- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old& w2 g% ^4 J- _. I; w+ {: n
Boy Induced by Indirect Topical4 j/ B& Y* m( H5 O7 p4 P
Exposure to Testosterone
* U- {: i- ?# r$ E3 `" V1 { E# e( @Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 j) O6 D8 k; n1 L, \0 R
and Kenneth R. Rettig, MD1, X' K+ w, f, H1 O- z$ |/ S7 _. T
Clinical Pediatrics; W. J; X4 @0 K" j+ r( _
Volume 46 Number 6
( J3 c/ e! h1 A {* Y3 WJuly 2007 540-543
+ q& t/ e- A; U; m, j7 A! x© 2007 Sage Publications6 ]# K) R2 o4 v5 Z: j$ _
10.1177/0009922806296651, K. I; d( I5 D% a6 |: S
http://clp.sagepub.com! ?5 Q/ T* m ~; }- {) ^0 d% k
hosted at7 w. ~) K9 y8 e" e
http://online.sagepub.com
. ~4 d z; P# {! m' i) _$ {Precocious puberty in boys, central or peripheral,/ Z7 h# U- W9 h, Q8 u
is a significant concern for physicians. Central! A" U/ Q H: J) ~. [* n
precocious puberty (CPP), which is mediated
4 D5 X0 `' i( T6 _% V4 O7 Ethrough the hypothalamic pituitary gonadal axis, has! y; I" r6 I4 A) l2 Q; x/ g& u+ m5 X
a higher incidence of organic central nervous system0 @7 f5 {" H3 M8 P
lesions in boys.1,2 Virilization in boys, as manifested" K9 g6 G/ {) H7 [/ D9 h/ I
by enlargement of the penis, development of pubic4 j) M$ b% I+ }+ {4 |& w
hair, and facial acne without enlargement of testi-
1 h, T4 z3 x, J# r4 Y! c& ~cles, suggests peripheral or pseudopuberty.1-3 We" s" Y6 Q8 w# w, W' Q: Q6 T
report a 16-month-old boy who presented with the
3 b. F: U2 g% I/ x3 \2 [- uenlargement of the phallus and pubic hair develop-1 K& }; Q9 C; {0 T- }
ment without testicular enlargement, which was due$ C' c+ Z/ ^4 q; Q5 S
to the unintentional exposure to androgen gel used by3 [8 {' N9 b; h P
the father. The family initially concealed this infor- I1 m' r( _, L% R% X# v. p0 |$ c
mation, resulting in an extensive work-up for this" j) i- k, k6 |$ l* @9 O- h( T* x9 c
child. Given the widespread and easy availability of
) ], m4 s/ Y: W. I" C8 Rtestosterone gel and cream, we believe this is proba-
& m$ X/ M1 g+ b% H9 Jbly more common than the rare case report in the; }! d/ E! V( q- W1 N5 o$ m0 r
literature.4 q7 \& ~/ e4 \9 Q
Patient Report& z6 Q' ^, X) X! W' D$ J1 O8 s
A 16-month-old white child was referred to the. s* g; A. J( g& e P
endocrine clinic by his pediatrician with the concern
2 `# e* O, I J" a; |& {of early sexual development. His mother noticed
( E% q/ `- `6 R" g' D Flight colored pubic hair development when he was
; i7 R- _% U& q. ^. b8 ~From the 1Division of Pediatric Endocrinology, 2University of
% T& Q0 l2 b: ^South Alabama Medical Center, Mobile, Alabama.
6 D& a Y7 u$ l. T; pAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 W$ i: b' u8 C& T6 S7 HProfessor of Pediatrics, University of South Alabama, College of5 T7 x) u0 S) |8 c' d/ g3 p6 D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ H8 Q, @+ I& |* x' H
e-mail: [email protected]." H! s% k& f5 ^+ x' M
about 6 to 7 months old, which progressively became
0 k# R$ \4 z! ~darker. She was also concerned about the enlarge-; q0 G7 @0 V& I) U2 m( I
ment of his penis and frequent erections. The child3 m8 z2 A9 w! A8 ^' W, C
was the product of a full-term normal delivery, with0 y6 U: X% o I) H3 ~# Z! D5 ^* K
a birth weight of 7 lb 14 oz, and birth length of: x0 N4 w v0 J, K3 D# v
20 inches. He was breast-fed throughout the first year
n1 D& U/ v( q1 ^* |of life and was still receiving breast milk along with& U. c: |9 `5 _* p& \* S6 t
solid food. He had no hospitalizations or surgery,
6 K# Q5 }. S. Z" y8 X S: Vand his psychosocial and psychomotor development( O7 Q8 T+ s( V5 [+ e
was age appropriate.
