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Sexual Precocity in a 16-Month-Old. a# k- u. |& I) Y& M
Boy Induced by Indirect Topical
: L1 w% ~$ [! U- cExposure to Testosterone8 d6 m5 G8 U5 L0 z, K* z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 s' }6 F# {1 T- X7 X5 aand Kenneth R. Rettig, MD1
( M7 V( W3 a5 X) t+ b& ^2 dClinical Pediatrics
. n9 r* v, M1 `Volume 46 Number 6 q9 n( x! C" s
July 2007 540-543
1 Y8 H, B: D* m© 2007 Sage Publications
+ d q- L, c, ?3 k' ]( ?10.1177/0009922806296651
# c! \/ N+ X- S$ ^& `5 ]http://clp.sagepub.com/ d" j J( _6 o# D. m- S. \9 M
hosted at( P' X1 K% A0 f9 \
http://online.sagepub.com
2 T* d) \/ K D* Y5 rPrecocious puberty in boys, central or peripheral,+ Q( m3 ^- H9 b4 L4 d
is a significant concern for physicians. Central
) {- R9 d, i* G/ ]! iprecocious puberty (CPP), which is mediated Q! v+ `1 f2 Q6 o
through the hypothalamic pituitary gonadal axis, has
$ R$ c/ _$ k! }* b) i5 ~6 ~$ Xa higher incidence of organic central nervous system$ U5 z& q/ F6 w
lesions in boys.1,2 Virilization in boys, as manifested
- X3 v+ ~" }% Q, G. ^/ a: u$ Yby enlargement of the penis, development of pubic$ _: m* C/ ^) ~9 J
hair, and facial acne without enlargement of testi-
: _6 f1 A$ j0 f3 ]cles, suggests peripheral or pseudopuberty.1-3 We6 B1 [% n( S2 s
report a 16-month-old boy who presented with the+ p5 i5 v! D. m0 z0 e4 j+ ~$ a1 O) [
enlargement of the phallus and pubic hair develop-2 R6 c# d/ d5 z* ^, T. N' u
ment without testicular enlargement, which was due
5 U2 {( e6 q3 O6 H& o3 q$ i0 Nto the unintentional exposure to androgen gel used by
0 o% q7 S9 H2 f9 K' s' I5 I: g& _8 ^the father. The family initially concealed this infor-6 |$ Z/ `: P9 X/ e" b5 H y% |# x
mation, resulting in an extensive work-up for this# u& |3 ]9 F c% w
child. Given the widespread and easy availability of
5 c* Z5 F' b. Ktestosterone gel and cream, we believe this is proba-8 w C8 i o+ C
bly more common than the rare case report in the {% H5 _ D( D
literature.43 P: ?2 {4 c0 j, b% T1 S
Patient Report
5 X. K) d7 Q, f, j9 D$ xA 16-month-old white child was referred to the0 ?1 p4 O* p5 ]2 v! f! N: G
endocrine clinic by his pediatrician with the concern
6 J6 o# p6 T) Q* {9 G8 n# ]: lof early sexual development. His mother noticed2 X! s. T" q j3 i
light colored pubic hair development when he was1 \8 r8 v6 j* u ~; ^1 J" q
From the 1Division of Pediatric Endocrinology, 2University of
3 m4 Y+ b7 k7 Y# Z- USouth Alabama Medical Center, Mobile, Alabama." \2 ~# [% z3 t- @
Address correspondence to: Samar K. Bhowmick, MD, FACE,
) C0 F* [9 i: U9 b/ UProfessor of Pediatrics, University of South Alabama, College of( w' d) O, a+ i1 _0 N; q0 y: ]
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. F) ]" [" R0 f6 F# s) o
e-mail: [email protected].5 L: d. Q: A9 ^& u6 ~$ r% m
about 6 to 7 months old, which progressively became
" H% q7 z; O- U) ]. I! f4 Ndarker. She was also concerned about the enlarge-
9 l% U" S) q7 B* n. zment of his penis and frequent erections. The child6 M& @( ~/ S4 x+ c' r" a c1 m+ y
was the product of a full-term normal delivery, with
5 C0 D. o* U+ |; ya birth weight of 7 lb 14 oz, and birth length of
# \9 V6 Y3 [" ~2 C! e& g! O& L" d( Q20 inches. He was breast-fed throughout the first year- A8 e3 O* M( J3 T4 a
of life and was still receiving breast milk along with
% P; a" m6 }, Z8 I; msolid food. He had no hospitalizations or surgery,/ p; f2 M7 _1 w. v" R I
and his psychosocial and psychomotor development0 @: {. D+ R- g" x$ {, ], ~4 Y
was age appropriate.
