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Sexual Precocity in a 16-Month-Old4 b( O; `( j" n4 _ V7 }
Boy Induced by Indirect Topical
1 A3 F9 z1 O8 R9 z" ~4 C; }8 hExposure to Testosterone# Y* W- C* p& R5 {& P4 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# {7 q$ O7 v/ \+ f% vand Kenneth R. Rettig, MD12 d+ @+ s4 w8 ~; o7 Q( {* L5 n) T
Clinical Pediatrics6 s7 j# @& a# d5 _4 Y
Volume 46 Number 65 Y& o o" c+ g! G2 l, f
July 2007 540-543
5 o: i& V' h- B© 2007 Sage Publications
- k# N+ G6 u0 e9 k7 K10.1177/0009922806296651
+ w, W5 r1 @& \& Ahttp://clp.sagepub.com; U0 b" H! k" F% ^$ b, I- b
hosted at0 k: F9 D& ~; ^) R/ W; _/ v& o
http://online.sagepub.com
/ v* `+ T& H6 v& U" @5 f/ ZPrecocious puberty in boys, central or peripheral,
1 }, ^" K6 m: E [is a significant concern for physicians. Central
. z5 ]- V' u/ l3 v# vprecocious puberty (CPP), which is mediated
8 d0 t' Q) y$ X" Z0 U- K2 m0 T9 zthrough the hypothalamic pituitary gonadal axis, has5 L; g! Z, C) K9 e4 a
a higher incidence of organic central nervous system4 ] E/ w) [0 v: E) f) K3 d
lesions in boys.1,2 Virilization in boys, as manifested
1 N2 B7 w% ?$ H6 c7 S3 U" Hby enlargement of the penis, development of pubic: h5 D4 G& O* i" u% X5 k
hair, and facial acne without enlargement of testi-8 \2 g1 ~4 q/ e: b) C
cles, suggests peripheral or pseudopuberty.1-3 We
- W2 R: d& x" z' {0 J6 `) \report a 16-month-old boy who presented with the/ ^& A& \) R, K( |- h* E3 X
enlargement of the phallus and pubic hair develop-8 t" i+ o0 U2 n! Q# @$ D
ment without testicular enlargement, which was due( b8 y: @ a. ?; o7 s
to the unintentional exposure to androgen gel used by, q7 r& @# K! j2 k% ^+ r; k6 S, U
the father. The family initially concealed this infor-: Z8 C% U# F. r. d( L
mation, resulting in an extensive work-up for this
) D5 [' K/ i, b3 U4 S/ Jchild. Given the widespread and easy availability of
4 Y v# q2 W# I/ T. J% Y* Btestosterone gel and cream, we believe this is proba-
$ p3 C# j3 k. N6 [bly more common than the rare case report in the
+ s4 S# y0 _8 ?8 j( H$ Lliterature.4- I- W& S) z; s: @5 ]
Patient Report/ @* G* B. p* v- g/ S+ H
A 16-month-old white child was referred to the1 \6 W0 h5 v3 _! g
endocrine clinic by his pediatrician with the concern
% E6 g/ Q4 Y% c: y/ q' s1 ^of early sexual development. His mother noticed! Q. J) I2 u3 k& U2 J" a
light colored pubic hair development when he was
# ]/ s' K" |9 n" k, V$ \+ xFrom the 1Division of Pediatric Endocrinology, 2University of% q' B- ~: X6 B' o
South Alabama Medical Center, Mobile, Alabama.6 l. Q, T* ]# F6 x( U2 q4 [: V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. E2 v2 w! C" Z$ UProfessor of Pediatrics, University of South Alabama, College of
1 `8 r/ S6 R4 E6 K4 O: E; [" pMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 f) |3 m% {( r4 z, q0 A) l+ B
e-mail: [email protected].; v$ E; ?1 @; M( d) B
about 6 to 7 months old, which progressively became1 S0 E* _4 ]5 |# c' U# x- n1 J- z# r
darker. She was also concerned about the enlarge-5 W( i+ g* j! G% Y7 Z3 r
ment of his penis and frequent erections. The child
: h+ P+ y) e/ v6 [7 m jwas the product of a full-term normal delivery, with
$ f, ]1 t+ |! \6 y. Ja birth weight of 7 lb 14 oz, and birth length of8 N* M, P) b7 \' q" U; ?
