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Sexual Precocity in a 16-Month-Old9 _ v. Z, Y" U" E% O" }6 p/ b B
Boy Induced by Indirect Topical
5 h8 j& Y/ d) a3 O/ n( y$ P& tExposure to Testosterone
. n: K3 V# e: X! l" S5 ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! o/ Q! K' d3 i( {. E0 K. M% Cand Kenneth R. Rettig, MD1, Q8 `: D6 u- h* s. k
Clinical Pediatrics7 \. U: R* ?: M, c, |/ u
Volume 46 Number 6' B: X: D2 ]& G* N, I+ X- [! ]
July 2007 540-543
3 A) o* R# {. g/ F© 2007 Sage Publications1 n: f5 n5 g, v- U r4 M2 d6 `3 Q
10.1177/00099228062966519 M- k, Q5 j9 s$ `+ `9 c& d+ B
http://clp.sagepub.com
' T# v# e" V% H4 J7 _hosted at
0 O: H8 [, A2 _% n$ J8 m$ ^http://online.sagepub.com
0 [2 }7 \, U E/ J5 ePrecocious puberty in boys, central or peripheral,) H! X; [9 @4 g6 k1 V6 t4 _
is a significant concern for physicians. Central3 P5 b$ u& l4 q* S" D9 J, m
precocious puberty (CPP), which is mediated
% I# {/ S& S6 p. t! C) cthrough the hypothalamic pituitary gonadal axis, has, r) E- K+ K$ _4 G: ?4 T5 T! }
a higher incidence of organic central nervous system
; e1 u3 b3 |' t& v5 v6 `lesions in boys.1,2 Virilization in boys, as manifested! Z! R$ f: d+ G$ A
by enlargement of the penis, development of pubic
A) ]; E, Y/ ]6 O* c3 A1 ^hair, and facial acne without enlargement of testi-
/ X0 C0 A" @- T/ Z& `cles, suggests peripheral or pseudopuberty.1-3 We
9 C6 o# L8 @1 ?! U$ b; c/ v& }report a 16-month-old boy who presented with the
6 H/ i8 n h9 U$ U5 v: Penlargement of the phallus and pubic hair develop-
: S* R4 Q( U* ?0 D1 iment without testicular enlargement, which was due5 Y. q8 c1 p" h" ` S; m1 Z8 H
to the unintentional exposure to androgen gel used by1 ?7 W. z2 J& n" N ]8 c3 w
the father. The family initially concealed this infor-. h2 Y i/ I. U# M' y
mation, resulting in an extensive work-up for this7 G3 a! v( ^& w
child. Given the widespread and easy availability of5 w t9 a: W _3 Z1 q7 L# d
testosterone gel and cream, we believe this is proba-
( J% F+ u, l0 E' n- Gbly more common than the rare case report in the( \ c& j' T: }
literature.4
5 T7 u( t$ B6 H- t% B5 p5 q% ?Patient Report
4 s+ o$ n" R* J) U" H8 u0 C( x5 eA 16-month-old white child was referred to the6 E) ?2 @6 v' Z3 q
endocrine clinic by his pediatrician with the concern
# \0 O3 b& F. e2 Nof early sexual development. His mother noticed
, T0 n. z" S: W/ ?light colored pubic hair development when he was
! A- l2 h3 t9 C C& {From the 1Division of Pediatric Endocrinology, 2University of3 ~. b; W# j! P$ Q$ Q/ |7 ]
South Alabama Medical Center, Mobile, Alabama.
