繁體中文
不翻译
简体中文
English
繁體中文
日本語
한국어
切換到寬版

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+ ~+ x$ ^) v1 l. @* J
Boy Induced by Indirect Topical
9 L) }; K% `$ Q* e8 YExposure to Testosterone: x: Z; e6 x$ D' y/ U: P2 R# j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) p$ f6 i4 g: g. F
and Kenneth R. Rettig, MD1
4 Z" Z7 v6 v% a$ C7 O- g% W0 y% d  GClinical Pediatrics% C& _* D0 q* G$ m& w9 p5 E
Volume 46 Number 6* \- T6 W1 y, ~& j7 \
July 2007 540-543' d! N( k+ o6 e
© 2007 Sage Publications
' a* P! R% g0 q4 Q: V10.1177/0009922806296651) q% ]' d8 U3 n6 Y5 }
http://clp.sagepub.com
" l, K$ j( }$ M3 f( i1 _hosted at. D& P+ M5 P/ t3 @  n9 ~3 J
http://online.sagepub.com
4 P( H9 L* Y4 K, T, v; p+ jPrecocious puberty in boys, central or peripheral,, k; M& w! L  k! j1 n  j
is a significant concern for physicians. Central
8 Y9 s3 @! `% F* E! Zprecocious puberty (CPP), which is mediated
0 I5 R, S3 O8 l- V! K3 f4 ~4 y6 H8 _through the hypothalamic pituitary gonadal axis, has: r" t4 C. z3 _' ^1 e' e8 [
a higher incidence of organic central nervous system
+ F; y8 ?$ H& l4 K! a7 Nlesions in boys.1,2 Virilization in boys, as manifested- K0 z) |  [- N! }; K
by enlargement of the penis, development of pubic. M/ c& K$ @, q5 M4 ]1 K; B% r% @
hair, and facial acne without enlargement of testi-
2 p3 }/ S/ N0 t1 Q& u1 acles, suggests peripheral or pseudopuberty.1-3 We4 c* K9 _1 r+ w
report a 16-month-old boy who presented with the
! w4 ]7 N7 }& X+ L2 s5 menlargement of the phallus and pubic hair develop-- p4 g* A* b4 ?2 C8 h1 x
ment without testicular enlargement, which was due
9 @! N) D/ l6 L% o6 |+ Oto the unintentional exposure to androgen gel used by2 y: b/ p8 M" Q0 _- d/ Q. v* u
the father. The family initially concealed this infor-. E' d3 l7 y% `
mation, resulting in an extensive work-up for this0 X3 Z" _; Y: ]* e! Y$ p8 c
child. Given the widespread and easy availability of
- F; O) d# F2 ?: @; \testosterone gel and cream, we believe this is proba-! L# {4 q& V2 Y/ G
bly more common than the rare case report in the& l# [# A( H7 m2 U
literature.4/ c( I; I$ f; `- A" o; z5 Y' G
Patient Report
  ~- J: x% m2 z* e) NA 16-month-old white child was referred to the
# W) X+ s3 S6 ?2 C5 yendocrine clinic by his pediatrician with the concern
+ o* U4 P! G/ Cof early sexual development. His mother noticed7 K5 ]( [0 G9 G0 u7 Z( x* |
light colored pubic hair development when he was1 X! J# L5 q  Q; @! `
From the 1Division of Pediatric Endocrinology, 2University of4 c7 T. s( c  y: A
South Alabama Medical Center, Mobile, Alabama.
3 p$ B! l# w+ ?( F6 VAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 A5 R5 a  I  o* k8 @/ L9 @
Professor of Pediatrics, University of South Alabama, College of" A' e  b# d% c1 r& e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 K# z: r2 K, h9 m; N. n) f8 A, G5 B
e-mail: [email protected].
  ^( K; E1 G0 W8 p5 e7 @about 6 to 7 months old, which progressively became5 v- I: I& D$ N( Y
darker. She was also concerned about the enlarge-
3 w' v8 N8 z2 Wment of his penis and frequent erections. The child
" {- \, _6 F: H7 {was the product of a full-term normal delivery, with
: W* f# b3 u/ A6 D2 za birth weight of 7 lb 14 oz, and birth length of
3 n. L8 c3 \5 o1 K5 \" o! g20 inches. He was breast-fed throughout the first year! C0 z& q9 \1 `# `
of life and was still receiving breast milk along with' o! p3 v* w: j% v# {1 c% [5 Y
solid food. He had no hospitalizations or surgery,
3 g; g6 G; U) C! T3 Q0 T4 \4 @1 ^and his psychosocial and psychomotor development6 ~4 b( S9 I# |. O
was age appropriate.3 K$ E9 h2 e+ g3 y% f& `
The family history was remarkable for the father,
* w- _' X( C9 o4 L+ Jwho was diagnosed with hypothyroidism at age 16,
& C; f. d. y4 t+ _which was treated with thyroxine. The father’s
' ^- n& {1 D+ f8 Wheight was 6 feet, and he went through a somewhat+ C9 {+ P1 w7 ]5 i9 S2 z7 R" O% w
early puberty and had stopped growing by age 14., n3 E! h2 h/ _/ Z1 S# V6 S
The father denied taking any other medication. The
" |  q, G" ?( U! x1 nchild’s mother was in good health. Her menarche
" N, r8 V# n- ^, y8 l7 s0 Lwas at 11 years of age, and her height was at 5 feet1 d% N8 a4 Y: y' y+ N
5 inches. There was no other family history of pre-
2 M2 \9 W/ _) R" Q$ Dcocious sexual development in the first-degree rela-' a* K! `- S: F) w  w( N5 S# _, N
tives. There were no siblings.
$ g/ c9 Z+ s! M5 |7 [! `$ \Physical Examination; x6 s9 t: s  \( s+ t) |
The physical examination revealed a very active,+ z2 h* K& x& ]
playful, and healthy boy. The vital signs documented
& ~! s/ H/ z. F' }$ z0 pa blood pressure of 85/50 mm Hg, his length was  `! w0 }1 L, A- ~9 D
90 cm (>97th percentile), and his weight was 14.4 kg
% O. Y  C+ l' Y- M  I1 k(also >97th percentile). The observed yearly growth
- `* m+ `* G6 J% N  {velocity was 30 cm (12 inches). The examination of% @4 T+ K( E$ J7 s
the neck revealed no thyroid enlargement.
