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-Old8 y7 p+ I3 S; O! y7 f# }
Boy Induced by Indirect Topical9 c5 P$ B; e% e& k% N
Exposure to Testosterone
  b6 L$ w/ R- cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# x* h+ m$ n2 q6 D) d0 V
and Kenneth R. Rettig, MD1
# p: y* q( q* x) G+ _0 q) DClinical Pediatrics  Y- Y+ A+ _4 f% K* c: ~$ \
Volume 46 Number 6
: \6 q" f! D" p. C, n0 i% GJuly 2007 540-543, a1 n6 t2 H- M7 r; S
© 2007 Sage Publications0 X+ E, U- M( K1 @, U# Y
10.1177/0009922806296651
" \9 T. y1 a  hhttp://clp.sagepub.com$ U+ |: q/ g% `/ o
hosted at
7 ?: K$ s6 A# I* w; {http://online.sagepub.com
7 f, A) G& K6 R! C/ z4 M2 @1 m) j5 o: t; OPrecocious puberty in boys, central or peripheral,' B" g! F" `, D
is a significant concern for physicians. Central
2 C( O; V( ^* x- m* ~precocious puberty (CPP), which is mediated
+ D- q% D0 [! C6 Q0 t  \: wthrough the hypothalamic pituitary gonadal axis, has
6 _, K7 `' V+ u7 C( y6 }& la higher incidence of organic central nervous system
0 n' U; z# o/ Z6 F; W. o9 V# ~5 Ulesions in boys.1,2 Virilization in boys, as manifested( K8 q% i5 @: Z7 B8 C7 n8 a
by enlargement of the penis, development of pubic4 y) r9 j' Z# C; |" v
hair, and facial acne without enlargement of testi-
: Y8 Z& d; X% P, b' zcles, suggests peripheral or pseudopuberty.1-3 We  |, w  i' k2 o; F
report a 16-month-old boy who presented with the4 W  H8 u( i* j3 [# y
enlargement of the phallus and pubic hair develop-
8 L' s0 ^1 H3 \ment without testicular enlargement, which was due
% C% c* {  w/ Ito the unintentional exposure to androgen gel used by
7 g" h7 [( \3 d# T$ Rthe father. The family initially concealed this infor-
0 m& \4 P- w* D0 m3 w2 n( T6 n& omation, resulting in an extensive work-up for this* L& s3 S9 @- X2 A$ [
child. Given the widespread and easy availability of' q9 y: B0 d  N) R0 a$ a
testosterone gel and cream, we believe this is proba-/ m, n% f  }3 o! U& `! P/ e
bly more common than the rare case report in the# k( H6 x* W% v2 w5 W  N
literature.4
, y; g( D7 h% ]+ f: Q8 b# }6 wPatient Report
) f5 R3 f* a$ o: AA 16-month-old white child was referred to the
6 c* S: n$ ~8 N/ n9 _! Sendocrine clinic by his pediatrician with the concern$ u/ G. N7 ~8 z4 B7 T! H1 S1 i+ b
of early sexual development. His mother noticed
1 M( V5 q( {! }& a5 xlight colored pubic hair development when he was
9 m( I! Y; c" s2 S2 r/ mFrom the 1Division of Pediatric Endocrinology, 2University of" |; j- r( D7 j8 _4 s
South Alabama Medical Center, Mobile, Alabama.6 R+ r/ k/ k1 q6 a! g5 x5 }* h. v
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& K) |5 t: {! @6 ~# nProfessor of Pediatrics, University of South Alabama, College of' V2 k; o9 o  D5 d. U' x: q6 @" u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 o9 E/ \! p! ^- ~: j
e-mail: [email protected].
7 i8 ~( ~3 J3 X2 P/ }; l& k" zabout 6 to 7 months old, which progressively became
4 l! r7 y4 F9 b' xdarker. She was also concerned about the enlarge-/ b2 q( B& |6 \
ment of his penis and frequent erections. The child
- F1 O9 I/ m* K7 n- o# L! rwas the product of a full-term normal delivery, with3 Q: H# V+ N" u1 N6 i: q
a birth weight of 7 lb 14 oz, and birth length of+ H8 J0 s" I2 X( ]) U' |2 N
20 inches. He was breast-fed throughout the first year
. E1 R6 v$ Q  Uof life and was still receiving breast milk along with
% @' D$ }2 R" K# \# E# esolid food. He had no hospitalizations or surgery,
* n7 o2 `1 ^2 I6 q& M2 }) Kand his psychosocial and psychomotor development4 q; F6 C3 H& c1 {% f
was age appropriate.4 k: I2 x, z+ O8 A7 _- F4 j: I
The family history was remarkable for the father,7 o/ U8 @7 m1 u! B8 s
who was diagnosed with hypothyroidism at age 16,
, m$ i; J# I& c9 Z9 zwhich was treated with thyroxine. The father’s9 _5 I: R; p6 J2 O1 B* W* g
height was 6 feet, and he went through a somewhat
' _1 ]. x: ~+ o- Qearly puberty and had stopped growing by age 14.
- q2 [' _- K& wThe father denied taking any other medication. The0 h, j2 r# U/ u: X
child’s mother was in good health. Her menarche% e- U# L" H+ S
was at 11 years of age, and her height was at 5 feet
: L6 |: G: [+ Z. x8 t4 x3 i5 J5 inches. There was no other family history of pre-9 a; Q4 W8 H5 x1 `; F
cocious sexual development in the first-degree rela-& u/ \% a- o9 e. `" o' h, [
tives. There were no siblings./ S6 r1 m, @5 m; g
Physical Examination' j" @4 P! n& `' C  b7 G
The physical examination revealed a very active,0 j! W/ W" J- D/ G- Y
playful, and healthy boy. The vital signs documented! Z" c# u+ [, A. K9 c0 T- X! G  v
a blood pressure of 85/50 mm Hg, his length was. ~- M: [' z/ ^0 Q6 @9 e  Q
90 cm (>97th percentile), and his weight was 14.4 kg
# b5 o. x( H9 I6 }(also >97th percentile). The observed yearly growth
' G0 g3 V# i) Y3 D, `6 \+ _( Yvelocity was 30 cm (12 inches). The examination of& g5 Q- H% q) R
the neck revealed no thyroid enlargement./ e" F) p3 @- S! b3 N$ v0 k
The genitourinary examination was remarkable for
) a/ m# w* c7 C/ Henlargement of the penis, with a stretched length of
( {- D* T/ p% m, q/ g9 J: u8 cm and a width of 2 cm. The glans penis was very well
  N$ S, \+ x! w; cdeveloped. The pubic hair was Tanner II, mostly around/ ?/ V! B* s$ V, n
540
+ b! J7 m- T7 e. Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  T% @% l$ }1 [) r; W+ f) _* H/ Nthe base of the phallus and was dark and curled. The
, i$ t$ B: D& _4 Q1 w* ~! Stesticular volume was prepubertal at 2 mL each.
