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Sexual Precocity in a 16-Month-Old
( U% L+ C' |$ s: kBoy Induced by Indirect Topical+ o+ Z8 g" k; |, I! K$ v9 {# \
Exposure to Testosterone
1 L2 m C! |: `! @Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; F( O* b) H7 X6 t5 c" i# z, sand Kenneth R. Rettig, MD1
# N; p7 J2 }$ Y% W* k9 ~4 ~Clinical Pediatrics$ }7 b- U9 j- Z; y' v
Volume 46 Number 61 \; m) |0 Q0 ?. ]9 S! c+ p3 g
July 2007 540-543
% q8 @ z% z! H& q+ x' r3 W, B© 2007 Sage Publications
! _- A: E9 d0 `4 I8 X1 P0 q10.1177/0009922806296651
% s0 N' b3 p. m c" u- Z! Chttp://clp.sagepub.com
4 L3 a! b: l4 D/ B2 T* uhosted at5 S5 `6 O! t- b! ?! u) b
http://online.sagepub.com
2 i1 _. A* O$ k6 a" C1 sPrecocious puberty in boys, central or peripheral,+ F) g- q9 K2 c8 E
is a significant concern for physicians. Central
2 O* B) }# q% P( k+ f M7 _precocious puberty (CPP), which is mediated
. `" ~$ {: z- @$ Uthrough the hypothalamic pituitary gonadal axis, has
9 J" r+ I' \, s6 @+ D- _3 Ja higher incidence of organic central nervous system
, b1 K" f% C6 F' m/ e( ~! @- jlesions in boys.1,2 Virilization in boys, as manifested
8 n; M% |! z. w! Jby enlargement of the penis, development of pubic
4 r% |) n8 {( l# Khair, and facial acne without enlargement of testi-/ O2 C4 u, z! F! O
cles, suggests peripheral or pseudopuberty.1-3 We
' S" j" u0 T0 C3 k! ~8 p5 u4 Sreport a 16-month-old boy who presented with the
n; w/ h7 F# h6 v2 Fenlargement of the phallus and pubic hair develop-
# \' v9 T1 k1 g% I) @, F2 I. S1 Hment without testicular enlargement, which was due
( x# |, Z A; ~to the unintentional exposure to androgen gel used by5 |2 f8 r4 s! m. z) a3 L$ \
the father. The family initially concealed this infor-
: [! j0 @" r4 z& s5 n4 A& ^9 Lmation, resulting in an extensive work-up for this
! F& e) ]; [; }# X4 w. _( ^7 Ichild. Given the widespread and easy availability of) V3 w) N/ l2 T" N8 y' k1 Z
testosterone gel and cream, we believe this is proba- H8 [. z9 W; k( P/ F V' c3 p" d
bly more common than the rare case report in the. i, U8 ]4 V) y4 _. W `
literature.4
& j$ _: s$ \: t2 F X0 BPatient Report, h: M+ q0 v" F8 W! [; N
A 16-month-old white child was referred to the+ _: Y" _3 U3 t: X, |
endocrine clinic by his pediatrician with the concern! g3 M3 I: F# ]$ ^
of early sexual development. His mother noticed
& |% b" B* B4 Nlight colored pubic hair development when he was i/ C' q8 t$ V N
From the 1Division of Pediatric Endocrinology, 2University of
, }! `# [9 q" N! q: w* f. jSouth Alabama Medical Center, Mobile, Alabama.) k/ T' P# L' {. K6 `
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, M! S: @/ J1 Z+ I) b9 X$ _2 {Professor of Pediatrics, University of South Alabama, College of
: S& p2 C4 k9 F' m9 A, E! u) oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 Q d% S8 f) Q& O7 ?6 |
e-mail: [email protected].
" w+ \% P' E; w- Y% ~about 6 to 7 months old, which progressively became
5 ^/ k- Z. Q' [ rdarker. She was also concerned about the enlarge-+ ?0 N) \' ~; J+ K% F+ I
ment of his penis and frequent erections. The child
7 r5 m% l! x P3 Q8 h' C& ewas the product of a full-term normal delivery, with3 U* Y7 V( C! |* f& J8 b9 @
a birth weight of 7 lb 14 oz, and birth length of! ^2 x9 M3 e2 |; r" V& r/ W9 ~: ~
20 inches. He was breast-fed throughout the first year
7 o$ Q; k; M2 P; Mof life and was still receiving breast milk along with
3 c/ l4 M1 l0 L9 J) Y2 x8 w, j# nsolid food. He had no hospitalizations or surgery,
6 w9 ^' e# P7 d; B0 `$ J5 }and his psychosocial and psychomotor development
$ n! C" V4 L# Twas age appropriate.
