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Sexual Precocity in a 16-Month-Old! X* Q! y- _% b# f
Boy Induced by Indirect Topical
0 N, p" Q- ^( Y0 H7 `; ?: `Exposure to Testosterone
# ~3 U' j9 D1 b$ R3 f" W. ~0 s% JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 ^5 o* Y0 r: m9 t+ ~2 d8 u; Nand Kenneth R. Rettig, MD1
, w: |9 G: r7 V/ K( Q0 V& JClinical Pediatrics
! D' p! n+ Q. _9 \5 |. tVolume 46 Number 6
" F v3 Z- C4 A( x2 MJuly 2007 540-543
9 d/ D6 Q, @# _/ y/ g! x2 D© 2007 Sage Publications
' w/ @4 @' f1 X" I- O10.1177/0009922806296651$ J7 [3 {8 J; _& U' m0 X; m" S2 U
http://clp.sagepub.com a- Q% R( @5 B# c" ^
hosted at. e: i1 p2 B* n W! R
http://online.sagepub.com) P. b) G7 {; v
Precocious puberty in boys, central or peripheral,
$ Q: K0 H8 t# Z* d. b. w+ c# F0 His a significant concern for physicians. Central7 o9 d- v+ t1 C# y# n
precocious puberty (CPP), which is mediated( f5 f* b/ f/ ]: u9 P: s
through the hypothalamic pituitary gonadal axis, has e" v5 j# g2 v: S# I3 N
a higher incidence of organic central nervous system7 \+ a8 b/ O4 ^
lesions in boys.1,2 Virilization in boys, as manifested2 I8 N: }! x: R* X3 f7 j
by enlargement of the penis, development of pubic% v. U! o5 I) e9 g! u
hair, and facial acne without enlargement of testi-! Y5 K% [# q. P2 Q
cles, suggests peripheral or pseudopuberty.1-3 We
# c( i t! O7 k: t, d4 zreport a 16-month-old boy who presented with the: n% e( `2 m, `1 G5 O+ ]/ E6 x. w
enlargement of the phallus and pubic hair develop-. e# X( g+ W- ~$ q, j) ^$ V$ L9 l
ment without testicular enlargement, which was due' y0 G- E$ X' }+ y
to the unintentional exposure to androgen gel used by
& i8 I: P6 x' p5 ^: p3 ]the father. The family initially concealed this infor-
/ _+ p: e5 R9 T, F; Wmation, resulting in an extensive work-up for this X7 q$ x6 v. L
child. Given the widespread and easy availability of
( f+ ]. ]! p( @% _( gtestosterone gel and cream, we believe this is proba-
8 ^5 E% S& s4 |9 U+ K; [3 xbly more common than the rare case report in the
7 ]' J+ o6 G6 Z) n- {! Wliterature.4' Y& r! i/ u& W/ s5 `, b
Patient Report
+ ~4 S2 R! l+ E: y+ I1 {- j3 bA 16-month-old white child was referred to the
% E; ]" \# s6 r$ |) Z9 |endocrine clinic by his pediatrician with the concern
0 c1 ?6 @2 F1 x) q0 X7 |of early sexual development. His mother noticed g- V4 G9 n* W. C' P% X2 t/ P
light colored pubic hair development when he was4 {) @& g/ O6 X9 g5 U' L S- D
From the 1Division of Pediatric Endocrinology, 2University of
4 Q. Z& I) m4 Y: h3 I9 ?South Alabama Medical Center, Mobile, Alabama.! V6 c* |# N2 I4 B5 @. m; n
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 n, E+ t+ h9 Y! J5 ]& g+ Q2 Z1 ^1 G
Professor of Pediatrics, University of South Alabama, College of
, N! N, e9 ?) X$ _+ u# @, u- p9 YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 ^) f8 G( P" L$ ]! s' Z/ p+ T V
e-mail: [email protected]." Y2 [7 g; U( v5 u E
about 6 to 7 months old, which progressively became0 i4 g9 C/ ?, K' l
darker. She was also concerned about the enlarge-
! H7 v( A4 i$ k4 t. e# X9 mment of his penis and frequent erections. The child8 G( ]- H( B! i" R* Z' V8 M3 [3 V
was the product of a full-term normal delivery, with, w+ W% n' g4 P! A6 o& K6 ?
