繁體中文
不翻译
简体中文
English
繁體中文
日本語
한국어
切換到寬版

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-Old6 O' c, C1 x' k( B) p$ R* `$ r
Boy Induced by Indirect Topical0 j& B6 E' T3 M
Exposure to Testosterone
- r6 l1 N5 L/ p1 \# bSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* L) c! d; S8 r: ?, A
and Kenneth R. Rettig, MD1* K1 \& K7 n, g1 h& K6 J
Clinical Pediatrics
# U; }) e; k, f% Y  N7 `, L& vVolume 46 Number 6. i, f+ q  D. b& l/ L1 t
July 2007 540-543
) b0 o. H" m$ b/ A% g' G3 }! X/ D0 G, J© 2007 Sage Publications: Q5 Y1 r% I1 X0 t8 c* g
10.1177/0009922806296651. A: _/ d9 J" i/ D1 x5 O
http://clp.sagepub.com
* h" |0 L+ e& d" Z. phosted at
  d  c' k2 y. v/ U0 Ehttp://online.sagepub.com
; f2 p/ h2 _1 V0 t9 H" @Precocious puberty in boys, central or peripheral,7 u/ I0 p* k  {# C4 M
is a significant concern for physicians. Central
( V. a* y5 x" Y" b' bprecocious puberty (CPP), which is mediated4 C( G6 @1 o8 H5 q! `
through the hypothalamic pituitary gonadal axis, has
! V+ K6 q+ o- K1 x9 X1 ma higher incidence of organic central nervous system
& G" `/ Q6 F. B7 ^% |' D2 K3 rlesions in boys.1,2 Virilization in boys, as manifested
2 K" A1 y. c, c  B% a  V1 b1 Qby enlargement of the penis, development of pubic$ S' j* E" y8 V( @  k
hair, and facial acne without enlargement of testi-
1 i/ P+ J# D. b" [$ g& H* F6 W7 }  Dcles, suggests peripheral or pseudopuberty.1-3 We5 \" c. P+ i8 g% _+ A
report a 16-month-old boy who presented with the
* @2 m: X4 h- Y/ [7 n" |3 l9 q8 L7 @enlargement of the phallus and pubic hair develop-1 d* e8 r# r# C4 C6 J# i
ment without testicular enlargement, which was due
: p$ s2 v! K! z* Q7 o, R" Kto the unintentional exposure to androgen gel used by
7 x; C9 x7 J7 |3 N; ythe father. The family initially concealed this infor-5 @1 j/ h2 u# [0 @; S+ D! ~0 S
mation, resulting in an extensive work-up for this" h0 W8 A/ |$ ]3 [9 [$ I
child. Given the widespread and easy availability of. i& r: m: [2 n0 h+ H2 X1 C* p
testosterone gel and cream, we believe this is proba-
+ V( }2 ]8 G5 E4 ]5 W) bbly more common than the rare case report in the
, v0 R8 D. u# m8 vliterature.47 V" ?, x% n& @; X- {4 K% A. l
Patient Report8 _; v* `) W4 M) _2 o
A 16-month-old white child was referred to the( e1 U+ Y; Z) P$ s' \" c
endocrine clinic by his pediatrician with the concern
& H- y8 s1 Q0 E: Lof early sexual development. His mother noticed
: _0 _* E" J, F" i1 v. xlight colored pubic hair development when he was
) _& O5 j: \2 m3 O- SFrom the 1Division of Pediatric Endocrinology, 2University of
) ], j( J2 W% A0 WSouth Alabama Medical Center, Mobile, Alabama.; o9 S2 T$ U& I8 G+ L$ U0 o, s% b
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 T- d& O, z9 c& E2 t+ N
Professor of Pediatrics, University of South Alabama, College of' x1 _, w3 P/ D0 P  b* f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ P9 z$ t4 H$ m( }5 p& S; p( X
e-mail: [email protected].
& e* o1 Z. u2 n2 S$ Aabout 6 to 7 months old, which progressively became" J. g# s: t5 r
darker. She was also concerned about the enlarge-7 z( X8 E* ]: v- x
ment of his penis and frequent erections. The child9 o% c* u! k; A# f; M% f) N; B
was the product of a full-term normal delivery, with
1 K5 w+ b9 f! B. e) M: {a birth weight of 7 lb 14 oz, and birth length of
4 r3 v' d/ z8 s! h& `$ {20 inches. He was breast-fed throughout the first year5 M# Y1 J4 I4 [  A! u2 X9 j
of life and was still receiving breast milk along with/ }  H7 v# S  a' B" T9 w1 G: z, J4 w
solid food. He had no hospitalizations or surgery,5 Z2 A6 d* w" u9 @
and his psychosocial and psychomotor development- Y4 \7 p0 p% j% k/ f
was age appropriate.' U1 f- ~3 G+ {9 X/ U  ]' t
The family history was remarkable for the father,$ X/ T& ]  `& k9 L
who was diagnosed with hypothyroidism at age 16,3 {" |6 j3 S! d6 ?" R# _- l
which was treated with thyroxine. The father’s
8 |9 f. b/ Q* A" {height was 6 feet, and he went through a somewhat& E( [6 N/ w0 K8 m; c
early puberty and had stopped growing by age 14., c; Y0 w( p6 T! S4 n
The father denied taking any other medication. The
$ {: C: ]& r9 echild’s mother was in good health. Her menarche
& A2 H3 u( N/ G- z$ Z! M) j  _8 Twas at 11 years of age, and her height was at 5 feet
# d! `3 p- w) ?$ `" p' {5 inches. There was no other family history of pre-
% c- ^" c, h' \cocious sexual development in the first-degree rela-
1 _* ^: ]! h2 Q# rtives. There were no siblings.
