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-Old1 I# c/ s! o! W$ ~
Boy Induced by Indirect Topical9 y7 P9 j+ J" I* ?0 v
Exposure to Testosterone# G. S# C9 S% u4 _! R2 \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. z7 ]+ }, s, d5 O
and Kenneth R. Rettig, MD1  Y% A) ]  r- z5 P0 m% I" [$ `
Clinical Pediatrics- V6 s+ o5 |3 R
Volume 46 Number 69 H( q  i  [$ d2 s2 l$ `
July 2007 540-543
8 n. ~& a, K7 Y9 H; F+ |$ u© 2007 Sage Publications8 p$ W" }# p. f8 K
10.1177/0009922806296651
7 v, i3 R. ^, T/ |, Whttp://clp.sagepub.com& ?/ I/ T+ D/ s' Y" D# Q+ e
hosted at( W+ d: V. E) u& d$ l+ z) ?
http://online.sagepub.com
! w0 ^) P9 H! y+ R; _$ Q1 ?9 `  PPrecocious puberty in boys, central or peripheral,
: I- {+ r- ?; Y- @7 nis a significant concern for physicians. Central( s9 U  P6 P5 V* ~2 a7 T, D
precocious puberty (CPP), which is mediated
5 f, w% H7 B1 N3 rthrough the hypothalamic pituitary gonadal axis, has
8 \4 H, w4 ^; v4 ja higher incidence of organic central nervous system( `( T- }+ z( _' B0 q( p( d3 K" U- X6 X; z
lesions in boys.1,2 Virilization in boys, as manifested/ q. f' O! m$ C4 D2 X' J( P4 ]
by enlargement of the penis, development of pubic- P/ c3 a6 ~, [' o  ?( N
hair, and facial acne without enlargement of testi-
' e# M5 }( g! Z; [# t& ucles, suggests peripheral or pseudopuberty.1-3 We
$ x4 O6 l. S. T( f' o3 [report a 16-month-old boy who presented with the
( U% x; s" _/ p7 Renlargement of the phallus and pubic hair develop-
3 Z( w. a8 x1 C/ Z. k$ ?ment without testicular enlargement, which was due
; k+ }; J0 y( p- C8 Xto the unintentional exposure to androgen gel used by; p; R! n& \1 \" B' g' o1 A
the father. The family initially concealed this infor-0 g+ ]. A: L/ N& f: [  R' x4 o2 N
mation, resulting in an extensive work-up for this3 o' o' s6 O9 y
child. Given the widespread and easy availability of
$ w( \( D7 }* Q" jtestosterone gel and cream, we believe this is proba-
% J4 |, X2 r( E* l0 Dbly more common than the rare case report in the/ o# H+ M9 O* o6 v1 [# @& h/ Y; m- E
literature.4
0 l3 S  B9 k: B; M; `" q) IPatient Report
2 x! }, ?  N) H! s% M% ~3 SA 16-month-old white child was referred to the
+ v: ?# [' Q+ C! p) Eendocrine clinic by his pediatrician with the concern' R# I8 a3 X, P3 C1 o# K
of early sexual development. His mother noticed
3 t( j) d: D- Ulight colored pubic hair development when he was
; h9 q) _( N/ oFrom the 1Division of Pediatric Endocrinology, 2University of( x2 e# f* q9 X2 P4 T: ^4 D6 A1 i
South Alabama Medical Center, Mobile, Alabama.
% m5 i% z8 A8 q) n( sAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, `$ g- U8 I' c( @9 @5 e8 n3 WProfessor of Pediatrics, University of South Alabama, College of2 y0 i, F! d+ w5 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 t5 }( r1 \7 J& S% {e-mail: [email protected].
! n/ ~9 [7 p2 ~/ G* J8 g7 Uabout 6 to 7 months old, which progressively became7 k( V" d4 W, i* j1 F+ r
darker. She was also concerned about the enlarge-
+ J3 Z# |* q/ o8 r% Z. O) w( ement of his penis and frequent erections. The child
9 X6 b, H$ `# _7 f: o3 B% ?was the product of a full-term normal delivery, with
5 {* u+ C5 h$ U3 y5 qa birth weight of 7 lb 14 oz, and birth length of9 Z8 v4 n: A! Z6 k6 q0 v3 m
20 inches. He was breast-fed throughout the first year. E2 y, G4 i- J  ~
of life and was still receiving breast milk along with9 n5 b4 P, {! t
solid food. He had no hospitalizations or surgery,
. c8 U( y- E; i" k" d  K! |and his psychosocial and psychomotor development0 I- K' A7 \# \* C) m  P
was age appropriate.! s+ y; @6 f) B7 P/ z, o3 @5 P; o) q
The family history was remarkable for the father,
' @' S& T  g* R7 H9 Owho was diagnosed with hypothyroidism at age 16,6 d* o: e% I5 u2 K' X9 K
which was treated with thyroxine. The father’s
% u( f9 A* Z$ e' X- M* r+ Cheight was 6 feet, and he went through a somewhat
$ w! c" r9 b7 Z8 z0 v7 Hearly puberty and had stopped growing by age 14.
8 K) B9 O: |! Z: @& G! c" X8 AThe father denied taking any other medication. The
; C% ]3 J) R8 n6 C* v" Tchild’s mother was in good health. Her menarche1 K# g) E5 V/ K
was at 11 years of age, and her height was at 5 feet' C# w: }& \& l4 i1 a- J5 B
5 inches. There was no other family history of pre-
) s8 J( s( ~" a3 B, d+ icocious sexual development in the first-degree rela-8 [# v6 V) P/ p+ g% W8 e) c7 D
tives. There were no siblings." L2 s9 v6 g5 n3 X2 m# |& i1 f7 S# K
Physical Examination6 T6 \8 P7 V" Y/ g, X  V! _+ l- |
The physical examination revealed a very active,$ K( i# V8 U. W1 `7 s
playful, and healthy boy. The vital signs documented
! I& |; L5 f7 S. V% T: l; Ua blood pressure of 85/50 mm Hg, his length was. @/ O0 R; g1 Y2 d3 `" _* _
90 cm (>97th percentile), and his weight was 14.4 kg6 ]5 [  v2 s% M6 L1 M
(also >97th percentile). The observed yearly growth! s' Z1 r& g! s/ A, s8 [) w1 v
velocity was 30 cm (12 inches). The examination of
0 E% N$ n0 {7 L; _0 K. mthe neck revealed no thyroid enlargement.; c" n- J8 ?" D3 c5 ~
The genitourinary examination was remarkable for. `3 X7 O0 _- e- r
enlargement of the penis, with a stretched length of
3 R9 F+ M8 {/ S5 e( t8 cm and a width of 2 cm. The glans penis was very well
9 ~: E8 x3 ~; [developed. The pubic hair was Tanner II, mostly around
  Z; A) H: a$ F6 ]3 G540
& p0 t# I1 |% K- aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 G5 c, X: A2 l5 T- j1 l
