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-Old0 l2 v! C+ \! i$ d3 Y3 F& l
Boy Induced by Indirect Topical
6 M  b- u! j- PExposure to Testosterone+ F2 i( B* A% r, f3 m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; T8 N4 l8 v, K; h' `and Kenneth R. Rettig, MD1
0 F% }" T: n1 y$ FClinical Pediatrics; f# h1 T6 L" j% D# D
Volume 46 Number 6
$ G. z% A, F  V! D! M: G$ SJuly 2007 540-5434 M' l+ @- v) H# b& x8 C5 O8 R) ?; y
© 2007 Sage Publications
3 ^0 b2 q1 B% l2 f10.1177/0009922806296651
8 j! d) G8 R# w9 ohttp://clp.sagepub.com# W; k! t, W+ j  e
hosted at3 ?- J  X, N& t+ R3 @9 u
http://online.sagepub.com2 x) |" F( W: ]3 ~, u$ B
Precocious puberty in boys, central or peripheral,  x, k3 ^% J! f( [9 [4 {4 p3 k
is a significant concern for physicians. Central
; l, e  O. Z1 z( xprecocious puberty (CPP), which is mediated" {( r, U! Q, I. }" Z/ w7 |+ y
through the hypothalamic pituitary gonadal axis, has
  m2 l2 L: J3 D* r9 ^# K% h; Wa higher incidence of organic central nervous system
+ ^: k) N( n( l: I2 @: f& ylesions in boys.1,2 Virilization in boys, as manifested
7 t& v) q) B4 o) T! n, kby enlargement of the penis, development of pubic* p1 Y9 n  D0 L/ x" B0 K2 y
hair, and facial acne without enlargement of testi-5 |. r9 P4 S( \) x7 j% L8 R
cles, suggests peripheral or pseudopuberty.1-3 We
: s# ?' B+ l2 ?) \" I7 k, T* S( Greport a 16-month-old boy who presented with the5 Z6 M9 N) z6 ^$ `
enlargement of the phallus and pubic hair develop-+ `+ R$ j' d# j# L+ v/ F, z
ment without testicular enlargement, which was due  C, N* {' S' n5 l
to the unintentional exposure to androgen gel used by
9 Z# f; f- `: Kthe father. The family initially concealed this infor-
# |9 F& |9 d1 r* b& Q; q6 ~2 Jmation, resulting in an extensive work-up for this. g' T' u# y8 X1 C% @% [/ A
child. Given the widespread and easy availability of) Y6 D+ ]1 n  W7 l
testosterone gel and cream, we believe this is proba-+ U2 J# N! W$ w0 r5 P2 i6 @1 O
bly more common than the rare case report in the0 H. N0 }' {9 h. s2 \( V0 A* p8 O
literature.48 d. f2 f/ p9 ?9 o9 u
Patient Report
0 g: ?- A! ?3 ]5 s9 k: V7 N" `A 16-month-old white child was referred to the0 p* e- z" r; h3 O
endocrine clinic by his pediatrician with the concern9 R5 w: }* z3 j; h4 _: O% m
of early sexual development. His mother noticed
, F* q  g2 E, Y0 y) w" slight colored pubic hair development when he was% V& E( ~2 E! M8 n
From the 1Division of Pediatric Endocrinology, 2University of
! f: ~* O6 D! M$ f4 Z0 V. Q" P) wSouth Alabama Medical Center, Mobile, Alabama.
  Z4 P9 W$ K8 f$ K4 {Address correspondence to: Samar K. Bhowmick, MD, FACE,% u( |1 U7 i/ V- ~4 {
Professor of Pediatrics, University of South Alabama, College of
6 x5 H- z% @5 \3 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 t/ y* T6 a' H6 B  c  i5 @e-mail: [email protected].
$ c* z4 t% n4 W& U" I9 wabout 6 to 7 months old, which progressively became
# n% h7 }* \' T' sdarker. She was also concerned about the enlarge-: ?; K% w8 E4 ?) a7 V, ~
ment of his penis and frequent erections. The child# E( L- U5 r' m* [; n  e: i4 S! ~3 i
was the product of a full-term normal delivery, with% K6 P7 }" ~. Y6 `( |: H
a birth weight of 7 lb 14 oz, and birth length of& W) W2 i, V: U* ]0 h# d
20 inches. He was breast-fed throughout the first year/ L: j5 x) J; p+ _9 i
of life and was still receiving breast milk along with
& c. c" e; Q+ S% Ksolid food. He had no hospitalizations or surgery,3 r7 F2 K( G# x: {
and his psychosocial and psychomotor development. A$ n9 x, a- B; u' [
was age appropriate.3 E% W( q0 m, i- l, T/ C$ }
The family history was remarkable for the father,
& h5 A. u9 f0 ewho was diagnosed with hypothyroidism at age 16,; S) x/ S# Q! P9 S7 P
which was treated with thyroxine. The father’s
  E  D  @! E( M% z1 m' g2 V5 f% uheight was 6 feet, and he went through a somewhat2 l+ _" A  H* x  J# r" \- r
early puberty and had stopped growing by age 14.
( Z# R+ ]4 Q0 f7 r0 h1 M! p. cThe father denied taking any other medication. The
3 c$ e& E  z1 O) @4 Y( zchild’s mother was in good health. Her menarche8 q$ I; b% b7 q/ U
was at 11 years of age, and her height was at 5 feet
0 M, k1 Y: s- Z0 I5 inches. There was no other family history of pre-
- J7 j7 K$ ~5 V" V  M' Mcocious sexual development in the first-degree rela-8 C* Q4 z/ W9 e1 A8 J/ }( ^
tives. There were no siblings.
# w; C/ B( |+ {$ b! s5 q8 I2 tPhysical Examination
! h: s; k1 U+ F* C- ~. ^The physical examination revealed a very active,6 t3 F$ q& M+ x6 R9 g' L( [" d" _; k- Q
playful, and healthy boy. The vital signs documented& E9 Z% m! c% I6 Q9 F* p( L0 a
a blood pressure of 85/50 mm Hg, his length was7 ?4 ^$ T& Y# i; ~
90 cm (>97th percentile), and his weight was 14.4 kg. U- W+ i1 C. f4 g
(also >97th percentile). The observed yearly growth
1 M, G# A% p$ |  X8 q7 `velocity was 30 cm (12 inches). The examination of
) l+ |1 q: q) R1 u5 qthe neck revealed no thyroid enlargement.
