- 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
3 j; G) l. ]7 g$ V7 e0 r: g% H/ NBoy Induced by Indirect Topical: @- v P. K! o1 a% V
Exposure to Testosterone
R* b9 ]0 _7 ~. g2 `* D9 H+ nSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 H: Z a* i7 P4 e$ X' r
and Kenneth R. Rettig, MD1" d! M+ z& v% h: n
Clinical Pediatrics
! w! n7 U% M9 ~$ t# |$ F& O3 wVolume 46 Number 66 m+ ~2 q* l6 F
July 2007 540-5430 v5 \" A, q( n! q# G: _! T) I
© 2007 Sage Publications V2 Z, w$ e- M. ~, l
10.1177/00099228062966510 D4 H8 H3 c: Y
http://clp.sagepub.com
0 I4 S- m t& ]7 x6 r7 thosted at
& a( X! u3 e8 {* E, uhttp://online.sagepub.com8 D( ]0 t3 n# W3 C) Q6 \! L, v! @
Precocious puberty in boys, central or peripheral,
7 f$ `: q+ D% V. Ais a significant concern for physicians. Central
: t, \- F+ H. d$ y {precocious puberty (CPP), which is mediated
5 h l( U6 H2 K) Ythrough the hypothalamic pituitary gonadal axis, has
1 d3 y: [3 A2 y! d- N9 ja higher incidence of organic central nervous system
) `. j6 Y( h' s/ A g" \% Jlesions in boys.1,2 Virilization in boys, as manifested
8 n7 ?& H4 |- ?8 X6 I) Xby enlargement of the penis, development of pubic8 b% x \& i7 d1 B2 m! H5 P
hair, and facial acne without enlargement of testi-: X9 j0 `+ s& S0 F: P5 Z- P5 N
cles, suggests peripheral or pseudopuberty.1-3 We- y3 d4 S# o, @; L, m- ^
report a 16-month-old boy who presented with the
3 j8 j+ P9 ~* wenlargement of the phallus and pubic hair develop-
j: @5 }- Z& `% p% {ment without testicular enlargement, which was due
8 U0 ~# v8 E! }' I8 m vto the unintentional exposure to androgen gel used by
7 f2 r4 a: [7 r) [the father. The family initially concealed this infor-
7 C: z3 [+ E3 `) K! n+ vmation, resulting in an extensive work-up for this2 Y0 ?5 C! u; {" l, S2 Y% n
child. Given the widespread and easy availability of4 t g% z/ @4 L8 A4 D4 d
testosterone gel and cream, we believe this is proba-8 @4 l+ n% G/ m/ P. E: i( x H
bly more common than the rare case report in the
: x% { H" J5 n9 a& F; Wliterature.4
+ S! e {$ \; g, Y- F( gPatient Report6 u' k9 f3 U# F
A 16-month-old white child was referred to the
& }4 C8 Y+ F5 e8 l) \ C6 A, Cendocrine clinic by his pediatrician with the concern
$ J- @2 z' L6 I( zof early sexual development. His mother noticed
' H2 b% H1 Q7 Elight colored pubic hair development when he was
3 i% _6 Q0 Y2 c* MFrom the 1Division of Pediatric Endocrinology, 2University of
6 W) j- I; T: u o* p$ m& J$ ]9 PSouth Alabama Medical Center, Mobile, Alabama.4 q7 d: D( l3 V
Address correspondence to: Samar K. Bhowmick, MD, FACE,4 l3 l* C$ o7 {+ g) Z+ e
Professor of Pediatrics, University of South Alabama, College of2 `$ B+ Y: M( f i" c E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 e3 m, R, Q& x; h: t1 c
e-mail: [email protected].
& \3 p0 y4 ~0 W4 ^% b+ m) \0 }about 6 to 7 months old, which progressively became
# u" T% `4 D, W. Q. Z- W/ Edarker. She was also concerned about the enlarge-4 j! S6 D7 a" k. l; t$ ?) q
ment of his penis and frequent erections. The child
- f* [$ l i# `% a- uwas the product of a full-term normal delivery, with
: j5 l* N; ?# I/ @6 S La birth weight of 7 lb 14 oz, and birth length of
& U% c' x" N; ^& ^5 z20 inches. He was breast-fed throughout the first year
7 l, |, R5 D. E, `- M( ^0 Dof life and was still receiving breast milk along with, _& V8 r, E) t; r' R
solid food. He had no hospitalizations or surgery,
9 I9 F7 o8 l: v5 Eand his psychosocial and psychomotor development& _+ |, d9 h; m1 z, F8 ~# n; L
was age appropriate.
