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Sexual Precocity in a 16-Month-Old' W4 B3 L: ?6 q) T9 e
Boy Induced by Indirect Topical
5 D7 z: E) c$ V. A" PExposure to Testosterone/ \2 r# q W1 q: I$ V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- a5 ^3 _; ~, V6 _
and Kenneth R. Rettig, MD1
. u/ I, ]3 `# f8 q; P$ |6 `! UClinical Pediatrics
9 W) p W3 |/ A: `' i0 A0 jVolume 46 Number 6
! Y! F0 O; u8 q6 u; n0 M" i; NJuly 2007 540-5438 h3 f7 ?2 P/ ?$ ^ [) B
© 2007 Sage Publications, j1 `# |( X/ H
10.1177/0009922806296651
8 d' H+ k7 A7 x+ X/ l; b6 Z" i( p7 l9 Chttp://clp.sagepub.com
- a. K' a6 G: [ v4 }; ^8 ~0 g4 v) uhosted at
: a5 S! R( x4 W6 e8 M, G8 D7 Rhttp://online.sagepub.com
/ j0 A8 J% w/ _+ l- j- a7 h& [, UPrecocious puberty in boys, central or peripheral,
# }% }2 J6 W& d* \" T; vis a significant concern for physicians. Central
$ b( O; C" v% J2 i8 V& h& j$ Uprecocious puberty (CPP), which is mediated8 i0 |5 r: O% i2 O
through the hypothalamic pituitary gonadal axis, has
( M/ g- p/ f/ U% h. O8 Wa higher incidence of organic central nervous system
0 w4 x5 u8 {$ }" l+ ]lesions in boys.1,2 Virilization in boys, as manifested
1 R$ C* y: @( {4 y; A0 oby enlargement of the penis, development of pubic
r% g7 s& M9 c! U* N% o8 ]hair, and facial acne without enlargement of testi-: ~' p M+ O# C: V# u
cles, suggests peripheral or pseudopuberty.1-3 We0 a3 y9 }4 d( S/ V* v
report a 16-month-old boy who presented with the
7 k. j& v$ K$ I+ L; o$ j8 menlargement of the phallus and pubic hair develop-
) W' }, T/ K3 X* hment without testicular enlargement, which was due
/ o- ?8 n: I# @, r7 s) }to the unintentional exposure to androgen gel used by
8 g; y# m4 O3 X2 ^* Bthe father. The family initially concealed this infor-
2 @1 L0 K: N) }9 emation, resulting in an extensive work-up for this) O- Q/ f6 T+ @, W m9 s, _% W5 T
child. Given the widespread and easy availability of6 V; c8 ~6 {. x7 C/ p2 u4 A+ z
testosterone gel and cream, we believe this is proba-
5 `: I# J3 N2 xbly more common than the rare case report in the
% v# W' L/ e: ~literature.4
% g4 t3 U& C! _9 i4 Z8 C* n1 I1 wPatient Report+ @& Q9 J6 w: Y- G: }
A 16-month-old white child was referred to the2 p7 @, u4 Y7 u! h6 _- ]# |- }5 ]8 ^
endocrine clinic by his pediatrician with the concern& k- p: G$ W9 s4 t8 Q4 ]9 K
of early sexual development. His mother noticed
& T H, h- M! p& }0 Dlight colored pubic hair development when he was
! e# h0 V5 m6 {" u/ p5 YFrom the 1Division of Pediatric Endocrinology, 2University of0 q1 A+ P9 T" D
South Alabama Medical Center, Mobile, Alabama.
; s" x, L, Z) ?+ i. y. h$ DAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ Y6 q0 U/ W$ O) b$ p
Professor of Pediatrics, University of South Alabama, College of
4 c4 X, J0 u9 I9 ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 j6 p% ^, l' f% p' F+ y! U- ^
e-mail: [email protected].