  J+ ]0 J7 z$ PPhysical Examination8 W' d3 G0 a5 E2 r% H( k  Y0 L
The physical examination revealed a very active,# G9 l4 z5 P2 M/ g6 F3 [: ^. @
playful, and healthy boy. The vital signs documented
) Z, }7 H0 C9 ~8 Ia blood pressure of 85/50 mm Hg, his length was
, Q  R8 {, m% R7 J- P  w90 cm (>97th percentile), and his weight was 14.4 kg
, N; ?4 w# w3 C( T9 A8 b(also >97th percentile). The observed yearly growth5 B$ ^7 T* ^: {( t: z& v/ Q/ u
velocity was 30 cm (12 inches). The examination of+ d8 b$ J" W: q- a! k
the neck revealed no thyroid enlargement.
  v. Z/ a9 f+ B- ^, }, nThe genitourinary examination was remarkable for
& x/ S* T: p8 ^" Henlargement of the penis, with a stretched length of
6 t3 s- w; J+ C7 y9 n( o3 G* ?8 cm and a width of 2 cm. The glans penis was very well
5 G6 Y9 ^1 T5 d: [. Ndeveloped. The pubic hair was Tanner II, mostly around
) z6 B2 v( ?0 `, D" B540" b$ ~% H* L/ @8 |' m" a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 c( w5 K  R) Q6 I3 H/ I& Qthe base of the phallus and was dark and curled. The
# f" X) J/ _1 \# R% Xtesticular volume was prepubertal at 2 mL each.; Q% m* w) x/ Z  p1 n+ W& f0 F+ a
The skin was moist and smooth and somewhat. N3 Z" ^' j1 F4 }0 t4 |
oily. No axillary hair was noted. There were no' y# z3 F  ?; G7 c9 c) g. ~) O
abnormal skin pigmentations or café-au-lait spots.# }, M+ l- E- |' Q, P9 E
Neurologic evaluation showed deep tendon reflex 2+
* m" g, Q7 @7 b/ t8 J. |bilateral and symmetrical. There was no suggestion8 P' m6 d( F$ ]* Y9 z1 P
of papilledema.
# Q( ~' g' Z- [, w" N0 V% K1 FLaboratory Evaluation  B1 I- U4 ?1 P0 [; N" L7 R* a4 D2 Y( L
The bone age was consistent with 28 months by! l  c. ^# _4 \) `
using the standard of Greulich and Pyle at a chrono-
8 H. O( w' b$ w/ w9 `& [, d& Elogic age of 16 months (advanced).5 Chromosomal
% l2 I8 m5 b! d, Pkaryotype was 46XY. The thyroid function test
, {' F  V( u& a2 rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% f8 H; u+ b# R) [  j( jlating hormone level was 1.3 µIU/mL (both normal).2 |2 W  d3 a$ n1 n5 T. u
The concentrations of serum electrolytes, blood; |7 m7 J4 f: \) l. V" F8 @& U
urea nitrogen, creatinine, and calcium all were
2 H' X1 y+ b4 E( s. m- p3 Zwithin normal range for his age. The concentration
4 J! ^5 v5 W& A# N( y& L* w7 u; ]! ]1 N$ @of serum 17-hydroxyprogesterone was 16 ng/dL
1 s2 W  }- A( J( |- N8 X' r$ r(normal, 3 to 90 ng/dL), androstenedione was 20
* O7 M+ u, h. r1 a- {% f- r% M7 ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 |$ f$ Q0 G! f& }# M! ^9 U1 v9 E" N  |terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ n( }# V0 q8 e; E. a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* G+ X" }5 z8 H3 G2 U$ a) m49ng/dL), 11-desoxycortisol (specific compound S)
" T9 h# A! I: E* E2 L- G5 nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 D1 \0 h) X1 e; v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! D5 u$ @% C2 n! U* c- L+ V6 B/ dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 L- d$ E, ~6 N6 hand β-human chorionic gonadotropin was less than
* C4 K9 m+ O5 F- y0 _' }: Q- t5 mIU/mL (normal <5 mIU/mL). Serum follicular
& L7 n: E0 l4 G& G; O) l+ Fstimulating hormone and leuteinizing hormone
9 l& ~4 W+ v6 F( c4 n. ]3 P7 Hconcentrations were less than 0.05 mIU/mL
5 a* D7 `2 Y) n5 x: C(prepubertal).9 T, p0 \( T  a: y
The parents were notified about the laboratory( m  Q. ^: _- p; j, g  k
results and were informed that all of the tests were) j; {/ b6 l6 f) a) G! j1 R
normal except the testosterone level was high. The
4 m- @+ @) Z0 k0 X) [1 k0 `, ffollow-up visit was arranged within a few weeks to
! W; X. z1 _1 @/ J/ v* ^. ~obtain testicular and abdominal sonograms; how-
6 X& o; J+ R% G2 a( A$ z1 Fever, the family did not return for 4 months.
; m: F- g0 @5 n6 O2 t) U  }0 {5 OPhysical examination at this time revealed that the
9 t5 e# P2 ?5 R: [$ l$ kchild had grown 2.5 cm in 4 months and had gained) g9 Y! \, I4 q) P0 N2 R+ z4 R8 h
2 kg of weight. Physical examination remained
) p* `( F; [7 u/ Wunchanged. Surprisingly, the pubic hair almost com-
3 p5 t( i( v9 B* Spletely disappeared except for a few vellous hairs at$ F( w9 u9 N- o* @9 s, l' F* }- X
the base of the phallus. Testicular volume was still 23 E1 v6 j# C+ E' _
mL, and the size of the penis remained unchanged.
9 Z( S4 r, ]: Y! w7 B& BThe mother also said that the boy was no longer hav-
6 _: W# ^1 u. M9 `ing frequent erections.
  \( Z/ ^  \, X$ m7 GBoth parents were again questioned about use of0 E' r. x! [7 {2 S- m; ^
any ointment/creams that they may have applied to
5 J$ N0 [* P" d, F# s6 g9 Uthe child’s skin. This time the father admitted the- h, @# x, D: x2 O- c% {/ [
Topical Testosterone Exposure / Bhowmick et al 541
9 |2 Z% h) Y- }1 h1 Puse of testosterone gel twice daily that he was apply-, r0 z, E! @% ]
ing over his own shoulders, chest, and back area for3 M8 f" k2 X9 A  Z
a year. The father also revealed he was embarrassed
" H8 R# ?0 M* ^3 q7 O( Zto disclose that he was using a testosterone gel pre-0 Z; a. L4 D" {6 n. m) j
scribed by his family physician for decreased libido
( q; B2 ^8 q! G3 [# P2 D- z/ psecondary to depression.
