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Sexual Precocity in a 16-Month-Old
- d" H" R, A7 _! y$ s: LBoy Induced by Indirect Topical
; r" v4 j! @! U' c0 o+ r6 `Exposure to Testosterone
4 \! O* e1 m% WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 t1 u/ s! c( N" K
and Kenneth R. Rettig, MD1
4 w, _' K8 E& G5 ^3 UClinical Pediatrics$ O6 m0 e8 i' l/ { f6 D3 a
Volume 46 Number 6
4 [, D) D+ M% s* N% K& ]* GJuly 2007 540-543; X& }- i% m T; g( a
© 2007 Sage Publications
2 v A5 j' n9 q% y9 D7 Z0 i3 B1 h10.1177/0009922806296651
6 @1 ?5 N1 G( f( f5 thttp://clp.sagepub.com
4 L0 X4 f! u4 H' ~: Whosted at# M5 n0 R) D, v' @
http://online.sagepub.com
5 Z( ]2 s) W7 m' ^0 V( ]( XPrecocious puberty in boys, central or peripheral,6 o6 H$ C; N2 _# O
is a significant concern for physicians. Central
1 P4 }$ j; l& [( I3 @$ ^ m6 C& ]precocious puberty (CPP), which is mediated
# |. Y8 |4 N0 lthrough the hypothalamic pituitary gonadal axis, has2 u0 X7 ~% m# ?1 J
a higher incidence of organic central nervous system- M# B. J5 K' k- |/ k- R+ ~
lesions in boys.1,2 Virilization in boys, as manifested8 ^# R/ d# y0 B2 _
by enlargement of the penis, development of pubic
0 O! T! a! a+ v" qhair, and facial acne without enlargement of testi-
1 a9 u" |7 @3 p$ a9 Z6 ?cles, suggests peripheral or pseudopuberty.1-3 We7 s3 a' a/ I8 h4 `( p
report a 16-month-old boy who presented with the0 ?2 k I1 O, ^7 b7 E
enlargement of the phallus and pubic hair develop-
) O- C4 \0 Y! k. J( ~7 @$ Jment without testicular enlargement, which was due \1 T7 Q; j, P
to the unintentional exposure to androgen gel used by" \+ J/ p5 W& F5 ~+ E: a0 ]% s
the father. The family initially concealed this infor-+ O7 k7 l0 e6 l5 Z$ g0 M* ]
mation, resulting in an extensive work-up for this/ o5 y" I1 n* u* Q: u
child. Given the widespread and easy availability of* s% ^" ]; M2 h" {( B
testosterone gel and cream, we believe this is proba-. V+ a# d+ {7 V+ u; g/ L9 e2 \" E0 w
bly more common than the rare case report in the" A5 d( ~1 L# Z% f: F8 c @
literature.4
1 X- X& p" r0 X" r8 MPatient Report. G: Y+ { b8 ^# ?- }: l
A 16-month-old white child was referred to the
+ {+ t @' A5 ]( I/ nendocrine clinic by his pediatrician with the concern
/ c, V( F% v9 _( B' Bof early sexual development. His mother noticed& J3 J( J) e5 [8 e, Z3 C* Y: c
light colored pubic hair development when he was
: |( J& w1 C$ s9 R/ K" v$ Y1 ~0 BFrom the 1Division of Pediatric Endocrinology, 2University of
% d4 G& U* Y4 S H3 ?* cSouth Alabama Medical Center, Mobile, Alabama.# i, y R0 i9 [( @
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ ^' Z( C1 t& C. \Professor of Pediatrics, University of South Alabama, College of3 g6 m( d+ D( o. O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! }2 W! Q( o) c' V3 A
e-mail: [email protected].