' e. A% ]. \6 C# Z* Zabout 6 to 7 months old, which progressively became u8 ~5 ^# b& c: m# ?- Q" a
darker. She was also concerned about the enlarge-
2 `" k. W% y" p1 D2 m Qment of his penis and frequent erections. The child
& Y* u0 v" f7 t. ^5 c/ a! Zwas the product of a full-term normal delivery, with/ Q2 P& g, n& Y" `2 }- M9 R
a birth weight of 7 lb 14 oz, and birth length of/ n- }+ u, |, J% n0 ~
20 inches. He was breast-fed throughout the first year
% S$ E; @/ o0 R! E$ e( n! d; i& yof life and was still receiving breast milk along with
L. d9 w8 }1 bsolid food. He had no hospitalizations or surgery,
Y& B2 G3 e4 \9 R' v! Y/ e* D0 Aand his psychosocial and psychomotor development4 w% A3 u7 W# d6 v; J+ {) W [
was age appropriate.
" E6 ~. J3 h0 U0 N* k4 U+ m. {" v+ [% |The family history was remarkable for the father,
. X" G! C' j$ {- W8 p3 [, Ywho was diagnosed with hypothyroidism at age 16,; v a! w: @! z( f
which was treated with thyroxine. The father’s
8 p6 L: r/ b/ u$ C F' }height was 6 feet, and he went through a somewhat8 D5 S/ \& T+ ], R% k7 y$ O8 F: ]
early puberty and had stopped growing by age 14.* k% b' Y" \0 ~6 O
The father denied taking any other medication. The0 E! [ r/ b3 k8 O* N+ F
child’s mother was in good health. Her menarche4 C- l4 a% \1 U2 {
was at 11 years of age, and her height was at 5 feet
' w2 w: k$ F4 x1 {' o! a( h& H5 inches. There was no other family history of pre-
1 n+ x" c8 n% k) w4 Bcocious sexual development in the first-degree rela-
3 V" f- {0 Y' r8 ^/ S+ Q1 h9 Jtives. There were no siblings.
) o9 \0 Q" U9 o' w* f5 S$ aPhysical Examination
* d" a# t8 s5 }- S9 |4 SThe physical examination revealed a very active,( F8 Z5 p9 G; t; F; v0 ?- t
playful, and healthy boy. The vital signs documented
0 `8 m: A% g4 t7 Ra blood pressure of 85/50 mm Hg, his length was" y) c1 L$ G9 o3 J3 \+ i
90 cm (>97th percentile), and his weight was 14.4 kg2 f) m, \2 J: B$ [& s8 h3 f- s
(also >97th percentile). The observed yearly growth
) E) [2 ]( w; M n8 |- }velocity was 30 cm (12 inches). The examination of. K" o, M0 F& f, W! a+ p
the neck revealed no thyroid enlargement.8 V' F' v' \+ `' o# [
The genitourinary examination was remarkable for
# s0 k5 e! ?' Renlargement of the penis, with a stretched length of
! d8 N) c, K! M, n! |8 cm and a width of 2 cm. The glans penis was very well+ U" R4 X6 v6 P$ i0 L7 v
developed. The pubic hair was Tanner II, mostly around. A' K- q2 A- {* Q( z3 _: ^$ P [/ ]7 y
540
- V% k( u) L5 m1 s, F) s8 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 U, m$ k3 ?, s2 `the base of the phallus and was dark and curled. The, L: {( m- _0 i
testicular volume was prepubertal at 2 mL each.
; P7 N- S, D- D- P+ z( I2 T- `. h% PThe skin was moist and smooth and somewhat
+ C' ^- Z3 T2 J/ T7 q: foily. No axillary hair was noted. There were no7 n* B! ^" l; e& v- d
abnormal skin pigmentations or café-au-lait spots.
" c, v; T1 A! M/ k- }# `2 UNeurologic evaluation showed deep tendon reflex 2+
- \, _1 e9 f) d- G' M) ]" w' E* |bilateral and symmetrical. There was no suggestion) a2 D: r8 [7 b, c
of papilledema.
