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
8 D6 `2 J! A6 o" j8 X8 `Boy Induced by Indirect Topical% E- ?+ P4 K+ n$ B  ?6 y
Exposure to Testosterone
) O% k1 m5 D7 Q* K+ P' J0 i$ H, XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 U3 Z5 Y" o* A# B  F* |and Kenneth R. Rettig, MD1
1 f4 q$ s% S' F# Q% B1 IClinical Pediatrics
1 S# `' \5 O4 x% y$ p, c  yVolume 46 Number 6) Y: a5 z$ A3 O7 n2 a
July 2007 540-5432 P; a! k( q5 {
© 2007 Sage Publications- j( H& \/ R9 L" v" b# L* q) x
10.1177/0009922806296651
. h" e2 ^! b" D8 ^8 y# khttp://clp.sagepub.com
; m5 V: a) e/ ohosted at
( R5 V% S& ?# O: p# chttp://online.sagepub.com# S7 N5 z/ M& X) a
Precocious puberty in boys, central or peripheral,
  I1 R1 J3 h1 [0 a) Pis a significant concern for physicians. Central
& ?/ J" r( n8 Z. I0 j& Uprecocious puberty (CPP), which is mediated
$ H! g3 H, R/ q/ Q9 B0 Gthrough the hypothalamic pituitary gonadal axis, has
1 D  s6 R! c1 f' y" ?+ ca higher incidence of organic central nervous system- ^  @- e7 y. \4 H1 v" k( Y) E
lesions in boys.1,2 Virilization in boys, as manifested
. `; G. J2 A' i4 f4 ~9 v) jby enlargement of the penis, development of pubic
" W9 z+ X% ?8 A! M* w; ghair, and facial acne without enlargement of testi-
9 P+ `8 z! T2 bcles, suggests peripheral or pseudopuberty.1-3 We( c, r- B+ H5 u/ Q
report a 16-month-old boy who presented with the
9 ?2 _: h* y3 G. Z- z% cenlargement of the phallus and pubic hair develop-
" o# u4 U  ?  w6 F$ dment without testicular enlargement, which was due
3 Y0 j3 L% v, C' z/ xto the unintentional exposure to androgen gel used by
# M) q2 L; ]7 ^; W' O( Y) _the father. The family initially concealed this infor-" ?1 ~" U( @$ {" g: V8 r9 M% ~7 r
mation, resulting in an extensive work-up for this
' a6 s" U' y* t1 P0 Q; Z; x9 K. L# Kchild. Given the widespread and easy availability of
7 S: j' u& `9 ctestosterone gel and cream, we believe this is proba-
: p" T& Y- O( Rbly more common than the rare case report in the
# _: q) e2 N/ c3 Nliterature.4
. B' Y5 }1 e7 S$ G4 U5 H( RPatient Report. |) O% |. r; E- ^
A 16-month-old white child was referred to the
: k6 G; V. k8 p9 @endocrine clinic by his pediatrician with the concern# d/ `3 U  q+ T( f7 m& x
of early sexual development. His mother noticed
# l0 Z4 ]6 N! J! Xlight colored pubic hair development when he was2 H& r% v& i: |! ^$ d: v
From the 1Division of Pediatric Endocrinology, 2University of
8 j2 e+ a; A' ~South Alabama Medical Center, Mobile, Alabama.
) g2 M# P: C$ X4 o0 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 X3 l0 N7 Q. u+ E9 p+ ~Professor of Pediatrics, University of South Alabama, College of
8 U6 U" m+ I0 [3 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 d$ M3 p# c& ^1 S# s) X0 qe-mail: [email protected].
9 n7 L- L! F; F) uabout 6 to 7 months old, which progressively became( z2 J, [' a7 A/ p* Z
darker. She was also concerned about the enlarge-
5 a3 Q0 |7 b& R* v/ t% K8 N# Pment of his penis and frequent erections. The child$ g  v5 Z$ ], m& {; t
was the product of a full-term normal delivery, with* [- y) L2 _1 v' o' |: b
a birth weight of 7 lb 14 oz, and birth length of
" a" y7 F, a+ g) I6 M2 c20 inches. He was breast-fed throughout the first year, Z! `! X, l( C9 v! a
of life and was still receiving breast milk along with/ G/ {& H! l3 |' f
solid food. He had no hospitalizations or surgery,2 b" r6 y" @' d  G3 j
and his psychosocial and psychomotor development
4 H8 g  a! s% e! ]! j* W9 f( Q$ wwas age appropriate.# t$ q& N  v  \# D, |. e
The family history was remarkable for the father,
# t8 ~1 X' R3 G9 g* c& vwho was diagnosed with hypothyroidism at age 16,! [5 \; J$ l: ^8 y. |
which was treated with thyroxine. The father’s/ m* z5 d* @( T! Z# z3 M: Y
height was 6 feet, and he went through a somewhat# b; P1 L. C1 o' `7 U6 I
early puberty and had stopped growing by age 14.1 w' o+ [- ]$ c( `! K* z
The father denied taking any other medication. The
& a! m8 M. }) M7 u' jchild’s mother was in good health. Her menarche3 q  w, D# K& q/ r
was at 11 years of age, and her height was at 5 feet* n5 }, S3 X% j. @$ o
5 inches. There was no other family history of pre-
- D  d/ ^) w- hcocious sexual development in the first-degree rela-5 n8 T  Y. ~. p( C/ k0 `& w; s
tives. There were no siblings.
