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
5 c4 O* i5 N4 b) dBoy Induced by Indirect Topical
# K% F& q! e7 ?3 ?2 B6 ]! ]Exposure to Testosterone' M; ^( _" ]" E/ g; r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% |, M0 |9 x5 b3 A3 p) }' q
and Kenneth R. Rettig, MD1( N- S  V& U# L2 C, a8 r
Clinical Pediatrics
' H7 t" p2 m( h) |" iVolume 46 Number 6
3 R) e* U. l6 F& T8 [July 2007 540-543
/ r4 X4 S7 D; m. G© 2007 Sage Publications
7 c# P7 _( g0 L+ F6 f4 F10.1177/0009922806296651
' X! y, D6 c8 w5 _. xhttp://clp.sagepub.com0 ]5 w. g$ x) G) A  M. O
hosted at
2 o! x6 B) A* S& fhttp://online.sagepub.com" c9 A" k5 L- G2 m! t4 }4 s
Precocious puberty in boys, central or peripheral,
0 c3 j: C: S# W( F1 jis a significant concern for physicians. Central& a8 V' O* i1 K. K( ^; Z
precocious puberty (CPP), which is mediated8 E# N! z1 h% ^+ L5 F" o
through the hypothalamic pituitary gonadal axis, has
: m% W# E% x8 m# da higher incidence of organic central nervous system5 n, y0 m3 E( H) V* [' _" f
lesions in boys.1,2 Virilization in boys, as manifested4 V" c1 A: s& r" M9 I
by enlargement of the penis, development of pubic
1 b& Q3 P1 E- G& |* rhair, and facial acne without enlargement of testi-
% E1 ~5 V3 D) Q6 r: w1 Jcles, suggests peripheral or pseudopuberty.1-3 We
) U' a" O0 S3 ureport a 16-month-old boy who presented with the
! L2 X& `; q/ P! ]: Z( n0 [enlargement of the phallus and pubic hair develop-* t4 T7 B% N% W, O0 k4 O  G8 m
ment without testicular enlargement, which was due" G: f3 P( t5 E" C* D* L
to the unintentional exposure to androgen gel used by
! I1 I& l  {! u/ S( L+ k; Ethe father. The family initially concealed this infor-& F5 t) s6 g* X8 f5 X( h3 E6 [3 \& U
mation, resulting in an extensive work-up for this
; h& ^, U  u0 v8 `child. Given the widespread and easy availability of7 T( x( K: {  a4 P
testosterone gel and cream, we believe this is proba-+ m; ^- n% j; y+ a. i' N
bly more common than the rare case report in the  y! [8 l, B9 Z0 Z8 j2 z
literature.4- O# U2 m5 O( S, o% P) M
Patient Report
0 H! W" r8 t8 N- cA 16-month-old white child was referred to the
" a0 S) I' A3 \6 S+ M( w3 p4 mendocrine clinic by his pediatrician with the concern, R3 }! y+ Z, f( _. a. f% L
of early sexual development. His mother noticed
4 x- o3 u+ q2 _. P  B% e# r& [light colored pubic hair development when he was
, C( w0 I# m) ?From the 1Division of Pediatric Endocrinology, 2University of
! u8 O0 ]' P& v0 r% E1 g/ ASouth Alabama Medical Center, Mobile, Alabama.
; H( r5 }: }) d( e: i7 KAddress correspondence to: Samar K. Bhowmick, MD, FACE,
8 m/ s8 a5 x& A9 x: }& x2 |Professor of Pediatrics, University of South Alabama, College of* a' m" P5 |. w; u0 S+ e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; X- _# |$ O0 J  M5 T, {4 E1 |3 ^) H* ^
e-mail: [email protected].8 W8 X5 N+ H% F
about 6 to 7 months old, which progressively became
  X! V6 H. K8 cdarker. She was also concerned about the enlarge-$ W8 Y5 B! G. S
ment of his penis and frequent erections. The child) Q( D  i5 U# U6 P" ^  Q  }
was the product of a full-term normal delivery, with
& V: V" V) Y+ u; T: T) }a birth weight of 7 lb 14 oz, and birth length of
  ^/ U* t4 A6 C9 C5 N! Y+ X$ u: t5 h20 inches. He was breast-fed throughout the first year9 Z! o) c- n$ L
of life and was still receiving breast milk along with
2 D; ^1 l" a0 N3 B7 R& hsolid food. He had no hospitalizations or surgery,
3 g3 o- g; p4 I; L) \and his psychosocial and psychomotor development: b1 E* M  u7 v  H
was age appropriate.
# g' Y. c3 M+ J6 m; o5 bThe family history was remarkable for the father,
" h, J: s, o( ~2 Q8 z; _' s1 |who was diagnosed with hypothyroidism at age 16,+ i5 Q: ^5 q& m* ]8 o
which was treated with thyroxine. The father’s
7 g3 S! u, q2 G  K! q) y9 r# [5 I8 f4 Zheight was 6 feet, and he went through a somewhat
* T) F9 t$ j8 U4 bearly puberty and had stopped growing by age 14.
6 C( d" s7 ^  J! l* hThe father denied taking any other medication. The' U! j$ T, }6 ^/ t) x" v2 Y
child’s mother was in good health. Her menarche+ W0 x' T; g6 E( D
was at 11 years of age, and her height was at 5 feet4 h1 q* |; n4 v0 {
5 inches. There was no other family history of pre-
0 o4 ]5 U2 R7 L  bcocious sexual development in the first-degree rela-
6 w% v: b' n5 Qtives. There were no siblings.6 i1 m' [) d* F* _2 N( {8 s+ n
Physical Examination5 y! c) [( e0 h/ R. _' v
The physical examination revealed a very active,9 w% v8 u# ]2 f8 W
playful, and healthy boy. The vital signs documented
* t$ b& a+ w' i, }7 M8 ba blood pressure of 85/50 mm Hg, his length was
" g3 _# U8 k1 f3 A/ C* P; G' ]90 cm (>97th percentile), and his weight was 14.4 kg
% u' [* p( \! J1 f7 ~* j! J/ ]! }5 F7 R(also >97th percentile). The observed yearly growth! [/ @8 K7 X, c. e9 I
velocity was 30 cm (12 inches). The examination of
! \# S: m0 t& ~* e  ^the neck revealed no thyroid enlargement.
