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-Old$ p+ @9 f0 b! Y% J7 w
Boy Induced by Indirect Topical& b# K0 E0 S( X1 W( o5 L
Exposure to Testosterone' A* |% f3 a  n- a1 R5 O/ N2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 E' S; D, x, i0 x. A
and Kenneth R. Rettig, MD1# t" @5 l4 X9 w. Q/ ?
Clinical Pediatrics
9 v! D6 o5 R: u! A5 y9 J: ?Volume 46 Number 6) X# s, w2 P& T, j7 v1 Y' ^6 L
July 2007 540-543
5 o- k, }- [$ k) J, X# {© 2007 Sage Publications7 o2 {0 \7 a- f" K- A
10.1177/0009922806296651
( F3 y! u; ~+ q5 d( shttp://clp.sagepub.com" N) E) ^3 _% b( c/ m. I# X1 V
hosted at
: l3 q2 _' k' g! ]http://online.sagepub.com. f, w4 ]* [& Q+ L3 r
Precocious puberty in boys, central or peripheral,
0 z. T- x# N& \is a significant concern for physicians. Central8 @7 V9 K3 I+ m' D
precocious puberty (CPP), which is mediated
0 ~2 \) D. m: z# c, e; ]" Ythrough the hypothalamic pituitary gonadal axis, has# q) z6 a0 h0 x* j+ K
a higher incidence of organic central nervous system
  a0 f7 n* L* l3 r; s. hlesions in boys.1,2 Virilization in boys, as manifested
( M5 \& C* l" l7 Dby enlargement of the penis, development of pubic
0 m  E9 l1 a6 M  p. m2 uhair, and facial acne without enlargement of testi-- s2 a! {9 N% T( J
cles, suggests peripheral or pseudopuberty.1-3 We) h1 |$ Q2 Q& A/ ?
report a 16-month-old boy who presented with the( c1 `" }3 k8 C; U- k
enlargement of the phallus and pubic hair develop-
3 E1 w. C+ A' o6 u; s$ y' g. E* Nment without testicular enlargement, which was due+ R& Y6 O) _: U( Z" u
to the unintentional exposure to androgen gel used by
" S: N; e' Z' q6 r$ N3 Xthe father. The family initially concealed this infor-. e5 |" B% o0 a% X0 w6 ]
mation, resulting in an extensive work-up for this+ ]& ]0 t* w9 e$ p1 b
child. Given the widespread and easy availability of
0 X9 G- t; x* M$ @/ K0 `' Xtestosterone gel and cream, we believe this is proba-
+ p+ ~6 i: z2 Lbly more common than the rare case report in the* p8 N: X) y/ ^0 y3 l4 z
literature.4
5 y) t( ~/ C% ^. C% `Patient Report) f4 b/ [. k  u, s8 O1 p0 a$ a
A 16-month-old white child was referred to the; f) f9 n, v! ]  @/ {
endocrine clinic by his pediatrician with the concern
) T2 Y3 P6 \- z- gof early sexual development. His mother noticed
0 O$ l' w6 ^2 b- Olight colored pubic hair development when he was  J: y: k2 t* k" C
From the 1Division of Pediatric Endocrinology, 2University of$ W0 e4 m; z8 |2 z6 ]* o
South Alabama Medical Center, Mobile, Alabama.# c$ ^$ ~5 s  _$ h
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ D5 d. G! ]& P" n' M: TProfessor of Pediatrics, University of South Alabama, College of
* u8 C" A/ t' N* [Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 B( r' c( j9 Z8 o9 |" v
e-mail: [email protected].
0 Q4 ?4 e: Z% K/ b% Q/ vabout 6 to 7 months old, which progressively became; p; S4 J$ H/ L* t) B) `
darker. She was also concerned about the enlarge-. J7 S1 S8 X# T8 W2 }7 y
ment of his penis and frequent erections. The child. o9 X* Y& j7 a/ t1 n
was the product of a full-term normal delivery, with
! T4 X8 _2 @/ Ja birth weight of 7 lb 14 oz, and birth length of
2 m# n; x* R* D3 N6 X20 inches. He was breast-fed throughout the first year5 f! _4 `7 G5 A- k/ x# T
of life and was still receiving breast milk along with
. i. f6 Q# S, H; o+ u/ c: Asolid food. He had no hospitalizations or surgery,
( `9 j1 ^) Z  ~5 ^: a+ k9 }* K  A0 Sand his psychosocial and psychomotor development
; V, y7 W# v: C" ]" h& swas age appropriate.' `* f- A! e4 O6 o, G
The family history was remarkable for the father,
* D3 {- b" ~8 y1 vwho was diagnosed with hypothyroidism at age 16,
* @* n/ g3 L$ ~& j$ A' L# Gwhich was treated with thyroxine. The father’s3 L: b; o/ P9 {9 k
height was 6 feet, and he went through a somewhat4 y  @: m! w  J7 n  ]$ I3 h0 g
early puberty and had stopped growing by age 14.
