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Sexual Precocity in a 16-Month-Old
8 m& d) Y$ R, CBoy Induced by Indirect Topical& A2 e" h8 q" \8 o) e. T
Exposure to Testosterone2 U0 _' c* ^ ]) j( @. R' @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 r; [8 c( g+ @' `3 ?
and Kenneth R. Rettig, MD16 K) P, w: v3 e3 U
Clinical Pediatrics1 N1 }8 F/ L7 X
Volume 46 Number 6 y+ j6 v6 t4 m# r7 @
July 2007 540-543/ ]4 w& O9 x% D( m( A
© 2007 Sage Publications* [* e3 o% \2 M( O
10.1177/0009922806296651
& ]- ~' g0 ?1 l1 U5 K( d8 T& jhttp://clp.sagepub.com: e/ V& J, p4 d5 ~! y! o+ Q- r
hosted at- n0 \) k& P; @1 ^* T
http://online.sagepub.com
. T4 G( }/ q! m/ G' _Precocious puberty in boys, central or peripheral,7 J( `4 y+ R3 U0 O1 E4 D$ i! e
is a significant concern for physicians. Central# f, g9 z, X3 X: r; c5 k
precocious puberty (CPP), which is mediated
& T4 @; Q$ x0 N& g! Dthrough the hypothalamic pituitary gonadal axis, has
+ l; J/ ~) f" R' q9 L( Na higher incidence of organic central nervous system3 z1 r' w5 S7 B; z6 a9 A
lesions in boys.1,2 Virilization in boys, as manifested
& Z. D% Q3 y" Fby enlargement of the penis, development of pubic
a- y" X, G' ihair, and facial acne without enlargement of testi-, Y& z- b# C/ U8 Q/ e1 z
cles, suggests peripheral or pseudopuberty.1-3 We
( n* e) }2 {4 @$ Nreport a 16-month-old boy who presented with the# E7 e" y4 v$ I# [# \# o
enlargement of the phallus and pubic hair develop-$ A5 ?7 b2 e X5 d% A! H; q
ment without testicular enlargement, which was due
8 O' U# Z& K. `# x( p8 B7 j( y2 `to the unintentional exposure to androgen gel used by
( W; C8 J0 ^. O, _9 ~the father. The family initially concealed this infor-$ Q" b( L8 r4 y) Q" x
mation, resulting in an extensive work-up for this) m5 b; o! o+ H. v! R. m
child. Given the widespread and easy availability of: ~/ w# Y, s. D. U
testosterone gel and cream, we believe this is proba-& @, `* I+ U# |& S3 a# v1 n" q
bly more common than the rare case report in the
# ^% z) E$ J6 V C! jliterature.4, K$ e1 D( r1 V) Q# u2 N
Patient Report
2 f( D" \: K7 c' Q% C7 }8 p# tA 16-month-old white child was referred to the
9 O* P1 Q5 i ^1 R0 i/ M7 j8 ?endocrine clinic by his pediatrician with the concern
8 r$ r0 ], Y% g) z2 Eof early sexual development. His mother noticed6 u9 d) s# I3 T" u- u
light colored pubic hair development when he was
0 Y4 l' m/ z8 cFrom the 1Division of Pediatric Endocrinology, 2University of4 {% j9 ]2 |7 ~! Q2 Z2 S
South Alabama Medical Center, Mobile, Alabama.
" @) \8 u0 D3 w! NAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 t, \: f: N( eProfessor of Pediatrics, University of South Alabama, College of1 B( `4 v l$ \& u& u7 W' E( Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* B5 W4 z8 ~/ ~6 x0 |
e-mail: [email protected].
, @$ \3 V m* [" a+ Q9 ?9 Mabout 6 to 7 months old, which progressively became' m9 q9 L! N9 f* V5 h
darker. She was also concerned about the enlarge-
% }0 J" x+ Q {" G0 pment of his penis and frequent erections. The child
; V( w9 M* M- z, \9 vwas the product of a full-term normal delivery, with8 s4 Y3 `9 p/ C* H% x
a birth weight of 7 lb 14 oz, and birth length of# m% i: H) S3 g6 A. c# [5 h. l; Q
20 inches. He was breast-fed throughout the first year! n1 w& Q1 Q4 S9 I# g7 Q
of life and was still receiving breast milk along with: n; q/ [4 a" S' p. Y1 x! ]' y' N
solid food. He had no hospitalizations or surgery,$ r0 ?' }, @: h+ G, r
and his psychosocial and psychomotor development5 ?* b" _" S# l; K
was age appropriate.
