- 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-Old
- [4 B# L( X* x a* nBoy Induced by Indirect Topical0 ?4 z9 E3 L- U0 l4 c0 }
Exposure to Testosterone
8 N$ ]: B# G+ J9 ~6 n, P# lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( X; `7 o3 S; S
and Kenneth R. Rettig, MD1
8 M5 g0 z! y8 d+ `3 ?8 V7 D- BClinical Pediatrics' I* m" I& c W* z+ Y
Volume 46 Number 6
0 R/ f4 F8 G7 H; @, j/ P" ?July 2007 540-5431 w( S6 ~* M7 H- D+ B/ R+ C
© 2007 Sage Publications* N* j1 g! [: A" k, T/ k
10.1177/0009922806296651
1 p( n. f, H Q, @7 w. ^http://clp.sagepub.com
! A4 N C3 f6 {! ^& D9 d8 ghosted at
; @7 u5 s _- B. Q1 ]0 zhttp://online.sagepub.com
8 \# c X" P/ v7 LPrecocious puberty in boys, central or peripheral,
1 t" G( k5 e$ [! ois a significant concern for physicians. Central
% C3 H: i7 l0 r8 |precocious puberty (CPP), which is mediated& V1 F' e# t- v& }. Y
through the hypothalamic pituitary gonadal axis, has1 T5 I1 Q' x" O: i
a higher incidence of organic central nervous system5 a! j% A9 s3 h! F2 y
lesions in boys.1,2 Virilization in boys, as manifested) J0 A4 B0 u9 U4 E7 s9 H* t
by enlargement of the penis, development of pubic+ j2 @6 S& z0 M' G! v# i5 [
hair, and facial acne without enlargement of testi-- T; y" @! C' D2 X0 U F
cles, suggests peripheral or pseudopuberty.1-3 We
+ r( \% n0 S3 m4 T9 Zreport a 16-month-old boy who presented with the% `% E" {! a% \3 N' y
enlargement of the phallus and pubic hair develop-7 C( ~5 F- H1 d5 K. H# Y* z3 _
ment without testicular enlargement, which was due1 }' `$ c- c, Y
to the unintentional exposure to androgen gel used by
% n" |, U* k; }9 G8 R' Pthe father. The family initially concealed this infor-
: S' M( t2 U' n% @& X( r6 ymation, resulting in an extensive work-up for this
) J" ?1 I' K' w8 B0 R* Zchild. Given the widespread and easy availability of
: D4 E, Y! f( C: ?9 ztestosterone gel and cream, we believe this is proba-
/ x# K _- P/ p$ W- [bly more common than the rare case report in the
0 r- R7 o3 ?4 n. B2 pliterature.4
I' n9 ^$ r/ W3 k$ A: Z- RPatient Report1 e5 J; K! d0 N4 s$ N) }
A 16-month-old white child was referred to the5 E* L! b( j0 K5 @
endocrine clinic by his pediatrician with the concern% m( A6 W: r. i
of early sexual development. His mother noticed
! S6 e. g& x- Y5 A9 klight colored pubic hair development when he was7 u- I5 i7 N2 V8 [
From the 1Division of Pediatric Endocrinology, 2University of
C7 {! `6 D( u1 E2 b9 bSouth Alabama Medical Center, Mobile, Alabama.0 ~1 u, p: [/ Z. P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% i( K" E( P0 I5 j3 m/ T; O: r, XProfessor of Pediatrics, University of South Alabama, College of3 L7 l8 K0 w- e5 L% S' E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ ]$ N% w; ^/ S7 i* m9 T! }
e-mail: [email protected].