v. R B1 j6 g, U; y7 EAddress correspondence to: Samar K. Bhowmick, MD, FACE,
% s. {0 \1 m% a$ X4 AProfessor of Pediatrics, University of South Alabama, College of
5 E. M4 o5 M! ]; R: s* YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 E2 L) z, G, n, ?* g+ Ne-mail: [email protected].& ~, X( p; @6 S
about 6 to 7 months old, which progressively became8 O" ? y; U$ F; U) z! e# C
darker. She was also concerned about the enlarge-
/ O5 j" ^" K0 p) @ment of his penis and frequent erections. The child4 R! h3 r. `5 N% R+ P+ m. i2 q
was the product of a full-term normal delivery, with& l) h6 |- E8 \' R
a birth weight of 7 lb 14 oz, and birth length of6 c0 E6 N& B! V- O) w. [+ ]
20 inches. He was breast-fed throughout the first year
8 |; a# n( v2 Q: N, e6 D; N, }of life and was still receiving breast milk along with
6 C, K4 \5 U8 Y+ Y8 a. q& ^! N# Z1 `solid food. He had no hospitalizations or surgery,
1 G3 L; v+ o1 m, {% p1 Q" Nand his psychosocial and psychomotor development
! ?7 y% g; T# F+ H0 [; P' ewas age appropriate." {8 M$ u8 S5 g) \, b; |
The family history was remarkable for the father,9 p( b1 A2 s* N: L9 @
who was diagnosed with hypothyroidism at age 16,- P4 m8 @$ Z, f" G& o! l; R
which was treated with thyroxine. The father’s- b: d; \6 B& W9 j) h
height was 6 feet, and he went through a somewhat
1 [5 B& D9 K9 Z/ r% ~, qearly puberty and had stopped growing by age 14.6 g2 M4 C, u2 c6 H! s
The father denied taking any other medication. The9 M, i- k0 k9 Y
child’s mother was in good health. Her menarche( Q/ r9 Y5 ^/ U5 {7 U( b0 K) \
was at 11 years of age, and her height was at 5 feet6 v4 v9 c c [7 f% T
5 inches. There was no other family history of pre-6 n6 D1 T. d- i7 ?7 v
cocious sexual development in the first-degree rela-6 E" p% f" N3 a% \" J
tives. There were no siblings. Q4 D7 I0 p* I r
Physical Examination
3 { Y) M/ U9 g3 MThe physical examination revealed a very active,
Q9 g) i- P) x' K! }playful, and healthy boy. The vital signs documented
( r. H+ T5 k1 r7 h3 r) V+ O. ?3 Za blood pressure of 85/50 mm Hg, his length was
/ Y3 m0 U5 g( r) Y% S' _90 cm (>97th percentile), and his weight was 14.4 kg
3 x$ u2 T, v- o/ C(also >97th percentile). The observed yearly growth9 q% Q( w9 J% Z$ x" N
velocity was 30 cm (12 inches). The examination of) p3 _$ L( Q: n/ i
the neck revealed no thyroid enlargement.4 X8 `. u2 }6 ^2 ]8 v
The genitourinary examination was remarkable for1 F8 V! S; G* m3 n9 S4 U6 @/ ~
enlargement of the penis, with a stretched length of# }/ {" [! g) e2 f
8 cm and a width of 2 cm. The glans penis was very well9 y7 ], u3 S. o3 ^& h
developed. The pubic hair was Tanner II, mostly around2 Y3 d/ p1 D# [; N& ~& M& z
540
/ p4 D( w" M( p7 cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# v) w8 {1 T/ h8 |the base of the phallus and was dark and curled. The
$ z, Q( A& e/ S& u1 d/ jtesticular volume was prepubertal at 2 mL each.* o8 m2 w5 M" h e+ p5 ~% X
The skin was moist and smooth and somewhat6 `4 b) b) [! ~. P' p
oily. No axillary hair was noted. There were no
p5 m; X9 K7 J) i* Jabnormal skin pigmentations or café-au-lait spots.
9 ^8 R8 p2 p' ?% O1 H% N$ c5 T* q' gNeurologic evaluation showed deep tendon reflex 2+( U& c* ^3 j, j' d) M) ?3 ?) `
bilateral and symmetrical. There was no suggestion0 ~* R5 B8 @0 G% [% X: C
of papilledema.
8 p5 U* T3 b2 _5 J' a/ ~6 P; H. cLaboratory Evaluation) {0 f, v$ c/ {, Y. s. b' V
The bone age was consistent with 28 months by$ i/ r9 m$ W; Z5 n* _4 ?