) K5 I0 u2 L4 y: O+ YThe family history was remarkable for the father,8 S$ e# V: w' f
who was diagnosed with hypothyroidism at age 16,
) [% E: |: d7 |; u1 t8 _* ewhich was treated with thyroxine. The father’s+ l' N% s! N ]2 N- F, M
height was 6 feet, and he went through a somewhat
L8 z$ p ^9 O$ W. Wearly puberty and had stopped growing by age 14.
4 l% |: W" |. J. j* a: n* U: b# c/ WThe father denied taking any other medication. The8 R+ J, Q8 V1 |# j- g
child’s mother was in good health. Her menarche
2 z y" ^+ P( a Qwas at 11 years of age, and her height was at 5 feet% @7 T( ]4 s$ }; W. L9 ?5 y, w
5 inches. There was no other family history of pre-
3 W/ J9 F3 I6 H& L" i5 lcocious sexual development in the first-degree rela-
8 ~6 ^7 z: ~$ z! d: stives. There were no siblings.
+ {& A9 u+ w5 TPhysical Examination
8 D F0 ?( D* ]& I& A9 FThe physical examination revealed a very active,, i" W0 b0 e- [1 [% g. ~* [3 b* f) V% |
playful, and healthy boy. The vital signs documented5 m% [( K9 I5 G9 K% y
a blood pressure of 85/50 mm Hg, his length was4 `1 K! o3 _# j' ?& |
90 cm (>97th percentile), and his weight was 14.4 kg0 q; V( t$ {( i# J' t- O% m* s- Z3 S
(also >97th percentile). The observed yearly growth' n# b i- u& M7 j: l
velocity was 30 cm (12 inches). The examination of
' Y7 f: g$ f, Y& Q; o9 s5 ]2 Othe neck revealed no thyroid enlargement.
; j) `! a8 t8 w9 XThe genitourinary examination was remarkable for
' G$ B, L, F5 P6 c: M) tenlargement of the penis, with a stretched length of3 ]. `2 s2 p3 [! Z' r
8 cm and a width of 2 cm. The glans penis was very well. V: L5 r# T9 @
developed. The pubic hair was Tanner II, mostly around
9 w: h" S6 M2 G, W7 R. Y& y# v540% E, V$ P" D+ \/ z5 h- N* ~3 y2 J s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) W& K L8 B) U( {
the base of the phallus and was dark and curled. The
5 e% Q4 e5 x" }% Vtesticular volume was prepubertal at 2 mL each.
n, A7 y( l5 J8 [The skin was moist and smooth and somewhat* L: y0 K O: G7 H
oily. No axillary hair was noted. There were no
( O: g3 n, w- L( ?* J- o( k/ Babnormal skin pigmentations or café-au-lait spots.
