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Sexual Precocity in a 16-Month-Old r3 _) B; s2 z* f+ P+ h, n
Boy Induced by Indirect Topical
. {. o5 z4 F0 G* I3 x: yExposure to Testosterone
1 c9 O* T6 d# iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: g" ^0 C- \+ D% L
and Kenneth R. Rettig, MD13 l8 J' ]) L+ E
Clinical Pediatrics) C/ y9 x @) N' I- ]+ r
Volume 46 Number 6
) [; J! W" V% u D0 K8 E& cJuly 2007 540-543/ U8 t; n( O- t+ B/ D) W
© 2007 Sage Publications/ D& v7 s4 |1 A# m9 F
10.1177/0009922806296651
6 U8 C- E, D: k% [9 X, f* n7 ]http://clp.sagepub.com
d! ?) C+ j Z5 P6 p+ Zhosted at. r1 e; M* r& J0 N* E8 V5 [& X- \2 E! ?
http://online.sagepub.com$ y7 d0 J; W$ B3 X# B
Precocious puberty in boys, central or peripheral,9 L; Q3 V6 k+ w& c
is a significant concern for physicians. Central
& k9 f K. }. E( y; O3 O+ Bprecocious puberty (CPP), which is mediated
7 j8 C( F+ A- g* `5 O; D0 jthrough the hypothalamic pituitary gonadal axis, has9 J2 \: R0 W$ z3 m
a higher incidence of organic central nervous system
) C/ R: l& s$ z# r$ B( X. I, Xlesions in boys.1,2 Virilization in boys, as manifested
' ~2 f/ D3 y. F5 a Y9 eby enlargement of the penis, development of pubic
; b# c# p3 z! O4 u0 xhair, and facial acne without enlargement of testi-! S: i! L; A! T8 R
cles, suggests peripheral or pseudopuberty.1-3 We
8 Q( Z5 j" [: D( H( areport a 16-month-old boy who presented with the' x& K4 t3 `, U
enlargement of the phallus and pubic hair develop-) O+ E! e5 N6 M; N
ment without testicular enlargement, which was due7 X0 d( f5 d) C
to the unintentional exposure to androgen gel used by
+ u8 ?2 Q* m& V8 z: T/ ^the father. The family initially concealed this infor-
# e" G2 r9 f7 a" v& n5 `3 _, V9 u' m xmation, resulting in an extensive work-up for this
9 I' z! {$ [& w, Cchild. Given the widespread and easy availability of) s6 \% G2 d$ W$ N5 Y
testosterone gel and cream, we believe this is proba-7 f$ F" m: E5 U3 C# I/ S
bly more common than the rare case report in the
0 S" j8 ^( f$ i3 T- O' ?; `6 J2 ^- Iliterature.4
P# H/ b" u1 W' O; X4 x3 u( s7 {Patient Report( |4 u+ M5 Y' K& @! N: ^0 X2 ]
A 16-month-old white child was referred to the
/ m0 R U0 ]; i5 Dendocrine clinic by his pediatrician with the concern
& }+ k- r- `) xof early sexual development. His mother noticed
) b- Q+ u* g2 h- Nlight colored pubic hair development when he was, J+ D t) u; o8 g% A$ @ l
From the 1Division of Pediatric Endocrinology, 2University of
: I, k* n) W2 p' G% GSouth Alabama Medical Center, Mobile, Alabama.
$ y9 |5 v& P* w: C0 P# {. ?# HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, z, {" Z2 N X6 uProfessor of Pediatrics, University of South Alabama, College of
% D; m0 Z3 F6 kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; W' o- j# c' |6 u: b, C
e-mail: [email protected].
9 e n. Q" m, x( @7 E tabout 6 to 7 months old, which progressively became
; w% _0 {! q& g8 r& Z" o' ddarker. She was also concerned about the enlarge-4 L- L7 T- C8 L" M3 d, F! @: q: C
ment of his penis and frequent erections. The child, L5 S8 O& E9 W! ]" d( G# N
was the product of a full-term normal delivery, with
1 R' f6 W$ ]( s$ H! y* o6 ^2 Za birth weight of 7 lb 14 oz, and birth length of" Q4 l- q8 r; e" _5 l
20 inches. He was breast-fed throughout the first year+ `" J, s/ R+ X1 }% H0 Y
of life and was still receiving breast milk along with
- l7 h9 ?% e! X/ lsolid food. He had no hospitalizations or surgery,+ ?$ e& b! X. _4 G9 k) M0 ~0 x
and his psychosocial and psychomotor development% b; ]6 C# l, ~9 Y* M0 a* ~
was age appropriate.
