoped that his final adult
5 D% b+ y# s$ e, Zheight will not be affected.  L" L7 g% K, ]) O* }% L$ r7 U
Although rarely reported, the widespread avail-
! x$ R$ I3 U  tability of androgen products in our society may
6 _' s) s  A: P4 t: I( x& aindeed cause more virilization in male or female
/ ]: k  p0 w. t9 Ychildren than one would realize. Exposure to andro-3 M; m, ^( Y  u6 {  }: [9 o
gen products must be considered and specific ques-
3 ?0 O1 l, R# m2 ntioning about the use of a testosterone product or; r8 a4 L* }  c- X) d& A
gel should be asked of the family members during* C3 c+ K7 h& L
the evaluation of any children who present with vir-
6 |9 b) K5 l& k8 h, Cilization or peripheral precocious puberty. The diag-
( i* h( G4 A2 j, o% x$ S: wnosis can be established by just a few tests and by' P1 S* `3 ~7 G3 C
appropriate history. The inability to obtain such a
7 H9 M! H- K& }) }  M( h) ]history, or failure to ask the specific questions, may
& L) @# A9 c7 Jresult in extensive, unnecessary, and expensive* M* Y6 H. f' P- X0 r
investigation. The primary care physician should be
/ h4 x& O, c. D6 D+ i5 L9 yaware of this fact, because most of these children
4 a1 C( f( P: R( x7 R+ Smay initially present in their practice. The Physicians’
* m( k1 G/ l1 E9 l! eDesk Reference and package insert should also put a0 c' W" ~) x1 }6 w4 F
warning about the virilizing effect on a male or7 O  v  j  l2 @2 r0 F4 q1 q
female child who might come in contact with some-
) i  Y5 \) @% a: yone using any of these products.
/ z: G  I! ^2 c% ]$ gReferences8 y, z1 R6 B8 E: z) u
1. Styne DM. The testes: disorder of sexual differentiation
5 s( _: s. X" j, |9 i3 B/ kand puberty in the male. In: Sperling MA, ed. Pediatric" x* h* e& l$ d0 D6 ]$ Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# b# y/ A8 [6 w) J1 R2002: 565-628.8 t+ M: H% z$ l0 d4 L- H% ^% p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 G) G( ]; \! M) ^puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 V* e! U5 {  N) i$ |$ o/ ]
Boy Induced by Indirect Topical
5 Q9 c" v6 m7 b, MExposure to Testosterone
' z6 h  _. i9 rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 s( v9 V1 l/ q$ `and Kenneth R. Rettig, MD1; x1 r, x, g. w( ?6 h2 q
Clinical Pediatrics. |+ P- n- B, e! n: c
Volume 46 Number 64 G* F/ N3 Q( c* F5 C
July 2007 540-543
- b8 t! F, z( D* w* ^3 Z% o© 2007 Sage Publications& ^+ {+ a; m  O. T: i( r- @
10.1177/0009922806296651! c3 k6 i2 @& {
http://clp.sagepub.com, F1 a$ z# r, c/ c. z/ X  ^6 J
hosted at
9 ]6 K  S( }+ v) j0 m8 n& k* A) z  a' ]http://online.sagepub.com
! P/ G/ D4 G1 @: V* y3 YPrecocious puberty in boys, central or peripheral,: @' |& y0 F* t9 l8 \- t0 k# s- Z+ y
is a significant concern for physicians. Central
/ |4 g$ ?5 v" A2 S3 `& r1 }precocious puberty (CPP), which is mediated
! M+ V7 _7 b# G9 Vthrough the hypothalamic pituitary gonadal axis, has
0 [% \- r- W1 `  i3 W2 |9 La higher incidence of organic central nervous system
% R& b2 \( J. U. T/ J6 v0 O0 _9 {lesions in boys.1,2 Virilization in boys, as manifested
