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Sexual Precocity in a 16-Month-Old8 |2 z3 Z5 V7 L+ n4 e8 R7 A, l
Boy Induced by Indirect Topical/ C5 Y. e5 Z, G
Exposure to Testosterone" e! X) o( E2 u( H3 a6 \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 E$ k/ d1 E9 S
and Kenneth R. Rettig, MD1. w- p7 u2 A, Q& C) W
Clinical Pediatrics
. {" Q- t% X0 a& `; S. J _Volume 46 Number 6
5 V+ |9 L* K" {! R" K0 ^* ?. ~3 C* IJuly 2007 540-543
$ s% h3 N5 ~& N: g( f© 2007 Sage Publications
7 ]! c- s, s3 O10.1177/0009922806296651
, |" y6 A2 H9 h/ z N& H/ |http://clp.sagepub.com; W* k. T3 V0 }# a
hosted at
4 i7 M: q* X. _$ s/ P+ a4 \http://online.sagepub.com
; b: G* u; M1 w) `4 s+ iPrecocious puberty in boys, central or peripheral,
* Y' Y" S1 g+ F4 i! e$ s) H. {# K1 }: eis a significant concern for physicians. Central
7 ?. @0 m; G) J5 `: r+ Qprecocious puberty (CPP), which is mediated5 I# r2 k% w) c4 M/ Y3 G& ?2 f- w! W" y
through the hypothalamic pituitary gonadal axis, has
( d0 X! b' u7 a) C0 i+ p, Ra higher incidence of organic central nervous system# N/ j5 L$ k! y1 F4 g+ X ?
lesions in boys.1,2 Virilization in boys, as manifested
6 n. T0 J$ R8 w" s# H/ w: D7 mby enlargement of the penis, development of pubic
1 k8 E3 l7 O; z* l: n+ U4 I5 g+ rhair, and facial acne without enlargement of testi-% ?* c# P) |& ^& k0 o" ^0 k' A
cles, suggests peripheral or pseudopuberty.1-3 We
# Q' W% f& b+ m7 x* z4 S9 t$ sreport a 16-month-old boy who presented with the
1 y4 O0 b8 K+ I y: k1 zenlargement of the phallus and pubic hair develop-& `. |6 g4 }$ C) F: j
ment without testicular enlargement, which was due7 @& ]- O$ K' h$ w8 n5 ]7 w
to the unintentional exposure to androgen gel used by$ e/ S9 }. c7 }4 C$ H
the father. The family initially concealed this infor-+ Y" v) Z; S% ^* d3 z4 C5 ~$ Q
mation, resulting in an extensive work-up for this: p7 y; V6 E. b# h
child. Given the widespread and easy availability of
! b: N$ I* T$ O, t; Ytestosterone gel and cream, we believe this is proba-9 r3 D i) ~0 R