# f/ ^" A, H! u6 c. k1 MLaboratory Evaluation2 [- W) \! e7 w! q9 a: _ p
The bone age was consistent with 28 months by+ h$ Q! L4 M- e8 I- D3 c
using the standard of Greulich and Pyle at a chrono-
; e# I4 N; p6 L+ b' a2 f0 p5 a# Mlogic age of 16 months (advanced).5 Chromosomal! I; {3 M. R' Q( ?# j
karyotype was 46XY. The thyroid function test H6 c7 o9 u5 \6 t" K- l
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, h- W0 m9 Y9 M* J3 q/ ] n. vlating hormone level was 1.3 µIU/mL (both normal).; `# Z6 K) x1 o# a" G% P
The concentrations of serum electrolytes, blood. G7 h* P; i% l- y7 ^8 L& y
urea nitrogen, creatinine, and calcium all were
a" p$ g# Y) Q0 twithin normal range for his age. The concentration
. m; v! Y6 j; m% k8 `of serum 17-hydroxyprogesterone was 16 ng/dL: v. D+ L, e4 w {* x' Z" O
(normal, 3 to 90 ng/dL), androstenedione was 20
1 A7 E. S1 N! C7 Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros- l% T5 j' ]$ h# z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ e2 @* K5 Q4 @+ V5 H6 G! A7 U; z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: C1 |3 m+ Q( P8 \49ng/dL), 11-desoxycortisol (specific compound S). y/ \9 r2 K1 Z0 p _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 n# k1 E2 g4 ?+ Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, y/ n y& Z, i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 }( k1 ~) I1 \4 z% ^and β-human chorionic gonadotropin was less than2 Y# v3 h' A+ H L ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- o* Y/ y$ c8 S( A) e( m: h6 qstimulating hormone and leuteinizing hormone
: z% c; _/ {9 c, z. I$ Vconcentrations were less than 0.05 mIU/mL
! W6 K! f$ j2 i, p5 ?(prepubertal).
" r4 h! Z) I2 A& P; b8 |* KThe parents were notified about the laboratory
* |# Z! `9 x* F& l$ `0 b% ~results and were informed that all of the tests were
2 E' y* O# ^# q( Wnormal except the testosterone level was high. The# H3 P( a8 ]; _( K% O* F5 g: l, s+ q
follow-up visit was arranged within a few weeks to
3 ^* j. C4 n) x9 N Q0 Hobtain testicular and abdominal sonograms; how-
+ M4 v, X: c: ^6 k% E% D# Cever, the family did not return for 4 months.4 y# M/ Z, N( g$ Y2 u4 `! \. d" Y
Physical examination at this time revealed that the \- q8 `) f6 L+ S9 {' N
child had grown 2.5 cm in 4 months and had gained
$ d1 o/ O( {/ H) q, J% O% A" E. ]+ Y2 kg of weight. Physical examination remained
( t( Z, n/ P2 U! m' c; gunchanged. Surprisingly, the pubic hair almost com-) V! B, |8 S f
pletely disappeared except for a few vellous hairs at0 ?7 d1 f& U: o' S, M. _8 G y
the base of the phallus. Testicular volume was still 2
- |# E! @. J7 E# d) J8 _( bmL, and the size of the penis remained unchanged.
I6 ~7 ~. M0 B' f6 FThe mother also said that the boy was no longer hav-; k- L% e, V. H" }0 }" G; W) \
ing frequent erections.
! |, V' _; E. O& u- S& W3 IBoth parents were again questioned about use of& ^% t7 H5 w0 Z5 ~" c0 I
any ointment/creams that they may have applied to; l& ]5 d$ F& J9 j" V6 f1 Y
the child’s skin. This time the father admitted the
1 H) n" J5 O; O V' W; Q1 o; tTopical Testosterone Exposure / Bhowmick et al 541* W6 @" f. L b8 I7 g! s; A) m
use of testosterone gel twice daily that he was apply-
0 c' I% P: e/ `: k. c# I7 k8 V1 r7 b( Ting over his own shoulders, chest, and back area for
% \. z" [5 F1 E* la year. The father also revealed he was embarrassed
* n- [$ S$ s9 ]3 f- Yto disclose that he was using a testosterone gel pre-
5 V, s" ]2 |) Q; [% L; w9 `scribed by his family physician for decreased libido o$ Y' d; c' E1 l( ^
secondary to depression.: U5 l" l- b6 P
The child slept in the same bed with parents.4 _3 N7 \" u! P7 g( B5 t
The father would hug the baby and hold him on his+ ~& ~. y7 ~9 S: b% P! E7 l: |
chest for a considerable period of time, causing sig-
9 I/ c4 j3 o" e4 F* M1 K* }nificant bare skin contact between baby and father.
& N3 X% u4 \% P% `# R! @: rThe father also admitted that after the phone call," _) m$ w2 Z+ ^0 ]1 f
when he learned the testosterone level in the baby2 l1 A; M6 e( C: M6 i3 T- j
was high, he then read the product information
8 _9 R8 i8 b- i# Dpacket and concluded that it was most likely the rea-
1 T B* E4 c1 i# Y6 Wson for the child’s virilization. At that time, they
" D, e+ S7 l9 m* W* K' n: H$ Odecided to put the baby in a separate bed, and the
- D" V' D# l( n* Y, T2 cfather was not hugging him with bare skin and had
( F& ]5 l+ Y' }: O0 k1 M# ~been using protective clothing. A repeat testosterone% Q/ j) V; b6 d8 ?
