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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-Old5 V9 k% z" k3 X% a
Boy Induced by Indirect Topical
4 t* L5 C' }/ H. @# h' t: H) NExposure to Testosterone0 y1 x2 T* Y0 `. M' Z9 g/ g# s
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& _8 U' T1 `2 A+ S! |/ kand Kenneth R. Rettig, MD1
3 n9 g) i2 m7 W& z$ vClinical Pediatrics
/ H0 H- R/ f4 p+ s, M( B6 |Volume 46 Number 65 h7 _  ?5 e% g
July 2007 540-543  M8 t* y7 \: q. x) d
© 2007 Sage Publications
4 h: M# [% U  k$ E8 ^10.1177/0009922806296651! v" V# y3 Q9 {- B, e
http://clp.sagepub.com
& T7 P) \- V/ m8 ^% zhosted at) G# R, N" j' ?% _1 Z' a+ I: P- k
http://online.sagepub.com
! \+ ~  N: @0 u& oPrecocious puberty in boys, central or peripheral,
( o0 [! h8 k* t7 H8 [is a significant concern for physicians. Central. X0 W+ d; z. Z5 \' X1 k# M. x
precocious puberty (CPP), which is mediated, O( X* }. x7 l' ~, h* @* q
through the hypothalamic pituitary gonadal axis, has
& R! W2 A) l' X! f0 pa higher incidence of organic central nervous system, _' T9 r, T' |( d
lesions in boys.1,2 Virilization in boys, as manifested
, I  h, d8 P( }' P6 [7 Bby enlargement of the penis, development of pubic
1 |5 G( Q9 }: e* z- H* z; X& U( Ohair, and facial acne without enlargement of testi-; s) K$ s9 w& @  r& G' k2 P
cles, suggests peripheral or pseudopuberty.1-3 We
' c1 y3 F$ `: y( Dreport a 16-month-old boy who presented with the* v7 {/ ~( b* I, B; [- n
enlargement of the phallus and pubic hair develop-
2 r5 O" \7 u; ^" K& Iment without testicular enlargement, which was due0 e8 z+ l+ ]8 Y
to the unintentional exposure to androgen gel used by
( P3 u! x/ \" xthe father. The family initially concealed this infor-
) \" ?6 V# I7 L' K7 y. umation, resulting in an extensive work-up for this
8 l4 L0 f" w) ~( ~child. Given the widespread and easy availability of9 L8 o' m' K( e( y& J
testosterone gel and cream, we believe this is proba-
# _. f4 l1 M4 G- X& O2 Obly more common than the rare case report in the
$ j5 T( @1 S: D0 `; B( Y9 @$ }" Lliterature.48 i% x4 p' ?1 h4 S- E
Patient Report
6 h! l9 `( \$ aA 16-month-old white child was referred to the" |5 K( c) l# d+ U
endocrine clinic by his pediatrician with the concern+ L. y/ t# z: J) y% B
of early sexual development. His mother noticed
# r. ~7 h: j: e. vlight colored pubic hair development when he was& Q, `4 n6 w! e: ~
From the 1Division of Pediatric Endocrinology, 2University of. J9 [4 @0 l' H/ X# m
South Alabama Medical Center, Mobile, Alabama.
' e8 a! G1 K4 WAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 s* a! {; q7 B$ j' d5 Q6 eProfessor of Pediatrics, University of South Alabama, College of
" ^" ]; W4 Q3 U' e# ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' O! g; @( Z2 D# c6 P6 G& |
e-mail: [email protected].
2 K& y  X# r% p( \about 6 to 7 months old, which progressively became5 J5 z& q- F/ y" {5 f) d) m
darker. She was also concerned about the enlarge-
9 L/ h% ~2 E2 H6 f4 [7 ~ment of his penis and frequent erections. The child8 r1 E9 K, W4 j4 p! N) a
was the product of a full-term normal delivery, with: P# i4 Y- b" a# b
a birth weight of 7 lb 14 oz, and birth length of
: V4 \' L8 P7 o/ l9 w( W20 inches. He was breast-fed throughout the first year0 @, X0 i1 `% A5 Q# \* m
of life and was still receiving breast milk along with! S" w! V& X- U* G6 U$ j
solid food. He had no hospitalizations or surgery,; a( A; v: E/ ]- g
and his psychosocial and psychomotor development. z% g' T2 z( A3 U# X) |, I4 b% A* y; L
was age appropriate.7 y6 u( f7 R, F4 R/ J6 K3 S1 \2 f% f$ _
The family history was remarkable for the father,
3 }9 _8 Z% B# p6 xwho was diagnosed with hypothyroidism at age 16,
$ x1 a$ D5 R( W4 r  {) ^5 k" Awhich was treated with thyroxine. The father’s; x) d5 {7 J- {& |1 i9 g0 c1 Q/ }+ ~) A
height was 6 feet, and he went through a somewhat
9 C+ l4 }% v& t1 [- ~( p# Z$ Searly puberty and had stopped growing by age 14.
! y6 Z% A6 M/ B7 iThe father denied taking any other medication. The
' J5 p, n3 ?) V; E% l, r  R) ~child’s mother was in good health. Her menarche
' Q9 q0 y( p/ Awas at 11 years of age, and her height was at 5 feet# Z7 |3 Q* T1 ~7 Q# g4 H
5 inches. There was no other family history of pre-+ B# k3 U$ ^& `8 E8 i
cocious sexual development in the first-degree rela-+ j' Q3 {, c6 r
tives. There were no siblings.3 X/ m* j1 R# U3 \6 q" L- n
Physical Examination
8 e8 w4 u4 x# c$ xThe physical examination revealed a very active,7 o, W2 }2 ]8 H% t& [
playful, and healthy boy. The vital signs documented. B' R9 ]  c7 a" L( v
a blood pressure of 85/50 mm Hg, his length was
2 t4 x$ d6 _, B. K4 Y0 Z  A  E90 cm (>97th percentile), and his weight was 14.4 kg
. c! K' ^- {. f7 F' D(also >97th percentile). The observed yearly growth4 `$ o% l3 B' u
velocity was 30 cm (12 inches). The examination of
1 V% N: v0 ~* v8 nthe neck revealed no thyroid enlargement.
" K' y- ?2 g) k. M/ H( \# fThe genitourinary examination was remarkable for8 f1 W9 g  W) i: W: k  [7 d
enlargement of the penis, with a stretched length of8 v- S# Q( F+ Y# E* i' r( y
8 cm and a width of 2 cm. The glans penis was very well: O( g0 M; }- m7 g
developed. The pubic hair was Tanner II, mostly around' q; |. G- P2 h7 S, \1 V( a
540
/ g: s* G) W( ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 W3 x# r0 p( j' c( K: J! k
the base of the phallus and was dark and curled. The" x$ m& i6 l2 S8 W# r% l) R
testicular volume was prepubertal at 2 mL each.
