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Sexual Precocity in a 16-Month-Old" a% {" G* @' [7 p g% e
Boy Induced by Indirect Topical
$ ]5 n! f) ]9 ]! J- dExposure to Testosterone
$ }) y# a+ B6 R4 LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 M( D. ~1 M A6 a: v A
and Kenneth R. Rettig, MD12 P( y$ a5 t+ F ~* P8 x
Clinical Pediatrics! `: r5 t5 T9 `. w' @) \% m
Volume 46 Number 6
* w/ J4 _% Q* h, O0 d6 x" mJuly 2007 540-543
/ z3 Q2 z5 Q5 ]# S. P© 2007 Sage Publications- G" i, [$ r2 f# w+ K, h1 S
10.1177/0009922806296651
" v% b0 E% X$ J- | Dhttp://clp.sagepub.com
% J; o/ W$ @3 N# I; t4 z$ S# Ehosted at' T. ]. y' a/ B
http://online.sagepub.com; ]% @& e8 d6 z4 I" b: C$ Y
Precocious puberty in boys, central or peripheral,
' n w/ m: a' ~$ i% ^( Wis a significant concern for physicians. Central
5 g/ y* o" Y5 x# Kprecocious puberty (CPP), which is mediated7 ~- o: X9 A( N% n
through the hypothalamic pituitary gonadal axis, has
]* u/ E' D+ I% b3 V$ [+ g; k7 aa higher incidence of organic central nervous system8 j% b; t3 p; r$ N8 [
lesions in boys.1,2 Virilization in boys, as manifested
! Q: P( x$ _; h/ m! sby enlargement of the penis, development of pubic
' Q# W% h+ I) L, R+ |3 jhair, and facial acne without enlargement of testi-
8 g3 l4 h6 m8 t" b- h' L; ^- {) ^cles, suggests peripheral or pseudopuberty.1-3 We% A `) N+ Q- x# X' r; I
report a 16-month-old boy who presented with the
' [) p4 f$ X0 W7 E Fenlargement of the phallus and pubic hair develop-
( j x3 H B" R: tment without testicular enlargement, which was due
& Y$ }+ a0 d" ~9 jto the unintentional exposure to androgen gel used by5 J |9 |6 F1 f0 t3 i ?( E. H
the father. The family initially concealed this infor-7 ^5 j- o* X+ p& H4 D
mation, resulting in an extensive work-up for this5 i, C" B5 E# q% [5 S6 h, P {
child. Given the widespread and easy availability of
$ T/ w9 ?% m7 g! g+ z* gtestosterone gel and cream, we believe this is proba-2 Z7 L% J4 u2 q9 e4 C
bly more common than the rare case report in the5 v- z U/ I/ A0 E. O8 W8 |3 ?
literature.4" L8 V% [4 Z. J; |( `/ W0 {' s. [+ a
Patient Report
4 ~) w0 B& c7 t1 g8 ?: GA 16-month-old white child was referred to the
M: A, R# R" q1 W# D$ Yendocrine clinic by his pediatrician with the concern( h0 O) x0 a3 z3 y" m% Q# f! n+ B: P
of early sexual development. His mother noticed
B$ G9 W8 N; U! ]8 e3 _light colored pubic hair development when he was
1 J7 i3 j: a- ]- H7 }$ I/ q" ]/ nFrom the 1Division of Pediatric Endocrinology, 2University of
1 b! w8 |' p2 m/ L# j+ U* i, p' OSouth Alabama Medical Center, Mobile, Alabama.$ ]: Q8 N# S8 O M3 b
Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 ?8 }7 q: ?! Z7 U% A% y [7 hProfessor of Pediatrics, University of South Alabama, College of5 L2 z( i$ c' U! Y' M' i1 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 A* O+ ~: `1 k+ x( J' Ce-mail: [email protected].6 D$ i+ z5 @! H `5 {( R
about 6 to 7 months old, which progressively became+ ^0 t0 Q+ o- C) D7 x" c
darker. She was also concerned about the enlarge-) M5 h1 {! G' l" N: H: A, L
ment of his penis and frequent erections. The child
3 \( ~% h3 @0 B; a+ L2 ?& J3 lwas the product of a full-term normal delivery, with
- [" P9 q( `# I3 P% q. `) n* H7 p. m* {a birth weight of 7 lb 14 oz, and birth length of
! z* `2 D! j8 @& H1 W. H20 inches. He was breast-fed throughout the first year
, M1 _9 B) K6 v1 \; R& oof life and was still receiving breast milk along with/ \0 I/ ]. J% Q+ N! I7 g) x' B
solid food. He had no hospitalizations or surgery,* O: x1 L( A9 p- S, h
and his psychosocial and psychomotor development) `8 T8 N7 O5 ~: i% ^0 X. _0 ^3 y
was age appropriate.
