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% P0 w0 ^5 ~( }1 Q+ f5 ~9 Y- C
Boy Induced by Indirect Topical
/ a( R+ \2 b- kExposure to Testosterone  \! K7 b% g2 P( h1 A; ]1 Y, b5 _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: M+ q1 s4 f0 v! _; u
and Kenneth R. Rettig, MD1; j( S& D4 Y4 C0 @( P; n5 p# `
Clinical Pediatrics
. E& u, `! ]- V. D3 n, x2 P3 {Volume 46 Number 6& c  M3 {+ i2 w. j" ~+ G
July 2007 540-543* b4 P/ b- v: L; _
© 2007 Sage Publications
$ r( J6 D2 E! K' L4 H3 A10.1177/0009922806296651
0 }7 t) d! J- e. E  Bhttp://clp.sagepub.com
' e$ U2 ]8 F) a0 h1 thosted at
4 c3 s. t; Y* ]3 g# g/ s! D' Fhttp://online.sagepub.com
. Y) x7 |- w3 l* ]0 Q# wPrecocious puberty in boys, central or peripheral,. j+ r$ n) O1 Z
is a significant concern for physicians. Central
/ y* K+ i+ U' e' nprecocious puberty (CPP), which is mediated8 Y& K! s: x$ y9 T
through the hypothalamic pituitary gonadal axis, has
! f* V& Y, u& q% i" V( Za higher incidence of organic central nervous system$ B  P; W* ^( s- T* d2 \5 b4 ?
lesions in boys.1,2 Virilization in boys, as manifested0 r2 c5 ]4 [" V9 q
by enlargement of the penis, development of pubic
4 T/ C) I9 M# M" j7 i; b) Ohair, and facial acne without enlargement of testi-
6 [0 z; g$ P8 V5 l" y: G9 T- ucles, suggests peripheral or pseudopuberty.1-3 We
- n0 }( V, `% A$ c2 F. s0 G$ yreport a 16-month-old boy who presented with the- p) o: F4 N9 N9 S8 B: `% r- `
enlargement of the phallus and pubic hair develop-9 S3 ]+ B/ q0 |) u
ment without testicular enlargement, which was due
8 {6 X4 N& X2 C8 s5 ^to the unintentional exposure to androgen gel used by( z! v7 Q3 l9 C% }6 y4 K$ y
the father. The family initially concealed this infor-2 i, p' g# m" p8 F. D% w
mation, resulting in an extensive work-up for this
" G& L) M( v( Zchild. Given the widespread and easy availability of
8 B2 E) c  m  [# [; i/ S7 Ctestosterone gel and cream, we believe this is proba-
* ^0 I, y4 I$ {2 n0 @; @bly more common than the rare case report in the
& U. z1 b* a, _" @literature.4
# o% u+ z( i4 c4 {0 Y) `! K4 dPatient Report! J. h, B2 r# g3 K* n9 |! U
A 16-month-old white child was referred to the
% B2 F: [0 ^, X1 P& h# hendocrine clinic by his pediatrician with the concern
4 s4 E9 x1 l; k: bof early sexual development. His mother noticed+ Y" m  H8 x4 ^. v7 L3 L+ X
light colored pubic hair development when he was2 `! P/ y5 w0 g' q. e/ l
From the 1Division of Pediatric Endocrinology, 2University of
' j1 ~' e" {3 a/ M# o/ Z' FSouth Alabama Medical Center, Mobile, Alabama.
6 L- w7 o8 J/ E# n: ?5 VAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ p" {4 K( ]6 U: z3 C
Professor of Pediatrics, University of South Alabama, College of
5 |3 Y+ R0 U5 S" {& I9 j& vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: g: X; h- Z1 J" P5 b2 a8 {e-mail: [email protected].
( t1 c9 {# }2 G% V" B6 Dabout 6 to 7 months old, which progressively became
) T3 T) F* {/ m9 q( c* hdarker. She was also concerned about the enlarge-
; |. w* l; G- {1 a1 H1 f5 o# fment of his penis and frequent erections. The child4 o3 `& S) a& T' \
was the product of a full-term normal delivery, with5 A( D1 `, p: t* l: @% J
a birth weight of 7 lb 14 oz, and birth length of
" v3 s6 `3 c8 n7 ~7 B, p% g20 inches. He was breast-fed throughout the first year' c' n: p+ M! y- O% K: X8 q1 R9 {
of life and was still receiving breast milk along with2 n- J  d+ ?# ~9 `. y
solid food. He had no hospitalizations or surgery,- i. w( K3 `3 L- U
and his psychosocial and psychomotor development
- Q0 N% G* v4 B. o" hwas age appropriate./ o8 r8 n0 p' e( `0 g# r3 p
The family history was remarkable for the father,- }% a; _0 h1 A" N8 O! L
who was diagnosed with hypothyroidism at age 16,: b9 ]1 \: b( b2 A: ~  b
which was treated with thyroxine. The father’s& g! W" m1 g) k* w+ G
height was 6 feet, and he went through a somewhat$ v3 v+ k7 f- |9 W, A
early puberty and had stopped growing by age 14.( ?" [# ~% k3 X
The father denied taking any other medication. The9 `0 e2 r7 N1 _# f, D( o
child’s mother was in good health. Her menarche0 G1 E9 L- n' U* e' z9 H* r* q
was at 11 years of age, and her height was at 5 feet
$ T2 x2 w/ k$ s$ K' A( e1 g/ ]5 inches. There was no other family history of pre-' l# h- @0 n; [6 A' s" b' I: n
cocious sexual development in the first-degree rela-- U7 u0 G5 z4 r+ e6 J; O  o2 {  ]
tives. There were no siblings.: a4 h+ d6 n0 h9 R% h6 t# ^* ~
Physical Examination! N. f' D3 g& v5 K- v
The physical examination revealed a very active,
: T1 h: n0 t+ d& \& l/ dplayful, and healthy boy. The vital signs documented$ i5 a. W* Z4 P+ R% m
a blood pressure of 85/50 mm Hg, his length was
; _5 y% o9 Z# z/ c6 D90 cm (>97th percentile), and his weight was 14.4 kg1 `% U& x5 X9 y! l2 K6 U8 q
(also >97th percentile). The observed yearly growth
6 w. b# d+ n5 L" A5 d9 Qvelocity was 30 cm (12 inches). The examination of
6 K& l4 T5 z0 ?3 ^the neck revealed no thyroid enlargement.5 \) g* L" ]5 S: M, w
The genitourinary examination was remarkable for' x; H" N% ^& B0 H
enlargement of the penis, with a stretched length of
+ E4 I6 J+ i) G. C) R8 cm and a width of 2 cm. The glans penis was very well, i8 u6 V0 y0 r" [$ A9 Z+ I! ]2 Z/ W
developed. The pubic hair was Tanner II, mostly around
8 N# a9 U0 r4 m5 q# a2 C4 r: r% {: `5406 b  V5 ^3 O( U. j: L$ u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: j9 h( F" A" o- e5 Cthe base of the phallus and was dark and curled. The
4 i9 J. }6 R# L  ftesticular volume was prepubertal at 2 mL each.
