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* g9 h& o0 a$ F1 r/ E
Boy Induced by Indirect Topical3 ?9 z! l( l' R) E
Exposure to Testosterone6 G* z: G+ k* n# R1 e) W% a) ?9 @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 h& O2 q* i- |9 B, t# \4 t& X
and Kenneth R. Rettig, MD1, O# {1 c! ?5 H' W
Clinical Pediatrics
! k; F9 R" D( A3 ]1 `Volume 46 Number 6
1 h) j; }; T$ Y- V8 }/ F1 U) _July 2007 540-543! z7 Q3 U8 y* q& E/ ?% X
© 2007 Sage Publications8 t) C2 Y2 r1 U: ~' s) i
10.1177/0009922806296651! w' t# z5 o/ W6 q% e$ O
http://clp.sagepub.com  N& T5 p. {* Q* y- J
hosted at; @$ z- N3 M/ B* q4 u
http://online.sagepub.com
; k0 q$ _  H" ^" W' Z" KPrecocious puberty in boys, central or peripheral,3 w7 W7 q! N8 V! b& z  V4 V( Y# H
is a significant concern for physicians. Central. l: \' _2 }0 F' F" M
precocious puberty (CPP), which is mediated! J1 e8 h. O: p: @3 [; W
through the hypothalamic pituitary gonadal axis, has! _8 H5 F3 F6 k2 I* k
a higher incidence of organic central nervous system
) w$ P1 A/ o0 d1 a% y. M  U) Clesions in boys.1,2 Virilization in boys, as manifested
) Z1 `) I& J2 j3 q2 X& H5 u2 X, dby enlargement of the penis, development of pubic" {5 w" p6 A# O' ~
hair, and facial acne without enlargement of testi-" i# K- z/ f5 B! G. k
cles, suggests peripheral or pseudopuberty.1-3 We+ W. M# g2 D; T5 S0 l# b' P
report a 16-month-old boy who presented with the8 H: e/ ?% x4 o5 S
enlargement of the phallus and pubic hair develop-5 `7 |! C  H* o4 C8 X' n2 n
ment without testicular enlargement, which was due
. [! [# p# s( W$ {' Fto the unintentional exposure to androgen gel used by
9 \  G- C9 _; m& w" Pthe father. The family initially concealed this infor-
5 e  }7 E2 L1 Z% k5 U8 i0 U% smation, resulting in an extensive work-up for this+ p$ o3 C2 }; @! V$ }6 \% S9 X
child. Given the widespread and easy availability of
! u( I3 @# x8 ]5 j: Ttestosterone gel and cream, we believe this is proba-. R: C0 W$ f3 G/ E
bly more common than the rare case report in the, N& O2 [  M6 m+ E: u; n
literature.4/ _( T3 r) j5 U& l
Patient Report7 T, b0 ^& ~1 ~' i
A 16-month-old white child was referred to the5 R! w7 S$ [9 @" p
endocrine clinic by his pediatrician with the concern1 r3 H- u4 `* `6 L5 G
of early sexual development. His mother noticed* s# ^5 v) W  O6 w, q4 t
light colored pubic hair development when he was6 a0 E: ]+ M+ V" R7 `
From the 1Division of Pediatric Endocrinology, 2University of
9 R$ s0 Z* {. K# ^  CSouth Alabama Medical Center, Mobile, Alabama.; y& G# Y  t5 `* u7 R' \
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' @7 T/ `+ p* \Professor of Pediatrics, University of South Alabama, College of, ^" V( Z4 ~7 B0 r$ M; U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, w* M# }" L* @* j3 U2 E; le-mail: [email protected].
, I: o- W0 n) l# Qabout 6 to 7 months old, which progressively became
- l: ]- g$ D/ O! v  Z8 ddarker. She was also concerned about the enlarge-
, V/ ~( V& [) W& w8 Ament of his penis and frequent erections. The child. y" q8 ~# M9 C( w* `
was the product of a full-term normal delivery, with
; d# p6 d6 I6 z' z  ga birth weight of 7 lb 14 oz, and birth length of
4 ^$ \" M7 n+ f- k, B20 inches. He was breast-fed throughout the first year
) J3 R% C3 @( G" G7 S  i9 yof life and was still receiving breast milk along with
" `: [! t/ u7 _4 q3 G" E5 N) esolid food. He had no hospitalizations or surgery,
& M( {# b* s& w$ y, a1 w3 X5 c7 _and his psychosocial and psychomotor development) \, V9 e& E7 l
was age appropriate.3 g' {& f4 B( s' u2 K  b$ J- y( i' t
The family history was remarkable for the father,
, W# ?9 X$ }$ S, [' Z8 }- d* ywho was diagnosed with hypothyroidism at age 16,) `+ Q; s( Y7 k1 o, H" {$ h
which was treated with thyroxine. The father’s- H- r/ c7 U# M& S9 N
height was 6 feet, and he went through a somewhat8 |$ K- e* v' \# y. [
early puberty and had stopped growing by age 14.
2 f9 u# x- m" P8 mThe father denied taking any other medication. The& h( l( \% d( Q! I2 C, c
child’s mother was in good health. Her menarche
) s, ]; W& X; P! P/ lwas at 11 years of age, and her height was at 5 feet
3 H8 g' t) }! E$ M6 e) S7 w, q3 V5 inches. There was no other family history of pre-
+ w# A0 D/ D+ S/ n. ycocious sexual development in the first-degree rela-
  w3 _9 {$ g4 xtives. There were no siblings.$ ^+ o6 x( C+ `: B
Physical Examination6 \, P: G3 x9 Q) Q# v3 n' t
The physical examination revealed a very active,5 ]! Z1 u+ J$ `' v7 {
playful, and healthy boy. The vital signs documented
% ^+ F0 ?0 ?: za blood pressure of 85/50 mm Hg, his length was: i! C' R5 s' S3 y2 S4 Y6 C/ R
90 cm (>97th percentile), and his weight was 14.4 kg
" c$ i1 k1 X+ I( w9 }2 Q(also >97th percentile). The observed yearly growth. y5 G" m! b9 L9 [$ U
velocity was 30 cm (12 inches). The examination of
! E8 v2 w/ D% T6 ?  X9 Lthe neck revealed no thyroid enlargement.% ?5 x' u$ v* F5 z# z+ U9 E
The genitourinary examination was remarkable for
& ]6 K+ a" o3 k4 P3 ]2 o9 {enlargement of the penis, with a stretched length of4 w( [( Y' O3 }* n- P
8 cm and a width of 2 cm. The glans penis was very well
' ?+ \8 C* {4 ?6 Fdeveloped. The pubic hair was Tanner II, mostly around1 ?0 v- _3 a7 P) R4 x5 G- q
540( c$ _5 k* h9 L! t7 p' C  g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 d. V1 W2 n. I# j- \! R
the base of the phallus and was dark and curled. The
$ `7 G# F; I) U0 B. C# w, Qtesticular volume was prepubertal at 2 mL each.
