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Sexual Precocity in a 16-Month-Old* N& Y2 n' F8 v% g! l" D
Boy Induced by Indirect Topical
: A( n. T. ^4 L& i% Q, l2 fExposure to Testosterone
. h8 r0 L4 N* v6 P! m7 g8 KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. W0 b% V0 i4 b) g3 r( V
and Kenneth R. Rettig, MD1$ _# [( S/ p! m& {' b9 T. z1 \7 x$ \1 R
Clinical Pediatrics- L+ r7 M" D/ o" U# B: R7 {0 i
Volume 46 Number 6
$ r5 L* ?7 v( y* FJuly 2007 540-543) r. G/ M) k1 `$ {8 S5 C+ @
© 2007 Sage Publications
" `: W7 L- s! t, u" D$ W7 x10.1177/0009922806296651, R' F& `! t2 {! Y
http://clp.sagepub.com* g0 J- k% `% a, I- }7 b6 B
hosted at
" V) M. d% u) H; L. c. L; W. t& Chttp://online.sagepub.com
w9 c4 e5 j. q* i0 [' BPrecocious puberty in boys, central or peripheral,/ J# z) z# Y2 |" Z
is a significant concern for physicians. Central
- I/ ^( y: G7 ^4 \precocious puberty (CPP), which is mediated
5 R! w- a' O' B% q. m* q1 {through the hypothalamic pituitary gonadal axis, has9 `: w/ D6 G, ~, m
a higher incidence of organic central nervous system
% M# c, ^, k6 l p5 v. l- elesions in boys.1,2 Virilization in boys, as manifested% \+ J: H8 G: m* ~, z8 p; Z
by enlargement of the penis, development of pubic
: r* U) {' W$ D. B1 b. T* Uhair, and facial acne without enlargement of testi-
4 }# l4 l- B% A9 G& F4 Gcles, suggests peripheral or pseudopuberty.1-3 We% `! n' Y( c- W9 q, [3 v2 R% t# V
report a 16-month-old boy who presented with the
5 @$ j6 g+ z6 ^. Fenlargement of the phallus and pubic hair develop-/ A' p" E2 l4 T0 Y" A5 Z
ment without testicular enlargement, which was due) M7 u% @& c w; U, r$ N- K
to the unintentional exposure to androgen gel used by# A! y( I! c& t% f; `* ^. I( D
the father. The family initially concealed this infor-
4 M3 y# d! {0 `% F+ amation, resulting in an extensive work-up for this) e7 C3 D1 ]/ y5 | u+ z% l q
child. Given the widespread and easy availability of/ ^; S5 [ E1 Z# B( B, a. g4 B# d( u+ u5 f
testosterone gel and cream, we believe this is proba-
, d/ s) L0 Z) o. b: i" q" rbly more common than the rare case report in the: O. b' h( c. K$ v2 }
literature.4
9 @& ]' a- z: ^) C$ T8 U7 F. `Patient Report
5 [9 D- j, {) P1 N; f( rA 16-month-old white child was referred to the% S0 F4 u6 F9 c# ~# X0 J1 U# M
endocrine clinic by his pediatrician with the concern* B7 C8 Z$ _- s& U
of early sexual development. His mother noticed, w0 d+ Z2 m3 g, f4 b
light colored pubic hair development when he was
# C8 o1 M0 b+ ]+ NFrom the 1Division of Pediatric Endocrinology, 2University of
; P3 K- c7 G# n# W$ X; k$ o2 JSouth Alabama Medical Center, Mobile, Alabama.6 \0 b+ m2 ~, z# k: J( N
Address correspondence to: Samar K. Bhowmick, MD, FACE, ^ ~+ s( Z S& L/ d+ W8 O
Professor of Pediatrics, University of South Alabama, College of
6 D1 ]! I- D1 a! u, Y, b# |5 l9 _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 j0 l3 d0 v" e9 J$ c
e-mail: [email protected].' L4 T0 e) T! u$ z. ^
about 6 to 7 months old, which progressively became
7 X% p3 a% m, v8 ?0 v ]; M: mdarker. She was also concerned about the enlarge- P1 f' V/ \9 \" z
ment of his penis and frequent erections. The child8 j+ L2 u8 e& O7 S/ E
was the product of a full-term normal delivery, with4 A+ j& o8 `2 ~( X! Z! Z
a birth weight of 7 lb 14 oz, and birth length of
, D- N: {! Q" Z4 X) G20 inches. He was breast-fed throughout the first year
# d9 ]7 @1 p& j* \- X7 \( Lof life and was still receiving breast milk along with
( e* z z& m; Y: E$ y2 Dsolid food. He had no hospitalizations or surgery,
F" R8 O! s# V7 Fand his psychosocial and psychomotor development
* E. a- M+ T% \; ~ ~- zwas age appropriate., j- G; I& @. u; e
The family history was remarkable for the father,1 _. x1 b9 i- m ]" B! N
who was diagnosed with hypothyroidism at age 16,; b% P" f; m# R& @( m' r: h
which was treated with thyroxine. The father’s
* q! O# j/ X- H9 j( r& Dheight was 6 feet, and he went through a somewhat
" Q: o% ], Z9 f$ ]early puberty and had stopped growing by age 14.
