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. R6 q8 y( f: [/ w  R' e+ c
Boy Induced by Indirect Topical- u" g( C! M) }( `
Exposure to Testosterone9 z+ L* m5 X* Q& g* S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 H8 }' ]6 R' h, C. P$ {" E
and Kenneth R. Rettig, MD1
5 ~5 H  ^4 H5 s. tClinical Pediatrics: i& {5 t2 o$ o: F3 G7 V
Volume 46 Number 64 @1 U* U, _, ~/ I1 ^. q
July 2007 540-5435 S1 M8 R$ M7 ^$ _5 l
© 2007 Sage Publications1 n* M1 r5 p* |" g; \- x
10.1177/0009922806296651
  ]( I& N- y3 o2 l5 U9 Phttp://clp.sagepub.com* g) r+ J) O( u2 u2 p
hosted at
# m* i& R1 N1 v* _2 X( {: M0 ]http://online.sagepub.com; ^, w4 u5 g# ~& {, J/ U! B* p
Precocious puberty in boys, central or peripheral,
" b6 i1 D* J/ p( pis a significant concern for physicians. Central
) Z4 ^0 A* M0 W2 d2 q6 O1 yprecocious puberty (CPP), which is mediated2 i7 i- K) e0 U2 R9 @9 v  y3 Y  Y' B* ~/ Y
through the hypothalamic pituitary gonadal axis, has
- I& z- ?! U$ c6 [: Y( ^: Ga higher incidence of organic central nervous system
0 H% L- ~3 E1 g- Xlesions in boys.1,2 Virilization in boys, as manifested/ D8 u& c, \9 M- f6 F$ O; c
by enlargement of the penis, development of pubic
( p( D- @. `* K* b2 J% ahair, and facial acne without enlargement of testi-
4 e0 i2 ?4 H: H7 N, Zcles, suggests peripheral or pseudopuberty.1-3 We
2 s+ v- a+ O7 ~, V3 j, breport a 16-month-old boy who presented with the
1 s" q( b- H2 }7 r' Denlargement of the phallus and pubic hair develop-
% ~1 q2 O" _( d8 K5 zment without testicular enlargement, which was due
+ z; m0 }  k! Yto the unintentional exposure to androgen gel used by
/ @, G- `* h8 `* T3 }3 cthe father. The family initially concealed this infor-
+ K5 o- Y3 X: q" o0 ~mation, resulting in an extensive work-up for this; Q$ _7 G1 K6 J3 o/ L
child. Given the widespread and easy availability of
. x' Z5 l8 U2 k+ P0 Xtestosterone gel and cream, we believe this is proba-
) w& t; J) L& p, L; `9 Pbly more common than the rare case report in the
" z8 k5 {& J' l+ bliterature.4
1 G. A% Q$ y6 z5 x6 \( xPatient Report
+ b1 g9 C) d$ o* M. SA 16-month-old white child was referred to the
% Y* _+ v% k: N$ T/ ?4 G! }  S# s% vendocrine clinic by his pediatrician with the concern- f; ~1 X. O9 L% q% ], K
of early sexual development. His mother noticed# p  M& H; i4 M" w5 U9 Y  x: V7 |) O
light colored pubic hair development when he was* W: G* v  K  n4 z( d* [; u& }
From the 1Division of Pediatric Endocrinology, 2University of1 n5 x1 }7 U0 P; Y
South Alabama Medical Center, Mobile, Alabama.
' o0 q# p- h* g; |7 uAddress correspondence to: Samar K. Bhowmick, MD, FACE,! L9 @  s. e5 R8 ~
Professor of Pediatrics, University of South Alabama, College of
6 j! a' `2 u& ?/ u, K% R. OMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 {' r+ b+ }1 _  Q( Ge-mail: [email protected].  X% K* e; U% C' M
about 6 to 7 months old, which progressively became
3 ]& v0 f# E6 b6 x9 z$ o+ L! x) Z9 Edarker. She was also concerned about the enlarge-- I3 l9 b" E+ U" O! t# P1 J9 i
ment of his penis and frequent erections. The child) n) N) n2 y! b7 G* z5 Y3 m
was the product of a full-term normal delivery, with& \# B1 ^8 v. e, Q: Y0 m& T0 X
a birth weight of 7 lb 14 oz, and birth length of& [% C! Z1 M6 e$ ^2 \$ t; k
20 inches. He was breast-fed throughout the first year1 i' T1 E$ Q/ u$ |( `: A; K
of life and was still receiving breast milk along with' ]' e8 B! I; E" H
solid food. He had no hospitalizations or surgery,
) {. G& F  q- g* i: Rand his psychosocial and psychomotor development# Q. G3 h! f5 S( X  ~
was age appropriate., @: f& d, o5 J$ G- _. k5 T
The family history was remarkable for the father,
- x7 u' _+ h( Y' y$ m. Mwho was diagnosed with hypothyroidism at age 16,9 \- O, c" E9 Z1 p3 [7 g  o# |# M
which was treated with thyroxine. The father’s8 J8 H) b  F6 W! C' j
height was 6 feet, and he went through a somewhat
# w; t& z$ \2 _5 V! g' zearly puberty and had stopped growing by age 14.
/ `0 v) [" y; J2 N" q! tThe father denied taking any other medication. The, Q/ _( f& t6 T$ V: \0 l
child’s mother was in good health. Her menarche
3 z: v4 d8 e1 g4 w8 L) iwas at 11 years of age, and her height was at 5 feet
% p7 _. C- k1 |+ W5 v. T- N$ ~# ?5 inches. There was no other family history of pre-
, _& U" w- |7 Ecocious sexual development in the first-degree rela-
  ?) |8 H" i  W% j% P' d8 @# Utives. There were no siblings.