; l; R) Y4 M5 J( jby enlargement of the penis, development of pubic, A$ o- x5 v  @: P
hair, and facial acne without enlargement of testi-0 j2 f3 Z0 O0 Y# y7 ?! z! k
cles, suggests peripheral or pseudopuberty.1-3 We
  o; S3 r/ e4 z/ R- ^report a 16-month-old boy who presented with the
& K3 D3 z& \9 h2 m. cenlargement of the phallus and pubic hair develop-
* ~+ V0 {# W* P- C$ zment without testicular enlargement, which was due
0 ]0 N& Q5 J' i1 O8 {to the unintentional exposure to androgen gel used by2 r- t8 D8 F/ C  _
the father. The family initially concealed this infor-( W  {# r# @' K! K" Z. |5 R
mation, resulting in an extensive work-up for this
# E0 S/ o9 i% M3 f. k0 D$ @child. Given the widespread and easy availability of. \) G' G, s" V' ~$ p# V; k, u( `
testosterone gel and cream, we believe this is proba-: Y, C0 t0 H3 y! A% ~( {3 R( h
bly more common than the rare case report in the
* z$ p$ |/ d6 `, Kliterature.4
8 h: c$ o; `( k$ v! \Patient Report! B" v: R9 e7 b- R$ M' B" n4 i6 E, ?
A 16-month-old white child was referred to the
; Y  `5 [' s4 r+ M+ fendocrine clinic by his pediatrician with the concern3 ^5 d+ R; R9 N% V" L( m5 g
of early sexual development. His mother noticed) S! d. @! l4 @/ w" {
light colored pubic hair development when he was& p. t) Z  q) U0 m$ ?
From the 1Division of Pediatric Endocrinology, 2University of& o, p# }7 \' M1 l+ q
South Alabama Medical Center, Mobile, Alabama.4 e: v8 T3 M% J5 ]* s, f
Address correspondence to: Samar K. Bhowmick, MD, FACE,  \- }, J" R0 L5 P2 h& H0 c
Professor of Pediatrics, University of South Alabama, College of6 i5 W5 x& _- j0 n7 x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- y6 n* y9 }  ^( C  se-mail: [email protected].5 G  O$ `! W4 u! d- d
about 6 to 7 months old, which progressively became- W; K! p0 h4 \
darker. She was also concerned about the enlarge-
( u& W, O% b" p4 J1 {/ Z9 T" Mment of his penis and frequent erections. The child1 s# g% e2 j5 K: Y, h% \
was the product of a full-term normal delivery, with* M. U$ Z; X- O4 w5 Y# \
a birth weight of 7 lb 14 oz, and birth length of
* {  q/ A# e0 D" }20 inches. He was breast-fed throughout the first year) m( f4 b1 O7 A! E  y6 ^! s
of life and was still receiving breast milk along with/ d- ]( ]4 u% F' k% F* J
solid food. He had no hospitalizations or surgery,$ E# F1 ]1 f8 C3 g' r; y: r
and his psychosocial and psychomotor development
2 g1 O' O2 V( S# F  |- h6 N! @was age appropriate.
; e, B" S/ D- X; ]The family history was remarkable for the father,
! h  g- k) H' F9 iwho was diagnosed with hypothyroidism at age 16,
. g' X& n/ J; V& x: p$ b* y- a- ]which was treated with thyroxine. The father’s1 h$ n) u0 v* ^, S4 N
height was 6 feet, and he went through a somewhat
4 O* D' A+ G. v/ {early puberty and had stopped growing by age 14.
5 Z* r- G( j/ O- [! v' y4 g) sThe father denied taking any other medication. The/ O" }" b+ a4 K! q) I0 C
child’s mother was in good health. Her menarche
, K( p- Q; \' ]* Fwas at 11 years of age, and her height was at 5 feet
* q* W$ T5 G3 o1 W5 inches. There was no other family history of pre-+ |% w& j2 s2 z  S' a' ^* D9 o
