- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
# ?" d- S, i) ^- uBoy Induced by Indirect Topical
8 ]0 ` v0 ~/ z& N2 c+ iExposure to Testosterone
- X/ t/ }7 H, T5 hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* u) y/ @" A4 i, Y' Tand Kenneth R. Rettig, MD1
g4 ^; }6 `; i% j. k# Y% GClinical Pediatrics
9 P# M0 W0 }1 X tVolume 46 Number 6/ ]% O. L( T/ ~ k
July 2007 540-543) [" }$ P0 p+ @ }/ A1 R7 q4 K
© 2007 Sage Publications& m) n0 B5 T! X
10.1177/0009922806296651 a0 G! x7 R; r
http://clp.sagepub.com
5 U' R: b8 y$ k1 h4 ~2 Fhosted at% g- z& q+ ^/ A2 d. R6 _+ U
http://online.sagepub.com, P4 n2 c1 v2 G( }4 C9 Y
Precocious puberty in boys, central or peripheral,
- ^( m# J: I# @is a significant concern for physicians. Central
; W! P4 C! p8 s3 S4 jprecocious puberty (CPP), which is mediated; c: `8 w1 J8 R7 P
through the hypothalamic pituitary gonadal axis, has- b8 ~8 v! W: `4 h! U
a higher incidence of organic central nervous system
! ]4 x9 i" }6 P: L( ylesions in boys.1,2 Virilization in boys, as manifested( V3 l5 u4 p. M. @4 U8 s% S
by enlargement of the penis, development of pubic
0 W4 J- p9 T7 A% g8 A; W: v2 shair, and facial acne without enlargement of testi-* a: v5 B5 G' h, B5 p
cles, suggests peripheral or pseudopuberty.1-3 We b' a( _* Q+ M% l# W
report a 16-month-old boy who presented with the. t6 o5 M- P: `- l1 u: @' y# N
enlargement of the phallus and pubic hair develop-
; S. F4 c2 ^( pment without testicular enlargement, which was due
" J+ U3 W9 m* t9 |to the unintentional exposure to androgen gel used by
- s' y& P9 q8 l6 ~& h/ ]the father. The family initially concealed this infor-
z; q- p6 |! f" nmation, resulting in an extensive work-up for this# v/ D/ A4 W G2 I
child. Given the widespread and easy availability of
. G1 }- C9 h4 }4 @testosterone gel and cream, we believe this is proba-' h& Y+ Y. e- f) X
bly more common than the rare case report in the
8 c- K. ]) l% M. X7 Aliterature.40 Y) t: E( U5 \! F: p. S/ m
Patient Report0 e' \( \3 a7 o6 l' ?
A 16-month-old white child was referred to the
* s1 \$ W' c4 i4 g5 Jendocrine clinic by his pediatrician with the concern0 O8 X5 z. E, u& F- A6 E
of early sexual development. His mother noticed
( Y- U$ O+ S0 g/ \! W; D1 R$ b/ A! Alight colored pubic hair development when he was! ~' `& t" O3 z& h
From the 1Division of Pediatric Endocrinology, 2University of# I& p% @- \2 C( {
South Alabama Medical Center, Mobile, Alabama.9 l( a8 Z Y( }" e+ Q9 |
Address correspondence to: Samar K. Bhowmick, MD, FACE,. q/ l- ]2 G1 \& a+ u: b2 Q
Professor of Pediatrics, University of South Alabama, College of2 z$ m, H2 e! s( H. r4 t8 K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% }( H) d( b7 W
e-mail: [email protected].( t h) R' K% U' X
about 6 to 7 months old, which progressively became
4 {8 ?; L# M4 j6 G4 d8 q( x# \darker. She was also concerned about the enlarge-1 c! U+ j6 z( J
ment of his penis and frequent erections. The child
h: N- O M/ a7 iwas the product of a full-term normal delivery, with
3 _/ M% b9 p+ M8 n7 @! b0 E1 @a birth weight of 7 lb 14 oz, and birth length of
: U3 G% Q% G: |2 V% u9 a20 inches. He was breast-fed throughout the first year( a" K' S$ Q; {: ^4 _- A- r
of life and was still receiving breast milk along with
* g. M% z6 m1 I+ l6 j1 Nsolid food. He had no hospitalizations or surgery,
8 u7 Q" o8 U& F1 xand his psychosocial and psychomotor development B- o0 A4 J- u; B
was age appropriate.
