- 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-Old0 O h6 K, u# ^; s. @8 W$ ^
Boy Induced by Indirect Topical
5 P2 B s: S1 b4 N7 HExposure to Testosterone" i/ h) ~9 z6 M) e9 Y- ]$ N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% j& n2 T D$ q8 n" ]& @% h5 Oand Kenneth R. Rettig, MD1
2 M5 v+ J0 j* h' ?; E4 ~# G! N. I0 V6 DClinical Pediatrics
/ Q- i& V% S. E" c$ \1 j- g9 y% kVolume 46 Number 6
# `( O3 }' H$ g7 T% R0 O5 [8 \July 2007 540-5433 q' l/ O# j6 {7 s. `
© 2007 Sage Publications$ k3 K/ z3 V$ s7 l) t
10.1177/0009922806296651
3 D+ J# l# h5 L* c% H# Nhttp://clp.sagepub.com0 ^. {4 p g# T
hosted at0 V3 N3 |# a. {4 O$ ^
http://online.sagepub.com
$ V7 S2 p: w. F; i$ `8 b* }: APrecocious puberty in boys, central or peripheral,! d. N6 o8 b, R7 f0 T
is a significant concern for physicians. Central
: ?) ~8 w7 Q, x5 _% Xprecocious puberty (CPP), which is mediated
0 I5 [1 ?5 s7 n$ Ythrough the hypothalamic pituitary gonadal axis, has
0 o$ R7 ]" \. M+ @a higher incidence of organic central nervous system
/ W5 b! D# R* h8 Glesions in boys.1,2 Virilization in boys, as manifested4 ]2 r( j* N. `" s. w8 i/ ?* @, T6 Y" r
by enlargement of the penis, development of pubic
- r$ U, s: W0 s! N9 M/ p. Yhair, and facial acne without enlargement of testi-
5 D) n' |$ `" Lcles, suggests peripheral or pseudopuberty.1-3 We$ a5 A" e- Q0 @
report a 16-month-old boy who presented with the K4 q: h; u! s- }# Y6 }
enlargement of the phallus and pubic hair develop-, U* S! O# C6 `* M2 s
ment without testicular enlargement, which was due' n- b8 ?8 P/ v$ T0 P6 `
to the unintentional exposure to androgen gel used by
9 {6 H( @3 @7 R5 F. {* Pthe father. The family initially concealed this infor-0 L0 s5 f8 s' E+ U, k& X( w( ]( ]
mation, resulting in an extensive work-up for this0 W. N; G$ \& }4 y6 T
child. Given the widespread and easy availability of u/ I6 w L, F- a& s$ _" x
testosterone gel and cream, we believe this is proba-' D1 m$ p# Z% p& Y# R, x- O
bly more common than the rare case report in the
6 P0 l4 R! k! _% M3 e. H$ S$ Sliterature.4
6 A6 x8 _ `2 APatient Report
9 H* m& Y% {6 d7 [5 q" T% [A 16-month-old white child was referred to the
7 R$ \' A0 b& R' l# o7 a+ W. [endocrine clinic by his pediatrician with the concern
5 `' B) k, ?/ E( X6 q) T* Yof early sexual development. His mother noticed; p$ ^) O9 B" Z0 v6 B/ V
light colored pubic hair development when he was0 W- _0 n4 B3 c/ ^( T# f
From the 1Division of Pediatric Endocrinology, 2University of% x. z; K( Z! X, U8 T; x
South Alabama Medical Center, Mobile, Alabama.' i F' n/ |7 j: f6 F
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 z* g4 \, u4 j
Professor of Pediatrics, University of South Alabama, College of
9 L' g3 V2 s/ \) lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 V8 ~! `8 O `; m' F& O3 O2 P: d
e-mail: [email protected].
