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Sexual Precocity in a 16-Month-Old
* t1 ^. ~* f* X- H( n. u, _) CBoy Induced by Indirect Topical2 A2 K+ R) M( q0 u
Exposure to Testosterone
6 _, A0 N% r( R+ D" W/ aSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
f" e: L: K+ h* ]" Land Kenneth R. Rettig, MD1 T" h9 z5 P ^
Clinical Pediatrics% V; `. ?+ J- C6 l
Volume 46 Number 6! s Q! h) s; @
July 2007 540-5433 v+ l' s9 x0 }& z' o
© 2007 Sage Publications* `7 {4 `5 S7 S" G
10.1177/0009922806296651$ C9 T+ T! Q) {3 p9 j
http://clp.sagepub.com7 o. u) y7 |) @$ p$ L" X' W3 T& P
hosted at
9 w; q+ d3 w) `! V. L9 i( u9 Jhttp://online.sagepub.com
4 R, y7 j! `& u% Q$ L& [Precocious puberty in boys, central or peripheral,
/ P2 d/ b5 n9 l4 a2 N9 s0 R; jis a significant concern for physicians. Central* S& d' a% ?2 M4 C; t) j
precocious puberty (CPP), which is mediated, _, l/ }4 D! Y) h- \$ a1 y" G" O
through the hypothalamic pituitary gonadal axis, has
9 S+ _/ A: {( w! |- n7 za higher incidence of organic central nervous system
! E5 M9 Z6 Q8 I3 W: mlesions in boys.1,2 Virilization in boys, as manifested( {% A$ r4 M) l2 E( `1 T, B" \" j
by enlargement of the penis, development of pubic
* J& H/ W% A* W Q+ B& ^5 ohair, and facial acne without enlargement of testi-# W5 v+ ^" `: Y6 P. M# U
cles, suggests peripheral or pseudopuberty.1-3 We
! j$ b( s3 R7 d3 F Kreport a 16-month-old boy who presented with the
4 O& L# |- b" O* Benlargement of the phallus and pubic hair develop-# P* N$ ^, d- A- [
ment without testicular enlargement, which was due
5 ^/ ]$ Y% A1 T; ]to the unintentional exposure to androgen gel used by
+ d% P( p4 z' A1 ~) ithe father. The family initially concealed this infor-
$ Z! L% m, x3 t7 c9 s, nmation, resulting in an extensive work-up for this
4 r* `% ~ i6 }) v$ f6 J; Ychild. Given the widespread and easy availability of2 t: S5 A7 g+ }% L( b% P6 E
testosterone gel and cream, we believe this is proba-' l) a$ G6 D% ]
bly more common than the rare case report in the& i F- U( ]7 r/ ?+ O
literature.4& o& o" k' c3 m0 m- L/ \6 X
Patient Report
$ a8 ?4 ]- \/ F6 m, [7 FA 16-month-old white child was referred to the' t# g& N5 t& {$ s4 g5 M5 Z! S: H) I
endocrine clinic by his pediatrician with the concern6 ^2 N9 L" [/ p- j8 K9 E1 G% t
of early sexual development. His mother noticed
# H- D1 n+ n+ m: v9 Y& s7 zlight colored pubic hair development when he was
: J, b! Q" `6 g" [From the 1Division of Pediatric Endocrinology, 2University of/ N8 a5 H% V4 M+ g, t
South Alabama Medical Center, Mobile, Alabama.