- u; Z- O  [9 @The genitourinary examination was remarkable for
% u2 u/ p, ?. O# k) Z9 uenlargement of the penis, with a stretched length of
* I3 ^! j' T* B$ i! q' S8 cm and a width of 2 cm. The glans penis was very well( ~( d  S7 C5 @: r* i7 }* D3 b& X
developed. The pubic hair was Tanner II, mostly around: \% S1 o& i: D( W& Z0 ]  `# x
540
1 b8 O. w' i$ `, U& y# q; gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  j! ]9 }* ?- m7 f+ c, f
the base of the phallus and was dark and curled. The2 j& U8 E$ J9 m* ?4 C" l( v- Z
testicular volume was prepubertal at 2 mL each.% M' p8 i. a2 {5 {# _. G( p
The skin was moist and smooth and somewhat9 S) B3 {+ ^0 s# {* o0 _" `
oily. No axillary hair was noted. There were no
# e+ |0 N) T4 O% V3 J! mabnormal skin pigmentations or café-au-lait spots.
0 w# f0 I" K1 \! rNeurologic evaluation showed deep tendon reflex 2++ s# ~0 l6 i0 ~' W# y% h
bilateral and symmetrical. There was no suggestion
% o' q; P) G% H& Cof papilledema.# `& `" P& E' i+ o
Laboratory Evaluation+ y; m& W# n9 e8 |* q9 x
The bone age was consistent with 28 months by2 W3 {( a+ O9 s- l9 ]: T4 O5 B
using the standard of Greulich and Pyle at a chrono-
/ G  S, x" r: c* Xlogic age of 16 months (advanced).5 Chromosomal8 b7 o" |$ H. k7 d- G2 I  G
karyotype was 46XY. The thyroid function test
% j0 Y& a  m# C7 U; Q* u( Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 _* m3 P% L0 O! m  X0 ?
lating hormone level was 1.3 µIU/mL (both normal).3 |& W( I2 ]9 g. |( s- q
The concentrations of serum electrolytes, blood
" W2 h# a9 X% ^urea nitrogen, creatinine, and calcium all were$ ]( ~6 W! z8 X' d. A
within normal range for his age. The concentration
) L8 |% ~* H% J/ Hof serum 17-hydroxyprogesterone was 16 ng/dL8 n; i1 U8 A$ k! e9 \2 w- r% j
(normal, 3 to 90 ng/dL), androstenedione was 20* Y: R: ]# n& B& H& _: Y5 A, O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& u& i- R+ P+ s0 U) q2 _  \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 K0 |& c5 x( ^+ Y- p4 H3 Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 V* @; i% b! d7 M# V
49ng/dL), 11-desoxycortisol (specific compound S)
$ n4 S4 N" H1 P. F: y  twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: B% b( Q9 u  c# s3 s" g: Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 F$ D4 l4 a$ m, Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 u- C* U8 |- ]- d+ h
and β-human chorionic gonadotropin was less than
+ l, l: L$ _, _  l7 U6 U* ~5 mIU/mL (normal <5 mIU/mL). Serum follicular: _/ u& z2 a# B3 W4 Z5 c: c/ K
stimulating hormone and leuteinizing hormone! e1 E$ f' {- @5 B/ j5 A' P
concentrations were less than 0.05 mIU/mL
. t  U  r" X8 J(prepubertal).6 c' M) |2 y, c! z) _; c
The parents were notified about the laboratory% L8 F' |7 L2 s9 f- k
results and were informed that all of the tests were- S6 {7 D+ i6 v/ }/ C9 k! p
normal except the testosterone level was high. The
4 J" ?  [* H. O. |; vfollow-up visit was arranged within a few weeks to
8 Q1 b" X( O" X2 ^* {0 bobtain testicular and abdominal sonograms; how-. ^: M; F! X& P) k3 d
ever, the family did not return for 4 months.
& G/ I5 G. @4 s$ Q+ b# L1 kPhysical examination at this time revealed that the
1 e% b5 K! }- pchild had grown 2.5 cm in 4 months and had gained& t0 p* k$ f$ l0 c3 N
2 kg of weight. Physical examination remained
) g  z6 h5 y, d( Wunchanged. Surprisingly, the pubic hair almost com-" c$ w1 L" i" n
pletely disappeared except for a few vellous hairs at2 Y1 V/ v! k0 B5 Y
the base of the phallus. Testicular volume was still 2
  a  z0 W+ v( `% P# X2 n) X2 UmL, and the size of the penis remained unchanged.
$ m7 A8 }5 i/ vThe mother also said that the boy was no longer hav-
' x2 M2 y- d. e! _& ^# {5 bing frequent erections.
$ D: E7 \/ @! d6 E% O5 T! ABoth parents were again questioned about use of
4 T5 T! t5 @8 X% t7 q0 A4 }any ointment/creams that they may have applied to
# W4 I: i$ D- i) l, Z$ x# rthe child’s skin. This time the father admitted the
: E9 G9 P4 ~; S3 d$ VTopical Testosterone Exposure / Bhowmick et al 541" D6 F: W5 `" k7 h8 Z
use of testosterone gel twice daily that he was apply-* [* ^' z1 G1 P
ing over his own shoulders, chest, and back area for4 c0 }: W7 p7 O, @. G2 B8 Q. u0 b
a year. The father also revealed he was embarrassed
* K2 L" a1 a0 pto disclose that he was using a testosterone gel pre-: ~! z, ?: A5 Z0 c
scribed by his family physician for decreased libido
2 h: S6 r* B) v8 l+ j% Xsecondary to depression." D. _! d. q! z
The child slept in the same bed with parents.
- L: l$ l- F9 ~( K% W; hThe father would hug the baby and hold him on his
! E( T2 D& x8 g: A% @* Echest for a considerable period of time, causing sig-
9 |% Z8 x: Z! e7 G7 d# m8 _nificant bare skin contact between baby and father." }4 Y, V2 a! K0 l* h% d
The father also admitted that after the phone call,( X/ ?9 [1 F0 e2 ^* g/ D+ \
when he learned the testosterone level in the baby% q) M. U6 x5 o% a# @
was high, he then read the product information
# `3 l+ g1 M, q! g9 d) B. W, u1 Vpacket and concluded that it was most likely the rea-+ s4 ~2 d: [& N: P8 j0 p
son for the child’s virilization. At that time, they6 \; }/ }. w0 v: c4 V' b% e
decided to put the baby in a separate bed, and the
2 `1 D4 D* D' z, d. q& x! h# {4 Lfather was not hugging him with bare skin and had
0 \; r: ^  Z1 s) q# ]been using protective clothing. A repeat testosterone
0 N1 i# k1 Q% m' T% F& f5 K% J* O2 e( r: Gtest was ordered, but the family did not go to the9 n* x8 j* {: T" }
laboratory to obtain the test.
