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Sexual Precocity in a 16-Month-Old
) v- U0 K. @) D8 P$ ]Boy Induced by Indirect Topical
3 U. ^- ~% j8 A8 b, m- OExposure to Testosterone
7 ]; Z5 k$ X& KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# I9 L" e9 T) K" M- f3 tand Kenneth R. Rettig, MD19 p. ^& g: D) U6 g- a! V! F
Clinical Pediatrics
( V1 |7 ]9 M& A8 QVolume 46 Number 64 U( a: n' D3 a
July 2007 540-543
; M, ]: h6 K2 r5 [+ ^" u1 Q© 2007 Sage Publications$ b; [$ W1 I3 h+ z
10.1177/0009922806296651
3 |9 C0 O4 t9 n. d3 qhttp://clp.sagepub.com
' x% m. H" ~3 _( P; ahosted at
1 t% E# t( O1 f4 v# G. Ehttp://online.sagepub.com
4 C8 y7 v4 ?6 v3 ^7 }Precocious puberty in boys, central or peripheral,2 R& K: h# P' U. n8 M
is a significant concern for physicians. Central
# m8 M1 u# Q4 w$ bprecocious puberty (CPP), which is mediated
+ c/ m' l; m$ U% s' B: wthrough the hypothalamic pituitary gonadal axis, has
2 {- @5 ^* \. p' o+ Da higher incidence of organic central nervous system
- Y5 o: ^( Q* K; e/ s" L! }lesions in boys.1,2 Virilization in boys, as manifested
+ D$ d; y7 g% A( j4 ?* f* M5 Qby enlargement of the penis, development of pubic1 ^! `8 Y' |0 O: g7 \
hair, and facial acne without enlargement of testi-
+ I- E1 r9 P) @cles, suggests peripheral or pseudopuberty.1-3 We
2 j+ a6 ^6 ]0 kreport a 16-month-old boy who presented with the
/ x y) U6 w6 l S2 Ienlargement of the phallus and pubic hair develop-
- l9 W$ g& B. M, ]& Hment without testicular enlargement, which was due+ O: U- k3 x' w' L5 e" @
to the unintentional exposure to androgen gel used by
; D) e. b: u5 R$ d9 _the father. The family initially concealed this infor-
/ i& L' q9 f! C7 r6 \" hmation, resulting in an extensive work-up for this h5 E l' q Z$ W4 y# z
child. Given the widespread and easy availability of
6 X9 w3 i% b8 E- a: btestosterone gel and cream, we believe this is proba-0 T" t, Q5 u/ ?; Y
bly more common than the rare case report in the
f" ], ~2 _' Vliterature.4
9 }! [8 I9 \7 p3 m! c- NPatient Report
8 E# J' T3 z6 m0 Z/ WA 16-month-old white child was referred to the
. _4 J0 r9 Y& f3 a4 I9 \endocrine clinic by his pediatrician with the concern) c: `$ j/ h% S3 q' f8 u$ g! L1 _
of early sexual development. His mother noticed' y9 h. Q) k$ b2 \+ g" r h
light colored pubic hair development when he was
$ U9 `$ ]3 F( Q1 n7 B& V) iFrom the 1Division of Pediatric Endocrinology, 2University of
9 t- }. |5 ^/ d/ ISouth Alabama Medical Center, Mobile, Alabama.0 P% f: H& Z0 C& y/ d
Address correspondence to: Samar K. Bhowmick, MD, FACE,4 _3 V2 n+ \8 i: t
Professor of Pediatrics, University of South Alabama, College of
5 u8 Y( z; [3 |0 o+ K. g; O( ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" Z4 i9 O5 f2 P9 p |7 w4 S9 D
e-mail: [email protected].
, j( T5 }" J1 B3 Pabout 6 to 7 months old, which progressively became
/ O$ O: I* z4 adarker. She was also concerned about the enlarge-, p, O9 |$ B- N8 e. T+ M' d
ment of his penis and frequent erections. The child: t* H) y! g' z! |" n
was the product of a full-term normal delivery, with
2 I/ s( G7 }8 J# O$ H4 k% G! A S" c( Va birth weight of 7 lb 14 oz, and birth length of
+ B; p1 l" U# I20 inches. He was breast-fed throughout the first year1 e, |" r+ G' M b
of life and was still receiving breast milk along with
" U z- i u, Wsolid food. He had no hospitalizations or surgery,
- Q0 |( \6 k$ c9 b7 q; S; Wand his psychosocial and psychomotor development
) _* {( Z1 ]1 i2 Z: e6 A9 Twas age appropriate.
