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Sexual Precocity in a 16-Month-Old. z n" ^% u4 J( p7 x/ V
Boy Induced by Indirect Topical
0 a( ~& n Q' S1 W3 j k% T) s! f( fExposure to Testosterone9 L/ H0 K1 a- I4 ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ y/ o6 f: f) b C: O- s
and Kenneth R. Rettig, MD1
$ A d$ a; t# w5 J% u' NClinical Pediatrics
- A1 h- O: q+ H2 h2 VVolume 46 Number 6
8 z0 Z* W' s+ R! B# W* uJuly 2007 540-543
# V! g: S C6 ~© 2007 Sage Publications
# `" |3 Z1 {5 D10.1177/0009922806296651
. c! A9 y5 k+ j/ j5 z/ Zhttp://clp.sagepub.com
( [ W* l+ g6 ?5 qhosted at/ [+ r ~! n8 |
http://online.sagepub.com
9 q4 e% p) d" I6 B+ {( r& rPrecocious puberty in boys, central or peripheral,1 {9 m$ o5 V0 X1 C3 C' i
is a significant concern for physicians. Central& a3 y7 V- x9 G/ h
precocious puberty (CPP), which is mediated8 ]( U" ]/ A$ ?$ b7 C
through the hypothalamic pituitary gonadal axis, has: A! U# V6 z0 n, f+ B- |0 x6 D
a higher incidence of organic central nervous system7 G( Y6 l6 q& L) A2 F/ ~; a
lesions in boys.1,2 Virilization in boys, as manifested% @& Z! _7 F) I, s( i: R" c5 r* q- P
by enlargement of the penis, development of pubic% G$ ?5 i' ~7 R+ u7 r( S
hair, and facial acne without enlargement of testi-
1 g/ m1 ?1 L( n3 z; Lcles, suggests peripheral or pseudopuberty.1-3 We
6 X7 ]; B% M! P3 ?5 Creport a 16-month-old boy who presented with the( {+ j0 E$ t+ J! u s; Y2 L
enlargement of the phallus and pubic hair develop-' F3 J0 c" Q% E; v: q+ X
ment without testicular enlargement, which was due
# @- \/ H `3 U+ P' b$ C9 Qto the unintentional exposure to androgen gel used by
9 v( l7 L. t$ L* zthe father. The family initially concealed this infor-) M5 {/ y5 G2 j | F
mation, resulting in an extensive work-up for this4 _) S! D; U7 o, a! p6 @
child. Given the widespread and easy availability of
: H5 o7 c- l) _testosterone gel and cream, we believe this is proba-
) U, b9 w0 K: P3 u% U. fbly more common than the rare case report in the
" A9 ]7 E+ e5 `4 ^" B2 ^' Xliterature.4. O! _" ]: p0 n4 I& i" S! S$ f7 w2 g
Patient Report7 x8 J" d3 \- ?/ q" W
A 16-month-old white child was referred to the# w; `8 n" `% ~" @
endocrine clinic by his pediatrician with the concern1 P9 a& u, R ?: A; B0 u6 \
of early sexual development. His mother noticed) e6 @1 W- N" l1 A6 L
light colored pubic hair development when he was
1 p5 Q: c- _; q' \7 Z, @; oFrom the 1Division of Pediatric Endocrinology, 2University of
2 t: C8 I4 `8 v P0 MSouth Alabama Medical Center, Mobile, Alabama.
& P/ K7 Z! u# @5 `% |2 G+ NAddress correspondence to: Samar K. Bhowmick, MD, FACE,! D4 w; ]4 C9 f# y, x- p3 \5 C9 _
Professor of Pediatrics, University of South Alabama, College of/ P+ W& L/ L, A- C; p2 i3 U/ r( w% F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" F3 Z* x+ j" X8 ^% _) |3 f9 `& ^
e-mail: [email protected].