7 h2 o+ x) d, x/ j, z, {Neurologic evaluation showed deep tendon reflex 2+
) u# \" [8 _) F# m- O$ y/ Jbilateral and symmetrical. There was no suggestion
0 ]: q! E G3 ]$ K* S" e* lof papilledema.! |+ j! }3 ]: b8 k8 \, U/ L
Laboratory Evaluation
/ \% z s. A3 q$ e* [( [The bone age was consistent with 28 months by+ E' ]$ B' F8 d; p* g I Y
using the standard of Greulich and Pyle at a chrono-9 b- R& J W# F4 x
logic age of 16 months (advanced).5 Chromosomal% r6 l+ {/ H" ?$ _6 E
karyotype was 46XY. The thyroid function test: b$ y) j& I5 c* O# d8 V5 n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# z* V% `+ F$ ~1 L1 }lating hormone level was 1.3 µIU/mL (both normal).+ }' Z% r/ j/ |0 \2 `1 t9 u
The concentrations of serum electrolytes, blood- E. e- Z2 e! p- n5 K; D
urea nitrogen, creatinine, and calcium all were% t7 j4 i- j* H' ?2 U3 B6 h) _9 |
within normal range for his age. The concentration
9 e! L/ {$ |$ ?of serum 17-hydroxyprogesterone was 16 ng/dL* {: C3 z: S$ E+ A
(normal, 3 to 90 ng/dL), androstenedione was 203 i0 x+ i9 s0 X! G4 v3 U( E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: z' w: s% L$ [% p, H2 C$ G4 o5 d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ ?) g1 J, Z7 S$ S3 \1 b I adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 ]; n7 s5 ?2 y8 X5 N( ]( v49ng/dL), 11-desoxycortisol (specific compound S)
# Z; C0 x5 \. y3 Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" T5 ^- j4 u( C, t Z. Z4 V
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ c3 y2 I/ ~8 e$ v& }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, T% m7 h" D' xand β-human chorionic gonadotropin was less than; W) U% P4 p1 n2 P6 e) d
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 A4 M6 a, G j5 n. Mstimulating hormone and leuteinizing hormone- v( v8 ?. W2 `: F7 r+ p3 W- f
concentrations were less than 0.05 mIU/mL
: J" Y; l8 ~$ q& }+ z; s: W: d(prepubertal).
" w. I9 n' e1 J1 l2 a+ R0 yThe parents were notified about the laboratory/ c; l$ n4 u6 k6 r4 G: X
results and were informed that all of the tests were
8 `; s. v# H9 L& b( F' xnormal except the testosterone level was high. The
5 a8 _( Z2 p* Z; \. n! W/ [! Sfollow-up visit was arranged within a few weeks to
- o, B# I8 \ J, Z" V" \, iobtain testicular and abdominal sonograms; how-. ?0 I/ ^7 C0 y2 E I% t9 }
ever, the family did not return for 4 months.
; I6 u0 N; K6 l* C5 nPhysical examination at this time revealed that the
0 ~# O. g V5 [. M, ^child had grown 2.5 cm in 4 months and had gained
* N# c+ j4 |% d6 w( K2 kg of weight. Physical examination remained6 Y# F" \7 R O4 W
unchanged. Surprisingly, the pubic hair almost com-
: Y% h) L2 c6 }! R+ s! N5 `. @pletely disappeared except for a few vellous hairs at
2 H% D1 L8 y* j* ^6 x3 ~4 xthe base of the phallus. Testicular volume was still 2* ^. R5 L- T: T4 z& u5 v
mL, and the size of the penis remained unchanged.( n) W$ Z% E. a$ l% l
The mother also said that the boy was no longer hav-6 j7 G% k8 V) g4 p% u: X/ H
ing frequent erections.
" v) K7 B6 |) `" PBoth parents were again questioned about use of" W# s4 |9 _! g8 ^8 H
any ointment/creams that they may have applied to
1 J/ Y" c' @) G) nthe child’s skin. This time the father admitted the1 _8 t- B8 v( W6 y
Topical Testosterone Exposure / Bhowmick et al 541, j) B, D. P! s5 F( Z
use of testosterone gel twice daily that he was apply-
9 w& i, u$ \# @0 `3 _) w$ a1 Ving over his own shoulders, chest, and back area for; o5 T9 j* n* S4 Q! Z! W6 V% D
a year. The father also revealed he was embarrassed) G% [: B2 Y0 _7 S/ ] P. M; n
to disclose that he was using a testosterone gel pre-" ?5 Z7 z3 J! e9 |9 M5 X
scribed by his family physician for decreased libido
# O; U; T' ?( _1 u; Ksecondary to depression.& e6 m3 \2 }7 @! ~6 c
The child slept in the same bed with parents.2 v+ S, S2 @: F$ F5 d. o
The father would hug the baby and hold him on his6 [, Y$ Q4 H/ A# E+ M
chest for a considerable period of time, causing sig-+ \; t2 K( d9 g9 M4 y! I
nificant bare skin contact between baby and father.* O$ k/ H' ?3 ^. P
The father also admitted that after the phone call,/ w% z8 h9 q# F% b; \
when he learned the testosterone level in the baby' Z6 d: O1 A6 H2 |
was high, he then read the product information
) O+ w3 U* I% O" A/ kpacket and concluded that it was most likely the rea-" g* y6 N6 o2 _8 B
son for the child’s virilization. At that time, they
- ]4 ?/ @3 v* ~* Hdecided to put the baby in a separate bed, and the
" @" u7 |9 `0 `& i+ j# G) vfather was not hugging him with bare skin and had2 W0 @0 E$ Z8 T9 J( K! Z4 _