the base of the phallus and was dark and curled. The
7 V8 Y  M7 A$ G3 [testicular volume was prepubertal at 2 mL each.
( i1 v) Q1 a, `# U* [3 M, [The skin was moist and smooth and somewhat
% Y( r) [9 p7 A6 Z9 Xoily. No axillary hair was noted. There were no2 S* c8 u5 @/ p) s9 x, V6 C
abnormal skin pigmentations or café-au-lait spots.
. D* A$ i" T& ~. R2 W3 {Neurologic evaluation showed deep tendon reflex 2+
/ Z, i! j* T7 P! G' rbilateral and symmetrical. There was no suggestion& k+ o$ a) p. `: b- q8 v
of papilledema.
; F5 l; x4 e0 \0 Y; x6 a% e, k6 GLaboratory Evaluation% U4 M% J$ Z% d: B( h. [
The bone age was consistent with 28 months by
5 x* x/ x6 z: l+ ausing the standard of Greulich and Pyle at a chrono-9 \4 @) O% l/ S$ t+ @
logic age of 16 months (advanced).5 Chromosomal
% [, O. q3 p& \) `/ Jkaryotype was 46XY. The thyroid function test
# R/ q. z6 U; p" @; K: s  Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, F+ s* T: S; B
lating hormone level was 1.3 µIU/mL (both normal).7 E. X& ^) W' \4 D% L
The concentrations of serum electrolytes, blood
6 z: v4 X5 v3 r8 wurea nitrogen, creatinine, and calcium all were% G* \& I( V- D% F
within normal range for his age. The concentration
3 ]0 n* D# O& \6 ~7 @* [! `of serum 17-hydroxyprogesterone was 16 ng/dL7 n% u+ f( V" V- ]
(normal, 3 to 90 ng/dL), androstenedione was 20
* w9 }( R/ P; F5 t* }7 Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 H1 ~4 h$ [8 k8 r; d1 g0 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 _, H! G3 Q) y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; Z! Q8 g  a: X% \# W  `
49ng/dL), 11-desoxycortisol (specific compound S)0 W+ C8 j: @# ^$ f3 o% M, l# x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" s5 [3 T( H* r2 U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, C- `, ]0 ^3 R/ \6 Stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& e- }" C3 V( F0 D
and β-human chorionic gonadotropin was less than
4 ^" X8 G/ C: ~5 mIU/mL (normal <5 mIU/mL). Serum follicular
- Q$ U9 P% n: X8 S% Astimulating hormone and leuteinizing hormone
8 w. {: F6 O: G9 Z" f- a7 s; Jconcentrations were less than 0.05 mIU/mL
; T# o5 j! N$ A3 T$ O+ |* f- g$ |8 \' k(prepubertal).& j1 t4 R$ R$ |2 u
The parents were notified about the laboratory
' Y: Y3 S: m, |  R+ Q3 H" |results and were informed that all of the tests were
  Q& p8 u3 Y% S- m2 G6 L5 xnormal except the testosterone level was high. The
5 ^, \. Y. O$ l1 t% i1 c8 {follow-up visit was arranged within a few weeks to# v) I. t' J: g% J# `+ A
obtain testicular and abdominal sonograms; how-
% j, _* D9 O6 Y$ o, A/ N; x: dever, the family did not return for 4 months.
7 Z& @' `2 Y% G+ \* sPhysical examination at this time revealed that the
+ e* d- E$ L: J% L% q' wchild had grown 2.5 cm in 4 months and had gained
; U# m( g' T" M. N2 kg of weight. Physical examination remained. r1 y$ _3 B- d; V% h
unchanged. Surprisingly, the pubic hair almost com-0 T8 F, \( n  b
pletely disappeared except for a few vellous hairs at
0 l0 p( t/ C5 y4 r5 V' \) `the base of the phallus. Testicular volume was still 2
2 y5 n8 h$ u+ d& I4 O; ^mL, and the size of the penis remained unchanged.% v, Y9 ]/ N: v, T  p
The mother also said that the boy was no longer hav-& r' }' h* n* Q5 [
ing frequent erections.
  v/ P  U5 W0 O( L/ O9 Y' ABoth parents were again questioned about use of2 D' M' [3 H, d% q0 x# B3 O: J
any ointment/creams that they may have applied to
' n" Q* a  H7 Z# Vthe child’s skin. This time the father admitted the
# N% y, m$ J) q# `Topical Testosterone Exposure / Bhowmick et al 5416 Q; m: d; k6 S8 M' }) S& j5 W. i3 d
use of testosterone gel twice daily that he was apply-
. I5 e! E  z0 v0 L. s1 Hing over his own shoulders, chest, and back area for
& q& h- E6 V8 |& _& {* L( o2 n, L( aa year. The father also revealed he was embarrassed; K1 D0 y# I' k2 r2 s+ C0 S
to disclose that he was using a testosterone gel pre-
& Y2 M4 `' \8 X+ Vscribed by his family physician for decreased libido7 K* T. j$ \8 b; o$ b: W! {& ~
secondary to depression.5 m+ Q- O% f' R9 o7 P: T% A
The child slept in the same bed with parents.
' e! }* _) X# h+ v# M1 dThe father would hug the baby and hold him on his
9 `6 G1 S6 n2 T3 tchest for a considerable period of time, causing sig-/ u# N- J" B8 `" Y  y; o
nificant bare skin contact between baby and father.
