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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* t0 X; ?# w2 Q) Q, |
Boy Induced by Indirect Topical4 x9 e. k5 Z3 Y
Exposure to Testosterone7 H7 b$ R9 w2 |" l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* Y8 s2 }$ \' [1 J2 i
and Kenneth R. Rettig, MD1
! M# [$ W4 e6 l* f( MClinical Pediatrics
1 d% b2 w% D1 N$ S0 B' Z# AVolume 46 Number 6
7 W) [  a+ I) ~$ C  XJuly 2007 540-543
" _' v5 V2 H- _8 D% Q. v/ ~, \© 2007 Sage Publications
' j! A9 }: ?- V2 U" [7 x10.1177/0009922806296651
. O# I# {# z* C' @8 [& H4 A% P" m2 Ahttp://clp.sagepub.com
6 t% P% {9 d& z0 i1 w2 G# ghosted at$ a% m' m% J- `' C% M! u9 H
http://online.sagepub.com( E* O& U8 b" f* R' x  F2 }
Precocious puberty in boys, central or peripheral,; G; c, W% S- R& C+ C  G3 f/ L
is a significant concern for physicians. Central
7 A4 m2 p) ?! _; J- b9 _: Gprecocious puberty (CPP), which is mediated0 v/ p5 f" H- h5 y3 [
through the hypothalamic pituitary gonadal axis, has
- C2 S9 f8 B, m; [- Z' h* q% [a higher incidence of organic central nervous system% e3 Y( p, ~9 C5 L+ y/ L
lesions in boys.1,2 Virilization in boys, as manifested/ K# P! p, q# m8 ~. e) g, z
by enlargement of the penis, development of pubic+ _: {! G: x) E8 f6 o5 e7 g
hair, and facial acne without enlargement of testi-
, ?5 F2 H* H: h! U) ~0 W. Scles, suggests peripheral or pseudopuberty.1-3 We4 h: U* t$ x' U& ?8 `
report a 16-month-old boy who presented with the
: O: c9 T% Y% Tenlargement of the phallus and pubic hair develop-
7 e( P+ f0 f' h% I3 d# W1 @6 mment without testicular enlargement, which was due* y  N# Z( h, h/ j9 T# ~* z
to the unintentional exposure to androgen gel used by
- l5 y& |$ \+ ~8 o: ?+ |the father. The family initially concealed this infor-
  A' c* |3 Y  [+ j, Emation, resulting in an extensive work-up for this
$ c' C$ {6 I% N- bchild. Given the widespread and easy availability of; P5 j0 u0 G: A. W/ O
testosterone gel and cream, we believe this is proba-; f$ M) q6 G* F; P4 L( d$ b0 u
bly more common than the rare case report in the& M' c) O% \* p, Y+ f% W4 P4 z7 I
literature.4! z0 z. Q0 x& p; a
Patient Report7 k& T1 Q( e; p7 V# Q9 E
A 16-month-old white child was referred to the
. P) ^9 S* s( j+ {endocrine clinic by his pediatrician with the concern. _% A0 l* k. I3 Z) |+ I
of early sexual development. His mother noticed& W! ^: U& [) f- p& W3 }
light colored pubic hair development when he was
0 m- v/ B- ]% dFrom the 1Division of Pediatric Endocrinology, 2University of% s, T! s; q& s) D! V; q
South Alabama Medical Center, Mobile, Alabama.) B* I, d; m; m& z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 R! s* ?; ?' y& w9 w. l; @! G, O5 EProfessor of Pediatrics, University of South Alabama, College of/ D; p; D' R- |% B7 O7 i. f! {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' o! r8 J+ c2 E; l2 N, o* a1 S
e-mail: [email protected].4 b( l3 S- R2 D' f
about 6 to 7 months old, which progressively became
7 _( J+ E0 f& u2 @+ ydarker. She was also concerned about the enlarge-  S# E+ ~8 g) Q) q. J
ment of his penis and frequent erections. The child: S) N% J0 `5 d# G) d
was the product of a full-term normal delivery, with
( n0 `' s5 W+ A# b" R6 Sa birth weight of 7 lb 14 oz, and birth length of
, u' R7 Y/ G4 S" L- X20 inches. He was breast-fed throughout the first year
2 J5 U- o. q- l$ u  q& gof life and was still receiving breast milk along with
  Q5 J9 A# W9 A- K) ]# ]solid food. He had no hospitalizations or surgery,
& V( W5 |8 b- ~: ?5 jand his psychosocial and psychomotor development
# A4 p" `5 z2 y; g/ ~2 Vwas age appropriate.. n) D8 U/ o$ C9 P) p# k
The family history was remarkable for the father,
4 i0 h0 @" A. C/ h2 J; swho was diagnosed with hypothyroidism at age 16,8 K) N3 _+ d: ~
which was treated with thyroxine. The father’s7 h/ B* a2 F% v% y- h. F
height was 6 feet, and he went through a somewhat
( E( b$ ~4 p' cearly puberty and had stopped growing by age 14.1 O2 ?# i, V& P4 ~
The father denied taking any other medication. The
. h; O- y* p, K" Hchild’s mother was in good health. Her menarche3 u- P* p6 g- F% A% q
was at 11 years of age, and her height was at 5 feet) m+ h5 w9 h8 s) n9 k
5 inches. There was no other family history of pre-' d' F- G' l( o- _) D6 p( x9 G& S, ~
cocious sexual development in the first-degree rela-
/ F& j1 u$ {% s5 h1 T* Utives. There were no siblings.' ]+ f6 v# W- J  }2 h2 r1 n# f
Physical Examination  a3 H4 m1 X; }  ?6 o$ s
The physical examination revealed a very active,* P  h1 a9 w& w2 @9 q& ]/ X
playful, and healthy boy. The vital signs documented5 B! h# H) P3 D: [" u
a blood pressure of 85/50 mm Hg, his length was
% r8 _1 e2 t/ o4 h: V90 cm (>97th percentile), and his weight was 14.4 kg/ Y) ?( Y& x+ x- ^( h  J
(also >97th percentile). The observed yearly growth
+ o' t. J" ]' u) G) Avelocity was 30 cm (12 inches). The examination of
3 M/ f- D" S' }) m' L+ V/ }) Y- W3 Ethe neck revealed no thyroid enlargement." \% d0 t* ?6 E1 Z
The genitourinary examination was remarkable for
* W4 C3 D4 k. Q' v  C0 Benlargement of the penis, with a stretched length of
8 x5 x4 }: ~1 y2 G8 cm and a width of 2 cm. The glans penis was very well, V( R! ?% g: `$ y# a! L' n3 g: Y( j( j
developed. The pubic hair was Tanner II, mostly around
; x$ k/ b* g1 O5405 U; T6 b* R/ y. n, u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 H$ b2 ^+ ]! I+ N
the base of the phallus and was dark and curled. The
) V6 n2 v6 |( G' B: W% Dtesticular volume was prepubertal at 2 mL each.