cocious sexual development in the first-degree rela-
7 H3 _" D! B9 L* N1 B9 Ltives. There were no siblings.
9 O1 f) T  W5 G" }Physical Examination
; K+ i- w3 P1 K1 AThe physical examination revealed a very active,
& w, [5 ?; B$ M; j5 }; mplayful, and healthy boy. The vital signs documented5 Z) m) k$ v& f: [1 u) e
a blood pressure of 85/50 mm Hg, his length was
$ x4 T" p! s! x2 o4 w! |3 z90 cm (>97th percentile), and his weight was 14.4 kg
5 t. V  U5 s9 d3 L(also >97th percentile). The observed yearly growth( e4 p3 v6 }2 F) v
velocity was 30 cm (12 inches). The examination of5 R' N8 [( j% G8 r: m) d
the neck revealed no thyroid enlargement.
. M2 s3 N/ K/ |$ ^" ^4 E3 w( N# mThe genitourinary examination was remarkable for
8 T) [; Z  \0 w# J- g7 [5 E9 Henlargement of the penis, with a stretched length of
0 H! V5 _3 _& W% n2 a0 R8 cm and a width of 2 cm. The glans penis was very well$ d1 w" w# ^! V
developed. The pubic hair was Tanner II, mostly around% E5 Y0 q! _' P- W
5407 H- R0 |2 J0 X' l0 q* N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, O. M7 O  K, a" L& h/ V
the base of the phallus and was dark and curled. The5 h# U  e. g6 W% c
testicular volume was prepubertal at 2 mL each.
6 f' x$ F% C! h4 yThe skin was moist and smooth and somewhat6 ?3 x9 C& H3 x+ I
oily. No axillary hair was noted. There were no: n) E+ s: H5 ?# d$ @; V
abnormal skin pigmentations or café-au-lait spots.
* P4 y% q+ z. G8 i) aNeurologic evaluation showed deep tendon reflex 2+* Z+ _8 b: V: A3 A1 S
bilateral and symmetrical. There was no suggestion- c: o* z1 C- v, C
of papilledema.- N! ?8 s0 E9 o7 t! z7 `9 x. \6 A
Laboratory Evaluation
" q- y' g0 j3 S) @; mThe bone age was consistent with 28 months by
  |  n: J( t/ z' c- z6 {6 _# Musing the standard of Greulich and Pyle at a chrono-
- T% T( G" L8 Q; Q" zlogic age of 16 months (advanced).5 Chromosomal% r' [$ ~$ R1 |/ b" S& l" |
karyotype was 46XY. The thyroid function test
7 a- b* o$ F/ V) e. S2 xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) b/ R5 u- r1 W+ blating hormone level was 1.3 µIU/mL (both normal)." L8 M2 D* K  Y% g
The concentrations of serum electrolytes, blood) b/ i* ^, M9 I3 D- b2 @
urea nitrogen, creatinine, and calcium all were4 m. ?$ O$ P* S, i  x
within normal range for his age. The concentration
; P7 q, `5 S* U$ C4 Rof serum 17-hydroxyprogesterone was 16 ng/dL/ j1 D1 q$ g& o& \; ~
(normal, 3 to 90 ng/dL), androstenedione was 20
8 }* s8 o) l: h) J% @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. o/ b# q& I8 O' e; Y9 j9 C( {terone was 38 ng/dL (normal, 50 to 760 ng/dL),. ^* B' e; F, w( C) u2 d# }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, Q/ N1 e% {* o8 c
49ng/dL), 11-desoxycortisol (specific compound S)9 h1 X. V+ u3 L5 q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ I9 Y) G# C# S' R* utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% ]$ q' I' s: F  h- i* x& e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ L- o6 I; Y" Q3 ~7 Q
and β-human chorionic gonadotropin was less than
6 M3 Q& d6 {) F0 ]  S0 ~; L! w5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 f& V! C/ h2 c' b' M5 u2 Lstimulating hormone and leuteinizing hormone
" h- f; y" H% ~  `: @* `) Pconcentrations were less than 0.05 mIU/mL
5 m7 _" H; y0 T(prepubertal).0 W  S) F# x$ t, s9 |
The parents were notified about the laboratory
1 [& B* H% J7 k- Wresults and were informed that all of the tests were* s8 M0 u& l; l
normal except the testosterone level was high. The. @# k  V3 }' c6 I
follow-up visit was arranged within a few weeks to! N; M3 f4 g$ K8 X% q$ d& e
obtain testicular and abdominal sonograms; how-* r/ l; a& m8 h; N: {7 `
ever, the family did not return for 4 months.
