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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
: ?: M$ j. r9 e4 kBoy Induced by Indirect Topical& m! l! a5 Y" f. u
Exposure to Testosterone4 M) l: _, X9 Y* Y$ g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) ?' Z& P) z% V! C- @and Kenneth R. Rettig, MD1  a0 \& l" R" S* |
Clinical Pediatrics
9 u0 a6 G$ w% H! L6 LVolume 46 Number 66 m+ N- D* b$ G* t' Z
July 2007 540-543
9 M( ]( F& T, c# q# s5 I* ~+ ^7 M' x& ]© 2007 Sage Publications
, P: k9 \6 c$ ]8 O10.1177/0009922806296651$ u8 @2 ~# W* j1 b
http://clp.sagepub.com
& U2 d- U2 _  v  mhosted at
- ^! z2 |/ F2 P/ Yhttp://online.sagepub.com! e) |: G- F" i  j, _5 b
Precocious puberty in boys, central or peripheral,
8 e! ]) K: U1 H4 X8 `is a significant concern for physicians. Central7 z8 f- d$ l2 s
precocious puberty (CPP), which is mediated; f3 n* D# [' S: i0 f
through the hypothalamic pituitary gonadal axis, has
2 _# q9 N" ~; ~0 S1 _a higher incidence of organic central nervous system
4 {5 i) L$ m  N% ^* c" I' Elesions in boys.1,2 Virilization in boys, as manifested3 ]" H; @9 k4 E" [+ e% T1 i
by enlargement of the penis, development of pubic, d* u3 [& c3 @/ b
hair, and facial acne without enlargement of testi-
! f$ @; o# r+ Acles, suggests peripheral or pseudopuberty.1-3 We
5 L2 w- y4 S; Q9 T9 zreport a 16-month-old boy who presented with the
, d2 p5 t0 P: Lenlargement of the phallus and pubic hair develop-$ V5 S+ k6 g1 Y3 N
ment without testicular enlargement, which was due: f6 g5 F9 E2 W0 Z& ?, _  p: Y
to the unintentional exposure to androgen gel used by
5 v# @9 A8 L: U  Mthe father. The family initially concealed this infor-
, B0 k3 t+ f+ E8 T' gmation, resulting in an extensive work-up for this6 X/ F% ^; @2 K& ]5 I
child. Given the widespread and easy availability of0 I8 w4 U3 i9 j) J& X6 y) L
testosterone gel and cream, we believe this is proba-& s  U2 H  B& C
bly more common than the rare case report in the* F5 c& D/ C# s! L4 J
literature.4
$ r" p7 a4 H, t! g3 f+ |! g8 @; ?Patient Report
9 R. U) J3 M1 d! s$ \( L) [( l! sA 16-month-old white child was referred to the
' z$ \3 S% G0 pendocrine clinic by his pediatrician with the concern( }+ ~, m+ b# d, ?( z' o# I/ {! g
of early sexual development. His mother noticed
7 y6 m& b2 P) l- I* Tlight colored pubic hair development when he was, n/ Z8 ~" @& f3 }
From the 1Division of Pediatric Endocrinology, 2University of
6 }; v, Y! B1 {& E# {/ _2 K0 PSouth Alabama Medical Center, Mobile, Alabama.. L5 t# V! q' s( w
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 \- a) f" S, r& @2 S  D/ T) ]Professor of Pediatrics, University of South Alabama, College of
" U* F# {6 ^  _8 S' MMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 q0 \* U' j! ?1 C; ]5 Be-mail: [email protected].. |6 b: L& b' I* n. o: g% d+ i2 @
about 6 to 7 months old, which progressively became
, d0 b% _( Q3 ]/ _" x; |' N3 sdarker. She was also concerned about the enlarge-
5 B( n2 M3 F, W9 ^# L9 h0 Sment of his penis and frequent erections. The child* H# C( K/ h8 ]' Z+ H7 z& V) {
was the product of a full-term normal delivery, with2 ]/ u- S) k. ^
a birth weight of 7 lb 14 oz, and birth length of. S0 i3 W9 C* A" Q2 r
20 inches. He was breast-fed throughout the first year3 `+ z8 F- t3 c* s( j" s: @
of life and was still receiving breast milk along with
9 @, M# `) ~9 i- o1 b  Ksolid food. He had no hospitalizations or surgery,
+ E7 X% v: W* j$ R. L; a! a* Yand his psychosocial and psychomotor development0 }& V4 F( t6 g1 T
was age appropriate.
; ~) ?: j+ ^1 p: l  F% XThe family history was remarkable for the father,
+ |/ }" m+ y+ A: twho was diagnosed with hypothyroidism at age 16,' O4 _8 v$ y9 [* ~
which was treated with thyroxine. The father’s
$ O- u% k' M! C+ i  @; m" x! G9 }height was 6 feet, and he went through a somewhat$ V% a0 B6 m9 ?. o% X
early puberty and had stopped growing by age 14.7 B* q& W$ k( k6 Q& m2 R
The father denied taking any other medication. The- S; v( T9 x% G  ^. I
child’s mother was in good health. Her menarche
1 p3 u; h) j, twas at 11 years of age, and her height was at 5 feet
/ X3 G. Z3 G5 N! L! `5 inches. There was no other family history of pre-: k; A" C# H- Z# F% w; K$ @
cocious sexual development in the first-degree rela-/ t( n6 R* m- E6 ^5 p- L+ X
tives. There were no siblings.
