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Sexual Precocity in a 16-Month-Old
% @- D0 M- ~: n( S# P+ b; U' uBoy Induced by Indirect Topical3 ]- C$ T- ?- N3 f2 F; Z
Exposure to Testosterone* V# C- }1 ^- M( S- g& t8 N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ D, w8 [0 r* H7 tand Kenneth R. Rettig, MD1. |) A/ }* {8 e" ?
Clinical Pediatrics6 l9 }6 S5 U4 s1 |# v, v3 z, s7 k: `0 E
Volume 46 Number 6- n* J E2 C }& i }5 O
July 2007 540-543
* f" d o$ z; J: f* J' s9 N© 2007 Sage Publications# ]9 B+ B, G2 g& W
10.1177/0009922806296651& Y+ f7 x0 U1 Y$ a) n' Y3 E
http://clp.sagepub.com
. S7 g% A2 V1 M+ zhosted at3 `! u3 j/ Q& Q( e
http://online.sagepub.com Z% X+ l" y0 E. k2 o4 T* i: h, g! I
Precocious puberty in boys, central or peripheral,; r1 n/ A: \% E: a- R( [* S
is a significant concern for physicians. Central" t! |: ?# J1 e& ?% V; P1 c4 Z
precocious puberty (CPP), which is mediated
2 W4 a' j! O8 X' k& Dthrough the hypothalamic pituitary gonadal axis, has. A, X/ C* H; _4 c4 B+ t$ x
a higher incidence of organic central nervous system
0 z+ H, m" f' Nlesions in boys.1,2 Virilization in boys, as manifested6 ~8 T3 M& k. S0 v+ t, u" b6 c8 k
by enlargement of the penis, development of pubic
! g% Y7 n3 w1 {6 ?( Z/ e2 _hair, and facial acne without enlargement of testi-
R8 H8 _* s _ Z! p0 @1 L/ ?, Icles, suggests peripheral or pseudopuberty.1-3 We
% z" |5 D2 \' Q* }1 V3 |! ~report a 16-month-old boy who presented with the
1 E& |$ o( v* G, oenlargement of the phallus and pubic hair develop-2 U: V2 t: I/ i+ |# R, N5 `
ment without testicular enlargement, which was due
/ i$ X, | _7 k* i9 x% ato the unintentional exposure to androgen gel used by
7 I# Q! i) k9 z2 fthe father. The family initially concealed this infor-
4 R1 E w( W- b5 G# Y" p' {mation, resulting in an extensive work-up for this7 J1 J# S# V8 h! M& ~, A
child. Given the widespread and easy availability of
7 Z5 T2 o% e7 Q$ ]7 n! S6 mtestosterone gel and cream, we believe this is proba-
1 l {4 M* ~$ U: X/ S* kbly more common than the rare case report in the
+ [1 o& V- B0 F2 P, U9 Fliterature.47 R) o) H N' W
Patient Report' }# B$ P& ]7 U4 d8 H. d7 h# e
A 16-month-old white child was referred to the
A1 z+ u* D# n \1 u0 M+ b3 R' iendocrine clinic by his pediatrician with the concern
( y# U0 g- _: A4 B/ Pof early sexual development. His mother noticed
8 S. r. ?. s( N3 ?9 g0 C( I' ~light colored pubic hair development when he was
+ _5 G$ H- W4 O' w( n9 sFrom the 1Division of Pediatric Endocrinology, 2University of% U' u d! m3 A% F# H+ y+ y
South Alabama Medical Center, Mobile, Alabama.- }2 V7 L! }$ ]+ Z4 \0 m" T5 c
Address correspondence to: Samar K. Bhowmick, MD, FACE,% c6 L3 o* k0 w& @$ m0 Y! n
Professor of Pediatrics, University of South Alabama, College of# t. E- r7 _7 A( ]7 C# X% I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; E, M- D* u, g v# ~+ Je-mail: [email protected].' [1 H& c2 l1 p2 |# A& E! w+ l
about 6 to 7 months old, which progressively became6 g: | s, K4 o! y ~: k( K
darker. She was also concerned about the enlarge-: u* s' X7 @ r% m. c
ment of his penis and frequent erections. The child
4 S. e( A3 C* Q; E& m- \6 \: awas the product of a full-term normal delivery, with) t7 b" r. l$ n
