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]
累計簽到:5 天
連續簽到:1 天
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-Old1 o3 }" C( y) E; v9 _
Boy Induced by Indirect Topical
* @" a+ f0 Z4 m3 Z6 r+ |4 D+ @7 ^5 HExposure to Testosterone
0 p4 o9 P- F9 o$ b# g# ^( J) ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 B: y' P; S3 Z0 R6 n* _2 i6 dand Kenneth R. Rettig, MD1
  y5 E) E. \, v5 i* A9 g& k. D" F3 vClinical Pediatrics5 D0 c, V1 z: S) A
Volume 46 Number 66 M1 E! K- j( ^8 P( _
July 2007 540-5431 B/ U" O. F% @+ q
© 2007 Sage Publications
- B# v0 Q% s& k  [$ V% `2 E10.1177/0009922806296651% L2 `0 R) p0 f. ^
http://clp.sagepub.com# u, h8 h. j$ P- O
hosted at
# j4 a- U5 z- ?& D1 b5 M) whttp://online.sagepub.com
1 ?! X4 b8 s6 G: D, n( V. H6 Z4 cPrecocious puberty in boys, central or peripheral,
0 y! e8 t; P# G+ gis a significant concern for physicians. Central
. B5 u) W& _: Q- \" p. M" Mprecocious puberty (CPP), which is mediated
# M$ q7 Z9 Y' T8 Q+ `6 wthrough the hypothalamic pituitary gonadal axis, has% W  m+ h/ C, H6 b
a higher incidence of organic central nervous system
) ?5 x; n: }( x0 K( b& e8 wlesions in boys.1,2 Virilization in boys, as manifested
5 V( n/ r' m! `; tby enlargement of the penis, development of pubic( {0 |" w3 ~) C! d4 U# f* O
hair, and facial acne without enlargement of testi-) r0 ~9 D9 U) ?& C
cles, suggests peripheral or pseudopuberty.1-3 We  x4 Y4 M* z0 R- ]5 h* _
report a 16-month-old boy who presented with the
" }# n; z1 n9 d  y0 oenlargement of the phallus and pubic hair develop-
7 D0 B3 Q/ j& h) mment without testicular enlargement, which was due( k) E/ m( l7 |" a+ T. V
to the unintentional exposure to androgen gel used by+ q# A. f3 E1 `
the father. The family initially concealed this infor-
" E2 t5 ~* [4 Z1 ?5 `mation, resulting in an extensive work-up for this
1 R6 n# [4 U+ B7 H3 b7 Pchild. Given the widespread and easy availability of
+ D( G) B0 F1 ^6 ]8 stestosterone gel and cream, we believe this is proba-( Y) `0 S4 y$ Y$ U
bly more common than the rare case report in the
, j8 b- M7 Z; c9 E6 Zliterature.4
  o/ [5 u( h) B$ V: LPatient Report& J1 X1 g; m* S/ ~
A 16-month-old white child was referred to the4 f' {) d) Q+ U- a+ V6 m' A
endocrine clinic by his pediatrician with the concern
3 _: p8 Y& X5 L$ C, @+ tof early sexual development. His mother noticed; ]0 u2 ]+ X$ L# m" v
light colored pubic hair development when he was7 L! M9 w) @- h: K
From the 1Division of Pediatric Endocrinology, 2University of8 O3 @4 {1 p1 G# ^: \. ]" B
South Alabama Medical Center, Mobile, Alabama.
3 E- w3 x3 U0 K3 gAddress correspondence to: Samar K. Bhowmick, MD, FACE,
  [5 \0 u# M% d1 lProfessor of Pediatrics, University of South Alabama, College of
$ }, ]0 J& u7 Z! e# p' n4 dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; j3 l. [  _  }" j
e-mail: [email protected].
* O' l5 Z2 m$ h8 zabout 6 to 7 months old, which progressively became
. b0 x$ S9 h# j8 E8 udarker. She was also concerned about the enlarge-9 U' f" I4 w& I
ment of his penis and frequent erections. The child3 `: y: [  n; E. W6 f" F
was the product of a full-term normal delivery, with" `1 B0 e! }- S6 }% b
a birth weight of 7 lb 14 oz, and birth length of6 m- [* a6 o: u# {
20 inches. He was breast-fed throughout the first year
1 D# L8 Q# r% {: I7 M6 uof life and was still receiving breast milk along with" p/ h% T+ i( r- w: \
solid food. He had no hospitalizations or surgery,+ x: q; J5 A6 r
and his psychosocial and psychomotor development
. P8 n, c* D% Ywas age appropriate.
7 r7 t  C3 e* x, X; B# qThe family history was remarkable for the father,
  i( f  \5 `9 c5 M6 _who was diagnosed with hypothyroidism at age 16,
* D1 R6 o, k7 fwhich was treated with thyroxine. The father’s! A3 h/ [8 E* q% s  \( m, i
height was 6 feet, and he went through a somewhat4 ]6 x& x3 c3 p+ ~
early puberty and had stopped growing by age 14.& c4 I( d, t! d7 o& Y" ~  {
The father denied taking any other medication. The
- U1 T9 b, B# f  s1 E7 Z1 ochild’s mother was in good health. Her menarche
( v+ W8 N4 D1 w  w( H* gwas at 11 years of age, and her height was at 5 feet  X. N, s! p5 y. A7 s
5 inches. There was no other family history of pre-6 X: I; @- f  ]% r3 ?* q
cocious sexual development in the first-degree rela-
4 j! Z% G' k: r! d* a+ qtives. There were no siblings.7 b2 j* I9 N) f8 B, _/ \* J
Physical Examination
* p! e' x5 X7 tThe physical examination revealed a very active,
( y; z( q. |- V5 h4 _+ eplayful, and healthy boy. The vital signs documented" Y; \2 n; F3 k& _: ~
a blood pressure of 85/50 mm Hg, his length was
4 _: `7 n' b& X, ~90 cm (>97th percentile), and his weight was 14.4 kg% [% ~# b5 t1 k! B4 T+ e0 y
(also >97th percentile). The observed yearly growth
1 Q7 J& c- g2 U8 r+ Dvelocity was 30 cm (12 inches). The examination of/ T6 ], B5 ]. d7 V6 U) H
the neck revealed no thyroid enlargement.5 U( C8 e2 j* U9 A6 m2 \- x" F. r
The genitourinary examination was remarkable for
4 T1 y# Q/ d' r( uenlargement of the penis, with a stretched length of4 n2 v6 Q7 n/ J6 Q* t
8 cm and a width of 2 cm. The glans penis was very well
' R/ f7 w2 `( b* e: v6 }developed. The pubic hair was Tanner II, mostly around
# Q0 f# ?5 I. t) p( c" D5408 W; y. R. ~' G& [4 b/ ]4 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  ?4 S4 j" m! x7 z6 e, J
the base of the phallus and was dark and curled. The
& T5 D9 _! _, @- `% Y. k8 ]testicular volume was prepubertal at 2 mL each.7 E5 [. s! ~5 |& h
The skin was moist and smooth and somewhat' [! U' F+ s% k% k" F
oily. No axillary hair was noted. There were no, B1 e+ T+ K% Y. _7 F0 {
abnormal skin pigmentations or café-au-lait spots.3 A  u7 S9 c3 W% c6 |
Neurologic evaluation showed deep tendon reflex 2+
0 x1 u, P* ?1 ^0 ubilateral and symmetrical. There was no suggestion8 \- \- r/ P& O8 e# ~
of papilledema.
