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Sexual Precocity in a 16-Month-Old, X+ h: [4 n8 q7 P1 k4 E/ ^
Boy Induced by Indirect Topical
5 W8 A& q' ^" Z+ E5 [3 TExposure to Testosterone
8 Q$ X# d6 x6 Z+ USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( E) c; l9 `9 g) P7 q$ d
and Kenneth R. Rettig, MD1; \! e5 r6 v- G' U' ]4 Z; X
Clinical Pediatrics% I' o% N( C3 l- j: c
Volume 46 Number 6
/ w/ a7 d5 {/ FJuly 2007 540-543$ {5 f4 |6 O& i% g2 q4 a
© 2007 Sage Publications
* r8 `. K- S+ m10.1177/0009922806296651
) c7 M, M1 E! Nhttp://clp.sagepub.com# T1 E9 q0 c I2 e' r. x0 O
hosted at
# e6 W3 _9 S+ J1 I: ^2 Lhttp://online.sagepub.com
) h; ~. b7 T# \7 d5 o, n( x/ e6 j! GPrecocious puberty in boys, central or peripheral,, H1 d2 v$ l5 M+ M$ h* C" s! k
is a significant concern for physicians. Central5 G" \( i8 A6 e' }* G7 H$ c
precocious puberty (CPP), which is mediated
9 u) }& f: _% A5 ?# x0 p+ bthrough the hypothalamic pituitary gonadal axis, has$ u4 A8 g/ Q" ?+ b6 c
a higher incidence of organic central nervous system8 E! v- X$ {2 N) ~4 l
lesions in boys.1,2 Virilization in boys, as manifested) W; X# f) |0 \1 N, G
by enlargement of the penis, development of pubic
& W8 j- _( j4 L# `) S3 thair, and facial acne without enlargement of testi-
/ `2 c0 Y9 |; b/ |0 {9 D+ l* N$ R7 icles, suggests peripheral or pseudopuberty.1-3 We
9 p7 O8 t4 k6 w" p( `0 r& Yreport a 16-month-old boy who presented with the
0 C' V- t" D. Y+ renlargement of the phallus and pubic hair develop-
) V6 n' e/ y* s# tment without testicular enlargement, which was due
( p- c4 k% e2 L. I |9 Y# K% ~to the unintentional exposure to androgen gel used by) [% |8 g2 E& q8 {# k# f, D
the father. The family initially concealed this infor-. T* I+ `! G* q' R0 x! E6 s; t4 x
mation, resulting in an extensive work-up for this
4 G; m9 P8 X5 ~- D, J, F5 J: achild. Given the widespread and easy availability of
9 m/ q( u8 i/ k2 C5 \% rtestosterone gel and cream, we believe this is proba-4 t4 L; L. R$ m( W, M1 w
bly more common than the rare case report in the
. m0 } ?0 l4 fliterature.48 l; a& n1 S! {- Z; _! X
Patient Report
& c/ c# H. \; J* s! l) [* b! F$ V0 CA 16-month-old white child was referred to the* F& D$ c- l7 S* i9 t3 [2 x
endocrine clinic by his pediatrician with the concern* ?# Q$ \+ m$ w/ Q$ C% w
of early sexual development. His mother noticed
6 r" g* ]9 @7 E& p. L& G, U1 klight colored pubic hair development when he was
1 l$ j4 b q( _2 f2 [0 WFrom the 1Division of Pediatric Endocrinology, 2University of A3 b$ A/ J, r4 U
South Alabama Medical Center, Mobile, Alabama.7 ^8 {) z1 B# Z% w; j9 q$ F
Address correspondence to: Samar K. Bhowmick, MD, FACE,# ]9 P; D& h! j2 c& i; j/ x
Professor of Pediatrics, University of South Alabama, College of6 Q/ E% C- Q4 ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; I; I" ?* O/ f' v9 f! u! b6 u
e-mail: [email protected].5 K* I0 C. i& O4 `3 v5 X
