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, f- \0 s" g' H' r& \
Boy Induced by Indirect Topical
+ P/ H& V/ V0 l. ]0 ]% M, c" @Exposure to Testosterone
9 |% l  M5 D1 _* vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- M5 k; N, H! `
and Kenneth R. Rettig, MD1
" ~; G+ n9 C/ d1 \! b7 FClinical Pediatrics
" n' v. G/ Z* _$ r( k; SVolume 46 Number 6
! ]8 _2 J% @1 S8 DJuly 2007 540-5432 u3 w+ g5 v8 l- \6 s7 w  ^: y
© 2007 Sage Publications
6 ?6 Y: x: ~6 P10.1177/0009922806296651
6 K- N9 h6 W- E# s$ E$ E1 ?7 q0 rhttp://clp.sagepub.com
, Z. H0 H3 Q: q) p  n2 [: ]hosted at; R/ G& u' x5 w3 S+ w* F
http://online.sagepub.com* l: t: n. b" L& `7 P+ M
Precocious puberty in boys, central or peripheral,
) ~" F6 @5 h4 z! ?: @& t/ r( Gis a significant concern for physicians. Central! i' h/ r5 H9 \  M# t
precocious puberty (CPP), which is mediated) F  Q$ Y7 a, @9 S. I! w! S* C1 W
through the hypothalamic pituitary gonadal axis, has
6 D7 w+ l' M2 a2 T2 G4 r; |a higher incidence of organic central nervous system! ^# y4 e( X# P. ?. y+ g" n
lesions in boys.1,2 Virilization in boys, as manifested
4 @+ W. _9 G$ T9 P$ nby enlargement of the penis, development of pubic" }/ q. C5 w" z4 j
hair, and facial acne without enlargement of testi-9 e: B4 Z5 ^4 \4 Z4 C: I
cles, suggests peripheral or pseudopuberty.1-3 We
0 }' i3 C0 x# N. Mreport a 16-month-old boy who presented with the; b1 P/ \1 U3 }9 ]5 d% S5 e* G
enlargement of the phallus and pubic hair develop-
$ R  E) j0 Y4 P8 M& ament without testicular enlargement, which was due, l6 B0 `: W  ]3 j* l& r, k
to the unintentional exposure to androgen gel used by6 @" T9 E# b+ L: k3 C3 X. K
the father. The family initially concealed this infor-& p+ L% F$ M5 w  M' V) ?
mation, resulting in an extensive work-up for this
' t) i3 f/ g6 O5 i: @) |0 Wchild. Given the widespread and easy availability of  W: B) G4 J! U" y
testosterone gel and cream, we believe this is proba-# B+ ~8 X! W$ z  t; F6 F" L
bly more common than the rare case report in the, e7 |. ~# x0 h* ]9 g8 U3 F
literature.4: h8 {( D. }6 l$ o
Patient Report3 D# Q& t$ t7 J6 w% ^2 x
A 16-month-old white child was referred to the
# q0 c9 |7 k+ m* G2 [6 Dendocrine clinic by his pediatrician with the concern
- _, T2 S, U% j  B/ f4 h- W$ ~of early sexual development. His mother noticed
2 r1 G" g! D2 E6 J3 A( v. Q% n0 ]& ~light colored pubic hair development when he was* l6 t8 [- `2 v# G$ f' n4 S& a8 a
From the 1Division of Pediatric Endocrinology, 2University of, B, C6 N' ?& z0 Z: V
South Alabama Medical Center, Mobile, Alabama.
: P. d  t5 |/ G+ FAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 F8 ^& L$ l5 a
Professor of Pediatrics, University of South Alabama, College of' m) L( N4 \/ z7 j  I, h4 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- \. a$ t$ F& k  A2 x8 ^2 p* C* x" fe-mail: [email protected].
8 f6 L9 ~5 n- v. c! g! Babout 6 to 7 months old, which progressively became
- n( n0 D- C  ydarker. She was also concerned about the enlarge-) l* B. Q6 m/ G' W
ment of his penis and frequent erections. The child
) V/ R, q0 h' bwas the product of a full-term normal delivery, with
- t9 K- K/ r6 i* c7 q; P% }a birth weight of 7 lb 14 oz, and birth length of( \) d& ~8 i  i  d2 ?* H: h
20 inches. He was breast-fed throughout the first year
( U+ ]9 j# ?  Wof life and was still receiving breast milk along with
% h: u0 N7 j& F; \2 `/ J/ Qsolid food. He had no hospitalizations or surgery,
0 _/ C1 D5 E! S5 C4 L2 L* W0 {and his psychosocial and psychomotor development" H' S1 M# @3 |7 u/ W0 o
was age appropriate.
/ t: I* c) x3 g. @2 }5 WThe family history was remarkable for the father,2 c/ D+ k; I; u! |* g. }6 |, \
who was diagnosed with hypothyroidism at age 16,
8 {: g6 B$ Y4 N0 gwhich was treated with thyroxine. The father’s5 F* [+ E; ?! e( R8 N8 J
height was 6 feet, and he went through a somewhat6 I8 R% w8 ?* I
early puberty and had stopped growing by age 14.& }: E7 R" a3 U& a4 l4 _
The father denied taking any other medication. The
1 P6 G6 I! t9 M5 nchild’s mother was in good health. Her menarche
2 C/ K& ^, D$ C! E. ~6 [( E* Nwas at 11 years of age, and her height was at 5 feet* ?! l9 A/ m) v- b' `' |  `
5 inches. There was no other family history of pre-" Y7 x4 N4 g) m( ?+ m
cocious sexual development in the first-degree rela-
7 @" a) O7 I$ \' M' g' C: k3 d( rtives. There were no siblings.
/ d  M' g/ L7 Q3 APhysical Examination* m! a; W7 W  ~+ p' G, O
The physical examination revealed a very active,5 n  n$ F0 {8 K
playful, and healthy boy. The vital signs documented
, _: @, R5 M% X1 w. B0 q: da blood pressure of 85/50 mm Hg, his length was2 \0 B' V; f# U7 s2 |5 Y( b9 \
90 cm (>97th percentile), and his weight was 14.4 kg$ H& b2 Y1 _) `7 ?! c
(also >97th percentile). The observed yearly growth
4 G4 Z4 p- {# V( j( U9 v% Kvelocity was 30 cm (12 inches). The examination of
$ A$ d, R) {( K* ithe neck revealed no thyroid enlargement.
