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Sexual Precocity in a 16-Month-Old
& {; B; Z, Q. q9 o8 i# d9 O {Boy Induced by Indirect Topical
3 e" \& W, ~- n) XExposure to Testosterone% w) w- [+ F# R) I) B' R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 X& p9 L6 ?6 Q* A3 R1 j
and Kenneth R. Rettig, MD1
: ^& y* {: f3 YClinical Pediatrics& ~* f, c4 I+ v4 F
Volume 46 Number 6* n, R# ~) q; r& }% W4 l
July 2007 540-543* Q. [* q# D- W1 C* k1 U) N
© 2007 Sage Publications
4 a) t4 r8 v R; i) H- ~- X. l10.1177/0009922806296651
$ `5 c* W$ U* c8 Yhttp://clp.sagepub.com
' [# t0 x& X* U3 K3 n" P" J4 ghosted at; G0 t: h; Z# r
http://online.sagepub.com( |7 L) s# Z6 x1 e
Precocious puberty in boys, central or peripheral,) |- \2 N, |' v- ?2 [; `& R) x
is a significant concern for physicians. Central0 [+ K, M! V0 Z3 @! y
precocious puberty (CPP), which is mediated
: A C0 Z+ \" Z% }' r+ \through the hypothalamic pituitary gonadal axis, has
; e- F+ l& e/ D j& g7 T- B/ sa higher incidence of organic central nervous system
! O- ~, M1 _+ Z. N% Ilesions in boys.1,2 Virilization in boys, as manifested% k( h( \, B7 i& R9 {7 _
by enlargement of the penis, development of pubic" V' z+ V* Q0 ]& G5 f: m
hair, and facial acne without enlargement of testi-- `# L3 P, x1 W9 i/ G; V
cles, suggests peripheral or pseudopuberty.1-3 We! }: X* k9 J! j
report a 16-month-old boy who presented with the$ t5 W: C( Y$ ?' f: v. ^+ ^
enlargement of the phallus and pubic hair develop-! ?: Y$ t3 n7 |; E& c( k" _
ment without testicular enlargement, which was due
5 e# L$ ~3 d1 J# \- I; Cto the unintentional exposure to androgen gel used by
G) G. g5 V$ l( Dthe father. The family initially concealed this infor-
- r/ [% t9 Q1 J t% t8 ^mation, resulting in an extensive work-up for this0 s) F6 G% J) m
child. Given the widespread and easy availability of
' q r/ k8 k7 {; A6 Ntestosterone gel and cream, we believe this is proba-
# r4 p i# U. W6 T1 g2 @2 h) r, cbly more common than the rare case report in the! |/ m7 G( h+ k
literature.4
* B9 M2 R! ^2 _Patient Report+ q1 [. f: w5 K( A' c) ^* H
A 16-month-old white child was referred to the
- ~" X* |- } Z2 G; B4 ]8 I% {endocrine clinic by his pediatrician with the concern% |0 m0 d: ^5 W2 `) F8 Z3 s* z9 ]6 ~
of early sexual development. His mother noticed5 ^- e8 s1 H J6 Q
light colored pubic hair development when he was9 l g X, }/ O
From the 1Division of Pediatric Endocrinology, 2University of
3 U0 K7 E6 ]: u9 x/ C% b) p9 tSouth Alabama Medical Center, Mobile, Alabama.! s: V) i) ~/ z* E: H' Z7 ^2 D
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ D$ |7 J3 w$ v7 _. z! ]Professor of Pediatrics, University of South Alabama, College of
1 z; v( u H: @6 V( hMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 k5 Y+ O4 ^% F& s. h/ a; }e-mail: [email protected].
