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Sexual Precocity in a 16-Month-Old1 j; K/ F8 v* o( e7 S/ @
Boy Induced by Indirect Topical. n3 n2 z2 O1 j! I1 M k
Exposure to Testosterone5 p/ s+ ^: |8 k# C0 W
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ |: s. B4 B# t3 ~, zand Kenneth R. Rettig, MD11 n: U$ u/ M" }, b' ~/ s/ V
Clinical Pediatrics3 `* q3 W; ~- I: @4 B, P: ]0 ^
Volume 46 Number 6: [& H) t& R2 U8 S# b! ?
July 2007 540-543
9 N3 x0 @# a6 j3 S1 R6 J© 2007 Sage Publications! c2 W, v( G: j! B: b4 i6 n2 O0 \
10.1177/0009922806296651
0 O7 \/ A# B; h8 w" W! Qhttp://clp.sagepub.com' R) g) ]& m8 a M
hosted at
* d3 X n; x; b+ }# q9 a) B3 Shttp://online.sagepub.com
, u, h" B9 C3 o" L/ h# {! a4 R0 s# iPrecocious puberty in boys, central or peripheral,! {3 l, A0 b! p3 i' E; z
is a significant concern for physicians. Central& w+ A/ o5 `: w C& v& x/ ]; G
precocious puberty (CPP), which is mediated+ Q+ y) e: L4 L: X0 T3 p
through the hypothalamic pituitary gonadal axis, has: T6 g6 Z+ }. b2 _5 z, E
a higher incidence of organic central nervous system5 K; D# ~; v4 q
lesions in boys.1,2 Virilization in boys, as manifested
\: n3 J+ k) S& f3 `5 t, A! Y' Q. [# tby enlargement of the penis, development of pubic
- o! }2 `' m. q5 Y9 w5 l( yhair, and facial acne without enlargement of testi-
: O+ f8 k( k6 R8 a0 icles, suggests peripheral or pseudopuberty.1-3 We7 }" u+ F- B8 b# K R' F5 e
report a 16-month-old boy who presented with the
9 z3 j9 n/ R. @5 ~8 ]( J }2 X6 X$ ^enlargement of the phallus and pubic hair develop-5 ~" t/ p1 o8 m2 G% j! {
ment without testicular enlargement, which was due
! N% z1 ~ w& f; `6 d u; ?7 ]+ dto the unintentional exposure to androgen gel used by9 r( f. Q) O6 G, e2 d3 E
the father. The family initially concealed this infor-9 C' E1 |% W2 r& C
mation, resulting in an extensive work-up for this8 Z! Y8 @7 {0 O( H* i
child. Given the widespread and easy availability of
: Y5 g# c2 ]( mtestosterone gel and cream, we believe this is proba-, `1 ]; q6 [1 n1 I: Q; C0 a2 w0 w+ ~ B
bly more common than the rare case report in the/ u: m3 ]* }8 @/ g% a' y ^
literature.4
7 t5 d8 X" y4 T) i: z1 Y8 y# yPatient Report
7 r5 f) I" }( R. x; G" @A 16-month-old white child was referred to the
" l0 W$ g }# Fendocrine clinic by his pediatrician with the concern
" F. i) U! ?, p8 pof early sexual development. His mother noticed9 e b$ I8 o, m; [& _) M7 D
light colored pubic hair development when he was# C% m7 X7 i, Y3 n0 Y6 m1 ]
From the 1Division of Pediatric Endocrinology, 2University of! B1 e$ {: R0 H* `% p2 o
South Alabama Medical Center, Mobile, Alabama.
3 o3 B# @* E2 i/ |4 L) J, tAddress correspondence to: Samar K. Bhowmick, MD, FACE,; h/ v# \1 c4 y% ~3 O
Professor of Pediatrics, University of South Alabama, College of- }( e7 V9 k u5 G. n5 ^, O& W
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* H5 f( q: u/ U
e-mail: [email protected].
