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]
累計簽到:5 天
連續簽到:1 天
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
* `. M) p( t: Y- EBoy Induced by Indirect Topical) j7 y4 C* m6 q# [( c1 Z, C4 p
Exposure to Testosterone+ A0 \7 `( Q/ U5 O+ e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, H3 u# o8 c- G3 u& Wand Kenneth R. Rettig, MD1/ |- r2 U8 s# D) k1 t! a5 m
Clinical Pediatrics: H# s3 ]' q) K2 l9 u
Volume 46 Number 6
- n- F6 x. _! H, rJuly 2007 540-543
$ r" H9 W% ~5 E$ J# q* y# W; |! G© 2007 Sage Publications! }3 M! v, [% D, d9 \- Z0 y
10.1177/0009922806296651% E& z, R+ ]0 ?3 p1 M7 x* N
http://clp.sagepub.com' t& Y1 ~" A+ N+ u  W( C2 G* F
hosted at& v1 S- v! ~- Q
http://online.sagepub.com5 v2 V  r. j5 {$ b" ]9 ^
Precocious puberty in boys, central or peripheral,' ?! S# O6 ^( \9 z/ u! Q7 {5 i
is a significant concern for physicians. Central2 W+ N' i8 J9 r. h
precocious puberty (CPP), which is mediated4 T1 D' M8 N7 ~; T" n
through the hypothalamic pituitary gonadal axis, has$ Z* O0 y7 `0 P, s" z& O* m
a higher incidence of organic central nervous system
( h  q6 `* o3 T, ~9 ~lesions in boys.1,2 Virilization in boys, as manifested: @) k0 s3 `& y% p$ a+ g2 q2 M
by enlargement of the penis, development of pubic) O8 `7 G& T  \/ O+ c
hair, and facial acne without enlargement of testi-' Q' U2 ]2 V/ U/ _
cles, suggests peripheral or pseudopuberty.1-3 We
/ H& B3 R5 w! rreport a 16-month-old boy who presented with the
4 S0 n/ I4 @+ S% E4 e3 R9 E; \4 I; xenlargement of the phallus and pubic hair develop-
$ P4 H9 S2 O; B! B/ R3 U. e. tment without testicular enlargement, which was due
# T/ ?& {$ m: @- S. Ito the unintentional exposure to androgen gel used by
; }% ^( @1 f& L+ u8 h- t& F' l8 mthe father. The family initially concealed this infor-
% ^. G$ j9 d. B$ N( x% j2 q" j- dmation, resulting in an extensive work-up for this3 T6 c( [. Z1 A5 Q+ @$ G/ q- A
child. Given the widespread and easy availability of, G5 D( e( v, f+ ?- Z7 K5 a
testosterone gel and cream, we believe this is proba-
* K0 F& ~- X# L3 Tbly more common than the rare case report in the
7 L2 c2 \+ ?: n" Wliterature.4
* ?, |9 g+ c5 K8 PPatient Report0 M1 T5 [9 x5 ]
A 16-month-old white child was referred to the, t/ Z8 K/ y. b& _2 Q
endocrine clinic by his pediatrician with the concern* l: x) P' H; X  k# P
of early sexual development. His mother noticed# W  _- W- ~8 V" X
light colored pubic hair development when he was
, u" n7 g( @! u; oFrom the 1Division of Pediatric Endocrinology, 2University of; n  o' T( L1 W. R1 Y  ^+ b6 e
South Alabama Medical Center, Mobile, Alabama.
( q( B' f2 l% n, G) Y9 n7 |Address correspondence to: Samar K. Bhowmick, MD, FACE,- G1 S( I1 M- h$ K
Professor of Pediatrics, University of South Alabama, College of3 a6 G! l% p, h( ]1 ?) j
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 X$ U( w- ~8 y: I6 K
e-mail: [email protected].
) B7 X& y9 ^4 e2 c. Tabout 6 to 7 months old, which progressively became
, e; Z9 b" i# X- q2 Z7 @darker. She was also concerned about the enlarge-
9 y. A7 |  i/ Mment of his penis and frequent erections. The child; g1 e& \* K8 b1 w8 Z
was the product of a full-term normal delivery, with& z$ Y7 e/ A9 u3 H! s9 z
a birth weight of 7 lb 14 oz, and birth length of
% K! S. k- L; W. C# i9 \1 I: I" n+ |- U20 inches. He was breast-fed throughout the first year8 Z" `/ d& w) T  C1 |$ G5 _) y
of life and was still receiving breast milk along with9 R" ]& {' m/ Z6 L9 p1 ^' u
solid food. He had no hospitalizations or surgery,
7 M4 ?7 g; A( k2 X1 ^9 Eand his psychosocial and psychomotor development
+ j' {7 L) w$ owas age appropriate.1 L! C3 H# E6 v: q
The family history was remarkable for the father,. U; ~! B. g4 F* G; i' n5 L) o
who was diagnosed with hypothyroidism at age 16,1 Q8 e, ?1 s) ~) A
which was treated with thyroxine. The father’s6 ^- k! [7 x: U, H5 O
height was 6 feet, and he went through a somewhat( r4 m* d5 |5 J' D! C
early puberty and had stopped growing by age 14.
& E% P3 M+ P) p2 E6 d0 f: rThe father denied taking any other medication. The7 g5 i, I. G" w4 p
child’s mother was in good health. Her menarche
2 Y: i7 I6 t) `3 D- ?* A2 jwas at 11 years of age, and her height was at 5 feet& G( g6 `, P. O
5 inches. There was no other family history of pre-+ H: f) U5 n. U0 x* ?
cocious sexual development in the first-degree rela-
/ w& A$ y! Q( @& f- S! U* V7 _. y" \tives. There were no siblings.
* Q5 _. ^9 F0 S5 O5 [Physical Examination
0 k# c: K" d5 |7 y8 o- UThe physical examination revealed a very active,3 c- [# m  N! Z, \2 q# L) i
playful, and healthy boy. The vital signs documented- P$ Z9 Y6 R. ]8 L- I5 N
a blood pressure of 85/50 mm Hg, his length was
5 ^9 y& |  T9 k4 J+ O9 L90 cm (>97th percentile), and his weight was 14.4 kg* u$ A% P$ k1 n. B# U7 H7 ?7 R& \/ K
(also >97th percentile). The observed yearly growth- l, l, p. M; q
velocity was 30 cm (12 inches). The examination of
9 [; {! v+ M+ K. V$ U8 xthe neck revealed no thyroid enlargement.