! j/ U4 L) n8 o& }5 L; Rabout 6 to 7 months old, which progressively became. W+ {2 m0 D* n" g: r! h
darker. She was also concerned about the enlarge-+ ~' R3 J; S9 a: L8 r% o
ment of his penis and frequent erections. The child
0 x" y j. o+ A5 P" e; l7 zwas the product of a full-term normal delivery, with' Q% |6 v$ `- y6 k( E# i+ C0 l
a birth weight of 7 lb 14 oz, and birth length of9 X' D* I$ J7 `1 P% m; L
20 inches. He was breast-fed throughout the first year, J4 B! H. C! g, L
of life and was still receiving breast milk along with
2 n7 G2 H6 ]& s3 V0 W) o/ b. y' Xsolid food. He had no hospitalizations or surgery,& e; s: k4 f& Y# t+ X- Z: o
and his psychosocial and psychomotor development
6 T a/ ]9 u F p* a* Gwas age appropriate.
8 S* \8 x$ B( N7 pThe family history was remarkable for the father," X0 I) }$ V- h+ J
who was diagnosed with hypothyroidism at age 16,
1 t% W9 d5 l5 O1 m9 N, Y- Awhich was treated with thyroxine. The father’s) ^1 w, K2 M. Z ]6 U/ _0 U3 h
height was 6 feet, and he went through a somewhat
% {- ]8 ?* H7 I& \7 y* j' Nearly puberty and had stopped growing by age 14.
/ Y; A/ {% _9 h# F* F/ @$ ~) q7 n. V/ kThe father denied taking any other medication. The5 I5 }9 k# u% l$ ?* a
child’s mother was in good health. Her menarche% G5 w9 A* Y" D: T" g" \' A
was at 11 years of age, and her height was at 5 feet
$ j5 e2 P5 R7 t4 u5 inches. There was no other family history of pre-
, P2 c* @2 @$ L7 ^0 G# @& F$ Y7 zcocious sexual development in the first-degree rela-0 s5 z7 b+ u5 g" D& n) x
tives. There were no siblings.# `" z+ ?3 y6 m( R7 u u1 h
Physical Examination1 K! g2 m* _7 q# E) }$ l
The physical examination revealed a very active,
+ v, T" j) T# i( k0 Q% Vplayful, and healthy boy. The vital signs documented
8 ?, l# I% E( k" R% A0 ?( R s+ za blood pressure of 85/50 mm Hg, his length was
7 d. w% }9 N2 ~% X1 N) O6 D90 cm (>97th percentile), and his weight was 14.4 kg
* ?8 ^0 r( z) m# T4 A(also >97th percentile). The observed yearly growth2 A! { p: ~, N" O7 B
velocity was 30 cm (12 inches). The examination of
; b2 F: w- r( G" n, fthe neck revealed no thyroid enlargement.
' w* L$ H* N5 P* Y6 @The genitourinary examination was remarkable for7 R1 ^8 p2 H" F7 M0 o0 i
enlargement of the penis, with a stretched length of1 \2 {- S$ |! L4 l- A
8 cm and a width of 2 cm. The glans penis was very well
: W/ l2 M0 j. O: _; i* e) b) xdeveloped. The pubic hair was Tanner II, mostly around
/ H( E( t, j& w( s( v( N540; t4 _: e7 I3 V9 e! V- L" R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; n8 R% l2 y$ r: Z$ |
the base of the phallus and was dark and curled. The
) U, `9 c4 r5 n7 ftesticular volume was prepubertal at 2 mL each.! R- e; p3 P: q' j4 q( \! y2 y
The skin was moist and smooth and somewhat
: w/ {( Y, X7 qoily. No axillary hair was noted. There were no
! T: l$ }( u4 G# f) }abnormal skin pigmentations or café-au-lait spots.