been using protective clothing. A repeat testosterone5 v# o% y, D. I6 Q2 b
test was ordered, but the family did not go to the
8 Z& t! Y! H9 Y( X& g$ r! Q4 Zlaboratory to obtain the test.
- X; D7 Z g9 I4 n7 }9 b8 }Discussion9 G6 p/ n+ F8 F8 `8 x+ w
Precocious puberty in boys is defined as secondary4 V5 f, T5 Z0 n8 H# i- C' I
sexual development before 9 years of age.1,4; `; |0 v8 J0 L( h' t- S
Precocious puberty is termed as central (true) when
# N+ Y! z" y3 d; N% l0 Cit is caused by the premature activation of hypo-: ~) C$ a3 e0 u+ z8 c' g
thalamic pituitary gonadal axis. CPP is more com-
/ l/ O- b$ x5 L/ u, L0 L4 f9 x& d- Omon in girls than in boys.1,3 Most boys with CPP
7 n7 l( o% G+ t1 mmay have a central nervous system lesion that is
1 [& P9 o! g) e) p- f1 C7 q# Fresponsible for the early activation of the hypothal-
* i) z# t4 P2 Y% @. Lamic pituitary gonadal axis.1-3 Thus, greater empha-
0 f: X5 [& t$ B1 @% Wsis has been given to neuroradiologic imaging in
* Y/ ~- Z- [4 h1 Z, Gboys with precocious puberty. In addition to viril-
9 B ~% |2 ?! M* e" Vization, the clinical hallmark of CPP is the symmet-3 t6 J- q( [0 p4 F) U
rical testicular growth secondary to stimulation by) Z/ ?! ~& W7 y( A3 W; ]
gonadotropins.1,3* Q: A% e6 a$ W Y, V0 X# c. J" o
Gonadotropin-independent peripheral preco-0 n2 K2 {! o g; X7 F+ v
cious puberty in boys also results from inappropriate. `& f: L$ R9 P) O9 _9 z) o- D
androgenic stimulation from either endogenous or! q, f5 \- A+ W% W3 u+ w+ m: s
exogenous sources, nonpituitary gonadotropin stim-$ M* Z( Q8 P, j( y* z. c- A! @
ulation, and rare activating mutations.3 Virilizing
) y3 }+ [7 h! S4 H2 X9 Scongenital adrenal hyperplasia producing excessive
; b, b% A5 [* }1 d+ Ladrenal androgens is a common cause of precocious
( \9 p) {" t G$ W3 cpuberty in boys.3,4
" s1 r, L, }: S% O9 v$ @/ sThe most common form of congenital adrenal* B; z4 I. ]0 ]4 I- c5 j
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 w2 j; W9 I, e7 k+ KThe 11-β hydroxylase deficiency may also result in7 H% B3 K) S, P
excessive adrenal androgen production, and rarely,
$ L% E3 Z3 h5 ean adrenal tumor may also cause adrenal androgen0 ~! j! D6 }3 b& \. v( N: {! H2 [2 V
excess.1,3- g5 V7 I/ w5 W1 M5 d' @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" j, y6 s4 A6 @0 B7 B' m! T- t6 P+ J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% R2 L: p+ M wA unique entity of male-limited gonadotropin-9 j2 w9 y2 P9 u0 r$ p# |
independent precocious puberty, which is also known. k1 L, k' ]5 d) H( l) B
as testotoxicosis, may cause precocious puberty at a7 z( F! I6 A4 X4 [% d$ D u
very young age. The physical findings in these boys1 s6 ^& ^. c! _" W
