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Sexual Precocity in a 16-Month-Old8 h% R( n' U, i1 W$ p0 ^/ u
Boy Induced by Indirect Topical2 H0 I' T1 _! u, l: H9 e1 R
Exposure to Testosterone
3 ~& C( M3 P! @, sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: s1 Z2 H. s# cand Kenneth R. Rettig, MD16 G3 `8 q4 j9 j1 A* f. F
Clinical Pediatrics
% w/ X1 `/ ?7 S. AVolume 46 Number 6
% | w) `0 Q& G7 Y" `! |5 x# uJuly 2007 540-543. ]" {/ _0 B3 r7 i
© 2007 Sage Publications! B9 Z1 K' F3 ~& \
10.1177/00099228062966515 y% D; v; m' K- \# ^& m$ c" _
http://clp.sagepub.com
+ X( j; J9 m/ U) p( w) }9 w3 q! J# ^ ^8 Nhosted at+ E* L$ p" Z# L5 w% \3 G% X Z
http://online.sagepub.com
/ H+ D* g# H; T4 u0 PPrecocious puberty in boys, central or peripheral,
& s( w z1 f2 T* \4 _/ F* _" xis a significant concern for physicians. Central, R" F2 y7 @; O t9 ?
precocious puberty (CPP), which is mediated$ u: @9 |; }4 j# e3 @) p3 B- F
through the hypothalamic pituitary gonadal axis, has, U! q. a: _+ _
a higher incidence of organic central nervous system
1 t- W' _9 D, _lesions in boys.1,2 Virilization in boys, as manifested
6 p" d0 k4 e {. c, p. q% ? [by enlargement of the penis, development of pubic( c, A0 L# [# z
hair, and facial acne without enlargement of testi-# ^8 g: d5 T& N# @" s
cles, suggests peripheral or pseudopuberty.1-3 We
+ K; k/ ]& u+ _$ ~: Sreport a 16-month-old boy who presented with the+ d: W9 @% {6 o) g1 \
enlargement of the phallus and pubic hair develop-
( m5 k1 A) K# oment without testicular enlargement, which was due5 C) q5 Q% \& X
to the unintentional exposure to androgen gel used by/ \2 l5 e! d! F1 i' Z" e6 H
the father. The family initially concealed this infor-' W0 ]' r) H; Y% u6 `$ M" u
mation, resulting in an extensive work-up for this
. b) W5 c& p4 Schild. Given the widespread and easy availability of
8 t- L7 c z5 L* H* v5 dtestosterone gel and cream, we believe this is proba-
: `7 Z: P, h) L7 p& ~bly more common than the rare case report in the
" k4 v4 X. C$ T6 t. @5 l+ E% e) R: Eliterature.4
$ X% V @2 w4 \9 O9 KPatient Report
; I6 C% e/ y% V5 E2 s; J4 VA 16-month-old white child was referred to the
3 m) I! ?5 x Q) d% ]2 Y8 h$ yendocrine clinic by his pediatrician with the concern
5 e: O P I+ d+ C1 _5 P X) C6 Xof early sexual development. His mother noticed1 `8 \0 N* _& w
light colored pubic hair development when he was
' a+ n, G. F: p7 Y/ xFrom the 1Division of Pediatric Endocrinology, 2University of0 _2 o# d9 x( }& L8 p
South Alabama Medical Center, Mobile, Alabama.6 ]2 Y& W- n' Y' V- n2 M% [
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 z2 D3 m' d0 _4 l+ _
Professor of Pediatrics, University of South Alabama, College of
) m& z l) y" w. @. {6 lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( D. x6 ~/ M5 x* a, X
e-mail: [email protected].
$ ]9 X4 k% @6 Y+ f1 \( V+ I- pabout 6 to 7 months old, which progressively became
f ]3 E# L" \' k% Ndarker. She was also concerned about the enlarge-: e7 X2 ^# c6 ]" W, {
ment of his penis and frequent erections. The child
2 J! G/ ^0 c3 o4 g, ]# i/ gwas the product of a full-term normal delivery, with$ K% P1 H3 w: H: f# Z
a birth weight of 7 lb 14 oz, and birth length of8 U' a9 X) L7 S4 Z
20 inches. He was breast-fed throughout the first year
( F: P2 S/ O3 O9 jof life and was still receiving breast milk along with
6 ^7 b# m1 |; m# n4 ]5 y0 _solid food. He had no hospitalizations or surgery,
3 w) M: }! a9 q* h3 g( mand his psychosocial and psychomotor development2 a# r+ T( w* |2 F; v
was age appropriate.
