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Sexual Precocity in a 16-Month-Old+ A) G8 g3 X i! X, p' r8 z
Boy Induced by Indirect Topical
2 a1 L7 E$ {3 L' K8 KExposure to Testosterone
( R0 f! ~- J3 n# P* ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ |' L v% @& W& B( j
and Kenneth R. Rettig, MD1
6 O, I8 K/ u/ E) g! o3 gClinical Pediatrics
! G0 u2 N3 ]; B9 qVolume 46 Number 6; W5 S/ I9 M U a
July 2007 540-5434 |, A0 l" [' c% h/ w1 ?
© 2007 Sage Publications) @" o- Y* K& X% T
10.1177/0009922806296651/ ]0 c; t. I( A. K6 D
http://clp.sagepub.com
# B; K0 j' ?( j7 o0 N' Lhosted at
/ c* V( e* ~) ]2 |( vhttp://online.sagepub.com
- e, l; n& h) ^* Y1 c1 v, @* VPrecocious puberty in boys, central or peripheral,, K! h$ H' \3 a4 Z6 S
is a significant concern for physicians. Central/ p: D5 m( K/ Q0 Y# Z
precocious puberty (CPP), which is mediated& x% Q+ ], r4 [+ q: Q
through the hypothalamic pituitary gonadal axis, has2 q3 U& S% |* X" G4 ?; j' ?+ e3 _
a higher incidence of organic central nervous system
- d, b* u3 w1 ]: blesions in boys.1,2 Virilization in boys, as manifested6 V, Y0 L( f' N( E0 v
by enlargement of the penis, development of pubic
4 o( B8 q8 ^: Nhair, and facial acne without enlargement of testi-
2 t/ x4 }: \0 o% ?' m. ?. Wcles, suggests peripheral or pseudopuberty.1-3 We
6 ?" p. m3 k; z! Jreport a 16-month-old boy who presented with the
7 R* U2 k; _2 ~2 X9 C Q! Denlargement of the phallus and pubic hair develop-
3 K8 h) i9 ?# B. x% w" H* @ment without testicular enlargement, which was due+ P4 D+ y# J9 X
to the unintentional exposure to androgen gel used by, q& {& N7 M8 M7 R2 H- N2 W
the father. The family initially concealed this infor-
- W! g$ ~: Y/ [, ^8 @/ V3 F5 Jmation, resulting in an extensive work-up for this1 c9 d) @) ?# U; o2 l/ |. G: X3 U
child. Given the widespread and easy availability of
6 d( T9 e r' [testosterone gel and cream, we believe this is proba-' @5 D" b* o* q: T( D; H" W& _7 ~
bly more common than the rare case report in the; _2 e8 N+ \ e; y: D: f
literature.4; J/ G5 O5 {/ a8 @# z- |; [
Patient Report# E' T5 k" }0 z1 [- J- @$ W/ ?* |4 q: e
A 16-month-old white child was referred to the) P; a) U% {) a1 @0 q
endocrine clinic by his pediatrician with the concern
% y! z. D: x' @6 k* P6 r0 D" ]) fof early sexual development. His mother noticed# M& b/ p6 |' h; I3 p7 e3 S$ {
light colored pubic hair development when he was
! ]9 I9 k, h$ D; D6 IFrom the 1Division of Pediatric Endocrinology, 2University of
, I+ a2 s/ _$ z3 {2 E6 Q' fSouth Alabama Medical Center, Mobile, Alabama., e, w; b) E" R$ {- O
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& E8 T, ?8 o9 F( \3 qProfessor of Pediatrics, University of South Alabama, College of
. ]& \1 ^1 O8 b8 n) D3 e9 _) TMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 {% F0 B8 m0 n& e0 b4 X1 R
e-mail: [email protected].: M9 \ M- z+ x" y' ~1 T) [
about 6 to 7 months old, which progressively became
1 k1 {) B! ~/ G1 L4 wdarker. She was also concerned about the enlarge-
/ i8 k$ U2 X, c5 L8 Nment of his penis and frequent erections. The child) Y4 S9 p5 X; A; v n6 ?