4 W8 y6 A5 N2 J6 q! [3 T" _The skin was moist and smooth and somewhat
) u) d# h1 y7 A& H4 S" Aoily. No axillary hair was noted. There were no
6 V! z  {, b8 p+ c; ^  i  n0 gabnormal skin pigmentations or café-au-lait spots.
0 G* P0 a* @) j$ a' f5 z( Y6 [1 T) bNeurologic evaluation showed deep tendon reflex 2+
0 s: F9 [9 ^  n( g! t# w* m0 Abilateral and symmetrical. There was no suggestion9 o/ h# l$ w8 F6 C
of papilledema.
; r2 b" P8 a) |$ RLaboratory Evaluation
7 j# v0 e, K1 ]/ C3 D9 DThe bone age was consistent with 28 months by! C/ x+ K5 T8 t9 O1 t( i3 t
using the standard of Greulich and Pyle at a chrono-
# t* l( k8 R) S( {9 }; W9 w/ Flogic age of 16 months (advanced).5 Chromosomal
  x8 R1 a( A) v1 e$ ?karyotype was 46XY. The thyroid function test
' U6 l) l0 ^: n2 v* Rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- }6 g. F$ P, ~+ P( i8 n. ?
lating hormone level was 1.3 µIU/mL (both normal).' J! q" A# w' w* m! b$ n
The concentrations of serum electrolytes, blood
$ T- Q0 v) f- L  Iurea nitrogen, creatinine, and calcium all were. {" r5 p5 s9 u  Q$ ^/ S
within normal range for his age. The concentration
- ~5 w0 K7 L1 |. ]* ]9 tof serum 17-hydroxyprogesterone was 16 ng/dL6 O. J; n) T; T1 P5 G! F
(normal, 3 to 90 ng/dL), androstenedione was 20$ R; y! _# e* a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ w4 }! w* |8 H# N% oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 R$ T2 a9 W" h6 V. i0 p2 V) Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! Y  N8 A: Y5 L6 _" _5 Q49ng/dL), 11-desoxycortisol (specific compound S)/ }0 C' {2 |# G6 y: X$ e3 _0 @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 O% v, B4 }$ Y8 m6 U- D' r% p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ `' v: s: z/ U4 Z) r( gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% ^% h  Q; f! Y! G1 j  [) M  {and β-human chorionic gonadotropin was less than
! h2 @, V9 \! g, u4 n5 mIU/mL (normal <5 mIU/mL). Serum follicular5 h: S4 b+ ^9 _: A, C4 ~3 L* @
stimulating hormone and leuteinizing hormone
9 S! r, o2 k  Q. Oconcentrations were less than 0.05 mIU/mL* j, Q0 n" B+ W
(prepubertal).
! y$ f0 x, T: S4 u& d) H( A/ e  ~The parents were notified about the laboratory0 F4 A) @3 s8 u+ O
results and were informed that all of the tests were
$ X) n+ ~. e) i$ {! rnormal except the testosterone level was high. The
( f& ~6 T% o; H9 ofollow-up visit was arranged within a few weeks to8 N* {) d$ B0 E# G
obtain testicular and abdominal sonograms; how-$ ~/ Y5 Y  w( V+ g# U
ever, the family did not return for 4 months.
8 [4 y* ~7 R8 ]0 f) i9 o) `Physical examination at this time revealed that the. ]! O' q6 ^4 T  p& e4 P$ n$ |
child had grown 2.5 cm in 4 months and had gained  y4 j- n) a4 p3 [' X# _8 p# [8 ^; E
2 kg of weight. Physical examination remained
3 r" d& ]/ i' }9 T$ Nunchanged. Surprisingly, the pubic hair almost com-
8 D& M; N3 L4 a' z+ Fpletely disappeared except for a few vellous hairs at
0 ^" B! h, h4 O% ^( B% l" ^4 Lthe base of the phallus. Testicular volume was still 2
' F6 v" ~0 J/ c3 WmL, and the size of the penis remained unchanged.' [3 L) e, O2 q' ]
The mother also said that the boy was no longer hav-# \) J+ o, ]" ^+ s# B: f
ing frequent erections.
+ o+ X% q/ a& a. |Both parents were again questioned about use of4 u5 U4 G- W6 a- v: b; H' Z4 k% f
any ointment/creams that they may have applied to
2 D1 ~  x' X- I0 }+ x& \the child’s skin. This time the father admitted the) f: n1 Q; a9 {  n. e6 B
Topical Testosterone Exposure / Bhowmick et al 5418 z! w+ f2 R& f: F3 W: V
use of testosterone gel twice daily that he was apply-
/ l! h( G8 z0 b  U2 p* |+ s  |8 ying over his own shoulders, chest, and back area for
' `5 O8 l$ R$ Ka year. The father also revealed he was embarrassed
5 E& o7 ?: v% q6 Pto disclose that he was using a testosterone gel pre-
, ?" ^; @+ q9 A/ J. ^" ascribed by his family physician for decreased libido
" B  @! _  B2 Bsecondary to depression.
2 O, C6 S' r0 W" U# pThe child slept in the same bed with parents.0 u; A3 g3 B5 C# A$ I2 ?0 x) c2 N
The father would hug the baby and hold him on his* t# h$ C$ i: D' D: d* \
chest for a considerable period of time, causing sig-! L# @+ s) e9 M
nificant bare skin contact between baby and father.
