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Sexual Precocity in a 16-Month-Old, O s! L. i4 I" K1 M8 z7 x
Boy Induced by Indirect Topical
7 q; U8 `, R6 t0 `$ aExposure to Testosterone
5 O3 o' d3 w( D/ Z& VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- y) i2 Z2 t3 S6 m% }$ N; L7 l
and Kenneth R. Rettig, MD1
' U) e; z5 x! ?% l) ^ dClinical Pediatrics9 B; |' _' K! s& j& ~' A
Volume 46 Number 6& B5 v4 V/ z# H& ^0 Y
July 2007 540-543
. f6 {: v: V; F5 v/ p$ Z$ _2 B* H© 2007 Sage Publications
/ c" e' R! e3 ?8 }+ K- a10.1177/00099228062966518 m1 L( T6 s2 x$ P
http://clp.sagepub.com( t8 O. V( d/ f9 ]
hosted at
5 {9 r) i9 ]6 G/ M" ^! U6 ^$ Ghttp://online.sagepub.com! {. u2 H1 f: @$ Y3 e
Precocious puberty in boys, central or peripheral,* s: a% b* Z& t' y/ K: k, u! l
is a significant concern for physicians. Central
; w: F" R, z7 K% s9 _precocious puberty (CPP), which is mediated! i& K* k; P% |' g# `! N3 s/ T
through the hypothalamic pituitary gonadal axis, has1 ~" q$ A0 M. E; k4 b! l0 C
a higher incidence of organic central nervous system
' m7 |6 S f2 L- j4 a1 t& Q9 B) b# klesions in boys.1,2 Virilization in boys, as manifested. M7 U% q3 }8 }
by enlargement of the penis, development of pubic
) ], Y$ W k K1 {( `hair, and facial acne without enlargement of testi-% b3 W' R5 g7 E3 p/ L5 ]/ F
cles, suggests peripheral or pseudopuberty.1-3 We
: m: \4 O5 t# J, G, V# |7 X7 ]; ]1 M( nreport a 16-month-old boy who presented with the
( q2 y, f# j) l y$ E0 [' z1 M0 cenlargement of the phallus and pubic hair develop-5 h5 f7 N- e- ]2 N
ment without testicular enlargement, which was due* k9 A: |! H5 \+ r( v" A
to the unintentional exposure to androgen gel used by
/ L: \4 p" w! j+ D: G- h/ S/ sthe father. The family initially concealed this infor-
( q7 k( h/ t i. ^" qmation, resulting in an extensive work-up for this, l. ?1 K/ \1 @) K& A
child. Given the widespread and easy availability of5 z# F: B/ O5 S" {( P7 w
testosterone gel and cream, we believe this is proba-
# b0 w: O! w9 Zbly more common than the rare case report in the
' h' q" L' b6 W9 U; R1 Xliterature.4& R+ t$ U8 |( i$ G, h# {
Patient Report
; l0 e6 e# u1 V; {' n" W, DA 16-month-old white child was referred to the7 u/ Z9 r4 m& T |" T& b& G, _
endocrine clinic by his pediatrician with the concern
7 g% `5 i8 V: w" O- oof early sexual development. His mother noticed* Z$ o/ H3 A0 D/ ? K$ m# L" D
light colored pubic hair development when he was l0 g. R; [4 R9 g6 G
From the 1Division of Pediatric Endocrinology, 2University of
, |- r+ j4 h/ S& C% d9 m0 n# SSouth Alabama Medical Center, Mobile, Alabama.7 s2 c. e, e( I6 G) X
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 |+ f% m9 D+ ^* k* X7 Q( K
Professor of Pediatrics, University of South Alabama, College of3 P7 @5 ]( x" k% y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 G5 k& T$ u( q. l* K, Y He-mail: [email protected].
% `3 N& S6 F- h2 _about 6 to 7 months old, which progressively became
2 T9 W2 u5 X8 |) [& Y$ e! fdarker. She was also concerned about the enlarge-4 k7 z2 x+ l7 t# j9 S- O
ment of his penis and frequent erections. The child, ^- a7 K, n, x* r4 _; ?" h
was the product of a full-term normal delivery, with$ I% [6 F- p+ I, E' z
a birth weight of 7 lb 14 oz, and birth length of
! P6 l" V b, v3 D1 I20 inches. He was breast-fed throughout the first year
9 X/ f% E$ w3 {/ m' aof life and was still receiving breast milk along with
1 s) h1 \ s: ]1 wsolid food. He had no hospitalizations or surgery,3 F6 r: i4 X' w7 k, m3 e
and his psychosocial and psychomotor development4 E) f; J5 z, @5 U- P
was age appropriate.