a birth weight of 7 lb 14 oz, and birth length of2 @1 g& H& b; V' k
20 inches. He was breast-fed throughout the first year
$ M- g. P: g# I. wof life and was still receiving breast milk along with
- M$ u* ?5 E3 R7 t$ G8 nsolid food. He had no hospitalizations or surgery,
/ D5 Z( S; ^5 p5 kand his psychosocial and psychomotor development
$ J, `0 k! p5 Uwas age appropriate.$ b, d* O" N/ X/ J% W7 d# |- ^
The family history was remarkable for the father,
7 @8 N8 p( m( H1 K& I' s. Fwho was diagnosed with hypothyroidism at age 16,- c7 Z5 B) J- E; M, L( g
which was treated with thyroxine. The father’s; Y2 O \0 r. D3 j( k
height was 6 feet, and he went through a somewhat
6 R7 G) ?7 N9 O" T( x. }' d Learly puberty and had stopped growing by age 14.1 z% t' t9 G0 J0 o8 f
The father denied taking any other medication. The
4 K+ G+ ]! G% m9 s8 B5 K4 hchild’s mother was in good health. Her menarche
8 P5 Z! \' s$ S$ b$ \1 w9 s9 Iwas at 11 years of age, and her height was at 5 feet
/ f3 r& {4 c& x# S( e8 S9 \5 inches. There was no other family history of pre-6 [; C- L) e6 ~. i/ Z P2 o' w1 u' ^/ w
cocious sexual development in the first-degree rela-
0 Q; a) \! e4 V9 x3 Otives. There were no siblings.( @! B; w( G6 V/ G8 r
Physical Examination
$ F; d9 s/ ]' P, xThe physical examination revealed a very active,
" d. J. T- y/ v# _playful, and healthy boy. The vital signs documented
8 w7 R3 ^+ }5 c" U, ^a blood pressure of 85/50 mm Hg, his length was
; z) J+ w1 M; m8 j% z6 t90 cm (>97th percentile), and his weight was 14.4 kg
! d& i/ l, Q' k* C. s(also >97th percentile). The observed yearly growth
# N9 ]7 P' }6 w1 S3 u- R- A" g9 fvelocity was 30 cm (12 inches). The examination of; j% _% [2 S" N4 U
the neck revealed no thyroid enlargement.
6 n$ ~5 e( W- B5 k5 t4 C1 {The genitourinary examination was remarkable for
! c# C: b9 t: p0 C9 Kenlargement of the penis, with a stretched length of/ n0 }+ z6 R/ K$ d7 J
8 cm and a width of 2 cm. The glans penis was very well. z- j7 ? }8 R7 x) ?
developed. The pubic hair was Tanner II, mostly around1 F4 a$ o8 C8 u- o0 i$ M
540
9 e' o4 M$ V. |' \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% w8 X2 S6 @) F1 l1 W
the base of the phallus and was dark and curled. The
- `# ]8 W5 p2 N7 ~; \testicular volume was prepubertal at 2 mL each.- T' H x' X; ^6 W$ }
The skin was moist and smooth and somewhat
: }7 _: ]0 r$ v, A4 Aoily. No axillary hair was noted. There were no$ v1 V0 d* s' p9 y8 X( `
abnormal skin pigmentations or café-au-lait spots. H) F5 q3 _- T& o7 x$ D4 O8 v
Neurologic evaluation showed deep tendon reflex 2+
) _5 M; k8 ?- U, i' a' y/ Dbilateral and symmetrical. There was no suggestion: l s" E4 c3 c- x; [$ j# Z
of papilledema.1 F& y1 B' V8 n4 u, N, e
Laboratory Evaluation
' S' L/ x6 Z7 m6 E, Z; a& W" F+ EThe bone age was consistent with 28 months by
' P8 f! G4 ~7 i5 J1 t# T/ e% q/ {6 m! nusing the standard of Greulich and Pyle at a chrono-8 N3 |6 D* o* M& b' j
logic age of 16 months (advanced).5 Chromosomal+ B2 U, I* i2 P$ M1 ~+ C" a# @( w
karyotype was 46XY. The thyroid function test
& z. E% g# W4 W% G: y# [ i6 {# vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 ^- D/ x# y7 @" o! T
lating hormone level was 1.3 µIU/mL (both normal).