5 k5 K6 _( N- Z! v$ J' eThe family history was remarkable for the father,/ H* g" F1 R ~: Z5 {
who was diagnosed with hypothyroidism at age 16,9 w4 d% f9 ?9 a3 X" t6 M
which was treated with thyroxine. The father’s
5 b" N. ~; j% q0 i% L! Y" |, hheight was 6 feet, and he went through a somewhat4 k2 g6 K/ n2 s% p' S9 @
early puberty and had stopped growing by age 14.
, W) E6 `0 v2 K" hThe father denied taking any other medication. The3 O/ ?( {! N. N1 J6 o9 D! ^2 f
child’s mother was in good health. Her menarche
/ `' r# ]( Q8 s$ uwas at 11 years of age, and her height was at 5 feet1 ~( R% z g `: D+ w
5 inches. There was no other family history of pre-0 H' c; B& H# m4 ^* Y% y$ \* t
cocious sexual development in the first-degree rela-
. K% w) G" V# ?; V6 l: q# vtives. There were no siblings. F% [9 T7 B, t7 `( w& }: e
Physical Examination
% ^: z3 ~3 D G7 i8 gThe physical examination revealed a very active,5 A$ v" ^' }6 g4 \3 @
playful, and healthy boy. The vital signs documented. m0 K" ?4 N- F& p; R
a blood pressure of 85/50 mm Hg, his length was3 {/ t8 C' l% y; i
90 cm (>97th percentile), and his weight was 14.4 kg
2 H: J5 ^& H* R4 ^(also >97th percentile). The observed yearly growth
) B# s( h J# T5 mvelocity was 30 cm (12 inches). The examination of
0 |' h6 ?0 [7 ~* ]2 p: Y Bthe neck revealed no thyroid enlargement.
1 h; b$ ~8 v1 q. jThe genitourinary examination was remarkable for% W) N# u) z5 |: [" O7 l9 V. }3 q
enlargement of the penis, with a stretched length of
+ w4 A) A0 `2 E. @: G2 ^8 cm and a width of 2 cm. The glans penis was very well1 I& ]/ Z3 n5 c5 n W, e
developed. The pubic hair was Tanner II, mostly around
( f2 D( {$ j, q h* ~) H |0 h540& c- ^ x% o+ D, _! @5 H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- y' k5 i3 q* @8 A4 i6 G- m
the base of the phallus and was dark and curled. The' d" |4 G' V. {6 |; B
testicular volume was prepubertal at 2 mL each.% X7 ^9 P K2 {) j1 l3 m% Q8 |
The skin was moist and smooth and somewhat4 }* N8 \& R% J: s
oily. No axillary hair was noted. There were no( A% I0 s1 b' U* e! b3 ^8 d
abnormal skin pigmentations or café-au-lait spots.
3 J9 G6 o' k7 Y6 E( CNeurologic evaluation showed deep tendon reflex 2+
$ i2 e/ W5 j3 x, cbilateral and symmetrical. There was no suggestion
/ q3 g( N5 o+ k3 q9 h9 m6 u1 U4 y4 t$ kof papilledema.
