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( G" G/ b' M' W5 n1 `; t
Boy Induced by Indirect Topical
7 o  C4 D' O) ^/ I$ oExposure to Testosterone4 o( E$ I0 C9 [2 r! `0 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 j* G9 {7 U5 Q) m0 G/ cand Kenneth R. Rettig, MD1& m4 h) B4 Z) D! m5 \  O/ I
Clinical Pediatrics
* o; V5 U- f, I, W7 i8 ZVolume 46 Number 63 @7 p1 H$ C( N0 d5 k, M
July 2007 540-5437 m6 @+ j, ?. }7 l
© 2007 Sage Publications
7 K; W2 e3 f/ e# j# u  R10.1177/0009922806296651
' ~0 w- e; u1 k2 ghttp://clp.sagepub.com/ i" x* s  X* y( a2 x" W( K/ ^3 O8 X
hosted at
) L! X+ S3 D1 G) Dhttp://online.sagepub.com. S* G6 ^/ |' [3 B
Precocious puberty in boys, central or peripheral,. T# t# N4 i: \2 p. \3 f  m
is a significant concern for physicians. Central1 c0 l; }8 J5 w3 ]2 S  Y
precocious puberty (CPP), which is mediated
' R3 d) f" i% W; ~, fthrough the hypothalamic pituitary gonadal axis, has* H4 @3 J* \$ P
a higher incidence of organic central nervous system
/ W: f# a# [" g6 K  r, M6 plesions in boys.1,2 Virilization in boys, as manifested
9 }1 A9 J3 ^8 T/ V  Y) Q; Yby enlargement of the penis, development of pubic
* }3 C% g7 \3 d) p1 g( hhair, and facial acne without enlargement of testi-
1 \: k0 F) L3 q6 z, k  N7 ~cles, suggests peripheral or pseudopuberty.1-3 We( ?" |) S9 @( o7 @3 W+ r
report a 16-month-old boy who presented with the
8 e/ }+ E) u4 h8 }( s- m, `& c. T2 lenlargement of the phallus and pubic hair develop-7 [0 R$ g( O; f9 X" ?$ l! y! }
ment without testicular enlargement, which was due
5 ~& o  [$ x( f' U. Wto the unintentional exposure to androgen gel used by
, O/ ~4 p7 a, O3 Kthe father. The family initially concealed this infor-
$ U, I) S1 X& _& u) Imation, resulting in an extensive work-up for this2 n' B! I: I, H- ]& q( A, W
child. Given the widespread and easy availability of
* k7 X. F5 }7 T% }testosterone gel and cream, we believe this is proba-$ ?; g, X* g( E9 L; {/ }1 C
bly more common than the rare case report in the+ c4 z2 u5 }6 Q7 |9 e8 O2 J
literature.4
3 U; Z. y2 W6 U8 P! VPatient Report/ ^; c% a' W* x- o
A 16-month-old white child was referred to the# G3 Y' u5 d8 I  @" V$ q* ~, a( u4 \' U
endocrine clinic by his pediatrician with the concern$ G. \% e& ^# H
of early sexual development. His mother noticed
/ r9 Z* ~# k8 T, h4 C9 M/ flight colored pubic hair development when he was5 h# M' u& q# Q3 Z* ^/ c. f4 M' B/ ]
From the 1Division of Pediatric Endocrinology, 2University of
+ k: H9 N6 B: g& I  SSouth Alabama Medical Center, Mobile, Alabama., _0 e$ K% H1 h1 Y+ |' o  g% W. N
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# n( ~0 m. ^4 `( Z, q; W) sProfessor of Pediatrics, University of South Alabama, College of9 Y' I/ b% D2 c% P" a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  f4 X/ J+ J+ i' ~. r4 d+ o" de-mail: [email protected].2 r9 C' j4 V6 h; d$ f
about 6 to 7 months old, which progressively became( Y8 K: x- i! C+ w6 |0 q( P
darker. She was also concerned about the enlarge-6 q4 q) D) \8 m6 c' y4 I! l
ment of his penis and frequent erections. The child
/ O' p* X8 O5 |$ K$ f/ L- ]was the product of a full-term normal delivery, with
; g* n3 ^0 q3 L( @: ja birth weight of 7 lb 14 oz, and birth length of
! k$ g* I* k" ~( P, i20 inches. He was breast-fed throughout the first year' Y: d- a. y& ~. V  r" z
of life and was still receiving breast milk along with1 A7 Z$ c  z1 A# q+ L7 {2 d
solid food. He had no hospitalizations or surgery,3 h# ]/ ^! a/ ?
and his psychosocial and psychomotor development
) j' U* f3 p' \+ R* e# Rwas age appropriate.4 B8 t9 `) v- P3 N
The family history was remarkable for the father,
7 y& x+ P' M4 w* ^2 o, `who was diagnosed with hypothyroidism at age 16,
0 ^. g6 f2 e$ V" }; ~which was treated with thyroxine. The father’s. y. {5 Z! t% @( b  l+ d6 m
height was 6 feet, and he went through a somewhat$ _1 K5 f, G& }. h6 N+ }2 c
early puberty and had stopped growing by age 14.
: ?. k3 C9 m+ F* v, XThe father denied taking any other medication. The
2 y/ Z( E- Q6 x1 d' x( p) wchild’s mother was in good health. Her menarche
% G0 Q6 D( M* e8 s. r9 Zwas at 11 years of age, and her height was at 5 feet
" W2 R. L- X' k" N4 }5 K5 inches. There was no other family history of pre-' W& g' ]+ X' \5 y. h( o  b
cocious sexual development in the first-degree rela-
" E/ L' U/ \1 N- Wtives. There were no siblings.2 D- J4 [+ Z4 E
Physical Examination/ y( q* }; v3 G7 M
The physical examination revealed a very active,9 b& G% S8 ?4 c5 s& a$ Q( @
playful, and healthy boy. The vital signs documented4 n, O) J" d8 B; X
a blood pressure of 85/50 mm Hg, his length was
* F9 Q3 g/ {; t7 Q3 ^' }  K; i90 cm (>97th percentile), and his weight was 14.4 kg
6 ?2 j1 h1 p4 C# \$ l" g! J. b; U(also >97th percentile). The observed yearly growth
) g6 i5 L) l, g2 v; Ovelocity was 30 cm (12 inches). The examination of  F$ \7 {( L  W% j* x2 s
the neck revealed no thyroid enlargement.
