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Sexual Precocity in a 16-Month-Old
: I" A6 {2 R* J1 C4 A, {Boy Induced by Indirect Topical
) E, r0 l4 c. \! d* lExposure to Testosterone
9 w9 j D7 V# DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ u( P5 k7 {* Q0 L" L
and Kenneth R. Rettig, MD17 f4 Z7 v% z" [6 e' a. M$ b
Clinical Pediatrics
1 k/ I: D0 m2 E8 oVolume 46 Number 60 Q8 i2 |7 K x' R5 c
July 2007 540-543
) ]* Q! c; Z: V% G$ p© 2007 Sage Publications4 V# G- S C) J9 K- `# m
10.1177/0009922806296651/ \. I3 H2 P& J$ O! P
http://clp.sagepub.com& r1 X+ c8 y( F7 s1 ~5 j
hosted at$ q6 }( Z( f) y" `& D
http://online.sagepub.com
* t( q2 B A/ o5 BPrecocious puberty in boys, central or peripheral,* h9 D$ ~5 u" i3 [6 @4 X* t
is a significant concern for physicians. Central) n9 X& K& Z! j" t3 A: g$ p! D4 ^
precocious puberty (CPP), which is mediated
% T+ S1 K9 ^- y* g' l' Cthrough the hypothalamic pituitary gonadal axis, has" B3 E& {& C1 }; z) i' ^% h1 x% w( d
a higher incidence of organic central nervous system5 b; }, z9 x' w; h1 k8 u- A
lesions in boys.1,2 Virilization in boys, as manifested# L! G( Y+ v: j/ q' B+ M! `
by enlargement of the penis, development of pubic! m: }" N7 t- @. s
hair, and facial acne without enlargement of testi-
: @( }0 H" d4 o2 c0 @/ Dcles, suggests peripheral or pseudopuberty.1-3 We) U* x. g+ s/ G, r, |' _ K' Y
report a 16-month-old boy who presented with the7 B5 S' u5 }) W6 u
enlargement of the phallus and pubic hair develop-
3 `! s- v& W$ k1 R# [) `ment without testicular enlargement, which was due
. _3 l1 A0 N9 h5 }+ I0 t: Oto the unintentional exposure to androgen gel used by
6 i+ ]( g# |7 A+ @' Ythe father. The family initially concealed this infor-
8 E6 P/ c" h; k, e9 r$ D6 K5 Zmation, resulting in an extensive work-up for this
5 a% B( T/ f0 {& |6 R' Rchild. Given the widespread and easy availability of3 Z# K4 f# F& \- @2 R# |( f# j- @
testosterone gel and cream, we believe this is proba-& F ?6 H6 J( ^2 s! R
bly more common than the rare case report in the6 A& }/ @3 \' U. p
literature.4
- y" W8 u4 n! GPatient Report2 \& k+ r/ G# z; v; f
A 16-month-old white child was referred to the1 f( S! [+ t- U1 m* n: {, z
endocrine clinic by his pediatrician with the concern
* \* {$ W- M$ U. vof early sexual development. His mother noticed9 V) ] G6 B/ @; r4 o, F% \. r! D
light colored pubic hair development when he was5 ]8 C/ \1 K7 F0 e, p3 p- l
From the 1Division of Pediatric Endocrinology, 2University of5 q" h! M/ U4 z2 Y8 V( z
South Alabama Medical Center, Mobile, Alabama.
# S/ g0 R6 d8 J2 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,! T# t, I% J. ?! O. p7 F0 }; G0 _0 Y
Professor of Pediatrics, University of South Alabama, College of
- _7 c9 R6 t: j( e+ d+ e" d6 cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( w8 ?1 e8 W5 x- u3 r z
e-mail: [email protected].
