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Sexual Precocity in a 16-Month-Old
( a$ | V3 x- O( b+ {Boy Induced by Indirect Topical
7 G0 G2 M5 C9 T6 X- oExposure to Testosterone
$ l# e2 J8 {: r* cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" G9 D0 @1 U8 d4 b8 Z: P2 u
and Kenneth R. Rettig, MD1
1 w G$ M6 Y6 C3 QClinical Pediatrics
# j6 k0 v- n1 DVolume 46 Number 6; R) Q. O2 ]% v3 o# g
July 2007 540-5439 q2 X& `( i2 s1 o
© 2007 Sage Publications& G0 g& k _- d c! \2 s
10.1177/0009922806296651
4 j4 D3 m( ], lhttp://clp.sagepub.com
/ x4 V4 l5 H8 ?, S9 n4 ~2 Ahosted at0 C X! s: q) j% r3 X1 I
http://online.sagepub.com
+ y0 E9 j9 s+ V) ^* E9 RPrecocious puberty in boys, central or peripheral,
& x4 E! [, W# m9 t6 n; `is a significant concern for physicians. Central* h# E% g& V8 P1 M1 T5 R9 C. K2 a- i
precocious puberty (CPP), which is mediated
5 B. F m: p% ]7 V4 |through the hypothalamic pituitary gonadal axis, has
) x& P& w$ A) ^a higher incidence of organic central nervous system
- v8 P1 f: W1 n% M+ F1 r7 olesions in boys.1,2 Virilization in boys, as manifested6 v+ R4 n0 @6 u0 l$ j
by enlargement of the penis, development of pubic" ]3 s- B% [5 f" k" ]" t% G
hair, and facial acne without enlargement of testi-
2 m% l0 h1 Z3 m6 scles, suggests peripheral or pseudopuberty.1-3 We
* c% R6 V' J7 \6 `report a 16-month-old boy who presented with the( v; B d- K, A# b# E1 G; H$ h
enlargement of the phallus and pubic hair develop-
' k) D% }3 @) h' P, ~ment without testicular enlargement, which was due6 |4 t1 K! Y$ D2 o; Q# b
to the unintentional exposure to androgen gel used by( ^/ M2 R/ r3 e$ |2 ~
the father. The family initially concealed this infor-
. E( N0 H4 H/ W; \, ^mation, resulting in an extensive work-up for this1 ^" ~; L- E; G ~
child. Given the widespread and easy availability of8 ^/ h/ ?& G4 Y$ A( i) J3 W& q
testosterone gel and cream, we believe this is proba-
- s8 S2 R, w) H) [7 k% J" Cbly more common than the rare case report in the
8 m; T0 {* F' Z+ W$ `; @, U6 Mliterature.4
3 V& a' f7 t- ?3 b8 `% @. u/ uPatient Report1 a* \- s; |9 c1 S) [* v
A 16-month-old white child was referred to the2 D2 T" V7 x9 N" r1 F( ^7 C }8 e: O
endocrine clinic by his pediatrician with the concern* t# V1 R9 x& z. L9 M' R9 B
of early sexual development. His mother noticed
. ?7 o; i, F& h* P) Klight colored pubic hair development when he was7 Q2 u% h: H1 O, v2 V
From the 1Division of Pediatric Endocrinology, 2University of5 Z) S" V' ~8 E( T/ ^+ |: M' J/ v
South Alabama Medical Center, Mobile, Alabama.
- y# z6 ^- W$ kAddress correspondence to: Samar K. Bhowmick, MD, FACE,
Z. a+ d |2 R4 g; MProfessor of Pediatrics, University of South Alabama, College of
& {2 g4 U) H5 e( a- ^( d& VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 C! A5 c" \! t! |$ ee-mail: [email protected].
