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
$ S; u+ o* h" W, T# y$ [Boy Induced by Indirect Topical6 o( O( {) b; C2 Z9 T# V2 C
Exposure to Testosterone
1 a1 i  Z8 |2 KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* r( ?. |8 U+ h  p: Z( J8 P% H. |- N+ X
and Kenneth R. Rettig, MD1- Y7 q7 l( l. _3 k( q
Clinical Pediatrics
+ \4 D0 m7 n) C4 T4 AVolume 46 Number 6
! \; F; y: n) I6 p; t: zJuly 2007 540-543# h9 N2 K( s6 k# I
© 2007 Sage Publications! a: q" E( j3 S5 t3 o# a  u
10.1177/0009922806296651
2 A3 n# J# G; a$ {* vhttp://clp.sagepub.com
- L- M8 }0 a$ g# F- ahosted at
+ L5 e1 ^4 v+ b2 G# P# d' T& Ghttp://online.sagepub.com
: F# Q2 ]  T) T( Y5 [; vPrecocious puberty in boys, central or peripheral,
5 @, ~0 e2 k! s9 `+ Z* Wis a significant concern for physicians. Central
( _3 N4 M( _. w5 Iprecocious puberty (CPP), which is mediated" S/ V6 y: g+ G& l# A+ A
through the hypothalamic pituitary gonadal axis, has5 r' s( }$ X1 [1 b
a higher incidence of organic central nervous system/ J8 ~3 ]; @: n- V% n! J
lesions in boys.1,2 Virilization in boys, as manifested/ w& R0 i% c+ D$ r- R
by enlargement of the penis, development of pubic/ C/ k6 F& T  P4 s* h
hair, and facial acne without enlargement of testi-& r' M8 ~" |: D8 z3 X
cles, suggests peripheral or pseudopuberty.1-3 We
8 q' I7 x4 S1 U7 T. N( d" Breport a 16-month-old boy who presented with the; t9 j2 j- f. r* w  z
enlargement of the phallus and pubic hair develop-. J( [" ^# H" _+ i7 D+ H4 X8 y
ment without testicular enlargement, which was due
5 Y) j1 J- L, Ato the unintentional exposure to androgen gel used by
$ _6 c1 Q6 E$ F9 c! f4 e( {the father. The family initially concealed this infor-+ z) B2 D) m0 a  M0 {: x
mation, resulting in an extensive work-up for this# A- M; t7 W- |9 L
child. Given the widespread and easy availability of# t" [! L9 U1 y  D
testosterone gel and cream, we believe this is proba-& `/ w0 s3 ~' O& a3 @8 a
bly more common than the rare case report in the) L" a) y9 L  d; v
literature.4# |  h; T: y# E% h& S
Patient Report
! W% F! I$ I# t6 f1 U* d0 L' qA 16-month-old white child was referred to the
. r3 o  R+ X8 j4 l' H1 A  z* Wendocrine clinic by his pediatrician with the concern! F3 @, Q+ D9 t& n9 E9 i
of early sexual development. His mother noticed# }5 M( ^, p6 e% J
light colored pubic hair development when he was$ o. ]  f7 ?6 X. l8 ?- s, d
From the 1Division of Pediatric Endocrinology, 2University of
" i7 }* }) }6 T) z0 c1 k; Y1 dSouth Alabama Medical Center, Mobile, Alabama.
/ R2 o* e* c% b4 k9 j. }& ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
# Q) a( ^$ Z( ]2 u+ M# |- o: Y" [1 tProfessor of Pediatrics, University of South Alabama, College of8 F' n; l3 d$ E0 b, y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! {& @# R, N3 w/ W
e-mail: [email protected].' W1 P9 Q+ T' p
about 6 to 7 months old, which progressively became& ^, }6 Y' H4 L& {
darker. She was also concerned about the enlarge-4 ^$ U. x1 K$ n' }% T* u
ment of his penis and frequent erections. The child% n7 |* O( d  F
was the product of a full-term normal delivery, with
% c' v( d  `6 {. e% i7 {a birth weight of 7 lb 14 oz, and birth length of
3 u; Q" o' W! G; M, D. o20 inches. He was breast-fed throughout the first year
2 S; {2 t$ X: `; dof life and was still receiving breast milk along with, O* ^& u  ]3 E7 i5 k: S4 c
solid food. He had no hospitalizations or surgery,
3 l/ P. X9 ^8 P( @and his psychosocial and psychomotor development
4 P( p: k% J4 |3 q8 O4 |3 ~# W5 d. Bwas age appropriate.
: Z& ^4 w4 a! P. c. s' W7 }The family history was remarkable for the father,* g$ b& e) j5 n1 p8 ?( ]
who was diagnosed with hypothyroidism at age 16,& n7 d0 l' `$ T. O" v
which was treated with thyroxine. The father’s
3 a" G' r( C3 A2 Bheight was 6 feet, and he went through a somewhat/ E  H+ y5 j( W1 |0 e
early puberty and had stopped growing by age 14.
! S- g9 T3 V! G2 hThe father denied taking any other medication. The" b2 Q- r2 W9 B/ H
child’s mother was in good health. Her menarche
; Y4 d0 w' s, h: ?3 @: ^was at 11 years of age, and her height was at 5 feet
9 d6 c& C- `& V, N; ]" q5 inches. There was no other family history of pre-, B: X9 ^$ a& u
cocious sexual development in the first-degree rela-5 U6 {  ^3 I7 D9 R9 P
tives. There were no siblings.
. |! ]: F( d: x- e9 LPhysical Examination  z- N& r3 @) O5 h9 h) l* u# D! G' g" {/ I
The physical examination revealed a very active,: Q3 Q' O/ D9 B" @3 N* i3 W) a
playful, and healthy boy. The vital signs documented
# v3 B, ]( U/ A5 }% j0 [! ?# ~- W0 qa blood pressure of 85/50 mm Hg, his length was
1 C7 ~7 b" ]1 y. d' J2 F/ g7 H90 cm (>97th percentile), and his weight was 14.4 kg9 T" ~( B' W$ C$ e. `% o
(also >97th percentile). The observed yearly growth
2 D3 L" [. J. K1 |0 ]% L0 B7 [$ [" zvelocity was 30 cm (12 inches). The examination of' y6 P* m, @1 ^( ^: h0 D
the neck revealed no thyroid enlargement.& ]; o9 g0 R4 e$ ?