+ v( g2 k" X D$ ]5 u K6 Z, q: n9 cThe concentrations of serum electrolytes, blood
* D+ M4 @7 j0 B4 M' O$ Nurea nitrogen, creatinine, and calcium all were
4 ~8 B1 ?% \' o5 h" S. k b- mwithin normal range for his age. The concentration
; a) S# k3 h& R0 z; ?* B1 p9 A; kof serum 17-hydroxyprogesterone was 16 ng/dL7 z% U+ w4 Z" X! v' H
(normal, 3 to 90 ng/dL), androstenedione was 203 E8 L6 g! z' J* f3 U' Z! a& |, D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: Q/ i1 P0 r+ z& y. B
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( [* l3 h4 @& z a) H: rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( g! d) P2 J6 ?* Q1 t$ E% U49ng/dL), 11-desoxycortisol (specific compound S)
" R* o, Y5 x }8 I0 w0 h/ wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
E8 H8 W; ^" c% z% U" _& rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' r# r, F$ C. T0 B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 m8 _- @; t3 j4 I; O" w
and β-human chorionic gonadotropin was less than
" v5 F! R1 i- y+ e" C- O. a5 mIU/mL (normal <5 mIU/mL). Serum follicular; s% X5 M- p/ B, M
stimulating hormone and leuteinizing hormone5 J, i) O8 T7 H {1 ~! l8 H/ X4 Z
concentrations were less than 0.05 mIU/mL
0 c- y9 s) s/ V" a. k3 e) h(prepubertal).
, R" {$ w) i! f. }+ hThe parents were notified about the laboratory
D! C6 z3 }5 z: W x: M: lresults and were informed that all of the tests were
& p- j/ f3 _ D- o, o& {normal except the testosterone level was high. The. q6 G3 [ I z, \; n( J3 Q
follow-up visit was arranged within a few weeks to% f1 i9 F& x' Z0 ?% l
obtain testicular and abdominal sonograms; how-
* X$ m# g/ x' N0 ~3 \0 U* W P; E4 @ever, the family did not return for 4 months.
. F" b- o, J5 [6 s3 @Physical examination at this time revealed that the
" j! N+ ^. u4 P* a7 Fchild had grown 2.5 cm in 4 months and had gained1 S+ b6 R$ ?9 E' V5 A8 P; A
2 kg of weight. Physical examination remained
6 f$ s |' a* l8 j$ S+ l5 Zunchanged. Surprisingly, the pubic hair almost com-3 a7 f' A- S$ W: T- ?& D$ E
pletely disappeared except for a few vellous hairs at6 y5 p! T6 Q. {# _2 N: A
the base of the phallus. Testicular volume was still 2
% m' K0 ], \3 ]mL, and the size of the penis remained unchanged.
; w( J, j4 Q9 z3 VThe mother also said that the boy was no longer hav-+ }3 x. Q+ x3 [4 [! g( t( Q* [0 M
ing frequent erections.7 N/ K" Y# y6 z t0 e& n
Both parents were again questioned about use of
& H! Y ~$ z1 I$ _1 Hany ointment/creams that they may have applied to
: o% y0 z Y8 ?( y; m8 ~$ O$ Gthe child’s skin. This time the father admitted the' N: m2 T' A$ u5 C6 Y
Topical Testosterone Exposure / Bhowmick et al 541* y2 R( x* L6 [% K
use of testosterone gel twice daily that he was apply-
; s4 C6 }- N/ v0 N9 y% }$ g* Ping over his own shoulders, chest, and back area for, L! d5 N% }5 q4 h. a/ X1 ~; _
a year. The father also revealed he was embarrassed
) U' U$ z& C9 h% nto disclose that he was using a testosterone gel pre-
, [ l/ }/ O% Fscribed by his family physician for decreased libido( C. z9 U1 l- N" j
secondary to depression.
& Q& ? F$ S! G& ]6 E# T' vThe child slept in the same bed with parents.
; b7 P3 L% f9 h, W2 N" P+ e; @The father would hug the baby and hold him on his1 P. ~' k& N: k5 L. b# }8 a8 L; C2 e
chest for a considerable period of time, causing sig-
& s9 ]4 M/ C# d" Lnificant bare skin contact between baby and father.
