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
3 h$ f5 f" f# F; ?* z% q# LBoy Induced by Indirect Topical
) s. a- c% s, fExposure to Testosterone
! d; p9 }4 x4 b* _4 ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 E* ~! E+ c# z2 Y7 S& band Kenneth R. Rettig, MD1
, @% m/ q7 a3 N- y9 d, vClinical Pediatrics
7 z$ v6 G/ i$ b/ tVolume 46 Number 6. j) p9 n& q' B/ C: y
July 2007 540-543
1 s$ j. _+ {% `% o& q* e* F© 2007 Sage Publications  O" W/ F# N& C; ^
10.1177/0009922806296651
- F2 `- h. }& l6 |http://clp.sagepub.com/ }, N' P. O/ N1 n
hosted at
+ Q8 J& Y7 [7 V4 O  qhttp://online.sagepub.com" L7 n. T& [4 [
Precocious puberty in boys, central or peripheral,
/ g" `7 n% a5 F  R/ bis a significant concern for physicians. Central
9 h4 q; V0 ^: P- ~precocious puberty (CPP), which is mediated, n8 i. v( [5 J4 I/ I
through the hypothalamic pituitary gonadal axis, has
) K! e8 \4 H3 U, A) sa higher incidence of organic central nervous system- O( U" K! F. s% g
lesions in boys.1,2 Virilization in boys, as manifested
# @) X- L0 d, s7 Xby enlargement of the penis, development of pubic
1 g5 {5 E6 a6 S4 ?3 {7 p) }hair, and facial acne without enlargement of testi-4 ^7 P1 S1 z: w5 y6 ?- Z
cles, suggests peripheral or pseudopuberty.1-3 We3 Q# b/ L) ^4 ~; g* T1 _+ `% ]$ p
report a 16-month-old boy who presented with the' t, ^' [- f4 D* d+ M# _2 O
enlargement of the phallus and pubic hair develop-& M; w5 b7 j' w
ment without testicular enlargement, which was due
  f% D' k7 W. Y% C' @8 w# Jto the unintentional exposure to androgen gel used by+ V; Q( U) A( s. u( _
the father. The family initially concealed this infor-
3 p( U' E, }; ?* t7 xmation, resulting in an extensive work-up for this
: H7 x  e% c" W) ichild. Given the widespread and easy availability of
+ s) S0 K* _2 D$ |) |( a& wtestosterone gel and cream, we believe this is proba-
$ L/ [8 n0 `4 B$ jbly more common than the rare case report in the1 f" o6 \( [+ ]9 z( y: n9 i, m
literature.4
3 E: F- a2 a9 vPatient Report
5 l6 a, }# q, E$ IA 16-month-old white child was referred to the
- Z- q; y3 m3 \+ F* K! zendocrine clinic by his pediatrician with the concern6 p" |7 s% F+ S  G9 k
of early sexual development. His mother noticed
' b2 x1 [- V- ~" H5 B# ^+ Olight colored pubic hair development when he was+ l. }( [% H# }2 Q" Q. d  ?1 G
From the 1Division of Pediatric Endocrinology, 2University of
7 U1 J) f  P. E# D) MSouth Alabama Medical Center, Mobile, Alabama.
, n0 f2 {- u/ l. D7 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# M* D! M  l, V8 M3 E6 \Professor of Pediatrics, University of South Alabama, College of
* L* @+ o0 C6 b+ T' C  a' tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 i- Z7 M& r* J% m6 G, P
e-mail: [email protected].
/ A; H7 E9 i! p! Qabout 6 to 7 months old, which progressively became
1 H; w, k% j' j: Z; h0 z5 qdarker. She was also concerned about the enlarge-
! h" z5 B$ }3 c. U- O4 O! W* yment of his penis and frequent erections. The child; ?) E0 O  M7 ?1 G4 i" ^8 L1 R& {0 @
was the product of a full-term normal delivery, with
# w7 Y& A& @( n7 z  i, oa birth weight of 7 lb 14 oz, and birth length of
; j' x2 O& W( \6 T- q0 b20 inches. He was breast-fed throughout the first year7 k! R9 V' {; q/ x# [; t) H5 m3 x7 j
of life and was still receiving breast milk along with. ^- H. d% Y# Y8 l& ^
solid food. He had no hospitalizations or surgery,5 |0 o, k9 c. t, H, d" M& P* g
and his psychosocial and psychomotor development$ U' ^- ]7 G1 H6 Y7 F. ?
was age appropriate.6 Y! e( M+ o" x! l
The family history was remarkable for the father,
  R$ A/ J3 X4 Kwho was diagnosed with hypothyroidism at age 16,4 H# g$ r  `* C/ A4 @
which was treated with thyroxine. The father’s  B+ v( \: l" }. @4 e$ p4 q0 J
height was 6 feet, and he went through a somewhat/ I5 B1 j- W* ^0 J6 X
early puberty and had stopped growing by age 14.. u9 O1 B0 X/ [" O0 d6 F
The father denied taking any other medication. The1 M% t* N5 \6 z4 ?( {
child’s mother was in good health. Her menarche8 x5 }! H2 w) T3 j
was at 11 years of age, and her height was at 5 feet
; r) }0 b4 E( y% b/ T5 inches. There was no other family history of pre-2 V, m0 A1 i/ K2 G
cocious sexual development in the first-degree rela-
% a4 K0 y* I9 stives. There were no siblings.
9 D0 x# K, m9 h7 ?+ m" A. cPhysical Examination
& A7 a; j- x0 ?" t& F& m& QThe physical examination revealed a very active,
! `% p5 {  Z7 U* Wplayful, and healthy boy. The vital signs documented
: {" W1 ]' ^6 O" l! wa blood pressure of 85/50 mm Hg, his length was8 p+ Q* l% X4 U* i  [. z' F* e3 H
90 cm (>97th percentile), and his weight was 14.4 kg
4 V0 j  |) V0 L: c; H! v; p& I(also >97th percentile). The observed yearly growth
8 y$ \- B; g4 D$ p$ _velocity was 30 cm (12 inches). The examination of* G3 ]' _, |0 o' Z- E$ J
the neck revealed no thyroid enlargement.