5 X$ Q& n' L; I8 P" d, W* _% j. O5 b, cLaboratory Evaluation
: R5 ?9 r ?. f% EThe bone age was consistent with 28 months by- Y) M9 G, N6 K: b: m1 m: }
using the standard of Greulich and Pyle at a chrono-
; K7 @& i& ^ X. B* p1 ~logic age of 16 months (advanced).5 Chromosomal: n" i7 j" n, X
karyotype was 46XY. The thyroid function test# B( ]' g/ z' W* ~4 w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ y! W9 t# S2 D$ Q/ blating hormone level was 1.3 µIU/mL (both normal).& }6 P% \- \/ `: X
The concentrations of serum electrolytes, blood- z5 D# O( e8 J3 H# p
urea nitrogen, creatinine, and calcium all were
, U& G5 F3 @6 A7 Vwithin normal range for his age. The concentration
8 s) W) E; S6 @of serum 17-hydroxyprogesterone was 16 ng/dL
9 f( Y+ m0 ]- d* P" Q! Z(normal, 3 to 90 ng/dL), androstenedione was 20
7 {2 @* y1 k* }. Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! A* `* F& _7 U' Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 j/ w* H4 I5 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% g$ Y) @) Q6 R* t! v8 [49ng/dL), 11-desoxycortisol (specific compound S)4 L, m4 y. K; J4 t; J+ r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 q9 I( v8 E \% H \8 K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 A9 ]# n+ O6 R- J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 {, D5 |( a. T7 c
and β-human chorionic gonadotropin was less than
. n7 b( E- j9 ]9 X( D5 mIU/mL (normal <5 mIU/mL). Serum follicular0 p8 ]$ s# C+ ]' y
stimulating hormone and leuteinizing hormone7 o' L9 O# u8 s* `4 I
concentrations were less than 0.05 mIU/mL
# x" F% g9 B* h+ \+ R9 R# X3 {4 @(prepubertal).4 I! n3 I5 q' b7 T' I+ S
The parents were notified about the laboratory
0 ~: }; O/ R7 s- J- cresults and were informed that all of the tests were
0 B- {. q% ?. y8 a; S. rnormal except the testosterone level was high. The5 I% O% d' d7 @+ N: l) }! q6 B
follow-up visit was arranged within a few weeks to) O# }, d: r K5 g2 C: }
obtain testicular and abdominal sonograms; how-
1 O" a; a+ k. k* c. d6 i( Lever, the family did not return for 4 months.
! L! T: ?% H/ ?/ h( H$ KPhysical examination at this time revealed that the
% \& @0 F) |+ H# R1 w- zchild had grown 2.5 cm in 4 months and had gained
& h G7 j- G3 |* N/ _8 j, l2 kg of weight. Physical examination remained
" C; ~$ X; n* x) iunchanged. Surprisingly, the pubic hair almost com-
/ w! Z5 g. ]5 s/ M+ fpletely disappeared except for a few vellous hairs at( n' D7 M; B1 p4 u4 d
the base of the phallus. Testicular volume was still 2* \$ x$ V, Z/ X) m3 b3 O2 ?
mL, and the size of the penis remained unchanged.
2 N8 \$ W! @6 u6 q0 S, V/ }The mother also said that the boy was no longer hav-6 Q5 p" Y9 E( E6 N6 d* s- u }
ing frequent erections.: U- }) q4 `/ g6 v& |/ N4 J
Both parents were again questioned about use of
' y) |" c o, p) H( yany ointment/creams that they may have applied to b% c2 i' C) V3 Z" g
the child’s skin. This time the father admitted the3 h' L" r4 y. R, e ?
Topical Testosterone Exposure / Bhowmick et al 541' r$ V; Z3 l: W! h3 c9 G
use of testosterone gel twice daily that he was apply-4 d. J! H1 R4 E y3 G
ing over his own shoulders, chest, and back area for5 B5 J& L- K2 _( ?0 s e# ]) B; E, e+ [
a year. The father also revealed he was embarrassed
4 p$ }. Y" Y* o! Bto disclose that he was using a testosterone gel pre-- G" ~3 U: A% D6 \( q
scribed by his family physician for decreased libido
/ Q' I* @4 T/ s7 [ ssecondary to depression.
