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
6 X! w( `- l6 O- [, JBoy Induced by Indirect Topical
( C! c3 a0 d. \# KExposure to Testosterone+ y4 o/ W3 z/ m' h( d& ]0 ~: |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; o$ f! b$ r* zand Kenneth R. Rettig, MD1% I" h/ v0 j- ^* B: p9 w" B# m7 c
Clinical Pediatrics7 W3 s5 e4 i3 \+ Q* R; ?
Volume 46 Number 6
9 w) I# z7 o& @6 JJuly 2007 540-543
3 _% z, H2 B9 T! ^© 2007 Sage Publications! L0 p+ _7 e* X& f' C# k1 r
10.1177/0009922806296651
; z, u' s8 v& D$ W) @9 U7 Dhttp://clp.sagepub.com- s- z/ V, R  q( D
hosted at
$ Z, k3 H4 o: l6 N  Q" a! _# }, w& Chttp://online.sagepub.com2 d1 y: G" |7 U1 m+ s& l( Q
Precocious puberty in boys, central or peripheral,
  Y7 L- J6 h0 _! L7 Z, jis a significant concern for physicians. Central
: q$ t/ U% L7 u6 f% }  gprecocious puberty (CPP), which is mediated
! |6 O- t; V6 g, _8 Pthrough the hypothalamic pituitary gonadal axis, has- z2 [6 W+ V/ ^8 N" O5 f8 ~) M8 W
a higher incidence of organic central nervous system4 u2 }, a0 c. j- `1 n1 x
lesions in boys.1,2 Virilization in boys, as manifested& ]$ l9 z2 E# J' ?# g" g6 H
by enlargement of the penis, development of pubic6 N( n% E( {+ {5 p
hair, and facial acne without enlargement of testi-
1 ]4 r* t( g: p* h* Y; k2 B* Ecles, suggests peripheral or pseudopuberty.1-3 We
2 `, ^3 N' M  K6 a  t; r' H/ breport a 16-month-old boy who presented with the
, p$ ^& P' V6 Ienlargement of the phallus and pubic hair develop-" b( g6 @0 M  q" N# M
ment without testicular enlargement, which was due
! W. `7 d. N; v% T$ \to the unintentional exposure to androgen gel used by
2 E! x9 F9 e6 E" U1 Z- c  K0 Jthe father. The family initially concealed this infor-3 m6 Q9 `# Y+ b. u' N
mation, resulting in an extensive work-up for this
/ v  Q7 p3 ?% F* n5 G) Ochild. Given the widespread and easy availability of
. F7 Z4 r7 K, F2 E' z+ ?testosterone gel and cream, we believe this is proba-; w) ?6 ]9 `' T0 c
bly more common than the rare case report in the/ a) j3 }4 G. h! g( C
literature.4' W0 R) l5 @) L- W7 m& }* w1 r
Patient Report' \, v9 C: \/ e4 Z9 Y$ R/ F& o2 f
A 16-month-old white child was referred to the
; R: Z" U# a6 v: o, m7 ]endocrine clinic by his pediatrician with the concern
: ]6 o4 b; R, P, j8 j) T# Gof early sexual development. His mother noticed
' e: X6 ^5 j: J; Ulight colored pubic hair development when he was. d; x+ S) N! s) @* G
From the 1Division of Pediatric Endocrinology, 2University of. _0 a3 `9 O+ Q8 j
South Alabama Medical Center, Mobile, Alabama.' d: B& U# O( r2 w* y7 o
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ U; Q: m( b6 ^0 ^) d4 RProfessor of Pediatrics, University of South Alabama, College of# g. o; Z1 ?' \2 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ U2 z& I/ l0 T: i
e-mail: [email protected].
' ?" T0 [4 I9 S; t5 H$ Y( Yabout 6 to 7 months old, which progressively became3 _4 o6 T( Z0 z. O
darker. She was also concerned about the enlarge-' c; B& E" \( @( W+ ^6 K) H0 n% q/ |
ment of his penis and frequent erections. The child
- F! }+ k# H5 s: n" uwas the product of a full-term normal delivery, with; a% Z2 F6 Q/ o; B
a birth weight of 7 lb 14 oz, and birth length of
( v' n% f! y) ^2 S) N/ i& Y20 inches. He was breast-fed throughout the first year& Q- A1 s- z5 N* O/ |
of life and was still receiving breast milk along with/ [+ D$ ^6 ?& K  b6 g; r1 O$ m/ k
solid food. He had no hospitalizations or surgery,. Q7 T8 f. f$ P# A- Q
and his psychosocial and psychomotor development
- L% n7 D6 r( L+ S. fwas age appropriate.- V/ q  g2 m: m) d" O6 q3 z
The family history was remarkable for the father,( i8 U, O: P. P6 u' o5 _$ ^. B
who was diagnosed with hypothyroidism at age 16,; F3 W2 t! e- E  k7 }
which was treated with thyroxine. The father’s) C: B4 a' ~6 X8 x' ^  A9 |- Z$ y
height was 6 feet, and he went through a somewhat
5 x8 B+ G; T+ N, }0 [' \" zearly puberty and had stopped growing by age 14.
# f# f& y+ M' @% }' S3 c& r  eThe father denied taking any other medication. The
8 ?  Z9 y9 y* m# p  B4 ?child’s mother was in good health. Her menarche
! f& @8 m( \1 a0 T4 }was at 11 years of age, and her height was at 5 feet/ }! i: c4 h+ g- D
5 inches. There was no other family history of pre-) [; I* s" I. }5 }
cocious sexual development in the first-degree rela-
2 Z, |' Z) s3 n* f& [) ]4 mtives. There were no siblings.
7 W9 y  S3 x/ K) {: vPhysical Examination
1 m/ O/ m" z! I; LThe physical examination revealed a very active,
) n; W9 }+ s& |! D9 O. jplayful, and healthy boy. The vital signs documented  _. G. I1 G- d" @& @8 Y4 h" |7 a
a blood pressure of 85/50 mm Hg, his length was& m7 j$ A9 `0 C2 }: a. b9 a
90 cm (>97th percentile), and his weight was 14.4 kg  d; \4 L- a0 {* @7 R
(also >97th percentile). The observed yearly growth
- @; }3 W8 ~9 k- j  @velocity was 30 cm (12 inches). The examination of  I1 E$ D' j8 w5 h- W) b
the neck revealed no thyroid enlargement." \" M$ b& r5 w) T) X4 k( t* o  Y
The genitourinary examination was remarkable for
) W' b# J3 T9 ?3 I/ }0 Z: G/ x: b$ tenlargement of the penis, with a stretched length of- \) j& {9 L, ~1 {# i3 e
8 cm and a width of 2 cm. The glans penis was very well
% ^% x, U" U, O0 }7 v; E3 ~- _developed. The pubic hair was Tanner II, mostly around
+ u0 F/ S4 F; R; n/ E# Q540! [2 i5 N6 `! q; x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  {) W! o. Z% _0 f
the base of the phallus and was dark and curled. The7 `9 O3 F- o; @8 a7 w6 I
testicular volume was prepubertal at 2 mL each.
