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Sexual Precocity in a 16-Month-Old/ O8 g- |/ W* s
Boy Induced by Indirect Topical) p$ N3 M- H! [& K
Exposure to Testosterone
6 n5 O4 R# i9 v2 `0 _1 tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 v" m$ Q8 x0 b* K! ^7 fand Kenneth R. Rettig, MD1
; s) N Y5 C' G9 U7 o- S6 AClinical Pediatrics
- F- [/ I- x' q# {5 jVolume 46 Number 6& H0 J2 p9 r. M, Y% E9 Q5 o
July 2007 540-543' v, m8 m; }* K+ }& h
© 2007 Sage Publications
1 ~% v' {# k( u) i) a# f7 c10.1177/0009922806296651
" y1 K E: @2 N7 _* B. Ahttp://clp.sagepub.com
$ }# Y2 [ G2 u" xhosted at+ N y, `0 j" f
http://online.sagepub.com' j- }1 D, L ^
Precocious puberty in boys, central or peripheral,
; j' V: M/ D4 m7 X8 n0 ~/ uis a significant concern for physicians. Central
6 D1 Q. G! k6 S& u$ W, p- r+ [precocious puberty (CPP), which is mediated
2 | H# `1 i+ Cthrough the hypothalamic pituitary gonadal axis, has
! @6 ]0 c& v) ^+ va higher incidence of organic central nervous system0 f' C" N1 Q0 z, @' M: _, ?0 k* a: a
lesions in boys.1,2 Virilization in boys, as manifested' z1 T- ~, }" X) e
by enlargement of the penis, development of pubic
. @1 G* {' b8 v0 G8 Xhair, and facial acne without enlargement of testi-8 b0 I7 u- z- S
cles, suggests peripheral or pseudopuberty.1-3 We) i2 W$ k5 f: X8 H5 v
report a 16-month-old boy who presented with the
1 y, l& @7 z5 N. m6 B+ Benlargement of the phallus and pubic hair develop-
: j) m5 F1 H! w2 s a. mment without testicular enlargement, which was due3 z$ \/ A- Z* i' E! s
to the unintentional exposure to androgen gel used by6 n. Y" S' g3 i6 X
the father. The family initially concealed this infor-
0 l% F9 ~0 q, H- }" i6 U* w$ imation, resulting in an extensive work-up for this/ A; z1 u, Z% ?) ^& ?3 D
child. Given the widespread and easy availability of" o4 p5 N% ?0 i# ^- R2 n
testosterone gel and cream, we believe this is proba-
5 v1 J# l1 \9 M# Y/ N1 jbly more common than the rare case report in the8 d- k. |! _' v2 x8 _) U$ X( N
literature.45 m) }& L ?; c% B) E+ d& O
Patient Report; V) k0 |3 _3 b
A 16-month-old white child was referred to the
6 X) n5 j5 K ?endocrine clinic by his pediatrician with the concern
- d/ G% Y$ ?* |of early sexual development. His mother noticed
5 P/ y9 S( j, x6 L3 S* [1 r* ?8 Glight colored pubic hair development when he was7 q1 b) A o- E8 L/ \6 N# Y" @# w
From the 1Division of Pediatric Endocrinology, 2University of8 x# ]/ g$ T) z' ?" e% b; F
South Alabama Medical Center, Mobile, Alabama.
# b. d9 b, M% {$ v8 s1 o7 Y" z! cAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 A/ v+ d3 E6 S1 V" S$ G" MProfessor of Pediatrics, University of South Alabama, College of
( l7 o0 D. q, P: K" EMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( ~* i; [, s7 [
e-mail: [email protected].5 q$ m& l2 @# i' s
about 6 to 7 months old, which progressively became9 r4 A7 k) |7 Z0 j. J2 l8 n1 }
darker. She was also concerned about the enlarge-
; R% @+ ?0 ]; z; r- n8 w0 r% c t. k7 ument of his penis and frequent erections. The child
6 R4 T/ n6 Z( d" l, vwas the product of a full-term normal delivery, with2 T* ~/ O! { |8 l6 p, L- q
a birth weight of 7 lb 14 oz, and birth length of7 s- d: M' z6 ^' ~4 C! i8 f
20 inches. He was breast-fed throughout the first year2 Q: H% H( c5 G8 ]9 N2 x) r
of life and was still receiving breast milk along with
7 |( d( E+ U& R: E; ?solid food. He had no hospitalizations or surgery,
" {: d) ]8 l+ V0 H2 k6 fand his psychosocial and psychomotor development6 s1 q( U+ `# S
was age appropriate.
