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Sexual Precocity in a 16-Month-Old: l7 j" l; e) f' z+ O
Boy Induced by Indirect Topical/ M* Q# _( _' z1 O2 n
Exposure to Testosterone
, ?* ~* ^6 D- j1 P& |- ~* |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ e1 K1 N3 ^4 @, Zand Kenneth R. Rettig, MD1
1 _ q& }0 z- K3 _' z/ pClinical Pediatrics
, u$ g. D5 ?* L$ l* o1 ] k' PVolume 46 Number 6# A! ^( `4 ^6 o8 h; v" v( s9 p
July 2007 540-543 q: s5 V$ z' I+ p
© 2007 Sage Publications* m7 U# q- G+ @9 C; Q' a# m1 C
10.1177/0009922806296651
. X: e: V2 P! M2 Lhttp://clp.sagepub.com
4 B5 I. {5 p: \! {4 A9 D" Shosted at
2 D. z" T* X" v' _- ?, `* Ghttp://online.sagepub.com
. I4 f& D1 p, J& D+ @Precocious puberty in boys, central or peripheral,+ b ~3 C% v; z+ _9 F& [3 ?
is a significant concern for physicians. Central( t) M y# q# g5 K1 a
precocious puberty (CPP), which is mediated9 R- _: c; N) ]9 u5 U" a
through the hypothalamic pituitary gonadal axis, has
4 D5 U9 Y/ x4 C" Qa higher incidence of organic central nervous system. W" E/ p0 T2 y; C" N9 ?
lesions in boys.1,2 Virilization in boys, as manifested! u7 B2 H- }/ x2 A1 }4 K* _9 `/ t
by enlargement of the penis, development of pubic
3 L! K) A3 {" w# F' B4 s d- z0 Qhair, and facial acne without enlargement of testi-) i6 f. u& i- m; X4 ~5 t0 G
cles, suggests peripheral or pseudopuberty.1-3 We! m% R4 |# [$ F( k8 y
report a 16-month-old boy who presented with the
) F1 t* z( w8 |) z, Wenlargement of the phallus and pubic hair develop-. C/ } O& P3 V$ d/ {. C) l. k+ ?
ment without testicular enlargement, which was due$ @: C* W& u- m) @# Q
to the unintentional exposure to androgen gel used by
! T3 a" k9 u4 g- l2 e. d% xthe father. The family initially concealed this infor-9 r0 M0 k" H7 }
mation, resulting in an extensive work-up for this
, C4 J( P6 Q! R. m$ B, Uchild. Given the widespread and easy availability of; X# i' g6 f8 l: R; W
testosterone gel and cream, we believe this is proba-
& m& E) Z. g! y3 V: s' ebly more common than the rare case report in the
" `# S* q' c% z, Y4 E( |literature.4
) b$ w: l4 m' o1 L" w5 i8 R2 mPatient Report8 T" U4 f3 Q; M4 b& P4 z i" `- |% ] d
A 16-month-old white child was referred to the- R& D n6 i7 V! p
endocrine clinic by his pediatrician with the concern
# k k4 [4 z# d' i7 }* P. Wof early sexual development. His mother noticed
# W4 U( O: g- V$ U( a% }light colored pubic hair development when he was- M6 q- Z+ p+ m
From the 1Division of Pediatric Endocrinology, 2University of
$ N( N! D: ~7 w! ?9 |1 `) XSouth Alabama Medical Center, Mobile, Alabama.
p" b0 I1 W) t1 l+ [Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ q2 r V- n+ J( F, i' uProfessor of Pediatrics, University of South Alabama, College of
' Y& c/ F% L: N( o! @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, u1 Z+ D7 w; T
e-mail: [email protected].+ [( E- H. d# G$ e9 x: z W2 T" u
about 6 to 7 months old, which progressively became6 a* k% X3 _7 I% f" a- M8 L
darker. She was also concerned about the enlarge-! ?' ? k2 h! _9 h& f% J+ S
ment of his penis and frequent erections. The child
$ u0 O2 l) \" Zwas the product of a full-term normal delivery, with y1 F/ V$ m" ^
a birth weight of 7 lb 14 oz, and birth length of) `% N( J$ |5 e5 Q+ U" M5 U, x/ }8 j
20 inches. He was breast-fed throughout the first year& n1 d' C; \( |* c8 M) S- c6 E4 _
of life and was still receiving breast milk along with
9 o& z3 y/ \/ Z8 Esolid food. He had no hospitalizations or surgery,; o [$ t; l# ^0 @7 S+ }5 n
and his psychosocial and psychomotor development+ h7 p3 B4 u$ x* M
was age appropriate.' G; b5 w' h5 ?