V( _. p+ Z% I9 _$ ?6 a# Aabout 6 to 7 months old, which progressively became
/ y, N( |2 K( odarker. She was also concerned about the enlarge-9 p5 n2 r1 i* E. i
ment of his penis and frequent erections. The child
; g$ m+ S) q! m) g2 J, R. dwas the product of a full-term normal delivery, with+ K7 w9 _6 R4 }% a# R
a birth weight of 7 lb 14 oz, and birth length of/ W7 o8 B& o0 N- q8 x* i! u# P
20 inches. He was breast-fed throughout the first year7 }" D Z& \, a/ @6 b
of life and was still receiving breast milk along with
! [4 N. N' y. Q: j/ w5 M; ysolid food. He had no hospitalizations or surgery,
' e8 \5 S$ `1 sand his psychosocial and psychomotor development
; M# d, ?0 [ F" uwas age appropriate.
0 V2 [& V1 O5 }! X* P( pThe family history was remarkable for the father,
* k' O7 }2 {7 w7 E2 ~; twho was diagnosed with hypothyroidism at age 16,
1 j. g8 c |6 y# S8 S* k, Cwhich was treated with thyroxine. The father’s
, P8 z7 C5 z0 q! {) Nheight was 6 feet, and he went through a somewhat
; ], y1 D" z* Nearly puberty and had stopped growing by age 14.) w$ M5 H0 P1 i% ]+ h, y
The father denied taking any other medication. The
: M* T6 z. f2 ]( V! D) j N; Xchild’s mother was in good health. Her menarche
9 ~5 v1 L+ S- X) ^ B- y, Gwas at 11 years of age, and her height was at 5 feet9 [* P. A* F4 U" `7 v
5 inches. There was no other family history of pre-
0 p' b# A7 I1 {2 @ b* Q4 D" J# J$ Fcocious sexual development in the first-degree rela-
7 c8 P5 P. \' Q( h5 |tives. There were no siblings.
% _: Y' ]+ A' J: x6 u# hPhysical Examination- J) ]1 j( p: u7 g6 v3 O# \$ M
The physical examination revealed a very active,
+ W0 z \% _- e5 L, fplayful, and healthy boy. The vital signs documented
- c* j# O& @& S5 Ma blood pressure of 85/50 mm Hg, his length was
) f1 T3 z- _: O- K* j7 z# R' V5 D3 {90 cm (>97th percentile), and his weight was 14.4 kg
# L6 O% V# m: ]) |! z' ?8 ](also >97th percentile). The observed yearly growth5 K) f$ `9 L6 `; b$ Z
velocity was 30 cm (12 inches). The examination of
f) I, B: `5 q& \) P: I. ~the neck revealed no thyroid enlargement.
- M* u/ V/ b: \$ yThe genitourinary examination was remarkable for! B. [0 u9 K- S9 Y* T) F4 a" i) W+ t
enlargement of the penis, with a stretched length of5 v$ u) G9 E- B& H/ C _# [
8 cm and a width of 2 cm. The glans penis was very well, T; i4 c V/ d+ D) A* e8 c& F
developed. The pubic hair was Tanner II, mostly around$ E7 M8 c9 Z5 c1 r/ N3 P
540) ^3 x4 P' U5 G v# ?' R' D! z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ]5 |. A/ V9 h
the base of the phallus and was dark and curled. The
, a/ Y8 j% {7 I& R1 ]7 G otesticular volume was prepubertal at 2 mL each.6 x, \0 h& ]) {) Z" r0 @
The skin was moist and smooth and somewhat* X% k0 w' J" t2 R' x
oily. No axillary hair was noted. There were no7 K" r7 h; Z! F: D5 v
abnormal skin pigmentations or café-au-lait spots.
5 |- X4 e' ?" d# N- d* k+ \Neurologic evaluation showed deep tendon reflex 2+; q% l" f- r% Z
bilateral and symmetrical. There was no suggestion
* D/ b( K( M4 Z% J8 sof papilledema.& K0 ]* d6 v# j9 r6 J6 ?$ m/ z
Laboratory Evaluation( X9 E5 C4 q7 G! t' e
The bone age was consistent with 28 months by
/ I% Z0 l1 _$ z3 fusing the standard of Greulich and Pyle at a chrono-* E$ ]7 D: h, z, v d
logic age of 16 months (advanced).5 Chromosomal
+ m0 E5 O8 Z+ N: L/ r: o$ [& xkaryotype was 46XY. The thyroid function test
, R X! G- z, _! f: H) P# e1 H6 Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 f- A- m/ G) _ G) ?( b2 y
lating hormone level was 1.3 µIU/mL (both normal).