% R4 L0 M5 f9 C0 C: [The skin was moist and smooth and somewhat
: f+ C7 c$ O  I' x) W2 yoily. No axillary hair was noted. There were no, h6 h+ _5 [$ R' \0 d$ I
abnormal skin pigmentations or café-au-lait spots.
, U4 E, T9 |% I: }$ F5 U+ HNeurologic evaluation showed deep tendon reflex 2+
, v; U, D6 a# o9 \5 xbilateral and symmetrical. There was no suggestion# C1 a4 m4 i( H0 {
of papilledema.0 m& ~0 F) P0 l. \! b$ a& j
Laboratory Evaluation5 m& j* j0 I  O5 F; [# r  a
The bone age was consistent with 28 months by9 L% X( \% M9 l- Y
using the standard of Greulich and Pyle at a chrono-
# c  f% p! x4 k$ Dlogic age of 16 months (advanced).5 Chromosomal
+ [5 x. p, W' D$ |3 s. H- O, ekaryotype was 46XY. The thyroid function test
, X8 H4 w4 E; z* [showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 Q3 K/ K, X1 H6 B$ @! h- o& l' w
lating hormone level was 1.3 µIU/mL (both normal).
* V4 @2 p4 V! S+ m) TThe concentrations of serum electrolytes, blood$ q! J0 U5 Z) f
urea nitrogen, creatinine, and calcium all were
: ?: F) x- S  f$ `+ Hwithin normal range for his age. The concentration
6 c' L5 ]% f; u) z: q8 G: A# Dof serum 17-hydroxyprogesterone was 16 ng/dL
8 C, a  }6 q* ^( k(normal, 3 to 90 ng/dL), androstenedione was 20" i  l/ Z- G( M: Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 l# b; X  m# t; T' T8 u4 w# N7 D8 B& P, fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 c( G4 t: V# t. `desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# R/ g" o; g3 b' T* w49ng/dL), 11-desoxycortisol (specific compound S)8 H' s, w4 {9 ], P1 R5 v& F+ @  B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) V! o) Q+ y8 t. w$ g6 m2 p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: x" ]+ m# C9 p- otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# f: Y+ V% X) f4 M# R% Fand β-human chorionic gonadotropin was less than& R9 R, G% b$ y0 g" H) O3 N6 ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: G( U* G% c9 r4 w3 ?2 lstimulating hormone and leuteinizing hormone  s5 {; k  \+ g6 ]  x" B
concentrations were less than 0.05 mIU/mL  F8 v9 i9 Y4 |8 Q
(prepubertal).. j% ?0 J8 K, x4 _: E- p% D& l
The parents were notified about the laboratory# Y$ U/ D. u" \+ ^  k' \" }& Y6 @
results and were informed that all of the tests were; r/ G4 P  b' ]  E4 k
normal except the testosterone level was high. The) i/ E, A. a4 G  @
follow-up visit was arranged within a few weeks to5 J. K5 J6 N! l. T; {8 q8 W2 e0 |
obtain testicular and abdominal sonograms; how-( s9 |+ @, i- L3 C* K
ever, the family did not return for 4 months.
8 y6 E/ ^. k: @3 l0 l' g, XPhysical examination at this time revealed that the1 \! e8 h1 Y, I1 V) t
child had grown 2.5 cm in 4 months and had gained# v& ?' d9 X: Y: `- w. L- h& R5 Z6 P
2 kg of weight. Physical examination remained: x$ n6 r2 ~  M# b' R1 p
unchanged. Surprisingly, the pubic hair almost com-( w2 M6 M4 Z: h0 T' a- A% K
pletely disappeared except for a few vellous hairs at/ \$ B: a8 D6 \6 g. q7 c- P
the base of the phallus. Testicular volume was still 2
( c4 E3 ~- s: j- r" T7 MmL, and the size of the penis remained unchanged.6 h2 n. o' k$ B$ f# S" z+ d
The mother also said that the boy was no longer hav-: [( X  v9 j  O- H0 g( g
ing frequent erections.+ U5 i% r9 q& |' \" g- _. f( O* j
Both parents were again questioned about use of
* q" D# u1 w$ ]3 U, ~any ointment/creams that they may have applied to6 j" S8 X" s5 d5 a6 l  Q
the child’s skin. This time the father admitted the+ u$ b1 K' a4 Q/ G" a
Topical Testosterone Exposure / Bhowmick et al 5416 N" E) H' H  V8 \/ O" P0 O$ W8 E
use of testosterone gel twice daily that he was apply-
# g+ |( J( T6 c9 T  ding over his own shoulders, chest, and back area for6 g5 Q. t" Y$ `( U
a year. The father also revealed he was embarrassed
  h. _/ p+ p" c' d9 N2 x; a9 Gto disclose that he was using a testosterone gel pre-" h- c/ J( ~8 `8 f  a$ G
scribed by his family physician for decreased libido
0 R( F7 r" c# ?' s% ]secondary to depression.4 m9 B# s9 Z/ ^' s' M) V0 I
The child slept in the same bed with parents.
8 s4 N) b8 T+ a  [- cThe father would hug the baby and hold him on his4 o( L) P- ?: t  g, v0 G" _
chest for a considerable period of time, causing sig-4 K" w8 u- @; w1 z2 O3 R- X" q
nificant bare skin contact between baby and father.
