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
  L* f! z, r  t5 h5 Z3 pBoy Induced by Indirect Topical
7 ~9 @% u, `1 b$ tExposure to Testosterone! B' Z6 C7 w1 F5 l1 O2 P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) C  A8 o( X8 H  H/ `and Kenneth R. Rettig, MD1% y3 a9 H5 u. ^' Q
Clinical Pediatrics
9 C6 _' z# Q3 wVolume 46 Number 6
5 j3 g) W3 ]( N1 V' LJuly 2007 540-543
" R: t; q5 j7 r! o% W9 d; s© 2007 Sage Publications) z' i; I6 h7 u5 h& P
10.1177/00099228062966516 H' ]7 L8 q% h+ e
http://clp.sagepub.com9 e6 F. V& O) O1 q3 W4 T
hosted at7 j" `1 f% s8 A$ o" @/ E
http://online.sagepub.com" h" E# b0 n0 b& V: `
Precocious puberty in boys, central or peripheral,, C- d" W3 B, a" `- B2 S5 V3 I
is a significant concern for physicians. Central. j3 ?5 F# ]+ h& |1 i
precocious puberty (CPP), which is mediated; a9 s# t& l; z; c5 K' ]/ t, u
through the hypothalamic pituitary gonadal axis, has
! u  f0 D) |$ D- _a higher incidence of organic central nervous system5 `; C; v5 R! \+ q, T
lesions in boys.1,2 Virilization in boys, as manifested
$ L5 n  n% c; p  Y- N; Eby enlargement of the penis, development of pubic8 c% j$ ~/ o; W) t$ [
hair, and facial acne without enlargement of testi-/ C$ @& ]  n" [; P1 U
cles, suggests peripheral or pseudopuberty.1-3 We1 j+ g; Z/ I& O' O; O/ p# [8 R
report a 16-month-old boy who presented with the
- G- m( _+ \  k5 yenlargement of the phallus and pubic hair develop-: }* ^- ~! W0 }8 I- }5 \0 Q
ment without testicular enlargement, which was due
4 t. @2 H" U* Tto the unintentional exposure to androgen gel used by2 ?6 f3 @4 W; h  ^
the father. The family initially concealed this infor-+ ~" E! K1 a! N/ i
mation, resulting in an extensive work-up for this9 z9 g* D6 k9 u( L  Y1 a
child. Given the widespread and easy availability of
# S4 Y/ @6 X0 X3 gtestosterone gel and cream, we believe this is proba-3 N% q+ J- t& p5 m' w" F6 n2 B
bly more common than the rare case report in the
% o8 z* r; x" {3 }7 \literature.4
3 R. a* V. [+ y# _, T+ E: APatient Report
! {: h7 l+ ]! VA 16-month-old white child was referred to the
  S# S* L; v! f4 k0 Iendocrine clinic by his pediatrician with the concern# J  t- `+ j; [
of early sexual development. His mother noticed
+ }! q7 _4 p4 P  F2 hlight colored pubic hair development when he was
3 ?& y$ A" M/ O" w: @! {From the 1Division of Pediatric Endocrinology, 2University of
: Z( E6 |$ m, C3 @South Alabama Medical Center, Mobile, Alabama.
! ~. P: ^$ L1 S3 I) W1 YAddress correspondence to: Samar K. Bhowmick, MD, FACE,
) V; m9 G7 L" t) l# YProfessor of Pediatrics, University of South Alabama, College of
* C2 P4 @4 F/ ^" oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ V% O. A9 S: Q, w" W; i
e-mail: [email protected].9 ^/ O6 P0 t5 a  ?- r+ C
about 6 to 7 months old, which progressively became
+ y3 M/ }8 q2 K5 F# \& b# Bdarker. She was also concerned about the enlarge-
. D7 b6 H/ u5 m7 n4 iment of his penis and frequent erections. The child
: E  n: K3 J/ v# W8 U/ \) i. x; wwas the product of a full-term normal delivery, with( C+ o* E1 d: \# f
a birth weight of 7 lb 14 oz, and birth length of
0 X* e3 X3 `$ i+ h, x20 inches. He was breast-fed throughout the first year3 G2 K5 s0 y5 g
of life and was still receiving breast milk along with
) M- S( j9 X! N9 E8 S1 U$ [' @solid food. He had no hospitalizations or surgery,0 \( {! f9 i- J6 [0 g
and his psychosocial and psychomotor development2 t- a. v4 i; F/ b/ ]+ j) V
was age appropriate.; S+ Z* x2 `  W3 p- ]5 J1 s3 B
The family history was remarkable for the father,3 g, _+ M, B- Z
who was diagnosed with hypothyroidism at age 16,$ @6 |9 [  S, f  G
which was treated with thyroxine. The father’s, [6 W' J1 o% W% [2 o9 _" l
height was 6 feet, and he went through a somewhat
$ a  v& Y5 v) Iearly puberty and had stopped growing by age 14.% O* `2 Y- e, O- b$ Z  u
The father denied taking any other medication. The! @8 s7 O/ S9 r* @; I
child’s mother was in good health. Her menarche5 L1 N! p2 U5 i
was at 11 years of age, and her height was at 5 feet0 V8 I3 C, v. o# I' r! @
5 inches. There was no other family history of pre-
4 C5 h6 ?3 N4 J; q  h: Zcocious sexual development in the first-degree rela-
) Q6 p6 p5 ]+ u# s6 {tives. There were no siblings.. V  T: f4 @' }. }2 X) x: q* B: B
Physical Examination
  ?* \0 S% I6 d1 I  `) Y3 \/ sThe physical examination revealed a very active,9 B( N) p) M+ @& z8 H
playful, and healthy boy. The vital signs documented8 j. M  ~5 `( ]& ~% F+ E6 F+ D% x
a blood pressure of 85/50 mm Hg, his length was9 [' W' l2 \+ o2 `0 @; O
90 cm (>97th percentile), and his weight was 14.4 kg# A6 V) l; C  {
(also >97th percentile). The observed yearly growth7 V+ t* s3 c  \8 G2 I: W
velocity was 30 cm (12 inches). The examination of
! Z9 C7 v  }$ G0 i, v6 O/ g2 v. Sthe neck revealed no thyroid enlargement." Y& R# k+ ]! F, N* z. R; E. b2 ]4 N
The genitourinary examination was remarkable for
' z/ U6 s+ k$ ?4 C2 u( D- R& Aenlargement of the penis, with a stretched length of
" ^& ^9 |( V5 M8 cm and a width of 2 cm. The glans penis was very well5 V# U1 J4 F' S5 l4 X- v- p
developed. The pubic hair was Tanner II, mostly around
2 |% a2 v; R# h% V' I2 d540
3 t  n9 q! R5 f$ w- M. k1 L  }; uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 K/ ?# k' o9 l3 j: S3 U
the base of the phallus and was dark and curled. The
; b2 g( U8 S( n/ K; r$ [8 Qtesticular volume was prepubertal at 2 mL each.