4 n. Z/ V7 f4 V) r4 s, jThe family history was remarkable for the father,
& u$ `3 a8 m" v0 i0 _who was diagnosed with hypothyroidism at age 16,! }7 x& g$ r9 a n9 q p& f0 Z& h
which was treated with thyroxine. The father’s
# ^/ x- Y8 P* f/ `2 X+ ?/ a9 Sheight was 6 feet, and he went through a somewhat M; v/ }: u/ W9 s% ]
early puberty and had stopped growing by age 14.* l5 ^# v% S! A4 ]( j: V" ~: ^7 u
The father denied taking any other medication. The& I( R- D9 C" _7 U4 @' b3 a$ E3 f
child’s mother was in good health. Her menarche$ M% K( k" K, l5 w
was at 11 years of age, and her height was at 5 feet
7 c! U3 g+ y; w) G1 p8 M! K5 inches. There was no other family history of pre-. A) K) r- b. j! g
cocious sexual development in the first-degree rela-
) D4 R& S. [9 x: d" z* w' qtives. There were no siblings.
3 O8 s5 `( B c1 oPhysical Examination
9 k) O' o/ L( SThe physical examination revealed a very active,
4 ~& B! ^, i! I, `3 T7 ^8 Fplayful, and healthy boy. The vital signs documented; n# C4 v8 M5 N' v* z$ _* Q4 j
a blood pressure of 85/50 mm Hg, his length was
, C1 ]# X0 U. W L6 l; Z# v- J8 ]3 ^90 cm (>97th percentile), and his weight was 14.4 kg
2 c/ f0 b7 [ ^$ ~* M7 a(also >97th percentile). The observed yearly growth
6 Q4 w8 u9 h* w* k' b- ^velocity was 30 cm (12 inches). The examination of1 K8 G3 W' k- X. B$ x# q; L2 n/ A: N
the neck revealed no thyroid enlargement.. L- z( r% }5 w. x- p7 `
The genitourinary examination was remarkable for
7 B- B: s$ s( ?) ^# m n2 }. Tenlargement of the penis, with a stretched length of5 g+ Q% q7 s& X4 b1 |
8 cm and a width of 2 cm. The glans penis was very well, q& r" j5 P, f% f+ p& g' P
developed. The pubic hair was Tanner II, mostly around1 k) D4 }6 a& t% L! |$ e% ^4 C6 L( B
540! A7 c- \4 B5 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) N; L" i+ ~4 ?5 Mthe base of the phallus and was dark and curled. The- j+ ]0 h H& H" j
testicular volume was prepubertal at 2 mL each.
( C+ Y* I- X- F- B3 i1 p+ ]9 [; lThe skin was moist and smooth and somewhat
* M0 Q" J$ ^% H2 s! n6 {* F! a1 P voily. No axillary hair was noted. There were no
. S* C0 \9 O babnormal skin pigmentations or café-au-lait spots./ I& N5 V: A' k0 W- X8 h- e
Neurologic evaluation showed deep tendon reflex 2+
$ @! |) d8 m2 Z7 pbilateral and symmetrical. There was no suggestion% Z- o% r. y4 O* V! T" {/ g
of papilledema.