/ O. ?# Z7 t& \3 PThe father denied taking any other medication. The
( z/ ^ t4 F! b& ^9 vchild’s mother was in good health. Her menarche$ m5 Z# P8 V- u
was at 11 years of age, and her height was at 5 feet
5 s {# [4 z' ^5 inches. There was no other family history of pre-
- c" P5 }1 {* Icocious sexual development in the first-degree rela-0 r8 o( M: y# u: m% Y' K: |' s
tives. There were no siblings.
2 ^& z) T3 J) U2 d) o0 ~) @Physical Examination" F8 l% H! d( B6 I
The physical examination revealed a very active,
- v8 v' ^; {: W# mplayful, and healthy boy. The vital signs documented" X% x% j3 R; \& {6 q
a blood pressure of 85/50 mm Hg, his length was
3 t7 b9 k( c3 n0 v. ~& ]$ f90 cm (>97th percentile), and his weight was 14.4 kg
' u7 K, B3 ]0 w(also >97th percentile). The observed yearly growth3 L% ~" {, g: f! t
velocity was 30 cm (12 inches). The examination of0 e( y7 Q$ g0 u4 N$ N" C0 p
the neck revealed no thyroid enlargement.
, l$ W6 `9 }! M# U! fThe genitourinary examination was remarkable for* [6 L* Z g: Z0 c
enlargement of the penis, with a stretched length of6 f1 T6 K, g: N5 M, d$ Y/ U/ Y( c& B: {
8 cm and a width of 2 cm. The glans penis was very well- y8 A( t: h6 i% v: S
developed. The pubic hair was Tanner II, mostly around# R [5 w+ A5 v8 S ~" ^
540
( w: Y5 E& h/ i! aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; _7 R9 l( a- m" W
the base of the phallus and was dark and curled. The6 K4 R9 x$ I3 F8 _+ ]
testicular volume was prepubertal at 2 mL each.
& `$ C4 e2 ^9 ?) p4 m# I+ SThe skin was moist and smooth and somewhat) O2 t6 r9 _( p
oily. No axillary hair was noted. There were no
7 V3 O- `- x$ d! O8 @abnormal skin pigmentations or café-au-lait spots.
: N; x, h& |8 g0 sNeurologic evaluation showed deep tendon reflex 2+- n" M3 X" O5 _ X
bilateral and symmetrical. There was no suggestion
. V6 v5 ] G2 f& s+ cof papilledema.- }+ _$ e4 \2 h6 |5 x( S4 {
Laboratory Evaluation
( u- ?" ~# H7 n) R4 Y5 s0 mThe bone age was consistent with 28 months by o+ M6 b: k; k" N
using the standard of Greulich and Pyle at a chrono-
W6 a; O6 L/ Z7 c7 V9 llogic age of 16 months (advanced).5 Chromosomal4 d r7 h) i2 U3 k+ \6 ^/ c
karyotype was 46XY. The thyroid function test
2 W1 `: a/ w* V/ b# o, ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-" S9 Y% P: v4 B4 s
lating hormone level was 1.3 µIU/mL (both normal).