: ~+ m6 k( ?% h3 @Physical examination at this time revealed that the
) r8 T  b5 M( `9 O1 m7 x, M; Fchild had grown 2.5 cm in 4 months and had gained- |+ Q( M" }. Y: j' t+ P+ E
2 kg of weight. Physical examination remained
# |" M1 ?6 l( _1 punchanged. Surprisingly, the pubic hair almost com-  D! b, g4 B; x# f, p5 E" e
pletely disappeared except for a few vellous hairs at$ ~; _' M  _% i
the base of the phallus. Testicular volume was still 2. g" y4 q( P1 `& G0 P( Y/ ^
mL, and the size of the penis remained unchanged.
5 b* e; N8 ~$ n, dThe mother also said that the boy was no longer hav-
# i) a( {9 C" ~& J: y2 K+ c/ wing frequent erections.5 Q  S( l- r# p4 _( m) W$ F' f
Both parents were again questioned about use of/ M2 U% b8 L/ t) c7 x7 V& ]
any ointment/creams that they may have applied to2 u. K( V- W! J2 N
the child’s skin. This time the father admitted the, a0 o/ Z+ [' M8 `4 |
Topical Testosterone Exposure / Bhowmick et al 541% ?8 Q' d$ R3 H+ e! W2 t- ^
use of testosterone gel twice daily that he was apply-
! y, l$ R8 ?  W( Q$ uing over his own shoulders, chest, and back area for; K2 Q4 u! e- q4 O
a year. The father also revealed he was embarrassed: c) T0 R. ?3 H( b* O) R! b
to disclose that he was using a testosterone gel pre-
! Q9 v/ M7 D  Q8 m: sscribed by his family physician for decreased libido
* f6 L  d* t' s) I3 Fsecondary to depression.
- W# T( j2 ]) z$ E, b6 BThe child slept in the same bed with parents.: t1 j# h) t  e. s. S, ]+ E0 A
The father would hug the baby and hold him on his
% r* y+ v! p+ W4 c- B5 M: \chest for a considerable period of time, causing sig-
% H' Q' N/ l* W# fnificant bare skin contact between baby and father.& j/ C2 Q) r) y' w/ Y5 t# ~
The father also admitted that after the phone call,# J; _- Y- y. T: M+ X9 G/ [
when he learned the testosterone level in the baby7 p, A2 i: b# L/ O7 ^+ Z
was high, he then read the product information
2 K) g* f& Y* P, u6 dpacket and concluded that it was most likely the rea-6 k1 @7 _  T2 _& U
son for the child’s virilization. At that time, they: p. n9 p: d/ f# I$ |, w
decided to put the baby in a separate bed, and the
. S  x% ?" Y! x9 Hfather was not hugging him with bare skin and had* H2 A% w8 m2 \7 b- |
been using protective clothing. A repeat testosterone
% ^+ L/ x8 X( i, F& l8 c  [test was ordered, but the family did not go to the. j* q/ `& H/ b
laboratory to obtain the test." w8 E1 p& T; w; W; ^3 Y
Discussion
5 r  W! B( Z0 u! W' t2 J& Q2 QPrecocious puberty in boys is defined as secondary
( S6 n! j. ?$ z7 |5 D" ?8 asexual development before 9 years of age.1,4
1 \6 A  B( z% QPrecocious puberty is termed as central (true) when
# j3 w" ~  D0 J! H  `; W0 O1 S1 Cit is caused by the premature activation of hypo-+ P' U1 b3 C& |$ F& P  m+ X
thalamic pituitary gonadal axis. CPP is more com-
& G" Y2 k2 N( D9 b! e/ }, Hmon in girls than in boys.1,3 Most boys with CPP; S9 \) s% b5 s
may have a central nervous system lesion that is
3 W0 }( h/ m5 ?% K) s2 G9 w, Dresponsible for the early activation of the hypothal-
0 g3 B/ a  h+ N5 \+ \8 ?8 Iamic pituitary gonadal axis.1-3 Thus, greater empha-
( h( w) N# {- S1 t" r- t! isis has been given to neuroradiologic imaging in