+ A! K. Q- d2 z3 L. habout 6 to 7 months old, which progressively became
& b* y4 v) J7 j% |/ b3 j5 `) udarker. She was also concerned about the enlarge-
% q) }" u7 Q/ xment of his penis and frequent erections. The child. q) z' W0 {4 @# z a. y. s
was the product of a full-term normal delivery, with+ O" L1 g# S" |. y! X# ~! \# E2 f5 d
a birth weight of 7 lb 14 oz, and birth length of# b, d4 d1 u' ?" K0 @
20 inches. He was breast-fed throughout the first year
- S3 x3 m$ r8 Z% cof life and was still receiving breast milk along with c$ H8 _+ M" G
solid food. He had no hospitalizations or surgery,
4 W" s/ ^" V; S; C7 Iand his psychosocial and psychomotor development
0 i0 O, g% G5 @. N0 J5 D* t* Gwas age appropriate.
$ d, {9 j$ `, u7 Y! _# VThe family history was remarkable for the father,
. u( @$ D, X$ Vwho was diagnosed with hypothyroidism at age 16,
$ j7 e+ ]* E- ~0 }, I+ ]3 @3 \which was treated with thyroxine. The father’s
0 ]1 x u2 z7 I* J4 \& o* Zheight was 6 feet, and he went through a somewhat
L$ |0 |! ]" Z) e4 S( rearly puberty and had stopped growing by age 14.* ?4 N1 I# I0 h( [
The father denied taking any other medication. The$ Y% P2 g, c) G- y9 E9 y+ L
child’s mother was in good health. Her menarche
3 H6 T( M6 e3 wwas at 11 years of age, and her height was at 5 feet0 Q6 ^; T& f* E% M3 G4 E3 L
5 inches. There was no other family history of pre-3 v' z# g \3 W/ t( u! ?% ]
cocious sexual development in the first-degree rela-# x) {2 j( I5 y: c
tives. There were no siblings.! ?: j- c# ?& q/ S
Physical Examination9 u1 G1 M: Z, o0 p6 n: n
The physical examination revealed a very active,( w* g i6 j7 T4 B/ b
playful, and healthy boy. The vital signs documented/ ^% K0 ] D) F! V2 a: E7 x# F, H
a blood pressure of 85/50 mm Hg, his length was
3 {8 Z4 h8 j0 B9 J4 e! v9 s90 cm (>97th percentile), and his weight was 14.4 kg
' }6 n# |- L W [(also >97th percentile). The observed yearly growth+ t* n: i' d, X A+ e8 F; V9 w8 [" V
velocity was 30 cm (12 inches). The examination of2 o) l. e' Y! f0 ` e
the neck revealed no thyroid enlargement.3 E1 ~* d+ q0 Y5 a- z5 o
The genitourinary examination was remarkable for5 F# C( G3 P6 R! L0 a2 k
enlargement of the penis, with a stretched length of1 G* @7 H0 M' n! L: |) j- V1 V
8 cm and a width of 2 cm. The glans penis was very well6 V( q8 S) n9 G- a, G5 g7 l- y5 @
developed. The pubic hair was Tanner II, mostly around
. q% U1 a; J) R0 e540& x ?& y0 K" }/ ^0 H" u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& @: E3 ~5 L# H, ~4 L' W
the base of the phallus and was dark and curled. The
4 K! A5 `6 @3 otesticular volume was prepubertal at 2 mL each.
& {- z, C; A8 Q3 G) f9 |8 RThe skin was moist and smooth and somewhat
7 w4 B: a2 E k) m3 Eoily. No axillary hair was noted. There were no
" W+ B9 ^+ H6 o7 Q8 `, ~abnormal skin pigmentations or café-au-lait spots.$ E. I+ g, J1 d1 C5 l: k3 J0 c
Neurologic evaluation showed deep tendon reflex 2+8 X' I' R, @/ Z! l2 s" G6 X9 B. k
bilateral and symmetrical. There was no suggestion1 _8 [5 ^! i& T2 l K6 E$ U4 n0 C
of papilledema." U/ e4 L8 G$ ~' T) k- q& m( O
Laboratory Evaluation
7 X( I0 ~+ U W3 A4 D% VThe bone age was consistent with 28 months by
7 i$ ?1 V' b% w1 R* M: Uusing the standard of Greulich and Pyle at a chrono-
; p& ]$ K3 ?. v( D! S! n; i2 plogic age of 16 months (advanced).5 Chromosomal
2 |' T" b8 H O) N' C" N/ kkaryotype was 46XY. The thyroid function test
6 `/ O: V+ k9 E% kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) e3 n8 x4 ^! _7 z8 J8 P5 c3 `lating hormone level was 1.3 µIU/mL (both normal).