; N- x8 m. U/ A$ I0 JThe family history was remarkable for the father,
, H. Z( N. D6 J9 S+ xwho was diagnosed with hypothyroidism at age 16,
, u: Z) Y) ?" k) U# u9 d S/ Jwhich was treated with thyroxine. The father’s6 @) d, {5 N4 v$ ]: O! N$ B6 m1 n; G( R
height was 6 feet, and he went through a somewhat
! \" J' E2 }- P7 {/ M' E3 Cearly puberty and had stopped growing by age 14.( s; b( W; x8 S/ ~% Y. z
The father denied taking any other medication. The
# K% u- R" j: i! y3 Bchild’s mother was in good health. Her menarche
2 G4 k: q5 k" \) p% \$ ]2 |; @7 Ewas at 11 years of age, and her height was at 5 feet
" ^! m. F; K# Q+ f& |1 v. k, u5 inches. There was no other family history of pre-
- n3 G) T4 o* ^2 n! {& s. Q: D0 ucocious sexual development in the first-degree rela-! c5 e8 y+ Y: C* \- \( b4 e
tives. There were no siblings.# C3 L1 d% h0 e! N$ f
Physical Examination. F, P; [& e! t! v) K
The physical examination revealed a very active,
' S3 F' l- X# _( D. b8 @4 @" jplayful, and healthy boy. The vital signs documented
5 g7 T, H4 B( S/ k7 K8 x; ~( `a blood pressure of 85/50 mm Hg, his length was5 X* ^: n; T& v1 A; @
90 cm (>97th percentile), and his weight was 14.4 kg p9 v# k% m% B3 D% O
(also >97th percentile). The observed yearly growth' T: w' n2 j+ J) @4 @. N4 O
velocity was 30 cm (12 inches). The examination of
: B+ @! F' M# I; @. Z! Y0 G" Mthe neck revealed no thyroid enlargement.
7 m& t0 b# o' d2 X9 R; m2 LThe genitourinary examination was remarkable for" @7 G, N( C$ e [' W8 u
enlargement of the penis, with a stretched length of' D' J9 D: m/ _
8 cm and a width of 2 cm. The glans penis was very well
7 ?3 H; F/ x* {developed. The pubic hair was Tanner II, mostly around S3 i! n1 O Q9 F7 O
540
8 G; ~0 F+ d) [* Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 o1 J8 ^! `- p m- ~
the base of the phallus and was dark and curled. The1 J7 g5 V0 m& z3 B+ G+ h
testicular volume was prepubertal at 2 mL each.
- O! g- t$ o( ^* H' q9 nThe skin was moist and smooth and somewhat
0 ~1 D- x8 Z3 R* f( t' koily. No axillary hair was noted. There were no/ w- q" v7 y: |; S( `* w
abnormal skin pigmentations or café-au-lait spots.
% e& R- p& N' E# ?Neurologic evaluation showed deep tendon reflex 2+
$ p* e5 m$ y9 h. u4 O( I$ Ybilateral and symmetrical. There was no suggestion
' u8 ]( N7 B9 k: @of papilledema.
