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Sexual Precocity in a 16-Month-Old6 m# f: Z+ f- N0 X5 Z+ [9 {4 N& [+ ]
Boy Induced by Indirect Topical- P; g) C, H, ` b* ~2 r9 X
Exposure to Testosterone6 H, G1 ]4 R7 f4 h' E
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) E3 \9 S) [8 N
and Kenneth R. Rettig, MD1
. A0 \' X" H, `/ EClinical Pediatrics
2 C- Q( n+ A; ^3 ~Volume 46 Number 6
% j# Q! N( P( r/ K/ X$ U3 [5 WJuly 2007 540-543
$ ]9 n- ^/ @% {2 w* x, J0 `9 {© 2007 Sage Publications
4 j; O" H3 u2 b- v: _: N* W& ?* F; N10.1177/0009922806296651
! v5 _6 ]/ v, ]1 l5 z" c5 p( \http://clp.sagepub.com
3 [* B, m8 x. c, |hosted at6 J% V9 F! a1 v: ^
http://online.sagepub.com
4 Z# b' |$ C# ~2 _9 K7 NPrecocious puberty in boys, central or peripheral,6 O+ [- B) I- Y# ]
is a significant concern for physicians. Central' R/ X+ c5 L9 O: y: _
precocious puberty (CPP), which is mediated2 U; s% G! i2 F$ E
through the hypothalamic pituitary gonadal axis, has+ R1 v# p! _1 `" @; c4 z% Y
a higher incidence of organic central nervous system" p6 I$ y( S N. m, B5 _
lesions in boys.1,2 Virilization in boys, as manifested
# D5 }7 D# u* I. ^4 v, q \2 Bby enlargement of the penis, development of pubic
+ `- y8 ]0 b. |7 O9 shair, and facial acne without enlargement of testi-
5 e) `$ W2 l$ K! |% @( ^cles, suggests peripheral or pseudopuberty.1-3 We
4 r5 z, n; I* z9 ?1 c- Vreport a 16-month-old boy who presented with the+ q* [1 R1 M1 n" C8 Y
enlargement of the phallus and pubic hair develop-. i7 c# L! L4 _4 o6 V
ment without testicular enlargement, which was due
5 |3 V6 |5 e! y8 @1 r) cto the unintentional exposure to androgen gel used by
" t# p( m N- S! z8 Xthe father. The family initially concealed this infor-) L' x. N) ]1 P8 `) p# S& P
mation, resulting in an extensive work-up for this
! Q C2 X9 f9 Ochild. Given the widespread and easy availability of
5 Y, d: g+ R6 _6 {% l$ e' ]testosterone gel and cream, we believe this is proba-' O3 r. d& }; @5 X$ m( O Y6 N4 h
bly more common than the rare case report in the% v2 T! i6 i% K; w
literature.4& I9 K2 q3 w! a9 K$ g" u/ b
Patient Report
" e h; {4 v0 y! ?3 B# P) r6 s, BA 16-month-old white child was referred to the+ C6 [& \4 y2 e
endocrine clinic by his pediatrician with the concern
9 c2 t' H& N6 d/ N! ?9 v; x- [: yof early sexual development. His mother noticed
9 N! Q4 b, a# |9 S+ ^+ Hlight colored pubic hair development when he was
' e1 s! A* R5 ?3 ^From the 1Division of Pediatric Endocrinology, 2University of
% |9 u4 v) F+ n7 k9 kSouth Alabama Medical Center, Mobile, Alabama.: m; x9 Y& |; t0 }: T7 c2 O
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 [) b ?; v5 c/ b. I. T8 k% ~Professor of Pediatrics, University of South Alabama, College of1 K$ e) x5 @& G3 I1 @% H1 d7 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ w: `+ w' ?# X% u! te-mail: [email protected]." R6 m# b$ ~( V" @3 |; H
about 6 to 7 months old, which progressively became
. _; \* r: {- q' zdarker. She was also concerned about the enlarge-& b2 }4 T L8 `
ment of his penis and frequent erections. The child
; c/ P4 P: a0 s4 H, ]" Pwas the product of a full-term normal delivery, with3 T+ S5 c! t5 y8 a( a/ Z. p. t
a birth weight of 7 lb 14 oz, and birth length of3 ?6 k4 w O5 O4 C u
20 inches. He was breast-fed throughout the first year2 m. ?$ u8 o5 z6 q8 F! F1 o& m
of life and was still receiving breast milk along with
8 e1 U) G: s7 y, n2 B* lsolid food. He had no hospitalizations or surgery,1 X4 s5 y" E- e, ]) C7 J
and his psychosocial and psychomotor development
$ N* D# ]6 v# C' Y8 A1 D0 nwas age appropriate.
