- 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-Old7 o# M/ l* p) O/ a D. _
Boy Induced by Indirect Topical
* K- \8 _8 e7 d4 P4 N( @Exposure to Testosterone' w0 u# [+ X' F r1 G" o$ {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 \" ~4 A @0 z2 ^4 E
and Kenneth R. Rettig, MD1
$ z# ~# L! C8 ]1 ]3 `/ u5 AClinical Pediatrics+ u: B+ d; s, p B
Volume 46 Number 6
6 b5 m) S Q. o, iJuly 2007 540-543- c t$ [ ^& D, [6 r, k. }) U
© 2007 Sage Publications9 S8 l9 C) F$ x6 g/ b" H
10.1177/0009922806296651
6 X6 s8 U2 P0 p+ r7 ]* G6 x8 I" _( ehttp://clp.sagepub.com$ j0 O7 P5 _ u ~
hosted at
4 N2 M7 Q! Z# h5 j: y; a2 j9 m3 whttp://online.sagepub.com
5 z: @% S! |3 ?% v! \2 f% m* hPrecocious puberty in boys, central or peripheral,2 S, n0 e; v& ?) B" e
is a significant concern for physicians. Central
* F8 `* Z1 s6 _precocious puberty (CPP), which is mediated4 @& N- t7 I- c2 }. z/ L6 f1 d/ h
through the hypothalamic pituitary gonadal axis, has4 H1 a) V4 W; y4 G3 A
a higher incidence of organic central nervous system
3 o. P$ f$ r+ elesions in boys.1,2 Virilization in boys, as manifested4 s: G1 \& q+ |8 g( Q
by enlargement of the penis, development of pubic
3 I4 F+ l; \% E' k9 g+ _4 xhair, and facial acne without enlargement of testi-& c) x1 |) v0 W( W2 r- L
cles, suggests peripheral or pseudopuberty.1-3 We
r% N6 D% D! a' zreport a 16-month-old boy who presented with the: f: D- Z4 F' g% i% A! T
enlargement of the phallus and pubic hair develop-
2 ^; C! m2 I/ P R6 [ment without testicular enlargement, which was due/ f5 D% V$ N+ _) H6 m8 K
to the unintentional exposure to androgen gel used by
, O# R/ D! w5 z8 L: ]1 o0 a, E+ ~& J) sthe father. The family initially concealed this infor-$ r. f3 j# ~8 d! D8 ]2 c) X
mation, resulting in an extensive work-up for this
5 X, e. g* b( Ychild. Given the widespread and easy availability of/ [) `) l" O* i# d
testosterone gel and cream, we believe this is proba-9 o2 c2 L/ j: O4 s
bly more common than the rare case report in the" g+ m3 t" z# E0 m6 A
literature.4
7 h7 }: B* J/ k" W1 u$ QPatient Report
* ^5 e; y' ]6 O" V0 h- @/ y9 eA 16-month-old white child was referred to the2 I3 r5 M1 k& j, d5 J4 f2 z
endocrine clinic by his pediatrician with the concern
K6 S6 [$ G# g7 z0 x. @( p7 d, dof early sexual development. His mother noticed+ T$ S' I" D; F
light colored pubic hair development when he was* z( _. D$ D1 s7 B& C; i# ~8 B
From the 1Division of Pediatric Endocrinology, 2University of
. _: M* Z7 H0 \( @6 S% {South Alabama Medical Center, Mobile, Alabama.
. `/ w% y6 e# m$ K: [Address correspondence to: Samar K. Bhowmick, MD, FACE," }. a: U B8 Q) v
Professor of Pediatrics, University of South Alabama, College of
! r7 {0 b* `& Q# zMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 y/ h" ~3 n. S: f/ c
e-mail: [email protected].
