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( o# I0 w9 W" }# U4 m* i. o
Boy Induced by Indirect Topical
3 S* G8 M: M. {% GExposure to Testosterone
7 }: D" }( A4 l" L& TSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ C0 J; v7 U! t9 l
and Kenneth R. Rettig, MD1
8 a) H" Y7 w) R8 o) a4 {) sClinical Pediatrics* ?) F. }3 Y- X+ O
Volume 46 Number 65 i+ ?% Z! _+ }6 W; |" h( n
July 2007 540-5435 B2 G5 O* k1 S7 Q1 ?/ M5 l
© 2007 Sage Publications2 a0 F) ?* Z6 }( F
10.1177/0009922806296651
0 M) s' W& C9 m0 A+ w$ ghttp://clp.sagepub.com
0 m- [: T' \& b3 f; M: qhosted at
( C& _5 q$ V) B0 B' _1 e* m& Chttp://online.sagepub.com$ d9 h5 V, ]  x
Precocious puberty in boys, central or peripheral,
3 b4 E8 P0 d& |4 Z! Kis a significant concern for physicians. Central
6 x3 R# P: m& g  K5 G8 @; g4 \9 Fprecocious puberty (CPP), which is mediated" x- p  ?" G7 U/ N& T7 g
through the hypothalamic pituitary gonadal axis, has
% r: t; S5 r% C* Za higher incidence of organic central nervous system/ `. a, d8 ^+ e$ ~3 z
lesions in boys.1,2 Virilization in boys, as manifested7 @9 E; w+ l8 p0 p  B& c
by enlargement of the penis, development of pubic  d! c/ ^9 K: e/ o+ C* v3 Y
hair, and facial acne without enlargement of testi-
' l- @1 O. ]% K0 q2 hcles, suggests peripheral or pseudopuberty.1-3 We
8 U1 \1 q9 o; p& q+ M( B( G' v% Oreport a 16-month-old boy who presented with the, ^- ?+ [* O/ H- w
enlargement of the phallus and pubic hair develop-
0 [. x0 T+ T* ^4 y! d- n, ^ment without testicular enlargement, which was due. H, A, @: b2 U1 {  R( H" L
to the unintentional exposure to androgen gel used by, P( v4 L8 @9 e9 k7 C7 V  U, ^' O
the father. The family initially concealed this infor-
' z$ e* Q! Q1 z7 D2 A- O9 Wmation, resulting in an extensive work-up for this
9 }# o& [  G% m, [child. Given the widespread and easy availability of3 w: U$ i" x3 U: o; z" E3 B
testosterone gel and cream, we believe this is proba-
9 |! F% j9 O! o7 b: rbly more common than the rare case report in the
4 R$ _1 R" q9 b. V$ Xliterature.4
/ A' @+ F3 `" a4 g2 A, K) ~Patient Report9 G. R' }# v; Y- H$ d
A 16-month-old white child was referred to the
. ?0 z- _; v* a  Yendocrine clinic by his pediatrician with the concern
" b+ k  g/ K+ {# Lof early sexual development. His mother noticed
8 r2 f6 U% w; \9 b' Alight colored pubic hair development when he was# K' N  z9 Z8 |
From the 1Division of Pediatric Endocrinology, 2University of# K  T5 V( e6 B( F3 ^. i# D
South Alabama Medical Center, Mobile, Alabama.
' S2 M. C, L- |4 u& bAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 {$ M- e- k* \3 c+ bProfessor of Pediatrics, University of South Alabama, College of1 P0 y/ e- E. P- t5 V- l) m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 n% c- q6 `6 m' g
e-mail: [email protected].
( I' x+ C* y9 y: c5 |: ]& o; nabout 6 to 7 months old, which progressively became( a. W, R6 @# q( |% ]; a
darker. She was also concerned about the enlarge-
. ^9 w' p) K1 F; ]! o# u9 `ment of his penis and frequent erections. The child  }0 q% q2 S* i' L3 j8 T
was the product of a full-term normal delivery, with% _) ^, x( S2 k: S& W4 b
a birth weight of 7 lb 14 oz, and birth length of
( X0 d0 b0 F: P( J! `20 inches. He was breast-fed throughout the first year
* T& Z3 T8 {! t0 q/ {  X4 Tof life and was still receiving breast milk along with( M" Z5 t8 S5 e; d- k: l
solid food. He had no hospitalizations or surgery,
% w" X  A, ]1 Jand his psychosocial and psychomotor development
0 x& ]$ a5 t+ }+ F& Y, Cwas age appropriate.
. b/ }6 \7 l) E- }+ N# [: H$ u& sThe family history was remarkable for the father,
; K; d4 I7 H* I. w: h; X* Uwho was diagnosed with hypothyroidism at age 16,  U: o$ d' K' ?! j; `. [8 e  C1 ?
which was treated with thyroxine. The father’s
9 C" Y) l  c5 C& s0 jheight was 6 feet, and he went through a somewhat
; F: e; l# Q% s  l" Eearly puberty and had stopped growing by age 14.% C+ m1 y, Q( p  N; K9 G" F
The father denied taking any other medication. The& z: @4 c4 k0 A& ?( y- Q8 ~
child’s mother was in good health. Her menarche! S9 M8 I. K1 a7 ]! R
was at 11 years of age, and her height was at 5 feet7 m( ^% g; E% `
5 inches. There was no other family history of pre-
. K% V0 E. r3 ?8 N8 R. ecocious sexual development in the first-degree rela-
: \1 U3 l2 o3 a% Q8 F% }tives. There were no siblings.- L8 e9 ?. b2 Z( I; y
Physical Examination: n; [& R( m! V5 ?7 x0 r
The physical examination revealed a very active,
5 C; o. V0 j, ^playful, and healthy boy. The vital signs documented
" _5 I: M' ~' P' Ua blood pressure of 85/50 mm Hg, his length was
9 x! [( j; ?% }  A+ U4 H6 K+ [90 cm (>97th percentile), and his weight was 14.4 kg! U7 z# l: R  h. ]3 n
(also >97th percentile). The observed yearly growth
& y# X1 `: t/ X$ ~$ Qvelocity was 30 cm (12 inches). The examination of
; G. X. v) @6 v# |5 i% \2 Qthe neck revealed no thyroid enlargement.
