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Sexual Precocity in a 16-Month-Old
p# d6 r6 Y) h5 W. B) jBoy Induced by Indirect Topical
/ m( r1 q! o! B$ N1 M% EExposure to Testosterone
- G/ J& X- p7 K7 I$ J6 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- }1 W- H H. p0 W! }' v6 band Kenneth R. Rettig, MD16 Y6 r' B ] q& r
Clinical Pediatrics
' _, Z# {% k G* p- ~' CVolume 46 Number 6% @' j$ a0 Q! a7 m
July 2007 540-543
* G6 B+ \/ r* o @7 a8 H6 \! B© 2007 Sage Publications
2 o( ^1 |( r8 Q8 C3 t5 N* Z10.1177/0009922806296651
4 i- H W; _6 |. W" hhttp://clp.sagepub.com
" J: F/ F: G rhosted at* H0 Q. @3 ~( {3 N0 C! P0 L
http://online.sagepub.com
0 V$ r- [- H7 u: r, ^! BPrecocious puberty in boys, central or peripheral,
+ q: `) C4 ?9 ?) Q3 p$ l& Mis a significant concern for physicians. Central
. K- \1 q/ J( [3 s& j. tprecocious puberty (CPP), which is mediated
5 h5 s$ |' x6 M7 m3 Z) Kthrough the hypothalamic pituitary gonadal axis, has
. j$ y, P0 i" @a higher incidence of organic central nervous system
7 L1 s" D8 D% y& ~lesions in boys.1,2 Virilization in boys, as manifested
' r% ?/ s& Y" h1 A+ D: bby enlargement of the penis, development of pubic
! X: X3 y) b7 S b1 chair, and facial acne without enlargement of testi-
0 D: r% q( W" g% _- P: j' Ycles, suggests peripheral or pseudopuberty.1-3 We* A& R& T: a5 } E! c) `7 L: h" o
report a 16-month-old boy who presented with the
. I1 `7 R. Z' {enlargement of the phallus and pubic hair develop-9 v+ [$ g. O7 \& C: @1 |, i( R
ment without testicular enlargement, which was due4 ~& {6 H' A9 l3 a8 d
to the unintentional exposure to androgen gel used by" ?; L8 ]* @& }4 b) q
the father. The family initially concealed this infor-1 Z: r s6 m2 ], W; u. j
mation, resulting in an extensive work-up for this
3 U. Y/ D: |" m" [! Lchild. Given the widespread and easy availability of
' X4 Q7 c$ ?3 Z# ntestosterone gel and cream, we believe this is proba-6 O. n. L* d/ t6 D$ y* c! @
bly more common than the rare case report in the
3 Y/ _) v2 h2 s$ {1 H U& bliterature.4
, z% K6 u: V0 ~- {8 ~. qPatient Report
7 \( a% d6 o0 GA 16-month-old white child was referred to the
0 r4 N- W, T+ A7 U2 ]& ]endocrine clinic by his pediatrician with the concern
$ r& F7 s$ A N1 e& }7 F4 a1 hof early sexual development. His mother noticed$ P* i/ C$ R! _
light colored pubic hair development when he was
3 ?) r" b1 T, p8 AFrom the 1Division of Pediatric Endocrinology, 2University of& E# }6 K6 ]! g4 _" `
South Alabama Medical Center, Mobile, Alabama.( C2 S( |: t: R
Address correspondence to: Samar K. Bhowmick, MD, FACE,& o! s p0 C# f" h b' G/ o* S7 N
Professor of Pediatrics, University of South Alabama, College of
3 S8 ^' ~$ \$ Z# J. sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ ^. j. y) b6 t0 G4 f% {0 x6 d! B
e-mail: [email protected].
6 I, Z' n7 @* I" U( {1 v: a$ jabout 6 to 7 months old, which progressively became
% ^8 F$ w9 O5 T( X% o% {darker. She was also concerned about the enlarge-8 ^3 ?- O& Q$ V- _
ment of his penis and frequent erections. The child
, K+ |$ s& ^9 d7 W* I9 e3 l; vwas the product of a full-term normal delivery, with
+ V" E* H: M: n' ]: N! \8 V5 Xa birth weight of 7 lb 14 oz, and birth length of
- R! ?% G) @5 r& U) m5 G5 a20 inches. He was breast-fed throughout the first year
8 a4 L# x' }$ oof life and was still receiving breast milk along with3 w; F9 f5 r) r2 H; B& U4 v3 z
solid food. He had no hospitalizations or surgery,& d* i9 u3 A: Y3 T
and his psychosocial and psychomotor development
( q. Y* o+ L/ B' l! Xwas age appropriate.
