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Sexual Precocity in a 16-Month-Old
6 `# b8 c# g( C. K( Q/ NBoy Induced by Indirect Topical+ _$ Z3 ]0 q b3 Z; o
Exposure to Testosterone! T2 X- Z6 {) F/ L6 B- U% h i, t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# s4 A) R& t9 N% J* y
and Kenneth R. Rettig, MD1
m, B" w- Y" X/ C! M+ | mClinical Pediatrics0 [& ]4 L( y1 k
Volume 46 Number 6
$ L$ Q! d/ E: t! R, rJuly 2007 540-543% B% z! e, b- W; r6 N' b' _
© 2007 Sage Publications# }+ p- G% N6 s7 C0 e% T4 G3 k- A: V
10.1177/0009922806296651' {) W. ^3 F: a* c
http://clp.sagepub.com
9 u1 A( |7 C9 Zhosted at
5 ?9 s& d- d! k, v) }/ |# rhttp://online.sagepub.com: o& k1 ?( M# V& n$ ~
Precocious puberty in boys, central or peripheral,$ _9 K2 J8 W1 v' W" g: i
is a significant concern for physicians. Central) R6 a" V& K1 U3 b* C
precocious puberty (CPP), which is mediated
9 I! ^2 Z: w4 V uthrough the hypothalamic pituitary gonadal axis, has
" B; b6 V5 N2 D$ y$ B( Ua higher incidence of organic central nervous system% ~* }( j O4 g# y* [7 ^
lesions in boys.1,2 Virilization in boys, as manifested
0 w3 Q' s' ?6 Hby enlargement of the penis, development of pubic2 E% F) m4 P5 v2 _6 N: ~
hair, and facial acne without enlargement of testi-: i; h+ _+ n6 _
cles, suggests peripheral or pseudopuberty.1-3 We) z5 _: m4 |5 K# V8 w
report a 16-month-old boy who presented with the+ R- r! f" R& c: d
enlargement of the phallus and pubic hair develop-
2 [1 z/ x& y' @# t& S! Gment without testicular enlargement, which was due
. T' G! a! X+ Z3 K+ i4 r1 I! I* qto the unintentional exposure to androgen gel used by
+ N# ~. i$ Y: L3 jthe father. The family initially concealed this infor- d! s% o. x' q7 x3 ^. w! D' j
mation, resulting in an extensive work-up for this
2 v! I/ l! k; [+ x* q/ P8 [child. Given the widespread and easy availability of9 I0 s6 Q! Q3 ~. Q9 z- t$ Q: ]
testosterone gel and cream, we believe this is proba-
/ h/ t6 e# |+ T4 ~3 a Jbly more common than the rare case report in the, H* J7 y$ b% r6 J. w
literature.48 `- W, x% ^5 P' R# U$ P8 {
Patient Report% u/ j( {9 U" L0 n7 B6 u
A 16-month-old white child was referred to the; S; K; {: Y' W! j7 W6 c2 r
endocrine clinic by his pediatrician with the concern
% j: ~1 L( Z: Q; g& K4 l/ Nof early sexual development. His mother noticed
) p% C# d/ A* C% h& c! W3 |) `light colored pubic hair development when he was
! G; _7 T3 x; |! u3 }; dFrom the 1Division of Pediatric Endocrinology, 2University of
' x9 i: r& O) O& USouth Alabama Medical Center, Mobile, Alabama.
4 I8 Z' }$ q8 i" Z6 }; tAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& j: C+ s( o5 T( pProfessor of Pediatrics, University of South Alabama, College of
- _0 F6 F5 ] M+ G2 @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& T3 c& ?7 _) J9 v# be-mail: [email protected].