1 X2 E9 w7 w. J6 u+ jPhysical Examination2 A9 t" L' ]2 m7 a* z7 }& k' z
The physical examination revealed a very active,4 f9 T! }' d. g$ p
playful, and healthy boy. The vital signs documented
5 X5 o1 `# }0 C; ja blood pressure of 85/50 mm Hg, his length was
, v, K5 k, n2 C* f4 ?* h& Y90 cm (>97th percentile), and his weight was 14.4 kg
, s* V, V( y+ P2 F& ^8 z, z(also >97th percentile). The observed yearly growth! d7 M+ j. T, D2 t0 T, n
velocity was 30 cm (12 inches). The examination of& }# T; C9 ^$ d) b; {
the neck revealed no thyroid enlargement.# ~) k1 U& ]! F. F1 J' t3 M
The genitourinary examination was remarkable for
& m) P' y# N6 [0 H: }6 Qenlargement of the penis, with a stretched length of% x- P8 v/ z: l5 M! p$ l, {
8 cm and a width of 2 cm. The glans penis was very well
$ S# z; X! A4 S( u1 ydeveloped. The pubic hair was Tanner II, mostly around: @% J5 V# ?7 [) x
540
% x& x8 x" d4 p1 Y; L2 E; Pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 r% p: g6 n3 Y* f3 \the base of the phallus and was dark and curled. The+ L0 A$ q& r7 m0 V: [8 ?  W; W  b
testicular volume was prepubertal at 2 mL each.4 M) H, |8 o2 C! v& s" t
The skin was moist and smooth and somewhat
: U8 S) O5 z* v% f8 s* _oily. No axillary hair was noted. There were no
  v' R. Z1 a$ |3 labnormal skin pigmentations or café-au-lait spots.
" }) g2 c0 ?& `Neurologic evaluation showed deep tendon reflex 2+1 Y. M! e) S* T3 f: J
bilateral and symmetrical. There was no suggestion
# m, I0 Q1 B* O* R9 C. A0 }0 U2 Hof papilledema." f* N" S8 o4 v/ O
Laboratory Evaluation
5 p, G$ T" [) ?& O* H% J3 }The bone age was consistent with 28 months by
" E7 z  b# Q* C. J& K" Ousing the standard of Greulich and Pyle at a chrono-
& C  e3 i$ g7 |logic age of 16 months (advanced).5 Chromosomal
/ P2 i6 ^8 Y2 j* o4 ikaryotype was 46XY. The thyroid function test
' K. V# A% f1 Z, cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 w1 w2 G! x) i4 s( \: Plating hormone level was 1.3 µIU/mL (both normal).
# _# E% m, ~( P; H( [$ O) \The concentrations of serum electrolytes, blood- L9 n7 |2 F( Y" }* g
urea nitrogen, creatinine, and calcium all were
) S, u( Z& N3 x) S: owithin normal range for his age. The concentration
! o; m+ N# E6 w. l  Cof serum 17-hydroxyprogesterone was 16 ng/dL+ e. i" S( a5 r
(normal, 3 to 90 ng/dL), androstenedione was 20
  ?; @: j3 g/ Z; S  S) z. ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. c$ G1 Y5 M$ W: z7 ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 E& U7 l, _% v8 @  ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to  e* x1 Y, L6 v4 A3 i
49ng/dL), 11-desoxycortisol (specific compound S)0 c: ^+ C# |8 y1 j- p- v
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 o$ h' |; u3 V2 U* P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; i' U) K6 M. B, ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 H1 a$ i4 J/ K# S5 O. Q$ B- |) {
and β-human chorionic gonadotropin was less than
7 i* k- i, t9 L6 E5 mIU/mL (normal <5 mIU/mL). Serum follicular' f9 a8 p- g- U: r; P2 }& B
stimulating hormone and leuteinizing hormone, n$ [; ^  \- C7 o+ j3 c
concentrations were less than 0.05 mIU/mL' O% t  H3 t9 E$ u
(prepubertal).
( s! A) `1 [/ I; H& t' T' @2 ]The parents were notified about the laboratory5 z- V: [9 c8 W- f+ j- V
results and were informed that all of the tests were$ v5 o4 X0 q4 f1 ?5 q/ T
normal except the testosterone level was high. The
1 e" e: x; Q. C/ Sfollow-up visit was arranged within a few weeks to) |1 v5 b+ `& y8 ^! ^3 J1 f6 w0 G; O
obtain testicular and abdominal sonograms; how-
- e& n9 r/ g: Oever, the family did not return for 4 months.' v% s, f& }# h9 Z' N6 m
Physical examination at this time revealed that the
0 Q9 y9 [+ D# D+ l0 \5 s$ ]1 rchild had grown 2.5 cm in 4 months and had gained4 z, F& ^& C$ o. h$ N! P% p
2 kg of weight. Physical examination remained
$ b& y8 R4 B. p: O$ bunchanged. Surprisingly, the pubic hair almost com-5 P! {' I, B: g  ^8 R5 j, w
pletely disappeared except for a few vellous hairs at
9 [" Z% e- B5 F; b$ u5 R% Ythe base of the phallus. Testicular volume was still 20 m; I! O# ~2 Z
mL, and the size of the penis remained unchanged.
, J7 w( a8 f0 Z4 S& m% @The mother also said that the boy was no longer hav-6 V) e( D- n% R1 ~, B' j: E/ W; p
ing frequent erections.0 N9 y0 z* ~; N) w
Both parents were again questioned about use of( U% w; j$ g1 h9 N) R
any ointment/creams that they may have applied to
5 H  F: o' z. Y0 cthe child’s skin. This time the father admitted the; c4 p: o2 S+ p& L3 X7 g9 C' M' q
Topical Testosterone Exposure / Bhowmick et al 541
+ _' L' X1 x! \. [3 q6 a7 i+ z+ u4 puse of testosterone gel twice daily that he was apply-2 }9 e. {$ z+ _& C
ing over his own shoulders, chest, and back area for7 m, I6 a$ v6 Z. O/ `7 V
a year. The father also revealed he was embarrassed
3 I# V, ^7 X- l  j! Uto disclose that he was using a testosterone gel pre-2 |9 K: ~. o* n8 j4 N
scribed by his family physician for decreased libido
) a/ I/ t# ?  p) f7 o7 Tsecondary to depression.
. k; `0 v$ s, o3 bThe child slept in the same bed with parents.3 V( f0 }# E/ o: U- Z
The father would hug the baby and hold him on his. Q; [5 s% ~# S5 H: g+ j
chest for a considerable period of time, causing sig-
6 ]1 y$ p* ]1 K8 l, inificant bare skin contact between baby and father.