was the product of a full-term normal delivery, with7 m) H P, e3 u F) ~
a birth weight of 7 lb 14 oz, and birth length of
% N1 j* L; u. r0 A: {20 inches. He was breast-fed throughout the first year) O9 u# h9 M+ K$ O
of life and was still receiving breast milk along with+ D4 m0 P' S; | Q
solid food. He had no hospitalizations or surgery,
: k; ~; S5 x9 aand his psychosocial and psychomotor development
6 G' s+ J; v) X! T+ b* v1 T' ]was age appropriate.
7 S( l4 m4 Z8 c# o' a+ G2 J6 i$ nThe family history was remarkable for the father, y% d- ]# N! o$ G4 D
who was diagnosed with hypothyroidism at age 16,/ [/ W, l n5 B% R! Y
which was treated with thyroxine. The father’s. }- Q/ y# F& t2 L
height was 6 feet, and he went through a somewhat
2 B, @; ~2 E0 d0 ?! n, J* ?' Zearly puberty and had stopped growing by age 14.
M6 B3 w) K* A# UThe father denied taking any other medication. The4 H8 V6 E# i, ?& H
child’s mother was in good health. Her menarche
) x/ j; }3 F2 e# O# o" x: ^was at 11 years of age, and her height was at 5 feet- ^& n. L% H3 c+ H
5 inches. There was no other family history of pre-
& E2 e8 q/ d, mcocious sexual development in the first-degree rela-3 b5 S7 H7 N. ^7 D5 y: l/ L( ^
tives. There were no siblings.
- d6 r L0 @8 GPhysical Examination4 R% N7 u: V# l* Q+ E E
The physical examination revealed a very active,
3 k; l5 c* s" _% J0 x6 wplayful, and healthy boy. The vital signs documented
+ `- w' I4 I+ F' E8 b6 P9 sa blood pressure of 85/50 mm Hg, his length was7 _; N# Q$ n2 Z
90 cm (>97th percentile), and his weight was 14.4 kg% P7 X) q" H/ I# a
(also >97th percentile). The observed yearly growth
* a3 o& y+ i/ X/ h, yvelocity was 30 cm (12 inches). The examination of
7 v; Q0 s4 A9 N' sthe neck revealed no thyroid enlargement.: `% W! v! S$ Y& X- p
The genitourinary examination was remarkable for
3 t$ N/ A8 a- p0 H3 B7 Penlargement of the penis, with a stretched length of! d/ G6 X& T6 t8 N) I
8 cm and a width of 2 cm. The glans penis was very well2 l4 E. y) J5 G
developed. The pubic hair was Tanner II, mostly around9 C- _$ i& O( b+ {2 f
540
2 c1 |; c$ l: P; @7 e: E" b- X$ Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 q' q; N P# |: P Z B
the base of the phallus and was dark and curled. The9 p. f; T- r K3 @. ?: H6 E- m
testicular volume was prepubertal at 2 mL each.
% G: r+ V/ j8 B/ ?6 i5 l7 MThe skin was moist and smooth and somewhat
+ o/ C) @5 [, M _7 v4 l) Moily. No axillary hair was noted. There were no. V6 {: R% I4 i8 u
abnormal skin pigmentations or café-au-lait spots.
; Y9 i6 F/ @, w! |0 H% Q; X5 INeurologic evaluation showed deep tendon reflex 2+# N7 F" ?) T4 ~5 S+ m$ ~( b
bilateral and symmetrical. There was no suggestion
1 H- s6 i6 P( h. _$ K7 ?, wof papilledema.
5 I+ r0 Q# O5 M( b! R# `Laboratory Evaluation0 Z d4 x9 |0 M# k) \0 s! D$ B) A
The bone age was consistent with 28 months by% ]& [# k; d: y( z4 t/ W7 e T- D
using the standard of Greulich and Pyle at a chrono- g! ^+ ?4 D' d3 _
logic age of 16 months (advanced).5 Chromosomal
9 c/ M) K% y! J! C& S2 s7 `karyotype was 46XY. The thyroid function test. k" k" e7 k$ j, D: ?2 c6 `7 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ p, ~8 N/ f wlating hormone level was 1.3 µIU/mL (both normal).