7 F$ {* X9 m5 Z* J" B& Z+ bThe genitourinary examination was remarkable for/ J  L+ c2 f5 |6 f; s. [
enlargement of the penis, with a stretched length of
- H( l# w/ T; [, E: A8 cm and a width of 2 cm. The glans penis was very well  X2 C6 y4 ?+ P! P
developed. The pubic hair was Tanner II, mostly around- C- K( t# y+ q
540
1 h  y" E0 M1 g& g" S. b5 B3 Z1 Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; Y: ]: B+ q+ f* J- m( ^0 u7 p6 [the base of the phallus and was dark and curled. The
. `$ I5 Z1 o- C  B. p% L' n  j; a# Btesticular volume was prepubertal at 2 mL each.8 o! w6 ~# g' Q# s' i' Q( @+ G
The skin was moist and smooth and somewhat2 w* x0 l6 W! A1 p# X
oily. No axillary hair was noted. There were no+ x" G5 S+ O" i
abnormal skin pigmentations or café-au-lait spots.
' T, V, x: h5 Q; c8 ?Neurologic evaluation showed deep tendon reflex 2+
& e9 t4 S( X7 J. ]. s, }6 bbilateral and symmetrical. There was no suggestion
; I' E* s. h7 h6 Kof papilledema.# d, m/ D5 V5 _- i5 m- l
Laboratory Evaluation
. J" r! C! y6 L3 oThe bone age was consistent with 28 months by7 U" B% p5 ~* x: L# y5 X/ _5 D: h0 {
using the standard of Greulich and Pyle at a chrono-, j# l5 x/ F) T2 A
logic age of 16 months (advanced).5 Chromosomal6 m9 I* |2 O9 r4 N3 m: ?" ?1 i1 r
karyotype was 46XY. The thyroid function test
# i0 w: n% h1 v' Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 r2 y! N$ e) |! Elating hormone level was 1.3 µIU/mL (both normal).  E+ M2 D# r2 o9 a7 p  h$ i
The concentrations of serum electrolytes, blood
: E+ U; W5 \" B/ curea nitrogen, creatinine, and calcium all were
* J7 m: S, L, m, p: w5 ~7 w# t2 twithin normal range for his age. The concentration8 g: D. `: {: c
of serum 17-hydroxyprogesterone was 16 ng/dL+ |1 B* @- V' P' {2 x  ]
(normal, 3 to 90 ng/dL), androstenedione was 20
2 W5 B/ z2 C7 {ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 M3 ^* w7 Q* W" g1 {% O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: w8 p9 P# g9 m  [$ d: p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# G; C' Z' i  U/ t- x( f# k
49ng/dL), 11-desoxycortisol (specific compound S); ]; P) J3 O# ~9 Z2 _5 w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, `+ B! X7 I# l/ F* N% z" G5 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 G$ A2 R' H) j- }5 }! b
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 u/ F8 h$ ~& T+ mand β-human chorionic gonadotropin was less than- Z+ ]9 V7 x0 f9 f$ o, u1 e
5 mIU/mL (normal <5 mIU/mL). Serum follicular! f+ t6 ?0 L! A+ m
stimulating hormone and leuteinizing hormone: `0 U/ _2 B+ ~
concentrations were less than 0.05 mIU/mL
2 Q! ~9 G8 w# O* l4 b(prepubertal).
. i2 w$ a- F+ r' u4 }The parents were notified about the laboratory) v* G5 ~, n! I# }
results and were informed that all of the tests were" z' P2 n1 ~) H% {" R# `  A6 _
normal except the testosterone level was high. The
9 m+ P' x3 K& G4 _4 Yfollow-up visit was arranged within a few weeks to$ Z; R9 j5 N+ r  l8 g. r0 j
obtain testicular and abdominal sonograms; how-
1 Q9 w% L+ y/ r2 _% {1 gever, the family did not return for 4 months.
& P) D8 b1 h3 s9 vPhysical examination at this time revealed that the; ~' g5 B8 ~6 ~
child had grown 2.5 cm in 4 months and had gained0 j  T  R; l/ \- K' v: ]4 J
2 kg of weight. Physical examination remained5 a1 k9 z% g2 ~7 b
unchanged. Surprisingly, the pubic hair almost com-5 U4 A& P5 O% I# i
pletely disappeared except for a few vellous hairs at$ i1 A2 X# A6 n* w
the base of the phallus. Testicular volume was still 2, C& N& V7 q1 a
mL, and the size of the penis remained unchanged.7 l6 ]+ u$ V) o( C
The mother also said that the boy was no longer hav-# }4 T6 Z4 C# B+ I8 Q7 P
ing frequent erections.
4 j2 j$ `" l! d% i; u4 _% cBoth parents were again questioned about use of
" P3 U3 Y" o" a" P+ {any ointment/creams that they may have applied to- k1 C  b; S, q+ Q6 J
the child’s skin. This time the father admitted the
: i; V2 L5 Q0 X4 A, f# hTopical Testosterone Exposure / Bhowmick et al 541  O: }8 ?" u% _/ i* c1 I
use of testosterone gel twice daily that he was apply-
& e( W/ S, s7 V: ding over his own shoulders, chest, and back area for) z0 S/ _/ H& N! w4 a3 K
a year. The father also revealed he was embarrassed
* `; S  |% x0 C' n8 Y* Xto disclose that he was using a testosterone gel pre-4 s+ Q7 b& w. m* ^! k3 g
scribed by his family physician for decreased libido3 L2 p! I) s; u% m; F" A
secondary to depression.
. L: u" Q+ X( L  C  X. Y, TThe child slept in the same bed with parents.
' H7 _, k5 K5 t; r. H- {3 OThe father would hug the baby and hold him on his
4 o, \3 @, y+ o: j/ N0 z) Rchest for a considerable period of time, causing sig-1 S6 d8 W5 ]: h2 ?% Z7 b
nificant bare skin contact between baby and father.0 D& ^$ y! W5 l4 Z; o4 J
The father also admitted that after the phone call,
# N. u, J; p& Y$ [2 S" x% Fwhen he learned the testosterone level in the baby
5 O: g* `8 U, m' @! ]8 T9 swas high, he then read the product information8 d2 }9 i& c1 u4 R# q
packet and concluded that it was most likely the rea-: l, {" K/ V6 l6 W( P( f
son for the child’s virilization. At that time, they, Z/ V0 L6 W  _
decided to put the baby in a separate bed, and the
" _+ s8 `3 U, I/ {$ A# w! Rfather was not hugging him with bare skin and had
/ {( x$ S9 F4 q  u8 `* ~been using protective clothing. A repeat testosterone( N' f5 _8 O& l5 f" H
test was ordered, but the family did not go to the: d9 H; W! }( h9 ?; l0 e
laboratory to obtain the test.