, L2 y* W6 p9 r; F1 J5 UThe genitourinary examination was remarkable for
# f/ l* z1 x: [enlargement of the penis, with a stretched length of
1 U! V5 f! h3 o8 cm and a width of 2 cm. The glans penis was very well# K- ^* N# M" N- c) l3 [$ X
developed. The pubic hair was Tanner II, mostly around
. \( V3 F' h1 r9 `# ?/ l540
! b2 w6 Y. c+ r2 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 \) S5 j" P4 [* K( K0 g( ?$ ]the base of the phallus and was dark and curled. The
- a) V% b% }8 ^6 E0 jtesticular volume was prepubertal at 2 mL each.* Y( L9 l* A# Y  X- h3 N0 w! w
The skin was moist and smooth and somewhat/ G; _0 N$ V8 G/ F9 A
oily. No axillary hair was noted. There were no$ ~* I) r6 D7 ?0 L) A) W' Q/ S) Z- F
abnormal skin pigmentations or café-au-lait spots.
: ?2 i% O6 q& m3 r8 s) M4 ]Neurologic evaluation showed deep tendon reflex 2+
, X6 h$ q' ?" Ubilateral and symmetrical. There was no suggestion
3 a" b( M+ Y5 \( p. |: h) |% Sof papilledema.
0 d2 T- n( k3 X- q; M0 M! ZLaboratory Evaluation
* o& E; p/ f7 H, m7 _. t! m2 `The bone age was consistent with 28 months by
5 \& R, X/ u0 ^  p  {$ A* X5 n5 L% Busing the standard of Greulich and Pyle at a chrono-
6 Y3 B" {$ s: ^, H7 c; ^+ X, a9 zlogic age of 16 months (advanced).5 Chromosomal& m: N( f- B  [/ z# y3 e# Z* j
karyotype was 46XY. The thyroid function test$ S6 \5 r7 v0 q+ b" o, W+ s/ W
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( O1 I3 _/ X; t2 `0 ~4 ^
lating hormone level was 1.3 µIU/mL (both normal).
( Z3 R: g9 }3 b( x# W. j8 D  PThe concentrations of serum electrolytes, blood
; r7 S# k0 g3 z* W8 f0 W$ {urea nitrogen, creatinine, and calcium all were
6 ]" c- x; D+ n, J. J$ g7 _  fwithin normal range for his age. The concentration6 M8 e0 l7 p5 f& Z' F/ g* l
of serum 17-hydroxyprogesterone was 16 ng/dL
# l$ c1 A5 g/ V0 ~4 {5 t(normal, 3 to 90 ng/dL), androstenedione was 205 n8 a+ a' C5 s- g' w; u8 i
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, {7 Q5 K3 z% H  x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 z) L$ A- o9 L: @2 H1 d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 I3 P. [' L) ^) @; U4 F, f49ng/dL), 11-desoxycortisol (specific compound S)
9 q0 S9 V; w% D2 k7 Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! |8 V6 v+ B  F2 V& ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  ?, D* u+ _6 B6 l( n; X+ Gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 r2 ~0 A9 E5 j/ q* n8 Y7 j
and β-human chorionic gonadotropin was less than
8 p! O& z; I5 V# s5 mIU/mL (normal <5 mIU/mL). Serum follicular
; u& C9 }5 d, qstimulating hormone and leuteinizing hormone
: }( e* q7 s3 b: F) O5 }" kconcentrations were less than 0.05 mIU/mL
! f" P% P! Z8 Y! [- t$ p4 v(prepubertal).) u' L6 N6 Q- u$ @! n# j+ `
The parents were notified about the laboratory# L5 P& x8 C6 h5 s
results and were informed that all of the tests were
7 M5 H# E( i$ o* h5 V: `normal except the testosterone level was high. The( n5 [, W- S1 F, U
follow-up visit was arranged within a few weeks to
1 V5 S6 E' W. T: k( @obtain testicular and abdominal sonograms; how-1 r/ T7 G/ s* ^- ], T7 y) m
ever, the family did not return for 4 months.
6 Z: \! r9 v! I5 v4 g8 c6 MPhysical examination at this time revealed that the2 y+ G  H9 `6 ^" ?) R6 S
child had grown 2.5 cm in 4 months and had gained
  o( j/ Y2 u, e8 P# }3 s2 kg of weight. Physical examination remained
2 e7 Z  z8 u' m+ `) @1 ounchanged. Surprisingly, the pubic hair almost com-
- N9 k: ?  [2 D5 n! \pletely disappeared except for a few vellous hairs at# |- S' E, J" L9 e; \
the base of the phallus. Testicular volume was still 2" q- N1 W6 j/ r7 ^
mL, and the size of the penis remained unchanged.
( w. k/ z7 |) Q( gThe mother also said that the boy was no longer hav-5 `2 Y! p2 J+ j' S) h# G
ing frequent erections.9 j& i7 I! ~! L+ O! q
Both parents were again questioned about use of
  d  O" C9 [; cany ointment/creams that they may have applied to- r0 O! a# B$ U0 O& J
the child’s skin. This time the father admitted the
$ T$ d3 K7 R( f$ ]. rTopical Testosterone Exposure / Bhowmick et al 5415 T7 i8 I- `) k* s
use of testosterone gel twice daily that he was apply-
* h6 l% T. K( u+ [0 E8 |: S3 ^ing over his own shoulders, chest, and back area for
1 W' d# {& Z" Ba year. The father also revealed he was embarrassed
# L6 n( r2 s# k0 ~+ lto disclose that he was using a testosterone gel pre-, F- ~5 r! q4 \- r! l8 x7 G
scribed by his family physician for decreased libido
1 i6 G! w: H. ~$ k4 isecondary to depression.
) y0 g7 N* ?! C2 r4 s6 @) RThe child slept in the same bed with parents.
