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Sexual Precocity in a 16-Month-Old" J% @7 [0 [5 e4 ~
Boy Induced by Indirect Topical
" O- `$ D$ D0 BExposure to Testosterone0 P" J& O/ B4 l, U# e" i- N6 c* p
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; `8 R- E5 \5 _- D5 X+ U2 H
and Kenneth R. Rettig, MD1
7 i+ ?/ F/ E, t$ W! SClinical Pediatrics
: @( U! ~$ y: uVolume 46 Number 6( L2 O q* M8 h! \. D/ J! U
July 2007 540-5433 f4 G6 {' f/ W# s- H8 ]& Z7 |! C8 H
© 2007 Sage Publications) n8 d& J8 B+ ]8 J! |. j
10.1177/0009922806296651
; {6 _7 Z+ b6 w2 W+ k/ whttp://clp.sagepub.com
7 Z7 R9 e3 \ u. ^6 K& D2 d ^hosted at A% {, @ Y; q1 F
http://online.sagepub.com
4 {& A& F8 w+ _+ gPrecocious puberty in boys, central or peripheral,
9 C* ?. K; l' Q* N) Y6 yis a significant concern for physicians. Central9 s' Q1 ?! e4 X$ {) ]
precocious puberty (CPP), which is mediated) a9 e; M9 z/ ^" x
through the hypothalamic pituitary gonadal axis, has! Y% y( |% y9 U- j4 z/ t
a higher incidence of organic central nervous system! b0 }, @# ^: r5 w( ~
lesions in boys.1,2 Virilization in boys, as manifested( D/ C% s$ D7 s6 m- j
by enlargement of the penis, development of pubic
9 z2 ]& E* i. V9 w2 _) C; Uhair, and facial acne without enlargement of testi-
, i% u2 r5 K9 N! pcles, suggests peripheral or pseudopuberty.1-3 We
3 D9 S6 Q- a0 e5 P/ M4 ^report a 16-month-old boy who presented with the
' P) L4 X/ ~ c9 G" x2 `: Qenlargement of the phallus and pubic hair develop-) C: o$ }- x- J' v, ]
ment without testicular enlargement, which was due
" X1 d- l( L6 T/ ito the unintentional exposure to androgen gel used by
( e3 ^4 y- h7 `, Pthe father. The family initially concealed this infor-
5 _' K' Z n/ n5 Ymation, resulting in an extensive work-up for this; e7 ^6 I8 B5 h9 k' }* f
child. Given the widespread and easy availability of
/ n6 S5 F) [# H7 F# k9 M) @, Qtestosterone gel and cream, we believe this is proba-
# R' u) N& O, k# }$ v$ a5 I7 s# _bly more common than the rare case report in the
! B6 r/ j s9 w" uliterature.41 G2 u/ l6 @3 K. n; L3 r1 |
Patient Report
% Z" @# ]9 i+ [A 16-month-old white child was referred to the
* \2 Y O% x$ `+ d! R6 E# Rendocrine clinic by his pediatrician with the concern- \ y% U( F2 d& k1 g
of early sexual development. His mother noticed
& I9 }3 a" T6 [' [light colored pubic hair development when he was
7 w8 u. U* w4 {' n7 \From the 1Division of Pediatric Endocrinology, 2University of
" B! ~3 V; K3 s+ ESouth Alabama Medical Center, Mobile, Alabama.
; h! R4 {8 J# q3 t OAddress correspondence to: Samar K. Bhowmick, MD, FACE,* w% f& h1 P. u8 A; ^
Professor of Pediatrics, University of South Alabama, College of
! S+ ]3 B8 }7 Q6 t& _/ n" sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# c3 @2 y: K3 p' {5 f0 Je-mail: [email protected].
' y! J6 R7 I/ N7 f# m# V" kabout 6 to 7 months old, which progressively became) r& c* ~" t0 e. ^
darker. She was also concerned about the enlarge-
' w6 t4 | N" a M. h2 ?; Ument of his penis and frequent erections. The child3 E9 t) K2 w) x( {2 T' }
was the product of a full-term normal delivery, with
! m6 P5 k. @- ~0 q5 ra birth weight of 7 lb 14 oz, and birth length of& ?7 O) I- h2 P2 g5 M1 w( L
20 inches. He was breast-fed throughout the first year. R; r8 W) O8 J# P, p; k
of life and was still receiving breast milk along with
+ i; L* I5 p" W* \4 \solid food. He had no hospitalizations or surgery,
$ x: T; M& e+ ?; k2 Tand his psychosocial and psychomotor development
O; w9 \# P, l( _* |% wwas age appropriate.