( v+ h- n' j' Iboys with precocious puberty. In addition to viril-$ i' O$ o  J2 {' }# c! E
ization, the clinical hallmark of CPP is the symmet-
3 B: A  s3 s- t2 I. ]# C3 }rical testicular growth secondary to stimulation by
% F( R" d% b4 {+ [/ fgonadotropins.1,3: A2 b6 D6 W1 u0 p
Gonadotropin-independent peripheral preco-, F. o/ ~. `8 f' h$ a
cious puberty in boys also results from inappropriate! M& H7 f2 G6 d
androgenic stimulation from either endogenous or
$ G1 g8 h5 A9 o% s4 aexogenous sources, nonpituitary gonadotropin stim-
% s: a0 M% A* i3 x# E) fulation, and rare activating mutations.3 Virilizing
3 A' v' n0 a  ?) J; G% qcongenital adrenal hyperplasia producing excessive: l" r. S/ _' Y5 X4 ^( \
adrenal androgens is a common cause of precocious
) T0 ~: b" h# n# K# c5 Xpuberty in boys.3,4" ^2 h; P& G6 S) h) J
The most common form of congenital adrenal
2 K5 k9 J8 _1 thyperplasia is the 21-hydroxylase enzyme deficiency.
- u' T  o8 e* J0 p- `The 11-β hydroxylase deficiency may also result in
% c; l* T) K/ J1 e% D% Cexcessive adrenal androgen production, and rarely,
7 s* s. |* }4 qan adrenal tumor may also cause adrenal androgen( c& X( Q  `7 i1 q+ n8 y0 B' e
excess.1,36 m% ~- B' {5 [) d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ o+ K% j! P- o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  q6 g& {5 {) |* f" Z) d
A unique entity of male-limited gonadotropin-
0 a! |$ G' J: |) l; G3 qindependent precocious puberty, which is also known
. z6 I3 j( p1 y9 H$ ]/ [as testotoxicosis, may cause precocious puberty at a
9 K; q  o$ L5 fvery young age. The physical findings in these boys
6 {" p  w. p' T+ Swith this disorder are full pubertal development,  o" k0 v. U3 S! r/ y
including bilateral testicular growth, similar to boys
- O) {5 c, v) E# n. @2 G5 wwith CPP. The gonadotropin levels in this disorder" P' C# F. ]3 M; m- {
are suppressed to prepubertal levels and do not show
, G4 i% `' \9 T, ]7 g( q+ ^% X! z. \pubertal response of gonadotropin after gonadotropin-6 f& P5 x( {* y! }$ Y. y
releasing hormone stimulation. This is a sex-linked; j; V& I; p4 {( G
autosomal dominant disorder that affects only% t5 q; c9 j4 ~! z1 e! V/ B' m7 y+ ~
males; therefore, other male members of the family
& p) w3 l5 i$ K$ F, pmay have similar precocious puberty.37 j6 e8 t4 [9 `1 n
In our patient, physical examination was incon-  q5 ^) P9 N/ ]( M/ b2 {
sistent with true precocious puberty since his testi-1 t. B6 y  o4 _* n, t
cles were prepubertal in size. However, testotoxicosis
# m& o  e0 g7 O1 S( _. ?was in the differential diagnosis because his father
: F$ ~( L+ }! A# R6 U/ fstarted puberty somewhat early, and occasionally,3 m$ w; q4 P5 z& C3 ?$ z9 u" {' S
testicular enlargement is not that evident in the
! n8 ?2 `7 m; ]beginning of this process.1 In the absence of a neg-
& u+ Y' W5 E, ?9 s( `ative initial history of androgen exposure, our5 y- r, c- f. J
biggest concern was virilizing adrenal hyperplasia,& E4 v4 [- b4 }! ?& V) h
either 21-hydroxylase deficiency or 11-β hydroxylase- N. G  m- h, h2 K$ k6 }# d
deficiency. Those diagnoses were excluded by find-2 c/ l5 V% ?$ U2 \
ing the normal level of adrenal steroids.
