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Sexual Precocity in a 16-Month-Old
6 f; @% a9 O% `$ z) @7 L/ F2 NBoy Induced by Indirect Topical
: _* H; U! |) t& j0 C% S6 mExposure to Testosterone
- B' k" P2 `1 z; R: o# ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 c1 r+ U6 X5 j5 @* h
and Kenneth R. Rettig, MD1
* K, E& t y6 A1 t% OClinical Pediatrics/ C% k: h. K" b0 J" E6 W2 Q/ v W
Volume 46 Number 6
! j( c. @% D8 _6 C( FJuly 2007 540-543+ h( ^! j2 w9 g+ q | P
© 2007 Sage Publications+ a+ w# C+ j, [& t O/ w
10.1177/00099228062966514 L# b; j; P3 {* ~7 Z a# f) t1 q
http://clp.sagepub.com+ q* P. K4 F9 p/ H
hosted at1 X9 Q9 }' Q; X4 o9 B* m" ]" G/ k
http://online.sagepub.com
% f8 b1 M/ r1 K: V, Z4 s2 j8 |Precocious puberty in boys, central or peripheral,; n. M; y: y2 u4 U0 w
is a significant concern for physicians. Central4 l( c: g( L w9 @) ?4 ~
precocious puberty (CPP), which is mediated
9 f7 h6 A: v+ i: ^- T8 kthrough the hypothalamic pituitary gonadal axis, has- G0 ` q8 \' H6 l) B
a higher incidence of organic central nervous system/ q7 J5 C6 {; T% y" r
lesions in boys.1,2 Virilization in boys, as manifested. a7 j( w; k; f% ?$ P# n. B
by enlargement of the penis, development of pubic
! T1 m* n% S7 F: dhair, and facial acne without enlargement of testi-
$ b0 M2 B6 ~ W. e! r% s; zcles, suggests peripheral or pseudopuberty.1-3 We
: H0 K' c- X' l: I8 q1 @report a 16-month-old boy who presented with the
% [" y- p$ A5 x; U/ g" W* t' `. renlargement of the phallus and pubic hair develop-+ N) E# L# E0 G+ @, l6 J+ L" g- Q
ment without testicular enlargement, which was due
7 c) i: Q. \/ k5 \' g7 S- i& pto the unintentional exposure to androgen gel used by U! Y X# A5 B$ W8 }2 m9 p/ p
the father. The family initially concealed this infor-
9 N0 c0 ~$ N/ b4 F% \5 b5 Omation, resulting in an extensive work-up for this* e3 ^/ z! ^! }3 D& ^
child. Given the widespread and easy availability of
& B# i; Q6 ^, D& n. Dtestosterone gel and cream, we believe this is proba-
1 ^0 @: O1 T* F$ s8 h' |bly more common than the rare case report in the+ J( q! p7 F) b% |5 W' z
literature.4
) r" {+ G; s/ D7 E. MPatient Report- Y/ W6 N% G: |4 Q4 Y. p0 N
A 16-month-old white child was referred to the
7 r5 z2 M" b2 a' r* N1 v3 `endocrine clinic by his pediatrician with the concern
* E9 M; w5 y* a6 mof early sexual development. His mother noticed
6 M. Z; Q0 P5 Z' E6 qlight colored pubic hair development when he was
% T0 H$ d2 e T9 a; OFrom the 1Division of Pediatric Endocrinology, 2University of
0 W0 y" P3 D; c( p& d0 \) U! W2 oSouth Alabama Medical Center, Mobile, Alabama.
! |3 Z" E& d2 t: e+ T9 U5 pAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 H* V5 i( M0 B3 s# z+ b* [" X& v
Professor of Pediatrics, University of South Alabama, College of, ?7 A: D: f- o9 w/ o& \/ A* O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% p" g4 C" N9 m1 G* o. U8 @ ]e-mail: [email protected].
