- 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 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
( r; L9 |" M) G3 l- g, Z/ r3 V1 i) SBoy Induced by Indirect Topical8 z( u. P# B, `: V6 ]
Exposure to Testosterone$ a5 f/ d! ]. v2 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' J/ D D- |- c* M
and Kenneth R. Rettig, MD1
9 f# O4 }5 U; HClinical Pediatrics
3 N/ p$ c* X; R0 r* `% V3 wVolume 46 Number 6
9 j4 I! F4 v% ZJuly 2007 540-5435 S" x( k! u" @9 @8 q. ?
© 2007 Sage Publications9 z+ Z5 u9 X9 d7 Q: y2 V
10.1177/00099228062966510 u# G* R! F b! H( w% M" D( J2 b
http://clp.sagepub.com3 ~0 I _. c$ N
hosted at& K. @0 B! m# Z- u* ^6 \7 U
http://online.sagepub.com
8 @0 D7 Q8 n8 j) e0 ~, xPrecocious puberty in boys, central or peripheral,/ l2 A; Q+ V% {. ^' |
is a significant concern for physicians. Central
0 D! t8 t- T, B4 |- ^" t3 Jprecocious puberty (CPP), which is mediated) J2 \4 Q2 E) o9 j6 T, c6 l
through the hypothalamic pituitary gonadal axis, has
1 M& T! `) t/ k8 y% za higher incidence of organic central nervous system1 h4 m) ^9 C) l$ u2 e
lesions in boys.1,2 Virilization in boys, as manifested
7 d+ X! s1 ]$ z# g: |) _- ^- i1 U6 ^by enlargement of the penis, development of pubic" F$ r+ p. @" l: N- ] \
hair, and facial acne without enlargement of testi-
- O, C: m9 I* b$ b B5 F, v! `cles, suggests peripheral or pseudopuberty.1-3 We
/ x5 N$ g+ t6 |/ B: qreport a 16-month-old boy who presented with the
% N- F0 i1 d; v) g7 O6 K+ M2 Senlargement of the phallus and pubic hair develop-
4 [! `6 M' ^, k/ [5 V& P6 A8 q" K/ Yment without testicular enlargement, which was due
, E6 P [1 q* g, Bto the unintentional exposure to androgen gel used by/ O7 ?9 D+ z4 N3 t: B; Y9 j& @0 j
the father. The family initially concealed this infor-
7 C2 g) C- O& |3 Mmation, resulting in an extensive work-up for this
1 S+ p: |/ g1 q( Q" j L, t& F0 q4 Xchild. Given the widespread and easy availability of4 q% D. D# ^ b+ _: T/ e5 g! ]
testosterone gel and cream, we believe this is proba-) l8 z1 L' }0 P. n+ q7 {
bly more common than the rare case report in the
2 d0 g; A+ h* U2 d2 Kliterature.4
& o- [7 a- s* U' ^# g9 i2 U; w2 NPatient Report
$ ~3 b+ q( A% d" k6 OA 16-month-old white child was referred to the: f* N* d) c8 r) C6 J
endocrine clinic by his pediatrician with the concern
) o. b$ a3 M) j G8 K$ l! @6 h# ?of early sexual development. His mother noticed
: Y8 H$ @9 p* D9 U. J2 c0 [light colored pubic hair development when he was: P- X: \6 |1 c( b* a: e
From the 1Division of Pediatric Endocrinology, 2University of
7 [8 ~8 c. n0 J3 D. ~South Alabama Medical Center, Mobile, Alabama.5 v1 Y& W0 F0 Z/ L
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 k& o2 b' w5 {9 @: [
Professor of Pediatrics, University of South Alabama, College of
9 E+ T5 S2 L5 j2 p0 LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( D; Q+ ^" w- g, t. _e-mail: [email protected].# w- ]' O# d% Y1 ^
about 6 to 7 months old, which progressively became
! S, |6 u2 _7 k: \/ vdarker. She was also concerned about the enlarge-% k5 F& F* L5 m$ _, N4 T% h
ment of his penis and frequent erections. The child$ O9 Z5 ?" a% v/ R
was the product of a full-term normal delivery, with