4 r" B" I4 |1 ]The genitourinary examination was remarkable for  F/ p# R; b0 n6 k9 l8 D6 |
enlargement of the penis, with a stretched length of& o2 \! H6 ~& M+ o, A
8 cm and a width of 2 cm. The glans penis was very well) x; D. h9 \* |- |! o
developed. The pubic hair was Tanner II, mostly around- S7 H; x: N5 q. C% U) |- C
540
/ j8 F1 U4 z2 z. q, l0 L3 \& ?, {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 ]  l  u* J/ E1 B+ X3 c8 r$ t+ F0 ?the base of the phallus and was dark and curled. The
$ d) W9 T: ?" A% t3 ctesticular volume was prepubertal at 2 mL each.- \5 s6 U& f, U& r, T# H- g6 \
The skin was moist and smooth and somewhat
. ?) G$ [9 x; e& Aoily. No axillary hair was noted. There were no$ q# G5 w" a3 |: h. T  U" ~# Y# J) M
abnormal skin pigmentations or café-au-lait spots.
& n+ W( [4 C8 x1 jNeurologic evaluation showed deep tendon reflex 2+
% }% A) t. e6 ~. \! Jbilateral and symmetrical. There was no suggestion, ~6 ^; v% v/ m7 D
of papilledema.- Y6 H& {3 W# q3 }- A. h4 H" E: [
Laboratory Evaluation/ z! f! Q3 P! Q/ ~
The bone age was consistent with 28 months by& @! \& Z+ T  w5 ]; K
using the standard of Greulich and Pyle at a chrono-
7 x" q8 s* r+ c9 [' w- llogic age of 16 months (advanced).5 Chromosomal2 z* N% N* t; C% j4 M+ I
karyotype was 46XY. The thyroid function test
& p6 \( v  [/ [  i9 v) b4 Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-; \9 S! Q- w! X& m7 g, L$ x% t
lating hormone level was 1.3 µIU/mL (both normal)./ q, b, V5 ], k7 K0 h' c
The concentrations of serum electrolytes, blood
  c$ d1 k( s$ Z1 D& |1 I  Nurea nitrogen, creatinine, and calcium all were' M! B: @# n/ c- u# B7 u4 O  ?
within normal range for his age. The concentration
. m% i& Q6 b- R- @4 p* p; F- k7 s  xof serum 17-hydroxyprogesterone was 16 ng/dL
) |# j/ i9 J; S! b0 T* z(normal, 3 to 90 ng/dL), androstenedione was 20
2 n! ]" S' g' q# H6 ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 B" q7 i( S7 W" N2 J8 V6 mterone was 38 ng/dL (normal, 50 to 760 ng/dL),  V! l( I4 ^' F5 y+ P, b5 N" Z7 @5 s3 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) T  k( ], C; y$ }5 `6 O- N5 k49ng/dL), 11-desoxycortisol (specific compound S)
! x) n/ u' j) L. R& d- jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' `$ P' z! Z: Q1 r; i/ Etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 ~* {& K" W6 |/ v8 `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 [! z' c: j/ W: f  f
and β-human chorionic gonadotropin was less than
, N1 c3 U# e, v8 g5 mIU/mL (normal <5 mIU/mL). Serum follicular* l1 T' y' M% A
stimulating hormone and leuteinizing hormone5 c+ Q: H& |' o# l# u* n: D$ U. E
concentrations were less than 0.05 mIU/mL; G; e& D) n$ F0 a& e5 M. x
(prepubertal).' c; f: b( g6 c7 B. ?8 _  R6 }8 L
The parents were notified about the laboratory9 F% Y& p% _" b, \& ~
results and were informed that all of the tests were' a- Y) D& R/ J$ l7 X" \, p
normal except the testosterone level was high. The. p( ^: G2 X; [: h1 k- a; y' T
follow-up visit was arranged within a few weeks to
& U$ ~# L$ r8 d4 h9 }obtain testicular and abdominal sonograms; how-5 Q3 g' l% \. c5 e" m- y
ever, the family did not return for 4 months.% \8 L' z0 ]! h) m- \! k
Physical examination at this time revealed that the
. p& A# {! w4 d0 {child had grown 2.5 cm in 4 months and had gained, C$ e% \2 u6 c3 D8 c
2 kg of weight. Physical examination remained) S7 Y: M" j, l) r  e$ u
unchanged. Surprisingly, the pubic hair almost com-
$ F/ X2 D' T& o7 Bpletely disappeared except for a few vellous hairs at& W" |, x- T( O, X
the base of the phallus. Testicular volume was still 26 l; |( T3 x0 s6 {  u9 V( k
mL, and the size of the penis remained unchanged.
1 o3 H7 y2 A  k7 O& y: TThe mother also said that the boy was no longer hav-
% J' z( Z, @* k3 ^  B8 Zing frequent erections.
+ u% X1 L" @  ?5 h; U( B/ D& p4 cBoth parents were again questioned about use of( U& n1 M9 J0 w( f% f
any ointment/creams that they may have applied to" Q( c! H  t8 I3 S, A
the child’s skin. This time the father admitted the$ O3 ]. X9 J! V" L
Topical Testosterone Exposure / Bhowmick et al 541( n- r0 \1 i/ g
use of testosterone gel twice daily that he was apply-
1 D7 _% ^3 W6 f- `% f! Wing over his own shoulders, chest, and back area for
4 I0 O' i4 M  s# h1 @# Ca year. The father also revealed he was embarrassed
$ W: H. q; q# x4 H5 M9 r/ E8 Qto disclose that he was using a testosterone gel pre-0 S6 z$ t4 p( F9 M
scribed by his family physician for decreased libido
0 g3 k- J$ _! W* N  d  Vsecondary to depression.
% N' S1 T7 e2 GThe child slept in the same bed with parents.