6 K1 L$ i  M4 p5 m1 }0 MThe genitourinary examination was remarkable for
# D6 `( y. y2 o2 d; a: ~" U8 I: [enlargement of the penis, with a stretched length of1 E$ B7 w1 _2 F
8 cm and a width of 2 cm. The glans penis was very well
; b" {* k" F8 ?developed. The pubic hair was Tanner II, mostly around
* ~/ O1 w( I- \4 }1 [$ A* G. E& N: }5401 H" X( H7 o: k, c6 c! a! s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 x0 E- g( R/ p7 \' W
the base of the phallus and was dark and curled. The
0 }% T& `8 e' {0 |) u, x; y+ ctesticular volume was prepubertal at 2 mL each.- g: y6 b# @3 h4 K$ @7 U  x) u, M3 h
The skin was moist and smooth and somewhat
5 u9 p, U# r5 u! p5 V: ]oily. No axillary hair was noted. There were no3 V3 Y) D4 u% ?8 e! B8 \+ @" S' @
abnormal skin pigmentations or café-au-lait spots.
( \4 }5 O# f2 q( _2 INeurologic evaluation showed deep tendon reflex 2+( g4 f$ L4 x# h0 U
bilateral and symmetrical. There was no suggestion
' c8 D( M2 @. z) y& Uof papilledema.
6 a0 A% t+ u  |4 r( [  e3 M: b# w3 VLaboratory Evaluation
/ T0 C. V7 i# c3 \; y: p$ b1 q) fThe bone age was consistent with 28 months by3 [; V7 n7 V" x0 C
using the standard of Greulich and Pyle at a chrono-
! p- \: g9 D3 G: Alogic age of 16 months (advanced).5 Chromosomal/ ~9 J2 ~" R; _1 i0 m% `) z' K' F
karyotype was 46XY. The thyroid function test3 O" E9 W( |- s  ]/ V4 u; }* {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 x: M' w$ p7 {lating hormone level was 1.3 µIU/mL (both normal).1 M& l+ U9 p( @, t6 `  T* D
The concentrations of serum electrolytes, blood" R- a' o% x* x! l
urea nitrogen, creatinine, and calcium all were# s$ m8 t3 T- l  _/ c+ X1 f7 D+ c
within normal range for his age. The concentration% |# J8 u. r( V& Q1 O2 b
of serum 17-hydroxyprogesterone was 16 ng/dL
. v9 y. R/ G  ]: }(normal, 3 to 90 ng/dL), androstenedione was 20
( a5 S5 Q" j% Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) V+ i/ z+ Q- [8 y# M% Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),* Q6 X2 E. s) E" b! S5 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" }7 \, Q- x. r; X2 h, D' e49ng/dL), 11-desoxycortisol (specific compound S)5 F9 G% S/ b# {5 O7 D$ W9 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 ?+ M7 Y, }( F  X# ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 C$ }* Y# z% G* g( t% k( r1 D, Ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 x9 O& }- F! N* Z3 J
and β-human chorionic gonadotropin was less than
1 A6 L+ g( L* v# o: p5 mIU/mL (normal <5 mIU/mL). Serum follicular" u2 X/ m9 h% u9 I' ]
stimulating hormone and leuteinizing hormone' b$ \2 V, w/ m1 L, z+ {2 h: D
concentrations were less than 0.05 mIU/mL
' t# Z% K2 n4 a8 V8 t. f(prepubertal).
6 u! x/ G" c& c" ~& T- _6 K! x$ `1 kThe parents were notified about the laboratory" d1 n4 Z" M4 l- c% m
results and were informed that all of the tests were
: n$ e- c# g! A4 Unormal except the testosterone level was high. The. Y; z' W  l/ x' L# l% b  z; M
follow-up visit was arranged within a few weeks to) M1 h. d  T/ g9 B( ]* G
obtain testicular and abdominal sonograms; how-0 n; z- B% H' M
ever, the family did not return for 4 months.
( Z: M$ ]+ E: n. s% m! R: lPhysical examination at this time revealed that the
5 `) K- g! r2 ?; V" Z" Y: achild had grown 2.5 cm in 4 months and had gained
# ~( l$ s% }+ T: `: t( _& H5 O2 kg of weight. Physical examination remained
  X  _; @, c+ c, |" Zunchanged. Surprisingly, the pubic hair almost com-5 C0 o) s& p# c& r9 U* W5 z
pletely disappeared except for a few vellous hairs at
; y0 n" K7 z8 ]% ?the base of the phallus. Testicular volume was still 26 C7 ~) @2 Z- x& m
mL, and the size of the penis remained unchanged.3 d, [* \' b8 P* n
The mother also said that the boy was no longer hav-
" G' S0 s+ f6 O( W3 `' Ming frequent erections.
4 m9 \3 E: @5 ?9 xBoth parents were again questioned about use of
: F& a6 P  `  nany ointment/creams that they may have applied to
% V0 z( o( j8 Y) T, _# zthe child’s skin. This time the father admitted the- [  ]" S& K8 r4 f0 I
Topical Testosterone Exposure / Bhowmick et al 541
' P' h3 W* |" E% C9 b1 R2 Luse of testosterone gel twice daily that he was apply-
! I. G& X: ^  J- H4 T( @, }ing over his own shoulders, chest, and back area for" M% o6 t& }' e7 u
a year. The father also revealed he was embarrassed
, K  ^" M, ~& D; d* u- \' bto disclose that he was using a testosterone gel pre-- A! y: I+ G  A$ \  y8 D
scribed by his family physician for decreased libido- e1 G. O8 R1 _) n6 ^
secondary to depression.7 W+ j/ l  `7 [
The child slept in the same bed with parents.( {- x9 R* B0 r, b4 `/ Z- Y
The father would hug the baby and hold him on his" H- P1 R2 j. ^' `2 g. V" `2 D! Q. L
chest for a considerable period of time, causing sig-
/ F) X9 a$ G( P2 wnificant bare skin contact between baby and father.
