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Sexual Precocity in a 16-Month-Old+ `; I5 x0 h8 n1 }0 \
Boy Induced by Indirect Topical
8 K# s7 z& z1 g3 N# k: RExposure to Testosterone
- Q7 R5 d: Y2 W1 E$ R4 BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 u* n: P1 M" I5 S5 \and Kenneth R. Rettig, MD11 `1 a/ ^ N3 B" e" u
Clinical Pediatrics& h7 Z4 o7 E$ W: U: [; _' V
Volume 46 Number 6
: F! i) c* m0 oJuly 2007 540-543% m7 O4 ?4 j" k6 z2 h
© 2007 Sage Publications: p% B2 C2 d" X+ J
10.1177/00099228062966510 @* `" m% [+ q) R8 V
http://clp.sagepub.com
$ f7 q3 l) @! Whosted at
( K( F/ @# x0 d3 m! F% Nhttp://online.sagepub.com$ Z: A& _0 S$ |3 h+ A6 T
Precocious puberty in boys, central or peripheral,
/ a/ g) H; x* bis a significant concern for physicians. Central
- i0 u- B6 j- C! P" i# [$ k4 `' xprecocious puberty (CPP), which is mediated( F' F; V% r$ E7 f; @
through the hypothalamic pituitary gonadal axis, has" v# u2 f7 e% a/ {
a higher incidence of organic central nervous system( l' d6 H0 v+ f
lesions in boys.1,2 Virilization in boys, as manifested
/ s2 M" @- r6 g+ \2 g# w& n8 Gby enlargement of the penis, development of pubic
a; M2 o0 l, `6 l) Fhair, and facial acne without enlargement of testi-6 @6 I( O8 y% b
cles, suggests peripheral or pseudopuberty.1-3 We
' w: z; N. J6 r4 ?( g0 [, greport a 16-month-old boy who presented with the: j: \+ Y; f/ v5 \' m
enlargement of the phallus and pubic hair develop-
& o0 o) C8 H& M' {( m6 Pment without testicular enlargement, which was due
/ Y4 J' o4 z2 N O6 r4 {9 nto the unintentional exposure to androgen gel used by: W, h! r& h7 C, {/ J q# O$ T
the father. The family initially concealed this infor-
& N" @+ L' x6 t1 f# Gmation, resulting in an extensive work-up for this7 Q; _( U1 a6 ?5 u
child. Given the widespread and easy availability of: r! L6 d" f- D/ @1 V* `( |
testosterone gel and cream, we believe this is proba-+ K) x8 a% o" r3 L* _3 t
bly more common than the rare case report in the
7 j9 L/ {' T3 ^* O1 a3 a+ @literature.4! m4 P7 z. o( k' A/ a
Patient Report! b; X! @! g5 D# u& J
A 16-month-old white child was referred to the3 E8 q' _+ Y7 }/ z: n* n. R1 k
endocrine clinic by his pediatrician with the concern5 w; O) e* @) ^0 g( A& |% \7 e
of early sexual development. His mother noticed
7 S! `8 J$ o& m* W9 J# ~& S: n/ nlight colored pubic hair development when he was
! G3 K! P3 r: G' R1 R9 nFrom the 1Division of Pediatric Endocrinology, 2University of( u; l( B1 V& J+ Q& b4 N
South Alabama Medical Center, Mobile, Alabama.
~9 s" P0 \" ]Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ D7 _$ i! K) [Professor of Pediatrics, University of South Alabama, College of9 @/ L2 O/ |* A/ V$ c+ O6 w4 s* O" K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& q S: ?( V) x" E3 s* j3 [2 h( `6 Le-mail: [email protected].
( M9 Z& K/ D$ h! @about 6 to 7 months old, which progressively became
' E/ X1 J+ y/ f d/ ]2 ~3 }% c& Bdarker. She was also concerned about the enlarge-( i, U Y2 _5 V5 e0 A6 h
ment of his penis and frequent erections. The child
3 Y4 A- q( v/ P- k9 T0 N. [- `was the product of a full-term normal delivery, with
" S3 [0 a1 F \* v; C6 P2 ~0 O+ \a birth weight of 7 lb 14 oz, and birth length of
5 @; l) s" Z1 Z, [8 |20 inches. He was breast-fed throughout the first year
# c$ a$ q8 a! U8 I( Qof life and was still receiving breast milk along with
( ]% v! M0 u. O7 nsolid food. He had no hospitalizations or surgery,
9 F- p1 m7 V# Y4 ^2 b( d, E! G& Tand his psychosocial and psychomotor development9 P& e" Q0 x- E! F) t1 W
was age appropriate.