6 Q' c  U7 p* q$ uThe child slept in the same bed with parents.) h+ S8 o6 F- i5 @, e/ _; y. ?$ T+ b
The father would hug the baby and hold him on his% R, y! m' Y/ O4 P
chest for a considerable period of time, causing sig-
4 G4 e; G  z* G" S6 \' Rnificant bare skin contact between baby and father.& t, W# p7 c8 d) R; P3 E
The father also admitted that after the phone call,
; R. n  O+ J4 e9 V! k# m/ L, Xwhen he learned the testosterone level in the baby- ~* f  s  U0 h& [9 b
was high, he then read the product information
# r$ |2 e% H' C1 L9 \: D; Bpacket and concluded that it was most likely the rea-
) E, C0 [2 t8 x% ?/ g  z; K' }$ Tson for the child’s virilization. At that time, they
# R- q( s1 _4 ]  |: E" ydecided to put the baby in a separate bed, and the( [/ k7 Y8 c* b$ L# o7 d0 Q
father was not hugging him with bare skin and had
4 U& [- X* Z" T$ u. O7 |) Jbeen using protective clothing. A repeat testosterone0 |1 |; U& _6 ~& `2 K* {
test was ordered, but the family did not go to the+ q6 @+ v7 c. h" `. S8 F. A( {* U# k
laboratory to obtain the test.
% X5 L9 R& O& d2 t+ G& BDiscussion
1 u# Q8 C) g2 o* M2 uPrecocious puberty in boys is defined as secondary5 F% F5 F5 d0 |, i
sexual development before 9 years of age.1,4
0 n# G) o, f* ^4 t8 w# ^3 GPrecocious puberty is termed as central (true) when0 C$ Z( \: ]4 b  I" t
it is caused by the premature activation of hypo-9 M0 j: |0 w5 [! O
thalamic pituitary gonadal axis. CPP is more com-6 t, I2 o# R1 S9 y2 ^
mon in girls than in boys.1,3 Most boys with CPP# C2 Z; T$ h7 l1 Z7 Z% i) Q1 v7 p
may have a central nervous system lesion that is
) w  W" M. v5 _5 ~% cresponsible for the early activation of the hypothal-
$ H& C* F3 {4 v8 k9 Samic pituitary gonadal axis.1-3 Thus, greater empha-
) C0 _9 s. I& c& c8 q1 ~6 {sis has been given to neuroradiologic imaging in" C7 W( @( d1 N
boys with precocious puberty. In addition to viril-) B" C+ H$ v; Z1 y$ b+ X2 h
ization, the clinical hallmark of CPP is the symmet-
$ b! f7 u% e& I5 X2 V& V4 lrical testicular growth secondary to stimulation by' l  W* j9 u1 r& `/ a1 ~! m
gonadotropins.1,3
5 C+ B# u% d2 \Gonadotropin-independent peripheral preco-
5 [" q: c8 a- B  _* ccious puberty in boys also results from inappropriate
. J4 W" q1 v* @; Qandrogenic stimulation from either endogenous or
9 w0 c" W. q$ G( R' M4 Z, Vexogenous sources, nonpituitary gonadotropin stim-; z; _. j1 l: r- V2 h5 t/ k( B
ulation, and rare activating mutations.3 Virilizing
7 a! A9 O7 @  B8 ^- E& Dcongenital adrenal hyperplasia producing excessive
: q8 U0 m; g- ^adrenal androgens is a common cause of precocious
" W; L8 `+ V( e4 Npuberty in boys.3,4% K( f+ D1 K9 q- H; g
The most common form of congenital adrenal3 Z" J5 n7 ?7 m
hyperplasia is the 21-hydroxylase enzyme deficiency.
- {9 c2 E& ]; ^5 ?; }0 oThe 11-β hydroxylase deficiency may also result in
! L; @- P2 t- q0 ]7 k* K: n* pexcessive adrenal androgen production, and rarely,
0 `1 t+ N) @6 b" R0 G' Y" q+ uan adrenal tumor may also cause adrenal androgen$ y5 W/ w3 f3 |
excess.1,3  i. @/ M8 N' _' s. t* h  c) |( N3 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% u: `( ~) d* `* j. ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* c& @3 z. M- s4 ?3 m# d1 P# a
A unique entity of male-limited gonadotropin-
4 Z4 K2 r, p, y0 @2 Kindependent precocious puberty, which is also known
+ ~$ W: R1 Y4 y; q, {. @as testotoxicosis, may cause precocious puberty at a
8 p5 i. U5 U8 W0 L- |: ~  D7 Fvery young age. The physical findings in these boys: f. V- u3 K0 y- A
with this disorder are full pubertal development,
- \: {' C; G+ }# w$ Iincluding bilateral testicular growth, similar to boys+ ], F3 z# ~* X' F$ S( Y7 U
with CPP. The gonadotropin levels in this disorder( K0 m! l& d, ]& y
are suppressed to prepubertal levels and do not show
& ^: o9 {" ~8 U7 p0 u: hpubertal response of gonadotropin after gonadotropin-& ]/ q8 d7 f" y# E
releasing hormone stimulation. This is a sex-linked
$ v2 X* A9 j: _& ~autosomal dominant disorder that affects only% L4 V0 P; l; W
males; therefore, other male members of the family
4 Y4 U' E& {. K0 Cmay have similar precocious puberty.3
! u7 F+ r1 c6 Z  V. `# B$ t* C8 v( CIn our patient, physical examination was incon-2 }5 M) J# Q9 p! a8 e6 j: @& W$ o
sistent with true precocious puberty since his testi-$ r9 M& c6 g' ?, b! ]8 @7 W
cles were prepubertal in size. However, testotoxicosis
7 m8 R5 ^- d8 i: ]8 I' q- e. vwas in the differential diagnosis because his father
2 r) E  k+ k# A2 v% Q- F, Ustarted puberty somewhat early, and occasionally,
- c; L4 E7 T- c+ }" qtesticular enlargement is not that evident in the
% r8 O; J0 o& p' zbeginning of this process.1 In the absence of a neg-
% R7 W4 x& i! P9 o) I+ S9 Xative initial history of androgen exposure, our
. U5 h' Y; `5 d* Jbiggest concern was virilizing adrenal hyperplasia,  k# e1 s  C7 K" l' e
either 21-hydroxylase deficiency or 11-β hydroxylase
! u/ l! H1 n. s9 Q, h7 f7 {deficiency. Those diagnoses were excluded by find-
  ?, F; \+ Q+ z7 d  w2 r( }ing the normal level of adrenal steroids.