" G/ i$ E; v- }# a1 Q  FPhysical Examination* Q* q" w  S! R+ X3 }+ H
The physical examination revealed a very active,
  @9 ^' |, `$ V) Xplayful, and healthy boy. The vital signs documented
7 G3 Z5 N  R& F& X) j4 za blood pressure of 85/50 mm Hg, his length was
7 u7 F5 h# |* ]7 w6 V9 _/ m- J; k; @. x90 cm (>97th percentile), and his weight was 14.4 kg' d( E* p) C6 m; ^9 b6 K, `3 s
(also >97th percentile). The observed yearly growth& F6 F+ E- H! Y, T2 T
velocity was 30 cm (12 inches). The examination of
/ Y" H2 g' c3 k* Qthe neck revealed no thyroid enlargement.. _: r+ c6 c$ Z7 d
The genitourinary examination was remarkable for; X+ z" l5 E  `
enlargement of the penis, with a stretched length of% V, q& q- K, k! G# Q5 L+ s
8 cm and a width of 2 cm. The glans penis was very well
' `7 m7 p3 V. Edeveloped. The pubic hair was Tanner II, mostly around
4 C0 @+ n2 Q, J; A1 h$ d540$ j% |) U3 v$ c' t* v& t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 U2 l! J4 @* m5 R9 Y0 S1 Hthe base of the phallus and was dark and curled. The
0 S0 ?  F: X, L5 y; ~+ Otesticular volume was prepubertal at 2 mL each.! r9 n" w; c7 M$ {5 `! N
The skin was moist and smooth and somewhat
! x' Y' m3 b% E' \oily. No axillary hair was noted. There were no
/ X* ~. G$ t2 kabnormal skin pigmentations or café-au-lait spots.3 Y1 d! R4 o3 D. L+ g& _
Neurologic evaluation showed deep tendon reflex 2+, e6 M8 Q+ u) t, u
bilateral and symmetrical. There was no suggestion$ s0 p3 A3 P7 ~/ p6 i0 H/ Q
of papilledema.
* ?+ D/ \' Y8 D9 j8 Q" b7 qLaboratory Evaluation
1 `/ e- X1 L- i( A# j$ HThe bone age was consistent with 28 months by
: v0 N0 z& S+ G. susing the standard of Greulich and Pyle at a chrono-
7 D4 p6 i% _  Q) I' glogic age of 16 months (advanced).5 Chromosomal
4 s3 `- P4 e, a/ }, Fkaryotype was 46XY. The thyroid function test- a+ V! {: P% ~/ V5 g( I9 R. x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 o. q' u2 ~6 `5 u! ~& f) m  Llating hormone level was 1.3 µIU/mL (both normal).9 }: q7 H) u7 [" Y1 w  G
The concentrations of serum electrolytes, blood
' Z6 x' P& S( zurea nitrogen, creatinine, and calcium all were! N. y. g; m5 G0 _- X& P2 {; b
within normal range for his age. The concentration
2 v  U+ ~; [+ u- {! r7 pof serum 17-hydroxyprogesterone was 16 ng/dL
9 E9 y; M4 C6 B% e, T( n(normal, 3 to 90 ng/dL), androstenedione was 20- z! R+ v; Z0 v$ r8 x+ n
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 v* ]5 P7 X7 a0 x+ b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 D: U& b' c' @/ E8 Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: E0 ]! `8 J  @6 t49ng/dL), 11-desoxycortisol (specific compound S)# g7 t2 A# ?+ Q, J
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 z  C) m, e8 q' ~4 Q) r  d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 I  W) ]/ I, `# J* ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 H! |! \2 g! Y8 {9 p2 O* \and β-human chorionic gonadotropin was less than, e$ S+ [! Z! c1 u% Z7 {: q3 N8 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 n! @1 A$ d" A! d& W' }/ pstimulating hormone and leuteinizing hormone
0 u( U  W; G9 _concentrations were less than 0.05 mIU/mL
* A! l" Y6 E- i- Y4 \8 ?+ J( [0 B(prepubertal).5 v' {$ q$ s$ E  W/ d& E. R" n
The parents were notified about the laboratory
4 Q3 F) w! r) d* N: B3 mresults and were informed that all of the tests were; P* i$ W7 J7 L6 b; o1 O0 ^
normal except the testosterone level was high. The
2 X; T0 C! H9 u( Z. Hfollow-up visit was arranged within a few weeks to; v- ], O; _4 Y9 x! O2 q+ g
obtain testicular and abdominal sonograms; how-. c) n" ~! o+ K, z& m) M
ever, the family did not return for 4 months.
' r) B& y  }9 x0 RPhysical examination at this time revealed that the9 j; ~% v; ~3 g! c' @
child had grown 2.5 cm in 4 months and had gained
+ |+ @; ~* L$ g3 O3 N1 w: i' f2 kg of weight. Physical examination remained0 u, }- u1 a3 I! H
unchanged. Surprisingly, the pubic hair almost com-; C: b* @5 G. K' R) Y# l  A; {2 e. q0 z
pletely disappeared except for a few vellous hairs at
' u7 j' o9 k% z  {the base of the phallus. Testicular volume was still 2" w# E% Q; }7 i6 B2 {9 A  |
mL, and the size of the penis remained unchanged.
- b, G" l5 ]+ ~5 T; P: |' u6 fThe mother also said that the boy was no longer hav-7 ^# h2 F" [5 s# T+ M; Z
ing frequent erections." @" _3 R, a& V' R2 M  j! c8 X
Both parents were again questioned about use of$ V2 E- d6 t( X) a- ?% ?5 s
any ointment/creams that they may have applied to- s9 u7 k- s" a# @
the child’s skin. This time the father admitted the/ {# S; s) j4 d- o' E1 s
Topical Testosterone Exposure / Bhowmick et al 541
$ H4 Y& |! @. e' i) L9 y7 uuse of testosterone gel twice daily that he was apply-
/ y- c* J: E- \2 D8 T1 @ing over his own shoulders, chest, and back area for
/ j5 Q, u* ~3 fa year. The father also revealed he was embarrassed0 W2 b) y/ J( u. O4 g0 f' u
to disclose that he was using a testosterone gel pre-6 i4 j: z# R2 z9 Q+ J
scribed by his family physician for decreased libido3 j6 |1 j' A; h  N7 ?: c
secondary to depression.) t7 g( F) a2 d6 ]$ t4 D$ K0 Z' b& }
The child slept in the same bed with parents.
) s4 i! s2 |: O0 Q' n. p2 u- W$ jThe father would hug the baby and hold him on his
: {$ ~4 _# E2 E! o/ \6 `8 _- g5 x( y) rchest for a considerable period of time, causing sig-
# B4 W2 k" i1 P- G9 f' C5 hnificant bare skin contact between baby and father.- c5 t8 Q7 E  E0 t( j* ^! K
The father also admitted that after the phone call,, d" a; O  m5 `/ s& o" j" l2 x7 X' y
when he learned the testosterone level in the baby9 g  I  M5 I" _) _) f8 \5 {
was high, he then read the product information
) y+ ^. y# N& E5 y/ ipacket and concluded that it was most likely the rea-9 I6 {! v/ Y7 o9 h1 \
son for the child’s virilization. At that time, they
0 V: ^. ?& i7 T# B8 ^3 M8 w8 ^' kdecided to put the baby in a separate bed, and the0 I6 ]3 `3 U! D# `5 \
father was not hugging him with bare skin and had2 P. Q9 d7 j3 ]
been using protective clothing. A repeat testosterone4 P7 ~& \' j# G# ^
test was ordered, but the family did not go to the
; i  i, n$ z* flaboratory to obtain the test.