8 Q% n: y- H6 l, R- eThe genitourinary examination was remarkable for
! U8 t* E" X& ?9 ]$ O: G# t5 z' Cenlargement of the penis, with a stretched length of/ o8 p4 W' \$ C9 u
8 cm and a width of 2 cm. The glans penis was very well3 u4 p& |, I8 n- B. q( A  q; V/ b
developed. The pubic hair was Tanner II, mostly around
/ i) r$ ~  @; y9 h2 S5 I2 }5402 p- g" {! S2 p3 p4 E$ ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; N1 V  O/ F) O" j6 Hthe base of the phallus and was dark and curled. The
) \7 d& ]2 `2 |+ p# dtesticular volume was prepubertal at 2 mL each.( d) k. F1 I3 F& \
The skin was moist and smooth and somewhat8 K5 N  G5 ~: I7 o; D
oily. No axillary hair was noted. There were no7 K9 ~1 V# j) e2 L/ @$ N% |' D
abnormal skin pigmentations or café-au-lait spots.) M9 a2 Q9 Y  ?8 ]) b
Neurologic evaluation showed deep tendon reflex 2+6 A# g% n% h8 y3 j- H
bilateral and symmetrical. There was no suggestion
8 j, M  E$ w) U+ E0 Wof papilledema.
5 j- m$ e* {& o$ A2 `Laboratory Evaluation
4 u' W* I+ v" ]) q0 vThe bone age was consistent with 28 months by' e' _& F- M8 D, j& f9 {: e  T" G" M
using the standard of Greulich and Pyle at a chrono-  k. \9 G5 b- S" z% n1 B8 ^$ |8 e
logic age of 16 months (advanced).5 Chromosomal
3 b3 Q: [  @  E; O2 j6 h4 hkaryotype was 46XY. The thyroid function test2 H$ f* ?3 J6 b; S, x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, Z2 @0 j" B) p# Y# p% F5 T# ~  V
lating hormone level was 1.3 µIU/mL (both normal).9 d- v* K+ O4 W9 j/ }9 v( r7 D
The concentrations of serum electrolytes, blood
; e* ~; v1 }5 }. Z7 g) Qurea nitrogen, creatinine, and calcium all were
$ A" [! B$ V5 @, N, c* m$ fwithin normal range for his age. The concentration
- d/ W- a8 T0 I9 t3 d' Iof serum 17-hydroxyprogesterone was 16 ng/dL
  Q. l' ~& m( c) C8 y2 T(normal, 3 to 90 ng/dL), androstenedione was 20
' W3 y* `" Q! T7 N& ^8 _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: N% [9 w3 u3 B2 c2 m* J. w3 v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" g9 x: z+ z' Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 W, O* H% d  z2 q1 L9 ]% ?
49ng/dL), 11-desoxycortisol (specific compound S)' X5 U! r, K4 ?2 g/ i* X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 j% _" x8 ^: a3 B  Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 H' {- {5 J7 v( a6 b# ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ O$ i4 t# P$ @# cand β-human chorionic gonadotropin was less than
1 F' S+ G, Z4 ~& M$ Q- r- R6 q5 mIU/mL (normal <5 mIU/mL). Serum follicular+ ^5 J# v2 k* \% k' D6 O0 |" R  _
stimulating hormone and leuteinizing hormone
  V1 \9 j3 e! q( x, |concentrations were less than 0.05 mIU/mL' k0 H; @! C$ k3 ^
(prepubertal).
, O% u1 r; Q/ }) P. LThe parents were notified about the laboratory3 R- |/ f2 O' t4 N5 o
results and were informed that all of the tests were" I, f2 M) Q3 _0 v- A
normal except the testosterone level was high. The. ]- l0 ~$ v7 B8 }" F2 T
follow-up visit was arranged within a few weeks to. {4 U- @( S, t; K( T3 A
obtain testicular and abdominal sonograms; how-
3 D5 p5 {, X% C9 zever, the family did not return for 4 months.
3 [' u- t7 k' R- P% CPhysical examination at this time revealed that the
" s- |; Z/ P, t2 S: j& tchild had grown 2.5 cm in 4 months and had gained
9 h( |: }! Q2 A) ^2 \2 q0 t; q5 T2 kg of weight. Physical examination remained, E! y, ?. [  m, Y6 r
unchanged. Surprisingly, the pubic hair almost com-& U4 _  p6 F) V$ E/ V* L
pletely disappeared except for a few vellous hairs at/ @' ~3 s* g% O8 ?. j8 Z
the base of the phallus. Testicular volume was still 2
+ A; m. I$ N' [2 l  M1 \* [mL, and the size of the penis remained unchanged.
, b# P9 n% M% B( b3 s" z- fThe mother also said that the boy was no longer hav-! O7 |8 k/ V) n! k/ a% `9 |
ing frequent erections., p$ @( W) K0 G6 ]. Z
Both parents were again questioned about use of
9 c- h# w* n# ~any ointment/creams that they may have applied to" q- [+ ~5 o' b0 x- n
the child’s skin. This time the father admitted the
, ?" O3 e9 f, G6 ~4 g( cTopical Testosterone Exposure / Bhowmick et al 541
/ d. q* _2 \3 Q. D% ause of testosterone gel twice daily that he was apply-- y: e8 x7 U: b% d1 l  E5 e0 o5 m
ing over his own shoulders, chest, and back area for) E+ i5 @, D9 T
a year. The father also revealed he was embarrassed! G- [' N0 d/ K: Q
to disclose that he was using a testosterone gel pre-
- `0 ?3 }  f0 y8 i! lscribed by his family physician for decreased libido
0 j' n' s. L) w; y/ E0 W6 f3 jsecondary to depression.
+ L. C( }+ a- @  x( j" k) uThe child slept in the same bed with parents.7 H8 B& j4 L! I( i' j
The father would hug the baby and hold him on his
% D: F* Z% U6 k3 Y! t  F+ Ychest for a considerable period of time, causing sig-
% k/ C& y; _0 P: E, N7 A+ qnificant bare skin contact between baby and father.