: Y3 \5 } @0 U+ Z3 J7 P. F) }The family history was remarkable for the father,
3 M9 a) e5 V2 t% ?$ r# F# dwho was diagnosed with hypothyroidism at age 16,: K. Z) k, D5 O; K' `$ r+ g
which was treated with thyroxine. The father’s
3 C- `6 }* R' G8 `height was 6 feet, and he went through a somewhat: X9 }4 @2 g' c5 K8 x0 D
early puberty and had stopped growing by age 14.
! m2 ]: V7 {( q; S0 l/ XThe father denied taking any other medication. The
; B. d( H @4 }' kchild’s mother was in good health. Her menarche& N! M& i* Z8 o3 w0 t. W4 u$ \
was at 11 years of age, and her height was at 5 feet4 n4 z+ G% Q$ g1 [
5 inches. There was no other family history of pre-2 ^! R5 Q& B6 o: N+ d# ^
cocious sexual development in the first-degree rela-3 c5 t2 i7 j2 x3 h
tives. There were no siblings.
2 b# \) ?, u" T% o$ q0 vPhysical Examination
* ]. _4 o4 d- Y# h8 OThe physical examination revealed a very active,
8 ]& W6 ?7 i6 o9 q+ T+ w! pplayful, and healthy boy. The vital signs documented B( G% Q+ d0 D4 }0 H+ i0 a
a blood pressure of 85/50 mm Hg, his length was
8 M7 i4 \$ L& i7 O! C+ Y90 cm (>97th percentile), and his weight was 14.4 kg
. T P, M, S6 {( x(also >97th percentile). The observed yearly growth
4 d. z! h, r1 k s' k: \velocity was 30 cm (12 inches). The examination of
# K z4 w0 ]( m1 Vthe neck revealed no thyroid enlargement.3 d3 B. T. y$ Q! V f# t
The genitourinary examination was remarkable for( y# h: i; \& {5 Y& a- h i
enlargement of the penis, with a stretched length of
0 N2 X' G: m- V2 j& E$ c' f8 cm and a width of 2 cm. The glans penis was very well
5 j: s- p$ K" }developed. The pubic hair was Tanner II, mostly around
5 k/ D3 r- T/ @! e2 g# B540
6 z* y7 X& {3 Q6 ?2 W# Q+ [8 Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( y- j" B2 s$ t
the base of the phallus and was dark and curled. The
- b* F8 I/ b1 i7 Ctesticular volume was prepubertal at 2 mL each.: Q3 A1 V+ b* v& @# {+ k% \; k
The skin was moist and smooth and somewhat
5 ^ ]- o: [! E9 { t3 v9 ~" roily. No axillary hair was noted. There were no _; t9 Z5 _# }; q
abnormal skin pigmentations or café-au-lait spots.3 S/ o/ l4 J: u( m/ ]. U
Neurologic evaluation showed deep tendon reflex 2+1 s( z9 v3 W4 c+ X. E' y
bilateral and symmetrical. There was no suggestion, o' e# c8 u* \3 Q# B
of papilledema.
: L: }- ~" m+ ?- }' i- C$ S) X) [Laboratory Evaluation
# M, V; A3 G3 A( J Y* rThe bone age was consistent with 28 months by
: V6 k$ I/ v! F3 ]using the standard of Greulich and Pyle at a chrono-( `% z& }$ E! j6 u5 N7 v% w
logic age of 16 months (advanced).5 Chromosomal
1 n8 Q1 h! ~6 b1 u& O7 Ykaryotype was 46XY. The thyroid function test z: {" l2 b; n* v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
& [$ A; |* y# m: @0 c! Y F7 xlating hormone level was 1.3 µIU/mL (both normal).