+ f, H2 T* d& m3 ^5 k7 C+ [Neurologic evaluation showed deep tendon reflex 2+
T2 Y% H" k3 t* D5 [* G* x0 jbilateral and symmetrical. There was no suggestion9 n# [3 N0 m. K: O
of papilledema.. K* q$ I. u8 W7 d& @+ q4 u, f% i& g
Laboratory Evaluation
& Z8 h. y0 }1 [0 N" NThe bone age was consistent with 28 months by
& D5 {6 c8 y8 [- g- r5 ?0 Q5 Zusing the standard of Greulich and Pyle at a chrono-
! p9 v O/ s8 l7 U! N' Tlogic age of 16 months (advanced).5 Chromosomal4 ~& ?5 F& q& p( _% b/ p* Z* N
karyotype was 46XY. The thyroid function test
7 o9 Y9 z. X/ }showed a free T4 of 1.69 ng/dL, and thyroid stimu-) l0 ? \5 `9 t7 s
lating hormone level was 1.3 µIU/mL (both normal)." R% t5 S& L& Y7 C5 p' y: A% {: `
The concentrations of serum electrolytes, blood7 {1 h0 I/ P, Y8 Z4 \; a
urea nitrogen, creatinine, and calcium all were
0 ]2 ^# j& s3 I8 w: s7 l; [3 hwithin normal range for his age. The concentration, N; `) C' g- M+ e
of serum 17-hydroxyprogesterone was 16 ng/dL
. N' c( ^% [) a2 u(normal, 3 to 90 ng/dL), androstenedione was 20
! Q4 p; r4 O( o4 y; z* |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 Y# D4 C4 z* t' @ v; A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 G2 m: M7 ~) ]+ g( }- Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to7 u' T, O) |! M# c
49ng/dL), 11-desoxycortisol (specific compound S)" a& v0 L: x$ ]4 w; p- [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% ]' L# C1 Y0 M( ~% x/ X6 _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ H, d# T3 }, n( K0 H
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 ~. w$ q5 x' S* w$ c. q* p( A
and β-human chorionic gonadotropin was less than
2 H# h2 N: u- C) c5 mIU/mL (normal <5 mIU/mL). Serum follicular
% y1 z3 f5 |% x9 Estimulating hormone and leuteinizing hormone2 X% t* b2 r: e9 X8 P% s0 \
concentrations were less than 0.05 mIU/mL
: ]! v) t4 c$ F( M, A(prepubertal).
! ?# L) o6 _% j( i1 P! \The parents were notified about the laboratory
6 X+ t; d, T& |! ` T* ]results and were informed that all of the tests were
" h, k$ c, \# n) snormal except the testosterone level was high. The
/ d8 _' h8 U8 Q3 Ofollow-up visit was arranged within a few weeks to) R$ X% h9 V" Z) B
obtain testicular and abdominal sonograms; how-2 x) R9 {9 [2 \
ever, the family did not return for 4 months.# f, p' L4 Y0 h3 P+ [& a
Physical examination at this time revealed that the
0 W9 }2 v! `: m/ K( Tchild had grown 2.5 cm in 4 months and had gained/ Y( e$ W# s: U% r+ t) p3 F
2 kg of weight. Physical examination remained
6 {+ r# ^4 W4 x6 z; o s' X5 |unchanged. Surprisingly, the pubic hair almost com-" v' C. U, @5 Y0 k% }
pletely disappeared except for a few vellous hairs at2 q$ ]# A5 D! B" n* m
the base of the phallus. Testicular volume was still 2
' S1 h! y3 E1 Q! x" D( A4 D- AmL, and the size of the penis remained unchanged.
# [# F* q, k8 b: k" m$ ZThe mother also said that the boy was no longer hav-; R3 d. A$ C, F; ~( n
ing frequent erections.3 q l# N$ q1 }" V# W
Both parents were again questioned about use of0 b/ C; i$ q2 I2 w( Z3 G/ M9 U8 B
any ointment/creams that they may have applied to
! X' _. e8 b8 K5 ^9 k* _1 Hthe child’s skin. This time the father admitted the
7 p' I5 c( W, [, O0 S5 ~' iTopical Testosterone Exposure / Bhowmick et al 541, x8 ~/ y: @8 _! e: M$ V
use of testosterone gel twice daily that he was apply-
$ D/ S# j3 b; N+ ]7 qing over his own shoulders, chest, and back area for
: W6 |! p& {9 Y1 u+ n$ ra year. The father also revealed he was embarrassed
) _% U$ a# T( m0 j7 z! {( Gto disclose that he was using a testosterone gel pre-
5 G+ n5 C0 w- X' p* R, h; Pscribed by his family physician for decreased libido; z- J9 q3 A: ^( k: y$ R- ~1 |
secondary to depression.
+ s' F0 l, P8 J5 t' {8 KThe child slept in the same bed with parents.
6 v* _( d$ E. @. I" Z0 l: w C/ IThe father would hug the baby and hold him on his8 E4 ]; E" v: a+ g9 h* t
chest for a considerable period of time, causing sig-
3 y/ }, {: [1 m0 snificant bare skin contact between baby and father.
