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
, m: [% x4 J" C0 v1 e0 PBoy Induced by Indirect Topical
% ^" X1 R. u) y8 eExposure to Testosterone
' [( R2 a/ L: O; y2 I! E, m; FSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 t7 Q+ D  p5 h4 _8 V% V* d  f
and Kenneth R. Rettig, MD1
9 D6 Z5 Q$ L/ d- JClinical Pediatrics
1 {2 C* ]! ^9 C5 ?# o$ A% z; wVolume 46 Number 6
' M* m1 x& D3 @% `July 2007 540-5432 ~+ t, |! v. K0 [
© 2007 Sage Publications5 a7 a5 j; m: u- E
10.1177/00099228062966518 a- X. e$ [7 s* H' W8 z
http://clp.sagepub.com
( {* A3 l$ s; r% l/ y, C7 qhosted at
' Q" D: `3 S3 v" R1 q" K; V8 vhttp://online.sagepub.com
+ {) n# ]' f9 w5 {1 S6 xPrecocious puberty in boys, central or peripheral,
& S" J% z6 Z* v; W8 H2 ?/ V6 G) z+ bis a significant concern for physicians. Central
$ E- q4 K0 ^0 c5 dprecocious puberty (CPP), which is mediated, f" ]9 s  h4 p( x+ H! Z
through the hypothalamic pituitary gonadal axis, has/ e' a4 R( [& L6 P
a higher incidence of organic central nervous system5 T4 C" }* h/ A- a/ l
lesions in boys.1,2 Virilization in boys, as manifested) z- s2 m6 H( b( R. _
by enlargement of the penis, development of pubic
- e% G2 j/ i7 Dhair, and facial acne without enlargement of testi-
! C/ O6 Z- H( Icles, suggests peripheral or pseudopuberty.1-3 We
# ]7 \' |$ L  |. breport a 16-month-old boy who presented with the
$ `! e, W# U" [  benlargement of the phallus and pubic hair develop-+ p+ k* F9 Q/ [5 `
ment without testicular enlargement, which was due
- e9 j5 X/ O/ I( J2 Qto the unintentional exposure to androgen gel used by4 f" W' U& J3 f
the father. The family initially concealed this infor-. D& M' c3 w% @4 C* r2 l
mation, resulting in an extensive work-up for this
+ p3 J& m6 [9 V# Rchild. Given the widespread and easy availability of5 F9 W6 F2 n* `1 F& S6 a
testosterone gel and cream, we believe this is proba-
& G" x6 \+ Y0 `  \# Q2 H4 Xbly more common than the rare case report in the
9 X! h4 ~. Y% Hliterature.4. ]3 L8 x3 w& ]1 s3 ?% x, A( G) q
Patient Report
# l  Q3 v, R' V9 p  {A 16-month-old white child was referred to the7 q/ A* `3 V, ]( e5 _5 P3 z
endocrine clinic by his pediatrician with the concern
7 Q1 V8 ^' K1 @% m( }; [of early sexual development. His mother noticed% U1 U! _0 F+ m7 _0 x3 ?
light colored pubic hair development when he was7 _  i( l" l; a6 U
From the 1Division of Pediatric Endocrinology, 2University of
8 W1 Z, B; U' E3 T5 ASouth Alabama Medical Center, Mobile, Alabama.
' Y9 i  \& e9 Z; W$ l" Y6 j" eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. B" [  T7 n% f( JProfessor of Pediatrics, University of South Alabama, College of( E' {8 d# j& R& j+ j* R- ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& Z: z. K  \$ L+ @/ [
e-mail: [email protected].
# A6 Q4 B0 K( @/ r, z9 Kabout 6 to 7 months old, which progressively became7 ]" r3 n( R' _4 z- y& J
darker. She was also concerned about the enlarge-
- `* Y- p0 Y& P0 @ment of his penis and frequent erections. The child
5 T  u% j/ ^! q4 g; Gwas the product of a full-term normal delivery, with1 _* [. X8 @" v/ A* R
a birth weight of 7 lb 14 oz, and birth length of
) t6 i& ~; F* y  _3 v2 |5 d' e7 M8 R20 inches. He was breast-fed throughout the first year* U4 a2 B' @  d8 w- p
of life and was still receiving breast milk along with
) f) E3 i& M& z  U! q0 g  Csolid food. He had no hospitalizations or surgery,
# o% O# i1 e+ I- S6 [. cand his psychosocial and psychomotor development/ v2 M: W- e; |* ?7 X$ F- u" ]
was age appropriate.- \0 e3 r  G0 U; P& D7 z
The family history was remarkable for the father,( F8 N/ O( N0 k6 @+ g5 z0 [& N
who was diagnosed with hypothyroidism at age 16,
# g$ m5 m9 B+ w1 @6 F) fwhich was treated with thyroxine. The father’s
1 I; I( o$ d% Y1 }height was 6 feet, and he went through a somewhat# ?+ u1 s* k1 S8 t
early puberty and had stopped growing by age 14., J' U8 n6 G' o7 Y" R% E0 f- ~  Z* W
The father denied taking any other medication. The; E: [& o3 k! m- W$ c  m( l
child’s mother was in good health. Her menarche4 s3 a/ j$ V) W
was at 11 years of age, and her height was at 5 feet2 Y1 o1 q  M/ Q* d
5 inches. There was no other family history of pre-& n# _" J1 v% v4 d* \) X  y
cocious sexual development in the first-degree rela-
* g. z# K" [0 j8 r4 `7 ^1 E1 M$ F" `9 Utives. There were no siblings.
