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Sexual Precocity in a 16-Month-Old6 b$ V( P# R5 ^/ t) X5 h
Boy Induced by Indirect Topical, o0 z, B: C+ N. H
Exposure to Testosterone
2 I" A6 G* S+ K+ w1 @/ oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. ]4 H3 b) E! o dand Kenneth R. Rettig, MD10 `# M3 \3 Z/ c( G
Clinical Pediatrics
" D/ x! M" Y: r0 \% |" O' GVolume 46 Number 6
3 b2 u" k6 d" g' ~: UJuly 2007 540-543
b- T' H% l; d$ C+ w- B© 2007 Sage Publications% u& q) h- Q& m# R
10.1177/0009922806296651
; @/ p" d" U( `1 `: Chttp://clp.sagepub.com
4 _: B& {, w; Y) H; N4 U- Uhosted at
, J7 W( x/ M& k6 e8 Hhttp://online.sagepub.com
4 q m1 n+ N( C- F7 qPrecocious puberty in boys, central or peripheral,8 v- O( R/ s' n0 |( u1 b% \( n/ k( G
is a significant concern for physicians. Central
4 J0 X% w) u) ~7 d$ Uprecocious puberty (CPP), which is mediated
" d X5 X& }7 y! G* w4 |through the hypothalamic pituitary gonadal axis, has. a$ B/ u: t# R5 {" G O& W
a higher incidence of organic central nervous system
8 `4 L+ C3 t3 @* jlesions in boys.1,2 Virilization in boys, as manifested
. ^1 B2 I( V. p: ]5 Q, y* D# hby enlargement of the penis, development of pubic+ {) f; W" l, O' k
hair, and facial acne without enlargement of testi-
0 z8 a3 y7 l2 ], Icles, suggests peripheral or pseudopuberty.1-3 We
# {" Z; k) C9 L4 A. ^8 U- ^report a 16-month-old boy who presented with the
' n; D/ i) g9 O2 f0 j' h" d5 S# x" s% Lenlargement of the phallus and pubic hair develop-
4 N6 S1 Y! o! m8 d7 K9 `$ k2 ement without testicular enlargement, which was due
! W* d8 ~! G6 T, j% \, Rto the unintentional exposure to androgen gel used by9 R& k! A% p% [. U& n
the father. The family initially concealed this infor-
9 L; y# I, G, l& emation, resulting in an extensive work-up for this2 b7 n i" ?7 E* J
child. Given the widespread and easy availability of; ]9 u4 s2 O8 H9 q9 R4 r
testosterone gel and cream, we believe this is proba-: I* S' \4 b, b
bly more common than the rare case report in the
, ]3 a3 M0 z6 y+ Eliterature.4
9 C0 {2 l* z( w/ J3 T/ zPatient Report; a% \$ W. v$ F0 `
A 16-month-old white child was referred to the
8 v( [8 r. w h+ E- q/ xendocrine clinic by his pediatrician with the concern" ^* N5 g9 @/ P8 Y0 v7 j. P
of early sexual development. His mother noticed
0 ~# S9 N# |% F2 A: ]light colored pubic hair development when he was
2 ?- ?$ @* T4 i; M2 S- H2 V# i( dFrom the 1Division of Pediatric Endocrinology, 2University of3 Z! h% o5 F( Z/ z2 Y( ^& w& W/ |/ v
South Alabama Medical Center, Mobile, Alabama.! p" V' k; r+ t& i- Q/ p
Address correspondence to: Samar K. Bhowmick, MD, FACE,- s6 ?; Y) \2 h/ d' T( P5 e
Professor of Pediatrics, University of South Alabama, College of8 X2 ~# o& j( t! P
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 u7 P# h7 E& H0 J- x/ N1 \! Ue-mail: [email protected].