% ^. Y% G* S8 W. m7 r' aThe concentrations of serum electrolytes, blood
$ s) C- g2 _7 G8 w" D( Vurea nitrogen, creatinine, and calcium all were
6 }, s9 Z0 v; ?1 D- ewithin normal range for his age. The concentration
3 N8 c. F4 \7 L9 i3 v/ k( H' @of serum 17-hydroxyprogesterone was 16 ng/dL
# `( ~ c5 h( Y% t& \1 b(normal, 3 to 90 ng/dL), androstenedione was 20
1 m, m( b7 ?- o! h3 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 G# m _( W. B* g! Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: n$ q. b) ~) |desoxycorticosterone was 4.3 ng/dL (normal, 7 to; [3 Q/ Z; k. E) s6 n; \: X; o
49ng/dL), 11-desoxycortisol (specific compound S) L4 y9 t2 l7 d. i9 P! b/ l, }. d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- M1 e2 i5 ]% G$ o4 H5 M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& k$ G+ C, r4 T8 Z) {/ L& _" Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ N+ t6 N7 H' w( {
and β-human chorionic gonadotropin was less than7 n/ F, l2 g" @6 ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 F) Z( m/ J" ?" ~. t( [1 G
stimulating hormone and leuteinizing hormone+ q- p' \1 t8 o# J. c/ ^) L' N
concentrations were less than 0.05 mIU/mL4 d. P3 o3 v& Z0 ?- E
(prepubertal). N1 j, v. x- b9 |
The parents were notified about the laboratory
0 q+ j/ u6 }$ }6 H. t' Nresults and were informed that all of the tests were! H8 z4 N" R, Q% B
normal except the testosterone level was high. The
+ Q9 L8 I+ c: k: `3 V4 P7 p h% Mfollow-up visit was arranged within a few weeks to8 M& z9 b4 ?5 R: _ j$ J
obtain testicular and abdominal sonograms; how-0 k5 t5 P1 B0 D; `. R) K7 H
ever, the family did not return for 4 months.
( S& H* w- Y) Q0 SPhysical examination at this time revealed that the: N; C g; U6 X N% Q+ ~- Z$ u( D
child had grown 2.5 cm in 4 months and had gained' I7 b- Z3 E1 k0 m9 c
2 kg of weight. Physical examination remained. h( n, m! S7 r- {5 {: u! X
unchanged. Surprisingly, the pubic hair almost com- f) d! n: D% [& \
pletely disappeared except for a few vellous hairs at
6 j5 q: P) C- m. b/ f7 tthe base of the phallus. Testicular volume was still 2
$ V( A( }1 ?. e" B; ^mL, and the size of the penis remained unchanged.
2 A, R& o8 M9 b& ~4 kThe mother also said that the boy was no longer hav-
2 I' e) ?5 N1 _: Q& {9 A3 C* Y5 J3 n, ying frequent erections.
$ S# @# `5 d* g& \Both parents were again questioned about use of* F7 n3 m& D0 ?4 ]& B
any ointment/creams that they may have applied to
) F5 i( c8 @. R) T) h) P% Wthe child’s skin. This time the father admitted the$ F% l# _, Z2 N5 T- b8 _
Topical Testosterone Exposure / Bhowmick et al 541: i y- F( p2 Z
use of testosterone gel twice daily that he was apply-& W2 K: B4 C# U
ing over his own shoulders, chest, and back area for
& R5 q2 U6 m+ Sa year. The father also revealed he was embarrassed
; B2 I# N. Q- h4 t; H1 i% bto disclose that he was using a testosterone gel pre-
+ n O/ _$ I f$ r( Pscribed by his family physician for decreased libido
3 D: O+ U6 l* ^' e9 F* j @* C! Hsecondary to depression. z) ?* d' i& Z: _" U
The child slept in the same bed with parents.
; f0 W5 D- R, ^: `: u, k5 fThe father would hug the baby and hold him on his
; }# X4 D8 j: }/ H% T2 D- Nchest for a considerable period of time, causing sig-1 P0 o# Q% m6 h1 ? U
nificant bare skin contact between baby and father.8 e# S7 u- I# Z+ i5 r" U: P
The father also admitted that after the phone call,* q" f4 r, [; Q& ?; q
when he learned the testosterone level in the baby
% B5 F i% g3 V, {3 d: D, C, `was high, he then read the product information! u. e, Z8 d9 K' \8 f
packet and concluded that it was most likely the rea-
5 o" F! I8 j* R$ q K3 Ison for the child’s virilization. At that time, they
1 b; ?2 M" U9 l7 T. o, c( Z$ pdecided to put the baby in a separate bed, and the
/ h6 ^6 {0 b# t& v! C# Lfather was not hugging him with bare skin and had+ o; k; z& W3 r# T+ B
been using protective clothing. A repeat testosterone
% @0 E' e2 z0 f' `test was ordered, but the family did not go to the
" z$ A5 E; q: R' Wlaboratory to obtain the test.
