- 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 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
+ F# I; J0 d) ]7 DBoy Induced by Indirect Topical
) e, @ \4 D7 P( f& f8 z( IExposure to Testosterone& ] N! p7 u* Q4 |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! B! O+ J' P0 b# z4 [
and Kenneth R. Rettig, MD1
& X- |4 d( R% K+ X% OClinical Pediatrics2 \' m, F$ z* W$ u6 e7 b( @, ~- a: j
Volume 46 Number 6( p1 W9 I6 G% h4 P) ]! ~
July 2007 540-543
$ a' @8 k+ _! A7 J3 f8 F© 2007 Sage Publications+ z' a( p& a8 Z/ j9 U) F- d
10.1177/0009922806296651( \1 K+ \" ^7 x% l& o& g, U, o5 a( b' T
http://clp.sagepub.com5 S% h4 t# g7 \, M) {
hosted at
, `/ F3 q* K9 O7 N+ R m4 lhttp://online.sagepub.com( o" N3 @/ `( W
Precocious puberty in boys, central or peripheral,, ` g, X/ I/ h5 x, X% p" u
is a significant concern for physicians. Central: H, Q, j, _- F, Y
precocious puberty (CPP), which is mediated
; E4 U& X: R/ @9 [5 z! ithrough the hypothalamic pituitary gonadal axis, has
8 P; R' t" s( @8 t0 v; h" oa higher incidence of organic central nervous system- H# z9 F; j/ o. a
lesions in boys.1,2 Virilization in boys, as manifested7 @4 e( e7 _' F& V0 s
by enlargement of the penis, development of pubic
8 p4 ~, L0 `* Q* a) k& g3 Q, y4 _hair, and facial acne without enlargement of testi-
; {# q3 V& k. z3 q! ocles, suggests peripheral or pseudopuberty.1-3 We
! h+ ^) x/ f* k% p/ ]" j1 Preport a 16-month-old boy who presented with the
; A- j0 c' ?8 q& tenlargement of the phallus and pubic hair develop-
& ~& T3 o4 r% g: y/ ^, ?ment without testicular enlargement, which was due0 A$ o7 U% ^- }5 _5 j, j5 v8 X
to the unintentional exposure to androgen gel used by
$ C9 @5 ] s8 O% U3 q4 S1 S! Uthe father. The family initially concealed this infor-, F9 _" \( s2 P C1 N- N
mation, resulting in an extensive work-up for this
4 G" p$ I, \5 ?, _' {child. Given the widespread and easy availability of+ t- s. s" f( j$ z* D2 _6 C
testosterone gel and cream, we believe this is proba-
6 l: o& o6 w4 Z: I8 D0 gbly more common than the rare case report in the I3 ~" J& a) `& K: x- {- r
literature.4
: L q! A" }/ d/ A% V. A9 DPatient Report+ G5 m2 w" {- c( b" B
A 16-month-old white child was referred to the y3 k5 _3 \, V5 D6 c( Y( t
endocrine clinic by his pediatrician with the concern
, F3 ~. Q! X3 s/ y* H! F' i* ^of early sexual development. His mother noticed0 i4 i1 v. W- y: }) ~& @. p
light colored pubic hair development when he was
8 d/ W2 }. r4 A# PFrom the 1Division of Pediatric Endocrinology, 2University of
$ T8 \; ^# e% Q4 B# e' E% d; o% G6 v: xSouth Alabama Medical Center, Mobile, Alabama.3 T: ]* W( U2 T# m" Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" W3 I) \/ A1 u; |! S! Q2 ?6 jProfessor of Pediatrics, University of South Alabama, College of; o$ [( E& j+ {5 g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 l5 u5 P: Q+ @$ y- }* g c9 r' re-mail: [email protected].7 T& f; h* p& e# D: P( h
about 6 to 7 months old, which progressively became3 G! C/ Y0 Z+ W
darker. She was also concerned about the enlarge-! F- F. \# W& r
ment of his penis and frequent erections. The child. r8 U8 J8 }. u' ]5 S& e
was the product of a full-term normal delivery, with
2 z/ \5 q/ \8 B& v9 a$ `$ s; h0 X, ?a birth weight of 7 lb 14 oz, and birth length of
' l8 h) a( Q* Q! s20 inches. He was breast-fed throughout the first year9 \0 S+ W# e2 b2 @
of life and was still receiving breast milk along with# F1 H# Y* F0 f% q( ^
solid food. He had no hospitalizations or surgery, f& p- j# I$ S& _+ R" M) h
and his psychosocial and psychomotor development
& n7 l, ?0 K3 ^0 Nwas age appropriate.
