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Sexual Precocity in a 16-Month-Old
3 |5 M/ k4 @3 L: B9 R% Y& H, ]4 M) r! ?" wBoy Induced by Indirect Topical( K7 o0 y; y2 T2 f
Exposure to Testosterone, d* U6 v( A1 R& |2 I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# Z$ g: u' O) X7 P) {and Kenneth R. Rettig, MD1
$ p/ l+ ~0 g- `# }' c8 oClinical Pediatrics8 c; r2 v1 v1 n$ U( z# }
Volume 46 Number 6
% l$ N( h; B- ~( I0 B" }9 aJuly 2007 540-543) O3 w/ f+ h# S/ r6 i w
© 2007 Sage Publications- }/ p0 ]& Z: c
10.1177/0009922806296651
2 v/ _6 b( N9 Ahttp://clp.sagepub.com
( b3 G6 Q% \& I) a! `6 v0 ihosted at- @9 s3 Y7 o' B2 k- H% ?7 u% k: ~! u
http://online.sagepub.com0 ^. o3 T4 H; [. Y8 x
Precocious puberty in boys, central or peripheral,
3 W2 N1 S+ J, R6 N* ]) Jis a significant concern for physicians. Central
; o; L6 h* X; b4 Oprecocious puberty (CPP), which is mediated% h G( `; m. D
through the hypothalamic pituitary gonadal axis, has7 g2 T( `! b2 P# |/ u3 K R
a higher incidence of organic central nervous system u6 \# ]4 Y0 `$ h2 e: V/ L
lesions in boys.1,2 Virilization in boys, as manifested
: L% M( V# K' ?! g5 J: wby enlargement of the penis, development of pubic6 @& o! Q( E, t+ H% ~
hair, and facial acne without enlargement of testi-
. D4 J/ y/ r& F" D/ d3 k! ccles, suggests peripheral or pseudopuberty.1-3 We* p# G& `. }6 O* ^) X
report a 16-month-old boy who presented with the
; t) i4 S( p( c, Q# n! O. yenlargement of the phallus and pubic hair develop-9 H" x% `$ P+ A0 w# |5 L
ment without testicular enlargement, which was due L3 [7 h0 P1 Y5 Z8 I% ?- j
to the unintentional exposure to androgen gel used by* _' o, t+ r, {6 \# l
the father. The family initially concealed this infor-" t% K8 f" w# A$ Y6 n G
mation, resulting in an extensive work-up for this
4 Y [. k3 G G- qchild. Given the widespread and easy availability of7 Q: t6 r* D" U- ~9 O, J; h
testosterone gel and cream, we believe this is proba-
) \8 }# {; B/ U( ^- R# rbly more common than the rare case report in the
( f& K- r; D+ b3 z Eliterature.4. c8 `$ I0 g$ d; a" I6 d
Patient Report
# x4 E9 U' n1 p* }) D. YA 16-month-old white child was referred to the
5 y& p# O) |$ ^6 z) w& |endocrine clinic by his pediatrician with the concern% W. \* e$ j: M' W, d
of early sexual development. His mother noticed) K! O4 k& Z, c) a6 G" d/ r3 g- w1 _
light colored pubic hair development when he was4 f; Q( V. D, o7 v
From the 1Division of Pediatric Endocrinology, 2University of
% A7 w+ s5 ?7 T8 R- I/ X; F4 Z6 eSouth Alabama Medical Center, Mobile, Alabama.
' | f% M: s( I1 o P3 i; Y! }! F& tAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& {* M9 z T" Q$ z4 TProfessor of Pediatrics, University of South Alabama, College of
$ Q$ x i3 P$ K- v ~0 z( IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 g A; w' O( oe-mail: [email protected].1 F4 o, ^6 d* J! ] x7 P
about 6 to 7 months old, which progressively became$ Q) @, I- b6 I( j' S
darker. She was also concerned about the enlarge-
: Y M' `: p2 k1 a) k4 O- \ment of his penis and frequent erections. The child
6 y3 Y. ?0 ~& v1 j9 z. q) |# ~was the product of a full-term normal delivery, with* Z4 f+ O( u) u
a birth weight of 7 lb 14 oz, and birth length of
- s/ }+ K W( l' `% P20 inches. He was breast-fed throughout the first year
5 p3 t0 Q9 f. x& G5 Wof life and was still receiving breast milk along with
7 g/ A( s6 y! l6 J) G0 m1 ^, Vsolid food. He had no hospitalizations or surgery,4 J; t ?* ~' q
and his psychosocial and psychomotor development
: e7 B# C9 a5 E' c/ Bwas age appropriate.