! u8 i, k3 u& L* |/ B7 S9 UThe family history was remarkable for the father,7 }, ~" _" w, p5 c$ f6 m. [0 {* `
who was diagnosed with hypothyroidism at age 16,
) o s. C) W! y9 D6 ~1 X. O, d+ v$ [$ qwhich was treated with thyroxine. The father’s# [" G, @7 }! q
height was 6 feet, and he went through a somewhat: h/ c5 L8 J' a$ D1 `, L
early puberty and had stopped growing by age 14.
/ S, ~- Y, r9 W9 P8 N* \The father denied taking any other medication. The) A% b0 v3 g/ [: r4 C
child’s mother was in good health. Her menarche' j# E% G4 u% Q) l
was at 11 years of age, and her height was at 5 feet2 z5 s7 E7 \% X4 C
5 inches. There was no other family history of pre-8 O( e6 Y3 W6 |
cocious sexual development in the first-degree rela-$ u2 d( o4 V& v, S& h
tives. There were no siblings.: o7 S# s e6 `( H7 K ^
Physical Examination
1 p& N4 G |6 P& \0 jThe physical examination revealed a very active,; {' S0 e) F( h3 ~& J
playful, and healthy boy. The vital signs documented
5 l+ _5 I7 O( V& Ta blood pressure of 85/50 mm Hg, his length was
5 [0 L% W$ M6 s w( {( G90 cm (>97th percentile), and his weight was 14.4 kg
" d7 S3 d& [1 n& ^9 x(also >97th percentile). The observed yearly growth) b' |& O7 o2 Q3 c9 ~
velocity was 30 cm (12 inches). The examination of
7 H. e4 k2 b5 g5 e9 H* H) q; {the neck revealed no thyroid enlargement.6 z2 `: `+ F; T* Y+ [' s+ `( ]8 t- [6 I
The genitourinary examination was remarkable for
6 ^$ V0 s4 [0 x8 k' K/ R) f* aenlargement of the penis, with a stretched length of' q8 q* ]+ o* \& q
8 cm and a width of 2 cm. The glans penis was very well
# |) q( l% a8 \ Ddeveloped. The pubic hair was Tanner II, mostly around) q& |+ y1 G( H4 y# J
540
2 r7 O1 j7 n) ?' a1 o; O0 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! D9 s) w0 m$ c9 k5 H4 y6 h" [the base of the phallus and was dark and curled. The6 r& ?% h$ W6 \( Y
testicular volume was prepubertal at 2 mL each.8 A1 G+ T* O( M4 v. [8 [
The skin was moist and smooth and somewhat( b/ C. y: V" I$ E* Z! |
oily. No axillary hair was noted. There were no
$ O/ Q9 b" Y+ Kabnormal skin pigmentations or café-au-lait spots.+ h' e" J9 q; ]4 C* v3 Y9 h& N6 F
Neurologic evaluation showed deep tendon reflex 2+
1 {4 _% k5 i! K( s4 s+ C9 w9 A6 fbilateral and symmetrical. There was no suggestion
) r/ g' P8 z' M2 x4 m; z# R! Sof papilledema. \0 S9 e& J3 T' r& Z
Laboratory Evaluation) P$ a) [" R% O, o6 A. U/ [
The bone age was consistent with 28 months by
- E U. f. U- Dusing the standard of Greulich and Pyle at a chrono-, X$ A' @$ d: R0 y" r0 P
logic age of 16 months (advanced).5 Chromosomal
- a& p2 I- z% b7 a4 hkaryotype was 46XY. The thyroid function test
$ s: p% d2 Y' H8 Z0 X; o) }showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ g- f) \$ i8 A; ~# Rlating hormone level was 1.3 µIU/mL (both normal).& g5 n8 F5 q1 u- y, ^6 S
The concentrations of serum electrolytes, blood
! ^0 {) v9 w; a5 \& m4 Qurea nitrogen, creatinine, and calcium all were. p, R) ^4 K7 m
within normal range for his age. The concentration
, c& C7 x! Q0 K4 u# ]of serum 17-hydroxyprogesterone was 16 ng/dL
% D+ G$ h2 Y( s9 U(normal, 3 to 90 ng/dL), androstenedione was 20# v1 S* g' K+ g- T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% T9 m% T% O5 M9 i, K0 [terone was 38 ng/dL (normal, 50 to 760 ng/dL),; {5 o/ ^% U0 |# |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" z, N, S- N, `1 W! f; @6 p
49ng/dL), 11-desoxycortisol (specific compound S)
) z1 Z4 B$ n- R# K6 ^was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, c9 D6 J: o2 v, F2 E3 J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: T+ ~% h9 X& Y8 X n R" K( v! l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 k3 {' U9 o l6 u, O' I: ?
