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Sexual Precocity in a 16-Month-Old( N& R( ?: M2 P8 E! ?
Boy Induced by Indirect Topical: @) ?' l& J4 q1 ?6 d! T+ c4 M
Exposure to Testosterone) s) f/ V) q* W8 W7 E" H7 V; p
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% E p" z ?& C9 W+ {3 ]8 L
and Kenneth R. Rettig, MD1
5 w# e6 p* |/ y9 gClinical Pediatrics
; f) x$ h5 @2 Z4 g& l& C" [7 {7 BVolume 46 Number 6
) d6 v$ k/ b( J' Y% a% n1 E( b# {4 S, ~July 2007 540-543! ?$ c) |, M, R% c( r4 c
© 2007 Sage Publications
0 Z- H' f! i) B$ R& ]" B10.1177/0009922806296651% x: {; ~# `9 @ l) X
http://clp.sagepub.com
+ c, q9 y2 E7 [hosted at! r4 @8 w8 X1 {# P5 y
http://online.sagepub.com8 B; m" N2 [3 O( e
Precocious puberty in boys, central or peripheral,
1 F2 t, k q; g/ @7 k( jis a significant concern for physicians. Central. T" c( }7 } k% g( A& M6 `* F& U
precocious puberty (CPP), which is mediated4 p% l H1 e- A8 s8 V
through the hypothalamic pituitary gonadal axis, has0 ]! F' M& I8 n* }6 p* T5 w
a higher incidence of organic central nervous system
3 F7 ~! w7 I5 N/ A4 E$ flesions in boys.1,2 Virilization in boys, as manifested N- t3 w# `: F3 K% y/ l# C/ h4 D
by enlargement of the penis, development of pubic
8 |7 G4 }4 A E; I1 jhair, and facial acne without enlargement of testi-6 K: i/ t S8 l4 [$ W
cles, suggests peripheral or pseudopuberty.1-3 We
1 _+ Q. H0 |2 e6 `2 {4 X1 qreport a 16-month-old boy who presented with the
& n$ t- h/ ] l) ?4 lenlargement of the phallus and pubic hair develop-
8 |# `: n3 l, w& l* X8 i0 m( g: rment without testicular enlargement, which was due
* t) B, y& K* z% D1 M) {* O Ato the unintentional exposure to androgen gel used by
8 u0 F6 i; \( ^) {. Bthe father. The family initially concealed this infor-. M, P# ?/ h9 A+ a3 ^; {! }
mation, resulting in an extensive work-up for this$ W. D' W, }) r& S
child. Given the widespread and easy availability of
% t k3 D' z7 b, x4 v3 Itestosterone gel and cream, we believe this is proba-, r7 W% I7 C9 X+ e1 w) x6 c
bly more common than the rare case report in the7 N/ e% T8 o$ W$ B
literature.43 T9 \2 _ D6 E; v, h
Patient Report8 u- G) `( l+ `) U
A 16-month-old white child was referred to the% {4 I* H9 ]' L8 a1 B8 P. _
endocrine clinic by his pediatrician with the concern
: {/ Q0 z" v& N# Lof early sexual development. His mother noticed
" \9 R* U7 w# vlight colored pubic hair development when he was1 S" F/ o+ v- d8 e4 ^
From the 1Division of Pediatric Endocrinology, 2University of
1 j/ T% r- t% o8 ^& t4 {; bSouth Alabama Medical Center, Mobile, Alabama.
& o8 Y* P3 W; o* I* mAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, |1 ~+ i b/ D: V: f9 c5 ?. QProfessor of Pediatrics, University of South Alabama, College of
# ]/ P1 C. x8 NMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 w4 Y) V8 @5 Ge-mail: [email protected].1 K0 W* `6 Q: e5 }1 c
about 6 to 7 months old, which progressively became4 G( Z. A% E. F2 A/ T
darker. She was also concerned about the enlarge-) G2 f# C) t; A: z5 J9 O+ F! l
ment of his penis and frequent erections. The child8 H" M' A2 s( O/ G. S W& x* j/ u
was the product of a full-term normal delivery, with
7 `; ~- _1 h, o0 Z! @, L8 K2 La birth weight of 7 lb 14 oz, and birth length of
$ c! u) r+ b% M/ L& O1 ?# A1 O20 inches. He was breast-fed throughout the first year% O$ Q) l$ ]0 n, W1 x; p) T7 O! k2 B
of life and was still receiving breast milk along with1 `! A1 ]/ y2 z, u; y) [0 v1 L
solid food. He had no hospitalizations or surgery,
5 ?3 ^- r& i L* f3 aand his psychosocial and psychomotor development7 v$ _6 F" b* W
was age appropriate.