2 @4 r) P4 c; ~* FLaboratory Evaluation# ^/ f7 |7 Q3 l) |5 n" N8 B) z
The bone age was consistent with 28 months by  E% w8 f' H/ @3 N9 O; v
using the standard of Greulich and Pyle at a chrono-
% v7 M) u- i3 G& Qlogic age of 16 months (advanced).5 Chromosomal
0 Z6 X) }( G1 |karyotype was 46XY. The thyroid function test
5 Y& Q3 B3 ^# e* T% Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 S" O& }, x) A5 Qlating hormone level was 1.3 µIU/mL (both normal).3 e6 d5 c! s+ @: |6 J3 K% N
The concentrations of serum electrolytes, blood' I7 N% t: i) w" F9 u+ n2 `  h
urea nitrogen, creatinine, and calcium all were
6 k5 E: B# A. n5 m6 B1 ^within normal range for his age. The concentration
3 @% y  l: _' ~6 E6 ?' l& i& jof serum 17-hydroxyprogesterone was 16 ng/dL
1 z1 f2 I. C' A8 W" }+ R' d7 R- _$ A(normal, 3 to 90 ng/dL), androstenedione was 20
) h$ A6 b! ?9 v0 L, ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 n; H" j7 [* ?* c. U+ v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 `1 F0 X5 v8 x: Q8 }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ x# w+ R  g' r% ^5 h49ng/dL), 11-desoxycortisol (specific compound S)$ K! P% s' J1 b9 c" G4 u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- ?/ e. y4 N* R- P* Q. B7 g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) k. l1 a* j: \# k5 g  F% vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. p! `- ]+ D9 W, q7 t
and β-human chorionic gonadotropin was less than$ X" b0 l6 Q. Q1 d; q
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ B, G: Z7 d- X& [6 J# q
stimulating hormone and leuteinizing hormone5 c! s) L( ^8 r7 p" z, t
concentrations were less than 0.05 mIU/mL
' i$ ?7 P+ I( P. k(prepubertal).3 \# e! Z: a6 t6 v, V4 c8 [  [
The parents were notified about the laboratory
' k( O( z% M& S: @% m7 e& Jresults and were informed that all of the tests were; ?  R! z" F: I/ Q- [5 Y0 Q  U
normal except the testosterone level was high. The6 q# n; y9 [* `$ R5 d
follow-up visit was arranged within a few weeks to) k+ w5 J  c: r2 E9 f% K
obtain testicular and abdominal sonograms; how-
& B% e- E9 w. [6 q7 j4 iever, the family did not return for 4 months.! ?* i' D/ X& `  k
Physical examination at this time revealed that the
" {& c5 e* ?% w) R3 [9 Qchild had grown 2.5 cm in 4 months and had gained$ f% ]) k4 N! A+ J/ q
2 kg of weight. Physical examination remained
% t. i* r! b' M! \6 L! i2 funchanged. Surprisingly, the pubic hair almost com-$ U2 C* B8 |1 k& I2 x2 j
pletely disappeared except for a few vellous hairs at4 p: P* F1 W% u# @* Z7 }* T, Z
the base of the phallus. Testicular volume was still 2
, v+ L4 ?2 z6 s0 C3 d( G  s- AmL, and the size of the penis remained unchanged.! T1 D8 x$ @+ v4 ?3 N
The mother also said that the boy was no longer hav-; [6 d  B% U8 @4 T( i
ing frequent erections.
, ]; o$ H2 A8 K+ z; x$ c2 MBoth parents were again questioned about use of8 E+ a* X+ E$ z/ Q. b5 p) t
any ointment/creams that they may have applied to* @2 o0 w, c( n8 F" O; U- z+ H- m
the child’s skin. This time the father admitted the
0 u; M  O& t' A! S9 MTopical Testosterone Exposure / Bhowmick et al 541
3 \8 S* c1 k, c" Z! z6 b  I3 c* U4 guse of testosterone gel twice daily that he was apply-
  P) l# {7 P( Y! t- H* ~: ging over his own shoulders, chest, and back area for! M' ]: g/ X3 b. y. |+ z7 a
a year. The father also revealed he was embarrassed
0 B- j$ B) d( @to disclose that he was using a testosterone gel pre-& A0 e$ H1 @; z
scribed by his family physician for decreased libido
- r  [4 Q4 u: L' s6 }4 I; zsecondary to depression.
9 ]# Z/ [! N" y$ J! L% l5 c) gThe child slept in the same bed with parents.
9 O3 |& Y* U) f; w( o4 yThe father would hug the baby and hold him on his
- C2 l: m8 G- f( `chest for a considerable period of time, causing sig-
: j8 {9 v  w6 F4 Anificant bare skin contact between baby and father., A/ q$ l0 |+ o. A% T
The father also admitted that after the phone call,5 x- c4 P( T, `; p3 |2 x& T
when he learned the testosterone level in the baby
$ \8 v0 V6 E5 Y* Lwas high, he then read the product information
" T5 l0 O. Q$ Ipacket and concluded that it was most likely the rea-% p  h5 i7 i8 @1 N( ?. D
son for the child’s virilization. At that time, they+ d! K) ]4 z0 x& M, m8 d
decided to put the baby in a separate bed, and the
' I4 S) R6 P. kfather was not hugging him with bare skin and had
5 ~: a" v# ^1 h5 K4 x( X0 Y% U8 L  t& Vbeen using protective clothing. A repeat testosterone
9 f' \$ D5 N0 m* `8 vtest was ordered, but the family did not go to the7 [0 ?# U+ M/ C: ]7 ]& J
laboratory to obtain the test.