- {9 C" ]. d+ E1 ^ m; w5 nThe family history was remarkable for the father,
' n9 ] y+ U& Q4 xwho was diagnosed with hypothyroidism at age 16,
S) S3 b3 C/ e2 P7 R3 k$ A0 t; Rwhich was treated with thyroxine. The father’s
6 R, r& T# X) _! Z; y' a2 i# @height was 6 feet, and he went through a somewhat6 ?" H+ v C5 n6 d* ]$ k% |. P/ V" D# N
early puberty and had stopped growing by age 14.
- p! N" } t" I) C9 f% SThe father denied taking any other medication. The# ]1 O1 B9 q& K
child’s mother was in good health. Her menarche: s& {+ P, r9 H; M0 k; u' O. H4 S
was at 11 years of age, and her height was at 5 feet
5 Z( `$ W' U2 l Z2 G* y5 X5 M5 inches. There was no other family history of pre-# }4 m) n( `) ^" A x* ]# @
cocious sexual development in the first-degree rela-" m N; u$ F2 v) P$ N. `
tives. There were no siblings.
; D5 p* _6 }# j" r0 rPhysical Examination! F: F" j4 y) P! F- o8 o
The physical examination revealed a very active,
4 d" X2 t. l: \( C! X+ |- O2 T( _* v/ Qplayful, and healthy boy. The vital signs documented
) H. y" ]+ R# g. K1 t; N" m+ G1 S2 `a blood pressure of 85/50 mm Hg, his length was# y! C' ~9 L3 L( k3 ^
90 cm (>97th percentile), and his weight was 14.4 kg
9 W* S# |& o% k, p0 O(also >97th percentile). The observed yearly growth2 x% O8 E6 b: O2 l& y
velocity was 30 cm (12 inches). The examination of
! m, y; N6 d9 Q1 x4 I4 Nthe neck revealed no thyroid enlargement. A0 J9 x! z. }( E
The genitourinary examination was remarkable for5 q5 b% O3 V. V0 F* u
enlargement of the penis, with a stretched length of
3 P3 H1 K- Z6 X J3 K* O8 cm and a width of 2 cm. The glans penis was very well N, p4 m O5 ~. d! m7 `# x7 k! k
developed. The pubic hair was Tanner II, mostly around% u+ V, N9 D) D- ?' D' T
540
' a# K0 r9 B$ b/ mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 b" h9 H" `; u; C: i; V$ zthe base of the phallus and was dark and curled. The! {. h1 {/ ?8 c
testicular volume was prepubertal at 2 mL each.! S5 h1 l. W/ N/ K5 M
The skin was moist and smooth and somewhat3 q6 w6 O# i# s: E' I8 c
oily. No axillary hair was noted. There were no
9 }3 Y' g+ s8 U) h s% Q3 Xabnormal skin pigmentations or café-au-lait spots.& @$ h3 v+ Z7 Z
Neurologic evaluation showed deep tendon reflex 2+% k3 z0 M1 i/ i; o
bilateral and symmetrical. There was no suggestion2 b' i' x; n# U; [3 c' j
of papilledema.# W: R" j# H) f) V
Laboratory Evaluation
$ V4 _: P/ r( q0 V# }# sThe bone age was consistent with 28 months by. k$ k; V: {7 f. Y8 R
using the standard of Greulich and Pyle at a chrono-
, T& v( X. z8 f/ g; alogic age of 16 months (advanced).5 Chromosomal
1 ~$ s8 O7 q- j x/ G9 E7 Bkaryotype was 46XY. The thyroid function test4 |) P; q, t# l/ U8 r" b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 D* `& a3 K- k' N$ w$ w, l6 D
lating hormone level was 1.3 µIU/mL (both normal).# v+ T, I6 w4 E- g2 P q- U2 @2 G
The concentrations of serum electrolytes, blood
J9 d9 Q: _7 H% H% X9 ^# uurea nitrogen, creatinine, and calcium all were
5 p6 f) B3 F$ V2 F; |' G6 Twithin normal range for his age. The concentration, Q: y$ w7 }' h
