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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: {- d' d* d9 P5 t3 ?; y
Boy Induced by Indirect Topical
0 b9 k4 B( z6 f/ xExposure to Testosterone- b; u! C. ?* }1 z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' F. J7 a& u) E5 ^3 Eand Kenneth R. Rettig, MD1
0 X" K4 l1 J: b. x5 qClinical Pediatrics3 O" \% t5 [/ W" }  m
Volume 46 Number 66 a. d6 |4 b% m3 g$ x
July 2007 540-543
* h- `; a% k5 b, j6 i© 2007 Sage Publications
  l& {5 `! W) [3 z0 S  [( K10.1177/0009922806296651  r1 M) J9 j% M: W
http://clp.sagepub.com% u" H1 r% @$ g) y# X4 e
hosted at2 r7 k& s3 g9 X  m
http://online.sagepub.com
! r  a# x1 r1 i: t  \9 RPrecocious puberty in boys, central or peripheral,- C) V6 f3 m4 C# v" ^
is a significant concern for physicians. Central) |" C! v) k& o1 U+ u2 g
precocious puberty (CPP), which is mediated3 r- w0 t7 |7 u- O' \
through the hypothalamic pituitary gonadal axis, has' ?- j# `; e7 q7 l
a higher incidence of organic central nervous system
  t* i: p' i2 A/ A1 n% T9 }lesions in boys.1,2 Virilization in boys, as manifested
0 ?0 R5 p: @) Sby enlargement of the penis, development of pubic& j- V. f' P7 z/ u
hair, and facial acne without enlargement of testi-+ j0 W# X* W5 H9 U+ L) k
cles, suggests peripheral or pseudopuberty.1-3 We
9 F! f: J# r  C/ ?" p6 D2 Areport a 16-month-old boy who presented with the: c0 I" {9 p! J' t$ j3 u4 a
enlargement of the phallus and pubic hair develop-
6 o5 r, ^5 z: J* s8 N# Cment without testicular enlargement, which was due
) j7 ]8 L# R, p2 k! k8 Ito the unintentional exposure to androgen gel used by
' r, A2 T& Y  H0 W/ s& p- d" `3 pthe father. The family initially concealed this infor-  P* o& K- M0 L4 O- r# L( i
mation, resulting in an extensive work-up for this4 y* j' X* C2 z3 }3 G: W* F% q" I( n) I
child. Given the widespread and easy availability of; V% I# e: Z5 `8 ]6 J! @" q
testosterone gel and cream, we believe this is proba-$ r" w! ]7 G) T! G: F
bly more common than the rare case report in the
! b0 o, e9 \* K+ z. e% ?  Lliterature.40 P* v* @; m) ?; i% W' g9 D
Patient Report
4 E4 Y/ G8 g$ ~% c7 h5 ]A 16-month-old white child was referred to the9 H$ O) o6 [4 w7 d" u& d; R
endocrine clinic by his pediatrician with the concern
! S) N* Q4 Q3 y7 o* Mof early sexual development. His mother noticed$ Y0 O& b1 A) x1 D
light colored pubic hair development when he was) }" b) J2 I& T/ @0 h+ Q4 Q
From the 1Division of Pediatric Endocrinology, 2University of
0 z/ c6 k) z! Z( X( B  Z3 r2 }& pSouth Alabama Medical Center, Mobile, Alabama.8 F$ `" H% ]2 w$ K+ E
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 t$ N; }' M* y- m# p) Z  H  ~
Professor of Pediatrics, University of South Alabama, College of  B: [3 n' s3 w( K9 }. w# C3 P
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* T) p$ Y! a" M; D" L, p
e-mail: [email protected].
6 G/ r6 s# Y  w2 Y$ dabout 6 to 7 months old, which progressively became! Q! Q" K) r- t/ t
darker. She was also concerned about the enlarge-
: T# L! |) X# I  ~* z' Y( lment of his penis and frequent erections. The child
. }% w0 m' t* b  kwas the product of a full-term normal delivery, with
+ |' a* \0 X9 k$ Ma birth weight of 7 lb 14 oz, and birth length of
7 u' U5 K4 x$ R$ X( `( h* k20 inches. He was breast-fed throughout the first year/ @2 @" s6 P! j" M
of life and was still receiving breast milk along with
5 Z4 z# F$ {: j- U! tsolid food. He had no hospitalizations or surgery,
3 e4 R% z  K& P. m* o6 rand his psychosocial and psychomotor development
0 g' X0 _/ @+ [; Swas age appropriate.
2 F4 O3 U8 T5 a- E) HThe family history was remarkable for the father,
1 e! B( k" O6 d# @5 B9 d0 iwho was diagnosed with hypothyroidism at age 16,* K' |  z* s3 s4 e0 ]( i$ `
which was treated with thyroxine. The father’s
4 W3 J* r/ R" j0 Fheight was 6 feet, and he went through a somewhat5 N2 |, t; D/ b8 w$ h: f
early puberty and had stopped growing by age 14.
6 Q) A& w7 d' NThe father denied taking any other medication. The
& q2 |8 Z' U4 r1 Echild’s mother was in good health. Her menarche$ m2 X! |; i, ]! d
was at 11 years of age, and her height was at 5 feet
! x% B3 L+ S  W- i4 {1 {5 inches. There was no other family history of pre-
; s! d$ z& M+ ^& r9 Vcocious sexual development in the first-degree rela-
5 U% a& N. g) ltives. There were no siblings.
: m8 S6 _6 h4 u1 cPhysical Examination: P, o" a4 Q- U, G+ }3 E3 T
The physical examination revealed a very active,3 ^- u2 |/ H# e9 H- V* g& K
playful, and healthy boy. The vital signs documented
1 @& p( w$ G7 ]a blood pressure of 85/50 mm Hg, his length was1 a) T9 B( l4 L- e
90 cm (>97th percentile), and his weight was 14.4 kg4 Z7 T, e2 O# V8 w
(also >97th percentile). The observed yearly growth+ o9 U- s6 C6 U9 G+ \& s
velocity was 30 cm (12 inches). The examination of
. F& l, k4 F/ [0 B: ~+ F6 Mthe neck revealed no thyroid enlargement.5 W* S2 G! ~4 L5 h$ G4 o$ t( q
The genitourinary examination was remarkable for
/ E+ g9 X; }. [1 p0 l# v" R4 venlargement of the penis, with a stretched length of, k% ]5 E, B) I6 q* k
8 cm and a width of 2 cm. The glans penis was very well
. z. T2 U, d- Zdeveloped. The pubic hair was Tanner II, mostly around) g+ [+ U* @" T4 [