8 a( d( W% X" O- H) @+ X3 u6 [The skin was moist and smooth and somewhat
) f% R, I: b- x8 k* O! hoily. No axillary hair was noted. There were no
  _9 }! S5 Z5 h, e- Habnormal skin pigmentations or café-au-lait spots.! Q  m# ^" H' V% a- X
Neurologic evaluation showed deep tendon reflex 2+
& ]2 m1 l% l! i4 y2 p- X5 m5 P8 _! kbilateral and symmetrical. There was no suggestion' l. K. \1 U. \2 Z- l
of papilledema.( d7 F5 C0 w3 Z( N8 \
Laboratory Evaluation
- S, u4 x  O. `% v  oThe bone age was consistent with 28 months by
" d. ^8 a# H# @4 r9 }2 ousing the standard of Greulich and Pyle at a chrono-
5 z0 c/ v: ^1 \8 Elogic age of 16 months (advanced).5 Chromosomal
/ j& E! L$ v. z. u4 ]1 m2 h- N, xkaryotype was 46XY. The thyroid function test
7 M# ^6 V, a+ J$ Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 J' L! z- j( z3 L; klating hormone level was 1.3 µIU/mL (both normal).
+ Z- y2 H- J% BThe concentrations of serum electrolytes, blood
" G( l6 k( f) i. ?0 O  N; R4 @) m0 Aurea nitrogen, creatinine, and calcium all were
4 [9 t% Z# f" A1 Wwithin normal range for his age. The concentration4 T3 R  ~, G# T4 }
of serum 17-hydroxyprogesterone was 16 ng/dL
" c$ B1 ?, v: G3 ](normal, 3 to 90 ng/dL), androstenedione was 20
" l- j) l. H* i0 o, T# png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! V5 @* R7 a) k5 l7 R) S( x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; C) t0 [# l* q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% ~$ Z4 b1 c& v- F49ng/dL), 11-desoxycortisol (specific compound S)
- L  H) b) s, [6 D& |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 U" E1 M. ^& |# D# \1 G% \  ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ q" t- A! Q* Gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- E3 P% b( Y( u3 R+ W7 S. c7 Pand β-human chorionic gonadotropin was less than" ^) b/ H: A# P: Q  a& L9 s
5 mIU/mL (normal <5 mIU/mL). Serum follicular. U  J! }3 @; X; D5 K6 D, |
stimulating hormone and leuteinizing hormone
# B9 P: k7 C3 [( c2 W3 w0 aconcentrations were less than 0.05 mIU/mL. i' O5 Q8 y9 G% e' E
(prepubertal).! E8 A7 n" r9 s8 s1 C; \
The parents were notified about the laboratory
5 c! d; Z; L" @results and were informed that all of the tests were
# @" D7 u# }: cnormal except the testosterone level was high. The
! x2 N7 X& @7 e" @7 {5 D( t( U/ Nfollow-up visit was arranged within a few weeks to
6 b3 o- Y4 ~. ?" u- f9 L) Nobtain testicular and abdominal sonograms; how-* _  {7 i/ k3 O$ H3 F$ B1 c
ever, the family did not return for 4 months.+ `& W* |* Z4 [
Physical examination at this time revealed that the' {' P6 P3 e* |1 j' h4 B' m' A
child had grown 2.5 cm in 4 months and had gained
4 e- M, Q% x, u2 s3 m& W: ?8 q% H2 kg of weight. Physical examination remained
9 I$ E1 ?. y/ H6 m+ ~unchanged. Surprisingly, the pubic hair almost com-- n0 |$ Q' z/ v
pletely disappeared except for a few vellous hairs at
. a& D5 D  B0 v! W7 T, g0 _the base of the phallus. Testicular volume was still 2
& e6 F5 f+ p! K4 _  @mL, and the size of the penis remained unchanged.
/ j8 l7 |# n) I# K( Y/ jThe mother also said that the boy was no longer hav-& i3 z# u5 }- C( p4 H
ing frequent erections.9 K, b7 S/ V$ ~
Both parents were again questioned about use of5 ^( G+ G, _/ p# t* g5 q7 @4 ~
any ointment/creams that they may have applied to
0 U3 B, p2 N8 Ithe child’s skin. This time the father admitted the9 u/ d8 q5 Q- c+ f
Topical Testosterone Exposure / Bhowmick et al 541
3 C# Z, c1 D4 x  N( e( Buse of testosterone gel twice daily that he was apply-0 z2 F% ]5 A  v; ~1 v
ing over his own shoulders, chest, and back area for
7 u) n8 b4 D% M5 c  C6 Xa year. The father also revealed he was embarrassed
# q: U' D% B7 U* \to disclose that he was using a testosterone gel pre-& W! p, |7 q! {/ T" E
scribed by his family physician for decreased libido- ^# R0 L1 c+ z0 U" l1 a  r
secondary to depression.' r( }5 B, q3 m" {5 T
The child slept in the same bed with parents.0 E3 T/ I9 s; M% D( R. y$ m
The father would hug the baby and hold him on his
0 a, m  f; w: v& d( ]# Z& Pchest for a considerable period of time, causing sig-
" B' o) H, ]# G. jnificant bare skin contact between baby and father.