of serum 17-hydroxyprogesterone was 16 ng/dL2 d, }, z4 ^ r) l+ x1 U
(normal, 3 to 90 ng/dL), androstenedione was 20+ e# ?6 F! o2 I U8 E' [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# l, f7 Y) G/ hterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 D6 Z+ z5 L$ h) ~5 F
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ G% I. Z# v ?/ d4 F
49ng/dL), 11-desoxycortisol (specific compound S)
6 ~* T* b: Z% u0 R1 w% Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' G( S* g1 J4 w ^( Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( O7 K9 H K" Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 o- [2 R3 m5 m" f" }8 kand β-human chorionic gonadotropin was less than
% I# h C: ~ }1 R) c/ m* w( G& t$ X9 K5 mIU/mL (normal <5 mIU/mL). Serum follicular
! i5 h, g. X A. r2 n, B; Wstimulating hormone and leuteinizing hormone* i0 b' h( V8 F) _) \8 C
concentrations were less than 0.05 mIU/mL/ F9 N+ T; W1 l1 j
(prepubertal).% u4 g2 _0 h( R8 ^& F6 o' R
The parents were notified about the laboratory1 L! K$ I0 ]6 ^* h
results and were informed that all of the tests were2 f8 f4 \$ j7 H
normal except the testosterone level was high. The7 s/ D$ S/ c& V0 b6 T
follow-up visit was arranged within a few weeks to" k4 G6 K! T+ O$ L
obtain testicular and abdominal sonograms; how-
6 _2 _- N/ B( S, Yever, the family did not return for 4 months.
' P$ `! ~0 \; J4 R) e; e# DPhysical examination at this time revealed that the
9 Q9 i8 c0 Q9 w& ychild had grown 2.5 cm in 4 months and had gained3 e: t1 E; ^3 x6 L
2 kg of weight. Physical examination remained
) o8 K4 U& G# |3 }# I8 punchanged. Surprisingly, the pubic hair almost com-
( S s7 S5 H6 cpletely disappeared except for a few vellous hairs at
, T! n4 S4 \4 n* I0 T8 j8 e4 ithe base of the phallus. Testicular volume was still 2$ b& ~4 P9 j- y A9 W0 e3 I; y
mL, and the size of the penis remained unchanged.
" ?$ L7 _, W% {The mother also said that the boy was no longer hav-
7 a8 O0 U: ?) i( a; L/ q5 King frequent erections.
4 a: e( u" w7 x& bBoth parents were again questioned about use of9 D0 y. S: H1 O
any ointment/creams that they may have applied to! i8 o: H2 _/ z2 z
the child’s skin. This time the father admitted the; Z5 q) N# O/ M* c s
Topical Testosterone Exposure / Bhowmick et al 541
/ j5 X% y4 ^9 T/ F6 K2 puse of testosterone gel twice daily that he was apply-
6 e5 z8 o" ]3 L. Ning over his own shoulders, chest, and back area for' M! M+ k% M, E8 b
a year. The father also revealed he was embarrassed8 ] d) g1 }* N# n& ^$ a7 T( e
to disclose that he was using a testosterone gel pre-
7 J5 a6 q7 B0 M3 Mscribed by his family physician for decreased libido8 o9 W- b, N! ^1 m$ g9 k
secondary to depression.3 g# _' }, b. A4 r' y$ T1 q8 ]( M% }
The child slept in the same bed with parents.6 n7 e7 K( h- W2 v. w) w+ P. g
The father would hug the baby and hold him on his6 R$ t b$ r' u d+ [! P
chest for a considerable period of time, causing sig-
" j+ l: p* d2 g1 Y6 _- ^+ n T9 snificant bare skin contact between baby and father.