/ Z  C( s, z7 a. I+ \2 }, xThe father denied taking any other medication. The& c3 C0 P8 y$ q3 V- w
child’s mother was in good health. Her menarche% R& n' \! A+ z
was at 11 years of age, and her height was at 5 feet, _: l0 V1 c) ~: x, q8 N$ t2 Q/ B
5 inches. There was no other family history of pre-3 U, P4 r+ m1 ?$ M* L2 B# C
cocious sexual development in the first-degree rela-5 I1 K3 w8 ?3 `" V, b4 n9 z: n
tives. There were no siblings.( Y  N3 X9 N% f# R& H, V+ N
Physical Examination
/ h. ~8 K- `2 ^2 t0 D: h8 dThe physical examination revealed a very active,7 x. v% Z, {2 n/ e" a7 s6 ^
playful, and healthy boy. The vital signs documented
3 d" w& U7 x  Oa blood pressure of 85/50 mm Hg, his length was! ^! A, \& _, l0 r( F
90 cm (>97th percentile), and his weight was 14.4 kg
! P+ J4 A! g% z( Y- W(also >97th percentile). The observed yearly growth
7 n2 p. [% b- B; J: L1 }velocity was 30 cm (12 inches). The examination of
: [% t, l$ T) h7 p5 {the neck revealed no thyroid enlargement.3 M1 X" w! g5 A! E* M+ x
The genitourinary examination was remarkable for
3 F) b( V; l: F1 menlargement of the penis, with a stretched length of
0 U$ l/ l5 r7 e% q7 O( s8 cm and a width of 2 cm. The glans penis was very well/ X- L) ?, I* `, z/ A; T5 i
developed. The pubic hair was Tanner II, mostly around) A% K6 l. e' b
5403 G4 ^: I- R4 e% d2 o; e; R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 A; }3 Y( P% ^3 t9 ^/ b' t
the base of the phallus and was dark and curled. The
! T5 V; |# G7 g) M$ {4 ^testicular volume was prepubertal at 2 mL each." F: e. d% p/ F6 T: y8 y8 C" g
The skin was moist and smooth and somewhat9 S( a* l  e' P! y( S
oily. No axillary hair was noted. There were no
& R* b7 l) w! C  Sabnormal skin pigmentations or café-au-lait spots.6 U0 x/ X+ @) E
Neurologic evaluation showed deep tendon reflex 2+; m9 t$ `% H7 X  [, e+ Q
bilateral and symmetrical. There was no suggestion, T$ r1 A$ v1 E3 h, K
of papilledema.* v: _4 c' g/ ~- O/ A" I
Laboratory Evaluation1 l( t) x# n& Y: D9 n* ~5 \
The bone age was consistent with 28 months by
2 {7 f% ?0 m7 O; Susing the standard of Greulich and Pyle at a chrono-5 t9 x2 j0 U" L( f! {; Y% R9 w% L! W
logic age of 16 months (advanced).5 Chromosomal
$ ^$ u: h2 M% V/ J/ H% R% P7 ]karyotype was 46XY. The thyroid function test- n1 ^" G9 @, `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 K+ e+ a7 ~2 w8 P0 ^! F, t5 ]
lating hormone level was 1.3 µIU/mL (both normal).4 V  `; J, o7 J* ?3 `
The concentrations of serum electrolytes, blood
( @8 u1 q' G: Z% u! ?urea nitrogen, creatinine, and calcium all were: b. z' e0 m) j' k/ C
within normal range for his age. The concentration
- w* a$ @. Z+ Aof serum 17-hydroxyprogesterone was 16 ng/dL
' O; n5 [& G) ^* |1 B+ x(normal, 3 to 90 ng/dL), androstenedione was 20: [& |6 N# X) r' O$ P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, t0 W6 R, `+ i9 |2 g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  K* F8 K5 ]& [' [  C- O2 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 f& I2 g7 a$ w6 M" ~
49ng/dL), 11-desoxycortisol (specific compound S)9 J% g2 F, U1 a/ N8 e& G! V5 F" a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 _- `. N+ Z9 I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; ^9 I* b# l' K8 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ N# i% r; w) P" V& r2 D
and β-human chorionic gonadotropin was less than
6 j7 t  ]! \+ T& {  c  X5 mIU/mL (normal <5 mIU/mL). Serum follicular
" ~# b" D; r* X- P8 I( b/ tstimulating hormone and leuteinizing hormone$ c, c. m" K# S  H& s) P, N$ r
concentrations were less than 0.05 mIU/mL7 r' A- w8 I/ r! H; j# l
(prepubertal).: e3 o& S& u. A
The parents were notified about the laboratory& O  ^* e" e4 h1 ^
results and were informed that all of the tests were
5 ]8 R" u1 R7 Q$ z. k( i; enormal except the testosterone level was high. The
3 `6 h) W9 x. Efollow-up visit was arranged within a few weeks to$ }( o9 p1 E4 I" e4 D% I
obtain testicular and abdominal sonograms; how-
8 N* u) y' a1 ]  ]8 ~, k1 rever, the family did not return for 4 months., [' a7 @% [$ d' D. s
Physical examination at this time revealed that the
$ z; w, _3 G* @( i: ~3 x& ]. `child had grown 2.5 cm in 4 months and had gained
/ g/ t$ Z( E$ C& O) q9 l! d2 kg of weight. Physical examination remained
' Z" j" c. @, }$ j$ A+ R  Junchanged. Surprisingly, the pubic hair almost com-
2 J4 V# |; W+ ?$ Apletely disappeared except for a few vellous hairs at' v1 J" a8 w1 B
the base of the phallus. Testicular volume was still 2
7 w0 s( D* D; r% F' x) p9 F3 QmL, and the size of the penis remained unchanged.
. X' P: B) ?, [' ~7 QThe mother also said that the boy was no longer hav-" J" Z$ l2 D6 {6 x$ B0 V( {
ing frequent erections.+ q, M5 |* W$ N- n# X# B* K, W6 o
Both parents were again questioned about use of7 v0 t6 m: k  G) {# G, |2 G
any ointment/creams that they may have applied to
3 T# u! t% v- E$ _/ Lthe child’s skin. This time the father admitted the' a( f2 @- @' @$ ?5 a0 W* X
Topical Testosterone Exposure / Bhowmick et al 541
( g9 p# s4 S& ~* E# t) L( B; L4 xuse of testosterone gel twice daily that he was apply-
3 x7 S$ ~# L/ wing over his own shoulders, chest, and back area for1 q; J& p2 r7 ^& T: `' J( H
a year. The father also revealed he was embarrassed
! p! o# z% e2 q; z9 E) D! ^. `to disclose that he was using a testosterone gel pre-& x, q) s& A; O  h
scribed by his family physician for decreased libido( H: w. L' C) U; k1 E  q6 Y% i5 c6 P
secondary to depression./ E+ U  H' ?, w) V
The child slept in the same bed with parents.
