- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old8 a: `+ }) U1 D; |0 n; O0 x+ W
Boy Induced by Indirect Topical
( k1 k- q4 U4 t) s0 e2 RExposure to Testosterone+ L! Z4 R9 u) B( D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 { I5 E$ A6 c9 G4 E; \
and Kenneth R. Rettig, MD12 ~: k- |; _5 H/ _) l
Clinical Pediatrics" g) q* N# k- Q
Volume 46 Number 6% P/ g) |6 E1 M' j) }% Y2 J7 e
July 2007 540-543# f, C0 J0 s$ p7 P" L& F* m. d
© 2007 Sage Publications" w% G5 Z; r A+ J6 S9 q; E
10.1177/0009922806296651- Q7 j! \) e# M0 L& p
http://clp.sagepub.com3 k1 L6 K- y7 [
hosted at
8 u4 d7 ^* k$ }( j9 z: r, \http://online.sagepub.com
5 E. Z" S) N4 g4 kPrecocious puberty in boys, central or peripheral,# T2 d& S4 X; |
is a significant concern for physicians. Central _/ J: S' C6 N: B0 a6 n
precocious puberty (CPP), which is mediated( X8 w: H2 w- F: [( @
through the hypothalamic pituitary gonadal axis, has
. {! |! v1 w. ^" x H' |! V( L0 Aa higher incidence of organic central nervous system7 c0 p* I. b' c6 h7 V8 G
lesions in boys.1,2 Virilization in boys, as manifested- e" _) E5 q M) ?* H* R) |
by enlargement of the penis, development of pubic7 {/ [* c6 Q5 z* V9 f9 z
hair, and facial acne without enlargement of testi-) E2 N" N: \4 ^! `1 W/ I" G
cles, suggests peripheral or pseudopuberty.1-3 We" p) K2 ?8 g* A8 O' d% L
report a 16-month-old boy who presented with the, B1 e* g5 i7 e: ^
enlargement of the phallus and pubic hair develop-
' g* H+ b4 }; l+ `ment without testicular enlargement, which was due
7 Q( Q! j4 t$ S! [7 V" i1 g; Wto the unintentional exposure to androgen gel used by7 O7 X& q: v2 {
the father. The family initially concealed this infor-
6 d( s3 q% ?7 H0 V; q- p4 G' wmation, resulting in an extensive work-up for this m: t: H& n0 W9 c: e
child. Given the widespread and easy availability of
8 W+ H! j; m+ N- g7 a+ L7 f Mtestosterone gel and cream, we believe this is proba-
( S2 J: O+ P5 u& F, dbly more common than the rare case report in the3 i9 B% d7 o. z* I8 ]
literature.49 `. T" ]7 _9 p7 H0 U+ q5 q. \
Patient Report
. j/ E' |6 Y7 `% @. E$ V$ @) TA 16-month-old white child was referred to the
T6 e: Y" O% f/ }endocrine clinic by his pediatrician with the concern& d( a: n J" S }2 H
of early sexual development. His mother noticed; k% g& Z; U; h
light colored pubic hair development when he was
I. l) L3 y" C8 w$ q- JFrom the 1Division of Pediatric Endocrinology, 2University of9 Z+ i" O- G. A2 d7 d5 N
South Alabama Medical Center, Mobile, Alabama.