+ _) d: d# v( GLaboratory Evaluation
1 x# H4 V0 u# g$ WThe bone age was consistent with 28 months by
4 {9 H0 T! u' H5 E* u ?# Vusing the standard of Greulich and Pyle at a chrono-" H9 L3 s: Y1 Z' f) C7 B6 B" `9 [
logic age of 16 months (advanced).5 Chromosomal
+ u" U1 L/ ]" U/ @karyotype was 46XY. The thyroid function test
0 _" p& Y- ~' h1 V1 |showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# x5 W5 [! F. [0 mlating hormone level was 1.3 µIU/mL (both normal)./ a' s4 { m) _' F8 Z+ a7 Y6 _* o
The concentrations of serum electrolytes, blood/ J# {! ^- h( U1 s- e" b
urea nitrogen, creatinine, and calcium all were
+ w" n* c3 s0 T/ G9 x9 V" k/ Fwithin normal range for his age. The concentration
4 f3 M* c/ W; @of serum 17-hydroxyprogesterone was 16 ng/dL( N" F( j) O: I: p1 J" T
(normal, 3 to 90 ng/dL), androstenedione was 20
2 t& [, h. _: y( fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 t ^" f6 A2 q6 A2 R4 {0 zterone was 38 ng/dL (normal, 50 to 760 ng/dL),( B0 Z1 z6 x. O9 ^5 M& `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 m4 I3 i4 g* R) C( R49ng/dL), 11-desoxycortisol (specific compound S)
& Y r# C _5 I s/ C. dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! x- Z b: p/ i& |; h2 U2 U. K2 d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 U* E% t6 v7 Z6 x* N) ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( S) o! N) Y Q) _
and β-human chorionic gonadotropin was less than* Q) i+ ^7 [2 P& o' p+ S5 o# [
5 mIU/mL (normal <5 mIU/mL). Serum follicular! A. m0 x4 v8 y8 }/ N! U
stimulating hormone and leuteinizing hormone
. J% x; v$ A7 ]8 M; c r- Vconcentrations were less than 0.05 mIU/mL
. Q* p1 x! l& ^1 Z(prepubertal)., Y' S) H. s3 y4 Q6 c
The parents were notified about the laboratory% p& B- H x0 s- T. R8 s; |
results and were informed that all of the tests were
% V+ w- a# w% onormal except the testosterone level was high. The
. W& \% e* N3 Q2 I9 k/ z8 j: Zfollow-up visit was arranged within a few weeks to' K3 P/ ^* f8 w) u: X) P1 G
obtain testicular and abdominal sonograms; how-
3 i3 C/ R" j& A" Qever, the family did not return for 4 months.
$ b! i) U! X5 l* l1 G/ A5 G0 b( M9 ~Physical examination at this time revealed that the; P+ R6 o& a- v2 [
child had grown 2.5 cm in 4 months and had gained" v1 X5 W; U x+ ?+ _7 B4 \
2 kg of weight. Physical examination remained
_; O/ l, y$ ]" o. Lunchanged. Surprisingly, the pubic hair almost com-+ d' e% Y# C9 G2 m
pletely disappeared except for a few vellous hairs at
: X/ B' X' |, t* S" t/ O3 c2 `the base of the phallus. Testicular volume was still 22 T* D1 ^5 F5 M9 t# f
mL, and the size of the penis remained unchanged.3 } v" t; f7 b w- k" h- h; T" u
The mother also said that the boy was no longer hav-
; ~9 n# y' `3 {( I* J( ving frequent erections.
: h. X& j: i3 I# B" v& a! TBoth parents were again questioned about use of, L1 s: t# E, r3 |8 f7 Q5 Z7 \7 G
any ointment/creams that they may have applied to+ E, z: Q8 a- r# m
the child’s skin. This time the father admitted the
/ o6 S% Z2 _( T' L1 P" J- ~4 Q. tTopical Testosterone Exposure / Bhowmick et al 5415 k% ?0 b! P& j1 \& ]
use of testosterone gel twice daily that he was apply-1 L7 o k) X5 h; S
ing over his own shoulders, chest, and back area for
* ?& u6 Q9 d( s8 W% T) g) ?a year. The father also revealed he was embarrassed/ \, a7 _) e2 m4 v: {7 j; N
to disclose that he was using a testosterone gel pre-
# H' v" M1 E- Cscribed by his family physician for decreased libido
+ C5 p$ i% n( \( s* Y. Osecondary to depression.! V& Z( F9 n8 R1 k) r
The child slept in the same bed with parents." p4 i$ {/ m: C0 `0 ]7 {9 m7 v
