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Sexual Precocity in a 16-Month-Old
5 f1 O. {, `0 q* `, {& |Boy Induced by Indirect Topical
, D6 t& r# q) \Exposure to Testosterone8 v# j$ T" u5 j9 e" I. g4 F2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ D/ c# S% S/ a7 w+ o* I9 u
and Kenneth R. Rettig, MD1
+ W4 E/ y" {- E; A( q0 h6 H/ cClinical Pediatrics
& O1 @$ ^1 I$ b0 c# _Volume 46 Number 68 c; `& n# O8 E! l
July 2007 540-5433 W3 x3 U5 D X( n0 l
© 2007 Sage Publications
% \2 n! }6 L$ J10.1177/0009922806296651
% S9 i. o; R k. e4 w$ Lhttp://clp.sagepub.com
7 C4 T \- B, e9 h2 T8 khosted at
8 u. r! C! h7 I# Vhttp://online.sagepub.com( R: _' y1 w& W# h" s: ~3 U" q
Precocious puberty in boys, central or peripheral,
+ q5 ?' l2 s, Yis a significant concern for physicians. Central1 b4 Z7 n' x1 \/ Z* s/ H
precocious puberty (CPP), which is mediated4 L3 H: K+ {" }& m/ X- m% T% r x* v
through the hypothalamic pituitary gonadal axis, has
5 l" Z$ P2 U" d$ G8 Na higher incidence of organic central nervous system3 ^( a9 b( h. I7 d# M% K0 Y; }
lesions in boys.1,2 Virilization in boys, as manifested
$ C4 n6 K" N+ _% Dby enlargement of the penis, development of pubic
# d3 n M g5 A5 X& D# chair, and facial acne without enlargement of testi-6 X* O) K" R: V `/ w* W
cles, suggests peripheral or pseudopuberty.1-3 We
; ]2 R v0 {$ d8 o$ j& ~6 wreport a 16-month-old boy who presented with the
# e2 K$ n9 K, G3 w& t/ W6 N+ uenlargement of the phallus and pubic hair develop- E6 B9 @8 X4 B5 h& [# c: J% d
ment without testicular enlargement, which was due
- c! U! F( _; ]5 Kto the unintentional exposure to androgen gel used by! [. i- ^4 E6 z. ~- d- Y6 v
the father. The family initially concealed this infor-
a4 V# a5 d% s5 M$ Dmation, resulting in an extensive work-up for this' m* ~* e$ B: h, N3 ~. ~3 Q
child. Given the widespread and easy availability of
6 q# d, o* X1 e9 Etestosterone gel and cream, we believe this is proba-# ?/ }, j" a2 B
bly more common than the rare case report in the
2 r; v) e2 }4 |" Aliterature.4
4 ~4 e! n' ]- ?2 B. NPatient Report
; \' u, a6 V2 O- xA 16-month-old white child was referred to the# B- `0 j: I4 j2 T$ ]
endocrine clinic by his pediatrician with the concern
: l8 P! n9 {9 p& hof early sexual development. His mother noticed
! }5 L# ^8 T4 K- u" U, b* K" Hlight colored pubic hair development when he was2 P" C6 U3 e0 ] P8 H# w
From the 1Division of Pediatric Endocrinology, 2University of, X5 O( \1 P7 l# D9 q
South Alabama Medical Center, Mobile, Alabama.
: B8 j) q, P* r8 V# g H$ [. k! iAddress correspondence to: Samar K. Bhowmick, MD, FACE,' c, U' ^, c( N, p: U
Professor of Pediatrics, University of South Alabama, College of
' q% K! E6 D, [/ Q7 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ J8 X' M3 _# x- r/ _
e-mail: [email protected].$ R5 F4 Y F- i0 n% E! {
about 6 to 7 months old, which progressively became
! `+ _* e2 H5 E8 A$ p0 J udarker. She was also concerned about the enlarge-
; j6 U. |8 l4 R4 ?ment of his penis and frequent erections. The child
1 z, u5 \* A$ ]3 y; r$ ~was the product of a full-term normal delivery, with
0 N% ~0 D. w0 P* H6 wa birth weight of 7 lb 14 oz, and birth length of
- E8 c% P: ~4 y/ q1 i$ @% {20 inches. He was breast-fed throughout the first year \: R8 i$ s5 i1 U2 p9 d; R
of life and was still receiving breast milk along with
! _$ @6 t& V- Bsolid food. He had no hospitalizations or surgery,9 R7 e- o; d6 J$ X/ K9 i+ ]2 O
and his psychosocial and psychomotor development
% X3 X4 A, G/ u; L. @5 Iwas age appropriate.) L$ n; E4 S# \6 K: R
The family history was remarkable for the father,4 C: V0 h% a, C( ~# X
who was diagnosed with hypothyroidism at age 16,% u, l% e1 f3 `! x+ f0 s* q4 A
which was treated with thyroxine. The father’s
. A8 D% j& s/ h. C- r" Wheight was 6 feet, and he went through a somewhat' a# v( _6 P4 I$ d/ T% I8 F
early puberty and had stopped growing by age 14.