) j7 Q$ [# q8 W, Z; NThe genitourinary examination was remarkable for3 T9 _3 z# R# m* S) n5 v
enlargement of the penis, with a stretched length of
2 {& Z$ l9 P! H+ ]0 X9 f8 cm and a width of 2 cm. The glans penis was very well
3 o) ]7 M+ h* J  @; ~6 S2 Edeveloped. The pubic hair was Tanner II, mostly around
* G9 \) u$ s5 r' i/ W540
9 @3 p# e& k3 F2 ]/ \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 h. V5 A% ?3 Y6 k" F2 j' @/ Othe base of the phallus and was dark and curled. The! c1 \8 x4 i7 l8 O& k5 f: n7 p
testicular volume was prepubertal at 2 mL each.. I7 U% o+ ~% t
The skin was moist and smooth and somewhat
2 O' u/ p% S8 M- N, W4 p' P1 Soily. No axillary hair was noted. There were no
% O" b+ }  u5 l' G6 S" K, U, C  b1 R/ dabnormal skin pigmentations or café-au-lait spots.% e% R  I. |, M( j1 G  m& N0 ^( ?
Neurologic evaluation showed deep tendon reflex 2++ I( _# Z# K4 j+ M6 |0 x  F
bilateral and symmetrical. There was no suggestion
( ^3 p9 v- Z0 wof papilledema.
, F2 E7 I& Q% _. iLaboratory Evaluation
9 [) D" g1 p: t; m  R" {% K% OThe bone age was consistent with 28 months by+ {4 _+ Q3 x. `" g# N( R
using the standard of Greulich and Pyle at a chrono-" E; f( c% i0 s4 l" n8 s9 ^# |2 J
logic age of 16 months (advanced).5 Chromosomal
, W  i5 X, Z/ jkaryotype was 46XY. The thyroid function test
* h2 ]' ~# q% rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 F/ ~; {2 R- y( S# F8 t" C
lating hormone level was 1.3 µIU/mL (both normal).
' P6 |6 N$ e) M. z- V( HThe concentrations of serum electrolytes, blood
2 d" J( _9 M5 M* X- Uurea nitrogen, creatinine, and calcium all were
- S- n6 u  Y/ ]5 `% }2 Qwithin normal range for his age. The concentration6 b' H; s+ z% }
of serum 17-hydroxyprogesterone was 16 ng/dL
' G0 P$ N# b3 ]8 U( W(normal, 3 to 90 ng/dL), androstenedione was 20+ t' m" x- m1 c7 i4 |# W4 ?
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: o% U( w! R$ Y* A) h; p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 W& C% S2 F( U5 \4 s
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) h& E4 K0 R9 `6 y49ng/dL), 11-desoxycortisol (specific compound S)+ {, r7 o1 w6 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( y+ g" `( p7 ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# f) a) v* \1 h* T, H0 D# [$ mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. {% r7 A" q. m4 O. R6 l7 x: r: @
and β-human chorionic gonadotropin was less than6 x1 \0 u4 g2 N9 y
5 mIU/mL (normal <5 mIU/mL). Serum follicular: p7 ?* F; m; s  B4 n
stimulating hormone and leuteinizing hormone
" C1 f( X9 u; a* d5 ~9 D' e+ Iconcentrations were less than 0.05 mIU/mL
$ d5 g* e3 `/ A* i! z% m7 _(prepubertal).
* A3 A7 p) z7 e- sThe parents were notified about the laboratory
" P( _; e6 W7 j2 g# [( ~; u% m0 Q7 Jresults and were informed that all of the tests were
) D* ]5 C* G' R) B4 nnormal except the testosterone level was high. The
4 O0 I- g0 `( z! s7 zfollow-up visit was arranged within a few weeks to
3 N; d9 I- u, [, q$ w6 z8 R% oobtain testicular and abdominal sonograms; how-" ^; v6 W- d' g* K( r2 j: V
ever, the family did not return for 4 months.
9 F6 c' N, H* pPhysical examination at this time revealed that the
4 P  J; d# v) Y4 jchild had grown 2.5 cm in 4 months and had gained
+ j+ U! e2 Y1 Y& f* }2 kg of weight. Physical examination remained
: I) y8 C: H* X2 n+ H' A% r" ^unchanged. Surprisingly, the pubic hair almost com-
" }- j. {2 U4 m/ x; }# upletely disappeared except for a few vellous hairs at
3 E: |7 B0 h5 f8 P& z% u0 Bthe base of the phallus. Testicular volume was still 2
( s+ H5 g/ W$ j) d, o0 v" `4 RmL, and the size of the penis remained unchanged.
5 P. r$ h# T: @+ y, ]/ q. ?( a* wThe mother also said that the boy was no longer hav-
( A3 w5 E5 ?0 ]( E5 Aing frequent erections.0 w; U/ x/ \0 D' T, |7 l5 t! _
Both parents were again questioned about use of0 t$ _9 t7 i  J. S6 K' f7 L: y7 u
any ointment/creams that they may have applied to9 T8 i- F# j/ d' `6 @& h
the child’s skin. This time the father admitted the0 C& Y2 l  e" b6 v, V; m: r
Topical Testosterone Exposure / Bhowmick et al 541
! D2 _( \3 T) B6 u4 X. Q, R( W! \0 ause of testosterone gel twice daily that he was apply-+ k  S  H8 ^2 |7 n
ing over his own shoulders, chest, and back area for* G' `% i" T: q; w2 {) @% N
a year. The father also revealed he was embarrassed
. l1 ?+ k9 m4 v& F. }to disclose that he was using a testosterone gel pre-
( v, c5 t$ f4 rscribed by his family physician for decreased libido
4 |) b. c( c9 `, Y) ysecondary to depression.
6 ]; _) |/ m! T+ S: {The child slept in the same bed with parents.6 |$ ~5 ?  L! s! j. g  J9 U
The father would hug the baby and hold him on his
, @( v- J1 u7 `- S& _6 j2 ?1 \chest for a considerable period of time, causing sig-
9 S% b8 n9 ^# M3 \, _) n4 fnificant bare skin contact between baby and father.
  s3 N$ R/ I! jThe father also admitted that after the phone call,
6 Z# R- k/ D) N( A  d! |$ \when he learned the testosterone level in the baby
$ e- a4 g: g- D; @6 r& M. }was high, he then read the product information
# w$ B( f/ e; M$ upacket and concluded that it was most likely the rea-8 [6 Q4 L4 C  Q$ t/ _5 k$ i, B
son for the child’s virilization. At that time, they% K4 v2 L5 O0 w
decided to put the baby in a separate bed, and the% p7 _  m$ q# n: j
father was not hugging him with bare skin and had  @. ^% X8 d' w
been using protective clothing. A repeat testosterone
4 }% s3 o  w3 z5 ?! qtest was ordered, but the family did not go to the
) ^  |2 U* O' K/ ?$ Klaboratory to obtain the test.