and β-human chorionic gonadotropin was less than
3 W* Q9 d7 z7 a- j [& C4 T5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ d; y5 s$ C( q+ R/ ~4 Istimulating hormone and leuteinizing hormone# O$ `; H: H, w& n9 s) d+ c4 F0 S
concentrations were less than 0.05 mIU/mL* Y0 L. e9 ^8 ~: V, Y
(prepubertal).& f; V) H% z9 B7 `) H7 V( v
The parents were notified about the laboratory) ]- S& K1 u5 Q) o7 \( f
results and were informed that all of the tests were6 Y, C# n6 S) j) @. C
normal except the testosterone level was high. The
8 {; f1 v: q5 ?" z* q7 n1 Kfollow-up visit was arranged within a few weeks to6 f& P8 C {) s" R: H
obtain testicular and abdominal sonograms; how-! S1 _# s! F- _" B" o1 ]) D
ever, the family did not return for 4 months.
2 H0 [& `- R9 xPhysical examination at this time revealed that the, _3 U4 x2 w+ I1 a. u. a% d' w
child had grown 2.5 cm in 4 months and had gained
+ Z C* s2 F. L* A2 kg of weight. Physical examination remained: F) M# f1 L, p+ f; n! O3 L
unchanged. Surprisingly, the pubic hair almost com-+ K A9 }; b, H) l0 c% p- e
pletely disappeared except for a few vellous hairs at
, N! b! H" E' y% Fthe base of the phallus. Testicular volume was still 2
3 M( p E9 z/ gmL, and the size of the penis remained unchanged.
2 `& Q# D) m" U, d5 J) `3 B" KThe mother also said that the boy was no longer hav-
- E3 L" {% z0 W4 V& Y, wing frequent erections.
4 q) t2 M' `% D) `- K2 G) ]Both parents were again questioned about use of
7 l# ]5 l7 e" ]/ r# Eany ointment/creams that they may have applied to. _7 Q, Z9 G7 Q" r- |1 f
the child’s skin. This time the father admitted the
# \$ t9 `8 D) B) W! tTopical Testosterone Exposure / Bhowmick et al 541
' h4 t- @$ j" t" N- suse of testosterone gel twice daily that he was apply-
4 l, o- ?* y- ?1 V+ Ping over his own shoulders, chest, and back area for3 @1 v0 w) D1 J% J# P% H3 ]" d
a year. The father also revealed he was embarrassed2 Y1 Q& k$ x$ _/ R
to disclose that he was using a testosterone gel pre-
5 g* E9 e# g" J) w1 i' m# b/ ]scribed by his family physician for decreased libido
' H0 M; u( A& W+ Isecondary to depression.
! E# s$ \6 S$ t; V1 ?( `5 y/ XThe child slept in the same bed with parents.& v' D' k( o; ^, P7 l% k
The father would hug the baby and hold him on his0 P: j( V; u' `1 M% r5 M
chest for a considerable period of time, causing sig-6 x! u7 i0 l8 ^* f2 C8 _3 `4 g& k
nificant bare skin contact between baby and father.) Q( F0 T! A g N9 L
The father also admitted that after the phone call,5 _1 o t# O/ C+ ?) h' P1 h$ X- z9 N
when he learned the testosterone level in the baby
& W9 a' H/ x$ ?* {( B5 [, u1 hwas high, he then read the product information
6 C c2 P: Q+ lpacket and concluded that it was most likely the rea-* p$ N3 @- \# e/ u
son for the child’s virilization. At that time, they/ X' |9 L. S) D* r/ j
decided to put the baby in a separate bed, and the# k0 h0 i( c6 M0 ]' u
father was not hugging him with bare skin and had
4 U7 M. ]4 p" c& ^# V1 X# R$ L P8 ^been using protective clothing. A repeat testosterone4 C, j7 {5 B( ~" q
test was ordered, but the family did not go to the+ f. Z j- y$ m& P( g/ N& C
laboratory to obtain the test.