4 I+ [& }* g1 W/ HDiscussion6 K- K4 e1 B7 M. c) y# R( F5 C0 k
Precocious puberty in boys is defined as secondary4 I$ k' ^  @/ d+ J( ?
sexual development before 9 years of age.1,4
1 q9 P5 C( b' f- GPrecocious puberty is termed as central (true) when
  H* s9 U+ \) y9 G7 @& O9 A2 z& @it is caused by the premature activation of hypo-
4 K& _4 i5 s$ a0 t+ Z; lthalamic pituitary gonadal axis. CPP is more com-) b! W% e0 N# ?
mon in girls than in boys.1,3 Most boys with CPP  P( _: Z( i! r6 s, q, Z4 |: S
may have a central nervous system lesion that is& S( ~" @. |' @4 e! R* ~/ [  C4 ]
responsible for the early activation of the hypothal-
5 W* A+ R/ Q# U6 {amic pituitary gonadal axis.1-3 Thus, greater empha-( m+ Y9 U1 m, f; t( W
sis has been given to neuroradiologic imaging in
& E% P! G9 U) B, B6 |6 ]$ Rboys with precocious puberty. In addition to viril-9 Q+ f% l* W; P. D# A0 T( q
ization, the clinical hallmark of CPP is the symmet-
" ^" B; V% C# p$ I6 ?rical testicular growth secondary to stimulation by* K9 l  T/ i8 Q3 O' P& b! B/ {, Y
gonadotropins.1,3
" j, m) \8 [0 V; p& ^; u2 GGonadotropin-independent peripheral preco-9 @' @% d% A8 z3 C. K+ |$ c8 a
cious puberty in boys also results from inappropriate
9 l" F1 X0 l9 v- Wandrogenic stimulation from either endogenous or: K8 X+ C5 {7 x. p$ I9 e- i# T
exogenous sources, nonpituitary gonadotropin stim-3 Y7 R  q2 t+ |0 l, e8 h
ulation, and rare activating mutations.3 Virilizing" F5 q  y8 V& }
congenital adrenal hyperplasia producing excessive
8 u6 o, O" u. }adrenal androgens is a common cause of precocious) H$ `3 X: p6 X: l* C6 W, ]7 e
puberty in boys.3,43 h7 |: `- `/ Y3 X4 ?  ~1 G, J3 ]
The most common form of congenital adrenal- F! \( V7 d  x9 w. Z/ _% u' R
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 m, K5 C* E4 p' e# ~2 |3 ^9 RThe 11-β hydroxylase deficiency may also result in: q: _' O- z# y, H+ ?% y- O
excessive adrenal androgen production, and rarely,/ w) P/ G: O8 J% d5 b
an adrenal tumor may also cause adrenal androgen
) x5 g! N/ ^6 |, k( Dexcess.1,3
0 K* {" m5 w  ]$ m/ Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 U5 b" [- J- L5 s
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 t- ~0 \' F( C  x" _  w) J5 v
A unique entity of male-limited gonadotropin-
2 _2 n: w' ], W; x9 D7 y  W4 Findependent precocious puberty, which is also known  z- o: L5 p% J% a& K
as testotoxicosis, may cause precocious puberty at a. l; S1 f. m- m4 L5 A9 T
very young age. The physical findings in these boys* ~0 y/ |! i, Y
with this disorder are full pubertal development,  k# T0 U% I- m
including bilateral testicular growth, similar to boys) a0 r2 h0 K2 I& Z: d/ f4 D
with CPP. The gonadotropin levels in this disorder
7 J/ p" X1 p5 Jare suppressed to prepubertal levels and do not show0 T$ e8 \+ i* m- Q7 Z. a
pubertal response of gonadotropin after gonadotropin-# h: b8 T: ?' i5 D8 j" t, q% y3 E6 s1 S
releasing hormone stimulation. This is a sex-linked
- O" b5 j! h: m- Y# C  f' ]autosomal dominant disorder that affects only9 Q( }1 D" X) B  u- ~* C/ ^6 \' I
males; therefore, other male members of the family* d- q& P2 v$ j+ f+ ?* q( c4 ^
may have similar precocious puberty.3$ G$ x' d; K# h0 u
In our patient, physical examination was incon-  [; x+ G* _+ ~1 U
sistent with true precocious puberty since his testi-
5 _# Z5 p5 j$ {5 K( _+ K7 F. i  H5 {cles were prepubertal in size. However, testotoxicosis+ U& b4 @/ X; D5 U, w
was in the differential diagnosis because his father
. l) |+ S; ?0 ^1 \3 Tstarted puberty somewhat early, and occasionally,
  Z; ~1 G( z( r5 Q6 e! d8 etesticular enlargement is not that evident in the& ~5 {  x6 W& z  P6 ~+ a; R
beginning of this process.1 In the absence of a neg-" u/ P" y+ c$ \8 `7 k
ative initial history of androgen exposure, our
( M+ U  h. k$ l$ p0 B! |/ V: Nbiggest concern was virilizing adrenal hyperplasia,& r" j* F9 B: j" n, o) N
either 21-hydroxylase deficiency or 11-β hydroxylase& J9 F- M+ a: J2 K& O1 |
deficiency. Those diagnoses were excluded by find-
% w9 l% t: ^! a5 S: Ying the normal level of adrenal steroids.* T  F- W5 h7 j$ U7 w- Y
The diagnosis of exogenous androgens was strongly! Y1 Q4 Q) X$ g6 Y  N/ e
suspected in a follow-up visit after 4 months because  Z& m4 H# i7 s& \. t1 S
the physical examination revealed the complete disap-
' G5 j' O2 M/ Y, z# d/ `pearance of pubic hair, normal growth velocity, and  w! g) c* n1 X  g
decreased erections. The father admitted using a testos-# Y$ `3 \* v/ R7 F, u; ?. o
terone gel, which he concealed at first visit. He was
. V. v, O  I. L" musing it rather frequently, twice a day. The Physicians’5 B/ q/ k5 a, `7 d4 E) h" w; i1 R
Desk Reference, or package insert of this product, gel or0 Z( `: L# _+ a2 E; W3 E! N7 Z
cream, cautions about dermal testosterone transfer to7 P* W: S( |3 R) j- ]7 r/ T5 W+ w
unprotected females through direct skin exposure.
