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Sexual Precocity in a 16-Month-Old
! v4 x2 `+ ]( x# I6 cBoy Induced by Indirect Topical/ I6 {6 D6 W; f
Exposure to Testosterone- ?9 \) k( U4 d3 L. D, A! t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& e8 O3 u4 E. \7 d) L! r/ \
and Kenneth R. Rettig, MD1
! @! f: [. c+ Z& L1 jClinical Pediatrics5 ^4 o. t$ A" J4 N+ X# ]+ B
Volume 46 Number 6& G0 J3 t$ S) @* [: h; C) l2 Y
July 2007 540-543, y* D) {# A0 @: V
© 2007 Sage Publications, ]% O$ Z: S3 f- B% ?
10.1177/0009922806296651+ @& [+ y7 U$ A9 F8 d5 w) o o# x
http://clp.sagepub.com1 g+ F0 R2 N7 u: P4 P, R- Q8 |
hosted at5 v Z$ h: H0 q8 }. {
http://online.sagepub.com
' ]+ B4 u; O- H B* A$ G7 GPrecocious puberty in boys, central or peripheral,; W' n% I2 b6 g* w3 _7 |
is a significant concern for physicians. Central5 L+ b: A0 \7 O' k5 L
precocious puberty (CPP), which is mediated
! L0 C: E1 P* M2 \! m+ A4 Kthrough the hypothalamic pituitary gonadal axis, has; g- e7 v+ }& U0 ?6 Y4 E) V
a higher incidence of organic central nervous system4 V! q' ~$ y0 c1 [
lesions in boys.1,2 Virilization in boys, as manifested
9 u5 C+ j/ ?" E! W1 a! Tby enlargement of the penis, development of pubic- q6 p4 a' P Y X* n2 j
hair, and facial acne without enlargement of testi-
+ ]5 f, I( W% A0 @$ E$ i) acles, suggests peripheral or pseudopuberty.1-3 We* P9 b( y2 ~4 Z* S- C Y
report a 16-month-old boy who presented with the
( g# Y0 D: \6 r1 {/ q2 p% genlargement of the phallus and pubic hair develop-5 p+ L, E, o* G5 P: T
ment without testicular enlargement, which was due' N5 F; j; T. V5 k' B
to the unintentional exposure to androgen gel used by+ C9 s8 _; l. f: z3 S
the father. The family initially concealed this infor-
9 V" s M: v. i$ f5 h# N8 J, ~mation, resulting in an extensive work-up for this; ^4 n' d9 j" W9 V
child. Given the widespread and easy availability of
, r; I- M' c1 Q' u; K+ E% }testosterone gel and cream, we believe this is proba-
6 }; X; ]/ z/ L, c3 ebly more common than the rare case report in the4 I3 @4 J! G0 i* h$ w* }( X
literature.49 U" C0 p3 L' _0 c+ V8 j) s- t% \
Patient Report( o" H" h' V ^/ C1 J
A 16-month-old white child was referred to the
$ h+ m6 W S" i6 a& oendocrine clinic by his pediatrician with the concern
! v, g. r% e5 H0 f/ |% wof early sexual development. His mother noticed4 K% G6 Y) s; b' \
light colored pubic hair development when he was
2 p% i0 h3 l3 S! o) F8 ]2 VFrom the 1Division of Pediatric Endocrinology, 2University of3 D$ ~2 L8 `% @8 B/ \4 d
South Alabama Medical Center, Mobile, Alabama.
7 ~8 n" ]3 w" o, |2 D K D/ z; k) ]Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ O" J- V7 u- N( y- AProfessor of Pediatrics, University of South Alabama, College of& x/ V3 H; w5 s6 ?6 k5 Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% x9 d* @1 I7 ^/ `7 Me-mail: [email protected].