& e8 k4 b. r9 k' t8 \; JThe concentrations of serum electrolytes, blood5 n, ^; e* M! x
urea nitrogen, creatinine, and calcium all were- O& s! N$ u) Y6 u
within normal range for his age. The concentration
2 V: C, e2 w5 P$ {5 ?! ~3 f7 xof serum 17-hydroxyprogesterone was 16 ng/dL
+ L6 l U# H. W n* s(normal, 3 to 90 ng/dL), androstenedione was 20
! i( W2 }4 R1 `7 H7 Z5 N2 F" i* @3 z2 kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% ?$ _% t3 U, x) t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) j* L+ J0 P. x: m& i! Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to( k, k: L! \5 j) v
49ng/dL), 11-desoxycortisol (specific compound S)0 ^& _0 S I. i. A" F( o( o s
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 E* ~) y* r' F4 ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* w+ M/ k! b5 S) `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: y% ^8 X+ j0 z3 _and β-human chorionic gonadotropin was less than
# l( G: \7 P _; S* u2 _3 K) `5 mIU/mL (normal <5 mIU/mL). Serum follicular/ {" e* \" @- }
stimulating hormone and leuteinizing hormone
& ]3 |5 m+ {, c! \" p( S- tconcentrations were less than 0.05 mIU/mL: k% m5 k& W1 _. O* S; k# F1 y5 r
(prepubertal).; q# z/ O% l- n: g
The parents were notified about the laboratory
* X( Y& i8 D E4 U/ S0 |results and were informed that all of the tests were& P# B: W; R7 H8 T2 z/ `
normal except the testosterone level was high. The- b2 D1 c, d2 [+ \$ H0 k9 _4 A
follow-up visit was arranged within a few weeks to
7 I9 m4 U! H* _+ V& R6 {4 {, }obtain testicular and abdominal sonograms; how-
* x" \; S3 f4 I0 T7 M2 q& e. v5 Q+ `) oever, the family did not return for 4 months.+ J% Y% V6 N7 p8 _3 F; ^6 D9 S
Physical examination at this time revealed that the
9 P5 M) e: P8 ~; V6 R- b% N* S8 jchild had grown 2.5 cm in 4 months and had gained3 }$ I6 ?1 e7 J! o( {" x" Z2 H( F
2 kg of weight. Physical examination remained
2 `/ s A' r1 r5 U1 P2 Aunchanged. Surprisingly, the pubic hair almost com-1 \) u& h; j6 v) O) `. I
pletely disappeared except for a few vellous hairs at& X8 I* W4 W* A
the base of the phallus. Testicular volume was still 2% l% _9 d6 b4 E" L* d
mL, and the size of the penis remained unchanged.
8 V% X, K/ N: a% x6 `3 V. B/ f$ K6 VThe mother also said that the boy was no longer hav-
& U/ }. L; s/ ]' aing frequent erections.. K$ n3 s/ f' w4 t
Both parents were again questioned about use of7 O; k( |# N& B" W! y
any ointment/creams that they may have applied to5 n2 B; A$ T' V3 u* p3 j1 T
the child’s skin. This time the father admitted the
* }# K# ]* V F4 W. E9 g; oTopical Testosterone Exposure / Bhowmick et al 541
5 j& t, ^9 k8 o: ]% e* G# yuse of testosterone gel twice daily that he was apply-7 J. e! `; v9 e4 z) u$ g" R' ]
ing over his own shoulders, chest, and back area for
( ]% T& `. u3 T; L" g* f" }a year. The father also revealed he was embarrassed& Q( Q. S( \% L- K$ g% J9 ^! y7 T
to disclose that he was using a testosterone gel pre-$ [# A u( [' v: h" h2 @) @
scribed by his family physician for decreased libido* S1 K; E$ l o3 A' E- d. M
secondary to depression.4 x7 e" ^3 ~- P' U1 D
The child slept in the same bed with parents.8 O) j7 n( W6 O6 Y5 @2 z u: e
The father would hug the baby and hold him on his
8 M& h% O W% Q; C1 r" uchest for a considerable period of time, causing sig-
( \7 s) Z3 P& z; v* D) T: U% ^nificant bare skin contact between baby and father.