3 L- u/ T: x2 h7 m( @9 v0 [2 s9 I6 J+ xThe father also admitted that after the phone call,# r; f/ Q, U0 S) b% m2 Y2 C
when he learned the testosterone level in the baby9 n* Q3 i$ _, Z* Z
was high, he then read the product information
5 n- N3 c+ u' B: A, Jpacket and concluded that it was most likely the rea-  ^! b; m$ j4 `( s7 v
son for the child’s virilization. At that time, they
5 o. \* D/ R" Y9 `6 i4 ^1 Pdecided to put the baby in a separate bed, and the
, t/ q+ R' _+ L- [father was not hugging him with bare skin and had
8 p$ @( x9 K# I5 T- l3 Abeen using protective clothing. A repeat testosterone
  n. W* }- E# E, t: [" L2 vtest was ordered, but the family did not go to the
; w2 F0 f; n$ ^2 Zlaboratory to obtain the test.
, h- u& Z$ o9 h% Y* Z, bDiscussion
* K4 H, m/ w! _3 f9 w* APrecocious puberty in boys is defined as secondary7 U' o$ s- i: f" x
sexual development before 9 years of age.1,4' V* d# g) |+ F" v! c$ Z% M
Precocious puberty is termed as central (true) when* }5 G8 \' v3 ^' T8 s
it is caused by the premature activation of hypo-* c4 z0 P( u* [. w* F1 ^# h4 z# c
thalamic pituitary gonadal axis. CPP is more com-9 @( ]( u2 S' Z( J( Y% Y& U
mon in girls than in boys.1,3 Most boys with CPP- @+ S/ Q+ H& ?+ q4 k- n( \& x
may have a central nervous system lesion that is
  [4 `0 Z5 b$ c8 M2 eresponsible for the early activation of the hypothal-! t: T0 Z: _9 |% O# b
amic pituitary gonadal axis.1-3 Thus, greater empha-6 Z; B0 \( @6 G, k5 @
sis has been given to neuroradiologic imaging in
+ b/ o( d+ V; M" \- w1 ]& L; ~boys with precocious puberty. In addition to viril-" h% n$ b) R, a' ?
ization, the clinical hallmark of CPP is the symmet-4 Z, N  U& s4 v- j* u
rical testicular growth secondary to stimulation by
& J% P: M8 ~/ y7 [2 @* j, Agonadotropins.1,3+ E; o! X* L# u
Gonadotropin-independent peripheral preco-
/ }; u4 u  X' C  \$ Ccious puberty in boys also results from inappropriate( n) w7 t7 q/ g" z8 A  u
androgenic stimulation from either endogenous or6 Q: x" R+ I7 p7 S4 d* M
exogenous sources, nonpituitary gonadotropin stim-: n1 w/ o: H6 Y6 y. E
ulation, and rare activating mutations.3 Virilizing6 M. K/ @6 Z! @; v. z
congenital adrenal hyperplasia producing excessive1 R. H- A; d9 T* v% J; @- u
adrenal androgens is a common cause of precocious
0 m% X0 x& p/ Tpuberty in boys.3,4
1 K3 O- L( s5 K# I9 N: S, C* \8 nThe most common form of congenital adrenal2 |" {3 M, h0 _  Y7 Q" S! J
hyperplasia is the 21-hydroxylase enzyme deficiency.
* d' A* Y: b" w" m% |The 11-β hydroxylase deficiency may also result in' d  ~, a2 u$ W4 \9 J# f
excessive adrenal androgen production, and rarely,4 ]7 ^! [3 F8 v/ G
an adrenal tumor may also cause adrenal androgen
# M8 W4 C( h; u( m% `! w- B  gexcess.1,36 a6 P7 R) i1 }; b2 }+ \+ F  k/ n  ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 N( z' U0 b# X1 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 ~/ I: W% Z8 P% p0 p; gA unique entity of male-limited gonadotropin-$ L/ I! a5 X, T8 D/ D
independent precocious puberty, which is also known9 R3 q2 K( }7 T6 n
as testotoxicosis, may cause precocious puberty at a2 J" I; o" y% Y2 P9 S( u' S  Y) a
very young age. The physical findings in these boys' L- H# v/ R( P. H" P3 m
with this disorder are full pubertal development,
" o+ Q  A0 w/ S( [2 r8 iincluding bilateral testicular growth, similar to boys/ C% K7 k! H* [; m* \& z
with CPP. The gonadotropin levels in this disorder
) n3 z) }* P4 ^! R' Kare suppressed to prepubertal levels and do not show, @" r4 g! E' e2 p' I
pubertal response of gonadotropin after gonadotropin-. M8 Y0 |( U7 k% a3 j
releasing hormone stimulation. This is a sex-linked
; z& a) n  Q. ^) m8 X6 t7 t' ]autosomal dominant disorder that affects only
, ~) s7 L  c% kmales; therefore, other male members of the family
& i6 b- ~8 }1 n, i& J" Kmay have similar precocious puberty.3
) f# I3 g, J1 x9 _In our patient, physical examination was incon-5 W0 r) _" D) {+ K/ Z( z2 F
sistent with true precocious puberty since his testi-5 G! {+ C8 R7 S
cles were prepubertal in size. However, testotoxicosis
" E) a: e" G: X. O* fwas in the differential diagnosis because his father
& F  \/ }, e' V0 i8 n) R% nstarted puberty somewhat early, and occasionally,
1 y" U% o" C7 c6 Gtesticular enlargement is not that evident in the
: b' k$ G9 K& V4 v1 O7 {) E: Y" z0 abeginning of this process.1 In the absence of a neg-
% m+ `* u/ o$ q0 R! {9 O" H- E+ cative initial history of androgen exposure, our
' u+ W# j1 v% k! i& F8 k1 \' Kbiggest concern was virilizing adrenal hyperplasia,0 I/ f3 L: J! U- [/ X+ }: X: Y; Y
either 21-hydroxylase deficiency or 11-β hydroxylase
- x! B, m9 q# B& a; i+ ^deficiency. Those diagnoses were excluded by find-. p. Z( d+ A7 q, }$ b3 b
ing the normal level of adrenal steroids.8 ?. N  t: ^+ D# e0 \: ~! p8 W
The diagnosis of exogenous androgens was strongly5 F9 M' H# ^* c) e
suspected in a follow-up visit after 4 months because
2 g1 @2 b5 |8 l( cthe physical examination revealed the complete disap-
" {# {& Y3 Y# O  t2 x" \, o7 r9 cpearance of pubic hair, normal growth velocity, and
/ t# b* o3 y1 w0 s4 E, ldecreased erections. The father admitted using a testos-4 ~/ q7 F7 v  \! B) N+ b3 c
terone gel, which he concealed at first visit. He was' k4 W' }  ?! P. ?