7 j) A( K7 u1 r7 ]1 f% C& oabout 6 to 7 months old, which progressively became) e) `6 m2 H( q% Q0 @8 d I* d5 b
darker. She was also concerned about the enlarge-+ T6 j1 \4 v$ m5 n) g; N
ment of his penis and frequent erections. The child8 `/ U2 s+ E% c& h
was the product of a full-term normal delivery, with$ o7 i# U1 ?; T/ \) Y+ c. R- z C
a birth weight of 7 lb 14 oz, and birth length of* t( o Z0 x9 K: u: A; m
20 inches. He was breast-fed throughout the first year* ?( ?6 h9 B/ |4 S9 M* r; c
of life and was still receiving breast milk along with
$ M# M* d& ], s7 I! osolid food. He had no hospitalizations or surgery,2 ?$ ]+ S" s1 r: Z
and his psychosocial and psychomotor development
5 X$ r$ M% ~' O4 ]( Xwas age appropriate.
9 W& ~+ {! ^2 H' WThe family history was remarkable for the father,+ E& P! @0 h/ B3 B3 l) p, g3 ^# j
who was diagnosed with hypothyroidism at age 16,
: `1 ?7 y' l0 f+ y" l: Xwhich was treated with thyroxine. The father’s( B8 l$ Q- g1 v5 Z3 L
height was 6 feet, and he went through a somewhat% h& y% ~1 f e- i+ [
early puberty and had stopped growing by age 14.
9 F" x6 |7 z+ d- R2 O4 FThe father denied taking any other medication. The" T& q& D9 S% w# d- d% l3 P* J
child’s mother was in good health. Her menarche
5 C b, Z A/ o9 ~/ twas at 11 years of age, and her height was at 5 feet
8 o! }7 N: z9 F8 B1 _" ^* ~5 r5 inches. There was no other family history of pre-
9 m; t8 p' z4 E1 n: kcocious sexual development in the first-degree rela-2 g& z& W8 e: O& C! J v9 W& G
tives. There were no siblings.; F, ?1 X# w, l& i7 p
Physical Examination. B9 w: E f% [1 K2 N% {' A
The physical examination revealed a very active,9 m5 \# X7 e( _3 \$ X/ l2 r
playful, and healthy boy. The vital signs documented1 @, }3 a8 N1 V; D [
a blood pressure of 85/50 mm Hg, his length was3 x% M: E! L6 j, ^+ p! J4 ^) R
90 cm (>97th percentile), and his weight was 14.4 kg" f' W6 L# @) H3 Q" R1 @
(also >97th percentile). The observed yearly growth% b) g o3 J' ], ^8 M& \9 V
velocity was 30 cm (12 inches). The examination of
- d. V7 h0 a3 o9 k+ \the neck revealed no thyroid enlargement.
! L. S8 k f) n8 R$ k1 O `The genitourinary examination was remarkable for
$ s8 E4 l1 P3 q# _4 B' q; }. lenlargement of the penis, with a stretched length of
6 H, | D+ @( S! j! O6 e7 N5 B1 a5 @3 k8 cm and a width of 2 cm. The glans penis was very well1 N# n* N2 H! F9 F ?8 n
developed. The pubic hair was Tanner II, mostly around+ v/ \- R+ ?; s8 H( ?; a/ G- F
540, B! y$ L# g2 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 X3 j: s( {- e5 Q f2 f5 w% [
the base of the phallus and was dark and curled. The* o7 d4 q5 \8 B/ Y
testicular volume was prepubertal at 2 mL each.
# d/ [7 r0 R4 ~2 _* ]The skin was moist and smooth and somewhat
0 p3 x! u% ~% W( x& d" M" N9 Y5 yoily. No axillary hair was noted. There were no
. W, |& @: T1 R$ cabnormal skin pigmentations or café-au-lait spots.7 x/ ^3 M7 P( K+ P% b, z1 Q! q, M
Neurologic evaluation showed deep tendon reflex 2+5 w* E) ~% \" |. L; k9 {$ ^
bilateral and symmetrical. There was no suggestion0 x/ _" _" V- n' @6 z9 F4 J/ {8 r
of papilledema.
t! ]/ w n3 ~" u5 j, T9 Y" JLaboratory Evaluation! ?, `0 U8 |/ g# t& H( J, S
The bone age was consistent with 28 months by
* O' N$ D# ?: V7 _* Z8 ]using the standard of Greulich and Pyle at a chrono-: h' r2 k. f' A- K- D1 W1 b
logic age of 16 months (advanced).5 Chromosomal4 I$ K) ]' v' y! v5 y0 ~0 U
karyotype was 46XY. The thyroid function test% c5 Y7 O d: o8 G3 @* B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 Y* Z* a$ d. E6 `$ A' l& `lating hormone level was 1.3 µIU/mL (both normal).
