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Sexual Precocity in a 16-Month-Old
9 Z. _! c$ H/ S2 N1 A. E2 {2 N% N8 \Boy Induced by Indirect Topical
& m2 g: @( R' Q2 g0 k3 N' uExposure to Testosterone4 k+ m7 g7 D4 {4 {. d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 ?/ }8 o# ]$ J0 S, e0 k, gand Kenneth R. Rettig, MD14 C6 J7 V* K! f- C2 k+ p
Clinical Pediatrics
- b5 z. a/ }3 Z5 B% F" y0 gVolume 46 Number 6 e6 L1 K4 e2 x0 W, @) V% P
July 2007 540-543
: ] L7 i% U+ I, N Q: F& [8 d G4 V© 2007 Sage Publications+ o8 \+ e+ t+ Z, T: X
10.1177/0009922806296651: K7 \/ j' i5 ]
http://clp.sagepub.com! I: K! [! z. c( j& N, z9 N
hosted at) p6 x5 G& F' s, k
http://online.sagepub.com
( r f9 e) V0 k1 p E5 kPrecocious puberty in boys, central or peripheral,
. V! S' s) T, S% y: Kis a significant concern for physicians. Central, a9 x- U0 j ^9 s/ m$ \2 N
precocious puberty (CPP), which is mediated1 S* K7 X0 L7 `' n. B
through the hypothalamic pituitary gonadal axis, has
7 F/ C! {7 ?0 z7 o* z3 m) w! fa higher incidence of organic central nervous system
: |8 h$ l$ {0 q0 ]6 F7 U: Clesions in boys.1,2 Virilization in boys, as manifested W- _+ z8 T* H/ i0 f4 M
by enlargement of the penis, development of pubic
0 { w' w) y- m2 B) _2 `hair, and facial acne without enlargement of testi-, p( j) \& @. `( r% U
cles, suggests peripheral or pseudopuberty.1-3 We7 ~- ^1 U g/ \: a( |% a3 U( e' |
report a 16-month-old boy who presented with the0 y3 Q% D% Y0 O( C
enlargement of the phallus and pubic hair develop-; l' `$ u6 ^0 r2 F5 r8 }$ |) @, a# r
ment without testicular enlargement, which was due
: {, G- s/ S3 H# H T$ e& Ato the unintentional exposure to androgen gel used by5 J; C$ [+ u9 U% ^% Z
the father. The family initially concealed this infor-
; A- M: Q6 I" t- S3 e, _& Pmation, resulting in an extensive work-up for this
% ^8 I/ N# ]( ], p- a3 nchild. Given the widespread and easy availability of& h: O4 O+ u$ Z; V$ a) l% v' @! ]
testosterone gel and cream, we believe this is proba-
3 n% _4 h. x) B0 F! vbly more common than the rare case report in the
3 H( H. {& n. `+ C4 J o( Sliterature.4
: R1 G% K7 ?, N& oPatient Report
; f3 n3 L. M9 J1 R2 ~A 16-month-old white child was referred to the; w# @" l) H q( \" \3 l& s
endocrine clinic by his pediatrician with the concern1 _1 ^: B, \/ l4 z9 e4 u+ x# m
of early sexual development. His mother noticed
. d4 U K5 ^+ _/ wlight colored pubic hair development when he was
8 m1 y* K; ] z' E3 O* fFrom the 1Division of Pediatric Endocrinology, 2University of4 ]- r5 S; X3 T1 f8 h! ]9 M
South Alabama Medical Center, Mobile, Alabama.
4 N7 C. }7 T4 @5 _9 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ g" L& b! |; ~2 k. j
Professor of Pediatrics, University of South Alabama, College of
: x, u' R2 w; u6 U, JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( z9 b r2 o4 l+ k: |3 Q8 Xe-mail: [email protected].
A7 p1 D2 K; n: tabout 6 to 7 months old, which progressively became0 F& u% m" U/ e# E$ U1 X) N( w
darker. She was also concerned about the enlarge-
i7 v x3 T+ \8 A9 F2 S2 `7 O6 `ment of his penis and frequent erections. The child
4 ?( f. I: r' ywas the product of a full-term normal delivery, with
" |' G$ a% G. za birth weight of 7 lb 14 oz, and birth length of
/ L# T. r' d6 X6 r9 _9 d _7 ?6 I: Q20 inches. He was breast-fed throughout the first year
$ [* ^$ e+ ~: ^) E( G2 q. ^) t- kof life and was still receiving breast milk along with
/ U5 n( q' Z* H( F Qsolid food. He had no hospitalizations or surgery,
R& Q0 z# g6 J* H; }6 hand his psychosocial and psychomotor development
; ]8 }2 ]5 b# z/ iwas age appropriate.