/ j2 W5 H0 U% L( m+ UThe family history was remarkable for the father,
, p+ ^3 H7 H1 j" q% a7 y3 k" N* X% rwho was diagnosed with hypothyroidism at age 16,
2 s" g9 I0 [) m bwhich was treated with thyroxine. The father’s" n% r* h' L/ k2 R+ s# Y
height was 6 feet, and he went through a somewhat) S0 a4 E4 Y/ }( |# A
early puberty and had stopped growing by age 14.! _8 G8 s3 K6 x; b+ V
The father denied taking any other medication. The
# D$ x, B+ n* M; Q. s) t7 v* Nchild’s mother was in good health. Her menarche! z) B; ?, t* L5 i4 k6 z
was at 11 years of age, and her height was at 5 feet
) S& C! h3 D0 @4 L* o. ?0 T/ V5 inches. There was no other family history of pre-( U3 I/ n9 D9 Z: B, V
cocious sexual development in the first-degree rela-$ a. z/ o* `/ |. w/ }, p
tives. There were no siblings.3 y4 ` ~5 B- ]8 |
Physical Examination8 i8 t4 p6 {: O4 j, ^( f: F: @
The physical examination revealed a very active,* S0 p0 S1 v8 L3 h# C
playful, and healthy boy. The vital signs documented
) I9 \* F# c n' ga blood pressure of 85/50 mm Hg, his length was
- \& I: u/ ?3 [8 F# p; j90 cm (>97th percentile), and his weight was 14.4 kg
9 ]; H" K; M; T/ M5 g& O' Q(also >97th percentile). The observed yearly growth
V! ^! Z7 {) V* k. F, Nvelocity was 30 cm (12 inches). The examination of. ?! u) q8 S: B8 g! T# m) l
the neck revealed no thyroid enlargement.
1 l2 V: ]/ A" r) [ c8 V. n0 ^The genitourinary examination was remarkable for
2 Z; T; n" z( ]. @3 J6 }6 G- cenlargement of the penis, with a stretched length of: J# W: @. s* r3 T- H1 h5 \$ H9 `
8 cm and a width of 2 cm. The glans penis was very well1 \1 u4 }/ F) c; d2 D8 e* [8 T
developed. The pubic hair was Tanner II, mostly around
0 F. z3 x2 r9 m- x7 C) T540
7 V+ C! m" z0 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 _. `; [- U% h- B6 t4 f( e D: x. ^% I+ [4 |
the base of the phallus and was dark and curled. The
* A( C8 ?6 K! H. F6 C# etesticular volume was prepubertal at 2 mL each.
5 ]3 V9 ?6 e0 B. wThe skin was moist and smooth and somewhat7 c/ t8 U4 {9 [
oily. No axillary hair was noted. There were no
6 R9 x' I P0 N$ Y2 kabnormal skin pigmentations or café-au-lait spots.# [! z% A: k/ X7 g5 V
Neurologic evaluation showed deep tendon reflex 2+* _7 `' K3 B# Y% w' [8 t( t. z
bilateral and symmetrical. There was no suggestion
* ]6 r0 F8 e7 [5 d" c, k7 iof papilledema.8 ]- Y: S1 x: {/ ^! A- p! s* }1 M
Laboratory Evaluation
/ ?7 k; I7 U, q$ AThe bone age was consistent with 28 months by" f6 x/ W$ h; M6 O
using the standard of Greulich and Pyle at a chrono-6 x# i7 }5 T& n8 D" \" F
logic age of 16 months (advanced).5 Chromosomal
# v9 q5 E/ V' }9 r- okaryotype was 46XY. The thyroid function test
; d8 }/ T6 |! z5 z6 J' Y, _: O- C. \showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 ^$ Y; e |, r5 ^' I' Q9 j
lating hormone level was 1.3 µIU/mL (both normal).: F/ u+ U2 A' x2 L3 v* e
The concentrations of serum electrolytes, blood
: ~. }- u5 R: R# xurea nitrogen, creatinine, and calcium all were: j2 C( {5 ~5 h% l7 @9 r1 |8 ?
