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Sexual Precocity in a 16-Month-Old( C( @ P% o9 j8 C. W& N
Boy Induced by Indirect Topical( a5 e+ T& l# F4 {" d- Z t
Exposure to Testosterone, [$ ?, ?1 H% k x/ z, K. }" c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 p4 [7 u+ s2 L6 N) Kand Kenneth R. Rettig, MD1
4 s B" E% P, q) L2 B9 CClinical Pediatrics2 k$ e' y* s5 I- R, d
Volume 46 Number 6
& ^2 P; I8 w5 r, L4 xJuly 2007 540-543
0 n& a0 r, s v1 [© 2007 Sage Publications7 ]& V6 W+ C1 t/ C4 w, E( n
10.1177/00099228062966513 M' F, Y4 i2 y/ C- i
http://clp.sagepub.com* ?( m4 d3 \( r0 Z" Q5 r k( ^2 q
hosted at j8 h* N9 L3 m1 b% L7 U+ X" f
http://online.sagepub.com
& u; b* ?$ ]. Q) o, L6 \- rPrecocious puberty in boys, central or peripheral,
" p5 u/ N4 }& v S+ b% iis a significant concern for physicians. Central
; b9 |+ w% g! n1 n. E; j3 n: E6 Y+ bprecocious puberty (CPP), which is mediated2 j1 w: n! J/ A. O$ E
through the hypothalamic pituitary gonadal axis, has
+ w3 D& k' _1 Y/ u/ o7 Z$ ta higher incidence of organic central nervous system
( v2 u7 S+ V$ G" Slesions in boys.1,2 Virilization in boys, as manifested& A) A& L% _* t* K K I
by enlargement of the penis, development of pubic! h3 u; |4 C6 P$ n- V3 H5 _
hair, and facial acne without enlargement of testi-
/ z/ K/ `. J$ a3 Fcles, suggests peripheral or pseudopuberty.1-3 We
% l( @ P! x* U. Xreport a 16-month-old boy who presented with the, O, I1 _& |" }5 L; N
enlargement of the phallus and pubic hair develop-, E w5 ]5 r, m' {; i5 W/ s
ment without testicular enlargement, which was due+ D" |. h J% A9 ?3 E
to the unintentional exposure to androgen gel used by
, M$ S: g: I' E; ^9 t0 A2 P2 cthe father. The family initially concealed this infor-- _2 E% Q/ s1 P3 g( R: v
mation, resulting in an extensive work-up for this
1 @- U/ F% W; x3 G% ` o5 o1 T4 Gchild. Given the widespread and easy availability of
; h4 Z s% G& A5 B0 p5 V9 Atestosterone gel and cream, we believe this is proba-
$ V1 W9 c/ d P- E S8 m Ybly more common than the rare case report in the
; y; `9 a# h2 i# D- s; zliterature.4
, k, [( k# Z4 x7 y/ VPatient Report. |. q! K& J9 f4 b
A 16-month-old white child was referred to the( u$ A( P% [& M1 c4 t3 g# p9 _
endocrine clinic by his pediatrician with the concern
$ |& _/ d* s+ ^( K9 [of early sexual development. His mother noticed
1 y% l9 U& i; s, u0 V5 z3 j1 jlight colored pubic hair development when he was# S3 P d. }* p |
From the 1Division of Pediatric Endocrinology, 2University of
0 ` z' a. Q9 c1 S4 PSouth Alabama Medical Center, Mobile, Alabama.* | f, ~, J1 g) i% k
Address correspondence to: Samar K. Bhowmick, MD, FACE,* c$ ^8 J; y& { s+ `- m
Professor of Pediatrics, University of South Alabama, College of
6 [: I2 j/ R4 I( q' V& oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" B: I2 Y6 l4 M0 ?
e-mail: [email protected].