2 ~6 z6 ]5 W3 m% HThe concentrations of serum electrolytes, blood
: _" }( @& w! m% k( X; \8 Eurea nitrogen, creatinine, and calcium all were
0 h$ u6 B! y% ?8 u5 X, ewithin normal range for his age. The concentration
+ k9 E+ G _# f2 N. C Yof serum 17-hydroxyprogesterone was 16 ng/dL1 ?3 y8 @7 c7 k3 L) K( A
(normal, 3 to 90 ng/dL), androstenedione was 20: b+ ?2 y* u, K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 q: z& _+ k$ B% o4 g$ F0 L+ Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, p/ \/ G4 i8 \desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ g% y" h+ F8 _; |49ng/dL), 11-desoxycortisol (specific compound S)0 e4 ?% q, Y5 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, J( x! U3 _. _3 x9 h1 P( s/ I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' V/ Y8 Y6 J' _: Btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& e; C! y8 E$ J% ?
and β-human chorionic gonadotropin was less than! h+ P1 F$ l# W9 H) c
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ u7 b9 a4 L9 l! C# A/ qstimulating hormone and leuteinizing hormone$ r& e' T% [' _3 U) ?7 t y0 B/ O' ~
concentrations were less than 0.05 mIU/mL
$ h& T4 S. L" P0 {2 W(prepubertal).5 X8 ]4 }6 ?) K& x6 Z: w5 A1 R
The parents were notified about the laboratory/ Q7 g# `' u. K' {
results and were informed that all of the tests were
5 N& s; R$ }4 Znormal except the testosterone level was high. The
3 M: e8 ?7 a# b0 `follow-up visit was arranged within a few weeks to6 u+ G* Z2 _& |6 C V0 ?! h1 ~" {, I
obtain testicular and abdominal sonograms; how-+ f6 V- X' _1 m
ever, the family did not return for 4 months.
6 e' c6 p$ |+ b$ ^( A, i+ TPhysical examination at this time revealed that the
; u" h* M/ J7 echild had grown 2.5 cm in 4 months and had gained
! u4 d; r+ F) @2 ~' I2 U% M0 X {2 kg of weight. Physical examination remained) n& o5 |# ]0 U& A! ]6 a2 _
unchanged. Surprisingly, the pubic hair almost com-) n1 d4 o4 N3 `# `' h
pletely disappeared except for a few vellous hairs at
6 F/ @ R. Z' V3 d( Ythe base of the phallus. Testicular volume was still 2
- a2 x( j4 Q, m. Z; @mL, and the size of the penis remained unchanged., s3 ^0 r' z7 h2 J; F2 Y
The mother also said that the boy was no longer hav-1 y. l* D8 a6 u, U2 y2 k) e
ing frequent erections.
1 ]* y; `$ D+ W% g6 tBoth parents were again questioned about use of5 a* e, m. P" `, m; \ t
any ointment/creams that they may have applied to
1 k% Z- o) n/ M2 Z" j% Zthe child’s skin. This time the father admitted the
L) i4 \* t+ i4 K9 v' @6 S& ^& E5 CTopical Testosterone Exposure / Bhowmick et al 541
1 n+ ]) z$ `# _$ O5 `$ @& Muse of testosterone gel twice daily that he was apply-: r5 X: a* k9 T7 a+ z) f
ing over his own shoulders, chest, and back area for* g4 n) q! Z" @. g" n% i
a year. The father also revealed he was embarrassed
" X( ]& a ^: Z) ~& `- U+ Yto disclose that he was using a testosterone gel pre-
0 f; F( V8 g/ v+ u6 O: @8 P+ @2 `scribed by his family physician for decreased libido
! I$ l9 _8 T" _/ H3 Vsecondary to depression.: S, Z5 T, [# A: v: r1 `$ l7 Q8 L
The child slept in the same bed with parents.
# R8 B4 q* v E8 d& tThe father would hug the baby and hold him on his1 Z0 L. c5 ]8 k" L4 {
chest for a considerable period of time, causing sig-
* @; E; L8 X' o8 X B4 lnificant bare skin contact between baby and father.