The genitourinary examination was remarkable for% J6 }  h( u& e1 s
enlargement of the penis, with a stretched length of" O  a, W* `6 B5 f3 N' V2 J  p% o* i
8 cm and a width of 2 cm. The glans penis was very well1 I3 t" A# |% p# @
developed. The pubic hair was Tanner II, mostly around. U5 m, \2 R3 E; ~
540, U& h" U! X" }+ q5 {, K9 Z$ x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 q8 H: S5 ?" R6 ]: y
the base of the phallus and was dark and curled. The
1 x* o- n8 l. v  p( N9 `testicular volume was prepubertal at 2 mL each.: X, F3 b9 U6 Z- V
The skin was moist and smooth and somewhat' ^6 r' J" I4 p5 F, J. M2 G
oily. No axillary hair was noted. There were no
8 d9 m- j8 \9 D2 `+ Aabnormal skin pigmentations or café-au-lait spots.
. i3 X: w; k5 T' lNeurologic evaluation showed deep tendon reflex 2+
* I- u0 d) Z; H3 y5 Mbilateral and symmetrical. There was no suggestion: ~: B. Y, f. K* n
of papilledema., a4 e# Q1 U/ h& x) C- [& G
Laboratory Evaluation/ z" v# H" D' \! F" |4 m: Y* g7 b
The bone age was consistent with 28 months by! O$ K3 T' i1 I& |
using the standard of Greulich and Pyle at a chrono-7 C9 e7 I% J( h1 x7 d' g; \
logic age of 16 months (advanced).5 Chromosomal
+ V( m! m  i* e) }7 Wkaryotype was 46XY. The thyroid function test7 e% i9 _2 |* C2 k; @; I9 ^
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# W0 w$ u9 T  t* [lating hormone level was 1.3 µIU/mL (both normal).
' ]0 l6 ~  g5 H5 M0 B! c! MThe concentrations of serum electrolytes, blood
$ V  u# i1 I! r6 x+ ]6 d% Qurea nitrogen, creatinine, and calcium all were
+ \! ?7 q$ k  w  V( Fwithin normal range for his age. The concentration
& t" }% a( F! V6 j0 v7 c% yof serum 17-hydroxyprogesterone was 16 ng/dL( u! F' L7 }# Q$ P
(normal, 3 to 90 ng/dL), androstenedione was 20
7 }9 U; q9 U) r0 U" F4 `0 Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 k+ T& i0 I  c) }0 C$ rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; ^5 A' n9 x' L2 ~1 G' ]& I$ V/ Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 c( h: |/ z  _# \- r8 T  n
49ng/dL), 11-desoxycortisol (specific compound S)
8 R7 d; f+ {8 c% qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# u$ X- q- v3 y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 K% s( R% A( t' L- w4 |. K& n9 X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 p4 ^6 M! O- w/ x1 {" Land β-human chorionic gonadotropin was less than  s$ T7 S% W& g+ ?+ I/ H
5 mIU/mL (normal <5 mIU/mL). Serum follicular. Q: R/ v& g& a+ F- j
stimulating hormone and leuteinizing hormone
+ |4 Z) L6 }1 {$ nconcentrations were less than 0.05 mIU/mL
. F! Q4 ?& _, y% z, p# v' y: g( K9 s$ A(prepubertal).4 O% R4 q* ?1 L# k
The parents were notified about the laboratory
* f7 Q' d$ |3 K9 a' _results and were informed that all of the tests were/ ~1 s! Y% ~9 ^
normal except the testosterone level was high. The
" r+ Z4 q+ R/ j' [& W# j$ x3 N/ Pfollow-up visit was arranged within a few weeks to
1 E% m; }# e/ R9 v6 `obtain testicular and abdominal sonograms; how-
1 X1 \/ \  y& `* Hever, the family did not return for 4 months.1 K# ^5 c% c! ]& X! g6 k" {2 P0 d
Physical examination at this time revealed that the
# ~: x# T* L# A- }child had grown 2.5 cm in 4 months and had gained/ `% T: O" h8 h0 y6 W% g
2 kg of weight. Physical examination remained
3 m; ]. P  v9 X2 J. H& tunchanged. Surprisingly, the pubic hair almost com-
- J4 @" m& _/ P* B6 G: x( Tpletely disappeared except for a few vellous hairs at
, n( }; P. |) o1 y" Z/ S: vthe base of the phallus. Testicular volume was still 2
% K1 }- T7 f: h* V; ?% ~mL, and the size of the penis remained unchanged.
8 A0 g* ]/ M3 y, I$ ^/ qThe mother also said that the boy was no longer hav-; K" X$ j/ L+ t8 V
ing frequent erections.
/ L9 ?( ^; x  u; e. T* q2 nBoth parents were again questioned about use of
' S7 Y" r6 a0 h; R/ ?1 \' Nany ointment/creams that they may have applied to
( a, A# r8 e7 s7 c9 E8 t# Z$ jthe child’s skin. This time the father admitted the
9 z- \4 N$ T* \* \. TTopical Testosterone Exposure / Bhowmick et al 541
: K# v: N" R+ N* N1 X7 U2 Suse of testosterone gel twice daily that he was apply-
: s) j: n; k: Wing over his own shoulders, chest, and back area for  K9 A  z+ b1 j- W% K
a year. The father also revealed he was embarrassed& _# P6 s  H! L9 s
to disclose that he was using a testosterone gel pre-# q& z( {' ~# [, G+ t- O6 s; _
scribed by his family physician for decreased libido- p6 ~: N8 A3 ]6 o5 y* d" g& D
secondary to depression.- ^7 F, u/ V+ b, J4 ]- W
The child slept in the same bed with parents.4 e$ z. [" @" ~* X  S
The father would hug the baby and hold him on his/ `/ _( l- i5 n7 ^* q8 k
chest for a considerable period of time, causing sig-
7 @- e/ I$ \" S6 s* E5 u# ]5 X0 \nificant bare skin contact between baby and father.# w0 D# E! X# t7 z: o
The father also admitted that after the phone call,  b; {( N( D7 p' }0 a9 m2 g
when he learned the testosterone level in the baby
( X* U; l* x2 z7 p  Qwas high, he then read the product information0 {# [, M2 a) `- |2 }
packet and concluded that it was most likely the rea-
1 t# E1 }) i  A3 n! x: U& W; f+ Dson for the child’s virilization. At that time, they- t0 P" H- P, y% z% i
decided to put the baby in a separate bed, and the
# b. R  ^+ X; V) Ifather was not hugging him with bare skin and had( x7 _" i4 n. J0 p' I3 ?: ?
been using protective clothing. A repeat testosterone
. o: L* f( ]% x1 Wtest was ordered, but the family did not go to the
; e  @7 P2 x4 g8 e$ alaboratory to obtain the test.