bly more common than the rare case report in the1 i. o+ F: Q7 R0 F- x6 W/ _# P
literature.4' _' z. e$ e( F
Patient Report0 k( P% G' O0 O$ C/ _2 c
A 16-month-old white child was referred to the4 `8 b& D- N! B) y4 F
endocrine clinic by his pediatrician with the concern
. c; ^' T& n& K9 E6 `8 E3 Zof early sexual development. His mother noticed
* Q' J, m! `& x! ?6 ~8 Vlight colored pubic hair development when he was
% _: Z/ g! j* G1 rFrom the 1Division of Pediatric Endocrinology, 2University of
2 F0 {. ^2 L; {South Alabama Medical Center, Mobile, Alabama.
% I% z n- C" ?: v' `( F" \; jAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 j0 |+ S7 k9 z* g/ _# y
Professor of Pediatrics, University of South Alabama, College of: k9 S0 X: N9 n# y* }9 \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# O" v" ?3 W4 S4 \e-mail: [email protected].8 R+ L( j8 J! R& Y/ O6 \+ H6 r
about 6 to 7 months old, which progressively became( O' Y, @- e, s+ z2 ?7 o; @( T
darker. She was also concerned about the enlarge-1 q- v3 v' W2 s3 v! D' u( r
ment of his penis and frequent erections. The child) K n6 S9 f2 K& f8 M1 X
was the product of a full-term normal delivery, with
# \( J( t5 v5 p# ra birth weight of 7 lb 14 oz, and birth length of
: }! C# c% y* Y$ w' V" Z; @4 k# X0 C20 inches. He was breast-fed throughout the first year
+ h) z7 b% m3 Y) m9 A( l! vof life and was still receiving breast milk along with( d/ K7 H% N5 ]% K3 r0 C* \# P
solid food. He had no hospitalizations or surgery,
$ `9 [. `, l5 V2 Qand his psychosocial and psychomotor development5 p5 ^7 F5 x- M/ d$ f
was age appropriate.8 \. w( C! s. m7 A- r2 p
The family history was remarkable for the father," l: m: Y8 e: i' `, r
who was diagnosed with hypothyroidism at age 16,
+ l6 G i2 O6 S; _2 X. V9 Jwhich was treated with thyroxine. The father’s2 A6 B# E# s2 L5 `( c+ L, ^+ f
height was 6 feet, and he went through a somewhat
* [( L1 Y; z1 v9 @4 W" ]early puberty and had stopped growing by age 14.
$ f3 ?3 ?! c4 iThe father denied taking any other medication. The
' K' q+ y7 b' J! K3 x& hchild’s mother was in good health. Her menarche
n- h! x* z: [4 E7 W( Nwas at 11 years of age, and her height was at 5 feet* g- D w$ K0 B! L
5 inches. There was no other family history of pre-6 T7 g6 ]8 F) m& f( @8 V8 }+ [
cocious sexual development in the first-degree rela- W+ q. M! O1 x) S, ? r
tives. There were no siblings.
F; T m+ T" A tPhysical Examination
5 G0 i5 c9 a0 w8 ?# i9 R+ CThe physical examination revealed a very active,! t. u. S {( P* @( j1 i# q
playful, and healthy boy. The vital signs documented9 D2 H8 r; O0 |9 c+ x' J; C) C, {
a blood pressure of 85/50 mm Hg, his length was/ F5 W$ i3 t- M8 n J9 O
90 cm (>97th percentile), and his weight was 14.4 kg
7 G, W, ~& O1 H(also >97th percentile). The observed yearly growth
% l" w, m( U) u' R$ V/ R _velocity was 30 cm (12 inches). The examination of" d" I/ v% r A& b# j
the neck revealed no thyroid enlargement.$ z1 j4 ~4 Z! [/ s' K# f3 [( F" U
The genitourinary examination was remarkable for
. Z" Z A' O! g% menlargement of the penis, with a stretched length of+ {: W5 Y7 P9 e
8 cm and a width of 2 cm. The glans penis was very well
; @* L9 U+ r& y+ | @2 I. ~/ xdeveloped. The pubic hair was Tanner II, mostly around0 G* F+ C+ u; S Q& }% R
540
: v7 q4 {/ s" Y6 h ]/ A5 }- \, T9 Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( n! K. b' K a2 p
the base of the phallus and was dark and curled. The
& y& m2 b9 e# i, p! {9 M6 ?9 I8 Ytesticular volume was prepubertal at 2 mL each.3 b* z7 p p5 |! S0 P n
The skin was moist and smooth and somewhat
: u1 V1 k6 i8 u5 u$ j: Goily. No axillary hair was noted. There were no1 k. E. J9 A1 @
abnormal skin pigmentations or café-au-lait spots.
& e0 f( S. k. n7 z+ ~: T) fNeurologic evaluation showed deep tendon reflex 2+/ t. `# }$ t$ G8 ?) c0 ^8 I
bilateral and symmetrical. There was no suggestion
% y. |" V# H6 O" W& yof papilledema.