a birth weight of 7 lb 14 oz, and birth length of' x( {) i1 s; Z2 U1 t R: Z$ J
20 inches. He was breast-fed throughout the first year) l2 w: }( g1 N- ~% P: w7 c
of life and was still receiving breast milk along with2 b9 ~. D8 w% z+ }4 i9 | {+ Q0 B
solid food. He had no hospitalizations or surgery,
9 W l6 `! b$ k3 N5 jand his psychosocial and psychomotor development
2 l% n* @) M$ w5 jwas age appropriate.. M" B! x4 Q. ~9 }1 R1 H& |
The family history was remarkable for the father,
+ p- [( P, T5 j, H* m& J5 C+ s1 }5 L7 Gwho was diagnosed with hypothyroidism at age 16,
7 [5 }5 z8 O3 ]' ywhich was treated with thyroxine. The father’s1 [, B- s6 d9 @; d- g
height was 6 feet, and he went through a somewhat) g% H. i5 B& ?9 F- K
early puberty and had stopped growing by age 14.
/ H- C: u1 l6 g* }* w4 ~. M4 Z( yThe father denied taking any other medication. The2 j- Z3 B K+ @: k
child’s mother was in good health. Her menarche
- j* G9 a* c5 s$ Lwas at 11 years of age, and her height was at 5 feet- I- ?* h: ?( s. a+ G
5 inches. There was no other family history of pre-" [5 t: ]- c- J4 B) X3 L
cocious sexual development in the first-degree rela-" @9 y# }4 B2 c* m* [+ s4 ~2 w
tives. There were no siblings.
5 U. S1 `% }6 NPhysical Examination
5 n( g1 P! g$ H: _; k- w8 ` t8 CThe physical examination revealed a very active,+ x9 ~7 z' o0 C
playful, and healthy boy. The vital signs documented
) S6 g, V3 o! h6 @# |a blood pressure of 85/50 mm Hg, his length was
: v6 N6 N8 N1 @ C9 P90 cm (>97th percentile), and his weight was 14.4 kg5 ]- a0 o# C5 P8 d
(also >97th percentile). The observed yearly growth8 D+ k% t6 d( Q6 H2 O: {
velocity was 30 cm (12 inches). The examination of
1 `. L- J+ n5 j3 A' Wthe neck revealed no thyroid enlargement.
; f4 H. o! l, I9 Q0 o6 aThe genitourinary examination was remarkable for' _+ l9 g' e+ l' U
enlargement of the penis, with a stretched length of
) r6 ^. M7 d* `- e3 M8 cm and a width of 2 cm. The glans penis was very well
( ]6 h' b c$ Y1 M. Ddeveloped. The pubic hair was Tanner II, mostly around5 M& Z7 H8 y* P6 r
540
& L. j7 ]' O3 ~9 ~# Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ N0 @8 u! d) w; P
the base of the phallus and was dark and curled. The
( @5 X2 ?" E" r* h9 ^* H) ttesticular volume was prepubertal at 2 mL each.
8 d8 |; y& k L) O2 DThe skin was moist and smooth and somewhat
$ p& U3 p$ K# |2 `oily. No axillary hair was noted. There were no* o \/ w- n; G7 e' {3 T
abnormal skin pigmentations or café-au-lait spots.; v$ s6 V: \3 C# {- r0 g- e7 Q
Neurologic evaluation showed deep tendon reflex 2+1 J& y ^$ H8 I/ C+ E
bilateral and symmetrical. There was no suggestion
. ~. Q. [9 K7 Q! E9 F" g+ Q; d, cof papilledema.' A9 L* S% o2 F3 i: t6 u3 [
Laboratory Evaluation8 O4 X z- a6 e9 V" Y0 k* Z6 ~
The bone age was consistent with 28 months by* i& [, G; C* u
using the standard of Greulich and Pyle at a chrono-* Q" Q- X7 F$ d; K4 M- m
logic age of 16 months (advanced).5 Chromosomal
/ J* `* r# t1 e* i+ Y7 kkaryotype was 46XY. The thyroid function test- e. f0 @2 o4 N: U, p0 @1 {5 I: f ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 w. o! W7 B5 H0 t% [* R
lating hormone level was 1.3 µIU/mL (both normal).
