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Sexual Precocity in a 16-Month-Old; h2 b# i& ~3 i3 w# J2 @
Boy Induced by Indirect Topical
* R1 Q# y: d" T! f7 GExposure to Testosterone
; ]" C- |; R8 E% n( |: l8 A* X8 I/ v5 KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 Z! N( Y3 h/ S9 z7 M; n' S% Aand Kenneth R. Rettig, MD1& q. O* u; j% R
Clinical Pediatrics! \' G; K; M2 P; H' x& I! e N* y
Volume 46 Number 6
2 n8 e) T: U1 F2 f+ V9 g( YJuly 2007 540-543
: F, g+ P7 y, w1 { a2 j$ K© 2007 Sage Publications" F% S6 w& o% V2 p
10.1177/0009922806296651
# G- @2 o! j3 g' g: r" lhttp://clp.sagepub.com
) b6 P5 _8 i: t2 E: f* y( khosted at
+ f: ^" e6 v% ?$ b1 |http://online.sagepub.com
5 f, ?- O- u Z6 b# a' VPrecocious puberty in boys, central or peripheral,/ u x; w8 m' M( \& H8 m, h! V
is a significant concern for physicians. Central; m# H; g* ^2 J' ~0 _* y
precocious puberty (CPP), which is mediated* q& p# u0 {: W! q4 [$ J
through the hypothalamic pituitary gonadal axis, has
" w, T0 b4 I" Z/ Z( na higher incidence of organic central nervous system
3 z) q5 A; N1 ?* K: Slesions in boys.1,2 Virilization in boys, as manifested
0 \: C3 a! D! n( y X' Oby enlargement of the penis, development of pubic
4 {; ^5 a" I; k7 Vhair, and facial acne without enlargement of testi-& ]) L9 m- ^3 s1 P
cles, suggests peripheral or pseudopuberty.1-3 We
$ c( m, }( ^+ t" `) p! n5 X8 Z! vreport a 16-month-old boy who presented with the
0 p: ` H; L7 o6 w% H) xenlargement of the phallus and pubic hair develop-
. ^2 C$ C( T5 [6 C+ `$ qment without testicular enlargement, which was due: t. J) |1 @6 G w
to the unintentional exposure to androgen gel used by0 S" ], ^+ F! \; k0 X
the father. The family initially concealed this infor-
5 H' r' N5 d* `. `% Kmation, resulting in an extensive work-up for this
) A& ]% V. \7 `+ u3 Jchild. Given the widespread and easy availability of
8 D& Z# G. w3 P |2 P' J1 E, z' z3 v0 z. Ztestosterone gel and cream, we believe this is proba-
1 \# K. @" g/ Z" G- ?6 F1 O' l- nbly more common than the rare case report in the
- v: V6 E; [' U0 N# l ^# Fliterature.4; Y* M, W+ W9 y
Patient Report- i0 d! R& {$ i9 s; y
A 16-month-old white child was referred to the
. e! W- y( J: \6 Mendocrine clinic by his pediatrician with the concern2 y7 G2 l0 i. F+ g4 B- R' N
of early sexual development. His mother noticed# u4 @' q6 S! |% g& K
light colored pubic hair development when he was
0 r, y. U7 u9 l1 P% x. K* IFrom the 1Division of Pediatric Endocrinology, 2University of
. D; f& T/ Y- WSouth Alabama Medical Center, Mobile, Alabama.
H3 B; x1 \: e: W7 Q3 z: bAddress correspondence to: Samar K. Bhowmick, MD, FACE,$ ?" \; N' w' R5 e% C2 W
Professor of Pediatrics, University of South Alabama, College of
( w* b4 \: \! j6 j. c: NMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 i/ Z$ N4 L3 ^$ O
e-mail: [email protected].