+ E5 r2 l4 ^$ b# b3 ?' qThe father also admitted that after the phone call,
+ J6 o. \" V! Z/ x; J- ^when he learned the testosterone level in the baby* B  H+ B, C: m8 I/ A
was high, he then read the product information
- _' k! l* P; Y* X0 ppacket and concluded that it was most likely the rea-7 S# a. |# X$ e. e, ^/ |! u7 V
son for the child’s virilization. At that time, they( A9 @8 q& A8 x) N- _+ H
decided to put the baby in a separate bed, and the0 i& a5 k/ i0 ^2 e' [: S% w
father was not hugging him with bare skin and had5 O  q2 G8 h" x% Y8 z7 u
been using protective clothing. A repeat testosterone
' b5 b; Y& t% G6 o# K! ktest was ordered, but the family did not go to the2 g& g! G3 ?& C8 d. o
laboratory to obtain the test.% B8 `$ z2 q9 A: s
Discussion
; H! l, w' O+ nPrecocious puberty in boys is defined as secondary+ b/ P3 s$ ^% [8 f/ ^
sexual development before 9 years of age.1,4) C- j3 W! x( |5 r8 W5 F$ S! W
Precocious puberty is termed as central (true) when1 E( _+ t1 b2 ^
it is caused by the premature activation of hypo-
* F, R8 U3 H. U6 _7 h4 Bthalamic pituitary gonadal axis. CPP is more com-% G+ V9 H  H6 Z2 ?; W! N, c
mon in girls than in boys.1,3 Most boys with CPP
/ q* j- [5 T4 u" |5 P+ t" k. bmay have a central nervous system lesion that is
# P! B2 Y  g- |1 }' Lresponsible for the early activation of the hypothal-: O! y6 X$ l7 C
amic pituitary gonadal axis.1-3 Thus, greater empha-
. i2 y3 O' ~2 ~" G4 L9 Msis has been given to neuroradiologic imaging in
9 T1 t* K  y9 b% C9 x2 |( Iboys with precocious puberty. In addition to viril-& @! a( L: M9 y' ^6 w( K$ q
ization, the clinical hallmark of CPP is the symmet-9 c7 `' f) a+ n0 [. X1 b
rical testicular growth secondary to stimulation by: S& g0 _% H) D1 r
gonadotropins.1,32 ^  w- I0 r; P4 I0 n0 H5 G
Gonadotropin-independent peripheral preco-. U8 F- m% }: Y
cious puberty in boys also results from inappropriate# n' J) z1 }$ i- a9 Q8 n
androgenic stimulation from either endogenous or
1 s6 Y& [" L2 [$ Eexogenous sources, nonpituitary gonadotropin stim-
: o5 J5 X* m8 ~0 v; P. _" |ulation, and rare activating mutations.3 Virilizing
1 p% n: R3 m" h* y; y3 _congenital adrenal hyperplasia producing excessive% b( B* p: c8 r& o7 e& }' d/ }
adrenal androgens is a common cause of precocious
  z. J. d+ ~0 `4 _* Lpuberty in boys.3,4# @- U8 M) o, s3 g  R# l
The most common form of congenital adrenal
: j: i$ L  a0 l1 ~# q7 Ahyperplasia is the 21-hydroxylase enzyme deficiency.6 |/ Q; D$ N) j7 }4 G1 |
The 11-β hydroxylase deficiency may also result in
, G: D5 F+ W6 u# wexcessive adrenal androgen production, and rarely,( n/ Q+ Y; N  x0 h7 {  S  K
an adrenal tumor may also cause adrenal androgen& {% k$ @6 L0 N3 o
excess.1,3( B; e4 Z7 Y" y/ V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 ^0 s1 j- U( s& w, M( p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# O/ C8 u' R& X( h
A unique entity of male-limited gonadotropin-- q: R( i* T& Q4 }3 ^; a2 X
independent precocious puberty, which is also known) m: x+ Z. A6 p% q: P
as testotoxicosis, may cause precocious puberty at a
% M2 G2 I/ f7 t1 c/ g, hvery young age. The physical findings in these boys
. m9 n* K$ a/ T8 kwith this disorder are full pubertal development,
7 O; t3 u3 j; R7 J; @  Y7 H- Rincluding bilateral testicular growth, similar to boys
: v0 L# @: A  f5 Nwith CPP. The gonadotropin levels in this disorder
5 _  F4 O" ?0 h" e& Q% @- @are suppressed to prepubertal levels and do not show
! Y& y& M% z3 r# j& N8 H+ ]pubertal response of gonadotropin after gonadotropin-" N- u* v, @; v  y
releasing hormone stimulation. This is a sex-linked
$ |9 o% K1 w3 u1 Bautosomal dominant disorder that affects only' x5 F8 v8 W" ?/ [* l/ S
males; therefore, other male members of the family+ N+ ]' K) D; s  j7 Q
may have similar precocious puberty.3
: R. ?+ |/ n" y, Y5 x7 O4 }) F  b1 nIn our patient, physical examination was incon-
& i( {1 o  y3 F' I/ x* y" c% Usistent with true precocious puberty since his testi-; D2 C* a: V- |- x% k! X
cles were prepubertal in size. However, testotoxicosis  i: D, l1 D, O, b
was in the differential diagnosis because his father7 v" y+ f" D8 N4 e# H
started puberty somewhat early, and occasionally,
1 ~! b( o  x1 Dtesticular enlargement is not that evident in the3 b/ S2 E' ]! s+ _1 J# w% e
beginning of this process.1 In the absence of a neg-/ y# M% l& U' v7 _2 d1 z
ative initial history of androgen exposure, our
9 G: Y5 S# u- R' p5 o7 b5 o3 \3 G2 Kbiggest concern was virilizing adrenal hyperplasia,- E8 \- f9 a. a, @8 s& Z' \
either 21-hydroxylase deficiency or 11-β hydroxylase1 }! }4 W; b' g* i0 w$ X+ T
deficiency. Those diagnoses were excluded by find-( y3 I8 u, I, s! E
ing the normal level of adrenal steroids.2 A  S  s- ?6 y6 D+ ]' e: V
The diagnosis of exogenous androgens was strongly
- @& w( B2 R7 b+ z& t& {1 Rsuspected in a follow-up visit after 4 months because
1 Z; Z- J; Z# Z8 c) V" ethe physical examination revealed the complete disap-
  F# ^7 I3 Z5 K4 Jpearance of pubic hair, normal growth velocity, and7 L: }  G+ C* z6 u6 h
decreased erections. The father admitted using a testos-1 S& C9 W  \8 p: W9 \4 w" O
terone gel, which he concealed at first visit. He was
1 c: H% b0 _4 j0 O+ I. B) Z; fusing it rather frequently, twice a day. The Physicians’
7 C8 W- U5 C. E& `5 y0 Z3 QDesk Reference, or package insert of this product, gel or; l& m, b; g2 k, V2 W3 a- u0 }) [
cream, cautions about dermal testosterone transfer to
6 y- ~* |$ Y4 cunprotected females through direct skin exposure.