3 e& m) v" E$ s0 g b4 }" V) {The father also admitted that after the phone call,8 V5 F4 w% Q& H
when he learned the testosterone level in the baby C+ u0 y1 K/ d9 I# t
was high, he then read the product information( o* m% D/ f- _3 `; J) h5 h9 G1 j
packet and concluded that it was most likely the rea-1 ~) v" }* u- p3 E t S* \
son for the child’s virilization. At that time, they. p5 H0 B& y- | i
decided to put the baby in a separate bed, and the7 L6 e; S! r# {
father was not hugging him with bare skin and had
4 |# ~" w0 g$ J5 v5 Q( ^been using protective clothing. A repeat testosterone/ U- G& c3 h, M% ]7 }+ f6 j
test was ordered, but the family did not go to the
" i2 ?' o# O% t" {' ^3 @+ s9 x+ Ylaboratory to obtain the test.) Z8 C# |: j' ?6 L* h% g+ Y
Discussion
) }- h; x% z# B7 Q" zPrecocious puberty in boys is defined as secondary
5 @- ~5 C7 W' z7 Hsexual development before 9 years of age.1,41 u: y' P& Q/ {8 _0 s6 @
Precocious puberty is termed as central (true) when
2 A6 d: J% X! q yit is caused by the premature activation of hypo-
6 H3 y- c Y" F' R* Dthalamic pituitary gonadal axis. CPP is more com-
7 N- l. t; l8 w. Y6 Smon in girls than in boys.1,3 Most boys with CPP! L# X' x/ M. K; @ R& Z9 K/ U" t& o
may have a central nervous system lesion that is
4 e. ^ J) O) t8 B: e& Bresponsible for the early activation of the hypothal-
) u# v9 U# p M! P2 ]! Lamic pituitary gonadal axis.1-3 Thus, greater empha-% q4 a; d" L# t/ H5 _! b! C
sis has been given to neuroradiologic imaging in
0 K A' V# a7 {& ^$ y5 k# oboys with precocious puberty. In addition to viril-
3 }% }' t5 x4 Pization, the clinical hallmark of CPP is the symmet-! E- {1 P- z" s4 U
rical testicular growth secondary to stimulation by6 u* I1 A% X$ r: ` n
gonadotropins.1,3
h: [$ Y1 G0 K6 F- V& N6 `: dGonadotropin-independent peripheral preco-9 r7 K7 O* w/ j! W: H
cious puberty in boys also results from inappropriate
- |7 q0 z& U) F5 t+ randrogenic stimulation from either endogenous or T; \# y" y6 ?# [
exogenous sources, nonpituitary gonadotropin stim-) Y2 M7 a b1 I8 u( k7 n
ulation, and rare activating mutations.3 Virilizing1 }1 L( Q) ~8 g* ~! p
congenital adrenal hyperplasia producing excessive
8 M1 Y/ O2 [( F$ Q4 Z5 `' t" Q, dadrenal androgens is a common cause of precocious9 @0 H: B$ \7 q0 v6 l+ q4 L
puberty in boys.3,4
* G J% Q% F: ]* I0 `The most common form of congenital adrenal- |+ E" j% p( q. @! g4 s
hyperplasia is the 21-hydroxylase enzyme deficiency.) e( c9 N5 T* e1 U* v8 o5 |' C
The 11-β hydroxylase deficiency may also result in
" H; |( Q9 u7 w7 b9 {; h1 Mexcessive adrenal androgen production, and rarely,
, j/ A% B }& N( j2 ]) G( Ban adrenal tumor may also cause adrenal androgen
- v4 C t, X$ h6 Iexcess.1,3
G7 O+ m8 J5 q- {7 E. Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" `8 { J& K2 G7 G4 m1 V, |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 D/ s% p$ N/ ]3 r5 b+ L) H% WA unique entity of male-limited gonadotropin-
6 T) s6 F; v9 L1 e3 C8 b2 Mindependent precocious puberty, which is also known
7 Z3 _' A+ Y2 }; \, T3 X. E$ [/ jas testotoxicosis, may cause precocious puberty at a
' O, H; r( R% J0 zvery young age. The physical findings in these boys3 A# s5 F( n3 K5 y3 T2 i, y
with this disorder are full pubertal development,
1 q$ e2 }. e. L' I- L! ?: dincluding bilateral testicular growth, similar to boys
3 r0 t/ Q- t& J; f/ O" j- Bwith CPP. The gonadotropin levels in this disorder
& v( ?% ~! b+ W3 d& V/ Kare suppressed to prepubertal levels and do not show* b5 _/ `0 j1 m# E- u
pubertal response of gonadotropin after gonadotropin-; a: @- R0 h" Y; o' U3 Q { B
releasing hormone stimulation. This is a sex-linked, O) W& r$ y* i; t
autosomal dominant disorder that affects only: q+ u" c5 h6 n8 d
males; therefore, other male members of the family
0 D% n( @$ b+ Y! O+ O/ Y4 @4 Amay have similar precocious puberty.3
7 ~) F, f0 h! _' |2 hIn our patient, physical examination was incon-