, n- y d* }1 w6 sLaboratory Evaluation
! u( O4 @, {2 C2 H/ b; y3 o! e( zThe bone age was consistent with 28 months by
1 S6 q' n& u6 l% f1 N: y9 F% yusing the standard of Greulich and Pyle at a chrono-
( S1 Y/ X) B }: P8 w6 ulogic age of 16 months (advanced).5 Chromosomal
?, V6 N; |& [; S7 w0 O# Z& B- Rkaryotype was 46XY. The thyroid function test
9 ^0 i, P% R ^( ]9 Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 n) y! v2 b. \' R I6 A* b
lating hormone level was 1.3 µIU/mL (both normal).! {* h2 f6 i n5 p" _
The concentrations of serum electrolytes, blood5 G4 [" W8 S: n/ K! Z! t
urea nitrogen, creatinine, and calcium all were | m$ W9 w; B5 K+ t! u9 d
within normal range for his age. The concentration
, ?6 R$ \8 _& G2 e; yof serum 17-hydroxyprogesterone was 16 ng/dL
" A! g, w' O( q5 l& e3 \. C9 b(normal, 3 to 90 ng/dL), androstenedione was 207 e' I I1 u2 m U5 J" I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 ?6 y/ Y, v2 y8 l$ W6 L X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 f" h% V# E" ]6 i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 S' f9 y6 _+ M$ u6 Z( C- D# C% f
49ng/dL), 11-desoxycortisol (specific compound S)# n9 } _5 u: z- g+ `+ q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% e' L. N: Q5 R1 {4 n" S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) V! f$ Y; Y* [ g" {. e1 Q! t/ A* G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 G+ \5 n8 k; _- O8 P
and β-human chorionic gonadotropin was less than; c" e9 T) N# n" `& S0 n8 h
5 mIU/mL (normal <5 mIU/mL). Serum follicular- j. c& k; I7 B" O H: o5 H
stimulating hormone and leuteinizing hormone
% d m; ~& Y, a: B% }concentrations were less than 0.05 mIU/mL
7 k, J7 L. n* K' \, ]2 D4 J(prepubertal).! S* \, a: h# w( D3 k) ^& k( S, r4 L
The parents were notified about the laboratory
$ ^3 P! R. V; r3 {% Mresults and were informed that all of the tests were
! F9 H1 w( F7 Nnormal except the testosterone level was high. The/ t' a+ k* X# _0 g4 n) c3 B8 X
follow-up visit was arranged within a few weeks to
/ |, s) B: `1 y4 D; I6 X3 n' Sobtain testicular and abdominal sonograms; how-) A9 l% j, g! t. T2 s' `% }
ever, the family did not return for 4 months.
6 g9 x8 l- ?3 w0 z0 X) FPhysical examination at this time revealed that the1 k, b, q# A* m) d
child had grown 2.5 cm in 4 months and had gained
$ f, F; P) x( J; }/ q: `2 kg of weight. Physical examination remained
\1 P1 w5 \- x4 U9 Nunchanged. Surprisingly, the pubic hair almost com-
4 d7 M+ H: n3 f4 W0 o" xpletely disappeared except for a few vellous hairs at6 U. r% F" V# d& e/ i6 _. r
the base of the phallus. Testicular volume was still 2
0 x4 N) h; I I1 y* z' ^7 xmL, and the size of the penis remained unchanged.
! }8 S: v. V3 f% N& q$ E5 BThe mother also said that the boy was no longer hav-9 e/ V* T/ g" y
ing frequent erections.
+ W+ U4 V" d' H1 a. w8 p; a2 JBoth parents were again questioned about use of
# ~/ J* d) G6 _% ?$ _+ Aany ointment/creams that they may have applied to
" S/ t1 `( P$ x1 o6 b. zthe child’s skin. This time the father admitted the$ d% {- K+ j! y1 ^2 W
Topical Testosterone Exposure / Bhowmick et al 541
4 A- H f( X/ @8 M0 Q, W+ e/ o/ e3 A" C8 Nuse of testosterone gel twice daily that he was apply-8 W2 h2 @1 V) N! I7 k
ing over his own shoulders, chest, and back area for
, p$ h( I& p4 w0 y6 t. Xa year. The father also revealed he was embarrassed
! z3 U5 h0 W/ N4 R! T: X; i2 v: L6 [4 sto disclose that he was using a testosterone gel pre-: U6 C2 l, q9 ]. A
scribed by his family physician for decreased libido
/ P% x s0 S' Q3 T& e, |* L; H- q( psecondary to depression.
) q) I, }! v, W6 U. f8 C5 ZThe child slept in the same bed with parents.
% W; R/ M0 }# H( s% l+ dThe father would hug the baby and hold him on his
2 E: B, K6 M0 k. h9 Jchest for a considerable period of time, causing sig-# k$ @: l7 R7 ^6 E+ C3 t
nificant bare skin contact between baby and father.
