- 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* E' g" A: f; m5 B7 Y8 {
Boy Induced by Indirect Topical' P3 n9 B$ H2 X1 f! v: T
Exposure to Testosterone
0 N! |, u9 U. T( y# k; c! w1 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ ^+ b$ y0 o4 U7 h
and Kenneth R. Rettig, MD1
9 s* h; N' |$ z+ _0 \" XClinical Pediatrics
$ t9 m$ n# @: ?5 K; s$ sVolume 46 Number 62 @! B9 K' G& z% [
July 2007 540-543
$ n) D. u- a2 m; V+ B; f3 M/ L© 2007 Sage Publications
# ?2 b) ^4 ^- [9 M6 ]10.1177/0009922806296651
4 |1 u" ]0 L L- phttp://clp.sagepub.com
- D/ }2 u3 v. i% f1 E& [hosted at
. P0 |2 S" ~* U* A$ d( Khttp://online.sagepub.com9 R( c+ n5 R- L; B0 p
Precocious puberty in boys, central or peripheral,5 j, q+ Y& ~ J- K
is a significant concern for physicians. Central
& g3 c/ p( }/ I( C, K4 `precocious puberty (CPP), which is mediated
& I9 S3 l& f# I* P Q# ^through the hypothalamic pituitary gonadal axis, has
0 P- k* P6 u' U/ ]1 F0 ma higher incidence of organic central nervous system4 i! R+ X, K% n6 Z
lesions in boys.1,2 Virilization in boys, as manifested
$ Z' x) l9 M6 z8 M4 g- |by enlargement of the penis, development of pubic6 I' K7 v% s, T3 s9 B R
hair, and facial acne without enlargement of testi-
7 H; v- R7 m( c7 N9 P0 F+ ]cles, suggests peripheral or pseudopuberty.1-3 We) d/ {3 D f( r8 X, A
report a 16-month-old boy who presented with the# L% l( X/ }2 b6 v; v/ |
enlargement of the phallus and pubic hair develop-6 j5 D5 [, p& T6 W: m
ment without testicular enlargement, which was due
5 j6 r: e/ M3 _to the unintentional exposure to androgen gel used by% D0 U9 t3 h3 ?0 ^) @: b
the father. The family initially concealed this infor- U w5 u0 S A: \+ Q
mation, resulting in an extensive work-up for this
# ~, O! C* ]! a j) T5 bchild. Given the widespread and easy availability of
" z2 `- C& d' k7 ]5 M+ Otestosterone gel and cream, we believe this is proba- i7 h v. x& k3 y* x/ L& V
bly more common than the rare case report in the
* q+ T; z- v9 s6 U6 p+ pliterature.40 S- S1 L/ k! w
Patient Report* Y0 @' t) k7 @1 a. A$ |: {
A 16-month-old white child was referred to the
- T1 ]# Z1 f- G6 ~4 E! x8 {! J; |. }/ fendocrine clinic by his pediatrician with the concern/ D3 W: {! k8 G# }; X; X* U
of early sexual development. His mother noticed8 S: x: L% b9 {
light colored pubic hair development when he was
( N" x* M2 q8 n; [2 r" MFrom the 1Division of Pediatric Endocrinology, 2University of, t8 x+ X; z+ E% Y. p. \) k4 U. ]
South Alabama Medical Center, Mobile, Alabama.8 |3 b X7 Y) m4 F9 e& {; r
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( w$ a, \; `, I8 `9 eProfessor of Pediatrics, University of South Alabama, College of" [ k7 S+ u8 b9 g* e4 @# n, H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 T, z. e( e, L9 b1 m6 ~e-mail: [email protected].
