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Sexual Precocity in a 16-Month-Old5 u% P( n/ T: U. W! \( O' M1 A9 d7 L
Boy Induced by Indirect Topical
! c5 ^4 v, d( T6 d4 KExposure to Testosterone% e0 s9 u, x/ L6 \5 D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& l: v6 u/ i5 z$ s9 D( Q: wand Kenneth R. Rettig, MD1- E. P- \+ ]% t1 S' ?/ i
Clinical Pediatrics
. f' ~+ R; M' ^) r! HVolume 46 Number 6
7 y# I5 M% |: z" B- ZJuly 2007 540-543
& I4 P% k3 ^; _4 b$ T. Y8 `2 e7 y© 2007 Sage Publications6 S0 S# ~# f. h2 ?. i+ y3 v1 k3 W
10.1177/0009922806296651
6 S P, u# ~% b- Ihttp://clp.sagepub.com
( T. R9 Q2 f1 A/ m, Chosted at# k2 F y: P) E/ e& T' k. T. z
http://online.sagepub.com
/ c U# @* E8 e$ xPrecocious puberty in boys, central or peripheral,
, \# A2 v/ J) Lis a significant concern for physicians. Central
$ @! C- _/ w: c: ^9 d) E4 G+ Jprecocious puberty (CPP), which is mediated& j% E( ^/ ~# }4 p9 O6 G, E9 q
through the hypothalamic pituitary gonadal axis, has8 _. `" S6 @9 K
a higher incidence of organic central nervous system
" z. }8 b# I2 ?6 O" jlesions in boys.1,2 Virilization in boys, as manifested
. E5 R' Y2 k O; k4 h Gby enlargement of the penis, development of pubic
, k; l3 }7 l8 ~hair, and facial acne without enlargement of testi-4 ?1 b) K& q4 N, d
cles, suggests peripheral or pseudopuberty.1-3 We* f4 M8 P- _( ]1 f
report a 16-month-old boy who presented with the
% B- ^4 Q6 P+ O4 `enlargement of the phallus and pubic hair develop-
" o, a, d7 w2 |! X7 q0 e& l3 }ment without testicular enlargement, which was due( k' S9 U, y2 Z+ ]& d
to the unintentional exposure to androgen gel used by" z9 ]' P- `: f+ L) x: D% R. L" s9 [
the father. The family initially concealed this infor-; z$ [9 E& Y3 F* T6 d& k' m. [! e
mation, resulting in an extensive work-up for this
$ ]. Q7 m9 ]* r/ q7 ]child. Given the widespread and easy availability of9 v2 `( Z* K# u
testosterone gel and cream, we believe this is proba-
) n. W$ r' W; K; l- r. ^# pbly more common than the rare case report in the
y8 L, b/ m% a2 l7 W- L3 L% `3 u% Qliterature.4
: ~. T) ?( X3 L3 O- nPatient Report7 p1 L( g, I9 E0 U6 M% u+ Y
A 16-month-old white child was referred to the# g% G' `: L ^7 R3 M0 z+ F
endocrine clinic by his pediatrician with the concern- y, m0 a2 D% N
of early sexual development. His mother noticed
9 K0 S7 H( k" O4 Ylight colored pubic hair development when he was
. V; F& x; e, T7 a% n, XFrom the 1Division of Pediatric Endocrinology, 2University of/ Z' w, e$ T- w" k
South Alabama Medical Center, Mobile, Alabama.
% D+ Q/ L% }2 ]; ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 m: ?7 V1 _$ X! @Professor of Pediatrics, University of South Alabama, College of# M$ r+ f* b4 Y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& G. l6 l; K% Q
e-mail: [email protected].
) ^3 I' g+ `. G/ r, uabout 6 to 7 months old, which progressively became, ]; W0 M/ m) ? I0 }+ G2 a; X
darker. She was also concerned about the enlarge-
} ]8 E1 f& ~+ @0 cment of his penis and frequent erections. The child
9 N) v$ z4 B# v3 L3 Qwas the product of a full-term normal delivery, with: @# `1 D; j: |1 V
a birth weight of 7 lb 14 oz, and birth length of
) ~+ \" z( Z' b20 inches. He was breast-fed throughout the first year
6 ?( P0 @7 k1 s- ?of life and was still receiving breast milk along with
5 Q j, h# J, V5 m S: Bsolid food. He had no hospitalizations or surgery,0 L1 S4 g! b6 i* P$ l
and his psychosocial and psychomotor development
+ P8 ?: Y4 ]0 e2 L' _: S) Xwas age appropriate.
