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Sexual Precocity in a 16-Month-Old# _. y* J! C) K
Boy Induced by Indirect Topical
: X2 C+ n0 Q( L/ E, @$ O( z3 O- BExposure to Testosterone3 B# e3 T9 H& Z$ e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
O3 Y, S i# y+ |and Kenneth R. Rettig, MD1
9 d* ^" s" ^9 S9 G+ n0 Z0 x/ lClinical Pediatrics: X# {2 I9 M3 X% f& S4 M4 Z
Volume 46 Number 6
; C& ]1 h V8 C7 mJuly 2007 540-5432 Y2 F+ U+ O3 X/ x
© 2007 Sage Publications
( J7 T$ X( n9 |5 A- q3 C( O10.1177/0009922806296651# [- P9 V# T1 E3 L1 U. k0 |. z
http://clp.sagepub.com
( S' d1 \+ Z( |* i% |6 chosted at: `0 _4 Y9 ~0 e/ k V i
http://online.sagepub.com
9 u9 K) Q- Z' }Precocious puberty in boys, central or peripheral,/ x, l, g0 g4 z5 {6 y7 l. g8 \
is a significant concern for physicians. Central9 b! s' s$ `: Y" V0 N
precocious puberty (CPP), which is mediated; S! e- S8 [, ? k( Q+ k# x
through the hypothalamic pituitary gonadal axis, has. U% Q" ^" q) O4 w* h
a higher incidence of organic central nervous system A% ~3 k# p3 E4 a' x* S k8 t
lesions in boys.1,2 Virilization in boys, as manifested( C+ R/ r0 v4 |& W; |+ c
by enlargement of the penis, development of pubic
! f. i3 a2 i& E) Y1 c4 Fhair, and facial acne without enlargement of testi-! [) D: R: c: n+ R$ `* D3 q7 e0 u
cles, suggests peripheral or pseudopuberty.1-3 We& H3 v$ q- N% q; {5 F
report a 16-month-old boy who presented with the5 ]6 [$ |" j* X, a' w5 w
enlargement of the phallus and pubic hair develop-
- B) G6 E L# P# |ment without testicular enlargement, which was due
7 F7 \9 c6 h+ oto the unintentional exposure to androgen gel used by/ O; x% G4 `9 Y9 H
the father. The family initially concealed this infor-! w1 j% ?- R# y3 ^: L( D3 ? s3 @: m
mation, resulting in an extensive work-up for this4 a0 Z/ I: o3 ?1 e
child. Given the widespread and easy availability of ~( x/ r; K* [! }# {
testosterone gel and cream, we believe this is proba-
) _( U) I( X$ Bbly more common than the rare case report in the
' h' f$ q- n* a0 W# m6 l7 B5 {; cliterature.4
5 a0 s3 Y' \0 g5 v3 Q, D1 X( ePatient Report% m" K& @$ M' T; T8 O! h6 Z
A 16-month-old white child was referred to the A3 H6 ?; H" l% t7 Z4 b. y: c
endocrine clinic by his pediatrician with the concern: \2 H( i$ b4 z5 y9 ]8 h) x% f
of early sexual development. His mother noticed
3 z' K: F; |$ C4 olight colored pubic hair development when he was
4 b2 A& n8 x- G6 Z. F3 R, N0 lFrom the 1Division of Pediatric Endocrinology, 2University of
8 d/ j* W9 [0 v, i1 E9 hSouth Alabama Medical Center, Mobile, Alabama.
7 w1 R2 n! Y0 d& \" |$ Z$ K2 k% e! hAddress correspondence to: Samar K. Bhowmick, MD, FACE,% N9 q6 {5 c% }0 f' a
Professor of Pediatrics, University of South Alabama, College of. D1 q- l* R7 a3 V) A1 S/ e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 P5 M- O2 O0 ?& n: L. C/ Q/ c
e-mail: [email protected].