2 H7 W4 x$ `: [" Zabout 6 to 7 months old, which progressively became
9 {. o% ~; R, t$ w' Pdarker. She was also concerned about the enlarge-
8 U% r: n+ b( x* T9 z, r& wment of his penis and frequent erections. The child
8 K | d+ q. i" Gwas the product of a full-term normal delivery, with: b' n& F) W1 S$ z! @; j
a birth weight of 7 lb 14 oz, and birth length of
- r$ e4 m" G: F' d; l% c20 inches. He was breast-fed throughout the first year
# _- X( S) T+ u9 gof life and was still receiving breast milk along with
8 n3 W. {7 S6 @9 |* ?) c5 hsolid food. He had no hospitalizations or surgery,/ c ^6 h* p1 W% s
and his psychosocial and psychomotor development
q8 p: b, R) s7 Q4 }was age appropriate.; k3 U; w1 p) m% D
The family history was remarkable for the father,
4 R3 L& B9 u; g& B3 _who was diagnosed with hypothyroidism at age 16,
7 [4 T1 m6 {1 p* D: ^which was treated with thyroxine. The father’s
, F4 @/ Y- m6 C3 f3 c) qheight was 6 feet, and he went through a somewhat; b! A( O- j6 u
early puberty and had stopped growing by age 14.6 k* E0 ~2 J1 `8 z" \' z7 G
The father denied taking any other medication. The: S, y* T8 X, q: S+ ?
child’s mother was in good health. Her menarche
2 l a: }( C% i! o1 owas at 11 years of age, and her height was at 5 feet
) x5 n1 q3 E' m9 S. {0 s% W, P# _5 inches. There was no other family history of pre-, g N% F5 P! s# e8 V
cocious sexual development in the first-degree rela-
* C7 ?# d- \4 q' v% |tives. There were no siblings.
. L! ?( [5 ^" FPhysical Examination
0 v C, M' E: Q, LThe physical examination revealed a very active,4 Q" ]5 K7 I5 \2 o0 t, h; d
playful, and healthy boy. The vital signs documented* L. ^# m! V' e s' x3 T
a blood pressure of 85/50 mm Hg, his length was
: r! R" X0 @5 r) h" {! [90 cm (>97th percentile), and his weight was 14.4 kg
2 j, u6 {4 b+ Y& V* n(also >97th percentile). The observed yearly growth7 d/ X3 o- X' o, U. S# ]
velocity was 30 cm (12 inches). The examination of0 e# H8 L8 x5 k; z2 h2 b
the neck revealed no thyroid enlargement.- T- Y W! ^' n
The genitourinary examination was remarkable for
0 @* w" @$ `* \! J* R4 Venlargement of the penis, with a stretched length of
" e( U) l. X, Q8 cm and a width of 2 cm. The glans penis was very well
0 [- o! ~! s4 H6 B( W* L9 sdeveloped. The pubic hair was Tanner II, mostly around& j i' i3 t4 s! c: M
540; v! O) N+ i+ Q2 i) @1 _- }0 u" ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" e0 A5 I* ?# _4 |$ e1 z0 E: dthe base of the phallus and was dark and curled. The
; [2 P$ M9 P/ C) i* ~9 W- E& ctesticular volume was prepubertal at 2 mL each.+ |0 }9 b8 |! D
The skin was moist and smooth and somewhat
4 w, A/ v1 b" R( C+ I& P5 ^oily. No axillary hair was noted. There were no W# j: v9 `" ~- F1 Z" d
abnormal skin pigmentations or café-au-lait spots.
+ E' N( t4 D6 r8 j7 `Neurologic evaluation showed deep tendon reflex 2+
1 v0 i. y5 V' `/ {, z" Wbilateral and symmetrical. There was no suggestion4 o3 g2 I) i; |1 l: j
of papilledema.. d/ h' }9 ] }- H" c0 x# J- _
Laboratory Evaluation9 I6 _6 Y0 O# u' ?) }
The bone age was consistent with 28 months by. j( H+ s+ B5 Z
using the standard of Greulich and Pyle at a chrono-
, G8 T: \3 @) t, k7 _/ E4 Jlogic age of 16 months (advanced).5 Chromosomal2 X4 A7 K6 C" t7 O
karyotype was 46XY. The thyroid function test
6 n6 A4 N6 B& q! y* Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: {# y- @$ T5 N; l. g# b" R
lating hormone level was 1.3 µIU/mL (both normal).