about 6 to 7 months old, which progressively became
) q" h0 @( W; `8 F8 P% y& Sdarker. She was also concerned about the enlarge-' M- c/ E5 ~9 I7 X5 |) {; N4 Z
ment of his penis and frequent erections. The child
5 r* X5 @; e. @% ~$ u/ vwas the product of a full-term normal delivery, with
: B( n- N1 ?9 d7 [4 b2 T* p# Ma birth weight of 7 lb 14 oz, and birth length of
# a% K5 h9 h: d0 m c% V1 _20 inches. He was breast-fed throughout the first year9 p. k# G' ^" n
of life and was still receiving breast milk along with
- g' G) k) a# v, m6 ~) j9 q2 G: osolid food. He had no hospitalizations or surgery,
+ e: i* ^/ P0 ]8 _. g' {6 U6 @8 Kand his psychosocial and psychomotor development
( U* r9 x4 V2 F& A, @( T. bwas age appropriate., L5 c ?% L( I7 \+ o. m' e
The family history was remarkable for the father,
$ y, ^0 E; C* D( H+ b- l* Zwho was diagnosed with hypothyroidism at age 16,
, @/ Y+ S3 |" Q+ Qwhich was treated with thyroxine. The father’s3 l5 W& m9 L( T. R. \& d
height was 6 feet, and he went through a somewhat
4 Q# K- K: j: g/ f- u: Cearly puberty and had stopped growing by age 14.+ x" |0 w& \0 H7 \( f; Z" l1 P
The father denied taking any other medication. The3 [. Z4 F+ r/ ^5 m
child’s mother was in good health. Her menarche c! _8 I2 f7 s* S
was at 11 years of age, and her height was at 5 feet! j, P6 r6 `7 i7 t# X. @
5 inches. There was no other family history of pre-
. d; n0 B6 g! y2 B U4 Zcocious sexual development in the first-degree rela-
4 d2 y- E7 v# V2 o! `tives. There were no siblings.
2 |: \) O+ J7 yPhysical Examination
4 C5 N P# C. V7 r# U6 r3 PThe physical examination revealed a very active,# T1 R- k1 b. G
playful, and healthy boy. The vital signs documented
$ a4 H! t) H" B3 w& ]9 ga blood pressure of 85/50 mm Hg, his length was0 Q! D0 ~7 |: _! |: g+ K
90 cm (>97th percentile), and his weight was 14.4 kg
" a( x, v9 M2 I8 e' Q2 k(also >97th percentile). The observed yearly growth( f" ]! y# K6 \+ j0 I
velocity was 30 cm (12 inches). The examination of* m4 K* g4 |& K `* O: u+ T
the neck revealed no thyroid enlargement." e( g! t/ x/ {' k- x, j* G
The genitourinary examination was remarkable for
k$ {2 V: ?; }9 e; Oenlargement of the penis, with a stretched length of
: ^7 j7 l0 j+ [, \. h+ k8 cm and a width of 2 cm. The glans penis was very well
" C0 C* [: ]& r) Z# ]' q( @developed. The pubic hair was Tanner II, mostly around g" L: t* y1 F) C8 [" I" F# O
5402 W6 `/ y6 I% }: R0 B. P. F+ S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. B3 g6 y% j0 Z9 d# b6 v g
the base of the phallus and was dark and curled. The
9 l2 L7 d6 n' `! B; L+ Y! @testicular volume was prepubertal at 2 mL each.) ^1 h4 W/ s9 N8 s0 r" F3 X* ]7 B
The skin was moist and smooth and somewhat
' p+ Z# x* g. F7 v7 h9 _4 L. ~oily. No axillary hair was noted. There were no w7 [' m9 o2 Y$ u; r! _1 ]
abnormal skin pigmentations or café-au-lait spots.