9 j/ S2 u1 f3 E+ E: m7 ] uabout 6 to 7 months old, which progressively became9 @# [0 [! v0 E: T6 J9 t9 J% F
darker. She was also concerned about the enlarge-
: B- }2 A4 y$ D7 j. Zment of his penis and frequent erections. The child
! i+ N; _7 f! Z/ g# |was the product of a full-term normal delivery, with9 V/ w; j' ~: W! k i$ y& K0 ?6 J
a birth weight of 7 lb 14 oz, and birth length of4 x0 X2 u% ^5 D5 e! @
20 inches. He was breast-fed throughout the first year* S5 ~4 x& E8 ^% O5 p
of life and was still receiving breast milk along with/ T# h- S/ h6 b- C8 D" G% T7 Y: k
solid food. He had no hospitalizations or surgery,
; S! D4 Y' x, ]and his psychosocial and psychomotor development
, Q+ r; d- `# n) y$ G% d! E$ zwas age appropriate.
/ l: |! S% D2 x: X2 V8 n4 bThe family history was remarkable for the father,0 |4 _ Y% u( k" [' p4 m
who was diagnosed with hypothyroidism at age 16,7 j8 K- z4 F3 H4 J7 s
which was treated with thyroxine. The father’s
' Z+ c+ U% A3 `, Q9 ]1 X+ wheight was 6 feet, and he went through a somewhat9 _* H- a! L$ }: L, ?
early puberty and had stopped growing by age 14.
; y! g) P6 h2 i8 s5 ]8 @0 @& x% zThe father denied taking any other medication. The
/ M- c( E+ D& xchild’s mother was in good health. Her menarche
; g( Q% {0 b' s( [9 ^6 N* Awas at 11 years of age, and her height was at 5 feet; M! l% E I3 ~2 v
5 inches. There was no other family history of pre-' a! p2 Q+ }9 x9 d0 d% z V9 h! n4 y
cocious sexual development in the first-degree rela-
" w/ X: m9 l$ i: `# R( k/ C0 rtives. There were no siblings.) c+ [0 R; J& ^# r$ `
Physical Examination
* q% ~/ p) M A! W5 V0 l/ RThe physical examination revealed a very active,
8 `! X$ G- v# q: i6 iplayful, and healthy boy. The vital signs documented( \# p2 u' N1 x" {" t, d8 A
a blood pressure of 85/50 mm Hg, his length was
" w8 r0 @' _8 o' D6 }; T90 cm (>97th percentile), and his weight was 14.4 kg- p. z6 g/ L2 f' F3 D/ W! a. x
(also >97th percentile). The observed yearly growth
' d. K- u$ i+ x8 a9 Mvelocity was 30 cm (12 inches). The examination of
1 c/ y5 G; f8 O( |! q2 @the neck revealed no thyroid enlargement.
/ l( U9 q A7 _' W5 b' _+ uThe genitourinary examination was remarkable for a. @- d9 j' ^# v4 ?0 n7 H
enlargement of the penis, with a stretched length of7 [: \8 I. t7 y
8 cm and a width of 2 cm. The glans penis was very well
( @, @: a9 I3 u2 p7 e e% Y) P" gdeveloped. The pubic hair was Tanner II, mostly around$ z, P6 k! Y6 ?& p7 |7 H
540& P& G/ [& Y' g; p$ g' u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& k0 ?. E/ E' @5 e5 nthe base of the phallus and was dark and curled. The
# C; W& F# i. n: Jtesticular volume was prepubertal at 2 mL each." X% G, k! K. \, |8 {
The skin was moist and smooth and somewhat8 `/ X/ Z R) p. }% B+ H
oily. No axillary hair was noted. There were no
7 h4 I1 g$ T! f+ vabnormal skin pigmentations or café-au-lait spots.
) H: C( n- Q. F3 \Neurologic evaluation showed deep tendon reflex 2+
) {7 Z0 G7 c% _( Abilateral and symmetrical. There was no suggestion$ g9 O& S6 R3 L, z( E
of papilledema.