5 K! {0 a; w! y! VThe genitourinary examination was remarkable for$ f2 c$ x) ~' ~8 T& n7 z
enlargement of the penis, with a stretched length of
$ f  b( q6 ?& J$ P8 cm and a width of 2 cm. The glans penis was very well) y( Y, o7 L, `5 e+ B/ e  s
developed. The pubic hair was Tanner II, mostly around: ]4 X0 X' R. Y& w
540: D+ u3 e% z$ N. ^7 n/ s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% t7 @, l& X! F, {% b$ N* R0 zthe base of the phallus and was dark and curled. The
1 Y1 b; T! s1 d9 H  w1 ctesticular volume was prepubertal at 2 mL each.
( A& n7 u" O' e0 s$ T+ }0 |7 p" e# YThe skin was moist and smooth and somewhat4 M$ ^8 k1 U. e& J
oily. No axillary hair was noted. There were no
: ]0 o- v6 z3 `$ Z+ ]abnormal skin pigmentations or café-au-lait spots.4 b4 a- b* Z$ k: o2 C8 H& ~/ s5 u
Neurologic evaluation showed deep tendon reflex 2+0 G/ Q0 R7 s; L1 ^6 U4 v
bilateral and symmetrical. There was no suggestion$ `/ t* i1 O6 K& C. M
of papilledema.4 O7 a2 c& D( ?3 j+ X. Y
Laboratory Evaluation# Y$ ?; X3 t& N0 Q. c
The bone age was consistent with 28 months by
7 T% P, ]3 Y8 t: k8 gusing the standard of Greulich and Pyle at a chrono-
7 p5 Y( i& N6 l$ }logic age of 16 months (advanced).5 Chromosomal0 H- H& G9 u' _
karyotype was 46XY. The thyroid function test
! T, n1 M+ ^3 ~) m; T4 P- fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 F) m) _: p* b9 Clating hormone level was 1.3 µIU/mL (both normal).
5 \/ G7 r! v/ ~The concentrations of serum electrolytes, blood
5 |2 \+ S' `& G1 Murea nitrogen, creatinine, and calcium all were4 j7 k% G8 f* z0 t2 K6 H/ q: @
within normal range for his age. The concentration* n2 h: A8 X) {" B; c
of serum 17-hydroxyprogesterone was 16 ng/dL
0 d3 {" z, w- o4 a* R(normal, 3 to 90 ng/dL), androstenedione was 20' w6 W0 }. E( \  Y# h! k- k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( l5 _$ ?2 A+ \  Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ U( l$ m. ]$ b4 q3 s( Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  D* Y; _1 x" A0 r49ng/dL), 11-desoxycortisol (specific compound S); j6 o2 w* Z/ b! E" j& g* A9 T/ T6 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* T6 U& N; ]0 r6 @4 u. O8 O: o( xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ i! z. `+ ?' t' B' y5 U# E8 U( n  l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 @1 o7 X' ]5 Q, o- F+ @( a. @and β-human chorionic gonadotropin was less than3 {+ i# z/ ^' e" A3 K% [+ d
5 mIU/mL (normal <5 mIU/mL). Serum follicular  y2 A) j' k8 W/ E9 \9 O8 ?
stimulating hormone and leuteinizing hormone( f5 V( a1 A  @
concentrations were less than 0.05 mIU/mL
6 ^- p3 P$ ]" m7 }& |(prepubertal).
) \; F% E; u* M+ x0 v# x/ YThe parents were notified about the laboratory# F4 j$ ^3 D2 y6 y
results and were informed that all of the tests were% G+ w2 f# w4 P6 M
normal except the testosterone level was high. The
3 g- \" A; T2 K, B  C! Jfollow-up visit was arranged within a few weeks to# W. x* z6 T' U* T2 Z9 W4 n5 M  T
obtain testicular and abdominal sonograms; how-
$ V; y( ]! T) ~- y  I% Eever, the family did not return for 4 months.8 ~1 _+ ?9 h# _# f: N
Physical examination at this time revealed that the
2 X. y! ^0 U  lchild had grown 2.5 cm in 4 months and had gained
4 E& u: g2 N) V3 ]2 kg of weight. Physical examination remained5 v7 w+ Z* j+ I6 I
unchanged. Surprisingly, the pubic hair almost com-
4 o0 j! d( m% @* xpletely disappeared except for a few vellous hairs at
$ Z8 s: V3 K! J8 E4 S* V$ nthe base of the phallus. Testicular volume was still 2' S4 a& L" U/ N% ~, \
mL, and the size of the penis remained unchanged.. D6 q$ R$ }& }0 L  r7 Q! k
The mother also said that the boy was no longer hav-
/ X, S( G# r5 r4 ]* U' E' ]ing frequent erections.- z7 L$ R% b: e, Q; `
Both parents were again questioned about use of
; G/ Q3 ?/ S( A( A" D1 Lany ointment/creams that they may have applied to5 z' k. ~7 W8 U
the child’s skin. This time the father admitted the
" U& _# j/ Y$ GTopical Testosterone Exposure / Bhowmick et al 541+ X" ]8 z( q8 b% K" ]5 ]
use of testosterone gel twice daily that he was apply-8 \1 A* s9 K- k% q
ing over his own shoulders, chest, and back area for
: r- D5 h- Z+ N6 j* n+ a, [a year. The father also revealed he was embarrassed+ t4 \: g* o; M) D* l' Q1 E) J& P; }
to disclose that he was using a testosterone gel pre-. T7 Z% F& h- ]9 M% I* f
scribed by his family physician for decreased libido, n% r, h) F* C
secondary to depression.+ W/ B3 g5 s# z2 _" a, q% h
The child slept in the same bed with parents.
& [5 r( @5 m' B4 [+ Y% IThe father would hug the baby and hold him on his
7 @  d! Y* X1 Q  L) A, schest for a considerable period of time, causing sig-
- b% p) v; Z5 ~# F: \nificant bare skin contact between baby and father." U8 o% V$ i/ S/ C0 z+ c
The father also admitted that after the phone call,
+ y) R( U: r: Q+ v5 m& u, twhen he learned the testosterone level in the baby' h  A. o. u* I, u
was high, he then read the product information3 N7 k1 R. o0 p4 m
packet and concluded that it was most likely the rea-
; O4 t0 ^, \2 [( ]$ @son for the child’s virilization. At that time, they
8 h5 t9 j1 s9 G- m+ [, Ddecided to put the baby in a separate bed, and the
& u/ Y* M5 h, o# Yfather was not hugging him with bare skin and had' Q/ B  J! G$ l* u$ ]) e
been using protective clothing. A repeat testosterone9 k' t: V3 e9 D. D) B# L$ n  n- T
test was ordered, but the family did not go to the- G% \0 `9 x  g
laboratory to obtain the test.