4 C( L" _$ D1 W; ]/ \Discussion! ?0 t2 }) X4 j# Z/ r9 k& ^
Precocious puberty in boys is defined as secondary8 s2 o$ u6 A( Y6 g
sexual development before 9 years of age.1,4* F% j; o0 ?1 ?# b7 {6 l
Precocious puberty is termed as central (true) when+ y8 N$ h; W2 m0 J
it is caused by the premature activation of hypo-2 [6 d: A: U: W8 X; E7 V
thalamic pituitary gonadal axis. CPP is more com-
5 W& \3 L5 i# E* omon in girls than in boys.1,3 Most boys with CPP5 W" D# x6 f( j
may have a central nervous system lesion that is
4 ]- @* ~6 G& Z" s% y8 ]( Cresponsible for the early activation of the hypothal-* I& B: E( f9 K1 l3 M) \0 i
amic pituitary gonadal axis.1-3 Thus, greater empha-( D/ z% Z) X. h2 Q# d4 n
sis has been given to neuroradiologic imaging in
- D  m4 l/ P8 @; bboys with precocious puberty. In addition to viril-) j' B# q! C" p
ization, the clinical hallmark of CPP is the symmet-( |5 i5 H7 j, O% ?
rical testicular growth secondary to stimulation by
. r" b: T  g# B$ S  l! [# Qgonadotropins.1,32 L! }0 x$ ~4 p  K
Gonadotropin-independent peripheral preco-
, ^8 L, _. K& S# i1 q& X8 u% g: Qcious puberty in boys also results from inappropriate5 P' t4 b7 i$ r. v' z
androgenic stimulation from either endogenous or+ |+ h; A  U( r+ @6 u9 y8 S" e1 i
exogenous sources, nonpituitary gonadotropin stim-! I; e/ `+ Y+ c* w! \2 W
ulation, and rare activating mutations.3 Virilizing& |3 z& k) }# M0 G
congenital adrenal hyperplasia producing excessive
& z/ a0 L% L1 y, x, }adrenal androgens is a common cause of precocious
5 O1 |' G. Z* l9 j) I+ jpuberty in boys.3,4
: R# Y2 {2 T1 v! u7 B8 Q) _The most common form of congenital adrenal; S  C/ p. G6 C6 Q4 O* s
hyperplasia is the 21-hydroxylase enzyme deficiency.7 b4 C. P9 o4 U3 u8 M  z
The 11-β hydroxylase deficiency may also result in) J- |3 I& s+ w( `' s
excessive adrenal androgen production, and rarely,; ?9 ]. K! y, o
an adrenal tumor may also cause adrenal androgen
: u. m% @& K- |% a  fexcess.1,3/ j# C% X7 Z) H) i( [3 j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) ?  G; U! ~5 D1 I$ I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ A* e0 R/ K9 ~. e) p
A unique entity of male-limited gonadotropin-) b5 Q# g; }" R
independent precocious puberty, which is also known2 X  w9 p) O( h* j, X3 [/ K2 M3 L& s
as testotoxicosis, may cause precocious puberty at a% l  f/ _* C: K) B
very young age. The physical findings in these boys
5 j; F: p; \* i: N4 A+ awith this disorder are full pubertal development,
+ V# ^6 l, e! x8 Dincluding bilateral testicular growth, similar to boys
, W, g' M6 J0 f9 Y+ W) v5 Rwith CPP. The gonadotropin levels in this disorder
2 O6 f* x& f' u% U6 yare suppressed to prepubertal levels and do not show
3 D: A' [, v7 K- I' R( h' qpubertal response of gonadotropin after gonadotropin-
6 ]$ u$ c; M: W+ G' hreleasing hormone stimulation. This is a sex-linked
: S2 v! z  v) o7 rautosomal dominant disorder that affects only
$ _2 F. e4 O4 U/ Vmales; therefore, other male members of the family6 @' c# l2 j4 z
may have similar precocious puberty.3
8 U3 P1 ~; t, V* o# JIn our patient, physical examination was incon-7 ~+ I; U' {' S& @
sistent with true precocious puberty since his testi-
7 z2 }7 s/ B. V3 E# m! R5 L& Pcles were prepubertal in size. However, testotoxicosis. P( J8 t! k- D9 X1 \
was in the differential diagnosis because his father
; |: [3 V7 f! k1 e4 Y7 c1 Cstarted puberty somewhat early, and occasionally,! U- A2 R" J6 f( u# q1 l
testicular enlargement is not that evident in the
" W- T1 ^& ~# r/ s1 L. H8 C& tbeginning of this process.1 In the absence of a neg-
0 d8 }' W# }; u0 @! M: [; ^+ ^ative initial history of androgen exposure, our
) [" W; F" P$ O' d2 X, u7 Zbiggest concern was virilizing adrenal hyperplasia,
5 j* E2 F' h0 \) S$ \* Peither 21-hydroxylase deficiency or 11-β hydroxylase
4 ~8 g. Z, y9 |/ f( ?: Jdeficiency. Those diagnoses were excluded by find-3 g8 A' b, p* b6 U. \5 ^
ing the normal level of adrenal steroids.9 D1 t( J0 x7 Y$ _
The diagnosis of exogenous androgens was strongly
) ]) `) I8 p- ~* O- L9 Dsuspected in a follow-up visit after 4 months because
' q$ t6 A0 h5 M; b, b1 gthe physical examination revealed the complete disap-9 n$ s) W: S( |/ ^0 n
pearance of pubic hair, normal growth velocity, and
" s  U. c3 n  `" ddecreased erections. The father admitted using a testos-
/ e% O! \' \* h9 Z# }; L+ G; Hterone gel, which he concealed at first visit. He was
9 y2 `# @" B8 x/ R& _: Lusing it rather frequently, twice a day. The Physicians’2 B) W; c! j' A- [- `5 j1 `
Desk Reference, or package insert of this product, gel or* K2 O. q; d% @0 I
cream, cautions about dermal testosterone transfer to
7 J0 ^+ M; f# ?* Qunprotected females through direct skin exposure.
9 `9 g/ L1 Q7 HSerum testosterone level was found to be 2 times the  v$ U: b4 P) ~( v; x! P# |
baseline value in those females who were exposed to
/ J& w% y4 B$ c7 e/ ~( S$ q; Ueven 15 minutes of direct skin contact with their male
8 x, I* G3 F/ }partners.6 However, when a shirt covered the applica-- F% T% f, Q( n9 W
tion site, this testosterone transfer was prevented.