- w1 ~% H8 ]' K2 J- H3 yLaboratory Evaluation
( ^8 S1 Y* H, V$ y3 p) JThe bone age was consistent with 28 months by& r9 x* F/ L9 [
using the standard of Greulich and Pyle at a chrono-
) ~7 W6 u6 _, I, p- w. Rlogic age of 16 months (advanced).5 Chromosomal6 [( x( p) f4 Z
karyotype was 46XY. The thyroid function test- F. U) J( U4 m1 X0 d6 d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 |) l1 V1 c1 ^/ Z& Q7 C" clating hormone level was 1.3 µIU/mL (both normal).* L! l' N* U/ ^1 m9 [7 U, ?2 J
The concentrations of serum electrolytes, blood. L% l* B' ~9 L- W& Y# X! M
urea nitrogen, creatinine, and calcium all were
7 ]: @7 k4 W$ h3 t4 b5 p: bwithin normal range for his age. The concentration: _) {" d5 T+ w7 _9 `
of serum 17-hydroxyprogesterone was 16 ng/dL/ |3 f+ z: T) S3 T! w/ r* A0 U* i
(normal, 3 to 90 ng/dL), androstenedione was 203 D; Z9 l- Q @8 A' J0 a, r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 }5 G* t# ^3 n" K0 T6 T( J3 Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),& s1 E8 T* B5 U: a" {
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( ]1 N) h* p2 a: h49ng/dL), 11-desoxycortisol (specific compound S)
r$ S( J5 G* X" I! I4 \$ ?' Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 [- R7 t4 p+ F0 ]/ g9 ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 f# a9 x* @$ w( t4 C" f W* l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( ]0 K: v# g) o' |
and β-human chorionic gonadotropin was less than& L2 O9 x/ S+ C4 Z) l% x1 `. [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
M1 g6 A- [) dstimulating hormone and leuteinizing hormone) a p/ y9 A. F2 T. F! P% z( D- [
concentrations were less than 0.05 mIU/mL
* c: e7 i" @0 H* L(prepubertal).
: J$ x# w" M# s$ s, D5 u/ V+ f' tThe parents were notified about the laboratory# l& ?5 O8 [- o, z1 \1 A( J
results and were informed that all of the tests were
* |5 Q. @& a# L* ynormal except the testosterone level was high. The* ?& K) @) ^! n, ?
follow-up visit was arranged within a few weeks to
8 i5 D" n) b, m. ?/ p" E9 @obtain testicular and abdominal sonograms; how-
2 c7 m' j+ b2 W& h: ^0 |ever, the family did not return for 4 months.0 @3 S. Z/ J; i+ Z# D6 D
Physical examination at this time revealed that the; N4 O" K' C& O$ V8 |. c
child had grown 2.5 cm in 4 months and had gained
- C7 D) ]6 y3 j$ m2 kg of weight. Physical examination remained% r9 s4 L" [# o! o' P0 \, |
unchanged. Surprisingly, the pubic hair almost com-
3 f$ C6 X1 \4 R$ H* ]! cpletely disappeared except for a few vellous hairs at
3 N5 ~& L l. |the base of the phallus. Testicular volume was still 2
6 E k9 O. W- ~# D: }2 zmL, and the size of the penis remained unchanged." I: X) U$ J3 ?' [7 S, f. k& ~
The mother also said that the boy was no longer hav-4 ^4 C! x/ l. Y, i8 d8 @9 ]
ing frequent erections.
% s' T6 F6 R) H. f$ D/ m% t3 s) bBoth parents were again questioned about use of/ s" Z. z }8 i7 Q( C% [
any ointment/creams that they may have applied to
* A& g" F1 @! r1 A7 cthe child’s skin. This time the father admitted the* v, Q3 f) r; l
Topical Testosterone Exposure / Bhowmick et al 541
* T3 |0 R* ~0 e0 n( y7 Huse of testosterone gel twice daily that he was apply-5 S" V3 V8 i% G( E1 r! C _
ing over his own shoulders, chest, and back area for
- w V! }% q( X4 O v3 J6 Aa year. The father also revealed he was embarrassed3 g, @, f' j' b% Q; ]
to disclose that he was using a testosterone gel pre-
5 z( d8 K2 w0 T" `; q. D+ ?scribed by his family physician for decreased libido2 W/ O: _- o' C' ?! Y
secondary to depression.7 \$ d" s5 j" {) [( F, _( @' g
The child slept in the same bed with parents.
