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Sexual Precocity in a 16-Month-Old
6 {+ m- W5 h/ W4 n8 cBoy Induced by Indirect Topical
+ H# @! [3 a* w( f7 G/ h1 TExposure to Testosterone. r2 \( p$ Q4 {- i* x( n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( L/ z, e ~8 W8 m) y/ U( ]
and Kenneth R. Rettig, MD16 `- L1 Q) s/ z: ?% Y- @& m# @
Clinical Pediatrics
2 O8 g4 b; ]/ w9 X) W3 g" WVolume 46 Number 6
2 b) v* C- E: B3 _- TJuly 2007 540-5433 x# S$ U7 K$ m( h/ [- r
© 2007 Sage Publications
4 Z! m. ]) C* U: K0 H) T10.1177/0009922806296651. j7 p- Q( h; n Z7 U+ y Y. [9 q
http://clp.sagepub.com
( ~5 g+ Z- F, rhosted at/ I/ W: ^" u+ z+ O7 B
http://online.sagepub.com( b0 ?; |9 c7 b6 \8 G" n
Precocious puberty in boys, central or peripheral,
# C9 a0 S9 K0 K+ I* Y9 T2 pis a significant concern for physicians. Central
1 q( G, F7 o& r6 |4 c; Sprecocious puberty (CPP), which is mediated# `7 o8 s6 `$ j% X9 C: R( a# f
through the hypothalamic pituitary gonadal axis, has) }% b s- n+ V, Z9 R5 W0 R- Q2 F
a higher incidence of organic central nervous system! W/ ?, N" D( C8 R0 [2 Q9 W
lesions in boys.1,2 Virilization in boys, as manifested
* z; o7 r" r( H3 s% P& z! zby enlargement of the penis, development of pubic Z/ c) \$ V) _( f; v) L
hair, and facial acne without enlargement of testi-
, V3 u3 A; [0 O: ?5 O- Hcles, suggests peripheral or pseudopuberty.1-3 We0 n5 T7 @( p3 }: ~% Q; j' n
report a 16-month-old boy who presented with the
; \/ C+ r; [& a! w' x% x9 Zenlargement of the phallus and pubic hair develop-0 p5 }7 \7 H$ J% I# M5 a# E: F+ t. }
ment without testicular enlargement, which was due
' H3 t+ h- \7 \, eto the unintentional exposure to androgen gel used by o& v1 [& x$ _& {# B4 }
the father. The family initially concealed this infor-
0 V9 G7 g/ s5 dmation, resulting in an extensive work-up for this
& X5 x8 E; b0 C, K- ychild. Given the widespread and easy availability of
# u: H' j- j- J7 g0 Otestosterone gel and cream, we believe this is proba-
0 W3 ^$ X8 X7 v, mbly more common than the rare case report in the
) W1 j6 F( ]% e# V5 j! c" @& x ]4 w, qliterature.4% [0 X, q+ w8 \6 ^. O' O. W
Patient Report4 \! |/ c i$ v" ]* N, p0 Z
A 16-month-old white child was referred to the7 {) W% @- x0 ?: N
endocrine clinic by his pediatrician with the concern
' ~# Z' W- u6 Fof early sexual development. His mother noticed: i1 k7 }! n2 ? l$ k% K
light colored pubic hair development when he was
9 _* b& x% o q; r) j/ a) DFrom the 1Division of Pediatric Endocrinology, 2University of
~6 C. Y S2 P* D9 {6 i' NSouth Alabama Medical Center, Mobile, Alabama." d& K Z2 d. Y" I& {
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 F {! z: i0 \# w. j0 yProfessor of Pediatrics, University of South Alabama, College of
* n" L1 `. j0 t7 ~; ?. gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 ^! o! E' `% v l) Q' C
e-mail: [email protected].8 U0 T+ z) O S% S( C; _7 b% l5 t
about 6 to 7 months old, which progressively became
3 m& X8 o6 K4 T' k. d. |darker. She was also concerned about the enlarge-
, }; O! {1 v) I' g% `7 C1 r1 Ement of his penis and frequent erections. The child2 s4 O' l# @# s" N3 Q
was the product of a full-term normal delivery, with
3 C! { d3 y. w% `- t2 {$ na birth weight of 7 lb 14 oz, and birth length of
( Z9 e, y& x2 Z: S/ l20 inches. He was breast-fed throughout the first year8 T$ W' g4 P2 r0 P7 ?& z% c
of life and was still receiving breast milk along with" e9 T; j" J+ v! x
solid food. He had no hospitalizations or surgery,5 c- M7 J: r& _8 @