test was ordered, but the family did not go to the; K, G: E& j7 H6 v6 Q
laboratory to obtain the test.
: `: {8 B# b+ T+ fDiscussion
) O/ H x1 u4 S( B& `Precocious puberty in boys is defined as secondary6 V: W$ q9 V2 k+ c& r7 w
sexual development before 9 years of age.1,4
; `0 k0 b* L, `8 y& d7 {; j& ZPrecocious puberty is termed as central (true) when
5 [# _7 c% K8 K; k. D2 h$ Pit is caused by the premature activation of hypo-
1 X2 x3 ], X) J% m4 J& `0 othalamic pituitary gonadal axis. CPP is more com- W- u. q: S1 O6 C9 L
mon in girls than in boys.1,3 Most boys with CPP" {4 x# s2 f' d+ N
may have a central nervous system lesion that is
6 g+ X, `0 k( f( m" l+ aresponsible for the early activation of the hypothal-
0 n# |$ \6 _( Y1 A5 camic pituitary gonadal axis.1-3 Thus, greater empha-# F' H: z; r' X- n0 h% s
sis has been given to neuroradiologic imaging in
; Y- y& X$ S. E/ {. Z9 eboys with precocious puberty. In addition to viril-
2 z% C& P: I, i, i% J9 U" Lization, the clinical hallmark of CPP is the symmet-* i2 b, n5 g% x1 H1 w' E0 @. T
rical testicular growth secondary to stimulation by" X5 `- B8 ]$ E
gonadotropins.1,3 f, }/ R/ ]) {4 W0 Y. M/ ^+ H
Gonadotropin-independent peripheral preco-4 U# r1 A7 W8 p+ v
cious puberty in boys also results from inappropriate
/ F& t2 p# L2 d% x/ mandrogenic stimulation from either endogenous or2 p# f1 N/ C7 a
exogenous sources, nonpituitary gonadotropin stim-
: l& h, d; h$ ^1 iulation, and rare activating mutations.3 Virilizing! B9 A7 R. m& C) ~, ?
congenital adrenal hyperplasia producing excessive
( a5 q5 T+ ~# V& t" Zadrenal androgens is a common cause of precocious
) q6 t( Z( m: W: opuberty in boys.3,4* S# R! Z8 M7 Q# _
The most common form of congenital adrenal
8 k1 a/ z$ f8 n/ W9 d4 \hyperplasia is the 21-hydroxylase enzyme deficiency.