5 p- w' R: X/ N, y7 s. \The family history was remarkable for the father,; W0 a8 C% |- Y- d9 f h
who was diagnosed with hypothyroidism at age 16,
# H5 u% |& h$ M; w3 ?5 lwhich was treated with thyroxine. The father’s
8 L2 n' R8 P' F+ vheight was 6 feet, and he went through a somewhat
' L" ]) _2 I( x+ z4 b; m5 mearly puberty and had stopped growing by age 14.
2 b' P. v9 E* ]7 e1 ~% GThe father denied taking any other medication. The
4 E% h1 b- R7 ~5 v3 e9 Y+ achild’s mother was in good health. Her menarche
6 e$ J2 C) w* d4 g# rwas at 11 years of age, and her height was at 5 feet9 m, \9 ]) [# d" D6 O+ q* w
5 inches. There was no other family history of pre-
2 j7 m4 h) `6 Ncocious sexual development in the first-degree rela-, N) v5 _& M3 C6 _
tives. There were no siblings.
, Z) O, m5 k" ^" TPhysical Examination0 y0 E( }* E# b/ ]
The physical examination revealed a very active,
+ y4 ~1 X& B) M! Jplayful, and healthy boy. The vital signs documented6 u; R3 s% ^5 C$ i- n' d% U
a blood pressure of 85/50 mm Hg, his length was
# p' Q) T. A$ W* u! D5 ^: L90 cm (>97th percentile), and his weight was 14.4 kg
* R/ l2 J8 V! V5 ]* Y' o+ v' [(also >97th percentile). The observed yearly growth
5 F$ G( v3 ]+ j7 fvelocity was 30 cm (12 inches). The examination of
* C5 [% A/ V) }the neck revealed no thyroid enlargement.
4 T3 t5 o. o1 ?5 m+ jThe genitourinary examination was remarkable for2 Z3 f' f7 q0 m6 X5 a
enlargement of the penis, with a stretched length of) Q. T* Q0 N7 |, n1 ]7 r( n
8 cm and a width of 2 cm. The glans penis was very well' E5 f& f5 ^+ N; g
developed. The pubic hair was Tanner II, mostly around
s. J! b* A8 U6 g5 Z0 V5405 G3 o+ k6 @! r) n2 V# E3 F1 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# p0 x9 F- x3 |# Wthe base of the phallus and was dark and curled. The/ b9 c8 M; X# S, s5 B! L# G
testicular volume was prepubertal at 2 mL each.. }9 Q Q# ~! b* X7 O
The skin was moist and smooth and somewhat
2 D/ G2 P8 X. H# u# C8 s& coily. No axillary hair was noted. There were no
; F$ X4 U8 ]$ m i8 y4 [abnormal skin pigmentations or café-au-lait spots." l% I, b8 [3 `8 E
Neurologic evaluation showed deep tendon reflex 2+; f1 Z9 ]' W, ]
bilateral and symmetrical. There was no suggestion8 V- ?& u7 ]1 E6 v& V
of papilledema.
( {+ v3 T& B) T6 D B& iLaboratory Evaluation
, @7 }5 \3 l" Y& WThe bone age was consistent with 28 months by
5 H3 ~1 X1 ]6 Ausing the standard of Greulich and Pyle at a chrono-
% w' ^ D4 E# W8 k; Ulogic age of 16 months (advanced).5 Chromosomal7 B# z/ r* `( z- ]
karyotype was 46XY. The thyroid function test
5 @0 T' c2 A" W8 V7 B% x1 fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: b5 D: Z3 F6 D/ T- O; h4 {( I; Vlating hormone level was 1.3 µIU/mL (both normal).) R0 a, u5 T$ k- O/ F% D
The concentrations of serum electrolytes, blood
1 O. a3 S4 F; N( N r, X( D) v: surea nitrogen, creatinine, and calcium all were/ D# {2 k* ^! i. A- m6 f
within normal range for his age. The concentration
/ C# F% E# p* C" Dof serum 17-hydroxyprogesterone was 16 ng/dL
5 m$ c8 N* v, G, h* L# i(normal, 3 to 90 ng/dL), androstenedione was 20$ C% [% R' S4 M/ c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ f! J) \4 V$ o* N8 t8 Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% S7 X) L4 [. L& {desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' |! d! c) ~$ H/ g4 {' Q% q49ng/dL), 11-desoxycortisol (specific compound S)+ s# S- ^, B! q4 n8 j3 `; }4 x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 g6 {* M( l. j4 [* _& f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: Q9 O) `5 N L" S' ?testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, ]/ J# W& @3 P" }, ?