' B/ L+ r2 \! n7 X$ @1 EDiscussion
3 y* p, Y/ x0 ^1 Z+ m# A; TPrecocious puberty in boys is defined as secondary8 N7 k& ^, w! Z9 R% X5 i3 q
sexual development before 9 years of age.1,4
" C+ \9 |1 O+ u& ?Precocious puberty is termed as central (true) when3 d& z1 U( \2 B* Y; Q' s
it is caused by the premature activation of hypo-' O" l% P0 c0 O" J( Q. x
thalamic pituitary gonadal axis. CPP is more com-" u8 Q( @, H" I2 s
mon in girls than in boys.1,3 Most boys with CPP
2 d( r* b' E2 z; p* r; S8 Q2 Zmay have a central nervous system lesion that is
3 ?- u7 v$ Y( l) H2 Nresponsible for the early activation of the hypothal-- x! ?) f! k: ]; [1 x  D
amic pituitary gonadal axis.1-3 Thus, greater empha-1 V9 M- I6 s5 I* V+ [2 t/ g
sis has been given to neuroradiologic imaging in
5 N5 V+ g1 X" L! Vboys with precocious puberty. In addition to viril-
2 E" T5 Q2 i0 i. u9 o, sization, the clinical hallmark of CPP is the symmet-3 G( n2 {9 W6 s5 H# e( S% Y! Z; J
rical testicular growth secondary to stimulation by
# f" F% b) o/ q* Ngonadotropins.1,3
9 D( |! [) |! Z3 A' HGonadotropin-independent peripheral preco-
3 Y) H$ a* s& u) @9 }, s1 a7 x; `1 Hcious puberty in boys also results from inappropriate; ~! E, u% p: N3 R6 P' \0 y7 q
androgenic stimulation from either endogenous or/ L* R% Z% l& [: y0 ?& q
exogenous sources, nonpituitary gonadotropin stim-
. Y3 [5 O2 }$ X+ ?8 K8 Y3 Iulation, and rare activating mutations.3 Virilizing( G! K. {, w' o/ ?+ @
congenital adrenal hyperplasia producing excessive4 Z8 ^- U% h  N5 i, {% U) w2 {
adrenal androgens is a common cause of precocious
8 H5 \* D; Z' C& o/ b( npuberty in boys.3,4
4 ]- u  }8 q. S! b& {The most common form of congenital adrenal
: f% {1 J  H7 }$ Z9 @+ z: \: q. b8 Phyperplasia is the 21-hydroxylase enzyme deficiency.
: p0 u7 j1 O+ x3 Q3 v+ TThe 11-β hydroxylase deficiency may also result in) e# J5 `" I# t
excessive adrenal androgen production, and rarely,5 O% T, J* ^, h
an adrenal tumor may also cause adrenal androgen
: ?. J3 r1 r/ u3 V( J& T6 P6 T& eexcess.1,36 L4 {7 p+ T& W) B, W/ j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' G% }3 }9 }' x# z# x* s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% N) Q. Z+ d# X" ~+ p
A unique entity of male-limited gonadotropin-
) D2 I4 T. j5 C' ?! J6 Cindependent precocious puberty, which is also known$ f, l  Y9 j0 W
as testotoxicosis, may cause precocious puberty at a
7 j$ u# i# I! {/ jvery young age. The physical findings in these boys
$ \* T5 q: [- g' d1 z' Hwith this disorder are full pubertal development,
9 V+ F; ?5 P9 O9 b  |- M$ Rincluding bilateral testicular growth, similar to boys$ t. [; L: P( l! q$ {
with CPP. The gonadotropin levels in this disorder
) v7 N5 m5 |* @are suppressed to prepubertal levels and do not show6 p& K" l- k. a. }3 w/ K
pubertal response of gonadotropin after gonadotropin-6 T3 h  [: G4 h/ V' t7 O" h5 A
releasing hormone stimulation. This is a sex-linked
% |* F& Q; ?, \$ ~autosomal dominant disorder that affects only
0 I* p0 O1 `; |. x3 H: v8 m+ k$ Qmales; therefore, other male members of the family
7 Z! E- c3 G" u5 k- umay have similar precocious puberty.36 R" @# N/ J/ @4 q- m- @" l+ B
In our patient, physical examination was incon-. G/ w7 j) p0 y
sistent with true precocious puberty since his testi-# r" p8 W6 ^8 j# w, P% T* j
cles were prepubertal in size. However, testotoxicosis: ]7 {3 ^% p& o, b+ c9 l
was in the differential diagnosis because his father2 S( j* E% {' B7 s5 |
started puberty somewhat early, and occasionally,# o5 ~! i' ?: W) j% C1 w
testicular enlargement is not that evident in the/ b7 H; P* ^7 f- [5 }0 q
beginning of this process.1 In the absence of a neg-
% D9 V! s+ l# Q/ M' Gative initial history of androgen exposure, our; R( \$ Q% R, S% G
biggest concern was virilizing adrenal hyperplasia,9 q! e& Z  V% s! R# ]- \
either 21-hydroxylase deficiency or 11-β hydroxylase
4 q3 \: S; r; u5 j- W* I& Qdeficiency. Those diagnoses were excluded by find-! r- h& z" h) o/ i& C1 E
ing the normal level of adrenal steroids.1 `( Z' {! X; X* |. c& y* Z0 }
The diagnosis of exogenous androgens was strongly
% f( d; h, q& Z  C: }' H! |# Osuspected in a follow-up visit after 4 months because
) w) P; q1 Y/ u& P, [" }5 pthe physical examination revealed the complete disap-, d7 Z  m8 `0 J* m; d
pearance of pubic hair, normal growth velocity, and
$ I3 d$ l7 W  M% |( x- \* vdecreased erections. The father admitted using a testos-
2 ^! K* W' d* F5 H6 xterone gel, which he concealed at first visit. He was$ j8 d7 Q4 m% a. ~, Q2 o
using it rather frequently, twice a day. The Physicians’
0 Q( K' K/ C: J5 [7 m  `0 B5 hDesk Reference, or package insert of this product, gel or
1 g& h( S6 h( A2 _* L9 \0 dcream, cautions about dermal testosterone transfer to+ f. k* D/ P. o+ {' t
unprotected females through direct skin exposure.* I: o% n( N& n+ H/ l
Serum testosterone level was found to be 2 times the% b# i8 Q4 e& s2 |; z
baseline value in those females who were exposed to
* w5 X( b5 p. h: b; ~4 S6 Veven 15 minutes of direct skin contact with their male1 I; u8 H* \& k
partners.6 However, when a shirt covered the applica-  }) K$ D% T& v: B: }* l
tion site, this testosterone transfer was prevented.