3 U' {' o7 P7 g; z! f% aThe father also admitted that after the phone call,7 ~0 R* n# b# G! d( A! }  z/ s
when he learned the testosterone level in the baby! O8 R4 l6 f: w
was high, he then read the product information% h' B5 M3 S3 [* \+ g; a# i; |
packet and concluded that it was most likely the rea-" G" O8 x2 y9 ]# Q
son for the child’s virilization. At that time, they/ C; P. o9 e+ p
decided to put the baby in a separate bed, and the
8 T) G2 p3 a% u1 W/ nfather was not hugging him with bare skin and had
9 s& B$ ?4 t5 B3 @: Mbeen using protective clothing. A repeat testosterone
: t% Y6 _5 L6 H7 w4 etest was ordered, but the family did not go to the
- r) V# x% T. K8 j% V$ Blaboratory to obtain the test.
3 Y4 u& N2 }5 a) TDiscussion& j( @# C% _! B- S) n
Precocious puberty in boys is defined as secondary
0 u: ^: W  i) ^5 f6 m2 A$ j1 Usexual development before 9 years of age.1,4
6 w" K8 J  O8 j9 v) e$ rPrecocious puberty is termed as central (true) when0 Q, H1 X, q- {: K7 Y& P; g
it is caused by the premature activation of hypo-
/ q; }6 d5 P3 u; k. Wthalamic pituitary gonadal axis. CPP is more com-
2 K% \9 W9 d; B& \$ Dmon in girls than in boys.1,3 Most boys with CPP0 i/ O: u- y: z9 e- w) I
may have a central nervous system lesion that is! C* N9 v: L: c) {+ s( r
responsible for the early activation of the hypothal-( a: E+ O7 @. i/ r
amic pituitary gonadal axis.1-3 Thus, greater empha-& p; |! z7 ~1 a  [( {
sis has been given to neuroradiologic imaging in
+ S2 C/ i" A% mboys with precocious puberty. In addition to viril-
/ e& w; Q$ n$ h" C. K; Bization, the clinical hallmark of CPP is the symmet-) A" Q, W+ [3 `% t# @; E2 D6 l
rical testicular growth secondary to stimulation by
9 F" l# t) M; r. r: j3 dgonadotropins.1,3
8 ~! x- A; m8 ?( A+ F2 y( w3 L. @2 a0 SGonadotropin-independent peripheral preco-! ~3 r5 ^) X* R8 L. \- p
cious puberty in boys also results from inappropriate
8 p8 v& `/ R9 D( N$ B% b1 B  Landrogenic stimulation from either endogenous or
! B; I* N# O2 o5 s4 fexogenous sources, nonpituitary gonadotropin stim-7 U6 J$ Y+ I# J# _& c
ulation, and rare activating mutations.3 Virilizing
3 f5 j/ W: ]; y% o/ t1 ~congenital adrenal hyperplasia producing excessive
$ e; ]3 {0 @$ dadrenal androgens is a common cause of precocious- _' p0 m0 S1 T+ W# v8 J
puberty in boys.3,4
$ k% W9 b4 r% {: O: p' C" eThe most common form of congenital adrenal
5 \& S+ z" i5 n9 M$ @4 a2 ]hyperplasia is the 21-hydroxylase enzyme deficiency.. z2 I' F# t% ^8 e% |0 ~; ^9 _
The 11-β hydroxylase deficiency may also result in# F5 N3 Z* \) j# e
excessive adrenal androgen production, and rarely,
# H9 W4 F  C" x0 jan adrenal tumor may also cause adrenal androgen) E  B4 _$ e) P4 s; ?) K3 i( e4 z
excess.1,3
8 }, K) B; o4 Q- b3 z/ t: \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& K4 X3 \8 m" U1 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ s! |! Q: |" j! j) R8 GA unique entity of male-limited gonadotropin-
# ^6 J0 |' S# l3 L4 aindependent precocious puberty, which is also known
3 U( ~/ S( n' S/ \5 xas testotoxicosis, may cause precocious puberty at a' A( J# K, e4 h
very young age. The physical findings in these boys5 P  M; ?0 g; B/ b0 M5 }3 h7 c3 R- c
with this disorder are full pubertal development,
' C$ z1 C: d, vincluding bilateral testicular growth, similar to boys
- M1 _; }# M" Q+ q" E+ vwith CPP. The gonadotropin levels in this disorder
: T3 a  l5 |  k- X6 b6 care suppressed to prepubertal levels and do not show" o9 B( t+ W- J9 i0 q4 l) Z' s& z
pubertal response of gonadotropin after gonadotropin-
1 Z1 `* ?3 Q# w* P: \6 Nreleasing hormone stimulation. This is a sex-linked
( i* M: k) O& @5 Iautosomal dominant disorder that affects only9 p: P$ F3 T# \8 f9 D! }
males; therefore, other male members of the family: S6 O' I* \6 T& m* \5 P1 ~8 e
may have similar precocious puberty.3
6 H7 n( W0 D! eIn our patient, physical examination was incon-, C; z4 c; i: v* z  @7 R( A0 n
sistent with true precocious puberty since his testi-) q6 N0 \  I+ y6 d5 Q) [4 {4 ~0 L
cles were prepubertal in size. However, testotoxicosis7 y5 q" y) y0 O- `
was in the differential diagnosis because his father
+ s0 R& y7 U$ j/ N3 q5 Kstarted puberty somewhat early, and occasionally,. M9 h1 `/ K% o& \4 A( A
testicular enlargement is not that evident in the
: c# ^- N$ P/ w5 D  K4 Fbeginning of this process.1 In the absence of a neg-
. {3 N& \7 u5 b1 y2 T. h! X8 u+ @ative initial history of androgen exposure, our
, E& z3 e" e# R* [$ j5 ~2 n- ~biggest concern was virilizing adrenal hyperplasia,
$ j: I, R5 X. z& s# I$ ]+ i$ leither 21-hydroxylase deficiency or 11-β hydroxylase
7 L# z- \: |) {8 S5 ]deficiency. Those diagnoses were excluded by find-$ A: n+ K7 v* A, k8 U
ing the normal level of adrenal steroids.