. g: y' T$ N' q! |% B" ]5 z! CThe father would hug the baby and hold him on his
) F4 c7 b. Y9 i0 ?; X# Ochest for a considerable period of time, causing sig-; ^- X' A& O3 z7 v3 h+ T7 c
nificant bare skin contact between baby and father.2 H% k# m% P% m1 t# i* E
The father also admitted that after the phone call,6 n& Q: T+ m4 a* @, l& [& ]/ n
when he learned the testosterone level in the baby& ]$ M9 _9 f% J8 D# z2 ^9 z2 l
was high, he then read the product information
% g% N3 M3 C* u0 i/ r& Gpacket and concluded that it was most likely the rea-/ s( n) O4 j% n
son for the child’s virilization. At that time, they6 o3 u/ X# Q2 T8 H$ |; i0 g3 x
decided to put the baby in a separate bed, and the
& r1 O" `9 D" U, K, |: v2 hfather was not hugging him with bare skin and had
4 n/ s2 C, N8 v) {& K5 U) G% `been using protective clothing. A repeat testosterone3 f& e# s; ~. c% C7 t6 ?
test was ordered, but the family did not go to the3 K0 E* F) k- n. N5 ~- N8 I
laboratory to obtain the test.
, c8 }) g$ r5 v! UDiscussion+ n7 m0 C) W* z) P. R
Precocious puberty in boys is defined as secondary8 W6 t- i4 j7 m  W3 n8 i% p' ?
sexual development before 9 years of age.1,47 @8 g. Z8 ?, ?2 J- I. W1 r7 I
Precocious puberty is termed as central (true) when0 c; y6 ?! k4 l
it is caused by the premature activation of hypo-- v# j% e6 Q4 A$ l2 N  I
thalamic pituitary gonadal axis. CPP is more com-
9 B% y4 _8 O5 h6 nmon in girls than in boys.1,3 Most boys with CPP
- m  G! u5 B' w7 l- e3 C' ]may have a central nervous system lesion that is( q8 [% R) [# [
responsible for the early activation of the hypothal-
; q' B: t9 d8 v9 O7 ?$ h+ K- ^amic pituitary gonadal axis.1-3 Thus, greater empha-; r$ d) X, L! H8 N# s
sis has been given to neuroradiologic imaging in5 z, ]# v) N- W
boys with precocious puberty. In addition to viril-
- p* v$ ~' w! Z" Dization, the clinical hallmark of CPP is the symmet-% {" W% k* t* f+ n
rical testicular growth secondary to stimulation by) X7 V" A. i1 V- [$ r- e
gonadotropins.1,3  o6 G. u4 y) c8 y  S
Gonadotropin-independent peripheral preco-
% z9 G! n, N( R. c% F; |cious puberty in boys also results from inappropriate9 i1 w+ D; N# ]; I, N
androgenic stimulation from either endogenous or9 t/ x4 K! Q* r. o  x: m6 i6 q
exogenous sources, nonpituitary gonadotropin stim-
3 w! u' j$ X- g0 x& _% ?ulation, and rare activating mutations.3 Virilizing' N  {; v1 X1 M6 T/ o8 ]% l
congenital adrenal hyperplasia producing excessive
# {, z2 U0 K3 k, ]+ z* B2 Xadrenal androgens is a common cause of precocious
- b/ u& x% ~2 g2 Gpuberty in boys.3,4
+ u! p4 Z5 ?( d6 k% ^The most common form of congenital adrenal
) \8 b, Y$ L! ^% \; h! ~/ i' W" \hyperplasia is the 21-hydroxylase enzyme deficiency.
7 F! B2 N; F+ t8 {* @8 x! K6 RThe 11-β hydroxylase deficiency may also result in* J: r1 V' w9 \$ Z- D) i1 @7 S
excessive adrenal androgen production, and rarely,
. Z8 f; J, K) z% t% x  v: L: s0 Man adrenal tumor may also cause adrenal androgen
! ]; o; s# X, u/ M8 @) R5 ~* dexcess.1,3
% \# Q- t9 m- p% W! ]3 V7 Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ s9 K: z, u6 W4 E/ k! p; ?3 R( W
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 }/ h- C" v" c9 |
A unique entity of male-limited gonadotropin-, {) A( Y5 J3 [
independent precocious puberty, which is also known
. O) K6 {. ~, {% j, s0 Bas testotoxicosis, may cause precocious puberty at a
1 T' L* G' h4 E$ ~0 overy young age. The physical findings in these boys3 ^2 f* M# B8 c8 p5 L0 i* ?
with this disorder are full pubertal development,8 I7 C5 ?2 I: a+ u3 E
including bilateral testicular growth, similar to boys
- F2 ?3 e% f  B) ~. r% O* |+ U  gwith CPP. The gonadotropin levels in this disorder- h/ ~$ S4 x9 ~3 t) N
are suppressed to prepubertal levels and do not show
4 C9 i2 s" `6 J1 Cpubertal response of gonadotropin after gonadotropin-
2 B. J* O" {: F, areleasing hormone stimulation. This is a sex-linked) L% _2 p8 A% m5 ?6 y, I9 _& ^
autosomal dominant disorder that affects only% Y& e  {  I0 j5 M! U3 u4 J
males; therefore, other male members of the family$ W! ^. Z4 c3 h* U9 _0 \+ p
may have similar precocious puberty.3
! m6 E% X' w. S& P7 V3 b7 i8 HIn our patient, physical examination was incon-7 H! {. D4 H# m- \/ `, s: X
sistent with true precocious puberty since his testi-' e  T2 P+ l/ u$ e2 `6 Z  u
cles were prepubertal in size. However, testotoxicosis
( ^' p# Q/ `0 M- b- _. t1 ?was in the differential diagnosis because his father& d$ S  ^% C1 z2 P5 U" |! z6 {" z
started puberty somewhat early, and occasionally,6 h1 |/ ?' J' O
testicular enlargement is not that evident in the
/ ?' N) t# p, w! i3 l; Wbeginning of this process.1 In the absence of a neg-
; T% f1 u- I  G( v- Q" Mative initial history of androgen exposure, our
& c0 s! j) I' C" W- R  N% Vbiggest concern was virilizing adrenal hyperplasia,2 z( ^' s: e1 r' `9 u, l8 z/ G: O
either 21-hydroxylase deficiency or 11-β hydroxylase
* h. Y; T" J/ o+ E9 T& c! X- N- Ideficiency. Those diagnoses were excluded by find-2 Z4 w! t& j8 p9 j2 u- F# b
ing the normal level of adrenal steroids.