7 c; D4 E! e) }0 f4 `/ kThe concentrations of serum electrolytes, blood
9 e0 t# n0 I" u; }, u' n7 Xurea nitrogen, creatinine, and calcium all were
& s4 [" @6 m! X+ u# N4 pwithin normal range for his age. The concentration# _) W& b6 H% |1 ~9 q
of serum 17-hydroxyprogesterone was 16 ng/dL
# Q. P" K) a' R9 @* T- b(normal, 3 to 90 ng/dL), androstenedione was 20- x9 A+ F& P. R3 F* S# G2 p1 F$ ~
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) X* d$ J; z- u. t/ `8 S. Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),9 l T8 M+ G2 X0 M( r% v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- N6 O) e/ a9 j/ Y; e
49ng/dL), 11-desoxycortisol (specific compound S): l3 L, G$ M4 y1 g+ {7 S. C
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 w, B" p) G5 g. D/ d" y- m$ [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 D) m, t, K9 K5 T- z4 ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* _9 q$ C6 a) Iand β-human chorionic gonadotropin was less than9 }2 E V8 {9 e9 y& w1 p- ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( V j# T5 N7 F( [4 o* d6 dstimulating hormone and leuteinizing hormone
. e9 ^8 i8 T2 I3 d+ s" c& Nconcentrations were less than 0.05 mIU/mL
' j% I' P4 V9 m* i3 m, m" u, D(prepubertal).. D3 S6 O& C. k! Y* W$ s" P5 |1 U
The parents were notified about the laboratory! N8 r& R! f2 E5 ?
results and were informed that all of the tests were
1 C8 G. r% Q; Jnormal except the testosterone level was high. The5 W. p; H/ N5 b, p
follow-up visit was arranged within a few weeks to8 K4 v8 p9 C9 y( ~1 W3 u0 J$ ]/ V
obtain testicular and abdominal sonograms; how-7 B' f8 @: T! e* H, M' i
ever, the family did not return for 4 months.
' u0 e0 D/ Q) k7 n$ nPhysical examination at this time revealed that the' i6 ]2 r# I: c( ]* j& I1 m' i. @
child had grown 2.5 cm in 4 months and had gained9 Q; i4 o# h3 i
2 kg of weight. Physical examination remained8 ^ Y6 `! P. `
unchanged. Surprisingly, the pubic hair almost com-
$ R& p3 g* q7 P% U) X7 Y% Spletely disappeared except for a few vellous hairs at
0 t; C8 d- R8 ]5 p) k7 J, zthe base of the phallus. Testicular volume was still 2
* j1 [; K. n7 V9 y. G! y( k& |5 |mL, and the size of the penis remained unchanged.
$ |( v! W( f+ HThe mother also said that the boy was no longer hav-
' H T0 @) x- v" y3 U% Ring frequent erections.
" b8 z4 K$ i l8 m3 f1 aBoth parents were again questioned about use of
) m3 l+ ?0 Q6 e; r# l/ d* sany ointment/creams that they may have applied to
5 W4 Z& p7 X1 Ethe child’s skin. This time the father admitted the. m6 O+ k# j0 x) Y4 J
Topical Testosterone Exposure / Bhowmick et al 5418 y& i! z4 G/ J
use of testosterone gel twice daily that he was apply-3 H4 f. e, z4 D' a2 @. y
ing over his own shoulders, chest, and back area for+ N5 ^3 J3 X' B5 ?
a year. The father also revealed he was embarrassed
: ~4 s8 s- M1 K& sto disclose that he was using a testosterone gel pre-6 I" b% j+ k2 B( M+ P1 d1 q$ ?
scribed by his family physician for decreased libido. ^3 u' k" D1 |; F
secondary to depression.