% T$ S S, {: @# Sabout 6 to 7 months old, which progressively became
, {9 G% Z f' a- hdarker. She was also concerned about the enlarge-2 U, X+ ]7 V8 B* O% g, B3 f
ment of his penis and frequent erections. The child' K3 ^9 _4 Q7 x! B; }
was the product of a full-term normal delivery, with
0 a# b7 {4 I f/ { V9 aa birth weight of 7 lb 14 oz, and birth length of
8 R5 G2 n9 o8 U; c1 i1 g, j R20 inches. He was breast-fed throughout the first year
7 Q. ?8 P$ _8 Lof life and was still receiving breast milk along with
, h! d9 S1 S, E. |solid food. He had no hospitalizations or surgery,% H& I8 v4 \4 T; J
and his psychosocial and psychomotor development
: F# U4 C" i" h7 r" s& ~was age appropriate., t5 m6 _" G# p) U
The family history was remarkable for the father,
4 G9 G3 E: v( B9 D; swho was diagnosed with hypothyroidism at age 16,& k T/ \& P% Q5 `; u! O0 V
which was treated with thyroxine. The father’s/ g3 B( s4 S& H0 g
height was 6 feet, and he went through a somewhat1 N( F8 Y& F& r6 H2 D% j& M
early puberty and had stopped growing by age 14., i8 I) d0 ]8 G8 T
The father denied taking any other medication. The, r- ?! O# G" w7 Z
child’s mother was in good health. Her menarche
1 k) ?! O/ r$ ^( q/ `! vwas at 11 years of age, and her height was at 5 feet/ s) x# {% d3 h( v
5 inches. There was no other family history of pre-8 e. G, @2 E* C& u# g
cocious sexual development in the first-degree rela-4 B" @4 `9 ]' \% ?% U
tives. There were no siblings.( a: A- Z; F* [ T. l; f
Physical Examination" d, `/ F) n# i% C/ ?2 a9 D5 ]+ M* x
The physical examination revealed a very active,$ i: R7 w- z$ c
playful, and healthy boy. The vital signs documented
0 ^, I: m& S) N& L: e1 x, m! Ca blood pressure of 85/50 mm Hg, his length was
: w; o! N" J. m& K( p90 cm (>97th percentile), and his weight was 14.4 kg5 P% j8 i6 p n2 y
(also >97th percentile). The observed yearly growth
" [+ H, G4 m* c* |( |velocity was 30 cm (12 inches). The examination of
! N) ^: l" S$ p$ \' Ythe neck revealed no thyroid enlargement.' y. l S6 j) v6 C' ?
The genitourinary examination was remarkable for* j8 x6 Y. u% C: _/ X! j
enlargement of the penis, with a stretched length of
: t) l/ I0 [! `6 g; r) y4 Y8 cm and a width of 2 cm. The glans penis was very well( Y3 s1 N, C5 x
developed. The pubic hair was Tanner II, mostly around
) \; S1 b8 f8 |5 m540. J) R% L0 x/ J( l4 F2 u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ b- v p! o* d0 [2 D8 A
the base of the phallus and was dark and curled. The. C) ^# r0 B3 K9 a% x d/ d
testicular volume was prepubertal at 2 mL each.& y1 ^6 M* }' X: ]) Q$ Y! J
The skin was moist and smooth and somewhat
- B! e1 O# D! U! |oily. No axillary hair was noted. There were no* B* r; S4 K, e5 w0 m
abnormal skin pigmentations or café-au-lait spots.% b& L. Q/ L. n* ]% }
Neurologic evaluation showed deep tendon reflex 2++ b% f2 q! ?" D8 M, i% _
bilateral and symmetrical. There was no suggestion- M8 W; f$ f/ r
of papilledema.% u( t* _. f1 p0 M/ Z( X" I ^
Laboratory Evaluation
8 s) G7 t5 U5 Y8 t7 PThe bone age was consistent with 28 months by; H' i8 T h4 F$ l5 n" V$ v& u
using the standard of Greulich and Pyle at a chrono-
H, z' r5 ?. f: L0 F" {; wlogic age of 16 months (advanced).5 Chromosomal9 g a1 i1 ~. I3 f) N3 g: h
karyotype was 46XY. The thyroid function test+ B9 h5 `2 @5 P
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ H' J6 I _: m( P: b% h" b
lating hormone level was 1.3 µIU/mL (both normal).
