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Sexual Precocity in a 16-Month-Old
, b( G7 d# I6 N- i+ u9 D. S. XBoy Induced by Indirect Topical
& h4 i/ @5 K* S/ K% RExposure to Testosterone1 c8 E) t2 R. b4 Y. u3 Z2 f- D- g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! i8 d" S8 ^) n( o& e6 w3 l% J
and Kenneth R. Rettig, MD1
& x) K+ z& G9 ~# r; D7 p! aClinical Pediatrics
* G( r& n: U. q% z+ o2 q4 }Volume 46 Number 6& C# ?8 j! J, ]! x5 Z
July 2007 540-543+ b3 e* t$ J d1 @& |! k0 ]9 I
© 2007 Sage Publications0 y5 m4 [2 P9 [3 P$ ~
10.1177/0009922806296651
% g* s0 E" o: B3 a' U0 Yhttp://clp.sagepub.com
% T' u0 R8 I6 a( J' qhosted at3 B* |9 M( B9 q1 u5 C
http://online.sagepub.com
; n W6 S/ Z. O4 d: ~: k3 S3 V) g$ sPrecocious puberty in boys, central or peripheral,1 i+ ?- G+ \' c% H8 g8 ^
is a significant concern for physicians. Central0 y& g( s& }5 v# ^
precocious puberty (CPP), which is mediated* c4 h$ C# d* ~, J5 o6 [
through the hypothalamic pituitary gonadal axis, has/ d+ K: u& H0 v% S) F4 a$ x
a higher incidence of organic central nervous system, A0 p; c' T* b4 d3 n
lesions in boys.1,2 Virilization in boys, as manifested! Q, K, O6 J) z& O
by enlargement of the penis, development of pubic
2 n h) v" k! h* V$ J' H4 Shair, and facial acne without enlargement of testi-6 b5 [% i2 u7 a$ A& `
cles, suggests peripheral or pseudopuberty.1-3 We9 c+ E$ C' d \$ K
report a 16-month-old boy who presented with the8 X8 I3 H/ ^. q( l" w0 [0 g
enlargement of the phallus and pubic hair develop-. `! U: P2 G7 ~2 H5 a, i
ment without testicular enlargement, which was due
% t$ H& ]7 i" \0 n$ Z3 yto the unintentional exposure to androgen gel used by
$ o% f" M' U4 Z9 f( w) L' Ethe father. The family initially concealed this infor-4 L4 E, q% f2 W' q
mation, resulting in an extensive work-up for this
1 M# K" |( x5 H! Jchild. Given the widespread and easy availability of/ ^: R* j% i5 P. l( M; ~
testosterone gel and cream, we believe this is proba-' e* b2 }" m3 n0 ?* [: l
bly more common than the rare case report in the% ?9 g0 j) Z1 i/ r; @5 q
literature.4
. `# [5 o7 i* p. b8 b9 R* UPatient Report7 u+ \; H" {7 a. ^- Q
A 16-month-old white child was referred to the
! s8 o8 @# \9 V4 i- w Aendocrine clinic by his pediatrician with the concern
& K" _( D1 B7 N+ y1 a* z+ u& i$ u- Kof early sexual development. His mother noticed
: N7 l5 K+ p' }" Ylight colored pubic hair development when he was$ e$ j: L7 E: B% a* ?3 j
From the 1Division of Pediatric Endocrinology, 2University of5 }; |% G6 ?2 t
South Alabama Medical Center, Mobile, Alabama.
8 _! p' K6 R0 N, k- ~; w- JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 { E4 W) ?! q( O! BProfessor of Pediatrics, University of South Alabama, College of5 S% |4 L) ^' |& n; m' k9 P
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" `1 x6 h$ Z' B) Re-mail: [email protected].! n; H3 Q" R3 `- c
about 6 to 7 months old, which progressively became
, w3 w X- v. ~darker. She was also concerned about the enlarge- I" J1 u- U# n2 v3 Q( L
ment of his penis and frequent erections. The child
_/ g. j# D% w% O8 k! _was the product of a full-term normal delivery, with
5 E4 T: |( y% d; _a birth weight of 7 lb 14 oz, and birth length of
+ C! H# N* X" I4 s; e& P20 inches. He was breast-fed throughout the first year
Y! \& W0 R C- Z" Zof life and was still receiving breast milk along with
2 D) Y, ?; Y1 a" w q# csolid food. He had no hospitalizations or surgery,; D7 }, z5 _- o7 u) R
and his psychosocial and psychomotor development
% w5 f7 Z5 E3 @& J# k" q) e. A% Nwas age appropriate.
