WK綜合論壇, WK综合论坛

 找回密碼
 立即注册
樓主: wk007

鄉下的妹子太便宜,一次四個都要了[12P]

[複製鏈接]
發表於 2025-1-4 03:25:35 | 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
Sexual Precocity in a 16-Month-Old
& Y9 B/ h3 P) W0 |* B+ t& D) b2 fBoy Induced by Indirect Topical. Z+ y7 w6 Y; ]
Exposure to Testosterone7 U2 d2 b1 a+ w% ^  N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 n! P/ r2 ^5 T5 q$ [+ i
and Kenneth R. Rettig, MD1
5 \( l; h0 ]+ n& q- }5 d8 `Clinical Pediatrics- B1 `5 x6 A; B! C% b  a4 p; {% [
Volume 46 Number 6
$ I3 D5 a. J3 c& r; i1 u4 d8 ZJuly 2007 540-543
; E& x% ?% [# O7 M4 G© 2007 Sage Publications6 L' S" W# ~1 u
10.1177/0009922806296651
( E. Y2 @; d0 M. F; Rhttp://clp.sagepub.com
7 d0 c, |% W6 Mhosted at( o8 J3 J+ F7 E' L
http://online.sagepub.com! o- h2 ^) d8 e1 R2 w
Precocious puberty in boys, central or peripheral,
! H0 S0 C  S3 I4 z* t* s% ?4 }% cis a significant concern for physicians. Central
5 Y2 B  `0 B7 ]2 m3 }: d- Hprecocious puberty (CPP), which is mediated( c: R+ D* O1 u- W6 X  w
through the hypothalamic pituitary gonadal axis, has* @$ R+ I1 @  D
a higher incidence of organic central nervous system! |% r/ Q# k/ v# {6 y% I
lesions in boys.1,2 Virilization in boys, as manifested
3 K2 H9 _. l: j* R" y" Wby enlargement of the penis, development of pubic- E* f1 G# Q0 Y$ K5 g1 c3 @% l
hair, and facial acne without enlargement of testi-7 Z" I7 x2 e$ l0 A- M1 R( K" k. _
cles, suggests peripheral or pseudopuberty.1-3 We
0 J. ], P& w0 U/ ireport a 16-month-old boy who presented with the
& J- ?& _! T  ]* q( f% \* Genlargement of the phallus and pubic hair develop-+ \. H. t- r5 g0 S: Y. ~
ment without testicular enlargement, which was due. V, i; @0 N! H, i& L+ X
to the unintentional exposure to androgen gel used by
  ?3 d; Q) U3 R0 S! x" ]( [$ ~the father. The family initially concealed this infor-: H6 P% A9 l8 n- R3 i7 m2 b2 q
mation, resulting in an extensive work-up for this
/ {* a5 x$ K6 `2 b+ ichild. Given the widespread and easy availability of
" f, x2 W, f# D* Etestosterone gel and cream, we believe this is proba-
; m% E8 b; _1 n! {$ Lbly more common than the rare case report in the$ _7 U* O/ l8 z7 G
literature.42 {/ d2 F; h+ U$ d7 |
Patient Report
, W, e: ?$ n0 mA 16-month-old white child was referred to the0 ~3 |% ~2 ]( z  u7 S2 p+ p$ l: d
endocrine clinic by his pediatrician with the concern5 j3 @' s8 N( H0 o, T- C, W; P( }- N
of early sexual development. His mother noticed. Y5 T6 ]5 p& U6 p, V/ z" P6 Y
light colored pubic hair development when he was. k. R* ^: t4 s9 b: h8 c
From the 1Division of Pediatric Endocrinology, 2University of4 f% d/ g1 m0 U2 l9 `: I8 B/ j. G
South Alabama Medical Center, Mobile, Alabama.
+ k) k( Z  m& D( O4 YAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# S; x0 E# z0 h# n$ ^4 P. W% ZProfessor of Pediatrics, University of South Alabama, College of
7 E& H# w. B* o  R2 w, m/ `& ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 F. Q# F8 E% I" J, h! @e-mail: [email protected].( s* d5 e7 E: i8 t6 \& d
about 6 to 7 months old, which progressively became
" j( [+ R0 m2 ydarker. She was also concerned about the enlarge-
& n  s2 W1 }+ S5 T9 sment of his penis and frequent erections. The child
  c) @% ^2 W8 {' W. [: D  k+ n1 h+ K9 \was the product of a full-term normal delivery, with
  @. ~8 r& `  ea birth weight of 7 lb 14 oz, and birth length of' i: \3 B- W4 t/ C  t& B, f5 D, P7 r, {
20 inches. He was breast-fed throughout the first year- a2 `0 {9 g6 I2 F/ s7 g+ s
of life and was still receiving breast milk along with
5 {0 q+ A/ J; R5 hsolid food. He had no hospitalizations or surgery,& r  z/ \: p4 `
and his psychosocial and psychomotor development
0 A' p1 R. a! C! p  d2 Q4 m/ kwas age appropriate.
+ ]0 j/ n0 X6 \8 ?, c& i# {The family history was remarkable for the father,
8 X6 ~- ]5 Q8 O7 Uwho was diagnosed with hypothyroidism at age 16,
' s( m8 E& h* Ywhich was treated with thyroxine. The father’s
$ `1 t' m% `/ s4 u: r5 yheight was 6 feet, and he went through a somewhat' T' e$ w9 Y- L3 a
early puberty and had stopped growing by age 14.8 m1 w. ?! }  W
The father denied taking any other medication. The6 N5 O: {9 p! X5 J9 i5 F
child’s mother was in good health. Her menarche7 V* D3 i% x6 S- ^$ z8 t4 c- A
was at 11 years of age, and her height was at 5 feet* \6 ^, G" w* \
5 inches. There was no other family history of pre-. I/ |& }9 I7 g7 C  }5 _& K
cocious sexual development in the first-degree rela-8 v" V% T/ n+ g2 ]  {# `
tives. There were no siblings.