6 L% P' k5 r! U& pThe father would hug the baby and hold him on his2 o) F3 [* ^) W
chest for a considerable period of time, causing sig-
3 b6 e4 ]& m0 Vnificant bare skin contact between baby and father., Y0 S2 F. t( B4 S
The father also admitted that after the phone call,. H1 W7 D, `6 d- X
when he learned the testosterone level in the baby: [" }9 e! _9 O7 U# c6 L8 T1 F! m, }
was high, he then read the product information" F( i4 j! i4 B- W
packet and concluded that it was most likely the rea-
/ v F5 S& K, y- ason for the child’s virilization. At that time, they' {) ?& ~# U, g3 B3 D
decided to put the baby in a separate bed, and the
9 ]3 ^5 P) O( t0 g1 |father was not hugging him with bare skin and had
; p4 Z; G. y- L3 p/ x$ A# S; o! Gbeen using protective clothing. A repeat testosterone
2 J$ }! z* t* u, Q% R+ _' Xtest was ordered, but the family did not go to the1 d+ q6 G+ t4 o0 ~
laboratory to obtain the test.
$ {% C% e( C7 a5 NDiscussion
( e" D& J; l5 r. z( P9 B; ]Precocious puberty in boys is defined as secondary7 ]$ G* H7 J/ O f
sexual development before 9 years of age.1,4' a- n) z+ h; R: Y0 I9 H
Precocious puberty is termed as central (true) when
7 I- p; h( Y( s3 p% kit is caused by the premature activation of hypo-
- m2 Q G7 }; Z+ x( b: R8 Ithalamic pituitary gonadal axis. CPP is more com-# f* m' M1 [& v2 K
mon in girls than in boys.1,3 Most boys with CPP
, S: p7 e* _- }) U: xmay have a central nervous system lesion that is
) B2 z9 g' }$ k$ g4 w" Fresponsible for the early activation of the hypothal-
- y- A& Z" l6 Camic pituitary gonadal axis.1-3 Thus, greater empha-! M6 N9 f4 o+ f3 h
sis has been given to neuroradiologic imaging in% e9 d6 s+ g, B7 D9 f+ ~
boys with precocious puberty. In addition to viril-5 O3 j4 C% s5 m* Q9 o3 F
ization, the clinical hallmark of CPP is the symmet-
* }5 G3 {5 e2 q% k B. m F# a( |rical testicular growth secondary to stimulation by* V9 k1 x7 l4 O% \
gonadotropins.1,3
8 a- x0 j b. z4 h# p/ }1 s2 JGonadotropin-independent peripheral preco-
# e, V9 A6 D0 x; R/ Mcious puberty in boys also results from inappropriate
0 C- ` j; J! V& ~8 K' Aandrogenic stimulation from either endogenous or
& _; B( z3 N0 E" Eexogenous sources, nonpituitary gonadotropin stim-
8 l' b K! t$ pulation, and rare activating mutations.3 Virilizing6 F8 {+ h; ]2 D' n7 D. x1 T2 L' Y+ `
congenital adrenal hyperplasia producing excessive
3 c7 j# V* z7 h* r8 w* Yadrenal androgens is a common cause of precocious
, @' C% o" p4 G& tpuberty in boys.3,4
' l0 I7 A! k5 X! f# QThe most common form of congenital adrenal0 s8 a3 F3 n2 M$ X
hyperplasia is the 21-hydroxylase enzyme deficiency." Y k1 d2 m r( u
The 11-β hydroxylase deficiency may also result in
/ C: [' [ h. b9 Texcessive adrenal androgen production, and rarely,
" F M* z1 \9 r8 f, W3 kan adrenal tumor may also cause adrenal androgen
! P o2 y! V. S0 ]5 v) Eexcess.1,3: h- w* J' o, G, h, a; {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 r j, [ L9 @& {! Y( M( y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 f' j- Z4 l% b8 n) H/ @A unique entity of male-limited gonadotropin-
1 T; B2 G. m8 p6 D. uindependent precocious puberty, which is also known
' a+ @( L( a* U( X7 o% t2 d; Fas testotoxicosis, may cause precocious puberty at a
8 N/ ?3 G8 P5 a1 y" D5 rvery young age. The physical findings in these boys6 H. `) j0 o9 \! X
with this disorder are full pubertal development,% S$ [; Y! \" v2 O0 ^. q
including bilateral testicular growth, similar to boys