/ p9 i# y+ @1 S( fThe father also admitted that after the phone call,$ g6 s# |; a6 O6 \- l9 B8 E. |
when he learned the testosterone level in the baby) U8 x/ T# R, K+ y4 m3 r) h+ W
was high, he then read the product information
5 L9 |* t1 T7 X! Npacket and concluded that it was most likely the rea-" l4 s, ~0 t5 `4 y
son for the child’s virilization. At that time, they, Y% f" S7 b! [* |" R
decided to put the baby in a separate bed, and the3 O' e5 |0 _; n& Q7 o
father was not hugging him with bare skin and had
" y9 r5 K) l! s8 r: g  G3 Vbeen using protective clothing. A repeat testosterone4 g% q- S3 p' N* ^" B, L
test was ordered, but the family did not go to the/ q* D- C: Y; _; m3 Q$ w9 e) ]
laboratory to obtain the test.
$ O# j7 `- ?2 U% BDiscussion: Y0 X; f  D! H4 c
Precocious puberty in boys is defined as secondary
& Y& e, Y3 F0 V- Wsexual development before 9 years of age.1,4- C3 O; a9 [) _3 v- G+ _
Precocious puberty is termed as central (true) when& c$ |  k8 F8 t" }
it is caused by the premature activation of hypo-% ~3 z. o' O- ], B! J/ U8 V0 V
thalamic pituitary gonadal axis. CPP is more com-  X. }# A7 W/ ]3 R, q6 I, [
mon in girls than in boys.1,3 Most boys with CPP4 }) m& U1 s5 F7 J- Q
may have a central nervous system lesion that is
- C8 v8 W1 l) j9 W  Zresponsible for the early activation of the hypothal-
1 k2 C: L: }6 v' f; aamic pituitary gonadal axis.1-3 Thus, greater empha-
- u8 X  h" f' |sis has been given to neuroradiologic imaging in
. R( F" q0 B$ hboys with precocious puberty. In addition to viril-+ V2 V2 R3 ]  ]4 K% x2 B% r# j
ization, the clinical hallmark of CPP is the symmet-
$ a% r) b# ?1 O& Arical testicular growth secondary to stimulation by8 D7 Q# f- C- N6 V* L, m. m. i0 [
gonadotropins.1,3( r5 [! L# b, _6 f
Gonadotropin-independent peripheral preco-
6 o; g9 i4 e/ Ncious puberty in boys also results from inappropriate4 C% Z0 F3 ]! o. h+ a. E0 o1 ]/ y: H
androgenic stimulation from either endogenous or
- }& T, n; U, d6 f; aexogenous sources, nonpituitary gonadotropin stim-' g+ R. @  R2 q1 B, }
ulation, and rare activating mutations.3 Virilizing# Z0 N5 J' C3 n
congenital adrenal hyperplasia producing excessive
3 q" E/ U. g% D$ [1 I& X1 q0 Gadrenal androgens is a common cause of precocious0 p# L! B5 u  F5 u" l! m, E
puberty in boys.3,4
4 N9 ?  x3 _, i4 k1 q9 N4 d, tThe most common form of congenital adrenal
. W7 ~) T! m- Y) p/ f' O; zhyperplasia is the 21-hydroxylase enzyme deficiency.
8 P% Y9 F( Z4 o' ]1 IThe 11-β hydroxylase deficiency may also result in
% G! Q- u5 W, w7 j% e: mexcessive adrenal androgen production, and rarely,6 n) Q5 K& M" u; w# M9 W
an adrenal tumor may also cause adrenal androgen
# G. h( s  l, Gexcess.1,3+ c; O7 F2 J5 q- B1 M/ K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 a$ G% e* y* Y  T- ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% ?; C% p0 \# C0 o. _
A unique entity of male-limited gonadotropin-
+ u1 z! O# p7 w+ M6 K* Z/ n$ X0 {independent precocious puberty, which is also known
( |& y: E) w( _4 P! tas testotoxicosis, may cause precocious puberty at a8 M: h: X: p$ ]5 k! w
very young age. The physical findings in these boys0 J  V- }6 W% b
with this disorder are full pubertal development,/ a% M; t- d0 U" c# N" B: ?
including bilateral testicular growth, similar to boys
" H. x) X3 \+ ?1 V+ ^5 Rwith CPP. The gonadotropin levels in this disorder' v6 v4 Q' L; x
are suppressed to prepubertal levels and do not show
1 L" C0 Y% G( E$ R) apubertal response of gonadotropin after gonadotropin-( ^) e4 e/ r% I9 L$ M  ^
releasing hormone stimulation. This is a sex-linked0 v* Z. f* \, u/ J/ ^, J
autosomal dominant disorder that affects only, T3 g& P/ x& ?
males; therefore, other male members of the family
+ M7 `9 V1 V, T7 Z; @may have similar precocious puberty.3
' ?( R; @* Z! j" ?) x. N. nIn our patient, physical examination was incon-5 k( Z( k! z" ~4 Q% k  k
sistent with true precocious puberty since his testi-0 }  J  t2 d9 ?1 ?1 g: ]/ r
cles were prepubertal in size. However, testotoxicosis, u7 H1 E$ Z' \8 o7 r3 L. v# w
was in the differential diagnosis because his father8 L* C' V, ~7 b# |( O: }- B) ~
started puberty somewhat early, and occasionally,! n( G4 C8 ]5 u$ U+ e
testicular enlargement is not that evident in the
/ r6 R! {& ^' b2 l5 D+ a# _beginning of this process.1 In the absence of a neg-
/ g- m7 f% z1 T# {5 lative initial history of androgen exposure, our+ O$ ^6 y, x& W+ W: h4 M" m
biggest concern was virilizing adrenal hyperplasia,
/ @( n- C4 p9 z# N9 F* L1 m2 G5 reither 21-hydroxylase deficiency or 11-β hydroxylase2 ?3 J  G5 s6 H- n- W# ^* q& E
deficiency. Those diagnoses were excluded by find-
; X% |2 U/ r0 X! f6 Cing the normal level of adrenal steroids.