5 u% H4 Y9 [* D AThe concentrations of serum electrolytes, blood; m+ _/ J, g" {0 \/ z' p. r! J7 s
urea nitrogen, creatinine, and calcium all were
, T" P8 S8 t' B9 L$ Bwithin normal range for his age. The concentration; ^ b! P4 ^6 v4 O
of serum 17-hydroxyprogesterone was 16 ng/dL' t- v5 @6 \1 N" z! I7 |$ B
(normal, 3 to 90 ng/dL), androstenedione was 20
. _$ w: K7 D) j0 @) c/ H4 M: G& tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! c1 w7 g9 I; r z* `+ m
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 n8 t/ o G* z- P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
x' Z* h4 C3 D, s: ~49ng/dL), 11-desoxycortisol (specific compound S)
, a* p% a5 s4 O0 r. ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 ?# k6 q6 l1 t6 v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 [% ?" p9 {+ Y: I/ E7 R
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 j9 \: N: Y2 X$ o6 p& M
and β-human chorionic gonadotropin was less than$ x# d8 d8 O( k1 \& v
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 A# n/ C3 i' O* mstimulating hormone and leuteinizing hormone
* y1 W( k1 H: y. C% Wconcentrations were less than 0.05 mIU/mL, T/ a, Y1 v/ P- A U8 b# w9 }
(prepubertal).( h* _ {+ r1 t' p7 X
The parents were notified about the laboratory
# P( S( K, A3 F3 i! ]6 hresults and were informed that all of the tests were
% i9 I% N9 r F9 Y: p7 tnormal except the testosterone level was high. The$ S+ x& V! q7 j6 s b8 H3 e4 f! l
follow-up visit was arranged within a few weeks to. z& e0 Y* {7 d
obtain testicular and abdominal sonograms; how-; u& _9 U' ^4 N7 u
ever, the family did not return for 4 months.
" M* C) c4 O$ n% U. |. y2 @Physical examination at this time revealed that the; B3 y# r( ^$ U' z$ a* p* d2 ?
child had grown 2.5 cm in 4 months and had gained
8 ?; ]1 A% U/ [9 O N: {2 kg of weight. Physical examination remained- B& f3 d4 P. O2 Y! N" @' l* [' U
unchanged. Surprisingly, the pubic hair almost com-' ^3 [3 w2 a: \7 Z4 V9 ~5 f$ U! a% R W
pletely disappeared except for a few vellous hairs at( _+ X$ S0 ?( J* W
the base of the phallus. Testicular volume was still 2
/ Z2 S9 J4 g& A+ A F; r, |! a- CmL, and the size of the penis remained unchanged., a5 F/ s: z" N
The mother also said that the boy was no longer hav-. N2 |7 s4 q& n3 a
ing frequent erections.9 B5 C% ?( ?3 E0 `. F
Both parents were again questioned about use of
1 `+ Y& p4 K1 m" Iany ointment/creams that they may have applied to; c' Z# e5 t9 O
the child’s skin. This time the father admitted the2 E! T# j% C. G s/ J6 p8 f; r2 d
Topical Testosterone Exposure / Bhowmick et al 5419 n3 E3 P/ h2 s6 P( @# H' U+ W
use of testosterone gel twice daily that he was apply-5 {8 ?) E% K% {
ing over his own shoulders, chest, and back area for
2 n5 ~( b, X. ^. F' z+ Ha year. The father also revealed he was embarrassed" w1 A5 g. c# s# X3 B
to disclose that he was using a testosterone gel pre-
2 E5 E3 N; H( v3 e" ascribed by his family physician for decreased libido
, {4 n) i* S+ l9 U6 c9 e( asecondary to depression.
0 x" w3 `$ ` nThe child slept in the same bed with parents.% M1 }/ P! a- Z) h& {9 r
The father would hug the baby and hold him on his* K2 U2 Q" B1 }
chest for a considerable period of time, causing sig-$ C) @4 n) w$ d0 Z: E' v, K
nificant bare skin contact between baby and father.3 B7 O7 L4 s; v$ J( Z9 a
The father also admitted that after the phone call,! S. v* F( O) y
when he learned the testosterone level in the baby
. b% Z+ {1 L0 Q( ]! F- i) J' |1 k) m* xwas high, he then read the product information6 k: I. J4 P6 J2 A5 k# J* N
packet and concluded that it was most likely the rea-, i |! J& d7 n
son for the child’s virilization. At that time, they4 L* G+ T7 A" b
decided to put the baby in a separate bed, and the* Z- A9 f* p- J# l. ^, O8 W
father was not hugging him with bare skin and had
- F8 n, p$ R0 G* xbeen using protective clothing. A repeat testosterone
. G l' m2 Z9 z3 C* Mtest was ordered, but the family did not go to the
" i$ Q/ R: \8 f4 alaboratory to obtain the test.
