- 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 {4 T+ z3 b& Y) P5 _( HBoy Induced by Indirect Topical; S- v) F* ]- g% S) _9 @/ ?7 S% @
Exposure to Testosterone# N0 _' r/ d6 N) ^# Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' t0 v3 K% N# ]$ b' ]# [: xand Kenneth R. Rettig, MD1
1 W7 @# G; y" {: q6 YClinical Pediatrics
5 |3 e0 T; s0 } W* O& J! TVolume 46 Number 60 O+ A7 P" j# n
July 2007 540-5434 }$ g% Z. d% o* @( v3 z
© 2007 Sage Publications
9 C$ d% I4 }& @9 w10.1177/0009922806296651
4 C5 T! M1 F( B0 T. a7 Y6 j- hhttp://clp.sagepub.com' ?, I! Y m: X7 `: X7 B5 m
hosted at
; H/ G' g T+ Zhttp://online.sagepub.com& Y9 [1 Q, |& P) J% m
Precocious puberty in boys, central or peripheral,
: F/ x% W- V1 z0 `is a significant concern for physicians. Central. \0 S- }, f9 u1 d* e# @7 ^1 ^
precocious puberty (CPP), which is mediated
4 N& q) p( {5 D1 V+ a Othrough the hypothalamic pituitary gonadal axis, has& m- n5 ~/ X8 l7 L' w i6 f. n
a higher incidence of organic central nervous system# |! m& Z1 T+ \% x1 H. a2 t
lesions in boys.1,2 Virilization in boys, as manifested
/ l1 d8 B) R8 N7 z0 G+ v0 oby enlargement of the penis, development of pubic
# U9 x& X X4 E9 Shair, and facial acne without enlargement of testi-
7 ^8 `9 {' A$ c1 T% |; Q3 Q$ hcles, suggests peripheral or pseudopuberty.1-3 We
5 c4 F% B4 O1 a8 d# Y& L8 b% Ereport a 16-month-old boy who presented with the7 X; \# b2 w' n4 |) n% O' Z% b
enlargement of the phallus and pubic hair develop-; Y) {% \5 G3 @) Z
ment without testicular enlargement, which was due
/ P z6 W4 e# o& J x/ {to the unintentional exposure to androgen gel used by
! J- F% S, Z$ U% k3 L/ hthe father. The family initially concealed this infor-! {. q# N1 Y6 s# `1 b) ]+ h4 n
mation, resulting in an extensive work-up for this
; u- a2 q) q1 h* X) h7 lchild. Given the widespread and easy availability of
' h# A8 a& j7 Ntestosterone gel and cream, we believe this is proba-, m4 K5 W1 C8 b% s3 {0 B* p. M
bly more common than the rare case report in the" _1 Q3 V* I0 Z V$ s! h. U
literature.4
2 @4 \% {& V3 j, h APatient Report
8 K: q: [& d8 |A 16-month-old white child was referred to the% s7 P* \$ B; Z! W% q; {
endocrine clinic by his pediatrician with the concern& q( Q/ a- u9 p8 n% U1 h
of early sexual development. His mother noticed
C. u' r4 J, {/ B+ W5 alight colored pubic hair development when he was6 n7 G* U9 T9 q. T7 C" P0 N) |# H$ S
From the 1Division of Pediatric Endocrinology, 2University of. U- s$ g6 E, B# H% _, H
South Alabama Medical Center, Mobile, Alabama.
4 Q, @4 w0 T k1 ^6 e4 k) G7 [8 JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
6 S& ]* ~4 H7 @5 S9 w: _1 @. X* iProfessor of Pediatrics, University of South Alabama, College of
5 E6 X' |, D, O2 Y, H+ q" XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) N! Y! [! R% V; W
e-mail: [email protected].