+ d% v) l& g) U. }% e; q0 ~The skin was moist and smooth and somewhat
' |+ z, [. I1 xoily. No axillary hair was noted. There were no7 e) V) y+ B( c" a; {2 ]4 P( {
abnormal skin pigmentations or café-au-lait spots.8 m, Z  _1 L6 t: P1 M8 M5 Y
Neurologic evaluation showed deep tendon reflex 2+
7 d+ x! O# _& [0 l0 Ebilateral and symmetrical. There was no suggestion
0 K, b1 A: H  |* Z+ fof papilledema.$ z- ~3 j3 ~3 D( g; \% Y# q
Laboratory Evaluation9 z, a0 j, J8 U% d# l2 b
The bone age was consistent with 28 months by. ~4 g) }, i; ?9 M5 c
using the standard of Greulich and Pyle at a chrono-% [8 ?. K3 L6 K- J2 E0 h' Z8 l& Z
logic age of 16 months (advanced).5 Chromosomal( }7 L7 {5 s' G. N
karyotype was 46XY. The thyroid function test. _$ _- v" j7 g8 b4 b# C
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- Y! ]9 W" ]/ |# |! e
lating hormone level was 1.3 µIU/mL (both normal).
; B! B" K) O, }, e5 M" c5 qThe concentrations of serum electrolytes, blood
* Q6 [5 e5 g7 S% h. Eurea nitrogen, creatinine, and calcium all were& @9 E# L0 m# F! A
within normal range for his age. The concentration: Y* a0 i. ~, M& Y9 X
of serum 17-hydroxyprogesterone was 16 ng/dL
- z; F8 L. s# f5 K' k(normal, 3 to 90 ng/dL), androstenedione was 208 W( P( B, M: m$ ~
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! A  \( I: |1 E& T' D5 mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! a- ~+ l, U3 U. Y1 [) s9 Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 c6 s6 Q5 S! [8 a5 \9 l49ng/dL), 11-desoxycortisol (specific compound S)4 V# {/ q6 e: V: V6 m+ R  I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 g3 `; w' O& P7 K5 q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ e6 X; X! q  v5 ]( f5 L
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 D: e* a7 Q: [
and β-human chorionic gonadotropin was less than1 M# P, ^8 f/ [; d5 }' V4 m2 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular( \$ \5 E: E/ C) E7 q9 O
stimulating hormone and leuteinizing hormone
5 u0 ]: o. j( p: N5 ~6 }8 z! tconcentrations were less than 0.05 mIU/mL
7 r9 s, h, Q, c1 a! u% u(prepubertal).
) n0 |- F  V6 k8 e; {8 Y1 xThe parents were notified about the laboratory, P: {( W$ K) C
results and were informed that all of the tests were1 x$ b$ \4 L  O
normal except the testosterone level was high. The
# ?3 D7 Y! r: B) A% Ofollow-up visit was arranged within a few weeks to7 z$ w# I$ q" l8 P- P3 L! r
obtain testicular and abdominal sonograms; how-3 Y  @& a, D& B% [7 d
ever, the family did not return for 4 months.+ \9 ?# A$ e) l4 ?- H; [$ D! E! c' {6 ?# u
Physical examination at this time revealed that the8 D5 P; ]3 g* C4 ?# Y/ R4 Q
child had grown 2.5 cm in 4 months and had gained
2 {! m: C9 k/ G3 X$ I' ?3 g+ w# D2 kg of weight. Physical examination remained7 C2 R+ V/ ]9 C5 g
unchanged. Surprisingly, the pubic hair almost com-9 W6 s- l$ D+ t# K# A, e1 {% Q5 a
pletely disappeared except for a few vellous hairs at
. N! e7 ~; q5 |5 }2 M# [6 jthe base of the phallus. Testicular volume was still 2* b9 }( V% y. M
mL, and the size of the penis remained unchanged.8 b+ m! ], ^- i# Z9 j1 v0 i
The mother also said that the boy was no longer hav-
" c' y6 Z# }) k0 D: r1 |ing frequent erections.+ t+ o0 k0 @; ?9 D
Both parents were again questioned about use of
! D: o4 o1 a3 O# }, i2 h1 [any ointment/creams that they may have applied to
8 E9 c+ C$ U. Wthe child’s skin. This time the father admitted the- T/ v  g6 }5 T& l$ y9 M( a' ?
Topical Testosterone Exposure / Bhowmick et al 541# J0 z0 V8 |# r
use of testosterone gel twice daily that he was apply-% E+ [0 ~- Z  Y
ing over his own shoulders, chest, and back area for" h  n7 S  h5 [' \6 i3 [$ G
a year. The father also revealed he was embarrassed
9 M, c' Y7 ?2 tto disclose that he was using a testosterone gel pre-
) N- R) t  K4 f; y1 N5 \7 [scribed by his family physician for decreased libido
/ V: {" f4 e( S# A$ b9 vsecondary to depression.
2 |! b6 P5 o1 b  z4 A2 j: U) GThe child slept in the same bed with parents.) x9 }9 U% _) h. l* h+ i" K
The father would hug the baby and hold him on his
, h, t# Y9 x/ B2 P. Ychest for a considerable period of time, causing sig-; ^$ @! I9 Y4 b+ \
nificant bare skin contact between baby and father.