# J9 {3 v6 D4 cThe diagnosis of exogenous androgens was strongly
$ y" @4 T- N/ csuspected in a follow-up visit after 4 months because( H* ?1 Z. B4 ?
the physical examination revealed the complete disap-
" X- K; `# u# b5 ~8 d4 F0 P- Hpearance of pubic hair, normal growth velocity, and
0 \& C3 j7 z( rdecreased erections. The father admitted using a testos-
+ H8 c' B. @  Z! I( |0 Fterone gel, which he concealed at first visit. He was
8 f- P7 a4 V+ R0 [6 Vusing it rather frequently, twice a day. The Physicians’8 E/ |# @& {: K. t7 d7 g3 e6 x' D2 M
Desk Reference, or package insert of this product, gel or' N) ^5 ]2 z* f
cream, cautions about dermal testosterone transfer to
7 E" U7 \; ]$ S7 b$ k& P- a  J' }unprotected females through direct skin exposure.
8 R% V- M' [) A) a2 \7 x& }6 aSerum testosterone level was found to be 2 times the
  t8 ]. R' n, ybaseline value in those females who were exposed to0 b3 b- B' i5 c, K
even 15 minutes of direct skin contact with their male
% Q! K! N: K1 P, h/ x$ H/ {+ Y8 r; fpartners.6 However, when a shirt covered the applica-3 @  I( m" q8 J8 U* _4 r+ I* L
tion site, this testosterone transfer was prevented.% C+ J1 x: X' ~: X5 I
Our patient’s testosterone level was 60 ng/mL,
0 I7 g& ^0 o+ B* G9 Ywhich was clearly high. Some studies suggest that/ ~1 d4 N2 t* m
dermal conversion of testosterone to dihydrotestos-
- x" r* i1 i6 Kterone, which is a more potent metabolite, is more5 ~. Q4 b( Z: |4 ^. _/ T
active in young children exposed to testosterone# R- F/ `1 N3 z# X- p0 j+ G
exogenously7; however, we did not measure a dihy-
5 }7 w: y, f( R# N0 ^$ h. O4 Ydrotestosterone level in our patient. In addition to( X# r/ U' H  |. `+ L- M. V' F% W
virilization, exposure to exogenous testosterone in$ T  _; A$ _5 c0 x
children results in an increase in growth velocity and/ Y% h( S$ ]0 {; k3 l" H, Q
advanced bone age, as seen in our patient.