" G. @# o: W1 F- ^The father also admitted that after the phone call,& X. b# g# t8 v$ R& l7 ^& p' {7 E
when he learned the testosterone level in the baby6 }3 _4 c- n) k, g
was high, he then read the product information% P. I8 v% Z1 m0 e5 O5 e+ U6 n
packet and concluded that it was most likely the rea-
% ^( c& z2 c, ?son for the child’s virilization. At that time, they
- |0 Z4 F' s3 M8 vdecided to put the baby in a separate bed, and the+ ]9 ^! Y! p+ h- [+ e4 ~2 N
father was not hugging him with bare skin and had1 ^+ I6 [* w/ T6 j X$ _: i
been using protective clothing. A repeat testosterone
5 O0 q. U* E/ C+ s4 [9 D/ s. Mtest was ordered, but the family did not go to the, H2 G9 M2 J- [8 M0 |' f* V
laboratory to obtain the test.+ T! c/ R3 h, ]' l; C) K, u
Discussion
% }/ s% [' H7 Z4 U& R3 D- t0 M, hPrecocious puberty in boys is defined as secondary+ f3 E, K0 T# g, D# Q! Z
sexual development before 9 years of age.1,4
7 O5 j& w& {. v& K5 XPrecocious puberty is termed as central (true) when1 T7 E6 z+ Z2 X. p. j# K) ?) j: N
it is caused by the premature activation of hypo-+ C1 w/ b: e: I- b, n/ P S0 l
thalamic pituitary gonadal axis. CPP is more com-$ z2 L8 [' c) p$ U4 M, s- ^
mon in girls than in boys.1,3 Most boys with CPP
H2 c- A2 i0 r \* ~& qmay have a central nervous system lesion that is- ~6 B( m; n9 T) q1 `8 T# Z
responsible for the early activation of the hypothal-! \- `- n: n+ }/ u2 [' W1 B
amic pituitary gonadal axis.1-3 Thus, greater empha-( V6 ~. C8 U, [4 @
sis has been given to neuroradiologic imaging in
: ?" m8 L( \: }6 {# y8 X0 [boys with precocious puberty. In addition to viril-
( p% V6 [- J, r0 }# X" H9 Yization, the clinical hallmark of CPP is the symmet-
( @# s$ H3 q' r( Lrical testicular growth secondary to stimulation by# |1 K6 X, h' X! k- ^& ]
gonadotropins.1,39 a6 S( D( f; o6 g5 G' Y
Gonadotropin-independent peripheral preco-
0 I& `. C! a$ w" E: p+ hcious puberty in boys also results from inappropriate2 H d$ p. f6 x: i6 d0 {
androgenic stimulation from either endogenous or: c: A: `) u9 ~2 C9 c4 B
exogenous sources, nonpituitary gonadotropin stim-
+ z% C8 T, \* E, N& n. Zulation, and rare activating mutations.3 Virilizing
; L0 h9 C" p8 j6 m0 _/ R: Icongenital adrenal hyperplasia producing excessive0 j6 `8 Q" Y' ]- y/ C# W
adrenal androgens is a common cause of precocious
5 P {1 }5 N6 z. U6 ^- \3 Q1 fpuberty in boys.3,4
% G6 g' m1 s0 P! T( } \6 Z" }The most common form of congenital adrenal* P# o1 e" P J/ I! A6 p7 E3 J( |) V
hyperplasia is the 21-hydroxylase enzyme deficiency.
) I5 H) |% ~% k9 C- P. jThe 11-β hydroxylase deficiency may also result in: q ~$ G! a' `* K$ v0 M
excessive adrenal androgen production, and rarely,
7 C9 D k/ V- @ P0 ~* r+ `* Aan adrenal tumor may also cause adrenal androgen- H8 N$ t& N+ H! D! O# K
excess.1,3; B# A8 @9 I" A4 y+ V- E! T5 w1 Z# Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from N$ p7 ]7 ^" |4 z
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 E3 V2 g$ J) C( E
A unique entity of male-limited gonadotropin-3 j$ f6 D Z& B$ `) J& r, l( j
independent precocious puberty, which is also known
' A# p0 E7 I7 x* x* f4 j0 Vas testotoxicosis, may cause precocious puberty at a8 R" K$ C Y M b! ^9 \) m+ F) A
very young age. The physical findings in these boys
: ~* x6 b9 J0 b( W" v- U/ u1 \with this disorder are full pubertal development,
