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Sexual Precocity in a 16-Month-Old, f, v% x, Q( z7 v' k2 D5 p' d8 e0 O
Boy Induced by Indirect Topical) n5 c* t0 u6 r
Exposure to Testosterone- K6 ^( L" {0 c$ v" R5 Q$ ^9 q% E6 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 R5 q) p" v7 F* x$ i
and Kenneth R. Rettig, MD1) B; v, ~9 G* h! t6 H5 x/ N
Clinical Pediatrics1 Q# Z. G" G5 ~1 N% ]# e5 z8 h, ]
Volume 46 Number 6
/ F6 N# f* z2 L! W+ FJuly 2007 540-543! I; x6 H6 c, L2 e0 H
© 2007 Sage Publications
# P" P& k% r3 r0 ^10.1177/0009922806296651
. @' l( U$ r, [/ v$ ^http://clp.sagepub.com
, A6 } L2 A4 R( ]8 p, O, r3 a& y1 jhosted at
R( u) H0 C0 V q( G/ ahttp://online.sagepub.com6 k! W' k8 x- \& z# i& w8 V
Precocious puberty in boys, central or peripheral,3 i B- z9 T) I: p
is a significant concern for physicians. Central7 i2 a1 S2 W x5 l
precocious puberty (CPP), which is mediated
6 W) k5 X2 Z/ w! {3 N/ L% o% Hthrough the hypothalamic pituitary gonadal axis, has
$ A6 u" r9 _1 E" y" v8 t" d4 Ja higher incidence of organic central nervous system' V. l0 K+ w9 j' N1 c
lesions in boys.1,2 Virilization in boys, as manifested, x+ a* y0 {; l% X( V) D
by enlargement of the penis, development of pubic# f/ V2 z# N8 q) d' @, `
hair, and facial acne without enlargement of testi-
$ j7 o5 q) T% g3 i$ \3 E3 n; Y @cles, suggests peripheral or pseudopuberty.1-3 We$ F& F0 P1 }* o$ j
report a 16-month-old boy who presented with the
7 w3 u V- t. r8 e- Yenlargement of the phallus and pubic hair develop-
- ]: M+ e1 j, I' Gment without testicular enlargement, which was due! f: Z0 z& ]* Z; F" {/ r
to the unintentional exposure to androgen gel used by
1 E7 u# \$ g1 j) ~' q4 Bthe father. The family initially concealed this infor-( g* b, J1 S$ J. L
mation, resulting in an extensive work-up for this
4 R$ ~- c/ w" [3 @' M: l) Achild. Given the widespread and easy availability of' z5 L X5 z5 [
testosterone gel and cream, we believe this is proba-% t ^4 Q k3 a: o% n
bly more common than the rare case report in the2 ~7 ^2 }+ n ?; X. b8 L
literature.4- P( H; ~% o6 P! y
Patient Report4 `# N' _: m: b$ ]
A 16-month-old white child was referred to the. V- M) D( W* \
endocrine clinic by his pediatrician with the concern
o- `" i; J. aof early sexual development. His mother noticed7 u# w! o( ?6 k. `2 f( w
light colored pubic hair development when he was
/ o3 A2 K9 D3 u/ {! j" c! |8 XFrom the 1Division of Pediatric Endocrinology, 2University of
2 s3 l5 L0 B! e+ HSouth Alabama Medical Center, Mobile, Alabama.
$ _6 V$ v, `; G7 E' Y$ c$ |" cAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, \8 K9 y) h y1 cProfessor of Pediatrics, University of South Alabama, College of- Y9 v2 C: r% _) Y$ F4 E N' n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 ?8 N% [0 q( R8 ?8 y* K* P
e-mail: [email protected].