' _2 n+ J3 V) y, T9 b% s% E& m, Pabout 6 to 7 months old, which progressively became
N( N7 f3 b! h6 |0 M+ ^darker. She was also concerned about the enlarge-( V" P, W: Z0 z. G- y
ment of his penis and frequent erections. The child
( j1 F+ {- w0 N, ^3 bwas the product of a full-term normal delivery, with4 Y$ y. W; u6 Q, ~7 X+ n9 T! v
a birth weight of 7 lb 14 oz, and birth length of
1 a( Z- |, k; S5 `) M20 inches. He was breast-fed throughout the first year' o/ o: A' m0 H1 _
of life and was still receiving breast milk along with1 F( \# [! r J+ V
solid food. He had no hospitalizations or surgery,. R* E7 c# f# h9 O
and his psychosocial and psychomotor development. j# M2 q) z4 Z& Y
was age appropriate.! d* x( i( I$ _" P
The family history was remarkable for the father,$ G/ \$ ?$ J' U2 ]
who was diagnosed with hypothyroidism at age 16,+ U0 F) L3 h0 @- }; ?. I# P/ f m
which was treated with thyroxine. The father’s8 Z0 u" R) Y! j/ l, e5 J( B1 t
height was 6 feet, and he went through a somewhat- s+ k* E% @/ R4 `# Y0 R& `% ^& ~
early puberty and had stopped growing by age 14.
F4 Q" X9 R7 q3 O' [2 NThe father denied taking any other medication. The
. y% A# M" O" C* A+ \. v. y" S qchild’s mother was in good health. Her menarche
! h, l3 {- {! V. Y$ D: e1 ^2 O Uwas at 11 years of age, and her height was at 5 feet" X' T/ K- M5 p" c4 G$ P2 H
5 inches. There was no other family history of pre-
X& S7 J$ C/ j/ k! gcocious sexual development in the first-degree rela-
9 {" y2 |' Q: \- P% Ztives. There were no siblings., x: |: s+ y' n) \! t2 j: _
Physical Examination) Q+ l# I) X- ?, {
The physical examination revealed a very active,2 i0 g7 V6 {$ Q0 n+ ^
playful, and healthy boy. The vital signs documented
2 z- M7 \# \) r3 d1 s( m+ h* n/ j0 e4 Ya blood pressure of 85/50 mm Hg, his length was
" [2 Y; _$ v* l5 Q+ P5 _% g90 cm (>97th percentile), and his weight was 14.4 kg
+ { T- q% S; l(also >97th percentile). The observed yearly growth
8 o6 b; `6 K& X! F. A2 h+ cvelocity was 30 cm (12 inches). The examination of
( \. k, v' D, N) l7 g0 D: jthe neck revealed no thyroid enlargement.
# J2 E0 s) b/ @/ TThe genitourinary examination was remarkable for5 g1 x% f+ w5 i; y& m% R
enlargement of the penis, with a stretched length of$ {+ }4 H+ q+ J7 L- |8 j
8 cm and a width of 2 cm. The glans penis was very well9 Y9 z7 @5 k1 N4 k$ J) M
developed. The pubic hair was Tanner II, mostly around
7 a1 ?* Y! T9 e9 Y2 a+ e540
9 j& r: {( S9 J% n% a: Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& I, q4 r6 R& Wthe base of the phallus and was dark and curled. The. N- c" e4 Q( y7 J8 K6 K" b
testicular volume was prepubertal at 2 mL each.; z& G* d7 E8 ^
The skin was moist and smooth and somewhat/ V2 X8 J5 S, M$ {- S( B) d
oily. No axillary hair was noted. There were no4 @9 ?9 l" ^0 S1 p/ C
abnormal skin pigmentations or café-au-lait spots.
P4 c: K) _# p7 T# G. P: w( ]Neurologic evaluation showed deep tendon reflex 2+9 `# C" S# [+ c6 J* x
bilateral and symmetrical. There was no suggestion
- C% y% e4 N6 p+ _5 D9 [of papilledema.1 m5 ~+ Q6 S/ O8 Y# ]# c
Laboratory Evaluation
; B/ C6 O' X; G( }The bone age was consistent with 28 months by
+ _- q/ g) `/ e# pusing the standard of Greulich and Pyle at a chrono-0 }; e T* V6 Y' K
logic age of 16 months (advanced).5 Chromosomal, J( o9 M# u# O
karyotype was 46XY. The thyroid function test
- }6 | {' o* T" dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! |9 T1 v6 i! k# V" ?* J3 N# Mlating hormone level was 1.3 µIU/mL (both normal).
