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Sexual Precocity in a 16-Month-Old w- X& n% A$ @2 m7 U7 L
Boy Induced by Indirect Topical5 t; S7 D7 J7 c" p3 a; U" E
Exposure to Testosterone
% ?2 P; g6 J# |' M2 d7 USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 U; P3 R0 ^2 O) O5 b. ]5 X, b
and Kenneth R. Rettig, MD10 U4 J9 B$ P* t) C/ R
Clinical Pediatrics1 X! R$ M, m- y+ j2 D- Z
Volume 46 Number 6
- w d" z) G: ]% F9 N, BJuly 2007 540-543
' y! z9 s# P. l& Q; k0 R8 S© 2007 Sage Publications# Y" h+ j( h% }+ Y5 H& b: i7 s
10.1177/0009922806296651
0 R8 i& b. [4 x: ~; Ohttp://clp.sagepub.com' s( c. t& @0 P! X H% o
hosted at
! u' P% T8 A: Xhttp://online.sagepub.com% [( ?( z& }+ p1 v0 g
Precocious puberty in boys, central or peripheral,
% }3 y: z5 i3 z$ K8 }. w: zis a significant concern for physicians. Central* L; Q8 W2 F, }, K. i( N
precocious puberty (CPP), which is mediated
( Z7 Z' N6 y1 w: Q& |/ d4 Kthrough the hypothalamic pituitary gonadal axis, has& l5 @4 C4 ]" K
a higher incidence of organic central nervous system( m7 c; O4 q% N9 Q8 L! z n% E
lesions in boys.1,2 Virilization in boys, as manifested# D, `3 E4 q5 s0 Z* p# S- z
by enlargement of the penis, development of pubic
& V7 z) S" F% Y- S8 O* M8 khair, and facial acne without enlargement of testi-
j& Y _4 L+ ^9 y5 T3 z) Q) Icles, suggests peripheral or pseudopuberty.1-3 We
: @ u: z. `0 h% greport a 16-month-old boy who presented with the2 n9 ~4 y& f4 q- n% w q/ e0 U
enlargement of the phallus and pubic hair develop-
6 Z' _6 Z, ~8 j' O0 P: f( cment without testicular enlargement, which was due
4 _: y7 o& M3 i. J8 Sto the unintentional exposure to androgen gel used by& ]4 I. b2 z0 O" k
the father. The family initially concealed this infor-+ W3 X$ b0 E; q, y( ^! @
mation, resulting in an extensive work-up for this2 n! b6 G( S" b2 r* k
child. Given the widespread and easy availability of
- Q0 S5 Z) k7 r* k. Ftestosterone gel and cream, we believe this is proba-
$ \3 C$ n( }1 d) t" Q, J# z9 E, qbly more common than the rare case report in the: L3 h. w/ y( u6 y
literature.4; V. x1 [$ u' e/ `
Patient Report
2 h- t" p, o# U; TA 16-month-old white child was referred to the
" ~6 F7 r% {+ |3 S. ] mendocrine clinic by his pediatrician with the concern1 x. [" n4 X% N2 I% H' P* u
of early sexual development. His mother noticed
' Y9 i8 b# y, o H u6 z, Slight colored pubic hair development when he was
5 d& A9 j. C6 `) [From the 1Division of Pediatric Endocrinology, 2University of
; d' ]8 i! |6 O# S4 t! OSouth Alabama Medical Center, Mobile, Alabama.! W0 X+ a" a9 c: l+ u' B- I5 p0 Z3 W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. ^' X2 v0 u; j8 v: R& T0 I) H. TProfessor of Pediatrics, University of South Alabama, College of
/ S1 N% D7 i) {6 y0 {# y# {' nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" Z) O3 T+ f7 W& @) M6 {5 v O
e-mail: [email protected].