4 a2 B0 k% }2 \: f B! Z* y/ I. qThe family history was remarkable for the father,
8 \' A' u( N2 G/ h) u5 Dwho was diagnosed with hypothyroidism at age 16,
% L% o; h# t. ^$ R( S6 X! ^which was treated with thyroxine. The father’s
+ W0 e- F. g1 W, Theight was 6 feet, and he went through a somewhat
: J3 O% \$ F; t) `- f, kearly puberty and had stopped growing by age 14.
& `( p' ~/ ?7 M, E7 F* k# x6 hThe father denied taking any other medication. The
B/ S' n- v- F9 P) N# nchild’s mother was in good health. Her menarche
9 ]' I# |' D& W9 l7 k2 @was at 11 years of age, and her height was at 5 feet
' j+ l4 v6 f7 O, ]- n5 inches. There was no other family history of pre-
q) s5 j& ^7 ?+ Q" r) Ycocious sexual development in the first-degree rela-' Y/ C, z* {0 Q
tives. There were no siblings.( C# w0 r; i$ w0 a3 U4 C! j% v
Physical Examination
1 l5 L3 x( E. p; I- ?4 K8 Q5 C( kThe physical examination revealed a very active,
# G k& |7 T+ b/ g% z- @playful, and healthy boy. The vital signs documented
% T& b! }. U1 sa blood pressure of 85/50 mm Hg, his length was- g) R, V: _1 H# D' ~+ ], g* G) q5 e
90 cm (>97th percentile), and his weight was 14.4 kg
* L# P$ y$ v Y2 F6 c' t(also >97th percentile). The observed yearly growth& u3 |9 U$ [ W: g7 ^; K
velocity was 30 cm (12 inches). The examination of/ p0 x" z) @1 C1 b% t
the neck revealed no thyroid enlargement.; [; h+ |$ z. |6 P/ ]- @: N9 F
The genitourinary examination was remarkable for* M# K* _: _+ h* m
enlargement of the penis, with a stretched length of' V6 _ i) p' @. {) \
8 cm and a width of 2 cm. The glans penis was very well
! q6 \0 M$ c/ i' N E% Z( Adeveloped. The pubic hair was Tanner II, mostly around2 F# L. V, ?, K" I
540
# q4 A) K1 e5 W/ h0 J, Z! X; J5 Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 L/ j( ?% o% ?: t5 G% A0 zthe base of the phallus and was dark and curled. The
/ a/ o% Z+ t0 [" @9 Ytesticular volume was prepubertal at 2 mL each.
! F6 c8 Y1 \' E9 KThe skin was moist and smooth and somewhat( ^/ X# V8 _+ W1 }8 v- U9 Z; h+ N. Z4 R
oily. No axillary hair was noted. There were no
2 F4 X2 p* J4 l1 i! {" i5 xabnormal skin pigmentations or café-au-lait spots.' ?) Y4 R( n/ `, X
Neurologic evaluation showed deep tendon reflex 2+
0 [7 `* [) E1 L" Nbilateral and symmetrical. There was no suggestion
% J/ L) p4 v( }% Cof papilledema.