/ [$ U" d6 r1 G5 }6 a& CThe family history was remarkable for the father,
% R; O; A5 O* e3 ]& K9 s! q( Kwho was diagnosed with hypothyroidism at age 16,
9 K- _9 l, K- Kwhich was treated with thyroxine. The father’s
% p6 o/ V% O, y, Kheight was 6 feet, and he went through a somewhat0 Z. r( I* f' f1 G- u9 O
early puberty and had stopped growing by age 14.
0 G. h7 M- D- ]: I! A# yThe father denied taking any other medication. The
) n) @! _ K* w2 Z0 Wchild’s mother was in good health. Her menarche/ M- k Y% d8 D9 I; L
was at 11 years of age, and her height was at 5 feet; n ~; I* ~& j
5 inches. There was no other family history of pre- d; Z- g/ c$ y, i$ f6 B
cocious sexual development in the first-degree rela-' r" M4 l' L3 {9 C5 U! l1 k
tives. There were no siblings.! ~' t: e( }1 q1 v9 N) ^, z
Physical Examination
& N* ?7 W9 x4 A8 ^' \: gThe physical examination revealed a very active,9 j; J; o( D2 k `* O/ ?5 r
playful, and healthy boy. The vital signs documented7 m5 x! I$ g0 @2 k5 h- G# e6 V
a blood pressure of 85/50 mm Hg, his length was; c/ \4 f8 b, [# F3 J
90 cm (>97th percentile), and his weight was 14.4 kg- j- Z' D; q- D
(also >97th percentile). The observed yearly growth, r0 h( S9 t9 K% ^7 ?3 O' C9 G$ m4 y& A
velocity was 30 cm (12 inches). The examination of
2 S5 r, J7 M3 q6 l' k! bthe neck revealed no thyroid enlargement.: X2 a; b1 M( ]% Q7 I
The genitourinary examination was remarkable for( a3 { O& G2 A1 t3 T: B# ]
enlargement of the penis, with a stretched length of
" ]% A! I3 f- x$ r8 cm and a width of 2 cm. The glans penis was very well
6 o/ R0 d- o1 I5 Cdeveloped. The pubic hair was Tanner II, mostly around
7 S/ H% N& y" a540, F. c& k# g5 A# b1 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! S8 i7 [& z& ~
the base of the phallus and was dark and curled. The0 ?3 V$ v" e! |8 t
testicular volume was prepubertal at 2 mL each.
) F" C. l! A; ]9 t& r. A) j. GThe skin was moist and smooth and somewhat. X/ [+ [9 D/ `2 G! x
oily. No axillary hair was noted. There were no
- W: T C- q: o6 i/ U( yabnormal skin pigmentations or café-au-lait spots.
/ U5 P, d8 A( `9 F: A* c) f2 V: hNeurologic evaluation showed deep tendon reflex 2+