! g5 L/ V3 Y. t2 I8 |The father also admitted that after the phone call,
/ U, m  h: k  H1 y5 vwhen he learned the testosterone level in the baby
- e8 T* B7 O$ t' j% Y4 ~was high, he then read the product information/ a( W% I, M! D8 P& A$ J: {
packet and concluded that it was most likely the rea-
$ a) s6 w% w. Y. d2 C& f, |son for the child’s virilization. At that time, they
; Q# z$ `: R; d! [% n2 ^: Fdecided to put the baby in a separate bed, and the5 V* j( x8 D% C  L- F" I
father was not hugging him with bare skin and had
  @' H* M* G; Fbeen using protective clothing. A repeat testosterone" t4 u+ L/ _! P2 E% R) G  R
test was ordered, but the family did not go to the1 L. K' F; m% _  P9 X
laboratory to obtain the test.$ v5 c6 B$ y% G  V) b
Discussion
4 A6 O+ Y( K) v  |) ?# }Precocious puberty in boys is defined as secondary- O9 B  E, u  G
sexual development before 9 years of age.1,4
- S  }" k3 X' W2 x+ Z$ TPrecocious puberty is termed as central (true) when
. ^7 p; B1 d& T1 r. W9 u5 B" d: g0 Eit is caused by the premature activation of hypo-
7 J2 @5 K% E, `8 }( a2 zthalamic pituitary gonadal axis. CPP is more com-
( ]; o% T/ ^& {mon in girls than in boys.1,3 Most boys with CPP
1 @- W5 f) p5 Omay have a central nervous system lesion that is; H: L, a  Z( h, L( s0 d% J
responsible for the early activation of the hypothal-% |! e, W8 A+ D8 y. N9 \. J8 v
amic pituitary gonadal axis.1-3 Thus, greater empha-$ c8 I4 H* k, b/ }8 x. {$ g
sis has been given to neuroradiologic imaging in
4 a3 E( \6 T/ [boys with precocious puberty. In addition to viril-5 J1 x7 w+ |0 f8 a! }
ization, the clinical hallmark of CPP is the symmet-) x5 `( {5 ?' p& R: N! J
rical testicular growth secondary to stimulation by4 E: U5 f8 o+ v& g+ p8 A% c
gonadotropins.1,3
8 {5 D, F) |0 v8 K  @7 wGonadotropin-independent peripheral preco-
" F+ Z! }/ ?. b, x' s0 ?cious puberty in boys also results from inappropriate- o, M4 ?6 \& C2 A
androgenic stimulation from either endogenous or
; [0 W( J& H# \; Yexogenous sources, nonpituitary gonadotropin stim-
1 _6 N6 j/ D( z: [3 tulation, and rare activating mutations.3 Virilizing9 c6 n9 A- J% G. e3 @
congenital adrenal hyperplasia producing excessive
5 [+ b  ~2 a% v1 _adrenal androgens is a common cause of precocious
4 i: m7 ]" |1 [) _puberty in boys.3,4+ `6 M1 o, ]* D" h" [% ^  ~; |
The most common form of congenital adrenal: ?, E, E+ {% N4 x4 P- P3 z
hyperplasia is the 21-hydroxylase enzyme deficiency.
# [/ D4 D; f/ @7 v  kThe 11-β hydroxylase deficiency may also result in& c& R- c) q- P( o, J
excessive adrenal androgen production, and rarely,' I0 u7 W! X1 f6 K( F
an adrenal tumor may also cause adrenal androgen0 n5 p; B# Z/ s! \/ p. }; n/ ]' E( W/ }
excess.1,35 {) r2 Y1 ~! ]7 t/ ^+ D0 k! h5 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 c5 `5 |' s) h- c; B) x8 Q3 N& v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; Q6 a, Z9 B2 {1 q3 t
A unique entity of male-limited gonadotropin-; x! T0 G: |+ T4 v7 a$ q. u
independent precocious puberty, which is also known! X; V% I/ x9 N! m7 G& C
as testotoxicosis, may cause precocious puberty at a+ n2 Q4 K! R( u" o4 j! J( \0 G) B
very young age. The physical findings in these boys% N3 z. f! d/ u& }
with this disorder are full pubertal development,9 R7 B- ?5 y0 i8 _
including bilateral testicular growth, similar to boys
' ~+ a6 T6 e8 T! X, P5 v" y4 ]2 uwith CPP. The gonadotropin levels in this disorder3 A6 q% c. F( H: \; i" _% Q
are suppressed to prepubertal levels and do not show& h  ?# @" W2 w
pubertal response of gonadotropin after gonadotropin-
8 q/ |9 v! V" T3 b( t# ?" @releasing hormone stimulation. This is a sex-linked4 M* e0 e3 i# K" A& _' v! r5 r- _
autosomal dominant disorder that affects only
$ r, z. V) q9 r- P' g/ I# o5 @& M7 Umales; therefore, other male members of the family4 Y2 A1 R  K- x
may have similar precocious puberty.3( ?: D+ q+ _6 j+ S  k8 C
In our patient, physical examination was incon-
% a! \) R' F" j, E1 Nsistent with true precocious puberty since his testi-
7 T$ e' N5 _3 M5 ^. Fcles were prepubertal in size. However, testotoxicosis
; ~1 E8 ?1 e' x5 ^8 z% _was in the differential diagnosis because his father" H3 E9 S* s( _; X
started puberty somewhat early, and occasionally,; T# i% A4 j; ]$ S' u
testicular enlargement is not that evident in the
. @7 `0 B& T7 g2 lbeginning of this process.1 In the absence of a neg-7 q( B/ \' |/ V) f% h( i
ative initial history of androgen exposure, our
( y, U" F% H4 ]. u$ H* n8 v; ^1 ]biggest concern was virilizing adrenal hyperplasia,4 ^) x  Y8 z" ~
either 21-hydroxylase deficiency or 11-β hydroxylase7 Y: ^* q  G) H) E
deficiency. Those diagnoses were excluded by find-: f  i# E' _. L7 M! T' t2 F- _
ing the normal level of adrenal steroids." r( R; q, j4 _7 z" |$ x6 _3 _
The diagnosis of exogenous androgens was strongly
  `# k8 M9 K. u  v* {; Ysuspected in a follow-up visit after 4 months because0 O7 `7 [7 I7 {% G. _
