- 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 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
4 J0 o5 H5 k5 Q1 p6 w) }# CBoy Induced by Indirect Topical5 S& K& h1 ]# {, C! C
Exposure to Testosterone/ E% ^ E/ t7 ^4 f6 d# R0 n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ D& [: r; t3 S jand Kenneth R. Rettig, MD1$ S V1 R5 p, e$ P' n( `
Clinical Pediatrics
& c- Z% Z) l0 ?0 q! q* f7 `Volume 46 Number 6
; @3 K& p5 A9 z8 [July 2007 540-543- W* k' {" `1 P3 c' i- ]! K# y# P# I
© 2007 Sage Publications/ a+ s; D5 A) U' ^9 ~8 P( E
10.1177/0009922806296651 m, v0 |) p+ K- ^: n) z e
http://clp.sagepub.com+ F: V- z, j/ ] Q+ l; S. ~
hosted at _( i% {' m2 `/ Z
http://online.sagepub.com, c h' V& ~" [' R
Precocious puberty in boys, central or peripheral,
0 V' u/ S, r2 b! cis a significant concern for physicians. Central
: I( Y" N# | tprecocious puberty (CPP), which is mediated
2 u: x3 i% [. G+ O# w( B3 ^through the hypothalamic pituitary gonadal axis, has
" l/ j2 B0 K$ K& ?a higher incidence of organic central nervous system: P# B$ B; A# U
lesions in boys.1,2 Virilization in boys, as manifested" K% r9 O! f6 F' B8 h# p
by enlargement of the penis, development of pubic
: U. _2 @, N# g, x/ s9 r1 ^hair, and facial acne without enlargement of testi-
' M+ ^/ @- Z+ ~( x# R; ocles, suggests peripheral or pseudopuberty.1-3 We3 k" l3 `+ B- j q# ^8 Q
report a 16-month-old boy who presented with the, g) W* O, t2 M; x+ Z* i& `
enlargement of the phallus and pubic hair develop-
" Q) ~6 F) X; o" rment without testicular enlargement, which was due6 m' c. C, B5 n: g, [9 f7 E" Q
to the unintentional exposure to androgen gel used by
! ~4 o: ]3 m2 _% j$ ]the father. The family initially concealed this infor-
' Z0 R8 v: Q( I/ k% s8 W" L! hmation, resulting in an extensive work-up for this
, f' X T& M! u$ g7 a& uchild. Given the widespread and easy availability of9 d& D: w3 Q" ^% F
testosterone gel and cream, we believe this is proba-0 n3 d: g+ W K; T% u
bly more common than the rare case report in the
4 {) ~, m4 O4 H* L1 Bliterature.4
! i/ E/ O: C# N0 @, U( FPatient Report t3 Y7 N+ P2 e' ]
A 16-month-old white child was referred to the' u: P; Y- C Z% {1 B% c$ B
endocrine clinic by his pediatrician with the concern4 X! A; G; Y$ V9 O8 m) { ^
of early sexual development. His mother noticed
6 b. C" r- Y l- A( j* @ Zlight colored pubic hair development when he was
/ w& `4 b; j3 X7 j4 P: ^! UFrom the 1Division of Pediatric Endocrinology, 2University of. N# P# X9 S+ t# |
South Alabama Medical Center, Mobile, Alabama.8 e% |2 \( `: t5 p# @9 y& ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,* M! T2 `9 t: E: h# v- _* I
Professor of Pediatrics, University of South Alabama, College of
z2 n7 U2 l, K$ S' ?7 jMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 d" X% N% U6 Y$ d& g/ u8 M3 l R$ le-mail: [email protected].. A; C/ H0 n% P' g# Q6 k- V. V' ~
about 6 to 7 months old, which progressively became
: U( j9 O- o) n- |& n3 ydarker. She was also concerned about the enlarge-* n0 \9 z4 A3 ]6 P. J8 T
ment of his penis and frequent erections. The child2 M6 ~, o" S K! C: g8 D: u. Y, L
was the product of a full-term normal delivery, with