7 J  F2 v. r1 M0 @& V4 d, ~9 QSerum testosterone level was found to be 2 times the! @4 S' e& X' r5 ~+ v( ^
baseline value in those females who were exposed to; t" t* F/ d+ Y; [8 }! r
even 15 minutes of direct skin contact with their male
0 N+ m/ q* C# P2 N  G: C7 @, Upartners.6 However, when a shirt covered the applica-0 t8 @5 D' _. ^. `
tion site, this testosterone transfer was prevented.
! O7 u2 d  c2 j/ xOur patient’s testosterone level was 60 ng/mL,! n* e  _( r0 ~. e1 l! v4 Y( P
which was clearly high. Some studies suggest that! G! ]: O- K- a
dermal conversion of testosterone to dihydrotestos-
4 y/ i9 M6 o$ D  E: ^terone, which is a more potent metabolite, is more. A# @. A& ]% H. W+ F. @, a7 \1 A0 e
active in young children exposed to testosterone
, W# n; Z8 i. J# ~exogenously7; however, we did not measure a dihy-% t& h2 V6 i" U+ A! K( F' p% u: M
drotestosterone level in our patient. In addition to
. z; y& I$ d6 e- r8 J7 k% ivirilization, exposure to exogenous testosterone in
3 d# g: H1 ~$ Ichildren results in an increase in growth velocity and
& B$ v1 T9 t* u, U/ t9 N# Eadvanced bone age, as seen in our patient.
# p; f8 {* O$ ~; w. w; x. uThe long-term effect of androgen exposure during; e8 F9 r  C8 G
early childhood on pubertal development and final
: X5 @, A! n, D. x" m& A) w; vadult height are not fully known and always remain' ~* t0 @, r7 G: e- h1 }
a concern. Children treated with short-term testos-
+ B, n, W7 C6 {% t: l2 y9 w0 ^terone injection or topical androgen may exhibit some
0 @$ @1 m" e4 [* oacceleration of the skeletal maturation; however, after
2 O2 ]9 a3 c( X4 `; N. j% k9 Mcessation of treatment, the rate of bone maturation
- O! U4 D+ W' K: X! l7 adecelerates and gradually returns to normal.8,9
2 w( _  M+ [# I3 ^) V) bThere are conflicting reports and controversy
2 p7 y3 F7 m0 f& p, v1 Y  ?0 \. L" z( {over the effect of early androgen exposure on adult
" v' m& k& q& ~  e+ J4 ?: tpenile length.10,11 Some reports suggest subnormal7 Z8 n  L- ~+ O( i
adult penile length, apparently because of downreg-
9 Z- }2 t! O2 S0 D6 @1 bulation of androgen receptor number.10,12 However,
9 r- S, Z4 v: U3 w0 g4 p* PSutherland et al13 did not find a correlation between" Y% C2 B5 H6 m6 L
childhood testosterone exposure and reduced adult
  O! V- v" q- Z- ^* Jpenile length in clinical studies.
% n! L4 q" o7 L9 l; N1 lNonetheless, we do not believe our patient is
1 Y+ Z0 Z* C7 K( \going to experience any of the untoward effects from
+ g4 n$ h% O1 z* h! `. M% M4 {' ?testosterone exposure as mentioned earlier because
- ?+ H' n) Q/ l6 Bthe exposure was not for a prolonged period of time.
& e9 k3 U; P$ w# z" x# |Although the bone age was advanced at the time of7 ^. h  L- x  g/ @
diagnosis, the child had a normal growth velocity at
4 O9 b# r4 E: N& T) @the follow-up visit. It is hoped that his final adult
; N& I! H* y( L2 |; e2 `1 Uheight will not be affected.
- d2 x; }: t) G" N  IAlthough rarely reported, the widespread avail-
  o& O8 }# x9 f" p# H# kability of androgen products in our society may
2 o7 q& O7 d# b+ L2 [  r( d* [indeed cause more virilization in male or female
- {# H! }- b/ x( a9 N; q, {1 Tchildren than one would realize. Exposure to andro-
) h; j& @4 E" K8 U3 J% jgen products must be considered and specific ques-
8 k4 f" I4 W: t% @! f' a. E; `tioning about the use of a testosterone product or. N2 H4 c# I# O# P+ z% K# K, T
gel should be asked of the family members during
; `) }: V" ^5 `% [the evaluation of any children who present with vir-
- U, \. d" x, }; H( A; Hilization or peripheral precocious puberty. The diag-
2 `) S; B# o" h6 A8 mnosis can be established by just a few tests and by
( A0 I! L. r+ I1 Sappropriate history. The inability to obtain such a
& O" {3 g6 l; e! c5 U- qhistory, or failure to ask the specific questions, may' F/ ^  g) J5 [( Y
result in extensive, unnecessary, and expensive
8 H; [! D3 ~: R0 c/ b7 zinvestigation. The primary care physician should be" _2 g; ?9 g0 P1 _- R
aware of this fact, because most of these children! T# R7 A) @5 h
may initially present in their practice. The Physicians’
- C" F2 G! f3 t2 VDesk Reference and package insert should also put a
; l; _+ j! C3 w2 }warning about the virilizing effect on a male or
# q# h! k7 a4 @5 t& cfemale child who might come in contact with some-5 a1 b* m7 j+ l5 Q: E3 l" b
one using any of these products.: w' N& }) j4 X+ u8 K
References; e5 V+ Q5 D2 Y' g4 h
1. Styne DM. The testes: disorder of sexual differentiation
8 z0 @: ~* A% s  V, W$ `and puberty in the male. In: Sperling MA, ed. Pediatric
0 p* G9 B% C9 P3 V6 ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) j- w8 U- I+ R+ y2002: 565-628.