: H( t& |; N; p" N- hThe father would hug the baby and hold him on his  Q0 |: Q, J; E1 `. K% M* F
chest for a considerable period of time, causing sig-
. k! S) ?* G0 E( X( R) }0 w- enificant bare skin contact between baby and father.6 l! p/ `* B3 G; n1 e" S
The father also admitted that after the phone call,
$ F3 i6 s+ ~! |) _% H" t) Kwhen he learned the testosterone level in the baby
! K: r3 z# V( o  w2 `" k8 m! Owas high, he then read the product information
  |" ?+ b9 o" }  hpacket and concluded that it was most likely the rea-
& f5 G5 l5 ^- h1 F6 Nson for the child’s virilization. At that time, they
. Z! u/ q- V0 odecided to put the baby in a separate bed, and the& J$ P0 b6 u* v% h' U4 b3 Q- ^3 c
father was not hugging him with bare skin and had5 [/ z: Y0 o1 U- Y! k
been using protective clothing. A repeat testosterone% m' B" s* M, |  }5 P" {
test was ordered, but the family did not go to the
9 x7 V# o3 e; I5 b$ u& e% Olaboratory to obtain the test./ l  w) V( x& {7 E$ \
Discussion
2 S5 C/ s& R' `5 Z6 i: @Precocious puberty in boys is defined as secondary
* R; N4 U7 H; J- f9 ?2 Dsexual development before 9 years of age.1,4# D9 B1 _- I1 G
Precocious puberty is termed as central (true) when+ c  f& r2 E! e- q, V" U
it is caused by the premature activation of hypo-) T! f* A% r' U( u1 [0 c
thalamic pituitary gonadal axis. CPP is more com-# ~! v0 B7 d  C, J
mon in girls than in boys.1,3 Most boys with CPP
9 i# o- Z% A" tmay have a central nervous system lesion that is6 o. A0 ]) X1 `7 g5 e
responsible for the early activation of the hypothal-
* v4 W0 J$ u( B8 bamic pituitary gonadal axis.1-3 Thus, greater empha-4 P3 _+ t/ U, r" l; q/ Z7 Y
sis has been given to neuroradiologic imaging in- R3 M6 G8 R- a% Z
boys with precocious puberty. In addition to viril-, c+ Q6 m7 x% ?5 l- _8 M: T9 e
ization, the clinical hallmark of CPP is the symmet-
. a  b: z% j) `4 S) @0 R; Rrical testicular growth secondary to stimulation by
" |( x, A- ~4 i; \gonadotropins.1,3
  D1 l2 u7 F, }8 r4 FGonadotropin-independent peripheral preco-
* y  H$ U0 U4 \4 j: d& Ucious puberty in boys also results from inappropriate6 Z- R+ ^; S# Q
androgenic stimulation from either endogenous or
8 L. K5 `, @% K) f4 L+ Lexogenous sources, nonpituitary gonadotropin stim-+ x- S# k- r% y5 z  A/ D
ulation, and rare activating mutations.3 Virilizing
( l* b2 ~; R5 O1 }8 n& R" d* Ucongenital adrenal hyperplasia producing excessive8 z" P, w& a* M# ^  G% M
adrenal androgens is a common cause of precocious0 E% r% l8 m% K6 ?# n1 `
puberty in boys.3,4
$ P& J6 Q- |7 n6 |% E! qThe most common form of congenital adrenal
1 h" N5 ~; B9 |9 J' Z: W9 |5 {hyperplasia is the 21-hydroxylase enzyme deficiency.8 e. r8 c  B% ^( W( {7 S' r
The 11-β hydroxylase deficiency may also result in
! H& L3 O2 G' c+ G# f& qexcessive adrenal androgen production, and rarely,. W$ ]0 q) a, \1 v
an adrenal tumor may also cause adrenal androgen
2 P. C$ W3 ]  e* s2 Hexcess.1,3
% l  U3 p, g' v1 v% n. Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 P! h6 |0 c9 X  W" h3 n/ ~$ L542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 T/ _/ b6 ~' N& h
A unique entity of male-limited gonadotropin-
9 x/ c3 A6 P1 y/ [independent precocious puberty, which is also known8 F3 `. Y5 D9 d  `# U
as testotoxicosis, may cause precocious puberty at a
! `3 Q( ~/ Z! wvery young age. The physical findings in these boys
7 f6 D- j/ J; m& owith this disorder are full pubertal development,
: y4 D6 U8 B9 v7 h( U/ W$ `including bilateral testicular growth, similar to boys
3 o! p/ `: ^4 n) v% v$ iwith CPP. The gonadotropin levels in this disorder
& o- v$ p- T2 w" ^/ t9 Zare suppressed to prepubertal levels and do not show5 l1 b. d* B6 R3 z$ p2 a
pubertal response of gonadotropin after gonadotropin-0 o7 P$ [$ t( q6 W; e2 q- D! q
releasing hormone stimulation. This is a sex-linked
: E8 k* J, e8 w% T0 j- Xautosomal dominant disorder that affects only8 U2 J( |3 N! X; B4 v! B
males; therefore, other male members of the family
- T( i: z8 `! O: V+ A" Fmay have similar precocious puberty.3
$ b, c8 k7 e1 t* |6 L: {% JIn our patient, physical examination was incon-
, x& q, l! z: Hsistent with true precocious puberty since his testi-" a$ K- {) J7 w0 c0 b3 T
cles were prepubertal in size. However, testotoxicosis
2 o/ c  W* X6 c: h6 O3 G/ b7 {was in the differential diagnosis because his father0 D0 V# w3 K9 p6 ^
started puberty somewhat early, and occasionally,
+ [3 l5 Q# g3 l5 Z% n* @testicular enlargement is not that evident in the
. A' w; S3 B, {  r2 tbeginning of this process.1 In the absence of a neg-' ~3 n: U1 n- A8 @1 E# I  C
ative initial history of androgen exposure, our
& O- h6 z; m$ V" i6 f/ \/ x  jbiggest concern was virilizing adrenal hyperplasia,
" o! ^: D# [8 y" H; ~+ J5 Peither 21-hydroxylase deficiency or 11-β hydroxylase/ `# G+ U8 S+ b, Q# b1 _" L9 N/ h+ a6 L7 Q
deficiency. Those diagnoses were excluded by find-5 [: D# D* i' G% A* V  z
ing the normal level of adrenal steroids.