; O) a6 ~- V  c7 h/ p; hPhysical Examination$ x! V$ ^- D8 `
The physical examination revealed a very active,  X. a  H6 A+ \  K% J& w
playful, and healthy boy. The vital signs documented& d' g5 I  N# u1 N3 R2 {
a blood pressure of 85/50 mm Hg, his length was
* T3 `4 H! k" s! G90 cm (>97th percentile), and his weight was 14.4 kg8 c' A$ R3 ~4 E  J. ~0 B. ~' h% v
(also >97th percentile). The observed yearly growth! e6 B0 h' T4 s- q1 e
velocity was 30 cm (12 inches). The examination of& l- l4 ?6 j3 K# r* N( {2 s
the neck revealed no thyroid enlargement., X2 x; ^  Z% t' K8 o/ F2 V
The genitourinary examination was remarkable for6 U: g% a$ D3 x9 ~0 G1 p
enlargement of the penis, with a stretched length of
  d1 A0 F& [/ J$ X, e- d8 cm and a width of 2 cm. The glans penis was very well+ ~3 ^' A( f  x
developed. The pubic hair was Tanner II, mostly around9 ]  J" T& P4 x" |
540
; s4 d. G! E3 J. K4 T# j3 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: _/ K# i# ]3 w' g3 b% ~! kthe base of the phallus and was dark and curled. The
7 [; X7 v0 E  ytesticular volume was prepubertal at 2 mL each.
5 ~1 A- h0 g8 O! `The skin was moist and smooth and somewhat
8 ?- G' p" X6 Zoily. No axillary hair was noted. There were no2 g& ~% I: `2 G) ~' H
abnormal skin pigmentations or café-au-lait spots.
* {& k, f+ u& h& U1 _  sNeurologic evaluation showed deep tendon reflex 2+* N, h- A' J, n7 O; u
bilateral and symmetrical. There was no suggestion
3 S2 Q# U8 |5 x* P" w2 S1 Cof papilledema.
+ n. |  y- ~. T+ r( y, i; ^Laboratory Evaluation
6 d4 Y0 n7 p3 r- G% O: WThe bone age was consistent with 28 months by
2 U- ^+ M) C  h2 F/ }, Husing the standard of Greulich and Pyle at a chrono-
4 A8 Y8 l6 Q1 W3 T$ `logic age of 16 months (advanced).5 Chromosomal- x2 k7 L! F1 x6 _$ t
karyotype was 46XY. The thyroid function test
+ G2 t4 y( |; c. I; g$ lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! o( x" V* \3 \+ M2 m" l. Alating hormone level was 1.3 µIU/mL (both normal).
+ p: m3 i+ D6 K" L/ }2 oThe concentrations of serum electrolytes, blood
- l7 V2 i# n0 r& `: E$ Xurea nitrogen, creatinine, and calcium all were
, r# m' Z' g% `; o8 Cwithin normal range for his age. The concentration, P( L( N( e) B% i# ?6 P, |1 L
of serum 17-hydroxyprogesterone was 16 ng/dL# H+ y0 ?) [& r5 Y% v; x) k4 w
(normal, 3 to 90 ng/dL), androstenedione was 20: \9 F- j5 H; g9 t3 N) _$ k: o( G0 k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! T& o# O9 T$ N- Pterone was 38 ng/dL (normal, 50 to 760 ng/dL),2 @, v4 g- }" [! d# m! w" U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 j9 h! |. |) l0 y5 [5 P49ng/dL), 11-desoxycortisol (specific compound S): N2 A4 @. R1 F% j3 @: |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: v3 J, C7 Y7 S1 p0 F7 q9 y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 t3 \+ T, j4 C) o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% ]  n; ?$ W6 c+ a1 g& @$ Nand β-human chorionic gonadotropin was less than9 e% _% v- v( t9 Z- [
5 mIU/mL (normal <5 mIU/mL). Serum follicular, X# }8 c5 z9 d
stimulating hormone and leuteinizing hormone  F) @3 t+ E) U5 E5 v. `
concentrations were less than 0.05 mIU/mL
! _( r* d- Z6 D7 F$ V(prepubertal).% L/ K8 j" A7 {5 `
The parents were notified about the laboratory
! Z, _, s) ?4 K  p- z% nresults and were informed that all of the tests were% B" B# A; c7 h/ d! T7 e
normal except the testosterone level was high. The
3 U" Z8 z, K3 x1 K9 X1 M( l# S. Sfollow-up visit was arranged within a few weeks to) k* A7 V3 U0 X  {; M' j. J* X
obtain testicular and abdominal sonograms; how-& u. L) F! a" w  H! a2 l8 v
ever, the family did not return for 4 months.# @" B4 C- H  r' H9 L0 Y. j
Physical examination at this time revealed that the
0 u* f1 @9 ~! n2 Nchild had grown 2.5 cm in 4 months and had gained
1 \+ b+ w! H. |6 M3 L' y2 kg of weight. Physical examination remained
* i3 w+ W/ [2 xunchanged. Surprisingly, the pubic hair almost com-
9 U+ Q" g/ i4 Opletely disappeared except for a few vellous hairs at( W6 Y& D4 U2 R. L4 E  e! e
the base of the phallus. Testicular volume was still 26 m# Y; T( B# m& n
mL, and the size of the penis remained unchanged.( {# @! D) L8 C+ Z0 s
The mother also said that the boy was no longer hav-$ s& a+ c7 n, U
ing frequent erections.1 L6 F- J! x8 U: ~( S
Both parents were again questioned about use of
* l6 f4 Z& Q+ Z+ I+ K- e5 _any ointment/creams that they may have applied to
3 o6 v8 c/ Z, w7 k1 p' K  jthe child’s skin. This time the father admitted the
7 \# x- \, V- d9 x) STopical Testosterone Exposure / Bhowmick et al 541
; ]9 C) q/ Z( y7 {( Puse of testosterone gel twice daily that he was apply-4 \% m4 a4 ]# O9 Z- l3 h) e/ b3 [
ing over his own shoulders, chest, and back area for% _3 G2 W+ H9 a# i
a year. The father also revealed he was embarrassed
1 v7 {3 W' G' m4 l4 f& Rto disclose that he was using a testosterone gel pre-
" o# U7 g9 P, b- R' J1 T7 i1 Xscribed by his family physician for decreased libido4 A- ^6 l( B0 X0 n6 y
secondary to depression.
4 u7 l8 k: o8 VThe child slept in the same bed with parents.
8 p+ c1 q6 R$ {, J9 j# q9 sThe father would hug the baby and hold him on his9 P- J. Z6 G% a
chest for a considerable period of time, causing sig-* r( X2 C/ u6 Y' X
nificant bare skin contact between baby and father.