# V3 x. x9 P% B% t6 _Discussion4 p* {* y9 m8 u2 r8 L
Precocious puberty in boys is defined as secondary
0 R2 ^- p. [7 |3 T. C1 Qsexual development before 9 years of age.1,4! j+ T/ n  q6 \8 P: x2 D
Precocious puberty is termed as central (true) when5 Q6 t5 Q4 c' h3 L- H( s
it is caused by the premature activation of hypo-" `. l) ]. V0 L( n8 E  ?' w7 m" E9 s
thalamic pituitary gonadal axis. CPP is more com-, K7 f* U* s! Q& z/ w/ Y4 s
mon in girls than in boys.1,3 Most boys with CPP
- m. p+ r' g; F5 c: w# _may have a central nervous system lesion that is/ {! |: T( @) x% b* f7 c" h
responsible for the early activation of the hypothal-
3 H7 z4 x; w  p+ n% Q, O  hamic pituitary gonadal axis.1-3 Thus, greater empha-
; U+ i( N! L! Q; |sis has been given to neuroradiologic imaging in/ ]/ t# r4 [+ m' W2 c) p
boys with precocious puberty. In addition to viril-; o8 o# a( ~4 i+ w; _, V3 [
ization, the clinical hallmark of CPP is the symmet-- e; r1 Z% R% k# `7 ^, Y
rical testicular growth secondary to stimulation by
8 _8 W+ T8 H7 Lgonadotropins.1,3
" A) r2 k: `( A4 ]7 BGonadotropin-independent peripheral preco-$ S8 E! H8 E7 ?+ i) a
cious puberty in boys also results from inappropriate
$ D0 I1 B  V! M8 Z2 u+ F' candrogenic stimulation from either endogenous or
; x8 f9 D6 x& s) y+ X) }7 h9 [exogenous sources, nonpituitary gonadotropin stim-; v! N5 q' B. h# X
ulation, and rare activating mutations.3 Virilizing
+ t9 O% j) F( T5 M; wcongenital adrenal hyperplasia producing excessive( Y+ g9 s* a( j% G
adrenal androgens is a common cause of precocious+ L7 k) [4 M/ U" }( F; q
puberty in boys.3,4! ^  t3 }) s1 O: [  E. N1 }
The most common form of congenital adrenal8 q% I& W! A4 b6 j& r' f) i
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 F" l& S. d. D/ f! x$ M3 o" HThe 11-β hydroxylase deficiency may also result in
+ K7 ^4 ~7 V1 z0 c2 Q5 |excessive adrenal androgen production, and rarely,! D+ B! s- D. }! M( W7 p4 h; u3 w
an adrenal tumor may also cause adrenal androgen6 p9 O1 V. ~# f
excess.1,30 U9 x4 o% d& |4 u1 ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- K9 [- C$ Q' G9 Z7 X1 V
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 ?' C$ g; C: k5 c2 E% t2 }; q/ XA unique entity of male-limited gonadotropin-) l4 Z3 o( l% Z) f  ?  S3 E
independent precocious puberty, which is also known
# u; I! N/ _% N" Qas testotoxicosis, may cause precocious puberty at a
, d1 ~/ |9 K, W! qvery young age. The physical findings in these boys" ?1 J  B6 u: U& E9 B
with this disorder are full pubertal development,4 Z7 I1 o3 k3 W/ T) u9 N: U
including bilateral testicular growth, similar to boys) P6 f5 ?/ A' R' U
with CPP. The gonadotropin levels in this disorder
+ w" k& g& h6 Z; t4 j. I8 z! Zare suppressed to prepubertal levels and do not show5 i9 w3 M! Z' E2 h
pubertal response of gonadotropin after gonadotropin-
) i8 |, v8 X3 @9 Q3 V3 T% breleasing hormone stimulation. This is a sex-linked
" U2 N, _9 a" T  l1 dautosomal dominant disorder that affects only
9 l4 i2 Y) m" r2 |0 |males; therefore, other male members of the family$ }. X2 b% z4 ]2 Y! a5 T) }& j
may have similar precocious puberty.3
, Z3 r/ N* e6 x/ v  K- MIn our patient, physical examination was incon-4 _) y1 ~3 V# w/ {7 n* V2 Y9 v, j
sistent with true precocious puberty since his testi-1 K2 R! }) H" D9 N* Q0 ~5 f
cles were prepubertal in size. However, testotoxicosis
6 S, J6 h  ?$ H6 `! q! u+ l& T' H4 `was in the differential diagnosis because his father6 [/ G8 W& k$ }  A# o, p
started puberty somewhat early, and occasionally,) g/ N+ Q6 D6 l& s0 N  g8 p
testicular enlargement is not that evident in the
# }! y% r( C: N1 V3 Z! U- q! X; sbeginning of this process.1 In the absence of a neg-
5 \9 M! M: `% P3 oative initial history of androgen exposure, our3 E/ L2 T: q1 m
biggest concern was virilizing adrenal hyperplasia,
2 C, B7 Z/ @1 q0 k0 }either 21-hydroxylase deficiency or 11-β hydroxylase
1 _$ B; u8 P. P  n* zdeficiency. Those diagnoses were excluded by find-
; N3 G2 w$ o) Z1 B+ R7 ]) Ling the normal level of adrenal steroids.) ?3 K6 ~+ Q6 x1 q6 G
The diagnosis of exogenous androgens was strongly
, t, l( m+ J8 A! o3 rsuspected in a follow-up visit after 4 months because. u' ^9 H; |! c
the physical examination revealed the complete disap-9 J; i9 r8 O+ ]0 k4 k1 d& L' V! c
pearance of pubic hair, normal growth velocity, and
; w9 [/ s5 L# @decreased erections. The father admitted using a testos-
! s2 w' H. e* E7 aterone gel, which he concealed at first visit. He was) c3 `: N* r& W. ?; t
using it rather frequently, twice a day. The Physicians’& v9 d4 a: j. f! G5 m- A2 x
Desk Reference, or package insert of this product, gel or
9 `: X" D" {  `: Pcream, cautions about dermal testosterone transfer to
: J9 M+ r3 b: h& O; lunprotected females through direct skin exposure.# {% i3 z1 R* N- Z" T# C
Serum testosterone level was found to be 2 times the2 O3 G1 i6 K2 ^+ q  L% ]: ?
