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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-Old2 R7 i# W. D+ O7 s2 V' H
Boy Induced by Indirect Topical
& T1 [: \: r( |; RExposure to Testosterone
" ^9 c- ?' s. [0 O+ F9 |4 \Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 o: @+ ?, J' F
and Kenneth R. Rettig, MD1
3 H, P, t  R$ e& T1 iClinical Pediatrics! _5 Q8 `. B) @( i% ?4 Z
Volume 46 Number 6) `% n. I" L2 o$ o! q, v' f7 y1 G
July 2007 540-543
' o" J4 d) }* b1 W/ r! |/ Q& K© 2007 Sage Publications
# [, T; K: n$ l10.1177/0009922806296651/ q" B* Y1 L  b3 a2 I$ S
http://clp.sagepub.com+ D) C+ w# r, e9 t5 e! U
hosted at
/ r, a. x' \1 c; A" u" ^" z: Nhttp://online.sagepub.com
& P4 }% Z. T/ G7 g; M9 {  @Precocious puberty in boys, central or peripheral,
5 E0 }" P9 x9 ~! [is a significant concern for physicians. Central, b7 m: Q4 z; s, o
precocious puberty (CPP), which is mediated, o, B" K: R4 _
through the hypothalamic pituitary gonadal axis, has/ P( _3 \) o5 \( G1 c
a higher incidence of organic central nervous system4 m& o8 @, o9 o) |& @
lesions in boys.1,2 Virilization in boys, as manifested
9 P) r( o4 F2 R1 Y# q3 ]" i! gby enlargement of the penis, development of pubic% y2 S$ T# u. [0 H- R& H
hair, and facial acne without enlargement of testi-* r7 X, ?. x$ F" E
cles, suggests peripheral or pseudopuberty.1-3 We
" _2 j# j( Q+ X, F& Kreport a 16-month-old boy who presented with the
# M6 O- A0 P7 Uenlargement of the phallus and pubic hair develop-) {9 d5 E! {) H" p5 x  r+ i6 F0 g
ment without testicular enlargement, which was due
" V: A9 t8 C8 lto the unintentional exposure to androgen gel used by
! a. l7 s7 D6 U' ^the father. The family initially concealed this infor-
" X8 ?! t# \, E0 V3 ~" J- emation, resulting in an extensive work-up for this$ v5 u3 U, T7 f  Z! {
child. Given the widespread and easy availability of
7 J# q2 E- |1 D2 W, k2 Utestosterone gel and cream, we believe this is proba-
" R) j1 b  `* sbly more common than the rare case report in the
: T8 i2 h! V! ]8 P9 u* qliterature.4
2 J/ Y. l1 _9 TPatient Report
, C! M7 \0 F% A8 C5 {& yA 16-month-old white child was referred to the
3 Z  ~1 I6 _! }- b' ~endocrine clinic by his pediatrician with the concern. W5 I% o+ r$ X& d$ t
of early sexual development. His mother noticed
/ g: {. r+ x" w6 Ylight colored pubic hair development when he was
6 F9 k: Q( {/ z+ z! Z0 p& \3 ?From the 1Division of Pediatric Endocrinology, 2University of
+ r$ I8 l/ F# h& E6 e" t. m" HSouth Alabama Medical Center, Mobile, Alabama.
1 I% p: Z$ ?2 B, C- T) F3 LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' X; [) t* m' @: f0 {1 J& `Professor of Pediatrics, University of South Alabama, College of9 e: w6 x0 a' b, Z" d8 ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! h: d  w1 _+ _
e-mail: [email protected].5 a6 O' ]1 Y* T/ [- G+ k
about 6 to 7 months old, which progressively became) `4 N+ t; v2 P6 `
darker. She was also concerned about the enlarge-% I* R/ G2 p2 _
ment of his penis and frequent erections. The child
+ D7 N# {# g5 H  E) e' c7 A( jwas the product of a full-term normal delivery, with
( ^" M. X/ z/ I9 W4 [a birth weight of 7 lb 14 oz, and birth length of5 Y  {4 Z- ~# j$ H5 V3 G
20 inches. He was breast-fed throughout the first year
+ l' M$ T! t" @% bof life and was still receiving breast milk along with$ w: Q! T4 h) L
solid food. He had no hospitalizations or surgery,0 ?9 u% a( c4 b- g! n
and his psychosocial and psychomotor development) T  g/ N1 ^/ Q7 t* j/ @! o2 j. t
was age appropriate.8 S$ Y8 K. v# {: V% A" S9 c
The family history was remarkable for the father,
2 J+ q2 W6 A* ~. R0 gwho was diagnosed with hypothyroidism at age 16,
) N2 w. }1 h) Q5 ~which was treated with thyroxine. The father’s# h  j- d% r8 Y1 P
height was 6 feet, and he went through a somewhat6 y5 Y/ d6 Q3 i' Y$ ^# j/ H" n
early puberty and had stopped growing by age 14.
+ C/ w- [+ x# B9 a: oThe father denied taking any other medication. The7 w3 n6 s5 x! B" \) `
child’s mother was in good health. Her menarche/ n% x* O0 F3 N3 L5 S, o; |
was at 11 years of age, and her height was at 5 feet
$ b* ]. e1 `( P* i5 inches. There was no other family history of pre-
9 y0 ~. U% J' r5 c/ N# Ococious sexual development in the first-degree rela-
. b. I& ?2 H# e% ^6 `: ktives. There were no siblings.
7 J3 B; }0 R2 WPhysical Examination
1 K' a1 G+ `& k/ A- pThe physical examination revealed a very active,
& q# O, O& r7 l% bplayful, and healthy boy. The vital signs documented
9 Q* f6 B$ x7 l9 \5 ~3 c2 Ma blood pressure of 85/50 mm Hg, his length was& Y. t  r; ^' I) z; ]# k5 ~( R
90 cm (>97th percentile), and his weight was 14.4 kg$ l2 G$ i& C2 J2 c
(also >97th percentile). The observed yearly growth; b' s4 [* I2 y
velocity was 30 cm (12 inches). The examination of
' O3 T# S8 ]& bthe neck revealed no thyroid enlargement.: ^' W  x8 D! g6 U
The genitourinary examination was remarkable for
) |, C8 p) H0 W  z* m: Q  f7 Cenlargement of the penis, with a stretched length of! v& `" g; r4 f# t8 d4 O' k" x
8 cm and a width of 2 cm. The glans penis was very well3 b  L/ `/ a) L& j
developed. The pubic hair was Tanner II, mostly around
* i# f2 h1 o/ d540# M0 {; B. G3 N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* j/ O2 J/ I* H4 \6 J/ \the base of the phallus and was dark and curled. The0 g: z7 E% ?/ ?/ l% d
testicular volume was prepubertal at 2 mL each.