5400 U( r8 b' `! k3 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# g& ]7 F" c. r
the base of the phallus and was dark and curled. The
6 O8 x8 _( G' Btesticular volume was prepubertal at 2 mL each.
8 \1 I4 ~5 {- G/ B/ gThe skin was moist and smooth and somewhat$ K( j+ T; E/ C7 Q4 @+ ~
oily. No axillary hair was noted. There were no
* Y7 l# t$ h6 K/ @& O8 u3 Wabnormal skin pigmentations or café-au-lait spots.0 u) H: J. o' a
Neurologic evaluation showed deep tendon reflex 2+
1 X; B0 k$ B8 \) l: \: }9 `7 O) _bilateral and symmetrical. There was no suggestion  x- f0 G* G, F& H. w4 n, c) R# \
of papilledema.
3 w7 }* [4 x; |- yLaboratory Evaluation  ]4 D% i: _+ K3 Y
The bone age was consistent with 28 months by& N$ X% ?* \# l3 X8 ?) l
using the standard of Greulich and Pyle at a chrono-
9 S" n) h6 j" h. u+ tlogic age of 16 months (advanced).5 Chromosomal- Q4 d" R. S: o7 h- i, i- P9 h
karyotype was 46XY. The thyroid function test. q( O& l6 v, |  i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- R! J* ^$ o- I" g* N7 F3 e
lating hormone level was 1.3 µIU/mL (both normal).
9 s: |2 S) Y1 v+ z' d9 ]4 w  XThe concentrations of serum electrolytes, blood; G+ D6 Y1 C4 c
urea nitrogen, creatinine, and calcium all were  v. _7 N# j( r& P. L7 h7 U- W3 A/ z
within normal range for his age. The concentration6 n% T5 R3 X( Q3 N) J
of serum 17-hydroxyprogesterone was 16 ng/dL
2 o* }: T) y4 t0 v2 ?; Y" J(normal, 3 to 90 ng/dL), androstenedione was 20
$ Y1 S  W! u. tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* I$ j6 W0 p& l1 e, }
terone was 38 ng/dL (normal, 50 to 760 ng/dL),! ]. U7 ?! r% c" `; m# n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 r  P) }# W8 ^; E5 j7 u$ d7 p/ ]
49ng/dL), 11-desoxycortisol (specific compound S)
3 j( e, g7 t$ y# Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 f5 K/ l: {( ^) ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% c4 T' O5 M) ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 W% z# E% q3 G  r( j. I7 Sand β-human chorionic gonadotropin was less than7 M- X' K2 ]/ e+ O, _
5 mIU/mL (normal <5 mIU/mL). Serum follicular, ]- a7 h2 e6 _) t* b. q" ?
stimulating hormone and leuteinizing hormone" X8 d' s* P9 y" V9 A' }
concentrations were less than 0.05 mIU/mL) }8 @# J1 ~" y# Z
(prepubertal).8 e" l3 x9 ?$ q( l6 ^/ j; f
The parents were notified about the laboratory( O. {+ s8 U% p0 `" k1 y
results and were informed that all of the tests were
  k0 `0 z* [% k7 o+ o! c  Gnormal except the testosterone level was high. The/ f' S4 N" [1 L+ }; ~
follow-up visit was arranged within a few weeks to
. h8 ~' ?, e! h" Q4 Y0 ^obtain testicular and abdominal sonograms; how-
; g) P) b6 e* u) r$ s4 x" [ever, the family did not return for 4 months.
: P* c5 @: d9 fPhysical examination at this time revealed that the
6 S( P7 Y+ q& Tchild had grown 2.5 cm in 4 months and had gained
  ^5 N0 ~, D- F, d) n! ]2 kg of weight. Physical examination remained. u0 Y0 ]3 i7 `9 o0 L  D; L
unchanged. Surprisingly, the pubic hair almost com-$ I1 M. g+ k% L+ P
pletely disappeared except for a few vellous hairs at3 A* c$ g5 N2 L- h0 H+ d" ]8 B
the base of the phallus. Testicular volume was still 2
5 N$ D- D2 }8 ^- n. t7 G* O: \mL, and the size of the penis remained unchanged.* n! e+ r& _, ]2 F
The mother also said that the boy was no longer hav-: |6 }; I2 w" \, d
ing frequent erections.
0 B$ Y. o% d3 M7 ]Both parents were again questioned about use of9 V8 E* W' |2 l2 G0 z4 n
any ointment/creams that they may have applied to
) ~$ C% J9 n+ d* d/ Hthe child’s skin. This time the father admitted the8 u* v% h1 P) T) `# s5 o
Topical Testosterone Exposure / Bhowmick et al 541
* x( a% I3 _+ {) i" f8 cuse of testosterone gel twice daily that he was apply-, s: V9 [' {8 M8 Y/ f, |* k7 _
ing over his own shoulders, chest, and back area for) y- w. G: s% r0 k
a year. The father also revealed he was embarrassed
6 e2 {* M# s! h6 f- h" Wto disclose that he was using a testosterone gel pre-7 I0 w9 S; ]7 l% ~1 _: r) e- b
scribed by his family physician for decreased libido
8 f' V" t1 x, C' [, Jsecondary to depression.
4 ~9 x. Y+ S# |$ }" c. FThe child slept in the same bed with parents.
, Q. I% ]% V+ d+ t9 U4 H6 gThe father would hug the baby and hold him on his
: p& z: W  A! D* }. ~, Dchest for a considerable period of time, causing sig-
+ M" Z) ^" x$ Anificant bare skin contact between baby and father.( ~! }" g$ c9 D3 {% m: x
The father also admitted that after the phone call,; _4 m# l( Y. W! ]
when he learned the testosterone level in the baby
$ P+ i! x% x' o& Nwas high, he then read the product information
5 I/ U( [' F! B' Epacket and concluded that it was most likely the rea-( [8 l7 b8 P7 {3 o* o2 B
son for the child’s virilization. At that time, they
4 W) E+ y" u8 {) }) P: idecided to put the baby in a separate bed, and the
6 C0 o# N, y/ |& Q2 @father was not hugging him with bare skin and had
8 j- Z9 N( B- r/ s  abeen using protective clothing. A repeat testosterone
8 {; V; X, B* q( m, qtest was ordered, but the family did not go to the
( F' x. Q" h) \" x% nlaboratory to obtain the test.
