- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old2 k/ M3 u; t9 j3 R" c2 a
Boy Induced by Indirect Topical5 C7 a$ t) d. b/ ~
Exposure to Testosterone0 H, }/ x# x6 c- u+ S4 u6 i. L" l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( {! i" q! I) w+ q2 u! b5 H1 k
and Kenneth R. Rettig, MD1% r o7 b C {7 p/ ]% Q* T
Clinical Pediatrics
% [ q8 Z5 L! `5 b! p* O- W( c8 p; RVolume 46 Number 64 z' S5 K+ F8 v) W; U8 Z
July 2007 540-543
# m' _+ _1 C# _; n* T0 n& e+ n% B© 2007 Sage Publications
0 Y8 X, w+ m9 g1 c: |! y7 E10.1177/0009922806296651; B( `0 w$ ^* w8 h
http://clp.sagepub.com* S5 X. y/ X( C6 [% Z8 N# k
hosted at6 {' n1 u- W7 c% T
http://online.sagepub.com
7 L0 F" i3 h& Q+ |0 }( {8 ~Precocious puberty in boys, central or peripheral,
2 e4 @- r1 F9 q4 |4 lis a significant concern for physicians. Central
/ c8 H' e0 U; _7 I- L( l3 y: eprecocious puberty (CPP), which is mediated
; ]0 H' F# u) t. xthrough the hypothalamic pituitary gonadal axis, has& `, ]. U0 |5 P# P. {+ q
a higher incidence of organic central nervous system) n9 {3 l9 O) ~# `0 r; [
lesions in boys.1,2 Virilization in boys, as manifested
3 A2 N" d5 _ C2 |0 o C7 vby enlargement of the penis, development of pubic: ~/ y8 u7 Z4 x2 }; ?! B
hair, and facial acne without enlargement of testi-
9 l# n- }2 D3 i3 e0 w+ xcles, suggests peripheral or pseudopuberty.1-3 We" a9 c& s7 p, w
report a 16-month-old boy who presented with the
( I3 k0 [5 |& {% jenlargement of the phallus and pubic hair develop-
) }6 c0 H: ~$ u' T8 m$ }" Y5 M8 [ment without testicular enlargement, which was due Z1 e. X* E) l- f& R8 p {6 J
to the unintentional exposure to androgen gel used by6 Q# S; A1 b- i4 i n
the father. The family initially concealed this infor-
) s: P' h6 }4 v- a& @6 }6 B* @mation, resulting in an extensive work-up for this
+ C( z! \6 j- [5 T4 v, ~8 u: w9 Bchild. Given the widespread and easy availability of
+ F+ D8 ?" c& z7 F; xtestosterone gel and cream, we believe this is proba-9 |9 ?; M- ~" k( p, r9 _
bly more common than the rare case report in the
7 s8 S" O0 R$ a' j8 ]literature.4, @/ E; L3 c5 ?' }
Patient Report
" ]3 T4 o! \+ pA 16-month-old white child was referred to the
5 b2 d- \! q: Qendocrine clinic by his pediatrician with the concern
5 J4 B" a3 T4 k j5 G* Pof early sexual development. His mother noticed( x/ y6 j0 Z- p6 f U1 `, @
light colored pubic hair development when he was
M. J: B# \5 I& z4 c% \9 p: `/ qFrom the 1Division of Pediatric Endocrinology, 2University of7 }# i* o2 s& [' h7 S, Z
South Alabama Medical Center, Mobile, Alabama.
0 }( h2 [0 i9 A$ U3 `Address correspondence to: Samar K. Bhowmick, MD, FACE,
! [( q" O# U8 w/ g* vProfessor of Pediatrics, University of South Alabama, College of( M3 F$ v. [9 j- T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# z0 i" o3 @8 c- n) re-mail: [email protected].
0 H7 `) l5 ]) W. y# s; eabout 6 to 7 months old, which progressively became4 ?) S6 ^7 j: k5 C
darker. She was also concerned about the enlarge-8 Y9 N4 Y0 G \; B
ment of his penis and frequent erections. The child$ h5 P: {6 W+ E9 v% o
was the product of a full-term normal delivery, with& N3 T9 D2 [8 y3 W1 @2 ~& F
a birth weight of 7 lb 14 oz, and birth length of2 J$ V; P, R. a8 a( J& b& {
20 inches. He was breast-fed throughout the first year
i9 G: ^' w# _- z: ]5 qof life and was still receiving breast milk along with" Z5 N! a3 S/ W, ]! [ U0 q# x
solid food. He had no hospitalizations or surgery,
6 d6 a2 f: H4 v4 [2 kand his psychosocial and psychomotor development3 [0 I" G$ d1 _- t; R" O3 y4 ^5 k# ~
was age appropriate.
