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Sexual Precocity in a 16-Month-Old
, Z; |( X; q+ w& ?' Y: E' wBoy Induced by Indirect Topical+ m+ h6 j/ u. q+ y8 ^
Exposure to Testosterone
6 t G0 a v' u" _! X6 RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ ]* m( r6 x3 S1 sand Kenneth R. Rettig, MD1. G# ~) q+ k9 j4 f+ E. c! e% W
Clinical Pediatrics
0 d& f; h1 J! S% G' c& o0 s" uVolume 46 Number 6# s, m7 P4 Z0 ]
July 2007 540-543
# B4 m" S0 A3 M, B" ?9 V" Z7 x© 2007 Sage Publications3 \4 W: o. \1 k( h
10.1177/0009922806296651
# `0 b5 U/ |8 y7 R! thttp://clp.sagepub.com7 e- l9 v5 V5 b3 \3 K1 i& j
hosted at
* `' e/ h: v4 y" Whttp://online.sagepub.com# h! d6 `# I n3 D9 h
Precocious puberty in boys, central or peripheral,4 p8 x& g' _7 F0 z- q3 B% w5 @# X% w
is a significant concern for physicians. Central
( Q/ M$ s6 F2 D: _) a# `# Wprecocious puberty (CPP), which is mediated
6 r9 E3 l0 ~' A& I1 Z# n4 Kthrough the hypothalamic pituitary gonadal axis, has% V' L+ @* G7 F/ _3 n; V1 t1 I4 b
a higher incidence of organic central nervous system
6 @5 d/ _% Q2 S/ A( |, Blesions in boys.1,2 Virilization in boys, as manifested& Y# Z- x0 ]4 n- {1 j! e
by enlargement of the penis, development of pubic
8 c- H: n2 ]6 T$ j( _2 fhair, and facial acne without enlargement of testi-
: k0 E/ d" B6 }& p$ @# \( f1 Gcles, suggests peripheral or pseudopuberty.1-3 We4 F: ]4 J2 j* m
report a 16-month-old boy who presented with the
, |* K. r; f) |8 T6 Nenlargement of the phallus and pubic hair develop-$ ]6 V2 x' L' ~& _' p
ment without testicular enlargement, which was due
' b0 c9 s. r0 e, Uto the unintentional exposure to androgen gel used by
8 F3 y- A: f; U* F) u7 Vthe father. The family initially concealed this infor-
' @/ b# W2 e6 \4 k5 y1 omation, resulting in an extensive work-up for this
4 i4 m. z9 w' _4 Echild. Given the widespread and easy availability of
4 d5 {: K/ G+ Ftestosterone gel and cream, we believe this is proba-; `/ d- W; c' S- p9 L: M: u
bly more common than the rare case report in the
@& @" n) I3 m( rliterature.4& T1 |& {' C9 y9 d
Patient Report
$ q P2 \- r c( l/ L% B9 U7 oA 16-month-old white child was referred to the! }" M. I2 t8 D A' x2 K# ]
endocrine clinic by his pediatrician with the concern$ v1 |. i. f+ ]
of early sexual development. His mother noticed1 W1 L4 V/ K: W2 A9 O* |7 B2 u6 I0 E
light colored pubic hair development when he was
* s5 ~: j* @4 m) j' q& Z/ D R1 TFrom the 1Division of Pediatric Endocrinology, 2University of
' j$ x9 H3 Q. U' _* w4 U2 D% W8 O, ASouth Alabama Medical Center, Mobile, Alabama.+ ]; l. ]# Z. W6 E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" q& M ]* S! H# i9 H3 [Professor of Pediatrics, University of South Alabama, College of$ @& t! J2 H& _. V: a6 `% M: ~) D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. E- G" N* @' [( @4 A+ w1 ~e-mail: [email protected].7 o: J- x% E8 Y: o9 b5 A E/ g
about 6 to 7 months old, which progressively became
( d- d7 X5 a% z5 U4 Hdarker. She was also concerned about the enlarge-
- O! ^2 O! w) Sment of his penis and frequent erections. The child( Q2 R2 C! s0 M5 a
was the product of a full-term normal delivery, with& Y$ P; [1 M# R% x7 k4 d4 Z5 e M
