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
+ [0 o8 a: ~' Q( UBoy Induced by Indirect Topical/ ?. q6 }6 B" z# F# E
Exposure to Testosterone
0 V4 @5 G9 j0 n6 b  GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  M3 \" {: y0 B; F, d( u( tand Kenneth R. Rettig, MD1
, L4 g3 p8 p  O. G% a4 YClinical Pediatrics
4 [8 Q) `2 f. h3 D2 Y  L) ?4 VVolume 46 Number 6/ J0 s" m0 D& Y8 s$ l
July 2007 540-543
& _; N9 J8 C0 a( c; M( [& A3 R© 2007 Sage Publications4 _+ q9 F' V+ P& p/ \8 S9 c" j  N
10.1177/0009922806296651! `3 _% S3 C4 C
http://clp.sagepub.com
% ~  }3 n1 F+ a! L, uhosted at' l1 g4 Z  ~9 D! L! b4 c% D( E
http://online.sagepub.com& t; ~0 s3 ^% j
Precocious puberty in boys, central or peripheral,
5 E$ \3 O. C, ~4 Kis a significant concern for physicians. Central$ |: O) ]3 B0 \7 \7 S9 b' q5 S
precocious puberty (CPP), which is mediated- w7 Q& o3 C# w  I5 m
through the hypothalamic pituitary gonadal axis, has
+ \/ z' V1 C, Ba higher incidence of organic central nervous system  e0 M0 l) v; @
lesions in boys.1,2 Virilization in boys, as manifested
) U4 h+ G  Q6 W" J" Rby enlargement of the penis, development of pubic# n' {5 C3 k2 g) O
hair, and facial acne without enlargement of testi-9 N! Z9 ]# D1 e5 L+ |
cles, suggests peripheral or pseudopuberty.1-3 We( K% \% l" z- r, I1 w
report a 16-month-old boy who presented with the3 y- h; n  k- ~: G9 |/ F
enlargement of the phallus and pubic hair develop-
* S1 Y( n/ J: N: Ament without testicular enlargement, which was due' e& p. Z7 [. k$ {7 l9 ~
to the unintentional exposure to androgen gel used by0 k1 i' A  {3 C4 I' u  f1 a1 U- }
the father. The family initially concealed this infor-
- }3 R: k" O3 ~' l: g8 f, d6 gmation, resulting in an extensive work-up for this
4 A! Y1 Q. e( n( C$ ?! c( pchild. Given the widespread and easy availability of2 D& E! G5 X& X+ x, q
testosterone gel and cream, we believe this is proba-
! X/ A/ w7 k& p1 L( E8 |3 {) Jbly more common than the rare case report in the
1 v! ^, ^- O  s2 g& Q3 zliterature.4
# X8 d; p1 G& A6 l  O% [8 P2 `! zPatient Report
: c# a3 e/ \1 eA 16-month-old white child was referred to the' W: W7 K, h# E1 m- D
endocrine clinic by his pediatrician with the concern3 U* l9 u+ c  P# ]0 [( c) h
of early sexual development. His mother noticed( d8 s$ U0 Y- C1 P
light colored pubic hair development when he was
7 y, Y: ]) w$ D) w2 @( H' |From the 1Division of Pediatric Endocrinology, 2University of6 D+ I& Z3 {2 h: Z2 A, I
South Alabama Medical Center, Mobile, Alabama.# I, a  U$ ]' w
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& X, f) h) \/ ]3 A  `, b2 s1 YProfessor of Pediatrics, University of South Alabama, College of7 g4 s$ o# L9 o! W1 U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 Y4 \7 t0 c* d$ P
e-mail: [email protected].5 ^8 C7 A/ S! k% n5 |
about 6 to 7 months old, which progressively became8 S. y3 y( W% ^) N
darker. She was also concerned about the enlarge-
# X" ]5 U- j& H( Sment of his penis and frequent erections. The child2 r7 g' n0 l' S  R; i
was the product of a full-term normal delivery, with
% R/ Z  u/ d. v0 [3 H7 xa birth weight of 7 lb 14 oz, and birth length of
1 Y4 H4 F6 l$ s! F0 U- X+ |20 inches. He was breast-fed throughout the first year; ?* }: W$ l, l! l$ `6 S
of life and was still receiving breast milk along with4 A- a8 b! u0 x7 U0 k0 A
solid food. He had no hospitalizations or surgery,& v9 r. [( R9 }7 X& p! l* x
and his psychosocial and psychomotor development
- M1 j+ y2 s8 z& }) }was age appropriate.
- r' x. _% f. _The family history was remarkable for the father,0 \$ I4 S. m. u, w" i' a
who was diagnosed with hypothyroidism at age 16,
8 \' {+ f- B) Gwhich was treated with thyroxine. The father’s
' ~  O8 o: z7 A7 h" K' a7 @# s$ lheight was 6 feet, and he went through a somewhat
5 o' X: g2 R: @& ]: ?, a1 ^early puberty and had stopped growing by age 14.
+ `- ^! `' E! P  N, TThe father denied taking any other medication. The
2 U  i# x0 e& h; O2 Lchild’s mother was in good health. Her menarche
! Z1 M" c" N# \7 t9 V6 Q& R3 i& ewas at 11 years of age, and her height was at 5 feet# P$ }: P' j# L: s% n  `
5 inches. There was no other family history of pre-
  N, G8 }9 {- ?5 q5 n8 Lcocious sexual development in the first-degree rela-5 I- b8 J1 Z- ~! P# W
tives. There were no siblings.: d# m  {) s/ k/ E
Physical Examination
# `- ]' T: l* p3 h5 E% I  uThe physical examination revealed a very active,# e$ z; e7 K) B" V! h% w8 S' _
playful, and healthy boy. The vital signs documented. q, E, B; S( f% k
a blood pressure of 85/50 mm Hg, his length was* r, y; U& K4 z- K( [
90 cm (>97th percentile), and his weight was 14.4 kg; h% W9 W9 R0 j6 }6 G
(also >97th percentile). The observed yearly growth( o$ W/ c2 v# ~9 p4 Y. f+ n/ Q& s
velocity was 30 cm (12 inches). The examination of" k' ]. K% b  A* ^4 ^/ P9 c2 |
the neck revealed no thyroid enlargement.+ B8 [/ e5 @- J. L+ W( X( D8 g
The genitourinary examination was remarkable for
7 Y5 w" `3 L" n' l9 @+ menlargement of the penis, with a stretched length of2 p8 ^3 _' ]0 j8 `+ }" R4 c. f
8 cm and a width of 2 cm. The glans penis was very well
& o& {# j) k& ^& y! Wdeveloped. The pubic hair was Tanner II, mostly around; l/ I, E. @: [- O5 B6 d6 I
540
4 O, ]- b% g: G- v( j' I; ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 P+ U/ `' }. h1 ythe base of the phallus and was dark and curled. The