$ S4 F. R, V @$ J) S7 c! F8 [9 @a birth weight of 7 lb 14 oz, and birth length of3 x' c7 r1 ]! t* n+ c
20 inches. He was breast-fed throughout the first year
# G6 a2 E; I* t$ M5 o' j- Jof life and was still receiving breast milk along with
# d& H3 H) R7 rsolid food. He had no hospitalizations or surgery,8 q% D: Y) ?0 z L3 Y
and his psychosocial and psychomotor development
6 [! m- R: e) p2 a6 a2 J0 }. F8 `was age appropriate.5 e( Y7 q( v! d1 @& X E: r
The family history was remarkable for the father,
' m/ @0 E; Y+ ewho was diagnosed with hypothyroidism at age 16,
X0 t8 W5 J' i( t/ Y1 j8 Iwhich was treated with thyroxine. The father’s, {! P" {8 z, o& n. G) L+ g
height was 6 feet, and he went through a somewhat+ S" _( w% U* y* U$ U) T( k7 ^
early puberty and had stopped growing by age 14.: i+ g- n# j9 c2 d! {0 V$ n
The father denied taking any other medication. The- y. T0 g* ]7 ?9 q7 s1 Z
child’s mother was in good health. Her menarche
+ ~. \/ W# W; x3 Owas at 11 years of age, and her height was at 5 feet! N! H, P' e) N' F8 U$ e
5 inches. There was no other family history of pre-" \) c2 ?3 c6 U. P+ v+ s
cocious sexual development in the first-degree rela-
; p1 E! s6 B$ itives. There were no siblings.
" i9 f# ~) `/ ^7 q% V5 J+ P/ RPhysical Examination
0 V( z- [, L) K) T8 TThe physical examination revealed a very active,! l M" {2 Y. m0 k* l, k1 _) Y
playful, and healthy boy. The vital signs documented% N% Y6 }' l) Q- g
a blood pressure of 85/50 mm Hg, his length was
. k9 o1 E; L" w+ o" i90 cm (>97th percentile), and his weight was 14.4 kg
9 w, k5 G# z ?5 X% l: L& E- t(also >97th percentile). The observed yearly growth
8 e" M$ F9 y: Lvelocity was 30 cm (12 inches). The examination of! m1 d B; B/ ?2 [( o5 i+ d$ m
the neck revealed no thyroid enlargement.7 R" x/ l5 b6 \: C5 R' O
The genitourinary examination was remarkable for
. U X7 u+ F. @' ?enlargement of the penis, with a stretched length of
, s+ H/ K& O! M' s- R6 a* B D8 cm and a width of 2 cm. The glans penis was very well# s: m2 q o' T- j
developed. The pubic hair was Tanner II, mostly around
$ P2 B# |3 X9 i x# l& r5405 \. W5 e, P3 t. ?! @0 w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 t. Z0 Z9 B5 u* k; Z2 fthe base of the phallus and was dark and curled. The
7 l: s9 }1 L" u# d; A) q/ jtesticular volume was prepubertal at 2 mL each.. L9 g' v, j" K8 \
The skin was moist and smooth and somewhat- Z g, b5 s; R" H \$ |6 ~' t
oily. No axillary hair was noted. There were no# y; P& O& c9 |2 x
abnormal skin pigmentations or café-au-lait spots.8 {) y6 J9 u! V2 N( G
Neurologic evaluation showed deep tendon reflex 2+- @% @3 ?$ U" K5 O0 o1 e2 \5 b
bilateral and symmetrical. There was no suggestion9 o* |* P$ }. `$ v
of papilledema.( x _$ H; r& l
Laboratory Evaluation% H; x( z- a+ V @- i: Z; H
The bone age was consistent with 28 months by
& j4 o7 ^) t/ q1 t8 Z/ i& h6 zusing the standard of Greulich and Pyle at a chrono-
- e2 e5 W% O- D# }4 Q. elogic age of 16 months (advanced).5 Chromosomal& M- |& Z# v4 \7 \
karyotype was 46XY. The thyroid function test
) d) e; a3 t2 s# k7 m" _showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 s# b3 o* q" B9 r2 N* ?