( A* b* _, I( k7 F ^* {The concentrations of serum electrolytes, blood. g& X- t! K; ?
urea nitrogen, creatinine, and calcium all were
: v0 k! E. k4 |/ Y( U- Pwithin normal range for his age. The concentration2 F( c3 @9 F0 b1 G+ _6 }& Q* Q' L
of serum 17-hydroxyprogesterone was 16 ng/dL
6 ^& t) u0 m) `. @ R6 { O(normal, 3 to 90 ng/dL), androstenedione was 20- F+ Z4 x) r/ K/ @$ H' p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, Y }' I8 j' j( e; K* j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; v! Y% b5 F9 J9 A+ M' v% X9 q2 J M& I! A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to! G( \( p- E6 ?( X: [1 m& _
49ng/dL), 11-desoxycortisol (specific compound S)
0 {. w, Q( I1 J5 h$ `was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 w5 C, t; N |! X3 E: Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: k D- I$ f! c! |- V& Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
H5 j7 B% Q6 X7 H6 l3 ^6 ?: O# iand β-human chorionic gonadotropin was less than9 v- g6 c- Z9 v
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) y- `6 [; y1 ]# S1 |3 bstimulating hormone and leuteinizing hormone) B) M$ l2 N6 u6 S/ {
concentrations were less than 0.05 mIU/mL; }) R) [7 W6 E. U2 n, R% N6 \5 G$ } D
(prepubertal).
8 z8 l) E$ S& @' s8 TThe parents were notified about the laboratory
1 j" R. N' |2 s; V7 V1 m5 r$ Hresults and were informed that all of the tests were0 N8 O: V( L9 c2 @
normal except the testosterone level was high. The
: ?% z6 g. o1 W5 g5 ufollow-up visit was arranged within a few weeks to
2 e; }+ Y D! c- uobtain testicular and abdominal sonograms; how-
* n9 Z. z: R: xever, the family did not return for 4 months.6 {8 ~: w# P: \3 g1 k
Physical examination at this time revealed that the( `2 n6 C7 H7 j" U- o+ x8 _! W
child had grown 2.5 cm in 4 months and had gained, ~- D# e, A. B8 `% Z
2 kg of weight. Physical examination remained
' ]& F( ~, E1 X+ F5 i7 w( l: bunchanged. Surprisingly, the pubic hair almost com-
& O6 @& ^- _6 C8 l* vpletely disappeared except for a few vellous hairs at1 {# R$ P8 Q1 v1 s4 X% q
the base of the phallus. Testicular volume was still 2
" N3 X' x% u9 N8 p! x rmL, and the size of the penis remained unchanged.
/ L3 } g2 R8 E- r+ R' m, N/ {, IThe mother also said that the boy was no longer hav-/ ]: C& A* N+ j7 V2 t. D2 v, E
ing frequent erections.
* J4 M3 T' o+ u0 rBoth parents were again questioned about use of
# c' s9 K1 ~: A$ c7 gany ointment/creams that they may have applied to6 y* i9 v! g7 R: }9 ]
the child’s skin. This time the father admitted the
- P0 I4 ^# d. b) x' K, t( WTopical Testosterone Exposure / Bhowmick et al 541( W- O1 p1 r* p8 B) r2 L5 i7 b
use of testosterone gel twice daily that he was apply-7 h* Y/ m. V- x
ing over his own shoulders, chest, and back area for
6 Z/ Y+ g4 O# ?. R2 xa year. The father also revealed he was embarrassed6 z/ v \0 X3 l8 ^: a. l
to disclose that he was using a testosterone gel pre-
/ L+ T4 b9 n0 T& f2 k' }, Vscribed by his family physician for decreased libido
5 S$ e1 C, x# N: bsecondary to depression.& `1 s& t9 K% D) L
The child slept in the same bed with parents.1 k8 \- b% F& W1 [
The father would hug the baby and hold him on his
$ @7 Y0 b- O) [; }: rchest for a considerable period of time, causing sig-
% \0 @. N- U. h% |nificant bare skin contact between baby and father.