! n' N* Y! ~4 O! ?. |The father would hug the baby and hold him on his. r+ Z4 j2 U0 i
chest for a considerable period of time, causing sig-6 B, q+ y; ?& s; I/ Q$ n  C' a
nificant bare skin contact between baby and father.! c) f" |5 a+ A5 F& t
The father also admitted that after the phone call,, f" L3 S6 B0 y) m, w* ?
when he learned the testosterone level in the baby0 [& `* Q% g& ?' `5 ?; E/ \$ \! Y" R
was high, he then read the product information
0 P' h& c0 _4 O# i) y: hpacket and concluded that it was most likely the rea-
0 W+ g4 {/ x) ?" y( E  ]son for the child’s virilization. At that time, they" I# X  \) T7 B
decided to put the baby in a separate bed, and the
0 a% \, o1 }, `9 |/ a  H& @& H- j+ tfather was not hugging him with bare skin and had3 v, S  j6 K' j2 j
been using protective clothing. A repeat testosterone
# T4 X& N2 R' z$ @- r2 L& M- d! Rtest was ordered, but the family did not go to the
2 @  X, e4 \7 P1 jlaboratory to obtain the test.% Z, S- u  s$ \
Discussion5 ~) M7 r+ }( D+ ?# K, k0 a5 [
Precocious puberty in boys is defined as secondary7 O- C1 F, r, O8 R5 @2 ?/ o
sexual development before 9 years of age.1,42 n  G, w/ d5 w( L9 r% V
Precocious puberty is termed as central (true) when
. v* [* V/ q) t9 \0 \it is caused by the premature activation of hypo-& u5 F* W1 m" k
thalamic pituitary gonadal axis. CPP is more com-- Z& c. \3 }8 V$ N* s
mon in girls than in boys.1,3 Most boys with CPP
3 Y# V0 J/ h! zmay have a central nervous system lesion that is
) e( l0 P* g- T1 f9 _, Oresponsible for the early activation of the hypothal-
( h& m- p0 d  c3 x$ X& Tamic pituitary gonadal axis.1-3 Thus, greater empha-
/ ]5 K8 `0 N; q8 msis has been given to neuroradiologic imaging in* |" W/ I7 r5 a( x# {  ]
boys with precocious puberty. In addition to viril-
* V0 B2 J2 ^7 X+ w9 g1 J3 O" v. iization, the clinical hallmark of CPP is the symmet-
% m& v; Q* c6 j8 Urical testicular growth secondary to stimulation by
9 ^: m& U6 G# Igonadotropins.1,3. Y7 s. t) J) q- ~! r
Gonadotropin-independent peripheral preco-
1 U5 g2 V% U# Z7 k1 `7 I( @cious puberty in boys also results from inappropriate; e- @; |$ y4 B- n3 f' z) d
androgenic stimulation from either endogenous or
- e" D! q' h/ }5 O6 f* kexogenous sources, nonpituitary gonadotropin stim-
) w0 Y' d" x* {) p: mulation, and rare activating mutations.3 Virilizing
; G2 Y* l5 S4 s: B+ K  ~congenital adrenal hyperplasia producing excessive" u& q# b3 ?: p  K  T1 z( S- i
adrenal androgens is a common cause of precocious
+ Q! O* d7 o3 N) h1 W- ?, gpuberty in boys.3,4
' ?0 J- D7 A2 K- T- OThe most common form of congenital adrenal. d# e+ p4 D' W' l6 G6 P
hyperplasia is the 21-hydroxylase enzyme deficiency., c% M5 A( p- E- U9 S
The 11-β hydroxylase deficiency may also result in
, j- G3 p8 h# @; H5 M1 L" ]& ^excessive adrenal androgen production, and rarely,
! g- h, Y  Y3 ?6 C' van adrenal tumor may also cause adrenal androgen
3 p: M) ~6 o; G1 K6 r7 s1 Bexcess.1,3, S) }& A" Z8 [7 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 h+ B. r/ p3 k542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 v& Y$ j3 M" y5 s, g* I1 ^
A unique entity of male-limited gonadotropin-
' A) \/ j; L0 m0 U$ u3 ]) Gindependent precocious puberty, which is also known
2 B; E7 S) p$ o$ h( V5 g% W' W! bas testotoxicosis, may cause precocious puberty at a
1 l$ q  @' }  O& |  vvery young age. The physical findings in these boys
% l0 Y. g& c& h; jwith this disorder are full pubertal development,
) H. k# w' j0 Mincluding bilateral testicular growth, similar to boys
" `: y- x3 w. {$ t; bwith CPP. The gonadotropin levels in this disorder0 N- Y; v  m# @* Q. y
are suppressed to prepubertal levels and do not show
8 X4 ]* L) K2 M. Upubertal response of gonadotropin after gonadotropin-! R/ I+ h5 r7 B9 o5 E0 |
releasing hormone stimulation. This is a sex-linked9 {0 g7 f* `5 l; |8 s- {& i0 Q
autosomal dominant disorder that affects only
# z! R) h( H: I# U+ g: l: T1 p' Smales; therefore, other male members of the family1 L. l/ L! E7 R0 x: Q
may have similar precocious puberty.3
& M7 N$ P2 }$ E, I  m* FIn our patient, physical examination was incon-0 r; K, @; T5 U' c
sistent with true precocious puberty since his testi-# k* J+ D; }( T! ^. v0 O, {$ A
cles were prepubertal in size. However, testotoxicosis, c* s7 ]  R8 t9 M
was in the differential diagnosis because his father+ p, G/ G( n3 F0 }
started puberty somewhat early, and occasionally,4 h5 \9 f* B* m
testicular enlargement is not that evident in the3 a: S9 l( y8 C4 I
beginning of this process.1 In the absence of a neg-
' v- I% Z( O1 x. dative initial history of androgen exposure, our
3 o+ R8 P0 C+ G7 N' m9 J, ], Hbiggest concern was virilizing adrenal hyperplasia,7 O- x7 z' n5 z  b& p6 O# Y- ~/ ~" N
either 21-hydroxylase deficiency or 11-β hydroxylase
: F/ v' N7 W, a2 sdeficiency. Those diagnoses were excluded by find-
! \4 v( O9 _* P- ?ing the normal level of adrenal steroids.6 {, X$ s, [, M+ x) ?' d' C% d
The diagnosis of exogenous androgens was strongly: k; t  x. x3 ], k" y  X
suspected in a follow-up visit after 4 months because, f) Q: {. d) ~5 I
the physical examination revealed the complete disap-
7 R( J5 T  D: Y; Z* p5 F5 ipearance of pubic hair, normal growth velocity, and
) A! n2 j% m9 V0 S+ ~' Xdecreased erections. The father admitted using a testos-; H$ X( C5 v& Z' W/ V
terone gel, which he concealed at first visit. He was: b* ?; Q2 d' a$ [( |& k' t
using it rather frequently, twice a day. The Physicians’
1 W) ?, y  H5 v! l  f8 R0 ^Desk Reference, or package insert of this product, gel or9 Y, c6 L6 b4 J/ Z7 ]* F
cream, cautions about dermal testosterone transfer to* X* [. ?/ W( }! r2 B
unprotected females through direct skin exposure.