" ]8 p$ l' L6 F. ?( K6 DThe family history was remarkable for the father,- F( ?2 V; P8 A) G( q8 e8 @; |6 f
who was diagnosed with hypothyroidism at age 16,# j: l" z; K# b+ i5 U$ d2 u
which was treated with thyroxine. The father’s; y: h8 n/ |) N: f" r
height was 6 feet, and he went through a somewhat- f& i; G* L7 `" ]% P. ^+ y
early puberty and had stopped growing by age 14.4 H& k3 ?# Y# m7 r
The father denied taking any other medication. The
) c) z1 m$ F3 W* v5 v- @child’s mother was in good health. Her menarche
. M" u! [" T: [* u/ Twas at 11 years of age, and her height was at 5 feet& w) {, Z; M2 J* e' I8 d! Q5 C Y
5 inches. There was no other family history of pre-
- e1 r3 q/ r- \8 Y P/ d, l8 k8 V! Qcocious sexual development in the first-degree rela-
. y; |% O, ]- O: ~. U) X; Ttives. There were no siblings.3 ^! j U8 F @8 p' J: ?$ p
Physical Examination
" D8 U2 w9 `& ?4 _3 n0 rThe physical examination revealed a very active,
' r V9 c+ }9 |/ I0 Qplayful, and healthy boy. The vital signs documented; @2 B+ u v, n% }: B
a blood pressure of 85/50 mm Hg, his length was
# a( j3 m* A& L2 G3 g; J90 cm (>97th percentile), and his weight was 14.4 kg5 H1 K. v z( @' S& x5 i/ |
(also >97th percentile). The observed yearly growth+ E+ H: S" g g! o$ L8 n/ P6 t
velocity was 30 cm (12 inches). The examination of! O* y) [- @0 L, B3 ?+ s
the neck revealed no thyroid enlargement.
; m9 V0 ~( Q1 P' q( {# y# |% ZThe genitourinary examination was remarkable for: p' y. {7 S5 N% u$ I0 O
enlargement of the penis, with a stretched length of) b( r& G6 d3 [, Y
8 cm and a width of 2 cm. The glans penis was very well5 p M' O! _5 G" j* M- t
developed. The pubic hair was Tanner II, mostly around
3 r7 ^2 j% `. v% Z2 Z0 x1 E540
' q, c& o( O' |3 eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 a3 P) A( Y5 U8 ^. w2 athe base of the phallus and was dark and curled. The( s, H5 n9 V8 G# y$ q: X' u5 a
testicular volume was prepubertal at 2 mL each.
8 d- n/ F4 R; ~ f& k$ tThe skin was moist and smooth and somewhat* c( T* A/ }5 l4 L' v
oily. No axillary hair was noted. There were no
. H& R8 \" n0 K/ [abnormal skin pigmentations or café-au-lait spots., O* o2 s( [8 l2 s
Neurologic evaluation showed deep tendon reflex 2+
7 N' G8 @* C# x, T$ T; o+ z& @# Vbilateral and symmetrical. There was no suggestion; r/ {5 C( N( V, E# \# v2 @9 V( A$ L
of papilledema.2 l8 k" c% }; C: L: d
Laboratory Evaluation; U# a& q3 _! A, O. j {! c3 a
The bone age was consistent with 28 months by# n. T/ R0 O$ ^) }8 J
using the standard of Greulich and Pyle at a chrono-
7 p1 O% q/ w) n) plogic age of 16 months (advanced).5 Chromosomal, x3 m ?" n! s# `: y
karyotype was 46XY. The thyroid function test
. S/ ^. n( d) \9 Oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-7 _$ v7 X+ v5 J/ @" ~
lating hormone level was 1.3 µIU/mL (both normal).