, T; a+ D# T. v+ S% j# M: x- nThe family history was remarkable for the father,
{! L! T% N0 ~: awho was diagnosed with hypothyroidism at age 16,; B) O) ~2 g, n1 E2 r5 n* ?; b, c# k
which was treated with thyroxine. The father’s/ S; k& j9 W) Q. K! @
height was 6 feet, and he went through a somewhat
( K9 M- `. U! f2 J# P6 g1 s( n2 hearly puberty and had stopped growing by age 14.
* W% T: f0 B3 R2 R4 h( nThe father denied taking any other medication. The# {5 T! x$ Q$ e9 Q/ b S
child’s mother was in good health. Her menarche
8 N5 J5 L4 Y7 d& o3 D) W. B% D* _" Jwas at 11 years of age, and her height was at 5 feet
6 x( Y( @: y" l/ x4 X5 inches. There was no other family history of pre-
6 X- C" z# F7 y3 ^: O, b$ a6 \9 Mcocious sexual development in the first-degree rela-' ~8 J2 K- @2 d* _: X$ Y
tives. There were no siblings.2 x- q1 X4 ?; I) J4 L% j- x
Physical Examination
5 W( O0 a' A7 [9 O9 ?The physical examination revealed a very active,4 y! r8 r0 H# l3 E! Z
playful, and healthy boy. The vital signs documented& W3 O" _5 U' ], Y
a blood pressure of 85/50 mm Hg, his length was
' M6 k" E1 i0 s: a90 cm (>97th percentile), and his weight was 14.4 kg# N) M: K! Y* N& i9 e# G
(also >97th percentile). The observed yearly growth
( X6 _! j, r1 @1 ?velocity was 30 cm (12 inches). The examination of) E' e! O, S; j
the neck revealed no thyroid enlargement.; R2 J& F9 y0 b$ l- u# v
The genitourinary examination was remarkable for& }3 N/ B3 y4 f3 s4 Z, w
enlargement of the penis, with a stretched length of
- L7 w8 _3 V1 T& t8 cm and a width of 2 cm. The glans penis was very well! b C# j, g9 B9 b3 q1 ~
developed. The pubic hair was Tanner II, mostly around
, _6 l. b3 S0 N) A3 M& A540% C! e- P! u0 d8 p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 ^: f# k4 A4 i% M4 a6 l0 ^8 W
the base of the phallus and was dark and curled. The4 C. z# g3 m. G% m+ m2 q
testicular volume was prepubertal at 2 mL each.
2 \9 f0 `. i w) c( S: P8 yThe skin was moist and smooth and somewhat6 w$ k$ ~( [) Y
oily. No axillary hair was noted. There were no; b2 C9 p# K3 a: {" j
abnormal skin pigmentations or café-au-lait spots.