! A0 { _( r3 N* uThe 11-β hydroxylase deficiency may also result in
0 x+ h% }; l. k W, xexcessive adrenal androgen production, and rarely,
P7 F# a9 i; {1 xan adrenal tumor may also cause adrenal androgen% H6 t0 E( X3 I! n, w
excess.1,3( m8 h% [# J+ N6 U9 U7 v8 q' C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 V8 r$ k5 I7 W3 f' \* \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, W; V: p9 u: xA unique entity of male-limited gonadotropin-
$ Z& }0 T5 R9 e6 V/ rindependent precocious puberty, which is also known5 a o7 R% m' _) o3 F2 I8 m/ C( V
as testotoxicosis, may cause precocious puberty at a1 ~2 G3 @4 d* x( d. B
very young age. The physical findings in these boys% n6 o4 T# f1 Z) y# U9 E
with this disorder are full pubertal development,
; b. M" ^' _0 R bincluding bilateral testicular growth, similar to boys
; m5 w2 h) a6 Z& S" hwith CPP. The gonadotropin levels in this disorder! U7 S% I2 z( J* [& m3 y; K
are suppressed to prepubertal levels and do not show; n2 K3 G# Q. e, S
pubertal response of gonadotropin after gonadotropin-; b8 l% c) j4 j: Q8 ]; Q2 g) p
releasing hormone stimulation. This is a sex-linked1 p4 C2 N, R5 I7 Z+ x. d9 @' Z
autosomal dominant disorder that affects only
4 I$ d2 g' H- {& Emales; therefore, other male members of the family% H5 \0 _" b- Q% S3 |
may have similar precocious puberty.3
3 N( S, W" l- [# HIn our patient, physical examination was incon-! G# }; C0 }5 t) ^# }1 I$ M E2 w
sistent with true precocious puberty since his testi-! @& e2 U' {" O
cles were prepubertal in size. However, testotoxicosis
# H+ Z, ]" z" ?was in the differential diagnosis because his father, N, T+ E; R+ o2 Z7 t* e4 X+ p: K1 H
started puberty somewhat early, and occasionally,& s$ S! P7 }$ Y2 ^! _5 H ]6 d7 C
testicular enlargement is not that evident in the
4 R8 q6 E9 U& I" jbeginning of this process.1 In the absence of a neg-2 k; J) q5 l9 H% U% |( Z' W
ative initial history of androgen exposure, our
3 Q( a% f' {( c* ~+ n1 r+ {2 z Y$ Obiggest concern was virilizing adrenal hyperplasia,: n6 S8 e( t1 W& v! ?' M7 |+ f# I2 \
either 21-hydroxylase deficiency or 11-β hydroxylase
+ F1 k. U# P7 C3 q, i: r7 C% wdeficiency. Those diagnoses were excluded by find-
0 H3 r Q* Y0 W+ K2 \ing the normal level of adrenal steroids.. y1 I' l, z, T- |4 E
The diagnosis of exogenous androgens was strongly
9 H/ x# F) `/ k" u. j' Asuspected in a follow-up visit after 4 months because6 R7 f: {0 M1 t# t0 S; L3 j$ j
the physical examination revealed the complete disap- w$ l* x5 o6 k) p5 k- R: U
pearance of pubic hair, normal growth velocity, and$ A/ S: |9 i5 R2 G
decreased erections. The father admitted using a testos-
/ _: g6 ]+ t" Y; `" b6 eterone gel, which he concealed at first visit. He was
) N o( {# T; D4 c9 susing it rather frequently, twice a day. The Physicians’
- _7 J. y, a& R8 e" D( KDesk Reference, or package insert of this product, gel or: U3 H/ N( g- K0 y) h, w
cream, cautions about dermal testosterone transfer to( J& K6 z6 S8 L% o D: m, x
unprotected females through direct skin exposure.# I! d! @, f3 {1 k; r+ v
Serum testosterone level was found to be 2 times the
+ P5 v. v" P1 p7 X3 Qbaseline value in those females who were exposed to
1 b1 T5 _& o0 r8 G) t7 _9 r' j6 @, leven 15 minutes of direct skin contact with their male
" l+ E* G; H" Y5 Dpartners.6 However, when a shirt covered the applica-6 j0 k4 A' H0 i+ G4 v$ i
tion site, this testosterone transfer was prevented." M7 W# E* S) q" k
Our patient’s testosterone level was 60 ng/mL,# [( D( ]' {: I2 J: P) t
which was clearly high. Some studies suggest that; T! {7 B3 R/ E' X; M
dermal conversion of testosterone to dihydrotestos-" ]7 @# }% ~- F
terone, which is a more potent metabolite, is more
3 w n6 z0 Y& s# z: \active in young children exposed to testosterone* O9 D5 U7 ^8 y& \# q$ U0 M U
exogenously7; however, we did not measure a dihy-
: I. ~+ g3 v* ?% P& Tdrotestosterone level in our patient. In addition to' E3 k V8 y/ |8 m9 q
virilization, exposure to exogenous testosterone in
( u2 A0 X5 T% `2 {children results in an increase in growth velocity and
; C# Y* P8 B0 Y6 w$ Xadvanced bone age, as seen in our patient.