3 J& R0 F/ b @1 d7 |) ]The concentrations of serum electrolytes, blood
( c, P5 E* k8 u. v- curea nitrogen, creatinine, and calcium all were" a: K2 R* U$ j9 `1 a( |
within normal range for his age. The concentration: z8 Y) n1 e& X6 T% p1 X& A
of serum 17-hydroxyprogesterone was 16 ng/dL5 V* L; _' n" }
(normal, 3 to 90 ng/dL), androstenedione was 20# j! Q0 t* \) l0 G0 C- U2 f3 O. g
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 x7 p4 B' F' D' M0 G* k
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, _* i8 C! v& U. w# ~' h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to) h4 {) k4 l5 O; K
49ng/dL), 11-desoxycortisol (specific compound S)
% B) q8 ]- Z9 d' ~' F: k1 t9 o/ Jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 t$ _' b% E" s2 p, _ btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( Y% T* H6 K3 k1 H0 {' l$ Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% E3 V/ l& o; ]' A
and β-human chorionic gonadotropin was less than. e# S! e1 C" u- `6 @% D8 L
5 mIU/mL (normal <5 mIU/mL). Serum follicular p7 |* }$ {+ b9 f
stimulating hormone and leuteinizing hormone
) O( h5 j: a% J& ]" s9 h, C7 Kconcentrations were less than 0.05 mIU/mL
$ ], M* @( j( @/ k5 }(prepubertal).
7 a4 ^0 @# ^. |3 b1 S! O& S. ~8 Z4 dThe parents were notified about the laboratory) P7 F7 Q6 l4 ]
results and were informed that all of the tests were
! O2 `, j* I8 T2 J2 Wnormal except the testosterone level was high. The
& `) S" p/ I7 Y" x/ E8 O* t: sfollow-up visit was arranged within a few weeks to
. _. K3 o1 ]/ p7 L2 S( N6 Y6 eobtain testicular and abdominal sonograms; how-
: M9 L1 k, e+ I5 X$ c! ~2 c4 zever, the family did not return for 4 months.
( G5 X5 t7 S: d, p+ ?Physical examination at this time revealed that the- p9 L: N( q+ d
child had grown 2.5 cm in 4 months and had gained
6 U2 [6 ^ c P& c* O) ]' M) q2 kg of weight. Physical examination remained" G3 j% i* I& r
unchanged. Surprisingly, the pubic hair almost com-7 r7 C0 P3 e. C3 o9 G
pletely disappeared except for a few vellous hairs at: d9 }- y5 x5 X
the base of the phallus. Testicular volume was still 26 o5 k* [) u p# |0 P, P- Z
mL, and the size of the penis remained unchanged.
, n+ b1 b9 I$ f4 X$ _$ s: Z4 |3 ZThe mother also said that the boy was no longer hav-% C) [9 x9 G5 e+ e
ing frequent erections.! }+ U" a1 O5 n0 {
Both parents were again questioned about use of
0 ~* R, ^4 f: z' i: N0 f0 K3 wany ointment/creams that they may have applied to9 t' f+ x: \4 }* ]
the child’s skin. This time the father admitted the
$ V4 b- c$ x" a) s/ |$ RTopical Testosterone Exposure / Bhowmick et al 541
I1 j, Z5 c4 r" X( w- p$ i, Guse of testosterone gel twice daily that he was apply-
- Z+ t! M6 s3 j( [# T$ g. D7 xing over his own shoulders, chest, and back area for& w2 ~5 n" U6 I* L, T8 W
a year. The father also revealed he was embarrassed
. F# L- a4 n$ a9 N1 Ito disclose that he was using a testosterone gel pre-
" r5 W" Z; h, P: pscribed by his family physician for decreased libido
& l( I: a& V! l: V5 {) j. E) }secondary to depression.
1 F3 u8 n. o: K* \) LThe child slept in the same bed with parents., z7 w. L/ C3 e- Q" e+ i3 D$ C
The father would hug the baby and hold him on his
( K/ j0 j9 T' L* D0 I5 \+ d4 n+ u9 }chest for a considerable period of time, causing sig-- L! ], I! }; ?0 B. C
nificant bare skin contact between baby and father.; P1 D8 S) y0 x4 a
The father also admitted that after the phone call,3 ?; Y0 E" k4 v) l* t
when he learned the testosterone level in the baby
7 \) i F {( \4 s" ywas high, he then read the product information) {7 {" J3 g! }5 p0 z% \( j
packet and concluded that it was most likely the rea-7 I/ w' V3 C+ y8 { G' H& S
son for the child’s virilization. At that time, they
9 k; h8 [ z" N+ Pdecided to put the baby in a separate bed, and the
* `4 Q. x4 X2 a3 {5 `0 Bfather was not hugging him with bare skin and had
% Q! V6 W- L- A7 D! i' z2 n7 }$ @been using protective clothing. A repeat testosterone4 j7 _8 F5 z9 ?8 U# z* `2 g5 b# d: |
test was ordered, but the family did not go to the! r5 m, G" c) v; ~
laboratory to obtain the test.
p: k, u1 S2 j& }' n9 hDiscussion
1 {( p0 S8 ^# U6 G( l4 fPrecocious puberty in boys is defined as secondary
+ c a1 z, K9 z6 _+ B* f8 X7 |/ }sexual development before 9 years of age.1,42 H2 E4 n0 q. g. ?