0 Y& ~% Q3 [$ ^ H/ o" K* `The family history was remarkable for the father,
' m9 Z& f& M" s% ?" s( {who was diagnosed with hypothyroidism at age 16,
6 C8 s( {% M% \. z- Wwhich was treated with thyroxine. The father’s
9 ]$ t6 h/ o! nheight was 6 feet, and he went through a somewhat
8 ^7 t4 K0 [, p/ {* Eearly puberty and had stopped growing by age 14.; c( Q! W6 ^8 @* ]/ C
The father denied taking any other medication. The; Z/ ^2 s* N5 V# @
child’s mother was in good health. Her menarche
9 z; Q7 m4 y( i: |was at 11 years of age, and her height was at 5 feet
( X% @) I" Y1 Z& ~- F8 U5 inches. There was no other family history of pre-
- b1 O$ y/ z1 C" q8 v8 v; a3 m4 Vcocious sexual development in the first-degree rela-( }/ E- Q4 A ^+ v6 t
tives. There were no siblings.' r- l/ o0 Y3 o4 l% D0 D
Physical Examination3 l; ]* C: P( e- D$ e) l" r1 `
The physical examination revealed a very active,) Q9 {5 w: w% o+ N# Q
playful, and healthy boy. The vital signs documented* g5 V: s |1 |' p# @8 L; K
a blood pressure of 85/50 mm Hg, his length was1 k# O/ m% `( b4 ]; m
90 cm (>97th percentile), and his weight was 14.4 kg8 |7 L( d; E v! E+ a8 {
(also >97th percentile). The observed yearly growth
! ]/ X& j) c$ {6 Vvelocity was 30 cm (12 inches). The examination of# Z f* n4 @- Q6 |% s" ~
the neck revealed no thyroid enlargement.
3 o4 w/ D5 q$ J. t5 R! ~The genitourinary examination was remarkable for
. ?' ^1 ]9 N4 `7 W3 U6 qenlargement of the penis, with a stretched length of; D' z, B. }3 S
8 cm and a width of 2 cm. The glans penis was very well
2 e5 r V/ ?# i+ [' R I/ s3 ]- bdeveloped. The pubic hair was Tanner II, mostly around
+ Y- m9 F* @, A4 h- {2 z( B- [3 U540, \5 l B$ ]0 z( P- t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 `' R/ v- F0 Kthe base of the phallus and was dark and curled. The
8 Y L$ I4 H7 x, Stesticular volume was prepubertal at 2 mL each.; s3 H, ], j3 e
The skin was moist and smooth and somewhat, {% V, w( R* ~# H& L" Z
oily. No axillary hair was noted. There were no
5 f8 G9 t- n ^7 M$ L( h% Yabnormal skin pigmentations or café-au-lait spots.
