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
2 u9 t* x, c8 v4 c7 C9 b" x0 lBoy Induced by Indirect Topical7 Q( M  z- h) R) _* {. T
Exposure to Testosterone5 _+ o2 h$ ^6 y" H
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% ?+ [  L  K0 E  H0 I8 J2 o% M
and Kenneth R. Rettig, MD1
8 }  x+ d8 o0 @# {: Q( gClinical Pediatrics  r" P5 }( G0 N' J# K! V/ Y
Volume 46 Number 6. b6 L+ _) I6 X, v
July 2007 540-543
) }" z( w1 p) n2 E9 j© 2007 Sage Publications
# s( D7 Z8 V5 w  H6 }$ @2 D. o9 w10.1177/0009922806296651
0 ~& |- \5 l: _9 S% f; z; I. vhttp://clp.sagepub.com2 m" W% I9 m1 C  l
hosted at- i$ ]: k, q8 F0 w  k8 s1 _1 j
http://online.sagepub.com
% j/ O+ D# S  f; C) [9 k% ]" j6 hPrecocious puberty in boys, central or peripheral,
& ?: i6 s9 `) s2 pis a significant concern for physicians. Central& L* t4 o) P; ~5 ?3 ~
precocious puberty (CPP), which is mediated
/ a/ B4 W- P9 a/ U, z- Jthrough the hypothalamic pituitary gonadal axis, has
% k# F& A/ ^; C; v5 @# _2 ka higher incidence of organic central nervous system, p5 |9 i3 o& C: I. t
lesions in boys.1,2 Virilization in boys, as manifested* f+ @) B6 l2 {3 l2 m
by enlargement of the penis, development of pubic1 w8 k5 ?6 K3 v& U) D3 K
hair, and facial acne without enlargement of testi-* j$ p" d# \: X! V) Y) p9 l
cles, suggests peripheral or pseudopuberty.1-3 We
5 I! |: D: u& dreport a 16-month-old boy who presented with the* g0 d; ~% U! z" w  Q4 Z! ^# M
enlargement of the phallus and pubic hair develop-7 P  }" F' ^; x+ [# }
ment without testicular enlargement, which was due& x" Q* H2 {4 }1 k% I
to the unintentional exposure to androgen gel used by
: v4 V0 a/ I: E: x0 kthe father. The family initially concealed this infor-
" n. e* I: J2 R3 w3 [2 c1 y! lmation, resulting in an extensive work-up for this0 B2 H4 ?' O5 M6 R* ~  X7 ~, p# k- `+ X
child. Given the widespread and easy availability of2 A3 }0 b# S4 s; ]. s
testosterone gel and cream, we believe this is proba-
7 v) V: `7 @* Y3 N1 \/ h, n! Vbly more common than the rare case report in the
$ }1 e% U3 n8 s" Vliterature.4- K& p" k1 p" W) o0 ]( u1 Q
Patient Report# G# ]$ e+ U' V* d
A 16-month-old white child was referred to the0 e* \, X& c3 A; Q  n4 e1 z7 O# L
endocrine clinic by his pediatrician with the concern
, F0 {  i- Q* F, W+ S9 Kof early sexual development. His mother noticed
! n1 O7 X6 {0 y' m4 Ylight colored pubic hair development when he was
% w2 e1 E5 l! ~2 a( `3 ~From the 1Division of Pediatric Endocrinology, 2University of
7 B/ Z5 e: H7 o$ p! v1 RSouth Alabama Medical Center, Mobile, Alabama.
2 k& b$ \0 q( F3 g; I$ LAddress correspondence to: Samar K. Bhowmick, MD, FACE,  k) {( ]$ g: Y6 \1 e$ C
Professor of Pediatrics, University of South Alabama, College of
, N0 w$ H' H* XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 Q0 J4 q, J0 T
e-mail: [email protected].
5 z  j) j: L% L7 }% @) z4 D" mabout 6 to 7 months old, which progressively became
/ t  x+ {/ w  M, |) Q! q' Wdarker. She was also concerned about the enlarge-  R2 L; ^- F- w5 e3 s
ment of his penis and frequent erections. The child
, d9 T* `3 H4 @% k! cwas the product of a full-term normal delivery, with. y: E% z* y2 r7 S
a birth weight of 7 lb 14 oz, and birth length of
) o1 j" L" x1 U1 A3 {; L1 h2 @20 inches. He was breast-fed throughout the first year
0 p# [, b$ C1 e' ^$ w4 hof life and was still receiving breast milk along with
( N' n8 b5 q) H: ?# v2 D+ ~& N( v; h. ?solid food. He had no hospitalizations or surgery,
$ v% N. k( K/ y3 s, X! @and his psychosocial and psychomotor development/ K" P4 n; A4 j
was age appropriate.
) c* H$ y; n* W9 {% q" H" L0 lThe family history was remarkable for the father,
/ [; q0 d/ i  I; Swho was diagnosed with hypothyroidism at age 16,6 {/ H2 _3 l6 C2 O$ F* s7 w& ]
which was treated with thyroxine. The father’s
, s$ q+ z. O6 Z  Iheight was 6 feet, and he went through a somewhat0 w' x3 U9 ?3 k4 l3 a' s' n7 s
early puberty and had stopped growing by age 14.: J. `, t% ]1 j
The father denied taking any other medication. The
0 m1 `* P3 G0 M& s. gchild’s mother was in good health. Her menarche
1 k& O' x& D' r  x: [4 w& xwas at 11 years of age, and her height was at 5 feet$ W* C+ g4 p1 i% Y7 b
5 inches. There was no other family history of pre-
: s8 J& [, {/ G; z! B& F2 ~cocious sexual development in the first-degree rela-: t  Y% u7 v  \% _
tives. There were no siblings.+ K8 O0 d# C8 g' g# ?
Physical Examination
  e' @' @% E& {7 JThe physical examination revealed a very active,
% |8 E* t9 _/ z1 {/ b( j( v9 Nplayful, and healthy boy. The vital signs documented% M$ g/ ?8 a/ i1 l
a blood pressure of 85/50 mm Hg, his length was% C5 e( ]. Q% J2 A) e, H
90 cm (>97th percentile), and his weight was 14.4 kg
: M# |2 Y$ r% ?* s7 c(also >97th percentile). The observed yearly growth% n& G  ~& ^, x( M/ G# U
velocity was 30 cm (12 inches). The examination of
& f! M; _( F! bthe neck revealed no thyroid enlargement.