) p9 s( ?8 J  P8 ?4 S# h( NThe skin was moist and smooth and somewhat
5 W9 Z  Z4 Q3 D: {4 Hoily. No axillary hair was noted. There were no
! x# {$ E. K1 B6 W; q, Uabnormal skin pigmentations or café-au-lait spots.6 }& E4 p9 y0 h& V' W
Neurologic evaluation showed deep tendon reflex 2+
  n- V/ i8 W& S# l8 v, {6 n* zbilateral and symmetrical. There was no suggestion
; ~  ?+ ^  N- I0 \$ ?& Fof papilledema.5 x3 ]: y9 x4 n1 _8 r5 ~
Laboratory Evaluation. C1 L. y) U0 H( G+ L
The bone age was consistent with 28 months by- b; E, L/ q% @( P
using the standard of Greulich and Pyle at a chrono-
) c+ R- s' n  K  r6 qlogic age of 16 months (advanced).5 Chromosomal3 T: [1 G- T+ _0 Q6 F1 f
karyotype was 46XY. The thyroid function test
! S2 L3 a$ ]- ?, S  j9 sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 r6 L7 G4 W, D* A7 P& J( Llating hormone level was 1.3 µIU/mL (both normal).
0 t' v" ~. _  p3 i/ u, F) \# A' v: pThe concentrations of serum electrolytes, blood
" \. D" g7 c! Uurea nitrogen, creatinine, and calcium all were
% j& a  s" M+ X, ^& b4 Wwithin normal range for his age. The concentration
* W4 u; I+ r4 y' U' Eof serum 17-hydroxyprogesterone was 16 ng/dL
; e- y9 }4 K* E2 l(normal, 3 to 90 ng/dL), androstenedione was 20
* s7 @4 H7 Y# ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 R0 I$ N/ I4 x2 f9 i( M
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  s" w4 J+ c  n8 `/ Z9 J' H5 f5 i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ Q$ @" }1 j; F' l- H1 `
49ng/dL), 11-desoxycortisol (specific compound S)& `! g" V/ h4 V: A, a4 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ r, t3 G2 q+ u5 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* e- N/ }+ M' H; j
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- v- H+ P/ n8 B& J7 u
and β-human chorionic gonadotropin was less than
4 O: ]& i7 S5 z* Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
. P' \/ M; T% a! J# ]  U$ Fstimulating hormone and leuteinizing hormone$ S- O9 ]! e8 A  [
concentrations were less than 0.05 mIU/mL0 j- e: `; B9 P
(prepubertal).
/ A; q0 H- \* hThe parents were notified about the laboratory" ?& s: g* G  _. U5 h( F
results and were informed that all of the tests were3 i2 u1 |4 R! {
normal except the testosterone level was high. The1 V* l( E! b' h  w5 `. o6 C; F
follow-up visit was arranged within a few weeks to' H- e+ s7 e/ b( }- O
obtain testicular and abdominal sonograms; how-
( V& e' f. s* m' v* ^: Pever, the family did not return for 4 months.3 S+ }" Z" P  }  K
Physical examination at this time revealed that the
1 ~! a3 [) U! G; C' N. cchild had grown 2.5 cm in 4 months and had gained- T9 H+ V* Q/ v6 U1 y* M
2 kg of weight. Physical examination remained
/ t; q1 ~: n; D" q0 J0 w7 Dunchanged. Surprisingly, the pubic hair almost com-
$ r- c/ e! X9 ~2 z6 G* Lpletely disappeared except for a few vellous hairs at/ a4 a4 r: P! H! o! g$ s) Q- R
the base of the phallus. Testicular volume was still 2
  q" {+ t3 h0 B9 F* `, M; umL, and the size of the penis remained unchanged.8 Q% V1 u" V) R* D; }; w8 T
The mother also said that the boy was no longer hav-
, c, w* o( {9 E) X3 B6 ming frequent erections.* ^( z  J6 ]5 O0 v
Both parents were again questioned about use of
: Z  a+ q8 D: G9 P$ \any ointment/creams that they may have applied to. M1 P5 P0 W. S. B8 f, }
the child’s skin. This time the father admitted the. w2 j9 f+ P4 S8 P* `8 v0 Q
Topical Testosterone Exposure / Bhowmick et al 541
( @5 c6 d$ H& u3 ]+ ouse of testosterone gel twice daily that he was apply-
  p) {, K* h, e* ming over his own shoulders, chest, and back area for
. N; Z9 J8 l5 Va year. The father also revealed he was embarrassed7 r% J1 t6 K( N: i
to disclose that he was using a testosterone gel pre-' B" N5 Z1 T3 H* m6 v" S
scribed by his family physician for decreased libido3 f; q: O) [( ?$ T
secondary to depression.  `1 F, `, x* x0 y8 Y
The child slept in the same bed with parents.
4 t1 u) J/ ]+ B+ z! BThe father would hug the baby and hold him on his
$ ?( S7 g  E$ q$ l% [; U" V6 f5 `chest for a considerable period of time, causing sig-
% i- j+ f! Y& I" Cnificant bare skin contact between baby and father.