4 m1 Z. p* Z4 V* s' yThe concentrations of serum electrolytes, blood
6 w1 p" a$ Z. W, Y- }! furea nitrogen, creatinine, and calcium all were
0 Q4 [% E" r8 t# \3 }3 K& d% ?within normal range for his age. The concentration7 h4 h' b. l9 J, E
of serum 17-hydroxyprogesterone was 16 ng/dL
# e% F- q: F' h, d6 h; H7 h& L% w8 Y(normal, 3 to 90 ng/dL), androstenedione was 20& F+ ~7 h0 m$ z: b& G7 o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" r9 S d; p7 ~/ G# B
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 y- v6 u0 a0 Z7 ~2 ]2 m/ Y6 @2 Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 ^. i( u' q, y2 Y: A! Z
49ng/dL), 11-desoxycortisol (specific compound S)) u- ]/ u! A, T4 j. W, M- j/ \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( w4 B% a: l; m
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ o- d' b5 a* n# Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 ?9 W* j3 i9 ]$ nand β-human chorionic gonadotropin was less than
* e6 S; o( ]( w, j2 Q5 F2 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular- e. z. Z$ Y+ \0 P8 M
stimulating hormone and leuteinizing hormone$ u4 x9 c+ F+ C# F. p6 A7 S
concentrations were less than 0.05 mIU/mL
8 Z: J, E% f0 P- m( Q" W(prepubertal).
: B6 [1 k' Q9 f" h# ^/ {The parents were notified about the laboratory
9 C9 y& C4 K6 C; `results and were informed that all of the tests were
c7 H/ G) Q( L* c7 Tnormal except the testosterone level was high. The
$ R- m1 Z. [& r( F8 Tfollow-up visit was arranged within a few weeks to
0 f+ |" z# ]$ b# P5 Nobtain testicular and abdominal sonograms; how-3 U) U0 }. n% I! d, h" F; w
ever, the family did not return for 4 months.
! S+ v# [( ~) S" a1 O) T7 A1 h: |5 IPhysical examination at this time revealed that the
0 u b0 f* i' k4 }! r$ b! |child had grown 2.5 cm in 4 months and had gained* S/ U. S; X6 T" n# I* U) E
2 kg of weight. Physical examination remained4 {3 o; ^; o& A% X, G' T
unchanged. Surprisingly, the pubic hair almost com-
/ f: p. h, G5 u. P8 R' q6 vpletely disappeared except for a few vellous hairs at
+ t7 O+ r' _' I; Nthe base of the phallus. Testicular volume was still 2
2 ^6 J R1 f. G+ @mL, and the size of the penis remained unchanged.# Y. G* Y# I" W7 m F0 z
The mother also said that the boy was no longer hav-
. B/ p' `( w4 c+ h9 `" \7 jing frequent erections.3 ? b, A; A- {4 W% e0 b
Both parents were again questioned about use of
! f# E- G3 Y# o1 ^8 R3 a# D" {5 Fany ointment/creams that they may have applied to, b" l1 }. d3 x6 R% m6 o$ v3 a/ Z
the child’s skin. This time the father admitted the% e7 T( O, @ ?9 A5 D4 k) M* z
Topical Testosterone Exposure / Bhowmick et al 541. ]8 F$ n0 l: y5 g' h
use of testosterone gel twice daily that he was apply-: U( r. Y: W- N# y& G6 B
ing over his own shoulders, chest, and back area for$ u2 o& O) f+ A7 ~# P3 u ~
a year. The father also revealed he was embarrassed4 [0 a! {1 F" G
to disclose that he was using a testosterone gel pre-
( G M6 {$ n+ z; H# p2 }' a9 j8 kscribed by his family physician for decreased libido2 \; n/ B: \! f* i: s! A. Q
secondary to depression.3 q7 {# O8 z9 }8 X9 c! H% S7 w; J7 a
The child slept in the same bed with parents.