J, d7 r" T" I: U4 R- iLaboratory Evaluation+ |- K7 S5 y* M0 P/ q
The bone age was consistent with 28 months by" W: e% }* O: T; v1 f! o2 \
using the standard of Greulich and Pyle at a chrono-
' `, G) \$ l' T1 C E0 y1 hlogic age of 16 months (advanced).5 Chromosomal) Z$ [$ j+ w- f' Z% {. t
karyotype was 46XY. The thyroid function test
% p* G1 v. e& M8 H/ \showed a free T4 of 1.69 ng/dL, and thyroid stimu-- m5 C2 @& S: ^: e6 S8 _7 N9 }
lating hormone level was 1.3 µIU/mL (both normal)." v% Y. g# w3 `7 E
The concentrations of serum electrolytes, blood3 T& E; H, U4 d$ c8 k. Z
urea nitrogen, creatinine, and calcium all were; v, Y* A/ Y4 p1 K
within normal range for his age. The concentration' O2 f' \, B+ ]' W5 I9 s% P
of serum 17-hydroxyprogesterone was 16 ng/dL
$ w6 F4 x8 i% I% X8 m; @+ M) c(normal, 3 to 90 ng/dL), androstenedione was 20
, c! ~9 k ^* ]. n& I1 Lng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- V s3 J K0 F4 E$ Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),+ _ E2 r* [. b! N# {% v8 h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* E* r' C; H6 j3 L% v! v49ng/dL), 11-desoxycortisol (specific compound S)& `1 W2 n( D& Y& r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' s* ?+ c* N; E# P8 l; I( Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 f, N0 `: X! k$ b @* Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),( t, P) }5 p5 `
and β-human chorionic gonadotropin was less than
6 M3 u! t {0 m, w2 R; X5 mIU/mL (normal <5 mIU/mL). Serum follicular' G4 P9 ~& e+ b; n& w; ` o0 w
stimulating hormone and leuteinizing hormone
8 x7 |1 w( U- H# S# Tconcentrations were less than 0.05 mIU/mL
/ v, @; w& }9 ~/ d(prepubertal).: }: N/ w7 b9 [, @' u: }
The parents were notified about the laboratory
+ e! O7 z1 X2 H% v+ F7 J/ xresults and were informed that all of the tests were( i: I. F- e" n8 c, y+ q
normal except the testosterone level was high. The
# f& Y3 |$ q6 t* ?* b% |1 U5 Bfollow-up visit was arranged within a few weeks to
. @4 D( Y5 P8 T: n# zobtain testicular and abdominal sonograms; how-
* ^! S+ j1 k4 ]# {! A6 yever, the family did not return for 4 months.
( H" \. M' _! f$ L9 {: [Physical examination at this time revealed that the
) ?: ~7 O8 p: @4 w! Zchild had grown 2.5 cm in 4 months and had gained {1 r7 a2 V6 B( Z8 w# ]: k
2 kg of weight. Physical examination remained
% u/ Y9 H7 d; I" A K2 Nunchanged. Surprisingly, the pubic hair almost com-
" ?1 u4 ^$ A3 b/ ?3 fpletely disappeared except for a few vellous hairs at# E5 W7 h7 Q8 \# s4 b
the base of the phallus. Testicular volume was still 2
2 r! Q; [1 X0 d) W6 v- r/ g5 w' ] ymL, and the size of the penis remained unchanged.8 ]2 G. L2 q6 {
The mother also said that the boy was no longer hav-
6 @7 C# I Y0 m1 U8 \" H4 E/ \ing frequent erections.% M8 W& ^7 r7 V) e
Both parents were again questioned about use of
+ H, b2 A, y+ Z8 s! f& b; a" D- n+ {any ointment/creams that they may have applied to
0 \ T7 |# K; L- zthe child’s skin. This time the father admitted the# a; k4 C9 d+ a7 p
Topical Testosterone Exposure / Bhowmick et al 541- u: B- R' C; V* i( `
use of testosterone gel twice daily that he was apply-) n1 V3 F# r- Z, G- i% b; y) v* d
ing over his own shoulders, chest, and back area for
* h" Y# ~$ S, na year. The father also revealed he was embarrassed
% g C3 S |+ U$ f- ]; H& ?to disclose that he was using a testosterone gel pre-
& F+ H1 ^5 L) I/ O9 Q, Oscribed by his family physician for decreased libido
" ?+ K8 H1 J+ V9 o/ a+ e6 csecondary to depression.
: D, d: r$ @8 R- uThe child slept in the same bed with parents.
