- 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-Old8 R! P$ _6 p$ U" G* r
Boy Induced by Indirect Topical4 s/ `. P- P' p2 P! z7 B5 \
Exposure to Testosterone$ f3 @1 v# Z8 b; w! ?+ E
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" w9 b( [. Z( Y7 u6 Zand Kenneth R. Rettig, MD11 h% G- _- F$ D$ s
Clinical Pediatrics* b% I! H2 O7 ?, y
Volume 46 Number 6# T) a2 q- k' E, F- P" z% l' a) @ S
July 2007 540-5437 [5 k* }1 @* U
© 2007 Sage Publications: X3 N/ [ b3 a" W2 A% {
10.1177/0009922806296651
1 m% x5 ^1 T5 m2 Ohttp://clp.sagepub.com
1 h; f! L# X) Q# C* n/ thosted at/ d$ ~' E$ k2 C+ I+ R1 l0 }
http://online.sagepub.com
3 A6 F1 ]" p" E2 [; {4 `# D% UPrecocious puberty in boys, central or peripheral,
# H Z* X1 p5 ?+ t3 Xis a significant concern for physicians. Central
" k7 D5 ~2 m1 {# D7 |. qprecocious puberty (CPP), which is mediated
# f- l& @: I+ X. F6 K6 [through the hypothalamic pituitary gonadal axis, has
8 j; U0 d0 I; Ha higher incidence of organic central nervous system
/ k, F3 i' N: q4 n; `lesions in boys.1,2 Virilization in boys, as manifested# d6 N8 W! X- U9 c8 I
by enlargement of the penis, development of pubic" F- i6 o) d0 r9 b
hair, and facial acne without enlargement of testi-5 l, T/ q i, |3 \+ N
cles, suggests peripheral or pseudopuberty.1-3 We
7 ^( k. B8 Z: F. X, J% r- |" Ureport a 16-month-old boy who presented with the# ~1 @- _: A" u) Z
enlargement of the phallus and pubic hair develop-, j4 W) P5 ^& u9 a+ M
ment without testicular enlargement, which was due" Z/ I# ~0 ]! a' G) _, O
to the unintentional exposure to androgen gel used by
& S& H" X6 ~$ z9 P+ O& O8 kthe father. The family initially concealed this infor-
- n9 p7 a5 J: [( Jmation, resulting in an extensive work-up for this
' q$ v$ R5 S/ X2 f# I, ochild. Given the widespread and easy availability of
7 \4 m/ j3 d# Z+ Ktestosterone gel and cream, we believe this is proba-
) L. F9 [3 T+ Y; Dbly more common than the rare case report in the
1 Y H* N3 O( `& i `; [5 V" ~% R: Qliterature.4# H! ?2 \& C1 z5 d7 d9 R% \
Patient Report# b5 i- X1 ^' b7 @7 k% i! @) D
A 16-month-old white child was referred to the) \/ S3 a9 `* W7 d7 |+ ~
endocrine clinic by his pediatrician with the concern6 U! C$ f" H: g2 T8 F5 G
of early sexual development. His mother noticed
3 V% I( z9 O* h: y/ q" xlight colored pubic hair development when he was* l3 I, k7 f# K) G
From the 1Division of Pediatric Endocrinology, 2University of
$ W, N% r7 m5 |* MSouth Alabama Medical Center, Mobile, Alabama.
: D3 v; ], F* C1 `Address correspondence to: Samar K. Bhowmick, MD, FACE,( K7 p4 A( i6 U2 m
Professor of Pediatrics, University of South Alabama, College of r v4 S1 @/ R( b& i* n8 `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( |3 N+ A* l4 B3 p( U0 Q1 Ue-mail: [email protected].