' H4 E; X. g- n6 a  ~The father also admitted that after the phone call,3 C# c) }8 p7 n, t
when he learned the testosterone level in the baby
' a: q+ H& N/ s3 J* rwas high, he then read the product information
# D! f, F. [! U0 |5 dpacket and concluded that it was most likely the rea-
' z  g3 z1 U* q# ~8 Nson for the child’s virilization. At that time, they2 q  G, }. \7 k( ]1 l0 |, [
decided to put the baby in a separate bed, and the
/ O7 b- g& X/ b0 Q8 g9 _father was not hugging him with bare skin and had
% V+ ^( A0 _/ tbeen using protective clothing. A repeat testosterone) v5 _6 i" D$ f4 n0 {/ o/ k' Z. X
test was ordered, but the family did not go to the
& B- Y5 }, B# M+ e5 olaboratory to obtain the test.4 l4 p, j5 D2 n- A7 q+ t1 _+ `
Discussion, S+ h) n7 ]6 K  R0 F) ]
Precocious puberty in boys is defined as secondary
% s  S: S: r+ Ysexual development before 9 years of age.1,4* O0 J2 R5 r& D" I) T: E
Precocious puberty is termed as central (true) when: n3 F+ [* w4 e! h+ ~8 [
it is caused by the premature activation of hypo-
# [+ e% }+ l( M* |8 t6 o' u1 Vthalamic pituitary gonadal axis. CPP is more com-4 q0 L" i" {* t% Q! I
mon in girls than in boys.1,3 Most boys with CPP* _$ Q5 h4 d, ]+ X: K9 t! V3 V
may have a central nervous system lesion that is
* c; g8 l$ C2 G) r$ Mresponsible for the early activation of the hypothal-
% Y& ^7 L9 O( X0 E4 h$ q. hamic pituitary gonadal axis.1-3 Thus, greater empha-( J% v% z: F; H2 r5 Z8 x. w
sis has been given to neuroradiologic imaging in
6 w/ X0 m- R2 [) ?" t# j; ]: xboys with precocious puberty. In addition to viril-3 d: I) u* z8 _7 ]
ization, the clinical hallmark of CPP is the symmet-
8 L( ~: e& d  x) r( N! ~! o2 Erical testicular growth secondary to stimulation by
% F0 r/ ]# U  ngonadotropins.1,3* W' U& I! x3 D+ y1 y! i7 ^% {
Gonadotropin-independent peripheral preco-
' J* Q0 G% V2 k! Ucious puberty in boys also results from inappropriate
2 r; y& Y/ T2 M/ ^$ F# Y; t8 M% ?androgenic stimulation from either endogenous or
! }4 d6 l! [4 R: c% \$ M* Fexogenous sources, nonpituitary gonadotropin stim-
! T+ S" s' k+ j3 m/ Sulation, and rare activating mutations.3 Virilizing# e0 Z% r- u; Y
congenital adrenal hyperplasia producing excessive
( j( V9 P0 j3 v- Nadrenal androgens is a common cause of precocious1 y" G% m2 A/ O3 L! r
puberty in boys.3,4
  a  ~( u* n. \8 |- pThe most common form of congenital adrenal
) O  K, C# t% b# b8 i* Zhyperplasia is the 21-hydroxylase enzyme deficiency.3 S, Q: V+ e+ {3 N- A+ x
The 11-β hydroxylase deficiency may also result in( O0 ?  n6 r- H* O9 E! I6 {( s3 |
excessive adrenal androgen production, and rarely,
  `3 z# G' V9 V# ^7 m2 k( \3 Z: \an adrenal tumor may also cause adrenal androgen. W" G* l9 y6 e) i; {
excess.1,3. t8 N) ~* k+ J( X1 ?0 b9 q9 S& P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& ^( m/ j. I3 K: z7 y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 _3 b4 p/ H6 Y$ S. ^A unique entity of male-limited gonadotropin-2 P; I- Y; L/ j8 L+ W8 E6 j% \6 [
independent precocious puberty, which is also known/ t! `% x) Y6 e! _$ g9 r
as testotoxicosis, may cause precocious puberty at a
  u/ U* k. W7 @! d' Xvery young age. The physical findings in these boys) I; M  [/ ?* }/ Y  l  y8 l
with this disorder are full pubertal development,
- ], m+ v' G9 x6 C1 ~  y6 @6 {* tincluding bilateral testicular growth, similar to boys$ b) C4 |; ?; _7 w: l9 H' [6 K
with CPP. The gonadotropin levels in this disorder
. a& [- j; }5 m  d$ j( iare suppressed to prepubertal levels and do not show8 u' h$ j0 A8 v
pubertal response of gonadotropin after gonadotropin-
. v  s; V6 v! T& L9 c  ireleasing hormone stimulation. This is a sex-linked7 f; D2 b$ A" }( C' s2 y
autosomal dominant disorder that affects only
8 z: C0 W% v  H) dmales; therefore, other male members of the family
& z) p' P1 k& A) O2 Wmay have similar precocious puberty.3
6 w! w$ f- e0 J! }& m: ]; V; d2 ZIn our patient, physical examination was incon-1 i5 }  j% r, ?# D
sistent with true precocious puberty since his testi-
* M# B# G  v! I" V' B0 _# c, T: Xcles were prepubertal in size. However, testotoxicosis
- i( ~; w1 E% K$ T: Ywas in the differential diagnosis because his father
) \* \# N+ J9 w/ C2 U% D- L  Zstarted puberty somewhat early, and occasionally,
) I* @) ?# U1 l, jtesticular enlargement is not that evident in the# y1 C! ^' `1 J& k2 k, E
beginning of this process.1 In the absence of a neg-( S& c& h% x! `8 O/ \0 j
ative initial history of androgen exposure, our0 D/ s! J+ f. }' u2 N7 I
biggest concern was virilizing adrenal hyperplasia,6 N  F) K. i' B3 x. {, I7 J; t
either 21-hydroxylase deficiency or 11-β hydroxylase; v2 T: V( o1 E2 X
deficiency. Those diagnoses were excluded by find-1 d7 b2 W9 u# K9 K4 k5 P# y3 [
ing the normal level of adrenal steroids.