! M8 b' C) Z' F9 ^2 W& QOur patient’s testosterone level was 60 ng/mL,. r, B! V( k, Y# g$ A
which was clearly high. Some studies suggest that
& N% U/ o9 W; M9 R& N- Tdermal conversion of testosterone to dihydrotestos-
' p7 i. j& o" E0 d1 P% K- s8 }terone, which is a more potent metabolite, is more
& C7 P/ v( O  v  w0 b4 Z/ Qactive in young children exposed to testosterone. d9 g; I* G1 a3 w/ i+ b
exogenously7; however, we did not measure a dihy-( i% i$ v' H7 {1 X- m
drotestosterone level in our patient. In addition to( g8 J2 g# `3 ~" g' Y
virilization, exposure to exogenous testosterone in
$ {4 W; U+ q+ Z/ Hchildren results in an increase in growth velocity and8 T) i! G5 }; p) Z
advanced bone age, as seen in our patient.( b3 m; k/ L8 U1 H9 Y2 g
The long-term effect of androgen exposure during8 w" a& ~; ~3 ?
early childhood on pubertal development and final* S( {" A2 D, `. J
adult height are not fully known and always remain
' Y# t" B5 [- J' ha concern. Children treated with short-term testos-' Z  ^7 T4 `4 L1 X' L& p
terone injection or topical androgen may exhibit some' M9 O* X( H. E( W7 {6 z' E6 F1 U
acceleration of the skeletal maturation; however, after1 p; T4 u+ E( Q' Q
cessation of treatment, the rate of bone maturation  `3 \6 r8 |8 |0 C3 L
decelerates and gradually returns to normal.8,99 Y: }7 q& S3 W9 b, t" F
There are conflicting reports and controversy0 |5 K1 s: J9 P* @1 w& V! }
over the effect of early androgen exposure on adult) R  |1 ~6 |( B" w
penile length.10,11 Some reports suggest subnormal
  c8 Z3 U2 m5 N; B9 g- xadult penile length, apparently because of downreg-; J5 n7 T$ O% v9 ]7 R+ n5 N; J
ulation of androgen receptor number.10,12 However,3 a5 x2 K0 J/ @* `; i
Sutherland et al13 did not find a correlation between$ c' H4 c! [1 z$ B+ u6 X+ c8 j
childhood testosterone exposure and reduced adult" v6 }, Z' y2 \, V9 e
penile length in clinical studies.
- a+ C1 b( ?( n& t0 z0 d: d2 TNonetheless, we do not believe our patient is
0 z8 s, m* b; C# I- }9 Jgoing to experience any of the untoward effects from, j8 r; ]* c! a1 j5 V; {+ Y
testosterone exposure as mentioned earlier because
) f6 g! i1 K3 u. |( j2 zthe exposure was not for a prolonged period of time.
# @. v! o" r& q; [  lAlthough the bone age was advanced at the time of( E2 G* U: w. u8 ]: m* ]
diagnosis, the child had a normal growth velocity at
  O  e6 g' ], Y7 Kthe follow-up visit. It is hoped that his final adult
# o8 o4 Q" [3 h& d- m9 `7 y( theight will not be affected.
" u: }7 ?1 C$ T! v/ }5 y* _8 s( lAlthough rarely reported, the widespread avail-9 ?7 }. l9 F# A3 s/ R* b" t
ability of androgen products in our society may' I/ f3 E% z8 R8 o% O
indeed cause more virilization in male or female: B  s7 ?1 w8 R; a+ Y
children than one would realize. Exposure to andro-$ o* d/ n5 o, g' \5 Y1 v
gen products must be considered and specific ques-# o  P2 b  T+ z' q
tioning about the use of a testosterone product or3 x/ Z. J/ K8 j) y
gel should be asked of the family members during
7 [/ ?4 r2 j5 ?the evaluation of any children who present with vir-( y/ w. B3 w. N$ l7 }# F1 a+ m6 v& F& ~
ilization or peripheral precocious puberty. The diag-* _9 x) {: A) r* f, i
nosis can be established by just a few tests and by0 H0 t- L$ `/ H# I' U
appropriate history. The inability to obtain such a8 R& ~0 G, c& R# v. C1 i: l
history, or failure to ask the specific questions, may
- X6 c* m2 S; x/ L- P' Tresult in extensive, unnecessary, and expensive9 [3 d6 b0 Q4 C8 m2 u
investigation. The primary care physician should be; f$ j2 x5 e- x3 w
aware of this fact, because most of these children
; m0 |% X8 @. U( d# {/ s( }may initially present in their practice. The Physicians’
: |- X' y4 F$ H# H9 XDesk Reference and package insert should also put a6 {5 O5 [* Q  G+ `$ S+ l9 R1 }
warning about the virilizing effect on a male or
2 d7 \+ P& o' O" b/ s# J4 s2 Jfemale child who might come in contact with some-% g+ ~6 `( h, x& O  V; e* r8 e
one using any of these products.2 ^. @6 x# B: {: E7 {" K7 u* n
References
  O" \. l. O# |5 g. m# c5 B1. Styne DM. The testes: disorder of sexual differentiation
% t  e+ P. y% u3 ^) H0 f1 Hand puberty in the male. In: Sperling MA, ed. Pediatric
7 }: D. \! ^: f6 p  AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& [$ O0 p, s: D  S
2002: 565-628.& N! d% W" R% r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 ]2 h: s+ g: f9 P
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-Old6 k/ d2 z" ?' ~! I6 L( t4 {
Boy Induced by Indirect Topical
8 U) ^$ x6 C( v! L. m' b6 F& JExposure to Testosterone
# ^/ t* X  Q+ x" o! ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* U( O( `$ _% W: d# Qand Kenneth R. Rettig, MD1+ x  ?' M" Y( q4 z1 F" h
Clinical Pediatrics
! _+ Q/ W$ C( b6 q: o1 A+ TVolume 46 Number 6: ^5 \3 \9 b0 }
July 2007 540-543* Z% _" ]5 _8 P4 U3 s/ a
© 2007 Sage Publications4 g. U7 d% Y; s9 M
10.1177/0009922806296651
  U" @: A* i4 x$ ^7 o& zhttp://clp.sagepub.com
( ]; O, K$ c9 ]1 B0 f  Z( K- Vhosted at! Q. D, T) p) P" Y7 _: c6 @
http://online.sagepub.com2 ^7 K1 ?. W* i: ?