/ N9 ]! K" `) Z3 J. u) y5 L" sDiscussion) @3 r. N! b. {- d, W
Precocious puberty in boys is defined as secondary
1 f z8 j! e8 H9 hsexual development before 9 years of age.1,4! r" i0 V: p6 Z4 B
Precocious puberty is termed as central (true) when
% k8 J' w- @: S* I4 \7 Lit is caused by the premature activation of hypo-
2 v3 w. U3 {% e. I. Tthalamic pituitary gonadal axis. CPP is more com-
3 P1 ]9 Y5 X! L" Z& x8 \, Kmon in girls than in boys.1,3 Most boys with CPP; r, S8 M! X$ }+ U
may have a central nervous system lesion that is) x) T8 T9 b8 I1 B
responsible for the early activation of the hypothal-. [* H' u- f% F5 a+ }8 A
amic pituitary gonadal axis.1-3 Thus, greater empha- {) O8 {& I5 I9 ]( u* t
sis has been given to neuroradiologic imaging in- o& q9 v! {6 h* B
boys with precocious puberty. In addition to viril-
9 C4 V" K# B2 d, [. f7 K0 pization, the clinical hallmark of CPP is the symmet-* y) ~# @& C: k% Q; [% I
rical testicular growth secondary to stimulation by
* y8 W0 w) F/ S; S/ I3 Hgonadotropins.1,3+ ]$ Q+ s# Q: {. T" A, ?6 H, a) c
Gonadotropin-independent peripheral preco-) }9 b; N: x B
cious puberty in boys also results from inappropriate; \2 F P) G9 z6 L# R' b8 R6 i
androgenic stimulation from either endogenous or
2 B* G, p0 a8 ~- n1 l/ a J2 Hexogenous sources, nonpituitary gonadotropin stim-; @! I# W# ^. m
ulation, and rare activating mutations.3 Virilizing! o" K, R0 |3 d
congenital adrenal hyperplasia producing excessive
8 h# W0 i( {/ t2 Aadrenal androgens is a common cause of precocious) q0 H8 j. F8 I1 w {4 q* P. w4 d
puberty in boys.3,4# V F3 S% d0 \ V( t0 [" y
The most common form of congenital adrenal# F' U( C1 t& H# j6 A6 M2 x
hyperplasia is the 21-hydroxylase enzyme deficiency.1 M6 C& B8 U8 z2 ^- l
The 11-β hydroxylase deficiency may also result in% R! G) h! s( a3 U3 `& t
excessive adrenal androgen production, and rarely,
$ r; J% Z/ s: ~an adrenal tumor may also cause adrenal androgen
. A; z3 X! Q/ b% d4 f2 S9 r lexcess.1,37 Q/ b+ y8 c: s) s5 |9 y* M& u, R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) ?% E; U7 g; a- x) I7 r) |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; V1 Q; T+ R5 G/ l c, B$ K2 Z
A unique entity of male-limited gonadotropin-
/ _! w N) O" A! @) t# j dindependent precocious puberty, which is also known
* x% m- E, A7 H2 D2 ]1 xas testotoxicosis, may cause precocious puberty at a( G+ g L& E$ g+ P# T/ o6 F
very young age. The physical findings in these boys2 L3 b1 i; k) P# G
with this disorder are full pubertal development,
8 u( r/ ?4 M2 B& y5 |4 q) A8 Gincluding bilateral testicular growth, similar to boys
8 H, J0 v: n3 n1 S( v1 @+ {$ gwith CPP. The gonadotropin levels in this disorder4 X# O0 E+ b/ E% e9 g1 P }
are suppressed to prepubertal levels and do not show
9 o4 [& c+ L& M' e7 `7 `pubertal response of gonadotropin after gonadotropin-
- _, K# \4 g. D( }: u7 N6 J ?/ }releasing hormone stimulation. This is a sex-linked1 X- \ Q" c9 L9 S+ A& x
autosomal dominant disorder that affects only s7 q* I' j! S0 P0 j3 ?2 ^/ I% I0 y' Y
males; therefore, other male members of the family
( n1 |" P/ j% ~1 lmay have similar precocious puberty.36 |) r M# b0 U
In our patient, physical examination was incon-