# `) L% W5 W8 e3 T3 ]8 q6 Habout 6 to 7 months old, which progressively became5 i" a, z5 p! S! W1 i; z. L
darker. She was also concerned about the enlarge-
' n' A6 [8 P( y3 J1 V' m9 \ment of his penis and frequent erections. The child
+ a2 ?% _; R' C7 e0 \/ M2 C9 Owas the product of a full-term normal delivery, with7 N i: |; _3 r, Y/ L. f
a birth weight of 7 lb 14 oz, and birth length of8 {3 c2 q4 q" [' j) K/ f; |9 b
20 inches. He was breast-fed throughout the first year5 |$ L2 w* a7 P9 U# F% G: F
of life and was still receiving breast milk along with
1 |7 S7 ^' C' d+ {* q2 c9 isolid food. He had no hospitalizations or surgery,
9 e) ^8 t7 t8 ]- c* Yand his psychosocial and psychomotor development% h0 g9 E W4 s; Z5 r
was age appropriate.3 X- j( u- m& I+ f- R6 S) ?; ^* }
The family history was remarkable for the father,6 p5 i8 I% r; h/ s5 O0 F: x; h
who was diagnosed with hypothyroidism at age 16, G- a- m" s/ r
which was treated with thyroxine. The father’s
5 I! E0 X/ K& g! D% s% N8 Hheight was 6 feet, and he went through a somewhat
+ E5 W* c) M T9 mearly puberty and had stopped growing by age 14.
, u' X$ i# M m9 f0 e, @, lThe father denied taking any other medication. The
+ U9 ?& M' N5 B1 C0 a* k" E2 ^child’s mother was in good health. Her menarche, K2 P/ f! o! g
was at 11 years of age, and her height was at 5 feet
1 X' t2 ~' y4 s$ K) C8 N4 i5 inches. There was no other family history of pre-8 o' N, L, M; c2 \" U+ R9 `9 E
cocious sexual development in the first-degree rela-
5 V4 a% B' Z/ z& Q( k6 n# Atives. There were no siblings.# K" V# H, q |, X1 }2 m0 o
Physical Examination% U5 e- w9 N7 r. M& i
The physical examination revealed a very active,
5 x! o% U1 w+ I! M$ lplayful, and healthy boy. The vital signs documented7 L" v' v' T" R
a blood pressure of 85/50 mm Hg, his length was' H% V/ J9 z; W, t) I* y
90 cm (>97th percentile), and his weight was 14.4 kg
- ]" K0 o* R2 U- }* i }(also >97th percentile). The observed yearly growth
0 k [5 u0 W5 @: zvelocity was 30 cm (12 inches). The examination of' e0 N+ Y- n8 u2 c1 m
the neck revealed no thyroid enlargement.# I( L. l6 b7 n- D# e) t8 S6 X
The genitourinary examination was remarkable for
( b; [1 } x# Q6 i @( penlargement of the penis, with a stretched length of
4 t4 o9 x' q$ |4 L5 e" C) n- h8 cm and a width of 2 cm. The glans penis was very well' |- s9 X. q% p; a! Z/ T. J5 \1 L
developed. The pubic hair was Tanner II, mostly around
( V, Z9 H Z% r540, g' x* r# W F2 K# @; C" U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( G6 g3 K% ^5 ^
the base of the phallus and was dark and curled. The' ^$ c3 ^5 T& s( q4 s/ K
testicular volume was prepubertal at 2 mL each.
4 v. z* a0 \1 d$ _The skin was moist and smooth and somewhat
% j0 W5 w) `0 xoily. No axillary hair was noted. There were no: [, `: ~3 K" u
abnormal skin pigmentations or café-au-lait spots.+ b2 x# C/ o: _" s& j
Neurologic evaluation showed deep tendon reflex 2+/ S# p; v3 [9 @) ^- z- h1 J* g
bilateral and symmetrical. There was no suggestion, C2 V; ^6 m* d$ a m; U1 g ?
of papilledema.
4 g4 c8 r2 I% B* [% ULaboratory Evaluation
7 ]- ^( R F5 t. _The bone age was consistent with 28 months by
6 ?0 ^! w: |9 o* Pusing the standard of Greulich and Pyle at a chrono-/ a' Y H' I6 Q
logic age of 16 months (advanced).5 Chromosomal0 C) {9 P$ s2 U! Z
karyotype was 46XY. The thyroid function test) U9 {0 k7 b. c, }) m; C/ Z; h: L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: \# |4 S9 F1 `1 U" J9 V6 ?
lating hormone level was 1.3 µIU/mL (both normal).
