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
8 ~* Q( `% \/ f/ \Boy Induced by Indirect Topical
) _* _) D3 r) z+ A( NExposure to Testosterone
+ k5 m6 @5 C, JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 E. P" z3 A+ p7 E) z$ Aand Kenneth R. Rettig, MD11 y0 `  Q& X# J0 x3 T
Clinical Pediatrics
# h2 |9 U8 p; P1 ^/ @- sVolume 46 Number 6
# m; k8 ]+ u/ \  M% q+ |July 2007 540-543- W5 ~. x1 R0 Z' D
© 2007 Sage Publications3 {( }2 a$ W1 q3 h; d$ {) l  H
10.1177/0009922806296651
7 N/ n" F2 H5 u. khttp://clp.sagepub.com  D* y5 R1 ?( `( w+ E4 {* F
hosted at
& ~3 T& X8 V6 }; I0 R% `$ Bhttp://online.sagepub.com. j! [# i; J% {! Z: y$ @$ a
Precocious puberty in boys, central or peripheral,
1 J8 T1 i) T7 V/ O$ Sis a significant concern for physicians. Central& v9 {! s. |5 C4 \, m
precocious puberty (CPP), which is mediated
8 \. x, [+ ~: E/ Q" ]7 K. ~& A+ rthrough the hypothalamic pituitary gonadal axis, has; S/ [8 t/ G% R6 [5 ~3 e
a higher incidence of organic central nervous system
7 V/ z2 ^  P! X5 N& Glesions in boys.1,2 Virilization in boys, as manifested
4 z5 N( j8 Q3 h+ Pby enlargement of the penis, development of pubic( k& j+ |4 a- N
hair, and facial acne without enlargement of testi-
0 U) V9 G, J* f/ A# xcles, suggests peripheral or pseudopuberty.1-3 We
% w( c: a, i8 D+ N5 dreport a 16-month-old boy who presented with the
) a5 m" u3 Z9 Tenlargement of the phallus and pubic hair develop-/ D: E# s5 ^( h5 ~) z2 j* ^1 Q6 Q
ment without testicular enlargement, which was due4 ]; ~5 I( W% o! s4 U
to the unintentional exposure to androgen gel used by
* H, Z; u! q: ]+ u# x' Pthe father. The family initially concealed this infor-% [3 F& m4 l& M$ e  H' s
mation, resulting in an extensive work-up for this- @2 Z3 f: r3 P1 M1 u/ _0 O
child. Given the widespread and easy availability of) _+ i$ Q: G% u/ I8 Z4 E
testosterone gel and cream, we believe this is proba-2 b/ G  z( x6 E/ p6 Q
bly more common than the rare case report in the
2 {6 c8 M5 t  L; }+ }8 nliterature.4
) o3 I8 o  P. k+ U! NPatient Report0 A# h$ G/ |! g
A 16-month-old white child was referred to the
# a& z) {  t9 q% Fendocrine clinic by his pediatrician with the concern; M* J. L% n% c0 T8 h* F, |2 c
of early sexual development. His mother noticed( S. B" ~0 v' `( r/ i: p
light colored pubic hair development when he was$ U( ~) O1 o  Z  ]+ {
From the 1Division of Pediatric Endocrinology, 2University of
  W2 Z3 D- ^2 {+ R5 M" a3 ESouth Alabama Medical Center, Mobile, Alabama.
3 a# I0 {5 b" B, `- U. m3 lAddress correspondence to: Samar K. Bhowmick, MD, FACE,/ }$ I3 s# _% P  m8 P! E
Professor of Pediatrics, University of South Alabama, College of7 K$ ?/ g7 S, c2 s0 W% l2 E4 t4 a+ R
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% V  x- C7 y  b% T7 B0 ]$ e
e-mail: [email protected].
3 |( g, D' S( T$ N' X7 Iabout 6 to 7 months old, which progressively became
% F& C: m* U; I: Mdarker. She was also concerned about the enlarge-
" A6 h1 a' ^" K* U* Pment of his penis and frequent erections. The child
1 \1 f) f0 L- L3 o; a& M9 twas the product of a full-term normal delivery, with5 ~& c- W" T; D
a birth weight of 7 lb 14 oz, and birth length of3 ?. h- }7 m% @  B! Z7 h4 p
20 inches. He was breast-fed throughout the first year1 X/ [5 i$ `3 e. Z+ e5 f
of life and was still receiving breast milk along with% j- i, F- ^/ M, t
solid food. He had no hospitalizations or surgery,
0 i6 E& K$ j7 ]8 A( c( E3 Gand his psychosocial and psychomotor development
5 m6 w( d  l  q# _* ]was age appropriate.
+ C: Q- d: O) X5 ?, M5 @The family history was remarkable for the father,8 z( a4 q6 Q  X* ~) o9 l3 F
who was diagnosed with hypothyroidism at age 16,
4 c# ?  m* V0 i' Qwhich was treated with thyroxine. The father’s
% J: p2 A$ g  I) O; i& M+ Cheight was 6 feet, and he went through a somewhat
! @+ l9 l0 N7 X+ Zearly puberty and had stopped growing by age 14.
- {8 M% L; o0 C) I; f& uThe father denied taking any other medication. The
4 @4 @/ l1 _; c; Z* i1 Qchild’s mother was in good health. Her menarche
# t1 A: K& t; h/ t% u9 swas at 11 years of age, and her height was at 5 feet. A6 Y1 W7 h. v  `) O+ X2 _! ~% P: \
5 inches. There was no other family history of pre-
! S; f: G8 X, H  w. D+ G9 |( icocious sexual development in the first-degree rela-
3 U! u2 e9 O# C( ?tives. There were no siblings.
* [. c. v/ C7 h: \8 X3 oPhysical Examination: S3 C' j8 t, R' r* H8 o: B7 N: N& ]
The physical examination revealed a very active,
4 W) l/ W4 B  _; c% b4 W2 @1 zplayful, and healthy boy. The vital signs documented
1 d1 I0 ]- w1 }6 k  q& L. Ba blood pressure of 85/50 mm Hg, his length was6 o+ m6 D# @) M* h1 i* f
90 cm (>97th percentile), and his weight was 14.4 kg% T1 B, `% K* P
(also >97th percentile). The observed yearly growth
! C! s2 j9 ]! b4 i+ [velocity was 30 cm (12 inches). The examination of
/ m& J0 S  u2 r6 t" Cthe neck revealed no thyroid enlargement." I. j+ b! v0 P# B
The genitourinary examination was remarkable for) u. T+ E- _8 Z8 b; S
enlargement of the penis, with a stretched length of
8 ^" x3 v! J( ?7 S! g7 \, F8 cm and a width of 2 cm. The glans penis was very well
. {) [/ R, l5 K5 p2 a; Edeveloped. The pubic hair was Tanner II, mostly around
5 C2 I1 X- s* W$ H  Q540+ U/ k, {4 t, P: x! w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# {; i4 H% p& k8 w' C" \  t* Q, `) I
the base of the phallus and was dark and curled. The
, A7 p3 q) O: T3 Ztesticular volume was prepubertal at 2 mL each." Y, U5 O0 z6 c- O3 ?