lating hormone level was 1.3 µIU/mL (both normal).- U+ B/ G1 e5 v1 I& g4 Q/ `
The concentrations of serum electrolytes, blood
- S5 R3 \+ o& L+ b/ z# vurea nitrogen, creatinine, and calcium all were% H3 M+ S2 u+ g) ?2 U; C
within normal range for his age. The concentration
$ I& R. O8 A! l* gof serum 17-hydroxyprogesterone was 16 ng/dL1 y4 _/ z3 U0 o9 [6 l
(normal, 3 to 90 ng/dL), androstenedione was 20
1 ^ G! ]5 u9 x H6 hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 ~; G' n) \7 j5 Q8 t& ?8 C5 {( _; \terone was 38 ng/dL (normal, 50 to 760 ng/dL),& I# i" K8 L& b; B- x; ^
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 M; U$ K7 E: m
49ng/dL), 11-desoxycortisol (specific compound S)
: j# u, m7 z! R1 @0 Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( ~& ^9 a- ]* ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' @6 f) y6 \" A3 s2 S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! M6 b" Y, Z3 N( Nand β-human chorionic gonadotropin was less than
" P) H+ V0 ~. K' n k8 E5 mIU/mL (normal <5 mIU/mL). Serum follicular6 j8 \, U( O7 I2 Y! V
stimulating hormone and leuteinizing hormone. E; M- z7 D- \! @) M6 w
concentrations were less than 0.05 mIU/mL
8 m d8 o- c/ a# ~% e: e(prepubertal).
2 o% l2 w+ A# @6 gThe parents were notified about the laboratory
# S/ V. F+ S9 T5 Zresults and were informed that all of the tests were
/ g3 A: u8 r" g- E9 c, a. Inormal except the testosterone level was high. The
6 n! @4 c6 i+ ?0 \follow-up visit was arranged within a few weeks to
$ |% U4 E. l7 ~6 fobtain testicular and abdominal sonograms; how-
9 c0 h, Z/ z9 x& Zever, the family did not return for 4 months.' A, _9 [9 l0 A' W5 _* P
Physical examination at this time revealed that the
8 E8 I8 x/ c- o4 {; O) F. Qchild had grown 2.5 cm in 4 months and had gained0 m: u% L \0 O
2 kg of weight. Physical examination remained
3 V5 T5 z1 |; T0 R, Ounchanged. Surprisingly, the pubic hair almost com-
5 l, G6 {$ X3 r9 `" y5 Mpletely disappeared except for a few vellous hairs at
; N4 ]/ T7 c) T: B, |8 O! P. c) \the base of the phallus. Testicular volume was still 2
! M. L# x/ l1 ZmL, and the size of the penis remained unchanged.
, u( |2 F' Y/ s4 w6 yThe mother also said that the boy was no longer hav-
# R/ [8 v: H* m6 x* j* \- cing frequent erections.
9 E3 f9 M! r& x3 l6 eBoth parents were again questioned about use of
: p0 k7 T/ w$ S0 R( A" ?9 G+ Wany ointment/creams that they may have applied to
3 s! f6 `' h$ z( rthe child’s skin. This time the father admitted the
9 Z( l9 E0 m- |% `; t% u& }2 F h9 x/ TTopical Testosterone Exposure / Bhowmick et al 5411 P. H: q3 K! _7 r) d
use of testosterone gel twice daily that he was apply-
* \; C; ]- `1 ^, j \$ O1 D% ping over his own shoulders, chest, and back area for
; ^% C( {$ u8 T, m* A4 za year. The father also revealed he was embarrassed& z: x: J) j Z6 {4 d, y
to disclose that he was using a testosterone gel pre-
3 z/ d# a% ?, s; Nscribed by his family physician for decreased libido1 E& [6 a; N( Y6 ]# g( n' D
secondary to depression.