using it rather frequently, twice a day. The Physicians’: ^& L. [- Z8 Z7 t
Desk Reference, or package insert of this product, gel or
0 A% D% F. G6 t' K$ [' |& Ncream, cautions about dermal testosterone transfer to" ?1 U6 w8 l0 {# Q) N
unprotected females through direct skin exposure.# T  r6 B+ ]5 p" S4 g" e7 X
Serum testosterone level was found to be 2 times the
0 o1 Q; ?7 Y, @baseline value in those females who were exposed to
! L9 u! m, l; K/ G) ^/ ?1 Geven 15 minutes of direct skin contact with their male2 d) Q/ L  v2 c# q* }( r
partners.6 However, when a shirt covered the applica-
' p* x* S* [! ]) W) q5 vtion site, this testosterone transfer was prevented.; ^7 r, s; W; c. ~3 n' P4 |8 H
Our patient’s testosterone level was 60 ng/mL,5 y$ n& V- ~" k3 T) T# i
which was clearly high. Some studies suggest that
- A# K2 ]* y" P+ }1 Bdermal conversion of testosterone to dihydrotestos-. P3 x+ P6 ^! V4 A' g' o$ L
terone, which is a more potent metabolite, is more. N) h1 M; t# C+ s( ?4 |/ v
active in young children exposed to testosterone
' q' t' ?% `* bexogenously7; however, we did not measure a dihy-
* p) F. O. w4 g- ]drotestosterone level in our patient. In addition to
! s( Q2 V+ W% h: d' w* L" @virilization, exposure to exogenous testosterone in
/ ?! i' O  u' c) ~children results in an increase in growth velocity and
9 F( M7 E8 C: C( O$ aadvanced bone age, as seen in our patient.) D- h- `# A( U9 x0 z2 v
The long-term effect of androgen exposure during5 ~: D' N( i& X; Y7 a6 k% S# b
early childhood on pubertal development and final' l" |5 m+ x3 [+ G6 H
adult height are not fully known and always remain( _% w0 G: e5 [1 a
a concern. Children treated with short-term testos-3 x) l" V* E- G
terone injection or topical androgen may exhibit some
1 y  t4 i( s- N( Bacceleration of the skeletal maturation; however, after. I3 P, ~! h; u) f
cessation of treatment, the rate of bone maturation( D: h; V, c" X) `# Q/ j
decelerates and gradually returns to normal.8,9
+ S( Z9 W' g3 c% Q0 W' P1 ]There are conflicting reports and controversy) n5 B2 u4 L4 `: B9 F/ \$ F, P, w
over the effect of early androgen exposure on adult
' G  x4 M, m+ L  Ipenile length.10,11 Some reports suggest subnormal0 N: Q: F. T8 T; m1 g" V7 g1 {. Q
adult penile length, apparently because of downreg-
4 C( ?- i+ \# g' eulation of androgen receptor number.10,12 However,: x8 V# B/ J! i' n& h, o1 {! i7 V
Sutherland et al13 did not find a correlation between7 d7 V8 c" Y4 v5 W* E) b# u
childhood testosterone exposure and reduced adult
: D0 B) F* U' `1 ~' {0 ypenile length in clinical studies.9 N: h5 N' f" [. }* y
Nonetheless, we do not believe our patient is
* i4 x4 b7 F& c) X0 }+ j9 u, Rgoing to experience any of the untoward effects from
8 F! X0 C) F" t' ^' |testosterone exposure as mentioned earlier because
- P4 G" N( @) R  p* @' l, U6 Y% f. ~the exposure was not for a prolonged period of time.. a8 |2 A# n% |% i! d; O
Although the bone age was advanced at the time of  }$ B; W4 X1 O. P% |5 ~
diagnosis, the child had a normal growth velocity at  l. ~% F8 X1 w' k  [8 {2 \* P& _
the follow-up visit. It is hoped that his final adult3 r* ?( j6 v# {4 l6 S
height will not be affected.; X' W4 l2 y5 U/ C- Q; v' X: N
Although rarely reported, the widespread avail-
, X2 i! s; q% E$ r) n2 e- e) hability of androgen products in our society may) ~" n1 H7 j1 @0 P
indeed cause more virilization in male or female
1 ~: t/ M, h1 q5 l% Z, H" pchildren than one would realize. Exposure to andro-( w0 M. I& \6 T& F1 X3 F$ j
gen products must be considered and specific ques-/ g. F9 S) v" `3 F
tioning about the use of a testosterone product or
. e' f2 N) h2 i9 h0 X( [  n& Ggel should be asked of the family members during7 ^* n" a! Y/ u2 O5 @8 t
the evaluation of any children who present with vir-+ g- y" `' t9 F: F3 b' h3 F4 E
ilization or peripheral precocious puberty. The diag-+ n4 P. d$ l% M/ Z% R
nosis can be established by just a few tests and by
( ?; U9 W0 b! q2 Y8 o& u* dappropriate history. The inability to obtain such a
& B  P/ Z" t4 R8 l- g/ Ohistory, or failure to ask the specific questions, may
# f# T/ t% l% [result in extensive, unnecessary, and expensive
# X5 h& U/ S0 M2 Binvestigation. The primary care physician should be& ^! R" r; w' J% l  l
aware of this fact, because most of these children
7 o9 H# \/ W. w5 wmay initially present in their practice. The Physicians’: Z9 m$ C( k9 T! X
Desk Reference and package insert should also put a4 I& g; ^5 i$ M1 k# I
warning about the virilizing effect on a male or1 u0 _4 p7 I2 A) I
female child who might come in contact with some-
7 s5 B+ I9 b# M5 ?one using any of these products.