! s6 p: j- x! Q2 A' Q4 yThe genitourinary examination was remarkable for
# n, L- p% b  }& C2 lenlargement of the penis, with a stretched length of- T$ i! j  C2 a7 ^1 n
8 cm and a width of 2 cm. The glans penis was very well1 {0 A2 k& A6 _! U
developed. The pubic hair was Tanner II, mostly around
# j* G2 T8 C4 W% f: I540! v( J% z# k6 o' ]3 H  E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ b" }# o; y$ Y  Zthe base of the phallus and was dark and curled. The" J* z2 o4 F. S, W7 z# J0 \1 D
testicular volume was prepubertal at 2 mL each.& N; `& w9 O, e% H
The skin was moist and smooth and somewhat
9 q2 Q3 u8 ~  R7 I7 U# w% Eoily. No axillary hair was noted. There were no4 J5 Y8 M$ [% j2 ]& x
abnormal skin pigmentations or café-au-lait spots.
1 y+ E. e' X9 n9 k4 _) ^Neurologic evaluation showed deep tendon reflex 2+
: y( ?  v8 e$ g3 M. Mbilateral and symmetrical. There was no suggestion( @* Y* }3 }) g/ Y1 U
of papilledema.
5 a' J' ?8 p: w' QLaboratory Evaluation
9 d; _4 h; Q$ A5 S4 k9 VThe bone age was consistent with 28 months by
: p5 l$ E# t9 c7 \2 k: A- e4 Cusing the standard of Greulich and Pyle at a chrono-0 Q8 j8 X$ w) p1 H, |7 W5 _5 |
logic age of 16 months (advanced).5 Chromosomal/ B7 c1 K, m  G8 f; Q& K/ v
karyotype was 46XY. The thyroid function test
+ x" ?* l' r- F! Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% v) ^, M3 R- H" c
lating hormone level was 1.3 µIU/mL (both normal).
/ l- O$ Q1 J6 w- M: oThe concentrations of serum electrolytes, blood! n' |0 m8 ?* A7 v$ G9 U7 D5 I
urea nitrogen, creatinine, and calcium all were
  U$ `& |( F# u* f: dwithin normal range for his age. The concentration
) I$ E* |; j3 k# Wof serum 17-hydroxyprogesterone was 16 ng/dL
' I3 n2 }; @; g0 }(normal, 3 to 90 ng/dL), androstenedione was 20
0 f9 r7 n* J( _8 `: o  ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. Q! q6 \( E) T5 f5 p+ z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, l+ W8 H6 D, u- u6 Gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 b# k3 W" j. b. r49ng/dL), 11-desoxycortisol (specific compound S)& A9 I9 P: O) O* F* H2 |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 \4 Z) t: e: e- E- z1 ^0 g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 s! g1 W) H& A& s1 p  c5 H
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( M7 Y. R1 q2 W  S3 Xand β-human chorionic gonadotropin was less than
" w$ I/ y; b  o  h/ T8 @0 S( H5 mIU/mL (normal <5 mIU/mL). Serum follicular
  N* ?2 m  h6 F* C2 s& {6 Pstimulating hormone and leuteinizing hormone3 g2 x+ b( J4 ^* L6 s# g. C
concentrations were less than 0.05 mIU/mL
4 \  m& \5 }2 [1 \4 l! T(prepubertal).4 m4 e  }9 ^' C& X8 ~5 }9 R
The parents were notified about the laboratory
  P* ?/ E8 [' rresults and were informed that all of the tests were
% m1 Z0 R( w. P# O4 onormal except the testosterone level was high. The
  I" X. m) T. S. g) v/ Jfollow-up visit was arranged within a few weeks to
4 z& R* @# J, d, uobtain testicular and abdominal sonograms; how-4 C3 k5 M. b! z) o4 ?
ever, the family did not return for 4 months.# A, V, B; s' I( H# }) t3 F
Physical examination at this time revealed that the
9 u$ n, i' @0 t9 l+ B0 lchild had grown 2.5 cm in 4 months and had gained
& s7 y' G+ G7 x0 q( |& s2 kg of weight. Physical examination remained  k& N8 B5 R$ _  c! U
unchanged. Surprisingly, the pubic hair almost com-$ X5 b$ F1 U8 h
pletely disappeared except for a few vellous hairs at
# j/ n6 M* \0 a# E1 n( U, F4 I9 ]the base of the phallus. Testicular volume was still 2
: t: A8 o- D6 \/ M/ LmL, and the size of the penis remained unchanged.
1 a/ @# v6 z# {" u: TThe mother also said that the boy was no longer hav-+ l5 O5 V+ ~6 h' L$ d
ing frequent erections." S, W2 g. K% o, W  s8 p2 Q$ |- C
Both parents were again questioned about use of
- U1 I$ v0 B5 ?4 S2 Hany ointment/creams that they may have applied to  X: e) d: ^& b$ N* H
the child’s skin. This time the father admitted the
/ D, G) V. |' Z8 K0 jTopical Testosterone Exposure / Bhowmick et al 541
+ k' x) d% S/ j* o0 G  O, Iuse of testosterone gel twice daily that he was apply-# L& D2 i1 }+ s# h! E; ]" X. i# \
ing over his own shoulders, chest, and back area for8 X0 S% R0 F# X9 }. @  F9 @
a year. The father also revealed he was embarrassed
- d4 h& W- |. ?6 ~to disclose that he was using a testosterone gel pre-! e5 ]3 o2 f) C/ E  E
scribed by his family physician for decreased libido0 m( e& P# [( t2 C
secondary to depression.0 v! w1 I/ U$ z5 K
The child slept in the same bed with parents.