The family history was remarkable for the father,! ]" Q, f- n& C7 A5 T& m3 x
who was diagnosed with hypothyroidism at age 16,' D' A) x+ L) i9 p
which was treated with thyroxine. The father’s; b, O* V8 v; S ^: l
height was 6 feet, and he went through a somewhat+ B9 P% w4 b _$ J% C
early puberty and had stopped growing by age 14./ z; f) e, \+ ]5 L u0 U" ^5 @
The father denied taking any other medication. The
! Q5 j$ R- k; G+ t+ Y# ]child’s mother was in good health. Her menarche# N; G7 C0 F* }
was at 11 years of age, and her height was at 5 feet: H* u* P) w- a. [3 v
5 inches. There was no other family history of pre-& `( |2 c0 W* y% t; }3 W8 B
cocious sexual development in the first-degree rela-2 Y+ v; ]+ e T9 x3 i& e- d% V( S
tives. There were no siblings.
( G+ h3 p9 J! j1 D9 TPhysical Examination
! k. X; \ T* Y& k UThe physical examination revealed a very active,
+ N% t2 S, e. Y0 |! Q5 u# F5 O4 D; E9 |playful, and healthy boy. The vital signs documented: V H3 T7 G- K$ n; g L
a blood pressure of 85/50 mm Hg, his length was
) O1 s: e& X9 h; ?" d" a( _90 cm (>97th percentile), and his weight was 14.4 kg* ?- b' y J/ u* C
(also >97th percentile). The observed yearly growth
' Y' a/ n6 B* e. V6 K3 [velocity was 30 cm (12 inches). The examination of* K. u1 i9 ?+ L! W1 S) {8 j
the neck revealed no thyroid enlargement.* f, S$ T& d3 S$ Q. l' I7 m0 U
The genitourinary examination was remarkable for4 ?/ |( J) C0 j+ W. w
enlargement of the penis, with a stretched length of
( e: u- @% p) }; T8 cm and a width of 2 cm. The glans penis was very well- `% w. G* p& J+ a% @/ M2 r% s" z
developed. The pubic hair was Tanner II, mostly around% T/ M( r* }* j" t3 T6 N+ e( U
540/ _% ~7 ]/ L, Q6 S8 d& j' T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 k( w* T; \2 a0 y7 y# K1 ~the base of the phallus and was dark and curled. The
" M& D& p- p- [0 X$ o2 ktesticular volume was prepubertal at 2 mL each.+ |1 K. M+ W4 K! K( ?
The skin was moist and smooth and somewhat6 C! x% ]: u3 Y ~2 n+ J0 ]7 R
oily. No axillary hair was noted. There were no( F4 d3 Z3 L; Q$ q) M% Y' \1 A& w" S
abnormal skin pigmentations or café-au-lait spots.3 F, O& c0 V& c0 b1 b
Neurologic evaluation showed deep tendon reflex 2+
, [3 L3 d& L p! s4 }$ O5 Q0 Obilateral and symmetrical. There was no suggestion
& ]# B; N$ E3 e& S" U( G" Dof papilledema.3 V5 ?7 v3 C5 t8 r% C3 {+ e
Laboratory Evaluation7 U8 D) Z" Y( O1 @/ t' a
The bone age was consistent with 28 months by* p( s" E3 a+ X* b. t- a
using the standard of Greulich and Pyle at a chrono-
7 D1 o3 d6 e/ ilogic age of 16 months (advanced).5 Chromosomal
1 P8 K% }( q! l+ ?$ O3 g6 ~karyotype was 46XY. The thyroid function test
4 k& X# `& v4 p7 M! [showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* [2 g& I3 \6 S: `; \$ F4 ?lating hormone level was 1.3 µIU/mL (both normal). T$ W% ]: `3 u$ @/ v- t0 x; Z9 u$ ^
The concentrations of serum electrolytes, blood
% E) A. l1 j4 K* ^1 Murea nitrogen, creatinine, and calcium all were) i2 x/ _, J: h( o1 ^# z" I! e
within normal range for his age. The concentration ?6 i& y9 s7 |: f0 u