. n( k% \- l+ Zabout 6 to 7 months old, which progressively became
! T' b/ A8 n* q. o& s8 q4 ~darker. She was also concerned about the enlarge-5 F6 ~, B5 S* J5 a: ]7 W/ C( \
ment of his penis and frequent erections. The child
6 Z' w: K( f+ N. Y( a$ r, _was the product of a full-term normal delivery, with
( N) l# Y( R) Y5 [% }a birth weight of 7 lb 14 oz, and birth length of
: F9 N/ k: c" k" Z% S) k20 inches. He was breast-fed throughout the first year1 N9 y- m, I' A4 Z9 t! O2 x
of life and was still receiving breast milk along with- y; Z! Y C# N
solid food. He had no hospitalizations or surgery,; X) s6 B6 Y& E
and his psychosocial and psychomotor development0 v4 v. }4 ]+ P- e/ ?
was age appropriate.) ~; K4 N- f' b5 Q8 \; H
The family history was remarkable for the father,7 c/ R: }' T8 A6 }( [3 h# @
who was diagnosed with hypothyroidism at age 16,; M. s* O k. [
which was treated with thyroxine. The father’s0 E# R' L" b' k5 K* R; t2 l
height was 6 feet, and he went through a somewhat7 k# l. ]4 l" W: ~9 M
early puberty and had stopped growing by age 14.. A4 B% t; k4 c- n W* I
The father denied taking any other medication. The! a+ O# K2 J5 i$ f
child’s mother was in good health. Her menarche8 { u7 J: p& E, R
was at 11 years of age, and her height was at 5 feet
# N7 S- L. h, K; }# @5 J5 inches. There was no other family history of pre-7 h" F; p% P4 d* p1 e, ]/ c$ y5 B6 a
cocious sexual development in the first-degree rela-8 m N! L' a O9 d/ d2 p
tives. There were no siblings.: D( {( R: c {
Physical Examination: Q& C" X/ O0 s& ^0 ~# Z) j
The physical examination revealed a very active,' R- U0 K, {& d$ u/ x K: A
playful, and healthy boy. The vital signs documented
( [& y) }8 r1 O5 Y5 b8 f: w' Ca blood pressure of 85/50 mm Hg, his length was
' G& t& ]( e4 c# g7 B6 X4 |" W6 M4 }90 cm (>97th percentile), and his weight was 14.4 kg
1 A) @1 u O; m- B3 m! G3 C2 g) M(also >97th percentile). The observed yearly growth2 k# w& H) g* p& }& u. S) D1 x+ b
velocity was 30 cm (12 inches). The examination of5 S0 `9 ~: Q, S3 b" h, V9 }
the neck revealed no thyroid enlargement.
5 [( S- L* m2 S' oThe genitourinary examination was remarkable for% m* v5 ?3 B6 u: w# W3 Z
enlargement of the penis, with a stretched length of8 S, w! W9 c1 M5 K w# s4 X
8 cm and a width of 2 cm. The glans penis was very well/ E3 g2 {8 {1 H! d
developed. The pubic hair was Tanner II, mostly around
# e* j! z( B9 ]$ x3 q540
; u& l6 M- ]' }! L0 d- H# y# V$ ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# W8 S4 a) Y, U, W# E' ]% cthe base of the phallus and was dark and curled. The, r$ K: F9 |* g: S9 W
testicular volume was prepubertal at 2 mL each.) `0 R) o0 b! N8 I9 \( S+ P
The skin was moist and smooth and somewhat
' Z2 w" Z, _7 M, o5 ooily. No axillary hair was noted. There were no- b2 s9 v' `; A- H' ^
abnormal skin pigmentations or café-au-lait spots.