: i1 q8 y" i* fThe father also admitted that after the phone call,+ o6 w' d/ ^3 c0 M. d$ k8 b+ n
when he learned the testosterone level in the baby
, \$ x/ ?1 R0 C! i8 _was high, he then read the product information
( ~3 ]$ T1 \# u8 y3 Y8 ^+ Lpacket and concluded that it was most likely the rea-( T1 r8 p' W( d) v
son for the child’s virilization. At that time, they
/ A: [6 T" D) m' \/ r# O* N+ |9 e8 Ndecided to put the baby in a separate bed, and the
5 U% h% m; Q5 {7 S' m. s# bfather was not hugging him with bare skin and had
% f0 l/ P& U A* h( Abeen using protective clothing. A repeat testosterone; U% Z$ \* j. F! Q1 E
test was ordered, but the family did not go to the# K5 `6 L7 G! x! m; w$ Q
laboratory to obtain the test. n$ Q: b; T8 r, Y1 D+ z
Discussion, w3 [- h0 F) t4 w @) ~7 }
Precocious puberty in boys is defined as secondary' E! m0 C7 s/ N3 M+ t2 ?
sexual development before 9 years of age.1,4
! U$ D: t9 a3 u2 H8 U2 o5 YPrecocious puberty is termed as central (true) when
: P4 A, V5 q: |+ U( Vit is caused by the premature activation of hypo-
5 j# ~- f6 T! L, h! ithalamic pituitary gonadal axis. CPP is more com-
( Z3 |& q& Q5 z' Pmon in girls than in boys.1,3 Most boys with CPP) i/ [3 I- N3 S2 ?2 ^& S
may have a central nervous system lesion that is, Z, n/ a$ h9 J. }
responsible for the early activation of the hypothal-4 ]5 ?) n3 A4 e. ?4 L; p2 o. a
amic pituitary gonadal axis.1-3 Thus, greater empha-7 v" v: h7 K$ b6 D- l$ b# ]- v1 O
sis has been given to neuroradiologic imaging in
+ |8 w8 B4 ^. \; z* m0 {3 xboys with precocious puberty. In addition to viril-
$ l8 p- v% K& `1 lization, the clinical hallmark of CPP is the symmet-9 f. j- n0 h% u2 o
rical testicular growth secondary to stimulation by
' [" `/ D6 V2 m& N2 T- F/ I& ygonadotropins.1,3
3 [+ ]# _" H3 o5 l7 wGonadotropin-independent peripheral preco-
* p- m9 s8 J8 x8 X( Kcious puberty in boys also results from inappropriate
- O; r% i0 p8 d9 h+ mandrogenic stimulation from either endogenous or# u3 \4 J1 f( S" s! `3 s
exogenous sources, nonpituitary gonadotropin stim-
- j9 P3 P' m7 P! i. q, ?. ~9 |. Pulation, and rare activating mutations.3 Virilizing
{2 Y: y8 c& Jcongenital adrenal hyperplasia producing excessive
2 p! A' d9 d. G; r4 u: |) z( \1 Eadrenal androgens is a common cause of precocious
) [7 v6 v1 U/ e/ q( j$ u9 N% gpuberty in boys.3,4
" a, t9 W2 B& w# x- \0 oThe most common form of congenital adrenal
+ T6 W: Q' J: T' H* S X; A3 c7 [7 Dhyperplasia is the 21-hydroxylase enzyme deficiency." c' x% E6 P9 y* N5 [2 R
The 11-β hydroxylase deficiency may also result in
" ^$ F$ h# n$ Lexcessive adrenal androgen production, and rarely,3 a! e- l4 x* v4 N% x) I) z# G0 J
an adrenal tumor may also cause adrenal androgen) t0 [$ c1 g9 e- {, G
excess.1,3
3 J( u" T$ @/ I3 K- K |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
}" r7 e# k" D& f542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% h& ]/ ~$ e! v3 [ p; R J4 GA unique entity of male-limited gonadotropin-
8 F1 l q H( P2 q% w! x( ^, J0 k0 Kindependent precocious puberty, which is also known: Z9 J3 U" K" @6 e1 f
as testotoxicosis, may cause precocious puberty at a
- `9 Z8 Q, ]. avery young age. The physical findings in these boys+ t( G M- d, R6 A
with this disorder are full pubertal development,0 q# ~3 n* D3 @5 O. E, \5 t5 r- S$ U
including bilateral testicular growth, similar to boys
