- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old( y5 w p6 I4 W) ^1 ?
Boy Induced by Indirect Topical
: |7 P4 I* h; ~+ O, V& M, AExposure to Testosterone
9 e( J- A: m, c* ~# n8 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 u, b0 z- Z* ~, P {! B4 Iand Kenneth R. Rettig, MD16 I( o B+ C& X# \; x. v) y, K5 G
Clinical Pediatrics
# W' w7 g+ ?- u* E" N. ZVolume 46 Number 6
# o+ Q2 e; u* C4 c9 w, a$ _' }% r( qJuly 2007 540-543. b$ k: V8 i8 v3 A% S( z" I
© 2007 Sage Publications# s( L2 l1 c6 z$ A2 x
10.1177/0009922806296651: ~& ~' B0 a# z& e% O5 _
http://clp.sagepub.com; v" H+ b; |& A8 f; }
hosted at3 _0 s# ^% [+ b% e2 L7 z
http://online.sagepub.com
: ^) A0 o1 K- G {' ^Precocious puberty in boys, central or peripheral,
0 S' G2 Z" |; { g" [" Ais a significant concern for physicians. Central
! r/ j) p) i5 c9 ~) d2 f1 yprecocious puberty (CPP), which is mediated
) S+ y) x( p9 t0 M) Y1 rthrough the hypothalamic pituitary gonadal axis, has
( V c1 L" e: @5 F$ E2 Q8 wa higher incidence of organic central nervous system
1 v0 l6 o7 m: f9 F5 c7 R: ylesions in boys.1,2 Virilization in boys, as manifested' `& t) u x* t( I0 H _
by enlargement of the penis, development of pubic9 v. a0 E! O" w
hair, and facial acne without enlargement of testi-
: E0 u9 {4 m- |: y# ?# Ecles, suggests peripheral or pseudopuberty.1-3 We
% @: W/ d+ v3 F3 V0 B9 n7 ]report a 16-month-old boy who presented with the, A" J+ z+ V' ^' I# n. l5 q
enlargement of the phallus and pubic hair develop-
6 {5 [, D, P5 ~2 g7 p0 wment without testicular enlargement, which was due
) }" x6 I! ?) R& g) ito the unintentional exposure to androgen gel used by
: G2 S2 Q! K: V; ithe father. The family initially concealed this infor-/ |! r, h5 O- h
mation, resulting in an extensive work-up for this9 K0 I8 T: i1 J; V) y
child. Given the widespread and easy availability of3 i( O. b6 S) l* Z, r, k
testosterone gel and cream, we believe this is proba-, `# s; \ F( M: M. C; S6 P4 S! s
bly more common than the rare case report in the
7 a4 X& } m2 Z6 I- jliterature.4, [ B8 R/ a7 b) ^0 G
Patient Report0 _# p0 l, @8 d! D$ j
A 16-month-old white child was referred to the+ i: c |9 o7 N# F- j
endocrine clinic by his pediatrician with the concern
3 a) K1 t/ v; R8 _7 R+ ~' sof early sexual development. His mother noticed
. |' `, L4 i$ W( z8 m/ j6 Mlight colored pubic hair development when he was
8 Z2 g6 i9 i) [+ Y0 E+ W6 f) }0 QFrom the 1Division of Pediatric Endocrinology, 2University of4 p7 e' \/ V8 [
South Alabama Medical Center, Mobile, Alabama.2 }. b- w( g+ _4 u& q
Address correspondence to: Samar K. Bhowmick, MD, FACE,* B; I6 R) l( M0 P; x
Professor of Pediatrics, University of South Alabama, College of3 A8 V5 ? ]4 A, x0 }2 y3 |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 ^3 s5 |7 e6 e/ E& b
e-mail: [email protected].
