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Sexual Precocity in a 16-Month-Old& G! A/ U; q' C1 B
Boy Induced by Indirect Topical, C, u' G M7 b8 [* N2 V
Exposure to Testosterone
" q4 R0 `7 j( {( `+ D3 s( USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 e' [# w( q2 H* s
and Kenneth R. Rettig, MD1
. S' E5 h) k2 ]- b* A8 t0 jClinical Pediatrics
$ Z9 |3 B. l0 k0 q5 X2 c" J% tVolume 46 Number 6( v3 }9 ~0 M( {5 a
July 2007 540-543
. L1 p& e" g+ s6 ^© 2007 Sage Publications+ O- P+ T4 n$ C% g0 _) I. Q
10.1177/0009922806296651# N& |; P! Q# Q# e
http://clp.sagepub.com
" K; g& t- W" ?1 l7 ]1 Jhosted at9 C5 I: P; z6 _" g$ E! ?6 r' B
http://online.sagepub.com$ O2 ^+ C8 _- u _* b# O5 t, q
Precocious puberty in boys, central or peripheral, j7 G* k- a6 ~, U' B
is a significant concern for physicians. Central4 e) m9 z# q. ?# _
precocious puberty (CPP), which is mediated3 j2 \' Q X& J5 B0 u! ^5 w
through the hypothalamic pituitary gonadal axis, has, g' b. s2 L" V2 q- x
a higher incidence of organic central nervous system" d5 E* w) i: ]8 J, `% l3 O8 ]# t
lesions in boys.1,2 Virilization in boys, as manifested
: ^2 Q8 A6 @6 t/ sby enlargement of the penis, development of pubic( w8 p) D. N) ?1 O/ c
hair, and facial acne without enlargement of testi-1 ]' F6 b, i) {( a
cles, suggests peripheral or pseudopuberty.1-3 We, @" ^9 l8 e6 w+ r; E& [
report a 16-month-old boy who presented with the1 a! [3 D C& v7 Y4 n+ G
enlargement of the phallus and pubic hair develop-
+ y" p9 p: J& r9 Q% ?ment without testicular enlargement, which was due0 h5 m3 r$ x# s7 t
to the unintentional exposure to androgen gel used by7 T$ F. M, a$ m1 x+ J
the father. The family initially concealed this infor-
0 t5 ~3 F$ O8 d. k% ?mation, resulting in an extensive work-up for this2 L, e# _3 H* l% v |4 R
child. Given the widespread and easy availability of. b" C$ W) m. j' G" K/ I5 `
testosterone gel and cream, we believe this is proba-
k+ r" n" J, Xbly more common than the rare case report in the
9 H3 ]6 v: c5 w' j" j1 S% m- Oliterature.4' A) k- L& q$ k, ]+ X9 ]% }) S
Patient Report
( O+ {9 t4 U% i, NA 16-month-old white child was referred to the
; ^, x% ^6 S& N3 H7 U. ~( rendocrine clinic by his pediatrician with the concern) t9 t! s2 ^& A8 [
of early sexual development. His mother noticed5 N7 d$ Z) Y2 z
light colored pubic hair development when he was
1 R- i) Q$ C; ^! P9 g$ OFrom the 1Division of Pediatric Endocrinology, 2University of+ t9 n j d" R G ^3 k! l9 H: t3 R
South Alabama Medical Center, Mobile, Alabama.
" a1 e, A) a6 s: \Address correspondence to: Samar K. Bhowmick, MD, FACE,4 B# `' d+ _: @0 J; `
Professor of Pediatrics, University of South Alabama, College of
% n8 w( Z( N y9 W$ `- b5 J- g" DMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 M1 k9 O7 W$ F8 `e-mail: [email protected].! E" k- W Y) b; P& b
about 6 to 7 months old, which progressively became3 L0 d1 r# t& _4 ^) p1 Y
darker. She was also concerned about the enlarge-, k7 }4 `9 {! B2 r6 l9 m
ment of his penis and frequent erections. The child2 R4 ]' k& y. a$ p1 P# u e0 c F
was the product of a full-term normal delivery, with
, Y# I5 J0 U1 k5 ea birth weight of 7 lb 14 oz, and birth length of, ~7 z# W5 H! u/ t* j; n2 u, y
20 inches. He was breast-fed throughout the first year/ }- |! F" E% m7 j/ b _$ Q8 J7 x
of life and was still receiving breast milk along with, P2 a/ F9 |; p& b
solid food. He had no hospitalizations or surgery,
8 o' ^$ T& f4 q K5 S: g/ ~and his psychosocial and psychomotor development
4 |1 N1 V- t& D& Hwas age appropriate.
