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
1 n) a9 E' b+ a7 bBoy Induced by Indirect Topical  o# n" o  ~6 I. P* c! x! h
Exposure to Testosterone) f% c1 `; g' {7 F' a5 g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! g: |( w! H# ]and Kenneth R. Rettig, MD13 j% u+ U! Z3 j: [- u, h
Clinical Pediatrics4 }3 f. z6 _6 i2 ^0 q
Volume 46 Number 6! y. p5 n6 }2 I* F5 E. _' x( |7 ]: `
July 2007 540-5430 n( R. T/ G! @5 n! H  b* Y8 {& G
© 2007 Sage Publications
! w( C0 V& t2 q10.1177/0009922806296651
" \2 |% j% w6 @- R& x. D3 _& Thttp://clp.sagepub.com
' @' [' i" M4 X/ jhosted at2 Q) K, s0 R! H* f# j5 K' ~
http://online.sagepub.com9 P! L) j8 C4 b5 A- {; f( X
Precocious puberty in boys, central or peripheral,0 S3 j* t- C' U" I  X8 _( u8 `
is a significant concern for physicians. Central
- g' d* u! x7 ^5 _precocious puberty (CPP), which is mediated
* N# h& j, Q5 q" G+ p8 Tthrough the hypothalamic pituitary gonadal axis, has
0 z9 B5 z4 b: F" s  ]8 [a higher incidence of organic central nervous system1 I, o$ Y% [1 V- l4 J! t7 v/ I6 G) F
lesions in boys.1,2 Virilization in boys, as manifested
6 Q6 K7 k  q! O  T- ~6 U/ ?0 ?by enlargement of the penis, development of pubic
) K0 G1 w- G) whair, and facial acne without enlargement of testi-
7 h8 r3 _! {$ j  c; D0 X* B$ bcles, suggests peripheral or pseudopuberty.1-3 We
  l1 t  c( X" T! o* d2 ]: v  ~$ Preport a 16-month-old boy who presented with the
$ P! U# ~0 b4 z" a  aenlargement of the phallus and pubic hair develop-
4 T8 Q4 J, [. v2 {* [ment without testicular enlargement, which was due
9 L! w& m. Y# bto the unintentional exposure to androgen gel used by
. G9 @% V# Q( T. e2 V. B9 K! K& \the father. The family initially concealed this infor-( x. }0 G% @( L3 |* q# V* b
mation, resulting in an extensive work-up for this+ B3 K+ @/ F% `9 T! m; L8 s% z
child. Given the widespread and easy availability of
* k+ I! g: k. a. D% ^/ H3 s- ^0 y) ktestosterone gel and cream, we believe this is proba-% l+ j* |) Y. z% L  ^* N
bly more common than the rare case report in the& Y- S' i* a1 D6 ?
literature.4
. ~; ^0 f" i9 l4 |- b' sPatient Report
& i& e4 l/ j* r; q# M: j. iA 16-month-old white child was referred to the; w) X1 O$ V/ {( @
endocrine clinic by his pediatrician with the concern
8 Y7 w) a% `. O/ Nof early sexual development. His mother noticed
, d2 h! r2 s* Glight colored pubic hair development when he was+ U% w1 @, P' {! A
From the 1Division of Pediatric Endocrinology, 2University of' a/ H, g+ B" x8 W- F( X+ l
South Alabama Medical Center, Mobile, Alabama.
# O8 X: u% [+ L5 B1 _+ |Address correspondence to: Samar K. Bhowmick, MD, FACE,
3 ]: L- p2 b: cProfessor of Pediatrics, University of South Alabama, College of& j2 ]) y' N$ H# a6 j- Y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( ]- D8 C" y: a  m4 pe-mail: [email protected].
1 c; ~2 c4 k+ ]about 6 to 7 months old, which progressively became
+ L8 ~( A3 Q4 X0 l; Gdarker. She was also concerned about the enlarge-
+ O3 B+ G* Q% ?7 `, C9 ?ment of his penis and frequent erections. The child# J9 J6 |4 ]0 S0 e( K
was the product of a full-term normal delivery, with$ _5 [( \8 q8 D( z2 U) x
a birth weight of 7 lb 14 oz, and birth length of: Z* n: a" Y+ v$ d9 ?
20 inches. He was breast-fed throughout the first year) r" D" ]& H$ G* ?. P2 ~2 T3 p4 F: D
of life and was still receiving breast milk along with
' M; z8 G  |2 t) \  K. y' k- L% ^( U/ bsolid food. He had no hospitalizations or surgery,
- s! b& g" m2 {, qand his psychosocial and psychomotor development3 m2 ^( U+ c4 y: L
was age appropriate.4 @% u4 l1 i: k( \' ?9 P7 |
The family history was remarkable for the father,
2 i, P& t- t  J, n) K- A7 n: p* ?0 _7 Bwho was diagnosed with hypothyroidism at age 16,9 X, [% S; R  p1 ~# E2 R
which was treated with thyroxine. The father’s
, _. D) X5 x8 q6 Y- t5 U! ?height was 6 feet, and he went through a somewhat
) f' o# ?. t7 a' D, P, X6 Z, X8 Bearly puberty and had stopped growing by age 14.) i" l: O9 |* m% S" P
The father denied taking any other medication. The
4 k3 i  O, {$ }0 ?4 s/ H, t6 Pchild’s mother was in good health. Her menarche+ G6 M1 I- J0 q& C4 W. R, U; X
was at 11 years of age, and her height was at 5 feet$ L) d! B% a5 m0 q) S" Y9 f
5 inches. There was no other family history of pre-, b9 L3 A7 }9 `/ R! L3 A/ [
cocious sexual development in the first-degree rela-
' N0 K5 |& b0 e% Atives. There were no siblings.1 j6 f1 `+ K4 M
Physical Examination8 u: Y. J5 ]7 @2 W7 k4 V( K
The physical examination revealed a very active,, U/ i: t( Q; R0 ]2 ?
playful, and healthy boy. The vital signs documented; F- S0 `/ @. h( V0 y* i
a blood pressure of 85/50 mm Hg, his length was8 {) |6 a% u/ _4 O8 ]" W5 A% ?