within normal range for his age. The concentration
* X v- i0 o- cof serum 17-hydroxyprogesterone was 16 ng/dL6 n. w0 s) W# A, }) }0 _
(normal, 3 to 90 ng/dL), androstenedione was 205 i9 K) m* _. m( _# l7 ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 C5 k& y$ v$ o+ @: H$ b* }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ y2 A6 k: [3 d4 P9 U1 R3 m0 }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 L% l0 d2 n2 q. L49ng/dL), 11-desoxycortisol (specific compound S)
. }. _' R+ }6 X: Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 ^4 W$ z I- U7 ~2 Z% a7 }( g1 t7 E9 i/ stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ G* }9 Y' Y' A& E, `3 ?6 C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ E( Y. R1 X' t7 \
and β-human chorionic gonadotropin was less than2 g+ O' t5 Q5 o6 C" t, b0 G
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" j9 i' q+ r* L+ U- q; e. m: nstimulating hormone and leuteinizing hormone3 V6 p6 {1 K2 {1 R4 v
concentrations were less than 0.05 mIU/mL
$ X" ~2 N' [5 X" X+ k$ Z+ o' ?(prepubertal).' ?) C) x7 c1 b, d/ {2 q5 E8 q
The parents were notified about the laboratory/ F f& {$ n) R9 \+ M2 [/ w, c( j9 ~% E' b
results and were informed that all of the tests were
0 ?9 N/ x+ _5 f: dnormal except the testosterone level was high. The
) k8 a4 ?& m' h) kfollow-up visit was arranged within a few weeks to
3 Z5 H! e( A- q+ Pobtain testicular and abdominal sonograms; how-+ C& ]8 g* h+ l. q: M. B$ G
ever, the family did not return for 4 months.
& ^5 u/ s, p& E6 h4 V3 dPhysical examination at this time revealed that the
1 T; m) `* T: y: {/ y/ Schild had grown 2.5 cm in 4 months and had gained7 }9 F0 }3 _- V
2 kg of weight. Physical examination remained1 N F- O4 p. _& l& u8 Z2 v- H
unchanged. Surprisingly, the pubic hair almost com-
, C5 U" B4 Y7 ?4 H* H8 ?/ A9 m' `pletely disappeared except for a few vellous hairs at
, q: f5 n+ f7 [" `! Uthe base of the phallus. Testicular volume was still 2
# }% V. W. \4 N4 Q! d4 g) ]! g4 GmL, and the size of the penis remained unchanged.+ F7 C% ^7 A& `. V! ~& Z6 I4 |7 \
The mother also said that the boy was no longer hav-
+ m9 Q$ M4 `. N( [1 \9 d" V2 ~6 ]. Bing frequent erections.
. k6 _% N# H5 K4 m) CBoth parents were again questioned about use of, V( u% E8 x! V1 A
any ointment/creams that they may have applied to1 G6 I8 w% H" k m7 L9 o
the child’s skin. This time the father admitted the
4 L! F" \- ~' |- \Topical Testosterone Exposure / Bhowmick et al 541
$ t9 O' P" h9 G" Fuse of testosterone gel twice daily that he was apply-( \5 O6 N) b5 o* K. _7 U
ing over his own shoulders, chest, and back area for5 n& v4 g* `+ i9 {' \! w$ L
a year. The father also revealed he was embarrassed/ X$ ~ O+ Z9 o$ ]" |5 {
to disclose that he was using a testosterone gel pre-
0 {- H: X( C# `$ _! R& Y! n" Bscribed by his family physician for decreased libido
& r8 |( m$ O3 R# f- |& @, Jsecondary to depression.
5 n( A' Y/ p% m. ~The child slept in the same bed with parents.
1 y! H0 s4 {& X/ A$ rThe father would hug the baby and hold him on his
+ K6 D4 b7 z. w6 m0 D: Mchest for a considerable period of time, causing sig-
/ e" w( z# g0 ^, c7 w0 z' w& Onificant bare skin contact between baby and father.