- p) A b7 H' LThe father also admitted that after the phone call,. Q) g2 c' H R4 d
when he learned the testosterone level in the baby* v0 i3 n; }0 K2 t& |8 K
was high, he then read the product information( H7 P' H/ L/ e8 T9 b
packet and concluded that it was most likely the rea-# d, I9 V( D6 O2 z
son for the child’s virilization. At that time, they
2 L; S$ g' j6 [% Fdecided to put the baby in a separate bed, and the3 J1 j0 x5 x- R5 b) _6 V
father was not hugging him with bare skin and had. J5 S+ h# d7 F1 ?2 ^4 j q
been using protective clothing. A repeat testosterone
2 l9 O# U! b2 G! P. r8 q- T1 S' D) _test was ordered, but the family did not go to the0 H0 p6 T, {' L
laboratory to obtain the test.- B1 p/ D0 f* N! g0 n
Discussion
1 e1 C& Z$ K e$ m' J0 {- CPrecocious puberty in boys is defined as secondary& h. m* A6 w- V5 i7 A2 s4 i
sexual development before 9 years of age.1,4: S# j+ C. O2 D5 o2 M7 Z+ M7 F
Precocious puberty is termed as central (true) when. b; [7 V0 U5 K& p/ S7 z% H& \% ~
it is caused by the premature activation of hypo-6 {9 r: }) r7 c+ i9 U1 Y
thalamic pituitary gonadal axis. CPP is more com-% S, m( _: ]$ m8 w }( K1 c
mon in girls than in boys.1,3 Most boys with CPP
7 R# E/ h; |1 pmay have a central nervous system lesion that is/ R* ?; Y9 S/ H; }% k) w! @) {
responsible for the early activation of the hypothal-
- G( u& @+ |& famic pituitary gonadal axis.1-3 Thus, greater empha-
( k, M8 K' {% G0 k) v Asis has been given to neuroradiologic imaging in/ G) E% Z0 t; y# Z) g- Y, b, ?) d: b
boys with precocious puberty. In addition to viril-3 j. d2 I, i8 q! B6 y6 G- s
ization, the clinical hallmark of CPP is the symmet-
; n( K& ^- `* [' A. W8 z4 b1 Jrical testicular growth secondary to stimulation by+ F" T5 e) F% P* K% ^9 r; q3 t' X
gonadotropins.1,3
+ g O% {. A2 w! e; l8 a/ YGonadotropin-independent peripheral preco-
( k/ `, {) ]: K: E i, ]3 ocious puberty in boys also results from inappropriate& m: I, ?6 U9 y
androgenic stimulation from either endogenous or$ C0 t- U. D) F6 f- k. P# E1 ]
exogenous sources, nonpituitary gonadotropin stim-. W7 U: m) d8 Y7 |) s7 F1 V$ q- U
ulation, and rare activating mutations.3 Virilizing
' k1 @+ U% N. [/ ?0 kcongenital adrenal hyperplasia producing excessive
3 I; f. r2 Z* o, Z0 |) {# o0 q/ ]6 Padrenal androgens is a common cause of precocious$ ~2 x$ n: i! \9 x
puberty in boys.3,43 B' A3 ~1 [, `" z2 ]
The most common form of congenital adrenal
; \' R/ ?$ D6 y2 jhyperplasia is the 21-hydroxylase enzyme deficiency.
