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Sexual Precocity in a 16-Month-Old
5 b7 [$ A* d& Q O4 I5 j5 ^8 k# y8 YBoy Induced by Indirect Topical# B+ S5 a- H. a! L% V
Exposure to Testosterone
9 G1 h0 o& |. p) X. B/ ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. X& ]* V* w7 I8 B! d, J
and Kenneth R. Rettig, MD1! O; L1 m) m7 |4 H5 q0 h1 l
Clinical Pediatrics5 d+ C* B- N# D
Volume 46 Number 6: P- r; B) q$ o4 H2 g% D
July 2007 540-543
' d; j9 X- U8 Y* i/ m3 W, m& w© 2007 Sage Publications7 W' d5 q$ J8 `( H# d0 `7 f
10.1177/0009922806296651
& K3 O7 z$ m: c3 z" \" x- Lhttp://clp.sagepub.com
8 K' L5 @0 h4 e( Lhosted at
e8 \3 A2 x3 C1 x' A3 ^http://online.sagepub.com
, t. R6 a% B" z' ?+ dPrecocious puberty in boys, central or peripheral,0 h- b+ H* M, S! n. ]
is a significant concern for physicians. Central
0 i% M+ L9 M' p" vprecocious puberty (CPP), which is mediated
8 }" ~. l5 U7 wthrough the hypothalamic pituitary gonadal axis, has
7 f/ v" c% M+ F& e. U% `) Sa higher incidence of organic central nervous system
. A+ B: `( f& {; u! ulesions in boys.1,2 Virilization in boys, as manifested3 _! _1 y R4 f' A9 L
by enlargement of the penis, development of pubic; w0 u2 u, _& y$ ~& a
hair, and facial acne without enlargement of testi-8 u& b" Z' m/ p
cles, suggests peripheral or pseudopuberty.1-3 We: \) F+ {0 _2 e/ ~2 C* R
report a 16-month-old boy who presented with the
" m5 F. U E* ?, I7 g6 N. Q1 S- henlargement of the phallus and pubic hair develop-" d; B/ S, _# |# v- y
ment without testicular enlargement, which was due
. p& l9 a3 T1 z9 ~to the unintentional exposure to androgen gel used by1 L+ T* l- y( s' E v9 X9 J' x
the father. The family initially concealed this infor-" y- p2 T, ^4 ~8 M& P) x: D5 }& g4 L
mation, resulting in an extensive work-up for this3 E. N& m( p3 w( `
child. Given the widespread and easy availability of
: i/ }, m' i( v0 Q& t4 i4 R) t% ytestosterone gel and cream, we believe this is proba-: }% x) ^% S4 s- f4 A3 \( R
bly more common than the rare case report in the
9 k: R7 V A, V9 S3 Cliterature.4/ j0 F/ H2 a* I$ [
Patient Report/ \3 u; E# I6 v7 _& w
A 16-month-old white child was referred to the
' [7 q( y3 O3 `! `% cendocrine clinic by his pediatrician with the concern
2 h, o+ m; U; O6 [: N3 ^of early sexual development. His mother noticed* A! Z5 M/ v. H( Y$ I: _3 E
light colored pubic hair development when he was8 N# K; c: W; y' n$ J# a8 E* e4 j
From the 1Division of Pediatric Endocrinology, 2University of
+ m8 k- h. ~7 w# W! B! g1 GSouth Alabama Medical Center, Mobile, Alabama.0 e: w4 T4 U' E) Z, V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 Q6 Y9 c ~) I2 C) v; ?Professor of Pediatrics, University of South Alabama, College of9 C- d; X+ Q0 F0 E9 x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 [1 B0 _7 Y: i$ E9 y$ U7 {e-mail: [email protected].