8 W5 \' w6 k* q& {& H8 h- R# T4 |testicular volume was prepubertal at 2 mL each.
9 D9 y9 i6 r8 m& yThe skin was moist and smooth and somewhat+ E9 Y, B3 a( p+ E& Y
oily. No axillary hair was noted. There were no# e) c, b* F7 R
abnormal skin pigmentations or café-au-lait spots.
% _2 X" }- \; A# L1 [* E2 LNeurologic evaluation showed deep tendon reflex 2+
9 j6 y" \; ~7 D3 o) m: Rbilateral and symmetrical. There was no suggestion
& T& ~/ P* ~% g) x8 tof papilledema.
' g" H1 e+ {! hLaboratory Evaluation7 {9 `* U5 V9 X5 p" R( {1 s
The bone age was consistent with 28 months by
  [9 P! y0 r% {; X5 rusing the standard of Greulich and Pyle at a chrono-- l% m( N5 O9 j( i: V
logic age of 16 months (advanced).5 Chromosomal
( i- Q$ t" z  M! @karyotype was 46XY. The thyroid function test
$ \  i' H6 a7 y2 a$ yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-# U  S/ V8 s" P+ j  a
lating hormone level was 1.3 µIU/mL (both normal).: o' K0 [0 D+ z/ E1 p9 I
The concentrations of serum electrolytes, blood, d/ k3 u# P# @4 k
urea nitrogen, creatinine, and calcium all were
* _2 c& J* g" r. |  gwithin normal range for his age. The concentration, J, V3 P. f2 Z3 |2 U+ Z
of serum 17-hydroxyprogesterone was 16 ng/dL
/ m3 o3 H! B! U- F/ e(normal, 3 to 90 ng/dL), androstenedione was 204 c2 G& J2 L$ @; Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 \) e) e) n4 F8 D) s
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( o6 \: X' H9 p/ Y1 ]/ l3 udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 j: G4 l) `/ N* p* E  f49ng/dL), 11-desoxycortisol (specific compound S)
8 _( x: V0 t" Y  Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 E' `" X3 I& Z( H; x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 {: q1 h7 ~/ X' ~7 E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" W2 S, A+ `  k- }" l, Qand β-human chorionic gonadotropin was less than7 l1 e  O/ }; G5 \' A0 T  |+ a
5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 [0 R; d1 c  @( wstimulating hormone and leuteinizing hormone
. C4 c/ g1 q) ?/ wconcentrations were less than 0.05 mIU/mL
0 Y* i# L7 s  t! }3 P  S, e(prepubertal).
6 x) w% E) o7 a3 S. c) _9 p4 z8 VThe parents were notified about the laboratory
' Z1 {7 S, k7 a# u/ Nresults and were informed that all of the tests were$ P9 G9 t: Q: a  I. {" F
normal except the testosterone level was high. The
( i5 a# T) r1 r  g& z" b+ Bfollow-up visit was arranged within a few weeks to* d; x/ \" R0 N2 }$ l+ f; g
obtain testicular and abdominal sonograms; how-
$ s' J3 J4 e2 k( oever, the family did not return for 4 months.; N. h1 F) V6 A" ^5 A
Physical examination at this time revealed that the
; @, ]5 p( w3 ?  q2 ^child had grown 2.5 cm in 4 months and had gained
3 O* q  F8 v- m- p; E7 b$ g2 kg of weight. Physical examination remained# [7 s! L6 \4 E/ A- }% j
unchanged. Surprisingly, the pubic hair almost com-% x0 V6 h  t( v9 U
pletely disappeared except for a few vellous hairs at
5 P7 A5 Z% |6 \2 G3 a9 s7 @0 hthe base of the phallus. Testicular volume was still 2' ?1 S6 ]1 F7 a6 k' M
mL, and the size of the penis remained unchanged.
4 P0 s1 }1 x& F3 XThe mother also said that the boy was no longer hav-
7 s/ Z. W  s4 A6 _ing frequent erections.
* H/ ?$ K, G/ {3 k3 j4 E) J, _Both parents were again questioned about use of
# U$ s- ^' F/ k0 W3 yany ointment/creams that they may have applied to2 ?' f& _  Z$ {1 Q9 k. t6 c+ E
the child’s skin. This time the father admitted the3 J3 H% {) _# D
Topical Testosterone Exposure / Bhowmick et al 541
& u/ g: J- [: j8 |! M. L/ fuse of testosterone gel twice daily that he was apply-
5 j) F/ O. j+ t) v. e$ `/ @ing over his own shoulders, chest, and back area for
  I% o. ]+ n8 w% u, V3 h7 Aa year. The father also revealed he was embarrassed
! V! `7 k. N2 K! K8 N4 N, Ato disclose that he was using a testosterone gel pre-
6 n2 |  y9 i/ w  G0 [( r2 xscribed by his family physician for decreased libido9 F! H9 U8 e5 ?
secondary to depression.
+ G1 M) [7 d  r1 w6 BThe child slept in the same bed with parents.