) u; g* h+ A# J: \3 K5 [The family history was remarkable for the father,
9 _7 r9 j, p# P P: \% }2 _who was diagnosed with hypothyroidism at age 16,: ` B' u* v& }& X( e' n
which was treated with thyroxine. The father’s4 T2 @/ J' ~( E( M V/ e( w
height was 6 feet, and he went through a somewhat" ^6 @) ~1 g8 i- C) j
early puberty and had stopped growing by age 14.
+ e0 n1 B: M7 J' S# I( h+ |The father denied taking any other medication. The9 T" K0 k: m8 \2 r$ T/ e5 ]
child’s mother was in good health. Her menarche' @0 F2 H9 w0 d0 a# B X' R7 S
was at 11 years of age, and her height was at 5 feet
; b( a% q" f/ a5 inches. There was no other family history of pre-' {9 b0 l1 \3 B+ P
cocious sexual development in the first-degree rela-3 y8 ^$ Q+ m5 q7 M4 v% D9 L
tives. There were no siblings.
! q; W7 m1 ?* `: j+ J1 fPhysical Examination
& a$ u& V+ @+ J4 P3 SThe physical examination revealed a very active,
; i2 x6 c' R( ?5 Lplayful, and healthy boy. The vital signs documented2 g' i2 L s# c; j+ _; j# ^
a blood pressure of 85/50 mm Hg, his length was; e3 t! U* z% h8 f8 g4 x
90 cm (>97th percentile), and his weight was 14.4 kg
8 B1 T* u, t! O# K$ I(also >97th percentile). The observed yearly growth
5 {" I2 q7 g% N. a7 r3 }velocity was 30 cm (12 inches). The examination of
- _4 w7 { d7 o8 othe neck revealed no thyroid enlargement.
; `' ]1 g" Q* _$ P3 R9 d" u* KThe genitourinary examination was remarkable for1 E0 a5 X/ a3 q( ?7 ~. V/ i8 L
enlargement of the penis, with a stretched length of$ p S9 w" o7 G" Q
8 cm and a width of 2 cm. The glans penis was very well
. |; e2 O& H @; o Udeveloped. The pubic hair was Tanner II, mostly around }- ~* `1 Y( C" O
5408 f/ n% n8 _# Y% P3 @& i5 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* A* j7 C- S- Z! s
the base of the phallus and was dark and curled. The
5 j8 @+ K' b# w8 M8 k6 w+ `3 c! Ztesticular volume was prepubertal at 2 mL each.$ y% {7 N9 a% w. h5 Z" a; U
The skin was moist and smooth and somewhat. G, [( P9 L2 f
oily. No axillary hair was noted. There were no& k" b& X- ~8 I/ X
abnormal skin pigmentations or café-au-lait spots.