; G; u* V% L. z: ?8 a2 [Discussion+ S# U" [+ D, |( P/ a
Precocious puberty in boys is defined as secondary& ?: G2 O$ g$ J7 r; [9 w
sexual development before 9 years of age.1,4
7 d8 O; u( ]/ E3 c( {; Y1 C9 w: G, VPrecocious puberty is termed as central (true) when: V! |7 r6 ^" R- ~! ]$ H3 f4 R- {
it is caused by the premature activation of hypo-- g- m0 D9 a) }% Y7 q; h. }; Y
thalamic pituitary gonadal axis. CPP is more com-
; g& l$ [# b- O" qmon in girls than in boys.1,3 Most boys with CPP
. ^1 y. j- H: X; B5 m9 L" [may have a central nervous system lesion that is: S+ o9 l5 D! A) |7 A' R! S: u" q( K  l
responsible for the early activation of the hypothal-* J( T$ c4 P7 {0 T! Y
amic pituitary gonadal axis.1-3 Thus, greater empha-
4 E$ q1 W. u& ?- J9 m+ T5 [sis has been given to neuroradiologic imaging in
7 t( n+ h5 r. \3 J7 W+ l8 @boys with precocious puberty. In addition to viril-
/ x+ `: [& f6 N0 Z( O, f- g9 Zization, the clinical hallmark of CPP is the symmet-1 ~2 O/ |3 ~0 |- g( K
rical testicular growth secondary to stimulation by  C9 Y: s: N9 j: x
gonadotropins.1,3
# C1 D' W8 b1 J: H% X+ @Gonadotropin-independent peripheral preco-
1 W1 c; O( o& Z" M# H0 ocious puberty in boys also results from inappropriate
, h% @6 M% K" _6 }3 oandrogenic stimulation from either endogenous or
( k- E; L7 ]+ W6 n' S. ?( [exogenous sources, nonpituitary gonadotropin stim-
  |" y% ]! s( E6 `ulation, and rare activating mutations.3 Virilizing
. L% F9 q7 o" Z: c' [: w. pcongenital adrenal hyperplasia producing excessive  g0 G- k+ Q2 C4 o% U
adrenal androgens is a common cause of precocious
- ~8 S) ]7 ?- j9 B5 `0 n- m6 lpuberty in boys.3,4
8 Q" h  G0 q7 ^, NThe most common form of congenital adrenal# @4 c! T0 o! _# h. p5 O, y
hyperplasia is the 21-hydroxylase enzyme deficiency.. f& ^* v; ?# F& t
The 11-β hydroxylase deficiency may also result in6 S7 k9 [' `. n2 \' a* {, ?7 R! Z
excessive adrenal androgen production, and rarely,$ O* Q9 z. k( ^7 U0 W! }: K; x
an adrenal tumor may also cause adrenal androgen
, H# L5 y+ \* A  |) W1 Y/ p, t$ Aexcess.1,3: I( A+ y: ]7 g2 }6 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. E9 c! \! ]3 x. _/ O1 f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( k# W- y& @1 c7 I; Z7 D% \
A unique entity of male-limited gonadotropin-. y# }2 x/ K3 i4 w- |, v
independent precocious puberty, which is also known
' k' a% B' P" M) jas testotoxicosis, may cause precocious puberty at a
3 K$ S6 R% Z) o+ P7 b! Every young age. The physical findings in these boys: _- p( P8 N: E' w& U' ]% ~& a
with this disorder are full pubertal development,
! }* C+ G3 M1 k$ p3 Jincluding bilateral testicular growth, similar to boys4 R7 G; R' y  ]% g
with CPP. The gonadotropin levels in this disorder
- |5 L6 C3 u3 |0 y7 Sare suppressed to prepubertal levels and do not show
# s$ U( h8 A6 b! D. vpubertal response of gonadotropin after gonadotropin-
$ {( y+ p* D1 [" u' n! \/ Treleasing hormone stimulation. This is a sex-linked6 e+ ]/ Q( y& O3 r* ^' D
autosomal dominant disorder that affects only
6 }: A6 k/ p" N- R5 j: ~8 f$ Smales; therefore, other male members of the family
2 {) l; w0 t7 \) L0 _may have similar precocious puberty.34 N% I& |1 f4 H* w( f
In our patient, physical examination was incon-. a# D6 t5 j2 H$ n! X# q
sistent with true precocious puberty since his testi-' A2 B0 v5 O8 \
cles were prepubertal in size. However, testotoxicosis
3 Y7 D) U. F* t, D9 Fwas in the differential diagnosis because his father
* x8 e/ M" J6 T$ P3 G- Tstarted puberty somewhat early, and occasionally,
: n) A  T- ^1 |2 Rtesticular enlargement is not that evident in the0 r7 U  t7 Y* I
beginning of this process.1 In the absence of a neg-/ \. Q3 y+ [" j% K+ H7 j
ative initial history of androgen exposure, our
+ c- k# n$ w9 b; Z, L' d1 o# [$ t9 Ebiggest concern was virilizing adrenal hyperplasia,
" m! n" a" W: h! X3 U  c) L3 X7 ueither 21-hydroxylase deficiency or 11-β hydroxylase
: y: N0 V1 ]2 t) e; Ddeficiency. Those diagnoses were excluded by find-2 t$ `% x% d  p& Z1 `2 c$ B
ing the normal level of adrenal steroids.