`# t+ I, ?+ _+ V4 r3 Labout 6 to 7 months old, which progressively became
6 ?4 ^5 ~: ]/ D: L- rdarker. She was also concerned about the enlarge-
$ _+ `$ U- o. r$ M& c, l" wment of his penis and frequent erections. The child
# u4 c" ?6 u [5 ?% a- ]0 Fwas the product of a full-term normal delivery, with" e: J* S7 O+ J; Q3 ?# G$ ~
a birth weight of 7 lb 14 oz, and birth length of
9 b5 E# R; ?4 E4 Z20 inches. He was breast-fed throughout the first year# f+ |0 q. |; m6 `2 Z( t
of life and was still receiving breast milk along with7 |8 M) I3 h/ w7 j
solid food. He had no hospitalizations or surgery,- h; p# J' A, R! I: ~
and his psychosocial and psychomotor development
$ U6 q6 s* }2 w/ ]+ X) K) Z) {was age appropriate.6 S5 M: o$ i* X0 m3 x; F+ R
The family history was remarkable for the father,% u- a ]3 k8 w5 }; T
who was diagnosed with hypothyroidism at age 16,
# z( T9 ]; |8 o$ r5 swhich was treated with thyroxine. The father’s
+ A& Q( p" T* i. d4 X oheight was 6 feet, and he went through a somewhat/ I: ?9 Q7 |: T, Q! `' z4 o9 B
early puberty and had stopped growing by age 14.
7 i( D! \& S' w; B) V# [The father denied taking any other medication. The, ~2 ?& }3 I" b. F
child’s mother was in good health. Her menarche, b. m! U' S7 w( ^$ F) D
was at 11 years of age, and her height was at 5 feet5 z2 m+ ?- Y- o, ^
5 inches. There was no other family history of pre-7 T/ S S: ~. O: {4 F
cocious sexual development in the first-degree rela-
5 G+ F: e; {- |8 I @5 jtives. There were no siblings.4 h" b: V# [8 D" F4 ?- p3 y
Physical Examination
) G) @+ e5 x1 C2 v3 @The physical examination revealed a very active,
2 D$ f/ Z0 H+ O4 Cplayful, and healthy boy. The vital signs documented2 V# e% P3 P& k
a blood pressure of 85/50 mm Hg, his length was! s* e# s* v' i1 g4 h0 U {8 @) Q7 X& w4 b
90 cm (>97th percentile), and his weight was 14.4 kg
. K' {% z) K7 q' b! ^; O(also >97th percentile). The observed yearly growth9 L* t3 f2 _! x
velocity was 30 cm (12 inches). The examination of
% Z. j% S- M2 s3 _the neck revealed no thyroid enlargement.
- H. z: ?$ U+ O, O- f* \8 X7 e# p6 dThe genitourinary examination was remarkable for% X1 ]: x! h' G. ]0 A5 g$ A7 F
enlargement of the penis, with a stretched length of
' U1 d; `# d, g) J- L* D8 cm and a width of 2 cm. The glans penis was very well7 [0 v8 ?0 [, t7 ~+ ^: m! B8 h
developed. The pubic hair was Tanner II, mostly around+ S5 a0 ^ A: x6 z8 k2 ]8 ?
540
; P* C9 r, }: o0 ]! u gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; b0 z6 @5 p5 K; t4 O; Ithe base of the phallus and was dark and curled. The
* k0 C7 _6 U }+ o4 ~testicular volume was prepubertal at 2 mL each.
, F) m( w, n( [8 cThe skin was moist and smooth and somewhat: N) F5 \3 H* a0 @4 Q5 ^, j7 ?
oily. No axillary hair was noted. There were no
6 L6 I6 c ?. M7 Cabnormal skin pigmentations or café-au-lait spots.8 P' P m4 s1 A: M+ I. @" ^: d
Neurologic evaluation showed deep tendon reflex 2++ ]. I/ u% Z- g |5 h
bilateral and symmetrical. There was no suggestion6 X2 B& r8 Q4 E0 R% a; H% f1 v
of papilledema.% v! H# D5 D1 @4 t |6 [. w
Laboratory Evaluation
# d: s( k) ^7 n7 `. a) `9 q6 `1 u8 _The bone age was consistent with 28 months by( n. W7 h" @1 K' l; \" A
using the standard of Greulich and Pyle at a chrono-
) X1 R# t1 R0 |! E' V" {* N- j) hlogic age of 16 months (advanced).5 Chromosomal" A* @* }$ V' K% Q
karyotype was 46XY. The thyroid function test
( N+ a( h( {2 s% Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 X- X/ k6 H: @6 |- \. x) x, F7 v% zlating hormone level was 1.3 µIU/mL (both normal).