, B3 m; @' K" J; C. GReferences
  ^9 j; ]8 V, k9 E7 o3 K3 r' G1. Styne DM. The testes: disorder of sexual differentiation2 x& v; s- N3 Y4 L. B
and puberty in the male. In: Sperling MA, ed. Pediatric
- }3 K+ I9 r& W  f; _& y9 B- F% F8 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! R& _# u, a: ~. A- L$ f
2002: 565-628.3 ~! h; L! |% |5 u/ C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* [9 P, s6 Q& Z7 [! r
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-4 03:27:02 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
Sexual Precocity in a 16-Month-Old$ O& z: T+ O5 h) K, m7 f
Boy Induced by Indirect Topical. K, S  c5 E' j
Exposure to Testosterone
% @* }8 Q; q% q0 w4 O. t9 c( K5 {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 ?/ U3 r8 W" r, w9 hand Kenneth R. Rettig, MD1
3 E& O- V  J9 o" A3 mClinical Pediatrics
6 e6 M# ^5 X% A' e2 p' fVolume 46 Number 6
2 H3 p0 N" F$ {4 L/ o( I7 QJuly 2007 540-543
0 o( c7 }0 n* D' T2 t© 2007 Sage Publications
4 D( l2 G2 B' p3 i: e8 P10.1177/00099228062966517 ?5 N6 [* Y- e) N) V
http://clp.sagepub.com
1 K0 D1 @" B5 a- Ohosted at
7 n) G) O& s' F% ^9 }http://online.sagepub.com# j, J) T) Q8 c  Q. r# i
Precocious puberty in boys, central or peripheral,, R8 D! P7 Y2 D- Y( A/ X) f+ R8 p
is a significant concern for physicians. Central
' w7 s; ]+ ~' T7 F% `/ y& mprecocious puberty (CPP), which is mediated
$ F2 f0 c, _2 X3 P4 xthrough the hypothalamic pituitary gonadal axis, has; z7 u, k; H# H6 i
a higher incidence of organic central nervous system- n! }; F- w. r& K+ u
lesions in boys.1,2 Virilization in boys, as manifested8 P- P0 u- a+ L$ Z4 C
by enlargement of the penis, development of pubic' T: O+ h0 P0 t
hair, and facial acne without enlargement of testi-% d- p* D6 U5 x3 h3 ?) b
cles, suggests peripheral or pseudopuberty.1-3 We7 |, ]0 Z% f" e; \
report a 16-month-old boy who presented with the
# I8 ]/ X1 _! j4 ]9 p% |( L/ j: ]enlargement of the phallus and pubic hair develop-
2 d9 n6 t9 c% M+ a, h/ Gment without testicular enlargement, which was due# X3 e7 P2 S- R4 g" E
to the unintentional exposure to androgen gel used by
7 {  q* B' l, _' z# D( }! athe father. The family initially concealed this infor-
# P9 Z+ ~9 ^4 h. T& Imation, resulting in an extensive work-up for this( w5 R* l3 _' Z
child. Given the widespread and easy availability of7 X$ n1 Z/ y& |( S
testosterone gel and cream, we believe this is proba-! i" @1 c# A8 F$ z8 q( t% t
bly more common than the rare case report in the% r/ e( U  A( F; g
literature.4
/ \  S& F* T4 \" |8 L5 t1 B2 YPatient Report
/ s/ v, S4 f+ Z6 v- S$ k# zA 16-month-old white child was referred to the* z0 Z) M7 J9 ^9 N
endocrine clinic by his pediatrician with the concern$ w1 N6 W  ?$ S7 `& f
of early sexual development. His mother noticed
" I; r* k: |- ]) i9 Flight colored pubic hair development when he was# H) C# L- @/ A9 Z
From the 1Division of Pediatric Endocrinology, 2University of
) I: T$ ]$ {; {2 QSouth Alabama Medical Center, Mobile, Alabama.
1 G! E  w* R4 U$ w) nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
( ?0 l3 G# Z6 B0 _Professor of Pediatrics, University of South Alabama, College of
* c# s! a3 a; A0 {% RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, O- Y2 ~4 E" w- Ne-mail: [email protected].5 ]5 o/ X* Z4 V0 Q
about 6 to 7 months old, which progressively became
) Y. v* _1 U) U! \6 Xdarker. She was also concerned about the enlarge-! T' f( r7 ^/ a' _8 ?) q8 }
ment of his penis and frequent erections. The child- ^6 B2 u$ }+ k3 O
was the product of a full-term normal delivery, with' o$ C/ I$ e1 C) n+ h+ @
a birth weight of 7 lb 14 oz, and birth length of
  q3 H& r2 e! R' d) Q) }9 B" m20 inches. He was breast-fed throughout the first year
' R& }" c' L' I( Nof life and was still receiving breast milk along with
" I7 M" K4 r+ Xsolid food. He had no hospitalizations or surgery,, m, \& t# {; {/ u1 [( x' Z
and his psychosocial and psychomotor development
, _, m# z; F+ c$ ]/ F/ H' C8 lwas age appropriate.
9 O. D  ^- x4 Y* T. L% CThe family history was remarkable for the father,
: y. d1 ~* t8 O% j( ewho was diagnosed with hypothyroidism at age 16,
; R8 J, m, g& ?: lwhich was treated with thyroxine. The father’s
7 _; l8 Y+ A7 R% pheight was 6 feet, and he went through a somewhat. A9 W' Q. f& a
early puberty and had stopped growing by age 14.# I- z4 X& C) R1 v! F' N
The father denied taking any other medication. The; l+ c5 e8 ?7 v  r! V, @
child’s mother was in good health. Her menarche
4 m6 C" `& k9 f1 h5 d, N8 Kwas at 11 years of age, and her height was at 5 feet
* e$ a  r4 n0 v, t2 f5 inches. There was no other family history of pre-# I7 a& O1 F8 L* A8 M  b
cocious sexual development in the first-degree rela-
  H7 `; ~: Q# K( ~( ^# Ftives. There were no siblings.8 m0 ~+ H" f3 M, g
Physical Examination( `4 u1 D6 u* t2 T: _5 S
The physical examination revealed a very active,
7 h" K: V0 X3 c1 [3 w* wplayful, and healthy boy. The vital signs documented$ r+ {6 Q6 X" ?* N
a blood pressure of 85/50 mm Hg, his length was
$ \9 i" n1 X* R5 B* w$ L) w90 cm (>97th percentile), and his weight was 14.4 kg( f- D' @" p  H1 A% f2 M
(also >97th percentile). The observed yearly growth
8 X2 y, c, C" @# J( d3 B. }9 Nvelocity was 30 cm (12 inches). The examination of
! {. v* \) X. qthe neck revealed no thyroid enlargement.