& g9 A; L% d" t4 O9 B: ]7 h  aThe diagnosis of exogenous androgens was strongly* C- O: n% ~5 {3 }: y! U
suspected in a follow-up visit after 4 months because2 ]/ \  W1 |4 Z' r
the physical examination revealed the complete disap-
4 M1 d* ]2 x1 S3 C: gpearance of pubic hair, normal growth velocity, and
# M: `& b/ ?# {5 j) mdecreased erections. The father admitted using a testos-! J% j% {9 x8 I3 E8 f; n& L
terone gel, which he concealed at first visit. He was
! z5 e" C* @% r: Z, v9 Z/ vusing it rather frequently, twice a day. The Physicians’0 {! Z3 f) Y; D1 m3 m9 A5 `
Desk Reference, or package insert of this product, gel or
; Y, z, K4 @/ h8 T; jcream, cautions about dermal testosterone transfer to
# |7 X3 D  j( ^6 l, u% P5 k( ^4 Wunprotected females through direct skin exposure.
5 G& _' n8 Y! G6 a, @, vSerum testosterone level was found to be 2 times the, ]4 O$ _8 L% k, X4 f
baseline value in those females who were exposed to4 j# H7 G0 L% o" ^' b% n3 u
even 15 minutes of direct skin contact with their male& ~8 y4 V/ v+ U
partners.6 However, when a shirt covered the applica-
) |) t  n& {1 l0 ~0 D& \% M" F9 Jtion site, this testosterone transfer was prevented.) X* v6 n5 ]2 u) M7 v/ {' h7 G* ^
Our patient’s testosterone level was 60 ng/mL,# j/ ^4 b' I5 e
which was clearly high. Some studies suggest that
" L" o( m$ p, J, w# o; c; sdermal conversion of testosterone to dihydrotestos-
. Q7 X+ Y( A" g" mterone, which is a more potent metabolite, is more
+ B3 [; \& }0 t/ U3 J: ractive in young children exposed to testosterone
3 f, ^- `5 p: f! i2 b& bexogenously7; however, we did not measure a dihy-& f$ g) Z8 F7 A: t6 [9 @
drotestosterone level in our patient. In addition to" D- m& ]6 g9 r) g( |7 J/ n: t
virilization, exposure to exogenous testosterone in5 G# h$ ]2 `5 U4 H
children results in an increase in growth velocity and
8 q1 T5 @+ h" fadvanced bone age, as seen in our patient.$ L! E: G% o2 `4 J# C6 F
The long-term effect of androgen exposure during
4 v7 v: t  j0 R/ z4 i% O* K! L/ jearly childhood on pubertal development and final
: m8 Q3 v8 ]' I' [, `adult height are not fully known and always remain! ^: B7 k# O" T
a concern. Children treated with short-term testos-
# H" d2 Y2 ^. a$ r" T9 }terone injection or topical androgen may exhibit some. Q8 N; B; G- o5 V6 W4 T6 i
acceleration of the skeletal maturation; however, after' ]' h% R& e) i+ b4 b
cessation of treatment, the rate of bone maturation# d$ Y9 U- o2 X0 U; H
decelerates and gradually returns to normal.8,93 n0 G; E* k/ r4 p9 S4 r5 f
There are conflicting reports and controversy5 J$ M' |# j& k/ @
over the effect of early androgen exposure on adult% w% f1 b2 B. q  b4 M, i
penile length.10,11 Some reports suggest subnormal
: n  W) z# A% s; S. \( Tadult penile length, apparently because of downreg-  A# a. c& t" A  m  ~/ w
ulation of androgen receptor number.10,12 However,
8 X% @1 H4 @: d  OSutherland et al13 did not find a correlation between
; b9 [8 S6 b( {" p3 M7 w: Ichildhood testosterone exposure and reduced adult5 L# L" k0 p+ x6 S. H& `
penile length in clinical studies.
6 J' f' ?. [. y8 ]Nonetheless, we do not believe our patient is
" J2 G1 A1 b4 b& S% n6 [/ h% ^4 xgoing to experience any of the untoward effects from
. ~8 c0 l6 {  x: |% t  Xtestosterone exposure as mentioned earlier because
5 F5 s2 a3 W% R7 T$ O) L9 cthe exposure was not for a prolonged period of time.4 c( P" Y4 S0 `, F
Although the bone age was advanced at the time of0 @, A: s$ i- M& d+ O0 v
diagnosis, the child had a normal growth velocity at
* U$ `% M# r& M& @& lthe follow-up visit. It is hoped that his final adult+ H" V+ p( n9 D$ F3 l2 V. H) u
height will not be affected.' g( H5 M3 p. l  D: R' A5 [
Although rarely reported, the widespread avail-4 I# n9 K. [9 m9 U6 \4 R
ability of androgen products in our society may
5 z) ?5 s# Z& a; d; b/ x" hindeed cause more virilization in male or female' E, N& y" n9 b. D2 L, E
children than one would realize. Exposure to andro-
. q  Y$ T. C) C8 H! @gen products must be considered and specific ques-
3 {& _6 x( Z, F9 e& {+ ationing about the use of a testosterone product or
% Z$ R  }- [- Ggel should be asked of the family members during* X+ D3 ^0 W3 W
the evaluation of any children who present with vir-# [. k/ x& G4 ?  K( L, M& Y% [
ilization or peripheral precocious puberty. The diag-
% h) u+ u) X6 Y8 r. N! C7 qnosis can be established by just a few tests and by8 @) m# b4 ]+ Z1 H! p, b
appropriate history. The inability to obtain such a( ^$ W5 M+ V  H5 a0 R5 @
history, or failure to ask the specific questions, may7 s3 ^+ W% ?6 w) U& G
result in extensive, unnecessary, and expensive$ G+ k6 n7 k& Q+ f' V
investigation. The primary care physician should be, C9 p5 {3 i/ \$ q# b  M" T
aware of this fact, because most of these children& b" i( R8 q/ Z" ^
may initially present in their practice. The Physicians’
. d& U' O' \  F: l( x- \Desk Reference and package insert should also put a" ]& G- V! f& Y$ P; g  k
warning about the virilizing effect on a male or3 B5 G' v: \4 [. G
female child who might come in contact with some-8 f' n  }( J4 q; ]
one using any of these products.
# V! S+ Q5 B2 z* `7 {0 q  b( l" W; bReferences8 i; U8 b$ L4 R2 F! C6 ?1 I* N
1. Styne DM. The testes: disorder of sexual differentiation
8 V7 ?& ]) V2 ?. ?; O% `3 Xand puberty in the male. In: Sperling MA, ed. Pediatric
, s$ z2 e, }! W$ z% }4 pEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 o9 F/ v0 R& ]
2002: 565-628.