a birth weight of 7 lb 14 oz, and birth length of
8 ^, ?5 o3 A- n+ ]20 inches. He was breast-fed throughout the first year
4 b9 ~8 x6 [7 |* O9 |of life and was still receiving breast milk along with
. s+ |- j% a8 E' j7 V0 usolid food. He had no hospitalizations or surgery,/ L# Q- q% {8 i9 P+ `3 N, D
and his psychosocial and psychomotor development
1 T: {; C6 @. X: kwas age appropriate.! H' |4 T+ w/ a; T; l$ G; V
The family history was remarkable for the father,* F$ ~8 A# Y1 u7 U2 W `; X; o
who was diagnosed with hypothyroidism at age 16,$ \& E2 n7 S' y
which was treated with thyroxine. The father’s7 X9 o3 W: q* s5 E0 `" E" ^2 R
height was 6 feet, and he went through a somewhat0 g& r N* v! Q4 r; c2 G
early puberty and had stopped growing by age 14.' f' u' F) X' _$ B0 W4 n
The father denied taking any other medication. The
& `( p7 V1 \2 D# n6 K `/ u& T# g' Ochild’s mother was in good health. Her menarche
" f6 \1 ~9 P! d Z6 ^" d$ Nwas at 11 years of age, and her height was at 5 feet; h9 E1 |: `1 C4 }/ o3 C
5 inches. There was no other family history of pre-
- {; V. X0 a5 l9 }; J9 ?6 ]% y, ]: acocious sexual development in the first-degree rela-& T4 |! E1 N% V* o# h/ L* \, A
tives. There were no siblings.* H# b: j6 Q ~- C0 p& A
Physical Examination
: E$ ?# G) w- y, P6 c/ M6 o+ uThe physical examination revealed a very active,5 p6 h4 t, c2 C: r+ _2 i2 C- \
playful, and healthy boy. The vital signs documented
! p# U M- S8 I% ?$ oa blood pressure of 85/50 mm Hg, his length was% j$ ^& p( y$ \% k7 Y
90 cm (>97th percentile), and his weight was 14.4 kg( N, x& c7 R8 r! @3 u% |9 x9 R' V
(also >97th percentile). The observed yearly growth' U$ ]' A/ m% H! I
velocity was 30 cm (12 inches). The examination of9 B* } o4 Q2 a6 a6 T5 X
the neck revealed no thyroid enlargement.
5 ~% G$ G' |% [* o; ZThe genitourinary examination was remarkable for
9 d0 u- d& z) z/ n% Q( Genlargement of the penis, with a stretched length of* R6 k: @' H+ M
8 cm and a width of 2 cm. The glans penis was very well# P& s. F& x% d
developed. The pubic hair was Tanner II, mostly around' l8 n! e' P4 G) G% v" z9 |
540
& o$ x; {# w! H: x- z- fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# }3 v ^6 D, Z: [, ~
the base of the phallus and was dark and curled. The8 ^/ E& g1 q* F j7 ~
testicular volume was prepubertal at 2 mL each.* f% f7 |8 r+ k% \5 \ ~! ?
The skin was moist and smooth and somewhat
. Q/ y# |5 }0 B1 w" M P0 foily. No axillary hair was noted. There were no
( Q8 f5 u( ~2 z0 tabnormal skin pigmentations or café-au-lait spots.0 V7 o1 x8 S8 {$ @6 @
Neurologic evaluation showed deep tendon reflex 2+
7 O! P; W) A. _% M( Jbilateral and symmetrical. There was no suggestion5 |; W7 v' Z, X( m1 l
of papilledema.
. b3 y* E6 H+ m0 B3 ^( ?7 lLaboratory Evaluation
2 N% P$ G) s3 D4 M' Z- H5 D- r1 zThe bone age was consistent with 28 months by: i6 N1 q9 Y) v* h d
using the standard of Greulich and Pyle at a chrono-
$ T6 J1 c2 D+ K* ?, f# i+ \logic age of 16 months (advanced).5 Chromosomal
* l' B3 [" R+ a0 ukaryotype was 46XY. The thyroid function test1 f7 V5 d7 b. L: w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-) t" \; p# T6 \4 O- ~6 h
lating hormone level was 1.3 µIU/mL (both normal).