6 b; w5 m7 u" p" k8 IPhysical Examination
' {: l4 T4 w2 q$ a$ g. ?The physical examination revealed a very active,6 @  H- R2 y7 [; f# e! R& ~! f8 y
playful, and healthy boy. The vital signs documented1 T  R1 v- }  d: j: A+ r
a blood pressure of 85/50 mm Hg, his length was
6 i# `* o& q) j' }! v90 cm (>97th percentile), and his weight was 14.4 kg
* _: i( O8 s) q6 |' s; K(also >97th percentile). The observed yearly growth2 @% P" R/ M6 D
velocity was 30 cm (12 inches). The examination of' c7 `2 B8 i+ c$ Z' L
the neck revealed no thyroid enlargement.8 d0 \0 ~: |, X2 T- b1 u
The genitourinary examination was remarkable for' ?0 Q1 {& u3 z$ b1 A- y. b) h
enlargement of the penis, with a stretched length of# g# ]4 e1 `; z
8 cm and a width of 2 cm. The glans penis was very well
. V/ X4 U8 {( j9 Tdeveloped. The pubic hair was Tanner II, mostly around( l# r: ?5 }) v- j8 j
540
- b4 K! d/ ^* I* z* j# H# v+ @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- @1 Y3 S1 G& H+ G% Q, b# [
the base of the phallus and was dark and curled. The
& ~1 K: a8 [; x9 S2 w% }: dtesticular volume was prepubertal at 2 mL each.0 L$ F% _1 l' v& N8 A5 ^
The skin was moist and smooth and somewhat  O) w! j& f$ ^6 d+ d+ A* d
oily. No axillary hair was noted. There were no7 o6 I% B) h3 V+ t' G2 Z
abnormal skin pigmentations or café-au-lait spots./ n1 n: f6 C3 g; E0 W7 Y; s5 }
Neurologic evaluation showed deep tendon reflex 2+
8 h' B, p$ E+ P1 k7 a0 W6 O+ |4 Zbilateral and symmetrical. There was no suggestion4 N# ?& c. H5 H6 l: i& q& o
of papilledema.% m) G( Q2 {+ W$ T. n; G1 }7 {% u0 F
Laboratory Evaluation
% n' t% L  g5 f* p8 Z6 `The bone age was consistent with 28 months by
' n1 X: y, n* iusing the standard of Greulich and Pyle at a chrono-$ W8 J3 e( \9 ~
logic age of 16 months (advanced).5 Chromosomal+ f, e8 `! }4 f2 M# r; b. G2 L
karyotype was 46XY. The thyroid function test$ Y( Q( z) r5 j" T9 w! J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# T, p) ?! u% V5 }lating hormone level was 1.3 µIU/mL (both normal).. @! V1 M; h. i% ?4 O2 h6 Z# Z8 [
The concentrations of serum electrolytes, blood! r# W- j# Q3 r
urea nitrogen, creatinine, and calcium all were& C1 k+ c! ^  f: r9 L
within normal range for his age. The concentration# F1 {9 H' d( O' Z6 O2 l
of serum 17-hydroxyprogesterone was 16 ng/dL# i8 o, T8 |$ H+ Q# a5 ^3 t/ e
(normal, 3 to 90 ng/dL), androstenedione was 20
; c5 ]. L$ |+ r6 r3 v% A- t; R4 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! M2 ~( Z: V- Q, b: n4 x- @, Y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 o( U3 X7 F0 l  n* `5 Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 V8 n" V/ X" H; @7 H49ng/dL), 11-desoxycortisol (specific compound S)
& U$ N+ D5 m1 ]) uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ z% G, H( F9 i8 E5 D# `: Q2 d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 C- D! s3 e2 p2 `! x. N" W9 P* |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; [! n3 a- x  B. n- o& {6 N
and β-human chorionic gonadotropin was less than5 t' j2 U/ m" p  a) j3 u" Q
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% y7 U: H( W' Astimulating hormone and leuteinizing hormone, K$ {! e3 g; E1 x
concentrations were less than 0.05 mIU/mL
" U' o3 l; |  t* b9 ]! u8 N" T3 N3 d  d(prepubertal).: L( n2 l4 X  K1 T9 U  w; q* W+ @' T
The parents were notified about the laboratory
+ Z/ R- z. ]2 sresults and were informed that all of the tests were
& |+ X' o- n- t6 s" s& Z$ v9 {normal except the testosterone level was high. The
& \$ u* |( }1 w! t( ]1 d0 sfollow-up visit was arranged within a few weeks to
4 c. r; y5 r! k! J# l4 {# p% w; _3 kobtain testicular and abdominal sonograms; how-3 P% _. X4 f  t% B
ever, the family did not return for 4 months.
- [3 M9 o% h5 i4 OPhysical examination at this time revealed that the$ q4 Y% G4 J& {* c, ^' p: V
child had grown 2.5 cm in 4 months and had gained( N% |- l4 W& w, X* l. c8 d
2 kg of weight. Physical examination remained) J2 i# t. \& V/ C7 s, E% p
unchanged. Surprisingly, the pubic hair almost com-& Z& b+ Y5 Q# v3 ]9 e2 I
pletely disappeared except for a few vellous hairs at7 y& f& F6 M9 j+ ?
the base of the phallus. Testicular volume was still 25 `5 s7 B/ D, i1 z( f
mL, and the size of the penis remained unchanged.; P" Y# Z6 ~) Y9 j- B9 o- s* m
The mother also said that the boy was no longer hav-
( i  f; L5 C" T( P! y" Sing frequent erections.+ [4 D) w5 p( N# v2 p; X' o1 L6 a
Both parents were again questioned about use of
# F! p# _) L6 p0 p2 S) Eany ointment/creams that they may have applied to* c  o/ P/ H' G0 X. [/ \8 S
the child’s skin. This time the father admitted the
& o: e- }2 J& `$ s, W) Q& dTopical Testosterone Exposure / Bhowmick et al 5413 t6 _$ r# ?6 [6 c: g. M) j) K
use of testosterone gel twice daily that he was apply-3 n# o# E4 f' P2 b
ing over his own shoulders, chest, and back area for
2 R! P! X; b) |) a" z( k4 ~* Na year. The father also revealed he was embarrassed3 |6 Q& j% F1 m4 f7 L
to disclose that he was using a testosterone gel pre-
6 |' q+ U3 i7 j2 W8 k0 kscribed by his family physician for decreased libido
$ l: u: S5 Y  n3 b, K; J1 ssecondary to depression.
7 `& d% N  e1 o! O* S$ VThe child slept in the same bed with parents., X1 B. V* d) F
The father would hug the baby and hold him on his/ I) M) p# N# h
chest for a considerable period of time, causing sig-+ f$ Q% P$ _4 y, _; e
nificant bare skin contact between baby and father.