7 S# k+ ^/ ]( z( c. x( E! k4 HThe father denied taking any other medication. The
& f! s0 S) N, |5 ^9 y. `1 \" z, tchild’s mother was in good health. Her menarche
* t% k7 }* h8 T Q& v9 ?! ?' Fwas at 11 years of age, and her height was at 5 feet
9 r- S% ?4 q# W; U _, ?5 inches. There was no other family history of pre-+ L9 ?6 \" n0 _' K
cocious sexual development in the first-degree rela-
% T \& ~4 V) M2 ?tives. There were no siblings.; M7 W) O! Y/ N
Physical Examination
1 z% q; ]0 v6 U3 Q w5 S3 A' TThe physical examination revealed a very active,
2 ^, ~1 C, o w' M; _5 `( k2 Aplayful, and healthy boy. The vital signs documented
2 [) p9 _* r, Z$ ?9 G2 U: \4 N Ta blood pressure of 85/50 mm Hg, his length was% Q" n; D. o) q+ B6 A6 J1 R2 v# i6 B
90 cm (>97th percentile), and his weight was 14.4 kg
1 C0 ?+ Y' Y4 d4 U6 D0 w, J& h(also >97th percentile). The observed yearly growth
! \% q) }! L: Kvelocity was 30 cm (12 inches). The examination of
1 s5 \# v- [* B0 pthe neck revealed no thyroid enlargement.. m1 w8 C& {; Q
The genitourinary examination was remarkable for
]# Z- [/ z+ ~6 V0 c/ e; nenlargement of the penis, with a stretched length of
6 c8 g% H& ^0 U4 c" m8 cm and a width of 2 cm. The glans penis was very well( s5 j9 u$ `9 {% q2 @7 }
developed. The pubic hair was Tanner II, mostly around' k4 ~2 ^4 }- L. B
540
2 r8 u' v" w b9 m8 n7 dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; e4 y! X" f4 J$ G; rthe base of the phallus and was dark and curled. The+ ^" z5 y0 A. _; M3 w$ I0 w
testicular volume was prepubertal at 2 mL each.
, i" E5 M3 o; _7 ]3 P. oThe skin was moist and smooth and somewhat
8 A1 X0 I# ^; Foily. No axillary hair was noted. There were no
9 |0 T# ]) s J+ w: cabnormal skin pigmentations or café-au-lait spots.
" x4 x. u; I& L& E/ aNeurologic evaluation showed deep tendon reflex 2+
4 w' N: T# U+ ^- Wbilateral and symmetrical. There was no suggestion b: H$ U" r7 R9 R' b' @
of papilledema.
4 f5 A9 _! A+ d) t7 g' C: bLaboratory Evaluation
# Q) g1 N- _' Q7 T# ^9 QThe bone age was consistent with 28 months by( d2 s5 a# M, \$ p- H+ e+ J8 s4 `
using the standard of Greulich and Pyle at a chrono-* ^; B" a) k. }. N6 V- U8 O4 b+ x
logic age of 16 months (advanced).5 Chromosomal! O* M- t; O2 Z! _ \ m( ?
karyotype was 46XY. The thyroid function test" x; c* b$ I: e7 e5 g& [* d& ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-) v* T. v) f' _1 i! A7 ]- i. U
lating hormone level was 1.3 µIU/mL (both normal).