1 r$ ]4 e3 H2 u; @! l7 sabout 6 to 7 months old, which progressively became' I, `. p: D$ R8 M' h9 ]! L) J- V
darker. She was also concerned about the enlarge-
. K0 [9 O; @3 H4 N% l3 lment of his penis and frequent erections. The child' Z$ ^( C( m) M3 P
was the product of a full-term normal delivery, with
3 ^! B- s7 X9 |# I8 e( O0 ia birth weight of 7 lb 14 oz, and birth length of: W5 O, ^7 Q* g6 l7 t/ V2 _
20 inches. He was breast-fed throughout the first year
' T# @4 r) f" { `$ S% tof life and was still receiving breast milk along with
' ]3 M+ j) A8 ]9 Rsolid food. He had no hospitalizations or surgery,- y/ Q4 z0 ]' e) c6 M3 Q' ]8 q
and his psychosocial and psychomotor development
. ~6 P# \9 T6 L2 p/ h/ wwas age appropriate.2 [7 O/ G/ a3 H+ E! u( B) Q
The family history was remarkable for the father,% o1 B3 c1 T4 S# \" s6 M
who was diagnosed with hypothyroidism at age 16,
" m+ }7 C7 j4 `% Twhich was treated with thyroxine. The father’s
3 {. _ ~8 B P. \height was 6 feet, and he went through a somewhat; m+ ~& \7 ?! |- F2 Z5 ?
early puberty and had stopped growing by age 14.
) l6 _/ C! J9 O1 {/ U7 W) YThe father denied taking any other medication. The a# z% H" X' c7 a4 n9 y
child’s mother was in good health. Her menarche; L8 r+ A `% c
was at 11 years of age, and her height was at 5 feet% v' S3 s, B9 E: s' X6 V. c2 v
5 inches. There was no other family history of pre-' z' L# x6 X. S4 e
cocious sexual development in the first-degree rela-
# Y/ I/ f" D/ G9 C0 s% ]$ J+ ?tives. There were no siblings.
% N" H" x0 |' \5 T) p; n8 o8 RPhysical Examination
. u4 Q$ d. D! w9 \6 T0 H" ~/ zThe physical examination revealed a very active,# n1 P( ~0 u0 |( H9 f& c+ n
playful, and healthy boy. The vital signs documented
0 o4 k' w4 ^. J# `a blood pressure of 85/50 mm Hg, his length was& _5 L( C1 L! Y" U
90 cm (>97th percentile), and his weight was 14.4 kg$ \+ W s0 a' r5 z# \, c
(also >97th percentile). The observed yearly growth3 K/ b9 {. W. f1 _5 \2 y
velocity was 30 cm (12 inches). The examination of6 p# s; X" G, w/ x# ?
the neck revealed no thyroid enlargement.0 r5 B' B1 w/ i6 S7 R3 x2 d7 V6 _) B
The genitourinary examination was remarkable for
. H; B5 d+ O- S2 @3 T0 X9 ]* }- [enlargement of the penis, with a stretched length of
. A* l& ^% n& O0 _; R3 ]8 cm and a width of 2 cm. The glans penis was very well% s/ J8 a& y0 Z: E# Y5 ?. R2 M7 f
developed. The pubic hair was Tanner II, mostly around
# [+ V0 Z. I1 d i. F% o540
- ]& B" M! Y# O- t/ }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 j. ]7 S0 G& F" y6 n- S5 e5 zthe base of the phallus and was dark and curled. The5 u; q" v# `9 k3 i# n$ c4 \( r7 C
testicular volume was prepubertal at 2 mL each.
1 j2 n4 I- U6 A) ^' ]7 qThe skin was moist and smooth and somewhat
, k. ^" w" f' x. ]1 ^4 {( Yoily. No axillary hair was noted. There were no
# L2 v5 R1 b9 |1 a3 q% xabnormal skin pigmentations or café-au-lait spots.$ Q% \" l& E# ?, ?$ u
Neurologic evaluation showed deep tendon reflex 2+! I! W) m2 L+ I, S
bilateral and symmetrical. There was no suggestion
% x1 {2 m1 q" Eof papilledema.4 L6 l( z8 s: v" H1 {% \! n9 A
Laboratory Evaluation3 p, H* A2 `7 f% @. S
The bone age was consistent with 28 months by
. A1 u0 ]8 c$ h2 J8 C! C1 gusing the standard of Greulich and Pyle at a chrono-/ K+ j4 p/ \; i8 _# Q1 u5 O. O
logic age of 16 months (advanced).5 Chromosomal4 o+ z/ v1 e% r+ Y2 T% A! K
karyotype was 46XY. The thyroid function test
2 [8 t* v: d+ V: w, rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
" y$ m$ e$ J+ zlating hormone level was 1.3 µIU/mL (both normal).