% E5 p9 o8 k7 n! w( ~The diagnosis of exogenous androgens was strongly3 N( H2 K# Y* m4 A/ h- s9 T
suspected in a follow-up visit after 4 months because
' d- B8 i6 p5 C# n4 i0 O2 fthe physical examination revealed the complete disap-
4 p/ s* N& \9 b3 z# cpearance of pubic hair, normal growth velocity, and
$ U9 m2 M: a9 Odecreased erections. The father admitted using a testos-
  e* X$ {( J8 O- Rterone gel, which he concealed at first visit. He was
; U. o- G6 p/ m& g' g9 S- B; v- nusing it rather frequently, twice a day. The Physicians’9 N5 M5 }4 |" p! Y  O+ j
Desk Reference, or package insert of this product, gel or
# |' F& S' [2 r( ocream, cautions about dermal testosterone transfer to
5 Q4 ^/ p0 W3 u; ^0 Dunprotected females through direct skin exposure.5 Y- Q/ A; B) J. v
Serum testosterone level was found to be 2 times the' g, r3 g) Q% K  b
baseline value in those females who were exposed to
5 n- Y6 `6 V: T; x9 p: D& P& X- ceven 15 minutes of direct skin contact with their male& J( D) Z2 M: t8 s8 ]0 f( A
partners.6 However, when a shirt covered the applica-6 j2 w! K3 J8 h
tion site, this testosterone transfer was prevented.
: ]( _8 |" Q- ?1 [( `4 X$ b- v( yOur patient’s testosterone level was 60 ng/mL,/ \+ z, a  k% B) Q# ~! e. r
which was clearly high. Some studies suggest that* B# `+ G; z& ~. F/ G
dermal conversion of testosterone to dihydrotestos-  E' v/ a* b' t1 p& O
terone, which is a more potent metabolite, is more
- l7 O' Z0 l8 {: Eactive in young children exposed to testosterone2 C3 Z4 k2 |! }3 U3 r) x8 g
exogenously7; however, we did not measure a dihy-
- \* K+ Z3 C$ c2 E% S, B$ Ndrotestosterone level in our patient. In addition to
' ?5 U7 t. k, |virilization, exposure to exogenous testosterone in
) j/ ?9 P8 U$ C% C; E( p" ochildren results in an increase in growth velocity and% }- B" d  f; f8 p4 b' l  i& e
advanced bone age, as seen in our patient.
- C5 n$ J$ K4 m, P% D; F* q# [The long-term effect of androgen exposure during& \9 D- [, C, M! c" F4 {: v6 Y
early childhood on pubertal development and final
( |# D9 h/ |; H, E" \5 Jadult height are not fully known and always remain0 t* t( n9 S6 a$ c" L% @  l
a concern. Children treated with short-term testos-
( m+ \6 @1 y+ C, d6 E5 Xterone injection or topical androgen may exhibit some
- u+ B/ w. S1 I! Y9 Z3 i) X' Zacceleration of the skeletal maturation; however, after! c$ `4 C+ ^1 J% V; U( M
cessation of treatment, the rate of bone maturation
/ K- B0 C$ E' Q* q2 z3 s* h9 adecelerates and gradually returns to normal.8,9
# ~. O  H- ]& ^, Y0 x9 h# X# JThere are conflicting reports and controversy6 }. M4 Y' Z$ q9 V: V% A
over the effect of early androgen exposure on adult- M  N  E9 @- Z+ [+ b! s) C
penile length.10,11 Some reports suggest subnormal
8 M7 k" B+ W) g) aadult penile length, apparently because of downreg-
# Y) `2 [  y1 ~7 t: Rulation of androgen receptor number.10,12 However,) k- M' F# a8 s7 x6 a: w( `, R
Sutherland et al13 did not find a correlation between
) ?5 ?* K0 [3 v) t1 kchildhood testosterone exposure and reduced adult" ?  g* W9 f7 I4 D9 j% M/ e
penile length in clinical studies.5 |0 A; @% z. [
Nonetheless, we do not believe our patient is; i$ ?; F" N0 e9 `
going to experience any of the untoward effects from+ r: Y( Y8 c. _; w6 _: f
testosterone exposure as mentioned earlier because" H3 \4 f8 W% z5 h2 F4 g  H
the exposure was not for a prolonged period of time.
) i" M. D; _& L' n5 b; x/ wAlthough the bone age was advanced at the time of  @/ \) ^; N9 E! Z
diagnosis, the child had a normal growth velocity at3 a: S: ?: v7 U. P3 s
the follow-up visit. It is hoped that his final adult, |  G9 r  o. u' r" I% Z
height will not be affected.
, t, ^9 R8 \1 p$ W# @7 W9 C$ Q" ]" SAlthough rarely reported, the widespread avail-/ P+ a; P* K* A' R6 V* L: z
ability of androgen products in our society may
' a% g8 D/ ~4 }% d# T. Y  M$ a$ Kindeed cause more virilization in male or female* R5 [/ m  }" {* \  v) t' i
children than one would realize. Exposure to andro-
% ]: l; n* ]) D$ q6 o& y" g7 tgen products must be considered and specific ques-
, r5 J- x, h+ _, Htioning about the use of a testosterone product or
! o# D1 D9 J0 S) @* Igel should be asked of the family members during
; E( L6 h' W# C& c: rthe evaluation of any children who present with vir-+ E. N) ]2 }7 w& j# u
ilization or peripheral precocious puberty. The diag-
( {6 i+ }/ U* m  {nosis can be established by just a few tests and by/ P' z# {3 g; Q) J. s
appropriate history. The inability to obtain such a' k: v9 `  S' z+ E( p2 {
history, or failure to ask the specific questions, may
4 Z  y* Q  g, Aresult in extensive, unnecessary, and expensive
  `; [* M  k8 Q. F! c/ Oinvestigation. The primary care physician should be
2 t' t' V( D7 v* X# @% yaware of this fact, because most of these children. J2 q  A8 B" ?0 i% |+ i
may initially present in their practice. The Physicians’
0 a, c/ I5 G* j( u% P6 r# pDesk Reference and package insert should also put a: K* N/ h4 B# _" X
warning about the virilizing effect on a male or: a  M3 P. h. y2 k' {( l* q
female child who might come in contact with some-
( v- R1 g2 f0 Done using any of these products.
" ]  ]5 u% W7 \& N7 e8 q, zReferences
- ^) c: C- Y7 n$ \# }% J1. Styne DM. The testes: disorder of sexual differentiation& p5 h3 Z2 W' n' H% Q- E
and puberty in the male. In: Sperling MA, ed. Pediatric. }9 r# N" Y; o2 e9 v' U" A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 C! E5 D1 }5 z! \
2002: 565-628.
