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Sexual Precocity in a 16-Month-Old
& R- P$ Y" ~( c! Y7 x5 vBoy Induced by Indirect Topical
7 P7 t& o4 M. I/ [: i* @% [; YExposure to Testosterone1 K2 N" H& y) K& r; _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: i9 g: P4 n% C, I
and Kenneth R. Rettig, MD1, S; j+ y! o% I- q1 c- W' S# h
Clinical Pediatrics
, o; s5 E6 ~3 o) n- EVolume 46 Number 6( Z6 w( z' m3 |
July 2007 540-543
9 A* _* e' |( k; E5 t/ j- v& n© 2007 Sage Publications
( ~. L6 Q+ O& B/ Q2 K( I* O. o% K10.1177/0009922806296651
% B" [1 u% h9 W' }! [http://clp.sagepub.com
* Q9 B! }9 O$ }$ _8 Ghosted at
0 c8 |, J4 t( F0 M( V1 H* _http://online.sagepub.com
7 O7 N* Z+ g7 \. e' gPrecocious puberty in boys, central or peripheral,
# T% l; S9 D2 [' |3 ]; V6 L, Z7 Qis a significant concern for physicians. Central5 I. r1 B% L5 H/ ]1 z- q, @
precocious puberty (CPP), which is mediated
& N+ W: b( J+ Y) D6 Y# O7 }/ dthrough the hypothalamic pituitary gonadal axis, has' A& S% Q$ k% Z( ^' `; M4 T
a higher incidence of organic central nervous system
Y6 i7 K5 G, l6 |: Z) w" dlesions in boys.1,2 Virilization in boys, as manifested
; j( m1 @6 w2 \2 }6 i; Mby enlargement of the penis, development of pubic, u" ?9 p4 |- {( m+ s6 i0 k: J
hair, and facial acne without enlargement of testi-
0 ^+ e, M, x8 Mcles, suggests peripheral or pseudopuberty.1-3 We
) v" ^9 I* y9 ^& j: q0 Yreport a 16-month-old boy who presented with the1 x7 n8 u/ g8 B# ^
enlargement of the phallus and pubic hair develop-/ X8 C& A: ^" [" V, W: F+ J
ment without testicular enlargement, which was due+ W, C& ^, L8 @0 l0 C1 L2 I
to the unintentional exposure to androgen gel used by
2 g) _" N& A' S0 O5 u1 hthe father. The family initially concealed this infor-
( B- R; ^% g5 `6 qmation, resulting in an extensive work-up for this
1 _& Y( x- S! y9 nchild. Given the widespread and easy availability of
: K f' ~% o# ^! n6 n9 ytestosterone gel and cream, we believe this is proba-
; T4 z9 {6 ^! ]8 h) i# Vbly more common than the rare case report in the
. h4 i( {+ k# k% Kliterature.4. s. X% k$ C. K! n0 H$ F4 _( X
Patient Report
( U/ I" m$ B, i3 H$ R1 C" R0 j/ p( VA 16-month-old white child was referred to the
/ X4 O+ @; c' z% F0 Sendocrine clinic by his pediatrician with the concern% `* W" Y y/ X. v& }5 U2 `( r
of early sexual development. His mother noticed/ Q7 \; h/ [( O
light colored pubic hair development when he was" B: ], x6 f( }1 K
From the 1Division of Pediatric Endocrinology, 2University of
* A4 {7 }9 t- U: M5 h( NSouth Alabama Medical Center, Mobile, Alabama.
9 a. l \( V2 A1 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ Q+ p* [2 A- `( _+ [) f3 i* cProfessor of Pediatrics, University of South Alabama, College of
1 x8 v" s5 B n! p' q9 N, c8 w9 D, gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- d% m' Q0 v: L" Fe-mail: [email protected]., N: r/ h; O' R$ [: ^- y- q
about 6 to 7 months old, which progressively became
( m4 v5 O& j) b6 F) v2 Vdarker. She was also concerned about the enlarge-2 b. F7 D% f4 H1 S# @
ment of his penis and frequent erections. The child1 }9 p: {! y9 z! ]5 {. w5 a
was the product of a full-term normal delivery, with- }: p, @4 O. X; q: y
a birth weight of 7 lb 14 oz, and birth length of
1 N# @9 U0 S: f+ Z+ q20 inches. He was breast-fed throughout the first year9 U' G7 d( Q r5 F( ^) I* ?
of life and was still receiving breast milk along with( \3 O6 Z5 }/ {: i3 S) x
solid food. He had no hospitalizations or surgery,
# ^; ~' K" X( F4 y# E( _and his psychosocial and psychomotor development9 c; `# P. E! O+ T, j: j
was age appropriate.