/ H& x7 B% t! b- j# Iabout 6 to 7 months old, which progressively became
6 Q" k3 G4 e7 o0 f4 W/ _darker. She was also concerned about the enlarge-
, G" H5 y/ s6 e6 e7 n6 l7 Vment of his penis and frequent erections. The child
7 q9 l/ v0 ]" {% y. G+ F5 dwas the product of a full-term normal delivery, with* }8 {. W3 p/ t6 P
a birth weight of 7 lb 14 oz, and birth length of
4 d. V1 D' p; N* ^( f1 N20 inches. He was breast-fed throughout the first year
8 n0 B- l P, fof life and was still receiving breast milk along with
4 }2 u: H3 H3 {( P: Q& s: w, G' z% t8 Jsolid food. He had no hospitalizations or surgery,3 T6 y! c. U. F- ?! m$ r
and his psychosocial and psychomotor development
1 O% U$ I) R9 R1 pwas age appropriate.9 j5 k/ Q3 W0 w7 @& J' A* e( O
The family history was remarkable for the father,7 a( I/ U5 T% Q! f
who was diagnosed with hypothyroidism at age 16,8 M1 e# Z9 x7 Q. l* ~/ A, n- y
which was treated with thyroxine. The father’s
3 [; E2 U B1 D k9 Xheight was 6 feet, and he went through a somewhat
8 M! m' E Y: L% x4 g4 |3 j+ U% R7 Q; qearly puberty and had stopped growing by age 14.: E( X* s! Z! x3 Q
The father denied taking any other medication. The2 Y& c( e9 c! y6 d5 X3 t
child’s mother was in good health. Her menarche
% [3 O- k) |0 ~4 ], Z4 r! A1 e8 hwas at 11 years of age, and her height was at 5 feet; y6 ]2 n6 U; S0 x
5 inches. There was no other family history of pre-
% I7 S$ d; C2 p% y, lcocious sexual development in the first-degree rela-) ~/ Q5 c9 w+ j6 y/ Q/ L( D
tives. There were no siblings.. L- c% R$ Y1 a% R7 u
Physical Examination
( k% @! e [6 K3 H0 ?0 mThe physical examination revealed a very active,
* b9 ~" L8 k* H2 _+ o$ qplayful, and healthy boy. The vital signs documented6 [, @: X6 K: U9 |8 H1 F
a blood pressure of 85/50 mm Hg, his length was
- {) z" r) B. z0 H90 cm (>97th percentile), and his weight was 14.4 kg
7 n! V I* }" H8 {: y* |(also >97th percentile). The observed yearly growth
' w2 F' P" z2 v" X4 |velocity was 30 cm (12 inches). The examination of7 {, b0 L; ?: H3 ~! L) V
the neck revealed no thyroid enlargement.
* h" K7 }* k5 b7 FThe genitourinary examination was remarkable for
) |3 Q d: q& O2 Yenlargement of the penis, with a stretched length of, s, D9 ^! y# J, \- q" R8 M
8 cm and a width of 2 cm. The glans penis was very well
9 T. E! L6 g3 q% V- y: g" m( J/ gdeveloped. The pubic hair was Tanner II, mostly around1 X- y$ U; @' N2 n- T/ P
540
- y) N; [# @. jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 b/ E: U0 e; Q2 N0 I/ O' F
the base of the phallus and was dark and curled. The1 b" E: a+ F* A: Z
testicular volume was prepubertal at 2 mL each." g7 F$ u9 C0 t0 U( i
The skin was moist and smooth and somewhat
+ o1 d2 `5 D. `7 f4 m& Roily. No axillary hair was noted. There were no/ z5 S4 y) D7 Y& L
abnormal skin pigmentations or café-au-lait spots.: i: K: d9 M {- f
Neurologic evaluation showed deep tendon reflex 2+
" J3 U1 s- [3 a- N# h: f; U) w- ibilateral and symmetrical. There was no suggestion
2 x) e* `8 `" t+ g! O5 ~of papilledema.1 w! l0 e7 p! Q+ Q, P: a
Laboratory Evaluation/ o. M+ R+ R2 I" H
The bone age was consistent with 28 months by
1 U, i0 [; d5 Z2 _. f% Ausing the standard of Greulich and Pyle at a chrono-
3 C$ S& z: @1 Ulogic age of 16 months (advanced).5 Chromosomal3 l: V5 Z$ C( G! e, d1 ]/ i
karyotype was 46XY. The thyroid function test' e7 q6 M- G5 S- t+ K2 X
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 f0 Y$ }1 W; p1 `- S4 A. T- K
lating hormone level was 1.3 µIU/mL (both normal).