. t2 ~1 U" a% h8 S, J7 nabout 6 to 7 months old, which progressively became
+ X9 i0 {% v( P9 P+ X, Y) R9 D% xdarker. She was also concerned about the enlarge-
. R2 k: \. Z, v7 V, C# E% [ment of his penis and frequent erections. The child
0 Q4 P5 F7 Z5 l/ S, E( @was the product of a full-term normal delivery, with
: M9 ]2 S! b* t% l) D O# Xa birth weight of 7 lb 14 oz, and birth length of
, T- s* J- O J( \' m- l3 B; @20 inches. He was breast-fed throughout the first year- c0 c2 ], u7 t* o
of life and was still receiving breast milk along with
) H2 J9 c/ ?* Zsolid food. He had no hospitalizations or surgery,
# t8 n7 W4 U: x+ p( T! b' t- e7 dand his psychosocial and psychomotor development
) g5 L# o) w+ y7 m5 s3 W6 qwas age appropriate.5 ?9 {* f- N" X8 }
The family history was remarkable for the father,1 f& o, d, W# P0 Q: ~/ }( N
who was diagnosed with hypothyroidism at age 16,
* }! {- i$ d( `3 T* A4 Cwhich was treated with thyroxine. The father’s
t8 }8 i7 F* xheight was 6 feet, and he went through a somewhat
+ [; M& T' f. ]. v* R/ _; o1 zearly puberty and had stopped growing by age 14.
# ^" x. P3 @& h' y; d5 k% |" m. LThe father denied taking any other medication. The9 i4 k. R1 Y# d1 e
child’s mother was in good health. Her menarche; g. s5 ^" X. ~9 W; n& X# M# E
was at 11 years of age, and her height was at 5 feet+ |( s- s! L# [9 L, i* Y
5 inches. There was no other family history of pre-
9 g% _# j1 }0 A& `& Fcocious sexual development in the first-degree rela-
% r9 I1 Z$ W! n9 Jtives. There were no siblings.$ `8 r$ j) F9 W$ m! F- t
Physical Examination
. M8 j9 R2 F9 L! I" P, XThe physical examination revealed a very active,2 z' c' f9 M! S6 p( C
playful, and healthy boy. The vital signs documented
- z0 z% }& c7 _$ @& Ca blood pressure of 85/50 mm Hg, his length was. {8 b6 U9 s( {7 N
90 cm (>97th percentile), and his weight was 14.4 kg
3 ]0 Y1 e4 K) |/ l) P2 A0 a4 Z(also >97th percentile). The observed yearly growth* i" f: i2 D; E+ @, @4 v3 T& I1 k
velocity was 30 cm (12 inches). The examination of
$ ?% c% n `0 k( g3 l& j( tthe neck revealed no thyroid enlargement.; y% E, k6 J+ a; x% t: ]
The genitourinary examination was remarkable for) \/ S4 {- M- z" {: |0 K
enlargement of the penis, with a stretched length of
! z2 N, l! m# w8 d) k4 M8 cm and a width of 2 cm. The glans penis was very well
& P9 G7 }5 ^/ \: rdeveloped. The pubic hair was Tanner II, mostly around
8 r! R( D, e4 p) b9 Y+ }+ w5402 n7 u$ L0 O/ w" T5 b. {1 c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* ^9 q7 }5 g- D3 i5 E$ `the base of the phallus and was dark and curled. The$ d T- }9 A3 T+ C
testicular volume was prepubertal at 2 mL each.- S7 G# J' A: g0 j6 E
The skin was moist and smooth and somewhat
8 J3 t! p5 F7 V- Y& K9 X( k& Foily. No axillary hair was noted. There were no1 t. T0 U! z: ^% q
abnormal skin pigmentations or café-au-lait spots.
5 r6 o$ L% j- ?6 ~Neurologic evaluation showed deep tendon reflex 2+
& i0 Y4 Y) }6 v3 m5 H) Q4 q) @, Obilateral and symmetrical. There was no suggestion
. Q& R- x( R3 O& f8 ~/ e0 `of papilledema.
% t+ Q5 h$ {# V$ O) Y5 dLaboratory Evaluation4 U* m' S, g9 C8 v5 w: W# t
The bone age was consistent with 28 months by
! L; W% ]# C4 L7 L7 Tusing the standard of Greulich and Pyle at a chrono-
$ ?+ v e. i2 [. O' a* |logic age of 16 months (advanced).5 Chromosomal
( w2 W Z' O% c D, z, @1 Ykaryotype was 46XY. The thyroid function test
; K/ ?# R* W7 h/ [/ qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) s1 j3 U5 u1 Clating hormone level was 1.3 µIU/mL (both normal).