# {3 C' c* I' {- C# bThe genitourinary examination was remarkable for; I% a" ?& o1 }1 J
enlargement of the penis, with a stretched length of
& T3 V; O( u/ K* x, a# t% K8 cm and a width of 2 cm. The glans penis was very well' d$ E4 a3 \/ L& E& c& s
developed. The pubic hair was Tanner II, mostly around
$ [1 ~5 ?, J) J! f0 X' x' J) G540
6 s1 Y$ U/ p1 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ r' z) |+ S; g2 D: _6 Mthe base of the phallus and was dark and curled. The* k& X  E! y: o; G7 H% L
testicular volume was prepubertal at 2 mL each.
& g8 p- S4 Q, X+ A! bThe skin was moist and smooth and somewhat
, C0 m% r7 ?' Woily. No axillary hair was noted. There were no
- O/ L- s2 i& v) P3 ]) Zabnormal skin pigmentations or café-au-lait spots.' W) L& F2 ]+ {0 w" ?6 H# Z
Neurologic evaluation showed deep tendon reflex 2+! ^, n# \# |5 g6 F
bilateral and symmetrical. There was no suggestion
# n* V# Q' G& t7 b6 Rof papilledema.2 I& n/ |' u% Z9 R' D
Laboratory Evaluation) Y! u% K- G* t! E1 b. i( J7 e2 \; Y
The bone age was consistent with 28 months by% d0 ^* T  [4 L) I$ F. C
using the standard of Greulich and Pyle at a chrono-" b# E# a3 t0 R2 O" s- Q) N
logic age of 16 months (advanced).5 Chromosomal7 M. A, \2 u5 A8 G- }
karyotype was 46XY. The thyroid function test; Q+ I6 Z* b8 F; L7 U' D. o# R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# |- \& \6 M' f- \) }  hlating hormone level was 1.3 µIU/mL (both normal).
* Z7 ]. i7 v$ K0 ^& V* RThe concentrations of serum electrolytes, blood4 v: F; R# I) q/ k: S# f
urea nitrogen, creatinine, and calcium all were6 i( z' r  T9 {4 j, c$ R. I/ N
within normal range for his age. The concentration
! O$ m# u2 E! H8 G7 Gof serum 17-hydroxyprogesterone was 16 ng/dL
% {% t" z4 X% G9 o& R  T9 o+ r(normal, 3 to 90 ng/dL), androstenedione was 20
8 ~0 P# v2 a# W, l0 y/ wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 y! @3 {3 o( q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 |1 y' h: J+ j% H# |! x' m
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# a4 u9 X1 @* k1 }) A( |49ng/dL), 11-desoxycortisol (specific compound S)9 H8 [7 _0 j6 d; y  Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 F* R$ O" l% S0 z. j* g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% \* m  Y! L) f% w$ L+ stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. y6 H' a5 I6 H" m8 O" J# ]/ \, W
and β-human chorionic gonadotropin was less than: b, p$ R; f' j! N3 ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 p* @7 n& f9 q  n
stimulating hormone and leuteinizing hormone3 S  w1 y) a, x
concentrations were less than 0.05 mIU/mL" N4 |! f# v8 _: f
(prepubertal).- |: V. a  P* r( Z# I- @6 w4 A9 J
The parents were notified about the laboratory
. Q9 ^! L3 v0 ]- W' _2 n. Gresults and were informed that all of the tests were
) r9 M6 Z9 s" {0 \normal except the testosterone level was high. The, v* R# a7 K3 y: b* r, Y5 D
follow-up visit was arranged within a few weeks to! i3 S/ L$ W( Z4 ~8 Y
obtain testicular and abdominal sonograms; how-
6 w( D8 j1 p: [& c9 x! _ever, the family did not return for 4 months.
7 I! f$ {2 W; y% lPhysical examination at this time revealed that the, @. l! s8 m0 I/ J4 m
child had grown 2.5 cm in 4 months and had gained
) o* g% k5 c' V2 kg of weight. Physical examination remained/ {2 Q7 t$ C' v! q3 j. S
unchanged. Surprisingly, the pubic hair almost com-
5 D6 |2 V0 g4 t0 i0 Q0 h* Z, O! K$ rpletely disappeared except for a few vellous hairs at* v8 S2 F. {5 x& ~9 r; U: H
the base of the phallus. Testicular volume was still 2
( {7 P0 x1 |. |+ c( k% `+ z5 j" I( z1 R# Z, dmL, and the size of the penis remained unchanged.
+ o7 D! T% p9 U9 z! r$ HThe mother also said that the boy was no longer hav-
9 S# _. S, P2 Iing frequent erections.
5 v+ R. o/ ]( _' |6 I% M& I, ~4 qBoth parents were again questioned about use of* n% q, i! X9 N, j! Q* k9 M
any ointment/creams that they may have applied to
! z/ u6 {& p$ \/ Pthe child’s skin. This time the father admitted the% W  G$ _" T) ~, t* I7 n+ ?
Topical Testosterone Exposure / Bhowmick et al 541
" Y. K' V1 [! J' p: \use of testosterone gel twice daily that he was apply-
3 i6 z* U' o: ]/ c  ~ing over his own shoulders, chest, and back area for
( f$ ?0 l* F! U. n! S# {$ ^a year. The father also revealed he was embarrassed
4 Z& e8 e% J$ }( t0 _- ^4 qto disclose that he was using a testosterone gel pre-
. f9 d% d, n4 ~/ j3 Y" j3 Dscribed by his family physician for decreased libido
6 W) |. f. f9 E, S4 `/ ^3 Qsecondary to depression./ b" c+ T5 p9 r$ l
The child slept in the same bed with parents.