baseline value in those females who were exposed to- ]. R' e% ?8 n8 m3 w
even 15 minutes of direct skin contact with their male0 N1 j7 p1 k5 h2 w" [: E  m. {; J
partners.6 However, when a shirt covered the applica-
, \" r' x. I8 {. Ftion site, this testosterone transfer was prevented.8 j% Q  J8 }8 m3 ?/ l1 y6 Y
Our patient’s testosterone level was 60 ng/mL,) b* W8 ^7 T) H' g! u
which was clearly high. Some studies suggest that
( j2 S7 g) ?' a/ R' Z" edermal conversion of testosterone to dihydrotestos-, t" m5 }% d! Q) p' h; [: s" r% C$ u
terone, which is a more potent metabolite, is more; h2 G5 G  |6 H7 E7 \
active in young children exposed to testosterone1 S$ S  l. K% Y' P
exogenously7; however, we did not measure a dihy-( J3 g" ~. Q3 v4 u8 i' F
drotestosterone level in our patient. In addition to7 ?5 h9 V" c& l4 P
virilization, exposure to exogenous testosterone in: G( v4 F" L7 c6 }! E& B
children results in an increase in growth velocity and, n. ?: f2 q6 K, D7 y. M  v& @
advanced bone age, as seen in our patient.
& s  L/ f2 {" p; T+ QThe long-term effect of androgen exposure during: Z6 ^3 P/ H% o: {
early childhood on pubertal development and final
& a' j5 u- `2 G/ \- Oadult height are not fully known and always remain8 R: n: x8 I1 O+ {$ s! ]' Y/ d; g2 e
a concern. Children treated with short-term testos-6 j' \9 t8 k; D6 @
terone injection or topical androgen may exhibit some
( i! t2 k' ^! @9 a3 k( p3 uacceleration of the skeletal maturation; however, after
0 g% r/ K0 t0 q9 c6 g" rcessation of treatment, the rate of bone maturation
% y7 N* u9 e5 sdecelerates and gradually returns to normal.8,9
3 D* Z7 n, S, Y9 z2 {7 T" B8 x  l; cThere are conflicting reports and controversy
. {6 R" {' `; Qover the effect of early androgen exposure on adult
* e& P5 e4 R" G1 S% }( dpenile length.10,11 Some reports suggest subnormal% g( b' \5 ~6 y/ x! K
adult penile length, apparently because of downreg-6 A. k$ j  L+ M- M; c1 X5 {- V
ulation of androgen receptor number.10,12 However,
3 W9 k' ~; [% i: r+ A1 }Sutherland et al13 did not find a correlation between
/ L" {% s1 ?- R* o1 @+ t. c- }4 achildhood testosterone exposure and reduced adult6 f9 c- M- m: q1 m. r$ ~
penile length in clinical studies.
+ w2 e8 h1 {4 l5 z" {8 n5 FNonetheless, we do not believe our patient is, h: n$ {" v: b# `
going to experience any of the untoward effects from8 o: u1 W; |" n* X7 E
testosterone exposure as mentioned earlier because: O' n$ |  v0 ?+ e; e
the exposure was not for a prolonged period of time.: q$ r* A/ m% D: ]
Although the bone age was advanced at the time of/ {" i5 a( E: d/ X; B
diagnosis, the child had a normal growth velocity at& N. I; \3 o5 j2 b$ i
the follow-up visit. It is hoped that his final adult
0 O( K, x0 b0 q7 D" w8 E0 \& V: xheight will not be affected.. _# Z- C  {; d+ e' P& D' z' {. ~
Although rarely reported, the widespread avail-% x$ W# i# t2 M+ j: k$ d! Y
ability of androgen products in our society may/ L; k& P, [+ ~
indeed cause more virilization in male or female
1 w3 |: s4 \7 W7 |& A* Bchildren than one would realize. Exposure to andro-" `- S) v- P6 s+ D7 X
gen products must be considered and specific ques-
% m$ c. D, N( R) }7 H1 y& @tioning about the use of a testosterone product or1 }+ v5 Q& N2 [" k: W1 |" k
gel should be asked of the family members during
* I9 x) V! _+ A5 y" y& i6 rthe evaluation of any children who present with vir-1 |- A0 R3 w% {' c% C
ilization or peripheral precocious puberty. The diag-
* j6 m, s3 ~* g# {1 n" w! ~. lnosis can be established by just a few tests and by/ [& }0 |" F, {: v1 O
appropriate history. The inability to obtain such a
: d/ {1 ^2 T/ l. T% {history, or failure to ask the specific questions, may8 S1 m8 h* T! M( q3 @9 w% Z$ Y3 @
result in extensive, unnecessary, and expensive/ b: e/ U( m. @
investigation. The primary care physician should be
: y- O5 q5 u- |! h( r4 _3 S7 waware of this fact, because most of these children4 B0 _& x9 a- l. v2 S# C8 Q
may initially present in their practice. The Physicians’
' W5 C+ m& Z& ^) f! Q  ]Desk Reference and package insert should also put a
. p2 w8 @$ i+ E: x* b: u7 Jwarning about the virilizing effect on a male or/ Z3 ?1 H- c! X4 j$ C9 }" U
female child who might come in contact with some-
& y' J/ j9 X7 |' v, cone using any of these products.
6 o; V2 F; a+ b/ m3 L  S0 |References( E) U% E& [  H9 r8 V
1. Styne DM. The testes: disorder of sexual differentiation
7 X  Q' g# m! I8 G( t! b, T3 u1 Sand puberty in the male. In: Sperling MA, ed. Pediatric
4 H6 {! e, g# {* `* y3 h% nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) _: o- G! b! S) g) v$ t. m2002: 565-628.