# a$ N4 C$ R: O2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, y8 ]8 u/ {% X8 upuberty in children with tumours of the suprasellar pineal
累計簽到:5 天
連續簽到:1 天
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: ~, q4 h' M5 s  I" M6 E
Boy Induced by Indirect Topical
. D+ V' h% [* @4 k% S! K6 c. @1 iExposure to Testosterone
+ X8 z- V. A$ RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" _' D6 `4 ?' C7 [+ W4 Land Kenneth R. Rettig, MD1
& {: ~8 L5 O8 M" n4 c: oClinical Pediatrics; P7 ~6 [: Z! {- ?1 @/ c! R; g
Volume 46 Number 6
; j: A; C( M. F8 v: K% [July 2007 540-5432 e" ~  N0 }2 [$ Z( F' H$ x3 S
© 2007 Sage Publications7 M: u0 F1 A: d: t6 W
10.1177/0009922806296651
% O+ b; X  Y9 s# W+ ?& |! chttp://clp.sagepub.com+ q4 n# d, r+ f, T$ z/ _
hosted at
3 C6 W' j* E# Rhttp://online.sagepub.com% W* h. W+ F1 y: }
Precocious puberty in boys, central or peripheral,
3 n+ |3 K9 g* z1 nis a significant concern for physicians. Central
/ I; I9 B3 ]% N0 ?  T( t8 x. qprecocious puberty (CPP), which is mediated) Q; O  ?) W4 |4 ]$ ]" s
through the hypothalamic pituitary gonadal axis, has
0 a. J6 N  j) D& c: Z( |, K: na higher incidence of organic central nervous system
! ?4 c' L& N, L9 C5 F7 F: alesions in boys.1,2 Virilization in boys, as manifested
. Y! W: I; }6 v5 xby enlargement of the penis, development of pubic: ~1 u9 S* R, D, W/ P* W1 [2 D
hair, and facial acne without enlargement of testi-
" E1 R0 q) o: W; R% A  o+ M4 M: ~) xcles, suggests peripheral or pseudopuberty.1-3 We6 v5 s/ Y& B4 w/ b
report a 16-month-old boy who presented with the
9 x6 U. ~# |7 `4 C/ v. K: X( kenlargement of the phallus and pubic hair develop-
2 e, s- S# s" f: G# Ement without testicular enlargement, which was due
. V1 J' W3 [* o8 J, Q0 J6 jto the unintentional exposure to androgen gel used by
3 @3 c8 ]8 `. q% T; I, |% `the father. The family initially concealed this infor-' _! B; c! f3 f. G! I; h
mation, resulting in an extensive work-up for this
1 p$ K. @, h. m( X# Q+ ichild. Given the widespread and easy availability of8 g9 J* Q- V2 `% a% |: }; y
testosterone gel and cream, we believe this is proba-! ?" {: u. q  f& j/ m
bly more common than the rare case report in the4 t) l: `& w3 e1 [4 m+ [
literature.4* p5 U$ G4 F( q- J$ l  ]; b. ~
Patient Report
3 v( m+ m  F9 W5 U; XA 16-month-old white child was referred to the2 m/ J; L& z& U  h) h1 l
endocrine clinic by his pediatrician with the concern
" _8 t7 O. q) q) y, Wof early sexual development. His mother noticed
- }4 p4 P& ^: y7 Alight colored pubic hair development when he was
+ V: q2 X3 o' l, mFrom the 1Division of Pediatric Endocrinology, 2University of
5 W7 y, a% ~6 X& X* K/ YSouth Alabama Medical Center, Mobile, Alabama.
& z, H" q/ K) i5 dAddress correspondence to: Samar K. Bhowmick, MD, FACE,
/ ~! E  V$ Y7 ~2 c; {/ c! xProfessor of Pediatrics, University of South Alabama, College of
# z- D  R" a2 x+ l7 wMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. ~* s: A. o* j- x7 D
e-mail: [email protected].
+ x5 B, A! K7 ?- P9 x$ u6 U! @about 6 to 7 months old, which progressively became
; U: [  k$ B; U5 c) Gdarker. She was also concerned about the enlarge-
8 y! M! U) w4 Iment of his penis and frequent erections. The child
) M3 Y, k+ P2 _. C( m: ]was the product of a full-term normal delivery, with
7 [5 n1 f4 P6 l( B$ }a birth weight of 7 lb 14 oz, and birth length of: Y1 m2 W% ?" i" o( M" x; N
20 inches. He was breast-fed throughout the first year
6 B* k/ g% Z3 B) s8 Tof life and was still receiving breast milk along with5 [4 `# A  \! H/ C
solid food. He had no hospitalizations or surgery,
- [" `& Z* H! n+ q/ |3 l8 Y! _and his psychosocial and psychomotor development
  K) T2 f3 s5 c, N6 L, T* dwas age appropriate.
* m+ N+ q# i2 {8 o. r+ _& PThe family history was remarkable for the father,; i" J4 C- q. K9 _
who was diagnosed with hypothyroidism at age 16,6 r% I2 F( ]7 Q" m
which was treated with thyroxine. The father’s
& j3 d" \% x% \) Q7 c+ y6 F1 L1 Vheight was 6 feet, and he went through a somewhat( E. V  y+ y1 S. w
early puberty and had stopped growing by age 14.
" N  }! i# ?" T. zThe father denied taking any other medication. The/ q+ a- ?# s1 {  n! l
child’s mother was in good health. Her menarche
9 @# F- v& K  n/ Z4 m9 Uwas at 11 years of age, and her height was at 5 feet
. ?& Q  ]4 V+ X5 inches. There was no other family history of pre-
7 ^$ ^1 f4 {) [8 H3 G3 v6 Fcocious sexual development in the first-degree rela-8 H% E3 n4 p% s# Z$ s
tives. There were no siblings., \0 ~. Q, o" L/ l' x5 H5 D" G
Physical Examination
: `7 a, p' k9 j2 ?! E* h. VThe physical examination revealed a very active,$ N9 E4 ]8 e% |: u4 D  s
playful, and healthy boy. The vital signs documented2 p( Z$ o6 E* l$ c
a blood pressure of 85/50 mm Hg, his length was
- v# s7 U2 w+ b; g0 C" Y8 [( [- |90 cm (>97th percentile), and his weight was 14.4 kg
* R7 U% B6 x, A; v8 F; V" V% O(also >97th percentile). The observed yearly growth7 f$ }! C* t/ s9 n/ K
velocity was 30 cm (12 inches). The examination of
: r' O  h" j: @' ^. `$ wthe neck revealed no thyroid enlargement.