9 J" ~, d: f V V0 uThe father also admitted that after the phone call,
& J/ `: Q) g0 P# u9 F; V* [when he learned the testosterone level in the baby
: [" w0 u+ h ~) ^3 V7 v+ h8 rwas high, he then read the product information3 z. L- r2 ?1 G, _ l% R8 o0 Y* x
packet and concluded that it was most likely the rea-
7 B; Y- o! b; d( g) z" s) Oson for the child’s virilization. At that time, they
/ f5 m5 I6 V2 {% \ k- Jdecided to put the baby in a separate bed, and the9 i3 |* i0 t) g/ m) H4 {
father was not hugging him with bare skin and had
3 ]8 R* _3 Y9 \: D# e9 n# ]! Bbeen using protective clothing. A repeat testosterone
5 k5 r) v% Q: stest was ordered, but the family did not go to the! Z: n* w& x' e: `* E8 d1 h9 Y
laboratory to obtain the test., C- H* p% \& @& |9 b4 `( D
Discussion P: ~- ?9 B h& h( k" ~
Precocious puberty in boys is defined as secondary0 \& b' [7 [7 K. ?/ ]. s
sexual development before 9 years of age.1,41 y/ ], v7 y3 _' C2 b- i3 z
Precocious puberty is termed as central (true) when
: t* n5 {; ~0 P; V& fit is caused by the premature activation of hypo-9 `5 Q' e9 M5 r. e
thalamic pituitary gonadal axis. CPP is more com-2 d2 {/ R- ^7 l9 D3 q
mon in girls than in boys.1,3 Most boys with CPP
, `8 P+ J: J5 imay have a central nervous system lesion that is0 u, ?9 f& B, O; e+ K: R
responsible for the early activation of the hypothal-
) o" ~! k) j [amic pituitary gonadal axis.1-3 Thus, greater empha-& {& R4 |( [4 X; P3 V
sis has been given to neuroradiologic imaging in
4 {' U" O5 O# B" w( iboys with precocious puberty. In addition to viril-
0 V# q- ? Y6 x: bization, the clinical hallmark of CPP is the symmet-
8 G5 K& c3 L' r9 Y3 k; G& V7 brical testicular growth secondary to stimulation by
/ |) ]5 J+ l) u. X) w# ^8 |gonadotropins.1,38 l! L! I$ A% @5 a9 b% I
Gonadotropin-independent peripheral preco-
0 Y, @) f5 H. M5 D% M1 lcious puberty in boys also results from inappropriate% d- X- g8 a; L$ g8 H# P
androgenic stimulation from either endogenous or
0 D9 f( f% h2 s9 Z) sexogenous sources, nonpituitary gonadotropin stim-6 J5 F. |) B: c' [* V% J6 {; C
ulation, and rare activating mutations.3 Virilizing' b8 N" p$ `- C# N L# f- [
congenital adrenal hyperplasia producing excessive6 L D: Y, |5 O9 O' V
adrenal androgens is a common cause of precocious5 Z0 ]& r: C: q& w) W
puberty in boys.3,4
' d! V% u$ b6 z/ Y, K5 nThe most common form of congenital adrenal5 `% V% @ ~3 r4 s+ o4 ^/ _: l
hyperplasia is the 21-hydroxylase enzyme deficiency." s# F' `8 p& l2 u- e
The 11-β hydroxylase deficiency may also result in
7 e* Y/ F4 w9 y3 Hexcessive adrenal androgen production, and rarely,& R7 I) O, M, _. b- {9 |
an adrenal tumor may also cause adrenal androgen
5 U1 R7 q; n# s3 Fexcess.1,3
( A% j4 x) @& O0 O ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 s; D" V1 \% P' n* ~542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 R, [2 E, B( N2 Z6 G
A unique entity of male-limited gonadotropin-
& |3 f8 S& Y2 v2 Dindependent precocious puberty, which is also known
2 }: m3 b, U' b* J2 k$ u$ k. sas testotoxicosis, may cause precocious puberty at a2 }( [$ W% r) H7 |+ X0 h
very young age. The physical findings in these boys
9 }/ e; H$ l5 n# qwith this disorder are full pubertal development,$ \2 {" g& d" M- Z/ ~/ J
including bilateral testicular growth, similar to boys/ J2 I+ \: w5 l' A1 [7 F
