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
! I2 J, Y7 i& x* ABoy Induced by Indirect Topical
+ m4 ?: m4 V0 Q; w3 PExposure to Testosterone9 ^& c* t) u# @' t7 \$ P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, A* D+ @/ u; K- r' K
and Kenneth R. Rettig, MD1
8 K. ~, {* U2 ^/ FClinical Pediatrics- y/ r5 B- i& v3 }5 e
Volume 46 Number 6& ]* ?& m9 w8 W5 g+ d( ?" l
July 2007 540-543
8 z& {/ F( z& M© 2007 Sage Publications
/ \; g# B2 X" K10.1177/00099228062966517 D2 |& g, K6 R+ Z5 J
http://clp.sagepub.com
, Y% H( @3 P8 S. W# j: [) vhosted at
4 J7 m2 E/ B7 D, m2 z6 `# v4 ihttp://online.sagepub.com2 K/ D% T' W9 G  Z2 P1 p! J: P) _
Precocious puberty in boys, central or peripheral,6 u7 w" i- q- m
is a significant concern for physicians. Central
% u: R6 u. ~1 A( L8 g4 E* |precocious puberty (CPP), which is mediated- I8 L  N& K- e, A* @- U1 r! b
through the hypothalamic pituitary gonadal axis, has1 Y2 v( o3 j1 B8 `6 b; V/ j' o
a higher incidence of organic central nervous system6 L  k. s, t, C4 @" V7 k
lesions in boys.1,2 Virilization in boys, as manifested
* ~& Q9 ]- `  m$ i+ Q7 _6 u$ E& i- Oby enlargement of the penis, development of pubic; d3 B2 T: J* c
hair, and facial acne without enlargement of testi-( C7 S, u1 K9 I8 A- r
cles, suggests peripheral or pseudopuberty.1-3 We. g. y3 N# p1 Z9 U7 q) `
report a 16-month-old boy who presented with the
" {/ d' A4 K) ?7 Q% Y) C& ^" k) `enlargement of the phallus and pubic hair develop-$ h( e5 C$ D. y& P  o5 }
ment without testicular enlargement, which was due
; Y% k& N  P3 T9 O3 ?  _to the unintentional exposure to androgen gel used by
2 ]+ r$ X3 g- ythe father. The family initially concealed this infor-
) Q) f9 M0 `" H& t; E/ Wmation, resulting in an extensive work-up for this
" E/ b+ M0 y- {- n7 xchild. Given the widespread and easy availability of, l- g9 H: i1 C: g* ~3 H( B
testosterone gel and cream, we believe this is proba-7 ^. ^/ E6 I. }
bly more common than the rare case report in the$ |, h+ v( R, k& F$ P
literature.4
7 {7 e1 D) _( _9 PPatient Report
. ?2 f% ^+ A/ k9 t# B! S( V( SA 16-month-old white child was referred to the
4 S) _* p# g' \endocrine clinic by his pediatrician with the concern
3 ]. r8 A( i& Xof early sexual development. His mother noticed, r' R2 Y* i# _; ]+ O% E
light colored pubic hair development when he was
6 H2 \5 Q7 d7 ^, N: k- iFrom the 1Division of Pediatric Endocrinology, 2University of8 U$ G# `0 U' h7 _/ ]9 _2 K
South Alabama Medical Center, Mobile, Alabama.
" B" S  p' F! {Address correspondence to: Samar K. Bhowmick, MD, FACE,- A4 L$ n' s- [) X! [/ W# G
Professor of Pediatrics, University of South Alabama, College of
' V5 ]1 b$ Q: i& f4 b0 V: H4 l7 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 Y) B( r8 Y. k8 ~% h. {
e-mail: [email protected].
" q9 z& `" s* ]: g; `0 Z) d# ?about 6 to 7 months old, which progressively became
, m6 J6 d2 a4 I% `& Idarker. She was also concerned about the enlarge-: o  V8 r6 i3 V. p% l
ment of his penis and frequent erections. The child
* D7 f8 B5 o2 l; twas the product of a full-term normal delivery, with
9 i2 F% {( }7 e! |3 wa birth weight of 7 lb 14 oz, and birth length of/ n# ^& }3 J. n  Y" o- g+ a* n1 w) o
20 inches. He was breast-fed throughout the first year
$ ~- w# h: ?* I: [1 h# M# T* bof life and was still receiving breast milk along with  d. d+ e: q# x/ [. p9 Q8 \
solid food. He had no hospitalizations or surgery,! [) L4 T8 z. W$ h
and his psychosocial and psychomotor development; g4 |, t, _$ v+ T/ l$ }2 c7 H2 m  ^
was age appropriate.
# P; C7 ]. S) k% k4 y: ~$ ^! DThe family history was remarkable for the father,
( ], P8 f7 E5 U6 q* S4 jwho was diagnosed with hypothyroidism at age 16," j" A9 `' V: M1 R9 S& i
which was treated with thyroxine. The father’s
$ ]3 f7 w1 Q3 n+ kheight was 6 feet, and he went through a somewhat. X' ]  T9 U- ~
early puberty and had stopped growing by age 14.' A( L. e8 `3 _; h
The father denied taking any other medication. The; K" d' }/ n. G
child’s mother was in good health. Her menarche* K; b7 u0 k) L- |
was at 11 years of age, and her height was at 5 feet. U, Z7 N3 R! y+ Y% y  z
5 inches. There was no other family history of pre-8 H' r% X; t! Y5 N5 o
cocious sexual development in the first-degree rela-8 J+ g$ p$ `' }3 l) V% b
tives. There were no siblings.$ n; Y. q4 l7 d# H: A0 M# q
Physical Examination! u) ^( }8 d, k1 y5 K
The physical examination revealed a very active,! P! Q  D$ ~0 ^% v; m
playful, and healthy boy. The vital signs documented
: i) C: S5 o& ?a blood pressure of 85/50 mm Hg, his length was
. a3 l0 ^# O5 R" l  N8 V( p1 z90 cm (>97th percentile), and his weight was 14.4 kg9 F6 Q, U" _3 |3 _! k9 m4 S3 _5 ]
(also >97th percentile). The observed yearly growth5 N& b3 k. m9 r5 [- t+ V
velocity was 30 cm (12 inches). The examination of+ v+ H5 N! l1 \, c
the neck revealed no thyroid enlargement.