7 O8 ^6 f! d8 G v: ?9 Uabout 6 to 7 months old, which progressively became1 ?1 L+ n6 s) l$ z" ]
darker. She was also concerned about the enlarge-
& H8 m& u5 i% l) |6 P2 y: {ment of his penis and frequent erections. The child
: h* ^; V; V1 C6 J% C; K4 V, kwas the product of a full-term normal delivery, with* v3 C. G' R% L6 G& U
a birth weight of 7 lb 14 oz, and birth length of
+ S' X! b; T$ x$ O20 inches. He was breast-fed throughout the first year( N8 {* i$ l0 b7 w5 O
of life and was still receiving breast milk along with
& m! z# m: ~* k) F, Qsolid food. He had no hospitalizations or surgery,
# ^4 p( `2 J! |3 p0 \8 I' v. `% n3 wand his psychosocial and psychomotor development4 p. p6 O* _8 N' E! a" @" B
was age appropriate.; a9 ]4 b' Z% ^- {8 U3 t
The family history was remarkable for the father,* I' Y! x1 K8 W! @' F
who was diagnosed with hypothyroidism at age 16,
. y) x: y/ s* M% g# r4 [1 _% C4 Twhich was treated with thyroxine. The father’s# G) }6 e8 [0 ]3 [
height was 6 feet, and he went through a somewhat7 }" U3 [/ g2 w3 T2 U- m" I
early puberty and had stopped growing by age 14.
' r& Y$ j) b7 H7 ^+ D. q2 `* {3 nThe father denied taking any other medication. The
! B* K* i9 u" t# f9 O3 Achild’s mother was in good health. Her menarche: X3 a$ W7 Y" e( v% m
was at 11 years of age, and her height was at 5 feet/ l7 S" L2 n2 ?6 V
5 inches. There was no other family history of pre-. j+ r+ N1 R$ v& h# }! A' U
cocious sexual development in the first-degree rela-
0 F- B3 ?' w) [tives. There were no siblings. \+ P. c ~) [) P$ d l
Physical Examination! a6 [4 Z+ O7 F9 S" d: ?9 b
The physical examination revealed a very active,
/ ]( {" n. ~$ y1 S1 b, l) Zplayful, and healthy boy. The vital signs documented- z( h' G! _9 n$ ~! O
a blood pressure of 85/50 mm Hg, his length was
( m5 D. s& B' R% @90 cm (>97th percentile), and his weight was 14.4 kg
; G+ |$ a7 v; c(also >97th percentile). The observed yearly growth
( H( Z) }8 C3 ?0 {6 avelocity was 30 cm (12 inches). The examination of2 S- o: Z4 S% ]* B; M$ e
the neck revealed no thyroid enlargement.+ }' H$ h# B" a
The genitourinary examination was remarkable for* ]; U4 x! n% o$ @/ H0 E
enlargement of the penis, with a stretched length of j, E+ r8 Z; w: r9 a _6 ^0 t. {
8 cm and a width of 2 cm. The glans penis was very well% ?- v/ U# S: u& \
developed. The pubic hair was Tanner II, mostly around9 b1 E# s- u, a5 {
540
8 D# k% L2 m9 l( Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 B# }: U" v' X
the base of the phallus and was dark and curled. The
6 \" q$ ?# x7 Z4 |3 D' ]testicular volume was prepubertal at 2 mL each.% }+ K. C! f& B' e" C% L* c
The skin was moist and smooth and somewhat4 A3 X; i4 P' S# a
oily. No axillary hair was noted. There were no6 M) G8 J8 _6 c+ C- P
abnormal skin pigmentations or café-au-lait spots.7 s1 l+ C- W3 Z3 X- a j
Neurologic evaluation showed deep tendon reflex 2+# p5 @6 G% O! q( K3 X- l
bilateral and symmetrical. There was no suggestion- c' E5 t" ~5 a6 t+ P
of papilledema." D. L# b+ P% D) c
Laboratory Evaluation; r B; |; ?7 p# m" |. D
The bone age was consistent with 28 months by
7 c( A. j5 {6 O4 pusing the standard of Greulich and Pyle at a chrono-% o& x5 p3 j4 r" k6 @
logic age of 16 months (advanced).5 Chromosomal6 F1 o. n/ o/ U' @/ p8 B
karyotype was 46XY. The thyroid function test
& g) o0 V" R \$ U# zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: A& z2 L6 _+ k6 L. D, `lating hormone level was 1.3 µIU/mL (both normal).