9 ]" ^ Z+ E9 t8 m8 C1 }2 MThe child slept in the same bed with parents.! t# ^2 o" u* _, P$ Z- e7 Y t& s
The father would hug the baby and hold him on his
% g6 R- Y& I3 P. o! Ychest for a considerable period of time, causing sig-
2 u- q9 J# C) F* ~) i8 Tnificant bare skin contact between baby and father.2 N; ?& h! L+ x3 M' v+ U, J
The father also admitted that after the phone call,
* |3 M, |& y$ i( B5 |( Twhen he learned the testosterone level in the baby
! i- a- g; H- w( h6 d7 E7 Xwas high, he then read the product information! W9 ]) w& |& P- Q6 `
packet and concluded that it was most likely the rea-
9 x# C9 @# p) J/ a" fson for the child’s virilization. At that time, they
4 g4 K- L4 g. ~: `) n1 Kdecided to put the baby in a separate bed, and the
% b% S8 W, U$ J2 q0 Ffather was not hugging him with bare skin and had
6 j7 ?' w) e7 b) ~been using protective clothing. A repeat testosterone
5 D6 z7 h# ^; etest was ordered, but the family did not go to the; f) K! C1 z6 b i
laboratory to obtain the test.
& Y) Y5 J6 J% g. S( Z7 KDiscussion
; v4 S! x% Z8 i% H6 m( kPrecocious puberty in boys is defined as secondary/ J( J1 S, O" j; p9 m. ]# E9 x
sexual development before 9 years of age.1,4
: t" \) M' Y) [! |6 Y- C8 nPrecocious puberty is termed as central (true) when+ N" s& N$ `: e4 `( h. r, O) p
it is caused by the premature activation of hypo-
1 b* r, [" [( J4 tthalamic pituitary gonadal axis. CPP is more com-
/ O0 m+ W# ~9 c4 Ymon in girls than in boys.1,3 Most boys with CPP
, @9 d) v5 }% w7 Nmay have a central nervous system lesion that is
( }* K; x: M) w" [9 W/ y- Bresponsible for the early activation of the hypothal-1 w1 @% G0 w" C+ p) W! S
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 G" `: m1 X; d. {3 h; N& p. Rsis has been given to neuroradiologic imaging in2 D( v; M% K" }! P% @1 j* Z6 h+ g
boys with precocious puberty. In addition to viril-( S1 J- E; q3 \! B2 T! j' ?
ization, the clinical hallmark of CPP is the symmet-
+ W4 X% T7 r$ b Hrical testicular growth secondary to stimulation by, m7 X4 C$ X1 v1 M
gonadotropins.1,3" }9 }8 w8 n9 O0 n1 D; f2 L+ b
Gonadotropin-independent peripheral preco-" S L1 T* V# a! |5 s
cious puberty in boys also results from inappropriate z! U# V1 N1 k5 i2 s _
androgenic stimulation from either endogenous or t- v, l6 z. _" k& s. p
exogenous sources, nonpituitary gonadotropin stim-
/ Z+ r5 Q! ?1 d2 |ulation, and rare activating mutations.3 Virilizing
" j+ s3 h! W2 x7 q8 W/ ^2 i5 |congenital adrenal hyperplasia producing excessive
: u: e* {$ Y3 v" Hadrenal androgens is a common cause of precocious& u" o' ?1 @$ c: S) A X- w
puberty in boys.3,4
/ S9 P. E5 G ]The most common form of congenital adrenal5 F, ~0 o4 w. o% g/ o% R/ _ W
hyperplasia is the 21-hydroxylase enzyme deficiency.& J+ d# H5 d" a
The 11-β hydroxylase deficiency may also result in
0 h" O- }: D2 l/ n2 L. W1 s" Cexcessive adrenal androgen production, and rarely,. J' c9 g+ R* K# s* ^/ [
an adrenal tumor may also cause adrenal androgen$ p, o& U% S; ^3 e. o- X
excess.1,3
2 k8 l/ C4 U$ f9 b. N, H) A0 Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 N1 C, i4 d+ Z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- g9 F( S0 {! ]" [+ r- ]. \A unique entity of male-limited gonadotropin-
/ K' A$ m% c( g% L7 V# J( \& Q+ |8 hindependent precocious puberty, which is also known
" Y- ~9 I0 L: k/ p7 h' bas testotoxicosis, may cause precocious puberty at a
- A3 G5 R% Z1 h* j1 H3 F& e1 Every young age. The physical findings in these boys
7 u" z1 |1 v! ~' Z2 {6 uwith this disorder are full pubertal development,7 y7 I- d- F! \+ ^