# Q7 {4 F1 z" nPhysical Examination
: i/ U3 n- F& u! P% mThe physical examination revealed a very active,1 j9 e; Y6 n0 R& l; i* V
playful, and healthy boy. The vital signs documented4 s8 Y4 I4 o5 m+ q' L4 X
a blood pressure of 85/50 mm Hg, his length was3 }6 i- c# l; X/ p8 U% S1 e+ T( d
90 cm (>97th percentile), and his weight was 14.4 kg: w9 E- j) j2 i3 b' ^2 b  C9 d
(also >97th percentile). The observed yearly growth
% a2 X% H( X6 B( `velocity was 30 cm (12 inches). The examination of
0 D8 U% H( L1 G& R* ^the neck revealed no thyroid enlargement.& n5 z# r6 g7 {! ~! K
The genitourinary examination was remarkable for, `+ v1 K( g; Z, e# M6 M5 s7 Q
enlargement of the penis, with a stretched length of- q/ ~$ J/ [+ F3 m7 @* o
8 cm and a width of 2 cm. The glans penis was very well$ |% F1 b7 L$ [& d, @
developed. The pubic hair was Tanner II, mostly around
& Y% e7 B* u7 w. Q# B# |; {540/ U; E6 l$ a; b* X6 G7 J2 ~% v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* s: _* _6 u& o& fthe base of the phallus and was dark and curled. The7 J) ~5 F" a) ?: O
testicular volume was prepubertal at 2 mL each.) W- m& A1 G. {
The skin was moist and smooth and somewhat
) u& N* T4 q" ^- X- M. ?oily. No axillary hair was noted. There were no
. ^" G% D# b2 U6 O7 ]abnormal skin pigmentations or café-au-lait spots.
) U0 \; [+ Y% |2 N2 z0 _/ QNeurologic evaluation showed deep tendon reflex 2+, v. `6 c* v" V+ ?
bilateral and symmetrical. There was no suggestion
/ P- [9 P) V$ W$ K  B; O6 v4 u5 O6 jof papilledema.
( U/ i8 ^+ `4 h' x( `% f0 i' qLaboratory Evaluation2 d2 I9 }8 V6 a
The bone age was consistent with 28 months by
$ p" G  m4 Y4 I. W' J+ N; ousing the standard of Greulich and Pyle at a chrono-
& u( ^3 }1 o, [logic age of 16 months (advanced).5 Chromosomal
7 d. Y+ _$ B2 V/ Ekaryotype was 46XY. The thyroid function test
$ L+ |& D9 v% d  s8 [. [) Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, P+ L$ w4 j1 [$ `2 h
lating hormone level was 1.3 µIU/mL (both normal).
9 m: a& a8 u. B+ K. ^The concentrations of serum electrolytes, blood0 U# H$ O" v, @3 E
urea nitrogen, creatinine, and calcium all were
1 E) J/ @- P+ T& S% F; r+ ]/ ywithin normal range for his age. The concentration
. a+ y' C- M: E4 iof serum 17-hydroxyprogesterone was 16 ng/dL
0 a. Y6 z7 B( z6 a+ b(normal, 3 to 90 ng/dL), androstenedione was 20
# Z) Q+ z9 u+ T! F0 x# ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 @8 K! {( a3 [terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 p1 l8 e1 A# K4 h( [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 {. u7 N  t7 Q5 V49ng/dL), 11-desoxycortisol (specific compound S)  j4 b, O, b$ k8 \6 D1 u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ ?  |2 ^9 q. Q; g2 ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# J3 S' k- G0 ?, k# z- |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ \$ j6 x9 D$ @# K/ |  K& c# R2 W  A) U# D/ dand β-human chorionic gonadotropin was less than
+ Z$ u4 ]6 M4 a1 y- H5 mIU/mL (normal <5 mIU/mL). Serum follicular1 V% J# G* |' I
stimulating hormone and leuteinizing hormone
9 W; a& j9 ]/ L# u1 m! X5 x. }6 ]concentrations were less than 0.05 mIU/mL; x6 ^3 s9 J/ }8 _
(prepubertal).
' Y) I7 Z4 D$ `  |  ?, cThe parents were notified about the laboratory
7 M9 ], R5 P7 j1 \1 b- L* yresults and were informed that all of the tests were
, a/ d  h2 y3 N1 U+ o9 w6 C: |normal except the testosterone level was high. The; d" j0 M  l# }- ?3 f0 W! o' c
follow-up visit was arranged within a few weeks to
" W6 Z- v* W4 v) ?2 J' gobtain testicular and abdominal sonograms; how-* r+ [' o5 Q0 Z. [  y  `' X
ever, the family did not return for 4 months.
8 T  Y5 f' A6 F( lPhysical examination at this time revealed that the
: Z  r' ~, d; Rchild had grown 2.5 cm in 4 months and had gained
9 C9 y! N8 c) x) v2 kg of weight. Physical examination remained7 r, Y- R9 o! ~( X) U7 Y" n
unchanged. Surprisingly, the pubic hair almost com-$ C8 ~# S2 q+ f1 X3 L8 r' q  c
pletely disappeared except for a few vellous hairs at
! \2 ^+ v% k' B1 G( R: o/ N2 q( othe base of the phallus. Testicular volume was still 2# z3 j1 Y7 X/ O" ^
mL, and the size of the penis remained unchanged.
$ U, X" n1 N  R+ C9 U4 W6 V3 lThe mother also said that the boy was no longer hav-
- g/ w7 Y% Q$ ving frequent erections.0 E9 ]& W* S: s8 z/ x% a$ z; ~" j( O
Both parents were again questioned about use of) b9 l8 C/ K9 k% g+ H4 j
any ointment/creams that they may have applied to
! }$ ?: n; @9 p1 n- l2 Jthe child’s skin. This time the father admitted the& ~' G: Q5 w6 O; Z& m2 x) R3 F
Topical Testosterone Exposure / Bhowmick et al 541" q) D- z* _( ]$ B6 x) l2 ~, P" i0 s
use of testosterone gel twice daily that he was apply-# g, [& d" E6 B* u, j. U. x' _
ing over his own shoulders, chest, and back area for
1 R4 H$ l- }( Q2 J5 h% ~a year. The father also revealed he was embarrassed% I' B9 t  l4 S3 ?
to disclose that he was using a testosterone gel pre-
5 H- N) {; ^, |9 U. x/ T5 oscribed by his family physician for decreased libido
& G" q! D9 \5 i9 A  d: Q3 [secondary to depression.# H( s0 J# ?8 S1 L) n' v
The child slept in the same bed with parents.  R- E* B+ d/ T# v3 N( X2 U
The father would hug the baby and hold him on his8 R- A  E- W$ r, E/ a: A
chest for a considerable period of time, causing sig-1 t3 O' u, A$ G9 E' @4 S7 N
nificant bare skin contact between baby and father.0 a6 h" x  B4 A5 O, ~2 i7 s1 Q
The father also admitted that after the phone call,( H( |: k# O2 J- x3 |
when he learned the testosterone level in the baby! |" L3 ]2 C, N  p
was high, he then read the product information
6 ~) b* y+ M/ g& m. Cpacket and concluded that it was most likely the rea-
, M5 ]  X% g$ g; wson for the child’s virilization. At that time, they" T+ R& P7 A2 W) k# N! b' W
decided to put the baby in a separate bed, and the
/ X8 M% E$ t4 Z% j, qfather was not hugging him with bare skin and had
  @  w- }- N8 k% ]% u" fbeen using protective clothing. A repeat testosterone
# u/ F- i" J7 W1 C/ Xtest was ordered, but the family did not go to the, j) n9 k& D0 G0 Q5 H. s$ g' t
laboratory to obtain the test.