. x( G, \" q8 r" G2 z+ i$ m. H- g! ZThe skin was moist and smooth and somewhat
& @( u4 s: X2 F( Uoily. No axillary hair was noted. There were no
5 d& k' e: I' h5 x* q* ~& p1 {- }- Kabnormal skin pigmentations or café-au-lait spots.
% I- Z: F" K* V) A$ {$ }Neurologic evaluation showed deep tendon reflex 2+
% D# ~- S* L5 z+ ^) Gbilateral and symmetrical. There was no suggestion' b- l2 w8 Q. N( G
of papilledema.
7 p6 ^: X2 E% RLaboratory Evaluation
# {% k$ _' K4 v. n/ yThe bone age was consistent with 28 months by
3 j, w( v8 B* p, M" I0 tusing the standard of Greulich and Pyle at a chrono-
6 R$ ^8 q& R% O! x5 zlogic age of 16 months (advanced).5 Chromosomal1 Z9 E2 [! i/ K! J5 c- v
karyotype was 46XY. The thyroid function test; O1 {* X# V9 s8 N6 R# j9 Q! \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 F9 k+ k8 q* ~. f  R2 [1 N* e0 vlating hormone level was 1.3 µIU/mL (both normal).
' B2 X+ w* O5 u2 v3 u: \5 B, _The concentrations of serum electrolytes, blood, ~, [, ^3 V( W) b% L
urea nitrogen, creatinine, and calcium all were( w8 r, H' \2 |6 t( \
within normal range for his age. The concentration
8 U  C9 w' @( c& j# zof serum 17-hydroxyprogesterone was 16 ng/dL
0 C2 [: i7 R. l/ d8 T4 b9 |) G(normal, 3 to 90 ng/dL), androstenedione was 20
9 I' x0 @4 ]( G: I3 {. Ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, r0 [! v+ A! Z2 X& I* V
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 L; g( g. ~3 Z- P  Z$ U3 O; A6 H. Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: c' t4 S7 L* K+ O( g: z& p8 g49ng/dL), 11-desoxycortisol (specific compound S)* f. h$ u9 P  }; d/ ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 k! g% \* K0 g1 v* e) \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ z* n$ x8 M# m" Utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),! G! n" o* S% t/ s
and β-human chorionic gonadotropin was less than! B  P; Z6 C9 G
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- P' H$ P7 I' h, `' ?& C; B, q1 g6 Jstimulating hormone and leuteinizing hormone
* \% b' ?& n& Gconcentrations were less than 0.05 mIU/mL
( o2 J- V% D! z. s* ]4 i0 Z9 I; A(prepubertal).
8 V) n; @6 ]+ m* FThe parents were notified about the laboratory
+ }2 G7 B; ~8 X) c. T# W$ ~" Jresults and were informed that all of the tests were4 o1 |! H+ j: g9 ?  G9 d, J
normal except the testosterone level was high. The1 q2 \. j8 F( m0 i" v
follow-up visit was arranged within a few weeks to# Q1 ^. P& c5 U
obtain testicular and abdominal sonograms; how-
5 y" o+ d& E4 E8 c* x! fever, the family did not return for 4 months.
( v# _: L. {3 F7 z1 D" X2 y. @Physical examination at this time revealed that the; m( d2 ]% Y5 i# ~* N3 k
child had grown 2.5 cm in 4 months and had gained
7 }1 I1 h3 B. Y# `* I9 q2 U7 z2 kg of weight. Physical examination remained& n. T. h; O5 A5 T8 v8 s3 ]; z
unchanged. Surprisingly, the pubic hair almost com-
' k7 r2 ?5 z2 Wpletely disappeared except for a few vellous hairs at
; `% H5 t" x  C5 ~the base of the phallus. Testicular volume was still 2
. \4 X- _* t  O- M: DmL, and the size of the penis remained unchanged.
# L+ }$ A1 N! h" K, O: p, P- AThe mother also said that the boy was no longer hav-
4 k0 N3 j4 L0 f) i$ }2 n3 s1 ving frequent erections.
  d/ J* }0 l, T) ~6 Z+ {; pBoth parents were again questioned about use of
$ q* b2 z  T" O7 Cany ointment/creams that they may have applied to
' C  o8 A2 h! ^6 dthe child’s skin. This time the father admitted the
7 z0 h3 t6 b4 VTopical Testosterone Exposure / Bhowmick et al 541
1 G& ]  n+ s* W4 a( |- K3 Ouse of testosterone gel twice daily that he was apply-% _+ _3 G1 O) e# f/ K' ^
ing over his own shoulders, chest, and back area for
9 H/ i0 {0 q* d$ o6 ?; da year. The father also revealed he was embarrassed  M- A  V0 h4 o4 a
to disclose that he was using a testosterone gel pre-# @; O2 _! k% c$ R
scribed by his family physician for decreased libido
% j. b" V, v' Y: U( C" Osecondary to depression.# n+ E0 }9 {, i
The child slept in the same bed with parents.
' o; C* E- R9 e# ?- GThe father would hug the baby and hold him on his3 W# f2 \' a+ L6 Y( I
chest for a considerable period of time, causing sig-
! t" H- e' v- M, y' C6 wnificant bare skin contact between baby and father., C, y% c4 i, z- @; x
The father also admitted that after the phone call,. Y. v. D# B( A9 e6 W# G
when he learned the testosterone level in the baby
" u6 {' S0 A: _$ \was high, he then read the product information5 R7 Q7 p4 R) u; t$ x
packet and concluded that it was most likely the rea-
7 o& {2 |3 p9 B, Q2 m: ison for the child’s virilization. At that time, they6 X9 \$ @1 h! `6 w: G% j9 E3 d
decided to put the baby in a separate bed, and the$ Y3 g: C5 O* a1 F2 e; ]
father was not hugging him with bare skin and had
: {6 `5 B7 g/ f  V3 J, Y+ Dbeen using protective clothing. A repeat testosterone1 D: x. J" l: c8 o
test was ordered, but the family did not go to the
* J: B6 N1 b4 y3 s) Flaboratory to obtain the test.