; i: ]; \" D9 y* v; s5 DThe genitourinary examination was remarkable for
) ^1 ]( Y' D% z6 S/ }enlargement of the penis, with a stretched length of
. Q( {" h6 z# H1 t8 cm and a width of 2 cm. The glans penis was very well; ^! T' C0 t; d9 ]& S$ J
developed. The pubic hair was Tanner II, mostly around3 k! x4 d% R  w7 s3 K* p% L) e
540
0 @- l+ Y9 @! U! F" vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 J! Y' d' d3 Rthe base of the phallus and was dark and curled. The$ q' v; b5 h% x1 {
testicular volume was prepubertal at 2 mL each.- `/ a0 Y3 e! ]' H8 X1 D
The skin was moist and smooth and somewhat4 I3 b0 H. g9 M
oily. No axillary hair was noted. There were no, v: k2 H5 |2 W& L* k
abnormal skin pigmentations or café-au-lait spots.
' _( g, R: w% J. w* s$ `( h, YNeurologic evaluation showed deep tendon reflex 2+
* }9 F# h- [4 a5 r; X- U. z, Xbilateral and symmetrical. There was no suggestion
' \0 f/ f2 G) r6 `' s6 Q% u1 \2 Uof papilledema.: @3 S; l8 K8 R2 C# d0 y4 b% W
Laboratory Evaluation
) s% r! D/ r3 \, c4 j! i0 y* RThe bone age was consistent with 28 months by2 E% k( o6 r4 ^2 s) k, M0 V
using the standard of Greulich and Pyle at a chrono-
0 ?: ?! Q; W! N/ n# u# ~& }logic age of 16 months (advanced).5 Chromosomal, Q$ J: J2 n, c( N& }+ F- D
karyotype was 46XY. The thyroid function test
1 `6 e0 f, H. z0 w( z% W* lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 D8 z+ v# g! E" ilating hormone level was 1.3 µIU/mL (both normal).5 U5 B) X4 ^: y8 n/ L  c
The concentrations of serum electrolytes, blood, C  Q1 A# _! y+ v' P7 S4 s7 o
urea nitrogen, creatinine, and calcium all were
" U- e' X8 Z3 c0 l; t- B8 F8 |within normal range for his age. The concentration
- z3 s" F& u9 Zof serum 17-hydroxyprogesterone was 16 ng/dL
! b+ O) ^, R0 I+ v% R( r% [(normal, 3 to 90 ng/dL), androstenedione was 20
) X5 F: Q! e( Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; Q, o/ u  U2 R3 [9 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. D8 U! P( v# r  ^6 H) @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to! p4 ^3 s, {" U- j# A7 Q2 S4 |
49ng/dL), 11-desoxycortisol (specific compound S)+ Z! R6 d$ f  U4 q) F; Z) w, [! a5 a7 ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ M- ~- s( W! }2 X# E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; z# d' z6 o9 E, f0 H& a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),  `$ S* f1 w- K) W4 N% I% @8 q
and β-human chorionic gonadotropin was less than* W$ m4 I. c! R; F
5 mIU/mL (normal <5 mIU/mL). Serum follicular% z, s2 j6 U  Y0 b: R. q
stimulating hormone and leuteinizing hormone; w! n0 P& s& U- A3 d5 E  M+ Y
concentrations were less than 0.05 mIU/mL) l- M. i  P9 o/ [4 U
(prepubertal).
; S$ f5 p: E* E8 M5 ]1 GThe parents were notified about the laboratory
7 x1 K& C: A/ ?# j& G' ]& C- m2 \results and were informed that all of the tests were6 `$ P" H. b3 @7 o
normal except the testosterone level was high. The
- |8 h4 D  v+ n  f) C/ J8 W+ Bfollow-up visit was arranged within a few weeks to4 D7 e! j) {5 `0 Z* L' q5 r
obtain testicular and abdominal sonograms; how-% t& h  x) w8 U$ z& b
ever, the family did not return for 4 months.# @& {/ H2 b# y
Physical examination at this time revealed that the9 Q6 M7 k  E8 ^4 `: `
child had grown 2.5 cm in 4 months and had gained4 A! A2 {" M' k0 Q1 z$ V: ?
2 kg of weight. Physical examination remained
1 Z$ x+ ?. u2 L% ^- U* Z- E  ?unchanged. Surprisingly, the pubic hair almost com-8 K. D2 l5 `+ Z  Q/ F6 ?
pletely disappeared except for a few vellous hairs at
- s% e; h0 h1 u. \* a( {the base of the phallus. Testicular volume was still 2
) R$ U' z3 q: Z& S( w' J( ?mL, and the size of the penis remained unchanged.. E5 W( o; t5 m5 x3 Q& ?0 f
The mother also said that the boy was no longer hav-$ @# A/ K  Z& x+ D2 r0 X8 u
ing frequent erections.' R) I2 S/ X  N2 i* t; a5 B
Both parents were again questioned about use of5 g+ s2 U# U1 D3 B  u; q" ~
any ointment/creams that they may have applied to2 _+ ?6 _$ N& h% b
the child’s skin. This time the father admitted the; U( X- @0 l9 V4 K4 B2 L0 l
Topical Testosterone Exposure / Bhowmick et al 541( ]. z/ u* G7 v- ]% ?
use of testosterone gel twice daily that he was apply-5 u3 n, C0 }: X" F) O
ing over his own shoulders, chest, and back area for
* p7 y' u) N7 N  A7 H$ oa year. The father also revealed he was embarrassed/ X! o) d0 Q6 U1 R5 j" |0 K
to disclose that he was using a testosterone gel pre-' J; y' E. r- f7 ]9 H7 R( t
scribed by his family physician for decreased libido& U0 V) _1 t+ l1 k3 o
secondary to depression.
* s1 ^3 W7 @3 S( r2 iThe child slept in the same bed with parents.2 d7 f6 y8 f1 R; q
The father would hug the baby and hold him on his- d0 k" }/ ~/ z2 S" L" H
chest for a considerable period of time, causing sig-
0 `3 b; W7 R  o6 _nificant bare skin contact between baby and father.