; V! T; r p& P5 {1 h. y9 {about 6 to 7 months old, which progressively became
5 J: X5 G0 b: W* ydarker. She was also concerned about the enlarge-
3 ^" N9 x" g2 }6 Lment of his penis and frequent erections. The child
1 a0 e2 Z* F9 }% M$ k" Q( v2 Lwas the product of a full-term normal delivery, with; ]7 I6 @+ u* l0 ]" q' K: N
a birth weight of 7 lb 14 oz, and birth length of
0 b2 C* V( ~' _% ?( J7 W" {20 inches. He was breast-fed throughout the first year
1 `, h7 C" y( S: Z, lof life and was still receiving breast milk along with; K6 W. o. t, N; w) m3 d" w/ U
solid food. He had no hospitalizations or surgery,2 p1 S$ Q& d0 W
and his psychosocial and psychomotor development% j. x/ C6 j7 M+ b" {' q# o: N
was age appropriate.& x- N% i6 r/ h5 K0 E4 K# o1 ^
The family history was remarkable for the father, c1 I8 f& E; F, C5 o. A
who was diagnosed with hypothyroidism at age 16,
& K( b' u( f# {which was treated with thyroxine. The father’s
# s+ Y3 T$ q% X( l8 ?9 Pheight was 6 feet, and he went through a somewhat9 J, E6 J0 [% D' Q7 T: Y
early puberty and had stopped growing by age 14.7 f* r/ c7 I' P/ e5 K
The father denied taking any other medication. The
3 c0 l: G0 I& h" vchild’s mother was in good health. Her menarche4 j" q# n ~- ^* O/ l
was at 11 years of age, and her height was at 5 feet
0 E5 N6 z( r5 h. q$ N5 inches. There was no other family history of pre-
, b" S" {( H" R- bcocious sexual development in the first-degree rela-
/ p8 s! W7 r. q* g* L* X8 ^6 Stives. There were no siblings.
2 c2 ~7 u+ v/ v [Physical Examination
' v+ T& W& h5 W$ _- _( FThe physical examination revealed a very active,
# H# z- t* N! Rplayful, and healthy boy. The vital signs documented
; Y0 M4 E+ a5 [8 Q J6 A1 Ka blood pressure of 85/50 mm Hg, his length was
6 q. P X4 r w/ F, T9 J) {; G90 cm (>97th percentile), and his weight was 14.4 kg
! q! H7 `6 _: q5 {; O# \& Y(also >97th percentile). The observed yearly growth
* A$ H8 G7 Y$ W& X- O2 x. Mvelocity was 30 cm (12 inches). The examination of7 u& h4 B0 `, j
the neck revealed no thyroid enlargement.* ~6 p1 w9 ?6 S/ w4 s7 N; P2 E
The genitourinary examination was remarkable for
, n" J# p7 {. ]8 C2 }! kenlargement of the penis, with a stretched length of' B" B. X2 N. @/ m/ @
8 cm and a width of 2 cm. The glans penis was very well
3 i% k* \9 \% i- T' w* B S; C* {- mdeveloped. The pubic hair was Tanner II, mostly around
( B3 w. ~* h* ?6 A) J- ?* ^" v540
( k' Y) w) k! l( ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 Z6 e6 J5 z9 I7 [( b3 ?! Cthe base of the phallus and was dark and curled. The
& d1 M' p9 f; T8 z' s' c' gtesticular volume was prepubertal at 2 mL each.
9 T$ L( A2 Z6 F/ l O) m& l4 UThe skin was moist and smooth and somewhat2 r# k6 r) O- o8 |2 R
oily. No axillary hair was noted. There were no: W1 h; z0 N5 b
abnormal skin pigmentations or café-au-lait spots.
) C2 Y Z$ w& J0 s, L: \ DNeurologic evaluation showed deep tendon reflex 2+
* V7 B8 F w. }# h, ~bilateral and symmetrical. There was no suggestion
0 d. i. T0 ?1 M7 ~- Kof papilledema.0 I/ b( g$ ]( M, O! `6 y
Laboratory Evaluation
$ y: J [3 e0 G! Z: h+ p$ ?% bThe bone age was consistent with 28 months by6 i3 X; e- J _5 \) F, {9 q( s
using the standard of Greulich and Pyle at a chrono-5 Y! v# y) C4 _6 L
logic age of 16 months (advanced).5 Chromosomal9 V( y! b, V1 [4 I- {
karyotype was 46XY. The thyroid function test
! p/ E, h: w3 l, b4 Y( y. E4 ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! |9 C* U1 W% f9 K) @. p/ F2 [lating hormone level was 1.3 µIU/mL (both normal).