8 s4 k5 e0 a0 \. oabout 6 to 7 months old, which progressively became
" ~2 X+ k7 \9 ~$ `. J2 S4 G7 odarker. She was also concerned about the enlarge-
; _1 b% i& o1 q2 c4 o& rment of his penis and frequent erections. The child K0 {( R5 @4 m7 T+ O; k
was the product of a full-term normal delivery, with
) c- q1 ?' k5 Z& M8 F( @a birth weight of 7 lb 14 oz, and birth length of$ H9 D" V: v5 F& t% s0 b; Y3 ~( U
20 inches. He was breast-fed throughout the first year4 a0 D- T4 y* z4 t9 e
of life and was still receiving breast milk along with. w) a. ~* a/ r
solid food. He had no hospitalizations or surgery,
( h' N* d) S3 T7 b4 G$ mand his psychosocial and psychomotor development' D7 f; h9 M. W: Y: c+ Q, y
was age appropriate.+ H+ l f$ Z- |; f/ w7 l
The family history was remarkable for the father,
& j% G2 S0 i u' g3 k1 S9 cwho was diagnosed with hypothyroidism at age 16,
2 i! v* w( a4 k3 Swhich was treated with thyroxine. The father’s. I4 H$ [: r4 C; ~4 S$ \$ \
height was 6 feet, and he went through a somewhat
7 e: `6 x7 e6 cearly puberty and had stopped growing by age 14.1 @& R r# ?4 l$ A5 J9 e
The father denied taking any other medication. The
) R [/ C) S& wchild’s mother was in good health. Her menarche
7 m0 u2 o9 ?! P/ {2 U- F, `was at 11 years of age, and her height was at 5 feet
8 Z2 N! w& K5 U+ J) a) w7 T# E5 inches. There was no other family history of pre-
4 Z' U- Y- Q+ ?4 Kcocious sexual development in the first-degree rela-
2 j3 w. ]% z4 E+ y2 F: P2 P7 dtives. There were no siblings. B5 d/ l4 C) y1 V) p ] p, ]
Physical Examination
7 U' |! K6 ]7 F7 |0 _ C* o9 |/ x" K* OThe physical examination revealed a very active,
6 D/ A4 b, W; I. \5 e* B" n7 D vplayful, and healthy boy. The vital signs documented' X/ K+ u! N! S8 d6 u- L0 J
a blood pressure of 85/50 mm Hg, his length was) A( U* j) S4 F4 S' g% G5 r
90 cm (>97th percentile), and his weight was 14.4 kg
4 \+ F% T. G7 V" `(also >97th percentile). The observed yearly growth
" p' j2 _% N% h- X8 [3 {/ e: ]# W3 vvelocity was 30 cm (12 inches). The examination of* b0 N5 H! ^# v- ^! y3 e
the neck revealed no thyroid enlargement.
1 [+ c# V( s/ j3 {. _3 [The genitourinary examination was remarkable for
1 ~2 F/ R+ j$ B& b4 J' Q5 O5 Benlargement of the penis, with a stretched length of
3 O0 l+ ]" a! W% N o1 U9 G' q9 Q8 cm and a width of 2 cm. The glans penis was very well
5 V3 F% d. B% z3 G7 W2 [/ I5 ddeveloped. The pubic hair was Tanner II, mostly around& ]7 I1 k2 u9 Y& G2 b3 l. }& l* o
5406 x- t! E S0 E5 h2 G# d6 Y2 y0 ~8 ]- Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ x; L6 { v8 W6 K+ o5 h8 Othe base of the phallus and was dark and curled. The& l( R5 w# H0 ^' s, Z6 C
testicular volume was prepubertal at 2 mL each.
6 L1 B; E: |% UThe skin was moist and smooth and somewhat) f/ ^5 H: {3 C8 \0 L
oily. No axillary hair was noted. There were no
0 ~% F+ ?% L8 B3 `' v( l+ babnormal skin pigmentations or café-au-lait spots.
1 O, m Y8 |' ^9 hNeurologic evaluation showed deep tendon reflex 2+
* S2 U8 { M* E9 p- ~: u) cbilateral and symmetrical. There was no suggestion
- r! p B) d A8 qof papilledema.! b; t( n. k* E2 ~+ A9 V( o f( F
Laboratory Evaluation
5 G0 W) [% C) m0 cThe bone age was consistent with 28 months by& k5 {4 \: H# `
using the standard of Greulich and Pyle at a chrono-
% S0 u" a- b; i! {( a! Ilogic age of 16 months (advanced).5 Chromosomal5 R; _" c' a: n
karyotype was 46XY. The thyroid function test/ V4 o* O# p: N7 w4 K/ G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 O! j; U; E- c2 F6 }* F; }lating hormone level was 1.3 µIU/mL (both normal).