& o+ d. Z S0 |6 z* I3 z; w* zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
- _+ t, Q, @& g( E: m, w7 wProfessor of Pediatrics, University of South Alabama, College of
3 y7 \1 z T& Q, \ b2 P/ i% nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 i3 P' H. N' s+ c2 V, u. Ge-mail: [email protected].6 t- P: t9 I! X- D. P8 k+ e( @
about 6 to 7 months old, which progressively became
; a: f3 d2 P( m3 rdarker. She was also concerned about the enlarge-
5 D3 @, b5 ]/ Gment of his penis and frequent erections. The child
' [3 N' j& y6 R" S/ jwas the product of a full-term normal delivery, with
1 [3 K9 ~0 v: g J5 i' s2 Ia birth weight of 7 lb 14 oz, and birth length of
0 x7 \! n6 ~4 u& V9 Z) M' X6 a20 inches. He was breast-fed throughout the first year
5 `1 T! P$ G6 P) i5 {: q0 c; Lof life and was still receiving breast milk along with1 }1 w- b4 L& u( N
solid food. He had no hospitalizations or surgery,: o4 Q u% L, d- Y, w0 j
and his psychosocial and psychomotor development$ j. `5 E% U: Z0 i/ A6 y
was age appropriate.( G" y' N. ?. F1 }% M, X8 ?7 _
The family history was remarkable for the father,
) r3 W* ^& R- {8 ? y" jwho was diagnosed with hypothyroidism at age 16,; }: ?: y$ M; {
which was treated with thyroxine. The father’s
' E1 _$ s2 l( C, p, A; @height was 6 feet, and he went through a somewhat
, J! D0 R5 z/ y0 Pearly puberty and had stopped growing by age 14.5 }6 H* r$ j/ P8 z1 [+ V; h. [
The father denied taking any other medication. The8 m# o, Q) H7 d' `) k, J
child’s mother was in good health. Her menarche
2 h* ?* Q& @& a+ nwas at 11 years of age, and her height was at 5 feet) s4 r; m" \6 [. K" n- @' ^; K
5 inches. There was no other family history of pre-& ]& }4 t+ i" I. r6 z
cocious sexual development in the first-degree rela-$ X% E- S9 A% P9 `- g
tives. There were no siblings.3 R# i; N5 v$ ~
Physical Examination
. f% H* n; `% D8 RThe physical examination revealed a very active,7 f2 s4 b6 y0 c, j! B& Z/ s9 Q% i
playful, and healthy boy. The vital signs documented6 y3 Y( B# a. ?, ~& W# _7 J
a blood pressure of 85/50 mm Hg, his length was. Z8 u5 \6 J# {+ |, c3 X
90 cm (>97th percentile), and his weight was 14.4 kg
- p7 s+ `4 k, N7 l ^7 K(also >97th percentile). The observed yearly growth
) g8 ~6 ]2 h1 h# b9 \# n! R: qvelocity was 30 cm (12 inches). The examination of
; C: F6 G+ Y5 P& tthe neck revealed no thyroid enlargement.
& ?4 { h) ]( xThe genitourinary examination was remarkable for6 Z1 v; X. f; N9 M5 k! f$ F% d; o
enlargement of the penis, with a stretched length of3 v, P R) ?3 h: m! t% Z7 b" f
8 cm and a width of 2 cm. The glans penis was very well
9 D( v5 {) z& xdeveloped. The pubic hair was Tanner II, mostly around* k9 ? I: b1 \( `
540+ E% g+ e( D# p2 @3 V2 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# e# i; d+ E. n8 k1 K% C$ ~* zthe base of the phallus and was dark and curled. The
! z' u+ u: h. {& i- ?( Ltesticular volume was prepubertal at 2 mL each.
, b0 m8 G7 L2 U$ m JThe skin was moist and smooth and somewhat7 V. h' i: w/ `( r- o
oily. No axillary hair was noted. There were no8 `3 h6 e. _2 I2 F6 t! M, ?' ~
abnormal skin pigmentations or café-au-lait spots.
+ n# l) {9 o) n( ]9 M( |* CNeurologic evaluation showed deep tendon reflex 2+0 y4 _5 y: q, O( k% X6 ~
bilateral and symmetrical. There was no suggestion
$ W2 Y: E4 o3 k4 F2 y7 bof papilledema.
5 `3 ~4 F+ x1 Y2 l% M+ s/ _Laboratory Evaluation* F) W j M. q! @5 j4 f7 H
The bone age was consistent with 28 months by" `6 m9 u: D5 G; f
using the standard of Greulich and Pyle at a chrono-3 a: F t9 `: h: }
logic age of 16 months (advanced).5 Chromosomal
2 N7 \& J+ x, R/ G& S/ ykaryotype was 46XY. The thyroid function test' R' Y" ?. J, p x1 u
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ J, ~; I# _& @6 }8 N. c' b
lating hormone level was 1.3 µIU/mL (both normal).5 D- e' b2 u/ ?. ?