) a% ~; y8 @! b- [! Iabout 6 to 7 months old, which progressively became& ~# r- N* u" ~* \) l- C6 [
darker. She was also concerned about the enlarge-
# X( E, F8 k. C9 `: cment of his penis and frequent erections. The child
* r2 [# j+ R+ i9 f+ {5 N" Qwas the product of a full-term normal delivery, with
# H* t7 u% z# K2 W& Na birth weight of 7 lb 14 oz, and birth length of6 B! R1 C* [6 g, T/ C( E5 j
20 inches. He was breast-fed throughout the first year+ l0 H0 u6 r6 e4 {7 s6 e' ]
of life and was still receiving breast milk along with6 ~! C9 p% V* u, W2 W$ G
solid food. He had no hospitalizations or surgery,
& q* j9 V9 k5 C+ |* ^$ K; i. Fand his psychosocial and psychomotor development
: w; E* f( S4 j% @& Twas age appropriate." d6 w5 s3 D4 `, o+ V% d, G; g
The family history was remarkable for the father,
$ Q! `: v+ h7 w' t& a2 Kwho was diagnosed with hypothyroidism at age 16,
) O. c( w: T, t- o; o# h, \: bwhich was treated with thyroxine. The father’s
4 F/ \* |: q) Y) gheight was 6 feet, and he went through a somewhat
) g+ l$ o; X: h# G# Iearly puberty and had stopped growing by age 14.$ I/ Z3 Z/ J7 O
The father denied taking any other medication. The
: g- U. ?. H7 P& i9 l, S, achild’s mother was in good health. Her menarche% a3 c' a, z9 l) a/ T& k$ l& ?* H
was at 11 years of age, and her height was at 5 feet
; v2 c7 ~% Z) B$ V I. g5 inches. There was no other family history of pre-, z6 m! b$ t+ i, m/ z
cocious sexual development in the first-degree rela-& K. K @ w* [! b8 E% P' N
tives. There were no siblings.
( X$ ?8 r4 }- H7 y* K5 @Physical Examination" G( `+ G; `5 \' V
The physical examination revealed a very active,- _8 R# ~" D& `
playful, and healthy boy. The vital signs documented, y0 ]- ~. F3 d+ a6 V
a blood pressure of 85/50 mm Hg, his length was- a$ g% a* S( {% Z0 `8 C
90 cm (>97th percentile), and his weight was 14.4 kg3 ~4 B6 I* P' T+ j7 E! X
(also >97th percentile). The observed yearly growth
, _6 Y/ y8 m9 x8 t' U2 j8 rvelocity was 30 cm (12 inches). The examination of
" w* ^: w5 [( T& wthe neck revealed no thyroid enlargement.
/ T6 ]9 e; C6 R5 ]) n" Y- rThe genitourinary examination was remarkable for
: }7 R, K0 [* e! E/ r; }enlargement of the penis, with a stretched length of
8 ^% V9 N. {& r6 X. Y* Y7 F6 C, l8 cm and a width of 2 cm. The glans penis was very well
( k( [& U! \$ Udeveloped. The pubic hair was Tanner II, mostly around
$ {& @6 u3 G/ ]540
- w5 t. f- h+ J, X/ m( aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 C0 J- D5 n. Ethe base of the phallus and was dark and curled. The
8 M, e* H7 z9 c j! _% |/ ~testicular volume was prepubertal at 2 mL each.. N: P/ H3 l O2 X) y& A) X
The skin was moist and smooth and somewhat
( q4 I7 ~0 X9 ^" J. j* K1 l' Noily. No axillary hair was noted. There were no* m6 s6 t/ {( C* R( A9 e) n
abnormal skin pigmentations or café-au-lait spots.
8 U1 N+ k) {/ ]* e6 s' eNeurologic evaluation showed deep tendon reflex 2+8 r, e b) \7 O7 g& m$ T+ b
bilateral and symmetrical. There was no suggestion4 k# k/ P7 t; m) ~, y$ h
of papilledema.
% m) \$ E+ q/ U0 `/ ~& o% l2 CLaboratory Evaluation- R' Z" U+ x1 F2 C$ B
The bone age was consistent with 28 months by
' p; ?3 f' [0 W# V$ Wusing the standard of Greulich and Pyle at a chrono-
) ]3 Z; U1 w8 v9 Nlogic age of 16 months (advanced).5 Chromosomal
# q a* r( A& x" R; x- J; v- U: Skaryotype was 46XY. The thyroid function test
0 U: u$ w! Y2 }* e9 P, W. y- pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
B5 k3 t- {' i6 plating hormone level was 1.3 µIU/mL (both normal).