7 B6 m9 C% X# `: s$ c9 FThe father also admitted that after the phone call,
+ g: e- d( A# xwhen he learned the testosterone level in the baby$ G# D3 h& r6 d6 G% V1 h
was high, he then read the product information
6 W/ }5 k6 ~$ \+ F% S2 w& _packet and concluded that it was most likely the rea-
; i4 s% U3 K! \- b2 Nson for the child’s virilization. At that time, they
/ t. h& H4 P- Fdecided to put the baby in a separate bed, and the
3 {8 `( I# q+ E2 P! ^7 k3 M; ~$ k5 vfather was not hugging him with bare skin and had1 @$ u% ]! p0 i0 @6 b- @
been using protective clothing. A repeat testosterone, g8 D$ [- p) t5 Z  C9 S, X- o4 W% z
test was ordered, but the family did not go to the
$ l# D6 j, E9 b1 a9 Jlaboratory to obtain the test.1 ]! ^7 R5 y: i* r% G
Discussion
* @: Y8 e" t3 C3 Q# {: dPrecocious puberty in boys is defined as secondary
9 s6 Z! F3 v9 f% C& ssexual development before 9 years of age.1,4
& C, `; O+ Z- F8 `' WPrecocious puberty is termed as central (true) when
. |( a4 _4 j* C( o6 e9 Git is caused by the premature activation of hypo-
7 o; a" o/ D+ A+ b( S! fthalamic pituitary gonadal axis. CPP is more com-! b4 S- A% R/ U
mon in girls than in boys.1,3 Most boys with CPP
3 n% Y- J3 _3 @may have a central nervous system lesion that is
8 X3 @8 j3 t$ S$ Q3 l, {responsible for the early activation of the hypothal-$ w9 W7 f5 R2 J" W" D5 N
amic pituitary gonadal axis.1-3 Thus, greater empha-4 U5 v. k' [4 N% Q. l
sis has been given to neuroradiologic imaging in: h6 ~5 t  r/ d) `  C( c
boys with precocious puberty. In addition to viril-8 M, I7 t" p8 s+ F8 o' z
ization, the clinical hallmark of CPP is the symmet-
7 I4 u, k* a$ n% X/ ^rical testicular growth secondary to stimulation by
0 S/ h' I4 I, {  {0 Y: |* `gonadotropins.1,3
! M6 C1 ^2 M8 a5 K5 `, w' a4 C; ]/ j+ @Gonadotropin-independent peripheral preco-' l$ C$ \* n) u7 ^* t* Y  Q
cious puberty in boys also results from inappropriate! H( D7 M: [6 f
androgenic stimulation from either endogenous or) |0 K5 p: P7 ~; a
exogenous sources, nonpituitary gonadotropin stim-* P4 P1 w* Y( U
ulation, and rare activating mutations.3 Virilizing
3 ~0 n* l1 q1 W8 s) bcongenital adrenal hyperplasia producing excessive
' S  k* _9 ^8 Y' x% Yadrenal androgens is a common cause of precocious# J% e, T1 M, o9 i- ^
puberty in boys.3,4  a& S& f6 n$ b2 K' P5 n3 Z& |
The most common form of congenital adrenal  U" U9 X2 M* ?" _# P+ a
hyperplasia is the 21-hydroxylase enzyme deficiency.& E6 l# w  g: `: g- @9 A0 G  X6 V& `& ~5 V: {
The 11-β hydroxylase deficiency may also result in; X2 J! c: E0 c5 v! C
excessive adrenal androgen production, and rarely,. {; k2 i# @6 T; L
an adrenal tumor may also cause adrenal androgen- U& q+ X: m$ j, X1 X
excess.1,3
  D' s' k7 b8 D3 Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ v/ H) y2 @" I$ a/ b542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
  S& `, E5 U/ `/ O' i$ SA unique entity of male-limited gonadotropin-! d/ k3 g6 w* @3 s4 ]  p
independent precocious puberty, which is also known( |0 ?* s3 q5 |
as testotoxicosis, may cause precocious puberty at a  ^1 T! H. t. Y
very young age. The physical findings in these boys: U' ~0 _! r9 q5 p
with this disorder are full pubertal development,6 U7 P) f( p; L
including bilateral testicular growth, similar to boys2 |* i7 q. c& d2 v- G9 Z0 Q
with CPP. The gonadotropin levels in this disorder1 k% e7 f: x: R$ W; O7 P9 s
are suppressed to prepubertal levels and do not show5 @$ s% [2 y4 V% y
pubertal response of gonadotropin after gonadotropin-
; w. Q* A( t1 c  }  {releasing hormone stimulation. This is a sex-linked
9 h; ]7 s% B& bautosomal dominant disorder that affects only
6 E% w6 k0 F; C2 v$ {males; therefore, other male members of the family4 w9 J. e" P" z& p0 K' b) U- e
may have similar precocious puberty.32 j: X/ S  V/ `& b
In our patient, physical examination was incon-9 W9 q6 h5 b; Z0 o/ r# u1 z
sistent with true precocious puberty since his testi-
3 |' ]7 ?1 a! X5 j+ c3 kcles were prepubertal in size. However, testotoxicosis( c2 t, E1 O9 D; L# v
was in the differential diagnosis because his father
3 H9 w2 U2 N( k# M# a  F1 dstarted puberty somewhat early, and occasionally,: }! U- ]' z2 g
testicular enlargement is not that evident in the
% u) J! u( `6 m2 z& i9 |! nbeginning of this process.1 In the absence of a neg-
! C! f( `; S/ Eative initial history of androgen exposure, our
, M* Q9 v) _5 W* s6 U% j% x! pbiggest concern was virilizing adrenal hyperplasia,
* a( }$ M5 y0 B' Ceither 21-hydroxylase deficiency or 11-β hydroxylase
$ [" ^* x4 Z' K! ]0 D; G9 Q% Z( J: ]0 Zdeficiency. Those diagnoses were excluded by find-
, }. c' _. k- b( q5 a8 Hing the normal level of adrenal steroids.