! L; E r: G) x& I* ?' u: LThe family history was remarkable for the father,5 A0 b2 R& s6 s4 M: k0 o: ^& Z
who was diagnosed with hypothyroidism at age 16,- p' o; S$ c) L Y) h) @& a
which was treated with thyroxine. The father’s. V1 L9 s. } @; T
height was 6 feet, and he went through a somewhat0 K% h1 {7 ]2 _- V' U, o( l
early puberty and had stopped growing by age 14.
, E* T7 q' [3 cThe father denied taking any other medication. The
?! v+ Y5 L& w( Achild’s mother was in good health. Her menarche( y ^, q W$ s+ U: H
was at 11 years of age, and her height was at 5 feet
5 d7 S- `2 [: w0 B5 M) r0 ^- P5 inches. There was no other family history of pre-" ~; w- l) s( B G' S/ _
cocious sexual development in the first-degree rela-
8 V* V, U- I( {+ M2 n- S- F3 F3 Utives. There were no siblings.
* h0 `' H8 ]5 g- N# j% `( h3 F OPhysical Examination
~$ m% E2 D& B. QThe physical examination revealed a very active,
7 ]$ }: ], |( e O% E0 }playful, and healthy boy. The vital signs documented8 q% f$ B6 F2 R, Y8 [
a blood pressure of 85/50 mm Hg, his length was
% D. g* M8 `4 A% Z1 z& d90 cm (>97th percentile), and his weight was 14.4 kg
% c4 V5 z9 x2 y+ V% _$ [(also >97th percentile). The observed yearly growth
, k& u+ C) F$ z9 _2 svelocity was 30 cm (12 inches). The examination of
3 \8 H5 Y+ X0 s! _9 xthe neck revealed no thyroid enlargement.9 K9 k7 U. x4 h
The genitourinary examination was remarkable for4 z2 {1 z2 _8 f. ~5 L! u6 n
enlargement of the penis, with a stretched length of7 o" w" e( p+ \; j
8 cm and a width of 2 cm. The glans penis was very well
: \% F5 L% r W6 p- c: t- U6 ]developed. The pubic hair was Tanner II, mostly around
9 j4 Y8 c8 J/ p: [) A4 U540/ m1 B& ~( W+ z5 A. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 u* c: Q; F* E8 `5 h. v2 [
the base of the phallus and was dark and curled. The
1 a. |, @: y/ z& }0 stesticular volume was prepubertal at 2 mL each.
; h- W- }* z1 u# g1 k9 \8 LThe skin was moist and smooth and somewhat
4 e0 X$ O2 D( U2 H4 G) ^% ?/ ~; F& Joily. No axillary hair was noted. There were no
" f6 e1 w% I6 K) Mabnormal skin pigmentations or café-au-lait spots.
# t2 S. T6 A6 h Q% b) f) jNeurologic evaluation showed deep tendon reflex 2+
1 }1 c& X! t# l7 k! y. c3 Vbilateral and symmetrical. There was no suggestion4 }" Y7 q( Y( |" h. G& K9 y: o0 i% K: }# V
of papilledema.
