- 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
/ i7 T& n" H3 V$ o7 f# T/ u! W3 vBoy Induced by Indirect Topical
6 g5 m5 i- t; K# ZExposure to Testosterone
! M, `: g/ N9 G' i2 Y& b- q+ YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* x8 z: b4 J0 u, k" @/ land Kenneth R. Rettig, MD16 W( {1 [- U# o1 ^! T
Clinical Pediatrics
! s( X/ q6 x pVolume 46 Number 6
2 H6 g. ?( \! E7 F: n! |July 2007 540-543
; k2 y j4 J4 i& e# s© 2007 Sage Publications
5 J U/ a! \* X7 _$ V10.1177/0009922806296651
3 O# b. O. s. F2 Q' lhttp://clp.sagepub.com
/ B; ~1 a$ T# T6 U/ O! L2 v5 yhosted at
7 z. I' D3 N: }, b5 n$ b5 M' Shttp://online.sagepub.com
. A A2 e/ d1 N# wPrecocious puberty in boys, central or peripheral,7 p/ w, N- g8 W' q( d
is a significant concern for physicians. Central1 E) @0 E1 [) q
precocious puberty (CPP), which is mediated
. A! @: m$ ]1 rthrough the hypothalamic pituitary gonadal axis, has
8 w3 B* v( x; q/ o. f6 G2 U# ?a higher incidence of organic central nervous system: u, O- T2 C: s& ]$ r: M
lesions in boys.1,2 Virilization in boys, as manifested
# f: s- T! ]2 V9 F+ ~by enlargement of the penis, development of pubic# X( N( O, E- P8 x
hair, and facial acne without enlargement of testi-: N0 R8 h$ K, R" a4 I
cles, suggests peripheral or pseudopuberty.1-3 We7 y! i& R8 a4 M' k
report a 16-month-old boy who presented with the
! d1 `( b+ n( M& `. B# senlargement of the phallus and pubic hair develop-
9 ~: B- s. n; ^ment without testicular enlargement, which was due
1 L( y0 ]' r) {- }9 H8 Kto the unintentional exposure to androgen gel used by
3 s2 H4 ?. k4 \( x. I7 P ], Kthe father. The family initially concealed this infor-( I( j# ]. w4 Y. C( Q( p
mation, resulting in an extensive work-up for this
$ [, x- B- ~9 X8 M/ V% kchild. Given the widespread and easy availability of
; r* h9 I4 i5 q, ~- _4 Wtestosterone gel and cream, we believe this is proba-% ~4 a, L/ X" j2 u
bly more common than the rare case report in the6 w$ H7 J" C2 s- g/ ~, B) G V8 R
literature.47 Y) t2 s7 f0 I _; V8 ]# g
Patient Report8 e7 ]0 n' I7 G
A 16-month-old white child was referred to the
. L( N# d- A0 w, hendocrine clinic by his pediatrician with the concern
3 u8 R6 M" R0 @$ Z0 {of early sexual development. His mother noticed% m0 D8 X M6 x
light colored pubic hair development when he was
0 c- N* o3 k0 x$ c: f1 s6 X" sFrom the 1Division of Pediatric Endocrinology, 2University of4 G" ?( }" s7 |- ~3 a: A; R% q
South Alabama Medical Center, Mobile, Alabama.
- p9 @8 Y% U0 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 M) I/ h- G( G1 d0 ]4 ]3 P8 OProfessor of Pediatrics, University of South Alabama, College of4 _( G1 K8 J' u# U# k# n* u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 ]2 {2 L I8 c Fe-mail: [email protected].( {9 z N) x/ @, C* U+ w
about 6 to 7 months old, which progressively became
2 {: M9 H: U- W4 edarker. She was also concerned about the enlarge-1 x% ]# W5 \. {; f: A- N; b
ment of his penis and frequent erections. The child
9 z% O X% `0 J5 d6 bwas the product of a full-term normal delivery, with
9 I9 D% {& F; Ya birth weight of 7 lb 14 oz, and birth length of, [: _2 A. _( H1 R# T, u4 A
20 inches. He was breast-fed throughout the first year: Y: P2 ^/ M) u9 V, i
of life and was still receiving breast milk along with7 U4 L- o7 Q# T' {5 o7 c
solid food. He had no hospitalizations or surgery,
! R: t# s( F8 S. Gand his psychosocial and psychomotor development
2 d3 Q& j0 O2 {8 m) I9 F# twas age appropriate.