5 Z/ y2 }7 P9 f( CThe father also admitted that after the phone call,$ V% s. u* J2 x1 ~1 B
when he learned the testosterone level in the baby
8 N, N6 ~2 J5 t5 w' }0 x% Swas high, he then read the product information
4 E7 V3 u$ Q- K- z5 O( Gpacket and concluded that it was most likely the rea-
: a* L( R# ^- k  M' hson for the child’s virilization. At that time, they
3 J/ I6 e# N# H/ |decided to put the baby in a separate bed, and the
: O! Z6 M* P" Mfather was not hugging him with bare skin and had
( C! g$ P8 M4 e% q, B$ U% U* Ibeen using protective clothing. A repeat testosterone
& k0 y/ S' {9 T- ltest was ordered, but the family did not go to the
  d. }; N! J! ]" F  ylaboratory to obtain the test.1 R3 S$ `3 |! A: M
Discussion
& E2 c' L8 s& y# A. CPrecocious puberty in boys is defined as secondary
6 o# j4 }$ r2 c6 Jsexual development before 9 years of age.1,41 k5 }7 i5 h1 f1 f" d
Precocious puberty is termed as central (true) when
9 R1 o+ g" f7 V0 Q" J  {7 Mit is caused by the premature activation of hypo-/ {# r+ d: w+ \% W  A
thalamic pituitary gonadal axis. CPP is more com-& V4 _0 M: n- y7 W
mon in girls than in boys.1,3 Most boys with CPP
$ S$ ]% j, ?. |/ E6 b5 mmay have a central nervous system lesion that is5 u2 a7 I$ d+ J2 K+ t4 B1 m9 b
responsible for the early activation of the hypothal-6 ~- c0 z6 R: N; k
amic pituitary gonadal axis.1-3 Thus, greater empha-
% A0 x0 W' D, P* isis has been given to neuroradiologic imaging in6 A7 W3 a& o/ ?' I
boys with precocious puberty. In addition to viril-7 ?4 w: d/ V* }. s6 f0 K
ization, the clinical hallmark of CPP is the symmet-+ z& B9 e( L# a  J. ~$ C3 i- [
rical testicular growth secondary to stimulation by
; o5 M' `* v/ N! d, @, J5 j% Lgonadotropins.1,3' {$ d  e; T; p  M: I" ~' q) S8 D" F
Gonadotropin-independent peripheral preco-- K7 j  k  c, \. w
cious puberty in boys also results from inappropriate7 X! i+ N1 D  t  G2 I9 W
androgenic stimulation from either endogenous or) {. R/ [9 ?* |! q5 i4 Z4 ^
exogenous sources, nonpituitary gonadotropin stim-4 ?2 t# J6 {7 h% h% b2 w* q
ulation, and rare activating mutations.3 Virilizing
; d1 |% I5 R2 acongenital adrenal hyperplasia producing excessive# v$ v+ u1 H# ~7 Y& Z
adrenal androgens is a common cause of precocious
+ \2 U. f; ?8 a+ I' W; w; s, a) Zpuberty in boys.3,4
6 B7 ^3 W) m* jThe most common form of congenital adrenal9 x. Y( v0 d+ b2 L
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 P. K) K0 I: q$ DThe 11-β hydroxylase deficiency may also result in
$ k4 ?) I" p' i- ~, Bexcessive adrenal androgen production, and rarely,8 u& h! {1 E6 g0 X" B2 P; R+ U
an adrenal tumor may also cause adrenal androgen0 L+ `- N5 n( F: y0 G/ d6 Y- H
excess.1,3
/ k! b4 Y! T- S) f; `" F( Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 g: b. R6 m& S  E1 R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# h: M& `, G% L  w6 P! SA unique entity of male-limited gonadotropin-
/ d; `; l7 n& ]: j! |independent precocious puberty, which is also known
; ?; a" D  V5 \. K% Pas testotoxicosis, may cause precocious puberty at a& T! {4 T2 p% i% q" L
very young age. The physical findings in these boys
. w: S! [8 A  _1 wwith this disorder are full pubertal development,! H0 j0 H% R  r! W* n3 B$ X* y, I
including bilateral testicular growth, similar to boys. ~; G3 }7 z* L) l' V3 ]; d- \
with CPP. The gonadotropin levels in this disorder8 R, e( r" t* G- `0 y6 o) F. C
are suppressed to prepubertal levels and do not show
' k8 D7 t" M5 O3 Fpubertal response of gonadotropin after gonadotropin-
! Y! C+ w; Q1 ~( Hreleasing hormone stimulation. This is a sex-linked0 f' l- g& m- P. r1 a- x, }$ r% e
autosomal dominant disorder that affects only
+ K# [" a3 f2 I* j0 \6 Lmales; therefore, other male members of the family
9 c, @' Y9 N8 T2 m2 xmay have similar precocious puberty.3
0 \. z3 Q) u. Q. Z8 Y5 hIn our patient, physical examination was incon-6 n2 @7 X  D( N  s4 `6 T
sistent with true precocious puberty since his testi-
' u# R4 E/ _% N! a1 ]1 o. Scles were prepubertal in size. However, testotoxicosis  Z( S7 V8 s5 a# K! h
was in the differential diagnosis because his father
& V; p  W: [0 N6 o1 s  Mstarted puberty somewhat early, and occasionally,
7 V; T  L0 m, q. H6 P  ~% }testicular enlargement is not that evident in the
# S9 \. e3 p' E- [8 K* x0 zbeginning of this process.1 In the absence of a neg-
. `0 z0 L- p1 P& m7 D% Pative initial history of androgen exposure, our4 e: q# E& I1 k/ g0 Z7 q
biggest concern was virilizing adrenal hyperplasia,
: ~$ ?" h$ H9 D1 q4 ^9 d, \either 21-hydroxylase deficiency or 11-β hydroxylase3 `/ z4 A& b. [( F