" l0 x- R. r* q" y9 y" LThe diagnosis of exogenous androgens was strongly
( f6 \5 X* w+ {+ j6 s1 O' A" Ysuspected in a follow-up visit after 4 months because, \& D" Z5 q' m# d# ]+ E! d
the physical examination revealed the complete disap-' X. a1 ]  m( F0 c( F4 W
pearance of pubic hair, normal growth velocity, and$ U6 S6 m  t4 a
decreased erections. The father admitted using a testos-' s* y) k6 K5 Y8 {) T
terone gel, which he concealed at first visit. He was* x4 D4 w' R7 t; O" U+ k
using it rather frequently, twice a day. The Physicians’7 X8 N, y' o2 t3 @0 U
Desk Reference, or package insert of this product, gel or
8 y& V8 R8 m. c: ucream, cautions about dermal testosterone transfer to. Q1 y: `" Z3 g( y# `& _( e
unprotected females through direct skin exposure.3 {" O" ~' g  {8 N' J% m
Serum testosterone level was found to be 2 times the
/ w; b9 O" J0 h1 `  K. Fbaseline value in those females who were exposed to
4 [& i7 q* J+ F+ X3 x$ c3 Q2 T! F: Jeven 15 minutes of direct skin contact with their male9 W) i7 |, c/ B5 U# l
partners.6 However, when a shirt covered the applica-8 @5 q" r) h6 g
tion site, this testosterone transfer was prevented.
+ ]( O/ l9 }9 D# mOur patient’s testosterone level was 60 ng/mL,
% G, m/ |+ C$ _1 S6 n  _- K4 t$ V% S) Rwhich was clearly high. Some studies suggest that+ m) P3 A; }. D  o8 |; ?
dermal conversion of testosterone to dihydrotestos-7 r8 |5 K" n* G, r+ A
terone, which is a more potent metabolite, is more
: b& N3 W# e& Kactive in young children exposed to testosterone8 h4 @( o( |; {9 J; P. M
exogenously7; however, we did not measure a dihy-% h8 W. s5 J# S
drotestosterone level in our patient. In addition to
+ t4 c% v7 U0 E# N: Vvirilization, exposure to exogenous testosterone in" m4 R! M* w) T
children results in an increase in growth velocity and$ p" d. `' H7 n3 i
advanced bone age, as seen in our patient.
/ Y5 f3 g0 O# j* l0 wThe long-term effect of androgen exposure during
6 \, W, a8 b; P5 |' N5 x& L6 kearly childhood on pubertal development and final+ w9 w5 a, T3 s/ d$ V
adult height are not fully known and always remain
' j& @1 u4 `5 P. |a concern. Children treated with short-term testos-
8 x/ r+ I$ }, }7 M# D/ Yterone injection or topical androgen may exhibit some$ t/ O3 q4 p" J/ d; H2 e' G9 r
acceleration of the skeletal maturation; however, after
* R" H% b* a9 D" h! scessation of treatment, the rate of bone maturation0 j& o: Q3 \+ T$ a7 \3 z3 D
decelerates and gradually returns to normal.8,9
3 X7 P9 D( H2 `) @+ {) c2 qThere are conflicting reports and controversy5 k- q+ w7 a2 ^* F" l% X. M/ |
over the effect of early androgen exposure on adult
+ ?' `$ x' u. R3 tpenile length.10,11 Some reports suggest subnormal
: t* e7 P, S. ^: D$ W* e( e1 Dadult penile length, apparently because of downreg-+ l; h% z8 Q) M7 ?; |! j6 D7 U2 I1 _
ulation of androgen receptor number.10,12 However,& B: T. [3 O5 H( D9 }  u  I
Sutherland et al13 did not find a correlation between6 y+ T$ H. W3 ?: ~
childhood testosterone exposure and reduced adult, [7 _; q- j& m* f- s! j9 t! C
penile length in clinical studies.- _% }- Y6 F6 S- j+ \3 A8 d' }
Nonetheless, we do not believe our patient is
* G' [. a0 V' _# |going to experience any of the untoward effects from
( n  m$ p* B& ?testosterone exposure as mentioned earlier because3 q: {6 s8 C, O3 y4 u
the exposure was not for a prolonged period of time.- W, X5 @( N. |. J+ C. z
Although the bone age was advanced at the time of
! v' @" `" L8 a9 b7 H( kdiagnosis, the child had a normal growth velocity at
" J* I0 }# T+ S7 e: s+ @, U6 fthe follow-up visit. It is hoped that his final adult
# d5 F% k- w8 g, p! w8 |height will not be affected.
. ~) M. i+ p4 ]! z8 |Although rarely reported, the widespread avail-
6 x& J0 h$ Q' Q5 J: L& K" [2 j1 Bability of androgen products in our society may
+ J$ O  [1 m' P% ?( @. `indeed cause more virilization in male or female' u7 `6 w1 e9 F7 F4 v
children than one would realize. Exposure to andro-5 F4 b! @$ g9 S" D
gen products must be considered and specific ques-
1 W5 y! h4 M$ Ytioning about the use of a testosterone product or0 @1 R- j4 n) J$ `( }# s& K+ }
gel should be asked of the family members during( B5 g: V# I9 N( L* M% Y* a0 A9 S3 X
the evaluation of any children who present with vir-: m4 d6 `0 A9 j- |
ilization or peripheral precocious puberty. The diag-
1 W( V% |+ W: hnosis can be established by just a few tests and by0 I: w; |' ], [8 T
appropriate history. The inability to obtain such a# i  g" s. G& v! b) W7 T/ l
history, or failure to ask the specific questions, may
) {  W6 A% ^% A. v2 Q; yresult in extensive, unnecessary, and expensive# A5 v& ^- Y0 t$ T
investigation. The primary care physician should be8 C) _! }" ?# U% P6 z
aware of this fact, because most of these children/ G7 P. b' ^' C/ D/ w
may initially present in their practice. The Physicians’
! B/ w- n* r. H' fDesk Reference and package insert should also put a! E$ X9 c" r8 B, A; `$ K- W
warning about the virilizing effect on a male or
6 e( o3 _; Y' w0 p8 ufemale child who might come in contact with some-$ z$ F$ E2 b2 q+ x" I% T
one using any of these products.