with this disorder are full pubertal development,6 l% R# a0 ]9 x" D- o
including bilateral testicular growth, similar to boys. Q) w/ `, ]* x$ \) [) |
with CPP. The gonadotropin levels in this disorder9 |+ R! D9 b" n4 }4 ?- E a
are suppressed to prepubertal levels and do not show# w3 P1 X! T& h, h* Q! N
pubertal response of gonadotropin after gonadotropin-
' p* p6 {; ?% ^releasing hormone stimulation. This is a sex-linked3 N, }7 B1 Z" l! P z; x2 m
autosomal dominant disorder that affects only& m! o/ D+ N$ G6 A. c$ M
males; therefore, other male members of the family
, t" V$ E$ }2 n9 X) g* b1 o4 {7 I3 h5 hmay have similar precocious puberty.3
- R- r( A5 S M4 bIn our patient, physical examination was incon-' T* \* [7 c4 O' b
sistent with true precocious puberty since his testi-( ~8 V2 _4 Y; _+ X
cles were prepubertal in size. However, testotoxicosis
& s/ G& f- ?/ y) u8 U6 kwas in the differential diagnosis because his father& g& _8 n+ t. i8 Z
started puberty somewhat early, and occasionally,
# ?: ?+ l r$ S# B( vtesticular enlargement is not that evident in the
: Z/ _) x0 L' R5 ibeginning of this process.1 In the absence of a neg-
% t9 o/ a4 M8 l/ @9 zative initial history of androgen exposure, our
- N" Z7 ^. h) {0 r; }/ y6 [biggest concern was virilizing adrenal hyperplasia,+ P% q6 h9 S( c- n" q f" L% Y/ l
either 21-hydroxylase deficiency or 11-β hydroxylase
9 E$ i& B1 L& |% [% _* sdeficiency. Those diagnoses were excluded by find-% M6 h3 y1 {1 ?+ x' \% {
ing the normal level of adrenal steroids., d$ z( `' a6 r/ g6 Z
The diagnosis of exogenous androgens was strongly
. C; e& X9 [. w5 K( msuspected in a follow-up visit after 4 months because: M, [7 d0 t) }( ^5 }
the physical examination revealed the complete disap-
8 e3 O' ]$ G5 n1 B0 Tpearance of pubic hair, normal growth velocity, and
3 ]/ I- A" i6 u3 S/ \0 vdecreased erections. The father admitted using a testos-
( u. i& M5 z M. @. _2 V+ A+ k6 ~terone gel, which he concealed at first visit. He was; [: V0 W7 i2 ~& v; r
using it rather frequently, twice a day. The Physicians’
/ k' q4 }8 p# E+ x5 |' Y; U8 Q6 Q3 sDesk Reference, or package insert of this product, gel or
1 S0 H9 z3 l4 l+ k* Acream, cautions about dermal testosterone transfer to
1 w! i) b/ ]3 E# [unprotected females through direct skin exposure.
# l/ O. R& `4 X: ]+ q1 a2 [- gSerum testosterone level was found to be 2 times the
. L4 u' F7 a4 bbaseline value in those females who were exposed to
, E' C- }0 W% \even 15 minutes of direct skin contact with their male
4 K* h* F# H4 M% j8 I- F# bpartners.6 However, when a shirt covered the applica-6 B O% D, b! @3 A
tion site, this testosterone transfer was prevented.