: [5 G+ ^9 L8 Q9 h3 W1 nLaboratory Evaluation
0 j0 U5 z/ }# q& uThe bone age was consistent with 28 months by
$ n9 d2 z+ L- ~; \/ r) W( fusing the standard of Greulich and Pyle at a chrono-
/ \+ U5 t6 ]6 ~3 _3 g& Alogic age of 16 months (advanced).5 Chromosomal
0 I1 w1 @! j8 \; Z, X& K5 V, Ukaryotype was 46XY. The thyroid function test c, ~. G* b; N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" \/ ]6 `* w; K2 S) rlating hormone level was 1.3 µIU/mL (both normal)./ ^2 H5 m& ]/ v
The concentrations of serum electrolytes, blood: q! C. Y1 I% s. u0 r% P
urea nitrogen, creatinine, and calcium all were
7 G, M3 m, R3 `9 m7 Swithin normal range for his age. The concentration- B s+ L! p0 x, N3 M y* \$ [) Z, o
of serum 17-hydroxyprogesterone was 16 ng/dL
_" W- s0 I5 G$ ?" i; ?+ ^(normal, 3 to 90 ng/dL), androstenedione was 20
+ ?' v# a3 A. x% u8 G/ Z# D6 E+ ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. Z- `2 B$ @% N; R4 Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),9 }) G" c/ m% s7 Y3 ]6 {* Q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( J# k2 P3 @" D N& Q9 p
49ng/dL), 11-desoxycortisol (specific compound S)
3 ^ @6 C& v' s# l4 `was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( S- Z( j8 w, m; m- D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ v p1 Y, c$ [# ]" |% ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 H8 P& \* L4 z/ T/ l
and β-human chorionic gonadotropin was less than/ { x0 R9 T/ K) @2 K) X* {" g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: ~6 s) M9 \ ^( ~0 d; C$ Y1 N8 xstimulating hormone and leuteinizing hormone
$ o+ e8 g+ m# z8 A! E& I# {7 Qconcentrations were less than 0.05 mIU/mL8 b" o. L+ m# ^+ \" |1 v5 m# s" ?
(prepubertal).. k' m1 @; T7 N+ l. C0 d
The parents were notified about the laboratory0 u# F* ~3 c7 P: i; h) I7 V
results and were informed that all of the tests were
* g- h$ U+ Q5 z; n, j" cnormal except the testosterone level was high. The
# ?6 Y( z4 a. p4 f5 j8 H* ]follow-up visit was arranged within a few weeks to- s; G8 U W0 M; Q
obtain testicular and abdominal sonograms; how-' }1 c$ i& f: V' _6 U
ever, the family did not return for 4 months.# ?" d# V' [, R/ L/ D9 H, P6 x. Q
Physical examination at this time revealed that the, N" E) ~# r# i. Y5 d- A' v
child had grown 2.5 cm in 4 months and had gained
% v% W, v7 M6 p* H: |1 w. s$ p# M2 kg of weight. Physical examination remained
4 W1 h5 V& s% O% j' E$ Munchanged. Surprisingly, the pubic hair almost com-! {0 s6 m8 f: a2 N
pletely disappeared except for a few vellous hairs at1 _+ H7 W; f; T, u( B/ }
the base of the phallus. Testicular volume was still 2
' F% `: m- s2 d3 ?* e9 H PmL, and the size of the penis remained unchanged.
+ |. b1 X& m* f% TThe mother also said that the boy was no longer hav-
; s z) y0 B% Ring frequent erections.( I( O- j. F3 H+ q2 q" b
Both parents were again questioned about use of! a9 o T# S" {7 f! |4 o
any ointment/creams that they may have applied to0 W& J6 @5 C/ L2 K
the child’s skin. This time the father admitted the
% b1 ?5 e# o4 k3 mTopical Testosterone Exposure / Bhowmick et al 5410 M V% j4 m& h4 ~5 m: P) Y* C
use of testosterone gel twice daily that he was apply-
4 X0 |7 ^8 P3 r. [" W, h Ding over his own shoulders, chest, and back area for7 I& H! F# z% T' T
a year. The father also revealed he was embarrassed
! K/ t7 ^3 `9 X/ c( a9 s Bto disclose that he was using a testosterone gel pre-
1 h) s! M' ]8 ~3 f+ M, a E; Pscribed by his family physician for decreased libido
O2 {7 {: C+ X0 x' e0 csecondary to depression.7 G( z* ?7 D: ]% c( V# w7 z9 G
The child slept in the same bed with parents.
% _$ p4 O$ N% a& b; YThe father would hug the baby and hold him on his; @8 }* ?- |# o* |0 h2 h# T( I
chest for a considerable period of time, causing sig-
: k* M( R8 j# Z, [nificant bare skin contact between baby and father.