! j4 ^9 P- x. i' U. s# tOur patient’s testosterone level was 60 ng/mL,# ]2 t' A; ^, V' [" r* @3 o/ O& x
which was clearly high. Some studies suggest that0 Z# l3 `9 r4 |. c! m
dermal conversion of testosterone to dihydrotestos-7 }: k8 `$ t: s9 x) f( K
terone, which is a more potent metabolite, is more6 J& e1 L0 ?' Y) j: j9 |0 L: R( Z
active in young children exposed to testosterone
8 ^& c7 Y& Q* ~: p7 c. R0 |exogenously7; however, we did not measure a dihy-/ B- Z; p( m6 v
drotestosterone level in our patient. In addition to
+ v: Y+ F% N/ \1 a/ K+ ^virilization, exposure to exogenous testosterone in
! ^7 U/ ]7 R2 D( D2 ^children results in an increase in growth velocity and1 n/ j1 k4 I7 q0 c
advanced bone age, as seen in our patient.! L2 O7 V5 N' H
The long-term effect of androgen exposure during
# m! k8 i3 H2 C& F& N+ W5 ?  tearly childhood on pubertal development and final. O# d* p2 F9 O( P* M. x/ W# T# V) L
adult height are not fully known and always remain1 M$ |* p2 `% n- X$ N; c
a concern. Children treated with short-term testos-
0 l" q( F6 f7 P* wterone injection or topical androgen may exhibit some# v* k2 Y8 ?8 P! h* z
acceleration of the skeletal maturation; however, after
+ t7 o2 ?+ ~' K# ?* ncessation of treatment, the rate of bone maturation+ C# m& ?" l: Z* v4 W" W3 f# c
decelerates and gradually returns to normal.8,9
  |, ?" l# n! D- s7 eThere are conflicting reports and controversy, J- i1 @0 x8 g. ~( U6 W2 P0 c- J
over the effect of early androgen exposure on adult
. k/ R; Q7 K2 F# M5 dpenile length.10,11 Some reports suggest subnormal% n( s' x6 b: V0 u+ Z: G
adult penile length, apparently because of downreg-5 s1 u) t+ N# w0 z0 r
ulation of androgen receptor number.10,12 However,
9 @! m4 I1 Y; M" MSutherland et al13 did not find a correlation between
5 a4 i0 o, m. }/ a6 t6 schildhood testosterone exposure and reduced adult
) ?# u, |0 s/ Y  K4 Hpenile length in clinical studies.
1 E* p( ^/ u9 p' }6 F% ]9 nNonetheless, we do not believe our patient is
! B# P3 S* }1 [6 Y0 L/ Y  p; Sgoing to experience any of the untoward effects from0 @3 ]' u6 ?" a0 v: F! M& }( w+ ~
testosterone exposure as mentioned earlier because
6 e! Q6 }" w6 T( _, `2 d0 [the exposure was not for a prolonged period of time.) ^" ?* k5 j2 e3 q8 S+ c* C9 n' J
Although the bone age was advanced at the time of
) L8 ~$ q7 c  q9 Sdiagnosis, the child had a normal growth velocity at
, @2 D' E# P' y5 Rthe follow-up visit. It is hoped that his final adult) }! y' b( s. H- M% q
height will not be affected.
; J0 A: t) V% BAlthough rarely reported, the widespread avail-
' K3 Y+ {4 ~, [# h# x$ ~$ [: tability of androgen products in our society may4 T" M8 b& I. d1 l% \
indeed cause more virilization in male or female
3 W: L+ ]$ _5 E$ S/ xchildren than one would realize. Exposure to andro-( l. T+ ]3 g  i2 K. z& J4 i+ T
gen products must be considered and specific ques-% C' C% H; s! n
tioning about the use of a testosterone product or1 g3 A7 `5 q4 t3 x7 |" m
gel should be asked of the family members during
) a* v" O$ z9 ^* C4 ?" ]5 B8 ?the evaluation of any children who present with vir-
9 s5 D6 H9 X: C# {0 c7 s- tilization or peripheral precocious puberty. The diag-
# Y- |, W3 J' n3 {2 d/ Y$ Jnosis can be established by just a few tests and by1 f7 e% [. j; e( U8 t# z7 `7 c& r
appropriate history. The inability to obtain such a' P1 a! U! _) V! U. _2 ^- a- H
history, or failure to ask the specific questions, may& c3 R) X; L$ Y! k1 E
result in extensive, unnecessary, and expensive
/ t' ^2 f& U6 ~0 |' m' V0 einvestigation. The primary care physician should be/ C  J0 Q2 k5 F3 h  ~
aware of this fact, because most of these children
* z% ]8 ^! m. S$ d" ?% l/ r1 \may initially present in their practice. The Physicians’
9 y3 p" ]" ?4 nDesk Reference and package insert should also put a: z( C# H" |' f4 o. r
warning about the virilizing effect on a male or% X0 z- X- S" [7 W( M- l
female child who might come in contact with some-
$ i, l2 t: z$ p7 s( l" {. Mone using any of these products.* K  z: _. E0 z3 j6 j+ d2 k5 P+ ]" Y
References
0 Q0 J' I6 z, A! `' M5 k: L. ]1. Styne DM. The testes: disorder of sexual differentiation
4 W# e" Q  R1 A3 Fand puberty in the male. In: Sperling MA, ed. Pediatric
* a; Q2 P. y0 s- M4 }( I- N+ wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! F8 L7 m/ K3 g
2002: 565-628.