. `; G3 f* `6 K" r$ hDiscussion* f5 o* `, D( S& B! m2 b0 l4 D% N
Precocious puberty in boys is defined as secondary! b0 w$ j8 }9 U' a* A/ R$ m) M  H
sexual development before 9 years of age.1,46 j1 I; f1 q( c! f' ^# b3 I
Precocious puberty is termed as central (true) when7 [) S% v+ J, _) m1 S
it is caused by the premature activation of hypo-
7 T, J, a! |, S+ r( P6 O. }thalamic pituitary gonadal axis. CPP is more com-6 U/ |, f: j' F& }
mon in girls than in boys.1,3 Most boys with CPP/ m6 j) O: Y! x" o$ S$ k% _2 N+ d! J
may have a central nervous system lesion that is, N. p: [, Z- e0 c1 Z+ W
responsible for the early activation of the hypothal-  m! U5 i3 C' D; d0 T! E& t' C& |
amic pituitary gonadal axis.1-3 Thus, greater empha-8 R6 |# G$ k4 V: c
sis has been given to neuroradiologic imaging in7 P7 Z; B2 H5 i" B/ A( I7 ]! q
boys with precocious puberty. In addition to viril-' ]1 F( o' L, ?: B1 f, U
ization, the clinical hallmark of CPP is the symmet-
. F& j; n% u5 \7 irical testicular growth secondary to stimulation by
5 c* S5 o5 w: x6 v8 u3 I0 mgonadotropins.1,36 C0 ]6 T, O' I' M) _, m0 O# [9 R
Gonadotropin-independent peripheral preco-
+ c& `- i$ w7 @) ^4 J/ v$ Q& ycious puberty in boys also results from inappropriate
/ V3 Y7 y& I4 F4 N6 Q# l# r) Gandrogenic stimulation from either endogenous or5 u% [+ T6 w9 D, f
exogenous sources, nonpituitary gonadotropin stim-
7 y3 D& z5 d. c6 y! u7 Iulation, and rare activating mutations.3 Virilizing+ p& W3 J$ K* z5 C+ m( Z7 g' S+ h, t
congenital adrenal hyperplasia producing excessive, V& [" u; B: M% B  L
adrenal androgens is a common cause of precocious6 b+ o$ [; K! B* O( y2 g
puberty in boys.3,4
& c7 `, F  X" b# R: g' Z6 G0 KThe most common form of congenital adrenal" z/ k8 p# B4 ^5 B9 N4 _
hyperplasia is the 21-hydroxylase enzyme deficiency.! N& _% b$ ?3 ^+ o9 m- Z: ^3 q
The 11-β hydroxylase deficiency may also result in
6 k! M4 }% J! Q5 Wexcessive adrenal androgen production, and rarely,
' r$ b. X7 v! m: }: |an adrenal tumor may also cause adrenal androgen" g: g( u5 ?" ]9 R8 J$ b
excess.1,3. y  s- X& F1 ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' n3 |; A, X" R1 b3 m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ w$ w6 h& }& Y) b% A
A unique entity of male-limited gonadotropin-
: @8 m& W; h- Y- Vindependent precocious puberty, which is also known
) ^6 Y& s+ L5 P  ~3 [as testotoxicosis, may cause precocious puberty at a9 h2 c4 Z8 X- B1 k
very young age. The physical findings in these boys# }5 }# G( s( z, O
with this disorder are full pubertal development,' L( w7 f# A) e9 Y5 [+ }
including bilateral testicular growth, similar to boys
- S% P' [, f& t$ R0 ^- F% hwith CPP. The gonadotropin levels in this disorder
7 s$ X3 P& W/ S  T, Bare suppressed to prepubertal levels and do not show4 o# Q& n6 ?% R- s; n
pubertal response of gonadotropin after gonadotropin-
* O, l( x+ b0 ^" greleasing hormone stimulation. This is a sex-linked
0 ~1 n3 V2 F: Pautosomal dominant disorder that affects only7 V+ R9 a/ B! L/ Q; n
males; therefore, other male members of the family
; c2 t2 Y! b3 ]: z  k/ ]$ j+ v% Vmay have similar precocious puberty.3% }" b( g5 \# L' q/ O
In our patient, physical examination was incon-
0 [% V" Q- o( w: A4 g4 x( Esistent with true precocious puberty since his testi-( i- I/ m5 i( V( p# a) Y; V- `
cles were prepubertal in size. However, testotoxicosis
* Q" q7 K" `. K/ z: }- @was in the differential diagnosis because his father5 ]+ k  v) W, I( _- ?
started puberty somewhat early, and occasionally,
' M  T6 @) X) Utesticular enlargement is not that evident in the
$ S7 |) _  b) }! ^/ P# Y6 `0 L: Ybeginning of this process.1 In the absence of a neg-8 M" S* a& F5 J% Q* V
ative initial history of androgen exposure, our7 n8 V8 U- ]: w, m0 h5 I
biggest concern was virilizing adrenal hyperplasia,
! h5 @2 f9 D' Leither 21-hydroxylase deficiency or 11-β hydroxylase( j1 A3 g* j3 e9 e5 m7 \8 ^+ l+ Y
deficiency. Those diagnoses were excluded by find-- C5 I4 T$ h6 c& ^. q
ing the normal level of adrenal steroids.