3 J7 B7 H  D8 d! ]The skin was moist and smooth and somewhat
: j) {( D( Z+ o$ Y$ R/ woily. No axillary hair was noted. There were no% }4 y0 Z7 z" j7 x
abnormal skin pigmentations or café-au-lait spots.! k& K9 A8 G0 S4 H. ]2 ~
Neurologic evaluation showed deep tendon reflex 2+
4 v4 [/ @& |3 ^3 }bilateral and symmetrical. There was no suggestion' Q; v6 M7 v2 D6 H6 G+ C
of papilledema.
2 i* S, @9 E) G, j/ R$ QLaboratory Evaluation2 \6 c' T4 I/ r" u0 G
The bone age was consistent with 28 months by
! c- R- S5 q9 K6 Lusing the standard of Greulich and Pyle at a chrono-
6 t/ y  j& }' ~+ n2 g: Slogic age of 16 months (advanced).5 Chromosomal/ q7 r: x5 D$ D+ V) ~$ I: C
karyotype was 46XY. The thyroid function test" R% ~. e, D5 B. I. u
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 s4 d  }! d0 q* m! Q9 S" \' z* e# C4 t
lating hormone level was 1.3 µIU/mL (both normal).1 M. r/ C5 v0 N& w- a5 w
The concentrations of serum electrolytes, blood; ?' x# A/ |2 I! l* E
urea nitrogen, creatinine, and calcium all were) S; G) d/ g1 X! E& p" A7 F
within normal range for his age. The concentration
( S0 U9 I7 x  y' E1 N, l2 Kof serum 17-hydroxyprogesterone was 16 ng/dL* t* m% _! C) Q& _
(normal, 3 to 90 ng/dL), androstenedione was 20
2 }" h* p# o/ j. b% }+ Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 L$ \& J( x5 S) {+ ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% K( m. l6 N! |  }9 c! Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 i3 G* H: ]7 i5 @: ^1 W49ng/dL), 11-desoxycortisol (specific compound S)0 h0 L( U0 t: n; ~& t, h
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 L1 U% G! n7 M  O+ ]# ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 m& e" `' m6 f8 O. q( xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' x$ U( y& Y9 v3 c# c* I  ~and β-human chorionic gonadotropin was less than
% T& U9 M0 c7 w% D1 B/ l/ j5 mIU/mL (normal <5 mIU/mL). Serum follicular) U. l0 F; e* Y) d; ?8 F+ N
stimulating hormone and leuteinizing hormone$ C6 p5 o# P8 [; n9 A
concentrations were less than 0.05 mIU/mL
# F7 {. H( V& Z6 g4 z(prepubertal).
  W% `' ]! L, N% `. _The parents were notified about the laboratory
  @; L( U" l, ^3 ]  Zresults and were informed that all of the tests were; o. g4 q2 y7 n7 T% C* k' X: s4 z$ y
normal except the testosterone level was high. The7 P; p& ~. j* Y6 v1 X) }
follow-up visit was arranged within a few weeks to
' s* `- M! _& {( D0 `1 x" g2 ]obtain testicular and abdominal sonograms; how-
' ]7 D- T$ y! j8 r5 T; w. G5 ?8 Oever, the family did not return for 4 months.
/ L* \: q0 J* [9 e: SPhysical examination at this time revealed that the9 ]* |; T. B) _1 h/ N
child had grown 2.5 cm in 4 months and had gained% h" C8 ^2 [/ j) b# R7 H/ {
2 kg of weight. Physical examination remained/ T* z& z1 i% D5 t7 @
unchanged. Surprisingly, the pubic hair almost com-
" S7 b9 x5 j; ]- ppletely disappeared except for a few vellous hairs at# R. s3 w  d- V! r$ ~
the base of the phallus. Testicular volume was still 25 f1 P% H; m8 k: f
mL, and the size of the penis remained unchanged.& H/ ~1 r9 C& S
The mother also said that the boy was no longer hav-: a3 d4 K, b( }) H1 O. c+ Y
ing frequent erections.
$ o0 ]1 g5 G/ I* v$ e+ yBoth parents were again questioned about use of& i& A; t" j6 V
any ointment/creams that they may have applied to
1 N0 Y/ H/ I' u' P5 ^) }% `the child’s skin. This time the father admitted the
' i4 S8 D, l& @- A5 \) OTopical Testosterone Exposure / Bhowmick et al 5415 r8 L. F) i, B% s( a  a# Y
use of testosterone gel twice daily that he was apply-9 x& @7 w. G2 E, A( s
ing over his own shoulders, chest, and back area for+ e. P8 G6 E  @! A2 f- [7 E* m
a year. The father also revealed he was embarrassed9 k# d/ \/ q! U: K9 d) h, q
to disclose that he was using a testosterone gel pre-" n1 E% H8 V( }$ X& k5 U
scribed by his family physician for decreased libido( p: `% m7 a0 ^" l5 a  ]! x
secondary to depression.
$ U7 ]4 `0 S; W# Q0 LThe child slept in the same bed with parents.
$ M( H3 b0 v" u( M! kThe father would hug the baby and hold him on his
) Z/ _# @3 O- A$ A# |8 a" Uchest for a considerable period of time, causing sig-
; A$ H( W: p4 ^# K4 w: ynificant bare skin contact between baby and father.