  B! G; P  ]/ o! d. T6 tThe father also admitted that after the phone call,
( Q/ T: x- B; v( M# m' Pwhen he learned the testosterone level in the baby
3 w0 m& d' c% Z; N' v1 V3 Lwas high, he then read the product information# ?7 @7 k! S4 c; X/ S+ g0 X6 S: J- T
packet and concluded that it was most likely the rea-/ n4 V7 V/ ]# A1 J9 e$ T# v
son for the child’s virilization. At that time, they6 J6 h1 i! e6 G  z1 ]
decided to put the baby in a separate bed, and the
3 E- R* K) K  |1 l- t1 Ifather was not hugging him with bare skin and had
- C/ L1 X) @' Y# Gbeen using protective clothing. A repeat testosterone
0 h. y) o/ ?) k( A& ^! M9 p* etest was ordered, but the family did not go to the
: V2 N5 c7 ~% B* T, Blaboratory to obtain the test.
. p" t7 d& J& NDiscussion' U9 G* c5 E) L. `5 X% u
Precocious puberty in boys is defined as secondary
2 _: O; |( J2 c# G9 O' msexual development before 9 years of age.1,4
) d' S+ {8 w) D* m( K4 @Precocious puberty is termed as central (true) when
6 a4 J9 Y+ J- }9 e# mit is caused by the premature activation of hypo-) T9 e+ b( Y, |0 P& z4 y
thalamic pituitary gonadal axis. CPP is more com-( U& C# F+ N3 o& H) S+ Z0 P
mon in girls than in boys.1,3 Most boys with CPP
0 T0 M/ X4 |) n& ~, v/ |8 ymay have a central nervous system lesion that is
$ T' O- K: k* i0 u, presponsible for the early activation of the hypothal-$ ]2 N( Y9 C4 L% g% _! G, x- L
amic pituitary gonadal axis.1-3 Thus, greater empha-5 |; T( o3 ~8 U+ G8 D  V. K
sis has been given to neuroradiologic imaging in, F4 P9 p! k( g% m  F
boys with precocious puberty. In addition to viril-
& a5 A( ]% S' `% E: r+ W/ @ization, the clinical hallmark of CPP is the symmet-  T0 |3 ?2 h- J
rical testicular growth secondary to stimulation by
& j- x& G" f) P& [( ggonadotropins.1,3
2 \8 e) c0 n/ K( eGonadotropin-independent peripheral preco-7 s! q$ a9 C5 ]' h
cious puberty in boys also results from inappropriate
6 e* a) ?. W: W+ w2 N! yandrogenic stimulation from either endogenous or1 W3 r- G8 T4 O, ^( e; i3 m
exogenous sources, nonpituitary gonadotropin stim-9 _9 i' w# K: \
ulation, and rare activating mutations.3 Virilizing, L8 t6 |) i' {) I4 ?4 X
congenital adrenal hyperplasia producing excessive
9 w: A5 I2 }% `4 `: s* xadrenal androgens is a common cause of precocious. s- K! l, L/ W9 ?9 ~# \
puberty in boys.3,4
2 Z4 u# _5 i. iThe most common form of congenital adrenal/ J$ h6 f& S' h) u3 k
hyperplasia is the 21-hydroxylase enzyme deficiency.4 x2 Q! j" A4 E# u- i+ g
The 11-β hydroxylase deficiency may also result in  _9 ?. ^, p7 t4 L1 o! R0 k7 h& Z
excessive adrenal androgen production, and rarely,# V2 @/ e6 f1 y2 f) m7 ?
an adrenal tumor may also cause adrenal androgen* v2 s9 x4 I/ I. }" F
excess.1,3& w+ k! ^1 L& D( l" z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" ^( L! q9 w; ~2 a0 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 m0 ?0 p/ \' ZA unique entity of male-limited gonadotropin-
! {/ V* G1 A! D0 Uindependent precocious puberty, which is also known0 o$ g/ R2 {, V5 o
as testotoxicosis, may cause precocious puberty at a" m) A8 {4 d# s  k' p! n8 \; a
very young age. The physical findings in these boys5 A# }5 {0 u! \9 y" ~) S- `
with this disorder are full pubertal development,
& k: @% J4 z9 g1 Z1 yincluding bilateral testicular growth, similar to boys
# ?; f5 ]& G) c% ewith CPP. The gonadotropin levels in this disorder
1 S" L1 {0 I: v  h6 C, I# ]: Care suppressed to prepubertal levels and do not show$ K- `: v  L! c+ T5 y
pubertal response of gonadotropin after gonadotropin-
9 O: B. }" o/ l/ M  \8 r8 z- Yreleasing hormone stimulation. This is a sex-linked) O, h7 X& b( p. n3 U
autosomal dominant disorder that affects only5 X) Q% m: j) h( ~' n
males; therefore, other male members of the family
  v0 R1 J1 N& G* @+ z. {! u8 ]6 O* Omay have similar precocious puberty.3
: V: z% O" w2 V8 h# UIn our patient, physical examination was incon-
9 C8 K$ q( q8 }- H& W0 F+ Q% p! {sistent with true precocious puberty since his testi-6 X. i( D) ~8 v* n6 K+ ?, ~
cles were prepubertal in size. However, testotoxicosis
$ A, m& p) ?% c$ Owas in the differential diagnosis because his father* F0 K5 f; \3 J( G4 i$ g4 ^
started puberty somewhat early, and occasionally,
0 w' g1 y6 S+ vtesticular enlargement is not that evident in the$ y( ~( \* }3 P8 V3 [0 ?/ X& M
beginning of this process.1 In the absence of a neg-
/ F9 o2 O0 `# A) `; Cative initial history of androgen exposure, our4 u' {9 A/ i* T# L
biggest concern was virilizing adrenal hyperplasia,
/ J$ Z5 y: `2 ~, J! z" leither 21-hydroxylase deficiency or 11-β hydroxylase
6 G( ?% Y! ~; |$ H  A, A, xdeficiency. Those diagnoses were excluded by find-
4 E2 R* i- X9 sing the normal level of adrenal steroids.- c/ C' K+ q: t" \
The diagnosis of exogenous androgens was strongly
! `. D- Q2 }  P; hsuspected in a follow-up visit after 4 months because, o$ m& {$ m9 J
the physical examination revealed the complete disap-
( H: o  u% q9 E& h  tpearance of pubic hair, normal growth velocity, and6 k& @9 U/ D  u3 @) ^1 C
decreased erections. The father admitted using a testos-
: I$ z' @) `* T) ?  cterone gel, which he concealed at first visit. He was6 B) v! N7 n: q: d- \
using it rather frequently, twice a day. The Physicians’& n7 X" N1 k) w
Desk Reference, or package insert of this product, gel or/ o5 o: I4 w/ u1 N% o" w" @
cream, cautions about dermal testosterone transfer to
$ K7 }( j* k3 Y) V+ V9 j$ j: R# @unprotected females through direct skin exposure.