% ]" O9 Q, v; o2 ?: p3 w, ?, U$ h" |Neurologic evaluation showed deep tendon reflex 2+
5 _* D! O# y7 k2 p: F4 E+ i" nbilateral and symmetrical. There was no suggestion
( B9 u: T$ ]/ _& B2 O7 l( W, N% L0 Hof papilledema.& |8 ]8 y2 n; o& F" f
Laboratory Evaluation
, k* |! A& ]1 f8 `/ E' ^" JThe bone age was consistent with 28 months by( K6 j5 b5 A% v, [
using the standard of Greulich and Pyle at a chrono-" @% r+ C+ O* j$ ?- j9 J6 F- F
logic age of 16 months (advanced).5 Chromosomal! U0 u$ V* [; h0 P6 n) v5 g4 C
karyotype was 46XY. The thyroid function test' ]- g. e/ X2 v+ t" `0 j& S4 j% F
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 L0 ~. n) J7 t0 J1 I" Y6 b: S3 Jlating hormone level was 1.3 µIU/mL (both normal).( F* L; r! s' _' j
The concentrations of serum electrolytes, blood
5 M- V9 L2 c# L# r( i z4 ~$ yurea nitrogen, creatinine, and calcium all were
8 t% B2 E% F6 }$ z: o/ Pwithin normal range for his age. The concentration, Y5 _3 ]0 F& P/ l- U, e
of serum 17-hydroxyprogesterone was 16 ng/dL$ X5 Z1 P) P! \9 P3 ^$ w' ~( S
(normal, 3 to 90 ng/dL), androstenedione was 20
4 V2 s+ s0 _" _7 T- ] O# _) R, vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" U0 q1 o6 L3 u u5 \* S+ O$ rterone was 38 ng/dL (normal, 50 to 760 ng/dL),0 [% ~( d8 D7 w- ^; s( H3 _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! j( m/ ?1 I3 ^& Y- W8 t- o49ng/dL), 11-desoxycortisol (specific compound S)8 `3 I8 P& e9 ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! Z" j6 c" k7 M# |7 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 V' |! G+ ^# Q2 a8 Z' {3 Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, e: j$ p' n# Uand β-human chorionic gonadotropin was less than: {( x ^% M1 O; j
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 o/ F0 L$ u! @0 o/ ~) P5 astimulating hormone and leuteinizing hormone
4 r$ Z( D: m) p6 }- Q! hconcentrations were less than 0.05 mIU/mL, f5 Q0 B- d8 F' d6 T
(prepubertal).
1 H- I8 P1 T9 C# i: HThe parents were notified about the laboratory4 [7 S/ A7 ` O" |$ v; Y# w. L. H
results and were informed that all of the tests were
. y1 F, l, a0 z: @0 W" t) hnormal except the testosterone level was high. The0 o- u& O' s$ B0 g: L2 Z+ r# I: `% A
follow-up visit was arranged within a few weeks to1 z3 ~! [: E( f1 K
obtain testicular and abdominal sonograms; how-0 S& N0 Q9 h6 t
ever, the family did not return for 4 months., C1 S3 ~) h9 i( r$ [- T
Physical examination at this time revealed that the
, j3 f1 H5 Q/ \# schild had grown 2.5 cm in 4 months and had gained
! Q# ?8 p: ^" ]& r2 kg of weight. Physical examination remained0 {4 m3 t& i. P7 J1 S
unchanged. Surprisingly, the pubic hair almost com-8 M8 P+ M5 Y: v2 ^" G* x! u6 S# a
pletely disappeared except for a few vellous hairs at$ x5 I1 D0 ?/ a( H& N8 l! V
the base of the phallus. Testicular volume was still 2
% R8 n5 P' ^9 F* g. s, T+ c q# i& JmL, and the size of the penis remained unchanged.
# u) E! ~" I# Y9 ^2 N/ h! i9 `The mother also said that the boy was no longer hav-: Z1 Q/ B: S9 f2 c* q; Q! L
ing frequent erections.
( v! R& T. G, G( m3 MBoth parents were again questioned about use of
1 ]& n6 b7 e) c3 [- R* fany ointment/creams that they may have applied to7 O: m# e4 `! L9 m; Y- F3 U$ s
the child’s skin. This time the father admitted the4 n: I; S% w$ s T( Z& N$ M& Y
Topical Testosterone Exposure / Bhowmick et al 541: U$ K, F* O- R2 ?4 {$ m6 [1 J! @
use of testosterone gel twice daily that he was apply-: j: H9 O' L! \3 ?
ing over his own shoulders, chest, and back area for
" u& ?8 C, K# _0 \% p: va year. The father also revealed he was embarrassed9 A' D* K; d" P
to disclose that he was using a testosterone gel pre-
# Q" Q8 o; t* e! G6 Cscribed by his family physician for decreased libido! P6 c# H+ ?6 {# E% O B
secondary to depression.