The skin was moist and smooth and somewhat
) c) N) S: P0 G0 _1 Koily. No axillary hair was noted. There were no
2 h/ H8 Y5 b/ q5 v/ habnormal skin pigmentations or café-au-lait spots.0 R( T5 V; I, x' G
Neurologic evaluation showed deep tendon reflex 2+
3 V8 @; P% F( d3 X* Rbilateral and symmetrical. There was no suggestion" |9 F- w7 s! y" P
of papilledema.0 X9 D' i9 R8 V  [& @* P( `6 k
Laboratory Evaluation
# [) u( o  P5 U6 w# _The bone age was consistent with 28 months by
9 a: x; |! q2 a1 L5 |  ^; H0 gusing the standard of Greulich and Pyle at a chrono-2 g+ p1 ]  a5 P$ n7 i$ x
logic age of 16 months (advanced).5 Chromosomal
# N1 @: U6 D0 z, E/ m2 A8 Ukaryotype was 46XY. The thyroid function test
' Q+ Z3 e* }$ h) ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 ~" q) z; W: ~lating hormone level was 1.3 µIU/mL (both normal).7 U$ O' R1 U) e2 \; C
The concentrations of serum electrolytes, blood
- R! n" v. j$ P: R. nurea nitrogen, creatinine, and calcium all were
" x# N: v0 T9 kwithin normal range for his age. The concentration( {4 }& J9 E% k0 x4 |
of serum 17-hydroxyprogesterone was 16 ng/dL0 p% G% K6 i  |6 \: o
(normal, 3 to 90 ng/dL), androstenedione was 202 m# V. A# C, Z4 g! Y) m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ M+ }' y; A3 s8 H9 F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),' `" y" F8 i/ P' P+ S* f, z1 A3 g$ w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% S  \  w: d; v* x8 r49ng/dL), 11-desoxycortisol (specific compound S), i; W7 F% l7 u; g  u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 P* ?( S* G' T$ L2 W% ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! q' d/ d) K4 m/ E' mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* H2 [, Q4 }* v# n# |4 D3 L
and β-human chorionic gonadotropin was less than' ^$ N: e7 W4 p: E- A. l
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  C3 {: [7 k8 l1 W' Bstimulating hormone and leuteinizing hormone+ {' s6 }/ @5 M( O* I" l  r  Z6 c
concentrations were less than 0.05 mIU/mL
! O% Q" y* y2 e2 C! H& |9 H; @9 M(prepubertal).
) i3 H$ d4 e4 k# S. {1 I9 QThe parents were notified about the laboratory) \- v0 l3 w: W) l
results and were informed that all of the tests were% V/ H& x, Q8 h) O/ q# c7 p/ K
normal except the testosterone level was high. The$ C. Y/ u. j# y5 i
follow-up visit was arranged within a few weeks to; l3 x: \3 @% z1 v* H" ^
obtain testicular and abdominal sonograms; how-
8 ^& \4 H" f7 o- Q5 i, ^/ uever, the family did not return for 4 months.3 \( J( D5 _$ l6 y" ]% ?
Physical examination at this time revealed that the
% R2 C! G- P7 y6 h5 a! ~$ pchild had grown 2.5 cm in 4 months and had gained3 T  O9 c" Z) y& \4 ~: x) z
2 kg of weight. Physical examination remained4 o6 ?  x# Q' ?0 Z" x
unchanged. Surprisingly, the pubic hair almost com-0 f' \$ H3 |" g" n$ i7 K5 @4 V
pletely disappeared except for a few vellous hairs at0 x( x3 h* z5 T8 r4 ]
the base of the phallus. Testicular volume was still 2
5 n# d' w7 k+ f% u" I+ R6 Q! ~mL, and the size of the penis remained unchanged.8 w  K. ~( L5 Z7 Y+ ?+ D# f. o+ o* a
The mother also said that the boy was no longer hav-+ F, Q+ Z) i7 C! q3 e/ s/ a
ing frequent erections.
; n2 b. Z+ b( C, Y5 S% n( g/ jBoth parents were again questioned about use of7 h/ Z! v; p5 `1 ^
any ointment/creams that they may have applied to8 n' f# i( Y. M3 i" ]! d
the child’s skin. This time the father admitted the  y9 |3 H* L, \4 F1 \, U, d' a
Topical Testosterone Exposure / Bhowmick et al 541
  W/ m3 C/ I- r* |2 P! }use of testosterone gel twice daily that he was apply-
. Z1 f& n% P( @' D; ring over his own shoulders, chest, and back area for" o. W6 X% u$ |& \
a year. The father also revealed he was embarrassed
' A% X( p. D/ m/ X! @, y, fto disclose that he was using a testosterone gel pre-
6 L2 R! Z6 U" |scribed by his family physician for decreased libido" T1 _4 m; L1 p" ]. Q8 k
secondary to depression.: e% x2 l+ c: n! _9 T
The child slept in the same bed with parents.
  r/ f4 Y. F' N$ s/ I# a& q/ I5 CThe father would hug the baby and hold him on his
* g1 s) x+ K) @2 ^chest for a considerable period of time, causing sig-+ c7 \/ R+ b; |5 w
nificant bare skin contact between baby and father.