# w0 \, Q- m$ P& _7 O* bThe father also admitted that after the phone call,
) \7 o8 X! w2 Swhen he learned the testosterone level in the baby9 e5 D9 M# d6 J6 h
was high, he then read the product information
; ^0 b3 V+ s# @# Upacket and concluded that it was most likely the rea-- o1 m- n+ z. K5 R
son for the child’s virilization. At that time, they
' B6 E! I4 j  l$ X0 V8 F5 f8 ^* Qdecided to put the baby in a separate bed, and the
8 u% x: F9 f6 Jfather was not hugging him with bare skin and had
/ J  p; Z- e7 D' _( m- |( gbeen using protective clothing. A repeat testosterone
* `$ J2 c1 q9 B( itest was ordered, but the family did not go to the
% X' d* `! R4 v- U+ E, I. Ylaboratory to obtain the test.& F8 H* N7 _& U8 a) z
Discussion
9 C0 _, A8 o$ o( \9 @! s% }9 RPrecocious puberty in boys is defined as secondary
* l' @3 U. l2 |sexual development before 9 years of age.1,4
' v) Y1 |; X6 _, u7 F. o; bPrecocious puberty is termed as central (true) when
( S. M6 L6 @0 C( V+ s7 lit is caused by the premature activation of hypo-: I2 K4 r6 y: ?9 l" G
thalamic pituitary gonadal axis. CPP is more com-
( [2 z: K' D& k7 \7 T1 S. omon in girls than in boys.1,3 Most boys with CPP
: q- U. h  N; X3 K5 ^/ ?may have a central nervous system lesion that is# G# D0 O1 o. Q1 L, M( ]
responsible for the early activation of the hypothal-! y; w1 e; ?6 L' T
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 f* b5 z( r2 Q4 b( }sis has been given to neuroradiologic imaging in
: v6 f8 [9 z6 s: _' G7 @boys with precocious puberty. In addition to viril-3 S/ A: t& q  }9 W* J: d
ization, the clinical hallmark of CPP is the symmet-
! E/ s1 ?% V9 X+ u7 Grical testicular growth secondary to stimulation by
. e# C% f. |* C3 Sgonadotropins.1,3' j+ m8 V& M1 _& X" n
Gonadotropin-independent peripheral preco-6 {2 g! X  Y; f( K3 \
cious puberty in boys also results from inappropriate
0 {) C, b& M. f* N0 J% handrogenic stimulation from either endogenous or; a( m& s* l) A! g
exogenous sources, nonpituitary gonadotropin stim-
5 Z2 G' M* m3 sulation, and rare activating mutations.3 Virilizing+ q2 \0 W. `8 }& C3 Y7 x) u" ^- T# [
congenital adrenal hyperplasia producing excessive( u6 h- z9 ?' {% G/ q7 V
adrenal androgens is a common cause of precocious
# d" a7 A  y* [! P8 opuberty in boys.3,42 v4 [. H" K# i  Z
The most common form of congenital adrenal' i5 I% \$ Q2 t" U6 V
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 E  X+ O( g6 ?( i: v6 a& RThe 11-β hydroxylase deficiency may also result in0 Z$ n: ^, H0 s$ r# f$ J5 j
excessive adrenal androgen production, and rarely,+ `; ]+ o+ |; \0 i2 N; H( P; |2 [+ Y
an adrenal tumor may also cause adrenal androgen% w9 C/ F8 Q+ H* @5 A6 R* S8 V
excess.1,31 b. ?6 i) A0 i  P8 }1 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& W; Y  }) O9 v
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" r2 f5 p& d; B- DA unique entity of male-limited gonadotropin-* g1 @+ c' U# m+ _
independent precocious puberty, which is also known
% M# z. P0 D  mas testotoxicosis, may cause precocious puberty at a
$ y2 x( V& p3 I4 ivery young age. The physical findings in these boys
- K; C. F1 V$ o# U  X1 t& K% Xwith this disorder are full pubertal development,
! k3 P  r- j- D, z6 m3 bincluding bilateral testicular growth, similar to boys1 {5 c5 f3 ~/ N5 s4 t
with CPP. The gonadotropin levels in this disorder
# W0 k1 x; }. W5 u8 c; ]# l: qare suppressed to prepubertal levels and do not show6 A- r( c2 j: ]5 i" e
pubertal response of gonadotropin after gonadotropin-& l9 O. }0 J- U7 D4 Y6 T/ E4 N
releasing hormone stimulation. This is a sex-linked
* c( H1 F2 l; h- _autosomal dominant disorder that affects only
+ w0 y! k5 j1 S: P0 N1 o, U3 vmales; therefore, other male members of the family4 \/ ~# ~0 Y% i2 g* Z
may have similar precocious puberty.3
$ b. Q/ g4 j! I% wIn our patient, physical examination was incon-
5 q2 _. M0 s+ O8 |& Qsistent with true precocious puberty since his testi-
; N  E5 o& q7 `2 p) \9 Jcles were prepubertal in size. However, testotoxicosis2 P0 n  a5 S5 |3 A  o( }6 g' L
was in the differential diagnosis because his father- A" S* }; }$ V% [# Y" G
started puberty somewhat early, and occasionally,5 ?8 T* a5 U8 X7 o; L5 j
testicular enlargement is not that evident in the( h0 c( X! s  W5 c$ S
beginning of this process.1 In the absence of a neg-
' \( V; z/ B* t# I. k! Uative initial history of androgen exposure, our
' }  W+ b" n" j9 E" ^% mbiggest concern was virilizing adrenal hyperplasia,) u# m$ Q: m" O) ^# X' T1 d
either 21-hydroxylase deficiency or 11-β hydroxylase; W5 `9 X: s5 u9 _
deficiency. Those diagnoses were excluded by find-4 g- l6 v- G( M  |) \- D& F; {( Q
ing the normal level of adrenal steroids.
  H5 Q( f) C8 h9 Z- P- c3 Z" eThe diagnosis of exogenous androgens was strongly8 A9 D1 T; G8 B% g# K
suspected in a follow-up visit after 4 months because5 X$ F# r, v/ Y/ W. L2 f
the physical examination revealed the complete disap-
$ G% {% ^- J4 V8 L; ]3 kpearance of pubic hair, normal growth velocity, and
. G7 N. b; }+ o$ B1 bdecreased erections. The father admitted using a testos-
- Z( a9 t, `/ y+ I: L( v2 \; ?  Cterone gel, which he concealed at first visit. He was
3 J, }7 O3 g) W2 Gusing it rather frequently, twice a day. The Physicians’$ {. A4 N- m# s) V1 ^+ ?
Desk Reference, or package insert of this product, gel or7 ?0 L! ~% k9 N- q
cream, cautions about dermal testosterone transfer to$ H% P* e: ~3 r$ b* s* U
unprotected females through direct skin exposure.