20 inches. He was breast-fed throughout the first year
! \* s6 Q- g( N% t8 n: Rof life and was still receiving breast milk along with
& @% T2 o3 b; {: H' ^- W& _) msolid food. He had no hospitalizations or surgery,$ I ^, L$ Q6 p0 m
and his psychosocial and psychomotor development
' V1 B% Y7 B# p( gwas age appropriate.% P3 W: [" A1 T9 i4 w
The family history was remarkable for the father,% y: q% d5 a+ X: k4 W
who was diagnosed with hypothyroidism at age 16,
1 Z' m( j+ y) w5 }. _. I) Iwhich was treated with thyroxine. The father’s! {$ m. F! t, Y$ a
height was 6 feet, and he went through a somewhat
7 x. ^) c a- Jearly puberty and had stopped growing by age 14.
3 C u0 R1 a7 t( A9 V# pThe father denied taking any other medication. The
/ g4 Q+ Y0 A$ ?/ m9 echild’s mother was in good health. Her menarche
. [! Y) Z! D g: j# T* Bwas at 11 years of age, and her height was at 5 feet
" p/ u4 [, l: x z* e7 d/ k5 inches. There was no other family history of pre-% y- r1 u; f9 r H% j) F
cocious sexual development in the first-degree rela-. \/ [& X0 T7 r& _. K0 |
tives. There were no siblings.+ u- n" b1 f& w3 @* b! O
Physical Examination" X; m! J7 I5 U" Y1 Y
The physical examination revealed a very active,1 Q" h% G" h" {& V" [' I
playful, and healthy boy. The vital signs documented7 i, u v: d5 I, }: j8 ^
a blood pressure of 85/50 mm Hg, his length was
% @6 V: o+ p- r, Z, D6 z90 cm (>97th percentile), and his weight was 14.4 kg
5 \% R3 V4 g- R& ](also >97th percentile). The observed yearly growth( `. R3 \2 J8 F. U1 M/ S" U6 k
velocity was 30 cm (12 inches). The examination of9 |; h5 N. }; F' u3 E# D9 B- S
the neck revealed no thyroid enlargement.
, q0 _; O: z6 C2 v. N1 F7 FThe genitourinary examination was remarkable for
/ m) l+ E1 e, w/ \/ c; T% Qenlargement of the penis, with a stretched length of
7 u- e& D7 `6 z* @( {; }8 cm and a width of 2 cm. The glans penis was very well
# b+ n0 i* m* R" B6 V- tdeveloped. The pubic hair was Tanner II, mostly around2 M* ]" z {3 T1 ~
540
4 P P% w' l, Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& R3 m4 @' T5 m' m$ g; ?# {7 M2 l# m
the base of the phallus and was dark and curled. The
6 D4 B- z j2 \0 Ltesticular volume was prepubertal at 2 mL each., A | {0 ^ o# T; p% F. s0 U
The skin was moist and smooth and somewhat
5 T) w+ G, E9 p3 m, roily. No axillary hair was noted. There were no. Q% F+ A$ Z3 K' |( M9 \& e
abnormal skin pigmentations or café-au-lait spots.
9 b9 j, i" y$ ]9 o2 yNeurologic evaluation showed deep tendon reflex 2+
3 T+ H: q) t% Lbilateral and symmetrical. There was no suggestion4 e3 ^0 Y9 x- |" N
of papilledema.7 ~8 E3 T0 q$ E) v" ~- Y
Laboratory Evaluation! l( {5 F7 z+ h* N! q
The bone age was consistent with 28 months by$ V i8 g' R; ?9 t: N$ L( {
using the standard of Greulich and Pyle at a chrono-2 n% p5 I! S) A6 a& q7 u
logic age of 16 months (advanced).5 Chromosomal* ]5 f$ g8 s9 ?; E* [4 m
karyotype was 46XY. The thyroid function test! }% w$ C' ^3 h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: v3 K0 J8 U! D7 [$ v% n
lating hormone level was 1.3 µIU/mL (both normal).