Precocious puberty is termed as central (true) when6 Y" V2 n$ H7 d' ^$ t
it is caused by the premature activation of hypo-
! b- b' L( \# E5 a1 A2 |thalamic pituitary gonadal axis. CPP is more com-
4 N& n5 w/ d$ b: z" H0 U8 Gmon in girls than in boys.1,3 Most boys with CPP w4 U) T0 f8 X. o( o8 c* i
may have a central nervous system lesion that is
. A2 `/ P' ]1 \5 v# gresponsible for the early activation of the hypothal-5 q: \- v- `) K5 S
amic pituitary gonadal axis.1-3 Thus, greater empha-0 D2 d7 I$ j2 {0 e6 W% `5 m# K
sis has been given to neuroradiologic imaging in
- n X. `4 W( c4 l* t. h5 O2 t: K( iboys with precocious puberty. In addition to viril-0 O; |" R6 u2 \/ X
ization, the clinical hallmark of CPP is the symmet-+ L4 A; ?3 ?/ T. C8 J1 B, g
rical testicular growth secondary to stimulation by
3 f6 _6 h9 S% H+ w: Ogonadotropins.1,3
& B. {% [' H/ I5 G% aGonadotropin-independent peripheral preco-9 ?7 c( l+ z* d! @( u" H& @6 B: W
cious puberty in boys also results from inappropriate, }+ v/ l, S9 a
androgenic stimulation from either endogenous or" a9 @+ y7 D* R8 q) u$ v
exogenous sources, nonpituitary gonadotropin stim-
) j8 M5 h1 A# I' wulation, and rare activating mutations.3 Virilizing
, F' t6 c+ m4 t) Econgenital adrenal hyperplasia producing excessive
/ h5 s' r6 A r$ r7 S! _% y9 Y' uadrenal androgens is a common cause of precocious5 k6 V l3 q8 N, I d3 J8 m
puberty in boys.3,4+ o: i4 i: i" E% Q! R3 D$ _- z
The most common form of congenital adrenal7 B( g a/ g0 A$ W) ?
hyperplasia is the 21-hydroxylase enzyme deficiency.
1 x8 ^: h& M* e! Y2 `The 11-β hydroxylase deficiency may also result in
' k. N( m9 V3 f7 N# P5 Z nexcessive adrenal androgen production, and rarely,
3 \7 G z: a2 S+ b) F, _an adrenal tumor may also cause adrenal androgen
& S& t; P- Z9 t2 J/ a9 n' `excess.1,3
) D: C& u$ V9 y5 v1 [( V- wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" r* | f& J. d0 G+ l l: x" A542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 }$ a4 Y9 s7 ?