  ~6 L4 e* B; T3 F+ }7 GThe skin was moist and smooth and somewhat5 C0 C" ^8 w; J7 @
oily. No axillary hair was noted. There were no* K( j# `6 Y4 v4 @
abnormal skin pigmentations or café-au-lait spots.4 T; n0 ^1 {# E% P$ Q
Neurologic evaluation showed deep tendon reflex 2+
+ s6 ?5 ^5 X, ?5 I( ^4 F; j& sbilateral and symmetrical. There was no suggestion
5 P: e  E  ?, l( o4 rof papilledema.5 X+ h# c6 G9 H
Laboratory Evaluation
9 n  u8 k6 J, A8 G/ Z* vThe bone age was consistent with 28 months by5 |, m$ z" b" Q9 @: A
using the standard of Greulich and Pyle at a chrono-0 o+ |- R* w5 y
logic age of 16 months (advanced).5 Chromosomal
- m0 k. w$ E7 G, Q1 z5 V, Dkaryotype was 46XY. The thyroid function test
6 o# I1 K( [0 e& i6 bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 o; s& ?  P. R& R1 D' {, t4 f5 R) @
lating hormone level was 1.3 µIU/mL (both normal).
& O& s9 S. \% a/ n0 ]8 @+ S2 uThe concentrations of serum electrolytes, blood
% R  K/ ~6 P- w% Q1 Yurea nitrogen, creatinine, and calcium all were# v+ b4 v; Z5 Y7 u
within normal range for his age. The concentration
5 @% n! E2 L! G1 J) ^of serum 17-hydroxyprogesterone was 16 ng/dL) |4 x8 {# f" ?( m  P* w# b
(normal, 3 to 90 ng/dL), androstenedione was 20
" e  k" t! Q# m! O+ m4 Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( y# I6 t6 B0 |7 V: P4 Y$ P3 Uterone was 38 ng/dL (normal, 50 to 760 ng/dL),% Z9 @  s. k8 f% H. M2 N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 L- l6 U+ v% S) N2 u* l) C; V49ng/dL), 11-desoxycortisol (specific compound S)
1 H, _2 \- ~& J# F8 k6 K6 B0 Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# Y/ J* T$ m! R( \( @5 h, I' ^
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! O6 V( l5 [: R% p7 Y+ N6 ~, Ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),! O  E: n# \6 [+ P* M9 F* U
and β-human chorionic gonadotropin was less than. A% P5 v& }$ }9 E* I7 G0 W
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ Y' x, T7 r3 G% h7 ]; v
stimulating hormone and leuteinizing hormone6 B) `. c' v* J& C
concentrations were less than 0.05 mIU/mL' f% \( @6 ]$ v
(prepubertal).7 [0 D7 X8 J2 q- j. u8 L
The parents were notified about the laboratory6 K! C6 h( h7 U6 |( {( R7 \+ E/ P) {: Z+ k
results and were informed that all of the tests were
: o- T8 L4 s( M- g/ @7 C5 Rnormal except the testosterone level was high. The
5 g$ ]' l0 D; V: A. N; P0 k4 Z6 xfollow-up visit was arranged within a few weeks to" L0 O' \' K* H# z
obtain testicular and abdominal sonograms; how-6 s  T  I  \, f3 a, b. ~; j: W
ever, the family did not return for 4 months.1 j5 X9 H  k( N) Q: |
Physical examination at this time revealed that the4 l: ^" N& p/ [6 y
child had grown 2.5 cm in 4 months and had gained
6 s9 @( w5 o+ ]% c( {3 r2 kg of weight. Physical examination remained. [/ x2 o  R8 I: }4 ^( b& u8 A
unchanged. Surprisingly, the pubic hair almost com-# N. n! ?# ^2 O' t
pletely disappeared except for a few vellous hairs at
) t6 X' V3 C" y( O( J  b( ^the base of the phallus. Testicular volume was still 2( J& Q# |) N4 q" a6 X4 z
mL, and the size of the penis remained unchanged.
4 Y( X) `& D' d) i5 G# DThe mother also said that the boy was no longer hav-" I' r  H) o( }) _+ P' [. q
ing frequent erections.
6 i$ K7 o6 O$ U  {3 G3 l. L- VBoth parents were again questioned about use of& l/ p/ l8 |- _' ^
any ointment/creams that they may have applied to- a. d% I$ n& t7 W
the child’s skin. This time the father admitted the
. j" X6 Q9 m. b, P* g  G$ CTopical Testosterone Exposure / Bhowmick et al 541
8 C. Y/ O% i' ^8 D% ?/ |6 K, Juse of testosterone gel twice daily that he was apply-
8 k) J: J! i8 Qing over his own shoulders, chest, and back area for* B# i6 _) P* L
a year. The father also revealed he was embarrassed
. C  B& {) p9 e' W7 t6 c' h% C2 Lto disclose that he was using a testosterone gel pre-
; Z* D3 v- z  c1 e+ r& Hscribed by his family physician for decreased libido
5 X  V+ P2 I& s$ f% zsecondary to depression.6 X6 X0 I6 u1 G  B, d
The child slept in the same bed with parents.+ m3 }. C+ ?6 X$ p1 }
The father would hug the baby and hold him on his! A$ \. z$ A  y
chest for a considerable period of time, causing sig-
% z' G5 n9 Z; N, G% j& K& onificant bare skin contact between baby and father.