2 Y6 b% x( j3 B& W( Z9 EThe child slept in the same bed with parents.
/ j* K2 g# D s, z' m: \The father would hug the baby and hold him on his
% o$ p3 U) W! o4 w6 A; N) Mchest for a considerable period of time, causing sig-3 L0 C4 X& T# {
nificant bare skin contact between baby and father.* M5 l$ Z% J! A$ {0 S& J# ]
The father also admitted that after the phone call,$ S# z! o0 |8 C9 V
when he learned the testosterone level in the baby
$ I: U: L& y6 f$ ]( T! |was high, he then read the product information. {: b! C3 H8 X+ K" @! B. n9 P
packet and concluded that it was most likely the rea-
2 X. T8 |" n |: f( { x" Oson for the child’s virilization. At that time, they
% {9 N% B& J2 Z; Wdecided to put the baby in a separate bed, and the( X( X2 v$ K1 Y7 l
father was not hugging him with bare skin and had
1 z5 Z6 J) V$ obeen using protective clothing. A repeat testosterone1 v% y; R; F# d( \
test was ordered, but the family did not go to the& D4 Z; r2 n9 b+ t6 E( n* v
laboratory to obtain the test.0 X2 Z' |+ @/ Y$ ^6 Z
Discussion
% ~: U1 u; }) ?Precocious puberty in boys is defined as secondary: |. ~+ n F0 ]6 `1 S
sexual development before 9 years of age.1,4
# p* f1 _ ?# W" J+ K* gPrecocious puberty is termed as central (true) when
$ O. S& v1 U. M+ q5 Wit is caused by the premature activation of hypo-
7 p5 C4 R3 ~+ a" n- o0 X: N! t) W/ fthalamic pituitary gonadal axis. CPP is more com-
: f' s; @: @6 d6 S6 v0 q6 Umon in girls than in boys.1,3 Most boys with CPP
3 |! k) {, i/ ~0 h0 j$ Hmay have a central nervous system lesion that is
* O& r( U7 O" f* Y6 A9 \) [" yresponsible for the early activation of the hypothal-4 X$ L( }4 Z; ~! N a
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 y1 t4 F) B5 ]0 t x3 h8 bsis has been given to neuroradiologic imaging in
; ^+ l4 B& O1 X/ i1 x# w: T. m* mboys with precocious puberty. In addition to viril-9 {# t8 Y) M- A' k/ @6 j
ization, the clinical hallmark of CPP is the symmet-
. o% _) m$ j6 d! t: y4 u8 Orical testicular growth secondary to stimulation by
: c) R/ T4 b3 R8 k/ Igonadotropins.1,3
7 n- Q: a, w' W7 j3 W# J' D* ^- ^0 CGonadotropin-independent peripheral preco-
7 q: |6 { v0 }5 W2 j$ K$ P, k; j! ccious puberty in boys also results from inappropriate
1 ~( M% m+ C( Y% o; p9 ?1 j% g) R$ ^androgenic stimulation from either endogenous or& b! d* S6 A& d% t: ]0 H$ S
exogenous sources, nonpituitary gonadotropin stim-% G3 Q; y' W# Q. c' D
ulation, and rare activating mutations.3 Virilizing
, G7 A8 O1 B& `, ycongenital adrenal hyperplasia producing excessive f9 v/ u& h3 L
adrenal androgens is a common cause of precocious
5 G4 i8 A9 o" B% e6 xpuberty in boys.3,4$ {* k( ~* F0 h ?& w4 i) _$ f
The most common form of congenital adrenal
/ A7 Q/ k# h( r" Y! H3 W8 fhyperplasia is the 21-hydroxylase enzyme deficiency.