# ~1 E; U) i" W: L% {0 @The concentrations of serum electrolytes, blood
! C+ R2 P) A8 M, Z' curea nitrogen, creatinine, and calcium all were3 D. ?& w4 T; t( A6 [- }& i
within normal range for his age. The concentration
( I+ H7 A" n. X& R" M4 ?& Uof serum 17-hydroxyprogesterone was 16 ng/dL
: [" p7 {8 H" @" w" K1 F4 V4 j4 T+ C(normal, 3 to 90 ng/dL), androstenedione was 20# w0 b' J* G# Y" j3 \1 X \" Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& x* y+ v2 D; m' l) m2 E0 L& }! I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ t: m( ?# }. ?0 r; P) vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to9 u8 Z8 x ~3 X8 y
49ng/dL), 11-desoxycortisol (specific compound S)
$ A7 @8 D, r/ k/ ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 F8 j, { j/ f; e4 I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* \' {! |8 m' ^$ l9 e+ R+ _! m, H* Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 \) w3 R; ?! S( H" H2 q+ T
and β-human chorionic gonadotropin was less than
& h( I2 ~/ Y; k. I7 h! Z2 {% o5 mIU/mL (normal <5 mIU/mL). Serum follicular, d$ Z" B5 V) p
stimulating hormone and leuteinizing hormone
0 \. X$ p# ~5 L8 u. I' uconcentrations were less than 0.05 mIU/mL
& e: t! x1 B \% V; Q2 h(prepubertal).
$ H# u8 A6 B8 r6 x9 w8 D* n; N5 W& @The parents were notified about the laboratory; ?% M' P: M) r6 d1 a- ~, |0 U, |8 K( c
results and were informed that all of the tests were6 V6 I) t* _! V. i
normal except the testosterone level was high. The5 C0 O- x# [4 C
follow-up visit was arranged within a few weeks to7 n2 }& o8 j' ]2 ?% }" V
obtain testicular and abdominal sonograms; how-
6 p1 m c$ Q8 r& ^! Q7 kever, the family did not return for 4 months.
; K0 r" n1 v$ f+ ^Physical examination at this time revealed that the9 d2 i& H [% S' R
child had grown 2.5 cm in 4 months and had gained- Z/ e7 i& p. g( c
2 kg of weight. Physical examination remained
# }2 d3 ?5 I2 o' R5 O# Nunchanged. Surprisingly, the pubic hair almost com-) V, E% e" q0 ?+ t2 k) X: K0 m
pletely disappeared except for a few vellous hairs at5 c, Z+ M3 m5 E' N8 [4 g" ?
the base of the phallus. Testicular volume was still 2 S) n! I5 a4 {9 o: u c. d! l0 p
mL, and the size of the penis remained unchanged.6 P! D% v6 n' `7 _4 `) v; `
The mother also said that the boy was no longer hav-$ R5 ?* ~0 A7 P" [( ^: \+ F* Q
ing frequent erections.8 z8 W: O# |* {3 \
Both parents were again questioned about use of
- j: m: D% T! e: W6 N$ _any ointment/creams that they may have applied to: R, x( N% o2 q8 }
the child’s skin. This time the father admitted the
: W: q' ~, [. }8 k b. o( HTopical Testosterone Exposure / Bhowmick et al 541
5 v! x1 i) a. n' s" P$ `use of testosterone gel twice daily that he was apply-
0 l+ G- V9 \; Z9 l/ Aing over his own shoulders, chest, and back area for' V7 A5 O$ ~) r+ D- t8 H0 K
a year. The father also revealed he was embarrassed, I& c- q* c- I, ^
to disclose that he was using a testosterone gel pre-
1 S, t& Z9 w4 }3 N# ~4 {: N- q+ {scribed by his family physician for decreased libido
! w( k4 t4 p. O2 g% Fsecondary to depression.