n7 c4 q0 ] Y# }% a1 W3 e* p( }Laboratory Evaluation4 I+ B5 J' D+ O7 J, ], B, Y
The bone age was consistent with 28 months by4 r6 E* M0 H7 H$ R8 F
using the standard of Greulich and Pyle at a chrono-) s) _. n$ |5 |: M7 Z' J
logic age of 16 months (advanced).5 Chromosomal3 L$ V E" o3 k4 c% |
karyotype was 46XY. The thyroid function test1 n5 Y# e: L" U( X$ T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 F% ~; K1 P$ r" _+ T5 Jlating hormone level was 1.3 µIU/mL (both normal).$ ]% \+ s7 ^4 h1 ^6 @
The concentrations of serum electrolytes, blood! ?; s4 N/ w8 \) C& m! U: Q& y: s, Y
urea nitrogen, creatinine, and calcium all were1 [5 n" u$ }8 ?* S, K! Q
within normal range for his age. The concentration1 }1 ^1 L& y* U) [; ?5 L
of serum 17-hydroxyprogesterone was 16 ng/dL1 Z5 M$ {) B3 r. s
(normal, 3 to 90 ng/dL), androstenedione was 20
V+ K8 m6 K3 n( c2 t. W4 t0 vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 C. y" S3 v, ]: j3 t4 eterone was 38 ng/dL (normal, 50 to 760 ng/dL),: _* D) ~3 u/ b1 h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! }0 u/ Z1 b0 x1 v: Z8 R9 h$ D49ng/dL), 11-desoxycortisol (specific compound S)6 \+ T4 \6 r, ]( t" ?0 D( u) W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 @$ V S. |# q4 K) ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. e, e2 z" ]( f4 e9 Q' I6 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# H& _7 y8 ?5 N. B; G& d
and β-human chorionic gonadotropin was less than
: d3 x" q. W- \2 }5 R! D! f+ h# y5 mIU/mL (normal <5 mIU/mL). Serum follicular& H6 i, `# n. f+ f/ W3 i6 Y% e
stimulating hormone and leuteinizing hormone
9 A Y( I& ?; U9 |' Y4 n+ qconcentrations were less than 0.05 mIU/mL" m( D9 m/ }9 H% d# Q
(prepubertal).
, A- n% p! S. q( J: T* t! qThe parents were notified about the laboratory! ?# n U7 R6 d1 w/ P% C/ r
results and were informed that all of the tests were6 ~2 ?7 |+ k c
normal except the testosterone level was high. The
- w3 z, V% f4 j) a# V1 V) Y; }9 lfollow-up visit was arranged within a few weeks to
# v) C! P% u/ ^7 wobtain testicular and abdominal sonograms; how- o5 Q4 `9 |6 {: v, ]8 e
ever, the family did not return for 4 months.
4 L" _+ `1 I1 A3 V, z% mPhysical examination at this time revealed that the
3 h; d' i) z* x. t# k* |/ z. Fchild had grown 2.5 cm in 4 months and had gained1 v @" Q& A M6 P) u$ W& r
2 kg of weight. Physical examination remained/ a# Y3 F. y$ f6 M5 _4 {
unchanged. Surprisingly, the pubic hair almost com-5 K; G, @# E: V8 q
pletely disappeared except for a few vellous hairs at
9 |9 b! y% O: [( y5 B, s% jthe base of the phallus. Testicular volume was still 2
9 g, o$ X- u. U1 n# X) `mL, and the size of the penis remained unchanged., r D* u+ T8 \5 P
The mother also said that the boy was no longer hav-/ K% H& a# Y j* d: X6 t, L
ing frequent erections.
, X# \: f4 `# c6 @! [* i# O: KBoth parents were again questioned about use of
/ ` T/ S O! c S% L' ^any ointment/creams that they may have applied to
% N( m2 d; \6 p; Bthe child’s skin. This time the father admitted the
, i5 N1 O7 c! ]% r0 LTopical Testosterone Exposure / Bhowmick et al 541, {# h8 N. L$ j) t* Q$ l- n
use of testosterone gel twice daily that he was apply-" K! f" F" E4 f7 K2 o* u% m i
ing over his own shoulders, chest, and back area for
& S$ B k% F; `2 oa year. The father also revealed he was embarrassed, a8 w0 O2 l8 R3 |* v
to disclose that he was using a testosterone gel pre-
# g- r& I) Y' A( m, A+ Escribed by his family physician for decreased libido
. ]. [3 j4 M7 h3 |0 v8 Ysecondary to depression.2 Z- C9 w7 H$ y; j, `% F; ?
The child slept in the same bed with parents.
& G) c7 c, ~2 X- m! \The father would hug the baby and hold him on his
) |0 T" x# ~0 q$ |+ f0 p7 achest for a considerable period of time, causing sig-7 a1 w0 H' c3 D6 ]& E5 W8 ~0 b
nificant bare skin contact between baby and father.