, Q: O6 D8 B$ V, N: `  t  pThe diagnosis of exogenous androgens was strongly1 e5 Y; L  D' t
suspected in a follow-up visit after 4 months because
$ \: e- ~  v! y9 Z6 @the physical examination revealed the complete disap-5 ], C1 X( A: O# |$ |2 k* A7 f  E9 [
pearance of pubic hair, normal growth velocity, and9 M9 W8 l  Q; V
decreased erections. The father admitted using a testos-; c* P2 C  H9 r+ Q" c
terone gel, which he concealed at first visit. He was
( ]0 i0 \( {% uusing it rather frequently, twice a day. The Physicians’$ I/ ?+ B+ ?. D/ g9 D
Desk Reference, or package insert of this product, gel or
. b# k0 b; ~0 f7 n) |. Ecream, cautions about dermal testosterone transfer to8 ]: Q- e) D  c  X0 u2 C
unprotected females through direct skin exposure.( B1 ~7 y5 B* [$ ?" T
Serum testosterone level was found to be 2 times the
+ f) t7 g6 ]- j/ F" ~baseline value in those females who were exposed to7 y  F8 [8 N, j- z6 Z8 D
even 15 minutes of direct skin contact with their male  y: {9 _0 y* Z8 j, M
partners.6 However, when a shirt covered the applica-! h' Y) f! b8 S6 g( s
tion site, this testosterone transfer was prevented.
, }# ~7 f- d& C" [Our patient’s testosterone level was 60 ng/mL,7 ^% F- }3 f5 |( p6 K' x1 ^4 o
which was clearly high. Some studies suggest that3 ~' m7 {$ p% ?) o: B1 f* S. e/ R; n
dermal conversion of testosterone to dihydrotestos-
- m+ o& H& R1 `, l  f- e& G% Nterone, which is a more potent metabolite, is more' b' c5 x3 C% T1 A, p  o- u
active in young children exposed to testosterone- c) A" t4 P8 i, z' D% B' m+ W
exogenously7; however, we did not measure a dihy-
2 f3 S+ ^; ?0 i( I' c5 }8 o, Idrotestosterone level in our patient. In addition to+ x% A0 q0 a9 U- @1 |  U- }4 J3 t
virilization, exposure to exogenous testosterone in* e) b4 h' P3 ~, ?
children results in an increase in growth velocity and: R% S, P" p, R3 k) ^" n
advanced bone age, as seen in our patient.* o- P! c7 S' o0 |
The long-term effect of androgen exposure during
; Q% l3 Y/ m3 I* cearly childhood on pubertal development and final
; p1 _+ J  N9 ]" ~, Z& e( e) Fadult height are not fully known and always remain6 P- z2 a# w4 T0 W+ Y. R
a concern. Children treated with short-term testos-  M' @% {) }( \* Z" T) v. k
terone injection or topical androgen may exhibit some
3 M1 K: X+ [* V) C9 \5 jacceleration of the skeletal maturation; however, after& f# ?2 j+ k2 W8 g, {
cessation of treatment, the rate of bone maturation
$ ^3 l) i; ~' F% I8 Xdecelerates and gradually returns to normal.8,9
' V" I( s! `0 G6 D( U: IThere are conflicting reports and controversy7 x* k! _: K! Y1 C  @1 |
over the effect of early androgen exposure on adult
" f/ D) r+ i$ P, k4 v' Ppenile length.10,11 Some reports suggest subnormal+ g: i: T2 N: ]" x. f! w, {
adult penile length, apparently because of downreg-+ ]1 ?6 s1 x+ n3 L; o; B7 P
ulation of androgen receptor number.10,12 However,7 {9 t2 c$ K, ]4 \
Sutherland et al13 did not find a correlation between
1 P4 z  }' ?$ B" p5 U" u% ichildhood testosterone exposure and reduced adult
+ I9 y) }& i+ g" ]& i3 D+ Apenile length in clinical studies.
- w' H  A7 R, q, y9 uNonetheless, we do not believe our patient is
1 X$ V; _3 M$ H4 }going to experience any of the untoward effects from; e' X1 }( ^' ^
testosterone exposure as mentioned earlier because, t# b$ y5 l. s; T
the exposure was not for a prolonged period of time.
# A& g  G" V. Q1 k$ C+ lAlthough the bone age was advanced at the time of
7 h# m/ d0 P; G; q: R; }diagnosis, the child had a normal growth velocity at; ]) [, S9 B1 G. D& t' @; m* S
the follow-up visit. It is hoped that his final adult( E/ |9 @, P0 @
height will not be affected.3 F& P( `  q) \
Although rarely reported, the widespread avail-
% J% ]" g( x- J3 S  j; tability of androgen products in our society may
+ U% F2 |. M8 \3 E( g5 J' H! ?4 Oindeed cause more virilization in male or female
2 B, q& y3 x3 e1 M! W; J9 K6 z( qchildren than one would realize. Exposure to andro-
- n0 W# }5 ~1 b( f( `gen products must be considered and specific ques-
8 L9 m! \3 v$ ^  T4 v5 t; Gtioning about the use of a testosterone product or' N7 c( P% j/ m4 e) m7 F
gel should be asked of the family members during
+ B( Y) e! U; T$ Lthe evaluation of any children who present with vir-1 E4 S% p2 \! V% G5 d( F- n* |$ A
ilization or peripheral precocious puberty. The diag-
/ R5 i6 ]: A! H- p5 cnosis can be established by just a few tests and by- r% q2 y% Y% v: S6 B. A* X& e) @
appropriate history. The inability to obtain such a
$ m- ^" R6 E: F9 [: uhistory, or failure to ask the specific questions, may2 _" q( t2 U; ?6 b
result in extensive, unnecessary, and expensive1 L. q$ T6 `. r& j
investigation. The primary care physician should be
0 ^4 L- _3 ~9 baware of this fact, because most of these children
  ?" j0 S' x5 l- ^8 e/ ymay initially present in their practice. The Physicians’7 U1 p' R/ z+ e% v8 j/ F+ q/ E9 x
Desk Reference and package insert should also put a
/ S$ a# [9 v4 e/ Jwarning about the virilizing effect on a male or
1 f* E0 d* v, T' I. M: H; i0 E, efemale child who might come in contact with some-
* t$ E  M, X/ Z7 V4 Yone using any of these products.