& W3 n! }6 b: ^3 qSerum testosterone level was found to be 2 times the6 J9 k3 Q: D% k; K/ S, R
baseline value in those females who were exposed to" y- d  `; \, ~6 j+ {2 z1 t( k
even 15 minutes of direct skin contact with their male  I" }  t& z. ^6 L
partners.6 However, when a shirt covered the applica-; O* o7 P! ]& f
tion site, this testosterone transfer was prevented.
# g  H/ ~9 k$ a$ UOur patient’s testosterone level was 60 ng/mL,
5 E- |+ ]0 o8 |. x9 R/ pwhich was clearly high. Some studies suggest that3 ]7 e3 Q: T' ]( J& `- Z" E- g
dermal conversion of testosterone to dihydrotestos-
! p8 f9 w3 J/ {0 Z6 z! P% a1 R( aterone, which is a more potent metabolite, is more4 j- ^  D$ v" n9 b0 I6 a: t
active in young children exposed to testosterone; c2 ]2 {$ T4 t0 K/ k
exogenously7; however, we did not measure a dihy-- P* C, C" G3 a; {
drotestosterone level in our patient. In addition to
9 d+ h; R# _3 @+ o' T* ^/ Wvirilization, exposure to exogenous testosterone in2 \' _2 r# p# u; a( B7 _6 r' P1 A( {
children results in an increase in growth velocity and
, B% w# [2 h7 x' V( j4 fadvanced bone age, as seen in our patient., C/ k" a7 d) T
The long-term effect of androgen exposure during
4 k$ g' ^$ Q5 F0 s  eearly childhood on pubertal development and final1 v7 L  F+ m3 h! p, S$ e# K
adult height are not fully known and always remain. U; t+ W: W+ U8 ]/ }
a concern. Children treated with short-term testos-# E0 z: e' Y4 C& Y
terone injection or topical androgen may exhibit some# k4 y: m: d9 }9 s- Q
acceleration of the skeletal maturation; however, after6 y% H* q5 q& }3 `8 @" {0 E
cessation of treatment, the rate of bone maturation
' m: M7 R+ l1 E  h' U3 Idecelerates and gradually returns to normal.8,9: ~* s4 ?3 h; I
There are conflicting reports and controversy3 C2 z$ @) f& k  ^- ]
over the effect of early androgen exposure on adult
) y4 g4 l2 o( w) X9 q: V1 j; xpenile length.10,11 Some reports suggest subnormal
3 m( I, e! Z, kadult penile length, apparently because of downreg-
! S1 G/ J. Q8 c) l' {1 nulation of androgen receptor number.10,12 However,
- F4 y7 \- `# ]Sutherland et al13 did not find a correlation between1 Z5 j# m! X1 Q- ?2 }
childhood testosterone exposure and reduced adult
" L% Y: a& p- a; Qpenile length in clinical studies.# w8 C) R+ B7 e) A+ v
Nonetheless, we do not believe our patient is
" }: J* d. H1 u4 `going to experience any of the untoward effects from" i2 l1 j# c7 M
testosterone exposure as mentioned earlier because
% _4 |# Y# c# s+ `* J$ xthe exposure was not for a prolonged period of time.; E$ @8 C: a9 w* j8 o
Although the bone age was advanced at the time of
! t- [8 p, A3 z+ rdiagnosis, the child had a normal growth velocity at7 t2 s% p. O; M- W  n/ A1 ^
the follow-up visit. It is hoped that his final adult
2 C) u& c  k1 J" V) ?" ~( F4 o! Aheight will not be affected.
4 s6 b- I1 b( m% I& j* M" RAlthough rarely reported, the widespread avail-
, F8 N; i7 y, ~  }% b) i! ~" @0 Q6 u3 qability of androgen products in our society may
3 ?; |5 r& @, {& r( I$ E9 m5 jindeed cause more virilization in male or female
! H5 k1 s5 `3 ~children than one would realize. Exposure to andro-
' M( O4 Y  ]$ X! Ygen products must be considered and specific ques-5 H  z; W1 v: ?% ]; t7 W
tioning about the use of a testosterone product or
; z3 T' |1 _: }+ W: z$ H( E6 Igel should be asked of the family members during5 o' Q! O& y) U& |0 F+ K  c9 D9 X
the evaluation of any children who present with vir-9 i  m7 W5 r  D6 k- K$ ?+ ]
ilization or peripheral precocious puberty. The diag-7 Y) e0 B- t7 a& H
nosis can be established by just a few tests and by: E: s& s. e* J' V$ h# V+ p
appropriate history. The inability to obtain such a
# |2 h+ v* ^, ]. s5 [3 {' Qhistory, or failure to ask the specific questions, may' Z" f9 s! ~- s; z- a, s) R. F
result in extensive, unnecessary, and expensive( x* U: `: Z+ h) F$ l, b
investigation. The primary care physician should be
9 _: i$ c2 L* _' T. C+ P9 n- [aware of this fact, because most of these children
! v5 p& N  r' P5 ~. s9 b$ b1 Amay initially present in their practice. The Physicians’
  c: s. U% ~% M: E0 K9 J8 @Desk Reference and package insert should also put a/ B5 x7 \( p5 q, {  Q8 ^2 U
warning about the virilizing effect on a male or! [# l$ G4 l  Y0 Q- h
female child who might come in contact with some-
% r7 e7 Y% ]4 A( c( qone using any of these products./ s' f8 d& P/ T- B
References3 N8 R6 z# K9 F; K0 s
1. Styne DM. The testes: disorder of sexual differentiation
; f7 E; d* [0 Wand puberty in the male. In: Sperling MA, ed. Pediatric
$ e, z/ E6 a) q% M8 h+ [  \4 B1 ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 j& |9 ~3 m* y+ v* `8 b+ C( I& `2002: 565-628.