& u+ n+ _% j6 d4 q+ a& n7 Fabout 6 to 7 months old, which progressively became i: T) n1 t y! u( ^" |
darker. She was also concerned about the enlarge-1 f7 y6 w% g& Y# D6 N$ \0 d: E& u; v
ment of his penis and frequent erections. The child
/ N$ n) ?$ s; y$ Y- q/ x5 ywas the product of a full-term normal delivery, with- S, \. l# E% F2 g* h* g, B3 O
a birth weight of 7 lb 14 oz, and birth length of
. F9 s/ l. O0 r) j+ k20 inches. He was breast-fed throughout the first year$ F6 W/ u) s8 v" {/ I" y
of life and was still receiving breast milk along with, ]4 {2 t+ ~3 o( }) l! Z1 [% u
solid food. He had no hospitalizations or surgery,
# Q6 K9 x( K: h) m9 E6 {and his psychosocial and psychomotor development
3 X9 T3 c% r0 H4 ]4 Ywas age appropriate.+ o) M: B1 N$ K6 ^. D
The family history was remarkable for the father,
( C' n; y" y6 P! wwho was diagnosed with hypothyroidism at age 16,
H( p6 b0 r3 g ywhich was treated with thyroxine. The father’s
+ ?* m7 }3 O0 G9 D" g# Fheight was 6 feet, and he went through a somewhat
! U& r6 J! \3 searly puberty and had stopped growing by age 14.. d( ?/ p3 }, `* Y4 d, ~2 G
The father denied taking any other medication. The4 P) S# a2 v6 G% R1 t) T |
child’s mother was in good health. Her menarche( K" b% [7 N; `9 N& k2 B
was at 11 years of age, and her height was at 5 feet3 ^" M, h. O- v+ T+ U
5 inches. There was no other family history of pre-+ N* d; S" `5 A0 V/ O
cocious sexual development in the first-degree rela-2 |. g& N# M- |) g. h" _
tives. There were no siblings.! ^6 N' P& {- }# _, r$ |/ E$ P' p
Physical Examination
$ [( V( d6 @2 b. D" F: B% `The physical examination revealed a very active,
/ g3 j7 A* U( V; i% V/ yplayful, and healthy boy. The vital signs documented5 t" L% S$ q; V6 I
a blood pressure of 85/50 mm Hg, his length was
# L3 d; O4 A* _. ?90 cm (>97th percentile), and his weight was 14.4 kg
' m3 U/ ]1 g u1 }' u* u6 Y(also >97th percentile). The observed yearly growth
" v. {1 w* B/ ]9 f9 A2 xvelocity was 30 cm (12 inches). The examination of$ H# }1 A, u/ m" i5 y3 E
the neck revealed no thyroid enlargement." G$ D9 m1 t. a3 b2 a
The genitourinary examination was remarkable for( Z# _+ b* F$ ]0 z* b
enlargement of the penis, with a stretched length of% ^, _4 C9 U1 Z* z% }3 g8 v) N
8 cm and a width of 2 cm. The glans penis was very well
( t4 g G! _ c8 C1 D1 W& x4 M: Vdeveloped. The pubic hair was Tanner II, mostly around9 m6 w, `- U3 I3 W( X# t, E
540
" E# ^8 p" {$ f7 _6 V6 x6 Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! `/ M! b! Y t) M e
the base of the phallus and was dark and curled. The- V, n3 E% j' v% R2 }
testicular volume was prepubertal at 2 mL each.
. K+ j! M. h- ? k0 c5 s N& yThe skin was moist and smooth and somewhat k8 O8 G8 G5 @) l' o
oily. No axillary hair was noted. There were no$ K7 g* {- D' k; L2 j) n9 s9 f% ~& G' e
abnormal skin pigmentations or café-au-lait spots.* O8 R# ]4 R' K' h+ _2 t
Neurologic evaluation showed deep tendon reflex 2+
' g5 j; t2 G9 J# gbilateral and symmetrical. There was no suggestion
5 ]! m0 `9 A) Y4 k' G* U9 [9 u4 M' lof papilledema.: K8 E; t; |: c8 u5 T! N
Laboratory Evaluation
2 i( i9 m* Z/ V, vThe bone age was consistent with 28 months by
4 ~( q- R0 {9 Dusing the standard of Greulich and Pyle at a chrono-
! i) y/ D6 O6 `# T, V& z- llogic age of 16 months (advanced).5 Chromosomal6 z1 Z( `6 C* Q& g
karyotype was 46XY. The thyroid function test
A a, d" L- x) ] o$ tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-& d/ M+ [1 U8 Z2 i Z @7 U4 I
lating hormone level was 1.3 µIU/mL (both normal).