! ?% T" C t: b9 Sabout 6 to 7 months old, which progressively became
; g1 C* p; L9 ^2 T9 ]8 ~darker. She was also concerned about the enlarge-$ h0 P& r: K! F2 w: U/ b
ment of his penis and frequent erections. The child
- }0 z: h2 N+ D, k9 d7 D. w+ kwas the product of a full-term normal delivery, with
: E; X- Y1 ^6 l# t: r8 k: Ua birth weight of 7 lb 14 oz, and birth length of1 g+ n2 w9 M8 b/ } j
20 inches. He was breast-fed throughout the first year% o. j3 G* z5 A1 a7 ~! b# l
of life and was still receiving breast milk along with7 L; {9 _0 f! f6 U" a
solid food. He had no hospitalizations or surgery,3 M7 z/ e9 y5 @
and his psychosocial and psychomotor development/ j( T8 Y. L) d& s2 p) K( L
was age appropriate.( C1 L4 i6 ~. T0 H! h
The family history was remarkable for the father,
2 T! h2 ? _1 {0 k( _who was diagnosed with hypothyroidism at age 16,+ ?- b) I# j- P+ v
which was treated with thyroxine. The father’s( V' p& S5 C: t! l _) ^, j: _7 ~
height was 6 feet, and he went through a somewhat4 `+ ^& c( R t
early puberty and had stopped growing by age 14.: [, b- s- {$ H$ u
The father denied taking any other medication. The* U+ f$ T3 }1 c# N
child’s mother was in good health. Her menarche3 B" ]; }9 w4 }: E2 s
was at 11 years of age, and her height was at 5 feet
' w o. L& s; w* Y c. d0 M9 x5 inches. There was no other family history of pre-' i& T& j4 C* C% o Z' {8 k5 ~5 b, V
cocious sexual development in the first-degree rela-
7 o) N* W( s9 {( C1 g3 xtives. There were no siblings.# _$ E+ a9 T" ~9 f2 M
Physical Examination
@' H# I' c2 D8 pThe physical examination revealed a very active,; ~. s( R. R3 L; W
playful, and healthy boy. The vital signs documented
, T0 H* D7 a* Y2 D D. A9 X. |+ `a blood pressure of 85/50 mm Hg, his length was
1 f1 f# a+ C7 B( P90 cm (>97th percentile), and his weight was 14.4 kg* ^8 D4 _" b! _, r
(also >97th percentile). The observed yearly growth9 z" Y0 p: u6 t2 ?
velocity was 30 cm (12 inches). The examination of. O, E5 F+ u- ]/ n9 N/ o
the neck revealed no thyroid enlargement.
5 e5 C; j* H% ~ LThe genitourinary examination was remarkable for; Q9 T9 }2 _6 i1 }! F' W
enlargement of the penis, with a stretched length of/ u% h. t$ A+ @- D: V( a% I7 ~( t
8 cm and a width of 2 cm. The glans penis was very well# d3 |8 y. o5 @
developed. The pubic hair was Tanner II, mostly around
4 S6 g: p# a: |: a7 r+ K8 A& ]540
" A5 _0 q! M1 ~7 D' X Y. g$ c4 Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; G' I" Q- L" t7 F5 Y
the base of the phallus and was dark and curled. The2 i A. J }9 }) l( S
testicular volume was prepubertal at 2 mL each.
6 f0 m/ t: [2 I3 `The skin was moist and smooth and somewhat
& q3 ?; x. `" S: `- E$ s, f' Hoily. No axillary hair was noted. There were no( h, _, R$ {& \) t" l" R
abnormal skin pigmentations or café-au-lait spots.
6 s7 R2 L3 B5 v+ l, G$ fNeurologic evaluation showed deep tendon reflex 2+: h2 v6 @& u* ~$ _8 v
bilateral and symmetrical. There was no suggestion4 A. F$ B6 u' c9 ?, \2 j
of papilledema.
! J' Q7 _! \' X: ~) I7 tLaboratory Evaluation0 W" h+ Z, \' L" W1 A6 H
The bone age was consistent with 28 months by' F3 i$ Q4 o/ ]) Z, s
using the standard of Greulich and Pyle at a chrono-4 b8 ^/ i$ x, s1 S
logic age of 16 months (advanced).5 Chromosomal
. u8 Y6 @2 u5 S5 t2 Q _6 F* kkaryotype was 46XY. The thyroid function test( M2 g0 [' D7 u- \6 D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 n8 R% Y3 ?& P) I6 w; v
lating hormone level was 1.3 µIU/mL (both normal).
