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Sexual Precocity in a 16-Month-Old
" ?1 n( S" g) NBoy Induced by Indirect Topical: }0 ~6 x' j2 l5 B2 L% `# g& ?
Exposure to Testosterone, y% t6 [/ I$ F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 _/ J5 p% b1 g5 U5 b
and Kenneth R. Rettig, MD10 z. k1 H: i ^- ]1 m
Clinical Pediatrics
2 a8 V' N# o! i, L6 r6 TVolume 46 Number 6$ f" g g" b) h3 M! q5 F5 C
July 2007 540-543
+ a* D4 T2 I; l9 @8 o+ B" q/ j© 2007 Sage Publications% M2 ]. y0 q' C% g
10.1177/0009922806296651& y+ g q$ D* d! g0 X
http://clp.sagepub.com
7 A) T; @! [" L; v* Yhosted at
2 F( N6 Y2 @+ K$ g: t( z, x3 yhttp://online.sagepub.com
7 @5 ?7 D' g% ]0 F8 Z+ [! iPrecocious puberty in boys, central or peripheral,8 ?% X1 A+ q$ m, Q7 P1 X
is a significant concern for physicians. Central
; X# H. r3 {5 Z- v% r5 iprecocious puberty (CPP), which is mediated6 ~6 [ r, W. d) K
through the hypothalamic pituitary gonadal axis, has
. E3 G6 j N2 W8 G0 Ya higher incidence of organic central nervous system) D" D8 ~/ M+ L6 G: E
lesions in boys.1,2 Virilization in boys, as manifested
( M7 p/ m3 e/ xby enlargement of the penis, development of pubic
$ h) e0 d/ d; X' Z' U; D, Uhair, and facial acne without enlargement of testi-
9 c! E8 S& Y; @ n+ s, L: ocles, suggests peripheral or pseudopuberty.1-3 We5 |' {) c/ d8 ^+ }+ [
report a 16-month-old boy who presented with the
- r7 ?8 t2 J9 M7 e J- venlargement of the phallus and pubic hair develop-
3 i: u) l# p! p1 X' Z9 F1 i, kment without testicular enlargement, which was due9 R1 Y3 K" S) }8 s }, B
to the unintentional exposure to androgen gel used by
, I Y& b" C. X: q F# ], @the father. The family initially concealed this infor-! n- G* B" l4 `# s* P
mation, resulting in an extensive work-up for this2 ?& m9 _: {; _7 v. T- ]7 G- u2 a
child. Given the widespread and easy availability of
/ [7 ?8 G8 [2 ^6 xtestosterone gel and cream, we believe this is proba-. B/ t3 u$ x6 F1 Z3 B
bly more common than the rare case report in the$ r$ F, d! r& j; U6 H
literature.4# x0 o& G7 d. x( A1 \
Patient Report
4 \8 o! c: u% R3 r2 ?2 K! b' x( WA 16-month-old white child was referred to the( c( K# ^' b, g# x7 E. T- s, M. W
endocrine clinic by his pediatrician with the concern- P3 G8 Y7 u3 n2 p! f: Q
of early sexual development. His mother noticed; ]" T% l3 e6 V" m! t/ }6 ^8 J1 g+ e
light colored pubic hair development when he was
5 Z/ C8 T" ^ LFrom the 1Division of Pediatric Endocrinology, 2University of: l& G9 c+ M& f9 C4 U" ?4 a
South Alabama Medical Center, Mobile, Alabama. c5 T- d2 l0 G- s* q! T' k3 n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% @) u8 c2 t( M! r+ NProfessor of Pediatrics, University of South Alabama, College of. W4 s4 P \( ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" r( x5 |) h/ _$ G3 g$ Q6 ee-mail: [email protected].# j) @4 p, A" a m' C1 q7 i
about 6 to 7 months old, which progressively became, _9 Q/ _- \) ]+ f1 h& W) a
darker. She was also concerned about the enlarge-! U. e; Q' J, Z% q, T) k
ment of his penis and frequent erections. The child3 D/ o, r N* E# @4 q
was the product of a full-term normal delivery, with$ o) V& V3 @- B8 ~; Z
a birth weight of 7 lb 14 oz, and birth length of
6 L' D, ?, ~" q: P20 inches. He was breast-fed throughout the first year
3 @0 k3 W4 d" Tof life and was still receiving breast milk along with
; T# L1 k7 t# I, D! |$ Y4 h1 Z: w. C- osolid food. He had no hospitalizations or surgery,& L) }$ R0 Z3 i Z9 A
and his psychosocial and psychomotor development
" |1 m8 z- Y" V2 awas age appropriate.