& ^: d$ l1 R( b5 X8 ?* pThe 11-β hydroxylase deficiency may also result in
# y0 f# v3 ^" j4 @+ X, f/ n) ]excessive adrenal androgen production, and rarely,; E8 r; z: e- x) o
an adrenal tumor may also cause adrenal androgen
. q6 B! ]2 d2 H# X" f/ t# k1 rexcess.1,3; t( C0 [3 ?' f% ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; R- i! `' v- z$ r' w542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 M# U4 I7 Z7 B
A unique entity of male-limited gonadotropin-2 k6 u1 I8 @& H$ [* I6 M9 k
independent precocious puberty, which is also known
+ {& h( A# a- E, Kas testotoxicosis, may cause precocious puberty at a5 i4 q1 J; ?4 s+ d. J* U$ A
very young age. The physical findings in these boys
1 v- S9 K& e: ]; r; s7 j) ?2 n8 iwith this disorder are full pubertal development,7 c4 P: ^1 ~) X/ P* _
including bilateral testicular growth, similar to boys% m! k" P: B7 R) M, S
with CPP. The gonadotropin levels in this disorder% F4 r# [& d* s
are suppressed to prepubertal levels and do not show
$ z) h) ?0 e9 D/ Apubertal response of gonadotropin after gonadotropin-
6 t, V' w, Z) P7 ]% xreleasing hormone stimulation. This is a sex-linked
! I4 T2 N9 P8 [* V) U4 Uautosomal dominant disorder that affects only
, _1 o, r5 {3 d# umales; therefore, other male members of the family& d6 v8 h Q! B! T0 f
may have similar precocious puberty.3
9 [- z+ @% V- ^# J, [' vIn our patient, physical examination was incon-
" `. Y4 j0 O: o1 t; ]6 `* Vsistent with true precocious puberty since his testi-
& d: M# N; w" A wcles were prepubertal in size. However, testotoxicosis
$ p7 ^7 ^. a' j6 ]# `was in the differential diagnosis because his father; N7 _+ z, ]. e. y
started puberty somewhat early, and occasionally,
3 U, K1 W+ D7 g) I0 _testicular enlargement is not that evident in the( R9 r% T; m- m5 O+ L' N
beginning of this process.1 In the absence of a neg-. t* d1 |( K' S: W1 \. Z' W+ J
ative initial history of androgen exposure, our9 o5 E k8 ^1 ]7 n& R
biggest concern was virilizing adrenal hyperplasia,( j9 v+ q# X8 P
either 21-hydroxylase deficiency or 11-β hydroxylase
7 c6 }# g6 s, b$ ?% b, q+ Mdeficiency. Those diagnoses were excluded by find-/ s4 x9 ^2 P1 _/ k8 _: S
ing the normal level of adrenal steroids.
, ?0 c; v5 |! |, g2 t7 EThe diagnosis of exogenous androgens was strongly F( U6 F, j- B7 a
suspected in a follow-up visit after 4 months because
) M4 M. `- v2 g0 S4 ~the physical examination revealed the complete disap-
7 I, z) ^0 q. ^+ u1 `% {pearance of pubic hair, normal growth velocity, and
6 g! s& R* l* S' f% Ndecreased erections. The father admitted using a testos-
8 S2 q6 \: B; M: B7 } ]. Fterone gel, which he concealed at first visit. He was
/ G: }2 _0 y5 v7 k/ N7 Vusing it rather frequently, twice a day. The Physicians’
* u) p: V; O7 K: @ l8 h$ kDesk Reference, or package insert of this product, gel or8 u* N- z4 g9 x l7 j
cream, cautions about dermal testosterone transfer to
+ W$ Z; j6 z6 U" A. eunprotected females through direct skin exposure.+ O. a6 u2 j0 c. Z6 L
Serum testosterone level was found to be 2 times the
V' z3 T" i5 x; w# }$ ]; lbaseline value in those females who were exposed to! `3 k: E6 r; F- [* U9 H
even 15 minutes of direct skin contact with their male
A* v: c* o0 T% m. W- {partners.6 However, when a shirt covered the applica-. v; F- |. R1 C, R& p& E
tion site, this testosterone transfer was prevented.3 x% X0 n- K2 a1 ?& E$ c
Our patient’s testosterone level was 60 ng/mL,; ?7 t$ F/ c* B# \- d K) [
which was clearly high. Some studies suggest that0 ]( w- {5 |* o; d
dermal conversion of testosterone to dihydrotestos-
6 k( C. z; k3 b' w: d7 w) C7 Pterone, which is a more potent metabolite, is more
8 i# ?7 |4 ] M) `7 Jactive in young children exposed to testosterone
6 o0 r; _& y5 j2 texogenously7; however, we did not measure a dihy-
5 g( @+ s! T# }+ f& e( ddrotestosterone level in our patient. In addition to* X; j7 A" c- s( v2 ?2 W+ X
virilization, exposure to exogenous testosterone in4 g4 n- o1 i- U4 v* S
children results in an increase in growth velocity and
8 J# R6 Q9 n- }$ M; padvanced bone age, as seen in our patient.$ [2 T$ E$ P$ D" I% a5 l% y( p
The long-term effect of androgen exposure during/ N7 D5 B7 V+ F
early childhood on pubertal development and final
2 ^6 {& Q. W5 `& n' P9 s1 O! a0 Eadult height are not fully known and always remain
1 ~4 e F5 d/ S2 y, ]" ka concern. Children treated with short-term testos-
9 J0 g' t* L/ N/ V4 Xterone injection or topical androgen may exhibit some
5 o8 k7 U% r( w' p, Cacceleration of the skeletal maturation; however, after
3 f* Y' X2 b5 ucessation of treatment, the rate of bone maturation& C; Z; X; N/ H2 {% L' `" M5 V
decelerates and gradually returns to normal.8,90 g- S$ B! I) Q' w+ L H) a% Z
There are conflicting reports and controversy) I) q) J. I8 k$ I: A
over the effect of early androgen exposure on adult/ W8 W! [- m2 H0 `, L: t. V
penile length.10,11 Some reports suggest subnormal
' T! _& x* r* W7 }! ~9 c6 ^# vadult penile length, apparently because of downreg-
: E7 F/ V& t" Kulation of androgen receptor number.10,12 However,, @. [, F: q! l8 Y8 @) S
Sutherland et al13 did not find a correlation between1 h: D K9 z8 y- \- J8 w/ p( M! U