' E9 x* E/ o6 zThe concentrations of serum electrolytes, blood
8 k$ c- T$ `" E' U- g; ~' rurea nitrogen, creatinine, and calcium all were
9 Z2 X6 K# M" t3 ]within normal range for his age. The concentration
; h- k* |0 y: K2 G+ i) yof serum 17-hydroxyprogesterone was 16 ng/dL6 w0 Z' [- e9 c- i
(normal, 3 to 90 ng/dL), androstenedione was 203 k8 w, j$ x4 x4 R, K* c: K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' ?* u0 }: H& e! m G: ?" ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 J1 n/ u7 A3 N, F6 F8 n/ }2 \desoxycorticosterone was 4.3 ng/dL (normal, 7 to' b1 T8 u- P. F9 n$ M
49ng/dL), 11-desoxycortisol (specific compound S)' D% D3 I2 n! Y0 {
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ }, o* L; {4 w; Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( h9 A) I# l" W; c/ e& h; U! s8 | \* Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),- r4 g3 ?1 g) M$ @5 `$ K/ b
and β-human chorionic gonadotropin was less than* @; R: s" a+ R$ A: Z8 a
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 L1 [- [9 P0 p* {8 Z
stimulating hormone and leuteinizing hormone
7 |7 N( w7 c! h# hconcentrations were less than 0.05 mIU/mL2 S4 H4 ^# A/ u3 x6 V! ~1 R
(prepubertal).+ M s1 Y! \# K
The parents were notified about the laboratory) `( H3 V, D. g5 P
results and were informed that all of the tests were
3 Q& x! q. ?4 n# x) inormal except the testosterone level was high. The
: j4 z- ^' ~! e' _7 g3 c8 hfollow-up visit was arranged within a few weeks to% {& \3 e v) B3 b; |2 [! h
obtain testicular and abdominal sonograms; how-
; {" y7 s; z; r5 `/ b M2 _ever, the family did not return for 4 months.
5 r3 U# _3 e) W4 `; K+ H) uPhysical examination at this time revealed that the# `$ B2 o: d, T% ~" d
child had grown 2.5 cm in 4 months and had gained1 U$ k! w$ L: Y4 b2 ^: ~6 [
2 kg of weight. Physical examination remained# Z b$ P+ Z- `" q
unchanged. Surprisingly, the pubic hair almost com-
, n- s5 ~9 e. ~& Fpletely disappeared except for a few vellous hairs at/ Z5 R5 n4 S4 j: n& `( t
the base of the phallus. Testicular volume was still 2
' C j$ @0 B) N2 f$ Z# |% OmL, and the size of the penis remained unchanged.
# N) n' z5 ?' Z6 V3 f vThe mother also said that the boy was no longer hav-" z# ^8 I9 l, N0 D* j+ {3 }3 P) K
ing frequent erections.9 j+ z+ Q4 S5 x' F1 @
Both parents were again questioned about use of. w3 x. o( ?" O5 O
any ointment/creams that they may have applied to
1 m- \' F# J& v3 Ethe child’s skin. This time the father admitted the
! \ D% ~& k0 I4 J# y. A& Q7 oTopical Testosterone Exposure / Bhowmick et al 541, C% { r" @5 v6 \/ G1 P5 o
use of testosterone gel twice daily that he was apply-
. \/ b/ H. a7 }; _7 Ring over his own shoulders, chest, and back area for
Q- r. ]3 c3 Ba year. The father also revealed he was embarrassed
5 F: v" C- o" P( e9 kto disclose that he was using a testosterone gel pre-
3 q' y% d- u# \! Z7 g# ]* Escribed by his family physician for decreased libido: T$ x+ h: V; U& Y' y& y7 J4 G3 v8 u9 b
secondary to depression.3 h7 `( u& y) z+ o: `, c. D& ]
The child slept in the same bed with parents.
; g3 P- G( {7 I, \8 rThe father would hug the baby and hold him on his) _, P1 H, J+ ` e# I. V
chest for a considerable period of time, causing sig-; B3 g- r% }% N( @9 ~
nificant bare skin contact between baby and father.