0 _8 {8 t0 \0 Z* d/ `Discussion
" I3 g, x+ R/ a" t2 f; YPrecocious puberty in boys is defined as secondary
. d0 Y: R0 M1 W* k+ Osexual development before 9 years of age.1,4' ]1 u2 g4 W% S4 P" K) p" D! l
Precocious puberty is termed as central (true) when9 N) w- W4 b/ J2 s3 b' U7 K
it is caused by the premature activation of hypo-
; R) j0 L" J, J  Y& M* J/ E- Zthalamic pituitary gonadal axis. CPP is more com-( q- v  |" J8 q
mon in girls than in boys.1,3 Most boys with CPP
. P5 {' \6 ~" |  K+ \' C/ \  H( hmay have a central nervous system lesion that is
  z. v* V' F. hresponsible for the early activation of the hypothal-/ y# [9 b: K  r3 F2 s8 m( Y9 M
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 E9 h" u) a7 z7 J; Ksis has been given to neuroradiologic imaging in# f. m4 `+ w3 K( c6 o3 d( H" ^0 O
boys with precocious puberty. In addition to viril-
. _% Z2 W8 @) ^5 p; T2 ~ization, the clinical hallmark of CPP is the symmet-2 j: c) V4 Y* Y3 S
rical testicular growth secondary to stimulation by  U2 v% n9 M$ a& u# G
gonadotropins.1,3+ O! d/ z# o/ T7 f! Y# [; v5 `9 l
Gonadotropin-independent peripheral preco-, a0 ]& e5 x& t' k
cious puberty in boys also results from inappropriate. |" E6 o  m" T8 z  b+ }
androgenic stimulation from either endogenous or% q3 O5 c8 X, V- R& I
exogenous sources, nonpituitary gonadotropin stim-" \4 J8 @. v7 P' C
ulation, and rare activating mutations.3 Virilizing
0 `$ y, i1 b5 D6 d# x1 C6 hcongenital adrenal hyperplasia producing excessive5 A3 _9 p* y- M5 s8 F5 W: M4 Z
adrenal androgens is a common cause of precocious
0 `9 U: }: S7 L5 upuberty in boys.3,4
% r; w0 q7 w+ |5 O% Q- wThe most common form of congenital adrenal4 x/ @1 h0 ^- e1 N8 Y
hyperplasia is the 21-hydroxylase enzyme deficiency.4 M, v  ~5 G0 U+ k" j+ y8 j6 o
The 11-β hydroxylase deficiency may also result in' v3 N) X/ K% t/ h9 c( ], |, |& u
excessive adrenal androgen production, and rarely,$ P! c2 \! J1 I. o. O7 _' k
an adrenal tumor may also cause adrenal androgen
" Q: P5 Q$ t4 r& U/ Y: uexcess.1,3
- C* L5 ~8 z: ]' I$ b! Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* I! j, O1 N# W9 f4 g
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ R* C9 y. H2 q4 d' ^! X/ M- M# A
A unique entity of male-limited gonadotropin-
8 D. o7 D9 f4 H+ |6 iindependent precocious puberty, which is also known1 N$ M) r- M8 I- {/ U& n' o! w
as testotoxicosis, may cause precocious puberty at a
7 U9 y6 j/ b' I# t, U& M3 Hvery young age. The physical findings in these boys7 ~4 y6 ?5 W, d" r
with this disorder are full pubertal development,
' S* u" U6 @4 V/ V: Vincluding bilateral testicular growth, similar to boys% `7 G: C3 i7 P, _  V% p1 `
with CPP. The gonadotropin levels in this disorder
2 \2 P- A, z# d2 y5 l, x; hare suppressed to prepubertal levels and do not show
% l4 q: F/ `1 a( upubertal response of gonadotropin after gonadotropin-  U4 {- L. Y2 F3 h! m0 ]
releasing hormone stimulation. This is a sex-linked( J8 _+ Q5 a6 }& b9 B/ `
autosomal dominant disorder that affects only% G4 _4 s2 _4 v6 W
males; therefore, other male members of the family
& P+ X/ L, i" l" t7 ~may have similar precocious puberty.3+ |) O2 f4 u2 A7 I/ D2 {
In our patient, physical examination was incon-. O: ]& I! R6 V* @  u) y
sistent with true precocious puberty since his testi-
' `% j- b6 B5 n" @5 ncles were prepubertal in size. However, testotoxicosis9 V! F4 U  T' G0 R5 d* l# J
was in the differential diagnosis because his father/ ^9 A( f9 d* J- x5 F* R% m% L
started puberty somewhat early, and occasionally,
$ C6 m1 J) c" d. T6 \testicular enlargement is not that evident in the: ~! m& A4 i% J, v' V+ \
beginning of this process.1 In the absence of a neg-
3 _. r. A3 c, ]/ o  O6 q, g/ pative initial history of androgen exposure, our* w  j9 `* @1 V
biggest concern was virilizing adrenal hyperplasia,& w3 {, f+ ~" y' a2 }8 \
either 21-hydroxylase deficiency or 11-β hydroxylase
, W& Y* Z6 D6 `; H) x6 Kdeficiency. Those diagnoses were excluded by find-
. x; w, q9 {* p9 e  aing the normal level of adrenal steroids.
