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Sexual Precocity in a 16-Month-Old1 P0 g1 O, S+ t1 {% \# L3 j
Boy Induced by Indirect Topical
9 \* z# w1 g7 |: h# h: KExposure to Testosterone
( M5 K) C+ U; ^, Q# JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' H( a: r; ?. s T/ Hand Kenneth R. Rettig, MD1
3 G* `& T$ Y4 U2 GClinical Pediatrics
$ x0 ~9 s2 @0 v3 u: u" BVolume 46 Number 6
8 c ]0 r) m' H) `' @( u/ E1 r: bJuly 2007 540-543$ y! n3 S) `2 k4 ^: Q
© 2007 Sage Publications
% e4 @8 j1 \3 c2 _; G' X10.1177/0009922806296651: h% ~: _. U9 i9 L9 z' S9 l! N' ~
http://clp.sagepub.com
1 z+ H3 E& U$ u: `- U3 fhosted at
( k6 k9 Y' m% Y4 phttp://online.sagepub.com
( X& `5 G" @$ h, dPrecocious puberty in boys, central or peripheral,
% [' M5 |% r, R& yis a significant concern for physicians. Central& @ d$ b8 ]. z3 r$ W) C4 U/ B* @' m
precocious puberty (CPP), which is mediated2 \8 T& J' v3 Z5 D1 u! D2 F, Y
through the hypothalamic pituitary gonadal axis, has* ~8 X; A0 ^* p- t: c- H
a higher incidence of organic central nervous system4 _0 N3 N" H3 n U/ V8 X: w
lesions in boys.1,2 Virilization in boys, as manifested
# T I. h' m/ F, f) }; [# b( Gby enlargement of the penis, development of pubic) f+ @5 [+ V6 ]1 |. k4 }
hair, and facial acne without enlargement of testi-
0 _/ L. J: f! A& j T1 l7 zcles, suggests peripheral or pseudopuberty.1-3 We
( K P, @7 k; e0 _% dreport a 16-month-old boy who presented with the
) G' h# `) E4 Jenlargement of the phallus and pubic hair develop-, I; o* H1 P1 B& i' M4 V
ment without testicular enlargement, which was due
% ^; }: ~6 o0 q5 H! v! `, \* v. Xto the unintentional exposure to androgen gel used by
* o+ s7 r$ H8 D' b2 ]( v' I7 S' A, Gthe father. The family initially concealed this infor-
! v/ X% b3 F9 @1 N3 z" ?4 i7 Amation, resulting in an extensive work-up for this) }+ s/ C6 Z9 u* s
child. Given the widespread and easy availability of2 s' Q5 G* L& @& q
testosterone gel and cream, we believe this is proba-
8 ~3 Z: T1 \* F- W/ j2 Fbly more common than the rare case report in the
5 S$ ]" ^9 s P0 f8 N1 vliterature.4, T) q& j2 N9 b# ?% }4 W
Patient Report2 \/ K+ x5 `) ~" O* J/ I1 f; r2 u; z
A 16-month-old white child was referred to the
- T) b# e9 H0 b' H; A4 t9 Oendocrine clinic by his pediatrician with the concern. g, \7 y8 F: v+ M
of early sexual development. His mother noticed
+ p( S+ H% z$ E; n( r( c! Y+ ?light colored pubic hair development when he was9 W2 A+ G* ^7 W- o! _
From the 1Division of Pediatric Endocrinology, 2University of6 y% ^- B# c% w7 @
South Alabama Medical Center, Mobile, Alabama.7 O7 l' ~" w/ e. ? J
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 _6 j0 q, E) `. W( I$ B
Professor of Pediatrics, University of South Alabama, College of9 X8 M% o8 H6 F& {3 F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, \- F/ j h+ t( q
e-mail: [email protected].( O$ |: k: h. J; L) a" E/ i, o8 q
about 6 to 7 months old, which progressively became
, R. e* s& h" c( H2 m5 O9 r- H7 Adarker. She was also concerned about the enlarge-4 L* }/ T0 `# d! Y
ment of his penis and frequent erections. The child' h- D6 r2 `" t G$ ]% N
was the product of a full-term normal delivery, with
7 w- i# S P; ^( v" B0 u/ g7 Ca birth weight of 7 lb 14 oz, and birth length of
* `0 l3 p+ ^4 M20 inches. He was breast-fed throughout the first year; x6 D! n; _; `% k/ i! Z5 d0 s
of life and was still receiving breast milk along with1 W0 J- c( o1 j2 G, ^; ?" Y, D
solid food. He had no hospitalizations or surgery,1 G" d, r, b4 y4 K% t5 w) z' H
and his psychosocial and psychomotor development/ R n& z. ^$ b) x6 i# ^- B
was age appropriate.- n$ O* k, l4 p: v* g0 U& ~ _
The family history was remarkable for the father,! m! C1 [9 o, U+ `% a% ^
who was diagnosed with hypothyroidism at age 16, q7 f$ b, B0 ], }9 t
which was treated with thyroxine. The father’s6 M; o- _: L1 H8 Y4 z
height was 6 feet, and he went through a somewhat
" B; F" W F" Searly puberty and had stopped growing by age 14.