$ o. A5 U- d, s8 s; b ?, I+ rThe concentrations of serum electrolytes, blood# p) p( u* Z7 S
urea nitrogen, creatinine, and calcium all were
- J; Q& n: D( L+ A' V- T; D: W5 ~within normal range for his age. The concentration
3 N+ j2 ?! o* A3 ^1 _of serum 17-hydroxyprogesterone was 16 ng/dL
, }/ V$ K, ?7 v8 x(normal, 3 to 90 ng/dL), androstenedione was 20
$ g9 c( \2 Q7 |. d0 ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: M- S6 U! I0 K% w( g" I7 C* }) N
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 Q1 h- d8 i! @6 u# j S" ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to" _7 s# f) r9 k' r% o6 e
49ng/dL), 11-desoxycortisol (specific compound S)2 p- A& a; y2 c, h4 ?( |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 {! K/ h1 W e; G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
@+ m. Y: t" {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* S! A6 M3 ?% [2 y# V7 b- s7 P
and β-human chorionic gonadotropin was less than4 u3 ^" X6 j& Y* N; V
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 c0 ~1 e; X" n
stimulating hormone and leuteinizing hormone/ L3 B) p9 o3 _# f- P
concentrations were less than 0.05 mIU/mL# X9 N! W! j# S
(prepubertal).
6 u' Q( B( r6 i4 @( z* iThe parents were notified about the laboratory
$ B* ?4 m4 O8 e& v. Fresults and were informed that all of the tests were' t* I$ g; C2 ]" J. F2 {8 h
normal except the testosterone level was high. The! e& P/ P+ d5 h
follow-up visit was arranged within a few weeks to' w# n$ K% _0 O- F4 F% N" b2 j( n
obtain testicular and abdominal sonograms; how-
$ N; H5 Y$ q9 Hever, the family did not return for 4 months.% X% b4 y, a, i2 |2 ~: _ \5 j
Physical examination at this time revealed that the
+ T) x3 a! p) {! x3 M' ]child had grown 2.5 cm in 4 months and had gained
: ^+ U" }/ l. [) x$ C2 kg of weight. Physical examination remained2 u# ?1 _# K: ]- v& _5 D# @3 F
unchanged. Surprisingly, the pubic hair almost com-3 ~ @# l$ b0 }3 Z) a5 j
pletely disappeared except for a few vellous hairs at* H3 X5 }2 h$ \; ?. C- \
the base of the phallus. Testicular volume was still 2: M- D$ E. X/ K J
mL, and the size of the penis remained unchanged.( r- }* M: F& Y% ~, g- M% \
The mother also said that the boy was no longer hav-
i/ |3 A) c$ n3 Y5 Y3 q8 h" |3 B* L9 Aing frequent erections.) ~2 m& Z9 y) p$ G; C/ e. H- A
Both parents were again questioned about use of( ]5 W7 o$ h' k; L
any ointment/creams that they may have applied to
: }5 w G% f, N& Gthe child’s skin. This time the father admitted the
2 a+ q, E, X- _Topical Testosterone Exposure / Bhowmick et al 541( N3 p4 F+ N7 e0 Y, w1 H0 T! t0 t
use of testosterone gel twice daily that he was apply-# J j8 I+ [0 s% @- s
ing over his own shoulders, chest, and back area for
1 z! ~ |0 p! w4 s+ R' Ea year. The father also revealed he was embarrassed
5 a' s1 `: @& b% `5 \7 jto disclose that he was using a testosterone gel pre-. ]+ y! u. L S3 A- M4 d& d/ u
scribed by his family physician for decreased libido
7 ]( o2 O6 k6 n0 l; _6 N. Esecondary to depression.
* Z; H4 Y! |) T% LThe child slept in the same bed with parents.6 D- r: r7 }8 w6 p0 {
The father would hug the baby and hold him on his
4 \1 O. K6 U' Q2 `3 ychest for a considerable period of time, causing sig-
+ U# w& O+ r- f6 f5 `nificant bare skin contact between baby and father.