7 n, B& Y! }, b7 H; @The family history was remarkable for the father,
& [8 Z: l5 v0 k& u8 rwho was diagnosed with hypothyroidism at age 16,
3 c1 k4 ^: r0 ^4 x iwhich was treated with thyroxine. The father’s& V& f Q: n$ [
height was 6 feet, and he went through a somewhat
- t0 }+ P( t- c1 _% [- r# eearly puberty and had stopped growing by age 14.
1 R( M- i9 W$ R2 yThe father denied taking any other medication. The
+ f: ]: W# F: z# L: ?child’s mother was in good health. Her menarche3 D7 U3 {2 ?. V
was at 11 years of age, and her height was at 5 feet
, N1 ?& }4 o& S+ k/ ]/ O, k5 inches. There was no other family history of pre-
( R/ d6 P) W$ {/ k# m( L. _. Wcocious sexual development in the first-degree rela-
# {+ Q7 Y! i, C( k5 m/ Ktives. There were no siblings.6 p/ E: h! l* H& P' }0 @0 s8 J
Physical Examination! P# @0 Y5 Q! d9 K
The physical examination revealed a very active,
' M1 k( M3 {% x- `playful, and healthy boy. The vital signs documented1 N+ z+ l% }) Q# C7 @# V
a blood pressure of 85/50 mm Hg, his length was
! A9 r6 T' m) a- L/ w90 cm (>97th percentile), and his weight was 14.4 kg; J/ `! v9 F M/ w# O! |, x: q) y
(also >97th percentile). The observed yearly growth
! @0 z: ~0 o7 ~" ` { uvelocity was 30 cm (12 inches). The examination of6 O5 Z- U& l8 W4 ~& C B
the neck revealed no thyroid enlargement.
+ e; P" q. w) Z: B" v8 RThe genitourinary examination was remarkable for1 H* a. @4 R8 H f: S2 q0 ]
enlargement of the penis, with a stretched length of7 A# c# z4 Y- G2 R
8 cm and a width of 2 cm. The glans penis was very well
. H7 u8 @/ ~* ~developed. The pubic hair was Tanner II, mostly around3 Z9 c( U8 i2 l* J1 ^
5409 {3 M- U9 S: \* P) K8 w& b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# J, K$ ]" W* ~8 Fthe base of the phallus and was dark and curled. The
6 O3 J* z% k* E- a5 Z9 t# B Etesticular volume was prepubertal at 2 mL each.
) d0 F3 R- w5 B+ AThe skin was moist and smooth and somewhat
2 n o; d0 ^% g+ S7 O7 Xoily. No axillary hair was noted. There were no# T5 `! b' H! C
abnormal skin pigmentations or café-au-lait spots.