% _! `: d. l# u9 ^The father also admitted that after the phone call,
: L5 C: y8 z8 k& g3 Mwhen he learned the testosterone level in the baby3 v9 _7 o9 c- Q6 m- z
was high, he then read the product information
% R0 I, I, Y2 epacket and concluded that it was most likely the rea-
4 H& U: H' q1 \" ^* c& tson for the child’s virilization. At that time, they
4 ?0 F/ V! ~% O2 j, r/ e% s6 [: W: idecided to put the baby in a separate bed, and the
$ h) k6 h* W% ~5 O3 ^father was not hugging him with bare skin and had0 r: G4 O/ t8 B  K5 b
been using protective clothing. A repeat testosterone
% u5 n: A2 e! ]  o) }% xtest was ordered, but the family did not go to the
4 ^! ~! p  f8 f& claboratory to obtain the test.
0 o3 n2 }- ^. `+ c4 W5 n: _8 ^Discussion4 o) q8 C/ j+ J* @+ n
Precocious puberty in boys is defined as secondary
! d# H5 }/ D. Y% \8 }sexual development before 9 years of age.1,4/ K' U* W# c! \
Precocious puberty is termed as central (true) when; v1 K) k0 d- E, W
it is caused by the premature activation of hypo-
5 C, K+ ]1 d/ j  }+ Ythalamic pituitary gonadal axis. CPP is more com-
) c3 X( I7 b/ H6 {  tmon in girls than in boys.1,3 Most boys with CPP
. z% _* I! v9 }6 p" g& Q# emay have a central nervous system lesion that is
! E5 b- }' T( i( \3 B6 U- J# u0 Zresponsible for the early activation of the hypothal-/ Y. Z) d$ f, N, P8 u. N
amic pituitary gonadal axis.1-3 Thus, greater empha-
. I: w) ~6 t+ h- n( V4 |& w8 esis has been given to neuroradiologic imaging in. u) @: d7 U$ {' u2 y4 E
boys with precocious puberty. In addition to viril-9 B8 [/ M7 E3 r
ization, the clinical hallmark of CPP is the symmet-
  [3 C0 i5 j+ [! J4 brical testicular growth secondary to stimulation by
+ d3 ^# @: z8 o/ o( m6 q. w$ igonadotropins.1,3( @* p& j/ S7 T% d: U
Gonadotropin-independent peripheral preco-
0 ?7 T0 P; Z+ \4 p  n) Z. }cious puberty in boys also results from inappropriate
  ?; ~" `  ^0 _" ]  W, oandrogenic stimulation from either endogenous or+ G9 Q; \1 {, @) f& B3 D
exogenous sources, nonpituitary gonadotropin stim-7 k+ B" A: K9 {" @8 G; d
ulation, and rare activating mutations.3 Virilizing
  v: m8 m* q# j  ?congenital adrenal hyperplasia producing excessive. |0 I! l2 k8 U8 V
adrenal androgens is a common cause of precocious9 a  }$ {' M% D, Q$ H, ?
puberty in boys.3,4
  R# e& }* W8 m4 c- d7 e& ~The most common form of congenital adrenal  `- Z. q8 Q8 u+ P7 f( n/ x
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 H2 e( A$ B; }# X/ S3 `The 11-β hydroxylase deficiency may also result in: X0 n1 r2 K2 }. y
excessive adrenal androgen production, and rarely,
; [8 Y7 M5 m/ R8 H0 k9 {an adrenal tumor may also cause adrenal androgen/ S7 c- F8 n5 \- e
excess.1,3/ E" h) ?. G2 V) A' o0 V) d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. L# }6 [( Q8 o+ l" N. `) P# j( ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) O8 Q% Y& l- E8 k- |* |6 N$ ]A unique entity of male-limited gonadotropin-8 r/ q$ D7 i9 R/ a2 R' I, C
independent precocious puberty, which is also known1 x5 M! J( `) r
as testotoxicosis, may cause precocious puberty at a9 s" k& k3 x* G& f7 H0 O1 X& r6 W7 N
very young age. The physical findings in these boys
, x& P4 g, I  U1 b6 Swith this disorder are full pubertal development,
1 V2 N/ o5 G: i4 x0 Qincluding bilateral testicular growth, similar to boys
' w, h2 {% |& cwith CPP. The gonadotropin levels in this disorder3 E& [. \' J3 R4 }0 w
are suppressed to prepubertal levels and do not show
- P" K) w' f/ P# {pubertal response of gonadotropin after gonadotropin-
* ?3 R) ~" O: Ireleasing hormone stimulation. This is a sex-linked' x0 J, J. I8 f  V
autosomal dominant disorder that affects only. w8 }9 p& z$ |8 d; s6 E4 z1 ^
males; therefore, other male members of the family# A+ g: D4 D; y6 b, R
may have similar precocious puberty.37 P5 S5 Z" x4 H2 {) {
In our patient, physical examination was incon-" H$ Z3 S4 U" \4 Q9 j/ T
sistent with true precocious puberty since his testi-* k1 o4 D/ O. S9 f- ]9 M
cles were prepubertal in size. However, testotoxicosis4 G3 i2 m4 |4 h6 I  _$ U
was in the differential diagnosis because his father- o% f$ b4 k3 r/ K! o3 B2 L. J
started puberty somewhat early, and occasionally,
/ n, R5 O( L. q0 E/ r& G& ?2 _6 ctesticular enlargement is not that evident in the& E9 \% _# F4 n! R
beginning of this process.1 In the absence of a neg-
. _. ^; @- Z& r0 k6 ~( pative initial history of androgen exposure, our
7 C% @3 `2 g- lbiggest concern was virilizing adrenal hyperplasia,# v- y# v9 Y8 l1 o$ x
either 21-hydroxylase deficiency or 11-β hydroxylase. u  \2 b5 T# i: N4 |& k$ {" U
deficiency. Those diagnoses were excluded by find-
* C- ^( ^4 j2 n  ]0 U. King the normal level of adrenal steroids./ I8 F2 D. d" i. K
The diagnosis of exogenous androgens was strongly, ]# U& v# k# F
suspected in a follow-up visit after 4 months because* s7 R5 N3 Y% k1 c2 c
the physical examination revealed the complete disap-
+ e8 ?7 @( S0 ~$ w% J, Hpearance of pubic hair, normal growth velocity, and! Q% X& v  f+ ^7 X; O4 R& T
decreased erections. The father admitted using a testos-
2 K3 Y3 P8 Q* P  }. G: sterone gel, which he concealed at first visit. He was$ f8 d/ q* ]% K; l) {; L& y
using it rather frequently, twice a day. The Physicians’
0 T/ ~4 Z3 N  z1 W7 f3 TDesk Reference, or package insert of this product, gel or
5 T* r* m% _/ x, F( {( n+ a* g0 S" Gcream, cautions about dermal testosterone transfer to8 c/ G  j/ f' ]. P. ~
unprotected females through direct skin exposure.