2 r) ], \( O  O, }0 ~The diagnosis of exogenous androgens was strongly1 @" i! x& o" A% J% v
suspected in a follow-up visit after 4 months because& F7 p3 F3 l0 E
the physical examination revealed the complete disap-. u( i: B/ C! I; s% d( A+ I
pearance of pubic hair, normal growth velocity, and
. p" L7 }. Y* C3 wdecreased erections. The father admitted using a testos-8 y2 m9 |8 U% C' |2 d  I
terone gel, which he concealed at first visit. He was- f+ [: o6 g8 }! h8 ~$ c
using it rather frequently, twice a day. The Physicians’
- T* V  _/ p6 e5 WDesk Reference, or package insert of this product, gel or" a7 `) K& y4 u4 B2 _
cream, cautions about dermal testosterone transfer to+ W' k' t; h# `2 `5 \- x
unprotected females through direct skin exposure.! q/ B0 l1 Z/ O- f# r: o+ ]" a" @- t9 w
Serum testosterone level was found to be 2 times the5 P; i( }) \% G% h2 S' i: ^( P) i
baseline value in those females who were exposed to' r( F" e# P, k( `# q
even 15 minutes of direct skin contact with their male. X8 a: l) e8 N! E. `4 C' r/ j8 B
partners.6 However, when a shirt covered the applica-
* l4 T% k8 z- Vtion site, this testosterone transfer was prevented.) F5 B( l: B) }/ N8 h- b
Our patient’s testosterone level was 60 ng/mL,1 B" `2 R4 y1 i3 f! g, `: z& p
which was clearly high. Some studies suggest that2 G' n1 ]$ Q8 p. S$ @, @" r
dermal conversion of testosterone to dihydrotestos-- f# b9 _9 |( }
terone, which is a more potent metabolite, is more
: M' u% ^! c  N! f7 zactive in young children exposed to testosterone: O  ^" m* h% O+ b0 G3 h/ C- n
exogenously7; however, we did not measure a dihy-+ w7 ~0 z' v& |  a
drotestosterone level in our patient. In addition to: K- ?/ F; w7 J$ ^' D& c) y% G/ ^
virilization, exposure to exogenous testosterone in
* |7 _% [; m' ~children results in an increase in growth velocity and
+ I6 b7 e; S6 w9 Aadvanced bone age, as seen in our patient.( I( J; n% h( Q6 S: i
The long-term effect of androgen exposure during
& U  V$ P' Y/ s1 oearly childhood on pubertal development and final! C! x/ L+ U2 U5 L8 B( p
adult height are not fully known and always remain
+ d7 P% h, R1 J# Qa concern. Children treated with short-term testos-* r) A+ p1 ?( z' n& E; [
terone injection or topical androgen may exhibit some& a0 j7 S8 |" c+ X' [. w& F
acceleration of the skeletal maturation; however, after
8 G9 w, i. P' g8 z+ Y# c. rcessation of treatment, the rate of bone maturation
  F" s) e1 }9 [" N5 }% z( ^0 Ddecelerates and gradually returns to normal.8,9
: c  ]" q0 {/ y/ fThere are conflicting reports and controversy
# ?, K: a8 d9 oover the effect of early androgen exposure on adult
% N: F% g/ H" d* r' W5 ?penile length.10,11 Some reports suggest subnormal
) p1 P$ R6 V& n) badult penile length, apparently because of downreg-+ I/ f0 v) x: k& E6 d) b$ }& ?
ulation of androgen receptor number.10,12 However,1 W1 N. c! T9 r
Sutherland et al13 did not find a correlation between- Y6 v' x' z( K# C9 t. l4 {/ ]
childhood testosterone exposure and reduced adult
! Y1 ]& s% Z& Y* C- ]4 L4 ~penile length in clinical studies.3 A6 o5 N6 t' q' h* M) n4 N$ Z
Nonetheless, we do not believe our patient is- ~8 z+ U6 q  P% J  P7 B
going to experience any of the untoward effects from
0 E1 s, a" x/ h/ e+ H% d+ b2 J5 U$ m2 Otestosterone exposure as mentioned earlier because9 F0 r, ]( p: {3 K7 D9 l
the exposure was not for a prolonged period of time.
' \, N$ f1 h* |$ D0 V. ~+ ^Although the bone age was advanced at the time of. I' @1 ]( M! E8 R1 C
diagnosis, the child had a normal growth velocity at
, Z5 ]7 x4 z6 J6 U5 S  C7 c* gthe follow-up visit. It is hoped that his final adult
5 n) S: r& G; z6 X& `" X/ z5 ?height will not be affected.; U& C) n  O: r" K
Although rarely reported, the widespread avail-# n$ h- g9 b3 ^+ O% V* F
ability of androgen products in our society may. t/ O  q; [9 A! N, L% t  k9 D
indeed cause more virilization in male or female
- S! k" D, ]  R* c: `children than one would realize. Exposure to andro-
2 Q' w+ F- M9 @; B0 R2 A* }5 pgen products must be considered and specific ques-# i1 y9 e2 F* u& a! ]( g  j# |' o
tioning about the use of a testosterone product or
' Y  e( v' u& R' T/ qgel should be asked of the family members during( Y0 B& k+ g; |! j" F! I
the evaluation of any children who present with vir-$ f( U+ ?% R% @- P
ilization or peripheral precocious puberty. The diag-6 R2 b5 D& s3 f! P4 L% @
nosis can be established by just a few tests and by3 l! g$ Z& n8 f( h
appropriate history. The inability to obtain such a
% S5 z4 @8 b! E5 F: Dhistory, or failure to ask the specific questions, may
* A, x' }& D, K9 F6 l4 p- Q: [result in extensive, unnecessary, and expensive
+ H" y2 u! Q0 a; Q( Einvestigation. The primary care physician should be
/ y+ X; E$ D% @. M" Aaware of this fact, because most of these children
" A" f) F% a6 J; F# V4 vmay initially present in their practice. The Physicians’* C& @' \$ Z. x2 X$ D/ I) ?: s' i
Desk Reference and package insert should also put a3 _& b, ]+ G- c0 p) k! K, H
warning about the virilizing effect on a male or
$ f2 M+ ?# s5 ~% ]1 ~( j! u- y6 Z! {female child who might come in contact with some-& o8 Y. K1 v8 P. j* ~) b
one using any of these products.- k3 q3 o0 R* X9 |7 S9 `
References
6 i/ O0 j+ q6 Q# M7 d1. Styne DM. The testes: disorder of sexual differentiation
9 A7 i3 G; A: O* J3 [and puberty in the male. In: Sperling MA, ed. Pediatric
8 d! E: `% w. n4 k- iEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) H$ H/ g( x2 _1 z  o/ d2002: 565-628.7 p3 u' l  V& c, b3 \, B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' m# g, A0 P/ z