! C; _8 Q0 t# L$ N& Z3 gSerum testosterone level was found to be 2 times the  B$ B' F- @, |. C
baseline value in those females who were exposed to5 K9 u# |- {) x4 i- f
even 15 minutes of direct skin contact with their male/ `* `7 B, k4 W7 K; o4 E
partners.6 However, when a shirt covered the applica-6 x# k6 R5 w8 {) c5 u. [
tion site, this testosterone transfer was prevented.
* d6 L, u) n3 aOur patient’s testosterone level was 60 ng/mL,
& `$ B) ~2 r4 [+ g8 ?which was clearly high. Some studies suggest that
" x, L7 [8 O: u0 T7 @; ]dermal conversion of testosterone to dihydrotestos-/ Q* I) n6 |/ v' j  e
terone, which is a more potent metabolite, is more
! R1 j8 y  o* [& R% vactive in young children exposed to testosterone
/ C$ T) y* c/ Bexogenously7; however, we did not measure a dihy-4 a. `0 L+ d. Z( h( n, R
drotestosterone level in our patient. In addition to
. e& }2 O: w& x+ z9 T/ Avirilization, exposure to exogenous testosterone in
& Y7 X1 t& a" y. Zchildren results in an increase in growth velocity and
' A$ r2 M! W" e$ Fadvanced bone age, as seen in our patient.
: E# [, _' M% Y$ V& NThe long-term effect of androgen exposure during
9 l! D6 W) _7 f( wearly childhood on pubertal development and final6 w, O8 M+ [: ]' C
adult height are not fully known and always remain
, m8 p; s, w) C$ [; g* qa concern. Children treated with short-term testos-: T+ o; r" r1 P' R7 a4 e# c
terone injection or topical androgen may exhibit some
6 P  ~- E1 y; p7 Hacceleration of the skeletal maturation; however, after: I  o2 |# w. k" X
cessation of treatment, the rate of bone maturation
* @4 M( ]* H' ^! W8 ndecelerates and gradually returns to normal.8,9. S7 z# O6 i( Q6 z( P: y
There are conflicting reports and controversy
4 D4 k$ A) U) |) w7 A. F! y$ eover the effect of early androgen exposure on adult% S7 D4 l8 U7 m. ?7 b: i; ?/ Z- D
penile length.10,11 Some reports suggest subnormal
- _: u  h! |1 Yadult penile length, apparently because of downreg-: _$ D4 `, s! U- T) p$ C
ulation of androgen receptor number.10,12 However,
: b* ?# P8 ?, M/ E' KSutherland et al13 did not find a correlation between6 R: f+ v# B  ]
childhood testosterone exposure and reduced adult
* M) B4 @2 _5 L" `3 L3 ]% ~# [3 Tpenile length in clinical studies.) Q) u9 N- _8 S5 H' n, t2 R
Nonetheless, we do not believe our patient is
: [" j! G+ I! D+ P; R( S3 q6 Jgoing to experience any of the untoward effects from
- |: B2 t  D; ?/ [3 Gtestosterone exposure as mentioned earlier because
& S% h( S  A) D4 `the exposure was not for a prolonged period of time.
* ]+ [" B9 W4 W+ T+ k0 ?; YAlthough the bone age was advanced at the time of
" L# c5 ]! |1 ~8 Z5 K7 ^: K# E: fdiagnosis, the child had a normal growth velocity at
. W% y, V  J& D+ ethe follow-up visit. It is hoped that his final adult9 O4 i' w2 P2 k: X; h5 q
height will not be affected.6 o* ]: t1 M7 ?3 U9 u4 E& m; `
Although rarely reported, the widespread avail-
& T2 n% A  G8 \3 Oability of androgen products in our society may1 Y( p) Y0 d/ ?3 E% \
indeed cause more virilization in male or female
: {0 N' L2 X, |) V) M# wchildren than one would realize. Exposure to andro-
5 V. i2 x+ N2 k3 c% Vgen products must be considered and specific ques-
9 Q( F: J$ a% [/ L0 ptioning about the use of a testosterone product or. z; r# t3 y1 q& I# l
gel should be asked of the family members during! Y* Y5 L  N* U  m) r( s
the evaluation of any children who present with vir-; Q) C$ k) ~% I- j; W! w! K
ilization or peripheral precocious puberty. The diag-. Q9 `, K/ I' k8 p- _
nosis can be established by just a few tests and by
: D3 f; u) @  ~+ ?" O/ Y# gappropriate history. The inability to obtain such a
  ~0 b* Z% d- {( {# q, X3 B% [history, or failure to ask the specific questions, may: B8 ^- k% o" P- X! l/ F
result in extensive, unnecessary, and expensive
+ x8 S; ~, X4 l1 d7 U  l* [# Rinvestigation. The primary care physician should be% l$ y0 b& r( c9 {0 I
aware of this fact, because most of these children
; h" D& A: n( p! U. D6 Lmay initially present in their practice. The Physicians’3 N; ~9 R- v  X! }- p
Desk Reference and package insert should also put a
* h4 u; Q3 L! h9 gwarning about the virilizing effect on a male or
$ Q! L6 b; F* B: U- efemale child who might come in contact with some-( M* O  Z/ X9 B- x% m
one using any of these products.
8 f1 _* N7 H. z& ~: ]2 jReferences
; z8 u' E, p7 C' G. _1. Styne DM. The testes: disorder of sexual differentiation
1 L2 c6 m+ b. T+ Vand puberty in the male. In: Sperling MA, ed. Pediatric
" y) ~9 t& K1 z# H' k4 A! WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  n1 {% H( S: L8 S7 L# v, K2 U) H6 G2002: 565-628.