90 cm (>97th percentile), and his weight was 14.4 kg- a4 W! q+ G8 i" C
(also >97th percentile). The observed yearly growth8 h/ W/ b2 c8 _  ^. n
velocity was 30 cm (12 inches). The examination of/ V1 M. z' H4 Q; S4 F+ |
the neck revealed no thyroid enlargement.
- E4 x8 G, C! k* i3 |The genitourinary examination was remarkable for
( m" D* M+ C! w! q% Kenlargement of the penis, with a stretched length of
: l' w! w' E  y# I, K* s$ E# j4 S1 B9 ?8 cm and a width of 2 cm. The glans penis was very well
7 Y. v5 L( O$ Y2 o7 Q" Cdeveloped. The pubic hair was Tanner II, mostly around  e$ b- Y, x- Q0 c
5406 t- ~# ]: |) Y& c% a+ {- @* N3 E- n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- i# H# z! U4 t1 Q9 u) O1 g5 d& c
the base of the phallus and was dark and curled. The
: t9 K8 d: l& Z: n; T' E9 ?testicular volume was prepubertal at 2 mL each.
* b. N& D  ?+ fThe skin was moist and smooth and somewhat
" ]# i3 U# y' Y% C. `oily. No axillary hair was noted. There were no
5 @6 H$ Z7 S2 l3 U  R, ^# aabnormal skin pigmentations or café-au-lait spots.
/ V0 _0 ]) k1 {! INeurologic evaluation showed deep tendon reflex 2+
* J5 U; @+ N7 G; F7 o2 z" K1 R+ R! zbilateral and symmetrical. There was no suggestion/ `; s! K9 b1 P" P1 p
of papilledema.
" h7 G6 g  d. l5 `& KLaboratory Evaluation
3 `" }" q- u6 L% y! m! bThe bone age was consistent with 28 months by
% H. \, @" C6 j1 [! y" ~) c$ T7 Iusing the standard of Greulich and Pyle at a chrono-
+ U5 [- [( g( W. Z5 [logic age of 16 months (advanced).5 Chromosomal
& Q9 A/ J3 U5 ]' p$ q; F  jkaryotype was 46XY. The thyroid function test- I  _5 c/ q: l# I1 h* `/ K! R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% g) }) r+ r6 O+ elating hormone level was 1.3 µIU/mL (both normal).* W; `8 q/ c# c# a# |' x/ i
The concentrations of serum electrolytes, blood/ w4 }' R  C7 a3 [2 w1 d
urea nitrogen, creatinine, and calcium all were
( ~( m# ~: K, ?. t& |$ z$ Kwithin normal range for his age. The concentration. ^  N* Z+ x9 v/ v
of serum 17-hydroxyprogesterone was 16 ng/dL
4 s6 C: N! j/ u) @, n(normal, 3 to 90 ng/dL), androstenedione was 20
5 ]; x3 u! ]/ x3 C; l6 l: [9 ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 A3 r/ ]9 P6 ?% A/ i( o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ }; }" b# E. P( o; ]+ e6 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: G1 W* m4 J2 b( p+ U" V$ u
49ng/dL), 11-desoxycortisol (specific compound S)
4 I; r. W0 ^6 p0 Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 G' y4 @# R) b: X& N8 M8 ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 ?/ W, J" _9 o2 Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),- Y& n6 m$ X% S# R7 Q. {; E6 ~9 p
and β-human chorionic gonadotropin was less than1 S" Y: Y# p, W
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 ^2 s8 }1 w- d
stimulating hormone and leuteinizing hormone8 G' K4 [* a, l- D8 O; z
concentrations were less than 0.05 mIU/mL$ y: `% A$ m8 |" U. r: n
(prepubertal).4 I* P9 O6 e  _# a1 G$ G, L
The parents were notified about the laboratory( X' n& w4 G4 v8 T( U& ^3 @, A
results and were informed that all of the tests were. v& N9 Q* p: m! a
normal except the testosterone level was high. The
* y) m0 g) {& n9 f# M1 L( J- Rfollow-up visit was arranged within a few weeks to# ]8 f/ [/ t" W+ c
obtain testicular and abdominal sonograms; how-
- B# g! w3 x7 h" o( ^9 ]! }ever, the family did not return for 4 months.3 p9 i0 o/ n' O
Physical examination at this time revealed that the( j+ ]1 t5 y9 O+ ~$ l4 `
child had grown 2.5 cm in 4 months and had gained' Y$ q8 e  N+ n1 V
2 kg of weight. Physical examination remained" g7 p! P" a+ A8 C
unchanged. Surprisingly, the pubic hair almost com-  X; J  a  S2 c' M2 J( p# n- d2 m/ O# h
pletely disappeared except for a few vellous hairs at
( L/ q$ b, Y$ r- ethe base of the phallus. Testicular volume was still 2
) X( X; J4 [! c* S* EmL, and the size of the penis remained unchanged.5 b/ x0 o, w- t  t
The mother also said that the boy was no longer hav-6 T) n5 b9 W5 R2 \+ V
ing frequent erections.
$ x0 @  r3 c/ x4 l; u; xBoth parents were again questioned about use of* M& @% I; K' W+ ^
any ointment/creams that they may have applied to
* j- u0 k2 |. hthe child’s skin. This time the father admitted the- [  E. t) l$ I7 V3 s  }. s" [* {7 ?
Topical Testosterone Exposure / Bhowmick et al 5418 }* Z) p4 {9 c( A; \
use of testosterone gel twice daily that he was apply-
" Q/ N1 s" E  \7 Oing over his own shoulders, chest, and back area for
7 G6 u; O3 w; g+ }" J) Ra year. The father also revealed he was embarrassed6 d" Q7 X% Y4 `3 B/ {
to disclose that he was using a testosterone gel pre-
( S8 m# h( x# q6 D5 P* f% kscribed by his family physician for decreased libido! U7 }5 P/ g. v7 M0 _4 t# V
secondary to depression.% j0 X6 m' q& A" f* m9 r: F
The child slept in the same bed with parents.$ P+ ?/ d1 g9 w1 I+ N3 j
The father would hug the baby and hold him on his$ B& A% [  ]3 l6 V; ]! s& y' P
chest for a considerable period of time, causing sig-) i( ?$ J3 O" E7 z" D- G3 K
nificant bare skin contact between baby and father.* L$ a2 V' b8 t/ l
The father also admitted that after the phone call,
/ @2 W, L  i9 u2 R6 Lwhen he learned the testosterone level in the baby
+ ?' A& p, k$ I& s4 rwas high, he then read the product information
; s. J+ a0 U; P: |- Gpacket and concluded that it was most likely the rea-7 m* H& p# H' b* J; ^& q
son for the child’s virilization. At that time, they; n6 |( P1 Y$ B1 B! c7 a, l
decided to put the baby in a separate bed, and the  }+ C" y) I; v6 `! j' r8 {
father was not hugging him with bare skin and had
% V) ?! q& L$ O0 L; _3 |8 [: sbeen using protective clothing. A repeat testosterone
  l# R6 w  E* h0 Z5 E) \7 t3 Qtest was ordered, but the family did not go to the, W8 Y0 t- Q$ S3 O' t: d, T! X
laboratory to obtain the test.