2 Q2 m! _, J* kDiscussion
8 K0 o" \( x$ ^( P" PPrecocious puberty in boys is defined as secondary
+ {1 u  ^! s1 Wsexual development before 9 years of age.1,43 p2 D9 _- E+ M" W7 x
Precocious puberty is termed as central (true) when* O  O. a% R) c. q. t9 i) ]6 h. s" ^6 K
it is caused by the premature activation of hypo-8 B5 K- @" S. N; b
thalamic pituitary gonadal axis. CPP is more com-
* R5 [( g7 y, e& S( R' hmon in girls than in boys.1,3 Most boys with CPP4 D0 W- |3 \  x% u
may have a central nervous system lesion that is
, O8 m' p& ~$ q  ^2 Jresponsible for the early activation of the hypothal-- b5 Q+ A0 G5 ]4 E" ^" x
amic pituitary gonadal axis.1-3 Thus, greater empha-
& g+ c( h) b7 x4 K  T% {sis has been given to neuroradiologic imaging in6 Y% K8 [; A/ k$ ]
boys with precocious puberty. In addition to viril-
( Y+ o. e) Q' Bization, the clinical hallmark of CPP is the symmet-$ w9 y" m0 A; \7 C
rical testicular growth secondary to stimulation by" U( y" i* L. z
gonadotropins.1,3; |6 V% S) G: y9 _8 k5 b7 D
Gonadotropin-independent peripheral preco-* M2 [0 ^8 P% m9 P' S( V
cious puberty in boys also results from inappropriate
3 m7 i$ f( T2 Bandrogenic stimulation from either endogenous or
; Y, G9 J6 H7 {8 W6 U4 uexogenous sources, nonpituitary gonadotropin stim-
/ j4 t/ F1 V- e  Z  Y; c& E- lulation, and rare activating mutations.3 Virilizing
4 c( S: F. @- |% N0 I5 o  I+ _+ ~congenital adrenal hyperplasia producing excessive
& Q& T' P8 ~3 V: yadrenal androgens is a common cause of precocious1 G) r3 {$ n( N8 u
puberty in boys.3,46 Z3 R0 l, z$ N4 y. }% o9 L( Y# a
The most common form of congenital adrenal
' }8 Q# F: g" Y. I% k4 Shyperplasia is the 21-hydroxylase enzyme deficiency.* _! F8 _' R3 P0 M1 a+ }
The 11-β hydroxylase deficiency may also result in; h' H/ y' v/ p" V
excessive adrenal androgen production, and rarely,9 n2 D, L5 ]1 R
an adrenal tumor may also cause adrenal androgen; V) o0 x9 a$ y  A
excess.1,3
9 Z9 w' L" u0 [! Y0 q! j9 u' v$ g% |% Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 t: R0 ?$ Q. e% I  R$ Z3 k
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 p( z. F) k1 ~1 Z" @* v# OA unique entity of male-limited gonadotropin-3 T7 U; @1 p+ a, x9 w  m
independent precocious puberty, which is also known
. a6 \1 D% _! K9 U& Qas testotoxicosis, may cause precocious puberty at a
  U' o5 j5 d' ]! Tvery young age. The physical findings in these boys9 ^( \' c. o& u$ K) B$ B
with this disorder are full pubertal development,. B' g. s; t! u' p9 @9 ]* N& T
including bilateral testicular growth, similar to boys3 m  E  x$ T5 M, u& w" T
with CPP. The gonadotropin levels in this disorder4 f% E& V$ L% J7 _" _8 H0 J
are suppressed to prepubertal levels and do not show6 `0 Z$ }2 a$ E4 |( f1 g' o7 F3 r
pubertal response of gonadotropin after gonadotropin-( l3 ^: y! M  H  x5 p
releasing hormone stimulation. This is a sex-linked1 M- q7 B( [- F! t" t+ U4 i) X. O
autosomal dominant disorder that affects only
* B7 d$ X* i5 kmales; therefore, other male members of the family( l: E$ J' E2 i7 B# Z
may have similar precocious puberty.36 \! K9 D, q$ {& _: Q
In our patient, physical examination was incon-
0 ^# E; W* B6 K7 Y+ U/ l$ Jsistent with true precocious puberty since his testi-
2 T+ V8 {0 S  J, I  Fcles were prepubertal in size. However, testotoxicosis3 C' [6 j; {( h5 B
was in the differential diagnosis because his father
$ i  {( _& _$ _9 Gstarted puberty somewhat early, and occasionally,
* w7 X, a9 v1 y) p* g/ Ktesticular enlargement is not that evident in the+ p* f1 r3 O: Y
beginning of this process.1 In the absence of a neg-1 {9 E7 J1 h, N. w6 a
ative initial history of androgen exposure, our
5 N) K; x" r+ G- Lbiggest concern was virilizing adrenal hyperplasia,* [. c+ m/ i4 P- a- t: B( z5 [  Y5 F
either 21-hydroxylase deficiency or 11-β hydroxylase' V$ }. p# r# Y. ]+ G* v
deficiency. Those diagnoses were excluded by find-9 ?/ @5 U1 n- O% H/ @8 _$ ~
ing the normal level of adrenal steroids.