: f0 ?/ A9 n) K( g3 Gbilateral and symmetrical. There was no suggestion
# J7 S$ R3 x5 O/ J! Sof papilledema.
" R" ~. z% B. @! @) LLaboratory Evaluation
x( @5 }- _; v: zThe bone age was consistent with 28 months by3 h" S; t$ M+ C. D" m% `' U
using the standard of Greulich and Pyle at a chrono-
1 L" `$ n5 O5 A% Zlogic age of 16 months (advanced).5 Chromosomal
8 F: g8 X# O* _( ^6 V1 wkaryotype was 46XY. The thyroid function test7 T* g; w. l3 O1 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 G' n3 E6 L2 d! R3 E' mlating hormone level was 1.3 µIU/mL (both normal)./ \! o/ t: j* b- S' i
The concentrations of serum electrolytes, blood0 u3 E' z# r8 ^; M# g# ^
urea nitrogen, creatinine, and calcium all were
& C1 h# ]* t/ A3 R' A0 [within normal range for his age. The concentration" ~6 E2 ~: @( r7 i5 h
of serum 17-hydroxyprogesterone was 16 ng/dL" ]3 B' w1 _: k- v4 F: w5 K
(normal, 3 to 90 ng/dL), androstenedione was 201 v- g( ~4 @6 C5 ~+ {$ X
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& @ G* k8 r* o Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),, _* f% Z- J2 g3 v, Z9 b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ o( p/ v" y# H7 g* t4 r& |49ng/dL), 11-desoxycortisol (specific compound S)8 h, H9 H) P0 S0 [5 T5 u, t/ B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 M( n, L% b6 g2 t/ |% X: D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& a( Y9 v! l5 n% Q& Q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 Z% ^+ A" {- J: S3 L% Q/ nand β-human chorionic gonadotropin was less than
5 _" _( I1 B# b t4 X, s5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 w, F1 {, _6 {stimulating hormone and leuteinizing hormone
- W0 H; O, m' Z) p4 pconcentrations were less than 0.05 mIU/mL2 x8 j2 z1 @0 ?5 ^( L. K
(prepubertal).+ ]! J) Q- U- F0 r6 E B/ x9 B
The parents were notified about the laboratory
4 a( p+ F% {! Z. z9 K3 Iresults and were informed that all of the tests were
& e9 M6 e, h8 V9 C. t1 w5 enormal except the testosterone level was high. The
* n5 R. k' v; l( ?9 cfollow-up visit was arranged within a few weeks to
# _9 R3 |6 k( l( c/ d- @! m$ ]obtain testicular and abdominal sonograms; how-
6 v* D. c/ E8 c! k5 A1 sever, the family did not return for 4 months.' f) w& H2 x, r7 e9 N( o
Physical examination at this time revealed that the
9 i0 H0 ?8 [9 p( h4 V* ?" {4 w" Cchild had grown 2.5 cm in 4 months and had gained& s" C+ J9 ~, l2 [
2 kg of weight. Physical examination remained
' v- M$ g5 `/ i" p8 S# Lunchanged. Surprisingly, the pubic hair almost com-% I* ?$ `8 U9 u: ?3 a! A
pletely disappeared except for a few vellous hairs at0 z' ?* H0 [' Y' O$ l2 O
the base of the phallus. Testicular volume was still 2
A% y2 a% N% d- n$ M, i& [mL, and the size of the penis remained unchanged.
3 O9 n7 |1 J* u4 M& G7 mThe mother also said that the boy was no longer hav-
- F) f# q; |! r) D+ _; e6 N* ]$ A6 `ing frequent erections.
8 p5 e R/ e7 g" M" O% jBoth parents were again questioned about use of7 d# t9 e1 E6 I7 R& [5 g8 F
any ointment/creams that they may have applied to p Q9 q* S$ A& b( N
the child’s skin. This time the father admitted the
0 k/ ^3 b x* T; [Topical Testosterone Exposure / Bhowmick et al 541/ y1 d, A1 W8 F& O4 |3 q' f5 m
use of testosterone gel twice daily that he was apply-
+ D: n5 q7 N/ S" l4 ying over his own shoulders, chest, and back area for8 Q/ p: S2 M3 \
a year. The father also revealed he was embarrassed
' Q/ X4 O) W! k) o, A8 Zto disclose that he was using a testosterone gel pre-
2 r8 B+ Q7 d6 W7 Xscribed by his family physician for decreased libido5 c# Q2 Z t- ?+ E. M7 B
secondary to depression.* J2 {- _/ a$ m4 _) H' \, `
The child slept in the same bed with parents.( ~* z% o! @" Q* B6 t0 k
The father would hug the baby and hold him on his
' C4 A8 K( |* d; Q {6 D( qchest for a considerable period of time, causing sig-
% S5 c. H% H/ Z5 R( V1 C$ ynificant bare skin contact between baby and father.