3 H# M" G- p1 z0 YThe child slept in the same bed with parents.7 K/ l' C3 w$ E
The father would hug the baby and hold him on his& i! h& [; Z# f
chest for a considerable period of time, causing sig-4 C! u/ G/ w3 l( @4 {$ W& T, \
nificant bare skin contact between baby and father.& \7 X& Q6 I% A
The father also admitted that after the phone call,
0 h9 T7 ~# {; D: ]& t/ Qwhen he learned the testosterone level in the baby% g9 h7 H9 y4 Z1 A/ d, H1 T
was high, he then read the product information
3 W: V) k m/ [: P3 upacket and concluded that it was most likely the rea-: Y7 D1 G- q- U9 Y4 j$ u- B) A
son for the child’s virilization. At that time, they
1 z( T' Z, T& C7 z# B. C3 bdecided to put the baby in a separate bed, and the- p# Q( |# B6 R. ?( Y
father was not hugging him with bare skin and had; ~ ^. V$ `- k* v
been using protective clothing. A repeat testosterone6 U$ e7 I% U+ K+ a$ l# Y1 y# t
test was ordered, but the family did not go to the9 E2 O7 y4 _( c C: G0 C+ o
laboratory to obtain the test.
^# Q0 I9 T' I6 p2 o+ {; IDiscussion' c) d4 m& Z4 [* R7 Q [4 L
Precocious puberty in boys is defined as secondary
& I0 ~4 }% b" |6 C2 qsexual development before 9 years of age.1,4* }! w( X' ~4 w5 i' w
Precocious puberty is termed as central (true) when# G- Y; i2 M- W! I5 v- x: E
it is caused by the premature activation of hypo-/ g0 j' {* t+ l- E3 ?
thalamic pituitary gonadal axis. CPP is more com-
/ {, k+ _5 z5 i# Smon in girls than in boys.1,3 Most boys with CPP5 v% T9 M3 `' y* r+ x$ [
may have a central nervous system lesion that is c5 }5 e- F/ g' T* V) y# |
responsible for the early activation of the hypothal-( o5 ~( K1 T& N+ e
amic pituitary gonadal axis.1-3 Thus, greater empha-) ~6 ^2 u: U! r! D+ {6 D( ]6 a, X* P
sis has been given to neuroradiologic imaging in
5 ]& ^# o: J# {boys with precocious puberty. In addition to viril-6 F- c" u% X9 y {# _
ization, the clinical hallmark of CPP is the symmet-" o3 U* x4 z' i/ @; k$ P4 [
rical testicular growth secondary to stimulation by# p" R7 L" R7 H; S+ [) ]2 R, `
gonadotropins.1,37 w8 U- n# Q* E0 G
Gonadotropin-independent peripheral preco-
' ^! J2 ]1 N1 F1 G; _; E; scious puberty in boys also results from inappropriate
`& _: h% Q. I3 @1 Jandrogenic stimulation from either endogenous or
1 G. P2 ]6 G3 [1 B# Uexogenous sources, nonpituitary gonadotropin stim-8 y6 i, w+ Q( x: o; G7 Y
ulation, and rare activating mutations.3 Virilizing
; V. b5 { Q8 l3 W; ocongenital adrenal hyperplasia producing excessive5 I7 I' e$ _9 I7 P
adrenal androgens is a common cause of precocious4 h7 G0 F. z+ I( A/ X6 h: X# x5 U1 ?, S
puberty in boys.3,4
& z# l F% m I* G7 N9 lThe most common form of congenital adrenal7 S3 K9 E; t t8 b
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 w8 n# S3 Z6 o# |The 11-β hydroxylase deficiency may also result in, e9 t$ X3 C6 O# W0 J1 f
excessive adrenal androgen production, and rarely,* q* w: r4 ^( e
an adrenal tumor may also cause adrenal androgen, j! a' q; }. m+ M+ q0 F3 z
excess.1,3$ T. {1 u9 J8 C u4 k7 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; W' R3 P! y5 S) T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* D( j, R) Y: T2 {0 x% c- a( X4 f
A unique entity of male-limited gonadotropin-# m9 j9 Z! J$ x& e1 ?