! g! i4 L, O; N. V+ c. NThe father would hug the baby and hold him on his
. U' K  b# J2 ^chest for a considerable period of time, causing sig-
; n: d  w6 M# a# ynificant bare skin contact between baby and father.: X' g- o3 E5 g0 V- I  T* c, Q
The father also admitted that after the phone call,
! s- A- I' D  W  h% H& Lwhen he learned the testosterone level in the baby
( Q" r/ V6 W" [" Y3 r3 ~7 |! Swas high, he then read the product information
# i7 N; L# N1 i. E7 tpacket and concluded that it was most likely the rea-( c) r% h$ _  e& O" B7 w1 q
son for the child’s virilization. At that time, they
5 h+ u7 W8 ^" y2 xdecided to put the baby in a separate bed, and the  o- x4 E4 Y9 d& h1 I& ^6 n- a# v* f  @
father was not hugging him with bare skin and had% Z; ]' f8 B4 M7 q- ?: [' o
been using protective clothing. A repeat testosterone
3 K1 f3 ~' E; @2 A: O- atest was ordered, but the family did not go to the
0 j. g6 Y- T7 Blaboratory to obtain the test.+ P" _# R' J6 ?: e6 c/ X
Discussion# n& S: s' L' t1 C7 u5 W
Precocious puberty in boys is defined as secondary: r; C4 h( U0 F. z* G; r! `
sexual development before 9 years of age.1,4+ A3 l1 C) @- `+ ]1 [" V
Precocious puberty is termed as central (true) when
5 ?% `& e3 g" H1 h. C0 wit is caused by the premature activation of hypo-
# \+ n7 ?6 r, X2 v" j. b+ ~" ]thalamic pituitary gonadal axis. CPP is more com-
, [# j8 L5 W7 e$ l6 `mon in girls than in boys.1,3 Most boys with CPP
, ]. a0 x- @# e7 Q6 ymay have a central nervous system lesion that is
( `, f5 J4 k; [3 C" H6 Y9 \responsible for the early activation of the hypothal-
. `( H$ c9 |0 h, `" p  Q! samic pituitary gonadal axis.1-3 Thus, greater empha-
1 ~/ M; v6 `: A# S/ E  Dsis has been given to neuroradiologic imaging in
, C# B/ }+ x  }/ ?! N# kboys with precocious puberty. In addition to viril-
; o3 a! D2 p3 K& Y% L9 oization, the clinical hallmark of CPP is the symmet-
" T+ M" y# I7 P' e% ]& o0 ]0 hrical testicular growth secondary to stimulation by
2 g$ o$ C' r& @/ g: Q8 Igonadotropins.1,3
" N6 ?& U7 v% `  ]$ F! {& u( ^Gonadotropin-independent peripheral preco-
9 E- Z$ o* C: Hcious puberty in boys also results from inappropriate
8 ^- o3 \5 G7 }2 w; |androgenic stimulation from either endogenous or- W( N7 }1 B9 g8 ?, O3 c
exogenous sources, nonpituitary gonadotropin stim-
* o0 |8 a! O4 Z) A( {; Qulation, and rare activating mutations.3 Virilizing5 [- \: ]0 x! T3 N# A, c6 }2 R
congenital adrenal hyperplasia producing excessive+ R- S3 [! M6 n7 V
adrenal androgens is a common cause of precocious
0 c$ e3 g( C7 ]puberty in boys.3,4
; J0 u0 ?$ f3 b! g- [  e6 EThe most common form of congenital adrenal
; t, P* S- V/ q, h8 r( p+ F- Whyperplasia is the 21-hydroxylase enzyme deficiency.
$ z, d# s+ d" m+ H1 o5 @5 {& oThe 11-β hydroxylase deficiency may also result in. l% z$ |; L/ l8 d& Q
excessive adrenal androgen production, and rarely,6 y* q, |% w( s* D' ^8 l% n
an adrenal tumor may also cause adrenal androgen
  F, L& P, o# pexcess.1,3/ b2 i1 M! N7 |1 N) M# }! {9 |2 p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; r- f4 V9 E! Q; r& K# q7 f# I542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, I. h9 @& f5 T1 G. B7 m. K
A unique entity of male-limited gonadotropin-
  v+ p3 _! S: X7 p" Hindependent precocious puberty, which is also known
' i, J: \: _( @# A: uas testotoxicosis, may cause precocious puberty at a
# V8 Z$ _4 h4 W# Tvery young age. The physical findings in these boys
- P$ b" Q: |/ n; m+ T, |with this disorder are full pubertal development,
& S! O) x' X/ @. a" z0 ?including bilateral testicular growth, similar to boys
! q$ }& r6 S/ V: w1 S' [' |7 gwith CPP. The gonadotropin levels in this disorder+ t% Z* A* `4 N7 G
are suppressed to prepubertal levels and do not show
0 V& J4 s# ^' y& s1 cpubertal response of gonadotropin after gonadotropin-' C$ m2 |8 m" G8 L, {2 }- E
releasing hormone stimulation. This is a sex-linked
% N! e" L( d" l  p0 U+ Hautosomal dominant disorder that affects only, b0 K# ?% {* ^/ [6 g$ F
males; therefore, other male members of the family
& w  N/ M. i, Jmay have similar precocious puberty.33 F1 I* _+ c7 @+ n+ ^' y: c- c
In our patient, physical examination was incon-- O* l4 K! o" M/ E2 R$ Y4 @% G
sistent with true precocious puberty since his testi-
# ^+ m0 a1 p: @' ]6 p) @cles were prepubertal in size. However, testotoxicosis
3 T  g+ f2 O' {$ r1 Rwas in the differential diagnosis because his father! k  Z/ N1 X, P2 L
started puberty somewhat early, and occasionally,
9 t8 z0 t+ y% a) [! Ptesticular enlargement is not that evident in the4 E$ f2 g( ^4 i9 [' F
beginning of this process.1 In the absence of a neg-4 s( W. u2 o# r! n& r. B
ative initial history of androgen exposure, our
! n0 X& x5 M( p5 \6 S# v/ \biggest concern was virilizing adrenal hyperplasia,- b' K- O* p, c' S8 P' X3 }
either 21-hydroxylase deficiency or 11-β hydroxylase: Q; B5 f4 M. l. l5 h5 O
deficiency. Those diagnoses were excluded by find-
% z/ ~2 `% f8 h% s/ r* z# |) x0 r& @# ding the normal level of adrenal steroids.2 }1 |$ W# x3 r$ ~
The diagnosis of exogenous androgens was strongly8 |7 L6 k- O) R7 \! y* K
suspected in a follow-up visit after 4 months because5 q+ B8 ]- h" r0 J
the physical examination revealed the complete disap-
. Q  W) j& B6 p" q: |pearance of pubic hair, normal growth velocity, and
# I; i' G* |0 T& }% f; M3 Odecreased erections. The father admitted using a testos-" @1 P: |% U# j0 n, _
terone gel, which he concealed at first visit. He was
) y7 Q& `! j# S# @7 U; S/ musing it rather frequently, twice a day. The Physicians’: t- S0 Q9 r( a$ x; I& t  x; W( g
Desk Reference, or package insert of this product, gel or
. w7 c8 D) s* I/ h6 _" tcream, cautions about dermal testosterone transfer to) Z% m- y9 m  C9 p: F4 \
unprotected females through direct skin exposure.