9 q5 c e' t; ]7 N! hThe family history was remarkable for the father,. ?! H2 l9 x! ]1 B
who was diagnosed with hypothyroidism at age 16,8 [" o( l2 J) q) {. a
which was treated with thyroxine. The father’s+ }) \) N/ S/ n0 x
height was 6 feet, and he went through a somewhat
$ y6 a% Z" k( w. h; `early puberty and had stopped growing by age 14.3 |7 h! C- ~* u, ?1 ~
The father denied taking any other medication. The
. R* S1 e) C+ Q( }: k6 x( }" zchild’s mother was in good health. Her menarche
O$ Y+ B$ d, G# p2 w/ t3 e6 wwas at 11 years of age, and her height was at 5 feet' h* }: q& Z% O: u: v9 v2 h/ o$ t
5 inches. There was no other family history of pre-
9 c6 l: S, p( u( \6 e+ v/ w+ Ecocious sexual development in the first-degree rela-
, A$ Z3 }# J$ @* B0 ]- Btives. There were no siblings.
* F( w1 ]- o6 {$ t; F% g7 R, OPhysical Examination
1 f! z. ?! x7 q, ~- zThe physical examination revealed a very active,0 o4 ?5 w) T. {1 r& H
playful, and healthy boy. The vital signs documented
" a* ^7 j7 T$ La blood pressure of 85/50 mm Hg, his length was
8 D+ k1 W7 w/ z90 cm (>97th percentile), and his weight was 14.4 kg
7 K( G3 @0 z! _. J(also >97th percentile). The observed yearly growth
) W4 ] Y. z/ C; S% i- h/ U$ uvelocity was 30 cm (12 inches). The examination of; z3 ]) P6 l" o, H9 q; r8 i
the neck revealed no thyroid enlargement. k. j3 \* r0 h( I0 X& l
The genitourinary examination was remarkable for
( B2 D S5 @0 benlargement of the penis, with a stretched length of
6 u2 W% n1 |! F/ u3 x% s% L( |5 {8 cm and a width of 2 cm. The glans penis was very well
7 S* U3 k8 p' }1 L: Y l# p+ Fdeveloped. The pubic hair was Tanner II, mostly around1 y' |3 z+ O) M! ^7 N$ m
540
" M8 |1 R, K, gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# t9 N! c* Q) V2 Q/ I
the base of the phallus and was dark and curled. The
& V" G. c8 n: `5 E1 o# wtesticular volume was prepubertal at 2 mL each.
* r# P9 U' o% pThe skin was moist and smooth and somewhat
0 g; u' u2 V. k+ m% |: k" ]/ {oily. No axillary hair was noted. There were no
* f6 S" n4 _- h4 u9 ~: [abnormal skin pigmentations or café-au-lait spots.
& t- z0 u+ B: O. N' ANeurologic evaluation showed deep tendon reflex 2+
8 a( q: k0 f# o9 @bilateral and symmetrical. There was no suggestion( W5 w1 }- N& v5 T# `: f
of papilledema.