- n0 i9 ?: H! v% ~6 u  N. sDiscussion
/ x0 K& E9 q7 _1 ?. lPrecocious puberty in boys is defined as secondary
% ]1 A2 P8 z9 R, ~0 Ksexual development before 9 years of age.1,40 P  y8 a5 \% A/ y6 n0 o' G
Precocious puberty is termed as central (true) when
# A: f/ S' R: Yit is caused by the premature activation of hypo-! N- U) W: D3 w; ~9 N" c! T
thalamic pituitary gonadal axis. CPP is more com-( V1 O0 @# {! o- k& o7 {
mon in girls than in boys.1,3 Most boys with CPP1 z; J2 X% o  G7 }# e
may have a central nervous system lesion that is/ W* Q) k6 E+ O, m8 d* a* X# `4 `; s
responsible for the early activation of the hypothal-4 @$ k5 r; T7 b* _+ o3 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ z+ V# c5 H. E( M1 rsis has been given to neuroradiologic imaging in
9 {2 |- W% r8 O5 l( B( C9 _' ~boys with precocious puberty. In addition to viril-
, c  j1 B* T* D( Mization, the clinical hallmark of CPP is the symmet-; `% Q% c1 z% L. K: q
rical testicular growth secondary to stimulation by  t: F' q! P! x1 h& S( P* ~
gonadotropins.1,3( n. h2 M/ M+ O5 ?0 E6 \
Gonadotropin-independent peripheral preco-5 ~8 Z( V6 ~/ p5 Z4 O
cious puberty in boys also results from inappropriate8 j( Y4 ~6 m7 n# N: k) K9 e
androgenic stimulation from either endogenous or
8 [, i+ g/ M" S( K" |0 q( Pexogenous sources, nonpituitary gonadotropin stim-0 O* i( ]. z1 a. p" ?3 S/ ?
ulation, and rare activating mutations.3 Virilizing
+ F9 M& U: ^+ d6 R+ h* @+ ocongenital adrenal hyperplasia producing excessive
( G. {/ f' c* w( s  d5 N4 Gadrenal androgens is a common cause of precocious* D9 n  I& h' v5 c# b- d
puberty in boys.3,40 b& w1 G& X- H, F( ?- l4 v
The most common form of congenital adrenal; [$ R0 x' d' y) K
hyperplasia is the 21-hydroxylase enzyme deficiency.
: d: ?7 x0 b8 D, M; ?6 f9 P" d$ CThe 11-β hydroxylase deficiency may also result in
: W( f# q8 W9 q2 U% E- eexcessive adrenal androgen production, and rarely,, i0 {; F9 _) S( d* B* T1 X# a3 N
an adrenal tumor may also cause adrenal androgen
; c$ v0 U6 L; t. @1 s' c6 x. Lexcess.1,3) f6 i5 b: H$ H; r, e8 `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, y5 G, k# |# l8 K$ v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ o% Y! G: j$ v9 L; r0 M
A unique entity of male-limited gonadotropin-8 \. ~3 @5 E8 d+ h8 g; Y, J
independent precocious puberty, which is also known$ c' E9 D1 ~/ L- [' }) [, ^# X( g
as testotoxicosis, may cause precocious puberty at a
. n( S2 I: _+ \# {% H- Overy young age. The physical findings in these boys$ s) c* j  Q( Z& ?+ C4 n& q3 Z
with this disorder are full pubertal development,7 \$ C6 {# a2 i* y+ {% Z
including bilateral testicular growth, similar to boys
3 p( M& H$ S! M, Y6 Q7 gwith CPP. The gonadotropin levels in this disorder4 h7 L' E% l8 J+ V9 n1 T- [  ^
are suppressed to prepubertal levels and do not show+ ~# N. ?3 m9 h
pubertal response of gonadotropin after gonadotropin-
1 B  i4 D4 S- S9 _& sreleasing hormone stimulation. This is a sex-linked
$ z2 Y7 a$ v  L6 X  n: P/ A+ aautosomal dominant disorder that affects only
2 B7 Z2 c" B; R% _) H8 m2 Jmales; therefore, other male members of the family/ t2 E! i' i4 h) X0 Z' ^
may have similar precocious puberty.39 g8 O+ m. `0 {) b! s1 m
In our patient, physical examination was incon-2 E" ?* s% a+ k4 s+ T- U: F
sistent with true precocious puberty since his testi-# b9 r4 [( D( R8 i/ Q+ }8 y6 S
cles were prepubertal in size. However, testotoxicosis$ q* t% b  s( u& D! q: V
was in the differential diagnosis because his father6 P  H- @0 v7 F- ]
started puberty somewhat early, and occasionally,3 b3 l* t/ A- B8 y$ A- i  f- k
testicular enlargement is not that evident in the
1 A4 u" T9 I5 b# \6 R, Mbeginning of this process.1 In the absence of a neg-
: R: n& N4 m+ J/ {1 n4 ^7 A5 A& v* X7 yative initial history of androgen exposure, our0 X  O: }* A1 U: \. a
biggest concern was virilizing adrenal hyperplasia,, X8 [! Z1 X7 [* v: P$ C( H
either 21-hydroxylase deficiency or 11-β hydroxylase3 y4 v& O- Q; Z
deficiency. Those diagnoses were excluded by find-
+ p& q7 A; x( qing the normal level of adrenal steroids.- K( e! d0 a7 A
The diagnosis of exogenous androgens was strongly
! i6 _7 s+ g5 k+ M: y8 H, O' Hsuspected in a follow-up visit after 4 months because0 b4 v9 K( N' Y4 h
the physical examination revealed the complete disap-
! ^, h0 t$ m. X$ R# Zpearance of pubic hair, normal growth velocity, and' T2 |4 x; i1 ~$ U$ K/ m8 t; c- q, l
decreased erections. The father admitted using a testos-
' _6 k  z3 U7 _/ p* m7 ^terone gel, which he concealed at first visit. He was
: t1 z* B" l9 q5 s2 G+ ~, U( n8 }using it rather frequently, twice a day. The Physicians’) Y" u! G; a0 I* {6 |$ i
Desk Reference, or package insert of this product, gel or
: {& f9 \: R( s9 Scream, cautions about dermal testosterone transfer to, U0 o# m5 B9 D$ P2 I: g3 L
unprotected females through direct skin exposure., l1 y; [8 v$ v9 G! n& l
Serum testosterone level was found to be 2 times the5 j% J" m' m7 r
baseline value in those females who were exposed to, C, ^7 b* b* A0 |  w! g" L
even 15 minutes of direct skin contact with their male2 C0 U5 k9 i" w3 r( y
partners.6 However, when a shirt covered the applica-
, L- l) u, X- btion site, this testosterone transfer was prevented.