1 G0 |( [8 @: G# oSerum testosterone level was found to be 2 times the
6 |8 d# K8 U" I! o) |baseline value in those females who were exposed to
' e- g% p5 {% X( A: d" o* Teven 15 minutes of direct skin contact with their male
) N0 W2 N/ f: U, j% ~partners.6 However, when a shirt covered the applica-
: P! g1 X  Z+ ^8 l+ c& etion site, this testosterone transfer was prevented.
8 r6 @& L$ B1 V3 \7 T/ tOur patient’s testosterone level was 60 ng/mL,/ h, W" @( Z6 l
which was clearly high. Some studies suggest that
5 G7 ^! L9 F5 T9 d4 D0 ^' d; t8 rdermal conversion of testosterone to dihydrotestos-+ A  [5 _; b0 N& ^
terone, which is a more potent metabolite, is more/ s3 k: c# W; e! r5 Z$ [2 f
active in young children exposed to testosterone
  @4 ]: o5 X+ S6 F& Zexogenously7; however, we did not measure a dihy-
, m+ l3 T4 M% G5 Gdrotestosterone level in our patient. In addition to7 I) o' R6 B9 y  b
virilization, exposure to exogenous testosterone in7 Q9 T9 c" U& |$ }  {2 G
children results in an increase in growth velocity and. I5 U% O4 O% b$ w( G5 n0 m
advanced bone age, as seen in our patient.+ B1 p) Z- L4 }, v0 N/ X' M6 f. @
The long-term effect of androgen exposure during
7 D! o1 G1 w* t$ O2 t$ Searly childhood on pubertal development and final
* @' m/ u& o' h5 T) }$ x& vadult height are not fully known and always remain- C" G% o; r( T# r8 B' [3 H3 V
a concern. Children treated with short-term testos-4 Y' p1 |3 X4 P8 i  U: ~3 `) @4 J
terone injection or topical androgen may exhibit some  d. l# p; _2 ?4 b. {) g0 @6 i
acceleration of the skeletal maturation; however, after
4 x' d& K/ L: @$ U$ L# F, mcessation of treatment, the rate of bone maturation
7 o* t# F% G6 A; ~; _decelerates and gradually returns to normal.8,9
5 U& R2 A2 W% L% Y% H/ l& [There are conflicting reports and controversy. _; j3 M  k! a0 X) u
over the effect of early androgen exposure on adult
3 b3 S. ?0 a4 z* openile length.10,11 Some reports suggest subnormal
, u# s0 C( N: k8 r9 m) Uadult penile length, apparently because of downreg-
1 w: B; V3 Z! w5 Z2 h2 D1 F' Z" a% X* iulation of androgen receptor number.10,12 However,( [! g: D0 c$ Y7 K
Sutherland et al13 did not find a correlation between
" Z5 [4 L. w" v3 X9 n& u% Kchildhood testosterone exposure and reduced adult0 J- w+ D% L% E: u
penile length in clinical studies.( p9 k/ T6 W' H" O
Nonetheless, we do not believe our patient is% c. F; }/ V9 t, V! \; y7 n
going to experience any of the untoward effects from
8 ~1 i: }! d9 M/ u+ M' L- m1 ctestosterone exposure as mentioned earlier because' H* o$ F+ [3 _7 {! U  Y' g
the exposure was not for a prolonged period of time.
, @& h: O* h7 PAlthough the bone age was advanced at the time of
! C: ~! h% a" T) K. L4 L( [% A  w3 ?diagnosis, the child had a normal growth velocity at3 Z2 g% `+ a3 b% [: Y3 h+ @
the follow-up visit. It is hoped that his final adult% ^- W3 h) ?, Z8 |7 r  E
height will not be affected.
: ~+ F2 b9 U5 x. \- w8 z9 M7 i' _% |Although rarely reported, the widespread avail-
5 n: M2 X: K7 V5 v- G" D5 tability of androgen products in our society may4 S+ h+ l+ h9 w% }  s. H) j
indeed cause more virilization in male or female
% x  \+ x* Q/ N8 i! l7 xchildren than one would realize. Exposure to andro-
. [: }; c  Q0 f9 T; ?gen products must be considered and specific ques-
0 Q" V  z( c- Otioning about the use of a testosterone product or% K) W$ I( y& j6 M, `4 g8 h9 n
gel should be asked of the family members during! T/ k$ P/ G) f5 M$ N5 |. ^4 K
the evaluation of any children who present with vir-
* G0 B% a+ z; J' x+ t# dilization or peripheral precocious puberty. The diag-
/ F5 Q: O' G5 w* I5 W: X9 gnosis can be established by just a few tests and by
2 E( t+ T* B. D2 f& happropriate history. The inability to obtain such a
6 |. z' y( P# c8 ^8 R  Hhistory, or failure to ask the specific questions, may
! p0 v2 V, b9 c' B# w- O7 `% dresult in extensive, unnecessary, and expensive
1 X/ t6 B0 |; h* j1 x( t5 xinvestigation. The primary care physician should be2 e, O0 \$ S* P# q5 R5 `
aware of this fact, because most of these children  W+ C1 \# B2 k
may initially present in their practice. The Physicians’
% h# |+ F* ^0 `% MDesk Reference and package insert should also put a. |# `9 Z4 K1 F, @' v) _
warning about the virilizing effect on a male or
, A* p. x- Y4 w" y) `3 k. W. Wfemale child who might come in contact with some-6 p! c1 u: n& [; ]' @
one using any of these products.
2 P* @& i- L4 j" P0 ~References0 x) o1 m$ ^0 {; o
1. Styne DM. The testes: disorder of sexual differentiation
  A! V' `; B7 e' T$ Qand puberty in the male. In: Sperling MA, ed. Pediatric& u1 {" T( D; T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ b' {" P$ s5 y+ g
2002: 565-628.