2 V Y. e+ G( @5 Q! ZThe concentrations of serum electrolytes, blood; j$ A4 A. b. u# `7 D: D x
urea nitrogen, creatinine, and calcium all were
1 {' J- \$ Y8 `) A" x8 C. Fwithin normal range for his age. The concentration) k* }2 i$ s( P- t: u1 n+ I4 g9 a
of serum 17-hydroxyprogesterone was 16 ng/dL% g* u( t0 c# H2 [. G
(normal, 3 to 90 ng/dL), androstenedione was 20- s/ F: A6 p( p3 p4 o( Z# Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% e- H* M7 ?7 t4 L
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 n! Y/ ~- r+ F! Z5 B9 u1 Rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ e; P( q5 o0 W& O b" A# ]49ng/dL), 11-desoxycortisol (specific compound S)
! W& l8 w# k3 A- ]was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& n$ }/ x3 s! ]. {- |2 f) y0 qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 c, M1 L/ `7 ~* K7 W+ dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
L! S6 u, u( I" W/ {! V$ cand β-human chorionic gonadotropin was less than
" ~: |. Z. [8 k0 W5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 M, b' A4 N& H8 w) Ostimulating hormone and leuteinizing hormone7 n( E) r* Y. o* R1 N
concentrations were less than 0.05 mIU/mL
2 f3 x' ?6 y/ V' u4 Y# ]$ t(prepubertal).% p1 C7 R1 I _" n8 p1 F
The parents were notified about the laboratory" c1 _ J$ I" v$ i& y
results and were informed that all of the tests were
9 C; j5 V# y& U* A4 n: X! p6 ]* T7 `+ Znormal except the testosterone level was high. The6 g2 y6 r3 w; w! T0 R8 L- t# h
follow-up visit was arranged within a few weeks to) B" Q; A ]: A" {3 f+ |0 @! _
obtain testicular and abdominal sonograms; how-
7 y+ {+ K8 P, f2 V- ?ever, the family did not return for 4 months.
6 R; }# R' P% d: zPhysical examination at this time revealed that the8 \) t+ t8 N0 X
child had grown 2.5 cm in 4 months and had gained) n) t% Q7 V% X. _
2 kg of weight. Physical examination remained& l6 T1 U) a- X* g. k* x4 O
unchanged. Surprisingly, the pubic hair almost com-
% N9 N ^, \5 epletely disappeared except for a few vellous hairs at
r9 ?7 p6 k1 f# w2 z* T7 o% Xthe base of the phallus. Testicular volume was still 25 }3 ^1 [& t! r
mL, and the size of the penis remained unchanged.. f- B8 F' g6 M4 {, e1 J( X
The mother also said that the boy was no longer hav-/ g# g' z6 l" h. h9 l3 F2 k
ing frequent erections.- L! m3 P9 J% i; @8 }+ r1 g& T
Both parents were again questioned about use of
6 w. y9 `; T9 U7 {any ointment/creams that they may have applied to
/ G4 h* a- l; g& Z. L3 T1 g% nthe child’s skin. This time the father admitted the* V e2 f, p& y3 ]
Topical Testosterone Exposure / Bhowmick et al 541+ `* b5 ? |+ `0 S
use of testosterone gel twice daily that he was apply-' d( |% S6 o; j1 j
ing over his own shoulders, chest, and back area for
( u% a% L6 A' x0 Y8 ~a year. The father also revealed he was embarrassed
# N3 t" J3 Q' ?. g- P; `to disclose that he was using a testosterone gel pre-
+ ?. I6 L! g# {+ v4 @scribed by his family physician for decreased libido0 F4 `, I% }/ z4 G" N' \1 h
secondary to depression.9 J7 b/ c. M5 T6 O1 n0 H
The child slept in the same bed with parents.
, m( j, B- c0 _- X! M: ^ X" c- O: W. yThe father would hug the baby and hold him on his
/ ^! K* U& y; k# G9 Vchest for a considerable period of time, causing sig-/ q3 E& Q2 O- N I, i6 U
nificant bare skin contact between baby and father.