% Q9 E- ^/ Q. }* r; }+ UThe diagnosis of exogenous androgens was strongly
) T1 E: o" X7 hsuspected in a follow-up visit after 4 months because+ L  g- z; e  Z, |6 F+ ^2 D# `
the physical examination revealed the complete disap-
, h5 e" ^- m* W# cpearance of pubic hair, normal growth velocity, and
1 z7 E5 Z& a3 B& Y: a+ h# Y( {8 r: Tdecreased erections. The father admitted using a testos-
9 {3 f0 ^9 K4 @, j3 aterone gel, which he concealed at first visit. He was# d0 J8 Z7 W+ ?! L
using it rather frequently, twice a day. The Physicians’/ o2 C  B% e7 @! J; u8 L% a
Desk Reference, or package insert of this product, gel or
) I8 q! }" A- G* I4 q- x7 a1 vcream, cautions about dermal testosterone transfer to4 y1 ]( l( U1 z) ?; ]
unprotected females through direct skin exposure.* [: i/ m% @2 v2 U$ J! ?; D
Serum testosterone level was found to be 2 times the
2 P) _1 @5 O& V& j! @! qbaseline value in those females who were exposed to3 K  [9 x- _8 R( ~! {
even 15 minutes of direct skin contact with their male# W4 e4 W1 g/ B5 `; A* V0 A
partners.6 However, when a shirt covered the applica-! }2 P2 X8 q$ ^  K, J0 A3 B  Z: \
tion site, this testosterone transfer was prevented.
( [/ M/ Z2 u: V. `Our patient’s testosterone level was 60 ng/mL," l; i  Z4 @( I  \8 B3 o0 M
which was clearly high. Some studies suggest that# I1 q$ q$ j. c) U) S$ ^" f1 e& w
dermal conversion of testosterone to dihydrotestos-
3 W6 |' V. F+ \6 iterone, which is a more potent metabolite, is more: y# o, r( W4 U0 J, N+ C" c1 e
active in young children exposed to testosterone' @7 A9 h; y3 W2 k& q' g7 c3 |; \
exogenously7; however, we did not measure a dihy-
0 L0 G( J0 {& F- ~drotestosterone level in our patient. In addition to1 F- H) u1 g9 u/ A
virilization, exposure to exogenous testosterone in
& H2 Y" Y" a0 T* tchildren results in an increase in growth velocity and
9 o8 R# d8 O- I9 X' Kadvanced bone age, as seen in our patient.
1 \1 h& v* J+ j& n( j; E! T& w' G7 jThe long-term effect of androgen exposure during. P% w+ Y  O5 q9 g
early childhood on pubertal development and final
$ z/ L6 \; w) B& m/ a5 H. y) Tadult height are not fully known and always remain2 b5 |( m9 D2 S0 A8 O- `9 v6 B7 h
a concern. Children treated with short-term testos-
8 U- O$ @3 M7 E: \: iterone injection or topical androgen may exhibit some; B! p* A- ]1 L
acceleration of the skeletal maturation; however, after" z3 H  e1 ^& D, Z) V/ b2 k" F! @/ a
cessation of treatment, the rate of bone maturation2 p- Y/ g4 S$ g. i. c4 T
decelerates and gradually returns to normal.8,93 N7 Q' P  v; y0 F0 U% u
There are conflicting reports and controversy
0 B& Z: F9 S) l# yover the effect of early androgen exposure on adult; f% ]. Q/ _/ M! C+ O
penile length.10,11 Some reports suggest subnormal1 U" D8 d1 ]# O' a* u
adult penile length, apparently because of downreg-
5 E" i" W+ S, K9 Qulation of androgen receptor number.10,12 However," z+ T% N- A% G/ n1 v
Sutherland et al13 did not find a correlation between
/ ]/ J+ V, |" [& c7 [childhood testosterone exposure and reduced adult
3 [& p, D0 ~0 u' upenile length in clinical studies.0 J) j3 m0 w' _/ `3 h/ ]
Nonetheless, we do not believe our patient is
( A: ~5 ~/ h; m9 Q& sgoing to experience any of the untoward effects from
) j3 q# A$ S' mtestosterone exposure as mentioned earlier because0 b0 g" I, _; }
the exposure was not for a prolonged period of time.8 j: A) Y2 p/ i9 I  F6 a
Although the bone age was advanced at the time of
& M5 [+ w) R) d" H( A; Cdiagnosis, the child had a normal growth velocity at
' u& L, s" k4 qthe follow-up visit. It is hoped that his final adult
8 c1 h' T. b% q. p. ^7 m, |3 b8 Sheight will not be affected.
, a; J% e& d6 T+ l3 t; A7 xAlthough rarely reported, the widespread avail-
7 d1 _6 m8 {& a, i$ f9 oability of androgen products in our society may+ D5 Z& p, G; F) a
indeed cause more virilization in male or female
7 T9 i2 O1 S% W; L9 Echildren than one would realize. Exposure to andro-
8 @0 `. R0 h3 P+ m: j) xgen products must be considered and specific ques-
  d0 f) |7 ^! O% X0 a  Ztioning about the use of a testosterone product or# [. U1 S0 _4 m6 k+ e$ z, V
gel should be asked of the family members during
/ F1 O7 [2 a- ]* C5 L0 _4 }5 r6 n2 Uthe evaluation of any children who present with vir-/ c% e5 W- C# ]5 S7 L! k
ilization or peripheral precocious puberty. The diag-1 x( I1 j+ R, P) `
nosis can be established by just a few tests and by
- G7 B& ~2 i3 s* _" `$ X6 dappropriate history. The inability to obtain such a
3 a' U3 x0 r1 q  s) F$ u, r8 o0 dhistory, or failure to ask the specific questions, may$ K  o) \6 F2 P4 y$ m( |% g
result in extensive, unnecessary, and expensive# y. M6 d6 U( L: o
investigation. The primary care physician should be# Q- p; O% G5 N3 @$ y
aware of this fact, because most of these children
5 Y$ [4 A* v1 s3 ^2 [" V# R0 Amay initially present in their practice. The Physicians’5 M( W( f: p) ~) x7 F; r5 s
Desk Reference and package insert should also put a
. v  D" R+ y% F9 u; Cwarning about the virilizing effect on a male or' E& o  l% a& m" K1 J8 J
female child who might come in contact with some-! L9 A- O& z) T5 z( D  F' l
one using any of these products.
2 w5 ?1 h- |/ JReferences
" G; _! Z& |0 a! y& ?1. Styne DM. The testes: disorder of sexual differentiation0 \' ]/ f7 P! b# Z
and puberty in the male. In: Sperling MA, ed. Pediatric
  u. A1 j6 K6 TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. d! n8 v( L0 G- V* K; h! I
2002: 565-628.