1 z* F+ N8 f8 [# z' g2 m( yThe father also admitted that after the phone call,
& D- y. W! ?6 g: J7 Q0 z( Q5 owhen he learned the testosterone level in the baby
$ k! V0 o8 C) a/ s( qwas high, he then read the product information
, R/ D) Z: f0 `- G* c' @9 \packet and concluded that it was most likely the rea-* m6 s4 Z" P. [. t3 `5 c6 j* x( q) p0 Y
son for the child’s virilization. At that time, they: }. Q! y5 T3 ]' h! e# G8 p. v, r8 b8 K
decided to put the baby in a separate bed, and the
o$ G2 \: K1 Hfather was not hugging him with bare skin and had
5 `+ X4 a) A* E% Ebeen using protective clothing. A repeat testosterone6 f+ K( y+ O1 i7 H A' h1 L
test was ordered, but the family did not go to the
$ r5 n" d f6 _( I* Alaboratory to obtain the test.
9 K* c/ M& T# d+ Z! {6 ADiscussion
4 c& T" H6 S0 }7 Z5 p- ^Precocious puberty in boys is defined as secondary; x. E3 U) U4 M7 S l
sexual development before 9 years of age.1,4
, b9 f7 P5 [, v3 S3 TPrecocious puberty is termed as central (true) when; v+ `0 h" O* g( i. I |, A( }
it is caused by the premature activation of hypo-
0 W9 a* J: V8 c0 |( f- nthalamic pituitary gonadal axis. CPP is more com-
' h! x/ I+ U. I7 n) E) }mon in girls than in boys.1,3 Most boys with CPP
@4 P# N4 O1 Q$ x9 G) z, Tmay have a central nervous system lesion that is
3 {& f) `' Q" R- Aresponsible for the early activation of the hypothal-0 n" B! J; T8 g: x4 G
amic pituitary gonadal axis.1-3 Thus, greater empha-" ^# H9 q* T/ c* K$ Z2 _9 F
sis has been given to neuroradiologic imaging in
8 o! s+ q1 k1 pboys with precocious puberty. In addition to viril-- v: L7 ~ V; D+ u6 @
ization, the clinical hallmark of CPP is the symmet-
q. p5 E0 J* y; N7 Brical testicular growth secondary to stimulation by5 H8 G5 z5 Q9 h) e R" d* H/ ?
gonadotropins.1,3
Y! C _* ^& { V1 b* }0 A) @Gonadotropin-independent peripheral preco-8 s7 Z3 _( N4 r5 p" }" e5 e
cious puberty in boys also results from inappropriate
& B' E! u1 q1 j( d- Kandrogenic stimulation from either endogenous or
# h$ E3 b+ ~* Z$ _3 cexogenous sources, nonpituitary gonadotropin stim-
3 q6 u; ]0 i1 P- a sulation, and rare activating mutations.3 Virilizing
7 B$ T' T) O" m/ r1 `/ ^% ]. `1 |congenital adrenal hyperplasia producing excessive
7 z# E" {( N2 e0 B# J) Tadrenal androgens is a common cause of precocious! x2 Q9 Z, L& s) I( J8 ?. N
puberty in boys.3,4
; S/ r% s' S6 S9 k+ e, KThe most common form of congenital adrenal
/ O3 T4 Z0 m. u/ S- _hyperplasia is the 21-hydroxylase enzyme deficiency.