{( J. e' |# V3 _ LNeurologic evaluation showed deep tendon reflex 2+
5 {0 I7 `3 L- ~- O2 abilateral and symmetrical. There was no suggestion7 @- H! ~- L/ F2 n. x+ a
of papilledema. k# }8 E F6 Z! @# R! a5 D8 ?( p
Laboratory Evaluation
% j9 S- x9 I9 x% S% U+ K) \The bone age was consistent with 28 months by7 u# {9 n1 U6 U8 L- W; J1 T
using the standard of Greulich and Pyle at a chrono-
: @ |. i2 o6 I4 [logic age of 16 months (advanced).5 Chromosomal
4 U9 A7 S/ W( ?8 @& Pkaryotype was 46XY. The thyroid function test4 V/ b' ?9 K7 T4 E$ s4 T* }
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 T3 I% g' I& y# t7 V' @
lating hormone level was 1.3 µIU/mL (both normal).8 a; L0 x& g% O; `
The concentrations of serum electrolytes, blood7 H0 C% t# i% U0 Z% [* _3 `
urea nitrogen, creatinine, and calcium all were
+ z5 w {- j2 K, n. }0 Q8 Dwithin normal range for his age. The concentration
1 U9 `' x* I9 ~6 q- K/ _of serum 17-hydroxyprogesterone was 16 ng/dL
3 h" M+ M! Y& `# N! e6 d(normal, 3 to 90 ng/dL), androstenedione was 20
/ V3 g+ H% V, n# I3 g- K e& fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# B- z; C. j& E. X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 g, P E( P* I" b; B% Ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to+ q' W2 e- p/ m/ h
49ng/dL), 11-desoxycortisol (specific compound S)8 `: H5 |/ y# W; p& R" e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 _. k1 d; j: z' ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' Y4 Y$ ~) |# W# {( s
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ O" Q+ ]2 v, I- ~
and β-human chorionic gonadotropin was less than& r, b. I) N i) S0 y
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 @* O) W2 D$ {2 `# l6 f+ B7 t Estimulating hormone and leuteinizing hormone
k0 w* |: {9 R) ] Oconcentrations were less than 0.05 mIU/mL
* y4 O# y6 }6 C( D, o(prepubertal).
/ n/ d4 f$ ^! E: | b% PThe parents were notified about the laboratory8 R; ]$ K. ~& l% s$ T( `8 g* G
results and were informed that all of the tests were
% k( V% a) P- c2 r; e M/ N# znormal except the testosterone level was high. The
# K0 P# r. D' i8 [follow-up visit was arranged within a few weeks to0 p4 g# r9 y% @/ G+ g
obtain testicular and abdominal sonograms; how-/ @5 C9 g, \$ |5 H- A
ever, the family did not return for 4 months.
0 }" ?+ _, P. O9 Z7 _# r/ HPhysical examination at this time revealed that the
: d. n( ~6 k* [& tchild had grown 2.5 cm in 4 months and had gained% f' s' q0 {4 b
2 kg of weight. Physical examination remained
6 a* K% ~/ p' y( z$ dunchanged. Surprisingly, the pubic hair almost com-
: v- J* s, X/ I0 Z7 Tpletely disappeared except for a few vellous hairs at: ]! m/ g+ J( a8 a z8 Y1 J: ^
the base of the phallus. Testicular volume was still 2- I' W# T d3 y/ S- ^2 I3 `
mL, and the size of the penis remained unchanged.
4 y( c6 B4 T$ Z q& HThe mother also said that the boy was no longer hav-
' ]6 d9 \/ p, u: p% ]2 }ing frequent erections.
: C* q, r, [# SBoth parents were again questioned about use of: M+ Q1 _, x s+ O
any ointment/creams that they may have applied to( R( z f) g% s$ V
the child’s skin. This time the father admitted the
! e- W+ q% s5 @8 v) B6 n7 ~" y# gTopical Testosterone Exposure / Bhowmick et al 541+ `$ G+ e, Y- e
use of testosterone gel twice daily that he was apply-
9 z) ]( G* e( E% w/ O. king over his own shoulders, chest, and back area for9 {' r/ s c: k% ]( |" l
a year. The father also revealed he was embarrassed% Z2 }& ~/ Q2 ]( j9 E
to disclose that he was using a testosterone gel pre-& b* s. R- P% S+ L0 L0 E; J
scribed by his family physician for decreased libido
! N/ `, p* l3 ]secondary to depression.
* h2 _5 b0 | F* vThe child slept in the same bed with parents.0 v& @4 t! X5 S/ u3 P S2 n: ]
The father would hug the baby and hold him on his
: x6 @. G$ K% M: ^; ?chest for a considerable period of time, causing sig-
8 S# d( a' ^$ N5 Inificant bare skin contact between baby and father., g( Z: w$ g3 {) I/ I
The father also admitted that after the phone call,. Z* n+ I5 d( f' h( Y7 |& o9 J7 ]7 h6 d
when he learned the testosterone level in the baby c6 @: B; j1 G% k
was high, he then read the product information1 r! s5 D& w, U0 ~% L. [9 Z B8 C
packet and concluded that it was most likely the rea-
7 Y1 N9 O! I1 U9 R5 _son for the child’s virilization. At that time, they% ]1 H1 R5 L& k5 d2 f+ u- z: r/ m8 k% ?
decided to put the baby in a separate bed, and the
. c. S, q/ _' [/ s( I( h( Ofather was not hugging him with bare skin and had( s3 d4 F9 q; i- B
been using protective clothing. A repeat testosterone
* [- C3 K7 {. m9 n' ~test was ordered, but the family did not go to the
2 s" E" l* @0 R# `+ c/ C" N0 elaboratory to obtain the test.