7 E% L7 g6 W9 \4 E- A- B- F2 X7 VNeurologic evaluation showed deep tendon reflex 2+2 J: S: _% z l0 I( e# _0 c6 e0 S
bilateral and symmetrical. There was no suggestion
* {& I% c1 Z- ?8 R6 ^3 h7 c! q& k' O$ Vof papilledema.% I9 @; Z% z! v0 a; B- X1 C3 [9 u
Laboratory Evaluation; [7 j$ R# [9 S6 M! j
The bone age was consistent with 28 months by
* I" {5 c7 _0 ?/ w) c# }using the standard of Greulich and Pyle at a chrono-
6 q& Y( J0 E0 w }/ G( Q, X( r7 `logic age of 16 months (advanced).5 Chromosomal
s3 W2 K! N J$ m2 U( o) ikaryotype was 46XY. The thyroid function test7 z* l, l; f+ K* D& U0 F$ L& F3 z1 `: [ D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ D0 r4 C- Z4 R2 f1 R
lating hormone level was 1.3 µIU/mL (both normal).1 W+ g/ E* |0 T3 M( T! `1 T
The concentrations of serum electrolytes, blood
; b1 Z# W0 [3 D3 P Q5 S: A6 H' murea nitrogen, creatinine, and calcium all were
! s* b2 w, ~, V7 ^, U- M$ owithin normal range for his age. The concentration7 M4 K1 ~: D& ^7 n- t! A
of serum 17-hydroxyprogesterone was 16 ng/dL
/ }; l& u( ^% |$ c" F/ W(normal, 3 to 90 ng/dL), androstenedione was 20# H9 F- u% F7 x# U. t- v/ x$ x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- K1 H; E1 ?2 D4 Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! M6 d+ J& N, S: M, adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( z( V8 Q$ E6 l% q4 p8 f49ng/dL), 11-desoxycortisol (specific compound S)
& S# p" e: j' X2 B" t* k0 j q4 vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. D( F2 t1 F S( v9 @) y0 ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( Z* y% c# C! g2 I* ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! i/ f I/ U1 p/ Sand β-human chorionic gonadotropin was less than
% ` d! A. ?8 ~$ i. W: h5 mIU/mL (normal <5 mIU/mL). Serum follicular+ U* f+ l( H, [* l+ a) o
stimulating hormone and leuteinizing hormone( I$ y7 j: f* e6 N) Z% O& I
concentrations were less than 0.05 mIU/mL2 {) ]6 d2 S C) |* E' |3 L5 E
(prepubertal).
9 H+ i9 |7 W3 s: `& uThe parents were notified about the laboratory
0 N( ~) D- o, q+ p, h( k2 bresults and were informed that all of the tests were
! U3 Z, F X! b4 P' g% anormal except the testosterone level was high. The
) b; W3 m, a$ z# v8 ~follow-up visit was arranged within a few weeks to
, O) R3 h# `3 Y- W0 ?obtain testicular and abdominal sonograms; how-
Z* N _3 F/ H+ e$ aever, the family did not return for 4 months.
6 Q1 k1 N u8 O9 o gPhysical examination at this time revealed that the* @( k! t; }4 H# m9 ^7 ^) o
child had grown 2.5 cm in 4 months and had gained
4 j' _# h- U5 R* D9 D4 X2 kg of weight. Physical examination remained6 F$ H3 z6 k j2 O) S% T1 p
unchanged. Surprisingly, the pubic hair almost com-: u+ I5 f* ~! {+ _
pletely disappeared except for a few vellous hairs at
% w# V: V9 A" Jthe base of the phallus. Testicular volume was still 26 P- \5 `) w+ a, t0 n. b- I
mL, and the size of the penis remained unchanged.
/ o* ]5 c, I# n& n4 mThe mother also said that the boy was no longer hav-
p% U3 |! |# k7 b7 ving frequent erections.
0 }* b( G9 d0 W, d6 U4 z0 M4 Z# ], RBoth parents were again questioned about use of" o, z3 g2 Y8 l$ i7 t
any ointment/creams that they may have applied to% z" b4 n1 x- D
the child’s skin. This time the father admitted the7 x$ k& w" F* g- ?6 C$ b9 d( T
Topical Testosterone Exposure / Bhowmick et al 541
$ ?$ e0 A# _) F3 S$ a" O4 d, }use of testosterone gel twice daily that he was apply-! y L. V( M# _3 O' T! I f$ [
ing over his own shoulders, chest, and back area for
4 E; d4 F) d, ?7 `0 `1 @a year. The father also revealed he was embarrassed) J0 l# a4 X* N+ J* ?
to disclose that he was using a testosterone gel pre-
9 t$ g3 |' _( O" G% yscribed by his family physician for decreased libido2 S% `0 c6 t) R/ p/ D" @* }
secondary to depression.
3 |8 m' ~4 |0 j3 ^0 c* u3 g+ uThe child slept in the same bed with parents.
5 g5 Z: F0 i Z9 \8 \- I0 vThe father would hug the baby and hold him on his/ R! s/ ~4 [# i6 n' \& V; Q, h
chest for a considerable period of time, causing sig-
. \* ]: X$ q0 W7 G# ^# @nificant bare skin contact between baby and father.