2 [4 U0 ~( b3 c& cabout 6 to 7 months old, which progressively became
" N. v! o. q, h' {darker. She was also concerned about the enlarge-
: R9 [7 [' A+ \- l% c% ~* Pment of his penis and frequent erections. The child3 ?( c$ \7 p/ o0 b: K7 v" o! Q: q$ I
was the product of a full-term normal delivery, with
& f. I1 g: H- [a birth weight of 7 lb 14 oz, and birth length of1 S, _" Y1 u4 _0 x
20 inches. He was breast-fed throughout the first year2 z5 g# p# F- w1 h! Z
of life and was still receiving breast milk along with2 |$ J/ V# V* a. o* e2 a4 l' @) ]
solid food. He had no hospitalizations or surgery,0 O s2 X! C1 ]5 C' K1 r5 g; v
and his psychosocial and psychomotor development; {/ d" v0 \# b( Q. g+ `( f" l
was age appropriate.
$ A y( P. m. Y- }" MThe family history was remarkable for the father,
7 y" N- A( d+ Z# Q7 `/ c5 `4 wwho was diagnosed with hypothyroidism at age 16,
4 Y- @" ?* `& @) ~# Jwhich was treated with thyroxine. The father’s5 a% m9 f$ }% F8 f7 x- M, m" [ W
height was 6 feet, and he went through a somewhat
_. B; r' @1 n _8 L" kearly puberty and had stopped growing by age 14.& V0 E) v7 p, j/ @
The father denied taking any other medication. The
4 X1 v/ c$ t/ Q% \! Y6 \child’s mother was in good health. Her menarche) c" e7 j; B' G& _
was at 11 years of age, and her height was at 5 feet/ H8 }7 }- {* l( ^+ F$ i
5 inches. There was no other family history of pre-
: u5 {0 ]+ i# z$ I: ococious sexual development in the first-degree rela-
/ m8 z: `: \$ K& r5 Z; ntives. There were no siblings.
0 x: }! \1 I: N. DPhysical Examination$ m1 X5 Z0 p; i9 I! u
The physical examination revealed a very active,, B g' i7 j7 s3 [3 H
playful, and healthy boy. The vital signs documented
4 l/ ^8 c: V; k/ \* B1 Da blood pressure of 85/50 mm Hg, his length was! T2 m: H# k3 O
90 cm (>97th percentile), and his weight was 14.4 kg
- R- E0 t6 m# X. W(also >97th percentile). The observed yearly growth$ K0 N/ {4 B4 M8 A3 V/ ^- o6 E0 P
velocity was 30 cm (12 inches). The examination of& S: |& @! c# A2 s4 p# A u
the neck revealed no thyroid enlargement.
4 v8 [! B' h) P" z/ Q, u) yThe genitourinary examination was remarkable for8 |0 L0 |7 D% Z' M Q
enlargement of the penis, with a stretched length of
+ d1 b' O& @ l7 a& e: }8 J8 cm and a width of 2 cm. The glans penis was very well4 M+ S$ }, m( l
developed. The pubic hair was Tanner II, mostly around
! S8 W1 G. ]. K" k1 ?6 o540
& I! Y) D4 } gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 [6 R0 x/ d! S, Wthe base of the phallus and was dark and curled. The
4 J% [2 G" G8 c0 X/ x( ], E( z, Qtesticular volume was prepubertal at 2 mL each.
& r- u/ a% }" H- C, `9 bThe skin was moist and smooth and somewhat
5 E7 a8 h: [7 {) z: {& \oily. No axillary hair was noted. There were no# f" f! M' Y+ \; n
abnormal skin pigmentations or café-au-lait spots.