( \3 S8 N8 Q$ n/ hLaboratory Evaluation+ F9 S8 L' U1 r$ a( g
The bone age was consistent with 28 months by- {3 [) V/ N' D8 i
using the standard of Greulich and Pyle at a chrono-9 J0 h ?8 ^. p: V' ~: C' H# L
logic age of 16 months (advanced).5 Chromosomal
! b; w( P# g5 r- ykaryotype was 46XY. The thyroid function test, f! W4 N, h1 m* @* {9 f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
y2 s4 l" r& S3 Rlating hormone level was 1.3 µIU/mL (both normal).* c A& J4 x" U& f% [$ V1 M" G
The concentrations of serum electrolytes, blood' M( K( W/ e- S8 [$ L! P
urea nitrogen, creatinine, and calcium all were
: }8 q1 N3 t: }7 E, B9 D! jwithin normal range for his age. The concentration
/ u8 h- I) |6 ?2 gof serum 17-hydroxyprogesterone was 16 ng/dL/ O3 n: c6 H3 i5 w8 z
(normal, 3 to 90 ng/dL), androstenedione was 20
) v7 z4 s5 P3 c# m# |) h1 ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 R: z$ u. _5 g" c( ~6 G4 K- W$ F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. C Y& e0 w ]4 L* p) N& [desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' V/ }& ^* [7 K% X49ng/dL), 11-desoxycortisol (specific compound S)
, \- W$ j; F; M" Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# i9 p* e% k5 \. h8 r) `5 [; k, etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& [2 a& }( l6 M0 A- l6 s6 [) R( s: V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; p# q& _# d/ |" u2 y9 w3 uand β-human chorionic gonadotropin was less than1 m4 g7 g* l( b% y9 J7 ?. J9 e& ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( M8 J5 E$ i. m( w* f: pstimulating hormone and leuteinizing hormone
2 L( }: \+ \4 F2 z y& h4 Kconcentrations were less than 0.05 mIU/mL
) W# m% Z9 _+ k# N(prepubertal).3 \3 i# R8 n x+ U/ d
The parents were notified about the laboratory
! Z5 \) H( b# @6 E2 Vresults and were informed that all of the tests were
* l+ R/ i5 Y, z5 I$ S9 e/ Tnormal except the testosterone level was high. The
8 O; ]* J s6 ]8 r2 Dfollow-up visit was arranged within a few weeks to
! y7 h" m1 b* m( F2 t" Zobtain testicular and abdominal sonograms; how-6 J1 ]* B2 B9 ~! p- ~: w, ]
ever, the family did not return for 4 months.6 ?, D* \& e0 \ Q
Physical examination at this time revealed that the
8 ^( K6 m6 A. R* h+ i, Achild had grown 2.5 cm in 4 months and had gained5 O+ ]7 C+ Z" K4 U4 H
2 kg of weight. Physical examination remained0 q3 h9 d' @: F# T1 d# Y+ q
unchanged. Surprisingly, the pubic hair almost com-
& w" j' {$ j F* B# F! d0 Z. |pletely disappeared except for a few vellous hairs at& z/ z9 Z6 N; o9 ]( K3 d
the base of the phallus. Testicular volume was still 2
9 p2 K* |2 v9 F: T4 x5 w$ K1 hmL, and the size of the penis remained unchanged.$ L+ t7 E. x' H) {
The mother also said that the boy was no longer hav-, {) A3 N! g/ ~, y' B6 D
ing frequent erections.
h8 B. e; F0 O& S+ N9 Z3 fBoth parents were again questioned about use of, p$ W5 i9 o8 a" P k1 C; p8 [
any ointment/creams that they may have applied to& P2 ^' `+ q4 ?# N
the child’s skin. This time the father admitted the% t) r* R) [: [
Topical Testosterone Exposure / Bhowmick et al 5414 |+ {/ O0 ^, m: y# @6 E8 h7 {
use of testosterone gel twice daily that he was apply-# E3 I6 J2 O2 U4 N3 \5 I3 T9 ` Q
ing over his own shoulders, chest, and back area for5 v) E( w0 K- X6 @# l' M
a year. The father also revealed he was embarrassed. f: q/ P" ?( x1 J/ w- N. Q
to disclose that he was using a testosterone gel pre- X4 W5 Q0 z s- |9 \; \
scribed by his family physician for decreased libido
- F; q) Q9 w" H3 Y$ Y! Isecondary to depression.7 ~* e/ B0 O2 j4 x
The child slept in the same bed with parents.
" K1 p9 |# Z/ E, F; \3 _The father would hug the baby and hold him on his- a5 _# k0 V; d% ^/ j& n0 i1 R* O
chest for a considerable period of time, causing sig-
3 N, q. I& C9 `; P! dnificant bare skin contact between baby and father.5 e8 j- f4 G2 q: r8 I
The father also admitted that after the phone call," X7 m' y) z* u- `+ W; ^/ ?
when he learned the testosterone level in the baby
/ X# ~: E! T/ C+ r+ cwas high, he then read the product information5 B3 y6 Z1 V V9 ?2 k9 n
packet and concluded that it was most likely the rea-
8 B: W1 l0 M% q' b( m7 Vson for the child’s virilization. At that time, they; q0 D6 ]6 m: R5 p* W- ], g
decided to put the baby in a separate bed, and the) j( l& p& F, R% m
father was not hugging him with bare skin and had
5 Z; H! ]4 x& L- s4 W" Rbeen using protective clothing. A repeat testosterone
: R$ G @( H b4 R4 X Y2 rtest was ordered, but the family did not go to the4 Y- H6 {5 W& s& `
laboratory to obtain the test.