h! k' s+ n" M6 i: u/ E4 `including bilateral testicular growth, similar to boys% J3 x7 Q: M& W( i- U" B
with CPP. The gonadotropin levels in this disorder
1 \% `, \3 p% [- r) b/ p- [& Oare suppressed to prepubertal levels and do not show" U. y% f9 Q# f0 q4 k7 Y$ q. D' n
pubertal response of gonadotropin after gonadotropin-
5 W: {0 G/ c1 F! L0 b x, Lreleasing hormone stimulation. This is a sex-linked+ Z5 X# t8 L9 S
autosomal dominant disorder that affects only- P/ n( N* V$ O
males; therefore, other male members of the family
& x9 N) U; h3 {+ ?! b. g: I8 \may have similar precocious puberty.3
* x4 u0 \8 l* b {In our patient, physical examination was incon-, V. P) P C9 r" ]1 e- n& m6 k
sistent with true precocious puberty since his testi-
+ C9 W: u' `/ V$ N/ K8 hcles were prepubertal in size. However, testotoxicosis
) W: Y1 ]6 H' ]' iwas in the differential diagnosis because his father
' l& \5 \4 G) s/ c9 j. ?started puberty somewhat early, and occasionally,
% u/ k" X4 W) n$ m* ctesticular enlargement is not that evident in the3 L" }; s6 A+ j: Y- K& X8 I
beginning of this process.1 In the absence of a neg-- _& D2 Z4 v/ R' }; z9 ]3 L- N
ative initial history of androgen exposure, our) r" H+ z5 K% ]% S
biggest concern was virilizing adrenal hyperplasia,( B' x# f- b. A' M: {2 k7 [8 L, A
either 21-hydroxylase deficiency or 11-β hydroxylase, @' P9 W9 W" U3 U/ M0 E2 Z
deficiency. Those diagnoses were excluded by find-% c6 W% D: B, H5 c
ing the normal level of adrenal steroids.
7 t1 L9 U# g5 J; S! qThe diagnosis of exogenous androgens was strongly
5 m) m% ]9 q/ n; s; g( y5 E/ U/ m; l% w4 gsuspected in a follow-up visit after 4 months because* X- v! Y" U- \" P6 D. }
the physical examination revealed the complete disap-
3 U* d) w" W0 \! L. X- u1 V9 Bpearance of pubic hair, normal growth velocity, and
" N, X& M+ Y) j* X ?' gdecreased erections. The father admitted using a testos-
/ j/ E7 w: _1 r$ M! Eterone gel, which he concealed at first visit. He was9 z7 @$ R% i. \7 s
using it rather frequently, twice a day. The Physicians’
. [- C7 ]) y, H9 E. \( KDesk Reference, or package insert of this product, gel or& |4 ~1 @/ q! m
cream, cautions about dermal testosterone transfer to
9 ~0 V7 ]! _$ z5 [* m4 wunprotected females through direct skin exposure.
5 C+ ^7 D4 [4 lSerum testosterone level was found to be 2 times the- x) c2 K3 r) Q( ]' d
baseline value in those females who were exposed to6 b! |( p( m1 S2 V" |
even 15 minutes of direct skin contact with their male- L; S) L9 J- i n+ ~
partners.6 However, when a shirt covered the applica- }: o" c# U" s
tion site, this testosterone transfer was prevented.0 N5 _9 D' H3 h# ^, E6 d
Our patient’s testosterone level was 60 ng/mL,6 O% y3 G& e4 D2 ?) f3 f0 K
which was clearly high. Some studies suggest that
) `; r1 j/ `. \% R6 ~% udermal conversion of testosterone to dihydrotestos-" s% i! Y6 ]+ s: J" h5 b4 i' t
terone, which is a more potent metabolite, is more; g% K9 P. k, X& Q4 D0 Q$ h
active in young children exposed to testosterone
5 g: y/ y+ O! z) nexogenously7; however, we did not measure a dihy-
8 c% |$ \, Z7 U, Bdrotestosterone level in our patient. In addition to
( y ]: l8 Q. Q3 W& _' g0 U5 @5 e2 Zvirilization, exposure to exogenous testosterone in5 ^* Z7 {( Y# b- a" C
children results in an increase in growth velocity and
. W+ I j8 F8 Q! q& zadvanced bone age, as seen in our patient.