" r& z1 q/ L$ s% L' P1 o% \References' Q, T  u$ u4 P4 F! k1 q% X
1. Styne DM. The testes: disorder of sexual differentiation& {" w, ^, U8 Q. j& q7 `0 x
and puberty in the male. In: Sperling MA, ed. Pediatric
+ B) x* E% H5 n8 T( h4 ~0 qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 R2 y( ]+ B! W) ^8 O5 }
2002: 565-628.. t6 n, }! h! u) c" D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 }5 D  B7 O+ H5 P2 Y6 K
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, M& L( P, I( @" ?  A, i
Boy Induced by Indirect Topical6 d2 |( {0 Q* Z
Exposure to Testosterone% Z3 |$ L1 N" B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ s2 e7 a* F" y! n$ M/ Land Kenneth R. Rettig, MD1" j: X% s- a. |+ L" K4 t
Clinical Pediatrics
0 z# F+ }% `2 T9 D+ }8 ~- uVolume 46 Number 6( P, m" {0 i( g; t# I
July 2007 540-543" @! C- e3 p+ k+ ]! \7 A7 Z# X$ c* P" V
© 2007 Sage Publications, Q  {5 [0 B' a0 x
10.1177/0009922806296651
7 |# M. H: C# l" M! C9 w6 ]$ Phttp://clp.sagepub.com
; v8 w( C6 Q/ ?  u. V# phosted at
! e4 Y9 Y$ @" Y1 a% h6 p5 vhttp://online.sagepub.com
% }# N, k& ^) TPrecocious puberty in boys, central or peripheral,9 q% k( T- m; ]+ v! W( n. K# S
is a significant concern for physicians. Central
+ F. f+ _- a8 @# b6 `precocious puberty (CPP), which is mediated% a( A" y0 s3 a) P  `' T
through the hypothalamic pituitary gonadal axis, has
1 i( K# Q8 b/ @' m) ]- v. @( t2 ya higher incidence of organic central nervous system0 Z1 F) k. X3 A& k5 I
lesions in boys.1,2 Virilization in boys, as manifested
5 Q( S. p* p' [/ aby enlargement of the penis, development of pubic
% p3 \* r# v0 X) c/ j* |4 shair, and facial acne without enlargement of testi-% r% Z- [5 H) P$ B
cles, suggests peripheral or pseudopuberty.1-3 We. T( F3 l) a& F- R
report a 16-month-old boy who presented with the' J/ `" o. o5 S. n3 X5 B
enlargement of the phallus and pubic hair develop-4 v1 m3 d# }/ V' s; |* M9 c
ment without testicular enlargement, which was due/ q# u# g5 ?0 K( I& \/ d
to the unintentional exposure to androgen gel used by
- }5 \  ^2 F2 y% Mthe father. The family initially concealed this infor-
! d5 e8 ~1 W: U/ q% U8 H9 [( bmation, resulting in an extensive work-up for this1 S/ v  X8 e' c" y. j
child. Given the widespread and easy availability of! C' Y. U9 ~( L$ x
testosterone gel and cream, we believe this is proba-& }  |2 Z" f. A$ Z0 A
bly more common than the rare case report in the9 g2 _& f6 a: S7 T$ ~/ s" H. a! o2 b
literature.4
& Z8 [# V) |' K4 Q( yPatient Report
9 Z1 g2 f8 F, y3 aA 16-month-old white child was referred to the) H% S& o# L' S5 v& U/ T# |
endocrine clinic by his pediatrician with the concern! ?4 L, w# e9 `5 t
of early sexual development. His mother noticed' x* `  s% i0 _: ^! @6 \9 P
light colored pubic hair development when he was5 i4 d& p+ o3 v5 I
From the 1Division of Pediatric Endocrinology, 2University of, a1 W# d% o7 \" |2 W. t
South Alabama Medical Center, Mobile, Alabama.6 V3 i4 v) R4 ~9 v6 E' M, C
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, R$ T- B* a5 H& C$ hProfessor of Pediatrics, University of South Alabama, College of
" s; L2 i; y. I- Y) gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) q# M' I" T1 fe-mail: [email protected].! J2 L; f; }/ }" u3 y( E
about 6 to 7 months old, which progressively became
, G6 f1 i7 t) ]0 v5 Rdarker. She was also concerned about the enlarge-$ _" e9 ~/ s% _* e7 V, z; g
ment of his penis and frequent erections. The child  l* ?- L# I  q& @! k
was the product of a full-term normal delivery, with
# V9 z7 @$ H2 I* K0 ^1 j5 ~a birth weight of 7 lb 14 oz, and birth length of' O+ D5 N6 J! `3 L
20 inches. He was breast-fed throughout the first year
1 z  u/ V/ Y) b. E7 |) F& j+ @of life and was still receiving breast milk along with
9 B5 E% t3 D) H6 {7 jsolid food. He had no hospitalizations or surgery,( T, p( h6 p8 W$ S6 s9 \+ V+ Q
and his psychosocial and psychomotor development; x' t1 f- q3 y; N* K
was age appropriate.% n  e1 W) W7 \4 l8 v3 d
The family history was remarkable for the father,1 A' U' R  B5 Q7 T
who was diagnosed with hypothyroidism at age 16,1 o8 ^7 r( g2 D; D" q" A
which was treated with thyroxine. The father’s9 _' v+ ^) x+ k! I
height was 6 feet, and he went through a somewhat
( Z- I7 X4 U& }; n4 a3 ~4 Eearly puberty and had stopped growing by age 14.
2 p$ ?% e9 G$ Q1 r$ z4 ZThe father denied taking any other medication. The
4 C4 h' u8 @. wchild’s mother was in good health. Her menarche  x' D* K& N8 x) R: C3 T% \+ s
was at 11 years of age, and her height was at 5 feet
% n9 @. U  b+ l0 J5 M, `  d5 inches. There was no other family history of pre-: M7 n6 p3 ^8 c: I2 s
cocious sexual development in the first-degree rela-* }( {; N. Q( Y) Z& e8 z  u' D
tives. There were no siblings.
. y& ?* y& i4 e- t( |. E! T7 oPhysical Examination5 C* T6 f$ m: y" ~; D
The physical examination revealed a very active,4 Y7 x8 Y' p2 c8 o( u' y6 g
playful, and healthy boy. The vital signs documented; T6 W% p7 a' P! M' u" P. H2 R
a blood pressure of 85/50 mm Hg, his length was7 [/ @4 ~3 g. h9 K
90 cm (>97th percentile), and his weight was 14.4 kg
6 B* v  n! C  _(also >97th percentile). The observed yearly growth
( X+ X  x1 ]# ]3 o* L: ovelocity was 30 cm (12 inches). The examination of7 B$ ?1 }8 m; z, t# S+ p8 S% _  c+ n
the neck revealed no thyroid enlargement.