" |+ D. j6 Y. C* I% k. n) UThe family history was remarkable for the father,- w4 h5 m) H: f" ^ a8 O
who was diagnosed with hypothyroidism at age 16,
" Y, n$ C+ I" a: V+ qwhich was treated with thyroxine. The father’s0 K5 ?, M l' g2 |
height was 6 feet, and he went through a somewhat: b5 B3 A( ^5 |+ p3 A x3 [, c# Z
early puberty and had stopped growing by age 14.; G1 ~/ r9 E# `
The father denied taking any other medication. The* x! d* R! m2 h( @
child’s mother was in good health. Her menarche
% D3 u5 `9 e/ P& {7 F! t/ Rwas at 11 years of age, and her height was at 5 feet
- k& P/ Y, S; u% `& r* [1 ?5 inches. There was no other family history of pre-$ l: j3 }( z, b' @2 X
cocious sexual development in the first-degree rela-+ T/ E, d5 \7 @5 y
tives. There were no siblings. Z" ^5 Y5 p$ u+ ]
Physical Examination! p" Q0 O" U" {2 R# f, x
The physical examination revealed a very active,
- L( }2 p* w v5 L: _; wplayful, and healthy boy. The vital signs documented0 Y0 _/ f- v+ a8 k5 e0 [) H
a blood pressure of 85/50 mm Hg, his length was
1 S% v- ^2 d, \; v& `( L8 I90 cm (>97th percentile), and his weight was 14.4 kg& b9 ]6 R) I W: n: T4 f2 V# F
(also >97th percentile). The observed yearly growth7 ^; [( v( x% b' O& c( V
velocity was 30 cm (12 inches). The examination of. V# n* ?7 N% n/ \- Y8 l
the neck revealed no thyroid enlargement.& m( o( \! V% q/ w+ w+ d: {
The genitourinary examination was remarkable for
0 ?, ]+ }3 G- }, v' Kenlargement of the penis, with a stretched length of
0 D% r0 v- p" S0 @( R& m8 cm and a width of 2 cm. The glans penis was very well
' r) z2 x* u7 y7 x( M6 {developed. The pubic hair was Tanner II, mostly around
/ a/ v/ x9 r. G: I% y& x' s7 A540$ \, ]6 N! O1 O* a7 d& J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% |- _, ^7 @9 S, e; ^3 ~+ uthe base of the phallus and was dark and curled. The L( v2 u2 U' o' X4 A3 N
testicular volume was prepubertal at 2 mL each.
$ G t- W6 b; K% P2 I% o5 UThe skin was moist and smooth and somewhat7 T- x9 t$ F4 U: J7 k& {
oily. No axillary hair was noted. There were no
1 @* c7 j! j& E3 b6 k6 j `5 b a6 Aabnormal skin pigmentations or café-au-lait spots.9 z6 x( y& p* @* ~
Neurologic evaluation showed deep tendon reflex 2+
$ T4 W0 `1 r$ a7 }' ~. k" u8 Mbilateral and symmetrical. There was no suggestion
/ `6 R/ {7 y" {, [: f' t7 C# lof papilledema.
+ I& {1 C* p. s1 j& j2 w5 K2 l" @Laboratory Evaluation
5 A6 |% P0 z) X5 y+ \The bone age was consistent with 28 months by
/ l* E6 P9 |* f! Z+ }7 ausing the standard of Greulich and Pyle at a chrono-# o' b Q. P3 X. x% M n0 {% |
logic age of 16 months (advanced).5 Chromosomal! M! o Z5 L3 d# Z" S+ I) d( r
karyotype was 46XY. The thyroid function test0 n) K$ R3 {& h3 t2 g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( U1 t/ M7 z4 {1 Q2 a! }1 E( X+ M
lating hormone level was 1.3 µIU/mL (both normal).