% [8 p- \$ a& e/ U/ @! _% OThe father also admitted that after the phone call,
5 e; f; _1 v1 [' C& U2 P2 _7 ^when he learned the testosterone level in the baby( P; i5 @' v5 h. p# e
was high, he then read the product information! x1 Z, r1 \ f, f) m' N
packet and concluded that it was most likely the rea-
' L/ G( ^ P. `8 T/ bson for the child’s virilization. At that time, they
* W9 k2 q; r' ~3 d8 K& adecided to put the baby in a separate bed, and the
+ t+ `, w/ W8 S; k! T6 A- Tfather was not hugging him with bare skin and had
% {( h9 z* ~2 hbeen using protective clothing. A repeat testosterone! A( \! y4 e& @6 {
test was ordered, but the family did not go to the
9 v; f3 @ Z' C9 M0 s; k% E/ Elaboratory to obtain the test.0 ^1 b, e9 S1 u' D% ?: P; K8 D
Discussion i$ `( V' b; |" Y" z/ f
Precocious puberty in boys is defined as secondary) h! O% J4 E0 Y a% O
sexual development before 9 years of age.1,4
! K/ Z: x' J6 {7 }8 ~7 rPrecocious puberty is termed as central (true) when
' b- d" J; i+ e0 Z4 Tit is caused by the premature activation of hypo-
4 y% S) z) j C3 ]: _thalamic pituitary gonadal axis. CPP is more com-
7 _* D. `; q+ m: v, j; _* r7 Vmon in girls than in boys.1,3 Most boys with CPP
0 Y6 v/ ?3 P9 B, \+ B; G( a' H7 Omay have a central nervous system lesion that is+ o5 t5 c/ E9 H8 h$ `' J! f
responsible for the early activation of the hypothal-
8 j3 q n* K* ]2 L4 |& k- |( ~* samic pituitary gonadal axis.1-3 Thus, greater empha-2 [8 T) |7 Z* ]# j
sis has been given to neuroradiologic imaging in
1 {2 T# C U8 g7 z* @boys with precocious puberty. In addition to viril-
- K% t# v9 j: h# j8 N- I. _ization, the clinical hallmark of CPP is the symmet-) {9 X# I* t* R. c: \0 s3 l
rical testicular growth secondary to stimulation by
, {7 a7 n8 ?! ~4 L- |gonadotropins.1,3. l3 E6 ?1 ~; [% b* j) e! \
Gonadotropin-independent peripheral preco-9 q) u8 k. u4 U% x
cious puberty in boys also results from inappropriate
+ a3 I% Z |/ Q6 F' N/ `androgenic stimulation from either endogenous or$ B# b( D2 B1 s* H
exogenous sources, nonpituitary gonadotropin stim-" ?+ H# K9 {4 H3 Q
ulation, and rare activating mutations.3 Virilizing" P, z. f+ ^. m3 N; W5 [
congenital adrenal hyperplasia producing excessive
0 J# R) k' e$ y8 p1 h' M/ W8 Padrenal androgens is a common cause of precocious9 X) d2 z3 H& f" \/ u i/ E9 [
puberty in boys.3,4
3 k7 i$ E" F# R% L+ J$ ?9 JThe most common form of congenital adrenal
: A+ m1 S1 o4 S6 A; Shyperplasia is the 21-hydroxylase enzyme deficiency.