) T' |# Z6 h/ |) N, B& q, dDiscussion8 T0 t+ L8 m+ R! @# o0 b
Precocious puberty in boys is defined as secondary; Q' [8 a! R* \0 b; D
sexual development before 9 years of age.1,4
% e" K$ H7 i. A1 y& P9 VPrecocious puberty is termed as central (true) when$ ?& g f% }$ D ?! @2 U% k" B, G6 Y6 b
it is caused by the premature activation of hypo-
; J* _* R/ y) J: Cthalamic pituitary gonadal axis. CPP is more com-
4 D, q+ Y V9 u7 _# C- l" Z4 emon in girls than in boys.1,3 Most boys with CPP4 ?5 p! [5 H9 Z% X1 M
may have a central nervous system lesion that is: U9 Z' q$ H) z/ _, b4 Y6 Q
responsible for the early activation of the hypothal- p R' u% s' F6 j
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 z# U. w# n: ^2 Lsis has been given to neuroradiologic imaging in3 \$ c# n( U0 v7 l. w- h
boys with precocious puberty. In addition to viril-3 H# w3 A h/ z- R- K8 s' u
ization, the clinical hallmark of CPP is the symmet-3 j! \- L' I; V
rical testicular growth secondary to stimulation by
+ E7 r" X4 {" ^gonadotropins.1,3
% Y& I7 ~1 X3 S2 ~+ k7 SGonadotropin-independent peripheral preco-
5 \7 H S5 I' F$ _cious puberty in boys also results from inappropriate4 `, `, Z- q8 j9 G# B4 P8 |9 q
androgenic stimulation from either endogenous or8 V; _2 v- `' h; r( f- C% x
exogenous sources, nonpituitary gonadotropin stim-
, r9 y/ R/ n# {* L/ Eulation, and rare activating mutations.3 Virilizing/ w' W2 n; C+ m# @9 {
congenital adrenal hyperplasia producing excessive
# [3 `" d' L( I0 z( Y! D8 s: E* W- aadrenal androgens is a common cause of precocious5 B! E; [' k% a2 d) K/ a) `
puberty in boys.3,4
3 _5 z! @0 v8 S& Y6 mThe most common form of congenital adrenal
# v R1 H" s, a/ Uhyperplasia is the 21-hydroxylase enzyme deficiency.1 f8 c" {0 ^5 \ K& g# c
The 11-β hydroxylase deficiency may also result in
$ Q3 R* R) ^7 o. _ Q Qexcessive adrenal androgen production, and rarely,: `2 M3 N/ R/ X6 C/ x6 D( T
an adrenal tumor may also cause adrenal androgen' d) J7 \- X9 E. }8 w) @
excess.1,3
% C+ B0 ?0 l; V8 G5 G( f7 D9 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 m1 C/ V* v# X9 D" H; D# H/ L542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 u5 P1 D7 t0 ]4 o+ q" _% G
A unique entity of male-limited gonadotropin-6 A7 _! S8 f& D2 o( u' M' J# K
independent precocious puberty, which is also known: H. e: t0 g2 ]. P3 |
as testotoxicosis, may cause precocious puberty at a" u4 Q0 t3 f5 t" M2 n' o" }
very young age. The physical findings in these boys$ s- v, r& A' D Y6 \. A: x& A
with this disorder are full pubertal development,
, A; @" Y3 Y$ R- p8 i# Uincluding bilateral testicular growth, similar to boys3 k H' ^+ R F" G6 z$ S
with CPP. The gonadotropin levels in this disorder5 d: h/ O: x! O3 Z$ `# p! J
are suppressed to prepubertal levels and do not show2 w7 S- l0 x" a+ b, A; b
pubertal response of gonadotropin after gonadotropin-! u% J$ E# |7 c; f+ V% D4 z" S% p# x
releasing hormone stimulation. This is a sex-linked, y# E" _9 W0 m7 P