. g. g' \2 l5 W( E0 oThe concentrations of serum electrolytes, blood& x/ B$ P- h9 h( b3 f/ q* H6 j
urea nitrogen, creatinine, and calcium all were
9 g7 q. V1 h: Awithin normal range for his age. The concentration% \# O! C# ~. f, k
of serum 17-hydroxyprogesterone was 16 ng/dL4 ]3 Z$ B5 T1 Z) d" T: H
(normal, 3 to 90 ng/dL), androstenedione was 20
3 {% y. Z/ j7 @1 A& i6 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 E4 a3 T1 e# h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ ?1 l$ j# { r* p1 ~' Hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to% \. F$ A( X+ T+ r: n, Y2 q6 C; r
49ng/dL), 11-desoxycortisol (specific compound S)7 B, J+ D/ a, e w% U3 p: w- T
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) Q7 E5 t, S/ w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, E' t8 ]! K4 t/ [, R+ B3 H7 }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 _' T* J$ S& h& d* I% H( h7 P
and β-human chorionic gonadotropin was less than
- M! u; g0 r+ O" t% ~6 z' q5 @5 mIU/mL (normal <5 mIU/mL). Serum follicular* [8 l2 V: X G4 @
stimulating hormone and leuteinizing hormone
. o- y( y3 r- D1 ?. Aconcentrations were less than 0.05 mIU/mL6 W9 T' W' Y* Y+ v& g2 c- O
(prepubertal).. d0 H& ]- J/ H. I4 l
The parents were notified about the laboratory, M. f) ^/ G: p" W
results and were informed that all of the tests were6 e* w3 i! @) a6 v6 T: b6 `. q
normal except the testosterone level was high. The3 g" d/ t" l& F7 x2 X: Z
follow-up visit was arranged within a few weeks to% A6 U' w0 k0 V& x7 |8 V* R9 y
obtain testicular and abdominal sonograms; how-8 u! r( z$ Q4 z5 q" L; T
ever, the family did not return for 4 months.
1 s9 w" a0 V5 @3 j# @% gPhysical examination at this time revealed that the
3 p i1 I- g1 _! ?% Pchild had grown 2.5 cm in 4 months and had gained
0 c, o2 i7 G- M' S1 d! N( P2 kg of weight. Physical examination remained
% l" R) x) f" [' Tunchanged. Surprisingly, the pubic hair almost com-
' ]: n4 q* F' ?/ Q* Qpletely disappeared except for a few vellous hairs at
& G0 U0 T/ v4 Z7 b& N# ~6 ^) fthe base of the phallus. Testicular volume was still 2
- O3 v7 H4 e9 `; ~' U ~mL, and the size of the penis remained unchanged.' g# p7 [3 |7 ^8 a
The mother also said that the boy was no longer hav-
( ^. e k: p4 Q# s2 Ning frequent erections.6 M& U$ }3 ~( b. t/ S/ p t1 u3 O
Both parents were again questioned about use of! g' q; j0 R2 k' Q" s* j/ Y# q
any ointment/creams that they may have applied to4 g* n2 b5 k! C3 c8 [! q$ r. j# {
the child’s skin. This time the father admitted the( T& R; G) V! G& H
Topical Testosterone Exposure / Bhowmick et al 5412 D- E( i. D/ V( T% A& r; D n
use of testosterone gel twice daily that he was apply-
; y" b4 _9 S% j+ q! Xing over his own shoulders, chest, and back area for
; X0 |$ H0 k% r0 {* Aa year. The father also revealed he was embarrassed
; E7 t, O! b }" Pto disclose that he was using a testosterone gel pre-+ `3 w! g# U9 i& y2 D
scribed by his family physician for decreased libido
( q( {7 \: B+ a* B2 s( [, ]secondary to depression.
& n7 x3 u2 u: a+ d4 FThe child slept in the same bed with parents.
: N3 }& P& w) V% ~" }0 w% u0 \The father would hug the baby and hold him on his
2 x( k) O7 |! ychest for a considerable period of time, causing sig-; ?# E \) ^- s* E1 E( @
nificant bare skin contact between baby and father.