- w5 P' |) P0 p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 t7 a8 G+ d. j: o$ R" F' E  P5 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
1 I' X! W, S; f+ j4 xBoy Induced by Indirect Topical
# S3 J/ U1 Z, {( zExposure to Testosterone) L$ c/ Z. Z' L# _/ J. G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. E( f8 C  Z; B
and Kenneth R. Rettig, MD1+ Z. A8 v, P( M* Z# w
Clinical Pediatrics: k& Y7 }, @1 E( W
Volume 46 Number 63 \" Y2 S& @9 Z4 V9 U+ s
July 2007 540-543  ?4 [; U3 ~7 s& S4 ^# s# l
© 2007 Sage Publications) |! x9 C$ Q5 L( e- V6 u
10.1177/0009922806296651! y4 g' K( ?) L8 _8 e7 k
http://clp.sagepub.com$ |; S/ t4 D% }, J) E6 s/ H4 }/ O
hosted at. d, q9 a  q2 J& \' V) P1 v
http://online.sagepub.com
" P0 Z6 r: c* lPrecocious puberty in boys, central or peripheral,7 p; q8 O1 y+ ~+ Y% v  W
is a significant concern for physicians. Central
' f* L  g- X0 U1 E9 ?5 Vprecocious puberty (CPP), which is mediated9 _* G( O$ A% h6 h: |9 g6 g
through the hypothalamic pituitary gonadal axis, has2 x; n2 k' b' K. _6 a5 ]; t9 O) V
a higher incidence of organic central nervous system
  k1 n3 r9 D  Zlesions in boys.1,2 Virilization in boys, as manifested" P, ~, Q& p! H) z  T- k& e" D6 [
by enlargement of the penis, development of pubic
% M% S" q# a. X6 F% Xhair, and facial acne without enlargement of testi-
# v# M% @, |" A1 m2 ]6 xcles, suggests peripheral or pseudopuberty.1-3 We
2 [. Q$ h& Y+ g5 wreport a 16-month-old boy who presented with the3 e. `/ a2 k5 o4 |9 I- W0 S. \% p0 q
enlargement of the phallus and pubic hair develop-
, r" L, T+ M3 Z$ ~; lment without testicular enlargement, which was due
3 h; v6 c8 A! K# B! A2 Gto the unintentional exposure to androgen gel used by
& [  B$ M# j" L7 ^. g/ D* sthe father. The family initially concealed this infor-5 m# w# |$ A: y* B" l
mation, resulting in an extensive work-up for this2 o3 U4 m. g8 G
child. Given the widespread and easy availability of: j6 s  t( V- \2 I1 o
testosterone gel and cream, we believe this is proba-
" p. M+ u, Z" Fbly more common than the rare case report in the- c2 v! g4 c- c. p( ?+ H- e  ?
literature.4
6 M7 `" n4 ^+ l1 d- bPatient Report
/ q2 x) r/ A( q9 d- v2 y: I# [+ JA 16-month-old white child was referred to the
( j! g3 O6 P9 M7 e8 Iendocrine clinic by his pediatrician with the concern
- ~# j; P- \, K5 }of early sexual development. His mother noticed) k) ]- g) g+ f4 i. [
light colored pubic hair development when he was3 N3 V5 q& u9 R' B
From the 1Division of Pediatric Endocrinology, 2University of
* n: Y) w8 v9 Z8 dSouth Alabama Medical Center, Mobile, Alabama.9 Z9 _' ~: H' u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 J- ~. D4 y- ~: F$ i" z+ fProfessor of Pediatrics, University of South Alabama, College of7 U, z2 n; j# M! `. `; V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- Y8 h( F- A3 d+ P2 h
e-mail: [email protected].
7 e9 g9 j) ]* y7 Eabout 6 to 7 months old, which progressively became2 e# v0 I# x7 c; l
darker. She was also concerned about the enlarge-
7 P. G* F. n2 C: Yment of his penis and frequent erections. The child% T0 J% \& n7 v+ C/ S; ]/ M
was the product of a full-term normal delivery, with
1 `' ^+ n2 g9 xa birth weight of 7 lb 14 oz, and birth length of
' ^0 \  j/ }, F; ^2 `& T20 inches. He was breast-fed throughout the first year
4 ~+ h+ j/ L) c7 f6 L& kof life and was still receiving breast milk along with
& _. a2 R* n* N& j7 L- O1 wsolid food. He had no hospitalizations or surgery,4 a( b3 w- o! A1 v- ?
and his psychosocial and psychomotor development$ [" ~3 X2 G. Y+ w# T
was age appropriate.
6 }. [) ]+ U6 w. ?( J7 T% c- K3 rThe family history was remarkable for the father,8 h; L) r5 I5 C& a1 D
who was diagnosed with hypothyroidism at age 16,+ f6 d: D5 ]+ O0 k
which was treated with thyroxine. The father’s
, ?* U; F: u8 q8 T9 nheight was 6 feet, and he went through a somewhat
" K3 S: ^$ J/ T+ j8 o9 searly puberty and had stopped growing by age 14.# W8 _1 U8 H- J* g
The father denied taking any other medication. The: l2 q2 ?6 ~5 `
child’s mother was in good health. Her menarche
% j" H. w9 v. q9 ~1 F/ \+ h% @2 J) [was at 11 years of age, and her height was at 5 feet6 l1 A) O# V1 d# f' \
5 inches. There was no other family history of pre-) |, ^% j0 O0 }, e$ c
cocious sexual development in the first-degree rela-2 S" t" E1 g" g" ~
tives. There were no siblings.