& y6 @5 V' F2 t- EThe diagnosis of exogenous androgens was strongly$ l# b6 Q+ K/ Z; T+ o' Q
suspected in a follow-up visit after 4 months because' g& D/ H$ b3 s+ f
the physical examination revealed the complete disap-
/ y) d# ]1 J. }; ^pearance of pubic hair, normal growth velocity, and
, N; ^$ W% w/ S: J3 Z: _5 sdecreased erections. The father admitted using a testos-
& O  P6 O5 c& d, Q* yterone gel, which he concealed at first visit. He was7 F5 `3 R% h4 e$ i
using it rather frequently, twice a day. The Physicians’) [$ w  Q- U0 i7 V: p
Desk Reference, or package insert of this product, gel or& n- u( c% L! i) q- l/ Z' j
cream, cautions about dermal testosterone transfer to
. B, ^1 x6 W1 t, f, Hunprotected females through direct skin exposure.: f5 {1 i  Q$ u
Serum testosterone level was found to be 2 times the
# P1 J! m- m+ W. k; q9 y: Ybaseline value in those females who were exposed to
  l* _6 ?! j4 C. s" l* f5 Heven 15 minutes of direct skin contact with their male
0 [1 L0 }8 K" Z; B5 c1 Qpartners.6 However, when a shirt covered the applica-+ }7 q) ?" t! r6 z. Y' q. r# h
tion site, this testosterone transfer was prevented.
9 `* ]8 d6 s! F$ jOur patient’s testosterone level was 60 ng/mL,5 Y$ V8 g+ b, q4 b. ]" ~/ ~4 ]
which was clearly high. Some studies suggest that, G' @" ]6 }& A! f! L. ]
dermal conversion of testosterone to dihydrotestos-
+ c$ e' X$ m7 [; K) Q: t& Dterone, which is a more potent metabolite, is more
8 ?, W4 u3 ?7 S6 m  ^active in young children exposed to testosterone
( j9 u& ]: U. q7 b+ F% ?exogenously7; however, we did not measure a dihy-" H% I  ^( r$ b# `0 @% F6 q
drotestosterone level in our patient. In addition to
9 Z0 V2 Y% d' W9 P  |- ovirilization, exposure to exogenous testosterone in
. x; w6 a% P: v! `- G  Hchildren results in an increase in growth velocity and
( D. H# z: z# u. Oadvanced bone age, as seen in our patient.
/ g0 w7 f5 R% H" [2 hThe long-term effect of androgen exposure during
5 H2 S5 P  J, O" y# [$ i# searly childhood on pubertal development and final% ^6 {/ @) X. r5 `# v+ w& L
adult height are not fully known and always remain6 o1 ?0 d9 M/ ?) x
a concern. Children treated with short-term testos-
8 ?+ ]1 z$ M  l( P. p' }3 uterone injection or topical androgen may exhibit some
$ u) r- ]' o, H6 U; r1 p* ]6 bacceleration of the skeletal maturation; however, after& U2 C; D" P3 G& ~
cessation of treatment, the rate of bone maturation8 u& x" g; e  D+ E( l0 f
decelerates and gradually returns to normal.8,9: s0 c! F# Z# W& M, D
There are conflicting reports and controversy
; F" \5 N6 h0 Z# o( n. L! Cover the effect of early androgen exposure on adult& o0 Q; W+ u  H. V
penile length.10,11 Some reports suggest subnormal
+ A) W# A& B7 m: iadult penile length, apparently because of downreg-7 Q. N) V5 B, v5 w
ulation of androgen receptor number.10,12 However,
1 }3 c1 y2 r2 E$ ~6 pSutherland et al13 did not find a correlation between
: s8 ~. F' ?# o; b3 c+ t1 ?childhood testosterone exposure and reduced adult
' H' g+ ~; X. @# ^! |1 P9 [penile length in clinical studies.
- s) u4 w3 q$ A: [( p1 b# aNonetheless, we do not believe our patient is
3 y' T; ?& M6 t& M# Xgoing to experience any of the untoward effects from' T+ L0 X4 |) H* t1 l
testosterone exposure as mentioned earlier because3 S9 i) o" L( L( B2 V/ j# p) S
the exposure was not for a prolonged period of time.
2 T, X8 w4 D& ~% C0 WAlthough the bone age was advanced at the time of8 {8 F" F5 ]+ e; V6 c
diagnosis, the child had a normal growth velocity at
4 Y7 F2 a/ q. x- w8 R" M8 gthe follow-up visit. It is hoped that his final adult
2 Y3 t, d& A; c# Xheight will not be affected.  M; h+ a' q/ E: [+ J( F
Although rarely reported, the widespread avail-
  E3 b% ^7 S8 N% Dability of androgen products in our society may$ F: }: S4 O: k
indeed cause more virilization in male or female
( x. f9 E0 B" \6 r, b( f) s0 C- e# tchildren than one would realize. Exposure to andro-9 J; p. ?2 E3 ]
gen products must be considered and specific ques-
8 U* d" {! v# j* |" T/ Rtioning about the use of a testosterone product or
2 g3 d" z5 V$ R9 R1 L* r' Vgel should be asked of the family members during
5 O4 b. ]. Q. G9 N0 e& ithe evaluation of any children who present with vir-( s! t# Y; Q  d" y
ilization or peripheral precocious puberty. The diag-& ]4 U5 d) L" Y4 t
nosis can be established by just a few tests and by. y- d# o( H- L/ B
appropriate history. The inability to obtain such a8 s1 g5 ?: s5 {2 o2 I% T6 P
history, or failure to ask the specific questions, may
7 ~2 c$ t. e* L, Gresult in extensive, unnecessary, and expensive
% S, T) T2 X8 Oinvestigation. The primary care physician should be
/ z% a! a4 W( ]1 h4 F- m* }' w# p" Kaware of this fact, because most of these children& S/ F# Y9 J1 y; `
may initially present in their practice. The Physicians’
, W9 D& `6 R7 x! k/ \6 EDesk Reference and package insert should also put a. `1 v- f. Y6 Y9 h
warning about the virilizing effect on a male or: Q0 F' K8 Z! s9 V# p' K
female child who might come in contact with some-
8 B9 t5 m* _3 i9 D2 ^( H' d: uone using any of these products.4 A  t3 ^7 O* ~0 f* z  \8 |6 g
References- v% s. h* b, M7 q; b7 c9 [
1. Styne DM. The testes: disorder of sexual differentiation9 T2 ~2 y3 u: A/ x! A, C; `4 A0 Q# H  n
and puberty in the male. In: Sperling MA, ed. Pediatric
8 F1 C1 K7 m# P6 U3 u% j; wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( \" T! W1 N: R* W2 z) ^  X2 l
2002: 565-628.