0 m2 n/ G6 o$ q2 TThe family history was remarkable for the father,# U9 Q+ D4 q8 A
who was diagnosed with hypothyroidism at age 16,
3 y3 I0 F2 M1 L1 S9 ~which was treated with thyroxine. The father’s/ a8 a+ r" i) u9 s( p- R; L
height was 6 feet, and he went through a somewhat3 W1 W' K6 T: z2 R. _$ T2 A s
early puberty and had stopped growing by age 14.
+ _ L% C& ^- VThe father denied taking any other medication. The
) `) g n, }5 n) A( qchild’s mother was in good health. Her menarche
- r0 O! L& g, W. b2 Lwas at 11 years of age, and her height was at 5 feet
2 |/ Q7 y5 s1 B5 inches. There was no other family history of pre-( R1 V- U6 r; u% ]) {
cocious sexual development in the first-degree rela-' Z0 \* H. [1 N! y( Y2 P7 ^2 c, N
tives. There were no siblings.
$ f. T1 L+ L5 y" J8 n HPhysical Examination. s) ^8 E, E, A @! p5 }/ y
The physical examination revealed a very active,, [" Z4 }4 Q* ~! W1 V" V3 t6 Z2 s
playful, and healthy boy. The vital signs documented. d( F( A" w: G" ?' g
a blood pressure of 85/50 mm Hg, his length was
0 I) z6 `3 V0 ]' B& U0 |2 o3 f90 cm (>97th percentile), and his weight was 14.4 kg; n; S, q8 S" Q+ N3 e: y
(also >97th percentile). The observed yearly growth4 q1 [# C3 `" _
velocity was 30 cm (12 inches). The examination of; J7 R# Q* F: D" G5 F+ {) \
the neck revealed no thyroid enlargement.
& u; F$ ]/ j2 F4 G0 T1 PThe genitourinary examination was remarkable for/ G6 A! i. J0 f6 ]& }
enlargement of the penis, with a stretched length of
) o, `5 B+ r6 `8 cm and a width of 2 cm. The glans penis was very well! j9 a& I& X7 b$ Z. v( J
developed. The pubic hair was Tanner II, mostly around* U7 [: _; v$ [; b- l
540
- O+ j, t% B' X" `8 L8 L7 w3 @0 Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
J3 ~" k5 t7 j" g4 z/ W* Fthe base of the phallus and was dark and curled. The0 S Q M7 Q4 B5 m8 u( v0 f, u; d$ N/ p
testicular volume was prepubertal at 2 mL each.6 ~! Z9 O6 V" {$ y2 q3 L2 @
The skin was moist and smooth and somewhat+ Q: J0 a' G9 G: I
oily. No axillary hair was noted. There were no
) H6 Q; z! R* a$ yabnormal skin pigmentations or café-au-lait spots.4 i6 \- ]5 p" ?) Q2 U
Neurologic evaluation showed deep tendon reflex 2+1 J7 t- _2 K2 n* k5 D* I. Z
bilateral and symmetrical. There was no suggestion
. y M# U4 R7 n. W r8 gof papilledema.
' L0 Y1 P$ l/ w% M8 c ILaboratory Evaluation$ {* a* |2 a% O) s K/ _
The bone age was consistent with 28 months by8 \# ?6 q$ a: }+ }) D4 B ^! f
using the standard of Greulich and Pyle at a chrono-
" c1 q# x3 D, q7 l. k, n& z7 ~9 `logic age of 16 months (advanced).5 Chromosomal
0 u; a6 F* q1 N i9 }5 [karyotype was 46XY. The thyroid function test e/ m; B! S7 X0 x$ r
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# ~6 N2 S4 O4 P8 |& Y0 P
lating hormone level was 1.3 µIU/mL (both normal).