3 i& x' [( q1 H9 y2 V3 @3 CThe concentrations of serum electrolytes, blood5 P5 O5 f# P+ Q2 @% v# U! }4 E+ |1 U
urea nitrogen, creatinine, and calcium all were
1 Y! f. z; S7 C3 X. Bwithin normal range for his age. The concentration
) H' e+ b# E8 E! h Z2 h; ^: Pof serum 17-hydroxyprogesterone was 16 ng/dL; A1 t6 R' f) w2 C# P- O
(normal, 3 to 90 ng/dL), androstenedione was 20
, z3 h e- j( T$ J2 I- Y! h dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 s5 ^2 K; k1 R: L3 @# A+ K( j* Z0 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' l U$ q0 `% t8 }' cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. q j& E3 @% J# w' E: R0 M
49ng/dL), 11-desoxycortisol (specific compound S)
- S n$ T) b$ Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 i+ V% ?+ t1 O" R( @+ v$ Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: d0 D u: r9 B- q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( e% b5 t# m7 H" y8 P% V4 g
and β-human chorionic gonadotropin was less than
! G; ?6 C- M% s; W1 F/ h5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 q7 I: `" s! W* X6 t3 @, Hstimulating hormone and leuteinizing hormone
& n3 ]* k( u; d! J2 I0 b* tconcentrations were less than 0.05 mIU/mL+ P6 F/ B& s8 K& h8 R
(prepubertal).
8 c: P, d4 V' s: n7 t' T. CThe parents were notified about the laboratory6 ^/ b- ^7 {' S7 V: r' f
results and were informed that all of the tests were
6 E: l, o- N7 S" b# dnormal except the testosterone level was high. The& \, G& [% B0 b' o( A; r
follow-up visit was arranged within a few weeks to$ j! ]- W8 U! x# }
obtain testicular and abdominal sonograms; how-
1 y9 _) t2 `3 Q) m2 Q$ m0 c; A lever, the family did not return for 4 months.
: g9 s) @; F% hPhysical examination at this time revealed that the
9 f) T1 U4 z: G( n& `# lchild had grown 2.5 cm in 4 months and had gained
9 W1 S1 P, m0 m2 kg of weight. Physical examination remained& U1 p( l! D7 c
unchanged. Surprisingly, the pubic hair almost com-5 s! Z" Z5 N2 g6 h! w
pletely disappeared except for a few vellous hairs at
9 V3 t1 ^. } m6 E( dthe base of the phallus. Testicular volume was still 2
4 h2 U4 r/ i9 I0 q" w9 fmL, and the size of the penis remained unchanged.
# }* `0 ^$ [' \' N+ ^* Z- E/ JThe mother also said that the boy was no longer hav-
5 l7 o5 l0 m v' T( j+ ging frequent erections." e: X9 D, x3 I6 L8 v
Both parents were again questioned about use of
. d( |) E* y5 Z$ S2 nany ointment/creams that they may have applied to: A/ m- R" {. V! y/ \
the child’s skin. This time the father admitted the" A: k# ^( O5 \6 Y
Topical Testosterone Exposure / Bhowmick et al 5418 R8 d# C+ w+ B) ?