0 Z8 S8 m- O1 s' wThe father also admitted that after the phone call,
0 |" w8 C, a9 z3 V* m3 Lwhen he learned the testosterone level in the baby
7 L! k; L1 x& b# o. I1 awas high, he then read the product information1 a- V; n8 q" m
packet and concluded that it was most likely the rea-; o" b2 x2 y6 s: i, y8 t }
son for the child’s virilization. At that time, they
* r3 h+ v# v; x! z. s2 ^- _+ i' a. tdecided to put the baby in a separate bed, and the
/ L, m% P2 Y& M, u- z& m% I5 Xfather was not hugging him with bare skin and had
2 S+ j" k) t; ]6 y E6 o# s Obeen using protective clothing. A repeat testosterone4 i4 i0 W# m% _4 q. Q& r
test was ordered, but the family did not go to the" O) }1 |5 i3 |) I t
laboratory to obtain the test.
# t. J0 ?3 R8 c) T9 MDiscussion
) \* L4 _' Q7 t3 t& h. T6 CPrecocious puberty in boys is defined as secondary
5 t7 O q: D D: F6 }sexual development before 9 years of age.1,4
. }, a( b, ^$ ~; P/ JPrecocious puberty is termed as central (true) when! L5 k; C, H& y3 D
it is caused by the premature activation of hypo-) X6 V; f4 ~9 f8 `5 } H+ v
thalamic pituitary gonadal axis. CPP is more com-
- j! ^, C3 ~! ~4 ~, Mmon in girls than in boys.1,3 Most boys with CPP
5 \4 K6 R; s* ^4 fmay have a central nervous system lesion that is
4 h+ p3 h) l; Gresponsible for the early activation of the hypothal-/ |4 D' Y( u# @; t
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 R9 f7 `. @" r' N8 n) [' qsis has been given to neuroradiologic imaging in" ~$ y* w; M0 n) o+ e
boys with precocious puberty. In addition to viril-
o3 M7 Y5 H% |# E u1 Aization, the clinical hallmark of CPP is the symmet-
+ y0 f3 q& o; R! s& i/ a& c- Srical testicular growth secondary to stimulation by
4 f1 ]9 F J7 bgonadotropins.1,3! } w6 u. _* b. x" D
Gonadotropin-independent peripheral preco-$ V0 W: z4 e1 Z9 z3 F" Y
cious puberty in boys also results from inappropriate
5 A1 o# T$ R/ F* N0 R7 [# zandrogenic stimulation from either endogenous or( R# ?( I) s8 h
exogenous sources, nonpituitary gonadotropin stim-
5 f4 [. P3 ]8 Culation, and rare activating mutations.3 Virilizing; w O/ Q7 r r# e8 k
congenital adrenal hyperplasia producing excessive
6 I2 Y) }, k/ I& d/ oadrenal androgens is a common cause of precocious
9 @0 b. ~2 ^# wpuberty in boys.3,4
0 N- U9 K& }0 x2 X. `+ eThe most common form of congenital adrenal: {' l5 w1 }- X! b0 X) A4 f
hyperplasia is the 21-hydroxylase enzyme deficiency.: k6 E' I1 b! C7 S7 @/ |
The 11-β hydroxylase deficiency may also result in
+ Z2 r* E/ t. B2 ^5 B/ e( mexcessive adrenal androgen production, and rarely,/ o# P: @* m! e
an adrenal tumor may also cause adrenal androgen% m: _- p; @5 Z
excess.1,3- e- L( q+ ?" H$ J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 b0 t5 D/ `. R; x! i9 H$ x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ ?% `! } W& Z7 H
A unique entity of male-limited gonadotropin-: N* y* ~3 l) `' v2 n b
independent precocious puberty, which is also known6 ~+ O9 o$ Y! i* y
as testotoxicosis, may cause precocious puberty at a
1 s! Q$ K5 d. {( a$ l* ~; Pvery young age. The physical findings in these boys
, x8 c) c. K- F0 Hwith this disorder are full pubertal development,
1 m( U' A5 z6 k+ }" Zincluding bilateral testicular growth, similar to boys
) C! M9 a% R% c3 B% U! R- i$ Pwith CPP. The gonadotropin levels in this disorder2 G8 W* n9 R+ X- M
are suppressed to prepubertal levels and do not show