. \. A8 q6 u0 bThe father would hug the baby and hold him on his
2 `: b7 z% A  ^- k9 g( V" S, }chest for a considerable period of time, causing sig-$ ]& i2 o6 ^3 Q
nificant bare skin contact between baby and father.' y; j# m+ o6 s
The father also admitted that after the phone call,( J" g  X8 \) ?& h1 e/ V" k
when he learned the testosterone level in the baby
5 e' ]( N$ j# z9 t+ G; m4 P- d; Hwas high, he then read the product information+ [9 e' R/ Q3 o3 G, n
packet and concluded that it was most likely the rea-
: j/ o9 G$ O5 u5 Zson for the child’s virilization. At that time, they
# I$ K2 ^" W2 ?/ G3 {2 cdecided to put the baby in a separate bed, and the% s2 a0 o& D' s$ `6 {6 x, ~- `5 a, t* x
father was not hugging him with bare skin and had1 J7 \  C' a" q
been using protective clothing. A repeat testosterone9 x3 h2 c% v  M5 g
test was ordered, but the family did not go to the! {; S2 `( w* G
laboratory to obtain the test.' W& k+ R( \9 N( X: S+ h* ]
Discussion" o& o0 e* c' X( G( q% c
Precocious puberty in boys is defined as secondary# z% A! h! d/ P
sexual development before 9 years of age.1,4# {. d2 P! c& J4 P
Precocious puberty is termed as central (true) when
: M5 K! ?& Q6 D6 h0 ^& @" `5 Kit is caused by the premature activation of hypo-6 n$ [0 O% j: |' l( f
thalamic pituitary gonadal axis. CPP is more com-
  k+ d, V$ i7 w" n" k* S5 Gmon in girls than in boys.1,3 Most boys with CPP
  }& j9 N$ G/ G; r% O: jmay have a central nervous system lesion that is
. P2 w) l( j% }. f" {* ]5 {* x  @responsible for the early activation of the hypothal-
* M) ^7 K- y2 ^2 B& {4 I: namic pituitary gonadal axis.1-3 Thus, greater empha-
; S2 j7 D  j- v9 q+ j: E! H( Psis has been given to neuroradiologic imaging in: I. S% D/ C' d
boys with precocious puberty. In addition to viril-; X( N& y0 r' b2 C3 J; Q4 y
ization, the clinical hallmark of CPP is the symmet-
! a. i% l+ q3 X, P+ Qrical testicular growth secondary to stimulation by
: k+ m$ t2 M+ V  _) e, V% Dgonadotropins.1,38 j4 r4 ~9 b- S: h  }% c
Gonadotropin-independent peripheral preco-& P* ]5 q* ~9 K! b) i% Q
cious puberty in boys also results from inappropriate6 [( p+ R" q: f: M0 \) C
androgenic stimulation from either endogenous or
7 u- ^( L% f' i9 ^6 F3 ?exogenous sources, nonpituitary gonadotropin stim-
% E. p5 j6 e6 U* J7 q% @( v, c$ Dulation, and rare activating mutations.3 Virilizing
; }; }: C3 p9 x! V' _- S  n- Bcongenital adrenal hyperplasia producing excessive
* ~9 R4 S& L! |' m4 A7 H$ Xadrenal androgens is a common cause of precocious
0 [4 _6 T0 l; u- v5 l0 opuberty in boys.3,4
+ M, i8 n2 c# W6 x8 xThe most common form of congenital adrenal+ ~* c7 R4 ]( Y6 x; y
hyperplasia is the 21-hydroxylase enzyme deficiency.
. M: C/ D5 @& o& W* S" _$ uThe 11-β hydroxylase deficiency may also result in
% V* A& F: W1 T- mexcessive adrenal androgen production, and rarely,
; Q; T6 l6 ~2 ?an adrenal tumor may also cause adrenal androgen% w6 U; \9 e4 E0 z: i
excess.1,3+ p  u) ?0 A  Q( t: H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  l6 W- u: X# z0 I542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  o4 M5 t( K- i1 ?' y, L- S: g
A unique entity of male-limited gonadotropin-* v4 J" ^& k$ Y; d) i" Z. C
independent precocious puberty, which is also known/ y6 F. e. L. r7 }4 O
as testotoxicosis, may cause precocious puberty at a0 o4 M. u; s. V$ y: C8 q
very young age. The physical findings in these boys
& M% Z) S* A( i1 L1 I4 Z- Q9 e7 T: ~with this disorder are full pubertal development,5 n8 d' f( e9 L4 Z( z1 s
including bilateral testicular growth, similar to boys
9 w' C2 n7 K' k: `7 ywith CPP. The gonadotropin levels in this disorder3 K4 k$ U; p. N
are suppressed to prepubertal levels and do not show) I/ S/ ~, W& [- `
pubertal response of gonadotropin after gonadotropin-
  {# N0 O4 K! ~8 ^/ S5 k6 xreleasing hormone stimulation. This is a sex-linked
  j, }" i# f( N2 C- D9 [3 Fautosomal dominant disorder that affects only
/ t* k# q& \/ i  C5 Fmales; therefore, other male members of the family
2 N% E4 b( V' bmay have similar precocious puberty.3
$ k) _4 Z* p0 V6 \& @  J. eIn our patient, physical examination was incon-
. O2 K& ^- ?6 z* }$ D' i) Nsistent with true precocious puberty since his testi-
6 D6 O% i: S% T( }6 A$ i, _cles were prepubertal in size. However, testotoxicosis
& i4 Y6 U. n; e4 j4 I- Z/ bwas in the differential diagnosis because his father6 A  {0 ?. B5 E
started puberty somewhat early, and occasionally,
8 n+ q8 n& v) c& [; Mtesticular enlargement is not that evident in the
/ c9 s/ a6 |+ I" r, h: C5 Z; Obeginning of this process.1 In the absence of a neg-; L  t: ~% t: d4 q9 Y, i$ e4 J) J
ative initial history of androgen exposure, our% t5 E. ]# W! r$ O7 [; Q
biggest concern was virilizing adrenal hyperplasia,5 F* T/ O6 b1 _8 `* |
either 21-hydroxylase deficiency or 11-β hydroxylase
" o4 M: }, s3 F- Z1 {7 X/ bdeficiency. Those diagnoses were excluded by find-  w! j* Q0 x$ m9 t9 O- O1 X
ing the normal level of adrenal steroids.. O. d9 |* Q3 \
The diagnosis of exogenous androgens was strongly" F, d  Y' w' B! Y4 R' Q2 c
suspected in a follow-up visit after 4 months because5 D4 }+ x3 K! Q4 E0 R. Q9 p2 K
the physical examination revealed the complete disap-
2 H, z# h+ ?* Lpearance of pubic hair, normal growth velocity, and
5 u1 C- B* l( C; G. S, u  _* h& ddecreased erections. The father admitted using a testos-. Y# b) u4 B! H
terone gel, which he concealed at first visit. He was
# e' w+ k9 G0 m9 b9 U; Gusing it rather frequently, twice a day. The Physicians’
- |- e6 s& }& _1 v0 I7 J6 LDesk Reference, or package insert of this product, gel or9 }& B/ \+ v0 o
cream, cautions about dermal testosterone transfer to$ l, K6 o5 j3 X; ~7 L7 I5 |
unprotected females through direct skin exposure.