, n0 t; i; i; a' U% nThe father also admitted that after the phone call,
3 H, j0 T/ z0 Z' l- H/ f% F! G5 E* Ywhen he learned the testosterone level in the baby
. J7 z8 ^& J5 V5 x' _was high, he then read the product information
5 d6 C, o: H1 Y; R8 W# w( z1 Ipacket and concluded that it was most likely the rea-
" h7 L9 p5 \( [son for the child’s virilization. At that time, they
  k0 C$ N" X) a7 K. Udecided to put the baby in a separate bed, and the% a4 _: f1 d7 N. C
father was not hugging him with bare skin and had
  l# J1 Y0 d" @6 a. }- `been using protective clothing. A repeat testosterone
9 Y7 f- g( w! q* b% gtest was ordered, but the family did not go to the
" W% n6 \7 J# r5 H9 S* Olaboratory to obtain the test.( R9 p2 y9 t- Q- Q4 I
Discussion
2 z8 {3 k8 l7 Z4 `Precocious puberty in boys is defined as secondary8 n: N4 x' N) |6 H& u" R1 _& ~% u
sexual development before 9 years of age.1,43 o; ~0 z( f! M& E8 v* `
Precocious puberty is termed as central (true) when
3 j8 i! [" w2 _it is caused by the premature activation of hypo-8 f" T  p# ?: i4 g9 }( U
thalamic pituitary gonadal axis. CPP is more com-
# p5 O5 \, j" Q# T& ]8 rmon in girls than in boys.1,3 Most boys with CPP, j5 P0 l+ i8 U" a+ [  q$ X" O
may have a central nervous system lesion that is0 x' o% |2 H$ V$ w
responsible for the early activation of the hypothal-4 Q$ F9 L) B. \' M) M3 M
amic pituitary gonadal axis.1-3 Thus, greater empha-5 j( a, N+ m( |2 [$ t4 E8 g
sis has been given to neuroradiologic imaging in
0 \5 `/ j3 F6 ]) h$ l: F: E/ Fboys with precocious puberty. In addition to viril-% f7 h+ i0 g( j
ization, the clinical hallmark of CPP is the symmet-
; f4 k9 E% h7 Z- J- mrical testicular growth secondary to stimulation by
1 C- Y* g$ C2 K( Y* \' W/ @gonadotropins.1,3! T+ b. D2 [( ?2 H
Gonadotropin-independent peripheral preco-# Q5 Z7 q6 i$ L) w3 e
cious puberty in boys also results from inappropriate
. |8 b, c$ K0 J+ L/ l& _% G7 \+ Y2 }androgenic stimulation from either endogenous or" F2 `% X; H0 |. o9 q, m* k3 F
exogenous sources, nonpituitary gonadotropin stim-. x0 T4 b- Z+ @8 Z
ulation, and rare activating mutations.3 Virilizing
& I: c. ~  {! ~& M3 y) ~1 s: Z2 @congenital adrenal hyperplasia producing excessive
1 ]5 s2 O# p& T. e6 i  badrenal androgens is a common cause of precocious" I5 ]1 _, A5 ^: g1 m
puberty in boys.3,4' q- U0 Y: O% f6 ?7 J' |
The most common form of congenital adrenal$ B5 ~& b' F$ ?4 Y1 n! p$ e$ q% L3 ^
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 \3 K+ n/ x, f: K+ a8 g  I1 `! gThe 11-β hydroxylase deficiency may also result in& h4 t( F  {/ e! K3 ?' Z8 \" T
excessive adrenal androgen production, and rarely,
7 N9 B; c! |- ^. G8 T2 han adrenal tumor may also cause adrenal androgen
3 T: l! `' [5 L4 Y( Gexcess.1,32 w. U% e+ q4 L% k) L9 Z& |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 D# Y( m# Q1 s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 s+ k" m- B" HA unique entity of male-limited gonadotropin-! S1 |. x! Z2 e, D7 z
independent precocious puberty, which is also known
. }( Y5 M6 f! r: o& L" p$ Uas testotoxicosis, may cause precocious puberty at a
/ E' T* R+ I9 n9 Bvery young age. The physical findings in these boys- b0 u7 z$ l; C) J* q$ Z9 T
with this disorder are full pubertal development,
3 G+ _/ v* I% R( Hincluding bilateral testicular growth, similar to boys
+ J9 Y. ~' U/ {" ^* Twith CPP. The gonadotropin levels in this disorder$ U/ }6 L8 I. F  @: C
are suppressed to prepubertal levels and do not show
( O  w# N" E$ bpubertal response of gonadotropin after gonadotropin-
: H6 O$ I( {3 ~, `$ d: {releasing hormone stimulation. This is a sex-linked
+ _# f, D) k3 e, D  K! v* Aautosomal dominant disorder that affects only
- e4 S) a' D3 [% P6 v9 \# J0 Vmales; therefore, other male members of the family
2 h2 n0 E% F7 R2 r0 p' k) ^8 {may have similar precocious puberty.3) X) T  q/ \( W: e1 v8 \# P
In our patient, physical examination was incon-
  s( m* w# A7 a; U$ `1 J* s; Usistent with true precocious puberty since his testi-5 ~9 Q2 d5 N& V/ n( O" p4 f. v& H, @
cles were prepubertal in size. However, testotoxicosis8 z4 ]& u3 L6 T- W- b7 |% j
was in the differential diagnosis because his father0 _: m: J: }# s7 X
started puberty somewhat early, and occasionally,+ R: c  Q8 {5 \9 s  S
testicular enlargement is not that evident in the
7 H' j% k  Y$ Z# h# o3 @8 w$ ~# Sbeginning of this process.1 In the absence of a neg-
" i1 V6 n6 s  o' H# T& ]/ uative initial history of androgen exposure, our
( q% r. @' K8 r* C; `! ibiggest concern was virilizing adrenal hyperplasia,+ k* C6 G- [" E6 \. @
either 21-hydroxylase deficiency or 11-β hydroxylase1 L% r% J" q9 I; Z/ l6 ]  F7 d) n
deficiency. Those diagnoses were excluded by find-
5 C. u! W/ M3 hing the normal level of adrenal steroids.
' m+ F! D5 n& @( h# o; j& @The diagnosis of exogenous androgens was strongly: `0 q6 X) V, ^# e+ n+ n/ J. B% A* b
suspected in a follow-up visit after 4 months because
$ t* H* V9 r  M8 {' v1 j+ [# `the physical examination revealed the complete disap-
$ E) p) p( {% J7 j4 Spearance of pubic hair, normal growth velocity, and# `5 }; H) @6 f1 m4 F8 \7 [* ~
decreased erections. The father admitted using a testos-& n3 B) I" X" z7 P  X; U
terone gel, which he concealed at first visit. He was9 L' c6 ?; ^4 f. Z6 J9 D2 d
using it rather frequently, twice a day. The Physicians’) p: Y/ |  @+ `+ C* d0 l
Desk Reference, or package insert of this product, gel or
' D. V7 E4 Q! T; M0 V7 X; j' o0 _cream, cautions about dermal testosterone transfer to; k/ S% g9 v. y. p& V8 p9 V
unprotected females through direct skin exposure.
