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Sexual Precocity in a 16-Month-Old: W3 S$ A/ D0 Y a% X: c% j6 W
Boy Induced by Indirect Topical
! W9 d" }. `! \; ^! X: @6 a/ \Exposure to Testosterone9 x0 ]/ b! f; G5 _4 w
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: m; W' q6 w! k' z
and Kenneth R. Rettig, MD1) q9 T2 O/ v9 V* {
Clinical Pediatrics
X0 a" V) }0 ], W( o% kVolume 46 Number 6
% J% f& ]% ^, _5 s1 U y3 B' hJuly 2007 540-543
+ ^; g3 z. u, K( Z" {8 [© 2007 Sage Publications4 J: T* v' w: r0 n
10.1177/0009922806296651
" b8 ]) G: Y- Thttp://clp.sagepub.com
; [8 h0 B% k- \+ v5 fhosted at3 z" @( k, R$ ?" j3 n3 K: b+ ]3 e
http://online.sagepub.com) ^& N/ x) `. w' K( |/ {% b0 J
Precocious puberty in boys, central or peripheral,
% H* W- o' [) n! P$ z9 gis a significant concern for physicians. Central4 N" q% A! Z! ~/ Q, q
precocious puberty (CPP), which is mediated6 \! j6 l( ]+ d7 ~9 a& `5 e
through the hypothalamic pituitary gonadal axis, has
& l2 _; ^' V8 a1 C. Ha higher incidence of organic central nervous system
# f& [( p: Z7 t) I j4 ^/ w. E elesions in boys.1,2 Virilization in boys, as manifested
( ~3 Y n, _, \) s$ X3 ^0 ` V9 Mby enlargement of the penis, development of pubic
: Y* u5 z- A0 }) Z3 H9 V- fhair, and facial acne without enlargement of testi-/ t- Y# b- N1 h' ~& u- [
cles, suggests peripheral or pseudopuberty.1-3 We6 y t9 t J9 c: R0 @0 h6 ^1 u
report a 16-month-old boy who presented with the0 A; `; q5 s- |. p- @' l1 x; g
enlargement of the phallus and pubic hair develop-0 ~1 Y4 C& `& C: v j
ment without testicular enlargement, which was due3 G' G9 j) ` L: \! `% I6 G0 e
to the unintentional exposure to androgen gel used by5 V* e* P( ?$ g0 C
the father. The family initially concealed this infor-) L7 x1 W* |/ Q- e- {! u
mation, resulting in an extensive work-up for this
: d# {- ~# p- T! Vchild. Given the widespread and easy availability of
" P- {4 g# g' J( R3 p8 F, \5 a6 c5 Jtestosterone gel and cream, we believe this is proba-+ P; u0 ~# f7 B5 F' X7 _; D
bly more common than the rare case report in the
3 Z; Y! S8 Q+ W( ?; Jliterature.40 r# d0 k' p |8 V; v
Patient Report/ Q6 _1 r) O7 }: z4 s$ j+ ~- k
A 16-month-old white child was referred to the) L. g0 s u5 b' \
endocrine clinic by his pediatrician with the concern
' _7 F6 O4 f$ e' tof early sexual development. His mother noticed
, A! ]& C, j. P' r1 Vlight colored pubic hair development when he was* I/ z) u) E1 k# W
From the 1Division of Pediatric Endocrinology, 2University of
9 v5 Q% a3 S/ g- U. `South Alabama Medical Center, Mobile, Alabama.
+ \7 x% K& K9 u9 y/ ?Address correspondence to: Samar K. Bhowmick, MD, FACE,2 R0 M) q S2 h4 a
Professor of Pediatrics, University of South Alabama, College of
* K, u/ [( W, q7 MMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! X1 o" J7 [1 Ie-mail: [email protected].