# |' _7 M- n. B4 W, |The concentrations of serum electrolytes, blood5 F. o! T) W. u2 ~/ @8 v! N
urea nitrogen, creatinine, and calcium all were6 \' {% v, E& k8 N
within normal range for his age. The concentration- D$ q8 H) _/ p
of serum 17-hydroxyprogesterone was 16 ng/dL
7 f$ J/ P. n& y' E(normal, 3 to 90 ng/dL), androstenedione was 20/ b8 x) k' i) ^+ U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ ^& L/ x$ p- c2 p$ j3 t. d1 d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),' [" d/ n `. w$ O: d# g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% j5 [5 }% X; R. e& Z3 s. b49ng/dL), 11-desoxycortisol (specific compound S)7 l7 X, i U8 ~9 G7 n% z/ q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 m8 k* n. t& o8 t: w& `+ w, s
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 q: _4 ?" i* [/ [' @0 Ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ O/ z6 @/ r9 Y% f# q: Gand β-human chorionic gonadotropin was less than
) W& ?1 e7 p: Q# S% O8 V, E5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 `) ^+ z3 A. M8 } M/ {# zstimulating hormone and leuteinizing hormone
9 I9 j/ X" U7 `6 e; oconcentrations were less than 0.05 mIU/mL6 t) u; {$ C- O% F6 o# l$ p
(prepubertal).
3 I% g) u4 c, X6 \# u/ u! IThe parents were notified about the laboratory) j" {6 K i+ ^. }5 {6 k2 ~, R/ C
results and were informed that all of the tests were( G" W4 F2 v6 X; d4 u9 K
normal except the testosterone level was high. The
/ c% K# S4 ~" g" Q* ?) kfollow-up visit was arranged within a few weeks to
7 N- a: t1 R' O0 y6 x" l- ]obtain testicular and abdominal sonograms; how-# j4 b9 y X; X& C5 N3 P
ever, the family did not return for 4 months.
, z' H! U% S5 ~* Z9 CPhysical examination at this time revealed that the
- C- G K2 L. X5 P- ychild had grown 2.5 cm in 4 months and had gained+ V* r) H! t2 T+ `1 |
2 kg of weight. Physical examination remained0 l) f+ o* X" h7 x& b2 L/ D
unchanged. Surprisingly, the pubic hair almost com-
# V9 n: `' \: x% X/ mpletely disappeared except for a few vellous hairs at
7 \6 R5 |% ^3 V# O/ A4 }0 d( V" N( r6 Dthe base of the phallus. Testicular volume was still 2& j! V, o5 L' I6 C) D& l
mL, and the size of the penis remained unchanged.% z& m4 }. q4 Y/ P- @5 B
The mother also said that the boy was no longer hav-8 y! o6 e7 f$ f+ h6 }! ^8 a
ing frequent erections.
0 e# V: b7 N. z/ |Both parents were again questioned about use of5 n# K; Q7 y+ @1 ^9 |) R7 [
any ointment/creams that they may have applied to
! p' z! ]1 g, Tthe child’s skin. This time the father admitted the
6 ?) l7 m- c1 L2 L% G/ S5 ~5 I: ^Topical Testosterone Exposure / Bhowmick et al 541
( z. u9 \. k# C U0 a! B8 muse of testosterone gel twice daily that he was apply-) `' q! ], }2 g: |/ D+ D
ing over his own shoulders, chest, and back area for
5 O; q9 r$ |: L6 H, \# ja year. The father also revealed he was embarrassed
7 c9 o5 O$ X! y; M+ _% u$ dto disclose that he was using a testosterone gel pre-
& {4 X1 b3 q Bscribed by his family physician for decreased libido
: E/ ]/ n1 ?* S& K" }" Z' Bsecondary to depression.) G6 Z0 v' C& Y+ E" G
The child slept in the same bed with parents.' y, ~$ h# g \8 Y
The father would hug the baby and hold him on his
6 z) J4 J0 p0 H5 hchest for a considerable period of time, causing sig-/ o5 f3 D2 r0 `& x: u
nificant bare skin contact between baby and father.
