- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
0 n0 R/ p( E5 D0 qBoy Induced by Indirect Topical
" S1 o6 B2 K' G" K, K$ ~0 IExposure to Testosterone# @; E( i4 [' W. `; Y3 c5 @ n$ I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% S* P# Y1 o3 T% n# Sand Kenneth R. Rettig, MD1' T4 g# p* \7 A, P4 q" t
Clinical Pediatrics+ B* {* F/ I9 j# U; ~
Volume 46 Number 6
, N& X0 o3 s8 l$ G. RJuly 2007 540-543
+ K9 G6 E+ G# |; I0 R) @© 2007 Sage Publications; T4 e* u& r) f8 }% b
10.1177/0009922806296651) G3 m( H5 b; w1 H$ i4 T; x' h `* F3 p
http://clp.sagepub.com" [5 p3 o: ~) b9 V+ U, i) R
hosted at
0 q2 U: Q Z* _8 G0 x) Vhttp://online.sagepub.com
9 g1 U, T3 L4 i" F, aPrecocious puberty in boys, central or peripheral,
' o! d9 s3 H8 l0 ~* P5 Z8 jis a significant concern for physicians. Central
: g- j- M5 c0 d# Y9 C8 hprecocious puberty (CPP), which is mediated9 b3 v$ n7 f/ E z+ n4 b7 @8 {
through the hypothalamic pituitary gonadal axis, has
4 o' G4 Q" n9 O# \ H+ |/ Ha higher incidence of organic central nervous system
; a! r. n6 W/ g6 h0 Y; u$ Mlesions in boys.1,2 Virilization in boys, as manifested0 U7 M e0 h) {3 F8 c8 _3 ]
by enlargement of the penis, development of pubic- t, [) B0 o1 Z6 z9 ]
hair, and facial acne without enlargement of testi-
2 w; X) M7 ~1 m8 Ecles, suggests peripheral or pseudopuberty.1-3 We
' i8 K( F( C6 ^8 K: F. Freport a 16-month-old boy who presented with the' u/ W1 R7 z' F7 z$ @. [/ n* e
enlargement of the phallus and pubic hair develop-! ~" w' @; V5 e
ment without testicular enlargement, which was due1 u3 q6 D) m9 i. S1 k; l
to the unintentional exposure to androgen gel used by
J# s2 o: u J% H5 ]the father. The family initially concealed this infor-3 A9 v2 F; V. ]3 r4 V1 L
mation, resulting in an extensive work-up for this
! Q: C3 S1 l: o2 R) h" g: fchild. Given the widespread and easy availability of
) o7 N- d/ U4 K3 u, M/ x+ p+ Btestosterone gel and cream, we believe this is proba-
2 Z2 T6 m4 C' _8 P! cbly more common than the rare case report in the
* _4 f0 c2 r( f. i" Tliterature.4
# v4 R1 F2 F+ t; yPatient Report6 I, D/ Q, l) q# k
A 16-month-old white child was referred to the1 y8 { y* W+ K& e w& ?4 |
endocrine clinic by his pediatrician with the concern, E0 N8 F; K D; b, ?% u6 V. M- W7 W
of early sexual development. His mother noticed
4 r l+ a- C" @$ N$ B4 x! {- zlight colored pubic hair development when he was
( y1 A) p3 D2 C9 j K$ QFrom the 1Division of Pediatric Endocrinology, 2University of. a! v! x2 @4 ?8 ^* S4 f
South Alabama Medical Center, Mobile, Alabama.
3 H, L2 T1 R& E7 i4 k: a+ E7 i+ Y1 KAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' P# A; S( m$ A8 pProfessor of Pediatrics, University of South Alabama, College of; m7 Z6 k& H5 L0 h# U4 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- j6 V' s5 M0 D0 A. _, n1 s
e-mail: [email protected].