% v! f1 U Z! {. L" }5 q$ aThe concentrations of serum electrolytes, blood
3 Z; j0 l) i. E- x- r" `urea nitrogen, creatinine, and calcium all were
# m/ X6 k! w' P% [8 r4 i: Dwithin normal range for his age. The concentration& k( c$ N* Y* W D9 k2 s* g
of serum 17-hydroxyprogesterone was 16 ng/dL" m; b$ Q. M l* |! i" A# ^+ W
(normal, 3 to 90 ng/dL), androstenedione was 20
1 J5 O4 N8 h- R' P' A Q0 A3 [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- {7 q1 r. B# _, X+ ]( [terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ z5 e- _9 F" `# `0 k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; M9 e3 Q2 Q8 M5 x* t/ W9 G3 m
49ng/dL), 11-desoxycortisol (specific compound S)3 a& }0 m0 ?: K8 i6 j
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 J9 a; y& |9 D; H: Z$ _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, }! J! Y9 O e$ h5 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: b. D; a, X, u% y% z; cand β-human chorionic gonadotropin was less than
" k. _+ o3 O6 F5 mIU/mL (normal <5 mIU/mL). Serum follicular. G! y! E( M, l4 o
stimulating hormone and leuteinizing hormone+ M. M+ s, w' z" Y) l4 ]
concentrations were less than 0.05 mIU/mL2 l# R! Q1 E/ O
(prepubertal).
/ G& d5 A# j4 i7 T5 D) N: ]2 ?* ]The parents were notified about the laboratory
9 `4 o; i5 [/ B5 e0 S" `results and were informed that all of the tests were
% M, q: u6 o) N3 T1 ~normal except the testosterone level was high. The. ]6 T. N, }. A5 I/ I
follow-up visit was arranged within a few weeks to
% S2 L @5 W8 t1 mobtain testicular and abdominal sonograms; how-
7 h- r# W, I9 F; d5 u. fever, the family did not return for 4 months.
9 L. z) \/ A% t) c* nPhysical examination at this time revealed that the f0 w( ?2 M4 e; D M1 I# g
child had grown 2.5 cm in 4 months and had gained
v/ |9 t% ]$ q" _8 o8 S2 kg of weight. Physical examination remained
% [& y) Z' C9 T i( aunchanged. Surprisingly, the pubic hair almost com-
# l/ e5 d' w B# \. }pletely disappeared except for a few vellous hairs at
5 }$ t W7 j5 k h8 F2 Hthe base of the phallus. Testicular volume was still 29 ~3 c/ F6 M0 F1 |! v
mL, and the size of the penis remained unchanged.) J9 v! w2 H! W3 j( n
The mother also said that the boy was no longer hav-
! w8 [ I6 e- h( ^ing frequent erections.
! C7 \( t( P3 d: ~& M" _2 N) dBoth parents were again questioned about use of- h2 r$ l% E ?2 [/ O4 r
any ointment/creams that they may have applied to
5 U( Y& h6 B& {& Q2 o' w9 i4 w, T d8 Wthe child’s skin. This time the father admitted the
, y1 g2 {( k& i0 h- gTopical Testosterone Exposure / Bhowmick et al 5412 p( q& ]6 x8 I9 _
use of testosterone gel twice daily that he was apply-
h+ L4 ^, T# d$ i6 V/ ding over his own shoulders, chest, and back area for) n& f# h% s- G" M- g
a year. The father also revealed he was embarrassed
6 ~6 L1 g0 d% r( N- _5 qto disclose that he was using a testosterone gel pre-2 {4 B$ ^" s% i1 b7 B. a
scribed by his family physician for decreased libido: g, b$ s& J9 {& E3 C' Q) L4 c
secondary to depression.' C* `8 w# x3 K* x& V* a% H
The child slept in the same bed with parents.
7 T O) n; M; O1 @" {: VThe father would hug the baby and hold him on his! h, S# b/ w; C% T1 o' i6 ]$ q5 X$ r
chest for a considerable period of time, causing sig- `! }7 r$ h8 T2 k1 [- h
nificant bare skin contact between baby and father.