( R+ B' |7 w4 xThe family history was remarkable for the father, v, m& w% _* f, |5 T' P6 m
who was diagnosed with hypothyroidism at age 16,2 p# q; }" R. q- ?% [- G9 y
which was treated with thyroxine. The father’s
7 w! N; @7 |! }$ I& d# {) S: g- aheight was 6 feet, and he went through a somewhat7 N/ }4 c4 n: P- K U+ W
early puberty and had stopped growing by age 14.$ e) |* i. o& o4 j4 O
The father denied taking any other medication. The
9 R% x: I) ^9 r _' _6 echild’s mother was in good health. Her menarche5 E1 t: |' \! s% \$ i8 r* r' j
was at 11 years of age, and her height was at 5 feet
8 _- _2 t |) [$ q! n5 inches. There was no other family history of pre-
7 {& b4 I W, [' @" J2 rcocious sexual development in the first-degree rela-
1 M0 _# S4 [/ b- P s/ I wtives. There were no siblings.
# ]' u/ A2 e9 I' F0 z$ }Physical Examination9 H% o% P7 s8 z3 E: ], O
The physical examination revealed a very active,
- m! z4 r3 f" j8 }playful, and healthy boy. The vital signs documented
0 V" A. ]% F# H' W. Ma blood pressure of 85/50 mm Hg, his length was" U7 D4 y) e. o4 r, \
90 cm (>97th percentile), and his weight was 14.4 kg2 r& Z5 _3 R- h
(also >97th percentile). The observed yearly growth4 @: L! G- Y4 m2 R1 h
velocity was 30 cm (12 inches). The examination of
5 T$ n, \+ i5 E6 D6 pthe neck revealed no thyroid enlargement.
) n4 V% y. o: L, @! uThe genitourinary examination was remarkable for
' e s* h S# D- {7 v5 fenlargement of the penis, with a stretched length of
0 M5 Y: s% z, e8 cm and a width of 2 cm. The glans penis was very well
9 I2 N- Q" x( @+ edeveloped. The pubic hair was Tanner II, mostly around! i' E8 Z* h1 Y1 Y) E2 a# r
5400 d! s3 ]" f: t) P' L- T
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the base of the phallus and was dark and curled. The q: b7 t3 v, S4 S) E
testicular volume was prepubertal at 2 mL each.
5 x3 Z. x7 p3 d0 tThe skin was moist and smooth and somewhat
. k6 c7 U" V2 G, f+ D8 J& Soily. No axillary hair was noted. There were no9 ^" I8 w. u% v. q$ |
abnormal skin pigmentations or café-au-lait spots.' }! S) e/ H: { k
Neurologic evaluation showed deep tendon reflex 2+" Z; W( A( y5 j, E2 v! {7 Y
bilateral and symmetrical. There was no suggestion
6 `0 T8 `( l* r* bof papilledema.0 N8 F1 i* E" f- N8 u. t# g' T6 Y
Laboratory Evaluation" x1 q# A4 ]& Y$ c! M; L
The bone age was consistent with 28 months by5 C- }! G2 t$ h |( X; E. |
using the standard of Greulich and Pyle at a chrono-
, Y: f! h4 t! B2 ^& F! Klogic age of 16 months (advanced).5 Chromosomal2 b* E6 n$ Y! Q# \3 _1 Y# M
karyotype was 46XY. The thyroid function test
6 T y. q+ Z# L: J4 H4 b! }4 ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
' {+ q O( ?- l# y( A& Ylating hormone level was 1.3 µIU/mL (both normal).& w1 M% V5 Q3 {7 @3 {, j* f
The concentrations of serum electrolytes, blood) b2 U. Y, p' v
urea nitrogen, creatinine, and calcium all were
' p0 C$ J. P: B, ^& ]% N; `- gwithin normal range for his age. The concentration
4 S" ~% o2 I$ T- wof serum 17-hydroxyprogesterone was 16 ng/dL
- n8 U! [; A* F(normal, 3 to 90 ng/dL), androstenedione was 20
2 Q) t5 d) O o+ ^. M- qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 v9 ?1 u* n4 C6 X i' c- Q- ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# |1 v A( C$ ?" Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 I1 N/ b7 B M% G3 a* y* O49ng/dL), 11-desoxycortisol (specific compound S)
* P' Z' u; a. E6 xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) S9 E% i- { n, U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 V) b6 J! G$ R( c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 h, I6 s; ]0 ~8 l; ?