/ W& ^9 F g' _" eNeurologic evaluation showed deep tendon reflex 2+
2 w; E Q W. |4 Bbilateral and symmetrical. There was no suggestion
3 s6 o [3 L7 d( _: |5 ^of papilledema.; U% o0 E4 h1 P2 Y$ Y
Laboratory Evaluation
9 E! @. ]; R* W& N8 j( B& |1 MThe bone age was consistent with 28 months by
% _3 R1 |- V3 G% E; t2 Pusing the standard of Greulich and Pyle at a chrono-
9 l, a7 @" a/ h7 G3 G* Blogic age of 16 months (advanced).5 Chromosomal/ z3 t0 X( c% V3 { J$ c, `1 o
karyotype was 46XY. The thyroid function test
* J% N5 i/ H& e g# \1 N& {showed a free T4 of 1.69 ng/dL, and thyroid stimu-( ^" k0 F$ D" f& W
lating hormone level was 1.3 µIU/mL (both normal).$ ^- P) P' @" G0 T5 n# o. O
The concentrations of serum electrolytes, blood/ s& C6 G/ ~' m" f) T
urea nitrogen, creatinine, and calcium all were1 v8 ]3 C0 W% O# v% P
within normal range for his age. The concentration
- a! k+ V$ U% j" Pof serum 17-hydroxyprogesterone was 16 ng/dL
$ h" W" u1 l6 p(normal, 3 to 90 ng/dL), androstenedione was 20$ D% _$ {& L, I# s% B& T% H7 Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 N+ i2 E2 w& h3 A5 S# C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 p" ]6 [5 M/ V; f7 C6 T3 i7 b& C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. j& [' f1 L# x# R& O. y; r, n49ng/dL), 11-desoxycortisol (specific compound S)( e+ r- r/ R% J+ {* p. g4 u1 U* g+ u- N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 S( {2 G# q e; n3 Y9 E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total S2 N, S. I0 s8 |6 @# [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( Y, L6 [- M$ c- M
and β-human chorionic gonadotropin was less than
) W. ?) v0 n. h3 F3 M5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 ?3 N4 _# L+ L" o8 ^2 W: ^$ Ystimulating hormone and leuteinizing hormone
) d$ }0 f& ?# dconcentrations were less than 0.05 mIU/mL
0 Y$ |8 \8 {1 v& O(prepubertal)., \+ B" g) w' b/ k
The parents were notified about the laboratory
! e$ s, ^) `% Y) ^+ s' d8 @) Q$ S Aresults and were informed that all of the tests were
* [* w* ~% Y# A: e8 Inormal except the testosterone level was high. The, J, d2 H% Y/ i7 I7 O- j
follow-up visit was arranged within a few weeks to
: G% G2 K5 O; N- iobtain testicular and abdominal sonograms; how-
' D5 a! n0 @- }8 g/ Cever, the family did not return for 4 months.
% T. _" s+ s* b' N2 ^) \Physical examination at this time revealed that the
+ O" \, q- b4 B# j7 C7 Echild had grown 2.5 cm in 4 months and had gained
# y$ E& H" ?6 Q4 ~! V0 L2 kg of weight. Physical examination remained- }/ h: X$ h7 w0 @2 ]/ g; N' v
unchanged. Surprisingly, the pubic hair almost com-7 A3 ^( }% n1 N) Z- u. H. I) r$ G
pletely disappeared except for a few vellous hairs at( |$ Z9 Q! U4 K4 t u; S
the base of the phallus. Testicular volume was still 2# s. ?+ p9 J" e$ _) `, @
mL, and the size of the penis remained unchanged.
% n* @+ X( K ZThe mother also said that the boy was no longer hav-! ^7 u# T! e R* o' \- s
ing frequent erections.
4 E9 |7 J8 k |Both parents were again questioned about use of/ ^; @* L' @" t( x
any ointment/creams that they may have applied to! @% _, N) ]3 Y3 k
the child’s skin. This time the father admitted the! d0 P8 t1 f# p1 t9 j1 V! e. d
Topical Testosterone Exposure / Bhowmick et al 541
5 ^! V& d# w4 Y8 R1 G" @3 J# Nuse of testosterone gel twice daily that he was apply-& X1 n$ _8 k+ Q( _5 L6 g
ing over his own shoulders, chest, and back area for" A ^) H4 k( r
a year. The father also revealed he was embarrassed
2 u) M1 O3 e1 @( h- dto disclose that he was using a testosterone gel pre-
" [0 |( ^ Q' u7 Cscribed by his family physician for decreased libido
* s4 Z1 N4 Z! l- d$ Qsecondary to depression.6 C( W& m! |* \ I3 g+ E3 A0 t
The child slept in the same bed with parents.
8 D; x9 {( l! c' ], a- xThe father would hug the baby and hold him on his3 |! V b* `: m- Z1 z; s- V
chest for a considerable period of time, causing sig-/ D3 ^- @9 v( d: J4 Z
nificant bare skin contact between baby and father.% r, M& Q8 a5 o
The father also admitted that after the phone call," b& v! w7 ^5 I& c4 D. v
when he learned the testosterone level in the baby, D; H p# X1 R( L- v
was high, he then read the product information
; x% r/ E/ h# N: Vpacket and concluded that it was most likely the rea-
9 Q6 e5 Q \" [! V! v0 Qson for the child’s virilization. At that time, they
( g0 {9 _* D# W5 ^0 K2 [3 Edecided to put the baby in a separate bed, and the
0 b# C8 d1 r& P3 h! j7 e7 e- Kfather was not hugging him with bare skin and had
% U/ z0 i7 U; T5 v8 Zbeen using protective clothing. A repeat testosterone
4 E: h3 `: K- ~$ O3 Vtest was ordered, but the family did not go to the
: |# l6 ]( E) ?+ R5 K% `laboratory to obtain the test.