5 Q0 ]/ T, j4 w- K! jNeurologic evaluation showed deep tendon reflex 2+
& m7 }- Q3 L: |4 q* A3 Pbilateral and symmetrical. There was no suggestion7 \( c1 T) W9 W7 ]7 b
of papilledema.4 d7 ] r0 g2 u& z& S
Laboratory Evaluation
: {: p( X' g: c( @2 g7 t7 _$ oThe bone age was consistent with 28 months by
) r. t) M& T5 t! r- a( _using the standard of Greulich and Pyle at a chrono-# {0 j& V. U" ?% ?+ L1 C
logic age of 16 months (advanced).5 Chromosomal0 z9 e# J: U( _0 x7 j' o( \* d
karyotype was 46XY. The thyroid function test
, C( b$ @1 L) u$ l% yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- I- _) c1 i- \# n6 S7 Xlating hormone level was 1.3 µIU/mL (both normal).1 p6 s+ r# \0 N' m4 h* A
The concentrations of serum electrolytes, blood5 V" j% B) P6 i8 m
urea nitrogen, creatinine, and calcium all were! H- Y" N/ e* f. M# Q! a4 k
within normal range for his age. The concentration
' r: S6 C' c+ E- ^# |of serum 17-hydroxyprogesterone was 16 ng/dL
- |) E2 y7 F7 Z) U(normal, 3 to 90 ng/dL), androstenedione was 20- Z+ ~5 Y* b8 `; ^6 v8 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! m0 E7 v( K( M( e# ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),% p7 I, V5 Q$ ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' U6 @* Y1 Z s Q$ f* f# n7 N49ng/dL), 11-desoxycortisol (specific compound S)
3 ^+ r2 D$ l( `- Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' w1 o/ Q3 Z% ^7 i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# | W: |8 k5 g9 y5 E- Ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) ^- G! K J, Rand β-human chorionic gonadotropin was less than: w$ [( ]+ D6 l" R, r$ d( m% g* m
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 v2 @( N* b7 { K0 ostimulating hormone and leuteinizing hormone( h0 g1 y* ?1 A! E" ^: Y
concentrations were less than 0.05 mIU/mL; s# C; F4 u$ c! p- M
(prepubertal).+ T/ X' _) c/ N9 e7 I
The parents were notified about the laboratory
3 X" f; l* K0 {- s8 Vresults and were informed that all of the tests were/ `: Q* Y9 y! V; N4 L
normal except the testosterone level was high. The4 N6 ~, R, ?6 n4 A# h
follow-up visit was arranged within a few weeks to% M" j4 _; w/ \8 b" r
obtain testicular and abdominal sonograms; how-+ s8 Q* A* P% f' U& f1 C& k
ever, the family did not return for 4 months.
/ d W3 U3 h9 X5 n8 C% z8 R0 vPhysical examination at this time revealed that the
; V2 ~' T& _* k9 n% Tchild had grown 2.5 cm in 4 months and had gained$ b* V/ A% K: s7 N
2 kg of weight. Physical examination remained
, m: i$ [9 P! {: t0 z8 J, W# xunchanged. Surprisingly, the pubic hair almost com-
1 k" e9 v' a8 d: {9 Epletely disappeared except for a few vellous hairs at. }0 ?# t- t( j0 m/ r; R# _, {$ ~
the base of the phallus. Testicular volume was still 2
) r: W( N4 N6 P9 a) umL, and the size of the penis remained unchanged.; U' F- {- ?, e; p9 i" o: e
The mother also said that the boy was no longer hav-+ ?0 b* F* r6 k2 H6 J Z
ing frequent erections.
7 s" x2 ]9 L6 S* T [. X) ^; O! p9 vBoth parents were again questioned about use of! q) ~+ r: }+ Q9 X. G/ q) {
any ointment/creams that they may have applied to. d, m# y2 h$ `0 v% S
the child’s skin. This time the father admitted the
5 C2 q" f9 W8 |. o+ hTopical Testosterone Exposure / Bhowmick et al 541( {0 H! l3 a; ~
use of testosterone gel twice daily that he was apply-
4 ^% N9 [; [/ b% X9 F3 B& w9 fing over his own shoulders, chest, and back area for
2 U0 x0 Q, ]5 ?5 Oa year. The father also revealed he was embarrassed
0 e- g$ r1 y5 N! Wto disclose that he was using a testosterone gel pre-
c$ H9 g" S1 d4 ~- @scribed by his family physician for decreased libido. K# z- p, I- N
secondary to depression.