# q) @; B2 a. }The father also admitted that after the phone call,
/ p- {+ K& ~! ]# X" y+ uwhen he learned the testosterone level in the baby* k/ D6 F; l# d3 ]# `0 Y
was high, he then read the product information- G, s% h. ~* z9 o7 O
packet and concluded that it was most likely the rea-: ]& |6 ^) f# H' l, i+ V! b
son for the child’s virilization. At that time, they1 L* T& m n+ }5 N3 P5 E: {$ e
decided to put the baby in a separate bed, and the
4 g3 A$ t; K7 j" M' X. S, }father was not hugging him with bare skin and had k, o& h4 d9 l1 w$ b# F
been using protective clothing. A repeat testosterone; p3 c: v# Z" a/ B; M
test was ordered, but the family did not go to the, X; D& I" g( u V7 Z3 t3 w
laboratory to obtain the test.
3 c; i7 q9 W9 q% n6 C# gDiscussion
* F) e% ^1 j; d }) v! uPrecocious puberty in boys is defined as secondary
- o* S% f) D! J5 l- jsexual development before 9 years of age.1,4
" W* k3 \' `+ rPrecocious puberty is termed as central (true) when
; U2 N% I6 Q- wit is caused by the premature activation of hypo-
8 A7 L9 ]. Q/ H, x+ E/ lthalamic pituitary gonadal axis. CPP is more com-
! U6 k) o6 d# t y# B5 zmon in girls than in boys.1,3 Most boys with CPP, C# a( K# [+ _
may have a central nervous system lesion that is
! X% ?; D( F% L4 g1 q; f8 k, v8 dresponsible for the early activation of the hypothal-
: E% S& D" x% P/ M6 bamic pituitary gonadal axis.1-3 Thus, greater empha-
1 k$ \) X8 [, ?$ ?& isis has been given to neuroradiologic imaging in" i h& k& d% |7 _. i1 J
boys with precocious puberty. In addition to viril-2 d7 N6 h1 X! u3 Z' H) n- \
ization, the clinical hallmark of CPP is the symmet-
, z! P# y3 z6 u7 F# [rical testicular growth secondary to stimulation by* T# N) G" R" j' R
gonadotropins.1,3% D) C! e* F; C; A0 o$ r
Gonadotropin-independent peripheral preco-% n" w, ^) c1 w# Z) ^
cious puberty in boys also results from inappropriate
. \5 W9 P/ s( B7 ?androgenic stimulation from either endogenous or
7 h! H3 n: _( L4 N: I% qexogenous sources, nonpituitary gonadotropin stim-
+ ~% p8 B! T$ s( eulation, and rare activating mutations.3 Virilizing
1 F. ^% z! l- r0 X! jcongenital adrenal hyperplasia producing excessive5 S9 S& F) B: U5 D- y( N9 E
adrenal androgens is a common cause of precocious0 q% C( R- ]( Y0 T* ^ Y
puberty in boys.3,4
% r# z( s' [2 `2 MThe most common form of congenital adrenal( c4 C$ W$ r, C' {0 }4 F' ?