* d) T+ l5 }2 S3 z, PThe 11-β hydroxylase deficiency may also result in
' \ N6 M, t/ J: i& @excessive adrenal androgen production, and rarely,* K$ K& w- ]3 B% j, O$ t' K
an adrenal tumor may also cause adrenal androgen
+ G" S' N# T$ | `2 oexcess.1,3
; {4 h9 i* `' G. q) t. y/ Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# n5 M5 \) t9 p8 b3 n1 h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: l; r( c; I; T& ~. F
A unique entity of male-limited gonadotropin-: n( Z1 j( C9 l. f
independent precocious puberty, which is also known# B9 O2 R# ^" w& p ~
as testotoxicosis, may cause precocious puberty at a! Q( O% Z( X* P; [' R' F
very young age. The physical findings in these boys# [! ?# z. l T$ t5 I
with this disorder are full pubertal development,
" r; a! {. S/ e0 |+ {including bilateral testicular growth, similar to boys, J# D( e7 k1 }: v) h! F
with CPP. The gonadotropin levels in this disorder! ~1 z, i$ P! K6 c1 L5 _% \; p
are suppressed to prepubertal levels and do not show1 I F0 l2 _( A( w$ g# r
pubertal response of gonadotropin after gonadotropin-6 T( x) P3 D% u+ g( O" o7 O$ Q
releasing hormone stimulation. This is a sex-linked
/ c5 \6 B7 R h$ dautosomal dominant disorder that affects only G: x: a) x9 J+ S; d8 r
males; therefore, other male members of the family3 G5 n! h$ y8 ^) Y
may have similar precocious puberty.3
2 `) S* C! h, H/ h* h/ |) ]+ _In our patient, physical examination was incon-7 n% M- f/ y* P4 V
sistent with true precocious puberty since his testi-! Z# i6 b b W3 ^% k
cles were prepubertal in size. However, testotoxicosis
0 e, w: v/ K% X9 M/ W) n Twas in the differential diagnosis because his father7 U; W3 u, O/ s1 c& ]' u
started puberty somewhat early, and occasionally,
3 c* c; }$ G! ytesticular enlargement is not that evident in the
+ [( M) c* O9 @- bbeginning of this process.1 In the absence of a neg-# u' {- j, h6 X' U' T
ative initial history of androgen exposure, our; ^7 I' R( m" h( k# M: {
biggest concern was virilizing adrenal hyperplasia,
& Z `6 r$ Q% |& Ieither 21-hydroxylase deficiency or 11-β hydroxylase4 a1 \; O2 w) b0 F @: f! B
deficiency. Those diagnoses were excluded by find-
* y2 S( }% [% Ting the normal level of adrenal steroids.) d7 Q! ?" X5 l5 B q
The diagnosis of exogenous androgens was strongly0 z/ C! t# }% s% K0 D" { n. H& }
suspected in a follow-up visit after 4 months because
( T9 v! ~9 e# C( Y! @0 Z+ C9 mthe physical examination revealed the complete disap-
: T# e! O2 E/ x: t/ p* q7 }pearance of pubic hair, normal growth velocity, and8 g+ r0 O9 Z( j% B! N' M% t
decreased erections. The father admitted using a testos-
! g0 C9 o7 P' h$ p7 y9 pterone gel, which he concealed at first visit. He was
& t: K, ~9 o+ l9 iusing it rather frequently, twice a day. The Physicians’
8 a& q7 s+ W3 T1 K; KDesk Reference, or package insert of this product, gel or$ `3 A8 H; [, { ?
cream, cautions about dermal testosterone transfer to. `: d; j' R& S9 A# r- L7 g; q* {
unprotected females through direct skin exposure.
, M" ?+ L2 ^" [& p$ kSerum testosterone level was found to be 2 times the( V8 `/ x/ a- V: Y- C) Y, `! s
baseline value in those females who were exposed to
' ~+ ?8 J* M7 _9 D% `; r" _even 15 minutes of direct skin contact with their male
! a3 N# X$ E0 O- B6 h' W1 C1 E& Zpartners.6 However, when a shirt covered the applica-
9 I' e( s$ |" V+ |( e0 Ttion site, this testosterone transfer was prevented.7 C; e% {. ^8 L" \6 i& w# L
Our patient’s testosterone level was 60 ng/mL,
+ |- ~% u+ E, t2 uwhich was clearly high. Some studies suggest that
" P( f; j2 D8 y) ?: i! cdermal conversion of testosterone to dihydrotestos-
! `2 e5 |0 {; u# ?% D. Dterone, which is a more potent metabolite, is more
0 e/ m! O+ R6 C& O0 k) uactive in young children exposed to testosterone
. J9 y& k* R* f$ ]) D: Z$ ?exogenously7; however, we did not measure a dihy-
( L2 G' `7 d6 ~& t% S& |( z. Sdrotestosterone level in our patient. In addition to