& p6 W7 y) c8 f9 g2 w* oDiscussion
% m" z- a, o6 Y0 W' xPrecocious puberty in boys is defined as secondary9 F/ m* }" L- L8 y: \# X
sexual development before 9 years of age.1,4/ r. u4 N# t J4 a& P7 ] {
Precocious puberty is termed as central (true) when _& T2 o7 f0 h9 U' k/ t- B" k* j
it is caused by the premature activation of hypo-; u' a. B0 f& Z9 `& N
thalamic pituitary gonadal axis. CPP is more com-- y5 n9 y6 H% R0 r1 }: f! [: t$ c
mon in girls than in boys.1,3 Most boys with CPP; s# u6 i0 N& B2 Q
may have a central nervous system lesion that is+ P$ t$ X- J4 r! C3 K3 ]
responsible for the early activation of the hypothal-
4 m% j) b" ?- C, |, Q: j0 jamic pituitary gonadal axis.1-3 Thus, greater empha-' M; w4 t* E: q3 F
sis has been given to neuroradiologic imaging in% V" R# x% i1 y1 s. ]% [
boys with precocious puberty. In addition to viril-1 m! |( C) i9 n% H% g/ H/ f" `
ization, the clinical hallmark of CPP is the symmet-
! i' C' V8 z% {! U( mrical testicular growth secondary to stimulation by, t, ^* O6 A1 E* r+ E
gonadotropins.1,36 |' A( C% g( C w: B' C; g7 t. T
Gonadotropin-independent peripheral preco-0 _4 `" i0 K& N
cious puberty in boys also results from inappropriate1 m- C+ v9 M, o4 Q
androgenic stimulation from either endogenous or
1 l' c( @- v, c! Dexogenous sources, nonpituitary gonadotropin stim-# y5 W! {/ `9 Z
ulation, and rare activating mutations.3 Virilizing9 Z9 ]3 U, w: ]( m" d
congenital adrenal hyperplasia producing excessive
+ s: n0 R! s) L0 N9 uadrenal androgens is a common cause of precocious
! h8 _) o" N3 u) m. c3 Rpuberty in boys.3,4# X! \3 E3 ?4 p3 D. \
The most common form of congenital adrenal* d3 v7 _! h& \7 n! g
hyperplasia is the 21-hydroxylase enzyme deficiency.4 `% I+ z# @- ^% Z3 Y9 s- Z
The 11-β hydroxylase deficiency may also result in( K4 K% O! G5 P
excessive adrenal androgen production, and rarely,
3 |. \$ L/ c3 _% c% Fan adrenal tumor may also cause adrenal androgen
7 b: K7 ]7 `0 r8 N8 {excess.1,35 s: j6 J9 V7 l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. L+ X9 w: x6 e1 O542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 o# U2 _$ e, h u) M$ u: U
A unique entity of male-limited gonadotropin-
+ q% A. J- y; Q) C& c( sindependent precocious puberty, which is also known
! U$ x0 c0 Y3 O8 yas testotoxicosis, may cause precocious puberty at a
! W" u' r# c$ H3 pvery young age. The physical findings in these boys
5 E( w- M3 v$ k& pwith this disorder are full pubertal development,
5 l: J: Q K" W% Aincluding bilateral testicular growth, similar to boys
, C" _( x: _$ u7 a7 u9 ^! Hwith CPP. The gonadotropin levels in this disorder
: Z& |4 w6 b5 _ B; U9 }0 q. D7 {. iare suppressed to prepubertal levels and do not show
2 u/ _9 s* x3 I; dpubertal response of gonadotropin after gonadotropin-
C! G# p1 h( K3 n9 C3 Ireleasing hormone stimulation. This is a sex-linked
5 ?6 }: \2 c, g/ {1 m; W. ^autosomal dominant disorder that affects only1 C4 Q% N( k: k5 Z8 q W$ X
males; therefore, other male members of the family: J" S/ z6 a5 D- w
may have similar precocious puberty.3
+ z4 S7 }, L! X; `6 ZIn our patient, physical examination was incon-
1 N6 O/ b K. C" N/ Tsistent with true precocious puberty since his testi-, g. J: x1 s8 M2 z7 I1 M/ I: |
cles were prepubertal in size. However, testotoxicosis1 |$ i% {* B4 C. o% w& @: c, U
was in the differential diagnosis because his father% P+ [' k# l, X. X: s
started puberty somewhat early, and occasionally,2 Q2 c3 F; G; D3 \! Z" F1 p& ?5 s9 r. `
testicular enlargement is not that evident in the