5 r5 W0 h1 J6 Y' ?! eAddress correspondence to: Samar K. Bhowmick, MD, FACE,7 w6 i8 w* p' V' c
Professor of Pediatrics, University of South Alabama, College of
0 d& [) }5 \4 M% R/ ]3 Q/ K3 ]/ Y4 MMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 ?" F3 i: H O0 r& H6 E8 ye-mail: [email protected].; {3 w$ R7 P5 t- ^6 q+ Q q
about 6 to 7 months old, which progressively became
* Y# x( [* r- ?( p: d; Z1 Q" h( o, q# ndarker. She was also concerned about the enlarge-
/ ], {+ h" L" J l Q8 _4 m5 ament of his penis and frequent erections. The child
& U9 p$ p6 m& E1 L# o) Nwas the product of a full-term normal delivery, with
9 B5 u" ]: T; a6 D7 t. ta birth weight of 7 lb 14 oz, and birth length of, M0 O" T1 V [6 }3 o: k2 a3 G
20 inches. He was breast-fed throughout the first year/ Z& C$ q5 V- J4 b) G2 O, F
of life and was still receiving breast milk along with+ r* `4 m/ C) r' s
solid food. He had no hospitalizations or surgery,9 Z! c6 [( E! E7 ?/ Y
and his psychosocial and psychomotor development3 V, h% w/ N( [
was age appropriate.$ I# Z/ Y$ L) Q& J7 I
The family history was remarkable for the father," a" k8 g& Y5 |! x% ~% Z3 S i
who was diagnosed with hypothyroidism at age 16,$ ]* r, j' p5 k
which was treated with thyroxine. The father’s
3 f2 j" y8 s) I. F: p' S. Bheight was 6 feet, and he went through a somewhat
) f# R& r3 G- r% b% @early puberty and had stopped growing by age 14.
?1 l6 v- z" SThe father denied taking any other medication. The7 r$ d: _% o! x1 Y& t, X- \: [! @2 |
child’s mother was in good health. Her menarche
' c8 H" i0 }3 ?4 Xwas at 11 years of age, and her height was at 5 feet
6 e; m9 I# ]7 A- t5 l4 \$ j k: j# |5 inches. There was no other family history of pre-' Z) t* g. ?6 z$ k1 b: {- o
cocious sexual development in the first-degree rela-! J7 m t7 c+ M0 X
tives. There were no siblings.. F2 N3 n! W$ h1 V+ b# Q& i( Q
Physical Examination
5 r: n" s8 z5 k! @) b# ]3 p- A' C# {The physical examination revealed a very active,
; }4 o7 M" g6 ?1 \/ bplayful, and healthy boy. The vital signs documented$ y2 L" Q8 K2 z( P
a blood pressure of 85/50 mm Hg, his length was
7 _$ D2 ^3 f, d& y90 cm (>97th percentile), and his weight was 14.4 kg% ], @. X S: U8 ]) i, i* r' [$ W0 c
(also >97th percentile). The observed yearly growth7 o2 Z& h1 {: W1 h% _, q C
velocity was 30 cm (12 inches). The examination of
6 x+ O* h5 H4 _the neck revealed no thyroid enlargement., L; Y4 X& K# I8 T% ^ G7 w& Q( c1 r
The genitourinary examination was remarkable for
' s; D: b1 D1 y7 _! Eenlargement of the penis, with a stretched length of! Q" R' k0 _$ @. K
8 cm and a width of 2 cm. The glans penis was very well
! Y3 X& P' } O1 Ideveloped. The pubic hair was Tanner II, mostly around& A$ p: C7 g% _5 Z! n
5404 Q# f |" J& G$ Z! Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) b. b2 _' F$ K$ v5 B8 G4 \3 jthe base of the phallus and was dark and curled. The8 b7 T* j* Y& g. g6 F) S+ X5 R+ j
testicular volume was prepubertal at 2 mL each.
# R) _' E% l9 ` uThe skin was moist and smooth and somewhat
$ {3 ^( ~. ]( d+ K) g/ |oily. No axillary hair was noted. There were no' Q5 ?! u$ ~9 Q2 I- n, l
abnormal skin pigmentations or café-au-lait spots.
$ G9 w, J% J$ Z& |' | d9 ~; WNeurologic evaluation showed deep tendon reflex 2+
" n) V- U8 Y6 ?: v2 f, xbilateral and symmetrical. There was no suggestion# }% [9 ^9 Q z1 |" ~ m
of papilledema.
9 ` P9 j9 M. K5 N9 P% D, PLaboratory Evaluation
4 X% o* W7 c; w2 u5 r3 yThe bone age was consistent with 28 months by
1 \2 G! b1 Q1 m+ M0 eusing the standard of Greulich and Pyle at a chrono-1 G$ z! _: D" J
logic age of 16 months (advanced).5 Chromosomal
+ c% T4 |5 X0 I; K" bkaryotype was 46XY. The thyroid function test7 I N$ `+ H1 r# H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 U1 w& }+ q0 e+ flating hormone level was 1.3 µIU/mL (both normal).