; e1 |$ f: x7 }  E! M" e+ MDiscussion7 l7 _8 {$ B8 h6 t( @) `! Q
Precocious puberty in boys is defined as secondary
; t$ E; t7 O4 Z3 Msexual development before 9 years of age.1,43 t4 J0 e8 \" ]. e+ C( `3 ~
Precocious puberty is termed as central (true) when
9 Z* Z: H, M" x* p& a# s3 B  @it is caused by the premature activation of hypo-
8 {3 ]2 K; j4 K+ i9 k2 nthalamic pituitary gonadal axis. CPP is more com-6 d  R, {0 P& P4 y! C
mon in girls than in boys.1,3 Most boys with CPP+ V5 X( B$ ^2 f0 K! m$ h( j" T
may have a central nervous system lesion that is. g9 D# _: `0 \5 o  Q
responsible for the early activation of the hypothal-
, R: ?* m0 u. y: `2 D2 kamic pituitary gonadal axis.1-3 Thus, greater empha-2 Y3 V) G1 U+ s& ^2 A: ^
sis has been given to neuroradiologic imaging in
0 m3 Z5 ?8 y, u. ~2 d1 O- j+ b+ _  Rboys with precocious puberty. In addition to viril-
9 @: A* v( E# Z& K) W- ]ization, the clinical hallmark of CPP is the symmet-
0 A; @0 {* u& M+ d2 f  X9 ^8 lrical testicular growth secondary to stimulation by( M6 b  u5 C. n4 \- d! C/ O  ?3 H
gonadotropins.1,36 C* w0 ~4 |5 k: z/ I9 j- P. t
Gonadotropin-independent peripheral preco-! W, e* s% I0 K" S1 w
cious puberty in boys also results from inappropriate/ P' R" \& O! ~* B1 r9 A/ I/ s
androgenic stimulation from either endogenous or
8 w# r( e0 a1 j# ~- |2 Jexogenous sources, nonpituitary gonadotropin stim-
* E2 V/ I# D, [" N5 Pulation, and rare activating mutations.3 Virilizing
+ j! `7 x6 I/ C& Fcongenital adrenal hyperplasia producing excessive
$ d, Q/ k0 o9 B, o+ o, ^7 K9 sadrenal androgens is a common cause of precocious, N3 r7 O4 f$ N& H- Y
puberty in boys.3,4
4 y% N3 K+ V+ \) A6 BThe most common form of congenital adrenal
+ m# g2 v6 S" B1 }2 g$ W) lhyperplasia is the 21-hydroxylase enzyme deficiency.
: D3 d' `. k& eThe 11-β hydroxylase deficiency may also result in: _/ f8 K8 n* R! [
excessive adrenal androgen production, and rarely,: E- j4 H9 z9 M' o
an adrenal tumor may also cause adrenal androgen( |" h+ N1 I6 d$ @
excess.1,38 S1 U- i9 @( c( T# Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. G3 ?2 Q2 }0 k4 t; j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: z* _4 ?" Z7 v) OA unique entity of male-limited gonadotropin-7 W; o( m- W/ n0 S+ k" _: X
independent precocious puberty, which is also known2 P$ T8 k2 _4 m
as testotoxicosis, may cause precocious puberty at a
; K% |3 c/ r; k: ~: Zvery young age. The physical findings in these boys1 ?' R( m: `( z( d5 c
with this disorder are full pubertal development,
* T, ]" e0 A3 L5 o2 X0 ]including bilateral testicular growth, similar to boys
- y" Q2 @( D* D3 c" U" O+ L5 owith CPP. The gonadotropin levels in this disorder
( [6 r% n3 `8 p+ j) s  l6 Gare suppressed to prepubertal levels and do not show( \! p+ @! z1 n# b: I
pubertal response of gonadotropin after gonadotropin-
8 J' Q: H1 A! \0 X7 L6 {$ a& oreleasing hormone stimulation. This is a sex-linked8 D5 I4 t+ u" G3 f/ b+ c
autosomal dominant disorder that affects only7 N! m, B5 \; z0 p4 G- l
males; therefore, other male members of the family" m) M6 H& T" R- u
may have similar precocious puberty.3* m  s" g. D$ K7 C$ T3 K* f
In our patient, physical examination was incon-
5 u" p8 m! G4 wsistent with true precocious puberty since his testi-) c6 r$ ?5 E! J- c) q
cles were prepubertal in size. However, testotoxicosis
" V" ]% T# C7 O: t4 R) ~8 Vwas in the differential diagnosis because his father  O& V* R, s8 R8 L+ u
started puberty somewhat early, and occasionally,
: }2 \5 E+ N( G  htesticular enlargement is not that evident in the
: J: G, d. z4 Q, A. Mbeginning of this process.1 In the absence of a neg-! L+ g1 _9 W; P
ative initial history of androgen exposure, our
5 l7 l/ B0 Q' f- q# }; ]" Qbiggest concern was virilizing adrenal hyperplasia,
7 g" R: B1 C3 @8 r3 ]5 Geither 21-hydroxylase deficiency or 11-β hydroxylase% _! [3 D! x! {9 w) H0 s
deficiency. Those diagnoses were excluded by find-
9 E" E; H4 ^% q( ]( k+ I' qing the normal level of adrenal steroids.
, W& c" T4 o) i) g6 ?8 rThe diagnosis of exogenous androgens was strongly: ?+ l/ f" j* h0 l0 S- x
suspected in a follow-up visit after 4 months because
+ g; r4 d) |* e& sthe physical examination revealed the complete disap-
6 `' Q, f  L! l1 opearance of pubic hair, normal growth velocity, and
: `1 l4 z0 y; _9 K6 F5 h5 cdecreased erections. The father admitted using a testos-
) p6 z, B: A! u) c( F- @terone gel, which he concealed at first visit. He was. C3 S% x8 ?# W7 O% m
using it rather frequently, twice a day. The Physicians’0 Z5 c0 I: {. _# h& s
Desk Reference, or package insert of this product, gel or- b# Q* s. [) T3 l) }; `; c, w/ |