( Z0 M0 _( L$ m1 t! c' I7 | RThe father also admitted that after the phone call,
3 {! b- r/ x) [+ o/ Y2 Y2 x3 uwhen he learned the testosterone level in the baby
0 E, v! |% m8 R5 O/ d: rwas high, he then read the product information
& x2 |" ` u2 |9 G9 M' F& cpacket and concluded that it was most likely the rea-
8 n. @7 c# v( H- q1 lson for the child’s virilization. At that time, they1 W4 b. g+ ?3 `
decided to put the baby in a separate bed, and the8 q8 z6 y+ d- X# y+ |% F8 \
father was not hugging him with bare skin and had
* H I; W' q) T1 p( Y vbeen using protective clothing. A repeat testosterone2 v$ b) E2 l& l3 X1 A& _
test was ordered, but the family did not go to the
7 y0 W: c& y7 P2 E$ Jlaboratory to obtain the test.
# F: Z E1 e3 X3 LDiscussion
" U: a$ m3 u% p ePrecocious puberty in boys is defined as secondary
" X1 e- {( j) Z' H0 Y& X& usexual development before 9 years of age.1,4
9 e8 Q& h! n) C v' M2 q" ?: UPrecocious puberty is termed as central (true) when
) p9 e- Y3 J7 l( m }' p Fit is caused by the premature activation of hypo-4 P+ |, N3 |# _' V
thalamic pituitary gonadal axis. CPP is more com-5 l( a8 y! a s! z4 X3 N+ X
mon in girls than in boys.1,3 Most boys with CPP: C; s2 a1 n$ p8 W) F
may have a central nervous system lesion that is
& t4 v- y, v7 v' Gresponsible for the early activation of the hypothal-
8 [: [" T! e5 q/ vamic pituitary gonadal axis.1-3 Thus, greater empha-
$ \% }2 k/ r& h$ o# ~sis has been given to neuroradiologic imaging in
* s7 |, w- p5 h$ I& D' Oboys with precocious puberty. In addition to viril-" E9 _0 \8 ?# v$ ]( A' x& x
ization, the clinical hallmark of CPP is the symmet-
8 }3 K3 D3 Z4 ^* I0 arical testicular growth secondary to stimulation by
! x: K$ D+ ?' ]* _+ Q: R2 Y5 x# pgonadotropins.1,3
8 j/ l4 J/ T2 j7 X; ?) F5 yGonadotropin-independent peripheral preco-8 A( x2 L: L7 U- V5 L
cious puberty in boys also results from inappropriate
( c7 y4 I' j& H2 ?androgenic stimulation from either endogenous or9 W4 F2 x$ K V2 |- _0 O% O/ Q
exogenous sources, nonpituitary gonadotropin stim-) F& x) `# m. |6 f5 X
ulation, and rare activating mutations.3 Virilizing9 |% [ \8 f* L+ E) e+ `! P
congenital adrenal hyperplasia producing excessive7 t+ X" ?2 S2 P
adrenal androgens is a common cause of precocious
% s" z1 @ o% D1 U$ rpuberty in boys.3,4
# C' Z6 @( g0 \; ?" w7 y3 _ tThe most common form of congenital adrenal
, V, x5 D, g7 A4 x J) M2 j4 Z4 _hyperplasia is the 21-hydroxylase enzyme deficiency.. P) x6 P$ |6 m) h( |6 ?. p' }: t
The 11-β hydroxylase deficiency may also result in, a5 r/ U! W+ E" L
excessive adrenal androgen production, and rarely,
! Y4 K2 C/ a* p. }' V9 K6 `an adrenal tumor may also cause adrenal androgen) L1 Z0 L5 G1 N) x/ m) F
excess.1,3
2 `8 n1 o1 k4 b( C+ h4 H& dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& m) Y* Q7 H; m9 v7 C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& w- ?% r/ Y/ a0 q g( d/ u( i1 eA unique entity of male-limited gonadotropin-1 ^* i* S5 ?- ]$ Y G& L
independent precocious puberty, which is also known
; l" U3 Y7 e; p5 _& X: Tas testotoxicosis, may cause precocious puberty at a2 ?- e) c& v8 p' D: F: w9 ]
very young age. The physical findings in these boys
! Z! x* g, l: G) e* g" A* ~with this disorder are full pubertal development,0 {1 K; a& g) E; L7 ~