0 N6 g# C* U1 a4 T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; Y. H7 i. }- 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( n8 c" Y2 C+ i, N( E% C
Boy Induced by Indirect Topical
( g' c, W2 v) m2 P' @2 t2 V' TExposure to Testosterone' ^0 b) p5 ^( u: ~9 z. e- m* L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 B2 Y6 n; }# |8 R1 A1 @( }and Kenneth R. Rettig, MD1
- `' Q, e- H2 }3 J0 V+ f6 mClinical Pediatrics
; _7 \- f; U* OVolume 46 Number 61 o; Q- O; H6 T/ I: b3 }6 M: |
July 2007 540-543
) p  d" @4 R5 K, f7 m, D© 2007 Sage Publications
% A) a7 h6 U7 C3 |: d( y10.1177/0009922806296651
5 X2 P1 @' n/ m$ j, ?" \0 [. a! ~http://clp.sagepub.com
7 K5 r* f4 Y- S) i% f7 L* T0 Zhosted at
- q* q: f& `1 e& C$ Hhttp://online.sagepub.com
( a. y8 V5 `3 Z- T+ y5 dPrecocious puberty in boys, central or peripheral,5 e5 K6 r( Y8 P. @& b$ y* Z
is a significant concern for physicians. Central
2 O8 h. \0 E' T. H+ p" W$ ^6 bprecocious puberty (CPP), which is mediated
* o8 A, l) B% z* D. ]/ M9 ~through the hypothalamic pituitary gonadal axis, has; `: P4 {5 J. b% d
a higher incidence of organic central nervous system: ]. _5 V; l  o
lesions in boys.1,2 Virilization in boys, as manifested
7 f2 m2 P+ D. B: i, t3 Lby enlargement of the penis, development of pubic. O7 y, u5 E; @
hair, and facial acne without enlargement of testi-7 Z" M. p' K9 g) |
cles, suggests peripheral or pseudopuberty.1-3 We+ B; ]. F- z5 \  o! |
report a 16-month-old boy who presented with the
$ W# z& S, [  [+ x6 P- Nenlargement of the phallus and pubic hair develop-/ T. k6 _7 u# L5 ]- a7 J: R" }( v
ment without testicular enlargement, which was due+ {1 K  y$ M( a, T, p+ Y6 J* G
to the unintentional exposure to androgen gel used by, k0 m! n) x6 u& l  {6 }
the father. The family initially concealed this infor-: C, Q/ ~7 i' \' w& L! k0 O- Y' i9 x
mation, resulting in an extensive work-up for this
9 e% ]5 l# Y: l; J; f$ A' T$ B$ cchild. Given the widespread and easy availability of
* W+ o0 r- [' w0 }testosterone gel and cream, we believe this is proba-
6 ]+ g0 U) S/ K+ Sbly more common than the rare case report in the8 a! J4 W3 G  p  @
literature.4
- I0 j. U9 E. ~4 A+ L0 u$ a  g$ `3 GPatient Report8 f$ Y2 P) b: I
A 16-month-old white child was referred to the
1 l6 Z1 }3 [, }8 J) Q( wendocrine clinic by his pediatrician with the concern
4 x" G, D7 [8 Sof early sexual development. His mother noticed9 J4 l% c- Y4 q% P2 ?
light colored pubic hair development when he was; j6 {- ?' a- ?; B# Q
From the 1Division of Pediatric Endocrinology, 2University of
- E% z9 h" r6 W% L% e5 G5 C% PSouth Alabama Medical Center, Mobile, Alabama., R0 K* u+ D3 H
Address correspondence to: Samar K. Bhowmick, MD, FACE,, G3 p: v$ v7 L% b2 Z' A# k- ^9 t
Professor of Pediatrics, University of South Alabama, College of
- p2 n  d# r6 V  i3 PMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 @; G. S. I+ a: a9 l! i5 U: a: ]$ N
e-mail: [email protected].
6 N4 B5 x& U& j" Vabout 6 to 7 months old, which progressively became( ]8 m% t& \+ ]3 D/ e8 J
darker. She was also concerned about the enlarge-# d7 U' Y# f- g: Q# ^; P3 n
ment of his penis and frequent erections. The child4 N* U" ]0 @" ]8 t5 P- ]- u
was the product of a full-term normal delivery, with/ S( \2 `8 p1 p. k' k% O$ z$ m
a birth weight of 7 lb 14 oz, and birth length of: N- b! @) a4 }
20 inches. He was breast-fed throughout the first year
( R8 H, W; `* E7 H. g/ q% kof life and was still receiving breast milk along with
5 n, R( }! A+ L# o( Asolid food. He had no hospitalizations or surgery,
/ U% g  O7 y  ?! {: j$ W, hand his psychosocial and psychomotor development3 t  c; W- n. Z) a0 P
was age appropriate.
' }9 `& t, Q# v: v( ?& T5 vThe family history was remarkable for the father,
. Z% q' n. c4 f# b7 j4 \who was diagnosed with hypothyroidism at age 16,/ a) M9 Z2 I( u  g5 g& J! f
which was treated with thyroxine. The father’s- J" V5 }, O% }/ x7 Y5 C& c. v
height was 6 feet, and he went through a somewhat
4 G9 R' s+ u* G/ k4 ^" @9 Kearly puberty and had stopped growing by age 14.& T8 i+ r& C1 c0 x* f
The father denied taking any other medication. The# g2 b3 P% S4 n, C7 b3 r
child’s mother was in good health. Her menarche( F# E* e% B3 g6 V+ W0 E
was at 11 years of age, and her height was at 5 feet
3 J" G7 P/ z8 J! \6 f7 w5 inches. There was no other family history of pre-
' i2 K% `/ r4 N; Pcocious sexual development in the first-degree rela-$ H+ ~; Z  e* g
tives. There were no siblings." l: j8 `' J! ~, l
Physical Examination
2 b0 }" W: G9 o) O# KThe physical examination revealed a very active,3 y- q" h( U- S! R/ f# Y
playful, and healthy boy. The vital signs documented* B+ m, s, Q% E2 Z1 M0 J5 b
a blood pressure of 85/50 mm Hg, his length was
, V- V8 D; l" ?/ l90 cm (>97th percentile), and his weight was 14.4 kg
) L4 t: g) ~3 r( z(also >97th percentile). The observed yearly growth
8 I4 B) Y) y8 s$ ovelocity was 30 cm (12 inches). The examination of' D! N+ u2 L- ?$ j7 z& R# \0 }& C
the neck revealed no thyroid enlargement.