# E! f1 z9 r% ]1 _. [$ dThe diagnosis of exogenous androgens was strongly
! q0 W  s" {! l0 F2 F7 K5 _  Isuspected in a follow-up visit after 4 months because! b6 D( l$ }3 ]( h# G0 X
the physical examination revealed the complete disap-
- N! ]$ [1 i5 Q$ k% O; o% h1 t$ gpearance of pubic hair, normal growth velocity, and  p7 O4 m6 `" e( q' L! c
decreased erections. The father admitted using a testos-" l2 @5 S# @: K- W
terone gel, which he concealed at first visit. He was
* x% O; O3 X; z+ f5 p  Qusing it rather frequently, twice a day. The Physicians’7 A+ |( K: y2 t8 @1 [) \4 o
Desk Reference, or package insert of this product, gel or4 _3 K" s8 w8 O8 f( p. v
cream, cautions about dermal testosterone transfer to
5 G" v1 H1 ]5 S9 L, W! V& Junprotected females through direct skin exposure., D3 w  R) ^6 q4 |+ R- E! v
Serum testosterone level was found to be 2 times the7 L6 K" v1 r3 S* T
baseline value in those females who were exposed to
; g: M7 \# A. P- u3 @$ i5 H$ ceven 15 minutes of direct skin contact with their male7 P' o1 R$ W$ ^3 H" @& M
partners.6 However, when a shirt covered the applica-6 n" L, m& Q- A6 U
tion site, this testosterone transfer was prevented.
4 `9 M' i" o. KOur patient’s testosterone level was 60 ng/mL,
! b8 B+ w1 N7 Gwhich was clearly high. Some studies suggest that' b, J1 W: p& F& F4 `6 O0 y! S) r; t+ t
dermal conversion of testosterone to dihydrotestos-* E  g  |& W+ B0 [( Y
terone, which is a more potent metabolite, is more. H' s; @6 A; j6 P
active in young children exposed to testosterone7 z8 e. S- m: S& d  S5 @4 w
exogenously7; however, we did not measure a dihy-
. s1 J& j$ ~: |drotestosterone level in our patient. In addition to9 n1 D1 [! u# ]6 b5 q* y/ U
virilization, exposure to exogenous testosterone in2 i1 x' q" \8 D+ ^7 H4 C5 A2 w" C$ b1 c
children results in an increase in growth velocity and
. m$ e, u5 u$ n( O% P, [* jadvanced bone age, as seen in our patient.$ V- v" Q9 I+ u" Y! Q. h" p
The long-term effect of androgen exposure during" |3 E! Y- n, v  K1 Y5 Q
early childhood on pubertal development and final
  g0 z$ v/ O4 L3 Z. S7 fadult height are not fully known and always remain& _) R% y% [1 Q% J! \" L
a concern. Children treated with short-term testos-
: c% L9 l  B) o* mterone injection or topical androgen may exhibit some
3 t- ]! H; `- S1 V/ M/ D1 J; o; Q1 Yacceleration of the skeletal maturation; however, after
" B- I, w+ \/ y) s7 v+ }3 y; t6 f$ P  E4 e5 xcessation of treatment, the rate of bone maturation
# z8 ^4 M& k  A7 k2 `/ @3 W8 ndecelerates and gradually returns to normal.8,9
- O$ N: M: b! @7 `$ K0 }There are conflicting reports and controversy: }( S3 H) }4 @9 a( u
over the effect of early androgen exposure on adult
) U2 r  Q9 L) a( H0 Vpenile length.10,11 Some reports suggest subnormal
9 F( A% @8 x' k- j3 _adult penile length, apparently because of downreg-
" X* N% _: E" s' Q7 Iulation of androgen receptor number.10,12 However,
4 h8 q  U) X9 f, |Sutherland et al13 did not find a correlation between# d7 H9 C# x; M. L6 N
childhood testosterone exposure and reduced adult! X" p! M$ G" }; J5 |9 |
penile length in clinical studies.
& H: \7 u% X% q! }* r+ o0 ]Nonetheless, we do not believe our patient is
3 Y+ a$ M7 ^  U# w! r% L3 [- u1 ?going to experience any of the untoward effects from
/ K+ S5 r+ \# `$ C6 Z# x: u7 _- Ltestosterone exposure as mentioned earlier because) v! g* X: y# j% o' I' ]
the exposure was not for a prolonged period of time.
- ^0 h2 |) ~  _+ _Although the bone age was advanced at the time of
6 j8 c1 j% V, |- i6 x6 a/ h. sdiagnosis, the child had a normal growth velocity at
6 ?* u0 Q) I" r7 d! b" `8 F9 [the follow-up visit. It is hoped that his final adult  z4 }. g. e3 G  x6 S% Q, O1 b
height will not be affected.
4 v, j  {/ ^# G6 V3 G* OAlthough rarely reported, the widespread avail-
7 K' O7 n+ w% h5 J, M6 p! Zability of androgen products in our society may
( x2 W. a' D: D$ C/ dindeed cause more virilization in male or female7 D( Y4 e  }: B0 E
children than one would realize. Exposure to andro-# E5 p- w, V2 M6 G6 e
gen products must be considered and specific ques-
9 Q0 Z; t. C) \' r" |tioning about the use of a testosterone product or
; V  E2 c5 ?9 sgel should be asked of the family members during* X! h/ D6 w9 s, H( g+ j
the evaluation of any children who present with vir-8 J! ]; i2 f9 Y
ilization or peripheral precocious puberty. The diag-' J5 m& F& u& d% Q4 w" O3 n
nosis can be established by just a few tests and by7 V- T4 T+ f2 C* Z
appropriate history. The inability to obtain such a
. g& o3 U2 x# S7 f5 Yhistory, or failure to ask the specific questions, may
9 N- h$ V6 E7 ~: j; rresult in extensive, unnecessary, and expensive4 g' u+ o! a3 U% J
investigation. The primary care physician should be7 O: ~* y  K' K) m
aware of this fact, because most of these children
5 Y$ @8 t% h) a1 r: i. p5 o* {may initially present in their practice. The Physicians’, p, V% t9 |; Q" l0 I% g9 `2 U
Desk Reference and package insert should also put a/ ~8 F1 [, ?  b/ r4 L. X
warning about the virilizing effect on a male or
4 L/ b) J7 a# g6 K$ M$ efemale child who might come in contact with some-5 L+ k( m: X: H7 b, P* p' H
one using any of these products.
$ S& [1 d" K& }' rReferences9 c! W- h# u$ o8 q) T. z
1. Styne DM. The testes: disorder of sexual differentiation- p; M; O- }% s1 J1 S
and puberty in the male. In: Sperling MA, ed. Pediatric6 ~5 @- L  S# B5 c) R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 {; t: D# U8 c) H2002: 565-628.