9 H1 F6 \2 L+ WOur patient’s testosterone level was 60 ng/mL,
( }2 B( b, f; a9 _which was clearly high. Some studies suggest that% W& ?( o; J  O: _1 i4 {# k1 Y
dermal conversion of testosterone to dihydrotestos-
! R9 G- O) Y# ~% T% Oterone, which is a more potent metabolite, is more1 H- {" J! q3 d. K1 Z! _4 J9 w/ C' J
active in young children exposed to testosterone" V3 c$ Y8 z3 h! H& S
exogenously7; however, we did not measure a dihy-
, u% g+ w! O, T2 p6 Rdrotestosterone level in our patient. In addition to
& \" O3 b. u7 m: E5 M  ^4 Cvirilization, exposure to exogenous testosterone in4 c% g5 D( N7 O- }6 |) P
children results in an increase in growth velocity and
) ^2 Y' V0 P) r$ K. P7 T! Kadvanced bone age, as seen in our patient., c+ f2 d' Z. {# X; \) j0 K+ v
The long-term effect of androgen exposure during
; w- e8 W1 Z* u6 u( C  Qearly childhood on pubertal development and final# V! t0 a7 Z1 {& W& k  V9 x) x
adult height are not fully known and always remain
6 f& p( }) T2 k# Y. O, a0 [) oa concern. Children treated with short-term testos-1 U" N+ D% F; M( Z& _7 J9 X
terone injection or topical androgen may exhibit some
, i$ R$ O0 k, k" X% x- jacceleration of the skeletal maturation; however, after/ j0 ~& {; Q! J) F- a
cessation of treatment, the rate of bone maturation/ N/ K: X& b& h) {8 j
decelerates and gradually returns to normal.8,9
" Y9 M6 Z5 ^$ ~* m) B$ hThere are conflicting reports and controversy
: e% C5 h  O; J# w7 w5 M1 G. Aover the effect of early androgen exposure on adult" m0 N. ~; P. s7 ~2 c
penile length.10,11 Some reports suggest subnormal6 [" u( J& h& A9 Q
adult penile length, apparently because of downreg-0 o. N$ x3 B' a" s5 W) C
ulation of androgen receptor number.10,12 However,
& h9 Q6 p3 c( |6 V4 a* m, oSutherland et al13 did not find a correlation between. w; y9 I4 B1 ~) i
childhood testosterone exposure and reduced adult, {$ J) g5 k% Z* r, C* D
penile length in clinical studies.
# n) _, e% l' Z8 s5 v) y, xNonetheless, we do not believe our patient is/ a, y5 B- O, l, J, Y
going to experience any of the untoward effects from
5 k' q  R1 z9 [  U& qtestosterone exposure as mentioned earlier because  @' z6 v+ `5 j/ K, \
the exposure was not for a prolonged period of time.
  J* G$ v" s# N# R4 ?Although the bone age was advanced at the time of6 f, l9 V" J! I  @6 p
diagnosis, the child had a normal growth velocity at# U; s4 T/ o/ d0 E& T
the follow-up visit. It is hoped that his final adult7 D. V" X( k& Z; @) O1 [1 {2 ]4 A
height will not be affected.
, J# i% M/ m) \& a+ A, b- ?Although rarely reported, the widespread avail-
- A9 ~+ Z+ S1 c  Z) t7 ~ability of androgen products in our society may8 D' {3 g& Z; w1 ?: ~
indeed cause more virilization in male or female
" f5 P/ r" l, K1 j2 e! hchildren than one would realize. Exposure to andro-
$ s0 N# |1 _0 |. cgen products must be considered and specific ques-: i  W8 y9 q% `5 ~+ H3 @
tioning about the use of a testosterone product or" V4 L2 I, Q& W/ I
gel should be asked of the family members during
- U0 s" H) j# r# Nthe evaluation of any children who present with vir-
: K! E3 H! Y# {ilization or peripheral precocious puberty. The diag-3 K1 y$ i  s  c( Y1 E- Q) C$ ?
nosis can be established by just a few tests and by
$ @0 S9 L9 a) U* e6 A+ _; Qappropriate history. The inability to obtain such a
  I1 A0 z% N. |1 phistory, or failure to ask the specific questions, may+ ^5 y7 i) X* _( v, m% ~  Y8 b
result in extensive, unnecessary, and expensive" c) u, o. M- Z8 l, W8 f! ]
investigation. The primary care physician should be
( q; Y3 J: K) g/ E1 D" E& ^& Caware of this fact, because most of these children
" ^$ G2 u3 Y! I7 ]9 pmay initially present in their practice. The Physicians’7 M: _/ p% G( V; R
Desk Reference and package insert should also put a
0 Z/ m: `; c# Z. R2 x: vwarning about the virilizing effect on a male or
* E* b' {; T# d5 Q0 S) dfemale child who might come in contact with some-; \2 y) J+ ?9 Z& T% \
one using any of these products.
) t  Z, E& b" V  N0 Y% vReferences# a0 C- b- ?- Z7 U' z, e
1. Styne DM. The testes: disorder of sexual differentiation
' n* k, W& ]0 S* _/ pand puberty in the male. In: Sperling MA, ed. Pediatric% x* S& N; N$ M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& c. p1 A% u/ G2002: 565-628.