; {* K( y( j% x0 o1 @" k0 wThe concentrations of serum electrolytes, blood
3 N- b! N5 ~$ M# I lurea nitrogen, creatinine, and calcium all were
0 O' w6 _2 F* e# `5 s' c# ]within normal range for his age. The concentration
" l& C- O# y/ @& T5 ?; D; Vof serum 17-hydroxyprogesterone was 16 ng/dL
* C0 k, J6 w( M- A(normal, 3 to 90 ng/dL), androstenedione was 20
( V5 D; ]7 l9 @5 G8 \ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, D' o4 E0 k" x4 q+ O9 {6 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),9 m0 e2 q5 x1 E$ b4 a, |% `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 z' t7 }& N: R# Q1 I! u; } i: b49ng/dL), 11-desoxycortisol (specific compound S)
4 N% i% [% D( d0 N+ fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 F/ P& g ]& f/ n" H! O0 y' K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' W% Z3 K- h# t. X: C* f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ N' G! i5 Y5 k2 u& C+ S0 jand β-human chorionic gonadotropin was less than/ @: ?& S$ k8 Y6 j
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: o* M7 g5 |* T8 Wstimulating hormone and leuteinizing hormone
# l' y6 X9 v% J6 c2 B+ l* N7 S3 mconcentrations were less than 0.05 mIU/mL
; K2 A, L: j9 V8 Z) O0 _! f' s8 D(prepubertal).% v0 m0 b& n) Z& ^ u$ a7 s
The parents were notified about the laboratory F$ p4 ^; s) V( C
results and were informed that all of the tests were$ C- @1 D' i. z% n
normal except the testosterone level was high. The: _4 \4 N" d# ?4 |+ _$ ~8 Q, V; X
follow-up visit was arranged within a few weeks to
4 S9 S# ^# X7 I3 B8 k6 k& Wobtain testicular and abdominal sonograms; how-
5 u8 z1 B _7 [) ~/ }, m7 Mever, the family did not return for 4 months.
% W3 `. q. f' Q: p& LPhysical examination at this time revealed that the* y$ {- @% V3 }9 K/ [
child had grown 2.5 cm in 4 months and had gained% \ [! A8 F Q
2 kg of weight. Physical examination remained( Z" x% b4 `% A: K* s) k
unchanged. Surprisingly, the pubic hair almost com-
* [! h" H+ f& |( R* hpletely disappeared except for a few vellous hairs at
/ J6 x$ M1 t% r: e% Z; |the base of the phallus. Testicular volume was still 2
8 G/ ~2 B* U! f5 t9 ], EmL, and the size of the penis remained unchanged.2 ?8 n2 O4 ]+ X4 h* r% z: N) e
The mother also said that the boy was no longer hav-5 d5 D% s! E3 n- e) |1 L5 i8 b+ t
ing frequent erections.
$ f7 z) E. S; S+ m3 c2 gBoth parents were again questioned about use of
* x% V) e' H4 O \: ^6 H" eany ointment/creams that they may have applied to+ N# P J5 s. a( D" H, |) W6 d" Q+ S8 O, a
the child’s skin. This time the father admitted the
0 i1 A! t- Q1 GTopical Testosterone Exposure / Bhowmick et al 541
' _; ^# i6 x4 h7 Z8 Y& ]use of testosterone gel twice daily that he was apply-
. |" q) D! T* B' Sing over his own shoulders, chest, and back area for, ^# n7 ?) a+ j! Q5 R) q: K! b
a year. The father also revealed he was embarrassed
, C: y( c* y# k2 C5 \+ qto disclose that he was using a testosterone gel pre-6 [" ?: g7 w: q, r6 K
scribed by his family physician for decreased libido- \" }5 d0 _0 v# B- V5 |/ l
secondary to depression.# G* W$ V: J$ k; H: f K
The child slept in the same bed with parents.
6 o% `" h5 ^0 N4 U, g# W2 {The father would hug the baby and hold him on his- K( K- g2 ], u7 G* r5 d4 g9 `* o4 K
chest for a considerable period of time, causing sig-
6 z+ V8 B9 C; m+ E6 x, g! \nificant bare skin contact between baby and father.$ |7 K& j, l" } K, f
The father also admitted that after the phone call,0 X0 c: Y" Z4 V: B+ q
when he learned the testosterone level in the baby
( [! |5 h, {$ s6 ^was high, he then read the product information
2 I& ^' g, p' H! T+ Wpacket and concluded that it was most likely the rea-1 @7 I' d9 n, j# b5 _2 S6 \3 e4 C
son for the child’s virilization. At that time, they H; m! o& k5 s5 ~! }+ j( T
decided to put the baby in a separate bed, and the
9 U! ^5 k) J1 z+ b: d8 B: Cfather was not hugging him with bare skin and had0 D7 \' d3 e' e+ Q; e
been using protective clothing. A repeat testosterone' c- _ R& s0 P* i5 D
test was ordered, but the family did not go to the5 d3 [* E' |! @4 B _1 Y$ B2 y* w
laboratory to obtain the test.