7 t! B1 L% u1 i+ A1 T1 Habout 6 to 7 months old, which progressively became& X: v* s; Z% J3 r& x L* g; f3 n
darker. She was also concerned about the enlarge-: f j( U4 D' U. ]
ment of his penis and frequent erections. The child
% c, H: ~3 @# @% h0 }$ U' Twas the product of a full-term normal delivery, with; s! g% ^ ^$ s# v m
a birth weight of 7 lb 14 oz, and birth length of! z K" R( [2 n5 Z# \! \( y% A
20 inches. He was breast-fed throughout the first year
% J8 f9 \0 l* Wof life and was still receiving breast milk along with% @7 |$ D, k; t6 F. i L( [
solid food. He had no hospitalizations or surgery,
, ?; x/ h0 Z$ o! p W. x2 wand his psychosocial and psychomotor development- ~' y# c% w7 ?1 E4 ^4 m+ E
was age appropriate.
) _$ `4 r: i4 C( `The family history was remarkable for the father,
) N. i) l) Q9 Q# `who was diagnosed with hypothyroidism at age 16,% |& P0 g# p2 V( Q+ O
which was treated with thyroxine. The father’s) ?, L2 }! a! J) ^' J0 A$ F x
height was 6 feet, and he went through a somewhat0 @+ k; R- k1 h1 ?. T
early puberty and had stopped growing by age 14.3 f) E9 e# m4 _8 {4 [
The father denied taking any other medication. The$ G! ~! B' i( P0 q1 \, @1 K
child’s mother was in good health. Her menarche
* Z/ H' A/ b, o) b4 |was at 11 years of age, and her height was at 5 feet% |' E4 Q- m* \5 _' ]
5 inches. There was no other family history of pre-
8 ]0 B1 [0 X& ]1 O9 d4 O( Jcocious sexual development in the first-degree rela-
: G& t8 C# d( f" l/ Wtives. There were no siblings.- Z6 S; ? j5 w& P1 F% P9 e* Y
Physical Examination5 H- x: b5 {0 O5 }% l1 H6 D9 t: K
The physical examination revealed a very active,
4 m) _4 y- N. m2 m4 k; @& x0 C# }playful, and healthy boy. The vital signs documented: \+ q, v4 T1 W! ]! E& F1 f2 z
a blood pressure of 85/50 mm Hg, his length was
. T7 z; ~% x8 b90 cm (>97th percentile), and his weight was 14.4 kg8 @+ r/ F# G7 L5 x$ g2 Q; e/ U
(also >97th percentile). The observed yearly growth) Y; ~& Z' g C! h7 q3 K
velocity was 30 cm (12 inches). The examination of
$ y- ?1 f2 z" w) f, Vthe neck revealed no thyroid enlargement.+ x. S T6 c7 Q+ L7 [# z! T e
The genitourinary examination was remarkable for% e( p% g5 ^5 ^8 k! E
enlargement of the penis, with a stretched length of8 U- E3 {' t( i. w
8 cm and a width of 2 cm. The glans penis was very well
( s5 j( t) o s+ Z7 \. ^- Z7 cdeveloped. The pubic hair was Tanner II, mostly around+ P( v" O3 i) O% I0 X
540
+ Q2 @8 C2 W+ Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, t, l" |% T1 I7 |% D- B* B/ ^
the base of the phallus and was dark and curled. The
% i) R" h) f$ @$ {testicular volume was prepubertal at 2 mL each.
, I6 h+ Y5 M0 G0 i' B* B, D% |The skin was moist and smooth and somewhat* Y/ Z' [& m1 \+ E. b: R6 X1 N
oily. No axillary hair was noted. There were no
. f8 R5 j3 g0 D/ s8 ?abnormal skin pigmentations or café-au-lait spots.