$ T& @0 m! Z( @/ y( i$ qThe child slept in the same bed with parents.3 N. @7 u p* l. j" s0 A
The father would hug the baby and hold him on his
' k1 i6 K. `, m/ T4 z( d9 vchest for a considerable period of time, causing sig-
/ F9 M7 C+ ]7 i; Vnificant bare skin contact between baby and father.2 O S5 q, I5 T% q L
The father also admitted that after the phone call,, z/ C/ a7 ?+ _' X; t+ Y
when he learned the testosterone level in the baby! S6 K9 E: F( h5 g B" Y2 \
was high, he then read the product information
* C. H c5 O8 Rpacket and concluded that it was most likely the rea-
9 I3 B; O9 q. N/ P3 B; P$ Mson for the child’s virilization. At that time, they& Z2 k2 r! `' r0 D8 _+ B! {
decided to put the baby in a separate bed, and the
. z4 L: m4 c" B" M/ l2 Ofather was not hugging him with bare skin and had$ X v( z; G u7 P9 y/ w: U' r) ^* |
been using protective clothing. A repeat testosterone
9 q6 v& S7 _6 `4 u* Wtest was ordered, but the family did not go to the
3 q' h! R% l# d- F" }! @laboratory to obtain the test.# X6 y6 @) ]6 Q- x! t
Discussion
& N7 Y) P# h9 V# k) p- HPrecocious puberty in boys is defined as secondary& ], C( |! t. T3 A
sexual development before 9 years of age.1,4
$ T9 t" u4 A! W4 xPrecocious puberty is termed as central (true) when- H( r) A" V3 `* j2 t
it is caused by the premature activation of hypo-: L0 }! A+ B" l% J" J; `
thalamic pituitary gonadal axis. CPP is more com-, i/ }& w6 I; t$ F5 @
mon in girls than in boys.1,3 Most boys with CPP" A$ O" K1 Y/ i( [5 e B5 U
may have a central nervous system lesion that is* J; X4 u ]4 d
responsible for the early activation of the hypothal-
" I4 R" a/ s; K# o3 i; k5 p1 Pamic pituitary gonadal axis.1-3 Thus, greater empha-$ c5 q) j$ Y g4 H: T. L. ]+ P4 k
sis has been given to neuroradiologic imaging in
3 I3 y& _/ }9 r0 N0 c6 A. L sboys with precocious puberty. In addition to viril-1 B6 b; E0 `% t
ization, the clinical hallmark of CPP is the symmet-
8 C9 p5 S @5 j) zrical testicular growth secondary to stimulation by
+ N% s- O9 T3 i/ Ygonadotropins.1,3& C- I- i7 H8 z) Y2 r) r4 O
Gonadotropin-independent peripheral preco-
4 i+ {" w- @0 f0 r/ z0 \cious puberty in boys also results from inappropriate6 B8 P: K5 |% c' O
androgenic stimulation from either endogenous or
/ C G" w0 M- \: m. V8 E1 _exogenous sources, nonpituitary gonadotropin stim-+ G% Q! P+ \" r& g# I$ E" F
ulation, and rare activating mutations.3 Virilizing
: W+ |2 d- W. I. }7 E) Qcongenital adrenal hyperplasia producing excessive" J- R* P, [# ~7 B$ E J
adrenal androgens is a common cause of precocious
: g) a8 N, i8 l' M+ w3 tpuberty in boys.3,4: h9 L2 v6 T" _1 X) ^) l2 ?7 F/ E
The most common form of congenital adrenal
3 m0 w5 S7 _$ o9 n; N" }hyperplasia is the 21-hydroxylase enzyme deficiency.
3 S$ g# `" r3 i9 W/ mThe 11-β hydroxylase deficiency may also result in3 x! t( v: j& h
excessive adrenal androgen production, and rarely,
% p) \0 |" |0 ^/ p: Y1 R9 T/ Q1 ~# fan adrenal tumor may also cause adrenal androgen% U' @0 ?% [0 `0 |8 D
excess.1,3
5 a) |; `0 u- I. w; d3 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! s) S$ @. ?5 w. R1 v
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 i" ^. Z) C3 M c( u2 H& Z' iA unique entity of male-limited gonadotropin-
8 X- f5 C; q# @. Windependent precocious puberty, which is also known
) E$ T* V) ^9 d" N: M, @$ Was testotoxicosis, may cause precocious puberty at a& y4 a/ F D) A- _/ c
very young age. The physical findings in these boys
+ K! ]& M# t- q# h0 l7 g" \+ Q4 Kwith this disorder are full pubertal development,
) H; u! P5 v1 o: r0 t9 N: u2 `# {2 Nincluding bilateral testicular growth, similar to boys& n) _$ V0 Z% |& y/ z+ U" t
with CPP. The gonadotropin levels in this disorder
5 y( N, J) n! m2 ^. x2 z! Nare suppressed to prepubertal levels and do not show d J% ~4 m9 Z/ N
pubertal response of gonadotropin after gonadotropin-( b; ?* X8 d3 q6 d7 P( Z
releasing hormone stimulation. This is a sex-linked6 K; w+ r1 ^6 f
autosomal dominant disorder that affects only
w) U2 f; X% V' l/ X/ hmales; therefore, other male members of the family