7 `' q0 C& g' @* Z0 q# [3 c8 n; Fvirilization, exposure to exogenous testosterone in$ v4 U* ^1 D# C6 k9 A6 o
children results in an increase in growth velocity and
! I; D4 V( m2 Y) v" y! `advanced bone age, as seen in our patient.8 O+ I+ |4 T& e+ p; O
The long-term effect of androgen exposure during
# C1 m! n- d+ a: ?early childhood on pubertal development and final
7 C0 ^ B2 [' I. O; Hadult height are not fully known and always remain
; F U7 R) n$ Q5 x+ K- [: M5 {& wa concern. Children treated with short-term testos-+ F9 h0 w1 t8 Q5 B' s
terone injection or topical androgen may exhibit some! M$ o5 p l- D/ X8 x* X8 P! U ^. F
acceleration of the skeletal maturation; however, after) d3 [6 }$ x- r# @8 o
cessation of treatment, the rate of bone maturation
1 O+ E+ b8 m$ D; u7 jdecelerates and gradually returns to normal.8,9
" t \6 A+ S2 {6 bThere are conflicting reports and controversy R7 O5 O$ x- t) c
over the effect of early androgen exposure on adult
& _6 [* `8 e8 C" |- l# ppenile length.10,11 Some reports suggest subnormal
7 Y0 ^" f) P# c; ?adult penile length, apparently because of downreg-) `2 {3 [3 H- w* o1 Z
ulation of androgen receptor number.10,12 However, o. m- s- H0 S+ D+ K/ D1 q3 K4 q4 b
Sutherland et al13 did not find a correlation between
8 |7 ^0 ?7 }7 n5 l2 ochildhood testosterone exposure and reduced adult
9 G) {$ d J$ ~; R6 \2 S. b: Npenile length in clinical studies.
" X' ~! @! j+ [+ jNonetheless, we do not believe our patient is
( Q1 q( y( ]3 L, V3 cgoing to experience any of the untoward effects from' f/ u% ]7 x' d" W9 \0 v) K
testosterone exposure as mentioned earlier because
3 \) U! z* a4 O- b! dthe exposure was not for a prolonged period of time." H7 t# K2 K! z& P; R6 y. A
Although the bone age was advanced at the time of+ d4 ~3 u+ ]* n5 {8 g
diagnosis, the child had a normal growth velocity at
+ g3 Y; P2 x# [# f- _5 jthe follow-up visit. It is hoped that his final adult
4 w. O/ o* h1 x9 W0 a. M9 K( g5 sheight will not be affected.! J; \/ X" T ^9 o! M
Although rarely reported, the widespread avail-+ R% J( g- H5 z" [$ C ^
ability of androgen products in our society may- p) u+ Q( c6 c v0 Y
indeed cause more virilization in male or female) g! R; R9 N- J, n; ^8 U# z
children than one would realize. Exposure to andro-
+ m7 V3 O O/ A7 R, Tgen products must be considered and specific ques-$ _# Q3 P; K% C2 }9 b$ R
tioning about the use of a testosterone product or$ x5 y# |/ r% U5 m- g
gel should be asked of the family members during) L; n: N0 r. t% F4 M* Y
the evaluation of any children who present with vir-
1 T7 R; Y( }0 y9 f" D A; Silization or peripheral precocious puberty. The diag-
2 g3 H1 ^, s# y% Cnosis can be established by just a few tests and by
% C3 T+ ?! m" s3 jappropriate history. The inability to obtain such a
6 y1 x( S4 p5 \" G. Q/ B& vhistory, or failure to ask the specific questions, may
' l; f+ _6 c2 z7 x1 M% w0 i. @result in extensive, unnecessary, and expensive' b- R0 q, R* |0 z5 C9 \/ ~
investigation. The primary care physician should be; D! d: z6 J. x
aware of this fact, because most of these children
5 f! n5 w/ |5 b. Mmay initially present in their practice. The Physicians’8 B, a& B" d$ @
Desk Reference and package insert should also put a) I: W% |: s) T O+ ]; M0 ?
warning about the virilizing effect on a male or0 A# K, T" M, }2 ], s) D& j: g
female child who might come in contact with some-$ w- O# ^! S- @5 u2 Y: E
one using any of these products.
2 c; M+ Q" `6 m/ {References: y& c6 Z: i( u% z% z
1. Styne DM. The testes: disorder of sexual differentiation
2 D9 y! R" j( ^+ Y; oand puberty in the male. In: Sperling MA, ed. Pediatric2 J T$ K, t) M9 Z# e
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, U" p O' l( M2002: 565-628.
3 t- `* b- X2 h9 f. ]9 n8 E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 V) c Y5 E8 D- ]) w5 v
puberty in children with tumours of the suprasellar pineal |
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