# M0 R. k& E  k% Z! DSerum testosterone level was found to be 2 times the/ G$ Y" ~* r, v+ P
baseline value in those females who were exposed to
" q" S) c9 _+ }) q$ Z' j7 Neven 15 minutes of direct skin contact with their male
% g7 B2 @5 F3 [- d1 a& X  jpartners.6 However, when a shirt covered the applica-
$ ^0 z" S. `) j, A( ~tion site, this testosterone transfer was prevented.
$ K4 }7 {3 |2 @& {3 DOur patient’s testosterone level was 60 ng/mL,
  Y2 P; N7 b: e3 Q. vwhich was clearly high. Some studies suggest that6 [7 A& d) ?5 L: C( K% L3 y
dermal conversion of testosterone to dihydrotestos-
- H* n5 V  x. ?9 S& g- a+ k6 Pterone, which is a more potent metabolite, is more5 v( U. E- y5 ?+ F: X1 E5 z) k8 |
active in young children exposed to testosterone8 J- h! L% Y2 R# g* a. a
exogenously7; however, we did not measure a dihy-
! }# ]$ a9 E- ]  c# ~drotestosterone level in our patient. In addition to
. G; \- H: Z9 Q3 z; p) E9 a2 H( ]virilization, exposure to exogenous testosterone in
5 Z* f8 q, b4 a. W- z0 gchildren results in an increase in growth velocity and
. h8 v9 ~1 ]7 F: wadvanced bone age, as seen in our patient.' Z! G4 n, G. N6 ?
The long-term effect of androgen exposure during
8 e2 ?" d2 D! F- hearly childhood on pubertal development and final
# Y0 m  _6 K: badult height are not fully known and always remain
, d! M7 z$ Y7 i- S* U( oa concern. Children treated with short-term testos-
+ O) i. `" m; ^/ L6 f" k. c- Sterone injection or topical androgen may exhibit some$ r* \# i- s' `1 S
acceleration of the skeletal maturation; however, after8 X0 _- `% `! [. X# d
cessation of treatment, the rate of bone maturation
* F( D3 R( T0 x/ X1 o$ U" S* }decelerates and gradually returns to normal.8,9
, g! l' y$ H- l0 k2 D/ nThere are conflicting reports and controversy
- @; @8 a" Y& p' V2 l. [# iover the effect of early androgen exposure on adult
! S* F" f+ P, h8 ^# x( Bpenile length.10,11 Some reports suggest subnormal
. ~6 M# ]1 \' ]adult penile length, apparently because of downreg-/ M/ \  x3 a; w% H" E8 ?' [
ulation of androgen receptor number.10,12 However,
. Z- i3 X3 R8 J5 L$ ^Sutherland et al13 did not find a correlation between
, @7 y& E% N8 v) W, nchildhood testosterone exposure and reduced adult5 C7 \$ u/ b: P1 W
penile length in clinical studies.( i  }+ O; A( f5 c1 \
Nonetheless, we do not believe our patient is
* a5 `% t  N4 a8 T, c6 F. ygoing to experience any of the untoward effects from
, Q" D: g. ?4 |- Utestosterone exposure as mentioned earlier because/ \' A* @( _* L
the exposure was not for a prolonged period of time.
) p" K/ U: V! ]Although the bone age was advanced at the time of) ~% s7 f2 P" u# p
diagnosis, the child had a normal growth velocity at* A/ l4 ]& L, p" e- L7 ~4 v
the follow-up visit. It is hoped that his final adult
  s4 z, q- H2 L. d# t; yheight will not be affected.$ b0 v* f/ r* [+ e
Although rarely reported, the widespread avail-: X1 a7 h& [6 S' k/ O, i, n9 n( ~
ability of androgen products in our society may
- Y) {( J5 {! A* `" mindeed cause more virilization in male or female# O. l) z$ s* p& i1 {! X5 o
children than one would realize. Exposure to andro-
) v( N0 n0 j4 X, `' ^. zgen products must be considered and specific ques-
$ y+ a6 I+ M& |3 o6 a6 Gtioning about the use of a testosterone product or( ]( D* T; N: H8 A
gel should be asked of the family members during7 N. _% y- R) h( T8 M
the evaluation of any children who present with vir-
! u. y% C- g. F8 @. A2 W  tilization or peripheral precocious puberty. The diag-
. b& \  O2 G. z( N: anosis can be established by just a few tests and by
4 ]. d+ \- u/ happropriate history. The inability to obtain such a
& ]5 a: a9 q$ E! L0 R0 {# ^* uhistory, or failure to ask the specific questions, may* k/ V3 G+ `- O. s8 Z
result in extensive, unnecessary, and expensive
  q" y6 l3 X3 Q/ k' F9 a6 rinvestigation. The primary care physician should be
2 @3 q- n9 @. k4 E# taware of this fact, because most of these children9 J9 d, Z) ~- |! }3 c
may initially present in their practice. The Physicians’
) B6 H' i# J; o7 ?% tDesk Reference and package insert should also put a' _' t4 V# B6 n( ?$ ?7 }  R
warning about the virilizing effect on a male or
. u9 U; Y; @) p' tfemale child who might come in contact with some-7 f/ M7 C: z4 x1 R6 x# m
one using any of these products.) Z5 y8 j; h! V9 A5 M: ~
References
* u" e: ]$ d3 {5 g6 w6 E+ @) y, M1. Styne DM. The testes: disorder of sexual differentiation9 q. z. Z* P) L5 [$ g6 g  Y
and puberty in the male. In: Sperling MA, ed. Pediatric