# }/ U4 h+ o3 R+ k. L; Kwith CPP. The gonadotropin levels in this disorder
2 L! n; i6 K/ a0 T5 zare suppressed to prepubertal levels and do not show; A! _# C+ [- c X! S t3 T
pubertal response of gonadotropin after gonadotropin-# m1 n0 ~: f" x4 q3 z; p
releasing hormone stimulation. This is a sex-linked
2 F; S7 W& Y9 J3 G+ }6 c7 xautosomal dominant disorder that affects only
5 m! |. C# v# }2 x9 v4 gmales; therefore, other male members of the family; F1 x- T- q+ O' q9 L! z: [
may have similar precocious puberty.3; @5 C M, j8 W0 s9 o8 d, E5 B* g7 Z
In our patient, physical examination was incon-
# z6 r: C$ D% @. Jsistent with true precocious puberty since his testi-. G L- l" x# S) Q: Q) A' v$ U
cles were prepubertal in size. However, testotoxicosis
1 p0 [+ [- W$ I/ z/ E% j' vwas in the differential diagnosis because his father7 B/ S& U* W5 }" m3 J, v
started puberty somewhat early, and occasionally,
5 r+ c, Q# H5 p- m! g6 Ftesticular enlargement is not that evident in the$ f; J" y* A7 H* b N" R
beginning of this process.1 In the absence of a neg-* K! u7 Z" ]/ j. C) e4 Z& `
ative initial history of androgen exposure, our
" Z! t! j# }2 \. hbiggest concern was virilizing adrenal hyperplasia,6 s, M3 g: A; R, m8 Y4 @4 n
either 21-hydroxylase deficiency or 11-β hydroxylase6 K0 G$ c5 l& M: G
deficiency. Those diagnoses were excluded by find-
7 U) K* [+ G' D6 Wing the normal level of adrenal steroids." t, Q' Q. y" F) g R0 \1 p
The diagnosis of exogenous androgens was strongly2 C8 e" U) W' `: [" b9 s
suspected in a follow-up visit after 4 months because
I1 t, w2 k$ h& ithe physical examination revealed the complete disap-
4 S, p. Z- `% K: G3 t: F G3 H+ hpearance of pubic hair, normal growth velocity, and: {* ^- l" [- ^% m; }8 x, E. y, t
decreased erections. The father admitted using a testos-7 d3 y% C- B0 {3 j# E, B9 k8 G( R
terone gel, which he concealed at first visit. He was1 o8 U; k6 {6 o5 s) M0 _9 h: }6 |3 f
using it rather frequently, twice a day. The Physicians’
) A* ]# T# s& x3 z! r% KDesk Reference, or package insert of this product, gel or
3 f1 W& U0 `. T G% r) r( rcream, cautions about dermal testosterone transfer to% k3 w. l3 n- [: `! z& B
unprotected females through direct skin exposure.( `0 q* w1 T6 E+ a
Serum testosterone level was found to be 2 times the
! z4 E0 D) m; p1 W! Jbaseline value in those females who were exposed to
) j1 C) ?: a9 F- h6 t7 O# `4 @5 g: eeven 15 minutes of direct skin contact with their male+ x) Q8 F5 f+ A- r6 p; K) L
partners.6 However, when a shirt covered the applica-/ f: J/ V& U7 E9 _4 S3 W
tion site, this testosterone transfer was prevented./ k. |- W8 s9 ?+ m
Our patient’s testosterone level was 60 ng/mL,
9 I% C0 U. @4 U; E( Swhich was clearly high. Some studies suggest that
( ?: X# ]: E$ Q3 Xdermal conversion of testosterone to dihydrotestos-8 I6 O: y+ l- s* s Y
terone, which is a more potent metabolite, is more
+ m. Q+ H6 l! y! K- |) {active in young children exposed to testosterone
# @2 p4 C$ N) lexogenously7; however, we did not measure a dihy-+ l& p; K, S6 M5 M! G. C
drotestosterone level in our patient. In addition to Q/ y6 H/ @# Y i8 Z
virilization, exposure to exogenous testosterone in
1 j9 r; A4 c# m5 lchildren results in an increase in growth velocity and# N0 H/ o. P" C* u" j
advanced bone age, as seen in our patient.