( _) x% @- L1 MThe family history was remarkable for the father,3 l/ r+ ?! Z d0 r
who was diagnosed with hypothyroidism at age 16, u0 H# G& Z; I& c5 a1 N% v/ ]
which was treated with thyroxine. The father’s
: L) \3 \; z4 C, ?6 o& x. R3 sheight was 6 feet, and he went through a somewhat2 F; H2 a1 |9 s* a
early puberty and had stopped growing by age 14.
# }* z1 f3 g" j3 RThe father denied taking any other medication. The6 `( ?5 u8 n- ]7 T! S8 v9 Z
child’s mother was in good health. Her menarche
: N2 Y0 T" F& ewas at 11 years of age, and her height was at 5 feet
6 k( a$ o, b1 V! z6 T1 c6 F5 inches. There was no other family history of pre-
' S1 h- U' B2 u: Y* d; H6 s4 hcocious sexual development in the first-degree rela-8 B3 K6 y# v: N, c ^3 ?
tives. There were no siblings.
" d/ v/ _: x8 j1 \6 yPhysical Examination5 b0 M0 n; E' ~; g
The physical examination revealed a very active, H7 E4 k! W$ R! `
playful, and healthy boy. The vital signs documented- @5 q5 b* Z- M# a7 L
a blood pressure of 85/50 mm Hg, his length was. h) U# h. D5 n$ X! C, B
90 cm (>97th percentile), and his weight was 14.4 kg
- p; k& N7 x( |& v) _, `4 D7 U(also >97th percentile). The observed yearly growth
' P2 Y( r& ]" T* n& ~velocity was 30 cm (12 inches). The examination of
7 l; Z4 |3 W0 _ a0 A; `5 gthe neck revealed no thyroid enlargement.2 t; u$ O w5 M7 d- e1 l
The genitourinary examination was remarkable for
0 @* P8 C- T, d: Q& h4 }enlargement of the penis, with a stretched length of
~/ i5 }+ r0 v6 p) q0 J% R9 g ]8 cm and a width of 2 cm. The glans penis was very well
( m) t% c6 h/ I( n# \0 ]developed. The pubic hair was Tanner II, mostly around
6 @9 E( E8 P) x" A/ B5409 k p+ x3 k- S8 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 D( ~0 U2 J' x2 A9 i, l* Tthe base of the phallus and was dark and curled. The- w! Z3 T8 w: Y$ w8 O+ R
testicular volume was prepubertal at 2 mL each.
" P* u5 r8 P: |7 B! i4 R% oThe skin was moist and smooth and somewhat. Y I3 \7 r' @ J
oily. No axillary hair was noted. There were no
7 ^8 P7 K# Z: r# S: o8 Zabnormal skin pigmentations or café-au-lait spots.. c/ R1 L4 b4 x3 y! M
Neurologic evaluation showed deep tendon reflex 2+- Z5 D; A/ A+ @4 @8 g" h- j4 z# F# M" V; q
bilateral and symmetrical. There was no suggestion/ M- ]1 R9 Y' Q+ \: y
of papilledema.