The father would hug the baby and hold him on his
. v" n) E/ _ _chest for a considerable period of time, causing sig- \ Z) C+ p* W5 Q% D" B
nificant bare skin contact between baby and father.' N3 w6 b4 X3 K) g" K9 D2 A7 ~: J* j
The father also admitted that after the phone call,
& Y1 d! }# c5 P5 \% Ewhen he learned the testosterone level in the baby
: W9 @' w- i" j; ^$ ^# s- Owas high, he then read the product information
" @; A" u% t- v p, z. [ Epacket and concluded that it was most likely the rea-8 ]4 P, Y; S" u8 r8 I5 s6 \! U" Y) D m
son for the child’s virilization. At that time, they) t8 J8 `7 D7 R. X; C0 h1 A
decided to put the baby in a separate bed, and the
4 O; V$ Z& O+ z+ {father was not hugging him with bare skin and had) A) P" S' o; R2 z2 p# a
been using protective clothing. A repeat testosterone1 ~% ?( _0 Y. i. n9 t2 A( B
test was ordered, but the family did not go to the. \3 e2 G' u: i' z7 x4 N
laboratory to obtain the test.8 U/ u/ A* |6 w* v5 q3 Z
Discussion* L7 Y- p) ]) L% @0 E+ w. F; h' ~
Precocious puberty in boys is defined as secondary
. L* x' L8 R- U. h) a: L- Xsexual development before 9 years of age.1,4! r! {: d2 l; G- {
Precocious puberty is termed as central (true) when
( K! N$ Z1 w- t2 F, w* X& Bit is caused by the premature activation of hypo-& s- [! A5 d7 Z! q" I
thalamic pituitary gonadal axis. CPP is more com-
! `1 y t. g( }mon in girls than in boys.1,3 Most boys with CPP* s6 F; L7 j. l h- O4 F
may have a central nervous system lesion that is
8 b( c: O E. c7 M+ dresponsible for the early activation of the hypothal-
9 W# L. v8 g. i0 ^amic pituitary gonadal axis.1-3 Thus, greater empha-
- ^( e1 ^) B: Ssis has been given to neuroradiologic imaging in
2 k- `) s Y7 ]' y9 Cboys with precocious puberty. In addition to viril-
8 [. t& D- V) v) h' Rization, the clinical hallmark of CPP is the symmet-% ~/ M! M2 `5 ?0 R% G0 h2 x' P
rical testicular growth secondary to stimulation by
4 N' d, n0 {& T6 Hgonadotropins.1,3( V, L7 u. U2 a+ W, z
Gonadotropin-independent peripheral preco-* f) |$ |& D* l
cious puberty in boys also results from inappropriate; K& k/ J# E" ^: c6 I2 G
androgenic stimulation from either endogenous or8 d) ?/ G) C* S7 O# S& [3 r: A6 Y
exogenous sources, nonpituitary gonadotropin stim-
- k" B% e* D8 Z4 n% I; }: b% `ulation, and rare activating mutations.3 Virilizing4 r( @8 ?) G6 }: x
congenital adrenal hyperplasia producing excessive
' X/ I" ]+ P1 L2 S1 J( c: \; Oadrenal androgens is a common cause of precocious
: L% D' u# x/ q$ n0 tpuberty in boys.3,4
5 Q% z; {9 o% ~7 B: X- p- @; T oThe most common form of congenital adrenal5 P5 d8 K9 x; w* P3 o
hyperplasia is the 21-hydroxylase enzyme deficiency.' O7 D3 r# G8 e) ~# z: s, Q
The 11-β hydroxylase deficiency may also result in! p% K3 r8 D4 g/ U% L
excessive adrenal androgen production, and rarely,: s0 @6 y$ p# ]6 v
an adrenal tumor may also cause adrenal androgen! b- g0 R/ d) k0 G! f
excess.1,3
4 n& k+ R) c1 S. C2 x$ Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ~& W0 a. Q0 j6 b! N6 U
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 H8 k* \$ o& Q7 T8 T- R
A unique entity of male-limited gonadotropin-# J$ c _" p; M/ l% r5 [! m% ~
independent precocious puberty, which is also known
- a& i8 g' B. x9 s, L8 vas testotoxicosis, may cause precocious puberty at a
) x. {8 _/ w) N$ b8 J* u9 f8 ivery young age. The physical findings in these boys
' h7 d; I5 D* z' a8 \6 [0 a) Iwith this disorder are full pubertal development,) v5 \& a% {7 z7 t5 P" V5 {7 d" R