0 ~) B% E6 [1 N* v# cThe child slept in the same bed with parents.. X/ k1 Q; O! u) M0 p
The father would hug the baby and hold him on his
@: x" F _9 W- Ychest for a considerable period of time, causing sig-
E. O" G. w' E P' g' ?nificant bare skin contact between baby and father./ q0 y8 i9 g8 M S/ i* p
The father also admitted that after the phone call," o9 N) q5 x F' |, P; v
when he learned the testosterone level in the baby% Y+ _- s/ l- {0 {+ _
was high, he then read the product information
8 c( N" x! o: `6 Ypacket and concluded that it was most likely the rea-7 X3 @( g8 u5 h' g/ g9 K4 t
son for the child’s virilization. At that time, they9 S. p* G% H; \
decided to put the baby in a separate bed, and the* h( d# ?3 C, q+ j' a( u
father was not hugging him with bare skin and had
' ^8 {- A% W; k9 ibeen using protective clothing. A repeat testosterone
6 a, ^! o2 }% a! y4 Y/ R5 atest was ordered, but the family did not go to the4 K0 Q% M; X1 F8 p, m$ J' Z
laboratory to obtain the test.- \6 V8 P( z: [2 x0 K
Discussion
8 p( H/ x4 d; jPrecocious puberty in boys is defined as secondary
. l( ]; P, {$ l) Bsexual development before 9 years of age.1,4& G4 I0 `& [4 {, C. @2 W9 _7 d
Precocious puberty is termed as central (true) when
- z3 N, Z* X/ d3 b" H5 |7 G) Lit is caused by the premature activation of hypo-+ W% b* L, ~0 d6 A9 b0 }/ O" b
thalamic pituitary gonadal axis. CPP is more com-& @( H8 i$ ]: ?( o' @
mon in girls than in boys.1,3 Most boys with CPP& `( K' l& X. q- X
may have a central nervous system lesion that is' l8 L: t' V, {4 W
responsible for the early activation of the hypothal-
+ e2 W0 W2 @$ }5 [3 l# _amic pituitary gonadal axis.1-3 Thus, greater empha-$ p& g/ i9 ]) f3 t' T
sis has been given to neuroradiologic imaging in
! z1 x9 U" `. y6 s8 @/ c0 cboys with precocious puberty. In addition to viril-2 C1 F' W8 G. u
ization, the clinical hallmark of CPP is the symmet-/ E j" C4 E8 I
rical testicular growth secondary to stimulation by
/ h" F0 v# m* G/ lgonadotropins.1,3
" P5 n% R8 |6 u2 r: r+ C* gGonadotropin-independent peripheral preco-+ W1 u0 T5 w) R( `. J3 U- u: G
cious puberty in boys also results from inappropriate- _* ]% _3 s) E
androgenic stimulation from either endogenous or
9 Z/ S1 D( Q) F9 |exogenous sources, nonpituitary gonadotropin stim-5 T8 T4 w8 u q' G4 c- Z
ulation, and rare activating mutations.3 Virilizing+ n8 y4 x* H. T! V* l" A% I
congenital adrenal hyperplasia producing excessive; | ?9 i( P* l/ n# y) w7 U8 w
adrenal androgens is a common cause of precocious3 P/ o! \8 C' K- C
puberty in boys.3,4
7 @! f9 O8 B; r; t) w5 m8 t: BThe most common form of congenital adrenal
6 d4 ~+ P( I; [1 Thyperplasia is the 21-hydroxylase enzyme deficiency.8 {* D' m- {$ U% y% d! ]
The 11-β hydroxylase deficiency may also result in- h- `4 h( q. h% r
excessive adrenal androgen production, and rarely,
, Y6 ^- K$ F. H" ~0 Nan adrenal tumor may also cause adrenal androgen
. f6 k8 ?9 {( Nexcess.1,3" y! l0 i; y+ b6 o5 W5 `, O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- r% Y9 I6 O) R* U# c2 e: T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# V, r: M" X6 [% U& C8 @6 B
A unique entity of male-limited gonadotropin-; Y& Q& V5 J4 v g
independent precocious puberty, which is also known6 a4 j( z. y$ q5 n/ \! b
as testotoxicosis, may cause precocious puberty at a
0 f0 ]0 J# H& L* Every young age. The physical findings in these boys5 j* ?; w) k/ O7 u, ^