( A& H% o9 z2 D) w( iThe father also admitted that after the phone call,1 D" G+ t/ w1 ]+ t, s2 t5 _
when he learned the testosterone level in the baby5 N9 A# K# b$ H% H2 i
was high, he then read the product information
2 T* T$ h! F. v, m3 s2 Qpacket and concluded that it was most likely the rea-4 d, m7 W+ C, E/ h! i! Z+ ^
son for the child’s virilization. At that time, they
" a4 m H9 K* d; P& B$ L0 G$ odecided to put the baby in a separate bed, and the
) r/ B: w, L2 t( U. tfather was not hugging him with bare skin and had
% E- \% k& g4 E" e* o3 w! c) [been using protective clothing. A repeat testosterone1 B" W4 h% M7 s3 e1 K
test was ordered, but the family did not go to the
$ A) I' n4 o" ~5 D: zlaboratory to obtain the test.! @9 H8 G6 F/ v! D7 E5 T
Discussion3 [4 S* J7 e I8 g0 D' D
Precocious puberty in boys is defined as secondary
% D$ z9 x/ Y- j6 Isexual development before 9 years of age.1,4
% C! B4 [" D% X3 d: {* ?6 hPrecocious puberty is termed as central (true) when
9 n' ^! p$ I% Z# v( K S; t( Zit is caused by the premature activation of hypo-
5 ^3 S4 K z% K/ Z$ |5 H5 Z/ hthalamic pituitary gonadal axis. CPP is more com-' U$ u0 Z: H6 T9 T i+ x% g" _( o
mon in girls than in boys.1,3 Most boys with CPP
- J n/ \4 n% J" x8 n& V9 q5 F6 M# T5 Mmay have a central nervous system lesion that is
1 S5 \7 C4 i8 ]1 @7 y/ k1 qresponsible for the early activation of the hypothal-0 y. D* `6 Y* T s& h8 m' m5 m5 A
amic pituitary gonadal axis.1-3 Thus, greater empha-% v" [3 K- w r0 i* O
sis has been given to neuroradiologic imaging in$ f; V7 ]# T0 _2 X# s2 {
boys with precocious puberty. In addition to viril-
2 B A3 L( Z8 F! m8 \% ~# V: Pization, the clinical hallmark of CPP is the symmet-
$ Y, w( z8 {8 o! Erical testicular growth secondary to stimulation by
! h3 c; t _# W% ugonadotropins.1,3" s% B2 w) I* [2 E) k3 G
Gonadotropin-independent peripheral preco-
, b/ N5 r3 K' s2 a- Pcious puberty in boys also results from inappropriate% N) h* B% ]; _4 a+ E
androgenic stimulation from either endogenous or
; i) v$ U# K$ j" Z4 Aexogenous sources, nonpituitary gonadotropin stim-( q9 C$ h/ D1 Q- _1 S3 n
ulation, and rare activating mutations.3 Virilizing8 f' l2 h' \0 W( ?/ d
congenital adrenal hyperplasia producing excessive8 m3 ] D$ J u* z3 j; X2 I
adrenal androgens is a common cause of precocious; L9 z: R+ `* X4 [, F2 w, f) V0 }
puberty in boys.3,4
% ?8 i. L3 @! M: e% [+ OThe most common form of congenital adrenal# d N; `/ E+ T0 L1 f
hyperplasia is the 21-hydroxylase enzyme deficiency.. v3 t0 r9 W5 _( W: r
The 11-β hydroxylase deficiency may also result in
$ z8 m- A- |2 c9 y" ]- aexcessive adrenal androgen production, and rarely,0 v- E; }% }4 j# j) j+ Q
an adrenal tumor may also cause adrenal androgen6 U$ q, \7 T/ F
excess.1,3
) ~4 g! R9 d3 I& b3 `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, j6 m4 K3 c, f' ^542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 K2 I8 P0 m7 g8 H
A unique entity of male-limited gonadotropin-4 J1 ?9 w1 c% @
independent precocious puberty, which is also known
) B7 o) S6 G: J6 k, A6 Tas testotoxicosis, may cause precocious puberty at a" l2 V* b. f5 t2 \& a: h: E
very young age. The physical findings in these boys- g8 x3 i/ z) P' ^+ |2 a* k
with this disorder are full pubertal development,. w. Z d7 x2 o! w% \2 [