9 k% L, M; G+ r0 [+ b/ v7 W0 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ _3 C0 I' T( |. B
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% m" f8 ^0 i, X
Boy Induced by Indirect Topical' ]! p" ]9 ?3 \2 A; c% M* p
Exposure to Testosterone: K$ O: s2 @. Q/ ^, u8 o0 |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- b0 q: G- M. k5 R# V( z  |9 Fand Kenneth R. Rettig, MD17 b- \- X( G, C. k( {
Clinical Pediatrics; E6 F* I2 ^% r; L7 q6 K
Volume 46 Number 66 }5 ]- t! w) @" J7 M) k! ]1 d4 a# N. L
July 2007 540-543% _2 W2 m9 r/ y7 Z/ I
© 2007 Sage Publications
; K8 n! p( |" E. h" ~  K! T: W3 D10.1177/0009922806296651
/ p5 N# a$ t! N  {+ `- N7 l( f- r1 e& Dhttp://clp.sagepub.com& `, A, Q+ V! [- R! {$ j/ n
hosted at
, D2 B. h9 ?. n$ w* R/ `, W: T# phttp://online.sagepub.com3 }0 L5 S! T: Z
Precocious puberty in boys, central or peripheral,; t; S' C% v' z' i' x
is a significant concern for physicians. Central7 s- ?+ `8 ?, B% v' _1 R) w7 n7 `
precocious puberty (CPP), which is mediated- K0 u3 h/ g' |, Z9 Y. ~
through the hypothalamic pituitary gonadal axis, has4 p* p5 C  O& X! A: O. t( q
a higher incidence of organic central nervous system, \, \$ |  B/ c% G" B. ]$ D, H
lesions in boys.1,2 Virilization in boys, as manifested; D- M4 c3 M1 h: w+ X
by enlargement of the penis, development of pubic
. L3 Z. }( S' ^; M1 E/ ]hair, and facial acne without enlargement of testi-
8 D7 x: U# F- g- c9 A. |# l# Mcles, suggests peripheral or pseudopuberty.1-3 We
6 ^1 M9 X* Q4 Xreport a 16-month-old boy who presented with the
, |" C5 `4 i9 l5 ?! a* L' t4 renlargement of the phallus and pubic hair develop-
. M# \% R1 S+ pment without testicular enlargement, which was due  Z; t/ F8 ^9 w. r5 g  W, a
to the unintentional exposure to androgen gel used by
" \9 G" a  m4 K9 _3 n! Hthe father. The family initially concealed this infor-
2 t+ S+ ~4 e% l5 K* o2 zmation, resulting in an extensive work-up for this
# x+ l3 `7 h7 ochild. Given the widespread and easy availability of
% N: X4 W. I0 D7 n# ntestosterone gel and cream, we believe this is proba-
+ V' k6 d1 c0 e5 j2 Zbly more common than the rare case report in the$ u/ A2 h7 V& z. {6 R; ?
literature.49 D( {  L% P7 k8 y# K( V# A
Patient Report
* L# e; z! z9 r% G$ W0 y3 z5 \A 16-month-old white child was referred to the8 A& a9 X. V+ ?
endocrine clinic by his pediatrician with the concern/ ~/ S( d- ^$ }# s3 M3 e  ]/ Q
of early sexual development. His mother noticed
+ k& l" y; z" ~: u( i3 j/ Vlight colored pubic hair development when he was
# ~- ]* Y6 C5 S6 xFrom the 1Division of Pediatric Endocrinology, 2University of  }3 z$ K0 `7 \6 a5 s, l. ^+ ?
South Alabama Medical Center, Mobile, Alabama.
2 Y5 m4 S5 Q# v, HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
! {: e' A  g) }* P( a2 ^8 HProfessor of Pediatrics, University of South Alabama, College of
9 x* S1 U3 g% KMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 g& l, F: S% s: {- p
e-mail: [email protected].
5 ?" u; G" L' Z' G, Pabout 6 to 7 months old, which progressively became- s: p0 U8 \" e) z" s
darker. She was also concerned about the enlarge-
9 O- Y/ g5 H$ k6 f' [/ ement of his penis and frequent erections. The child
  T$ v9 E# }  rwas the product of a full-term normal delivery, with( r* Q0 [& s9 x, d: f5 m8 a, N
a birth weight of 7 lb 14 oz, and birth length of4 r3 y/ M0 q8 M- r& J2 u- U
20 inches. He was breast-fed throughout the first year
* {+ r' a* E  S$ P9 Fof life and was still receiving breast milk along with( k( ^- A+ y/ K5 n" J
solid food. He had no hospitalizations or surgery,
( s$ R9 _5 Q" a+ O  s6 J1 ^# Kand his psychosocial and psychomotor development/ y$ `; \  ~% R, ~0 l  ^
was age appropriate.
% N) V$ O0 |( _( jThe family history was remarkable for the father,8 @& ^5 |: z; r' B& p7 C
who was diagnosed with hypothyroidism at age 16,8 E" u' z+ K: |- }9 }; }
which was treated with thyroxine. The father’s5 e" F1 a: V% o* X3 R
height was 6 feet, and he went through a somewhat2 C& t1 H3 l6 j! G3 p) Q* @/ s
early puberty and had stopped growing by age 14.! _) y/ b' g, f
The father denied taking any other medication. The
2 U% t( S( A# U( e+ X( }child’s mother was in good health. Her menarche
' k4 H- g2 a8 ]* l, H% Kwas at 11 years of age, and her height was at 5 feet( r0 n7 |7 r. S. r' W
5 inches. There was no other family history of pre-
$ V5 Z  I0 E/ Kcocious sexual development in the first-degree rela-# d( b5 K$ \- u( x# {/ V
tives. There were no siblings.2 L" l7 u/ A2 y8 `
Physical Examination9 F* L) ?1 r$ z/ k
The physical examination revealed a very active,& l* g0 D, [* t* |2 U7 G( O
playful, and healthy boy. The vital signs documented
  g, Y4 B$ [+ Y* Q  b/ ja blood pressure of 85/50 mm Hg, his length was" |5 N7 P9 ]  N9 p
90 cm (>97th percentile), and his weight was 14.4 kg, w/ a) q: E6 B0 z
(also >97th percentile). The observed yearly growth
  b+ ?! y1 [" Y; N) wvelocity was 30 cm (12 inches). The examination of2 f7 U! p/ P4 A
the neck revealed no thyroid enlargement.