and his psychosocial and psychomotor development x: ~4 j/ j% k+ A' l! d! y! ]! p
was age appropriate.5 F* U5 y$ I i* }. K5 O. O' B
The family history was remarkable for the father,& B& |3 `. m. R9 h0 h4 U
who was diagnosed with hypothyroidism at age 16,
2 f+ C5 H8 K: ^" I% q$ [" Hwhich was treated with thyroxine. The father’s
) I, [+ O+ C8 b' oheight was 6 feet, and he went through a somewhat
# @1 E! B" B pearly puberty and had stopped growing by age 14.2 J* I, j6 W2 Q: _, d# T& X
The father denied taking any other medication. The! a1 {* J; f p
child’s mother was in good health. Her menarche$ p) A, p! j* W( k
was at 11 years of age, and her height was at 5 feet
4 j2 F) J& u# R/ g+ e; F( Z0 M: d$ Q5 inches. There was no other family history of pre-
& `+ M7 z" \3 M4 Xcocious sexual development in the first-degree rela-1 ` Y. m0 c, x! ~# S
tives. There were no siblings.
# N6 c9 q9 l& e6 n0 M9 QPhysical Examination2 {# ~7 I! }0 m7 C( m3 M" |
The physical examination revealed a very active,( m$ d. ?: E3 e* {( x
playful, and healthy boy. The vital signs documented1 M, X5 x& ~: l, }- d
a blood pressure of 85/50 mm Hg, his length was
$ Y4 t2 T7 g. G& h90 cm (>97th percentile), and his weight was 14.4 kg, b& Z3 @$ ], F( c% x
(also >97th percentile). The observed yearly growth' G* f, h4 V' f$ Z+ Q0 ]- j
velocity was 30 cm (12 inches). The examination of5 F$ U7 c/ I1 x" E% i
the neck revealed no thyroid enlargement.6 Z! U. }4 \5 F
The genitourinary examination was remarkable for
, [& b6 ^; V) Jenlargement of the penis, with a stretched length of3 r0 i f+ m v& l1 {7 F; X" P% z
8 cm and a width of 2 cm. The glans penis was very well1 Q+ L+ ?. V( Q- j( Z5 a; [
developed. The pubic hair was Tanner II, mostly around. _# ?7 ^+ [5 `' P
540$ z, ], l1 \% n3 {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( B# I8 p( _$ F; b) h- sthe base of the phallus and was dark and curled. The' r5 j9 ~* Z% s) E
testicular volume was prepubertal at 2 mL each.4 G- \5 W0 U( O' a
The skin was moist and smooth and somewhat0 s& o7 b8 i$ M' T. D* _
oily. No axillary hair was noted. There were no
! q2 i% H1 S0 l( Y& gabnormal skin pigmentations or café-au-lait spots.- B7 F! {7 _$ i9 C [$ J
Neurologic evaluation showed deep tendon reflex 2+
- J6 f+ v" h5 o- S1 ^) ibilateral and symmetrical. There was no suggestion
, I6 O1 K! Q O( m* D# u1 pof papilledema.$ l6 G* G, S) A$ s. f2 f: n
Laboratory Evaluation& B1 y% u# z z9 z' x; `% Q9 g
The bone age was consistent with 28 months by4 x2 T0 B2 F) Y0 P3 U- _0 R: J( z5 r
using the standard of Greulich and Pyle at a chrono-
. p4 q5 f; z9 d, k- S5 v/ Nlogic age of 16 months (advanced).5 Chromosomal/ p) f: q4 ^& @; O2 @, N s
karyotype was 46XY. The thyroid function test& u+ K& a5 j9 g+ I( }6 M+ f! B4 P3 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! d& l3 k! u' Ulating hormone level was 1.3 µIU/mL (both normal).6 i$ [0 g2 `, Y1 q9 Z
The concentrations of serum electrolytes, blood z j5 O7 U8 [) i9 _8 P% E
urea nitrogen, creatinine, and calcium all were$ V$ G" X$ U, B- v+ q* Y
within normal range for his age. The concentration
) R- E, p$ F9 f S7 F) N% Vof serum 17-hydroxyprogesterone was 16 ng/dL
2 ?5 d5 i- f; L! q3 M5 n J$ s(normal, 3 to 90 ng/dL), androstenedione was 20
8 M1 U' ~2 z/ Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 [% C8 @ w, O }7 B2 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),( o4 d6 y8 t. `! k9 w5 L* A: m5 f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ M$ x4 B7 u F3 c" b$ ^