using the standard of Greulich and Pyle at a chrono-
* o* p7 ^7 j6 s- |. z' e4 @logic age of 16 months (advanced).5 Chromosomal
# Z: S4 ^# C7 u; ~karyotype was 46XY. The thyroid function test
: A g) F5 }& X( f7 ~4 P6 X" vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 ~: Y# j( t5 ^" K, f
lating hormone level was 1.3 µIU/mL (both normal).- g0 [1 H$ P$ z( x7 p! c9 ^8 {
The concentrations of serum electrolytes, blood
; b9 W1 t7 g" ~1 k3 Lurea nitrogen, creatinine, and calcium all were# i% }% G* h/ ]- V7 i" D& `
within normal range for his age. The concentration
3 F' W3 T1 u/ V% c% v7 _5 V- nof serum 17-hydroxyprogesterone was 16 ng/dL
" S8 } R9 z P1 \(normal, 3 to 90 ng/dL), androstenedione was 20
, j; l1 O9 j: ?; u3 p0 a" Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
Q+ U" b5 k7 N+ B6 U* Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),- @& c6 x! p: T0 n+ J; {
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 D. O1 {) O- p49ng/dL), 11-desoxycortisol (specific compound S)
! B1 U# k$ _* C% \% m/ V; jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! |6 e5 D9 m1 @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- U+ v- M9 l) b' R4 Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) c$ S5 a; j( n+ `$ z, d/ @! m
and β-human chorionic gonadotropin was less than
1 H/ u4 k0 [! Z. t5 d5 mIU/mL (normal <5 mIU/mL). Serum follicular y9 ]% v. G7 L3 b( J$ ^& `
stimulating hormone and leuteinizing hormone
+ s6 \2 K# y$ pconcentrations were less than 0.05 mIU/mL
* k* H1 W' s' ?/ {; Y( g- e(prepubertal).! k; n/ S" p. i6 w* R
The parents were notified about the laboratory N4 o, g& E6 }1 t" L
results and were informed that all of the tests were) C& z$ \- `- c' k. K% ]' {& F
normal except the testosterone level was high. The
6 y# _5 G, K# @. l8 J6 mfollow-up visit was arranged within a few weeks to0 |) i. j' Q% R4 o- \0 u# O' E
obtain testicular and abdominal sonograms; how-
8 \: T; m$ \( x2 k1 Vever, the family did not return for 4 months.& K/ O/ N& [, {* k4 w% e$ b
Physical examination at this time revealed that the
1 k8 v$ A8 v$ w2 a9 V2 B" i6 W+ |+ Vchild had grown 2.5 cm in 4 months and had gained, G5 [' X) C4 }) {. f
2 kg of weight. Physical examination remained
' b' o8 q0 R% p6 J6 i7 Gunchanged. Surprisingly, the pubic hair almost com-
- A6 u' U% x6 ]( U/ `) cpletely disappeared except for a few vellous hairs at
3 M7 G- Q/ O- n( Y; Wthe base of the phallus. Testicular volume was still 2
" s/ {2 V* K) D. j, ?; BmL, and the size of the penis remained unchanged.1 u- b$ z1 q1 G& i( V
The mother also said that the boy was no longer hav-
. j2 B6 n. b$ j4 ting frequent erections.% {+ A* A4 u" N0 J5 V
Both parents were again questioned about use of
5 k+ i8 O6 R: _- ]2 G# r0 c9 ]any ointment/creams that they may have applied to" ?2 ]) X) C9 Y3 ?$ q8 x9 ?9 K3 G- v
the child’s skin. This time the father admitted the: t+ t, t4 A# P8 h. ]
Topical Testosterone Exposure / Bhowmick et al 5418 ^% V5 s8 P; q* _8 H5 W" W9 X4 V- [
use of testosterone gel twice daily that he was apply-3 G) E" }9 {6 x( b
ing over his own shoulders, chest, and back area for
; o& H/ Y! y1 W/ `; la year. The father also revealed he was embarrassed
* `0 G/ I- t& `$ Y% n* qto disclose that he was using a testosterone gel pre-- [/ c, A, u% X" m' `* z
scribed by his family physician for decreased libido
/ |, A N. Q. E6 Y" b( \0 `secondary to depression.( b) Y2 S$ v* g
The child slept in the same bed with parents.
0 p5 Q! u, _- X. g/ X* m7 d6 aThe father would hug the baby and hold him on his5 Q4 O2 n! @7 o+ f, ?
chest for a considerable period of time, causing sig-+ U. e2 F; V3 d4 P. j
nificant bare skin contact between baby and father.