. G% t3 G# e  _# P! F  s4 z* {& |The father would hug the baby and hold him on his5 P+ S5 ]; g' N0 C% D
chest for a considerable period of time, causing sig-( q: ~/ h8 H" i9 r, ?" Y
nificant bare skin contact between baby and father.4 s( W4 N1 S( Y$ k, \$ R' u; y
The father also admitted that after the phone call,
9 y: J+ W- Z$ ~when he learned the testosterone level in the baby
% b) C) C+ `2 r8 {6 i+ l2 C$ dwas high, he then read the product information0 [) I# [2 N3 h. g- f6 m9 t
packet and concluded that it was most likely the rea-: M. u# e7 V6 I6 C0 v# p3 U
son for the child’s virilization. At that time, they
  z- P2 N# P/ ]) ^, m7 W7 Vdecided to put the baby in a separate bed, and the
! j9 h  `& g: H! x: j, D8 Yfather was not hugging him with bare skin and had
- G1 H4 F2 K: K/ p' g# ebeen using protective clothing. A repeat testosterone/ g5 o' A! [: c2 X- e
test was ordered, but the family did not go to the
" V1 E. Q& ?: ]2 S1 b$ d6 g5 m) flaboratory to obtain the test.) N4 q' R9 I* m7 U8 o9 ~. W
Discussion) T& ?. C6 Y; T
Precocious puberty in boys is defined as secondary) `* C- o6 R& M, z) r) M/ T$ Q. x
sexual development before 9 years of age.1,4. i1 w, Y+ Q  U2 d
Precocious puberty is termed as central (true) when$ V, N9 m( n# h2 M9 H, U- }& q
it is caused by the premature activation of hypo-, @3 l+ D- N$ e5 C
thalamic pituitary gonadal axis. CPP is more com-1 Z8 N6 n1 O& ~/ s+ K7 i1 P% H
mon in girls than in boys.1,3 Most boys with CPP
7 X. p. r* ~* Rmay have a central nervous system lesion that is9 O/ _% q0 E0 ]7 z* U1 |8 O
responsible for the early activation of the hypothal-& Y9 s# E0 O1 W
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 s7 ^/ }% K& Vsis has been given to neuroradiologic imaging in/ g+ j+ l/ M% T0 Q; f
boys with precocious puberty. In addition to viril-
4 U; u$ O  W+ S: a2 N7 rization, the clinical hallmark of CPP is the symmet-
, _& n- ]7 p" \8 Irical testicular growth secondary to stimulation by
1 C3 T% K" N" v8 ygonadotropins.1,3( A7 ?: A7 o7 I! ^( ]) m+ }; Z
Gonadotropin-independent peripheral preco-
3 Z1 P0 o( e, Wcious puberty in boys also results from inappropriate/ ~8 u# U9 c$ S: N
androgenic stimulation from either endogenous or
! }; W2 }% [* o4 e- c, sexogenous sources, nonpituitary gonadotropin stim-
, w  L& e4 x5 }+ o2 q/ z& ?ulation, and rare activating mutations.3 Virilizing
( c3 [) ?' R. V. b* V4 Y( Gcongenital adrenal hyperplasia producing excessive
1 X' h% T  b( m. v; z% V  L) c+ badrenal androgens is a common cause of precocious
1 P+ R) \. b1 upuberty in boys.3,4
0 T% a4 N8 @7 T1 iThe most common form of congenital adrenal3 P# r+ _! ^: f. c5 _
hyperplasia is the 21-hydroxylase enzyme deficiency.. T+ U& N/ e0 n& J$ S( j2 i. x
The 11-β hydroxylase deficiency may also result in+ Z0 I' m. r5 G! f7 h& `
excessive adrenal androgen production, and rarely,
4 v9 t7 a6 n6 @. U* Oan adrenal tumor may also cause adrenal androgen
& H; y; G9 z/ n) y+ \" Wexcess.1,3
; B7 O6 _5 ?4 \, j8 S8 s5 ~/ sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% _: l8 o/ Z, F8 ~& M. c" b542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 ]8 J4 c# {3 u8 Q1 L5 U5 _3 K; PA unique entity of male-limited gonadotropin-
) x4 o# F, o; B7 }: c8 vindependent precocious puberty, which is also known
; N) S' i7 O5 d% p: r4 aas testotoxicosis, may cause precocious puberty at a7 l$ ]8 \# L1 |! T" w4 c7 S  Q
very young age. The physical findings in these boys
. G) q  x- W  d/ e4 iwith this disorder are full pubertal development,
  c. w/ `$ z6 ^' S% gincluding bilateral testicular growth, similar to boys
* u& B& \# N% T6 Nwith CPP. The gonadotropin levels in this disorder" T: z. f; ^# I( w2 X" ^; w
are suppressed to prepubertal levels and do not show
3 G# Y. x+ [) Fpubertal response of gonadotropin after gonadotropin-7 |3 |( N3 I0 c
releasing hormone stimulation. This is a sex-linked8 V5 I+ ~, j5 u
autosomal dominant disorder that affects only
- i. i& w4 X' O/ @% Q; e  z; S6 Pmales; therefore, other male members of the family
) G; x& L) |. o1 M2 f! I7 wmay have similar precocious puberty.3( `. r3 Z  _4 `% H7 S
In our patient, physical examination was incon-
8 V0 G  }8 i1 Q% ?% Q  d( \+ x  k' [sistent with true precocious puberty since his testi-
0 O8 A: H5 C4 h, ^& A( Y* Pcles were prepubertal in size. However, testotoxicosis
" N" k/ \/ _& W1 gwas in the differential diagnosis because his father" \# d( s/ \- A& q
started puberty somewhat early, and occasionally,  G7 P5 w4 X# B" a
testicular enlargement is not that evident in the
% v9 y  G/ `# C& i* ~beginning of this process.1 In the absence of a neg-
- m( a" I+ B. R  ?( y  }9 mative initial history of androgen exposure, our
3 j# H3 j9 ~4 E+ T5 ?+ A6 x! rbiggest concern was virilizing adrenal hyperplasia,. T  ?+ \6 v. F; y7 Q' N2 o6 ^
either 21-hydroxylase deficiency or 11-β hydroxylase2 t1 p3 ], @3 T3 ^3 l" a$ L
deficiency. Those diagnoses were excluded by find-
# L4 D9 |3 I+ |" ming the normal level of adrenal steroids.
& I6 Z' a7 P  MThe diagnosis of exogenous androgens was strongly- ^7 T& c2 c* ^2 |! D
suspected in a follow-up visit after 4 months because4 l1 v4 O. ?( |3 Z" m9 z. e1 A
the physical examination revealed the complete disap-
2 W- l2 \% R! mpearance of pubic hair, normal growth velocity, and
# z3 z: ^+ l# r& m0 ^decreased erections. The father admitted using a testos-
: E9 ?; n! M& ]6 i( _terone gel, which he concealed at first visit. He was
5 F( ~* q! Y& s) ~using it rather frequently, twice a day. The Physicians’* i$ `6 _5 S3 J8 y- e! H4 Q
Desk Reference, or package insert of this product, gel or
' Y" V/ M) m/ z9 j! icream, cautions about dermal testosterone transfer to1 A$ X3 H' `5 ?4 r3 ~
unprotected females through direct skin exposure.