independent precocious puberty, which is also known
2 [; k! [" B- S* z) _1 G3 O7 O oas testotoxicosis, may cause precocious puberty at a) H n7 m' T. F, X$ v8 n9 u3 N2 Q
very young age. The physical findings in these boys; q% |4 v2 Z- b1 t+ M! V( U1 s
with this disorder are full pubertal development,
7 _: i7 s+ i: O4 m' qincluding bilateral testicular growth, similar to boys
8 a# _" L' f& V4 I" gwith CPP. The gonadotropin levels in this disorder' Y1 B+ W% }% k$ i) k5 p
are suppressed to prepubertal levels and do not show
* Q% H/ K6 C, {9 Cpubertal response of gonadotropin after gonadotropin-
% p# o* m4 ?. i- B. preleasing hormone stimulation. This is a sex-linked
a. o$ d5 N4 l0 Aautosomal dominant disorder that affects only5 ]) z" H. q1 R6 h+ Z
males; therefore, other male members of the family
) m. h' D) X) Pmay have similar precocious puberty.3
' R0 m3 X: E( F t/ p( e& D& w/ PIn our patient, physical examination was incon-
$ ~+ ]+ z, J5 H" Bsistent with true precocious puberty since his testi-
) d( ^6 Q. O( F1 y Q. s* c2 fcles were prepubertal in size. However, testotoxicosis- g3 } m& c- x5 J5 ~' W! ^
was in the differential diagnosis because his father
/ T! T% `3 V9 g0 @1 N4 nstarted puberty somewhat early, and occasionally,
' v/ }- F* ]5 R5 itesticular enlargement is not that evident in the ^/ _- b5 g7 x5 O
beginning of this process.1 In the absence of a neg-* z, c( I9 {& u: Q% {, F- |" L3 d
ative initial history of androgen exposure, our
( f$ _$ |$ o* x A, A" Nbiggest concern was virilizing adrenal hyperplasia,
, o; {% \ J# `+ L' i- geither 21-hydroxylase deficiency or 11-β hydroxylase6 R7 O9 }, ?: f4 _: ^, `
deficiency. Those diagnoses were excluded by find-& S0 W; o4 V: X1 c& t, w
ing the normal level of adrenal steroids.: ~" A' L1 i* L% Y9 b F
The diagnosis of exogenous androgens was strongly" \: ^7 D8 p( E0 v+ D( ~0 x
suspected in a follow-up visit after 4 months because
. v/ a% t0 Y8 _1 O- I# {the physical examination revealed the complete disap-7 |' F h* e Y$ ^- a# g
pearance of pubic hair, normal growth velocity, and' x: Q% v1 q2 L, @4 Y) u7 N
decreased erections. The father admitted using a testos-% Z1 L! c0 d+ O7 i6 n+ u
terone gel, which he concealed at first visit. He was
. e/ Y: z) q0 I* Zusing it rather frequently, twice a day. The Physicians’ K( f7 q# V- O5 q8 T- I# a4 T
Desk Reference, or package insert of this product, gel or1 B8 u) Z. B7 r8 {
cream, cautions about dermal testosterone transfer to
( u6 ^/ x( L# ?9 U0 d# I3 ~unprotected females through direct skin exposure.
% i1 I6 q' d- tSerum testosterone level was found to be 2 times the
9 p) m) s: J2 dbaseline value in those females who were exposed to
5 d' A5 I% o- T! V. j$ _, qeven 15 minutes of direct skin contact with their male1 [% l9 t0 e- ~7 v( M( T, ]
partners.6 However, when a shirt covered the applica-
3 p0 d1 a2 ?9 P! c" @tion site, this testosterone transfer was prevented. a+ O+ ]. }4 |$ L
Our patient’s testosterone level was 60 ng/mL,
5 O# B6 ~" e, }! r3 Gwhich was clearly high. Some studies suggest that( @) i1 @5 C& X. q/ F
dermal conversion of testosterone to dihydrotestos-/ g- t) z8 J6 k: m- D
terone, which is a more potent metabolite, is more8 T8 k! A- I9 u
active in young children exposed to testosterone
4 n7 `+ M: [8 ^exogenously7; however, we did not measure a dihy-
. i j! Q2 P) f9 Bdrotestosterone level in our patient. In addition to
% m+ D$ _+ y, Z( q# Ivirilization, exposure to exogenous testosterone in
9 K" ]& L5 h9 V5 Vchildren results in an increase in growth velocity and
4 g" ~4 k& _: Q( [* C9 fadvanced bone age, as seen in our patient.