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' W4 B3 L: ?6 q) T9 e
Boy Induced by Indirect Topical
5 D7 z: E) c$ V. A" PExposure to Testosterone/ \2 r# q  W1 q: I$ V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- a5 ^3 _; ~, V6 _
and Kenneth R. Rettig, MD1
. u/ I, ]3 `# f8 q; P$ |6 `! UClinical Pediatrics
9 W) p  W3 |/ A: `' i0 A0 jVolume 46 Number 6
! Y! F0 O; u8 q6 u; n0 M" i; NJuly 2007 540-5438 h3 f7 ?2 P/ ?$ ^  [) B
© 2007 Sage Publications, j1 `# |( X/ H
10.1177/0009922806296651
8 d' H+ k7 A7 x+ X/ l; b6 Z" i( p7 l9 Chttp://clp.sagepub.com
- a. K' a6 G: [  v4 }; ^8 ~0 g4 v) uhosted at
: a5 S! R( x4 W6 e8 M, G8 D7 Rhttp://online.sagepub.com
/ j0 A8 J% w/ _+ l- j- a7 h& [, UPrecocious puberty in boys, central or peripheral,
# }% }2 J6 W& d* \" T; vis a significant concern for physicians. Central
$ b( O; C" v% J2 i8 V& h& j$ Uprecocious puberty (CPP), which is mediated8 i0 |5 r: O% i2 O
through the hypothalamic pituitary gonadal axis, has
( M/ g- p/ f/ U% h. O8 Wa higher incidence of organic central nervous system
0 w4 x5 u8 {$ }" l+ ]lesions in boys.1,2 Virilization in boys, as manifested
1 R$ C* y: @( {4 y; A0 oby enlargement of the penis, development of pubic
  r% g7 s& M9 c! U* N% o8 ]hair, and facial acne without enlargement of testi-: ~' p  M+ O# C: V# u
cles, suggests peripheral or pseudopuberty.1-3 We0 a3 y9 }4 d( S/ V* v
report a 16-month-old boy who presented with the
7 k. j& v$ K$ I+ L; o$ j8 menlargement of the phallus and pubic hair develop-
) W' }, T/ K3 X* hment without testicular enlargement, which was due
/ o- ?8 n: I# @, r7 s) }to the unintentional exposure to androgen gel used by
8 g; y# m4 O3 X2 ^* Bthe father. The family initially concealed this infor-
2 @1 L0 K: N) }9 emation, resulting in an extensive work-up for this) O- Q/ f6 T+ @, W  m9 s, _% W5 T
child. Given the widespread and easy availability of6 V; c8 ~6 {. x7 C/ p2 u4 A+ z
testosterone gel and cream, we believe this is proba-
5 `: I# J3 N2 xbly more common than the rare case report in the
% v# W' L/ e: ~literature.4
% g4 t3 U& C! _9 i4 Z8 C* n1 I1 wPatient Report+ @& Q9 J6 w: Y- G: }
A 16-month-old white child was referred to the2 p7 @, u4 Y7 u! h6 _- ]# |- }5 ]8 ^
endocrine clinic by his pediatrician with the concern& k- p: G$ W9 s4 t8 Q4 ]9 K
of early sexual development. His mother noticed
& T  H, h- M! p& }0 Dlight colored pubic hair development when he was
! e# h0 V5 m6 {" u/ p5 YFrom the 1Division of Pediatric Endocrinology, 2University of0 q1 A+ P9 T" D
South Alabama Medical Center, Mobile, Alabama.
; s" x, L, Z) ?+ i. y. h$ DAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ Y6 q0 U/ W$ O) b$ p
Professor of Pediatrics, University of South Alabama, College of
4 c4 X, J0 u9 I9 ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 j6 p% ^, l' f% p' F+ y! U- ^
e-mail: [email protected].
' e. A% ]. \6 C# Z* Zabout 6 to 7 months old, which progressively became  u8 ~5 ^# b& c: m# ?- Q" a
darker. She was also concerned about the enlarge-
2 `" k. W% y" p1 D2 m  Qment of his penis and frequent erections. The child
& Y* u0 v" f7 t. ^5 c/ a! Zwas the product of a full-term normal delivery, with/ Q2 P& g, n& Y" `2 }- M9 R
a birth weight of 7 lb 14 oz, and birth length of/ n- }+ u, |, J% n0 ~
20 inches. He was breast-fed throughout the first year
% S$ E; @/ o0 R! E$ e( n! d; i& yof life and was still receiving breast milk along with
  L. d9 w8 }1 bsolid food. He had no hospitalizations or surgery,
  Y& B2 G3 e4 \9 R' v! Y/ e* D0 Aand his psychosocial and psychomotor development4 w% A3 u7 W# d6 v; J+ {) W  [
was age appropriate.
" E6 ~. J3 h0 U0 N* k4 U+ m. {" v+ [% |The family history was remarkable for the father,
. X" G! C' j$ {- W8 p3 [, Ywho was diagnosed with hypothyroidism at age 16,; v  a! w: @! z( f
which was treated with thyroxine. The father’s
8 p6 L: r/ b/ u$ C  F' }height was 6 feet, and he went through a somewhat8 D5 S/ \& T+ ], R% k7 y$ O8 F: ]
early puberty and had stopped growing by age 14.* k% b' Y" \0 ~6 O
The father denied taking any other medication. The0 E! [  r/ b3 k8 O* N+ F
child’s mother was in good health. Her menarche4 C- l4 a% \1 U2 {
was at 11 years of age, and her height was at 5 feet
' w2 w: k$ F4 x1 {' o! a( h& H5 inches. There was no other family history of pre-
1 n+ x" c8 n% k) w4 Bcocious sexual development in the first-degree rela-
3 V" f- {0 Y' r8 ^/ S+ Q1 h9 Jtives. There were no siblings.
) o9 \0 Q" U9 o' w* f5 S$ aPhysical Examination
* d" a# t8 s5 }- S9 |4 SThe physical examination revealed a very active,( F8 Z5 p9 G; t; F; v0 ?- t
playful, and healthy boy. The vital signs documented
0 `8 m: A% g4 t7 Ra blood pressure of 85/50 mm Hg, his length was" y) c1 L$ G9 o3 J3 \+ i
90 cm (>97th percentile), and his weight was 14.4 kg2 f) m, \2 J: B$ [& s8 h3 f- s
(also >97th percentile). The observed yearly growth
) E) [2 ]( w; M  n8 |- }velocity was 30 cm (12 inches). The examination of. K" o, M0 F& f, W! a+ p
the neck revealed no thyroid enlargement.8 V' F' v' \+ `' o# [
The genitourinary examination was remarkable for
# s0 k5 e! ?' Renlargement of the penis, with a stretched length of
! d8 N) c, K! M, n! |8 cm and a width of 2 cm. The glans penis was very well+ U" R4 X6 v6 P$ i0 L7 v
developed. The pubic hair was Tanner II, mostly around. A' K- q2 A- {* Q( z3 _: ^$ P  [/ ]7 y
540
- V% k( u) L5 m1 s, F) s8 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 U, m$ k3 ?, s2 `the base of the phallus and was dark and curled. The, L: {( m- _0 i
testicular volume was prepubertal at 2 mL each.