: |0 n. h" E, ^: Q& O0 L$ @The father also admitted that after the phone call,
9 U/ b' O6 B/ f6 Lwhen he learned the testosterone level in the baby9 H5 k( U4 J4 j
was high, he then read the product information
% A" W0 r+ d$ s, @packet and concluded that it was most likely the rea-
+ |# u2 D/ C$ O- ?$ Y: k* U! Y# Mson for the child’s virilization. At that time, they g9 V. z( l0 k$ n# g" X4 ?0 W- M7 ^
decided to put the baby in a separate bed, and the9 `. Z( c& n2 J4 y5 }
father was not hugging him with bare skin and had* i+ d5 d" L9 @9 C+ I8 n8 x% l$ k
been using protective clothing. A repeat testosterone
4 \: A7 ~/ f) N$ {8 V# Y4 ~test was ordered, but the family did not go to the
, {' V3 ?& U% ^% Rlaboratory to obtain the test.. G G ]6 e& c# P' Y3 ]- i6 I
Discussion
/ Z, V- E- K3 z% B APrecocious puberty in boys is defined as secondary$ u9 h; V5 z% ?& M- Y% R
sexual development before 9 years of age.1,43 ]- ~, i) o6 G# K! Z1 P7 h [
Precocious puberty is termed as central (true) when+ |" ~: q) U/ r6 Z" v! e
it is caused by the premature activation of hypo-, Y, k5 b$ }3 S$ @) H
thalamic pituitary gonadal axis. CPP is more com-
5 N8 O9 a( Q; m, c3 n2 q, f, Rmon in girls than in boys.1,3 Most boys with CPP
/ k, M: @0 t* J) y, d$ Rmay have a central nervous system lesion that is
) ]* E6 ]5 Y9 w" Sresponsible for the early activation of the hypothal-' L) C( p! @1 N
amic pituitary gonadal axis.1-3 Thus, greater empha-; E+ o m! p" ~* v0 Y1 M" L7 E
sis has been given to neuroradiologic imaging in/ ^7 _7 i# B; e4 f1 ]
boys with precocious puberty. In addition to viril-/ R, ^9 W# d/ |, n9 q1 `7 O+ `
ization, the clinical hallmark of CPP is the symmet-
2 V& ~, U0 y, R, y2 j9 \rical testicular growth secondary to stimulation by* U% l; X- {& `4 B8 y" j# y% C! c
gonadotropins.1,3
% Q6 a! h; K }; V% R4 XGonadotropin-independent peripheral preco-
* K" V8 v9 q- s4 x* d% J5 s; Jcious puberty in boys also results from inappropriate8 u6 i' m3 B% P5 K
androgenic stimulation from either endogenous or
3 z2 B9 C" L& r/ Y2 u4 r5 L5 rexogenous sources, nonpituitary gonadotropin stim-
: H* [( M- h0 [9 p' culation, and rare activating mutations.3 Virilizing9 N" C: \! s) X+ C0 Z
congenital adrenal hyperplasia producing excessive
$ y! b) {* _, y" T$ Tadrenal androgens is a common cause of precocious
0 h( @ k8 g/ d9 B# Q1 Wpuberty in boys.3,49 C$ i$ R; G# A6 L' G, T: F7 R
The most common form of congenital adrenal% F, h5 _' Z( X: z' k
hyperplasia is the 21-hydroxylase enzyme deficiency.# x- X3 R9 ?6 z
The 11-β hydroxylase deficiency may also result in
2 K7 Q& {& i6 o+ kexcessive adrenal androgen production, and rarely,2 U8 s' y: G$ X- T" ?9 R1 E6 x* e
an adrenal tumor may also cause adrenal androgen$ V, Q8 h' G1 Q0 J
excess.1,3
- [/ c" v8 ~* ]+ b1 ?* ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& d* A# X7 Z: z& W1 R542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 y7 m7 q0 N/ X
A unique entity of male-limited gonadotropin-+ G' l) W) o$ }9 G' z' y0 S+ s# D
independent precocious puberty, which is also known, j9 p3 `# B9 M9 i& u9 W$ p
as testotoxicosis, may cause precocious puberty at a
/ T5 i6 E) w7 @. [% j' f- `! Fvery young age. The physical findings in these boys
q0 J2 q4 ~( ~% Jwith this disorder are full pubertal development,