' Z/ ?5 k. R! e5 Q+ O4 u' h( AThe father also admitted that after the phone call,3 j8 G" f# d! {
when he learned the testosterone level in the baby
' b) J& o, n) w* E" vwas high, he then read the product information. ]0 s$ B. o& M- d. N/ J1 T0 L
packet and concluded that it was most likely the rea-
  V) u( B( Y7 t6 O0 D! sson for the child’s virilization. At that time, they
" J9 U  J2 b7 b* ]decided to put the baby in a separate bed, and the& f9 [% [9 J3 C( s" H& I5 P* M  f
father was not hugging him with bare skin and had! ~& V6 u8 [, \3 ~+ ]
been using protective clothing. A repeat testosterone
$ G# x% _: A! b8 R$ o3 atest was ordered, but the family did not go to the- F! L+ ~- V$ K  p" U- G* ]
laboratory to obtain the test.1 R3 W( P4 z. W
Discussion
1 K. T* g) [2 KPrecocious puberty in boys is defined as secondary* U1 Q6 Z- j( Z, e- {
sexual development before 9 years of age.1,4
# n% ^; S- A. e. q6 G& @$ |4 ~; PPrecocious puberty is termed as central (true) when1 |' @& h# J/ t
it is caused by the premature activation of hypo-% h/ C5 Z, J: C6 z+ ^  m2 X
thalamic pituitary gonadal axis. CPP is more com-2 a' e1 G" V: m' [) }* h. m
mon in girls than in boys.1,3 Most boys with CPP9 a( e5 |% v( R: V
may have a central nervous system lesion that is1 I' A: q/ J' ]2 }; Y0 [
responsible for the early activation of the hypothal-- C+ ]1 c7 F/ B" g: J, w9 |
amic pituitary gonadal axis.1-3 Thus, greater empha-4 I4 Y/ z3 E4 j7 z2 d! k: ^! F* B
sis has been given to neuroradiologic imaging in( Z1 b+ a+ T$ W( \+ b. @
boys with precocious puberty. In addition to viril-6 |) o9 N& h3 W8 J0 \  h4 g
ization, the clinical hallmark of CPP is the symmet-
; M# Q9 `9 s+ |" Prical testicular growth secondary to stimulation by
% {" R$ B- S0 Ogonadotropins.1,3+ K2 m( k8 m8 x- T+ {
Gonadotropin-independent peripheral preco-4 W1 ?9 p$ G6 Q' Q
cious puberty in boys also results from inappropriate. V* `+ S6 x/ g; z; t
androgenic stimulation from either endogenous or8 f: I4 Y- N' Y
exogenous sources, nonpituitary gonadotropin stim-4 S4 D8 @, o$ V& _8 e. B
ulation, and rare activating mutations.3 Virilizing
# j2 P3 T8 M- d/ Xcongenital adrenal hyperplasia producing excessive, U9 ^$ l% N! d) G
adrenal androgens is a common cause of precocious5 G& D. |5 u3 O7 h6 H5 u
puberty in boys.3,4
0 K$ ~. \, t  G( C! \The most common form of congenital adrenal5 o' p9 `, I6 O+ \* R1 a7 m9 F7 y
hyperplasia is the 21-hydroxylase enzyme deficiency.% ~+ b: `2 `, ~8 L; O/ x! |/ V
The 11-β hydroxylase deficiency may also result in
( r: M! k2 o- ~5 ?" M$ a8 Rexcessive adrenal androgen production, and rarely,/ E: V# e5 B6 W5 R# O8 P& k
an adrenal tumor may also cause adrenal androgen# B& f' {( `7 K, |+ _4 b
excess.1,3
4 E! }4 Q" y! q/ Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 w# A* q  c/ [+ A$ \8 o! F; W; r542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% p1 R# g1 j9 _7 p7 Q9 lA unique entity of male-limited gonadotropin-
7 K, L% c: w" A" ~/ k, P8 v/ Zindependent precocious puberty, which is also known
3 x' J6 x' v$ h7 Y9 O; W- Nas testotoxicosis, may cause precocious puberty at a5 A. G! G4 ^3 E' u
very young age. The physical findings in these boys
: ]. D7 Q1 }% W4 q; Swith this disorder are full pubertal development,
7 e$ a) m& d6 Q# Mincluding bilateral testicular growth, similar to boys
: B- J: i; e7 D) n# G- l( ?with CPP. The gonadotropin levels in this disorder
5 C: ~6 \$ \. C7 P% s% G1 V3 x, iare suppressed to prepubertal levels and do not show+ e% V. Z* B/ L/ [% M. S1 i
pubertal response of gonadotropin after gonadotropin-( N0 b1 ?4 ~" E: q; b! T
releasing hormone stimulation. This is a sex-linked
7 R0 W: F( }9 \  qautosomal dominant disorder that affects only, n  V3 D; G, Z; y6 g0 {' u
males; therefore, other male members of the family
5 O: c9 w- T: D9 Y( u4 z  e( Kmay have similar precocious puberty.39 k6 a: e" j: w$ M2 K! I
In our patient, physical examination was incon-3 B  ?3 N  ]+ _% W, W/ S1 H  x
sistent with true precocious puberty since his testi-6 i( D# w1 x# Z5 V2 {* p
cles were prepubertal in size. However, testotoxicosis( K: V' ~1 q+ g) @  @: v( C/ z& h
was in the differential diagnosis because his father
' ~9 H; a% N5 e1 P2 b" }% mstarted puberty somewhat early, and occasionally,
7 p* l/ y5 {( \testicular enlargement is not that evident in the
6 Y" H$ e8 b/ Y+ ?$ Nbeginning of this process.1 In the absence of a neg-* L* ^' n/ V! F( M! T
ative initial history of androgen exposure, our- h6 Q) m& R  Z, X1 L2 w
biggest concern was virilizing adrenal hyperplasia,
9 ^4 u4 w+ o/ s4 P" F' Keither 21-hydroxylase deficiency or 11-β hydroxylase3 X9 P# m4 u) r: o* g) h* G
deficiency. Those diagnoses were excluded by find-
5 R) }) b3 s# z' ]ing the normal level of adrenal steroids.! B- K! Z5 h/ A4 ~, q
The diagnosis of exogenous androgens was strongly
4 A+ r( E- K! {suspected in a follow-up visit after 4 months because! C8 w6 I- J6 f! U
the physical examination revealed the complete disap-0 B; G4 U% \' _; ^3 ~
pearance of pubic hair, normal growth velocity, and
6 p7 j8 B: v1 e& l) n: h, fdecreased erections. The father admitted using a testos-8 J" U3 z/ J  C* H
terone gel, which he concealed at first visit. He was
6 g- J) ~6 |! s, {using it rather frequently, twice a day. The Physicians’
# E% f% o2 ]. JDesk Reference, or package insert of this product, gel or
8 r1 `+ g1 {/ t, e8 d! dcream, cautions about dermal testosterone transfer to
  E. u/ n3 Q- D4 D  @1 {unprotected females through direct skin exposure.7 J. R6 Y5 p/ X' K
Serum testosterone level was found to be 2 times the
* O5 Q  j' X- F$ s* f" Bbaseline value in those females who were exposed to! C/ n* e, H+ I1 C
even 15 minutes of direct skin contact with their male
% E( ^5 |. Q- A6 L  m/ Z+ Npartners.6 However, when a shirt covered the applica-$ [/ r+ R! F5 g' m
tion site, this testosterone transfer was prevented.