* X! |7 z8 S6 i% c4 n' d$ ?about 6 to 7 months old, which progressively became# O6 z p, t$ x; e; J
darker. She was also concerned about the enlarge-$ m8 _, @8 c, ?: G: z
ment of his penis and frequent erections. The child; U3 ?; [6 Y! y% l9 {4 V
was the product of a full-term normal delivery, with
$ Z8 D* p- |8 u( {$ @% {; j+ [a birth weight of 7 lb 14 oz, and birth length of( ?! K# H1 ?. P+ P! d3 M T
20 inches. He was breast-fed throughout the first year
( A6 e# J; y, G1 ~of life and was still receiving breast milk along with; V! x. Y+ `; Q! t7 V5 i' s
solid food. He had no hospitalizations or surgery,% N* y2 y/ |( H& ~% ] _
and his psychosocial and psychomotor development- b2 v+ d, X+ \& t
was age appropriate.( m' w2 I9 R6 D; Z
The family history was remarkable for the father,* K, \+ C R( q. ~2 y$ ?
who was diagnosed with hypothyroidism at age 16,2 C2 B1 T6 f7 a! G7 h& e2 Q
which was treated with thyroxine. The father’s
. n- p" B8 M6 z% C1 \height was 6 feet, and he went through a somewhat
& P/ W6 t6 ~( Z; bearly puberty and had stopped growing by age 14.# o a- v4 q$ J
The father denied taking any other medication. The
# Z' M) U7 E$ t* ~+ \# xchild’s mother was in good health. Her menarche$ M0 ]& o6 j" A4 N0 U1 B: B- u4 L
was at 11 years of age, and her height was at 5 feet
: X$ {3 N1 y* [- K1 A5 inches. There was no other family history of pre-
6 ?# @4 d! J: A7 N1 Ecocious sexual development in the first-degree rela-
$ \9 R8 c( s7 K5 i* a+ ~5 Vtives. There were no siblings.
6 A) W- t% v) M+ W7 @2 ?Physical Examination
0 ]1 W+ ~) r: ~; k- KThe physical examination revealed a very active,
: _7 h% M& t1 M3 {' K: O O: fplayful, and healthy boy. The vital signs documented' \7 A! G( K/ ^2 G7 _8 X
a blood pressure of 85/50 mm Hg, his length was
* w* {$ G+ ~, }' F7 _; ]90 cm (>97th percentile), and his weight was 14.4 kg- N9 O$ U; z5 [2 t; ]) O
(also >97th percentile). The observed yearly growth* @4 X5 `7 D) f1 A$ ]
velocity was 30 cm (12 inches). The examination of. ^( H6 p9 e- r1 w$ S0 d$ L+ `
the neck revealed no thyroid enlargement.
1 m; M1 p6 _7 {The genitourinary examination was remarkable for
3 f5 l8 Z) g; W* [7 l6 oenlargement of the penis, with a stretched length of
: n8 }( m0 R$ z8 cm and a width of 2 cm. The glans penis was very well/ l4 ~+ v' a5 A1 d& b( A4 s7 L1 t
developed. The pubic hair was Tanner II, mostly around. b, q) K0 X7 _: ~/ l$ M
5407 a, Q0 j6 b) Q. ~' I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; k- q# M0 b0 t* {$ w( I3 J. X5 e/ athe base of the phallus and was dark and curled. The
) |, l( R. B% |) M- i) i, T* n6 dtesticular volume was prepubertal at 2 mL each.4 Y" k. e+ C; M1 E
The skin was moist and smooth and somewhat
} |+ J2 [2 o& u1 R& x, Yoily. No axillary hair was noted. There were no; b$ o$ E" A; r. F M6 c' ^
abnormal skin pigmentations or café-au-lait spots.
# x! |- D6 q4 F1 fNeurologic evaluation showed deep tendon reflex 2+
+ Q! l! G( R. r. ~: O( o3 ybilateral and symmetrical. There was no suggestion
& o/ p# x1 e+ v' vof papilledema.( Q) D1 [! x- V8 a+ k& e/ N! J% I
Laboratory Evaluation, f0 }0 ]. q, ?9 ^2 }& Z. o$ N" k
The bone age was consistent with 28 months by; h: g1 m( M: \& g9 A0 J& V
using the standard of Greulich and Pyle at a chrono-) B% P0 ]4 R8 m f7 p0 a Z* h3 o
logic age of 16 months (advanced).5 Chromosomal- l# }. v8 N) B9 `& l6 Q
karyotype was 46XY. The thyroid function test
7 W+ O: [2 Y6 }) {showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( Y* f6 m: a3 Y/ [lating hormone level was 1.3 µIU/mL (both normal).