: s* W5 T+ o# l6 Q3 r0 a+ UThe father also admitted that after the phone call,1 c; {! t3 ]& P4 Y
when he learned the testosterone level in the baby
' Z% A' F& g1 P' Ewas high, he then read the product information2 M; D4 y( @$ s( W. m8 L- f8 I
packet and concluded that it was most likely the rea-$ l  U" S$ ]8 v, `
son for the child’s virilization. At that time, they2 P& V1 m, P* z
decided to put the baby in a separate bed, and the
( K: Y" L9 C* D. Q8 ofather was not hugging him with bare skin and had
* x3 D) O& [+ K/ X2 `been using protective clothing. A repeat testosterone- V0 h7 s  g' p$ @* M
test was ordered, but the family did not go to the0 ~4 `! D: ?9 `( S0 P) W! Z7 ~
laboratory to obtain the test.2 v& M1 G2 v. i# M9 V) }
Discussion% ], G, Z" O/ C' u
Precocious puberty in boys is defined as secondary' y% M- e, ?- V( r- W
sexual development before 9 years of age.1,4
; g; k. j' N" z! ~. _) j. _Precocious puberty is termed as central (true) when; {  [# q( g) l5 s
it is caused by the premature activation of hypo-
( E4 u9 m( k0 a, Vthalamic pituitary gonadal axis. CPP is more com-
" ?% Q& u, n$ P4 ^$ Z! `9 U" bmon in girls than in boys.1,3 Most boys with CPP
$ b: O. _3 _  L& Z3 @( a4 h( E7 Bmay have a central nervous system lesion that is; o/ b* J, x" y( z
responsible for the early activation of the hypothal-$ T3 @: k& r+ }" Y
amic pituitary gonadal axis.1-3 Thus, greater empha-
" b$ u* ?5 h5 M8 S  Osis has been given to neuroradiologic imaging in& v2 \+ r2 W0 [; }2 w; p/ L- O
boys with precocious puberty. In addition to viril-: V( [- l( l+ O5 B1 V: V$ m
ization, the clinical hallmark of CPP is the symmet-
( f8 C4 b$ m0 b$ e) Brical testicular growth secondary to stimulation by
; T* j4 k4 X( Q$ z( U8 cgonadotropins.1,3
5 v- ^& \4 o' v# tGonadotropin-independent peripheral preco-; e  _) {. J/ ]6 E. A
cious puberty in boys also results from inappropriate9 j8 N( }& h3 ^2 [/ m! R
androgenic stimulation from either endogenous or
- I: e8 F& B( Q2 ]exogenous sources, nonpituitary gonadotropin stim-3 Z. R1 Q: E2 @: A4 x, c; ]
ulation, and rare activating mutations.3 Virilizing7 V% B9 [4 e0 T. I" u
congenital adrenal hyperplasia producing excessive
3 _4 i8 Y0 E8 N; n2 `' D+ Zadrenal androgens is a common cause of precocious+ @5 ~3 G1 e2 M  w. p- K
puberty in boys.3,4
- P( f) t2 |8 w; g9 {& RThe most common form of congenital adrenal) c3 Y7 x- M, ^- n: j  k( @
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 A2 u+ _8 r* U" V2 U* f; b/ e$ HThe 11-β hydroxylase deficiency may also result in( U" S! N) U9 p
excessive adrenal androgen production, and rarely,
6 H- A! C+ f6 g. u" q# ban adrenal tumor may also cause adrenal androgen
& U( g1 U9 z" b. _excess.1,3  J+ Q- \+ ]$ P6 F! |* J5 @6 D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 p5 b& G6 o; i. l! H
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 @' A3 o; {! m  `% ~( IA unique entity of male-limited gonadotropin-
, B# I; L7 d* [6 }, ?/ M) yindependent precocious puberty, which is also known
( V1 J) `5 `% e: Ras testotoxicosis, may cause precocious puberty at a/ A  f* z: g4 i( |
very young age. The physical findings in these boys
* r3 K' ]8 g/ g; ^- twith this disorder are full pubertal development,7 r2 n+ ]  T, q( a7 r$ w+ a$ ?
including bilateral testicular growth, similar to boys% @5 V' N. x$ n' W
with CPP. The gonadotropin levels in this disorder
4 _! x# |; G7 y/ Xare suppressed to prepubertal levels and do not show
  j- d6 G, G1 z, m& y5 d: d8 ^pubertal response of gonadotropin after gonadotropin-; C* b( A. ~4 R8 d1 m$ T0 m
releasing hormone stimulation. This is a sex-linked% A/ y  L  a# c4 a8 [' `4 E! @
autosomal dominant disorder that affects only* _) Z! v) A5 O2 p, F6 z
males; therefore, other male members of the family1 G( B, W: y2 {5 s
may have similar precocious puberty.3
3 D5 N9 C0 D7 YIn our patient, physical examination was incon-
/ c' `$ G% ]  \" D8 q: G' osistent with true precocious puberty since his testi-1 o6 ^- A8 O3 X0 [" T6 A
cles were prepubertal in size. However, testotoxicosis
5 q) ?6 G2 k) E- i! Rwas in the differential diagnosis because his father' c) x- e4 t8 r
started puberty somewhat early, and occasionally,  q+ V, s2 \$ e9 V8 j' K
testicular enlargement is not that evident in the" y- H% P% E+ y: ], C4 D$ z
beginning of this process.1 In the absence of a neg-
0 m/ g6 ]! x, `" l, ~- z7 i$ @ative initial history of androgen exposure, our
5 c9 C( c+ W) Y$ e2 jbiggest concern was virilizing adrenal hyperplasia,
: k/ Y7 W" C1 Y5 ?7 X6 ]. ?+ Reither 21-hydroxylase deficiency or 11-β hydroxylase
1 `9 R3 n2 J8 O$ Y' s) ]4 Z" ^deficiency. Those diagnoses were excluded by find-
& H5 d( P) ]. d; c( Ring the normal level of adrenal steroids./ ^, H* J$ D% ?; i5 B7 {$ @7 O
The diagnosis of exogenous androgens was strongly
8 D& P! }& J5 v/ Qsuspected in a follow-up visit after 4 months because
) h& F  x, `' y$ E3 M3 fthe physical examination revealed the complete disap-" t! n. r% ?/ V! x
pearance of pubic hair, normal growth velocity, and& S" L) D6 A/ H* K8 `* M2 V
decreased erections. The father admitted using a testos-
1 j2 @' H5 j: x+ o) ~5 q% n( A) Nterone gel, which he concealed at first visit. He was3 v  q$ W. f, L$ D5 O9 m' e
using it rather frequently, twice a day. The Physicians’7 n5 `6 S) n1 i+ |; G/ w
Desk Reference, or package insert of this product, gel or
& n+ ~% h1 a5 L( l0 y' P9 q2 o3 _cream, cautions about dermal testosterone transfer to
* C( T6 F) z( C0 f7 e/ Ounprotected females through direct skin exposure.