7 D% [$ D M! I: z, t. g' VThe father also admitted that after the phone call,
9 j$ V/ x% V& G d: |8 O- P+ o6 hwhen he learned the testosterone level in the baby7 a, }7 Y/ n/ [2 {: c- |! W6 M
was high, he then read the product information
6 Z# q, Q/ w) k) h$ v3 e( F9 tpacket and concluded that it was most likely the rea-
7 v1 z# h+ f3 @+ x' V/ L7 S Pson for the child’s virilization. At that time, they2 h1 \" u$ L9 w: i: E
decided to put the baby in a separate bed, and the, S1 W8 }1 y: `7 b
father was not hugging him with bare skin and had4 T2 q) {$ ] u+ V
been using protective clothing. A repeat testosterone/ y* @+ a' ^3 j5 `1 r# w, r
test was ordered, but the family did not go to the
' ?" p5 J( p: plaboratory to obtain the test.* g0 D3 |+ z8 Z( w) l' I, p
Discussion/ e9 m& v+ j: ?5 t i y1 B) D0 y
Precocious puberty in boys is defined as secondary6 L3 `' t) D Q6 P$ y% Z
sexual development before 9 years of age.1,4' Q8 c% o+ S, V( `% [
Precocious puberty is termed as central (true) when J" y; o; b) b& ^6 Q
it is caused by the premature activation of hypo- ~. C4 }& e; {" ?7 `; h8 p
thalamic pituitary gonadal axis. CPP is more com-
: I M+ x. Q+ Q- X% a i/ [mon in girls than in boys.1,3 Most boys with CPP; |1 A# e4 r; q; }; {& }. f
may have a central nervous system lesion that is; m7 f S0 ?2 g4 X- i
responsible for the early activation of the hypothal-" t, S1 H, ?' O9 p* u
amic pituitary gonadal axis.1-3 Thus, greater empha-
, Z, W+ G8 P* o( A2 Z/ h& ?: Fsis has been given to neuroradiologic imaging in6 z2 x7 {; N6 G: @, F& L
boys with precocious puberty. In addition to viril-4 h3 `7 n' _5 Q
ization, the clinical hallmark of CPP is the symmet-
# e. \1 |+ q) m; Trical testicular growth secondary to stimulation by, e. O9 G+ ]' Y9 R# F5 s
gonadotropins.1,38 V' t$ x4 W/ K, x1 W4 E1 d6 f
Gonadotropin-independent peripheral preco-
* ^3 N. K4 A5 v3 a7 u/ q, s: L G. rcious puberty in boys also results from inappropriate: L5 k9 S6 O, L# m1 e) b
androgenic stimulation from either endogenous or
% Y% Z" z: \3 Q0 t7 ?# Z; Mexogenous sources, nonpituitary gonadotropin stim-
) r1 o8 V* v4 N: x$ {: ~ H& ]- B: Hulation, and rare activating mutations.3 Virilizing" \4 G7 n) M3 L) k6 H! I" y
congenital adrenal hyperplasia producing excessive
8 Y2 @, D" Z0 \( {adrenal androgens is a common cause of precocious. X( p Q6 G$ p: h' a9 V
puberty in boys.3,4
4 x' y0 V2 m6 oThe most common form of congenital adrenal+ |. h( H" z2 W! f9 ?1 G2 u
hyperplasia is the 21-hydroxylase enzyme deficiency.6 s% b2 f2 ], o9 z7 B8 V- ?. _
The 11-β hydroxylase deficiency may also result in
' T8 T- R. Z2 L5 O% @: }- texcessive adrenal androgen production, and rarely,. c! }; a7 t. g( Z, ]
an adrenal tumor may also cause adrenal androgen" r+ l* T0 B% q( P+ A$ V
excess.1,34 D1 q V! L" `. Q! f4 }6 V2 c% q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 w6 ]1 z$ N5 }3 Q' b6 z. T0 y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! Z5 }9 E0 p1 { |/ ]. v0 _" A
A unique entity of male-limited gonadotropin-
. q M0 M8 @6 p! F& Kindependent precocious puberty, which is also known3 H1 J9 N( A. W5 w
as testotoxicosis, may cause precocious puberty at a$ q2 [2 _ p' I. |. a1 \! o% [
very young age. The physical findings in these boys4 r& \9 ]- Q3 u# m1 H& H! ~
with this disorder are full pubertal development,# C# t) M) F% R1 d6 f9 f