the physical examination revealed the complete disap-
  o7 p2 H0 W2 Npearance of pubic hair, normal growth velocity, and* x; H" b* |3 k6 |
decreased erections. The father admitted using a testos-
6 I; {- H# h9 f; [terone gel, which he concealed at first visit. He was
4 w+ C/ I" e! A( H2 d; A7 {1 E5 u- tusing it rather frequently, twice a day. The Physicians’0 L" X* b* D- A% D6 I6 y- u
Desk Reference, or package insert of this product, gel or( I# w( K0 W( w
cream, cautions about dermal testosterone transfer to
( ^% R3 R  `' k$ n9 Cunprotected females through direct skin exposure.* W5 v- u! q) y# Z" f3 o. g
Serum testosterone level was found to be 2 times the
- R% x; e. [$ G, \9 T, Dbaseline value in those females who were exposed to  t) G9 r9 ]1 o4 t+ V" h
even 15 minutes of direct skin contact with their male/ E3 @" `7 S. M4 s7 Q: e  ]6 L7 _
partners.6 However, when a shirt covered the applica-8 }2 O1 u8 ^% D. b  ]
tion site, this testosterone transfer was prevented.4 S$ i4 A% g: Q. v- y& d: Q
Our patient’s testosterone level was 60 ng/mL,  C- }( Z# d% y6 [
which was clearly high. Some studies suggest that
  Q2 p+ G- x! y0 c' Qdermal conversion of testosterone to dihydrotestos-
- [; A- a) u7 t$ Yterone, which is a more potent metabolite, is more
+ v. M' f1 J1 K* Jactive in young children exposed to testosterone
8 D" j& T4 A% E: [exogenously7; however, we did not measure a dihy-7 v9 C' f- S8 i2 q% X
drotestosterone level in our patient. In addition to
; o7 n$ Y3 `9 ~$ ]; O! tvirilization, exposure to exogenous testosterone in2 p8 ]( ^% L" p+ \
children results in an increase in growth velocity and
# b  G1 L( @3 j( Wadvanced bone age, as seen in our patient.  P1 |4 o0 W9 {
The long-term effect of androgen exposure during
6 `& s, f+ w( h5 }8 Z% g& q* kearly childhood on pubertal development and final
  k2 h- @8 s" kadult height are not fully known and always remain- H% B) ~% k; m/ A( |- U
a concern. Children treated with short-term testos-
/ A+ ~6 V  E5 Y2 B# Tterone injection or topical androgen may exhibit some
: [: t- L* r0 Tacceleration of the skeletal maturation; however, after8 a& r0 z" S. U8 j5 R
cessation of treatment, the rate of bone maturation% e( V. k; x/ P2 l+ K
decelerates and gradually returns to normal.8,9; Q) e' J8 E" d* K' ?4 `- t
There are conflicting reports and controversy2 R8 Y4 c0 F' M, S8 ?3 e
over the effect of early androgen exposure on adult* j& p  M# O8 N' R' [- o: }
penile length.10,11 Some reports suggest subnormal. _( s( P& V9 z2 U+ Z
adult penile length, apparently because of downreg-) ^1 x6 G+ t; P. J7 a
ulation of androgen receptor number.10,12 However,  N# Z% L2 B  _. W
Sutherland et al13 did not find a correlation between; e% ?5 A8 [; m0 v" |, W# b- h
childhood testosterone exposure and reduced adult
: |$ [4 y1 n) V" `penile length in clinical studies.2 `+ P9 ~+ R! w/ s1 n
Nonetheless, we do not believe our patient is: L  m0 N- [* T: m* `# ?
going to experience any of the untoward effects from
# [5 W( g# ?3 f, ]/ ?8 F: s  U) M* }testosterone exposure as mentioned earlier because
. T% I' m+ a$ q6 cthe exposure was not for a prolonged period of time.
9 N% l2 u4 I, `+ r# b/ FAlthough the bone age was advanced at the time of
) r* H7 Y1 D, D9 Idiagnosis, the child had a normal growth velocity at- o) e6 O5 m# y( y  e& q* t- q
the follow-up visit. It is hoped that his final adult
& c7 O+ B& V1 B, A$ pheight will not be affected.
$ o4 ]* D0 O1 E) h* WAlthough rarely reported, the widespread avail-) V8 z5 k; A( D& [  S
ability of androgen products in our society may
# j: A" g" [, X5 o* E9 Rindeed cause more virilization in male or female4 v0 {! B8 l  o5 U3 e2 s5 C
children than one would realize. Exposure to andro-
2 d9 u8 X# n- y: Lgen products must be considered and specific ques-; f0 G( M; L) r' U- n
tioning about the use of a testosterone product or
1 n% x3 @( i" j7 `8 G2 ^' Mgel should be asked of the family members during
0 s! P' Y) q1 V# [# v, Tthe evaluation of any children who present with vir-5 a% S- J+ N6 ~+ x2 X9 u3 _
ilization or peripheral precocious puberty. The diag-
5 A  i4 g% U& r9 m+ [1 J0 }nosis can be established by just a few tests and by
) g; }' @- I& |" q8 w* H+ Q2 eappropriate history. The inability to obtain such a  K$ c. Y; j5 w6 Q# a3 m
history, or failure to ask the specific questions, may1 G! s5 ?- k  g) Q: p" B
result in extensive, unnecessary, and expensive: A% {1 r5 p& J# v( p& ~8 h
investigation. The primary care physician should be
4 \5 j; a) P/ D: h5 eaware of this fact, because most of these children5 K5 ?1 V5 q% O% o0 l
may initially present in their practice. The Physicians’
1 }. |( H  H* W$ k1 M, ?Desk Reference and package insert should also put a
' p% U+ j% o6 [, [2 P( Twarning about the virilizing effect on a male or  n% l- ?% D8 Z8 U. X
female child who might come in contact with some-7 ?8 J. c+ e& ?