4 r8 H9 [" Z" _9 sDiscussion
+ X2 B  d; U" o8 i. q: \Precocious puberty in boys is defined as secondary
: G" T7 S) \7 O/ C' _8 Gsexual development before 9 years of age.1,4) Q" ]# v( `' k9 l8 d
Precocious puberty is termed as central (true) when
9 X8 F7 u/ Y! `" q0 k; Zit is caused by the premature activation of hypo-
; s$ \% ]0 ]. V+ wthalamic pituitary gonadal axis. CPP is more com-
% ^6 w; f: v' e0 w8 I2 Imon in girls than in boys.1,3 Most boys with CPP
5 D% L( W' w- \4 {! q6 a% rmay have a central nervous system lesion that is
5 x. a+ K6 L9 ~' ^responsible for the early activation of the hypothal-
: ~- M% I3 L8 p0 damic pituitary gonadal axis.1-3 Thus, greater empha-  y. G' ~+ H; x/ s
sis has been given to neuroradiologic imaging in
1 g. g9 g$ S2 i" ^boys with precocious puberty. In addition to viril-& ]7 o( T9 x% Z) l# m" T5 P" x! ]( V
ization, the clinical hallmark of CPP is the symmet-. w& P$ W. ^# I5 Y. P2 X0 A
rical testicular growth secondary to stimulation by3 j0 `8 v% {* F1 c
gonadotropins.1,3
! x3 [# }3 ?* p' N% ~Gonadotropin-independent peripheral preco-' r6 E) T  |% e- T
cious puberty in boys also results from inappropriate  r  D8 O' E2 j* ~) \
androgenic stimulation from either endogenous or1 c6 p( Z( m7 V
exogenous sources, nonpituitary gonadotropin stim-  y8 L* \+ s  s9 z
ulation, and rare activating mutations.3 Virilizing7 Z, s  P7 h5 a
congenital adrenal hyperplasia producing excessive2 n# D& o0 P) S! N6 |2 d! x
adrenal androgens is a common cause of precocious. q4 Z2 u3 n6 M# J/ u
puberty in boys.3,4# q, V3 G9 j: ?  M' x
The most common form of congenital adrenal, `1 R$ R, T  c% f# o& C
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 D: y9 s) Y3 x7 U/ P: A8 _The 11-β hydroxylase deficiency may also result in
% P7 V& _7 Q7 ~. q1 S/ v' Yexcessive adrenal androgen production, and rarely,
# O# ]6 f/ L* |8 m; g: U8 ]: M& ran adrenal tumor may also cause adrenal androgen
' h; o* I: m* gexcess.1,3$ ^& |, m- L( b5 c  h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" D) R" C$ z' Y% k
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& Q! e3 N$ i4 h
A unique entity of male-limited gonadotropin-
3 j2 L6 u+ `# m% Iindependent precocious puberty, which is also known
9 j+ ?* i3 ~/ H) C0 M( kas testotoxicosis, may cause precocious puberty at a
' ~: O: I' y( h( R2 _4 {& Every young age. The physical findings in these boys
. ]6 V/ r, Q: E! m( ^1 pwith this disorder are full pubertal development,
3 J& K4 {! Y2 xincluding bilateral testicular growth, similar to boys% {9 P9 D# `! p+ q
with CPP. The gonadotropin levels in this disorder: q% v% q/ E2 f. G' q
are suppressed to prepubertal levels and do not show5 P  d% Z: \' _3 d
pubertal response of gonadotropin after gonadotropin-( S( H" C, h4 @( }
releasing hormone stimulation. This is a sex-linked
' ^, b7 m) O/ z# s8 Nautosomal dominant disorder that affects only) w( T4 p" L- J. }7 s; T
males; therefore, other male members of the family
& F4 O) S- Z3 qmay have similar precocious puberty.3; h' @8 G; W# `7 ?) `& @
In our patient, physical examination was incon-
, m! @$ O0 C: P- |  u, N/ X7 @, Y* j/ \8 usistent with true precocious puberty since his testi-4 l+ u  z7 n$ I, `' |
cles were prepubertal in size. However, testotoxicosis
5 J* F$ Z- b8 N4 K! Qwas in the differential diagnosis because his father
( U8 F& _5 a! o0 Lstarted puberty somewhat early, and occasionally,
0 p$ C- ?6 v9 o0 B6 stesticular enlargement is not that evident in the" B' p( H- A/ T; E5 X8 k1 ]
beginning of this process.1 In the absence of a neg-
& ]& R- c5 F8 `+ oative initial history of androgen exposure, our
- S) |6 L& }( p* Xbiggest concern was virilizing adrenal hyperplasia,3 W8 d; M+ u  f8 P( k
either 21-hydroxylase deficiency or 11-β hydroxylase: w3 V4 j& e3 u5 w/ e8 J1 s. u
deficiency. Those diagnoses were excluded by find-# o8 N5 c7 Y. j# d3 N* i- x
ing the normal level of adrenal steroids.3 y* h* ?4 M7 \0 Y% u6 @* v7 W
The diagnosis of exogenous androgens was strongly' R3 ^3 e1 g2 I9 e! r
suspected in a follow-up visit after 4 months because/ B) w) M- _" f6 Y, ?* t
the physical examination revealed the complete disap-6 z) k: A7 z9 J0 S  U. U
pearance of pubic hair, normal growth velocity, and: O% C3 C! D" P' ^% z# f
decreased erections. The father admitted using a testos-
% t! l) L$ d1 }3 k3 H9 I5 j* yterone gel, which he concealed at first visit. He was
9 |) n# n' ?+ n% K7 wusing it rather frequently, twice a day. The Physicians’
+ C4 Y, r7 X' wDesk Reference, or package insert of this product, gel or7 X, S: C( a# p' J9 Y1 R7 g
cream, cautions about dermal testosterone transfer to
* f: A2 s) S* z, U# @9 ounprotected females through direct skin exposure.