7 T) i% z! `3 k9 E2 | O: t- iThe family history was remarkable for the father,
7 w, P% R+ D% x$ V& p# pwho was diagnosed with hypothyroidism at age 16,& S- l3 ~$ z$ B, C9 U
which was treated with thyroxine. The father’s
1 H a8 o7 T3 Hheight was 6 feet, and he went through a somewhat
& l! `) Z1 e' c+ G1 I2 W; e1 tearly puberty and had stopped growing by age 14.
0 i. V# q8 g- n" j8 dThe father denied taking any other medication. The
( b: F6 C' D6 _# v& R, j% mchild’s mother was in good health. Her menarche' B: O: u9 `' l
was at 11 years of age, and her height was at 5 feet
0 n1 a' T3 F' y, S$ _+ J0 k5 inches. There was no other family history of pre-; z$ W2 z. g9 ?) G0 P
cocious sexual development in the first-degree rela-
1 |+ T. E: Y# R# ltives. There were no siblings.9 a# N$ s) Y* k4 U, n c; @
Physical Examination
3 X9 W5 X5 t/ h) G- BThe physical examination revealed a very active,! W- t+ o) r( k" j; Y
playful, and healthy boy. The vital signs documented9 I1 h" U& ~" X* _
a blood pressure of 85/50 mm Hg, his length was
' A4 x% i# j* K: i/ a" {% X90 cm (>97th percentile), and his weight was 14.4 kg8 ]) u( {( `) _( V4 F9 t' A
(also >97th percentile). The observed yearly growth
: P3 N/ O' v6 P o: mvelocity was 30 cm (12 inches). The examination of
( h4 Z0 c' }3 jthe neck revealed no thyroid enlargement., ]& c* e" n' R" k3 p
The genitourinary examination was remarkable for
8 w& p% N" M8 |! K ^9 ienlargement of the penis, with a stretched length of8 K. P6 S& k3 r# M) [( D6 Q7 R8 @
8 cm and a width of 2 cm. The glans penis was very well1 E2 U2 v. S0 P- D5 w& W
developed. The pubic hair was Tanner II, mostly around' d, m5 x( c" S* t$ B, j" r
540
4 O9 }. R& x/ @2 E% F' {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# z: X3 L$ A+ b, k4 u0 F4 B6 x' Dthe base of the phallus and was dark and curled. The
9 ^) t. J9 n a8 utesticular volume was prepubertal at 2 mL each.0 f0 A7 T# Z! g' G5 t( I
The skin was moist and smooth and somewhat; y s! t7 @4 |6 U0 c
oily. No axillary hair was noted. There were no
0 D, V9 A% j) T/ \abnormal skin pigmentations or café-au-lait spots.+ n* C6 w1 o: V( m" \- y+ @
Neurologic evaluation showed deep tendon reflex 2+! v- x' q+ v) s0 m2 |) a4 P3 o
bilateral and symmetrical. There was no suggestion" M3 y- X9 ^4 B( h, ^$ h
of papilledema.: _. \( x4 L2 c$ Y7 v1 ^3 t3 C* Y6 d
Laboratory Evaluation
# y( z- M2 B. [) XThe bone age was consistent with 28 months by, t8 c- \! u( d" }6 Z. S' `! E
using the standard of Greulich and Pyle at a chrono-5 T& m1 v! { R; P) e
logic age of 16 months (advanced).5 Chromosomal
2 M. c& \* H: P2 a: Xkaryotype was 46XY. The thyroid function test
( ?3 T8 r: y0 Q/ z. D; o2 C$ U) fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-' j& v8 J) O% o; P0 G( i
lating hormone level was 1.3 µIU/mL (both normal).