2 P2 ?$ C& Z$ M8 i2 I( FNeurologic evaluation showed deep tendon reflex 2+
0 K8 A' M8 _; v' [1 a6 Q3 r( x- ~bilateral and symmetrical. There was no suggestion
9 P3 Y3 K/ x& F" K: O) s6 L, s% lof papilledema.
7 j- _! G- Y% v J {( g4 L; H8 QLaboratory Evaluation
$ L! Q5 Y0 _% D! U2 K, ]The bone age was consistent with 28 months by
9 Q& C. n8 ?$ ?) Musing the standard of Greulich and Pyle at a chrono-
+ g n+ `) m' g. Plogic age of 16 months (advanced).5 Chromosomal) }0 L4 k( r6 d
karyotype was 46XY. The thyroid function test
. F5 i2 {. U5 J6 B% ]+ _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* H3 ^$ X6 c# ~& a M# u3 R" n/ alating hormone level was 1.3 µIU/mL (both normal).5 r8 g6 w. t l
The concentrations of serum electrolytes, blood
7 a+ f9 t$ @ Iurea nitrogen, creatinine, and calcium all were
# B% G; t; R) h. u% F* b7 S! `within normal range for his age. The concentration
: W3 X2 `! b1 Z0 v7 oof serum 17-hydroxyprogesterone was 16 ng/dL
" j+ l1 `5 M- i+ N* j(normal, 3 to 90 ng/dL), androstenedione was 20" M2 b$ B6 o+ P) j5 A* a0 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; D E) K0 i$ D8 Q0 V# H3 ?, Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( ^0 Y* n& d# a% odesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 x% h/ K- j% ]4 W* f
49ng/dL), 11-desoxycortisol (specific compound S)
6 e+ t6 X5 W' D3 @9 J2 o# Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 X3 H" q$ f8 v1 c; b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 ~: \4 [+ T# qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 j \! P9 a Iand β-human chorionic gonadotropin was less than
$ t) L% F9 t) K) Z+ {5 mIU/mL (normal <5 mIU/mL). Serum follicular+ N+ q D. [1 u+ B4 k6 K
stimulating hormone and leuteinizing hormone# f, E; C4 b5 p h: Y- E* n& v
concentrations were less than 0.05 mIU/mL
( [3 g5 r# y- B% i- _, U% e(prepubertal).
1 ^3 P% R! I* z: y8 J- EThe parents were notified about the laboratory5 H- p* F0 S- C1 s
results and were informed that all of the tests were
, m! o, z2 f1 `$ f. K" T6 ~' Inormal except the testosterone level was high. The
4 z& U6 o/ n: S5 b8 d% T. rfollow-up visit was arranged within a few weeks to0 _5 e3 F- \ x# |
obtain testicular and abdominal sonograms; how-
9 _/ [& S' x0 qever, the family did not return for 4 months.
0 ~1 m4 L! ~! e+ i$ sPhysical examination at this time revealed that the* h4 k- M/ O2 z$ ]1 r! g% g2 {
child had grown 2.5 cm in 4 months and had gained
4 v" a) K" R; X! f2 [# }1 s* \. ~5 e2 kg of weight. Physical examination remained# F y( o+ N& N7 ?: p
unchanged. Surprisingly, the pubic hair almost com-
- L' V3 k( E. m, |+ K# q9 h7 |pletely disappeared except for a few vellous hairs at
0 w+ }; c2 _% g* |4 J5 Sthe base of the phallus. Testicular volume was still 2
& a% O8 f2 a8 ?8 o m4 S2 WmL, and the size of the penis remained unchanged.5 r8 F8 i4 f; T3 s' `
The mother also said that the boy was no longer hav-
9 ~) A Y* ?' ning frequent erections.
9 A+ {# d2 g( _, u+ lBoth parents were again questioned about use of
3 _5 _$ X1 Q2 c$ }" p* X0 U0 k7 Eany ointment/creams that they may have applied to6 m+ q) u3 l% r, I* P3 N7 D! d" R, u
the child’s skin. This time the father admitted the
1 h* N1 h8 U2 y, f9 ^Topical Testosterone Exposure / Bhowmick et al 541
& C/ m, A. d; J2 U: z( juse of testosterone gel twice daily that he was apply-6 k- v3 D4 J' ` m" X% ?
ing over his own shoulders, chest, and back area for
0 K: L$ U9 ^; V5 Qa year. The father also revealed he was embarrassed
/ K6 G- ~ }$ ~7 nto disclose that he was using a testosterone gel pre-
" F P9 a8 _! X9 ?scribed by his family physician for decreased libido* ]2 w8 I$ o6 _" l$ o1 J/ \0 f/ b& {1 g. ]
secondary to depression.
3 k. Y- {0 l: R# A9 gThe child slept in the same bed with parents.$ J* g/ {( G4 r4 K
The father would hug the baby and hold him on his5 q8 E0 e: ]) K D3 G' i6 Y
chest for a considerable period of time, causing sig-6 k A! Z! k- V' V( g
nificant bare skin contact between baby and father.