6 M( ^* A0 ~' B1 U( {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' C0 d/ {, u2 C* y3 W+ z
puberty in children with tumours of the suprasellar pineal
回復 支持 反對

舉報

累計簽到:5 天
連續簽到:1 天
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
, K/ w0 R: k, h; q4 e4 X3 IBoy Induced by Indirect Topical
) D( N9 W/ Z1 x8 |Exposure to Testosterone) d3 M8 k. W/ r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 n0 H: A/ f) Q% c& s! X! j$ |9 K
and Kenneth R. Rettig, MD1
/ P! a0 G3 r8 ^( p) ~8 T$ a  @- SClinical Pediatrics% g! l2 C* p' Z' u3 q, _
Volume 46 Number 6
  _) G6 n" f$ sJuly 2007 540-543, i# U# _2 N* Z, e
© 2007 Sage Publications/ I. y5 I- r  i( x
10.1177/0009922806296651
. P) N3 u0 _1 t; _2 u, Rhttp://clp.sagepub.com
& S. c- w; x! T& [5 t- |hosted at: l# ?; Z+ R: [$ q# o
http://online.sagepub.com0 H, ^( e) M# o# M
Precocious puberty in boys, central or peripheral,
" a1 z8 b/ C4 E- S1 }is a significant concern for physicians. Central
  D) E" V" |* j3 {& ^% ?% hprecocious puberty (CPP), which is mediated
) V7 ~) Z$ G1 X1 n; pthrough the hypothalamic pituitary gonadal axis, has- |& |4 Q% l9 J3 e
a higher incidence of organic central nervous system2 ~1 W# @9 d9 q6 W( h! a: A5 y5 W% O
lesions in boys.1,2 Virilization in boys, as manifested
/ K( j4 V  l% H0 gby enlargement of the penis, development of pubic$ m& ]7 p. O" c, H" `! e6 t
hair, and facial acne without enlargement of testi-
, \8 v7 t/ t$ |+ I; _, ycles, suggests peripheral or pseudopuberty.1-3 We
( B9 N- W$ v; U7 u% D5 ^report a 16-month-old boy who presented with the* z, n. o7 }' \( n4 ?( [
enlargement of the phallus and pubic hair develop-
* U) n  z9 I& g" ~; k/ U, W5 R# kment without testicular enlargement, which was due
& N7 X7 R' A# t7 A* R8 ^- r( b" I) hto the unintentional exposure to androgen gel used by/ @6 v+ C2 d' f) j3 d
the father. The family initially concealed this infor-+ w4 I  t9 H5 L& e7 s7 d% K
mation, resulting in an extensive work-up for this
& r- P' x2 E6 {7 `# s/ Cchild. Given the widespread and easy availability of  N8 O& A# d. c3 }0 ?, a
testosterone gel and cream, we believe this is proba-8 M7 _2 L8 e8 L3 T
bly more common than the rare case report in the
; d( ^6 `) m4 r+ b1 ~" iliterature.4
4 m6 ]8 X, [* k4 q0 J% LPatient Report) c, C; @0 @7 f1 m+ }, O
A 16-month-old white child was referred to the
3 x" w8 `) U0 E6 q2 {; r5 W  w+ Lendocrine clinic by his pediatrician with the concern
( X! e3 C( P' t6 t  v: Vof early sexual development. His mother noticed
4 _6 c+ o9 A9 u! {1 m) c! ilight colored pubic hair development when he was
% z. m/ n1 M8 C0 W- B. N9 a: c  t" WFrom the 1Division of Pediatric Endocrinology, 2University of  d- C8 @0 I! G/ z) s( `2 h$ @
South Alabama Medical Center, Mobile, Alabama.
8 l; R* m/ q0 P5 v, CAddress correspondence to: Samar K. Bhowmick, MD, FACE,
  c$ U) c* g; ^: Y2 @4 ^3 m  QProfessor of Pediatrics, University of South Alabama, College of
& y* Y6 q! k4 a; w; NMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 d0 w3 D3 n$ y
e-mail: [email protected].% L" t7 D; C  S% L! }2 k
about 6 to 7 months old, which progressively became
! X* Y& {% N2 e; n  ~' j; T, tdarker. She was also concerned about the enlarge-2 m2 [& w( c! f1 {9 \9 a; E6 T2 R
ment of his penis and frequent erections. The child4 ]' ]  x& l" Z
was the product of a full-term normal delivery, with, ?4 f  F( K" b, N; X7 z) r
a birth weight of 7 lb 14 oz, and birth length of* h, w6 k  `4 n5 u! o
20 inches. He was breast-fed throughout the first year( [  b4 N' q# x/ F
of life and was still receiving breast milk along with* I4 F4 [0 k5 o. N
solid food. He had no hospitalizations or surgery,
) m0 ]9 ~2 ?* ~: Z( n/ Aand his psychosocial and psychomotor development
. V2 G/ W9 S4 w: o5 {% \' |  ~2 jwas age appropriate." t# ]; e0 x. P# x* k
The family history was remarkable for the father,
, t" I; L! _9 \* @who was diagnosed with hypothyroidism at age 16,
" \' h/ L; U, J  ~4 `9 O3 _3 H7 M" cwhich was treated with thyroxine. The father’s
: p  w; l7 S2 I* [) B2 eheight was 6 feet, and he went through a somewhat; T" a# A: T$ M' q0 v
early puberty and had stopped growing by age 14.4 l- |2 R$ B* [4 J% `0 q  U
The father denied taking any other medication. The$ Z3 O: J6 h, ?
child’s mother was in good health. Her menarche% a4 {" `* p" M7 ]- I9 T
was at 11 years of age, and her height was at 5 feet. Z  E& o0 N. ~. Z4 x
5 inches. There was no other family history of pre-+ a5 I; P  A+ \9 s% [" c* T# F9 \
cocious sexual development in the first-degree rela-
9 B( h! Y  Z  K# m+ g( }" utives. There were no siblings.
4 K3 j) a5 |/ n! \7 UPhysical Examination
) W, F! V+ f) D2 O4 y; T& \The physical examination revealed a very active,: [: y. A8 v) p4 O  }
playful, and healthy boy. The vital signs documented3 A0 y' Y1 C/ R$ j6 n! C
a blood pressure of 85/50 mm Hg, his length was
* Q! m( z8 c  o( X90 cm (>97th percentile), and his weight was 14.4 kg
7 C6 x/ G/ a2 ^7 o8 H  x& `(also >97th percentile). The observed yearly growth
5 {: ?, W9 {; @+ u0 `4 Cvelocity was 30 cm (12 inches). The examination of
* D- e! m! @  k: Uthe neck revealed no thyroid enlargement.