1 }# f1 c! j3 ^9 oThe concentrations of serum electrolytes, blood
D4 L- @2 A$ Z) g& `4 _) E# aurea nitrogen, creatinine, and calcium all were2 V" Z+ _4 @( W. c/ E K
within normal range for his age. The concentration c4 z3 {) U( a+ g
of serum 17-hydroxyprogesterone was 16 ng/dL
- S [7 G* |. \" j4 Z# A(normal, 3 to 90 ng/dL), androstenedione was 208 _7 E4 t* J5 q: l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 A u7 [8 t! M3 i3 P, Q+ vterone was 38 ng/dL (normal, 50 to 760 ng/dL)," S; v \. P) i+ W1 Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' E L/ I8 b" M+ s3 p5 I+ m/ Q* k9 X/ l* _
49ng/dL), 11-desoxycortisol (specific compound S)% u1 h4 F* }7 Q. c2 R$ ]3 h
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. e2 O2 k7 y' w* c# e4 K; O. Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 Z7 H$ e, B5 v- j# C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 D& _4 z {! X/ I$ a$ M Qand β-human chorionic gonadotropin was less than
& ~9 w( p+ O' [5 mIU/mL (normal <5 mIU/mL). Serum follicular
* c8 n$ ]' j* S0 g$ h1 l9 Estimulating hormone and leuteinizing hormone1 H9 w! N3 D0 h! u9 G% A5 Z
concentrations were less than 0.05 mIU/mL" F% g* o* `% \
(prepubertal).) o9 x: O5 ?' t
The parents were notified about the laboratory
# F) i/ n. V4 h# jresults and were informed that all of the tests were
! i/ v0 J3 B* `3 c7 r0 Znormal except the testosterone level was high. The
5 `8 k3 {7 ^! I [8 gfollow-up visit was arranged within a few weeks to$ E1 M. H2 ~% c1 F
obtain testicular and abdominal sonograms; how-3 ^/ @8 y7 E( X" U
ever, the family did not return for 4 months.) J$ g1 r- b6 j, t Y9 H. X/ f
Physical examination at this time revealed that the
+ Y1 ?" V0 F% ]9 Zchild had grown 2.5 cm in 4 months and had gained
S, {- u z. s; w3 L+ R& ]% Q2 M! E2 kg of weight. Physical examination remained! q2 e" s4 u& l! l+ r$ x4 n2 M
unchanged. Surprisingly, the pubic hair almost com-3 l1 J( ~; Z+ H
pletely disappeared except for a few vellous hairs at
: |: m( ]5 V+ E" T% p3 Z$ Vthe base of the phallus. Testicular volume was still 24 _& A0 m1 v o3 U$ {
mL, and the size of the penis remained unchanged.
& h; I- l; `0 b7 ]% \9 iThe mother also said that the boy was no longer hav-' s) ~3 K" [+ |* z& n# p
ing frequent erections.! L, j9 k: b$ H- ~* R9 x# u
Both parents were again questioned about use of3 ]1 P* n1 h7 I& n4 u( y* d2 K
any ointment/creams that they may have applied to
5 G7 w, C, ?- s) Bthe child’s skin. This time the father admitted the0 _# {8 m# E. ?( O f# B
Topical Testosterone Exposure / Bhowmick et al 541
" ]' O( U8 k# @" x* H+ Ause of testosterone gel twice daily that he was apply-: ?. g* l& i$ q( b% b
ing over his own shoulders, chest, and back area for
% Q/ V \/ D, h- w; G4 la year. The father also revealed he was embarrassed
! e3 S5 |0 Q, lto disclose that he was using a testosterone gel pre-
. j" V- t5 P7 b1 l; L- J* Ascribed by his family physician for decreased libido
2 U9 c3 F1 N% v6 H9 Dsecondary to depression.
) R" q; }: V( W1 e" e+ g+ L9 RThe child slept in the same bed with parents., E/ s7 _" \ [1 V3 P
The father would hug the baby and hold him on his5 w( X3 ]- X! B
chest for a considerable period of time, causing sig-0 A; X4 E4 a0 g/ M
nificant bare skin contact between baby and father.3 ?) [' f" i/ `( ^. G* r5 x
The father also admitted that after the phone call,
* ]* I2 s/ x4 p0 kwhen he learned the testosterone level in the baby
D+ ]/ D# k, k3 Z- A% {4 |- l: Vwas high, he then read the product information
5 z! q5 W; _6 P$ N1 Rpacket and concluded that it was most likely the rea-
; Z- M7 Z! g' ^$ `son for the child’s virilization. At that time, they
. f4 C% i( w2 adecided to put the baby in a separate bed, and the
6 H0 k# |3 z1 a6 Z3 F9 Ffather was not hugging him with bare skin and had
7 ~, m& {- T* l) { n8 Wbeen using protective clothing. A repeat testosterone
/ K8 _ C% }- b! ~* G+ m6 F. ~! Ptest was ordered, but the family did not go to the- D' [4 j$ n6 E& P; e! `5 T+ I
laboratory to obtain the test.