6 O+ I- O5 G1 ~8 _; C, C; S5 @8 HThe long-term effect of androgen exposure during" S' {+ o# s% ?0 U0 S$ t
early childhood on pubertal development and final) r' U% i9 f4 J5 ?
adult height are not fully known and always remain
: @% |& b) a% L9 t+ _a concern. Children treated with short-term testos-
0 }9 t! q: \8 ^, j( ]6 jterone injection or topical androgen may exhibit some
3 K! W: Y3 `! e) e" t3 ?) p; {acceleration of the skeletal maturation; however, after
) W) I# p$ K, C0 q6 dcessation of treatment, the rate of bone maturation' k+ _4 M7 _: o3 y: v& V0 ?
decelerates and gradually returns to normal.8,9
) y* }: E M8 Z0 @0 H9 N, d* DThere are conflicting reports and controversy
! O0 t; E2 u+ I, Vover the effect of early androgen exposure on adult
3 |; o. c4 o4 Ypenile length.10,11 Some reports suggest subnormal; n" P0 R) X3 B2 D( m+ v4 |
adult penile length, apparently because of downreg-6 ^' b, x2 A; N! @$ s5 j
ulation of androgen receptor number.10,12 However,
' `. B3 W! J) m- A% q( vSutherland et al13 did not find a correlation between
3 ]4 _# ~! f) u, d& l& I/ Cchildhood testosterone exposure and reduced adult
7 d: U/ v4 c& q5 M Z: i( `0 A5 O/ openile length in clinical studies.
( ?/ g: x, u, w) {% D( A" w5 HNonetheless, we do not believe our patient is2 b; V4 \% W% f
going to experience any of the untoward effects from" @ ~* u$ v/ n* S" u2 W2 N
testosterone exposure as mentioned earlier because
7 d5 n+ B4 \0 _! q! `. Tthe exposure was not for a prolonged period of time.
+ B! y& o( _: x# h* k$ yAlthough the bone age was advanced at the time of
5 [- p P2 W" ?6 L7 J% T3 s8 m& Fdiagnosis, the child had a normal growth velocity at
7 m& O& q1 r7 P# f t- fthe follow-up visit. It is hoped that his final adult
6 o- B1 L% O9 gheight will not be affected.
! m# s* V; n# p, Y7 _7 ^5 dAlthough rarely reported, the widespread avail-
7 {0 w- R, |& F0 M; [# ^/ Fability of androgen products in our society may; u. O z! e( ]- [* b
indeed cause more virilization in male or female/ F/ b& g1 @) `4 I3 k) T# N
children than one would realize. Exposure to andro-
) w! a5 m2 |( k- z0 |gen products must be considered and specific ques-4 v' M- ?$ B' v+ d6 t
tioning about the use of a testosterone product or8 S. J( C2 k o9 Z
gel should be asked of the family members during
2 {/ V) ^ Y6 h u# S& ythe evaluation of any children who present with vir-. D- H* \: y* ?6 w% j
ilization or peripheral precocious puberty. The diag-
9 i- \- U" ~1 n( c! h Z4 Anosis can be established by just a few tests and by7 c: O8 ?) @0 o& a$ D. J' d$ w( @
appropriate history. The inability to obtain such a ?* m- s2 `6 O9 X) `: y
history, or failure to ask the specific questions, may
* ]4 _5 x7 g! R8 {. eresult in extensive, unnecessary, and expensive
. Y! Z% T0 D. p$ b' {investigation. The primary care physician should be- t& V& U- d9 V+ v, o# ^ f; i
aware of this fact, because most of these children- h) A$ u/ c( g5 E9 }
may initially present in their practice. The Physicians’
/ X6 x3 c3 i; U* }2 z- l2 d& LDesk Reference and package insert should also put a1 _" o& t" A4 O5 Z
warning about the virilizing effect on a male or
6 j) [* f. \8 F- m8 {female child who might come in contact with some-% U) Y" \ U r: \5 m* o( P0 B0 a1 u
one using any of these products.
. ?1 Y" l5 R2 L/ h% l- x5 ^References
$ o2 w1 d4 T2 H$ d! _: P2 e/ B! y% ^1. Styne DM. The testes: disorder of sexual differentiation8 r* c9 [2 f( E6 n# ~8 e7 j6 v
and puberty in the male. In: Sperling MA, ed. Pediatric
2 u% L# i! F+ z9 BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 K+ }, i/ g" Q2002: 565-628.3 J4 z+ K4 T: K, G" X r, Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 L5 K; b7 F+ Y$ i3 a2 Lpuberty in children with tumours of the suprasellar pineal |
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