A unique entity of male-limited gonadotropin-
( r; Y3 r9 T4 g& ?- yindependent precocious puberty, which is also known- t' Z% T. X c! f
as testotoxicosis, may cause precocious puberty at a' Y0 n( }+ |9 ]
very young age. The physical findings in these boys
. h1 P. I& Z* ?* hwith this disorder are full pubertal development,
, B- L: ?6 f; u/ V7 @2 Wincluding bilateral testicular growth, similar to boys
. ]4 r7 I$ f# Pwith CPP. The gonadotropin levels in this disorder
5 }! x3 p( j3 J# L. Nare suppressed to prepubertal levels and do not show' `5 R. a4 X! F8 ^) h: C3 f3 H7 h
pubertal response of gonadotropin after gonadotropin-+ n0 a9 {$ x/ ?: c* v( r- T& H( r" H
releasing hormone stimulation. This is a sex-linked
4 }0 O) Q, {) i% n3 `9 z' r6 Tautosomal dominant disorder that affects only
; n) @0 n0 B: E: r$ amales; therefore, other male members of the family5 ~/ W$ _9 R, W- H: G0 W4 u6 u% n
may have similar precocious puberty.3
* j6 E/ a( ]# z; Z0 M9 PIn our patient, physical examination was incon-
4 K! @: o, A9 V& k1 I2 B+ m v8 Rsistent with true precocious puberty since his testi-
/ p f% _, W6 R$ f/ |cles were prepubertal in size. However, testotoxicosis
9 k3 @) G& A5 ~; Q! ]* K- Bwas in the differential diagnosis because his father
/ D5 }; V9 i' F3 @8 c0 C5 \" Nstarted puberty somewhat early, and occasionally,
# [: b) y6 @9 K. j) x) x4 H1 Ktesticular enlargement is not that evident in the
+ G; M! J! Z$ n$ mbeginning of this process.1 In the absence of a neg-# N; `: J5 F9 B3 X& b
ative initial history of androgen exposure, our& A$ r, J4 O6 M
biggest concern was virilizing adrenal hyperplasia,
/ @* i, o# o. @7 x, W. x8 Beither 21-hydroxylase deficiency or 11-β hydroxylase; g4 L8 }+ l5 ?8 O
deficiency. Those diagnoses were excluded by find-
]2 i- `# N" y, b* k. ?( F& x) Ping the normal level of adrenal steroids.3 F: w' m$ ?7 J, V4 C
The diagnosis of exogenous androgens was strongly
& t. A7 ]1 g7 @% a T8 Ususpected in a follow-up visit after 4 months because
1 {9 G% H2 d3 j4 Fthe physical examination revealed the complete disap-" V9 R: `2 x6 }! ~; w
pearance of pubic hair, normal growth velocity, and- d0 X: K2 L1 ^) s1 x5 N4 ~% L8 k5 j
decreased erections. The father admitted using a testos-
5 {. @5 K$ Q: {/ u3 k# Jterone gel, which he concealed at first visit. He was
, @' B* p! n1 h1 ~- z, c$ Rusing it rather frequently, twice a day. The Physicians’: p) o" Y; \$ R2 E3 i/ G
Desk Reference, or package insert of this product, gel or1 `# x6 R+ r. o, `6 a
cream, cautions about dermal testosterone transfer to
* v. Q& C" N r" B* L9 Tunprotected females through direct skin exposure.
: O$ W0 c! \' h0 k+ K5 f3 LSerum testosterone level was found to be 2 times the5 r- n6 Y' z+ b+ p, t ?
baseline value in those females who were exposed to! c( H0 M- }- W2 A* _/ r5 w
even 15 minutes of direct skin contact with their male
8 Q5 o' L: L0 g& v% P( bpartners.6 However, when a shirt covered the applica-5 u; _7 v1 [" D* i; m- f7 X
tion site, this testosterone transfer was prevented.! y; ]* w. c+ T# @6 s! D7 Z* t
Our patient’s testosterone level was 60 ng/mL,0 E, @1 w1 P$ ?7 D; P9 ^4 W
which was clearly high. Some studies suggest that7 Z' V: G- N: N0 @0 _: z$ w* w
dermal conversion of testosterone to dihydrotestos-
3 ]8 Y5 m+ l! G$ D& aterone, which is a more potent metabolite, is more# E5 `3 H2 {# K. O7 C' t! f, |
active in young children exposed to testosterone& f, b: o2 T: f+ j- O+ K" M1 ^
exogenously7; however, we did not measure a dihy-
# t9 G+ O) p7 {& n4 u1 cdrotestosterone level in our patient. In addition to5 X* m4 d) r( f: U
virilization, exposure to exogenous testosterone in4 [2 ?. J* W& S: e- U
children results in an increase in growth velocity and1 x% h# T7 r) N+ O: b9 U, k" U
advanced bone age, as seen in our patient.