( W- n0 k2 v1 k. d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 o" Q' P4 p& _
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
7 l3 ?. e: \' [( _0 y. TBoy Induced by Indirect Topical5 G( o0 y, i& |
Exposure to Testosterone# e: U& \, p+ D) Q8 M9 }4 ~& S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 F: _8 h$ Z6 T9 ^$ K
and Kenneth R. Rettig, MD1
. ]. X4 f# z) @% xClinical Pediatrics
! s! O( q2 N* R0 eVolume 46 Number 6
8 C( f5 ?) B8 IJuly 2007 540-5431 B  T2 ]( T8 [
© 2007 Sage Publications1 [4 z: L. v* U- c/ H1 q( Z* C
10.1177/0009922806296651( `1 t4 p; X" y' {
http://clp.sagepub.com! ^0 f6 o% Q! j" e+ t* o8 ^+ i0 j; r
hosted at
# l( [' g6 A+ O# nhttp://online.sagepub.com
1 n3 }8 ]& l8 b/ I0 zPrecocious puberty in boys, central or peripheral,
/ S. y- i) n! M! Vis a significant concern for physicians. Central
0 h9 Z) l6 \+ p  kprecocious puberty (CPP), which is mediated6 ?4 F$ u& G& H" b8 y+ z% p
through the hypothalamic pituitary gonadal axis, has
' d7 A; {$ v: G8 Ya higher incidence of organic central nervous system
7 @8 h2 R8 w8 V! @lesions in boys.1,2 Virilization in boys, as manifested
* m- h# G' d, l3 Vby enlargement of the penis, development of pubic
' z9 I7 [" f5 M+ W6 uhair, and facial acne without enlargement of testi-
- M4 \0 t1 i1 w, ycles, suggests peripheral or pseudopuberty.1-3 We
, k3 m) Q* ?% T* U0 [! B7 X% ^1 D' O& creport a 16-month-old boy who presented with the' d9 U  I+ A$ e$ B+ `
enlargement of the phallus and pubic hair develop-
( o: i6 F) S& ]4 N: Jment without testicular enlargement, which was due
) I3 Q) f+ x4 `" E3 uto the unintentional exposure to androgen gel used by
8 U! l( ^5 ?, [& L" [8 `- n0 wthe father. The family initially concealed this infor-
6 q  ^9 p. K& u/ wmation, resulting in an extensive work-up for this
% _* }( t$ i- `. U( Schild. Given the widespread and easy availability of
! A( O0 u2 v  t! vtestosterone gel and cream, we believe this is proba-# C9 b3 g$ {& B7 U' m
bly more common than the rare case report in the
0 O) D) C7 D& T* Pliterature.4
2 {$ a$ f; \6 Q5 C+ o- mPatient Report
$ i; u4 s0 b. b+ I  G) |6 VA 16-month-old white child was referred to the
2 u& d  W' S! Q: Rendocrine clinic by his pediatrician with the concern
) G: Z! Z# K; u. }of early sexual development. His mother noticed
6 @9 h4 Y1 p. {% D: a2 `* d' llight colored pubic hair development when he was. t4 x! Q7 I( Z$ ~: M4 Y" p7 \. ?
From the 1Division of Pediatric Endocrinology, 2University of: L- i! t' A) b
South Alabama Medical Center, Mobile, Alabama.
$ q8 R& M( k& k. d/ M8 C" \Address correspondence to: Samar K. Bhowmick, MD, FACE,
; u" d6 L9 ]' a/ y. ~% aProfessor of Pediatrics, University of South Alabama, College of
3 o* r& l( h. S' p: B$ I$ YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, G* F# t" ?: n( ^' m1 l% b. J
e-mail: [email protected].
8 ]  f# C* u( U1 Habout 6 to 7 months old, which progressively became
/ m) ~) f4 B1 |# ], hdarker. She was also concerned about the enlarge-
5 j4 B" y! a6 F+ t4 O8 \ment of his penis and frequent erections. The child
. o+ R" U0 _+ I% o' mwas the product of a full-term normal delivery, with
1 A# m8 k6 }' p% M. A! Ha birth weight of 7 lb 14 oz, and birth length of: d% L! p0 C  G  w+ Y# B, K
20 inches. He was breast-fed throughout the first year' W, ]4 ?4 o3 h8 \7 n& Y) I
of life and was still receiving breast milk along with
: ^5 [# \& w, B! ]8 ?3 Q: D- dsolid food. He had no hospitalizations or surgery,1 g* N0 N! C2 |" o' Q
and his psychosocial and psychomotor development, j% |. X) R1 |, T9 C5 f, o/ I. C: |
was age appropriate.
* }% i, N$ T9 a9 G  RThe family history was remarkable for the father,# A4 }6 T! Y& T
who was diagnosed with hypothyroidism at age 16,. X. q; `' s' }8 {/ N, o
which was treated with thyroxine. The father’s
( P5 p2 O4 K0 D' G: d- d$ eheight was 6 feet, and he went through a somewhat
/ H5 N$ _! }/ A! {early puberty and had stopped growing by age 14.) v$ Y# e8 a* S9 j  v; x
The father denied taking any other medication. The
9 u4 V$ ^% i- B% dchild’s mother was in good health. Her menarche
1 g3 a7 _. P6 S' P& wwas at 11 years of age, and her height was at 5 feet
. B- B% c' ^+ f# r$ r+ Q- d- d5 inches. There was no other family history of pre-
, T% m" Y$ V2 V( o' N: z" pcocious sexual development in the first-degree rela-! O0 o8 X+ x' m# c4 k) p8 o& \; f! f& l
tives. There were no siblings.7 y9 Q' [, {0 B/ c( [1 d
Physical Examination
, T# R5 g: E$ j' {0 d! w; fThe physical examination revealed a very active,
1 ^7 S$ d( a9 \5 |$ O7 iplayful, and healthy boy. The vital signs documented
& _9 F3 {2 i3 ?) `& z- t) q+ g8 aa blood pressure of 85/50 mm Hg, his length was
, Q; _/ G, F2 k$ A2 P7 x- T& d/ `90 cm (>97th percentile), and his weight was 14.4 kg
- y8 ]; b% a2 T$ c4 _* g(also >97th percentile). The observed yearly growth8 s7 t, K5 K8 _+ M9 k$ j
velocity was 30 cm (12 inches). The examination of
- J" l4 O: b! \the neck revealed no thyroid enlargement.