4 `* y( S! I2 g0 D- u  SSerum testosterone level was found to be 2 times the; Y. D% L) s6 x- W
baseline value in those females who were exposed to
" S) m* Z7 Q1 ?" s) `0 T2 v+ keven 15 minutes of direct skin contact with their male
* U# u) h( m- u$ u0 opartners.6 However, when a shirt covered the applica-6 X, i/ h4 N/ ^3 @( h4 }3 @( V
tion site, this testosterone transfer was prevented.
. a' q* E( W1 N, FOur patient’s testosterone level was 60 ng/mL,
) h1 C: _" m% f, P/ V" b  _" mwhich was clearly high. Some studies suggest that
# D" a% ]5 N* D9 E2 w5 y6 edermal conversion of testosterone to dihydrotestos-2 f, S" X. b) b7 K8 F
terone, which is a more potent metabolite, is more; Y  ^2 Q4 p7 g( b& ]
active in young children exposed to testosterone  X) I) i' H  L5 h! @
exogenously7; however, we did not measure a dihy-
0 l, {1 Q0 V& w7 A, Z  N1 s* jdrotestosterone level in our patient. In addition to
. g4 P1 _, S) }6 i8 A* y+ wvirilization, exposure to exogenous testosterone in
6 X+ [+ P, P6 @. Q. qchildren results in an increase in growth velocity and: o' X. g% q8 A2 m- b+ c
advanced bone age, as seen in our patient.0 F# s# Q: U, A" U
The long-term effect of androgen exposure during" v" V9 G6 \7 ?* M/ \
early childhood on pubertal development and final; i6 h. K! t  i, R7 z
adult height are not fully known and always remain2 V0 `: [  s; E4 V% n& F
a concern. Children treated with short-term testos-
. v- y7 j( }' a& v8 F% w" Aterone injection or topical androgen may exhibit some( M: k' Y$ Y0 Z: m9 c8 p, V' a
acceleration of the skeletal maturation; however, after3 l' w9 p# Z$ }$ c
cessation of treatment, the rate of bone maturation% S9 G. P- `* R/ x
decelerates and gradually returns to normal.8,9. M: ?! A% g$ P' B
There are conflicting reports and controversy
. ?9 L3 t  ^' _3 K' U6 j6 Y! Aover the effect of early androgen exposure on adult9 L# `8 X8 V  r, ^3 S: K5 `, u
penile length.10,11 Some reports suggest subnormal+ T0 {) `) I: {, b9 g2 m
adult penile length, apparently because of downreg-
  `( n- B, ~/ @' z- v/ rulation of androgen receptor number.10,12 However,
+ P' ^; n/ a& K$ R* `Sutherland et al13 did not find a correlation between
" J. r' p, n; u# B% Kchildhood testosterone exposure and reduced adult' H$ d  b/ [& v: d8 S
penile length in clinical studies.
) x# O* J+ F: E4 v- D5 xNonetheless, we do not believe our patient is
- U) M" U- h& r1 ~: `going to experience any of the untoward effects from
' m  f! U" w4 B! W, c, @& X2 R0 u0 Htestosterone exposure as mentioned earlier because
: i' R. P; }! h. A6 `5 y' M7 D. ]4 kthe exposure was not for a prolonged period of time.1 ?2 y& a5 i- y& G* z
Although the bone age was advanced at the time of8 {4 Q$ S4 n) V( M2 }# e
diagnosis, the child had a normal growth velocity at
. {! e" `2 s3 `4 Vthe follow-up visit. It is hoped that his final adult& `0 y8 r) `  s7 e3 [0 z
height will not be affected.7 L1 Y* }, L$ C; b- E) g  w9 Q
Although rarely reported, the widespread avail-
! Y$ [8 O( v6 \& q+ \! T+ Oability of androgen products in our society may
+ P- k& u" F, y- E- F2 Nindeed cause more virilization in male or female
2 J; S3 @: o+ s2 F. Jchildren than one would realize. Exposure to andro-
# S1 K# u; ~, n$ R' y% \gen products must be considered and specific ques-7 T+ r( D+ H/ c$ Q
tioning about the use of a testosterone product or; L: S  g$ F3 ^- t! I
gel should be asked of the family members during8 c4 U/ R! r8 q; J2 d8 _: X
the evaluation of any children who present with vir-
% ~- B: j; h% r5 d' E2 Ailization or peripheral precocious puberty. The diag-9 d4 Y. r0 G" _; F2 x2 t- C% y
nosis can be established by just a few tests and by$ e* j  f0 y$ c3 Q7 r1 X! J
appropriate history. The inability to obtain such a. J$ D/ y' ?2 w& p7 e1 M; }/ f
history, or failure to ask the specific questions, may
( d) E/ N- \0 Y" cresult in extensive, unnecessary, and expensive
( l/ c5 Z) v! C1 k( U6 t" Y. ]% T. Pinvestigation. The primary care physician should be
0 D1 z8 c( o# I- |( Z' F& k. baware of this fact, because most of these children
! h+ F" B8 L4 N8 c/ e* p! s9 V; ~may initially present in their practice. The Physicians’
% X; y. S! _" q. lDesk Reference and package insert should also put a0 e8 l* `# E: z# n$ W; O
warning about the virilizing effect on a male or
& U( q3 T( u( q, v9 Sfemale child who might come in contact with some-2 z+ R; t. c; K$ R* O3 V) N! c# m( t
one using any of these products.4 E( e/ W, _+ b5 a5 w
References7 x5 O* P4 d, s% Y4 e. ?: U- C
1. Styne DM. The testes: disorder of sexual differentiation
- h5 S' \' z( P8 M0 Kand puberty in the male. In: Sperling MA, ed. Pediatric
' x" \* {* M% I; @9 fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 J4 P/ @' w; ^
2002: 565-628.3 r* v/ i1 J; M8 [, U6 q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 w5 r1 T' R0 J  ~7 ipuberty 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-Old) R5 L1 m* T; `" C
Boy Induced by Indirect Topical
; V2 U3 U( L) V1 t  x0 RExposure to Testosterone5 t8 {5 i4 O; @9 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 P. o9 o2 I3 K, \) C
and Kenneth R. Rettig, MD1