( p! o% d# x: WThe diagnosis of exogenous androgens was strongly6 ~3 D, G/ o5 U% x: w3 N4 x
suspected in a follow-up visit after 4 months because
' D$ M- m1 q  _the physical examination revealed the complete disap-: w* D* o9 W* G6 U& K# C
pearance of pubic hair, normal growth velocity, and
4 N! ?7 D9 g, U# c9 w( l1 q! k+ `decreased erections. The father admitted using a testos-
/ z) N) z0 [- H' U# Gterone gel, which he concealed at first visit. He was
5 w0 @1 V$ Y  M( y5 @using it rather frequently, twice a day. The Physicians’
8 t1 j  L1 _/ XDesk Reference, or package insert of this product, gel or6 c/ g8 h: q+ i' K
cream, cautions about dermal testosterone transfer to
- I/ F* c  c6 Q# d$ ^3 _  runprotected females through direct skin exposure.
. [* t7 \$ w' [# s6 V0 z7 @Serum testosterone level was found to be 2 times the& w- J! N: i2 f7 d/ b2 \! |  z2 o
baseline value in those females who were exposed to0 X! b' a- J4 G1 G
even 15 minutes of direct skin contact with their male
: ~$ P& B( v8 J& G* k$ A/ |3 lpartners.6 However, when a shirt covered the applica-
9 J1 o, d1 M9 `# b" V- n) Gtion site, this testosterone transfer was prevented., B1 D+ {' A+ {7 G, s0 @9 e
Our patient’s testosterone level was 60 ng/mL,
& C/ r; d! H- b$ Z  D8 Jwhich was clearly high. Some studies suggest that
, y; Z) n% Z. `( N/ Z/ q0 V. ]dermal conversion of testosterone to dihydrotestos-) h, Q3 ~; A2 t3 t
terone, which is a more potent metabolite, is more: S  ~/ k4 l5 F8 j9 V; {
active in young children exposed to testosterone1 {( K4 O6 S& Y6 j& D% g
exogenously7; however, we did not measure a dihy-
5 `2 i& @4 Y! Edrotestosterone level in our patient. In addition to
: ?( o3 `1 ~, p( D; V; Y! U# Fvirilization, exposure to exogenous testosterone in" D0 |  s& z# b5 S$ B# K
children results in an increase in growth velocity and/ S' w! G4 |  v' E2 w
advanced bone age, as seen in our patient.
/ v+ h' [6 S7 {5 E8 IThe long-term effect of androgen exposure during" l& K( U4 r* q, y" J' m
early childhood on pubertal development and final0 j6 _: g; M/ _6 a" X
adult height are not fully known and always remain
4 J! o2 t5 Z& ?9 D! ea concern. Children treated with short-term testos-
% {. U  {8 g0 M, Xterone injection or topical androgen may exhibit some5 H3 k% w1 P/ _5 f4 f0 U3 y0 N
acceleration of the skeletal maturation; however, after
# m% |4 V: l7 f0 q; X8 S+ N* `: n* p1 bcessation of treatment, the rate of bone maturation
( n* F+ e( Y. a# }, ^decelerates and gradually returns to normal.8,90 y* u. T! ^6 n* M
There are conflicting reports and controversy3 U5 b. m7 t6 l! v7 I/ X8 U
over the effect of early androgen exposure on adult2 N  I) F/ g; H5 e6 f, X8 d5 Z7 Y
penile length.10,11 Some reports suggest subnormal/ V$ U+ d* W4 h0 ^8 i
adult penile length, apparently because of downreg-
4 X1 x& V  Y' r% v  I9 m3 w* yulation of androgen receptor number.10,12 However,
2 ~  h  M2 d: U% g% jSutherland et al13 did not find a correlation between7 C4 p5 O: f3 }2 p
childhood testosterone exposure and reduced adult
* K. S& y1 r0 D+ G& Z! _penile length in clinical studies.
% O' s1 M, k' y2 W" H( o# b, I% t8 UNonetheless, we do not believe our patient is
% E; t; W) O( Z& qgoing to experience any of the untoward effects from
) `# A6 o. o# K. e& l; ?testosterone exposure as mentioned earlier because# c. m4 ~5 I0 g5 v: Y( w$ C7 B
the exposure was not for a prolonged period of time.  ~' A% m2 {- B. O  A( ~$ x
Although the bone age was advanced at the time of
7 }' i4 `( p7 j! P6 Rdiagnosis, the child had a normal growth velocity at& N. k5 n$ ^4 o) K* H% H
the follow-up visit. It is hoped that his final adult
4 `; R' d" I. j  C* U" {9 [height will not be affected.
% G/ ~: ]0 Y: K. dAlthough rarely reported, the widespread avail-
: Q: F2 Z" U" [  Z8 {ability of androgen products in our society may
9 b1 K! A, N$ u; Q  V9 Findeed cause more virilization in male or female
0 Q  j  q# k& \: d) qchildren than one would realize. Exposure to andro-3 j  b2 Z* s  u4 z7 s- T
gen products must be considered and specific ques-
- |' M/ ~8 ?6 R3 F& ttioning about the use of a testosterone product or& c" S5 M' i$ f1 V7 H4 r% R. o6 D
gel should be asked of the family members during$ b7 W! [) a' _3 [
the evaluation of any children who present with vir-* G' V1 y+ K1 B
ilization or peripheral precocious puberty. The diag-
1 C0 G# a# s2 i2 L1 snosis can be established by just a few tests and by0 h8 P* _. h3 `. B' m9 O
appropriate history. The inability to obtain such a8 s- D0 ?4 ^  D8 x& I
history, or failure to ask the specific questions, may  g; v9 A6 z! x. [6 `2 t
result in extensive, unnecessary, and expensive( o7 e& \9 ?; x- I& F; d9 {
investigation. The primary care physician should be
% _  Y$ _3 C7 X8 {aware of this fact, because most of these children. ^% a0 K5 g4 J7 [" T
may initially present in their practice. The Physicians’: ^3 K: x, _3 V
Desk Reference and package insert should also put a
5 a& }; b7 ?7 C9 k7 k- R  ~: fwarning about the virilizing effect on a male or
: O  `$ N" L' H; cfemale child who might come in contact with some-
1 H' |* ], V7 L6 e# q$ g# fone using any of these products.- ]2 r+ T6 o' Y6 f) g
References2 R' r( P2 R' S7 x% n4 X& _2 ~/ r
1. Styne DM. The testes: disorder of sexual differentiation
* X8 ^: I* N# V) t3 qand puberty in the male. In: Sperling MA, ed. Pediatric
6 v  S/ V, I0 K( S4 v# vEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 E! l+ h1 I2 h+ X8 _# {5 u
2002: 565-628.