5 }& T0 D# {' k s; h' l' KThe concentrations of serum electrolytes, blood
, D' T L W7 u+ p- }urea nitrogen, creatinine, and calcium all were7 t/ o0 C: h5 F- s- U. z6 i1 i
within normal range for his age. The concentration# n' M- }& j+ M, n9 P
of serum 17-hydroxyprogesterone was 16 ng/dL: \. A, v& ]* f7 s
(normal, 3 to 90 ng/dL), androstenedione was 20
( F1 \: ?( ~4 Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 s7 c' F; R g7 d+ Z2 D8 wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! W I# @3 I5 j: ?# a3 T) ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to- a7 Y+ A G# }; T9 Q3 X
49ng/dL), 11-desoxycortisol (specific compound S)* O+ C& e5 |$ n2 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ Y% B% ?. h6 R. D0 rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( V4 e! `# y y5 u4 X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% r r3 @% v* B. r" h U! Wand β-human chorionic gonadotropin was less than
2 B5 e# `1 G N3 i; i5 mIU/mL (normal <5 mIU/mL). Serum follicular$ |& _: _( `; G. J0 F( M: d3 K
stimulating hormone and leuteinizing hormone7 s& Z# s8 C& ]& ` q
concentrations were less than 0.05 mIU/mL3 [# d' ^, c' A! G8 I7 `! k- F1 M
(prepubertal).. a# `) l4 ~3 G8 I, E
The parents were notified about the laboratory( B8 z. T7 C! Y1 o2 M
results and were informed that all of the tests were( C, s5 |/ v) c4 u
normal except the testosterone level was high. The
$ p! ^' {2 Q# [: J) K" |: Ufollow-up visit was arranged within a few weeks to* R% Z, T' r/ x5 d: C
obtain testicular and abdominal sonograms; how-9 p* g. I$ K7 s8 J, \' S; l
ever, the family did not return for 4 months.& Z/ k2 t2 N5 Z
Physical examination at this time revealed that the; I1 g( A F8 Q- m9 |7 r' ~& @4 _/ L
child had grown 2.5 cm in 4 months and had gained
% j' y* d O0 N" T `1 i4 a2 kg of weight. Physical examination remained, K" `" l/ c. H/ \, @+ {
unchanged. Surprisingly, the pubic hair almost com-
0 `6 f* {7 f$ m* s6 Lpletely disappeared except for a few vellous hairs at: y8 ]2 e9 d! A+ m u
the base of the phallus. Testicular volume was still 26 t2 M. n2 m* X
mL, and the size of the penis remained unchanged.5 i2 ]; d$ ~1 S: J4 h+ u
The mother also said that the boy was no longer hav-
9 |* L. F: M' }. Zing frequent erections.
: ?# N2 I/ N# i; v" ABoth parents were again questioned about use of
6 l; j5 h6 s: p; a0 G6 f& Cany ointment/creams that they may have applied to
. v( q T2 J) ^' z1 N& b6 ]the child’s skin. This time the father admitted the
3 C& E9 B0 B$ ~3 o! R" `Topical Testosterone Exposure / Bhowmick et al 541
* m3 l' O. O: v$ B4 Ruse of testosterone gel twice daily that he was apply-! z9 K; ]( n' p0 b$ j/ l# m# C
ing over his own shoulders, chest, and back area for
2 p& b; x/ n! _7 |a year. The father also revealed he was embarrassed+ y$ A4 I# e6 m1 P8 @% b. N D
to disclose that he was using a testosterone gel pre-
5 x5 O4 x+ u" U0 Oscribed by his family physician for decreased libido
. P! x7 \" U6 P$ I& dsecondary to depression.2 F& r$ j+ E$ u! o
The child slept in the same bed with parents.
7 f- L1 Q* U0 L! E7 p5 AThe father would hug the baby and hold him on his' }. a- s2 S: I8 j2 c* {
chest for a considerable period of time, causing sig-/ K; O; h% w, {9 C% F! N' S
nificant bare skin contact between baby and father., w3 t# b6 |4 [" y, n7 A" \* W
The father also admitted that after the phone call,, x6 C0 ?& p0 d
when he learned the testosterone level in the baby
( k: L+ G& v) Q6 rwas high, he then read the product information. y5 a! C9 Q7 }, r& g6 d, a% T7 e! z
packet and concluded that it was most likely the rea-
7 `2 k( `! b3 w: e2 e* a- vson for the child’s virilization. At that time, they
7 Q& Q. A( `& |6 r% d. P/ }decided to put the baby in a separate bed, and the
- T0 v- U& n! d; R; [# |father was not hugging him with bare skin and had
7 a6 _2 }1 m. }3 v* T, `been using protective clothing. A repeat testosterone" `0 O4 T9 O) w8 s4 q6 R: p
test was ordered, but the family did not go to the& `7 N6 l( @/ P t& L7 m) j' l- q
laboratory to obtain the test.