) M: Z( s( |3 v8 v4 s8 \The genitourinary examination was remarkable for" l7 Y0 S! i, _; l
enlargement of the penis, with a stretched length of( ?" D& {1 o7 r2 {% B" y4 @
8 cm and a width of 2 cm. The glans penis was very well
" h9 \0 Y# G' Tdeveloped. The pubic hair was Tanner II, mostly around
4 G0 z6 {/ n* e# ?0 b540) V  B: b7 [- K/ u, w+ ?, m4 h: E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* s0 y& W. t( i6 F/ ~the base of the phallus and was dark and curled. The: u0 f7 @& m0 _% v
testicular volume was prepubertal at 2 mL each.1 \: N) ?4 V3 {( F: W* p# n2 s
The skin was moist and smooth and somewhat
- H# |+ W7 I2 O: soily. No axillary hair was noted. There were no8 E9 f" }$ ?/ r' ^! R' z+ P3 N% i; _
abnormal skin pigmentations or café-au-lait spots.9 Q6 j# M2 T- J2 i' T) T; ^
Neurologic evaluation showed deep tendon reflex 2+" L" k" ^  D1 D
bilateral and symmetrical. There was no suggestion& ?8 w. L) l. {& q1 B9 [: e8 y
of papilledema.
+ w; O9 l" q& X! u; V7 R, eLaboratory Evaluation
9 U& Z0 T' x; O0 i6 Q/ v" T+ _2 rThe bone age was consistent with 28 months by7 \% f* t$ {( w+ M% I  Q
using the standard of Greulich and Pyle at a chrono-6 h: Y  p4 n1 ]( e8 G7 h& \
logic age of 16 months (advanced).5 Chromosomal% m# s3 X; R( l* ?7 z
karyotype was 46XY. The thyroid function test
7 t( \- ^% h& f: u$ l# Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-/ U7 C' h9 Q+ h  M
lating hormone level was 1.3 µIU/mL (both normal).) d# }3 w" \& K% Y2 H! Y
The concentrations of serum electrolytes, blood
. O5 u9 \& E. |+ ]6 p0 G% m3 H) Ourea nitrogen, creatinine, and calcium all were
- m" o6 \7 R1 s: ]+ [within normal range for his age. The concentration( ^5 Z# ^( r! Y3 Y
of serum 17-hydroxyprogesterone was 16 ng/dL* q& G; Y, ~0 O; N# Z1 J& W
(normal, 3 to 90 ng/dL), androstenedione was 20
0 B$ l' c6 M0 ^" R% n9 T0 rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& ^4 }3 B! F2 w: h1 t2 S* w/ c
terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ c7 B. c& J' W0 t7 a5 M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 |, I6 [- S6 h9 a6 x& M49ng/dL), 11-desoxycortisol (specific compound S)8 J* l" |* `+ W  c9 O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 M& Z  h$ D+ C$ ?5 g0 `$ y& H% Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% j' q5 ^; F: j) O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, R" x6 A/ E$ ^2 \1 ]) i8 j4 L1 ^
and β-human chorionic gonadotropin was less than# P( t" `1 U# J
5 mIU/mL (normal <5 mIU/mL). Serum follicular% z6 i  n) p2 k( z
stimulating hormone and leuteinizing hormone
0 @5 i* o2 r) [* ?. s, _* Xconcentrations were less than 0.05 mIU/mL
5 P* M8 W: ?$ z; U& h6 K(prepubertal).- t# G% r' X% P; O4 I4 b
The parents were notified about the laboratory) \7 f/ Y% n/ v9 B- B" K% s
results and were informed that all of the tests were8 A. v- H7 [2 x2 Q
normal except the testosterone level was high. The
" y7 ]( O3 W- a( B4 ?follow-up visit was arranged within a few weeks to
8 k4 M4 m9 q$ h' X% l. _' f8 @obtain testicular and abdominal sonograms; how-" p9 ~; r3 Z9 ~. n' D: {
ever, the family did not return for 4 months.
- }1 P. h* S5 O) L5 V* o* KPhysical examination at this time revealed that the
% |; E' p" e% [6 I4 Y2 Ychild had grown 2.5 cm in 4 months and had gained
. s: |) p! f9 @( p: U6 I; g. h4 D! L2 kg of weight. Physical examination remained
, O% Y0 S0 s/ q8 E* S2 _/ Ounchanged. Surprisingly, the pubic hair almost com-9 U) W) d  V$ Y: B1 R8 W$ Z9 V  x
pletely disappeared except for a few vellous hairs at4 X0 ?7 j' @& _4 u- u* m& p
the base of the phallus. Testicular volume was still 2+ M9 _* k1 {$ X; `+ e
mL, and the size of the penis remained unchanged.* q9 a; H+ ~- P$ G! i9 {
The mother also said that the boy was no longer hav-
+ d0 P3 D% x( @ing frequent erections.! J$ H' X) b( l& }: o
Both parents were again questioned about use of+ E0 J. }( `, Q4 r' T4 a1 c' {
any ointment/creams that they may have applied to, U- A9 G$ M# X, ~6 Y2 O
the child’s skin. This time the father admitted the
% [- l7 ^9 O3 \# M/ r5 F" n* @Topical Testosterone Exposure / Bhowmick et al 541
  G# F7 k4 s; z1 A  X* Yuse of testosterone gel twice daily that he was apply-  f' P, ^/ v9 J9 z" F/ I5 M9 ~
ing over his own shoulders, chest, and back area for; L& q# J  ~6 t1 S$ E" _
a year. The father also revealed he was embarrassed. F8 L9 v8 I. D+ n/ ^. {4 }
to disclose that he was using a testosterone gel pre-
. t# K% d8 f; Z) Y, L3 f- A, l1 mscribed by his family physician for decreased libido8 S. P' ]# e0 A' p0 \
secondary to depression.- P' O- `0 v8 l2 T" Q2 ?+ L
The child slept in the same bed with parents.  j4 w. Y" q/ Y% s, z, q
The father would hug the baby and hold him on his
1 K4 C- P" N+ c: r8 v. N3 ?8 I. w0 Tchest for a considerable period of time, causing sig-
7 j+ A. e+ H' Bnificant bare skin contact between baby and father.2 Q0 B" T+ C8 @7 v# `
The father also admitted that after the phone call," e' U) W. Z+ C
when he learned the testosterone level in the baby
+ n0 u$ Y% e, a- }7 n) f9 Ywas high, he then read the product information
) d' z0 j- G. b( _, Kpacket and concluded that it was most likely the rea-- C! U# m  |' R  z6 \
son for the child’s virilization. At that time, they8 Y1 V. j" |7 j. }
decided to put the baby in a separate bed, and the
5 {! B1 i1 Z; ~1 s' Qfather was not hugging him with bare skin and had2 |+ Q4 }* d8 U- G! R2 ^( k
been using protective clothing. A repeat testosterone) @/ l7 o9 h- T- A8 C/ q* b% ^