. R. Z" a- x- F& `4 s5 S" A7 lSerum testosterone level was found to be 2 times the7 |$ g; O9 P$ ?7 X
baseline value in those females who were exposed to# M9 L8 C* C9 Q) G$ i0 o
even 15 minutes of direct skin contact with their male
7 ?- ~8 U4 B4 S& m9 A' p, v" zpartners.6 However, when a shirt covered the applica-
' f6 t; F; \- x9 Z5 t+ xtion site, this testosterone transfer was prevented.
8 r/ \* T; ?, SOur patient’s testosterone level was 60 ng/mL,. q, W+ v7 b$ Z; D. x
which was clearly high. Some studies suggest that
" y4 c# @0 q' M  A0 r1 idermal conversion of testosterone to dihydrotestos-
. \! ?3 T. V8 V$ a7 s0 s1 _terone, which is a more potent metabolite, is more
! z9 d3 E% E0 H% F5 n3 Nactive in young children exposed to testosterone, B  m. g1 v# t
exogenously7; however, we did not measure a dihy-
$ u/ b  Y$ @2 R- r' ^! C7 c& T% h9 ddrotestosterone level in our patient. In addition to# Z; ?# m* @) R
virilization, exposure to exogenous testosterone in5 Q( K; p6 e3 i
children results in an increase in growth velocity and
( G+ m5 J' w7 b- L5 Radvanced bone age, as seen in our patient.  U% T4 O: v3 S3 {: G$ R% ^
The long-term effect of androgen exposure during
2 k( b( E# k* f! Q: Bearly childhood on pubertal development and final
6 ~' }4 `: h( Radult height are not fully known and always remain
6 s6 W& _" I7 f' ]/ wa concern. Children treated with short-term testos-
* O+ J1 E. C4 o# B  xterone injection or topical androgen may exhibit some
2 E; k+ T; G2 Oacceleration of the skeletal maturation; however, after4 f5 N* j$ E" R( V6 }$ p5 @
cessation of treatment, the rate of bone maturation
2 O$ m: Q. ?- Fdecelerates and gradually returns to normal.8,9
$ S1 e6 T  ?$ E, _; y% _There are conflicting reports and controversy% L8 Q* a. W+ X4 p1 y
over the effect of early androgen exposure on adult
. ?, N, g: ], e) ]penile length.10,11 Some reports suggest subnormal
. \, ^7 }% S$ |$ \  C1 W: ~adult penile length, apparently because of downreg-
5 w; I8 X0 a. \4 B% k' g8 pulation of androgen receptor number.10,12 However,
0 y' T$ o& u: S$ \9 GSutherland et al13 did not find a correlation between! I# V3 }$ A2 N3 t1 b! W% R) a
childhood testosterone exposure and reduced adult
, l2 C! P3 k( Y; [penile length in clinical studies.
1 C3 X( f* p4 }  W& T: MNonetheless, we do not believe our patient is) _+ }' J6 B7 x8 L
going to experience any of the untoward effects from: e6 a( z8 {- a* j4 n
testosterone exposure as mentioned earlier because
. i* U: ]$ [$ j8 [9 K( L8 ?, Mthe exposure was not for a prolonged period of time.2 m2 \1 p! S; q( S) h; q4 y# o
Although the bone age was advanced at the time of
* _, L; l( d1 w4 @( }diagnosis, the child had a normal growth velocity at
2 L4 H: G6 C: f  u, h% |$ _the follow-up visit. It is hoped that his final adult
1 p. i. V5 K. G: theight will not be affected.
: E2 A& q/ w) I" F9 W1 Z5 C# `, jAlthough rarely reported, the widespread avail-
% u3 |9 h4 {& L6 ?1 S' p; b5 Wability of androgen products in our society may. R7 T0 {1 Q# k  Y. U
indeed cause more virilization in male or female
$ i+ v( G- [4 G5 r3 t. gchildren than one would realize. Exposure to andro-
3 L9 t' f/ C8 O. Lgen products must be considered and specific ques-
% J4 q& N4 ]& F5 A4 C! T: P4 R# ztioning about the use of a testosterone product or
1 ]4 I/ c. f3 d  f% Qgel should be asked of the family members during
# U7 k7 f! k+ j" _9 M! u$ Ethe evaluation of any children who present with vir-! _" W) s* w4 T% b1 M$ B+ p* T
ilization or peripheral precocious puberty. The diag-5 |# n$ o6 I! x2 D/ p/ d
nosis can be established by just a few tests and by5 C1 C0 A6 Q3 Z0 y# b
appropriate history. The inability to obtain such a- j" Z( `  U6 t; K
history, or failure to ask the specific questions, may
; [+ x2 d4 d% Q  n) d: \9 z% a8 Iresult in extensive, unnecessary, and expensive
2 ^6 @; @' j' b3 Iinvestigation. The primary care physician should be
- F1 u; Y1 d( w3 d' G& c! Kaware of this fact, because most of these children) d7 b$ ?+ y+ t& G% T0 s% L
may initially present in their practice. The Physicians’2 ]- k' N+ c5 ], ~. Q
Desk Reference and package insert should also put a
- d! d- Q( f! awarning about the virilizing effect on a male or/ o6 Z* g6 }" v- z
female child who might come in contact with some-
7 {$ x0 O5 O; u# None using any of these products.* y" t% ?# ^6 X# A( s2 Z) `
References) {8 T2 v3 b+ P: A9 d1 U6 u, m
1. Styne DM. The testes: disorder of sexual differentiation; k5 y% m7 H# K# m3 k
and puberty in the male. In: Sperling MA, ed. Pediatric0 |+ ?% a( ^  n  K6 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; @# E: K. ?6 u+ L2002: 565-628." C4 A) v6 V: a/ y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 s7 [5 O7 X3 C
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old, R" Y" q% B) }) F4 s