$ ^) M3 e2 E9 ^' V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ u) D0 V, M9 n, e6 \; X7 d
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-4 03:27:02 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
Sexual Precocity in a 16-Month-Old
2 y/ Y) @" H+ D( i8 NBoy Induced by Indirect Topical. u# o$ M, f; s
Exposure to Testosterone
, \. t" T3 N& _5 G$ HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" C8 C, M1 g! d9 f$ `
and Kenneth R. Rettig, MD1
1 Z+ W+ m( ~& UClinical Pediatrics
  L+ N, F1 J, P( u% F: m' w8 I: _& [0 ]Volume 46 Number 6
0 M; i# H, R& t" Z1 e& X0 ~July 2007 540-543$ A- E. L- l0 E8 I9 x* j
© 2007 Sage Publications
: G; z7 w( m- `/ J10.1177/0009922806296651
, X2 b4 ]& p7 a" t4 D; s# Xhttp://clp.sagepub.com+ Y* Z. y. f; J! j* S
hosted at. p' D- h6 n" \; M1 J/ U( I( }
http://online.sagepub.com
1 @/ @: y+ ]4 SPrecocious puberty in boys, central or peripheral,& a* v& E1 G! Y2 p# _
is a significant concern for physicians. Central, s1 X- _" m( o' G) z+ }
precocious puberty (CPP), which is mediated6 T. I+ g: Q7 N
through the hypothalamic pituitary gonadal axis, has  k# B9 d0 g( M
a higher incidence of organic central nervous system7 S" w$ T3 ~0 z) z  O
lesions in boys.1,2 Virilization in boys, as manifested
' U) j4 V/ w$ tby enlargement of the penis, development of pubic) ^* j( X5 F$ L+ ^- o/ c
hair, and facial acne without enlargement of testi-8 W8 E7 Q( P5 ?' a
cles, suggests peripheral or pseudopuberty.1-3 We
, F/ `1 B) E# g5 R& zreport a 16-month-old boy who presented with the
, I2 U+ G% w- d2 c4 e' b4 ~enlargement of the phallus and pubic hair develop-' z; B" l8 J+ @6 y4 ]0 D
ment without testicular enlargement, which was due8 H1 b  D5 E# t7 x+ q0 `; E
to the unintentional exposure to androgen gel used by. y0 f; U# h# O* M: q: }0 d
the father. The family initially concealed this infor-* [& a$ O* M) Q
mation, resulting in an extensive work-up for this; }0 @' v! D$ x* g7 g
child. Given the widespread and easy availability of
  _0 Y8 l7 A/ l' F; O) D& ^* g# Y5 g# Mtestosterone gel and cream, we believe this is proba-
6 R3 A1 d3 Y7 i, T8 Ybly more common than the rare case report in the
5 M6 B( ~1 r: Z3 Xliterature.4* ]) ^/ ^( N* u! G
Patient Report
* f3 D  V2 p; U) g8 O* s0 HA 16-month-old white child was referred to the/ Q6 K& ^* x' t( G% G* m, i
endocrine clinic by his pediatrician with the concern
7 r, F1 c; r# D( Mof early sexual development. His mother noticed/ e) m) A$ i# ?9 J0 O
light colored pubic hair development when he was) J4 a4 r7 w8 w
From the 1Division of Pediatric Endocrinology, 2University of
6 T7 H! d/ z9 n6 x% Y8 b$ e) g" ASouth Alabama Medical Center, Mobile, Alabama.3 ~2 z4 v. `% a' |, g
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& z' w" c. `% v$ S9 cProfessor of Pediatrics, University of South Alabama, College of2 j: t* H, n9 w: N9 r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 d% G* r8 q7 C! M5 Z6 N+ o5 F1 Ue-mail: [email protected].
; ]% I$ L+ M) ^3 v  V* n! o; nabout 6 to 7 months old, which progressively became$ \- k6 q# D, G
darker. She was also concerned about the enlarge-
& z$ \: D) ^0 P$ [3 h8 Ument of his penis and frequent erections. The child$ T8 H( R0 |: D5 ]1 e! d
was the product of a full-term normal delivery, with
- Z; F1 A; j, Q! t3 |" Pa birth weight of 7 lb 14 oz, and birth length of
; g. P% v3 A/ s/ N  ?7 L, b20 inches. He was breast-fed throughout the first year4 P6 |0 e3 ?/ x6 n. y; @
of life and was still receiving breast milk along with& [( H8 u  x# I) S. Q& e8 ]- _5 O