: x& m; L+ \- u, {The father also admitted that after the phone call,
) p* N& m7 g! o& awhen he learned the testosterone level in the baby
& W* i& ]; P6 n8 i7 V p/ t. Twas high, he then read the product information
' |, V2 D. G2 n9 G1 ], \1 }packet and concluded that it was most likely the rea-6 u, J5 C% Y& l3 w2 I
son for the child’s virilization. At that time, they
3 m6 v' t* i7 U: ]$ xdecided to put the baby in a separate bed, and the
% @8 t2 J: O4 J" V5 w5 D7 k }& \father was not hugging him with bare skin and had$ ^* ]+ B( [; \' t
been using protective clothing. A repeat testosterone2 B+ n0 c. P( n; K
test was ordered, but the family did not go to the
. X% t: t, H7 Nlaboratory to obtain the test.
" M( `: Q7 u. j7 l* S8 Y3 Q/ UDiscussion
6 l" p2 P! B" iPrecocious puberty in boys is defined as secondary3 U2 G- O- D* ]' d: e
sexual development before 9 years of age.1,4
D c9 Z7 V% }$ J) W) X* N* WPrecocious puberty is termed as central (true) when8 x7 r" |' T. A6 t1 E
it is caused by the premature activation of hypo-2 h+ `% |, j; J7 z
thalamic pituitary gonadal axis. CPP is more com-
4 [$ }& [ J0 k7 ]8 Lmon in girls than in boys.1,3 Most boys with CPP1 w5 q8 G2 \1 t. d
may have a central nervous system lesion that is
+ M" l& F6 C7 [' k9 `( g7 j, a% cresponsible for the early activation of the hypothal-1 j, n0 h+ V+ m# k) O
amic pituitary gonadal axis.1-3 Thus, greater empha-. C$ |8 e. S& J" C
sis has been given to neuroradiologic imaging in! ^0 T' M/ w) b. M: k$ f0 |6 K* o
boys with precocious puberty. In addition to viril-
5 N5 m0 y; {2 y% y7 @ization, the clinical hallmark of CPP is the symmet-
$ U, ]* E1 f# o- j' }4 Rrical testicular growth secondary to stimulation by
4 r' `* p: G( A6 Fgonadotropins.1,3
. g/ Z% E1 S* c8 j& @) u$ h- nGonadotropin-independent peripheral preco-
& m$ e+ X& \9 F. ~2 w9 Xcious puberty in boys also results from inappropriate
$ P: F0 B9 t) xandrogenic stimulation from either endogenous or7 q! K5 u5 p" C' V
exogenous sources, nonpituitary gonadotropin stim-- R% u" V. [1 U" P, q `6 n9 {3 W; d
ulation, and rare activating mutations.3 Virilizing
9 p( o6 m$ u: f/ fcongenital adrenal hyperplasia producing excessive2 H5 ~5 o5 u$ i& y3 Z' n4 A, G4 J4 ]
adrenal androgens is a common cause of precocious2 D# {* ]* T0 d' i6 J/ y5 T i' j# O
puberty in boys.3,4
$ c/ Z& O& r" X# X1 OThe most common form of congenital adrenal
) i$ E+ W. X( q% u2 _hyperplasia is the 21-hydroxylase enzyme deficiency.