& y/ l9 d1 e, F5 v# lThe father denied taking any other medication. The
$ e( B7 U0 u" n' k/ z9 A; fchild’s mother was in good health. Her menarche
, O! D9 `( e$ j% F# t& a' [9 twas at 11 years of age, and her height was at 5 feet$ \, R6 a2 l' `. w& }# S+ E* y
5 inches. There was no other family history of pre-
) k# {; L5 h! n! ^7 Y% g( V& Tcocious sexual development in the first-degree rela-1 q4 M5 U! v* j6 Y7 Z
tives. There were no siblings.; N; m# G6 e( \' T3 q% j3 b. i/ H
Physical Examination- n6 K/ k7 x1 v
The physical examination revealed a very active,/ {6 I3 b% P# k4 F, `4 ~# g
playful, and healthy boy. The vital signs documented
. Y& f( B) L% x/ t5 ya blood pressure of 85/50 mm Hg, his length was
2 x: l* S. \9 U6 u: A" F90 cm (>97th percentile), and his weight was 14.4 kg
; l3 _& A) \4 ]- [# R(also >97th percentile). The observed yearly growth3 X+ C7 b! x3 D3 B
velocity was 30 cm (12 inches). The examination of
/ | J! B( T) q0 j8 O/ j8 \6 e" Nthe neck revealed no thyroid enlargement.1 }4 Y0 t8 p5 ?) h$ G3 t/ V3 G! N
The genitourinary examination was remarkable for5 I" s" G* U$ j
enlargement of the penis, with a stretched length of
3 |( ?$ W, J2 E, m8 cm and a width of 2 cm. The glans penis was very well
! E7 C8 J1 }! X* ~developed. The pubic hair was Tanner II, mostly around7 r4 U. m; l' r+ D# {
540
9 K0 q9 b7 Z/ S' P$ _, T1 ?( ?5 eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: S+ Z, s G8 j' c
the base of the phallus and was dark and curled. The( F! n( E+ v1 C; i B. R
testicular volume was prepubertal at 2 mL each.
5 j1 F5 y# n }5 ~! JThe skin was moist and smooth and somewhat; h ~. ]8 E% M* T( Y& C
oily. No axillary hair was noted. There were no4 j$ v# }; H2 W& ~/ I
abnormal skin pigmentations or café-au-lait spots." `, R; Z3 a/ C0 U
Neurologic evaluation showed deep tendon reflex 2+
0 O/ l& @- l6 U0 tbilateral and symmetrical. There was no suggestion! L& Q7 \* S% ^ }( P& u
of papilledema.