" \1 K# a+ i- E |' R4 r& V+ DDiscussion
/ z; b5 C/ `8 x3 t2 K1 W- |4 IPrecocious puberty in boys is defined as secondary1 D' B' a* ?9 Z
sexual development before 9 years of age.1,4( `6 J" w! u6 _( S
Precocious puberty is termed as central (true) when1 ~, ]! M1 C8 T$ x8 W
it is caused by the premature activation of hypo-/ G1 k9 i1 d. Q7 {, v& o
thalamic pituitary gonadal axis. CPP is more com-/ f9 L0 O3 e# i3 V% m
mon in girls than in boys.1,3 Most boys with CPP
/ a9 `( F3 a* T+ B% {; Z' |may have a central nervous system lesion that is
$ p0 p# b! z1 Y4 ^' gresponsible for the early activation of the hypothal-
$ N7 n: d7 \0 m% W6 m t: Hamic pituitary gonadal axis.1-3 Thus, greater empha-
* ^7 Z3 K1 H" L3 g% qsis has been given to neuroradiologic imaging in5 D& S) I z4 u U
boys with precocious puberty. In addition to viril-
+ Z4 Q( J3 g; u. Q+ D% _ ~# oization, the clinical hallmark of CPP is the symmet-3 J1 d# ]2 u* J1 n& q% @$ b* T/ W
rical testicular growth secondary to stimulation by8 B; `5 V4 P( B- ^( d, C' e2 \
gonadotropins.1,30 l% w' T0 y V* H6 _
Gonadotropin-independent peripheral preco-$ }7 [' b5 ?8 Z i1 ?. Z% r
cious puberty in boys also results from inappropriate+ M( ^" r9 q( P5 J! [( n
androgenic stimulation from either endogenous or5 d) }2 @1 c1 ]8 J! O. e
exogenous sources, nonpituitary gonadotropin stim-
$ X, J' `+ V8 @3 lulation, and rare activating mutations.3 Virilizing* X( O# B7 O' ]
congenital adrenal hyperplasia producing excessive
, `- h2 r: @3 ]adrenal androgens is a common cause of precocious
" O, z9 ]0 T) ipuberty in boys.3,4* L( `; U: Z9 S, u! s# r
The most common form of congenital adrenal
$ O$ d3 g$ |& _ s# T. d5 ghyperplasia is the 21-hydroxylase enzyme deficiency., O$ z/ x8 _, r5 u- X b5 e& r
The 11-β hydroxylase deficiency may also result in- j5 E8 e6 w; E ?