of serum 17-hydroxyprogesterone was 16 ng/dL& y( a+ d+ e) q* C; R
(normal, 3 to 90 ng/dL), androstenedione was 20 B* p4 x) ?2 b4 a3 f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ }8 ` f* j5 i: l+ S8 h) [, |terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 M# w( ^. j3 l( K2 E+ S/ \' ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 G1 p& p8 v" _: ]+ R @# s49ng/dL), 11-desoxycortisol (specific compound S)3 {. U$ ~) [3 t* N$ i
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& I2 i r3 @& J/ w5 @$ R0 Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total X* J# t) Q [2 x8 I. L6 q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# Y* J; E; x3 k5 `" Cand β-human chorionic gonadotropin was less than' x' n7 l* e; |% F0 `: y% Z5 A7 @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 G" Q0 c; {3 C5 ~stimulating hormone and leuteinizing hormone
3 t: v1 L3 y$ ~% nconcentrations were less than 0.05 mIU/mL
+ G& L: I) ^6 Y$ w9 f(prepubertal). Z$ q4 O8 K P8 c! A0 W
The parents were notified about the laboratory9 ^+ u& _9 h1 C( V2 D0 k
results and were informed that all of the tests were
* |! _8 d, Y3 D7 ^5 Y0 [1 |normal except the testosterone level was high. The
}0 }# n; K' \( Z# l: b4 \follow-up visit was arranged within a few weeks to+ i/ m4 E9 B4 `! L, ?/ k7 U, y
obtain testicular and abdominal sonograms; how-
" V; k" m. n. Kever, the family did not return for 4 months.
$ H7 U. Y4 B* X5 _& t! ^7 i/ ^Physical examination at this time revealed that the
; \/ C( w2 Q" |: o& t% H; ^2 [child had grown 2.5 cm in 4 months and had gained- A4 B- ?% z) ?- w
2 kg of weight. Physical examination remained
# l p/ ?4 h; w4 Punchanged. Surprisingly, the pubic hair almost com-
( n3 X/ f. r6 U* _pletely disappeared except for a few vellous hairs at
U6 r f& N) jthe base of the phallus. Testicular volume was still 2
4 w6 `* E3 W& P4 r" cmL, and the size of the penis remained unchanged.; d2 ?" i5 i2 f# m4 R
The mother also said that the boy was no longer hav-
) H7 S, X, p. M( q* W6 Qing frequent erections.+ [- W' q) P. c
Both parents were again questioned about use of2 Y9 ^, P0 W, L: {# Z. a
any ointment/creams that they may have applied to; D3 x6 u2 `6 |: @: H" L
the child’s skin. This time the father admitted the$ f: j' Y! N# n' _3 V4 ?. Q
Topical Testosterone Exposure / Bhowmick et al 541% M9 o- ?; e) M {3 x$ C. U! _; V
use of testosterone gel twice daily that he was apply-* i' W$ O) n2 T. E) a$ x4 @
ing over his own shoulders, chest, and back area for5 r3 ?9 |, W: |# o
a year. The father also revealed he was embarrassed
* n. y) S* [& R+ W. _to disclose that he was using a testosterone gel pre-+ l/ s' r. u6 S+ o7 P" n6 ~
scribed by his family physician for decreased libido* E3 ]9 M, c9 v) @ @# N
secondary to depression.
. u7 \) x v, F6 w ZThe child slept in the same bed with parents.
/ ^- @0 T a- d8 Z8 uThe father would hug the baby and hold him on his
5 F* I9 R$ c; b+ V1 M5 achest for a considerable period of time, causing sig-7 y: S5 o8 E& O) ^* X
nificant bare skin contact between baby and father.8 x M$ w) Y {+ Q0 m! ?