5 F M1 E$ u# D& t9 N0 w7 GThe long-term effect of androgen exposure during0 z/ ]/ g# G7 o8 a
early childhood on pubertal development and final
8 |+ p) D% z/ `adult height are not fully known and always remain
" ^8 A$ W% O$ X: k( t) U9 R0 Za concern. Children treated with short-term testos-
v7 k( x. s9 q: N5 wterone injection or topical androgen may exhibit some
; x% K2 I- g% g3 B1 K, xacceleration of the skeletal maturation; however, after/ W3 [6 S% c" i' f/ z- J1 d5 k
cessation of treatment, the rate of bone maturation
) R- x' C1 Q) `2 Z2 g0 vdecelerates and gradually returns to normal.8,9
/ e0 K+ d; H) ]$ x. K1 p( [' [ g9 wThere are conflicting reports and controversy
X# I% K! Z, S1 L) q: fover the effect of early androgen exposure on adult6 l+ u4 N: c; g4 N2 e$ @- |9 A
penile length.10,11 Some reports suggest subnormal$ J) F# a' {1 x
adult penile length, apparently because of downreg-3 d5 @1 p1 z9 U+ U1 F) P- W
ulation of androgen receptor number.10,12 However,# U1 L& |% U: m( H% F
Sutherland et al13 did not find a correlation between- F2 h3 D- c' B- D
childhood testosterone exposure and reduced adult, I' {1 D7 A) F, K' d% o$ P
penile length in clinical studies.6 A- d. g, H! p/ U% L# G! s
Nonetheless, we do not believe our patient is) ~& @: z8 l* [1 w
going to experience any of the untoward effects from" ?7 M) L) ?, `' w Q- i3 I9 R
testosterone exposure as mentioned earlier because* f# V) q$ b. \7 z) w
the exposure was not for a prolonged period of time.5 B O+ t' y/ i8 C
Although the bone age was advanced at the time of
. w* Q* Y, ]; a0 Rdiagnosis, the child had a normal growth velocity at
& D$ S/ F: ` b: Gthe follow-up visit. It is hoped that his final adult1 Y/ l7 `- H9 t( @) d0 {
height will not be affected.& P) }; p9 l8 W5 B
Although rarely reported, the widespread avail-/ R9 F: r/ n6 C R, w* v. G8 l
ability of androgen products in our society may
% |# |5 m' E; n: t, q3 T2 pindeed cause more virilization in male or female* e) I0 Q; ^ k0 N" \
children than one would realize. Exposure to andro-
' x! z p; E5 Z; W k% hgen products must be considered and specific ques-
, X7 Z8 ?/ u+ \+ e8 ^, x% |tioning about the use of a testosterone product or* {/ s8 N$ g6 s+ `6 O1 l& N, q
gel should be asked of the family members during2 ^7 V) R* C' U2 Y& z
the evaluation of any children who present with vir-
& j: u7 g } @) M5 G3 m; E! ]ilization or peripheral precocious puberty. The diag-' n0 m! l& z2 R; M1 U7 g& J
nosis can be established by just a few tests and by
( Y3 O) S4 G! c* m7 y0 A' vappropriate history. The inability to obtain such a! K: K) j" o t3 L
history, or failure to ask the specific questions, may
, y* ?( l7 u u* @6 Zresult in extensive, unnecessary, and expensive( K+ W6 d9 y% R
investigation. The primary care physician should be
1 b# t, a6 m0 Q- y7 _. Q; Oaware of this fact, because most of these children5 b) A, C. Y8 l- j
may initially present in their practice. The Physicians’
5 Q! x5 F% W) v9 v/ ~Desk Reference and package insert should also put a1 ~' i" J ~7 F
warning about the virilizing effect on a male or
; o- k3 `$ L" ]- ?: t) [female child who might come in contact with some-5 Y' e3 u. |( O; H' W7 g( M( N" x
one using any of these products.- e( ]8 ~2 z) e0 @6 X4 I
References
6 [4 r% W' R' [' I3 n0 D3 c1. Styne DM. The testes: disorder of sexual differentiation
2 y9 v) ?: W3 J: W- x$ T0 F0 band puberty in the male. In: Sperling MA, ed. Pediatric+ u( d& f- J+ w+ w5 Q" X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# h7 _5 l0 S) y* U# a
2002: 565-628.
/ Y, `3 P6 T" u* K+ }2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" b. [) i3 W) k4 S8 \1 G B, W1 Xpuberty in children with tumours of the suprasellar pineal |
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