0 n( [8 r% V& uThe father also admitted that after the phone call,
: E# ?. x. U$ g+ I$ g' J( l7 p4 ]when he learned the testosterone level in the baby
( T- M: C* o' {was high, he then read the product information8 x9 y* Y; n/ Q% M8 q
packet and concluded that it was most likely the rea-
8 y. T0 g' V" J" s8 x. m5 V1 Bson for the child’s virilization. At that time, they
9 L1 c0 U( ?# M7 q# \7 `6 z2 tdecided to put the baby in a separate bed, and the/ T3 P. \& r3 A/ h3 J3 |( X
father was not hugging him with bare skin and had
3 {( N* [- Z& A0 pbeen using protective clothing. A repeat testosterone
+ A1 Z+ j( P6 F1 dtest was ordered, but the family did not go to the
: N' e' n" _/ h1 o# f) n  Plaboratory to obtain the test.
0 D  g% \0 Y, H' E1 j5 ?Discussion
, X8 \/ P/ c/ Z9 N% A: v0 u9 [Precocious puberty in boys is defined as secondary
+ S% c/ I1 L( X  T6 x$ M. Msexual development before 9 years of age.1,4# H9 }# j8 w- h3 S
Precocious puberty is termed as central (true) when1 N. N2 ~+ K' L1 R; F# Q1 o) W
it is caused by the premature activation of hypo-
* o, T$ c* e1 A  dthalamic pituitary gonadal axis. CPP is more com-7 Q* F2 H8 O, U$ x
mon in girls than in boys.1,3 Most boys with CPP: _- A5 W! J+ K. [  S, w# ~$ ^
may have a central nervous system lesion that is
! s* R" W2 `2 z" `) k" b6 Eresponsible for the early activation of the hypothal-
$ R% [; s$ ~' j& [; h' \$ Famic pituitary gonadal axis.1-3 Thus, greater empha-
1 j2 c9 |/ ]. k5 K0 Usis has been given to neuroradiologic imaging in
( M1 r, {" N2 B" C' ?boys with precocious puberty. In addition to viril-. J4 b0 J# ~8 D
ization, the clinical hallmark of CPP is the symmet-) q0 Q% I4 E3 K. T6 @6 j0 Z
rical testicular growth secondary to stimulation by
; M$ r' ?2 D* _' ^gonadotropins.1,37 f, ^. _( b" t, p+ T
Gonadotropin-independent peripheral preco-' J% l- G6 L: m4 |  e
cious puberty in boys also results from inappropriate
, e- A4 m# p: Q  Iandrogenic stimulation from either endogenous or
" z- e' A, a2 J, `) \: Lexogenous sources, nonpituitary gonadotropin stim-& |( v/ Z( K- q
ulation, and rare activating mutations.3 Virilizing- E( ?& I1 Y. [
congenital adrenal hyperplasia producing excessive
' f* a: M! ]' S: e, Iadrenal androgens is a common cause of precocious
$ P6 C; I" {) ^; l7 D0 Wpuberty in boys.3,43 [; Z  S. g. S- M! V' m; O
The most common form of congenital adrenal
# l' e$ H6 \0 u  }. b: L5 C% phyperplasia is the 21-hydroxylase enzyme deficiency.. m. V9 @+ @7 S3 n2 _; p) P/ y
The 11-β hydroxylase deficiency may also result in3 `+ g' \! p& l2 u' N7 t
excessive adrenal androgen production, and rarely,
: c. ]  x  Z7 G+ H3 y: b+ y3 }" San adrenal tumor may also cause adrenal androgen- O1 i! i0 ~( i- s* D0 G/ p+ x8 h
excess.1,3
3 m/ ~7 u" s8 H) Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. a7 e1 m& R: o% w/ y
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 K( }( ^- W; m; G9 Q, R. T
A unique entity of male-limited gonadotropin-
9 c/ _7 O' X& t! p) I, Aindependent precocious puberty, which is also known# M+ h. ~/ p- P3 v- b/ m
as testotoxicosis, may cause precocious puberty at a
4 T* M, j& ?8 s  M) \very young age. The physical findings in these boys
# P: R+ `" y2 gwith this disorder are full pubertal development,
9 d# Q/ B& w2 j, Z) Zincluding bilateral testicular growth, similar to boys$ J+ v4 [6 |6 R+ a
with CPP. The gonadotropin levels in this disorder5 e2 A6 O( F: {& N( ?& `2 z- q& @+ o
are suppressed to prepubertal levels and do not show
5 ?4 k2 Y- ^. V3 k( _- Opubertal response of gonadotropin after gonadotropin-; e! d; D5 n' V  U; H
releasing hormone stimulation. This is a sex-linked
7 N9 w# U- i' N9 j/ a$ Uautosomal dominant disorder that affects only7 w4 a& h9 x% h- k0 F9 m' u
males; therefore, other male members of the family
, P* `7 d! V3 Vmay have similar precocious puberty.31 S$ x2 H" k1 H% J3 v& Z
In our patient, physical examination was incon-
1 s" l$ U. a9 V0 P  }1 P, ^sistent with true precocious puberty since his testi-8 m$ q1 m8 s7 M1 S& _# `* M4 q9 |
cles were prepubertal in size. However, testotoxicosis
2 F; P/ t( ^) \$ l9 ?0 T8 B, kwas in the differential diagnosis because his father6 H8 j! C4 e, V$ r
started puberty somewhat early, and occasionally,: ?* ^8 E: m8 B( v8 O
testicular enlargement is not that evident in the* T: A! L4 s; S- l
beginning of this process.1 In the absence of a neg-! g0 }  N# e( ?: L6 d- D
ative initial history of androgen exposure, our* {3 N( @9 _+ O6 z/ j# T
biggest concern was virilizing adrenal hyperplasia,: L& ~! |2 H4 A+ ^3 e) M
either 21-hydroxylase deficiency or 11-β hydroxylase
4 N' ^# m7 Q( M& g& S( S+ B2 _" o2 Bdeficiency. Those diagnoses were excluded by find-
+ `3 c4 C$ n; H9 E/ E2 sing the normal level of adrenal steroids.  D( l* L3 E: j  q
The diagnosis of exogenous androgens was strongly# n* c3 y* s6 W& o' k& T) T4 W8 D
suspected in a follow-up visit after 4 months because: I" A1 l3 p1 l- g+ ^* U# v$ j
the physical examination revealed the complete disap-
2 `& L! D  _6 Qpearance of pubic hair, normal growth velocity, and
' D5 M) Q8 }6 ]5 _: Ndecreased erections. The father admitted using a testos-3 [# H% ^) L( I+ C, P
terone gel, which he concealed at first visit. He was( \% t! `0 u* U" @$ j7 l5 R. h
using it rather frequently, twice a day. The Physicians’# H4 N# m8 P/ C8 ^
Desk Reference, or package insert of this product, gel or  a. b8 D# ^4 R. g$ e  E
cream, cautions about dermal testosterone transfer to
+ u9 n1 i+ _8 I& ^unprotected females through direct skin exposure.