9 f7 S6 Q. W# w x6 R+ WThe family history was remarkable for the father,
- u' K+ b, k$ R1 Z% Q9 {& xwho was diagnosed with hypothyroidism at age 16,
9 \! E: P0 Q3 p, ]7 Qwhich was treated with thyroxine. The father’s
* s7 S: _; M4 o1 o& U m4 wheight was 6 feet, and he went through a somewhat
- u$ T% p: W4 t! K1 ]; w0 z Wearly puberty and had stopped growing by age 14.
1 a$ W( k% L0 q6 I4 g1 IThe father denied taking any other medication. The
- d. L8 y6 G5 V! |; F) O, Tchild’s mother was in good health. Her menarche
) s3 A1 R& W" U2 Y8 g9 U) c! v2 Qwas at 11 years of age, and her height was at 5 feet
# I# y" c" Z) U, Q% [2 M, c. ]5 inches. There was no other family history of pre-- X# k7 \6 F5 d4 v5 S$ q
cocious sexual development in the first-degree rela-
- g% M" j9 n3 H, }tives. There were no siblings.. V& g8 t8 J+ g# j5 l. S" l* h+ ?
Physical Examination
' Z3 G9 ?5 m$ QThe physical examination revealed a very active,; B6 T- [1 q& j( j4 P9 p. N$ F
playful, and healthy boy. The vital signs documented
/ Z1 i: c, M7 D1 [3 y! Ga blood pressure of 85/50 mm Hg, his length was
1 k: w" V, H b2 y$ M9 B4 s5 [: t0 d$ B90 cm (>97th percentile), and his weight was 14.4 kg- f6 s- O% m# F0 p& p
(also >97th percentile). The observed yearly growth
2 Z6 d" ]( B3 B6 lvelocity was 30 cm (12 inches). The examination of
* @# l+ g- D# D' Xthe neck revealed no thyroid enlargement." u* V" y6 F1 @; @) y& k
The genitourinary examination was remarkable for
$ P m# x$ M0 \3 C7 xenlargement of the penis, with a stretched length of
' B5 Y0 @+ }, p) s* L8 cm and a width of 2 cm. The glans penis was very well7 c1 M) b7 E& ?7 H5 Q" F& h( u, F
developed. The pubic hair was Tanner II, mostly around! B5 G1 ^! r6 v4 {5 j
540
# o$ X% k1 \: S' Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
~. S( }' U0 ]$ U( D2 U( Gthe base of the phallus and was dark and curled. The
! f7 O& Q3 A, K+ etesticular volume was prepubertal at 2 mL each.5 D* U, s4 V) I3 a# A' c9 }9 X7 z
The skin was moist and smooth and somewhat, N: k: N& o; w6 c! s$ C9 A. c7 x8 t) M
oily. No axillary hair was noted. There were no5 i2 E2 r' \+ Y. j
abnormal skin pigmentations or café-au-lait spots.
: a. N2 K& o2 Y% WNeurologic evaluation showed deep tendon reflex 2+$ ?% D7 l# Z) X( v8 T& K
bilateral and symmetrical. There was no suggestion
; |2 J: f8 \& Eof papilledema.
$ M: a) I' m0 k: [7 F, h" aLaboratory Evaluation
. n" b0 Q J/ k8 [ X1 JThe bone age was consistent with 28 months by
& d: g; X. o B \, L* x8 dusing the standard of Greulich and Pyle at a chrono-
/ p8 m! _8 [3 z/ d- ~" _logic age of 16 months (advanced).5 Chromosomal- b) X& z5 p6 b
karyotype was 46XY. The thyroid function test
0 f1 A: n5 I0 B$ _% B1 Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) j4 S: L+ D4 @lating hormone level was 1.3 µIU/mL (both normal).