% c! B1 P6 @+ x1 Z3 }: IThe father also admitted that after the phone call,
/ f3 J2 t9 Q+ P1 c/ H8 kwhen he learned the testosterone level in the baby
; u. `. U# e9 n) Q! y8 Qwas high, he then read the product information
! s, y9 N$ O- w8 K6 [' ^packet and concluded that it was most likely the rea-3 K5 Z' _ }; C
son for the child’s virilization. At that time, they2 P( \% b, w$ e& _/ M0 c
decided to put the baby in a separate bed, and the, J6 n1 T4 S& v+ P% F
father was not hugging him with bare skin and had
. f% d! L+ _3 ]+ I$ E, c obeen using protective clothing. A repeat testosterone
. |9 }( u3 E9 {- [. ?& w8 stest was ordered, but the family did not go to the
2 t T2 \. F( F1 ?laboratory to obtain the test., @' {. D, a& `1 A @4 }, }& m
Discussion
4 E( `. D! @7 C8 h- @6 s& XPrecocious puberty in boys is defined as secondary* V- }7 f2 ]: Z ? M( W
sexual development before 9 years of age.1,4
0 D, q' b( P1 q& K. EPrecocious puberty is termed as central (true) when
- R, \; @2 Z) w3 ~it is caused by the premature activation of hypo-, F5 t! f' N+ D+ C; x4 G( }; s
thalamic pituitary gonadal axis. CPP is more com-
; p8 h6 S' E* {mon in girls than in boys.1,3 Most boys with CPP" N6 H( p6 H. I$ T5 T: L' ~
may have a central nervous system lesion that is
, b) X: M5 N# o5 H I- oresponsible for the early activation of the hypothal-
* X3 }1 [. j8 X S. M& Q% y& A0 Samic pituitary gonadal axis.1-3 Thus, greater empha-3 H! G6 `! ?7 y2 L: d
sis has been given to neuroradiologic imaging in
g. c) j# }- T6 E) j7 } Cboys with precocious puberty. In addition to viril-
5 b+ v8 a9 X3 k; n8 {! x$ cization, the clinical hallmark of CPP is the symmet-1 I' }2 g: |6 o9 ~, a. Z% f: t' f
rical testicular growth secondary to stimulation by3 I5 Q) ~9 G, W( c- ]( j
gonadotropins.1,3# W- V& O8 f$ ~8 ^( }0 d1 m
Gonadotropin-independent peripheral preco-8 k) o4 q( r9 a+ D: a5 A& @6 I5 N
cious puberty in boys also results from inappropriate
/ T2 R. z( Z! s, q" Landrogenic stimulation from either endogenous or* p! m8 c- e: e2 Z( w$ ]( l3 I
exogenous sources, nonpituitary gonadotropin stim-6 @" z; J! J" P- B; d- i1 _" l
ulation, and rare activating mutations.3 Virilizing4 \7 G. q7 _! H8 o/ }
congenital adrenal hyperplasia producing excessive/ o: ^" ^& g, I. g( z3 n; i
adrenal androgens is a common cause of precocious, }' x, f6 |/ n) L# T4 J5 c9 }
puberty in boys.3,47 i: u \! X! B1 q
The most common form of congenital adrenal
" F8 M: D) \6 a7 R$ _# c; \hyperplasia is the 21-hydroxylase enzyme deficiency.% u4 ]) c$ O0 N5 r* k
The 11-β hydroxylase deficiency may also result in" }5 V/ @; ]# s. [! M" p
excessive adrenal androgen production, and rarely,0 L0 e$ B9 ~* `- q' `1 h
an adrenal tumor may also cause adrenal androgen( O# x+ ?: r$ r2 }2 g: R9 g
excess.1,3+ B4 X) l2 o8 P' Z: T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 o4 F% r* R7 g- q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 q% f; E. M- aA unique entity of male-limited gonadotropin-
/ x' a- C8 x; a9 O; H/ _0 C/ \independent precocious puberty, which is also known( b$ b4 K4 k5 @$ j# v4 D
as testotoxicosis, may cause precocious puberty at a
1 `3 W Z% t2 uvery young age. The physical findings in these boys0 P4 D( f0 u. k( r; U, f