including bilateral testicular growth, similar to boys; \ Y. L. S1 s
with CPP. The gonadotropin levels in this disorder
( {" b. ?3 z$ d' E6 t S' hare suppressed to prepubertal levels and do not show$ T1 a I) l1 S
pubertal response of gonadotropin after gonadotropin-5 {! |7 k/ _3 W6 c5 ~9 h) K
releasing hormone stimulation. This is a sex-linked$ ~; }8 X" {; T' m
autosomal dominant disorder that affects only
. s6 B1 z+ s& G& P; y/ Umales; therefore, other male members of the family$ B6 R0 d! S% g3 p4 M5 A& v* T
may have similar precocious puberty.3
2 i+ A; @) p4 kIn our patient, physical examination was incon-
! P- F2 O& H" ]9 ^. t, u& L/ L! fsistent with true precocious puberty since his testi-0 s/ j1 _4 P& [; z& ^
cles were prepubertal in size. However, testotoxicosis
1 K. R8 U; n0 F$ j' C; _& M5 Swas in the differential diagnosis because his father
" c8 ?9 I& ] w3 F& M# dstarted puberty somewhat early, and occasionally,
9 z. V, h6 v! b/ \ i# m) {, j0 B8 Utesticular enlargement is not that evident in the
, p2 k; H! E" T o8 P: Q, qbeginning of this process.1 In the absence of a neg-# v; ^+ Y" [! B' [! }( y8 E
ative initial history of androgen exposure, our
% b* Z7 I1 `# K0 `$ X7 [5 K7 nbiggest concern was virilizing adrenal hyperplasia,6 @4 s: T2 i$ S+ K: w
either 21-hydroxylase deficiency or 11-β hydroxylase! B/ H4 R( w+ ?; y. U
deficiency. Those diagnoses were excluded by find-
1 @! v% }+ s3 Q' L2 ring the normal level of adrenal steroids.- z! O0 u; n" Z8 @
The diagnosis of exogenous androgens was strongly
( L. e: F5 v; q, asuspected in a follow-up visit after 4 months because, k6 x# i. G) Q( H
the physical examination revealed the complete disap-$ c" a" \8 y# x, h# Z
pearance of pubic hair, normal growth velocity, and
* U/ S5 o( n' c$ g3 f( ~decreased erections. The father admitted using a testos-
& A3 c, S" ]0 jterone gel, which he concealed at first visit. He was
4 d% p* e! {, A0 ?/ e/ jusing it rather frequently, twice a day. The Physicians’7 r0 Y* T/ h2 W+ P; g- k
Desk Reference, or package insert of this product, gel or( D: c$ Z. }9 H. R
cream, cautions about dermal testosterone transfer to
! z( ?: X2 }; s. Punprotected females through direct skin exposure.
$ R6 v, }# {6 c6 `. wSerum testosterone level was found to be 2 times the
$ X( a/ h# _/ e _6 u9 s2 Ebaseline value in those females who were exposed to
1 D/ L8 R7 D# X: ~3 M) @5 Heven 15 minutes of direct skin contact with their male
- j! e6 G; t; Xpartners.6 However, when a shirt covered the applica-
/ A9 o# q+ l( M1 o( h7 vtion site, this testosterone transfer was prevented.
& a/ b+ z* V5 l$ Z- l5 ^& }% D! i9 ~' oOur patient’s testosterone level was 60 ng/mL,$ J( T& |! \1 o) R4 u/ T
which was clearly high. Some studies suggest that
# C6 B5 M X5 G; c5 Cdermal conversion of testosterone to dihydrotestos-
& B; _' q6 f. T2 \terone, which is a more potent metabolite, is more' x* r8 F \1 g
active in young children exposed to testosterone, _ l+ b) N5 u8 O* n
exogenously7; however, we did not measure a dihy-/ `" U R& g' r: }) o
drotestosterone level in our patient. In addition to' {8 ?# p, j O1 y# _
virilization, exposure to exogenous testosterone in
2 V: L9 \+ B+ n+ K: q% Ochildren results in an increase in growth velocity and
4 i# k" u+ C8 _% Madvanced bone age, as seen in our patient.