) v9 `- U" ]' s. E3 s, x& N* j1 ~The family history was remarkable for the father,
' t4 b' R* X- R- s+ ]who was diagnosed with hypothyroidism at age 16,
/ x0 W8 A7 ?' P5 Wwhich was treated with thyroxine. The father’s# Z1 X& ]% y) x0 [3 U' k7 ]9 _
height was 6 feet, and he went through a somewhat
+ |2 M: ]9 ~8 Gearly puberty and had stopped growing by age 14.
3 d. t: S- U; S. G5 dThe father denied taking any other medication. The/ y, z8 s4 W# p& \9 B! c8 x
child’s mother was in good health. Her menarche
7 O- O& `: k) S+ }+ d/ Bwas at 11 years of age, and her height was at 5 feet( B1 Z1 T2 g3 ]5 H- n
5 inches. There was no other family history of pre-
5 m( z0 j" `4 A2 r4 e+ ~cocious sexual development in the first-degree rela-
& g3 x% Z( ]4 q+ d: otives. There were no siblings.' n$ d( z4 d# i# X1 x e$ w
Physical Examination) z: a1 N& ^+ d
The physical examination revealed a very active,
5 v' q$ i0 Y( r% A1 xplayful, and healthy boy. The vital signs documented3 c2 D7 g( f0 y+ n. k0 H
a blood pressure of 85/50 mm Hg, his length was
4 _3 [& I; a$ k$ e2 Q90 cm (>97th percentile), and his weight was 14.4 kg1 B& F+ E! L2 Q" ^9 B% s
(also >97th percentile). The observed yearly growth! N4 q8 J& p/ n" s+ d$ j
velocity was 30 cm (12 inches). The examination of$ @6 s6 f5 b& x1 E7 g1 H& [* @
the neck revealed no thyroid enlargement.! w6 H5 a# b V0 v( A
The genitourinary examination was remarkable for% j3 [* M9 Q0 A$ K7 i! E2 Y- I$ V
enlargement of the penis, with a stretched length of# J2 U# c4 F' S7 V5 o" L
8 cm and a width of 2 cm. The glans penis was very well
7 [2 @( L: I5 d3 tdeveloped. The pubic hair was Tanner II, mostly around
! T8 j: q) k; _& }540
0 v, b! ~) Z4 A7 B* t8 C8 Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 v6 Q- a6 H Pthe base of the phallus and was dark and curled. The
* C9 E9 G; k9 ]( Wtesticular volume was prepubertal at 2 mL each.
0 p8 A2 Z! I6 P9 H) I% e* oThe skin was moist and smooth and somewhat
& e' I( i" [% `3 C2 l! Doily. No axillary hair was noted. There were no/ A6 R! q$ D, j3 x: J0 l
abnormal skin pigmentations or café-au-lait spots.
' c& B% Q/ w2 [4 Q! r9 E. |% BNeurologic evaluation showed deep tendon reflex 2+
) N. r. E; I$ T7 P: Xbilateral and symmetrical. There was no suggestion
, b) P3 O% u) Lof papilledema.9 W9 D3 _: i7 D% A G9 l% T
Laboratory Evaluation" l! n3 l2 O3 g: a7 n; k, k* h
The bone age was consistent with 28 months by C8 b9 x' f Q) c1 u
using the standard of Greulich and Pyle at a chrono-
* O' A; `: Y1 ~2 H( glogic age of 16 months (advanced).5 Chromosomal
7 E6 y) @& R/ wkaryotype was 46XY. The thyroid function test# e2 t. i7 T: A0 F' i6 S( U2 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 P4 V a e2 S$ k9 [) y2 M
lating hormone level was 1.3 µIU/mL (both normal).