$ ~2 B+ Z: @2 Z7 ^The concentrations of serum electrolytes, blood
3 e$ H: I9 R+ N+ S/ j% Zurea nitrogen, creatinine, and calcium all were
# @0 E; l; ?8 n& Y" Jwithin normal range for his age. The concentration
: y6 ~2 d; W/ v, v: qof serum 17-hydroxyprogesterone was 16 ng/dL
/ U1 i/ R1 G" }5 z4 g0 W2 `(normal, 3 to 90 ng/dL), androstenedione was 20
9 p5 j1 N6 d* U3 j- v8 i; cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 g) S! ^6 _ V" O) b0 t4 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ v! k5 u- B X5 [8 e3 u8 g6 K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! h/ Q$ S( H5 N. b1 c49ng/dL), 11-desoxycortisol (specific compound S)" Z' z$ @* v3 \! \( L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 r/ p1 T9 Q& z8 y8 d" p& c6 xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 N2 b- w6 z- |/ j, [9 ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* r6 z- n; `# J$ G: g+ ?and β-human chorionic gonadotropin was less than
1 Q; R/ T0 ^% B: I, T5 mIU/mL (normal <5 mIU/mL). Serum follicular
" ]4 X4 O7 k3 v6 z) jstimulating hormone and leuteinizing hormone
0 i7 n6 F& u, M( X& Q( |concentrations were less than 0.05 mIU/mL: n8 ]$ v( y$ q4 r$ m% R$ t
(prepubertal).
0 V% j0 B( u! P& BThe parents were notified about the laboratory
# Z) N. i3 ^) Y& O. u7 y4 Cresults and were informed that all of the tests were
3 f; } D p( }' v' Y! j8 fnormal except the testosterone level was high. The7 c7 o, r/ H) Q: H2 ?
follow-up visit was arranged within a few weeks to
- E$ o" \3 M% f" n7 tobtain testicular and abdominal sonograms; how-
" H. W$ }& G F5 L7 j% F* L8 Gever, the family did not return for 4 months.
! ]. a% F; H% }$ jPhysical examination at this time revealed that the
8 R+ c+ \) H6 \+ Uchild had grown 2.5 cm in 4 months and had gained
9 b' s. `* {1 n3 i1 e2 kg of weight. Physical examination remained! w' W" c. R; K5 ^# L% C( E7 a
unchanged. Surprisingly, the pubic hair almost com-4 T, z. \2 Y V9 v F6 F2 u0 x
pletely disappeared except for a few vellous hairs at
/ p2 E/ W; P( @* q' k$ kthe base of the phallus. Testicular volume was still 2
1 B& s2 l+ E7 i' J+ Y5 nmL, and the size of the penis remained unchanged.0 ?4 C3 [# A/ j3 @
The mother also said that the boy was no longer hav-( O7 o' l) C7 i
ing frequent erections.
; p4 |3 {, m5 b. aBoth parents were again questioned about use of2 _: z( [- e8 x+ S
any ointment/creams that they may have applied to
! s9 T9 d y) Q( A! k* f; Vthe child’s skin. This time the father admitted the+ q/ ~4 Z1 J& j" {+ d6 y4 L
Topical Testosterone Exposure / Bhowmick et al 541
1 l& g! h* u/ m8 xuse of testosterone gel twice daily that he was apply-$ z0 I% k8 ]1 K, v" K
ing over his own shoulders, chest, and back area for
/ i. V( S9 }& Ea year. The father also revealed he was embarrassed0 u, Y' E- k% A5 u. ]
to disclose that he was using a testosterone gel pre-/ }" `+ C+ I/ f* d+ R3 {
scribed by his family physician for decreased libido& S' @) y8 H$ M7 k
secondary to depression.3 J" d, s- s2 q6 e K. z4 O
The child slept in the same bed with parents.6 Q# N! M1 s9 | j
The father would hug the baby and hold him on his% h- A5 u# I6 t- w3 Q
chest for a considerable period of time, causing sig-! C- @7 a! q" o9 x# I6 L, |
nificant bare skin contact between baby and father.% y2 C5 |7 e* p. T
The father also admitted that after the phone call,
' c/ {$ j9 P- o2 h% s( r" Fwhen he learned the testosterone level in the baby8 r5 s, _) v4 f$ d. X; S' Y
was high, he then read the product information+ R. D7 M1 a) n: @4 ]# d, A. @
packet and concluded that it was most likely the rea-
7 b) ~0 v2 A: Q1 bson for the child’s virilization. At that time, they
7 i' l, G/ a7 }: pdecided to put the baby in a separate bed, and the
o- n, R' Q6 c' B a' c- Cfather was not hugging him with bare skin and had
' P2 I9 O" f Q6 T4 Ubeen using protective clothing. A repeat testosterone: W9 f2 d, X8 r
test was ordered, but the family did not go to the
7 _5 e7 U9 b& q/ C* P0 ^laboratory to obtain the test.