6 Z* p1 r! c) [/ U' p+ xThe long-term effect of androgen exposure during
4 A2 ^2 G* T4 o- h! ^7 Cearly childhood on pubertal development and final; |$ B- o& c! b `
adult height are not fully known and always remain
( f, K! L3 W) k0 L7 r4 v1 Ia concern. Children treated with short-term testos-: L. u0 i, L+ s. s& [. ~8 Q
terone injection or topical androgen may exhibit some
. ^/ `+ W9 F) x% _' x7 Vacceleration of the skeletal maturation; however, after% H& ~! f# P$ s9 Q2 n5 @- K
cessation of treatment, the rate of bone maturation& C; N+ R, X" {4 [1 M, r- r
decelerates and gradually returns to normal.8,9
4 Z, D1 t& }1 k& AThere are conflicting reports and controversy4 t" e+ w1 b2 g
over the effect of early androgen exposure on adult
1 s G; j3 ~0 D3 y( E. Fpenile length.10,11 Some reports suggest subnormal& c7 w8 S) T Y! B& O4 C, R9 ~- O, k
adult penile length, apparently because of downreg-: J5 s; l( z, k6 Y \
ulation of androgen receptor number.10,12 However,7 ~7 }* G, S$ o3 J: Q# N+ a
Sutherland et al13 did not find a correlation between6 C# R: w1 j* I# b( W2 Y
childhood testosterone exposure and reduced adult. ]( x6 o1 R5 V8 U% O% ?
penile length in clinical studies.' n8 ^) Q6 s0 Y( S
Nonetheless, we do not believe our patient is
; y: {; ?2 k6 `+ v, zgoing to experience any of the untoward effects from2 N6 ?2 x6 ^& g& b
testosterone exposure as mentioned earlier because
1 Z: [2 u) f* D2 [the exposure was not for a prolonged period of time.9 W4 a7 E4 u! p7 J2 ~
Although the bone age was advanced at the time of
& P% u2 x% o+ X+ z; ldiagnosis, the child had a normal growth velocity at: H- K" i* h5 V- e, |2 ^8 G
the follow-up visit. It is hoped that his final adult( J' M V" T' W/ N3 K! E0 r, _
height will not be affected.% u- I: X c5 ?* C/ {! H
Although rarely reported, the widespread avail-; I k9 Y# _' O( o
ability of androgen products in our society may
2 z3 @( k7 o1 q+ S' qindeed cause more virilization in male or female) O7 K+ I# z, l' ]
children than one would realize. Exposure to andro-
5 R7 E- n, O' \gen products must be considered and specific ques-; P$ t9 z" z! F4 [8 P& i
tioning about the use of a testosterone product or
5 q; B! D/ w0 {! _2 c4 I) j9 tgel should be asked of the family members during- P6 b5 @) o! K6 c+ Q- i5 W
the evaluation of any children who present with vir-6 z! s( P5 C. c# s2 R' y3 a
ilization or peripheral precocious puberty. The diag-- K% p# R7 u4 ^5 Q2 r* D! y/ t
nosis can be established by just a few tests and by
. d! U$ q/ t3 jappropriate history. The inability to obtain such a) _# s4 o0 h. `# g V( f5 u- W
history, or failure to ask the specific questions, may) _# L c0 s7 w) h5 q5 w
result in extensive, unnecessary, and expensive
6 m. h8 m M$ Y7 ~2 H) i9 e) hinvestigation. The primary care physician should be) n; Z( K0 r7 `1 X
aware of this fact, because most of these children
0 D- W; x* n$ J3 Q5 g/ g% y# M& G& C3 Bmay initially present in their practice. The Physicians’
' G& C. ~; J8 X; ^Desk Reference and package insert should also put a( h# s" w) x" j1 P
warning about the virilizing effect on a male or
" l! P$ s$ u2 B9 w( [7 _female child who might come in contact with some-
0 M N% v- V" L7 P; h, Wone using any of these products./ n; {5 M) w" L6 O
References
5 \; O' X3 d1 }& f4 q' U1. Styne DM. The testes: disorder of sexual differentiation5 i& u9 h! M+ ~2 k, F: _3 R' J% N
and puberty in the male. In: Sperling MA, ed. Pediatric* ^/ z6 \; ~3 G. X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 v! ]: v5 ^# I2002: 565-628.
. d( Y, _* L9 `0 ~6 N1 O* M2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 E2 a, m, M; r* D2 M. _, z, R
puberty in children with tumours of the suprasellar pineal |
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