% C6 @* z- A: O3 X6 F- zpubertal response of gonadotropin after gonadotropin-
. j1 b* `" j) S2 w8 ^/ Q! C& qreleasing hormone stimulation. This is a sex-linked
* q& d; T, y' I0 m3 o- m) U9 tautosomal dominant disorder that affects only7 j& }* r* S3 e/ `- [. F3 D
males; therefore, other male members of the family5 J- T( f$ U" |' U% {/ v6 o* _# J
may have similar precocious puberty.3
% t( \- N3 b( J3 E6 f5 X: YIn our patient, physical examination was incon-
6 O' O! ]( ^, s3 @, zsistent with true precocious puberty since his testi-
Y) k8 N5 x- z# Ucles were prepubertal in size. However, testotoxicosis/ S& L/ H4 |/ c4 j8 s& w* W+ Z
was in the differential diagnosis because his father# n/ H# F- L& h4 n+ T) O
started puberty somewhat early, and occasionally,% k( l2 S7 c( ~: e
testicular enlargement is not that evident in the+ O8 d3 v/ ]- \; q( T* D
beginning of this process.1 In the absence of a neg-* S! _4 l4 C; Y1 t5 ?/ Y
ative initial history of androgen exposure, our* k3 J8 {8 |. o
biggest concern was virilizing adrenal hyperplasia,
, d* F- m5 F2 U0 s7 I$ |either 21-hydroxylase deficiency or 11-β hydroxylase
5 _ y( @1 X+ C8 J9 z6 F' Udeficiency. Those diagnoses were excluded by find-$ Y/ x& C4 u$ }
ing the normal level of adrenal steroids. F3 Y# P8 c+ z+ e7 `+ @; }
The diagnosis of exogenous androgens was strongly1 w6 }! _( W6 N
suspected in a follow-up visit after 4 months because
% f" H- u' r2 v( P6 E- ?the physical examination revealed the complete disap-
) d! [( H, v I" B) o+ jpearance of pubic hair, normal growth velocity, and
- w" Z' K8 F% ]0 B/ P# N1 x! [) jdecreased erections. The father admitted using a testos-
% w r1 S' l# W) W1 \% oterone gel, which he concealed at first visit. He was4 t4 \. o; O( V
using it rather frequently, twice a day. The Physicians’
) N2 n) K' e6 E7 J' nDesk Reference, or package insert of this product, gel or
4 i; f2 p& ?% x/ a8 h" S! wcream, cautions about dermal testosterone transfer to% a/ c) Y# b" C! k6 {$ z
unprotected females through direct skin exposure.7 T5 s s/ P4 U
Serum testosterone level was found to be 2 times the t. Y* a. q% n. B- @
baseline value in those females who were exposed to; s- U5 j; P1 Q; D: `
even 15 minutes of direct skin contact with their male8 d) m( \. i7 W6 n' ^7 G, ~
partners.6 However, when a shirt covered the applica-
: a! l9 w* A* ^7 s8 D, ^+ Mtion site, this testosterone transfer was prevented.3 p- t9 {0 y9 H0 X2 l* w5 ]# `/ Q2 \
Our patient’s testosterone level was 60 ng/mL,
t7 ^" W$ }8 L6 y' Hwhich was clearly high. Some studies suggest that4 N- t6 O- G; h$ }: G; m
dermal conversion of testosterone to dihydrotestos-: S: |9 c \& S7 t/ U7 v
terone, which is a more potent metabolite, is more0 u; c; K9 O( F8 i
active in young children exposed to testosterone/ \8 q: B& V! q _
exogenously7; however, we did not measure a dihy-
8 X% o: E. W: G6 `, e) [9 sdrotestosterone level in our patient. In addition to; O/ |+ x$ [" V6 E5 p
virilization, exposure to exogenous testosterone in `9 p/ r0 ~% c0 r0 y% T Z
children results in an increase in growth velocity and# `4 h0 j9 k; X+ H$ L
advanced bone age, as seen in our patient.! C' l5 L p& }! {
The long-term effect of androgen exposure during
* |0 x q) s( I4 h9 Z! m% a$ zearly childhood on pubertal development and final9 f3 Z. b' ?' A( p7 [1 l S) X, Z
adult height are not fully known and always remain
5 p, @$ O4 }! o7 A$ ]$ A* W& Ka concern. Children treated with short-term testos-