u6 u* V y C$ YLaboratory Evaluation
% c* E2 }6 r% [/ P' i( v- hThe bone age was consistent with 28 months by
- L# m6 `: x4 f" H8 R, g% m( \7 x* Xusing the standard of Greulich and Pyle at a chrono-
9 U2 Q: y% f6 [: {. ` `logic age of 16 months (advanced).5 Chromosomal
7 o d+ Y# m6 ]& z; H4 Ikaryotype was 46XY. The thyroid function test8 r& C7 M. N4 G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 E- I# T! @# Q- Y+ j2 s: ?! a
lating hormone level was 1.3 µIU/mL (both normal)./ m# i" J5 d; I0 m% W
The concentrations of serum electrolytes, blood) o4 S7 N* f k' o+ ~/ i
urea nitrogen, creatinine, and calcium all were
0 y4 `5 d# s, t( I4 X0 ?7 [: ]within normal range for his age. The concentration
/ A9 Q, }) A7 A, {) |- B9 ~: l! hof serum 17-hydroxyprogesterone was 16 ng/dL* T2 e; L$ ~1 x' J! n) N
(normal, 3 to 90 ng/dL), androstenedione was 209 W/ B/ J) Z$ c& ?# U% Y$ T9 Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 J/ s0 I: B1 f6 S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 Z2 V' A! p/ \/ edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ V. L0 f9 N5 W$ Y/ G7 b49ng/dL), 11-desoxycortisol (specific compound S)' q5 O# B& d$ U7 b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, i" I, c8 W4 L4 u/ G" j
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) B% Y% j- J$ d, ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 x" U, y5 R4 U( B: N
and β-human chorionic gonadotropin was less than" j* g! k( w. ~' L3 t
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 u. y/ G0 S) w, E2 w3 K# U
stimulating hormone and leuteinizing hormone: }8 j2 j) l+ O5 s
concentrations were less than 0.05 mIU/mL0 b# `9 K" }4 T! V- k
(prepubertal).
9 j4 w+ K# `0 |8 t \9 o- gThe parents were notified about the laboratory
6 r: i. y) U% g" @- H9 {. M: Gresults and were informed that all of the tests were0 ?& F/ b9 P& e
normal except the testosterone level was high. The
$ C* }& l" R6 u X. a" Ufollow-up visit was arranged within a few weeks to
$ n, H1 q1 M; x5 Zobtain testicular and abdominal sonograms; how-5 N; P7 G3 P2 j& I, |: [
ever, the family did not return for 4 months.
; K- M& _* T2 B% n% t! {' m+ lPhysical examination at this time revealed that the- l, p1 r% H2 G# e6 t
child had grown 2.5 cm in 4 months and had gained
3 S; s6 l6 I5 O( t: j$ J+ T$ l2 a2 kg of weight. Physical examination remained X$ j9 v" y) e A/ U( h
unchanged. Surprisingly, the pubic hair almost com-& ~' V$ `2 W8 x w. A3 M
pletely disappeared except for a few vellous hairs at
* ]+ N X% {7 I: K2 [3 k" qthe base of the phallus. Testicular volume was still 2# H! v5 d ?- B' v$ G2 t: z: u
mL, and the size of the penis remained unchanged.' O& E' ? l, p; i
The mother also said that the boy was no longer hav-/ D' _2 T- ]! ?. [9 c# }7 h6 Y+ x
ing frequent erections.# A1 i! v, i# x
Both parents were again questioned about use of
4 v, N! P7 i& r1 i1 S# Rany ointment/creams that they may have applied to9 q$ l, H' T- n3 r
the child’s skin. This time the father admitted the' J# r! R/ J, e! Z5 i
Topical Testosterone Exposure / Bhowmick et al 541
& F3 x/ A9 c R" i! `use of testosterone gel twice daily that he was apply-7 y+ {8 b* m; h( \5 I
ing over his own shoulders, chest, and back area for3 L. f" r4 e; _& k( q A, G1 M
a year. The father also revealed he was embarrassed
' @* h. {& n1 n: z/ M# Sto disclose that he was using a testosterone gel pre-1 ?- q! F2 H" i7 {0 X# N) d
scribed by his family physician for decreased libido
l5 a, n6 J0 y: G4 t% h; C3 @secondary to depression.$ h# d% K$ E0 @$ r
The child slept in the same bed with parents.0 X, y. \8 r# v# z- H# K( ?