8 Z! Y/ w0 G# B5 dClinical Pediatrics5 P! y. L4 |& G) z: j/ m4 F3 ^8 \
Volume 46 Number 6
7 Q' k# K$ E7 @( a) HJuly 2007 540-5439 r$ f8 k# ?, H  J
© 2007 Sage Publications" Z6 s5 w' j/ ^( B# r8 A& ~4 N
10.1177/0009922806296651" T  l- @* r4 Q8 N& x! q3 u; O9 r
http://clp.sagepub.com
( P2 R3 a' Y8 K: Bhosted at& w; _9 T3 u8 V$ w4 T$ ?$ O
http://online.sagepub.com+ k9 |  a4 M- X. q! H: a; R: i5 U
Precocious puberty in boys, central or peripheral,
! c- E5 B' z; ]/ C+ {6 iis a significant concern for physicians. Central
7 q& ^6 I5 |& l) `4 e4 s' dprecocious puberty (CPP), which is mediated+ Y! n+ f( B- g  N; P
through the hypothalamic pituitary gonadal axis, has  ?0 V& L6 ~3 U8 K* c3 r9 N
a higher incidence of organic central nervous system
# l7 G- [1 ]2 Q9 _1 Glesions in boys.1,2 Virilization in boys, as manifested
$ E# q* y- v( y4 r/ p/ o; L- Lby enlargement of the penis, development of pubic9 @5 s! F' n3 W( Y$ w: ]
hair, and facial acne without enlargement of testi-
( H. k/ u; j! X" icles, suggests peripheral or pseudopuberty.1-3 We5 j; [; Q& C; C$ \! k
report a 16-month-old boy who presented with the& n' n1 i, x* ^! n7 j
enlargement of the phallus and pubic hair develop-
2 t7 g3 X$ ]/ x+ ~ment without testicular enlargement, which was due
' Q0 M( n: d# f- X6 ~: H% R- {1 Nto the unintentional exposure to androgen gel used by
( n0 D' I8 x0 U% l- V( O9 l: Xthe father. The family initially concealed this infor-
7 S  w) a) Y3 Hmation, resulting in an extensive work-up for this+ ]; a  }# o- Y: A  }1 j
child. Given the widespread and easy availability of9 F: o5 S) @& {2 a! a
testosterone gel and cream, we believe this is proba-1 b+ [0 ?7 l: ?& U3 {4 p
bly more common than the rare case report in the
- V1 c: ~: X' ]3 {5 tliterature.4
7 {: N8 [  r& P/ h% LPatient Report
2 s3 w8 g! K. X4 M: A& jA 16-month-old white child was referred to the
- H8 L; a) }: L3 B# w. G6 kendocrine clinic by his pediatrician with the concern
1 ]* c* E& J* eof early sexual development. His mother noticed. {, Z: E, S& i; F/ e8 p7 U
light colored pubic hair development when he was
& {& c6 X! e- Q2 u7 V% sFrom the 1Division of Pediatric Endocrinology, 2University of9 _4 L) ^* J0 X! @
South Alabama Medical Center, Mobile, Alabama.
/ {8 n2 ?& [  o3 s; _9 t" V1 E) dAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ U% d( n* ^. c) P5 i
Professor of Pediatrics, University of South Alabama, College of
  d% H3 X/ h- L* vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# ?# E: {' T2 |% H
e-mail: [email protected].
1 `7 ^# E" `$ Z0 k9 [# E) S' Labout 6 to 7 months old, which progressively became
! w: U/ _5 M  @# S! bdarker. She was also concerned about the enlarge-& E8 [4 n" o- y! f' L3 w; T; V
ment of his penis and frequent erections. The child
3 |- N8 V  v3 F' w& ^" [/ |  I2 Twas the product of a full-term normal delivery, with' u! h. H8 V/ d* M. t/ D0 J) B
a birth weight of 7 lb 14 oz, and birth length of
9 o! b; r% J) M( y3 _  H% y20 inches. He was breast-fed throughout the first year
) J* B- @* I2 y1 n' z9 ]  Uof life and was still receiving breast milk along with- B$ }4 g  M9 S- i
solid food. He had no hospitalizations or surgery,
7 _) i  s5 j) J' B. @and his psychosocial and psychomotor development& v4 h5 P# q4 Y
was age appropriate.
" a% p. v  L7 r$ Z6 w3 s$ }% bThe family history was remarkable for the father,) W* O. i6 u' R/ Z* C
who was diagnosed with hypothyroidism at age 16,5 r- Z$ J1 D  o1 d1 X
which was treated with thyroxine. The father’s
  E+ B- h; Y/ Z- u, v& Q$ V5 wheight was 6 feet, and he went through a somewhat3 \# y( I' g$ U( _7 k( x
early puberty and had stopped growing by age 14.
0 j! d2 s, i7 t' N9 h* C  |  RThe father denied taking any other medication. The
4 ?" j8 W2 y6 A% b3 m3 nchild’s mother was in good health. Her menarche
0 y! x# c, |9 Q2 C2 e7 rwas at 11 years of age, and her height was at 5 feet
5 K' J7 L4 n- p! E5 inches. There was no other family history of pre-
& n& J7 P* @$ E/ F! m% Lcocious sexual development in the first-degree rela-& v" {1 J7 \- o! R
tives. There were no siblings.
% F1 y$ O# F3 R3 z  A, z! MPhysical Examination
. a( @8 @7 {* QThe physical examination revealed a very active,' s" i1 K; j" q1 n7 ]9 \1 m
playful, and healthy boy. The vital signs documented
$ `' I# [, S' C9 ?) U2 La blood pressure of 85/50 mm Hg, his length was0 {: h" w0 P+ m  M6 G! R
90 cm (>97th percentile), and his weight was 14.4 kg
# [/ o7 e  V! z; ]6 a! ~! I4 y(also >97th percentile). The observed yearly growth
/ L& V5 G  i7 J- O7 jvelocity was 30 cm (12 inches). The examination of
9 Q& H! A+ A8 I5 ethe neck revealed no thyroid enlargement." M. w+ @: V) {$ A
The genitourinary examination was remarkable for- j8 m3 V6 D7 k$ P1 z4 V! W
enlargement of the penis, with a stretched length of
6 r% c' E4 }+ I7 ^1 U8 cm and a width of 2 cm. The glans penis was very well
* O' o2 E- n  _4 }* P% W1 Tdeveloped. The pubic hair was Tanner II, mostly around
; E" \* E+ w2 W) A540% d, g* X( j# }  Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ k: N: _) R) N0 G7 T: A! lthe base of the phallus and was dark and curled. The! k& j3 i! ~; {* F8 t) O! l
testicular volume was prepubertal at 2 mL each.