3 [! O! O& s. n# l$ R' }5 Z' j! DReferences- Z$ T! D4 x0 M2 M5 ~/ |8 K
1. Styne DM. The testes: disorder of sexual differentiation
3 f& Q3 |' f0 W. z8 _' S/ X& qand puberty in the male. In: Sperling MA, ed. Pediatric
6 @0 d# {% d. ]  j6 |9 z/ EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 Z' i$ r7 }9 D8 ^! F( U2002: 565-628.& g/ S: w" W3 F0 k- }: V; W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( N5 W3 m! W( s; t: e* Z
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; l; {" l5 S9 x3 j4 A
Boy Induced by Indirect Topical  O+ X# V) X0 \) z: F- {' L+ c
Exposure to Testosterone8 G2 Z$ j8 e2 _* K  m6 b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ E7 [% ?, A6 w, k+ x
and Kenneth R. Rettig, MD17 T% X9 @% ?' ]7 M
Clinical Pediatrics
# ?# N- C; x5 E9 E3 A1 D' bVolume 46 Number 6
3 A* q9 I, z$ j# SJuly 2007 540-543
( d1 ~  R7 [3 A0 V4 y) r© 2007 Sage Publications4 D0 P9 X# _9 T6 {" d" b
10.1177/00099228062966516 J2 }; c' b7 e: M
http://clp.sagepub.com
* y. w1 B+ |+ k  x3 [) Y7 ahosted at6 b0 s$ z" ]3 a1 L! y5 H' I
http://online.sagepub.com
) k) Y3 t; y% f: k/ D9 nPrecocious puberty in boys, central or peripheral,4 t6 U9 T9 y$ V' x0 t
is a significant concern for physicians. Central
# [4 ~$ `; C5 o6 N) e; |  `  Qprecocious puberty (CPP), which is mediated
5 v# |% l- y# F! A( R) j0 q7 @through the hypothalamic pituitary gonadal axis, has; h+ g% a; ^0 a5 Z. o4 ]! ~
a higher incidence of organic central nervous system
6 @# O6 P; Y$ Q% vlesions in boys.1,2 Virilization in boys, as manifested1 E; ~" v/ `# G. z( S- P
by enlargement of the penis, development of pubic
. Q, T8 |% D. z0 S& z7 `; }' T3 R$ [# A% Ohair, and facial acne without enlargement of testi-7 H$ `: H0 B  {5 O. a
cles, suggests peripheral or pseudopuberty.1-3 We
, K& n1 a2 i( J+ V, F" Ureport a 16-month-old boy who presented with the  t7 e  _8 l$ A8 u; d6 Z5 s
enlargement of the phallus and pubic hair develop-
$ I& V: S  p3 Hment without testicular enlargement, which was due
- ?1 D# W; n% I* O) d+ a7 I" ito the unintentional exposure to androgen gel used by
  \) X. D% p" i  W% Jthe father. The family initially concealed this infor-
3 j  }$ d9 T0 _: J% `# vmation, resulting in an extensive work-up for this
) n, v. d0 m, n/ H' J: fchild. Given the widespread and easy availability of
/ w( X/ W, M2 \0 h5 h3 m' Z  qtestosterone gel and cream, we believe this is proba-8 A& I; W* @# m0 g
bly more common than the rare case report in the+ n" h; ?( m3 M# S
literature.4* o0 b' Q5 B) P( ^$ I* }
Patient Report" D7 C  ^% @2 U( r% L% x7 m
A 16-month-old white child was referred to the$ L# m; j2 t) z4 ]) T# W
endocrine clinic by his pediatrician with the concern. J) S- @9 ^  r# l+ w
of early sexual development. His mother noticed
1 h7 d$ H, t5 F' Olight colored pubic hair development when he was
+ X3 f! g8 q3 NFrom the 1Division of Pediatric Endocrinology, 2University of$ J, C) R1 r5 z3 S, B3 o1 P( \+ A
South Alabama Medical Center, Mobile, Alabama.( s8 z7 ^; }4 P/ p) \/ k* Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 F, c6 z6 X9 F( j- G, r3 oProfessor of Pediatrics, University of South Alabama, College of
1 ?* T# _8 p- @, bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: ]* I% P/ J0 H3 b- q
e-mail: [email protected].
, t8 z3 c- n- }. c3 Sabout 6 to 7 months old, which progressively became( ]) T* E2 B( K; W# E& Z
darker. She was also concerned about the enlarge-. W8 {9 D$ }$ e: O% l7 d
ment of his penis and frequent erections. The child
* X& ~, |$ i2 F* j0 vwas the product of a full-term normal delivery, with
; a. K' B8 |2 }  N2 {3 L+ ca birth weight of 7 lb 14 oz, and birth length of
1 {& R. m; M: V; e20 inches. He was breast-fed throughout the first year& v( h! z5 d: `- U$ o1 L, E
of life and was still receiving breast milk along with
% |, e  L* q/ Y: B2 ~$ o5 Qsolid food. He had no hospitalizations or surgery," J$ G- B+ `- ]* K
and his psychosocial and psychomotor development( }' p$ o+ f" ?- c5 e# Y: P
was age appropriate.# ~7 c8 C- ^( G) @
The family history was remarkable for the father,
( O9 o) q" B. B: x, {who was diagnosed with hypothyroidism at age 16,
( ?8 Y0 r" W" f/ b& n, D* z0 d; e% Swhich was treated with thyroxine. The father’s
9 ]% J4 S3 p& R- Lheight was 6 feet, and he went through a somewhat
( k$ E* J0 U( {8 M" a5 y+ eearly puberty and had stopped growing by age 14.
  Q$ t! h* v( g7 [5 xThe father denied taking any other medication. The
4 v* P+ M) y1 U# K# wchild’s mother was in good health. Her menarche1 X# |/ ^4 R) g) Z
was at 11 years of age, and her height was at 5 feet
! B+ z$ p4 N) A% Y9 e5 inches. There was no other family history of pre-6 `5 z7 H+ m7 c4 }
cocious sexual development in the first-degree rela-
/ @* b/ W! y, Ytives. There were no siblings.  w4 g( |; v- c6 |) m) _% x
Physical Examination
6 l9 C9 x% T3 H6 E' ^' XThe physical examination revealed a very active,. q' D" f2 G1 i& ^  s
playful, and healthy boy. The vital signs documented. e1 Z; [/ ^! [* t$ o4 D8 n& n  l. h+ [9 X
a blood pressure of 85/50 mm Hg, his length was
5 V" ?8 @* B$ v8 K0 s  y+ f90 cm (>97th percentile), and his weight was 14.4 kg, K0 J& T$ l/ U# t  V1 _$ L# [( M. ^7 ~
(also >97th percentile). The observed yearly growth
3 a1 ]) m# A4 Z1 i$ I( Kvelocity was 30 cm (12 inches). The examination of1 p# w3 G2 \7 Q1 c
the neck revealed no thyroid enlargement.# b) `: m1 }6 D) ~' y) j. v) l
The genitourinary examination was remarkable for
) D8 g2 V+ X6 f1 [$ Xenlargement of the penis, with a stretched length of
  R9 B$ V$ H) e8 cm and a width of 2 cm. The glans penis was very well
! t$ O( g4 h, U. f, e: sdeveloped. The pubic hair was Tanner II, mostly around
# J% z8 v6 B4 b5 j2 I0 m1 P540
2 {" T6 w9 A- O" u: Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* B# y4 w8 }+ x  Xthe base of the phallus and was dark and curled. The
9 D, ]1 [0 t/ x5 ?( c4 stesticular volume was prepubertal at 2 mL each.
# a' l: O: m* r2 [) PThe skin was moist and smooth and somewhat
7 a3 Z1 ~4 ^8 Y. A# N) aoily. No axillary hair was noted. There were no
4 e! x& [! n3 ?abnormal skin pigmentations or café-au-lait spots.