. v0 o, t: T4 `" Y0 d A$ [The father also admitted that after the phone call,
' v9 g; U/ }2 [! w5 s) Swhen he learned the testosterone level in the baby' h v" a( A5 P+ }( [& f! Y- l
was high, he then read the product information; k$ b& V, u' {4 t
packet and concluded that it was most likely the rea-
& V. A0 a- s$ O; ?$ _ Dson for the child’s virilization. At that time, they
8 k7 ]) `' ^' _+ R) A, vdecided to put the baby in a separate bed, and the
9 C/ R( e0 X4 d- d- a4 o% `3 \+ Cfather was not hugging him with bare skin and had7 I, W4 i3 }% @+ m
been using protective clothing. A repeat testosterone' K- [- X" @5 L% v8 j5 u; m6 ]
test was ordered, but the family did not go to the
3 Y- y" S4 W9 s6 T1 ?3 olaboratory to obtain the test.
2 c$ Q# R0 y. G4 eDiscussion
: H; P! _# ?, y t% \Precocious puberty in boys is defined as secondary( r' u9 n/ ~% z9 N8 g+ v
sexual development before 9 years of age.1,4
. ~ w. v a R+ YPrecocious puberty is termed as central (true) when+ n5 {9 |! g+ P( K! q' A6 |
it is caused by the premature activation of hypo-
0 V3 W# S# I+ b# \! C; y7 ?thalamic pituitary gonadal axis. CPP is more com-
! H. w; ~0 K/ t. Omon in girls than in boys.1,3 Most boys with CPP
2 Q; G$ B; X! U$ V( E2 q/ Nmay have a central nervous system lesion that is
7 u) o, s3 T1 [responsible for the early activation of the hypothal-
1 Q7 F2 e; u9 O' m7 j4 n* c. Uamic pituitary gonadal axis.1-3 Thus, greater empha-
" P/ d2 ~: D% q/ _sis has been given to neuroradiologic imaging in
1 i' A! b" y2 @% M$ S( }/ oboys with precocious puberty. In addition to viril-' J! [8 K$ v5 L0 V
ization, the clinical hallmark of CPP is the symmet-- q8 y/ y" } q8 O9 T& v6 v
rical testicular growth secondary to stimulation by! y: I% V* V# G3 N0 a" ]
gonadotropins.1,3; A6 y& z, q& o" P0 L
Gonadotropin-independent peripheral preco-
7 Z+ D! m# X- ^" G6 \( H ecious puberty in boys also results from inappropriate# L: T' q. W9 t$ B6 B# ~4 r4 ?
androgenic stimulation from either endogenous or9 J6 A. }6 e$ x) y- w' N. k/ i
exogenous sources, nonpituitary gonadotropin stim-/ _2 R2 T0 i& ]) B
ulation, and rare activating mutations.3 Virilizing
/ m5 b1 F7 ^/ L* N, s/ X; A+ C/ Acongenital adrenal hyperplasia producing excessive3 V3 p9 ]- Z. d' i1 Q7 |
adrenal androgens is a common cause of precocious( G2 T3 p( e& A- @+ [
puberty in boys.3,4- ]! U2 s3 B1 {: G) ~2 ~9 t7 I9 T9 d
The most common form of congenital adrenal' g! y d/ K& N6 ?7 O# c7 e- `
hyperplasia is the 21-hydroxylase enzyme deficiency.1 t7 R+ S6 |; t6 M u# t. G+ P
The 11-β hydroxylase deficiency may also result in
# b W6 e+ B# z4 q5 pexcessive adrenal androgen production, and rarely, t6 u8 g" l0 B- n6 B
an adrenal tumor may also cause adrenal androgen
5 Y0 k; [; w. c% ?- @excess.1,3
1 |5 |2 G: _0 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 q# b0 D. C% t: Q& P' o* e+ ?# A542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 K/ y1 w$ D- }1 g5 P3 OA unique entity of male-limited gonadotropin-9 K- c5 l5 L# _" J# {* l
independent precocious puberty, which is also known0 v" d1 p" z0 O7 j# k
as testotoxicosis, may cause precocious puberty at a1 y: l8 w' A2 c) t* n; y( j7 |
very young age. The physical findings in these boys3 u0 H, F: X+ [0 I2 w
with this disorder are full pubertal development,
( X- F! F. v4 d! {8 vincluding bilateral testicular growth, similar to boys
_$ n1 V/ Y# C' o/ e. ^* b. Bwith CPP. The gonadotropin levels in this disorder, A, Y2 [4 J& t! M2 ~5 X7 E+ E! {& D$ o
are suppressed to prepubertal levels and do not show
% B2 h( u) U! Tpubertal response of gonadotropin after gonadotropin-
# v; R3 d1 l# t& ?9 ureleasing hormone stimulation. This is a sex-linked2 @! {8 x t) N7 |1 ?. _
autosomal dominant disorder that affects only! c$ `) J0 U# o: f, }
males; therefore, other male members of the family
7 _. {% B0 {6 w3 I+ Z" {0 vmay have similar precocious puberty.3# h3 w5 ]/ d: {* O" I