( e4 `4 B6 n& n. U8 S" XSerum testosterone level was found to be 2 times the
) Z2 k4 r6 W- I: ~baseline value in those females who were exposed to
4 u- L' S4 V2 Z2 g/ Q8 Q( Oeven 15 minutes of direct skin contact with their male
* @  x& V# G1 j* S8 {partners.6 However, when a shirt covered the applica-8 L/ m0 ?4 g% A$ S
tion site, this testosterone transfer was prevented.; R' l. l' _" H% w/ Z. z
Our patient’s testosterone level was 60 ng/mL,
/ t% b0 }# ~0 ]+ O# R7 kwhich was clearly high. Some studies suggest that0 O. \: Q$ ]' f
dermal conversion of testosterone to dihydrotestos-
4 {. P% f2 o6 u0 A; \- r; C8 |9 ~  Aterone, which is a more potent metabolite, is more* N$ x$ X9 X. j! q( f/ s# Q7 B: W
active in young children exposed to testosterone, G  E9 u7 d6 t7 N, D: L+ c5 r
exogenously7; however, we did not measure a dihy-
$ r0 N7 o5 l+ m. {4 Ldrotestosterone level in our patient. In addition to; `+ |3 i7 p3 u& k
virilization, exposure to exogenous testosterone in: f5 N, V. S4 G. T/ \5 ?' b
children results in an increase in growth velocity and
6 U6 N2 e" k5 Cadvanced bone age, as seen in our patient.
5 V, U; k. O; [* ~# O0 I. YThe long-term effect of androgen exposure during  T+ A5 V) @0 }8 Q
early childhood on pubertal development and final
, \/ X9 r8 o0 x) s9 |0 A3 nadult height are not fully known and always remain
) m: C9 |0 P) C4 m; s3 ~0 xa concern. Children treated with short-term testos-
% G# o3 i2 N- u. mterone injection or topical androgen may exhibit some
+ H, t7 X& f9 ?- K7 R4 ?acceleration of the skeletal maturation; however, after5 f2 R/ i* M' R) {% k+ @
cessation of treatment, the rate of bone maturation
) q! L$ F0 t; T* \* c7 ydecelerates and gradually returns to normal.8,9
% X! r$ c  A, i! B, UThere are conflicting reports and controversy
. V$ r9 Q2 d  y  uover the effect of early androgen exposure on adult
; T9 Y. b4 e: ?) tpenile length.10,11 Some reports suggest subnormal0 S1 N0 P6 m: E: L. K! |. X
adult penile length, apparently because of downreg-" H) G( R4 V( t* p% |( m: d1 u: q$ p
ulation of androgen receptor number.10,12 However,8 G# |2 @( A' P3 H7 J6 B
Sutherland et al13 did not find a correlation between8 ~; e# H' `; b! E0 c) ?
childhood testosterone exposure and reduced adult( x  P3 m3 W3 k4 \" d
penile length in clinical studies.
, n9 O) c5 p4 |2 aNonetheless, we do not believe our patient is
9 f6 Y' p- D" ~" Bgoing to experience any of the untoward effects from, K8 Y; [# d  o: O0 T5 B
testosterone exposure as mentioned earlier because
3 b& u( Q7 t5 l3 c; F! i3 L- [the exposure was not for a prolonged period of time.) \4 i) g4 a. K3 K: k# q) y
Although the bone age was advanced at the time of4 l: ~' d/ k& ^: N* |3 `) w
diagnosis, the child had a normal growth velocity at
" s( l7 c0 ^. B4 p2 Dthe follow-up visit. It is hoped that his final adult1 @# l1 y7 [) t
height will not be affected.
8 B: V4 n# G8 G4 M. W$ g  g% eAlthough rarely reported, the widespread avail-
9 ^1 S7 |" Q9 Q6 ?9 {' ^ability of androgen products in our society may& s6 t' `4 X" @5 I' B' g
indeed cause more virilization in male or female
9 ?( C) U/ \1 qchildren than one would realize. Exposure to andro-, ^& `% }0 C5 C$ k, @# r
gen products must be considered and specific ques-
& g. x1 p9 |& E2 ?4 T! ytioning about the use of a testosterone product or
1 R- n& [+ {  d. v1 Tgel should be asked of the family members during+ P; C7 G0 G+ ]) C0 w/ i
the evaluation of any children who present with vir-9 \  [1 c+ M0 V; c* A* R
ilization or peripheral precocious puberty. The diag-
3 T3 h" g& g: l4 Unosis can be established by just a few tests and by
3 V  Z& L3 o- R& Fappropriate history. The inability to obtain such a- B% P  @* M/ k) _& ]% j4 U
history, or failure to ask the specific questions, may
8 o9 i$ i( r2 j- @; x$ v2 ]result in extensive, unnecessary, and expensive
, m: S! A7 z8 I7 \, U* ^! kinvestigation. The primary care physician should be
' b! E$ y! H4 daware of this fact, because most of these children
. Y& {' j! Q  y, Jmay initially present in their practice. The Physicians’& [# O1 \5 `. c0 g0 E
Desk Reference and package insert should also put a( b% {1 m7 o8 o5 Q, c
warning about the virilizing effect on a male or  `) I! a% c; s% x- \6 D6 y/ N
female child who might come in contact with some-; `6 R7 d6 E7 X
one using any of these products.1 \" z/ N! G% K$ c3 z& ~
References
# K" y* n0 b+ i9 b! Z1 i% V1. Styne DM. The testes: disorder of sexual differentiation
5 C* p, Z0 ?  @% S9 ]/ land puberty in the male. In: Sperling MA, ed. Pediatric0 v- g  e/ Q, [0 |
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: a% M! |' o& @' t* u, S
2002: 565-628.6 q. I, i: Z; U( X# |; }* f
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- v* v) \/ s7 u, \/ E
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-4 03:27:02 | 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