The concentrations of serum electrolytes, blood
0 _; f# @- f0 w6 D5 e/ F+ yurea nitrogen, creatinine, and calcium all were
: R1 |# b, T8 A# ^- H. @' uwithin normal range for his age. The concentration
: P) \1 T" C* yof serum 17-hydroxyprogesterone was 16 ng/dL- a' ]! m1 `2 T
(normal, 3 to 90 ng/dL), androstenedione was 20
% d/ A0 y& F" w% L' ^: `' Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 D& [* P4 b1 \/ C; Z) ~& `7 o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. `, z3 F" p y1 T: ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 {) O* X7 j% y/ ~& U% j: X3 _) j3 q
49ng/dL), 11-desoxycortisol (specific compound S)
8 i" ~9 i: ]% p% Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! B4 l9 F b7 ~* d6 i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ k" F$ Z0 Y. N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! Z( ^/ R3 U. _. j; Z% @+ dand β-human chorionic gonadotropin was less than
8 Z0 Q! {7 e5 X4 a- U5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 Y* D3 D. f2 D( y( Ostimulating hormone and leuteinizing hormone; ^, a' c) e7 `& W
concentrations were less than 0.05 mIU/mL
$ v1 {% M% G9 E(prepubertal).; W, {! B# K( o8 I: ]& Q4 U# y
The parents were notified about the laboratory
, j6 h8 ]* G3 j1 V; U4 `) G* cresults and were informed that all of the tests were3 d4 Y, S D+ F5 y/ b" b: L* m
normal except the testosterone level was high. The, A8 D: N7 ~, f' B% r' E
follow-up visit was arranged within a few weeks to
7 p' o. r0 E0 F. Gobtain testicular and abdominal sonograms; how-
5 q0 S- P) |% D& Pever, the family did not return for 4 months.$ N* s, E J1 q- Q/ B: ?, g
Physical examination at this time revealed that the% ^, Q6 \& q. Y4 ~
child had grown 2.5 cm in 4 months and had gained/ i4 E% | p2 A: ~2 D* c
2 kg of weight. Physical examination remained8 H; Y* q' G; R; k4 o* e; z% `
unchanged. Surprisingly, the pubic hair almost com-
: {0 ^/ W0 j* P8 r( \pletely disappeared except for a few vellous hairs at% C0 l8 a4 S k$ O/ S1 B0 }% G
the base of the phallus. Testicular volume was still 21 p, y# D+ R1 _$ u% \9 q7 |3 l( U
mL, and the size of the penis remained unchanged.
* B, N; z' ]& H' s. }The mother also said that the boy was no longer hav-; x) x3 N v6 E$ E7 M
ing frequent erections. a4 O, H+ w1 r6 C/ _' I
Both parents were again questioned about use of
5 z' j- |9 d9 J% D5 M Sany ointment/creams that they may have applied to
/ ] E1 U. I! s8 wthe child’s skin. This time the father admitted the
- _! x, c9 n t/ `9 j: \% yTopical Testosterone Exposure / Bhowmick et al 541
5 I& k) X* {; T& o6 Euse of testosterone gel twice daily that he was apply-( R+ V+ |* k. l0 A" P$ U) Y
ing over his own shoulders, chest, and back area for
8 u) L( X( `8 n, ], Q) ]a year. The father also revealed he was embarrassed& J1 _: Z: I% Q& L- m7 d4 N
to disclose that he was using a testosterone gel pre-+ L$ A! V3 I; @- P
scribed by his family physician for decreased libido& M+ k7 s& G( L& }3 D9 T# J
secondary to depression.+ V# n) }4 K. s( K
The child slept in the same bed with parents.
8 j8 ~9 F, A% f2 _ \' iThe father would hug the baby and hold him on his
; r9 v; ^: n- L" e& W4 H# b* `chest for a considerable period of time, causing sig-' U' [7 ~! \! y$ {8 i3 t; G+ f
nificant bare skin contact between baby and father.
5 }1 }6 V9 N/ K5 `; P5 l+ }The father also admitted that after the phone call,3 x6 }8 s; y" d- J' n6 d2 H
when he learned the testosterone level in the baby
8 ^- }1 }" g) w1 @' K2 Zwas high, he then read the product information" q! b7 F% s+ E+ i9 p
packet and concluded that it was most likely the rea-" K! a+ _# Q7 s% l: O
son for the child’s virilization. At that time, they
* F! f' Y! _) d& f% b& [( H) Mdecided to put the baby in a separate bed, and the3 F. t0 J! c& f2 R
father was not hugging him with bare skin and had
5 J; b6 g1 a. v( t) X# y, c3 F: hbeen using protective clothing. A repeat testosterone! ^3 Z2 x7 ^: _% F, d
test was ordered, but the family did not go to the# w8 L- l/ K/ x1 F7 P: v
laboratory to obtain the test.4 P9 ]) b. w, Y8 z4 F8 E
Discussion
- E2 J5 U7 C1 c! VPrecocious puberty in boys is defined as secondary
# y( X2 g6 [# {7 ?2 L' isexual development before 9 years of age.1,4! m% X: |, q. F! }) z
Precocious puberty is termed as central (true) when
# p* G4 }& e, |% G5 Z; P7 L6 F2 Rit is caused by the premature activation of hypo-
) T" r& Y: a3 Xthalamic pituitary gonadal axis. CPP is more com-- a' D' [9 g; p) M/ ]
mon in girls than in boys.1,3 Most boys with CPP+ m/ x* X) b1 z% a4 g# q8 ?