2 J' ]# W+ D, n) Z3 nabout 6 to 7 months old, which progressively became/ w; q" K' `0 j6 b
darker. She was also concerned about the enlarge-
! M% E N& O8 O6 g3 J" H+ Y6 ~ment of his penis and frequent erections. The child
7 ^5 b q* T. E" p5 O* ]+ owas the product of a full-term normal delivery, with
1 W( z, C9 z7 _5 Ja birth weight of 7 lb 14 oz, and birth length of
. |) C p* e- C) T& t. d4 n20 inches. He was breast-fed throughout the first year
% Q0 X9 s5 q' w8 nof life and was still receiving breast milk along with% o- y: f! @8 A+ h% r
solid food. He had no hospitalizations or surgery,, {5 h; ?7 v4 E0 O6 E7 R' O
and his psychosocial and psychomotor development
/ @& V- q4 r2 d }+ c: p$ Kwas age appropriate.
) K7 }4 t. A& y2 v/ rThe family history was remarkable for the father,
, S2 h$ {% H6 I% Gwho was diagnosed with hypothyroidism at age 16,9 T' H# b. g8 n2 ^; Y) ~
which was treated with thyroxine. The father’s) I; G$ A; P' T/ a8 ^9 p3 z( O, t
height was 6 feet, and he went through a somewhat
) k4 d" [/ I5 _2 yearly puberty and had stopped growing by age 14.
' z' Z* z( S/ }; k( N9 v/ MThe father denied taking any other medication. The8 n I; e3 o7 ~7 C! ~
child’s mother was in good health. Her menarche
0 N: t6 X; |# T# T! J0 lwas at 11 years of age, and her height was at 5 feet0 W+ ~6 `' k8 L; t* |" G6 \. r
5 inches. There was no other family history of pre-' i7 z# i! _: G! N+ F5 f" Y/ k! M
cocious sexual development in the first-degree rela-
: j, L% E/ z7 U, |: z- P2 C$ Y) e5 dtives. There were no siblings.5 R& G( Q: _0 W6 d- |1 M1 |9 R, Y
Physical Examination
" H H" f% q8 E0 C' a. V2 C( x; n* MThe physical examination revealed a very active,
$ P7 b9 S7 q: C: Eplayful, and healthy boy. The vital signs documented
' A3 G, {' x0 H! |a blood pressure of 85/50 mm Hg, his length was
& ?) L# x5 C! `4 n. u90 cm (>97th percentile), and his weight was 14.4 kg, p9 l8 T; \" c
(also >97th percentile). The observed yearly growth) v3 p2 i. y. [; v4 Y+ h
velocity was 30 cm (12 inches). The examination of
% ~8 C+ e( s: y8 w% x: Sthe neck revealed no thyroid enlargement.* A5 S7 P) e" q6 q( F$ s, K
The genitourinary examination was remarkable for
3 T, y4 r% R2 D& Y4 r9 G# O& Denlargement of the penis, with a stretched length of2 `# m/ D% K# o6 ~
8 cm and a width of 2 cm. The glans penis was very well- s2 [$ |3 Q" |* n8 R h' B
developed. The pubic hair was Tanner II, mostly around2 x& q: m8 F1 N
540
& A) [5 J% b# W7 X% yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 {0 f* j) b' n; mthe base of the phallus and was dark and curled. The
& p O& _( T; m {& ftesticular volume was prepubertal at 2 mL each./ w/ k, U* i F0 m
The skin was moist and smooth and somewhat0 e1 q; E; f$ ]$ S; g
oily. No axillary hair was noted. There were no
4 Q( r7 u* N, I6 {, S3 y7 Zabnormal skin pigmentations or café-au-lait spots.
# \# T( b" u1 v! t: ZNeurologic evaluation showed deep tendon reflex 2+
5 m+ }2 ^$ m# p) X Bbilateral and symmetrical. There was no suggestion1 j( q9 z) `: S! d2 ]9 g7 n C \
of papilledema.0 R9 u0 a6 |# {/ u S- R+ B
Laboratory Evaluation" L, k, g9 g: W/ h6 a. V
The bone age was consistent with 28 months by& f9 g# y9 _/ g) p- f6 H' x% n
using the standard of Greulich and Pyle at a chrono-
8 f9 j) R& }2 I9 E4 ^) x5 zlogic age of 16 months (advanced).5 Chromosomal, ~8 f' X E2 f7 V. b" ~
karyotype was 46XY. The thyroid function test& t/ k4 y+ L% y% D( L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 u2 _, V! T' F" d) y _
lating hormone level was 1.3 µIU/mL (both normal).