( Q  a( ]- [5 L9 K8 CThe long-term effect of androgen exposure during
! a% }0 f# X6 k; rearly childhood on pubertal development and final
6 i' s  I2 X2 C2 [adult height are not fully known and always remain
% y4 ]3 P0 Y# ~4 B9 [9 C1 ?. U" m! E6 pa concern. Children treated with short-term testos-: `/ |, E9 ~4 ~
terone injection or topical androgen may exhibit some5 |/ O- B3 t0 u  E3 c" S9 Q
acceleration of the skeletal maturation; however, after
# I3 `/ W  `7 K8 {: \6 V' Ncessation of treatment, the rate of bone maturation) Y$ Y( s; e. x. E
decelerates and gradually returns to normal.8,9/ k3 E1 S# U* c7 ?" z' P
There are conflicting reports and controversy: _, |2 x% U1 k/ t8 r
over the effect of early androgen exposure on adult
6 [1 p9 `9 i- M9 `) g; Tpenile length.10,11 Some reports suggest subnormal
! H1 ^+ w, k/ W* l* t; l, j1 \adult penile length, apparently because of downreg-
3 u6 v; f# y) Q7 e0 y' l( r$ aulation of androgen receptor number.10,12 However,7 v; X* C2 t+ h; V. N& C
Sutherland et al13 did not find a correlation between
4 S* j6 \% N  _/ E% mchildhood testosterone exposure and reduced adult( k! Z, U$ u9 j2 P8 A& Z: p
penile length in clinical studies.
# V, H+ M  o9 K2 T" bNonetheless, we do not believe our patient is
1 d7 a6 _4 I+ j4 J0 {! P7 B* fgoing to experience any of the untoward effects from
5 R' y$ {2 \/ N3 Stestosterone exposure as mentioned earlier because
% H9 [( _# n7 X! z+ Dthe exposure was not for a prolonged period of time.0 y+ @( Y, v( _9 c2 A+ c
Although the bone age was advanced at the time of9 f! T7 l5 D& s5 d2 b
diagnosis, the child had a normal growth velocity at3 n7 a( c! U5 x& |% G- B* E4 R
the follow-up visit. It is hoped that his final adult
. _' A! ]7 P/ Y: n; uheight will not be affected.% P) I' f9 U! D( T
Although rarely reported, the widespread avail-/ m/ k( c# }9 k4 Z8 @
ability of androgen products in our society may
  l$ n1 p- w  [' k; X/ X8 _" pindeed cause more virilization in male or female% Y  \6 W) m7 S- A
children than one would realize. Exposure to andro-0 U  a  g" R5 [) r6 p( E$ r
gen products must be considered and specific ques-% |( M5 p/ V  g$ J+ u3 u6 h; e
tioning about the use of a testosterone product or
+ i6 Y" Z/ M, `/ Pgel should be asked of the family members during
6 R0 f1 ?8 q3 pthe evaluation of any children who present with vir-
. G5 }+ S' T5 Lilization or peripheral precocious puberty. The diag-, K/ A; ]- D1 J" c2 C+ d
nosis can be established by just a few tests and by
4 Z" [3 T2 r+ [, H  ^' }, Iappropriate history. The inability to obtain such a$ U/ Z3 J8 v2 ~$ S& U" f. _( t
history, or failure to ask the specific questions, may  l/ D$ J1 d  k$ @1 j
result in extensive, unnecessary, and expensive7 l0 r' p8 n7 P- Y* E. E2 n
investigation. The primary care physician should be
: _( i8 H' ~; _8 B3 iaware of this fact, because most of these children3 }5 G: _; \: Y6 G0 [
may initially present in their practice. The Physicians’' ~; K, f, G, q9 f
Desk Reference and package insert should also put a/ F/ g& W2 e; Q# w
warning about the virilizing effect on a male or) H3 u4 Y  }1 j' X; r4 Q
female child who might come in contact with some-9 [5 U  L" f, a9 z
one using any of these products./ }/ h) Z5 E) ^" _4 U& J2 z
References
% a: A" l/ T& m) x- I1. Styne DM. The testes: disorder of sexual differentiation' C2 L% _9 g9 c! |2 d* T6 Y
and puberty in the male. In: Sperling MA, ed. Pediatric
" M4 w% [8 E* R$ Q' R% MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( Q3 s& z  E6 Z# c2002: 565-628.# n4 n; w  S3 i) l( K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& m' k3 M: D- v5 npuberty 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
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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

( P9 P7 }% P% x) [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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