The father also admitted that after the phone call,5 @" J/ ]! y' L; ^
when he learned the testosterone level in the baby
5 Z. i+ Q' E0 t- F8 ewas high, he then read the product information
" s. X- a* K6 q! Bpacket and concluded that it was most likely the rea-" g' u8 s) @+ v2 T" r
son for the child’s virilization. At that time, they; `1 d6 @. U3 C3 [9 E7 g# y
decided to put the baby in a separate bed, and the
/ i; r$ `6 C. ^, s9 B8 X0 E: `father was not hugging him with bare skin and had
; f( O+ h5 \% O- |! ]been using protective clothing. A repeat testosterone
9 V9 {+ E0 B2 f1 Ztest was ordered, but the family did not go to the3 ~+ I% O* S& \) t, A4 x6 w2 U; K
laboratory to obtain the test.
, O! [ m5 D* T4 y- BDiscussion
7 e5 _# n4 U! R7 e5 uPrecocious puberty in boys is defined as secondary) L! |, k: u! }+ m& Q B: Z! m; R/ K
sexual development before 9 years of age.1,4# ~+ u4 a/ ^' m/ w# u# |; ?
Precocious puberty is termed as central (true) when
L( V; D! z0 i8 X, a; _$ Z. mit is caused by the premature activation of hypo-6 {+ b |- S j) d- w
thalamic pituitary gonadal axis. CPP is more com-' Y+ A# ?$ u0 ]4 o9 w0 N
mon in girls than in boys.1,3 Most boys with CPP
, G3 A$ }% i+ C2 U+ i6 amay have a central nervous system lesion that is+ F& @) |" {9 Q1 U
responsible for the early activation of the hypothal-
( E2 ]' [8 L+ `$ [amic pituitary gonadal axis.1-3 Thus, greater empha-! z6 @) v4 I/ A6 i5 P( I
sis has been given to neuroradiologic imaging in
8 @3 g: F% Q" d1 fboys with precocious puberty. In addition to viril-
& t1 k `6 P9 lization, the clinical hallmark of CPP is the symmet-" A& \6 \" ]' b( U8 Q0 Y
rical testicular growth secondary to stimulation by
4 C* W( A, z7 K) h. ?; ygonadotropins.1,3) B6 ?4 ^" T; ]1 V( n; |
Gonadotropin-independent peripheral preco-' A \0 \6 J$ T. a9 c
cious puberty in boys also results from inappropriate
$ k5 K( f3 G) i4 Aandrogenic stimulation from either endogenous or" @) s5 `6 O( b( x
exogenous sources, nonpituitary gonadotropin stim-1 @$ G* n% r# P% Y2 C
ulation, and rare activating mutations.3 Virilizing
* b5 q0 V1 e0 @5 T+ S, s$ e/ w4 j: xcongenital adrenal hyperplasia producing excessive- j- a8 y8 F2 b- h: R/ D- k
adrenal androgens is a common cause of precocious
C" R, r/ F4 B) Ppuberty in boys.3,4# a& I' ^& @6 X, D
The most common form of congenital adrenal
* }+ E0 k2 k6 o& w9 a9 B5 Fhyperplasia is the 21-hydroxylase enzyme deficiency.
6 q& `0 A/ X2 e$ T4 A9 c$ S" h5 V4 GThe 11-β hydroxylase deficiency may also result in
; J3 d! b; o8 Fexcessive adrenal androgen production, and rarely,
0 a6 p7 E5 T; M3 ~- ~3 b% U/ z6 Uan adrenal tumor may also cause adrenal androgen4 j/ {+ Q) r. M2 f1 Y0 a
excess.1,3 b" B% ~/ w# p' ]( I- ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. Z% N; e% k! c( u" ?1 B" m% d' V" v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. \* m( Y+ d; P3 iA unique entity of male-limited gonadotropin-' \* F7 J) r# {, z% `! b- b, O
independent precocious puberty, which is also known0 W7 D9 O8 }% O% ^: s
as testotoxicosis, may cause precocious puberty at a
/ n. i+ h! ^ Xvery young age. The physical findings in these boys: r3 ?- G" f6 ?, p/ b8 R5 m9 }: L
with this disorder are full pubertal development,6 s3 U) ~2 G, S3 G+ H" }. |
including bilateral testicular growth, similar to boys6 M* ^8 F3 G- Y3 F' l# M
with CPP. The gonadotropin levels in this disorder/ G7 Q, R! c) t2 q& u
are suppressed to prepubertal levels and do not show
$ n m9 [! i: p4 Z( {pubertal response of gonadotropin after gonadotropin-
3 [3 w }1 _ `4 w* ]( lreleasing hormone stimulation. This is a sex-linked0 Y6 d( G; E$ d0 Q, A7 P% E* f
autosomal dominant disorder that affects only8 B! ? o7 c* T e
males; therefore, other male members of the family+ x0 }: \8 V5 C0 G4 O5 d
may have similar precocious puberty.3: i1 ~( Y2 N* G
In our patient, physical examination was incon-0 I: ]# h2 }; W' ?- O4 g
sistent with true precocious puberty since his testi-
. T/ m' A4 ]- c% B2 Lcles were prepubertal in size. However, testotoxicosis6 I. m4 ?+ h ?: @
was in the differential diagnosis because his father4 E$ t0 ?+ m$ t, [; ?1 L
started puberty somewhat early, and occasionally,
* l" b9 _; d( n' Ntesticular enlargement is not that evident in the! m& i. u8 i; E! h, M3 ?