; l! y- j( k% x& [5 k* H% [4 t4 ^4 qThe father also admitted that after the phone call,
# e9 j4 ]+ J% ]" B- Jwhen he learned the testosterone level in the baby
/ \6 g' [7 t# Nwas high, he then read the product information9 i9 L8 q; k5 |, m0 j
packet and concluded that it was most likely the rea-/ v2 ]; ~& H( k
son for the child’s virilization. At that time, they
* \( o8 ] q" |/ m! q3 Y+ a6 ~" |4 ldecided to put the baby in a separate bed, and the
( g8 N" m- P8 m6 m. ]3 kfather was not hugging him with bare skin and had/ c. H9 l8 a: ]6 H
been using protective clothing. A repeat testosterone. t- D' g7 U; ^& _% c
test was ordered, but the family did not go to the+ t' z+ o1 q" ~: |+ s/ m/ x
laboratory to obtain the test.
; t8 w# i/ G# U) qDiscussion1 c0 `/ G' K; Z" c/ L+ [
Precocious puberty in boys is defined as secondary( B1 n" g8 k/ o* F' Y6 t
sexual development before 9 years of age.1,4+ a2 `* l3 C S
Precocious puberty is termed as central (true) when
, c4 N' F8 n9 O" E* uit is caused by the premature activation of hypo-# P* z0 C$ M) B& B; k5 }
thalamic pituitary gonadal axis. CPP is more com-
; q4 U) G1 c# t% d& Nmon in girls than in boys.1,3 Most boys with CPP8 E/ G+ \$ g. L0 o* k
may have a central nervous system lesion that is2 u1 _3 i) R Q7 n% _' c
responsible for the early activation of the hypothal-# h, L; K1 Y4 U
amic pituitary gonadal axis.1-3 Thus, greater empha-+ x! Z* _( h: i+ ^( n
sis has been given to neuroradiologic imaging in
?0 |- c5 i$ f+ T4 T0 B& u. T N9 Hboys with precocious puberty. In addition to viril-5 o; }! I& q' a+ J2 v4 }3 ]: i
ization, the clinical hallmark of CPP is the symmet-
7 [! }* ?& W2 P( K# T! @/ Brical testicular growth secondary to stimulation by
2 x# r; B# ?( }8 E( ]; E: ggonadotropins.1,3! B7 `4 E- v: ^& u4 Q1 Y
Gonadotropin-independent peripheral preco-
: X9 D3 d; N2 H% t9 j: r& gcious puberty in boys also results from inappropriate; k# r8 Y5 [ | k2 p
androgenic stimulation from either endogenous or8 {5 x% {3 y0 y4 g* o! x; j9 d) E
exogenous sources, nonpituitary gonadotropin stim-8 X1 i$ v/ t; X" X( I) ?
ulation, and rare activating mutations.3 Virilizing
6 n5 M' U! Z! M9 z) b8 l7 f6 Xcongenital adrenal hyperplasia producing excessive) i! f+ t9 B! P) L8 X* Z
adrenal androgens is a common cause of precocious- F" Q2 t, M- x8 ^2 z/ F
puberty in boys.3,4 _* x9 u4 k, w6 w* {, j# G; k3 o
The most common form of congenital adrenal: ^! `" M" [: i" E/ ]: P
hyperplasia is the 21-hydroxylase enzyme deficiency.
6 B" j c5 P& l" I! D1 ^9 ~3 sThe 11-β hydroxylase deficiency may also result in0 e3 s! H0 ^* Z2 v1 b" \ |
excessive adrenal androgen production, and rarely,. y* I% S2 x" G6 \
an adrenal tumor may also cause adrenal androgen
7 C' W; Y) B/ ^: j/ x% A6 `. k1 ?) gexcess.1,3
8 e$ g6 {4 l2 b3 Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: G7 A$ V. z$ f2 v5 w: v4 `$ f5 g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 f+ r1 E" {' y8 l( Z! oA unique entity of male-limited gonadotropin-
# F7 M/ T7 E g" `, Y5 A* Nindependent precocious puberty, which is also known
, ^8 _% K8 _+ F$ g, B; I n$ Jas testotoxicosis, may cause precocious puberty at a
, j8 n. K/ g3 f, J9 bvery young age. The physical findings in these boys, _# t# g$ C& f1 S
with this disorder are full pubertal development,
i. I3 n- v' U& a& I& l2 Pincluding bilateral testicular growth, similar to boys