3 s3 b; w5 s4 p, s/ s1 o; zThe concentrations of serum electrolytes, blood: Q+ F* s) _8 S' R- s' Q l5 h
urea nitrogen, creatinine, and calcium all were
" w) g; |4 b3 F3 A* w) x6 Twithin normal range for his age. The concentration
. p$ j5 u; e4 F8 j- P* X" aof serum 17-hydroxyprogesterone was 16 ng/dL( v. N2 x& k# o7 ?
(normal, 3 to 90 ng/dL), androstenedione was 20: h1 O: A2 V4 f# y7 x3 d/ J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; a# X: s: {/ y$ @) L! o% g$ \* Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),; h @* z! i. K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
& C$ w1 T6 m. H# E49ng/dL), 11-desoxycortisol (specific compound S): z9 V# W8 [: R8 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 r- W( T( ]. |% z( q8 `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 G( d+ l+ n6 _! @) ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ o5 u+ h, q) I, h$ Z9 _$ vand β-human chorionic gonadotropin was less than- t4 o& h+ P' R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
@8 I, H, F8 l" f5 tstimulating hormone and leuteinizing hormone
7 l& V7 L! X& _0 l/ u: w1 Z3 uconcentrations were less than 0.05 mIU/mL
8 G$ F( |2 ] J) N(prepubertal).
K; U+ R5 E* ^: C' K. ~The parents were notified about the laboratory: i( ~$ b6 M# ^1 G! C& e
results and were informed that all of the tests were
+ K$ ^2 M) x+ Ynormal except the testosterone level was high. The0 B- D; W1 D2 f& s/ y. |
follow-up visit was arranged within a few weeks to8 x. Z- X- z4 o5 M2 |
obtain testicular and abdominal sonograms; how-8 d6 C- T, I& a- W. I( G' c! _* d
ever, the family did not return for 4 months.
3 x0 y- h% e1 ]3 VPhysical examination at this time revealed that the
, W: O5 m% _3 n* S$ `) ~child had grown 2.5 cm in 4 months and had gained! D# }% A! Y* a8 D$ ?- f
2 kg of weight. Physical examination remained
0 L7 l# w# g$ r3 C& p0 f6 G! ^unchanged. Surprisingly, the pubic hair almost com-
2 {/ j/ _; F7 l7 J) M8 q, ~pletely disappeared except for a few vellous hairs at
6 H5 z! ~ D4 V1 Q( R3 H* Q6 ]1 pthe base of the phallus. Testicular volume was still 2
4 ] K8 E/ u4 o, |! H$ D0 d% lmL, and the size of the penis remained unchanged.
" N A# g5 N$ K3 KThe mother also said that the boy was no longer hav-
0 \ V. [$ r$ e2 E$ T iing frequent erections.
+ Z; d2 m8 j2 _+ MBoth parents were again questioned about use of& G4 x( G: F3 c5 z( u
any ointment/creams that they may have applied to/ I# x6 B+ Y! b; g# I
the child’s skin. This time the father admitted the* q ` S' z/ h* c d- ~
Topical Testosterone Exposure / Bhowmick et al 541
0 c4 ~: W+ `2 H1 X: [ X4 x! \use of testosterone gel twice daily that he was apply-; W* {+ [( ~2 F. W! [
ing over his own shoulders, chest, and back area for/ n: s+ o- L) _! W0 x P% F/ j
a year. The father also revealed he was embarrassed6 B9 D! a) N% Y6 X6 o$ L% P
to disclose that he was using a testosterone gel pre-
/ t s2 h0 c, e- Tscribed by his family physician for decreased libido0 w8 g2 N; s I8 U+ S. d' ~% H
secondary to depression.
% b+ F6 @- t2 p9 L# dThe child slept in the same bed with parents.7 `* k9 P; O7 I. B+ V% c& ~' G2 c
The father would hug the baby and hold him on his
/ V& @2 I2 t' g+ I4 qchest for a considerable period of time, causing sig-
8 j0 K# V4 V7 Fnificant bare skin contact between baby and father.