' n! H5 S* k) U; u' |5 B! v1 SThe skin was moist and smooth and somewhat! j4 ?6 @( `/ A- r7 m4 s
oily. No axillary hair was noted. There were no. f3 K. {% X# e0 d( M; M
abnormal skin pigmentations or café-au-lait spots.
) k% K2 ?- J' H/ E/ lNeurologic evaluation showed deep tendon reflex 2+
2 n1 I8 w, K8 e1 A* N) ~+ dbilateral and symmetrical. There was no suggestion1 J/ ^9 X0 I9 ?: e# q7 p
of papilledema.3 f7 A4 t1 b$ g6 W9 A3 L
Laboratory Evaluation
, F8 {* q; a+ w& w! TThe bone age was consistent with 28 months by- E/ K; }$ d' M4 g/ K
using the standard of Greulich and Pyle at a chrono-( E8 U* _" W+ @- a
logic age of 16 months (advanced).5 Chromosomal
: h5 g* ?8 y* U# z0 `( _1 zkaryotype was 46XY. The thyroid function test7 N1 P( c' Y$ X$ _* b) t
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 o) Z1 b% Z- L! q5 f' Rlating hormone level was 1.3 µIU/mL (both normal).
& Y9 U0 Q  N% R" a$ |7 a% f3 R4 {4 SThe concentrations of serum electrolytes, blood1 K' ^, s1 b! p' o
urea nitrogen, creatinine, and calcium all were
3 E+ @4 i2 X; e/ s8 w4 ?: `4 twithin normal range for his age. The concentration
+ ]7 W4 V/ W' p! v- Aof serum 17-hydroxyprogesterone was 16 ng/dL
! G  Q; V. h9 x5 m! T(normal, 3 to 90 ng/dL), androstenedione was 20
, v* L% q8 }* `4 [  `+ @  a  |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: i0 p# b: K6 Q3 \6 |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 Q8 c# D( K9 O6 F* z" L  N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; a5 W4 N8 X5 T% `  Q49ng/dL), 11-desoxycortisol (specific compound S)6 g8 a& h% I( u/ S; O" y+ I: j+ U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# e& U7 J' L# u, Z5 Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 O/ F; N' ~  y2 W# P3 e! wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 O; a+ }8 e) K+ L
and β-human chorionic gonadotropin was less than. N1 H3 V, s' m; i5 o6 f7 R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# S  t! b* l8 v; e) k/ x) {5 kstimulating hormone and leuteinizing hormone
, U0 d' a2 b; Y* b+ }8 wconcentrations were less than 0.05 mIU/mL
$ ~  w& K+ g/ D9 B(prepubertal).
' i0 x" E4 r* ?( v% `9 fThe parents were notified about the laboratory4 Y& W( Z5 f+ M* t
results and were informed that all of the tests were
- ^# u' S- A" P1 Onormal except the testosterone level was high. The) \) p' {; k& Y5 C& ~. s  b
follow-up visit was arranged within a few weeks to
' H; q' r' ^9 j: d& O: Eobtain testicular and abdominal sonograms; how-
) s8 @( ]( q& W9 U8 Pever, the family did not return for 4 months.
4 `7 O/ \, W8 j8 H8 E4 q0 A/ r1 SPhysical examination at this time revealed that the
, ^* H, R9 \0 N5 W* v+ e. ?; p: \) wchild had grown 2.5 cm in 4 months and had gained
4 f1 n+ k- G; l( {8 }$ R2 kg of weight. Physical examination remained
1 S  H' C+ Y3 ^, S8 f2 ?; h, O4 Bunchanged. Surprisingly, the pubic hair almost com-
; B0 S0 h2 m9 \) N8 ppletely disappeared except for a few vellous hairs at! g/ L1 H/ C" }6 }- y+ `0 ~( Z6 ?
the base of the phallus. Testicular volume was still 2
0 z- y; L# o/ dmL, and the size of the penis remained unchanged.
0 D+ L8 c- t# h& O( |! bThe mother also said that the boy was no longer hav-% P+ }( k' i) G  q  C' H$ T5 C
ing frequent erections.1 i+ E5 I* I$ i6 b: D
Both parents were again questioned about use of
, N' K8 |( R( lany ointment/creams that they may have applied to0 l8 \: ]) N/ u* w( _9 R+ v
the child’s skin. This time the father admitted the
7 x' U3 a, i% V4 HTopical Testosterone Exposure / Bhowmick et al 541
5 k& J4 e7 w, d: tuse of testosterone gel twice daily that he was apply-. z, H3 r% B) J- F( `( ?" P
ing over his own shoulders, chest, and back area for
) u  h4 y" ~* Q/ _$ a2 H4 Va year. The father also revealed he was embarrassed, A4 O* u3 f5 v3 e1 ^6 v* q4 ^
to disclose that he was using a testosterone gel pre-0 N6 M0 C# D' K* `6 T. J
scribed by his family physician for decreased libido
' R# V6 }0 N! P4 Gsecondary to depression.
2 d: C9 l+ e. h1 U( V4 ]The child slept in the same bed with parents.8 w8 M  e( Z/ |9 g0 O: N$ ~
The father would hug the baby and hold him on his
; G$ [4 ^$ J, q! v7 y: T  h* ~/ achest for a considerable period of time, causing sig-3 U3 ?% L9 @9 M( c* x
nificant bare skin contact between baby and father.
5 @" K0 r1 u$ h  g/ S" Y7 NThe father also admitted that after the phone call,/ J# n. e6 x$ |+ G* ^
when he learned the testosterone level in the baby
: j& i* i2 w/ l, b% Rwas high, he then read the product information* n$ f2 H* V% j
packet and concluded that it was most likely the rea-3 N2 L! Q) I7 f( P' ~* ]
son for the child’s virilization. At that time, they1 X5 e0 l" E5 }
decided to put the baby in a separate bed, and the
! |  Q' V8 }  b/ o4 N! ?1 M1 Jfather was not hugging him with bare skin and had" K0 A& Y$ u+ W0 S' e
been using protective clothing. A repeat testosterone3 I7 j" B$ B3 P) s7 J
test was ordered, but the family did not go to the
" a/ e2 d$ O* ?# mlaboratory to obtain the test.