5 S c( J' ~. B j8 yNeurologic evaluation showed deep tendon reflex 2+
/ [& F+ V3 T+ s( b! G0 Lbilateral and symmetrical. There was no suggestion
. F1 A9 C, @0 e9 N. nof papilledema.. X7 p5 Y0 C) e8 |! l% s
Laboratory Evaluation- k4 x2 X/ j: x' ~
The bone age was consistent with 28 months by0 S* r- z/ G% n- j
using the standard of Greulich and Pyle at a chrono-
, u$ C8 O0 ^& V: m: I1 jlogic age of 16 months (advanced).5 Chromosomal
# m$ e t0 c- `9 C! |, }/ p; qkaryotype was 46XY. The thyroid function test8 O' ^3 H4 a+ G" @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ B9 E4 \9 {: j0 D3 {( @lating hormone level was 1.3 µIU/mL (both normal).: B2 c6 |1 f; G% q& ~: Z0 k* w9 x
The concentrations of serum electrolytes, blood
0 x6 G" v5 r+ O t; r& _; \urea nitrogen, creatinine, and calcium all were' b' n6 B: f& n- n) E$ i# z. u
within normal range for his age. The concentration
6 n% v: o! B( U+ x' {of serum 17-hydroxyprogesterone was 16 ng/dL
# j8 N/ k& ? _" ?(normal, 3 to 90 ng/dL), androstenedione was 20
1 c+ W* @0 ?- g& | L' Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) Z* Y u! i) Q* {9 I7 l$ Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& G3 U1 P7 M! A: W6 V1 r! P( adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' O* q6 @( m( n6 {% l9 Z6 M49ng/dL), 11-desoxycortisol (specific compound S)
- V) \$ K3 P2 ~" f' ]+ Y2 }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 m$ q6 S3 u* t3 ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# P; t8 m# j$ `$ J8 o; ]* Q1 Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' {; s1 a* R, F/ J
and β-human chorionic gonadotropin was less than
! y. l) }- O$ z) s5 mIU/mL (normal <5 mIU/mL). Serum follicular
* W5 L$ Z9 u/ r/ \* mstimulating hormone and leuteinizing hormone
) e( g; z2 c/ O# h& X" _" I/ [concentrations were less than 0.05 mIU/mL
3 K @! U6 c; W6 U1 w# q(prepubertal).
( r, ^0 d3 F+ k3 `The parents were notified about the laboratory
' }1 T' s$ s5 Aresults and were informed that all of the tests were
) U% L! E& ?) v4 h! Z8 pnormal except the testosterone level was high. The& l) F. \" @ K6 A+ g
follow-up visit was arranged within a few weeks to
- E3 w: F* I# r5 p8 q; L5 ]obtain testicular and abdominal sonograms; how-5 J% Q+ |" e' {0 \
ever, the family did not return for 4 months.
' f w8 w. c; Y& b! }Physical examination at this time revealed that the
. R- V* B/ k/ _+ xchild had grown 2.5 cm in 4 months and had gained/ Q# I& O& ~: f' D9 S( J
2 kg of weight. Physical examination remained
0 J5 }$ Y5 e$ w) t; ~- junchanged. Surprisingly, the pubic hair almost com-$ g% l2 b% q R/ {
pletely disappeared except for a few vellous hairs at, p- {! C! \6 z8 _% ^- h5 j1 L
the base of the phallus. Testicular volume was still 29 V' w6 {) L4 V) T: b$ h
mL, and the size of the penis remained unchanged.: q/ H' W) b2 H
The mother also said that the boy was no longer hav-
6 o$ X ^+ ^) c; l) Sing frequent erections.
% R, u0 c$ R& d* W- U/ N2 QBoth parents were again questioned about use of
- u: \+ a! s- gany ointment/creams that they may have applied to1 f8 x+ z: H$ H3 i, e8 u
the child’s skin. This time the father admitted the5 H. @8 }4 m% B- K
Topical Testosterone Exposure / Bhowmick et al 5417 c7 I$ \* R0 ?3 c |9 Z' h/ I- k
use of testosterone gel twice daily that he was apply-" z- n% z( J4 B! r0 T% T
ing over his own shoulders, chest, and back area for6 i" ?: Z3 N6 s; [5 v. X
a year. The father also revealed he was embarrassed
( k8 H& b$ j+ X. ]+ E7 Q' eto disclose that he was using a testosterone gel pre-4 H- [9 |. m$ N