! ?0 F+ Y) d- }! g% AThe genitourinary examination was remarkable for0 l: e# d2 t8 F. H
enlargement of the penis, with a stretched length of2 z/ X* A& v. |. `5 F. I# S
8 cm and a width of 2 cm. The glans penis was very well9 w9 v$ _% d4 {+ Y1 B! u
developed. The pubic hair was Tanner II, mostly around
; g' [) a+ d! h) e# _; y540, ]) V9 y  H6 B/ n- a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& Q' o2 b6 b3 m' @
the base of the phallus and was dark and curled. The, Y) q; e  V  D: R& U6 ^
testicular volume was prepubertal at 2 mL each.
! x/ _  M6 q7 wThe skin was moist and smooth and somewhat( g9 c9 A/ z4 o" {7 ^; I, ^( x
oily. No axillary hair was noted. There were no
( n& y3 Y8 ^; K; m5 Fabnormal skin pigmentations or café-au-lait spots.
0 ^8 Y* z  \4 \; \6 @Neurologic evaluation showed deep tendon reflex 2+6 ?7 h5 @/ ?7 O
bilateral and symmetrical. There was no suggestion
/ E0 i0 i6 w& w) {: @* V# k( iof papilledema.
* Q' k( T9 w$ t+ o5 ?$ tLaboratory Evaluation
7 C% h  U! F6 `% }The bone age was consistent with 28 months by5 ^9 m, A* I4 F
using the standard of Greulich and Pyle at a chrono-3 w: s2 p. t. i
logic age of 16 months (advanced).5 Chromosomal8 s( k8 L$ t5 i' Y# z' q* T; G/ x
karyotype was 46XY. The thyroid function test
- X! X( O) |5 [, i/ R( mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-  g7 O6 M8 U8 E6 k" {2 F/ _9 `% J
lating hormone level was 1.3 µIU/mL (both normal).9 O0 Z! z  }; u+ M
The concentrations of serum electrolytes, blood3 K3 I+ _4 N$ ]. K% ~
urea nitrogen, creatinine, and calcium all were& x8 i% L/ ~9 \+ G" D/ s
within normal range for his age. The concentration
8 O8 {# C+ q4 v4 p  g6 N5 eof serum 17-hydroxyprogesterone was 16 ng/dL( h: P- }% S0 n/ k4 |
(normal, 3 to 90 ng/dL), androstenedione was 207 Z6 K. s4 t8 N. `2 C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ l" m! s  D* v) J" Y/ jterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 J+ O9 u2 r/ z* }$ B/ w0 T7 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ E2 X1 S: D0 M& L! _49ng/dL), 11-desoxycortisol (specific compound S)$ H; K- k6 v% B+ X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 k2 v) c# J& s8 Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 q8 g6 j1 C* O; D$ D. H, wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 V2 J0 s8 D: K  v! |
and β-human chorionic gonadotropin was less than
  E- P  c( x. X" U5 mIU/mL (normal <5 mIU/mL). Serum follicular
% e4 D% U% i/ e5 Astimulating hormone and leuteinizing hormone" S  n, m6 Y* ?" d4 x" G8 Z4 m( t
concentrations were less than 0.05 mIU/mL
5 Q$ N$ n+ x) U  t(prepubertal).
  C8 p' p5 _( i, Y, v7 {) r- }: |The parents were notified about the laboratory
8 t0 \* M4 |7 k5 }5 h; Tresults and were informed that all of the tests were
8 U" g' Q" k" u2 ^: v( L) anormal except the testosterone level was high. The; {" a8 h6 ?# d7 c
follow-up visit was arranged within a few weeks to7 n( F2 I4 y% @, h" N- X" ~
obtain testicular and abdominal sonograms; how-
! q) o% R! X& y3 H* a  pever, the family did not return for 4 months.9 h5 Y: T- ]3 r8 d. I4 d/ a
Physical examination at this time revealed that the* \3 y! E0 o4 I* K5 }
child had grown 2.5 cm in 4 months and had gained: u7 L9 X+ @+ F1 T
2 kg of weight. Physical examination remained
& E8 q3 c$ @. S+ {unchanged. Surprisingly, the pubic hair almost com-0 z7 d0 C" z2 o2 K. x8 s: F
pletely disappeared except for a few vellous hairs at
7 J( \- C8 F  m0 Ythe base of the phallus. Testicular volume was still 2: N7 Y+ g# f9 P- J2 i' g% o8 v- ~) C, d) G
mL, and the size of the penis remained unchanged.+ I+ |) V8 K$ u/ {7 R7 |
The mother also said that the boy was no longer hav-
4 C- F% ]. h" M( q2 ?7 C: [8 H0 ving frequent erections.4 N8 o2 |5 B4 s6 w. S
Both parents were again questioned about use of
0 O  P) i1 Q: S9 a9 g& z3 fany ointment/creams that they may have applied to& `" c9 U5 T* V* g: Z
the child’s skin. This time the father admitted the* x- J+ ]6 l. ]; j2 d
Topical Testosterone Exposure / Bhowmick et al 541* _' V/ o! s% M2 m7 H  k4 M" O
use of testosterone gel twice daily that he was apply-
' U2 |9 o, L3 Ging over his own shoulders, chest, and back area for; ]: a) s4 D, z; A/ X, k
a year. The father also revealed he was embarrassed$ \- ~; k+ m; ~" e7 j2 ~
to disclose that he was using a testosterone gel pre-& e7 d# R, Z# f9 J9 ^2 l
scribed by his family physician for decreased libido
. H0 F! ]/ a8 l- l7 i# q8 xsecondary to depression.- m$ M5 S; x+ m- B. p) x! L
The child slept in the same bed with parents.' n2 D' d. b+ `% o2 y/ b7 j* u
The father would hug the baby and hold him on his; y% N3 ?+ u  g3 V5 ]( g
chest for a considerable period of time, causing sig-7 b5 T" l% V# J
nificant bare skin contact between baby and father.; }7 U; x- f' T
The father also admitted that after the phone call,3 O( ?+ @' C) B& v* w9 w* l* c
when he learned the testosterone level in the baby7 Q0 d2 {/ k$ u7 R% H) P
was high, he then read the product information0 G2 x* \# ~$ Q$ Q! W) m9 y
packet and concluded that it was most likely the rea-
8 z2 m; I# ^6 p/ Yson for the child’s virilization. At that time, they. g2 {3 |/ ?' r2 E1 B