/ [) T: L( O8 n6 |7 n; D8 W" TDiscussion
: u' ^1 y7 V. ePrecocious puberty in boys is defined as secondary
, F3 l( E( }8 r4 }8 y: s& V$ lsexual development before 9 years of age.1,4
" I; |) i' p0 J0 vPrecocious puberty is termed as central (true) when
) ]; N6 H+ C0 X9 wit is caused by the premature activation of hypo-
$ h: C) o6 F5 W0 u4 sthalamic pituitary gonadal axis. CPP is more com-* f' R3 e3 u* {; L6 F& g4 r1 p
mon in girls than in boys.1,3 Most boys with CPP
" [6 \" }9 f/ N3 C9 n" t8 |+ T: Amay have a central nervous system lesion that is% f' L7 l: b1 ?" W& Q
responsible for the early activation of the hypothal-
z3 B' S# s1 s; k p# ?amic pituitary gonadal axis.1-3 Thus, greater empha-$ U7 O* n f/ m3 j7 u0 g
sis has been given to neuroradiologic imaging in
. ^5 ?: ]$ \/ O2 I4 `boys with precocious puberty. In addition to viril-# F1 e) e0 N r3 Y
ization, the clinical hallmark of CPP is the symmet-/ U' q8 ~( I* I& G ]4 F
rical testicular growth secondary to stimulation by
" m! O. w# M" Q# O" ngonadotropins.1,3( V, T. ?+ F8 m) ]; Q
Gonadotropin-independent peripheral preco-
; J7 ^4 r2 b' P+ ?3 \( Ccious puberty in boys also results from inappropriate
% {1 u. @( w7 V. A: e8 I/ X$ Landrogenic stimulation from either endogenous or
& k* L. x8 k2 q# y9 Nexogenous sources, nonpituitary gonadotropin stim-. d: N$ U( U5 M7 Z- \% P
ulation, and rare activating mutations.3 Virilizing
; s& K2 i& Z4 [' c8 ^) Z6 o# g1 w8 xcongenital adrenal hyperplasia producing excessive
3 R2 a1 j/ s. Q/ K9 O/ fadrenal androgens is a common cause of precocious
/ D: q% |& n5 W& C2 r/ M4 Y9 Epuberty in boys.3,4
2 Z4 a- v- @* W5 O; E3 {8 kThe most common form of congenital adrenal7 J3 v8 f1 t6 D( Y+ S3 f; b" k+ b: X
hyperplasia is the 21-hydroxylase enzyme deficiency.7 a- G7 [9 s# B- e. d2 K' t8 c5 S
The 11-β hydroxylase deficiency may also result in5 M) v; _3 |% |4 S
excessive adrenal androgen production, and rarely,* u4 ^% O7 M1 _2 |6 Y
an adrenal tumor may also cause adrenal androgen7 \1 }! Q2 |* C5 |( {( o- @
excess.1,3: S2 t3 g, @1 Q+ {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" L. w3 Y1 u6 D+ I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& s9 V. ~7 @/ Q4 b$ ]- u8 a/ L
A unique entity of male-limited gonadotropin-
3 h/ B) h0 Q) l8 e6 vindependent precocious puberty, which is also known% b: O- F6 @5 [
as testotoxicosis, may cause precocious puberty at a
, O( T3 Q' h- p* h* n3 cvery young age. The physical findings in these boys6 y' a6 I, w4 O. H
with this disorder are full pubertal development,
' q% |9 i7 e u2 n* P) T9 Z N6 eincluding bilateral testicular growth, similar to boys
3 T- R. y& r( Q- J. e1 X2 w+ ~2 ~with CPP. The gonadotropin levels in this disorder
+ N: S- I" k/ D; Q& K1 r0 |% gare suppressed to prepubertal levels and do not show
6 Y3 d( `" o. ~) E) V' O* Ypubertal response of gonadotropin after gonadotropin-
1 o2 t, w' D$ Z0 R5 U" E7 wreleasing hormone stimulation. This is a sex-linked