+ p( u5 \: L$ ?$ n8 m0 zSerum testosterone level was found to be 2 times the
/ U* |% Z# n, A8 Y# `baseline value in those females who were exposed to3 `% v( u" A$ [2 _4 r1 J7 V
even 15 minutes of direct skin contact with their male
8 e( A8 `8 J; M4 n% z+ m1 O4 Epartners.6 However, when a shirt covered the applica-
* u! A6 L$ F0 e6 O" D% Ution site, this testosterone transfer was prevented.
' U' Z4 _: B7 F: v8 i* L) hOur patient’s testosterone level was 60 ng/mL,# s3 N+ M+ o1 `: K# V+ x2 q
which was clearly high. Some studies suggest that8 b+ b" b/ E. A8 X, S' x
dermal conversion of testosterone to dihydrotestos-
. |/ q  e! @, y6 e2 R* B' n* K7 z0 Rterone, which is a more potent metabolite, is more" C$ a* s0 W, k! V
active in young children exposed to testosterone$ p+ v$ P6 q( d7 v3 J
exogenously7; however, we did not measure a dihy-
4 ^( o2 Q  C0 B4 B' kdrotestosterone level in our patient. In addition to
0 i' j' A, B  n) ?5 x8 X, ^& bvirilization, exposure to exogenous testosterone in
% U, h' [* G, e3 D& r, Tchildren results in an increase in growth velocity and; g- R# _0 S- p% x. p; D7 c& y% s3 l
advanced bone age, as seen in our patient.
: p; a' Y8 y" u) U$ IThe long-term effect of androgen exposure during4 N- z4 x5 N! z( A
early childhood on pubertal development and final/ R7 a- `, @' r  H4 U
adult height are not fully known and always remain
* n6 F! ~( G# V4 h4 d. ba concern. Children treated with short-term testos-. M$ Y2 P' c4 J/ H& u
terone injection or topical androgen may exhibit some8 d% o* i3 l7 o. ]. U$ T
acceleration of the skeletal maturation; however, after
& N6 ?. w! t; w: i, h4 xcessation of treatment, the rate of bone maturation
+ e+ P* v: d. sdecelerates and gradually returns to normal.8,9  @  @5 ]! e# J
There are conflicting reports and controversy  w7 p" L1 L) k" P$ _+ G7 y7 O
over the effect of early androgen exposure on adult# s) ?, t  s- E  z
penile length.10,11 Some reports suggest subnormal" @  O0 ^6 {3 F; ^2 M
adult penile length, apparently because of downreg-. h) [4 d6 M' ]
ulation of androgen receptor number.10,12 However,9 L9 s% B. C1 L* a+ [$ U3 o+ V
Sutherland et al13 did not find a correlation between9 K" |3 _; Q6 T
childhood testosterone exposure and reduced adult
" t( S) |# r+ q. z+ ]penile length in clinical studies.
' b1 C- `% c5 E. fNonetheless, we do not believe our patient is( D6 a, X# Y! {# T9 f, d8 d$ J0 g
going to experience any of the untoward effects from
" S+ F" l- q0 q+ Stestosterone exposure as mentioned earlier because! v3 Z! M" F6 V* E
the exposure was not for a prolonged period of time.
: |$ ], }% o# F2 G4 Z+ {* @Although the bone age was advanced at the time of
4 C# U; m0 [" K, Rdiagnosis, the child had a normal growth velocity at
' |4 F# K/ Q7 g  f/ G+ \' c6 [the follow-up visit. It is hoped that his final adult( ?/ B: z8 P" C# s/ w. G6 d
height will not be affected.
1 a: P& W/ F+ ^& ?+ E& t2 ?; d; |Although rarely reported, the widespread avail-
# q* F+ v- S/ X6 F1 `ability of androgen products in our society may+ {6 P7 O/ }% V# j0 Z2 Y6 R# h
indeed cause more virilization in male or female
  W- x8 ^& b8 Z2 fchildren than one would realize. Exposure to andro-4 S% H, ~) R7 R* j7 I
gen products must be considered and specific ques-
( p! }# I4 }. v2 z9 ktioning about the use of a testosterone product or
) G/ B% Q: u3 D3 I; vgel should be asked of the family members during
- H! ~# }! ^/ ~6 l) V( y3 W, tthe evaluation of any children who present with vir-
4 A8 I+ h/ A0 ailization or peripheral precocious puberty. The diag-' r( M4 |! p( f. j! \  L
nosis can be established by just a few tests and by
, @0 f8 L, ]( p1 y: ?  d. b' E8 ~appropriate history. The inability to obtain such a
: b2 W% E( T& o5 Shistory, or failure to ask the specific questions, may2 ?5 k% T2 d0 U" z% \/ D$ N6 a1 ^
result in extensive, unnecessary, and expensive* X  r* O4 w: e$ \0 R5 a
investigation. The primary care physician should be
! [2 E9 g9 Z7 r# w& jaware of this fact, because most of these children7 {2 G# D# ~9 b" t
may initially present in their practice. The Physicians’
/ A5 |- w  @8 r0 ?7 r) Y$ rDesk Reference and package insert should also put a
2 a. o' `2 B7 c9 f% z! g" Mwarning about the virilizing effect on a male or5 J4 D& G& V) n& l
female child who might come in contact with some-. _6 U6 U7 E# {! ^
one using any of these products.* a# r9 n0 v' [9 \' k
References7 @( B7 j( h1 n" N8 y0 e
1. Styne DM. The testes: disorder of sexual differentiation9 E' z7 S: u' X, y& T, u, }
and puberty in the male. In: Sperling MA, ed. Pediatric; B/ T, }- h: B' B- G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( z4 ?6 p( a  N& [# m- E5 G( {' {
2002: 565-628., e* j0 a* _9 [& u
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# q3 b. E. @: S0 t! D; x! U- U
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-4 03:27:02 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