/ \2 f' O2 W* y* E% g9 xThe genitourinary examination was remarkable for& ?( i' @) I  j. i+ y3 w9 k/ o
enlargement of the penis, with a stretched length of
& ^# J  W! x; B5 _: U8 cm and a width of 2 cm. The glans penis was very well  G, o. o2 |& \/ x/ y, Z
developed. The pubic hair was Tanner II, mostly around5 s, Q, z3 o' P
540
; |* {7 R: v; S1 Y& H5 h* V& Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) D- e% q9 h! ~- z" jthe base of the phallus and was dark and curled. The
  O* h* d) d7 Gtesticular volume was prepubertal at 2 mL each.
; |6 e, ?2 ~3 _! `, J& O( rThe skin was moist and smooth and somewhat
' {" s$ t7 [( r0 Noily. No axillary hair was noted. There were no9 K: G2 g+ r$ V
abnormal skin pigmentations or café-au-lait spots.
' e8 A* A6 A4 i+ b& @6 M: l) {0 FNeurologic evaluation showed deep tendon reflex 2+" E; L) `8 o8 j4 E
bilateral and symmetrical. There was no suggestion
. k7 ?/ q& a5 R( K; ], i) iof papilledema.
3 I! j$ e. O% j5 Q5 m4 |: QLaboratory Evaluation
- S$ x. Y3 i7 eThe bone age was consistent with 28 months by
9 j2 g9 T, L& F1 B  Yusing the standard of Greulich and Pyle at a chrono-- v' w- R" A# |5 S/ q
logic age of 16 months (advanced).5 Chromosomal
( ~+ l7 L+ [$ w) [# h8 nkaryotype was 46XY. The thyroid function test) g5 u) [& {( M8 [# t3 k; H/ O' H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; u$ J% |1 ^7 y, b* w' w& Y. }  S
lating hormone level was 1.3 µIU/mL (both normal).
% P2 f8 h9 o: B/ L. m" k* NThe concentrations of serum electrolytes, blood
- i( C; G: R2 @% _6 v2 d# Gurea nitrogen, creatinine, and calcium all were* O* v0 ]1 j% r2 ~( ~
within normal range for his age. The concentration% [/ {; p7 S7 b6 D: [
of serum 17-hydroxyprogesterone was 16 ng/dL% O- @6 s; x4 C& h0 T
(normal, 3 to 90 ng/dL), androstenedione was 20: w  H# u  x& d  T7 @* Z2 p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ @' D! e. k  E9 O& W) ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ i8 d! T# G6 G( O$ Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" U  \' u8 j0 V( B; b49ng/dL), 11-desoxycortisol (specific compound S)# D/ `8 O# w* _, _: e, H
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! {/ e/ p; J+ D7 W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% I) j9 L4 i/ Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 v0 `0 O) V4 R& m2 O" }  P, i  O/ [and β-human chorionic gonadotropin was less than
/ N9 O+ q/ K  }! L  v5 mIU/mL (normal <5 mIU/mL). Serum follicular0 d! t. T. D6 S/ w
stimulating hormone and leuteinizing hormone$ R1 K( N7 y, c0 m! _
concentrations were less than 0.05 mIU/mL2 v8 s. p! w. Q% s. L) u
(prepubertal).
( E6 ~# x6 J' ]. y! e& v- tThe parents were notified about the laboratory7 Z  a% T) v2 H  x* i
results and were informed that all of the tests were2 W9 q  h+ A5 I3 [) f: r& i
normal except the testosterone level was high. The
2 }2 A) x) F4 X3 cfollow-up visit was arranged within a few weeks to
! {  s, Q0 L; `: C' |2 \* ^5 ^' n, jobtain testicular and abdominal sonograms; how-
3 ~. W& v, A$ Y& {. yever, the family did not return for 4 months.
9 G2 v# @( D; a: DPhysical examination at this time revealed that the
9 M+ s% k) n% {: E- z6 _4 Pchild had grown 2.5 cm in 4 months and had gained
  |* z, f  k, C$ r8 o2 kg of weight. Physical examination remained
. P4 O2 J. K1 h( m, Qunchanged. Surprisingly, the pubic hair almost com-4 O) }  S, ]  J# \; o3 o
pletely disappeared except for a few vellous hairs at
0 z* V) u# {: m: U" _  }the base of the phallus. Testicular volume was still 2. C+ _0 t' G; b# r: x
mL, and the size of the penis remained unchanged.
- N& y; _- d$ u7 A  eThe mother also said that the boy was no longer hav-5 X( G9 c& w. Z. {  b$ b) X0 `
ing frequent erections.  ~: b- m9 U% U! B. Z
Both parents were again questioned about use of, d0 s* T/ N/ |& C9 k! X6 M1 @
any ointment/creams that they may have applied to
3 E3 O- }/ w4 W. m, a, Z: Ethe child’s skin. This time the father admitted the
# S% ?3 I% _- @; P8 A8 |0 Q5 `Topical Testosterone Exposure / Bhowmick et al 541
0 x2 c# }/ M; e  c) F5 w+ Iuse of testosterone gel twice daily that he was apply-. `9 Y+ x, K' \
ing over his own shoulders, chest, and back area for: [, J. D/ b  c, X
a year. The father also revealed he was embarrassed
( I, P, Q2 g+ |. D" Y0 h- xto disclose that he was using a testosterone gel pre-8 \- I1 @% L2 l5 A1 A& y% U2 \
scribed by his family physician for decreased libido: p; H0 g7 h- J- n0 k
secondary to depression.- K; |7 y1 ]+ X1 O7 d
The child slept in the same bed with parents.1 q3 m# d: J. b% u
The father would hug the baby and hold him on his6 q/ j7 l* N+ a/ _5 G( P
chest for a considerable period of time, causing sig-
, z, D5 g1 j8 l& @7 Hnificant bare skin contact between baby and father.4 N: L' a# q- m0 K( T1 R
The father also admitted that after the phone call,
7 D, y6 u3 F* t6 Pwhen he learned the testosterone level in the baby
, R% b, Q' w1 A, {4 z( `( L: awas high, he then read the product information1 A, a! p( y/ @& `" p
packet and concluded that it was most likely the rea-
( B& c1 A; j' u9 [1 F4 U. Tson for the child’s virilization. At that time, they
  ^) F5 y4 ?! @! K8 I& L  ?decided to put the baby in a separate bed, and the% ?7 p" A' n' T7 N1 g& f6 U
father was not hugging him with bare skin and had. y: y, ?) H: p3 s
been using protective clothing. A repeat testosterone8 r4 B+ G7 \6 N2 x
test was ordered, but the family did not go to the% G: W" _3 T5 _2 c# Q3 y
laboratory to obtain the test.