% Q' _' a* a9 ^' r. Y5 {" [The concentrations of serum electrolytes, blood
2 k) L# W: M) i+ w g: f9 Aurea nitrogen, creatinine, and calcium all were, G8 W: m- ~+ @0 b3 v* }( t" \# z
within normal range for his age. The concentration
! [4 `) }5 j, c: v/ B: Hof serum 17-hydroxyprogesterone was 16 ng/dL1 C; o" j7 w* u! Y% S
(normal, 3 to 90 ng/dL), androstenedione was 20
4 M; w5 V) I4 ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 W# m4 d4 A, o# L. h9 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 p- t2 M% i0 d/ i5 b* a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 o; k- u$ F3 H" A' x" \3 t2 ~
49ng/dL), 11-desoxycortisol (specific compound S)4 L( R& j. V3 f/ ~+ z& L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 a( G2 k+ _' Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) r/ e& u, A) @% C( s& D# {9 h) Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ @ b' i6 s9 d/ V/ |1 x/ r7 g
and β-human chorionic gonadotropin was less than, @/ f! G3 L1 \; Y% }4 ?: i, p+ T
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- m4 o/ e: K8 @1 @& I: estimulating hormone and leuteinizing hormone
; M$ G8 D, v6 l; H. g Oconcentrations were less than 0.05 mIU/mL. W/ t j! ]8 _5 O
(prepubertal).
+ T! o1 ], y8 J* A$ f/ ?The parents were notified about the laboratory
- }* J/ M; t h8 q2 oresults and were informed that all of the tests were
+ r6 D# P& w. Z! h/ Tnormal except the testosterone level was high. The
4 c/ W8 H- D: l0 d) H" ifollow-up visit was arranged within a few weeks to
* c# U, Q4 W( k$ a. Y5 Eobtain testicular and abdominal sonograms; how-$ Q, \5 Q: s6 ]( J7 M" w8 {
ever, the family did not return for 4 months.! Y5 Z- |% A) ]# f" A
Physical examination at this time revealed that the
' I5 _- f' |7 F- j' schild had grown 2.5 cm in 4 months and had gained, s& k; t- f% Z X. P& f+ I
2 kg of weight. Physical examination remained# T8 |3 f$ e$ ^/ K
unchanged. Surprisingly, the pubic hair almost com-
: \; Q+ |! P0 I; \. ^# p/ Jpletely disappeared except for a few vellous hairs at$ x4 ?( w# c. U# o0 s1 z3 g
the base of the phallus. Testicular volume was still 2
, j5 z. B5 f ?! `* W! G3 bmL, and the size of the penis remained unchanged.
, N0 `, w# k3 \- cThe mother also said that the boy was no longer hav-: p7 X- A8 F! ] V- c
ing frequent erections., M6 l3 @: g4 F' k" q* v9 w
Both parents were again questioned about use of
. K: T/ o# a9 z8 g5 h4 r8 N/ oany ointment/creams that they may have applied to
7 I) b+ l3 e2 N. tthe child’s skin. This time the father admitted the2 S( |5 ?2 H3 L0 h# n$ Q
Topical Testosterone Exposure / Bhowmick et al 541
; V! K, G! _+ nuse of testosterone gel twice daily that he was apply-+ L! n. r& {' ?* U2 K2 z- k
ing over his own shoulders, chest, and back area for
* e) m5 B, X4 G2 Y8 I! Ra year. The father also revealed he was embarrassed
% N4 G: C/ F0 d# lto disclose that he was using a testosterone gel pre-# B. u' F1 \( Q/ ?
scribed by his family physician for decreased libido( X( h# Z }1 }" m* B, N2 l
secondary to depression.
, ] E! k9 T) w8 eThe child slept in the same bed with parents.
; P! d0 G9 a+ l$ c* s2 R TThe father would hug the baby and hold him on his
1 {7 x$ f0 H7 I* D: pchest for a considerable period of time, causing sig-
% h4 r8 ]) R# A7 t5 Xnificant bare skin contact between baby and father.