6 a& t6 }0 l4 }/ v; \The father also admitted that after the phone call,: x: i3 ]4 S2 l* Z" Z- k% w
when he learned the testosterone level in the baby* q1 u& m, A I. g
was high, he then read the product information, w2 o8 E5 E8 L# N+ o! \( _
packet and concluded that it was most likely the rea-! u: @3 u$ j1 H1 V$ h `% |9 e5 ]. d
son for the child’s virilization. At that time, they
2 Y! \) z6 S) l* idecided to put the baby in a separate bed, and the2 |6 g- i9 f Q8 x& F
father was not hugging him with bare skin and had" Y9 O8 A8 Z& W. ~
been using protective clothing. A repeat testosterone
* D# ^# Q% R- K* t. z1 s' I P4 A |test was ordered, but the family did not go to the
8 T8 e% k2 H# e& Y) v+ u9 X7 ]3 L7 Xlaboratory to obtain the test.3 U) I$ f2 n& r$ ?& d' c
Discussion
4 E1 x' O5 e. ]) [ G5 jPrecocious puberty in boys is defined as secondary
7 Z+ L# a3 I4 a' q6 l3 i/ {+ osexual development before 9 years of age.1,4
% Y! K9 A4 x/ b7 Z& ?: sPrecocious puberty is termed as central (true) when
. u) y# A5 ^9 `6 E$ s+ ?; n0 Jit is caused by the premature activation of hypo-. E6 b' f! s; z/ a5 h( T
thalamic pituitary gonadal axis. CPP is more com-2 p5 }* Y0 j3 m/ b, f% y$ L) \
mon in girls than in boys.1,3 Most boys with CPP3 U* W k F" Q) Z
may have a central nervous system lesion that is' u7 `1 ]7 `2 J- S) F- `0 o2 q( [
responsible for the early activation of the hypothal-
% Z' E% M8 l: x9 E- c$ k namic pituitary gonadal axis.1-3 Thus, greater empha-
7 \$ _2 @' i# Zsis has been given to neuroradiologic imaging in& c+ \/ D" N' ^. Z$ Z$ v
boys with precocious puberty. In addition to viril-$ r q7 K. }2 n& Q: _: W
ization, the clinical hallmark of CPP is the symmet-
4 o% h, n5 N( L+ srical testicular growth secondary to stimulation by, i. r, v9 S9 a6 I' V
gonadotropins.1,3
) X* c5 _* G0 G- PGonadotropin-independent peripheral preco-
" Y# v% x0 R7 G4 \$ \cious puberty in boys also results from inappropriate1 W; D9 \0 {; ]% S! f7 J {/ A
androgenic stimulation from either endogenous or# V% _9 K& c) F* W" w
exogenous sources, nonpituitary gonadotropin stim-
9 |! W, s& l; `. N& a7 D: D/ T, F6 hulation, and rare activating mutations.3 Virilizing' L/ i* h4 h- [& u/ Y8 t
congenital adrenal hyperplasia producing excessive
0 q8 j7 ]7 k, S' b& Aadrenal androgens is a common cause of precocious3 p; s8 H7 G( `; z% Y6 \3 r
puberty in boys.3,4
6 @/ f5 f9 B9 d" HThe most common form of congenital adrenal
7 W3 m! e4 b e/ a/ i! m1 l) Khyperplasia is the 21-hydroxylase enzyme deficiency.% f, m0 u8 J6 O# z, ?4 W7 T
The 11-β hydroxylase deficiency may also result in: N' G1 \6 h# x3 ~4 O
excessive adrenal androgen production, and rarely, W+ V; F: r) x8 t/ u9 j
an adrenal tumor may also cause adrenal androgen7 Q# I" h3 i8 q: `& w) H4 f
excess.1,3
) ?) Q: C2 W, f# aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 t: K2 |; O3 G" X
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 [' p& o F# m1 p