3 x# h6 g( S( n3 yOur patient’s testosterone level was 60 ng/mL,
! Y- n) L$ }0 b( jwhich was clearly high. Some studies suggest that" ~* j" y0 Z( r/ b8 ]
dermal conversion of testosterone to dihydrotestos-
7 x' N" z; d  n  G, d9 \: g0 [terone, which is a more potent metabolite, is more
$ `8 o' T4 T) |# j+ S1 eactive in young children exposed to testosterone. Z; R; [( S5 S6 j0 `0 [1 e' c2 k* s
exogenously7; however, we did not measure a dihy-
6 |5 Y: N$ D1 }  t, [. mdrotestosterone level in our patient. In addition to
) D0 Q9 q0 J% E! ^; P: dvirilization, exposure to exogenous testosterone in" Z0 w" Y# F& S: ^9 ]$ c' F
children results in an increase in growth velocity and$ P  B3 W) e( V5 k$ A- i
advanced bone age, as seen in our patient.
" l5 n' u3 D) v( |; u# wThe long-term effect of androgen exposure during( k1 M6 [& b7 h8 ^0 }! z
early childhood on pubertal development and final
* z% q$ i4 z6 y1 oadult height are not fully known and always remain
8 X. r2 A: W+ [# ua concern. Children treated with short-term testos-) g8 D+ P( V7 H! j. @& b  k0 H
terone injection or topical androgen may exhibit some0 W1 f! G  s+ J. k/ P, {8 Y
acceleration of the skeletal maturation; however, after
/ b' D4 M4 y, E( ^# F+ C6 Hcessation of treatment, the rate of bone maturation2 ]% |4 e3 E  H% a
decelerates and gradually returns to normal.8,9
# p$ V$ J+ S/ e" t- @+ j" vThere are conflicting reports and controversy
/ ^! y# w( k9 j6 b( Q, ]0 cover the effect of early androgen exposure on adult
* Y8 |$ B7 k4 l+ |' L8 Z# jpenile length.10,11 Some reports suggest subnormal
2 [+ O0 Y, w3 f! H! qadult penile length, apparently because of downreg-
8 s& w% g! h; q5 r& ?ulation of androgen receptor number.10,12 However,7 g- l0 z% y. ^3 D; b4 n) x9 [
Sutherland et al13 did not find a correlation between
5 x: q) H) c, Y& H- Zchildhood testosterone exposure and reduced adult
/ _/ p0 h/ \, r2 Y0 Ipenile length in clinical studies.) ~6 P1 x' L- ~2 {1 z0 P& J9 F1 a
Nonetheless, we do not believe our patient is; m# q5 g4 v3 U" Z- \2 X% |' |' m
going to experience any of the untoward effects from
3 Q2 E! j: [! k, Ztestosterone exposure as mentioned earlier because8 q9 }& v2 w- O4 z
the exposure was not for a prolonged period of time.
, h, W7 w. a" x5 CAlthough the bone age was advanced at the time of* Y0 O% a& M# [& h; Q
diagnosis, the child had a normal growth velocity at/ y: W: F3 ~* w  @! \
the follow-up visit. It is hoped that his final adult
8 t& }6 v* |# I1 Uheight will not be affected.
1 ^/ L1 F3 v3 N' S" x2 RAlthough rarely reported, the widespread avail-
& G* k, x4 L! P( h: F9 Pability of androgen products in our society may, E' v/ p7 P3 S6 O4 v" n1 C
indeed cause more virilization in male or female* D/ K6 @" u1 a* v: B
children than one would realize. Exposure to andro-
+ r2 U. {. I0 k1 e# I/ ngen products must be considered and specific ques-& [- f2 W1 R3 N+ Y
tioning about the use of a testosterone product or5 |/ j1 C) C. A3 y! B: y1 a
gel should be asked of the family members during
; n8 }* l/ M0 _; [) P3 G" m8 R4 cthe evaluation of any children who present with vir-
* M+ o+ i& R* h3 {- Rilization or peripheral precocious puberty. The diag-
! l- O+ X( ]% J' Ynosis can be established by just a few tests and by
1 S7 g' N/ k' P+ o! B/ v" _appropriate history. The inability to obtain such a- P) W* _/ {8 ]7 z. T
history, or failure to ask the specific questions, may
( a, z( b$ s. T/ I' Aresult in extensive, unnecessary, and expensive
4 }# J8 J6 c9 l% w1 y4 ^$ t! xinvestigation. The primary care physician should be$ U$ P% D3 a' |  J- l- w/ D
aware of this fact, because most of these children
/ [$ n4 T: k  P7 v' q; {may initially present in their practice. The Physicians’
  U' @3 T6 I2 HDesk Reference and package insert should also put a' p2 A$ m9 x( A9 r& ^
warning about the virilizing effect on a male or
8 u: x6 S$ v1 l$ h5 p2 A* Pfemale child who might come in contact with some-
2 p* j% r% U. F  Aone using any of these products.