0 q# C7 V" {* _% gThe father also admitted that after the phone call,6 a( T. e0 G/ F [5 E
when he learned the testosterone level in the baby
6 k" Z+ C0 u5 t* U7 T0 `" T( p& t1 t5 Bwas high, he then read the product information
" I/ s; u3 z0 o" D8 p- W; d+ Dpacket and concluded that it was most likely the rea-
% k# b8 Z7 b& W% [; q" J8 Z" Yson for the child’s virilization. At that time, they3 i# L. _- |' c2 X8 I: B: Q6 N
decided to put the baby in a separate bed, and the
5 P# p8 Y. P+ V+ B2 ffather was not hugging him with bare skin and had
/ H+ r) Y; S v+ b7 l; `been using protective clothing. A repeat testosterone
9 f B& ? f" itest was ordered, but the family did not go to the8 {1 v9 J" Y1 `% y5 D( J# l
laboratory to obtain the test.* P% z p; \2 C7 m3 i
Discussion- A$ B6 X: F5 j" U; S
Precocious puberty in boys is defined as secondary
% d- b6 C1 a/ X4 C; lsexual development before 9 years of age.1,4- u$ i, l4 a- V; C! y- F
Precocious puberty is termed as central (true) when
6 V3 \( i a) A ?it is caused by the premature activation of hypo-5 e9 l) P9 Q3 X& n& v
thalamic pituitary gonadal axis. CPP is more com-* D3 M5 p# w; j G* w _
mon in girls than in boys.1,3 Most boys with CPP& Z# k% }2 P# w+ ^1 {1 s
may have a central nervous system lesion that is: d4 _3 H z1 A' t" r8 E
responsible for the early activation of the hypothal-. r. x$ g, ?% Q% E. k, O3 c
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ T/ z2 A, B/ o* E3 `0 j0 _sis has been given to neuroradiologic imaging in
4 ?( U5 C" l( Vboys with precocious puberty. In addition to viril-
f' Y M, |4 bization, the clinical hallmark of CPP is the symmet-+ a7 |4 C3 K' J3 V5 c$ a4 f4 o
rical testicular growth secondary to stimulation by9 K+ G1 G. `1 l' Y
gonadotropins.1,3+ ^2 I$ O# i" m$ k6 t
Gonadotropin-independent peripheral preco-
! ^* t y- W" {8 ^' P7 Ocious puberty in boys also results from inappropriate
/ ?( |0 E- ?: W0 f: r& s% I# O# fandrogenic stimulation from either endogenous or
2 b3 I" Q8 \: a6 k' Sexogenous sources, nonpituitary gonadotropin stim-( e( u7 L5 A% H1 ?
ulation, and rare activating mutations.3 Virilizing7 T6 ]0 i) H; G1 A2 ]: n3 L- E6 l7 \
congenital adrenal hyperplasia producing excessive
6 |$ r' Q- w- B2 \" H% eadrenal androgens is a common cause of precocious
# k1 \/ I' p5 x" mpuberty in boys.3,4
9 ^" \$ X9 S( |! ^4 p/ v( n3 iThe most common form of congenital adrenal: R: w% _( W2 W* @
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ d) }6 C) [% UThe 11-β hydroxylase deficiency may also result in
0 i. w. l4 c; Aexcessive adrenal androgen production, and rarely,! v3 o+ x; ]! w( l0 Q' \5 A( q; T! T
an adrenal tumor may also cause adrenal androgen. L9 t! t1 c( ]$ F- i$ H6 a
excess.1,3
$ K, e! l% u/ m N Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& E% S3 q' `! }0 `8 w& m. J
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 Z9 n" w! B2 l( f/ Z) C
A unique entity of male-limited gonadotropin-* f! Z7 k3 U. c2 Z( C* G3 k* a, [% w' ~
independent precocious puberty, which is also known
' z) m9 a2 }8 R1 Uas testotoxicosis, may cause precocious puberty at a
' p8 i8 r9 p& K, D- xvery young age. The physical findings in these boys
, m E8 |# H/ [1 }# [& O# Jwith this disorder are full pubertal development,
1 m# Q$ m- r: K, S# ~including bilateral testicular growth, similar to boys4 `9 x H& c% c! _" z9 _
with CPP. The gonadotropin levels in this disorder
`" y1 x# x7 `# U0 zare suppressed to prepubertal levels and do not show6 `/ f) a+ U* N
pubertal response of gonadotropin after gonadotropin-
4 n+ Y, x D* }/ M7 Rreleasing hormone stimulation. This is a sex-linked6 {6 a0 V8 a( d: v
autosomal dominant disorder that affects only2 ?8 ^, ]8 ^7 \4 J
males; therefore, other male members of the family; A E0 L9 V& G8 n. q7 C0 E
may have similar precocious puberty.35 B3 r4 J* r3 Q& L$ i; v
In our patient, physical examination was incon-