deficiency. Those diagnoses were excluded by find-
8 K3 R3 w7 d/ O! Zing the normal level of adrenal steroids.
$ e& w7 _5 j% e' _4 V/ Y- uThe diagnosis of exogenous androgens was strongly; Z- t# V' b0 ?" X0 X
suspected in a follow-up visit after 4 months because
# ~( C" O! m/ I6 v7 h# U* ?the physical examination revealed the complete disap-
, g8 u0 ]8 D+ O' F  |8 s" ?# g# Vpearance of pubic hair, normal growth velocity, and
  g0 X/ W1 e2 l0 \& e6 wdecreased erections. The father admitted using a testos-( z! `# s  p- R  ]2 X* I
terone gel, which he concealed at first visit. He was
" b- o. s  G  S. H+ y7 Qusing it rather frequently, twice a day. The Physicians’
8 P0 M" M5 Q2 R4 T0 CDesk Reference, or package insert of this product, gel or, _( r. U! i: f5 q
cream, cautions about dermal testosterone transfer to. I. W  m+ V. X
unprotected females through direct skin exposure.+ f: y" }9 o: u5 _# t9 F+ i
Serum testosterone level was found to be 2 times the
/ D& f, p) n2 A# Q$ Y9 Z5 [baseline value in those females who were exposed to
% g$ W) T5 E% y& n) y0 z2 Y* geven 15 minutes of direct skin contact with their male
* r0 V- I  `/ {7 R6 Lpartners.6 However, when a shirt covered the applica-* V; U" A6 ?$ N: @! O
tion site, this testosterone transfer was prevented.
# ~' u. H) S' _Our patient’s testosterone level was 60 ng/mL,
2 j  L- m, D7 J- K3 G% Lwhich was clearly high. Some studies suggest that2 Q  K0 O, N' z; E( u( p
dermal conversion of testosterone to dihydrotestos-
% [1 n- L/ V+ G; C! u. x2 Y/ Tterone, which is a more potent metabolite, is more7 F  D$ u/ L  f# H% X( q' h
active in young children exposed to testosterone
7 w6 N* ?$ f  Zexogenously7; however, we did not measure a dihy-
6 z: w! F8 m% W" edrotestosterone level in our patient. In addition to+ R4 V9 D. B% x
virilization, exposure to exogenous testosterone in5 c( i' q: _& _. I$ U0 L- z& C
children results in an increase in growth velocity and
  D( N8 p! g, K- O) padvanced bone age, as seen in our patient.
7 V9 P2 I( j0 m  j9 W1 p* B) nThe long-term effect of androgen exposure during2 h8 V4 m! j! p) b7 ]
early childhood on pubertal development and final1 U/ u/ _4 h8 ]# c2 N0 P& P
adult height are not fully known and always remain
- T' P7 _* g& Z9 M5 G& X$ Pa concern. Children treated with short-term testos-
! w; b3 q. x) Sterone injection or topical androgen may exhibit some& b7 t; e5 w; g7 F! a# j
acceleration of the skeletal maturation; however, after
6 d$ w* j# G+ Rcessation of treatment, the rate of bone maturation
4 l5 q: ?2 }. N3 J4 c  S) ~" _decelerates and gradually returns to normal.8,97 \  v7 [9 B5 G" L6 G
There are conflicting reports and controversy
% b; m, s- u/ `$ eover the effect of early androgen exposure on adult
4 k2 c2 ]1 r2 ^8 b; @7 b; hpenile length.10,11 Some reports suggest subnormal$ C7 x9 i9 h9 M0 b
adult penile length, apparently because of downreg-
6 W/ s9 z) ?# z8 j& u4 ]7 Wulation of androgen receptor number.10,12 However,- c2 m% p! M+ J. G1 O# l
Sutherland et al13 did not find a correlation between
. q# S' ]7 A& f$ Q0 schildhood testosterone exposure and reduced adult5 n+ B* W9 [: t1 y1 Z( \! g
penile length in clinical studies.
. g  `* s3 J5 O5 oNonetheless, we do not believe our patient is6 t9 ~. V( h7 D
going to experience any of the untoward effects from9 [" c8 q; {3 @. v9 g( Y# ^
testosterone exposure as mentioned earlier because4 I/ J. W) z5 q
the exposure was not for a prolonged period of time.& U* O4 D0 k- d* g0 E( {5 `3 q+ H) w
Although the bone age was advanced at the time of) @  v8 _2 z" l
diagnosis, the child had a normal growth velocity at3 c  ]0 y( y( o/ D, q1 V  ~
the follow-up visit. It is hoped that his final adult- }8 Y% d- X4 f: D! @) u
height will not be affected.- K. J5 h6 N' V5 j4 f
Although rarely reported, the widespread avail-
" f" F* v5 R6 |" f0 |( D0 n0 r! dability of androgen products in our society may% U/ _+ N* t6 d
indeed cause more virilization in male or female
& R5 e) b& c( n3 Hchildren than one would realize. Exposure to andro-( B+ l; `) P. X
gen products must be considered and specific ques-  _( o) N- H  C! Y
tioning about the use of a testosterone product or! C$ ]; I! e5 X* W
gel should be asked of the family members during' i5 q/ ~" `! Z
the evaluation of any children who present with vir-
* i$ V" Q, N  ^! \6 O# K2 g# ~6 Xilization or peripheral precocious puberty. The diag-. M+ \5 [; h6 p$ E5 N; L
nosis can be established by just a few tests and by4 n5 Y) V4 e6 B3 U8 u
appropriate history. The inability to obtain such a# I9 m  C, c/ q8 l
history, or failure to ask the specific questions, may
3 O0 c* B1 s2 Z4 c. Y' x* Xresult in extensive, unnecessary, and expensive& A' u8 f7 Q0 e" g+ M
investigation. The primary care physician should be( b6 l! e, c1 Z$ ?7 w: z
aware of this fact, because most of these children( }6 h" m" `* p0 C, r
may initially present in their practice. The Physicians’
5 L% B1 @6 y  sDesk Reference and package insert should also put a
$ M. R( s- P, H& P* Xwarning about the virilizing effect on a male or' M% x9 P4 |5 U) D8 P$ s3 p
female child who might come in contact with some-  k- F3 I) \0 b0 {) O
one using any of these products.
* ~$ Q0 x2 b  d! S/ ~* o% kReferences
5 A' ]: c5 U  }' Q1. Styne DM. The testes: disorder of sexual differentiation# Y. S% w; m( N- l8 t
and puberty in the male. In: Sperling MA, ed. Pediatric
  ]- n: K! @, x' hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 J3 e+ p! o; @; M2002: 565-628.