: K& E7 ?) ]& \/ h0 _$ _7 E( ?The genitourinary examination was remarkable for
$ j; q4 ^: }" f, z1 T7 senlargement of the penis, with a stretched length of
7 e2 c, u0 n% T9 G- L( \8 cm and a width of 2 cm. The glans penis was very well% N/ G0 M' a1 S4 c
developed. The pubic hair was Tanner II, mostly around8 ~* A( C2 ]1 @6 _) D. }
540
4 U  C" S% m6 L* [' t! N  M( ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: o" V1 E4 d' ~" B, M
the base of the phallus and was dark and curled. The" [; _" n6 a* f
testicular volume was prepubertal at 2 mL each.
; D" S2 _4 `9 A) R5 z* n, [! f+ QThe skin was moist and smooth and somewhat$ W$ O7 a: V, i2 a
oily. No axillary hair was noted. There were no( S. q. f+ q) U! J$ M
abnormal skin pigmentations or café-au-lait spots.
$ A/ q1 |. }3 I9 S5 q* lNeurologic evaluation showed deep tendon reflex 2+* d  e) {/ O! i
bilateral and symmetrical. There was no suggestion) f9 b* @- F+ c8 n
of papilledema.
8 u& J& J: b- }! X: ZLaboratory Evaluation6 b" u& V% p" a4 E* K8 o
The bone age was consistent with 28 months by
/ i; J5 y: i3 fusing the standard of Greulich and Pyle at a chrono-
. [! x+ E  ?; M+ L7 W9 Clogic age of 16 months (advanced).5 Chromosomal
% ~+ ~9 D/ Z% y) }" ykaryotype was 46XY. The thyroid function test* k9 d; i7 U: p7 @$ c& G" V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- L5 @% t9 B7 z. Jlating hormone level was 1.3 µIU/mL (both normal).' }5 ^1 a1 A+ \1 t
The concentrations of serum electrolytes, blood
) @# j1 A3 `' c, I  ?urea nitrogen, creatinine, and calcium all were
9 X1 M9 A# r( f" f/ q; f2 a' e4 Lwithin normal range for his age. The concentration
, Z+ ^1 D2 |! `, A, nof serum 17-hydroxyprogesterone was 16 ng/dL
- M% @/ S* K' M. B+ ~+ F(normal, 3 to 90 ng/dL), androstenedione was 20
* \+ I* U  x# c  A  a1 |  Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% l1 p0 j9 o4 W3 Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& D+ Z2 M# r% k" \desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ `) K- B: P( }, |49ng/dL), 11-desoxycortisol (specific compound S)
/ {/ t9 x" A3 h& Z# mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& H% L8 E8 w0 ?7 p+ C) X) `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 R9 n' W( ^  S1 `1 @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  t4 V# f8 y. W6 Rand β-human chorionic gonadotropin was less than
( W, {5 S2 k1 o5 mIU/mL (normal <5 mIU/mL). Serum follicular# O0 b+ e. P  V: N5 v4 Y) f! m
stimulating hormone and leuteinizing hormone; \1 ]  n! K' l3 Z& f  K' P
concentrations were less than 0.05 mIU/mL$ O/ q: P6 h8 R+ G
(prepubertal).7 j% K  c) Z/ Z- Z& k8 M
The parents were notified about the laboratory2 a8 B' q- `; C7 n
results and were informed that all of the tests were1 }3 B6 B; k. d' P1 Q3 X7 d- x
normal except the testosterone level was high. The2 r3 s- f0 H" G
follow-up visit was arranged within a few weeks to
3 ?$ V5 e7 {  x7 `9 ]1 @obtain testicular and abdominal sonograms; how-; m$ K7 V2 R5 _8 L/ I
ever, the family did not return for 4 months.
, S& A- t( E$ X# Q7 y* H- L: CPhysical examination at this time revealed that the
! M. r0 x" s+ Y6 M. _child had grown 2.5 cm in 4 months and had gained
7 g. B. l0 P# [0 W7 M2 kg of weight. Physical examination remained9 }7 v* s6 b' o; V
unchanged. Surprisingly, the pubic hair almost com-( k$ r' a& C) @) Q& S" @
pletely disappeared except for a few vellous hairs at
1 d. _* ~0 W6 Q* t+ f, ?. M$ athe base of the phallus. Testicular volume was still 2
* N. ~% C/ g* h6 PmL, and the size of the penis remained unchanged.
) m. M8 o! ]; [* d. l; @1 cThe mother also said that the boy was no longer hav-# _) T! j4 `3 o9 l5 {6 }
ing frequent erections.9 ?8 l9 p9 A7 }( Q
Both parents were again questioned about use of" M, }* f; r8 J7 W% W6 e! V
any ointment/creams that they may have applied to
2 ^5 `5 ?& l& N! O$ Othe child’s skin. This time the father admitted the3 E, m( `$ c) E+ o8 g# N$ `
Topical Testosterone Exposure / Bhowmick et al 541
( |9 O$ }# h4 v5 ?: P0 }use of testosterone gel twice daily that he was apply-
+ D2 E9 w( I3 W& {: L. i2 Ving over his own shoulders, chest, and back area for
/ k3 R9 N/ M5 h" e- Aa year. The father also revealed he was embarrassed
( X# C' @1 ~$ N' m5 lto disclose that he was using a testosterone gel pre-
/ b) r0 ?: t1 ?% n% g6 Zscribed by his family physician for decreased libido( }9 u& Y) F) g" c# P! n, N( d
secondary to depression.
, g# e, \7 _: L& w. dThe child slept in the same bed with parents.
2 h+ T9 Q& a+ k+ r; d+ v( y0 hThe father would hug the baby and hold him on his
  [# O) O. Y; s* h: E6 X6 Lchest for a considerable period of time, causing sig-' [- G4 P! x5 E7 \7 \% ?2 A
nificant bare skin contact between baby and father.