and β-human chorionic gonadotropin was less than' b* ]$ D! Y. d4 |9 P* ? @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
T+ Y- [/ @- X# Kstimulating hormone and leuteinizing hormone
2 Y/ n G e7 @* P7 sconcentrations were less than 0.05 mIU/mL h! T) F/ z2 S/ p3 ]
(prepubertal). j9 \* L, P6 S w0 P, O
The parents were notified about the laboratory- p7 n8 i/ |0 D: B V6 F
results and were informed that all of the tests were1 x2 R! W X# ?# X( h& ?" t9 e
normal except the testosterone level was high. The
6 ?! K/ c4 o" V# C2 H# U# z( ufollow-up visit was arranged within a few weeks to
! K, \/ H P3 z. W* [+ cobtain testicular and abdominal sonograms; how-
# R" O }; x: r+ c3 ?ever, the family did not return for 4 months.
2 N- B* }0 q4 } v7 _Physical examination at this time revealed that the( w' I$ {( L- l# ^( [
child had grown 2.5 cm in 4 months and had gained8 V) z4 Z3 s+ N+ u0 h T* @
2 kg of weight. Physical examination remained* i# U: e5 G' d, w, u( z9 a: s
unchanged. Surprisingly, the pubic hair almost com-) w# B V. r0 j% M- Z2 N _
pletely disappeared except for a few vellous hairs at
# l/ k* F v! X% }the base of the phallus. Testicular volume was still 2
) a3 y. W9 _3 F! [3 pmL, and the size of the penis remained unchanged.9 p: U% w4 _, A* [; @( @$ J: j
The mother also said that the boy was no longer hav-
' n8 h- U' ^1 [7 x! Xing frequent erections.
9 h$ M C! ?- Q3 T' F, cBoth parents were again questioned about use of% V( G" A: [$ y
any ointment/creams that they may have applied to
2 g: j0 F/ K9 z3 @* n0 p. zthe child’s skin. This time the father admitted the
! f; v' K- B* X# u2 t0 ETopical Testosterone Exposure / Bhowmick et al 541
! f' p, G2 z+ N9 w! \. [( t `use of testosterone gel twice daily that he was apply-
+ x8 m+ h" D! Ding over his own shoulders, chest, and back area for
2 V; W3 T" X: J! K7 G# K' aa year. The father also revealed he was embarrassed* j) s" [) @7 `3 a3 X& B$ Q% }
to disclose that he was using a testosterone gel pre-7 m, I6 \7 M4 n7 b& a% y7 ?
scribed by his family physician for decreased libido
$ E* j6 I' c8 @* W Y9 q) fsecondary to depression.
1 }$ g! a% B- n; r% EThe child slept in the same bed with parents.
8 E7 m7 g+ v( E5 p" ^; uThe father would hug the baby and hold him on his
; Q g! V% E) x# t/ ochest for a considerable period of time, causing sig-6 n# \. l8 r2 L. u$ y
nificant bare skin contact between baby and father.
( P! B6 n5 e, X, s' Q0 x: f3 RThe father also admitted that after the phone call,; |% Z9 Q6 m5 _/ L
when he learned the testosterone level in the baby
; ~7 F' S r) t8 twas high, he then read the product information" I% o' A4 d0 u- }" B
packet and concluded that it was most likely the rea-
9 x; N6 g2 X3 d4 O) I, R; O$ Nson for the child’s virilization. At that time, they
9 A. m0 o% I) x$ w% r$ Jdecided to put the baby in a separate bed, and the
+ Y. S% q! b, d5 Q( N& Wfather was not hugging him with bare skin and had
" B X6 U0 i) Y/ H6 ~4 tbeen using protective clothing. A repeat testosterone* u2 ~7 f( x( ~: _
test was ordered, but the family did not go to the
2 v3 o! r- d5 [8 Slaboratory to obtain the test.