* r; c& N6 O! h2 hsistent with true precocious puberty since his testi-& R( K! w! ~) N! N0 M7 j8 ~
cles were prepubertal in size. However, testotoxicosis
1 s/ D* |9 J& p( Xwas in the differential diagnosis because his father
7 j% @# @5 A! o2 C! Istarted puberty somewhat early, and occasionally,
' o; W& Q ]4 f8 G& ^# u3 b0 Vtesticular enlargement is not that evident in the
; z* u- h! l$ Q) R: [ N, p# Q# Ebeginning of this process.1 In the absence of a neg-
( j3 [3 t- _5 b# E) M) a$ b# v' Zative initial history of androgen exposure, our2 V* c, }' R$ y' p; D
biggest concern was virilizing adrenal hyperplasia,. Y5 [, s" I" N' `; @: M
either 21-hydroxylase deficiency or 11-β hydroxylase
8 a; F; p8 b- d1 Rdeficiency. Those diagnoses were excluded by find-; [% E0 d. n" m5 \' M( d
ing the normal level of adrenal steroids. T B6 e+ B9 s) b4 U$ M
The diagnosis of exogenous androgens was strongly
9 X, q# |4 V( G3 A4 i( Isuspected in a follow-up visit after 4 months because
' s, a. _, C& W; P- g! e% Y; ]! z) i3 othe physical examination revealed the complete disap-
5 h6 W w9 g/ a P" ppearance of pubic hair, normal growth velocity, and6 x; M- Y6 B( Q) K( @6 s/ v
decreased erections. The father admitted using a testos-
j. `% k/ m N# T3 j: y7 Wterone gel, which he concealed at first visit. He was8 O) `( m F& ?8 c6 V6 A7 d- B5 _; ~' k
using it rather frequently, twice a day. The Physicians’+ u$ C2 l$ L( U3 q# G/ L
Desk Reference, or package insert of this product, gel or) ~* I I6 [* j1 h
cream, cautions about dermal testosterone transfer to
% c5 h* e, d3 @ |8 g$ i) `unprotected females through direct skin exposure.
! d4 v6 n7 x# G9 x- cSerum testosterone level was found to be 2 times the
+ j( f' `* A1 n6 g$ M1 |' wbaseline value in those females who were exposed to. B# ?4 w/ j+ Z) j# l
even 15 minutes of direct skin contact with their male
* ~9 R% b- a' l8 y0 xpartners.6 However, when a shirt covered the applica-3 k) b# Z- k( `2 z8 d$ q6 x* c
tion site, this testosterone transfer was prevented.
5 d1 h) C5 i# J+ M& mOur patient’s testosterone level was 60 ng/mL,
8 ^; u; |2 {0 A/ {which was clearly high. Some studies suggest that
( O8 h. G2 Q- U5 {! Ddermal conversion of testosterone to dihydrotestos-
e" o5 \0 Z2 ~9 X+ P1 Bterone, which is a more potent metabolite, is more
4 z) d6 B, M! S% }* s- I* Xactive in young children exposed to testosterone1 z. C p5 w0 c7 ]/ Y' J9 [3 h* U
exogenously7; however, we did not measure a dihy-
8 R0 k9 s1 m8 K/ c: W4 {drotestosterone level in our patient. In addition to5 p, v2 G0 L6 M& B( e
virilization, exposure to exogenous testosterone in
( S- S1 c" V; G- {0 S$ Q! n6 Dchildren results in an increase in growth velocity and
2 |3 S' W0 ~3 Z6 G2 W/ S+ @advanced bone age, as seen in our patient. h. V% q3 M7 C# E6 \/ S. c4 k( v
The long-term effect of androgen exposure during& I3 o8 b$ m& J \$ J
early childhood on pubertal development and final
" h- N2 {$ g* q, aadult height are not fully known and always remain0 C3 ]0 B; q/ a
a concern. Children treated with short-term testos-" c( e# q2 q$ v+ y9 m1 d5 D4 c
terone injection or topical androgen may exhibit some
$ F% G$ Q3 Y( ]7 T* g) z, `# macceleration of the skeletal maturation; however, after
' Z7 V( U" H/ Dcessation of treatment, the rate of bone maturation
) x8 `* c2 J. C! a: c8 L7 ?decelerates and gradually returns to normal.8,9
{6 R" B! k S! y1 gThere are conflicting reports and controversy: x( z2 j% |$ V% p
over the effect of early androgen exposure on adult( D1 _; x9 T$ `* X, L& [+ |* L: e
penile length.10,11 Some reports suggest subnormal
: P r1 w/ v- n: x: Qadult penile length, apparently because of downreg-
* P% l/ l' U- D7 s5 sulation of androgen receptor number.10,12 However,. }& A; ]2 n, V1 Q5 i
Sutherland et al13 did not find a correlation between
' t- o3 Y7 S4 k1 E3 ?8 {4 Qchildhood testosterone exposure and reduced adult/ D R' [7 }# Z
penile length in clinical studies.3 ?9 t; }; Q( V! Q J6 y0 ?