49ng/dL), 11-desoxycortisol (specific compound S)) ~3 y3 ^$ k) Z5 K8 M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 G I9 I+ O8 E6 w9 r7 A0 ]5 T0 ^ Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 A+ k' a+ @/ T- y% _9 g V+ ]testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 {" H2 ^" u0 ~- ~- |5 C3 ~and β-human chorionic gonadotropin was less than: }0 b+ q0 r0 v+ m9 `+ x( b+ g0 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 O( X7 {* Y; P) j7 O) x1 w! wstimulating hormone and leuteinizing hormone
1 @9 y' w7 |1 iconcentrations were less than 0.05 mIU/mL
! b7 m! F7 l2 X0 y- n(prepubertal).* r w; `' F% x$ E' s
The parents were notified about the laboratory: d! J# e+ x) Z T
results and were informed that all of the tests were
1 V: i d5 b- h! d7 R7 A- E$ cnormal except the testosterone level was high. The
: Y+ g; v& z2 xfollow-up visit was arranged within a few weeks to% o G$ _' m4 q
obtain testicular and abdominal sonograms; how-
$ F" l9 F7 M4 V6 G# ?# g" kever, the family did not return for 4 months.
# w6 t* I8 W* d( e) ^" a' l' FPhysical examination at this time revealed that the
7 e3 P7 u4 \+ {+ dchild had grown 2.5 cm in 4 months and had gained
m/ @1 [' D: Y2 x2 kg of weight. Physical examination remained' w- C) r6 l; y: B- T$ h* F8 \- p$ U
unchanged. Surprisingly, the pubic hair almost com-, C* i& C' U4 K( `) N2 Z7 `
pletely disappeared except for a few vellous hairs at% @! `# B2 r) v; S, A' U2 H7 q4 w
the base of the phallus. Testicular volume was still 2( _) I: H2 Q5 o) A: F4 c* I
mL, and the size of the penis remained unchanged.
V- {3 P9 K7 Y c% W; |The mother also said that the boy was no longer hav-/ B& @ E: H* @8 H. ]/ Z
ing frequent erections.' ~& N, [8 u9 b' k/ w" o% y N
Both parents were again questioned about use of
6 K- e# q% X( t' xany ointment/creams that they may have applied to
- R- A6 [ T" H; `5 s. N$ `the child’s skin. This time the father admitted the
- U# o, _& e. q. pTopical Testosterone Exposure / Bhowmick et al 541# a/ N/ N3 @2 |& \. {& O/ \
use of testosterone gel twice daily that he was apply-% `- |6 ^4 Z. }- Y! b1 W% H- V
ing over his own shoulders, chest, and back area for
2 z1 k) ]3 F9 S, K, o/ sa year. The father also revealed he was embarrassed
# _4 a1 U- x( h4 }% u( Nto disclose that he was using a testosterone gel pre-
# G5 \' Z# }3 p9 r+ q8 ~' sscribed by his family physician for decreased libido
H$ f3 e( t! r5 Z% A8 y+ o" s, f5 ~secondary to depression.! U0 L. N6 V' e) ^! a; E, D. W' B
The child slept in the same bed with parents.
# q7 Z7 Y, E- S! C* |$ n9 L' wThe father would hug the baby and hold him on his& O" ?% S* a. y' j8 |
chest for a considerable period of time, causing sig-
* O- d+ O& s: p! f; tnificant bare skin contact between baby and father.6 D+ ^1 Q$ `1 w. x! }- f0 g! @: C% Z
The father also admitted that after the phone call,* }2 \; l O, V% f: K
when he learned the testosterone level in the baby
/ _6 F; G3 V' |& I$ G/ ?was high, he then read the product information2 M( S# l. K( {, p* g) b
packet and concluded that it was most likely the rea-
1 \. Y T3 ?+ R+ A$ o+ t2 ?son for the child’s virilization. At that time, they
& K2 Z! p$ u, P* h$ v$ B2 h# ydecided to put the baby in a separate bed, and the
; _$ m' i1 J8 dfather was not hugging him with bare skin and had3 A, ]2 D0 Q& ^& ~
been using protective clothing. A repeat testosterone/ l( f- J: S3 l) p
test was ordered, but the family did not go to the8 K) a) k; a5 l0 E4 G3 U) ]0 H
laboratory to obtain the test.