* B' u- _! D! d8 s6 ^2 rThe genitourinary examination was remarkable for& j' D8 }, c- R2 {% K- E) J
enlargement of the penis, with a stretched length of
9 w0 `! Y8 L/ J0 b* J8 cm and a width of 2 cm. The glans penis was very well- S" c; \8 Y7 E9 W% l/ y( V8 F8 N
developed. The pubic hair was Tanner II, mostly around& @' Z! n( f! Q: k
540
" d3 n% C4 ^7 h2 Z% b0 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 S7 ]9 W1 H, q; [3 |) o# O& u" ?; E- }$ d
the base of the phallus and was dark and curled. The
) ^( G* L- e! b6 {2 f" xtesticular volume was prepubertal at 2 mL each.
' ]& w' i" t5 ?# zThe skin was moist and smooth and somewhat8 q- @' O3 M# J4 v  P( }0 f- d
oily. No axillary hair was noted. There were no
6 \' E" O' [% m5 ]9 I4 Eabnormal skin pigmentations or café-au-lait spots.3 m7 @6 u/ _/ F! e
Neurologic evaluation showed deep tendon reflex 2+
- W! O9 I4 i" H$ I9 |) A8 Tbilateral and symmetrical. There was no suggestion  L. e- A8 ~8 S4 S6 s2 y
of papilledema.
/ ~" h6 D/ i. B1 H' F( g5 }! yLaboratory Evaluation7 ?5 V% i% g8 Z- T, i, |# l
The bone age was consistent with 28 months by3 g: l# R1 H  R2 u& z0 y6 m
using the standard of Greulich and Pyle at a chrono-
# {: v. {/ J: k$ Vlogic age of 16 months (advanced).5 Chromosomal
) U( J- U% }- U6 t* ~; r" ?6 ?karyotype was 46XY. The thyroid function test
# X( n, w6 B& q0 J; R1 _showed a free T4 of 1.69 ng/dL, and thyroid stimu-! k. d0 a/ _3 i+ u& v: s" J# \# G
lating hormone level was 1.3 µIU/mL (both normal).. m" W7 B! V/ l
The concentrations of serum electrolytes, blood. D! z- x7 n2 i4 M0 p$ h
urea nitrogen, creatinine, and calcium all were$ J& [- `9 p; M! d
within normal range for his age. The concentration' |8 V1 {: `  h9 F% `
of serum 17-hydroxyprogesterone was 16 ng/dL
' N& v# I2 v5 U1 p- M/ a6 ?) J(normal, 3 to 90 ng/dL), androstenedione was 20
5 z$ Y& K% p- b, M. y9 ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 _# k( |& i7 n8 L9 @5 c. [  ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& l8 W& M! `1 e3 M: r; d$ E7 H3 P, E* H+ Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 |: J# k* m5 t+ A5 T$ L  y% X
49ng/dL), 11-desoxycortisol (specific compound S)+ z7 M- [( n$ o" c$ R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; A2 ?* l& r% f2 Q, _; t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 W8 |; r" o/ i) J# i) k$ w) G* Btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 d. r! j" {& M  o# f0 D- y- Rand β-human chorionic gonadotropin was less than) ~- \0 d  D! P/ L
5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 c2 _6 O( ?* d* e- \' |, @1 Cstimulating hormone and leuteinizing hormone
$ o  L* p1 G/ i4 qconcentrations were less than 0.05 mIU/mL; d% f- w3 F3 b
(prepubertal).. R, q) q6 V: R0 `/ e8 I  x
The parents were notified about the laboratory
* j  P8 D' S3 t! Jresults and were informed that all of the tests were5 I. ]' a1 W" K2 y' P
normal except the testosterone level was high. The
- T% G; W  A4 g, l" f' nfollow-up visit was arranged within a few weeks to
2 r' U1 t  c- o2 eobtain testicular and abdominal sonograms; how-
& s( ]. {- y. oever, the family did not return for 4 months.
! i* n" g" E% R/ M: J" N. LPhysical examination at this time revealed that the$ a0 _  t3 p4 W& e) K! J; v0 M# j& X7 Y' ?
child had grown 2.5 cm in 4 months and had gained; i; R! E! h. b. x  j0 D4 j
2 kg of weight. Physical examination remained
1 j: d# Q' b; h3 _9 c3 k8 Uunchanged. Surprisingly, the pubic hair almost com-4 Z* [$ Y+ _0 }* v% e0 P
pletely disappeared except for a few vellous hairs at
$ V9 D1 T: Y5 ?# t' J7 S& {1 n; {the base of the phallus. Testicular volume was still 2
1 u: n$ ?4 e) Z! Z5 smL, and the size of the penis remained unchanged.) [6 Z# I  X& u
The mother also said that the boy was no longer hav-6 u  A! |: b6 b$ _! g) L$ ~/ O# L
ing frequent erections.
) c) |/ R( Z# ABoth parents were again questioned about use of
5 A6 V# r) B6 _) }4 [$ xany ointment/creams that they may have applied to2 g" k) {& W6 e, v6 I+ e" i# x2 j
the child’s skin. This time the father admitted the
& [' [  j# E: J. m8 q& ~; PTopical Testosterone Exposure / Bhowmick et al 541
0 c: w' K  A0 Vuse of testosterone gel twice daily that he was apply-  p& S# Y- \! D8 e
ing over his own shoulders, chest, and back area for
: E% f4 e0 v# M6 O- Ba year. The father also revealed he was embarrassed7 h; l5 t& W5 b# Q8 X$ _6 e6 W
to disclose that he was using a testosterone gel pre-- A( b; [- k2 n8 A" `) p* [; j0 |
scribed by his family physician for decreased libido/ c4 e' h4 T% P9 I: `: h7 c/ K
secondary to depression.
9 V) v8 s9 o# `+ j( D! N. }The child slept in the same bed with parents.
- C5 ]2 l& E3 s# v0 tThe father would hug the baby and hold him on his
6 F" h& k( n: D# n( qchest for a considerable period of time, causing sig-* j6 X  J; l2 I1 d3 J/ A2 N4 @
nificant bare skin contact between baby and father.