; D' Y9 J' J8 ~; kThe concentrations of serum electrolytes, blood
( k0 X* i c/ ?- u ~6 uurea nitrogen, creatinine, and calcium all were. H) A1 [" D+ h9 v+ y& R* x
within normal range for his age. The concentration/ w. i* y: l' i6 z6 j: L- Q
of serum 17-hydroxyprogesterone was 16 ng/dL
6 M) L" V; H5 E8 z! [% F2 W0 T(normal, 3 to 90 ng/dL), androstenedione was 20
/ f6 c: X/ j/ u2 o/ Y3 h( P( q4 v2 ~! gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ u1 Y4 E% y0 s: d
terone was 38 ng/dL (normal, 50 to 760 ng/dL), {8 T- R* f0 s9 x$ v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ p, }3 k: B- G8 } c: X7 R5 a49ng/dL), 11-desoxycortisol (specific compound S)
. n: }: i! D& X9 Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% Q- j! f: x utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ V/ s- H2 P) Z6 e- C- Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 p& o/ o, z7 P ]3 Uand β-human chorionic gonadotropin was less than
F- P0 q3 o {5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 W( y% T! k$ vstimulating hormone and leuteinizing hormone% M. G5 N8 D% c( \" Y( y
concentrations were less than 0.05 mIU/mL
) N, u0 H6 ?6 O6 \- k; }, Q d6 G(prepubertal).# e5 S' O& [/ v0 M6 s3 D
The parents were notified about the laboratory
& z9 ?$ @: {( q" Oresults and were informed that all of the tests were/ b& p4 V/ Q: V5 ]" W6 ~ t
normal except the testosterone level was high. The, |! e. n0 c- e/ p5 J5 H& l4 _
follow-up visit was arranged within a few weeks to
: _- X" A* r( k! O, K$ Fobtain testicular and abdominal sonograms; how-. m8 b Z& l% ~6 v: n
ever, the family did not return for 4 months.
/ w+ s1 w9 |3 L/ i) q. P$ I- MPhysical examination at this time revealed that the
! k/ |4 Y6 K' V/ qchild had grown 2.5 cm in 4 months and had gained% _& W) b* R% L) `* c1 H! d( C/ D4 K
2 kg of weight. Physical examination remained
6 O: H& X" I' q9 _unchanged. Surprisingly, the pubic hair almost com-
0 Y( b9 `. d2 V9 F' qpletely disappeared except for a few vellous hairs at2 W7 e- [8 D' E3 u& l' ]
the base of the phallus. Testicular volume was still 2
p# U$ b5 F2 a( B. [, imL, and the size of the penis remained unchanged.2 i' _$ b! O3 x! P, C
The mother also said that the boy was no longer hav-% @# u+ a. _; P, a0 Z9 |" |
ing frequent erections.' F$ a& h5 _7 h6 N C( W/ H
Both parents were again questioned about use of5 D: M" g1 A$ J @1 h. O
any ointment/creams that they may have applied to
7 E6 O# }1 j2 ^6 y3 B6 v1 u1 wthe child’s skin. This time the father admitted the$ r* h, f$ z" P9 T& j# L- A- @. Z' P4 r
Topical Testosterone Exposure / Bhowmick et al 541
6 b7 Z7 C' g% Q3 c% k1 }use of testosterone gel twice daily that he was apply-
4 v8 l0 C3 H8 {7 C0 S. N9 Cing over his own shoulders, chest, and back area for X; r% n! _3 |7 F2 y
a year. The father also revealed he was embarrassed& t6 W/ Q2 M# T) g9 a& w% _
to disclose that he was using a testosterone gel pre-
5 v: V* G! p6 B; A3 o2 d8 Xscribed by his family physician for decreased libido$ J& ~* t. [: ?, S& ^
secondary to depression.! Z/ C& Z; s5 H9 N% w
The child slept in the same bed with parents.( H) i& W4 F' m8 f
The father would hug the baby and hold him on his1 w7 T: y. C9 ]7 [% I
chest for a considerable period of time, causing sig-& _, c& {, H; Q3 P5 Q
nificant bare skin contact between baby and father.