- B6 e4 i9 L) E9 r' [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: u, ^# A0 l/ [4 l
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
7 n' N- `3 C+ v# |9 o3 h& G- P& yBoy Induced by Indirect Topical
; I  V4 }' o6 r4 L3 eExposure to Testosterone) Q" @6 K# M7 V. N8 }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 T$ A: D1 x# _3 S1 z7 z0 hand Kenneth R. Rettig, MD1" E3 H% L$ i" x- M( N* p, o4 F
Clinical Pediatrics$ L1 {0 u/ k! C
Volume 46 Number 6* y( t' C8 B" D
July 2007 540-543' j% |! c4 ~* j' X/ ~, i* s
© 2007 Sage Publications
) q+ K$ I0 ^* j2 q) }7 k, @; R10.1177/0009922806296651
4 ~4 m: N0 O4 V) {  b, j0 i1 whttp://clp.sagepub.com
7 Q' U; Y& y, s1 |1 m- Ahosted at7 ]; F8 e/ I7 g9 C6 d$ Q1 i
http://online.sagepub.com3 ]- ~& O. y0 e8 E0 E5 A
Precocious puberty in boys, central or peripheral,
& x1 x3 z; |  _2 Ois a significant concern for physicians. Central) |+ @/ s9 U2 i5 |; w
precocious puberty (CPP), which is mediated! ^$ L& z1 P4 V* G9 T% M7 s* X) {$ M
through the hypothalamic pituitary gonadal axis, has. S, j2 c$ i' r6 f' I
a higher incidence of organic central nervous system
8 F  T* ~: _  n, L" l6 _lesions in boys.1,2 Virilization in boys, as manifested
6 Y4 h- z3 S  D- _1 }7 o/ uby enlargement of the penis, development of pubic# i0 S* O; Z6 F* C# R" }2 A: ~( d& g% o
hair, and facial acne without enlargement of testi-& T# `8 e& p+ r9 D4 z3 A/ g6 v9 u1 h
cles, suggests peripheral or pseudopuberty.1-3 We
& C/ G3 a$ a+ x% Vreport a 16-month-old boy who presented with the
2 B! @( E& l1 F" z! V6 Yenlargement of the phallus and pubic hair develop-, J7 s  q0 G2 \  @
ment without testicular enlargement, which was due9 S2 N- i" y0 Q4 `! c  m6 T
to the unintentional exposure to androgen gel used by" L2 y9 t& g& ^- {. i
the father. The family initially concealed this infor-
8 p7 W( ?+ {/ _  |$ Zmation, resulting in an extensive work-up for this# q1 k8 x4 d7 b
child. Given the widespread and easy availability of' j; G3 R2 M+ W
testosterone gel and cream, we believe this is proba-
) y+ a, n/ y# }7 D( W; @bly more common than the rare case report in the$ p' D* z  O/ k& f* H
literature.4
) ^0 B8 T8 n0 M1 ?2 p1 qPatient Report
* R9 P0 {# s: x, f9 `, VA 16-month-old white child was referred to the( Q/ ~( u5 ]; w8 ]2 @& p  T0 f! w
endocrine clinic by his pediatrician with the concern) i) D4 U( p( K% U' ?+ ?- L: v
of early sexual development. His mother noticed
! D' f& m) z; U% k7 ^! _. Slight colored pubic hair development when he was
5 `# U  k4 v$ GFrom the 1Division of Pediatric Endocrinology, 2University of7 j) E% J) `# [2 i5 b2 v( t
South Alabama Medical Center, Mobile, Alabama.
$ Q7 K7 G) h0 p9 |* ^$ }2 lAddress correspondence to: Samar K. Bhowmick, MD, FACE,: G* u% S) L( F6 ?# c6 x) j
Professor of Pediatrics, University of South Alabama, College of
8 M$ V; {6 \: O, H1 X  c2 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 J- F2 S5 D; V: Z, m
e-mail: [email protected].% v4 G2 o, y+ a. {; W
about 6 to 7 months old, which progressively became
9 u( ~" o6 J+ \; @2 V' ^! f* W: Cdarker. She was also concerned about the enlarge-" N$ b6 [& M2 |0 z6 m# k( M
ment of his penis and frequent erections. The child, M8 R3 c! j9 e. w8 q
was the product of a full-term normal delivery, with. k3 u; m/ C8 W" c: P
a birth weight of 7 lb 14 oz, and birth length of  o! V" z( {# T4 l
20 inches. He was breast-fed throughout the first year7 X; o+ ~- t. G
of life and was still receiving breast milk along with6 m7 S  z5 d3 T: s/ U
solid food. He had no hospitalizations or surgery,( B& c" K1 t) b' _# _& D
and his psychosocial and psychomotor development
+ P3 T$ ~4 a6 m! y& q* Y1 {was age appropriate.
) v( D7 C- ^- o' @& TThe family history was remarkable for the father,: t; \7 A6 X2 U/ W
who was diagnosed with hypothyroidism at age 16,
& V3 O# {) s8 p/ kwhich was treated with thyroxine. The father’s
7 M4 j& z* X- X( ^% l6 yheight was 6 feet, and he went through a somewhat/ d/ C" K5 v: J8 r4 y4 y
early puberty and had stopped growing by age 14.+ j( m7 O  R/ x
The father denied taking any other medication. The
* B; i, W% [1 }3 w7 h4 Nchild’s mother was in good health. Her menarche
$ L3 E4 J7 `1 ]  Zwas at 11 years of age, and her height was at 5 feet' q* v7 n. v( U* y0 s, L; w; @
5 inches. There was no other family history of pre-
; u4 u6 J, `/ Q# F: f" E  H. {cocious sexual development in the first-degree rela-
& p8 R0 a+ V0 Ytives. There were no siblings.