$ h3 C* G$ d7 b0 H5 `7 @! U. H) |4 s& osistent with true precocious puberty since his testi-
1 v& n3 ?6 ~0 m3 m* Y' lcles were prepubertal in size. However, testotoxicosis
# K0 u3 A( J5 k4 n" ?was in the differential diagnosis because his father9 O* L8 ?* R k! |
started puberty somewhat early, and occasionally," g8 m; q( F% E1 d6 L( G6 a
testicular enlargement is not that evident in the4 w7 S/ }: w+ C5 \
beginning of this process.1 In the absence of a neg-/ {5 y" `$ u( e5 M x4 |
ative initial history of androgen exposure, our3 d" d, r9 b0 u. T' q: |
biggest concern was virilizing adrenal hyperplasia,
. \( Z+ U( f7 r4 {0 l2 \either 21-hydroxylase deficiency or 11-β hydroxylase
6 z" S" g; a% u& \0 J! Vdeficiency. Those diagnoses were excluded by find-
; Z: `+ B* M6 \ing the normal level of adrenal steroids.
8 E. Q& m4 f9 D% M& `9 g" d) YThe diagnosis of exogenous androgens was strongly
/ c/ r H% o1 Y5 Tsuspected in a follow-up visit after 4 months because
i' _& x* U0 y' Z7 l2 nthe physical examination revealed the complete disap-2 @1 A8 K9 t o' B' w/ h9 S. o
pearance of pubic hair, normal growth velocity, and+ M# c2 }6 y4 t# h |9 `
decreased erections. The father admitted using a testos-8 b1 H0 z- L* f+ f& R! U$ I
terone gel, which he concealed at first visit. He was
- Q& K, l1 p9 a* iusing it rather frequently, twice a day. The Physicians’
' M, y# r, x% x( M- X" R& {% ~Desk Reference, or package insert of this product, gel or
0 x* A: Z$ R2 z# I3 x$ Y6 R* n6 j( gcream, cautions about dermal testosterone transfer to0 t* X1 c) w W1 K t
unprotected females through direct skin exposure.
3 v& S" g/ p# ]( H6 B8 ~' e, tSerum testosterone level was found to be 2 times the; b, `2 |1 S* `
baseline value in those females who were exposed to( [. R1 Q; S5 \/ Y& q
even 15 minutes of direct skin contact with their male
& j1 e+ r! X- q4 I% t$ R9 Lpartners.6 However, when a shirt covered the applica-
; U9 O4 U1 L! M' Ition site, this testosterone transfer was prevented.
; g3 V6 [/ F( Q+ @Our patient’s testosterone level was 60 ng/mL,
3 u$ Q# D2 O5 V! k8 c- c, iwhich was clearly high. Some studies suggest that
* h6 } s, J! P0 T4 F: A1 E+ c L/ {' cdermal conversion of testosterone to dihydrotestos-
5 z' ?2 ~, K3 Yterone, which is a more potent metabolite, is more% t0 J2 u5 ~- L( L
active in young children exposed to testosterone
! h- `" f" I' O, D( Y+ |exogenously7; however, we did not measure a dihy-
" K7 B4 o T0 n$ o; |6 h! Hdrotestosterone level in our patient. In addition to
@! U0 H: X3 x3 a* w: n. r2 B1 fvirilization, exposure to exogenous testosterone in4 h; b" O7 Q: |( H
children results in an increase in growth velocity and$ s( S6 i( u3 I6 F3 z. Y' H
advanced bone age, as seen in our patient.& I9 ]9 C$ R6 F; B5 M4 f8 S
The long-term effect of androgen exposure during6 a& j# `2 D! O0 b6 \
early childhood on pubertal development and final- i5 Q' }' |$ z( S7 {: [& b! f
adult height are not fully known and always remain5 f6 T6 d7 Q: k! Y, f0 w
a concern. Children treated with short-term testos-$ h) h3 e2 M; ~ M6 Y: h: _' a
terone injection or topical androgen may exhibit some! R. I2 P# ^7 P; g( Q, f- q$ \$ u" p
acceleration of the skeletal maturation; however, after2 {) e$ F. M- b% x4 O# C1 K$ k# g: j, L
cessation of treatment, the rate of bone maturation- F. B2 ^5 P c2 Z: @* }
decelerates and gradually returns to normal.8,9! |, B$ ]- Z; t9 l" S$ |
There are conflicting reports and controversy) Y9 k1 j+ z; I! l
over the effect of early androgen exposure on adult
, j+ R. w% x/ X# R* fpenile length.10,11 Some reports suggest subnormal8 ]" L+ X: z: c* e5 H9 C! h5 q6 t
adult penile length, apparently because of downreg-7 i& p. r: ]' a5 ~
ulation of androgen receptor number.10,12 However,. }$ w$ `. D' K
Sutherland et al13 did not find a correlation between
5 {: d+ ^3 f7 }2 I5 P" Z' {. Kchildhood testosterone exposure and reduced adult
" \. s5 w! `. E# ]$ f9 Q8 @penile length in clinical studies.