3 Y h" v8 t* W OThe concentrations of serum electrolytes, blood# |4 b, g. O* `* h- t% [
urea nitrogen, creatinine, and calcium all were
9 `" ?# U( u5 _5 d- G7 g$ ?within normal range for his age. The concentration# P1 p- `" c8 S# d# A* A3 W/ L
of serum 17-hydroxyprogesterone was 16 ng/dL6 u! ^3 {; O( N1 N! l# y( @+ @* e2 C
(normal, 3 to 90 ng/dL), androstenedione was 20
+ x( G) F! G# |! J* X0 K( xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 w) I# p+ E) y8 c. l, ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; z3 V& ^! O& k0 c2 Z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) [2 p# [" z; N0 C! f A+ X9 m( e/ W49ng/dL), 11-desoxycortisol (specific compound S)7 u2 F# r( _2 {& u7 N- n: t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# D$ H4 {2 o1 Z4 c2 _4 B: M& \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! ]6 i, h" d @: d8 U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% F4 e) \+ ^$ D8 F5 `and β-human chorionic gonadotropin was less than
0 n- |& q9 k% B+ r* |) z: a6 f5 mIU/mL (normal <5 mIU/mL). Serum follicular
( @: O6 v1 h: v, A- h! {stimulating hormone and leuteinizing hormone
4 K8 W5 i* a8 }& m9 O# Vconcentrations were less than 0.05 mIU/mL3 T! J5 q- V. R2 `! h/ R
(prepubertal). f* i% X9 |3 y9 \% R
The parents were notified about the laboratory
% @; b4 F P% g4 ^% l# r6 A gresults and were informed that all of the tests were6 r+ v1 O* N+ P9 b7 Q2 h& g3 o) A6 w& `
normal except the testosterone level was high. The
0 i1 o0 F5 }& D2 W P4 l, i8 a& yfollow-up visit was arranged within a few weeks to% y( ]- t O* g) H! `) ?3 @
obtain testicular and abdominal sonograms; how-
6 e2 `9 }0 D2 ~+ J8 x7 P1 K* fever, the family did not return for 4 months.3 @9 z5 R2 F6 N6 Z: P
Physical examination at this time revealed that the
2 ^9 |* n1 W; z1 ?0 ~8 t) g$ Qchild had grown 2.5 cm in 4 months and had gained
) \1 R' D$ [) ~% T! Y ^; F2 kg of weight. Physical examination remained
" f1 A% x8 N* [1 U% zunchanged. Surprisingly, the pubic hair almost com-
$ Q! l6 {/ ?% v8 Fpletely disappeared except for a few vellous hairs at
$ }) X: i8 K( L: \8 f8 c- Pthe base of the phallus. Testicular volume was still 2
; [4 C: c' E+ Y* V" V0 g2 CmL, and the size of the penis remained unchanged.3 V! T, K8 C7 Y {% i+ c4 ?
The mother also said that the boy was no longer hav-
3 N0 r, G0 ^1 C, C, c/ z7 Ving frequent erections.$ y1 Z/ a* G* c X$ G6 W3 E
Both parents were again questioned about use of
* S/ H) b0 Q* qany ointment/creams that they may have applied to
( r2 j( @( v* j: ]$ ]- othe child’s skin. This time the father admitted the1 k' H7 s) p- F" S t) g
Topical Testosterone Exposure / Bhowmick et al 541
& F" w, P3 Q6 U2 s6 I2 ause of testosterone gel twice daily that he was apply-
0 E {9 N3 ]. L- z' a( ping over his own shoulders, chest, and back area for
1 w/ T4 g( `2 T) I* ]( Ca year. The father also revealed he was embarrassed: o) o9 p% Y5 K; W
to disclose that he was using a testosterone gel pre-
% e2 Y$ y) K: m8 d+ w# }7 T( hscribed by his family physician for decreased libido
3 ^+ R5 Q" }1 U* r* y. V: `& Rsecondary to depression./ v& o# o+ I9 t) w7 X
The child slept in the same bed with parents.& O* I+ J- b: w" p- F
The father would hug the baby and hold him on his. l' W- M" W7 h1 t, ^3 U. l
chest for a considerable period of time, causing sig-
) H9 ?+ m$ Y9 ynificant bare skin contact between baby and father.8 b m; N6 ?. D% s2 o5 _4 ?