8 m9 |6 N+ T: _8 `* ZPhysical Examination
7 D. _( A0 j0 N+ E* R% F% YThe physical examination revealed a very active,
% i+ E+ w5 Z3 L! v9 \! w! s# x* Cplayful, and healthy boy. The vital signs documented5 ?- J3 w) a" l, _; g! ^
a blood pressure of 85/50 mm Hg, his length was
  K( m( j2 l3 {3 @* [% T90 cm (>97th percentile), and his weight was 14.4 kg
- i) [  r3 q8 b  w) S(also >97th percentile). The observed yearly growth
$ `% v* s! R! f/ hvelocity was 30 cm (12 inches). The examination of
% J) D+ m9 [9 _% @. Hthe neck revealed no thyroid enlargement." [' E+ p4 M0 e1 U; {2 y) c, V/ H
The genitourinary examination was remarkable for& E( v# S5 \( P, ]
enlargement of the penis, with a stretched length of
( Y' B/ P2 {7 B7 H' ~/ m7 x$ Z8 cm and a width of 2 cm. The glans penis was very well9 N+ R$ j; p) }  N! A4 n* r5 E
developed. The pubic hair was Tanner II, mostly around# S3 O* J+ A  D8 H. K9 S1 s
540% O; e! h; c/ D+ F0 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 R* ]9 O, o5 ?% z0 Vthe base of the phallus and was dark and curled. The- x+ \) z! e5 a7 H$ h$ N
testicular volume was prepubertal at 2 mL each.
* V9 `  ~) D* F" k& \The skin was moist and smooth and somewhat' u. r4 P7 a' {7 o2 L
oily. No axillary hair was noted. There were no
3 Q' r! Z; I& u0 `$ C* Jabnormal skin pigmentations or café-au-lait spots.8 j; m1 w5 o0 J' D- X" ]
Neurologic evaluation showed deep tendon reflex 2+. c' w( A1 U  U& c# r7 b3 g- i
bilateral and symmetrical. There was no suggestion
' s: v) G; ^! R+ F; m. b1 Dof papilledema.: |# `8 h) i8 |' }5 f
Laboratory Evaluation
  Y' ~/ @1 z% q2 l  OThe bone age was consistent with 28 months by1 v) _" q9 ], d6 d9 T5 s5 a3 A
using the standard of Greulich and Pyle at a chrono-
; i6 m5 F: [3 G# _logic age of 16 months (advanced).5 Chromosomal5 [! g' Z/ U+ A+ H
karyotype was 46XY. The thyroid function test
  B' a6 I# ?5 _2 t8 i+ x% b9 l' r5 eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
& ?0 m( A$ m0 x7 Y5 t3 ylating hormone level was 1.3 µIU/mL (both normal).' c4 T& c0 }4 U: N
The concentrations of serum electrolytes, blood
# L4 T0 U( u, T; ]% ^" \9 l" turea nitrogen, creatinine, and calcium all were
- j7 V3 H! J; D0 z0 S+ [0 _0 v! Mwithin normal range for his age. The concentration6 o1 w! Z8 F# M! F- ?" b6 J* {7 Y
of serum 17-hydroxyprogesterone was 16 ng/dL
  c2 _. ?6 v; r5 L9 q% B(normal, 3 to 90 ng/dL), androstenedione was 209 y1 H+ `# n& O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: ]) s9 s! L  R0 I7 E" |+ D+ Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 b' S! j! O& K. P. S/ y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& g% G$ E7 N! f( S2 s5 n7 X8 D6 Y
49ng/dL), 11-desoxycortisol (specific compound S)0 d  t" z1 T& G4 i% |4 O% w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% ~4 O" U8 X3 Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: M7 q2 p+ Y* c# Y4 stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ Z2 U7 O( F* l% r
and β-human chorionic gonadotropin was less than5 J' s/ c2 V' O8 X5 j1 C. M+ e
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% @2 @/ o+ {8 }( J5 |& ?# b) nstimulating hormone and leuteinizing hormone
5 g/ }. P% Y/ Xconcentrations were less than 0.05 mIU/mL
* s6 G8 I" _' M2 T(prepubertal).8 `% q6 I% Q0 s3 D6 g2 @
The parents were notified about the laboratory
0 t9 F7 L. w9 ]$ T& y# Mresults and were informed that all of the tests were
+ Z3 _% q# t. e6 mnormal except the testosterone level was high. The/ r8 w0 ^. N! M1 y1 U: {+ X
follow-up visit was arranged within a few weeks to! e+ i0 w; h+ w9 w
obtain testicular and abdominal sonograms; how-
' v' X& f/ Z3 U! \# Fever, the family did not return for 4 months.( G3 K4 ^9 ], _% ^/ k
Physical examination at this time revealed that the9 b' e! J' {4 X' f
child had grown 2.5 cm in 4 months and had gained7 H2 D+ A" Y* q- L
2 kg of weight. Physical examination remained8 [1 x4 {0 i& D' C6 z
unchanged. Surprisingly, the pubic hair almost com-
( }& d' x. G' d/ _2 Spletely disappeared except for a few vellous hairs at1 p4 h! @5 U* m
the base of the phallus. Testicular volume was still 27 g0 _, l' Y" v3 m! W. b+ Q
mL, and the size of the penis remained unchanged.9 |/ p, E3 N7 {% |
The mother also said that the boy was no longer hav-
( g" S7 H4 P7 A) ^ing frequent erections.
8 Q* R( n/ [. P# a3 I% h: Y) z( zBoth parents were again questioned about use of
* N2 J4 ^3 Z8 O- q1 A+ E0 |any ointment/creams that they may have applied to
3 G. ^+ ^, T, T4 S! fthe child’s skin. This time the father admitted the
: _3 I5 m) h4 h3 zTopical Testosterone Exposure / Bhowmick et al 541" c3 m3 a& A' \2 q
use of testosterone gel twice daily that he was apply-* c5 x1 r! v. S! Z. ]2 s6 |2 Z