- h: `3 O7 p" Y" `7 u' WNonetheless, we do not believe our patient is
- j0 f) i! n7 g' ]/ \, I7 cgoing to experience any of the untoward effects from) X C& N4 L0 n1 S9 Y9 A& I3 v
testosterone exposure as mentioned earlier because8 J1 I/ z# `8 T4 W0 N0 f- {: j
the exposure was not for a prolonged period of time.
- l2 ^3 @4 L( K T0 ], a/ LAlthough the bone age was advanced at the time of
V4 a1 ]1 e" k$ R% ndiagnosis, the child had a normal growth velocity at$ |( {4 v( h% n4 j3 L" U1 U
the follow-up visit. It is hoped that his final adult
1 q3 s! y5 f' i ~; o9 d( m" Aheight will not be affected.
/ K9 I- D, n0 Q9 fAlthough rarely reported, the widespread avail-
" Q3 W) K& L& }! aability of androgen products in our society may: ^' f4 e3 z- F7 B' K+ E& P/ V! `
indeed cause more virilization in male or female
& `4 k* @ r/ l2 C' [9 wchildren than one would realize. Exposure to andro-
( Q# @4 C5 B: R$ ?0 M0 ^gen products must be considered and specific ques-3 V5 P2 T0 u- P+ e7 U0 a
tioning about the use of a testosterone product or1 N5 z4 }3 `/ _- e: s
gel should be asked of the family members during5 K( {) M# R, V- z' g! |0 R" P
the evaluation of any children who present with vir-
% `0 ~( A1 W( }; l5 v7 _# [ilization or peripheral precocious puberty. The diag-
% b6 h0 @7 E' h' nnosis can be established by just a few tests and by6 e8 y+ l. a3 m4 A) K( t
appropriate history. The inability to obtain such a
; |: s) s" `0 N# } z( @, d3 T8 ghistory, or failure to ask the specific questions, may
) T; H$ H( o. S& u, _result in extensive, unnecessary, and expensive
) d$ e( C" F4 C$ {2 Qinvestigation. The primary care physician should be
6 ^ c: p: q& L: L& @4 `9 I. \4 ]" vaware of this fact, because most of these children
; y& H2 P) y9 V) X- g5 Lmay initially present in their practice. The Physicians’
6 x7 w" s7 E& J6 f! p- ?* T1 MDesk Reference and package insert should also put a. W$ l2 _) `3 D
warning about the virilizing effect on a male or
$ W. F' f* ~% f* f5 j- Nfemale child who might come in contact with some-1 ~% Y4 j A& A5 R/ M8 V. F. i9 [4 J% h
one using any of these products. Z: |# z" L& @% c9 z" @1 x
References. z$ N" V$ J- m; c
1. Styne DM. The testes: disorder of sexual differentiation( Y1 S' t+ u( r3 [" `7 G
and puberty in the male. In: Sperling MA, ed. Pediatric# u. a- U% v+ }) P$ i9 w8 {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 [: m+ `; C0 ^! e0 _: O9 T0 ]2002: 565-628.
( S" T* y) E3 n) A% V: U) @2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) H/ m5 r! r( L+ g! _' @" E
puberty in children with tumours of the suprasellar pineal |
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