8 D% I7 H' @0 }3 B: j  C: {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: P2 K$ s& U9 Dpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
! \! K$ k) m3 R* b, RBoy Induced by Indirect Topical
, J* C& ~8 s/ Q4 H$ F# |9 K; ?9 vExposure to Testosterone
! W) \/ w& e6 \2 ?# mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% @- ^6 R2 t% E% v1 J
and Kenneth R. Rettig, MD1* X- {& M9 ?6 _% Z
Clinical Pediatrics
/ y; K, Z4 i+ Y. u" c. ~Volume 46 Number 67 Y0 W# N; n& B1 V
July 2007 540-543
( T' P0 p3 o0 I© 2007 Sage Publications
1 Q- y- T' V% w8 I7 `3 y3 [10.1177/0009922806296651" T2 r+ x5 O5 M+ p# P  O5 @, _  y
http://clp.sagepub.com
! O; E6 y' _0 g$ g0 |6 j% _hosted at2 b' L. ?2 n2 k4 D
http://online.sagepub.com
: \4 a, `7 `$ n) ], M5 e. l8 d+ {Precocious puberty in boys, central or peripheral,
  O7 ]# h9 {' W0 b: ^0 H) M" y2 ris a significant concern for physicians. Central
$ Z8 r- Q- a/ d! u" B4 zprecocious puberty (CPP), which is mediated7 ~4 d/ k6 U1 w4 Y6 d$ t
through the hypothalamic pituitary gonadal axis, has
4 `2 M& x- ]& n& m7 g& e- ya higher incidence of organic central nervous system) M/ E. g6 L# |  k$ N! l' o
lesions in boys.1,2 Virilization in boys, as manifested
7 h8 ?6 M/ N& m( f3 G4 Uby enlargement of the penis, development of pubic. X, r0 d" q5 i& k
hair, and facial acne without enlargement of testi-7 R' x6 h0 y  T
cles, suggests peripheral or pseudopuberty.1-3 We
1 F; y/ h) H/ i( |1 Q% y9 ereport a 16-month-old boy who presented with the, C  `' D% b! q: B. U' S1 l7 ~
enlargement of the phallus and pubic hair develop-
1 ]! }. j; M/ E2 kment without testicular enlargement, which was due
0 E  N4 J: ^" w4 l3 Dto the unintentional exposure to androgen gel used by
2 U4 r: v# l* E- bthe father. The family initially concealed this infor-8 [7 {4 `- ?1 y
mation, resulting in an extensive work-up for this( _1 l. G% P& m
child. Given the widespread and easy availability of
& p1 [0 u9 ^+ m" Btestosterone gel and cream, we believe this is proba-& _) l& @* l/ Q: e. I
bly more common than the rare case report in the+ U' J* ^# ^6 u# I
literature.4
- E- k7 W( I! x( i) P7 N/ GPatient Report
+ L% Z' t: c% K  F: m+ e/ a4 a7 EA 16-month-old white child was referred to the4 H# u: j& S4 Z$ m! [+ b
endocrine clinic by his pediatrician with the concern+ W/ P- r, p1 g3 `: I; Y
of early sexual development. His mother noticed
5 ]4 B7 g' a8 s4 t- l1 Alight colored pubic hair development when he was
% C0 M0 @: t* t: u( p( h1 XFrom the 1Division of Pediatric Endocrinology, 2University of1 E& u% a/ ?- a2 z
South Alabama Medical Center, Mobile, Alabama.0 K- y( l4 _2 }7 c! @
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 Z& Q: ?; q" W% x. y: U
Professor of Pediatrics, University of South Alabama, College of
: F, }2 B& O4 Y3 \7 M% D+ @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 w" b3 S! t: H# k6 b
e-mail: [email protected].3 w5 B! }2 i5 p6 S
about 6 to 7 months old, which progressively became2 X7 X. G. d7 H& P) j
darker. She was also concerned about the enlarge-
) I7 `) [8 y: D5 [* Pment of his penis and frequent erections. The child
6 L' j/ _2 c1 A- h. rwas the product of a full-term normal delivery, with: s$ q% V4 Y! |+ Y
a birth weight of 7 lb 14 oz, and birth length of+ m2 J  w* R; c6 K2 ^1 x/ V% Q2 ?% |
20 inches. He was breast-fed throughout the first year
; B2 R& e  _8 `: A6 k% n2 }of life and was still receiving breast milk along with
. F: L" n$ m6 @! Zsolid food. He had no hospitalizations or surgery,
, y" J* a& V  F: ~- p+ oand his psychosocial and psychomotor development/ V: M# Y4 Y, L$ j" W: e# A; y, V
was age appropriate.0 [% A1 x) {; }/ K/ d
The family history was remarkable for the father,! l- h( x! k3 i/ A) g! b/ T
who was diagnosed with hypothyroidism at age 16,, {6 R3 |" N. X8 \  K$ Q, M$ X
which was treated with thyroxine. The father’s
: R, G0 T0 z: I5 Gheight was 6 feet, and he went through a somewhat7 l; \0 X: ^$ I
early puberty and had stopped growing by age 14.+ i2 J7 J/ F) W  k# v
The father denied taking any other medication. The
% U' c- o8 i# U) j) r& \; Lchild’s mother was in good health. Her menarche
* b' }  R& X$ G. J: Vwas at 11 years of age, and her height was at 5 feet
0 b- S$ }5 a6 ^* _& v5 inches. There was no other family history of pre-- G7 N+ U( u( E1 J5 c
cocious sexual development in the first-degree rela-
7 ]& a; t6 ~1 J6 r' A; q3 y3 B% Wtives. There were no siblings.& N: S/ P  F$ m$ L( N2 S
Physical Examination" L. S! b* w- i1 n, I
The physical examination revealed a very active,
* G6 B8 \6 }2 ^0 n/ A7 [playful, and healthy boy. The vital signs documented
% d2 E! Z6 c3 Z0 q4 O4 qa blood pressure of 85/50 mm Hg, his length was: E) T9 }' @* H1 u$ x" }8 _; ~1 T
90 cm (>97th percentile), and his weight was 14.4 kg
( v; _! c: D6 r1 _) x: e/ d2 H(also >97th percentile). The observed yearly growth* [; ~2 l- k7 x  \2 |# S9 d
velocity was 30 cm (12 inches). The examination of
  n1 P/ l1 t6 M- x$ ?) Jthe neck revealed no thyroid enlargement.3 x# v! x9 r( `
The genitourinary examination was remarkable for
) Z3 t. G0 s6 J& j: _enlargement of the penis, with a stretched length of
( c% r0 W' _5 b* u* I6 s' H) V  _8 cm and a width of 2 cm. The glans penis was very well
% |8 \+ T7 U7 k8 ?8 t$ t9 x* Qdeveloped. The pubic hair was Tanner II, mostly around8 Z4 o; y+ I7 Y* t% B& t( D' S% p; [
5402 P: L" i8 u' o0 i$ l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) I% O5 c% c3 \8 _. T  p2 F8 c
the base of the phallus and was dark and curled. The
* F9 D/ N# z' h0 itesticular volume was prepubertal at 2 mL each.