; `' F G4 c6 h) j T3 B2 e+ E! `terone injection or topical androgen may exhibit some
- G" _: e6 _- H7 \4 g. G6 Aacceleration of the skeletal maturation; however, after
, t* [3 @6 z' i& T( d; Bcessation of treatment, the rate of bone maturation
: q9 b& |, ]) o4 w8 Ddecelerates and gradually returns to normal.8,9! U/ j8 g/ [0 i) c
There are conflicting reports and controversy/ q x( V \2 Y# e
over the effect of early androgen exposure on adult
5 V0 ] G2 v# ^penile length.10,11 Some reports suggest subnormal
5 E9 }# y, W& e1 v5 @" Xadult penile length, apparently because of downreg-
" q3 m. y5 o7 a" ]8 C( Y! _; @ulation of androgen receptor number.10,12 However,! \9 i7 E" z$ }$ Y) s
Sutherland et al13 did not find a correlation between! U8 _, U# \6 Z+ R8 ~8 G, B
childhood testosterone exposure and reduced adult; y* a9 @4 `5 G1 j) Q) A, Z
penile length in clinical studies.- }/ o) ]& r8 \0 |, O6 x
Nonetheless, we do not believe our patient is
+ I3 G' h. @1 a6 s& L0 c0 {going to experience any of the untoward effects from% ]- Z# C* _; }3 h3 F2 H7 I+ s
testosterone exposure as mentioned earlier because4 J$ x, c% x7 R; s
the exposure was not for a prolonged period of time." t+ t' l$ _3 G* A
Although the bone age was advanced at the time of9 G- F# }; V5 J% u
diagnosis, the child had a normal growth velocity at" ?# u( _ [: n0 v
the follow-up visit. It is hoped that his final adult( Q3 A: ~' c- y; P4 S
height will not be affected.
" e# t; B, o6 D; _5 O( n( EAlthough rarely reported, the widespread avail-
) I. `# A! T `( x0 @, h9 m. G! ^ability of androgen products in our society may; R) n% x( N# X9 a1 e
indeed cause more virilization in male or female `' U3 E8 P/ O% W9 d& ~8 b+ c! [
children than one would realize. Exposure to andro-
/ ]% w% ^: l, X& o) Ogen products must be considered and specific ques-. w9 \$ K G# q( ~) b7 W
tioning about the use of a testosterone product or
8 K1 X8 M( F, |' O. zgel should be asked of the family members during' B* p7 j# Q, K
the evaluation of any children who present with vir-" n) w8 ]& r W) d5 S9 }" W
ilization or peripheral precocious puberty. The diag-
+ W* P! f! j) q; k$ e3 J3 Fnosis can be established by just a few tests and by& o( `, s' i: m* `
appropriate history. The inability to obtain such a1 J5 `2 D7 n) X
history, or failure to ask the specific questions, may
! u' O8 `! H9 h N! r8 |0 Tresult in extensive, unnecessary, and expensive7 f2 J# A# c) u! g( q% R# n# j
investigation. The primary care physician should be
- k$ J4 @" \ X, vaware of this fact, because most of these children
% H: I2 \; l/ f' C2 j0 ^5 kmay initially present in their practice. The Physicians’ u5 E8 a* b0 f3 ^1 s9 M
Desk Reference and package insert should also put a$ Q" o" U& K$ C7 I3 _" Y- e9 h
warning about the virilizing effect on a male or
* u! O1 H0 N- W. d# }female child who might come in contact with some-
1 {. P. G0 i0 f; A6 gone using any of these products.& S, m- s8 U$ Z" G; f) o/ @
References
: z" Y1 R2 M* L) n9 |3 C0 i1. Styne DM. The testes: disorder of sexual differentiation
4 |& M* O8 z0 G6 ~ t/ Q+ m- [0 s" p, |and puberty in the male. In: Sperling MA, ed. Pediatric
- c: F, V" [% L9 D& A$ HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
I( C5 f G- B: R/ O" Q2002: 565-628.3 u; `% d& O/ j5 q) W, H6 n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 `0 h# w, U! v: n0 N Ipuberty in children with tumours of the suprasellar pineal |
|