with this disorder are full pubertal development,* E7 C0 \+ |2 F) K3 @, E8 n1 U2 V
including bilateral testicular growth, similar to boys
( ]$ T. @+ r6 j5 r" x8 Twith CPP. The gonadotropin levels in this disorder) ^7 l9 h2 J7 R, h" c4 m3 O
are suppressed to prepubertal levels and do not show+ `( O: X" s2 o' F7 ` J2 J' R: P$ J
pubertal response of gonadotropin after gonadotropin-, [- b7 X; u! U6 G. l3 Y
releasing hormone stimulation. This is a sex-linked) n0 J {# ?" l; y+ Y
autosomal dominant disorder that affects only; d) r8 ~. {6 k. _
males; therefore, other male members of the family
9 K$ F: J9 l/ v: H% J. \may have similar precocious puberty.3
& G& F% x2 P& d: [% bIn our patient, physical examination was incon-
+ z% Y0 B% x; B( g' X1 Asistent with true precocious puberty since his testi-- H8 E4 j" Y7 w& `" p
cles were prepubertal in size. However, testotoxicosis- M) c' A( k, r' T0 I& @
was in the differential diagnosis because his father
; s8 ]6 U) z, T0 \' Pstarted puberty somewhat early, and occasionally,
4 y) r% l( M1 |, atesticular enlargement is not that evident in the
8 b, s3 H! X# C9 Nbeginning of this process.1 In the absence of a neg-
8 G% p+ v+ P7 aative initial history of androgen exposure, our4 L. ^2 o4 o* M& G; o
biggest concern was virilizing adrenal hyperplasia,7 H6 U4 P( U A( f, W
either 21-hydroxylase deficiency or 11-β hydroxylase
' ?! L) y' Y6 W% ydeficiency. Those diagnoses were excluded by find-! \( Y1 c& J6 P3 w' n! p* s4 a
ing the normal level of adrenal steroids.! y1 a" G& o# }" d5 l) G* z
The diagnosis of exogenous androgens was strongly+ \# r+ L; k+ D7 p* Y: F/ H @
suspected in a follow-up visit after 4 months because5 \/ G0 B! F: H" x+ l
the physical examination revealed the complete disap-* D& c6 {% ^$ A# h8 b% k
pearance of pubic hair, normal growth velocity, and
) F' A* f1 S/ N z1 B: H- P- \decreased erections. The father admitted using a testos-
* ]9 F* ?8 {* oterone gel, which he concealed at first visit. He was
) s* _1 b; \/ {6 Z! j, Tusing it rather frequently, twice a day. The Physicians’- y* g; v5 A# n% F5 {5 c# m% {
Desk Reference, or package insert of this product, gel or$ X9 B2 r$ J& x3 F( x
cream, cautions about dermal testosterone transfer to
$ x4 o% Q7 k' a3 N- Junprotected females through direct skin exposure.2 L) p: ]! r* @; Q# J! S
Serum testosterone level was found to be 2 times the/ X9 c: [, j# Z9 d" K
baseline value in those females who were exposed to
% t( s' R; m7 F# Y9 Beven 15 minutes of direct skin contact with their male& q4 [+ g: `& R% t7 n9 h
partners.6 However, when a shirt covered the applica- R0 W- b8 e a# t9 Z, m
tion site, this testosterone transfer was prevented.
- ]/ ^1 v0 z) J" Q/ j) mOur patient’s testosterone level was 60 ng/mL,
, `% T7 m! B; H9 }which was clearly high. Some studies suggest that2 s& S. z2 E; w! ]
dermal conversion of testosterone to dihydrotestos-
* Y# I" R- x1 `9 Yterone, which is a more potent metabolite, is more
+ v! j7 H. G1 [active in young children exposed to testosterone$ f! m! |5 R. z& ^# L: L
exogenously7; however, we did not measure a dihy-& t8 G# ~1 F5 X9 C$ L& m$ @$ E2 P
drotestosterone level in our patient. In addition to8 p% X) E, K; ]
virilization, exposure to exogenous testosterone in, g# N" k8 _ A/ x* ^# Z5 ?7 D
children results in an increase in growth velocity and' }0 b; d/ ?) a- k. S% H. A: Z
advanced bone age, as seen in our patient.