7 o7 N/ W6 I4 K/ [Serum testosterone level was found to be 2 times the
' F: v/ U  |1 t- G. c  g3 v& z- rbaseline value in those females who were exposed to
* ?+ R/ s7 ^% \even 15 minutes of direct skin contact with their male3 p; [5 \' ~7 H. @
partners.6 However, when a shirt covered the applica-
) [/ z! A( B, a: V  a, Ntion site, this testosterone transfer was prevented.
; H8 t( d8 B  {  D: q5 V) WOur patient’s testosterone level was 60 ng/mL,
- b9 f/ c( J. |3 Q/ Iwhich was clearly high. Some studies suggest that1 F3 c9 W4 I, ~1 g" K9 W
dermal conversion of testosterone to dihydrotestos-# S' `0 @& a# b2 [. h, K
terone, which is a more potent metabolite, is more) h8 R( Y4 G( n
active in young children exposed to testosterone
$ Z! G& N  Y6 [* D& }exogenously7; however, we did not measure a dihy-/ [1 P: l: o9 ?
drotestosterone level in our patient. In addition to
0 o0 }) _* _7 j" f: `virilization, exposure to exogenous testosterone in! X- M) s& U2 ?
children results in an increase in growth velocity and! l% p$ \1 e; F: [: c3 T: v
advanced bone age, as seen in our patient.8 w# O+ s( O! l8 M
The long-term effect of androgen exposure during
1 {6 p( T- B# W  dearly childhood on pubertal development and final  D& a: f5 b- N# s, ]. q0 {
adult height are not fully known and always remain, q7 T2 l5 t( n1 O( `
a concern. Children treated with short-term testos-) n3 y" s( e1 n5 |4 o% g
terone injection or topical androgen may exhibit some
, h  h7 h% R) I& }# V, Lacceleration of the skeletal maturation; however, after8 o/ u9 p: ?2 B- v- [
cessation of treatment, the rate of bone maturation
% I+ `" s* s$ N: s5 ldecelerates and gradually returns to normal.8,9
" `1 m2 ?) A1 ?) dThere are conflicting reports and controversy& b+ D8 y4 ^6 \5 S/ X5 X" X
over the effect of early androgen exposure on adult
2 s3 \$ h7 z( e: Bpenile length.10,11 Some reports suggest subnormal7 z) G$ C# A/ ?% d1 p3 O: J( j
adult penile length, apparently because of downreg-, w9 M4 v9 m+ C" B
ulation of androgen receptor number.10,12 However,
: r- l" T2 Z. {" y. uSutherland et al13 did not find a correlation between: M! M) ?+ {. V8 k: h* {9 j" [
childhood testosterone exposure and reduced adult0 m. W; y+ g% u3 s
penile length in clinical studies.. }/ c/ u, r1 K
Nonetheless, we do not believe our patient is6 v: u1 b+ k  w" a
going to experience any of the untoward effects from3 B! }3 [. Q! Q4 p2 [+ t$ _. `
testosterone exposure as mentioned earlier because8 j" R2 h  ^8 [, b8 R+ C3 c% e7 ~/ n
the exposure was not for a prolonged period of time.
' ^* ~0 N: X4 a0 `6 J! b; W0 L& ?Although the bone age was advanced at the time of3 u9 Y; k% d( ^6 [0 H* O
diagnosis, the child had a normal growth velocity at8 e* }' o' X. a( a$ ?8 h/ t
the follow-up visit. It is hoped that his final adult0 i' [  ?+ t) |7 q, c$ Y
height will not be affected.3 k( h' W6 p3 o; q
Although rarely reported, the widespread avail-
% O6 j$ O3 _+ |& }/ j; Tability of androgen products in our society may
" ?# \/ ?; ]' Z/ a, T4 D% findeed cause more virilization in male or female
$ j1 L  _4 f4 r" {" G$ Zchildren than one would realize. Exposure to andro-
! m2 P& X, y6 V5 Dgen products must be considered and specific ques-
, B4 m* U, @, j$ m- F1 ftioning about the use of a testosterone product or8 k# t. E% p) l* ^) N8 u
gel should be asked of the family members during' Y! B5 Z1 y: A3 I0 k  ~
the evaluation of any children who present with vir-
3 H3 t* p% j) a% E3 @& A' Kilization or peripheral precocious puberty. The diag-
5 U$ b7 h) G4 Y2 p% Gnosis can be established by just a few tests and by  `' o( h8 A0 P( _/ `% O( Q
appropriate history. The inability to obtain such a' W9 v" X2 a7 I$ s6 Q/ i7 r2 t8 X
history, or failure to ask the specific questions, may2 ?8 ]- \& p% s( @* T. y1 p
result in extensive, unnecessary, and expensive
5 ~  N3 R" t& Z4 n0 V0 e. dinvestigation. The primary care physician should be# E0 N+ V  E0 w9 u
aware of this fact, because most of these children
3 s% n, T. ^" o6 x1 a  s3 d: hmay initially present in their practice. The Physicians’
: Y1 A) \0 _$ }" }, mDesk Reference and package insert should also put a
+ {6 q# B" W+ I- i8 b4 G, Zwarning about the virilizing effect on a male or+ c3 p- ]& I- M: M% T
female child who might come in contact with some-
/ M+ w# J$ {- q! U) aone using any of these products.
6 Z8 u$ k3 f; y6 e$ }References
& t' E# s* r' o0 E: @1. Styne DM. The testes: disorder of sexual differentiation
. q. w. P- U# a, b, kand puberty in the male. In: Sperling MA, ed. Pediatric) {0 S3 C1 l4 d- N7 X1 M: f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: T: X7 n; C5 j* Z5 y/ _4 d
2002: 565-628.