The father would hug the baby and hold him on his
: s/ |5 k0 a$ z/ s7 N3 P1 |9 Qchest for a considerable period of time, causing sig-9 ^ d( |$ U8 G/ W1 V( h0 K
nificant bare skin contact between baby and father.4 z& M/ p7 w5 X8 p% d0 ^* G1 n; l5 o
The father also admitted that after the phone call,
: A# K& w& p9 N, E2 Cwhen he learned the testosterone level in the baby
% r e- \( O% {+ ^: h$ Dwas high, he then read the product information
$ a, O+ z/ [! o2 @3 [1 _packet and concluded that it was most likely the rea-+ O9 p0 z8 Y% Z3 B/ t$ j! d; m
son for the child’s virilization. At that time, they
0 Z ?* ?1 Z2 Udecided to put the baby in a separate bed, and the3 {! r; }" I- f
father was not hugging him with bare skin and had
0 Z# y$ p+ X( J# U; T3 |been using protective clothing. A repeat testosterone
( k5 V- W- {+ Q: Btest was ordered, but the family did not go to the
4 u4 r$ x; @" |/ e) ulaboratory to obtain the test./ v3 T X" ~ G% q( A
Discussion
& t8 s: f. m+ iPrecocious puberty in boys is defined as secondary
: b& F# E- F$ x8 \: l" H' wsexual development before 9 years of age.1,4
. f8 n6 i2 g) g5 F; V' S D$ fPrecocious puberty is termed as central (true) when I- Z' V' e% t9 n T } y
it is caused by the premature activation of hypo-
- ~8 ?, J9 s' e, g& G! [( qthalamic pituitary gonadal axis. CPP is more com-) s2 C- n4 I4 H4 `6 n4 a
mon in girls than in boys.1,3 Most boys with CPP# C3 P: o- K5 _7 d0 M) z* }: q
may have a central nervous system lesion that is; h7 K/ M9 }7 s- \ {
responsible for the early activation of the hypothal-
' [- J- _, y4 z. t* hamic pituitary gonadal axis.1-3 Thus, greater empha-9 l5 I1 q. G+ M, L4 e8 u+ Z7 w
sis has been given to neuroradiologic imaging in
. _+ o6 P5 z7 j9 ~( qboys with precocious puberty. In addition to viril-
+ x* |3 g/ @/ x: y& n4 w& Tization, the clinical hallmark of CPP is the symmet-6 L, k! s( e! O: c+ k* c- R4 ^" B2 X, ~
rical testicular growth secondary to stimulation by
7 p4 K* O9 g; {* Kgonadotropins.1,31 |3 r8 X+ }5 h; M/ w; W
Gonadotropin-independent peripheral preco-- G, T9 o p0 S( h" i, E0 e: z
cious puberty in boys also results from inappropriate! h4 L1 m! e3 S0 c+ H/ [
androgenic stimulation from either endogenous or
% B1 _ t8 {& S( Iexogenous sources, nonpituitary gonadotropin stim-8 h& d F- X" ^) b+ h$ t
ulation, and rare activating mutations.3 Virilizing. f; }; V9 r6 e2 F% l; t* @
congenital adrenal hyperplasia producing excessive9 ?) k4 U* m3 x/ B! e, G
adrenal androgens is a common cause of precocious
* X( G6 F9 ^" f: k. J$ L7 w, J! Ppuberty in boys.3,44 E' e' j2 ]. A- I, ]
The most common form of congenital adrenal
2 {) N. o" t' z: U& a. n+ c# J2 uhyperplasia is the 21-hydroxylase enzyme deficiency.