; A L+ _; m* }+ p. V/ Lwith CPP. The gonadotropin levels in this disorder
0 ^( r6 o0 {$ w+ N) j8 Lare suppressed to prepubertal levels and do not show
6 | N/ T" |* M6 p: }pubertal response of gonadotropin after gonadotropin-% @) u8 P+ J- y7 P" o8 M( n
releasing hormone stimulation. This is a sex-linked
: K1 i" C) H6 S' O3 |; V* aautosomal dominant disorder that affects only
1 `% h2 y" g+ {7 {; c/ Q& K. H, Hmales; therefore, other male members of the family' y5 z4 s* F8 G* H# c8 n, c* c1 e
may have similar precocious puberty.3/ n+ B2 z3 ?- l0 c' O; ]
In our patient, physical examination was incon-0 N$ d* ]6 \0 C/ a7 a2 H( z, I
sistent with true precocious puberty since his testi-
I% X6 V# P; {/ m% Qcles were prepubertal in size. However, testotoxicosis8 F7 a, K5 A4 S) m% T
was in the differential diagnosis because his father* ~' P: F% F5 x+ P+ W8 g
started puberty somewhat early, and occasionally,+ E( f! r* v: S7 I9 N
testicular enlargement is not that evident in the. Q! b5 L% g; R8 A0 X7 v
beginning of this process.1 In the absence of a neg-
: ~$ S0 z5 a, E7 I" ^! y" A2 Cative initial history of androgen exposure, our
2 |( ]' a R: z, |6 v" U% Z, s$ Ubiggest concern was virilizing adrenal hyperplasia,
0 @$ F( a, K6 l% z/ h6 }either 21-hydroxylase deficiency or 11-β hydroxylase
3 w* h7 @+ a7 Zdeficiency. Those diagnoses were excluded by find-
1 S* S" l: u* W. w2 ]* w9 wing the normal level of adrenal steroids.3 T$ n% ^5 T# M2 p+ Y; l/ J
The diagnosis of exogenous androgens was strongly7 f( K" O7 c9 ?
suspected in a follow-up visit after 4 months because
3 R) N u( n2 m5 f: s$ wthe physical examination revealed the complete disap-; A: b& y7 S; |: H K/ e
pearance of pubic hair, normal growth velocity, and
1 Y3 q& C) M, mdecreased erections. The father admitted using a testos-
+ O- D0 E- q' j8 i7 zterone gel, which he concealed at first visit. He was! o! S2 o4 \7 o& |
using it rather frequently, twice a day. The Physicians’, C; h3 Y( m; T8 @. @7 O
Desk Reference, or package insert of this product, gel or
/ j3 b/ h N4 _cream, cautions about dermal testosterone transfer to9 m5 d! o/ ~6 ]2 o6 v1 B0 k3 u
unprotected females through direct skin exposure.+ F, y5 h. e$ z! p: C( g2 T' \
Serum testosterone level was found to be 2 times the0 B! m3 _6 H* p! S# H/ l
baseline value in those females who were exposed to' Q4 t8 t# o7 Q# S: H8 g3 s
even 15 minutes of direct skin contact with their male
2 Q0 q J3 f$ ?6 Ppartners.6 However, when a shirt covered the applica-& @4 H4 m4 Y( y* [5 Z; S
tion site, this testosterone transfer was prevented.' j! r {5 B) [# k6 Y6 o! [
Our patient’s testosterone level was 60 ng/mL,
1 _5 T; v9 r; u( z3 ewhich was clearly high. Some studies suggest that
1 P7 k, k. R, M( ?. E! Odermal conversion of testosterone to dihydrotestos-& {5 x6 o9 S0 t
terone, which is a more potent metabolite, is more
( y) v f7 L* e5 G1 ~active in young children exposed to testosterone( j. X3 I+ J8 u$ |6 l
exogenously7; however, we did not measure a dihy-/ |; s3 j% E, c5 M
drotestosterone level in our patient. In addition to
" q2 `1 d: R5 u9 o A: Nvirilization, exposure to exogenous testosterone in7 Q4 y" C9 K) X4 n- q! L" f
children results in an increase in growth velocity and
l% x6 H* D( Qadvanced bone age, as seen in our patient.# ~+ j6 Y6 W: n; L5 U i
The long-term effect of androgen exposure during
1 G5 \/ |" k7 K0 N/ @. Fearly childhood on pubertal development and final
( h2 Q9 |- ?, E% A; I/ iadult height are not fully known and always remain7 D' A9 P% h+ g" N8 J( p6 u