. H) U7 p2 D9 H% u! O* t' ssistent with true precocious puberty since his testi- w5 h3 j# f7 d' m+ q! c6 I
cles were prepubertal in size. However, testotoxicosis; t( \( V) a! N& o4 h
was in the differential diagnosis because his father' c6 f0 t( j2 O
started puberty somewhat early, and occasionally,
. E$ \% N7 b+ G8 a! A3 q, E5 ]- n0 {testicular enlargement is not that evident in the A" O8 A/ Y9 T
beginning of this process.1 In the absence of a neg-
2 E7 F2 F* a( g/ ~ative initial history of androgen exposure, our
4 x: b# K4 x. i1 k. hbiggest concern was virilizing adrenal hyperplasia,
: K0 b8 R# W2 R2 [. L; p8 s2 X; ]either 21-hydroxylase deficiency or 11-β hydroxylase, `) p+ E& A: @5 I: K
deficiency. Those diagnoses were excluded by find-, n0 Q9 |% Z% x1 F" X+ O+ D
ing the normal level of adrenal steroids.
2 {. s1 {! J- O Y8 J2 H# DThe diagnosis of exogenous androgens was strongly+ Y& z2 Y* z. y% L
suspected in a follow-up visit after 4 months because
9 _2 B v8 L( E! C2 @7 Ithe physical examination revealed the complete disap-6 X1 @* x+ A2 P+ G9 B9 c5 B
pearance of pubic hair, normal growth velocity, and6 d$ t! E2 d: l
decreased erections. The father admitted using a testos-4 \) J: [ C$ |' B
terone gel, which he concealed at first visit. He was
2 |0 b0 e& e7 S: Cusing it rather frequently, twice a day. The Physicians’
& s$ T' n2 @" V2 g* M0 L5 ]Desk Reference, or package insert of this product, gel or7 X! U) O: r% y5 m- W
cream, cautions about dermal testosterone transfer to
$ {( `- f! x# `5 @' v' tunprotected females through direct skin exposure.
6 ~$ z8 y" I$ x( L" nSerum testosterone level was found to be 2 times the2 t b! d; ?- S6 _
baseline value in those females who were exposed to# u9 ]: F% o, w$ [
even 15 minutes of direct skin contact with their male! o8 o! |+ g" B! i4 f
partners.6 However, when a shirt covered the applica-
, D: I7 K, s- j% B# @) o2 ~4 ption site, this testosterone transfer was prevented.5 u! v+ M& I u1 y1 L
Our patient’s testosterone level was 60 ng/mL,2 T/ ^7 T: \: O+ _% Q& I% j
which was clearly high. Some studies suggest that V1 y# k+ g9 ?9 F
dermal conversion of testosterone to dihydrotestos-/ d5 o! @& t3 I; h" V! \; w/ w7 V( e
terone, which is a more potent metabolite, is more8 x& F6 G7 q8 M# `3 \* o, D
active in young children exposed to testosterone& d) D5 y8 _5 f1 f A0 v& m
exogenously7; however, we did not measure a dihy- S) g4 _, P* l+ }1 T! g. u6 |
drotestosterone level in our patient. In addition to2 \4 ?0 ]) c9 ~" d( Z- @
virilization, exposure to exogenous testosterone in
' G$ K/ `8 d3 A3 _$ `0 Pchildren results in an increase in growth velocity and' p$ x4 H2 T. f! B, J/ ^1 z( G
advanced bone age, as seen in our patient.* H- p* ?$ g: S3 D4 k
The long-term effect of androgen exposure during
& D2 y3 Y! r9 g4 Q) d! Pearly childhood on pubertal development and final' o l0 K0 k& u" h9 _* |. _- Q
adult height are not fully known and always remain5 [( A5 e+ S7 s+ L, t
a concern. Children treated with short-term testos-
9 J; q- H$ R4 Gterone injection or topical androgen may exhibit some
( F# ]/ z8 a% n5 B- y! n$ kacceleration of the skeletal maturation; however, after
" b1 X4 v* X, X) }' Jcessation of treatment, the rate of bone maturation