, S6 x4 G8 t+ K$ ]" x% ^' sbeginning of this process.1 In the absence of a neg-! o" y' F6 Y. R$ Z$ n
ative initial history of androgen exposure, our; T( y( i$ P% Z: h( X4 K
biggest concern was virilizing adrenal hyperplasia,/ l) a6 N- a; n6 B
either 21-hydroxylase deficiency or 11-β hydroxylase
) ~9 V! \8 M, @( K4 T5 w6 Edeficiency. Those diagnoses were excluded by find-% w2 n$ |3 I! B7 v5 w7 U+ L
ing the normal level of adrenal steroids.5 L4 e" d$ R' Z' w- _
The diagnosis of exogenous androgens was strongly3 K2 ^! O$ D7 Z5 ~( t
suspected in a follow-up visit after 4 months because
( o1 f' g5 k$ C2 y3 @$ R3 rthe physical examination revealed the complete disap- k8 a" a7 ?" c& x; j$ f0 u
pearance of pubic hair, normal growth velocity, and
% V# O: T9 I! n v" mdecreased erections. The father admitted using a testos-
; n) V0 b: l; L5 H* [" Mterone gel, which he concealed at first visit. He was
. x: m$ C9 O+ }% u9 i9 T" z* Musing it rather frequently, twice a day. The Physicians’
6 {" b, a; U, K& T7 h0 YDesk Reference, or package insert of this product, gel or: J2 Y2 h0 X. k4 I7 c
cream, cautions about dermal testosterone transfer to! Z, V( T0 w6 l# o( L5 p
unprotected females through direct skin exposure.
# ^7 q. f i, p) g5 L3 Q- n( F7 aSerum testosterone level was found to be 2 times the" K) F- F s% Q; A1 X* J
baseline value in those females who were exposed to
7 R, y' T2 c8 A6 M9 B5 Q) Heven 15 minutes of direct skin contact with their male0 B; ]! D; N4 `* i" ^. R
partners.6 However, when a shirt covered the applica-
: m( _* O# g. z+ J. a2 o! ttion site, this testosterone transfer was prevented.+ G3 E! ^' F+ |. l1 a4 H
Our patient’s testosterone level was 60 ng/mL,
4 d" {* G9 F! J0 T' A/ kwhich was clearly high. Some studies suggest that$ f9 g. z. Z$ O9 L
dermal conversion of testosterone to dihydrotestos-$ J4 I4 J$ S. l% m+ v4 E6 Z: Z
terone, which is a more potent metabolite, is more9 d" t W( X0 J0 { F, |
active in young children exposed to testosterone
2 M9 m; A$ k' H1 M. W5 }. z9 d; jexogenously7; however, we did not measure a dihy-# O' k4 g. F$ W8 o4 H. h
drotestosterone level in our patient. In addition to8 c/ F$ V3 Z$ T M a
virilization, exposure to exogenous testosterone in
7 J4 i( F1 E+ ]# e bchildren results in an increase in growth velocity and3 P: \7 c% I% t' L; v# V+ r
advanced bone age, as seen in our patient.; A) C% P/ \- ~
The long-term effect of androgen exposure during
# K. \- {& b" r2 K# O |early childhood on pubertal development and final
8 y; b1 f7 \& E. wadult height are not fully known and always remain% j- ^# Y! P# I# i, O; Z
a concern. Children treated with short-term testos-
1 t, J5 o, o! @7 t; t- t% j2 ~( Aterone injection or topical androgen may exhibit some
) b* R5 E" X! Y: m+ n |acceleration of the skeletal maturation; however, after" J- V# X+ o2 L: N' r1 j' I
cessation of treatment, the rate of bone maturation
- H7 O' i( c" b% {& h4 H' idecelerates and gradually returns to normal.8,9+ w4 q. ?6 a- R
There are conflicting reports and controversy
* J: K# N8 [. g8 Q# d, z2 Mover the effect of early androgen exposure on adult
/ ~7 x* u2 b& q& Lpenile length.10,11 Some reports suggest subnormal8 I, g: F* c8 F) j/ O6 `
adult penile length, apparently because of downreg-
# I# K; b! y( M1 M- i" E9 b* vulation of androgen receptor number.10,12 However,) q: p( A7 W; ?0 t. X7 R4 r, _
Sutherland et al13 did not find a correlation between
8 m' x* r+ m/ s4 a2 p$ g5 J( q+ H5 Qchildhood testosterone exposure and reduced adult( ~/ \) o6 a/ F. C* i8 t9 ?: x
penile length in clinical studies.