; x( J- G3 o: @, G; W4 GPhysical Examination
3 F$ H( o+ ~7 x# V% o, s" @The physical examination revealed a very active,6 d# q1 ?3 Y$ g) W
playful, and healthy boy. The vital signs documented
1 N% a! D7 o' a1 r3 F  @6 {: A  W; Fa blood pressure of 85/50 mm Hg, his length was/ X5 w) d! w4 F: G4 l8 s( F
90 cm (>97th percentile), and his weight was 14.4 kg: ~0 ^. q1 u! ~& B) h+ k
(also >97th percentile). The observed yearly growth
5 V3 h8 v' g% s( P; x' b; f/ y' Q/ L; Rvelocity was 30 cm (12 inches). The examination of( P) [, s7 E" |5 l1 o
the neck revealed no thyroid enlargement.6 Z: B, W, e3 \9 k
The genitourinary examination was remarkable for
( y. ?* ~3 ^+ G2 _8 T- W- m# nenlargement of the penis, with a stretched length of
: @& r( c8 X' l" M8 cm and a width of 2 cm. The glans penis was very well. S% w. y  N4 R" O9 E; y1 U
developed. The pubic hair was Tanner II, mostly around0 \  N( [4 y8 J  H# l
540
& }+ ]) w8 q( k7 m% ^) [' N+ y1 qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# B( D* ?7 @% W' K! S! A, v! L
the base of the phallus and was dark and curled. The* N) r7 i/ ^! {+ ^4 u. y
testicular volume was prepubertal at 2 mL each.
% S2 A# F% D0 }The skin was moist and smooth and somewhat
6 f" B8 d2 B: Poily. No axillary hair was noted. There were no
, F  }/ u: O/ r5 o& H1 J2 mabnormal skin pigmentations or café-au-lait spots.! Q: n1 [9 u) _7 t
Neurologic evaluation showed deep tendon reflex 2+
( E# D9 o* t! T! rbilateral and symmetrical. There was no suggestion
2 \# [6 ^1 p& _* ]of papilledema.
1 m$ v7 ?* |& d' V; A! FLaboratory Evaluation
& y4 g6 u8 X1 j1 z: u' d, fThe bone age was consistent with 28 months by, C6 o! G" Q  }0 J4 K) ?
using the standard of Greulich and Pyle at a chrono-2 b( ]( O+ t; o% b
logic age of 16 months (advanced).5 Chromosomal
* [3 _, n: \2 Vkaryotype was 46XY. The thyroid function test2 v1 S0 h5 L/ l4 j! k0 O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; U- u8 ^) o: N* K; s0 F
lating hormone level was 1.3 µIU/mL (both normal).
3 E* h6 s8 A! R' E6 yThe concentrations of serum electrolytes, blood0 a" @3 ]3 R: ^% d: ^
urea nitrogen, creatinine, and calcium all were. ]( \- J& a) u' ^) t
within normal range for his age. The concentration6 ]6 n" j2 z$ J% o. b& i* K# p- E2 _
of serum 17-hydroxyprogesterone was 16 ng/dL* B  V! ^  Z1 ]* k' m6 A3 `$ \
(normal, 3 to 90 ng/dL), androstenedione was 20: S7 l4 @- J- z- M# x: ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 i1 M1 ^3 [, g8 W% A: t  l) ^# X5 q' yterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ v/ ?2 h% X: F+ I" a/ o) B' |  X
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 ~& B( L2 y3 x  \' l& e  u49ng/dL), 11-desoxycortisol (specific compound S)5 v) G' x, s9 O6 S/ a& ^' t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! a! R/ e# @  |. l. W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( I! [( T7 F, a- z$ X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* Z5 a. E) n: |3 [* g, w8 Jand β-human chorionic gonadotropin was less than
9 L0 V" I! W$ ~0 I( C8 Q: Z* k( a5 mIU/mL (normal <5 mIU/mL). Serum follicular3 y) R, [, I+ o& M. T
stimulating hormone and leuteinizing hormone5 |8 P* o* c/ N( v/ ?  b9 K
concentrations were less than 0.05 mIU/mL
3 Z+ H  u7 U* [, }2 V(prepubertal).
0 {/ M- j  _0 z' XThe parents were notified about the laboratory
) {2 S  L$ f8 M' yresults and were informed that all of the tests were. j# M4 Z3 P6 o; T  a+ k7 V
normal except the testosterone level was high. The1 t6 F0 Y0 x* j- X- p
follow-up visit was arranged within a few weeks to
3 \, _$ w& r/ ~1 i7 a/ W, Y' y; sobtain testicular and abdominal sonograms; how-, b/ ~- f' D2 V% Y
ever, the family did not return for 4 months.& A" [, L( ]3 i4 \- |( U
Physical examination at this time revealed that the$ q  r$ P& R4 S& M% X) r7 [
child had grown 2.5 cm in 4 months and had gained! o. D/ m+ ^! g7 s$ e2 y
2 kg of weight. Physical examination remained% `" ?$ b* C! }3 I! E5 u3 E
unchanged. Surprisingly, the pubic hair almost com-3 e% K9 _: `0 P
pletely disappeared except for a few vellous hairs at  s; F2 I; d5 Z0 T* ^* J5 h. u" T6 ~
the base of the phallus. Testicular volume was still 26 a& t! N0 O/ [1 Z2 N. Z$ C$ \
mL, and the size of the penis remained unchanged.+ B( Y- @+ ]  ]) ~& z  g& u
The mother also said that the boy was no longer hav-" t1 x, ?' a. S* C  A: x; o: Y
ing frequent erections.
. Z9 k8 D5 e+ u2 v! C! N. IBoth parents were again questioned about use of$ d: U; A6 _4 O6 H
any ointment/creams that they may have applied to
  i2 w: S6 a( S, z  p! c8 Bthe child’s skin. This time the father admitted the
* x9 d( _7 S9 B; w! ]Topical Testosterone Exposure / Bhowmick et al 541. `  }: {* i( l4 ?- O- f2 D
use of testosterone gel twice daily that he was apply-
7 W% C( r& V* V1 q' ying over his own shoulders, chest, and back area for  `6 ~  Y( M! X' d- v
a year. The father also revealed he was embarrassed0 v: o) \& d9 w$ F. d- h7 c
to disclose that he was using a testosterone gel pre-0 F" [1 O) |5 |  M- d
scribed by his family physician for decreased libido& H$ D7 Y8 I  e
secondary to depression.2 ]6 [" ]: M) d4 ?( e
The child slept in the same bed with parents.