including bilateral testicular growth, similar to boys
: X" d8 s( }* U: ywith CPP. The gonadotropin levels in this disorder
5 R3 y4 T7 M4 L7 D$ s* Pare suppressed to prepubertal levels and do not show v( y& c+ y' ?8 w+ x0 S7 q4 B
pubertal response of gonadotropin after gonadotropin-
4 ^/ g7 \3 S/ Areleasing hormone stimulation. This is a sex-linked0 ~9 ~* j! w$ K$ J2 D O+ D* a% v
autosomal dominant disorder that affects only
1 f, M7 z# ?7 q" i8 C; F- Gmales; therefore, other male members of the family5 [6 Y5 `: s6 ~# L# S; T
may have similar precocious puberty.3
9 U& Y% t" z ?- TIn our patient, physical examination was incon-- @' d7 x+ ]$ v9 w' e7 @. Y$ i' ]
sistent with true precocious puberty since his testi-1 m+ K" s- Q1 u% W$ [
cles were prepubertal in size. However, testotoxicosis) j+ c! d# _! g1 s
was in the differential diagnosis because his father, f w" v" ]; ]
started puberty somewhat early, and occasionally,
/ _: V! ]4 x% S, i: C gtesticular enlargement is not that evident in the
( _- n. K! b+ t% Q) Tbeginning of this process.1 In the absence of a neg-
# F( u! A( i) r6 ?. }# j' Tative initial history of androgen exposure, our
* r- j; T! y+ _0 r! c/ l- S! s7 Xbiggest concern was virilizing adrenal hyperplasia,) k- A, m8 X. C1 j
either 21-hydroxylase deficiency or 11-β hydroxylase: \1 K+ J; F" G' ?% }
deficiency. Those diagnoses were excluded by find-
3 o0 b( g+ R8 R2 Uing the normal level of adrenal steroids.
+ n, B" ^) G$ w% `The diagnosis of exogenous androgens was strongly7 m! t" J2 D* \( ]8 n
suspected in a follow-up visit after 4 months because' R1 L8 E5 V+ m1 g/ ^5 Y
the physical examination revealed the complete disap- q" P9 w/ H3 D# m: s1 o
pearance of pubic hair, normal growth velocity, and- t9 m+ u* E4 c0 ~& n
decreased erections. The father admitted using a testos-
+ V2 b1 o4 V& p2 vterone gel, which he concealed at first visit. He was
' T @1 f5 a0 s; ]+ f. `1 Yusing it rather frequently, twice a day. The Physicians’
# K) c9 P/ V3 ^5 B* ^Desk Reference, or package insert of this product, gel or! E- ]) g3 B. ~) M: B
cream, cautions about dermal testosterone transfer to
+ U$ U6 \( z' T; yunprotected females through direct skin exposure.
: L: j! Q$ i( R! f8 uSerum testosterone level was found to be 2 times the3 D# l$ `! Z) W; _% o/ _# {
baseline value in those females who were exposed to: _ @) ?/ d* U+ y: u! N
even 15 minutes of direct skin contact with their male
1 e) p; ~' I3 R. D& Gpartners.6 However, when a shirt covered the applica-
$ W1 G, O- U4 Ztion site, this testosterone transfer was prevented.' j) A& c: a+ T* i `
Our patient’s testosterone level was 60 ng/mL,% e+ s7 d! J5 A; t, A& Y- _
which was clearly high. Some studies suggest that
" z9 n2 R8 j' q5 odermal conversion of testosterone to dihydrotestos-8 r2 D! Q" O2 u' d, n+ I; d% \- _
terone, which is a more potent metabolite, is more
3 S; J" z( i* zactive in young children exposed to testosterone
$ a6 X5 k( ~* U2 H' Bexogenously7; however, we did not measure a dihy-9 d& M& X3 d) P% h6 c0 F, ?9 G( R
drotestosterone level in our patient. In addition to: G1 |1 X$ D* Y7 N
virilization, exposure to exogenous testosterone in
( q. z W- d$ H, B3 Echildren results in an increase in growth velocity and
1 j; ?) ^, r% T, B% \0 d6 |advanced bone age, as seen in our patient.