. y" ]/ t( k7 Y/ t8 T d/ D' T! CThe father also admitted that after the phone call,$ x* M9 {% `8 G9 e
when he learned the testosterone level in the baby/ J! S# I8 L- N
was high, he then read the product information/ | x% d) L8 N I
packet and concluded that it was most likely the rea-
6 c& [3 b9 k7 U V+ i! ?son for the child’s virilization. At that time, they
5 m- Q2 T" f/ o4 c/ \decided to put the baby in a separate bed, and the* |" N s# J" B' E1 C* S' M/ v9 u
father was not hugging him with bare skin and had/ j2 f; ^( }: a9 l
been using protective clothing. A repeat testosterone
. C0 ^% u& @" n/ \, J. \3 Y( {test was ordered, but the family did not go to the
5 B1 Z/ h6 ?: l' M8 Ulaboratory to obtain the test.
2 U! ?' Q+ X( e, [( UDiscussion9 _6 R3 k) C# G
Precocious puberty in boys is defined as secondary; Y( ?9 ~) l- g7 [; l% @; E- i. ^5 T! g
sexual development before 9 years of age.1,4
9 s- b% _: H! K+ B1 y5 T* j) l& C# \Precocious puberty is termed as central (true) when/ E* W I1 q9 y9 ], k
it is caused by the premature activation of hypo-7 E: }$ ?2 i3 v9 K
thalamic pituitary gonadal axis. CPP is more com-
& l/ T f2 e# { Jmon in girls than in boys.1,3 Most boys with CPP9 l' f. g, |& Z* Y1 w
may have a central nervous system lesion that is
8 [- ~3 V! l( k* f6 I9 L% eresponsible for the early activation of the hypothal-
* V* I+ ^2 c. O+ Q% vamic pituitary gonadal axis.1-3 Thus, greater empha-( m7 ~3 H& u$ l, N1 K% {/ ]- q
sis has been given to neuroradiologic imaging in
9 b9 B% v6 \4 f- Jboys with precocious puberty. In addition to viril-
/ p& z& c/ H% W6 i: ?0 ]( Gization, the clinical hallmark of CPP is the symmet-/ q; P( l) K, v, k4 n0 Y
rical testicular growth secondary to stimulation by
) F$ i1 y1 A1 U0 Ngonadotropins.1,3
% ^, d. x- g, D) BGonadotropin-independent peripheral preco-
. s( M: w1 F5 P' Z3 Z9 J9 W3 N& Ycious puberty in boys also results from inappropriate
7 }! r% p6 |1 H1 nandrogenic stimulation from either endogenous or0 ?/ h" w5 G, i* ]# |$ K
exogenous sources, nonpituitary gonadotropin stim-
' c* b) i5 X9 K: p5 t9 julation, and rare activating mutations.3 Virilizing# @) n S- C; i9 P& B- W# v
congenital adrenal hyperplasia producing excessive
# t' j2 r; C; Wadrenal androgens is a common cause of precocious# I/ ~8 k( T: H& F3 ~
puberty in boys.3,4, c3 l( N6 _2 V' `0 u
The most common form of congenital adrenal% h, e/ v: x: q0 R) \
hyperplasia is the 21-hydroxylase enzyme deficiency.
" Z' x+ ^+ P% o2 ^1 F g4 RThe 11-β hydroxylase deficiency may also result in/ g, g K6 F/ ^- j2 R( `
excessive adrenal androgen production, and rarely,: G) c" f) S+ C- T" \* V5 F# X
an adrenal tumor may also cause adrenal androgen
* q& h- v$ \" D) @. mexcess.1,31 O: y8 l a( x, ]- c# ^! G( X' k. |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 }4 ^9 G; M5 O l3 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- m3 S; O- ?* J, O# P/ g' ?