( ?: U, h0 [9 R+ L( c1 \3 q' KDiscussion% [) O5 j& w) K) q& ^- {' H4 B% o
Precocious puberty in boys is defined as secondary
* }; B2 @2 a) ^' I3 I; U# x0 p$ a9 [4 F) ]sexual development before 9 years of age.1,46 O5 _/ t8 s+ d; n8 V- H. b: P
Precocious puberty is termed as central (true) when
' F4 t9 u0 [+ O5 Vit is caused by the premature activation of hypo-6 i( w/ h% D/ Y. u/ N
thalamic pituitary gonadal axis. CPP is more com-
* L" Y3 j9 a% P7 [mon in girls than in boys.1,3 Most boys with CPP
: V3 l( @$ E7 r% D# f" vmay have a central nervous system lesion that is
: x6 ~# ?7 t! V7 Presponsible for the early activation of the hypothal-* V7 }# R- i( p7 d9 A6 f* G
amic pituitary gonadal axis.1-3 Thus, greater empha-" E, {$ w% k6 E3 E$ n' m. V2 V+ {
sis has been given to neuroradiologic imaging in0 J8 b c" D( {3 D9 k
boys with precocious puberty. In addition to viril-
0 Z0 F% t( ?+ |% Y5 r0 Vization, the clinical hallmark of CPP is the symmet-* r6 z' _/ E \$ g; m, j) a9 H
rical testicular growth secondary to stimulation by
: M% x' o8 t S, @6 p0 {, Igonadotropins.1,3
$ h* f" G* d5 {# O; J$ u+ N* pGonadotropin-independent peripheral preco-; e9 j1 w! n4 l4 N: h+ _
cious puberty in boys also results from inappropriate
. L: b( c( \0 `+ b! d8 c6 K3 Pandrogenic stimulation from either endogenous or9 G! R. b, W8 L
exogenous sources, nonpituitary gonadotropin stim-* k# T4 P' r6 e, d
ulation, and rare activating mutations.3 Virilizing
* m$ F8 \- i- d# {congenital adrenal hyperplasia producing excessive
# n @) \7 W& M0 C2 r/ Kadrenal androgens is a common cause of precocious; u2 M6 w: c" O( L- B# p; K5 y& v
puberty in boys.3,4
Q, R* z* c) K, r. yThe most common form of congenital adrenal
# ~4 g6 Z7 p( j4 l, n1 u6 p1 x2 Jhyperplasia is the 21-hydroxylase enzyme deficiency./ o+ M" `3 g: A) |; _! [+ h( Z
The 11-β hydroxylase deficiency may also result in
* I8 j" ?4 g" g& T1 ]! I% f+ k; gexcessive adrenal androgen production, and rarely,
/ h" z+ M; w' j6 Xan adrenal tumor may also cause adrenal androgen
: [- o7 m- O, Wexcess.1,3; h% w$ v1 B/ I. @; _1 q# G) l9 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% `1 q7 T, j/ d' X542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& V1 p+ m- x5 d5 O" ~# A' y7 UA unique entity of male-limited gonadotropin-
4 i* s3 H$ |5 j7 F4 P; q* uindependent precocious puberty, which is also known5 E8 G0 u* K2 M/ }7 l
as testotoxicosis, may cause precocious puberty at a7 }# P9 K) O( l; a! b Q& ?" {7 {
very young age. The physical findings in these boys* |. y9 b' q3 ^/ ~/ z: w, @7 H
with this disorder are full pubertal development,- ?/ y" M; X4 e- E+ C. {
including bilateral testicular growth, similar to boys
, k+ {7 \/ t& T& Hwith CPP. The gonadotropin levels in this disorder; L" f. t! O) w3 x* D& R
are suppressed to prepubertal levels and do not show& V2 k5 G# z8 H" y, v
pubertal response of gonadotropin after gonadotropin-
$ V2 r& E9 d0 s5 Oreleasing hormone stimulation. This is a sex-linked9 l% W9 C X% _5 C+ d