4 I& p& k4 ]/ V9 q" |6 s0 T2 nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( y3 ^# Z, M- y& Q, ?" X2002: 565-628.9 u7 I% X/ M% U$ }9 [2 p4 B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* w) l' T0 _. t: B7 p% t" Epuberty 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-Old9 m/ I2 _3 h$ g" S
Boy Induced by Indirect Topical9 b+ L6 W8 p1 ]- v1 n
Exposure to Testosterone
; g$ i2 U9 i8 A9 w/ WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 s) g2 ~( X( u% ~% g
and Kenneth R. Rettig, MD1
! E, ~6 T! Z1 w$ c2 F/ X' uClinical Pediatrics
6 b9 u: W2 M! Q. QVolume 46 Number 6" Z: J" o  k5 G9 _7 {0 E
July 2007 540-5432 y; M. I+ I! a  s# q7 J- W# g
© 2007 Sage Publications
! j7 S! Y% C; |2 y& ^10.1177/0009922806296651
% }( W* _  ^$ b, w) O* V4 v/ qhttp://clp.sagepub.com
3 M$ ?$ U/ w0 Q9 ]8 F- Q# M- {hosted at" r3 q: l- e  e, s( O, d/ Y! {
http://online.sagepub.com
" V! @" J+ D# Y  wPrecocious puberty in boys, central or peripheral,
& Y. `7 b5 ]9 yis a significant concern for physicians. Central$ G: E2 m  I% ]  H1 t$ d
precocious puberty (CPP), which is mediated- r6 l8 i( Y; H: K
through the hypothalamic pituitary gonadal axis, has2 i' ]9 _. D1 Z3 P
a higher incidence of organic central nervous system
2 M/ ^& w& m& [: e( K! Glesions in boys.1,2 Virilization in boys, as manifested! {+ T; {9 A2 B
by enlargement of the penis, development of pubic3 x8 W2 q& X1 R2 I0 J& k+ Y# ^
hair, and facial acne without enlargement of testi-* I3 x0 R% V# t' H2 P; W
cles, suggests peripheral or pseudopuberty.1-3 We+ ?% A! q# [2 Z) @% K  z1 E# h+ ^
report a 16-month-old boy who presented with the4 e. e/ N1 c, J' g  N5 ?0 T; m
enlargement of the phallus and pubic hair develop-3 p5 ~3 u" \6 y; L5 J  E7 b. E
ment without testicular enlargement, which was due* X, v* m9 U. o. b6 V
to the unintentional exposure to androgen gel used by& k8 L9 f3 I4 L: H6 N
the father. The family initially concealed this infor-
' o4 S( R/ G* j( {mation, resulting in an extensive work-up for this
; o* l$ y+ ]$ s: b0 I7 o9 `+ uchild. Given the widespread and easy availability of
9 J$ [  H/ w% ]# H; z2 ttestosterone gel and cream, we believe this is proba-9 H. V9 Z, [$ r, ]% w. ]
bly more common than the rare case report in the  R' l% Z( g! }2 j
literature.4
; b* L8 D6 t: @; }( n' E, T4 sPatient Report9 n/ j5 y: T+ i
A 16-month-old white child was referred to the
: @3 ~1 C- [0 \. Z1 B5 rendocrine clinic by his pediatrician with the concern+ W  ~. }: e/ Z/ O" [* ~
of early sexual development. His mother noticed" C+ s5 J+ {6 `$ Y7 K
light colored pubic hair development when he was7 Z' f1 I' b3 _" j, a0 D
From the 1Division of Pediatric Endocrinology, 2University of
  W2 y% L1 f, l! NSouth Alabama Medical Center, Mobile, Alabama.
  G/ _, D1 |! ]Address correspondence to: Samar K. Bhowmick, MD, FACE,3 f/ {5 u( k7 |, S. q4 L4 g
Professor of Pediatrics, University of South Alabama, College of" b8 ~- B; k5 y. d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 o" Y* o; s0 T& k6 m( We-mail: [email protected].
- v5 Y3 p8 d( R8 O* _1 C) B4 T; zabout 6 to 7 months old, which progressively became4 o/ z' e' ~( F! J& \1 K
darker. She was also concerned about the enlarge-3 g( {* c8 a& j% C
ment of his penis and frequent erections. The child& r2 u( R" x, g' \
was the product of a full-term normal delivery, with  F. _, V+ H2 k- v
a birth weight of 7 lb 14 oz, and birth length of
9 O& Z" ~! Q9 \+ d. k$ _5 m20 inches. He was breast-fed throughout the first year1 N9 i2 U' M$ T; ^5 N! k9 A, j
of life and was still receiving breast milk along with
3 ^& r% n: \5 k& Asolid food. He had no hospitalizations or surgery,
0 D( _+ O! U4 ]$ w0 ^$ e  H8 ]* Rand his psychosocial and psychomotor development
1 I1 |, l( w7 C! v# y6 P  }  W, cwas age appropriate.. D! D  _; h( z$ V/ Y; F
The family history was remarkable for the father,
" }' Y5 a. f2 t" C! Ewho was diagnosed with hypothyroidism at age 16,8 F" |* e$ l: e# z
which was treated with thyroxine. The father’s
( i, j/ @. U6 xheight was 6 feet, and he went through a somewhat
, S9 k/ d4 ~  T, a& k( E# gearly puberty and had stopped growing by age 14.! O; Y2 D) w: Y% ]1 S
The father denied taking any other medication. The/ a2 a& c- F& R  z/ q+ g+ B
child’s mother was in good health. Her menarche/ z; p) U& |: f% r8 r: N
was at 11 years of age, and her height was at 5 feet% v: P5 ~' y6 h4 J7 Z* G& }
5 inches. There was no other family history of pre-
9 W2 O+ Z% ~$ Xcocious sexual development in the first-degree rela-/ B% H4 V( P! Z/ c5 _* r! V% A! `7 C
tives. There were no siblings.