- o( q* ~3 Z% V+ S! Z$ d) ?( Z9 yThe father also admitted that after the phone call,
, x/ L2 P) i- Y, L# ?when he learned the testosterone level in the baby
# q7 u$ X7 X1 A/ uwas high, he then read the product information
: T+ l& ~% \3 t, B, fpacket and concluded that it was most likely the rea-
. c2 ~" ^& S6 W' Yson for the child’s virilization. At that time, they
& M" V( I; J4 d [2 l/ J7 P" xdecided to put the baby in a separate bed, and the6 J( V0 \5 F6 G6 ^3 ] _2 Y
father was not hugging him with bare skin and had1 Q: `* t3 Q: `
been using protective clothing. A repeat testosterone
) L, Q1 G2 ~; |% |2 A1 gtest was ordered, but the family did not go to the
# W, y7 X4 V2 R; Xlaboratory to obtain the test./ M! K5 H: g5 {8 i4 m4 d$ g
Discussion
3 ^; j8 g, g" q6 w7 lPrecocious puberty in boys is defined as secondary+ p+ x# s! |( _# Z( l8 p
sexual development before 9 years of age.1,46 H' g( P# f4 m8 R9 ?, T5 a% N& p
Precocious puberty is termed as central (true) when
0 e$ m# \4 R0 Sit is caused by the premature activation of hypo-2 C4 d7 M" P' q0 {0 A, a4 D, o( D! U( }
thalamic pituitary gonadal axis. CPP is more com-. n! K x" L' }" ^0 v
mon in girls than in boys.1,3 Most boys with CPP2 v5 `; v. ~. [5 I$ A8 x* t2 I
may have a central nervous system lesion that is
8 K! z8 J# X/ K0 n Xresponsible for the early activation of the hypothal-5 {% e. E! {3 F8 b* r. A! k* _
amic pituitary gonadal axis.1-3 Thus, greater empha- z6 x( P1 c2 f) d7 h- n+ L$ n' ~ B
sis has been given to neuroradiologic imaging in
! K* J0 S5 k$ d3 I, _" }$ C! Gboys with precocious puberty. In addition to viril-
- D$ A# m, o( kization, the clinical hallmark of CPP is the symmet-8 H/ `5 t! Q3 H# q- [
rical testicular growth secondary to stimulation by1 r1 X' q; [9 m; S! I
gonadotropins.1,37 ]6 b1 V7 K9 f) j3 ^
Gonadotropin-independent peripheral preco-
1 z$ d6 s, s! E' [cious puberty in boys also results from inappropriate/ L* G0 L/ r( A3 ?7 n
androgenic stimulation from either endogenous or
1 ^/ O1 i( A% k( t2 jexogenous sources, nonpituitary gonadotropin stim-- t9 N% Y' {6 F0 ?
ulation, and rare activating mutations.3 Virilizing
% Q6 h: W2 {. ], I0 ncongenital adrenal hyperplasia producing excessive
# A; Y4 R. @" }! P5 yadrenal androgens is a common cause of precocious; S8 ]3 H4 {4 z9 Q. k: k+ z
puberty in boys.3,4" G- y) M- L d" {& l3 _5 }
The most common form of congenital adrenal
" c3 W+ g v$ @hyperplasia is the 21-hydroxylase enzyme deficiency.7 o3 g5 o% x+ J8 W6 R" A) d
The 11-β hydroxylase deficiency may also result in
- W u3 F0 F8 E( u- oexcessive adrenal androgen production, and rarely,
8 l. n' u2 W+ z, Lan adrenal tumor may also cause adrenal androgen4 Z% Q" S! @- a% O7 t
excess.1,3% K2 B+ j) r+ B9 C) ]0 ?" L9 d. v2 |# C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 \- m8 F# F0 [& k
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, p4 }9 F! A( D6 u, {
A unique entity of male-limited gonadotropin-7 p7 F, u0 g6 L- ^: L7 ~
independent precocious puberty, which is also known
+ |: d0 R5 t0 a! O! vas testotoxicosis, may cause precocious puberty at a
7 S: k: p% p1 K8 b$ _very young age. The physical findings in these boys
9 X% ^! O, }0 b! L5 ]4 U Nwith this disorder are full pubertal development,9 B" K0 F$ Y" W6 C$ \) ?( e- H
including bilateral testicular growth, similar to boys