Boy Induced by Indirect Topical
# Y: {% L& U* TExposure to Testosterone
9 t0 ~- ~/ D% M! I- |2 w7 t( qSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' |: v" N% t. d* B* gand Kenneth R. Rettig, MD1: C/ p: u4 r- f0 Y
Clinical Pediatrics
# }7 q+ i3 r. xVolume 46 Number 6+ ]8 D3 A3 t) I8 o
July 2007 540-543
4 _# g" |) c5 R© 2007 Sage Publications; G. v8 J4 O* |
10.1177/00099228062966514 t  q( P; R7 u# j' z  K! D
http://clp.sagepub.com2 j8 J  ^( \/ ^
hosted at5 T5 _8 d! M2 |9 l* Y
http://online.sagepub.com* ~) _( ^* g! k" q6 H" |
Precocious puberty in boys, central or peripheral,
4 V/ e) B$ I% ois a significant concern for physicians. Central
* S) `0 G1 w: n0 r2 kprecocious puberty (CPP), which is mediated
3 Y1 S1 j; H9 V1 n( r4 _through the hypothalamic pituitary gonadal axis, has$ x3 U6 p: L, m5 U0 e
a higher incidence of organic central nervous system0 T  E4 q6 ]$ C  O0 f
lesions in boys.1,2 Virilization in boys, as manifested( y2 Y6 z1 G6 o0 d: _/ s
by enlargement of the penis, development of pubic7 ~; N1 B! p. I3 w
hair, and facial acne without enlargement of testi-
: ?& x+ Y$ X8 Q! a1 ocles, suggests peripheral or pseudopuberty.1-3 We  K( K: O7 d- k& b) x* I( s
report a 16-month-old boy who presented with the
+ W: _2 `6 }1 L/ r; N4 penlargement of the phallus and pubic hair develop-" M$ X. L% o5 ~+ W7 f* e4 Z, v* \
ment without testicular enlargement, which was due
9 W" f$ Y# U$ O2 c. f! Kto the unintentional exposure to androgen gel used by
5 _5 R$ y4 o6 `3 x6 q) \, X7 nthe father. The family initially concealed this infor-
8 w9 {* _8 k: z9 [1 W3 ?2 Vmation, resulting in an extensive work-up for this' U* }7 R7 b9 n: W2 ^$ `) h
child. Given the widespread and easy availability of1 W, Q% w2 d( P+ C! w$ Q
testosterone gel and cream, we believe this is proba-
) C4 F: d. r5 O2 b' }bly more common than the rare case report in the% s: l& s) C, D5 N' B, r
literature.4
# _6 e6 O) [  J5 p! b  E4 yPatient Report
6 E" e! q. C0 z" P$ wA 16-month-old white child was referred to the
/ z8 d, B+ K8 x% ^endocrine clinic by his pediatrician with the concern( R/ a7 O& H; P
of early sexual development. His mother noticed
4 R2 Y; d  c3 N! Q! {! s" Xlight colored pubic hair development when he was
6 [8 x8 m4 v& W4 VFrom the 1Division of Pediatric Endocrinology, 2University of  d8 m0 b5 t1 O. F& b
South Alabama Medical Center, Mobile, Alabama.
& t" W. V( {2 B' a* A$ oAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' F* n* h9 }. |' K8 \Professor of Pediatrics, University of South Alabama, College of. K0 O, z6 q3 q) I+ a) q6 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- V1 b! t8 {1 q$ E/ v6 t( @e-mail: [email protected].5 C- A) \' V! g! a* t+ ?
about 6 to 7 months old, which progressively became1 f* F: r! b$ D3 S# _
darker. She was also concerned about the enlarge-' `) @% c! Z! B3 Q; U5 u' i
ment of his penis and frequent erections. The child4 W$ H. x4 b9 w4 t; u" q
was the product of a full-term normal delivery, with6 h3 B6 W1 n7 ]0 v/ F
a birth weight of 7 lb 14 oz, and birth length of
6 d: Y- U1 w. G7 v8 u3 u( l20 inches. He was breast-fed throughout the first year
6 @3 K( Z3 V' b% \of life and was still receiving breast milk along with
  o7 v) ]% J6 L2 y$ csolid food. He had no hospitalizations or surgery,
3 \: l/ F* d" d4 Nand his psychosocial and psychomotor development7 H8 C$ p  s0 l2 }) f4 y* q! P
was age appropriate.
- l$ H& J9 W% mThe family history was remarkable for the father,- K/ X( \" ^% B6 K+ M
who was diagnosed with hypothyroidism at age 16,  F) w$ p1 G; K9 {) [# \
which was treated with thyroxine. The father’s4 ~8 k, P# I0 j+ g( ~, [: s: b
height was 6 feet, and he went through a somewhat
4 l5 A* }. f# Z$ S+ wearly puberty and had stopped growing by age 14.
& @; w4 V0 H% f2 U- o% E3 [! @The father denied taking any other medication. The; E+ ^) u; |0 B2 N3 u8 i4 L1 U) n- Y3 Q
child’s mother was in good health. Her menarche
$ w' v- ~4 h  n6 o" i: J# Dwas at 11 years of age, and her height was at 5 feet$ {  b1 N- `1 o. Y% c$ r& _$ V2 y
5 inches. There was no other family history of pre-
4 U, L" E& I. j. p  ~cocious sexual development in the first-degree rela-7 G) `& c1 _; y! F( O
tives. There were no siblings.
7 A- e. B$ h  APhysical Examination
; Q" F2 V: n3 u3 v4 t0 ]% h8 _9 oThe physical examination revealed a very active,
) y* E' y$ U/ m& w: aplayful, and healthy boy. The vital signs documented
$ S; k( F( z: w  j. i. O4 C8 g7 ia blood pressure of 85/50 mm Hg, his length was8 ]8 x6 }' ~7 s3 ?" }( a
90 cm (>97th percentile), and his weight was 14.4 kg% X+ Q4 X; {  H$ j- r) W& v
(also >97th percentile). The observed yearly growth  H7 N, W* C( t; O0 ~
velocity was 30 cm (12 inches). The examination of( s3 h* x1 {1 X: P( Q( I$ |
the neck revealed no thyroid enlargement.