4 _2 m8 p5 I( G$ B) ~Discussion5 _" W8 ? F, U4 }. c0 Y; E1 ?
Precocious puberty in boys is defined as secondary
) t3 T: G; M* G$ `3 }( s/ p; usexual development before 9 years of age.1,4. T; E- C6 n) ?3 W s- Z# t; _
Precocious puberty is termed as central (true) when
1 c' Q Q1 e, |it is caused by the premature activation of hypo-
$ |% k7 |+ |, n& p2 i. hthalamic pituitary gonadal axis. CPP is more com-
w1 W- J) z9 |+ K2 _' O' K0 C# B( ]mon in girls than in boys.1,3 Most boys with CPP
' ` n. D8 o/ t* p6 ~4 ymay have a central nervous system lesion that is/ Z# E3 L! s9 Z
responsible for the early activation of the hypothal-
4 B. ^9 q" Q( U. i( {% ^) {amic pituitary gonadal axis.1-3 Thus, greater empha-
3 t% C$ b) H! u: J$ ?sis has been given to neuroradiologic imaging in5 O/ y/ s3 i2 b5 o8 M
boys with precocious puberty. In addition to viril-
# o; P6 C6 t/ v& p' q0 sization, the clinical hallmark of CPP is the symmet-3 r- r, z( X) A+ U L* _
rical testicular growth secondary to stimulation by' o6 l# K% ~$ P* v2 P( E+ [8 T
gonadotropins.1,3: ]; m( P G: L) h( v# ?5 t7 U1 u5 L& U
Gonadotropin-independent peripheral preco-
. U& _# @7 \! ^: E6 j! e' M! } }cious puberty in boys also results from inappropriate
. c2 H+ h( t6 K# ?androgenic stimulation from either endogenous or& | k |( Z& `. }8 \9 x& n
exogenous sources, nonpituitary gonadotropin stim-
8 I: J* t% H( p2 H! Aulation, and rare activating mutations.3 Virilizing
/ t/ `% m7 ~( v e; @: ?5 c- ncongenital adrenal hyperplasia producing excessive
8 _4 v1 u0 Y" m+ U" l/ i6 n+ Jadrenal androgens is a common cause of precocious
, J; y" X( C5 i$ b5 A5 vpuberty in boys.3,4
1 v% P% \7 ~3 _" C4 V v" XThe most common form of congenital adrenal" p+ j+ [ r; d3 O
hyperplasia is the 21-hydroxylase enzyme deficiency.- d a: j6 [: v' `0 ^) F( Q5 \
The 11-β hydroxylase deficiency may also result in) O2 Q8 ~, V/ b- }) `% J4 R0 K' P
excessive adrenal androgen production, and rarely,$ e) S) P7 y) l* w. ^
an adrenal tumor may also cause adrenal androgen3 I* R& ]- R6 c* }& m- m
excess.1,3
: W: o& I5 D' R& vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 ^; a: Y8 o3 {- G, W; P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ l: V; W$ L- gA unique entity of male-limited gonadotropin-2 [0 z2 K: H6 h, C6 S9 G8 D6 L
independent precocious puberty, which is also known+ h% u- R0 y+ z( q3 J
as testotoxicosis, may cause precocious puberty at a- @; C* p$ e3 l8 ~8 W a
very young age. The physical findings in these boys
$ ?5 W+ B3 V: y% Lwith this disorder are full pubertal development,
8 j% P P8 d. P+ L$ e6 U; }' zincluding bilateral testicular growth, similar to boys
" V7 u3 [" D8 b9 t/ S' Owith CPP. The gonadotropin levels in this disorder0 }) j' i6 I( Z: R" x& |" f
are suppressed to prepubertal levels and do not show/ t w; D! o* h7 V. ^) | O0 I
pubertal response of gonadotropin after gonadotropin-
' o% R* ~- F' G$ V, g Yreleasing hormone stimulation. This is a sex-linked