5 _. e0 n" P) [; f- _( x% S* xReferences
& s9 {7 o( c& x8 _! m1. Styne DM. The testes: disorder of sexual differentiation3 E0 H8 L9 Z0 p. X# }& [
and puberty in the male. In: Sperling MA, ed. Pediatric
) E! H% p& k4 @/ iEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& S2 o: o1 I3 Q- j
2002: 565-628.0 m; v* q% J. A% r  [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 }" @. l' F5 N% wpuberty 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
2 }7 s5 ~; o9 }: oBoy Induced by Indirect Topical
1 }; E$ q: z: _Exposure to Testosterone$ H# q0 v7 l: \3 `  L# x
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 l' m0 K6 G& M, U% ^: Oand Kenneth R. Rettig, MD1, E$ T  P/ |2 |# Z2 Z+ r6 T
Clinical Pediatrics
" `, L8 p: N5 }. P; {Volume 46 Number 6
/ |6 E" \$ l4 R# T& I, mJuly 2007 540-543
+ v# L' ^: Y" f' x/ @+ x+ L© 2007 Sage Publications
* A* F  M7 y1 ?0 h1 z6 Q10.1177/0009922806296651
: t, i0 S* ?8 p+ r. Chttp://clp.sagepub.com
+ K# Z# g/ c( whosted at
: r6 {2 e2 U3 T1 e9 T$ Jhttp://online.sagepub.com4 O+ U2 T& g& h
Precocious puberty in boys, central or peripheral,! m( W/ n7 j& t, j' q8 s+ C' i+ F
is a significant concern for physicians. Central2 C& W- W" J3 _# i
precocious puberty (CPP), which is mediated# s- N1 Z0 {, X7 R$ a
through the hypothalamic pituitary gonadal axis, has
* l) K7 e( n. ~6 M' V3 Da higher incidence of organic central nervous system1 L, L4 W! Q; _% \$ I8 o% z
lesions in boys.1,2 Virilization in boys, as manifested5 U, U( q$ o7 ~: ?8 c& s( ]% C( O
by enlargement of the penis, development of pubic
1 F3 d  L: N* U% V7 vhair, and facial acne without enlargement of testi-  k, H8 y/ o; p8 V( G
cles, suggests peripheral or pseudopuberty.1-3 We' t) O4 c$ f$ z5 S1 D0 S
report a 16-month-old boy who presented with the4 u; }6 m2 ?3 t6 ^4 j$ {
enlargement of the phallus and pubic hair develop-# F3 t& X$ p& {) A
ment without testicular enlargement, which was due
2 A+ l5 x) d7 n8 A4 [) m( Mto the unintentional exposure to androgen gel used by
$ ], [# W9 S* m3 p2 \4 T4 Mthe father. The family initially concealed this infor-7 p8 T+ V/ C2 x1 {3 D6 ]1 u
mation, resulting in an extensive work-up for this. M. T. J$ {+ N' i5 }- K% ]
child. Given the widespread and easy availability of
* d0 a/ S7 |$ S; t' N! |testosterone gel and cream, we believe this is proba-
+ ~, k4 B- ^- i1 Gbly more common than the rare case report in the
7 H; O) O2 D6 b  K5 e0 @! xliterature.4. I. x. I9 d; b% b+ w
Patient Report  A" _* e' z/ y8 b- k
A 16-month-old white child was referred to the
6 t9 H' b' W' X& K: i/ d4 n& O7 zendocrine clinic by his pediatrician with the concern, H' I. {( M, i4 l- o+ A1 o# D
of early sexual development. His mother noticed
; l& M+ ~2 h$ P, Z9 G. U  F4 h: \light colored pubic hair development when he was
+ n  U3 G! T: S; C( hFrom the 1Division of Pediatric Endocrinology, 2University of
! M# x. [2 ~0 N1 _8 A7 u# TSouth Alabama Medical Center, Mobile, Alabama.
# R3 a' A2 L: M0 _! t; kAddress correspondence to: Samar K. Bhowmick, MD, FACE,- B/ `! Z2 V; F) ]6 P/ C
Professor of Pediatrics, University of South Alabama, College of  d2 f, B  @! K3 c* G! q- H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 ?! a, n" V& D$ z. Z/ ^8 be-mail: [email protected].) o: D$ W, G) [2 B' B: ~2 ?
about 6 to 7 months old, which progressively became
3 C. g3 P- m3 b% I, zdarker. She was also concerned about the enlarge-! H* a& L- K& L# A) u7 z4 c
ment of his penis and frequent erections. The child
; X: K$ Y1 Y: O4 E( P1 P0 F1 uwas the product of a full-term normal delivery, with. t1 p& k$ g( a
a birth weight of 7 lb 14 oz, and birth length of
6 K' d- U+ N; A# D+ p. g20 inches. He was breast-fed throughout the first year9 s0 X" v6 o6 e' Y8 T
of life and was still receiving breast milk along with- x6 k$ j, J( J
solid food. He had no hospitalizations or surgery,$ Z) ?/ k: {3 x% {
and his psychosocial and psychomotor development( X$ A0 x8 J% V; E3 ~( e9 `! _
was age appropriate.; j/ n) a& M, g1 |$ e& L1 b- z
The family history was remarkable for the father,: ?4 r$ d" m) t; U6 ^& l# f
who was diagnosed with hypothyroidism at age 16,
, Z) Q* g. O; H# Q/ G3 X, [which was treated with thyroxine. The father’s% i' P% X1 R! B: P8 U( ^
height was 6 feet, and he went through a somewhat
% r6 N1 c# M! _/ Q$ H5 \5 Uearly puberty and had stopped growing by age 14./ a2 Z& j7 t3 F' `$ r0 M
The father denied taking any other medication. The
& i! a6 L9 d: b9 _  K9 Fchild’s mother was in good health. Her menarche
5 z. o/ m: X- P! }: C4 Vwas at 11 years of age, and her height was at 5 feet! c# S  M' b3 P& B+ K
5 inches. There was no other family history of pre-
% i! ~: s( H( C/ Jcocious sexual development in the first-degree rela-3 H# Y8 {1 r5 B8 k8 j
tives. There were no siblings.$ {2 `! N% d( D% P  V3 w2 [! s2 f) x
Physical Examination) X3 r* u' L- H+ _& ^' o# j/ \8 T
The physical examination revealed a very active,2 [- x# I2 i; d1 j8 ^& D% R
playful, and healthy boy. The vital signs documented: E( c) z5 e% s/ r0 ~1 P* u
a blood pressure of 85/50 mm Hg, his length was
$ n% j* J2 w' O8 b" Y5 Y90 cm (>97th percentile), and his weight was 14.4 kg" x8 [4 `; B2 D5 V" N" }( y) H
(also >97th percentile). The observed yearly growth0 d6 n; O6 l6 g! L
velocity was 30 cm (12 inches). The examination of
" x9 M; H; d  w0 z! t9 ?% D, K8 ^the neck revealed no thyroid enlargement.: M: ]/ B+ l4 N6 }2 z: {' T
The genitourinary examination was remarkable for1 Y7 I4 f( e6 q; M' A
enlargement of the penis, with a stretched length of1 R% O* B( }% Y/ K* Q/ n; ^  O
8 cm and a width of 2 cm. The glans penis was very well
1 F; M( h" ~" H! B8 [; jdeveloped. The pubic hair was Tanner II, mostly around: ]& s8 U; _+ C4 Y* g
5409 \% n# O2 L# t% q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" d9 C- ~8 B* ]& j2 T
the base of the phallus and was dark and curled. The
2 Z$ ?9 L: Q+ J; ^5 dtesticular volume was prepubertal at 2 mL each.% m8 Q& i' [# U/ K4 f
The skin was moist and smooth and somewhat* o1 H# f; d) X' y6 ^8 Z5 b; z
oily. No axillary hair was noted. There were no
2 W* \  Z! W$ e' K/ I. Tabnormal skin pigmentations or café-au-lait spots.' w5 ?& d% P3 f
Neurologic evaluation showed deep tendon reflex 2+
% X, w( }- Z0 `+ d2 i  ibilateral and symmetrical. There was no suggestion
0 j* r  A9 t9 D2 S4 n! cof papilledema.