& s7 ~, g X% ^- T/ Z, a8 k: D* TThe concentrations of serum electrolytes, blood
3 Y9 O! p7 K) y$ E( Xurea nitrogen, creatinine, and calcium all were1 x i4 Q6 h5 Q% e: r: l% p2 h
within normal range for his age. The concentration
2 e) y; m! s( k5 `! P" g+ y& `of serum 17-hydroxyprogesterone was 16 ng/dL& Y2 \/ q/ N. _# X, p- t- {
(normal, 3 to 90 ng/dL), androstenedione was 20
; k' U$ X* Q5 f# I# i7 B% ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ r$ O& w; o8 b8 L4 ]; O. w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% M6 S8 @' @5 ^' l/ s4 ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 s" p. }2 G# i. i( H
49ng/dL), 11-desoxycortisol (specific compound S)/ H- D) W: ~4 B/ k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 }" r5 f4 y5 [3 ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 E% O: ]& g% Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' C; D6 P/ [0 x' o; a
and β-human chorionic gonadotropin was less than
1 j; R v5 m6 K |0 }5 mIU/mL (normal <5 mIU/mL). Serum follicular3 z* I+ `3 G+ x/ S; Y% T
stimulating hormone and leuteinizing hormone H* _ ]$ C, h8 g. T
concentrations were less than 0.05 mIU/mL
Z: I6 i5 J& @6 Q% a) ]5 n(prepubertal).' y6 R/ I2 Z% g0 Z; k% r
The parents were notified about the laboratory
& i1 d2 V6 l! P# m# [results and were informed that all of the tests were
; S9 [7 W4 @" x% E% `, rnormal except the testosterone level was high. The
6 i2 N3 _3 V, k* \0 cfollow-up visit was arranged within a few weeks to
$ E$ y5 ?# l6 C, z5 @obtain testicular and abdominal sonograms; how-0 V. V- b/ g3 s: p$ V. r' s4 q
ever, the family did not return for 4 months.
7 v; B$ ?. t i. UPhysical examination at this time revealed that the
2 U( W' k3 T: f+ achild had grown 2.5 cm in 4 months and had gained9 k9 x) l' \8 f/ E0 g3 b
2 kg of weight. Physical examination remained# r1 a, g8 Q; R( `; Y
unchanged. Surprisingly, the pubic hair almost com-
( U# b" Q$ ]+ apletely disappeared except for a few vellous hairs at) X0 i- T5 M8 B- _' g% M% \( O; y
the base of the phallus. Testicular volume was still 2
; l; x' @7 f/ L3 BmL, and the size of the penis remained unchanged.
6 H% W9 Q. k( |6 z6 SThe mother also said that the boy was no longer hav-
+ ?/ b* n$ {5 s( |ing frequent erections.- D5 @1 C, a2 u" `! [3 |0 D/ x
Both parents were again questioned about use of, S& ~# _* T% { M/ k Y! U
any ointment/creams that they may have applied to
* C. d' Z2 Y! ~9 Y0 O& Zthe child’s skin. This time the father admitted the# q1 F4 c7 C1 Q; C0 k* W I5 l
Topical Testosterone Exposure / Bhowmick et al 541
; P, \1 ]8 e3 L+ F2 D8 @& Vuse of testosterone gel twice daily that he was apply-0 `1 l. v" c3 B4 y4 t
ing over his own shoulders, chest, and back area for
$ I0 O2 X% x' s: pa year. The father also revealed he was embarrassed
0 n/ b% Y6 P' Q# a8 U2 mto disclose that he was using a testosterone gel pre-- x1 s2 J9 B7 Y9 i6 B
scribed by his family physician for decreased libido4 p k+ L9 b: k4 F
secondary to depression.
; n5 L3 e4 M& D5 p* h1 d% nThe child slept in the same bed with parents.