solid food. He had no hospitalizations or surgery,' a# q' W* a* B: F, Z2 w
and his psychosocial and psychomotor development1 I- X0 R( @2 Y
was age appropriate.3 u& N; N. g- b; d
The family history was remarkable for the father,
  ]4 H0 g5 N' S( Nwho was diagnosed with hypothyroidism at age 16,
- L# s; `5 |) ]which was treated with thyroxine. The father’s4 b+ v# D( U! n5 m
height was 6 feet, and he went through a somewhat
# W4 r* d; Z( E+ eearly puberty and had stopped growing by age 14.
% p" W+ A; a5 ^$ O+ d7 KThe father denied taking any other medication. The% j+ y0 Y8 I: M- L
child’s mother was in good health. Her menarche' @3 O' c/ s3 O  c4 @: k
was at 11 years of age, and her height was at 5 feet; x9 s. O/ I" z' s2 y
5 inches. There was no other family history of pre-
% Z7 @* L8 K0 d) H) Dcocious sexual development in the first-degree rela-" W0 Z% `3 c  U9 J; T
tives. There were no siblings., ?" S8 J3 L- |( I* N2 j
Physical Examination3 z1 R! ?6 ^# `' J4 a
The physical examination revealed a very active,
& b9 @: d- n9 W' Hplayful, and healthy boy. The vital signs documented
9 ~+ n! P2 o* {3 u4 }2 T5 Aa blood pressure of 85/50 mm Hg, his length was6 Z4 e2 y8 g( m/ V+ E
90 cm (>97th percentile), and his weight was 14.4 kg
; h. n% S( m* I2 h0 C9 f& q(also >97th percentile). The observed yearly growth
9 G; k3 _; z7 V$ J9 R2 v) Jvelocity was 30 cm (12 inches). The examination of  D# A( F+ ?0 t& G; [# f7 @
the neck revealed no thyroid enlargement.1 X9 Z& D4 \( h8 c; L( |6 h& V+ e' s
The genitourinary examination was remarkable for
* D8 |3 S7 [1 ]5 ^$ J1 Senlargement of the penis, with a stretched length of
+ B, O0 ]% R/ {: c6 p* Y* l- A# u* A8 cm and a width of 2 cm. The glans penis was very well
  C# Z# P- e/ v$ Y$ udeveloped. The pubic hair was Tanner II, mostly around
8 K& Y9 y* e- S$ ]6 B& h5 {540  }  w5 |( p- b+ @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: ^& U) S* J3 q9 Z
the base of the phallus and was dark and curled. The
- s( ?! ^: M3 _; B; Z5 A4 l- g! f' \testicular volume was prepubertal at 2 mL each., n' c6 `; B' u& [2 M
The skin was moist and smooth and somewhat$ \) F7 S$ t0 a; f$ u* A& e
oily. No axillary hair was noted. There were no/ C! Q$ r+ v$ ]/ V4 R! j, b) O
abnormal skin pigmentations or café-au-lait spots.# ]" |, E  D' b
Neurologic evaluation showed deep tendon reflex 2+
8 p+ S( g) C( s% [2 k6 ^* ubilateral and symmetrical. There was no suggestion- a7 x( Q* d. [+ h
of papilledema.
8 Y7 }9 c5 Z. gLaboratory Evaluation
8 k  d; z( G/ ^! y' `& uThe bone age was consistent with 28 months by! a" R1 A; |; _! ]/ }9 m7 [4 b
using the standard of Greulich and Pyle at a chrono-
% W5 S) z/ `0 i4 clogic age of 16 months (advanced).5 Chromosomal& I) m4 b, g# F" ?- ?( V/ w  g0 y
karyotype was 46XY. The thyroid function test
% x& _1 z7 M7 eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ C4 x* S2 s! B/ j& v! c' S' ~. N+ Glating hormone level was 1.3 µIU/mL (both normal).
( j$ w4 |4 e& j& RThe concentrations of serum electrolytes, blood
8 [8 N! E( R; r5 u: W/ M: E6 zurea nitrogen, creatinine, and calcium all were/ {' [  ?2 R. x. ?+ f- {, z
within normal range for his age. The concentration- `/ C0 w0 i& _2 P  f
of serum 17-hydroxyprogesterone was 16 ng/dL
" H: F: b5 ~* X; l(normal, 3 to 90 ng/dL), androstenedione was 20" _" R7 Y' U7 n1 E: ?
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 I7 }% g: l* [  S' i" _9 e3 E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( A0 r# P& ]) w  ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' h# `/ A+ x$ g6 v49ng/dL), 11-desoxycortisol (specific compound S)
( |4 M: d. U9 _' K: a* ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& l/ N2 L# i& [! |- m; @& P8 d6 M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& n7 ^5 E, W, F0 @/ v5 T- E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& [' P6 `+ W3 E* K) \" s% @
and β-human chorionic gonadotropin was less than2 w0 D! d0 ^* a; L% p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% {1 C- E% s3 }stimulating hormone and leuteinizing hormone$ f/ D" L3 q9 Q& W# I
concentrations were less than 0.05 mIU/mL
' E7 f% V: C7 {9 w. `2 D8 u& A; s(prepubertal).3 g% s- ?- B2 ]9 f# f
The parents were notified about the laboratory+ t+ J, P  B, q/ F: ~
results and were informed that all of the tests were; N1 W8 e  }6 z: c% p% M
normal except the testosterone level was high. The
% {, S* q9 G2 V( [# ~follow-up visit was arranged within a few weeks to1 t* C- R3 h# ^: r+ \
obtain testicular and abdominal sonograms; how-3 @; `9 p2 k) L! ^
ever, the family did not return for 4 months.
1 ]0 Q7 K7 J, g0 k6 \9 M9 CPhysical examination at this time revealed that the
7 h4 T1 D$ U9 y1 n+ Tchild had grown 2.5 cm in 4 months and had gained
/ X& n& d8 S: E4 S1 k& `, s3 B1 k2 kg of weight. Physical examination remained' y7 C; D7 L  v# k/ |
unchanged. Surprisingly, the pubic hair almost com-
5 y& \' Q' j' D* c- j+ Spletely disappeared except for a few vellous hairs at9 ?' k2 o/ n' u* z
the base of the phallus. Testicular volume was still 2) \8 t& a& [  w# c  f; Y
mL, and the size of the penis remained unchanged.. u( g0 ]( Z) a" a. u
The mother also said that the boy was no longer hav-
8 f7 u, I0 p" j$ oing frequent erections.7 j' O  |4 Y$ A. j( b
Both parents were again questioned about use of
* G- ~5 k! f  g9 A6 |  t5 ]any ointment/creams that they may have applied to* l- y  }0 o/ ^, m  T( L
the child’s skin. This time the father admitted the/ t, u0 ^9 C" K! N: t
Topical Testosterone Exposure / Bhowmick et al 541
% N; z3 ~$ @/ Z  buse of testosterone gel twice daily that he was apply-; G9 r' Q# v8 T2 c
ing over his own shoulders, chest, and back area for
& ]. C$ ?$ X& j% u, v3 |a year. The father also revealed he was embarrassed, ?  \( p: K0 ^; A3 ^
to disclose that he was using a testosterone gel pre-
( `& h/ G7 g; a$ {1 p3 d/ i: _scribed by his family physician for decreased libido
( F" b( f; R% [9 Csecondary to depression.  I' q4 F4 E: M% Z+ X
The child slept in the same bed with parents." H1 i3 y& _; j1 L1 {
The father would hug the baby and hold him on his
% |: `* K" J, echest for a considerable period of time, causing sig-" j; s' u, W; T  U& f
nificant bare skin contact between baby and father.0 S) s# l% G; c. {
The father also admitted that after the phone call,
4 ^8 m1 S3 m, N0 r. R* m  M/ j8 kwhen he learned the testosterone level in the baby4 Z' F2 x8 v, a8 R% g6 B) J
was high, he then read the product information6 t! A$ c- A: j- \' K6 z
packet and concluded that it was most likely the rea-
" D% Y+ s8 A& X+ l' i1 j8 L- F7 K/ nson for the child’s virilization. At that time, they
; `0 q9 y7 x4 m( `& Qdecided to put the baby in a separate bed, and the5 N: ?! @) c& K
father was not hugging him with bare skin and had
' H* q) Q6 v! N% h% a% @been using protective clothing. A repeat testosterone
9 G8 @/ ~, [% F0 o( `- Ctest was ordered, but the family did not go to the; ~' _7 f& d4 q- w( Q
laboratory to obtain the test.4 ?0 J( Q) u% \: t. b2 Z- b. d. O
Discussion
, p; q& \! [1 Z" \# E8 ?/ z. hPrecocious puberty in boys is defined as secondary7 [& p: l# J& c
sexual development before 9 years of age.1,41 g) S' _3 ]: i$ W
Precocious puberty is termed as central (true) when2 x5 H. I- z; z7 ~
it is caused by the premature activation of hypo-4 Z) K: F  i; ?! Z% J: [  d& T
thalamic pituitary gonadal axis. CPP is more com-7 e' L& w, g2 t3 g- A. L0 n
mon in girls than in boys.1,3 Most boys with CPP
$ A. I3 t' o: c9 Z# c% K! X0 O$ B/ mmay have a central nervous system lesion that is
! F. M% Z8 i+ b! c5 F3 ]2 T. Lresponsible for the early activation of the hypothal-