: [8 a0 E7 r- a( r/ rNonetheless, we do not believe our patient is4 ~, O: s( S( H3 d: M4 q0 D) E( @
going to experience any of the untoward effects from% H* K) V/ v {% T" n
testosterone exposure as mentioned earlier because
/ D/ {* e9 X; k6 othe exposure was not for a prolonged period of time.# K. M1 d7 j) Q0 `: x$ P7 K
Although the bone age was advanced at the time of
% D$ U5 {; w5 ?% L6 ?* \6 Vdiagnosis, the child had a normal growth velocity at, g5 Q3 S# U; s: G% P
the follow-up visit. It is hoped that his final adult
2 j# Z2 p* r9 o+ m( Cheight will not be affected.! [$ I- a2 r" u+ @' G9 N% s4 i. j) ?
Although rarely reported, the widespread avail-
/ k4 n! t* V3 ^7 b7 iability of androgen products in our society may
* u. W3 D8 v* d/ o' V5 B mindeed cause more virilization in male or female
7 ~# |. E' |9 Gchildren than one would realize. Exposure to andro-7 s: j! ?+ R1 `) }6 t; @
gen products must be considered and specific ques-# |3 {8 ]5 H2 B- J+ p
tioning about the use of a testosterone product or
3 |/ J' m4 w9 l% U3 i6 f7 d. s4 E* e2 ?gel should be asked of the family members during2 h& s% H h. v. h2 E3 \" S- I* A! f
the evaluation of any children who present with vir-0 n, m; V! F" J# U! u
ilization or peripheral precocious puberty. The diag-" j* v+ u! `2 |6 G5 l
nosis can be established by just a few tests and by
3 d Y9 ]/ X+ ?! E2 Y% C: Xappropriate history. The inability to obtain such a( r: o: w" r/ u5 q( a) I
history, or failure to ask the specific questions, may) c1 z, w: W, l
result in extensive, unnecessary, and expensive3 P# c3 `- X6 C- T
investigation. The primary care physician should be4 I! D H4 ^! f/ q. \
aware of this fact, because most of these children
( R7 V: R! |9 H( Z1 P) l9 X$ Rmay initially present in their practice. The Physicians’. ?9 {% {+ b' Z- ?- ]; J
Desk Reference and package insert should also put a
3 C8 j% n/ w2 A- q5 N2 Nwarning about the virilizing effect on a male or
3 V* ~0 r0 Y& X( i. g2 Lfemale child who might come in contact with some-
" \+ F/ y% y( {3 z+ w7 Wone using any of these products.
. L9 a! Y( Q- C& S: p0 l7 i. oReferences4 t, A/ f0 Y, \. [4 q" B. D, D# w& z
1. Styne DM. The testes: disorder of sexual differentiation
# n# I. c: f# u6 @0 y9 n6 o+ z! _; kand puberty in the male. In: Sperling MA, ed. Pediatric, s& E9 o9 C9 B7 W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ a# c9 e8 P& _9 z, N2002: 565-628.# T8 [2 _* c7 T8 y1 ]" _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 w# p3 H& t2 J+ ]4 G
puberty in children with tumours of the suprasellar pineal |
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