' H5 ]1 q- A% M* i# mThe concentrations of serum electrolytes, blood {) j0 b& O0 ]/ i" u
urea nitrogen, creatinine, and calcium all were5 {' x" a" S" R q! X
within normal range for his age. The concentration# Z0 E2 M$ ?. j+ V
of serum 17-hydroxyprogesterone was 16 ng/dL( T z% a5 }8 [) N- ~' C, _5 p
(normal, 3 to 90 ng/dL), androstenedione was 208 a9 }% { c4 S, v: @9 R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' @% Q6 t! I9 Z6 [. k2 h: Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 }4 ?! k0 s( [4 f3 _/ N1 Z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- U" V! ^- |% n9 J* e1 O I3 Q
49ng/dL), 11-desoxycortisol (specific compound S), m8 ^8 P9 r( y) }/ C3 x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 q; u( D0 S& x: u8 itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 ^8 W+ y& D7 Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' p+ J9 V) r5 v! H$ z' G5 u6 q+ J$ \
and β-human chorionic gonadotropin was less than
$ G6 p- }" i0 a- |, ]1 L7 B5 n- R5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 ~. u) N# w1 @/ |4 s$ d+ Zstimulating hormone and leuteinizing hormone
9 V0 u% n% S6 D j0 Q. ^% Cconcentrations were less than 0.05 mIU/mL
1 W8 u3 t" T- a# N9 ?(prepubertal).5 m+ k5 f* X7 p' n& X9 h5 y' Z
The parents were notified about the laboratory
8 k4 m) i0 M) ] Q' cresults and were informed that all of the tests were
. t1 w+ y6 S0 R7 d: z$ K8 hnormal except the testosterone level was high. The
( d4 `2 b1 x) Y: Y3 v1 F4 xfollow-up visit was arranged within a few weeks to7 ^9 a" S- W. e# |* L1 |5 y3 ]
obtain testicular and abdominal sonograms; how-
- q# s) M7 ?/ _) E) N) Z0 t! A* Eever, the family did not return for 4 months.
2 {- Z) R4 L3 f6 \ n+ ~4 \2 `Physical examination at this time revealed that the) {2 n9 m9 @5 x. o- j3 @" y& k
child had grown 2.5 cm in 4 months and had gained u5 X S3 K, e8 j
2 kg of weight. Physical examination remained
' | X- P0 m" Hunchanged. Surprisingly, the pubic hair almost com-4 a; Q2 U5 Q& W) I" i( `
pletely disappeared except for a few vellous hairs at- n# C2 t' B1 M* x: ^
the base of the phallus. Testicular volume was still 2
% P% [. ]& Z# |. emL, and the size of the penis remained unchanged.+ H3 j7 |8 I) ?6 e
The mother also said that the boy was no longer hav-2 s+ C/ u0 _9 `% B) @! k8 a9 O
ing frequent erections.
1 U9 A3 X7 u2 e. D$ {Both parents were again questioned about use of! O: k, S2 Z* D, i
any ointment/creams that they may have applied to
' Q/ n% ]7 e" @/ l) q# athe child’s skin. This time the father admitted the0 W: q/ ^9 E2 D+ L, D
Topical Testosterone Exposure / Bhowmick et al 541
% K! u- K) g! q, h/ n1 suse of testosterone gel twice daily that he was apply-
8 Z" P* |+ K. Y& ging over his own shoulders, chest, and back area for
9 K7 P2 w) [ f5 f+ e6 Va year. The father also revealed he was embarrassed8 H# F$ |2 q$ V8 w; X. L( N
to disclose that he was using a testosterone gel pre-
/ R9 p2 O$ z: F8 b8 b( x, U0 ascribed by his family physician for decreased libido
- a. ]% T0 _$ \7 x; x* Fsecondary to depression.* N9 k" ~& K, L2 c
The child slept in the same bed with parents.- Z3 m" P2 q) z; q
The father would hug the baby and hold him on his
: [3 n. C$ s4 u1 y/ hchest for a considerable period of time, causing sig-6 ?" m9 o5 z3 }7 A
nificant bare skin contact between baby and father.4 J- c# Y" R8 }: b# D! u4 S! V2 W6 ]
The father also admitted that after the phone call,) w7 Y% `: N: j+ }9 t2 O