1 b' H! l( m) L& [a birth weight of 7 lb 14 oz, and birth length of
" I( W& D2 a" r- r0 E20 inches. He was breast-fed throughout the first year( c* Q! ]& _4 D
of life and was still receiving breast milk along with
+ _* Q) n, B. T3 K9 y& y+ Nsolid food. He had no hospitalizations or surgery,
+ x4 F( {5 y/ }and his psychosocial and psychomotor development
3 w ~! e+ \! d" l) dwas age appropriate.& G5 p1 D0 s/ b0 F [
The family history was remarkable for the father,
' T) Z M k. v* c$ y6 }' zwho was diagnosed with hypothyroidism at age 16,
: G/ |* m* L2 I- I( m, Fwhich was treated with thyroxine. The father’s* }+ b, o, i% ^
height was 6 feet, and he went through a somewhat& \* _, t+ @* g2 B% G
early puberty and had stopped growing by age 14.) }% K, E0 n( C
The father denied taking any other medication. The
4 `' I/ Y7 N* G9 ochild’s mother was in good health. Her menarche0 `: e6 h _$ b6 A
was at 11 years of age, and her height was at 5 feet9 j0 r! V, X, @7 F& M1 E5 }
5 inches. There was no other family history of pre-& z; p) Z# X, u i" o
cocious sexual development in the first-degree rela-4 Y1 @. v; `, r; ]* M
tives. There were no siblings." h) ]: S+ d; w- D; R g
Physical Examination: n7 i5 V4 k3 J: H0 ?3 |. F$ u
The physical examination revealed a very active,7 }$ C) ~* x+ v9 f! }0 ]# m2 K6 f
playful, and healthy boy. The vital signs documented
" s7 X) u7 L6 J8 Ta blood pressure of 85/50 mm Hg, his length was
6 L' s# O* p; Q( s5 m90 cm (>97th percentile), and his weight was 14.4 kg
9 O4 P' `$ q1 p7 b(also >97th percentile). The observed yearly growth$ V9 d. A6 K9 M, \6 ] J0 F% r( a; L0 w
velocity was 30 cm (12 inches). The examination of
: V' l8 }0 P& Pthe neck revealed no thyroid enlargement.
' M; p6 u0 P yThe genitourinary examination was remarkable for! j- @8 p5 m. Q( a8 ]
enlargement of the penis, with a stretched length of
! v/ z& S( o4 _+ o0 S8 cm and a width of 2 cm. The glans penis was very well4 T. |) X/ z) c) y7 u9 S5 c
developed. The pubic hair was Tanner II, mostly around& h( i8 s2 @9 `6 G# X; K
540+ y3 A- Y+ c) s. @; q/ z. N( Y, ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' }* n: L B+ w6 c
the base of the phallus and was dark and curled. The# G& T/ z9 T/ [, P6 b5 @' y
testicular volume was prepubertal at 2 mL each.$ f8 o6 K5 T" I9 j1 O/ D
The skin was moist and smooth and somewhat8 ~1 j0 I* X" v# t1 b
oily. No axillary hair was noted. There were no
( ?, E& J' {& R' r- ?9 ^8 Y+ ]4 ^abnormal skin pigmentations or café-au-lait spots." ]$ f1 A" D# M% S0 ^5 c- s# u
Neurologic evaluation showed deep tendon reflex 2+
% B( V$ M! F! e' m! O6 mbilateral and symmetrical. There was no suggestion$ J1 U4 V k# ^$ ?# c
of papilledema.
, B* e" H* M. |5 ~1 A/ p2 {9 DLaboratory Evaluation
l# M$ K8 B# O: J' n- ]1 lThe bone age was consistent with 28 months by
9 s% R1 ?+ q- g4 n* H) ^ ~using the standard of Greulich and Pyle at a chrono-
# r! m5 g6 Q1 S% T1 v! P% ulogic age of 16 months (advanced).5 Chromosomal. q# d: H4 t' Q. Q1 a4 b
karyotype was 46XY. The thyroid function test) q2 h3 m, l6 { r: q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: B+ {" g9 p% w% U" wlating hormone level was 1.3 µIU/mL (both normal).