3 j1 h; E* ~; u% y. l2 ^The family history was remarkable for the father,
- z h; K0 B- y5 I- E; I! x4 pwho was diagnosed with hypothyroidism at age 16,
% k1 y+ M' F/ a9 t; V: ewhich was treated with thyroxine. The father’s
1 [. C; a% O6 g& h5 uheight was 6 feet, and he went through a somewhat
+ U B' l2 }8 {& M: I9 ]7 vearly puberty and had stopped growing by age 14.
5 p! z( h2 E3 {( z2 e7 gThe father denied taking any other medication. The- r+ B9 x4 W9 ]% J# ]! C5 m
child’s mother was in good health. Her menarche' ^" [, b7 V! v
was at 11 years of age, and her height was at 5 feet
9 T5 H z( z# k. a V5 inches. There was no other family history of pre-
2 d5 X+ V) j6 Y# D$ b. P& w8 ycocious sexual development in the first-degree rela-$ D: C' o+ `3 X, \: u
tives. There were no siblings.
( l3 U3 u/ @1 a. g) J! Y# {8 T( EPhysical Examination
; \% d3 Z* _3 A8 W% [The physical examination revealed a very active," j, k' I5 q- K+ u: d
playful, and healthy boy. The vital signs documented! S0 {( ^7 E0 ~/ K! M: E8 l6 \
a blood pressure of 85/50 mm Hg, his length was, X4 c1 C# h5 W9 Z0 P8 S
90 cm (>97th percentile), and his weight was 14.4 kg+ D' N, o6 q5 I$ o
(also >97th percentile). The observed yearly growth r6 T9 b$ \/ o/ z% t3 ~2 { _
velocity was 30 cm (12 inches). The examination of$ q/ ]& _' N! k2 g8 {" D9 N
the neck revealed no thyroid enlargement.7 t: o! F6 U" X% j: u$ e
The genitourinary examination was remarkable for
. C. x. v- ?+ G* n; ^9 xenlargement of the penis, with a stretched length of$ t8 `2 l1 j& o- S
8 cm and a width of 2 cm. The glans penis was very well
3 y' \# K, p3 h- z, \, Wdeveloped. The pubic hair was Tanner II, mostly around1 M% i2 x/ N( x$ P6 D# P4 i
540# R; D! | X7 Q S/ E" l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' I- e: O5 u. y9 S& ^% p
the base of the phallus and was dark and curled. The( \ h8 q; N$ d
testicular volume was prepubertal at 2 mL each.* A$ d8 p0 a/ [# s" Z
The skin was moist and smooth and somewhat9 U# D0 B2 I5 W& }4 h# C6 m2 }7 ]
oily. No axillary hair was noted. There were no
; |* D( O( d! X2 a) s+ gabnormal skin pigmentations or café-au-lait spots.- B8 a8 P" q$ h# q7 y( k" N5 a& ^
Neurologic evaluation showed deep tendon reflex 2+( ^5 j: ~+ ?9 b6 ~) a- c! H) R
bilateral and symmetrical. There was no suggestion E0 N+ f! Q) A8 E; b! D
of papilledema.9 C8 j. \" h$ U9 f# Q& F
Laboratory Evaluation
; O& W( H4 x# [8 D' ~The bone age was consistent with 28 months by
! j5 t7 d! z" O" c5 Yusing the standard of Greulich and Pyle at a chrono-
4 k# z8 O A/ ^+ z" Vlogic age of 16 months (advanced).5 Chromosomal: D; ? P/ |. \% B0 w
karyotype was 46XY. The thyroid function test! f- g* I7 F% H6 u R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 c, {, q/ D3 H5 {0 {+ ^
lating hormone level was 1.3 µIU/mL (both normal).