; y* i7 J2 F( D* Z, e# lThe concentrations of serum electrolytes, blood. A8 s! x, [0 V6 g2 P
urea nitrogen, creatinine, and calcium all were
6 F0 o) k1 ?7 d. Ywithin normal range for his age. The concentration$ G% {+ g, Z- ?( t% K: u" I
of serum 17-hydroxyprogesterone was 16 ng/dL" n3 a& E: N$ Y0 O9 S+ I3 {
(normal, 3 to 90 ng/dL), androstenedione was 20 `. f; G3 U( `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! d9 f0 Z9 Q8 L, F7 P; c- v, Z4 ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),* S, H: K- j3 Z, ~7 a0 `2 p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ e! k0 y" i1 K( |49ng/dL), 11-desoxycortisol (specific compound S)
5 P. D+ ~# O2 n! A" ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) ]; _9 C+ ?4 U8 |$ @2 e" W5 r
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 m3 V4 V& v2 N0 i/ k2 t
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, S/ t i$ o/ w) |' xand β-human chorionic gonadotropin was less than
# g" N% B& n6 I( G5 mIU/mL (normal <5 mIU/mL). Serum follicular7 W/ q% P! S9 y; z+ Y+ {
stimulating hormone and leuteinizing hormone
. N3 n/ q3 @5 a3 fconcentrations were less than 0.05 mIU/mL/ h; T4 m$ P4 _
(prepubertal).
5 J# J- a$ y: C, x' o3 e6 YThe parents were notified about the laboratory2 g6 k8 T. X0 d% t8 C2 i; c7 f+ E& k
results and were informed that all of the tests were+ q$ S, P# ~ P* i2 o* n& A5 H x
normal except the testosterone level was high. The
' K$ w- z' \0 d4 Pfollow-up visit was arranged within a few weeks to
# k" X. |1 w' \+ Q+ K+ j- d7 ]. Uobtain testicular and abdominal sonograms; how-
, S3 M! ^6 T( ]7 aever, the family did not return for 4 months.1 `& X' N* b x
Physical examination at this time revealed that the
+ s* e1 [% r0 x d0 Z; p7 `child had grown 2.5 cm in 4 months and had gained: o8 g" C- W/ e& b
2 kg of weight. Physical examination remained" B/ c6 Y% \/ Y
unchanged. Surprisingly, the pubic hair almost com-
- E; ~# p4 ~9 ]& N, I) ]! @3 Npletely disappeared except for a few vellous hairs at) M! d- P4 }1 [. x. ?. B" v
the base of the phallus. Testicular volume was still 2
- w- i c7 V* T. [3 M1 v6 ~/ RmL, and the size of the penis remained unchanged.
0 T! @& a% B, I" [The mother also said that the boy was no longer hav-, j/ @" Y' J: L( W* @- { v- E. _$ P
ing frequent erections.
0 z- J; K5 p9 t0 D4 \" V B$ [" y9 JBoth parents were again questioned about use of
/ Z6 n$ D3 }, r# @8 D5 Kany ointment/creams that they may have applied to
: ~3 R* }& d3 z- i+ F* P( [' zthe child’s skin. This time the father admitted the e. t: q- R+ s( a K9 D- Z' j
Topical Testosterone Exposure / Bhowmick et al 541
7 h0 v* h- p+ x7 p% \5 M4 Huse of testosterone gel twice daily that he was apply-9 {/ C# B7 N* q9 B0 G& c8 v
ing over his own shoulders, chest, and back area for$ t5 H' N* w; y* s1 V( @/ _, P5 j
a year. The father also revealed he was embarrassed
- k4 H0 g& U' Y6 Z3 y% s; gto disclose that he was using a testosterone gel pre-
1 V6 z, _4 u, a4 R- |7 F2 e) |scribed by his family physician for decreased libido5 v2 L1 b) f% v' {
secondary to depression.