autosomal dominant disorder that affects only
7 [) ]0 i3 J8 f( L5 I* o6 }' omales; therefore, other male members of the family; j0 Q* T0 N) z2 F5 ?. S+ g
may have similar precocious puberty.3/ Q/ i5 m# n, x8 @
In our patient, physical examination was incon-" H. S$ {+ N4 e2 P. f9 K) G' w
sistent with true precocious puberty since his testi-
9 f7 k( ?* B ~$ Vcles were prepubertal in size. However, testotoxicosis" ?$ ^7 P, w3 |+ I$ I
was in the differential diagnosis because his father) a1 c5 M$ S6 s6 c5 w1 p) A
started puberty somewhat early, and occasionally,: W, X$ X, n7 _4 q
testicular enlargement is not that evident in the
F* u" N2 B1 w, ibeginning of this process.1 In the absence of a neg-
) ]# r( U0 N" p8 o6 x; Yative initial history of androgen exposure, our W$ L9 L1 O0 e; m
biggest concern was virilizing adrenal hyperplasia,9 i; a6 {. O: ~1 B, c5 k4 x
either 21-hydroxylase deficiency or 11-β hydroxylase) s& _1 J7 X: g& P
deficiency. Those diagnoses were excluded by find-' O* G# \( x, C. i3 @" u5 H
ing the normal level of adrenal steroids.5 a z7 N' [2 b1 [! |9 Q
The diagnosis of exogenous androgens was strongly
7 G+ B' \+ i, n) m4 d1 N, Gsuspected in a follow-up visit after 4 months because
; o" ]7 G( ?% y2 Nthe physical examination revealed the complete disap-
7 e6 k2 J9 [3 [# _pearance of pubic hair, normal growth velocity, and
! t, Z/ B; B9 W) Hdecreased erections. The father admitted using a testos-
v' A. O6 ]/ G3 W# e) m( ] {terone gel, which he concealed at first visit. He was
& V5 |# A5 W) }$ V* f1 C4 F* vusing it rather frequently, twice a day. The Physicians’% \, d5 P; F2 u+ p2 k
Desk Reference, or package insert of this product, gel or
. r" v; Z P! Bcream, cautions about dermal testosterone transfer to" r, X' n1 y* }6 [" t$ a: r! C5 f
unprotected females through direct skin exposure.
' ?% |$ a8 E7 [+ K& F( ^1 oSerum testosterone level was found to be 2 times the2 d' X, {! }, C, u' ^
baseline value in those females who were exposed to
2 q& L3 C. u) b' `5 f; Geven 15 minutes of direct skin contact with their male
& n. @& L8 t4 L5 h7 n" ~1 `partners.6 However, when a shirt covered the applica-5 `1 x! E+ Q: W) ?3 V& ~; u
tion site, this testosterone transfer was prevented.
- F6 b R* }9 k, w0 x: JOur patient’s testosterone level was 60 ng/mL,
# {5 l- ]2 i/ ?& _3 e9 l ?which was clearly high. Some studies suggest that2 u t1 h3 R" s5 h) g5 m% z
dermal conversion of testosterone to dihydrotestos-( e7 R, I5 U7 |; `) }# p
terone, which is a more potent metabolite, is more
, _4 W* W1 N4 u, R- E! Wactive in young children exposed to testosterone% W+ H# k8 ~: v9 v5 j
exogenously7; however, we did not measure a dihy-$ `1 B9 x3 a" U, u
drotestosterone level in our patient. In addition to
8 Q7 K _) ^" a7 t+ p' O; |virilization, exposure to exogenous testosterone in. E" c. b }0 k9 J
children results in an increase in growth velocity and1 \/ K6 o& T- P; m% C4 l
advanced bone age, as seen in our patient.