/ {" N( Q6 F) D, `  y! d" N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  ]2 ~) M( L# P" m3 e. L1 E" zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old$ @7 G3 R  i( G; F* C
Boy Induced by Indirect Topical
: N) r* H6 b' }: _; f1 c5 DExposure to Testosterone
( t$ O, G% X: F* uSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  m/ I# E, ]3 Q2 f) \7 H3 y' fand Kenneth R. Rettig, MD1
$ n! n" x+ @3 w6 G6 o( B% yClinical Pediatrics# D; Q! ?5 i* _$ q) }
Volume 46 Number 6% t! j0 Q; M+ @2 _
July 2007 540-543
9 _( v& A+ K. s" F$ G© 2007 Sage Publications
/ I$ y1 K3 X' k$ ~! S10.1177/00099228062966519 \5 e0 j' q. W9 R: @( S
http://clp.sagepub.com- P) X6 N- ?6 F2 w9 E, W/ ^
hosted at' E- B- p% C! F8 O& s
http://online.sagepub.com. G3 d7 S: I$ ]7 h
Precocious puberty in boys, central or peripheral,  D$ v$ m7 {: i. q5 d2 Y4 j3 `
is a significant concern for physicians. Central! I- G7 y% T( @. p& O
precocious puberty (CPP), which is mediated% W. O' m# |% M
through the hypothalamic pituitary gonadal axis, has( l" l' I! D* ~. O
a higher incidence of organic central nervous system
- r  p  E5 ?% {. j/ m7 mlesions in boys.1,2 Virilization in boys, as manifested% |. E9 ~# r9 t& U
by enlargement of the penis, development of pubic
) E$ T& X5 z+ q" X# Mhair, and facial acne without enlargement of testi-
) Y+ ?3 {& [% X% Q& Hcles, suggests peripheral or pseudopuberty.1-3 We
* R; w' A  L% e( L3 Creport a 16-month-old boy who presented with the  G$ S2 Q; I0 j) z' d& P
enlargement of the phallus and pubic hair develop-3 {& @+ X4 y  x8 p) E/ v) ^$ x
ment without testicular enlargement, which was due3 y. ?& D: p( T# J
to the unintentional exposure to androgen gel used by- C+ i1 D- b0 T7 \- s/ q1 @: P
the father. The family initially concealed this infor-
% Z1 g  B5 E4 j, J+ t  S% w0 E$ c# G! Hmation, resulting in an extensive work-up for this7 G& \0 H! H7 H+ m# t
child. Given the widespread and easy availability of) g4 z: L/ d2 n2 a% _- @
testosterone gel and cream, we believe this is proba-2 `' \4 w, e! [7 c5 R0 w
bly more common than the rare case report in the4 K$ q. d: _/ I
literature.4, \( ]" `$ K* a0 _" U" V. _
Patient Report1 ^+ _+ Q4 s. M' m: X/ Z
A 16-month-old white child was referred to the/ R7 v/ b3 I% j5 y0 \4 Y  P7 P
endocrine clinic by his pediatrician with the concern. V# F5 U. Z0 s  c# l
of early sexual development. His mother noticed; j9 t% y9 [: y/ `! a. O
light colored pubic hair development when he was  [9 p  U3 Z0 v
From the 1Division of Pediatric Endocrinology, 2University of( t9 X6 n! G& y& l- f
South Alabama Medical Center, Mobile, Alabama.1 w6 m/ o% e3 b+ p. D% }$ Z, V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ d- n* I' p/ E6 g; f+ }Professor of Pediatrics, University of South Alabama, College of
. e! u! }# w: z' Q1 \Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 n% Y# a# G. }4 M7 g% C  w% U$ `' fe-mail: [email protected].
! H7 {; B" X4 z5 W0 }+ |about 6 to 7 months old, which progressively became" |" s& |# P; L. I0 Y0 m
darker. She was also concerned about the enlarge-3 V+ w/ @* K( S( d4 r5 c" x% X: n
ment of his penis and frequent erections. The child
* z9 F. C7 ~6 B3 ~8 fwas the product of a full-term normal delivery, with1 s, w; u% ?* Q$ M5 E
a birth weight of 7 lb 14 oz, and birth length of
' N6 C) v) ?; `; F# s% G  L20 inches. He was breast-fed throughout the first year* j2 t; H8 H. m$ j! H8 m  B
of life and was still receiving breast milk along with
8 y6 _; j# S! fsolid food. He had no hospitalizations or surgery,
0 f  |( T, l* yand his psychosocial and psychomotor development
: r3 x, a2 L$ v. Rwas age appropriate.
* _% q/ _' q: K/ b  IThe family history was remarkable for the father,+ r& d0 V8 A! Z
who was diagnosed with hypothyroidism at age 16,0 j9 s3 k' L; t2 z
which was treated with thyroxine. The father’s' d# a) c: L8 l* ~, A; q+ d: Z
height was 6 feet, and he went through a somewhat
% [5 ]5 e# n. A5 e3 d6 V1 ^% L" aearly puberty and had stopped growing by age 14.
2 f3 ^! w( v3 P  ~The father denied taking any other medication. The
3 I: i, }8 i- K: Rchild’s mother was in good health. Her menarche  d8 B2 \& q- b! o7 B( i: m" z
was at 11 years of age, and her height was at 5 feet; ^6 H9 N5 q, B# B
5 inches. There was no other family history of pre-2 Y* `0 ~7 b$ v+ f7 N5 p4 A3 e1 z
cocious sexual development in the first-degree rela-$ i' G. }+ ^3 k
tives. There were no siblings.2 o8 l5 h7 m1 E
Physical Examination
- e7 Y# `: q+ H) R% @The physical examination revealed a very active,
5 P$ C1 f$ L0 N' s; _playful, and healthy boy. The vital signs documented
/ w; @; ?  @+ j5 E# j4 I! ua blood pressure of 85/50 mm Hg, his length was, p6 E# f: R1 n. b9 ]
90 cm (>97th percentile), and his weight was 14.4 kg
# L1 V- b4 r/ w3 }(also >97th percentile). The observed yearly growth  _. B8 ^1 i) a5 R. _+ l# k5 d
velocity was 30 cm (12 inches). The examination of
* |7 V& W  m6 H7 d$ m! Gthe neck revealed no thyroid enlargement.* {8 ^; u4 q4 ~0 o& W3 g% v1 J- z
The genitourinary examination was remarkable for
4 d/ j+ v& C1 W+ denlargement of the penis, with a stretched length of
  K6 ?  \$ L, k  I+ N8 cm and a width of 2 cm. The glans penis was very well
2 n. d% h5 A, s1 L& jdeveloped. The pubic hair was Tanner II, mostly around( t; w+ z# x) ]
540  G' B0 z* C' g; x# n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, e/ l- t5 J5 Othe base of the phallus and was dark and curled. The
% S) r# O0 f1 _testicular volume was prepubertal at 2 mL each.* @( [3 y* D, z; V
The skin was moist and smooth and somewhat
# b6 A. b. c5 d2 I' d1 f, Xoily. No axillary hair was noted. There were no
/ M4 W8 |% q: X* |+ }7 b8 F' X1 Habnormal skin pigmentations or café-au-lait spots.