* i$ b7 r& |8 ~6 RSerum testosterone level was found to be 2 times the4 C7 K9 f3 D. [) `1 _5 ?
baseline value in those females who were exposed to
- ?. @% q  b, ^+ Heven 15 minutes of direct skin contact with their male& c+ q/ @2 u; d1 `: b
partners.6 However, when a shirt covered the applica-
7 o- T2 i8 D7 D+ `& R  W9 Y0 Ktion site, this testosterone transfer was prevented.
4 r5 Z0 i1 L% Z# ?7 ]- g* `Our patient’s testosterone level was 60 ng/mL,
3 @! \0 O5 ^% M- R: w: m; hwhich was clearly high. Some studies suggest that3 m4 h% I( Z/ k; n9 Z0 t* I
dermal conversion of testosterone to dihydrotestos-  z$ X$ h4 C2 a; N
terone, which is a more potent metabolite, is more
: y0 u( n, F+ S" }active in young children exposed to testosterone
" Y% X4 w. _. [. `3 Q/ \* Jexogenously7; however, we did not measure a dihy-7 }: T# C1 `" Y
drotestosterone level in our patient. In addition to4 \* G2 K0 i( k; B, y6 x& v
virilization, exposure to exogenous testosterone in, n* j( X3 q+ h; e5 u2 H4 W
children results in an increase in growth velocity and% _4 y) A& S: d  T
advanced bone age, as seen in our patient.) K' N, u" u( o
The long-term effect of androgen exposure during
% ?' d( F$ a7 q" `early childhood on pubertal development and final6 ]0 q- c* F- c6 b5 D; s
adult height are not fully known and always remain% m6 R4 \& H# N5 {5 F  |
a concern. Children treated with short-term testos-+ w4 t0 E( i$ P+ v. e0 _
terone injection or topical androgen may exhibit some
4 z* {/ r5 v; v" wacceleration of the skeletal maturation; however, after/ n; X  }2 K* |4 w7 y
cessation of treatment, the rate of bone maturation
. Q" Z9 M& \1 I- E" O* z9 u) Ndecelerates and gradually returns to normal.8,9
/ c! N8 q; a5 s# c( e. fThere are conflicting reports and controversy7 F6 k1 f) v. r1 g3 o
over the effect of early androgen exposure on adult
1 O6 q# l9 a3 o+ f7 U4 z# H* ypenile length.10,11 Some reports suggest subnormal
  l4 I/ `9 m8 D  V; Gadult penile length, apparently because of downreg-5 p7 v, @5 C- A% C2 ^
ulation of androgen receptor number.10,12 However,6 @( p9 r" x4 X7 s* t4 P5 m
Sutherland et al13 did not find a correlation between  o5 i' o1 z: z: g% S1 T* j  _
childhood testosterone exposure and reduced adult
9 h) b( p4 d; h# K+ Ypenile length in clinical studies.( U7 o1 o# C, g7 S3 R& ]
Nonetheless, we do not believe our patient is
$ e* O' F$ o2 W) q' F7 }2 ]going to experience any of the untoward effects from
0 e- q. W2 ]0 ?9 @testosterone exposure as mentioned earlier because
- E2 Z+ u! n8 [2 Athe exposure was not for a prolonged period of time.8 \* h3 u2 y3 P8 O) o; O/ N+ I$ W
Although the bone age was advanced at the time of
* [8 E( d$ `% f8 Qdiagnosis, the child had a normal growth velocity at
$ p0 [. B/ i; kthe follow-up visit. It is hoped that his final adult& g: k; {/ G# y$ J0 x
height will not be affected.
1 E$ ?% l2 F! Z5 P6 p" XAlthough rarely reported, the widespread avail-5 p( S0 s/ j+ t
ability of androgen products in our society may2 V) b' ~2 Z( o$ i6 w! J4 i3 b
indeed cause more virilization in male or female- \% x% l( F* H5 |/ P; u" [4 a
children than one would realize. Exposure to andro-
3 G1 b. P. M- q$ rgen products must be considered and specific ques-! Q; A, I7 a- f+ i& n: y
tioning about the use of a testosterone product or
. R, ^4 @0 k8 G' y6 Ygel should be asked of the family members during/ a7 j" X' z4 y1 h
the evaluation of any children who present with vir-
6 |  R6 E; H7 w0 T: A2 \ilization or peripheral precocious puberty. The diag-/ q( e  D, O4 ~) ?) E
nosis can be established by just a few tests and by
! h+ ]2 P- A) {: K: f+ \appropriate history. The inability to obtain such a
8 {' ^. H! y; ?' U+ rhistory, or failure to ask the specific questions, may8 N0 o( _8 U( P! v6 @& z# I$ c) }6 D
result in extensive, unnecessary, and expensive
( _* [1 @* a9 y8 Q  O- ?investigation. The primary care physician should be9 Z9 c/ E4 G( D, L# B* w
aware of this fact, because most of these children
" ?, w& o8 b" S  @* T: c4 Y9 a# t6 |7 Nmay initially present in their practice. The Physicians’
/ d9 L( r0 k0 S( u! S0 bDesk Reference and package insert should also put a
  v" M" G# p. l& B1 mwarning about the virilizing effect on a male or( R7 K/ v, L% n1 k+ y/ s+ ~
female child who might come in contact with some-9 {- h/ r% G/ w& h- @) j# P
one using any of these products.- l- _/ ?- F: r! Q: D
References
7 W0 l) K* O$ z* y1. Styne DM. The testes: disorder of sexual differentiation
: X6 ^; z2 b5 V3 S5 iand puberty in the male. In: Sperling MA, ed. Pediatric1 G6 `1 x* O/ o8 x! Z7 J' B6 V# s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ _6 s8 y- J4 ^/ @" s5 ^2002: 565-628.