7 h. ~) s) N1 }( O  L3 G1 GThe genitourinary examination was remarkable for
% y6 k6 t1 S2 l/ [# a' Qenlargement of the penis, with a stretched length of
3 R; z$ @/ t' V7 y' D$ j8 G: y8 cm and a width of 2 cm. The glans penis was very well5 H7 B( Y. S. }, D+ G4 `  f
developed. The pubic hair was Tanner II, mostly around1 U/ W2 W, W% {& l
540
9 `4 P, m. B- ^/ N0 D7 h! cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 q* }) m$ J  ethe base of the phallus and was dark and curled. The/ a. a- D, J. K' i4 `
testicular volume was prepubertal at 2 mL each.3 ^4 A9 j) |7 }9 H
The skin was moist and smooth and somewhat
/ j- G$ {, i- ~$ f: K8 Coily. No axillary hair was noted. There were no( z3 J+ r7 P4 j$ B
abnormal skin pigmentations or café-au-lait spots.5 C) A# s; ]! u. F+ U
Neurologic evaluation showed deep tendon reflex 2+  s0 R* M; O* ?) L3 S
bilateral and symmetrical. There was no suggestion' U, t8 O: a' q' V- c. o0 t( H0 O
of papilledema.3 L2 q: e, q- _9 m
Laboratory Evaluation
, C4 k' R- ^/ x8 K+ j) }; B7 @3 qThe bone age was consistent with 28 months by1 F# ?0 |8 c. Z
using the standard of Greulich and Pyle at a chrono-! q5 r4 w4 `6 e" u8 \0 C0 q. i
logic age of 16 months (advanced).5 Chromosomal
: B6 k4 ~1 C0 V0 D: Z% a6 hkaryotype was 46XY. The thyroid function test' s1 \- U; @2 d$ @/ W2 {9 p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& |4 Q9 B0 Y. M; V: P. q
lating hormone level was 1.3 µIU/mL (both normal).
. Z" z; A, x+ f) Z/ lThe concentrations of serum electrolytes, blood  ~- l0 h& g1 T( |  I9 ?2 q
urea nitrogen, creatinine, and calcium all were
( R% I  t! t) v& I2 n: d$ zwithin normal range for his age. The concentration! I! Q2 ?0 i( ^! @
of serum 17-hydroxyprogesterone was 16 ng/dL4 P6 u8 h6 A" H5 h* y7 y+ S
(normal, 3 to 90 ng/dL), androstenedione was 20; |3 P' X1 {, r4 f4 t- r. V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 q5 T0 T8 k" c1 ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 |; k& u2 N/ I& [9 ^
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* A% T! q' K9 }0 G# k3 I49ng/dL), 11-desoxycortisol (specific compound S)
- D8 `6 l& i; v2 L) o" s% Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ ]1 v6 m$ h9 A1 a# @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" _. w, S8 R4 a& S3 B1 G, Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ h; ~2 l' b/ M
and β-human chorionic gonadotropin was less than3 p7 z0 M+ U4 z8 R* f
5 mIU/mL (normal <5 mIU/mL). Serum follicular: ^6 b2 ^/ [0 y: i
stimulating hormone and leuteinizing hormone
; V9 ]: L# i0 Gconcentrations were less than 0.05 mIU/mL
/ m* j( G! U# s$ C  V1 @(prepubertal).
. f5 Z4 I6 t% \. `: B+ o# TThe parents were notified about the laboratory3 Z  n# k. U2 b. r; [
results and were informed that all of the tests were
% }+ z9 U! X. r; e( p# }normal except the testosterone level was high. The
: q  q, r7 j9 x* A$ B/ P/ Ofollow-up visit was arranged within a few weeks to; i6 n! L+ L! k1 L& d1 ~
obtain testicular and abdominal sonograms; how-
& r+ U7 y! Q8 L; qever, the family did not return for 4 months.* |+ i$ l; I) `: A( O+ v
Physical examination at this time revealed that the
% a4 W3 m) C2 y2 A" p' wchild had grown 2.5 cm in 4 months and had gained5 p$ Y5 R# T! U5 w' {% X
2 kg of weight. Physical examination remained
) f) n, M# W9 `' Y( R  k+ \, W- z, Junchanged. Surprisingly, the pubic hair almost com-2 `9 j' Z) c) `  n9 N) Y! G
pletely disappeared except for a few vellous hairs at
0 x9 t. g' L+ Z& Q* R1 {the base of the phallus. Testicular volume was still 2" D+ a+ v3 p" C% J  G
mL, and the size of the penis remained unchanged.
+ Z% g- R5 M. HThe mother also said that the boy was no longer hav-% H. V' _* t0 K! f) h- q
ing frequent erections.
0 ]* i: p3 H0 J. gBoth parents were again questioned about use of
# T9 H0 ^( L" n4 Aany ointment/creams that they may have applied to1 U# v8 j! W& j. l3 A
the child’s skin. This time the father admitted the
* ]8 }* ]8 a) p, j4 x9 gTopical Testosterone Exposure / Bhowmick et al 541
. y) ~. b# `8 L2 u1 vuse of testosterone gel twice daily that he was apply-  u2 D3 ]% n  r( R# i' W
ing over his own shoulders, chest, and back area for
- D: D: }& @5 \a year. The father also revealed he was embarrassed% ^! R( ?' e; F2 x# h2 I5 L/ W
to disclose that he was using a testosterone gel pre-
& L3 n0 E( T- d) p' \+ F$ rscribed by his family physician for decreased libido
6 {* a/ S, t) x7 m* dsecondary to depression.