" e, B& [/ Q& A, B( F' uDiscussion
0 h- R! i. R3 b) M* E3 OPrecocious puberty in boys is defined as secondary
2 G- m) d& a8 m0 n. ~& x0 h; ysexual development before 9 years of age.1,4
* L+ q" M* X* m" a7 j, A5 sPrecocious puberty is termed as central (true) when' @3 W8 s/ h- M4 K8 e! ^) w
it is caused by the premature activation of hypo-9 Q; Y$ Q- ]) U0 v7 o+ E
thalamic pituitary gonadal axis. CPP is more com-
, v( _) W3 [" \( e6 }7 nmon in girls than in boys.1,3 Most boys with CPP" {( ]: M' W, G. M6 I9 K# l( Y
may have a central nervous system lesion that is
, @; B/ r+ D/ b1 Aresponsible for the early activation of the hypothal-
' W7 m" [5 W$ @% w! p1 Z+ S5 [0 lamic pituitary gonadal axis.1-3 Thus, greater empha-' D8 J4 d6 e! @! E) r6 Z5 q8 u
sis has been given to neuroradiologic imaging in
! _% Q; e1 O3 f3 k/ S- G1 Rboys with precocious puberty. In addition to viril-: S* ~5 l6 y0 T7 _% j8 U& C2 ^: b
ization, the clinical hallmark of CPP is the symmet-
4 s! m( t" N# Jrical testicular growth secondary to stimulation by
# H& ?8 Q. k9 j& @& @8 }gonadotropins.1,37 K4 m) }2 j2 [5 y8 s# M# `) N
Gonadotropin-independent peripheral preco-$ c; W: O' d5 W g& P* h
cious puberty in boys also results from inappropriate" D+ U/ ~% I8 ?$ O! P; j: b
androgenic stimulation from either endogenous or
+ A# Q" K6 I" k, B$ ~exogenous sources, nonpituitary gonadotropin stim-1 p* d X. a# c4 O4 p6 r# ~
ulation, and rare activating mutations.3 Virilizing
! V3 ?# p4 S4 v+ i8 z; s. Scongenital adrenal hyperplasia producing excessive. f0 T6 w; w: e; b/ j2 W9 v8 Q8 o0 }
adrenal androgens is a common cause of precocious' u8 D% {5 m9 E6 v/ g+ l
puberty in boys.3,41 G) C3 ?* U" y8 E4 j
The most common form of congenital adrenal8 R: o( c: n2 f$ r
hyperplasia is the 21-hydroxylase enzyme deficiency.% d( b, o Y' h( _& H) K
The 11-β hydroxylase deficiency may also result in5 v9 [. e& z5 r- v8 V! a
excessive adrenal androgen production, and rarely,
& a& Y6 S* f b$ p$ `! tan adrenal tumor may also cause adrenal androgen
; W+ ^) w. `7 \& fexcess.1,3
: ]# b& q) P# Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 }/ r/ Z* b% I' E( i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; S) c) Q4 g9 |' u1 P( h7 E9 {6 L) R( E5 k
A unique entity of male-limited gonadotropin-% z, [, H# t" m1 h4 T
independent precocious puberty, which is also known! S* b& \8 j; B. }5 p
as testotoxicosis, may cause precocious puberty at a2 H# z/ y% l5 ^1 n( Q! L3 g
very young age. The physical findings in these boys
* N4 l; V. t& z2 x( H6 v7 awith this disorder are full pubertal development,
2 `. q! S' n3 b8 I/ \1 Y# Xincluding bilateral testicular growth, similar to boys; z1 o/ K# G9 l9 p, I
with CPP. The gonadotropin levels in this disorder
8 ?/ s2 j5 J6 B$ E! R8 k! nare suppressed to prepubertal levels and do not show
2 R% B/ j) @$ |, K7 n& Dpubertal response of gonadotropin after gonadotropin-
4 m8 e$ P$ N' s$ Vreleasing hormone stimulation. This is a sex-linked