; e- x4 w' Y$ G) `The concentrations of serum electrolytes, blood
5 l) c9 |& l+ b e; G3 H) Curea nitrogen, creatinine, and calcium all were/ ?% W* `' M4 x1 A
within normal range for his age. The concentration
! j" Z. G2 e) A) Uof serum 17-hydroxyprogesterone was 16 ng/dL) `9 j7 _- M9 m6 O5 O- E
(normal, 3 to 90 ng/dL), androstenedione was 20 p) n- [1 v4 a* F. X: z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* w: F2 l$ j% ]2 h7 I3 T6 T3 c) G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 e3 Y2 D! `, F% cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to9 [7 n- G) X& R3 {2 I
49ng/dL), 11-desoxycortisol (specific compound S)- g( k6 c6 ~: c, F4 b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 v) V, f) ~$ m1 p6 utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, e# Z6 E8 H# S6 Z$ e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( y- |5 X) t6 ~
and β-human chorionic gonadotropin was less than
& m% J( u, y0 l/ F' v. x5 mIU/mL (normal <5 mIU/mL). Serum follicular W, T2 R! q- M9 ^5 \
stimulating hormone and leuteinizing hormone
; m2 u, b* x! P* k6 }# B; ^concentrations were less than 0.05 mIU/mL
( D ]% x' r6 D(prepubertal).& t+ J$ {' V0 H1 ~, R1 W7 _
The parents were notified about the laboratory
- u4 Q/ ?4 W+ G( Fresults and were informed that all of the tests were. H3 b8 V1 m9 [5 P: p) f
normal except the testosterone level was high. The
# C( N1 G- J: w3 jfollow-up visit was arranged within a few weeks to
8 z* U. x b3 }; x: G+ @obtain testicular and abdominal sonograms; how-8 V& _6 k- {6 Y) p* B$ z
ever, the family did not return for 4 months.7 h- m4 w* P. L
Physical examination at this time revealed that the
' y- U9 ~" K8 E4 i! r" n& w0 fchild had grown 2.5 cm in 4 months and had gained
1 v1 q7 v- ~0 v3 B. H2 kg of weight. Physical examination remained, X+ X4 j: o2 {; G( y! A1 }
unchanged. Surprisingly, the pubic hair almost com-2 \& N: w4 y0 G* v4 h
pletely disappeared except for a few vellous hairs at
" X* \7 [3 @& s2 T0 r3 M+ X; gthe base of the phallus. Testicular volume was still 2
1 ~- L3 O8 t$ P5 A2 VmL, and the size of the penis remained unchanged.
% n& A* M8 P$ e7 q( n5 ~The mother also said that the boy was no longer hav-7 F) }- L$ ^7 s
ing frequent erections.
$ A# [& ]& Y, V: @* i% dBoth parents were again questioned about use of! G* b8 ]/ t. h7 a9 k$ r
any ointment/creams that they may have applied to: S8 N2 {4 j5 h9 |! Y- C3 _; D
the child’s skin. This time the father admitted the
& H& M* W% R# k+ M4 OTopical Testosterone Exposure / Bhowmick et al 541. E$ n) ?- _, Y% H. W
use of testosterone gel twice daily that he was apply-
\9 C# o$ H* H; r) Ving over his own shoulders, chest, and back area for
F& r6 A+ f! h' a0 E' C; q; Xa year. The father also revealed he was embarrassed3 R. N( A% P y( k$ i
to disclose that he was using a testosterone gel pre-0 H* g: R4 V0 }2 B
scribed by his family physician for decreased libido3 Z# F5 s; N( s3 O* W6 c# m ~ c
secondary to depression.