2 W; J4 z7 `, Q8 iamic pituitary gonadal axis.1-3 Thus, greater empha-0 P: `6 ]6 E4 ?
sis has been given to neuroradiologic imaging in
7 J' k4 s5 P1 z3 O" a% J3 `boys with precocious puberty. In addition to viril-
; z( ~$ }4 c; Vization, the clinical hallmark of CPP is the symmet-3 j' l1 d- @6 v4 a
rical testicular growth secondary to stimulation by/ T" a' k+ X9 d* L( T
gonadotropins.1,3
  u+ B+ n2 `8 A7 `Gonadotropin-independent peripheral preco-8 U8 h% y, F  A; T
cious puberty in boys also results from inappropriate. A- }2 U) `7 w" I
androgenic stimulation from either endogenous or8 C: Q0 U6 B5 Z
exogenous sources, nonpituitary gonadotropin stim-
  t; E5 B9 \  M$ _2 R6 F8 p/ h& }ulation, and rare activating mutations.3 Virilizing
9 s4 w% b* Q9 e; rcongenital adrenal hyperplasia producing excessive0 }" b- D% ~/ U& Z) G! W
adrenal androgens is a common cause of precocious
( v+ S) s4 J6 |0 ]9 [# |0 k4 Apuberty in boys.3,4
! [2 I7 W3 x" x: |9 V2 J" yThe most common form of congenital adrenal7 W& {" n; K' [6 m, ?9 t
hyperplasia is the 21-hydroxylase enzyme deficiency.
% i8 e) f/ P: n+ t3 X" HThe 11-β hydroxylase deficiency may also result in
* ~$ S$ U3 S+ b: R$ q' ~, Pexcessive adrenal androgen production, and rarely,$ r5 v% W, q% K/ q, `: l% E4 o
an adrenal tumor may also cause adrenal androgen' F# z8 q  }0 \6 r% Y
excess.1,3) O. P, \! K, x' Q8 V3 K6 U& x: o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 H6 I0 M5 ]0 y7 O8 R) m
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' \$ [) C8 }5 ~5 y" |7 l8 jA unique entity of male-limited gonadotropin-
/ M4 R$ k8 M8 t& m" U/ p, mindependent precocious puberty, which is also known
# A% f0 a9 h8 ]& x3 j1 aas testotoxicosis, may cause precocious puberty at a
4 m5 N$ i2 g& }3 c# I& |1 c" overy young age. The physical findings in these boys! T; R0 V) o- I
with this disorder are full pubertal development,4 P: \( ~; t0 m5 B+ k0 ], |
including bilateral testicular growth, similar to boys
% a7 p( p0 R' Rwith CPP. The gonadotropin levels in this disorder8 e) r" M5 v- N/ F( A/ j
are suppressed to prepubertal levels and do not show, S& `7 o. D, [4 v6 W' `; u! b
pubertal response of gonadotropin after gonadotropin-6 L8 K7 O% l- G! D0 y
releasing hormone stimulation. This is a sex-linked, a/ P' l- S* [. Z2 ?5 e
autosomal dominant disorder that affects only
+ K! `$ x8 k! K; G2 d& Lmales; therefore, other male members of the family0 s( J6 X0 D* |" i+ X
may have similar precocious puberty.3' g2 p, x+ F$ T# j
In our patient, physical examination was incon-! r2 C! M! e1 ^2 K8 O5 B+ P) P
sistent with true precocious puberty since his testi-
1 @5 h! g; y# X7 U' d/ K% vcles were prepubertal in size. However, testotoxicosis6 O' p- ?5 V% [
was in the differential diagnosis because his father
$ l; I7 g9 V% X- S' ?5 \4 m3 j8 astarted puberty somewhat early, and occasionally,8 X0 S, U# [2 e& C  g' W
testicular enlargement is not that evident in the9 l1 P  n, N; l* F
beginning of this process.1 In the absence of a neg-
( ?1 E! a& `6 E3 j5 z5 ~% Bative initial history of androgen exposure, our  F. j5 S9 M* n1 h/ f
biggest concern was virilizing adrenal hyperplasia,. I& B4 |6 s; a
either 21-hydroxylase deficiency or 11-β hydroxylase( D; o3 h) U7 u8 ~
deficiency. Those diagnoses were excluded by find-
& c0 v& @* v* O1 ?/ g% g/ iing the normal level of adrenal steroids.