0 E3 {  e* m4 `* uThe genitourinary examination was remarkable for
* L# a  X* [' {3 |enlargement of the penis, with a stretched length of
0 W8 x8 I' }- s8 cm and a width of 2 cm. The glans penis was very well
) M6 d! E3 P" k" e1 [developed. The pubic hair was Tanner II, mostly around0 t. {! ]2 @- ^& z; ^
540# e( Y2 f( \$ I/ ^4 _' r/ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% h& ?5 e- ?  B& ]the base of the phallus and was dark and curled. The
8 w2 r0 L* }5 Rtesticular volume was prepubertal at 2 mL each.4 A- b+ z( D7 U  X4 ~  Y  K5 \
The skin was moist and smooth and somewhat
5 B; c; J1 Q& n( F1 ^oily. No axillary hair was noted. There were no
7 ?7 D; D: a0 v# Z6 I2 L1 vabnormal skin pigmentations or café-au-lait spots.
6 A9 h0 W: I0 q3 D  G9 v) i" `Neurologic evaluation showed deep tendon reflex 2+
3 b6 H9 k" ]( d! I4 Kbilateral and symmetrical. There was no suggestion1 i/ Q  g0 }& f
of papilledema.
* p5 G$ X% L6 h- eLaboratory Evaluation" y5 a2 E% S9 f  G$ i1 }; H5 H+ M
The bone age was consistent with 28 months by
  g# f% {2 W3 {$ S0 ?using the standard of Greulich and Pyle at a chrono-7 V! X0 p  k2 l( Z- }
logic age of 16 months (advanced).5 Chromosomal
, W7 z8 D- {. o" `. fkaryotype was 46XY. The thyroid function test
* v( ^6 J* S+ e% d& D: P4 I6 @" u! P/ qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 t: n& z2 g% M+ Y- c
lating hormone level was 1.3 µIU/mL (both normal).
" X; `6 Y' s+ ]- X% |The concentrations of serum electrolytes, blood" E) b, S6 M+ S6 i% C
urea nitrogen, creatinine, and calcium all were
0 x) B2 x3 v1 q2 Zwithin normal range for his age. The concentration
& o  M7 q, W0 p$ [( O4 Pof serum 17-hydroxyprogesterone was 16 ng/dL" ]: L; s4 o- k5 G7 a
(normal, 3 to 90 ng/dL), androstenedione was 200 a( j3 B# k+ C% |5 O! D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 o$ w; o7 W8 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) i6 \* {( H6 A8 ^5 P& \
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ T- P. f8 X: d) h0 ~8 g
49ng/dL), 11-desoxycortisol (specific compound S)1 `' h: v( g; T  H& I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 b! b( c( D% I1 d) X" Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" ~6 Q$ K/ j/ r4 W! r$ Q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 S) ^" L# X/ i1 _and β-human chorionic gonadotropin was less than
, n2 i7 [: ?+ x/ @5 mIU/mL (normal <5 mIU/mL). Serum follicular1 z1 ?" l* Y1 F4 U1 _
stimulating hormone and leuteinizing hormone4 Q9 ~8 ]% A% q6 j& u. ~
concentrations were less than 0.05 mIU/mL
; T4 y: t- O$ p* b7 m9 [(prepubertal).4 h4 }% j* o" u8 P/ H: w" z
The parents were notified about the laboratory% `3 P& G* _) S; R; a
results and were informed that all of the tests were
$ D5 h7 B& p2 S9 t9 @4 Pnormal except the testosterone level was high. The: K( l- n$ {, q* Z) e
follow-up visit was arranged within a few weeks to
. N' Z5 u1 a9 W7 Yobtain testicular and abdominal sonograms; how-' k% X$ l2 {! O/ O( a- s
ever, the family did not return for 4 months.! |  [. J: }% `9 \1 u
Physical examination at this time revealed that the
1 {' d+ X6 E1 M9 D7 E  A- M. bchild had grown 2.5 cm in 4 months and had gained% f+ Y( p8 W7 {% t/ P
2 kg of weight. Physical examination remained2 k; a, H4 x* ?7 m  U) k/ O  {
unchanged. Surprisingly, the pubic hair almost com-
) J: f  w) R7 i) ?pletely disappeared except for a few vellous hairs at9 b" `& T  X' y
the base of the phallus. Testicular volume was still 2" ?4 P& H0 l0 v  K2 K
mL, and the size of the penis remained unchanged.
4 b" a5 U; A+ I6 E# kThe mother also said that the boy was no longer hav-
5 J) ?6 h) t$ ?( }6 _2 n1 x  b7 Ding frequent erections.
: V# V; Y  x$ J! [Both parents were again questioned about use of- ?( |- Z6 r6 s) v
any ointment/creams that they may have applied to- {& U+ K+ J) _  D9 n& d3 ]- W
the child’s skin. This time the father admitted the
6 f: A+ Z0 f4 H5 A* u8 h3 R" |' GTopical Testosterone Exposure / Bhowmick et al 541: u; f, `# Y4 e9 t$ P- a+ y" q
use of testosterone gel twice daily that he was apply-; o9 J8 F* V+ _( x( \/ B' U# ~
ing over his own shoulders, chest, and back area for
( E+ r- ^  Z4 ~& s/ ]: K. ua year. The father also revealed he was embarrassed
" x* i  `) @0 A) \/ fto disclose that he was using a testosterone gel pre-
& J. ^% U, V: D: Xscribed by his family physician for decreased libido
/ d$ f' w8 c# m- S' ~% B5 [! ]secondary to depression.
9 ~2 \3 h5 L* ]! m& AThe child slept in the same bed with parents.