excessive adrenal androgen production, and rarely,
' o# \7 G$ h6 V- r5 \an adrenal tumor may also cause adrenal androgen
3 J! d: l: ~6 J. A+ ]. f( m* Z+ _excess.1,3
8 s9 J. ^) y0 L( \2 w: l' _0 ]5 kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 t$ D, Z4 N* P+ e( m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 B2 \$ K) x! Q: e: B* GA unique entity of male-limited gonadotropin-
+ _+ W+ Q4 q9 X6 ]. windependent precocious puberty, which is also known0 M' i( ~& H+ z' y, R' C$ P$ J
as testotoxicosis, may cause precocious puberty at a
' @) Z2 X& ^1 T, S% k" Yvery young age. The physical findings in these boys( m' X1 Q6 q1 ?5 O9 b" X; w, b& i
with this disorder are full pubertal development,
! m# e- |5 @% d) mincluding bilateral testicular growth, similar to boys# f8 O+ h- [% U, c
with CPP. The gonadotropin levels in this disorder; p8 }7 u4 e8 `6 f, J7 K
are suppressed to prepubertal levels and do not show7 J- u; ^/ B, [( D1 G! S. j
pubertal response of gonadotropin after gonadotropin-, r7 t. @% F% Z9 {; v Y' q% @* k
releasing hormone stimulation. This is a sex-linked
% u- F# e2 w. E; H3 ?$ o: K6 cautosomal dominant disorder that affects only
W; N1 e8 G" w% D) @5 _6 Pmales; therefore, other male members of the family
3 m; ~& \+ G3 `) z2 qmay have similar precocious puberty.3
/ g8 M% e. @$ q- W3 {# X/ |8 A7 dIn our patient, physical examination was incon-
/ z! y( Q5 y* v. Y5 Vsistent with true precocious puberty since his testi-1 G- S/ Z) Q- r# I0 z
cles were prepubertal in size. However, testotoxicosis. [+ T$ l! V( P( J) B$ ^0 }
was in the differential diagnosis because his father
H: T X' z; X1 w& {: F! _started puberty somewhat early, and occasionally,, T1 {2 i7 f( C( w/ V( }
testicular enlargement is not that evident in the
) R3 u' K/ @: Mbeginning of this process.1 In the absence of a neg-* t7 O/ y0 k( l g1 p& k! E5 p
ative initial history of androgen exposure, our
$ ]6 H9 }! C# h0 |: u3 b5 Tbiggest concern was virilizing adrenal hyperplasia,% I# j5 v4 a3 K: H) h& }
either 21-hydroxylase deficiency or 11-β hydroxylase
, u2 X& D* `' q: G) udeficiency. Those diagnoses were excluded by find-
; K2 M: @* F7 T( u7 S; Cing the normal level of adrenal steroids.% u! Q. m) z/ r' r& U
The diagnosis of exogenous androgens was strongly; m" a/ d/ P- |* I
suspected in a follow-up visit after 4 months because
7 R* x- b- y0 E* qthe physical examination revealed the complete disap-
" u5 ~" l5 M. a7 a9 _; V( gpearance of pubic hair, normal growth velocity, and- N$ H; G. k/ q& ]# v! D* t5 H I
decreased erections. The father admitted using a testos-/ P# _$ [1 b& }0 J$ ~3 g' y
terone gel, which he concealed at first visit. He was
" j9 N6 l/ K* L' @using it rather frequently, twice a day. The Physicians’- F7 I3 A t& T9 B# _, C u) n& i0 Y/ l
Desk Reference, or package insert of this product, gel or) I. \' r; k5 G7 H8 U
cream, cautions about dermal testosterone transfer to
, h7 W. v& k6 h( gunprotected females through direct skin exposure.
5 s9 F c H; B7 |Serum testosterone level was found to be 2 times the
* G: ?5 f* \0 I# H% d- m* Ybaseline value in those females who were exposed to6 B0 J I4 @$ Z3 K7 R' F9 v
even 15 minutes of direct skin contact with their male
/ s1 Z q# r, x/ r5 T' upartners.6 However, when a shirt covered the applica-2 {1 b) t+ C S$ G1 l
tion site, this testosterone transfer was prevented.
/ d/ p. G# A0 \, YOur patient’s testosterone level was 60 ng/mL,/ {$ n# \) O, n) [% R& H
which was clearly high. Some studies suggest that
* z$ j( r% e9 b/ ^+ gdermal conversion of testosterone to dihydrotestos-5 Y6 p! X& x5 D0 m
terone, which is a more potent metabolite, is more
' G+ y- s% O7 o; C$ W3 \active in young children exposed to testosterone
3 T9 A8 r& v2 j! s" R) ~/ j2 B) X" @9 `exogenously7; however, we did not measure a dihy-8 T% ]8 J6 k! J B5 i
drotestosterone level in our patient. In addition to
! Y! W$ U0 B/ x3 {& r( {% nvirilization, exposure to exogenous testosterone in
f) e, Z! `8 g" e& f% ichildren results in an increase in growth velocity and
, ?. e2 ?+ M Cadvanced bone age, as seen in our patient.) ?& ]: R# ]" O- A2 [: K
The long-term effect of androgen exposure during
3 z+ _% H( d$ b+ S3 T% W8 vearly childhood on pubertal development and final, K3 f3 g/ J' ^5 S5 L3 z" d, T
adult height are not fully known and always remain# E* M& X. W* [- ?3 ?4 {, ^
a concern. Children treated with short-term testos-
7 b8 a7 W2 r6 b& k; Y* y- k( N2 Aterone injection or topical androgen may exhibit some
, t, U% n w0 v5 V* Aacceleration of the skeletal maturation; however, after; z. \4 \/ U1 b
cessation of treatment, the rate of bone maturation- J# |; h4 {& n5 o- W" E
decelerates and gradually returns to normal.8,9
2 M* i7 [9 `5 Q) w3 [3 lThere are conflicting reports and controversy% A# S0 ]5 C2 s2 k' V
over the effect of early androgen exposure on adult8 ?/ c& M: `# ^2 Q0 R4 Q
penile length.10,11 Some reports suggest subnormal. y/ T$ f7 n& ]: D
adult penile length, apparently because of downreg-
! P! {% L% X' o6 p9 _ulation of androgen receptor number.10,12 However,$ b$ u G* p2 a7 G( r& z' M
Sutherland et al13 did not find a correlation between9 I$ j7 M1 N& F4 N
childhood testosterone exposure and reduced adult
! K3 s6 o8 C- {" l' ]- V2 ]0 hpenile length in clinical studies.