4 m+ v( f9 y5 h3 r# `2 ?The long-term effect of androgen exposure during
& s3 ]1 v; @$ u( |* uearly childhood on pubertal development and final
) y. u9 c/ e" s2 e9 M0 s7 T- e! radult height are not fully known and always remain
8 O# h. ]1 `: t( m" ?9 F1 H; }a concern. Children treated with short-term testos-
1 Q0 a* U1 Q5 R0 N* V8 Qterone injection or topical androgen may exhibit some
8 A3 U H, s" Macceleration of the skeletal maturation; however, after; S4 K1 I) j% X& l- j ]
cessation of treatment, the rate of bone maturation
8 p2 P+ ?& M2 }! N# \decelerates and gradually returns to normal.8,9
+ ~: T( v7 d7 X1 ~- Q8 cThere are conflicting reports and controversy1 ?; R, e, U0 c: m
over the effect of early androgen exposure on adult
7 A/ X- @0 Y2 n2 u& T6 K0 spenile length.10,11 Some reports suggest subnormal
+ N3 i m7 k2 ]( Q" ]$ U7 |. Fadult penile length, apparently because of downreg-
2 Q5 ?, s5 l: [3 t& }9 V3 M) e2 {+ ?ulation of androgen receptor number.10,12 However,
' k) f1 o& s5 i& m7 RSutherland et al13 did not find a correlation between3 u! E# o2 r" f% p0 \( ^
childhood testosterone exposure and reduced adult
- { f: Q+ D! o. c% v& r% Epenile length in clinical studies.8 Y- U7 r# n% b
Nonetheless, we do not believe our patient is. M8 O; F* F+ D% P
going to experience any of the untoward effects from" }& }2 s9 T) \; b5 K" j$ W
testosterone exposure as mentioned earlier because
" {/ N% {: a) }- [9 f; ~9 \the exposure was not for a prolonged period of time.8 \& F) x' k4 J8 S- w: T) `
Although the bone age was advanced at the time of& G0 q1 M1 x8 ^& h0 n |1 V1 D
diagnosis, the child had a normal growth velocity at
3 A$ p% t$ M6 H2 N# ythe follow-up visit. It is hoped that his final adult
) m$ b1 d+ a1 t A( c2 h5 E" lheight will not be affected.
3 Q- f7 b9 T x: c8 ]Although rarely reported, the widespread avail-* t" P. J. R7 p+ N
ability of androgen products in our society may* @( V' S! G K: M+ @" Q/ A
indeed cause more virilization in male or female. O+ p, U, w1 w& C; p# ]
children than one would realize. Exposure to andro-
( p! G4 E. J6 u( @gen products must be considered and specific ques-
/ d2 ?, u" P' V: f9 [! ytioning about the use of a testosterone product or
3 j" ^: ]8 q; ?5 b% Z# D: p) bgel should be asked of the family members during
; x" S+ W; T5 N0 s3 \+ G; f% C- ?the evaluation of any children who present with vir-
7 N* J0 |# G5 U% gilization or peripheral precocious puberty. The diag-
$ L$ P. P$ `6 k# inosis can be established by just a few tests and by
+ t2 \0 @2 s- e3 P aappropriate history. The inability to obtain such a
* i y1 z: p" _8 O$ D0 U6 ~: e: _history, or failure to ask the specific questions, may3 y8 G$ k5 G& `* P9 q
result in extensive, unnecessary, and expensive
+ d; k$ \- ^1 j W3 d _; Uinvestigation. The primary care physician should be8 |7 v) c* Y$ @0 K
aware of this fact, because most of these children
. b" Z+ F' R4 a7 k! l2 Zmay initially present in their practice. The Physicians’
3 s' o. e* Q+ N& y1 jDesk Reference and package insert should also put a3 Q) P! \% C1 ?9 [* e
warning about the virilizing effect on a male or
) w3 P# U3 Q0 H1 [female child who might come in contact with some-' P( M; f. F9 v' Z7 r. m, ]. g4 |8 j
one using any of these products.
5 m: x6 P/ a6 L# NReferences! L% H8 Y! b1 v/ a, A$ Z
1. Styne DM. The testes: disorder of sexual differentiation
7 ~0 B* o/ I- zand puberty in the male. In: Sperling MA, ed. Pediatric7 V+ g |2 C, Q/ C4 j% C7 D
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 ?3 q7 I$ a! c! Y0 ?. g
2002: 565-628.* G3 f$ U& I+ ?5 G5 S# a2 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. V( F' K7 c. F* y
puberty in children with tumours of the suprasellar pineal |
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