* |8 R6 F r# c* C2 W3 Y3 gThe concentrations of serum electrolytes, blood
0 ]8 }- D8 D" Z0 furea nitrogen, creatinine, and calcium all were1 `4 s% x3 }8 a( d7 e
within normal range for his age. The concentration2 c) h0 q/ }- {2 S, Y' W6 p1 A) A& x
of serum 17-hydroxyprogesterone was 16 ng/dL' [& \) m% s- m0 |8 v$ e( W
(normal, 3 to 90 ng/dL), androstenedione was 200 Y' u4 o$ k% e* S; ~# g& i6 {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ h. n( v, X9 ~1 o: X6 ], c
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( o7 y0 V, t4 q. {desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 [' B+ }. ^* r; W# g
49ng/dL), 11-desoxycortisol (specific compound S)
! S# { J+ p# s0 j) v9 ?) n7 Y5 ]7 uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ P0 I5 W5 O6 F$ T, h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 {& c0 c9 G, X; G4 G9 T) l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- ]' P3 b( P* ~! T6 j
and β-human chorionic gonadotropin was less than
& v# K1 i+ D9 S) F5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 i! p7 R9 F6 a$ R+ z5 f* lstimulating hormone and leuteinizing hormone1 e6 l! i# _, q, d3 M6 a
concentrations were less than 0.05 mIU/mL! L" X* ~4 L! a+ n' \
(prepubertal).
( t7 ?: u. t8 \1 ]" fThe parents were notified about the laboratory7 P& G9 z9 M/ |1 U( R5 ]
results and were informed that all of the tests were
. p2 F0 y" Y- \, w! Q2 |/ L8 {% Snormal except the testosterone level was high. The* @ Y$ @ v. W5 x# n
follow-up visit was arranged within a few weeks to
, s$ ]; @$ \: O6 T* p8 Pobtain testicular and abdominal sonograms; how-( v- F& k8 ^& f8 V( i! m) H5 a
ever, the family did not return for 4 months.
( N+ J- D; `6 G6 p* OPhysical examination at this time revealed that the
: [& p7 O/ h5 lchild had grown 2.5 cm in 4 months and had gained
, S$ o$ y1 u+ l9 e5 F2 kg of weight. Physical examination remained
1 z. U) f% V* l2 l$ S& Junchanged. Surprisingly, the pubic hair almost com-
; R$ T& z' E0 D9 Y9 r' X$ [: [) fpletely disappeared except for a few vellous hairs at, L" c* B7 \- o* |' d
the base of the phallus. Testicular volume was still 2
+ X) b( P* ^& v; V# _# TmL, and the size of the penis remained unchanged.
8 h$ H/ y. u1 k+ [' kThe mother also said that the boy was no longer hav-
' h O+ ~: @( ]- b# {, p) ^ing frequent erections.4 p' D3 s2 X& _/ F
Both parents were again questioned about use of
& x* J1 N; O- E6 d2 X+ uany ointment/creams that they may have applied to
; t1 _& E3 w2 V% o- U; @the child’s skin. This time the father admitted the1 t( v1 e5 n0 ~3 [5 d5 n
Topical Testosterone Exposure / Bhowmick et al 5415 s/ X* f! |; S) v
use of testosterone gel twice daily that he was apply-5 q D. r( K, G, a' |* l% {- S9 Q$ M
ing over his own shoulders, chest, and back area for
/ l y. `, F" ?( J4 Ba year. The father also revealed he was embarrassed/ [! B3 ~( [& B
to disclose that he was using a testosterone gel pre-
( j4 p" n! F+ g0 T7 U8 Q0 Lscribed by his family physician for decreased libido0 H& j% Q6 P! r& J) n2 `- c% t+ v
secondary to depression.
& T- {; h4 ^, G) |The child slept in the same bed with parents.; Z! n7 d7 k8 n
The father would hug the baby and hold him on his2 m- q5 S" w2 d0 j2 ]
chest for a considerable period of time, causing sig-7 o- x9 H1 i$ f: z+ N. C; @/ u
nificant bare skin contact between baby and father.