; P7 N- S, D- D- P+ z( I2 T- `. h% PThe skin was moist and smooth and somewhat
+ C' ^- Z3 T2 J/ T7 q: foily. No axillary hair was noted. There were no7 n* B! ^" l; e& v- d
abnormal skin pigmentations or café-au-lait spots.
" c, v; T1 A! M/ k- }# `2 UNeurologic evaluation showed deep tendon reflex 2+
- \, _1 e9 f) d- G' M) ]" w' E* |bilateral and symmetrical. There was no suggestion) a2 D: r8 [7 b, c
of papilledema.
# f/ ^" A, H! u6 c. k1 MLaboratory Evaluation2 [- W) \! e7 w! q9 a: _  p
The bone age was consistent with 28 months by+ h$ Q! L4 M- e8 I- D3 c
using the standard of Greulich and Pyle at a chrono-
; e# I4 N; p6 L+ b' a2 f0 p5 a# Mlogic age of 16 months (advanced).5 Chromosomal! I; {3 M. R' Q( ?# j
karyotype was 46XY. The thyroid function test  H6 c7 o9 u5 \6 t" K- l
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, h- W0 m9 Y9 M* J3 q/ ]  n. vlating hormone level was 1.3 µIU/mL (both normal).; `# Z6 K) x1 o# a" G% P
The concentrations of serum electrolytes, blood. G7 h* P; i% l- y7 ^8 L& y
urea nitrogen, creatinine, and calcium all were
  a" p$ g# Y) Q0 twithin normal range for his age. The concentration
. m; v! Y6 j; m% k8 `of serum 17-hydroxyprogesterone was 16 ng/dL: v. D+ L, e4 w  {* x' Z" O
(normal, 3 to 90 ng/dL), androstenedione was 20
1 A7 E. S1 N! C7 Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  l% T5 j' ]$ h# z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ e2 @* K5 Q4 @+ V5 H6 G! A7 U; z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: C1 |3 m+ Q( P8 \49ng/dL), 11-desoxycortisol (specific compound S). y/ \9 r2 K1 Z0 p  _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 n# k1 E2 g4 ?+ Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, y/ n  y& Z, i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 }( k1 ~) I1 \4 z% ^and β-human chorionic gonadotropin was less than2 Y# v3 h' A+ H  L  ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- o* Y/ y$ c8 S( A) e( m: h6 qstimulating hormone and leuteinizing hormone
: z% c; _/ {9 c, z. I$ Vconcentrations were less than 0.05 mIU/mL
! W6 K! f$ j2 i, p5 ?(prepubertal).
" r4 h! Z) I2 A& P; b8 |* KThe parents were notified about the laboratory
* |# Z! `9 x* F& l$ `0 b% ~results and were informed that all of the tests were
2 E' y* O# ^# q( Wnormal except the testosterone level was high. The# H3 P( a8 ]; _( K% O* F5 g: l, s+ q
follow-up visit was arranged within a few weeks to
3 ^* j. C4 n) x9 N  Q0 Hobtain testicular and abdominal sonograms; how-
+ M4 v, X: c: ^6 k% E% D# Cever, the family did not return for 4 months.4 y# M/ Z, N( g$ Y2 u4 `! \. d" Y
Physical examination at this time revealed that the  \- q8 `) f6 L+ S9 {' N
child had grown 2.5 cm in 4 months and had gained
$ d1 o/ O( {/ H) q, J% O% A" E. ]+ Y2 kg of weight. Physical examination remained
( t( Z, n/ P2 U! m' c; gunchanged. Surprisingly, the pubic hair almost com-) V! B, |8 S  f
pletely disappeared except for a few vellous hairs at0 ?7 d1 f& U: o' S, M. _8 G  y
the base of the phallus. Testicular volume was still 2
- |# E! @. J7 E# d) J8 _( bmL, and the size of the penis remained unchanged.
  I6 ~7 ~. M0 B' f6 FThe mother also said that the boy was no longer hav-; k- L% e, V. H" }0 }" G; W) \
ing frequent erections.
! |, V' _; E. O& u- S& W3 IBoth parents were again questioned about use of& ^% t7 H5 w0 Z5 ~" c0 I
any ointment/creams that they may have applied to; l& ]5 d$ F& J9 j" V6 f1 Y
the child’s skin. This time the father admitted the
1 H) n" J5 O; O  V' W; Q1 o; tTopical Testosterone Exposure / Bhowmick et al 541* W6 @" f. L  b8 I7 g! s; A) m
use of testosterone gel twice daily that he was apply-
0 c' I% P: e/ `: k. c# I7 k8 V1 r7 b( Ting over his own shoulders, chest, and back area for
% \. z" [5 F1 E* la year. The father also revealed he was embarrassed
* n- [$ S$ s9 ]3 f- Yto disclose that he was using a testosterone gel pre-
5 V, s" ]2 |) Q; [% L; w9 `scribed by his family physician for decreased libido  o$ Y' d; c' E1 l( ^
secondary to depression.: U5 l" l- b6 P
The child slept in the same bed with parents.4 _3 N7 \" u! P7 g( B5 t
The father would hug the baby and hold him on his+ ~& ~. y7 ~9 S: b% P! E7 l: |
chest for a considerable period of time, causing sig-
9 I/ c4 j3 o" e4 F* M1 K* }nificant bare skin contact between baby and father.
& N3 X% u4 \% P% `# R! @: rThe father also admitted that after the phone call," _) m$ w2 Z+ ^0 ]1 f
when he learned the testosterone level in the baby2 l1 A; M6 e( C: M6 i3 T- j
was high, he then read the product information
8 _9 R8 i8 b- i# Dpacket and concluded that it was most likely the rea-
1 T  B* E4 c1 i# Y6 Wson for the child’s virilization. At that time, they
" D, e+ S7 l9 m* W* K' n: H$ Odecided to put the baby in a separate bed, and the
- D" V' D# l( n* Y, T2 cfather was not hugging him with bare skin and had
( F& ]5 l+ Y' }: O0 k1 M# ~been using protective clothing. A repeat testosterone% Q/ j) V; b6 d8 ?
test was ordered, but the family did not go to the; K, G: E& j7 H6 v6 Q
laboratory to obtain the test.