; p3 j C& b2 e+ z! ^7 ?" J) D6 |Nonetheless, we do not believe our patient is
8 m) Z4 @5 ?; S, t* lgoing to experience any of the untoward effects from! p/ @) J2 x& I* Q3 V+ I- ?6 l
testosterone exposure as mentioned earlier because/ I" [$ h! O! l) ? I
the exposure was not for a prolonged period of time.# K! n: b( ~$ b& {3 Z" _
Although the bone age was advanced at the time of+ _ C! ]+ Q8 ]( K! `) P
diagnosis, the child had a normal growth velocity at. T% {6 c4 z$ ^' w! H, [+ T; D
the follow-up visit. It is hoped that his final adult
& Y. i9 H9 B2 P% V# X" g' U5 Fheight will not be affected.
* i" ~% h2 [7 T2 a5 VAlthough rarely reported, the widespread avail-
$ s: ^. B3 f, b/ q7 qability of androgen products in our society may
& h0 i* n# I* h! bindeed cause more virilization in male or female
8 H# ], B. f, Y9 G$ ]% }' Mchildren than one would realize. Exposure to andro-# d6 M G! o) W- V+ H, B8 V% Q
gen products must be considered and specific ques-# i9 j- L6 Q8 T# F5 x0 S' n
tioning about the use of a testosterone product or, P, n/ ^" R9 Y$ D% K' |9 ?+ E$ D
gel should be asked of the family members during
% I; d* B) L4 Y8 F& _/ cthe evaluation of any children who present with vir- E {3 Y+ J1 X
ilization or peripheral precocious puberty. The diag-
5 X }5 g1 N. L) W0 i$ Cnosis can be established by just a few tests and by
. _% z& b- X# Q- l* Q$ r9 rappropriate history. The inability to obtain such a
) w O9 R" P, `% C8 [! ~: xhistory, or failure to ask the specific questions, may
0 k& N9 Y; q% Z. C9 `7 R* x0 Dresult in extensive, unnecessary, and expensive2 \2 x8 H3 }4 y' Z/ J& m. B$ s% d% e
investigation. The primary care physician should be
2 n- J- @+ i! s( z4 R; naware of this fact, because most of these children
0 {+ F* U+ O& W% }may initially present in their practice. The Physicians’
' J6 `/ w; s. B8 X7 q% _8 XDesk Reference and package insert should also put a
' n, U T( R" Cwarning about the virilizing effect on a male or
. A& V" l- w* v3 V8 |female child who might come in contact with some-
" d9 N' ~4 |$ A# C2 U/ S) F* Cone using any of these products./ U/ ?* Z( @& u t' j# k% l
References7 @7 I" Y% V( q4 t. P' @3 B, q: n
1. Styne DM. The testes: disorder of sexual differentiation- F$ u0 |- x$ ?/ D8 m$ s
and puberty in the male. In: Sperling MA, ed. Pediatric( F9 l7 N# e. s# {. \; a7 g
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 R3 K- E1 Q/ C! C/ K
2002: 565-628.1 ]2 j' ?& M; m8 N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% T0 m5 Z( I# i5 g6 d( Y. g$ Tpuberty in children with tumours of the suprasellar pineal |
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