use of testosterone gel twice daily that he was apply-6 U, }: p+ Q, B9 i4 i1 y+ h
ing over his own shoulders, chest, and back area for) ^% I' @. z$ L3 G
a year. The father also revealed he was embarrassed
# ?" ?4 ?2 j- O& J/ U! w! p- \) Q# Uto disclose that he was using a testosterone gel pre-( j {3 }! c( [2 }& J
scribed by his family physician for decreased libido
1 U/ k9 I% e3 g1 @: i8 P5 rsecondary to depression.& K+ ^, i2 r9 V) C+ m/ \2 ^" D
The child slept in the same bed with parents.9 v; T- j: v( z
The father would hug the baby and hold him on his3 h. `/ W% I- N: _5 K+ `: H7 c
chest for a considerable period of time, causing sig-+ O% n* O- X. `! s
nificant bare skin contact between baby and father.0 ?' Q0 c3 K k! v! m0 H+ w. g
The father also admitted that after the phone call,4 n1 X- B$ F2 ~- ]- j, X! p3 ^- W
when he learned the testosterone level in the baby/ x5 }5 [6 \0 q2 K1 s3 ]1 h& [( |
was high, he then read the product information' I' O! S! B( `; u% `3 k8 j
packet and concluded that it was most likely the rea-
; ~( F, {7 t9 @$ \5 cson for the child’s virilization. At that time, they
1 D% a' ~/ Y/ g! }! d, m9 Qdecided to put the baby in a separate bed, and the
3 E% f& n- {. b7 `( q$ Bfather was not hugging him with bare skin and had% b) v4 B6 P) W
been using protective clothing. A repeat testosterone/ C; h2 a& X, B
test was ordered, but the family did not go to the
! J i4 k M5 X1 F1 @$ k0 Elaboratory to obtain the test.. {# k7 Z8 o9 K, e# k6 x/ y4 C9 p
Discussion
$ B5 y) ]" X" P% R7 |* F7 TPrecocious puberty in boys is defined as secondary
% d$ F \) t+ x( bsexual development before 9 years of age.1,4
2 f+ d, _2 T0 j# CPrecocious puberty is termed as central (true) when
" |' J" t8 c* n7 @/ K" hit is caused by the premature activation of hypo-9 w& t% }' m6 u( {) R2 B
thalamic pituitary gonadal axis. CPP is more com-5 u9 b" V) a3 _. v S
mon in girls than in boys.1,3 Most boys with CPP7 ] ?+ n% u; G. d$ q
may have a central nervous system lesion that is
4 [( Q! ~ S* T6 ^responsible for the early activation of the hypothal-/ l6 f0 g0 J1 }3 m% u0 E$ g
amic pituitary gonadal axis.1-3 Thus, greater empha-2 L' b U: l+ c! V M
sis has been given to neuroradiologic imaging in
/ t! A4 e8 o; v4 `0 ~% hboys with precocious puberty. In addition to viril-- D* A' Q. B( G8 m( n
ization, the clinical hallmark of CPP is the symmet-- c+ U3 N/ u( R
rical testicular growth secondary to stimulation by" V. H9 Y0 f3 Q7 Q2 i+ D
gonadotropins.1,3
; s+ K4 u, y8 Y! f4 \) LGonadotropin-independent peripheral preco-
$ q+ _" i5 P6 u- ~# |" Jcious puberty in boys also results from inappropriate
+ w' f) c" ^6 h# k1 Qandrogenic stimulation from either endogenous or5 N, L( d# T& I2 K
exogenous sources, nonpituitary gonadotropin stim-* Q' V l" @& Y: ~9 T, p2 p4 H
ulation, and rare activating mutations.3 Virilizing0 A& S5 e e3 `
congenital adrenal hyperplasia producing excessive% _$ a7 h0 w; Z6 y/ P# X
adrenal androgens is a common cause of precocious/ ^ b# h2 `+ R. A3 ~
puberty in boys.3,44 T8 C! X2 k, |8 m4 t6 `6 r
The most common form of congenital adrenal
/ t+ c$ p7 \( W3 c) yhyperplasia is the 21-hydroxylase enzyme deficiency.6 h4 _9 O( A! Q' B3 K
The 11-β hydroxylase deficiency may also result in( v/ I. z* c( d* F
excessive adrenal androgen production, and rarely,
" N9 f3 S! b; T4 m; {7 W0 Tan adrenal tumor may also cause adrenal androgen
5 e% ~$ C1 C" S& g) g* T0 h) A) mexcess.1,3
4 @6 F/ w7 Y% P" D- [8 f) @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 F. P" q* n7 {8 h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, Q4 N! t Y4 m! `/ u' l( OA unique entity of male-limited gonadotropin-
?' s' _$ R2 Z* l5 E' Windependent precocious puberty, which is also known
" l2 S! h6 z+ q# b* l1 las testotoxicosis, may cause precocious puberty at a
* V, d% Y! W- V! b% ^. y! |2 cvery young age. The physical findings in these boys+ q% ^! ~. \ _2 y% M; c
with this disorder are full pubertal development,
9 s# V& q9 f. M$ B- h2 y" l# ^/ Lincluding bilateral testicular growth, similar to boys
( j% k% p- V1 f) bwith CPP. The gonadotropin levels in this disorder
. W) v3 a- i& \( care suppressed to prepubertal levels and do not show; N: j! G$ o* ?. ~8 V
pubertal response of gonadotropin after gonadotropin-5 S; L# I$ |. P. g2 ~1 o8 ?: S" W
releasing hormone stimulation. This is a sex-linked
# B) s& J0 L* J4 v' v7 ?' xautosomal dominant disorder that affects only6 E. O" a- L" {$ ?$ }7 C
males; therefore, other male members of the family7 K* T: T! X& W# R+ j9 w% d; M
may have similar precocious puberty.36 X8 n' a) _7 a+ F) K: u6 ^
In our patient, physical examination was incon-
0 k9 X$ d! @# q* J( isistent with true precocious puberty since his testi-
W; c7 Y" {, i' T, Qcles were prepubertal in size. However, testotoxicosis
) C4 Q' F9 K q# O8 ?was in the differential diagnosis because his father) [7 S9 }8 K/ m6 }! N% ^8 a
started puberty somewhat early, and occasionally,
4 P; H, @# }) E( g8 E( otesticular enlargement is not that evident in the) P% j# q8 N: ^
beginning of this process.1 In the absence of a neg-. p/ h2 W0 F$ w+ D. Y$ h, ?+ i
ative initial history of androgen exposure, our2 q# h; c# U3 ?7 n2 }: B! A0 h0 ?