Precocious puberty in boys, central or peripheral,! N0 e" n6 y9 G& s
is a significant concern for physicians. Central- r# ~+ L: w# k! b
precocious puberty (CPP), which is mediated% F7 ]( f- @+ t; Z6 q
through the hypothalamic pituitary gonadal axis, has
! i4 Z% `/ S' W9 B- Pa higher incidence of organic central nervous system
/ P; K$ J2 \* llesions in boys.1,2 Virilization in boys, as manifested6 Q( |# C( n% Z# ~/ U
by enlargement of the penis, development of pubic
, D% K' q( ^. K& v3 Lhair, and facial acne without enlargement of testi-3 ^9 K4 V" O& t
cles, suggests peripheral or pseudopuberty.1-3 We
& ]+ _, B2 q3 R! p8 @: k) P8 Sreport a 16-month-old boy who presented with the
6 n# E3 O, M* Xenlargement of the phallus and pubic hair develop-7 `/ P/ X, m4 m  W8 }' @) O- a
ment without testicular enlargement, which was due
1 ^1 f& c. Q% o& yto the unintentional exposure to androgen gel used by9 I) D+ _  M1 A2 {. ~
the father. The family initially concealed this infor-- Q( t5 ~0 I/ M4 U$ _. C% x9 s* m3 [
mation, resulting in an extensive work-up for this
" M' i8 p0 Q8 f6 e' [child. Given the widespread and easy availability of* X* O: k; Q- N" w8 n0 p" b; V/ m
testosterone gel and cream, we believe this is proba-  f5 p5 g* G7 w3 x5 h( t
bly more common than the rare case report in the! E" ^4 w9 b% @) ?8 c
literature.4
' f  ?3 |% V7 @0 L) q* Z( p) mPatient Report
* t3 t9 ?6 d+ ~3 ^. v# H6 B' _A 16-month-old white child was referred to the* J2 n- R5 c) o7 ~3 e
endocrine clinic by his pediatrician with the concern
  s& ]; ^2 T. A, h; d: b* fof early sexual development. His mother noticed
/ j$ c" _. `' ylight colored pubic hair development when he was1 l+ s) e2 ]4 ?- j! Q" |6 h8 k0 p
From the 1Division of Pediatric Endocrinology, 2University of
: D& @  e( L: V) Y5 d1 `0 \, ISouth Alabama Medical Center, Mobile, Alabama.1 z$ W& A7 l2 u" O' W
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ P* l6 Y+ |% E5 ^) F! D) w
Professor of Pediatrics, University of South Alabama, College of
# f% [9 L9 {- U  i) v$ T3 W8 V2 ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" t1 Z$ T2 M- G" ^# N- E
e-mail: [email protected].
9 H( ~0 ~  X% ?% V- _  u1 ^. xabout 6 to 7 months old, which progressively became
' r+ p; ?( R- m* W5 |darker. She was also concerned about the enlarge-
( K  T5 d7 _! x# F* S! m, \# oment of his penis and frequent erections. The child" e' p" B# z3 `3 n
was the product of a full-term normal delivery, with
7 [! [6 ?4 d, u( I. da birth weight of 7 lb 14 oz, and birth length of
; y% E! m$ W2 w' ?4 j2 ]6 @20 inches. He was breast-fed throughout the first year
8 ]. T( t, v  gof life and was still receiving breast milk along with
  R/ d% n" E# R7 ^solid food. He had no hospitalizations or surgery,; u- m* f2 A; ~2 v' h
and his psychosocial and psychomotor development
0 ~, I7 R! S2 Swas age appropriate.
' `7 M: C; f5 T+ i. ^The family history was remarkable for the father,
0 e/ F7 R& L9 B& q( c; G- Jwho was diagnosed with hypothyroidism at age 16,
6 s" V  W3 X; O  p( P5 V/ S8 jwhich was treated with thyroxine. The father’s
  d2 E9 n. N1 `1 Rheight was 6 feet, and he went through a somewhat
. U1 Q- I& L6 t5 s2 _# e) Oearly puberty and had stopped growing by age 14.
8 d9 u) F  H" t$ i$ h1 h9 R( jThe father denied taking any other medication. The! C" \8 b* w. D- |' S
child’s mother was in good health. Her menarche
# u- P  r. o4 y$ qwas at 11 years of age, and her height was at 5 feet
0 q0 r6 c/ Z7 T/ O5 inches. There was no other family history of pre-
! J% A5 e/ U% Z. @$ P, S9 _cocious sexual development in the first-degree rela-
) I; u0 U. w6 e1 T% i- Q' Ltives. There were no siblings.
* _: {% a. d& W& N" n6 y% cPhysical Examination
1 a! q( b8 E8 V& ~* R$ OThe physical examination revealed a very active,
( [; U( H7 b! w& L$ \playful, and healthy boy. The vital signs documented
9 F" I+ J- n0 a7 Ca blood pressure of 85/50 mm Hg, his length was% C+ y6 h5 d" S  @/ D4 `
90 cm (>97th percentile), and his weight was 14.4 kg
( K: p8 [6 D; |% v(also >97th percentile). The observed yearly growth" ~* S6 Y: O# {/ F7 A) f: l
velocity was 30 cm (12 inches). The examination of; ?0 ^- ^  u* P
the neck revealed no thyroid enlargement., E- n4 d4 z! w* g
The genitourinary examination was remarkable for- W! \6 l# {& i  R6 Z
enlargement of the penis, with a stretched length of
% z3 X( b1 N+ o/ W! g8 cm and a width of 2 cm. The glans penis was very well
: x$ n- m( f% U. G1 \2 M9 C2 Vdeveloped. The pubic hair was Tanner II, mostly around$ ^; W- @6 x9 L9 _0 N/ C
540+ }- p& Z  l3 l; n) R' H9 B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 r! S1 Y, J! K. Y
the base of the phallus and was dark and curled. The, R6 v# M( F- e. l# B
testicular volume was prepubertal at 2 mL each.