; i5 c' a/ t' @# B* H5 wThe skin was moist and smooth and somewhat$ B9 c! J3 l$ F
oily. No axillary hair was noted. There were no
( p4 U2 V8 n" b3 S+ ^8 Z2 E  E4 vabnormal skin pigmentations or café-au-lait spots.
9 {( B. m. w7 S2 pNeurologic evaluation showed deep tendon reflex 2+
: n  _2 ]% p+ L. Y- H- Qbilateral and symmetrical. There was no suggestion
: C, B* K" D5 H- e% s2 p* iof papilledema.. ~. m2 e( G( ~/ \3 \
Laboratory Evaluation
5 P/ R$ g5 i  x: M& c7 @' T2 _The bone age was consistent with 28 months by
- W( I2 x7 ^2 ]6 i& a6 lusing the standard of Greulich and Pyle at a chrono-
. A- J% Q% k9 v6 ~- M5 Wlogic age of 16 months (advanced).5 Chromosomal
2 j, ~, G( U3 S" O: O- L1 o  ukaryotype was 46XY. The thyroid function test) i. \6 i1 G( `! I( Z& M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& P7 j0 X6 `1 u: g
lating hormone level was 1.3 µIU/mL (both normal).
! O) p" H* T4 s6 eThe concentrations of serum electrolytes, blood7 s0 t! T( _; b% Y( O+ v" n
urea nitrogen, creatinine, and calcium all were
% p; D- ?4 k% ^8 ^within normal range for his age. The concentration0 }8 R' ]4 U2 `) d# ^! ]
of serum 17-hydroxyprogesterone was 16 ng/dL
. t* ]2 d% Z9 z% r' s9 z% w(normal, 3 to 90 ng/dL), androstenedione was 202 R* Q2 C' l7 `3 e% F# J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 f% a. ]) h7 m+ x- vterone was 38 ng/dL (normal, 50 to 760 ng/dL),' |# N0 l$ z! V) Q( w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& U) w9 P- R$ ]2 ^* V2 z9 o# [
49ng/dL), 11-desoxycortisol (specific compound S)3 w5 h8 T6 z# x1 w8 B. j+ l2 P
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% Z. ^/ h4 L7 r; Y/ r9 Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ I4 Y/ A/ g: \  J4 y% a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 X5 G/ p4 g6 V+ {" Hand β-human chorionic gonadotropin was less than
' b$ C, o. _4 R" a. z5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 X' b; @# M& Q, |7 O# Estimulating hormone and leuteinizing hormone
, ^0 t: R* h/ @, o/ I, k0 p( @' R( Qconcentrations were less than 0.05 mIU/mL3 ^& n. ?4 T$ T# `
(prepubertal).
4 E$ A# |& f/ U9 EThe parents were notified about the laboratory
. l6 V; @) E* w) y' gresults and were informed that all of the tests were
" a' K* x8 X  G: i! H) [. Hnormal except the testosterone level was high. The
- R  w- X2 {! Yfollow-up visit was arranged within a few weeks to! m. r) l% z$ N5 @& X! F+ X
obtain testicular and abdominal sonograms; how-+ K/ G9 B: w" }1 r3 V8 M0 U
ever, the family did not return for 4 months.
* g. V" {+ v2 m; d; m# ?Physical examination at this time revealed that the
" i* |, r0 W$ U+ i: Echild had grown 2.5 cm in 4 months and had gained
8 k( W. w/ x4 X+ b6 O' y2 kg of weight. Physical examination remained
( a- e. A( o3 S9 Cunchanged. Surprisingly, the pubic hair almost com-
7 K& H- B" a. G: _- Opletely disappeared except for a few vellous hairs at8 x0 h. @- |9 B% W
the base of the phallus. Testicular volume was still 2" y# ~4 C; b% j) p" \$ `
mL, and the size of the penis remained unchanged., p1 a! t% I7 Y, w( u
The mother also said that the boy was no longer hav-7 P: y8 u. W# y
ing frequent erections.) @0 E9 L& W8 G5 F$ E
Both parents were again questioned about use of
( h6 d% m1 L' Yany ointment/creams that they may have applied to
) E2 H, j8 s6 D: Tthe child’s skin. This time the father admitted the
9 B6 R; S0 j/ e/ w1 e* k# _0 HTopical Testosterone Exposure / Bhowmick et al 5411 G7 s$ f# c; a4 q* _0 ?! F2 t9 o( u
use of testosterone gel twice daily that he was apply-
' L# i% n6 ~$ U8 L: K4 R) eing over his own shoulders, chest, and back area for7 `% C2 R" m/ a9 @/ \
a year. The father also revealed he was embarrassed% l# ~5 d- x1 b) l
to disclose that he was using a testosterone gel pre-
) v; w4 A5 U$ q* h* F# jscribed by his family physician for decreased libido3 R* B" M9 }; x
secondary to depression.+ ^2 Y' H9 Z8 r( Z3 _6 F' W' X. \$ E9 t
The child slept in the same bed with parents.