: w# y* L7 H: n! DThe father would hug the baby and hold him on his: Z- e8 t3 F$ t% S2 ?
chest for a considerable period of time, causing sig-
& S7 I7 m* W' hnificant bare skin contact between baby and father.: W8 z2 v" n" @0 g6 s
The father also admitted that after the phone call,
" n: \5 F. z* B+ x( ?when he learned the testosterone level in the baby
& J( h4 i3 X. ?# d* a$ Ewas high, he then read the product information
; S  i) P& O/ opacket and concluded that it was most likely the rea-
  o9 g, j9 R" _& w$ O7 Vson for the child’s virilization. At that time, they: \' ?! E' k7 q6 Y# n  f
decided to put the baby in a separate bed, and the7 ]' K6 m( [7 }  G
father was not hugging him with bare skin and had3 ]+ W; l9 \& Q2 e; i) k
been using protective clothing. A repeat testosterone
' f" S3 Q0 v* y$ G: D8 q8 _test was ordered, but the family did not go to the7 x  P, m& }- \- C$ Z: A5 t; l
laboratory to obtain the test.
, j7 i! ~  {  J& Z* A+ KDiscussion7 @6 m) ?/ X; V1 D2 h4 ]
Precocious puberty in boys is defined as secondary) d# y: f4 Y/ s! O* ]
sexual development before 9 years of age.1,4, A4 U5 q3 ?) R
Precocious puberty is termed as central (true) when# Q" ?6 n$ O. @) R
it is caused by the premature activation of hypo-
* e; t" n$ E  J4 N4 o" Uthalamic pituitary gonadal axis. CPP is more com-
7 \% t! P+ J: R3 s# Pmon in girls than in boys.1,3 Most boys with CPP
: z3 z2 Q  O. p( V% n5 X0 H& U' L- {9 C% bmay have a central nervous system lesion that is' P/ I6 {9 m+ ^0 e* Q
responsible for the early activation of the hypothal-3 D0 H2 {  N% g: n/ x. f
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 ~2 u4 h- m8 O8 {, B% Esis has been given to neuroradiologic imaging in: W; P9 M$ ^6 Z' |- c3 u/ _
boys with precocious puberty. In addition to viril-
2 j( |$ ~7 S! ^9 _- C2 r. lization, the clinical hallmark of CPP is the symmet-& {+ p/ Y# r+ g6 d' r" e
rical testicular growth secondary to stimulation by9 C8 r* k# ]9 y7 a  k
gonadotropins.1,3# _. P3 x4 S# G4 U  l
Gonadotropin-independent peripheral preco-
4 x$ T3 _" O0 k' ]6 I7 Hcious puberty in boys also results from inappropriate
) X4 t" @7 \! U- o, {& dandrogenic stimulation from either endogenous or) `' E. z, N8 j
exogenous sources, nonpituitary gonadotropin stim-
- D) W6 Z" }2 ^; z* X1 g2 a- ~. hulation, and rare activating mutations.3 Virilizing8 q$ t) s0 L' e
congenital adrenal hyperplasia producing excessive
* n1 Z: y( l4 sadrenal androgens is a common cause of precocious! I4 j4 ?2 o/ j$ e% W
puberty in boys.3,4
8 Y! w. n: T' B+ P  A9 d8 \The most common form of congenital adrenal
& ~' N/ R3 S/ c# A  i8 ?8 ghyperplasia is the 21-hydroxylase enzyme deficiency.
+ `' V/ ^$ M( K3 X" P" SThe 11-β hydroxylase deficiency may also result in7 ]8 B3 W& {1 W
excessive adrenal androgen production, and rarely,; @  t- y+ s. P3 ]6 v
an adrenal tumor may also cause adrenal androgen
) R! M& b+ |& I" z* t$ Y( sexcess.1,3
1 _7 ?  O5 n" v) V8 M( Z# Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 H2 Z4 @& C5 y& p9 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 T, d$ S. {8 r6 i) a8 ]* |A unique entity of male-limited gonadotropin-' c3 q$ Z& ], S& F0 Z+ X- W
independent precocious puberty, which is also known
. g0 G5 G( `1 e% Tas testotoxicosis, may cause precocious puberty at a
! S: p' K" {6 q' n6 X/ Xvery young age. The physical findings in these boys4 U5 O+ q0 X* P- p" E
with this disorder are full pubertal development,; F/ i1 D! P( q9 L, E
including bilateral testicular growth, similar to boys) h" _, R6 X2 F! m- p5 }
with CPP. The gonadotropin levels in this disorder! Y0 c% G# W" }* B
are suppressed to prepubertal levels and do not show
7 y7 G- r. h4 `5 Zpubertal response of gonadotropin after gonadotropin-
# l& v" p0 K# `4 y9 Breleasing hormone stimulation. This is a sex-linked, \7 D% Z# c: u, N: ?5 Q1 S( k3 u
autosomal dominant disorder that affects only
8 G8 ~+ w/ l1 _; V& _$ i# l, O  Zmales; therefore, other male members of the family
6 M/ y; S0 _/ C7 Tmay have similar precocious puberty.3
, x4 t( m* ], u4 E5 QIn our patient, physical examination was incon-
& @5 D, `4 s' O# J9 |; `sistent with true precocious puberty since his testi-
: {$ ?* O8 Q9 m& ncles were prepubertal in size. However, testotoxicosis3 Z" ^, b4 [0 r* r6 F9 D5 q; M
was in the differential diagnosis because his father1 }; D( t1 b/ B; G
started puberty somewhat early, and occasionally,
- B: A" W% U- J# ]# H5 z' itesticular enlargement is not that evident in the  s, G$ f  @" l' t* F/ W
beginning of this process.1 In the absence of a neg-! G$ O1 u: ]0 j* ?: ]% f( L7 i
ative initial history of androgen exposure, our
) z! y4 r# A. w4 a, zbiggest concern was virilizing adrenal hyperplasia,
" n" T7 L' w; }1 N4 j, R' P; zeither 21-hydroxylase deficiency or 11-β hydroxylase
8 m7 t! R- h! n) P9 hdeficiency. Those diagnoses were excluded by find-; m3 q9 C- {3 S. t6 F. g
ing the normal level of adrenal steroids.
4 v' l/ m- _+ K) e9 S/ CThe diagnosis of exogenous androgens was strongly/ j8 s2 m8 m) C, N; A7 A6 D% q# N
suspected in a follow-up visit after 4 months because
5 c& ]- u0 H4 gthe physical examination revealed the complete disap-
$ F6 k; J4 {9 Ypearance of pubic hair, normal growth velocity, and
7 j, x- m4 H/ G$ t% {, m) fdecreased erections. The father admitted using a testos-
4 `# Y+ ?. E: ^6 X2 _, eterone gel, which he concealed at first visit. He was
& c9 L( O7 F, [* o' N4 I  \% N+ Dusing it rather frequently, twice a day. The Physicians’8 D; x2 N) F0 n& e$ b" F7 k
Desk Reference, or package insert of this product, gel or
" T# |* M% {, v/ `5 Gcream, cautions about dermal testosterone transfer to6 n% p. v, w& O" a0 j* ]
unprotected females through direct skin exposure.