1 o9 M6 v- `8 cNeurologic evaluation showed deep tendon reflex 2+
- ^8 f/ q6 p: o, T9 n5 h: Ybilateral and symmetrical. There was no suggestion) |5 u6 ~; C# k+ H6 ~
of papilledema.5 b; b- I: B, i8 P
Laboratory Evaluation+ c' f& Z+ k7 c' w( v2 ^
The bone age was consistent with 28 months by9 }, H% b: j* R+ i: Y: D0 [# B
using the standard of Greulich and Pyle at a chrono-
0 V4 W: d6 U2 H8 I2 G0 Tlogic age of 16 months (advanced).5 Chromosomal0 R0 [/ ^* [, S/ \0 y( P
karyotype was 46XY. The thyroid function test
3 T* R' R" S/ o6 T6 eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 L6 `0 X6 C3 y( g/ Y7 Plating hormone level was 1.3 µIU/mL (both normal)., p2 `9 h6 R( y# Q" ]9 ~
The concentrations of serum electrolytes, blood" B/ n+ e' L/ |: e4 C4 f
urea nitrogen, creatinine, and calcium all were) V8 X& t" U7 C
within normal range for his age. The concentration
7 |& _* n4 L! F8 P! Eof serum 17-hydroxyprogesterone was 16 ng/dL
( Y2 y9 g& S: F" I" `/ |2 }(normal, 3 to 90 ng/dL), androstenedione was 20
: J, F8 i; g! V: ]8 c7 Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) L+ }9 L! d* b0 h7 f. n  Q; ?6 ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( W& X% s4 R" z7 Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  b% a" Y) t/ {49ng/dL), 11-desoxycortisol (specific compound S)
* e3 r9 q" k" O* iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( X3 k2 N# W- h+ _1 L# L' I0 S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 D: H9 g7 O1 ]( t7 }4 Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),( ~2 ~1 Y* S- W9 J
and β-human chorionic gonadotropin was less than& F" d0 _8 R0 R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  `  E8 W; Q6 _4 S5 u9 v; ^* A* m( X% Sstimulating hormone and leuteinizing hormone
% G' F2 N/ R& i5 [concentrations were less than 0.05 mIU/mL8 N8 }. G' ^) o
(prepubertal).
! y' d7 T$ ?( e1 ~: F8 b/ \The parents were notified about the laboratory
# \8 b0 p4 o6 ~/ n9 s8 nresults and were informed that all of the tests were
0 T$ U# B- ]$ V8 M1 knormal except the testosterone level was high. The
$ V$ Y" D9 a) Rfollow-up visit was arranged within a few weeks to
6 ]1 m, {6 O6 l8 E0 Robtain testicular and abdominal sonograms; how-
; @# c( H+ l/ \9 l3 s5 Aever, the family did not return for 4 months.& N4 r! p) L& P" ]) [5 K
Physical examination at this time revealed that the4 N: H: Q, C: l
child had grown 2.5 cm in 4 months and had gained
  D" l4 f" N# M" ~4 j' g/ o2 kg of weight. Physical examination remained, m; F- N4 f8 E, [
unchanged. Surprisingly, the pubic hair almost com-; z* R) _+ J, C  C* ]
pletely disappeared except for a few vellous hairs at/ n* Y) P/ n/ S3 A' ]! |
the base of the phallus. Testicular volume was still 23 `$ b. u# ^# P2 z# M
mL, and the size of the penis remained unchanged.$ |7 \* z" E1 s5 z) C& N
The mother also said that the boy was no longer hav-
: W( M" \' x- p4 Ning frequent erections., |/ G9 q5 Q% [  u; }. Y
Both parents were again questioned about use of' o& @+ y7 @# l% n% J
any ointment/creams that they may have applied to" u1 @- w2 ]- Z: l. |
the child’s skin. This time the father admitted the/ O6 l6 ^2 n5 ?2 c0 X7 D
Topical Testosterone Exposure / Bhowmick et al 541
8 x: [/ ]4 r# S. }3 O' Yuse of testosterone gel twice daily that he was apply-+ g7 C6 Y' i. |
ing over his own shoulders, chest, and back area for
) \. ]8 j1 E' N6 {a year. The father also revealed he was embarrassed! A$ S' ?: o# l5 U" o  Y
to disclose that he was using a testosterone gel pre-1 L+ q7 v3 G1 f
scribed by his family physician for decreased libido
2 n  q. L$ G7 D! a- c8 o, \secondary to depression.
# u5 X9 w0 e" n. L% KThe child slept in the same bed with parents.
9 H) j! B* E0 l% HThe father would hug the baby and hold him on his( G/ ]: N, `  C
chest for a considerable period of time, causing sig-
( {' ~7 a1 c8 ^nificant bare skin contact between baby and father.