1 g% ^4 J9 G9 IThe father also admitted that after the phone call,
7 _; [/ }! F! y" ?when he learned the testosterone level in the baby
5 q6 h, E6 M" X- M' P o4 C0 fwas high, he then read the product information
& E% v% F5 H0 mpacket and concluded that it was most likely the rea-3 f( M. e& j1 p$ @- K* p
son for the child’s virilization. At that time, they$ d" C9 R6 H0 p
decided to put the baby in a separate bed, and the0 A( N! w, [# y5 L2 ^ G& g
father was not hugging him with bare skin and had
# j. W6 P! `) {" E( |; z% m% wbeen using protective clothing. A repeat testosterone V0 y8 z6 G8 L
test was ordered, but the family did not go to the: O. n, @$ W+ c1 o( A- S& t1 B
laboratory to obtain the test., H. M' i* K# h, l7 z' S
Discussion
1 e. ~' V2 ] h2 u' h+ I+ n" HPrecocious puberty in boys is defined as secondary7 R: u4 I7 H, c! j% D3 g* N
sexual development before 9 years of age.1,4
8 M% t& N2 |) i' K& w9 J( dPrecocious puberty is termed as central (true) when0 {7 j7 d$ {' \5 m3 b& k
it is caused by the premature activation of hypo-
) I2 f. l( h- ^* k0 m! V7 o3 w2 Tthalamic pituitary gonadal axis. CPP is more com-
# N- I- Z% w4 Nmon in girls than in boys.1,3 Most boys with CPP* _% o) V4 e) r1 v* V5 ?
may have a central nervous system lesion that is8 w- O; Z$ W2 B* c9 l5 u
responsible for the early activation of the hypothal-) Z' ]# M9 X2 H+ ?1 F1 \
amic pituitary gonadal axis.1-3 Thus, greater empha-
# n2 g% r/ h8 E- R4 Z, vsis has been given to neuroradiologic imaging in
. A! M, @! i2 X* d* c! xboys with precocious puberty. In addition to viril-
' W$ W1 a1 ]' ]: j7 c* zization, the clinical hallmark of CPP is the symmet-' `' G$ P- m; S5 S& H7 g* K
rical testicular growth secondary to stimulation by
5 o v# ~7 h" E5 } pgonadotropins.1,3
, o% s4 c8 U7 k1 k/ Z9 _+ PGonadotropin-independent peripheral preco-
# R: c% ?, d* r- Bcious puberty in boys also results from inappropriate
6 J* B% t# x! i: Z" ]( C) _3 n% }androgenic stimulation from either endogenous or3 W2 l: H* g$ z' l
exogenous sources, nonpituitary gonadotropin stim-. S/ Z% b2 v+ p% @9 }' [( j/ r& p
ulation, and rare activating mutations.3 Virilizing
/ t0 m- r: y$ L. |congenital adrenal hyperplasia producing excessive+ l; U6 N) `$ {: o% @
adrenal androgens is a common cause of precocious
2 L T8 s' U5 |5 W, J8 q* C5 npuberty in boys.3,4# U$ f: x4 P& s( y
The most common form of congenital adrenal! A4 z* |; ]3 K6 T
hyperplasia is the 21-hydroxylase enzyme deficiency.
" Q# O! M! C, z9 E, i, fThe 11-β hydroxylase deficiency may also result in' e) {( D9 m8 O* O/ f
excessive adrenal androgen production, and rarely,
7 v* ~% N/ a/ y$ T2 ~ S2 C0 ban adrenal tumor may also cause adrenal androgen3 n( b! Z U( d) I4 i, |" w& s) t
excess.1,3
1 u$ \% F4 ~, U4 _- M! Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 E7 t3 p4 g! K! H+ t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' ?' L& h4 X/ u( _; O- rA unique entity of male-limited gonadotropin-% B' K& G L$ }9 E+ y) e- p& b
independent precocious puberty, which is also known
0 v+ O. _' e" H* a# G. d! }+ ias testotoxicosis, may cause precocious puberty at a1 Q) `0 ]8 E+ J. |
very young age. The physical findings in these boys% L6 g" o8 \. ^0 k% K9 z4 x
with this disorder are full pubertal development,. N) K/ _, _% b( B