/ g: w; J, x& ? q. d5 g# e+ LThe concentrations of serum electrolytes, blood; C0 j7 Y$ M$ ^
urea nitrogen, creatinine, and calcium all were
' e2 U6 c- x. F" E1 bwithin normal range for his age. The concentration
( H# S% }: {4 M! q4 A( o" _" _: O3 ?of serum 17-hydroxyprogesterone was 16 ng/dL
5 X% X8 X$ _4 [6 y% T- M5 _(normal, 3 to 90 ng/dL), androstenedione was 20
) U1 T& u$ s" a) png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! z3 ~- B: x$ S: o' V+ Y, ~) I. L. _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 M. V3 V7 O$ l% w$ ^9 C' B6 _; b$ ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to9 f% j* b4 i) j! T+ s+ q# h
49ng/dL), 11-desoxycortisol (specific compound S)
1 x6 T$ O& X2 }. N+ l+ S7 Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ M. `4 D0 ~2 I2 Q! A0 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 q- t7 _9 F4 S1 a- F' U, l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, d3 b/ r* {- C* Y; pand β-human chorionic gonadotropin was less than
" `2 k1 k: Y8 u, B c( J) f( x- Y5 mIU/mL (normal <5 mIU/mL). Serum follicular3 T o0 d8 @! x E1 O
stimulating hormone and leuteinizing hormone, Q5 _5 j" B" C# ?: c: l' j9 a
concentrations were less than 0.05 mIU/mL
/ ]% O) z8 K8 K5 |' k, a(prepubertal).7 `% b( u4 h' Z$ T
The parents were notified about the laboratory
9 U9 _; c1 [$ s+ dresults and were informed that all of the tests were
$ ^3 S3 b) L/ u+ ~ rnormal except the testosterone level was high. The
; G8 {1 K7 b. i; V% Q& afollow-up visit was arranged within a few weeks to7 t G" I1 V( S7 F
obtain testicular and abdominal sonograms; how-
( ?, }9 l$ J, p+ O n5 Yever, the family did not return for 4 months.! @' `) i; I2 ?& `* Z5 W1 T
Physical examination at this time revealed that the
- X' t+ D1 c& t9 p1 [, `' Mchild had grown 2.5 cm in 4 months and had gained0 W) I, O% l- C- w7 O& d: p6 E. A' }
2 kg of weight. Physical examination remained
- }- J4 `9 [7 b, xunchanged. Surprisingly, the pubic hair almost com-
5 p- n% J$ x! ^0 M7 ypletely disappeared except for a few vellous hairs at
# |+ B; T0 k0 ?2 m8 z/ s6 y. lthe base of the phallus. Testicular volume was still 2% H: V, A. n* _, B0 ?
mL, and the size of the penis remained unchanged.
5 }, w6 G5 X; n8 aThe mother also said that the boy was no longer hav-
: o5 S: o" e( @) `$ e4 ?ing frequent erections. o0 ]' L% A5 ]' f/ _, c8 V# z9 o
Both parents were again questioned about use of |3 E/ w" d' N6 f8 ?
any ointment/creams that they may have applied to% x5 r; q7 }( a( ?5 k
the child’s skin. This time the father admitted the
/ U. W/ P4 O3 q; P% rTopical Testosterone Exposure / Bhowmick et al 5417 m: O, Z( I# T7 C5 l) G
use of testosterone gel twice daily that he was apply-) q9 z: |. R& L; a7 m7 y7 x
ing over his own shoulders, chest, and back area for' u) o' T+ V4 d3 Z! I- L4 @
a year. The father also revealed he was embarrassed8 |3 m! \+ Z6 d4 U
to disclose that he was using a testosterone gel pre-
% {: ?! F) p6 s! qscribed by his family physician for decreased libido
3 }/ H( u( Y5 ?$ ]4 A* asecondary to depression.
' Z( N4 C8 Y8 J' FThe child slept in the same bed with parents.