' j" n" L- ~/ O% Y' [* ^4 X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 H9 w# S% P: K% U2 `% o3 Opuberty 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$ }2 ?: ^( _" U1 z7 A
Boy Induced by Indirect Topical+ ?0 X! C/ n9 U  P+ F' [) x- Q. R
Exposure to Testosterone
# C$ C3 m$ b: p0 ^, e; bSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 O& ]8 `9 M' Q5 l9 B, q8 land Kenneth R. Rettig, MD1
- k( x2 o: U: ZClinical Pediatrics7 P2 q+ I" f0 s
Volume 46 Number 6
3 N5 Q' j9 l+ q1 h. n$ ]: CJuly 2007 540-543
  X- a+ e* ]7 f" _; R© 2007 Sage Publications
9 o; A5 U* \. Z; c10.1177/00099228062966519 U  s, e: n- q% l; M/ ]* }$ r8 y
http://clp.sagepub.com& K4 x. {2 V2 u- U' Z% I. j" R' d
hosted at3 S, {4 K2 i3 v( e  W! |
http://online.sagepub.com/ h2 y7 i( n" j+ j& J, q5 f6 X; O3 ]7 _
Precocious puberty in boys, central or peripheral," i, P; L9 ~6 V, W9 P
is a significant concern for physicians. Central! x# n' `* C* c& T8 \& D- U  g
precocious puberty (CPP), which is mediated. m& d7 r9 f" h7 h# v
through the hypothalamic pituitary gonadal axis, has3 W5 c6 ~1 j# Z# I% U; l" N) A
a higher incidence of organic central nervous system
1 q. n0 D" K8 Qlesions in boys.1,2 Virilization in boys, as manifested$ l6 n1 L  X1 b  }5 c, L( j
by enlargement of the penis, development of pubic* K+ A. q' ^5 z# t) P' b
hair, and facial acne without enlargement of testi-3 R' I/ h/ D" _9 g% L8 u
cles, suggests peripheral or pseudopuberty.1-3 We
& ?0 T7 E: q) ]$ w8 |# _# Ereport a 16-month-old boy who presented with the
, ^& j8 C' p4 c1 genlargement of the phallus and pubic hair develop-
& _! o* z8 ]6 ~3 e: |! S* \+ B/ tment without testicular enlargement, which was due
) g/ G3 w! y* N6 f( ~6 ~% ^9 ?6 wto the unintentional exposure to androgen gel used by- A3 g9 N% d9 ~6 O5 i
the father. The family initially concealed this infor-5 E8 t  c2 e7 v: |
mation, resulting in an extensive work-up for this
; x5 a; \4 @; b0 i" L* c/ R! }) Bchild. Given the widespread and easy availability of+ X, P2 q- T9 S
testosterone gel and cream, we believe this is proba-6 G+ S6 E4 l) [- l" ]2 Y$ ^
bly more common than the rare case report in the( ~! V9 `1 C. B5 {: w$ h) F
literature.4% R  e4 b6 U) h& g
Patient Report
. R5 l2 J; }2 n3 ^2 H) v: Q6 UA 16-month-old white child was referred to the( n: H9 a7 K8 K5 f$ g6 v
endocrine clinic by his pediatrician with the concern
+ n2 P4 H# ~  Uof early sexual development. His mother noticed8 w: h3 _0 x" V! R
light colored pubic hair development when he was
3 z% Y2 y( {6 N0 j: y# o% L% t( CFrom the 1Division of Pediatric Endocrinology, 2University of# q. ~! y. r2 a7 O2 F
South Alabama Medical Center, Mobile, Alabama.
* q7 [# d( c; U* x: tAddress correspondence to: Samar K. Bhowmick, MD, FACE,7 `6 W1 |6 }& v
Professor of Pediatrics, University of South Alabama, College of. h! M2 c: S# s3 Y, r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  g4 h. }9 U: e) J. P
e-mail: [email protected].
& l1 b1 k" n5 {# Qabout 6 to 7 months old, which progressively became
3 j% U1 `  ^' _( a# V$ k7 n' qdarker. She was also concerned about the enlarge-2 t$ h8 C$ Q4 ^  U+ `  p* `/ O
ment of his penis and frequent erections. The child
2 |6 o/ f3 d  ?( ^( `! n* ?was the product of a full-term normal delivery, with
% m' K/ H0 l, ?7 F+ D1 w! f* J; ^a birth weight of 7 lb 14 oz, and birth length of
4 H, y; H/ g: J, S) q20 inches. He was breast-fed throughout the first year
$ C/ b% p% o. ^5 q" l% fof life and was still receiving breast milk along with
; h8 C4 L0 C3 R( Y; osolid food. He had no hospitalizations or surgery,
9 G$ ?0 B- o0 Y6 i9 c8 `" w9 q8 Hand his psychosocial and psychomotor development1 f5 A+ {8 y5 ~' @: q
was age appropriate./ d3 u& E6 K% P8 W; K7 |
The family history was remarkable for the father,; I/ d5 c; _' w/ u7 z1 e
who was diagnosed with hypothyroidism at age 16,( Z! b3 J* L. d5 i, q' ~2 \
which was treated with thyroxine. The father’s0 q4 N' H1 S$ ?3 F) _- b7 x
height was 6 feet, and he went through a somewhat$ Q2 }9 p  d4 T/ l3 t0 C1 D
early puberty and had stopped growing by age 14.
% I( V- l) P4 k$ Q( Q$ v) iThe father denied taking any other medication. The
9 `# y. r. K$ Q; b7 Vchild’s mother was in good health. Her menarche
, z- V. t- K1 M" C3 ewas at 11 years of age, and her height was at 5 feet
% X" r% d: J, T4 K$ e" D5 inches. There was no other family history of pre-
/ g( e9 L, O# K  q$ qcocious sexual development in the first-degree rela-
5 Z9 ]" P2 ^1 q, l  N% U8 Ytives. There were no siblings.; w; l4 w; p' X: Q6 S
Physical Examination
' S4 _, g1 y/ o0 k8 M$ OThe physical examination revealed a very active,
3 c8 W% d6 ~$ b. I: C! s0 @/ Iplayful, and healthy boy. The vital signs documented
5 S0 p8 U3 E. Ga blood pressure of 85/50 mm Hg, his length was
$ W+ p' J, z% y; V5 y90 cm (>97th percentile), and his weight was 14.4 kg/ h; n7 h9 D( C6 o  ~
(also >97th percentile). The observed yearly growth/ W8 |( }7 ?4 F
velocity was 30 cm (12 inches). The examination of4 y" y2 N4 {9 x7 |5 d$ ~
the neck revealed no thyroid enlargement.