; ]7 J5 [( J+ b& L9 P0 B" e  r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 o1 P# Y6 J" u) M6 Kpuberty 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; X" z' F5 V) H7 I4 S- V4 }
Boy Induced by Indirect Topical
* L' V% z9 ^/ L, R1 R) oExposure to Testosterone
& M* L) S0 H/ i3 U! T1 r$ s8 fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ r0 ^3 l+ h( M9 M* g
and Kenneth R. Rettig, MD1
$ N, N2 S& p  CClinical Pediatrics! x" ^) O) ?% D/ L3 f
Volume 46 Number 6! g" I' o3 i1 ~5 L1 T
July 2007 540-5431 r' s' c$ l9 B6 a) c
© 2007 Sage Publications
! @5 g+ T# e' |5 j10.1177/0009922806296651
6 e- H" M6 K3 c1 H- }http://clp.sagepub.com0 O1 P( a- q4 f2 d* Y, u
hosted at8 l: W) \! ~( a0 A8 ^; r9 x8 Y1 C
http://online.sagepub.com
) k* E6 W" X, {# dPrecocious puberty in boys, central or peripheral,& m4 |. Z6 e3 b2 m0 C
is a significant concern for physicians. Central
$ B/ e) ^. x8 [3 {) S0 [precocious puberty (CPP), which is mediated
; F! S! g- D% b' vthrough the hypothalamic pituitary gonadal axis, has1 R- p$ G/ @& P1 i; |$ n- }
a higher incidence of organic central nervous system
6 c" I/ e8 J6 e. i# Plesions in boys.1,2 Virilization in boys, as manifested
' f2 o/ S- ]2 r, l9 D3 xby enlargement of the penis, development of pubic* [& Y& Z8 ^7 I0 [
hair, and facial acne without enlargement of testi-1 O$ x( H5 K4 ]( q* S
cles, suggests peripheral or pseudopuberty.1-3 We
; z# d. _! S3 I* {" q% n0 W. Ureport a 16-month-old boy who presented with the
* L0 {3 W# ?* U* ]enlargement of the phallus and pubic hair develop-- |; N. z1 `. U" }* v! C% m
ment without testicular enlargement, which was due7 C& J7 ?3 s6 ?. v! N& \3 m/ W! d
to the unintentional exposure to androgen gel used by
* _) Y- S- a5 l! B0 `( _the father. The family initially concealed this infor-
: L, q# j* g) Omation, resulting in an extensive work-up for this
) Y" v' P3 |% B" E. x' h7 Ichild. Given the widespread and easy availability of7 u0 b( u7 ?& ~, S' L, J  T
testosterone gel and cream, we believe this is proba-
6 Z2 J4 Y& q  ]- @bly more common than the rare case report in the' J7 ^) L4 N  `( E9 i  D" x+ s
literature.4
7 Y! e3 _' _2 c7 P7 q- [Patient Report
0 j3 ^% M6 j# x1 Q. m. ~A 16-month-old white child was referred to the
/ z( \4 W' z# b# F  ^endocrine clinic by his pediatrician with the concern
' _, V+ Y0 ~8 }/ _of early sexual development. His mother noticed
. E+ c" t! a+ }5 c) O+ ?& i$ Tlight colored pubic hair development when he was
; H: `# H2 ~1 O# m+ I, Q: Y, C; FFrom the 1Division of Pediatric Endocrinology, 2University of
; \8 ?# f, _: b# n' e: ]" K' CSouth Alabama Medical Center, Mobile, Alabama.# N6 r; z/ j* N- u& f, j
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 p' u+ T5 u) N# R4 _* i8 P: `2 Y2 {
Professor of Pediatrics, University of South Alabama, College of- m& E  A* ]3 T! G6 i! Z0 ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& C# X# }! _: k3 I+ U5 c' ~e-mail: [email protected].
: d6 V% ?' k- [' u+ _: C2 |/ dabout 6 to 7 months old, which progressively became
# ]6 d8 s) Y  c( n, hdarker. She was also concerned about the enlarge-% d: D6 c4 d0 H. n, F, t5 y- f
ment of his penis and frequent erections. The child7 |1 [/ E: ?, T: x
was the product of a full-term normal delivery, with( T0 n3 a- P- C& O% E4 ]
a birth weight of 7 lb 14 oz, and birth length of. f: G0 z: z3 r7 k
20 inches. He was breast-fed throughout the first year
2 D- ?) V7 h' l! i* Z* c& _of life and was still receiving breast milk along with
) K: s; W2 @, [8 f0 Z0 Xsolid food. He had no hospitalizations or surgery,
8 ^9 e/ `" j4 j/ q* E+ Oand his psychosocial and psychomotor development
  ]# Y9 h$ H. Qwas age appropriate.
+ p0 b$ x) [8 E( h3 c* P# @The family history was remarkable for the father,
  b8 f+ B. S! d, {$ J: c- Fwho was diagnosed with hypothyroidism at age 16,
- T/ d& H5 l. C$ A0 ?/ owhich was treated with thyroxine. The father’s
) n7 l1 \4 F; _9 C, Y' A1 x7 Y% Rheight was 6 feet, and he went through a somewhat# C0 |# o" h( Q. i. Q2 K
early puberty and had stopped growing by age 14.3 m8 A3 e$ _8 \8 T! C7 G! S
The father denied taking any other medication. The
& s- J* {& ~6 Ichild’s mother was in good health. Her menarche
7 H) q+ N) j; e( P' Dwas at 11 years of age, and her height was at 5 feet! O' G! z: Z4 k0 G% A  ]0 m& C: ^
5 inches. There was no other family history of pre-) z, d0 O$ o+ R! _( x& ~9 _
cocious sexual development in the first-degree rela-
1 q/ E# {7 L4 i& g7 Dtives. There were no siblings.! @: y- D9 f; D( X# [# L
Physical Examination
( b! o5 x( k( n% ~The physical examination revealed a very active,
3 W  h  v7 F7 ^. ~. u, o4 z. X* wplayful, and healthy boy. The vital signs documented! z( d3 m+ S$ `, i; a" s
a blood pressure of 85/50 mm Hg, his length was2 P3 v+ q$ @& z6 _7 n9 p
90 cm (>97th percentile), and his weight was 14.4 kg
9 D6 u% `7 p, _(also >97th percentile). The observed yearly growth
) _& h: @1 W$ }7 p0 a! nvelocity was 30 cm (12 inches). The examination of8 m3 U' {: u5 H; m7 b/ S0 m
the neck revealed no thyroid enlargement.