In our patient, physical examination was incon-
7 G( q0 n) F9 ]1 ?8 Jsistent with true precocious puberty since his testi-2 H- P- D. L- l; }- R
cles were prepubertal in size. However, testotoxicosis' W; ~! j: H& m8 Q1 l
was in the differential diagnosis because his father$ b/ W* j& B/ c/ m) e, U C
started puberty somewhat early, and occasionally,9 ~" m3 t! B2 a, k" a) X! U
testicular enlargement is not that evident in the
/ ?& ]- q) N/ W( Nbeginning of this process.1 In the absence of a neg-' G% I- Z: K# i
ative initial history of androgen exposure, our
/ V- ], C, b# ?/ Ibiggest concern was virilizing adrenal hyperplasia,
- m2 `- Y0 \$ l/ j: p2 z# L% seither 21-hydroxylase deficiency or 11-β hydroxylase" [+ u: a% j& }4 L1 |3 V
deficiency. Those diagnoses were excluded by find-$ d9 u& E( x7 x: c# s. U
ing the normal level of adrenal steroids.
, D/ i! c" n% ]The diagnosis of exogenous androgens was strongly
- U6 `% R1 V8 }5 A4 A+ B/ o) F( z+ R+ rsuspected in a follow-up visit after 4 months because/ r2 w7 C3 k- z% f5 s
the physical examination revealed the complete disap-
' M. |8 R) L p$ _pearance of pubic hair, normal growth velocity, and
. C3 W2 c1 j3 a& u/ Fdecreased erections. The father admitted using a testos-" c* L4 X8 b/ J' F( L5 v
terone gel, which he concealed at first visit. He was
' t9 B! Z) k$ V' G3 I% P, D( vusing it rather frequently, twice a day. The Physicians’
; S& e1 ]" U b8 W# }, MDesk Reference, or package insert of this product, gel or
) y: }6 V# B6 |% }cream, cautions about dermal testosterone transfer to& {8 N' ?& M0 }
unprotected females through direct skin exposure.
) k% P* y7 H3 I9 z% c5 B5 H( P$ ~Serum testosterone level was found to be 2 times the6 X- ]. Z6 @9 c) c, L
baseline value in those females who were exposed to
' N* w$ `: u& }# Y- d% beven 15 minutes of direct skin contact with their male
/ i" Z" D$ `, f: |partners.6 However, when a shirt covered the applica-3 M, X" }" V& m& v
tion site, this testosterone transfer was prevented.9 D) Q: D6 y( G3 {0 m
Our patient’s testosterone level was 60 ng/mL,5 V% K0 S9 i& v
which was clearly high. Some studies suggest that
* J( |9 l4 }% ^& Hdermal conversion of testosterone to dihydrotestos- x0 w2 ~3 c2 ]# Z- p. H. m
terone, which is a more potent metabolite, is more
) w( P3 g5 v0 |6 `, @' lactive in young children exposed to testosterone+ o+ U1 ] \/ d: _; H* ]) I V
exogenously7; however, we did not measure a dihy-' }3 z4 d! H( x- r& G2 {$ R
drotestosterone level in our patient. In addition to
9 l) K4 M, Z! i1 c- F/ Hvirilization, exposure to exogenous testosterone in
% g! `: ^. u( Z2 V) o6 S. Wchildren results in an increase in growth velocity and
9 Q) J& j- l6 B# |1 u p6 I5 Hadvanced bone age, as seen in our patient.. W; n; k6 R p0 ?% ^' h
The long-term effect of androgen exposure during
3 a/ k( o, i K3 k, bearly childhood on pubertal development and final
+ }3 o, ~# [ b9 K+ a; ?6 R2 xadult height are not fully known and always remain
. r2 u2 E# e: X. S L& ta concern. Children treated with short-term testos-
& w6 [& l( ]9 y* b* Bterone injection or topical androgen may exhibit some
3 n9 \/ @5 a8 n# c) H" C1 {0 yacceleration of the skeletal maturation; however, after; ^! y3 o/ y: \" A. \' q9 L% X
cessation of treatment, the rate of bone maturation: `, }2 [3 E0 H5 i3 v! S4 Q
decelerates and gradually returns to normal.8,9
& ?8 J$ U' i) U7 dThere are conflicting reports and controversy
5 x3 A4 v& h" q6 O3 }2 ?2 eover the effect of early androgen exposure on adult
) Q8 l/ Q9 p' Q" l/ |penile length.10,11 Some reports suggest subnormal
- r% T! v' D9 m6 K8 h+ Dadult penile length, apparently because of downreg-: I+ V e' m' `% o5 R% D
ulation of androgen receptor number.10,12 However,
% | f# w8 |+ o6 {. e! ] s2 q: F/ K8 FSutherland et al13 did not find a correlation between4 w$ S& c T6 h' w1 g2 ^
childhood testosterone exposure and reduced adult
2 s [6 d9 c* p9 n. kpenile length in clinical studies.