9 m' L7 e' | H& Z; t$ |7 d0 @The father would hug the baby and hold him on his& y$ G0 E( I+ o) V: ]
chest for a considerable period of time, causing sig-
x# G; g( O8 V( U* Onificant bare skin contact between baby and father.1 F) v) U0 Z4 e, a! w0 C
The father also admitted that after the phone call,
7 [2 N! y: A2 s0 Rwhen he learned the testosterone level in the baby
) R$ y3 V9 n5 a1 vwas high, he then read the product information+ Q$ Q! ?, V7 |! `; v( K' M0 R
packet and concluded that it was most likely the rea-# F' Z4 @0 q7 a0 `2 t
son for the child’s virilization. At that time, they2 O: ~9 v+ [$ l+ E- B* E
decided to put the baby in a separate bed, and the
8 H7 N# C' u1 \6 U8 v, {! ]father was not hugging him with bare skin and had6 ?) c& U8 {/ r: q; ^" L5 b8 ?3 L
been using protective clothing. A repeat testosterone& j. A' N% z3 _8 _
test was ordered, but the family did not go to the8 W) j$ }6 t3 r& h" n- K
laboratory to obtain the test.
[/ s/ S$ b- tDiscussion3 o* d% A: L9 Q/ A1 u
Precocious puberty in boys is defined as secondary! r0 Q: {( V3 W. t
sexual development before 9 years of age.1,4
6 ^5 @- V3 q4 E/ wPrecocious puberty is termed as central (true) when0 v6 I$ @! f9 K c. x- }/ u. K
it is caused by the premature activation of hypo-
+ u. O% x) w ]thalamic pituitary gonadal axis. CPP is more com-
8 n, b, Z: X. cmon in girls than in boys.1,3 Most boys with CPP0 P- @* e1 b$ x0 X0 a8 @0 m f
may have a central nervous system lesion that is
/ ^' n& g) T& s: ]responsible for the early activation of the hypothal-
' Y/ m A" n$ H1 J: q0 ^2 m9 _& Eamic pituitary gonadal axis.1-3 Thus, greater empha-: I* b; E' z* D2 t6 y# y
sis has been given to neuroradiologic imaging in
5 [: M9 ]7 ?$ Z8 S8 }boys with precocious puberty. In addition to viril-
# n9 [. u7 @- L4 J$ R# Nization, the clinical hallmark of CPP is the symmet-
1 z1 q1 }: K0 _% D6 ^rical testicular growth secondary to stimulation by
/ W0 X! p7 v. g+ R+ {/ @* Z4 @gonadotropins.1,39 @3 I8 S& x+ T- W( G' N9 f
Gonadotropin-independent peripheral preco-! e2 E$ D2 q. r$ G
cious puberty in boys also results from inappropriate1 D8 b! ^+ Y- @$ o6 G" B
androgenic stimulation from either endogenous or
- q( k+ P5 x- Cexogenous sources, nonpituitary gonadotropin stim-
& [2 `, _$ K0 P: ]( o' b, `ulation, and rare activating mutations.3 Virilizing
2 ~! q3 t- P# V( Acongenital adrenal hyperplasia producing excessive
J, u4 f5 P- H, \6 gadrenal androgens is a common cause of precocious l% a2 R; ^* E4 B7 }
puberty in boys.3,4% d0 S6 N' n9 r9 s
The most common form of congenital adrenal
+ S( M/ c4 E2 [) T1 x, B: khyperplasia is the 21-hydroxylase enzyme deficiency.