6 R& P$ G& p, V+ G" T9 G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' \, N* w  _- upuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& `6 ~5 \3 _- C0 Z9 k7 a+ a- ABoy Induced by Indirect Topical
' a" }0 h9 E9 @Exposure to Testosterone
  K" y9 X6 i: ~) }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* v* d8 o% u# p7 |, ?. ^+ l: [! zand Kenneth R. Rettig, MD12 z; C% X5 Q! a4 d
Clinical Pediatrics
& {% @6 g$ }; E' _. S+ A, rVolume 46 Number 6
$ v" [" b- k+ B* M/ KJuly 2007 540-543
3 J* w9 ]$ X( B: |+ {© 2007 Sage Publications
- q( r1 A8 N+ \: d10.1177/0009922806296651
4 c- c  w% }: P1 I0 C" T* Uhttp://clp.sagepub.com2 O8 U5 r3 Q+ {6 v( U1 u2 E
hosted at* j: y! ?& m; _& ]
http://online.sagepub.com8 _) J7 U9 Y, o8 `4 P6 `
Precocious puberty in boys, central or peripheral,
, A$ G0 ^9 s* f: ~9 u; z( W$ Zis a significant concern for physicians. Central
5 j  S+ X$ F% C6 K+ Rprecocious puberty (CPP), which is mediated
. s' G( U4 O/ ~* ~6 dthrough the hypothalamic pituitary gonadal axis, has
  N" _2 B( q7 {% x0 K6 Oa higher incidence of organic central nervous system5 w$ n0 Y% p- |: s, S
lesions in boys.1,2 Virilization in boys, as manifested
  f" D3 q' @9 o% t+ a6 @by enlargement of the penis, development of pubic6 R: `' a7 R. l8 n( `9 H$ `+ u4 ~
hair, and facial acne without enlargement of testi-
# B0 S# _: p" G3 ecles, suggests peripheral or pseudopuberty.1-3 We
6 [- U7 C. ~+ o# u# L1 p" Treport a 16-month-old boy who presented with the
! T6 i  Y8 _! `  Renlargement of the phallus and pubic hair develop-
; |5 S+ E3 |- q& q+ L3 P0 oment without testicular enlargement, which was due
. E+ }$ x1 {- O1 uto the unintentional exposure to androgen gel used by
2 ]5 D* Z# I8 u" @- Y1 P3 }1 X: rthe father. The family initially concealed this infor-% R) k! R  q4 {- A  N  _* c& |* T1 f
mation, resulting in an extensive work-up for this( q# W: E/ k# x$ ^: X& A
child. Given the widespread and easy availability of/ B3 t! ]5 X% f" K/ W5 E9 ~6 f
testosterone gel and cream, we believe this is proba-
( N3 d8 N' D7 f$ X) ?3 Nbly more common than the rare case report in the: k. k# g+ O7 ^' S. C5 o
literature.49 r! P: @  E4 {$ Z. W
Patient Report0 {$ Y- }) R5 u3 g
A 16-month-old white child was referred to the
+ K% s  k' y3 u) s/ Cendocrine clinic by his pediatrician with the concern6 z6 q; D5 X  @
of early sexual development. His mother noticed
" t8 ~. s' P# T: ]light colored pubic hair development when he was( y6 F# B! m) l# }+ p
From the 1Division of Pediatric Endocrinology, 2University of- q, {8 Q. ?/ U' s8 C
South Alabama Medical Center, Mobile, Alabama.
9 x( @$ Z* g% }* c5 fAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ {5 M7 x; m& t% B& I$ z* e* f  @' NProfessor of Pediatrics, University of South Alabama, College of
( R1 `+ @& ]- [5 z* TMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 I  D" G! X: F6 A2 Ae-mail: [email protected].1 R% {& s0 U9 G4 M
about 6 to 7 months old, which progressively became. U8 V4 b$ u" {6 B' ?
darker. She was also concerned about the enlarge-
9 m5 P4 A( H4 j. Qment of his penis and frequent erections. The child, o: C1 G* [4 q& V( i2 W
was the product of a full-term normal delivery, with
- H+ I' M- \* T( X; J% S2 M  c* xa birth weight of 7 lb 14 oz, and birth length of9 L! N- {9 V; s/ z9 d
20 inches. He was breast-fed throughout the first year) Y- p7 ]) t4 z! a
of life and was still receiving breast milk along with
  N1 M3 f' c, T: a) t1 m3 ?8 b  X  v. R9 h4 ]solid food. He had no hospitalizations or surgery,
# o! w/ a' Q; l1 @and his psychosocial and psychomotor development
5 Z2 r" q4 O9 ]; ~9 H- bwas age appropriate.3 _2 L- l2 H* N- g
The family history was remarkable for the father,( s4 g6 U# m1 g+ x
who was diagnosed with hypothyroidism at age 16,9 c) t/ e( I: q% P, g  H% N
which was treated with thyroxine. The father’s
3 i2 k- t& ]5 O! i  w2 o  @height was 6 feet, and he went through a somewhat
; l+ {( V* J/ @! fearly puberty and had stopped growing by age 14.