# D/ c. u% T# V8 n3 a: h8 ?+ i" l3 uautosomal dominant disorder that affects only
* L9 O/ [, \ `) |5 wmales; therefore, other male members of the family! i( ]& r- p7 e! F5 ^. E; p$ \$ ]
may have similar precocious puberty.30 Y; ]; _7 t# Q5 x- F
In our patient, physical examination was incon-7 P3 x1 Z1 \; Q
sistent with true precocious puberty since his testi-
, n5 p$ ~) W. B4 J3 d; H6 N( z: ~) |8 ^cles were prepubertal in size. However, testotoxicosis, Y6 T! V- E4 p8 U. q; U+ `
was in the differential diagnosis because his father* N; [/ c' d- k: t
started puberty somewhat early, and occasionally,
$ W9 |+ A9 ~# x0 G9 b' @testicular enlargement is not that evident in the
4 Z* X: V1 Y: ~1 Lbeginning of this process.1 In the absence of a neg-
4 Z8 D0 f2 R/ c8 D# J2 Aative initial history of androgen exposure, our3 k4 k5 B9 v) |9 g
biggest concern was virilizing adrenal hyperplasia,4 C3 m8 b7 Z6 [. y
either 21-hydroxylase deficiency or 11-β hydroxylase
+ V% [2 K8 J* Y4 V0 ?/ ^$ J3 Sdeficiency. Those diagnoses were excluded by find-6 m6 }+ g: n0 v" e+ G. F1 Z# J
ing the normal level of adrenal steroids.4 \2 m9 B- K( H0 _9 c3 g: _' y
The diagnosis of exogenous androgens was strongly
6 w; P( c s5 r/ c3 Zsuspected in a follow-up visit after 4 months because
( f9 p( s1 y" ]) y( f" |8 z8 cthe physical examination revealed the complete disap-/ b7 g* H' q1 O# ~7 R# c4 u! ^
pearance of pubic hair, normal growth velocity, and+ F, [4 g3 q% m& E! K) Z4 C8 I
decreased erections. The father admitted using a testos-
9 z) }* ^- w- F" Z7 Z2 r( c4 Jterone gel, which he concealed at first visit. He was* e9 B* Y1 v" d/ c5 p; _
using it rather frequently, twice a day. The Physicians’
1 q4 u& D1 | v% PDesk Reference, or package insert of this product, gel or7 y2 \% Y; g; c9 B
cream, cautions about dermal testosterone transfer to& K* ?' h7 x8 [- e, [8 t# |
unprotected females through direct skin exposure.+ ~) Z! i! P7 H3 i4 t8 A0 w
Serum testosterone level was found to be 2 times the, x5 S. G9 u1 G
baseline value in those females who were exposed to3 Q4 W. D9 F" F+ E1 V
even 15 minutes of direct skin contact with their male
, U. W; R$ h: E. W$ g( }! e1 `partners.6 However, when a shirt covered the applica-
. N% x- y) A7 E* qtion site, this testosterone transfer was prevented. r: G& N2 i1 B h, x0 _- K* s
Our patient’s testosterone level was 60 ng/mL,! o- ^/ K( w$ ]% ]. [
which was clearly high. Some studies suggest that, N; y1 X z( T, H2 D3 H# {' m, c8 j
dermal conversion of testosterone to dihydrotestos-
+ T8 o4 D' `+ i; y. _terone, which is a more potent metabolite, is more9 \5 Z2 M; z1 S2 m# k
active in young children exposed to testosterone
7 }2 N v+ R7 k1 texogenously7; however, we did not measure a dihy-
6 O2 }% t! C) R& {# C- odrotestosterone level in our patient. In addition to
: k8 w5 y0 m( ]# \; @9 T9 }" [virilization, exposure to exogenous testosterone in. q1 [' p5 `# v" x
children results in an increase in growth velocity and
4 [# J, k. A. p% G. J9 f+ A; ^advanced bone age, as seen in our patient.