and β-human chorionic gonadotropin was less than O7 W! B O3 U' A2 s' v$ g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 V/ X# W) ^. N5 ?, Q7 bstimulating hormone and leuteinizing hormone
7 o9 ]; f. p# T5 y3 nconcentrations were less than 0.05 mIU/mL& J A+ Z* n+ U; G
(prepubertal).9 O" D. e* ^- K5 Z7 }$ G( Q: @+ Y
The parents were notified about the laboratory8 R- e0 I6 L! S) a8 Y W
results and were informed that all of the tests were
8 z2 v9 e& A! S8 ~% A- Onormal except the testosterone level was high. The& y4 y& E8 ^2 j8 w1 o3 Q! \
follow-up visit was arranged within a few weeks to
- t* [* u% m( O6 b& {: vobtain testicular and abdominal sonograms; how-
. W2 W' Q' K$ N0 O7 g' tever, the family did not return for 4 months.
/ [: n$ Z/ r3 G# h2 w* H2 IPhysical examination at this time revealed that the
6 d# r9 Q5 a$ o5 X2 b& Vchild had grown 2.5 cm in 4 months and had gained
" B( S/ v! L9 `4 b! M2 kg of weight. Physical examination remained. ]; Y% z2 t9 O1 a) s8 P& \7 F
unchanged. Surprisingly, the pubic hair almost com-; U: Q! l* e# R! w
pletely disappeared except for a few vellous hairs at
; `5 `- Z( H! ], K5 Zthe base of the phallus. Testicular volume was still 2
' }% K2 Q1 K4 S# C& Z) {mL, and the size of the penis remained unchanged.% e. K. B6 H9 H' ]* @2 [% c% C
The mother also said that the boy was no longer hav-
: k$ ^3 F w. T, h" }6 X) g, cing frequent erections.; u1 m: z' `% g) t* I
Both parents were again questioned about use of( o, q0 ~9 K* t$ Z0 U
any ointment/creams that they may have applied to: }( J6 u1 _9 ~- i. }0 r6 u" v4 i
the child’s skin. This time the father admitted the0 S' ~5 d! e* m: w& c5 F( X! [
Topical Testosterone Exposure / Bhowmick et al 541. R* }, P- D& |1 l+ b0 u1 s
use of testosterone gel twice daily that he was apply-
0 _0 Q/ \2 E1 r" j! f# S# Ping over his own shoulders, chest, and back area for
4 O( R/ O2 \' D: _# Ba year. The father also revealed he was embarrassed
- A& D, ~5 a* Ito disclose that he was using a testosterone gel pre-2 ?2 k# b# l9 s* _7 g! s
scribed by his family physician for decreased libido
8 C7 s) _4 e [+ M* q8 {secondary to depression.& w* i5 j3 N# Z* |4 W, W
The child slept in the same bed with parents.
' H" U8 m& Y& R) @2 n1 P9 I3 y4 SThe father would hug the baby and hold him on his
$ w! d: U, [# Z: c" [0 N" uchest for a considerable period of time, causing sig-
) T( O- l" R5 z' u( C! U2 t, tnificant bare skin contact between baby and father.