including bilateral testicular growth, similar to boys
* x$ e: ?8 s% J! Xwith CPP. The gonadotropin levels in this disorder0 S' }. X! B8 r; v4 j4 ^, Q
are suppressed to prepubertal levels and do not show
( e0 J! L/ j0 }% m9 Hpubertal response of gonadotropin after gonadotropin-1 v+ y6 H2 K5 @3 H; K7 y l
releasing hormone stimulation. This is a sex-linked' Z$ B. l; k! B2 E- v
autosomal dominant disorder that affects only4 i( q& s r2 F7 p( [3 ] y5 K
males; therefore, other male members of the family
3 E6 y5 A) l, N" l* g% Smay have similar precocious puberty.3* h3 N& f* p$ q' g
In our patient, physical examination was incon-
! U c9 J4 p8 C- Q2 asistent with true precocious puberty since his testi-$ J- ?0 t: s6 Z; x+ E8 b
cles were prepubertal in size. However, testotoxicosis
5 K H7 i6 o1 f8 J( M1 Pwas in the differential diagnosis because his father5 h+ T2 Z' l5 y$ ]+ m: d4 d
started puberty somewhat early, and occasionally,
- K. w5 y8 O4 n. ]. q" v! ztesticular enlargement is not that evident in the% z4 |( Y |1 e- F" |% p' a
beginning of this process.1 In the absence of a neg-
! c9 j/ j# G! @6 N' ~ative initial history of androgen exposure, our
6 ~- j) |1 w1 A1 \biggest concern was virilizing adrenal hyperplasia,
" Z5 H: F& H+ v( Reither 21-hydroxylase deficiency or 11-β hydroxylase" i& P$ a# l) a% ~
deficiency. Those diagnoses were excluded by find-
7 y0 n! }6 P4 [* S+ g# o1 i' Ying the normal level of adrenal steroids.- y7 q/ s* D) f- l( u3 N
The diagnosis of exogenous androgens was strongly
; k: x3 M' D( L0 \suspected in a follow-up visit after 4 months because7 G. t' S2 n- \
the physical examination revealed the complete disap-
* z) a: p* v3 i4 N# p& mpearance of pubic hair, normal growth velocity, and
% [! l, j7 l8 L* y$ udecreased erections. The father admitted using a testos-
& U4 k+ M4 f4 R( d$ W& _2 ?7 vterone gel, which he concealed at first visit. He was6 M% c2 F5 L: Q" y1 ^ k
using it rather frequently, twice a day. The Physicians’1 Q3 A' c8 f& p
Desk Reference, or package insert of this product, gel or
6 s% B$ T& ` A. T5 H( Q6 f9 S/ U) Ccream, cautions about dermal testosterone transfer to# y, Q' M0 H" l# r# A: f) t
unprotected females through direct skin exposure.
( t8 V( P6 M7 ESerum testosterone level was found to be 2 times the
; p6 [( |" [1 W8 E4 g9 Jbaseline value in those females who were exposed to1 V7 N+ `5 K% x5 V; V
even 15 minutes of direct skin contact with their male) |1 J/ U3 ~4 q$ r, F
partners.6 However, when a shirt covered the applica-
/ V& ]4 A: ^/ n& k4 G" Wtion site, this testosterone transfer was prevented.
( v* i+ V9 x* j$ d( k$ W5 H5 yOur patient’s testosterone level was 60 ng/mL,, o3 k5 x+ s" Y+ V6 z1 r" o7 H- h
which was clearly high. Some studies suggest that
7 H* X' x0 G3 I( a( adermal conversion of testosterone to dihydrotestos-
# B4 W \/ j6 U0 v8 D0 A% ^# @terone, which is a more potent metabolite, is more( h' L/ Q2 W0 V1 L4 m; ^$ R& B
active in young children exposed to testosterone+ @$ [; Z, B- w
exogenously7; however, we did not measure a dihy-% Y# B( `( P! j$ x8 B: {: s( a
drotestosterone level in our patient. In addition to" p: I- P+ B& G. N+ @: t/ P! r
virilization, exposure to exogenous testosterone in. g: _+ G# [/ K f( L, [+ ^; Y( w; r
children results in an increase in growth velocity and
+ a: g' [& ?$ s4 f6 zadvanced bone age, as seen in our patient.' x0 J: F9 U l6 Q8 M
The long-term effect of androgen exposure during7 a9 T$ h8 I; P6 `8 h8 c0 B
early childhood on pubertal development and final$ u6 E/ s# P7 b) p/ n1 T6 q c
adult height are not fully known and always remain