- D6 [: N ~" v' K1 YLaboratory Evaluation
9 W$ r3 L; z2 k' u2 i' c$ PThe bone age was consistent with 28 months by7 k* f( @9 [0 k& I& f. n
using the standard of Greulich and Pyle at a chrono-
) ]6 c" w' B# V" p2 U% k7 Llogic age of 16 months (advanced).5 Chromosomal6 N; Y6 V/ G/ m/ D0 }) m# H
karyotype was 46XY. The thyroid function test! N/ t( {0 n9 M) i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 a/ j8 U# u* q* y8 t: Flating hormone level was 1.3 µIU/mL (both normal).- f: G- I; N: P+ [
The concentrations of serum electrolytes, blood
9 K" q4 O+ [! t" L( D: N3 furea nitrogen, creatinine, and calcium all were
6 K- T5 B+ c6 G; Lwithin normal range for his age. The concentration& {4 D: O1 I1 U
of serum 17-hydroxyprogesterone was 16 ng/dL0 w1 @4 v3 c) }, y
(normal, 3 to 90 ng/dL), androstenedione was 20; P+ w6 [2 T" j6 T: v; e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! I/ a) G9 K3 z# E( u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ Q) c" Z, `6 `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( q5 w! l, Z8 r49ng/dL), 11-desoxycortisol (specific compound S); L8 l9 ~+ }* ]* g5 Y" E+ O; ?' ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 q0 m# o3 }& z6 P, `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 n* R, C4 O2 U- Y1 q S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ P3 O6 F) s9 X9 N( e/ Nand β-human chorionic gonadotropin was less than
/ G2 z5 @, ?- `" D4 `5 mIU/mL (normal <5 mIU/mL). Serum follicular0 U2 P$ v, ]9 h4 x
stimulating hormone and leuteinizing hormone
4 X2 x# Y7 `7 s! s/ Gconcentrations were less than 0.05 mIU/mL1 H, k( b+ U2 E
(prepubertal).( W' @1 n1 ?6 `$ U; b7 A
The parents were notified about the laboratory
" n5 M( b* g' J4 H3 E: Y) B! [results and were informed that all of the tests were) [6 \5 D- Z+ K1 b1 a; K; H
normal except the testosterone level was high. The1 [& u Q0 Z" S- ^: b
follow-up visit was arranged within a few weeks to
( Q9 y3 v4 G, L0 C% x. r# Jobtain testicular and abdominal sonograms; how-0 h- ]4 A, m) X3 o8 H
ever, the family did not return for 4 months.3 Z6 e& B J1 _2 Z+ Y5 d
Physical examination at this time revealed that the
& u6 k' B8 Q* L7 k4 jchild had grown 2.5 cm in 4 months and had gained( m: d+ M- I5 ?* q/ p9 n% z+ {
2 kg of weight. Physical examination remained6 |/ x3 S& F# t0 b! `1 u
unchanged. Surprisingly, the pubic hair almost com-
4 O! V0 w C2 U9 d& }# xpletely disappeared except for a few vellous hairs at
2 [, H g, {# h5 d$ W c1 B' Xthe base of the phallus. Testicular volume was still 2
2 |% ]2 A6 q& R& g+ `6 M0 LmL, and the size of the penis remained unchanged.: I' Q' [5 e' f$ X
The mother also said that the boy was no longer hav- L7 T, e3 S* q1 O5 G
ing frequent erections.! d& ~5 Y- {) e" T/ n9 Y
Both parents were again questioned about use of9 K) \# Y3 n d4 B
any ointment/creams that they may have applied to
4 @4 A* d) I% ~, K/ qthe child’s skin. This time the father admitted the! L; G) y3 K9 m2 {8 n
Topical Testosterone Exposure / Bhowmick et al 5411 p& M; l! T" Z2 D/ O% x- M
use of testosterone gel twice daily that he was apply-
, E) A: V) a6 `1 G) ~% O2 uing over his own shoulders, chest, and back area for
6 c8 b& P" ?3 M: c7 y, }0 Sa year. The father also revealed he was embarrassed
5 H! }7 x2 d$ D1 p1 K9 hto disclose that he was using a testosterone gel pre-. `+ Y9 |! ?7 ~8 R. P4 Y2 D( E
scribed by his family physician for decreased libido
0 Y9 Q t3 x5 ]0 O* Y" G0 vsecondary to depression.
3 C$ I) w: \$ j1 X5 C* X* b6 }2 M8 aThe child slept in the same bed with parents.
) P! U3 o1 l' C, nThe father would hug the baby and hold him on his
# M0 i5 C6 X: s Z# bchest for a considerable period of time, causing sig-. m7 O7 x6 o! c0 t2 E7 }
nificant bare skin contact between baby and father.