test was ordered, but the family did not go to the
6 T& [+ _5 R1 d( a4 F9 Flaboratory to obtain the test.
9 r4 p  c; \5 {) H" yDiscussion% [! c: `1 g0 @
Precocious puberty in boys is defined as secondary8 V7 X) |9 d7 q9 _0 T  {" ^
sexual development before 9 years of age.1,45 A' }: N/ N# d" ]
Precocious puberty is termed as central (true) when. ]# t, Y* D, X) a. d
it is caused by the premature activation of hypo-
, w) h! x0 \" G$ J9 J' [thalamic pituitary gonadal axis. CPP is more com-$ x- `8 k. O2 r6 R% n1 N- K/ A) m- ^
mon in girls than in boys.1,3 Most boys with CPP
4 o$ m% [$ `2 i' amay have a central nervous system lesion that is
" y! N5 _9 T% k2 wresponsible for the early activation of the hypothal-
2 u& ?6 }: Z" J# g' r) o* _amic pituitary gonadal axis.1-3 Thus, greater empha-
0 J. O  j' {" _, Dsis has been given to neuroradiologic imaging in- o' C# _- n5 w6 D7 Q
boys with precocious puberty. In addition to viril-
1 A! t5 P  X% j, i1 aization, the clinical hallmark of CPP is the symmet-
. k9 ~7 A4 s  w% krical testicular growth secondary to stimulation by% h9 ^+ ?% C9 G1 N$ E" M3 Q) `  j
gonadotropins.1,3  r6 }2 N7 z. H" C2 |+ j3 j5 ?* b
Gonadotropin-independent peripheral preco-
6 j6 g9 B( l  m9 l5 ccious puberty in boys also results from inappropriate. s$ l8 o8 Q7 ^) B7 M7 e
androgenic stimulation from either endogenous or- ^0 R9 o$ b$ ]9 y& @6 C/ B
exogenous sources, nonpituitary gonadotropin stim-
+ Z( ~& n) @" xulation, and rare activating mutations.3 Virilizing% P1 Z( w' C6 \0 Y: L* |7 ^
congenital adrenal hyperplasia producing excessive: v2 v; m8 h) E
adrenal androgens is a common cause of precocious$ ~. T+ g6 Y( z( A3 h" D
puberty in boys.3,4
8 N8 v  x0 i3 v- k& Q7 yThe most common form of congenital adrenal$ \0 \4 I# A$ H) p- n9 e! @- E
hyperplasia is the 21-hydroxylase enzyme deficiency.
' H- \. c1 D, v9 C; r1 h, y! MThe 11-β hydroxylase deficiency may also result in
6 u* f5 J, H* H# J- ]excessive adrenal androgen production, and rarely,
4 I8 A5 [! H) V9 G  Y! J. s- Han adrenal tumor may also cause adrenal androgen. G! ~4 ~4 A- a( P( k! F/ T
excess.1,3
1 t3 g2 W7 r, n2 @7 p9 h/ Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, T! _, n5 a; Z/ [542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* ?4 a2 Y: H2 L3 v/ y# ~- L6 I& T
A unique entity of male-limited gonadotropin-$ C0 M( J6 n$ S7 o
independent precocious puberty, which is also known
' i; J$ A! `* [% U5 s. oas testotoxicosis, may cause precocious puberty at a
3 U7 b" m1 ^6 G0 \; |0 Avery young age. The physical findings in these boys
- p5 ]! s7 M# t/ ^with this disorder are full pubertal development,+ W3 `$ B* m" R) |
including bilateral testicular growth, similar to boys& Z! x4 d8 @$ x, J! ?
with CPP. The gonadotropin levels in this disorder/ a7 L5 Z: C0 l
are suppressed to prepubertal levels and do not show
* i; n  k0 w% F* j; ^. t8 vpubertal response of gonadotropin after gonadotropin-8 H. W$ y# c& x/ X6 I
releasing hormone stimulation. This is a sex-linked1 R* R3 R/ D" Y, n0 j
autosomal dominant disorder that affects only2 N/ y) |3 o- w9 h' R( l) v
males; therefore, other male members of the family
! i- N3 y. M( L  e2 o5 e# smay have similar precocious puberty.3
- a+ X2 _! M* u( A- }# _0 dIn our patient, physical examination was incon-
) {9 q# P: U/ h8 M7 dsistent with true precocious puberty since his testi-) c0 t5 E$ ]# {" v& A; a! [
cles were prepubertal in size. However, testotoxicosis7 D7 v; x5 V# S/ e0 r) q7 |
was in the differential diagnosis because his father
3 U' [, l% k$ o: _$ mstarted puberty somewhat early, and occasionally,
+ M: S3 P8 X; @2 O8 g4 K- Ztesticular enlargement is not that evident in the5 d7 N" B/ t% T; J5 \2 s/ Q
beginning of this process.1 In the absence of a neg-/ f5 t) t# C, Q( u7 T' e
ative initial history of androgen exposure, our
6 j9 o$ }2 }  z( E- p0 ?biggest concern was virilizing adrenal hyperplasia,, F7 ]& n* o7 o8 Z3 D: }& m
either 21-hydroxylase deficiency or 11-β hydroxylase
6 S* B9 Y9 S. m9 V$ L: vdeficiency. Those diagnoses were excluded by find-
7 u3 `: x; M' f( m# E8 E7 king the normal level of adrenal steroids.