$ q+ H/ H/ j0 ?The 11-β hydroxylase deficiency may also result in) S$ | Q1 Q7 l; P/ C! Q3 d
excessive adrenal androgen production, and rarely,
% ~- u* D5 ?1 q$ p I; Y3 u) Z! San adrenal tumor may also cause adrenal androgen
5 n5 L# N; x6 s& aexcess.1,34 t; ^& b/ z1 X! J2 s! r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ K9 B( ^8 d+ a2 B/ H/ x3 {* ~( c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 e. o' d4 r5 r& _+ L3 n% r( ~A unique entity of male-limited gonadotropin-5 S4 y$ O! a6 o# ?; Q
independent precocious puberty, which is also known; B& F" } Z% R/ l. B* q
as testotoxicosis, may cause precocious puberty at a
: }0 r* d$ {7 b; Vvery young age. The physical findings in these boys
2 j! @0 c3 g6 S# P6 j; y- g! ^with this disorder are full pubertal development,
9 w; C: ~: r8 |# J% yincluding bilateral testicular growth, similar to boys8 z% a8 _3 g. P! E( U Q
with CPP. The gonadotropin levels in this disorder# O9 V+ I( F5 J/ g( k% u) ^
are suppressed to prepubertal levels and do not show
# v/ R8 [" _" q' cpubertal response of gonadotropin after gonadotropin-; n+ ^' _! ^" A8 K" Z% x
releasing hormone stimulation. This is a sex-linked8 m9 ]# K% k2 o; S
autosomal dominant disorder that affects only5 Q: y( ~ \# k* V' T' @: B: a" N8 t
males; therefore, other male members of the family
, g: G: v2 Z! D0 Ymay have similar precocious puberty.3
2 G) o# y; s6 N) B* G, w! hIn our patient, physical examination was incon-6 \# a" p, }- n6 z& ~0 k3 U; R
sistent with true precocious puberty since his testi-
3 p! J3 S4 A1 T. D8 L Wcles were prepubertal in size. However, testotoxicosis7 h" y1 N0 ^- r, \
was in the differential diagnosis because his father
& i5 u2 b! H, |% E( R+ d; x% Jstarted puberty somewhat early, and occasionally,
9 [ b3 n2 K% y+ L8 Otesticular enlargement is not that evident in the
" `: I; u2 T4 l7 i% e" Ubeginning of this process.1 In the absence of a neg-6 r6 T- D" [; h# ]
ative initial history of androgen exposure, our
. l2 N; m" I! R. C: O% l( |0 [biggest concern was virilizing adrenal hyperplasia,' C- V' @6 K1 n" {/ [
either 21-hydroxylase deficiency or 11-β hydroxylase
/ V6 H0 }/ B. r- N6 ^% L4 Ndeficiency. Those diagnoses were excluded by find-
7 N# D& s, _( X/ O' Jing the normal level of adrenal steroids.8 T ?+ M- P. N3 D
The diagnosis of exogenous androgens was strongly) m% Y6 b9 h& O; R9 M
suspected in a follow-up visit after 4 months because
! y- ^! }! `6 Q6 d, ?& E: C+ ithe physical examination revealed the complete disap-
* z1 @, ], n1 v+ apearance of pubic hair, normal growth velocity, and
! D$ J, X+ \; ^2 s# ?" n/ x: @decreased erections. The father admitted using a testos-- H! ]% P6 Y0 r' b7 Z6 f) r
terone gel, which he concealed at first visit. He was9 n4 v7 m) N+ J; Q! k2 c
using it rather frequently, twice a day. The Physicians’2 G, _. K+ f% \! v; A0 {0 X7 f
Desk Reference, or package insert of this product, gel or" P2 J3 R* n6 F3 l3 K9 H6 o4 R: B# _
cream, cautions about dermal testosterone transfer to( @; t( p1 A2 M( j# a
unprotected females through direct skin exposure.
5 A0 T8 b% [' ]* vSerum testosterone level was found to be 2 times the8 z: W% b% \ B- `0 A$ r j
baseline value in those females who were exposed to
0 [/ ]& A( a; p9 l# Keven 15 minutes of direct skin contact with their male! @/ P. D( H; T: W! _
partners.6 However, when a shirt covered the applica-
* X2 k" P; z! M. p& e7 Mtion site, this testosterone transfer was prevented.
- V# x+ ]/ j4 q! ~8 f; MOur patient’s testosterone level was 60 ng/mL,$ f, u5 s) h7 a5 _7 w
which was clearly high. Some studies suggest that
' E; _" J: `- d9 q/ `dermal conversion of testosterone to dihydrotestos-4 l5 q; a2 b% Y5 ^) p8 T/ J
terone, which is a more potent metabolite, is more
6 _- k3 K% _! _8 Sactive in young children exposed to testosterone
9 R/ T7 `0 C1 G6 _3 Vexogenously7; however, we did not measure a dihy-6 d" {; ^8 r* N3 s' M; j
drotestosterone level in our patient. In addition to7 u% R" ]6 a) P6 H) [+ V
virilization, exposure to exogenous testosterone in# o& M! `! R/ L
children results in an increase in growth velocity and4 E" D" i: F+ L0 i5 k7 S( t" t! y
advanced bone age, as seen in our patient.