A unique entity of male-limited gonadotropin-2 Q6 Z6 U) `. e& M2 a$ Z5 N# o
independent precocious puberty, which is also known* h) S" V4 z: v5 S) g, F# D
as testotoxicosis, may cause precocious puberty at a# B$ G" y2 [: s& o( k' m" x
very young age. The physical findings in these boys
: \" j" E& P3 z2 i3 v& k0 j; dwith this disorder are full pubertal development,& }% b( K3 J" _6 }# z
including bilateral testicular growth, similar to boys5 L' H8 b8 j1 @$ a8 p
with CPP. The gonadotropin levels in this disorder; U, b/ l2 \$ F) H" E
are suppressed to prepubertal levels and do not show8 O# s8 |4 S0 i N
pubertal response of gonadotropin after gonadotropin-4 P6 @( A3 F1 V8 I
releasing hormone stimulation. This is a sex-linked
5 x9 [6 @% p- j2 k; w" S/ A' G5 yautosomal dominant disorder that affects only- ?* f( n W1 K& [& A; H# x
males; therefore, other male members of the family5 P! W/ G# ~0 Z }8 U/ _8 u
may have similar precocious puberty.31 ?+ @7 o" _7 R9 h6 Z4 `: q
In our patient, physical examination was incon-5 b# f2 x* M) D+ ^- x
sistent with true precocious puberty since his testi-
+ z- {) Z, g6 m) ~cles were prepubertal in size. However, testotoxicosis% m6 i" P' Q5 ~8 b3 J3 q
was in the differential diagnosis because his father! P3 X) G) y# D2 t' L
started puberty somewhat early, and occasionally,+ f3 w' z$ \" V! j" E8 J
testicular enlargement is not that evident in the* y t6 W: l/ x* c/ _, y
beginning of this process.1 In the absence of a neg-% P" [8 j5 X8 M
ative initial history of androgen exposure, our2 p/ V3 _) c- \9 x8 N; _- t# l7 {' W- ]3 s
biggest concern was virilizing adrenal hyperplasia,
. q5 R* Y, ^' heither 21-hydroxylase deficiency or 11-β hydroxylase
1 }) D7 P- ^( a+ Tdeficiency. Those diagnoses were excluded by find-
& f/ o/ x* W5 |% n6 Jing the normal level of adrenal steroids.
1 _) C5 {; w# D. f( I' f% F) wThe diagnosis of exogenous androgens was strongly
8 Q2 w. U$ s( {8 g% osuspected in a follow-up visit after 4 months because) N3 k; p' s5 g/ x/ c: k7 r( m' g
the physical examination revealed the complete disap-( T2 `3 m4 V) C5 ?* p
pearance of pubic hair, normal growth velocity, and
% J- h6 f8 a9 q# hdecreased erections. The father admitted using a testos-7 S1 V' j- t, B3 S: Q, E% h, M
terone gel, which he concealed at first visit. He was
2 T" O m W$ a8 ^* X. h, |using it rather frequently, twice a day. The Physicians’
& `9 z7 W* s4 S" Z; L# wDesk Reference, or package insert of this product, gel or
: k2 s( Y0 d1 vcream, cautions about dermal testosterone transfer to5 Q! C- t0 L1 Q: r Y4 Z% T2 k1 U
unprotected females through direct skin exposure.; N( \. M9 r" d) c7 C: j
Serum testosterone level was found to be 2 times the1 a8 A! h4 b. K" w& ^) U" G0 E! R
baseline value in those females who were exposed to
s% t; B1 U- _4 geven 15 minutes of direct skin contact with their male
8 C, J' n6 [4 }) U- Zpartners.6 However, when a shirt covered the applica-
. c5 n4 u% B# L x# l ttion site, this testosterone transfer was prevented.