# D3 {+ F9 f" I( q* b5 e/ _' R( LThe child slept in the same bed with parents.4 M: m/ s" b1 S5 V8 V: b6 q
The father would hug the baby and hold him on his
6 R* A5 ~$ V' F* d8 O' C) jchest for a considerable period of time, causing sig-' _% h) }) g9 Q( }* ]) B
nificant bare skin contact between baby and father.: {2 R3 m2 s! h& v7 r
The father also admitted that after the phone call,
' e" O9 t3 |! _* Fwhen he learned the testosterone level in the baby
: E$ T/ }& |$ ~) Swas high, he then read the product information0 V% R! p7 R4 K6 b/ w+ g$ e
packet and concluded that it was most likely the rea-
2 `- ?# h+ s$ Q! z& N! xson for the child’s virilization. At that time, they
2 S' E* x+ w B3 sdecided to put the baby in a separate bed, and the4 U- Y. M7 B) |; K8 l. {
father was not hugging him with bare skin and had- a f G( B5 s4 }5 a' m" ~0 O5 X
been using protective clothing. A repeat testosterone
: ~3 N. q$ h" o( o) ^/ r) Dtest was ordered, but the family did not go to the. Y' J. X" x( X" z5 D/ S
laboratory to obtain the test.
2 W$ E$ P+ N7 n/ U6 @2 N& Z* ~Discussion
7 k! b9 W. ]' Z! E) r" E. SPrecocious puberty in boys is defined as secondary
! n% u# x; L2 T) N! gsexual development before 9 years of age.1,46 S/ H7 B" L4 Z
Precocious puberty is termed as central (true) when1 ?) F/ e7 B" Q& a$ X: p
it is caused by the premature activation of hypo-1 v- Q: o( D( I) @) Z6 E
thalamic pituitary gonadal axis. CPP is more com-1 i; |2 F( R n2 X
mon in girls than in boys.1,3 Most boys with CPP3 q( x$ f; C0 u! G4 s8 U! p4 _
may have a central nervous system lesion that is
% o: K2 |4 C5 v. J( _responsible for the early activation of the hypothal-% p% `# W2 _6 L$ {' Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ t0 X1 U# D1 @sis has been given to neuroradiologic imaging in
% T+ u9 i! U+ a* g! U# v+ i, J* m3 hboys with precocious puberty. In addition to viril-
( v5 p# O) @! N6 `2 hization, the clinical hallmark of CPP is the symmet-8 P7 i: v) g- t* [* d5 P+ r# ~
rical testicular growth secondary to stimulation by8 e, L$ o! n: f* N+ w1 y1 p
gonadotropins.1,3 J& B. P9 O: u+ U+ N
Gonadotropin-independent peripheral preco-
( H2 C: |" o0 D- |8 Q6 D5 I# Qcious puberty in boys also results from inappropriate3 u6 o) j2 Q3 o& m
androgenic stimulation from either endogenous or Q% J( }9 f2 ~/ A i4 s3 A
exogenous sources, nonpituitary gonadotropin stim-9 g4 D2 O& a" u3 g i9 k
ulation, and rare activating mutations.3 Virilizing
. X% e; H1 X( Dcongenital adrenal hyperplasia producing excessive
9 I( f7 S/ d4 c; iadrenal androgens is a common cause of precocious' I; \$ f# l2 ?4 _
puberty in boys.3,4
& R5 w1 ^. l5 tThe most common form of congenital adrenal
" f: [0 {. `0 E% uhyperplasia is the 21-hydroxylase enzyme deficiency.