when he learned the testosterone level in the baby# J. ] m& O9 I5 g9 b
was high, he then read the product information3 t7 ~3 O% \# H {$ x6 _# T* z
packet and concluded that it was most likely the rea-
+ g3 z* M( z' {! o0 ison for the child’s virilization. At that time, they
4 w2 p3 o, ^0 Y8 G2 Fdecided to put the baby in a separate bed, and the
+ W y" S0 _, F, rfather was not hugging him with bare skin and had) \) ?8 l! B$ Y; K& g/ h3 n) ]
been using protective clothing. A repeat testosterone( w6 y* T8 [3 D, F
test was ordered, but the family did not go to the; V( h7 z+ v: Z4 R; g" C
laboratory to obtain the test.9 o1 A9 E1 O4 p& h. d( r% e1 ]
Discussion& L7 w; e, N$ G, j" `
Precocious puberty in boys is defined as secondary
/ V6 x$ \/ C5 T% Psexual development before 9 years of age.1,4
7 w/ @& b" a; x9 R# dPrecocious puberty is termed as central (true) when+ Q+ e7 T. z. c+ e( G9 ~. }& N
it is caused by the premature activation of hypo-1 U7 P* ~2 N3 G: { V d3 Y5 Q" j* |# O
thalamic pituitary gonadal axis. CPP is more com-6 j1 a& k0 \ |6 x7 C( w
mon in girls than in boys.1,3 Most boys with CPP0 {6 v: r2 x* K
may have a central nervous system lesion that is
2 z/ C: q1 q- E8 K& Zresponsible for the early activation of the hypothal-
; |' J( ?9 j1 O+ Qamic pituitary gonadal axis.1-3 Thus, greater empha-
* E; I+ l+ n3 f8 asis has been given to neuroradiologic imaging in+ j: Z( g" y" ^
boys with precocious puberty. In addition to viril-& t' \; w! Q& R$ b/ B( t, L* _
ization, the clinical hallmark of CPP is the symmet-5 Q" z7 n- L5 N; D& a% V# ^# g
rical testicular growth secondary to stimulation by; p& d* f1 O- c
gonadotropins.1,3
; S$ D3 D/ T& F7 r) [Gonadotropin-independent peripheral preco-
9 M3 N, n& M! F) c' C) U3 Ocious puberty in boys also results from inappropriate7 p4 c9 m' i- j3 A+ T
androgenic stimulation from either endogenous or
3 G( v7 v9 e \5 ]; E$ k) Zexogenous sources, nonpituitary gonadotropin stim-* y7 b! k& N" C0 G
ulation, and rare activating mutations.3 Virilizing' F3 Z( G( U+ k' k0 T+ |
congenital adrenal hyperplasia producing excessive
0 r' F/ F4 G4 Z6 [" F+ w' ^adrenal androgens is a common cause of precocious% i2 ?, @" Y, F; w0 A
puberty in boys.3,4
& [5 I# R' L% d- A( w6 z; PThe most common form of congenital adrenal
! T4 S% }. |6 o' D2 Chyperplasia is the 21-hydroxylase enzyme deficiency.5 Q! Q( j7 o1 h" I7 p9 p+ K. E
The 11-β hydroxylase deficiency may also result in6 r* W/ z( b) b; a7 a3 A5 ]' l
excessive adrenal androgen production, and rarely,
% l# b2 }& r$ X( K/ Aan adrenal tumor may also cause adrenal androgen
& w/ s# z F+ `( C0 _excess.1,3/ G: K- H7 Q5 O" g/ {: u. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: e/ O2 V. ]: v3 Y) C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 ], O9 T0 E; z' k! R; n" H
A unique entity of male-limited gonadotropin-: ^6 q; O" E' R) j7 r5 j
independent precocious puberty, which is also known
. x# M5 K( ^) Z3 N' Cas testotoxicosis, may cause precocious puberty at a
' g5 F% T0 u+ S. y2 j+ ]* l! gvery young age. The physical findings in these boys: n F4 j+ M7 w/ `1 V4 [* Y0 t, x- a
with this disorder are full pubertal development, p9 u. a$ F% s
including bilateral testicular growth, similar to boys
0 w1 M p" {: A4 Q6 ^; ?2 {5 \, jwith CPP. The gonadotropin levels in this disorder
7 v3 Z; k* k- B8 g: a; ~1 ]7 Zare suppressed to prepubertal levels and do not show: ?6 V4 l, F: o% ?/ N% Y0 [1 Z