Sexual Precocity in a 16-Month-Old& w2 g% ^4 J- _. I; w+ {: n
Boy Induced by Indirect Topical4 j/ B& Y* m( H5 O7 p4 P
Exposure to Testosterone
* U- {: i- ?# r$ E3 `" V1 {  E# e( @Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 j) O6 D8 k; n1 L, \0 R
and Kenneth R. Rettig, MD1, X' K+ w, f, H1 O- z$ |/ S7 _. T
Clinical Pediatrics; W. J; X4 @0 K" j+ r( _
Volume 46 Number 6
( J3 c/ e! h1 A  {* Y3 WJuly 2007 540-543
+ q& t/ e- A; U; m, j7 A! x© 2007 Sage Publications6 ]# K) R2 o4 v5 Z: j$ _
10.1177/0009922806296651, K. I; d( I5 D% a6 |: S
http://clp.sagepub.com! ?5 Q/ T* m  ~; }- {) ^0 d% k
hosted at7 w. ~) K9 y8 e" e
http://online.sagepub.com
. ~4 d  z; P# {! m' i) _$ {Precocious puberty in boys, central or peripheral,/ Z7 h# U- W9 h, Q8 u
is a significant concern for physicians. Central! A" U/ Q  H: J) ~. [* n
precocious puberty (CPP), which is mediated
4 D5 X0 `' i( T6 _% V4 O7 Ethrough the hypothalamic pituitary gonadal axis, has! y; I" r6 I4 A) l2 Q; x/ g& u+ m5 X
a higher incidence of organic central nervous system0 @7 f5 {" H3 M8 P
lesions in boys.1,2 Virilization in boys, as manifested" K9 g6 G/ {) H7 [/ D9 h/ I
by enlargement of the penis, development of pubic4 j) M$ b% I+ }+ {4 |& w
hair, and facial acne without enlargement of testi-
1 h, T4 z3 x, J# r4 Y! c& ~cles, suggests peripheral or pseudopuberty.1-3 We" s" Y6 Q8 w# w, W' Q: Q6 T
report a 16-month-old boy who presented with the
3 b. F: U2 g% I/ x3 \2 [- uenlargement of the phallus and pubic hair develop-1 K& }; Q9 C; {0 T- }
ment without testicular enlargement, which was due$ C' c+ Z/ ^4 q; Q5 S
to the unintentional exposure to androgen gel used by3 [8 {' N9 b; h  P
the father. The family initially concealed this infor-  I1 m' r( _, L% R% X# v. p0 |$ c
mation, resulting in an extensive work-up for this" j) i- k, k6 |$ l* @9 O- h( T* x9 c
child. Given the widespread and easy availability of
) ], m4 s/ Y: W. I" C8 Rtestosterone gel and cream, we believe this is proba-
& m$ X/ M1 g+ b% H9 Jbly more common than the rare case report in the; }! d/ E! V( q- W1 N5 o$ m0 r
literature.4  q7 \& ~/ e4 \9 Q
Patient Report& z6 Q' ^, X) X! W' D$ J1 O8 s
A 16-month-old white child was referred to the. s* g; A. J( g& e  P
endocrine clinic by his pediatrician with the concern
2 `# e* O, I  J" a; |& {of early sexual development. His mother noticed
( E% q/ `- `6 R" g' D  Flight colored pubic hair development when he was
; i7 R- _% U& q. ^. b8 ~From the 1Division of Pediatric Endocrinology, 2University of
% T& Q0 l2 b: ^South Alabama Medical Center, Mobile, Alabama.
6 D& a  Y7 u$ l. T; pAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 W$ i: b' u8 C& T6 S7 HProfessor of Pediatrics, University of South Alabama, College of5 T7 x) u0 S) |8 c' d/ g3 p6 D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ H8 Q, @+ I& |* x' H
e-mail: [email protected]." H! s% k& f5 ^+ x' M
about 6 to 7 months old, which progressively became
0 k# R$ \4 z! ~darker. She was also concerned about the enlarge-; q0 G7 @0 V& I) U2 m( I
ment of his penis and frequent erections. The child3 m8 z2 A9 w! A8 ^' W, C
was the product of a full-term normal delivery, with0 y6 U: X% o  I) H3 ~# Z! D5 ^* K
a birth weight of 7 lb 14 oz, and birth length of: x0 N4 w  v0 J, K3 D# v
20 inches. He was breast-fed throughout the first year
  n1 D& U/ v( q1 ^* |of life and was still receiving breast milk along with& U. c: |9 `5 _* p& \* S6 t
solid food. He had no hospitalizations or surgery,
6 K# Q5 }. S. Z" y8 X  S: Vand his psychosocial and psychomotor development( O7 Q8 T+ s( V5 [+ e
was age appropriate.
5 k5 K6 _( N- Z! v$ J' eThe family history was remarkable for the father,/ H* g" F1 R  ~: Z5 {
who was diagnosed with hypothyroidism at age 16,9 w4 d% f9 ?9 a3 X" t6 M
which was treated with thyroxine. The father’s
5 b" N. ~; j% q0 i% L! Y" |, hheight was 6 feet, and he went through a somewhat4 k2 g6 K/ n2 s% p' S9 @
early puberty and had stopped growing by age 14.
, W) E6 `0 v2 K" hThe father denied taking any other medication. The3 O/ ?( {! N. N1 J6 o9 D! ^2 f
child’s mother was in good health. Her menarche
/ `' r# ]( Q8 s$ uwas at 11 years of age, and her height was at 5 feet1 ~( R% z  g  `: D+ w
5 inches. There was no other family history of pre-0 H' c; B& H# m4 ^* Y% y$ \* t
cocious sexual development in the first-degree rela-
. K% w) G" V# ?; V6 l: q# vtives. There were no siblings.  F% [9 T7 B, t7 `( w& }: e
Physical Examination
% ^: z3 ~3 D  G7 i8 gThe physical examination revealed a very active,5 A$ v" ^' }6 g4 \3 @
playful, and healthy boy. The vital signs documented. m0 K" ?4 N- F& p; R
a blood pressure of 85/50 mm Hg, his length was3 {/ t8 C' l% y; i
90 cm (>97th percentile), and his weight was 14.4 kg
2 H: J5 ^& H* R4 ^(also >97th percentile). The observed yearly growth
) B# s( h  J# T5 mvelocity was 30 cm (12 inches). The examination of
0 |' h6 ?0 [7 ~* ]2 p: Y  Bthe neck revealed no thyroid enlargement.