# @3 l! ^7 M4 j' gNeurologic evaluation showed deep tendon reflex 2+
* f; U0 _1 n' e3 z% R9 Qbilateral and symmetrical. There was no suggestion
3 H/ q8 I4 x# B3 W3 Bof papilledema.
8 T4 y& C j2 ^3 m+ y- ~1 C9 ^; L! l7 ?Laboratory Evaluation! J: R% t/ K3 x# f
The bone age was consistent with 28 months by% Z9 [+ {% ?! q1 I
using the standard of Greulich and Pyle at a chrono-9 `0 j2 `2 l! P, V
logic age of 16 months (advanced).5 Chromosomal9 Y' |0 L8 D4 ]. V a2 b* I
karyotype was 46XY. The thyroid function test
- D, q0 F' S1 X$ A- q- x, V Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
' O$ @( {, x; h, a( r! O# x& ]' rlating hormone level was 1.3 µIU/mL (both normal).1 f2 K' J# U" P
The concentrations of serum electrolytes, blood4 L0 n( j! [, L4 v! K* ]0 z- ?5 v
urea nitrogen, creatinine, and calcium all were" a5 r7 l- {1 t- q% h1 e
within normal range for his age. The concentration
6 H8 r+ g3 M- iof serum 17-hydroxyprogesterone was 16 ng/dL
9 j* [/ }- ~$ Z- e" |" e m(normal, 3 to 90 ng/dL), androstenedione was 207 @* \8 f: u$ S0 G/ o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 o) d1 Z. \5 H0 U! u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),# B6 @+ m9 q# P6 x! B7 U1 V$ v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 }& `% i, v. O' y49ng/dL), 11-desoxycortisol (specific compound S)
* l9 i. C2 E' F, c% nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ w2 l% q/ e6 Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: F/ \3 T! C, [% Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! z2 G: H% Z* _and β-human chorionic gonadotropin was less than7 D5 `" X* J& Q; @/ Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular" u9 _! y% J ~/ ~0 o
stimulating hormone and leuteinizing hormone
& p8 b* Y# @0 w+ A2 ]concentrations were less than 0.05 mIU/mL
2 w* c0 {4 p+ Y(prepubertal).
7 V! N6 ~- D, y; d6 SThe parents were notified about the laboratory. d2 e& d4 R1 a3 x& n6 X
results and were informed that all of the tests were0 Y; ]# f0 P- O9 M6 ^0 r6 t) D) l3 f) J
normal except the testosterone level was high. The
% A8 J- D# ^4 V% P; M% b6 h- Tfollow-up visit was arranged within a few weeks to8 Y; V6 s/ w5 S* A
obtain testicular and abdominal sonograms; how-, V0 r6 A Z- O& z: O2 S
ever, the family did not return for 4 months.
+ M1 s4 A" \2 Q8 }( J4 V1 jPhysical examination at this time revealed that the
o) o1 i) s7 Q' P, N' Cchild had grown 2.5 cm in 4 months and had gained- r% ?: `. \* g; @$ h- U6 C9 ?
2 kg of weight. Physical examination remained8 X% e1 _9 s) p0 d6 V! a1 f
unchanged. Surprisingly, the pubic hair almost com-+ P& ^3 q% j5 J' a: ~: k8 f; G2 E
pletely disappeared except for a few vellous hairs at
, P* w' t! R' X5 [% r2 Q* f Gthe base of the phallus. Testicular volume was still 2
/ N* Y m6 b" q" ]) }# j& R2 T2 P- FmL, and the size of the penis remained unchanged.
3 ^2 u/ ^3 P& u3 |% w+ ~+ Y0 a2 HThe mother also said that the boy was no longer hav-
$ w8 t1 K8 k( h3 ~5 g# H4 P; }ing frequent erections.8 k; U1 T( ? W0 r, C; R7 I
Both parents were again questioned about use of
/ X: g: h5 i2 e. z4 b& ]any ointment/creams that they may have applied to6 f' X8 _. j; s" ~
the child’s skin. This time the father admitted the
" }8 m" e$ `" KTopical Testosterone Exposure / Bhowmick et al 541+ z+ r! _$ \+ t8 E
use of testosterone gel twice daily that he was apply-
- A9 ^& @2 J! p$ E, B$ r. o& i+ |ing over his own shoulders, chest, and back area for+ D% W% ^1 X. V2 W5 C- N2 j
a year. The father also revealed he was embarrassed9 b( t8 A8 M$ b( z" f1 z
to disclose that he was using a testosterone gel pre-0 @& D5 ]# K+ b
scribed by his family physician for decreased libido
; }; e+ X! _ Z# Y0 V, usecondary to depression.
' B8 a. e1 u/ W7 Z* Y. \The child slept in the same bed with parents.
q4 A( v# @; Q x1 j+ _$ QThe father would hug the baby and hold him on his4 _8 A) Q% l I% U. n: i) z$ M: K g
chest for a considerable period of time, causing sig-
) i6 ]6 |# m$ fnificant bare skin contact between baby and father.