with CPP. The gonadotropin levels in this disorder3 x2 f8 {6 ~$ w+ Y! E5 @8 `5 _, F
are suppressed to prepubertal levels and do not show* `. U( u7 j4 G9 i8 O
pubertal response of gonadotropin after gonadotropin-# ^5 `( x1 `6 ~* _
releasing hormone stimulation. This is a sex-linked6 Z! Q9 S9 Q( H! s) z3 e6 K
autosomal dominant disorder that affects only: {) ]5 Q \6 z2 h* Q! T
males; therefore, other male members of the family
) j6 v3 y' _6 }7 V; l3 Qmay have similar precocious puberty.3
1 G0 _/ U0 G' X* f+ @6 cIn our patient, physical examination was incon-6 `- ~. J c. Z/ ~. ~3 V
sistent with true precocious puberty since his testi-
1 u& S# C3 ?0 A b$ Jcles were prepubertal in size. However, testotoxicosis, @5 d0 `0 R% v5 |, M2 W
was in the differential diagnosis because his father
8 H/ I; A/ E! p7 ~0 {started puberty somewhat early, and occasionally,7 X/ g7 Q: k) c8 W' s' F
testicular enlargement is not that evident in the: u/ u, ~6 m5 u
beginning of this process.1 In the absence of a neg-1 \% K i0 i% e: K- S/ N
ative initial history of androgen exposure, our
5 f: {8 v |2 I+ L* M# _0 wbiggest concern was virilizing adrenal hyperplasia,$ F$ |' |, u) g8 s0 m
either 21-hydroxylase deficiency or 11-β hydroxylase( k7 V {; v* p( V4 y
deficiency. Those diagnoses were excluded by find-" _2 M1 x& l8 |5 y/ f' K) `
ing the normal level of adrenal steroids.
/ N' E1 n! H8 a4 w ^3 ^The diagnosis of exogenous androgens was strongly( s' L9 i( ]5 z& j9 L7 R7 { h
suspected in a follow-up visit after 4 months because" \7 O" W7 U, i. I
the physical examination revealed the complete disap-
) D& y, ~- X0 R7 |8 B3 D' cpearance of pubic hair, normal growth velocity, and
6 B2 h$ Y' m0 K2 E" M& fdecreased erections. The father admitted using a testos-/ i) ]; c |- c
terone gel, which he concealed at first visit. He was
8 R+ ^' P: r- `( V9 Y1 f$ P5 Kusing it rather frequently, twice a day. The Physicians’
! u2 P ^8 h7 A$ r% L' k) BDesk Reference, or package insert of this product, gel or! d- s) x+ ?* ^8 J5 c2 e( y: F
cream, cautions about dermal testosterone transfer to C1 s( w$ v/ B
unprotected females through direct skin exposure.. ?2 y9 q6 S$ C$ \7 L' K
Serum testosterone level was found to be 2 times the
! P) y2 M$ o0 y" V# n) Ubaseline value in those females who were exposed to" `: [. l8 X4 d; r- D5 f
even 15 minutes of direct skin contact with their male1 Y- g: u- i1 }# N; Y( ?& |1 Z% j
partners.6 However, when a shirt covered the applica-4 z( ^: N1 }+ C& F8 f: N
tion site, this testosterone transfer was prevented.4 F! w1 d, j, W2 p- ?
Our patient’s testosterone level was 60 ng/mL,
" d# g, E: s' _% T6 H% Xwhich was clearly high. Some studies suggest that
# |1 ]. z7 l. b5 U' C$ gdermal conversion of testosterone to dihydrotestos-, @& p3 T Y6 s7 k/ A
terone, which is a more potent metabolite, is more0 f7 i4 A" W# j% Y( }# G
active in young children exposed to testosterone2 n8 O. [+ }+ B- P4 N* p
exogenously7; however, we did not measure a dihy-' C9 s% F2 b* G6 S. ^8 D
drotestosterone level in our patient. In addition to
; l' e5 h! k1 D5 s8 Jvirilization, exposure to exogenous testosterone in6 a$ \% e! [+ C' ]* M
children results in an increase in growth velocity and
$ n v6 I/ Y' E7 g7 }advanced bone age, as seen in our patient.