" Y% B2 s. [6 l" cDiscussion# S4 f. [; u5 @8 d9 y9 M7 s* o
Precocious puberty in boys is defined as secondary( z3 y8 O7 J& t' |, j( i9 ?
sexual development before 9 years of age.1,4
! { S9 K1 N6 ]3 X- M9 x0 F2 ^Precocious puberty is termed as central (true) when
* q% W" Y' l! a' R8 Sit is caused by the premature activation of hypo-
7 S- X+ D' D ?& o$ s% Q7 ~- _thalamic pituitary gonadal axis. CPP is more com-
3 @: F$ y* y v% B" Pmon in girls than in boys.1,3 Most boys with CPP
* H$ F+ B4 J; _- v2 ?' n5 kmay have a central nervous system lesion that is
* k% a2 O; H2 sresponsible for the early activation of the hypothal-, ^# ?5 o0 |- ?! F0 R/ B
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 C4 {2 D p% D$ }" O' Wsis has been given to neuroradiologic imaging in
- h+ r; V* Y1 X+ y- J, sboys with precocious puberty. In addition to viril-
% L( |$ N" n7 \6 `( `ization, the clinical hallmark of CPP is the symmet-
- D: a8 j s. F: Zrical testicular growth secondary to stimulation by
( |0 o% }3 K7 H. K/ [+ Dgonadotropins.1,3) T% T! h9 F. Q7 A, `1 W) @' a
Gonadotropin-independent peripheral preco-+ q! x d6 F1 q0 U
cious puberty in boys also results from inappropriate
, d* l# j$ c* V" X) Tandrogenic stimulation from either endogenous or% V4 n3 J+ H7 \
exogenous sources, nonpituitary gonadotropin stim-0 m2 |1 k5 s; {, }. I: d0 ?# \& U
ulation, and rare activating mutations.3 Virilizing
3 [- ~) P' d/ R6 U* v. k+ O3 ^4 ccongenital adrenal hyperplasia producing excessive- Y4 I8 ?( B- H5 A7 M% _9 R, H$ C
adrenal androgens is a common cause of precocious8 R% S( q, u/ b/ [
puberty in boys.3,4
# [% F, R! ]9 `: v5 q+ d3 xThe most common form of congenital adrenal- y/ s6 H) B5 E7 E: r- g, d
hyperplasia is the 21-hydroxylase enzyme deficiency.3 ]3 ^, P- q/ o
The 11-β hydroxylase deficiency may also result in$ P! c. |) X$ T A+ F, N
excessive adrenal androgen production, and rarely,+ V7 m5 W' w7 d1 l7 j$ f
an adrenal tumor may also cause adrenal androgen' T1 R5 a- ~5 A- y1 t
excess.1,3
8 w( u' I, ]! t& W* d0 j* hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: Q. T) R9 S, N0 ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. O; Q1 @* i Z" ~& q
A unique entity of male-limited gonadotropin-
8 U* z- I- |1 M, i0 kindependent precocious puberty, which is also known: f% v( L. m- S6 A; H
as testotoxicosis, may cause precocious puberty at a+ C/ G$ w* }. O+ A. d! o0 v: e
very young age. The physical findings in these boys
# g) j/ u* D6 Q# D) g$ K+ G" _with this disorder are full pubertal development,
" S+ B+ l: k8 {9 p% Z0 p+ hincluding bilateral testicular growth, similar to boys7 Y! v# E7 S+ g+ }% Y2 S& \
with CPP. The gonadotropin levels in this disorder
9 h R9 n' E& I9 n8 {8 S1 zare suppressed to prepubertal levels and do not show
) X; C: S0 ~! A% vpubertal response of gonadotropin after gonadotropin-
5 a0 s( n/ y. o* r& b, X2 _releasing hormone stimulation. This is a sex-linked
. W3 w% O" D' a) B6 X+ D gautosomal dominant disorder that affects only
* K0 L9 G9 l7 A4 Q) C% Zmales; therefore, other male members of the family
* M& q9 i1 X$ k% H" z) \& ?may have similar precocious puberty.3
3 i) U% m/ V% c: S6 z$ X2 KIn our patient, physical examination was incon-
8 l1 B' ?4 f' g/ \9 Ysistent with true precocious puberty since his testi-
+ r/ x% @. N1 z( M. W. x! M. f$ pcles were prepubertal in size. However, testotoxicosis$ A* A* @5 D' {! Z+ G4 Q A
was in the differential diagnosis because his father
/ [3 \! s2 m. O1 \! q0 pstarted puberty somewhat early, and occasionally, d; g) C# u5 A4 e) D+ M
testicular enlargement is not that evident in the& C, k7 _- k+ Y