including bilateral testicular growth, similar to boys; i/ U/ j/ M; k, H3 o
with CPP. The gonadotropin levels in this disorder; u, o% j' j- ]0 k$ f7 P' ?& Z3 k
are suppressed to prepubertal levels and do not show; S9 Y! b1 I- Q2 W, `) H3 w. k! N
pubertal response of gonadotropin after gonadotropin-
% y8 T( N" ~+ v- vreleasing hormone stimulation. This is a sex-linked
5 b% ]: ]/ H' L9 j+ C" I3 W( o, ?autosomal dominant disorder that affects only
1 D( G2 a! a) Q0 J' ^3 @males; therefore, other male members of the family9 a% F5 ^4 |5 k8 ?# g. [( p0 K
may have similar precocious puberty.3# n5 I) H' l4 N
In our patient, physical examination was incon-
! G* ?/ f2 ~0 k% c. m" fsistent with true precocious puberty since his testi-
0 \9 z* |3 n9 }7 p) v' @' a0 g: xcles were prepubertal in size. However, testotoxicosis' j+ W9 w& |, m( G# c8 g6 a
was in the differential diagnosis because his father
{* Y) L- c) [- o3 \8 jstarted puberty somewhat early, and occasionally,4 }- g1 k ^/ K4 X: X
testicular enlargement is not that evident in the- \% a9 X# v3 j5 o
beginning of this process.1 In the absence of a neg-
" N8 l. {7 c% r# X) wative initial history of androgen exposure, our/ b# X, t; e' ]; a5 c9 L
biggest concern was virilizing adrenal hyperplasia,
8 b4 Z1 Y7 q8 D! t1 Eeither 21-hydroxylase deficiency or 11-β hydroxylase5 ?% o0 l2 l+ R' `9 g" ~
deficiency. Those diagnoses were excluded by find-* N8 h- ^- D3 T# I
ing the normal level of adrenal steroids., |5 i4 ]8 D$ U" M- V5 ~
The diagnosis of exogenous androgens was strongly/ Z& j. a m" u" l
suspected in a follow-up visit after 4 months because8 m" _5 Z3 _0 S' t
the physical examination revealed the complete disap-
6 p! a5 |/ t8 ?% p1 dpearance of pubic hair, normal growth velocity, and
+ g4 n/ J7 \, C" v0 K& jdecreased erections. The father admitted using a testos-7 g$ Z- x- [* s( i% }
terone gel, which he concealed at first visit. He was
+ }- `* d. p; ~using it rather frequently, twice a day. The Physicians’
# [6 x9 G. r$ q8 |Desk Reference, or package insert of this product, gel or5 K8 N+ S- B/ {4 z
cream, cautions about dermal testosterone transfer to8 y, @2 T! ^8 W: u* d/ G
unprotected females through direct skin exposure.5 o0 v1 M* a( j) {
Serum testosterone level was found to be 2 times the
G9 p) T8 `; Dbaseline value in those females who were exposed to" b& q# B& \+ z4 j, W- \
even 15 minutes of direct skin contact with their male4 z* I0 x$ a) A8 D0 ]9 D, e. R3 c
partners.6 However, when a shirt covered the applica-
0 H5 l+ ^9 ?, w& v4 y& ftion site, this testosterone transfer was prevented.8 F I9 ], u V$ }$ @
Our patient’s testosterone level was 60 ng/mL,. u" |3 Q, E, I' A" f
which was clearly high. Some studies suggest that6 D3 Y( K p% z) Y* ^' Z
dermal conversion of testosterone to dihydrotestos-
$ b( W( k( \% p: |( l" _0 q6 cterone, which is a more potent metabolite, is more8 Q% f ?; G* S4 R" ~
active in young children exposed to testosterone
7 f* f5 I, Y$ `6 \- c! Texogenously7; however, we did not measure a dihy-: I0 g, n* u: N7 U& o7 o
drotestosterone level in our patient. In addition to* l( d5 J, ^0 j4 F
virilization, exposure to exogenous testosterone in) `- ]+ a1 ^( H2 t5 Q& B2 r
children results in an increase in growth velocity and) z2 U4 P6 w' I- d
advanced bone age, as seen in our patient.) l( |: f" B8 h
The long-term effect of androgen exposure during* I+ X9 B* Z5 `7 }
early childhood on pubertal development and final2 J# Y& x L+ ~0 G9 X2 u# t, ]
adult height are not fully known and always remain# c7 l J! ~4 `" {