1 h; b$ ~8 v1 q. jThe genitourinary examination was remarkable for% W) N# u) z5 |: [" O7 l9 V. }3 q
enlargement of the penis, with a stretched length of
+ w4 A) A0 `2 E. @: G2 ^8 cm and a width of 2 cm. The glans penis was very well1 I& ]/ Z3 n5 c5 n  W, e
developed. The pubic hair was Tanner II, mostly around
( f2 D( {$ j, q  h* ~) H  |0 h540& c- ^  x% o+ D, _! @5 H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- y' k5 i3 q* @8 A4 i6 G- m
the base of the phallus and was dark and curled. The' d" |4 G' V. {6 |; B
testicular volume was prepubertal at 2 mL each.% X7 ^9 P  K2 {) j1 l3 m% Q8 |
The skin was moist and smooth and somewhat4 }* N8 \& R% J: s
oily. No axillary hair was noted. There were no( A% I0 s1 b' U* e! b3 ^8 d
abnormal skin pigmentations or café-au-lait spots.
3 J9 G6 o' k7 Y6 E( CNeurologic evaluation showed deep tendon reflex 2+
$ i2 e/ W5 j3 x, cbilateral and symmetrical. There was no suggestion
/ q3 g( N5 o+ k3 q9 h9 m6 u1 U4 y4 t$ kof papilledema.
5 X$ Q& n' L; I8 P" d, W* _% j. O5 b, cLaboratory Evaluation
: R5 ?9 r  ?. f% EThe bone age was consistent with 28 months by- Y) M9 G, N6 K: b: m1 m: }
using the standard of Greulich and Pyle at a chrono-
; K7 @& i& ^  X. B* p1 ~logic age of 16 months (advanced).5 Chromosomal: n" i7 j" n, X
karyotype was 46XY. The thyroid function test# B( ]' g/ z' W* ~4 w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ y! W9 t# S2 D$ Q/ blating hormone level was 1.3 µIU/mL (both normal).& }6 P% \- \/ `: X
The concentrations of serum electrolytes, blood- z5 D# O( e8 J3 H# p
urea nitrogen, creatinine, and calcium all were
, U& G5 F3 @6 A7 Vwithin normal range for his age. The concentration
8 s) W) E; S6 @of serum 17-hydroxyprogesterone was 16 ng/dL
9 f( Y+ m0 ]- d* P" Q! Z(normal, 3 to 90 ng/dL), androstenedione was 20
7 {2 @* y1 k* }. Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! A* `* F& _7 U' Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 j/ w* H4 I5 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% g$ Y) @) Q6 R* t! v8 [49ng/dL), 11-desoxycortisol (specific compound S)4 L, m4 y. K; J4 t; J+ r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 q9 I( v8 E  \% H  \8 K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 A9 ]# n+ O6 R- J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 {, D5 |( a. T7 c
and β-human chorionic gonadotropin was less than
. n7 b( E- j9 ]9 X( D5 mIU/mL (normal <5 mIU/mL). Serum follicular0 p8 ]$ s# C+ ]' y
stimulating hormone and leuteinizing hormone7 o' L9 O# u8 s* `4 I
concentrations were less than 0.05 mIU/mL
# x" F% g9 B* h+ \+ R9 R# X3 {4 @(prepubertal).4 I! n3 I5 q' b7 T' I+ S
The parents were notified about the laboratory
0 ~: }; O/ R7 s- J- cresults and were informed that all of the tests were
0 B- {. q% ?. y8 a; S. rnormal except the testosterone level was high. The5 I% O% d' d7 @+ N: l) }! q6 B
follow-up visit was arranged within a few weeks to) O# }, d: r  K5 g2 C: }
obtain testicular and abdominal sonograms; how-
1 O" a; a+ k. k* c. d6 i( Lever, the family did not return for 4 months.
! L! T: ?% H/ ?/ h( H$ KPhysical examination at this time revealed that the
% \& @0 F) |+ H# R1 w- zchild had grown 2.5 cm in 4 months and had gained
& h  G7 j- G3 |* N/ _8 j, l2 kg of weight. Physical examination remained
" C; ~$ X; n* x) iunchanged. Surprisingly, the pubic hair almost com-
/ w! Z5 g. ]5 s/ M+ fpletely disappeared except for a few vellous hairs at( n' D7 M; B1 p4 u4 d
the base of the phallus. Testicular volume was still 2* \$ x$ V, Z/ X) m3 b3 O2 ?
mL, and the size of the penis remained unchanged.
2 N8 \$ W! @6 u6 q0 S, V/ }The mother also said that the boy was no longer hav-6 Q5 p" Y9 E( E6 N6 d* s- u  }
ing frequent erections.: U- }) q4 `/ g6 v& |/ N4 J
Both parents were again questioned about use of
' y) |" c  o, p) H( yany ointment/creams that they may have applied to  b% c2 i' C) V3 Z" g
the child’s skin. This time the father admitted the3 h' L" r4 y. R, e  ?
Topical Testosterone Exposure / Bhowmick et al 541' r$ V; Z3 l: W! h3 c9 G
use of testosterone gel twice daily that he was apply-4 d. J! H1 R4 E  y3 G
ing over his own shoulders, chest, and back area for5 B5 J& L- K2 _( ?0 s  e# ]) B; E, e+ [
a year. The father also revealed he was embarrassed
4 p$ }. Y" Y* o! Bto disclose that he was using a testosterone gel pre-- G" ~3 U: A% D6 \( q
scribed by his family physician for decreased libido
/ Q' I* @4 T/ s7 [  ssecondary to depression.