6 ^* f  o0 P( F% L' ySerum testosterone level was found to be 2 times the* t, P* |% n! S. M0 H5 S
baseline value in those females who were exposed to
# N! ~- d( v. O) b  S6 seven 15 minutes of direct skin contact with their male& r0 p) g6 D5 O: U% b7 `, j
partners.6 However, when a shirt covered the applica-
; c6 B) e7 I- |& Ttion site, this testosterone transfer was prevented.% B" _9 ?! @. s+ k
Our patient’s testosterone level was 60 ng/mL,. F  f& u% t# l9 B5 l
which was clearly high. Some studies suggest that
( j' _8 ]2 W0 n0 odermal conversion of testosterone to dihydrotestos-1 J& i" r- c6 l) z9 W
terone, which is a more potent metabolite, is more
4 o- U2 d  s, ]. z( ^active in young children exposed to testosterone6 M  v: V* [+ c! w
exogenously7; however, we did not measure a dihy-
6 _5 x/ J( w7 udrotestosterone level in our patient. In addition to
+ ]6 D1 M. c7 f# B# l+ m# Y6 j+ jvirilization, exposure to exogenous testosterone in
3 c5 u3 f& {) Ochildren results in an increase in growth velocity and
5 ?7 w- {1 S/ u6 o. s5 z% {/ v5 q3 ]2 ladvanced bone age, as seen in our patient.1 Q. x' h  P: J/ H! ~7 ?
The long-term effect of androgen exposure during
# E+ ]8 C. M) y: f/ E+ Tearly childhood on pubertal development and final! X9 A/ m1 d2 k% I& ~; G) L$ N3 f
adult height are not fully known and always remain' N  ~. }( S+ N! x
a concern. Children treated with short-term testos-
! z  [9 \/ k' _7 i+ m* ?6 tterone injection or topical androgen may exhibit some0 ?6 R8 X  }% o8 ?, Q' M# p5 W
acceleration of the skeletal maturation; however, after2 O7 o9 m4 ?4 E, N2 ^
cessation of treatment, the rate of bone maturation0 x- g- [' ^3 y' O
decelerates and gradually returns to normal.8,9
  C9 X0 }- [8 aThere are conflicting reports and controversy
6 S  g: e* w0 k2 N, Q: G; Jover the effect of early androgen exposure on adult7 F9 b9 D$ [8 C' _$ n5 D
penile length.10,11 Some reports suggest subnormal0 U( }! z. o- t
adult penile length, apparently because of downreg-5 y9 `* P4 ?" `( L
ulation of androgen receptor number.10,12 However,* D$ D: z/ p/ v1 N
Sutherland et al13 did not find a correlation between4 X8 o' Q! A% M* I5 K$ u
childhood testosterone exposure and reduced adult
% c" ]/ S% t2 w3 }, [penile length in clinical studies.
% V7 o1 e5 ]1 g6 X. ZNonetheless, we do not believe our patient is: [2 n, n& A+ |5 B8 s
going to experience any of the untoward effects from
, t% h9 q, I: k5 B+ E( ptestosterone exposure as mentioned earlier because
. `# |  e/ l' u' @the exposure was not for a prolonged period of time.' n( G. w: o1 L! |
Although the bone age was advanced at the time of# k) @7 f8 Y9 C2 s% W6 q0 b
diagnosis, the child had a normal growth velocity at# r6 u8 Q5 E% z( d
the follow-up visit. It is hoped that his final adult: K! T6 T2 O5 G/ \
height will not be affected.
  w' `5 m3 Y8 @4 X, f) j, E$ v" gAlthough rarely reported, the widespread avail-$ E/ H, c2 D& c
ability of androgen products in our society may
2 a1 M8 J0 f6 f" ^) Eindeed cause more virilization in male or female/ `) v# [# `0 f5 u
children than one would realize. Exposure to andro-) z0 A# a% T; k' U2 K1 f, Y
gen products must be considered and specific ques-. d4 f! v+ Q5 j4 a3 {5 l
tioning about the use of a testosterone product or9 c- J1 l  w$ f7 e1 D5 }6 J
gel should be asked of the family members during
) F% w' Q% \% K1 bthe evaluation of any children who present with vir-) T7 p$ O6 I/ w8 h4 S' c. `
ilization or peripheral precocious puberty. The diag-
  M3 {: ~( u8 `* x& xnosis can be established by just a few tests and by, c7 ]7 ]" r3 ]( p. ]& f
appropriate history. The inability to obtain such a2 l8 l1 H) w* ^5 l/ W" {0 A
history, or failure to ask the specific questions, may% x; J7 D1 s  Q8 ]8 V4 I; A
result in extensive, unnecessary, and expensive
6 K' P0 m0 ~5 E" |( K2 [0 dinvestigation. The primary care physician should be
; H; W) P* K) e. v/ eaware of this fact, because most of these children
  G; ?6 d; @. Q: bmay initially present in their practice. The Physicians’. o2 M9 i7 ]9 ]4 T8 S
Desk Reference and package insert should also put a
6 a" ^* x3 S( ^5 C1 Awarning about the virilizing effect on a male or9 i; o3 a8 A! q
female child who might come in contact with some-! i0 f' s( A, b+ b  J
one using any of these products.
, Q0 ]4 Y7 Q) h! ~. k4 oReferences+ W2 |* h$ h! ^3 y0 B6 A5 c. o% d- H
1. Styne DM. The testes: disorder of sexual differentiation
) h7 q3 r: `( ?- ]. L" D' cand puberty in the male. In: Sperling MA, ed. Pediatric7 b2 R! i9 g2 O. w+ H+ m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 Y% F+ p7 P! Q7 d" O2002: 565-628.