Sexual Precocity in a 16-Month-Old0 O  h6 K, u# ^; s. @8 W$ ^
Boy Induced by Indirect Topical
5 P2 B  s: S1 b4 N7 HExposure to Testosterone" i/ h) ~9 z6 M) e9 Y- ]$ N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% j& n2 T  D$ q8 n" ]& @% h5 Oand Kenneth R. Rettig, MD1
2 M5 v+ J0 j* h' ?; E4 ~# G! N. I0 V6 DClinical Pediatrics
/ Q- i& V% S. E" c$ \1 j- g9 y% kVolume 46 Number 6
# `( O3 }' H$ g7 T% R0 O5 [8 \July 2007 540-5433 q' l/ O# j6 {7 s. `
© 2007 Sage Publications$ k3 K/ z3 V$ s7 l) t
10.1177/0009922806296651
3 D+ J# l# h5 L* c% H# Nhttp://clp.sagepub.com0 ^. {4 p  g# T
hosted at0 V3 N3 |# a. {4 O$ ^
http://online.sagepub.com
$ V7 S2 p: w. F; i$ `8 b* }: APrecocious puberty in boys, central or peripheral,! d. N6 o8 b, R7 f0 T
is a significant concern for physicians. Central
: ?) ~8 w7 Q, x5 _% Xprecocious puberty (CPP), which is mediated
0 I5 [1 ?5 s7 n$ Ythrough the hypothalamic pituitary gonadal axis, has
0 o$ R7 ]" \. M+ @a higher incidence of organic central nervous system
/ W5 b! D# R* h8 Glesions in boys.1,2 Virilization in boys, as manifested4 ]2 r( j* N. `" s. w8 i/ ?* @, T6 Y" r
by enlargement of the penis, development of pubic
- r$ U, s: W0 s! N9 M/ p. Yhair, and facial acne without enlargement of testi-
5 D) n' |$ `" Lcles, suggests peripheral or pseudopuberty.1-3 We$ a5 A" e- Q0 @
report a 16-month-old boy who presented with the  K4 q: h; u! s- }# Y6 }
enlargement of the phallus and pubic hair develop-, U* S! O# C6 `* M2 s
ment without testicular enlargement, which was due' n- b8 ?8 P/ v$ T0 P6 `
to the unintentional exposure to androgen gel used by
9 {6 H( @3 @7 R5 F. {* Pthe father. The family initially concealed this infor-0 L0 s5 f8 s' E+ U, k& X( w( ]( ]
mation, resulting in an extensive work-up for this0 W. N; G$ \& }4 y6 T
child. Given the widespread and easy availability of  u/ I6 w  L, F- a& s$ _" x
testosterone gel and cream, we believe this is proba-' D1 m$ p# Z% p& Y# R, x- O
bly more common than the rare case report in the
6 P0 l4 R! k! _% M3 e. H$ S$ Sliterature.4
6 A6 x8 _  `2 APatient Report
9 H* m& Y% {6 d7 [5 q" T% [A 16-month-old white child was referred to the
7 R$ \' A0 b& R' l# o7 a+ W. [endocrine clinic by his pediatrician with the concern
5 `' B) k, ?/ E( X6 q) T* Yof early sexual development. His mother noticed; p$ ^) O9 B" Z0 v6 B/ V
light colored pubic hair development when he was0 W- _0 n4 B3 c/ ^( T# f
From the 1Division of Pediatric Endocrinology, 2University of% x. z; K( Z! X, U8 T; x
South Alabama Medical Center, Mobile, Alabama.' i  F' n/ |7 j: f6 F
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 z* g4 \, u4 j
Professor of Pediatrics, University of South Alabama, College of
9 L' g3 V2 s/ \) lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 V8 ~! `8 O  `; m' F& O3 O2 P: d
e-mail: [email protected].
. n( k% \- l+ Zabout 6 to 7 months old, which progressively became
! T' b/ A8 n* q. o& s8 q4 ~darker. She was also concerned about the enlarge-5 F6 ~, B5 S* J5 a: ]7 W/ C( \
ment of his penis and frequent erections. The child
6 Z' w: K( f+ N. Y( a$ r, _was the product of a full-term normal delivery, with
( N) l# Y( R) Y5 [% }a birth weight of 7 lb 14 oz, and birth length of
: F9 N/ k: c" k" Z% S) k20 inches. He was breast-fed throughout the first year1 N9 y- m, I' A4 Z9 t! O2 x
of life and was still receiving breast milk along with- y; Z! Y  C# N
solid food. He had no hospitalizations or surgery,; X) s6 B6 Y& E
and his psychosocial and psychomotor development0 v4 v. }4 ]+ P- e/ ?
was age appropriate.) ~; K4 N- f' b5 Q8 \; H
The family history was remarkable for the father,7 c/ R: }' T8 A6 }( [3 h# @
who was diagnosed with hypothyroidism at age 16,; M. s* O  k. [
which was treated with thyroxine. The father’s0 E# R' L" b' k5 K* R; t2 l
height was 6 feet, and he went through a somewhat7 k# l. ]4 l" W: ~9 M
early puberty and had stopped growing by age 14.. A4 B% t; k4 c- n  W* I
The father denied taking any other medication. The! a+ O# K2 J5 i$ f
child’s mother was in good health. Her menarche8 {  u7 J: p& E, R
was at 11 years of age, and her height was at 5 feet
# N7 S- L. h, K; }# @5 J5 inches. There was no other family history of pre-7 h" F; p% P4 d* p1 e, ]/ c$ y5 B6 a
cocious sexual development in the first-degree rela-8 m  N! L' a  O9 d/ d2 p
tives. There were no siblings.: D( {( R: c  {
Physical Examination: Q& C" X/ O0 s& ^0 ~# Z) j
The physical examination revealed a very active,' R- U0 K, {& d$ u/ x  K: A
playful, and healthy boy. The vital signs documented
( [& y) }8 r1 O5 Y5 b8 f: w' Ca blood pressure of 85/50 mm Hg, his length was
' G& t& ]( e4 c# g7 B6 X4 |" W6 M4 }90 cm (>97th percentile), and his weight was 14.4 kg
1 A) @1 u  O; m- B3 m! G3 C2 g) M(also >97th percentile). The observed yearly growth2 k# w& H) g* p& }& u. S) D1 x+ b
velocity was 30 cm (12 inches). The examination of5 S0 `9 ~: Q, S3 b" h, V9 }
the neck revealed no thyroid enlargement.