* e9 \* z1 H) y, l  ^7 WLaboratory Evaluation3 G) K2 o; G; S% {, e2 {- ]& t7 ~
The bone age was consistent with 28 months by% m( |7 J2 e, G8 [4 B
using the standard of Greulich and Pyle at a chrono-
( `$ R: S  M7 Tlogic age of 16 months (advanced).5 Chromosomal; b6 u  x* j, M/ n3 ^* u
karyotype was 46XY. The thyroid function test
0 P! d9 X8 R* G# n3 j% @6 _# A: Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# s( [) Y+ B1 Slating hormone level was 1.3 µIU/mL (both normal).
) Y( N2 }5 b9 y4 s1 mThe concentrations of serum electrolytes, blood; q' L8 \0 j" V% U
urea nitrogen, creatinine, and calcium all were
9 h& z$ V, `6 f5 k4 `within normal range for his age. The concentration$ P: x+ W9 J9 ?. B5 o
of serum 17-hydroxyprogesterone was 16 ng/dL
; m/ z" x- R9 i) o(normal, 3 to 90 ng/dL), androstenedione was 20  G3 ?1 X$ S1 O! ~" a0 a6 C5 v+ ?
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) Z( C5 D" w! O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, O$ Z7 \% b2 K7 X5 j0 _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 ^3 w$ U7 n  u: y
49ng/dL), 11-desoxycortisol (specific compound S)
3 H% J8 d% D0 _' Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 A3 J$ @/ h0 T1 b. Atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; e5 T" \8 O* n5 J2 c" h; Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 k3 M7 E. v9 W
and β-human chorionic gonadotropin was less than: r; E9 M* U, b
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 V* u) P5 o1 D+ e4 d# T
stimulating hormone and leuteinizing hormone& r3 F2 O! i! e6 g
concentrations were less than 0.05 mIU/mL
& a7 X5 R( M9 F2 u- z1 x$ A4 o6 `. a(prepubertal).
$ M7 n. }* ]$ P  K. Q0 ]) \The parents were notified about the laboratory
: L$ k* T/ F$ Gresults and were informed that all of the tests were
6 l& `2 f4 O: ]2 ~6 ]normal except the testosterone level was high. The' K6 O# R& e/ V& t" n6 Q. q8 y
follow-up visit was arranged within a few weeks to6 O! J! f7 Y; M# G2 U3 q% f( A
obtain testicular and abdominal sonograms; how-
- @3 o5 }7 |" p8 Hever, the family did not return for 4 months.
% ?3 R! l  u$ e$ U8 ^Physical examination at this time revealed that the
7 C6 r) v( ^' K' H* _& Ichild had grown 2.5 cm in 4 months and had gained& m! l7 m/ s' }8 Q. k7 `
2 kg of weight. Physical examination remained9 f0 ^! H- }7 b- p" x8 ]/ x0 C8 Y
unchanged. Surprisingly, the pubic hair almost com-$ |# q4 _: t% R' B9 y/ w3 s
pletely disappeared except for a few vellous hairs at
+ d( ~, I& Y$ M! K; r& [the base of the phallus. Testicular volume was still 2
9 J  p: }- |5 Q" g4 h8 K! N3 `mL, and the size of the penis remained unchanged.3 [: Y* O9 V: A9 b' C
The mother also said that the boy was no longer hav-4 ]; j/ H% U# k. E! }9 v9 K
ing frequent erections.
4 p! `! V( t( v( z/ c8 y: b0 {) qBoth parents were again questioned about use of
- E" J  {3 J$ Y! S8 Lany ointment/creams that they may have applied to/ {  \7 b. K6 ^, h: l0 G
the child’s skin. This time the father admitted the
3 W0 N' b! W- d( STopical Testosterone Exposure / Bhowmick et al 541* }+ |& y* M6 }6 k6 l+ q
use of testosterone gel twice daily that he was apply-6 L, @8 k0 c, A2 E; M( E$ ~$ r
ing over his own shoulders, chest, and back area for4 J; G% G, ^: d. v% q% ^
a year. The father also revealed he was embarrassed
9 {7 {4 g0 j0 `, h4 mto disclose that he was using a testosterone gel pre-( t& M" O6 B- O4 J; [1 O9 ~+ J9 y
scribed by his family physician for decreased libido* M0 O1 R8 k- ^' ~1 R
secondary to depression.2 _# Q2 X/ L& e/ G1 G0 q
The child slept in the same bed with parents.- f' ]; U0 f8 v; S4 s. {
The father would hug the baby and hold him on his
+ s6 t& v; j: e8 \) ]chest for a considerable period of time, causing sig-9 w' C2 |% ^/ k; F$ |* r
nificant bare skin contact between baby and father.