: c+ x# U# p% n, ]) ?The diagnosis of exogenous androgens was strongly
; K* g, Y: i/ k* L5 Qsuspected in a follow-up visit after 4 months because
. z8 m9 r4 C# a( ?the physical examination revealed the complete disap-& s4 Q' q! F. `
pearance of pubic hair, normal growth velocity, and9 I0 t" A$ o; Z1 p  R2 j
decreased erections. The father admitted using a testos-
! r, K4 l) W5 h' O8 v. _terone gel, which he concealed at first visit. He was9 c' e1 ^+ |: i" l
using it rather frequently, twice a day. The Physicians’' g' R7 B3 j7 \7 J$ T; n$ V
Desk Reference, or package insert of this product, gel or
/ K5 Z& L. m) z8 x1 u, ^cream, cautions about dermal testosterone transfer to! l, R$ ~/ E4 Y! C9 U
unprotected females through direct skin exposure.# E: O! f6 G& j1 j- g9 l
Serum testosterone level was found to be 2 times the
* {) O' Z; x- V% S4 T) {% Lbaseline value in those females who were exposed to' P& a! X* ?; H
even 15 minutes of direct skin contact with their male, G& Q4 h( ?* P+ z, @5 h
partners.6 However, when a shirt covered the applica-
* m/ R7 Z0 s* _/ G) Vtion site, this testosterone transfer was prevented.% B" z' _; h2 a, S, ~
Our patient’s testosterone level was 60 ng/mL,4 I6 W7 K- y, K, a
which was clearly high. Some studies suggest that4 T$ p0 W/ F$ R2 @  J! p% M
dermal conversion of testosterone to dihydrotestos-; i- `& Z) J: |5 M: t% D- w
terone, which is a more potent metabolite, is more
: ?) g( \+ {; f- cactive in young children exposed to testosterone0 }) [$ e! Q. p  n
exogenously7; however, we did not measure a dihy-: r' w& C  ^& z" P7 h
drotestosterone level in our patient. In addition to
+ y1 d) t& Z# _7 Q" d2 P5 g& `6 Z- [virilization, exposure to exogenous testosterone in
0 f7 [# b2 N) p, C0 dchildren results in an increase in growth velocity and) r3 o9 R% H, g) o, d* C- ~+ K
advanced bone age, as seen in our patient.1 E  A+ x7 F8 ~+ A8 R
The long-term effect of androgen exposure during
7 }- o; D+ F1 Nearly childhood on pubertal development and final- H' ~0 n, x) r9 J) m: b
adult height are not fully known and always remain
- _5 ]6 ~5 @3 \a concern. Children treated with short-term testos-
- t5 L9 h2 x8 W6 X( y  d, ?terone injection or topical androgen may exhibit some
' I# d) L! N; }% H! q; [/ R* H  Kacceleration of the skeletal maturation; however, after
3 u9 C6 S8 j$ {* Y. T: Kcessation of treatment, the rate of bone maturation
3 y. U+ q- K) X3 x+ R* rdecelerates and gradually returns to normal.8,9
2 G8 s/ P) w5 JThere are conflicting reports and controversy
, C. M! l. C" o3 Nover the effect of early androgen exposure on adult, N0 z" _( W# P  W9 Z
penile length.10,11 Some reports suggest subnormal
0 _9 |/ p; J: k- d2 }( j3 e2 Zadult penile length, apparently because of downreg-
1 U2 y, E) ~3 ], L& |ulation of androgen receptor number.10,12 However,
8 G9 k+ h/ t2 r% eSutherland et al13 did not find a correlation between/ Q8 F1 v2 n& h( R( l9 x- o  c6 a$ l
childhood testosterone exposure and reduced adult' M" h& v3 N. f' V! }4 C
penile length in clinical studies.
  m/ Q7 j/ }) C# xNonetheless, we do not believe our patient is$ i; A" n! ?! B( |1 H, d
going to experience any of the untoward effects from
% f  \7 G0 c$ i6 a9 ftestosterone exposure as mentioned earlier because, w, G$ n) L$ [+ M  [0 O# O/ I
the exposure was not for a prolonged period of time.
& S+ k" o( K$ z+ {Although the bone age was advanced at the time of2 s5 I; N8 x; g5 C
diagnosis, the child had a normal growth velocity at
1 z+ v# G' z" ]/ i3 \the follow-up visit. It is hoped that his final adult
% u9 h0 k4 i& Y1 \; Zheight will not be affected.
3 g/ ~$ q3 S& X  C8 AAlthough rarely reported, the widespread avail-
: u4 q7 K- i6 X6 Y  Hability of androgen products in our society may5 T/ Y* k" W5 \
indeed cause more virilization in male or female1 f- \7 g$ ^9 k/ v0 x5 S
children than one would realize. Exposure to andro-, d5 Z) ^* k0 n5 b+ S: M7 j
gen products must be considered and specific ques-
, m9 x9 j2 q8 ptioning about the use of a testosterone product or* t$ N( H9 c" C8 x, P4 z  ?
gel should be asked of the family members during0 J! z" \( f2 P& U0 C
the evaluation of any children who present with vir-- x1 w0 ~! Q. a& d" f2 ^
ilization or peripheral precocious puberty. The diag-
, i) [  C1 ]/ K+ dnosis can be established by just a few tests and by
  m) n9 Z2 o# Lappropriate history. The inability to obtain such a
7 p2 [; M" _2 r* ahistory, or failure to ask the specific questions, may% t9 ]; V) a' A  @$ l
result in extensive, unnecessary, and expensive, U; Z' ?1 N# R' M4 R* J4 F) k' c7 ^
investigation. The primary care physician should be
" L& R" R9 c7 J) n( Vaware of this fact, because most of these children; w4 s9 T1 V; F/ |2 u
may initially present in their practice. The Physicians’- S+ U. d5 f- U2 J
Desk Reference and package insert should also put a
+ m; [& k1 ^, k5 y* F8 I  L4 Jwarning about the virilizing effect on a male or3 z5 ^, M! U! |% O( ^! q" [
female child who might come in contact with some-, L/ Y! R" E* |3 V
one using any of these products.