pubertal response of gonadotropin after gonadotropin-6 [# T( v& \# |8 s W
releasing hormone stimulation. This is a sex-linked
1 o6 c! r! ]" Y3 K' b/ `; mautosomal dominant disorder that affects only& \2 C( Z. g5 s" K7 d3 `: c
males; therefore, other male members of the family
' Q2 C4 B, f* n& M% K, Gmay have similar precocious puberty.3
2 _& p7 {# v# c/ J5 Q0 wIn our patient, physical examination was incon-
. ^1 @; M3 O' V& q# P( jsistent with true precocious puberty since his testi-$ A0 }0 J0 A+ o3 ^/ H
cles were prepubertal in size. However, testotoxicosis
. r0 q2 y9 K" n g) I# gwas in the differential diagnosis because his father
3 {8 j- c1 D, D; Lstarted puberty somewhat early, and occasionally,
) w0 G2 x9 M/ W* gtesticular enlargement is not that evident in the% s( a% O2 A/ V# a
beginning of this process.1 In the absence of a neg-- L3 c- C6 {/ d; l0 ]0 m/ \
ative initial history of androgen exposure, our# k3 h& g4 C- {6 ~8 Q6 @
biggest concern was virilizing adrenal hyperplasia,7 ~" t( D' I6 Q$ b0 v
either 21-hydroxylase deficiency or 11-β hydroxylase% G: l* d: e0 i3 g J$ ]$ \
deficiency. Those diagnoses were excluded by find-
5 z+ ]" E! C1 E( H0 ~ing the normal level of adrenal steroids.
/ a" r5 i4 x6 \$ n6 ~5 ?The diagnosis of exogenous androgens was strongly9 K; ^# f" n, Q) w( Z
suspected in a follow-up visit after 4 months because1 Z7 V$ T4 Q2 |! N
the physical examination revealed the complete disap-
: t$ r- N' g2 }# u' ypearance of pubic hair, normal growth velocity, and3 f* c" {, A7 V2 Q" h+ f
decreased erections. The father admitted using a testos-
) |+ P4 V+ ?& J2 yterone gel, which he concealed at first visit. He was
% F8 E5 ]2 Y/ ^) E9 Musing it rather frequently, twice a day. The Physicians’
: |4 E ?5 |+ `5 {. {1 Y( h, MDesk Reference, or package insert of this product, gel or
) A Z: Z5 Y6 W4 ?" Q. Tcream, cautions about dermal testosterone transfer to
3 @& t9 B2 _% C4 O7 ~unprotected females through direct skin exposure./ S/ o: V) q# P. o9 C: Q) B( X
Serum testosterone level was found to be 2 times the2 |: {" j9 A o
baseline value in those females who were exposed to: R( O3 x4 Z) D! t
even 15 minutes of direct skin contact with their male5 n! B9 Z9 T6 y y
partners.6 However, when a shirt covered the applica-% c7 B% ]5 G( e0 c4 R C
tion site, this testosterone transfer was prevented.4 X: L7 y/ z' l2 x7 j2 z2 J7 W. m P
Our patient’s testosterone level was 60 ng/mL,
$ q' c, S, w" J* ^. hwhich was clearly high. Some studies suggest that
' W$ a a3 A, ]8 w' P% O0 xdermal conversion of testosterone to dihydrotestos-
5 s3 b5 j" Q& x" X- M! Z5 x, b; vterone, which is a more potent metabolite, is more
. {& J- b) I' M. t% s/ eactive in young children exposed to testosterone
6 i% ~2 I5 E; T6 n; z% M0 wexogenously7; however, we did not measure a dihy-( J* J4 r" X: Z, E" ?$ m, O
drotestosterone level in our patient. In addition to
) u$ \( W' C7 q/ K" t1 Wvirilization, exposure to exogenous testosterone in
' t, m) j4 {+ R$ a, mchildren results in an increase in growth velocity and
, x% q j6 F; y; [& y: M Kadvanced bone age, as seen in our patient." E2 j3 F, D9 G7 {
The long-term effect of androgen exposure during/ }- ~8 ^+ j' P& U: s; |
early childhood on pubertal development and final9 A7 c: P2 p8 d5 T" K. I
adult height are not fully known and always remain
! q& I q7 k }. m ?4 qa concern. Children treated with short-term testos-