2 o- e; z1 h" X5 ^! r* SPhysical Examination
  c4 G) U' r: L! [/ o  tThe physical examination revealed a very active,
5 ?, r6 \# T+ a. U% [7 `playful, and healthy boy. The vital signs documented  {, O5 {9 V: D3 v7 ~
a blood pressure of 85/50 mm Hg, his length was; x; K1 {3 q  t' ?0 a5 w' e# h% \# b5 F
90 cm (>97th percentile), and his weight was 14.4 kg$ O, T* V1 Y8 r' v2 G
(also >97th percentile). The observed yearly growth* ~: ^' i& e% M6 ~$ `/ H5 S
velocity was 30 cm (12 inches). The examination of$ h* z$ f5 v6 B
the neck revealed no thyroid enlargement.9 M& e( T* B1 [, {. V* Y
The genitourinary examination was remarkable for
& e$ S) K4 h3 |: s3 {0 ], K$ S, {enlargement of the penis, with a stretched length of
1 {$ f7 S9 g2 \" R) B# }. K8 cm and a width of 2 cm. The glans penis was very well" b4 H- m) b. I4 O' d
developed. The pubic hair was Tanner II, mostly around
! X+ R9 B( c; W540
. }- N+ H4 p/ x" i/ s! L, uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 f7 p' i/ n# Z5 E9 x% b% g) s7 Wthe base of the phallus and was dark and curled. The1 h" g0 u% ]  Q2 W" A5 Y; D3 S" y. @5 A
testicular volume was prepubertal at 2 mL each.
8 u, ]. O9 J" U, ?The skin was moist and smooth and somewhat# `9 W  W( M; F
oily. No axillary hair was noted. There were no
+ p# w- X& I+ n9 \- l) O8 [abnormal skin pigmentations or café-au-lait spots.% x2 h$ U4 Z( h* t
Neurologic evaluation showed deep tendon reflex 2+. v/ I, L& J% Q9 [. R9 |8 K$ C
bilateral and symmetrical. There was no suggestion/ O7 [! }  d- K& Q" Z7 ]; x+ H
of papilledema.
8 ?6 E: ^- [* _- wLaboratory Evaluation# c% P" h0 z2 c! C! r
The bone age was consistent with 28 months by
$ C/ R& s* C/ z' w2 l9 o3 nusing the standard of Greulich and Pyle at a chrono-
# X/ v* E( ^( |9 ~; g/ m0 Clogic age of 16 months (advanced).5 Chromosomal3 H6 G! b3 y* f  l
karyotype was 46XY. The thyroid function test
& Q3 V& Y5 }, \% Vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( M1 l& s) G7 B0 Nlating hormone level was 1.3 µIU/mL (both normal).
- G8 z2 r0 W4 Z8 E; Q/ VThe concentrations of serum electrolytes, blood
- a& B9 \9 Z" burea nitrogen, creatinine, and calcium all were" z% Q4 w1 g& {, T. s4 O+ a* M6 b
within normal range for his age. The concentration0 X* r: Q( i0 T6 o% H# w
of serum 17-hydroxyprogesterone was 16 ng/dL! b: L# u! ?  L6 o/ }# i+ |# L
(normal, 3 to 90 ng/dL), androstenedione was 20
6 }7 J' i4 z% _- @% `- h% z6 \2 s3 Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 O+ ?/ D" C! ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 v0 i! X; ]" Q( |/ c/ c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& P0 A. ]  J8 i% {; @" y7 d
49ng/dL), 11-desoxycortisol (specific compound S)
5 P9 X% A& M& ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) h+ Z( |$ Z; \4 q( X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, J0 T, r: k" [. D4 J! C: X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ x! J2 y3 B( n6 Q* n1 c/ dand β-human chorionic gonadotropin was less than4 H1 w' A6 Y1 D* Y$ {" O$ ~
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 n7 l) Y$ `, o. n9 C7 ?3 N7 e; z  tstimulating hormone and leuteinizing hormone7 q/ Y/ P& ?. O8 ^
concentrations were less than 0.05 mIU/mL
7 z7 ]7 A; b  W& M7 g, I(prepubertal).
2 p4 e! X  x' C$ n; sThe parents were notified about the laboratory
! ?5 M* w* H; L! Z& V- ^results and were informed that all of the tests were
& S. `* }0 u' N* ?& W( H% S* Qnormal except the testosterone level was high. The
  Y: t+ [3 [# ~5 z, t$ X% sfollow-up visit was arranged within a few weeks to
0 D& u1 ~6 a* u$ Uobtain testicular and abdominal sonograms; how-
8 d; V5 m% _8 V0 x" ^" v; W! Jever, the family did not return for 4 months.
( t, X( F) h4 ~) E' m3 t- R1 YPhysical examination at this time revealed that the
- }$ ^! t6 g5 `& t' }! Dchild had grown 2.5 cm in 4 months and had gained
. X! r8 _. G6 K& m( y; c0 R1 k$ u2 kg of weight. Physical examination remained
. g/ H0 v: [8 A/ a4 v. lunchanged. Surprisingly, the pubic hair almost com-' _1 x' Y6 @$ u, G* g4 F" @
pletely disappeared except for a few vellous hairs at6 ~6 J8 ?4 C; M9 d5 L: n0 A
the base of the phallus. Testicular volume was still 23 N) r1 V8 r# r1 w  l6 t
mL, and the size of the penis remained unchanged.
; Q) Y- q5 g/ \3 ~The mother also said that the boy was no longer hav-% w, K* A9 |0 n. B3 z3 T5 S) a
ing frequent erections.; t; l6 ?+ G! F) i5 u
Both parents were again questioned about use of$ e/ M+ I/ A9 u3 B8 ^* \+ `  g
any ointment/creams that they may have applied to
/ j, Z7 [  ~7 J+ e& ?; rthe child’s skin. This time the father admitted the
# {& V2 K' F1 t, QTopical Testosterone Exposure / Bhowmick et al 541
0 ~0 a+ D1 X9 G5 A6 vuse of testosterone gel twice daily that he was apply-; r% G' X* [; |2 w3 ]
ing over his own shoulders, chest, and back area for9 d  I' \/ U9 q! e
a year. The father also revealed he was embarrassed
3 \/ y( t* m6 r3 c1 @) @# f) D& bto disclose that he was using a testosterone gel pre-5 q0 j/ m+ L3 |( p* C/ G7 X* R1 c) D
scribed by his family physician for decreased libido
+ v8 C5 A/ C0 csecondary to depression.0 U( ^* U# C$ w) G" \' s7 z% ?. o
The child slept in the same bed with parents.