* t. b$ e) F3 X4 D2 q3 E3 K9 BReferences
! R* g& R. y/ u, t  }  O4 O1. Styne DM. The testes: disorder of sexual differentiation6 z# N8 A" D: M0 ?  |$ L6 H
and puberty in the male. In: Sperling MA, ed. Pediatric
  d+ E/ L( _) O3 s* s2 yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ U( H( r. c( o! y1 d$ [# o
2002: 565-628.& f$ u1 a$ j( q; C; K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: j0 d3 v4 A$ p/ Apuberty in children with tumours of the suprasellar pineal
回復 支持 反對

舉報

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
. ]3 m- h3 n8 ]4 k3 G6 X( S$ dBoy Induced by Indirect Topical( g2 y$ o2 M4 m' a; o. |  b/ \, i
Exposure to Testosterone9 z, S6 {+ B  B8 x. x# f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% E7 [1 P9 l1 C* ^! R% u+ d$ Y
and Kenneth R. Rettig, MD1
  R% t- ]" T4 mClinical Pediatrics; l. p+ ]6 m& a8 l9 E9 v
Volume 46 Number 6
  o/ {8 w/ Q2 U7 o# N+ t0 g8 OJuly 2007 540-543
1 m6 R4 J/ `6 r© 2007 Sage Publications4 d8 [& j9 e: p# s( s+ x
10.1177/0009922806296651
5 D: H' |; N3 N1 ahttp://clp.sagepub.com2 z' Z# {3 y) z
hosted at
' Q$ n! ~' o. p- l( |& Ahttp://online.sagepub.com' V- X. J4 x/ R9 u# a
Precocious puberty in boys, central or peripheral,9 k5 u3 [! A) N9 |2 [7 b& j& Z
is a significant concern for physicians. Central0 s7 H9 ]* m4 E, x, |$ q$ p9 A8 h
precocious puberty (CPP), which is mediated
8 W6 w& c# X4 S7 x' F- t! B2 n$ Ithrough the hypothalamic pituitary gonadal axis, has
) ], S, a5 W( U& Ma higher incidence of organic central nervous system
$ t( A( W' _  Y; [& ~2 F5 g6 a& q4 xlesions in boys.1,2 Virilization in boys, as manifested
& N* m8 O/ M6 pby enlargement of the penis, development of pubic
1 N: z4 [% v7 C7 f+ A: {$ Dhair, and facial acne without enlargement of testi-9 r* H  d$ x7 P) k9 o
cles, suggests peripheral or pseudopuberty.1-3 We
' L! E& ]+ k; t( G* `  G+ Q7 Ureport a 16-month-old boy who presented with the+ P# @0 J% _7 T: e
enlargement of the phallus and pubic hair develop-1 n& ^/ D% Z  X2 G0 o, M, V
ment without testicular enlargement, which was due% C/ r" L" U4 ^+ M
to the unintentional exposure to androgen gel used by/ j/ \- x$ g# u' p% o/ I( N
the father. The family initially concealed this infor-- `  t2 J1 y1 r# Z( i; \. j
mation, resulting in an extensive work-up for this
5 F% n+ p6 L2 a* ?: R/ Cchild. Given the widespread and easy availability of
) h. x' M) t, x! ~8 xtestosterone gel and cream, we believe this is proba-
: Z/ {7 K- c% w" wbly more common than the rare case report in the
. j& U! T9 z9 N- ~+ p# i- N: sliterature.4+ e& G/ G' S) ]) @! h5 j2 `
Patient Report
1 o7 a9 U; V# n% QA 16-month-old white child was referred to the; n6 `% V6 L7 t8 }
endocrine clinic by his pediatrician with the concern
, X& F/ r6 s% W# V- Y% {of early sexual development. His mother noticed* K( `3 f# j  x5 x6 ~
light colored pubic hair development when he was
4 |; P4 |( d* f1 s4 w2 J0 _/ qFrom the 1Division of Pediatric Endocrinology, 2University of4 T8 g  m* L* m" z$ V- E3 \
South Alabama Medical Center, Mobile, Alabama.
3 _5 K8 W  w7 M: X9 O7 zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; H& @/ o- J' n6 C9 G! `% W1 _Professor of Pediatrics, University of South Alabama, College of( Q# n- j4 W# x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 J3 i- `9 p7 [2 R1 T/ C) |
e-mail: [email protected].
( N6 t% [& f0 S# c" Vabout 6 to 7 months old, which progressively became
6 D  T/ E0 V0 [$ L# u4 Zdarker. She was also concerned about the enlarge-# C: Y5 m% \" E( v- u$ n- V
ment of his penis and frequent erections. The child
. X# e6 @, X  d$ @8 Swas the product of a full-term normal delivery, with. S8 C3 t8 ?& v, X1 ?. U
a birth weight of 7 lb 14 oz, and birth length of
; z4 t( T$ v" @: k" o20 inches. He was breast-fed throughout the first year$ i9 M' F7 U! j" ]
of life and was still receiving breast milk along with
$ A" d0 k5 }! y8 H" Zsolid food. He had no hospitalizations or surgery,
6 k: e* Y. ^3 `and his psychosocial and psychomotor development, G) }9 a* c  o. p" n2 \
was age appropriate.
- Z' V! t7 L) f5 y* M3 R* j2 VThe family history was remarkable for the father,
3 |% [/ P1 m& S8 q+ X' T9 B. Twho was diagnosed with hypothyroidism at age 16,
& I2 S; k% Q: A* v! w! s$ Twhich was treated with thyroxine. The father’s" M5 U" G4 b# ]/ D' P+ R& g
height was 6 feet, and he went through a somewhat
5 S! M& ]+ I1 h' S3 H6 J) W7 d* Bearly puberty and had stopped growing by age 14.
# ~7 l7 ]3 c; P% ]# ?! p) a; e, KThe father denied taking any other medication. The- q9 b) X. D) l9 }, w: Q$ I, \
child’s mother was in good health. Her menarche# a& [7 G  Z* U! w
was at 11 years of age, and her height was at 5 feet
% P4 [* ^+ T: {8 T5 inches. There was no other family history of pre-: _- }% i; z) v( {
cocious sexual development in the first-degree rela-
2 a. S2 @& y3 N% X) K3 ztives. There were no siblings.
$ F/ Q# ^% }" o: q7 P; n9 ^% CPhysical Examination9 v4 K' n6 _( N! `$ M
The physical examination revealed a very active,
4 j) n0 T! U; d3 o3 K0 r; m* rplayful, and healthy boy. The vital signs documented
; X! i0 E3 O+ Ja blood pressure of 85/50 mm Hg, his length was! m, U2 D! T1 T4 {% L
90 cm (>97th percentile), and his weight was 14.4 kg
4 H6 e' n  J* p8 [* p% G(also >97th percentile). The observed yearly growth0 j/ o1 n5 e; P1 |+ a4 @: f
velocity was 30 cm (12 inches). The examination of! I0 w7 w, a' o* v, ?; l, t2 ?
the neck revealed no thyroid enlargement.