& N3 v9 }! b( S% w+ |6 c4 t XOur patient’s testosterone level was 60 ng/mL,
@8 P4 @. x, Q, i% S" Nwhich was clearly high. Some studies suggest that
/ q% ]8 L' C! N/ N: Tdermal conversion of testosterone to dihydrotestos-
) D6 }5 D W6 M8 x% zterone, which is a more potent metabolite, is more
. h) h, J: B) o$ n6 u: Dactive in young children exposed to testosterone
6 v7 E! v7 _& K+ H0 zexogenously7; however, we did not measure a dihy-, j! n# h$ O0 ^$ c4 f
drotestosterone level in our patient. In addition to
; Z& }- N, }9 v e7 \virilization, exposure to exogenous testosterone in
/ P6 i; S a+ X$ @7 @, Dchildren results in an increase in growth velocity and u- z( L% O: D; K4 o! |$ c
advanced bone age, as seen in our patient.2 }- i) c; D3 R$ f
The long-term effect of androgen exposure during: c r! O, x3 u- w+ ^' M% f2 I1 |) l
early childhood on pubertal development and final
6 q, }0 o+ b) kadult height are not fully known and always remain3 T2 l6 z" H, s" R6 S
a concern. Children treated with short-term testos-+ E1 ?5 r6 v- u' b" }- s
terone injection or topical androgen may exhibit some) N; P8 x4 _$ p
acceleration of the skeletal maturation; however, after
, K3 f4 s8 N/ ]! Ocessation of treatment, the rate of bone maturation1 P9 N$ t# x# u3 d0 b
decelerates and gradually returns to normal.8,9
- G f1 E' G3 ~$ Z1 t6 s5 ~1 R/ aThere are conflicting reports and controversy
% m- U8 ~: x0 W" i" ~' x' q8 Eover the effect of early androgen exposure on adult3 o( h; C, k: V/ i5 \% [
penile length.10,11 Some reports suggest subnormal
) [/ C- Z. p3 t$ Vadult penile length, apparently because of downreg-0 r7 ~6 i8 ]3 e( l+ `
ulation of androgen receptor number.10,12 However,: P* Y! {0 j& D. [/ H$ \! N
Sutherland et al13 did not find a correlation between
6 ~$ C/ s/ u3 s8 N: k `childhood testosterone exposure and reduced adult/ o1 \- o- S( n+ s/ R/ w
penile length in clinical studies.: L/ x5 |) C, K
Nonetheless, we do not believe our patient is. a1 [- M' t) m3 g" W* J( j9 G \
going to experience any of the untoward effects from
u. z" R1 ]5 x; r4 w& Otestosterone exposure as mentioned earlier because
( x' Y. c$ m, f& f+ T1 q X) w9 U) nthe exposure was not for a prolonged period of time.0 q, |% ~: v2 X- v3 A! \( u3 p
Although the bone age was advanced at the time of4 R. M/ ]6 z5 s& z- i& H3 x) g9 [
diagnosis, the child had a normal growth velocity at
' s: N: D; W) s; z/ ythe follow-up visit. It is hoped that his final adult0 V3 T0 O+ a% n& M* c/ T
height will not be affected.
$ R, }6 r' j' HAlthough rarely reported, the widespread avail-! C( T2 K: S5 B) b' f4 L
ability of androgen products in our society may3 i Y4 F z1 R0 C: t' @
indeed cause more virilization in male or female
4 N' W% G6 a+ w- S) [' rchildren than one would realize. Exposure to andro-9 l# @) g6 l3 G! g7 [
gen products must be considered and specific ques-, B: a( Z* ^" C5 f1 W. I- A
tioning about the use of a testosterone product or! p& B) s0 R& E0 J `3 t
gel should be asked of the family members during: g* o1 s( G1 v8 [- M; {. n& G
the evaluation of any children who present with vir-
S: o# a7 I2 ?+ B2 y- X$ cilization or peripheral precocious puberty. The diag-& w& K8 [. @8 _9 w2 U
nosis can be established by just a few tests and by( s/ g! w/ U7 f" J6 l' p% r
appropriate history. The inability to obtain such a& z2 h" e; A# F
history, or failure to ask the specific questions, may
1 Z. i: P. v/ x1 b; dresult in extensive, unnecessary, and expensive
% u; i9 D+ _0 ~- Ainvestigation. The primary care physician should be
2 n3 B4 H/ m/ h( Z2 v+ A, eaware of this fact, because most of these children
1 Y! c, K- Y2 @& k. Hmay initially present in their practice. The Physicians’
h$ V- v c) _; BDesk Reference and package insert should also put a
/ f/ y G5 A6 hwarning about the virilizing effect on a male or- L( Z, ~. R5 u' Y7 N: i" C/ ]- C$ J
female child who might come in contact with some-
6 }2 E0 n6 X; T! g2 T) p, k: R4 w2 ione using any of these products.
0 g9 \- ^' V' P0 O4 V c3 R: AReferences
) h! ~, N& q" O! Q! q# l1. Styne DM. The testes: disorder of sexual differentiation1 b9 f8 F2 L: G; r! D* P V
and puberty in the male. In: Sperling MA, ed. Pediatric
/ x- n" d1 J! [( N8 u0 D2 z/ W- j9 I% IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 h9 T4 X1 Q7 C
2002: 565-628.9 E& N# Y. O2 T2 z( _. D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ O/ W3 q" C! r
puberty in children with tumours of the suprasellar pineal |
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