: `: {8 B# b+ T+ fDiscussion
) O/ H  x1 u4 S( B& `Precocious puberty in boys is defined as secondary6 V: W$ q9 V2 k+ c& r7 w
sexual development before 9 years of age.1,4
; `0 k0 b* L, `8 y& d7 {; j& ZPrecocious puberty is termed as central (true) when
5 [# _7 c% K8 K; k. D2 h$ Pit is caused by the premature activation of hypo-
1 X2 x3 ], X) J% m4 J& `0 othalamic pituitary gonadal axis. CPP is more com-  W- u. q: S1 O6 C9 L
mon in girls than in boys.1,3 Most boys with CPP" {4 x# s2 f' d+ N
may have a central nervous system lesion that is
6 g+ X, `0 k( f( m" l+ aresponsible for the early activation of the hypothal-
0 n# |$ \6 _( Y1 A5 camic pituitary gonadal axis.1-3 Thus, greater empha-# F' H: z; r' X- n0 h% s
sis has been given to neuroradiologic imaging in
; Y- y& X$ S. E/ {. Z9 eboys with precocious puberty. In addition to viril-
2 z% C& P: I, i, i% J9 U" Lization, the clinical hallmark of CPP is the symmet-* i2 b, n5 g% x1 H1 w' E0 @. T
rical testicular growth secondary to stimulation by" X5 `- B8 ]$ E
gonadotropins.1,3  f, }/ R/ ]) {4 W0 Y. M/ ^+ H
Gonadotropin-independent peripheral preco-4 U# r1 A7 W8 p+ v
cious puberty in boys also results from inappropriate
/ F& t2 p# L2 d% x/ mandrogenic stimulation from either endogenous or2 p# f1 N/ C7 a
exogenous sources, nonpituitary gonadotropin stim-
: l& h, d; h$ ^1 iulation, and rare activating mutations.3 Virilizing! B9 A7 R. m& C) ~, ?
congenital adrenal hyperplasia producing excessive
( a5 q5 T+ ~# V& t" Zadrenal androgens is a common cause of precocious
) q6 t( Z( m: W: opuberty in boys.3,4* S# R! Z8 M7 Q# _
The most common form of congenital adrenal
8 k1 a/ z$ f8 n/ W9 d4 \hyperplasia is the 21-hydroxylase enzyme deficiency.
! A0 {  _( r3 N* uThe 11-β hydroxylase deficiency may also result in
0 x+ h% }; l. k  W, xexcessive adrenal androgen production, and rarely,
  P7 F# a9 i; {1 xan adrenal tumor may also cause adrenal androgen% H6 t0 E( X3 I! n, w
excess.1,3( m8 h% [# J+ N6 U9 U7 v8 q' C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 V8 r$ k5 I7 W3 f' \* \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, W; V: p9 u: xA unique entity of male-limited gonadotropin-
$ Z& }0 T5 R9 e6 V/ rindependent precocious puberty, which is also known5 a  o7 R% m' _) o3 F2 I8 m/ C( V
as testotoxicosis, may cause precocious puberty at a1 ~2 G3 @4 d* x( d. B
very young age. The physical findings in these boys% n6 o4 T# f1 Z) y# U9 E
with this disorder are full pubertal development,
; b. M" ^' _0 R  bincluding bilateral testicular growth, similar to boys
; m5 w2 h) a6 Z& S" hwith CPP. The gonadotropin levels in this disorder! U7 S% I2 z( J* [& m3 y; K
are suppressed to prepubertal levels and do not show; n2 K3 G# Q. e, S
pubertal response of gonadotropin after gonadotropin-; b8 l% c) j4 j: Q8 ]; Q2 g) p
releasing hormone stimulation. This is a sex-linked1 p4 C2 N, R5 I7 Z+ x. d9 @' Z
autosomal dominant disorder that affects only
4 I$ d2 g' H- {& Emales; therefore, other male members of the family% H5 \0 _" b- Q% S3 |
may have similar precocious puberty.3
3 N( S, W" l- [# HIn our patient, physical examination was incon-! G# }; C0 }5 t) ^# }1 I$ M  E2 w
sistent with true precocious puberty since his testi-! @& e2 U' {" O
cles were prepubertal in size. However, testotoxicosis
# H+ Z, ]" z" ?was in the differential diagnosis because his father, N, T+ E; R+ o2 Z7 t* e4 X+ p: K1 H
started puberty somewhat early, and occasionally,& s$ S! P7 }$ Y2 ^! _5 H  ]6 d7 C
testicular enlargement is not that evident in the
4 R8 q6 E9 U& I" jbeginning of this process.1 In the absence of a neg-2 k; J) q5 l9 H% U% |( Z' W
ative initial history of androgen exposure, our
3 Q( a% f' {( c* ~+ n1 r+ {2 z  Y$ Obiggest concern was virilizing adrenal hyperplasia,: n6 S8 e( t1 W& v! ?' M7 |+ f# I2 \
either 21-hydroxylase deficiency or 11-β hydroxylase
+ F1 k. U# P7 C3 q, i: r7 C% wdeficiency. Those diagnoses were excluded by find-
0 H3 r  Q* Y0 W+ K2 \ing the normal level of adrenal steroids.. y1 I' l, z, T- |4 E
The diagnosis of exogenous androgens was strongly
9 H/ x# F) `/ k" u. j' Asuspected in a follow-up visit after 4 months because6 R7 f: {0 M1 t# t0 S; L3 j$ j
the physical examination revealed the complete disap-  w$ l* x5 o6 k) p5 k- R: U
pearance of pubic hair, normal growth velocity, and$ A/ S: |9 i5 R2 G
decreased erections. The father admitted using a testos-
/ _: g6 ]+ t" Y; `" b6 eterone gel, which he concealed at first visit. He was
) N  o( {# T; D4 c9 susing it rather frequently, twice a day. The Physicians’
- _7 J. y, a& R8 e" D( KDesk Reference, or package insert of this product, gel or: U3 H/ N( g- K0 y) h, w
cream, cautions about dermal testosterone transfer to( J& K6 z6 S8 L% o  D: m, x
unprotected females through direct skin exposure.# I! d! @, f3 {1 k; r+ v
Serum testosterone level was found to be 2 times the
+ P5 v. v" P1 p7 X3 Qbaseline value in those females who were exposed to
1 b1 T5 _& o0 r8 G) t7 _9 r' j6 @, leven 15 minutes of direct skin contact with their male
" l+ E* G; H" Y5 Dpartners.6 However, when a shirt covered the applica-6 j0 k4 A' H0 i+ G4 v$ i
tion site, this testosterone transfer was prevented." M7 W# E* S) q" k
Our patient’s testosterone level was 60 ng/mL,# [( D( ]' {: I2 J: P) t
which was clearly high. Some studies suggest that; T! {7 B3 R/ E' X; M
dermal conversion of testosterone to dihydrotestos-" ]7 @# }% ~- F
terone, which is a more potent metabolite, is more
3 w  n6 z0 Y& s# z: \active in young children exposed to testosterone* O9 D5 U7 ^8 y& \# q$ U0 M  U
exogenously7; however, we did not measure a dihy-
: I. ~+ g3 v* ?% P& Tdrotestosterone level in our patient. In addition to' E3 k  V8 y/ |8 m9 q
virilization, exposure to exogenous testosterone in
( u2 A0 X5 T% `2 {children results in an increase in growth velocity and
; C# Y* P8 B0 Y6 w$ Xadvanced bone age, as seen in our patient.