cream, cautions about dermal testosterone transfer to
  T. ^4 n# c5 aunprotected females through direct skin exposure.
+ y4 F  U  H* _6 c+ FSerum testosterone level was found to be 2 times the
# Q1 f& I" _4 b; H) R1 ^& D$ V' Tbaseline value in those females who were exposed to# q" s. C6 g* y* E7 B
even 15 minutes of direct skin contact with their male, w8 a2 M( R" s+ O
partners.6 However, when a shirt covered the applica-- u& A( c- R8 E( H# [: A
tion site, this testosterone transfer was prevented.1 \. O+ [1 ~' h2 _" G  U
Our patient’s testosterone level was 60 ng/mL,
" ^" M3 L( O8 W; gwhich was clearly high. Some studies suggest that
) b3 T# o" _& H; w& Adermal conversion of testosterone to dihydrotestos-9 o" o8 C+ |8 Y/ [' @
terone, which is a more potent metabolite, is more  Q9 m0 I0 m! g; s: e% t. A8 E
active in young children exposed to testosterone& L& K/ c- c; @( O
exogenously7; however, we did not measure a dihy-
/ f7 Z% ~) @/ z4 |$ l" h, c4 ndrotestosterone level in our patient. In addition to
- x# }8 J% G  y- fvirilization, exposure to exogenous testosterone in/ @, E+ I1 ]1 w- c4 J  `
children results in an increase in growth velocity and
) L0 e; [  Z* Vadvanced bone age, as seen in our patient.' F* N: b& N' ^5 A) o
The long-term effect of androgen exposure during! W  w) X" v4 V1 `. h3 A  q8 `
early childhood on pubertal development and final% A3 X" i& ~2 n
adult height are not fully known and always remain/ ^3 N3 a4 \. p( X
a concern. Children treated with short-term testos-
0 c( L: I/ d# I/ m% q3 W3 B( t" cterone injection or topical androgen may exhibit some
! ], d% G$ c1 eacceleration of the skeletal maturation; however, after( [2 q  j; D# R
cessation of treatment, the rate of bone maturation
, t8 l. p& w! |7 Y, S# Fdecelerates and gradually returns to normal.8,9* D1 Z6 a2 g9 h; a
There are conflicting reports and controversy8 g" y* Y4 s: N  ^! l4 H; f
over the effect of early androgen exposure on adult8 X- e- N- f# |( _( ~7 C+ R
penile length.10,11 Some reports suggest subnormal
4 b7 w" p0 W5 U8 A6 madult penile length, apparently because of downreg-
- K/ N7 Y- X$ ~6 f3 Tulation of androgen receptor number.10,12 However,
0 o& O; _$ M% t, }$ h* USutherland et al13 did not find a correlation between
: Z% C- C+ V$ Z5 x0 J* cchildhood testosterone exposure and reduced adult0 k" p8 l4 H; p. l+ Z7 G
penile length in clinical studies.
  j+ d9 w. g; o' ?Nonetheless, we do not believe our patient is
% t+ p# ~2 u4 o: h- V' m/ e3 j3 ugoing to experience any of the untoward effects from
5 _- E  b$ E. }2 ztestosterone exposure as mentioned earlier because
" ]* y6 ^7 g1 |- Q6 Othe exposure was not for a prolonged period of time.# Q! W: b# A. L# Y1 Q. C" c: o! B
Although the bone age was advanced at the time of
$ z& y  G$ X4 p5 K1 d' t, A1 vdiagnosis, the child had a normal growth velocity at
. t0 b! |) o( M# O7 B# R6 C( ythe follow-up visit. It is hoped that his final adult- o1 k) s& o8 p0 c, f( j. f
height will not be affected.
  L  F9 [( Y: Q, O  D0 S' rAlthough rarely reported, the widespread avail-& k& E+ j+ V# M) m9 v/ G
ability of androgen products in our society may6 g7 y4 }/ Q( s3 k1 l2 l( g2 R5 w2 e
indeed cause more virilization in male or female
4 t2 f3 Z5 y' i5 ~  B) J% ]children than one would realize. Exposure to andro-/ P$ }4 n6 ]; g
gen products must be considered and specific ques-8 i! a5 |/ F- M7 |: B! Q6 ^
tioning about the use of a testosterone product or
7 N/ v& @0 Q! _! F6 Y, Pgel should be asked of the family members during! _9 B6 ^$ K3 y. X. T
the evaluation of any children who present with vir-* P* D9 F! u4 Q
ilization or peripheral precocious puberty. The diag-9 _2 L0 |6 g  X/ {3 S, f
nosis can be established by just a few tests and by' h  P7 {7 g$ J1 f) k, P# }+ C7 ~
appropriate history. The inability to obtain such a
9 F  @+ D* u$ U/ S. ]' R/ Z6 Thistory, or failure to ask the specific questions, may
* [/ O9 R$ W: J* X, uresult in extensive, unnecessary, and expensive; r  u5 m+ o, S
investigation. The primary care physician should be
8 B2 Q9 M) b: A2 K. k7 ]aware of this fact, because most of these children$ Q4 T0 |# Y4 K+ S
may initially present in their practice. The Physicians’. E/ o% a) x/ s4 D7 r
Desk Reference and package insert should also put a& C) `* ]1 o, D) a& t3 H
warning about the virilizing effect on a male or
0 s( |8 z4 W% i) ufemale child who might come in contact with some-
# @9 M. _0 e* g8 I- @8 Vone using any of these products.
. Q2 i3 k" ]+ B  A9 HReferences* ~3 D  p3 i" O5 T0 f$ P' u8 C
1. Styne DM. The testes: disorder of sexual differentiation5 i0 W% g$ P( a) {( e$ x
and puberty in the male. In: Sperling MA, ed. Pediatric  b) X& _+ z& ~* @4 h5 K2 n! t7 o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' ?$ \2 i  K% D, d$ G2 `; X
2002: 565-628.