% i9 J3 n% O& e4 P$ F- y. Y" [The father also admitted that after the phone call,
) ]* h6 v5 `& E% `0 Fwhen he learned the testosterone level in the baby
" q) V3 V# _7 ^& Q0 O5 Lwas high, he then read the product information
/ U) z0 z' a) r+ ^packet and concluded that it was most likely the rea-# s- G% q( H  N2 u9 k9 z. p0 _3 q
son for the child’s virilization. At that time, they5 N  _: N# x9 e# {5 u: N
decided to put the baby in a separate bed, and the
! G4 Q, ^9 C+ a6 h! Efather was not hugging him with bare skin and had& R! [( [. l& e0 O& G4 h
been using protective clothing. A repeat testosterone# y+ [, _9 {; t6 Z
test was ordered, but the family did not go to the. j% @# p- J$ z9 h" K* t) H
laboratory to obtain the test.
7 X6 G5 Q. D4 |. m: @! ?- A" `Discussion
. T. B1 Z8 s! a3 Z! Q1 r7 kPrecocious puberty in boys is defined as secondary' x7 z. `+ W/ c+ z3 s
sexual development before 9 years of age.1,4% x$ T# {. f5 B) e7 }7 c8 {; m
Precocious puberty is termed as central (true) when! Q& o" O1 k9 A. C' g$ d1 M
it is caused by the premature activation of hypo-
5 r( f7 H* m$ t4 @& C  ythalamic pituitary gonadal axis. CPP is more com-2 j6 ^* I6 ^( _/ b# z' H
mon in girls than in boys.1,3 Most boys with CPP7 j8 g/ F* p9 I
may have a central nervous system lesion that is% |) v$ r$ t7 R/ x1 ]
responsible for the early activation of the hypothal-# y2 [3 G+ `5 I4 u6 j* X
amic pituitary gonadal axis.1-3 Thus, greater empha-0 p! K( O2 R0 s% o* Y% a) x
sis has been given to neuroradiologic imaging in# x7 L2 Q. r6 b, \. K% `  ^
boys with precocious puberty. In addition to viril-
7 k, ^+ e5 c! v, |0 W% r4 kization, the clinical hallmark of CPP is the symmet-
+ n9 ~9 q6 M" Mrical testicular growth secondary to stimulation by
) K, f) I! [. h& D9 Ugonadotropins.1,3
# A! p0 Z& g: i# p( oGonadotropin-independent peripheral preco-* v3 m2 L+ C3 k* G. G
cious puberty in boys also results from inappropriate
1 w- b8 t- D+ K; E% Bandrogenic stimulation from either endogenous or
4 r0 ^( j- ?  ]# v! Z& |/ w" Uexogenous sources, nonpituitary gonadotropin stim-
7 j! E* K/ U  Fulation, and rare activating mutations.3 Virilizing
/ ^2 C, g! z- e: R7 k; \" a  Ycongenital adrenal hyperplasia producing excessive# }( @+ O1 o& ~( i
adrenal androgens is a common cause of precocious8 p  i# ^0 x2 n* q
puberty in boys.3,4
$ n( f5 m7 u4 E( `5 n( f+ o1 }; w+ \* S- uThe most common form of congenital adrenal
6 L: M: V4 F7 }  x! {hyperplasia is the 21-hydroxylase enzyme deficiency.+ f' i7 a* w. w2 C6 |6 y% D% j* D
The 11-β hydroxylase deficiency may also result in
1 J* I+ v* }; M" h, `& F% q, |excessive adrenal androgen production, and rarely,2 K1 A' o) j8 {) J
an adrenal tumor may also cause adrenal androgen% n' Z" Y1 y+ X9 u; g" Y0 O
excess.1,3
+ v, X) Z, L0 uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 z3 R; S1 X0 E$ c% C: a+ v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, r7 z+ o! D; Y  aA unique entity of male-limited gonadotropin-
+ \+ r- |7 R8 `0 Y/ l2 Y6 `6 s3 t$ d1 Zindependent precocious puberty, which is also known7 f/ d9 N4 [  ^% S* S, a6 ?
as testotoxicosis, may cause precocious puberty at a
* M( S/ K5 d  zvery young age. The physical findings in these boys/ B) z+ @5 F' z3 D1 q
with this disorder are full pubertal development,
# g# c/ f& I2 x) cincluding bilateral testicular growth, similar to boys
8 j8 b6 |7 _6 N$ A" Hwith CPP. The gonadotropin levels in this disorder
; T+ }5 {1 H9 l! e: mare suppressed to prepubertal levels and do not show
! \2 e& T; ~/ e' H; Dpubertal response of gonadotropin after gonadotropin-
  V' z* Y, ~" U. A; E6 Preleasing hormone stimulation. This is a sex-linked
, Y, c) t9 D$ ~) X* mautosomal dominant disorder that affects only
) H, K- T2 T! y$ v' k& w* i! _- V5 Tmales; therefore, other male members of the family1 h/ Y0 V" s4 q! ^0 W( j+ b
may have similar precocious puberty.3
) c6 N5 F$ d/ y8 k* p( b& t( hIn our patient, physical examination was incon-
9 X, R9 q1 m4 L4 l: m; Y  \sistent with true precocious puberty since his testi-
/ y/ \1 q/ Z) Z: ~3 V! o& O8 ecles were prepubertal in size. However, testotoxicosis  T- w1 M; h3 f* J! @( E
was in the differential diagnosis because his father+ C3 a8 A0 H& t4 l7 `; f& n* b
started puberty somewhat early, and occasionally,
% i! I* n( l* _' i! \$ G5 Rtesticular enlargement is not that evident in the" l/ x/ _2 C3 ^) C
beginning of this process.1 In the absence of a neg-% m+ y& D. k1 k
ative initial history of androgen exposure, our$ w2 \0 l$ ?* i  F6 {
biggest concern was virilizing adrenal hyperplasia,0 H/ V8 M6 t  P4 k4 r2 \0 S
either 21-hydroxylase deficiency or 11-β hydroxylase
8 X8 f1 ^0 ]. A+ ~deficiency. Those diagnoses were excluded by find-
, b* v: @9 B1 z( c/ K- E  ming the normal level of adrenal steroids.
. c  z+ |$ g& rThe diagnosis of exogenous androgens was strongly- g+ f3 |( V% r, f
suspected in a follow-up visit after 4 months because8 B) ~% s4 L1 W( K& S1 m
the physical examination revealed the complete disap-5 r. ]* ~$ u& |0 d" z
pearance of pubic hair, normal growth velocity, and" L, d: A1 P( X6 E7 o$ r; R; ]5 m$ x
decreased erections. The father admitted using a testos-) X( R2 W" Z! Q/ D
terone gel, which he concealed at first visit. He was
8 Y- r. J. i9 v' h; t5 W4 ausing it rather frequently, twice a day. The Physicians’; N- v( X6 e/ M& j7 ~
Desk Reference, or package insert of this product, gel or& G. h- M7 V/ W. a+ d4 D% r8 j
cream, cautions about dermal testosterone transfer to
  E9 T% [8 \) g) |! F- }unprotected females through direct skin exposure.