childhood testosterone exposure and reduced adult
3 M6 N8 {4 c6 t5 A, R9 u. Openile length in clinical studies.
% p( D! d1 ?! |+ z# SNonetheless, we do not believe our patient is
* Q3 C+ J' u. ~( U$ Qgoing to experience any of the untoward effects from& T" N" t& h' C$ ]; i
testosterone exposure as mentioned earlier because
! u& h+ e, o3 ]" [the exposure was not for a prolonged period of time.4 c$ [# e6 H, k/ u8 b: ]4 T9 W
Although the bone age was advanced at the time of
6 Y' t0 _4 R9 L9 O5 O7 Ydiagnosis, the child had a normal growth velocity at
) F% f5 o# _9 h+ E( A) u1 g9 [the follow-up visit. It is hoped that his final adult
) R" l! Y/ g& }: qheight will not be affected.4 F7 d- z5 K# L# Z: T
Although rarely reported, the widespread avail-! l0 H! \1 [# g$ g( c, d7 G
ability of androgen products in our society may3 D( Q6 Z$ ]( ~ w3 k, ~/ B' G
indeed cause more virilization in male or female7 r2 N# [5 M: q% [& u# T, m$ W
children than one would realize. Exposure to andro-
1 R' Y- J3 w+ S+ P) J; `. G5 zgen products must be considered and specific ques-
% ^; A% E. C' L$ ]$ vtioning about the use of a testosterone product or
/ o. M! W6 Q1 z) ~8 ygel should be asked of the family members during7 y: L2 ^; c* Y
the evaluation of any children who present with vir-
: k. K& ^6 c) m9 L, A/ m+ Rilization or peripheral precocious puberty. The diag-
9 b z! j& ~; Rnosis can be established by just a few tests and by
& K: f' d. [1 _" Q5 ]appropriate history. The inability to obtain such a
4 k! s6 i& `# ?" i$ d; {history, or failure to ask the specific questions, may
+ p5 z/ ]/ `& @' |3 dresult in extensive, unnecessary, and expensive( z1 v, X |7 D" M7 U
investigation. The primary care physician should be4 }/ L& w/ ?* N% [& c1 h& t
aware of this fact, because most of these children. R2 |: {, Z" |, M0 m
may initially present in their practice. The Physicians’$ M7 L) {' K( _9 q
Desk Reference and package insert should also put a2 c+ Y6 L& M& \/ h9 y
warning about the virilizing effect on a male or* g/ E6 j/ E3 f# E) z7 e
female child who might come in contact with some-6 M/ B$ u+ Q5 X5 Y; w& T$ Y, K6 X
one using any of these products.
( x0 `% R% Z, MReferences( B' C( m* c" I
1. Styne DM. The testes: disorder of sexual differentiation
& z2 ]. C, F/ U* eand puberty in the male. In: Sperling MA, ed. Pediatric
, T8 `7 t" D$ s( `/ ~+ ~% DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 }: |2 r$ f/ F$ h0 \
2002: 565-628.( X6 F S$ G( k$ z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* a1 z K3 i0 N3 a6 j# wpuberty in children with tumours of the suprasellar pineal |
|