' K1 t+ S z# w, DThe 11-β hydroxylase deficiency may also result in- T4 z" n+ ~8 s, h* {+ m
excessive adrenal androgen production, and rarely,7 U( m$ g" k! p
an adrenal tumor may also cause adrenal androgen
, S: V/ @" [2 g( H4 ~excess.1,3
& d3 y8 Z3 h1 o3 n9 @) j. Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& V# {( g& h# j, n& i. [+ G
542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 p5 f' [. m% P0 e$ Y3 c- F
A unique entity of male-limited gonadotropin-- D1 ]5 q2 q: y3 @5 O! k6 G! y
independent precocious puberty, which is also known
O4 A! d: s& O; |as testotoxicosis, may cause precocious puberty at a" K! l4 N$ F+ B) _2 K
very young age. The physical findings in these boys
. v( R* Q* F: R' `& |with this disorder are full pubertal development,+ Q' j# v0 X3 L L
including bilateral testicular growth, similar to boys5 j2 I9 Y1 b5 U5 K0 u, I7 w
with CPP. The gonadotropin levels in this disorder
1 W M& Y \3 y2 J+ a* V" eare suppressed to prepubertal levels and do not show c# \) K# {( `8 ^
pubertal response of gonadotropin after gonadotropin-
8 N# e, p/ W" k) Nreleasing hormone stimulation. This is a sex-linked
1 | i- h7 n* H, Y2 X2 P. ~autosomal dominant disorder that affects only
8 T& |0 g$ G$ M: ^, tmales; therefore, other male members of the family# t- j$ V0 R0 |9 U4 `0 g* e5 H
may have similar precocious puberty.3
6 x" n% b2 n0 I/ \2 I iIn our patient, physical examination was incon-/ l/ z9 t5 `) E% c8 ]" j3 [
sistent with true precocious puberty since his testi-( R" X# ?+ Z8 l- p" V7 D
cles were prepubertal in size. However, testotoxicosis
! S4 `, F6 j3 t8 \5 A0 swas in the differential diagnosis because his father
z6 x# k9 p* G% L$ `- Wstarted puberty somewhat early, and occasionally,
1 C6 Y- r9 }$ ?: X2 R5 }9 ?( @testicular enlargement is not that evident in the
! C" q' [9 E& c d" w3 Jbeginning of this process.1 In the absence of a neg-
* ?. g5 ^+ F) r6 V/ ^1 S+ p( kative initial history of androgen exposure, our
9 k E0 b7 c+ n" ?% Cbiggest concern was virilizing adrenal hyperplasia,
% H! h4 o; | Neither 21-hydroxylase deficiency or 11-β hydroxylase
' D- [% }. j0 n! ddeficiency. Those diagnoses were excluded by find-# s! d, a( x$ f
ing the normal level of adrenal steroids.. F$ I6 u" h5 x! ^3 Q) z m
The diagnosis of exogenous androgens was strongly$ b* h1 ?6 J* P* W. e
suspected in a follow-up visit after 4 months because8 i; N9 }$ `5 f' i' ^- S* t
the physical examination revealed the complete disap-5 Q+ f% Y6 v4 Q) q! M
pearance of pubic hair, normal growth velocity, and7 q4 H2 B: ]8 S0 H/ o
decreased erections. The father admitted using a testos-: z: l1 k) N+ ~& P4 N2 J
terone gel, which he concealed at first visit. He was7 T+ E1 t# |0 x$ o* }
using it rather frequently, twice a day. The Physicians’
- j1 Y5 m- H& m* Q8 gDesk Reference, or package insert of this product, gel or9 n. `0 n8 Z3 r! I/ c6 F
cream, cautions about dermal testosterone transfer to# J3 r6 g! j; [. Z5 F6 M5 R+ ]- y) I
unprotected females through direct skin exposure.
# p0 u, X8 k, t5 c6 xSerum testosterone level was found to be 2 times the
! v9 I6 c* q+ ]9 \" r7 J9 Qbaseline value in those females who were exposed to
& h0 n, a( X; X, b, i# T& [even 15 minutes of direct skin contact with their male
& B2 a& L% |# \( t5 Opartners.6 However, when a shirt covered the applica-
- D+ h, Z# ?. |( }* y4 z" jtion site, this testosterone transfer was prevented.3 J b3 a6 \0 K8 j# Z) B
Our patient’s testosterone level was 60 ng/mL,( r% S9 A; J, t' r, G, [( x" l
which was clearly high. Some studies suggest that4 i5 G; k6 b+ `# Q2 n
dermal conversion of testosterone to dihydrotestos-
5 s" ~ U$ B! [1 s; |+ ]( o* _terone, which is a more potent metabolite, is more
7 } J F5 Y: ~. W0 D& {active in young children exposed to testosterone: c" g* o0 f9 {- [( p9 R
exogenously7; however, we did not measure a dihy-& [- d. ?* @1 Z5 q- k0 [0 z
drotestosterone level in our patient. In addition to/ u' T, d" f$ X2 j+ [5 Y
virilization, exposure to exogenous testosterone in
$ v/ t9 E/ J% n) E: xchildren results in an increase in growth velocity and
+ v4 {; g# q& l- G% k. Iadvanced bone age, as seen in our patient.