' N+ C7 g) w) `. G5 v% w9 kThe child slept in the same bed with parents.5 n. R9 R# Y: Q- [) M) |
The father would hug the baby and hold him on his
$ C8 x, [2 x Bchest for a considerable period of time, causing sig-
' s) C* Y, X C" N# E( N( p4 [& Qnificant bare skin contact between baby and father.0 `8 G: P! _3 y# z9 ^
The father also admitted that after the phone call,
" F1 a# c$ t* a# G. Rwhen he learned the testosterone level in the baby; Y. A" w/ H) X# G7 m/ e/ Y
was high, he then read the product information
3 P5 d/ E+ W0 ?' u9 Tpacket and concluded that it was most likely the rea-
5 E8 N4 a( v3 R1 ^, U2 ason for the child’s virilization. At that time, they
0 k% M7 @2 r1 wdecided to put the baby in a separate bed, and the# v- o) `3 T! {6 {
father was not hugging him with bare skin and had' h D+ y8 H0 b% S% n4 [
been using protective clothing. A repeat testosterone
5 O( L1 v& u( b5 W/ N3 Atest was ordered, but the family did not go to the( E# y7 {3 V% j2 Q
laboratory to obtain the test.' `) l5 b4 I2 f/ n
Discussion
* _- z5 E2 B( J2 d+ L! IPrecocious puberty in boys is defined as secondary: n- M; E) E2 T7 }& k4 A
sexual development before 9 years of age.1,4! V7 D7 J, \3 p; i
Precocious puberty is termed as central (true) when
2 ^, q$ c7 I3 u6 kit is caused by the premature activation of hypo-
* k" T( n b6 K+ H3 wthalamic pituitary gonadal axis. CPP is more com-- ~6 f4 K3 ]$ E
mon in girls than in boys.1,3 Most boys with CPP
8 q, s' ?2 I( g! mmay have a central nervous system lesion that is
( A1 {/ E, q8 s6 ]% V" _2 mresponsible for the early activation of the hypothal-! e# a5 H. r3 X9 ^1 `
amic pituitary gonadal axis.1-3 Thus, greater empha-0 a2 N. }; i: x
sis has been given to neuroradiologic imaging in1 o3 \4 t: P2 l, p6 U4 h- r8 T
boys with precocious puberty. In addition to viril-
: f, v6 ]6 a8 j' u8 u5 zization, the clinical hallmark of CPP is the symmet-
1 U+ z; T( ]" D4 w% erical testicular growth secondary to stimulation by
! C5 r1 q# l" h% G% D dgonadotropins.1,3- u2 R* @) @1 l' s, u2 A
Gonadotropin-independent peripheral preco-
9 R+ n4 a6 c( _, Lcious puberty in boys also results from inappropriate
$ ^2 S+ D/ G( w: o2 }& V9 ?androgenic stimulation from either endogenous or
, o; B- H' V) z8 K/ `exogenous sources, nonpituitary gonadotropin stim-! i: u' `3 ?0 y/ ~+ V8 P* z
ulation, and rare activating mutations.3 Virilizing
3 y$ L! L' z- a/ B( Pcongenital adrenal hyperplasia producing excessive: D8 V9 Q7 I+ I- ?% m
adrenal androgens is a common cause of precocious
. c! i% z8 a$ B( {- bpuberty in boys.3,45 h6 @- H. j+ E# \; l
The most common form of congenital adrenal, k5 T" D9 Z6 n4 ?# m$ Y1 q- {% [5 h
hyperplasia is the 21-hydroxylase enzyme deficiency.
. t" O3 O m' c% [The 11-β hydroxylase deficiency may also result in% s& h- i5 f% h$ q, L
excessive adrenal androgen production, and rarely,
m- n+ a* j( w+ J9 b9 r; Ban adrenal tumor may also cause adrenal androgen( x) p0 k! B6 O
excess.1,3; k/ E# E' ]& K9 q; \" }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 o; ?% a4 s( d8 Y6 M x3 r
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' R9 y ?8 v( h/ ?