; m; N* h+ E3 Y3 w( l4 b9 `about 6 to 7 months old, which progressively became
& V. X) F1 M0 b% L# ~6 B/ idarker. She was also concerned about the enlarge-, r1 I) R. e$ L4 ?
ment of his penis and frequent erections. The child
: P$ O' g, }" _0 h, Nwas the product of a full-term normal delivery, with
1 K6 G5 l# H% y% o, c3 v: Y# \; ]# W' k6 `a birth weight of 7 lb 14 oz, and birth length of
1 S6 w0 T- R; q1 f; y9 T. ^# @5 K20 inches. He was breast-fed throughout the first year
) p- _- ~* Z+ g4 N- {# A' nof life and was still receiving breast milk along with
' t3 B) `" A* ~* N0 Xsolid food. He had no hospitalizations or surgery,: c7 C) X7 r0 O2 ?! f, \
and his psychosocial and psychomotor development
3 E5 ~( a2 {, x& N! B& b9 {was age appropriate.
4 [5 ^/ J( L9 L. k/ ?9 EThe family history was remarkable for the father,
& l: Q% U/ U) }/ f& E+ Uwho was diagnosed with hypothyroidism at age 16,
+ s) ~, j1 l4 a9 R7 j2 mwhich was treated with thyroxine. The father’s1 n8 L1 P: ^( r+ r8 v2 D9 u
height was 6 feet, and he went through a somewhat
7 v8 E, V4 U4 u. Z9 _, t/ hearly puberty and had stopped growing by age 14. X. S+ `! v! ^0 K/ ?2 p& x
The father denied taking any other medication. The: o/ p) S- z0 u. e
child’s mother was in good health. Her menarche, m. E6 }( Y$ X0 B3 m
was at 11 years of age, and her height was at 5 feet
i8 j- L' a3 r5 h1 E8 ?( P; I& d2 R8 N5 inches. There was no other family history of pre-
6 p9 [9 [: q% q0 d, q8 Xcocious sexual development in the first-degree rela-
' X, E. n1 U3 M) r/ U: s* ^tives. There were no siblings.
" q) ^1 J3 U% p" U, y: q" W' dPhysical Examination
: f% f8 N( v) O; o* u- hThe physical examination revealed a very active,
# D4 G8 q: [2 _' q0 }, y+ dplayful, and healthy boy. The vital signs documented" g1 p5 ?2 V4 h& I
a blood pressure of 85/50 mm Hg, his length was3 z9 l V1 W6 _: r4 M# y) ^/ Z6 |
90 cm (>97th percentile), and his weight was 14.4 kg) U! G; N0 i6 o' Q( R( u) ?
(also >97th percentile). The observed yearly growth. d8 t/ p# F4 s( o8 s0 M; d
velocity was 30 cm (12 inches). The examination of
4 Q7 \- |' s! v5 x) Vthe neck revealed no thyroid enlargement.7 P/ e: I/ X9 H+ k. i' X, D
The genitourinary examination was remarkable for3 C0 V, Z( K) u+ N% u
enlargement of the penis, with a stretched length of7 _- V- a2 u+ O. z2 v, X
8 cm and a width of 2 cm. The glans penis was very well% u8 R3 C6 @5 x! _0 U$ d8 R
developed. The pubic hair was Tanner II, mostly around
7 Q% z; Z2 ]) d- ?+ l' V* Z540
6 b0 h8 I; d6 E7 B; Y1 R5 d) Q% aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 M8 E! J) V# G; Cthe base of the phallus and was dark and curled. The
' E) [( L, U6 p7 Z+ Stesticular volume was prepubertal at 2 mL each.5 }9 C$ u* F6 Y5 L6 u
The skin was moist and smooth and somewhat0 d$ M3 y, F: W8 t7 ]" P/ e$ k- [
oily. No axillary hair was noted. There were no
3 m, F$ f& C) f7 ]abnormal skin pigmentations or café-au-lait spots.5 r5 v/ l) ~3 q
Neurologic evaluation showed deep tendon reflex 2+1 L0 { Z% H8 s- d9 Y
bilateral and symmetrical. There was no suggestion4 m K+ K/ P9 u6 J
of papilledema.
# s! _0 S* L% ~$ L0 LLaboratory Evaluation
4 F2 R+ C2 r" r! YThe bone age was consistent with 28 months by: D4 N+ K4 X, |" x7 s* U
using the standard of Greulich and Pyle at a chrono-
. r5 x9 R: ^4 Llogic age of 16 months (advanced).5 Chromosomal, ]# L- k+ n2 d! |3 \ ?. I7 B3 D1 e3 P
karyotype was 46XY. The thyroid function test: x: k% r* p6 w. n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
W% p9 J" N, B. h% z# Klating hormone level was 1.3 µIU/mL (both normal).