* b3 y9 U* ~2 h$ R9 p9 w  B' A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: c/ m7 @" K8 T" u9 |# F
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: }: y& E! h3 \9 L
Boy Induced by Indirect Topical1 `( V7 A8 g) U+ O
Exposure to Testosterone* Y) ]4 X8 G4 K2 n# n" f4 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# p6 f5 C* y7 K9 i% T0 Sand Kenneth R. Rettig, MD1
2 h# o) B5 @7 Q+ FClinical Pediatrics; d. ?8 \  }6 O4 q/ w
Volume 46 Number 6
3 J0 a6 H4 w. G- J9 f; rJuly 2007 540-543, w6 k. _5 s* l  f7 N& M" ?
© 2007 Sage Publications( l# R  r$ s& H" Q% W
10.1177/0009922806296651
2 m+ ?0 h5 m6 H. X. o8 d' [# Z% Ahttp://clp.sagepub.com
6 B3 T0 z$ B3 qhosted at
9 S5 H* X, g. F) F/ Bhttp://online.sagepub.com! W. u/ C% ?6 [4 v% F; C- D
Precocious puberty in boys, central or peripheral,0 P: |# D9 J1 f$ ]! ^! ^2 u5 x. ^
is a significant concern for physicians. Central/ Z* [5 Y& W3 U' \2 r$ C- t4 t7 W# X+ ~
precocious puberty (CPP), which is mediated
" l( [" C3 n) y' H" E( Dthrough the hypothalamic pituitary gonadal axis, has
! ^0 d( f5 s7 \a higher incidence of organic central nervous system1 P3 B# q4 N" h; `
lesions in boys.1,2 Virilization in boys, as manifested% p: k, u, K; O6 R+ x4 `
by enlargement of the penis, development of pubic$ J8 M# m2 w4 P/ H4 c1 w# `
hair, and facial acne without enlargement of testi-
/ }6 r1 B% A- A. I- B* \cles, suggests peripheral or pseudopuberty.1-3 We5 Q1 i2 ?/ A4 V: Y
report a 16-month-old boy who presented with the
# ~7 Z* q3 |9 {+ h8 s* t# J' Xenlargement of the phallus and pubic hair develop-7 \* J' `; ^. j& l* X! v8 d
ment without testicular enlargement, which was due
3 t6 F1 O) t* Cto the unintentional exposure to androgen gel used by# x; I: S7 K4 v) g$ s9 ^4 |8 [5 A
the father. The family initially concealed this infor-
0 s/ n( J4 P7 v0 T' c) s; H" _mation, resulting in an extensive work-up for this7 I5 Y$ D2 E2 x9 |) x
child. Given the widespread and easy availability of. s5 b* t1 }, T2 M& v
testosterone gel and cream, we believe this is proba-
* P( V/ C( s$ m' v8 Z& sbly more common than the rare case report in the
& v/ P# M2 f" rliterature.4; o; ~  H/ |: y8 ?; m
Patient Report' f* l; w$ F1 o: [) m( l" Z
A 16-month-old white child was referred to the4 n4 {& T+ [/ I8 \5 V8 ?
endocrine clinic by his pediatrician with the concern
1 O: t  L" Z% D0 }of early sexual development. His mother noticed& F$ J; a: S, s4 f7 U
light colored pubic hair development when he was2 ]5 G1 b* t8 M$ i. P9 Z" X
From the 1Division of Pediatric Endocrinology, 2University of. t+ D' F' G2 E+ q
South Alabama Medical Center, Mobile, Alabama.3 A! p& I. T( _8 J3 s
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- |7 P9 u: W" A7 D% [Professor of Pediatrics, University of South Alabama, College of
- |# ~; j; k) f, u# {0 U, aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. G& }, Q8 ?4 m, P' K
e-mail: [email protected].* j9 p  V+ I' b; k% T0 v
about 6 to 7 months old, which progressively became# N  R! ?) m. @: X: C
darker. She was also concerned about the enlarge-
6 ]2 s& [: a$ H' P9 Y4 G9 x- Ament of his penis and frequent erections. The child  o( ^1 \7 l( W- `2 D0 {
was the product of a full-term normal delivery, with
" F, l; }  Y( ]  H, a; Q3 Da birth weight of 7 lb 14 oz, and birth length of! H  O" z% G2 W9 C7 Y2 ^
20 inches. He was breast-fed throughout the first year" a' t; B- T9 Z) ]0 _3 l! v
of life and was still receiving breast milk along with
5 v7 E+ k- w. a2 I! W9 i9 Tsolid food. He had no hospitalizations or surgery,
- @5 a5 q) v2 L* A0 B* e. D7 D0 kand his psychosocial and psychomotor development
# z# X5 F# A* q+ X* qwas age appropriate.8 ^% Y+ t% ^  Q) H1 M8 U
The family history was remarkable for the father,
/ F% s9 a. _# Q0 T/ x% cwho was diagnosed with hypothyroidism at age 16,
7 @9 i8 Z0 n4 Q5 I. y& ?  `/ jwhich was treated with thyroxine. The father’s
: ?. U8 s9 k8 \: i. d' T4 hheight was 6 feet, and he went through a somewhat1 C* Y2 j3 q  h6 V
early puberty and had stopped growing by age 14.
. z: l' O' [2 E4 x+ L. AThe father denied taking any other medication. The
8 ~  s, `8 n+ U0 @2 M4 `child’s mother was in good health. Her menarche
  ~+ H7 n; {  Hwas at 11 years of age, and her height was at 5 feet7 Y3 W: j4 d5 b! y1 [# Q
5 inches. There was no other family history of pre-7 I3 R% \, z- M
cocious sexual development in the first-degree rela-
  ~  `5 t+ o7 B! W) Htives. There were no siblings.7 B6 z) L2 C: B3 `2 T
Physical Examination2 a# _2 V3 g' \7 }. f  ]$ K
The physical examination revealed a very active,5 [1 ?, M. i% |; e
playful, and healthy boy. The vital signs documented) k# P) k- _* S9 |- i% j
a blood pressure of 85/50 mm Hg, his length was; F8 h/ c4 b) b7 q0 f& n2 v
90 cm (>97th percentile), and his weight was 14.4 kg
. S& b' A* B. \0 N$ p0 h, H( E(also >97th percentile). The observed yearly growth
7 L8 N& L( P6 T7 ?. }6 hvelocity was 30 cm (12 inches). The examination of# U& V6 p, w. p
the neck revealed no thyroid enlargement.