, j3 X: [( \$ }* NThe concentrations of serum electrolytes, blood' g4 y5 Q3 i3 ~1 V
urea nitrogen, creatinine, and calcium all were# f' d y, S0 V$ ~/ l: H6 d$ w
within normal range for his age. The concentration9 {0 s5 `' P9 ?3 ^1 F% U7 T
of serum 17-hydroxyprogesterone was 16 ng/dL8 ?0 ?8 ~7 E, e4 j& T( Y$ j" w
(normal, 3 to 90 ng/dL), androstenedione was 20
' j9 d9 E- i# Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) q3 F) ~2 o3 ]* o0 Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( z# I- O0 D4 ^/ T- M0 pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 D3 g1 @& f1 Z1 f/ d4 I# I49ng/dL), 11-desoxycortisol (specific compound S)0 E9 i' t+ x/ b8 t& ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# V' F) d, o$ Y( h, Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 U. r5 M! A* a4 ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" L; N9 [" H9 kand β-human chorionic gonadotropin was less than
) w; ]9 k, T+ d5 P: p( ?+ y0 j) \! f5 mIU/mL (normal <5 mIU/mL). Serum follicular
& U @. F/ f7 R* m9 {- ~3 e) u: G' s* tstimulating hormone and leuteinizing hormone, R3 _' t: J' @
concentrations were less than 0.05 mIU/mL; {+ Y' d Z$ W: ?
(prepubertal).( N# j- d, E+ R* i: f$ F# Y; q& f
The parents were notified about the laboratory* @6 Z0 r6 q) ^9 {
results and were informed that all of the tests were* v' |0 B9 o' v+ c3 q
normal except the testosterone level was high. The8 T* f' [+ E& z; L1 U* d, t/ }
follow-up visit was arranged within a few weeks to
1 U/ Z* h/ t. A2 @obtain testicular and abdominal sonograms; how-* N) h% p" t1 j& U" Q* d' [* Z, \( S$ M
ever, the family did not return for 4 months.& Y5 a8 J; a4 Y% G$ d4 v3 Z
Physical examination at this time revealed that the6 W5 z$ N0 j3 `- W' k, o
child had grown 2.5 cm in 4 months and had gained
7 a; m. Z$ B) N5 [4 r. S7 ]) g/ g2 kg of weight. Physical examination remained
) D# q$ I' p* {- E9 z/ O8 {8 Bunchanged. Surprisingly, the pubic hair almost com-$ G# }& U( J1 J
pletely disappeared except for a few vellous hairs at( u. i9 H! z, s3 T, v8 O" B
the base of the phallus. Testicular volume was still 2
6 f' o7 q2 j1 u o4 t/ M2 [, N' WmL, and the size of the penis remained unchanged.
0 ~( Z2 q7 A7 W |. D. dThe mother also said that the boy was no longer hav-
# p4 ] |9 u* F: {2 N) ?8 ming frequent erections. g# c" Q' D1 I, n( H- h
Both parents were again questioned about use of6 t7 m; s; r- p G( |# `9 x0 E
any ointment/creams that they may have applied to* K4 Q3 U0 U8 u! ?0 W2 M% L& a, d
the child’s skin. This time the father admitted the
8 ^( ^, x4 M2 J8 |, i; uTopical Testosterone Exposure / Bhowmick et al 541
4 ^6 h [2 W3 l* u+ X8 g; _7 euse of testosterone gel twice daily that he was apply-
8 W- A- h) J l- cing over his own shoulders, chest, and back area for) g' W2 k. ~( F3 A, b7 E
a year. The father also revealed he was embarrassed2 T1 S# v$ L- `4 b5 U* y1 L
to disclose that he was using a testosterone gel pre-! l4 e( Q* I7 ~$ R% h: v
scribed by his family physician for decreased libido
5 g9 b/ ?2 @7 Lsecondary to depression.. o7 z; O& ?( R
The child slept in the same bed with parents.' {: R* I, O) {8 X
The father would hug the baby and hold him on his
2 m1 i: J, @7 S% W9 Bchest for a considerable period of time, causing sig-
! s4 R( @: n1 j+ o0 P; knificant bare skin contact between baby and father.6 S' u; M! V7 R; Q, f
The father also admitted that after the phone call,+ O {2 i5 g3 e( ^% r
when he learned the testosterone level in the baby; f* g3 a$ p& |
was high, he then read the product information7 z7 i+ ~. R* w: ^' U
packet and concluded that it was most likely the rea-6 Y& e+ Q& S# U5 J/ z2 z& s
son for the child’s virilization. At that time, they
6 u' _9 X4 b% c; pdecided to put the baby in a separate bed, and the, L8 g' a$ H/ i# ]
father was not hugging him with bare skin and had) D% i" N1 F& h' ?/ B. j
been using protective clothing. A repeat testosterone
. z* e6 z0 q+ g' w+ M( G! E3 }, stest was ordered, but the family did not go to the
3 }3 y) @: |2 H- W3 alaboratory to obtain the test.