* t7 o& X0 G7 U% u7 l5 YThe concentrations of serum electrolytes, blood7 I# u9 X7 ?5 P2 ?
urea nitrogen, creatinine, and calcium all were
1 t U i. i3 ~! T% nwithin normal range for his age. The concentration
2 `/ @ e1 h2 Aof serum 17-hydroxyprogesterone was 16 ng/dL
3 w8 Q3 o8 f; M+ L(normal, 3 to 90 ng/dL), androstenedione was 20
5 R7 [9 U. o' `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) e0 X P d F) h
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," c' ?( N6 E4 T+ E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. z( T1 s9 \6 l0 Z' s6 S3 K4 w- ?
49ng/dL), 11-desoxycortisol (specific compound S)
3 r3 u2 I z+ o+ h) a, `) dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: Z3 p- K" z, V9 S$ V, E% ], L
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ J1 F& |/ I! X( ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 d8 t$ T; ~1 m( Q! X' Kand β-human chorionic gonadotropin was less than
7 p7 I1 D' _; r( h8 V# m" e2 m6 @; `7 r5 mIU/mL (normal <5 mIU/mL). Serum follicular$ T( S: t1 H: J6 [+ d+ ^( q
stimulating hormone and leuteinizing hormone
6 `) q! L( r, i, S5 a8 |3 {concentrations were less than 0.05 mIU/mL ^1 P5 v. T: ^7 ?
(prepubertal).: q4 S6 R+ x- s( u b' [
The parents were notified about the laboratory1 A2 n y/ j# ], Y8 ^6 H
results and were informed that all of the tests were
, E s! N0 ]# Znormal except the testosterone level was high. The
# c* E c/ Y5 Gfollow-up visit was arranged within a few weeks to
! I J! v' L C7 p. e" j) ]obtain testicular and abdominal sonograms; how-. M5 S6 e; D8 y# K9 F' c
ever, the family did not return for 4 months.
- w/ i B( ^) K. u% Z- \Physical examination at this time revealed that the
# O- ?% f1 Z5 {. t, e2 S- xchild had grown 2.5 cm in 4 months and had gained
( A& z( i6 f4 ^2 kg of weight. Physical examination remained
2 s4 p! a* c4 ^: X( H ~unchanged. Surprisingly, the pubic hair almost com-: `' |3 b" t4 U4 `6 s
pletely disappeared except for a few vellous hairs at
" A- I) b6 a4 [5 J Ythe base of the phallus. Testicular volume was still 2
* m9 h! @- _, j v) k* ZmL, and the size of the penis remained unchanged.. X6 ]: O9 _0 W# C v
The mother also said that the boy was no longer hav-3 ]- O' G8 q) v. M6 b
ing frequent erections.# O$ I! \3 S5 F
Both parents were again questioned about use of5 e- v- ?2 ^1 [: c3 o: ~+ y2 u
any ointment/creams that they may have applied to
( z' G/ ]' L, c( Q1 ^the child’s skin. This time the father admitted the
% `% w" |5 Y$ h3 P" lTopical Testosterone Exposure / Bhowmick et al 541
& h$ V: c& ~4 T; I) i% Nuse of testosterone gel twice daily that he was apply-: n( h- t3 Q' j, x& y4 T- U$ s
ing over his own shoulders, chest, and back area for
' b% h7 t3 U7 qa year. The father also revealed he was embarrassed7 R& G% y$ R/ @9 K4 X
to disclose that he was using a testosterone gel pre-& t+ q& H1 z$ X0 z6 @4 }
scribed by his family physician for decreased libido- d9 p7 H4 _% h* z1 X
secondary to depression., L; Q5 V8 q5 G" e+ D) c
The child slept in the same bed with parents.# T: I5 u+ P. |% s# R
The father would hug the baby and hold him on his3 t% {; Y5 I4 h2 {7 c" }4 x/ H
chest for a considerable period of time, causing sig-+ }- G/ s/ V) H& x
nificant bare skin contact between baby and father.