7 F; W  m; @( k! NThe father would hug the baby and hold him on his
/ Z- A: U( b$ U+ ?, Ychest for a considerable period of time, causing sig-
! v1 V( q* m& p9 X/ bnificant bare skin contact between baby and father.0 N! l/ l* u0 U! L# ~' J/ x6 U
The father also admitted that after the phone call,/ x/ M' p$ B) u1 E. i! P8 k
when he learned the testosterone level in the baby
) V# W1 o# j% d  ]+ r5 j+ K' Q- Hwas high, he then read the product information/ o/ b* X- {3 ~  j8 G! f
packet and concluded that it was most likely the rea-
7 @7 l! S% A! T. o. j7 P6 M0 Qson for the child’s virilization. At that time, they& _/ n- K6 r8 h
decided to put the baby in a separate bed, and the- m. U0 c# o" D; ]8 `2 s
father was not hugging him with bare skin and had1 Q' P, r( C  G+ [( q
been using protective clothing. A repeat testosterone" P+ ~8 r1 u; d) I
test was ordered, but the family did not go to the
, v. K$ Q: D8 Z. dlaboratory to obtain the test.8 o+ R* A. V2 [! M
Discussion9 W% J% ?9 P! |0 q- o
Precocious puberty in boys is defined as secondary9 U# b) h( Z# {# B! H
sexual development before 9 years of age.1,44 {- S& K! Z; j/ a
Precocious puberty is termed as central (true) when
2 _4 |( E; ?2 \6 b7 {( U: ]) Xit is caused by the premature activation of hypo-
2 l0 w' \2 P) o5 Bthalamic pituitary gonadal axis. CPP is more com-% O0 Q6 A; D- h0 v# z' A
mon in girls than in boys.1,3 Most boys with CPP( s+ ]5 O% I% p/ Q, R
may have a central nervous system lesion that is
! g1 u+ v, `5 J5 j1 I, Y$ g) }+ Mresponsible for the early activation of the hypothal-
( N& P: s  b# u$ V/ Bamic pituitary gonadal axis.1-3 Thus, greater empha-+ n8 d2 ?# x7 n) v1 e
sis has been given to neuroradiologic imaging in) j2 o/ Y. d& D  {9 {1 ?' j
boys with precocious puberty. In addition to viril-  [- D! D: k7 R$ E* s* r* H
ization, the clinical hallmark of CPP is the symmet-
6 w; P# `- y! Zrical testicular growth secondary to stimulation by
8 z  M9 }7 f( ~- j1 _& `- Hgonadotropins.1,3
6 I" z% S, D; |3 ~( B" p7 g  YGonadotropin-independent peripheral preco-+ y; l& M& m7 z
cious puberty in boys also results from inappropriate2 J; q; z  j+ c# _# o7 Q
androgenic stimulation from either endogenous or
0 _& X/ D. a* V- kexogenous sources, nonpituitary gonadotropin stim-, R9 r2 M- S" ?4 ^* N3 u- k; }
ulation, and rare activating mutations.3 Virilizing( L: u7 G& ]( p; h1 ?
congenital adrenal hyperplasia producing excessive
  J/ ^3 x9 o, @& ?4 Zadrenal androgens is a common cause of precocious- F1 t0 j4 Z4 D% D; y) q8 m
puberty in boys.3,4
* h8 C: X& l4 LThe most common form of congenital adrenal1 p3 f& J/ p' D7 M9 N2 C
hyperplasia is the 21-hydroxylase enzyme deficiency.
' B, F& v" K- m5 c; ?6 [! pThe 11-β hydroxylase deficiency may also result in
3 |6 ]/ D2 g& m/ x; ]" g3 qexcessive adrenal androgen production, and rarely,
1 f2 F0 \: q( a4 o6 _an adrenal tumor may also cause adrenal androgen
" o9 {9 G, u# E5 ]9 gexcess.1,3
( S7 a* v. n! q- X* O$ kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' H) F. w7 x% j( c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* V/ N( ]8 ]( e4 pA unique entity of male-limited gonadotropin-
/ y  a; ^/ i3 w; a4 cindependent precocious puberty, which is also known$ W9 f) I) z# _- L3 A3 p
as testotoxicosis, may cause precocious puberty at a
; O$ F0 \- s5 vvery young age. The physical findings in these boys
/ U; [  I) y% P1 B9 Twith this disorder are full pubertal development,- q& H/ ^3 _, g$ k& E0 f3 D8 D( K
including bilateral testicular growth, similar to boys+ \8 j7 W5 d+ s; A
with CPP. The gonadotropin levels in this disorder
. s5 e, D5 A6 Yare suppressed to prepubertal levels and do not show
; l2 |& k! ~, A1 u; dpubertal response of gonadotropin after gonadotropin-
1 ~( J- L/ P# P( ?releasing hormone stimulation. This is a sex-linked
4 p2 v* v# S: ]+ w5 Oautosomal dominant disorder that affects only
9 A4 x, v( y# V& W/ Omales; therefore, other male members of the family  M/ R9 P, g7 p, @  f1 j
may have similar precocious puberty.3
8 P8 c* \) P8 D6 _  L, cIn our patient, physical examination was incon-6 l$ y0 [0 J4 ^; K- J- W& G
sistent with true precocious puberty since his testi-6 j, O; \' [$ s# N- A
cles were prepubertal in size. However, testotoxicosis# S% \" s7 t" ^$ m. s
was in the differential diagnosis because his father
* v5 Z+ B8 ~! x) q: W! lstarted puberty somewhat early, and occasionally,& P3 U# j1 i0 z- i' ?
testicular enlargement is not that evident in the
( ?: M3 G' I7 l9 Lbeginning of this process.1 In the absence of a neg-& u& I& Q% R, @9 q7 F$ S+ O
ative initial history of androgen exposure, our; P+ i! s2 a# W/ V$ S  {
biggest concern was virilizing adrenal hyperplasia,8 U; g- h  d  p
either 21-hydroxylase deficiency or 11-β hydroxylase
7 e; N7 A. Z: L2 h  Gdeficiency. Those diagnoses were excluded by find-# s1 z2 C2 V5 ?" l5 i
ing the normal level of adrenal steroids.' C% ]& P# F8 b' b/ t
The diagnosis of exogenous androgens was strongly' D- p0 G, `. D- u4 t# i/ k5 |
suspected in a follow-up visit after 4 months because
( n' p: `! L. zthe physical examination revealed the complete disap-
, d6 u( [7 d9 \9 c6 H6 Jpearance of pubic hair, normal growth velocity, and1 W6 w) z% @* a! K4 A7 ~2 U
decreased erections. The father admitted using a testos-
6 c3 @3 k* U+ ?* k7 O( w, f' [terone gel, which he concealed at first visit. He was
3 y) \0 g! b6 C! d* }/ Tusing it rather frequently, twice a day. The Physicians’
7 f, X9 X1 g! h% H6 v- PDesk Reference, or package insert of this product, gel or+ `- r# F) E" }$ t1 b5 B( x- o
cream, cautions about dermal testosterone transfer to# h) ]- `, n& S7 t- n- }% D& B' J
unprotected females through direct skin exposure.