Y. v* I" r1 m3 SThe long-term effect of androgen exposure during' a5 a; Y& K9 E! y3 Q
early childhood on pubertal development and final. w9 E. ]# @) G7 X" C" m
adult height are not fully known and always remain
7 j6 g1 T1 y! q( M$ A* D% t8 H- Xa concern. Children treated with short-term testos-& K: P# o2 c6 A/ |2 L
terone injection or topical androgen may exhibit some9 U0 `' \ n5 {$ ?
acceleration of the skeletal maturation; however, after( e" u) r8 T# \: V
cessation of treatment, the rate of bone maturation7 ]; I. e. a: H1 J2 Y' Y/ T: [
decelerates and gradually returns to normal.8,9 S- [8 _0 ^( \% j. O6 @. V- }
There are conflicting reports and controversy5 S* V* S# G/ C G
over the effect of early androgen exposure on adult
. h6 i$ [) a6 Q% \+ j3 _* q1 Hpenile length.10,11 Some reports suggest subnormal
7 \0 o) X) D+ U- L8 `4 |* Qadult penile length, apparently because of downreg-3 z! r4 c, t% w8 N) U- k, K! a
ulation of androgen receptor number.10,12 However,
6 s5 c2 `+ B( l) USutherland et al13 did not find a correlation between0 ^ R; t. n" V* g& H( Q
childhood testosterone exposure and reduced adult- _% [2 u% \1 ~, d0 e$ J j3 T
penile length in clinical studies.
+ u6 g8 z! I+ h7 M# u+ VNonetheless, we do not believe our patient is
6 m5 w# s) k& X6 k$ O: G' xgoing to experience any of the untoward effects from
2 u F9 B$ ?: { Ctestosterone exposure as mentioned earlier because
$ x( U1 b! f! }6 ^- q. u4 }9 \the exposure was not for a prolonged period of time.
9 H( e- A, j3 |) [: u& {+ TAlthough the bone age was advanced at the time of6 A- E4 D: M6 x7 o* G7 L* e7 M
diagnosis, the child had a normal growth velocity at& j2 s8 `; A; z" J( ]
the follow-up visit. It is hoped that his final adult; G7 i% Y' P8 U2 O. [& E. e
height will not be affected.
4 X( D3 g+ d. c, GAlthough rarely reported, the widespread avail-* [ g* g5 Y* ^" ?& D1 {
ability of androgen products in our society may( h7 ^1 S3 g+ a+ Y1 \0 ^
indeed cause more virilization in male or female4 G3 h9 ?7 {, q
children than one would realize. Exposure to andro-2 v+ w m7 l) B3 e8 e# y3 n) e
gen products must be considered and specific ques-; j* I! G1 k' \# W: }8 W8 S9 _) [5 O
tioning about the use of a testosterone product or
! n5 H8 L" [! W6 V& B" {gel should be asked of the family members during
, o! j. ^: `2 @% othe evaluation of any children who present with vir-
u# f+ I4 _7 D Y# ailization or peripheral precocious puberty. The diag-
# o$ i/ X+ i0 D7 A+ Dnosis can be established by just a few tests and by
* X7 Z( q9 c$ b! x& Eappropriate history. The inability to obtain such a0 Y, ~9 o+ n/ H" y3 Z
history, or failure to ask the specific questions, may
I$ p2 P: C! c1 q7 C) a% n, hresult in extensive, unnecessary, and expensive* Y7 w9 p. u- q% w
investigation. The primary care physician should be& F7 B$ @$ R( o
aware of this fact, because most of these children
7 G& P' e$ C% E4 rmay initially present in their practice. The Physicians’4 K2 b4 a+ C6 u( k$ x3 g, r
Desk Reference and package insert should also put a
' j' A1 f6 f' n( p$ _& x5 l& G. ?& u5 Vwarning about the virilizing effect on a male or
0 I0 i0 d7 [ J; q" y& f% S; ?" kfemale child who might come in contact with some-
% f3 E4 f# s7 d$ s' l, n G$ Kone using any of these products." i9 x# T o9 Z7 Z2 o6 G- Y, @
References7 C. G& @* k- b6 p' o) ]6 S
1. Styne DM. The testes: disorder of sexual differentiation
: X0 |( S' J6 u2 Mand puberty in the male. In: Sperling MA, ed. Pediatric# M$ a" j% X# h" C8 I; t7 G9 A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 L O8 b+ ?( C( }4 y2002: 565-628.
1 D+ Q9 b* x2 w' [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
I7 t: v, ^/ r- ipuberty in children with tumours of the suprasellar pineal |
|