* N) v0 d4 o, m$ K* ~2 _6 c0 }The father would hug the baby and hold him on his
# ?% j6 \+ }! ]# O: f8 P# |( I. zchest for a considerable period of time, causing sig- ^8 U* P' t6 C! M
nificant bare skin contact between baby and father., [) M. J) f* _2 j5 R2 a
The father also admitted that after the phone call, G: W+ s9 @; e. {0 q
when he learned the testosterone level in the baby- v7 m, i9 y. v6 o9 u( v% }( p
was high, he then read the product information
: y/ W* H: G" V3 I, d9 k2 G \0 Rpacket and concluded that it was most likely the rea-3 u, ]# S( {! X* r
son for the child’s virilization. At that time, they0 g% D& O+ O0 k8 z
decided to put the baby in a separate bed, and the
: H5 g4 k+ T% {% ^- Ofather was not hugging him with bare skin and had- B3 `1 s- A8 J4 A& R
been using protective clothing. A repeat testosterone; V, r1 G/ C. c' w. ]
test was ordered, but the family did not go to the
' j/ x6 E: N. a/ H" A3 Flaboratory to obtain the test.
( n3 P6 S. a; i, g, e3 R/ s7 WDiscussion
& A% {5 r7 T5 `+ MPrecocious puberty in boys is defined as secondary
! o+ A5 e5 w5 e% }$ s% N# ?sexual development before 9 years of age.1,4
) m" r% R8 K& o" C+ e' uPrecocious puberty is termed as central (true) when
% Y2 A1 y u1 M0 z4 O. f; Git is caused by the premature activation of hypo-6 |- f' ~1 M+ a- q6 p/ V
thalamic pituitary gonadal axis. CPP is more com-% H/ p6 Z( K: L5 x; X$ v4 W- f
mon in girls than in boys.1,3 Most boys with CPP
8 d0 x. x' G, {! Imay have a central nervous system lesion that is
# n6 a2 ^3 t, j' G& A: Qresponsible for the early activation of the hypothal-
3 T5 V) K( @5 E* g4 l1 namic pituitary gonadal axis.1-3 Thus, greater empha-
* D7 l9 P$ r6 J1 o, n8 ^sis has been given to neuroradiologic imaging in
3 u2 l; b* u5 D N1 ]boys with precocious puberty. In addition to viril-
, H- l0 a( N, G7 P3 Gization, the clinical hallmark of CPP is the symmet-
U+ u- i; x) ~3 J7 Prical testicular growth secondary to stimulation by1 r+ S r- T9 ~" [- z
gonadotropins.1,3" r9 e% @$ Y# h6 l: ]
Gonadotropin-independent peripheral preco-9 B. S! A# x$ I1 w
cious puberty in boys also results from inappropriate
5 ~' e! x+ ~ G6 @: fandrogenic stimulation from either endogenous or
, L/ `7 l7 I: E* E# C4 Hexogenous sources, nonpituitary gonadotropin stim-# [7 [! X4 t2 A' L- Q
ulation, and rare activating mutations.3 Virilizing
/ l* m4 t& v5 a. z0 g6 h0 P# bcongenital adrenal hyperplasia producing excessive8 f Z( L2 k1 ?- {1 \- X) Y
adrenal androgens is a common cause of precocious3 ^! I- G! t8 l. ]- A
puberty in boys.3,4
3 a$ Z) c1 ]& l2 U6 f" K3 MThe most common form of congenital adrenal( C' c6 o9 J$ M @3 q) n# H& R, V7 z
hyperplasia is the 21-hydroxylase enzyme deficiency.( c$ s; g a: a% N. e7 z/ s, H
The 11-β hydroxylase deficiency may also result in% E6 g% z# E3 ]! @7 ?8 `" t$ Y+ u: N. A
excessive adrenal androgen production, and rarely,1 S) f: k1 l7 g
an adrenal tumor may also cause adrenal androgen2 Z+ I* a+ Z. r) l5 R
excess.1,3, Q, r9 T/ P3 ^$ ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 c2 o3 F& Q r, ]- \ w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 d2 K5 L6 E1 J# S4 F% WA unique entity of male-limited gonadotropin-
) N4 ]5 K0 d/ n' f( windependent precocious puberty, which is also known% f/ n, p" H9 ^* Q1 z" @- J d
as testotoxicosis, may cause precocious puberty at a
# n% v9 x2 ^+ H$ Q hvery young age. The physical findings in these boys/ C- t( F0 d; u4 c. C6 i! e! W3 v
with this disorder are full pubertal development,) n( Z; l1 o4 U8 S
including bilateral testicular growth, similar to boys, N$ r# k2 N4 c1 u
with CPP. The gonadotropin levels in this disorder
6 P1 k7 v: T3 ^- p6 Nare suppressed to prepubertal levels and do not show+ A' d6 y+ W: Y8 d4 n- u6 q
pubertal response of gonadotropin after gonadotropin-' Z C: A! J0 m
releasing hormone stimulation. This is a sex-linked
' p, v6 P+ y. Fautosomal dominant disorder that affects only0 `( X6 S8 A. K t
males; therefore, other male members of the family
2 k3 @! i! q3 m- h6 L; k8 W) Ymay have similar precocious puberty.38 ~* d% [( i7 Q0 i$ ?