) _& e& b3 i: C- z. z& v2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; G# P* a+ U' W$ v4 N( [
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) J5 f0 ?( V* f& M
Boy Induced by Indirect Topical1 E8 a) ]  l0 H6 F8 S6 Q3 @
Exposure to Testosterone0 P$ _1 g& q, G0 _% K+ N: U6 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' e. O* Z( R% [% w' R  c5 X& ?, q/ hand Kenneth R. Rettig, MD1! d" N. w% S. C( X  V0 o; _; S  M# W5 @
Clinical Pediatrics
7 f- ?. D) K5 M$ y/ b4 HVolume 46 Number 6  @: }  a5 w2 G4 o  N: M. j. f* ?
July 2007 540-543& p7 o2 B, i% m% J2 n' d
© 2007 Sage Publications
6 x/ A5 d  t  O7 J/ f10.1177/0009922806296651, i6 g9 X) I1 J& h  J4 U) D
http://clp.sagepub.com
' T: Y' B2 ~& n$ R; H1 Khosted at- N) I/ H' k  l6 t; I; q, u
http://online.sagepub.com& ]/ [* K  Z, ?! H
Precocious puberty in boys, central or peripheral,
) m2 q0 O' l% g0 }& Q1 d$ vis a significant concern for physicians. Central, U1 O- C' P- \2 c" F% `$ [( b* m0 Z
precocious puberty (CPP), which is mediated
" l0 R: z/ c; {# ?9 Tthrough the hypothalamic pituitary gonadal axis, has3 a: M3 w7 @7 R. l3 D* t
a higher incidence of organic central nervous system
5 g& `# A. ?) y: d) L0 S0 v( C/ nlesions in boys.1,2 Virilization in boys, as manifested
3 i3 b' M3 ]+ k8 r" Sby enlargement of the penis, development of pubic" X% S* C' _/ E% g" d1 l& @0 T
hair, and facial acne without enlargement of testi-
5 k' q1 Z1 j' m  Mcles, suggests peripheral or pseudopuberty.1-3 We
: w9 i: \; W7 V! Q# s7 _report a 16-month-old boy who presented with the
" T7 @+ B8 a1 J; D" m! E% Henlargement of the phallus and pubic hair develop-
& P0 p( x8 {. ~0 pment without testicular enlargement, which was due4 G+ |; c8 q9 f$ R
to the unintentional exposure to androgen gel used by
" s8 O1 B5 m$ f% w3 o4 Ethe father. The family initially concealed this infor-! N6 x! W8 f$ G8 V
mation, resulting in an extensive work-up for this
7 ]& @3 Q- P/ y1 d1 Ochild. Given the widespread and easy availability of
$ P6 E6 R, o% ^8 @  Ctestosterone gel and cream, we believe this is proba-
, u% h* p' @4 Ybly more common than the rare case report in the
& T. k- J' K% ?5 V0 B5 Qliterature.4  Z9 ^! X3 q. j4 Y
Patient Report0 R  L: t, b7 h* E' P& p) f$ |. _
A 16-month-old white child was referred to the
3 o2 ?( {/ e; i0 ^1 Qendocrine clinic by his pediatrician with the concern$ s1 ^* ^3 w. Z
of early sexual development. His mother noticed( V/ a+ p3 S! \# p* N; e
light colored pubic hair development when he was+ z5 Y1 i7 l# N  ]* q
From the 1Division of Pediatric Endocrinology, 2University of
4 c6 Z3 q$ w. r* b9 }* t/ c7 N/ RSouth Alabama Medical Center, Mobile, Alabama.# d: P, G) A: y5 X  t
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 X# l: ?* m7 rProfessor of Pediatrics, University of South Alabama, College of
9 J& w& y" P) Y- h: RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 V. x9 @% j3 H) v8 M, W
e-mail: [email protected]., f/ g/ V9 V; K" }8 R8 K
about 6 to 7 months old, which progressively became
8 l5 @# m% e6 p9 I. q  Fdarker. She was also concerned about the enlarge-
) \8 Q+ g+ G: n0 g2 s+ Wment of his penis and frequent erections. The child' d6 D3 Q. ~* y6 v" Q1 [
was the product of a full-term normal delivery, with
& A8 C& z; u5 K, v! @a birth weight of 7 lb 14 oz, and birth length of
& X8 G! I$ ^9 O* B6 l20 inches. He was breast-fed throughout the first year+ p: Z! S, k1 Q  y% ~* o
of life and was still receiving breast milk along with% I. O! ^, S" X! S1 H
solid food. He had no hospitalizations or surgery,6 d. q0 F7 M0 R6 j6 N
and his psychosocial and psychomotor development
6 u# ]) {! O& ]4 v, t$ Jwas age appropriate., p" E/ N7 F4 i0 E: `
The family history was remarkable for the father,
4 y! Z4 @" e) E& l. @" Uwho was diagnosed with hypothyroidism at age 16," C# d7 S5 t( b& a
which was treated with thyroxine. The father’s( i  g5 s* O# q0 i1 q3 }
height was 6 feet, and he went through a somewhat9 P( |) q  n; d- [
early puberty and had stopped growing by age 14.
* }/ R1 G3 S' j  B+ B5 ~3 S- Z( g, oThe father denied taking any other medication. The
  D1 R5 _" g6 Nchild’s mother was in good health. Her menarche: p2 h* \3 S1 ?8 S
was at 11 years of age, and her height was at 5 feet) X. _# K3 f' ]6 d4 K  l( g% x
5 inches. There was no other family history of pre-
% j& D. |% q! p5 U6 x+ Jcocious sexual development in the first-degree rela-. h* ~$ l. j  r; ^+ j* H3 c
tives. There were no siblings.' y" @) K+ m- \9 j
Physical Examination, |; |/ k. {8 c  P
The physical examination revealed a very active,
' w, k& h- K  l$ P# Y2 \. v8 Rplayful, and healthy boy. The vital signs documented
$ m, i4 `* r- O, A- U. Aa blood pressure of 85/50 mm Hg, his length was
, h# N4 p5 Z2 t9 k. u" l4 N90 cm (>97th percentile), and his weight was 14.4 kg+ M: p' R, Q* D# Z4 ^- {
(also >97th percentile). The observed yearly growth
, \0 ~0 ]: I: E" H0 q* X# Svelocity was 30 cm (12 inches). The examination of5 J& j$ w# x3 k9 `
the neck revealed no thyroid enlargement.8 M8 v" `4 m- l7 p; C
The genitourinary examination was remarkable for
) n' E- A2 Q# d" t5 T' Cenlargement of the penis, with a stretched length of
$ o; o8 q- w, h4 w8 cm and a width of 2 cm. The glans penis was very well
# j9 M( V5 I9 w; N$ v: tdeveloped. The pubic hair was Tanner II, mostly around$ Z4 w7 K+ M9 l5 u+ x: u
5405 {7 [  ?5 a6 V7 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% d' a$ k2 i$ w! e9 ?; Y0 Dthe base of the phallus and was dark and curled. The4 h' [+ T/ q5 S% M4 {' G% R
testicular volume was prepubertal at 2 mL each.