% e) b( Q( b: a% S8 l+ U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ S8 Q; L: h8 Y4 S; `
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-Old
8 m& d) Y$ R, CBoy Induced by Indirect Topical& A2 e" h8 q" \8 o) e. T
Exposure to Testosterone2 U0 _' c* ^  ]) j( @. R' @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 r; [8 c( g+ @' `3 ?
and Kenneth R. Rettig, MD16 K) P, w: v3 e3 U
Clinical Pediatrics1 N1 }8 F/ L7 X
Volume 46 Number 6  y+ j6 v6 t4 m# r7 @
July 2007 540-543/ ]4 w& O9 x% D( m( A
© 2007 Sage Publications* [* e3 o% \2 M( O
10.1177/0009922806296651
& ]- ~' g0 ?1 l1 U5 K( d8 T& jhttp://clp.sagepub.com: e/ V& J, p4 d5 ~! y! o+ Q- r
hosted at- n0 \) k& P; @1 ^* T
http://online.sagepub.com
. T4 G( }/ q! m/ G' _Precocious puberty in boys, central or peripheral,7 J( `4 y+ R3 U0 O1 E4 D$ i! e
is a significant concern for physicians. Central# f, g9 z, X3 X: r; c5 k
precocious puberty (CPP), which is mediated
& T4 @; Q$ x0 N& g! Dthrough the hypothalamic pituitary gonadal axis, has
+ l; J/ ~) f" R' q9 L( Na higher incidence of organic central nervous system3 z1 r' w5 S7 B; z6 a9 A
lesions in boys.1,2 Virilization in boys, as manifested
& Z. D% Q3 y" Fby enlargement of the penis, development of pubic
  a- y" X, G' ihair, and facial acne without enlargement of testi-, Y& z- b# C/ U8 Q/ e1 z
cles, suggests peripheral or pseudopuberty.1-3 We
( n* e) }2 {4 @$ Nreport a 16-month-old boy who presented with the# E7 e" y4 v$ I# [# \# o
enlargement of the phallus and pubic hair develop-$ A5 ?7 b2 e  X5 d% A! H; q
ment without testicular enlargement, which was due
8 O' U# Z& K. `# x( p8 B7 j( y2 `to the unintentional exposure to androgen gel used by
( W; C8 J0 ^. O, _9 ~the father. The family initially concealed this infor-$ Q" b( L8 r4 y) Q" x
mation, resulting in an extensive work-up for this) m5 b; o! o+ H. v! R. m
child. Given the widespread and easy availability of: ~/ w# Y, s. D. U
testosterone gel and cream, we believe this is proba-& @, `* I+ U# |& S3 a# v1 n" q
bly more common than the rare case report in the
# ^% z) E$ J6 V  C! jliterature.4, K$ e1 D( r1 V) Q# u2 N
Patient Report
2 f( D" \: K7 c' Q% C7 }8 p# tA 16-month-old white child was referred to the
9 O* P1 Q5 i  ^1 R0 i/ M7 j8 ?endocrine clinic by his pediatrician with the concern
8 r$ r0 ], Y% g) z2 Eof early sexual development. His mother noticed6 u9 d) s# I3 T" u- u
light colored pubic hair development when he was
0 Y4 l' m/ z8 cFrom the 1Division of Pediatric Endocrinology, 2University of4 {% j9 ]2 |7 ~! Q2 Z2 S
South Alabama Medical Center, Mobile, Alabama.
" @) \8 u0 D3 w! NAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 t, \: f: N( eProfessor of Pediatrics, University of South Alabama, College of1 B( `4 v  l$ \& u& u7 W' E( Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* B5 W4 z8 ~/ ~6 x0 |
e-mail: [email protected].
, @$ \3 V  m* [" a+ Q9 ?9 Mabout 6 to 7 months old, which progressively became' m9 q9 L! N9 f* V5 h
darker. She was also concerned about the enlarge-
% }0 J" x+ Q  {" G0 pment of his penis and frequent erections. The child
; V( w9 M* M- z, \9 vwas the product of a full-term normal delivery, with8 s4 Y3 `9 p/ C* H% x
a birth weight of 7 lb 14 oz, and birth length of# m% i: H) S3 g6 A. c# [5 h. l; Q
20 inches. He was breast-fed throughout the first year! n1 w& Q1 Q4 S9 I# g7 Q
of life and was still receiving breast milk along with: n; q/ [4 a" S' p. Y1 x! ]' y' N
solid food. He had no hospitalizations or surgery,$ r0 ?' }, @: h+ G, r
and his psychosocial and psychomotor development5 ?* b" _" S# l; K
was age appropriate.
4 n. Z/ V7 f4 V) r4 s, jThe family history was remarkable for the father,
& u$ `3 a8 m" v0 i0 _who was diagnosed with hypothyroidism at age 16,! }7 x& g$ r9 a  n9 q  p& f0 Z& h
which was treated with thyroxine. The father’s
# ^/ x- Y8 P* f/ `2 X+ ?/ a9 Sheight was 6 feet, and he went through a somewhat  M; v/ }: u/ W9 s% ]
early puberty and had stopped growing by age 14.* l5 ^# v% S! A4 ]( j: V" ~: ^7 u
The father denied taking any other medication. The& I( R- D9 C" _7 U4 @' b3 a$ E3 f
child’s mother was in good health. Her menarche$ M% K( k" K, l5 w
was at 11 years of age, and her height was at 5 feet
7 c! U3 g+ y; w) G1 p8 M! K5 inches. There was no other family history of pre-. A) K) r- b. j! g
cocious sexual development in the first-degree rela-
) D4 R& S. [9 x: d" z* w' qtives. There were no siblings.
3 O8 s5 `( B  c1 oPhysical Examination
9 k) O' o/ L( SThe physical examination revealed a very active,
4 ~& B! ^, i! I, `3 T7 ^8 Fplayful, and healthy boy. The vital signs documented; n# C4 v8 M5 N' v* z$ _* Q4 j
a blood pressure of 85/50 mm Hg, his length was
, C1 ]# X0 U. W  L6 l; Z# v- J8 ]3 ^90 cm (>97th percentile), and his weight was 14.4 kg
2 c/ f0 b7 [  ^$ ~* M7 a(also >97th percentile). The observed yearly growth
6 Q4 w8 u9 h* w* k' b- ^velocity was 30 cm (12 inches). The examination of1 K8 G3 W' k- X. B$ x# q; L2 n/ A: N
the neck revealed no thyroid enlargement.. L- z( r% }5 w. x- p7 `
The genitourinary examination was remarkable for
7 B- B: s$ s( ?) ^# m  n2 }. Tenlargement of the penis, with a stretched length of5 g+ Q% q7 s& X4 b1 |
8 cm and a width of 2 cm. The glans penis was very well, q& r" j5 P, f% f+ p& g' P
developed. The pubic hair was Tanner II, mostly around1 k) D4 }6 a& t% L! |$ e% ^4 C6 L( B
540! A7 c- \4 B5 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) N; L" i+ ~4 ?5 Mthe base of the phallus and was dark and curled. The- j+ ]0 h  H& H" j
testicular volume was prepubertal at 2 mL each.