In our patient, physical examination was incon-
! g, `" j5 K, g$ C# O6 Z ^sistent with true precocious puberty since his testi-
3 J3 P2 O2 M; r1 ^$ jcles were prepubertal in size. However, testotoxicosis
6 U0 Z+ \+ Z+ C+ kwas in the differential diagnosis because his father K- h% a8 k0 l2 O) z9 a5 h
started puberty somewhat early, and occasionally,+ A+ c* C0 R- H2 Q3 c- M) I
testicular enlargement is not that evident in the k& M* S3 q. j- @3 D9 O' _
beginning of this process.1 In the absence of a neg-4 @, u. l* n! `) ]# T: m) h: _
ative initial history of androgen exposure, our
' @: k7 e8 X7 I" n5 V! X2 rbiggest concern was virilizing adrenal hyperplasia,
" d# n( l: l- B' H2 p. g/ Jeither 21-hydroxylase deficiency or 11-β hydroxylase
6 _/ y( i$ B# w7 {deficiency. Those diagnoses were excluded by find-5 W* R% Z: j' K1 Y9 Z5 G0 D3 c) Y
ing the normal level of adrenal steroids.
1 ]" x- n& [* H: HThe diagnosis of exogenous androgens was strongly. \' G' I8 J( _3 G& O& n! q
suspected in a follow-up visit after 4 months because- l m) d7 L3 Y8 ^& K
the physical examination revealed the complete disap-+ F$ X5 `6 X8 K3 D: i
pearance of pubic hair, normal growth velocity, and5 k4 t- K" R3 p2 f2 H/ X" [; Y& d
decreased erections. The father admitted using a testos-1 H$ Q4 w U* ?- T1 u% d
terone gel, which he concealed at first visit. He was. v* b+ f. K3 H; y: o; X
using it rather frequently, twice a day. The Physicians’) h9 G, F3 [9 F( n
Desk Reference, or package insert of this product, gel or
8 k8 g0 N& G: J# tcream, cautions about dermal testosterone transfer to6 t5 W0 L$ d# C0 W3 ~
unprotected females through direct skin exposure.; x8 D; `3 \" {$ u. k
Serum testosterone level was found to be 2 times the. X o7 M' @* h: N* D
baseline value in those females who were exposed to
4 S+ b5 f! D* V9 }even 15 minutes of direct skin contact with their male
8 o8 R% O, r4 }; M, ]0 [6 |. Lpartners.6 However, when a shirt covered the applica-5 U' U, H% _7 H- g
tion site, this testosterone transfer was prevented.
0 y* u1 N; L4 c8 _6 P# ~8 X3 `Our patient’s testosterone level was 60 ng/mL,
2 T }# v9 W5 L4 Hwhich was clearly high. Some studies suggest that
! t5 H1 e8 d: i8 S( `/ q ?dermal conversion of testosterone to dihydrotestos-# Z- Z) j; v+ ?$ l4 ^# {7 J! t: J
terone, which is a more potent metabolite, is more
1 f% H+ p: F) k' t$ L& r6 p+ Gactive in young children exposed to testosterone
: t! i3 H$ O( B5 }exogenously7; however, we did not measure a dihy-* R) w, @6 B$ I) `
drotestosterone level in our patient. In addition to/ z; o" T/ D; w' I$ D6 w% m
virilization, exposure to exogenous testosterone in
& r8 r! S# w' t8 ]children results in an increase in growth velocity and
% ]) o* k: n- ]& @6 U7 B, q8 D4 _advanced bone age, as seen in our patient.