with this disorder are full pubertal development, O# y5 O' [4 {9 F: Z
including bilateral testicular growth, similar to boys4 P. V7 t- ]; M, Y* r( @
with CPP. The gonadotropin levels in this disorder9 s4 M, r7 e% a
are suppressed to prepubertal levels and do not show
8 k! g( |3 R% O1 U$ a) ypubertal response of gonadotropin after gonadotropin-8 D( B6 Q5 z. c- s* h
releasing hormone stimulation. This is a sex-linked
: [" y2 ]1 g; o5 h. Oautosomal dominant disorder that affects only( U6 \ }; n( ?% ~' I8 _
males; therefore, other male members of the family
# q/ F5 w+ X* a3 gmay have similar precocious puberty.3
5 w9 I. E, D2 V# k8 d, F5 LIn our patient, physical examination was incon-0 G$ i2 }# _/ B0 B
sistent with true precocious puberty since his testi-! Y" b- t4 i* \6 K! o) ]: X
cles were prepubertal in size. However, testotoxicosis
4 D+ G# g, t5 K6 @+ ywas in the differential diagnosis because his father) p6 l! A0 c, I& Y* X2 U
started puberty somewhat early, and occasionally,
& ^2 y2 J6 g% I W1 U% Mtesticular enlargement is not that evident in the" @$ b% V1 n" i' Q8 C0 z
beginning of this process.1 In the absence of a neg-: H5 O- ?+ K% Z
ative initial history of androgen exposure, our
8 h, y( E1 r1 w' Xbiggest concern was virilizing adrenal hyperplasia,/ r, ?+ ?* K" o' u* k
either 21-hydroxylase deficiency or 11-β hydroxylase
6 P7 A4 Q! h2 v4 C& W6 u2 zdeficiency. Those diagnoses were excluded by find-
, m5 E: k5 ?9 W0 |8 I" {ing the normal level of adrenal steroids.4 h& G6 q6 _% S: x9 ^/ @: [" J& w) {
The diagnosis of exogenous androgens was strongly
# Z3 R0 ?1 V( P4 c9 S; e: i* A! _" ~4 tsuspected in a follow-up visit after 4 months because( v. n3 {/ q( I, T/ P2 D- z6 ?/ P
the physical examination revealed the complete disap-+ b0 X0 ?( e9 K c, s3 V* _) c( E: P
pearance of pubic hair, normal growth velocity, and
& u4 \0 V; q0 U1 D' _# fdecreased erections. The father admitted using a testos-
4 t! c. S3 g; ]8 q5 f' _terone gel, which he concealed at first visit. He was
( `' L/ A4 {. i$ D6 }- ?using it rather frequently, twice a day. The Physicians’
; S# Z2 J2 C3 N4 t' k" a) FDesk Reference, or package insert of this product, gel or
2 u- }9 h. O1 C2 Ecream, cautions about dermal testosterone transfer to0 [9 Y; ] ~; t2 A* v& _
unprotected females through direct skin exposure.4 u1 |0 N5 f. \
Serum testosterone level was found to be 2 times the( S$ r3 R1 f) Y, ~4 a3 u
baseline value in those females who were exposed to
8 a/ H! H) X4 B7 jeven 15 minutes of direct skin contact with their male
# o6 O5 z. q2 d/ D1 y2 Upartners.6 However, when a shirt covered the applica-; V8 w% j, p) a( q9 B
tion site, this testosterone transfer was prevented./ d, q5 S0 ]- Z& }2 R
Our patient’s testosterone level was 60 ng/mL,
, ~5 t! a" o7 D2 h' @, zwhich was clearly high. Some studies suggest that
. w& M/ y6 {7 [& U, J3 w& p |dermal conversion of testosterone to dihydrotestos-& q$ _9 C( D2 G- n( C# e
terone, which is a more potent metabolite, is more
1 p M, O/ ]5 i, X3 Lactive in young children exposed to testosterone
$ `2 f+ C; ^4 ^. H& `0 }) E1 @exogenously7; however, we did not measure a dihy-& s8 l. y' M! H5 w8 ?