5 @% @* ?+ H* qThe 11-β hydroxylase deficiency may also result in# Z& {, U2 U! l/ d* }! N1 T
excessive adrenal androgen production, and rarely,
; W9 p9 e- x7 l. j. B) ] b8 Pan adrenal tumor may also cause adrenal androgen# X1 O6 l3 S' H0 M% z/ a" n
excess.1,39 u4 S& k; ~/ N- A' x' G1 T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% k! y7 t% y8 o6 V2 h# a542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' c! \' G0 q3 S
A unique entity of male-limited gonadotropin-4 R5 J5 R' \& N1 a+ N% ?8 P/ z
independent precocious puberty, which is also known
7 Q0 H( C j" J8 [$ yas testotoxicosis, may cause precocious puberty at a) r5 ?% a* M! o
very young age. The physical findings in these boys
' n$ [, X% G, R1 V2 Hwith this disorder are full pubertal development,2 Q* p! v& ~$ |' {! {$ i
including bilateral testicular growth, similar to boys8 R. r* ~2 H) l' l% k' l _' I
with CPP. The gonadotropin levels in this disorder( s* D/ s! K& @$ b
are suppressed to prepubertal levels and do not show, L ^4 r2 I8 T
pubertal response of gonadotropin after gonadotropin-
) F; C0 u/ E% ]releasing hormone stimulation. This is a sex-linked D3 l, R8 @4 Z/ @
autosomal dominant disorder that affects only
) P$ q K9 o' x# z! dmales; therefore, other male members of the family1 {* r5 B. l7 W% P0 z: J; k6 t
may have similar precocious puberty.3( G! F5 G1 Z- L5 K3 ?" \
In our patient, physical examination was incon-4 G/ z3 k- P% N8 {
sistent with true precocious puberty since his testi-( N+ }. H N9 t# q; u4 | l
cles were prepubertal in size. However, testotoxicosis+ P% ~0 w- A& M0 Y$ V
was in the differential diagnosis because his father- n" z& { P' E
started puberty somewhat early, and occasionally,
: B& E9 h' Z2 B8 k4 Q+ T5 F- `2 |% Y, xtesticular enlargement is not that evident in the
( Q% F& {1 E1 }* V8 @beginning of this process.1 In the absence of a neg-
4 j# S: P2 T. K) D% B4 @ative initial history of androgen exposure, our
9 B( r3 a' o- C* vbiggest concern was virilizing adrenal hyperplasia,' _! M5 I7 X9 e e/ h, v( _8 q9 j
either 21-hydroxylase deficiency or 11-β hydroxylase
) o; z: u* C0 Hdeficiency. Those diagnoses were excluded by find-3 j0 f5 B+ o6 P: Q
ing the normal level of adrenal steroids.
: o- D }" f- H) o& }' c! ZThe diagnosis of exogenous androgens was strongly
+ Y5 b* W* x9 N4 Z! wsuspected in a follow-up visit after 4 months because
+ C, J5 @+ q+ B# i3 Ythe physical examination revealed the complete disap-
: O- A$ d9 B. O5 y* z% A/ W5 spearance of pubic hair, normal growth velocity, and# G; `9 r0 H! D U% h9 W
decreased erections. The father admitted using a testos-# Z6 y4 Q; y; R% O' W2 T
terone gel, which he concealed at first visit. He was
6 f5 l/ Y7 U* p* @5 dusing it rather frequently, twice a day. The Physicians’
, H3 C4 @: W, G4 P9 S" yDesk Reference, or package insert of this product, gel or
, X1 O' h& T9 Q, V! j; jcream, cautions about dermal testosterone transfer to
* H" ] k* ]" N" }9 C+ |5 Q8 Bunprotected females through direct skin exposure.
+ v0 e E T; `% ^; o# @Serum testosterone level was found to be 2 times the
( \# o) } U* B( _# z0 ?6 Cbaseline value in those females who were exposed to6 |) L! Z% l( D
even 15 minutes of direct skin contact with their male7 v6 _5 r( I; G
partners.6 However, when a shirt covered the applica-- }) T( D' U# p6 n x$ o
tion site, this testosterone transfer was prevented.; K% h) t5 g+ Y* A
Our patient’s testosterone level was 60 ng/mL,3 i( w x' ?* w f3 M8 v
which was clearly high. Some studies suggest that4 j# Z! i7 _$ g; X$ a
dermal conversion of testosterone to dihydrotestos-5 X5 T3 ~, F5 T4 V) {7 S0 j
terone, which is a more potent metabolite, is more0 }8 [* I5 d+ l! p2 Y2 y1 I! _
active in young children exposed to testosterone
" R1 ]! Q; \) J6 t# B% X" Kexogenously7; however, we did not measure a dihy-& ?9 Y- q7 W4 u7 a! Z8 d
drotestosterone level in our patient. In addition to+ a! T. w/ _# _$ y" t# U2 H
virilization, exposure to exogenous testosterone in
1 r, U( A2 M; ^# k2 A: f' nchildren results in an increase in growth velocity and# P& S6 V, j4 o) P7 [- @. ?
advanced bone age, as seen in our patient.