1 l2 L7 f' [, k2 i4 `% U1 T8 oDiscussion
: C- }2 d, u; W6 j  k4 p3 M+ KPrecocious puberty in boys is defined as secondary
2 T+ m9 C/ W! X# V7 [4 ~* L8 Ksexual development before 9 years of age.1,4
# \0 `7 I6 W3 N2 M( k: g9 e" l& r! ~' BPrecocious puberty is termed as central (true) when! A& ?9 t0 ^1 v% U
it is caused by the premature activation of hypo-/ N+ K+ N3 E; @! {; `+ \
thalamic pituitary gonadal axis. CPP is more com-
2 @; c& K" e# a: E- i% ^9 c+ o0 r6 Mmon in girls than in boys.1,3 Most boys with CPP, C. S; S5 l! K, ?; @
may have a central nervous system lesion that is
2 u. H4 k/ W( y+ V" b! Dresponsible for the early activation of the hypothal-
- L" m  R% a% h# R( D6 E! Hamic pituitary gonadal axis.1-3 Thus, greater empha-& {. q3 u$ }' H( y* T. r, y
sis has been given to neuroradiologic imaging in" X& M. z. B$ x$ s- H5 Y  Z. l
boys with precocious puberty. In addition to viril-: }8 S& z/ p, W  }$ B3 J4 m/ S
ization, the clinical hallmark of CPP is the symmet-
; g4 T& W. M7 q6 |. h# y, grical testicular growth secondary to stimulation by
9 |0 a% z5 R' I* k; ?+ |- M7 Ggonadotropins.1,3
  g7 `: g; k9 `6 J+ k% a+ ]Gonadotropin-independent peripheral preco-
) Q$ S8 D8 {8 p4 v- d6 i, |" scious puberty in boys also results from inappropriate' x3 \5 F4 y+ X) X
androgenic stimulation from either endogenous or
3 P" F. o5 s- Rexogenous sources, nonpituitary gonadotropin stim-
! X9 |+ T" O1 ?; hulation, and rare activating mutations.3 Virilizing
; ~( S  J: H" y( J3 e- O* Pcongenital adrenal hyperplasia producing excessive. T; s( y, @" c  y+ z+ U
adrenal androgens is a common cause of precocious3 ?& v7 J5 p6 d1 k: \
puberty in boys.3,4( H* e8 O6 s2 E& i
The most common form of congenital adrenal
8 w  }( i7 \. O8 n) r3 chyperplasia is the 21-hydroxylase enzyme deficiency.
+ x1 k4 T" O- B' P3 f* w- ~( UThe 11-β hydroxylase deficiency may also result in
+ Y$ R+ ~8 W5 B0 ~5 t; b/ X0 n$ Eexcessive adrenal androgen production, and rarely,0 _2 l: w+ P. ]! T
an adrenal tumor may also cause adrenal androgen
$ ]  d" _, n* a/ fexcess.1,3
( V, u% F" F  V) Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 v) s; D" Y+ F542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 S( A" L1 ]. I- e% EA unique entity of male-limited gonadotropin-
2 j' z) ^& k5 o4 K; r1 `0 j+ [independent precocious puberty, which is also known1 a+ ^2 ]& ?) F- c/ l; l
as testotoxicosis, may cause precocious puberty at a2 ~* W% x1 w. U
very young age. The physical findings in these boys9 f( d' D2 P" ^* d% j
with this disorder are full pubertal development,% U2 b" C& h: f$ A! J% S
including bilateral testicular growth, similar to boys
3 z! |+ k% Y) `, J: gwith CPP. The gonadotropin levels in this disorder9 o% k3 s, f$ s+ V7 J/ R, {$ N
are suppressed to prepubertal levels and do not show- B" F- D2 P+ g' R- t
pubertal response of gonadotropin after gonadotropin-
( H+ w- t) k6 ^5 ~. I; {; m; Breleasing hormone stimulation. This is a sex-linked
- _# l. r& ^/ ?autosomal dominant disorder that affects only2 W$ W5 `2 O1 E( [: f$ \
males; therefore, other male members of the family$ Y4 `3 t. @: K  H2 S) A
may have similar precocious puberty.39 y  m5 c* [) c3 B$ a
In our patient, physical examination was incon-
+ _5 G1 T: E4 }/ u* @, Ysistent with true precocious puberty since his testi-
- R2 X7 o, G. m4 |  l1 S% E1 A/ [cles were prepubertal in size. However, testotoxicosis" Z9 }5 Y$ S# C9 h7 [3 H8 A' c# h# U
was in the differential diagnosis because his father
$ t# u9 S, x, g/ ?( t6 e6 F: Pstarted puberty somewhat early, and occasionally,
: |, k  R& [0 f: `* o: `9 Dtesticular enlargement is not that evident in the  [2 C# W8 ^( [" r, A" z- _$ @
beginning of this process.1 In the absence of a neg-; u6 i, U+ p0 a7 [0 G, e7 y$ Z
ative initial history of androgen exposure, our
- `. R1 U# z3 g! K3 ^biggest concern was virilizing adrenal hyperplasia,
5 C$ i0 g+ v% w5 qeither 21-hydroxylase deficiency or 11-β hydroxylase. @/ ]/ w: K7 D* }4 N9 ^' f+ ^8 h
deficiency. Those diagnoses were excluded by find-1 S  P# J! B1 F
ing the normal level of adrenal steroids.
4 |3 s/ g9 {1 A/ SThe diagnosis of exogenous androgens was strongly
) b8 K, ]" E& c# v3 asuspected in a follow-up visit after 4 months because" |( K' b1 z* {; `3 K
the physical examination revealed the complete disap-4 M! e! D$ i) L5 o- c+ R( f
pearance of pubic hair, normal growth velocity, and
1 b& A/ c1 p$ C3 Odecreased erections. The father admitted using a testos-2 \( M1 ?3 K/ l- s# H* G
terone gel, which he concealed at first visit. He was' m3 N6 Y1 Q. N' k( H, u+ o
using it rather frequently, twice a day. The Physicians’
, R2 _1 y( e5 B2 L2 b+ A7 uDesk Reference, or package insert of this product, gel or3 s3 K( _! E8 }6 F
cream, cautions about dermal testosterone transfer to' X' y: \) F. U' g5 ^" |/ K6 f8 A  l
unprotected females through direct skin exposure.