, m# q) a( e- l& i4 ]+ I: e6 d, PThe father also admitted that after the phone call,
+ f5 ~6 V& _; C. mwhen he learned the testosterone level in the baby
, y K! O$ k* X: ]$ L3 `: Nwas high, he then read the product information! k! f. P+ g% `' y0 D3 Q) f; `1 ]
packet and concluded that it was most likely the rea-
8 o# L3 H) a/ V1 Q7 gson for the child’s virilization. At that time, they
* y: ?$ g9 g& A6 a* Ndecided to put the baby in a separate bed, and the; L4 S0 B% A" I4 `4 Y
father was not hugging him with bare skin and had; h0 l, O: C4 e- N- Q
been using protective clothing. A repeat testosterone( G, F: b) Y4 V* j5 j+ a" j
test was ordered, but the family did not go to the6 Q- Z, ]: H3 f: z9 z
laboratory to obtain the test.
/ `1 ~0 p0 i2 W" `, LDiscussion
3 J2 H& I" N- j& Z2 e+ bPrecocious puberty in boys is defined as secondary
9 y! n( t5 @7 t& b1 bsexual development before 9 years of age.1,4) D* T# J N; q8 D. s
Precocious puberty is termed as central (true) when6 c4 e) w5 X3 E1 M) U5 E
it is caused by the premature activation of hypo-
* }& Q0 k- H, q4 {6 cthalamic pituitary gonadal axis. CPP is more com-
4 I. E+ }' E& y! imon in girls than in boys.1,3 Most boys with CPP
, E1 y3 I/ o1 ^% W, @) ?: L# S" s$ h5 Gmay have a central nervous system lesion that is
* f9 W" M) F# H# X9 G8 @9 Nresponsible for the early activation of the hypothal-
- h: m& a7 E* xamic pituitary gonadal axis.1-3 Thus, greater empha-
' q- k U5 D e9 R Fsis has been given to neuroradiologic imaging in: H# {0 t: C/ r2 j3 F% \7 E
boys with precocious puberty. In addition to viril-
2 B5 R" u8 G' Q* [ P3 j Cization, the clinical hallmark of CPP is the symmet-
, d* V) l3 E' q5 _2 H. B5 \rical testicular growth secondary to stimulation by
& S) Y% Z C/ e2 d! t3 Lgonadotropins.1,30 k) o/ G; \$ E9 E* s
Gonadotropin-independent peripheral preco-
" |; c! z, ]) ~' _) R1 jcious puberty in boys also results from inappropriate9 r' W# `3 u5 a6 O, Z' N
androgenic stimulation from either endogenous or
* V2 I4 h7 k9 s" |) x1 c) Cexogenous sources, nonpituitary gonadotropin stim-9 D$ [ a: |" f( f- |3 H- _
ulation, and rare activating mutations.3 Virilizing6 N) v' Q& B0 d7 Q, x v
congenital adrenal hyperplasia producing excessive
- ]# |1 _" f/ V. a- madrenal androgens is a common cause of precocious% P0 o' a% G* P9 T' u: ?
puberty in boys.3,42 e1 x! F8 Y( a g3 W( X
The most common form of congenital adrenal
C" ~2 W) r+ ?* `2 thyperplasia is the 21-hydroxylase enzyme deficiency.
. K5 T6 l- X- K5 u8 x+ D) T8 z. tThe 11-β hydroxylase deficiency may also result in0 x+ ^! H6 r G# T* ^& S/ p
excessive adrenal androgen production, and rarely,0 U: G/ |8 g3 e( J8 [
an adrenal tumor may also cause adrenal androgen
1 I' Z$ y3 @- |# Texcess.1,3 N/ E" s' j' s# y' j+ [7 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- V1 ]! o* i0 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: k( U* p( t6 o f ]) Q# d
A unique entity of male-limited gonadotropin-% Q) e6 G, q: z) ?