2 }* ~, k, l) I- x% YSerum testosterone level was found to be 2 times the
9 ^- ~. N) d+ D7 gbaseline value in those females who were exposed to+ \1 A* s+ ^; {9 `
even 15 minutes of direct skin contact with their male
/ w0 `/ Z: E! }$ }! Tpartners.6 However, when a shirt covered the applica-
  w; R, x+ j6 i! q5 X/ _. etion site, this testosterone transfer was prevented.
% Z8 B9 b6 O, A+ Q; l3 _4 fOur patient’s testosterone level was 60 ng/mL,+ k/ y; j& \9 Z8 {, u$ p7 L
which was clearly high. Some studies suggest that
" c( e! T3 I# X5 z# u" I8 _! pdermal conversion of testosterone to dihydrotestos-( O% L: C6 Q4 K4 d  R! A0 k4 k
terone, which is a more potent metabolite, is more
% e) O& A+ w6 r5 W2 Cactive in young children exposed to testosterone
  o7 W5 E1 M4 r3 m8 C8 iexogenously7; however, we did not measure a dihy-. ~% f- _! O6 D& ~: i' c
drotestosterone level in our patient. In addition to) q" y- s4 ?% D8 N
virilization, exposure to exogenous testosterone in
# y" h4 \- j& ?# mchildren results in an increase in growth velocity and! X: W1 X# [/ V' h* J" }1 r! x
advanced bone age, as seen in our patient.: Y7 L" S9 Y9 E
The long-term effect of androgen exposure during
& l' u& D  B9 L  b* e2 z0 ^/ s$ oearly childhood on pubertal development and final3 ?7 ^0 F% ]. M! k7 k1 Z9 R, D
adult height are not fully known and always remain; A* r: W# |! Z: ~- b7 J2 r
a concern. Children treated with short-term testos-
. u* n+ Z  _  z3 ^/ }+ B& @" f' o9 pterone injection or topical androgen may exhibit some
6 X5 N3 o& i6 b% v: {2 z& {acceleration of the skeletal maturation; however, after: A8 G# \  g( {/ T0 ]
cessation of treatment, the rate of bone maturation9 T. w1 u- h1 O* p% @2 A- e# [1 Y$ z+ x
decelerates and gradually returns to normal.8,9/ r- C' M! n( Z
There are conflicting reports and controversy4 M/ o/ l7 K: t
over the effect of early androgen exposure on adult- F; A' v7 ?: {, f$ M% m  r
penile length.10,11 Some reports suggest subnormal0 y4 j! H+ R' R0 s
adult penile length, apparently because of downreg-$ Y- |* b0 `! N- _  K
ulation of androgen receptor number.10,12 However,0 O& N& n; q9 R2 H5 j4 J
Sutherland et al13 did not find a correlation between
# L" z+ S) b7 C5 h# ychildhood testosterone exposure and reduced adult
: x# ^1 P+ {7 ]% O* d- h  {penile length in clinical studies.
1 j8 m7 n' X' x  a& P  M& w) p( cNonetheless, we do not believe our patient is" V, w* S/ _, W; l' |. }
going to experience any of the untoward effects from
6 j) _% U# q( d8 s% c3 {4 ttestosterone exposure as mentioned earlier because
3 y9 P/ l+ _* q; L+ z1 x/ r9 Jthe exposure was not for a prolonged period of time.
% K, q& v0 M' mAlthough the bone age was advanced at the time of0 G8 Z- ^! x5 s6 R9 ~# H
diagnosis, the child had a normal growth velocity at
5 H1 R% P; x4 Ithe follow-up visit. It is hoped that his final adult8 a: o; W, d, S7 q8 o/ C9 L
height will not be affected.
8 R6 z2 p4 {$ Y/ v1 sAlthough rarely reported, the widespread avail-/ N5 t7 z/ Y8 G1 x! N
ability of androgen products in our society may
3 S/ J! t; c! @# D- o+ Uindeed cause more virilization in male or female
) w3 b- R7 }9 D6 Achildren than one would realize. Exposure to andro-" P% \: w  o* S+ f) \# G  [
gen products must be considered and specific ques-
% i; @' M! e1 Ationing about the use of a testosterone product or: F6 v/ @: j# G: M; B6 l
gel should be asked of the family members during
& m6 i) z2 Z- |& h" Cthe evaluation of any children who present with vir-: m, @- f6 u! }4 b9 B+ l$ c
ilization or peripheral precocious puberty. The diag-
# |  A4 O& t! [7 G$ Dnosis can be established by just a few tests and by3 }# L7 n) V) e4 b+ e6 R4 k, S
appropriate history. The inability to obtain such a" F9 |1 z$ Q8 {) d! v! J' B4 P: B
history, or failure to ask the specific questions, may; i) p1 M3 k5 u0 `/ B$ F
result in extensive, unnecessary, and expensive# G" W0 }2 `! v8 Z3 m2 H
investigation. The primary care physician should be
. v1 H0 R7 Q, u  [7 m- v7 @5 `6 paware of this fact, because most of these children
: a) P! g6 W- ~: Xmay initially present in their practice. The Physicians’
; s) _8 C$ W: ADesk Reference and package insert should also put a
2 @: y/ C- E$ I& u( G$ x" [warning about the virilizing effect on a male or# r' X6 @  ?/ V! D7 D+ m$ Y
female child who might come in contact with some-. ?: @. a( I5 k' a: F% _
one using any of these products.1 p( P! ]% i8 W( a
References
$ \/ k6 S& U! S0 R! R, h1. Styne DM. The testes: disorder of sexual differentiation! [3 L" c. i' Q/ X4 i3 [; a& v, |' A
and puberty in the male. In: Sperling MA, ed. Pediatric. Y3 K3 r1 |* u! z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 m5 @) r! J9 ^, S& ~
2002: 565-628.
* W8 a# Y. ~/ a5 T2 A9 [% S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# a' J% O5 J+ }% p
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
7 q+ H* f( H( |$ ~( i2 _
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