9 ~5 y3 h+ r% F" v& c$ _9 U% o5 xThe concentrations of serum electrolytes, blood! | S2 M6 U. L0 ]& K
urea nitrogen, creatinine, and calcium all were
9 a1 f$ K3 @+ @; I: G0 j% uwithin normal range for his age. The concentration8 u: V5 X. ]! w9 \0 @$ p+ l: J
of serum 17-hydroxyprogesterone was 16 ng/dL
& l2 j# I( x; @(normal, 3 to 90 ng/dL), androstenedione was 205 k9 B7 m5 b' l% P5 i; m; H" l, B
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 S9 t: v: ]3 Z, n7 G, f% m+ e7 Tterone was 38 ng/dL (normal, 50 to 760 ng/dL),) O+ a7 W) e7 t. U! J9 h- e/ Z1 G
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" U E0 H$ H; R" q- A5 [3 c4 R8 z49ng/dL), 11-desoxycortisol (specific compound S)
8 f( B9 g( i- Z; Xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 j$ Y0 R8 q2 L4 d0 F3 ]
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 [/ s K* p9 V2 F3 d$ M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' ]! H! f- C3 g, f' x
and β-human chorionic gonadotropin was less than2 G5 W ]: f6 J, f% a
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 g) o6 v a T4 g6 _/ _7 Zstimulating hormone and leuteinizing hormone# ^) v/ J E. e! w
concentrations were less than 0.05 mIU/mL9 }1 `# _) ~+ G; U* w9 W' A5 L2 L
(prepubertal).
, T8 `. n% `$ g VThe parents were notified about the laboratory5 ?) ]3 H# M! f9 ]1 m4 A' n7 ^2 T
results and were informed that all of the tests were+ G; b. O7 N$ ` T# N, _( u- p
normal except the testosterone level was high. The. x. |4 f7 P' M/ L
follow-up visit was arranged within a few weeks to
2 j- x+ t* Y3 ^# b+ t$ D: Nobtain testicular and abdominal sonograms; how-
' D& U+ s" F8 m( bever, the family did not return for 4 months.
0 e( M, z1 e: |- A$ ~. ?! G! lPhysical examination at this time revealed that the' e* N( p& F) b' n/ M
child had grown 2.5 cm in 4 months and had gained
" o$ v9 E; m7 b. W: u" [8 k) R2 kg of weight. Physical examination remained3 p; U0 q7 k1 s& _9 @7 k
unchanged. Surprisingly, the pubic hair almost com-- R& A4 S! {4 s8 L8 T" y A! ?
pletely disappeared except for a few vellous hairs at/ n0 s2 y. W6 Q5 [" M/ l2 Y$ X
the base of the phallus. Testicular volume was still 20 ~# W! [9 f- ^' X7 n! p& p
mL, and the size of the penis remained unchanged.
. b& @5 t$ v% }" w1 T2 |( qThe mother also said that the boy was no longer hav-
9 L2 B0 R6 Q8 O% y( Ving frequent erections.
3 ~$ i; S" n4 I1 RBoth parents were again questioned about use of
r* o. R7 n8 C( N4 ?+ Many ointment/creams that they may have applied to
' Q* p- p9 j, ?$ {the child’s skin. This time the father admitted the
7 Y$ y- H9 I; n' ]* _8 fTopical Testosterone Exposure / Bhowmick et al 5413 t9 Y! h# o6 c( p) F
use of testosterone gel twice daily that he was apply-) m. s4 d. s. P
ing over his own shoulders, chest, and back area for9 o5 ~ i' a4 k: ~" w1 q4 G2 K) H
a year. The father also revealed he was embarrassed
. y2 R, R# O. T- Bto disclose that he was using a testosterone gel pre-
% \. E8 C8 a5 n4 l) Vscribed by his family physician for decreased libido
- t5 F1 y1 E: x% dsecondary to depression.; n; p6 Q0 J y6 t( F% ^2 g
The child slept in the same bed with parents.
" d7 i' O! j. [" [ ~& [. cThe father would hug the baby and hold him on his1 N) G2 G* i- v! `
chest for a considerable period of time, causing sig-
2 a' C& Z8 J! t0 f g) R+ }nificant bare skin contact between baby and father.