& g8 ]5 l% R, w& ^The father would hug the baby and hold him on his2 i7 A. |; V) d& a2 j1 P) [3 G' I1 s
chest for a considerable period of time, causing sig-2 C4 R5 e& T3 h% |' \
nificant bare skin contact between baby and father.( G$ @4 j; o4 W! b
The father also admitted that after the phone call,3 [& e3 i8 C' |! {; B* z1 i
when he learned the testosterone level in the baby
* g- Q7 e9 d: L! h- ewas high, he then read the product information
1 [* U* J8 U# B7 @packet and concluded that it was most likely the rea-5 C, o4 g/ \$ P1 q6 b/ b
son for the child’s virilization. At that time, they( v" {, T6 S5 Q' }8 j
decided to put the baby in a separate bed, and the
/ }$ I; ]. t! |5 g: E4 l* [, Gfather was not hugging him with bare skin and had& o4 n# B7 ~% p$ F' }0 G1 ?3 r
been using protective clothing. A repeat testosterone* u1 p, H$ ~' ?8 J& o9 R7 {
test was ordered, but the family did not go to the
5 U7 R: o' K. v9 I! @- } Klaboratory to obtain the test.+ w3 W: Y2 ?) g1 p' N
Discussion
4 S" R" ]; O$ R) V1 e5 bPrecocious puberty in boys is defined as secondary
6 L0 Q [+ ^0 E8 }$ t. o1 Isexual development before 9 years of age.1,4
: E2 X+ }! s% ]! H5 JPrecocious puberty is termed as central (true) when* |2 q: D' k# z2 |
it is caused by the premature activation of hypo-
# U( O( b4 G1 Z6 k* F, P) ]thalamic pituitary gonadal axis. CPP is more com-( `! F. m1 h1 @3 z
mon in girls than in boys.1,3 Most boys with CPP
& @+ g" T: G# R' Y3 ^may have a central nervous system lesion that is
- u/ u1 v* D' Yresponsible for the early activation of the hypothal-2 l: a3 ~. Q7 X* L! l5 ^) n6 E* A
amic pituitary gonadal axis.1-3 Thus, greater empha-" h% c- N1 S3 f4 h
sis has been given to neuroradiologic imaging in
# }8 o! O7 [8 U+ |; E; Bboys with precocious puberty. In addition to viril-9 B8 t$ ?$ Q# S( _! H2 Q. F
ization, the clinical hallmark of CPP is the symmet-0 e5 i0 R3 Z9 ?5 f6 |
rical testicular growth secondary to stimulation by: I- G2 _# H6 X4 [, f# O
gonadotropins.1,3
; y. \3 |/ D# n" V3 V$ y+ v: wGonadotropin-independent peripheral preco-
* y) N' I* G0 G. K9 c8 Y: J6 f8 r+ Ycious puberty in boys also results from inappropriate
1 a* c; [* U+ E# }% h6 {androgenic stimulation from either endogenous or4 ^6 Z! [0 ~5 r
exogenous sources, nonpituitary gonadotropin stim-
& D/ r" ?; [) vulation, and rare activating mutations.3 Virilizing3 [ N$ w8 F- e
congenital adrenal hyperplasia producing excessive
5 T p9 g. R t# n8 l _adrenal androgens is a common cause of precocious! P, n( j' r+ h: o8 ]) Q+ e1 E
puberty in boys.3,4. j0 p, N* O7 H& l
The most common form of congenital adrenal
$ r3 u) l; e- m' T" lhyperplasia is the 21-hydroxylase enzyme deficiency.$ Y( `0 H$ b1 Y( I$ s9 V+ J" z: l
The 11-β hydroxylase deficiency may also result in6 ~) X5 b( L2 }+ [
excessive adrenal androgen production, and rarely,9 o, V/ I: x/ h0 L
an adrenal tumor may also cause adrenal androgen
! H( p9 P3 U9 `) aexcess.1,3 c4 P( |- ?& N; U. C, \7 q C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 \8 _6 |: p0 Q& v }! ]542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 @5 }# k/ a' n3 F, c, R) m
A unique entity of male-limited gonadotropin-
, n& t8 w, H$ J9 m7 mindependent precocious puberty, which is also known' H5 f6 H) x! m" j- z$ [7 ^
as testotoxicosis, may cause precocious puberty at a
3 ^. P- R. C' m- L, f; |very young age. The physical findings in these boys
+ V* _: A3 d7 D6 z1 V- `5 Mwith this disorder are full pubertal development,
6 i# A* W; O, Eincluding bilateral testicular growth, similar to boys
$ o' O; O0 y1 s* Jwith CPP. The gonadotropin levels in this disorder0 j, q1 Q$ D. X
are suppressed to prepubertal levels and do not show7 h8 \6 D& m2 Z
pubertal response of gonadotropin after gonadotropin-$ W3 F& z& P5 h D' X% a4 v' P
releasing hormone stimulation. This is a sex-linked
% P0 k! @3 Q: Bautosomal dominant disorder that affects only
/ e7 C' p: u9 C; Imales; therefore, other male members of the family
7 g2 Y1 Y, P# Y1 Z4 d1 d2 ^& A+ Gmay have similar precocious puberty.3