9 n3 j( {3 W8 R) rThe concentrations of serum electrolytes, blood
; m% Y: P3 E) v9 d$ D: furea nitrogen, creatinine, and calcium all were+ n8 q6 H3 B) o% z: c. p- k# \& v4 {
within normal range for his age. The concentration
% i" R- P' `+ e G$ K& I' o2 K9 c) Bof serum 17-hydroxyprogesterone was 16 ng/dL
, Q& S9 S. w2 K8 [( L7 m \(normal, 3 to 90 ng/dL), androstenedione was 20
- I. v% v; a8 e* H2 |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 y. k0 ~* g6 K# Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 a- Y* T4 ?2 x! Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to- D5 c+ l y7 M! P0 x/ M! d/ G
49ng/dL), 11-desoxycortisol (specific compound S)5 d1 ?" I+ t- ^9 V, m6 _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ L$ f! V5 a- `% H2 {. Z9 Q$ wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 b) K: |# F; c P4 j2 @' ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),; J' M5 w: F( i; w+ Z" y3 B
and β-human chorionic gonadotropin was less than
3 S5 l" u8 {5 a& g0 f5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 f4 ]8 \5 O* L% Nstimulating hormone and leuteinizing hormone
% E& k7 Z( |( T* {% [& V( b+ \concentrations were less than 0.05 mIU/mL
9 J$ S% S2 u3 Z; M5 ^+ z. q/ N |6 T3 @(prepubertal).( L" S0 s2 M3 y+ N
The parents were notified about the laboratory
: u) o+ C7 K9 B, c& x) ?results and were informed that all of the tests were' w7 G% a3 q( P: [/ q
normal except the testosterone level was high. The
. W( U& t5 F3 d ofollow-up visit was arranged within a few weeks to' c" {$ m5 h7 @2 J9 w( H6 V
obtain testicular and abdominal sonograms; how-
7 j+ a2 o* K9 Q9 e$ g( @ever, the family did not return for 4 months.* F( U) s4 e7 L, Q5 x) h* V& X
Physical examination at this time revealed that the
) z) p: D/ C4 w- Ochild had grown 2.5 cm in 4 months and had gained/ R0 a6 `% u$ H/ R$ d8 n. O. `
2 kg of weight. Physical examination remained" l( o2 R% a6 {
unchanged. Surprisingly, the pubic hair almost com-
: k, O7 e- `( Opletely disappeared except for a few vellous hairs at
! z# U# R7 \& u$ lthe base of the phallus. Testicular volume was still 2, h [; b }2 n9 y
mL, and the size of the penis remained unchanged.
: _& b( K) d% A1 Q, x3 sThe mother also said that the boy was no longer hav-
' U' @, P+ Y( Z, O3 xing frequent erections.+ o5 J, K7 `4 A6 T* z% h
Both parents were again questioned about use of
% y% j+ M4 a2 V1 {5 [8 Dany ointment/creams that they may have applied to# \8 R) i. s$ G* f# x3 D9 p, j
the child’s skin. This time the father admitted the
. l4 u/ C* ?$ B5 |9 i$ `Topical Testosterone Exposure / Bhowmick et al 541. G( [5 z* |$ n: Z) F7 K2 R
use of testosterone gel twice daily that he was apply-
; Q) d3 J7 ~, y) P; |ing over his own shoulders, chest, and back area for
0 p. ?% }1 E( r8 P9 da year. The father also revealed he was embarrassed3 K0 m4 C' T7 i L9 l8 A
to disclose that he was using a testosterone gel pre-9 m# o! ^( {$ x* m" J8 j
scribed by his family physician for decreased libido+ ?' t, N) }' G0 o7 v( S7 c/ J
secondary to depression.