# m: A1 m" {& E4 e/ ~% RSerum testosterone level was found to be 2 times the; U6 ^. m0 M  k! {
baseline value in those females who were exposed to
3 Y! p& g- t0 [# G% feven 15 minutes of direct skin contact with their male
7 J6 r) p) I  p9 {+ m: Gpartners.6 However, when a shirt covered the applica-
& |" z5 f' ^, P0 i% ~4 t" Ction site, this testosterone transfer was prevented.& z# a* z1 F: X0 s+ T
Our patient’s testosterone level was 60 ng/mL,3 K" Q4 }. I6 P
which was clearly high. Some studies suggest that
9 C$ {5 ]! X9 j( odermal conversion of testosterone to dihydrotestos-* P1 O/ H8 Z/ v. h, Z
terone, which is a more potent metabolite, is more
& x% j8 A7 e$ B% K& sactive in young children exposed to testosterone6 Q- d5 O& v% s
exogenously7; however, we did not measure a dihy-) K: ]7 b) i- i8 x4 E
drotestosterone level in our patient. In addition to) r+ ]* d* V5 m, v. S0 W
virilization, exposure to exogenous testosterone in, f; Z% J! A" t
children results in an increase in growth velocity and
8 \* F) h- ~3 g* j0 Badvanced bone age, as seen in our patient.% y4 j: @6 d/ k
The long-term effect of androgen exposure during
4 A" a5 I  C9 I9 a1 T* Cearly childhood on pubertal development and final; G" |( B1 I3 C5 O9 C+ T
adult height are not fully known and always remain
8 y% G9 c6 y: n9 X) ka concern. Children treated with short-term testos-
' p7 D' E7 k, v* V7 K! T& @terone injection or topical androgen may exhibit some
, O5 @' h7 B- vacceleration of the skeletal maturation; however, after
1 a) e  E$ q/ m) l) e9 d+ _" Ncessation of treatment, the rate of bone maturation
" |) {8 F6 ?' @+ C) Sdecelerates and gradually returns to normal.8,9
' d) R" f/ j' G/ @; r( N$ `) A& p( JThere are conflicting reports and controversy8 t9 @( R) e5 p! C4 x" z
over the effect of early androgen exposure on adult
0 x, `: Y+ I! p+ j/ wpenile length.10,11 Some reports suggest subnormal
$ R  G$ b- Z) Y( r4 ]* `; A3 qadult penile length, apparently because of downreg-
- ^. Z, V+ A& }' h6 X. |. {% W, v' }ulation of androgen receptor number.10,12 However,
. L* Z. W: I: h- h" }3 X4 e0 w( XSutherland et al13 did not find a correlation between2 K& z% m% M% u6 {/ u6 S  Y
childhood testosterone exposure and reduced adult2 C, ~4 B  e/ g$ g
penile length in clinical studies.
  K! h8 U1 f+ [3 \0 N$ E  c% yNonetheless, we do not believe our patient is
6 ?+ Z9 O) Z! N- n( J, ?: Bgoing to experience any of the untoward effects from' E7 h+ B3 o' v& H  l, K
testosterone exposure as mentioned earlier because
5 `9 c: G" {/ @- athe exposure was not for a prolonged period of time.4 |. ]& b6 A( ?3 F- n3 T
Although the bone age was advanced at the time of
% F8 F) |7 F2 K9 ^9 _! Ldiagnosis, the child had a normal growth velocity at5 Z( ~5 @8 p7 {* v
the follow-up visit. It is hoped that his final adult' R+ B/ R- Z5 H) A
height will not be affected.
6 R5 n: `0 ^0 n! X8 n! H( \% YAlthough rarely reported, the widespread avail-6 n6 ^0 R, T7 o2 D
ability of androgen products in our society may
  M% ?$ ]5 G+ B: zindeed cause more virilization in male or female
8 h9 t; e/ s: `" y8 q0 `, ], ?children than one would realize. Exposure to andro-4 ^3 \! t7 \9 U7 K6 ^
gen products must be considered and specific ques-/ s* X$ K9 k: r
tioning about the use of a testosterone product or
7 x: \: D' M3 y6 a( o* y$ Dgel should be asked of the family members during9 X# E$ ~4 u5 `
the evaluation of any children who present with vir-. v( f" ?4 A7 B' D" u
ilization or peripheral precocious puberty. The diag-
; h5 D- h# i4 u1 f; e! Y2 Lnosis can be established by just a few tests and by
+ I( b! T7 t8 C% ?appropriate history. The inability to obtain such a
. ?# @4 G1 m/ z" z! L4 W+ o* Zhistory, or failure to ask the specific questions, may
8 o  H" }3 Z5 |5 b# ?result in extensive, unnecessary, and expensive% ]: \1 d8 |3 X7 N
investigation. The primary care physician should be
7 M. `& I9 A: A/ `$ u6 haware of this fact, because most of these children
5 g  U: e! v8 a% M, Imay initially present in their practice. The Physicians’% A* \1 S5 d, K" L$ n9 o- d* P
Desk Reference and package insert should also put a
  g4 H% f1 K3 n9 ^" @warning about the virilizing effect on a male or
2 t/ [! i. i" [) w; O) r  e4 A' sfemale child who might come in contact with some-  F% J3 P( K; y$ H
one using any of these products.
! r+ \7 ^- b# w* K% B/ {% eReferences% ^) M, k% H9 Z0 D& z, D, D* `" @
1. Styne DM. The testes: disorder of sexual differentiation
- {6 W: K: _" H) Z' h9 Vand puberty in the male. In: Sperling MA, ed. Pediatric
0 Z& v" q% q6 _- WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* D+ @- e9 {3 C7 o! R* f) o8 r  b  i2002: 565-628.
$ X4 f* }5 G) j/ _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: c3 M% N0 x7 V  b1 e8 B# X6 t: Z/ k
puberty 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
/ W, j  o2 P9 A: A
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