- H9 f v) H: u" v6 B6 M( j( _6 @The concentrations of serum electrolytes, blood
) r# X4 p7 |. v Eurea nitrogen, creatinine, and calcium all were9 F7 d5 L% B. u5 C' N, q
within normal range for his age. The concentration
( E' n0 ?: E. m4 U$ Zof serum 17-hydroxyprogesterone was 16 ng/dL
: N/ g+ I: A$ z# t$ I( o(normal, 3 to 90 ng/dL), androstenedione was 203 k1 K2 h' E! E9 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 f/ E2 r/ P4 o1 S: j9 [terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" A7 T6 i2 i# G! u8 @3 w, H6 x6 Fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" [8 C3 H0 w; n+ t2 ^$ r) b# P+ `49ng/dL), 11-desoxycortisol (specific compound S)* A5 v2 |7 O4 ]8 z: N1 l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( X0 [3 K1 P: U: E1 Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% x& m+ v% l2 l$ Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# r6 n& F# G* U$ H" G# z) ]and β-human chorionic gonadotropin was less than+ u! Z" o+ E' g v) u7 H
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) ^; T: N) T+ A. {) R# wstimulating hormone and leuteinizing hormone
6 q3 s9 G1 A$ a' h3 G, econcentrations were less than 0.05 mIU/mL1 s6 h( F- v. Y$ C! g$ b+ ^) H
(prepubertal).
# ~# _# d3 R- ^The parents were notified about the laboratory
- b( c$ B$ f9 xresults and were informed that all of the tests were
' u3 H- b$ T) y+ y$ l6 Bnormal except the testosterone level was high. The
% [8 v6 Y, E' cfollow-up visit was arranged within a few weeks to+ C% r ?# I3 _2 w9 Y9 t# o) ~
obtain testicular and abdominal sonograms; how-# J5 O4 W$ v% [, X! d: |- V
ever, the family did not return for 4 months.' o' z1 M' y1 n* |) p
Physical examination at this time revealed that the: u4 J4 t' u7 m3 e) J3 _1 g
child had grown 2.5 cm in 4 months and had gained
- d6 U! h. W+ a" N7 q, Q2 kg of weight. Physical examination remained, ?- \+ b7 T# ]
unchanged. Surprisingly, the pubic hair almost com-
- }; B% G) ]4 K$ E* r fpletely disappeared except for a few vellous hairs at6 |. _: h: s* c
the base of the phallus. Testicular volume was still 21 b1 |7 K$ U, \2 N' M
mL, and the size of the penis remained unchanged.7 w* D' y1 E5 }6 O5 |9 b$ o7 S
The mother also said that the boy was no longer hav-
) d6 Z4 b# a/ K- L1 D) t3 |ing frequent erections.1 ~; L& i L& z: E( m, ~0 C, V
Both parents were again questioned about use of
( i( r% m1 d( w+ Sany ointment/creams that they may have applied to, S) ?+ D" u: k4 f. z D5 M
the child’s skin. This time the father admitted the1 v9 E: f2 w$ x
Topical Testosterone Exposure / Bhowmick et al 541
" i. j3 E& T, F0 @use of testosterone gel twice daily that he was apply-
8 I9 h7 ]3 T& f) Ming over his own shoulders, chest, and back area for/ {5 k9 V$ W6 ~1 K! W- k7 Z
a year. The father also revealed he was embarrassed3 V2 x$ R0 W! a5 G
to disclose that he was using a testosterone gel pre-8 Q: L6 [1 k$ r3 b( [/ O0 w
scribed by his family physician for decreased libido
1 s; b% c2 E; h' }# ]+ E& j& rsecondary to depression.
! n/ H! f$ k% P ~9 C+ N0 fThe child slept in the same bed with parents.& u& Y) f) p7 S
The father would hug the baby and hold him on his* u4 S7 N# N5 E# V Z
chest for a considerable period of time, causing sig-
: N( M7 b/ L0 I }nificant bare skin contact between baby and father.