2 Y6 b% x( j3 B& W( Z9 EThe child slept in the same bed with parents.
/ j* K2 g# D  s, z' m: \The father would hug the baby and hold him on his
% o$ p3 U) W! o4 w6 A; N) Mchest for a considerable period of time, causing sig-3 L0 C4 X& T# {
nificant bare skin contact between baby and father.* M5 l$ Z% J! A$ {0 S& J# ]
The father also admitted that after the phone call,$ S# z! o0 |8 C9 V
when he learned the testosterone level in the baby
$ I: U: L& y6 f$ ]( T! |was high, he then read the product information. {: b! C3 H8 X+ K" @! B. n9 P
packet and concluded that it was most likely the rea-
2 X. T8 |" n  |: f( {  x" Oson for the child’s virilization. At that time, they
% {9 N% B& J2 Z; Wdecided to put the baby in a separate bed, and the( X( X2 v$ K1 Y7 l
father was not hugging him with bare skin and had
1 z5 Z6 J) V$ obeen using protective clothing. A repeat testosterone1 v% y; R; F# d( \
test was ordered, but the family did not go to the& D4 Z; r2 n9 b+ t6 E( n* v
laboratory to obtain the test.0 X2 Z' |+ @/ Y$ ^6 Z
Discussion
% ~: U1 u; }) ?Precocious puberty in boys is defined as secondary: |. ~+ n  F0 ]6 `1 S
sexual development before 9 years of age.1,4
# p* f1 _  ?# W" J+ K* gPrecocious puberty is termed as central (true) when
$ O. S& v1 U. M+ q5 Wit is caused by the premature activation of hypo-
7 p5 C4 R3 ~+ a" n- o0 X: N! t) W/ fthalamic pituitary gonadal axis. CPP is more com-
: f' s; @: @6 d6 S6 v0 q6 Umon in girls than in boys.1,3 Most boys with CPP
3 |! k) {, i/ ~0 h0 j$ Hmay have a central nervous system lesion that is
* O& r( U7 O" f* Y6 A9 \) [" yresponsible for the early activation of the hypothal-4 X$ L( }4 Z; ~! N  a
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 y1 t4 F) B5 ]0 t  x3 h8 bsis has been given to neuroradiologic imaging in
; ^+ l4 B& O1 X/ i1 x# w: T. m* mboys with precocious puberty. In addition to viril-9 {# t8 Y) M- A' k/ @6 j
ization, the clinical hallmark of CPP is the symmet-
. o% _) m$ j6 d! t: y4 u8 Orical testicular growth secondary to stimulation by
: c) R/ T4 b3 R8 k/ Igonadotropins.1,3
7 n- Q: a, w' W7 j3 W# J' D* ^- ^0 CGonadotropin-independent peripheral preco-
7 q: |6 {  v0 }5 W2 j$ K$ P, k; j! ccious puberty in boys also results from inappropriate
1 ~( M% m+ C( Y% o; p9 ?1 j% g) R$ ^androgenic stimulation from either endogenous or& b! d* S6 A& d% t: ]0 H$ S
exogenous sources, nonpituitary gonadotropin stim-% G3 Q; y' W# Q. c' D
ulation, and rare activating mutations.3 Virilizing
, G7 A8 O1 B& `, ycongenital adrenal hyperplasia producing excessive  f9 v/ u& h3 L
adrenal androgens is a common cause of precocious
5 G4 i8 A9 o" B% e6 xpuberty in boys.3,4$ {* k( ~* F0 h  ?& w4 i) _$ f
The most common form of congenital adrenal
/ A7 Q/ k# h( r" Y! H3 W8 fhyperplasia is the 21-hydroxylase enzyme deficiency.
& ^: d$ l1 R( b5 X8 ?* pThe 11-β hydroxylase deficiency may also result in
# y0 f# v3 ^" j4 @+ X, f/ n) ]excessive adrenal androgen production, and rarely,; E8 r; z: e- x) o
an adrenal tumor may also cause adrenal androgen
. q6 B! ]2 d2 H# X" f/ t# k1 rexcess.1,3; t( C0 [3 ?' f% ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; R- i! `' v- z$ r' w542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 M# U4 I7 Z7 B
A unique entity of male-limited gonadotropin-2 k6 u1 I8 @& H$ [* I6 M9 k
independent precocious puberty, which is also known
+ {& h( A# a- E, Kas testotoxicosis, may cause precocious puberty at a5 i4 q1 J; ?4 s+ d. J* U$ A
very young age. The physical findings in these boys
1 v- S9 K& e: ]; r; s7 j) ?2 n8 iwith this disorder are full pubertal development,7 c4 P: ^1 ~) X/ P* _
including bilateral testicular growth, similar to boys% m! k" P: B7 R) M, S
with CPP. The gonadotropin levels in this disorder% F4 r# [& d* s
are suppressed to prepubertal levels and do not show
$ z) h) ?0 e9 D/ Apubertal response of gonadotropin after gonadotropin-
6 t, V' w, Z) P7 ]% xreleasing hormone stimulation. This is a sex-linked
! I4 T2 N9 P8 [* V) U4 Uautosomal dominant disorder that affects only
, _1 o, r5 {3 d# umales; therefore, other male members of the family& d6 v8 h  Q! B! T0 f
may have similar precocious puberty.3
9 [- z+ @% V- ^# J, [' vIn our patient, physical examination was incon-
" `. Y4 j0 O: o1 t; ]6 `* Vsistent with true precocious puberty since his testi-
& d: M# N; w" A  wcles were prepubertal in size. However, testotoxicosis
$ p7 ^7 ^. a' j6 ]# `was in the differential diagnosis because his father; N7 _+ z, ]. e. y
started puberty somewhat early, and occasionally,
3 U, K1 W+ D7 g) I0 _testicular enlargement is not that evident in the( R9 r% T; m- m5 O+ L' N
beginning of this process.1 In the absence of a neg-. t* d1 |( K' S: W1 \. Z' W+ J
ative initial history of androgen exposure, our9 o5 E  k8 ^1 ]7 n& R
biggest concern was virilizing adrenal hyperplasia,( j9 v+ q# X8 P
either 21-hydroxylase deficiency or 11-β hydroxylase
7 c6 }# g6 s, b$ ?% b, q+ Mdeficiency. Those diagnoses were excluded by find-/ s4 x9 ^2 P1 _/ k8 _: S
ing the normal level of adrenal steroids.