/ Z* F: @! t2 X* @The child slept in the same bed with parents.1 [" P1 H9 o6 S& V# A" l
The father would hug the baby and hold him on his, O3 b! ~  \  O2 T# N
chest for a considerable period of time, causing sig-
+ c8 k8 H) v% t% X  t8 Z) [nificant bare skin contact between baby and father.* b& ~8 Z. Y( y. Y
The father also admitted that after the phone call,
2 G) v8 ~: {: ^$ qwhen he learned the testosterone level in the baby4 p6 H3 E2 A$ C  G, m
was high, he then read the product information+ a: H' R( o8 `, ^1 u: O8 J
packet and concluded that it was most likely the rea-
: v* t, G8 b8 E- v* D: Json for the child’s virilization. At that time, they- N$ Z0 P7 k' [0 H
decided to put the baby in a separate bed, and the
/ }3 x( g+ D* Z" Pfather was not hugging him with bare skin and had
- \* d3 S. v; m& _6 a9 pbeen using protective clothing. A repeat testosterone
; m0 T8 w5 g" Z+ Y+ {( Utest was ordered, but the family did not go to the' T- o6 B, i8 R3 _# R' F
laboratory to obtain the test., @8 H7 J: ]9 u1 F9 w' a1 f
Discussion
  R4 |; j# k9 s  h0 v* b5 qPrecocious puberty in boys is defined as secondary9 r* V" t1 Q' |
sexual development before 9 years of age.1,4& T# ~* o/ K' s
Precocious puberty is termed as central (true) when: I! H" Z# r' v0 a
it is caused by the premature activation of hypo-
( K" M! y2 f2 m' x% kthalamic pituitary gonadal axis. CPP is more com-
& i2 I& x3 _* Smon in girls than in boys.1,3 Most boys with CPP
. ?5 g# ^7 G" `4 dmay have a central nervous system lesion that is
. d1 z/ B9 W) u; g" e; j2 [responsible for the early activation of the hypothal-2 S5 s* P2 o8 G8 g. w* T
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 `5 \2 A' p( _9 D0 Csis has been given to neuroradiologic imaging in# g; W! @% c( i! V" q% h
boys with precocious puberty. In addition to viril-
% I9 e+ s8 `1 Pization, the clinical hallmark of CPP is the symmet-" t/ i0 d8 B5 N% j; a% m& v
rical testicular growth secondary to stimulation by
) `* W5 V' {$ Z+ K+ ~gonadotropins.1,3. _  d2 ]6 g- u7 |2 Z* v" ]" ]
Gonadotropin-independent peripheral preco-' ~9 f4 Z( u* T# q! A2 d
cious puberty in boys also results from inappropriate6 r* Y4 C  M* r3 n  b
androgenic stimulation from either endogenous or% A- [' E, y2 c$ }2 I3 r
exogenous sources, nonpituitary gonadotropin stim-4 w% r( r& p4 S; @  H$ f! a6 R
ulation, and rare activating mutations.3 Virilizing
5 u% _( Q) u: u$ I3 p! B9 Tcongenital adrenal hyperplasia producing excessive* i/ W6 N  `$ w3 K' W2 n; `% s1 w+ `
adrenal androgens is a common cause of precocious9 ]# ?# j" ]; }+ _3 O3 {7 D/ P
puberty in boys.3,4
1 n8 m9 B$ T8 F; a% i6 Y( GThe most common form of congenital adrenal1 V0 Y9 g8 N8 t7 p
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ E) }" E6 k0 ]* i+ zThe 11-β hydroxylase deficiency may also result in
+ d" b7 [2 ^/ n5 X6 iexcessive adrenal androgen production, and rarely,( W  E% _( m+ W) S4 o' j: Y) X: ~
an adrenal tumor may also cause adrenal androgen
# G7 _5 F+ d4 U# [7 [excess.1,3& |0 e$ m* f5 E# v8 ^+ q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' W3 F- w: D& `% S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 m9 F! y- R9 R$ v! j  `! LA unique entity of male-limited gonadotropin-
8 r" |, _( }0 l* U+ N# Lindependent precocious puberty, which is also known
2 _" @- ~( t7 Yas testotoxicosis, may cause precocious puberty at a+ r/ Y, \* A2 E5 t! m" H* v* W
very young age. The physical findings in these boys
; |. m" ^! K4 y% U2 Lwith this disorder are full pubertal development,; F1 r6 v( N& _( \
including bilateral testicular growth, similar to boys
' F7 }# F0 z% {! J5 \+ jwith CPP. The gonadotropin levels in this disorder
$ Y' [- n: V! |" Tare suppressed to prepubertal levels and do not show6 {- j( d4 E& B
pubertal response of gonadotropin after gonadotropin-
" w; \0 I# X9 h% w- M/ Areleasing hormone stimulation. This is a sex-linked
+ G* _! |% y( n6 J0 o: L7 o7 k$ Rautosomal dominant disorder that affects only
; I& t/ o: z. _4 w" Amales; therefore, other male members of the family8 C1 |- Z9 w$ J; A" n
may have similar precocious puberty.3
. M& E+ [2 S5 P+ L. ?In our patient, physical examination was incon-$ B  W) y9 S+ }4 m4 J( ^+ g& @
sistent with true precocious puberty since his testi-
7 l. k: |. A0 Z0 jcles were prepubertal in size. However, testotoxicosis
1 Z: S& H  }- m3 Kwas in the differential diagnosis because his father
+ [% Q- _% A- F8 K/ Qstarted puberty somewhat early, and occasionally,
  d% k; c5 _  }* wtesticular enlargement is not that evident in the
, B4 [5 k, z' N% Qbeginning of this process.1 In the absence of a neg-
8 c$ y  U7 S/ X3 X+ ]: ?' vative initial history of androgen exposure, our
' e9 G4 o5 ]. M9 ^+ x! v$ xbiggest concern was virilizing adrenal hyperplasia,
% P' C) P6 E5 j- I/ meither 21-hydroxylase deficiency or 11-β hydroxylase5 `& b' ]" W- ?  r6 l
deficiency. Those diagnoses were excluded by find-
) f. `6 H' f& }2 Ming the normal level of adrenal steroids.! b5 B* f' ~4 l
The diagnosis of exogenous androgens was strongly; _3 M  T: m6 L# q5 y) q+ F
suspected in a follow-up visit after 4 months because
7 |7 \) E% w: a" Mthe physical examination revealed the complete disap-
$ d3 s1 Z! L3 O( K5 Cpearance of pubic hair, normal growth velocity, and
3 K" Q- _9 n3 i; R8 Gdecreased erections. The father admitted using a testos-, S# A. {/ W; A/ ?% L4 H# ?
terone gel, which he concealed at first visit. He was& N. I- s6 _8 A9 g8 y9 r& j
using it rather frequently, twice a day. The Physicians’* }, s2 F% I1 g1 }1 i+ Z/ n
Desk Reference, or package insert of this product, gel or; i1 V8 r1 Z5 u$ X+ c
cream, cautions about dermal testosterone transfer to
% j0 t/ M1 u6 N3 j0 \unprotected females through direct skin exposure.* x( R# f  y  f6 R  j( O, j
Serum testosterone level was found to be 2 times the. c' G5 y4 f4 S3 o
baseline value in those females who were exposed to4 O. q, s* k" v6 q+ D% i2 l
even 15 minutes of direct skin contact with their male8 o* y! E  ^6 Q  ]- }" @
partners.6 However, when a shirt covered the applica-
1 |3 f$ d, d( {$ v& |& u8 a' }tion site, this testosterone transfer was prevented.