- q' Q. N3 H8 e& d( K1 q+ I# o+ ]The father also admitted that after the phone call,5 _/ }4 X* M8 ^) M& S k
when he learned the testosterone level in the baby
- R/ W, z* V4 D5 a. Y! awas high, he then read the product information
! P( a3 \3 g) h* E; }6 Dpacket and concluded that it was most likely the rea-/ L. C& J5 h" j1 M+ q
son for the child’s virilization. At that time, they
1 h( Z0 ?* K9 J, i7 v$ Vdecided to put the baby in a separate bed, and the" g7 c6 ~9 m' A
father was not hugging him with bare skin and had
. q/ p2 o% n: ?% G4 ~3 Bbeen using protective clothing. A repeat testosterone/ t$ D6 Q S q% N9 K- b/ m v
test was ordered, but the family did not go to the/ a0 _# E8 ~" v9 |
laboratory to obtain the test." ?, @- K( `: D0 n7 E- A$ }: c+ b
Discussion. N3 J7 h" @! G, U: g
Precocious puberty in boys is defined as secondary2 N U9 ?& f" f: Z
sexual development before 9 years of age.1,4
* G! T' @# M% C$ ]$ kPrecocious puberty is termed as central (true) when& v0 ~! Q! W+ d/ h: M
it is caused by the premature activation of hypo-: `: ]5 t( k+ d: o* v6 p( U
thalamic pituitary gonadal axis. CPP is more com-
4 l- Z4 i' k% T& Y% Omon in girls than in boys.1,3 Most boys with CPP
, W1 |8 H2 }6 {. t8 jmay have a central nervous system lesion that is
' ?6 i% g9 R+ j2 A! C! Fresponsible for the early activation of the hypothal-8 Q; K2 d. b) `$ u
amic pituitary gonadal axis.1-3 Thus, greater empha-
! A: K. ?- c+ a' `8 m2 w# L9 Y; gsis has been given to neuroradiologic imaging in
/ m( o1 L3 e5 G+ d2 H" N$ X: Dboys with precocious puberty. In addition to viril-
" C, e T5 p: d( Nization, the clinical hallmark of CPP is the symmet-
" X+ G, d5 t% u5 c7 M' x. D% X: `rical testicular growth secondary to stimulation by+ H* W" |+ P$ G" X p! @
gonadotropins.1,3# @$ l% u B7 |8 E* e
Gonadotropin-independent peripheral preco-
4 }0 w+ V- q' N! _% i* Bcious puberty in boys also results from inappropriate
- B m' H, R+ U: M4 c5 o' handrogenic stimulation from either endogenous or
3 Z/ ^; K7 G/ j3 x3 N9 aexogenous sources, nonpituitary gonadotropin stim-- Y; v9 ^& h6 |
ulation, and rare activating mutations.3 Virilizing4 V. c) y# v7 L! L
congenital adrenal hyperplasia producing excessive
2 _- q* | d, j8 X# `& _, l: cadrenal androgens is a common cause of precocious! v( T, b$ y. ^2 U
puberty in boys.3,4% o! O6 S: [5 T0 r i
The most common form of congenital adrenal
2 H* S6 `$ v O3 khyperplasia is the 21-hydroxylase enzyme deficiency.0 S: T# ^+ O4 s$ _0 V& i: S
The 11-β hydroxylase deficiency may also result in
% ]% |7 r9 j( w2 i2 H6 h) Cexcessive adrenal androgen production, and rarely,
) v4 ]$ [/ s5 g- Yan adrenal tumor may also cause adrenal androgen
f/ V3 x' j# W7 I& wexcess.1,3
/ z5 k4 X( d/ j, [7 a4 F" V0 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 c7 H7 f1 X! M. y2 O: d# G; C% u
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ w6 o* Q$ r4 x4 J6 s
A unique entity of male-limited gonadotropin-! _! d; T5 n8 ^4 p
independent precocious puberty, which is also known9 D+ M3 _1 d. m. R" E
as testotoxicosis, may cause precocious puberty at a
, Z9 k: H5 r- p8 wvery young age. The physical findings in these boys( I9 g+ a% B- k: y+ i
with this disorder are full pubertal development,/ _( }( C2 L9 W0 L. w
including bilateral testicular growth, similar to boys
/ E1 L; I" C* U$ k( [7 qwith CPP. The gonadotropin levels in this disorder$ F, v8 s. Z4 |' ^. U. p, ]
are suppressed to prepubertal levels and do not show