. p+ u& ~- h# a8 W6 KDiscussion- S" x, o6 S9 J. M
Precocious puberty in boys is defined as secondary
2 @0 T/ x; V) j3 o) gsexual development before 9 years of age.1,4
6 ]2 Y! }' v7 s6 `7 |! JPrecocious puberty is termed as central (true) when
- w7 Q* W1 h$ N/ dit is caused by the premature activation of hypo-8 m& D. B1 _& A l N9 y
thalamic pituitary gonadal axis. CPP is more com-. k% \! \, p# O4 \1 S) e7 L( S4 Q9 F
mon in girls than in boys.1,3 Most boys with CPP
/ w; _9 X3 E% M" n" |may have a central nervous system lesion that is
& O( ^2 p: a* f+ tresponsible for the early activation of the hypothal-
6 e i+ z+ C2 t6 u4 p8 w9 K% g! mamic pituitary gonadal axis.1-3 Thus, greater empha-6 J) C! X6 r. o: k
sis has been given to neuroradiologic imaging in! L- D+ D# M3 |8 e- B
boys with precocious puberty. In addition to viril-
; E% o; G" U, d5 ?; ^' q9 J! xization, the clinical hallmark of CPP is the symmet-# L3 A. m2 s( ^4 q' q, l& f) |1 k
rical testicular growth secondary to stimulation by. Z, f' a: f% o! T
gonadotropins.1,3& k* B* ?' y6 u% \/ E3 |) ^3 q8 {
Gonadotropin-independent peripheral preco-
& p$ c, R. Q a6 C* X* {5 s5 Q6 ucious puberty in boys also results from inappropriate
% a- W# f+ B. {1 }androgenic stimulation from either endogenous or! k. f4 N2 Q0 F& _- U
exogenous sources, nonpituitary gonadotropin stim-+ K) t8 o6 K9 D6 I5 p# [
ulation, and rare activating mutations.3 Virilizing$ i# [: \7 P6 Z1 G5 t! `
congenital adrenal hyperplasia producing excessive
3 R! C0 N2 J9 o/ |6 U& Kadrenal androgens is a common cause of precocious% ^ e, y, ~6 ]2 C* v5 X' O
puberty in boys.3,4
; a# d3 w: G3 n9 QThe most common form of congenital adrenal
9 ^. `, Q! Y9 fhyperplasia is the 21-hydroxylase enzyme deficiency.- R. r0 e; D& }/ `4 e" }; f
The 11-β hydroxylase deficiency may also result in
0 m; E0 E; a, l$ c Qexcessive adrenal androgen production, and rarely,6 g" m0 C% R- {% u0 x# a) G3 K
an adrenal tumor may also cause adrenal androgen- C+ }8 q4 c' e& O
excess.1,32 c, o3 l0 ^ V, C3 e7 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 @1 ~. l* i; q) W: Q4 A
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& Q- t3 O5 ^/ r4 `' ^9 q1 }! g
A unique entity of male-limited gonadotropin-4 }% N- v% ]4 C7 G" t: Y
independent precocious puberty, which is also known
) ^- f' [! X% A: Vas testotoxicosis, may cause precocious puberty at a
2 E5 k% {& E( J6 z* c+ Hvery young age. The physical findings in these boys
# e& D! j$ g+ ^; L9 owith this disorder are full pubertal development,
2 v7 o3 [& }, V* ?3 y6 k; Nincluding bilateral testicular growth, similar to boys- ], q3 L d8 ]; u
with CPP. The gonadotropin levels in this disorder
: I* u2 m) z! Z9 D5 n5 R0 q* {6 kare suppressed to prepubertal levels and do not show' `2 H4 `% x5 S& d7 V) p3 T: C
pubertal response of gonadotropin after gonadotropin-
/ t2 I7 R0 U3 areleasing hormone stimulation. This is a sex-linked) G2 Q1 S. I0 x2 _: e3 {; z