{1 F9 v6 O+ ]$ ~ qIn our patient, physical examination was incon-
, t0 x& e+ r2 W5 |3 @9 y4 Fsistent with true precocious puberty since his testi-0 C; C' k- g, F- b9 [
cles were prepubertal in size. However, testotoxicosis
9 W5 U! J6 v) M: k6 Qwas in the differential diagnosis because his father
1 ?! l) k* g" r* L* j) j2 I; s9 Ystarted puberty somewhat early, and occasionally,' v! t, o9 L- g
testicular enlargement is not that evident in the
0 J2 f9 x& l3 n2 k Y( D7 Kbeginning of this process.1 In the absence of a neg-
" h! I% r1 z! s# u+ I. R* ^4 Qative initial history of androgen exposure, our
/ C( o+ r1 N6 E8 {! z* q4 ~) x8 |, e& {biggest concern was virilizing adrenal hyperplasia,9 M) ?; o* @! u
either 21-hydroxylase deficiency or 11-β hydroxylase
% K) l3 K! [+ V% u& {) r+ [deficiency. Those diagnoses were excluded by find-
4 A+ I2 K) Y5 ~2 E" K+ Ning the normal level of adrenal steroids.
) X) L0 V+ G4 T5 A- L* fThe diagnosis of exogenous androgens was strongly
, }3 E) j% B8 l+ A0 ~# a8 i+ `suspected in a follow-up visit after 4 months because
$ H" Q: C+ L6 k/ Bthe physical examination revealed the complete disap-8 B% [8 O/ m' Q
pearance of pubic hair, normal growth velocity, and
, Q R8 d' z+ {/ X6 o( S" y9 [& Cdecreased erections. The father admitted using a testos-
& q& ]& E& Z5 hterone gel, which he concealed at first visit. He was H" G4 B. M2 @0 A4 ^9 z& X$ I
using it rather frequently, twice a day. The Physicians’( }+ o o' W+ }1 g" t8 {% E) j
Desk Reference, or package insert of this product, gel or5 N5 ?; W+ O8 Y% r& O: r
cream, cautions about dermal testosterone transfer to
. f% a' H' V. M) i3 Z" b, S: punprotected females through direct skin exposure.
$ ^) x m, `* `( Q; K, `* P- ySerum testosterone level was found to be 2 times the, s& E8 B/ Q2 o# X
baseline value in those females who were exposed to
6 a. S' r9 q, P ?, k# X, |even 15 minutes of direct skin contact with their male4 ^6 C: @6 M% N8 |* y
partners.6 However, when a shirt covered the applica-6 i9 n" u! n- k5 n6 }+ `9 f
tion site, this testosterone transfer was prevented.* L! o+ e7 C: ^2 h; o7 X
Our patient’s testosterone level was 60 ng/mL,9 M8 E$ y. r- `& ~2 q
which was clearly high. Some studies suggest that2 \* M1 R1 n# g9 B& r
dermal conversion of testosterone to dihydrotestos-
$ s1 K2 K ~3 q7 k9 L' h- oterone, which is a more potent metabolite, is more( @* c Z$ t# X [9 D0 I
active in young children exposed to testosterone! ]( I3 r- j1 W$ u: o
exogenously7; however, we did not measure a dihy-3 Y+ H& ` B. u3 j
drotestosterone level in our patient. In addition to0 N( J+ z, T# J
virilization, exposure to exogenous testosterone in0 d7 D& \! G: _- t/ Y1 m
children results in an increase in growth velocity and3 k2 ^) X( G0 r! s0 a+ P
advanced bone age, as seen in our patient./ h. ]( ]5 B, q- G
The long-term effect of androgen exposure during; j# \# x+ o( o3 `% W/ L
early childhood on pubertal development and final4 z/ X. F5 w9 `- `5 G
adult height are not fully known and always remain' i* C, U6 ^* ^
a concern. Children treated with short-term testos-3 o; x: `: g4 q' B: h
terone injection or topical androgen may exhibit some
* @$ v- Z8 J# j2 g( h* z4 L& }acceleration of the skeletal maturation; however, after- k. m7 o! r# ~- ~. H
cessation of treatment, the rate of bone maturation3 f' I! b/ Z) X8 ]! L5 {& U
decelerates and gradually returns to normal.8,9
2 M1 f: j1 a3 E$ k/ {7 `! jThere are conflicting reports and controversy5 S; H! T: z- q: \* e6 b
over the effect of early androgen exposure on adult
. M# C2 T) {8 ]0 kpenile length.10,11 Some reports suggest subnormal$ T7 v. c. K0 H6 {4 }- L v
adult penile length, apparently because of downreg-5 K% J9 o, e1 V. O3 E: E* J3 W/ x, H# f
ulation of androgen receptor number.10,12 However,: w9 l) X; \$ L1 {4 G& p+ g' |
Sutherland et al13 did not find a correlation between; P1 E& l/ F0 I. O: I
childhood testosterone exposure and reduced adult
7 z( W4 ^, U' j5 h5 mpenile length in clinical studies.