one using any of these products.* X: Y+ f3 B2 @* N4 a
References& x; w6 \: |6 w0 K# M/ L( J6 q
1. Styne DM. The testes: disorder of sexual differentiation- W! H" V6 T' ]
and puberty in the male. In: Sperling MA, ed. Pediatric
; H; N5 m6 S2 u+ x  p9 r3 H3 Y" \Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- J8 ~+ P, g4 b! o2002: 565-628.# F2 L# q2 @9 R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 Z/ l) V1 t& C1 b2 Epuberty 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
, x' W7 x& B' Q8 z# E* B+ a' mBoy Induced by Indirect Topical
# h/ ~( L: G. UExposure to Testosterone
. z" J: r5 Y" R+ A) ^! zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 ^/ U/ C; r7 N+ `6 B% S7 Dand Kenneth R. Rettig, MD1" S2 v7 z- {' r) \" U
Clinical Pediatrics8 h/ `' J. A6 G! W
Volume 46 Number 6  \! j7 d) M* w1 ]; \3 G7 j
July 2007 540-543. y9 c' S+ ^: A, q' M8 D8 v
© 2007 Sage Publications
( c8 ?# P6 N3 X+ X5 Y0 o10.1177/0009922806296651
; z+ H* |4 d) ^. ?; c% ahttp://clp.sagepub.com
6 p# j8 L6 K5 Z2 ]4 ]hosted at- q% v' m& @  O+ V# n
http://online.sagepub.com8 q( j: [- o6 o# _, b" q4 y! V
Precocious puberty in boys, central or peripheral,8 P! I# j) I. L& W4 e% n
is a significant concern for physicians. Central2 ]+ _1 w5 H, c* G. T
precocious puberty (CPP), which is mediated# m( o* ?, _7 {9 Z# h4 U5 ?  j& g( G
through the hypothalamic pituitary gonadal axis, has
1 ]& ^! A+ z) P1 _& h$ [a higher incidence of organic central nervous system
7 \4 Y7 ?2 M# C. |% l" Hlesions in boys.1,2 Virilization in boys, as manifested
3 z/ c* {$ Q$ ^0 A3 e5 \: G# vby enlargement of the penis, development of pubic
8 n, D/ {- F2 v: s5 n+ o* {hair, and facial acne without enlargement of testi-+ H1 n  R2 X3 ~$ N# X6 [
cles, suggests peripheral or pseudopuberty.1-3 We
! [9 N) w  T- {3 H5 zreport a 16-month-old boy who presented with the
% }2 a- ]/ ]9 Tenlargement of the phallus and pubic hair develop-8 c' c6 ?9 g2 X3 d5 F
ment without testicular enlargement, which was due
7 a5 f; P1 t$ j1 b" \to the unintentional exposure to androgen gel used by
! {9 y/ X5 E& u/ L/ }1 h, ?) E( ]the father. The family initially concealed this infor-
' y3 E9 b1 l) S' a( U* }mation, resulting in an extensive work-up for this: F5 B" Y+ d4 n; F$ @1 R# V
child. Given the widespread and easy availability of
8 W2 @' `2 D0 Q6 |2 k! ~testosterone gel and cream, we believe this is proba-; I9 y8 O" D- B) l$ e* `2 H
bly more common than the rare case report in the
* s6 @5 i6 P# ?5 o% W3 b4 q4 Tliterature.4
7 G$ e) V) t! W5 T1 GPatient Report. u& g, a7 _* I
A 16-month-old white child was referred to the- t$ [# v& r- Q
endocrine clinic by his pediatrician with the concern
; F2 Y( F! v& Fof early sexual development. His mother noticed( T, l+ a- n" w
light colored pubic hair development when he was1 G# U  R: K( X/ I
From the 1Division of Pediatric Endocrinology, 2University of/ d! O% R- d4 f; W( V
South Alabama Medical Center, Mobile, Alabama.
5 A( P$ A# I* F0 m7 ^7 _8 B% UAddress correspondence to: Samar K. Bhowmick, MD, FACE,; n8 j3 v1 ]/ U0 E0 u
Professor of Pediatrics, University of South Alabama, College of. _  o6 h6 f" Q8 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 F8 l2 u( B& P0 s8 k# B' O% U$ De-mail: [email protected].8 Q) U: k# R. n
about 6 to 7 months old, which progressively became
, ^- o' i+ V+ E+ @9 q) Vdarker. She was also concerned about the enlarge-
; ?! W$ c6 Y1 y* s+ K  p0 ?ment of his penis and frequent erections. The child& j5 M( f$ _1 a; S. m
was the product of a full-term normal delivery, with
4 _) L: E. z! B* c7 r3 ]5 z* u( [a birth weight of 7 lb 14 oz, and birth length of4 h' W% y  m" p
20 inches. He was breast-fed throughout the first year  Y8 H4 V# \* q" [1 J. Q5 m8 A
of life and was still receiving breast milk along with
# a3 f' T/ @( p2 |3 Msolid food. He had no hospitalizations or surgery,
% d2 D, E" Q* g) cand his psychosocial and psychomotor development
5 x1 S, z+ S$ }- owas age appropriate.
! v: r, ]) ^$ J  e. N3 W( G% ^The family history was remarkable for the father,
: E$ ]: y( r0 q7 l2 n# xwho was diagnosed with hypothyroidism at age 16,
) B- A1 w" ?: Y$ Xwhich was treated with thyroxine. The father’s
) k3 ?/ ^! Y' X' B) Pheight was 6 feet, and he went through a somewhat6 _8 m1 A: W3 Y% `) p8 S. X& ]
early puberty and had stopped growing by age 14.3 ?, B+ q2 z/ ]$ X+ }. {7 I/ v
The father denied taking any other medication. The
4 U1 Q) k# [5 ~3 jchild’s mother was in good health. Her menarche
  p4 V" `, a1 J! @' M$ ewas at 11 years of age, and her height was at 5 feet& x0 ?3 A+ ]3 m; h4 I0 P: f: T5 g
5 inches. There was no other family history of pre-
3 D4 D9 O. W' t! R' [: jcocious sexual development in the first-degree rela-
2 f8 p6 l! ^3 W4 ?- ptives. There were no siblings.
! W; Y- {' _# r$ k8 O# HPhysical Examination" @3 ~; T2 P' @
The physical examination revealed a very active,- e: S1 w1 Y* m& v& x% ?2 T% ?
playful, and healthy boy. The vital signs documented% }5 M! w' f8 G; z, i! V, a' Z
a blood pressure of 85/50 mm Hg, his length was: B  c  y& P$ {
90 cm (>97th percentile), and his weight was 14.4 kg6 |% K( k) H2 Y8 o" Z' ~
(also >97th percentile). The observed yearly growth
+ ?* |- ]/ g. n7 X2 p  Evelocity was 30 cm (12 inches). The examination of
0 ]/ m. J* H. i& Y  ?, C) t2 o/ [the neck revealed no thyroid enlargement.