2 g5 S7 y8 S( k% J8 B4 n+ \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% @6 T3 X& g, W. Gpuberty 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
  b4 o# o+ ~# X1 m' @' Y5 f! Q8 YBoy Induced by Indirect Topical
" T/ ?. k( r4 @" J7 WExposure to Testosterone7 u; l5 H$ b- o+ b* n0 I/ r  ^4 d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 [& l- b$ V3 U( c. Y
and Kenneth R. Rettig, MD1
% f, P3 y( ~, ~/ i9 }+ [Clinical Pediatrics
" U: R$ H7 d" ^# [0 }) r# WVolume 46 Number 6
: @5 [! s/ s5 i. t& H5 c* VJuly 2007 540-5430 N3 J3 q& ~: b* z8 ^% s
© 2007 Sage Publications
9 B, `: T0 M+ Q! p: B" J10.1177/0009922806296651: I3 B+ I4 e; t" S! K- `
http://clp.sagepub.com( J4 ^$ u7 W9 B5 J/ ~( t' W$ E9 ]3 b) p
hosted at
# s. \, q" }9 z5 Hhttp://online.sagepub.com: ?3 G" l9 G3 {% F4 _' \6 y- k
Precocious puberty in boys, central or peripheral,
; M/ G  o0 T- f/ G1 Y' kis a significant concern for physicians. Central2 F" ?0 S# }) B* h1 M: x
precocious puberty (CPP), which is mediated
/ V, f& l  E! ]' x# T- ~; u" [through the hypothalamic pituitary gonadal axis, has
6 S" s2 _. l4 S' [a higher incidence of organic central nervous system
  Y5 |$ W. x) v+ {5 V& U& rlesions in boys.1,2 Virilization in boys, as manifested( v& N& a+ B1 A% Z. L
by enlargement of the penis, development of pubic
4 G4 g$ t* A- ^, a, C1 m% X; uhair, and facial acne without enlargement of testi-: t6 p2 u6 x; `" x( e$ b
cles, suggests peripheral or pseudopuberty.1-3 We
+ J( d3 O' u; m, A6 Zreport a 16-month-old boy who presented with the' [1 c3 B- H! C+ N" k
enlargement of the phallus and pubic hair develop-4 x) R9 Q3 h- h
ment without testicular enlargement, which was due
/ }( S1 @. v3 ^' J8 _' Ito the unintentional exposure to androgen gel used by
5 e$ }  O; \$ t; e) ^the father. The family initially concealed this infor-- P7 S* J; K3 M# F) H, F3 [# \% i
mation, resulting in an extensive work-up for this
( J4 h% K# H. J. R* e8 F4 |8 uchild. Given the widespread and easy availability of+ T: T% h# p/ ?% e# J
testosterone gel and cream, we believe this is proba-
# [( m. I$ [4 F9 i3 Ibly more common than the rare case report in the; f6 ?+ _1 `! K- M
literature.4( W- G1 i4 u& F1 T
Patient Report# }& j% i) f5 e: D
A 16-month-old white child was referred to the
6 e9 _' J) \  Y' w( Kendocrine clinic by his pediatrician with the concern
2 f: Y* u% @% Z9 pof early sexual development. His mother noticed0 B2 J; ~: b) q* r6 R& f  M7 _: H
light colored pubic hair development when he was
% e6 `. r% Q& v% _; y0 {4 DFrom the 1Division of Pediatric Endocrinology, 2University of
3 ?& m" z- _9 X- cSouth Alabama Medical Center, Mobile, Alabama.4 X9 W3 w* [3 p5 P/ z$ T
Address correspondence to: Samar K. Bhowmick, MD, FACE,* N- g; G  K) E* V
Professor of Pediatrics, University of South Alabama, College of
" {0 m9 f0 d' J" _. ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  g1 y' a  K& i% B* X' V
e-mail: [email protected].! a  r# h9 @& A# X
about 6 to 7 months old, which progressively became0 F5 P; i" H6 ?8 S% o
darker. She was also concerned about the enlarge-
8 K+ r- S- v0 Z2 W8 X% Fment of his penis and frequent erections. The child+ z4 l' t% H) @
was the product of a full-term normal delivery, with
. d- j2 N" m+ d. ^: _a birth weight of 7 lb 14 oz, and birth length of
: v0 f8 h+ P8 {; f: z* G0 P' Z20 inches. He was breast-fed throughout the first year
; |' Y, k( |/ S7 O/ K+ X! Oof life and was still receiving breast milk along with: s/ s9 S* ^# n0 c; d7 D2 A7 E
solid food. He had no hospitalizations or surgery,- Z& D- }* t; c3 p7 C' q
and his psychosocial and psychomotor development$ V4 e% w/ k, I7 E5 R# L
was age appropriate.6 x; m+ N9 D5 l7 c
The family history was remarkable for the father,' Z7 Z7 R. j1 _/ Q1 f5 a
who was diagnosed with hypothyroidism at age 16,- c7 V6 K" n$ P$ l
which was treated with thyroxine. The father’s* X  R% x8 a# f! ^
height was 6 feet, and he went through a somewhat3 j6 @% X2 p6 J
early puberty and had stopped growing by age 14.
1 w2 u% A0 J& l- T' u) B0 rThe father denied taking any other medication. The
) b8 s* Y" X# A4 I; m' |/ schild’s mother was in good health. Her menarche
5 ?* U  u. K% ~* [# t4 q2 @was at 11 years of age, and her height was at 5 feet
2 B0 {! J" l$ K& f1 }7 q5 inches. There was no other family history of pre-
( E$ B$ h8 k/ {" Gcocious sexual development in the first-degree rela-
5 I9 u' n( Z9 u: ptives. There were no siblings.
1 ~1 l* E: a. F* h* OPhysical Examination
1 E" `/ n$ v' ?" j; l+ n1 ?3 `The physical examination revealed a very active,
6 {) V" a. P! A6 g- C3 E- fplayful, and healthy boy. The vital signs documented8 a+ n3 Q% \8 f2 P5 ]( M
a blood pressure of 85/50 mm Hg, his length was
' H1 f5 X! k* J+ j3 Q90 cm (>97th percentile), and his weight was 14.4 kg
: _! R3 W$ d# Z8 l3 L6 l1 N(also >97th percentile). The observed yearly growth, a0 g; G1 f( e3 V  `6 ~9 c8 g
velocity was 30 cm (12 inches). The examination of2 R" R$ a8 Z; n0 P+ A/ W% B. X
the neck revealed no thyroid enlargement.