, A4 {) D3 m: ^% j7 `+ I) G% a* S7 jThe father would hug the baby and hold him on his8 P6 A5 s6 i0 K1 x3 T
chest for a considerable period of time, causing sig-9 U- O: p! v1 ~' e
nificant bare skin contact between baby and father.6 o9 r8 s" B9 [2 G; A
The father also admitted that after the phone call,( c4 P( E% Q( S0 T" \. K! }
when he learned the testosterone level in the baby
7 ?' f M! L+ [8 \; t6 C& a- U+ h& ?was high, he then read the product information
# w9 d4 N$ G( @8 wpacket and concluded that it was most likely the rea-
0 e4 v) v7 z6 B* {% sson for the child’s virilization. At that time, they
' X% ?- T6 j1 Q; n2 r X+ i2 q; zdecided to put the baby in a separate bed, and the1 C7 u8 ^. E& S- P) i2 S# m. y
father was not hugging him with bare skin and had8 D9 [3 c/ X! j) x& H
been using protective clothing. A repeat testosterone
3 v# z- Y, Z/ h" Y5 Etest was ordered, but the family did not go to the
' _9 [7 w) A. Q! O' Jlaboratory to obtain the test.* i: x5 A$ v* U7 h
Discussion
4 e: r* o% u7 ~/ U( Z1 @% F2 {Precocious puberty in boys is defined as secondary
) ~9 g; B) }" h: T. I. g8 u9 dsexual development before 9 years of age.1,4
! O! M) O: [& C1 H7 K8 `+ C- _3 f: RPrecocious puberty is termed as central (true) when _4 m# ^' K7 \ h. }1 ~0 Q5 z+ w
it is caused by the premature activation of hypo-
! d( S/ \2 I5 [$ [thalamic pituitary gonadal axis. CPP is more com-$ c, r5 {! v) \% F* C9 Q! E
mon in girls than in boys.1,3 Most boys with CPP: x( ` r! `" h0 l. S' K
may have a central nervous system lesion that is* o, u- O! v* y# k
responsible for the early activation of the hypothal-) ~. p4 ]& V9 |6 p8 i2 h3 \
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 ^3 J$ g" C) @/ V$ j, csis has been given to neuroradiologic imaging in
# X) n: X/ y+ l! I6 Nboys with precocious puberty. In addition to viril-
/ \. p' R; ^; s" vization, the clinical hallmark of CPP is the symmet-
0 @3 J7 C4 a* Wrical testicular growth secondary to stimulation by1 q- P4 ]# ]& L8 \+ t
gonadotropins.1,3
: _' n) G- y2 Y7 V# I: FGonadotropin-independent peripheral preco-/ ~9 _9 |1 t$ @- A
cious puberty in boys also results from inappropriate6 M8 l; Z: B! _# Q
androgenic stimulation from either endogenous or! V" y: b3 p4 ?
exogenous sources, nonpituitary gonadotropin stim-. m0 v" [/ j/ j( W1 R' S
ulation, and rare activating mutations.3 Virilizing
) ]& \0 J7 F% b0 q# _; Qcongenital adrenal hyperplasia producing excessive
$ v2 n/ h [1 u# Nadrenal androgens is a common cause of precocious
3 @7 X1 {, b$ w" w. O9 P* H6 ]puberty in boys.3,48 U" r/ x- ^$ Y7 [/ ^
The most common form of congenital adrenal
: I, _8 L) N8 Xhyperplasia is the 21-hydroxylase enzyme deficiency.. F$ w- S, N; r) ?6 o
The 11-β hydroxylase deficiency may also result in
4 Y! E+ z( Y" Q% Eexcessive adrenal androgen production, and rarely,
. d9 ~& ^ M( Uan adrenal tumor may also cause adrenal androgen) v) u; S6 \% T% v" e) y: G
excess.1,3
/ |% B7 d5 J5 B' W( t) _$ F$ {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 _" u/ U4 p) `9 c8 E6 W542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 z7 S6 ]9 K& S; g# d, k! x+ M
A unique entity of male-limited gonadotropin-) _" R; @8 c7 q% C7 e
independent precocious puberty, which is also known" s1 j/ \) I7 O0 X6 X4 c4 h
as testotoxicosis, may cause precocious puberty at a
% r( y( Z- q+ |4 L. Mvery young age. The physical findings in these boys
1 D. j; Y M7 l# v0 N- @; [with this disorder are full pubertal development,5 K" D( | i, ?( \- d& @" _& W" ^9 }
including bilateral testicular growth, similar to boys
1 |$ [( k$ C5 \ W. Nwith CPP. The gonadotropin levels in this disorder: D0 n5 H! G; H* N
are suppressed to prepubertal levels and do not show
' b0 i7 @/ j4 D& M- Gpubertal response of gonadotropin after gonadotropin-2 [1 M( Y5 S; g% f6 w) i; c
releasing hormone stimulation. This is a sex-linked3 G0 x6 J/ m/ p, j" C
autosomal dominant disorder that affects only O) |: V' o! ~: M) [) ?