- _, G  d$ n+ I* V- w5 [Neurologic evaluation showed deep tendon reflex 2+
6 A6 N- j1 h; k/ Y& Qbilateral and symmetrical. There was no suggestion! S3 c) ?/ X+ D( h" ^
of papilledema.
& {. e8 Z8 F6 b  sLaboratory Evaluation
; c% M9 Z2 d0 ^3 ^The bone age was consistent with 28 months by; [7 a* x/ e& D
using the standard of Greulich and Pyle at a chrono-
' W) N# H# i$ A2 n5 zlogic age of 16 months (advanced).5 Chromosomal/ J0 Z6 h& [6 z
karyotype was 46XY. The thyroid function test
9 H1 d5 ^$ K. Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 v' \* Q6 q! X( h" ?lating hormone level was 1.3 µIU/mL (both normal).
. H9 W% F* u' M7 v, Z9 tThe concentrations of serum electrolytes, blood0 C- c. H7 q  J) d+ a4 u
urea nitrogen, creatinine, and calcium all were* V3 F: t$ z1 f8 W/ K7 O: ~
within normal range for his age. The concentration' |6 p: j2 B. A9 B
of serum 17-hydroxyprogesterone was 16 ng/dL  n$ w9 {' \! J
(normal, 3 to 90 ng/dL), androstenedione was 20+ D5 P! d2 O4 A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# m% ?  u# \6 E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 M3 l4 S2 x+ t
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# j" G3 \! H& O1 f$ H6 E1 N49ng/dL), 11-desoxycortisol (specific compound S)
9 j2 f: V3 X2 q  [  y, j" o( C/ Dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# \2 R) s  A5 k2 o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' g0 C, p8 u1 J) w3 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ h2 k: o; F3 B( J+ Y- O; {
and β-human chorionic gonadotropin was less than/ `3 [* o; J7 `/ B, Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# F2 F" l" i9 s( K' gstimulating hormone and leuteinizing hormone
/ `) N3 U+ e/ p4 X8 `% ~concentrations were less than 0.05 mIU/mL
* `- t! Y6 p1 s9 K/ v6 Z# L) L(prepubertal).
% m2 q4 g# D/ p/ J. z, a8 G# o# eThe parents were notified about the laboratory
8 \5 Y  t2 E& z1 S4 a( H; M" Vresults and were informed that all of the tests were
; R0 b3 X8 @; \) I) w* H5 vnormal except the testosterone level was high. The, H1 ?$ m/ Z; e+ i0 l- x: e
follow-up visit was arranged within a few weeks to$ ^: p6 E3 T- Y- S
obtain testicular and abdominal sonograms; how-
+ n  v* ?' F9 W6 Z9 qever, the family did not return for 4 months.0 A9 z+ B) H0 p1 V% J
Physical examination at this time revealed that the
0 R3 u0 _3 x* e* X3 }# X( g" j0 Pchild had grown 2.5 cm in 4 months and had gained4 V4 B; `- I6 _. `. i' u5 f. f9 a
2 kg of weight. Physical examination remained' v9 m$ i) r3 x' b- O9 T
unchanged. Surprisingly, the pubic hair almost com-
; H* k2 R# G- i* [" Jpletely disappeared except for a few vellous hairs at
7 q1 N7 I# r/ R2 Dthe base of the phallus. Testicular volume was still 2$ ?+ @0 {  b, A" ^0 R
mL, and the size of the penis remained unchanged.8 ]! v1 W3 ~8 c9 d5 n+ M. k
The mother also said that the boy was no longer hav-
9 m6 F# I7 k+ c8 Y. S# N3 Aing frequent erections.
. a, m* P0 ^) l  BBoth parents were again questioned about use of# s( b3 j! J  k4 ]- Q1 u' B1 S
any ointment/creams that they may have applied to
+ F. s) l. W: x. G+ gthe child’s skin. This time the father admitted the7 |/ Z( W+ L! y% T
Topical Testosterone Exposure / Bhowmick et al 541  [, q8 \9 \+ ?8 R
use of testosterone gel twice daily that he was apply-
" F0 Z$ _+ }" }# U' `( o1 hing over his own shoulders, chest, and back area for
7 }$ g6 S7 k- l' wa year. The father also revealed he was embarrassed/ @8 }2 u# V, Y. [/ ]
to disclose that he was using a testosterone gel pre-8 z4 }$ D5 |9 L- `* M/ \. f
scribed by his family physician for decreased libido
( |: b" i" J5 |7 Q# ]: hsecondary to depression.