3 }' J' V. p' }, D: pThe skin was moist and smooth and somewhat
) m9 p* }& K* Foily. No axillary hair was noted. There were no  U) L1 w! m/ T% \; o: E
abnormal skin pigmentations or café-au-lait spots.
; }, w0 ~" t. {9 zNeurologic evaluation showed deep tendon reflex 2+( M5 a9 R" N! i5 n: U
bilateral and symmetrical. There was no suggestion
9 v8 j9 z9 n4 ?$ _: n. X- Sof papilledema.
4 c2 A  r: q( w6 O: DLaboratory Evaluation) y2 [4 ]# ]' X, s: K
The bone age was consistent with 28 months by: ?* R7 ]" z% T* |+ s
using the standard of Greulich and Pyle at a chrono-1 v  w! M& p6 {6 i. h
logic age of 16 months (advanced).5 Chromosomal
) B7 [; j# P3 K1 e" u, ukaryotype was 46XY. The thyroid function test8 U; Q/ x8 r1 q8 \+ d+ q7 [! h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ X1 Z* ^( `) z/ Mlating hormone level was 1.3 µIU/mL (both normal).
! j# Q  c3 s/ t9 h& L* f$ e( V# \' B( [The concentrations of serum electrolytes, blood
2 A! p7 n" u2 D8 Z2 G) V7 V' Rurea nitrogen, creatinine, and calcium all were7 \6 K# S4 t; Q4 I# W
within normal range for his age. The concentration: t3 s% k( p/ L& q- t" X0 ~) s: ?
of serum 17-hydroxyprogesterone was 16 ng/dL
4 `1 V" O" p5 ?) X# D* U9 h+ q(normal, 3 to 90 ng/dL), androstenedione was 20$ ]: Z1 c. s2 H' I- A7 Y! ]* h' u, C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) Y1 ]+ j4 G# ]& v+ I  v4 s1 O6 J1 F" iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ q  v* Q' p4 X/ u3 B) rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 v& b! {1 D2 e7 N- u6 @49ng/dL), 11-desoxycortisol (specific compound S)" g  \. @& P* y( X- m% x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ a' X. o/ P  {( ^; V
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ q& i4 }5 W! Q6 T' H% R9 ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 y6 L, ], C( u) g2 y1 mand β-human chorionic gonadotropin was less than
! M, ]% z% j5 ~$ i( \5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ Z, l# [1 E) X& G; U8 mstimulating hormone and leuteinizing hormone
6 p# o1 n( J+ ?0 J# pconcentrations were less than 0.05 mIU/mL
5 g7 V9 E3 X4 x. L! l7 z/ k(prepubertal).8 A7 y) r/ v: u4 n9 w
The parents were notified about the laboratory
, s6 A9 `9 R5 G, ^4 |8 Kresults and were informed that all of the tests were
  K7 G) G( j! k& nnormal except the testosterone level was high. The" b- p$ S3 _+ ?& S0 \. x. S
follow-up visit was arranged within a few weeks to. w. h3 l5 M' D
obtain testicular and abdominal sonograms; how-  L3 f8 @  S. ?" ]& |
ever, the family did not return for 4 months., H, Q7 U( _5 z* H$ Z
Physical examination at this time revealed that the
/ {- n+ O3 f+ T8 Ychild had grown 2.5 cm in 4 months and had gained
6 q8 ~: c9 y- q8 K6 o$ H+ K2 kg of weight. Physical examination remained
* p- k/ L/ j' ^$ |2 d/ r) f' Junchanged. Surprisingly, the pubic hair almost com-; ?8 c' J, r& X: y% Y/ f
pletely disappeared except for a few vellous hairs at" o$ C; q; x% v* _
the base of the phallus. Testicular volume was still 2' m1 K) P# c& M' E3 b( U
mL, and the size of the penis remained unchanged.
% M9 g9 a8 k3 ^The mother also said that the boy was no longer hav-+ G& k1 D  l; j+ A6 h! L& i
ing frequent erections.
8 ^% N& a+ A( V0 R& `. MBoth parents were again questioned about use of4 m; j# g, b9 A1 G
any ointment/creams that they may have applied to% n. @3 W* l% t
the child’s skin. This time the father admitted the
' ?/ t: f) t8 V" |# B1 ]Topical Testosterone Exposure / Bhowmick et al 541
2 k4 {' c9 w: r6 o. Juse of testosterone gel twice daily that he was apply-
; M4 [; `1 q. ding over his own shoulders, chest, and back area for
2 {5 i2 {& y5 I( `# c. w# e, T. @a year. The father also revealed he was embarrassed# V: x. F9 L2 T- K* B8 K# u9 B
to disclose that he was using a testosterone gel pre-
' i% d" _8 |) Y2 L) A, N/ Vscribed by his family physician for decreased libido8 q, M  Y5 Q! N% U
secondary to depression.
4 ^+ d% M" Z3 B- T3 ?( b, FThe child slept in the same bed with parents.
7 A5 |% E% }2 w) f- ^, rThe father would hug the baby and hold him on his
4 s1 |, x) c' Tchest for a considerable period of time, causing sig-# R! J: a( m* Z( _* L- F
nificant bare skin contact between baby and father.