1 c& P' ^6 ~- j6 ZThe long-term effect of androgen exposure during* n+ c2 r& [1 O/ {, d/ U
early childhood on pubertal development and final# ?! n1 m6 Q6 f, X' D9 f* V; T
adult height are not fully known and always remain; ]( B" [) m6 x/ B3 w. Y
a concern. Children treated with short-term testos-
- |3 ]7 m- z+ q) Gterone injection or topical androgen may exhibit some+ ^+ q4 P _/ Z9 ^
acceleration of the skeletal maturation; however, after' ]/ o v$ d. R9 B
cessation of treatment, the rate of bone maturation
) h1 W- E' k8 s2 X9 fdecelerates and gradually returns to normal.8,9% j9 U) B, K8 \0 d$ ^
There are conflicting reports and controversy
" h4 b# g2 q: G( d1 x4 eover the effect of early androgen exposure on adult
; X: T3 A8 d. J; Apenile length.10,11 Some reports suggest subnormal5 m* v* X$ J6 w: t! ?' E- {
adult penile length, apparently because of downreg-2 j$ ?, d$ y6 I
ulation of androgen receptor number.10,12 However,- S( \7 R: `$ B
Sutherland et al13 did not find a correlation between; o; ?: G9 |4 f- N
childhood testosterone exposure and reduced adult+ P& e% k1 H% U
penile length in clinical studies.
- `4 ^7 _ P5 q! bNonetheless, we do not believe our patient is) @( ~7 T) ]" ?) F- R* a6 l; e; @' z
going to experience any of the untoward effects from
% ~- G T' g6 ctestosterone exposure as mentioned earlier because% n6 }+ E& g0 K" n. E
the exposure was not for a prolonged period of time.
/ `* E7 g) \6 J# U! m8 B( i6 G1 }Although the bone age was advanced at the time of
( z' X3 S4 [: y* V b9 V3 Tdiagnosis, the child had a normal growth velocity at4 d9 t% N0 ^9 e- u! C$ P2 T
the follow-up visit. It is hoped that his final adult
! `/ f- h. `' @! ^7 {# qheight will not be affected.
0 K' ^1 S) ^: y2 P3 D5 p& oAlthough rarely reported, the widespread avail-. s+ S f$ Y' k: i! `% {
ability of androgen products in our society may8 Q9 V) h6 d3 {2 z* Y$ |
indeed cause more virilization in male or female7 [ T- f5 J* J/ ?& t9 s; \% h
children than one would realize. Exposure to andro-+ p5 W5 K. c: E9 r$ O
gen products must be considered and specific ques-# g V/ z- `; ~
tioning about the use of a testosterone product or- n) o8 ^& n6 z$ N m4 ?- b9 V6 M- J
gel should be asked of the family members during
, [9 r8 |. K8 s* B7 f+ ~5 h, jthe evaluation of any children who present with vir-( w8 f. C! T. X# L$ L/ n7 i
ilization or peripheral precocious puberty. The diag-
* b X! U* a7 C; {nosis can be established by just a few tests and by$ |2 ~* s7 q6 c3 |
appropriate history. The inability to obtain such a
8 o+ V# |, s# v8 o( E9 w% bhistory, or failure to ask the specific questions, may6 c. Y! G* j$ M* d
result in extensive, unnecessary, and expensive f. n. u8 n3 W
investigation. The primary care physician should be
/ A" F; D7 y0 H2 p; Maware of this fact, because most of these children
E. R' ^& U5 N$ z5 H- Rmay initially present in their practice. The Physicians’/ M, j8 g. K Y @' ?6 x; f
Desk Reference and package insert should also put a
3 j+ e) w9 r3 ?/ Z6 u4 e; r! Uwarning about the virilizing effect on a male or) Z* M7 ^) e7 O: \' L
female child who might come in contact with some-8 ^" t( n5 U2 o. d* [4 g$ ^
one using any of these products.
4 B* p# B9 g1 E- N# i, d. E& @: KReferences4 y+ }! u9 K6 K& `/ h5 U$ a
1. Styne DM. The testes: disorder of sexual differentiation
( n% D& j- }4 s7 P$ X8 ^4 Land puberty in the male. In: Sperling MA, ed. Pediatric- y* J' x/ g; ]$ z, o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 ?3 K" @' {1 A* R. f
2002: 565-628.+ I' o) y8 _7 u; o* i! F* o% J% A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 d9 k, V/ B: H0 L; R
puberty in children with tumours of the suprasellar pineal |
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