# k' d! h/ t# \' u5 R6 V2 A8 N" y" xThe genitourinary examination was remarkable for8 J+ s. k0 y  T: E
enlargement of the penis, with a stretched length of) K( [. P0 t0 `" I
8 cm and a width of 2 cm. The glans penis was very well
$ T& [! f$ b; N6 b" a; v; Kdeveloped. The pubic hair was Tanner II, mostly around% o3 \( H! o1 s0 a, K
5407 w: f! |7 D8 I8 l# C, h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 k0 J' `' M' q- `& N
the base of the phallus and was dark and curled. The
, @/ V7 C: Q% ?( I3 p9 g; ~testicular volume was prepubertal at 2 mL each.# k# {9 A5 X/ y+ k
The skin was moist and smooth and somewhat% f/ _1 _0 o; e1 o7 d' ]. j
oily. No axillary hair was noted. There were no
2 r; b8 g3 E" J8 x- yabnormal skin pigmentations or café-au-lait spots.
! ]7 }7 F& k5 F5 XNeurologic evaluation showed deep tendon reflex 2+7 r5 R  I6 |$ w4 F
bilateral and symmetrical. There was no suggestion
# q% Q( g) g) M: Pof papilledema.
1 `) W- k( s  P' a8 T) m$ zLaboratory Evaluation7 O# \, h6 J# g) \* f. M
The bone age was consistent with 28 months by% w2 T9 O, O6 a
using the standard of Greulich and Pyle at a chrono-& }# x1 W' l$ ?$ D3 y$ y
logic age of 16 months (advanced).5 Chromosomal, h/ f7 Y2 l2 {; v( G
karyotype was 46XY. The thyroid function test) C$ b" ?2 F3 x6 a. X7 t% p2 j% U* ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. v4 j. }( z& f# ]9 }& z5 c3 T9 Plating hormone level was 1.3 µIU/mL (both normal).% f- w2 i: O5 k+ i9 O! Z; u
The concentrations of serum electrolytes, blood
2 ]" H( Y* K; z; J" \6 d* @, R9 burea nitrogen, creatinine, and calcium all were
% j( l1 p' \- E- s( twithin normal range for his age. The concentration
/ m8 @. F+ m7 V$ c+ q' r5 @# ^of serum 17-hydroxyprogesterone was 16 ng/dL3 o6 C& j5 U- B3 E+ ^
(normal, 3 to 90 ng/dL), androstenedione was 20
! \0 ]4 q* D( t0 F# ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 F' q; X# c; J4 m6 p+ D
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 m  C  f$ V% v! V5 }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 I3 U1 ?% J  E1 m6 b49ng/dL), 11-desoxycortisol (specific compound S)
, k3 g7 {. [  I1 i' V" jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( F7 R. ]6 M, A4 Z* ^$ a7 k4 W/ Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) f# P, }1 o2 a/ E, P. F1 X  Atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( s- \6 f) ]5 F) @- S2 v0 F% Gand β-human chorionic gonadotropin was less than
' W! n5 E2 n+ z* p. I0 r5 mIU/mL (normal <5 mIU/mL). Serum follicular
% a: J3 W2 m* \1 istimulating hormone and leuteinizing hormone
" F: L. N0 Z& T# r. M" tconcentrations were less than 0.05 mIU/mL
4 t* q( }& d7 x. e(prepubertal).
2 R* n. b) i5 |0 }4 Q3 DThe parents were notified about the laboratory! K( x' e2 O9 {
results and were informed that all of the tests were
8 ?7 a8 u- L/ T: U: |: T1 N$ i3 wnormal except the testosterone level was high. The
6 H( F, L: x. t( r) bfollow-up visit was arranged within a few weeks to
; x/ S$ l' G7 {/ o* g0 X% A2 cobtain testicular and abdominal sonograms; how-
  K' J* |1 }7 e5 h& ^% Q8 Wever, the family did not return for 4 months.
' f! t" B  Q7 w* k9 uPhysical examination at this time revealed that the3 s( I, V3 c2 R
child had grown 2.5 cm in 4 months and had gained$ I6 P5 O1 e# N; W' x
2 kg of weight. Physical examination remained
8 r; k; J1 ?9 ^9 H' ~6 d8 Sunchanged. Surprisingly, the pubic hair almost com-3 b% K- C  c$ T/ e5 O- I7 S+ w
pletely disappeared except for a few vellous hairs at2 \4 ^9 o" o( z4 K$ }& E
the base of the phallus. Testicular volume was still 24 D6 x& n- V- I: J8 \) L  `1 D
mL, and the size of the penis remained unchanged.! R0 ^. `2 T' V- u
The mother also said that the boy was no longer hav-* N1 S- F! h. M4 s8 t! O3 V. o
ing frequent erections.7 u5 w& S/ f# q
Both parents were again questioned about use of
' t# J: b& l$ c6 Q4 T/ B/ R9 d; c; jany ointment/creams that they may have applied to" G' s/ ?6 B5 R7 s& R1 y% ?# C
the child’s skin. This time the father admitted the
% d! @, k& E; F' L7 jTopical Testosterone Exposure / Bhowmick et al 5417 X, y- F+ z; m
use of testosterone gel twice daily that he was apply-5 Q( r) E! n  D! B" d8 w" V
ing over his own shoulders, chest, and back area for
& d3 L9 w& ^' c6 @a year. The father also revealed he was embarrassed" F: q" @3 }0 a- x; I
to disclose that he was using a testosterone gel pre-3 K9 Z! m5 m. X8 S
scribed by his family physician for decreased libido! [5 D) A8 }; R3 b
secondary to depression.  P8 U" Y& G: I
The child slept in the same bed with parents.
9 {. t5 f  c# hThe father would hug the baby and hold him on his6 T, U0 O( v, I9 @' y# b
chest for a considerable period of time, causing sig-5 f6 }9 N( k$ j5 f. q/ `" c& {
nificant bare skin contact between baby and father.