7 K- d8 B1 o1 Y. tThe diagnosis of exogenous androgens was strongly
* R6 P# A. R8 h0 dsuspected in a follow-up visit after 4 months because
3 w8 A: I+ t8 h3 p; f) O9 N/ [the physical examination revealed the complete disap-
2 o& b0 K' H& ?, z$ }) ]pearance of pubic hair, normal growth velocity, and
# b5 R- E/ T# {: adecreased erections. The father admitted using a testos-
4 X  x& @1 U9 y+ M$ jterone gel, which he concealed at first visit. He was
4 W- E3 t$ T1 T  Yusing it rather frequently, twice a day. The Physicians’
* D* `% u4 p: |1 @7 t/ P0 U' NDesk Reference, or package insert of this product, gel or$ q/ c, i( X' B1 f7 X
cream, cautions about dermal testosterone transfer to$ A$ g5 U: q: m5 X
unprotected females through direct skin exposure.; }" Q8 s/ u) e* `3 Y3 X( q
Serum testosterone level was found to be 2 times the
6 G5 A# {4 ?6 y2 w) Mbaseline value in those females who were exposed to+ h% H* T. R9 _* G  E. _# d  H/ b
even 15 minutes of direct skin contact with their male4 |1 p2 x8 j8 X; f( |
partners.6 However, when a shirt covered the applica-
: }9 \* e6 E  i. Ktion site, this testosterone transfer was prevented.. @& ]4 d0 `+ O( l/ I+ t& X
Our patient’s testosterone level was 60 ng/mL,. b0 p# R' R, ^# X8 r7 S
which was clearly high. Some studies suggest that
; p( q9 v! Q& K& b9 \dermal conversion of testosterone to dihydrotestos-1 o0 F( @! H3 w3 s. Z* y
terone, which is a more potent metabolite, is more7 w7 [# b* k* G. P- h% K( a9 F
active in young children exposed to testosterone! P; K7 c+ \- j: Z/ i
exogenously7; however, we did not measure a dihy-
- |- O; N, V6 ^  B8 Qdrotestosterone level in our patient. In addition to0 t( A' _6 O! ^3 b; a# t1 s) K  _
virilization, exposure to exogenous testosterone in
0 \/ q0 J; X. r  Q  x" _4 b7 ]children results in an increase in growth velocity and
' |! Y! O) K1 ?/ L: M  w. Madvanced bone age, as seen in our patient.
# r" ?$ q9 ~) QThe long-term effect of androgen exposure during2 z5 C0 h) `6 M& i( `
early childhood on pubertal development and final
. f) I* C3 Z0 R3 s+ eadult height are not fully known and always remain
  W, M) X) X; y. T4 V) T1 na concern. Children treated with short-term testos-
6 S% Y0 J  o; [% Qterone injection or topical androgen may exhibit some3 K) Y; z: q; N0 O9 t* x
acceleration of the skeletal maturation; however, after
; O$ ~/ ~! z- w. Dcessation of treatment, the rate of bone maturation
. {% @" S$ }! u7 c$ V0 rdecelerates and gradually returns to normal.8,9( ^* j1 `8 z: u% I  a
There are conflicting reports and controversy
8 m7 P9 n' T5 c  m) T- Jover the effect of early androgen exposure on adult
$ K# w1 c/ k9 Y( }! ]1 B( i' [/ Gpenile length.10,11 Some reports suggest subnormal5 x4 t9 x9 E8 p2 o4 u
adult penile length, apparently because of downreg-
1 p1 e* ?  h( ?" Dulation of androgen receptor number.10,12 However,6 i7 q& a2 C: m$ j
Sutherland et al13 did not find a correlation between
. o. B6 R4 E5 |$ \2 uchildhood testosterone exposure and reduced adult: Y! t9 V$ v9 H% s! n! R! b
penile length in clinical studies.
- k" j0 I% U( ?/ {Nonetheless, we do not believe our patient is
7 }0 ~9 W; \0 fgoing to experience any of the untoward effects from- }7 X8 E' E4 _8 ?3 r4 U" ~. }
testosterone exposure as mentioned earlier because
# J* {9 L' d! c7 d+ z6 J$ rthe exposure was not for a prolonged period of time.
9 g! B2 r8 Z) y$ v9 c& VAlthough the bone age was advanced at the time of
. w& Y" R% N5 e5 M# \2 H3 Z' k' Pdiagnosis, the child had a normal growth velocity at0 g" n" I8 Q2 `4 H
the follow-up visit. It is hoped that his final adult. h7 b# U: F3 w3 t
height will not be affected.
% [: g, _3 @' j- Y: R# BAlthough rarely reported, the widespread avail-0 J- y& `; H# T. ?
ability of androgen products in our society may: k& @! U5 ?- t* e* S' r& Z8 ^
indeed cause more virilization in male or female, q% O9 V  H5 r  P
children than one would realize. Exposure to andro-
" q$ t) @$ z1 Q. k7 s, Ogen products must be considered and specific ques-8 }/ s( g9 t! [; j1 @. |. e5 B
tioning about the use of a testosterone product or
; }9 T$ }- i8 D+ B- a- Q" Dgel should be asked of the family members during
0 W* G4 K. H; o( x2 z! E# ythe evaluation of any children who present with vir-$ {8 n7 ?$ P+ `$ ~4 J
ilization or peripheral precocious puberty. The diag-, D# F- ~; r/ i: V7 R# J8 ]" {' l+ E: @4 X
nosis can be established by just a few tests and by
  E8 c3 O$ i8 ~6 b0 V( N7 B5 \appropriate history. The inability to obtain such a- h  _7 R0 q: y" ~: g& x: K
history, or failure to ask the specific questions, may3 k5 W% D: ~' v
result in extensive, unnecessary, and expensive' d% f9 }6 r' i  ?$ {' Q
investigation. The primary care physician should be( @, d0 z6 g& k8 F0 J( I2 b
aware of this fact, because most of these children
8 |3 A+ v' [! J/ ?) O, K) E7 xmay initially present in their practice. The Physicians’
9 s0 t+ n1 ?' x& Q% `0 g. f' HDesk Reference and package insert should also put a
/ E) H% ^8 W" `9 Bwarning about the virilizing effect on a male or4 n0 d7 m5 G6 y; s2 t2 a
female child who might come in contact with some-2 Z0 \! R4 G' }4 m  R% m
one using any of these products.* s' E$ O6 m) a& h1 D
References  Y# g" k! V) V' o
1. Styne DM. The testes: disorder of sexual differentiation
2 T: Q  e: j# k7 c$ s4 Cand puberty in the male. In: Sperling MA, ed. Pediatric
$ C1 `( E6 A" U  ?! XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 o! N( z  {# t
2002: 565-628.
# {- C* p# }# i0 M2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 c% x- f7 p) D* \+ M, Dpuberty 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# [# S6 ~8 h/ 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