" X. \# n v( ?- y* Z( Qterone injection or topical androgen may exhibit some* [" J5 C+ \2 m+ o4 ^
acceleration of the skeletal maturation; however, after
5 m p7 r6 }8 Z1 hcessation of treatment, the rate of bone maturation
9 ^ l5 S0 i; i3 Udecelerates and gradually returns to normal.8,9
3 b/ [; X) |& }There are conflicting reports and controversy
" P0 v/ r/ Z# G- q8 ]# V- Vover the effect of early androgen exposure on adult
+ g1 V5 @$ v8 Q5 y6 t( wpenile length.10,11 Some reports suggest subnormal
4 n' I! i) A6 F9 |' padult penile length, apparently because of downreg-
$ F& @# O( D- y# n8 R' i8 {) ^" ~ulation of androgen receptor number.10,12 However,
, M M0 ~! x8 Y: q! O- I: @2 ISutherland et al13 did not find a correlation between
K3 }" b7 I8 l0 pchildhood testosterone exposure and reduced adult! O/ n0 V. p# G# g2 t+ |
penile length in clinical studies.3 G! M l Z8 Z& l, b4 [9 z0 O
Nonetheless, we do not believe our patient is: M2 |/ a" K, H- C; p3 J
going to experience any of the untoward effects from6 m. \4 k9 O1 ^4 X" F1 l
testosterone exposure as mentioned earlier because+ t& _2 t7 Z u7 s
the exposure was not for a prolonged period of time.
8 y2 {8 T# ?7 }: KAlthough the bone age was advanced at the time of, ` n9 p" ^; o: x- ]& u. q
diagnosis, the child had a normal growth velocity at
# F2 h* [2 o! ]' c; e U8 S5 kthe follow-up visit. It is hoped that his final adult( S$ D$ o8 m3 G5 O, P0 K8 l
height will not be affected.
; H. H# f: _% X, G" Y. z2 K0 RAlthough rarely reported, the widespread avail-- s% u8 }# x& s: T& X) O1 `
ability of androgen products in our society may8 w, o9 d3 ?6 @
indeed cause more virilization in male or female
4 r5 [# `7 G9 ~8 pchildren than one would realize. Exposure to andro-
2 c( l1 |7 S/ C9 dgen products must be considered and specific ques-
8 i* D& D3 O! x8 y7 G5 etioning about the use of a testosterone product or
7 N8 e9 H" J; dgel should be asked of the family members during
2 a4 {5 |0 }5 q1 C, y1 hthe evaluation of any children who present with vir-
) r9 T0 z8 b5 M& H% ~: f2 m6 l" Y' Silization or peripheral precocious puberty. The diag-) \- r; }4 Y4 e/ ~
nosis can be established by just a few tests and by
F' Y3 {/ u& S7 aappropriate history. The inability to obtain such a
! `6 U7 M3 E, Y' j5 p3 q& M% o- Bhistory, or failure to ask the specific questions, may2 a( G4 \; B6 O& i
result in extensive, unnecessary, and expensive
1 `+ B) W: L0 V! M( Q! i+ Y) v0 Rinvestigation. The primary care physician should be
c6 G" _3 h- r ~8 a1 eaware of this fact, because most of these children# v4 u* n4 ~! l" _, `
may initially present in their practice. The Physicians’
, ]) E( J: h3 C& jDesk Reference and package insert should also put a
) p& s; ^3 S- o! [! ?warning about the virilizing effect on a male or2 L5 x! Q" ?# k1 Y6 d) ]- y) U* \
female child who might come in contact with some-# b2 b& [" N! G
one using any of these products.* j5 H' U: z$ R- a8 M2 Z7 j
References
# q, s2 z) Q; d6 W k- c* y1. Styne DM. The testes: disorder of sexual differentiation
" W @: ^3 ?; ^8 \! |5 q* T# land puberty in the male. In: Sperling MA, ed. Pediatric
* f$ z+ h5 C* FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 j4 K! C1 C6 J6 C0 w4 O2002: 565-628.
k+ e& t( f M) n3 @2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 D3 b* d7 q" n* ]7 {. o
puberty in children with tumours of the suprasellar pineal |
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