# }4 b/ i( |; HOur patient’s testosterone level was 60 ng/mL,. X' w' u: I& Z; ^" \1 n- s; O2 V% j
which was clearly high. Some studies suggest that
) f8 T1 ?& p6 C% y' C; ddermal conversion of testosterone to dihydrotestos-
( i. T# n0 f) k# B; \! X4 K5 ^4 q7 Wterone, which is a more potent metabolite, is more
- n+ p( Q( u4 s, W9 H6 q# C- bactive in young children exposed to testosterone
, F4 q3 I* |- _' \' m$ rexogenously7; however, we did not measure a dihy-
# d% w7 K. y8 t Wdrotestosterone level in our patient. In addition to
0 l1 a) a! h0 w3 Evirilization, exposure to exogenous testosterone in: u) E" d0 O0 G# N9 o' U
children results in an increase in growth velocity and0 ]6 N( |, e- a6 c2 _$ y" U4 i3 L
advanced bone age, as seen in our patient.! x$ a2 n% _3 A+ x$ F. r
The long-term effect of androgen exposure during
% j' D/ @" N8 r( u9 K9 q% a9 Dearly childhood on pubertal development and final3 L4 l% y l3 z8 |. _ [' _
adult height are not fully known and always remain, L5 [ G- N& Y) v/ d# I
a concern. Children treated with short-term testos-
# t" z0 r! E+ V' Bterone injection or topical androgen may exhibit some l: \/ }3 E% U5 H
acceleration of the skeletal maturation; however, after# I- @" U# X; o
cessation of treatment, the rate of bone maturation% g/ ?+ K7 y# N1 w' P7 `
decelerates and gradually returns to normal.8,9+ D1 M* Y% u5 t! n
There are conflicting reports and controversy
1 J4 Y/ s2 \5 _/ ~over the effect of early androgen exposure on adult! T8 D9 ~% |* i% ~, M) o* v3 [
penile length.10,11 Some reports suggest subnormal
& t% y0 y6 Q8 d% dadult penile length, apparently because of downreg-8 O$ V8 @0 Z9 C' S7 Y) l
ulation of androgen receptor number.10,12 However,; L0 h/ }+ ^! b. Q z
Sutherland et al13 did not find a correlation between1 x2 M2 R+ z% R! }
childhood testosterone exposure and reduced adult: G/ r+ v2 z2 O) }8 D. M; v: c
penile length in clinical studies." S, N+ K x0 G# V
Nonetheless, we do not believe our patient is# d" q- j+ L, Y# |6 [
going to experience any of the untoward effects from9 Z4 I ^1 |. f( q5 b
testosterone exposure as mentioned earlier because) v; R3 x* m" p6 ]& ]3 h' N
the exposure was not for a prolonged period of time.3 C9 Y& z! |, i. A3 ]* Y8 v* o
Although the bone age was advanced at the time of
" k" ^* h \- f8 E Ndiagnosis, the child had a normal growth velocity at9 ~% I. I) t5 e" o5 J4 R0 \
the follow-up visit. It is hoped that his final adult
% |( o3 N9 Y' N) pheight will not be affected.
3 j2 X" B, ^+ V7 nAlthough rarely reported, the widespread avail-
# C. V, w- E8 r: b; _: s9 iability of androgen products in our society may5 t' W- F% l( ]4 @: s q
indeed cause more virilization in male or female1 _! s- a0 x% J6 @: N" ~
children than one would realize. Exposure to andro-9 B# w2 L+ \9 f/ i, R! b6 v9 J
gen products must be considered and specific ques-
+ o1 @, i ~/ W- Gtioning about the use of a testosterone product or' C) l0 B. A( S/ G8 {! m7 x3 s
gel should be asked of the family members during
* ]6 \1 b( x. b9 a7 g; H% O+ e) I& ]the evaluation of any children who present with vir-
7 F5 Y! e i2 [* D7 Silization or peripheral precocious puberty. The diag-
( Z) e0 H$ K: }$ H; Qnosis can be established by just a few tests and by, b3 o* i# s9 i
appropriate history. The inability to obtain such a
, T& ?; ?* q* s+ s7 @history, or failure to ask the specific questions, may
2 J$ l- c/ J, w$ m& I7 Xresult in extensive, unnecessary, and expensive- h! \8 k! t+ p6 i
investigation. The primary care physician should be
9 i$ H, d" C* y# \7 @* n: ?aware of this fact, because most of these children
6 `2 ?. i. Z/ a# |" p: gmay initially present in their practice. The Physicians’& }( \" Y2 k: U" I v# O$ P
Desk Reference and package insert should also put a
0 G, x( J% X$ J& k; u/ `7 Ewarning about the virilizing effect on a male or
+ u0 L& W* H( }$ R+ hfemale child who might come in contact with some-* I U1 h& ]2 F: m1 S% o
one using any of these products.
v& }3 d6 H# l, o4 ]References
5 d, z: A! w: c3 a( B1. Styne DM. The testes: disorder of sexual differentiation$ F; ], c5 z+ j. S
and puberty in the male. In: Sperling MA, ed. Pediatric
' d- V, `! a; q9 cEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: A* f. i8 L2 T S9 ?2 l$ ^. K2002: 565-628.$ X0 ]0 y1 d+ ] h# q7 b9 S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( G& H O4 `: ]5 X1 ]. w6 \/ Q# S
puberty in children with tumours of the suprasellar pineal |
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