autosomal dominant disorder that affects only
+ `5 r% a/ y/ E8 s1 Amales; therefore, other male members of the family/ K ^' _4 L {0 E
may have similar precocious puberty.3
% n$ b4 {* F6 M' t" o ]In our patient, physical examination was incon-
! x6 U2 K7 Q1 e* z" D- csistent with true precocious puberty since his testi-% Y8 {8 r4 @. `
cles were prepubertal in size. However, testotoxicosis
) T/ \- ^" A7 @was in the differential diagnosis because his father
3 ]" s# z6 V G" h2 ^2 |started puberty somewhat early, and occasionally,
# H0 T+ I) S, ?. u. l) n2 gtesticular enlargement is not that evident in the2 p" {. v" R# v0 U% X# |) k( I& B
beginning of this process.1 In the absence of a neg-8 v b+ ^+ C9 N7 X+ Q- V
ative initial history of androgen exposure, our
9 s/ |4 x* L8 W& Wbiggest concern was virilizing adrenal hyperplasia,$ C* g D) S5 Y6 c7 ]
either 21-hydroxylase deficiency or 11-β hydroxylase9 C. V+ k' D; t( a6 K5 {- W, F, [
deficiency. Those diagnoses were excluded by find-/ Q! i" P0 n. q) ]; K c
ing the normal level of adrenal steroids.4 j! G/ S+ t5 b+ p+ C
The diagnosis of exogenous androgens was strongly
4 k8 r) D1 k+ c6 a# P+ {2 _( ]suspected in a follow-up visit after 4 months because" e0 _. k* p# ~* N! F
the physical examination revealed the complete disap-
7 R; S9 A8 z% ]3 j7 Fpearance of pubic hair, normal growth velocity, and
" y& H! a) n1 s9 K* qdecreased erections. The father admitted using a testos-
: L$ P2 Y4 O, H/ S) nterone gel, which he concealed at first visit. He was
h% J4 I/ M5 y @1 h8 Iusing it rather frequently, twice a day. The Physicians’
. U! j6 T4 c6 `, hDesk Reference, or package insert of this product, gel or# {6 s: p. T- W; c9 |
cream, cautions about dermal testosterone transfer to: }4 K7 ~, P. M' W* P6 N) V5 J
unprotected females through direct skin exposure.
) C! R7 \9 h6 y; C( R' dSerum testosterone level was found to be 2 times the, D0 ^* J! r% \% z; G7 I( a
baseline value in those females who were exposed to9 c" A* d" Q9 g
even 15 minutes of direct skin contact with their male
5 P0 W; F8 C9 ^4 u3 [2 J6 d# kpartners.6 However, when a shirt covered the applica-
7 V& H9 Q5 L# @, B. _2 Qtion site, this testosterone transfer was prevented.
- z% m4 ~* [4 V+ T9 v# OOur patient’s testosterone level was 60 ng/mL,7 {9 ?6 \! h& n' X; d
which was clearly high. Some studies suggest that$ J9 `4 T% X% ?
dermal conversion of testosterone to dihydrotestos-! ?$ T @6 g4 @! R0 g) G
terone, which is a more potent metabolite, is more
2 y" w6 X: B+ @, v- ^5 g' I8 Xactive in young children exposed to testosterone
+ b9 H! i5 k# s! _! O5 Gexogenously7; however, we did not measure a dihy-
1 M g& Y |) Y% z7 p# T: Zdrotestosterone level in our patient. In addition to
" J- |/ N! t5 j" qvirilization, exposure to exogenous testosterone in
1 Q: a" Q) y$ K6 x2 V0 Jchildren results in an increase in growth velocity and
) t" `' P: q# ]advanced bone age, as seen in our patient.