8 R4 }. e0 [! @$ h2 m. i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, m2 ~# O' i. N5 T3 `2 a, u
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-Old3 R, K6 p- b! \1 D6 ?5 [6 S
Boy Induced by Indirect Topical# b( B. d, G7 G7 l( G+ s6 D* O
Exposure to Testosterone8 a& d. f$ N* l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* |8 }% S4 z: @. J& aand Kenneth R. Rettig, MD1
, m/ V; |6 M( @, b+ c# L8 DClinical Pediatrics
2 M# W6 f7 p; n: UVolume 46 Number 6( M# z' e* g+ i# W
July 2007 540-5439 Q- N( n! t% ]' N( T# u) B# K' @) T! T
© 2007 Sage Publications
: a! l$ g6 e0 R: M10.1177/0009922806296651& z8 p, f1 P- j% s4 z) g3 {: x
http://clp.sagepub.com
1 C2 p" i# O5 x9 l; \hosted at, u& q" U" m8 K; \( s* S9 s
http://online.sagepub.com
. e+ z+ l, Z9 L% U* U9 wPrecocious puberty in boys, central or peripheral,* t' h) a- _  E6 j" @
is a significant concern for physicians. Central
2 L: w. f6 c2 B" E. Y6 P# Vprecocious puberty (CPP), which is mediated
6 K1 e" X, K* F, c: Y" Hthrough the hypothalamic pituitary gonadal axis, has
. j+ M$ m) `- s0 N5 c. G5 x3 ~7 za higher incidence of organic central nervous system
% ]- }  W4 x( c$ @lesions in boys.1,2 Virilization in boys, as manifested6 F# ~9 o- `- u$ ?  c" s. g
by enlargement of the penis, development of pubic, w# o3 E6 b+ V8 J
hair, and facial acne without enlargement of testi-
3 w, ~: E3 T6 z, _. n. ^5 Ocles, suggests peripheral or pseudopuberty.1-3 We# l' h, o' q; T" Q$ J$ `8 ]- n
report a 16-month-old boy who presented with the# |& i( S3 Q% z4 C
enlargement of the phallus and pubic hair develop-
. i& {0 d# G# x( t2 {! K# X8 gment without testicular enlargement, which was due7 @# l& K  e: D, n, C- ~* q
to the unintentional exposure to androgen gel used by
2 F& }1 K- s; a8 Jthe father. The family initially concealed this infor-" z+ k: j- A: Y
mation, resulting in an extensive work-up for this
4 H. A# A/ B; }$ m4 s, \1 x) ~child. Given the widespread and easy availability of( |1 F  x2 Y" I. |
testosterone gel and cream, we believe this is proba-/ w, t% r. ?0 m5 {# v- X7 U& e
bly more common than the rare case report in the
7 T8 ~  n" X" Q( f, wliterature.4
* J9 _0 e& D2 u$ oPatient Report1 M- Y- i9 {1 ]7 p% \
A 16-month-old white child was referred to the$ J: p' N8 l; i$ }5 {
endocrine clinic by his pediatrician with the concern
1 s4 ?: f: G: X' k; ~" hof early sexual development. His mother noticed
4 D9 o4 N* W5 C' h1 dlight colored pubic hair development when he was$ i  y( L7 e3 t: d! _: O+ {
From the 1Division of Pediatric Endocrinology, 2University of% k! l* R' ~$ r) j, w2 n0 U, X
South Alabama Medical Center, Mobile, Alabama.
, \% n  L7 m/ Y3 [Address correspondence to: Samar K. Bhowmick, MD, FACE,) @# E9 y/ t: b- Y) I% P3 L4 ~
Professor of Pediatrics, University of South Alabama, College of
. e: }" V$ F! B/ h3 rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  w% f2 n+ S7 B) k8 j7 r- i
e-mail: [email protected].0 [' K- i4 K' g  \* Q- D, e" Q7 ?+ O
about 6 to 7 months old, which progressively became5 \3 n3 D8 l3 U. O% h
darker. She was also concerned about the enlarge-+ L" g9 U  q8 i1 ^9 U1 d
ment of his penis and frequent erections. The child
' ?( }1 I  C+ R* D& Iwas the product of a full-term normal delivery, with: {. X- `0 h' e! h$ T4 e. r; I: s
a birth weight of 7 lb 14 oz, and birth length of
+ |& W% d; j* U: B0 ^20 inches. He was breast-fed throughout the first year
, l' ]! }% n6 K' v" y, fof life and was still receiving breast milk along with
, ^/ B" K/ e) p# \solid food. He had no hospitalizations or surgery,( `% r& a1 b/ U* L6 J1 {$ e
and his psychosocial and psychomotor development
/ S' @* ^( h0 \' i/ L, nwas age appropriate.4 ]9 w. g/ c, f& f' ~& X: O
The family history was remarkable for the father,
1 I* t/ ^3 X! ~) U* t. B% V1 jwho was diagnosed with hypothyroidism at age 16,# i" p: X+ h0 V- V' l
which was treated with thyroxine. The father’s7 ^. L  E6 d- n4 z+ ?" m
height was 6 feet, and he went through a somewhat! a. S1 F! a; l( J* H' Z
early puberty and had stopped growing by age 14.4 f9 S3 U, R9 M5 G7 Y
The father denied taking any other medication. The
( }, [3 l. }$ ~1 J+ uchild’s mother was in good health. Her menarche' w4 P' n8 u$ Q
was at 11 years of age, and her height was at 5 feet
+ R  o: {, `5 e5 inches. There was no other family history of pre-  c2 ~% u5 H  R+ Q, p3 C' y
cocious sexual development in the first-degree rela-
* T; I$ e# ~) u  stives. There were no siblings.