@0 K* d% I# D- nincluding bilateral testicular growth, similar to boys6 v7 S% W- B/ O
with CPP. The gonadotropin levels in this disorder: o0 j: H+ s6 Z7 u: }$ L3 O
are suppressed to prepubertal levels and do not show
; d5 W/ j$ f# |& Q- L4 jpubertal response of gonadotropin after gonadotropin-5 q* o' c! @8 Y" i6 R& A5 [
releasing hormone stimulation. This is a sex-linked( U! N- z7 ^$ \) t2 o" O
autosomal dominant disorder that affects only+ w3 [: B2 A9 W9 a9 t" @: v
males; therefore, other male members of the family
! w- h5 E8 f8 C# Y2 emay have similar precocious puberty.30 d6 P l* R8 n+ L
In our patient, physical examination was incon-
: V5 o8 q3 p9 ^8 [" Vsistent with true precocious puberty since his testi-# J9 ?5 `4 G* ?7 [1 B
cles were prepubertal in size. However, testotoxicosis+ D9 A% B9 S1 Q
was in the differential diagnosis because his father
3 {9 G# T% V" m& G# J. Cstarted puberty somewhat early, and occasionally,% z" m! e& l; W, ?4 | v
testicular enlargement is not that evident in the4 p1 l3 m' U% n& `/ ~
beginning of this process.1 In the absence of a neg-' e; D9 F p0 t ]; D6 Z; `
ative initial history of androgen exposure, our1 ]: S# A) B8 \- ^+ ]1 Q( V5 R* b
biggest concern was virilizing adrenal hyperplasia,: ^+ \: r+ `* \& v# d) x B& O
either 21-hydroxylase deficiency or 11-β hydroxylase
% c" U4 c2 a$ wdeficiency. Those diagnoses were excluded by find-
- ?/ K. w, O/ y6 {# G! ?ing the normal level of adrenal steroids." C* g& l1 v H: H9 ~! E
The diagnosis of exogenous androgens was strongly
0 \: Z) L5 w5 h( R7 }( vsuspected in a follow-up visit after 4 months because, }, P* j. q9 P- k
the physical examination revealed the complete disap-' `1 |$ x8 f/ I+ A# J
pearance of pubic hair, normal growth velocity, and( D3 W: r2 |* C; W9 b
decreased erections. The father admitted using a testos-
2 }: D. E5 x B# V+ ^ @terone gel, which he concealed at first visit. He was
, W6 l! V" F* C2 [7 vusing it rather frequently, twice a day. The Physicians’0 H1 C: ?1 L% U& z& o
Desk Reference, or package insert of this product, gel or
* s6 f& m. u6 k* p, }# l9 f& Jcream, cautions about dermal testosterone transfer to( u/ D6 u" E/ o& i( J
unprotected females through direct skin exposure.
, S0 A" V4 |: e/ [Serum testosterone level was found to be 2 times the
9 E: n- z/ v" t' `4 Nbaseline value in those females who were exposed to1 ]9 C, S5 M, r* ^( d/ x3 z" ]$ @
even 15 minutes of direct skin contact with their male/ M1 _6 f) F% h, ~* n& e4 C5 B/ |
partners.6 However, when a shirt covered the applica-
6 K- M! U+ J6 B5 \ f0 ?tion site, this testosterone transfer was prevented.
$ ^: P; Q$ _* l9 W# X" BOur patient’s testosterone level was 60 ng/mL,+ \+ `3 W! O( _9 Y9 @; y! d
which was clearly high. Some studies suggest that
/ [* S" e3 H; A! xdermal conversion of testosterone to dihydrotestos-' }/ i; x/ \6 [; u; T
terone, which is a more potent metabolite, is more
0 p* y3 e6 m# Jactive in young children exposed to testosterone
8 U# V' \* e- M& wexogenously7; however, we did not measure a dihy-
) Q+ U4 U- k% t4 `& i- Edrotestosterone level in our patient. In addition to. R! {. e' E" d- u
virilization, exposure to exogenous testosterone in1 @: P" t+ B) ?$ b) @' p8 s
children results in an increase in growth velocity and
8 h$ k! l# Q$ a4 Fadvanced bone age, as seen in our patient.