beginning of this process.1 In the absence of a neg- P& M" N8 @: [8 _& |
ative initial history of androgen exposure, our
; u5 i, [( e; Wbiggest concern was virilizing adrenal hyperplasia,8 [5 z0 [3 A! |6 L0 i6 P
either 21-hydroxylase deficiency or 11-β hydroxylase
4 _0 h5 S# _& J' p! x9 i4 wdeficiency. Those diagnoses were excluded by find-5 p0 G8 h; U4 b% c. \8 F' K
ing the normal level of adrenal steroids.9 M1 v2 i" r, J' d- D1 a
The diagnosis of exogenous androgens was strongly
; G& q6 r% w) Z2 C& Dsuspected in a follow-up visit after 4 months because% [6 b2 S. E; J5 c" {' o. J
the physical examination revealed the complete disap-" c9 D- \8 ~8 X+ k# W. |! M
pearance of pubic hair, normal growth velocity, and
# h o T, L& S% n4 h; ^/ o6 h$ adecreased erections. The father admitted using a testos-
, v7 U/ k% q" cterone gel, which he concealed at first visit. He was2 i! k# Q+ o8 {$ m
using it rather frequently, twice a day. The Physicians’* Y/ w: W2 y7 h* V% Y+ A1 U
Desk Reference, or package insert of this product, gel or
h! M. S+ s7 Xcream, cautions about dermal testosterone transfer to$ B; ?$ z+ ]8 e. x' s1 ]" x
unprotected females through direct skin exposure.
3 L0 T5 p5 W8 jSerum testosterone level was found to be 2 times the9 u0 H, h% t1 t. N4 Q% Y1 I: D7 Z
baseline value in those females who were exposed to" j" N$ C9 t* ]+ P" R5 u
even 15 minutes of direct skin contact with their male- W5 q( {- M0 e/ m6 f6 N' A; J
partners.6 However, when a shirt covered the applica-
) k) X5 b: S: V& {tion site, this testosterone transfer was prevented.
9 M: \* b2 U0 c7 F* J( W- i! {# eOur patient’s testosterone level was 60 ng/mL,
8 u% ?5 T5 m8 I9 d) P! w: d6 y& N! s; [which was clearly high. Some studies suggest that* h+ |; W* q D. q, a1 n6 z6 H9 g7 R, g
dermal conversion of testosterone to dihydrotestos-
4 E( q+ Q" G0 k* i3 B/ _terone, which is a more potent metabolite, is more* {$ s5 V. H1 b6 T4 i/ t
active in young children exposed to testosterone
5 K' R. p8 k1 ~1 f0 T! K) S2 wexogenously7; however, we did not measure a dihy-" C5 {" \/ ]9 x8 i' j) l: f
drotestosterone level in our patient. In addition to5 C- ]" W7 j3 C7 \* q
virilization, exposure to exogenous testosterone in% p% w& Y, b; R# t# e- {: B
children results in an increase in growth velocity and
+ r/ I" y% r3 A9 [3 Iadvanced bone age, as seen in our patient.6 x( ~$ ]7 b) z E2 P' R" i5 ~
The long-term effect of androgen exposure during
5 T9 } [6 \+ I; y0 b2 w8 V6 e; uearly childhood on pubertal development and final
& T9 c, y' B# D. T9 L; O5 A% Y1 i' radult height are not fully known and always remain
: T. g6 a, b, V$ B3 \5 f8 s; ja concern. Children treated with short-term testos-
+ `5 g7 b7 K& [4 S! n5 vterone injection or topical androgen may exhibit some
$ d4 g- h' P0 d1 a& ~/ Nacceleration of the skeletal maturation; however, after% C5 U1 x3 w, E4 ]
cessation of treatment, the rate of bone maturation: V0 S8 |* w% \; W' z- s0 g
decelerates and gradually returns to normal.8,9
% ?* }0 V. H. E* W% @) h/ LThere are conflicting reports and controversy& R2 c% l* h* C8 y0 q
over the effect of early androgen exposure on adult
9 a( G0 h+ V apenile length.10,11 Some reports suggest subnormal
) K& P* `6 Y Y- C1 kadult penile length, apparently because of downreg-
) S6 ]. Z. i3 ~0 bulation of androgen receptor number.10,12 However,
1 }" A+ w( \6 M- TSutherland et al13 did not find a correlation between
+ x5 Y# R i2 h0 \$ o. ^# K/ Mchildhood testosterone exposure and reduced adult5 r: D& K; K- V# t2 E
penile length in clinical studies.