' H3 _# [  C6 iPhysical Examination# T2 {7 X; |' P2 r/ f% [7 m) v
The physical examination revealed a very active,
' z" |- T/ o! }+ C% `7 h: ~playful, and healthy boy. The vital signs documented
. [7 L& }) f6 k: ua blood pressure of 85/50 mm Hg, his length was" c3 `0 x# d# l' ]8 l
90 cm (>97th percentile), and his weight was 14.4 kg& a. P. H% X/ J
(also >97th percentile). The observed yearly growth
% n9 H9 R6 t  j6 b! T3 D# Pvelocity was 30 cm (12 inches). The examination of
3 q  q* i; L7 p2 B, E  L. Xthe neck revealed no thyroid enlargement." y! v( ?) z/ F: w4 N( V( r
The genitourinary examination was remarkable for
2 y( }( ?; g9 Q: m) nenlargement of the penis, with a stretched length of1 d! w0 e/ Q0 N  S/ ^
8 cm and a width of 2 cm. The glans penis was very well
# Y: A, F  Z; r2 tdeveloped. The pubic hair was Tanner II, mostly around5 b5 z8 u2 i- i/ m% z% ~
5406 A  H6 [4 p' N- ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; ]  U0 ~& m  w6 }! ^8 A6 [the base of the phallus and was dark and curled. The
, T# E9 O& M: Z* Y' Ctesticular volume was prepubertal at 2 mL each.$ U5 [% i8 E8 u; g$ U. d- p
The skin was moist and smooth and somewhat% l- a1 t+ Z0 F! Z8 j5 l/ l% g
oily. No axillary hair was noted. There were no
" Y( Q* v! q, r6 a" A7 [2 \  Gabnormal skin pigmentations or café-au-lait spots.
" k! B) \6 ?6 p" [; J5 N5 ZNeurologic evaluation showed deep tendon reflex 2+" o8 u# K1 T1 U! C; ^% X! @
bilateral and symmetrical. There was no suggestion5 }* d, k) L1 r6 }1 J
of papilledema.. R' ~# z" J' ~: r- u
Laboratory Evaluation
" j! A* |$ O5 o6 M/ h) c( }The bone age was consistent with 28 months by: ?4 V% q3 n6 i! z" J' J1 m
using the standard of Greulich and Pyle at a chrono-
" s& B# A1 S: `8 ?6 _% jlogic age of 16 months (advanced).5 Chromosomal
, v; Z% m: b; n: okaryotype was 46XY. The thyroid function test
) W0 [& X- G  @% X$ h- u0 Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ \+ t& P6 D- P+ I* P5 ilating hormone level was 1.3 µIU/mL (both normal).# h8 M9 h$ F4 d  n* q* a6 L
The concentrations of serum electrolytes, blood
* V1 t. V. i* r; t4 d' Aurea nitrogen, creatinine, and calcium all were- u8 g* t) q( P/ B
within normal range for his age. The concentration7 ]3 m, L( j  Y, Q$ ]! O
of serum 17-hydroxyprogesterone was 16 ng/dL
; o. K+ d2 i0 `+ @/ }1 T(normal, 3 to 90 ng/dL), androstenedione was 20* g1 z$ ^' ~$ A- p2 M+ `2 C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ n: a; X' A% D3 f& s( J9 P! _: @
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 A# d' T' U* Y# B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 C# I, G2 c  ?  f0 F& v0 }  K
49ng/dL), 11-desoxycortisol (specific compound S)6 {8 m+ e5 J, R$ q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, ^1 D; k; F. l$ I7 z$ z# d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 H2 M0 z; I  W2 i, {  J" Y5 ?testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& ?  @8 A3 P' }- T, i
and β-human chorionic gonadotropin was less than
% Z0 S' ?# ]0 J" F4 K8 r- F5 mIU/mL (normal <5 mIU/mL). Serum follicular
. Y  u" {$ [3 d) Pstimulating hormone and leuteinizing hormone0 t; o5 ?: n/ x8 Y9 F1 g3 \5 |5 C
concentrations were less than 0.05 mIU/mL6 I2 ^  Y8 {$ d7 L7 R0 ]
(prepubertal).
' g& s$ z* r. W& P. X9 S1 @The parents were notified about the laboratory9 }, a# I/ I" i) \
results and were informed that all of the tests were
- T" _2 {9 }1 m! t+ R: fnormal except the testosterone level was high. The
& U5 i+ ?" R9 }2 P( qfollow-up visit was arranged within a few weeks to$ {: y! S0 Z5 v' C0 T% E5 ?) P
obtain testicular and abdominal sonograms; how-
/ X% o4 L' u7 P8 w; y; pever, the family did not return for 4 months.
8 d1 T) Q. S3 C! N4 V7 ~Physical examination at this time revealed that the1 H& p& }1 J3 B9 {+ ~, n
child had grown 2.5 cm in 4 months and had gained, _; y( y+ j2 u; Q7 _4 E+ e3 {) C
2 kg of weight. Physical examination remained  c! c  r+ m, V( y; T, f
unchanged. Surprisingly, the pubic hair almost com-2 P4 D  q$ n3 u8 V0 }
pletely disappeared except for a few vellous hairs at& c+ P. \  B0 K1 U1 }
the base of the phallus. Testicular volume was still 2
8 h9 g* o# _+ [0 C. e2 V- y5 TmL, and the size of the penis remained unchanged.+ c/ r* c. |+ M9 b, x3 m: D$ L" u8 D
The mother also said that the boy was no longer hav-9 b) c) P- v3 A5 H4 E+ d
ing frequent erections.
# [8 p7 Z* l5 H" \9 dBoth parents were again questioned about use of6 Y. c3 E% P6 m) f
any ointment/creams that they may have applied to$ d6 j$ \( M9 y  }. q' l  b
the child’s skin. This time the father admitted the3 _, ~2 q* Z& R& I+ u& v
Topical Testosterone Exposure / Bhowmick et al 541+ a# U1 H9 z* |: j/ E7 C5 c7 ~
use of testosterone gel twice daily that he was apply-, g5 q& P" i& [, F
ing over his own shoulders, chest, and back area for& S' }' u1 ^  m- g) B+ R; `
a year. The father also revealed he was embarrassed
! p; N% y' d, k6 L; S* p1 gto disclose that he was using a testosterone gel pre-
" H9 i+ }( ?. N8 }9 w5 Iscribed by his family physician for decreased libido7 D$ W4 e: s4 n
secondary to depression.# w4 J$ O8 ~1 L$ V* S
The child slept in the same bed with parents.# O4 H2 }4 A# K" O/ F
The father would hug the baby and hold him on his
8 @% l" x0 y6 _) T! K+ }; Xchest for a considerable period of time, causing sig-! \( Z* H: E1 J* k
nificant bare skin contact between baby and father.$ L3 [8 b' z, I2 ?