0 u6 l+ P: \8 v* x! ]/ p3 qThe long-term effect of androgen exposure during
7 |2 y/ H+ |/ X4 W8 k! Gearly childhood on pubertal development and final
7 E6 O/ y) l. ?+ t7 Y/ {adult height are not fully known and always remain
, L2 _( L: G: n3 ca concern. Children treated with short-term testos-
) g! }' H" o5 \; Rterone injection or topical androgen may exhibit some5 S) P; ~$ _6 k: N
acceleration of the skeletal maturation; however, after
x, c" @' P5 L# b6 ? M7 mcessation of treatment, the rate of bone maturation3 V5 \' `0 g% _. i
decelerates and gradually returns to normal.8,9
! |# K9 a5 ^1 y$ a" }There are conflicting reports and controversy
6 o5 S* m0 g# I0 `8 `! F; d+ xover the effect of early androgen exposure on adult
" q Y! m; v7 _" vpenile length.10,11 Some reports suggest subnormal$ M: D i2 p; e$ p1 Q0 e
adult penile length, apparently because of downreg-
/ Q) m- T! N" i. e& Oulation of androgen receptor number.10,12 However,
; j& p% u; N2 j0 I* _, L# dSutherland et al13 did not find a correlation between7 f. M7 u/ j- q9 p7 {7 U
childhood testosterone exposure and reduced adult
6 C8 Y9 n# ?. A* epenile length in clinical studies.. y8 M3 @8 a( _( h! X. h$ z. R
Nonetheless, we do not believe our patient is
" F! e. Q/ A$ _going to experience any of the untoward effects from, G. A! H3 t7 r: l" z/ k3 V
testosterone exposure as mentioned earlier because
: ?" J0 i: ^( W3 C4 M1 u5 g4 |the exposure was not for a prolonged period of time.' _9 D3 ~& g1 e7 B2 k
Although the bone age was advanced at the time of
Z, l$ J8 y% P8 ydiagnosis, the child had a normal growth velocity at
1 p, V2 ~, I3 w. W" Dthe follow-up visit. It is hoped that his final adult
) v* ?; n- o& m `4 o, w4 |8 Lheight will not be affected.) B7 p! U" w' ^+ ~% L
Although rarely reported, the widespread avail-
, Z0 r- `+ y. A' @' @5 M) l3 R( eability of androgen products in our society may
) W5 U' S7 x: \indeed cause more virilization in male or female
, [# X: f8 B' p% gchildren than one would realize. Exposure to andro-
1 b: {1 s6 h* j+ q8 ?1 Ugen products must be considered and specific ques-
- Q2 W" P4 Y% F1 ^6 Vtioning about the use of a testosterone product or
/ F) w& F7 u9 s) _3 E4 Dgel should be asked of the family members during
- T6 i V9 N4 t+ `( g1 bthe evaluation of any children who present with vir-
! W4 T3 ]8 O; l) y2 \+ vilization or peripheral precocious puberty. The diag-2 z H' @. g7 E3 Z3 Y
nosis can be established by just a few tests and by
$ ]) z5 W9 d; v6 x+ Eappropriate history. The inability to obtain such a
0 e5 C" f! b% s) u& Z) i7 nhistory, or failure to ask the specific questions, may# ?/ V# l9 F8 v+ ^ t$ K) l( H! h* y
result in extensive, unnecessary, and expensive
) m2 p, o5 ^" i1 Linvestigation. The primary care physician should be- `, x1 W9 {) `7 t$ R& j2 S
aware of this fact, because most of these children/ N; T/ x$ j+ I# W2 {) G9 Q
may initially present in their practice. The Physicians’
) y7 E1 z* E% F# e0 g$ }( VDesk Reference and package insert should also put a6 H3 G0 c) S/ c h1 z0 Q- m
warning about the virilizing effect on a male or
& x6 S" J) {( R: ?0 O* _0 ^ Qfemale child who might come in contact with some-
5 ?6 g5 l9 M3 t M3 }9 none using any of these products.
7 z/ c1 g- J6 V6 }) D! ]1 ?, rReferences
$ l/ F; m+ i( K+ [1. Styne DM. The testes: disorder of sexual differentiation
, |! n! `2 _; n! G" X" zand puberty in the male. In: Sperling MA, ed. Pediatric
# u. f6 i* q) H5 C# e& t( mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 T0 U, d6 Y6 j5 f2002: 565-628.8 Q3 W& @: H; W& K( ]% _3 W" h7 B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; l5 u9 M+ R) T3 `% G& u
puberty in children with tumours of the suprasellar pineal |
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