beginning of this process.1 In the absence of a neg-
5 {$ _- t6 v" g! I1 Rative initial history of androgen exposure, our4 A1 c- t6 i F& g- d p
biggest concern was virilizing adrenal hyperplasia,5 O+ }( e' }4 p% ~
either 21-hydroxylase deficiency or 11-β hydroxylase
6 P# k, g6 j( |1 t6 z- h9 Pdeficiency. Those diagnoses were excluded by find-
, U/ A1 x! y4 q2 T8 f( s( ring the normal level of adrenal steroids.
; f( q9 \! _/ b6 |The diagnosis of exogenous androgens was strongly t2 s1 M- }& q$ N& Q+ @- O& d. R
suspected in a follow-up visit after 4 months because, [7 w, T3 ]8 J2 W" W0 F0 o7 h
the physical examination revealed the complete disap-
0 b, B% G$ i9 o2 P3 @1 Hpearance of pubic hair, normal growth velocity, and
# H# {* P% u/ z6 U+ V2 v( M2 wdecreased erections. The father admitted using a testos-
( J2 {1 q9 h5 ~& i- U$ A# r# V; hterone gel, which he concealed at first visit. He was% y4 p- H/ c, ^) P! L
using it rather frequently, twice a day. The Physicians’1 ?4 T$ `6 L- a6 ]3 }5 L# e' W" m3 T4 g
Desk Reference, or package insert of this product, gel or$ p; m1 U% b8 f6 e7 @/ Z e
cream, cautions about dermal testosterone transfer to; T/ X2 N: s6 ~! ]
unprotected females through direct skin exposure.
& c# V9 B# O# d$ |7 o& `Serum testosterone level was found to be 2 times the
# f2 P' [- I/ Zbaseline value in those females who were exposed to
+ w! }. O& Y5 M* Peven 15 minutes of direct skin contact with their male
8 I1 B/ o8 W7 t! T4 E! Vpartners.6 However, when a shirt covered the applica-8 m* j$ }* u: g( x
tion site, this testosterone transfer was prevented.
1 Y5 C) Y0 q# G& v) o4 r( w7 Q5 JOur patient’s testosterone level was 60 ng/mL,
& H( T' w$ r5 O. l6 a0 z/ |which was clearly high. Some studies suggest that6 L h& p- x3 F% K, s# e, y
dermal conversion of testosterone to dihydrotestos-
: Y5 K6 a$ ~3 a8 b% D& Dterone, which is a more potent metabolite, is more
$ f( S# J- X: j4 j; u9 Ractive in young children exposed to testosterone/ h g; r6 W/ m- z0 X) Z7 \
exogenously7; however, we did not measure a dihy-
/ v* N: o4 M6 J) Mdrotestosterone level in our patient. In addition to3 A7 @8 D4 ~( l, l& c
virilization, exposure to exogenous testosterone in2 W1 x7 ]6 s0 Y5 r
children results in an increase in growth velocity and
$ r- y& ]8 ~* k7 `$ } T) a) [advanced bone age, as seen in our patient.. L; A) K8 B9 f0 `
The long-term effect of androgen exposure during- }, z' A! U0 r
early childhood on pubertal development and final. Y! B: j7 i" }0 B
adult height are not fully known and always remain7 g# d$ g+ ^$ i) B6 Q
a concern. Children treated with short-term testos-
) ~& Q4 y& o$ {$ B- h6 oterone injection or topical androgen may exhibit some O5 i5 Y0 q, j
acceleration of the skeletal maturation; however, after
& G' n Z# q. I. q' K; qcessation of treatment, the rate of bone maturation
. E1 h5 n8 Z; P3 d6 Z& S6 D" tdecelerates and gradually returns to normal.8,9
* q0 {/ d/ o9 f. yThere are conflicting reports and controversy
5 \! d0 J/ k$ Vover the effect of early androgen exposure on adult