+ Y9 e% Q& q7 w5 y. _The child slept in the same bed with parents.9 H, S" H# K' e
The father would hug the baby and hold him on his; d4 |3 K- e: M _% @3 J
chest for a considerable period of time, causing sig-. p, i" [. }6 b& g' p. g# }! G5 N
nificant bare skin contact between baby and father.2 B" _& f9 ~' h
The father also admitted that after the phone call,
! j- |" v* A' V2 Z9 E# Y/ r1 vwhen he learned the testosterone level in the baby" T, x6 l' o/ }5 `
was high, he then read the product information
) @9 }" ~9 N" n8 @packet and concluded that it was most likely the rea-
+ J# n0 A7 `; |. f; S, wson for the child’s virilization. At that time, they1 c, E/ S1 g4 w6 T. D: r1 d
decided to put the baby in a separate bed, and the$ q" _/ C5 e% l9 a; |
father was not hugging him with bare skin and had
; }( [* \% X- T- O ` gbeen using protective clothing. A repeat testosterone
& ^$ l- {7 O# m- O X6 w+ Ttest was ordered, but the family did not go to the/ J$ ~8 d! W, ]
laboratory to obtain the test.# L, K4 v. d/ ]3 ]+ U
Discussion
+ E4 G& ^2 g. T7 t3 M) hPrecocious puberty in boys is defined as secondary$ T9 A" Y, I- j; w! _* O7 o
sexual development before 9 years of age.1,4
i3 u9 E5 { u6 Z9 r" k7 jPrecocious puberty is termed as central (true) when2 w$ L0 O. ]* R, P( E$ M
it is caused by the premature activation of hypo-
9 s G* G0 {: k: k& U: b3 othalamic pituitary gonadal axis. CPP is more com-
5 e+ K3 O' C2 f) e& _, i4 hmon in girls than in boys.1,3 Most boys with CPP
1 P- E0 m% ]* Z5 |. B4 B8 @( Mmay have a central nervous system lesion that is
+ W: t+ U& g' ?/ J& B1 nresponsible for the early activation of the hypothal-
* A; ]! T! l; qamic pituitary gonadal axis.1-3 Thus, greater empha-
, ?( S% S" H- r1 y( M8 K- {sis has been given to neuroradiologic imaging in" g1 I, t3 r( H* l* C" X2 H; j; \; w7 O
boys with precocious puberty. In addition to viril-
' J, |% P* X6 v0 v4 B4 \ization, the clinical hallmark of CPP is the symmet-
$ Q0 \% H) x; orical testicular growth secondary to stimulation by0 ^' e- P: i! F! @7 o% S
gonadotropins.1,3
) ?2 s0 e9 @. Y# A9 B) S. eGonadotropin-independent peripheral preco-
5 e, B* }0 o U5 a5 o5 s0 z/ `cious puberty in boys also results from inappropriate
4 O6 ^9 F: h' m; fandrogenic stimulation from either endogenous or3 |% D$ g9 N' {: ^5 Y
exogenous sources, nonpituitary gonadotropin stim-
- P9 o( a: C2 H+ P9 |ulation, and rare activating mutations.3 Virilizing6 j. l1 J; l3 @3 p% n
congenital adrenal hyperplasia producing excessive
/ x$ y' H8 L! G' T2 [adrenal androgens is a common cause of precocious+ N6 a% f* ~' Y7 k8 A( v$ Z
puberty in boys.3,4+ w/ c8 }& y2 w! a
The most common form of congenital adrenal
- V% w3 g: I$ e" dhyperplasia is the 21-hydroxylase enzyme deficiency.# }1 I; w' a/ X1 l( ?: i
The 11-β hydroxylase deficiency may also result in
2 U! B2 E6 }! Y& F5 Zexcessive adrenal androgen production, and rarely,: i6 h4 a4 f: o3 K( n9 f
an adrenal tumor may also cause adrenal androgen
E* F2 A; d% E! q2 Cexcess.1,3+ D) U9 g! Q% H! J& B x5 V9 f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" E# U8 G4 y5 g" o/ r542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( U3 l' P! ^/ H: T0 L8 V! s; _. r
A unique entity of male-limited gonadotropin-
; w3 S+ {1 U2 ~1 y# a, B6 hindependent precocious puberty, which is also known
9 f+ h& g) [* h' I# aas testotoxicosis, may cause precocious puberty at a
8 B, L; K- {- K/ T2 J1 jvery young age. The physical findings in these boys9 H0 S7 U2 ^8 q5 E" t
with this disorder are full pubertal development,
: e; a3 k, q- x* C& M, e3 Iincluding bilateral testicular growth, similar to boys2 r/ C- h0 {9 s: l; d1 I$ U
with CPP. The gonadotropin levels in this disorder
: K8 z/ c9 a2 }% Eare suppressed to prepubertal levels and do not show9 I2 a% K7 L8 t4 t5 ^
pubertal response of gonadotropin after gonadotropin-: a8 X2 O! x, B7 x# Z" i
releasing hormone stimulation. This is a sex-linked/ N$ I3 N% o- x
autosomal dominant disorder that affects only4 j; u% C8 Q! F! \ k' ^( N