The father also admitted that after the phone call,7 `/ t/ x) w6 E( R4 ]
when he learned the testosterone level in the baby
) L3 _9 y L- i! T/ d& k+ zwas high, he then read the product information
% ], {/ j7 X" X: _/ N/ i) U3 rpacket and concluded that it was most likely the rea-
8 p6 Q4 M" m4 w6 b& @- ^son for the child’s virilization. At that time, they
( F( f# }! Z5 L; Q# J5 c& Kdecided to put the baby in a separate bed, and the6 {& q. B' k! X+ w1 q2 k1 t4 S$ ~0 j
father was not hugging him with bare skin and had
8 ]4 P, v/ l. q W4 Ubeen using protective clothing. A repeat testosterone) g# l2 V$ G1 J3 W: p* h7 P
test was ordered, but the family did not go to the- q. W$ o' R9 b7 m" d; u
laboratory to obtain the test.. P4 z k/ N- n/ w/ s- | Z
Discussion* v0 L) K, O) d
Precocious puberty in boys is defined as secondary( o9 W2 t9 B" A5 W/ o
sexual development before 9 years of age.1,4' c1 d9 N3 a6 H
Precocious puberty is termed as central (true) when
' ?/ j. o. N8 D% Cit is caused by the premature activation of hypo-
7 K4 [4 q9 U1 t9 Y" c, @5 Rthalamic pituitary gonadal axis. CPP is more com-* U& E s f8 a" E
mon in girls than in boys.1,3 Most boys with CPP
& M' e" h: O& ? b% Gmay have a central nervous system lesion that is
) n2 t0 ?/ q, s2 A$ M: j( Cresponsible for the early activation of the hypothal-; m# ^. K. k* o, g+ c
amic pituitary gonadal axis.1-3 Thus, greater empha-
; T8 V6 u U. L" a3 Tsis has been given to neuroradiologic imaging in3 @3 m9 t3 J# c4 w
boys with precocious puberty. In addition to viril-
4 Z1 ~! i" T ^2 A: x3 e6 Wization, the clinical hallmark of CPP is the symmet-
s. F; @" i; U5 crical testicular growth secondary to stimulation by
- W3 \6 I+ `- I3 @ Y$ Egonadotropins.1,3! S3 J& {5 f7 j
Gonadotropin-independent peripheral preco-% D# _/ w! Y. M3 R6 V' C5 w7 s* N* g
cious puberty in boys also results from inappropriate
+ h. T" ^. y( |; h- V7 r( pandrogenic stimulation from either endogenous or5 B9 f/ B4 b/ V9 l
exogenous sources, nonpituitary gonadotropin stim- T% a! c+ D( `. k' u: I
ulation, and rare activating mutations.3 Virilizing; Y @4 ]4 H! N2 A; @' [. ]
congenital adrenal hyperplasia producing excessive( X5 b5 Y# Y' n! I# W" @
adrenal androgens is a common cause of precocious, G/ j7 e8 h" X7 b2 ?9 I" f* e/ l* e
puberty in boys.3,4& s u# `5 x# p1 I. b" f5 L
The most common form of congenital adrenal. M( A8 D" G# ~+ n3 z
hyperplasia is the 21-hydroxylase enzyme deficiency.8 w# l4 X2 s+ W7 L
The 11-β hydroxylase deficiency may also result in F# F) P4 G, W; q% {' m
excessive adrenal androgen production, and rarely,3 v- X- g- n6 e9 X, u% h
an adrenal tumor may also cause adrenal androgen+ x) n y% W1 v/ ^. @* a
excess.1,3
7 [: U8 P# y8 C2 j0 P: Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 N0 N: \7 P! V' O9 F# K5 a
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& H( P3 n( u, }
A unique entity of male-limited gonadotropin-
1 Y2 i; B: j& X6 ]! w, n, }: Rindependent precocious puberty, which is also known4 i$ G% O: \) I% @9 Q
as testotoxicosis, may cause precocious puberty at a
4 c6 y# P$ C& `very young age. The physical findings in these boys/ D0 }3 g# J; j, m: [" L; p
with this disorder are full pubertal development,