/ j, m+ g. G1 UThe genitourinary examination was remarkable for5 ]* v" e6 E  v* x7 T9 F+ R
enlargement of the penis, with a stretched length of
( E3 C- N6 ]" Y- E5 Q0 _4 |8 cm and a width of 2 cm. The glans penis was very well  M$ n2 _  i+ A8 A6 C0 u* T
developed. The pubic hair was Tanner II, mostly around. L9 ?, k4 t& {2 x4 e3 E' h
540' U- W! l4 F+ x0 u+ e3 n7 u- @/ d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 D" y( `1 \$ W+ J2 J2 Gthe base of the phallus and was dark and curled. The
1 m; ~) K' R& U4 Jtesticular volume was prepubertal at 2 mL each.* p4 z: O, m# |/ u9 P
The skin was moist and smooth and somewhat
- Y' L/ Z+ G8 c5 w& p. ]oily. No axillary hair was noted. There were no
- R( c1 d3 ~4 q) ?3 N' h6 zabnormal skin pigmentations or café-au-lait spots.8 o& `0 ^9 o$ d: c
Neurologic evaluation showed deep tendon reflex 2+! ~' \* ?$ ?- n4 d+ t
bilateral and symmetrical. There was no suggestion8 O7 ?. s$ K" w
of papilledema.
! G3 a( k" C9 ?& f: {Laboratory Evaluation5 n* N, n0 f+ M' ?! ^3 F1 V6 Q
The bone age was consistent with 28 months by( O! m( l% R: ?/ l
using the standard of Greulich and Pyle at a chrono-) H/ ]3 X  o7 e+ ]1 K; e( ~
logic age of 16 months (advanced).5 Chromosomal  v6 K- s4 ?) J# E! y! f0 Q
karyotype was 46XY. The thyroid function test
# M( Q% A; V; O) e1 dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-. y+ W6 g* \8 s2 N
lating hormone level was 1.3 µIU/mL (both normal).
# W" _/ I: w( }The concentrations of serum electrolytes, blood, j( }$ b/ X9 d* G' R6 j1 u6 |
urea nitrogen, creatinine, and calcium all were
3 E, G0 w) C% T1 }: k2 Iwithin normal range for his age. The concentration
! t, Y, H! K9 T: w, S- Mof serum 17-hydroxyprogesterone was 16 ng/dL! B  j9 j) R9 I1 [) A
(normal, 3 to 90 ng/dL), androstenedione was 20
9 a9 r2 _: |, ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& |( |: O5 p3 U0 Q! O( i
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
  x7 U) U& e" g; ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. p. f8 i( L! [, p; o49ng/dL), 11-desoxycortisol (specific compound S): J4 J7 p0 b: P6 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 Y, H4 |0 w; {  y: G8 [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ x! b( D2 C1 g- q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," @8 j# b. ?3 w
and β-human chorionic gonadotropin was less than( E* g# j8 s, Z9 g, ?6 u
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 I1 Z8 m+ R  H- X5 r4 N# astimulating hormone and leuteinizing hormone
* W" m& Z& H; Econcentrations were less than 0.05 mIU/mL
, d( m. o$ {3 |! |8 \(prepubertal).
1 g9 Q3 t" L4 C$ {4 s1 g  }The parents were notified about the laboratory
- x) N. _& b6 F) dresults and were informed that all of the tests were5 n0 [( e! d/ z. u- H
normal except the testosterone level was high. The  g. ?/ C# x, R% l) W) I- I$ E
follow-up visit was arranged within a few weeks to
. b- {: ]! T# t5 J: T8 P8 _7 }, gobtain testicular and abdominal sonograms; how-: V( k0 f. N2 i
ever, the family did not return for 4 months.' c! M' I7 ?& m" k8 e( d
Physical examination at this time revealed that the) x% X! J4 \+ `8 W+ a
child had grown 2.5 cm in 4 months and had gained/ U' b5 E% t: H: E5 B
2 kg of weight. Physical examination remained
2 I9 e$ A6 o( zunchanged. Surprisingly, the pubic hair almost com-
0 S- Y/ d. I* `4 y- ?pletely disappeared except for a few vellous hairs at
: o" q9 e, G  `& w7 U% dthe base of the phallus. Testicular volume was still 2( @" a6 _$ k. ?, u
mL, and the size of the penis remained unchanged.) y  M/ m4 f6 u  Z- ?  B
The mother also said that the boy was no longer hav-
' o2 ?" ^8 w5 h! i& S! ?ing frequent erections.
: S1 I& c- }' p6 LBoth parents were again questioned about use of
- y1 ~9 M8 N0 x1 T# qany ointment/creams that they may have applied to3 c3 n7 }, H4 m4 R' a( y2 m
the child’s skin. This time the father admitted the
6 |' d9 I+ c  o  S' KTopical Testosterone Exposure / Bhowmick et al 541
% y: x, o; ]7 ?# O8 E8 s8 R+ Huse of testosterone gel twice daily that he was apply-
' x( W- y* p% sing over his own shoulders, chest, and back area for# s$ Y; t. B$ W5 p$ ~) O7 d8 z
a year. The father also revealed he was embarrassed
+ j& `  \5 c9 b; t1 _7 ?% ^to disclose that he was using a testosterone gel pre-1 f1 Z% f, p) k
scribed by his family physician for decreased libido
7 i  L; c6 U& `. b' L* {# P( `0 k2 nsecondary to depression.
$ [& _" W. [5 S7 @' H8 K1 ~The child slept in the same bed with parents.3 }9 Q5 a8 c* T- o0 S
The father would hug the baby and hold him on his
) R+ N8 w  X4 v+ C0 e' Bchest for a considerable period of time, causing sig-
8 t) c8 e5 M$ K! e- j0 |  \nificant bare skin contact between baby and father.: m& c' e% ~  \" T
The father also admitted that after the phone call,
4 d4 h2 S) U9 G2 r/ @, Vwhen he learned the testosterone level in the baby- m5 u* v6 F' s  S  X+ ^; [
was high, he then read the product information
, L" m% v8 x  W4 w! Hpacket and concluded that it was most likely the rea-. u  H; o# K& k+ ~) ~' W
son for the child’s virilization. At that time, they) l3 ]2 W2 }: M9 P' Z
decided to put the baby in a separate bed, and the/ j) {, O- P8 [) f5 \: T7 V
father was not hugging him with bare skin and had: x- o  m- e9 A4 _
been using protective clothing. A repeat testosterone# q: u. P3 Y/ A8 h7 p
test was ordered, but the family did not go to the
' F" d" H5 \" G, m' H8 Dlaboratory to obtain the test.