including bilateral testicular growth, similar to boys
/ @% M* Z% r' l! g- x; [with CPP. The gonadotropin levels in this disorder4 ^5 F, s( l- i. A& C3 {4 c0 V
are suppressed to prepubertal levels and do not show% ^8 j( N5 _+ m# z4 _7 U8 c/ t% O
pubertal response of gonadotropin after gonadotropin-
$ ]' j9 C1 k1 V& l x$ U* L" Hreleasing hormone stimulation. This is a sex-linked
% s. ?, }8 D: c; P1 P, e7 O/ S. |autosomal dominant disorder that affects only
$ z$ T$ y) t' L7 I& w. q' Nmales; therefore, other male members of the family
c; T7 Y ^) S4 ^ ~; d1 Hmay have similar precocious puberty.3
: p6 F. H" L; r: B. K! Q/ GIn our patient, physical examination was incon-
6 h4 \9 q/ i9 s: w& H: Nsistent with true precocious puberty since his testi-% I. L5 c- g1 u3 y
cles were prepubertal in size. However, testotoxicosis# p# n7 \& U6 x4 h% V4 f/ U4 d
was in the differential diagnosis because his father2 {0 g1 Q% }3 _$ \% A
started puberty somewhat early, and occasionally,
, T( V! r3 E* o' w$ T8 ltesticular enlargement is not that evident in the
& B! J3 z2 u" B6 [" p/ Qbeginning of this process.1 In the absence of a neg-
9 k' s& {0 n. t+ a6 Jative initial history of androgen exposure, our, @" H( O# E( u% W/ C0 `# P, W
biggest concern was virilizing adrenal hyperplasia,
+ {+ q/ c: [ R, leither 21-hydroxylase deficiency or 11-β hydroxylase
+ m) Q$ U. t2 M2 X! @7 H; x: Fdeficiency. Those diagnoses were excluded by find-! l) b( f* G9 {" t- T
ing the normal level of adrenal steroids.
8 k, g6 ]/ \% s; [( i3 RThe diagnosis of exogenous androgens was strongly8 }1 J$ _& V; X3 s( W, w
suspected in a follow-up visit after 4 months because: |! E) J3 b/ x# ?6 g+ d
the physical examination revealed the complete disap-0 A: c8 Q+ ? t: A) d( ^/ i/ b+ \
pearance of pubic hair, normal growth velocity, and/ b* |1 L1 C% A; N0 |. F
decreased erections. The father admitted using a testos-
& o+ ~- ]2 U" U. q- bterone gel, which he concealed at first visit. He was5 k4 z- F" y# b4 ~2 _; y
using it rather frequently, twice a day. The Physicians’8 Z/ B8 t5 W6 m* x" ]
Desk Reference, or package insert of this product, gel or, p! O) o B. E' y1 U9 O
cream, cautions about dermal testosterone transfer to" E* J p a; H9 t2 b8 o
unprotected females through direct skin exposure.
9 `" j8 C# k8 g6 sSerum testosterone level was found to be 2 times the, y: ^0 ?) \5 @# k5 m
baseline value in those females who were exposed to
. s" b1 ~! E. o, x leven 15 minutes of direct skin contact with their male
+ p- U6 {6 O( \9 {6 D8 epartners.6 However, when a shirt covered the applica-
. `2 h1 ~7 `. j6 Q2 K) jtion site, this testosterone transfer was prevented.' W0 }, C: `9 z+ T% S
Our patient’s testosterone level was 60 ng/mL,9 u- l& K! L) V$ j2 {5 P
which was clearly high. Some studies suggest that
O2 U7 \ w$ T9 l8 C5 Ndermal conversion of testosterone to dihydrotestos-( @+ K2 u% c) D. S6 w9 `
terone, which is a more potent metabolite, is more
% C- p. w: P+ yactive in young children exposed to testosterone$ J% @* ~ @1 v$ Q( |
exogenously7; however, we did not measure a dihy-5 p6 `7 l+ w0 B0 F! X* P
drotestosterone level in our patient. In addition to- e, s0 ?. q. |7 @- k
virilization, exposure to exogenous testosterone in
Y) W) \) `) R7 |& m- ]children results in an increase in growth velocity and
5 a: z8 Y U1 ~) G9 Padvanced bone age, as seen in our patient.