$ P* e4 a- ^+ p* g, I# j! u9 ONonetheless, we do not believe our patient is9 M! n# U0 o3 I- L
going to experience any of the untoward effects from1 D8 Q: T8 M: I E: ]) P
testosterone exposure as mentioned earlier because
3 ?0 H2 P0 Y1 g' m: l/ n- N4 ]$ `" @the exposure was not for a prolonged period of time.
) \5 \7 C' G4 y9 a$ w( z5 B! P7 H1 k6 F" ZAlthough the bone age was advanced at the time of
/ Z7 l, l" y, S7 a+ M( Mdiagnosis, the child had a normal growth velocity at
1 H9 F6 t# r, X2 }, O6 I0 s& `) Rthe follow-up visit. It is hoped that his final adult
; ]& H; z# R0 Nheight will not be affected.5 t9 D4 e u& K: ?+ R ^
Although rarely reported, the widespread avail-
8 f1 ?$ a/ o! Aability of androgen products in our society may
9 N" F* h0 D# T& [! ?indeed cause more virilization in male or female
9 {# H! Z/ I: R+ mchildren than one would realize. Exposure to andro-
" f( H' d. p, q2 _% qgen products must be considered and specific ques-% E' _) x% ^- c5 c* D4 h$ p
tioning about the use of a testosterone product or
2 s% e0 q3 ^( e3 \ v* ogel should be asked of the family members during
) f4 e- M! @0 G# v7 a; Q9 bthe evaluation of any children who present with vir-
2 W9 N$ {) S+ L& nilization or peripheral precocious puberty. The diag-( N7 g' _2 }6 l, z$ N( e' n" T/ x
nosis can be established by just a few tests and by0 k& u7 e9 l& U' U0 _% w
appropriate history. The inability to obtain such a9 `5 f2 E; r4 Z3 t; S" w
history, or failure to ask the specific questions, may4 m' e1 Z% ]9 t) A+ }. ^& y$ L
result in extensive, unnecessary, and expensive7 r( B n Y( l; q z' l& l. ]
investigation. The primary care physician should be
' ^9 @/ ?# d- c/ X" N( A2 D Z* i8 qaware of this fact, because most of these children
6 }3 K2 B+ a* M( n) Nmay initially present in their practice. The Physicians’8 R6 q8 r7 X5 I, r' H: x
Desk Reference and package insert should also put a, O# U# E% ^4 P ~5 r! r
warning about the virilizing effect on a male or
% u* _1 D& [% W" Q( `8 @female child who might come in contact with some-
3 \- Z6 ]# w# D9 Z, Aone using any of these products.
$ q1 M1 B8 v: Q3 Z* NReferences% j: C X( ~* o' m+ y1 g* j
1. Styne DM. The testes: disorder of sexual differentiation4 h r' F- h4 q) S3 E4 {7 W1 t
and puberty in the male. In: Sperling MA, ed. Pediatric( Q, ?# h2 B0 {2 G7 h* E' `% }( o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 S M$ A0 f! |" D
2002: 565-628.
, a' Y+ t+ u7 U% I2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 V: @2 e0 B/ e) k- U0 [4 d+ F
puberty in children with tumours of the suprasellar pineal |
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