; Q: z; R3 { s, W; i" |, FThe father also admitted that after the phone call,
0 n b$ @" i- N( k& l' M+ X* n' awhen he learned the testosterone level in the baby
5 p' u/ ^: B5 U5 gwas high, he then read the product information
6 [4 C0 r1 V+ B. F% }packet and concluded that it was most likely the rea-
6 X& {: ^5 G3 f; E$ `son for the child’s virilization. At that time, they' G3 C9 g8 C: F$ ^, \
decided to put the baby in a separate bed, and the
9 _: D" n9 s L* X1 u, f. F) ^4 s% kfather was not hugging him with bare skin and had
( {) k* H6 y ^6 ~0 ybeen using protective clothing. A repeat testosterone% V# s n+ N e9 }7 N8 I! u
test was ordered, but the family did not go to the; I+ N* I5 \2 X* Q
laboratory to obtain the test.
- O3 Y4 X/ {! D0 U1 C& @% x0 I/ G2 pDiscussion" B0 q, I) E/ A+ z1 Q- w, _- @
Precocious puberty in boys is defined as secondary4 m, ^) p$ D7 Q% D5 Q
sexual development before 9 years of age.1,40 b6 Y# L* s4 h) k7 D
Precocious puberty is termed as central (true) when
. j. E% u4 L1 x, P! L' _" Git is caused by the premature activation of hypo-; Q; \4 I& v+ r( l; r
thalamic pituitary gonadal axis. CPP is more com-4 r, H! K6 _; ?# L& }
mon in girls than in boys.1,3 Most boys with CPP4 D p* l; y# G: A' s
may have a central nervous system lesion that is
3 Y7 E: B( k c+ f H, M) }responsible for the early activation of the hypothal-7 @9 a' W: ^3 p6 O
amic pituitary gonadal axis.1-3 Thus, greater empha- V3 S& k4 v) t$ a5 U' ^- n: `3 ^
sis has been given to neuroradiologic imaging in
+ x5 Q0 q" B) p! R, Sboys with precocious puberty. In addition to viril-
V, d" p5 q: \0 yization, the clinical hallmark of CPP is the symmet-
1 M+ b3 i5 z/ p# M; o; A+ erical testicular growth secondary to stimulation by) ~! u; S4 [3 |+ l2 F
gonadotropins.1,37 ^# e; M5 D# ]. R4 N
Gonadotropin-independent peripheral preco-% ]. [" S# A8 O; l0 f
cious puberty in boys also results from inappropriate
2 X- u3 ~, Y1 tandrogenic stimulation from either endogenous or
/ p8 t; X) ~' b4 O- R* m8 X2 ?* Uexogenous sources, nonpituitary gonadotropin stim-; W. \9 ^1 ^+ T2 d/ W
ulation, and rare activating mutations.3 Virilizing. J3 o- I. r$ z) z& T, o) V
congenital adrenal hyperplasia producing excessive
0 p) i9 t& k6 dadrenal androgens is a common cause of precocious% `8 X' P( M. a) F, ^5 C8 \
puberty in boys.3,4
+ T7 T* i- J& A; J6 \, N2 q6 \0 ^The most common form of congenital adrenal; }9 x( ]- q' Q' g! k
hyperplasia is the 21-hydroxylase enzyme deficiency.' A5 l ~ h! D; o8 T
The 11-β hydroxylase deficiency may also result in$ k% O. z) Q% s+ {/ [$ ~) U& Q P
excessive adrenal androgen production, and rarely,
, ]# i( N; Q' G, _an adrenal tumor may also cause adrenal androgen
" e1 m( ]( o+ _. u1 Y5 l. hexcess.1,3
) A$ P1 _% D6 T) W+ eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# C) `* n, i5 _' M$ H5 P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# h* L! W) m# O
A unique entity of male-limited gonadotropin-7 K6 c, @ a' D3 i" q3 L
independent precocious puberty, which is also known
3 }9 K7 s) k1 _0 |8 O6 Ras testotoxicosis, may cause precocious puberty at a
/ l2 i/ I8 |1 [9 W, nvery young age. The physical findings in these boys
# O; a4 @, H$ Z s8 o% X" H2 kwith this disorder are full pubertal development,/ C% w K1 V7 f' x& \* [0 T7 g
including bilateral testicular growth, similar to boys# R e( G% g4 T" }3 s: `, M