9 O/ P8 L8 \* W8 W6 pOur patient’s testosterone level was 60 ng/mL,8 _3 ]5 M) ^) P
which was clearly high. Some studies suggest that
: I7 L4 y5 p$ p0 g$ b/ ]+ I5 odermal conversion of testosterone to dihydrotestos-7 ?5 e' H4 i# |7 L7 V
terone, which is a more potent metabolite, is more* Q) e2 b& C1 x2 Y) ?4 L
active in young children exposed to testosterone& ^1 D; Q" Y6 h4 a
exogenously7; however, we did not measure a dihy-
2 Z3 J) i5 r4 a4 N1 @! r2 g1 ~drotestosterone level in our patient. In addition to
8 S$ b( N. f# S$ m9 b1 T/ wvirilization, exposure to exogenous testosterone in
: m( f4 g9 l7 |% O! _6 ~! O/ `children results in an increase in growth velocity and
& Y- E) T! \8 ~! e, `% @advanced bone age, as seen in our patient.
: R+ T- ]1 ]  w% t1 q2 n" x- t2 X8 YThe long-term effect of androgen exposure during6 H1 r) _! \3 P, B
early childhood on pubertal development and final
9 j: B: X. l8 X3 R1 r1 qadult height are not fully known and always remain
8 |1 U. d0 G1 m. U& e. la concern. Children treated with short-term testos-6 ]# P, _$ w% o, c; R7 O
terone injection or topical androgen may exhibit some2 w9 L% _( b7 K& h0 ^0 x* f
acceleration of the skeletal maturation; however, after
: s7 P+ q6 @! R& q9 T) B# v5 lcessation of treatment, the rate of bone maturation
0 r0 y: A# d+ {$ \/ g" `9 hdecelerates and gradually returns to normal.8,97 c2 ^# J5 G& i7 u
There are conflicting reports and controversy
( g0 |. |7 t- ]* Vover the effect of early androgen exposure on adult5 ?# |' m& F" E5 C6 e8 ~' U& ~# U
penile length.10,11 Some reports suggest subnormal" G9 R5 O+ g* j' x& b
adult penile length, apparently because of downreg-
0 V& i# b) N% z, r" H' Hulation of androgen receptor number.10,12 However,& [% T- z+ Q7 |9 K: ?: C' @  T
Sutherland et al13 did not find a correlation between* y. X; C) F1 R1 l
childhood testosterone exposure and reduced adult
& d0 {2 q, D$ _penile length in clinical studies.
: l0 e; P. I* h, I* cNonetheless, we do not believe our patient is
) v) L/ U; [$ fgoing to experience any of the untoward effects from
! r6 Q. L7 a- Z# W  dtestosterone exposure as mentioned earlier because
! c' c- W, Z/ b7 ?; u9 vthe exposure was not for a prolonged period of time.0 C8 q+ Q2 h, ^8 F+ I
Although the bone age was advanced at the time of
4 X$ @$ g# w! {, J# P' [diagnosis, the child had a normal growth velocity at
9 T9 m1 L. K! a: othe follow-up visit. It is hoped that his final adult( B- H7 o1 D9 c' n7 }
height will not be affected.4 f! r" j8 J1 u2 U0 J
Although rarely reported, the widespread avail-
: c7 d9 z" F9 Y0 }) }9 x9 Aability of androgen products in our society may% A- K( u3 L( U
indeed cause more virilization in male or female6 i* z2 q3 @5 L
children than one would realize. Exposure to andro-2 }! g- ?9 u+ @7 y- X
gen products must be considered and specific ques-1 e' Z' K5 `" i2 q. |0 P. ?
tioning about the use of a testosterone product or
! J/ e. }! i9 X) _; fgel should be asked of the family members during
! b7 S# F1 j" x5 ]the evaluation of any children who present with vir-: Z% T; i6 ?6 L  ^
ilization or peripheral precocious puberty. The diag-
$ j- Q+ A' t2 j5 V2 znosis can be established by just a few tests and by
( v3 f$ ]8 Q1 G( F# o! \/ xappropriate history. The inability to obtain such a+ e( {, X: i) a7 E+ t/ V9 l
history, or failure to ask the specific questions, may) E7 V( f% D( J' t
result in extensive, unnecessary, and expensive  ?  g0 j+ _# E5 N
investigation. The primary care physician should be
* q7 b9 c0 [; i$ vaware of this fact, because most of these children0 q4 F, e# d# D. ]2 E
may initially present in their practice. The Physicians’
# H- i: X  K6 d# D8 y* v, t7 ~Desk Reference and package insert should also put a
+ ]5 i! K% b# Y: e. Iwarning about the virilizing effect on a male or! ^( _0 N  @' I8 [) R' y
female child who might come in contact with some-
! r  l; P, k8 ], E* [one using any of these products.- b' ]9 Q$ {5 k+ h, t
References. N) Z4 L, T/ z7 ^$ ?
1. Styne DM. The testes: disorder of sexual differentiation9 K2 d" O! J2 B
and puberty in the male. In: Sperling MA, ed. Pediatric' F2 U8 N* n- A0 ^5 ]' g: i, ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 h$ b- v1 o/ _  C0 Y2002: 565-628.
6 H- M! R. {! H, L4 Y' t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 r7 P, T& L3 k* w" G7 X
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!
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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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發表於 2025-1-19 02:41:05 | 顯示全部樓層

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