+ A# j! E% R: V2 S* X* C |& mDiscussion6 U# ~- Y: \ D+ v# T/ I5 O
Precocious puberty in boys is defined as secondary. m: v" r( X/ I' D
sexual development before 9 years of age.1,4
1 }% Y+ y, |0 p; ]: K h- n* z$ s0 l: u& oPrecocious puberty is termed as central (true) when! T0 ?7 q+ t* E
it is caused by the premature activation of hypo-& ~* z d8 l2 D1 B) x
thalamic pituitary gonadal axis. CPP is more com-) h; a4 d, V' w J
mon in girls than in boys.1,3 Most boys with CPP
3 i2 p0 p6 o! }$ Hmay have a central nervous system lesion that is
! m4 D3 b# F: j" H5 E# m) P; ^responsible for the early activation of the hypothal-8 |: e2 Q" M: u4 w& \% @9 m3 [9 f
amic pituitary gonadal axis.1-3 Thus, greater empha-3 F7 C2 \# s7 { y' x
sis has been given to neuroradiologic imaging in5 a, j% A7 \- l6 E5 X5 z- O( z1 _
boys with precocious puberty. In addition to viril-0 N) f% _2 k6 f/ @) i
ization, the clinical hallmark of CPP is the symmet-
" K4 o0 g& D6 L/ Yrical testicular growth secondary to stimulation by4 s H( l: c# |& [4 O- H
gonadotropins.1,3) s6 A+ Y/ g5 U7 y$ f! o! v5 y, J
Gonadotropin-independent peripheral preco-
' S* A% A+ U, Z# D, ~cious puberty in boys also results from inappropriate
& m8 ]9 b6 U% H6 z* Kandrogenic stimulation from either endogenous or# V: M! A0 J5 \& W6 h. v1 b9 p, F9 D
exogenous sources, nonpituitary gonadotropin stim-* {3 H% h1 }8 l5 L
ulation, and rare activating mutations.3 Virilizing
# D3 F' f1 Y. u' h5 u" s7 Y1 Mcongenital adrenal hyperplasia producing excessive; z3 f+ g( K2 i1 `9 ?$ S6 x
adrenal androgens is a common cause of precocious
$ ^2 @- Q a D8 I% d& lpuberty in boys.3,4
7 {1 M2 Z! {5 @" T2 X' Y' lThe most common form of congenital adrenal7 a9 }9 E8 j3 P2 V
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ u/ D1 s8 g! {0 N9 o1 x, J7 T6 W, f' bThe 11-β hydroxylase deficiency may also result in* Q' R0 B% M# P
excessive adrenal androgen production, and rarely,5 E6 ?3 \6 Z! ^# B7 n5 C- h+ u
an adrenal tumor may also cause adrenal androgen
Z2 }$ n1 E1 W6 e# dexcess.1,3
4 a9 p0 i7 K7 p% L. [% ` d6 M/ {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( B/ e' n2 z+ p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& f: M. ^ i3 V9 h! k5 q1 i' v
A unique entity of male-limited gonadotropin-
* o! I+ `; v2 A4 [& U* cindependent precocious puberty, which is also known0 ^1 ]* N5 O4 I& F( @7 N
as testotoxicosis, may cause precocious puberty at a
5 d2 N- N! f, c% t# B% ?very young age. The physical findings in these boys
! P$ j' i O+ Q; Hwith this disorder are full pubertal development,
& Z+ [( h, v+ t# j9 @3 Fincluding bilateral testicular growth, similar to boys
3 T1 D6 J4 P0 |3 dwith CPP. The gonadotropin levels in this disorder
3 }8 M( J2 u8 yare suppressed to prepubertal levels and do not show
9 E6 L" W0 }: |% {4 Z* j; ?pubertal response of gonadotropin after gonadotropin-
- z @' }0 v! Q0 ?' u* K9 k! xreleasing hormone stimulation. This is a sex-linked- ~5 F$ n7 t! M) t0 P0 \8 \- a% G
autosomal dominant disorder that affects only8 |' E3 l' F& R% M, \& |
males; therefore, other male members of the family
4 z3 q* h6 J* b" I1 dmay have similar precocious puberty.32 A* P5 B( |5 c6 l, \7 r
In our patient, physical examination was incon-4 B# _- e x+ ?# s8 J: ?) R
sistent with true precocious puberty since his testi-. L1 g5 D, I8 l0 x( _, {
cles were prepubertal in size. However, testotoxicosis( Z) p4 @8 u. c, m$ B
was in the differential diagnosis because his father" a @# f( L( l7 l
started puberty somewhat early, and occasionally,+ R! J7 ]6 n) {