, ]2 Y; T% `5 dwith CPP. The gonadotropin levels in this disorder
+ F$ x8 t7 n: ~* @9 | p, Mare suppressed to prepubertal levels and do not show2 w! o- h& ~2 m! ?, h
pubertal response of gonadotropin after gonadotropin-1 p$ h3 r5 c9 b" l, a1 v. Y
releasing hormone stimulation. This is a sex-linked
{0 |9 G% ]; Y+ P6 _% R- L7 Vautosomal dominant disorder that affects only' B; f7 A) D" K4 x
males; therefore, other male members of the family
- A$ H: g' n6 c$ J4 u% o: V2 jmay have similar precocious puberty.3
+ p; ~4 w8 r/ s5 K1 v0 e0 U( B" H' c4 kIn our patient, physical examination was incon-% }4 s; K) `6 P/ }
sistent with true precocious puberty since his testi-
# |* Q9 `9 A" d( M+ Zcles were prepubertal in size. However, testotoxicosis
# f% M3 Q9 A" c/ D0 Y& ]was in the differential diagnosis because his father, ? I4 S7 R* k" M2 l
started puberty somewhat early, and occasionally,8 E/ S7 `- y: ^1 Y% t
testicular enlargement is not that evident in the
9 f+ U( Q6 l" ^* f" [) }beginning of this process.1 In the absence of a neg-
4 y9 K7 o, Q' \9 z8 k; ^ative initial history of androgen exposure, our
8 B$ i" L! P* j+ j3 Fbiggest concern was virilizing adrenal hyperplasia,8 [7 E+ d K+ ]* o) U- d7 K
either 21-hydroxylase deficiency or 11-β hydroxylase
* Y5 r! v' Z+ M, K( ^/ T! P. {deficiency. Those diagnoses were excluded by find-
( @( r* z6 d. V; b9 d/ ?- uing the normal level of adrenal steroids.
; N9 L- z0 Z% z wThe diagnosis of exogenous androgens was strongly* u9 o' P7 g: {
suspected in a follow-up visit after 4 months because a3 Q! v0 @: V
the physical examination revealed the complete disap-/ }! m0 }( V+ W2 r$ A
pearance of pubic hair, normal growth velocity, and
+ u2 l6 c5 K O4 Z0 g3 P. B% c) h2 rdecreased erections. The father admitted using a testos-# ]5 |4 ?; D9 u2 }
terone gel, which he concealed at first visit. He was8 j- N- d; }$ B0 j7 M( u
using it rather frequently, twice a day. The Physicians’) A8 e! W$ [" J2 h A. {
Desk Reference, or package insert of this product, gel or2 H/ ~8 L6 \2 H& a9 F
cream, cautions about dermal testosterone transfer to, [; r$ {+ l/ K$ Y6 p7 o a
unprotected females through direct skin exposure.3 i& d8 b. L9 D8 N& q
Serum testosterone level was found to be 2 times the
8 o$ J, _2 `. w8 |! c }$ K% j" _baseline value in those females who were exposed to
4 n" T _* e9 seven 15 minutes of direct skin contact with their male6 G4 h5 P6 M/ D' k& [( g3 p
partners.6 However, when a shirt covered the applica-$ ?3 G" ?1 V% _0 b, O! |7 ^& E4 Y' ?
tion site, this testosterone transfer was prevented.
2 G/ h; z) G0 e, A, POur patient’s testosterone level was 60 ng/mL,
+ j+ z6 L& B) |) o; p$ Hwhich was clearly high. Some studies suggest that: [5 C0 P: Q; D, w
dermal conversion of testosterone to dihydrotestos-) e" }6 k2 f3 z
terone, which is a more potent metabolite, is more
- t. B4 g% O2 X+ h! Tactive in young children exposed to testosterone
8 ^+ c9 D" ~, E" p6 f: F/ p6 |exogenously7; however, we did not measure a dihy-' `' T+ z5 o* j. G2 |" J# G8 S. d
drotestosterone level in our patient. In addition to+ e+ D# R6 C5 U- h. ^& `
virilization, exposure to exogenous testosterone in
5 J5 R# J7 v5 T# Xchildren results in an increase in growth velocity and
) l' J( A+ u$ A. E' F; _6 Nadvanced bone age, as seen in our patient.