+ |7 ]$ T. e# H! e) ]! p/ kThe 11-β hydroxylase deficiency may also result in# E* W! A \7 b& V
excessive adrenal androgen production, and rarely,
3 [7 t4 X' N+ f5 ~! P2 c) p( {" ran adrenal tumor may also cause adrenal androgen
- T- r8 ~$ q, u/ zexcess.1,3/ N7 K( D6 e5 L) Q" H* e- m5 e: T" Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ c# f, D" M! J. r7 _5 b
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' U* h$ v& L* i4 f% m
A unique entity of male-limited gonadotropin-
0 U) y7 x2 Z n+ t& {) m# Windependent precocious puberty, which is also known F6 o% Y" [! ^ }
as testotoxicosis, may cause precocious puberty at a
! x% {2 K5 I p# U! {$ }very young age. The physical findings in these boys
" }. x m! Z! t, C) n G$ |with this disorder are full pubertal development,
8 h' a. C. S. [" b7 k3 k1 Aincluding bilateral testicular growth, similar to boys
, r- W/ ^4 V7 ^$ C/ B3 }& _% b( gwith CPP. The gonadotropin levels in this disorder
; ~+ j, d7 x# ]+ k+ `. D: R, r3 pare suppressed to prepubertal levels and do not show
m! J6 K" u6 B, F& M& `pubertal response of gonadotropin after gonadotropin-& U& D8 L: j/ e0 j
releasing hormone stimulation. This is a sex-linked0 }; A/ ]. z! _
autosomal dominant disorder that affects only! u, v. E' g* e O* X
males; therefore, other male members of the family( Q3 w" y2 p3 x$ x7 B& G3 X, S( _
may have similar precocious puberty.37 {9 x0 S k, |( `( i7 r1 G0 y
In our patient, physical examination was incon-, D7 ^& Y, y7 b- K' s
sistent with true precocious puberty since his testi-
5 K- q/ c! l9 E) h, |cles were prepubertal in size. However, testotoxicosis. z7 z! R8 T# @- c `
was in the differential diagnosis because his father
# f d$ |! T/ I# O: Y8 istarted puberty somewhat early, and occasionally,
& Y6 C' ]) ?) `$ }/ @testicular enlargement is not that evident in the# a$ l: u) {5 ]7 a0 i1 P
beginning of this process.1 In the absence of a neg-$ H5 F$ P. X6 p7 a" }+ A
ative initial history of androgen exposure, our' R3 X* C$ `$ V
biggest concern was virilizing adrenal hyperplasia,- M: ], @0 K* x" M3 l2 p
either 21-hydroxylase deficiency or 11-β hydroxylase9 r- U: B' ^& E" M
deficiency. Those diagnoses were excluded by find-
6 n1 }" q! L, Y+ }ing the normal level of adrenal steroids.0 y- |- {( ^" [, k Y) s
The diagnosis of exogenous androgens was strongly; G& b: x3 O3 Z8 [
suspected in a follow-up visit after 4 months because
5 w, _* E$ y, gthe physical examination revealed the complete disap-
' i# u4 P! @+ G9 U$ h' H0 x# c. X% mpearance of pubic hair, normal growth velocity, and! \, a8 o5 z) U p' S" t3 h
decreased erections. The father admitted using a testos-
" _7 M* ^" t8 ]- u3 S% _; {# Pterone gel, which he concealed at first visit. He was; @9 n2 i- H- o1 Q$ b D0 @8 ?3 G& ^
using it rather frequently, twice a day. The Physicians’0 C9 k2 s8 A6 u4 m; O
Desk Reference, or package insert of this product, gel or# i0 q4 F# _6 v# ]9 T4 c
cream, cautions about dermal testosterone transfer to
$ h- A2 @3 i K F! S3 aunprotected females through direct skin exposure.( X) t# y. T9 ?0 J
Serum testosterone level was found to be 2 times the
' @, {6 K$ K) \5 s. Jbaseline value in those females who were exposed to
4 X2 A8 e1 [6 R4 t( ` jeven 15 minutes of direct skin contact with their male7 E; v6 [3 U3 u/ j, p- b
partners.6 However, when a shirt covered the applica-
+ D, W z) a8 r. K, R8 ^tion site, this testosterone transfer was prevented.4 z( ~" y) a4 I& H
Our patient’s testosterone level was 60 ng/mL,
/ R9 H. q# j5 c( [which was clearly high. Some studies suggest that, k% f) i2 ]( Z2 ^2 x |8 g
dermal conversion of testosterone to dihydrotestos-: r' | t: _ X, t# c
terone, which is a more potent metabolite, is more6 Z5 G: g; ^5 N: t
active in young children exposed to testosterone
4 \2 H' n! T) kexogenously7; however, we did not measure a dihy-0 |) o1 w& T5 W- m* w
drotestosterone level in our patient. In addition to, @- @5 Q5 D0 \& V