males; therefore, other male members of the family8 g& P: }* Z) {7 M5 ^ O
may have similar precocious puberty.3
; F6 A) i1 Q) L! L4 [7 M3 q; A. uIn our patient, physical examination was incon-; l% s1 W2 {8 O! t
sistent with true precocious puberty since his testi-5 b! `- k+ ^6 o4 s: ^0 N. P
cles were prepubertal in size. However, testotoxicosis
" @$ J+ Q0 e2 \- T: E! k$ R+ dwas in the differential diagnosis because his father
* }% m0 e! A8 R" y' ^# T7 G2 L0 Qstarted puberty somewhat early, and occasionally,
2 b: ?0 B! T6 Ntesticular enlargement is not that evident in the# t/ m& A: r% x$ s D8 }' L" C; U; Q
beginning of this process.1 In the absence of a neg-0 e9 s, s4 {8 O/ J; u- R9 V
ative initial history of androgen exposure, our9 h) M, R' N g- n/ s6 v
biggest concern was virilizing adrenal hyperplasia,
) l. [( F! ^* l7 m4 e* s9 |either 21-hydroxylase deficiency or 11-β hydroxylase* j A% o k+ r- F2 K* U/ }
deficiency. Those diagnoses were excluded by find-# N4 U+ n3 S" Y2 H/ H( p
ing the normal level of adrenal steroids.% L& r( ~' j3 q& `) w# `% q
The diagnosis of exogenous androgens was strongly5 G8 W; {! @& C8 f/ R
suspected in a follow-up visit after 4 months because
1 Y, b5 `3 b- b6 r7 bthe physical examination revealed the complete disap-& A4 e6 l: X( c* [
pearance of pubic hair, normal growth velocity, and0 f# A2 Q0 f6 a3 `$ B# d$ L
decreased erections. The father admitted using a testos-
5 W3 D. Z" h3 I3 f" H/ a+ hterone gel, which he concealed at first visit. He was" R2 N( \1 S/ d- z r6 U4 Q# v
using it rather frequently, twice a day. The Physicians’
2 H$ W' I4 P& e. T) S% rDesk Reference, or package insert of this product, gel or9 m1 W: p/ D1 M( e3 s
cream, cautions about dermal testosterone transfer to
8 K0 A& H# | Y) ?unprotected females through direct skin exposure.
. M8 [( _. p G( U: D7 tSerum testosterone level was found to be 2 times the+ H: I- b- ?( o2 l, E6 Y( P0 V
baseline value in those females who were exposed to
# x: y8 X- }3 {+ f5 b; d+ l: yeven 15 minutes of direct skin contact with their male3 n$ F, w2 A1 ]( Y8 A
partners.6 However, when a shirt covered the applica-5 M5 k, Y2 k8 ?" T( B- c
tion site, this testosterone transfer was prevented.
. l. O' N5 G9 kOur patient’s testosterone level was 60 ng/mL,' p$ ]0 l5 t8 y; r/ J; d5 E( l
which was clearly high. Some studies suggest that5 x8 n* k% }0 R3 p
dermal conversion of testosterone to dihydrotestos-! ], u: A" @. x* `/ S
terone, which is a more potent metabolite, is more
. x' v6 C! U/ n6 _active in young children exposed to testosterone3 d) ^: j+ |" \* c" R; @
exogenously7; however, we did not measure a dihy-
8 h+ T, Z" R/ v8 a7 X8 i: h6 idrotestosterone level in our patient. In addition to
: T3 [) s9 C" g% _* N1 {, Vvirilization, exposure to exogenous testosterone in4 Q* d8 f6 {2 V! z( [% @; p
children results in an increase in growth velocity and
$ c+ R7 W! K1 M1 b9 Zadvanced bone age, as seen in our patient.