, ?0 c; v5 |! |, g2 t7 EThe diagnosis of exogenous androgens was strongly  F( U6 F, j- B7 a
suspected in a follow-up visit after 4 months because
) M4 M. `- v2 g0 S4 ~the physical examination revealed the complete disap-
7 I, z) ^0 q. ^+ u1 `% {pearance of pubic hair, normal growth velocity, and
6 g! s& R* l* S' f% Ndecreased erections. The father admitted using a testos-
8 S2 q6 \: B; M: B7 }  ]. Fterone gel, which he concealed at first visit. He was
/ G: }2 _0 y5 v7 k/ N7 Vusing it rather frequently, twice a day. The Physicians’
* u) p: V; O7 K: @  l8 h$ kDesk Reference, or package insert of this product, gel or8 u* N- z4 g9 x  l7 j
cream, cautions about dermal testosterone transfer to
+ W$ Z; j6 z6 U" A. eunprotected females through direct skin exposure.+ O. a6 u2 j0 c. Z6 L
Serum testosterone level was found to be 2 times the
  V' z3 T" i5 x; w# }$ ]; lbaseline value in those females who were exposed to! `3 k: E6 r; F- [* U9 H
even 15 minutes of direct skin contact with their male
  A* v: c* o0 T% m. W- {partners.6 However, when a shirt covered the applica-. v; F- |. R1 C, R& p& E
tion site, this testosterone transfer was prevented.3 x% X0 n- K2 a1 ?& E$ c
Our patient’s testosterone level was 60 ng/mL,; ?7 t$ F/ c* B# \- d  K) [
which was clearly high. Some studies suggest that0 ]( w- {5 |* o; d
dermal conversion of testosterone to dihydrotestos-
6 k( C. z; k3 b' w: d7 w) C7 Pterone, which is a more potent metabolite, is more
8 i# ?7 |4 ]  M) `7 Jactive in young children exposed to testosterone
6 o0 r; _& y5 j2 texogenously7; however, we did not measure a dihy-
5 g( @+ s! T# }+ f& e( ddrotestosterone level in our patient. In addition to* X; j7 A" c- s( v2 ?2 W+ X
virilization, exposure to exogenous testosterone in4 g4 n- o1 i- U4 v* S
children results in an increase in growth velocity and
8 J# R6 Q9 n- }$ M; padvanced bone age, as seen in our patient.$ [2 T$ E$ P$ D" I% a5 l% y( p
The long-term effect of androgen exposure during/ N7 D5 B7 V+ F
early childhood on pubertal development and final
2 ^6 {& Q. W5 `& n' P9 s1 O! a0 Eadult height are not fully known and always remain
1 ~4 e  F5 d/ S2 y, ]" ka concern. Children treated with short-term testos-
9 J0 g' t* L/ N/ V4 Xterone injection or topical androgen may exhibit some
5 o8 k7 U% r( w' p, Cacceleration of the skeletal maturation; however, after
3 f* Y' X2 b5 ucessation of treatment, the rate of bone maturation& C; Z; X; N/ H2 {% L' `" M5 V
decelerates and gradually returns to normal.8,90 g- S$ B! I) Q' w+ L  H) a% Z
There are conflicting reports and controversy) I) q) J. I8 k$ I: A
over the effect of early androgen exposure on adult/ W8 W! [- m2 H0 `, L: t. V
penile length.10,11 Some reports suggest subnormal
' T! _& x* r* W7 }! ~9 c6 ^# vadult penile length, apparently because of downreg-
: E7 F/ V& t" Kulation of androgen receptor number.10,12 However,, @. [, F: q! l8 Y8 @) S
Sutherland et al13 did not find a correlation between1 h: D  K9 z8 y- \- J8 w/ p( M! U
childhood testosterone exposure and reduced adult
3 M6 N8 {4 c6 t5 A, R9 u. Openile length in clinical studies.
% p( D! d1 ?! |+ z# SNonetheless, we do not believe our patient is
* Q3 C+ J' u. ~( U$ Qgoing to experience any of the untoward effects from& T" N" t& h' C$ ]; i
testosterone exposure as mentioned earlier because
! u& h+ e, o3 ]" [the exposure was not for a prolonged period of time.4 c$ [# e6 H, k/ u8 b: ]4 T9 W
Although the bone age was advanced at the time of
6 Y' t0 _4 R9 L9 O5 O7 Ydiagnosis, the child had a normal growth velocity at
) F% f5 o# _9 h+ E( A) u1 g9 [the follow-up visit. It is hoped that his final adult
) R" l! Y/ g& }: qheight will not be affected.4 F7 d- z5 K# L# Z: T
Although rarely reported, the widespread avail-! l0 H! \1 [# g$ g( c, d7 G
ability of androgen products in our society may3 D( Q6 Z$ ]( ~  w3 k, ~/ B' G
indeed cause more virilization in male or female7 r2 N# [5 M: q% [& u# T, m$ W
children than one would realize. Exposure to andro-
1 R' Y- J3 w+ S+ P) J; `. G5 zgen products must be considered and specific ques-
% ^; A% E. C' L$ ]$ vtioning about the use of a testosterone product or
/ o. M! W6 Q1 z) ~8 ygel should be asked of the family members during7 y: L2 ^; c* Y
the evaluation of any children who present with vir-
: k. K& ^6 c) m9 L, A/ m+ Rilization or peripheral precocious puberty. The diag-
9 b  z! j& ~; Rnosis can be established by just a few tests and by
& K: f' d. [1 _" Q5 ]appropriate history. The inability to obtain such a
4 k! s6 i& `# ?" i$ d; {history, or failure to ask the specific questions, may
+ p5 z/ ]/ `& @' |3 dresult in extensive, unnecessary, and expensive( z1 v, X  |7 D" M7 U
investigation. The primary care physician should be4 }/ L& w/ ?* N% [& c1 h& t
aware of this fact, because most of these children. R2 |: {, Z" |, M0 m
may initially present in their practice. The Physicians’$ M7 L) {' K( _9 q
Desk Reference and package insert should also put a2 c+ Y6 L& M& \/ h9 y
warning about the virilizing effect on a male or* g/ E6 j/ E3 f# E) z7 e
female child who might come in contact with some-6 M/ B$ u+ Q5 X5 Y; w& T$ Y, K6 X
one using any of these products.
( x0 `% R% Z, MReferences( B' C( m* c" I
1. Styne DM. The testes: disorder of sexual differentiation
& z2 ]. C, F/ U* eand puberty in the male. In: Sperling MA, ed. Pediatric
, T8 `7 t" D$ s( `/ ~+ ~% DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 }: |2 r$ f/ F$ h0 \
2002: 565-628.( X6 F  S$ G( k$ z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* a1 z  K3 i0 N3 a6 j# wpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
" a. B7 L) M' v- a# ~6 S" p
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