# v9 r6 ~6 v. Y9 _The genitourinary examination was remarkable for2 z# @* {3 q. ?* U) a
enlargement of the penis, with a stretched length of/ b; ^& P8 F0 X, D6 L/ r
8 cm and a width of 2 cm. The glans penis was very well2 A$ z# P' v9 x6 |. c0 p
developed. The pubic hair was Tanner II, mostly around
, i0 V* A& _  k" Y540
' ^6 J* K. D7 z) O, b5 I; t  Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 k$ r/ A+ ~. L
the base of the phallus and was dark and curled. The& n. ^+ U; o/ q8 A: R
testicular volume was prepubertal at 2 mL each.
$ x& M9 ?) e6 M# A' |The skin was moist and smooth and somewhat% ^% X4 ?. W1 O
oily. No axillary hair was noted. There were no
$ n7 d/ U$ ?# H, x" R3 habnormal skin pigmentations or café-au-lait spots.
1 [1 A. l: f' x1 g8 i% r' K  ^Neurologic evaluation showed deep tendon reflex 2+
9 b: `# A6 t2 i' L$ U* ^bilateral and symmetrical. There was no suggestion( d- F% m1 k- l( O$ @4 ~5 _
of papilledema.
+ o2 |0 O7 l' @! lLaboratory Evaluation  g* P: u' M7 T# i8 y
The bone age was consistent with 28 months by; Y* f8 m- M0 V) l: G/ P8 A
using the standard of Greulich and Pyle at a chrono-) L5 B* ], ]/ Q8 n5 W
logic age of 16 months (advanced).5 Chromosomal
' _) q7 u4 c7 e# @7 [; [; }3 _* Dkaryotype was 46XY. The thyroid function test
$ B$ o# \8 B3 ^+ w0 t) z3 i% W$ vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- O- {: U, K5 G+ K2 P! {% ?lating hormone level was 1.3 µIU/mL (both normal).
$ Y9 m# o! x/ z, aThe concentrations of serum electrolytes, blood
) a9 U7 H8 c7 Q2 p2 curea nitrogen, creatinine, and calcium all were
- H$ B9 p- `4 K# @* b0 Zwithin normal range for his age. The concentration# ~7 h; x) z) @0 [* c' R
of serum 17-hydroxyprogesterone was 16 ng/dL
! a) G% p* w, d2 b(normal, 3 to 90 ng/dL), androstenedione was 20
4 m. A1 z! ?; P$ a; Q- W" png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 Q! z; S( P9 D# ?, X8 k2 [1 L
terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ J9 C+ f5 k9 Y2 I* l2 M# y/ I/ a, C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 S  \9 A. x+ z) M3 F& C1 z
49ng/dL), 11-desoxycortisol (specific compound S)
5 m* M* |0 ?- W+ K' jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ D4 O$ p0 U5 q/ N6 Y0 _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! E3 A% ^; @& M' C- m# Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ Q4 v8 B6 b$ E, Land β-human chorionic gonadotropin was less than
5 O$ A3 D$ r9 j6 z5 mIU/mL (normal <5 mIU/mL). Serum follicular
& G/ H4 D. T1 G- @" H* Hstimulating hormone and leuteinizing hormone
7 j! E7 U' {5 N9 u. Lconcentrations were less than 0.05 mIU/mL
) K  w# B0 x" I% s3 H( f# \, p(prepubertal).
" h+ M* e/ o3 Q( JThe parents were notified about the laboratory2 k" s. h: T7 P7 d2 t- A
results and were informed that all of the tests were
; S& W0 v+ ]" l( O9 Q0 N. Enormal except the testosterone level was high. The8 F. {! P2 g- ]
follow-up visit was arranged within a few weeks to% V$ m3 y. E0 Z) z1 h3 j8 Y. u. Y% }
obtain testicular and abdominal sonograms; how-
9 z- B: x' T' C! {+ b" a* aever, the family did not return for 4 months.# m: d4 f: |' k2 M5 p( d
Physical examination at this time revealed that the
/ _2 w0 U% s5 C( o+ l. xchild had grown 2.5 cm in 4 months and had gained
# h. _8 V# N1 M5 c2 kg of weight. Physical examination remained
% _0 x4 w3 E0 F0 ~8 U6 J# u- E3 runchanged. Surprisingly, the pubic hair almost com-7 s. G" a7 B5 |# {* Y
pletely disappeared except for a few vellous hairs at; I5 B3 z+ X7 Y" e6 f1 b
the base of the phallus. Testicular volume was still 29 j" @1 r: B  g4 g$ |$ @
mL, and the size of the penis remained unchanged.1 H( r3 h; K% K; K/ A! _
The mother also said that the boy was no longer hav-
3 a1 Y! s7 k# R$ ^ing frequent erections.
+ J6 ^/ S- {' ?' }/ T5 m# tBoth parents were again questioned about use of7 Z- A% g* @" D
any ointment/creams that they may have applied to/ g  d( Z5 G4 x$ r' `
the child’s skin. This time the father admitted the
' _" w9 \+ b$ _9 J$ yTopical Testosterone Exposure / Bhowmick et al 541
! Z1 L( V, K6 r& w0 h" Iuse of testosterone gel twice daily that he was apply-$ Z* L, i* g6 D+ B) E
ing over his own shoulders, chest, and back area for$ ?( E% D  W; M
a year. The father also revealed he was embarrassed- D# j, A4 y& ]( ~4 e
to disclose that he was using a testosterone gel pre-
# ~; t- C* }. z& l( `, Wscribed by his family physician for decreased libido2 h! p( c8 P) d% ^6 a* G- N! ~  p
secondary to depression.% s; F3 C4 p- T/ S) v
The child slept in the same bed with parents., B! U; }1 B2 d8 k) h* B
The father would hug the baby and hold him on his
9 p3 T( D6 E0 s* ?: L# S3 Z6 ^  h- Uchest for a considerable period of time, causing sig-, w0 h" C9 D/ I5 Z9 k1 N
nificant bare skin contact between baby and father./ T5 }. J: `3 q1 c4 r& T0 |
The father also admitted that after the phone call,6 R. y- s4 f- n- h3 Z$ O2 S3 }
when he learned the testosterone level in the baby. `3 z1 N: N/ U+ r0 V' [- ~! |
was high, he then read the product information
0 w' e" p8 L' [  l5 ?$ C2 h3 Mpacket and concluded that it was most likely the rea-' I4 M( c9 j6 c* P4 u( u
son for the child’s virilization. At that time, they. B. U* f# K$ b$ V- T
decided to put the baby in a separate bed, and the
, r( h+ V2 _" d8 h8 Xfather was not hugging him with bare skin and had
. N/ ?8 K* W7 b: p' P& }been using protective clothing. A repeat testosterone+ L0 i5 J' I# ?1 I* K
test was ordered, but the family did not go to the- ]( [0 i. S3 _' Z0 ^' E% O
laboratory to obtain the test.