/ C$ G6 |5 O5 p# LThe father also admitted that after the phone call,
( V9 E5 J4 Q4 Y; Iwhen he learned the testosterone level in the baby
" @: `8 M" r( z) H5 G! P( |was high, he then read the product information6 g1 @% Z; U) F; R$ z
packet and concluded that it was most likely the rea-
6 J, Q, {# A" U1 j7 E* [$ fson for the child’s virilization. At that time, they
7 o5 F i* v0 F* W5 p+ M/ p+ {# Xdecided to put the baby in a separate bed, and the* w* K4 F8 l; R* l' Y5 J" c
father was not hugging him with bare skin and had
8 U$ T, X- j8 |) H. u7 b1 ybeen using protective clothing. A repeat testosterone
( z: \' g% O" _1 Q/ M" _test was ordered, but the family did not go to the9 P2 C' u& r, m5 Y8 O- Y$ g
laboratory to obtain the test.
! s$ U, j# s- i" ^Discussion
9 a; b# a' T! gPrecocious puberty in boys is defined as secondary( N' P! q/ F. [/ a `
sexual development before 9 years of age.1,4! ?5 i; M2 a- j4 ^7 X( T
Precocious puberty is termed as central (true) when
) h& T8 ?7 k! \1 m. iit is caused by the premature activation of hypo-
* J$ E. Y& L/ P) e1 Rthalamic pituitary gonadal axis. CPP is more com-+ Q- Q" A# e6 |6 T( [; _
mon in girls than in boys.1,3 Most boys with CPP$ ^ a/ m. k5 t
may have a central nervous system lesion that is8 I, X7 r/ W2 W7 D
responsible for the early activation of the hypothal-
. P% }8 w& k, z( {; ~amic pituitary gonadal axis.1-3 Thus, greater empha-. q6 _0 w( z2 E: ^5 B/ ~, @: T. G a% H
sis has been given to neuroradiologic imaging in
8 j- l% c J' }5 D1 k' C$ vboys with precocious puberty. In addition to viril-2 ? r5 h( m5 ]( o2 M4 o3 S
ization, the clinical hallmark of CPP is the symmet-+ C: X, }; a! j
rical testicular growth secondary to stimulation by3 W7 ]; }8 \8 J/ [; W: F
gonadotropins.1,33 c, P4 a/ [0 _5 e: m
Gonadotropin-independent peripheral preco-
! N6 _, U5 x# r+ Mcious puberty in boys also results from inappropriate
- d% Y$ _( R1 O' P. V4 G4 _) D9 Xandrogenic stimulation from either endogenous or! m% c) b+ p1 ~: n. A Y2 [
exogenous sources, nonpituitary gonadotropin stim-
) @3 Z' o& j6 `- c1 Aulation, and rare activating mutations.3 Virilizing
7 Q7 a4 g8 t7 U2 {congenital adrenal hyperplasia producing excessive, j; g) D# _8 L- T: b+ H
adrenal androgens is a common cause of precocious' ~+ O2 @- t: c
puberty in boys.3,4% M. V9 h% Q U" }+ n& l: e7 f' R
The most common form of congenital adrenal# O2 K- e2 W6 t8 t
hyperplasia is the 21-hydroxylase enzyme deficiency.( v; t8 Z8 G( k/ u( s$ n
The 11-β hydroxylase deficiency may also result in- g- N/ r" m) z! y- r5 R0 y
excessive adrenal androgen production, and rarely,
+ A3 z: m9 S7 X8 ~. Y& r4 f( | m9 Pan adrenal tumor may also cause adrenal androgen
- g8 y6 y& ]& l! T! [" vexcess.1,3
6 ]' ^: x9 a2 y: v+ Y& _$ r/ Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 i; h) w8 K6 G9 l; q3 z
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 t& n# F, q8 D$ ~5 j7 L
A unique entity of male-limited gonadotropin-
, j; J! N/ a+ D Eindependent precocious puberty, which is also known! B0 V/ [* D. |( {/ j w
as testotoxicosis, may cause precocious puberty at a
- o- E' V) f7 q5 I3 ?very young age. The physical findings in these boys
4 i R- W' C' `with this disorder are full pubertal development,
: h( H |3 {6 f4 mincluding bilateral testicular growth, similar to boys3 n9 h( `* d$ |, B, P