5 [( S- L* m2 S' oThe genitourinary examination was remarkable for% m* v5 ?3 B6 u: w# W3 Z
enlargement of the penis, with a stretched length of8 S, w! W9 c1 M5 K  w# s4 X
8 cm and a width of 2 cm. The glans penis was very well/ E3 g2 {8 {1 H! d
developed. The pubic hair was Tanner II, mostly around
# e* j! z( B9 ]$ x3 q540
; u& l6 M- ]' }! L0 d- H# y# V$ ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# W8 S4 a) Y, U, W# E' ]% cthe base of the phallus and was dark and curled. The, r$ K: F9 |* g: S9 W
testicular volume was prepubertal at 2 mL each.) `0 R) o0 b! N8 I9 \( S+ P
The skin was moist and smooth and somewhat
' Z2 w" Z, _7 M, o5 ooily. No axillary hair was noted. There were no- b2 s9 v' `; A- H' ^
abnormal skin pigmentations or café-au-lait spots.
2 P2 ?$ C& Z$ M8 i2 I( FNeurologic evaluation showed deep tendon reflex 2+
0 K8 A' M8 _; v' [1 a6 Q3 r( x- ~bilateral and symmetrical. There was no suggestion
9 P3 Y3 K/ x& F" K: O) s6 L, s% lof papilledema.
7 j- _! G- Y% v  J  {( g4 L; H8 QLaboratory Evaluation
$ L! Q5 Y0 _% D! U2 K, ]The bone age was consistent with 28 months by
9 Q& C. n8 ?$ ?) Musing the standard of Greulich and Pyle at a chrono-
+ g  n+ `) m' g. Plogic age of 16 months (advanced).5 Chromosomal) }0 L4 k( r6 d
karyotype was 46XY. The thyroid function test
. F5 i2 {. U5 J6 B% ]+ _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* H3 ^$ X6 c# ~& a  M# u3 R" n/ alating hormone level was 1.3 µIU/mL (both normal).5 r8 g6 w. t  l
The concentrations of serum electrolytes, blood
7 a+ f9 t$ @  Iurea nitrogen, creatinine, and calcium all were
# B% G; t; R) h. u% F* b7 S! `within normal range for his age. The concentration
: W3 X2 `! b1 Z0 v7 oof serum 17-hydroxyprogesterone was 16 ng/dL
" j+ l1 `5 M- i+ N* j(normal, 3 to 90 ng/dL), androstenedione was 20" M2 b$ B6 o+ P) j5 A* a0 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; D  E) K0 i$ D8 Q0 V# H3 ?, Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( ^0 Y* n& d# a% odesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 x% h/ K- j% ]4 W* f
49ng/dL), 11-desoxycortisol (specific compound S)
6 e+ t6 X5 W' D3 @9 J2 o# Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 X3 H" q$ f8 v1 c; b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 ~: \4 [+ T# qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 j  \! P9 a  Iand β-human chorionic gonadotropin was less than
$ t) L% F9 t) K) Z+ {5 mIU/mL (normal <5 mIU/mL). Serum follicular+ N+ q  D. [1 u+ B4 k6 K
stimulating hormone and leuteinizing hormone# f, E; C4 b5 p  h: Y- E* n& v
concentrations were less than 0.05 mIU/mL
( [3 g5 r# y- B% i- _, U% e(prepubertal).
1 ^3 P% R! I* z: y8 J- EThe parents were notified about the laboratory5 H- p* F0 S- C1 s
results and were informed that all of the tests were
, m! o, z2 f1 `$ f. K" T6 ~' Inormal except the testosterone level was high. The
4 z& U6 o/ n: S5 b8 d% T. rfollow-up visit was arranged within a few weeks to0 _5 e3 F- \  x# |
obtain testicular and abdominal sonograms; how-
9 _/ [& S' x0 qever, the family did not return for 4 months.
0 ~1 m4 L! ~! e+ i$ sPhysical examination at this time revealed that the* h4 k- M/ O2 z$ ]1 r! g% g2 {
child had grown 2.5 cm in 4 months and had gained
4 v" a) K" R; X! f2 [# }1 s* \. ~5 e2 kg of weight. Physical examination remained# F  y( o+ N& N7 ?: p
unchanged. Surprisingly, the pubic hair almost com-
- L' V3 k( E. m, |+ K# q9 h7 |pletely disappeared except for a few vellous hairs at
0 w+ }; c2 _% g* |4 J5 Sthe base of the phallus. Testicular volume was still 2
& a% O8 f2 a8 ?8 o  m4 S2 WmL, and the size of the penis remained unchanged.5 r8 F8 i4 f; T3 s' `
The mother also said that the boy was no longer hav-
9 ~) A  Y* ?' ning frequent erections.
9 A+ {# d2 g( _, u+ lBoth parents were again questioned about use of
3 _5 _$ X1 Q2 c$ }" p* X0 U0 k7 Eany ointment/creams that they may have applied to6 m+ q) u3 l% r, I* P3 N7 D! d" R, u
the child’s skin. This time the father admitted the
1 h* N1 h8 U2 y, f9 ^Topical Testosterone Exposure / Bhowmick et al 541
& C/ m, A. d; J2 U: z( juse of testosterone gel twice daily that he was apply-6 k- v3 D4 J' `  m" X% ?
ing over his own shoulders, chest, and back area for
0 K: L$ U9 ^; V5 Qa year. The father also revealed he was embarrassed
/ K6 G- ~  }$ ~7 nto disclose that he was using a testosterone gel pre-
" F  P9 a8 _! X9 ?scribed by his family physician for decreased libido* ]2 w8 I$ o6 _" l$ o1 J/ \0 f/ b& {1 g. ]
secondary to depression.
3 k. Y- {0 l: R# A9 gThe child slept in the same bed with parents.$ J* g/ {( G4 r4 K
The father would hug the baby and hold him on his5 q8 E0 e: ]) K  D3 G' i6 Y
chest for a considerable period of time, causing sig-6 k  A! Z! k- V' V( g
nificant bare skin contact between baby and father.