a concern. Children treated with short-term testos-) |( O2 F1 u# d4 y
terone injection or topical androgen may exhibit some* l( g% o4 z9 v& a8 n. I. l1 H& z
acceleration of the skeletal maturation; however, after9 Z* f' X- d8 p6 n
cessation of treatment, the rate of bone maturation. F% h6 f4 f9 p' s4 k5 N
decelerates and gradually returns to normal.8,9
+ @- U" B+ b, ^ [% _There are conflicting reports and controversy( R+ W7 T' S0 [+ @) O% v: F4 O
over the effect of early androgen exposure on adult
' s7 C& r, q5 r' ~9 W0 x ^penile length.10,11 Some reports suggest subnormal
& O7 S. J& t/ q$ Yadult penile length, apparently because of downreg-- q+ g* E7 ^% V# E8 s8 u
ulation of androgen receptor number.10,12 However,' ^5 A- g4 I% g$ X; w( g! Q# R
Sutherland et al13 did not find a correlation between
- Z: e$ N5 \" x5 _, x. Achildhood testosterone exposure and reduced adult( I7 G6 z6 z: q9 B/ h1 A
penile length in clinical studies.( x% P( i- s! m$ @
Nonetheless, we do not believe our patient is
* D6 F/ w+ d, I% \going to experience any of the untoward effects from
# ^1 X8 d: p: h# B7 `3 v% g& a3 L+ ?testosterone exposure as mentioned earlier because
, g* [# f% S( P/ J" rthe exposure was not for a prolonged period of time.
( ^1 x- |0 O* Y5 _! bAlthough the bone age was advanced at the time of
% n- q' I6 s. u+ O* Vdiagnosis, the child had a normal growth velocity at
8 q2 \+ B/ @' T' _the follow-up visit. It is hoped that his final adult
S/ i8 t* e( z- I3 L1 L) \6 mheight will not be affected.. T" G5 ]+ L+ F7 ]- i2 q/ p
Although rarely reported, the widespread avail-+ p2 J) I' Q0 T7 ]3 Y( l; U
ability of androgen products in our society may8 q% Z; H- a# y9 f3 ]: Y0 O1 u
indeed cause more virilization in male or female
; U1 L3 S- a8 r' G! z$ Qchildren than one would realize. Exposure to andro-
% e5 D* t$ y1 v0 bgen products must be considered and specific ques-: {$ _1 @: n. K% V$ ?
tioning about the use of a testosterone product or
- K1 |$ ^9 y s& l& j- [1 Y! d; bgel should be asked of the family members during1 i: J4 X1 j9 D8 y0 i
the evaluation of any children who present with vir-* }: i: Y) l9 _! Z6 w! m! f
ilization or peripheral precocious puberty. The diag-# e! e2 R/ a a! M' Y; q% t
nosis can be established by just a few tests and by
, [! d- J; J6 c2 M' }appropriate history. The inability to obtain such a9 ]1 S$ e; T! K* I9 Y4 e/ |
history, or failure to ask the specific questions, may
8 m/ u1 O/ x* P9 N# K) m% D/ }2 eresult in extensive, unnecessary, and expensive
. k/ ?# ?, N3 |: E; \* Sinvestigation. The primary care physician should be
8 N5 R5 [( M: |1 caware of this fact, because most of these children& Y2 W! U/ B. P, N1 O# i! J( M
may initially present in their practice. The Physicians’9 d) t& {6 `/ t+ c Q
Desk Reference and package insert should also put a
- G2 y3 I0 W K7 D, K6 M$ jwarning about the virilizing effect on a male or
/ g1 H5 h- W# j$ o& ifemale child who might come in contact with some-
7 G# k5 V0 F; ~: I' Z2 E2 Yone using any of these products.
) W2 X/ O& M2 l4 R9 D# v, e8 JReferences
" }) V9 `3 v( T8 \6 l1. Styne DM. The testes: disorder of sexual differentiation! |1 J! l9 T9 Y
and puberty in the male. In: Sperling MA, ed. Pediatric
- ~( e! J$ B5 q6 h. p" o9 ?0 IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 q1 r/ j! {3 J& m% N2002: 565-628.* ~" [. z/ t& p# y- v2 W# O8 L* C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" q3 M) B2 j! J% xpuberty in children with tumours of the suprasellar pineal |
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