+ f: N4 G1 j0 s Z5 j; H eThe long-term effect of androgen exposure during
6 _) F7 d, b5 B2 t( `5 T- H# p; P, Vearly childhood on pubertal development and final! i4 u/ Z3 t# c6 R2 p% Q
adult height are not fully known and always remain
$ N4 t5 w0 K& `: s( H0 c( e* B9 }a concern. Children treated with short-term testos-+ L! ^) E) R! Q! I' m& H
terone injection or topical androgen may exhibit some
0 w" k& t1 w' |acceleration of the skeletal maturation; however, after
2 w/ p) g' i8 q$ f1 O7 B& z$ Z# _cessation of treatment, the rate of bone maturation
" e6 e3 o/ o3 I+ v, jdecelerates and gradually returns to normal.8,9
: o# {: j3 d/ t( C/ {" }2 ^There are conflicting reports and controversy" X( p: y8 ^* h4 c* F7 |
over the effect of early androgen exposure on adult) c7 }1 o& K5 P( ]
penile length.10,11 Some reports suggest subnormal9 z9 n W$ L- t! l
adult penile length, apparently because of downreg-: V# _. S* g; W+ r& x
ulation of androgen receptor number.10,12 However,
& K/ t) U$ w: u% t1 XSutherland et al13 did not find a correlation between2 r O. a; b3 z$ [
childhood testosterone exposure and reduced adult- t5 b4 W" l$ t$ f2 x3 G
penile length in clinical studies.# x* Q" ]2 ?) y) }6 Y( p
Nonetheless, we do not believe our patient is K8 }( n+ d. d% Y$ A |
going to experience any of the untoward effects from4 I" l7 x4 M1 n% C! Y+ }' L* z3 t
testosterone exposure as mentioned earlier because8 ^; ~. k6 z9 K+ s4 ^% @/ @2 r: o
the exposure was not for a prolonged period of time.. Y& p/ W5 h% ]! `. l0 T
Although the bone age was advanced at the time of
: l/ c3 D2 |7 t! Udiagnosis, the child had a normal growth velocity at/ x E, W) S0 f6 @6 V( f5 F
the follow-up visit. It is hoped that his final adult) `; p- F+ z$ O
height will not be affected.
* C! c Z2 S2 G2 z$ n! T5 k fAlthough rarely reported, the widespread avail-6 _( k$ g1 O# ?7 U
ability of androgen products in our society may
, Z0 u; l+ A- }, k$ dindeed cause more virilization in male or female e; p) c% ^7 `9 k* ]5 w
children than one would realize. Exposure to andro-
1 K$ Z; ^5 D1 W1 |gen products must be considered and specific ques-8 Y( Q1 G7 e( x' J5 i& A; Y
tioning about the use of a testosterone product or* h2 T" a4 I% T4 u3 g+ h
gel should be asked of the family members during! U% U5 V$ f2 r9 [
the evaluation of any children who present with vir-( s. E3 m; r% X8 L. s1 f, h2 A
ilization or peripheral precocious puberty. The diag-
& E5 R9 H: S' Y7 x& m! H2 D( l2 U) ~nosis can be established by just a few tests and by, k- s/ k' `$ o) Z' }" }* ]1 ]5 g
appropriate history. The inability to obtain such a9 \, L1 `% v7 w1 _+ r
history, or failure to ask the specific questions, may' \0 B6 k( ]7 n( _7 z' x( J
result in extensive, unnecessary, and expensive) N* m! B6 N/ i; b
investigation. The primary care physician should be m. Z8 t& d; @: }2 R3 e3 g5 f
aware of this fact, because most of these children
8 ]$ S5 H$ k6 A/ f; G7 Qmay initially present in their practice. The Physicians’- D" G% J: A$ t* A
Desk Reference and package insert should also put a9 x8 z+ `' W1 z+ T. r: n
warning about the virilizing effect on a male or& l/ w, A$ ?2 t0 f; T
female child who might come in contact with some-
* h3 y7 ?- W( D8 p0 J, y( h8 n% Xone using any of these products.0 c! p* I% X6 E: V0 b5 O
References
" v: \/ B1 q- S. U: R7 _1. Styne DM. The testes: disorder of sexual differentiation0 |) {4 S2 `! i, O, j7 r% N" ^
and puberty in the male. In: Sperling MA, ed. Pediatric
0 t3 M: W' ?, B! S, q6 aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: u1 ?) N) H9 q4 H2002: 565-628.
( _& m& X$ j- N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 {8 W2 u, j$ m4 j- g% S
puberty in children with tumours of the suprasellar pineal |
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