/ a% m* `2 T4 t5 X' p) sa concern. Children treated with short-term testos-3 U& `7 N" w1 o% ]4 Y, f
terone injection or topical androgen may exhibit some
9 i4 T7 g Y9 [- Sacceleration of the skeletal maturation; however, after2 [$ y, f' M, M# `/ a
cessation of treatment, the rate of bone maturation3 k2 r: U5 T: B6 u, F
decelerates and gradually returns to normal.8,90 s; r1 g: c* N2 q2 j$ T' H( ~$ \
There are conflicting reports and controversy. U9 E' K) S' x' F# |6 o
over the effect of early androgen exposure on adult4 W' i0 q3 f& Z2 K8 D
penile length.10,11 Some reports suggest subnormal. l0 ^/ h0 S' w# |- W4 X
adult penile length, apparently because of downreg-
8 N/ H5 O) E( b% culation of androgen receptor number.10,12 However,6 R4 G! i$ [( E8 Q
Sutherland et al13 did not find a correlation between) G$ b$ n( ~1 G- Q2 O: ~6 L+ b
childhood testosterone exposure and reduced adult# J. I; c, e8 G! a
penile length in clinical studies.5 Z4 q3 ]4 x1 C; v: x$ g) V
Nonetheless, we do not believe our patient is3 u; o' D3 s( |$ L. X1 C3 w% ~" V
going to experience any of the untoward effects from. b0 [1 O1 k& j `+ u# G
testosterone exposure as mentioned earlier because
9 R5 _1 J1 s8 i$ u$ x+ ?/ |) Zthe exposure was not for a prolonged period of time.
+ b, Q9 }6 h8 g$ V- y+ [5 J6 h7 `Although the bone age was advanced at the time of# P1 i7 U* J) S0 {
diagnosis, the child had a normal growth velocity at
# N0 M) J1 ^# ^- e1 K2 @the follow-up visit. It is hoped that his final adult5 c) c4 J4 L# V6 d3 i1 h z+ F: H
height will not be affected.
7 z! v- {$ M" V& f5 \& w( NAlthough rarely reported, the widespread avail-( m2 f: C# Y; J& f6 h+ m1 v
ability of androgen products in our society may
$ T. J# j4 f' K3 t' ?indeed cause more virilization in male or female
/ f1 ?3 D1 f% M) Q I" R, wchildren than one would realize. Exposure to andro-
n* g8 N8 z- Y$ `0 ogen products must be considered and specific ques-
0 i6 ^, c7 b- ~1 s+ i, D. \) Htioning about the use of a testosterone product or
( w* z1 O6 B% X0 b9 Rgel should be asked of the family members during
! }7 v; y( v1 Y8 z* V3 kthe evaluation of any children who present with vir-; S( I; `: r1 H; e$ I7 L: t% v* N
ilization or peripheral precocious puberty. The diag-
4 L$ C# c4 G/ u& c% A: V/ tnosis can be established by just a few tests and by
% G# `* z) a6 z0 Oappropriate history. The inability to obtain such a7 D* H* ?# t: b* O2 `. L! i$ p
history, or failure to ask the specific questions, may
$ X) ^1 r8 z! j1 bresult in extensive, unnecessary, and expensive; w2 L# s; h6 Q) A C) E
investigation. The primary care physician should be
0 }7 Q2 p" W5 baware of this fact, because most of these children; g: v/ C- E6 ~7 D' ]
may initially present in their practice. The Physicians’+ I6 w4 J; H4 n% x, V$ i7 N
Desk Reference and package insert should also put a
* t* |6 a9 f2 A2 ewarning about the virilizing effect on a male or
4 N. D& j3 {4 s8 b! t# ~2 tfemale child who might come in contact with some-
/ |; Q4 T9 l3 S1 X0 d$ g, C* C4 lone using any of these products.' F! M6 q- L, X( w$ |
References
" E# z4 S; m- n1. Styne DM. The testes: disorder of sexual differentiation# v- M1 Z, k P: B. m
and puberty in the male. In: Sperling MA, ed. Pediatric
% H0 R0 q5 i1 p1 d, d4 VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 v5 G8 {7 A4 {$ s R
2002: 565-628.
A- o, h+ @! U, d& _; K9 b* X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ p! w$ L% g5 a9 F8 Wpuberty in children with tumours of the suprasellar pineal |
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