1 G2 E. j: A6 B" M* j/ E! {The skin was moist and smooth and somewhat- L7 K, S6 |; C& R' ~
oily. No axillary hair was noted. There were no3 W8 B" r& [/ B# {6 b! M1 O& X
abnormal skin pigmentations or café-au-lait spots.4 V  \$ B8 Y  X7 v& r/ a
Neurologic evaluation showed deep tendon reflex 2+
5 t: s% N7 ], e/ }: w( E) ?bilateral and symmetrical. There was no suggestion
6 J) H& t2 X7 R7 h1 Nof papilledema.
4 \' A$ h6 T5 J2 b1 I4 NLaboratory Evaluation6 |' P% s" L- T. i5 J: c) S
The bone age was consistent with 28 months by
2 ]' k. }1 v0 {; A6 F: Iusing the standard of Greulich and Pyle at a chrono-3 j7 u8 W% F: x( s
logic age of 16 months (advanced).5 Chromosomal8 P% `. |" `) `- M# {
karyotype was 46XY. The thyroid function test
- K( W: Q! r/ p: mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 C$ h/ W& R8 c8 x' b6 A
lating hormone level was 1.3 µIU/mL (both normal).
9 @! r! o" a  b1 o2 xThe concentrations of serum electrolytes, blood8 e2 V# O$ V4 a* f1 W/ S
urea nitrogen, creatinine, and calcium all were' }! T% P0 y; K4 q& _
within normal range for his age. The concentration# H2 `5 z5 s1 e: j' ]! C$ h3 C
of serum 17-hydroxyprogesterone was 16 ng/dL
. k' J' t8 O: T3 t* {- {(normal, 3 to 90 ng/dL), androstenedione was 207 }; H% Y. i; e6 Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 Y" m8 f& M/ h- dterone was 38 ng/dL (normal, 50 to 760 ng/dL),+ @0 y: ?6 b7 ?  K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% m7 u  i& W6 I  x49ng/dL), 11-desoxycortisol (specific compound S)
5 K4 z: x/ f( F3 Kwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 y5 _( H2 m# R( Y5 w2 a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 v. U" {  S; \. J; a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% y& n4 e$ M" i: I) p/ o
and β-human chorionic gonadotropin was less than; K, r1 T7 N0 e
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ }+ @" O, G7 \: B1 y. N9 N- ~
stimulating hormone and leuteinizing hormone- N' B5 ]' k. R4 t! z+ K
concentrations were less than 0.05 mIU/mL
) \7 s' _9 j. ?(prepubertal).
/ g. X" h3 V+ l7 \, z) KThe parents were notified about the laboratory, T! w6 Z% U, ^3 u7 ^/ E8 U% X4 F
results and were informed that all of the tests were3 U7 _3 `5 j: ^" Y- u% T
normal except the testosterone level was high. The# n7 W4 J+ r/ z/ s# x% M" s
follow-up visit was arranged within a few weeks to
- y$ a2 {* b" c. F% }obtain testicular and abdominal sonograms; how-
( Y2 b# b1 B, m2 Lever, the family did not return for 4 months.- D( |/ S% Y+ A1 O4 C, c
Physical examination at this time revealed that the
, M! x6 a2 t! [child had grown 2.5 cm in 4 months and had gained
9 O2 p3 {7 B# X) p) k3 K3 }2 kg of weight. Physical examination remained+ e% s% M3 J" s( {7 s1 O1 z' Y
unchanged. Surprisingly, the pubic hair almost com-6 h& N6 J+ n( C! f
pletely disappeared except for a few vellous hairs at4 y4 A: N2 G! Z
the base of the phallus. Testicular volume was still 2
6 ~, x, P( Z- W  ?1 \! \/ PmL, and the size of the penis remained unchanged.8 B% l5 f& l+ P- m4 B
The mother also said that the boy was no longer hav-0 E* u. Z$ H  b* [
ing frequent erections.8 J& u! r! v( }6 a, I8 i3 D0 I5 I
Both parents were again questioned about use of
# s, K" ~' g/ _2 _* b9 Nany ointment/creams that they may have applied to3 ]* @! Q4 h, ^
the child’s skin. This time the father admitted the0 h5 l! |3 @/ f0 o
Topical Testosterone Exposure / Bhowmick et al 5418 h$ \' h. Y: P5 a) r5 w% m
use of testosterone gel twice daily that he was apply-
) W# ?/ i5 w% Z5 k1 r/ ring over his own shoulders, chest, and back area for
) F/ A8 E! G% e, q" Pa year. The father also revealed he was embarrassed
9 m" {' P5 I8 ?+ N, Q7 Fto disclose that he was using a testosterone gel pre-
9 [' s0 Y9 X0 @$ B$ [, y# Bscribed by his family physician for decreased libido, I0 X) F* D+ o& L
secondary to depression.. w7 y/ u/ }3 S! q( W; i
The child slept in the same bed with parents.& M; u7 n4 \  c- x6 E* W
The father would hug the baby and hold him on his
/ h; u/ f: P6 }7 ^4 S& F% ochest for a considerable period of time, causing sig-
  w5 q1 n. ?0 w5 knificant bare skin contact between baby and father.