' Y3 Q. q A* z) R: n, H+ N* Swith CPP. The gonadotropin levels in this disorder
N( a! A9 }& H& v. rare suppressed to prepubertal levels and do not show' ]4 @0 G" V* |
pubertal response of gonadotropin after gonadotropin-
? `- E; ~3 ~, _& _8 l1 J" p, y% u3 Ureleasing hormone stimulation. This is a sex-linked4 i/ W0 ~! p) n* Y' ?. z
autosomal dominant disorder that affects only) F# ~4 L! G1 p, P% e
males; therefore, other male members of the family5 z" y% `5 J8 [# g% c* B
may have similar precocious puberty.35 ?; ^& X. j- z% t
In our patient, physical examination was incon-% s$ b& y4 M$ c' a) M6 V
sistent with true precocious puberty since his testi-2 L' f) a2 p" |6 D+ r! G$ K x8 J# X
cles were prepubertal in size. However, testotoxicosis$ K. L# J( w, F, {0 K! O5 l
was in the differential diagnosis because his father; Q0 o; _- s3 D: t! x' J# F8 |" u
started puberty somewhat early, and occasionally,6 Z; \3 C% K! I6 N- A- N
testicular enlargement is not that evident in the8 d3 H1 T& d; G9 Y4 ~. P! i
beginning of this process.1 In the absence of a neg-
) O7 C( u: K, f$ T: A" j. I5 Bative initial history of androgen exposure, our
. B1 y/ Z- e1 a- U' [/ w3 Ebiggest concern was virilizing adrenal hyperplasia,
$ R7 u; C& f1 O. \# ]! D. |either 21-hydroxylase deficiency or 11-β hydroxylase& `3 N z3 |) x$ L4 b
deficiency. Those diagnoses were excluded by find-
6 o+ u! b+ U/ L; u; `ing the normal level of adrenal steroids.: o$ p. G4 d' ~
The diagnosis of exogenous androgens was strongly3 @4 G: V9 `# d" c; e1 _
suspected in a follow-up visit after 4 months because
, [& [( a) x* c' K& athe physical examination revealed the complete disap-
/ G' }5 S% g$ m! m x1 m1 Hpearance of pubic hair, normal growth velocity, and% R, V5 S$ H- m$ R- i- ]6 B6 }
decreased erections. The father admitted using a testos-3 h7 S5 D8 n5 H. V
terone gel, which he concealed at first visit. He was! |0 s+ I- [: S! d* m4 A) m' U
using it rather frequently, twice a day. The Physicians’' c" u' ^0 ? i. q
Desk Reference, or package insert of this product, gel or
, Y2 l5 a$ ~, A: d% acream, cautions about dermal testosterone transfer to, ]9 ^# ?- |9 K
unprotected females through direct skin exposure.. ]0 {. g3 s0 B- I
Serum testosterone level was found to be 2 times the! r$ H0 T. D1 G" i- E
baseline value in those females who were exposed to
0 ^. k1 ^! s0 B8 ?7 a6 Peven 15 minutes of direct skin contact with their male
* l* W. v; ?8 mpartners.6 However, when a shirt covered the applica-
8 u/ E1 Z1 A3 J+ C! {tion site, this testosterone transfer was prevented.! f, ^0 w4 h2 M6 q5 y# ?5 z! _6 d
Our patient’s testosterone level was 60 ng/mL,
# H9 \: D! V. \- s2 d. Vwhich was clearly high. Some studies suggest that0 d3 S5 @4 Y5 r, F; s* v W
dermal conversion of testosterone to dihydrotestos-3 `" l6 E; F. \1 E; z! W
terone, which is a more potent metabolite, is more( N2 }; z: ^2 j; n b: C
active in young children exposed to testosterone$ c* I6 Y% q2 a8 k1 |, b2 P( L; n
exogenously7; however, we did not measure a dihy-
( I, K R2 ^5 y/ j# q3 p& mdrotestosterone level in our patient. In addition to
" C" } q$ {7 ]virilization, exposure to exogenous testosterone in* Q7 H6 f. j3 _8 B) M2 d: i) \' a
children results in an increase in growth velocity and
, W! L9 N; ^! |( Cadvanced bone age, as seen in our patient.