1 K }1 ?! \" B6 gmay have similar precocious puberty.32 W6 p4 \+ t) {9 q. s8 w
In our patient, physical examination was incon-
, I' ^" W4 G" z! `2 Xsistent with true precocious puberty since his testi-" U+ @2 {# }3 x
cles were prepubertal in size. However, testotoxicosis8 O4 P- u2 m- f/ E2 z, G
was in the differential diagnosis because his father
0 R3 b, ]. M' W% D' M8 D7 tstarted puberty somewhat early, and occasionally,- `$ e4 l* X7 `. a) K. Z
testicular enlargement is not that evident in the7 C9 W+ v* i1 m: S i9 a% O5 v
beginning of this process.1 In the absence of a neg-
9 P# y" N2 [- }3 V0 k6 T& Pative initial history of androgen exposure, our" [* Q/ a5 I# ]/ N- K) B. Y, D$ r
biggest concern was virilizing adrenal hyperplasia,; K3 y6 \+ j4 m5 j
either 21-hydroxylase deficiency or 11-β hydroxylase
: t) W* i+ |/ {" Zdeficiency. Those diagnoses were excluded by find-
* y7 {, x" h; G( @# l" Cing the normal level of adrenal steroids./ n7 ^8 M% b& E# h/ k; k% h' c
The diagnosis of exogenous androgens was strongly
! l( O: P( G: D3 H8 b. Ssuspected in a follow-up visit after 4 months because
$ u; m6 w1 ?; o6 g2 L. I& sthe physical examination revealed the complete disap-
& Z' k, V4 T( B0 U) Y* jpearance of pubic hair, normal growth velocity, and
+ q% p, b- T# p5 Sdecreased erections. The father admitted using a testos-
/ {" b3 c+ d4 E$ [8 T) u: S) Fterone gel, which he concealed at first visit. He was0 I! s1 p, r. z# G I
using it rather frequently, twice a day. The Physicians’
* `7 X) x ^% E$ H' J; c- G" `& ^# hDesk Reference, or package insert of this product, gel or& a( x: R' j# k& E- i1 s
cream, cautions about dermal testosterone transfer to! v! l9 a6 d! L* `7 [- K
unprotected females through direct skin exposure.
* p& i2 X5 n9 z: S% X. vSerum testosterone level was found to be 2 times the
' P$ J1 _3 P3 c* E) ubaseline value in those females who were exposed to
2 H' [2 ?5 M% J& {: weven 15 minutes of direct skin contact with their male" u* F( T [& m* a: r& B7 u' v
partners.6 However, when a shirt covered the applica-% y' X: @4 |: V+ k0 C) x
tion site, this testosterone transfer was prevented.
$ E1 X P1 j m' s* ]7 [' @' i7 |Our patient’s testosterone level was 60 ng/mL,
+ i3 a% W* L# ^; mwhich was clearly high. Some studies suggest that, A& s# { z. W4 d- F
dermal conversion of testosterone to dihydrotestos-8 C# j# c: |' P. \) H; c
terone, which is a more potent metabolite, is more
7 q1 _; M" {3 Q! W. Jactive in young children exposed to testosterone3 i. r9 ~" I; c
exogenously7; however, we did not measure a dihy-8 s4 r5 y c; V* U1 P5 |
drotestosterone level in our patient. In addition to3 u1 e: h" t% m+ C7 p" M: v+ Q3 ~
virilization, exposure to exogenous testosterone in5 s9 U$ _/ ]0 z' g
children results in an increase in growth velocity and
1 ^4 D2 [6 A4 B- @* Z0 }6 ~advanced bone age, as seen in our patient.1 n$ D$ Y! m7 Y H: Q i+ s5 w
The long-term effect of androgen exposure during" U, [! V) K1 r( i
early childhood on pubertal development and final
# S% J% X3 q9 S5 i$ Q2 Q1 [2 Iadult height are not fully known and always remain& a E2 j3 x5 i" T8 j
a concern. Children treated with short-term testos-
( J2 K" |2 A% p. lterone injection or topical androgen may exhibit some2 |% u" e3 k/ x$ | S( A
acceleration of the skeletal maturation; however, after, s R, `4 u* e1 T J
cessation of treatment, the rate of bone maturation/ u+ k2 r/ i9 G2 V4 W( [
decelerates and gradually returns to normal.8,9
/ @' V: N6 _% Z8 \- D' E0 GThere are conflicting reports and controversy
: U1 a$ D. r, [' w; y8 {" P# jover the effect of early androgen exposure on adult1 ]& X" M1 h; v
penile length.10,11 Some reports suggest subnormal$ q1 }% o' F' X0 o$ k5 y8 c q9 g
adult penile length, apparently because of downreg-! k9 u- \0 ` F' b) R
ulation of androgen receptor number.10,12 However,
9 W9 _8 V! O8 ]; QSutherland et al13 did not find a correlation between
T3 x4 r( l/ D5 p" l. Z5 I5 Wchildhood testosterone exposure and reduced adult7 K! n9 w' h+ i/ s L
penile length in clinical studies.