& S* }: d+ c* _* m' oThe long-term effect of androgen exposure during' k9 S/ F; P& R
early childhood on pubertal development and final' j7 F3 V; [2 k& `
adult height are not fully known and always remain6 O+ O$ E4 y8 E$ y
a concern. Children treated with short-term testos-3 R/ R; i! W9 D, t, j
terone injection or topical androgen may exhibit some
* m0 K. T/ V! ` g! }acceleration of the skeletal maturation; however, after! U' K L- N4 E* v1 o
cessation of treatment, the rate of bone maturation$ j6 ?# v6 L3 t1 _9 u7 u' b
decelerates and gradually returns to normal.8,9% u# y+ R3 v; d
There are conflicting reports and controversy
1 n, ~ N( U+ |+ ]) X4 Qover the effect of early androgen exposure on adult1 U# c3 z7 t- u/ u" z
penile length.10,11 Some reports suggest subnormal
) e, f6 s: ~. R4 Qadult penile length, apparently because of downreg-/ A8 G5 f) J) a9 R, w1 I
ulation of androgen receptor number.10,12 However,3 d y3 L, k; P* c
Sutherland et al13 did not find a correlation between
5 W# M: ~ d) _ R! ~$ b1 H! G5 Ochildhood testosterone exposure and reduced adult
- o' G, I; Q Q7 m; v6 a2 `penile length in clinical studies.
' J0 h5 l/ {' m* z# LNonetheless, we do not believe our patient is
: ^! F3 N' v$ K$ |- Ygoing to experience any of the untoward effects from: x5 @$ t" E% G) U5 h+ r; w: q
testosterone exposure as mentioned earlier because
) ~6 Q( i. D0 rthe exposure was not for a prolonged period of time.* F9 o) ]1 i3 L2 D3 y5 h
Although the bone age was advanced at the time of
8 r; A$ k5 O/ W5 ldiagnosis, the child had a normal growth velocity at
$ x7 z4 k1 u2 r0 g, vthe follow-up visit. It is hoped that his final adult
5 |% W5 s. @' E+ o( E, H: lheight will not be affected.
8 L) O5 W# R$ J/ X$ q# QAlthough rarely reported, the widespread avail-
7 A7 _/ U! G9 L4 X4 e3 N- m' R. g2 v, r# {ability of androgen products in our society may
5 k S: Z5 i' o- S( F) a. oindeed cause more virilization in male or female( D! |+ ~0 c$ ?1 a% d' t" ?- i
children than one would realize. Exposure to andro-
$ x+ U! Y+ _0 o$ Vgen products must be considered and specific ques-
2 T; l$ g0 \" }tioning about the use of a testosterone product or6 g" H' @" p$ B0 p' o, Q1 g
gel should be asked of the family members during$ H) F1 k' ]6 y$ C
the evaluation of any children who present with vir-
& \: H5 y0 o5 p. M+ t7 Wilization or peripheral precocious puberty. The diag-) r' t1 B! A6 a2 r5 W% U
nosis can be established by just a few tests and by
4 [" r* ?( d3 ?appropriate history. The inability to obtain such a
- m$ X- H4 {+ @# Xhistory, or failure to ask the specific questions, may4 [' I2 w3 |7 M" A5 s; v
result in extensive, unnecessary, and expensive* [/ u; X9 N8 c# v. | u$ H
investigation. The primary care physician should be
5 D! G8 S& D2 ~! Waware of this fact, because most of these children
8 ^0 ?8 h2 B5 p3 R ]5 dmay initially present in their practice. The Physicians’
' F- S% H, F7 [; p8 l1 BDesk Reference and package insert should also put a
2 P5 V$ e0 ~ a; d4 X% dwarning about the virilizing effect on a male or
. f. {; u4 l1 ~female child who might come in contact with some-
9 x5 W4 t9 k/ W% S+ P. Qone using any of these products.4 o8 R. @/ P" a2 z
References# w% [, {" n# U8 b
1. Styne DM. The testes: disorder of sexual differentiation
3 N1 I1 ?4 e: k1 N! `and puberty in the male. In: Sperling MA, ed. Pediatric" N. b3 p. H- { G- e. i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! Q. d9 n0 D* ?! a0 ^2002: 565-628.- F$ B" s6 t: Y. K$ H
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# X9 G+ {0 ]. d6 O- vpuberty in children with tumours of the suprasellar pineal |
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