, ?4 Y! O# H3 z6 k9 H' DThe father also admitted that after the phone call,9 h1 i4 u& U- z+ p/ B% I$ R
when he learned the testosterone level in the baby9 h% p1 |4 G& L
was high, he then read the product information5 _1 b/ ^$ P$ f
packet and concluded that it was most likely the rea-
. D$ @4 ^3 H' o8 \son for the child’s virilization. At that time, they
3 h+ H. P% [; D! wdecided to put the baby in a separate bed, and the
7 B; D: D) ?1 H) x; zfather was not hugging him with bare skin and had
0 r4 L* a# A$ [been using protective clothing. A repeat testosterone. h. _" l4 i1 `4 `6 W/ O4 h
test was ordered, but the family did not go to the
0 {6 l f; W) @- Flaboratory to obtain the test.
9 f( h2 O/ Y9 h0 MDiscussion
/ [7 M& t- {4 M7 D4 CPrecocious puberty in boys is defined as secondary
( u) F5 B0 V* N! ~8 g1 m# Msexual development before 9 years of age.1,4
) ^6 W3 o: U( pPrecocious puberty is termed as central (true) when( U6 a$ F, ~: |& y/ o- P
it is caused by the premature activation of hypo-
3 y( u' L+ e0 v8 [0 Y3 [: a$ Athalamic pituitary gonadal axis. CPP is more com-
# S0 q3 }0 G5 x; n0 c: T* amon in girls than in boys.1,3 Most boys with CPP
+ M$ d# N: T3 [3 Tmay have a central nervous system lesion that is
( E9 T! i. ~% |9 f6 Y: Gresponsible for the early activation of the hypothal-
, S7 a7 P; L4 O9 z2 Pamic pituitary gonadal axis.1-3 Thus, greater empha-
& Y3 o Y' L2 G' m+ T; i% W/ q5 zsis has been given to neuroradiologic imaging in
7 c5 v9 T' m3 b. c$ cboys with precocious puberty. In addition to viril-: h* z z# O% C3 Q: Z
ization, the clinical hallmark of CPP is the symmet-5 `* m# B% }3 S' @ Z
rical testicular growth secondary to stimulation by
; \# f* Y9 g! M4 T4 L* S8 b8 k3 }gonadotropins.1,3
& z- n- r$ C4 r4 g3 ]Gonadotropin-independent peripheral preco-
# m# k; W4 d3 K4 n9 E, ?3 Acious puberty in boys also results from inappropriate- O/ ~* A/ q' H! ]1 F9 v4 w
androgenic stimulation from either endogenous or
: x7 m% Z, [ V8 x$ X6 Jexogenous sources, nonpituitary gonadotropin stim-4 }, c5 |, {# i8 t0 |( R& x+ M
ulation, and rare activating mutations.3 Virilizing0 Q1 s3 s% E9 {! B! V
congenital adrenal hyperplasia producing excessive; W* H& E, P8 y
adrenal androgens is a common cause of precocious
4 u2 i. ]; W& _" Y9 P& b. n* M# Ypuberty in boys.3,4$ [% k5 Q8 J1 X+ _$ U7 N# ?* c2 L
The most common form of congenital adrenal
4 e* f) x# A- S% ~hyperplasia is the 21-hydroxylase enzyme deficiency.