with CPP. The gonadotropin levels in this disorder
% M f6 z1 R- q8 H7 V& care suppressed to prepubertal levels and do not show
0 s( U0 D6 n" J6 f+ xpubertal response of gonadotropin after gonadotropin-
' J- g" F e1 X1 s# nreleasing hormone stimulation. This is a sex-linked7 g6 V& x. o, p5 w/ k$ j
autosomal dominant disorder that affects only
! I% G4 A2 H$ s0 j. a$ a: u9 Mmales; therefore, other male members of the family3 J8 O' u% T7 o( Q; K. q9 N
may have similar precocious puberty.3! @0 D! A( y$ Y# m
In our patient, physical examination was incon-9 C5 C' R, p. J
sistent with true precocious puberty since his testi-
1 [/ G4 Z+ h# e& Ocles were prepubertal in size. However, testotoxicosis3 {3 r- R2 w5 i3 i
was in the differential diagnosis because his father& Z2 V' n7 n* G. {' o B
started puberty somewhat early, and occasionally,
9 I6 ~$ v0 v- c7 Stesticular enlargement is not that evident in the8 C' a( J5 }, l' m W5 c" X5 W
beginning of this process.1 In the absence of a neg-
0 u a' s8 |% N& E4 {( L% f% jative initial history of androgen exposure, our/ {( {2 K% q9 E- e" b3 ]
biggest concern was virilizing adrenal hyperplasia,4 m4 @4 d+ T3 [* F! m" Z6 x1 Z
either 21-hydroxylase deficiency or 11-β hydroxylase
# }+ D2 \6 y. }0 N% r7 jdeficiency. Those diagnoses were excluded by find-
0 G: \% r8 o1 `# s# R* Fing the normal level of adrenal steroids.
" c& ?* N* n s X. ]The diagnosis of exogenous androgens was strongly
* H6 D% c3 `# ~/ J, lsuspected in a follow-up visit after 4 months because
0 L) a( i' H6 X1 j9 F& J& g! Hthe physical examination revealed the complete disap-
+ k" B5 p2 w- \" Dpearance of pubic hair, normal growth velocity, and6 {& U2 |' y' @ |
decreased erections. The father admitted using a testos-& e3 ]6 M# i, ?) X+ N# E
terone gel, which he concealed at first visit. He was8 ?5 c! P+ G7 j5 O% D& @& p2 E
using it rather frequently, twice a day. The Physicians’
9 ^( k) B' N. n1 b3 O) w! X( |Desk Reference, or package insert of this product, gel or r! F7 \* i2 [/ k% m% H
cream, cautions about dermal testosterone transfer to
9 d3 X$ C$ v- k6 C# c! Ounprotected females through direct skin exposure.
1 X5 h: u1 `/ @Serum testosterone level was found to be 2 times the
3 w/ q( ^$ I2 f2 T ?- C) z, Nbaseline value in those females who were exposed to+ R) j2 J: }/ I
even 15 minutes of direct skin contact with their male3 Y1 A, G; `& ~1 k
partners.6 However, when a shirt covered the applica-6 `/ G) d& K, p- w5 y& b8 d* R
tion site, this testosterone transfer was prevented.
6 q$ w1 l* h Y: NOur patient’s testosterone level was 60 ng/mL,5 h& {8 h7 G3 \0 ]6 i, t' W
which was clearly high. Some studies suggest that
( L3 }' P# {9 K, M$ Ndermal conversion of testosterone to dihydrotestos-8 b& X6 R+ n7 ~" V/ ]- N
terone, which is a more potent metabolite, is more
* g* [+ d3 `/ k0 Vactive in young children exposed to testosterone& q: D3 `0 Y$ E5 e
exogenously7; however, we did not measure a dihy-
5 E: A2 U- d4 }) I: ~6 C4 udrotestosterone level in our patient. In addition to
8 V2 c' f& q2 Gvirilization, exposure to exogenous testosterone in
5 c; _5 k/ q7 pchildren results in an increase in growth velocity and- u9 Q) n# T3 K) k+ _+ a, f# H
advanced bone age, as seen in our patient.