) J' J* f0 I8 \8 I0 [The father also admitted that after the phone call,; u$ {+ R" V4 F, ~' o) {! z6 k& V
when he learned the testosterone level in the baby
" ^0 `5 u: o# ]( p" `, zwas high, he then read the product information5 ]+ k& D1 x& n8 r+ g
packet and concluded that it was most likely the rea-
# X" [# d( ~; i& f3 R7 J7 e: k  X% tson for the child’s virilization. At that time, they
$ e* Q1 `& b1 W$ g) c+ L  a6 mdecided to put the baby in a separate bed, and the2 S( a) c) F2 i5 {
father was not hugging him with bare skin and had' G+ B% f+ J: _6 H% \
been using protective clothing. A repeat testosterone. [3 J; E8 g, V$ \
test was ordered, but the family did not go to the
) [8 X* p8 \& @laboratory to obtain the test.6 V! c7 ]' S% N' l: J
Discussion  `/ Y$ c: x, h2 E! F2 G
Precocious puberty in boys is defined as secondary# {% c+ m; K. P. ]
sexual development before 9 years of age.1,43 _( k# o. A( Y& _# F4 M+ \
Precocious puberty is termed as central (true) when2 H" d) m! h; f
it is caused by the premature activation of hypo-
# n6 @4 r. }: vthalamic pituitary gonadal axis. CPP is more com-  T7 ?# \1 D1 H# U3 I
mon in girls than in boys.1,3 Most boys with CPP) o5 l1 p5 }; j' J7 G
may have a central nervous system lesion that is
5 m* e/ e* C: dresponsible for the early activation of the hypothal-
9 M- f5 c7 I, U; @5 e1 c: mamic pituitary gonadal axis.1-3 Thus, greater empha-: \, d6 _8 }- X! ]+ u
sis has been given to neuroradiologic imaging in( S) ]3 N8 a4 n% A$ S& m% d" Q
boys with precocious puberty. In addition to viril-
1 G/ w+ d$ e% a$ `$ m+ `ization, the clinical hallmark of CPP is the symmet-! ]3 b6 N8 t, y" \* X; d
rical testicular growth secondary to stimulation by
8 j( a& C8 X, L8 T5 ygonadotropins.1,3! N& D( K( {* _5 |' w4 y2 p. c/ ]
Gonadotropin-independent peripheral preco-, T/ D9 x; V) ~3 A) o0 U
cious puberty in boys also results from inappropriate* t- }3 Y5 G- c  T# }
androgenic stimulation from either endogenous or
; H& o8 H8 I/ ?0 y* C4 r1 ^' r0 r0 cexogenous sources, nonpituitary gonadotropin stim-. o  t, R$ X2 u0 E
ulation, and rare activating mutations.3 Virilizing
# G! ]8 ~2 R2 p2 \8 econgenital adrenal hyperplasia producing excessive
3 O1 Z1 Y+ ^# Wadrenal androgens is a common cause of precocious$ g3 z# u: ]8 d' n8 C$ j
puberty in boys.3,4- w) n0 E8 u2 ^. ^% a0 v
The most common form of congenital adrenal
5 Z; g% H& M8 E. z1 ~/ R) A/ rhyperplasia is the 21-hydroxylase enzyme deficiency.' y% h2 B+ L/ @1 S% e
The 11-β hydroxylase deficiency may also result in
# c6 n5 s( t! s2 u! }excessive adrenal androgen production, and rarely,: C: X+ T. G4 D7 u8 i. Q; Z
an adrenal tumor may also cause adrenal androgen/ I) h) f: o! m6 ^; ]( [0 B' O
excess.1,3% j% H1 O/ x( y# c5 f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# r/ S7 p) k" }7 A. b1 V  w3 `# }542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 E4 g+ X5 G, ~
A unique entity of male-limited gonadotropin-. x6 \, B9 u4 b9 G
independent precocious puberty, which is also known
- f/ Y! Z% Q) s! }% ^9 m2 }as testotoxicosis, may cause precocious puberty at a/ G+ `# B  s, }& ^' l* o
very young age. The physical findings in these boys7 `; p$ M; v: b4 {/ @
with this disorder are full pubertal development,
) H% l: z" q/ i; W3 f; kincluding bilateral testicular growth, similar to boys; F) Y/ ~2 r- i7 _: G! m4 U! P, @; l
with CPP. The gonadotropin levels in this disorder
6 O. H' c! ]/ Z2 ~1 {are suppressed to prepubertal levels and do not show
: w1 {4 p  M/ g6 j! D. q3 d4 f  e5 zpubertal response of gonadotropin after gonadotropin-
0 \7 l3 d# p3 b! Areleasing hormone stimulation. This is a sex-linked8 n$ G( M! f0 {% Z
autosomal dominant disorder that affects only
  l  h% [/ j: T3 c& m: C/ Smales; therefore, other male members of the family
5 W' s! J( f7 E* W: Smay have similar precocious puberty.3
4 m, B/ h$ e9 q6 T+ lIn our patient, physical examination was incon-
. k6 W% |+ N1 [4 T+ tsistent with true precocious puberty since his testi-: ]3 w0 z6 j& b/ ]1 @# J9 U; N8 @
cles were prepubertal in size. However, testotoxicosis* H) p( s* k9 Q
was in the differential diagnosis because his father0 h: u" J3 U( H0 S4 [, c& Y) u5 e) X
started puberty somewhat early, and occasionally,
4 C  ]% E" S0 h& `testicular enlargement is not that evident in the8 K1 a5 R, K2 s* N
beginning of this process.1 In the absence of a neg-
: E: p$ O* ~: m7 W9 j6 G1 g: pative initial history of androgen exposure, our7 q# g& `5 R2 C4 [7 }) C5 u
biggest concern was virilizing adrenal hyperplasia,
; F+ A) n3 Q: b2 q$ b+ @1 heither 21-hydroxylase deficiency or 11-β hydroxylase: b) i+ g6 m0 o- G
deficiency. Those diagnoses were excluded by find-3 e- j6 W* u. ^! U+ T. ~) `& y! ^
ing the normal level of adrenal steroids., c( U8 _/ P' h  p
The diagnosis of exogenous androgens was strongly
& \5 i% S+ N8 [. l( m5 O- w/ zsuspected in a follow-up visit after 4 months because
5 v" ^$ `# L1 q, K) wthe physical examination revealed the complete disap-+ H, e  T5 f1 [" e* \8 |
pearance of pubic hair, normal growth velocity, and
9 S% L7 W- q+ H7 ~, r+ X" tdecreased erections. The father admitted using a testos-+ N8 X7 d2 S" R0 H6 ]) Q
terone gel, which he concealed at first visit. He was
6 ^& C0 h  q% W; T4 N( Jusing it rather frequently, twice a day. The Physicians’
/ D- |; @2 r. T' BDesk Reference, or package insert of this product, gel or# s  O, {; ^/ |. O* p' o! v8 @, ^
cream, cautions about dermal testosterone transfer to; w) Z( p; v) C- w
unprotected females through direct skin exposure.