: U7 J7 n& u. _3 ?3 _8 nThe diagnosis of exogenous androgens was strongly( x8 n1 f( V' f' T+ u
suspected in a follow-up visit after 4 months because
+ h7 F' {7 A0 b! [3 d/ }the physical examination revealed the complete disap-. _2 ^. u2 q6 j. k7 {4 w
pearance of pubic hair, normal growth velocity, and/ q# K( a- J: v
decreased erections. The father admitted using a testos-
5 D$ m1 t  C1 K& h$ {1 jterone gel, which he concealed at first visit. He was$ q' x1 h$ f" t6 E4 o- m3 l
using it rather frequently, twice a day. The Physicians’# |# t. K& F+ A3 q8 g+ r
Desk Reference, or package insert of this product, gel or
6 m6 T( z& C( _9 ?% n1 Fcream, cautions about dermal testosterone transfer to
4 ]& f4 l5 b, g% B! ^6 Lunprotected females through direct skin exposure." N  U: @; D" A2 L* g
Serum testosterone level was found to be 2 times the; e6 ]' r9 f0 q4 o: `* A9 e6 `
baseline value in those females who were exposed to  t' S# v4 w) a4 n+ \
even 15 minutes of direct skin contact with their male+ _5 |5 K+ C+ I* n& Z7 u
partners.6 However, when a shirt covered the applica-% h2 ~4 R9 K4 ^+ g8 G
tion site, this testosterone transfer was prevented.' G( L7 X8 n; o1 {, P( |
Our patient’s testosterone level was 60 ng/mL,+ y; g! S7 [8 U  U
which was clearly high. Some studies suggest that1 V2 x( O6 S! ^  ]$ I% u) ~
dermal conversion of testosterone to dihydrotestos-: x( s$ O; ]8 I! i/ A) r5 Q
terone, which is a more potent metabolite, is more
8 o& q0 N8 L. Vactive in young children exposed to testosterone
1 c* Z& A; C3 N4 Rexogenously7; however, we did not measure a dihy-0 T+ A4 s4 q7 {8 \9 t
drotestosterone level in our patient. In addition to
+ W# M% f8 N1 vvirilization, exposure to exogenous testosterone in
; U/ U  U! }1 R. p! G  q+ z) i7 b2 qchildren results in an increase in growth velocity and4 ~' \. Z0 ~# F5 y6 [, h5 u7 R
advanced bone age, as seen in our patient.4 T  f8 M$ \! v6 T$ Z3 P# I
The long-term effect of androgen exposure during
) z" {0 H( R1 C' {8 qearly childhood on pubertal development and final7 e0 S5 W3 o8 k4 [3 H' O) K
adult height are not fully known and always remain
  S1 Z" o8 d- ~a concern. Children treated with short-term testos-
: M# U0 m" P, |- E9 Y& sterone injection or topical androgen may exhibit some+ H% v( J. `  r4 S) g5 E, O2 G8 k
acceleration of the skeletal maturation; however, after9 J; G9 Q1 M# z2 K1 T
cessation of treatment, the rate of bone maturation  L- `4 \* c) J; c0 n
decelerates and gradually returns to normal.8,9
" W' C( e. S& t9 a4 tThere are conflicting reports and controversy
6 f* E, K, f: ]- E9 rover the effect of early androgen exposure on adult# j- }& ?" a( z+ N: j
penile length.10,11 Some reports suggest subnormal
5 R5 r! ?. p) @8 g3 N3 h3 Q; `- _adult penile length, apparently because of downreg-
9 z; c1 N( X+ h. p5 f: z) Pulation of androgen receptor number.10,12 However,9 u' d) @9 i- x& g2 Y: d5 f
Sutherland et al13 did not find a correlation between
; p" Q% `4 q/ ~$ O6 {childhood testosterone exposure and reduced adult+ P3 R! B  G7 t+ a9 p, U9 v6 C
penile length in clinical studies.
  H% g  T2 L& N3 ?0 B, eNonetheless, we do not believe our patient is( r0 j! O3 B; H/ g
going to experience any of the untoward effects from
; r, K. T; H8 M6 J3 ?testosterone exposure as mentioned earlier because
8 y. w3 G+ c) u9 {: Vthe exposure was not for a prolonged period of time.1 |- ?/ q+ ]. B8 T$ n  K. ^( m7 m& k$ M
Although the bone age was advanced at the time of
# S, X" y- q0 U$ rdiagnosis, the child had a normal growth velocity at) T! H4 ?/ X* S( ]8 x
the follow-up visit. It is hoped that his final adult2 t- t0 l' q0 n' p" ]! Q
height will not be affected.; }2 `5 f+ N. B  Z8 x) x  y
Although rarely reported, the widespread avail-/ |, ^! J# p' _; a$ @& k
ability of androgen products in our society may
  b8 F/ A$ V8 i; Hindeed cause more virilization in male or female
( O3 g  p% s" P4 K$ ~5 s9 F0 Achildren than one would realize. Exposure to andro-) e4 T( T8 k3 b  k* z5 x; _
gen products must be considered and specific ques-7 d. Q4 A) e2 K& i: y4 q
tioning about the use of a testosterone product or* \# n' p) ?. T
gel should be asked of the family members during
2 U( |3 U' J+ Cthe evaluation of any children who present with vir-% e: g' @) R* z4 ?+ H( {+ F/ a
ilization or peripheral precocious puberty. The diag-+ o$ _5 @* w8 S* I0 K4 A
nosis can be established by just a few tests and by
3 F2 r, k% x% {% I! ~8 r) eappropriate history. The inability to obtain such a
( O* q6 f* m9 l0 u' V( y0 Thistory, or failure to ask the specific questions, may, q$ n) R! o% M$ y
result in extensive, unnecessary, and expensive; x/ Y, Z+ W6 E  F, w7 r
investigation. The primary care physician should be/ v; r( M! {  H6 Y
aware of this fact, because most of these children
8 _+ l$ Z# I" @( V7 }* ymay initially present in their practice. The Physicians’" G* C0 Y5 ~0 @% m# g6 M- M
Desk Reference and package insert should also put a- }4 h3 S& s" H3 i
warning about the virilizing effect on a male or; ?6 C6 t/ G' {8 d+ X2 h  V  ~% z( P
female child who might come in contact with some-8 A) u: \5 ~' u& q* |4 X( x
one using any of these products.8 k& E& [) _6 T
References
! k8 \* j6 H4 Z7 b& d) S! M8 ?1. Styne DM. The testes: disorder of sexual differentiation
5 i4 w, Y* T, Q! X8 R% Hand puberty in the male. In: Sperling MA, ed. Pediatric
" ]% j) d' k. E, T% Y9 {' c& t& F! h, mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 L( _, q. g) I- B7 z0 l/ J2002: 565-628./ V2 D0 q* w  j, {( _% b/ A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! R5 v% ?8 e5 t+ i0 y/ }5 dpuberty 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
& S* G- g! U# _6 H4 V: h. l+ r7 t* ~Boy Induced by Indirect Topical
  }* P4 S! @) D! Q+ cExposure to Testosterone# M. U$ v0 [% C. F% C  V( [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ k% g; J1 C) o& @( y( f
and Kenneth R. Rettig, MD15 X6 y7 h0 o2 b! X5 `% q
Clinical Pediatrics
0 N/ Q4 `  P1 S/ M  K' jVolume 46 Number 68 z6 W' |/ z/ r0 r' F
July 2007 540-543. S0 X% ]9 h" Y
© 2007 Sage Publications  c$ K8 P7 d* r2 m0 a4 ^- K
10.1177/0009922806296651
; T0 ]" e* p$ R/ m( x! qhttp://clp.sagepub.com
: g" ^8 r3 p/ d  s& `# Chosted at; x$ g; ^7 s) S8 A& q" K3 ?