1 |5 t: R8 X% J/ x7 C. ] tThe long-term effect of androgen exposure during* l3 c6 M* e# Q% M
early childhood on pubertal development and final2 `) }; |6 \( q* Q* ]/ I+ a2 Z
adult height are not fully known and always remain% R' X% a! k- Y$ e6 j
a concern. Children treated with short-term testos-
6 G7 c4 M9 w6 G: p5 P* O( l: fterone injection or topical androgen may exhibit some
/ t" F! e! C5 |* R Z/ Eacceleration of the skeletal maturation; however, after, `# s! M2 h* P2 O Q# f. f; j" R
cessation of treatment, the rate of bone maturation( {4 F4 ~& B3 |+ n
decelerates and gradually returns to normal.8,9
2 ?/ ]! h& [& d; @: MThere are conflicting reports and controversy1 Y. o( q+ q Q' V& K5 I; c4 F& ~3 ^
over the effect of early androgen exposure on adult
8 k4 d+ f* \) {8 A1 g) `: i5 B3 ?# @penile length.10,11 Some reports suggest subnormal
0 Z6 y8 `) [ P* Fadult penile length, apparently because of downreg-1 a1 N0 I! r; X' N
ulation of androgen receptor number.10,12 However,
/ i7 `1 m# M6 a" q4 bSutherland et al13 did not find a correlation between
8 r2 O: H, S: o5 }' cchildhood testosterone exposure and reduced adult$ B V, |( m" d( N# X
penile length in clinical studies., j* |8 d+ m1 E' f: ?( R. F
Nonetheless, we do not believe our patient is
8 u$ p9 k/ _' W& ]& _5 e* V; Y- y* `; ?going to experience any of the untoward effects from( @7 K) [0 B5 c) _
testosterone exposure as mentioned earlier because
8 Z0 [8 \, ]& R5 F" _2 s9 ithe exposure was not for a prolonged period of time.
1 ]8 H1 w j5 Q- h, tAlthough the bone age was advanced at the time of: X' ]# n$ d, q
diagnosis, the child had a normal growth velocity at
- o: r. s) ]6 z0 gthe follow-up visit. It is hoped that his final adult' M4 V& O1 c8 T8 o, x5 b
height will not be affected. a# J, n ^' z
Although rarely reported, the widespread avail-
. e; r% L5 c1 \$ ?$ ^$ `ability of androgen products in our society may; s( `+ h8 P1 r% h
indeed cause more virilization in male or female
* T% u) P& m! g8 h# i/ Lchildren than one would realize. Exposure to andro-
) [3 J+ c( P( O5 X' @3 U( R9 |& Wgen products must be considered and specific ques-4 R3 h! W3 E3 w1 d
tioning about the use of a testosterone product or2 R3 Z) a5 Y0 q# t! E: ?
gel should be asked of the family members during
; k8 t. k# V$ [ W" M |the evaluation of any children who present with vir-
8 \! W5 C$ Y5 Q8 V, _ oilization or peripheral precocious puberty. The diag-% w( |& M! x% b1 ^; c: q
nosis can be established by just a few tests and by
1 o! H: \& l8 i4 iappropriate history. The inability to obtain such a9 a0 ]6 Y+ e( E& n+ {
history, or failure to ask the specific questions, may# Z: J4 Q: v& B1 u. f1 Y) o
result in extensive, unnecessary, and expensive, V) E( A2 n% {5 \# ]4 ^! F
investigation. The primary care physician should be6 e( q1 _5 E" l* U$ n9 F5 A* j( `
aware of this fact, because most of these children: M. i0 Z0 v7 V0 X1 l0 c; l6 x
may initially present in their practice. The Physicians’6 L% h, |9 @& }! U. ?) g0 _- T0 G
Desk Reference and package insert should also put a$ e: k4 B* m6 d6 ~
warning about the virilizing effect on a male or: P1 {' p) T$ F6 \
female child who might come in contact with some-5 W: w0 c2 O1 `8 T/ T% `
one using any of these products.
' ] J8 T3 w" k9 ~4 cReferences
4 o, h+ o: b/ J* R1. Styne DM. The testes: disorder of sexual differentiation& Y) X8 R3 T" D
and puberty in the male. In: Sperling MA, ed. Pediatric
" K7 [* Q7 L6 r$ }: q% O5 aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- n* ]6 _, Q! C2002: 565-628.
) N6 Z$ }) Z8 C$ g2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 x. W; O1 ?6 `3 Epuberty in children with tumours of the suprasellar pineal |
|