% r6 w" G# I- r P7 I; SThe concentrations of serum electrolytes, blood. z( X; b" b5 |+ k' R8 v
urea nitrogen, creatinine, and calcium all were# U G& L( n4 ]" ]( x
within normal range for his age. The concentration
% p! `) u" A. J$ c# `7 Q0 Tof serum 17-hydroxyprogesterone was 16 ng/dL
( B$ V7 E$ d5 b7 J. C0 g(normal, 3 to 90 ng/dL), androstenedione was 207 C: A/ W& X* N9 c0 V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% A: H% w5 I3 C% O* J/ J9 K5 _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. M4 }$ W- w5 `9 n6 D. i6 H Kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; x. h4 h/ \% ]/ E# L49ng/dL), 11-desoxycortisol (specific compound S)
- I0 G2 J5 Z. e' b: gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ R7 r7 C# U7 o+ s' a6 q! h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 L8 Y, U; N6 k* h5 V- b' t+ [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# d7 [1 B5 d. b+ A ~+ g% _- fand β-human chorionic gonadotropin was less than- y& M" J+ O1 j* H% }+ B
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" i8 {/ N; \; _" ]+ sstimulating hormone and leuteinizing hormone/ V3 E+ F& a f2 Q$ ]: |& y( B' E
concentrations were less than 0.05 mIU/mL" o6 \* r1 }& p" S
(prepubertal).
) }& F6 p) U1 T8 a3 pThe parents were notified about the laboratory2 W) d4 J7 p% F2 b- ]( h
results and were informed that all of the tests were* o. t9 A' ]/ I! b
normal except the testosterone level was high. The
" D! D' Y6 o# N% P4 `1 gfollow-up visit was arranged within a few weeks to- z# u. ?7 N; Y' R& E
obtain testicular and abdominal sonograms; how-$ M; c: ~( f/ x2 b& ^4 R" I: z/ {
ever, the family did not return for 4 months.& g: q6 e5 _2 B, d# P' C# e0 V
Physical examination at this time revealed that the+ Q- `; c- v2 R O. O& Q
child had grown 2.5 cm in 4 months and had gained& x' ~* L2 Q: k1 V7 o/ l
2 kg of weight. Physical examination remained
2 ?/ N3 z$ K5 l* [unchanged. Surprisingly, the pubic hair almost com-
6 I$ C8 T5 h5 cpletely disappeared except for a few vellous hairs at5 ?7 l7 x0 R% X" D. ~9 i3 a5 Z$ v
the base of the phallus. Testicular volume was still 21 Z0 }! `: E, L4 R* N- J! Y
mL, and the size of the penis remained unchanged." l e) g I4 ], |
The mother also said that the boy was no longer hav-- p) [ ]% {% V+ P2 \" N* Z
ing frequent erections.
7 f1 b, E; m- F) o) g9 W. |& zBoth parents were again questioned about use of3 X4 _( X; Z1 D3 @; X* [
any ointment/creams that they may have applied to" g' z- c0 `6 [/ }' x* K. d
the child’s skin. This time the father admitted the
, M5 X: M- f0 n; iTopical Testosterone Exposure / Bhowmick et al 541
8 M7 Z/ H3 N8 J! w" ]3 ~use of testosterone gel twice daily that he was apply-! @ l. |; a# M) K }8 z' B
ing over his own shoulders, chest, and back area for
3 _! A. U! r2 O4 N0 |a year. The father also revealed he was embarrassed# n- b$ p2 \ i3 q6 k; W' |7 U
to disclose that he was using a testosterone gel pre-2 u& K M* P: g* Z% y9 j) \+ A
scribed by his family physician for decreased libido
e, H3 X' f' hsecondary to depression.# Q. t2 {1 d$ x1 Z
The child slept in the same bed with parents.