virilization, exposure to exogenous testosterone in
, b* C9 Q+ c9 ^; S3 ~' b R5 @9 xchildren results in an increase in growth velocity and
& i) u: u2 @# q' X3 B7 l0 ~advanced bone age, as seen in our patient.' `) `1 M& p: p; M* E
The long-term effect of androgen exposure during+ V/ i: @8 e. a7 k6 i
early childhood on pubertal development and final/ e9 g6 o0 P' P$ @" i& d7 \" ^, K
adult height are not fully known and always remain
}1 O/ _+ M' ^: ]0 Xa concern. Children treated with short-term testos-
7 b! \6 ~' n! m% C- O2 K* \terone injection or topical androgen may exhibit some4 Q3 d3 Y$ B4 l5 d: }3 V6 n
acceleration of the skeletal maturation; however, after
% R2 y; @; j% e6 zcessation of treatment, the rate of bone maturation: }+ f2 n3 R5 F9 s6 l: c) Y5 y
decelerates and gradually returns to normal.8,9, |2 v) l" r2 U; [ I& @
There are conflicting reports and controversy+ \8 m; X9 c4 @ R4 X8 s6 a
over the effect of early androgen exposure on adult7 [3 }4 Z3 ]. ^+ J# p: o
penile length.10,11 Some reports suggest subnormal' n' _. K2 p n0 T& O; P' X1 r
adult penile length, apparently because of downreg-
+ z* j% ?$ _4 _: A$ U7 S$ p V2 Yulation of androgen receptor number.10,12 However,
* R% Q [$ K2 `. a5 bSutherland et al13 did not find a correlation between
( K; U2 B$ ~; n. h. n; Y+ ]* ~childhood testosterone exposure and reduced adult8 }+ [# t9 C8 r. t P
penile length in clinical studies.4 f: Z( H- i' E1 {: j+ j
Nonetheless, we do not believe our patient is
6 |% ?7 N- y2 n6 e# }going to experience any of the untoward effects from1 ^( }0 G3 J @5 u
testosterone exposure as mentioned earlier because7 g5 r. P+ H, Q, N* E# z: ]
the exposure was not for a prolonged period of time.* F2 o# ]; T) p; p4 l: b
Although the bone age was advanced at the time of/ f; p$ M; q: V \
diagnosis, the child had a normal growth velocity at& _. M1 O$ W1 I- u4 @
the follow-up visit. It is hoped that his final adult
4 l* r4 b$ q- g6 z8 C- A- Iheight will not be affected./ o# _3 y7 U' p; b) g
Although rarely reported, the widespread avail-# o; j" d) ~( V" V
ability of androgen products in our society may
" \% t; G' t- w. i4 W, K4 z; Jindeed cause more virilization in male or female5 k- j- B: {; ~' f) ?* @+ b- P
children than one would realize. Exposure to andro-, I1 v7 S' ?6 \
gen products must be considered and specific ques-1 ?) Y+ c2 R3 n' q. K8 K
tioning about the use of a testosterone product or
; c; K6 D5 f2 ]7 x% agel should be asked of the family members during
/ m$ D1 a0 J4 B$ i2 Pthe evaluation of any children who present with vir-
( ~: [3 B% s2 N1 z4 X% q1 kilization or peripheral precocious puberty. The diag-4 ~2 m8 q! l+ A+ v
nosis can be established by just a few tests and by
H+ h1 P) j% ? e$ u1 _appropriate history. The inability to obtain such a
& A7 Z" ]3 g3 B% f1 Vhistory, or failure to ask the specific questions, may
1 x" \7 d8 ?6 r' mresult in extensive, unnecessary, and expensive
% q6 }: X9 w4 \( n; Iinvestigation. The primary care physician should be$ z9 b ]$ P) ~
aware of this fact, because most of these children
8 [8 Y" q2 N7 @9 W8 a& Q; S( bmay initially present in their practice. The Physicians’
9 v2 W- T$ p; }Desk Reference and package insert should also put a
5 q9 N9 y' E5 F5 Y4 T) A Q h' hwarning about the virilizing effect on a male or
. g7 |/ X- v0 P6 X. D" cfemale child who might come in contact with some-
8 U( B; M: ~0 u5 w# Q! none using any of these products.# F( x; q) b: E9 @3 e [
References
1 y. s1 t7 [0 N' Y9 o1 d/ X" }; J1. Styne DM. The testes: disorder of sexual differentiation, o$ I- t9 A9 f* s& ^
and puberty in the male. In: Sperling MA, ed. Pediatric
0 F: I! W5 p% E* u5 u2 ~* gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- I% I3 m9 f7 P B# j
2002: 565-628.( D- d: A$ d2 n+ O$ i! i5 `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: D0 Q6 }( P+ j; Z& W0 U. _
puberty in children with tumours of the suprasellar pineal |
|