independent precocious puberty, which is also known
1 G4 l6 n# e9 Nas testotoxicosis, may cause precocious puberty at a7 \5 A- H5 w! `2 L5 G. m; H: `
very young age. The physical findings in these boys
, n1 k- L- T0 y' H0 Vwith this disorder are full pubertal development,! H$ a* h# ^. ~/ L, Y$ f7 L' H/ _
including bilateral testicular growth, similar to boys
8 i9 L @5 a% X( y* w" w" `2 O. gwith CPP. The gonadotropin levels in this disorder
% A% t, }( @ l8 [# P# H$ R' nare suppressed to prepubertal levels and do not show* x+ M4 T" n! ~/ v7 }, I
pubertal response of gonadotropin after gonadotropin-
! `6 k& [/ P; w Q, ^1 i3 oreleasing hormone stimulation. This is a sex-linked
6 ^5 z) ?5 N8 B7 f! L, s; D9 xautosomal dominant disorder that affects only
+ w% e g$ Y! K# R; `males; therefore, other male members of the family
0 `5 K, X- `: Q: Tmay have similar precocious puberty.3
& y3 U. o6 M3 ?4 P7 zIn our patient, physical examination was incon-7 |& ^* `! u" Z4 I1 K
sistent with true precocious puberty since his testi-$ B# y. R0 k; b' F% q3 h; C
cles were prepubertal in size. However, testotoxicosis
. { C4 P% Q/ U/ uwas in the differential diagnosis because his father, A: ]8 M R' q& k3 o
started puberty somewhat early, and occasionally,
+ X/ r2 T# e8 ktesticular enlargement is not that evident in the- i7 X, _8 X. x4 E0 u
beginning of this process.1 In the absence of a neg-- u7 F$ l( b8 C/ T* i, F& t( }3 {
ative initial history of androgen exposure, our* ~% h! Z" o6 {1 Y
biggest concern was virilizing adrenal hyperplasia,
0 h8 ?2 e2 ]. L5 J$ _! k0 meither 21-hydroxylase deficiency or 11-β hydroxylase
. \+ O5 X9 h+ Y" \0 }- H! O0 p$ adeficiency. Those diagnoses were excluded by find-8 n) ?! R" \" P( H: X$ R( D
ing the normal level of adrenal steroids.0 Y) N+ D$ U$ ~2 D% l
The diagnosis of exogenous androgens was strongly
9 Z4 A$ J& Y& X# p1 d6 Osuspected in a follow-up visit after 4 months because% k2 h1 i& A& ?0 X K2 ]
the physical examination revealed the complete disap-: |! H9 s1 }6 z
pearance of pubic hair, normal growth velocity, and
7 V, D7 a8 c$ `9 |- l: ]decreased erections. The father admitted using a testos-
4 |( N. i5 _7 ~: b2 ^terone gel, which he concealed at first visit. He was
7 k+ T( F* Y3 x& S9 u: xusing it rather frequently, twice a day. The Physicians’0 X6 g2 o8 ^2 l9 b) J7 z
Desk Reference, or package insert of this product, gel or
- q, U' X- C( j) ]2 N5 J8 Wcream, cautions about dermal testosterone transfer to2 W0 V' H: t1 X- T- S- f1 h6 H+ I
unprotected females through direct skin exposure.; l5 b* Z% V" e+ c
Serum testosterone level was found to be 2 times the
r7 m0 c3 y- p2 @4 i" Sbaseline value in those females who were exposed to+ y1 g% H `- t* k2 L D
even 15 minutes of direct skin contact with their male
4 G7 m* G3 s9 P1 h3 w' i1 Ppartners.6 However, when a shirt covered the applica-
+ t6 P7 v$ q! f1 f! d& ition site, this testosterone transfer was prevented./ c- G' B3 B2 V' W
Our patient’s testosterone level was 60 ng/mL,
# z$ j& i% S6 r# gwhich was clearly high. Some studies suggest that& K, v+ b6 E/ e& h K
dermal conversion of testosterone to dihydrotestos-; C. Z' Q2 P) j0 E; v) `$ F
terone, which is a more potent metabolite, is more* r, Z* H0 u. O* M
active in young children exposed to testosterone6 h% i) x. @8 e4 O* H
exogenously7; however, we did not measure a dihy-5 ?* A, ~$ v. M" q
drotestosterone level in our patient. In addition to
+ H8 G7 ]7 u6 Rvirilization, exposure to exogenous testosterone in
/ P- O4 ] ~9 ^, ] q( U. Ychildren results in an increase in growth velocity and" Z4 h) i7 x9 D- u) a- k9 c
advanced bone age, as seen in our patient.