" K/ Y% ?% |9 h0 i5 K9 _The genitourinary examination was remarkable for* _, L# X2 m% e! b9 J# X
enlargement of the penis, with a stretched length of
5 N1 n' a; g7 |) s4 w8 cm and a width of 2 cm. The glans penis was very well
( V# A- W6 m$ ?/ ?0 T& xdeveloped. The pubic hair was Tanner II, mostly around* H, \; U7 ~7 t- Z' g- d% K, W
540
3 [2 f; H  U5 A; P9 E; s% g; ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 F- e" L* n# ]2 X/ o
the base of the phallus and was dark and curled. The
6 R; [6 J- I' ~) x! ~5 qtesticular volume was prepubertal at 2 mL each.# V1 W$ B6 ]9 ]( N( p
The skin was moist and smooth and somewhat* L' `. ^+ x: f
oily. No axillary hair was noted. There were no
1 _& V$ U# f5 h' a) t2 [- jabnormal skin pigmentations or café-au-lait spots.
4 R1 K4 \& _$ T: l# ^* Q, C' wNeurologic evaluation showed deep tendon reflex 2+
. |8 u1 F8 k1 A) lbilateral and symmetrical. There was no suggestion4 }( Q4 Q/ M4 C$ Q4 u% V9 O. Q/ |0 S
of papilledema.
) k7 Q/ V4 N+ A  H2 E2 ULaboratory Evaluation, G- H% f2 q7 i$ I% q
The bone age was consistent with 28 months by
, E- U& g3 I" B, Q* ausing the standard of Greulich and Pyle at a chrono-( i* u, T4 i7 Y$ v- F( h
logic age of 16 months (advanced).5 Chromosomal9 `% z7 W+ ]+ f  c* C
karyotype was 46XY. The thyroid function test- [3 \6 h. Q: {% ?  r8 L, \2 m
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ \7 Y7 _3 O* C% |) nlating hormone level was 1.3 µIU/mL (both normal).% [) O) N: u: v/ w# l6 W, m* C
The concentrations of serum electrolytes, blood* h; e, \! g4 l$ B2 \3 K6 {
urea nitrogen, creatinine, and calcium all were
* f3 d1 z3 @9 m0 b* U. c5 @within normal range for his age. The concentration
4 i5 p8 G% N. T( Pof serum 17-hydroxyprogesterone was 16 ng/dL* s# L& y' X" O; ]; L9 t; h
(normal, 3 to 90 ng/dL), androstenedione was 20
5 [# q6 B4 D' e6 W" }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ _4 ?1 B0 F' o1 }- f0 W5 a- h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),# O- l/ l% X- u1 j# y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 R5 W. p6 r) t  Y$ G% }
49ng/dL), 11-desoxycortisol (specific compound S)6 O( c- {$ O8 _8 Y; k5 ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# |! k4 S2 C0 m; W# htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* {+ B0 m4 r' x( p3 }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) C9 l! `, w! iand β-human chorionic gonadotropin was less than
; k  ~  a$ S2 N% a$ g5 mIU/mL (normal <5 mIU/mL). Serum follicular) G9 A4 ^( ~5 H
stimulating hormone and leuteinizing hormone$ q8 G8 _$ `1 d
concentrations were less than 0.05 mIU/mL% V4 `* j1 J+ D+ L6 L
(prepubertal).
  a& H/ ]+ K' ^7 u6 W) q) P8 SThe parents were notified about the laboratory, M. _$ T& R$ Y+ e  ?2 L/ g$ F
results and were informed that all of the tests were
7 a1 h9 z# M# e) K' B/ O* tnormal except the testosterone level was high. The
+ x8 @/ z/ E, y, y* Q* c9 vfollow-up visit was arranged within a few weeks to
  e9 \) [2 l& r: pobtain testicular and abdominal sonograms; how-% {# g! v. [3 N9 T- t+ u! ]
ever, the family did not return for 4 months." T& y9 t% b$ Z* i8 O) v- S
Physical examination at this time revealed that the" x5 |5 X. \$ c, X3 U
child had grown 2.5 cm in 4 months and had gained
% x2 ?- Z4 X6 h( E$ Z2 kg of weight. Physical examination remained
7 [6 P5 b6 R# G! ?7 v$ Hunchanged. Surprisingly, the pubic hair almost com-
6 w( d/ ^5 u  `+ R# Opletely disappeared except for a few vellous hairs at
9 y5 _! U1 H1 i0 X8 athe base of the phallus. Testicular volume was still 2) V0 M# O9 @& w- i8 p% i. N
mL, and the size of the penis remained unchanged.( S2 ?! j2 _3 u5 O
The mother also said that the boy was no longer hav-3 U6 t/ H$ {& n+ y
ing frequent erections." v" C: H0 O7 n; d5 a8 p" y3 Y
Both parents were again questioned about use of2 E& {/ k+ N  }3 w0 `% H
any ointment/creams that they may have applied to3 \  T5 q" Y/ O% Q2 f2 I# f( p2 Y* Y
the child’s skin. This time the father admitted the  q$ L" l5 I5 S( ?8 H
Topical Testosterone Exposure / Bhowmick et al 541
6 F) W7 H2 ~- k3 _6 o3 z/ nuse of testosterone gel twice daily that he was apply-2 R3 N3 f/ P) b2 R. o' c7 m0 x1 J
ing over his own shoulders, chest, and back area for
9 h. c" S2 D% T# [a year. The father also revealed he was embarrassed
4 l3 o; g  X( `( Bto disclose that he was using a testosterone gel pre-
3 t% d" b' S" X! t( `1 y  U7 n. _scribed by his family physician for decreased libido- E5 ^2 r8 G3 l* G% ?