! {( V. F6 Y) b, J/ Zautosomal dominant disorder that affects only8 K/ K/ V( D4 u, _+ M
males; therefore, other male members of the family& {# a/ P( }$ T4 B8 v7 k
may have similar precocious puberty.3' k* u" N8 l! K
In our patient, physical examination was incon-
4 \2 k& y5 R& Z9 ~9 M8 {sistent with true precocious puberty since his testi-: q( e# M8 N {
cles were prepubertal in size. However, testotoxicosis" f$ {' |9 C% U) l# K$ a# Z! d9 ]
was in the differential diagnosis because his father9 i/ ^ R- [0 ~# c4 g5 ~
started puberty somewhat early, and occasionally,& f% Z( f8 `3 k+ o: q) }
testicular enlargement is not that evident in the
8 g1 _$ z: `- zbeginning of this process.1 In the absence of a neg-" f9 h2 Z# g; J+ g) d! _7 E
ative initial history of androgen exposure, our4 m7 C6 c) j% d }# V* t" }& g) K
biggest concern was virilizing adrenal hyperplasia,
' V! a4 S! j% \either 21-hydroxylase deficiency or 11-β hydroxylase8 p4 L( w+ Q/ Y! V1 e3 ^3 v
deficiency. Those diagnoses were excluded by find-% o; i5 Y& `: d, Z( _9 c
ing the normal level of adrenal steroids.+ w) {, n7 F9 S. ?' P
The diagnosis of exogenous androgens was strongly) g- \- s- e* I) Y( d! H
suspected in a follow-up visit after 4 months because
9 h% l e' ]9 L! K3 g! |/ [the physical examination revealed the complete disap-
) f. y3 T8 K3 r5 Upearance of pubic hair, normal growth velocity, and Q1 Z8 C$ J/ O+ a" w6 A5 w
decreased erections. The father admitted using a testos-
' K8 R8 F4 A: f u& e! W& sterone gel, which he concealed at first visit. He was
O1 {) _/ H& O/ H. c, Q( fusing it rather frequently, twice a day. The Physicians’& L) ^, z G; m! g9 r$ T
Desk Reference, or package insert of this product, gel or- f5 z9 ^* n! o$ U, V5 R7 }% m, d
cream, cautions about dermal testosterone transfer to
" C3 }9 _# }! M, j: s( f2 ]unprotected females through direct skin exposure.! y' H1 H" a5 ~7 s9 }; E# M# F
Serum testosterone level was found to be 2 times the
+ V- `5 O9 f1 V" i. B& q! ibaseline value in those females who were exposed to
6 ?) J, y f! s6 seven 15 minutes of direct skin contact with their male
3 b1 t* w8 U. j( cpartners.6 However, when a shirt covered the applica-, b& q4 u& R* c
tion site, this testosterone transfer was prevented.
7 n- z$ h e7 t4 ~6 w+ Z0 jOur patient’s testosterone level was 60 ng/mL,
3 Z& V4 ~5 x& [4 I% g" a, Wwhich was clearly high. Some studies suggest that
0 L1 y- [4 H% m0 f! i; ^dermal conversion of testosterone to dihydrotestos-* ^, ]) I& e& _8 m5 h
terone, which is a more potent metabolite, is more2 A6 g: k% c4 j6 K. [
active in young children exposed to testosterone
/ y) ` `& i( ?/ Xexogenously7; however, we did not measure a dihy-
% t& X" P6 G# x0 Odrotestosterone level in our patient. In addition to0 u0 w% X# w& X: }2 L/ |
virilization, exposure to exogenous testosterone in# L5 C7 @/ U7 C. l% K" E7 p
children results in an increase in growth velocity and% t. m- j( ~1 o/ [# n- r/ k3 T1 n/ \
advanced bone age, as seen in our patient.