with CPP. The gonadotropin levels in this disorder
4 b/ w- i0 v& r1 I+ c- O, c3 l# e" uare suppressed to prepubertal levels and do not show4 i0 w, \2 Y& I
pubertal response of gonadotropin after gonadotropin-) W" K$ t: @$ O- F% ]1 R
releasing hormone stimulation. This is a sex-linked9 T, M. A$ Z6 ~0 L5 l
autosomal dominant disorder that affects only
1 d% L6 ?( p) `( l0 {5 Mmales; therefore, other male members of the family$ T$ [# E( x" f( m6 i
may have similar precocious puberty.3
a- _9 R- B! vIn our patient, physical examination was incon-' q. _5 y5 v2 L5 ?$ u a
sistent with true precocious puberty since his testi-: M, U: A4 g2 L( ^3 B: O
cles were prepubertal in size. However, testotoxicosis
+ ^, j. h1 N* A* L# e- F( rwas in the differential diagnosis because his father! T l* ^! w; ~. A, } O
started puberty somewhat early, and occasionally, t5 `9 O7 t& t. ^) s$ _
testicular enlargement is not that evident in the
* Z* s$ ]) D. t6 F5 {% x @& H$ Rbeginning of this process.1 In the absence of a neg-/ r2 F l ? c1 E( p5 U
ative initial history of androgen exposure, our
: c4 u5 t) O, j; R# ubiggest concern was virilizing adrenal hyperplasia,
& Z6 V3 K3 f% N' d3 z) u, [* |either 21-hydroxylase deficiency or 11-β hydroxylase( a; ?1 I: C; ~, C9 d9 f
deficiency. Those diagnoses were excluded by find-
, O6 j3 B# \5 S2 J; Jing the normal level of adrenal steroids.
$ p8 A( \* k) _% BThe diagnosis of exogenous androgens was strongly
- ]9 X, I/ e R! U6 Vsuspected in a follow-up visit after 4 months because
n3 h, j8 }. Y0 L$ d5 a5 D6 q' othe physical examination revealed the complete disap-# ]1 B2 N8 m# o" d( i. Q
pearance of pubic hair, normal growth velocity, and5 G/ t' Y& a2 p7 u9 L1 O3 D$ E; Q
decreased erections. The father admitted using a testos-& H N! |- I3 J( y$ T4 A6 h
terone gel, which he concealed at first visit. He was
5 j3 [- N, a* B. eusing it rather frequently, twice a day. The Physicians’5 Y+ R! U- H( e& [3 ?, e
Desk Reference, or package insert of this product, gel or
" H, Z, p9 |* r, P# f( V* Fcream, cautions about dermal testosterone transfer to
4 k4 X" T' U' l$ uunprotected females through direct skin exposure.
6 i+ N6 Z, E; S0 TSerum testosterone level was found to be 2 times the
0 N3 ^2 s2 S" ]+ x: `, {baseline value in those females who were exposed to
5 c& n% K, G- y; ` geven 15 minutes of direct skin contact with their male
+ w2 f# h6 r" ] T5 b% Fpartners.6 However, when a shirt covered the applica-: y- u# C x4 |
tion site, this testosterone transfer was prevented.
7 }5 t' }0 o( J5 { V9 m$ L2 w E* WOur patient’s testosterone level was 60 ng/mL,
- {( w; S4 x' D* x$ A' _9 [which was clearly high. Some studies suggest that0 J/ A2 q$ a" C1 d1 j
dermal conversion of testosterone to dihydrotestos-* P' x3 D0 h$ p4 m
terone, which is a more potent metabolite, is more
% b, \4 N+ z3 hactive in young children exposed to testosterone/ X; t6 t! h* @3 I! Y' f- K
exogenously7; however, we did not measure a dihy-
( j A( k/ |' _- U. o% Mdrotestosterone level in our patient. In addition to6 ^) d, ^4 R6 d: R I: j
virilization, exposure to exogenous testosterone in" {0 k: q4 N( _; L9 P
children results in an increase in growth velocity and& O, C8 W# ]' R1 j9 W# f, v
advanced bone age, as seen in our patient.