: d0 s8 N  N# a' uThe diagnosis of exogenous androgens was strongly
& M2 `! L! X1 Q+ @suspected in a follow-up visit after 4 months because' ~) m5 }4 m+ ]0 y( t
the physical examination revealed the complete disap-
- h5 n& H" d$ L0 C! D: Xpearance of pubic hair, normal growth velocity, and* o. v* m& w, K+ Z- g
decreased erections. The father admitted using a testos-
# Z2 i6 D7 E( Y9 o5 X$ Hterone gel, which he concealed at first visit. He was
$ F5 M! g& T/ [+ Fusing it rather frequently, twice a day. The Physicians’
* {& J% _: _/ O( @& sDesk Reference, or package insert of this product, gel or, g0 t) T' L% }: k
cream, cautions about dermal testosterone transfer to& B4 l: [( R" U5 O- _
unprotected females through direct skin exposure.( S3 v  F6 O. \, Y# q
Serum testosterone level was found to be 2 times the! o: r( I0 F9 ]' j* {5 T
baseline value in those females who were exposed to
3 v1 Q  Q* O$ J( j' g9 Veven 15 minutes of direct skin contact with their male
( b6 o& p7 D" |2 F2 p; h. l; cpartners.6 However, when a shirt covered the applica-
" O0 ^% q. }1 k, z' C7 B) xtion site, this testosterone transfer was prevented.; R5 Y1 \% k* D: h' {
Our patient’s testosterone level was 60 ng/mL,
# \! {2 j% ^/ S$ c* Lwhich was clearly high. Some studies suggest that
4 ^9 R& p, N! u) pdermal conversion of testosterone to dihydrotestos-
9 e8 I- O' U, H2 |) L6 Hterone, which is a more potent metabolite, is more+ S* P0 N# O) b1 \
active in young children exposed to testosterone
$ Q9 q  L* ]+ F; m" j/ S: mexogenously7; however, we did not measure a dihy-
$ v4 ?* c7 P  ?" {' p" edrotestosterone level in our patient. In addition to: W: J5 Q( C7 ?+ R8 g. n
virilization, exposure to exogenous testosterone in$ m1 G- ^. A6 N) [# v% U/ _2 p9 t9 H
children results in an increase in growth velocity and
; [  @- e+ [; l2 |advanced bone age, as seen in our patient.
6 ?; }, z0 J, `The long-term effect of androgen exposure during
" I; x$ |# y+ S% aearly childhood on pubertal development and final3 C! J, P; g( O! z: h- i
adult height are not fully known and always remain% Q: p& s0 a/ ?4 v2 X3 B- B) M
a concern. Children treated with short-term testos-
. O1 N4 V) U% H5 N  H% y6 ]' U+ Pterone injection or topical androgen may exhibit some& h# F; l; x' r1 b4 q) a
acceleration of the skeletal maturation; however, after
4 D- l3 |* f: F; D  hcessation of treatment, the rate of bone maturation
. l- Q8 `9 k# Q' ~- cdecelerates and gradually returns to normal.8,9$ h0 U$ _' ~5 ?
There are conflicting reports and controversy
" K: k+ S# h! [1 H) s& _( B7 Eover the effect of early androgen exposure on adult& M- x  q8 H" |" P+ f# c' x% Q
penile length.10,11 Some reports suggest subnormal, S2 o& N* e  Q! q) I
adult penile length, apparently because of downreg-
* b6 }, W0 ^2 {- ?7 A9 Y0 z) ?+ Wulation of androgen receptor number.10,12 However,
! n% V) O% g0 M" w5 WSutherland et al13 did not find a correlation between
' U1 o# c5 `% j- y  I7 D% w2 x3 ?  pchildhood testosterone exposure and reduced adult
+ H/ b, D  L* L' e  w, p* O0 T! bpenile length in clinical studies.
/ C/ y" n7 e6 {9 UNonetheless, we do not believe our patient is
! i; r# C( }* b8 Ggoing to experience any of the untoward effects from0 Z' D! S& m* g8 O- h6 b# Y9 u
testosterone exposure as mentioned earlier because+ L, F) [/ r; h3 o7 A
the exposure was not for a prolonged period of time.
7 k5 ]6 y- S. I+ M+ DAlthough the bone age was advanced at the time of2 t$ a* o& P$ e. X5 |( X
diagnosis, the child had a normal growth velocity at
" m; B: b# V; q% \& X3 c# Fthe follow-up visit. It is hoped that his final adult
; G) ^# D! b1 @; Z/ ]% [height will not be affected.
. \( ?1 v- s( G6 j" y, jAlthough rarely reported, the widespread avail-
9 N" c' p6 ~- ~% ?7 Tability of androgen products in our society may
1 F+ F6 q+ P; H3 y4 B! T) Oindeed cause more virilization in male or female
2 M+ g# \" U4 Zchildren than one would realize. Exposure to andro-
- {9 R6 }- R" v  f) n3 Lgen products must be considered and specific ques-
6 |: K  }- v  j& I, xtioning about the use of a testosterone product or4 K# a1 f( ~: X, K
gel should be asked of the family members during
* c' p( a* S4 [5 L* S# tthe evaluation of any children who present with vir-3 b& ~: e/ S7 s- F% i6 W
ilization or peripheral precocious puberty. The diag-
% [4 W$ S/ [8 r' r  j8 unosis can be established by just a few tests and by; b+ w4 O& V$ h( I( L! ^; |
appropriate history. The inability to obtain such a2 [* A! [) L' z5 y5 V! H) i  _6 L
history, or failure to ask the specific questions, may) B9 v# X; O, f; B2 ^0 M
result in extensive, unnecessary, and expensive
7 m4 u' I5 _7 S. }; Ninvestigation. The primary care physician should be
( {7 o0 u' N' B( [2 _) D$ ~3 j% I* Yaware of this fact, because most of these children  F; q4 f% ^" ]1 _3 ]/ X
may initially present in their practice. The Physicians’7 {& X: r, F4 p( k: Q( a- v) X
Desk Reference and package insert should also put a
' H. t! E3 k- A4 ~2 Fwarning about the virilizing effect on a male or
4 ?$ s; p$ T9 B% v$ q- }female child who might come in contact with some-
% g. N6 p7 o2 Tone using any of these products.
6 ]. Y' o+ |, G4 o2 {0 ?3 \References
( V  y( K6 V% l4 X. _1. Styne DM. The testes: disorder of sexual differentiation7 J' H: l" Z* s' q
and puberty in the male. In: Sperling MA, ed. Pediatric9 }0 g6 n8 e- _$ H4 l& `+ n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, J8 v! u/ {7 t5 r# R% i+ r
2002: 565-628.
( s% F; p; l5 e  K5 n- P' A: y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 [  I+ n' Y% N( R  {
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
( H+ `, Q% a( q6 ~# R
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