" F6 a! n& G C3 }7 x2 L& `* n* gThe long-term effect of androgen exposure during
- d2 x/ f) D8 oearly childhood on pubertal development and final2 D1 o! ]" G; T0 e: u
adult height are not fully known and always remain+ R& j0 Y2 u$ r2 `
a concern. Children treated with short-term testos-
' V: ]3 F$ [1 V$ [" I2 X% a0 Vterone injection or topical androgen may exhibit some2 e$ G; Y: [- H) \" G
acceleration of the skeletal maturation; however, after
2 v2 F6 I7 k' a6 l2 p: kcessation of treatment, the rate of bone maturation
0 ^: t- v, z! d2 p rdecelerates and gradually returns to normal.8,9
# I1 q# H. m. T7 k! m* oThere are conflicting reports and controversy
6 i0 o: q2 |! Y% R; k0 xover the effect of early androgen exposure on adult3 E p% ]/ \8 R" L: m% q0 n3 p9 g
penile length.10,11 Some reports suggest subnormal' X, q6 a, ]. Q" H
adult penile length, apparently because of downreg-
+ Q i: V6 y/ [+ iulation of androgen receptor number.10,12 However,4 ~! c/ Z. j7 T$ I9 o
Sutherland et al13 did not find a correlation between
, i6 F+ B' @& h2 H: v, Xchildhood testosterone exposure and reduced adult; c" a \$ t/ ?; i% J- A4 q
penile length in clinical studies.5 n# a& B2 d" I) ?6 i
Nonetheless, we do not believe our patient is; n, f- A! X! ~0 C7 f w
going to experience any of the untoward effects from
0 [0 {# ^; W* u" g' |1 W; ftestosterone exposure as mentioned earlier because5 U$ `, `4 T, j; Z
the exposure was not for a prolonged period of time.
* i" g5 |: c3 y) N% G6 X5 aAlthough the bone age was advanced at the time of# O7 X# e+ x: O) m* H! {) q" s& o7 O
diagnosis, the child had a normal growth velocity at
c1 H) q; N8 w2 |/ ~/ @( u7 R6 ~the follow-up visit. It is hoped that his final adult3 [0 `& F6 P* Q
height will not be affected.
' U+ I/ C& f6 d2 u( z; a5 L; Q6 h; JAlthough rarely reported, the widespread avail-
/ z8 `2 o+ t8 jability of androgen products in our society may
4 l2 [ t/ I4 r% tindeed cause more virilization in male or female2 G6 S. f. K' }5 F; A) }
children than one would realize. Exposure to andro-
3 \. k6 l/ X+ A* G# W: ugen products must be considered and specific ques-
/ `; l/ ]' a1 [tioning about the use of a testosterone product or
" m0 R. Z( L( h8 m+ cgel should be asked of the family members during
- _! F) ^0 S* ^, s' ythe evaluation of any children who present with vir-
$ H: y( M; h6 B) E+ cilization or peripheral precocious puberty. The diag-" F; {% R' o D3 G
nosis can be established by just a few tests and by
# i4 p h; j+ R: F- I% Fappropriate history. The inability to obtain such a
$ L" J0 j! A. N H: @& Ohistory, or failure to ask the specific questions, may w/ O2 s7 W% M) W9 ^
result in extensive, unnecessary, and expensive
; \+ j; k4 {) F$ j1 |investigation. The primary care physician should be1 _ Y5 ]" h5 s7 h& s
aware of this fact, because most of these children
W9 g9 G1 x1 W: |, U2 Cmay initially present in their practice. The Physicians’
0 [2 n3 S2 |7 `% B7 J- F$ j4 EDesk Reference and package insert should also put a
3 b6 w0 [. G3 e( Z# ^4 Gwarning about the virilizing effect on a male or
* J: Z) [# }) u4 _- k0 q, A0 Pfemale child who might come in contact with some-5 }7 t7 k# h+ ` S$ C' D
one using any of these products.* x5 b. p# J2 [6 _% I
References
: U5 U. O3 h3 a s1. Styne DM. The testes: disorder of sexual differentiation
# Z# M; ] f# aand puberty in the male. In: Sperling MA, ed. Pediatric8 ~7 e& C5 E1 i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( P4 D( L- g/ t; i, x" p* }
2002: 565-628.; o# J6 s: L+ ?3 H3 b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 d2 m5 W$ @7 S3 t. D) _) A# Q
puberty in children with tumours of the suprasellar pineal |
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