( C+ Y* I- X- F- B3 i1 p+ ]9 [; lThe skin was moist and smooth and somewhat
* M0 Q" J$ ^% H2 s! n6 {* F! a1 P  voily. No axillary hair was noted. There were no
. S* C0 \9 O  babnormal skin pigmentations or café-au-lait spots./ I& N5 V: A' k0 W- X8 h- e
Neurologic evaluation showed deep tendon reflex 2+
$ @! |) d8 m2 Z7 pbilateral and symmetrical. There was no suggestion% Z- o% r. y4 O* V! T" {/ g
of papilledema.
+ _) d: d# v( GLaboratory Evaluation
1 x# H4 V0 u# g$ WThe bone age was consistent with 28 months by
4 {9 H0 T! u' H5 E* u  ?# Vusing the standard of Greulich and Pyle at a chrono-" H9 L3 s: Y1 Z' f) C7 B6 B" `9 [
logic age of 16 months (advanced).5 Chromosomal
+ u" U1 L/ ]" U/ @karyotype was 46XY. The thyroid function test
0 _" p& Y- ~' h1 V1 |showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# x5 W5 [! F. [0 mlating hormone level was 1.3 µIU/mL (both normal)./ a' s4 {  m) _' F8 Z+ a7 Y6 _* o
The concentrations of serum electrolytes, blood/ J# {! ^- h( U1 s- e" b
urea nitrogen, creatinine, and calcium all were
+ w" n* c3 s0 T/ G9 x9 V" k/ Fwithin normal range for his age. The concentration
4 f3 M* c/ W; @of serum 17-hydroxyprogesterone was 16 ng/dL( N" F( j) O: I: p1 J" T
(normal, 3 to 90 ng/dL), androstenedione was 20
2 t& [, h. _: y( fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 t  ^" f6 A2 q6 A2 R4 {0 zterone was 38 ng/dL (normal, 50 to 760 ng/dL),( B0 Z1 z6 x. O9 ^5 M& `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 m4 I3 i4 g* R) C( R49ng/dL), 11-desoxycortisol (specific compound S)
& Y  r# C  _5 I  s/ C. dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! x- Z  b: p/ i& |; h2 U2 U. K2 d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 U* E% t6 v7 Z6 x* N) ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( S) o! N) Y  Q) _
and β-human chorionic gonadotropin was less than* Q) i+ ^7 [2 P& o' p+ S5 o# [
5 mIU/mL (normal <5 mIU/mL). Serum follicular! A. m0 x4 v8 y8 }/ N! U
stimulating hormone and leuteinizing hormone
. J% x; v$ A7 ]8 M; c  r- Vconcentrations were less than 0.05 mIU/mL
. Q* p1 x! l& ^1 Z(prepubertal)., Y' S) H. s3 y4 Q6 c
The parents were notified about the laboratory% p& B- H  x0 s- T. R8 s; |
results and were informed that all of the tests were
% V+ w- a# w% onormal except the testosterone level was high. The
. W& \% e* N3 Q2 I9 k/ z8 j: Zfollow-up visit was arranged within a few weeks to' K3 P/ ^* f8 w) u: X) P1 G
obtain testicular and abdominal sonograms; how-
3 i3 C/ R" j& A" Qever, the family did not return for 4 months.
$ b! i) U! X5 l* l1 G/ A5 G0 b( M9 ~Physical examination at this time revealed that the; P+ R6 o& a- v2 [
child had grown 2.5 cm in 4 months and had gained" v1 X5 W; U  x+ ?+ _7 B4 \
2 kg of weight. Physical examination remained
  _; O/ l, y$ ]" o. Lunchanged. Surprisingly, the pubic hair almost com-+ d' e% Y# C9 G2 m
pletely disappeared except for a few vellous hairs at
: X/ B' X' |, t* S" t/ O3 c2 `the base of the phallus. Testicular volume was still 22 T* D1 ^5 F5 M9 t# f
mL, and the size of the penis remained unchanged.3 }  v" t; f7 b  w- k" h- h; T" u
The mother also said that the boy was no longer hav-
; ~9 n# y' `3 {( I* J( ving frequent erections.