, Q! d! i4 g$ B3 J5 }, gThe long-term effect of androgen exposure during
" J; |9 o+ K4 l2 [$ z' nearly childhood on pubertal development and final+ v$ t: k4 n- G
adult height are not fully known and always remain/ w1 | D& j7 z+ n6 R
a concern. Children treated with short-term testos-
6 R1 x+ x: W8 k1 T7 B, Yterone injection or topical androgen may exhibit some
& K$ N( r0 Y1 |) @% Dacceleration of the skeletal maturation; however, after
2 H7 F. H% A3 T/ I& R8 z+ E1 }cessation of treatment, the rate of bone maturation
3 S+ ~$ I* h, u0 T) l7 y! H& ?decelerates and gradually returns to normal.8,9* B! C1 ^5 g# ^; l
There are conflicting reports and controversy% M( o' f8 s8 I# i+ E7 d
over the effect of early androgen exposure on adult
+ N3 W& g( M' h5 }' H: }% L5 D1 upenile length.10,11 Some reports suggest subnormal
4 V/ a6 D9 t3 n. v5 x* dadult penile length, apparently because of downreg-: |8 P H4 [ F
ulation of androgen receptor number.10,12 However,! w! K4 v& o4 w0 {9 G5 c
Sutherland et al13 did not find a correlation between- B* v% D0 B4 H5 _9 ^! b0 p7 ~
childhood testosterone exposure and reduced adult* \; {+ D- }* U0 \
penile length in clinical studies.1 @% ~* G9 _+ \* K; r% F6 c3 ^9 U
Nonetheless, we do not believe our patient is
. a2 F, b6 b+ b: d9 `going to experience any of the untoward effects from
: k1 x/ h4 e( \# R" F U; Ntestosterone exposure as mentioned earlier because
+ ]0 j' b+ K( @6 L' L6 ethe exposure was not for a prolonged period of time.
; I* k5 _2 u; \" L! o" O* CAlthough the bone age was advanced at the time of
7 T& r, r) O2 V9 }+ ^diagnosis, the child had a normal growth velocity at
9 \2 u* p; E$ i' N; X6 Pthe follow-up visit. It is hoped that his final adult
4 t. L. X- B+ y! \0 x) xheight will not be affected.3 H# \# S/ e! z; x6 I
Although rarely reported, the widespread avail-
" y: f$ t0 h+ W0 d3 `* Vability of androgen products in our society may
. D( s8 v% t% s3 V; q3 l, m/ eindeed cause more virilization in male or female
8 c; V) W6 B) t- X3 D" A1 zchildren than one would realize. Exposure to andro-
$ V5 `$ E( D" M- Kgen products must be considered and specific ques-
5 r, m8 x# o( d; F. C- wtioning about the use of a testosterone product or
5 r9 R+ v; E5 F! H8 k" ^( e, ugel should be asked of the family members during
6 ^' i1 R4 ~6 ithe evaluation of any children who present with vir-% R; A/ r$ z9 y. C7 }* g, z
ilization or peripheral precocious puberty. The diag-
6 z+ Q5 k' v5 d! R2 ?2 |nosis can be established by just a few tests and by
0 f: ~% Z* D6 N2 c. Z5 Cappropriate history. The inability to obtain such a2 J2 W8 { B& ]0 W, _+ M
history, or failure to ask the specific questions, may, ^ n; b7 M7 e* B
result in extensive, unnecessary, and expensive
2 `, @+ F$ [8 z. w/ h. g0 Iinvestigation. The primary care physician should be
) t2 T- V. T9 B' E+ |aware of this fact, because most of these children
o E9 k6 f" [" ^) K4 F9 T4 kmay initially present in their practice. The Physicians’
H6 X7 w" _; k3 i/ o9 jDesk Reference and package insert should also put a" z- w. Z3 }- U! f* m |
warning about the virilizing effect on a male or
4 [9 a" d. j0 @female child who might come in contact with some-$ |& D: Y0 U# O& |
one using any of these products.7 Z( k( }+ d3 j8 n2 O9 K$ y8 U
References
- ]3 }1 Z' |% C s T8 i( c1. Styne DM. The testes: disorder of sexual differentiation/ u5 Z0 e9 g. M, a# B
and puberty in the male. In: Sperling MA, ed. Pediatric
4 @( U, M3 T. R$ V6 x5 yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" I/ n' w4 W p1 X% ^
2002: 565-628.2 Z q) X9 H4 ?; ?6 y2 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) o9 f' K2 d- r3 Z0 T, v
puberty in children with tumours of the suprasellar pineal |
|