9 D* D* B8 G% ^The family history was remarkable for the father,
% n* Z% ^ ]% Z" L! }5 ywho was diagnosed with hypothyroidism at age 16,
- J% V# u2 J9 X4 e6 O' r4 @which was treated with thyroxine. The father’s
! S4 k8 B: p, F/ nheight was 6 feet, and he went through a somewhat
2 T' k- t# u' c- u) m& e+ Qearly puberty and had stopped growing by age 14.
4 W" e2 O4 P( I6 i8 u+ zThe father denied taking any other medication. The" {& K$ {) @$ x: y8 |% D0 k1 D' c
child’s mother was in good health. Her menarche( J' i5 m; Y. h. U( c2 x) l
was at 11 years of age, and her height was at 5 feet
0 c( o2 q# P" p. z. y+ ]5 inches. There was no other family history of pre-
& o' m$ r" f: I- D: u# l0 tcocious sexual development in the first-degree rela-5 G6 H Q5 W% L$ \6 P8 j W
tives. There were no siblings.( a& b/ C$ u) |, m% b8 P& u
Physical Examination, z+ V2 v" C$ Z) V4 [
The physical examination revealed a very active,2 ?4 b' j) e3 c: t
playful, and healthy boy. The vital signs documented
6 x4 q$ f2 K w* k7 _- L$ Ma blood pressure of 85/50 mm Hg, his length was
# R! C( m% w: @. Y7 |/ s90 cm (>97th percentile), and his weight was 14.4 kg
; {) O7 H7 M1 V) @(also >97th percentile). The observed yearly growth
" R, M {) Z3 E' _velocity was 30 cm (12 inches). The examination of" N8 B( H. ~+ d
the neck revealed no thyroid enlargement., n9 \6 n4 y# @% k: }
The genitourinary examination was remarkable for4 {* H5 J3 O7 t
enlargement of the penis, with a stretched length of
$ e C# [& p0 g; o; x0 [/ [5 ?+ H8 cm and a width of 2 cm. The glans penis was very well
& M) a+ Q1 I6 W+ Z5 S' p0 zdeveloped. The pubic hair was Tanner II, mostly around
) H! U0 J0 u' j540) Q% ]1 Q: i/ ` L4 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 o: F& P- E7 o. H' v4 V& z( `. m
the base of the phallus and was dark and curled. The
# d5 K3 C6 x1 C7 W) ktesticular volume was prepubertal at 2 mL each.9 W5 D3 ?9 E& g# a* F) c/ X: j
The skin was moist and smooth and somewhat
|$ K9 q: L4 A4 p. h) y R% woily. No axillary hair was noted. There were no0 @& f2 S4 c6 v8 X8 b2 ~0 t1 u
abnormal skin pigmentations or café-au-lait spots.
, h4 s t& G( oNeurologic evaluation showed deep tendon reflex 2+1 q0 Y0 O( @0 D) h) z
bilateral and symmetrical. There was no suggestion
' [) {# Y9 r0 `" v( I0 s) Iof papilledema.; j; S2 K' D- Z' S) O* E
Laboratory Evaluation
* p, ?/ C1 p9 |, O" fThe bone age was consistent with 28 months by
+ e( I% B$ [; n5 }/ S4 b& E0 ~using the standard of Greulich and Pyle at a chrono-
/ [2 v+ H3 M% u* B4 U: X: t llogic age of 16 months (advanced).5 Chromosomal4 E8 q4 ~0 Y4 U7 ^ F6 G- `
karyotype was 46XY. The thyroid function test
& L' k8 w X/ X3 v6 y) }showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 E6 ?, h" k4 A9 O
lating hormone level was 1.3 µIU/mL (both normal).