+ _) N9 {( Y' Z' v% ~The father would hug the baby and hold him on his
: Q$ @3 L$ @: z8 U  @3 Tchest for a considerable period of time, causing sig-, ?' i! K' Z! T+ f. F' i$ x) e6 M
nificant bare skin contact between baby and father.1 x& E0 m+ C; b
The father also admitted that after the phone call,. A& m, S2 H* d0 w& a6 ], m% T
when he learned the testosterone level in the baby
+ X7 B5 F( a5 I. B; dwas high, he then read the product information( Z3 L* L  ?% ^; m: ^# I( m
packet and concluded that it was most likely the rea-
+ ^" I9 }* C) N) K& W5 k+ hson for the child’s virilization. At that time, they
1 w" c( `9 s7 U3 O9 adecided to put the baby in a separate bed, and the
7 j6 A. k1 i; {$ Qfather was not hugging him with bare skin and had3 C3 P9 z9 c" d4 B5 X+ N8 Q4 `
been using protective clothing. A repeat testosterone' t# O7 f8 S: I# w
test was ordered, but the family did not go to the3 g" H3 D  W1 M5 G1 \
laboratory to obtain the test.5 j  C0 L' `( \3 O+ c/ o0 D
Discussion
6 i1 e& z* a! ?! \Precocious puberty in boys is defined as secondary3 y# l! V8 e* x( H
sexual development before 9 years of age.1,4
( ~9 S2 E1 V) k! y* JPrecocious puberty is termed as central (true) when& c! p! v# a4 A
it is caused by the premature activation of hypo-
* G$ Q  Y7 u9 p- W8 p! ~thalamic pituitary gonadal axis. CPP is more com-
8 A  P2 E; Z- _/ C/ r* hmon in girls than in boys.1,3 Most boys with CPP
  R+ j) x+ ?" S. Fmay have a central nervous system lesion that is
* H( E# `5 J4 a) {: cresponsible for the early activation of the hypothal-# y2 Y9 s" Z$ [! A4 ?
amic pituitary gonadal axis.1-3 Thus, greater empha-/ Y; L& d3 Z6 d* a& S+ h
sis has been given to neuroradiologic imaging in
3 D- t: B: a4 x+ rboys with precocious puberty. In addition to viril-
- t4 }+ T3 X1 q1 ~6 _, Z: f1 {ization, the clinical hallmark of CPP is the symmet-
; n( o* e9 R- _6 Drical testicular growth secondary to stimulation by
* S7 k; Y5 a! p! J* lgonadotropins.1,3' P  K" i0 c5 r. x0 D8 v& X
Gonadotropin-independent peripheral preco-' x. t. J+ f: u: ^
cious puberty in boys also results from inappropriate
& T/ Z& \7 m* D, @6 r# Candrogenic stimulation from either endogenous or
; \9 d" d1 W' ]  e- n6 z( Nexogenous sources, nonpituitary gonadotropin stim-1 j+ i: b9 Q! [3 }3 b+ n- D
ulation, and rare activating mutations.3 Virilizing" {, W0 ?9 l# J& h" V& a' ^. x" ], c
congenital adrenal hyperplasia producing excessive/ K6 i1 n2 Z2 {% j# @
adrenal androgens is a common cause of precocious
! p; P6 D: N7 b% ~puberty in boys.3,4
- w% `; K( P1 Q/ g( ZThe most common form of congenital adrenal# Z, W& {6 f+ j3 J' C
hyperplasia is the 21-hydroxylase enzyme deficiency.* d0 R! ?: K' Z! D2 `
The 11-β hydroxylase deficiency may also result in
! ]5 E) L) V" Q6 P$ ]9 B, fexcessive adrenal androgen production, and rarely,, M( w) }0 f1 l+ j. l! B( f4 v% V1 k
an adrenal tumor may also cause adrenal androgen
# Y9 N- N/ P  w2 eexcess.1,3' A7 k) B1 I5 m$ r% `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; Z5 T, a% S+ z" ?/ q) z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; h6 M" y0 s& \1 K
A unique entity of male-limited gonadotropin-" V. E3 |: C' L) l. s! ]- K
independent precocious puberty, which is also known
; y, y; u8 P$ A7 ?as testotoxicosis, may cause precocious puberty at a4 ?/ k0 `4 u( `( U$ e# I' U0 ]* q
very young age. The physical findings in these boys0 g( \/ y; C" {: D
with this disorder are full pubertal development,+ F* ?/ w# u7 w
including bilateral testicular growth, similar to boys
1 F! M, I" F- n  f3 u: V; vwith CPP. The gonadotropin levels in this disorder/ F! P8 D1 d5 [
are suppressed to prepubertal levels and do not show' H' Y% j4 W5 X4 ^( ]
pubertal response of gonadotropin after gonadotropin-
; n' H  b5 ?/ n* Oreleasing hormone stimulation. This is a sex-linked' u$ l) A( ]) i  _
autosomal dominant disorder that affects only( ~7 c. W( r/ j
males; therefore, other male members of the family8 d0 Y/ `/ \! E- I0 i  ?  s
may have similar precocious puberty.34 {: H" z+ E, J
In our patient, physical examination was incon-) f" Z. s( s) {
sistent with true precocious puberty since his testi-# T" \) N! n( _- \
cles were prepubertal in size. However, testotoxicosis+ t- @5 S- |% T5 W1 u
was in the differential diagnosis because his father7 R# I6 d; I/ X# Q  Z1 x: Q4 |- v- h
started puberty somewhat early, and occasionally,7 a7 x2 r* d6 G( O/ o
testicular enlargement is not that evident in the
; D# C1 T* y- o7 S+ o3 {9 E. bbeginning of this process.1 In the absence of a neg-
- Z- d& W' K' q2 p3 J  k$ W! lative initial history of androgen exposure, our
0 f) I& c. E' _biggest concern was virilizing adrenal hyperplasia,+ g8 `- T' v3 Q3 P! K
either 21-hydroxylase deficiency or 11-β hydroxylase- p$ L3 J: A4 ^) S1 Y6 I
deficiency. Those diagnoses were excluded by find-& y+ ~- K* S* u
ing the normal level of adrenal steroids.