: s; q+ Z- ?7 T9 LThe long-term effect of androgen exposure during
! e- B8 e- x: Q8 o5 bearly childhood on pubertal development and final9 D/ i1 a; [& ~8 K% I) g4 G5 [
adult height are not fully known and always remain
; ?& G& n( N3 y4 j U, y# P6 Fa concern. Children treated with short-term testos-7 `" X- `" Q/ v# N5 U+ N9 f7 C7 t
terone injection or topical androgen may exhibit some
0 |6 B' Z. \& ]acceleration of the skeletal maturation; however, after
% d @( J3 o4 T. N( A: ^& T: ycessation of treatment, the rate of bone maturation, G% ^ z. Z9 i3 H3 Q
decelerates and gradually returns to normal.8,9
5 H2 A4 e& l. ]# c3 J4 {There are conflicting reports and controversy$ [, A# L' k( F: \
over the effect of early androgen exposure on adult
+ ?% J( Y) N3 J& ^2 cpenile length.10,11 Some reports suggest subnormal
8 @$ c K- O: J# eadult penile length, apparently because of downreg-
% P- j1 _8 I9 ~+ t+ K" S# xulation of androgen receptor number.10,12 However,1 E+ L1 F9 L. }0 r
Sutherland et al13 did not find a correlation between+ T* A& ^6 a$ P8 N
childhood testosterone exposure and reduced adult
9 P; n' `, r0 ]& x" A8 spenile length in clinical studies.+ L, G) L k3 E/ ]1 M
Nonetheless, we do not believe our patient is
/ j$ @( e& S( ]. X6 b/ y, s2 cgoing to experience any of the untoward effects from
3 }% T( D2 w/ _, P" v; Rtestosterone exposure as mentioned earlier because& C. l$ I: o% _/ A+ s0 {
the exposure was not for a prolonged period of time.7 y; }# V4 ]! K' k3 X8 m
Although the bone age was advanced at the time of4 \* J5 }5 w; D) s; w) e# |! n: F9 G
diagnosis, the child had a normal growth velocity at
( [4 z) O- w: `5 u7 [the follow-up visit. It is hoped that his final adult' Y2 E! ?/ ?: Q& Z2 R
height will not be affected.
0 Z9 O. t( n0 Q) d# V0 v0 vAlthough rarely reported, the widespread avail-# J% [4 V3 e- `; x( f1 _" L
ability of androgen products in our society may+ T5 Z8 Q6 `1 h! I4 B& c
indeed cause more virilization in male or female) k. v; V) j6 t) ^( x
children than one would realize. Exposure to andro-. n+ O: l! X9 ~' U1 N' u8 | v8 i
gen products must be considered and specific ques-9 E/ [' X, X! x
tioning about the use of a testosterone product or
% Z5 B9 G. M& Z) ~" X0 egel should be asked of the family members during
1 E: ? G: s* ?- R! xthe evaluation of any children who present with vir-5 V, S0 {$ z6 F+ m
ilization or peripheral precocious puberty. The diag-% M" w |$ ^0 J/ R* V
nosis can be established by just a few tests and by( V! b: X1 e) Q( h: U2 j2 {
appropriate history. The inability to obtain such a- m( c+ S$ x9 H( I1 `0 `9 a t) h" M
history, or failure to ask the specific questions, may
2 ? r, E& ?/ z5 d- p$ t8 Eresult in extensive, unnecessary, and expensive3 p! Q9 P1 w* p" A+ D
investigation. The primary care physician should be
8 \ A# d8 C% vaware of this fact, because most of these children
; w& H4 |& ~3 Xmay initially present in their practice. The Physicians’
. I* b: G# L) u. \1 v/ IDesk Reference and package insert should also put a
( {0 Y) r, D/ `8 i- k# u$ swarning about the virilizing effect on a male or/ ~1 v2 A( q+ x7 r- @1 h
female child who might come in contact with some-
5 e1 J1 s' R7 B! L9 v Rone using any of these products.
: V {+ I7 ]" r4 ~References8 ]7 j1 B! w Q' W, o8 d; l" d
1. Styne DM. The testes: disorder of sexual differentiation) P/ V3 Y8 M$ w5 y) p1 }# ?2 ]
and puberty in the male. In: Sperling MA, ed. Pediatric
% g, ?$ x6 z# H z; v2 cEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 z1 h n% s; w$ h4 s4 ~2002: 565-628.6 a& L& m2 }8 q' J3 Z4 |: N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 c& t: J$ M6 x- m: A0 e; G. t$ xpuberty in children with tumours of the suprasellar pineal |
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