males; therefore, other male members of the family! R" a/ ^3 ?. d6 g, r
may have similar precocious puberty.3, h9 Y- ]6 y; }
In our patient, physical examination was incon-
4 t v' x& `3 n6 Y# Fsistent with true precocious puberty since his testi-
+ C6 l; G/ T; t+ S8 ^cles were prepubertal in size. However, testotoxicosis
. W8 b) i$ n# B3 R" f8 nwas in the differential diagnosis because his father
* e! i/ G8 O: ]& V+ Ustarted puberty somewhat early, and occasionally,( u. z4 Q. w2 G8 M5 R* h
testicular enlargement is not that evident in the
' g' m. t% @8 E" dbeginning of this process.1 In the absence of a neg-
; F+ q3 u2 l) A, eative initial history of androgen exposure, our. O9 Q7 @' {' F, A; W7 ^& J
biggest concern was virilizing adrenal hyperplasia,
0 P9 U8 l& H: y6 e, @, T+ leither 21-hydroxylase deficiency or 11-β hydroxylase6 F% H7 m. u+ y: L
deficiency. Those diagnoses were excluded by find-% s: \0 G# {& H( B; o B
ing the normal level of adrenal steroids.+ ]8 O/ A& w2 X9 Q" ]
The diagnosis of exogenous androgens was strongly
6 T1 B+ U8 l6 H$ A: Asuspected in a follow-up visit after 4 months because) _, w" O) Z( U5 k
the physical examination revealed the complete disap-
4 M4 v+ y. u3 w" [( B- Fpearance of pubic hair, normal growth velocity, and
, h$ d& `7 K! e" m' bdecreased erections. The father admitted using a testos-
0 l2 w7 P) B* ^# {& S( Kterone gel, which he concealed at first visit. He was) o$ T, Q+ m! x
using it rather frequently, twice a day. The Physicians’" z+ \# O! }( J! X$ P# V7 M. \! Z
Desk Reference, or package insert of this product, gel or( P& ~/ i& ~0 C) Q$ c
cream, cautions about dermal testosterone transfer to3 D' S; c9 Z6 l1 l) u! \+ y- |! C
unprotected females through direct skin exposure." p3 V; R( F6 Q& d; d
Serum testosterone level was found to be 2 times the" g% G7 D6 S! J% k8 W9 s$ w; E
baseline value in those females who were exposed to( O+ C1 i- C$ M. K% c& k2 @
even 15 minutes of direct skin contact with their male+ X4 P) u7 T* K3 j& }$ H
partners.6 However, when a shirt covered the applica-/ j! e4 S" m) ?& T! m1 \
tion site, this testosterone transfer was prevented.
6 `# J" C' H5 r& c; ?- G- h+ FOur patient’s testosterone level was 60 ng/mL,- E- q# {- i* B
which was clearly high. Some studies suggest that
" }) t) I$ @! [9 n9 {4 y" Vdermal conversion of testosterone to dihydrotestos-
2 C0 d8 ^# _" @2 S7 N& s Kterone, which is a more potent metabolite, is more
7 |% E% X# I5 C$ Dactive in young children exposed to testosterone
3 p/ p: n1 I, y8 J! `$ @4 \exogenously7; however, we did not measure a dihy-6 b/ ^5 f. e q9 y7 J
drotestosterone level in our patient. In addition to
: ]! q0 i9 ], @, C6 t* Nvirilization, exposure to exogenous testosterone in- v* n3 y$ H( r; B" F" d; J
children results in an increase in growth velocity and
* {- l" h! M( I- [! U& M! {/ hadvanced bone age, as seen in our patient.. k9 N. O+ I7 e) N- r# m
The long-term effect of androgen exposure during6 J1 l8 U' y$ V: p1 [, T
early childhood on pubertal development and final; X' e9 Z& o8 L9 m5 ^* e
adult height are not fully known and always remain) E2 P1 _# U% b7 U
a concern. Children treated with short-term testos-
4 c$ T" v; u, a/ C3 aterone injection or topical androgen may exhibit some
, |2 U, P4 i3 M/ H0 Yacceleration of the skeletal maturation; however, after
8 r/ x0 r2 @6 p; j& {$ {1 D( E/ w7 Dcessation of treatment, the rate of bone maturation, O) y& i m9 Y9 c5 `% E' i, T% ?! l
decelerates and gradually returns to normal.8,98 H. o$ ?( y- I& Q+ u7 d( n; x
There are conflicting reports and controversy* T7 @6 h+ Q3 q. W K! H9 m
over the effect of early androgen exposure on adult" Z$ k" M3 b& F( a
penile length.10,11 Some reports suggest subnormal
& E9 Y4 w* g$ [: G% o& _- b) I: Jadult penile length, apparently because of downreg-
( o6 V1 I5 Q( rulation of androgen receptor number.10,12 However," A& [& b/ h3 k
Sutherland et al13 did not find a correlation between
8 `; L% ?' h8 Uchildhood testosterone exposure and reduced adult
+ u7 ~' b% b( Jpenile length in clinical studies.