* q+ N8 u7 @- M, x) ~The genitourinary examination was remarkable for
, z2 W* G0 M' m! j$ aenlargement of the penis, with a stretched length of
+ F& T# V7 d7 S- C5 N1 C& V8 cm and a width of 2 cm. The glans penis was very well
6 [. u8 I8 M) N9 \4 vdeveloped. The pubic hair was Tanner II, mostly around
# _' M" t, W9 ~5400 B' x' P$ }8 m1 ~" h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  m$ E! }! I' f% T+ R; T$ I" {the base of the phallus and was dark and curled. The
$ A6 n  Z+ C5 z  u; u5 ], ytesticular volume was prepubertal at 2 mL each.
& x# Z! `" K+ l1 k9 HThe skin was moist and smooth and somewhat
, ?, H  n7 x. ^& F9 k7 Woily. No axillary hair was noted. There were no  O& Q. L! M" v: p) I+ X8 L9 j
abnormal skin pigmentations or café-au-lait spots.' d8 f7 a# h$ F# u
Neurologic evaluation showed deep tendon reflex 2+4 b$ m" s' C0 d1 x- y3 [8 X
bilateral and symmetrical. There was no suggestion1 x/ ^$ _" V. U' f) H6 [
of papilledema.9 e% [1 [3 N$ E; m$ Q+ u5 p/ }
Laboratory Evaluation. @% L" F* W# j: F
The bone age was consistent with 28 months by
; ~+ |8 Z1 m( ^7 q  Z" G2 susing the standard of Greulich and Pyle at a chrono-! w) H) {( A6 t1 @2 M2 L
logic age of 16 months (advanced).5 Chromosomal
% e5 q- M9 B3 G  U6 ~' k4 Ekaryotype was 46XY. The thyroid function test
2 O4 ~8 S- `0 J7 D+ j8 _# l, gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 t6 F- K5 ^$ l* N. Jlating hormone level was 1.3 µIU/mL (both normal).6 D# t' ^' f: a7 O  ~$ Q2 D
The concentrations of serum electrolytes, blood* L& A# {% o- ?2 w
urea nitrogen, creatinine, and calcium all were: D9 z" a9 N1 F7 F2 ]
within normal range for his age. The concentration
- }2 {( s  H2 O2 N& [1 S: W7 qof serum 17-hydroxyprogesterone was 16 ng/dL
2 a3 {! H; B& r4 X: b7 ^(normal, 3 to 90 ng/dL), androstenedione was 20
& E. w. B. V) }, Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; Q+ m7 M5 k, M0 ]. \terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# L6 Q! ]* p+ q+ X* Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to' F0 h; B1 e6 L4 ?0 G0 {
49ng/dL), 11-desoxycortisol (specific compound S)
3 y/ b# l! u4 ~" r* Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 W% A- Y2 e+ `% \4 @% K: E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 d+ S  T: O0 O0 V; p0 `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 ]. F! e; N; ?  E2 x3 g9 c
and β-human chorionic gonadotropin was less than" T" V4 ?' v6 E7 N* Q- R8 l
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ i% ?4 C7 @# X( a
stimulating hormone and leuteinizing hormone
" `; a4 C4 ^& w, }. [' v( P9 Jconcentrations were less than 0.05 mIU/mL$ ?1 m. i. V" e8 V, O* m
(prepubertal).
' J3 q( V/ d& a# c, M/ oThe parents were notified about the laboratory4 u5 w/ T/ B; U' z0 k  m$ y
results and were informed that all of the tests were
( G0 V* C4 U! J" X  v6 Qnormal except the testosterone level was high. The
8 U6 F4 y+ N: d% h0 Z7 G6 wfollow-up visit was arranged within a few weeks to- D* o/ n3 L. K% |
obtain testicular and abdominal sonograms; how-
' o9 k: ~0 t: u  L8 X8 j; k7 f* jever, the family did not return for 4 months.! ^$ A. o' t" s5 Q7 B
Physical examination at this time revealed that the
+ h. @1 v3 [- R  E8 Jchild had grown 2.5 cm in 4 months and had gained
' \/ q( I: K# ~' P' E8 A$ s; T2 kg of weight. Physical examination remained+ z* [7 i/ b9 N& p2 m0 s4 b9 Y! Z. ?
unchanged. Surprisingly, the pubic hair almost com-% D$ M* X7 Y. Y9 j5 C
pletely disappeared except for a few vellous hairs at  g- K' k- G; S9 R3 J. _4 r3 H* |/ V
the base of the phallus. Testicular volume was still 2
  [! N: `6 k' L4 @mL, and the size of the penis remained unchanged.) {/ J. {6 d6 z( j  Q! O
The mother also said that the boy was no longer hav-6 R# u' S; N$ }7 h2 N1 D* M
ing frequent erections.
( A4 v6 `# v1 ~' e& z  E& rBoth parents were again questioned about use of
9 e6 E, }/ K5 e7 C! J/ `% Many ointment/creams that they may have applied to; g5 H  }. A  G; T# X7 i4 S2 B8 _
the child’s skin. This time the father admitted the, ~9 ~# m) S4 u- {$ V% I8 l! n- g
Topical Testosterone Exposure / Bhowmick et al 541  a; V- ?  ^/ y
use of testosterone gel twice daily that he was apply-
; ~3 c7 n  T7 `ing over his own shoulders, chest, and back area for- u; b2 f1 U) ?* @7 W8 c9 ^  o7 M4 b
a year. The father also revealed he was embarrassed
  F. {2 [5 k# c0 o( Nto disclose that he was using a testosterone gel pre-( w5 x* b; z& `7 x+ G
scribed by his family physician for decreased libido
1 Y3 H# ?8 r) ?: i5 Esecondary to depression.5 J% s; y( A, a( }# \- t: }
The child slept in the same bed with parents.