7 ]( y! ~& w0 ]5 @2 E1 N) cThe father would hug the baby and hold him on his
1 H& j) p+ S, ochest for a considerable period of time, causing sig-
( D" z0 @! A& a1 |2 a1 Y: h8 v+ |& P5 Vnificant bare skin contact between baby and father.( P( J L+ }, m% N- g; x5 L
The father also admitted that after the phone call,+ G/ e3 p) E6 c4 ^9 c/ g# _% ~5 H
when he learned the testosterone level in the baby
' K9 t6 b+ k$ D8 rwas high, he then read the product information
% R' z# x" _( \( V _4 n! Apacket and concluded that it was most likely the rea-. H" p k/ R5 @3 b8 C: N$ M2 k
son for the child’s virilization. At that time, they
0 A; E7 U7 E& }decided to put the baby in a separate bed, and the6 v8 V, s& _% ~9 @+ y
father was not hugging him with bare skin and had* @, V- n( r8 ^% f% O7 W4 @
been using protective clothing. A repeat testosterone* Z n/ f! Q0 R5 g; l2 `; B! O+ s
test was ordered, but the family did not go to the
! p: d" B! U5 Elaboratory to obtain the test.# P/ w5 e0 f5 L) [0 i
Discussion3 H$ c% Z$ h3 R# A7 I
Precocious puberty in boys is defined as secondary
* M( ?3 J, c4 x1 _; Zsexual development before 9 years of age.1,4
N) o; X. D5 x) @+ c, [Precocious puberty is termed as central (true) when
* q1 ]+ W. t' F4 }it is caused by the premature activation of hypo-
. I7 G; \. V6 @6 zthalamic pituitary gonadal axis. CPP is more com-
( P3 l1 s1 o2 ^3 G8 ?; p/ omon in girls than in boys.1,3 Most boys with CPP! g; w" N! F- z, |) f( F
may have a central nervous system lesion that is
2 g: Y- r* `7 ^3 o* m+ U2 oresponsible for the early activation of the hypothal-
1 n/ G3 C+ F3 L3 s/ q4 bamic pituitary gonadal axis.1-3 Thus, greater empha-
% e/ d. ]# P/ t- h6 N0 _7 ?sis has been given to neuroradiologic imaging in
4 u/ v! f8 B. Jboys with precocious puberty. In addition to viril-
) w; q6 n3 c: e( Xization, the clinical hallmark of CPP is the symmet-
& }# \5 Z1 o% P0 e4 D% Q- r, Vrical testicular growth secondary to stimulation by
' L9 X1 v# @- P3 Zgonadotropins.1,32 G2 l6 \: E$ B: O2 D$ S+ D
Gonadotropin-independent peripheral preco-
- q7 g; x1 a" m) q0 H2 p7 J: e. h( Mcious puberty in boys also results from inappropriate
0 j) g& Y; X, b3 M' `& @androgenic stimulation from either endogenous or
; F3 p# o+ i5 q' j; W D" Cexogenous sources, nonpituitary gonadotropin stim-
& J- r, S4 w- A) @8 h; @9 A1 [7 Y& Mulation, and rare activating mutations.3 Virilizing
, c; {* {$ X; n- p7 U1 k& pcongenital adrenal hyperplasia producing excessive
% i. b8 @' ?/ l; r! i {adrenal androgens is a common cause of precocious( u% ?; ?: L# t, m& g/ j: P5 e
puberty in boys.3,4/ ~# y" c# u" o8 b9 F+ O$ ?/ g7 a
The most common form of congenital adrenal0 f+ y* H7 V( u; B: Z
hyperplasia is the 21-hydroxylase enzyme deficiency.0 N% P+ ]8 P2 C! _- O/ q! `3 `
The 11-β hydroxylase deficiency may also result in
3 k3 q/ y# K( F# |2 Dexcessive adrenal androgen production, and rarely,
/ a" [( ^1 F1 w& K) }" y5 lan adrenal tumor may also cause adrenal androgen
+ F8 U/ e$ ]! |6 s0 e. U, ~excess.1,3