& f5 m! h* s) y# B6 [The father would hug the baby and hold him on his
9 {! Y4 ]# t4 H2 achest for a considerable period of time, causing sig-3 y+ _: M% k7 U) J, V
nificant bare skin contact between baby and father.5 Y) E/ E" s; E, _
The father also admitted that after the phone call,0 N  z* p, ~7 q6 Y7 X1 @: Q' L
when he learned the testosterone level in the baby
: s  r; B3 ]* {) W, Jwas high, he then read the product information, N3 ]% h, Q0 H$ I# A$ b
packet and concluded that it was most likely the rea-
' q" s" _) }/ U1 ]3 Rson for the child’s virilization. At that time, they
7 v. e* S- P  a& c. a; l/ }decided to put the baby in a separate bed, and the
* d/ b+ |2 P- \0 M: mfather was not hugging him with bare skin and had
, m" a6 ]( t  O5 |1 i/ dbeen using protective clothing. A repeat testosterone/ ~* e& Q3 g+ }1 ^
test was ordered, but the family did not go to the; c; Z& B% \( C% h5 P: r; f0 U
laboratory to obtain the test.6 C1 }9 P' i+ f% u+ \# R; N+ t
Discussion. n/ ?" _. ?. a  c
Precocious puberty in boys is defined as secondary4 F3 R0 }8 ]/ F- L7 T
sexual development before 9 years of age.1,4" m& l9 x) y0 J6 O
Precocious puberty is termed as central (true) when
4 r$ [2 w  c5 Z8 P" y' Fit is caused by the premature activation of hypo-
) Y7 n3 E5 @$ `8 Lthalamic pituitary gonadal axis. CPP is more com-2 \1 t- ^  j* k
mon in girls than in boys.1,3 Most boys with CPP
" n6 N' N/ x3 p, t9 smay have a central nervous system lesion that is
9 p+ r( I3 G' X2 `responsible for the early activation of the hypothal-# e2 M1 H9 c( a  u/ y/ ~
amic pituitary gonadal axis.1-3 Thus, greater empha-8 J0 k, o) B! z( \2 B
sis has been given to neuroradiologic imaging in8 V: d: Y$ L7 ?% ^/ y7 q1 [  [
boys with precocious puberty. In addition to viril-
: l9 {5 U9 ]) P+ v7 Z( P+ eization, the clinical hallmark of CPP is the symmet-
- v0 r. z; }2 \' t: @rical testicular growth secondary to stimulation by  q  |& `3 q9 _/ d3 N$ p% F
gonadotropins.1,3
$ g3 ~0 ~% X' _- y% RGonadotropin-independent peripheral preco-
2 W- g- M6 d0 ^  O, ]% g' @& Jcious puberty in boys also results from inappropriate: h! d, r! w( ^! F4 V( x
androgenic stimulation from either endogenous or2 F+ d  b8 y% [  U/ |) `- G" e6 D
exogenous sources, nonpituitary gonadotropin stim-9 M; n6 L% W% w/ W! I4 A
ulation, and rare activating mutations.3 Virilizing
0 N7 ~! _. [/ e3 o4 m/ h9 Q+ _" Xcongenital adrenal hyperplasia producing excessive7 J" K2 }0 g7 z2 A3 s# i9 `
adrenal androgens is a common cause of precocious
7 _1 ]$ Y6 f1 A$ npuberty in boys.3,4
( R/ m+ Q' J4 U0 |The most common form of congenital adrenal
: c: N  U6 ?5 j' o5 bhyperplasia is the 21-hydroxylase enzyme deficiency.
9 F  W; `1 W% P. O9 m2 u! z( N  uThe 11-β hydroxylase deficiency may also result in
1 ]( [% N1 P6 D/ wexcessive adrenal androgen production, and rarely,) ^" _4 D' u; Z8 ~) d
an adrenal tumor may also cause adrenal androgen5 f, _2 z' X. ?
excess.1,3) l  R, s' R* L5 ^  {1 \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 R5 w/ i% c* f2 k. L+ o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 I- K7 [) _% A; tA unique entity of male-limited gonadotropin-5 M# g  q9 s1 d
independent precocious puberty, which is also known& A3 n$ Q+ O% U( n
as testotoxicosis, may cause precocious puberty at a
* ]: y3 F& H; O& ]. P+ Fvery young age. The physical findings in these boys) r2 N) ]3 o' w
with this disorder are full pubertal development,: W  r! ~" X& d" P- L/ _
including bilateral testicular growth, similar to boys% c4 ^  I! z( \( {5 t) @- j
with CPP. The gonadotropin levels in this disorder8 a0 D! B, E- [, x! f3 H
are suppressed to prepubertal levels and do not show
5 G2 V* c3 A3 s! V* ]pubertal response of gonadotropin after gonadotropin-
7 K2 L; L  ~; n8 S, b" Sreleasing hormone stimulation. This is a sex-linked5 n; I8 ~7 V' Q/ X
autosomal dominant disorder that affects only
2 a5 e! g* l5 ~" {males; therefore, other male members of the family8 R" O% a4 P" L
may have similar precocious puberty.3
4 }1 |, D  K) v8 ?0 wIn our patient, physical examination was incon-0 t. K/ y- e1 `8 l. @5 f6 L
sistent with true precocious puberty since his testi-, P! {  t% s+ \" I0 l( X
cles were prepubertal in size. However, testotoxicosis  l" x6 y$ R7 m$ V
was in the differential diagnosis because his father
7 \" {6 i+ w) i2 Xstarted puberty somewhat early, and occasionally,4 R* E! |: g* O
testicular enlargement is not that evident in the* @* V( ~. V2 k. b2 S
beginning of this process.1 In the absence of a neg-
9 Y7 F  Q. d  L& l( P. y5 E4 u0 vative initial history of androgen exposure, our
3 U9 b2 M* }9 O* L1 `  {biggest concern was virilizing adrenal hyperplasia,% P6 t& {; Z5 e1 e! N- I
either 21-hydroxylase deficiency or 11-β hydroxylase
* ]% r# Z; P6 \deficiency. Those diagnoses were excluded by find-
: h* M8 a0 z) R/ fing the normal level of adrenal steroids.
" R  r4 J; R2 x. K" j4 \" ?The diagnosis of exogenous androgens was strongly7 }: T" r( [$ i, s: f; y
suspected in a follow-up visit after 4 months because3 u1 `7 Q" [2 I7 `
the physical examination revealed the complete disap-
) X9 h; X4 v  A! y) T' Cpearance of pubic hair, normal growth velocity, and* A% e1 q' h; o5 w/ M# {$ t
decreased erections. The father admitted using a testos-
: T9 z# n1 S# U% H5 u+ Vterone gel, which he concealed at first visit. He was9 a  G) P: E7 ^
using it rather frequently, twice a day. The Physicians’4 F$ _" b3 K5 G/ A; X! W) I0 Q
Desk Reference, or package insert of this product, gel or, o+ [6 P6 v) H& X
cream, cautions about dermal testosterone transfer to
. j! v- |3 |$ Iunprotected females through direct skin exposure.