" D$ E+ M9 Q3 J# t: M Y+ ^Nonetheless, we do not believe our patient is3 Y/ } j9 X% r! W% y
going to experience any of the untoward effects from. s6 s0 H# [3 B* N2 I8 [! Y
testosterone exposure as mentioned earlier because' r8 S1 K9 _; H, S
the exposure was not for a prolonged period of time.
6 y$ e- Q$ p9 _ e8 e, u v$ J3 VAlthough the bone age was advanced at the time of
G/ x$ V. b. O, o" O" adiagnosis, the child had a normal growth velocity at
5 ^% `. Q) B" z7 F# `4 ^- L: Hthe follow-up visit. It is hoped that his final adult
. I3 s5 V. F" h! {. F' Yheight will not be affected.; j. ]2 Z: w5 Z# L6 c6 N9 V
Although rarely reported, the widespread avail-
* o- i9 y5 M, I" U6 `; Mability of androgen products in our society may3 r) u0 E7 E! k0 J+ m. G/ p- h
indeed cause more virilization in male or female
1 J. ~7 o7 h0 v# u9 W2 B" kchildren than one would realize. Exposure to andro-) P; T7 f; b1 m, |7 J2 [9 Q
gen products must be considered and specific ques-
. L& h! C7 m9 V5 z; _ etioning about the use of a testosterone product or
I# j/ x0 `/ `: P1 _8 s: r7 Ygel should be asked of the family members during
5 r* h. @' o; \+ P' V5 \2 bthe evaluation of any children who present with vir-
' S! O5 A) ~1 oilization or peripheral precocious puberty. The diag-
. u7 W6 l+ r0 j$ ?nosis can be established by just a few tests and by
' F& a7 R5 }: R h% pappropriate history. The inability to obtain such a
* g: g1 H V! U+ l8 e% }history, or failure to ask the specific questions, may6 R- Y! X& Y% j! {* J& H
result in extensive, unnecessary, and expensive7 I4 x$ P: m; {, C! L8 p6 O
investigation. The primary care physician should be& v' x- H/ I* I U9 {
aware of this fact, because most of these children
3 t: I- i4 c3 p( s0 l) v' W* j; Dmay initially present in their practice. The Physicians’
7 H* r3 s+ y( TDesk Reference and package insert should also put a
" D8 m% s3 V' c- Y- h; w4 d& y1 K1 Ywarning about the virilizing effect on a male or
3 n8 l8 ]$ }) s& Mfemale child who might come in contact with some-# l) g, F; ^( V( m Z! M* F5 S
one using any of these products.
( |* P3 Y& F+ F2 ~% ?) HReferences8 `4 W6 R0 W; D) ~3 w2 v; H$ Y' \
1. Styne DM. The testes: disorder of sexual differentiation
" {" B4 j( m1 x- s+ mand puberty in the male. In: Sperling MA, ed. Pediatric
9 ^: R- b6 {! k2 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 J7 `% C7 u2 h5 Y$ c( H% q2002: 565-628.
3 U7 C0 t; O' p L) K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( G z. `! y/ C/ ^% u* A7 @
puberty in children with tumours of the suprasellar pineal |
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