hyperplasia is the 21-hydroxylase enzyme deficiency.3 f# I5 i' H0 R0 z( z) |0 L
The 11-β hydroxylase deficiency may also result in0 m J/ a6 v' m5 \
excessive adrenal androgen production, and rarely,( C9 c! A) V* C8 ]* G- d
an adrenal tumor may also cause adrenal androgen9 k4 Y3 L' s# f; k8 Z9 x, }4 Z
excess.1,3
3 m/ O- K" C$ ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% C0 X* g$ a' a, z" z8 [542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, v0 s r1 Y# u, m" N( ?% ]: iA unique entity of male-limited gonadotropin-
7 a% }8 j- y3 d! d4 w- K; x( @independent precocious puberty, which is also known) [ m* w* B+ _4 e0 u
as testotoxicosis, may cause precocious puberty at a2 H. H* z/ {, W$ R7 @
very young age. The physical findings in these boys
1 s4 e+ h+ x3 U& |# Ywith this disorder are full pubertal development,
3 x F( f$ I7 A4 z! i# yincluding bilateral testicular growth, similar to boys
* e3 c" t$ b0 x5 D. {, xwith CPP. The gonadotropin levels in this disorder: O! d- |( |& {: g! N5 L
are suppressed to prepubertal levels and do not show$ z% `- v. C$ H/ n9 p9 D
pubertal response of gonadotropin after gonadotropin-
0 [# k" V, N2 _+ C1 v& t2 {releasing hormone stimulation. This is a sex-linked
: s/ {, @' f+ u0 Y3 e; i. x' uautosomal dominant disorder that affects only
& t5 R2 ?' i+ D( b% J- W5 B6 B2 bmales; therefore, other male members of the family
, \. {! S5 ^2 h' V$ \: \may have similar precocious puberty.3
r" p, O: [" RIn our patient, physical examination was incon-
" `: ?( S4 F# ^( `( Tsistent with true precocious puberty since his testi-
2 w) \+ f9 d4 M2 @7 q2 M# Q Ycles were prepubertal in size. However, testotoxicosis
0 I, F+ ~( }' D- W& Ewas in the differential diagnosis because his father
8 y" Q# [2 a9 y5 Nstarted puberty somewhat early, and occasionally,
) @( \$ ~; w. d( Ttesticular enlargement is not that evident in the! k2 S8 P9 g2 p( i; Q8 n/ y. y
beginning of this process.1 In the absence of a neg-
6 _* l2 F7 D3 e/ }7 S0 oative initial history of androgen exposure, our% ~: ]; |; H4 C8 L% b& O
biggest concern was virilizing adrenal hyperplasia,
0 Z* G ~0 U% j0 Yeither 21-hydroxylase deficiency or 11-β hydroxylase+ Q& T5 v$ M& s9 i% k6 p
deficiency. Those diagnoses were excluded by find-6 U" a# _- d7 i- \7 ~9 i
ing the normal level of adrenal steroids.9 }. b/ S8 {+ o) `6 P
The diagnosis of exogenous androgens was strongly5 _1 @. M1 [; t8 ~- v
suspected in a follow-up visit after 4 months because9 h" H4 [7 P# N$ q5 v
the physical examination revealed the complete disap-- I. p1 k# b+ M) |+ l
pearance of pubic hair, normal growth velocity, and
# B8 W: R+ s$ G7 d/ Edecreased erections. The father admitted using a testos-% n& r! \! |: ^4 G
terone gel, which he concealed at first visit. He was# @* ^: g; ~) Y5 \. h" y- `
using it rather frequently, twice a day. The Physicians’1 [2 w" y( t! O: x1 Z: U, e
Desk Reference, or package insert of this product, gel or
: y- ^4 L" w& t9 i6 v( fcream, cautions about dermal testosterone transfer to
* j& f( E" W+ w( s2 r Wunprotected females through direct skin exposure.
8 R; h% [- j( V5 U3 c- y) WSerum testosterone level was found to be 2 times the
4 C, f- K* N3 L% V# D Q5 v3 rbaseline value in those females who were exposed to( w) t+ Z/ A0 s4 Y5 F9 b
even 15 minutes of direct skin contact with their male I" b8 f1 d7 `
partners.6 However, when a shirt covered the applica-3 u: G3 E. ^4 ^8 J! H
tion site, this testosterone transfer was prevented.
& P. w- g! b; @8 uOur patient’s testosterone level was 60 ng/mL,: X: a- z, N" E( a8 g3 T
which was clearly high. Some studies suggest that
# l$ w& W- u6 ^9 R" s9 odermal conversion of testosterone to dihydrotestos-
4 {7 M) L7 ^' |, `; |- Nterone, which is a more potent metabolite, is more
% A4 b# a" F: f+ E* ]: q+ Xactive in young children exposed to testosterone
9 H, V% a4 ?/ i% F: [ |1 ?exogenously7; however, we did not measure a dihy-
. [5 k( d! r# F6 k! k' Bdrotestosterone level in our patient. In addition to4 l3 ^; U: h) H: v6 c
virilization, exposure to exogenous testosterone in
+ {8 s6 G& B- {children results in an increase in growth velocity and' u1 ^% d5 C' C p) B
advanced bone age, as seen in our patient.5 i9 ~' ^1 s& K9 j; W" o+ X" E4 m/ B
The long-term effect of androgen exposure during7 W i) C7 V6 g/ m, T! l7 @
early childhood on pubertal development and final' b1 e9 w5 S4 v' T4 x, I! R3 ?