4 `$ |. V e7 V7 i1 nThe father also admitted that after the phone call,
: D9 A% V4 h; m; r5 D7 kwhen he learned the testosterone level in the baby' m2 h+ J! p& {
was high, he then read the product information
' ] M/ m6 u6 @2 y$ c Opacket and concluded that it was most likely the rea-" J( }& j. s% j) Y
son for the child’s virilization. At that time, they
! a# \& f4 Z( e* P: n. C' Xdecided to put the baby in a separate bed, and the; O/ l6 O% G1 \/ k+ ?0 {5 J% Q4 O4 s
father was not hugging him with bare skin and had+ ^' Q# @0 f) [2 p j0 G
been using protective clothing. A repeat testosterone
, F9 k: k& R5 b D/ k& v, K; jtest was ordered, but the family did not go to the
, G5 f7 x& l! p+ |laboratory to obtain the test.7 r- d" r+ |; J! @3 F, B5 A) E
Discussion
7 V: f: V8 k1 \0 M @4 `' I# S1 ` rPrecocious puberty in boys is defined as secondary+ A' B4 q! E- G! K+ ]0 s+ A( S$ L2 y
sexual development before 9 years of age.1,4- N& _: l. G# V9 K. A
Precocious puberty is termed as central (true) when0 s+ ^9 e) z% Y. n" s
it is caused by the premature activation of hypo- y) I1 W) t. {4 u6 E1 R
thalamic pituitary gonadal axis. CPP is more com-
4 c! n ` x4 k* b$ l- W2 cmon in girls than in boys.1,3 Most boys with CPP; x" L: V, @6 b; s+ m' x2 e% P. z
may have a central nervous system lesion that is
* D& Z+ R, Q7 O3 b$ p0 Yresponsible for the early activation of the hypothal-3 b0 E" D! b8 B5 N% a
amic pituitary gonadal axis.1-3 Thus, greater empha-
. h ?% a' X( Z) E: dsis has been given to neuroradiologic imaging in1 d8 `3 @! x5 ]
boys with precocious puberty. In addition to viril-6 j f$ R( ]: B0 r
ization, the clinical hallmark of CPP is the symmet-
8 X# _+ Q/ H7 \rical testicular growth secondary to stimulation by
0 d' L* s$ O$ t* x0 k, G7 Cgonadotropins.1,3( d5 l& O! @5 f% t! v) B% _# K
Gonadotropin-independent peripheral preco-
, v% z3 F5 C% v# k8 vcious puberty in boys also results from inappropriate
: [1 ]" x6 b! randrogenic stimulation from either endogenous or2 C- p. U) k* ~% [7 U. v7 M! l3 I
exogenous sources, nonpituitary gonadotropin stim-) d. U1 O. k) [7 v
ulation, and rare activating mutations.3 Virilizing
+ C' v/ w+ F8 S+ m4 C- ~: lcongenital adrenal hyperplasia producing excessive
( }" h4 E; b. o$ ?adrenal androgens is a common cause of precocious
/ O# p3 i3 K7 }% P9 U: Y8 M# xpuberty in boys.3,45 U0 Z) f0 g( S9 ~
The most common form of congenital adrenal5 K3 N- D i' ~: S
hyperplasia is the 21-hydroxylase enzyme deficiency.# w% r% O; _9 R
The 11-β hydroxylase deficiency may also result in# }2 L3 J% w Z7 p! \# q( B v
excessive adrenal androgen production, and rarely,3 \* r4 x1 y( J8 _* H3 A1 z! a# x- E
an adrenal tumor may also cause adrenal androgen
' b2 r$ _: |6 e- s I/ Hexcess.1,3
: K3 ^* t! |0 Q6 I Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 W4 T# j' i; Z2 k8 s0 Z6 \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 b- g# |# c( U4 A& w# J. |
A unique entity of male-limited gonadotropin-- w) b4 Q) `8 m1 c8 f
independent precocious puberty, which is also known
9 W6 G0 K4 Y/ M8 Jas testotoxicosis, may cause precocious puberty at a% F3 k, C( M! `7 d4 d
very young age. The physical findings in these boys$ r7 K: \( W$ {7 u5 T. l- L- ~3 c
with this disorder are full pubertal development,
9 E- z% ?7 T$ E8 Q6 j( X: Xincluding bilateral testicular growth, similar to boys* O" z4 z, h! `- ]9 C" |% ` S7 R
with CPP. The gonadotropin levels in this disorder3 m/ k6 Y1 g* l9 L7 l+ ^* ^
are suppressed to prepubertal levels and do not show+ ~) z4 S# O, d( j. X3 `
pubertal response of gonadotropin after gonadotropin-" Z* d' g/ R) [6 `, }& |, q
releasing hormone stimulation. This is a sex-linked
& B3 q3 {7 ?! w2 Tautosomal dominant disorder that affects only
* d, n3 ?& B* f6 }% L, m! b' L: imales; therefore, other male members of the family( D0 U* ^4 u% u! i$ G5 l1 g/ g+ J
may have similar precocious puberty.3( ?) j2 @2 F9 K, j% S
In our patient, physical examination was incon-9 k4 @8 g0 y$ T7 q& m
sistent with true precocious puberty since his testi-8 M y8 c f9 j4 E& W: |5 ^
cles were prepubertal in size. However, testotoxicosis! L. ]/ e3 Y0 `# m7 h) Z" \! T
was in the differential diagnosis because his father' y& F% }+ p, \8 Q- {% ]% R+ f
started puberty somewhat early, and occasionally,2 H L2 S: V% V" i) h- ?