5 u# K8 t }& l) r" [5 p7 A3 c& ipubertal response of gonadotropin after gonadotropin-
9 I+ _8 J/ r# `' Q/ }' ?releasing hormone stimulation. This is a sex-linked
. K" t" k% h0 `, \& bautosomal dominant disorder that affects only8 r( o& r u" n' ]7 D
males; therefore, other male members of the family% ?, | v7 }. S' x* w* p1 ~- l
may have similar precocious puberty.3
( b' P* `/ h# k4 F/ G1 x8 gIn our patient, physical examination was incon-5 m( |+ i& \8 n" W- `
sistent with true precocious puberty since his testi-! n! _- Y* Y! M
cles were prepubertal in size. However, testotoxicosis
! N/ I8 N% ` t& s4 M9 Qwas in the differential diagnosis because his father
: A' Q4 m, r! C$ v3 \started puberty somewhat early, and occasionally,
- y/ d, e( Q) r0 \6 ]testicular enlargement is not that evident in the! G7 \! E3 w: o) A' M
beginning of this process.1 In the absence of a neg-- \2 O7 w2 {$ f' @7 W8 D
ative initial history of androgen exposure, our& `. g: h: N1 l) m+ M( S9 L1 r
biggest concern was virilizing adrenal hyperplasia,3 s% Q4 {* l9 O2 ~* F
either 21-hydroxylase deficiency or 11-β hydroxylase; V! q8 H( W' Q# A6 Y9 w3 \9 z
deficiency. Those diagnoses were excluded by find-
" k' z: C/ j4 V( B2 B; ^( a4 aing the normal level of adrenal steroids.
& N& L$ v" a! D3 m1 XThe diagnosis of exogenous androgens was strongly e$ p! J# m. a5 A' D, V# L
suspected in a follow-up visit after 4 months because" A1 H) L! Q, }: y( E7 g; f
the physical examination revealed the complete disap-7 F n8 `- p. D/ C: W& i
pearance of pubic hair, normal growth velocity, and
# m3 e' j' N; v' w1 g- |decreased erections. The father admitted using a testos-5 g. C. {. I: n l
terone gel, which he concealed at first visit. He was9 C+ F; s8 E2 v
using it rather frequently, twice a day. The Physicians’2 P0 b1 L* |2 K; {
Desk Reference, or package insert of this product, gel or& F/ l& Q% j1 R
cream, cautions about dermal testosterone transfer to' z0 Y7 V: G( n# j! w( y
unprotected females through direct skin exposure.' \2 U5 c! b+ H' A: J7 x) ?0 U
Serum testosterone level was found to be 2 times the: L( E1 c& c% W& D) |% G! G5 @/ U7 k
baseline value in those females who were exposed to
: ~3 K$ g, s& keven 15 minutes of direct skin contact with their male/ O" m" L/ r# N
partners.6 However, when a shirt covered the applica-
* \$ K$ W: u# U. U5 \tion site, this testosterone transfer was prevented./ x7 I9 i `, {) P( i
Our patient’s testosterone level was 60 ng/mL,
2 a8 e4 i/ S2 mwhich was clearly high. Some studies suggest that
: d* E' g7 i4 Z9 i# _5 j+ y2 idermal conversion of testosterone to dihydrotestos-2 \5 V, c4 q$ J% U0 E8 A j
terone, which is a more potent metabolite, is more0 ?9 p% r6 F+ E1 K3 N' b% b
active in young children exposed to testosterone
# i& p3 U& k5 u/ ^- Q: z& kexogenously7; however, we did not measure a dihy-, o0 r8 ]5 _0 `; c+ ^+ G
drotestosterone level in our patient. In addition to
( R. M/ e6 I2 D9 x; K! Ivirilization, exposure to exogenous testosterone in
# O% @' w3 s* Y& ~* Echildren results in an increase in growth velocity and( v1 j2 }4 \# _
advanced bone age, as seen in our patient.. A8 v# e8 n# ~ T7 b
The long-term effect of androgen exposure during
, p/ P$ P/ `# Cearly childhood on pubertal development and final
% q+ q# H0 D8 }adult height are not fully known and always remain
9 C" L( {% f* g! ya concern. Children treated with short-term testos-* \) w/ f) Q" \5 ~; _