4 g2 e' \' {9 ~5 A5 nThe 11-β hydroxylase deficiency may also result in# c8 c3 l$ b2 t: S
excessive adrenal androgen production, and rarely,
& C- T1 B: g( Q; W k8 Fan adrenal tumor may also cause adrenal androgen
. @# P# _1 l7 R2 F8 k5 Aexcess.1,3
/ T. s. q+ L) ^3 T% Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% Y3 J% g/ r* K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 j, Y' R" d' Q2 pA unique entity of male-limited gonadotropin-
+ a& L% @2 S- `independent precocious puberty, which is also known: y, [$ i1 C' }+ v7 l( v7 m
as testotoxicosis, may cause precocious puberty at a
( L' K# [/ U; \7 jvery young age. The physical findings in these boys
4 a0 f2 _. T# U: |1 Mwith this disorder are full pubertal development,
1 Q6 U3 _8 L Oincluding bilateral testicular growth, similar to boys
5 a- L' _; p% r+ vwith CPP. The gonadotropin levels in this disorder
) e/ c: a" h, W3 c7 n7 Pare suppressed to prepubertal levels and do not show
) ]3 g" l: J' S1 Y: W4 M8 u% wpubertal response of gonadotropin after gonadotropin-* i+ A; d) X( u5 X3 W
releasing hormone stimulation. This is a sex-linked) H# G( w/ C, Q7 }( U( ]8 k/ c* l
autosomal dominant disorder that affects only
/ l: H1 R8 C. N2 Qmales; therefore, other male members of the family
- u$ z# }6 c9 Z* I# [may have similar precocious puberty.3
4 `# O% V2 P( WIn our patient, physical examination was incon-
' u' n, d% E% @" T0 z. y% hsistent with true precocious puberty since his testi-' k `8 F3 D% ~* Q4 I
cles were prepubertal in size. However, testotoxicosis
* @' b7 h# |9 h0 d Y, R' p( ]was in the differential diagnosis because his father' f$ w Z5 \: ?- p
started puberty somewhat early, and occasionally,
! ^2 P- B" C, F/ W8 [testicular enlargement is not that evident in the
8 L( k- q6 \/ `beginning of this process.1 In the absence of a neg-, S" j U9 Y# W, `. |
ative initial history of androgen exposure, our9 f* N7 |, F; M5 c! I4 K
biggest concern was virilizing adrenal hyperplasia,7 T5 g) T; p& F; E- A
either 21-hydroxylase deficiency or 11-β hydroxylase
s' _9 E! p& |. hdeficiency. Those diagnoses were excluded by find-' L* Z8 w4 X7 A; ^4 w
ing the normal level of adrenal steroids.5 |% R; H- }' f3 l0 E N: A; A
The diagnosis of exogenous androgens was strongly
* ]" N, A0 M9 z: B' \- Hsuspected in a follow-up visit after 4 months because- d- i5 T7 v% ?; r) H% A3 ]
the physical examination revealed the complete disap-
/ g( A5 R3 X8 X( M9 I. Kpearance of pubic hair, normal growth velocity, and" R0 Q' f, {! o$ s9 ?( E* r
decreased erections. The father admitted using a testos-
% D; l0 w: |; u! ^4 P) G1 L" ~terone gel, which he concealed at first visit. He was% f2 T I/ N& f; f" G, ~' t
using it rather frequently, twice a day. The Physicians’
! h3 {9 _* A9 p8 l* qDesk Reference, or package insert of this product, gel or' U& W& D, W Z, A* I7 x) W, L l
cream, cautions about dermal testosterone transfer to0 q. z! f! Y! P# E
unprotected females through direct skin exposure.0 W! U& s2 W. ?! j: N' e H
Serum testosterone level was found to be 2 times the
$ W. r. Q' o, f( }8 {8 }$ ?7 G( Cbaseline value in those females who were exposed to
6 x" D$ ~1 @1 R; X( h& }4 aeven 15 minutes of direct skin contact with their male
* J f: A, ], l& x2 ?partners.6 However, when a shirt covered the applica-* v! E$ o0 A' f. _$ C( B- M
tion site, this testosterone transfer was prevented.' T# c/ u; I7 p( k- w3 `) \) F
Our patient’s testosterone level was 60 ng/mL,/ o% ~9 G3 N2 n% v
which was clearly high. Some studies suggest that
. ^# O0 S+ b: y1 D1 J/ K3 Q) s) S pdermal conversion of testosterone to dihydrotestos-3 f3 o2 X7 _& E* m
terone, which is a more potent metabolite, is more: f" M# X1 _( X; g* K) T
active in young children exposed to testosterone7 L) r9 n4 h) k
exogenously7; however, we did not measure a dihy-/ [# r. @$ @4 i6 \/ _
drotestosterone level in our patient. In addition to