testicular enlargement is not that evident in the
; m. f ^( V) e5 ~3 J! w4 w" tbeginning of this process.1 In the absence of a neg-) o& o+ t0 F1 h
ative initial history of androgen exposure, our8 U0 D: B' P5 W7 t7 f6 X, |+ {
biggest concern was virilizing adrenal hyperplasia,
9 |% e: \" b" s7 @either 21-hydroxylase deficiency or 11-β hydroxylase
7 S( c2 K2 d" a! j# udeficiency. Those diagnoses were excluded by find-- [8 E4 g Q- J6 K. |6 W! Q" h" u
ing the normal level of adrenal steroids.
& J g* u% y* ], u5 v, H4 }. j1 wThe diagnosis of exogenous androgens was strongly7 k2 y1 C: H3 H& x9 j
suspected in a follow-up visit after 4 months because
& Y$ \$ ~5 C2 X6 \ a: R$ Vthe physical examination revealed the complete disap-1 m) U7 s. ]% r" E( y
pearance of pubic hair, normal growth velocity, and. _. A& k3 C+ R- O& d% `4 Z9 x
decreased erections. The father admitted using a testos-, n6 h; x/ _7 ?! {" ^% O
terone gel, which he concealed at first visit. He was
; ~& | ~3 z Z; z" A' g# Xusing it rather frequently, twice a day. The Physicians’
8 L y2 O( @, O4 f' A2 _* DDesk Reference, or package insert of this product, gel or0 ^: M. u1 t+ `5 Z- o
cream, cautions about dermal testosterone transfer to1 |( z x# `8 z6 q
unprotected females through direct skin exposure.% k" n C( x% M" P
Serum testosterone level was found to be 2 times the# d3 P4 D: j* w1 a$ k
baseline value in those females who were exposed to
/ [6 r4 Q# O. `2 zeven 15 minutes of direct skin contact with their male& ^ c' |/ T: x
partners.6 However, when a shirt covered the applica-
1 E2 o1 N4 _: d1 T9 ution site, this testosterone transfer was prevented.. L+ \9 u/ } x7 x h# J
Our patient’s testosterone level was 60 ng/mL,: a& V& A, p5 }: J2 X7 K, A! H
which was clearly high. Some studies suggest that- S; w) ]& K# b- w. l7 P3 Z9 V
dermal conversion of testosterone to dihydrotestos-
& P; U$ y2 b) _terone, which is a more potent metabolite, is more
% E6 d$ p( Z( h7 f4 Dactive in young children exposed to testosterone
' \) n% ~7 Q$ G5 S( Aexogenously7; however, we did not measure a dihy-' a' C9 Y9 J) v+ e; F5 \
drotestosterone level in our patient. In addition to6 z b0 L+ o0 F
virilization, exposure to exogenous testosterone in" A! E/ e) S: t
children results in an increase in growth velocity and
h! v) F' L A. U5 ]. yadvanced bone age, as seen in our patient.; p. H# K( o/ v! i7 V
The long-term effect of androgen exposure during: Y, d0 I' u, s& s- R ^" g& ^6 @
early childhood on pubertal development and final
# ^4 f3 T( q0 B5 `adult height are not fully known and always remain4 e6 |/ t+ Z- o" }& s; q6 ^5 L K! U
a concern. Children treated with short-term testos-
, {( v% P& N) q% hterone injection or topical androgen may exhibit some
$ S9 t3 s0 c1 M" F4 P: }. dacceleration of the skeletal maturation; however, after6 [# j, ^) D- Q+ s0 d! s# [
cessation of treatment, the rate of bone maturation
# D7 N t4 q1 q, ~decelerates and gradually returns to normal.8,9# x7 G6 J( J/ O+ c9 u
There are conflicting reports and controversy
9 s1 V$ ]6 n, W1 k- dover the effect of early androgen exposure on adult
% u' n& U9 l% f# apenile length.10,11 Some reports suggest subnormal; J$ l8 @/ U3 J+ i
adult penile length, apparently because of downreg-8 Y8 f Z, V8 H4 @, `( X
ulation of androgen receptor number.10,12 However,
0 H) b7 m' l( a# J: L0 OSutherland et al13 did not find a correlation between$ ^5 A% P4 k1 f5 o7 F, Y8 }: _
childhood testosterone exposure and reduced adult
! o7 S# \; Y- ^ h N7 o1 w1 [penile length in clinical studies.