autosomal dominant disorder that affects only
% ` O: N! N& f9 T9 B; c3 U3 R( @males; therefore, other male members of the family9 `8 o& G% @% ~9 J0 q, o
may have similar precocious puberty.3
d% K- k; v- [% i+ ]( PIn our patient, physical examination was incon-$ Z3 ` [ |2 t8 x- G
sistent with true precocious puberty since his testi-
/ |- J4 M3 Y) O' d. icles were prepubertal in size. However, testotoxicosis
& ?" S( t8 L% H: h2 ]was in the differential diagnosis because his father
; o- ?3 C3 ?5 n0 Lstarted puberty somewhat early, and occasionally,
4 ?* O0 q8 J% \testicular enlargement is not that evident in the4 q# a/ l7 `1 Q3 h* T& {
beginning of this process.1 In the absence of a neg-) v1 w! ~2 h6 Y
ative initial history of androgen exposure, our
$ A- G( P$ C7 _% |: V( ^# ?' Qbiggest concern was virilizing adrenal hyperplasia,+ I5 q Y: B- C$ |
either 21-hydroxylase deficiency or 11-β hydroxylase
% M; l4 e2 p4 k8 t1 x4 A; vdeficiency. Those diagnoses were excluded by find-! E0 P. ]* |* L0 p2 i- _
ing the normal level of adrenal steroids.
l' U' D' p% j) ?, ~The diagnosis of exogenous androgens was strongly6 `* S1 q9 ~% b6 ]4 z
suspected in a follow-up visit after 4 months because
& ]1 a' t9 d! {( X0 U* j4 T1 ~the physical examination revealed the complete disap-' B0 L8 M! l! u
pearance of pubic hair, normal growth velocity, and
! b2 d# D6 h- D8 Udecreased erections. The father admitted using a testos-
2 G0 h, C) N' |8 M/ D! jterone gel, which he concealed at first visit. He was
8 @! w! h. f# zusing it rather frequently, twice a day. The Physicians’
! W. B$ I9 [: B9 K5 z xDesk Reference, or package insert of this product, gel or ]# o8 n$ x l7 p
cream, cautions about dermal testosterone transfer to4 ^8 n! _4 P: o2 [8 w
unprotected females through direct skin exposure./ m* ?8 G" s: g+ h
Serum testosterone level was found to be 2 times the7 E- i7 ~; j( n/ c. i. y
baseline value in those females who were exposed to9 B2 @8 G7 L+ z$ Y3 x' |; w
even 15 minutes of direct skin contact with their male
8 g, h/ N( W/ \. gpartners.6 However, when a shirt covered the applica-
; {/ h* N5 ~, r( j. ltion site, this testosterone transfer was prevented.% G( N% V# R' `
Our patient’s testosterone level was 60 ng/mL,
# R ~5 e9 C7 E6 G. R- Wwhich was clearly high. Some studies suggest that6 j: ?9 M# Q4 ?3 ]' a9 }9 q9 L3 \1 G; A
dermal conversion of testosterone to dihydrotestos-
; N) W/ B& ^# z; R, S/ q0 gterone, which is a more potent metabolite, is more- F% O) [ ?( g5 g+ l. @
active in young children exposed to testosterone" `6 c4 N2 N; K) d
exogenously7; however, we did not measure a dihy-7 X5 f) T7 p. c! S8 |) b6 [. a
drotestosterone level in our patient. In addition to
8 M2 _6 G, t+ U& |' }3 h1 L. s7 t' tvirilization, exposure to exogenous testosterone in
$ M1 R% w+ u! J8 Schildren results in an increase in growth velocity and
- L: i* W+ v' m+ y+ {) e7 a7 Badvanced bone age, as seen in our patient.