/ W# C5 V3 e5 [3 y; W6 Q$ @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% f$ W B; |7 o5 E5 u542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. k9 V, E( n. b! c8 L9 ]6 }A unique entity of male-limited gonadotropin-: l% `9 [7 E5 [, e I6 o6 T
independent precocious puberty, which is also known
8 V* n9 w# i7 X7 r6 B% M" y* Yas testotoxicosis, may cause precocious puberty at a* \" A, F* A# C& Z8 {
very young age. The physical findings in these boys
2 X, x6 }& g$ Z9 U# ]with this disorder are full pubertal development,
7 o, V ^5 s& y6 x X9 |including bilateral testicular growth, similar to boys
5 t& E- L7 S2 i1 ^* Bwith CPP. The gonadotropin levels in this disorder d: Q2 x9 [! E6 X
are suppressed to prepubertal levels and do not show
, T$ P8 y V5 y% `2 dpubertal response of gonadotropin after gonadotropin-
& ]7 g# b# _( Areleasing hormone stimulation. This is a sex-linked
' l* h. `+ u {# t1 I5 w; sautosomal dominant disorder that affects only
5 h' f2 ~. d3 {& r. R: y6 omales; therefore, other male members of the family
- ?& V+ S- i W7 t* H1 R6 b# H! Lmay have similar precocious puberty.35 w# b" B( R: o! u
In our patient, physical examination was incon-6 I5 F' W( {8 D# Q/ e6 D
sistent with true precocious puberty since his testi-
, c; @ A. L: u( U& a' B# V/ s# @- xcles were prepubertal in size. However, testotoxicosis
% D5 N8 o: [6 |) v) H/ b7 p cwas in the differential diagnosis because his father
$ }! Q1 F5 p/ T0 s8 P! S% Pstarted puberty somewhat early, and occasionally,
6 |7 Z- P/ {5 Z$ I: d0 _testicular enlargement is not that evident in the
; ~0 M# O! C- A q0 v$ nbeginning of this process.1 In the absence of a neg-
$ C# b, [6 N8 L% l3 @9 Hative initial history of androgen exposure, our
: F, c0 `' ?% P! obiggest concern was virilizing adrenal hyperplasia,
! i6 Z+ ~: t7 \either 21-hydroxylase deficiency or 11-β hydroxylase C+ T4 m9 k {, j/ i4 @1 \/ Q1 h j
deficiency. Those diagnoses were excluded by find-; Y! r. G8 A* O7 w8 V& c
ing the normal level of adrenal steroids.
) Q$ R) o; U. G- m( w) ^, }The diagnosis of exogenous androgens was strongly
9 a: e- }8 s: g; x( xsuspected in a follow-up visit after 4 months because
( J1 P5 c( q; N8 I1 nthe physical examination revealed the complete disap-6 c; | |& e7 q+ K6 z+ b
pearance of pubic hair, normal growth velocity, and, u [9 Y7 U6 [! Y8 a, ]
decreased erections. The father admitted using a testos-
! i6 c I5 k" ^% h% ]0 m7 [terone gel, which he concealed at first visit. He was$ }: Q$ E" u2 j/ `( A" }
using it rather frequently, twice a day. The Physicians’
% i% |$ v# e( NDesk Reference, or package insert of this product, gel or* l/ o7 @5 Q& H$ F
cream, cautions about dermal testosterone transfer to
/ [4 `& Z$ R2 R3 ?& o+ O: @0 ~; b2 D' iunprotected females through direct skin exposure.
' ]( o0 q4 a) ~4 VSerum testosterone level was found to be 2 times the
. V$ l' o$ a% w) I2 Z6 R9 ybaseline value in those females who were exposed to2 r" H/ ?. v! V8 a8 G# b/ S
even 15 minutes of direct skin contact with their male, i/ k: u; K0 n1 R# ~/ M/ O
partners.6 However, when a shirt covered the applica- v1 `; o9 i. A1 B8 m
tion site, this testosterone transfer was prevented.