including bilateral testicular growth, similar to boys* |# X4 I( C/ w) c6 a- M
with CPP. The gonadotropin levels in this disorder
2 `" ?+ c, a& o1 Xare suppressed to prepubertal levels and do not show% W: o' N6 ^2 G2 Z$ [5 r
pubertal response of gonadotropin after gonadotropin-3 J- u3 D2 R# B6 I
releasing hormone stimulation. This is a sex-linked
3 `: f" ]9 B( Z( Z( H& jautosomal dominant disorder that affects only& D8 C a# L c# U3 \
males; therefore, other male members of the family5 c+ j O* g* ?) v9 r
may have similar precocious puberty.3
: i9 i% o0 L; x1 _$ Y. O& SIn our patient, physical examination was incon-; G% L1 s$ ~, k" G* @: U4 |9 W
sistent with true precocious puberty since his testi-
4 m$ [, l0 d1 Q- m0 h" g8 \( qcles were prepubertal in size. However, testotoxicosis, I0 D$ ^" L+ s- |( p5 \
was in the differential diagnosis because his father" a" M* I. ~" d' Z5 k9 g
started puberty somewhat early, and occasionally,: Z' ]2 a% m' w! C2 C; Z1 T
testicular enlargement is not that evident in the
% |' r$ d- o' w: ~# K4 ]4 d# Fbeginning of this process.1 In the absence of a neg-$ F4 ?2 ]; ^" ~5 Y
ative initial history of androgen exposure, our
e* q. q5 E9 E( h d4 n5 y2 Ybiggest concern was virilizing adrenal hyperplasia,
/ C2 W# f8 K1 p0 Weither 21-hydroxylase deficiency or 11-β hydroxylase' ]& S1 K2 j) @8 L
deficiency. Those diagnoses were excluded by find-
) t0 t: J& I3 M2 `" Ving the normal level of adrenal steroids.; ~& d8 o$ C; s9 L( Q
The diagnosis of exogenous androgens was strongly
2 y R3 I6 W# V% fsuspected in a follow-up visit after 4 months because- [. k3 N" M& D/ t% |( o8 `
the physical examination revealed the complete disap-! v3 \$ b& n* q
pearance of pubic hair, normal growth velocity, and5 I# V+ F! z2 N6 W# s0 ?
decreased erections. The father admitted using a testos-( b4 m" Y' T. C5 i. a* J
terone gel, which he concealed at first visit. He was3 o1 U- C3 M Y5 ^
using it rather frequently, twice a day. The Physicians’
- L7 J3 x, J" S# }Desk Reference, or package insert of this product, gel or
. j( x! v# q {+ tcream, cautions about dermal testosterone transfer to
3 H3 C+ N3 A2 munprotected females through direct skin exposure.: m% m8 i" J; u( r$ K
Serum testosterone level was found to be 2 times the7 o' J" i* k0 I1 O, i4 U( Y/ M
baseline value in those females who were exposed to
! s; X- T2 C7 u9 R7 C- Reven 15 minutes of direct skin contact with their male
0 T$ n* m1 J. s: E; n6 j. R; W- h7 S6 Ypartners.6 However, when a shirt covered the applica-
" a9 j0 j% c( Otion site, this testosterone transfer was prevented.& B! e0 B( D+ E2 j/ K- i" j O2 f$ I6 F! m
Our patient’s testosterone level was 60 ng/mL,
9 L% o5 ^. y/ @8 \1 Jwhich was clearly high. Some studies suggest that
1 M t7 E/ b0 T0 u; j: h. ]dermal conversion of testosterone to dihydrotestos-
6 C9 Y8 q3 M! _" d; \% Uterone, which is a more potent metabolite, is more2 R# a( d! t; m4 j+ d
active in young children exposed to testosterone" l/ P+ }& q5 o5 q; v5 L: x4 h* o
exogenously7; however, we did not measure a dihy-
7 h8 @3 a, f, A! R2 Rdrotestosterone level in our patient. In addition to' J' e& ~, `% O( {2 q; ?) I
virilization, exposure to exogenous testosterone in, K% X6 \( s# e
children results in an increase in growth velocity and/ o* v- o8 `" {9 j
advanced bone age, as seen in our patient.