scribed by his family physician for decreased libido
3 P: X; R# p- s& ysecondary to depression.
3 o& F% [1 y$ I* U6 ^ V1 _+ ]The child slept in the same bed with parents.& T: m# k1 A4 E& L, I. M& {( q% A
The father would hug the baby and hold him on his7 N' d1 x+ p1 M6 k" o, H9 K2 e4 u
chest for a considerable period of time, causing sig-1 Y. x; L7 f1 L8 l, z9 t: _
nificant bare skin contact between baby and father.* x' o6 I5 p8 t. B9 C
The father also admitted that after the phone call,7 c: x0 ~/ ~& G6 y# P
when he learned the testosterone level in the baby
/ P1 G% T' R' D: p, Vwas high, he then read the product information
: J, i( d- I& h9 P3 m' [* ]/ Y4 E, Lpacket and concluded that it was most likely the rea-- j0 A5 \9 n- ]5 I8 X; W3 ?% `
son for the child’s virilization. At that time, they( r# d2 v2 k: S# N1 \; V# e
decided to put the baby in a separate bed, and the
. i0 q4 I2 c( [2 Xfather was not hugging him with bare skin and had
- c8 s% e9 v& r: mbeen using protective clothing. A repeat testosterone$ Z; D8 _3 o7 ]
test was ordered, but the family did not go to the
, |4 [- Z' s4 G# _/ Q1 i4 Vlaboratory to obtain the test.; E4 Y" b- P/ x) e; ^0 M0 f
Discussion
" f' b- \1 @# ?+ {: g) YPrecocious puberty in boys is defined as secondary
0 f; b2 _* s1 S% Dsexual development before 9 years of age.1,4
& B: ]; P* D" E( cPrecocious puberty is termed as central (true) when9 I+ G6 w$ Q& Z/ h
it is caused by the premature activation of hypo-* u1 V, _1 I, E
thalamic pituitary gonadal axis. CPP is more com-9 A3 v9 |& C5 Z- x V8 u
mon in girls than in boys.1,3 Most boys with CPP+ G }0 o) s" K' P; x5 U
may have a central nervous system lesion that is
! b+ x N: b) }( T! Z9 uresponsible for the early activation of the hypothal-$ j. {2 Z8 v# N; b6 T I7 S
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 F8 X! p6 q z$ |* f- s& ~sis has been given to neuroradiologic imaging in
' z$ U; `( K6 |boys with precocious puberty. In addition to viril-" D* ?/ O2 O) r2 S! H
ization, the clinical hallmark of CPP is the symmet-. s. `% D$ B f/ g( O
rical testicular growth secondary to stimulation by/ P( x5 p5 z! h/ k0 S Z
gonadotropins.1,3
" @! E$ ^; U9 q( h/ t% K yGonadotropin-independent peripheral preco-; P- _+ S; S4 ?6 l2 n
cious puberty in boys also results from inappropriate
* q8 D7 q- N/ s5 B9 {5 \2 Uandrogenic stimulation from either endogenous or
5 O. ]2 ]; `& x4 Dexogenous sources, nonpituitary gonadotropin stim-
0 U3 B5 X( I& }2 F0 O* ]& _ulation, and rare activating mutations.3 Virilizing4 R( A9 x* d% `0 _+ u. N4 y; y C
congenital adrenal hyperplasia producing excessive/ O. F) L0 q5 X. |. A) j5 a
adrenal androgens is a common cause of precocious1 s2 }( U8 W4 k
puberty in boys.3,4& \6 V, m* W6 y$ e4 m" [9 L3 I0 X5 y
The most common form of congenital adrenal0 c. z' K5 f, j$ t8 u1 v+ _5 O
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ w0 m" @8 G+ C% H+ A4 X# @( [The 11-β hydroxylase deficiency may also result in4 w) |' I- p; z% y) G# q0 M5 \6 o
excessive adrenal androgen production, and rarely,7 L7 n( ~3 ?8 f
an adrenal tumor may also cause adrenal androgen
" O6 G6 {- v+ C7 c* o' Cexcess.1,3- I$ j- X1 B9 }& y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" C8 x& L/ v6 s3 m" n5 ]3 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& T8 j3 s; `9 Y4 h$ L1 [
A unique entity of male-limited gonadotropin-/ I3 a7 x/ X6 b* L3 t
independent precocious puberty, which is also known
! b7 K! l. t$ r& ]. x; Q* ?as testotoxicosis, may cause precocious puberty at a+ W# u# l% e) Y- E5 ?! k