testicular enlargement is not that evident in the
; o& Q+ M5 }2 P& V" k6 t; u" Ibeginning of this process.1 In the absence of a neg-
) \" E6 T5 z! F1 L* a {ative initial history of androgen exposure, our1 w, \, Y5 V$ v8 W
biggest concern was virilizing adrenal hyperplasia,
2 w6 D% A; {! e% W* E5 deither 21-hydroxylase deficiency or 11-β hydroxylase
, l( \* d5 J5 a o' D& j- Sdeficiency. Those diagnoses were excluded by find-
& S- l1 x% K- O) A; ?. y ~& Xing the normal level of adrenal steroids.
$ L! z# M* _% f9 H% ^9 jThe diagnosis of exogenous androgens was strongly0 h/ O+ H: k0 I
suspected in a follow-up visit after 4 months because
/ G8 g1 d& B: w2 o. y! Vthe physical examination revealed the complete disap-
4 z1 }' C- ^; I/ i" W) |pearance of pubic hair, normal growth velocity, and
. z( v+ K7 R' bdecreased erections. The father admitted using a testos-4 r- j) }8 M7 z- c' W
terone gel, which he concealed at first visit. He was
. m! u4 t' y! ^4 X3 \using it rather frequently, twice a day. The Physicians’6 O! \8 _, M8 K7 ]+ g$ f2 |
Desk Reference, or package insert of this product, gel or
, j! `/ ]: M, h- o3 i- Wcream, cautions about dermal testosterone transfer to
7 k& w( Z# N0 P. q R3 zunprotected females through direct skin exposure.
7 ? R3 s7 r B+ W: J* zSerum testosterone level was found to be 2 times the
* H2 w7 R( }/ jbaseline value in those females who were exposed to
# K$ ~' t. p) s$ `even 15 minutes of direct skin contact with their male2 s) ?) r- ?8 U$ a6 z8 R/ T$ i
partners.6 However, when a shirt covered the applica-% @0 z& j% ^3 O( `( M' ?4 x6 D
tion site, this testosterone transfer was prevented. i( K* \# Y# }/ v" u
Our patient’s testosterone level was 60 ng/mL,( Z' C9 B8 q9 b3 k
which was clearly high. Some studies suggest that7 G6 }" a# c; f$ p) c x/ B
dermal conversion of testosterone to dihydrotestos-
% q+ ]3 [) V6 z, y# Uterone, which is a more potent metabolite, is more. ~) h5 k1 `& ]! S
active in young children exposed to testosterone
j# d+ c# u( u- J/ C0 P/ U; Jexogenously7; however, we did not measure a dihy-, Q; v8 C! W: C f% A; _1 M
drotestosterone level in our patient. In addition to( ~0 M9 b: j4 z+ t7 A
virilization, exposure to exogenous testosterone in% M$ Q9 K$ P$ Z& L; |6 e& m. u
children results in an increase in growth velocity and. G" H9 t$ ~, k! e: Z P2 B
advanced bone age, as seen in our patient.