) T: U7 P4 f. e& ^# dpenile length.10,11 Some reports suggest subnormal8 J" o% H2 x! e+ X2 T% F
adult penile length, apparently because of downreg-1 d8 ]( z W+ W3 g9 s _
ulation of androgen receptor number.10,12 However,
1 D# o$ O0 k* I1 X0 V# WSutherland et al13 did not find a correlation between
' z$ U1 l5 j" p6 U- Q- k8 mchildhood testosterone exposure and reduced adult2 G H1 o! P; D, E- e" k
penile length in clinical studies.$ I% Q4 {. W q$ G; i. r. m
Nonetheless, we do not believe our patient is; E' ^/ d8 V8 v! d' q
going to experience any of the untoward effects from/ i" C" C* o. z8 G7 J: |* ^
testosterone exposure as mentioned earlier because* Q4 a2 `# Y, Z8 T1 o8 }$ y) X. B
the exposure was not for a prolonged period of time.
# i; P9 f; B' @" w9 |3 P& a* DAlthough the bone age was advanced at the time of
# T7 h( y* Y4 f4 ]3 [- kdiagnosis, the child had a normal growth velocity at5 c& s! e' Q" y5 f0 `2 W/ R$ W3 @2 e
the follow-up visit. It is hoped that his final adult
2 b" ^8 k c0 @: Gheight will not be affected.; G A% o( T# Z8 ~; I
Although rarely reported, the widespread avail-
8 v4 n& S/ c$ z* Q" ]+ v# oability of androgen products in our society may
+ j1 u( {7 l% y ]/ ~indeed cause more virilization in male or female
; J" E0 n, m+ [* d0 ?- o2 W4 hchildren than one would realize. Exposure to andro-
* Q0 D- s, [ d; k7 k# f; tgen products must be considered and specific ques-3 T$ f/ U1 P" {, g% }8 D9 {
tioning about the use of a testosterone product or
6 e; w$ F, M0 {4 fgel should be asked of the family members during
# S, G) p( t+ Z0 A# v2 \7 sthe evaluation of any children who present with vir-3 Y' ^9 G8 D4 W, o8 E) |
ilization or peripheral precocious puberty. The diag-( [* R# F+ ^1 j" u/ n/ J D
nosis can be established by just a few tests and by
( g' ~7 B/ T$ o: A& _6 n. ~appropriate history. The inability to obtain such a
! z# z9 h$ U `history, or failure to ask the specific questions, may
* N4 x5 k' ]$ R4 K& q. Y$ u$ Tresult in extensive, unnecessary, and expensive
9 p: H3 s- l: m* N1 _' ?+ j, x( O% rinvestigation. The primary care physician should be
+ O( P. d3 m, \ u! E$ u0 aaware of this fact, because most of these children
% B# Y- _2 g# M. q9 ]. tmay initially present in their practice. The Physicians’
# g: D& B' A# j7 e( SDesk Reference and package insert should also put a: K1 u7 G6 ~4 u5 o: y5 ~
warning about the virilizing effect on a male or
5 H) s% {# N; o8 T" w; O6 C9 Kfemale child who might come in contact with some-8 L( n% t2 r1 M- R# \: Q& U2 Z
one using any of these products.
; M- {/ D3 }( o1 W) |, sReferences
' ^6 Y3 E* p5 c; m* ^+ \* n1. Styne DM. The testes: disorder of sexual differentiation
( h! w) n6 v1 }/ E! eand puberty in the male. In: Sperling MA, ed. Pediatric: L& W. S! U2 d# ?9 j( S. _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 B4 ]3 {" ?1 c; d- ]% ~2002: 565-628.
; D! `0 h8 S# m0 V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 q6 Z# D4 j! z$ z! w b$ mpuberty in children with tumours of the suprasellar pineal |
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