; o0 C# m3 n/ S- V$ z* k$ A0 {The long-term effect of androgen exposure during) n0 E5 _- X- N
early childhood on pubertal development and final% ^9 B" v* E. G! n F+ L9 ?7 y
adult height are not fully known and always remain
' d- O8 Z8 N. B4 p' q" Z3 S5 |* ma concern. Children treated with short-term testos-* k4 n! F9 l0 F* Z; d# e
terone injection or topical androgen may exhibit some% n+ q: J6 k0 p
acceleration of the skeletal maturation; however, after: [8 ^$ v" }2 j& M7 `/ J* r
cessation of treatment, the rate of bone maturation5 R5 P& h3 L/ Q2 X2 u. U+ b- f
decelerates and gradually returns to normal.8,9
8 \$ D. H) I7 x4 _7 p# V2 aThere are conflicting reports and controversy
9 V4 L+ L4 F+ v( l2 A- G/ H+ F- zover the effect of early androgen exposure on adult
5 N2 R1 p% \* c7 i1 `8 R& Jpenile length.10,11 Some reports suggest subnormal& R! d/ y0 p3 D9 c" _6 e3 O8 P
adult penile length, apparently because of downreg-
: \+ |) q4 Z$ n( F8 nulation of androgen receptor number.10,12 However,
; S$ H+ b& H9 }" R8 }% K+ JSutherland et al13 did not find a correlation between
7 i9 {0 H [. Q" i7 w; S. M% q# r& vchildhood testosterone exposure and reduced adult! r, `/ {: P$ C5 O
penile length in clinical studies.
8 D$ S7 T Q2 cNonetheless, we do not believe our patient is
( b9 X3 r6 j' R, c1 E9 y) O1 ]( Wgoing to experience any of the untoward effects from+ s+ b9 Z4 {( M6 x
testosterone exposure as mentioned earlier because
0 s. a4 k# n4 F3 n8 Xthe exposure was not for a prolonged period of time.
* I/ f! p% D" H& D8 q+ QAlthough the bone age was advanced at the time of: I; W' n) B: q: O$ y) R
diagnosis, the child had a normal growth velocity at$ \" l( ?. U \- C3 Z# b" V5 v) H
the follow-up visit. It is hoped that his final adult! e6 _5 R8 J& W- q/ V3 J7 X0 {+ m
height will not be affected.8 ^( S& A3 R- b$ V4 V5 m; ~+ \
Although rarely reported, the widespread avail-
+ t; B w& Z4 Kability of androgen products in our society may7 G) T& @" B1 N: u& a
indeed cause more virilization in male or female0 M1 q5 a8 e4 i( O
children than one would realize. Exposure to andro-
5 j+ f8 a9 I9 o# B( r4 fgen products must be considered and specific ques-1 o. r. R+ ^( q( w3 h- W
tioning about the use of a testosterone product or9 O0 M, b7 a) H' H! T9 B6 R$ j
gel should be asked of the family members during2 ~9 t: ~1 ~7 |. _9 O
the evaluation of any children who present with vir-
( C% m, i f$ k$ ~' f" Lilization or peripheral precocious puberty. The diag-
' I% y! p/ g* r' C- s3 s2 H9 `nosis can be established by just a few tests and by
% C# o/ L6 y2 R/ F' N# Oappropriate history. The inability to obtain such a' I$ j6 C8 s) s. _
history, or failure to ask the specific questions, may
7 P# o, L/ O; L/ M9 k' u8 k! lresult in extensive, unnecessary, and expensive
$ q5 F8 i( C2 B% y& Finvestigation. The primary care physician should be7 B1 p" |+ J+ [+ }* G
aware of this fact, because most of these children
5 U; R/ d- k1 {6 Vmay initially present in their practice. The Physicians’
; z& k- p- X8 i! ~& ]Desk Reference and package insert should also put a
$ k! R7 X g c, C7 Wwarning about the virilizing effect on a male or
5 d! M) B' f4 ~ z) V: v3 g& ?female child who might come in contact with some-
- h' g. a' R3 i* o# E0 w( H) |one using any of these products.
3 B# \$ G7 O: D9 VReferences* a0 @$ _& w2 y! h3 ], s
1. Styne DM. The testes: disorder of sexual differentiation3 q- v+ U# Q6 S
and puberty in the male. In: Sperling MA, ed. Pediatric
0 i7 M& f1 L1 c! lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% u1 A' y9 N J# A2 c4 w- P8 ~2002: 565-628.5 W! a/ `+ b& E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- s) c# G( Q2 Q/ ^! x* U9 L6 A ipuberty in children with tumours of the suprasellar pineal |
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