$ M6 G/ d2 w9 ~9 k% ?The father also admitted that after the phone call,
" m6 ^* ^4 w) j* A$ nwhen he learned the testosterone level in the baby
5 {+ S6 F3 s t3 |was high, he then read the product information$ y6 D% K: B8 \3 I0 p
packet and concluded that it was most likely the rea-9 |) H$ X0 M. T$ j ~* s1 o
son for the child’s virilization. At that time, they1 j) Q- m+ m' G8 x" Q
decided to put the baby in a separate bed, and the' i4 l7 e5 W* L# r& e. k
father was not hugging him with bare skin and had! z. V8 N! D. h0 D. c
been using protective clothing. A repeat testosterone
2 B) a% }& Q: y" g- J5 Y2 otest was ordered, but the family did not go to the
0 l! U% q( b# `% X f# i! vlaboratory to obtain the test.; Y, T5 J9 e$ a: C r
Discussion& |, B9 F) n& i* P, e7 P9 y0 |
Precocious puberty in boys is defined as secondary. r+ R$ j. u7 h# C
sexual development before 9 years of age.1,4
2 Y3 |- k- q' o8 M3 Y4 v7 X( H4 Y4 qPrecocious puberty is termed as central (true) when# |1 Q: T+ m! O* w5 V
it is caused by the premature activation of hypo-4 Z, Q5 `9 y7 U& [& L
thalamic pituitary gonadal axis. CPP is more com-6 ]5 B! ~2 z# q; }
mon in girls than in boys.1,3 Most boys with CPP
$ F) O0 C \$ r3 A! y$ q% amay have a central nervous system lesion that is# a* A' B0 M( A9 P8 k) H& ^
responsible for the early activation of the hypothal-8 K& n9 ~0 P1 U" e, k
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 r0 M1 M9 f0 W$ F4 Csis has been given to neuroradiologic imaging in
9 L. t/ v* _- q$ m+ T- R9 g( Dboys with precocious puberty. In addition to viril-
, j3 o) T4 U+ y: g$ \0 L& ?ization, the clinical hallmark of CPP is the symmet-" n7 n8 I8 g& E7 {2 G- e
rical testicular growth secondary to stimulation by
4 {; t) d6 }6 Q$ o* H0 Tgonadotropins.1,34 x: C, Z# V) o- {3 \
Gonadotropin-independent peripheral preco-
0 c6 u9 o9 ~- s r7 _' |- wcious puberty in boys also results from inappropriate# j! F6 c7 M# e! `4 l4 }# H# h
androgenic stimulation from either endogenous or; `6 s, r. {; i8 x/ _4 p0 \2 J
exogenous sources, nonpituitary gonadotropin stim-
) {* E( S& O! o6 K& n/ [/ ~ulation, and rare activating mutations.3 Virilizing
" k/ q, R! W! {: K1 U0 s; l" wcongenital adrenal hyperplasia producing excessive
$ Q. O# H, {( |/ B, I& [adrenal androgens is a common cause of precocious3 y1 y }2 x# w
puberty in boys.3,4
5 ~: {* c2 i/ x: p- }The most common form of congenital adrenal. k" {0 I0 V8 ^% P }
hyperplasia is the 21-hydroxylase enzyme deficiency.. N4 i% N* O: f$ H4 F
The 11-β hydroxylase deficiency may also result in
' B Y8 L8 m, V* u. z0 L8 Vexcessive adrenal androgen production, and rarely,; S% ?, x/ v- d5 G2 e. ^6 r
an adrenal tumor may also cause adrenal androgen
0 v/ m0 ?! J) f: q+ y3 A8 Gexcess.1,3
, ?( Q! R" X# q# {. ^+ e8 Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, O) u* k9 _8 C3 N! |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- @: V; [5 Y n' }4 w% V- M+ C
A unique entity of male-limited gonadotropin-
V% e- A+ U8 y9 i3 V) }independent precocious puberty, which is also known$ B$ G+ z+ ]7 g
as testotoxicosis, may cause precocious puberty at a
+ i3 Q/ @& P& E U% q( pvery young age. The physical findings in these boys
7 f- d: \1 H( \0 H; swith this disorder are full pubertal development,
* P# F( d8 E( M K+ \* i- ?including bilateral testicular growth, similar to boys0 |8 O; a2 }( @" e# G0 e: u
with CPP. The gonadotropin levels in this disorder
/ n z" |8 e/ P" o h, s G Iare suppressed to prepubertal levels and do not show
) L5 w9 `" z7 R6 w q, Epubertal response of gonadotropin after gonadotropin-
6 f5 _3 {; N0 S6 c+ v6 areleasing hormone stimulation. This is a sex-linked) R M& e9 N/ X' s1 J: ?