( }1 v2 C) w' u7 j; H9 R- c# vThe father also admitted that after the phone call,
9 u) H2 f8 A$ |: Nwhen he learned the testosterone level in the baby4 I8 @2 Q3 m7 N! `7 p% v3 X. z
was high, he then read the product information8 v) f; [; z7 v3 s8 |. _. K
packet and concluded that it was most likely the rea-
' d. }: x3 z; lson for the child’s virilization. At that time, they7 O- k" W6 ~& H2 D3 j
decided to put the baby in a separate bed, and the
2 Q! t3 q2 G5 h) u, o% [* f9 Kfather was not hugging him with bare skin and had+ _" Y2 v- v7 \5 u' [
been using protective clothing. A repeat testosterone
" L7 x! {1 _, V9 E! I7 p8 X+ Atest was ordered, but the family did not go to the
9 F. K, r$ |' y5 K( zlaboratory to obtain the test.
/ _! z: A$ t' F7 i2 J1 ?) H5 kDiscussion+ ]5 |7 p/ K9 m5 f
Precocious puberty in boys is defined as secondary
! I( Z6 E3 g; Msexual development before 9 years of age.1,4
# m! I4 m: p2 G; jPrecocious puberty is termed as central (true) when
/ f& w: s6 G; }4 f3 q, p" @it is caused by the premature activation of hypo-
! M: t* C6 p: Z6 r! m; M7 Othalamic pituitary gonadal axis. CPP is more com-; \& C( S' _$ s( c9 Q1 i7 w
mon in girls than in boys.1,3 Most boys with CPP+ N2 G. f  Z0 c; l
may have a central nervous system lesion that is
5 H, O$ b; I' _responsible for the early activation of the hypothal-6 P$ ]% {' C; S& t
amic pituitary gonadal axis.1-3 Thus, greater empha-1 K( c# P5 N! f& x- n# H
sis has been given to neuroradiologic imaging in
& A6 Y) g/ m- `  n1 I6 D- Q( J* N- uboys with precocious puberty. In addition to viril-3 Q' ]6 N, q" {3 i+ v. N, r
ization, the clinical hallmark of CPP is the symmet-
& _4 s1 {- K$ D; Xrical testicular growth secondary to stimulation by$ T) c8 N7 N; D6 E" F
gonadotropins.1,3
( R" M  |* C5 }6 @! Y% e- a) R3 IGonadotropin-independent peripheral preco-# q0 c8 [6 B! [6 O) ^
cious puberty in boys also results from inappropriate' \& ]  C0 ~& d2 N% F. k# K
androgenic stimulation from either endogenous or3 n% I, j) }8 A- S1 a: j- w
exogenous sources, nonpituitary gonadotropin stim-
* P6 F8 T3 \+ F# julation, and rare activating mutations.3 Virilizing5 u% G! q9 ^) Y% m. R2 e2 B  q4 o/ ?
congenital adrenal hyperplasia producing excessive
" s5 N" X+ n& `3 p" _! hadrenal androgens is a common cause of precocious6 F7 t7 q3 S8 D% d, {( n1 u4 \
puberty in boys.3,46 U; D* {% h- Y8 Z, T' {% c
The most common form of congenital adrenal
7 f( d& |- a3 {2 s4 c" s9 vhyperplasia is the 21-hydroxylase enzyme deficiency.8 y, g& x1 p/ d( G# J# s; ]7 K# e
The 11-β hydroxylase deficiency may also result in
0 T4 P% P) Y/ E+ eexcessive adrenal androgen production, and rarely,  V! M8 d5 M2 R# F* a  ]7 \) `
an adrenal tumor may also cause adrenal androgen+ S6 H6 ^, Y+ \
excess.1,3  i  h7 D* E1 a& i9 G! ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 s  s8 `- v/ d- ]5 o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) E4 g- V2 a( I! o* v8 RA unique entity of male-limited gonadotropin-2 Y8 A  {) q; b2 k" ~- N
independent precocious puberty, which is also known( i9 l* V' v5 Q- Y4 H5 t% d- e
as testotoxicosis, may cause precocious puberty at a( F# d" _% c6 I# a" y
very young age. The physical findings in these boys
7 Y& `" H  q2 |( B3 W: w* w7 Lwith this disorder are full pubertal development,
' F/ @: T" x( z, m1 u& aincluding bilateral testicular growth, similar to boys
7 C4 {& K% p4 U9 zwith CPP. The gonadotropin levels in this disorder% h- @/ h4 i' ^0 `$ \. g
are suppressed to prepubertal levels and do not show7 J6 E; E1 i% a9 a
pubertal response of gonadotropin after gonadotropin-
" V3 Y( g* r; Q! G1 Freleasing hormone stimulation. This is a sex-linked* [* [" }* o4 t, i# O5 D
autosomal dominant disorder that affects only: V  m" J* t$ O6 {; A- b
males; therefore, other male members of the family% c; n& e) P8 j! W* }
may have similar precocious puberty.3
: Y  _; ]# y& FIn our patient, physical examination was incon-
: c/ A/ x, a3 k! s5 S8 h& V$ A* msistent with true precocious puberty since his testi-3 W$ W7 q) p( S9 l3 p6 j
cles were prepubertal in size. However, testotoxicosis! M" N6 B, p; i( l/ f/ u
was in the differential diagnosis because his father
. h$ g! D9 P! n7 |! O2 Nstarted puberty somewhat early, and occasionally,
0 `2 H% I2 D/ M0 H( `testicular enlargement is not that evident in the% I; D  T+ o! ^! `# X$ \
beginning of this process.1 In the absence of a neg-
' s: X0 H9 d, |8 v" Iative initial history of androgen exposure, our
4 d& \& N; R4 m2 q! v* u3 w% O$ Mbiggest concern was virilizing adrenal hyperplasia,4 d! p3 G9 G$ v2 g9 k3 A
either 21-hydroxylase deficiency or 11-β hydroxylase2 b& L0 p' P5 E3 ^
deficiency. Those diagnoses were excluded by find-, J+ R6 |$ M7 t" c4 `! ~
ing the normal level of adrenal steroids.
# y* |: i: m% C6 t+ YThe diagnosis of exogenous androgens was strongly
! k  {0 D3 M! O; W/ k5 [5 D" vsuspected in a follow-up visit after 4 months because, C8 I  ]4 n7 A
the physical examination revealed the complete disap-
- @2 V7 R" P6 h& B- r0 wpearance of pubic hair, normal growth velocity, and$ |$ w0 z% ~. k! ^: D& j! q
decreased erections. The father admitted using a testos-
: Q0 X- W* S' {terone gel, which he concealed at first visit. He was2 a( b; _$ N" x
using it rather frequently, twice a day. The Physicians’# p, O0 m0 d3 H3 M! q' F
Desk Reference, or package insert of this product, gel or4 U; X* _& u8 k8 m/ v& Q
cream, cautions about dermal testosterone transfer to% _: i: P1 p; n0 R6 m; }( U
unprotected females through direct skin exposure.