% c! B1 P6 @+ x1 Z3 }: IThe father also admitted that after the phone call,
/ f3 J2 t9 Q+ P1 c/ H8 kwhen he learned the testosterone level in the baby
; u. `. U# e9 n) Q! y8 Qwas high, he then read the product information
! s, y9 N$ O- w8 K6 [' ^packet and concluded that it was most likely the rea-3 K5 Z' _  }; C
son for the child’s virilization. At that time, they2 P( \% b, w$ e& _/ M0 c
decided to put the baby in a separate bed, and the, J6 n1 T4 S& v+ P% F
father was not hugging him with bare skin and had
. f% d! L+ _3 ]+ I$ E, c  obeen using protective clothing. A repeat testosterone
. |9 }( u3 E9 {- [. ?& w8 stest was ordered, but the family did not go to the
2 t  T2 \. F( F1 ?laboratory to obtain the test., @' {. D, a& `1 A  @4 }, }& m
Discussion
4 E( `. D! @7 C8 h- @6 s& XPrecocious puberty in boys is defined as secondary* V- }7 f2 ]: Z  ?  M( W
sexual development before 9 years of age.1,4
0 D, q' b( P1 q& K. EPrecocious puberty is termed as central (true) when
- R, \; @2 Z) w3 ~it is caused by the premature activation of hypo-, F5 t! f' N+ D+ C; x4 G( }; s
thalamic pituitary gonadal axis. CPP is more com-
; p8 h6 S' E* {mon in girls than in boys.1,3 Most boys with CPP" N6 H( p6 H. I$ T5 T: L' ~
may have a central nervous system lesion that is
, b) X: M5 N# o5 H  I- oresponsible for the early activation of the hypothal-
* X3 }1 [. j8 X  S. M& Q% y& A0 Samic pituitary gonadal axis.1-3 Thus, greater empha-3 H! G6 `! ?7 y2 L: d
sis has been given to neuroradiologic imaging in
  g. c) j# }- T6 E) j7 }  Cboys with precocious puberty. In addition to viril-
5 b+ v8 a9 X3 k; n8 {! x$ cization, the clinical hallmark of CPP is the symmet-1 I' }2 g: |6 o9 ~, a. Z% f: t' f
rical testicular growth secondary to stimulation by3 I5 Q) ~9 G, W( c- ]( j
gonadotropins.1,3# W- V& O8 f$ ~8 ^( }0 d1 m
Gonadotropin-independent peripheral preco-8 k) o4 q( r9 a+ D: a5 A& @6 I5 N
cious puberty in boys also results from inappropriate
/ T2 R. z( Z! s, q" Landrogenic stimulation from either endogenous or* p! m8 c- e: e2 Z( w$ ]( l3 I
exogenous sources, nonpituitary gonadotropin stim-6 @" z; J! J" P- B; d- i1 _" l
ulation, and rare activating mutations.3 Virilizing4 \7 G. q7 _! H8 o/ }
congenital adrenal hyperplasia producing excessive/ o: ^" ^& g, I. g( z3 n; i
adrenal androgens is a common cause of precocious, }' x, f6 |/ n) L# T4 J5 c9 }
puberty in boys.3,47 i: u  \! X! B1 q
The most common form of congenital adrenal
" F8 M: D) \6 a7 R$ _# c; \hyperplasia is the 21-hydroxylase enzyme deficiency.% u4 ]) c$ O0 N5 r* k
The 11-β hydroxylase deficiency may also result in" }5 V/ @; ]# s. [! M" p
excessive adrenal androgen production, and rarely,0 L0 e$ B9 ~* `- q' `1 h
an adrenal tumor may also cause adrenal androgen( O# x+ ?: r$ r2 }2 g: R9 g
excess.1,3+ B4 X) l2 o8 P' Z: T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 o4 F% r* R7 g- q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 q% f; E. M- aA unique entity of male-limited gonadotropin-
/ x' a- C8 x; a9 O; H/ _0 C/ \independent precocious puberty, which is also known( b$ b4 K4 k5 @$ j# v4 D
as testotoxicosis, may cause precocious puberty at a
1 `3 W  Z% t2 uvery young age. The physical findings in these boys0 P4 D( f0 u. k( r; U, f
with this disorder are full pubertal development,  O# y5 O' [4 {9 F: Z
including bilateral testicular growth, similar to boys4 P. V7 t- ]; M, Y* r( @
with CPP. The gonadotropin levels in this disorder9 s4 M, r7 e% a
are suppressed to prepubertal levels and do not show
8 k! g( |3 R% O1 U$ a) ypubertal response of gonadotropin after gonadotropin-8 D( B6 Q5 z. c- s* h
releasing hormone stimulation. This is a sex-linked
: [" y2 ]1 g; o5 h. Oautosomal dominant disorder that affects only( U6 \  }; n( ?% ~' I8 _
males; therefore, other male members of the family
# q/ F5 w+ X* a3 gmay have similar precocious puberty.3
5 w9 I. E, D2 V# k8 d, F5 LIn our patient, physical examination was incon-0 G$ i2 }# _/ B0 B
sistent with true precocious puberty since his testi-! Y" b- t4 i* \6 K! o) ]: X
cles were prepubertal in size. However, testotoxicosis
4 D+ G# g, t5 K6 @+ ywas in the differential diagnosis because his father) p6 l! A0 c, I& Y* X2 U
started puberty somewhat early, and occasionally,
& ^2 y2 J6 g% I  W1 U% Mtesticular enlargement is not that evident in the" @$ b% V1 n" i' Q8 C0 z
beginning of this process.1 In the absence of a neg-: H5 O- ?+ K% Z
ative initial history of androgen exposure, our
8 h, y( E1 r1 w' Xbiggest concern was virilizing adrenal hyperplasia,/ r, ?+ ?* K" o' u* k
either 21-hydroxylase deficiency or 11-β hydroxylase
6 P7 A4 Q! h2 v4 C& W6 u2 zdeficiency. Those diagnoses were excluded by find-
, m5 E: k5 ?9 W0 |8 I" {ing the normal level of adrenal steroids.4 h& G6 q6 _% S: x9 ^/ @: [" J& w) {
The diagnosis of exogenous androgens was strongly
# Z3 R0 ?1 V( P4 c9 S; e: i* A! _" ~4 tsuspected in a follow-up visit after 4 months because( v. n3 {/ q( I, T/ P2 D- z6 ?/ P
the physical examination revealed the complete disap-+ b0 X0 ?( e9 K  c, s3 V* _) c( E: P
pearance of pubic hair, normal growth velocity, and
& u4 \0 V; q0 U1 D' _# fdecreased erections. The father admitted using a testos-
4 t! c. S3 g; ]8 q5 f' _terone gel, which he concealed at first visit. He was
( `' L/ A4 {. i$ D6 }- ?using it rather frequently, twice a day. The Physicians’
; S# Z2 J2 C3 N4 t' k" a) FDesk Reference, or package insert of this product, gel or
2 u- }9 h. O1 C2 Ecream, cautions about dermal testosterone transfer to0 [9 Y; ]  ~; t2 A* v& _
unprotected females through direct skin exposure.4 u1 |0 N5 f. \
Serum testosterone level was found to be 2 times the( S$ r3 R1 f) Y, ~4 a3 u
baseline value in those females who were exposed to
8 a/ H! H) X4 B7 jeven 15 minutes of direct skin contact with their male
# o6 O5 z. q2 d/ D1 y2 Upartners.6 However, when a shirt covered the applica-; V8 w% j, p) a( q9 B
tion site, this testosterone transfer was prevented./ d, q5 S0 ]- Z& }2 R
Our patient’s testosterone level was 60 ng/mL,
, ~5 t! a" o7 D2 h' @, zwhich was clearly high. Some studies suggest that
. w& M/ y6 {7 [& U, J3 w& p  |dermal conversion of testosterone to dihydrotestos-& q$ _9 C( D2 G- n( C# e
terone, which is a more potent metabolite, is more
1 p  M, O/ ]5 i, X3 Lactive in young children exposed to testosterone
$ `2 f+ C; ^4 ^. H& `0 }) E1 @exogenously7; however, we did not measure a dihy-& s8 l. y' M! H5 w8 ?