/ o7 z% R' r6 \$ r7 h3 W& KThe father denied taking any other medication. The9 w" s3 ~4 `2 x! w+ o" E- X  n
child’s mother was in good health. Her menarche* H' _/ x7 W( ~8 B5 y$ @
was at 11 years of age, and her height was at 5 feet
1 h  S/ y" R% P& q- R* k% i5 inches. There was no other family history of pre-
5 S9 d4 H! Y' e+ C* tcocious sexual development in the first-degree rela-$ f5 j5 Y0 A; p: X2 H$ S
tives. There were no siblings.7 Y$ @% s: d* c5 J7 a
Physical Examination
4 b3 v% y- y, {, B; `5 iThe physical examination revealed a very active,7 N7 \$ p1 K1 |- Q& @
playful, and healthy boy. The vital signs documented) p) }8 L& ~/ C$ I$ e+ g7 Z: E
a blood pressure of 85/50 mm Hg, his length was
! q* ~3 P! M4 w5 [) X90 cm (>97th percentile), and his weight was 14.4 kg
; ?+ l$ ]5 R, b  e(also >97th percentile). The observed yearly growth% a% `1 o/ p2 O* G6 v. c
velocity was 30 cm (12 inches). The examination of
4 N0 x9 l, u5 _the neck revealed no thyroid enlargement.4 S, M4 M8 }5 W3 y, g" U+ F
The genitourinary examination was remarkable for
4 Z5 t+ z+ [* r$ lenlargement of the penis, with a stretched length of% e4 J# F# n( J+ V7 ?: B! @* }  l
8 cm and a width of 2 cm. The glans penis was very well
( Y: F( B0 ^+ M5 X5 b! Rdeveloped. The pubic hair was Tanner II, mostly around9 l3 P% @2 r1 S5 ]2 L
540# n3 Y4 W8 k- F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 ]6 }! B+ Z, ^+ q2 Qthe base of the phallus and was dark and curled. The1 _; i0 t* U& r9 W) \
testicular volume was prepubertal at 2 mL each.5 }4 \- H. t, ?3 W$ u1 Q
The skin was moist and smooth and somewhat5 z9 |( @" R6 I& e! K
oily. No axillary hair was noted. There were no
9 ^: ?' H; a# n0 J- t* Aabnormal skin pigmentations or café-au-lait spots.0 w. u/ y) t4 g* M% a5 c
Neurologic evaluation showed deep tendon reflex 2+. @6 ^8 X7 _, d! T* A1 W
bilateral and symmetrical. There was no suggestion. A$ X/ N6 A" b4 k9 @6 o
of papilledema., {4 Z/ p6 i& d1 O' A
Laboratory Evaluation
6 |* a" B7 |9 D8 ?% s6 eThe bone age was consistent with 28 months by' c( \" B) J8 d4 y; s# L
using the standard of Greulich and Pyle at a chrono-/ [- v2 {2 |8 o) t/ d9 t1 k
logic age of 16 months (advanced).5 Chromosomal
) `$ \) @' d. C/ O* d8 s! Ukaryotype was 46XY. The thyroid function test# \  p# Y% \) }+ ^& l5 Y3 @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, |& T6 W: w( }4 c7 b6 q
lating hormone level was 1.3 µIU/mL (both normal).
; N1 U! I8 c1 [The concentrations of serum electrolytes, blood
+ C$ Z' I/ {7 q, l" f- r0 furea nitrogen, creatinine, and calcium all were+ {; J. I  I: K2 x- V% f
within normal range for his age. The concentration
7 U/ d; h0 Q# ?. m- T; O- @5 [of serum 17-hydroxyprogesterone was 16 ng/dL. g; e4 V: k& j# ~
(normal, 3 to 90 ng/dL), androstenedione was 20% Q9 Q- _; n% x& i
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ u% \6 L; X/ W; `+ T6 \8 Z# K$ _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) g1 g, Z  I+ ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 T- z- [2 o! K$ n
49ng/dL), 11-desoxycortisol (specific compound S)
8 y9 @+ y. G$ Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 ?: `0 |2 W9 V# ]+ ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# A: Z; d; |: t  y; s' E. [" ?" _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 O  |( ?$ M8 |' K( Rand β-human chorionic gonadotropin was less than
7 V8 T/ ]6 b) J2 n8 V5 mIU/mL (normal <5 mIU/mL). Serum follicular4 W/ X# x$ P$ E7 C: T$ g
stimulating hormone and leuteinizing hormone
- L4 }1 L& M- s4 y( tconcentrations were less than 0.05 mIU/mL+ b& |: [  j7 D" i( Y1 Z, L
(prepubertal).
0 O2 m: C/ Y+ ]7 x) N$ jThe parents were notified about the laboratory- j' g+ T. j! d' }( Q' H3 D1 I8 m
results and were informed that all of the tests were8 v' F# E& u2 N. {' I2 N
normal except the testosterone level was high. The/ [  _+ @* A# c# q6 e* b
follow-up visit was arranged within a few weeks to' ?5 Z3 Z1 C5 t3 Y
obtain testicular and abdominal sonograms; how-
  g% H+ ]% G& m2 O( lever, the family did not return for 4 months.! G: @, F: w! ~, O0 C
Physical examination at this time revealed that the" O3 w! \* m6 ~& _
child had grown 2.5 cm in 4 months and had gained$ k: O; b" c: C6 [8 H
2 kg of weight. Physical examination remained+ J" B& o+ @8 k6 @3 ]: P9 B
unchanged. Surprisingly, the pubic hair almost com-
  a6 @2 G3 j9 U7 w$ u4 {pletely disappeared except for a few vellous hairs at. C3 N4 g$ e: H$ E8 P: S
the base of the phallus. Testicular volume was still 2' s( Y8 j- n/ X) b* \8 H0 u. Q8 M! S
mL, and the size of the penis remained unchanged.: G  Q( a/ N9 g- a( U
The mother also said that the boy was no longer hav-
) |5 K+ g, }' E' Ring frequent erections.
# Z  M5 R9 Q0 ABoth parents were again questioned about use of% b; B9 l) q: G3 T' O; [
any ointment/creams that they may have applied to- v4 ]  s" f% d- e
the child’s skin. This time the father admitted the
5 F1 E0 l7 }- T( |% l$ f5 S4 tTopical Testosterone Exposure / Bhowmick et al 541: _& ]" B; W8 y5 H! j# m* _
use of testosterone gel twice daily that he was apply-
1 x( c1 s& s' t# {% G0 E) ning over his own shoulders, chest, and back area for
2 s  s/ a7 t+ v' F" ]% K' Ua year. The father also revealed he was embarrassed
, y, u" R3 y& u- lto disclose that he was using a testosterone gel pre-# v' D8 I2 S* a
scribed by his family physician for decreased libido
3 L; E: x2 D7 _( n+ d: Wsecondary to depression.
' Q: X3 D- M3 x7 ]' SThe child slept in the same bed with parents.% \' Z" E- r. M( V; h/ ^
The father would hug the baby and hold him on his
2 H7 u+ F: c- l! Nchest for a considerable period of time, causing sig-
! u# O; t' @! O! m  \9 Y  Knificant bare skin contact between baby and father.