0 u6 l+ P: \8 v* x! ]/ p3 qThe long-term effect of androgen exposure during
7 |2 y/ H+ |/ X4 W8 k! Gearly childhood on pubertal development and final
7 E6 O/ y) l. ?+ t7 Y/ {adult height are not fully known and always remain
, L2 _( L: G: n3 ca concern. Children treated with short-term testos-
) g! }' H" o5 \; Rterone injection or topical androgen may exhibit some5 S) P; ~$ _6 k: N
acceleration of the skeletal maturation; however, after
  x, c" @' P5 L# b6 ?  M7 mcessation of treatment, the rate of bone maturation3 V5 \' `0 g% _. i
decelerates and gradually returns to normal.8,9
! |# K9 a5 ^1 y$ a" }There are conflicting reports and controversy
6 o5 S* m0 g# I0 `8 `! F; d+ xover the effect of early androgen exposure on adult
" q  Y! m; v7 _" vpenile length.10,11 Some reports suggest subnormal$ M: D  i2 p; e$ p1 Q0 e
adult penile length, apparently because of downreg-
/ Q) m- T! N" i. e& Oulation of androgen receptor number.10,12 However,
; j& p% u; N2 j0 I* _, L# dSutherland et al13 did not find a correlation between7 f. M7 u/ j- q9 p7 {7 U
childhood testosterone exposure and reduced adult
6 C8 Y9 n# ?. A* epenile length in clinical studies.. y8 M3 @8 a( _( h! X. h$ z. R
Nonetheless, we do not believe our patient is
" F! e. Q/ A$ _going to experience any of the untoward effects from, G. A! H3 t7 r: l" z/ k3 V
testosterone exposure as mentioned earlier because
: ?" J0 i: ^( W3 C4 M1 u5 g4 |the exposure was not for a prolonged period of time.' _9 D3 ~& g1 e7 B2 k
Although the bone age was advanced at the time of
  Z, l$ J8 y% P8 ydiagnosis, the child had a normal growth velocity at
1 p, V2 ~, I3 w. W" Dthe follow-up visit. It is hoped that his final adult
) v* ?; n- o& m  `4 o, w4 |8 Lheight will not be affected.) B7 p! U" w' ^+ ~% L
Although rarely reported, the widespread avail-
, Z0 r- `+ y. A' @' @5 M) l3 R( eability of androgen products in our society may
) W5 U' S7 x: \indeed cause more virilization in male or female
, [# X: f8 B' p% gchildren than one would realize. Exposure to andro-
1 b: {1 s6 h* j+ q8 ?1 Ugen products must be considered and specific ques-
- Q2 W" P4 Y% F1 ^6 Vtioning about the use of a testosterone product or
/ F) w& F7 u9 s) _3 E4 Dgel should be asked of the family members during
- T6 i  V9 N4 t+ `( g1 bthe evaluation of any children who present with vir-
! W4 T3 ]8 O; l) y2 \+ vilization or peripheral precocious puberty. The diag-2 z  H' @. g7 E3 Z3 Y
nosis can be established by just a few tests and by
$ ]) z5 W9 d; v6 x+ Eappropriate history. The inability to obtain such a
0 e5 C" f! b% s) u& Z) i7 nhistory, or failure to ask the specific questions, may# ?/ V# l9 F8 v+ ^  t$ K) l( H! h* y
result in extensive, unnecessary, and expensive
) m2 p, o5 ^" i1 Linvestigation. The primary care physician should be- `, x1 W9 {) `7 t$ R& j2 S
aware of this fact, because most of these children/ N; T/ x$ j+ I# W2 {) G9 Q
may initially present in their practice. The Physicians’
) y7 E1 z* E% F# e0 g$ }( VDesk Reference and package insert should also put a6 H3 G0 c) S/ c  h1 z0 Q- m
warning about the virilizing effect on a male or
& x6 S" J) {( R: ?0 O* _0 ^  Qfemale child who might come in contact with some-
5 ?6 g5 l9 M3 t  M3 }9 none using any of these products.
7 z/ c1 g- J6 V6 }) D! ]1 ?, rReferences
$ l/ F; m+ i( K+ [1. Styne DM. The testes: disorder of sexual differentiation
, |! n! `2 _; n! G" X" zand puberty in the male. In: Sperling MA, ed. Pediatric
# u. f6 i* q) H5 C# e& t( mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 T0 U, d6 Y6 j5 f2002: 565-628.8 Q3 W& @: H; W& K( ]% _3 W" h7 B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; l5 u9 M+ R) T3 `% G& u
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

% k0 a* l6 R7 e3 z0 G( v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