9 p, Z. b9 S0 I, |% P( EThe father would hug the baby and hold him on his
0 Z0 M8 z3 O8 A7 j; S* Pchest for a considerable period of time, causing sig-
+ a  {4 X; |- k4 v, B/ V& Hnificant bare skin contact between baby and father.  f& \6 g! V/ N& c6 K% ~
The father also admitted that after the phone call,
3 l& Y! w% D  M- }$ n, vwhen he learned the testosterone level in the baby
$ U' l) F* |; G3 cwas high, he then read the product information
) _- O2 s% ]" x- Y# N, E: \packet and concluded that it was most likely the rea-
( u. d! d* @% g7 ~* {+ e& ?& fson for the child’s virilization. At that time, they0 ]" V9 s3 r. X- `8 R
decided to put the baby in a separate bed, and the( M5 B- U, u0 Y+ w! S9 ~, o
father was not hugging him with bare skin and had
1 `7 e6 A' V6 L6 F! q  h' Xbeen using protective clothing. A repeat testosterone0 c& y3 P. a. }: H
test was ordered, but the family did not go to the
( g% M; P& W$ U9 n2 Alaboratory to obtain the test.3 b3 ?# o& e  Z) O! {8 q* D. |
Discussion! h. r/ a% Y8 T6 L* L( ~
Precocious puberty in boys is defined as secondary( R+ i. c" \1 \! Z1 E
sexual development before 9 years of age.1,4( [, r4 f( L7 a/ i
Precocious puberty is termed as central (true) when; ?$ Z7 Y- W% P4 e, [5 X, P* V
it is caused by the premature activation of hypo-
6 g! E8 U7 E* x8 |- _8 b, f0 Dthalamic pituitary gonadal axis. CPP is more com-$ H$ H4 c# m( Y3 E
mon in girls than in boys.1,3 Most boys with CPP3 {/ e5 B: z* o% c; s  ]* R% R
may have a central nervous system lesion that is9 W5 G4 b9 k5 N" V2 [7 g# V
responsible for the early activation of the hypothal-
) Q+ V5 N6 g3 P+ _0 F+ F0 e! tamic pituitary gonadal axis.1-3 Thus, greater empha-
& m6 Q; ]# q0 V' Z* O  Y8 jsis has been given to neuroradiologic imaging in# J* O) p. {  B
boys with precocious puberty. In addition to viril-
( n5 g) ~7 ?) g: g; R. uization, the clinical hallmark of CPP is the symmet-4 y3 u8 k0 R1 _9 S; m- k  _
rical testicular growth secondary to stimulation by+ l' A+ K" \3 k: ^
gonadotropins.1,37 {% m5 W8 Z  N. X. _
Gonadotropin-independent peripheral preco-7 E, D4 y( c, E& o' K; c( j5 _
cious puberty in boys also results from inappropriate
2 X! s2 S/ u' f; J( p% p- F/ L. iandrogenic stimulation from either endogenous or) y2 c8 V$ W+ h6 R, M) A$ N/ M
exogenous sources, nonpituitary gonadotropin stim-
) G- S6 {- B6 V2 m9 S2 C, W$ wulation, and rare activating mutations.3 Virilizing
2 v+ }! ^- x8 ]( H, B) ]4 h, ]$ i. wcongenital adrenal hyperplasia producing excessive
! l1 L4 Y7 i2 v3 Xadrenal androgens is a common cause of precocious. t9 J* C0 v+ ~- ~7 s
puberty in boys.3,44 T  q1 J( m' r5 C0 b1 g
The most common form of congenital adrenal$ l% M" B, B2 P1 z' v
hyperplasia is the 21-hydroxylase enzyme deficiency.
4 y' W5 f( z: J: A1 |The 11-β hydroxylase deficiency may also result in
# ]& m( u" q) {! d" X& \3 Z) |% s! }excessive adrenal androgen production, and rarely,* }  H) i. H/ Q0 N
an adrenal tumor may also cause adrenal androgen- J: }* y0 ~6 i" {
excess.1,3
" e( |" u" q$ |! K. d) P) y5 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" g3 x: p1 Q5 A2 i3 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! p% f3 P% z- @; b
A unique entity of male-limited gonadotropin-, _5 E- t, ?# c& |
independent precocious puberty, which is also known
$ x. o) L( _" p6 gas testotoxicosis, may cause precocious puberty at a, \: W9 ^( A' Z. a
very young age. The physical findings in these boys7 z2 X5 T# k- I( m5 s% E
with this disorder are full pubertal development,9 k4 v" p0 h" M$ ?
including bilateral testicular growth, similar to boys6 g# z2 F9 B- W/ U! [$ R
with CPP. The gonadotropin levels in this disorder
4 G  z1 X  _" D+ z$ Lare suppressed to prepubertal levels and do not show
+ u+ D5 ?" {, Apubertal response of gonadotropin after gonadotropin-3 M" F8 C/ N: J0 D
releasing hormone stimulation. This is a sex-linked4 O, Z' e( v3 [5 G
autosomal dominant disorder that affects only9 e3 V2 ^* L* b8 j9 @
males; therefore, other male members of the family) T; |% L+ }' R
may have similar precocious puberty.3
- ?6 B1 z& R" ^5 XIn our patient, physical examination was incon-
( @7 f& G4 c7 x. B  |( qsistent with true precocious puberty since his testi-
- V* ^+ n7 x# G8 X. }cles were prepubertal in size. However, testotoxicosis' X0 }9 Y! v* k2 f4 m, Q5 f
was in the differential diagnosis because his father
) U; T8 K9 d2 ~7 ?2 ~started puberty somewhat early, and occasionally,
* w6 ?" t8 q* f/ gtesticular enlargement is not that evident in the
# ~0 F: O4 f% w( p2 Ubeginning of this process.1 In the absence of a neg-& z8 z9 m/ \/ w: r+ ^( y
ative initial history of androgen exposure, our
' ~2 _- j7 {% hbiggest concern was virilizing adrenal hyperplasia,
) [6 S8 N# Z. \either 21-hydroxylase deficiency or 11-β hydroxylase
% [* Q# ^$ U# l5 o$ _  B: Pdeficiency. Those diagnoses were excluded by find-. t: L& p4 R' v  Q4 z. h# x. b
ing the normal level of adrenal steroids.