0 v& U* F2 U+ `! f6 M& Z: eThe father also admitted that after the phone call,
- D* t4 x2 S+ M. swhen he learned the testosterone level in the baby# t3 |( T7 k% f2 z* t0 X5 H! p1 W. k* F
was high, he then read the product information
5 w1 E& j7 i8 q9 upacket and concluded that it was most likely the rea-
" K: {% \% m- j/ L4 I" d8 nson for the child’s virilization. At that time, they
4 W* U) k2 H% T% U5 Jdecided to put the baby in a separate bed, and the0 \4 r5 l! _1 N" k  I0 @
father was not hugging him with bare skin and had1 r) ~' D4 A. i5 |9 c7 K$ |3 f
been using protective clothing. A repeat testosterone! D" k  b& e( d" o& B. ]& A; k
test was ordered, but the family did not go to the6 P( l$ @/ m6 L
laboratory to obtain the test.
7 C4 i7 P$ f8 G( PDiscussion
) o8 Y4 [( m. t. m  ~Precocious puberty in boys is defined as secondary
6 |' Q8 \# s. [5 l6 W6 }sexual development before 9 years of age.1,4
5 j- j. n5 S$ H4 a$ oPrecocious puberty is termed as central (true) when$ [' P2 B7 S2 e$ u0 n
it is caused by the premature activation of hypo-
' _$ g2 a) ~8 G% c& ?  athalamic pituitary gonadal axis. CPP is more com-
* G3 U3 B& w) u0 X8 z  |, Q- Gmon in girls than in boys.1,3 Most boys with CPP
7 R# x8 i, f/ K6 n. f$ Qmay have a central nervous system lesion that is
3 h: y0 d9 G. Kresponsible for the early activation of the hypothal-' W) |$ V7 r+ x( d$ C" n
amic pituitary gonadal axis.1-3 Thus, greater empha-3 d- b( m; e7 i  l( a! A7 p
sis has been given to neuroradiologic imaging in
2 Q& C% U0 P" j; ?9 j+ Vboys with precocious puberty. In addition to viril-
$ J' _5 m) o+ p( X6 P0 ]ization, the clinical hallmark of CPP is the symmet-
- \4 S" h1 V3 t3 g: o2 P. rrical testicular growth secondary to stimulation by% D: f: d& P6 X3 c# }  @
gonadotropins.1,3# e: U, `% Q" c2 D, [9 C+ ~
Gonadotropin-independent peripheral preco-
# C! Z, V) k; i! p8 Bcious puberty in boys also results from inappropriate/ B7 c2 W+ i5 ]4 x- T1 D
androgenic stimulation from either endogenous or
0 \2 D  V1 |8 [+ T# m' V, S6 ^exogenous sources, nonpituitary gonadotropin stim-" m1 e/ K8 d" X4 n9 t
ulation, and rare activating mutations.3 Virilizing- c* A4 |+ V; l+ z
congenital adrenal hyperplasia producing excessive
0 {0 \6 v! @0 E( i4 B% ?adrenal androgens is a common cause of precocious( G! U6 h& W( ?* ~8 \3 {/ ]3 {: t$ O1 E
puberty in boys.3,4# x; C, \& E# y" L( v( Q; P
The most common form of congenital adrenal0 G( r* e9 o. i( R6 I
hyperplasia is the 21-hydroxylase enzyme deficiency.4 q7 H$ j" k* w% c, v
The 11-β hydroxylase deficiency may also result in7 I% p1 B' S) }
excessive adrenal androgen production, and rarely,
' z$ \8 l. F% Dan adrenal tumor may also cause adrenal androgen, F' u9 e8 l4 |0 w' w
excess.1,3
6 w7 |8 f8 j- @+ Q" \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# B7 V2 @8 P$ S$ x
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' ?3 U& F2 ~- V2 e' C
A unique entity of male-limited gonadotropin-
, A( L. s- S% d4 a4 e4 Hindependent precocious puberty, which is also known) x/ ]6 i- b1 c& Z) h
as testotoxicosis, may cause precocious puberty at a4 ]3 M  A6 t* t) h' n: \! n
very young age. The physical findings in these boys
1 e; H" @" V7 awith this disorder are full pubertal development,
* _9 o# C6 @0 b) O' [6 M/ q- V% m! c7 gincluding bilateral testicular growth, similar to boys
9 ]' H+ _$ G* z* U0 e$ O, Owith CPP. The gonadotropin levels in this disorder* O( I0 f' I+ s% C7 F$ |, K; o
are suppressed to prepubertal levels and do not show4 f' Z5 m4 z- z. Q2 U* Z+ v. q
pubertal response of gonadotropin after gonadotropin-0 z! |. T6 j; K4 i8 w
releasing hormone stimulation. This is a sex-linked
0 G( Y" O- j% cautosomal dominant disorder that affects only7 S8 U4 d/ I6 J2 |  U4 x
males; therefore, other male members of the family
. u3 o# G4 X, k* ?' jmay have similar precocious puberty.3
3 R  h/ z6 Q0 e  H+ z7 HIn our patient, physical examination was incon-6 V" o. T2 \& c; x0 H2 a
sistent with true precocious puberty since his testi-
: g4 @- u/ @" L9 Ocles were prepubertal in size. However, testotoxicosis
8 _( n9 R1 B. ^was in the differential diagnosis because his father. Z: _# @% E  V" v7 L$ X, |4 [
started puberty somewhat early, and occasionally,/ n9 |( Y6 ^2 t/ j2 ^6 k
testicular enlargement is not that evident in the
9 E6 t$ S4 c: y8 ebeginning of this process.1 In the absence of a neg-
. x/ ~) P4 w. q; x  vative initial history of androgen exposure, our2 r% o3 ]8 W6 Q# v# H: S8 V
biggest concern was virilizing adrenal hyperplasia,8 W& w; O9 k& {! t9 p
either 21-hydroxylase deficiency or 11-β hydroxylase: {0 S$ j$ l  u) J+ X
deficiency. Those diagnoses were excluded by find-" u, f; c0 u1 K7 z8 c& g
ing the normal level of adrenal steroids.