( g2 u+ @6 z/ wDiscussion" M& E+ q% K- i7 x+ [# V) T$ }
Precocious puberty in boys is defined as secondary
7 |2 v9 t+ c: {, h, lsexual development before 9 years of age.1,4( {/ @& r' \5 } R
Precocious puberty is termed as central (true) when4 j) V0 o8 ]) g3 H% e4 Q
it is caused by the premature activation of hypo-+ X2 [ W/ Z& P5 a0 L" V7 A4 t5 a; p
thalamic pituitary gonadal axis. CPP is more com-
$ J# I1 e3 S! ^3 B: i4 {' _' ?. n* }mon in girls than in boys.1,3 Most boys with CPP
/ g. `# E* A6 s+ q2 t, s4 [. Dmay have a central nervous system lesion that is1 J7 h& K# |# Z Z' p+ x
responsible for the early activation of the hypothal-9 R: y a# D" j! J! E, z% ?
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 X* j7 O; [% csis has been given to neuroradiologic imaging in$ t* D P. h* X2 ]3 f- j0 M
boys with precocious puberty. In addition to viril-& u7 O2 [( I* L* b
ization, the clinical hallmark of CPP is the symmet-
( `2 _: D# C$ r+ N; vrical testicular growth secondary to stimulation by
- F' O# h4 n {2 P8 r. W4 u$ dgonadotropins.1,3
: T. F! f( B* A* b! }' z; UGonadotropin-independent peripheral preco-4 ]' f. d( m! s% i1 w
cious puberty in boys also results from inappropriate0 F' ~) c% d7 A4 V+ {
androgenic stimulation from either endogenous or0 l: D6 J1 K6 ^5 f9 S, I. B
exogenous sources, nonpituitary gonadotropin stim-
9 O% J1 g! P& {: l C8 U( Rulation, and rare activating mutations.3 Virilizing* ~" ]1 b3 R2 v
congenital adrenal hyperplasia producing excessive' E: E" r" z& ?; Y
adrenal androgens is a common cause of precocious
7 Y# j" B, @0 N0 Z- d; Spuberty in boys.3,43 C$ n$ K. I0 O) N0 k
The most common form of congenital adrenal
( }& U- g$ u- O- ?+ }hyperplasia is the 21-hydroxylase enzyme deficiency.: [0 B- y! G0 S* ]5 Z; j7 b) n
The 11-β hydroxylase deficiency may also result in ?6 T' i* |4 t8 J4 L
excessive adrenal androgen production, and rarely,
$ c0 _& I2 b# K I% j- ean adrenal tumor may also cause adrenal androgen
+ L Z. |) h2 D7 _* P1 Nexcess.1,3
5 l- B( a. s8 X& V) I8 H* ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 Z7 B2 r T( T) T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' O& o- E- A1 m" X c( ?% }
A unique entity of male-limited gonadotropin-4 k8 B* [# T) |& V) `
independent precocious puberty, which is also known# ]) w( ?% ?8 N( W3 A
as testotoxicosis, may cause precocious puberty at a Y5 X$ P0 c, G7 A# X
very young age. The physical findings in these boys6 n4 m1 X! u% W% a& m8 R6 m5 c0 V
with this disorder are full pubertal development,
, i9 j* @# q1 L6 Bincluding bilateral testicular growth, similar to boys5 x$ a. _1 X2 d- r