- T% P) j; C% W* zThe father also admitted that after the phone call,
" w; o. _# k) X4 `: Y4 L- Twhen he learned the testosterone level in the baby0 U5 _0 H+ F; ^( {
was high, he then read the product information
" S5 ~6 L/ C5 O% \( ipacket and concluded that it was most likely the rea-, E( m7 ]7 q& J4 @+ l9 W+ V
son for the child’s virilization. At that time, they1 M7 X7 H, V. F( A) I. h
decided to put the baby in a separate bed, and the! H7 i+ j  e1 F/ N8 w8 y
father was not hugging him with bare skin and had
4 e4 K, n8 _( \; J( ^7 j, Tbeen using protective clothing. A repeat testosterone
& _$ J2 D( z7 c. s* i& mtest was ordered, but the family did not go to the1 U# w7 ^/ R1 c3 @5 A
laboratory to obtain the test., ]$ {0 z5 I* u6 @
Discussion3 H6 `. F6 S( R( C* E- N! w' }
Precocious puberty in boys is defined as secondary
- y. c+ R' G: B' ~6 _5 ysexual development before 9 years of age.1,4- @+ G9 Y( J! ?- R- Y
Precocious puberty is termed as central (true) when
! j! Y4 N' t0 T7 Z/ Pit is caused by the premature activation of hypo-8 t( S7 X$ j/ q+ }; R! ~( t
thalamic pituitary gonadal axis. CPP is more com-# m9 p* l$ Z3 J( `) q
mon in girls than in boys.1,3 Most boys with CPP6 ]' S# A" p" \% s$ S. q
may have a central nervous system lesion that is- q4 H% R7 g* Q$ d
responsible for the early activation of the hypothal-6 |; \" W  f, w2 N0 J" g$ ]" F+ o
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 Y3 C6 Q5 M, t: |) h5 k  tsis has been given to neuroradiologic imaging in1 s1 a) i# j( w4 d/ v" i& |
boys with precocious puberty. In addition to viril-5 y8 t+ w" l1 i/ }2 E
ization, the clinical hallmark of CPP is the symmet-
0 Y+ N8 ^! ~' c, S% mrical testicular growth secondary to stimulation by
7 b; \4 l8 ?- T1 u: @8 K8 q6 [7 ugonadotropins.1,35 T* Q9 }; y) J
Gonadotropin-independent peripheral preco-- U) G. P; w7 d9 O; U- D
cious puberty in boys also results from inappropriate  U8 Z: m2 e  D# A6 w
androgenic stimulation from either endogenous or& k7 q& Z' @* `/ b  B) J- i' A
exogenous sources, nonpituitary gonadotropin stim-+ a+ x+ e* W, ~
ulation, and rare activating mutations.3 Virilizing
- Y! D" H- N! Y. m7 v6 ccongenital adrenal hyperplasia producing excessive
1 n0 M4 [$ v8 m/ @/ H/ B% ]# U. j# o$ y  O# ~adrenal androgens is a common cause of precocious
2 g" K5 W$ o* Q9 t. xpuberty in boys.3,4: f- `/ |& P1 a( |
The most common form of congenital adrenal) c7 e' C7 X- S! U! @; O& }* h
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 O" C. f! L( U$ E7 e' I- V; hThe 11-β hydroxylase deficiency may also result in1 X) e% M) h; I/ c6 f: \; W
excessive adrenal androgen production, and rarely," h% }% T: A/ x1 X% H
an adrenal tumor may also cause adrenal androgen% \; C1 O6 E* G7 G2 A3 a
excess.1,3; m% ]% \: L* f0 w, ^0 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: U7 v4 x% Y4 b1 \* @5 g
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  G/ g8 p3 ?6 U' x5 j- I7 {
A unique entity of male-limited gonadotropin-
8 E8 |( w+ ^' [" ~! o1 jindependent precocious puberty, which is also known' Q. g# J* |( ]6 E
as testotoxicosis, may cause precocious puberty at a
$ F/ a+ f( T7 H! F2 [very young age. The physical findings in these boys
' g. f' x" f# T+ kwith this disorder are full pubertal development,: I/ t9 H4 a- S& o& G
including bilateral testicular growth, similar to boys1 ~" z# e/ c) t9 k# E& k- t* N3 E
with CPP. The gonadotropin levels in this disorder
# B) j, |$ j- ?! Pare suppressed to prepubertal levels and do not show- F- o  w, Y* g+ G- Y: e! u7 G
pubertal response of gonadotropin after gonadotropin-9 A4 {8 u% a* _& V, O' j
releasing hormone stimulation. This is a sex-linked
  d. ]: }3 b- U+ j! d, I2 uautosomal dominant disorder that affects only7 j% j' o$ ^* R8 I, `$ \
males; therefore, other male members of the family! D: t% O# }9 C  ^1 c
may have similar precocious puberty.3
# c# h; D# a1 Q# P+ V2 CIn our patient, physical examination was incon-* p% j& c; u* ~% @
sistent with true precocious puberty since his testi-
2 J) g% U$ l# E. M2 @cles were prepubertal in size. However, testotoxicosis
% _2 M" r7 |7 F2 e3 g; jwas in the differential diagnosis because his father
2 D- u4 o! |% j% }+ b' D, Bstarted puberty somewhat early, and occasionally,7 {* A- }! I/ `* r# B$ P
testicular enlargement is not that evident in the2 A/ |& C# I% X! H; p. c
beginning of this process.1 In the absence of a neg-
5 {) [$ T6 z& c6 qative initial history of androgen exposure, our
% f+ F$ U& M( O8 i" Z2 ~, U% u( }biggest concern was virilizing adrenal hyperplasia,# o& x1 X/ c% ^8 Y7 N9 H# w
either 21-hydroxylase deficiency or 11-β hydroxylase
  n$ t& t" v3 X: @deficiency. Those diagnoses were excluded by find-
1 I6 K: W. Q) j; fing the normal level of adrenal steroids.
% G; ^: l1 ~& N* eThe diagnosis of exogenous androgens was strongly
$ H+ S" d" C6 j; A3 u/ `+ isuspected in a follow-up visit after 4 months because, Q% p! ~; l  M  ^9 v( B
the physical examination revealed the complete disap-
9 t, j/ o% P9 Q$ k+ ~# spearance of pubic hair, normal growth velocity, and/ C( k# `* `/ Q( F! b  m
decreased erections. The father admitted using a testos-- z' f7 K  a5 p
terone gel, which he concealed at first visit. He was; K/ h3 W; w& W+ o2 @# ~
using it rather frequently, twice a day. The Physicians’
, N" |& N+ N# p/ L0 [Desk Reference, or package insert of this product, gel or
" P5 Q  }. N, r" Kcream, cautions about dermal testosterone transfer to
; ?% r; R3 X$ _8 Z. ], aunprotected females through direct skin exposure.