secondary to depression.9 y7 ~* i8 H+ p
The child slept in the same bed with parents.6 V% B  |9 o5 R$ h: U
The father would hug the baby and hold him on his; e% U' u$ F6 W. h9 Z0 E% m
chest for a considerable period of time, causing sig-  Q% c3 _1 O" ^% Z. Y  l6 S
nificant bare skin contact between baby and father.* ^: @' X5 D6 L2 Y1 Y1 s
The father also admitted that after the phone call,: W, h7 v1 M0 H2 d5 i0 U7 m
when he learned the testosterone level in the baby
4 U% G! f# ~/ ^6 A6 Fwas high, he then read the product information
* c% o  y% [* H0 S- d1 lpacket and concluded that it was most likely the rea-9 q! G* B$ {$ T
son for the child’s virilization. At that time, they8 t& i0 ]" j" g  L& k
decided to put the baby in a separate bed, and the6 `+ i- a# w4 ~( t- ]# X! ?0 f
father was not hugging him with bare skin and had
! i$ V& ]8 G2 o6 obeen using protective clothing. A repeat testosterone
0 a; R: i6 J& y/ xtest was ordered, but the family did not go to the
" p6 S: k1 }+ g8 t% B  claboratory to obtain the test.+ Q* {) v+ O# D
Discussion: M8 c1 d% u; ]9 ?# h( D
Precocious puberty in boys is defined as secondary) [; k7 A8 M$ l9 j
sexual development before 9 years of age.1,4) o- i4 P6 a  R% t$ z3 }
Precocious puberty is termed as central (true) when: @5 Z* C, x5 G2 G1 @6 n5 z- Z
it is caused by the premature activation of hypo-
; o5 J) q# n0 Vthalamic pituitary gonadal axis. CPP is more com-
# a8 {8 A( V* d7 {mon in girls than in boys.1,3 Most boys with CPP, U+ @; U8 T6 A- M5 O. }+ e* m
may have a central nervous system lesion that is4 {$ @& R& m5 z& ^7 m
responsible for the early activation of the hypothal-6 b8 f/ u6 W, |# j' {. a2 _
amic pituitary gonadal axis.1-3 Thus, greater empha-6 Y1 [% [4 ^- L& H, B
sis has been given to neuroradiologic imaging in, D7 h9 `+ W3 x3 C/ ~9 }" `' d) E
boys with precocious puberty. In addition to viril-) f3 K8 p9 c/ K2 n
ization, the clinical hallmark of CPP is the symmet-
$ P. C9 U+ V% o9 R* frical testicular growth secondary to stimulation by
+ t/ B/ v1 ]# D: K0 Dgonadotropins.1,3
; C  \, G3 ^# T, x! j0 lGonadotropin-independent peripheral preco-
1 x: x) c  s) u$ c) qcious puberty in boys also results from inappropriate- u! W: _  a/ E6 ~
androgenic stimulation from either endogenous or; m7 M, t6 o" q2 [  R
exogenous sources, nonpituitary gonadotropin stim-) g5 R6 d5 x% Q2 o' K
ulation, and rare activating mutations.3 Virilizing
) I0 y/ }, c6 ^congenital adrenal hyperplasia producing excessive0 Z! H- ?, s) I9 z* I
adrenal androgens is a common cause of precocious1 p8 t3 h/ j! w' A' Q4 S
puberty in boys.3,4% Y( [. c5 w0 f4 ?6 M8 _
The most common form of congenital adrenal  {/ S5 h' M4 l
hyperplasia is the 21-hydroxylase enzyme deficiency.  F: ^6 q; V9 L7 t# b
The 11-β hydroxylase deficiency may also result in6 [% B4 g) s# u9 s- R
excessive adrenal androgen production, and rarely,
  b; n& a( g8 @0 ?5 ian adrenal tumor may also cause adrenal androgen
) [6 ]9 _8 Z! y4 o  w/ Nexcess.1,3
/ N! j7 ]/ P1 n4 |, p0 ~# d; i: u4 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ?% S9 w2 J: A8 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% X5 A: U& |2 ~7 Z
A unique entity of male-limited gonadotropin-
; I6 F% H0 A# q: S) i0 ]independent precocious puberty, which is also known1 O9 ?; n1 i4 l& Y$ i
as testotoxicosis, may cause precocious puberty at a& c& Q2 w9 A8 X( z) |# c# W
very young age. The physical findings in these boys
: \9 ], ?- K$ W! lwith this disorder are full pubertal development,
0 C4 W' X! b' T2 ~& Iincluding bilateral testicular growth, similar to boys! M; y, J: x3 I( a( K6 l
with CPP. The gonadotropin levels in this disorder
0 @2 R$ B/ V6 p, B( g) Z, o0 U7 tare suppressed to prepubertal levels and do not show
- x& e  o' s" m& [: ~1 qpubertal response of gonadotropin after gonadotropin-: }* E" K8 q6 E, t, ?  t8 x5 Z# ?
releasing hormone stimulation. This is a sex-linked
3 H3 T2 p9 R& {' Y2 |autosomal dominant disorder that affects only5 }. P+ M$ t4 P. C, l
males; therefore, other male members of the family
! S8 T9 U# t, O6 Bmay have similar precocious puberty.37 t( S+ r; i/ @$ }- E$ h
In our patient, physical examination was incon-4 h6 S* q$ T2 a
sistent with true precocious puberty since his testi-
& L7 R2 g& x, V) F# Xcles were prepubertal in size. However, testotoxicosis- O  l" {* B2 v. d/ w
was in the differential diagnosis because his father
, g: i  q! r9 h4 ?started puberty somewhat early, and occasionally,
6 w$ u" d: g) I" etesticular enlargement is not that evident in the8 b% q" N' t; s$ d4 ]/ @( p
beginning of this process.1 In the absence of a neg-
$ Y0 v: D( n6 h, [9 \( ?  Qative initial history of androgen exposure, our2 x/ _" l! w5 a( k
biggest concern was virilizing adrenal hyperplasia,0 A& I* j0 n4 x/ v5 ]3 t2 c, f