autosomal dominant disorder that affects only1 u# |- }9 c f7 }4 m Z% A
males; therefore, other male members of the family3 \# \8 {6 u# j, K3 f
may have similar precocious puberty.3/ _; r2 J- I* ^# n
In our patient, physical examination was incon-
1 j4 P- k. [, K1 A# Rsistent with true precocious puberty since his testi-
: k0 F. t/ ~& J8 Rcles were prepubertal in size. However, testotoxicosis
! |" C1 ~ J% m8 D7 X6 d$ nwas in the differential diagnosis because his father
8 b' E9 F, [5 n; N$ o$ vstarted puberty somewhat early, and occasionally,
4 B: {- j2 t/ r, j1 Gtesticular enlargement is not that evident in the/ i* E1 A- \2 I
beginning of this process.1 In the absence of a neg-
1 s* l' y1 T& N' Z9 n" |ative initial history of androgen exposure, our
0 t2 E5 `" z6 \) gbiggest concern was virilizing adrenal hyperplasia,
7 w. J2 r9 ~' y5 ueither 21-hydroxylase deficiency or 11-β hydroxylase
6 T i& w, v+ |: c: G) P: Y) cdeficiency. Those diagnoses were excluded by find-
" d& H. z6 ~6 m0 Jing the normal level of adrenal steroids.
. D- h; s5 }( GThe diagnosis of exogenous androgens was strongly j$ _9 a4 J7 t! B W9 |$ `% b
suspected in a follow-up visit after 4 months because
7 F4 \' X% A) j4 [1 I2 K: Wthe physical examination revealed the complete disap-
0 G; I4 @+ E/ Q, f& ~0 g/ upearance of pubic hair, normal growth velocity, and9 [4 O* D9 j: Y/ C9 R' r
decreased erections. The father admitted using a testos-" T0 ~2 @9 g( _; I3 j
terone gel, which he concealed at first visit. He was2 L+ z- O) M; p. F' }; m
using it rather frequently, twice a day. The Physicians’( ~$ z1 A& [! F+ }. r8 ^
Desk Reference, or package insert of this product, gel or8 v4 T; ]3 b( S! z$ F* O/ o
cream, cautions about dermal testosterone transfer to
! H- B- y0 w3 h' Y, F' vunprotected females through direct skin exposure.
$ |' r9 T/ \2 f! K+ `1 {Serum testosterone level was found to be 2 times the
% S. c! h ^( g% k4 bbaseline value in those females who were exposed to
6 _, c% p! L9 _2 P* beven 15 minutes of direct skin contact with their male8 M- y3 R4 u) P, o) h C
partners.6 However, when a shirt covered the applica-0 f! k& I. _7 [3 V. E
tion site, this testosterone transfer was prevented.5 |" I/ M( p: d0 M9 P( p/ Q' f; R$ `
Our patient’s testosterone level was 60 ng/mL,7 b" W `' K5 Z/ A& a
which was clearly high. Some studies suggest that; |, J6 o9 z z: d, l
dermal conversion of testosterone to dihydrotestos-
! p# e, j: a4 Q( [9 m; ^. q6 xterone, which is a more potent metabolite, is more1 j; U2 P( @, Z: S& Y
active in young children exposed to testosterone
* [; j. w+ M: z- u: q1 j8 Vexogenously7; however, we did not measure a dihy-
, P. i2 ^. W& ]/ H$ C- Rdrotestosterone level in our patient. In addition to0 ]1 ?8 j5 m C) }0 _! s+ @' \
virilization, exposure to exogenous testosterone in( q1 ^8 n: m+ B" V$ K% [& ]) W2 M
children results in an increase in growth velocity and
! E* r9 c0 Y1 L% n0 q3 V' Kadvanced bone age, as seen in our patient.; ?3 l! M' }. t0 Y# g% y
The long-term effect of androgen exposure during
( f3 p' c. c' s4 q" M/ c$ T2 Kearly childhood on pubertal development and final
( s1 ^& [1 R$ d; ~5 _5 yadult height are not fully known and always remain0 B% B0 w) k7 H1 D0 S7 E
a concern. Children treated with short-term testos-
/ `; h: L& c: [- p( U; t& Mterone injection or topical androgen may exhibit some# F8 o( k1 I+ l/ R5 R
acceleration of the skeletal maturation; however, after" o* Q+ h, E N1 M3 O% z/ c
cessation of treatment, the rate of bone maturation
+ Z3 D" f& M9 P* v, Fdecelerates and gradually returns to normal.8,9 }: V$ K% w, c- W$ D# N
There are conflicting reports and controversy! F% R! C2 H4 f# i' e
over the effect of early androgen exposure on adult
# S/ J( D! |" J! v& mpenile length.10,11 Some reports suggest subnormal. _5 v; M8 b6 q" C4 C3 t/ f
adult penile length, apparently because of downreg-( ` v8 D+ _2 l6 |9 W
ulation of androgen receptor number.10,12 However,
1 A' f: D% n& L# _4 b, [" {0 P6 [Sutherland et al13 did not find a correlation between# k' P, C& ~" W+ B8 K6 Z
childhood testosterone exposure and reduced adult& q& o" i" t, \
penile length in clinical studies.