% z" d5 q C4 D" eThe father also admitted that after the phone call,$ y5 Y5 q9 @0 _1 ]' o0 a1 x) |
when he learned the testosterone level in the baby$ S" p) g0 n1 }1 M
was high, he then read the product information
0 ]) r1 ?6 j! h: Gpacket and concluded that it was most likely the rea-3 B" }' p# y- {, X) p
son for the child’s virilization. At that time, they
9 F7 _" K" W4 Hdecided to put the baby in a separate bed, and the
1 ~* I& w8 a# e1 Y7 k, ?5 Y- s( Ofather was not hugging him with bare skin and had& R1 p b$ X* N6 U6 v+ u( b
been using protective clothing. A repeat testosterone1 b: R1 k \7 V. k/ h0 ]1 l
test was ordered, but the family did not go to the
. Y! s/ V2 E; C# X: f% J' l4 Xlaboratory to obtain the test.1 s O2 Z( K$ O% U( }
Discussion& o& c- B3 ?7 L: A" o+ v) v
Precocious puberty in boys is defined as secondary
% s& v, k2 X: ~7 O& @3 N esexual development before 9 years of age.1,42 W6 ]" \7 s% D
Precocious puberty is termed as central (true) when2 v/ t6 e1 [+ U
it is caused by the premature activation of hypo-$ O4 u2 R& N0 t& P" q. F7 E
thalamic pituitary gonadal axis. CPP is more com-+ Y: s; n4 s7 d
mon in girls than in boys.1,3 Most boys with CPP
2 {( N- G- n f$ k: b1 O/ o, gmay have a central nervous system lesion that is4 z- C, A4 ~$ n: f
responsible for the early activation of the hypothal-. x% t' L9 b' h( @) L4 {( E6 |+ i
amic pituitary gonadal axis.1-3 Thus, greater empha-
; _8 ]# S. K5 M5 ]sis has been given to neuroradiologic imaging in l; K; j& M4 w. T5 z2 G& k
boys with precocious puberty. In addition to viril-
! ~4 a- @( s4 q7 Y! O1 eization, the clinical hallmark of CPP is the symmet-* h/ A8 i7 i1 B M# t; e( b4 N
rical testicular growth secondary to stimulation by& x5 `* `4 ?* i5 V
gonadotropins.1,3( |6 S; U$ L2 i
Gonadotropin-independent peripheral preco-; _7 N+ c( I+ k- V5 F$ l- f
cious puberty in boys also results from inappropriate
7 c4 d" ?/ P- X! s& w% Iandrogenic stimulation from either endogenous or
" ]2 ^+ m* q8 X. U3 G. s0 H# Iexogenous sources, nonpituitary gonadotropin stim- l( W. r7 a% T, j0 N! ~
ulation, and rare activating mutations.3 Virilizing& b* S0 P ?$ Y# X, V- ^
congenital adrenal hyperplasia producing excessive4 q3 F) t0 K! K. y+ W
adrenal androgens is a common cause of precocious5 H7 @! o( M- d/ x( g
puberty in boys.3,4
+ B& h" n) U8 \1 hThe most common form of congenital adrenal
8 Z+ V6 B7 _ [( L5 ehyperplasia is the 21-hydroxylase enzyme deficiency." ?7 E* W. s" |5 N+ B$ A
The 11-β hydroxylase deficiency may also result in! e( i! v' }! R5 w3 E8 P r, W
excessive adrenal androgen production, and rarely,
( j8 E% J# {+ I5 \an adrenal tumor may also cause adrenal androgen4 m' l- p1 O) [; f
excess.1,3! m" j+ V+ g3 K6 |, R+ J$ k7 X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from v% B: B& A! |( s
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 S- t* i$ N8 _. o7 z5 K8 v
A unique entity of male-limited gonadotropin-
, E" a! u: y3 L- _: uindependent precocious puberty, which is also known! c7 C, E, ~5 |8 K0 i' x
as testotoxicosis, may cause precocious puberty at a
4 I: r7 [( i# j/ Yvery young age. The physical findings in these boys
! }$ | f8 m: t: e7 K! Jwith this disorder are full pubertal development,
( }/ ~2 v3 S- ^, v+ Xincluding bilateral testicular growth, similar to boys
! l- ~+ O5 s! a3 N( rwith CPP. The gonadotropin levels in this disorder/ O* X7 V/ ]( D+ X! F
are suppressed to prepubertal levels and do not show) s) m& y4 `% X0 R6 g/ p
pubertal response of gonadotropin after gonadotropin-
3 X! d6 P8 O* dreleasing hormone stimulation. This is a sex-linked2 @$ f% G% A( a; ~( _% E
autosomal dominant disorder that affects only/ [! K/ z2 l0 K5 b5 n U9 A- U
males; therefore, other male members of the family! ]$ K5 g- n) l1 ?