$ I7 |& N$ c8 O4 Z$ a& ^$ [The diagnosis of exogenous androgens was strongly
' G- p5 T. t/ D2 o6 k3 xsuspected in a follow-up visit after 4 months because
9 n% j3 b5 T3 |% K) X) I; r7 vthe physical examination revealed the complete disap-
5 ~) K  z) A: V4 m) Y$ r8 fpearance of pubic hair, normal growth velocity, and
& }- M7 y6 m0 N0 Z" B2 O/ X9 kdecreased erections. The father admitted using a testos-4 a. `* b* \+ ^% C
terone gel, which he concealed at first visit. He was2 {* f  P$ N9 [
using it rather frequently, twice a day. The Physicians’5 n" y8 |. [0 b7 i2 E/ w  S3 J! D
Desk Reference, or package insert of this product, gel or  K  X. C0 t' v: v, O
cream, cautions about dermal testosterone transfer to
. l! m0 V4 w$ gunprotected females through direct skin exposure.
+ ?8 h8 _1 I* qSerum testosterone level was found to be 2 times the# A/ F: M  P0 S, [, v. g
baseline value in those females who were exposed to+ y7 X! o# l" x! N2 k9 m. I# [+ ^/ z
even 15 minutes of direct skin contact with their male6 F" K& k3 n  K7 M$ p; x; C2 H$ o
partners.6 However, when a shirt covered the applica-
$ k# W. A9 o* Xtion site, this testosterone transfer was prevented.5 @. v4 L, y$ h+ B& ?
Our patient’s testosterone level was 60 ng/mL,+ j/ x" W# T' G3 [
which was clearly high. Some studies suggest that6 X2 w& B' s& o
dermal conversion of testosterone to dihydrotestos-) x! S" R4 @+ |/ N; Z, W( _: y
terone, which is a more potent metabolite, is more
4 S% E6 y0 \! J' @  sactive in young children exposed to testosterone; z- X% I1 S  M
exogenously7; however, we did not measure a dihy-3 h, G& Z; I0 D5 p; i
drotestosterone level in our patient. In addition to8 M" H: e1 s; a' A& m0 I% C3 r. B
virilization, exposure to exogenous testosterone in
; W, C2 U  _2 |% ]! d8 Dchildren results in an increase in growth velocity and
# Z6 a) }( Z5 o# |+ \advanced bone age, as seen in our patient.
3 c* g& w3 g* ]/ z) G$ tThe long-term effect of androgen exposure during0 K' @- o6 V$ Q/ L
early childhood on pubertal development and final
5 D6 d2 R' H- a) C# Qadult height are not fully known and always remain: Q2 @* q) a" p+ q/ @' L/ O
a concern. Children treated with short-term testos-: w  ~! V1 t. g" O
terone injection or topical androgen may exhibit some
& M) W$ u  f" F; X4 u( ~2 Facceleration of the skeletal maturation; however, after, J: _8 S% ~+ Z  V+ H" H) g
cessation of treatment, the rate of bone maturation$ \" ~% u! x1 b3 I) D" c
decelerates and gradually returns to normal.8,9
6 H/ S$ Y  J: MThere are conflicting reports and controversy
/ t! P9 c9 s; N: c7 d- Y$ _7 bover the effect of early androgen exposure on adult
8 P  b) s* S4 j/ {7 rpenile length.10,11 Some reports suggest subnormal) P3 p8 P) p, m0 X% c
adult penile length, apparently because of downreg-
1 r" M' T) s7 u' z7 lulation of androgen receptor number.10,12 However,. \/ p& j) i( X3 u
Sutherland et al13 did not find a correlation between4 G: P" K& D  F
childhood testosterone exposure and reduced adult2 A: Y- i+ `7 z
penile length in clinical studies.4 K$ W9 G( Q( B2 ~+ m) g
Nonetheless, we do not believe our patient is
# t) R" A% i5 t3 X# X/ ?going to experience any of the untoward effects from
; v. Q( f4 D( ^8 u, d+ ntestosterone exposure as mentioned earlier because5 D7 p. ?+ _+ M9 ^8 {+ V# b
the exposure was not for a prolonged period of time.
, N; c! I7 w+ h  SAlthough the bone age was advanced at the time of/ s: u) e2 u! @# I. \" E# Y
diagnosis, the child had a normal growth velocity at3 T: O5 S) s( d, |
the follow-up visit. It is hoped that his final adult. N( W" C, t$ ?6 _
height will not be affected.9 B& ?: A+ U, S1 X' P# W
Although rarely reported, the widespread avail-
7 Q% m1 R& W9 wability of androgen products in our society may% M- s3 M+ N- ?( q& M" b
indeed cause more virilization in male or female! S. r. G+ i+ Q, G% I
children than one would realize. Exposure to andro-
: I$ v# `) E/ D- R+ p% [; Cgen products must be considered and specific ques-1 f' P- N4 e' U, J9 k5 b% S
tioning about the use of a testosterone product or
5 z$ k' m8 w8 {+ w0 N4 x1 Cgel should be asked of the family members during
' F4 X2 c8 ], [& y: \! g* Zthe evaluation of any children who present with vir-
( F8 H' c2 G; t' w% L( b% qilization or peripheral precocious puberty. The diag-
+ P! a+ Y8 |, Q- p) l1 Z9 Y- Xnosis can be established by just a few tests and by: b) j- U" J8 `, O9 ^$ c
appropriate history. The inability to obtain such a
7 z8 m( ~# J  thistory, or failure to ask the specific questions, may
/ C" ~( ]9 g8 @) q& Nresult in extensive, unnecessary, and expensive9 H- X, e) |: W- [
investigation. The primary care physician should be
6 v- u1 ]/ \' d; O) X2 N5 aaware of this fact, because most of these children* W. q/ l+ X3 _. d9 ]
may initially present in their practice. The Physicians’  [+ e& L. w1 s7 v
Desk Reference and package insert should also put a
1 S  Z" [* X% C: r4 r, pwarning about the virilizing effect on a male or! O7 W7 v& e3 D0 E6 y3 X% @$ Z
female child who might come in contact with some-, m. u4 L$ S1 b% N+ R
one using any of these products.
4 P6 }; u6 `# s* k0 w2 zReferences: b% f6 q% ?- d9 R  P; I6 @/ }
1. Styne DM. The testes: disorder of sexual differentiation% H' g& s+ Z2 l% H/ [. g
and puberty in the male. In: Sperling MA, ed. Pediatric
- E6 H( G  ]1 i9 E, I3 IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  p7 \8 n) ~( `7 T) J5 a' Y) L
2002: 565-628.  g, \! U/ c4 \$ E  @6 @
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, N8 b9 F: f. Kpuberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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

, P7 C6 d  |8 a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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