% }, j: p. B; J9 j% f  eThe father also admitted that after the phone call,
5 y$ W0 D! O, ^6 Q1 gwhen he learned the testosterone level in the baby$ Z, m; d4 U. o8 c: S- L3 U
was high, he then read the product information  M) s( U" H. C2 y2 C8 u. @
packet and concluded that it was most likely the rea-+ [$ ~4 T/ ?' s0 b4 H" s- r$ Z
son for the child’s virilization. At that time, they9 P+ ~6 _$ p- j
decided to put the baby in a separate bed, and the/ ]; F5 l9 M. m$ h
father was not hugging him with bare skin and had0 c: w3 i1 z* h9 s7 d) q
been using protective clothing. A repeat testosterone
3 S: h7 p, t% Y1 J8 vtest was ordered, but the family did not go to the- y: B( m6 [, a4 e0 }% s
laboratory to obtain the test.: M5 x5 T6 [: g" |6 T! ?2 k, Q
Discussion% U# A& c9 A* y* m3 G
Precocious puberty in boys is defined as secondary5 K& Z9 B( ?& L2 f7 D. A
sexual development before 9 years of age.1,4( `5 L6 T$ J3 u3 v0 O& F
Precocious puberty is termed as central (true) when( d% I' p2 B. ^" v: Z9 f$ g
it is caused by the premature activation of hypo-
" _% g. q! L  U" J# Gthalamic pituitary gonadal axis. CPP is more com-" Y# W0 A; x% Q! S
mon in girls than in boys.1,3 Most boys with CPP) r0 u4 f8 [' p. {- U, y
may have a central nervous system lesion that is& K4 I4 A/ k9 m/ U. t; z. J% h$ j
responsible for the early activation of the hypothal-
( n* Z) e0 \) u9 P0 k2 W+ }amic pituitary gonadal axis.1-3 Thus, greater empha-
1 }% m% K7 H: `3 j" {sis has been given to neuroradiologic imaging in7 g6 z2 ?/ K* @% c& _8 d
boys with precocious puberty. In addition to viril-1 c: Q7 I0 O) |5 ~: n0 J* q% j
ization, the clinical hallmark of CPP is the symmet-. m- y- ]% x$ ]& l4 p
rical testicular growth secondary to stimulation by( o+ ~% R' \' X! W9 n% x8 C% }% S
gonadotropins.1,3
+ I; a6 l& n, YGonadotropin-independent peripheral preco-1 s  {( u" h$ I6 F1 O
cious puberty in boys also results from inappropriate
  K! I' V* L! Iandrogenic stimulation from either endogenous or
' f* }+ s& |; Z2 t2 m/ M9 [exogenous sources, nonpituitary gonadotropin stim-
  v3 @  [1 N) v/ O- d1 ]ulation, and rare activating mutations.3 Virilizing1 k9 J2 g+ |8 V7 w2 z4 v
congenital adrenal hyperplasia producing excessive
8 {$ X' j. k2 w: B/ ]2 D4 ?* uadrenal androgens is a common cause of precocious
( }3 w% Y0 ]% u. M; v" Spuberty in boys.3,4
" B* K7 n5 r; A6 j0 nThe most common form of congenital adrenal
( p$ O4 I3 W3 |. Ehyperplasia is the 21-hydroxylase enzyme deficiency.! e0 X% x8 ~- N' C6 l
The 11-β hydroxylase deficiency may also result in
6 w% _+ ?9 w" S- L& ^excessive adrenal androgen production, and rarely,2 G4 h' S; l. i
an adrenal tumor may also cause adrenal androgen
7 q4 u7 S" x: q' K! zexcess.1,3% p1 q* E+ N  y; c0 N3 T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! @+ x1 ~! E$ i# Q+ h& {0 y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% S0 q+ I/ B6 }3 \$ ?- ZA unique entity of male-limited gonadotropin-; r; `" }, z/ b# l3 @
independent precocious puberty, which is also known
; |8 I" B4 E, Z% O. J. T4 aas testotoxicosis, may cause precocious puberty at a
! Z. B$ _/ z9 P# i9 {very young age. The physical findings in these boys
7 M4 m4 `- C+ j  o9 i$ D. mwith this disorder are full pubertal development,
, h' l2 G$ Z0 [: H3 `4 P+ \including bilateral testicular growth, similar to boys, ?' f2 ^/ g" e; U0 e
with CPP. The gonadotropin levels in this disorder0 z* ^) y/ W( s5 ?, P0 J
are suppressed to prepubertal levels and do not show6 m0 h$ p2 t3 T) i
pubertal response of gonadotropin after gonadotropin-6 [. z# E$ F4 c
releasing hormone stimulation. This is a sex-linked
9 ]  J1 b) E1 Rautosomal dominant disorder that affects only5 }# J/ h# Y$ N7 [: U
males; therefore, other male members of the family
, m) t7 S3 r( A% Wmay have similar precocious puberty.3
) ?- L/ M  c& j! MIn our patient, physical examination was incon-
# G! J. n+ t  c( \sistent with true precocious puberty since his testi-
/ G5 u0 t+ E: v& g! tcles were prepubertal in size. However, testotoxicosis
- X5 }+ t2 g/ L' U7 G6 gwas in the differential diagnosis because his father
5 g, C; w4 O' Vstarted puberty somewhat early, and occasionally,2 u/ h- i3 h5 B
testicular enlargement is not that evident in the
# [* U4 _& i, y+ ybeginning of this process.1 In the absence of a neg-
6 S  ^6 s/ X. N. R3 V' T, c1 |& rative initial history of androgen exposure, our
" A3 z3 L6 Z7 U5 g* \1 `biggest concern was virilizing adrenal hyperplasia,
5 y, T& n% W6 U4 Peither 21-hydroxylase deficiency or 11-β hydroxylase9 }! x' U+ p) W- n# H' ]" T
deficiency. Those diagnoses were excluded by find-
- m; E, ^; ^; f3 Ming the normal level of adrenal steroids.