! y6 b5 s" ~ r* {% |, x7 i6 `. wThe concentrations of serum electrolytes, blood
0 E3 V0 s; [) l! z7 \4 Xurea nitrogen, creatinine, and calcium all were& r8 F' T. w7 _ J9 I
within normal range for his age. The concentration& M" Q6 h6 s/ s4 S$ b
of serum 17-hydroxyprogesterone was 16 ng/dL; Z2 ~) G0 g! B4 _/ P, x$ {) S
(normal, 3 to 90 ng/dL), androstenedione was 20
+ \+ S, l- p! j, X- T- N& m0 i' ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! Q5 a2 @# M2 R3 R3 o: T7 ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 n% b$ O; d! z; G: rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
. n9 g6 `7 d7 m, E49ng/dL), 11-desoxycortisol (specific compound S)
2 r" w# H( C! {; R) Z5 Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ O$ R7 G, Y# `7 g# @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) I' r2 h' M8 F* t: G1 g jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ p6 K: ]' ?) zand β-human chorionic gonadotropin was less than
7 Q: M3 T- P6 R8 f$ ^- F% F# i5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ V4 C" v- v9 t' t2 vstimulating hormone and leuteinizing hormone
1 P w/ d* i% I$ M7 Gconcentrations were less than 0.05 mIU/mL' s& @* ~ u, Z* U! t
(prepubertal).
8 A! J& B9 y3 H8 {The parents were notified about the laboratory
0 e3 p: u6 g2 W' dresults and were informed that all of the tests were6 z. E% n8 k) B
normal except the testosterone level was high. The
+ C- c+ w- D! l, Hfollow-up visit was arranged within a few weeks to
8 r. B+ x' o ?* u7 Y6 f8 f6 ~: l0 cobtain testicular and abdominal sonograms; how-- ?. Q/ G5 w2 N4 q- L
ever, the family did not return for 4 months.
! S, `. ?5 P* k+ E' q, sPhysical examination at this time revealed that the x$ Q6 E/ R F, T! C/ r4 g
child had grown 2.5 cm in 4 months and had gained
' G4 ?6 F; \- _) ~( G2 kg of weight. Physical examination remained
" b( u K" o6 J, q) m. ^6 Xunchanged. Surprisingly, the pubic hair almost com-
- |0 x' s# b8 p2 m' [; kpletely disappeared except for a few vellous hairs at$ D6 ^& `3 G3 r9 z% B+ m
the base of the phallus. Testicular volume was still 2 D ?% U- q: Q* I6 g3 z; @
mL, and the size of the penis remained unchanged.
* \: e6 r' m) Y0 r( ^7 R- N" PThe mother also said that the boy was no longer hav-. P1 X- m/ a# N0 C: b
ing frequent erections.- P" Q6 h% ^0 o) ]+ |0 R
Both parents were again questioned about use of: c/ e9 w0 ^( E$ v% u7 Y- v0 ~
any ointment/creams that they may have applied to
8 @. I) n! i- T! {1 N& D$ Fthe child’s skin. This time the father admitted the& L" j1 \) d$ R0 N+ h$ f" Y/ P
Topical Testosterone Exposure / Bhowmick et al 541& B# S1 r, J5 d" X1 s6 X& u
use of testosterone gel twice daily that he was apply-
' c2 `, @8 S1 u; n/ Y8 w# b1 [ing over his own shoulders, chest, and back area for8 e9 S- R+ _( m$ g
a year. The father also revealed he was embarrassed; h, L4 }2 G) k) Z
to disclose that he was using a testosterone gel pre-! z1 G9 L y$ {8 y/ S
scribed by his family physician for decreased libido# J- }' s1 E! A: _! ]4 J
secondary to depression.+ x, w1 F; c' K1 k
The child slept in the same bed with parents.