2 ~( }8 S. O3 a6 n" ~6 M9 g5 UThe child slept in the same bed with parents.+ N6 h/ F! u& V1 ^' X
The father would hug the baby and hold him on his) h; e7 L5 Q, X/ `, o
chest for a considerable period of time, causing sig-6 s, @+ L& Z; Z0 g( a1 v5 Z
nificant bare skin contact between baby and father.# _- Y; S) v9 F0 h
The father also admitted that after the phone call,& Y, s, a' d& t6 i1 S: ]
when he learned the testosterone level in the baby# j  m3 n5 |7 X7 @" @
was high, he then read the product information
: u: V4 z/ T7 `packet and concluded that it was most likely the rea-: t3 @- l& ]( V4 }6 ~6 s) g8 j
son for the child’s virilization. At that time, they
; a, ?0 n1 W  m3 d2 U$ S' D% S8 T+ _decided to put the baby in a separate bed, and the
1 _& L4 X5 D+ @! Vfather was not hugging him with bare skin and had8 S* Q4 U/ c) m8 s0 t7 Y9 L% b
been using protective clothing. A repeat testosterone' |1 v2 x' H, g! n" o* m% O+ i8 I
test was ordered, but the family did not go to the4 h) Z2 P- j/ r( q- U- H% b7 E
laboratory to obtain the test.# b7 m* g: L4 \) w* x
Discussion$ L, @" @% n0 D3 m  r4 x8 \# I: U
Precocious puberty in boys is defined as secondary
& @% p7 u5 a- z4 X  ]& |3 P0 P+ _sexual development before 9 years of age.1,49 d; p" {3 ~3 q
Precocious puberty is termed as central (true) when- s0 {9 @5 v4 c2 I, P
it is caused by the premature activation of hypo-4 A; Q% C& ?1 ^+ B$ T' ]
thalamic pituitary gonadal axis. CPP is more com-
7 ]: i% O9 l1 [" \! n2 c4 Vmon in girls than in boys.1,3 Most boys with CPP
, t. t" n2 a' n: `! Jmay have a central nervous system lesion that is; e$ I  z* P  j1 w
responsible for the early activation of the hypothal-
9 g$ t. F. F- d# t3 Z  `, e; gamic pituitary gonadal axis.1-3 Thus, greater empha-5 u! c; _- a% v  @0 z2 q" D
sis has been given to neuroradiologic imaging in+ ^6 f3 v3 ^; ]9 e
boys with precocious puberty. In addition to viril-
& s1 L- {/ V6 T6 oization, the clinical hallmark of CPP is the symmet-
; ~" W9 s2 c7 v+ ?rical testicular growth secondary to stimulation by
- R7 B) Z2 A- Z5 k2 Z( Zgonadotropins.1,3$ Y& `4 ~  l; L9 A
Gonadotropin-independent peripheral preco-' C- i* T5 ^* w, f7 x
cious puberty in boys also results from inappropriate
0 h  ]& a  y2 M$ u+ v7 handrogenic stimulation from either endogenous or7 M2 y% T& q8 h  \* b$ K
exogenous sources, nonpituitary gonadotropin stim-9 u- O/ ^, ~: g( z' {5 o
ulation, and rare activating mutations.3 Virilizing
' ]% O" L3 n$ u* q* vcongenital adrenal hyperplasia producing excessive& j2 G, k* A6 t+ p: o
adrenal androgens is a common cause of precocious0 @3 R9 _/ ~7 _; s4 x3 c
puberty in boys.3,4) Z$ ?: a+ x3 O! \- C; A- A
The most common form of congenital adrenal
$ O" u# g* `2 N" k- x# s5 ]8 Ohyperplasia is the 21-hydroxylase enzyme deficiency.
% W& R  M4 e3 I1 z: f0 S6 B* YThe 11-β hydroxylase deficiency may also result in* d1 z9 l2 q. ]" F- @
excessive adrenal androgen production, and rarely,
5 ~4 O7 _2 H" Ian adrenal tumor may also cause adrenal androgen
2 J$ e7 U$ t0 x4 F- O! [9 p" Kexcess.1,3. h, @& u$ |. z( I9 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 H) G( G. z7 z% J7 {1 Y6 q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& ~0 U, l8 i9 E1 i/ wA unique entity of male-limited gonadotropin-
: H/ i$ ^5 S3 u# _  ^* Jindependent precocious puberty, which is also known6 s* b9 _, w; p+ Y7 q- q- k1 h" ~
as testotoxicosis, may cause precocious puberty at a, U3 H( d9 ^3 `& {5 A
very young age. The physical findings in these boys  u5 w" q- U( t+ e4 d  @3 k
with this disorder are full pubertal development,
1 @& J& z6 S# E2 Z4 @. sincluding bilateral testicular growth, similar to boys
' Z( I/ c& G# w4 q- C- q; Kwith CPP. The gonadotropin levels in this disorder: I2 |$ B- X1 z. `, H& |, D) ]- k; H
are suppressed to prepubertal levels and do not show
% O0 ~0 z% R9 Gpubertal response of gonadotropin after gonadotropin-( T" ?4 X8 x& X% z) k" N3 M
releasing hormone stimulation. This is a sex-linked0 t4 K  ]  u0 x; Z. Y. G
autosomal dominant disorder that affects only
8 c& _9 r1 A! ]  d" Z+ \) y+ D* ~1 ?& Imales; therefore, other male members of the family3 m- v$ I8 c  D# L
may have similar precocious puberty.3
9 E0 N4 e% v' X) N1 ~8 TIn our patient, physical examination was incon-  o& H1 z7 U# b! E
sistent with true precocious puberty since his testi-
% o% G8 [' R5 p' @3 r/ ]- |' T- W  t3 \cles were prepubertal in size. However, testotoxicosis8 U7 ~& ~. A4 r/ S3 v
was in the differential diagnosis because his father- \8 N" g5 }6 G  X  |
started puberty somewhat early, and occasionally,8 F4 m: [. o) n: V6 \
testicular enlargement is not that evident in the
' w, r; a9 L4 ]3 I$ d! E+ R/ C1 }* Ibeginning of this process.1 In the absence of a neg-- `* G" s! r9 W+ Y1 @
ative initial history of androgen exposure, our4 E# {7 F& W& p8 w
biggest concern was virilizing adrenal hyperplasia,
( B8 R' m3 T( D% `either 21-hydroxylase deficiency or 11-β hydroxylase
. _* k8 ^$ X* p% V4 B7 B0 vdeficiency. Those diagnoses were excluded by find-
5 c# r! N0 q5 Z0 Y- `ing the normal level of adrenal steroids.: h: l' x6 `! e8 @
The diagnosis of exogenous androgens was strongly
$ }+ p  }1 l. g/ H1 u; Ssuspected in a follow-up visit after 4 months because7 ^0 b1 \7 U0 I; N8 `3 a! P1 _
the physical examination revealed the complete disap-
! O4 W# u' i$ q2 \$ {  \pearance of pubic hair, normal growth velocity, and6 z8 p# ~. @6 `# Z3 O1 `% x
decreased erections. The father admitted using a testos-
- j" E/ A9 c& V; j4 Vterone gel, which he concealed at first visit. He was7 n; x7 y6 Z# C) E( |# l% D# ^- I1 L/ T
using it rather frequently, twice a day. The Physicians’% m3 E# D0 p* f0 k$ p0 ?" u
Desk Reference, or package insert of this product, gel or1 C8 B& Q) W3 h, X- o' f
cream, cautions about dermal testosterone transfer to
' U; j  x7 ?  ]1 L/ Uunprotected females through direct skin exposure., H' K* p# X/ O  \) O
Serum testosterone level was found to be 2 times the
, s# h/ n0 d# v! c9 Z& Ibaseline value in those females who were exposed to0 ?, }1 _3 z3 H. [  W! Z3 r
even 15 minutes of direct skin contact with their male0 X" Q% ^! T; V; h/ W6 c& ?