; Y! |- C" {2 p* o# i$ [The long-term effect of androgen exposure during# a- r# g" d: X1 j2 u
early childhood on pubertal development and final# A1 t! p6 ?9 R$ F; @* b" i
adult height are not fully known and always remain/ K1 K3 }5 m# ]6 q; j
a concern. Children treated with short-term testos-, a% [ l7 H: A3 B' |
terone injection or topical androgen may exhibit some8 x' N9 q, {1 R7 [- \
acceleration of the skeletal maturation; however, after1 z1 O8 k. F3 \' Y9 V1 d% i b7 k
cessation of treatment, the rate of bone maturation
+ @7 l5 a( U! g- v3 w5 B+ G# Mdecelerates and gradually returns to normal.8,9
; ?+ D: X$ B9 L( F% \4 t1 f$ OThere are conflicting reports and controversy2 X+ z' B6 k; X, E3 c
over the effect of early androgen exposure on adult
4 L* ~3 R9 N; J# @6 R7 x1 ~' C9 Rpenile length.10,11 Some reports suggest subnormal0 d9 `# j# a7 p" ~
adult penile length, apparently because of downreg-3 v3 F" X9 j i- ~* c3 ~6 ^* {
ulation of androgen receptor number.10,12 However,
9 K" K. b& j! }) D# USutherland et al13 did not find a correlation between
( v% i3 N" R/ N2 Q0 Dchildhood testosterone exposure and reduced adult' s5 V& ?3 h2 }/ a. q
penile length in clinical studies.
6 T' f0 e5 h% O: Z* PNonetheless, we do not believe our patient is0 E8 o! U4 _7 o) V/ ?3 B" H7 m
going to experience any of the untoward effects from g" \" ?4 X; J- q
testosterone exposure as mentioned earlier because
# }; |% y6 }: ^+ N. Ethe exposure was not for a prolonged period of time.
0 K6 O' y$ u6 J& M9 T' ~% c3 UAlthough the bone age was advanced at the time of% Y" B d* A* Y3 `( R& Z7 g! @( L
diagnosis, the child had a normal growth velocity at
A" R4 [& o& z Othe follow-up visit. It is hoped that his final adult
# ^* p" }4 A2 Z9 V" {! w% Theight will not be affected.2 y. J. M. i: K8 j- K& v
Although rarely reported, the widespread avail-
% Y% t" L! B# w: r3 @' tability of androgen products in our society may
* k/ M" U8 E b$ g9 o% p* D$ D6 Vindeed cause more virilization in male or female
( e* `: _$ k+ b$ Gchildren than one would realize. Exposure to andro-
9 `0 Z0 }% t! v2 q7 ugen products must be considered and specific ques-( p% X6 Z" G( r
tioning about the use of a testosterone product or
# H) b% t' }6 n$ v6 t2 g, {gel should be asked of the family members during
* ~; Y/ N3 o3 T i, c2 Tthe evaluation of any children who present with vir-
" z4 K. K: P. O! A: k4 ?# yilization or peripheral precocious puberty. The diag-7 {! ]9 r7 b0 i% ^! p
nosis can be established by just a few tests and by" {+ ^$ o( B' S! n: g) F
appropriate history. The inability to obtain such a
1 k9 H {, K d# Ahistory, or failure to ask the specific questions, may
3 h- f' Z1 i, I3 B$ D; w1 r9 ~result in extensive, unnecessary, and expensive
6 ~! b' P! w! uinvestigation. The primary care physician should be
/ z) i0 T. P- b W+ L. daware of this fact, because most of these children3 q' n/ ]4 j+ P' U5 K
may initially present in their practice. The Physicians’
# G; A) R; e: B. l j/ U& YDesk Reference and package insert should also put a
4 y$ p+ Q- O7 t _' H" i' J0 Qwarning about the virilizing effect on a male or
8 c6 B' b3 F, Afemale child who might come in contact with some-
' C+ S j4 z. B0 y3 Wone using any of these products. ^+ @' k% ~+ d7 r6 Y1 d" H" U
References
, X. k7 P7 L% a5 v( v1. Styne DM. The testes: disorder of sexual differentiation0 v' V$ E$ P D# S! c) H
and puberty in the male. In: Sperling MA, ed. Pediatric
+ O# q) h1 H. u( oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 F1 c, J h7 l" B4 ^! {
2002: 565-628.
5 G2 l( u0 b8 |! O+ N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( T9 Y8 S% B+ H0 ^5 j2 L9 N
puberty in children with tumours of the suprasellar pineal |
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