3 v* V3 U" I& `. K) s3 }6 AThe long-term effect of androgen exposure during
2 N7 n+ I w3 L- Iearly childhood on pubertal development and final; I' B* {$ E E' D; D0 A
adult height are not fully known and always remain
- L) P' t3 z8 ~0 Ba concern. Children treated with short-term testos-7 W* ^$ w# W9 J
terone injection or topical androgen may exhibit some
, P+ g; D! Q" W. \0 O0 M$ dacceleration of the skeletal maturation; however, after. m) Z/ `3 _# A- i5 m* f9 V5 ~! e
cessation of treatment, the rate of bone maturation
( G1 L) g3 t% q1 L/ T% ~decelerates and gradually returns to normal.8,9
0 L+ P5 X/ f! C, h. |( R+ iThere are conflicting reports and controversy8 I3 C0 a( E* Y, F# | }# g
over the effect of early androgen exposure on adult o' N* c1 @" s1 s' K
penile length.10,11 Some reports suggest subnormal* T- P) m- y( d/ q* K4 x4 k
adult penile length, apparently because of downreg-( b5 i9 l& M; d/ c4 i/ @4 A0 v
ulation of androgen receptor number.10,12 However,
/ ]( N2 v6 N H C+ T. K4 q* zSutherland et al13 did not find a correlation between
$ o e, I" @+ @9 hchildhood testosterone exposure and reduced adult' S3 w- s7 ]& `
penile length in clinical studies.
" `% p$ v5 E5 C H2 s) jNonetheless, we do not believe our patient is
4 Z( s' w( K! L: k5 W' Rgoing to experience any of the untoward effects from
3 |5 z7 e( E; b0 l g" s- }testosterone exposure as mentioned earlier because' r% f+ \4 g/ U1 p/ V: L9 y( `
the exposure was not for a prolonged period of time.
2 b% P z" [3 ^' RAlthough the bone age was advanced at the time of
; @; e% J' d2 S6 A3 pdiagnosis, the child had a normal growth velocity at8 P3 [2 X1 e. [$ ^) X; ?8 `
the follow-up visit. It is hoped that his final adult' a5 ^3 D8 e9 f' J! r$ j% R: o9 ?
height will not be affected.
( B" I5 X9 B) ~, S4 L& AAlthough rarely reported, the widespread avail-! a* _! j4 D) V6 r) y+ h" X
ability of androgen products in our society may4 T9 Q% D. H3 ] U S+ ^4 z
indeed cause more virilization in male or female
) c/ u, M! j4 L- [& Kchildren than one would realize. Exposure to andro-
; u: ?" v/ B8 C6 Jgen products must be considered and specific ques-, {9 T! I5 M/ J$ C
tioning about the use of a testosterone product or% B0 k6 X' c6 h
gel should be asked of the family members during: U1 Z5 \: w; c
the evaluation of any children who present with vir-3 |, z! @1 Z! R7 x6 I9 B, c
ilization or peripheral precocious puberty. The diag-
! _9 }$ T# E/ o% ?nosis can be established by just a few tests and by" b8 | X- W! y0 m
appropriate history. The inability to obtain such a- z7 k h' M( E! v
history, or failure to ask the specific questions, may
3 Y0 W4 l3 k2 o6 Z; e4 sresult in extensive, unnecessary, and expensive
, n; l8 |5 N; i, ]3 R; O6 {investigation. The primary care physician should be$ Z" U: d8 m' l8 Q" p
aware of this fact, because most of these children
/ i$ a/ R7 X& o g/ ^may initially present in their practice. The Physicians’2 U$ J, i8 N" t
Desk Reference and package insert should also put a
& @1 b9 d2 y9 b1 iwarning about the virilizing effect on a male or
% v- T/ X2 s" ^- f, H- X5 cfemale child who might come in contact with some-
1 ]$ l4 n: J6 x/ Z' S bone using any of these products.
! U2 E) d, o' w& SReferences
# l5 W( B U, o& _1 S6 e1. Styne DM. The testes: disorder of sexual differentiation+ G8 y+ T7 E- r
and puberty in the male. In: Sperling MA, ed. Pediatric/ @& ^, L/ H6 x; }( H Y& W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 v ~, a- } X) p3 V% L$ e2002: 565-628.0 B( h: d# ^6 p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 ]# \# T: T' I/ I( `puberty in children with tumours of the suprasellar pineal |
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