very young age. The physical findings in these boys, C, z+ O6 p6 H# W9 U8 Q' L6 H
with this disorder are full pubertal development,$ h8 d' u: A' Z) z+ X. E
including bilateral testicular growth, similar to boys
) u$ F3 M7 w7 T1 @with CPP. The gonadotropin levels in this disorder3 x3 Q! I& Q) x
are suppressed to prepubertal levels and do not show8 H2 |. {: _" c/ z0 o
pubertal response of gonadotropin after gonadotropin-
1 r3 K% {% m1 i# }3 f# mreleasing hormone stimulation. This is a sex-linked" F0 D' V+ C E) J, r) w: d
autosomal dominant disorder that affects only
) G' ]& q7 p* @( }males; therefore, other male members of the family2 I$ k& e4 k+ q3 _4 b
may have similar precocious puberty.3
- V* O' }& B0 F& r$ u- CIn our patient, physical examination was incon-' i2 E# B3 Q/ g4 R( t! V, a7 g- X) I
sistent with true precocious puberty since his testi-& V) [2 h2 w* p1 w4 Z
cles were prepubertal in size. However, testotoxicosis# R1 q, g! |$ {: s
was in the differential diagnosis because his father3 ^% i1 w; K( w# L( r% @ k' G3 D
started puberty somewhat early, and occasionally,3 V& h' D! B' R) V
testicular enlargement is not that evident in the
. R# w/ w j$ l; H1 _ A5 g6 Pbeginning of this process.1 In the absence of a neg-- d' ^, K Z0 w) |3 H1 U
ative initial history of androgen exposure, our
( W& H( a' {' k/ O- qbiggest concern was virilizing adrenal hyperplasia,' L% R, h% n# [8 e' I; t
either 21-hydroxylase deficiency or 11-β hydroxylase
' k7 a3 C% Y* [deficiency. Those diagnoses were excluded by find-
! C. T8 o3 Q5 w: W3 ^, u& ~ ving the normal level of adrenal steroids.- d2 V7 f _' d5 g
The diagnosis of exogenous androgens was strongly
! G- W" v. C, X: {' Z `1 rsuspected in a follow-up visit after 4 months because1 g8 n5 p6 E# V8 `" C# M
the physical examination revealed the complete disap-
& M9 L% {, U0 `# u! u4 ypearance of pubic hair, normal growth velocity, and
% i r5 N: [0 {3 X3 [0 |/ pdecreased erections. The father admitted using a testos-1 {1 O+ z% l5 X6 Q8 g$ P
terone gel, which he concealed at first visit. He was& y% I3 n) G6 j- ?
using it rather frequently, twice a day. The Physicians’
) i8 l, t$ b4 |7 D# m8 _9 dDesk Reference, or package insert of this product, gel or
+ n( {! G2 N, |8 J: Bcream, cautions about dermal testosterone transfer to
f7 M6 [/ a, d! kunprotected females through direct skin exposure.
, b- s) X' R/ t$ ^/ v: U* P/ mSerum testosterone level was found to be 2 times the7 F O0 {6 J4 |' _6 |' q
baseline value in those females who were exposed to. }4 S8 b' V5 i" ?# }
even 15 minutes of direct skin contact with their male0 [+ ?; N0 ?' n& A
partners.6 However, when a shirt covered the applica-
& k4 }" N! T! Jtion site, this testosterone transfer was prevented.4 x N% {" g/ t# G3 r3 X: S/ t
Our patient’s testosterone level was 60 ng/mL,( T9 z8 l4 G& b& x
which was clearly high. Some studies suggest that
. N* @5 S1 T! J2 vdermal conversion of testosterone to dihydrotestos-; N+ d \# l2 \4 u# [+ Q* \
terone, which is a more potent metabolite, is more
2 F8 R1 W; r9 {' u4 M+ gactive in young children exposed to testosterone
4 h5 @. U( l; d, z2 @exogenously7; however, we did not measure a dihy- S* `- M0 S# x5 m1 u9 P/ h4 z$ N
drotestosterone level in our patient. In addition to. y; @/ m. _: l. U, ]+ \1 u" h" l
virilization, exposure to exogenous testosterone in
# h/ h; w7 J4 P5 U- Xchildren results in an increase in growth velocity and
. @3 h! P3 H/ U- Aadvanced bone age, as seen in our patient.