1 p- n$ u( d# u* e4 v- Dvirilization, exposure to exogenous testosterone in: ^7 Q0 L3 `) o$ ]9 B/ V& {
children results in an increase in growth velocity and
2 Y$ L/ D: v- u" a" f1 Z+ \advanced bone age, as seen in our patient.: z; G1 S# R, E3 h/ l' c
The long-term effect of androgen exposure during
* p" n: S7 S9 O% e% F0 searly childhood on pubertal development and final
' |# k b# x2 p( _adult height are not fully known and always remain
2 h3 r! C# j: Ha concern. Children treated with short-term testos-/ Z t, {5 t' b( Q( n- H# G5 e9 Q
terone injection or topical androgen may exhibit some
0 i6 H+ k2 s- d3 T$ Facceleration of the skeletal maturation; however, after1 j- p# Z1 p5 o6 p$ s
cessation of treatment, the rate of bone maturation
4 R. m0 ? t; M, `& @$ zdecelerates and gradually returns to normal.8,9* `! ?- M8 r1 s; w0 m
There are conflicting reports and controversy
- N, F) E6 \9 d, c4 sover the effect of early androgen exposure on adult6 `% x0 ~2 {& K" R( \/ U- a
penile length.10,11 Some reports suggest subnormal
. g6 n, r0 F2 w0 h4 N/ w$ }7 Kadult penile length, apparently because of downreg-
" M" L; ^1 I( B+ I4 eulation of androgen receptor number.10,12 However,6 ?+ l3 D3 i. ]( N4 ^7 @8 b# B1 e+ _* _
Sutherland et al13 did not find a correlation between
& X. F/ r: i" |2 l2 ~$ Fchildhood testosterone exposure and reduced adult5 x/ r ~3 r( _! \% y4 T
penile length in clinical studies.: a( ~3 c* r8 Z! h( O J4 E7 Z
Nonetheless, we do not believe our patient is, M8 |% V3 W) {$ ]. d* |
going to experience any of the untoward effects from
: u3 Q" ` o/ j" g& `, Jtestosterone exposure as mentioned earlier because
$ I2 ^ V4 D, B, [0 X; |8 Z' f. c& }the exposure was not for a prolonged period of time.
2 \% C1 w, d+ K: JAlthough the bone age was advanced at the time of# }+ N# |& M5 B9 r4 p/ R1 T7 N6 X
diagnosis, the child had a normal growth velocity at
, L% y. m s+ c! e6 @the follow-up visit. It is hoped that his final adult+ y$ Q! P3 a3 x7 x' e2 P
height will not be affected.
3 t2 v5 J, [9 ` h4 ~+ E9 V: b0 tAlthough rarely reported, the widespread avail-
6 M K. i- @+ ?2 F( Qability of androgen products in our society may# K: Z/ w* h9 {3 }% J3 ^( K
indeed cause more virilization in male or female$ |0 P0 t: v) F" Z
children than one would realize. Exposure to andro-
! `" C7 g3 M" `( F: s. n' rgen products must be considered and specific ques-4 j% c4 S, `' o/ G
tioning about the use of a testosterone product or! B2 M9 P |6 m( B8 X% p- C
gel should be asked of the family members during7 b- X4 k9 _+ P2 V
the evaluation of any children who present with vir-6 Z3 R/ z: M M# R& e
ilization or peripheral precocious puberty. The diag-
! [' S! U/ c( \! V5 o0 ]nosis can be established by just a few tests and by
9 k$ d* b0 G. `4 I$ G/ l4 x, cappropriate history. The inability to obtain such a2 f* \8 i5 x) a
history, or failure to ask the specific questions, may/ S/ G( M$ d9 G+ _$ D. ?2 w
result in extensive, unnecessary, and expensive/ T5 D! C6 Q8 \9 F1 P8 M; J
investigation. The primary care physician should be
2 c+ N. ^# O S2 f% M" v. ?aware of this fact, because most of these children2 {& N# w! y" T, q" X/ m3 P1 t$ w+ B8 M
may initially present in their practice. The Physicians’) a+ y; Z0 |+ c* ]5 q7 P5 d
Desk Reference and package insert should also put a
( {2 E9 S3 E3 y) e1 twarning about the virilizing effect on a male or
$ b, ~5 f- @( E+ H1 {; {2 Hfemale child who might come in contact with some-
. I3 n4 y! G' [/ |7 ^5 X- J& bone using any of these products.
( ^0 k& Z& \: v- Y! D" M rReferences
$ l& ~& T0 P+ [' _9 H& A1. Styne DM. The testes: disorder of sexual differentiation
! r* H1 r" f0 u/ d4 y! G, u Hand puberty in the male. In: Sperling MA, ed. Pediatric- Z" b8 \ \: D" F8 f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. K$ ^) K4 M3 Y \( a8 C: L
2002: 565-628.9 N! s* M1 d+ B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! G2 }- r5 D, o3 b# ?
puberty in children with tumours of the suprasellar pineal |
|