decided to put the baby in a separate bed, and the
2 n) w& U' s' `% a( Ofather was not hugging him with bare skin and had: P6 V  ~& b+ @) u
been using protective clothing. A repeat testosterone4 I# x) Z; B' n/ s% |
test was ordered, but the family did not go to the
, \4 R/ T; @& M* Q, {laboratory to obtain the test.0 s2 ]0 Q% A/ u) j( {0 Q
Discussion8 P9 l+ `( U* J7 Q; I8 q
Precocious puberty in boys is defined as secondary% k7 v0 T7 N# `) s6 n" B5 p/ _
sexual development before 9 years of age.1,4
' v8 [# F% e  z- X- x) P2 `Precocious puberty is termed as central (true) when
! D5 V0 f6 e+ ~: o) `# q8 Wit is caused by the premature activation of hypo-9 x# W. `8 u2 Y/ [2 e/ d6 i
thalamic pituitary gonadal axis. CPP is more com-! C; v1 O5 Z' ~6 N) O
mon in girls than in boys.1,3 Most boys with CPP
3 ?# ]/ t3 j0 j, ~/ fmay have a central nervous system lesion that is( }$ l* n$ U8 |
responsible for the early activation of the hypothal-2 F" m" J2 W! h3 X# u9 y* u% V
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ L2 ^& P" O3 }. o- gsis has been given to neuroradiologic imaging in! l( P8 h( l0 j) u( i
boys with precocious puberty. In addition to viril-9 O2 M# B! ?0 O, e
ization, the clinical hallmark of CPP is the symmet-
$ v& Y8 u1 o& C, d2 ?rical testicular growth secondary to stimulation by4 x/ j# U8 q" J1 Y' }5 x& |9 o
gonadotropins.1,3
" u  N0 T0 L' h- b) N: g/ a1 hGonadotropin-independent peripheral preco-
8 t8 r; F9 v. m+ t- ~cious puberty in boys also results from inappropriate
2 G9 Y$ J  F6 o. ?androgenic stimulation from either endogenous or
) n3 k7 t+ F6 M$ `* W1 ^exogenous sources, nonpituitary gonadotropin stim-8 W) Q; W9 c# A7 N# l6 _
ulation, and rare activating mutations.3 Virilizing
% E) Y$ l2 S) @( p0 j( Dcongenital adrenal hyperplasia producing excessive! n) h# M/ t7 W. z) \
adrenal androgens is a common cause of precocious
# |1 O2 V1 M) S- t. ?puberty in boys.3,4. `( G$ E2 [2 [5 B. l; [( n
The most common form of congenital adrenal8 R% F6 J- V$ _# @$ A' T5 j
hyperplasia is the 21-hydroxylase enzyme deficiency.
# v# u) [* v  ^0 V6 r# YThe 11-β hydroxylase deficiency may also result in2 I( n3 ?2 u. H  s
excessive adrenal androgen production, and rarely,
, z! [. T/ p9 y% g' g0 s# g. Qan adrenal tumor may also cause adrenal androgen
& e! E( |0 o& Eexcess.1,38 }, Y. E) f# Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ ^* e4 X  C; D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: ~* X+ k2 L: w2 I8 M9 DA unique entity of male-limited gonadotropin-
  G! R+ I" P( s* Jindependent precocious puberty, which is also known' ?' K  [; H6 L3 J! i/ a
as testotoxicosis, may cause precocious puberty at a
! A2 Z$ T( ]0 o  ^very young age. The physical findings in these boys
1 R7 D& u8 b3 T. M" s' U  k! Xwith this disorder are full pubertal development,8 Y0 I0 D2 a  ^6 l  _
including bilateral testicular growth, similar to boys
5 G/ P! h" |( d# J( K7 I( hwith CPP. The gonadotropin levels in this disorder
8 _4 o0 P( Q( c: A: dare suppressed to prepubertal levels and do not show# C: x) ?' l! `- ^
pubertal response of gonadotropin after gonadotropin-! @& E( b) P/ p$ W+ [. l
releasing hormone stimulation. This is a sex-linked# N9 v+ b: v7 b, B8 j9 D
autosomal dominant disorder that affects only6 t4 _* B& H5 |, U$ i0 y& U
males; therefore, other male members of the family
" w2 w2 h& F4 K: A8 Amay have similar precocious puberty.3
0 M3 X- @1 j! [$ i) l3 l# QIn our patient, physical examination was incon-$ d+ ~$ e% M9 G5 d' D; u) F6 f
sistent with true precocious puberty since his testi-
4 {" A( P) B/ F/ T( i* Kcles were prepubertal in size. However, testotoxicosis+ z1 h! v  t. V! h6 G" P% w
was in the differential diagnosis because his father  [0 S& L- j9 O
started puberty somewhat early, and occasionally,
8 U$ l) u# ^* h6 O5 {- v/ ^- J0 _& ttesticular enlargement is not that evident in the$ h! G7 Y# P6 ]6 O5 g( m3 x
beginning of this process.1 In the absence of a neg-4 p- V. ^) Y& _! W! P$ L
ative initial history of androgen exposure, our6 a# z, ], A' c
biggest concern was virilizing adrenal hyperplasia,! {/ W, K2 ]% n7 A8 F
either 21-hydroxylase deficiency or 11-β hydroxylase5 \7 ~, H6 a5 z6 |  j8 p
deficiency. Those diagnoses were excluded by find-
9 z( G, L+ v% J& B2 l) ~, ~" wing the normal level of adrenal steroids.8 d/ I% I, c  y. _% N
The diagnosis of exogenous androgens was strongly) ]9 |: ~, Y' v! y6 E
suspected in a follow-up visit after 4 months because) `( l+ H( `7 T9 d) W
the physical examination revealed the complete disap-
7 a. e3 l+ ^: d* I, Upearance of pubic hair, normal growth velocity, and; I* L1 P, q  b$ K
decreased erections. The father admitted using a testos-" v, k, p1 \! R5 q" U+ t
terone gel, which he concealed at first visit. He was
- d1 n6 M3 n2 xusing it rather frequently, twice a day. The Physicians’
; R0 ]- d5 E! A2 g: u" ^Desk Reference, or package insert of this product, gel or2 n3 C6 f4 e2 q; B3 P8 w# V
cream, cautions about dermal testosterone transfer to( I+ B# i. a; M& l9 x; q
unprotected females through direct skin exposure.