7 K( V; T8 b# a: xDiscussion6 a  H' k+ h" a' {# B2 m# t; l# {
Precocious puberty in boys is defined as secondary) d9 |# {  E5 P, A
sexual development before 9 years of age.1,45 G5 u+ A4 a, U, Q6 V  P& |
Precocious puberty is termed as central (true) when) J: a% X, V7 ?. D
it is caused by the premature activation of hypo-
! u, ^' ^( E  tthalamic pituitary gonadal axis. CPP is more com-9 u( \" v- S/ X- H' i
mon in girls than in boys.1,3 Most boys with CPP
7 z  E6 Z' Y0 \may have a central nervous system lesion that is
& b3 {* v8 x/ a/ `5 Hresponsible for the early activation of the hypothal-
: m- u8 ?- V1 U4 Xamic pituitary gonadal axis.1-3 Thus, greater empha-& @7 Y# R) c4 z$ Y' L
sis has been given to neuroradiologic imaging in
  j' }$ B$ }5 ^6 V+ _* R$ w, ?+ Uboys with precocious puberty. In addition to viril-' m, ?. y- n$ B. M, `
ization, the clinical hallmark of CPP is the symmet-
/ P: U9 J% I# k) q, N/ {# v# F- ?& grical testicular growth secondary to stimulation by6 a  @& G% A# b5 W/ r
gonadotropins.1,3! f- A, z8 O2 y, ^( |  F7 z
Gonadotropin-independent peripheral preco-3 ?  V3 K; O; S8 E& O6 x
cious puberty in boys also results from inappropriate
2 Y) G4 y+ O0 M2 T3 Candrogenic stimulation from either endogenous or+ _: L3 d7 e( v
exogenous sources, nonpituitary gonadotropin stim-* t7 i* f  q  q- k6 J4 h  Q) W( S
ulation, and rare activating mutations.3 Virilizing
9 i. D5 {! f0 d8 t3 A7 A2 m) kcongenital adrenal hyperplasia producing excessive
; k6 i' W0 u1 R  n3 {adrenal androgens is a common cause of precocious- X  N- O: K# \, p& c
puberty in boys.3,4
& B) Y- R; ?) f, SThe most common form of congenital adrenal
" R. x, k) O* |* _* K9 G0 dhyperplasia is the 21-hydroxylase enzyme deficiency.- n6 q/ |; M4 W1 `2 ~* z( H
The 11-β hydroxylase deficiency may also result in  [0 j- U: W, p" [$ `
excessive adrenal androgen production, and rarely,' [( \1 M! p2 d3 E* g6 E. \  Q: m) L9 D
an adrenal tumor may also cause adrenal androgen- s" r# D. L( ]1 W
excess.1,3
" O- [  ^9 I, I9 Y. Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 T( T# E" I( Y* I: Z542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 g5 ^. R$ q& O, I5 H' e
A unique entity of male-limited gonadotropin-- l; C, {* x8 j* Q/ P+ r
independent precocious puberty, which is also known( q2 O& p8 v  s  t) r
as testotoxicosis, may cause precocious puberty at a
! B( x+ z( c3 e$ ~very young age. The physical findings in these boys
5 U8 u* H# ~0 ?% C, [with this disorder are full pubertal development,
& u1 G; |/ [- eincluding bilateral testicular growth, similar to boys
7 H. T( D: L9 {with CPP. The gonadotropin levels in this disorder
1 A9 T# r+ c! i$ d4 yare suppressed to prepubertal levels and do not show3 X2 a, Y! p/ B0 n5 ~$ _
pubertal response of gonadotropin after gonadotropin-. u/ C1 A. ?* o5 X1 U  ?
releasing hormone stimulation. This is a sex-linked
5 b. B. v- ~% `9 j* Sautosomal dominant disorder that affects only
- u( B  g0 p5 Z- _% rmales; therefore, other male members of the family
7 S- m" J; d" emay have similar precocious puberty.3& |) @5 _  X( z* h3 b4 Z
In our patient, physical examination was incon-/ {$ K% h! f9 [5 ]7 t2 p) I$ ~
sistent with true precocious puberty since his testi-0 c' C) O  J1 I/ |6 L2 u* m
cles were prepubertal in size. However, testotoxicosis4 P6 O8 P6 X1 x' U3 g7 H9 |
was in the differential diagnosis because his father9 E; a. L. G  C4 D: Z
started puberty somewhat early, and occasionally,* k- z+ ^  y' I6 H7 V0 m
testicular enlargement is not that evident in the
# |, r: @  B/ f$ x3 r$ v' s: Cbeginning of this process.1 In the absence of a neg-" R+ i; d- a7 R  G% y
ative initial history of androgen exposure, our
) o4 H# f6 T" K" Dbiggest concern was virilizing adrenal hyperplasia,
2 @! h, g# H1 n  t6 z+ c& qeither 21-hydroxylase deficiency or 11-β hydroxylase- z3 ?% Z6 M" h. j0 B
deficiency. Those diagnoses were excluded by find-
& r6 O  z0 e7 ~6 Q; r- J; c1 @, k. Oing the normal level of adrenal steroids.