2 p0 O4 d" [5 z" r+ s3 s( w# KNonetheless, we do not believe our patient is2 L3 S0 C" N# `% R
going to experience any of the untoward effects from
. n8 v: K7 @ k0 I% L0 [0 |' Etestosterone exposure as mentioned earlier because
; y9 a/ x8 d, ^* `) U) ]the exposure was not for a prolonged period of time.0 A0 u0 ]* f2 k* ]' J# A
Although the bone age was advanced at the time of
& R0 r: _3 z/ F2 A5 S# v/ hdiagnosis, the child had a normal growth velocity at# G8 Y/ I5 Z! O6 W$ N% a. g j
the follow-up visit. It is hoped that his final adult
$ H6 x9 z) u- Oheight will not be affected.
, u8 Z! [& i8 h$ A3 P+ cAlthough rarely reported, the widespread avail-
7 n- z+ C8 n2 X4 r- k5 ^4 bability of androgen products in our society may
6 E9 ?9 a( u; E' N5 |. Eindeed cause more virilization in male or female
+ x. c0 z5 L) V7 x* b3 G' ychildren than one would realize. Exposure to andro- v$ x( @2 R# n- c" }
gen products must be considered and specific ques-0 u& c$ L/ G$ p
tioning about the use of a testosterone product or* ^- q7 V5 ]- G
gel should be asked of the family members during
: j# o5 T' Z8 w. _: K2 Pthe evaluation of any children who present with vir-9 Q# c/ B H4 X% M: I+ r: {% J, }
ilization or peripheral precocious puberty. The diag-1 z* A' l+ M2 E$ ^' p8 p
nosis can be established by just a few tests and by
- M1 i% l% v3 R* _* b; M% b3 i% tappropriate history. The inability to obtain such a
9 c$ c4 A6 ^: g. U- Y: R# khistory, or failure to ask the specific questions, may
6 o' E4 I0 y( b) i; \8 E$ uresult in extensive, unnecessary, and expensive
8 H# Q7 w- k( t' h7 z3 f7 x" r3 Ninvestigation. The primary care physician should be a1 J8 [4 h8 W! m8 g+ E4 b9 e5 b
aware of this fact, because most of these children
* j3 u2 {( x8 v1 D4 @; Smay initially present in their practice. The Physicians’4 m; U& \ I8 Q- X1 f/ q- g
Desk Reference and package insert should also put a
" g+ e, |, X V9 Twarning about the virilizing effect on a male or. H1 m% \+ H6 V
female child who might come in contact with some-- G8 p% p& r" a9 a% u/ ~ z
one using any of these products. X2 k5 t4 J) |
References
1 }. g# J6 k( D' y1. Styne DM. The testes: disorder of sexual differentiation* [2 f9 }. x# | N; z
and puberty in the male. In: Sperling MA, ed. Pediatric
2 ^. I( T( e7 V) ~6 N) b9 OEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ E6 r( t( t7 J8 k; G
2002: 565-628.
; X. b- `( n7 ~& \4 _" H* G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ b; V3 E) ? {4 c! ]: O' Q
puberty in children with tumours of the suprasellar pineal |
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