9 v: h9 B) A7 ~$ JThe father also admitted that after the phone call,, u! ?7 Z7 k$ G; F
when he learned the testosterone level in the baby
) c2 r" R( {7 }/ Zwas high, he then read the product information( L* {8 o& S) C; F8 b( d; X+ w
packet and concluded that it was most likely the rea-
) V$ n4 S5 H, J/ cson for the child’s virilization. At that time, they
6 D6 |( R& q, ~decided to put the baby in a separate bed, and the
6 ]6 W* @9 E. j# r1 y/ ^6 ?father was not hugging him with bare skin and had
; B0 D$ p3 P% x: Y, Obeen using protective clothing. A repeat testosterone
4 p/ S% f- |4 P: \7 X: xtest was ordered, but the family did not go to the& l  n  E# w, }
laboratory to obtain the test.
6 R8 k0 |5 }+ l/ D% z3 s$ l! zDiscussion
$ k$ f6 F: X& {Precocious puberty in boys is defined as secondary4 p8 z5 x; A" I
sexual development before 9 years of age.1,4! E  q! r; o* K3 i" k, K& }- H
Precocious puberty is termed as central (true) when
0 H# A! O# K- R; m- E* Git is caused by the premature activation of hypo-
0 q9 Q- O3 H7 g: X) ^. Xthalamic pituitary gonadal axis. CPP is more com-
' C. J# L8 q* {4 e; @$ P1 Ymon in girls than in boys.1,3 Most boys with CPP! \1 l2 _  i' s3 `
may have a central nervous system lesion that is
: ]# r2 E& q( {3 u6 cresponsible for the early activation of the hypothal-) v  W* e) J- D/ O
amic pituitary gonadal axis.1-3 Thus, greater empha-6 a- s9 M; X" B+ \) v3 [
sis has been given to neuroradiologic imaging in
8 |5 ?. A1 U2 ?) Yboys with precocious puberty. In addition to viril-
& D. y# w  k: f( f* [ization, the clinical hallmark of CPP is the symmet-7 c; C/ R/ }. @9 K! L
rical testicular growth secondary to stimulation by
, L6 S: ]/ v' Q' M+ u* c; ugonadotropins.1,34 Q' G: U/ X; I
Gonadotropin-independent peripheral preco-
! e. B( l7 A4 `% Z( ocious puberty in boys also results from inappropriate
& ~2 `3 U7 q$ W" sandrogenic stimulation from either endogenous or
  P2 e. c6 |! s9 ^exogenous sources, nonpituitary gonadotropin stim-
/ s1 ]9 _6 y9 ~4 ~) fulation, and rare activating mutations.3 Virilizing( S/ C% I  y$ y- m' |  s
congenital adrenal hyperplasia producing excessive4 D: ]2 Y/ w2 N( d; v6 P" b
adrenal androgens is a common cause of precocious; ~3 r7 A, W- n: _
puberty in boys.3,4; W+ O) f6 p) B% n5 l6 y! O" l: {
The most common form of congenital adrenal
) X/ ]- w  U, K2 L5 phyperplasia is the 21-hydroxylase enzyme deficiency.
* Z  `- T# s" }8 T* V" ]" tThe 11-β hydroxylase deficiency may also result in
: [& k' O% x: Y( `* a; ?4 vexcessive adrenal androgen production, and rarely,
# W; t( u" M) I! E- U1 ~! \an adrenal tumor may also cause adrenal androgen
) w8 V( P, b/ Oexcess.1,3
5 u! O9 S! v( H1 @6 }* {5 F0 Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, v% M2 X9 g6 g1 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: E$ W2 N7 S8 {. z, _A unique entity of male-limited gonadotropin-
# [$ ]% b* N0 Q2 Jindependent precocious puberty, which is also known
( r; k2 n8 }! |3 R- Pas testotoxicosis, may cause precocious puberty at a# f) @" A" `* v2 u9 f
very young age. The physical findings in these boys
: i. n, m- b3 V, z, _8 x0 ywith this disorder are full pubertal development,
" ?# [% ?) S6 e  |including bilateral testicular growth, similar to boys( u0 J, t) H3 ]6 I; ^0 M$ |
with CPP. The gonadotropin levels in this disorder# t7 C0 I$ S6 u! `" ~" @
are suppressed to prepubertal levels and do not show% H' N9 ?5 a/ T" z% p8 |5 J
pubertal response of gonadotropin after gonadotropin-9 T6 D6 j* }3 o" v
releasing hormone stimulation. This is a sex-linked0 f4 @) R7 H1 P" i$ Q( l3 Z: M( c0 e
autosomal dominant disorder that affects only
8 d2 ^3 }0 k/ ]! p8 f7 N. O3 J1 Hmales; therefore, other male members of the family
5 l  ]: e4 R. o1 C, I' o5 wmay have similar precocious puberty.31 K# {! W2 b) h4 N, P) N
In our patient, physical examination was incon-9 m, R% L- Y: B& \# B
sistent with true precocious puberty since his testi-
) I9 b; t( j- \* E. n( Qcles were prepubertal in size. However, testotoxicosis! q& l- _4 H8 o8 ~; |6 e
was in the differential diagnosis because his father
2 t* W; l( @; Vstarted puberty somewhat early, and occasionally,
1 Z& a' Q2 ]+ x. e- vtesticular enlargement is not that evident in the2 o) V5 y" t9 Z' K
beginning of this process.1 In the absence of a neg-( a1 C. j$ X' z$ h' s7 C
ative initial history of androgen exposure, our( \$ Z9 N( }) S/ U8 K; C
biggest concern was virilizing adrenal hyperplasia,5 \9 E4 h; k% Q
either 21-hydroxylase deficiency or 11-β hydroxylase  J: ]. L* r$ a4 K2 R4 g7 O1 _
deficiency. Those diagnoses were excluded by find-+ ~- J' d# m1 }3 X+ V/ ~; l  k7 R. G
ing the normal level of adrenal steroids.