9 }- Y- O: R/ u4 FThe long-term effect of androgen exposure during
$ X1 F+ J( q6 i& [0 Y1 aearly childhood on pubertal development and final' M7 H: \+ S/ y, _: _. |0 K# y$ O
adult height are not fully known and always remain
5 u0 o! U4 b% R# m9 F( a+ h$ u aa concern. Children treated with short-term testos-
8 J1 ~& y: T: F) r6 I; ]& N) vterone injection or topical androgen may exhibit some2 v |4 Q1 d0 I9 w; m
acceleration of the skeletal maturation; however, after
* S) D/ z( e# Acessation of treatment, the rate of bone maturation
' `$ m$ Y/ c& s7 ]5 Adecelerates and gradually returns to normal.8,9: u% T! L% a' s" @2 ?* ?, I
There are conflicting reports and controversy
1 c2 ~, G2 f0 l; @5 v" E: Mover the effect of early androgen exposure on adult
# a7 R; @6 {( @ W7 Ppenile length.10,11 Some reports suggest subnormal8 Y$ R8 d4 n* F- l" a" z
adult penile length, apparently because of downreg-- K3 s6 J6 e6 m9 L# j- }: R
ulation of androgen receptor number.10,12 However,6 W! G$ r- a0 d: k; {+ c
Sutherland et al13 did not find a correlation between; {. i1 [# y% `5 l/ C
childhood testosterone exposure and reduced adult. t' P3 a% a' F
penile length in clinical studies.5 Q8 {% L& t( F. ~1 Q
Nonetheless, we do not believe our patient is0 p8 k* ^7 R8 N V( F0 k2 ]+ t8 e
going to experience any of the untoward effects from
) k- Z; h6 M5 z1 \4 b, Etestosterone exposure as mentioned earlier because- Y0 ~9 Z0 B& ~% K! o2 a* v! O9 O
the exposure was not for a prolonged period of time.7 H1 n1 S. A9 Q5 ^4 R2 M
Although the bone age was advanced at the time of& _/ k1 f$ @* }1 n' ]9 z
diagnosis, the child had a normal growth velocity at
8 j/ P1 j0 Q8 \$ y7 othe follow-up visit. It is hoped that his final adult
% ~! Y$ m' _# K& ` X# Wheight will not be affected.
- U t1 l. L* e# z% kAlthough rarely reported, the widespread avail-0 ~& O' C0 \5 j$ k% x0 V
ability of androgen products in our society may3 u. |- X) g( W; n$ u" M- B
indeed cause more virilization in male or female7 t* y! a& @7 E$ Z9 K3 ~4 P3 h, x
children than one would realize. Exposure to andro-3 i ~; ?* E4 u# ~; Y* j
gen products must be considered and specific ques-
5 ?1 z W6 {/ M* ptioning about the use of a testosterone product or
( A" m( }: K# Z5 Sgel should be asked of the family members during
7 h, v& k( b n, L1 Q8 Sthe evaluation of any children who present with vir-- t$ _ ]1 \+ z: s* T3 X
ilization or peripheral precocious puberty. The diag-1 A# Y0 G& n- K, o Y1 S( N6 U
nosis can be established by just a few tests and by
) @4 G* R9 b" K- R& kappropriate history. The inability to obtain such a
7 f- ]; C' e/ T2 _/ e! nhistory, or failure to ask the specific questions, may2 N( A( n6 l& I6 k, [$ X* S, U7 r8 P
result in extensive, unnecessary, and expensive
/ u! L9 [& ^9 ? ?$ V/ h2 Dinvestigation. The primary care physician should be- U( }2 b0 P6 g9 E- _6 Q
aware of this fact, because most of these children; G, M$ E o2 j* }; n0 ~
may initially present in their practice. The Physicians’. A7 l) Q, v$ {# v# N M2 F
Desk Reference and package insert should also put a
# q& s* P) @3 e4 ~9 Z, t( b5 Jwarning about the virilizing effect on a male or
! W8 Q4 I9 l! ^female child who might come in contact with some-
, \, I8 ] g. ]0 H2 vone using any of these products. \) @7 w8 h: [2 h4 ^, Y
References
9 q9 T# A+ `% p+ `1. Styne DM. The testes: disorder of sexual differentiation
: q6 K/ a% N8 Xand puberty in the male. In: Sperling MA, ed. Pediatric; Q" I9 \6 i6 H1 d2 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( U5 m- F7 t9 F& I7 E
2002: 565-628.
1 N1 i3 F- r$ D9 b+ X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ z3 N0 l k) `4 F+ h3 s3 h& b5 I
puberty in children with tumours of the suprasellar pineal |
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