partners.6 However, when a shirt covered the applica-1 P& G# m8 o) `. ]8 `7 ^
tion site, this testosterone transfer was prevented.$ _$ h" m7 l$ i6 _
Our patient’s testosterone level was 60 ng/mL,$ m1 ^9 T) B1 J% j9 y% k" s" s) B
which was clearly high. Some studies suggest that
- |4 t8 m* B  W1 Qdermal conversion of testosterone to dihydrotestos-
4 v# T) x+ V9 f& Xterone, which is a more potent metabolite, is more7 N$ ?0 A- n3 _+ A# _( p5 }! U
active in young children exposed to testosterone  H' S% S( i, ~
exogenously7; however, we did not measure a dihy-- ^8 J7 s% M% w& F5 q% ?
drotestosterone level in our patient. In addition to
0 ^- D  M  k, `. X# _3 |virilization, exposure to exogenous testosterone in
) F7 S7 R- R6 {) q3 mchildren results in an increase in growth velocity and* F* \/ b) n" k& M
advanced bone age, as seen in our patient.
9 f1 y: H$ s  V% q6 `' i( _! zThe long-term effect of androgen exposure during8 E1 o+ _1 J& ~6 u
early childhood on pubertal development and final
* m$ l- k) g! G9 m$ @1 `adult height are not fully known and always remain! L- M! U  n) P2 T/ K
a concern. Children treated with short-term testos-9 Q( M% e9 `4 _4 U& ?9 \3 }
terone injection or topical androgen may exhibit some
2 L6 S7 O% z; R& T! Aacceleration of the skeletal maturation; however, after  q* @# r- B- d$ U3 u5 e# i2 J# `( r
cessation of treatment, the rate of bone maturation" x" C  \% b/ |+ x
decelerates and gradually returns to normal.8,9
: a8 J! V7 Q& RThere are conflicting reports and controversy
0 p/ Q2 J8 u2 J; B0 B* j: c8 W* Z$ ~. i6 jover the effect of early androgen exposure on adult+ @$ g* W& Q$ x% m
penile length.10,11 Some reports suggest subnormal
" D( r+ t7 t/ H6 jadult penile length, apparently because of downreg-1 {- l/ ?8 \6 M& O" u3 F6 K3 H( k
ulation of androgen receptor number.10,12 However," @9 F$ A4 Q- p4 ?1 G; S6 v
Sutherland et al13 did not find a correlation between
" S3 F# A5 y: V% v1 t; P3 g6 r  {% jchildhood testosterone exposure and reduced adult$ g' ?' h3 d) l, o
penile length in clinical studies.2 o/ \: B2 C1 r0 U  c
Nonetheless, we do not believe our patient is, B$ t$ k$ n4 F- _* ]! B
going to experience any of the untoward effects from
/ P% ~" H6 D  `- h) E+ G& m1 m! Gtestosterone exposure as mentioned earlier because6 Z  c& v; K( p( G8 s& z
the exposure was not for a prolonged period of time.8 y! N" z) J, ]: K0 _
Although the bone age was advanced at the time of
- e& E# ]: Y% i" cdiagnosis, the child had a normal growth velocity at+ @) }- |7 G# z# ^+ c8 a7 k5 x# |
the follow-up visit. It is hoped that his final adult
+ n4 \  x" M+ F' R9 u; v9 Nheight will not be affected.
( K4 F  r% I* I; H5 @9 zAlthough rarely reported, the widespread avail-
6 `6 n1 F) l. ]0 |0 g% sability of androgen products in our society may
/ ?. g: F# [$ ^4 F2 Sindeed cause more virilization in male or female5 ~- E; c# l- M& w
children than one would realize. Exposure to andro-
, x/ L1 N8 b& G) f8 W+ u# }0 l) W# lgen products must be considered and specific ques-
5 s: m, S' E4 s6 N$ `9 |tioning about the use of a testosterone product or/ i7 f2 b% B  l' T0 E5 y
gel should be asked of the family members during# m) t$ M) _# f& L& t( i
the evaluation of any children who present with vir-
: [1 }: ]5 P! T* z) oilization or peripheral precocious puberty. The diag-
/ T9 ?' @* e. m) n9 L. X4 K" qnosis can be established by just a few tests and by
& B# F- G. Q2 E$ Z$ ]) f# lappropriate history. The inability to obtain such a
  G5 s" }2 r; K2 P" S6 I2 V8 ?( ~6 Jhistory, or failure to ask the specific questions, may
) G0 h$ q* l7 G- F" C: aresult in extensive, unnecessary, and expensive
: ?! r% n+ V. W% Q8 Pinvestigation. The primary care physician should be% z  z6 a9 G: K1 \6 o" \) K) i
aware of this fact, because most of these children
( s1 j% B- L9 k% H. n8 X# Ymay initially present in their practice. The Physicians’
/ e  H! e5 Z" e9 f5 V, f) IDesk Reference and package insert should also put a4 Q! b% _" |( G
warning about the virilizing effect on a male or
9 M: M6 }6 R( Z( i- T6 h$ Ffemale child who might come in contact with some-$ @4 f. K0 F% r: C) o
one using any of these products.
7 H" g8 V" W, `, zReferences
1 i: ?3 P( P# O" K7 d+ G- ^1. Styne DM. The testes: disorder of sexual differentiation
4 V) X! A$ N. }) [  v$ N) Hand puberty in the male. In: Sperling MA, ed. Pediatric
* X  p1 O$ M) |, q4 @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 u4 c0 e& ]& h8 W- ~9 i2002: 565-628., C+ E! s7 \1 _6 @4 \6 w0 \
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 n% v+ @0 r( e+ Epuberty 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

- {8 ~6 t) E* D. ]3 U) Z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