% ^, F0 u4 F. F J4 tThe long-term effect of androgen exposure during
$ o5 C9 [0 Q+ `1 w0 I. ^8 W) pearly childhood on pubertal development and final$ I2 Z* @3 M8 L& f4 Q
adult height are not fully known and always remain
- _8 S4 B9 {+ G) k { \a concern. Children treated with short-term testos-& ?% u z4 r# Y4 r
terone injection or topical androgen may exhibit some8 R: A9 k B) A; X
acceleration of the skeletal maturation; however, after
$ n# T, S: }0 N1 l7 S8 E- Zcessation of treatment, the rate of bone maturation
* G9 ^* \2 U; f/ r$ ddecelerates and gradually returns to normal.8,9
: h+ n" x" L. w7 k; mThere are conflicting reports and controversy
9 g0 ]/ K5 v5 D& e- U n* Nover the effect of early androgen exposure on adult
8 I" T& e# B4 ypenile length.10,11 Some reports suggest subnormal
- |! X' {* i6 aadult penile length, apparently because of downreg-
_/ d2 s. O! b' ?1 H8 p7 w# Julation of androgen receptor number.10,12 However,
* U8 w( _0 `; g! JSutherland et al13 did not find a correlation between
# A* o0 }# `0 d3 Lchildhood testosterone exposure and reduced adult
: v" X5 E# T, s2 Z Y) ?$ f# Npenile length in clinical studies.
3 W6 c9 C0 g: {& W7 [Nonetheless, we do not believe our patient is7 K& s# F, u( ~5 ~7 w" m- G2 P
going to experience any of the untoward effects from
; {$ H, @; @1 O# i4 F( gtestosterone exposure as mentioned earlier because, V, Q6 a2 F( j
the exposure was not for a prolonged period of time.
7 d& A% B6 r) s8 m8 c% [Although the bone age was advanced at the time of/ i/ C! \7 M% l4 L$ d4 U
diagnosis, the child had a normal growth velocity at
, r( d+ U' Z0 ?) ], a7 y) Wthe follow-up visit. It is hoped that his final adult6 l2 d* J( c5 X' {
height will not be affected.
- Q) j. W( q! X$ c* \Although rarely reported, the widespread avail-
( p* }7 v# T1 z7 _1 u: V2 fability of androgen products in our society may0 }% I8 X' H! d9 }& n8 q& r) l
indeed cause more virilization in male or female. R; y0 j2 d% [3 t! u) j$ R
children than one would realize. Exposure to andro-7 A' C4 M' o: a% B: ~% h
gen products must be considered and specific ques-9 v4 G% Q- o- J
tioning about the use of a testosterone product or
4 X' Q" k) Y6 m/ A( Egel should be asked of the family members during# o2 m6 ?1 s2 R N M* C M! @
the evaluation of any children who present with vir-9 {! Q W1 w0 U/ Y
ilization or peripheral precocious puberty. The diag- }* m2 r- t8 w5 Q3 z
nosis can be established by just a few tests and by9 G$ A+ C3 C. F1 Q
appropriate history. The inability to obtain such a
' Y& c7 C: u) `9 q3 ^) zhistory, or failure to ask the specific questions, may
0 Q* T5 c5 X6 u$ ~result in extensive, unnecessary, and expensive
) A0 Z! e. `$ t' ~! A' F3 Hinvestigation. The primary care physician should be
9 L7 P/ C3 U7 \* q* u8 L" o1 e' v( Paware of this fact, because most of these children
0 b# z, \) m* k0 P) omay initially present in their practice. The Physicians’2 a7 `; y% Z! n" R9 ]8 k
Desk Reference and package insert should also put a- h% F% e6 C4 c
warning about the virilizing effect on a male or
& x7 l. R l8 f$ Lfemale child who might come in contact with some-
4 L# `! d* v- Fone using any of these products.
1 |! M& M8 X& {, r" U; X1 t4 EReferences+ r0 T6 h" l# T! R4 t7 Q7 C
1. Styne DM. The testes: disorder of sexual differentiation& T! T7 c- U- s
and puberty in the male. In: Sperling MA, ed. Pediatric* L% u: O2 b' @* U5 B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" V. Y2 h" u( ?" M& H4 W1 o1 d/ W6 N
2002: 565-628.+ H2 A" g* \ S9 \
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 F6 K9 Q! ~( i. F, apuberty in children with tumours of the suprasellar pineal |
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