biggest concern was virilizing adrenal hyperplasia,
! r p4 o2 O+ h- s7 y* Seither 21-hydroxylase deficiency or 11-β hydroxylase( O [& `3 ~# w G: W6 v
deficiency. Those diagnoses were excluded by find-" n2 `2 }1 N! V$ {7 q
ing the normal level of adrenal steroids.: ^4 t* Q: D3 C& S; r3 c# s# x( h; {
The diagnosis of exogenous androgens was strongly0 ~& W- K& B; G) q1 T2 y0 [" \% c
suspected in a follow-up visit after 4 months because! M( Y7 R9 R) S! g4 B6 r" m' O5 _
the physical examination revealed the complete disap-
4 d- [6 P7 N6 _9 O7 k( N- apearance of pubic hair, normal growth velocity, and3 \) |1 b% n( M1 Q; o$ i g
decreased erections. The father admitted using a testos-6 }6 ~) E. a4 H; a2 X
terone gel, which he concealed at first visit. He was
! K c6 s4 a/ Z/ K" Busing it rather frequently, twice a day. The Physicians’
, y; h" o9 s* hDesk Reference, or package insert of this product, gel or1 }' |4 q" n7 p
cream, cautions about dermal testosterone transfer to2 d; h" v' ~& M- D* k- t
unprotected females through direct skin exposure.; G( T, k1 O: u
Serum testosterone level was found to be 2 times the
! ~: f. z4 a' Y& W- f R2 fbaseline value in those females who were exposed to: f1 ~/ V1 q( h, V8 }3 m! P
even 15 minutes of direct skin contact with their male
2 v" b" b+ {$ D6 N- R+ Lpartners.6 However, when a shirt covered the applica-
) k- f5 F+ i# y8 ]6 |' ttion site, this testosterone transfer was prevented.