The father also admitted that after the phone call,
: ?- f+ O  r1 [- jwhen he learned the testosterone level in the baby8 N* y2 U! V7 D
was high, he then read the product information8 p# K! t4 ?2 _# k( H* k2 j6 q
packet and concluded that it was most likely the rea-
5 M& S% H5 c0 l0 y9 I5 b9 Yson for the child’s virilization. At that time, they
! T# S7 j1 ]" E  y" Ydecided to put the baby in a separate bed, and the3 \( T$ \/ c, U* ]$ y
father was not hugging him with bare skin and had8 @. c/ @/ K0 X* p9 B+ }2 e
been using protective clothing. A repeat testosterone
4 z1 p6 n* v! \+ Ytest was ordered, but the family did not go to the
  R) k6 W+ M$ n- E( G2 U% X; llaboratory to obtain the test.
% m: p( F, @1 S* g/ i) d. gDiscussion5 K+ q2 z( D2 ~: e
Precocious puberty in boys is defined as secondary
- h* D. i( t1 V  N7 O7 `sexual development before 9 years of age.1,4" g, A. O5 B1 S/ }8 K
Precocious puberty is termed as central (true) when$ e. Z1 z- @2 p9 Y1 j* J
it is caused by the premature activation of hypo-2 c9 U$ k/ o  @6 Y5 H" t
thalamic pituitary gonadal axis. CPP is more com-& ^; V3 q( S+ X
mon in girls than in boys.1,3 Most boys with CPP
4 v* C- H5 [/ g; u. g5 H2 Pmay have a central nervous system lesion that is- G) v% g1 E0 S9 \
responsible for the early activation of the hypothal-2 ~" c3 H" Q! r+ d( Q, F
amic pituitary gonadal axis.1-3 Thus, greater empha-
% O/ Z8 p+ w, F. l) z4 H6 {sis has been given to neuroradiologic imaging in
4 S. r5 u- P* N, v) W2 `2 X/ K+ jboys with precocious puberty. In addition to viril-
3 D+ W5 J9 _1 h- ~8 Mization, the clinical hallmark of CPP is the symmet-$ W9 o- t5 F" R6 t6 T' \1 z; N, f
rical testicular growth secondary to stimulation by+ `7 Z5 Z  z0 q5 e  U0 I
gonadotropins.1,3- U% c/ k/ z2 L( U! @" ^& N
Gonadotropin-independent peripheral preco-3 u: Y, ?8 ~/ g4 E7 L
cious puberty in boys also results from inappropriate; J* @! E" j- Q' I
androgenic stimulation from either endogenous or1 z3 ?6 w2 }: w8 z+ r! p2 K
exogenous sources, nonpituitary gonadotropin stim-
5 {- A# q! R# [; z4 X' d! `ulation, and rare activating mutations.3 Virilizing
- t- I  M/ k+ w  }/ u' hcongenital adrenal hyperplasia producing excessive
# L3 L3 @* z# X3 k  M: Q- S) aadrenal androgens is a common cause of precocious4 D& y( i$ N* Q6 r! [
puberty in boys.3,4
: M3 H! _9 x7 j4 L0 J7 G- UThe most common form of congenital adrenal9 C$ G+ [* l  {- `" p
hyperplasia is the 21-hydroxylase enzyme deficiency.- P# }! L) O  ^- {% x/ K
The 11-β hydroxylase deficiency may also result in: O0 x9 Z. `0 T2 l9 P
excessive adrenal androgen production, and rarely,9 b2 \. Y- l) @
an adrenal tumor may also cause adrenal androgen9 Q: Q8 ~& ^: g" H
excess.1,3. q6 Z" C* k% r3 N/ g8 q2 n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# x: H9 O( d8 f* a6 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- _  J+ \* f! P% ~
A unique entity of male-limited gonadotropin-
. a4 X8 L% Q6 ^, U! p  Gindependent precocious puberty, which is also known
! z. Q' B9 ]& X1 C  I% c: fas testotoxicosis, may cause precocious puberty at a. s, Z: _; z6 l, \7 W
very young age. The physical findings in these boys
; l# t* i- |- Awith this disorder are full pubertal development,% i6 L, d3 V: B9 v* B+ n3 \
including bilateral testicular growth, similar to boys9 H3 v' N" r. |9 N- }/ o
with CPP. The gonadotropin levels in this disorder
- _: w2 i& F/ `are suppressed to prepubertal levels and do not show
9 c3 y: v7 [$ n/ i  x$ Z8 [4 T9 opubertal response of gonadotropin after gonadotropin-5 L% k5 ]8 R0 a' L9 ^
releasing hormone stimulation. This is a sex-linked
2 z* r3 }5 T9 z; z! n5 s& ^autosomal dominant disorder that affects only
. ?5 t  Z% F) K1 @% [males; therefore, other male members of the family+ u# z. w* S1 a0 X7 G0 H! h
may have similar precocious puberty.3
6 z3 V7 a. D/ F4 EIn our patient, physical examination was incon-1 q( o- r( E9 j& a8 f3 `
sistent with true precocious puberty since his testi-
# A" b9 h! ~/ }/ X- {' J: x* vcles were prepubertal in size. However, testotoxicosis
9 y& t, C# P9 x" {was in the differential diagnosis because his father/ v, V8 T- q4 J8 D+ j
started puberty somewhat early, and occasionally,3 Z% i6 B5 f& t, ]2 T
testicular enlargement is not that evident in the
" ]) n+ K) Y  h0 l) a  E" kbeginning of this process.1 In the absence of a neg-
8 g9 `$ ?9 I, r+ W, aative initial history of androgen exposure, our
0 I' ?4 f9 d; B# L+ Mbiggest concern was virilizing adrenal hyperplasia,* [+ ^5 E: @# q. f' F& G0 h& P% d, R
either 21-hydroxylase deficiency or 11-β hydroxylase
0 s. R) M2 N0 t. Hdeficiency. Those diagnoses were excluded by find-! U0 i( y# J4 P" Q0 X
ing the normal level of adrenal steroids.