A unique entity of male-limited gonadotropin-
# s5 M; B2 Q5 c1 v* [% Cindependent precocious puberty, which is also known# z- b: W4 t1 l2 X6 G2 L# {$ W' w
as testotoxicosis, may cause precocious puberty at a8 j9 H m; {1 g8 `6 T3 v2 s; m }$ d
very young age. The physical findings in these boys9 M+ E, ]2 Q2 o* U$ @, f
with this disorder are full pubertal development,: i3 x! I$ S' n: z+ i
including bilateral testicular growth, similar to boys" W. @2 Y+ v" }, a7 e. d* z
with CPP. The gonadotropin levels in this disorder# ^. T- p# {5 M9 v* B: a# O
are suppressed to prepubertal levels and do not show
* B: T3 v6 ?: p% tpubertal response of gonadotropin after gonadotropin-/ i9 |0 G0 f) K7 n7 F0 t
releasing hormone stimulation. This is a sex-linked' F5 a- H9 N7 ], m6 s1 h6 k
autosomal dominant disorder that affects only
Y$ N3 V7 }& Umales; therefore, other male members of the family9 q4 @* ` e) [5 f, n% V
may have similar precocious puberty.38 ^/ I1 n- Y' ?- j3 A4 Y- J4 D: T7 {
In our patient, physical examination was incon- j; i/ d2 z3 P+ [. v9 x8 e
sistent with true precocious puberty since his testi-2 x) x5 I( C' y) Z. N! I( z
cles were prepubertal in size. However, testotoxicosis- T" M* A9 C! I% Y% w
was in the differential diagnosis because his father% n5 U5 ] Y2 F3 Q% y7 p* m
started puberty somewhat early, and occasionally,
8 G. D* A- T4 G0 S8 ^/ P, G3 Ztesticular enlargement is not that evident in the
+ b7 s& _! m1 ]0 p. J( J W6 fbeginning of this process.1 In the absence of a neg-
5 s4 A% h! G: g4 {ative initial history of androgen exposure, our9 u: d2 k' ?4 U
biggest concern was virilizing adrenal hyperplasia,) q% S Q, u; Y: K, n1 K6 p
either 21-hydroxylase deficiency or 11-β hydroxylase
. o2 d( ?4 a& G6 Q& U9 Mdeficiency. Those diagnoses were excluded by find-- s4 S, u9 H$ Z, l- E9 G! G4 n( H" t
ing the normal level of adrenal steroids. s3 q! i+ @2 v* X1 v& |+ i) x
The diagnosis of exogenous androgens was strongly
7 q( o+ A; q8 e/ o( L4 e! C* ssuspected in a follow-up visit after 4 months because
1 E- Y* V4 e% E# _2 u8 rthe physical examination revealed the complete disap-: i2 X3 k) E' f* d/ ]# h
pearance of pubic hair, normal growth velocity, and
9 ^; D- M& r' t- _& A# w0 Wdecreased erections. The father admitted using a testos-5 {# K5 `8 O0 G- X
terone gel, which he concealed at first visit. He was
2 x: ?8 S4 u4 c1 Y( A0 h& k# `; Xusing it rather frequently, twice a day. The Physicians’! z' p6 w3 E U8 }+ Y2 n
Desk Reference, or package insert of this product, gel or& I2 \9 T9 {2 @
cream, cautions about dermal testosterone transfer to* d6 Y9 h% f! Z- F
unprotected females through direct skin exposure.4 g4 J# u o# u- Y- o! X
Serum testosterone level was found to be 2 times the' O! a/ ]0 I! M: K( P, q
baseline value in those females who were exposed to0 e9 j$ o1 T8 f% k+ I1 R
even 15 minutes of direct skin contact with their male2 o) g% j5 D7 ] ^
partners.6 However, when a shirt covered the applica-
% K3 |& n. D4 s, b# N& _1 [tion site, this testosterone transfer was prevented.
, R" Q* @4 |6 U/ |; IOur patient’s testosterone level was 60 ng/mL," p2 J2 r- |5 |, j2 @1 x! x
which was clearly high. Some studies suggest that6 Q$ }. W# b2 n) i3 N- q
dermal conversion of testosterone to dihydrotestos-& M8 A. i G: l& @' H m
terone, which is a more potent metabolite, is more: D5 _. ]0 r- X' S9 w! N
active in young children exposed to testosterone5 M: U' l* z1 v3 s+ w9 m
exogenously7; however, we did not measure a dihy-
7 Y: f1 H3 @# Edrotestosterone level in our patient. In addition to3 r+ M$ S& ]! m4 E5 |7 v8 |0 Z
virilization, exposure to exogenous testosterone in
( K1 E& m4 J, [' n- gchildren results in an increase in growth velocity and: K2 D7 x0 M* h# M
advanced bone age, as seen in our patient.