( w7 M, {5 Z/ B) N! t' p6 Y* Q6 cThe long-term effect of androgen exposure during
% B+ C* {2 s7 `' O- X: dearly childhood on pubertal development and final
7 g7 F6 H6 R' J# q7 G; C/ d( \! ~# Cadult height are not fully known and always remain
" ~, K2 {. t" u. l- j# j" Y$ [a concern. Children treated with short-term testos-& y* {- N8 H) c# H7 X, G& a1 E
terone injection or topical androgen may exhibit some
$ L9 y& O( n! D) C/ g; c, |acceleration of the skeletal maturation; however, after6 z3 e5 X. O6 r
cessation of treatment, the rate of bone maturation
7 X, v( H7 K+ J( f* _decelerates and gradually returns to normal.8,9, Q: X4 o( Q3 D% S3 G/ v
There are conflicting reports and controversy
% S( C+ {3 e+ J+ I9 P ^over the effect of early androgen exposure on adult1 c2 Z0 I* T" s6 d" `
penile length.10,11 Some reports suggest subnormal' [, [# Z3 d+ A
adult penile length, apparently because of downreg-
: N9 a- D( ] Q" l2 X9 julation of androgen receptor number.10,12 However,
1 Y8 g, o; a- Q" f' J" g- FSutherland et al13 did not find a correlation between
( M% e7 f4 `. e' z& P2 [0 J+ ochildhood testosterone exposure and reduced adult% C3 g# R+ H4 I
penile length in clinical studies." U- a3 G& h& v3 O* g+ g- L
Nonetheless, we do not believe our patient is
3 `- J4 i5 j, ?9 N7 Ogoing to experience any of the untoward effects from
8 X" X% S2 k+ R6 Btestosterone exposure as mentioned earlier because
! y @. V( `6 \% Rthe exposure was not for a prolonged period of time.
6 D3 @2 N9 q! {! R$ xAlthough the bone age was advanced at the time of
4 Y9 x! A& @# t$ udiagnosis, the child had a normal growth velocity at
I% a' H& M$ K+ ~% n, ?$ ]1 Ythe follow-up visit. It is hoped that his final adult
; m6 Q( |! g( B* w! l1 H. r' J4 Oheight will not be affected.
$ F/ A7 Q( ?" V+ B, ~5 g5 Y3 A7 JAlthough rarely reported, the widespread avail-- z% q/ _$ ?' S/ F$ {( W" n
ability of androgen products in our society may9 r* M' H/ b1 l/ H" e: q# K, n
indeed cause more virilization in male or female- _& K: z, X9 {! M$ Y( x
children than one would realize. Exposure to andro-- A% z( N6 f3 E5 b$ s: @" T
gen products must be considered and specific ques-
: P" z1 L! v" J5 I; ?$ ftioning about the use of a testosterone product or2 ~- o1 r3 A; Q8 o$ y
gel should be asked of the family members during' y) x9 c, Y5 _6 A, Q
the evaluation of any children who present with vir-
) F: a5 t1 l: ~2 A& b+ Nilization or peripheral precocious puberty. The diag-7 M$ B/ {0 `) G" i# v
nosis can be established by just a few tests and by. H; Y6 p1 ?5 O1 n* ?
appropriate history. The inability to obtain such a5 @& w4 w+ @$ X" ^. v
history, or failure to ask the specific questions, may/ L9 J0 q8 ^# I+ f v& x
result in extensive, unnecessary, and expensive6 e; ~$ @, N+ z8 Z
investigation. The primary care physician should be
1 k8 V( Y! I' s1 v9 ]aware of this fact, because most of these children* R/ L: P( Y; Q' w
may initially present in their practice. The Physicians’
' P) }. @2 }1 e: U) m* T7 ^Desk Reference and package insert should also put a
3 J" v: C: A% U/ Ewarning about the virilizing effect on a male or6 G1 _2 [1 r0 }, h; i
female child who might come in contact with some-
( c" E- b. @& s0 N; ^one using any of these products.
L6 G6 S$ u7 G6 @0 vReferences0 O& f y$ t1 u1 E0 }. ?$ G5 X
1. Styne DM. The testes: disorder of sexual differentiation; M5 g; P. f# |. D) v0 ^, E
and puberty in the male. In: Sperling MA, ed. Pediatric$ s) N& u/ k; ^. S2 S/ ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" H; a& z# Q- ]5 e* k9 }- k8 u
2002: 565-628.
" y% K7 c" ?) f- A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& C6 _% f, s. _# L( a4 J' T
puberty in children with tumours of the suprasellar pineal |
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