3 M& o' h9 ^( z* Z6 M4 f4 {' h5 UThe child slept in the same bed with parents.0 o/ v+ }7 o4 Z# u
The father would hug the baby and hold him on his
8 B& ^' S9 B+ ?& B& gchest for a considerable period of time, causing sig-
0 X& r1 g* {+ Enificant bare skin contact between baby and father.
+ O1 A+ ~+ K2 X- f& S6 D! H! tThe father also admitted that after the phone call,
0 M8 l9 T: H& o- u- f, c V: m4 v nwhen he learned the testosterone level in the baby. h L" w) h9 \- r. x X8 T
was high, he then read the product information1 g! c% J" F3 V# X# c" E
packet and concluded that it was most likely the rea-
- d9 m! e2 O2 e/ K5 Y0 \son for the child’s virilization. At that time, they
: \. w- U" @3 X. D! S; w" Wdecided to put the baby in a separate bed, and the, M+ C) Z5 y0 F1 `5 y& R
father was not hugging him with bare skin and had
% U; r. l9 U N& Q- Hbeen using protective clothing. A repeat testosterone: `3 M" ^: H5 G2 i6 Z
test was ordered, but the family did not go to the
1 M* x& j$ C2 R! B2 `5 i+ _7 ?laboratory to obtain the test./ n: \3 m6 I M1 ?& k
Discussion
) t/ y- W) V6 L7 w' iPrecocious puberty in boys is defined as secondary y, u0 K( }" _, r9 V& R8 r) C
sexual development before 9 years of age.1,4
, A/ @0 ~. M- uPrecocious puberty is termed as central (true) when
$ C1 V% s' ]9 y; ^( rit is caused by the premature activation of hypo-
: R; A4 N, |9 e8 E5 L! k% U4 f2 xthalamic pituitary gonadal axis. CPP is more com-! U6 o* W9 m( r, M5 O9 F
mon in girls than in boys.1,3 Most boys with CPP
' L9 V' r9 }- b% D) e( R' m9 Amay have a central nervous system lesion that is9 C5 h4 w0 ]% x
responsible for the early activation of the hypothal-- L+ Z& M$ \8 ~$ z" I) \* w
amic pituitary gonadal axis.1-3 Thus, greater empha- ]& C5 D8 i& R- o
sis has been given to neuroradiologic imaging in
- _9 O" Y# h. Z6 H$ h8 Rboys with precocious puberty. In addition to viril-# F) ~- |( R; j2 A0 L1 v1 P
ization, the clinical hallmark of CPP is the symmet-6 E/ G* Q2 B9 k1 O2 {; P
rical testicular growth secondary to stimulation by5 m( {' E8 p" r6 j! n
gonadotropins.1,30 S* W+ F; t& F$ {2 n% F
Gonadotropin-independent peripheral preco-
q8 u8 Z2 N5 S( F! L2 ^: fcious puberty in boys also results from inappropriate
$ A$ q( m7 L7 Wandrogenic stimulation from either endogenous or
! b; u, S) A( x4 W5 O, n) V9 sexogenous sources, nonpituitary gonadotropin stim-/ v8 s# _" C0 j" v
ulation, and rare activating mutations.3 Virilizing
: m; T8 P* Z% U8 |) K9 U4 vcongenital adrenal hyperplasia producing excessive2 i; |2 ]1 W+ N# K. N( j5 O7 b
adrenal androgens is a common cause of precocious$ F6 {) ?1 |4 k+ k$ M6 s
puberty in boys.3,4
% Y# x+ Z+ W( E' y4 G# q. HThe most common form of congenital adrenal
& j& e2 g- v' _* y4 F4 \$ Vhyperplasia is the 21-hydroxylase enzyme deficiency.& S! K; y0 g9 j5 @# R7 @4 h
The 11-β hydroxylase deficiency may also result in# _) L" m- R' G$ N: U2 a
excessive adrenal androgen production, and rarely,
' M# M3 o3 S* k# M, c! h' y, uan adrenal tumor may also cause adrenal androgen7 R* ? N5 H; m% C) Q. I5 Y
excess.1,3; M6 U+ A/ N* m) p* H+ \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 s5 T- q. N6 t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% x9 l; N+ b& e4 @
A unique entity of male-limited gonadotropin-$ ?7 ~$ E. l9 f% o
independent precocious puberty, which is also known
9 M; M2 B- Z* @. @8 ]as testotoxicosis, may cause precocious puberty at a9 r3 \0 v' j5 _0 J& c+ Q3 o