: i( Q6 x# d/ v2 M+ EDiscussion5 C: ]% W$ }% @8 O7 ]( w
Precocious puberty in boys is defined as secondary
- C* a0 L5 C' g; ?( }% k2 X/ @ R$ F lsexual development before 9 years of age.1,4& T) I4 x! o3 w5 t3 ^
Precocious puberty is termed as central (true) when
* m [2 ~+ ^8 v# E8 x# I" Xit is caused by the premature activation of hypo-
A6 a7 l9 h0 T" T) j4 N6 O3 Othalamic pituitary gonadal axis. CPP is more com-
+ f h6 _# q; j+ Jmon in girls than in boys.1,3 Most boys with CPP2 I: }% u8 D/ P! ~+ {& F$ ]) Q+ k- `
may have a central nervous system lesion that is
& x$ s5 n5 c; V% R2 r; P, O/ Cresponsible for the early activation of the hypothal-
6 i: e; O# \1 s! p" ]amic pituitary gonadal axis.1-3 Thus, greater empha-; E1 a3 Y9 g( V* Z! [( m' s; m4 e
sis has been given to neuroradiologic imaging in
, x j* R/ U0 Q* o* a& dboys with precocious puberty. In addition to viril-$ [/ D& Y% ?4 P3 O0 F
ization, the clinical hallmark of CPP is the symmet-
' V1 K9 r; {$ \$ e* S9 ~rical testicular growth secondary to stimulation by
0 M/ O' |0 {/ Q* c+ }1 ]# Q2 egonadotropins.1,38 B' \* L3 ~8 i$ W$ b
Gonadotropin-independent peripheral preco-
! t4 Y! h9 c2 p; R% s* [( Tcious puberty in boys also results from inappropriate$ h2 U* s) Y! y" J- p
androgenic stimulation from either endogenous or3 f2 `" F j. E! J* ?' S
exogenous sources, nonpituitary gonadotropin stim-
8 l1 i( C7 x; g' [ulation, and rare activating mutations.3 Virilizing
( N2 N6 C" f0 {0 K# }2 i. qcongenital adrenal hyperplasia producing excessive
0 H( F0 |0 [1 x# Y+ ]adrenal androgens is a common cause of precocious- k; V0 X4 s, I' y0 C0 Q* Y7 W
puberty in boys.3,4
# i! |! W! f/ a& LThe most common form of congenital adrenal
$ R* a- M# R2 { V4 chyperplasia is the 21-hydroxylase enzyme deficiency.
% @; ~% l6 v0 PThe 11-β hydroxylase deficiency may also result in9 J* C( u4 ]' d* y) R: \& v
excessive adrenal androgen production, and rarely,3 C& E) P; O" y6 b; o
an adrenal tumor may also cause adrenal androgen" M2 S9 h' j% j* w! n0 ?: U5 j6 v
excess.1,33 @' H' @3 o! i" Z* ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 o6 f3 G/ ]! `6 ~4 L
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( y( ?, M2 o+ A! o: v1 Q
A unique entity of male-limited gonadotropin-
5 W, R' q; M N1 t V: n; ]- Gindependent precocious puberty, which is also known
2 f# b$ \9 \- j) A) I& V, R* O* Nas testotoxicosis, may cause precocious puberty at a, I" v- u# l6 S- v2 B& W
very young age. The physical findings in these boys5 A5 q2 u: G: \+ x- V4 f
with this disorder are full pubertal development,
! H9 K0 P) g0 Z/ _7 B: S) j4 Iincluding bilateral testicular growth, similar to boys e! }3 r8 N' o% u9 N