) }3 j! p" W) Z1 y1 K0 Kincluding bilateral testicular growth, similar to boys7 m3 f) S' C" B1 L/ @9 q p
with CPP. The gonadotropin levels in this disorder
) c1 r/ E0 Y, ~0 B# |are suppressed to prepubertal levels and do not show
( P. y( G" F0 Y/ ]pubertal response of gonadotropin after gonadotropin-/ E" V+ U* A+ o4 r) j
releasing hormone stimulation. This is a sex-linked1 J0 {2 e% V3 o9 ?* e
autosomal dominant disorder that affects only
! O& _) Q1 h! T: dmales; therefore, other male members of the family
, n- u a" @$ K2 Q$ H# s5 _may have similar precocious puberty.3# `/ M; C9 B* d0 F# h
In our patient, physical examination was incon-& ^9 ~* T0 d+ J8 D+ ^' ^* a
sistent with true precocious puberty since his testi-
0 N9 H- A; D. H" `7 e+ _cles were prepubertal in size. However, testotoxicosis* x* z& U# j a7 `3 W- T
was in the differential diagnosis because his father
' w/ E1 Z, c, A) ?started puberty somewhat early, and occasionally,
+ h8 z- S3 ?0 r7 itesticular enlargement is not that evident in the4 s& a5 d- c( B& c( X- j
beginning of this process.1 In the absence of a neg-
+ R- Q3 j- Z* S! X* z6 yative initial history of androgen exposure, our
8 L$ o* L, \- T+ ~biggest concern was virilizing adrenal hyperplasia,1 {. Y9 u- M9 V( {
either 21-hydroxylase deficiency or 11-β hydroxylase5 e F, |2 Q _; @4 A1 B: r
deficiency. Those diagnoses were excluded by find-
- N) M) r, T+ j* Ting the normal level of adrenal steroids.
% L! h# C, m4 s* t4 c9 VThe diagnosis of exogenous androgens was strongly; c% C/ M; y! y9 R: C
suspected in a follow-up visit after 4 months because
2 o4 n4 W4 z4 m8 m- lthe physical examination revealed the complete disap-! F J3 E5 z+ v* F2 z9 L) \3 X
pearance of pubic hair, normal growth velocity, and
6 y9 x& Z/ G" m( ^2 H" wdecreased erections. The father admitted using a testos-
1 i4 V L" M7 C" M vterone gel, which he concealed at first visit. He was
& f" }( O1 r0 h$ k1 ^& Ausing it rather frequently, twice a day. The Physicians’% ^' H, W1 f0 v( [. L5 T: q7 X
Desk Reference, or package insert of this product, gel or, A2 J9 p, ^( ^
cream, cautions about dermal testosterone transfer to
3 b, {2 ~6 P, l: punprotected females through direct skin exposure.
; J4 ^2 p4 R$ [" v: H3 |Serum testosterone level was found to be 2 times the J, M( p+ R7 y" D
baseline value in those females who were exposed to1 Z/ P% M9 U1 F" m
even 15 minutes of direct skin contact with their male2 q* m4 n' x6 H5 F
partners.6 However, when a shirt covered the applica-
/ S- C. K& v2 y# o6 stion site, this testosterone transfer was prevented.
! q7 m5 b# t. S( c0 B" Q: dOur patient’s testosterone level was 60 ng/mL,1 I/ i1 Q) @- a0 w% _( h" r
which was clearly high. Some studies suggest that+ J$ g8 f; G( T7 `
dermal conversion of testosterone to dihydrotestos-
- r' _# B+ L1 J5 Pterone, which is a more potent metabolite, is more
# }4 Q1 W! S1 n' _5 cactive in young children exposed to testosterone
- b2 u, e7 y5 [6 s( r9 H5 I1 ?exogenously7; however, we did not measure a dihy-3 R/ ]( g& K9 J; B A
drotestosterone level in our patient. In addition to5 E' e0 a% X9 Z. G) p2 B
virilization, exposure to exogenous testosterone in7 J2 C! k( [3 ^" l
children results in an increase in growth velocity and
" H c, Z% _+ Z# ?3 l5 f& I _6 L* l% Uadvanced bone age, as seen in our patient.