3 [* x* {# l* q6 D& o+ pDiscussion6 c; R/ R: }6 Z4 K, d% t* L
Precocious puberty in boys is defined as secondary/ ]7 K% f3 V% a" Z/ T3 P
sexual development before 9 years of age.1,4% u) t( r$ o$ M2 I4 c$ y
Precocious puberty is termed as central (true) when! |' y% m/ j0 U
it is caused by the premature activation of hypo-: w! _! w5 i/ Y) p1 p# P
thalamic pituitary gonadal axis. CPP is more com-
6 F1 k1 K$ n6 I5 xmon in girls than in boys.1,3 Most boys with CPP
6 l2 r# }: c4 a# p, V+ Gmay have a central nervous system lesion that is
: y7 X0 [& O/ u/ Tresponsible for the early activation of the hypothal-& l5 R- I( \% I! {5 E' c5 p9 Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 |1 O) G: r3 R4 fsis has been given to neuroradiologic imaging in
2 p. E/ {8 }! W/ a* v  e$ lboys with precocious puberty. In addition to viril-7 T: l% _7 V+ p" E
ization, the clinical hallmark of CPP is the symmet-
/ }* P7 V; F1 @- Y0 X( Frical testicular growth secondary to stimulation by' z% @6 V3 W7 |  }
gonadotropins.1,3
8 J% d* x" ~* s% ~' u# c$ |4 `0 QGonadotropin-independent peripheral preco-
8 G2 s2 e, b1 V' B( tcious puberty in boys also results from inappropriate3 o* U: K( i; o
androgenic stimulation from either endogenous or9 |/ d4 P2 H6 E0 b
exogenous sources, nonpituitary gonadotropin stim-
9 c8 U( U" I) O% }7 D5 E3 R$ Hulation, and rare activating mutations.3 Virilizing& `0 t: N; Y+ H
congenital adrenal hyperplasia producing excessive5 [) g1 p, ]4 V( f; }
adrenal androgens is a common cause of precocious0 v$ L& K* `) K0 o2 G
puberty in boys.3,41 V& ^  j2 B1 W% C% X# F+ c
The most common form of congenital adrenal
7 X/ |* s! E. {hyperplasia is the 21-hydroxylase enzyme deficiency.
. v; i% B+ f4 x2 u+ y0 mThe 11-β hydroxylase deficiency may also result in. h& i: C& X5 y: z9 {
excessive adrenal androgen production, and rarely,
& U7 C) n$ q" x5 Z/ U9 C0 [an adrenal tumor may also cause adrenal androgen
& D( m) z7 C! R9 T) Qexcess.1,3. c9 b& B" R1 K% a) v+ O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 L4 F( j2 J1 k8 z8 M" ^, k
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. t- R6 {* N* a: q' {% RA unique entity of male-limited gonadotropin-( u5 H) X+ {. J$ M
independent precocious puberty, which is also known
3 D) F  \- a, h! ?as testotoxicosis, may cause precocious puberty at a
" C( ~( W% v; N. h2 o4 V, Mvery young age. The physical findings in these boys
5 R. G1 y+ e- `- I" Hwith this disorder are full pubertal development,* L6 C/ y1 A" Y* K' O, P' ~2 ]
including bilateral testicular growth, similar to boys
3 e0 }) F3 H$ w% Zwith CPP. The gonadotropin levels in this disorder; {8 J" A% O& u2 b
are suppressed to prepubertal levels and do not show
* F4 f- d+ X+ ppubertal response of gonadotropin after gonadotropin-
& P2 ~0 o1 ~/ Treleasing hormone stimulation. This is a sex-linked
. Q: u0 f, U( f/ t2 {* _; |2 eautosomal dominant disorder that affects only
) A# _* k% R' b" \5 |* N0 a3 emales; therefore, other male members of the family+ z, a% J5 ^" E, M% ^9 E% b: Q
may have similar precocious puberty.3
$ e/ F% C: L, i6 e6 c# N% N5 FIn our patient, physical examination was incon-6 M1 n! t4 s+ X! A" t
sistent with true precocious puberty since his testi-3 `8 X) _: J5 a& e  o$ o7 S
cles were prepubertal in size. However, testotoxicosis+ E& F! }: l0 e0 ~  f
was in the differential diagnosis because his father& B- W0 _: [. G$ |% B4 B3 Y+ o
started puberty somewhat early, and occasionally,
+ P4 m; s/ ^1 Etesticular enlargement is not that evident in the
: g. [7 p) U! _) ~1 o) M7 H. W, Tbeginning of this process.1 In the absence of a neg-8 b- m7 x) }; q7 p
ative initial history of androgen exposure, our9 [; ~' H% t$ Z% `. `  T
biggest concern was virilizing adrenal hyperplasia,
% n" w6 ]" d. x' |' c( S- @either 21-hydroxylase deficiency or 11-β hydroxylase
& S: F: i( h8 O3 ^- w' odeficiency. Those diagnoses were excluded by find-
) T: j; [3 q: h! ying the normal level of adrenal steroids.