ing over his own shoulders, chest, and back area for
# f5 E+ Y) X5 i6 ?3 Ba year. The father also revealed he was embarrassed
7 B$ C9 i4 N! wto disclose that he was using a testosterone gel pre-
7 ]: f4 p8 U1 q) U  y% cscribed by his family physician for decreased libido
5 J  J8 G0 i8 F+ Wsecondary to depression.
  I, l9 o5 S6 V! Q4 y; ]+ zThe child slept in the same bed with parents.( N' ~8 g. M/ H: F. K
The father would hug the baby and hold him on his
2 s+ L& Q' {6 {. y3 V' p% Xchest for a considerable period of time, causing sig-
* {) J6 r! A0 X0 S* T& z) U7 Mnificant bare skin contact between baby and father.% l1 T3 M& T$ }' F8 _3 k
The father also admitted that after the phone call,
4 p) V' N4 ~8 N% vwhen he learned the testosterone level in the baby/ ^9 s( K/ k. l* m, }+ g
was high, he then read the product information
! l# h$ e5 K2 R- m  s( {, y9 G- ^' cpacket and concluded that it was most likely the rea-# X8 t* x1 i# E+ V) }
son for the child’s virilization. At that time, they
! \* f/ \: {% x( v, _* X' Qdecided to put the baby in a separate bed, and the  c9 [, n1 @& c! s
father was not hugging him with bare skin and had! q3 q* `. r/ E: T( o5 D6 f
been using protective clothing. A repeat testosterone
1 C( `) b, _4 c/ I, otest was ordered, but the family did not go to the
3 d: N- S* F2 _# y8 V$ ~laboratory to obtain the test.4 I' `- t0 o8 |, s
Discussion9 E% t2 ^7 B( p  U
Precocious puberty in boys is defined as secondary% U3 B5 D) [% b* a  n
sexual development before 9 years of age.1,4
" m0 p) X# A& Q- VPrecocious puberty is termed as central (true) when
$ X/ M9 X8 `. h- H6 J8 Sit is caused by the premature activation of hypo-
3 K# r6 J$ A2 v5 @- [1 R/ ethalamic pituitary gonadal axis. CPP is more com-3 Z' x" S4 d6 w0 R- `# b
mon in girls than in boys.1,3 Most boys with CPP; r! d8 E2 Y) Q( V' z7 R
may have a central nervous system lesion that is" C' c) f  g1 I5 a5 b
responsible for the early activation of the hypothal-
  M* i$ }2 S/ h- I+ G$ Lamic pituitary gonadal axis.1-3 Thus, greater empha-
# U# G4 T! _9 E! csis has been given to neuroradiologic imaging in
5 m! k& [) D% |boys with precocious puberty. In addition to viril-
7 p+ U, p. u2 {: m( Sization, the clinical hallmark of CPP is the symmet-
% U( M/ }+ M' |rical testicular growth secondary to stimulation by
! N9 o6 H: d2 s$ m/ \gonadotropins.1,3
& I0 s2 t5 b( K. h; WGonadotropin-independent peripheral preco-2 T' H+ H! E/ j1 E6 _6 E6 {
cious puberty in boys also results from inappropriate" a5 ^6 r7 W& D$ y* o
androgenic stimulation from either endogenous or
$ U9 i( w; E5 E  i2 G8 n" oexogenous sources, nonpituitary gonadotropin stim-# i, `/ n) x# R1 J% P
ulation, and rare activating mutations.3 Virilizing
6 F7 A1 t( g; a+ h. K8 xcongenital adrenal hyperplasia producing excessive. V6 J$ k; l$ U0 ~$ W
adrenal androgens is a common cause of precocious  c: P. p6 J) d+ k8 ]) P
puberty in boys.3,4: ]3 [# _8 I$ O0 D
The most common form of congenital adrenal, |5 q  z: [6 z1 @
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ c# r! a% |; _The 11-β hydroxylase deficiency may also result in. V, g) b2 {3 i. I$ y9 r
excessive adrenal androgen production, and rarely,% K! p) c7 l- l1 ?3 d# f
an adrenal tumor may also cause adrenal androgen* `; T5 l1 B" t, \" O# |. C
excess.1,3
; T# ?' k6 g9 s- ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 Q  x5 |- [: N: u  w2 _; d542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 z+ A' r: X; C4 `
A unique entity of male-limited gonadotropin-
9 s* }- R$ o: q) B" hindependent precocious puberty, which is also known' c5 o- o  @3 l' \
as testotoxicosis, may cause precocious puberty at a
, S# O1 G6 @" i+ L+ H/ ~( {" r" h2 U0 svery young age. The physical findings in these boys  I/ a% I. |3 O8 |0 J
with this disorder are full pubertal development,3 `! A- K  J- ]  m/ T, Q, ]$ |' w
including bilateral testicular growth, similar to boys. s& z* x5 E% s& Z
with CPP. The gonadotropin levels in this disorder
* A( ]3 w# r- u* care suppressed to prepubertal levels and do not show' A# N7 J- n5 M" B0 @; F+ f
pubertal response of gonadotropin after gonadotropin-
/ L  C+ B  Y5 B8 y5 x" Ireleasing hormone stimulation. This is a sex-linked1 y: [7 d7 q$ I4 N% B
autosomal dominant disorder that affects only6 G( w& _: b! D% m
males; therefore, other male members of the family2 K- l% ]) ?& G. B1 _. \& @2 D0 w
may have similar precocious puberty.36 @" L! g6 ^; ?' h% h" t8 h. l
In our patient, physical examination was incon-0 {  Y& {( p0 O+ b
sistent with true precocious puberty since his testi-
* l/ k1 z3 ]' M4 w( ]  @) ~" d, O$ Jcles were prepubertal in size. However, testotoxicosis
' }9 e, u, I" J% Q, O2 e! t& {  Swas in the differential diagnosis because his father8 Z1 `1 `. ^- N7 H# ?# q8 D6 k( |0 Y
started puberty somewhat early, and occasionally,
: [$ s, t4 N, D# w$ W  }9 ltesticular enlargement is not that evident in the
6 k6 G+ Y# l0 \& Q6 ?beginning of this process.1 In the absence of a neg-; X, `, ]& K* r- ~2 H
ative initial history of androgen exposure, our
3 T' @/ {/ A' y; r. \. Dbiggest concern was virilizing adrenal hyperplasia,
3 X) i5 _5 r; i' Teither 21-hydroxylase deficiency or 11-β hydroxylase
  ]' h3 Z. d- m) E) \& ?, c- B( Zdeficiency. Those diagnoses were excluded by find-3 y" u; d% \* f. K: G
ing the normal level of adrenal steroids.
$ D) g; f$ L5 y1 h! Y, ~The diagnosis of exogenous androgens was strongly
" I/ N4 ^9 H0 }3 ?5 G; O5 T3 |suspected in a follow-up visit after 4 months because6 a; M6 ]6 ?( F& D2 O. S  `
the physical examination revealed the complete disap-
  `( _6 `" `! _" F9 kpearance of pubic hair, normal growth velocity, and
# r4 y- ^2 ~9 [) u! ?decreased erections. The father admitted using a testos-  f" ?& O+ ?( N. m+ l$ L5 t+ z; I
terone gel, which he concealed at first visit. He was
2 X2 }1 U  ~4 N! ]; U* c6 i! ?! gusing it rather frequently, twice a day. The Physicians’
' c! s8 @- y! y6 h1 qDesk Reference, or package insert of this product, gel or
8 J; v2 k) O$ H- i- q% S( Hcream, cautions about dermal testosterone transfer to
, I* T3 Y' b+ l+ v7 Z" I; Bunprotected females through direct skin exposure.