2 ~8 ~# k' h) i Z- ]0 ]+ MThe father would hug the baby and hold him on his
) ]. a! |% K. o) p( x' N6 I5 [chest for a considerable period of time, causing sig-/ a& T& l9 v1 |$ W0 I# C
nificant bare skin contact between baby and father.5 w+ @2 c, R( g; h" h0 \
The father also admitted that after the phone call,
6 q) }6 X* C- v$ B, hwhen he learned the testosterone level in the baby
$ c. O! c4 N2 Q* y1 J8 Z! Rwas high, he then read the product information G. E8 }5 ?0 d* j( c5 x7 M% R
packet and concluded that it was most likely the rea-
1 K1 [, a' |% ]2 M4 M4 gson for the child’s virilization. At that time, they
% n/ d' u/ X% T- y4 _) |, F6 M# }decided to put the baby in a separate bed, and the
( W( m1 ?* d5 ^5 p) tfather was not hugging him with bare skin and had8 j5 s0 a' m7 z0 p b' Z, | D
been using protective clothing. A repeat testosterone* I& o! k h0 m0 l0 L& j
test was ordered, but the family did not go to the
( O" g& p2 G/ G+ d* ?1 \& @4 M' Hlaboratory to obtain the test.8 e1 b8 q. E( }
Discussion
- C1 V! y$ l, }0 V1 h4 |Precocious puberty in boys is defined as secondary
! H7 E6 k9 V& N y& S( ^& `/ @sexual development before 9 years of age.1,4; l+ x G0 P7 C1 a! q1 e: O
Precocious puberty is termed as central (true) when6 P0 {7 ~, |7 e, K5 w0 c+ Y, _
it is caused by the premature activation of hypo-3 o3 K( U$ u( X7 {8 J; Y
thalamic pituitary gonadal axis. CPP is more com-8 [+ f; l4 |! R( {% q
mon in girls than in boys.1,3 Most boys with CPP
1 P5 ~4 S7 b) y& l$ r, a6 M3 I6 Vmay have a central nervous system lesion that is- Z5 d5 a' i. Z3 Q/ D
responsible for the early activation of the hypothal-
! i" X. S; c4 t2 A0 ~/ oamic pituitary gonadal axis.1-3 Thus, greater empha-6 R" s7 ~2 G, A! U' A. \! ` T7 B
sis has been given to neuroradiologic imaging in( E9 g I* x7 G) V2 d# `) m o' Z
boys with precocious puberty. In addition to viril-4 ?7 U u a& D! }# b( T# w
ization, the clinical hallmark of CPP is the symmet-1 a" x9 ^8 U0 h/ w8 Y
rical testicular growth secondary to stimulation by# I% s ?2 ?: _% ^
gonadotropins.1,3: o2 h0 l! V1 _" Z w: I
Gonadotropin-independent peripheral preco-7 }; w. A8 ~8 d- s& k
cious puberty in boys also results from inappropriate* r! Q* `& a3 t' |+ t
androgenic stimulation from either endogenous or9 A" r4 e* N6 r4 Z" I$ {
exogenous sources, nonpituitary gonadotropin stim-
* {3 J2 _+ J9 D) R5 g L# Gulation, and rare activating mutations.3 Virilizing6 o5 D$ ~; r5 |+ l1 @' R
congenital adrenal hyperplasia producing excessive, }1 x; E V' ]$ \# |
adrenal androgens is a common cause of precocious; B* o' l7 @3 \) F& G
puberty in boys.3,4
/ m4 ]' R" i( w U* wThe most common form of congenital adrenal
1 K$ G$ ~8 }$ b) H7 Khyperplasia is the 21-hydroxylase enzyme deficiency.9 y9 c9 r1 G, k/ d
The 11-β hydroxylase deficiency may also result in
( r+ O& _/ C* D- i& _' t2 r2 vexcessive adrenal androgen production, and rarely,; ]) g1 ~0 m" y0 b$ @, ~
an adrenal tumor may also cause adrenal androgen
. _+ r$ `/ V4 \+ Wexcess.1,3
$ _, z1 _, |0 ?8 t ^7 q' cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, ?' x& H( Z+ Z% Y1 J' a
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 I5 V, L3 c# P Y! f+ f+ k
A unique entity of male-limited gonadotropin-! _1 ~4 u) S# \
independent precocious puberty, which is also known
( Y4 h4 {* q5 D' F: r4 q! _as testotoxicosis, may cause precocious puberty at a
( B* J. P q, v3 j* j6 S5 Q2 s4 k! Qvery young age. The physical findings in these boys
, z2 s/ B! y& D4 Y& s$ i9 W; y1 S# Fwith this disorder are full pubertal development,
* {/ Z) X/ q6 n6 |3 P* A4 \including bilateral testicular growth, similar to boys; e4 ?( I2 v5 H" d6 y0 s) O! L
with CPP. The gonadotropin levels in this disorder/ o# S% ?. W" J, M8 a
are suppressed to prepubertal levels and do not show
" f0 I& [( C9 R- J4 X% g1 }pubertal response of gonadotropin after gonadotropin-
: @* D+ w' x8 U4 t& a9 F5 Sreleasing hormone stimulation. This is a sex-linked
0 a% D0 d' D: k, X3 Z" [* yautosomal dominant disorder that affects only' h8 t& Q* R" A