very young age. The physical findings in these boys; B7 J: U7 W+ b% q/ }+ P' E' f& m
with this disorder are full pubertal development,- S; T2 M% ]0 i/ @! f
including bilateral testicular growth, similar to boys
4 Z4 T q+ Q# w) U, [% T8 r) hwith CPP. The gonadotropin levels in this disorder
* G# Z! O+ q+ o( P! Aare suppressed to prepubertal levels and do not show
5 ]' A+ E, D* p/ c0 Q1 m/ o2 K/ mpubertal response of gonadotropin after gonadotropin-' V' h; Q7 ^( ?. n* v9 |/ i4 I
releasing hormone stimulation. This is a sex-linked
' O& D: U5 l! ?; E3 r3 `autosomal dominant disorder that affects only& f. J; H0 @% A6 v/ q
males; therefore, other male members of the family
( @' m2 u2 H/ Imay have similar precocious puberty.3) [4 ^) P- g% w3 ~
In our patient, physical examination was incon-' J* f- c& t$ t/ f5 F
sistent with true precocious puberty since his testi-
/ Z) l4 M- t2 ~& scles were prepubertal in size. However, testotoxicosis) U6 z& f# o- v) A* u
was in the differential diagnosis because his father: Y* f3 U, B( v o- u# A$ `( D
started puberty somewhat early, and occasionally,
0 W3 G1 X+ c8 ^+ { T7 Y1 Htesticular enlargement is not that evident in the
. w$ ^2 l7 T' T1 \4 r# `8 F3 Kbeginning of this process.1 In the absence of a neg-/ B$ w* v O9 Q8 w- S
ative initial history of androgen exposure, our8 p# P4 O" {. U( R& ^+ N5 L
biggest concern was virilizing adrenal hyperplasia,8 d) |! B5 ]8 l r: ^- Y- R
either 21-hydroxylase deficiency or 11-β hydroxylase
2 I2 F, @$ J- n/ O4 h# u* `* [deficiency. Those diagnoses were excluded by find-
) T6 s" I" z% s% wing the normal level of adrenal steroids.
& w6 n& D1 n5 G% F) g% rThe diagnosis of exogenous androgens was strongly
% b! A m2 ^6 b0 {/ k+ @$ qsuspected in a follow-up visit after 4 months because
1 w& m; P2 P, f! c2 Pthe physical examination revealed the complete disap-1 y4 A2 S3 C1 G. k6 q: F
pearance of pubic hair, normal growth velocity, and
/ e1 {' M% q; O" t7 Wdecreased erections. The father admitted using a testos-
' Y d# K5 Y2 v8 aterone gel, which he concealed at first visit. He was( P4 w1 t5 g( x" N7 K/ I. b
using it rather frequently, twice a day. The Physicians’0 N: @& y8 e" r8 J' x
Desk Reference, or package insert of this product, gel or% ~. S w! g2 J7 X
cream, cautions about dermal testosterone transfer to4 R) y5 B5 ?3 ^4 k
unprotected females through direct skin exposure./ [* G) \& M4 @' j3 w
Serum testosterone level was found to be 2 times the# r, n/ m* Q% a y
baseline value in those females who were exposed to2 C) E6 k0 H% F1 ?
even 15 minutes of direct skin contact with their male4 p$ k/ F, \- \: a# j2 M
partners.6 However, when a shirt covered the applica-
& t1 C- o' ~) y! O0 B- rtion site, this testosterone transfer was prevented.* b. G! g g* ?; U! j/ _9 O) n. O
Our patient’s testosterone level was 60 ng/mL,
' c+ U0 x. H1 E$ @+ `which was clearly high. Some studies suggest that
. V }* r& D, I& J# j1 Ydermal conversion of testosterone to dihydrotestos-
% s& ^4 l, U/ r9 |! {$ I: tterone, which is a more potent metabolite, is more
" b9 h2 e9 M' v# j+ g1 k; Zactive in young children exposed to testosterone
+ M* W& O0 {1 }5 {2 B( u% rexogenously7; however, we did not measure a dihy-2 L8 T! e+ v" S. n+ J! }. N
drotestosterone level in our patient. In addition to! d4 }* M8 {& Q* Q: m' p
virilization, exposure to exogenous testosterone in
1 Y' g0 N; t% dchildren results in an increase in growth velocity and
% l* o% N) z' D9 _8 {2 |* Z* n% aadvanced bone age, as seen in our patient.