with CPP. The gonadotropin levels in this disorder
* a8 ^4 _1 D' w2 w6 O- x i0 zare suppressed to prepubertal levels and do not show5 x- v/ I& q! a" s. h0 l! F% ^
pubertal response of gonadotropin after gonadotropin-
7 c4 i( J! d; f5 ]5 a6 e0 b" k4 ]releasing hormone stimulation. This is a sex-linked+ M, Y% Z" M% z# Q
autosomal dominant disorder that affects only
7 J, A: y4 @7 imales; therefore, other male members of the family7 f# g$ T7 F" g m; ]+ S
may have similar precocious puberty.3
- C6 [/ {, d% {# c5 d, p3 V* o, yIn our patient, physical examination was incon-, `' V( s' D g) V. J. v+ p( w
sistent with true precocious puberty since his testi-
4 T3 k5 E4 s6 i; D, L$ ocles were prepubertal in size. However, testotoxicosis5 h0 a9 g! \+ q4 Y
was in the differential diagnosis because his father3 e7 @4 a& T% H) [$ F- Y6 Q
started puberty somewhat early, and occasionally,
$ L: {5 e! e( ~- P$ v/ s& mtesticular enlargement is not that evident in the
( g" B, v' W$ I: y0 m0 R! Ibeginning of this process.1 In the absence of a neg-
$ t5 N9 w0 Q d3 D" s5 O; mative initial history of androgen exposure, our
0 O6 T$ F$ ]$ Q, t( A: g% sbiggest concern was virilizing adrenal hyperplasia,
1 P, G: N; Z/ _$ s3 a$ Y' n. {either 21-hydroxylase deficiency or 11-β hydroxylase& [$ g$ }, H6 [4 p& z
deficiency. Those diagnoses were excluded by find-5 s6 w% u. B+ ?
ing the normal level of adrenal steroids.
. v. O! v x# ?& ?5 E3 n8 U5 ]The diagnosis of exogenous androgens was strongly
/ H2 y Y8 r9 r" y8 ^8 u N4 x( m& Vsuspected in a follow-up visit after 4 months because0 K% Y3 c) M( h/ R$ ^1 f
the physical examination revealed the complete disap-
# N% _3 T& p9 m) w( O5 k' R# m1 Upearance of pubic hair, normal growth velocity, and+ [ h1 ?% u- B' a: y9 D& k c, ?
decreased erections. The father admitted using a testos-
8 g; ~0 L/ q7 J+ _; S3 qterone gel, which he concealed at first visit. He was, d) ?7 ?' F3 K! D1 t2 k
using it rather frequently, twice a day. The Physicians’
}; F3 _: r- y$ K+ ?Desk Reference, or package insert of this product, gel or/ f( x: s3 Q T; ]: o
cream, cautions about dermal testosterone transfer to7 M* P$ y0 `) H1 O
unprotected females through direct skin exposure.
. K) o/ \8 U& s5 k) |( L$ XSerum testosterone level was found to be 2 times the, ]6 k- B. _/ _7 h2 _+ Q, | Z
baseline value in those females who were exposed to. h2 c8 [* O% r7 A+ A
even 15 minutes of direct skin contact with their male8 x( T0 X: K8 ]+ U) X& W/ L8 U
partners.6 However, when a shirt covered the applica-. M2 T+ A, l; G0 a0 g) `5 }2 q
tion site, this testosterone transfer was prevented.