A unique entity of male-limited gonadotropin-
( F0 P. I: i5 z' Q5 @independent precocious puberty, which is also known
' G$ p: m7 j. S f7 u4 `as testotoxicosis, may cause precocious puberty at a
' C) v9 P1 n& b. t: j$ ^, Lvery young age. The physical findings in these boys; I" U8 t" g; _
with this disorder are full pubertal development,8 p1 e8 ?/ S+ |/ A/ |
including bilateral testicular growth, similar to boys
6 E* m1 f. k, {4 `1 `+ m( d# }with CPP. The gonadotropin levels in this disorder" h& K& a& |6 f9 U
are suppressed to prepubertal levels and do not show; r5 w. E$ u6 R3 D
pubertal response of gonadotropin after gonadotropin-) `3 P3 Z, w3 O
releasing hormone stimulation. This is a sex-linked
0 I" Q. k }) K* zautosomal dominant disorder that affects only1 v Q, v7 h" v
males; therefore, other male members of the family% Y# D5 [8 l6 o+ x+ x0 p A) T
may have similar precocious puberty.3: ~, b z2 k0 R
In our patient, physical examination was incon-/ a7 o% f; B+ f. b; h* \+ q
sistent with true precocious puberty since his testi-
2 |. S5 L0 F x/ `! Gcles were prepubertal in size. However, testotoxicosis5 G2 p; u% a) y
was in the differential diagnosis because his father
q( e% K5 V" B- X1 ystarted puberty somewhat early, and occasionally,
' p- e; y/ Q! O v# @ Q$ f+ V8 H. `testicular enlargement is not that evident in the
1 w5 E* i* |) e' Lbeginning of this process.1 In the absence of a neg-8 ?- s0 P; C. V1 j/ ~* A& T
ative initial history of androgen exposure, our
4 |$ V* ?3 s, V% H# j. X8 @9 }biggest concern was virilizing adrenal hyperplasia,
/ H7 Y! `# q" z1 M5 \; Heither 21-hydroxylase deficiency or 11-β hydroxylase( R' Q; Y) z( T* I- j
deficiency. Those diagnoses were excluded by find-
# @& i2 K3 D+ e$ x% M2 {. eing the normal level of adrenal steroids.
4 i8 t6 f9 B0 ?5 ]The diagnosis of exogenous androgens was strongly; i9 Z4 \4 v9 o' ^: {( G0 ~9 d( _
suspected in a follow-up visit after 4 months because
J5 _2 @2 S) @1 L' g4 Y! M$ D/ uthe physical examination revealed the complete disap-& Q0 {& M9 u# k4 P( g
pearance of pubic hair, normal growth velocity, and
1 q( @& m. b/ Y3 W' ~$ ^decreased erections. The father admitted using a testos-
$ l% Q' Z. i- O5 F# b! Zterone gel, which he concealed at first visit. He was
+ @8 y8 L- P% j' J, @using it rather frequently, twice a day. The Physicians’; b4 J, @' M; o& |' r1 b
Desk Reference, or package insert of this product, gel or
" m# n9 C( }) O/ l1 y: T. g- jcream, cautions about dermal testosterone transfer to
& d0 L- u9 a8 r! o+ }unprotected females through direct skin exposure.' y5 `. O6 ^! c0 d
Serum testosterone level was found to be 2 times the
. V+ }2 M. O7 `. A7 C0 W: K5 Abaseline value in those females who were exposed to% V/ o7 N3 n% L3 o! I* q; X8 t4 `# Y% M
even 15 minutes of direct skin contact with their male8 v) m. o8 k) O
partners.6 However, when a shirt covered the applica- B$ i/ b1 Q# W5 |" Y# @# L# F
tion site, this testosterone transfer was prevented.& n' u1 b3 E1 H6 U1 o2 S
Our patient’s testosterone level was 60 ng/mL,
: W* U# z& h8 q8 X% z- ^which was clearly high. Some studies suggest that
+ g) e' h2 F: u: b9 q: Zdermal conversion of testosterone to dihydrotestos-" d$ ]/ e1 q# [ }8 h8 n
terone, which is a more potent metabolite, is more4 g3 f; @* i' g$ n$ e2 a4 Z
active in young children exposed to testosterone
6 a& a6 s Q2 Z) L" \exogenously7; however, we did not measure a dihy-# n7 }" ^0 `7 x' b$ M+ V* k# F5 ^
drotestosterone level in our patient. In addition to' `# O: n9 S% S9 A
virilization, exposure to exogenous testosterone in w* g1 g' i5 w( ^& D( O; o7 q
children results in an increase in growth velocity and
. N: v0 Y- N3 S1 w. Tadvanced bone age, as seen in our patient.