) w, |5 i: A* Y- F& o5 E. pThe long-term effect of androgen exposure during0 ^7 c3 U A$ h- |/ t$ o% V+ T& c
early childhood on pubertal development and final: G; G p8 n: V( \$ t7 N4 z
adult height are not fully known and always remain
- ]1 c, \" a* ]+ Sa concern. Children treated with short-term testos-
/ Z6 p5 ?9 s6 P* _% i8 v: sterone injection or topical androgen may exhibit some
% `- t) N+ K3 j) @acceleration of the skeletal maturation; however, after+ I$ A+ C8 ^. d
cessation of treatment, the rate of bone maturation" `, k/ K) a' ^
decelerates and gradually returns to normal.8,9
3 m- @8 M0 G: g! L& r: `& T! @. y# G: vThere are conflicting reports and controversy- e8 J" g* H+ K7 |, |
over the effect of early androgen exposure on adult
. I/ M1 M6 H [; I: ^* a' fpenile length.10,11 Some reports suggest subnormal
$ O1 d, ~6 `/ P" xadult penile length, apparently because of downreg-
/ k# S4 l% e9 _2 C6 S7 h+ Gulation of androgen receptor number.10,12 However,
! f! |- u t" X4 WSutherland et al13 did not find a correlation between
. K/ c6 o9 y. nchildhood testosterone exposure and reduced adult, K/ ]9 h( ?" |* g5 A! C
penile length in clinical studies.
/ g6 z% ^/ H1 F2 B6 N/ _- W/ C: ?Nonetheless, we do not believe our patient is; @, {% ~6 J6 C; O/ @
going to experience any of the untoward effects from0 P- A1 j9 [, Y, V
testosterone exposure as mentioned earlier because$ \. F1 q6 G/ g2 R+ ^9 F
the exposure was not for a prolonged period of time.8 n- _- m4 N7 A# i# I) O) C/ ~* A
Although the bone age was advanced at the time of
4 r& u2 r5 L3 m0 S; h" ^diagnosis, the child had a normal growth velocity at
/ I |" ~! b1 @1 ^! E. wthe follow-up visit. It is hoped that his final adult5 b) R# o" d* Q" A2 h
height will not be affected.: R4 A4 N, G; {, ]8 K6 F- @
Although rarely reported, the widespread avail-
- M0 I& X2 a% d: q& jability of androgen products in our society may
) ]/ r: G+ _! S/ p% h$ i$ L l2 n+ lindeed cause more virilization in male or female3 W- W1 q: W( j; X; F9 w- C
children than one would realize. Exposure to andro-* ^7 J/ ?$ ^- v9 f+ a3 F
gen products must be considered and specific ques-
# d9 {" }/ i0 D- u$ }* u0 wtioning about the use of a testosterone product or! y+ |9 W+ @1 [9 q6 C1 T
gel should be asked of the family members during; }# I6 M/ n" z1 ~
the evaluation of any children who present with vir-
1 \3 H' W+ x( eilization or peripheral precocious puberty. The diag-
& U+ g+ P. k: Rnosis can be established by just a few tests and by
9 P# u F7 U; T, E/ }9 Tappropriate history. The inability to obtain such a; n$ z# u" F" ~; S" K# m
history, or failure to ask the specific questions, may- Q9 Q; q; a: B7 |# w
result in extensive, unnecessary, and expensive, n: a2 [0 k! Y _+ [0 k/ ~
investigation. The primary care physician should be' r2 }% n7 t1 ?/ X3 v! i: e
aware of this fact, because most of these children |# R: ^( x$ w. u
may initially present in their practice. The Physicians’
! d" k5 B" ^$ O" ^: {% s1 f' x" Q% v8 |Desk Reference and package insert should also put a
* {1 B, H, O$ \, iwarning about the virilizing effect on a male or% e6 [# a% }$ T% y- ?9 \1 x
female child who might come in contact with some-
: C! i% p- Q3 lone using any of these products./ E# n, M1 L L" ]/ V
References# ~, S' r" Q: h! r% m1 B: B+ ]
1. Styne DM. The testes: disorder of sexual differentiation
; S2 z3 {: d6 ]3 u) E% Tand puberty in the male. In: Sperling MA, ed. Pediatric
0 P* i1 p: W- o4 hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 B% E) \+ |! |, p
2002: 565-628.
& y/ I6 M: p% B- b; k( D* N$ C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- ]' y7 ?9 X7 d, t$ u
puberty in children with tumours of the suprasellar pineal |
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