5 P) g2 @! Z4 Z3 y! }The long-term effect of androgen exposure during5 G3 l# q+ T' \2 N
early childhood on pubertal development and final
$ D0 x! U6 `2 Y0 ~adult height are not fully known and always remain% `1 h% D4 T+ O5 s! a, z
a concern. Children treated with short-term testos-
8 @+ R4 M& W* S# @# Rterone injection or topical androgen may exhibit some
8 P/ z; E* ~# r8 U2 i: Y8 \8 @5 jacceleration of the skeletal maturation; however, after
8 F1 ^, h+ M- z4 s* ^3 p9 Vcessation of treatment, the rate of bone maturation2 f: c. L+ C# {6 m
decelerates and gradually returns to normal.8,9) U4 ^* }; X$ v$ x4 n. ?5 m. w* Z
There are conflicting reports and controversy
& X+ |1 U9 \2 m" g* Y6 Gover the effect of early androgen exposure on adult7 w4 K% z, H+ R! ?; e1 }- ^) Y
penile length.10,11 Some reports suggest subnormal6 J, c' [8 |, O
adult penile length, apparently because of downreg-# z3 h$ ~& `. E9 f e! C' d) H3 J
ulation of androgen receptor number.10,12 However,4 K h0 l) N) k; a g& P) G5 u
Sutherland et al13 did not find a correlation between
+ N/ p% ]0 i# o ?4 ?+ _childhood testosterone exposure and reduced adult
0 P! Y/ Z) g [; jpenile length in clinical studies.
( h' ]* U4 M4 v& yNonetheless, we do not believe our patient is
; l7 w4 g7 _" l) [8 Kgoing to experience any of the untoward effects from
M/ c N% R$ a2 V5 ]testosterone exposure as mentioned earlier because
1 m% _( Q b1 R8 a, F- Lthe exposure was not for a prolonged period of time.: Z& \( a2 P9 n$ f
Although the bone age was advanced at the time of$ z, K1 B1 [$ x+ S
diagnosis, the child had a normal growth velocity at) v" r& B9 l* L% s4 |0 v1 q* d
the follow-up visit. It is hoped that his final adult) q; M- s8 B, F# T% m
height will not be affected.
% p3 a8 k3 E# E+ f$ p, yAlthough rarely reported, the widespread avail-$ `6 D9 \# J+ V, j
ability of androgen products in our society may( O% v) _1 _+ `, C, a) A& l
indeed cause more virilization in male or female9 m1 c6 |' B/ q, J, }) {
children than one would realize. Exposure to andro- n2 g3 Z! t) n9 O: O/ _- E2 C
gen products must be considered and specific ques-4 {) }7 w; J$ M- V6 g L6 W7 A
tioning about the use of a testosterone product or
9 h( J5 j% V! _/ Ngel should be asked of the family members during* {8 p, z( h7 \: V/ f) z
the evaluation of any children who present with vir-' X: U# k( V2 e& b+ Y! `3 K" Y0 L9 |# n
ilization or peripheral precocious puberty. The diag-
9 p/ M, |4 P6 t) N+ dnosis can be established by just a few tests and by6 v6 C/ F3 p, A l% B0 y8 B# e( h: _
appropriate history. The inability to obtain such a
7 m r+ s$ w9 D2 s- n! ]5 T' whistory, or failure to ask the specific questions, may
4 p" |1 H0 q3 m9 a H* i hresult in extensive, unnecessary, and expensive' a) \& Z; q6 y
investigation. The primary care physician should be
% |! z- R/ K- i2 M4 {' `8 Zaware of this fact, because most of these children
! P' U6 T! F) i4 W$ O2 e$ kmay initially present in their practice. The Physicians’5 M5 X6 j6 K4 m: d7 u6 h
Desk Reference and package insert should also put a
6 P6 k4 g( G# T# c) Vwarning about the virilizing effect on a male or
4 o# d A, v; y& Qfemale child who might come in contact with some-
: Z3 W% `1 k+ d9 l9 B* Y6 Rone using any of these products.7 M- v% o$ e" f* B8 z. T+ `
References0 s& r0 H" s8 m
1. Styne DM. The testes: disorder of sexual differentiation
/ B) A0 Z: \$ W c0 |, w) kand puberty in the male. In: Sperling MA, ed. Pediatric
% f( h7 ^: c" R5 nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; k! @ z9 V4 q4 m5 {8 p4 n
2002: 565-628.! `- Z, v. S( K# |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- F) P& W7 X( G- epuberty in children with tumours of the suprasellar pineal |
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