4 d$ B' A0 m, a2 @Nonetheless, we do not believe our patient is1 V" D* A7 l; P0 ]) u, [. N+ m$ g: e
going to experience any of the untoward effects from
6 z% z0 K+ ^; Y* f; ctestosterone exposure as mentioned earlier because
8 | }- Y$ t x# a/ e9 }5 mthe exposure was not for a prolonged period of time.0 f: k6 K- m- }; L* K
Although the bone age was advanced at the time of
! s5 s8 H2 x$ ~/ A: d4 bdiagnosis, the child had a normal growth velocity at9 U; Z) E, x7 E ^* u, C0 ?
the follow-up visit. It is hoped that his final adult
6 A2 l+ `7 H2 [) H, mheight will not be affected.
6 o% g/ ^1 ^7 v9 o9 I4 m4 I$ `$ iAlthough rarely reported, the widespread avail-
. C7 W- l. g2 i4 q* N- T! sability of androgen products in our society may2 R% L, M9 G5 W, W& q2 k6 N
indeed cause more virilization in male or female
% R) e3 j9 ^, H( Mchildren than one would realize. Exposure to andro-& s; T2 _2 G2 m! `. T! }
gen products must be considered and specific ques-
. d1 S8 S( @ ]/ w2 E W2 S. Ntioning about the use of a testosterone product or) o: g. [! q1 O; D2 q! g' }
gel should be asked of the family members during
7 R- C4 r0 d8 dthe evaluation of any children who present with vir-' Q/ X7 d( R w# Y( w0 Y% ?
ilization or peripheral precocious puberty. The diag-0 ^) }9 K$ |' z
nosis can be established by just a few tests and by
) w+ A" F/ A, H: J1 U! Rappropriate history. The inability to obtain such a* z7 ^2 @1 ~% E" b: k3 v2 C
history, or failure to ask the specific questions, may
. J% e4 S& W, r; A) rresult in extensive, unnecessary, and expensive0 F5 c! }, F: c1 i2 _8 x
investigation. The primary care physician should be8 `& g( s2 A) |: E$ L) H" K1 L% p
aware of this fact, because most of these children/ z# S; C( m' [& } k) X
may initially present in their practice. The Physicians’
9 i+ ~0 z. K( nDesk Reference and package insert should also put a/ \1 z* W6 a( d4 e- y( _+ d
warning about the virilizing effect on a male or
7 s' n9 B& \; l/ U* b) O. [female child who might come in contact with some-
) L7 K9 j" b! Y3 A# h% Wone using any of these products., x. E$ @. o5 p, M; F6 O
References5 W; ~4 T: K: B# P, J8 A8 p
1. Styne DM. The testes: disorder of sexual differentiation& F# k+ |$ g; l2 b ]+ m! w
and puberty in the male. In: Sperling MA, ed. Pediatric0 G( \9 O9 L) m$ N9 {5 p" v/ b
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ ]3 f: n3 w) u$ w- Z, }
2002: 565-628.9 Z. t# h, f1 N ^$ `* d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: [* k1 p. v! J: |* o E
puberty in children with tumours of the suprasellar pineal |
|