) r7 o4 f( ]& i3 O( NThe genitourinary examination was remarkable for" ]( U- L1 f! Q- a( D6 t
enlargement of the penis, with a stretched length of
9 l& M4 `3 _; ^8 cm and a width of 2 cm. The glans penis was very well) p3 o" k. {9 H; N& v" N
developed. The pubic hair was Tanner II, mostly around
. {6 ]$ e4 ~" s1 p540+ @+ H& z# p  f& d" N6 B& }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& G) `( T+ B; C& L+ |8 Z
the base of the phallus and was dark and curled. The
7 }8 w8 ^1 Y. c2 T! Ytesticular volume was prepubertal at 2 mL each.) y* x1 f; V& |% f- Z
The skin was moist and smooth and somewhat/ N+ U" }1 v& j* u: i3 |0 j* A
oily. No axillary hair was noted. There were no
) |; i  d( E; \2 G9 D( a, `0 a- Habnormal skin pigmentations or café-au-lait spots.3 O! y1 K8 i6 T, n) l
Neurologic evaluation showed deep tendon reflex 2+
# j, i( D  X/ rbilateral and symmetrical. There was no suggestion& ]2 V. x' U& _6 V' Y/ `
of papilledema.7 f' w1 K) h- T1 O( D' F5 `" X
Laboratory Evaluation
5 M1 L) Q# h; ZThe bone age was consistent with 28 months by6 n% `' Y7 ?9 I+ F
using the standard of Greulich and Pyle at a chrono-
8 L1 e7 _% E' y/ @. n; W1 Glogic age of 16 months (advanced).5 Chromosomal% f0 o$ ^1 E/ J
karyotype was 46XY. The thyroid function test
! p' U; d" g' k1 m4 b+ ?& F- Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  e+ z/ R6 |! w: z) V  Tlating hormone level was 1.3 µIU/mL (both normal).
1 I- k' s8 l" d$ f4 Z7 IThe concentrations of serum electrolytes, blood
; _1 ~& [" H1 t0 {2 K1 `urea nitrogen, creatinine, and calcium all were
# B2 {: g9 `2 _' Cwithin normal range for his age. The concentration! h* u0 _0 _5 W$ K5 S. T  q
of serum 17-hydroxyprogesterone was 16 ng/dL) v4 e4 L: ?$ X0 N9 w/ ~$ ]
(normal, 3 to 90 ng/dL), androstenedione was 20: Y+ H7 P+ r1 ^" S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 h) Q/ f( M$ X* F& J( E: B/ Pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
  P: T) z+ v* V. X* a- gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" B$ q) m; M7 u# e( b49ng/dL), 11-desoxycortisol (specific compound S)
9 Q- {. x4 Q. @% Q/ [8 Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 Q; N$ C: z7 o. u/ @. s; C8 Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 Z9 o! D; {7 Q, \2 O+ R- ]0 Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 v0 s8 i" Q! B  }+ Q2 @/ hand β-human chorionic gonadotropin was less than& B4 q! _- S, A
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 {' V# [, d) |, M
stimulating hormone and leuteinizing hormone5 a9 m5 S- [  a0 h% F) R' @# o2 J
concentrations were less than 0.05 mIU/mL
3 j, `3 C4 S9 z(prepubertal).
. X- Y, H4 X, T# v5 P7 r9 K: RThe parents were notified about the laboratory
% v+ c- c  G  H/ _* x' Rresults and were informed that all of the tests were1 v# }. z& q6 Y
normal except the testosterone level was high. The
# c; t4 B/ \' s, |& l" nfollow-up visit was arranged within a few weeks to
( S6 X) f: Q  c, h" bobtain testicular and abdominal sonograms; how-
! k- g8 i, f! x! H. zever, the family did not return for 4 months.
& D/ S3 a1 t. ?9 LPhysical examination at this time revealed that the8 v& q4 V" V2 |& p1 l6 K1 _9 c
child had grown 2.5 cm in 4 months and had gained
5 o8 r: ~+ J& F6 Q5 o2 kg of weight. Physical examination remained2 ~/ ]2 T+ g7 }( L
unchanged. Surprisingly, the pubic hair almost com-5 r- y* o. q8 N# W. Y+ t) i. i
pletely disappeared except for a few vellous hairs at& ?& O, d+ s# @  L  `
the base of the phallus. Testicular volume was still 2
  A/ p# `& d& _4 S+ YmL, and the size of the penis remained unchanged.
/ @5 y6 Y  ^5 u2 D$ hThe mother also said that the boy was no longer hav-- U; T4 R' h4 [; N1 m1 D# `
ing frequent erections.
$ M+ d) i, {  K" U* O9 w# mBoth parents were again questioned about use of
% ]7 Y  }5 Q1 G" @! a1 u: I" M6 Hany ointment/creams that they may have applied to
: B  u1 ^$ s2 @0 L7 Wthe child’s skin. This time the father admitted the
5 ]5 u. q4 X1 GTopical Testosterone Exposure / Bhowmick et al 541
( T8 Z! S1 }0 Guse of testosterone gel twice daily that he was apply-3 u! ~( N3 l5 R6 m" y8 |9 S6 P
ing over his own shoulders, chest, and back area for. [5 C" v* E9 K( M6 A
a year. The father also revealed he was embarrassed4 r+ d: ^3 G2 P% C
to disclose that he was using a testosterone gel pre-; Z3 {/ D1 |0 \+ Z' i
scribed by his family physician for decreased libido" g7 R) {* j2 u, n0 U: V  X
secondary to depression.