7 I% j1 ?1 Q4 hSerum testosterone level was found to be 2 times the
& X- h6 f& F" T: z8 E% T  x/ Dbaseline value in those females who were exposed to1 x2 S: K) e8 V  Z6 S& d, D
even 15 minutes of direct skin contact with their male
& m2 P& Q2 F4 E- r8 A; Wpartners.6 However, when a shirt covered the applica-  e: C" d% B' z, [
tion site, this testosterone transfer was prevented.
, v! e( f% r+ a. P: ]) x* \4 P6 XOur patient’s testosterone level was 60 ng/mL,9 {: n. G) t, d- l) e
which was clearly high. Some studies suggest that" W: p2 ^* {) L' b& Y$ s; ^+ C/ a
dermal conversion of testosterone to dihydrotestos-( U8 |. W! I, `* Z6 u
terone, which is a more potent metabolite, is more
0 A: I4 J- F5 V1 d7 a. gactive in young children exposed to testosterone
! k2 @8 h0 F0 H, k, fexogenously7; however, we did not measure a dihy-/ `- ]8 p) f7 U, e. g5 q- v! k
drotestosterone level in our patient. In addition to
3 l# ^2 Q8 I9 j2 lvirilization, exposure to exogenous testosterone in
+ I; d  x1 Z" x. qchildren results in an increase in growth velocity and0 M5 \) M) D8 L' A+ M+ T
advanced bone age, as seen in our patient.
$ C& F( G+ m3 {# ?4 j+ @4 H8 Q( {* YThe long-term effect of androgen exposure during9 O6 |8 N! }- o. B
early childhood on pubertal development and final
* _& u! e, d* r1 {! xadult height are not fully known and always remain0 T* X  g  C/ \) d7 ]* r  }. O
a concern. Children treated with short-term testos-
" O# d* c8 y# E" W0 [6 J+ _) Lterone injection or topical androgen may exhibit some) N. V1 Z8 U/ f+ \, }  i+ d
acceleration of the skeletal maturation; however, after
, Z4 q) i/ B# l$ l& i) R/ P+ ~cessation of treatment, the rate of bone maturation
$ A/ ^: E; V$ Y2 u# A* @decelerates and gradually returns to normal.8,9% a' v/ c7 f* S% q2 o' l% L
There are conflicting reports and controversy
' r% X4 x/ n. P' Y. g' uover the effect of early androgen exposure on adult
$ F. O7 V9 T  o' U$ @penile length.10,11 Some reports suggest subnormal4 e; R: x8 E8 }" K
adult penile length, apparently because of downreg-
- S( w2 }6 y- i0 {2 @  Q& n0 Oulation of androgen receptor number.10,12 However,9 O$ |. U2 C6 E9 f$ J9 y
Sutherland et al13 did not find a correlation between
5 e8 G  u% _$ r; [, ^: xchildhood testosterone exposure and reduced adult% m- `1 s) A2 {( E! \) i
penile length in clinical studies.
4 Y+ e% o& V0 u  ?1 KNonetheless, we do not believe our patient is
  R6 V6 z5 j3 b9 N7 M: N$ ]) ?0 Wgoing to experience any of the untoward effects from
8 \6 }" c6 C4 |& C3 S8 h+ j6 otestosterone exposure as mentioned earlier because2 o  U# p- ~% C4 s
the exposure was not for a prolonged period of time.5 U! \  H( e. r
Although the bone age was advanced at the time of
9 \9 Z& d+ ]0 `; j7 P/ odiagnosis, the child had a normal growth velocity at, Q4 Q5 I0 m7 u/ y# {" ?: v: N
the follow-up visit. It is hoped that his final adult3 A$ K. Z. q) ^* B: Q; Y
height will not be affected.2 E) Q' @, |9 n& d0 E9 V
Although rarely reported, the widespread avail-
& R8 m: t- Q! T( \4 k* o# j+ n  |ability of androgen products in our society may
) K. L, i' |! \9 C! o6 l  [. nindeed cause more virilization in male or female1 ?( S2 t! V8 z0 L* U
children than one would realize. Exposure to andro-
) f4 s- P7 H2 {9 p' U' O7 d  igen products must be considered and specific ques-
$ c4 x- I& ~" I, Rtioning about the use of a testosterone product or
$ w" v, g; S6 L$ X9 {2 i2 r' egel should be asked of the family members during
/ L; X7 h# O$ H+ Vthe evaluation of any children who present with vir-- e$ s9 V( c/ r# W/ J+ R6 w/ ]8 }
ilization or peripheral precocious puberty. The diag-0 z' \5 p' @- C( Q8 M* j
nosis can be established by just a few tests and by8 l) U5 Q5 R" S. X1 |! J( n4 \' l
appropriate history. The inability to obtain such a
, |( B/ l- S2 @2 [history, or failure to ask the specific questions, may
5 @3 X8 _8 t5 ^2 I, P; H$ Uresult in extensive, unnecessary, and expensive, c/ Q! [" u9 r' }& |
investigation. The primary care physician should be. C% J( e3 A  ]6 T
aware of this fact, because most of these children, p  B( B0 A; E; A- {$ @
may initially present in their practice. The Physicians’% @" I) ]. h( i
Desk Reference and package insert should also put a8 c0 g4 t& b( ^, I2 K& D7 e
warning about the virilizing effect on a male or/ I2 u3 I& [. m0 \2 m7 k0 q8 v
female child who might come in contact with some-
( Y$ H, `' A1 Done using any of these products.4 a. |8 j% E* r7 }, p' S
References. u( d- z2 L  f
1. Styne DM. The testes: disorder of sexual differentiation& \( E: ]3 }. B& N9 Y3 p
and puberty in the male. In: Sperling MA, ed. Pediatric2 o2 Z7 f. m9 f3 u* d' n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. ^* h& V- J% l1 [2 F2002: 565-628.
4 I5 _: k/ G5 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 r# I& S! c9 G. K" v8 X6 [
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

+ U; J+ K+ Q  J  @' V1 i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