* R* C! f1 k+ A* f2 CThe long-term effect of androgen exposure during y g4 A0 l! ~# x: i+ g
early childhood on pubertal development and final8 Z: g# \: l8 f- q" Y. M
adult height are not fully known and always remain
# L6 w/ m, I2 p# C# k) ]0 G" Ma concern. Children treated with short-term testos-: G) B. v. F: ^% I1 T2 o. d
terone injection or topical androgen may exhibit some
4 s( }. ^" ?& jacceleration of the skeletal maturation; however, after: l, f; H* e7 z! ?# p1 A# N5 H
cessation of treatment, the rate of bone maturation" g, M8 u& ? r7 C, h A4 R
decelerates and gradually returns to normal.8,9$ M' P; o4 w+ l, M* P% A, [% U
There are conflicting reports and controversy
$ S% e# D, @! E8 Gover the effect of early androgen exposure on adult
) y$ ?7 L q5 A% dpenile length.10,11 Some reports suggest subnormal
% t+ D" w& ^$ B' q9 E) u% R6 cadult penile length, apparently because of downreg-4 A2 \$ D% D. f
ulation of androgen receptor number.10,12 However,) D6 J" J' D, a+ V
Sutherland et al13 did not find a correlation between) K0 n. F, Q: X/ _
childhood testosterone exposure and reduced adult+ w9 z/ U. W3 z* U: R5 x
penile length in clinical studies.
( U e* [" l! a3 @& bNonetheless, we do not believe our patient is
g2 y% Q" x0 m- ?( mgoing to experience any of the untoward effects from
5 u f( T7 x* k4 B" ytestosterone exposure as mentioned earlier because' h' f) @: m( K, h# O( U1 O
the exposure was not for a prolonged period of time.
6 Q& |9 G6 |! j9 u* zAlthough the bone age was advanced at the time of
& M, V( F6 O$ {diagnosis, the child had a normal growth velocity at
6 f& j; F8 i, rthe follow-up visit. It is hoped that his final adult# m' F+ ~* _& M: S
height will not be affected.+ o( y9 ?/ y6 p: j
Although rarely reported, the widespread avail-
x* _* L) ^8 } ]" j' M5 m. r6 Hability of androgen products in our society may
0 z2 T: ?% M% F& f2 h) g2 a2 [indeed cause more virilization in male or female
( f6 M4 U. m4 X+ {4 ?9 R! O; ?children than one would realize. Exposure to andro-
% A' I% G$ B: m8 T2 c- `gen products must be considered and specific ques-
7 ~7 r& E( a1 U! I3 w( w0 Itioning about the use of a testosterone product or- i- ]2 a y0 z6 B3 f) R
gel should be asked of the family members during6 q o) G3 o9 [& F; X
the evaluation of any children who present with vir-
% c5 j& O; n7 N4 k. oilization or peripheral precocious puberty. The diag-
& M% C5 p% S+ J" C6 W1 Snosis can be established by just a few tests and by
/ S- W) z$ \% s1 P+ H1 lappropriate history. The inability to obtain such a
( s+ {- C! `6 B7 f* Chistory, or failure to ask the specific questions, may
" q; L( C! q9 n6 \4 _result in extensive, unnecessary, and expensive8 D! T# t0 `' R( H1 o3 i
investigation. The primary care physician should be
/ G7 ?* @: Q4 p( f9 saware of this fact, because most of these children
4 N4 F! b$ |) hmay initially present in their practice. The Physicians’
2 F; K- ~; }. U2 U9 YDesk Reference and package insert should also put a# m# |8 H1 n6 w5 R( l0 v H
warning about the virilizing effect on a male or
% c' v: a" H3 G' e( hfemale child who might come in contact with some-9 A: O ~4 q% ?0 n% c T
one using any of these products." ^! I8 D2 t) n7 z0 |
References# q. c2 P2 m: v# Q9 S
1. Styne DM. The testes: disorder of sexual differentiation
8 [* O& V' R1 [5 i( ^and puberty in the male. In: Sperling MA, ed. Pediatric
4 q5 F6 i! V0 u- v/ u/ O, UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* q2 m, M5 n8 o, N2 {0 d3 O+ k. _
2002: 565-628.
( |5 `: D4 S1 L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 @- o Z" n$ d- F; l( lpuberty in children with tumours of the suprasellar pineal |
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