terone injection or topical androgen may exhibit some
' Y5 g$ ~* c( o9 n9 r% Q2 t. lacceleration of the skeletal maturation; however, after
9 \( ^% Q t( i3 N# J3 Ccessation of treatment, the rate of bone maturation# V; B9 I& J: d3 d- Z: c7 |6 j& P& B
decelerates and gradually returns to normal.8,9# [6 [* l, G0 r
There are conflicting reports and controversy
1 o* d* _8 {+ j' v5 yover the effect of early androgen exposure on adult
; D ^+ j2 A0 Z1 g, }penile length.10,11 Some reports suggest subnormal
) |1 c/ X: G+ V6 l) hadult penile length, apparently because of downreg-$ b; ^# Y, I! ^5 I7 F# j, t
ulation of androgen receptor number.10,12 However,3 D" X& l6 `2 E: r3 k( i: U! y
Sutherland et al13 did not find a correlation between
$ C7 m; d+ o7 e; k. B, qchildhood testosterone exposure and reduced adult/ j: u* r( q) m, p: Z
penile length in clinical studies./ p, [% K. s/ S$ u" C8 a* F" r
Nonetheless, we do not believe our patient is
3 [$ t9 ^+ c- A4 X2 s! }going to experience any of the untoward effects from4 c; C3 i. E: S' Z! Y4 \' g2 U# c
testosterone exposure as mentioned earlier because
6 }; _* T/ | ^* b: othe exposure was not for a prolonged period of time.
9 L5 \$ Q8 Y; `$ U* ^Although the bone age was advanced at the time of' v5 E+ x4 v3 y2 t# ~
diagnosis, the child had a normal growth velocity at& o: g! J/ q# y" D; A" A$ K
the follow-up visit. It is hoped that his final adult5 W7 A! i$ [# @1 t# z5 G
height will not be affected.
2 S+ i/ U+ H! b8 ]. L" bAlthough rarely reported, the widespread avail-
2 E0 [/ ]! L zability of androgen products in our society may# Y+ c2 P' a- X
indeed cause more virilization in male or female9 V- f* I+ Q0 }0 F
children than one would realize. Exposure to andro-% C# _, @; K4 p1 s. o
gen products must be considered and specific ques-2 N% m! ^. X0 e# _% G0 p
tioning about the use of a testosterone product or
A9 M5 g2 ~# Y* M; ~4 j5 W8 n% ^0 Mgel should be asked of the family members during8 i; b9 c) D; v d' r0 Y) T
the evaluation of any children who present with vir-
3 {' E" T. _ V' ~, n# Y3 W9 Silization or peripheral precocious puberty. The diag-) q9 t) I# m3 h4 w! \
nosis can be established by just a few tests and by
; b. ]( `& I- ]- `6 E$ vappropriate history. The inability to obtain such a3 ~& e5 A# H6 e9 S/ N+ z: V
history, or failure to ask the specific questions, may3 s; s ^4 Y" i, F, S1 ~$ y
result in extensive, unnecessary, and expensive5 G+ U$ ^2 q/ u9 K! [( d% W
investigation. The primary care physician should be
- ?$ D& g3 C. d* }6 K: s8 Kaware of this fact, because most of these children; {5 R7 A: X6 f! ]! f
may initially present in their practice. The Physicians’. `; Q3 Q T6 m w
Desk Reference and package insert should also put a. B5 d1 ?- U: ]
warning about the virilizing effect on a male or1 _4 a$ s& F; k+ ?
female child who might come in contact with some-
1 I' j) A! c" _4 v# X% Cone using any of these products.% q2 E, V! L5 d+ {7 U8 A9 b2 f
References L6 w4 ]" U& h6 ~6 i
1. Styne DM. The testes: disorder of sexual differentiation
" e$ T7 r; A) T( ]3 [# S& ^and puberty in the male. In: Sperling MA, ed. Pediatric
' _+ D' j' v' D: L EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% o' r# T: S! K8 K: M2002: 565-628.
' @& a9 Y! q5 L" O2 ~2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: x% x9 v Y: F4 opuberty in children with tumours of the suprasellar pineal |
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