8 c( k( j% W3 B; Q F5 a/ U' W( ~% Qautosomal dominant disorder that affects only
+ b3 Z+ ]; c5 }) Omales; therefore, other male members of the family& K$ s3 e0 o B: u# I2 k- B
may have similar precocious puberty.3( \- x6 t' C6 m- E7 z
In our patient, physical examination was incon-* e; B( M2 h3 l, _
sistent with true precocious puberty since his testi-) {1 s, b$ T0 f% Z8 D
cles were prepubertal in size. However, testotoxicosis
* @- N, A3 [% G- I: ewas in the differential diagnosis because his father2 A8 _, w1 B# A% |
started puberty somewhat early, and occasionally,4 B% z7 h7 Z4 h% l3 f" K9 e2 ^
testicular enlargement is not that evident in the
6 j- f) U. N j4 h- ]beginning of this process.1 In the absence of a neg-5 b4 ?9 `9 G4 m/ O( k: g' e
ative initial history of androgen exposure, our! h7 v9 A1 c5 a ~# `
biggest concern was virilizing adrenal hyperplasia,/ `9 z2 z8 K0 Y# D6 z4 v- W
either 21-hydroxylase deficiency or 11-β hydroxylase
_; l2 i) ]3 V/ C# [& edeficiency. Those diagnoses were excluded by find-9 B% I+ X$ s) I2 m* h
ing the normal level of adrenal steroids.
) p9 o d) `! _* u9 k- j/ pThe diagnosis of exogenous androgens was strongly* f( m- l" c) Q" V# f
suspected in a follow-up visit after 4 months because
, p; b5 g# N$ ~% \7 ]" Kthe physical examination revealed the complete disap-
) m/ H6 ~ e' D3 Y/ Y& `5 y, ipearance of pubic hair, normal growth velocity, and5 I$ t9 H, r, R; \/ V2 z( G1 \9 m* @
decreased erections. The father admitted using a testos-) K2 Q% X6 y; q2 ^! S8 m/ M4 D
terone gel, which he concealed at first visit. He was
# H5 s' V2 |2 `) @using it rather frequently, twice a day. The Physicians’! J2 ?* p' z7 w- D* E k. L
Desk Reference, or package insert of this product, gel or
+ ~# [/ n& `' m8 X' T7 V5 ?cream, cautions about dermal testosterone transfer to0 l; r9 e1 v B5 P" ]0 G
unprotected females through direct skin exposure.9 I5 ` E' ^: s) K3 b5 R" q% K/ [
Serum testosterone level was found to be 2 times the" D/ v# w8 a/ ? `& M. B; Z
baseline value in those females who were exposed to/ l9 v5 T9 r1 H2 M+ o T4 j
even 15 minutes of direct skin contact with their male' h& U0 Q5 J' m/ j" |4 M) a1 p9 F) X
partners.6 However, when a shirt covered the applica-
: K, T" U6 \5 S9 d+ F0 V) M3 s9 q; _tion site, this testosterone transfer was prevented.& e% Z/ D" \4 p. r
Our patient’s testosterone level was 60 ng/mL,: Z7 x6 w% h0 ^) u, {
which was clearly high. Some studies suggest that- I- x' f/ ?" I- A# u2 c; ]
dermal conversion of testosterone to dihydrotestos-/ S' _% |- {1 Q, i: ~
terone, which is a more potent metabolite, is more' H" B) K! k8 Z" y) l W
active in young children exposed to testosterone
1 D* H4 r# t; T* { Xexogenously7; however, we did not measure a dihy-/ i9 z7 h- B$ s0 i
drotestosterone level in our patient. In addition to
& I# k& E7 c( e' \. h Fvirilization, exposure to exogenous testosterone in9 ^$ K" s$ j2 m
children results in an increase in growth velocity and5 {! J: J* a: J4 l* I
advanced bone age, as seen in our patient.