with CPP. The gonadotropin levels in this disorder
& v- L( L z8 S9 v* ware suppressed to prepubertal levels and do not show
- K" x+ ~+ f# m8 c4 I8 tpubertal response of gonadotropin after gonadotropin-1 l6 i, }$ A5 d, E
releasing hormone stimulation. This is a sex-linked5 O& Y' i7 W- y. q) z
autosomal dominant disorder that affects only
# f' I2 h# `2 X8 M7 X* Ymales; therefore, other male members of the family
: m; h6 ]3 F4 L J* [4 ?. @$ Qmay have similar precocious puberty.3
/ q3 [% Q& N9 J- k+ X( I9 ~7 o1 dIn our patient, physical examination was incon-
% Z- r& y/ k' I. N+ k$ N# _sistent with true precocious puberty since his testi-
9 {' [% _# v8 P2 _# _7 ^cles were prepubertal in size. However, testotoxicosis
* I4 R# ^; ~& r2 ~4 Bwas in the differential diagnosis because his father
( ]8 P) ~# `" P/ u c- @5 m1 tstarted puberty somewhat early, and occasionally,
- J* N+ y$ t/ y* `- a! z. utesticular enlargement is not that evident in the
6 X) U* q k! T5 Z: g+ p$ w% Bbeginning of this process.1 In the absence of a neg-( P* A- Y( e# w( J) U& c5 q, h! u, s
ative initial history of androgen exposure, our
5 c% b1 v4 `: \' Xbiggest concern was virilizing adrenal hyperplasia,) Q5 {4 K. p8 t6 U
either 21-hydroxylase deficiency or 11-β hydroxylase
* x, w( M* m$ S8 }! g0 o7 m- xdeficiency. Those diagnoses were excluded by find-9 r1 k z" p# M. m, i1 ^
ing the normal level of adrenal steroids.
/ ?, r2 m9 S' j# X; V6 V: Y! \The diagnosis of exogenous androgens was strongly2 c" N! i- F7 b
suspected in a follow-up visit after 4 months because
0 O% P# H. ]6 D2 }' g: {% ^" Rthe physical examination revealed the complete disap-
* l" \! G; [% ?0 c, G% Hpearance of pubic hair, normal growth velocity, and
+ v6 k4 q- x9 O' C! G6 C7 w3 Adecreased erections. The father admitted using a testos-
+ j7 V+ G0 j# O7 T0 s* ?, _terone gel, which he concealed at first visit. He was
* r9 `8 Z( t' u- Y/ U* R2 susing it rather frequently, twice a day. The Physicians’5 e5 w4 {2 ?( A) p8 }3 t
Desk Reference, or package insert of this product, gel or( I$ h6 Q$ Y. [5 j1 ?) u8 y
cream, cautions about dermal testosterone transfer to
; F* Q, @( w" U$ G. B% c; S; u8 U- ?# Uunprotected females through direct skin exposure. y, Y5 u, Y; P. Y
Serum testosterone level was found to be 2 times the
: r$ [' ?0 G8 \# g4 T/ Q0 U: {baseline value in those females who were exposed to
' t0 W$ A6 l$ y* L$ meven 15 minutes of direct skin contact with their male/ c8 T/ J4 _5 Q" A- \7 f) ?
partners.6 However, when a shirt covered the applica-8 A- p0 C- g4 n5 b# Y& A& U
tion site, this testosterone transfer was prevented.