7 l: {& U( \ k+ ?The long-term effect of androgen exposure during
7 Q/ a' z% s9 C [1 u# Wearly childhood on pubertal development and final( p8 Z7 e& U) [- }
adult height are not fully known and always remain
8 _% v4 q/ M! V# x: Ba concern. Children treated with short-term testos-
~2 \& b+ C, R8 q' F$ Tterone injection or topical androgen may exhibit some& G* j7 s5 l; e4 |* d P
acceleration of the skeletal maturation; however, after
0 L) F5 e* S' P% R; F2 P- acessation of treatment, the rate of bone maturation6 F- u% h8 E4 o/ u8 d" `
decelerates and gradually returns to normal.8,92 V- _2 z8 R( L c2 m" g
There are conflicting reports and controversy' o6 t' c+ A0 g& `9 M2 T
over the effect of early androgen exposure on adult0 p! j8 F- F- T5 L
penile length.10,11 Some reports suggest subnormal. R1 X( H% I, S2 j) v( k
adult penile length, apparently because of downreg-- ~3 ?/ y- e- Y$ F
ulation of androgen receptor number.10,12 However,( ^: g2 \) \- r% e3 x R0 @3 ?
Sutherland et al13 did not find a correlation between
} e0 O( K# ]childhood testosterone exposure and reduced adult5 Y8 j; B9 k: s& |4 }
penile length in clinical studies.
0 }$ M8 c, O0 a, a( n! L0 [' T/ JNonetheless, we do not believe our patient is
( L6 X# y1 p ?6 m) D( Wgoing to experience any of the untoward effects from
: Z4 A5 x. i* g% O' j7 ~) | Btestosterone exposure as mentioned earlier because _ C# s& I9 k
the exposure was not for a prolonged period of time.
& F2 L; ?" |, Q! d0 p( @: GAlthough the bone age was advanced at the time of
4 U8 z. }1 W4 M1 a4 Mdiagnosis, the child had a normal growth velocity at
% }% D: v: ?% s/ N% D# J) tthe follow-up visit. It is hoped that his final adult9 ?6 G: P( g+ \; G
height will not be affected.0 K! P+ N1 v. m$ n4 e8 Y l
Although rarely reported, the widespread avail-
+ J% k1 _6 ~0 e! Yability of androgen products in our society may
$ b5 _6 D, H* I9 l( Y7 U5 W+ Uindeed cause more virilization in male or female
. S* ~& ^5 W9 }2 g( Y: i+ Achildren than one would realize. Exposure to andro-
i0 g3 B. b% K( b/ v tgen products must be considered and specific ques-5 V& {. E8 v. M! R
tioning about the use of a testosterone product or9 k# ~# x+ Y2 j5 s
gel should be asked of the family members during
3 G" \+ E: ^, j3 J$ n7 vthe evaluation of any children who present with vir-, M0 {- ?/ y" X1 w9 w" l
ilization or peripheral precocious puberty. The diag-
' A% \! d- o$ J; P L! \; Knosis can be established by just a few tests and by( @' q3 s0 m4 B
appropriate history. The inability to obtain such a
6 D O/ O' S* d+ P) Q% I, mhistory, or failure to ask the specific questions, may
( L3 |% _! s& Eresult in extensive, unnecessary, and expensive
5 ~9 m. R8 f ?' {) ^6 Xinvestigation. The primary care physician should be
; V# a8 j3 [# M! J& e0 R- k' M5 Raware of this fact, because most of these children+ a: P$ f4 o. a0 a4 [" v
may initially present in their practice. The Physicians’
1 W8 k/ G4 [! XDesk Reference and package insert should also put a
, R, o! o V4 c9 lwarning about the virilizing effect on a male or5 h# Z$ w. f L4 w A; o+ F
female child who might come in contact with some-
- ?4 l1 y/ W z( [ [' y# [- Kone using any of these products.
/ i; o* n5 D. F/ p0 j+ f4 z- dReferences
7 J P o+ F3 s: ?4 m; F1. Styne DM. The testes: disorder of sexual differentiation9 T- J; R* h/ o( h3 R, P
and puberty in the male. In: Sperling MA, ed. Pediatric0 N4 [( u( d' O7 E% [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& w% S) Z0 [' d" c% s; B7 l" \
2002: 565-628.
$ W# S5 B' T* S0 _5 C/ V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* G o* d9 e) \' t9 }( w
puberty in children with tumours of the suprasellar pineal |
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