may have similar precocious puberty.33 V7 Z$ h3 h0 t- ]; t* R1 W
In our patient, physical examination was incon-- g ^5 Q" @" \9 _, w- l+ S
sistent with true precocious puberty since his testi-
7 q& }# f+ M' L; O- G6 s4 zcles were prepubertal in size. However, testotoxicosis0 G& k, `7 b8 N' _: f! V
was in the differential diagnosis because his father
9 s; s! r1 y$ o! h$ ?started puberty somewhat early, and occasionally,
5 L( F- p6 I+ O9 ~, S1 Y9 Qtesticular enlargement is not that evident in the
`; o6 U8 N2 C" _. Abeginning of this process.1 In the absence of a neg-
) [2 C( R# r- N2 G8 ~ative initial history of androgen exposure, our3 t, ~* T& x5 h+ {$ x3 \! r8 s
biggest concern was virilizing adrenal hyperplasia,
$ b9 [6 \9 \* ~; reither 21-hydroxylase deficiency or 11-β hydroxylase" i& b$ U5 f$ Q' C/ z8 T4 |
deficiency. Those diagnoses were excluded by find-: `" C3 T/ N- D3 w
ing the normal level of adrenal steroids.
7 U- B6 s# O: R4 b/ Q+ LThe diagnosis of exogenous androgens was strongly
2 G/ u) a2 ~- Bsuspected in a follow-up visit after 4 months because- W5 ~8 m' U! T: C
the physical examination revealed the complete disap-
2 p5 z1 E& m3 T' N6 n& Upearance of pubic hair, normal growth velocity, and
8 T( O3 F V& K T& wdecreased erections. The father admitted using a testos-- q2 I* s3 c; [. N9 {( T
terone gel, which he concealed at first visit. He was3 S5 a2 M+ K6 A! Q# F5 ?$ {5 }2 ^
using it rather frequently, twice a day. The Physicians’
! X# W3 C) T& e c* H" zDesk Reference, or package insert of this product, gel or
# x% N, B u7 W8 A4 q- t' ~cream, cautions about dermal testosterone transfer to
- V! r; u( {1 S6 w8 t# y8 b6 {$ T! {unprotected females through direct skin exposure.
8 a# p/ S J1 f6 f3 XSerum testosterone level was found to be 2 times the
2 [4 s) h) e$ y- Jbaseline value in those females who were exposed to; K9 J& g2 E# K& P1 H% G( E( C
even 15 minutes of direct skin contact with their male3 p/ {2 o4 e2 t% M* p) C
partners.6 However, when a shirt covered the applica-
d4 K7 I' u* ?- ltion site, this testosterone transfer was prevented.! L& X2 ]3 O+ }; Q0 w
Our patient’s testosterone level was 60 ng/mL,. b3 I3 l5 @& o; w7 c3 d& j
which was clearly high. Some studies suggest that
4 |/ I, g2 M. A Idermal conversion of testosterone to dihydrotestos-
2 }3 H _ O' C; s) Tterone, which is a more potent metabolite, is more- [5 [5 f* s+ j" [$ k6 y& ?% @
active in young children exposed to testosterone
- R2 w# E# }; K. E! Lexogenously7; however, we did not measure a dihy-' a$ t z+ W$ ?" R& m7 Q
drotestosterone level in our patient. In addition to
/ s5 y, [( B7 _1 N/ S. ^- y2 Rvirilization, exposure to exogenous testosterone in
3 L& E; m7 O8 ?$ q4 [children results in an increase in growth velocity and
4 V7 T5 J1 S2 U( V4 ^advanced bone age, as seen in our patient.: \# u, T. n' S, }( g& t; u& e
The long-term effect of androgen exposure during
/ a$ k F2 n# W- Learly childhood on pubertal development and final% E) y x; {- I
adult height are not fully known and always remain
$ {2 O6 F% M( j0 E4 ~* Ia concern. Children treated with short-term testos-
0 @+ X- M; y9 N1 @% Y1 l7 O! |9 v Tterone injection or topical androgen may exhibit some) T; s! R, X3 v) k9 Q3 r
acceleration of the skeletal maturation; however, after