2 R {5 e( v# f. ddecelerates and gradually returns to normal.8,9$ W1 a* P5 Z" w/ O1 f! M
There are conflicting reports and controversy
. b0 ~. @# B' g: E' }/ Bover the effect of early androgen exposure on adult
) @2 C) F9 O5 t& q: apenile length.10,11 Some reports suggest subnormal! B- Z w; ~! M* L) D
adult penile length, apparently because of downreg-
' k' F+ T; s4 m, w( a5 ]% q! sulation of androgen receptor number.10,12 However,
) F6 @ u+ @* a0 I. I" N1 |Sutherland et al13 did not find a correlation between5 V. f: `1 W/ }! _' J
childhood testosterone exposure and reduced adult
+ N3 _+ L; e5 s* w1 D K2 _; |0 l; Xpenile length in clinical studies.0 Z1 [* H0 C Y l3 D
Nonetheless, we do not believe our patient is9 }3 _2 t/ b, X @3 f
going to experience any of the untoward effects from
+ L$ ~7 {0 U9 ?4 P1 etestosterone exposure as mentioned earlier because
: {0 B6 A% P9 G+ G1 Vthe exposure was not for a prolonged period of time.$ M( t- y+ @) j2 o' V2 |& Y# @
Although the bone age was advanced at the time of
. Z2 i: X4 Y- a. P) Pdiagnosis, the child had a normal growth velocity at
- ^; T3 w. B7 e2 n0 R ethe follow-up visit. It is hoped that his final adult; Z7 m# w" k/ U4 u5 `
height will not be affected.' b4 p6 z" b% e3 C2 z
Although rarely reported, the widespread avail-
3 O- F5 O" K- i+ [9 i9 ~ability of androgen products in our society may
" r2 A9 {% z# F% {indeed cause more virilization in male or female
& o; W1 S5 Y; y cchildren than one would realize. Exposure to andro-
% x. `5 u. o/ d- C3 s" Lgen products must be considered and specific ques-
+ L# u2 z% V- d' `$ k+ \0 ktioning about the use of a testosterone product or. Y5 o' T6 ?. T5 K* S" ^0 @
gel should be asked of the family members during
2 r! |8 u! J9 E3 J5 U+ k5 cthe evaluation of any children who present with vir-
6 T C w8 w; B1 hilization or peripheral precocious puberty. The diag-
0 v7 \6 D& s( b3 cnosis can be established by just a few tests and by7 n( f' [* G8 q6 ~2 Y2 @/ f W
appropriate history. The inability to obtain such a
1 H8 T4 m4 d9 `# r/ x# P, Xhistory, or failure to ask the specific questions, may
6 ^6 }& u: R: gresult in extensive, unnecessary, and expensive2 ~5 }: l+ b+ v3 n- E( k
investigation. The primary care physician should be; y/ m% J+ \4 `6 a
aware of this fact, because most of these children
6 t3 ~' k+ l* t ^1 M2 J7 N: }6 p3 S3 hmay initially present in their practice. The Physicians’
# l, H" p# f- K: K# ODesk Reference and package insert should also put a: D5 y- X+ m4 p2 M. S9 C' p$ E
warning about the virilizing effect on a male or+ g! H2 q* V: d
female child who might come in contact with some-
' S, X* M8 c. S9 `one using any of these products.3 D. b4 J# L/ Q; P9 E- t% V
References* W4 {: M# v, ]) M, V7 W
1. Styne DM. The testes: disorder of sexual differentiation
1 W: W3 Y" ^5 ?* }and puberty in the male. In: Sperling MA, ed. Pediatric
- W0 s q+ `2 m3 R- kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( }+ Y: f7 d, q6 Z" x: ^, g
2002: 565-628./ G9 m4 g- w; _' [: ?5 K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, c; B5 C* S8 A, E S* n d$ hpuberty in children with tumours of the suprasellar pineal |
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