males; therefore, other male members of the family
0 O. \1 |& g2 Y; T2 Rmay have similar precocious puberty.3
4 J8 P% u* v2 f' ?* X! O% S, sIn our patient, physical examination was incon-
4 C3 g" n0 J6 V. p6 M: X P2 vsistent with true precocious puberty since his testi-
% V% H. x' L9 U4 rcles were prepubertal in size. However, testotoxicosis. F/ G3 u% ~( N; B1 V
was in the differential diagnosis because his father
' V: e v- N" G" I1 E- ostarted puberty somewhat early, and occasionally,
" ]6 H# k- W- Z3 }2 M1 o% {testicular enlargement is not that evident in the
7 c9 x$ B# L" o! G. Tbeginning of this process.1 In the absence of a neg-! j6 k. o6 ?# L0 b2 [2 r `
ative initial history of androgen exposure, our
+ R1 }% d$ b& ^( F4 k% r; ebiggest concern was virilizing adrenal hyperplasia,
$ c. W1 H, U) J) V$ Teither 21-hydroxylase deficiency or 11-β hydroxylase2 `+ c+ @; ?2 _' \* E$ X" v q
deficiency. Those diagnoses were excluded by find-
& x x& i0 c& }6 Ving the normal level of adrenal steroids." C6 \, a. j7 d/ t7 Q, z% Z0 F9 B
The diagnosis of exogenous androgens was strongly' |$ N0 O& ]# q- {( V5 \) n
suspected in a follow-up visit after 4 months because
( H5 a1 s( c6 H+ q! jthe physical examination revealed the complete disap-
j% c3 W1 F2 e& j Zpearance of pubic hair, normal growth velocity, and! h& o( h; |' Z$ l
decreased erections. The father admitted using a testos-+ X' i7 d4 [( x* H2 X
terone gel, which he concealed at first visit. He was! q A6 q+ _+ e- V5 x8 G
using it rather frequently, twice a day. The Physicians’
8 y4 l( t( g+ j' B# ~( R( KDesk Reference, or package insert of this product, gel or) e3 ?' ?/ I4 z, K+ e5 m
cream, cautions about dermal testosterone transfer to
; ] N3 L1 M! V ]! C# uunprotected females through direct skin exposure.
: r7 Z Y( ^# ?! I& bSerum testosterone level was found to be 2 times the" X% g& W. h* T6 J* S5 x
baseline value in those females who were exposed to
3 ?1 ?7 y2 Q% Q. K' @1 v* Deven 15 minutes of direct skin contact with their male( Q) d4 D0 [ c/ a3 G
partners.6 However, when a shirt covered the applica-' i5 t L( Q! O/ T
tion site, this testosterone transfer was prevented.6 ~( p0 Q1 G4 w k! t! `4 q F
Our patient’s testosterone level was 60 ng/mL,9 Y3 j6 R9 i- Q) e: O
which was clearly high. Some studies suggest that
- |9 c8 r1 F$ W4 L) c/ s$ Rdermal conversion of testosterone to dihydrotestos-, i2 r8 \! v7 G6 |
terone, which is a more potent metabolite, is more1 b& O1 [7 D7 L
active in young children exposed to testosterone
+ b4 T' c; ? ]1 o- C/ Xexogenously7; however, we did not measure a dihy-7 U! ]! q v8 g, d- T( @
drotestosterone level in our patient. In addition to
$ Y/ J. Z/ n0 g5 Ivirilization, exposure to exogenous testosterone in y6 q% Q+ U0 D) H
children results in an increase in growth velocity and
& C# s( C" o: c6 nadvanced bone age, as seen in our patient.' h, y0 m7 a. c, Y3 X
The long-term effect of androgen exposure during2 G( P+ K) j7 {7 m4 I- R
early childhood on pubertal development and final% i( ^6 F4 ~5 d. Q9 j1 {
adult height are not fully known and always remain8 m! U5 P9 Y6 s
a concern. Children treated with short-term testos-: p2 D. T+ l. d
terone injection or topical androgen may exhibit some1 o3 A: ^* L1 x" P8 g0 J
acceleration of the skeletal maturation; however, after: u( Y4 c% u- ?) [* m+ E
cessation of treatment, the rate of bone maturation
, L" S- U u' E3 k1 k- ^. `( O0 idecelerates and gradually returns to normal.8,9
" g( o$ e; `/ |# S8 F2 u" O# E+ xThere are conflicting reports and controversy
G# w, X/ @' L* x4 L8 ?over the effect of early androgen exposure on adult
6 ^4 v1 R" @& Q7 ]% T7 ~" l0 Ypenile length.10,11 Some reports suggest subnormal( W7 L0 x& x7 a, m
adult penile length, apparently because of downreg-
0 \! v0 R" b' L. Bulation of androgen receptor number.10,12 However,. Z; d6 P# [% V! f' M
Sutherland et al13 did not find a correlation between" @( s9 B5 @0 F5 C4 j: A' O
childhood testosterone exposure and reduced adult
& w" o5 L% \' I( cpenile length in clinical studies.