$ f4 {  y2 [& t' G& ~The child slept in the same bed with parents.% v+ o8 e; n$ h4 ~! e+ k
The father would hug the baby and hold him on his0 l# g) x/ n0 g$ t
chest for a considerable period of time, causing sig-
& K- H  p' a0 n4 W; n% [+ ~8 wnificant bare skin contact between baby and father.- ?" X, S  n: y" u0 V3 \
The father also admitted that after the phone call,' o6 X4 X$ s% }6 ?+ F- [; W/ b
when he learned the testosterone level in the baby
3 ]  ^) L' _2 i) h. C# q5 Y6 Cwas high, he then read the product information! L! V& P) X9 z$ {/ Y1 ]5 d* a  I
packet and concluded that it was most likely the rea-' l$ @. G  A& k$ |2 ]/ H/ l
son for the child’s virilization. At that time, they
* w) O7 `/ }' o, Fdecided to put the baby in a separate bed, and the1 D9 {( R3 o1 k/ `( v
father was not hugging him with bare skin and had
) n9 Q5 W$ I- f, z# Rbeen using protective clothing. A repeat testosterone$ h/ b, v8 a7 z, z% s% U. X% M
test was ordered, but the family did not go to the. }  m2 c% o8 |0 w: F
laboratory to obtain the test.% T! g/ ~$ U' I/ u5 P* }% F% Y
Discussion, C& b: _5 f2 T9 T, j/ k
Precocious puberty in boys is defined as secondary
7 b3 p( N  `, R5 X  {sexual development before 9 years of age.1,4
% @: \. F' x8 Q# s0 B3 UPrecocious puberty is termed as central (true) when
2 |# t" H3 r1 V0 @# q7 e+ nit is caused by the premature activation of hypo-% e, q# a4 \5 p8 u- l0 D
thalamic pituitary gonadal axis. CPP is more com-1 G* D9 h- j& c
mon in girls than in boys.1,3 Most boys with CPP& v8 @& ?7 c5 Q- S
may have a central nervous system lesion that is! T! e" E2 ^; X. d
responsible for the early activation of the hypothal-0 F% Q, t( b7 J" S
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ w- x2 f& x; x# Psis has been given to neuroradiologic imaging in
* ]. D# D! O  [% n# wboys with precocious puberty. In addition to viril-& n, i* C- g: o$ u
ization, the clinical hallmark of CPP is the symmet-' S5 m3 p+ ?7 }: A' y
rical testicular growth secondary to stimulation by9 X; r& H7 }  _6 z6 d
gonadotropins.1,32 G$ v. u4 j# S4 ]; i( b8 I/ C
Gonadotropin-independent peripheral preco-, H- T' I4 P+ O' m3 z3 W; M: W; V
cious puberty in boys also results from inappropriate6 b" W8 X8 M9 r. R2 [
androgenic stimulation from either endogenous or& f; j& ?! S0 M: ]0 ?8 I6 R# h
exogenous sources, nonpituitary gonadotropin stim-
  ~5 u3 c2 r5 m3 V$ E- mulation, and rare activating mutations.3 Virilizing1 P1 g+ R$ f1 l, a2 x. L' E- H9 f( V
congenital adrenal hyperplasia producing excessive. P# n# Z8 h, `  t- G$ ], s( a
adrenal androgens is a common cause of precocious, H' c- c- m3 u+ H  ^
puberty in boys.3,4
5 \  w' x# A9 ]+ }. zThe most common form of congenital adrenal
1 ?( w* W2 V! s* ^$ M: b* Nhyperplasia is the 21-hydroxylase enzyme deficiency.' v5 j0 j' Q6 E+ Y6 e7 }1 a( Y* o
The 11-β hydroxylase deficiency may also result in
9 p* t* r2 Z2 }" ^9 Q  j: {( Z& mexcessive adrenal androgen production, and rarely,- V2 l5 O! [9 [! {" c
an adrenal tumor may also cause adrenal androgen
% f- D* L0 b' ?+ B/ ^excess.1,3
: r/ {/ R+ F6 p) _% o. J1 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 v$ o" v8 E' D) z, e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 e3 f& a) G6 \0 z9 D! HA unique entity of male-limited gonadotropin-! I0 c1 x. _5 l2 W3 t2 \) K
independent precocious puberty, which is also known6 \6 R# a$ ?. L/ \( z# u$ L
as testotoxicosis, may cause precocious puberty at a3 p, j8 I5 v4 W
very young age. The physical findings in these boys
$ D, S; S# n9 |8 Z, `with this disorder are full pubertal development,( g$ U2 V: o3 \* E1 c) N4 i
including bilateral testicular growth, similar to boys( S3 g% N% f3 j
with CPP. The gonadotropin levels in this disorder2 i, b9 t8 H% g( k/ [, _
are suppressed to prepubertal levels and do not show
% I* e+ B2 ~# `# Bpubertal response of gonadotropin after gonadotropin-
& s6 l! X8 R0 {7 Vreleasing hormone stimulation. This is a sex-linked
/ k  r- {  {, G+ f6 A: dautosomal dominant disorder that affects only" g9 r' X2 V1 s% \7 O# T/ M" f$ [
males; therefore, other male members of the family
% v  E" E: y* |" @# u# @( ^# v0 ~may have similar precocious puberty.33 M" z$ }. l  ^+ q
In our patient, physical examination was incon-8 }& `3 d+ h, ^. V6 s' W4 O+ J+ c
sistent with true precocious puberty since his testi-
- o3 a- B4 R4 b% qcles were prepubertal in size. However, testotoxicosis1 X" y& |8 b5 A5 G( ]9 _; @" y
was in the differential diagnosis because his father
6 Z* D* S: }, A2 ~! N! N' ostarted puberty somewhat early, and occasionally,  L" i: E, ^# S* F! i
testicular enlargement is not that evident in the2 Z# d4 P8 H; i, R+ l0 K
beginning of this process.1 In the absence of a neg-
8 y9 J. V& F$ f7 c+ ~ative initial history of androgen exposure, our) |4 |: ^1 [; }9 D: d0 B! |8 F+ F
biggest concern was virilizing adrenal hyperplasia,
, V+ u  [* V/ seither 21-hydroxylase deficiency or 11-β hydroxylase3 }6 c; g/ m; S3 Z8 Z
deficiency. Those diagnoses were excluded by find-
, u* W8 k9 |* N' w) v8 u& Q0 @' W0 ting the normal level of adrenal steroids.
! o: Y! {0 v0 p1 q5 P9 _4 cThe diagnosis of exogenous androgens was strongly4 |6 D( ?6 ~, n0 M/ T7 [
suspected in a follow-up visit after 4 months because
% {. h% f2 x6 R9 J: P' f, nthe physical examination revealed the complete disap-
: N& }* @* f0 d' Y/ Y, d+ i) l( h3 xpearance of pubic hair, normal growth velocity, and
) ?3 D7 D" a/ m1 @0 C0 Kdecreased erections. The father admitted using a testos-$ j" E7 E7 C$ U% e( Z6 q. a7 h4 g
terone gel, which he concealed at first visit. He was
9 U& \' U; o6 @& zusing it rather frequently, twice a day. The Physicians’
2 a8 G9 l: S/ Q3 [3 J1 }- ~Desk Reference, or package insert of this product, gel or' B+ Y+ x, }( `' A4 e# _
cream, cautions about dermal testosterone transfer to
9 n6 s! ?" r  |* u7 U% w+ T9 [unprotected females through direct skin exposure.& f8 E0 l0 Z4 C1 B  C. o
Serum testosterone level was found to be 2 times the& F. Q  {: n+ |6 x5 b9 [# S
baseline value in those females who were exposed to, l5 Y1 B! U9 K% [: A+ Z( X
even 15 minutes of direct skin contact with their male
4 }% z* B, i3 H* `7 }- gpartners.6 However, when a shirt covered the applica-: e5 J9 h1 m. d0 p7 z& _& K
tion site, this testosterone transfer was prevented.