2 A+ U& v. L5 j  VThe diagnosis of exogenous androgens was strongly
. s2 x+ ?5 \$ d+ ?suspected in a follow-up visit after 4 months because: n  k  D- z; w! a( ^
the physical examination revealed the complete disap-5 I/ Y# L, ~" y( q6 E, `
pearance of pubic hair, normal growth velocity, and
; Z" G+ e' I- ~9 idecreased erections. The father admitted using a testos-
7 r, R: Y+ F  L4 Bterone gel, which he concealed at first visit. He was, {- C9 m  O# B6 T, Y
using it rather frequently, twice a day. The Physicians’
) M5 S  _0 Q4 n! z% z- jDesk Reference, or package insert of this product, gel or
3 C8 Y9 g! }" F  j7 Acream, cautions about dermal testosterone transfer to, _4 H6 `% D1 N0 j$ N! u
unprotected females through direct skin exposure.3 t/ i# Z6 e8 Z4 }; F/ D
Serum testosterone level was found to be 2 times the( M' R* [4 Z3 {8 U: Z
baseline value in those females who were exposed to
% F$ K* s" O! M- ~7 }" ^2 x$ yeven 15 minutes of direct skin contact with their male) @& n8 X7 g8 ~  w6 p' l' a. @) H
partners.6 However, when a shirt covered the applica-' T, i. N- O5 M2 C/ a7 J
tion site, this testosterone transfer was prevented.9 S. q8 N" G/ [# P3 K0 _
Our patient’s testosterone level was 60 ng/mL,
( W  A( k  v; j3 z% ^: Dwhich was clearly high. Some studies suggest that/ M/ g# y3 n: v+ {5 N* l
dermal conversion of testosterone to dihydrotestos-
- `$ d8 G+ m' P3 }1 r- sterone, which is a more potent metabolite, is more
5 p# q7 P6 s$ E4 F9 v4 j7 E7 Pactive in young children exposed to testosterone
$ p5 Z7 |2 H/ e, z7 cexogenously7; however, we did not measure a dihy-
8 Q0 \# U' ]) i6 w" X  sdrotestosterone level in our patient. In addition to
+ z4 {1 x  _) Q7 A) `+ A( |virilization, exposure to exogenous testosterone in
( f8 o; D& x: Y% |# T" v. ?( T. ochildren results in an increase in growth velocity and
' C* |( {6 z) ?advanced bone age, as seen in our patient.
' U( I0 Q: |; g( N; I6 EThe long-term effect of androgen exposure during
4 R; w( w) J) I5 D: yearly childhood on pubertal development and final$ D1 w+ d! V: r; V& c3 z. P8 Q
adult height are not fully known and always remain
1 E5 e" W4 ~  t' b2 k$ H5 Ma concern. Children treated with short-term testos-5 o! k3 |1 E: V- U1 V( t
terone injection or topical androgen may exhibit some
, y; X5 x3 j" q5 O5 {acceleration of the skeletal maturation; however, after; \( F0 s& X3 C3 M3 W
cessation of treatment, the rate of bone maturation/ P1 I3 z! |* n9 ^* c& K2 \$ @- m
decelerates and gradually returns to normal.8,93 G- ]/ m* B, H- S
There are conflicting reports and controversy: C3 X! c, w/ O6 o* Y- u. K5 c
over the effect of early androgen exposure on adult
6 W! G: w3 ^8 M5 Q. l& vpenile length.10,11 Some reports suggest subnormal
4 u9 C, i# g  m; \+ ?adult penile length, apparently because of downreg-
( w; r8 O7 F4 p: T/ N" j# ?ulation of androgen receptor number.10,12 However,
, ~" \. A' i' s! Y5 qSutherland et al13 did not find a correlation between4 g- J) R: Z: J. U8 Q# u
childhood testosterone exposure and reduced adult
/ P" K1 R% a2 Tpenile length in clinical studies.: `: D5 V. `' W. ~
Nonetheless, we do not believe our patient is0 l& C' {$ Z' c. I
going to experience any of the untoward effects from
3 R8 I( C, }" y. M; Htestosterone exposure as mentioned earlier because
7 v1 z) j6 x7 h+ y+ athe exposure was not for a prolonged period of time.
9 g. H2 ?* N1 S7 v3 s+ ZAlthough the bone age was advanced at the time of: }5 }9 B+ b3 f- z
diagnosis, the child had a normal growth velocity at; ]5 c, Y- ?. B$ B# J
the follow-up visit. It is hoped that his final adult
9 W, S$ J: n) O5 j3 v, zheight will not be affected.
& g1 a* _- D0 ^6 WAlthough rarely reported, the widespread avail-
9 z6 Y0 {3 z$ H6 `. |ability of androgen products in our society may; v" z( p" E( u4 [" W
indeed cause more virilization in male or female& d6 W+ W: [9 a/ z$ L! U# I
children than one would realize. Exposure to andro-2 y1 Q3 T+ V+ E+ Q
gen products must be considered and specific ques-
. Y9 d  w0 i  F' C9 ftioning about the use of a testosterone product or* R5 u5 S% i* R4 S  }% @
gel should be asked of the family members during5 L& z2 L6 W" U  u4 c* J4 j
the evaluation of any children who present with vir-
6 L& A2 p! X' |, V4 M$ Ailization or peripheral precocious puberty. The diag-
" }5 z' c: Z3 l8 Rnosis can be established by just a few tests and by. Y0 _1 ?- \5 Z
appropriate history. The inability to obtain such a
: y9 K% P: R% F/ S3 k! S+ Whistory, or failure to ask the specific questions, may; {$ o3 o# d4 Q- y( N$ G4 ?  \* L' r
result in extensive, unnecessary, and expensive
) r; \# `& I  J) n7 p! w8 xinvestigation. The primary care physician should be: @( A, p+ j  p
aware of this fact, because most of these children7 ~8 I* w3 I) q( a
may initially present in their practice. The Physicians’' D" C% y1 B/ O8 e( Z
Desk Reference and package insert should also put a8 v+ n6 r7 Q5 V; |  c6 ^
warning about the virilizing effect on a male or
$ ?* N, O% v+ ]& X' @female child who might come in contact with some-0 C, o1 a) K% b6 U8 \
one using any of these products./ l) \* z0 z/ A# K9 _3 a" o
References' v' R, H# a9 E* Q
1. Styne DM. The testes: disorder of sexual differentiation9 o) p, i! p( a
and puberty in the male. In: Sperling MA, ed. Pediatric
6 T1 Q8 [4 V* u3 v1 O! o) F! FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' `; u8 y/ X" F) Y6 m2002: 565-628.2 |3 R( w2 F3 G1 \
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- ?! W3 t, B  D" x* d: K8 W* _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

5 [$ B5 m; ?# l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