+ H" e& u$ L( a3 TOur patient’s testosterone level was 60 ng/mL,- h. c, _9 r @2 Y+ ^9 Y3 V
which was clearly high. Some studies suggest that
8 t* N) j3 M& |dermal conversion of testosterone to dihydrotestos-' d% V7 r6 E1 f$ q0 C
terone, which is a more potent metabolite, is more
8 ^: ]7 ]" `1 B/ i6 j( ]% factive in young children exposed to testosterone
% Y7 q$ g/ ]* o y5 Qexogenously7; however, we did not measure a dihy-! ^3 W, [* W# X k9 D+ p6 c# \
drotestosterone level in our patient. In addition to
. \+ d" |1 m \( J8 L. a& Tvirilization, exposure to exogenous testosterone in
% e6 ?; F' O4 a/ Vchildren results in an increase in growth velocity and
" F1 e8 V$ }. c; M& ?( a9 \advanced bone age, as seen in our patient.# O9 q2 j/ \9 g
The long-term effect of androgen exposure during+ G" e) K, p% B+ e2 ~' `$ u0 u
early childhood on pubertal development and final
+ J+ y1 B- d9 h" B( Kadult height are not fully known and always remain6 L) d3 z5 ~( H5 S e6 M
a concern. Children treated with short-term testos-3 g# M4 G7 d$ m4 b" O# H. k0 O+ j
terone injection or topical androgen may exhibit some
% i+ q4 b5 [1 e' Racceleration of the skeletal maturation; however, after% v) ^9 X/ K: s( E9 f# V
cessation of treatment, the rate of bone maturation
$ D! t; z9 n N `% ^$ C; t7 i+ ]decelerates and gradually returns to normal.8,9
7 q; t, _3 {0 E. E0 p1 j( H" kThere are conflicting reports and controversy
3 n! s. A. M4 `% i; z$ mover the effect of early androgen exposure on adult2 l. n: v% m0 \* E+ ]* Y- M1 s
penile length.10,11 Some reports suggest subnormal2 [! Z. ?( p& ?- m
adult penile length, apparently because of downreg-
4 q' q) P% O. x+ d! q* Zulation of androgen receptor number.10,12 However,
! F& _- d( {2 W9 n2 nSutherland et al13 did not find a correlation between
2 Y5 r4 B `6 X9 m: [- Y7 hchildhood testosterone exposure and reduced adult
% Y- x7 p* u9 P# _4 X) bpenile length in clinical studies., W, {# k% J5 I0 Y& z f
Nonetheless, we do not believe our patient is2 e+ n3 q4 G. k& |4 S; x
going to experience any of the untoward effects from
) I1 t$ B. |) A' q0 ctestosterone exposure as mentioned earlier because
. i2 s& m; [7 k0 B1 [0 xthe exposure was not for a prolonged period of time.
; X9 G3 w4 Z* F5 F1 EAlthough the bone age was advanced at the time of
) l6 |5 ]0 O$ M0 O9 o* Q4 Zdiagnosis, the child had a normal growth velocity at
* t; v3 b# P. U- g; T& U7 athe follow-up visit. It is hoped that his final adult
, w( ~" S+ y! j P) j! k* Qheight will not be affected.
) S6 w0 x! n3 [* J2 uAlthough rarely reported, the widespread avail-, ^& m0 S4 G( Q& j- u3 v6 \6 p# ]
ability of androgen products in our society may
) X$ H8 O+ U% O( C# `8 {indeed cause more virilization in male or female
& _% }, w7 `4 Y# G* z- ~0 echildren than one would realize. Exposure to andro-8 p; N' P0 y* _
gen products must be considered and specific ques-8 N3 Q+ d4 l- D( e7 t
tioning about the use of a testosterone product or
) G% J+ a8 M2 u0 Z" B+ [gel should be asked of the family members during
0 Q% s l$ M3 o8 f6 p1 _the evaluation of any children who present with vir-& L1 C4 |- N/ X
ilization or peripheral precocious puberty. The diag-) ]- A. M$ [# x/ ^& P8 i
nosis can be established by just a few tests and by
: X& Q2 L; X9 c2 J- c G: ]appropriate history. The inability to obtain such a
: P9 v/ j1 q/ K& W) H+ `; G/ uhistory, or failure to ask the specific questions, may
) v+ O. a/ @4 _. P; _$ _" b3 bresult in extensive, unnecessary, and expensive H: F( |/ c) [& w
investigation. The primary care physician should be* J0 g. e4 c' x" g: j
aware of this fact, because most of these children5 d1 M0 P6 K) ?+ v; p
may initially present in their practice. The Physicians’
: O3 ~9 C) s$ n! PDesk Reference and package insert should also put a% {4 T- T: O" d* H, y! r" |* V; b
warning about the virilizing effect on a male or
}+ R7 Q D8 O3 L3 F) p6 b$ g2 Nfemale child who might come in contact with some-
) x6 f T# E4 B3 N r% T3 wone using any of these products.4 p* T" p& N- |
References1 A' T' E; y3 Q7 i9 u, `
1. Styne DM. The testes: disorder of sexual differentiation- i& U4 E2 O6 Q, q" I! o. ?$ Z' p
and puberty in the male. In: Sperling MA, ed. Pediatric) D1 X3 l: _# Z, ^( W/ ]! u$ R' u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 u/ ]5 @' @! {% J8 t0 }( f2002: 565-628., M7 {2 l" z9 a) p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
C% u9 ?2 f- K. {puberty in children with tumours of the suprasellar pineal |
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