+ |0 n+ o2 V/ }) mThe diagnosis of exogenous androgens was strongly
2 b' A4 _5 X8 e. b4 @suspected in a follow-up visit after 4 months because! s' O) y' |5 ^$ R8 Q& t( Y3 R( {, r
the physical examination revealed the complete disap-
8 N; y* K+ V; t" zpearance of pubic hair, normal growth velocity, and
' ]9 M/ K" C4 ~- Vdecreased erections. The father admitted using a testos-
4 C  e* p* ]( M: U2 L, bterone gel, which he concealed at first visit. He was
' A9 U3 ~" A  O8 busing it rather frequently, twice a day. The Physicians’
) E+ I3 H) q# b7 F9 oDesk Reference, or package insert of this product, gel or" j* h/ \0 d: Y4 p$ }; m
cream, cautions about dermal testosterone transfer to2 d" r, P9 Y5 q
unprotected females through direct skin exposure.) d6 T, q6 u. a3 u7 i) }: R
Serum testosterone level was found to be 2 times the
6 N* S$ r( ~1 z4 X; g& s, kbaseline value in those females who were exposed to
5 A  k0 D# V, \) x' k7 o- seven 15 minutes of direct skin contact with their male
4 A! g( D* D! W" ?$ T0 u/ t2 T. I! Cpartners.6 However, when a shirt covered the applica-6 d8 x" ~. W3 f) p
tion site, this testosterone transfer was prevented.  e# `0 y0 q3 [, k3 v7 @
Our patient’s testosterone level was 60 ng/mL,
/ ]. Z1 g# ^. F# Q; J1 L% @8 O% Q% wwhich was clearly high. Some studies suggest that2 c! e6 o, u0 M0 `* S
dermal conversion of testosterone to dihydrotestos-
2 X3 ?5 n/ M! c0 J, [. ~9 V/ c- f& Y+ Yterone, which is a more potent metabolite, is more
7 T8 e8 K1 d2 c* [' vactive in young children exposed to testosterone
. M8 P$ F2 o8 b! P4 {4 h# G+ B! s* wexogenously7; however, we did not measure a dihy-
: v6 \- k/ H( ddrotestosterone level in our patient. In addition to& r0 X: D9 ?; j, h1 X$ N( @
virilization, exposure to exogenous testosterone in
( q/ ]7 X5 x- l. }. S* z+ Tchildren results in an increase in growth velocity and
" I% K# T' N' d& f8 w2 l5 zadvanced bone age, as seen in our patient.4 l( d+ c/ o- Y% q
The long-term effect of androgen exposure during- V6 B. Q" u- B) d2 D7 k* Y3 Q5 Y9 Y
early childhood on pubertal development and final
% n) G7 o# t. S  {7 Cadult height are not fully known and always remain1 D! L0 W( H& n- f6 Z; p
a concern. Children treated with short-term testos-, }3 v1 M' S$ o# V% g3 F# A
terone injection or topical androgen may exhibit some; O* L+ Q/ B8 f% M: T/ w; D
acceleration of the skeletal maturation; however, after
4 F- w# ?! ?* S0 T# fcessation of treatment, the rate of bone maturation- z1 ~; e' Q6 l, y
decelerates and gradually returns to normal.8,9
3 K9 p7 p4 \7 s" e* S! B/ u9 @There are conflicting reports and controversy( U$ @' p0 y1 E4 B* [' T
over the effect of early androgen exposure on adult
$ s9 r7 |) E! }penile length.10,11 Some reports suggest subnormal& z: Z& s5 G9 ~" r
adult penile length, apparently because of downreg-
+ S( ~  y2 m4 k4 m. Z& pulation of androgen receptor number.10,12 However,# w1 G7 ?3 R4 i9 e% U
Sutherland et al13 did not find a correlation between# ]/ G0 X- Z8 e$ T, j2 x
childhood testosterone exposure and reduced adult0 c: {9 K* R, M- o  s- g
penile length in clinical studies.
' v% x% N. P9 |, o6 n1 t# TNonetheless, we do not believe our patient is
( Q; Z, J) A% jgoing to experience any of the untoward effects from2 t* @+ ]0 u5 P* z$ ?
testosterone exposure as mentioned earlier because8 u7 p. P( a0 F9 \
the exposure was not for a prolonged period of time.
* h/ X! ^6 T8 \6 S  j& y7 qAlthough the bone age was advanced at the time of
$ Y. w* w- H' a& m3 A5 ddiagnosis, the child had a normal growth velocity at0 P' T! O4 n: J: @; \3 P1 |
the follow-up visit. It is hoped that his final adult
1 T5 s+ j& e& q/ O; A* g5 {height will not be affected.5 e( K6 z: I0 s+ `, s# u$ v; N
Although rarely reported, the widespread avail-
& @& W2 z- ~. u  B. w! O" y4 A& rability of androgen products in our society may
1 @6 V( E$ |* V" j" I' i2 ~$ O# bindeed cause more virilization in male or female8 V* C  J: r+ k9 ^/ Y% ]2 n- w% z
children than one would realize. Exposure to andro-
, T9 \% `5 R( g0 I4 {$ ?# U2 Ngen products must be considered and specific ques-
( ~6 ?9 H- I5 L1 W3 etioning about the use of a testosterone product or
4 b+ M+ l6 A6 ]4 [' Lgel should be asked of the family members during0 n9 r0 t* q" t2 e
the evaluation of any children who present with vir-
" [; M  o+ Y3 H& q% J- `  N: z3 \ilization or peripheral precocious puberty. The diag-+ F4 @* }3 w$ L7 C& ]( m  m5 M3 c
nosis can be established by just a few tests and by
0 X- I8 Y. _  Mappropriate history. The inability to obtain such a
- h( g' R8 o) x- Zhistory, or failure to ask the specific questions, may0 P' Y: v# U! f7 R6 f
result in extensive, unnecessary, and expensive
5 k# U+ O2 m' L0 V( H; h, ^investigation. The primary care physician should be; H3 R4 O/ `8 N1 _3 a  H; e
aware of this fact, because most of these children" a2 ~) E! i  S8 {+ p8 f' B0 B
may initially present in their practice. The Physicians’) `: b6 |5 o8 u% {
Desk Reference and package insert should also put a
2 W! _# ]" a  l$ s- [, d7 C1 Fwarning about the virilizing effect on a male or# }5 _- n) U+ C% a9 G
female child who might come in contact with some-
% n" P  M, h+ d; r+ \/ S4 Q5 {one using any of these products.& h3 s5 o# e' x2 Q9 S
References
8 ~" \+ t# I/ f) R  [: G" [' Z1. Styne DM. The testes: disorder of sexual differentiation1 P, D+ J8 W5 {/ o. R8 o$ A3 [
and puberty in the male. In: Sperling MA, ed. Pediatric' q2 D: X! _" j5 Q0 s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' G% A" n* L% B2 `; i# ~, V2002: 565-628.4 q6 h8 d) O# I, ^6 {  k7 d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, _! b8 w* ~0 B2 r$ g& T$ \$ jpuberty 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

" z( p4 {' j  V: K' R; g2 s" i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