2 [0 k7 l& \0 ^9 K H/ h9 s5 X/ [cessation of treatment, the rate of bone maturation
' Q' x1 u! i7 @5 J* h5 rdecelerates and gradually returns to normal.8,9
( q# Z: s. A* r3 vThere are conflicting reports and controversy
9 {" v& d& {6 x3 k, B, \7 T% Sover the effect of early androgen exposure on adult
; G J0 X* T; p4 g' }penile length.10,11 Some reports suggest subnormal8 S2 O1 v! ?' W- [5 a' R
adult penile length, apparently because of downreg-
4 K* ~2 M$ R* d/ s- Oulation of androgen receptor number.10,12 However,) n7 \$ B" |0 E1 \6 v" m
Sutherland et al13 did not find a correlation between
/ ~+ f, u& H2 Jchildhood testosterone exposure and reduced adult
. w1 v9 u. I, k ^$ qpenile length in clinical studies.5 m1 W& X2 d6 K, ?8 B/ i
Nonetheless, we do not believe our patient is
7 m9 G) a' m( ]+ jgoing to experience any of the untoward effects from
4 l7 X/ @/ V2 V: H- a4 Y. Jtestosterone exposure as mentioned earlier because
5 y" i5 h3 D" g# G6 g& e" v/ e" Dthe exposure was not for a prolonged period of time.6 l) h8 L! `. b8 _9 `* V
Although the bone age was advanced at the time of
5 }& S( W: \! V" {diagnosis, the child had a normal growth velocity at: }0 c: b+ W3 F$ T a
the follow-up visit. It is hoped that his final adult
+ w$ H, k O, q% ?! k8 Rheight will not be affected.+ e' f- G3 |9 q, k9 o2 [5 ~
Although rarely reported, the widespread avail-% L' ]4 }8 J& X; M% V
ability of androgen products in our society may
/ q; N8 q: [& T" a8 ?indeed cause more virilization in male or female
$ X, [0 n0 }1 z* H5 v# {+ T7 q7 cchildren than one would realize. Exposure to andro-
# o7 r0 c+ Z8 g# W% p" o9 Hgen products must be considered and specific ques-
- J i. L# }: ]1 Ytioning about the use of a testosterone product or' { V- x7 N0 t: a9 l5 K* r
gel should be asked of the family members during4 o) C9 g! X6 l; d" P- \
the evaluation of any children who present with vir-
9 @! \& L0 Q8 b, z* K8 v0 d5 ~ilization or peripheral precocious puberty. The diag-
% w, _$ @9 l8 anosis can be established by just a few tests and by
( \# s: z. i1 y+ G7 z+ Cappropriate history. The inability to obtain such a3 h5 m# H9 b7 T7 X$ x% T8 d: i
history, or failure to ask the specific questions, may/ e# ]% q5 P, ?- T4 x+ t2 |
result in extensive, unnecessary, and expensive: ?6 }- v- Q& u" G, a, _, E
investigation. The primary care physician should be
* a5 ~" j$ Q( k. iaware of this fact, because most of these children) k' f+ I. V& g+ U* u' u7 T
may initially present in their practice. The Physicians’ w2 W0 U( o. B& m0 n6 A
Desk Reference and package insert should also put a
/ Z8 r2 {6 h4 z9 x- o, ]warning about the virilizing effect on a male or. i0 K9 `, e9 T) }, p+ B
female child who might come in contact with some-6 i6 x5 m1 ~5 `1 m& r4 ~; m
one using any of these products.
/ v2 Y# I N6 ~1 ^+ G- _References% m2 @# G: X( W* d
1. Styne DM. The testes: disorder of sexual differentiation
. u5 ^: o* O4 S5 Qand puberty in the male. In: Sperling MA, ed. Pediatric3 Y7 }2 [. B4 O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* R5 y4 D% S p2002: 565-628.
6 g) u( `+ P+ b# h- C2 c7 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! b1 O6 a$ n, E4 l; [puberty in children with tumours of the suprasellar pineal |
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