9 ^7 M1 w O: ?5 ?9 _; h: fThe long-term effect of androgen exposure during9 Z/ [5 n, j# l) V
early childhood on pubertal development and final0 U8 f: i* Q' e5 Y
adult height are not fully known and always remain8 ~- G1 Z- K$ F( ]+ P% f0 w% d
a concern. Children treated with short-term testos-* F& V! e9 A+ T0 ?
terone injection or topical androgen may exhibit some
: d/ a) R& l3 U* P! B* Q% Facceleration of the skeletal maturation; however, after5 O1 G2 V3 d0 G: b$ \
cessation of treatment, the rate of bone maturation& S' a; S h* V2 X3 Z
decelerates and gradually returns to normal.8,9
% [! n4 B4 j) d' z2 W( q0 r; G1 K5 j' hThere are conflicting reports and controversy
) y' n- j( b! X% y( Y7 |1 |. x" Yover the effect of early androgen exposure on adult1 M0 g/ H0 l2 a* A) Y. A
penile length.10,11 Some reports suggest subnormal, w' X, s; c( o$ P5 F: B; y
adult penile length, apparently because of downreg-2 d6 Z1 E% _- r3 }9 r: C2 u& l
ulation of androgen receptor number.10,12 However,3 D$ t3 j3 o9 e* m1 q
Sutherland et al13 did not find a correlation between
9 a+ A1 F2 j" O1 P. w+ }childhood testosterone exposure and reduced adult! [7 a) e" |% G- ], b
penile length in clinical studies.
" [$ p* T8 b+ c( M) A# s9 X6 c( rNonetheless, we do not believe our patient is
* N9 h: b% [- |$ I8 q b- Ggoing to experience any of the untoward effects from
7 P4 s: i. W9 D' ntestosterone exposure as mentioned earlier because
( A* \8 y" v9 W9 F, \2 b! }- l- Vthe exposure was not for a prolonged period of time.
1 A+ A9 L5 c0 Y7 |; O7 _' A. JAlthough the bone age was advanced at the time of; z8 i5 ^5 {, v' \
diagnosis, the child had a normal growth velocity at
! c5 ]" ]7 }- _( e; q" Pthe follow-up visit. It is hoped that his final adult) M) t ?: V8 T) e" F& i
height will not be affected.
8 d2 W$ x) K G3 nAlthough rarely reported, the widespread avail-
, ?) M8 ~& }8 dability of androgen products in our society may
/ o) J: F2 q2 O3 U1 `) jindeed cause more virilization in male or female( n- W" a! Z# f7 j6 w3 \* L; M" L
children than one would realize. Exposure to andro-4 U8 ^. A1 g& N `$ I* p' Z% M" k
gen products must be considered and specific ques-
* ~2 O5 B3 u8 a! D: A+ D0 p, H2 X( Htioning about the use of a testosterone product or. i6 K. s; r, P h, X. O8 \
gel should be asked of the family members during
' Z. J4 K% V# k9 O1 a" q athe evaluation of any children who present with vir-
" c, X4 h+ D$ {) n# [/ f' gilization or peripheral precocious puberty. The diag-
' B$ `% @9 b9 J3 A. Q# V# l2 K; t( ?nosis can be established by just a few tests and by" Q6 `) s6 M+ e' B$ V& E% N
appropriate history. The inability to obtain such a- B4 @" [# `* ~9 @0 A3 u
history, or failure to ask the specific questions, may
1 }: E2 r: D/ w4 r+ t" m9 xresult in extensive, unnecessary, and expensive
$ d$ h; B! ~. E9 L2 uinvestigation. The primary care physician should be
8 ~5 w4 E0 Y7 w+ haware of this fact, because most of these children8 @; A% j0 o% v ^9 |. X0 ~* L
may initially present in their practice. The Physicians’
; O8 A/ r; C; H) }+ MDesk Reference and package insert should also put a" f5 I( m2 R' y8 p. ^% c2 V y
warning about the virilizing effect on a male or9 A; w" W! K1 ^4 X3 D3 ]# h; k9 a
female child who might come in contact with some-
- J) k7 F, c$ c) q! R/ w4 E+ k; z0 Qone using any of these products.
3 ]$ A' `& W! I0 KReferences
1 N" Z% b& A5 J5 S+ N6 h4 |/ A1. Styne DM. The testes: disorder of sexual differentiation
% u) n* T! n6 w2 }4 @( N; Aand puberty in the male. In: Sperling MA, ed. Pediatric
* l3 \7 _" ~7 I* [ ~5 jEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; K' j" H/ w) b# f' r- i
2002: 565-628.( F" d) J( I5 i: ^. l1 u
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* g# f! U4 ?. j# X; _6 Spuberty in children with tumours of the suprasellar pineal |
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