$ q* s$ Q% v$ L. oOur patient’s testosterone level was 60 ng/mL,) I) K) u% i7 _1 W
which was clearly high. Some studies suggest that4 Q- \, Q& C3 J7 b/ R( x
dermal conversion of testosterone to dihydrotestos-( L4 D- F% }( z; J, F- z7 I/ ^& w. v
terone, which is a more potent metabolite, is more: H; c$ y) s% c) ]" Y
active in young children exposed to testosterone
+ y2 a. |' b9 Z8 xexogenously7; however, we did not measure a dihy-# Y' f1 S% k/ \" a" [1 Y0 C
drotestosterone level in our patient. In addition to! K; B& k# V4 W  _/ r) a3 }6 O
virilization, exposure to exogenous testosterone in
  |' @2 ^/ N2 o3 P4 \: x( rchildren results in an increase in growth velocity and
; y9 u$ L! @; m+ g* @. tadvanced bone age, as seen in our patient.7 q4 p* _3 g. U4 z1 W, o# V
The long-term effect of androgen exposure during
1 g4 _6 K: I/ k" ]3 }7 [0 mearly childhood on pubertal development and final; u' V( J5 h* I
adult height are not fully known and always remain! q$ W  K0 T+ {8 p/ C$ l
a concern. Children treated with short-term testos-
1 Y! N( F" F( }2 z( Rterone injection or topical androgen may exhibit some9 d$ Y. y( l9 d6 I5 t3 h$ z4 |/ i
acceleration of the skeletal maturation; however, after
3 z. U* u8 @" j% t8 i0 z/ D4 G% f% Fcessation of treatment, the rate of bone maturation* H" j$ W4 o$ [& l
decelerates and gradually returns to normal.8,9
$ h: d# w- e3 K+ K/ @6 a. FThere are conflicting reports and controversy  W* M, f' n0 M- t- l/ B
over the effect of early androgen exposure on adult* {" u; u* C- |& M
penile length.10,11 Some reports suggest subnormal  I& E& H) M) u6 X5 P. M
adult penile length, apparently because of downreg-
( ^  v  L+ e& N2 C1 }# A3 oulation of androgen receptor number.10,12 However,
8 b3 ?; Z& ^5 m$ @1 S8 rSutherland et al13 did not find a correlation between
! D, c; c! O/ j( f6 kchildhood testosterone exposure and reduced adult* ?- ^0 N* b# V* Y3 s+ Q- K! A2 h* W7 i
penile length in clinical studies.) V! O4 d" z$ e% V, p: _: h
Nonetheless, we do not believe our patient is
' L' r; o% U. c$ v) S" t9 j% U/ O  Egoing to experience any of the untoward effects from9 U/ t# |$ S% F+ A9 x1 g0 z( u" c
testosterone exposure as mentioned earlier because
1 u7 _# N  ?5 E9 i+ P7 othe exposure was not for a prolonged period of time.7 v$ t5 c3 O" E2 y& {- ^2 l
Although the bone age was advanced at the time of  S9 `% E( U) u' a( A
diagnosis, the child had a normal growth velocity at
/ F( B7 i" o+ R9 Ithe follow-up visit. It is hoped that his final adult5 X* f5 p7 R; l: O# v
height will not be affected.2 ~2 \6 {& X* i4 j$ r6 R; L& |
Although rarely reported, the widespread avail-
5 t. B4 u- @2 j' nability of androgen products in our society may- r! ^& c1 v5 n$ V
indeed cause more virilization in male or female$ N% l2 f* y* U; |& G+ d/ f
children than one would realize. Exposure to andro-* {0 Q# s% B4 z3 U1 w1 n( O' U
gen products must be considered and specific ques-" Z  P3 e2 o3 A
tioning about the use of a testosterone product or
4 w) Z7 R1 L+ r( n6 Rgel should be asked of the family members during5 a. r  _$ e: {$ O% F) N8 x( `
the evaluation of any children who present with vir-
  b9 V- e7 z' t( C0 ^ilization or peripheral precocious puberty. The diag-6 r8 D+ I0 \8 {" _6 _7 @; i
nosis can be established by just a few tests and by! c; S" {: b" ?& `! F% W
appropriate history. The inability to obtain such a1 N6 V3 R/ v' }! Z3 K, M! e
history, or failure to ask the specific questions, may
& Y4 K7 O: A) k- s# w3 iresult in extensive, unnecessary, and expensive4 k1 q1 e* p$ J  O3 O
investigation. The primary care physician should be
4 W. [0 P, g- jaware of this fact, because most of these children% G5 t. k5 V7 t, }( f0 ^) j/ z
may initially present in their practice. The Physicians’
1 N$ M( m+ S/ A$ E# U- N+ ?* UDesk Reference and package insert should also put a
+ g% a& ~1 A' |* \$ x, z( U$ m$ p: bwarning about the virilizing effect on a male or
2 S7 v5 K2 q# n2 w: u% D0 H( Sfemale child who might come in contact with some-" i5 ^) e0 M0 H: x
one using any of these products.+ h% g' T, Z  K! W" ?) u
References5 u! n2 b; J$ G4 ?0 [: K
1. Styne DM. The testes: disorder of sexual differentiation
" M9 V8 [  Z4 Q1 j' @and puberty in the male. In: Sperling MA, ed. Pediatric
: I) b* i8 E* u, j- VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: I( \: O+ s8 f% ]4 Z
2002: 565-628.
: X6 h  \# C( j, {0 U- x  R1 w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 p" i  x5 P9 k" {
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 G4 {, `* V0 d2 ]8 [- Q/ t
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