4 B- H: w& @. VThe long-term effect of androgen exposure during; ]3 F' r/ A- \( d( Y# P
early childhood on pubertal development and final; q$ d( U! u, W& J( c7 i0 d; I" d
adult height are not fully known and always remain
! b; n6 S2 f' \+ e0 ?6 c. Da concern. Children treated with short-term testos-0 W' J4 |. e& f$ L
terone injection or topical androgen may exhibit some
9 [4 p; w! m9 d( x7 m. [, Oacceleration of the skeletal maturation; however, after$ T. o6 ~# f1 I' |5 A
cessation of treatment, the rate of bone maturation" | B: H q3 F* N: ~
decelerates and gradually returns to normal.8,9
* |1 E$ x$ R) Q4 u& nThere are conflicting reports and controversy9 L& f% ^% P2 W% K
over the effect of early androgen exposure on adult
% Q" z, W9 v* }4 J9 Kpenile length.10,11 Some reports suggest subnormal
K3 C) u2 m! Y2 p5 f. o( Kadult penile length, apparently because of downreg-# u2 [* B4 n3 N+ t% b) {$ w# ^) f3 T
ulation of androgen receptor number.10,12 However,
/ V: a" |# k; a( y( @2 W$ t5 R" S3 p. USutherland et al13 did not find a correlation between8 _7 S% C: z+ |2 g# n; `9 w" Q5 j
childhood testosterone exposure and reduced adult
) Y6 B, [# h/ w) @) B |" mpenile length in clinical studies.
* p- G% m& B( E i' G" A' TNonetheless, we do not believe our patient is
) F, Q& C* O! Lgoing to experience any of the untoward effects from: O! d5 r0 |/ O, z" ]$ [; o1 I
testosterone exposure as mentioned earlier because
7 |# b y' y- R* ^7 Kthe exposure was not for a prolonged period of time.8 R9 ] @( m, I0 u% L$ J+ i+ q
Although the bone age was advanced at the time of
+ C3 K! _( K6 Rdiagnosis, the child had a normal growth velocity at8 S( L( [# w* G; e' S8 Z S
the follow-up visit. It is hoped that his final adult& p- a* V8 u9 D! h
height will not be affected.
+ R2 O6 {9 R8 T3 P7 a5 yAlthough rarely reported, the widespread avail-
& z' P* b0 K! ~9 a/ p% d# |, zability of androgen products in our society may
! b6 s2 |, G) n* K4 r! P+ yindeed cause more virilization in male or female/ l( m7 q( ~3 @# c' @$ b- n9 X0 U
children than one would realize. Exposure to andro-
4 O9 V! o5 u9 _- p, M/ q. f! Ugen products must be considered and specific ques-* `: h) U- K$ L7 p1 |' x
tioning about the use of a testosterone product or7 l$ F' g3 s, ?' B. ~& T# M7 ^
gel should be asked of the family members during( }% P; ^, q8 P P
the evaluation of any children who present with vir-8 X3 J5 \% d; h9 w' p
ilization or peripheral precocious puberty. The diag-
* U [. t3 }( W: B% E# [nosis can be established by just a few tests and by
3 P* i g& R' ]4 g* aappropriate history. The inability to obtain such a
. K2 S# t" y$ o/ [, s* ohistory, or failure to ask the specific questions, may
% f$ D6 N5 H3 Uresult in extensive, unnecessary, and expensive
) ^/ g# ?! ^7 [- c/ x3 xinvestigation. The primary care physician should be
: m) O1 R* r6 F) q0 ]4 Oaware of this fact, because most of these children) m) h" [7 b4 I# n; ^7 S: ~
may initially present in their practice. The Physicians’
5 {3 k1 }/ K& i) x" fDesk Reference and package insert should also put a6 D) m6 ^ }8 H+ A6 Y% ^0 Y) V
warning about the virilizing effect on a male or
! c+ s& |! X! Afemale child who might come in contact with some-, h: ~7 z) `# l( W9 Q- a
one using any of these products.- I) l% Y( Z( [4 ]# H$ u# W5 c" j
References
# v6 W. d9 S6 u7 w: K1. Styne DM. The testes: disorder of sexual differentiation
/ H" F& r! @& L; fand puberty in the male. In: Sperling MA, ed. Pediatric
( b0 W" c/ c; n$ O, WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ \2 {0 `& T+ a+ e4 a5 H
2002: 565-628.
2 A+ T+ u( `2 W# |( J$ m0 f1 n$ N' V+ U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( v% m, t' u ~, g% i# Lpuberty in children with tumours of the suprasellar pineal |
|