drotestosterone level in our patient. In addition to! J) ^& Z) T& b6 r* w
virilization, exposure to exogenous testosterone in
9 w# U, m6 K# Tchildren results in an increase in growth velocity and
. {+ c7 z, M- g' B! u7 Iadvanced bone age, as seen in our patient.! m& y5 D% j% Z( O/ o+ S9 _# [
The long-term effect of androgen exposure during6 O- t& W2 s' U) X5 w P
early childhood on pubertal development and final
$ b& r2 t) f6 @) T( aadult height are not fully known and always remain$ f8 M" V8 I$ |* N. J5 _
a concern. Children treated with short-term testos-2 h4 @* r5 `) e, }* ?9 c7 a; Y
terone injection or topical androgen may exhibit some& F" ]: Y7 c6 [( _8 O9 c& {; F
acceleration of the skeletal maturation; however, after/ {2 n. H; k# k$ ~6 m8 f
cessation of treatment, the rate of bone maturation
9 H( F( T L, S) U# b2 v* Wdecelerates and gradually returns to normal.8,9
3 B% J L. S% j5 h! w& MThere are conflicting reports and controversy
' o5 T& ]6 _! p, p) } Q* kover the effect of early androgen exposure on adult
* [+ h: d- b# m' spenile length.10,11 Some reports suggest subnormal
7 @/ \* E2 X4 p2 jadult penile length, apparently because of downreg-6 T4 G" ?" Z2 |! t
ulation of androgen receptor number.10,12 However,
h2 U% w9 Q( u3 V S% P! RSutherland et al13 did not find a correlation between z. U& ?9 t/ f1 O9 [& d1 O
childhood testosterone exposure and reduced adult
& M1 u+ ~( R# a3 t% Epenile length in clinical studies.
5 `, k8 j6 Y' E r3 MNonetheless, we do not believe our patient is2 c6 g( H# x- k8 A$ ~& B; p
going to experience any of the untoward effects from
% c$ c/ |* ]) x; N; O$ ptestosterone exposure as mentioned earlier because2 D, d! v. k4 M0 Z m9 p
the exposure was not for a prolonged period of time.
+ ^, I# q% v8 K2 b. BAlthough the bone age was advanced at the time of
0 \; T. R; g- ~4 Fdiagnosis, the child had a normal growth velocity at
$ I5 C( n7 o: N" i' @( Qthe follow-up visit. It is hoped that his final adult4 ]5 d0 b$ a9 @8 u- O) |5 d) K1 R
height will not be affected.* g. N% P$ m1 Z
Although rarely reported, the widespread avail-6 T( F! u$ x- m7 S6 O# r
ability of androgen products in our society may
- p( E) t H! `2 y+ {indeed cause more virilization in male or female
$ D( n! C) Z6 Q4 Lchildren than one would realize. Exposure to andro-
7 A: n. r( G2 O1 y2 C8 O. Fgen products must be considered and specific ques-2 V( X5 D4 U0 r1 o- M
tioning about the use of a testosterone product or
1 r7 k, x9 H& h# Cgel should be asked of the family members during
1 s. ^7 {- y, f% I# T3 L1 v6 N. S& Zthe evaluation of any children who present with vir-9 q5 L j" u" \* ~: W. j
ilization or peripheral precocious puberty. The diag-
& I- D! Q4 U/ S4 H' E: p( Bnosis can be established by just a few tests and by
( K/ c) t$ d4 E* I5 _appropriate history. The inability to obtain such a
5 s6 |: m/ ]. B# Xhistory, or failure to ask the specific questions, may
4 G, l2 B& @; F# Nresult in extensive, unnecessary, and expensive
9 y9 O- W6 k9 I8 Binvestigation. The primary care physician should be
E$ n/ o8 y# Xaware of this fact, because most of these children
9 ]* ?; w+ [* z! s7 @may initially present in their practice. The Physicians’
+ l7 X: s3 d3 X2 ^: \Desk Reference and package insert should also put a
$ _ L) s+ N4 S' G. ^warning about the virilizing effect on a male or( r$ q8 p' F5 V0 A. p4 |- M* {
female child who might come in contact with some-7 `% l" r0 v T& C" H: I8 G& J
one using any of these products.
$ V9 V8 k H% ?; H2 |& x" rReferences
U1 v7 B6 S G9 X) y1. Styne DM. The testes: disorder of sexual differentiation1 m Q: W3 f, G) {
and puberty in the male. In: Sperling MA, ed. Pediatric
6 B$ f+ F" L3 [, TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 _9 j. M# X1 R/ l$ p2002: 565-628.) N! D% n- p& Q6 G, U# s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" }4 \. z( d& o1 {
puberty in children with tumours of the suprasellar pineal |
|