. U5 h) {. U2 U7 v0 j$ Q; b* USerum testosterone level was found to be 2 times the
, C1 W" m/ @% ?. D2 Z3 n( xbaseline value in those females who were exposed to/ L4 ^+ Q+ H) s' G
even 15 minutes of direct skin contact with their male  O. q+ j! T( X4 t* K6 M+ h6 x# m/ Q
partners.6 However, when a shirt covered the applica-
% g; n8 c+ g6 ~7 n; s; h9 ution site, this testosterone transfer was prevented.
, ]% d) o$ Y: Z% f" g& C1 @# j" KOur patient’s testosterone level was 60 ng/mL,$ D$ h5 z' P4 o
which was clearly high. Some studies suggest that' Q& E; s* }) i7 p; ~
dermal conversion of testosterone to dihydrotestos-  [2 ]9 _3 b" g! z9 |7 Y, r0 v
terone, which is a more potent metabolite, is more
2 {, Y' h; M/ h. H* }: K' cactive in young children exposed to testosterone
, Z/ l* n4 |1 w' L* wexogenously7; however, we did not measure a dihy-, R4 p6 s2 s) V/ L
drotestosterone level in our patient. In addition to
  K$ D( @: [  ?1 Z% c% m& hvirilization, exposure to exogenous testosterone in$ d! k+ J6 @" k, _- l
children results in an increase in growth velocity and
6 m$ A/ _5 j% [( |1 f6 ladvanced bone age, as seen in our patient.
7 n8 E/ Y" T' u* T: \The long-term effect of androgen exposure during
/ D5 L% x. T- d0 c$ Q! P7 \early childhood on pubertal development and final  z  l! f9 F6 G0 @  j% W$ s
adult height are not fully known and always remain' \- E1 L; ^5 R$ k
a concern. Children treated with short-term testos-) q" D) \0 R& x! e3 t  I
terone injection or topical androgen may exhibit some
+ g( p- q' _  q# o, ~acceleration of the skeletal maturation; however, after0 n; v: P* A' y( r3 \
cessation of treatment, the rate of bone maturation
& ^! L4 c  C, c. W, ~; Edecelerates and gradually returns to normal.8,90 K  X+ }$ m& |5 y# q
There are conflicting reports and controversy
/ g: \2 @" m' c$ i4 c, ~over the effect of early androgen exposure on adult" C2 J, w. o6 E+ Q( Y% C
penile length.10,11 Some reports suggest subnormal
/ q; b/ V. b- |7 u. B! c* }7 I7 sadult penile length, apparently because of downreg-
' X' _( ?1 c) R5 q) ?3 ?  Y7 A1 bulation of androgen receptor number.10,12 However,/ f+ z. L) m: v  j: f
Sutherland et al13 did not find a correlation between4 n4 b, D) ]1 s- t
childhood testosterone exposure and reduced adult8 f- h/ S; w/ [' n$ ]* N0 _
penile length in clinical studies.
& T. X; o1 o+ K' j% dNonetheless, we do not believe our patient is3 d# J6 m7 R! v- N8 D, k0 F. B
going to experience any of the untoward effects from  M, a& h( ~# j" h: o" n, ^
testosterone exposure as mentioned earlier because9 E% \  \( j# ~: x+ _* a
the exposure was not for a prolonged period of time.
9 b- y4 R' B: _& [# V7 ^Although the bone age was advanced at the time of
, T; B1 R: y0 D0 Z7 q" f0 Adiagnosis, the child had a normal growth velocity at! j" h+ M4 e* \, @
the follow-up visit. It is hoped that his final adult
3 A* i0 s& `+ xheight will not be affected.( S* ?+ P2 |" Q
Although rarely reported, the widespread avail-
2 i! G8 k$ ?1 w! }ability of androgen products in our society may
% k; X) m8 Y- l0 a) w* C& q& e+ Q: dindeed cause more virilization in male or female; b( w' E- C& J/ Q1 H- s7 |
children than one would realize. Exposure to andro-6 V" x# K3 d  L; }
gen products must be considered and specific ques-" T+ K: j+ V/ E0 Q  l
tioning about the use of a testosterone product or- w9 t0 q' z( L3 i: u* W4 M6 K
gel should be asked of the family members during
! ], H9 v2 [8 n& ^2 Jthe evaluation of any children who present with vir-5 T/ j0 A3 \- G: ^
ilization or peripheral precocious puberty. The diag-
' T; Y- R# F' n7 u* mnosis can be established by just a few tests and by8 H5 s" E1 v/ _) m2 J
appropriate history. The inability to obtain such a% B' K4 j3 y; |( j* k
history, or failure to ask the specific questions, may" {. |3 k& r3 i: X) C# w. [
result in extensive, unnecessary, and expensive
: a' \  @: Y+ `6 \0 Cinvestigation. The primary care physician should be1 E" L) a& i* n% S8 _0 h/ h8 r" d! G1 Q
aware of this fact, because most of these children1 Y# i( Z: n4 F; i% f
may initially present in their practice. The Physicians’- @; H5 S1 y" S1 x7 t; o& a
Desk Reference and package insert should also put a  {, g( g1 N! g
warning about the virilizing effect on a male or, \& a! q5 x& V0 h" g
female child who might come in contact with some-
: F5 B" k) p* F# L) i4 t& done using any of these products.
0 f/ p$ \4 _- B+ A9 W0 d- k; wReferences$ J, I3 T! D1 t3 U3 ^$ l, ~
1. Styne DM. The testes: disorder of sexual differentiation
, [% x3 j; L! M4 i  B- y9 \0 h) nand puberty in the male. In: Sperling MA, ed. Pediatric
1 d3 R2 X. r5 yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 p9 F# q4 C4 m, s
2002: 565-628.
* c4 S( \* ~% K& U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' t% }( U( X( L8 b  G, o  Hpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

7 o, h' ^1 m1 k( E( O% _6 o2 ?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