adult height are not fully known and always remain
1 p4 Z/ T3 } q9 Wa concern. Children treated with short-term testos-
/ t5 t" b! I8 f: j8 B8 D% \, \terone injection or topical androgen may exhibit some
& W% o* `+ [: v; M$ _acceleration of the skeletal maturation; however, after e& ]. n2 j) |1 c& |* l
cessation of treatment, the rate of bone maturation) }' `+ @, G6 N% o3 @/ J
decelerates and gradually returns to normal.8,9
3 G) \# ^& w2 ?8 j9 i. [3 u& BThere are conflicting reports and controversy M( s& i! W' L3 @' x8 ^' {
over the effect of early androgen exposure on adult
2 X3 ~& k& K' F9 Wpenile length.10,11 Some reports suggest subnormal
0 V( S# u- ?7 A! `8 Xadult penile length, apparently because of downreg-
! u9 S& D1 }. V6 Tulation of androgen receptor number.10,12 However,+ {5 m1 k0 ], z$ _+ h
Sutherland et al13 did not find a correlation between
8 }, i' ~0 u) Ochildhood testosterone exposure and reduced adult
# p6 @/ r, W0 epenile length in clinical studies.
% V$ C& u+ J* ?4 |0 C0 c0 H2 _Nonetheless, we do not believe our patient is ]) A2 q: R2 a( a2 k: u+ [, S; x, N
going to experience any of the untoward effects from3 Y# s" p7 ~" n4 i* u' o9 x
testosterone exposure as mentioned earlier because
: ?) y5 X+ Y d! T, d$ c+ dthe exposure was not for a prolonged period of time.1 ]: }9 Q; h6 C
Although the bone age was advanced at the time of
, }2 O8 ^( w. D. y- h9 Wdiagnosis, the child had a normal growth velocity at
" T; e; y6 I+ N/ X2 u% I0 O- pthe follow-up visit. It is hoped that his final adult
' ?. o% N# F+ u/ H1 M1 m3 H1 o7 fheight will not be affected.
3 \# x6 I1 Z' J0 H/ q* I8 [/ L" KAlthough rarely reported, the widespread avail-
9 h" m. M8 \: P$ ] ~. Vability of androgen products in our society may
" K/ T" S8 r: Y5 N0 e- ]% aindeed cause more virilization in male or female7 F# r: o q, f& `
children than one would realize. Exposure to andro-+ c& P/ @$ {% I
gen products must be considered and specific ques-
5 e' j: w2 h0 k) O2 Qtioning about the use of a testosterone product or
3 ^, P3 n8 a8 L' G* Ngel should be asked of the family members during* @; N/ N" m+ P& t- b
the evaluation of any children who present with vir-, `; p4 T* v# r
ilization or peripheral precocious puberty. The diag-5 f n$ }. D# E0 l- s4 ~) j
nosis can be established by just a few tests and by2 O: ]& D9 Y1 y: y
appropriate history. The inability to obtain such a' A$ u, T) ^# U/ n3 p
history, or failure to ask the specific questions, may
8 V) e4 W4 v5 l/ d' Cresult in extensive, unnecessary, and expensive0 j- A- E4 p+ e! Z7 \
investigation. The primary care physician should be
; c6 D" y a2 s9 X& z) ?6 f( oaware of this fact, because most of these children
' ~" v* M/ S- @' ^may initially present in their practice. The Physicians’
6 Q. O' \4 U- @: ?+ G4 gDesk Reference and package insert should also put a- _" \: P Y& {. f! c
warning about the virilizing effect on a male or; p F1 W2 J' b# C7 ]
female child who might come in contact with some-
* F- }. {7 U9 uone using any of these products.: L( w' n+ g) l" R* L5 V
References
) w% P, z6 x( I( x: w) ?# W1 U6 h1. Styne DM. The testes: disorder of sexual differentiation) l( q* e; x- f1 c3 z3 A
and puberty in the male. In: Sperling MA, ed. Pediatric4 K4 Y/ U0 i0 s( F0 @4 A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ H8 [7 m/ ~2 K4 r# b% a3 G
2002: 565-628.
1 W7 X3 A t# b) {3 Z% R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& P% J+ n7 _3 C" D
puberty in children with tumours of the suprasellar pineal |
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