/ i7 P: r" d% P3 A# Y! |Serum testosterone level was found to be 2 times the
  T8 O' `; V$ ~baseline value in those females who were exposed to
4 I) M! C" G2 }) T0 `even 15 minutes of direct skin contact with their male+ g% R4 Z1 X% g& A
partners.6 However, when a shirt covered the applica-+ L0 o4 N, o3 u# @
tion site, this testosterone transfer was prevented.
8 L4 G9 d6 D6 P/ l% K7 mOur patient’s testosterone level was 60 ng/mL,: D5 P1 V8 S+ y; @
which was clearly high. Some studies suggest that' h( r8 B! F  p6 O
dermal conversion of testosterone to dihydrotestos-& Z; n3 t% D  I! |- q9 F, l9 K
terone, which is a more potent metabolite, is more
/ z1 F; b5 L) @6 y# L3 G$ {active in young children exposed to testosterone3 P0 X7 m' }8 o5 D. K1 {* Q/ X7 U
exogenously7; however, we did not measure a dihy-& f% @' \: S: P0 P$ w
drotestosterone level in our patient. In addition to
2 n' E  D; {5 n  Nvirilization, exposure to exogenous testosterone in
2 J* V; y. q  E& ?children results in an increase in growth velocity and
/ }2 c! p# V7 Q- n+ H2 S( Sadvanced bone age, as seen in our patient.
% P+ O$ j8 c8 eThe long-term effect of androgen exposure during, \8 ~# t7 w. J1 ]4 p/ T
early childhood on pubertal development and final
. l! ^: {  y/ r6 b6 X; V% sadult height are not fully known and always remain
% O8 V) N9 U: R/ W  ca concern. Children treated with short-term testos-! o) ~4 W! {  h
terone injection or topical androgen may exhibit some
& }8 T$ A6 C# X/ \+ S$ Gacceleration of the skeletal maturation; however, after
; G$ `) o4 ^" M5 o2 P1 ]* x0 m$ G3 [5 \* ycessation of treatment, the rate of bone maturation" [8 v3 H6 N$ d
decelerates and gradually returns to normal.8,9( M: M1 v) g9 z. h' V1 ^% c, k
There are conflicting reports and controversy# O, m3 Q. E7 |' ?
over the effect of early androgen exposure on adult
8 v; j, _; ~) P: g% V$ Z7 R: Jpenile length.10,11 Some reports suggest subnormal9 ?" n. W% K; m4 ~$ \0 o
adult penile length, apparently because of downreg-% f% S( N" |1 q( U
ulation of androgen receptor number.10,12 However,
# W/ \. O  A& hSutherland et al13 did not find a correlation between
' Z% P+ z) x% J- g! }! P3 d( F, |childhood testosterone exposure and reduced adult
1 r7 M( f) U5 \$ Q4 d1 lpenile length in clinical studies.+ i. y$ v% d: @3 f2 t- [
Nonetheless, we do not believe our patient is
$ F2 K" y- U# O9 h/ egoing to experience any of the untoward effects from' m' Q) f7 D0 j1 S1 {
testosterone exposure as mentioned earlier because5 r2 R0 z) x- Y" f: k" A3 O
the exposure was not for a prolonged period of time.
( M) o9 r: N6 m! V. PAlthough the bone age was advanced at the time of
) y. W, i5 }& S8 \1 |) D( Sdiagnosis, the child had a normal growth velocity at* L1 P% L0 Y3 [1 _( ]$ a
the follow-up visit. It is hoped that his final adult4 h1 s: v+ _( E* E) n5 S6 a* g% ~' }
height will not be affected.
4 `# o, K: R# m4 F9 \( NAlthough rarely reported, the widespread avail-2 F5 g2 o( z' |4 @2 U8 W
ability of androgen products in our society may% H% u4 X$ F# x  C& N
indeed cause more virilization in male or female
/ H" o3 K* N( I  ?" Y5 {children than one would realize. Exposure to andro-; [- E1 t; K# l/ w
gen products must be considered and specific ques-
. I$ ~/ N; y( e( F4 @7 E( @tioning about the use of a testosterone product or0 j7 r$ ^0 r$ J6 g9 a$ O
gel should be asked of the family members during0 }8 t" ~% H& Z- }2 \7 }
the evaluation of any children who present with vir-8 b8 G. Z  [6 h) B, K2 ]
ilization or peripheral precocious puberty. The diag-) G. }) B/ k0 J9 v4 n& u) i5 S/ B
nosis can be established by just a few tests and by1 ^- C- {0 a8 e3 A1 N
appropriate history. The inability to obtain such a
7 ^, B5 m3 R( O5 ]+ X+ h, t% X9 |history, or failure to ask the specific questions, may
3 N' _3 [) H( H0 ]* Z5 Gresult in extensive, unnecessary, and expensive
' H3 \4 J  t; e: m7 d9 ^' iinvestigation. The primary care physician should be3 R  E7 f" l! K& p' g; r
aware of this fact, because most of these children
1 \0 Q2 ?6 F) @may initially present in their practice. The Physicians’
3 }0 O5 e% [, Z( ~" dDesk Reference and package insert should also put a
! n% W8 [$ Y4 b' Gwarning about the virilizing effect on a male or# f: U9 i% n+ p$ Z/ g* Q2 p/ _
female child who might come in contact with some-; v& v7 j1 x+ Z- m  L$ P
one using any of these products.* A! x, z. i' T3 _, S6 `5 w3 R8 g/ N
References) E( Z8 m  m( U
1. Styne DM. The testes: disorder of sexual differentiation
: _4 M( Z$ Q! m  C: P4 {0 o6 l' ?and puberty in the male. In: Sperling MA, ed. Pediatric3 R+ Z  T& x1 c: d8 m7 A8 s4 X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 ~% ^6 I% c0 q- O5 T2 i
2002: 565-628.' O- K" x  x2 J- N1 t: U7 k; L
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. W+ H! V! a/ x; k! W: M
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

3 n$ ^) P0 F; U4 D7 `+ C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