Nonetheless, we do not believe our patient is
f7 a" B% E, _7 o* U5 igoing to experience any of the untoward effects from
1 E$ Z% q# D/ [: D3 u+ ^+ u1 B& t* itestosterone exposure as mentioned earlier because# u) `" V- l; @7 N" {
the exposure was not for a prolonged period of time.6 ~" w/ r+ k$ W- b
Although the bone age was advanced at the time of1 J/ q7 h5 I6 ?6 M
diagnosis, the child had a normal growth velocity at
o$ ^9 q/ i' S) `# ~. m, Tthe follow-up visit. It is hoped that his final adult
/ p; ^ D! y* s5 j$ i$ Fheight will not be affected.1 C, Y, x0 E* ~+ f' [
Although rarely reported, the widespread avail-
, Y% G: R/ @6 J* _' n: |ability of androgen products in our society may" I& a6 j/ y$ Y* ]
indeed cause more virilization in male or female
5 f3 a+ b7 n% _) @children than one would realize. Exposure to andro-6 z q; B' b/ V& P" K
gen products must be considered and specific ques-7 u7 I, _4 B" K+ u( W9 o: X. _5 q
tioning about the use of a testosterone product or
+ h6 A- F: i4 e$ e1 Hgel should be asked of the family members during
) X& y! b/ Z% v Athe evaluation of any children who present with vir-
) o1 Y5 Q" T7 | _# u) N6 p% Y# Iilization or peripheral precocious puberty. The diag-1 c z4 L6 Q4 g( o+ a! k
nosis can be established by just a few tests and by( ]( d& J$ `8 E% r
appropriate history. The inability to obtain such a
! S4 a+ P8 c d0 m2 Xhistory, or failure to ask the specific questions, may+ A3 _6 G4 d+ m: G1 I
result in extensive, unnecessary, and expensive
# X1 a$ @( K3 Iinvestigation. The primary care physician should be
. S, w* T# @' Xaware of this fact, because most of these children: C4 c) X( K+ d( v# l8 V( t
may initially present in their practice. The Physicians’9 q( _5 c) I. H9 h2 j$ L5 m
Desk Reference and package insert should also put a; w( x5 _3 _9 C6 g. A" c; R
warning about the virilizing effect on a male or
0 x8 ^. ]1 E9 P6 k5 t5 _( Yfemale child who might come in contact with some-2 X" c( `+ d9 ?$ M& O1 O( Q+ h
one using any of these products. G- c. r+ M" i, x
References
4 `' h- T D. K1. Styne DM. The testes: disorder of sexual differentiation% x& ~. M# K/ i2 W1 I
and puberty in the male. In: Sperling MA, ed. Pediatric
6 [) X9 I/ z+ K$ B% B& y; z# b8 a5 fEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ H2 t% ]0 u& C
2002: 565-628.
8 c. I0 u+ ]- A, s8 q3 I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, {- v& A' s1 @( ]* Ypuberty in children with tumours of the suprasellar pineal |
|