H% Y7 [5 R2 a# ]The long-term effect of androgen exposure during
4 J0 g; d! ?2 V# o4 _& Uearly childhood on pubertal development and final, D7 Z1 t& l% }' t, Y8 ~
adult height are not fully known and always remain$ \+ R; t! h, Y+ }( Y2 W
a concern. Children treated with short-term testos-
' a; W6 _3 |2 ?4 P6 H+ G: R- g, F5 m1 {terone injection or topical androgen may exhibit some8 o# o0 w% I% R0 `
acceleration of the skeletal maturation; however, after
- w3 l+ j4 Z& K- n* o3 Ycessation of treatment, the rate of bone maturation8 J" [( `! Q2 ? C7 c
decelerates and gradually returns to normal.8,9) F0 n8 g& [6 M6 _8 {" Z( {4 i
There are conflicting reports and controversy+ w% h* h2 g& Y' I. C: L
over the effect of early androgen exposure on adult+ z2 j$ E+ M" K8 {( C
penile length.10,11 Some reports suggest subnormal- e, B. F* l; N9 v) s
adult penile length, apparently because of downreg-
; @7 {# _ ?+ q6 [% g9 b) |4 U' A; aulation of androgen receptor number.10,12 However,% L/ g3 T: S+ T% V' t0 G, s
Sutherland et al13 did not find a correlation between
x6 g+ [( K6 wchildhood testosterone exposure and reduced adult+ l4 L2 k$ l$ K' i* W
penile length in clinical studies." X9 b" d( b0 F7 Z5 Z
Nonetheless, we do not believe our patient is
0 f% [2 \9 Y/ ~+ x: e. z% g7 bgoing to experience any of the untoward effects from
_& m5 P: E8 v5 q5 D4 B0 ]: |% jtestosterone exposure as mentioned earlier because
' \) Y; Z4 q6 H$ ]3 Vthe exposure was not for a prolonged period of time.
+ s5 Z- @9 |8 h3 oAlthough the bone age was advanced at the time of
0 t" h5 G: L6 L3 [diagnosis, the child had a normal growth velocity at( c8 M% E0 `2 u' Q" ]3 b
the follow-up visit. It is hoped that his final adult
3 T' P2 |; [! hheight will not be affected.9 T4 V/ |3 g% D% j
Although rarely reported, the widespread avail-( n) F# `: [ `5 R: p7 L' M9 A
ability of androgen products in our society may- g* U4 c, [& h4 u; s( {7 t
indeed cause more virilization in male or female
6 Z9 a, ^/ B: M2 _* F: Lchildren than one would realize. Exposure to andro-
' {) N6 j' H$ T+ H2 \- Z$ w; Kgen products must be considered and specific ques-
5 ?1 Q" \- ?+ q' v' Ptioning about the use of a testosterone product or
; q3 ?- y$ |/ e5 xgel should be asked of the family members during6 e! O, [5 D; X9 }
the evaluation of any children who present with vir-
/ l: m# ]& n6 h5 U: u/ milization or peripheral precocious puberty. The diag-
) D: h# k) `) Onosis can be established by just a few tests and by
: W7 n% H) [4 G9 V$ I; K1 ]appropriate history. The inability to obtain such a
" P( c5 Q+ {, }! l- E. `history, or failure to ask the specific questions, may0 k+ S$ T, h/ N$ W U& T
result in extensive, unnecessary, and expensive
. v" `% e1 [ l! j( cinvestigation. The primary care physician should be
" C7 o% ]( j8 ]2 ]9 Paware of this fact, because most of these children( Y2 y& o! U( ?9 d! s9 \5 e, p
may initially present in their practice. The Physicians’ }$ {2 ]2 |6 J- H+ k% x, s
Desk Reference and package insert should also put a" K, p& `2 w# W: f. F
warning about the virilizing effect on a male or: ~0 f* m. R h2 G9 d9 e9 B
female child who might come in contact with some-/ s9 o/ j/ ~9 t6 _% }- Y
one using any of these products.
# B* Q, ?+ Z; S. i+ N5 j0 U: b, wReferences
6 I- T& X9 d' L. H) G4 t1. Styne DM. The testes: disorder of sexual differentiation
) h8 l: X3 X) w& y+ Jand puberty in the male. In: Sperling MA, ed. Pediatric$ T" c* n2 y' O. [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! k' p' ~. z4 ~# \& X% U
2002: 565-628." e( G' P9 Y' u' d% c$ d: l. W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" e( r) w! K6 d1 O0 [puberty in children with tumours of the suprasellar pineal |
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