7 \5 J4 N+ O4 X! I2 cThe long-term effect of androgen exposure during
, M# Y! h+ {9 d* f' v% Y# T5 d. C; _early childhood on pubertal development and final& |5 _5 k7 ~& ~
adult height are not fully known and always remain
8 t8 Z; r6 f- }a concern. Children treated with short-term testos-
. x3 n1 ?1 G2 zterone injection or topical androgen may exhibit some: B( x5 n a. ]3 _$ V8 L3 z
acceleration of the skeletal maturation; however, after& C2 F$ ]5 k# y9 _; v$ p
cessation of treatment, the rate of bone maturation/ A: [: f: f3 H% j4 T
decelerates and gradually returns to normal.8,94 z J7 R% E' P; T
There are conflicting reports and controversy
r1 u' X- D. T+ B7 J+ ?/ H3 Sover the effect of early androgen exposure on adult
! o: f" O: r' D: `penile length.10,11 Some reports suggest subnormal# l0 f1 l0 ~" Q( v! _4 Y
adult penile length, apparently because of downreg-
! `/ P+ p$ R' s. B2 c1 Qulation of androgen receptor number.10,12 However,2 e3 k1 E# Y& m3 `9 B/ I
Sutherland et al13 did not find a correlation between
c9 D" Z0 p2 t" l7 k& C. G' k* {childhood testosterone exposure and reduced adult& I# C* B" B v/ M8 Q. ~, K" e
penile length in clinical studies.5 }. G/ U; f" i9 k6 Z9 ?
Nonetheless, we do not believe our patient is5 @4 e) D8 @+ P. z3 |: g# c! G# s5 G
going to experience any of the untoward effects from! N' q& C* k" u6 j A
testosterone exposure as mentioned earlier because0 s7 l C( [' T- B8 F, g5 t% G
the exposure was not for a prolonged period of time.
- ^" }. B J9 z; z$ uAlthough the bone age was advanced at the time of! X+ I M! [$ t" `: _% p
diagnosis, the child had a normal growth velocity at
( g, F1 t8 X C. @the follow-up visit. It is hoped that his final adult
! M! N$ A* j& m( y8 |# D T" rheight will not be affected.
; d. A8 X2 E* a; JAlthough rarely reported, the widespread avail-. y# X5 c, V; F6 ^" z" U- z, I
ability of androgen products in our society may
& r) d6 I& c0 r, d, X9 C6 u U5 r( |! Zindeed cause more virilization in male or female) m) ]% m6 X7 {4 J+ b$ ?8 I
children than one would realize. Exposure to andro-4 B: Y/ R$ L, U0 f
gen products must be considered and specific ques-
9 B) e6 \" w' c3 Z. z' \" ntioning about the use of a testosterone product or. q! J2 X$ ?8 s: d: G6 a
gel should be asked of the family members during
; U+ i0 z' [1 z- g8 jthe evaluation of any children who present with vir-2 V! A+ m: ^7 f' l4 i
ilization or peripheral precocious puberty. The diag-
8 N9 X0 E/ N& x* U4 Anosis can be established by just a few tests and by
/ I( U. G: U7 M$ z+ eappropriate history. The inability to obtain such a
' O4 q2 x8 m& w* Q- V6 ^+ [ t7 ^6 P; Whistory, or failure to ask the specific questions, may
% }; m; i+ n6 Iresult in extensive, unnecessary, and expensive
$ r8 Z- C( t3 hinvestigation. The primary care physician should be
0 L: _& k8 n! i# ^* j4 x5 zaware of this fact, because most of these children
& o$ C" T3 Q: s4 Z& h: o+ w: Gmay initially present in their practice. The Physicians’2 a' r* i/ K* A/ h
Desk Reference and package insert should also put a0 R" d. \' O i
warning about the virilizing effect on a male or
' P [, E4 a& t$ _! Lfemale child who might come in contact with some-
6 @* g& U. H7 s6 o u+ Lone using any of these products.) q l" Y& @% r9 c X; M6 A
References6 Y) V& Q* Q' ]( o1 p" A
1. Styne DM. The testes: disorder of sexual differentiation, f3 w3 o7 u, h' T! j
and puberty in the male. In: Sperling MA, ed. Pediatric
8 k0 Y; X" u0 n% W) W; }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! G3 x! W1 J c8 E8 g2002: 565-628.
/ u( o! H. j/ A8 a4 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 ^; Y' g$ ^" n) c7 G
puberty in children with tumours of the suprasellar pineal |
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