a concern. Children treated with short-term testos- y. L, V$ G( h: y$ i2 L- B l
terone injection or topical androgen may exhibit some
" r x* @8 a, g# h) macceleration of the skeletal maturation; however, after) S9 I4 G7 n0 r6 |% {+ W
cessation of treatment, the rate of bone maturation3 z/ v+ E8 ?* ~2 k9 {, z0 i
decelerates and gradually returns to normal.8,9
) i, g2 `- t+ i P$ J3 c" dThere are conflicting reports and controversy
& d5 i/ s5 w9 ~! A0 w/ \2 h5 ?3 _over the effect of early androgen exposure on adult
2 ]5 T5 [7 S+ U+ H9 a* apenile length.10,11 Some reports suggest subnormal
' r- \ a7 a" e5 _* yadult penile length, apparently because of downreg-
$ ?( i2 ^, B J, v* Z. z% Kulation of androgen receptor number.10,12 However,; O5 z# C8 A: ^* J+ V- s: Q" x3 F5 P) w
Sutherland et al13 did not find a correlation between% H' h6 s, O5 M# s; i1 D8 N
childhood testosterone exposure and reduced adult7 q9 j S( i& s8 `9 J! T+ U# f/ R
penile length in clinical studies.) Z2 F, R- q `$ M8 f& a
Nonetheless, we do not believe our patient is( X0 N- k' b2 B1 {
going to experience any of the untoward effects from
$ f: Z$ X& J* `) itestosterone exposure as mentioned earlier because
# @* L ^6 F2 p; t. Z' K& athe exposure was not for a prolonged period of time." j8 E8 {- @7 ]0 h7 Y4 j2 O
Although the bone age was advanced at the time of
6 `; j. F! g; e" ediagnosis, the child had a normal growth velocity at
) m/ ~ \- |. C" Q/ dthe follow-up visit. It is hoped that his final adult. [& Q# _( E& B$ p7 N
height will not be affected.0 t N( f' w- l+ r/ _. ]
Although rarely reported, the widespread avail-
' C$ k! A2 _8 l/ k, }) T/ Vability of androgen products in our society may
0 [/ [4 L' j1 I; `! zindeed cause more virilization in male or female" y2 V6 v2 I, e' m0 R! N' ~6 }
children than one would realize. Exposure to andro-
) |* o" A$ E7 b8 M! U0 Q" u2 sgen products must be considered and specific ques-" \; t. f! Z( s8 \
tioning about the use of a testosterone product or
& M& a( J5 Y5 C% r( M/ J; cgel should be asked of the family members during# p* N- L4 D" Y- r4 i2 m3 B& d
the evaluation of any children who present with vir-0 [7 c7 B& @' W2 E# o4 ~* H
ilization or peripheral precocious puberty. The diag-
9 T4 U5 f* o, I. e" mnosis can be established by just a few tests and by, U" k0 N7 z1 P1 A/ j
appropriate history. The inability to obtain such a4 A- q6 A4 E1 L9 s" P! g4 P( Z
history, or failure to ask the specific questions, may" y5 p. z+ e# K9 @, C
result in extensive, unnecessary, and expensive8 V7 d5 z# y, }1 Z4 c# K
investigation. The primary care physician should be z: O7 I( G/ \+ J8 v
aware of this fact, because most of these children J2 v1 k2 n; q
may initially present in their practice. The Physicians’+ w( Z0 z: F: a7 `0 ]
Desk Reference and package insert should also put a
6 l+ {, {6 T4 |1 ~. lwarning about the virilizing effect on a male or2 V0 H0 c. f# Y+ b* V
female child who might come in contact with some-
" t- m z0 ]+ L- q& ?one using any of these products.
# n2 b5 D n! A0 LReferences
q9 p2 u% q k8 q1 w2 p1. Styne DM. The testes: disorder of sexual differentiation& F; y2 ^4 M* J% B
and puberty in the male. In: Sperling MA, ed. Pediatric' R- v6 ^1 J. B% s) U6 B4 @
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- Z5 h5 q! N4 C3 s5 |* ^8 B2002: 565-628.
: P# p* P( _, a k0 p: {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# A! w9 G3 e; d) Y# U2 Fpuberty in children with tumours of the suprasellar pineal |
|