/ F& K% v1 X  a7 K: ?7 }The diagnosis of exogenous androgens was strongly8 {4 N/ [1 k0 X: }. J
suspected in a follow-up visit after 4 months because
* H4 w! ~- R( e) b- sthe physical examination revealed the complete disap-
, }7 l1 L' Q: h7 f- |/ Qpearance of pubic hair, normal growth velocity, and) _7 D4 X  H; f: b8 B9 m* P
decreased erections. The father admitted using a testos-0 p6 y2 b" [- F$ d8 i% R6 @- I
terone gel, which he concealed at first visit. He was7 q; @' x, g7 c
using it rather frequently, twice a day. The Physicians’/ F- M& c; e8 U* h% _( i- M' W  x/ u
Desk Reference, or package insert of this product, gel or1 q+ ~8 U" Q6 Q/ [+ K
cream, cautions about dermal testosterone transfer to
4 |; x8 Y  W4 H0 }  |$ U# ~' `, yunprotected females through direct skin exposure.; z4 G; }% a0 t4 L
Serum testosterone level was found to be 2 times the
* C5 V/ i# O- M; s# Fbaseline value in those females who were exposed to
& U1 B! x$ j" Zeven 15 minutes of direct skin contact with their male
/ C7 M$ v# b7 P3 Kpartners.6 However, when a shirt covered the applica-7 y. c; Z/ o  ]
tion site, this testosterone transfer was prevented.9 X4 l6 H5 k7 Z+ |
Our patient’s testosterone level was 60 ng/mL,
4 X- o! Y* v, M) m5 Xwhich was clearly high. Some studies suggest that
: q* @: D/ w5 p+ s3 {) d' Udermal conversion of testosterone to dihydrotestos-
9 w0 L+ {+ \( qterone, which is a more potent metabolite, is more
1 S1 m' ^" d2 `" z# zactive in young children exposed to testosterone5 S4 K- u5 i! U3 n! {9 `! L, Z
exogenously7; however, we did not measure a dihy-
) ~$ x8 ^& s4 D2 H7 {& q7 Pdrotestosterone level in our patient. In addition to
0 l1 o* d- |3 g: q4 L+ a8 yvirilization, exposure to exogenous testosterone in& ~6 N& M+ N8 J
children results in an increase in growth velocity and8 o9 b! c$ Y) @0 d/ T
advanced bone age, as seen in our patient.8 Q3 C" v. B7 K! X/ B. s
The long-term effect of androgen exposure during
1 ~; r  P# x" J) _" I  Kearly childhood on pubertal development and final
- q( L- l' ~, j3 W# Qadult height are not fully known and always remain; l8 A" t2 v- N- R
a concern. Children treated with short-term testos-
9 f* `9 }& l* Z5 ^# B% |1 c3 nterone injection or topical androgen may exhibit some, W- ~1 S# w; s2 B. E
acceleration of the skeletal maturation; however, after+ W! H) M% E# Q  {
cessation of treatment, the rate of bone maturation) f& F# {2 D7 b
decelerates and gradually returns to normal.8,9; u: _: G% Q" ^0 j! a3 i% u# K
There are conflicting reports and controversy; t# _; W# j& v
over the effect of early androgen exposure on adult
" |' F$ y1 I- I" Tpenile length.10,11 Some reports suggest subnormal
% t0 ]% z3 `& C0 t) Badult penile length, apparently because of downreg-) B9 M( C, o( x/ v; C
ulation of androgen receptor number.10,12 However,
0 \. P6 n5 X+ j6 R% q$ U, ySutherland et al13 did not find a correlation between
2 b. v" P& [8 c2 l+ D- i: m# Hchildhood testosterone exposure and reduced adult
+ |' a! y9 }) G6 q0 P+ u; x3 D% npenile length in clinical studies.
4 S5 n9 w+ u/ cNonetheless, we do not believe our patient is7 N: ^" o- ~- ^3 a2 u) Z: e
going to experience any of the untoward effects from
. K- Z- T6 s) e$ y* C* mtestosterone exposure as mentioned earlier because
) ]: E& |. C1 B: l3 g( I/ [the exposure was not for a prolonged period of time.
. H# g+ a: d& r+ p' a$ pAlthough the bone age was advanced at the time of
/ n1 P+ \( [9 n% A5 {' Qdiagnosis, the child had a normal growth velocity at
9 k6 K- O/ ^- a6 x2 f' e9 i8 uthe follow-up visit. It is hoped that his final adult
* g. F3 G2 K" E4 C+ ^" fheight will not be affected.. D* A4 Z0 G* k3 `+ T. v( o
Although rarely reported, the widespread avail-
$ d" c* c1 L( M$ C9 u/ x) L1 Xability of androgen products in our society may
- j$ w* R' D9 F7 g8 iindeed cause more virilization in male or female
( P2 L" U+ b  ]3 @4 U% wchildren than one would realize. Exposure to andro-
$ i+ ^2 S* e) R) S: O. \gen products must be considered and specific ques-
  k! V- N# c1 r% Btioning about the use of a testosterone product or# Q( z. R5 W: `: D7 ]' K2 X7 Y
gel should be asked of the family members during
2 t9 M# q3 D$ H* v9 |the evaluation of any children who present with vir-% \+ b/ ?$ i9 a6 f3 u
ilization or peripheral precocious puberty. The diag-
8 ]7 h) f4 i- \; V9 \+ G$ ]2 hnosis can be established by just a few tests and by
- g' `* t2 r, Vappropriate history. The inability to obtain such a" i  A" ~9 u: q! q
history, or failure to ask the specific questions, may/ g; Z' G9 y1 W" |! Z
result in extensive, unnecessary, and expensive
) Y8 D# y: b* a, U. S3 ninvestigation. The primary care physician should be9 X- S4 H3 {5 A5 _" l5 n
aware of this fact, because most of these children! J' M& @& ?; `
may initially present in their practice. The Physicians’8 S3 M& h  M, h2 z
Desk Reference and package insert should also put a7 }8 n  q* l/ U& c
warning about the virilizing effect on a male or
/ o1 A  x( R5 O) Hfemale child who might come in contact with some-
' c  R9 v; `" i+ U. |4 I! F; bone using any of these products.
% w8 Q" G5 O* CReferences& h4 ]! |0 h4 {( h2 B
1. Styne DM. The testes: disorder of sexual differentiation. ?/ X; Y3 h  \5 a
and puberty in the male. In: Sperling MA, ed. Pediatric' r4 i2 [7 |- [( v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* O: W) u' x( f3 ?
2002: 565-628.
1 D" a, \. u4 U* P# i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. B' H+ ]' m/ U! i: k7 [9 V$ s
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

0 N! \* B- T3 W) u& J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