5 Q i3 v! A; cThe 11-β hydroxylase deficiency may also result in' N# S; J6 R% g; Z, \. e
excessive adrenal androgen production, and rarely,
6 F' }' B% w- O5 @2 m5 G: r% M1 man adrenal tumor may also cause adrenal androgen
/ U0 R/ \4 d7 W- ?; {7 ]excess.1,3 s2 E6 e, M- j3 j* i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 ^- h4 b i( ^/ E4 f3 `. J2 W542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 f' d o3 t P$ S% q7 a$ ?A unique entity of male-limited gonadotropin-
1 s4 v$ Z5 F# \8 i- \- h' ?independent precocious puberty, which is also known. r/ k: ?! @6 Y" O* K
as testotoxicosis, may cause precocious puberty at a m9 ?+ S2 n" Y0 e( q/ U' ?; M) `
very young age. The physical findings in these boys6 g( G6 t$ o7 Y c# ~7 A2 s
with this disorder are full pubertal development,( t: K% Y. d I5 e
including bilateral testicular growth, similar to boys
& {% w) d1 L- t; }with CPP. The gonadotropin levels in this disorder8 j% U* X# n2 ]9 I0 f
are suppressed to prepubertal levels and do not show! \' j7 }0 }2 E: [7 w! d
pubertal response of gonadotropin after gonadotropin-
! ~& L5 j1 ] D7 V! g9 `8 D, [releasing hormone stimulation. This is a sex-linked
* D0 D( o* D8 @/ A5 ~autosomal dominant disorder that affects only: r7 g- |3 ~( L. V
males; therefore, other male members of the family
7 `! l" N X3 M( omay have similar precocious puberty.3
; }0 n w i4 a5 GIn our patient, physical examination was incon-( o u5 I0 V0 C6 B) u
sistent with true precocious puberty since his testi-! e% [( Y7 R% K$ j5 M K
cles were prepubertal in size. However, testotoxicosis2 Q7 t* f6 p, m! m: v2 I! W6 F
was in the differential diagnosis because his father8 c% i1 D z' ^! m
started puberty somewhat early, and occasionally,
1 T/ d8 C9 n' Atesticular enlargement is not that evident in the
P# ~" P. A$ X2 B s4 t9 T2 L9 s) z4 |' Obeginning of this process.1 In the absence of a neg-3 X r8 z0 x. o2 ?7 h! L/ M* k
ative initial history of androgen exposure, our
7 A6 Q: A7 H; h* w/ Bbiggest concern was virilizing adrenal hyperplasia,
6 r) M6 M* M$ |6 i. ^+ m3 Meither 21-hydroxylase deficiency or 11-β hydroxylase+ |0 g. H: _5 L9 U
deficiency. Those diagnoses were excluded by find-
4 t. o, h' P" Ving the normal level of adrenal steroids.# b% R, Z9 W. m6 @% n: w
The diagnosis of exogenous androgens was strongly6 ~1 x2 o' I, l: S9 V
suspected in a follow-up visit after 4 months because
. K9 M# }4 I' M7 ethe physical examination revealed the complete disap-0 y8 J5 V% O' y
pearance of pubic hair, normal growth velocity, and: z* {/ O F0 {5 h- j2 z3 N
decreased erections. The father admitted using a testos-
9 ]3 t H) R- yterone gel, which he concealed at first visit. He was
- n% X$ U! E) K6 a) }3 Ousing it rather frequently, twice a day. The Physicians’
0 e- D) G0 o4 M% D, RDesk Reference, or package insert of this product, gel or
! Z- h7 s% \( [( K4 |4 Lcream, cautions about dermal testosterone transfer to3 j( Q' O. p" n! q2 Q7 V* W4 Q7 A
unprotected females through direct skin exposure.
5 K; z0 G! H+ F% [. [Serum testosterone level was found to be 2 times the* N& X+ N# S% V& | M$ o% }$ Z
baseline value in those females who were exposed to& M# s3 e, E6 g9 s' |
even 15 minutes of direct skin contact with their male$ r7 `! ]' U1 p) k6 L/ k
partners.6 However, when a shirt covered the applica-7 e* `3 ?7 u' G7 @; X7 a/ F
tion site, this testosterone transfer was prevented.6 f/ t, j- F/ i; Z( g& Z3 \, D, z4 B5 ~8 W
Our patient’s testosterone level was 60 ng/mL,# V5 P( N! {0 f+ h$ x7 N7 j" }+ M; L
which was clearly high. Some studies suggest that
: P( K. l# U5 P) R3 v, qdermal conversion of testosterone to dihydrotestos-
* t% H) g" r+ b- t2 D, ?( v* j2 I. Qterone, which is a more potent metabolite, is more
: v$ W7 } h+ ?# _8 t- m1 Cactive in young children exposed to testosterone1 V8 m; A: Z$ i- C
exogenously7; however, we did not measure a dihy-
# X0 x, i+ Q* c- \6 Idrotestosterone level in our patient. In addition to
2 V% P; s2 A9 S' m) i1 Q% Fvirilization, exposure to exogenous testosterone in. A5 I. \; S! X! c
children results in an increase in growth velocity and: k, y+ x! y# d" O2 Q( X1 R7 g
advanced bone age, as seen in our patient.