4 N! {" W% a6 [% R" r, `* |$ dOur patient’s testosterone level was 60 ng/mL,4 y1 F/ C5 R0 Z2 \! [" q
which was clearly high. Some studies suggest that
$ P5 w9 r2 |8 q4 X9 Wdermal conversion of testosterone to dihydrotestos-$ p+ d& k9 J, p) |( a4 h5 z! Q; u
terone, which is a more potent metabolite, is more8 e7 v: f& e# u7 W( `9 ?+ h0 p! e$ A
active in young children exposed to testosterone
: D1 y1 T; r: n! Pexogenously7; however, we did not measure a dihy-
8 n2 {9 V* z2 R. Gdrotestosterone level in our patient. In addition to5 f8 |" E5 Y8 u4 }
virilization, exposure to exogenous testosterone in: A4 J) C5 |. t' a
children results in an increase in growth velocity and7 b- r, S7 N/ O/ }
advanced bone age, as seen in our patient., m. p9 N0 c2 P/ {6 l, D6 [
The long-term effect of androgen exposure during
9 x0 S4 `# w# ]2 f# rearly childhood on pubertal development and final7 g' z1 h% {1 W& y- |) C6 L: V2 U
adult height are not fully known and always remain" ]8 b' U+ s8 c$ o% _1 Z' y
a concern. Children treated with short-term testos-
- F8 C, b! i- V( o3 gterone injection or topical androgen may exhibit some
& e9 K+ h- q X* ?5 u5 o6 [acceleration of the skeletal maturation; however, after+ q( C9 T" T* t) I: x
cessation of treatment, the rate of bone maturation
8 R+ Z# E" `3 b, E2 ?/ Qdecelerates and gradually returns to normal.8,9
" k" d2 A) D! K9 M# T7 ?0 w1 eThere are conflicting reports and controversy c4 v0 H+ B \
over the effect of early androgen exposure on adult
* T2 B% g' R1 J* Lpenile length.10,11 Some reports suggest subnormal0 d6 E5 ?0 e; c. B! n$ S' O* B
adult penile length, apparently because of downreg-' ~6 g4 c. X( i ~, w) y6 [0 a' L9 Y
ulation of androgen receptor number.10,12 However,
6 z+ H2 ?! c* R, L6 G KSutherland et al13 did not find a correlation between
* p, `# T* u% b$ f, a6 J" E- h" `% Z5 achildhood testosterone exposure and reduced adult3 ^& D8 a' u+ O: j$ V
penile length in clinical studies.2 \5 C0 L% m$ d% [ T R
Nonetheless, we do not believe our patient is r2 N: D+ R/ P L- \$ M
going to experience any of the untoward effects from* W# D3 w0 g& |1 U# E$ h
testosterone exposure as mentioned earlier because
* ^! [% D' {; `8 k4 q( |+ ^! x- mthe exposure was not for a prolonged period of time.$ T* `4 y& [# v4 t; u& a
Although the bone age was advanced at the time of+ E% B& u2 U) p) Q: }
diagnosis, the child had a normal growth velocity at5 c7 z1 L6 ]! l+ X5 S3 |, `
the follow-up visit. It is hoped that his final adult7 G, o% X2 F% Q3 w, F
height will not be affected.
4 B/ @/ G+ |* l6 t/ [Although rarely reported, the widespread avail-4 k4 o2 Q" T3 l) ^
ability of androgen products in our society may' q/ \" R% n T! u4 S
indeed cause more virilization in male or female
2 |# x, ]8 ^0 }' `children than one would realize. Exposure to andro-
" K/ ?8 [2 A7 l9 k% g" }4 H7 Xgen products must be considered and specific ques-# o/ _4 j/ V- f! o4 Y- R
tioning about the use of a testosterone product or
1 j- f2 ]+ G8 i: T! Xgel should be asked of the family members during
# O- n, o5 `0 `. {1 n& T; Pthe evaluation of any children who present with vir-. b# J0 P4 r: f, F1 w
ilization or peripheral precocious puberty. The diag-
) P/ X7 S4 p- E& w6 d# A! d& p$ Unosis can be established by just a few tests and by
9 O+ w- @% l# s$ f' Q$ U iappropriate history. The inability to obtain such a) q% {' n" J( }1 N3 @
history, or failure to ask the specific questions, may4 d" H: S1 f( C% j1 g) }
result in extensive, unnecessary, and expensive
( {8 i( ^5 s+ ^ Kinvestigation. The primary care physician should be. H% d' N! X$ \
aware of this fact, because most of these children) E" u6 y6 I/ P0 W5 T
may initially present in their practice. The Physicians’; V$ g/ z" Y7 ]5 s! `8 j
Desk Reference and package insert should also put a U$ m4 O, d3 }5 M
warning about the virilizing effect on a male or0 G! A; v& n$ T. h( l8 J
female child who might come in contact with some-
+ i* J% `, D t; {one using any of these products.- Q6 e9 V0 A. H( x
References7 [, Q) b) q* ?2 T, w h
1. Styne DM. The testes: disorder of sexual differentiation/ J( ^* R, s6 f$ z2 @
and puberty in the male. In: Sperling MA, ed. Pediatric# S V9 w" f, j' _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) d9 U' g% w6 f1 U. `0 e1 j, e, r
2002: 565-628.5 s# }- |9 A. h1 N. {" T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) V5 @! Y6 [' F3 P* Wpuberty in children with tumours of the suprasellar pineal |
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