: h. X& j: i3 I# B" v& a! TBoth parents were again questioned about use of, L1 s: t# E, r3 |8 f7 Q5 Z7 \7 G
any ointment/creams that they may have applied to+ E, z: Q8 a- r# m
the child’s skin. This time the father admitted the
/ o6 S% Z2 _( T' L1 P" J- ~4 Q. tTopical Testosterone Exposure / Bhowmick et al 5415 k% ?0 b! P& j1 \& ]
use of testosterone gel twice daily that he was apply-1 L7 o  k) X5 h; S
ing over his own shoulders, chest, and back area for
* ?& u6 Q9 d( s8 W% T) g) ?a year. The father also revealed he was embarrassed/ \, a7 _) e2 m4 v: {7 j; N
to disclose that he was using a testosterone gel pre-
# H' v" M1 E- Cscribed by his family physician for decreased libido
+ C5 p$ i% n( \( s* Y. Osecondary to depression.! V& Z( F9 n8 R1 k) r
The child slept in the same bed with parents." p4 i$ {/ m: C0 `0 ]7 {9 m7 v
The father would hug the baby and hold him on his
. v" n) E/ _  _chest for a considerable period of time, causing sig-  \  Z) C+ p* W5 Q% D" B
nificant bare skin contact between baby and father.' N3 w6 b4 X3 K) g" K9 D2 A7 ~: J* j
The father also admitted that after the phone call,
& Y1 d! }# c5 P5 \% Ewhen he learned the testosterone level in the baby
: W9 @' w- i" j; ^$ ^# s- Owas high, he then read the product information
" @; A" u% t- v  p, z. [  Epacket and concluded that it was most likely the rea-8 ]4 P, Y; S" u8 r8 I5 s6 \! U" Y) D  m
son for the child’s virilization. At that time, they) t8 J8 `7 D7 R. X; C0 h1 A
decided to put the baby in a separate bed, and the
4 O; V$ Z& O+ z+ {father was not hugging him with bare skin and had) A) P" S' o; R2 z2 p# a
been using protective clothing. A repeat testosterone1 ~% ?( _0 Y. i. n9 t2 A( B
test was ordered, but the family did not go to the. \3 e2 G' u: i' z7 x4 N
laboratory to obtain the test.8 U/ u/ A* |6 w* v5 q3 Z
Discussion* L7 Y- p) ]) L% @0 E+ w. F; h' ~
Precocious puberty in boys is defined as secondary
. L* x' L8 R- U. h) a: L- Xsexual development before 9 years of age.1,4! r! {: d2 l; G- {
Precocious puberty is termed as central (true) when
( K! N$ Z1 w- t2 F, w* X& Bit is caused by the premature activation of hypo-& s- [! A5 d7 Z! q" I
thalamic pituitary gonadal axis. CPP is more com-
! `1 y  t. g( }mon in girls than in boys.1,3 Most boys with CPP* s6 F; L7 j. l  h- O4 F
may have a central nervous system lesion that is
8 b( c: O  E. c7 M+ dresponsible for the early activation of the hypothal-
9 W# L. v8 g. i0 ^amic pituitary gonadal axis.1-3 Thus, greater empha-
- ^( e1 ^) B: Ssis has been given to neuroradiologic imaging in
2 k- `) s  Y7 ]' y9 Cboys with precocious puberty. In addition to viril-
8 [. t& D- V) v) h' Rization, the clinical hallmark of CPP is the symmet-% ~/ M! M2 `5 ?0 R% G0 h2 x' P
rical testicular growth secondary to stimulation by
4 N' d, n0 {& T6 Hgonadotropins.1,3( V, L7 u. U2 a+ W, z
Gonadotropin-independent peripheral preco-* f) |$ |& D* l
cious puberty in boys also results from inappropriate; K& k/ J# E" ^: c6 I2 G
androgenic stimulation from either endogenous or8 d) ?/ G) C* S7 O# S& [3 r: A6 Y
exogenous sources, nonpituitary gonadotropin stim-
- k" B% e* D8 Z4 n% I; }: b% `ulation, and rare activating mutations.3 Virilizing4 r( @8 ?) G6 }: x
congenital adrenal hyperplasia producing excessive
' X/ I" ]+ P1 L2 S1 J( c: \; Oadrenal androgens is a common cause of precocious
: L% D' u# x/ q$ n0 tpuberty in boys.3,4
5 Q% z; {9 o% ~7 B: X- p- @; T  oThe most common form of congenital adrenal5 P5 d8 K9 x; w* P3 o
hyperplasia is the 21-hydroxylase enzyme deficiency.' O7 D3 r# G8 e) ~# z: s, Q
The 11-β hydroxylase deficiency may also result in! p% K3 r8 D4 g/ U% L
excessive adrenal androgen production, and rarely,: s0 @6 y$ p# ]6 v
an adrenal tumor may also cause adrenal androgen! b- g0 R/ d) k0 G! f
excess.1,3
4 n& k+ R) c1 S. C2 x$ Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ~& W0 a. Q0 j6 b! N6 U
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 H8 k* \$ o& Q7 T8 T- R
A unique entity of male-limited gonadotropin-# J$ c  _" p; M/ l% r5 [! m% ~
independent precocious puberty, which is also known
- a& i8 g' B. x9 s, L8 vas testotoxicosis, may cause precocious puberty at a
) x. {8 _/ w) N$ b8 J* u9 f8 ivery young age. The physical findings in these boys
' h7 d; I5 D* z' a8 \6 [0 a) Iwith this disorder are full pubertal development,) v5 \& a% {7 z7 t5 P" V5 {7 d" R
including bilateral testicular growth, similar to boys
* x$ e: ?8 s% J! Xwith CPP. The gonadotropin levels in this disorder0 S' }. X! B8 r; v4 j4 ^, Q
are suppressed to prepubertal levels and do not show
( e0 J! L/ j0 }% m9 Hpubertal response of gonadotropin after gonadotropin-1 v+ y6 H2 K5 @3 H; K7 y  l
releasing hormone stimulation. This is a sex-linked' Z$ B. l; k! B2 E- v
autosomal dominant disorder that affects only4 i( q& s  r2 F7 p( [3 ]  y5 K
males; therefore, other male members of the family
3 E6 y5 A) l, N" l* g% Smay have similar precocious puberty.3* h3 N& f* p$ q' g
In our patient, physical examination was incon-
! U  c9 J4 p8 C- Q2 asistent with true precocious puberty since his testi-$ J- ?0 t: s6 Z; x+ E8 b
cles were prepubertal in size. However, testotoxicosis
5 K  H7 i6 o1 f8 J( M1 Pwas in the differential diagnosis because his father5 h+ T2 Z' l5 y$ ]+ m: d4 d
started puberty somewhat early, and occasionally,
- K. w5 y8 O4 n. ]. q" v! ztesticular enlargement is not that evident in the% z4 |( Y  |1 e- F" |% p' a
beginning of this process.1 In the absence of a neg-
! c9 j/ j# G! @6 N' ~ative initial history of androgen exposure, our
6 ~- j) |1 w1 A1 \biggest concern was virilizing adrenal hyperplasia,
" Z5 H: F& H+ v( Reither 21-hydroxylase deficiency or 11-β hydroxylase" i& P$ a# l) a% ~
deficiency. Those diagnoses were excluded by find-
7 y0 n! }6 P4 [* S+ g# o1 i' Ying the normal level of adrenal steroids.- y7 q/ s* D) f- l( u3 N
The diagnosis of exogenous androgens was strongly
; k: x3 M' D( L0 \suspected in a follow-up visit after 4 months because7 G. t' S2 n- \
the physical examination revealed the complete disap-
* z) a: p* v3 i4 N# p& mpearance of pubic hair, normal growth velocity, and
% [! l, j7 l8 L* y$ udecreased erections. The father admitted using a testos-
& U4 k+ M4 f4 R( d$ W& _2 ?7 vterone gel, which he concealed at first visit. He was6 M% c2 F5 L: Q" y1 ^  k
using it rather frequently, twice a day. The Physicians’1 Q3 A' c8 f& p
Desk Reference, or package insert of this product, gel or
6 s% B$ T& `  A. T5 H( Q6 f9 S/ U) Ccream, cautions about dermal testosterone transfer to# y, Q' M0 H" l# r# A: f) t
unprotected females through direct skin exposure.