$ x. P/ Q( O: X3 m( H: ~+ [' o# xThe diagnosis of exogenous androgens was strongly1 T% W4 a( U! H' f, j+ O, f* N! V
suspected in a follow-up visit after 4 months because7 Y8 M- k% }) |9 T
the physical examination revealed the complete disap-
4 y9 g  \/ K- L  @6 fpearance of pubic hair, normal growth velocity, and
6 m* p, X: h6 }8 \7 h  l7 ndecreased erections. The father admitted using a testos-; u! A4 l1 x# R1 U% ~2 j8 _$ z
terone gel, which he concealed at first visit. He was; _2 t& _5 K, y6 \( |
using it rather frequently, twice a day. The Physicians’
: l8 W3 n0 _: m, \# S% `* ~! H. ADesk Reference, or package insert of this product, gel or4 s" P1 p/ a6 `. p" g6 O, e; H
cream, cautions about dermal testosterone transfer to
0 z) H- L* z' S6 N. V/ F1 sunprotected females through direct skin exposure.9 U% J# @+ ^' n
Serum testosterone level was found to be 2 times the
% o3 D; [, y# V9 ubaseline value in those females who were exposed to3 L' K, W' h: G, H+ R4 Z3 P( q
even 15 minutes of direct skin contact with their male
6 C* k' {# [( lpartners.6 However, when a shirt covered the applica-( i4 M" T% Z* \4 s9 v( D
tion site, this testosterone transfer was prevented.8 M0 b6 Z& L1 \5 _- H9 w% h
Our patient’s testosterone level was 60 ng/mL,
; Y, \0 f9 y; Q& {which was clearly high. Some studies suggest that
( G( k4 h+ s) l  fdermal conversion of testosterone to dihydrotestos-- ^/ J1 }" X% C0 f
terone, which is a more potent metabolite, is more
. u% X; t7 f4 t+ J0 s2 dactive in young children exposed to testosterone; D7 ^) b' }2 n0 w+ a0 u
exogenously7; however, we did not measure a dihy-1 m9 S3 g' n. z7 Y8 P0 q( w
drotestosterone level in our patient. In addition to) ^5 Y; t7 o$ m, K. y9 Y  q0 L
virilization, exposure to exogenous testosterone in' q4 s+ ]/ `; N/ Q# c$ x
children results in an increase in growth velocity and
0 N5 k. u$ m8 E/ h( n2 F% O) ?advanced bone age, as seen in our patient.3 w  y8 P; E8 o& F8 c# n6 u
The long-term effect of androgen exposure during  y6 f/ r( R/ v* d9 z
early childhood on pubertal development and final
6 g0 y0 p8 K& w% [9 Vadult height are not fully known and always remain4 d& S/ [8 Y: p  F" ^
a concern. Children treated with short-term testos-
, E; R" y1 A; ~3 ~6 a" h. cterone injection or topical androgen may exhibit some# v3 u6 P; l% |0 |1 }+ D; f
acceleration of the skeletal maturation; however, after
8 ~- ?2 g/ ]' E0 d" z8 Jcessation of treatment, the rate of bone maturation6 T0 z; b9 @6 `3 F3 n! T3 P  F' U
decelerates and gradually returns to normal.8,9+ y/ X+ a( K# a+ T% S) \
There are conflicting reports and controversy" T. m6 ~8 Y1 {, l( d
over the effect of early androgen exposure on adult: x0 U3 x! W( s' |( T5 k5 i
penile length.10,11 Some reports suggest subnormal# D, A+ `# c& `
adult penile length, apparently because of downreg-
( Y! i2 r5 k+ O1 d1 z6 y! eulation of androgen receptor number.10,12 However,
  z! J) ]6 H$ h. H+ @Sutherland et al13 did not find a correlation between" ~) M3 ]' l; |
childhood testosterone exposure and reduced adult  F0 T: j! b9 T1 |' C
penile length in clinical studies.
5 M. Q; x6 j  u5 y* s$ e8 }; `Nonetheless, we do not believe our patient is: v/ E- p& T3 y- J4 |- c! {) H
going to experience any of the untoward effects from$ L  [8 l  Z5 {1 L; e: g6 |
testosterone exposure as mentioned earlier because
* ^- W  u" Y* v/ _: Wthe exposure was not for a prolonged period of time.
3 j( g8 j2 Q3 ?" ^Although the bone age was advanced at the time of! t3 Z8 t! [$ {) g' @
diagnosis, the child had a normal growth velocity at' R9 e/ s+ W# p
the follow-up visit. It is hoped that his final adult
4 m4 w, w% v! S; D2 ?3 ^height will not be affected.( `$ `/ m2 W) e- v! z7 }
Although rarely reported, the widespread avail-# l" q) i0 o9 i1 m% i" |) g2 f
ability of androgen products in our society may
2 ?: i. T+ D7 W1 d1 y+ _  hindeed cause more virilization in male or female; b9 T3 b- A$ h3 U- R
children than one would realize. Exposure to andro-
7 q+ W) G% G/ K9 C  U( z2 ]gen products must be considered and specific ques-
  ^/ a4 o* V6 F1 @, Utioning about the use of a testosterone product or
0 o1 K2 Q* n, {& b0 jgel should be asked of the family members during! x3 s3 e" p/ g6 D$ z' B
the evaluation of any children who present with vir-4 y8 l9 A2 N, ^, `4 Q. o! H" F
ilization or peripheral precocious puberty. The diag-$ a  W4 {# L0 K: t# p* ]% U
nosis can be established by just a few tests and by
& f% E8 z9 f% B- W# K) t* Nappropriate history. The inability to obtain such a& v+ h9 s6 @0 P+ j
history, or failure to ask the specific questions, may0 t, w7 J3 J3 F! w2 m
result in extensive, unnecessary, and expensive6 Q7 M" r3 H0 S( o+ G$ C7 B
investigation. The primary care physician should be
3 r& J2 A. b& ?& E% X# A, D3 oaware of this fact, because most of these children$ T( d! O, E0 b6 K% [
may initially present in their practice. The Physicians’5 w5 @& u* H$ S  U3 \6 M
Desk Reference and package insert should also put a- [' E- U! \# g1 I: a4 a' S$ s: p8 g
warning about the virilizing effect on a male or3 U' T) E3 B$ P: b) i& m* R1 F- f( |' S
female child who might come in contact with some-
; Z9 c7 I, r( l2 N$ {0 gone using any of these products.- W0 i4 [$ {2 I, U3 Q8 x) p" V
References
4 L4 c4 J  v$ r2 B" Q* Z6 @1. Styne DM. The testes: disorder of sexual differentiation
6 |7 M7 r, ^  T5 T: W- f' K" tand puberty in the male. In: Sperling MA, ed. Pediatric
2 o: X8 u  t2 e3 S/ ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# t) w% e' q1 O+ w; r! H
2002: 565-628.
3 F: b/ C9 V/ o- k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% U/ [: r$ g3 o3 O' X  }puberty in children with tumours of the suprasellar pineal
累計簽到:176 天
連續簽到:4 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
* r9 d  W( V+ A
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