$ X* e1 U2 D' h% m0 T. u7 g5 d9 PThe long-term effect of androgen exposure during( O1 s( ?* \+ O! p3 T
early childhood on pubertal development and final- b/ A2 M2 Y4 S" C: s! n5 d8 L2 h
adult height are not fully known and always remain' L3 d5 H, v! d! z3 `: f' L
a concern. Children treated with short-term testos-) N3 P: ?7 K* o* s6 A4 U
terone injection or topical androgen may exhibit some5 |6 a4 U4 f! }9 y0 K
acceleration of the skeletal maturation; however, after
5 \3 k% A+ k7 e' d; jcessation of treatment, the rate of bone maturation& F0 U$ v' e2 i4 q" W
decelerates and gradually returns to normal.8,90 w- \* y, d5 \7 y. L* V5 N/ {
There are conflicting reports and controversy
' M* T' M2 H2 I% Pover the effect of early androgen exposure on adult0 D/ ^3 p8 ^# @" l2 i8 [
penile length.10,11 Some reports suggest subnormal
. I, q+ K" r! ? `) J2 [/ ]adult penile length, apparently because of downreg-+ t) j) R/ p s. [2 ^
ulation of androgen receptor number.10,12 However,
0 k/ n, l& U& ~6 i8 qSutherland et al13 did not find a correlation between
+ Y2 b- s% R: ~3 ?6 F8 m Ichildhood testosterone exposure and reduced adult
* o& B+ Y: s1 z+ R1 y' N5 o) w) Ipenile length in clinical studies.! j# b8 u% @; O& G* s! \
Nonetheless, we do not believe our patient is4 Z" F& |% N/ z0 O, A/ y
going to experience any of the untoward effects from1 j8 i' V* d# ] g% a1 ^$ o
testosterone exposure as mentioned earlier because
: U" o% B# \% x' V2 Mthe exposure was not for a prolonged period of time.
' f/ t; {% |3 O4 V: A- U/ z r+ FAlthough the bone age was advanced at the time of8 y+ D9 x9 Y0 \) ~( [
diagnosis, the child had a normal growth velocity at
, n+ P8 W, }+ D2 _8 a* ethe follow-up visit. It is hoped that his final adult: a# f/ |: v" u, c. {6 G. y, [2 C
height will not be affected.
9 z! m( j: g/ F) F9 i& |Although rarely reported, the widespread avail- t3 \$ g$ h" Z$ h( p
ability of androgen products in our society may) \) W% P2 w0 s/ z8 t
indeed cause more virilization in male or female
) d1 }" t$ C5 m7 g: h. T9 |- |/ r5 xchildren than one would realize. Exposure to andro-
6 E, j2 V" q& ~. f6 |gen products must be considered and specific ques-
7 H* ~0 }1 D8 K' otioning about the use of a testosterone product or
" b% x8 P0 R4 |5 P% q# a$ qgel should be asked of the family members during
) D% f/ J( X2 vthe evaluation of any children who present with vir-2 w0 M: C7 f& |4 Q
ilization or peripheral precocious puberty. The diag-
' `. s0 u$ \* K- P" n5 _) Qnosis can be established by just a few tests and by
, |7 ?2 I' o" {- l1 ~8 g5 b) o: U) ^appropriate history. The inability to obtain such a
. P5 e& T$ E. |. Zhistory, or failure to ask the specific questions, may4 M) S3 l* B: Y& H2 u( p" h
result in extensive, unnecessary, and expensive
/ D1 ^5 g4 t) k! w: ]* {+ `investigation. The primary care physician should be
0 a% [, k( F- zaware of this fact, because most of these children7 [% O# o, Z9 s8 E' C
may initially present in their practice. The Physicians’
+ v8 r( e$ t- w- d+ jDesk Reference and package insert should also put a
9 m8 y( H: _1 {5 Xwarning about the virilizing effect on a male or
n- l: }8 q6 g# {6 |female child who might come in contact with some-9 O3 b/ l7 N: F! ^
one using any of these products.
: c; e$ o( Z8 Z7 {( EReferences- _8 M4 { j1 ]0 a4 l% f; U
1. Styne DM. The testes: disorder of sexual differentiation
/ E; L. s6 h8 M: p+ \' tand puberty in the male. In: Sperling MA, ed. Pediatric8 J, o% v z2 _$ h I$ H; x9 v% s7 m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 F$ M( p: C6 X. s' J; \
2002: 565-628.5 X) G/ t& Y( e. e$ J$ i
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# I0 n# B$ ^8 F5 a/ ^
puberty in children with tumours of the suprasellar pineal |
|