6 x6 ?% O, N5 G' \Our patient’s testosterone level was 60 ng/mL,
) U' X$ z6 g) w/ k6 O% ] mwhich was clearly high. Some studies suggest that7 o6 i. Y, W5 m- r
dermal conversion of testosterone to dihydrotestos-0 o L) N6 \( e* |
terone, which is a more potent metabolite, is more; K/ q; y/ @* u) L9 D" o
active in young children exposed to testosterone* N6 q2 V# E/ {5 u( M5 I1 w
exogenously7; however, we did not measure a dihy-
/ y% \/ m& w& S: v% ~# P3 u+ O9 Mdrotestosterone level in our patient. In addition to
5 G8 q/ s' z! h; U2 ?- F# Kvirilization, exposure to exogenous testosterone in) p- ^" B( |+ r3 d3 C
children results in an increase in growth velocity and) m, H" [8 i0 V
advanced bone age, as seen in our patient., M& a5 u% \1 S" U) f9 D' j
The long-term effect of androgen exposure during
* h" w* I1 N3 v3 }* y) eearly childhood on pubertal development and final
5 a* {+ F! G/ a& x. Y' a4 q) f( Kadult height are not fully known and always remain
+ G9 q! g m( k9 v4 N6 Ma concern. Children treated with short-term testos-
1 l; Q- R: V9 m0 [0 lterone injection or topical androgen may exhibit some
' a; i6 X( o+ ?+ T ] Pacceleration of the skeletal maturation; however, after
+ X/ v9 U1 g# t9 V6 z" Kcessation of treatment, the rate of bone maturation
6 A1 h7 q4 R- \$ W( H% u: M) m. Odecelerates and gradually returns to normal.8,9
7 l+ m: u% R( j2 sThere are conflicting reports and controversy
7 E' Z9 E; F' f c! iover the effect of early androgen exposure on adult6 x4 [( t) ^! r1 r" m0 w
penile length.10,11 Some reports suggest subnormal% B% b2 K2 T, \
adult penile length, apparently because of downreg-
6 t! i- J& I9 b! |ulation of androgen receptor number.10,12 However,7 U' C F9 q+ }0 d+ w# V' l
Sutherland et al13 did not find a correlation between
: {- Z$ o' B2 W$ d, m% j+ Zchildhood testosterone exposure and reduced adult7 n. b' `+ k q+ I! Y! n- L1 |
penile length in clinical studies., K- r0 z9 I! i/ I& W) Q8 r
Nonetheless, we do not believe our patient is: q( e1 O! K, m) d3 l
going to experience any of the untoward effects from
# V4 G$ i+ @. C/ Q) P9 I# otestosterone exposure as mentioned earlier because
) S: L/ W0 s" }the exposure was not for a prolonged period of time. x ~ I% l: l# y% @+ P% I
Although the bone age was advanced at the time of4 ?. ]& r* n# j3 C4 x* ~8 t9 C
diagnosis, the child had a normal growth velocity at2 _: z c" n8 A& Z ^9 a! q
the follow-up visit. It is hoped that his final adult
5 Q/ u2 C |$ z+ k: Zheight will not be affected.
1 I+ |. L; B$ {Although rarely reported, the widespread avail-" Z: x% T% E" H* A, D# _
ability of androgen products in our society may7 B7 u- ?; A6 x) R e% K3 }
indeed cause more virilization in male or female
. x. m0 J) y0 u: jchildren than one would realize. Exposure to andro-. a2 H$ {% n! k( x7 B6 j2 v/ ?
gen products must be considered and specific ques-. L+ d9 {+ j$ J. f: |4 x
tioning about the use of a testosterone product or
4 i2 v4 F6 D. s9 F* L1 _gel should be asked of the family members during
5 |, Q _. ]6 J. J* O& O/ N0 Ithe evaluation of any children who present with vir-
7 T; [# @0 q! A) I, _6 ~ilization or peripheral precocious puberty. The diag-
1 ~) ~2 |( Y Tnosis can be established by just a few tests and by
# Z( E& G9 B0 k! A7 y" G& Sappropriate history. The inability to obtain such a9 u. n2 W. z, H) k t1 {. F
history, or failure to ask the specific questions, may
4 }' r R) M, R, C; `) N7 Y5 xresult in extensive, unnecessary, and expensive
$ U4 |% N5 g6 ?. D! Z8 J; ?4 kinvestigation. The primary care physician should be
! o$ c: E. r5 V1 T, W3 I) W9 g) {; z) [aware of this fact, because most of these children
- G+ b9 R! h) s6 Omay initially present in their practice. The Physicians’& w' Y$ j8 T4 e( T9 e
Desk Reference and package insert should also put a
$ z" t M2 j* ]- l$ jwarning about the virilizing effect on a male or- l* v ?9 A- T1 ]0 i
female child who might come in contact with some-
; H$ a# F, {8 H5 e% Pone using any of these products.! q: V; ^3 K9 F! B+ k
References5 S0 d% f% ?% B0 s% L6 L6 v* F. H0 B
1. Styne DM. The testes: disorder of sexual differentiation% b; P4 _) u4 K; E3 [3 o: w
and puberty in the male. In: Sperling MA, ed. Pediatric: ^1 C- L9 |8 M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 j/ ]1 ]$ }3 p2002: 565-628.
+ D3 O9 c1 ~2 ~* k) b& f" `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- I2 j7 d# l r3 D+ W3 ?puberty in children with tumours of the suprasellar pineal |
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