" X/ _9 F- q3 DThe long-term effect of androgen exposure during
0 V4 a2 y" q$ o& I: Vearly childhood on pubertal development and final2 Z) d0 p+ s0 H3 z9 l" \
adult height are not fully known and always remain- R7 u+ m4 a6 h
a concern. Children treated with short-term testos-
q+ z6 d: m% r* N- Oterone injection or topical androgen may exhibit some# v5 X* C- ?4 E9 {1 ^/ v
acceleration of the skeletal maturation; however, after1 R$ w, }8 b* b3 W/ d- T0 k- j
cessation of treatment, the rate of bone maturation
$ v( V, S8 n3 S) N7 u# H& ?7 ?decelerates and gradually returns to normal.8,9/ S8 c* G* R+ \) F9 x
There are conflicting reports and controversy
# m4 {6 P- u& K3 \1 M, E; Xover the effect of early androgen exposure on adult
& [$ [; s6 F4 K6 G) x* B8 ppenile length.10,11 Some reports suggest subnormal
8 g4 g, j" C+ R/ ^5 _! Padult penile length, apparently because of downreg-
; y# i; v* M+ H7 tulation of androgen receptor number.10,12 However,5 d8 ?& r! @" j1 w r1 h" e
Sutherland et al13 did not find a correlation between
, S- X: M& s v' Dchildhood testosterone exposure and reduced adult
. C3 \- G( L& @- S) u' Lpenile length in clinical studies.
5 Z1 W0 R. [2 G# m6 D, M- yNonetheless, we do not believe our patient is
2 b: S+ {( Z4 J ]/ tgoing to experience any of the untoward effects from; U A: S9 c, o# c
testosterone exposure as mentioned earlier because
/ v) c6 p% w: s0 h0 Sthe exposure was not for a prolonged period of time.
Z* l4 P# K; \7 ]+ eAlthough the bone age was advanced at the time of+ {" D% b: y0 B5 ?# _) `2 L& V
diagnosis, the child had a normal growth velocity at
" S4 r8 W5 s* d" b/ Cthe follow-up visit. It is hoped that his final adult, [# k2 m& P. Q0 h; K9 u z
height will not be affected. u2 D7 T' r& S( ?: q: k* J, [
Although rarely reported, the widespread avail-
8 w! ?& u+ F0 v5 `" eability of androgen products in our society may5 _ g* B- n% @: h- J
indeed cause more virilization in male or female6 B# R) @% c4 v( k$ s' R! k/ [
children than one would realize. Exposure to andro-! {$ E; i1 V6 Y# ^- }0 H
gen products must be considered and specific ques-
2 |3 z$ J9 q+ C: Htioning about the use of a testosterone product or
2 I4 U- O$ i2 W2 Pgel should be asked of the family members during7 Z# d e$ {9 q$ Y- r' r( H2 u; z
the evaluation of any children who present with vir-
( b# m% }% t1 h, wilization or peripheral precocious puberty. The diag-
+ A. A- r: }5 `9 M, q7 H9 pnosis can be established by just a few tests and by) y6 e% [/ y2 [. u4 B' J$ j/ E8 ^& B
appropriate history. The inability to obtain such a
, y" v6 Y) s X! z* ihistory, or failure to ask the specific questions, may; q7 {. n! n5 z. K4 q) O8 I( Y
result in extensive, unnecessary, and expensive- h' }# |6 B% F7 O# @
investigation. The primary care physician should be
0 M j4 l" P& j! j' V% J5 \+ Gaware of this fact, because most of these children0 h) L% y3 D" q! [ `7 A& f( g# v' E
may initially present in their practice. The Physicians’
: b, u0 v# C! V) }Desk Reference and package insert should also put a; U$ g; S. E$ V/ ~
warning about the virilizing effect on a male or
5 I: X- B2 L7 ~ kfemale child who might come in contact with some-' [; E4 C; y6 y- D/ ~: b
one using any of these products.: R7 |; v: C7 E2 i9 _! x
References
% ]! M' d7 f; d' R( v1. Styne DM. The testes: disorder of sexual differentiation
0 E7 }! M+ _2 ]and puberty in the male. In: Sperling MA, ed. Pediatric9 O; _. R8 K" D/ O& N* F" h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ h3 G1 e+ j2 y+ q" _: M
2002: 565-628.
: [$ s, m1 j k. {% T' r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 n2 u& |/ `+ x& D, V3 A* h: U
puberty in children with tumours of the suprasellar pineal |
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