either 21-hydroxylase deficiency or 11-β hydroxylase
' u+ z! K$ }. A6 W4 ?) V# N6 Kdeficiency. Those diagnoses were excluded by find-
7 D6 {0 Z3 e7 Z/ q! ?" I$ @2 oing the normal level of adrenal steroids.
7 K' s6 Q; l9 G8 GThe diagnosis of exogenous androgens was strongly
9 ?8 ~% H; e4 S2 k' zsuspected in a follow-up visit after 4 months because
- F" T* \2 m1 n. O/ u" [the physical examination revealed the complete disap-
/ N& x* f5 p* J$ a( b5 e* @/ Hpearance of pubic hair, normal growth velocity, and
1 u' `1 @) }1 W0 n& [5 n1 Edecreased erections. The father admitted using a testos-: I2 q& t  _0 a" X5 P
terone gel, which he concealed at first visit. He was
, i6 U1 Z$ ?9 j0 }using it rather frequently, twice a day. The Physicians’  T: Y2 T+ S/ h( O" \9 g8 k, o
Desk Reference, or package insert of this product, gel or
2 |# m8 ]% s' {. o4 jcream, cautions about dermal testosterone transfer to9 ^; I) z: Z0 W2 k" x
unprotected females through direct skin exposure.: C/ _4 I) x6 m/ r2 z
Serum testosterone level was found to be 2 times the
$ M3 B9 C; K% n' S! B4 J! u4 g9 Xbaseline value in those females who were exposed to
) M. G+ @/ p  d6 Z! Deven 15 minutes of direct skin contact with their male# J& y/ q; v" T: }2 z' P- V
partners.6 However, when a shirt covered the applica-. ~. K5 D9 s7 ^4 ?  m* c; Y
tion site, this testosterone transfer was prevented.- x/ T/ I  {8 j, V# b) s6 W5 d
Our patient’s testosterone level was 60 ng/mL,( ]/ U& z# \: e; z4 a9 ~
which was clearly high. Some studies suggest that* K, B9 b, h' w+ b& W
dermal conversion of testosterone to dihydrotestos-7 l! i& U* G# h- F
terone, which is a more potent metabolite, is more8 o' C2 C4 h+ ^
active in young children exposed to testosterone5 ?# ~6 ?+ A  K- @! B
exogenously7; however, we did not measure a dihy-
, J, n8 \( g9 w' s+ Vdrotestosterone level in our patient. In addition to
) h$ [/ z! B9 O$ uvirilization, exposure to exogenous testosterone in) k/ X+ \0 w! |3 T! k. \5 H6 \
children results in an increase in growth velocity and
2 k' g' l4 z5 q0 E* |% @advanced bone age, as seen in our patient.* C0 t) f, r) T, E* F% I! V
The long-term effect of androgen exposure during
* O  f5 k* ^" Z) q3 x1 ^early childhood on pubertal development and final* z4 r) @# H+ v( l5 c" S
adult height are not fully known and always remain2 _! R# I6 ?( u2 P
a concern. Children treated with short-term testos-
3 o0 c0 n1 G0 C" i+ Yterone injection or topical androgen may exhibit some
) O7 K4 F) L( J7 `; ?/ qacceleration of the skeletal maturation; however, after
9 ^7 ^3 }2 ~9 P. Icessation of treatment, the rate of bone maturation* a$ G; U. b. E
decelerates and gradually returns to normal.8,9
- _! R% a3 `$ d0 R% ~There are conflicting reports and controversy
% }$ t" J/ H0 ?9 b' P+ |: sover the effect of early androgen exposure on adult8 [. b2 O# j. v" a8 G2 u
penile length.10,11 Some reports suggest subnormal6 O; M; C& ~9 m. [
adult penile length, apparently because of downreg-( l" D. q7 h) `! l
ulation of androgen receptor number.10,12 However,
7 {5 c6 v# r6 }6 f9 Y" [Sutherland et al13 did not find a correlation between( t' y* b, ^1 t& H
childhood testosterone exposure and reduced adult
" n' {, [! O2 E  Jpenile length in clinical studies.3 B# y0 f8 f" H6 c1 f2 |
Nonetheless, we do not believe our patient is
$ ?3 ?- O, c6 y& u/ z' mgoing to experience any of the untoward effects from
- T+ Z' e8 r$ u8 Z7 s, _testosterone exposure as mentioned earlier because& f9 I* \# L) n/ [; P" B# D
the exposure was not for a prolonged period of time.
/ b5 O: n! i9 `% S  l0 y; ]Although the bone age was advanced at the time of* ~4 F, r, _0 T' ^1 {
diagnosis, the child had a normal growth velocity at) W1 d9 y7 A" I, ^( _( B
the follow-up visit. It is hoped that his final adult
  I, b  x0 Z) d2 E  ]# |- c  oheight will not be affected.' G% ~3 a% P* c
Although rarely reported, the widespread avail-
. x8 b! E0 D: }2 t* R5 E: D) sability of androgen products in our society may6 Y; B" R& H6 ^. p/ Q# E2 s. a: {( q" K
indeed cause more virilization in male or female
; f: I8 V! X' ^2 m- _children than one would realize. Exposure to andro-( o) x/ n% |6 }& H' K9 N
gen products must be considered and specific ques-4 U& ]# C( t7 B" Y
tioning about the use of a testosterone product or" p: G. S3 S# }9 k. A$ n
gel should be asked of the family members during
4 N5 e! J, l  ^$ u8 ?9 _the evaluation of any children who present with vir-9 X2 ^8 L/ X' K8 M
ilization or peripheral precocious puberty. The diag-$ Z8 B6 V$ u. l/ f- y! `% }3 }
nosis can be established by just a few tests and by! {' s. Z' M" R" }8 _9 k* m" u  [
appropriate history. The inability to obtain such a
; h/ b: i# u' _history, or failure to ask the specific questions, may* J5 l& D% _0 T+ K. W$ L
result in extensive, unnecessary, and expensive. g$ e( _' I. E! D0 s2 E- c  V) B
investigation. The primary care physician should be
, I7 s6 s1 d# {aware of this fact, because most of these children- ]. O) F9 b0 b/ X5 H
may initially present in their practice. The Physicians’
4 a7 I7 W# \* m8 q# O9 EDesk Reference and package insert should also put a
" K; s+ [/ Y1 {- M, pwarning about the virilizing effect on a male or- g/ _1 F2 b' v$ R6 w
female child who might come in contact with some-% o* [, i& x; [: }
one using any of these products.
( V& l: k0 |, v7 IReferences
9 @4 d( p+ ~3 X1 X4 [$ q  S1. Styne DM. The testes: disorder of sexual differentiation! Q' Z% T1 o! O
and puberty in the male. In: Sperling MA, ed. Pediatric; r* W9 O, f$ n) M3 R6 k* G& h, c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 b% D  d4 [  S0 G9 u0 [' s- a/ n
2002: 565-628.
$ O% ?4 d0 {$ r5 @* i6 k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 P; v; g# @  B. ?
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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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

6 Q: ~  V2 a; H- o5 Q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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