9 a3 s0 f& v6 r/ M, s8 iThe long-term effect of androgen exposure during
/ `. x& G/ X+ M1 P9 searly childhood on pubertal development and final1 t3 t9 C; J3 f, s
adult height are not fully known and always remain
0 W* [- Y( e# ^) v+ z( Qa concern. Children treated with short-term testos-* B0 A* c& `3 i9 j
terone injection or topical androgen may exhibit some
) G4 {1 X c3 e, F; X6 l7 Xacceleration of the skeletal maturation; however, after
; |! d; G, j% H% k4 Lcessation of treatment, the rate of bone maturation/ U( r+ L8 A7 p5 P1 O ^
decelerates and gradually returns to normal.8,9
- L- t! ?: E1 R9 G( k1 `There are conflicting reports and controversy
9 n. Y5 s1 `6 a2 X1 Pover the effect of early androgen exposure on adult
, Y/ L9 L ?! @6 Ypenile length.10,11 Some reports suggest subnormal
1 f8 r, y( `* f" radult penile length, apparently because of downreg-
- R; w9 p8 m) g0 `. {. bulation of androgen receptor number.10,12 However,
0 K e% N" C8 ~; _( u* X! iSutherland et al13 did not find a correlation between, `7 [; ?; T4 M! C: c
childhood testosterone exposure and reduced adult
$ c- D" ], M ~% H" v' ]( bpenile length in clinical studies.$ x* U+ y( w1 s6 K/ Q& c/ \
Nonetheless, we do not believe our patient is6 w/ t9 x3 @8 o& x$ d! @' o7 B
going to experience any of the untoward effects from/ l/ U4 R' t, a- r; u5 t! x8 ?. O
testosterone exposure as mentioned earlier because
, W* @# U- D8 Tthe exposure was not for a prolonged period of time.
$ u# ?7 v6 E( t( w2 \4 rAlthough the bone age was advanced at the time of
* M: T6 W. F& h2 wdiagnosis, the child had a normal growth velocity at
$ t% q" w3 o8 X' ethe follow-up visit. It is hoped that his final adult
* K8 U+ g4 }$ h8 dheight will not be affected.. o j" Q, |4 ^- V8 [ ]
Although rarely reported, the widespread avail-* W" X' b. |, {! f: d- G- C: @- d
ability of androgen products in our society may
% s8 j. k' O6 y3 j8 `! Q1 \& G0 pindeed cause more virilization in male or female
) A2 o% N3 i; X: y3 m2 Q7 Schildren than one would realize. Exposure to andro-. x) i1 c6 b" ~3 I3 S3 A
gen products must be considered and specific ques-
" |) @" D0 }' h2 x+ l: E( Ctioning about the use of a testosterone product or3 z# v/ W" V9 D. O9 l
gel should be asked of the family members during' T, U: w' n+ N# ~; Z
the evaluation of any children who present with vir-4 M$ j; s7 e+ h1 u+ f
ilization or peripheral precocious puberty. The diag-5 \% t5 ?8 g! l) v
nosis can be established by just a few tests and by2 V. [5 P* I1 N( g3 X
appropriate history. The inability to obtain such a
U9 P( p& Z" n" Y. xhistory, or failure to ask the specific questions, may5 a& O; m6 p! ]6 j S( \, x
result in extensive, unnecessary, and expensive& h2 i2 ] V3 g& h/ n3 w7 I7 \; z+ F
investigation. The primary care physician should be
* K" l. B) a! Y: W5 M5 l6 C, Faware of this fact, because most of these children
8 l; D: B6 u7 bmay initially present in their practice. The Physicians’6 }* J7 g( O3 w# ]
Desk Reference and package insert should also put a7 _3 {- s/ x/ x/ T
warning about the virilizing effect on a male or
$ N9 B" R& c A. w( G% m/ Yfemale child who might come in contact with some-
2 o- q) S$ v& \8 z0 L" vone using any of these products.
- z* }/ [& J ?5 e$ HReferences
. E c% t! k, X( O9 h1. Styne DM. The testes: disorder of sexual differentiation
9 R- `6 u. P3 Y# i; l3 Kand puberty in the male. In: Sperling MA, ed. Pediatric2 S- c L( Z$ Y% b* v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 h, j4 @+ ^7 Y6 Q, s6 r9 M4 I6 x2002: 565-628./ X( R) P D' T; e8 ]6 v2 K) l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" l- F8 S- J" c; f4 V+ ppuberty in children with tumours of the suprasellar pineal |
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