" w6 H. c/ K- i7 B4 V; j! D* GNonetheless, we do not believe our patient is
- _3 x: w3 y: Vgoing to experience any of the untoward effects from5 m q- q8 q+ P8 F0 o, @ ?
testosterone exposure as mentioned earlier because. l9 }9 l( E+ Z7 Z3 I
the exposure was not for a prolonged period of time.$ O4 Q2 p( R' ^* K; F
Although the bone age was advanced at the time of
) m ?$ _7 q- O, U6 Fdiagnosis, the child had a normal growth velocity at
: T( q* F% K7 t1 {* L5 {# I; t& C& nthe follow-up visit. It is hoped that his final adult
0 B% H* U9 ~8 G: H3 ]6 Fheight will not be affected.# @) A" ]# U7 W6 q/ |& U& Y' A
Although rarely reported, the widespread avail-
" b2 b3 W: s4 q) f, A$ J3 lability of androgen products in our society may3 M4 x5 O s- Q4 ?% r' |8 }
indeed cause more virilization in male or female$ ^7 i4 \# K5 B& A) o. R8 j- @
children than one would realize. Exposure to andro-; U$ h' t! J& A, c( q5 Z$ l. s- K
gen products must be considered and specific ques-; B+ o) `" }, R( h* U% y
tioning about the use of a testosterone product or
$ `2 N! M, I1 a, {2 S. J9 F3 dgel should be asked of the family members during
3 R+ |) H: {# q- u7 i2 @; h/ Wthe evaluation of any children who present with vir-
2 Q3 N+ G+ O9 o! ^* ]$ }ilization or peripheral precocious puberty. The diag-' S& G# Z" f- f* h( z8 A* s/ V) |2 u
nosis can be established by just a few tests and by0 l8 X. G& y! f, _( o
appropriate history. The inability to obtain such a
5 {8 K R5 c: k2 g+ Y$ \" dhistory, or failure to ask the specific questions, may
% Z9 I# ~7 d0 g0 M9 W. hresult in extensive, unnecessary, and expensive ]. v( J# b, A, d6 Y2 F
investigation. The primary care physician should be3 K( Y- _" ?# F+ ?- G- I% a( E
aware of this fact, because most of these children! p2 C1 p, c4 S, K- M6 Q$ ^
may initially present in their practice. The Physicians’1 p9 O( d/ }, I) T$ i. _
Desk Reference and package insert should also put a: O) R; P' B4 Y5 F
warning about the virilizing effect on a male or& O+ t3 w8 P& q3 K
female child who might come in contact with some-8 j2 W2 e/ ^( U# R4 D7 |) R
one using any of these products.
& `! I# k$ [: W/ V8 f; A! {References
9 Y0 }' D3 d+ {3 D: c/ ^7 c! D' o' R1. Styne DM. The testes: disorder of sexual differentiation9 @# H3 V6 n; x: } V
and puberty in the male. In: Sperling MA, ed. Pediatric
) @: j1 }8 f' L9 S4 uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 T" x v6 H4 ~2002: 565-628.
4 j6 l- Q2 s- C0 \, q4 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" e+ u0 P B0 v3 M x h
puberty in children with tumours of the suprasellar pineal |
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