( ~, J; b0 E+ Y# _# p# ]+ _The long-term effect of androgen exposure during3 _3 S% S% l5 h0 F2 {& ?: z8 L7 J
early childhood on pubertal development and final# F: }% a2 Q2 z! b! U
adult height are not fully known and always remain
* m* X4 R: @" E: k1 K& F/ [+ qa concern. Children treated with short-term testos-
$ s6 @6 [( ~- ?8 \terone injection or topical androgen may exhibit some
2 m/ O9 A, l9 n9 k* ^9 u& Vacceleration of the skeletal maturation; however, after$ y+ |% B R0 Q y4 ]
cessation of treatment, the rate of bone maturation1 j" t% M5 c; q- c2 T
decelerates and gradually returns to normal.8,9$ m8 g* b6 O$ B- c6 V4 E
There are conflicting reports and controversy
( J: D- V6 u; e2 }1 c$ K7 C% zover the effect of early androgen exposure on adult
. d: P+ |) n& rpenile length.10,11 Some reports suggest subnormal
. f4 [, |. s, M- j' a& ?8 g$ oadult penile length, apparently because of downreg-
2 D9 A+ n) i$ X. p' e Z- Iulation of androgen receptor number.10,12 However,! l7 ?( v2 ? @9 c
Sutherland et al13 did not find a correlation between" p; [ Q" _9 w. s* j! b
childhood testosterone exposure and reduced adult2 M( y" k/ Y9 ~" \. F
penile length in clinical studies.5 y3 T2 b% [/ b! E* @
Nonetheless, we do not believe our patient is
) B1 U% v8 _) T( y% g+ Kgoing to experience any of the untoward effects from6 S; U3 [) X8 s
testosterone exposure as mentioned earlier because! f6 j* z. t& F
the exposure was not for a prolonged period of time.
1 {) Y$ y0 \" pAlthough the bone age was advanced at the time of- a$ i9 X: U- }9 |. O, ?1 N
diagnosis, the child had a normal growth velocity at
1 W# ~# e2 W+ E+ u v$ x* nthe follow-up visit. It is hoped that his final adult
4 n' G( j; ]4 W {height will not be affected.
" o) f1 @3 Y5 WAlthough rarely reported, the widespread avail-
1 d! u: H( b. X- P4 v, g1 [ability of androgen products in our society may
2 c4 ^: ?! G% ]( _1 }indeed cause more virilization in male or female- q; B4 d* i1 e9 [& w
children than one would realize. Exposure to andro-6 `' l4 x; ~' v0 B. s* Y. A
gen products must be considered and specific ques-
1 `+ R4 v1 a; q+ C* w8 G+ o. Vtioning about the use of a testosterone product or
, P) B4 p L: W) c5 [% Mgel should be asked of the family members during
9 J, s T( i8 K7 J7 @/ F8 J3 O$ Xthe evaluation of any children who present with vir-
4 m2 o, D4 B5 y3 [: p/ f/ q# U, X" z: jilization or peripheral precocious puberty. The diag-% D, G0 C3 `+ ~0 u- B
nosis can be established by just a few tests and by2 O$ t) Y6 `) D" w) V+ R1 u! A1 U
appropriate history. The inability to obtain such a; t* C5 g% J/ E- x% c( Y" i
history, or failure to ask the specific questions, may
w2 d# L S; @. Sresult in extensive, unnecessary, and expensive
: B, w& x1 A! D. l; hinvestigation. The primary care physician should be
, e8 a& h. r( Z3 x" m% taware of this fact, because most of these children
7 P4 c+ W" \: G' ymay initially present in their practice. The Physicians’
6 j( w, f. h) l2 n; B& [Desk Reference and package insert should also put a" {& f" r( ~( _4 i
warning about the virilizing effect on a male or
2 \4 B! v: \" `2 xfemale child who might come in contact with some-
& H" T1 G. W5 V! E5 Zone using any of these products.6 h! V. ~. ]0 }. [3 S, r* i
References
" O2 p; `" g! V2 u; k1. Styne DM. The testes: disorder of sexual differentiation& b% {7 R& K" i6 s8 Q; r' q
and puberty in the male. In: Sperling MA, ed. Pediatric5 P, q1 j5 S t! Q- w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 u; K$ G4 \9 b$ B: o
2002: 565-628. P/ } G5 H% T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 y4 x- D( v2 mpuberty in children with tumours of the suprasellar pineal |
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