6 j6 _% g4 ` @5 h" C. ^6 J6 |: r$ jThe long-term effect of androgen exposure during
- P% w6 _4 H' r- o: Rearly childhood on pubertal development and final+ |5 X4 \4 |* A* f# Y' Y4 t+ ^
adult height are not fully known and always remain
( N1 }+ ]% P: S0 w8 F! na concern. Children treated with short-term testos-
5 z5 X+ \, ?" z& P" C: M/ dterone injection or topical androgen may exhibit some
* I i/ e6 @: I3 P- Aacceleration of the skeletal maturation; however, after" l- F* [1 `4 }& P, X+ M
cessation of treatment, the rate of bone maturation
( f" S% }5 e* b& q1 Y5 hdecelerates and gradually returns to normal.8,9
$ y: M- r9 k" X6 i5 O# f- }There are conflicting reports and controversy
1 Q3 q: I7 P6 N* o, H. F2 lover the effect of early androgen exposure on adult& ^1 I( `3 ~ Q7 z
penile length.10,11 Some reports suggest subnormal
0 N; | Y% r! i) Nadult penile length, apparently because of downreg-
2 i: K) H6 m: f) T3 Nulation of androgen receptor number.10,12 However,6 ?2 M" _6 Q0 s! z. B
Sutherland et al13 did not find a correlation between2 j) G0 p/ n+ G7 o X
childhood testosterone exposure and reduced adult+ B/ \+ c# C6 m9 t, G3 Q% ], ]! v
penile length in clinical studies.1 z/ q8 w' c9 z5 o
Nonetheless, we do not believe our patient is
7 \4 _' f% f9 P. O: vgoing to experience any of the untoward effects from" ~* s/ ^' v, x4 U
testosterone exposure as mentioned earlier because
, U, G% _: W7 |6 x7 u' qthe exposure was not for a prolonged period of time.
; C" H' U9 W5 s6 L/ hAlthough the bone age was advanced at the time of: B7 {( ]! |( r: k% U T1 F/ l
diagnosis, the child had a normal growth velocity at
2 K& q* ?7 ^$ K$ g |7 \the follow-up visit. It is hoped that his final adult( j4 C% _0 a- F2 g; C/ s( G8 s. J! Z
height will not be affected.
: }3 n7 a9 J: W$ T T% o, eAlthough rarely reported, the widespread avail-
% n \3 H7 ]$ Uability of androgen products in our society may
7 H; _* T3 t8 U0 A Lindeed cause more virilization in male or female( a4 o% I/ |/ M) v$ o
children than one would realize. Exposure to andro-* A) f+ x9 | V5 J: T( I) s
gen products must be considered and specific ques-) E3 D- x0 C; |$ B, p. s) h
tioning about the use of a testosterone product or9 O8 ^" u/ u3 n6 J+ x& o
gel should be asked of the family members during
! @/ X( ]2 f* j) Y" D, F3 g8 ^the evaluation of any children who present with vir-
( L6 ?7 G) C* l$ n$ D, Silization or peripheral precocious puberty. The diag-) D* N7 E) ~5 U
nosis can be established by just a few tests and by2 F& C, K! B+ B( b
appropriate history. The inability to obtain such a
3 I/ B" n1 _* rhistory, or failure to ask the specific questions, may- |# C0 G9 @8 q$ p+ K% y% p& H
result in extensive, unnecessary, and expensive% W2 `4 I" n4 v
investigation. The primary care physician should be2 R q: G+ f* P& T
aware of this fact, because most of these children F/ i* E1 C8 m! }* m1 Z9 z; l. F. M
may initially present in their practice. The Physicians’! g. m) ^, c5 i
Desk Reference and package insert should also put a3 D& n A7 a2 X2 t; ?# {1 C
warning about the virilizing effect on a male or
. w2 |% E/ g) g( T) u& Pfemale child who might come in contact with some-
8 r8 i8 Z+ B0 n1 A/ C: U/ I" @+ Lone using any of these products.
5 b, m) \- X3 K# Y( X% a" mReferences# ^2 R% X6 h- C5 o
1. Styne DM. The testes: disorder of sexual differentiation
. R {! k5 V! a2 u5 band puberty in the male. In: Sperling MA, ed. Pediatric
. F b8 i6 n' v/ o. n& K8 |+ ]* B" t. ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; a% V! j' q r5 w0 a2002: 565-628.* m' e% f$ V% U6 g3 U" k8 r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 B( j, ?8 C/ {
puberty in children with tumours of the suprasellar pineal |
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