1 M  ^6 r5 p7 ?: b4 GSerum testosterone level was found to be 2 times the
# Y) D2 \: W$ m+ f  a" o( L6 K6 ybaseline value in those females who were exposed to' \9 u+ j. l$ ]' r5 M( a
even 15 minutes of direct skin contact with their male
; j& d* I0 j# @9 r2 M* o4 ?+ cpartners.6 However, when a shirt covered the applica-
$ `6 Q9 m# {4 S- d" @6 ytion site, this testosterone transfer was prevented.) z9 g+ J+ t+ _1 |
Our patient’s testosterone level was 60 ng/mL,
7 x! }4 c& l+ m' v" Nwhich was clearly high. Some studies suggest that
& U! q9 o" o6 R& F9 X. qdermal conversion of testosterone to dihydrotestos-! g! t, ~  g+ h" j4 \2 Y2 M9 k
terone, which is a more potent metabolite, is more
" F* {% s) O1 f8 J, Yactive in young children exposed to testosterone4 u( G# W- w( I
exogenously7; however, we did not measure a dihy-
0 Y1 u5 F; z6 I) n- U3 ~7 r( \drotestosterone level in our patient. In addition to
9 m9 J4 }# c+ [" M& L* {! V$ Hvirilization, exposure to exogenous testosterone in; Q! j/ P$ k% b7 o
children results in an increase in growth velocity and" n4 f0 o/ {6 H6 }
advanced bone age, as seen in our patient.& h! S' o0 V9 X) I
The long-term effect of androgen exposure during
2 k, f+ c5 _6 [$ bearly childhood on pubertal development and final
. B: Q2 N' I4 D: y3 Ladult height are not fully known and always remain7 D: s9 T/ q  T$ d) f/ F
a concern. Children treated with short-term testos-5 x9 Q6 y5 T" u) {
terone injection or topical androgen may exhibit some
, f8 N1 q; g; F: o0 U( e. [2 Z. Kacceleration of the skeletal maturation; however, after
# s( N: b! ~5 ^/ y* F  rcessation of treatment, the rate of bone maturation
* X1 c3 L; L3 Udecelerates and gradually returns to normal.8,9  ^. _/ r" K' l3 k: c7 s
There are conflicting reports and controversy( r6 ^3 Y4 _( K5 P2 E6 q
over the effect of early androgen exposure on adult/ f- d- y$ U8 H6 O4 |- y1 L
penile length.10,11 Some reports suggest subnormal5 g: k. Q. v3 M3 e
adult penile length, apparently because of downreg-3 M' R4 c: P; V
ulation of androgen receptor number.10,12 However,
; g% `; W5 g; R  |: [Sutherland et al13 did not find a correlation between7 k5 D% K2 z2 |: P
childhood testosterone exposure and reduced adult
8 a( F; ^8 ]5 L. Ipenile length in clinical studies.
6 l" o6 ^/ p9 F& @: |: iNonetheless, we do not believe our patient is
% C% U" b% x$ p  C2 [6 ygoing to experience any of the untoward effects from3 k0 K: ?7 W) n" V/ v: z
testosterone exposure as mentioned earlier because. a$ k! g6 M+ Y* p9 Y$ O
the exposure was not for a prolonged period of time.
3 E, p; K6 g6 ]  h: ?0 Y3 |0 o/ YAlthough the bone age was advanced at the time of5 h5 z7 A! b% ]9 j$ o
diagnosis, the child had a normal growth velocity at
# E, U7 u( a( y: W. L( o7 N* f" l. s: Hthe follow-up visit. It is hoped that his final adult, p7 ]! i% w+ p* @& o9 o/ U+ Z
height will not be affected.# b6 q7 H/ g! t* P5 e+ v% q
Although rarely reported, the widespread avail-
' ?& V0 d, _: F+ r+ ]. e: `7 Hability of androgen products in our society may
5 s3 J) g+ ]1 G5 Oindeed cause more virilization in male or female
, v7 N3 h- Y) O4 u" mchildren than one would realize. Exposure to andro-
5 c2 j3 I7 J! m! l! Y0 N- cgen products must be considered and specific ques-
) L; E  c3 R0 J$ N/ M0 xtioning about the use of a testosterone product or
* T+ r4 U3 p5 l! s  ~6 b/ `gel should be asked of the family members during
6 a1 y# T& n  s" Othe evaluation of any children who present with vir-, d3 I2 a$ ^. n6 E& \5 v. B
ilization or peripheral precocious puberty. The diag-4 i, P% ]3 a& y; U" U+ Y/ v
nosis can be established by just a few tests and by
) w9 |% }: O2 T+ Yappropriate history. The inability to obtain such a( _* `  K. |; ~: E# t/ k, _
history, or failure to ask the specific questions, may
/ H6 Z4 a: V# R# J; ^) Nresult in extensive, unnecessary, and expensive
% `$ j+ ?. _7 A- v! D( l' W2 Rinvestigation. The primary care physician should be
# @. B7 l) V, `2 Maware of this fact, because most of these children9 P$ K$ o  E# h( S* O' K& f
may initially present in their practice. The Physicians’6 q* v! @3 k9 p3 l0 j
Desk Reference and package insert should also put a
5 \% @. X0 B1 ]: U! ~7 Q) ~2 kwarning about the virilizing effect on a male or: u  ^) v7 E0 u8 v
female child who might come in contact with some-
' o" B0 B5 Q2 L- hone using any of these products.4 j  `% u7 I7 w6 _. W- g
References
; O9 j+ V0 K- X. S  R1. Styne DM. The testes: disorder of sexual differentiation
" V4 q9 I0 ]% S+ d9 T1 wand puberty in the male. In: Sperling MA, ed. Pediatric
: i* {8 m4 b0 K7 Z. b$ dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 X! L6 t$ M/ R' F2002: 565-628.& c& d! k+ S* v
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- G2 b* v' M( h& p3 Npuberty 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

7 l0 P" r/ M. d" M. ~6 g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