( D- b# Y3 W7 ^2 b  P, {Serum testosterone level was found to be 2 times the
2 t( S6 v: Q7 u& S% mbaseline value in those females who were exposed to
) T) u$ Q1 l* Z8 j1 ?  a( p5 teven 15 minutes of direct skin contact with their male: {; b- [4 ~  @8 |+ @. P- s5 b1 P4 T
partners.6 However, when a shirt covered the applica-
- G* G+ w% ~0 t$ mtion site, this testosterone transfer was prevented.
* e( p& a, J7 v' V% ?Our patient’s testosterone level was 60 ng/mL,4 E2 _' t$ L+ g* V
which was clearly high. Some studies suggest that
, N! a8 p4 R. F8 z3 i# S2 Xdermal conversion of testosterone to dihydrotestos-
3 o: k4 \; C- p! w% b/ }) \. u: fterone, which is a more potent metabolite, is more
+ J! K- p* v, [2 N0 ]+ u7 lactive in young children exposed to testosterone
" w- L( |- l& E: Jexogenously7; however, we did not measure a dihy-
1 P' g# @' Z! |, ~) _drotestosterone level in our patient. In addition to
$ B  l1 }: o- b: Y: m4 Pvirilization, exposure to exogenous testosterone in' a% _1 c1 B; Z. t( \, i% [. S3 @
children results in an increase in growth velocity and
+ X: P4 N9 E) w! madvanced bone age, as seen in our patient.
1 f. W: v$ t9 t. fThe long-term effect of androgen exposure during
) D7 D  K1 E8 }, b0 N- Mearly childhood on pubertal development and final
0 Q2 W9 R/ {- J4 @" `+ q$ Qadult height are not fully known and always remain
* h% c3 [: g7 \a concern. Children treated with short-term testos-( y: k7 y9 e# H/ Y& X
terone injection or topical androgen may exhibit some, D$ z! R% X9 V: O2 d
acceleration of the skeletal maturation; however, after+ ]' p* q1 O: H+ b$ b1 z+ K
cessation of treatment, the rate of bone maturation0 E; O  }0 t3 Y* T9 ?. e
decelerates and gradually returns to normal.8,9- |3 c3 P- s/ I9 t8 G: @
There are conflicting reports and controversy
+ @' u( F1 t8 g6 Pover the effect of early androgen exposure on adult, n( z4 V. }+ N8 e1 H8 P3 q
penile length.10,11 Some reports suggest subnormal
* Z/ i* F1 Y. f% }6 ^; _6 t+ [% \adult penile length, apparently because of downreg-8 A# X$ M2 `9 @; p- H" a- a
ulation of androgen receptor number.10,12 However,
: g+ E7 B: I; ?1 h# D$ S2 ASutherland et al13 did not find a correlation between
  t& x% F* ]9 Y5 dchildhood testosterone exposure and reduced adult+ j) _7 V- O+ P" s; D
penile length in clinical studies.
7 v6 h- ^* J& v" L/ |Nonetheless, we do not believe our patient is
. S- C: a: l& ?going to experience any of the untoward effects from
- f/ Z6 N! X1 d6 ?) @% Itestosterone exposure as mentioned earlier because* _) R" }* l' t; q0 m
the exposure was not for a prolonged period of time.& Z) A6 h" Y: P9 q  ]7 k: y! P# [
Although the bone age was advanced at the time of
, S# E' F4 a; u+ ]8 b2 wdiagnosis, the child had a normal growth velocity at
3 ^5 ~  f; }* U# u8 o) `! Qthe follow-up visit. It is hoped that his final adult* e3 S7 k3 H+ ~* \0 g* Z, v/ c
height will not be affected.
5 }. H) Q) l9 M9 JAlthough rarely reported, the widespread avail-. |' R3 B( B2 R% M
ability of androgen products in our society may
  m* J% U9 e- vindeed cause more virilization in male or female) m! e6 q" s2 v& b% o! f6 r
children than one would realize. Exposure to andro-4 z: }5 {" _8 q# Q: [
gen products must be considered and specific ques-- \( T$ {; s* ?2 w8 w1 X! ]' a, A3 P
tioning about the use of a testosterone product or- C8 |. J* }- e' F! @, \
gel should be asked of the family members during
: l. Q3 h5 P) W" f# R3 |the evaluation of any children who present with vir-
2 [  H2 V8 u( w9 u# Z, rilization or peripheral precocious puberty. The diag-
* A; W# L. H9 B* `4 M/ p; snosis can be established by just a few tests and by
: U* V& y: g, N0 G0 h- ~. P* eappropriate history. The inability to obtain such a
, Q+ \# h! ]0 i% yhistory, or failure to ask the specific questions, may) C9 T, c* k8 K& a+ b, s2 Y& y
result in extensive, unnecessary, and expensive- Y7 x$ V7 o4 }. c# K, f! F, E; e
investigation. The primary care physician should be# `, q5 a! C$ _$ p
aware of this fact, because most of these children
5 `' D4 o# D; ~" Amay initially present in their practice. The Physicians’
5 p5 I& \; j, _/ t+ d3 {( U6 jDesk Reference and package insert should also put a) D) p8 p3 e' S  n% ?2 x% H
warning about the virilizing effect on a male or8 a5 d$ u3 o. ^7 R. C! J
female child who might come in contact with some-" h. m9 \7 c: M- I
one using any of these products.8 S: r& ?, B4 l9 Z5 h% b$ |
References
; I. k7 C) @- w, n+ p1. Styne DM. The testes: disorder of sexual differentiation7 L1 e$ v6 L) R& i7 w0 E5 g
and puberty in the male. In: Sperling MA, ed. Pediatric5 W+ ]5 O4 z# n) h! o5 L
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 W. x$ Q* x" S* N$ C2002: 565-628.4 G9 {9 l$ v- f
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  k' ]) \) Z% F- g9 Q
puberty in children with tumours of the suprasellar pineal
累計簽到:176 天
連續簽到:4 天
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!

尚未簽到

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!
累計簽到:11 天
連續簽到:1 天
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

尚未簽到

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?
累計簽到:3 天
連續簽到:1 天
發表於 2025-1-19 02:41:05 | 顯示全部樓層
& z# I: ]5 [( P  G+ J
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

尚未簽到

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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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