http://online.sagepub.com' l2 x4 I( }* ?
Precocious puberty in boys, central or peripheral,
: F* F, S( u1 [. t) Ais a significant concern for physicians. Central
" Y  H! S+ F) {. I" \4 T: a. Mprecocious puberty (CPP), which is mediated$ H" d9 h  a3 U3 D: n" m
through the hypothalamic pituitary gonadal axis, has) e3 `4 |: m. [7 t* S. w" l1 {& }$ ~
a higher incidence of organic central nervous system. Q" i1 Q" t0 C
lesions in boys.1,2 Virilization in boys, as manifested
( n6 P% |6 O  D% j& Uby enlargement of the penis, development of pubic
9 h1 t& U2 k1 _hair, and facial acne without enlargement of testi-
4 [, B) ]1 ~7 x; jcles, suggests peripheral or pseudopuberty.1-3 We
9 q! E# o' Z( Z0 X/ s6 p5 Hreport a 16-month-old boy who presented with the! P) Y% c8 h+ ^4 a$ v$ ~$ i0 l
enlargement of the phallus and pubic hair develop-# ^; K. B$ K; R4 g6 D9 z
ment without testicular enlargement, which was due
& B4 x( H" n) ^1 y  Bto the unintentional exposure to androgen gel used by' n- i& b; Y( y( w5 X8 E
the father. The family initially concealed this infor-
1 Y$ E+ x! q9 O1 q8 i5 z1 _mation, resulting in an extensive work-up for this
& x$ p6 h! z9 t! Kchild. Given the widespread and easy availability of
$ ~/ U* M( C2 T4 @$ C3 U0 ttestosterone gel and cream, we believe this is proba-
! U% o; {& L9 y6 |7 Z' U. X5 Mbly more common than the rare case report in the" o0 |  H) M1 n: B8 `( M3 p
literature.4
2 ^8 J. J- @. h8 P( ~7 uPatient Report
5 H- q  r" c+ k) i3 ~, uA 16-month-old white child was referred to the6 m7 L6 X. ]3 u' i. X
endocrine clinic by his pediatrician with the concern% G1 x/ v5 B. i& {6 W
of early sexual development. His mother noticed9 J  m2 v/ P. j! K) h
light colored pubic hair development when he was8 \3 U* M: p" s5 I1 G( b1 E
From the 1Division of Pediatric Endocrinology, 2University of" S* G4 v4 f' c3 m
South Alabama Medical Center, Mobile, Alabama.; O9 o  X0 H# u& E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 n, c0 x2 n! @- p0 XProfessor of Pediatrics, University of South Alabama, College of. j8 a: E# n  ?" |5 N4 f, S; h8 `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* [% P! V3 n; o9 T$ P4 ge-mail: [email protected].
7 r4 p, U8 D7 k4 I( m: k6 qabout 6 to 7 months old, which progressively became: H# f% q* v% r3 w% R
darker. She was also concerned about the enlarge-
: H" P, |4 h1 s4 F. T) l7 H2 Jment of his penis and frequent erections. The child& z; u' m' _6 R) e" Y4 Z
was the product of a full-term normal delivery, with
1 d  n. a% W, va birth weight of 7 lb 14 oz, and birth length of: @' P2 o+ m. D5 C; \
20 inches. He was breast-fed throughout the first year
. v% k' }8 C! H- Wof life and was still receiving breast milk along with
9 K: F0 A2 G' Y, R$ F: T0 msolid food. He had no hospitalizations or surgery," w6 m! u: ^% N# I2 V
and his psychosocial and psychomotor development
6 U5 J  E: y3 Owas age appropriate.0 Q7 L" c$ u* b
The family history was remarkable for the father," T, z  f/ G. x& z
who was diagnosed with hypothyroidism at age 16,
% B* n! A; G2 [& \5 u! lwhich was treated with thyroxine. The father’s5 B/ K: y+ E! l
height was 6 feet, and he went through a somewhat! y% w; ]3 W9 |2 O2 O) W
early puberty and had stopped growing by age 14.
, G* g5 t& z3 i" @The father denied taking any other medication. The7 u+ P# n" J; B6 I7 v2 [, F
child’s mother was in good health. Her menarche4 K6 j! Q2 Y4 R. S+ h3 ?
was at 11 years of age, and her height was at 5 feet4 N" @2 X' |5 K& h* c% H* c
5 inches. There was no other family history of pre-) j) R' Z* O# i7 `! r+ l
cocious sexual development in the first-degree rela-0 F! @1 ^, @7 c. n
tives. There were no siblings.) ~6 E% f  a% w7 H2 ~4 J, g
Physical Examination& L4 ^4 [& I& U. q+ ]) L: A9 w: t8 h
The physical examination revealed a very active,
, E9 X& o9 g8 n8 cplayful, and healthy boy. The vital signs documented; t7 j& o$ _" u- X$ m
a blood pressure of 85/50 mm Hg, his length was
. G. a$ e3 R4 a90 cm (>97th percentile), and his weight was 14.4 kg, ~* s7 {. z) z4 S& U
(also >97th percentile). The observed yearly growth$ n7 r6 P3 Y( q, z/ o
velocity was 30 cm (12 inches). The examination of0 J4 B7 E5 W6 r
the neck revealed no thyroid enlargement.