. O* q( ?: z# @" P8 l* vNonetheless, we do not believe our patient is
. H9 X% U( R7 ^) l9 Vgoing to experience any of the untoward effects from3 N9 f0 A5 T7 L+ v3 I" ? |
testosterone exposure as mentioned earlier because5 \7 a4 g: K' v, G9 r y
the exposure was not for a prolonged period of time.
/ I$ j; V1 i' C2 ]4 K$ c( xAlthough the bone age was advanced at the time of
/ l2 b- B ]2 S3 K% I2 E$ Vdiagnosis, the child had a normal growth velocity at6 x; |' \3 J2 [1 ]4 u- X& b
the follow-up visit. It is hoped that his final adult
& D: ?) V8 j7 s# |& Xheight will not be affected.
: k4 ~2 W) E7 y3 h' |5 D- o& ?) [Although rarely reported, the widespread avail-: r2 }0 l. O) |# A- e6 P
ability of androgen products in our society may
; a/ e: _9 i! C2 P* f% m- R' h ~indeed cause more virilization in male or female# {$ I& U/ h$ I. W/ Q; x
children than one would realize. Exposure to andro-
$ p- A$ R4 p& D3 s9 ngen products must be considered and specific ques-
$ U+ H! T' X! u* j5 X+ E1 Ytioning about the use of a testosterone product or
4 ` H# D9 @1 d2 u# M$ ?gel should be asked of the family members during* n+ X- N8 E; n2 G
the evaluation of any children who present with vir-% y& q7 H* N2 h
ilization or peripheral precocious puberty. The diag-- y0 h. w; K' K9 T/ Q
nosis can be established by just a few tests and by! i Q) y) B, f0 @- n5 P
appropriate history. The inability to obtain such a8 B1 C i; G' N& Y0 z! \/ D% v
history, or failure to ask the specific questions, may$ V% Q7 s5 E- @; Y
result in extensive, unnecessary, and expensive8 T* k4 O. @: t& A; r* w3 j7 ~
investigation. The primary care physician should be, C' f6 ^- e" C0 e9 K
aware of this fact, because most of these children
5 g1 K Z1 s: {5 lmay initially present in their practice. The Physicians’
5 n2 V, t& f, V: j0 b3 @Desk Reference and package insert should also put a
( J, Z3 ]+ K! G' g. gwarning about the virilizing effect on a male or( U# H& S. y% M0 l& d" n
female child who might come in contact with some-; Y }" F3 C8 k+ n3 c
one using any of these products. w8 H) u& P3 }. a- K& i
References
, z$ }0 V7 I& c3 ~, H% L1. Styne DM. The testes: disorder of sexual differentiation& V3 f2 O* P3 g# y$ _5 |
and puberty in the male. In: Sperling MA, ed. Pediatric
8 p* S) Z3 ?! H1 EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! F. E3 q( H j
2002: 565-628.2 S' q" X |0 J' w) w9 L* i: T2 K4 O
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% d! q) V! H, q, {6 l8 c# Upuberty in children with tumours of the suprasellar pineal |
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