' S: R# b' [0 x4 b: TSerum testosterone level was found to be 2 times the( D$ `7 ~3 g+ L
baseline value in those females who were exposed to, Z/ N4 u# N- [; G
even 15 minutes of direct skin contact with their male
0 Q" d& B% Q% U6 `partners.6 However, when a shirt covered the applica-' M3 S8 a. u" J# q( W" R5 q$ l
tion site, this testosterone transfer was prevented.8 Q: F% C) `2 ?
Our patient’s testosterone level was 60 ng/mL,
' Y- L  t0 @) x+ s5 r5 O- }0 {which was clearly high. Some studies suggest that- N, u3 m2 F% l+ |5 s3 t. C
dermal conversion of testosterone to dihydrotestos-
& a5 W* Y' M7 Z/ Fterone, which is a more potent metabolite, is more' S( q6 O! ]5 ~6 t# Y& u
active in young children exposed to testosterone
3 u, R5 E4 [6 d# d' q; Eexogenously7; however, we did not measure a dihy-! D1 \$ F. N2 t+ U) K1 u# N
drotestosterone level in our patient. In addition to9 l4 H2 x# j8 F. t+ ]
virilization, exposure to exogenous testosterone in' }  G& \1 P8 f' b: g
children results in an increase in growth velocity and8 k6 s) u6 x4 p' Y, L4 @' J
advanced bone age, as seen in our patient.
% x  b9 r' T4 v  z" PThe long-term effect of androgen exposure during% |: U, Y3 m3 q  A% v
early childhood on pubertal development and final
3 \6 Q1 V9 r' J! y8 _. {, ~$ zadult height are not fully known and always remain* g/ L* c8 {# a6 W+ C
a concern. Children treated with short-term testos-3 e% f/ r0 v8 g. v5 H
terone injection or topical androgen may exhibit some6 }/ t4 E+ i- W0 A% w( P/ u0 @2 ?0 s
acceleration of the skeletal maturation; however, after
  U4 Q! x" N1 r: {cessation of treatment, the rate of bone maturation
! {2 `( {6 D* O% s0 u2 U. |, ~decelerates and gradually returns to normal.8,9
# |9 F2 c5 D  E$ b( x# ]There are conflicting reports and controversy
3 x$ d+ E/ B" q/ c  F" T- `8 pover the effect of early androgen exposure on adult
8 `6 g+ \' }# N$ W& C7 xpenile length.10,11 Some reports suggest subnormal
7 o2 _1 n: v4 f! B4 {adult penile length, apparently because of downreg-
+ Y/ G$ L6 I- U( m% culation of androgen receptor number.10,12 However,* R8 e' e* V$ {. u2 C% A5 R; X- l
Sutherland et al13 did not find a correlation between5 k$ ?! {1 ^7 X2 k" Z8 J1 z
childhood testosterone exposure and reduced adult
& k3 D" y/ l$ `( ppenile length in clinical studies.
# t. V# g& D7 A' Q/ \/ tNonetheless, we do not believe our patient is' O$ v4 s4 e8 L8 L! X
going to experience any of the untoward effects from
' z1 p0 [1 \/ S' h3 v+ g, `testosterone exposure as mentioned earlier because$ q0 i1 C" u$ w: M! u0 R
the exposure was not for a prolonged period of time.
, D0 x  e0 W6 @% [$ i. tAlthough the bone age was advanced at the time of
3 V- x% m* Z+ F" ddiagnosis, the child had a normal growth velocity at0 X/ {4 Y6 M5 ?1 r5 \
the follow-up visit. It is hoped that his final adult
! C% }! ]& I1 C; V4 q8 wheight will not be affected.5 [# @+ s: g2 U$ }% G) k
Although rarely reported, the widespread avail-. T) [$ p2 V! Y5 c
ability of androgen products in our society may/ v6 \' ~, d3 N+ H
indeed cause more virilization in male or female4 ]- Q% L8 S' [4 k7 l" U
children than one would realize. Exposure to andro-
7 _4 c9 F1 J0 Q& ?: Dgen products must be considered and specific ques-4 R, e/ G& R  Q
tioning about the use of a testosterone product or2 a3 v' A, z/ q2 j
gel should be asked of the family members during# C! o4 Z9 [( u! Q  e
the evaluation of any children who present with vir-
5 c* u; _- M! i+ C5 }" a( ailization or peripheral precocious puberty. The diag-
0 x9 B5 S5 E" x' N0 g/ t- _8 Fnosis can be established by just a few tests and by
+ R* `8 J! O# V9 e( h* i) [% I/ bappropriate history. The inability to obtain such a+ P( G- v& {+ d* V
history, or failure to ask the specific questions, may4 [" j3 Q, ~  W
result in extensive, unnecessary, and expensive+ O7 ?8 ~( ]- s" g' l0 z! c
investigation. The primary care physician should be
# H" \+ N1 G- W% _: G) H7 Caware of this fact, because most of these children2 G# U0 r" o( F' X
may initially present in their practice. The Physicians’
" ^( p$ K5 s6 X7 L7 J6 QDesk Reference and package insert should also put a* U. x  e1 N* x  n+ i
warning about the virilizing effect on a male or
0 U! T/ P0 n4 tfemale child who might come in contact with some-/ B  h5 m" C7 k% C
one using any of these products.
( {' V0 a5 k# J* z* jReferences# v* ~" O+ K0 ~
1. Styne DM. The testes: disorder of sexual differentiation
' Z0 n! G- ^% ^0 ^5 i- Qand puberty in the male. In: Sperling MA, ed. Pediatric
  |$ W* v4 N, y4 m% P+ q1 {Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 L6 Q6 S* L9 `  v/ [* g
2002: 565-628.+ r! i, _; l* I/ Z; j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) k9 j% S2 I0 F" w. l* C) ppuberty 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

) J2 K9 R( M3 s$ I+ z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