! G1 Y/ p: C' u. N' f) YThe genitourinary examination was remarkable for' t4 q. L/ U8 Y
enlargement of the penis, with a stretched length of
* D5 R0 s# U7 H2 o8 cm and a width of 2 cm. The glans penis was very well
& R, \& x0 d9 h1 xdeveloped. The pubic hair was Tanner II, mostly around9 Q% c$ U1 @, g7 R6 Z# o0 n" |
540! w7 g. ^: ]3 k1 Z. E9 y! D2 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. ]" x( @3 h, u, a" _6 N! mthe base of the phallus and was dark and curled. The: r* k0 S$ X+ w4 I
testicular volume was prepubertal at 2 mL each.) @4 m, h; I& E3 M' f# l0 C; }
The skin was moist and smooth and somewhat! s4 n2 O/ t6 N; p+ g& @
oily. No axillary hair was noted. There were no- ]0 k8 k! e( F( ^, v
abnormal skin pigmentations or café-au-lait spots.
4 ?; u6 Z8 I! P* lNeurologic evaluation showed deep tendon reflex 2+
+ m9 y5 q: ]# v4 J; _3 m" xbilateral and symmetrical. There was no suggestion
. Z( [$ \/ i) j" O$ Qof papilledema.
+ N, n2 G/ c+ `1 s# g- FLaboratory Evaluation
# A- _. G7 m; g5 A8 n8 G# Q. WThe bone age was consistent with 28 months by
  ?/ ~3 Q( v( T) Y- r! u% n, musing the standard of Greulich and Pyle at a chrono-4 ~4 ?- J# N( C/ g& k
logic age of 16 months (advanced).5 Chromosomal
: ?& f8 F" S: B* E% f: ?karyotype was 46XY. The thyroid function test' U) _! J- ]/ @; @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! `4 v  {7 o. r3 Klating hormone level was 1.3 µIU/mL (both normal).
" A' h' x8 L  k* P' E" |The concentrations of serum electrolytes, blood+ M6 o  X0 V! E* x
urea nitrogen, creatinine, and calcium all were
; C* c4 n: y9 \+ pwithin normal range for his age. The concentration  W8 k4 p- H3 @
of serum 17-hydroxyprogesterone was 16 ng/dL
5 V& v6 K9 j. c(normal, 3 to 90 ng/dL), androstenedione was 20
* g, {& q% e2 F6 ?2 B1 J7 H9 E8 yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' X# {) {& I- y9 U' uterone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 t' w4 e. K) N3 ]' q* D0 ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 ]% P4 c# [+ T+ S. D49ng/dL), 11-desoxycortisol (specific compound S)' t  n/ \, Z+ ^8 Z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( E4 X- X( G% I& y; @2 k& d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 L0 d6 `' l, {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 E/ Y6 a: m" e5 b7 M
and β-human chorionic gonadotropin was less than
7 d) L# q& Y! y  G5 mIU/mL (normal <5 mIU/mL). Serum follicular
  O5 q% b, J; n( }( Y0 [5 s2 ^stimulating hormone and leuteinizing hormone
2 q; I  a2 j7 g1 J: Hconcentrations were less than 0.05 mIU/mL8 p6 \" Y' `' s1 }- X0 ?
(prepubertal).# a8 ~2 @0 _. j) m0 a$ w# A
The parents were notified about the laboratory3 x$ N9 i4 J2 n+ w* i$ x4 e* Q* X
results and were informed that all of the tests were. L  B$ t' w$ X; f- V
normal except the testosterone level was high. The& S( E# x) I$ P$ {7 g3 N" W
follow-up visit was arranged within a few weeks to
+ L9 y) u& a- @4 y; Eobtain testicular and abdominal sonograms; how-3 k( o$ B0 A) ~4 u8 f: U8 n
ever, the family did not return for 4 months.
. ^: [. ?" J6 W  V' lPhysical examination at this time revealed that the
# L0 f) u; n$ d( U" k9 pchild had grown 2.5 cm in 4 months and had gained! [; W+ F$ ^  N  M% _
2 kg of weight. Physical examination remained
! ~. j1 s, @0 }. u" dunchanged. Surprisingly, the pubic hair almost com-
+ i  E$ a) _' l) v( p* w7 E+ M0 vpletely disappeared except for a few vellous hairs at  B/ r# m- x8 G
the base of the phallus. Testicular volume was still 2
. Z  N( E4 _& C8 X/ ^mL, and the size of the penis remained unchanged.0 z8 ]$ C, {1 q( R
The mother also said that the boy was no longer hav-
9 Y% L, N- g* \+ M4 O- t2 Ging frequent erections.
9 Y, U1 P4 X! K0 F6 y+ x5 ?Both parents were again questioned about use of
! T, J: V9 H- p4 H+ `" w3 ~' gany ointment/creams that they may have applied to3 s; ?: `/ @8 |8 _' f
the child’s skin. This time the father admitted the
; n, [( m+ w3 KTopical Testosterone Exposure / Bhowmick et al 541) e3 M( @' r: ~; {5 s" n& Z3 _
use of testosterone gel twice daily that he was apply-) }/ v4 j; h7 g2 N" F
ing over his own shoulders, chest, and back area for3 {: K2 a3 U  y. N" B8 [+ T
a year. The father also revealed he was embarrassed
: f9 X9 n3 S+ V: mto disclose that he was using a testosterone gel pre-
: u2 t; @- q1 }; J: x, W' ascribed by his family physician for decreased libido4 P7 ^' I5 O/ h! f7 v
secondary to depression.
; v0 W$ M: ?# w$ g8 c9 c$ G4 DThe child slept in the same bed with parents.0 A+ K8 w6 Q1 B. ]7 \. }% ^7 K; r% m
The father would hug the baby and hold him on his
* p$ N9 P9 T  S5 V+ Ichest for a considerable period of time, causing sig-
" g2 O! ]1 {1 D0 n+ m4 ~nificant bare skin contact between baby and father.