5 S2 c- z( v5 Q; D8 _8 @; L# Z' iThe diagnosis of exogenous androgens was strongly
1 J: {7 f0 e  ?4 Fsuspected in a follow-up visit after 4 months because
, v6 {1 ~' t1 V4 P7 [( P4 ~' b0 H( pthe physical examination revealed the complete disap-$ ~3 a2 O. Y, h4 t# V  Y- {
pearance of pubic hair, normal growth velocity, and
; \9 ^7 [8 v) D: ndecreased erections. The father admitted using a testos-7 b: d; q2 s) ?  H
terone gel, which he concealed at first visit. He was1 W/ X; d/ n; Z9 c
using it rather frequently, twice a day. The Physicians’
/ r+ D! Y# L3 T. {- v+ Q9 fDesk Reference, or package insert of this product, gel or) h, B  Q1 n( h+ P, z  L# V
cream, cautions about dermal testosterone transfer to
; H+ G% c. Q) W! k1 ?' _unprotected females through direct skin exposure.
4 J- {0 \# |' Y% l% z! L5 kSerum testosterone level was found to be 2 times the* k3 _5 i& K& j/ g
baseline value in those females who were exposed to) }# j; d% _# [. o
even 15 minutes of direct skin contact with their male" s. [$ K1 `4 g' P3 T
partners.6 However, when a shirt covered the applica-
  @; {" g* F; S+ A  K9 ttion site, this testosterone transfer was prevented.2 _$ x' ~0 }& l. |4 ~
Our patient’s testosterone level was 60 ng/mL,8 ^9 [/ J- Y" `
which was clearly high. Some studies suggest that
+ c% P4 T. Y7 B* `& ^dermal conversion of testosterone to dihydrotestos-
9 ^. I2 u* ?/ R) F% N$ Nterone, which is a more potent metabolite, is more
8 |- ]# D" E1 yactive in young children exposed to testosterone: i" R! V# b8 l0 R" O6 _
exogenously7; however, we did not measure a dihy-% @( z2 V) h; {% d% J* v
drotestosterone level in our patient. In addition to- W" c, Q$ M6 ~+ H, i, b
virilization, exposure to exogenous testosterone in+ v8 c4 z+ Z& k
children results in an increase in growth velocity and
* K( {: M- p' T8 @; s! |advanced bone age, as seen in our patient.
- `! `: ~: ~8 U6 N" p& _8 gThe long-term effect of androgen exposure during
8 i6 L9 ]5 D$ x& Q7 S( L+ ~. W$ C( k) learly childhood on pubertal development and final
7 A+ s; E) l4 y" d# r) x+ b0 M4 hadult height are not fully known and always remain
, ?: f3 ?2 k5 h# q  M* Z3 ba concern. Children treated with short-term testos-# I5 E9 m+ T6 S0 i. U
terone injection or topical androgen may exhibit some
( _# d% a: o# l: ?9 cacceleration of the skeletal maturation; however, after  [; R" E+ a7 k6 T. @( s0 L3 u& w
cessation of treatment, the rate of bone maturation
8 _1 `& {' h0 c$ i6 |, M& Ydecelerates and gradually returns to normal.8,9
, m. o3 b& l" C5 h& w% ?. [There are conflicting reports and controversy
$ x/ `) f& _# T6 qover the effect of early androgen exposure on adult2 f8 j5 V7 N6 N% [
penile length.10,11 Some reports suggest subnormal
( {9 l4 X* u5 b, T! f, hadult penile length, apparently because of downreg-* F  i$ V( F* o. N
ulation of androgen receptor number.10,12 However,; v. I/ n& j) w9 n- ~/ ?& k
Sutherland et al13 did not find a correlation between# M' S9 L/ X# C- |. D) M
childhood testosterone exposure and reduced adult
# R7 ?3 _1 T7 l$ l! z2 a1 gpenile length in clinical studies.* L# D. G8 {' [: v# N
Nonetheless, we do not believe our patient is
. Y+ ^+ C* }4 hgoing to experience any of the untoward effects from6 k% T: H; m1 q* x1 \
testosterone exposure as mentioned earlier because& v! h/ p1 e/ h. R* x
the exposure was not for a prolonged period of time.1 T; W3 H5 `5 |$ W* x
Although the bone age was advanced at the time of7 \) m. Q) K% K# K6 u. a
diagnosis, the child had a normal growth velocity at
' |$ J# }( e( d, Fthe follow-up visit. It is hoped that his final adult# w& }; ]2 B% z: @+ z! Z4 X
height will not be affected.
- ?0 s. k4 V( _, P, O3 D# k1 ~Although rarely reported, the widespread avail-
9 X- r2 G% ]8 I9 Rability of androgen products in our society may
$ s/ M/ Z8 m4 E' J( findeed cause more virilization in male or female2 c( z  V- _: m. w
children than one would realize. Exposure to andro-; J7 y- u; I' U. p
gen products must be considered and specific ques-9 \1 ?1 X; @6 h! H4 O! a& c
tioning about the use of a testosterone product or& V% h  i7 q/ ?) b" v% p$ Z
gel should be asked of the family members during7 x- [7 ^2 _; G" z
the evaluation of any children who present with vir-
! m) N# N( N, {ilization or peripheral precocious puberty. The diag-
4 [% B' {! _- Z8 Jnosis can be established by just a few tests and by3 h" y8 y5 x: t* m' A3 t7 T
appropriate history. The inability to obtain such a/ Z. q4 o3 \  m2 C# d
history, or failure to ask the specific questions, may" `. ?+ u" Y8 U* o
result in extensive, unnecessary, and expensive2 ]" h+ D' n- h1 |
investigation. The primary care physician should be' Y# }; o9 A5 A/ q0 s9 C$ X" \7 c  T
aware of this fact, because most of these children8 |: p; [4 D+ G
may initially present in their practice. The Physicians’
9 m% d! Y9 T8 M* L& j: |Desk Reference and package insert should also put a9 f' i5 r& H) b5 [( Y
warning about the virilizing effect on a male or
7 f% T/ Q7 i& [1 Vfemale child who might come in contact with some-  b: c$ s: x* V3 ]8 J7 K5 W( L
one using any of these products.
2 @1 E+ ]+ b5 kReferences
" r, N, K$ K1 f1. Styne DM. The testes: disorder of sexual differentiation+ L  K/ s7 g1 D
and puberty in the male. In: Sperling MA, ed. Pediatric0 J2 L* k8 A) w: Z( h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 s# l$ x4 H- q% w
2002: 565-628.
, x& B' T8 k5 s0 T2 I7 K( L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ _  a7 p7 l) q2 c, ?3 H
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

. E0 q) `3 Z1 l  C! f0 e% B' |+ b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