3 V+ W' a: ^2 ~- @: xThe diagnosis of exogenous androgens was strongly( h) H: q6 n. ~8 C$ s. m
suspected in a follow-up visit after 4 months because1 Z# T: l. a. Y/ ]* V
the physical examination revealed the complete disap-
7 E0 A2 O- c& p2 \/ ]' ipearance of pubic hair, normal growth velocity, and! P, u$ p9 J& l0 I$ T+ n( R! d
decreased erections. The father admitted using a testos-
, R: Y! }$ C! K  R/ T  t- L' lterone gel, which he concealed at first visit. He was+ Z" K' P# P) [) o1 ^
using it rather frequently, twice a day. The Physicians’
& a* ?6 ^; d8 r3 y1 l# o- EDesk Reference, or package insert of this product, gel or
  @+ y, e) t# s) J& E4 ocream, cautions about dermal testosterone transfer to- E3 K/ z/ E! X4 R
unprotected females through direct skin exposure.' p# j4 O$ G9 Z* w- U  v
Serum testosterone level was found to be 2 times the
7 a/ Q, F2 F) P5 f. wbaseline value in those females who were exposed to4 n+ o% Y( U; F/ w- D' J" R
even 15 minutes of direct skin contact with their male5 i7 g  [5 n7 Y/ L* Y
partners.6 However, when a shirt covered the applica-
0 T  W! A$ y  c: Ntion site, this testosterone transfer was prevented.' R9 t  j: E! y. a! P9 \% K
Our patient’s testosterone level was 60 ng/mL,+ A  A- }7 r. t, U) L' A9 _  G" [
which was clearly high. Some studies suggest that
, _& ~* r2 O( U, mdermal conversion of testosterone to dihydrotestos-- a) T1 T3 e4 Y) x
terone, which is a more potent metabolite, is more
" P0 u7 H  T! e% D  oactive in young children exposed to testosterone8 T* T' R7 P0 I- D5 Y
exogenously7; however, we did not measure a dihy-
$ |/ y2 ~& @( i* \# udrotestosterone level in our patient. In addition to
3 p% l/ |) S& Uvirilization, exposure to exogenous testosterone in% R- N; R/ }! F- V+ h, }& e
children results in an increase in growth velocity and9 ]5 ?# O# N; `* U
advanced bone age, as seen in our patient.
4 x# ]- Y% J" J4 a4 ~5 V/ D/ rThe long-term effect of androgen exposure during+ c- r; q: n  c1 _
early childhood on pubertal development and final
( F+ `/ Q9 m& ]( xadult height are not fully known and always remain
2 W- ~4 {6 D) e" pa concern. Children treated with short-term testos-5 T6 g, [- o0 O6 q. g5 C
terone injection or topical androgen may exhibit some
, v4 J+ a+ D! oacceleration of the skeletal maturation; however, after8 w* M! `. ]1 W$ Z5 Q
cessation of treatment, the rate of bone maturation. i! G$ j4 p. W8 I  E. a1 S; ?
decelerates and gradually returns to normal.8,99 `5 ^6 `$ U, M4 k( S) p$ v; C+ K
There are conflicting reports and controversy- S: G' c+ i* F& R- M  O
over the effect of early androgen exposure on adult
- x. L0 n( r; x3 D5 apenile length.10,11 Some reports suggest subnormal
* Z/ h8 @) c- |4 x3 ?( Z3 zadult penile length, apparently because of downreg-
! j! `5 w- D# y/ xulation of androgen receptor number.10,12 However,7 r" U, g7 v" K+ i- V
Sutherland et al13 did not find a correlation between1 a/ l8 L% O" D6 a" Z3 A
childhood testosterone exposure and reduced adult$ E4 e# c9 L0 I1 n
penile length in clinical studies.
0 p+ V5 n- n! C! t- H, B/ N0 VNonetheless, we do not believe our patient is
& _6 b  z) |9 \3 ~7 j8 s- H8 `going to experience any of the untoward effects from
1 u  w* s( C+ G9 m9 }. v. Qtestosterone exposure as mentioned earlier because
* L- w2 x* y% u! w$ Ithe exposure was not for a prolonged period of time.
' m$ s( }1 J) i# Y$ QAlthough the bone age was advanced at the time of
' ]8 Z) _8 Y7 p6 b0 vdiagnosis, the child had a normal growth velocity at
  z$ U" Z% S/ W, Xthe follow-up visit. It is hoped that his final adult0 A* I/ _3 t" |# C' h; U2 R
height will not be affected.- H! Y2 s% T% a+ d
Although rarely reported, the widespread avail-
8 p4 e9 h. N. J% S8 U0 I/ cability of androgen products in our society may' F* }: O3 d. y. _% c( p
indeed cause more virilization in male or female
4 _2 x: }6 P$ V' ]0 qchildren than one would realize. Exposure to andro-
; z/ M5 l# w) i8 b+ u$ |gen products must be considered and specific ques-
6 v+ k5 E, @4 I5 y1 r  R% ationing about the use of a testosterone product or
8 c" O# C4 k2 s3 G2 Z' |gel should be asked of the family members during& ?2 u& F* R' ~
the evaluation of any children who present with vir-
8 W/ l2 Q7 y5 A& t" S- pilization or peripheral precocious puberty. The diag-
& i( w: U. R+ Bnosis can be established by just a few tests and by$ w8 i6 c& k% k% z" @0 c* D
appropriate history. The inability to obtain such a
* W( N5 O. D6 D' Mhistory, or failure to ask the specific questions, may
: V+ k7 s2 v9 K( |( ]result in extensive, unnecessary, and expensive! t2 E6 n/ z. |5 l# k* g. U
investigation. The primary care physician should be
! P; w$ p: r& @" V  |# raware of this fact, because most of these children
: N$ O$ ^. A0 M' `- dmay initially present in their practice. The Physicians’- t' a/ a6 H4 I; i1 ~+ r
Desk Reference and package insert should also put a4 \0 D$ k/ z2 C4 t% i
warning about the virilizing effect on a male or
+ `. P( f$ S+ \& a3 Yfemale child who might come in contact with some-
% r& y* {& C2 Q9 C$ Y& [1 X  s! None using any of these products.
1 W  P  _, l/ |5 }) ^/ u' cReferences3 N* A+ y+ P* \4 z0 {; t
1. Styne DM. The testes: disorder of sexual differentiation
4 N: V1 H$ o( x, M( o+ S, a9 }3 Oand puberty in the male. In: Sperling MA, ed. Pediatric2 q* S' l* ?  K1 Q" q2 x
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; y* t! P0 z" |8 `% g' p2002: 565-628.0 p7 i7 ~4 Z7 P4 L: x3 b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ O% q" k4 T% X) R: rpuberty 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

8 t  t) B4 |8 L# M$ i9 m精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
您需要登錄後才可以回帖 登錄 | 立即注册

本版積分規則


快速回復 返回頂部 返回列表