5 E9 \) }! L- n, `) |1 _The 11-β hydroxylase deficiency may also result in/ O+ [5 O7 ?# Y8 z
excessive adrenal androgen production, and rarely,/ {2 }% l G3 o* V
an adrenal tumor may also cause adrenal androgen0 L& ?7 t) M& L6 K( s9 G, B
excess.1,3 N7 T% f# M* m: V2 i. r& o$ X* d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ S" K) L3 C' f5 {% g- c1 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 A; m4 x) k) C' g; yA unique entity of male-limited gonadotropin-1 ^ X+ j H" y* y |
independent precocious puberty, which is also known
: E" X( M5 F1 | ~/ K$ qas testotoxicosis, may cause precocious puberty at a4 D( |2 f! d2 ~
very young age. The physical findings in these boys8 p$ [# n' [& x* V' o. C
with this disorder are full pubertal development,
! L: Z7 F5 t2 ]+ C8 ^& {including bilateral testicular growth, similar to boys
! y( }1 l; N8 l% I- ` S+ ~with CPP. The gonadotropin levels in this disorder" ~5 d% q9 a# J0 w! }2 I8 x
are suppressed to prepubertal levels and do not show
* i1 |! T# x8 K dpubertal response of gonadotropin after gonadotropin-
1 `* D8 v/ G/ g0 v) k* ]' t/ Creleasing hormone stimulation. This is a sex-linked. r! u, S. E4 ~
autosomal dominant disorder that affects only
; N8 F/ P9 d$ R2 g1 Nmales; therefore, other male members of the family6 a. R% i9 S; l. W8 s* d) G# y5 t
may have similar precocious puberty.3+ i% k$ i7 }9 y' X0 l
In our patient, physical examination was incon-, |2 H) G- }5 _7 V" R9 ?* S, {" {# o8 i
sistent with true precocious puberty since his testi-& e1 x5 H( }$ o: a( l4 E, i& d
cles were prepubertal in size. However, testotoxicosis
& M$ @/ k* \5 Fwas in the differential diagnosis because his father' K2 @. e9 L7 T+ K |
started puberty somewhat early, and occasionally,
$ _& @5 [, X- u( w4 X, O+ Z: @testicular enlargement is not that evident in the& }: K' X0 d. t) p1 A, s% z
beginning of this process.1 In the absence of a neg-4 O. R0 k7 ^% E$ C! P$ y
ative initial history of androgen exposure, our: p) j2 ~! s; C
biggest concern was virilizing adrenal hyperplasia,) w9 [) o& [' C2 k1 }+ M$ c
either 21-hydroxylase deficiency or 11-β hydroxylase
' _' x( l5 x4 q) c5 z) r( ddeficiency. Those diagnoses were excluded by find-
6 u8 l# H2 V* D3 l( c4 ^ing the normal level of adrenal steroids.
; }9 ?3 E4 P& A9 U2 p! Y: |2 CThe diagnosis of exogenous androgens was strongly- [4 |( q/ e! s4 I
suspected in a follow-up visit after 4 months because
/ G# b& X2 [9 f4 ]- Rthe physical examination revealed the complete disap-9 x- ~& q3 f$ P, ]
pearance of pubic hair, normal growth velocity, and
9 f+ o4 X2 p, Qdecreased erections. The father admitted using a testos-* Z4 R. a* F# [: b
terone gel, which he concealed at first visit. He was
3 O# {/ u% c" B5 L) D8 Husing it rather frequently, twice a day. The Physicians’ \5 B# I {" U- u
Desk Reference, or package insert of this product, gel or
) y ] s$ |/ W1 }& Zcream, cautions about dermal testosterone transfer to
+ V5 Q+ Q+ y0 F7 E, \0 Wunprotected females through direct skin exposure.
# A* r: F3 W( U5 d2 e! s$ i' ZSerum testosterone level was found to be 2 times the
& f `' M( _ Q( T' kbaseline value in those females who were exposed to* n7 |. `* J. D! b) d
even 15 minutes of direct skin contact with their male7 d* c$ K9 j/ Z* q) n
partners.6 However, when a shirt covered the applica-
" l3 ?! C9 f% w7 e( K0 Gtion site, this testosterone transfer was prevented.: X4 z4 F8 F6 x/ I# [; f! G: p
Our patient’s testosterone level was 60 ng/mL,
5 h* q( y" c* o; Jwhich was clearly high. Some studies suggest that& ?$ G* f' S/ m3 P7 m
dermal conversion of testosterone to dihydrotestos-% ~/ n( ^7 ~% a$ O6 b# S! R
terone, which is a more potent metabolite, is more
1 _) M8 N' J' m) C4 s: gactive in young children exposed to testosterone1 M! [( ?$ R4 N