3 I3 n7 {6 l E- r# ?Our patient’s testosterone level was 60 ng/mL,
. b* W% ?$ B9 q) K) r' ]which was clearly high. Some studies suggest that) ~3 J* v" ?+ s
dermal conversion of testosterone to dihydrotestos-
( i* A Y' f1 Y, pterone, which is a more potent metabolite, is more5 l1 R7 M8 Z. }( O6 I
active in young children exposed to testosterone2 a/ u _, d" u! j
exogenously7; however, we did not measure a dihy-( K" @& ^7 F3 `! r. j
drotestosterone level in our patient. In addition to5 }* b8 X0 F6 w: j4 i& T1 C" ^
virilization, exposure to exogenous testosterone in
$ {* K+ U* @4 xchildren results in an increase in growth velocity and3 w7 Y! ^% z: J% N9 r1 I
advanced bone age, as seen in our patient. @2 U# e! v0 X
The long-term effect of androgen exposure during" q9 c% i; x$ \' o9 K0 a
early childhood on pubertal development and final
: y W, v, N& b, {* w% _: Zadult height are not fully known and always remain
" R' V$ Y+ j, A5 Va concern. Children treated with short-term testos-
, s' F/ k0 E2 Bterone injection or topical androgen may exhibit some' V; V0 c( ?8 q5 k- A M. Q5 m
acceleration of the skeletal maturation; however, after2 _' ~/ x5 B, ?' ]7 Q
cessation of treatment, the rate of bone maturation
: n8 f7 i( d7 ^, Q( qdecelerates and gradually returns to normal.8,9
; p( J- @: ]; U& p2 FThere are conflicting reports and controversy8 c; r! u1 \: O* ~6 \' u- d
over the effect of early androgen exposure on adult0 y( Z/ M& ?/ J8 ?6 `# o3 W
penile length.10,11 Some reports suggest subnormal4 q7 M7 l& T7 j) v0 s2 _
adult penile length, apparently because of downreg-5 v- L" O1 J1 g6 ~& _/ f" q$ Y$ w
ulation of androgen receptor number.10,12 However,
7 U7 i# K$ }& T! C' xSutherland et al13 did not find a correlation between
/ K G$ [3 p7 U- d# U+ }' m; v8 S6 m9 achildhood testosterone exposure and reduced adult
2 A5 T' Z( ~/ j( Xpenile length in clinical studies.* w, h& D2 p: y+ Q( \( j
Nonetheless, we do not believe our patient is
: _* k+ O! @- y; K$ Y# q5 u9 W$ Rgoing to experience any of the untoward effects from
, B; N! }& x' ]; F1 Etestosterone exposure as mentioned earlier because
) h" x* [$ v2 \the exposure was not for a prolonged period of time.
( o( V# W) n1 p4 y$ e8 {Although the bone age was advanced at the time of
; o6 x$ |+ n1 ]/ ]4 K( Ydiagnosis, the child had a normal growth velocity at0 k! Y& y: S3 K2 G
the follow-up visit. It is hoped that his final adult
6 ?; a5 Z; T- }# R8 @1 A+ V# Bheight will not be affected.3 Z4 l0 F/ n, A
Although rarely reported, the widespread avail-
3 U! g8 H/ U7 W& Z6 Dability of androgen products in our society may y( m) n2 Z7 G2 R
indeed cause more virilization in male or female8 K/ w* g: v; r, o
children than one would realize. Exposure to andro-" R! I& E/ R: d' y9 l; j; {! Z
gen products must be considered and specific ques-& v0 ~% K; H% B, z
tioning about the use of a testosterone product or
9 M) h& @+ L- p) Ggel should be asked of the family members during0 a6 s$ \& e/ e- o/ d* \/ a2 j/ V: C+ b
the evaluation of any children who present with vir-+ N& d I2 R% z; I
ilization or peripheral precocious puberty. The diag-
( s# x/ c4 M Bnosis can be established by just a few tests and by
7 k8 U; h' F v6 B2 ~0 i+ K* Jappropriate history. The inability to obtain such a
8 f7 Z' V: I g- J5 S8 u3 Mhistory, or failure to ask the specific questions, may
7 J! a3 a" L( y' G0 Iresult in extensive, unnecessary, and expensive6 @' `8 E# z) r4 R
investigation. The primary care physician should be
7 r4 _$ M* Q$ K. i# R8 r4 daware of this fact, because most of these children
* n" F8 M3 c1 T' c( {0 D0 s8 Xmay initially present in their practice. The Physicians’, G7 e9 e- O2 x$ u6 _+ J1 q
Desk Reference and package insert should also put a
: q2 P$ s2 ^, V7 vwarning about the virilizing effect on a male or# d& o5 ]+ M$ p
female child who might come in contact with some-
, |. T4 t3 b. g/ q* _8 Done using any of these products. [7 v# r6 V& M) ]
References# A$ P' `6 ?! a$ W5 ]- X7 m$ ~) I
1. Styne DM. The testes: disorder of sexual differentiation" [7 C/ U5 r; j, ~8 {5 W1 R9 m
and puberty in the male. In: Sperling MA, ed. Pediatric* ]) m$ [1 ]9 M# O" n; k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
p" R" [5 W" b P% D4 s2002: 565-628.
/ Q9 @: e7 E% c! P+ M& z8 _9 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
W/ I% y; v/ v0 C( Zpuberty in children with tumours of the suprasellar pineal |
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