  }9 N0 w1 W* d: ?7 u9 lThe father also admitted that after the phone call,5 {. z: I6 b; k. |. S0 v  A' F/ O0 ]! h
when he learned the testosterone level in the baby
6 H* e& T1 C) R1 X  r: vwas high, he then read the product information
: X! v- K, y5 j! s% ~( fpacket and concluded that it was most likely the rea-
* E  x6 _# v6 ~son for the child’s virilization. At that time, they
# N& N" b! U" `# S, {- |8 h/ K  Edecided to put the baby in a separate bed, and the: N& N- I. G2 @7 V! O
father was not hugging him with bare skin and had
' H: U- W  K" B+ _# @1 z$ D0 Sbeen using protective clothing. A repeat testosterone
/ J; @5 a# S3 M) L% Rtest was ordered, but the family did not go to the- x/ R% n' s; b% I% H' H2 ~0 T* \
laboratory to obtain the test.
3 M1 S' l; Q# e9 G* b' C$ wDiscussion
5 X8 ]+ U/ e2 W% t; lPrecocious puberty in boys is defined as secondary
: Z3 S& o( P+ e  M! j! {2 i2 Bsexual development before 9 years of age.1,4
. C  ?+ _% h- B& VPrecocious puberty is termed as central (true) when
2 Y# Q7 U0 H/ J& y8 m" \it is caused by the premature activation of hypo-1 ^* \) Z) r6 i; n
thalamic pituitary gonadal axis. CPP is more com-
( _, d) e" q3 I2 D5 z! Bmon in girls than in boys.1,3 Most boys with CPP1 b+ v' q! u' H# B. C
may have a central nervous system lesion that is3 F$ ~. q# b& I7 ?
responsible for the early activation of the hypothal-* g7 K9 h. n1 e5 h$ x
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ k1 w# t/ B( e; b( Psis has been given to neuroradiologic imaging in& d3 c. ~5 D* S5 A& ^: A
boys with precocious puberty. In addition to viril-
8 B" X1 W) ^& n* H  ]$ R+ wization, the clinical hallmark of CPP is the symmet-
  d4 Q3 i- Z8 s. M  Qrical testicular growth secondary to stimulation by% a9 w# y) v# x* D% @
gonadotropins.1,3
( X: Y1 z' l; r! m" ?+ NGonadotropin-independent peripheral preco-" a4 B' t8 u! j8 C% x4 }: X6 _
cious puberty in boys also results from inappropriate, F) i7 M& o5 |/ G: @( M! R
androgenic stimulation from either endogenous or
! ~7 S! O+ R! y3 Y: k3 {! }exogenous sources, nonpituitary gonadotropin stim-
! d* p/ R9 B& B! d* f1 I# \' n5 A0 Iulation, and rare activating mutations.3 Virilizing
$ n$ P! N1 `# w5 R' k% xcongenital adrenal hyperplasia producing excessive8 P0 Z5 E$ {, ?% m! E: \. k
adrenal androgens is a common cause of precocious0 X- V: p) x: r1 a5 _* r+ j+ M
puberty in boys.3,4
" u" Q: F" ?# y1 V% W( Y: q4 r8 c) YThe most common form of congenital adrenal1 _, s# ?. C$ v& ]! P4 H
hyperplasia is the 21-hydroxylase enzyme deficiency.  ]* v/ Y, ~8 }& }
The 11-β hydroxylase deficiency may also result in* f$ [0 v/ x! C$ X& b$ E0 ]/ z
excessive adrenal androgen production, and rarely,( j" c( c# }! n+ f* n' B, v; k
an adrenal tumor may also cause adrenal androgen
! A% K- g* W& `% @/ _3 texcess.1,3
) S+ g/ [# g" I' Y, m0 [. p% Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  v" }. c* Q; n% O2 O$ i: x0 }0 Q% h542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 X+ l& A- L% [7 c% Z1 p
A unique entity of male-limited gonadotropin-
& Z+ l: f$ s7 b+ I. \independent precocious puberty, which is also known% o) e. Z( }+ Q) C
as testotoxicosis, may cause precocious puberty at a
4 @" d9 K/ H5 d) l2 S/ R- \very young age. The physical findings in these boys; E# N6 E% f7 K- l$ h+ F
with this disorder are full pubertal development,
: ~% S6 e2 ~7 `9 d8 Yincluding bilateral testicular growth, similar to boys4 d! I" V5 X' n/ D6 i  W
with CPP. The gonadotropin levels in this disorder
7 m9 p' [- u5 ?' c$ {+ Xare suppressed to prepubertal levels and do not show
: ^. c* a9 j8 r, n' Y  z% @9 [7 wpubertal response of gonadotropin after gonadotropin-
5 O1 a, _" }- c5 o* \releasing hormone stimulation. This is a sex-linked; @6 [+ G1 G5 L0 v" a( m9 A
autosomal dominant disorder that affects only2 C( o0 I: q, N2 A& f
males; therefore, other male members of the family
1 O7 K8 |7 }5 ^+ ?may have similar precocious puberty.3
8 M: W) s3 e7 TIn our patient, physical examination was incon-! q6 @; u" h- S9 y
sistent with true precocious puberty since his testi-5 H+ k3 B% D: W- D4 M0 z: m% X; D
cles were prepubertal in size. However, testotoxicosis, A, Z2 [1 m( ]
was in the differential diagnosis because his father
1 s* b  |2 w0 a! G8 kstarted puberty somewhat early, and occasionally,
* I5 m8 z  h) x# B  Htesticular enlargement is not that evident in the
/ @; E+ ~: W2 z, ebeginning of this process.1 In the absence of a neg-
% G! E0 e* K% w" V# D7 i; T) Dative initial history of androgen exposure, our! G8 X1 {  `1 t! {+ [7 q& a. s1 V
biggest concern was virilizing adrenal hyperplasia,
( F- D. t$ D: k  F$ Feither 21-hydroxylase deficiency or 11-β hydroxylase  b# Y2 ^# B  W
deficiency. Those diagnoses were excluded by find-
; M, ?6 o! X( d' k$ Hing the normal level of adrenal steroids.