, \* s' g) N" [( w% g$ eSerum testosterone level was found to be 2 times the  g) s* d* }7 D
baseline value in those females who were exposed to% x+ j) P- A# n5 ^. n5 ^
even 15 minutes of direct skin contact with their male+ ?: L! p2 @0 E) d5 C+ R1 R
partners.6 However, when a shirt covered the applica-) s4 p4 b7 l; H# E
tion site, this testosterone transfer was prevented.
3 U! d0 _# L6 e, }% ~% A" rOur patient’s testosterone level was 60 ng/mL,
2 n9 m9 x( E- Nwhich was clearly high. Some studies suggest that
) C0 j" F9 J" f1 |6 X+ Odermal conversion of testosterone to dihydrotestos-
. j- Z0 l- ]9 }* v4 n# X9 v% w. ?terone, which is a more potent metabolite, is more+ G, Q* y3 E- u( r9 W
active in young children exposed to testosterone% i/ a+ D5 z4 C/ i. }
exogenously7; however, we did not measure a dihy-
+ [9 B3 K% e' E+ Cdrotestosterone level in our patient. In addition to2 o9 S3 I9 U% z" [/ _1 C% H
virilization, exposure to exogenous testosterone in
, E3 D0 C- C( L5 ^children results in an increase in growth velocity and
7 ]9 ^1 h' V( b8 Fadvanced bone age, as seen in our patient.
( N' H1 v! V8 j" N  e* n& BThe long-term effect of androgen exposure during
$ x5 v" ^0 m+ {, s9 y; y0 zearly childhood on pubertal development and final
, r* ^6 K; X6 P% {1 kadult height are not fully known and always remain: F( \0 u, _( Q* {
a concern. Children treated with short-term testos-
' e- e. I) C) L2 d  G( Zterone injection or topical androgen may exhibit some
. ]& l* _6 s+ M% r( a& Z6 D0 r5 d0 Uacceleration of the skeletal maturation; however, after
+ l9 m3 j1 B2 o4 Kcessation of treatment, the rate of bone maturation
" f  l/ a6 m, o* N* N* q, |; j- Rdecelerates and gradually returns to normal.8,90 U4 f' q, e# A2 o) ^
There are conflicting reports and controversy2 M$ c6 p3 v& r& h  z
over the effect of early androgen exposure on adult
* u" l, y; ?0 T+ h0 E' ?9 u% ypenile length.10,11 Some reports suggest subnormal
2 d7 @: o) a4 c6 @) Wadult penile length, apparently because of downreg-
2 y  S; l& @+ n; E( d2 \# X8 s4 |ulation of androgen receptor number.10,12 However,# }9 t3 l1 r- V
Sutherland et al13 did not find a correlation between
5 D6 X' O0 }" t: r: ochildhood testosterone exposure and reduced adult
% D! Y& _$ D! Hpenile length in clinical studies.2 O- S/ K6 \& n- Z0 p
Nonetheless, we do not believe our patient is
$ O/ C1 w. |. P% Zgoing to experience any of the untoward effects from
9 Y% g9 V' ]9 Y" W) Itestosterone exposure as mentioned earlier because0 H& ?! Q5 U' `3 B9 c) b# s1 \" y
the exposure was not for a prolonged period of time.* U2 t! k9 _" x/ L1 ^
Although the bone age was advanced at the time of
! K7 q4 P5 h7 c- _5 Adiagnosis, the child had a normal growth velocity at9 u/ j) b5 U! y+ |( E& q% [
the follow-up visit. It is hoped that his final adult7 Y0 k  \. d( q
height will not be affected.3 g8 [$ q5 L7 |
Although rarely reported, the widespread avail-- {5 I0 j) }2 P' u: M; Y$ W" w8 G
ability of androgen products in our society may3 B5 B: X. ^5 }" i0 [/ o
indeed cause more virilization in male or female
! `3 ^3 B. I1 [$ J! `children than one would realize. Exposure to andro-4 V5 ], d3 q. f' A* n
gen products must be considered and specific ques-
) q9 O  N+ m+ Xtioning about the use of a testosterone product or3 L; {. B# f. G
gel should be asked of the family members during- X" x' q- x( I
the evaluation of any children who present with vir-
) g3 c- A. h5 r% tilization or peripheral precocious puberty. The diag-" e" y4 w; W! z' h
nosis can be established by just a few tests and by' c: L; p3 j" h  m9 n6 X' Q+ \
appropriate history. The inability to obtain such a5 ?7 m! H. l6 M* f# z
history, or failure to ask the specific questions, may* P7 z( E: O8 s
result in extensive, unnecessary, and expensive2 Z' n  r% y$ E2 l. E9 g
investigation. The primary care physician should be
* [+ I- Z/ a9 b# `4 H) n: faware of this fact, because most of these children
$ x! [* w0 ~3 T, N8 l: r2 zmay initially present in their practice. The Physicians’
5 U9 H# ~5 I, |+ O! {6 N) PDesk Reference and package insert should also put a
. L: O4 k4 Y- V, H; Awarning about the virilizing effect on a male or
8 @8 {4 t$ a  e8 ^female child who might come in contact with some-
7 g; ?! e. W% m7 {6 b$ wone using any of these products.$ g4 g. g( a+ |$ H! M$ y
References
" r( ?- V0 Q6 k& t1 \9 ~1 A1. Styne DM. The testes: disorder of sexual differentiation3 U+ _+ H* _" [4 d# e  H8 E, J! o
and puberty in the male. In: Sperling MA, ed. Pediatric
4 C4 G: |8 s/ e2 O( TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* h! ?* Z: A9 d, \2002: 565-628.4 u- a  g, k2 l) ~. \& p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 q* y( W# o1 B5 y) u, G  {1 ]% Ppuberty in children with tumours of the suprasellar pineal
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女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
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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
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