( t8 V( P6 M7 ESerum testosterone level was found to be 2 times the
; p6 [( |" [1 W8 E4 g9 Jbaseline value in those females who were exposed to1 V7 N+ `5 K% x5 V; V
even 15 minutes of direct skin contact with their male) |1 J/ U3 ~4 q$ r, F
partners.6 However, when a shirt covered the applica-
/ V& ]4 A: ^/ n& k4 G" Wtion site, this testosterone transfer was prevented.
( v* i+ V9 x* j$ d( k$ W5 H5 yOur patient’s testosterone level was 60 ng/mL,, o3 k5 x+ s" Y+ V6 z1 r" o7 H- h
which was clearly high. Some studies suggest that
7 H* X' x0 G3 I( a( adermal conversion of testosterone to dihydrotestos-
# B4 W  \/ j6 U0 v8 D0 A% ^# @terone, which is a more potent metabolite, is more( h' L/ Q2 W0 V1 L4 m; ^$ R& B
active in young children exposed to testosterone+ @$ [; Z, B- w
exogenously7; however, we did not measure a dihy-% Y# B( `( P! j$ x8 B: {: s( a
drotestosterone level in our patient. In addition to" p: I- P+ B& G. N+ @: t/ P! r
virilization, exposure to exogenous testosterone in. g: _+ G# [/ K  f( L, [+ ^; Y( w; r
children results in an increase in growth velocity and
+ a: g' [& ?$ s4 f6 zadvanced bone age, as seen in our patient.' x0 J: F9 U  l6 Q8 M
The long-term effect of androgen exposure during7 a9 T$ h8 I; P6 `8 h8 c0 B
early childhood on pubertal development and final$ u6 E/ s# P7 b) p/ n1 T6 q  c
adult height are not fully known and always remain
/ a% m* `2 T4 t5 X' p) sa concern. Children treated with short-term testos-3 U& `7 N" w1 o% ]4 Y, f
terone injection or topical androgen may exhibit some
9 i4 T7 g  Y9 [- Sacceleration of the skeletal maturation; however, after2 [$ y, f' M, M# `/ a
cessation of treatment, the rate of bone maturation3 k2 r: U5 T: B6 u, F
decelerates and gradually returns to normal.8,90 s; r1 g: c* N2 q2 j$ T' H( ~$ \
There are conflicting reports and controversy. U9 E' K) S' x' F# |6 o
over the effect of early androgen exposure on adult4 W' i0 q3 f& Z2 K8 D
penile length.10,11 Some reports suggest subnormal. l0 ^/ h0 S' w# |- W4 X
adult penile length, apparently because of downreg-
8 N/ H5 O) E( b% culation of androgen receptor number.10,12 However,6 R4 G! i$ [( E8 Q
Sutherland et al13 did not find a correlation between) G$ b$ n( ~1 G- Q2 O: ~6 L+ b
childhood testosterone exposure and reduced adult# J. I; c, e8 G! a
penile length in clinical studies.5 Z4 q3 ]4 x1 C; v: x$ g) V
Nonetheless, we do not believe our patient is3 u; o' D3 s( |$ L. X1 C3 w% ~" V
going to experience any of the untoward effects from. b0 [1 O1 k& j  `+ u# G
testosterone exposure as mentioned earlier because
9 R5 _1 J1 s8 i$ u$ x+ ?/ |) Zthe exposure was not for a prolonged period of time.
+ b, Q9 }6 h8 g$ V- y+ [5 J6 h7 `Although the bone age was advanced at the time of# P1 i7 U* J) S0 {
diagnosis, the child had a normal growth velocity at
# N0 M) J1 ^# ^- e1 K2 @the follow-up visit. It is hoped that his final adult5 c) c4 J4 L# V6 d3 i1 h  z+ F: H
height will not be affected.
7 z! v- {$ M" V& f5 \& w( NAlthough rarely reported, the widespread avail-( m2 f: C# Y; J& f6 h+ m1 v
ability of androgen products in our society may
$ T. J# j4 f' K3 t' ?indeed cause more virilization in male or female
/ f1 ?3 D1 f% M) Q  I" R, wchildren than one would realize. Exposure to andro-
  n* g8 N8 z- Y$ `0 ogen products must be considered and specific ques-
0 i6 ^, c7 b- ~1 s+ i, D. \) Htioning about the use of a testosterone product or
( w* z1 O6 B% X0 b9 Rgel should be asked of the family members during
! }7 v; y( v1 Y8 z* V3 kthe evaluation of any children who present with vir-; S( I; `: r1 H; e$ I7 L: t% v* N
ilization or peripheral precocious puberty. The diag-
4 L$ C# c4 G/ u& c% A: V/ tnosis can be established by just a few tests and by
% G# `* z) a6 z0 Oappropriate history. The inability to obtain such a7 D* H* ?# t: b* O2 `. L! i$ p
history, or failure to ask the specific questions, may
$ X) ^1 r8 z! j1 bresult in extensive, unnecessary, and expensive; w2 L# s; h6 Q) A  C) E
investigation. The primary care physician should be
0 }7 Q2 p" W5 baware of this fact, because most of these children; g: v/ C- E6 ~7 D' ]
may initially present in their practice. The Physicians’+ I6 w4 J; H4 n% x, V$ i7 N
Desk Reference and package insert should also put a
* t* |6 a9 f2 A2 ewarning about the virilizing effect on a male or
4 N. D& j3 {4 s8 b! t# ~2 tfemale child who might come in contact with some-
/ |; Q4 T9 l3 S1 X0 d$ g, C* C4 lone using any of these products.' F! M6 q- L, X( w$ |
References
" E# z4 S; m- n1. Styne DM. The testes: disorder of sexual differentiation# v- M1 Z, k  P: B. m
and puberty in the male. In: Sperling MA, ed. Pediatric
% H0 R0 q5 i1 p1 d, d4 VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 v5 G8 {7 A4 {$ s  R
2002: 565-628.
  A- o, h+ @! U, d& _; K9 b* X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ p! w$ L% g5 a9 F8 Wpuberty 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
/ v. E  O: P. v
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