: E/ P& j* `' N/ u7 N& y; s% S1 wThe father also admitted that after the phone call,! }7 f7 t9 a+ S) f2 w6 t6 q5 X
when he learned the testosterone level in the baby, H9 o- `" V% c+ V9 z% r
was high, he then read the product information- k' i, ~; ^* p9 o) @& c9 q
packet and concluded that it was most likely the rea-- p0 w, ?' i' Q7 n# c' H! K* f4 Y
son for the child’s virilization. At that time, they
9 l% S$ Y! s5 L9 `6 Gdecided to put the baby in a separate bed, and the
$ B6 @. d, l3 [7 G4 U' Q: Q" ~, w6 V# Nfather was not hugging him with bare skin and had. q% U! r2 s9 @- H. }. p( o
been using protective clothing. A repeat testosterone% [, V* H. H' {0 {- j$ F6 v
test was ordered, but the family did not go to the' E1 m" i1 O( m2 f" a0 O! j9 J+ ?
laboratory to obtain the test.. J4 o. f. Q1 C! V0 |& j/ J- q" Y/ M
Discussion) M+ ?4 N3 X- H, G- f* B8 m
Precocious puberty in boys is defined as secondary
+ E8 h' ?( r% L0 C5 Dsexual development before 9 years of age.1,4
+ w7 [4 j( e. T4 w3 j% G2 WPrecocious puberty is termed as central (true) when$ W: C" Q/ ^: D0 x
it is caused by the premature activation of hypo-
- r0 B8 H* ^3 ]/ f! e/ s* Uthalamic pituitary gonadal axis. CPP is more com-1 v9 t' Z0 B( r+ m$ M
mon in girls than in boys.1,3 Most boys with CPP$ I9 [# I! Z- C+ d4 v
may have a central nervous system lesion that is, _* B6 F- U' M$ s4 u3 f& A2 C
responsible for the early activation of the hypothal-/ Y6 y( N6 p7 a% Z1 r
amic pituitary gonadal axis.1-3 Thus, greater empha-7 S' \6 r) T/ _" J1 U4 G  L2 D  z
sis has been given to neuroradiologic imaging in
: u$ {8 m( }" p: R5 A. Jboys with precocious puberty. In addition to viril-1 ~$ e; o2 ]( ^$ H( b, Q
ization, the clinical hallmark of CPP is the symmet-$ n) ~" e, K) P
rical testicular growth secondary to stimulation by
; ~) X. a3 I0 j' i1 C: N2 Tgonadotropins.1,37 n8 J* s  E; k) t+ i
Gonadotropin-independent peripheral preco-0 \* i6 d' {( N( l
cious puberty in boys also results from inappropriate- r/ S# a* U5 k- A: _
androgenic stimulation from either endogenous or
0 u3 N0 [7 p+ W: _' _' Y& u0 zexogenous sources, nonpituitary gonadotropin stim-$ @  l4 T9 f6 T# M9 s1 v  T
ulation, and rare activating mutations.3 Virilizing
' W' O$ q# Z% D) ^% t& I: U0 ccongenital adrenal hyperplasia producing excessive2 d& F. n9 H0 E, E: k( u) a6 M
adrenal androgens is a common cause of precocious2 l  _" E/ x/ }  S( b# i3 w
puberty in boys.3,4. h! s/ o4 I  e" Z$ u
The most common form of congenital adrenal
1 G7 O% h7 Y* W) ^9 A0 B6 s# Xhyperplasia is the 21-hydroxylase enzyme deficiency.9 R, v$ k1 q7 n. k& |6 p) ?* I6 w
The 11-β hydroxylase deficiency may also result in! A( _+ [2 O9 h' l' s: x1 x
excessive adrenal androgen production, and rarely,
$ U, P1 x! h( _3 X8 san adrenal tumor may also cause adrenal androgen
$ T7 C% w6 p& i* t' W8 v" gexcess.1,3
1 N' x& ?/ w, v! o+ a) bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 H( Z1 h1 ?5 D3 b2 b% |3 n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 o5 B* o- K% U$ mA unique entity of male-limited gonadotropin-
! S- D& L/ x$ H/ sindependent precocious puberty, which is also known: n% Z8 e+ E2 S. [7 G9 s5 l
as testotoxicosis, may cause precocious puberty at a, q3 v' c" ~+ [) U% v/ M
very young age. The physical findings in these boys
1 N) U! Z/ F, Twith this disorder are full pubertal development,% z1 b  N8 U& W% j& V# I/ [" L- x
including bilateral testicular growth, similar to boys
% H* n6 F$ L( o! Q+ y$ K6 {with CPP. The gonadotropin levels in this disorder
# ?3 w3 ^/ R: S9 o- gare suppressed to prepubertal levels and do not show
9 \- U5 j2 C8 W( T- E4 W3 X$ rpubertal response of gonadotropin after gonadotropin-
1 W% B$ M" Y- V' R! n* j7 v" Oreleasing hormone stimulation. This is a sex-linked
2 j9 \7 s+ Y9 ]2 }autosomal dominant disorder that affects only
0 \, T3 y9 y+ _7 S& w( b5 s/ Pmales; therefore, other male members of the family4 P" [& Q, P& x$ T
may have similar precocious puberty.3
. E, Z1 O- G6 F& R8 Q6 l3 [  X4 oIn our patient, physical examination was incon-
) j' Q" w% w; i. \; {! x. Z) q1 j  gsistent with true precocious puberty since his testi-
- T) p$ z. B6 L) Bcles were prepubertal in size. However, testotoxicosis
' F5 G6 Z% `7 Xwas in the differential diagnosis because his father6 w! Y, r) O$ c; I( H1 \( A4 T" S
started puberty somewhat early, and occasionally,4 z$ `/ v5 C" f; v' J" q
testicular enlargement is not that evident in the
$ ?* |# p1 N, J% g$ `# abeginning of this process.1 In the absence of a neg-
6 t; B+ G( C# o; b5 Zative initial history of androgen exposure, our
; x& _. V8 x2 N; N. }biggest concern was virilizing adrenal hyperplasia,
" ?! ]2 E) S' z! ?. J( S( M* seither 21-hydroxylase deficiency or 11-β hydroxylase
" O& [9 N) ^  }9 wdeficiency. Those diagnoses were excluded by find-
, a: [- p; V8 Oing the normal level of adrenal steroids./ ]* n) z% \6 L) y
The diagnosis of exogenous androgens was strongly
1 v) R! ^) n3 _1 p0 Z5 v* Isuspected in a follow-up visit after 4 months because
% a' ?+ b* M, z% H0 n0 y$ nthe physical examination revealed the complete disap-! W0 I! R  r, z) C; j4 u% ^8 z- U% a
pearance of pubic hair, normal growth velocity, and: b, b$ c' n- @7 s, P0 m6 R
decreased erections. The father admitted using a testos-
. U8 S$ Y' f) hterone gel, which he concealed at first visit. He was
, i3 c  y/ h* M3 l4 }using it rather frequently, twice a day. The Physicians’
' ?# L0 k# F5 u! _! \* F: YDesk Reference, or package insert of this product, gel or4 U. E0 y! U/ c0 d, V
cream, cautions about dermal testosterone transfer to1 P) C) ]& _5 \: H
unprotected females through direct skin exposure.3 B0 I3 m. U% ^# }/ K. E  U6 X$ M