7 x; l0 X. V0 g6 \Nonetheless, we do not believe our patient is" |: f, m. W! `1 Q0 P+ P
going to experience any of the untoward effects from
* U6 w3 f+ `+ atestosterone exposure as mentioned earlier because
' [" [1 K0 w7 G) a( G, q! r. t! Uthe exposure was not for a prolonged period of time.) O2 z3 F. y9 t, o0 r6 r
Although the bone age was advanced at the time of% h9 ^& l1 I# J4 X
diagnosis, the child had a normal growth velocity at' P' t. @$ F3 ~7 |- V) s$ q
the follow-up visit. It is hoped that his final adult: N0 c3 B& t7 F/ ]$ c0 ?' R, q% g
height will not be affected. d8 s0 A# F+ ]5 k* n# }) `
Although rarely reported, the widespread avail-7 e; M, l3 ^. O
ability of androgen products in our society may @. ^, [' Y0 I) ~* c( o
indeed cause more virilization in male or female
8 Q2 N. k) V7 s, K* O6 zchildren than one would realize. Exposure to andro-+ M$ e6 X% R5 @; c+ T& x
gen products must be considered and specific ques-4 y) @9 ]! a/ Q. Q
tioning about the use of a testosterone product or
! C9 a0 K+ G& U" f1 [* ygel should be asked of the family members during
9 n* U7 j- c+ g& D% h8 V) bthe evaluation of any children who present with vir-
! D5 A0 X" r, \ilization or peripheral precocious puberty. The diag-. g# j2 V6 t: u- v. d$ \3 S% \
nosis can be established by just a few tests and by
1 K) n+ l0 h5 u6 Q7 ?3 mappropriate history. The inability to obtain such a
* b+ C& d6 S: e& L- [4 f. K& Hhistory, or failure to ask the specific questions, may
5 X. s3 L! H) uresult in extensive, unnecessary, and expensive: U6 ]/ A$ m. m* u
investigation. The primary care physician should be
- Z/ d2 r8 F' h- faware of this fact, because most of these children( O6 X$ z: s( d3 Y' ?1 O }
may initially present in their practice. The Physicians’
! A9 v0 Q' M! |$ [% LDesk Reference and package insert should also put a
: {& e7 {4 C5 c% e1 }warning about the virilizing effect on a male or/ m+ O( D, F+ Q
female child who might come in contact with some-' K h- O# Z1 \" w
one using any of these products.
( w& h, }( W; @! C- C, zReferences* @% P+ [6 E6 G9 Q, x6 k D6 P% E
1. Styne DM. The testes: disorder of sexual differentiation+ ~# z- O' Z" N2 s0 }% V; D$ U
and puberty in the male. In: Sperling MA, ed. Pediatric0 U) b( E, M! G2 n+ E$ t/ l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 j1 @- X i$ C$ S3 Z# i# C2 D2002: 565-628.; E. E/ r- S' s" }3 F0 d# B) O
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( Q6 m# o, _. p5 I9 J& X: ]& ? x
puberty in children with tumours of the suprasellar pineal |
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