3 ?, x9 Z" m4 \/ ?6 v3 M8 YDiscussion, m7 T  ~: h9 {8 Q3 v7 [- ^+ n0 o
Precocious puberty in boys is defined as secondary; N8 R8 @+ z  A# h. |6 U5 {7 ]
sexual development before 9 years of age.1,4& ^" B1 U! l  }
Precocious puberty is termed as central (true) when4 I$ K6 V" S; B$ S, V1 U
it is caused by the premature activation of hypo-
) o( r/ Y# |- ]- r- M. D- I: Bthalamic pituitary gonadal axis. CPP is more com-
9 g7 @$ I2 M# a7 Mmon in girls than in boys.1,3 Most boys with CPP
# s/ e; P8 @$ |* v) O  }7 [; }may have a central nervous system lesion that is
+ P; ^- q# F# G0 _- b* Zresponsible for the early activation of the hypothal-
$ u( P( x" `( Q- y# r# r9 ~amic pituitary gonadal axis.1-3 Thus, greater empha-; W5 ?7 p+ N# m
sis has been given to neuroradiologic imaging in  b' n$ s% B' Z
boys with precocious puberty. In addition to viril-4 H5 H9 b( \5 d
ization, the clinical hallmark of CPP is the symmet-5 ^; L# t: ?* L6 f9 C) ^5 ?2 E: G
rical testicular growth secondary to stimulation by8 P! p* S: Q% q7 ]8 j" A3 X
gonadotropins.1,3
7 m7 `2 g) f! f8 |! h7 N: eGonadotropin-independent peripheral preco-+ V, ?$ S/ J0 ~3 V0 j5 Q4 \, @
cious puberty in boys also results from inappropriate- p) B" Y& j: t+ g0 r# D: T3 Y
androgenic stimulation from either endogenous or
* ]1 h2 m) s$ D/ ^4 Y& Oexogenous sources, nonpituitary gonadotropin stim-( m. \5 }3 V* `( s( K( I
ulation, and rare activating mutations.3 Virilizing9 V; x4 F, J- X1 _3 ~8 U  P
congenital adrenal hyperplasia producing excessive, d4 }1 e6 R+ Y8 O
adrenal androgens is a common cause of precocious( A3 h4 P; E* A8 R0 B
puberty in boys.3,4; x& \- T6 D& L0 r5 U2 o' K
The most common form of congenital adrenal
* e# R- A/ Z# v0 T! M& D, Ghyperplasia is the 21-hydroxylase enzyme deficiency.9 m& h' a3 z3 M
The 11-β hydroxylase deficiency may also result in
) F" L& Z. T& \$ l% _excessive adrenal androgen production, and rarely,- E# s3 c3 D, Z0 p, q- ?
an adrenal tumor may also cause adrenal androgen5 p8 ~! d. Y4 P3 y5 ^" Y0 ~% p
excess.1,34 B; F+ j) r2 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) A& }: b% m" ], I6 Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, Q5 T6 Y6 [2 [( D) gA unique entity of male-limited gonadotropin-
2 o8 w* f- G2 ^4 k/ g+ qindependent precocious puberty, which is also known6 J: h: {$ ^, b* k/ g" P
as testotoxicosis, may cause precocious puberty at a
; B! P$ Z+ G7 Rvery young age. The physical findings in these boys) |9 X4 V: c: y- S0 y$ a
with this disorder are full pubertal development,
8 }5 u4 C& M4 r& k4 v  C/ q+ S7 Rincluding bilateral testicular growth, similar to boys  ~6 H8 Y  K! P) f' _+ K2 n
with CPP. The gonadotropin levels in this disorder9 B  J( H5 f+ C; R1 g
are suppressed to prepubertal levels and do not show
6 A# u0 ^- L8 T3 [) \# }# k$ G5 ]# e1 vpubertal response of gonadotropin after gonadotropin-3 X# G, }5 R2 O* G
releasing hormone stimulation. This is a sex-linked
" c/ t( [) {; C4 B* Dautosomal dominant disorder that affects only3 x. c7 \/ B6 M; ?2 B
males; therefore, other male members of the family
, S5 ?3 T4 @5 i, Tmay have similar precocious puberty.3; r! H8 G) T7 k# J+ k! k
In our patient, physical examination was incon-; F2 }2 A7 ]/ y
sistent with true precocious puberty since his testi-( C' J  b1 k% W  b! G
cles were prepubertal in size. However, testotoxicosis4 R4 P. x- l1 G0 [9 D
was in the differential diagnosis because his father' t6 j- Q# G& a8 r2 M6 T6 ?
started puberty somewhat early, and occasionally,5 e  y( F) k$ q4 E$ a0 B; y  `
testicular enlargement is not that evident in the' `& q+ T0 b, y4 d0 k6 z% g
beginning of this process.1 In the absence of a neg-7 y, i, d' H9 t2 j3 W
ative initial history of androgen exposure, our! t0 L! s5 p( H/ F
biggest concern was virilizing adrenal hyperplasia,
& o# B! W% d, p, H( D6 P$ zeither 21-hydroxylase deficiency or 11-β hydroxylase
6 K$ z$ M+ m) Zdeficiency. Those diagnoses were excluded by find-) C. |/ v* }( {! e8 Q1 x. N3 ^
ing the normal level of adrenal steroids.
8 G% i  h; C2 v! m8 w  wThe diagnosis of exogenous androgens was strongly
6 c4 e; j" j1 ~2 h7 B' i( gsuspected in a follow-up visit after 4 months because, W, ]5 O6 }* \0 G) E9 X
the physical examination revealed the complete disap-& c1 ^. m2 U" q6 q
pearance of pubic hair, normal growth velocity, and
2 ~+ _# X# F' d2 y5 @2 j* W0 idecreased erections. The father admitted using a testos-: ^( T3 k6 q: j/ N$ [6 H: z
terone gel, which he concealed at first visit. He was
: H6 k$ D+ e0 |3 T, v  qusing it rather frequently, twice a day. The Physicians’
/ m* z) y# i; t# Y7 oDesk Reference, or package insert of this product, gel or. ^& S8 }1 a3 R" W: ^8 P6 |5 s
cream, cautions about dermal testosterone transfer to
4 n7 u" V2 L1 z8 runprotected females through direct skin exposure.. E& |/ E% g5 n9 h7 C
Serum testosterone level was found to be 2 times the
! h) I" Q% e& W5 G% B; a% k1 p6 hbaseline value in those females who were exposed to! `+ M8 G$ M" E; G! c
even 15 minutes of direct skin contact with their male
4 A% s3 v7 F; m; c, K, x( B1 cpartners.6 However, when a shirt covered the applica-
- s+ @/ q0 I1 u1 }( `tion site, this testosterone transfer was prevented.