" g2 K# q% ^. A5 p0 r, s2 p* BThe long-term effect of androgen exposure during
+ j% u5 b. Q% H# @7 W% H0 J/ W9 S kearly childhood on pubertal development and final
; x; x/ v: `2 cadult height are not fully known and always remain0 u! W/ L7 {* g
a concern. Children treated with short-term testos-
5 r3 g+ h3 c* O D( oterone injection or topical androgen may exhibit some
7 g, r( b/ g& s8 E( ]; bacceleration of the skeletal maturation; however, after" F' e4 s$ _6 A, Z' M6 L6 K
cessation of treatment, the rate of bone maturation
6 e/ l3 e' j# j) Z4 Vdecelerates and gradually returns to normal.8,96 k+ d# P; w6 R. ~1 h7 o) K
There are conflicting reports and controversy
( ?4 e6 j. d% ^8 |: Sover the effect of early androgen exposure on adult
4 }% }- O Q+ S: I. l' y' \' kpenile length.10,11 Some reports suggest subnormal
1 F% t9 E1 n6 q4 e8 _' x# B Madult penile length, apparently because of downreg-. {2 y- j. ?" o& [ z3 h {
ulation of androgen receptor number.10,12 However,
^$ ^* Z3 ]7 t& V. o0 e8 ?$ pSutherland et al13 did not find a correlation between2 r" o+ K5 m: s& ~7 V1 w- f0 e
childhood testosterone exposure and reduced adult
4 M$ D$ l* \. L9 M3 H2 k$ Y( e) ]penile length in clinical studies.5 @0 q' w0 ?7 S2 H( F" s" c
Nonetheless, we do not believe our patient is
( G& V6 H* d! q) Lgoing to experience any of the untoward effects from
5 }7 d; t# x& u2 r) n+ u- H6 Utestosterone exposure as mentioned earlier because
; N; V# w, l# x- I3 B$ o+ d1 Fthe exposure was not for a prolonged period of time.- y) {* m( F* w! q( K" C2 E* O
Although the bone age was advanced at the time of
- c7 D% t3 I) s& X6 pdiagnosis, the child had a normal growth velocity at# r" z. m4 p# n( ]' \
the follow-up visit. It is hoped that his final adult" G* D5 ~( X0 @: c
height will not be affected.
8 }# z/ A' Y7 nAlthough rarely reported, the widespread avail-
6 B0 P* y, v" c- Oability of androgen products in our society may. z0 F0 I i' o$ g( e1 {7 ~
indeed cause more virilization in male or female
8 k2 k) F) W* X0 `/ l W3 schildren than one would realize. Exposure to andro-
) e) \2 Z* {# A- J, b3 ~gen products must be considered and specific ques-
/ e; i/ O. S8 B$ k* ^5 \: `tioning about the use of a testosterone product or# ?& M6 H* l2 |& M9 B- _
gel should be asked of the family members during
k6 W- |" n6 ?- R$ r7 \$ cthe evaluation of any children who present with vir-7 r3 j+ T7 w5 N" ?+ R. ~8 P
ilization or peripheral precocious puberty. The diag-9 G4 U [1 _. C0 m$ E
nosis can be established by just a few tests and by
$ l4 T! L/ L. f/ M+ ^ M0 bappropriate history. The inability to obtain such a
& d& }: P9 q9 D9 Y$ a( t& d, ehistory, or failure to ask the specific questions, may
g- ~$ h7 f P b* M3 ]result in extensive, unnecessary, and expensive1 Y" c( r8 h4 O. {4 d; M
investigation. The primary care physician should be: k7 [( m7 ~7 Q+ E7 Z
aware of this fact, because most of these children
1 W7 c- j, S. R* E$ E- cmay initially present in their practice. The Physicians’
2 t4 P' f3 v( _& H: D* M# w6 }* \Desk Reference and package insert should also put a
/ H' n( u8 J2 E$ I+ f1 Dwarning about the virilizing effect on a male or
" j. X: Q# a' b$ b6 Xfemale child who might come in contact with some-2 v" |' Q' C1 R! e* h
one using any of these products.5 Q$ C" F- K/ l/ {, _, }. \) ]( s7 R
References7 G# u- J/ [- ?. b1 c% L! S
1. Styne DM. The testes: disorder of sexual differentiation# T4 _0 I& A D* Y4 G7 X7 i
and puberty in the male. In: Sperling MA, ed. Pediatric
, p0 s$ w6 B2 w& n4 j9 YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ Z6 J( a' J- Y5 A+ w2002: 565-628.
! g; ~# n7 k& i6 ~# _9 Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% w! {8 o5 m+ q7 [) K( }
puberty in children with tumours of the suprasellar pineal |
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