0 ]' T4 G" C9 A! h5 ~" n9 DThe long-term effect of androgen exposure during
" ], ~% Y \+ c3 x a9 zearly childhood on pubertal development and final- U1 D; U" @& Q. I/ }6 A: H0 w
adult height are not fully known and always remain6 o# J5 U9 h5 C; i
a concern. Children treated with short-term testos-
! h3 \- D' z; |7 F1 m0 s! @terone injection or topical androgen may exhibit some: l3 `# K- i4 _5 a1 H7 v
acceleration of the skeletal maturation; however, after& L* ~4 u7 F7 |4 ?5 S m( Z
cessation of treatment, the rate of bone maturation
7 k8 W9 n* J5 kdecelerates and gradually returns to normal.8,9/ @+ Q) T5 }" {5 \. S1 p% L- F
There are conflicting reports and controversy, K; {- M# P3 D6 @2 p4 T# c
over the effect of early androgen exposure on adult2 m' a% B0 @: B; c
penile length.10,11 Some reports suggest subnormal5 i* N# g& S) J# a& J
adult penile length, apparently because of downreg-
& f* s9 D2 \( p3 Qulation of androgen receptor number.10,12 However,; F0 d- `' i4 k" O
Sutherland et al13 did not find a correlation between
! k `/ u# c! E5 J( {1 Cchildhood testosterone exposure and reduced adult
% X0 R9 h% m2 |4 |- rpenile length in clinical studies.
, H& x: z/ c; C& T7 a5 qNonetheless, we do not believe our patient is
) M+ }0 s# D+ e3 w& Ggoing to experience any of the untoward effects from' x% I z0 w- D
testosterone exposure as mentioned earlier because( e t d! R& W7 ~ M
the exposure was not for a prolonged period of time.
2 ~. e) e% [: tAlthough the bone age was advanced at the time of
1 p/ u7 ?4 }+ N: L3 t/ m0 gdiagnosis, the child had a normal growth velocity at; U. @ W( N3 E" T) X4 \' K& T$ Q. O
the follow-up visit. It is hoped that his final adult
! ^( t9 |. |: _, kheight will not be affected.6 i! z5 w0 ~$ p# M. W" G) j
Although rarely reported, the widespread avail-7 {# R- U9 w1 M. f0 C
ability of androgen products in our society may6 u" W& L3 |3 `+ W' ~
indeed cause more virilization in male or female' c9 Q7 e. t; K7 ^/ a9 d! O
children than one would realize. Exposure to andro-) w; g- }, g9 V& [+ c: z
gen products must be considered and specific ques-
) V) J5 V7 Y1 `# i# h+ e8 k2 Ctioning about the use of a testosterone product or
, B# u3 A; C, D( S+ \- c& R; Qgel should be asked of the family members during
2 N4 P. O( |0 {the evaluation of any children who present with vir-
4 s% Z# Z4 H$ Qilization or peripheral precocious puberty. The diag-, P. ^. i. Z9 j* T
nosis can be established by just a few tests and by
/ K+ C0 G( s# I) P- Dappropriate history. The inability to obtain such a2 B3 i7 \% P7 Z/ Q% A0 s- ?) r
history, or failure to ask the specific questions, may
" b0 E: _+ Z* zresult in extensive, unnecessary, and expensive) R& f8 `- C3 k9 f
investigation. The primary care physician should be
- d- k( y0 Z8 Raware of this fact, because most of these children- F7 Y G, P2 {
may initially present in their practice. The Physicians’7 X3 c; b; _, z, l, A; \2 s* v
Desk Reference and package insert should also put a
' Q9 D2 E% F p: fwarning about the virilizing effect on a male or% G y+ _+ j2 s! D: B! q
female child who might come in contact with some-
p4 K2 a2 z' |one using any of these products.
' }! T: R6 T9 u2 q V: PReferences
# [; g% b: T3 F) H: Z1. Styne DM. The testes: disorder of sexual differentiation' `, a" u4 ^4 L% f7 I! ?: f; i
and puberty in the male. In: Sperling MA, ed. Pediatric
0 C2 v- L6 F7 l5 k% I! R' MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& J2 G9 |% O R% r! d, @
2002: 565-628.
6 t7 ?+ n! b+ V s/ A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 I; i1 A' D- I, Q. O5 t
puberty in children with tumours of the suprasellar pineal |
|