# i( H0 K) t9 MThe diagnosis of exogenous androgens was strongly
# l$ w; j3 v. V; }* s9 A+ v$ `suspected in a follow-up visit after 4 months because
& X/ a7 K$ k1 b: W, Wthe physical examination revealed the complete disap-: u0 i; H" J8 `" x. @
pearance of pubic hair, normal growth velocity, and1 Z0 ^% }( x+ x# m+ E6 B. S; y
decreased erections. The father admitted using a testos-
# H: ?1 L, _- w9 Rterone gel, which he concealed at first visit. He was7 S. o$ w5 t0 I2 I2 D" H
using it rather frequently, twice a day. The Physicians’
0 T1 R$ m" Y; Q  o  T) KDesk Reference, or package insert of this product, gel or
0 q# s) E7 Z9 K0 ccream, cautions about dermal testosterone transfer to9 V+ }7 z: x3 t1 @% a9 Y
unprotected females through direct skin exposure.; _- r$ F: [, D, }, n; g0 j. ?' d
Serum testosterone level was found to be 2 times the
9 X8 M0 K" x. C0 A( |baseline value in those females who were exposed to; v4 }: }! l, w; V  f+ S3 M4 p
even 15 minutes of direct skin contact with their male& ?! E. u9 S2 v1 X7 _+ \# Q
partners.6 However, when a shirt covered the applica-3 _: I3 H2 s* U' \) i
tion site, this testosterone transfer was prevented., `# W2 p3 p( [; n/ a
Our patient’s testosterone level was 60 ng/mL,3 P2 q4 T* [3 Y  e
which was clearly high. Some studies suggest that
5 |) m- w& R* Q, W* N+ o/ ddermal conversion of testosterone to dihydrotestos-6 `: r4 G* K: C# o, D  b
terone, which is a more potent metabolite, is more
- V( s  `2 `" _7 N: Eactive in young children exposed to testosterone3 g  k+ a# a4 L* N: J& W
exogenously7; however, we did not measure a dihy-
: z, W- a! N& a& Bdrotestosterone level in our patient. In addition to7 Y9 h  V. P9 h' \/ i7 k
virilization, exposure to exogenous testosterone in
/ X9 s/ H7 n% D+ Zchildren results in an increase in growth velocity and3 @0 i4 s& c) d4 E- e1 V' I! n- k
advanced bone age, as seen in our patient.
9 W5 n. r2 {4 KThe long-term effect of androgen exposure during7 `0 Y1 w$ u; x! M( E3 l
early childhood on pubertal development and final
/ Q3 {# n$ H* h1 ?7 iadult height are not fully known and always remain) n6 c, z+ \( s7 ^6 m
a concern. Children treated with short-term testos-
* U# O; J% v7 v8 i5 L  E3 Eterone injection or topical androgen may exhibit some
5 |# H# V* I* zacceleration of the skeletal maturation; however, after
& J6 m0 X& H5 M* j- j5 }2 u9 bcessation of treatment, the rate of bone maturation
8 V  @/ i2 a, h0 a3 E2 f/ Y' r( R* ndecelerates and gradually returns to normal.8,97 l  m! h4 @& _5 w& A
There are conflicting reports and controversy
4 L9 ~; K7 B: u% l* c% e* |) qover the effect of early androgen exposure on adult/ H" j- V& H/ G1 e' E
penile length.10,11 Some reports suggest subnormal
% h& r7 K0 O3 x. u9 q$ iadult penile length, apparently because of downreg-* t3 Z; N$ E$ G+ Q0 S. W' V
ulation of androgen receptor number.10,12 However,
6 p  C  U6 @0 Q/ v2 `Sutherland et al13 did not find a correlation between
$ ]- [9 U0 n# A- echildhood testosterone exposure and reduced adult5 F% S7 [7 l( v! C5 h4 l) @
penile length in clinical studies.
; w5 F! S& s3 }$ V& PNonetheless, we do not believe our patient is
& E$ Y3 K! m% b( G' }" S% ]; [going to experience any of the untoward effects from
! @1 D+ y& ]0 P8 s# |testosterone exposure as mentioned earlier because' P. u, [% @1 s2 W6 O8 B
the exposure was not for a prolonged period of time.
& Q. K# ~" |5 v& B$ qAlthough the bone age was advanced at the time of
% D+ z$ U4 S% Ediagnosis, the child had a normal growth velocity at% Y5 @* g* f, G$ t6 K
the follow-up visit. It is hoped that his final adult
% y! ~, A; |3 R/ {$ Yheight will not be affected.3 c$ e9 B' K; X6 A7 S* |; u% B
Although rarely reported, the widespread avail-
- ~( C# m8 y, |6 Z* j! D4 N5 B7 pability of androgen products in our society may/ y; C, s4 i7 t6 l
indeed cause more virilization in male or female
! [. f5 \! m) schildren than one would realize. Exposure to andro-: ?6 H% U( W; q
gen products must be considered and specific ques-
" c4 u" U; |/ d' u. q/ {/ ~tioning about the use of a testosterone product or
3 Z3 k$ V- m0 y4 Ngel should be asked of the family members during
  Z3 w8 r9 @' S+ D1 P, _the evaluation of any children who present with vir-) |, y, s8 J' d% ]! ?" I
ilization or peripheral precocious puberty. The diag-3 |4 M% a+ R! C# ]. V& Y/ L
nosis can be established by just a few tests and by
% ]4 i+ g# @+ q& e+ |9 o) I; kappropriate history. The inability to obtain such a
) l/ I2 T1 c* ]! y8 l6 v0 Q" N' \history, or failure to ask the specific questions, may
$ |0 `: K- ?+ b( R/ v6 q! L1 oresult in extensive, unnecessary, and expensive- \' o& N) [5 g+ H6 T
investigation. The primary care physician should be
( l: X2 ?! S7 z/ L% Haware of this fact, because most of these children6 Q" h7 G- A. r9 Q: E4 ^2 S0 y/ R
may initially present in their practice. The Physicians’) z2 U9 B0 @: b1 {% S7 D
Desk Reference and package insert should also put a7 m. F" i9 O4 `- A5 f
warning about the virilizing effect on a male or+ o6 {' z/ C4 `9 I7 j  O7 }
female child who might come in contact with some-8 K: k' P" l3 a5 Z6 g0 Z
one using any of these products.! R1 q! [3 n: n: L8 j4 D
References, r& Z* \! ?1 D" O+ }
1. Styne DM. The testes: disorder of sexual differentiation/ m0 o2 r) h* [# E4 D
and puberty in the male. In: Sperling MA, ed. Pediatric/ I  m$ W. o( u- i9 v8 t& d
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 b: u" l, u$ s- i; |4 }2002: 565-628.# Y! m3 {) f- {2 |, E6 ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: t5 l& ]) h. I2 n( d
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

+ d# j7 `- e7 V  n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