drotestosterone level in our patient. In addition to! J) ^& Z) T& b6 r* w
virilization, exposure to exogenous testosterone in
9 w# U, m6 K# Tchildren results in an increase in growth velocity and
. {+ c7 z, M- g' B! u7 Iadvanced bone age, as seen in our patient.! m& y5 D% j% Z( O/ o+ S9 _# [
The long-term effect of androgen exposure during6 O- t& W2 s' U) X5 w  P
early childhood on pubertal development and final
$ b& r2 t) f6 @) T( aadult height are not fully known and always remain$ f8 M" V8 I$ |* N. J5 _
a concern. Children treated with short-term testos-2 h4 @* r5 `) e, }* ?9 c7 a; Y
terone injection or topical androgen may exhibit some& F" ]: Y7 c6 [( _8 O9 c& {; F
acceleration of the skeletal maturation; however, after/ {2 n. H; k# k$ ~6 m8 f
cessation of treatment, the rate of bone maturation
9 H( F( T  L, S) U# b2 v* Wdecelerates and gradually returns to normal.8,9
3 B% J  L. S% j5 h! w& MThere are conflicting reports and controversy
' o5 T& ]6 _! p, p) }  Q* kover the effect of early androgen exposure on adult
* [+ h: d- b# m' spenile length.10,11 Some reports suggest subnormal
7 @/ \* E2 X4 p2 jadult penile length, apparently because of downreg-6 T4 G" ?" Z2 |! t
ulation of androgen receptor number.10,12 However,
  h2 U% w9 Q( u3 V  S% P! RSutherland et al13 did not find a correlation between  z. U& ?9 t/ f1 O9 [& d1 O
childhood testosterone exposure and reduced adult
& M1 u+ ~( R# a3 t% Epenile length in clinical studies.
5 `, k8 j6 Y' E  r3 MNonetheless, we do not believe our patient is2 c6 g( H# x- k8 A$ ~& B; p
going to experience any of the untoward effects from
% c$ c/ |* ]) x; N; O$ ptestosterone exposure as mentioned earlier because2 D, d! v. k4 M0 Z  m9 p
the exposure was not for a prolonged period of time.
+ ^, I# q% v8 K2 b. BAlthough the bone age was advanced at the time of
0 \; T. R; g- ~4 Fdiagnosis, the child had a normal growth velocity at
$ I5 C( n7 o: N" i' @( Qthe follow-up visit. It is hoped that his final adult4 ]5 d0 b$ a9 @8 u- O) |5 d) K1 R
height will not be affected.* g. N% P$ m1 Z
Although rarely reported, the widespread avail-6 T( F! u$ x- m7 S6 O# r
ability of androgen products in our society may
- p( E) t  H! `2 y+ {indeed cause more virilization in male or female
$ D( n! C) Z6 Q4 Lchildren than one would realize. Exposure to andro-
7 A: n. r( G2 O1 y2 C8 O. Fgen products must be considered and specific ques-2 V( X5 D4 U0 r1 o- M
tioning about the use of a testosterone product or
1 r7 k, x9 H& h# Cgel should be asked of the family members during
1 s. ^7 {- y, f% I# T3 L1 v6 N. S& Zthe evaluation of any children who present with vir-9 q5 L  j" u" \* ~: W. j
ilization or peripheral precocious puberty. The diag-
& I- D! Q4 U/ S4 H' E: p( Bnosis can be established by just a few tests and by
( K/ c) t$ d4 E* I5 _appropriate history. The inability to obtain such a
5 s6 |: m/ ]. B# Xhistory, or failure to ask the specific questions, may
4 G, l2 B& @; F# Nresult in extensive, unnecessary, and expensive
9 y9 O- W6 k9 I8 Binvestigation. The primary care physician should be
  E$ n/ o8 y# Xaware of this fact, because most of these children
9 ]* ?; w+ [* z! s7 @may initially present in their practice. The Physicians’
+ l7 X: s3 d3 X2 ^: \Desk Reference and package insert should also put a
$ _  L) s+ N4 S' G. ^warning about the virilizing effect on a male or( r$ q8 p' F5 V0 A. p4 |- M* {
female child who might come in contact with some-7 `% l" r0 v  T& C" H: I8 G& J
one using any of these products.
$ V9 V8 k  H% ?; H2 |& x" rReferences
  U1 v7 B6 S  G9 X) y1. Styne DM. The testes: disorder of sexual differentiation1 m  Q: W3 f, G) {
and puberty in the male. In: Sperling MA, ed. Pediatric
6 B$ f+ F" L3 [, TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 _9 j. M# X1 R/ l$ p2002: 565-628.) N! D% n- p& Q6 G, U# s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" }4 \. z( d& o1 {
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

( Y4 e. R7 m# ?4 j, ^; }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!
您需要登錄後才可以回帖 登錄 | 立即注册

本版積分規則


快速回復 返回頂部 返回列表