) q; O" H: o, K5 C$ R$ U9 ?: Q" LNonetheless, we do not believe our patient is: P, `0 T9 I* E. S6 J
going to experience any of the untoward effects from
7 [! g v( r1 W* t$ w- v8 \testosterone exposure as mentioned earlier because* Y7 s7 `8 l9 }3 W0 s T
the exposure was not for a prolonged period of time.* k- {& \5 o: D' `7 _& _! c' |
Although the bone age was advanced at the time of
2 s4 a6 M& W; |1 p/ [' Q$ jdiagnosis, the child had a normal growth velocity at
$ D, g2 H6 A0 M" U; t9 E7 G) Uthe follow-up visit. It is hoped that his final adult
6 v) v0 p( u% r7 [. Fheight will not be affected.
9 h o* n: X. A H/ KAlthough rarely reported, the widespread avail-
% _2 K* z- d" X1 {( v% Hability of androgen products in our society may
5 w( J; p# x$ Kindeed cause more virilization in male or female0 q# ~1 T6 d9 |3 D+ O/ b6 E
children than one would realize. Exposure to andro-3 B! L5 U" O# _+ r
gen products must be considered and specific ques-
X4 B9 e. J/ p6 V1 W* f& Q, Stioning about the use of a testosterone product or o r$ W& E- G. W3 ~8 \! O
gel should be asked of the family members during5 \: t5 v' v1 z2 ?; r' P% _) N$ p
the evaluation of any children who present with vir-( {& d7 B$ T6 W
ilization or peripheral precocious puberty. The diag-4 {5 p( ]: G* C, K& E1 N
nosis can be established by just a few tests and by
, B ^; d, o1 L! V3 O$ F6 x: n4 aappropriate history. The inability to obtain such a; L: z/ Z# j( ]. K" m5 \, ~
history, or failure to ask the specific questions, may; [$ |& ?/ Q, h
result in extensive, unnecessary, and expensive
& s, m9 ^% t( o. f# Xinvestigation. The primary care physician should be
. e7 }1 a! v$ A9 A. o0 i8 R1 \aware of this fact, because most of these children
* }( h" f1 _& Y' Amay initially present in their practice. The Physicians’
/ q2 p U' V6 T# j- Z0 F# P' C' j# BDesk Reference and package insert should also put a
& ]0 q" e- c: t- h f% Dwarning about the virilizing effect on a male or
; E$ H$ w* H' J+ ^ W- s4 Afemale child who might come in contact with some-
2 y( ~ p8 _0 Cone using any of these products.
6 p4 ?' S: t7 k# l6 L- ?' ~+ |References) \) T0 X) H# j/ c' X1 U
1. Styne DM. The testes: disorder of sexual differentiation
& a3 v+ c5 r( N% D* t4 Land puberty in the male. In: Sperling MA, ed. Pediatric N- ]# @7 i; y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; @. j9 B9 n; o- W2002: 565-628.
9 h' `; H( E2 J! l j! {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: P+ R$ [, H* X- z3 ^% Xpuberty in children with tumours of the suprasellar pineal |
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