$ o# y) W+ z) ^3 aSerum testosterone level was found to be 2 times the/ P( H5 V9 x0 b, {3 Z' j5 k: j
baseline value in those females who were exposed to
( ]" @% U- S2 C6 neven 15 minutes of direct skin contact with their male& Q7 @0 C7 d0 _( S. T2 s4 o% j
partners.6 However, when a shirt covered the applica-- j2 ?4 P) A& ]! p+ L. k  o
tion site, this testosterone transfer was prevented.
, i1 A8 }$ N  U1 m  MOur patient’s testosterone level was 60 ng/mL,9 o1 s: g  ^4 f" y0 T6 S7 G2 D
which was clearly high. Some studies suggest that9 d* Y2 Q6 J1 g* w! M& q( H
dermal conversion of testosterone to dihydrotestos-( G7 f8 S3 L) o3 b9 W0 j
terone, which is a more potent metabolite, is more
. I# S# E' f  a- u9 A% iactive in young children exposed to testosterone
0 @. M3 A- A- ^; Y$ Y. F; r6 Vexogenously7; however, we did not measure a dihy-; e, d  K- V# d5 n
drotestosterone level in our patient. In addition to, r, j  G+ E# p) y5 F5 ^
virilization, exposure to exogenous testosterone in
# r, L  \/ p; S7 S4 y7 {# p3 i# h& s1 m! w4 pchildren results in an increase in growth velocity and
! j4 Q4 |) L6 v2 A. aadvanced bone age, as seen in our patient.
3 r! V3 P0 h+ ~+ N% zThe long-term effect of androgen exposure during  o( `. e. c4 I' N7 F$ i
early childhood on pubertal development and final
7 ?" x+ O" _7 E. y# w' p' U( Z( ^/ x! x0 ]adult height are not fully known and always remain: f: [; ^9 |% b9 R9 N  d  W9 F' `
a concern. Children treated with short-term testos-/ X) Q4 P& ]3 N; H+ ]/ W- K
terone injection or topical androgen may exhibit some. B) s0 O( b/ t0 a0 z
acceleration of the skeletal maturation; however, after, S+ ~* {9 i6 ?& v. e" `
cessation of treatment, the rate of bone maturation
; X" i% U5 e" ?7 S( d5 s, pdecelerates and gradually returns to normal.8,9
, e) f9 a/ }/ [& Y/ ?8 X1 u; jThere are conflicting reports and controversy
0 B( q$ Q! C/ i- Hover the effect of early androgen exposure on adult
. i* Q/ H! H- e7 H( Tpenile length.10,11 Some reports suggest subnormal4 W8 N, U4 W; n" a' E
adult penile length, apparently because of downreg-
3 n% @. N! v7 r; P# E5 B1 A1 W% Uulation of androgen receptor number.10,12 However,
& C( U6 O  }1 z& C9 i7 OSutherland et al13 did not find a correlation between
% g8 [8 n! k" Vchildhood testosterone exposure and reduced adult
4 L  r9 I- e3 ?; }3 A7 O" ?5 Qpenile length in clinical studies.* _9 Y& u) O) G6 K: W: p- d/ V* P( T
Nonetheless, we do not believe our patient is
  e2 q/ Q$ _. Z3 m2 p2 ~2 xgoing to experience any of the untoward effects from) |. w/ E8 ?: ?) S1 d
testosterone exposure as mentioned earlier because
% `+ Z3 `! }1 \/ Bthe exposure was not for a prolonged period of time.
9 o$ |/ l/ w, A8 i+ A# u9 F: YAlthough the bone age was advanced at the time of
* n( H" ~3 X, ?6 Tdiagnosis, the child had a normal growth velocity at
, J- s6 Y; ]9 k: u/ X1 uthe follow-up visit. It is hoped that his final adult+ }( W- w1 C0 f' J7 l* J
height will not be affected.
) ^: x2 I# }9 V- kAlthough rarely reported, the widespread avail-# `" m' O4 g4 y
ability of androgen products in our society may
: Z6 J6 |  O. P5 h, u! j6 h9 rindeed cause more virilization in male or female
( H, n% {5 j5 K: |3 R8 `children than one would realize. Exposure to andro-2 W7 z* Z6 D5 U$ ^" @
gen products must be considered and specific ques-
( ~# W) F' b2 t. e$ M& |- Rtioning about the use of a testosterone product or
) ?' f% `3 V. F6 Ogel should be asked of the family members during
- s3 L" H5 `7 ~% o; k# C, N- V' Ithe evaluation of any children who present with vir-1 A5 _4 U# N0 K$ v3 S
ilization or peripheral precocious puberty. The diag-$ ~/ p6 V6 a8 t
nosis can be established by just a few tests and by  Z2 q. T* t  b. ]
appropriate history. The inability to obtain such a
; ?2 {* V# U; y% X9 [& m% T7 Yhistory, or failure to ask the specific questions, may
* X$ ]/ v# Y8 w! a* j, Y, Dresult in extensive, unnecessary, and expensive
. x3 k2 c: j$ N" q/ m- x$ Dinvestigation. The primary care physician should be
1 }# c8 R6 B7 z* q6 Kaware of this fact, because most of these children7 ~; Z/ X2 @0 {6 u& W7 t
may initially present in their practice. The Physicians’" ~0 M9 ?, ^& R
Desk Reference and package insert should also put a2 H# L( [1 E( U! i
warning about the virilizing effect on a male or
1 y# l' K! M" H8 u- v$ L9 V; ?female child who might come in contact with some-# F( t- R8 I* \4 X7 \  h( k3 e
one using any of these products.
  i" w  ]# ^5 B5 EReferences. }, p, f0 v3 ~
1. Styne DM. The testes: disorder of sexual differentiation
( S4 T: `# p) p" b5 N6 e  E# zand puberty in the male. In: Sperling MA, ed. Pediatric
& z5 B- A8 l+ x+ @1 TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' @2 ~6 f: O8 j" `: \- g+ }2002: 565-628.
+ T* K- T' T& `6 [5 Y. h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' b* D- G9 A; |
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

: u. B7 }) L" v; C; P* v8 @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