Serum testosterone level was found to be 2 times the, W) v; K! F- t' e: L
baseline value in those females who were exposed to
, @' L$ y# J# z* x; Y. Yeven 15 minutes of direct skin contact with their male
5 v3 i9 {* _, _& `7 u6 upartners.6 However, when a shirt covered the applica-
8 T9 F' g' H, k# @  F5 S* y  gtion site, this testosterone transfer was prevented.
* `  Z4 r& E3 P, cOur patient’s testosterone level was 60 ng/mL,
8 _; h& A+ Q! K% Q- ~  @which was clearly high. Some studies suggest that
! \$ F4 j7 E2 y% G3 Rdermal conversion of testosterone to dihydrotestos-
- I* g! X# [% }( A3 L* f( |# ^terone, which is a more potent metabolite, is more
9 c# V' o8 D; |" Vactive in young children exposed to testosterone) Y$ B, w) t  W' o* N3 l
exogenously7; however, we did not measure a dihy-: x* P) H& w( T# U
drotestosterone level in our patient. In addition to
& D7 `" t& Q9 U6 ~. o/ fvirilization, exposure to exogenous testosterone in5 N* r) v* k1 D3 d
children results in an increase in growth velocity and) \4 W2 |; D4 n; B. P) b. ]
advanced bone age, as seen in our patient.! |/ _3 M& I$ @& {' s5 Y9 u
The long-term effect of androgen exposure during) Q: _% M" T& Q2 }* ]6 {2 s! k
early childhood on pubertal development and final) e$ J: u3 W+ k* _% h7 {8 ]) D
adult height are not fully known and always remain7 u- E- j; e* F6 H8 _! g
a concern. Children treated with short-term testos-
4 \: {) `$ x7 _2 I6 v4 Bterone injection or topical androgen may exhibit some: q5 C2 p3 H1 g/ _* B
acceleration of the skeletal maturation; however, after
7 \/ C2 Q  c8 {) ^6 ^% Q0 |cessation of treatment, the rate of bone maturation$ r; d6 s, }, {7 Z/ @
decelerates and gradually returns to normal.8,9
( [! ~! h- F5 {( \$ l. NThere are conflicting reports and controversy, Z' e# S9 A# p3 j3 n- t
over the effect of early androgen exposure on adult
' C# U8 F. o; L8 tpenile length.10,11 Some reports suggest subnormal
$ Q/ M, @' B  fadult penile length, apparently because of downreg-
% ~+ n& Q& [, [. s7 e& `* x6 lulation of androgen receptor number.10,12 However,
( l0 f  f  {3 kSutherland et al13 did not find a correlation between
1 N; ?( x3 F5 s& ^& j4 d! H' ochildhood testosterone exposure and reduced adult
% o# h. ~6 Y; P5 R1 t3 |penile length in clinical studies.
9 o5 ^( H; B  [3 ~  K* U4 XNonetheless, we do not believe our patient is
! @7 f6 G  \: f1 n/ `( s+ n8 Fgoing to experience any of the untoward effects from
2 v9 `1 B0 r- E  x; Jtestosterone exposure as mentioned earlier because
6 M, q# I. d" z8 ]. M$ \0 x5 jthe exposure was not for a prolonged period of time.
- H" j6 s$ w) K: M" z/ a4 {Although the bone age was advanced at the time of* y6 ?" l8 v1 w5 V! Q; v" ?5 K
diagnosis, the child had a normal growth velocity at  M6 X( M* g7 i) }/ z( _) P8 A
the follow-up visit. It is hoped that his final adult
/ M* p3 J' s5 r. H6 {- S. cheight will not be affected.
4 Q  o1 ?/ U, M, F, VAlthough rarely reported, the widespread avail-3 P6 k! R$ V& S+ [! j* F3 S" V
ability of androgen products in our society may" i3 y' D  T( q4 f
indeed cause more virilization in male or female
& Q5 D+ l% D8 n' q) J+ r9 hchildren than one would realize. Exposure to andro-0 K% @  E2 l% ^) u) ?2 u2 Z0 c
gen products must be considered and specific ques-
0 _  s' x5 J6 Etioning about the use of a testosterone product or
/ W* C/ O3 {+ Ygel should be asked of the family members during
0 G0 }- z4 h; C. E. Kthe evaluation of any children who present with vir-3 b' P# R& u7 R" L$ X: z) e. G6 P; t2 p
ilization or peripheral precocious puberty. The diag-
. O8 |1 O2 B" R5 R$ vnosis can be established by just a few tests and by% ?  i; t  M  A* `; p
appropriate history. The inability to obtain such a
: M& V- y7 Z3 i) [  N2 ghistory, or failure to ask the specific questions, may7 d+ u# N3 ~7 T0 t
result in extensive, unnecessary, and expensive5 w7 K5 U& K. y+ T
investigation. The primary care physician should be
( ?/ `: {' d! Yaware of this fact, because most of these children
- i; O  g* x6 C7 o+ O& gmay initially present in their practice. The Physicians’
3 a( B# L/ _* }Desk Reference and package insert should also put a
3 x2 X9 s7 c; p7 E% u' m4 N, _. b  Qwarning about the virilizing effect on a male or0 [+ I& N; l# X- i6 l% }
female child who might come in contact with some-
! M5 Z5 G9 [2 T, Eone using any of these products.
6 Y* t9 ~& D& d3 S9 T+ S1 b- HReferences3 F: i7 j! t) d2 {/ m/ A
1. Styne DM. The testes: disorder of sexual differentiation
5 N! a+ P- k6 j+ E9 vand puberty in the male. In: Sperling MA, ed. Pediatric, }, R) `3 _5 ]) y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' N, [8 G1 k# ?" I, z; f- o+ M
2002: 565-628.; s4 R9 e+ q2 i- h/ m
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, R2 T( t% `+ tpuberty 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
. s* J! x; g0 D" D( `9 M
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