. o) Y% c' Z7 z1 D: W' b) P. }( \Our patient’s testosterone level was 60 ng/mL,5 f, U3 O6 C2 `9 y
which was clearly high. Some studies suggest that
* n* v9 Z& ]. Y# rdermal conversion of testosterone to dihydrotestos-
7 G  m( p0 X  r& c: F  aterone, which is a more potent metabolite, is more
! `( @% U1 X0 Z4 x6 H, Aactive in young children exposed to testosterone
* Q& H: I: Y& L* w6 rexogenously7; however, we did not measure a dihy-0 Z* D9 g2 q2 a
drotestosterone level in our patient. In addition to6 x6 ]; _& U+ z
virilization, exposure to exogenous testosterone in; m2 `* b; k) }% [/ g, }4 u) i
children results in an increase in growth velocity and
! t2 m  I' X# F7 B# `" @# Uadvanced bone age, as seen in our patient.
7 y; d4 p8 b- l! v7 q9 `4 L# X) {The long-term effect of androgen exposure during+ z* _* ~7 N$ Z/ y: u
early childhood on pubertal development and final* a4 T" X4 D- Z( Q! O
adult height are not fully known and always remain& j" n9 s* T/ d% i
a concern. Children treated with short-term testos-. `, b; G5 a" `3 z+ d- X7 p1 \
terone injection or topical androgen may exhibit some
1 h3 |% v! r( i& a& b0 ?" t1 Oacceleration of the skeletal maturation; however, after
8 K. \3 H6 t/ kcessation of treatment, the rate of bone maturation! B& a% W5 L% S
decelerates and gradually returns to normal.8,9  ?$ ^% A0 B. ?" I% @& k
There are conflicting reports and controversy
8 z8 @1 ?+ T- f' L# wover the effect of early androgen exposure on adult
$ w6 _1 r$ `- a) k" i5 epenile length.10,11 Some reports suggest subnormal
; l! y2 X( l& z# C% padult penile length, apparently because of downreg-+ `# p- E6 p6 n6 n: n& Q! l0 ?+ o
ulation of androgen receptor number.10,12 However,
% w9 l3 x; E! P; Q+ ~  \; U7 eSutherland et al13 did not find a correlation between
& o* j5 ?% P! u4 p, lchildhood testosterone exposure and reduced adult* N) z3 h4 M9 |
penile length in clinical studies., ~8 |) B7 l) t3 o4 E
Nonetheless, we do not believe our patient is' V. a" p# u5 U) s
going to experience any of the untoward effects from
7 v# X# U5 ?- ~. Ytestosterone exposure as mentioned earlier because
/ c7 J# P: j7 w. P4 n3 x/ `) nthe exposure was not for a prolonged period of time., W7 o! v; k  J; s
Although the bone age was advanced at the time of* Y8 z$ b% R& o: U, X' I2 L5 x
diagnosis, the child had a normal growth velocity at
7 O: M8 C3 ?+ l* m- `; X& |! Ethe follow-up visit. It is hoped that his final adult" p+ L$ y! @9 C/ ?
height will not be affected.0 q( k" U& z6 M3 B$ F& U# B7 Y
Although rarely reported, the widespread avail-! T$ P; \9 W. ^* m7 F' q
ability of androgen products in our society may- }" ^: D# h- B% D8 X$ q. e4 ~
indeed cause more virilization in male or female8 B  f$ O7 G; B$ F2 d& v* Y
children than one would realize. Exposure to andro-% d* V2 \) @! H2 S( E; S
gen products must be considered and specific ques-' u: m5 K% U: U( z- C
tioning about the use of a testosterone product or
- Q' t; ~+ K, i: Q. `  K7 tgel should be asked of the family members during
' Z- j# G. W) R# l) C, Sthe evaluation of any children who present with vir-" j1 L# I& b. _
ilization or peripheral precocious puberty. The diag-
' \0 p5 ?1 }  m2 B/ ?nosis can be established by just a few tests and by
5 P' ]1 P/ T. q( {* P0 G/ o) a' fappropriate history. The inability to obtain such a
3 ^! x6 T# h- L/ I$ Zhistory, or failure to ask the specific questions, may2 k7 D9 A' _! r5 T$ q7 h2 N% r
result in extensive, unnecessary, and expensive
' j* u, f+ E6 q9 Einvestigation. The primary care physician should be5 N2 b. l! o4 C4 [
aware of this fact, because most of these children8 g7 L9 G2 w$ d4 C( b
may initially present in their practice. The Physicians’
3 w: ~) a& z5 a, EDesk Reference and package insert should also put a
" v7 y8 W$ f. }warning about the virilizing effect on a male or9 M/ e2 c5 i" m2 u1 E% K5 g7 k8 c
female child who might come in contact with some-
; s" A$ e0 q4 s2 _0 a/ ?  _3 aone using any of these products.
' g! M2 l& _* h& oReferences
5 N. h3 q+ A9 _- c1. Styne DM. The testes: disorder of sexual differentiation
1 B/ A! E+ B) V' V9 Land puberty in the male. In: Sperling MA, ed. Pediatric  Z( S/ p5 ]9 m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ f' j9 _: q! j0 V' i# c, p, n4 R: R
2002: 565-628.' d& B2 N! W+ x4 g. D9 X3 F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 o4 C9 o  m3 Vpuberty in children with tumours of the suprasellar pineal
累計簽到:230 天
連續簽到:1 天
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!

尚未簽到

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!
累計簽到:11 天
連續簽到:1 天
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

尚未簽到

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?
累計簽到:3 天
連續簽到:1 天
發表於 2025-1-19 02:41:05 | 顯示全部樓層
# H! N0 H: C: H' C+ N5 n
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

尚未簽到

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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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