; X+ K7 y: W( r3 D* M" `6 VThe diagnosis of exogenous androgens was strongly1 W6 A9 d/ \8 U  }4 U6 ^
suspected in a follow-up visit after 4 months because; i7 e2 t% q6 u0 r7 g) C
the physical examination revealed the complete disap-. t' d5 A: R2 l. Z
pearance of pubic hair, normal growth velocity, and
6 |! w" F; T# c9 ?" {; w1 r9 M2 Mdecreased erections. The father admitted using a testos-. T4 E( \$ a2 l  z. t: V& I
terone gel, which he concealed at first visit. He was( K/ j. F0 _' ?% B) Y8 T
using it rather frequently, twice a day. The Physicians’
7 G1 H% N7 N9 w& v2 VDesk Reference, or package insert of this product, gel or1 h! l. j- W6 J1 W; G  h- y, Z! J
cream, cautions about dermal testosterone transfer to
9 J+ b2 x6 N2 v8 Y# U* Wunprotected females through direct skin exposure.0 b1 h- I! U: ]
Serum testosterone level was found to be 2 times the
+ s! M+ y# t7 p7 @* J7 [3 Cbaseline value in those females who were exposed to) p8 ?7 r. f  f
even 15 minutes of direct skin contact with their male" y% y/ Q- o+ X- Q. a  f7 q
partners.6 However, when a shirt covered the applica-
; C! Y3 M& H+ K/ `/ c. U* G( Ttion site, this testosterone transfer was prevented.  _4 O9 Q) u/ J* {2 l$ v/ ]
Our patient’s testosterone level was 60 ng/mL,
' N4 x4 v8 Q" [% t% V7 H2 g2 fwhich was clearly high. Some studies suggest that. e. `' J( X: L, u# i: P
dermal conversion of testosterone to dihydrotestos-
5 V$ `) {2 M+ g1 U2 [( c2 m' `terone, which is a more potent metabolite, is more
5 v3 I* B3 X7 q) T; Y. xactive in young children exposed to testosterone7 W% J) ]2 F. W! h; Z
exogenously7; however, we did not measure a dihy-+ Y7 i+ l( E$ |6 T$ B! j
drotestosterone level in our patient. In addition to# S7 M7 R; H. I  |: X: ~
virilization, exposure to exogenous testosterone in
) n+ W- k# X: w  J8 n! rchildren results in an increase in growth velocity and
0 ?. |3 |4 A5 x* I. |2 Iadvanced bone age, as seen in our patient.( ]2 B) m% A0 V; J# T3 A  S
The long-term effect of androgen exposure during
0 f. @9 _0 ]. {# B, h( D! D% Bearly childhood on pubertal development and final, |, K# m" }* y
adult height are not fully known and always remain/ ]8 |% N$ [: {! u
a concern. Children treated with short-term testos-: t! N/ x+ l1 l3 x% z) w
terone injection or topical androgen may exhibit some
) Z9 A9 }$ H6 Y/ r+ C  R+ yacceleration of the skeletal maturation; however, after
! m, D+ Q! Y2 h/ ^2 @8 ucessation of treatment, the rate of bone maturation! e6 S: S3 c3 b% l0 b4 M3 M
decelerates and gradually returns to normal.8,9/ c. j! c9 D. m* s
There are conflicting reports and controversy
$ V: _+ r4 {/ m. P% O! `over the effect of early androgen exposure on adult
6 `+ A+ I& z# ~$ D7 s$ [penile length.10,11 Some reports suggest subnormal
8 h& P5 f2 u# U: ]( Q5 N+ hadult penile length, apparently because of downreg-5 G* `. k- T5 S$ d
ulation of androgen receptor number.10,12 However,# j( N. {. W5 l* I6 b2 y
Sutherland et al13 did not find a correlation between
- ?. S* c3 U; b! m- S) n' z6 dchildhood testosterone exposure and reduced adult$ \" J3 j# Y3 S! _  c) J
penile length in clinical studies.: c2 _1 w' ?* @" R/ K8 v5 y
Nonetheless, we do not believe our patient is
+ R  f2 W0 G! A0 D) c* ogoing to experience any of the untoward effects from7 @: l5 [% j7 M0 b
testosterone exposure as mentioned earlier because9 d5 P) L& I& V& E! A$ S( ?
the exposure was not for a prolonged period of time.
) `. t& ^9 w6 h0 f. m! E$ J8 [9 vAlthough the bone age was advanced at the time of' Y3 l  z3 I: y4 L+ D8 U
diagnosis, the child had a normal growth velocity at9 j8 }4 y6 N# ^2 O5 J! U* G
the follow-up visit. It is hoped that his final adult( Y* Y" P% V9 l5 b1 F5 B
height will not be affected.
" I  y2 p2 p0 dAlthough rarely reported, the widespread avail-
  ^) g) D% v- p4 q% @1 zability of androgen products in our society may
% Q4 p0 ~  ?, L5 Kindeed cause more virilization in male or female; x8 z: G9 W1 v' V
children than one would realize. Exposure to andro-
9 R8 [( \! A( qgen products must be considered and specific ques-
/ j8 J7 j+ u. H/ p" J) ftioning about the use of a testosterone product or+ s: O1 v7 W9 G, J( s5 c3 x
gel should be asked of the family members during
/ \( E  E/ R+ o* ]2 {4 W. c# cthe evaluation of any children who present with vir-2 |  m. z( Y1 O) Z' [
ilization or peripheral precocious puberty. The diag-
+ P; g/ O- V0 C: @: g! U* v+ p) o) _nosis can be established by just a few tests and by- \1 X; `4 L' \5 H+ D6 J
appropriate history. The inability to obtain such a
; Q  h" F" ?7 i; \history, or failure to ask the specific questions, may
( D  V3 v2 l+ q( o: i0 cresult in extensive, unnecessary, and expensive" Q$ `; x' u. [' z5 g
investigation. The primary care physician should be
$ g2 o' ?9 k9 A. ^+ `& @) H" Y8 r4 iaware of this fact, because most of these children6 X# f. A" A) q$ f
may initially present in their practice. The Physicians’# L2 D+ v3 q% d, J. C; y$ d( q
Desk Reference and package insert should also put a
2 q2 c& y- _# Lwarning about the virilizing effect on a male or
( r- }! ~! ^, A# z6 Ifemale child who might come in contact with some-
3 ]; k9 w2 r5 none using any of these products.- [/ Q: s  z5 _9 D; M: `# L
References: |" t- _& ]; y
1. Styne DM. The testes: disorder of sexual differentiation
* n9 G1 h" ^; y2 W& _' F+ h6 k, r* rand puberty in the male. In: Sperling MA, ed. Pediatric* g3 H) @: o- S4 j% T. `$ l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 x; Y' V8 Y9 H1 c2002: 565-628.; m& @: F4 o! C' Q9 `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- E3 N. C: n5 p1 K9 opuberty 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
6 s8 X% R  h1 ?7 W6 `
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