exogenously7; however, we did not measure a dihy-
/ V: | H+ l6 b4 Edrotestosterone level in our patient. In addition to
5 V5 d* M! |6 i: Zvirilization, exposure to exogenous testosterone in, i3 O* r1 K0 @
children results in an increase in growth velocity and
9 Q, k) ^* q5 A* r3 K$ wadvanced bone age, as seen in our patient.
& H# |9 P/ _" B: sThe long-term effect of androgen exposure during" A: P' b8 V! Z& [% e* U
early childhood on pubertal development and final
3 \6 k v9 o8 N6 d" b |8 qadult height are not fully known and always remain% R7 ^! N' _2 B
a concern. Children treated with short-term testos-: @9 W& ]6 G; R" Y
terone injection or topical androgen may exhibit some$ a1 }+ p C L1 c: ~% j# Q9 {! [0 y
acceleration of the skeletal maturation; however, after1 t# `$ L% T9 q' |/ N R$ z
cessation of treatment, the rate of bone maturation
1 k) W0 u* `& ~1 y! j9 w. m$ C4 Ndecelerates and gradually returns to normal.8,99 e) Q( h0 R- s. j8 S. f1 w
There are conflicting reports and controversy1 y. p6 K+ Q' ?4 z; N
over the effect of early androgen exposure on adult* g$ { e8 O& _
penile length.10,11 Some reports suggest subnormal" U) I# Q2 X& b0 u' k1 z: S
adult penile length, apparently because of downreg-
5 y: S! s# h: q( G X- B sulation of androgen receptor number.10,12 However,
9 {- k; G) W/ v4 x; t4 g' ^Sutherland et al13 did not find a correlation between2 m, W0 ] {# N; s( l
childhood testosterone exposure and reduced adult
0 U+ |5 Z4 m- D2 p% x" I% m& npenile length in clinical studies.1 E( e9 ] u/ A S K
Nonetheless, we do not believe our patient is! g) A: ?( P" v$ u: I! I" q. P
going to experience any of the untoward effects from
w4 q5 V9 Q7 h# ?: d4 D' x% ltestosterone exposure as mentioned earlier because- T/ q) c- F8 |) @8 O
the exposure was not for a prolonged period of time.
}3 t7 G1 M9 a1 s; x/ oAlthough the bone age was advanced at the time of, V% C( m/ p' Y, q
diagnosis, the child had a normal growth velocity at
% @6 a4 S, V. ?0 H9 N& M! uthe follow-up visit. It is hoped that his final adult
' m7 ?, t9 g& h6 t# r# Rheight will not be affected.
* d; f! [% x* B; X7 dAlthough rarely reported, the widespread avail-
7 {" @3 {+ Y* V" [ability of androgen products in our society may3 V; L) n- G+ F3 _+ i+ j: g
indeed cause more virilization in male or female
: k6 V$ v1 M4 [/ M& I. S" T3 Achildren than one would realize. Exposure to andro-
5 Q( c8 a9 {. k6 U& Z z" tgen products must be considered and specific ques-
2 D# t O' v3 n) Y& V5 Etioning about the use of a testosterone product or
0 p4 k, a* F( m) X4 Mgel should be asked of the family members during
5 Y7 G; `* n3 A' |1 H3 kthe evaluation of any children who present with vir-
7 {& ^+ y) K# H7 B- ^: q* vilization or peripheral precocious puberty. The diag-# K9 h' c+ b+ J& q! Z' k
nosis can be established by just a few tests and by
* \/ { ~. X" ^' B/ jappropriate history. The inability to obtain such a
* X3 O$ g1 M# b3 j( M5 phistory, or failure to ask the specific questions, may
- p0 d P1 x+ _; i! p* U! d1 B" K/ p# G4 mresult in extensive, unnecessary, and expensive
8 [% l! Y) W& qinvestigation. The primary care physician should be3 a8 U, B: W1 w" E. y, \/ [
aware of this fact, because most of these children8 W) l+ X- q! ^6 m
may initially present in their practice. The Physicians’
0 N4 h7 h* \* A2 ^6 fDesk Reference and package insert should also put a( |+ v9 t! Q( s* ^
warning about the virilizing effect on a male or4 x0 M1 R% N7 f6 X s6 D
female child who might come in contact with some-% k3 }+ g2 K/ }6 U7 v+ `: {4 E
one using any of these products. h3 a9 u" g+ I/ q
References/ D1 O: S6 z+ Y: W; N3 j4 B" x* J! I4 l
1. Styne DM. The testes: disorder of sexual differentiation
6 r' C. d4 v& s9 z4 Oand puberty in the male. In: Sperling MA, ed. Pediatric4 S& Y F y$ g: ~, E- t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ ]5 O1 `% B' i. T; ]/ c& \2002: 565-628.( U2 v. e6 W% l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- g( Y0 b$ o h+ V7 ^ j2 ~puberty in children with tumours of the suprasellar pineal |
|