$ @7 u; X6 K1 x& Y! s1 _; c% G6 f6 dThe long-term effect of androgen exposure during
* K6 ?# [! z. T; Y D" {6 [early childhood on pubertal development and final
% H2 v, S9 r w) _# u G9 gadult height are not fully known and always remain
( _6 T& U3 y3 s$ E6 p* Pa concern. Children treated with short-term testos-) B. [8 d# }, _7 ?% `0 A7 g
terone injection or topical androgen may exhibit some
a" R9 S5 [7 c% Wacceleration of the skeletal maturation; however, after4 G1 n! j" d4 J8 h- E7 F; N
cessation of treatment, the rate of bone maturation
) L2 K6 {1 |% u& e9 D- v1 l9 Hdecelerates and gradually returns to normal.8,97 {$ P2 ` R8 t- L4 B( h. v
There are conflicting reports and controversy
5 F1 q) O2 m( w: Dover the effect of early androgen exposure on adult
. J5 |2 B, A6 I( x4 ^penile length.10,11 Some reports suggest subnormal
8 H3 X, o" \- }9 l8 C, I' P$ Cadult penile length, apparently because of downreg-. L4 A8 O2 s, D
ulation of androgen receptor number.10,12 However,
) S# o5 L% I' U7 YSutherland et al13 did not find a correlation between! b7 ^7 w3 _# e( Y: Z0 _
childhood testosterone exposure and reduced adult
& J& v Y# b9 A4 ~penile length in clinical studies.
% i3 H8 t6 \$ U4 Q3 s- c8 pNonetheless, we do not believe our patient is% Z* o2 _- n2 O/ v7 U. Z
going to experience any of the untoward effects from
3 m7 @+ ]" h' ?testosterone exposure as mentioned earlier because
`; C1 K/ V% ^the exposure was not for a prolonged period of time.
0 }! @; ?/ \' l. T& M. @+ D; TAlthough the bone age was advanced at the time of m% N& M+ J/ @, t% D5 W
diagnosis, the child had a normal growth velocity at N8 d1 [# S3 Q! `! ^0 V1 Q
the follow-up visit. It is hoped that his final adult3 }+ D C6 e+ |% N6 l8 ]- a
height will not be affected.$ D& |, E: v3 z' V( w; |* U9 ]
Although rarely reported, the widespread avail-/ m/ {& H' |+ \! n5 l0 N
ability of androgen products in our society may$ l7 K6 _% t: D7 ?9 o
indeed cause more virilization in male or female: L% j1 H) d' s: q+ O
children than one would realize. Exposure to andro-
. T6 k( S" H$ O5 a5 ogen products must be considered and specific ques-0 E$ V- e+ q4 d) R9 b. i& |
tioning about the use of a testosterone product or
! G2 i, s3 Y" [4 f& @7 \gel should be asked of the family members during
' A. d" |8 L" O; I. Z' Vthe evaluation of any children who present with vir-
1 D" ^. b3 x3 c0 i! V1 j# Gilization or peripheral precocious puberty. The diag-. S9 n7 x6 h6 D2 K! G
nosis can be established by just a few tests and by
, s6 O( h! P: Q6 H0 y0 S: p" F: yappropriate history. The inability to obtain such a
! v- s9 P7 N* G, ?5 Y/ F" o" Vhistory, or failure to ask the specific questions, may
$ G$ x, x& K- _- Vresult in extensive, unnecessary, and expensive7 x: a$ q4 A% h
investigation. The primary care physician should be
# ~0 y, T6 e5 \1 S; w' uaware of this fact, because most of these children( w. N# a7 A* f" k3 X
may initially present in their practice. The Physicians’
" p: {1 v. v% C7 VDesk Reference and package insert should also put a
8 q/ \0 l8 W! ^6 S/ pwarning about the virilizing effect on a male or
9 Q* ?( U" i5 H% Y$ J5 g; B4 zfemale child who might come in contact with some-
; K2 q, M8 r( \& w! g C+ i. d* ~9 jone using any of these products.
6 r: y1 s) O$ NReferences; ?: c1 C* D+ n- |8 o- ^+ a$ y) ~, c
1. Styne DM. The testes: disorder of sexual differentiation. A g: u' ]' h9 [2 U" s& P$ F
and puberty in the male. In: Sperling MA, ed. Pediatric: p- N6 s! M0 U/ o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 e+ b5 E) [, s; e
2002: 565-628.( `% a/ @/ ?3 K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 w& x, ~4 @$ a) ^puberty in children with tumours of the suprasellar pineal |
|