  D* X0 e5 J. Z5 c: \Serum testosterone level was found to be 2 times the7 i2 w8 b$ N8 J" }# n
baseline value in those females who were exposed to
: p7 H' F" c/ a0 Ieven 15 minutes of direct skin contact with their male4 F. t, I/ \) ~) s* I5 |) ?2 z. }
partners.6 However, when a shirt covered the applica-! s# J7 e, \3 \, ~
tion site, this testosterone transfer was prevented.8 ?8 o, K- v( S# C
Our patient’s testosterone level was 60 ng/mL,
/ R1 U- q" d% S/ A; M  a* ~which was clearly high. Some studies suggest that
+ L! J0 d( @2 ?! \dermal conversion of testosterone to dihydrotestos-
. O3 A- t3 j( G3 eterone, which is a more potent metabolite, is more
5 \% t- i: ]2 W3 ?5 m1 oactive in young children exposed to testosterone
. M# L& E9 l% O7 k) Jexogenously7; however, we did not measure a dihy-* K: @2 E* t( r) o, ~
drotestosterone level in our patient. In addition to
4 i2 m) ]: ]( S# Avirilization, exposure to exogenous testosterone in) U) N! d$ U& v1 f) }( ^" v
children results in an increase in growth velocity and6 Z# E( B, N. x- l0 h1 \
advanced bone age, as seen in our patient.0 F0 p& y- m- Q
The long-term effect of androgen exposure during
2 x* J$ d- }2 u( X, e1 _early childhood on pubertal development and final5 B* v2 D& ~1 c" F$ P/ C4 @* K+ |# m
adult height are not fully known and always remain  j; E; Y4 A: ~$ B. ~
a concern. Children treated with short-term testos-
5 r1 M5 H# G$ L% g3 _5 @9 Eterone injection or topical androgen may exhibit some
" z% N1 F' @0 u/ d9 ^acceleration of the skeletal maturation; however, after7 B; A1 \' w7 Q. A  h' I4 ]) C
cessation of treatment, the rate of bone maturation
- Y1 D5 I5 X! k1 ]* ydecelerates and gradually returns to normal.8,9
- O4 {; _. r$ O; j- H/ b8 uThere are conflicting reports and controversy
- D# n) e1 M1 c1 c) Jover the effect of early androgen exposure on adult- K+ }1 T8 z& G* F4 M
penile length.10,11 Some reports suggest subnormal
/ Z5 q& L9 \7 W: p) `adult penile length, apparently because of downreg-) u1 T  I. c: r) G# X% i7 e* v
ulation of androgen receptor number.10,12 However,
; p# N6 Y* q0 C# ]' y4 ~2 W* S0 PSutherland et al13 did not find a correlation between( d4 U* I8 a# T" Z2 ^& o
childhood testosterone exposure and reduced adult
2 L' k6 S) x/ O/ z$ Upenile length in clinical studies./ S* \" U; Q7 U( f. K& T
Nonetheless, we do not believe our patient is: E* m; W' R% d! Y/ D: Y
going to experience any of the untoward effects from. |9 _' F. }% a$ g
testosterone exposure as mentioned earlier because% ?$ h4 Y1 N& V3 W
the exposure was not for a prolonged period of time.
* B0 O" [; o1 h8 J+ gAlthough the bone age was advanced at the time of. S1 i" m5 s$ z4 J) R4 V2 M, p' g
diagnosis, the child had a normal growth velocity at& ?! K" I  D5 W! C4 V
the follow-up visit. It is hoped that his final adult
: [" J! K: A' v' Theight will not be affected.
6 L, y$ L& n' o$ g1 Y% _+ NAlthough rarely reported, the widespread avail-
% ]- U- g+ |( J1 m' v+ [ability of androgen products in our society may3 N( O) Z+ M8 P) T0 n3 ^' P" }0 s
indeed cause more virilization in male or female3 }8 |7 f# v: L% q* `3 M
children than one would realize. Exposure to andro-
0 Y  m2 Y) f4 u0 }# n$ i9 |gen products must be considered and specific ques-; C1 [( K$ O; l. X$ f9 m4 S7 Z
tioning about the use of a testosterone product or
( [6 P, H% y) Hgel should be asked of the family members during
3 u3 u; U+ K0 R# C9 t% s$ _the evaluation of any children who present with vir-2 _2 {$ M" Z( m2 g
ilization or peripheral precocious puberty. The diag-( x  }! ?$ r8 U; r' e" R3 {
nosis can be established by just a few tests and by
) g7 {  `- C7 I7 ^  {: Eappropriate history. The inability to obtain such a" V5 X. U# A/ l- q) ]
history, or failure to ask the specific questions, may
+ C4 L" F  k4 S7 Gresult in extensive, unnecessary, and expensive( p) e" D" y! T3 C" S- D1 \: T6 @
investigation. The primary care physician should be
2 e' l! H) H- |aware of this fact, because most of these children
! s& Q, U6 a$ T% f4 g4 Xmay initially present in their practice. The Physicians’% m! Z$ v, k/ ?3 [
Desk Reference and package insert should also put a5 j1 N! X- h, W
warning about the virilizing effect on a male or* I' Y. G$ Y4 F& e, U, l
female child who might come in contact with some-+ x3 R! R; j# K5 ^1 ?$ \
one using any of these products.
( U/ }' `5 J. \5 i% [9 R/ tReferences
9 ~3 c9 N8 v2 W9 C0 O: L$ ~1. Styne DM. The testes: disorder of sexual differentiation
$ D( @( x* O4 R/ C4 k, b7 f: s; W  Oand puberty in the male. In: Sperling MA, ed. Pediatric
# c3 a% F9 j* x$ d- x  t9 L8 REndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- }( B5 t5 a" B! G
2002: 565-628.$ M5 S5 O$ _# z5 c
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- A6 P$ r5 q+ O5 m  opuberty 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
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

- N9 q& e0 n: w# {: _6 s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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