may have a central nervous system lesion that is" r% ]* n# d4 d9 S- v5 I
responsible for the early activation of the hypothal-
( m( X9 I& v# y' J) t/ q: A# pamic pituitary gonadal axis.1-3 Thus, greater empha-+ k4 N Z' M; Y% A: Y( k! U1 ]
sis has been given to neuroradiologic imaging in4 q" k4 e: k2 M. o) A! x
boys with precocious puberty. In addition to viril-' I. S1 W# l& f0 q9 R- S5 U
ization, the clinical hallmark of CPP is the symmet-
8 D0 O, j% t7 @( }: Orical testicular growth secondary to stimulation by& R! x& J" J, d5 b! E) s+ A
gonadotropins.1,3- I1 X+ u$ j/ j" Y! D- h7 C z
Gonadotropin-independent peripheral preco-
5 ?$ W1 }( ?+ {1 Rcious puberty in boys also results from inappropriate7 z9 ]7 `$ l' s
androgenic stimulation from either endogenous or6 ^4 ^6 W( n8 O; \! E
exogenous sources, nonpituitary gonadotropin stim-
- f4 }$ ?4 N6 \) Y2 rulation, and rare activating mutations.3 Virilizing
. l' u) O. \1 p) q5 _& A5 tcongenital adrenal hyperplasia producing excessive* q# X2 K6 G) `( z5 c: F' F/ o
adrenal androgens is a common cause of precocious
* i6 w0 {, i% j/ l2 _puberty in boys.3,4* J* W3 ^( u0 r% J
The most common form of congenital adrenal
, o A( B: R) z `* r! vhyperplasia is the 21-hydroxylase enzyme deficiency.
6 F9 @9 I6 i3 u6 O5 A2 @The 11-β hydroxylase deficiency may also result in
( t q; r* {: B' W3 p0 Zexcessive adrenal androgen production, and rarely,; O8 i6 g9 G1 e8 _ G6 Y) Q
an adrenal tumor may also cause adrenal androgen
& Z: @& i$ f% p. ~+ Jexcess.1,3
" I( X% ^" ^, Z: Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* `; f8 {' e! x7 d) ?7 P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ p2 D: [2 v* v: xA unique entity of male-limited gonadotropin-, D, N7 o8 l9 E3 |
independent precocious puberty, which is also known" q7 \6 w* \, e6 ?
as testotoxicosis, may cause precocious puberty at a( C/ ^" n* o, }: E
very young age. The physical findings in these boys X& [3 ~/ }+ n, T* l
with this disorder are full pubertal development,
] l3 X; u( D: C, bincluding bilateral testicular growth, similar to boys
# n4 g% p% D$ t: T% F( H! bwith CPP. The gonadotropin levels in this disorder
+ y8 x! Q, T* a' w% care suppressed to prepubertal levels and do not show, `9 [% R) S3 k8 X2 O
pubertal response of gonadotropin after gonadotropin-4 _9 V* l$ a" v7 X5 n( W
releasing hormone stimulation. This is a sex-linked" F+ q" X0 g5 r4 x7 ]- T
autosomal dominant disorder that affects only5 N' g0 G q; K( r X. C3 x
males; therefore, other male members of the family$ b- A3 k& O5 u
may have similar precocious puberty.35 \+ J# ]0 b1 `0 H6 ^% ~6 }; Y
In our patient, physical examination was incon-; h) g' I% e% J8 ^! g
sistent with true precocious puberty since his testi-. ]9 I1 s7 \7 B5 @
cles were prepubertal in size. However, testotoxicosis
; b$ L. G2 V3 C0 A7 L: E3 Qwas in the differential diagnosis because his father
6 g7 g2 D! B/ t' I5 e6 Vstarted puberty somewhat early, and occasionally,( Z9 {/ K- |7 f% i0 F. E8 [: K
testicular enlargement is not that evident in the+ u- N1 I% A" G: I3 [$ p
beginning of this process.1 In the absence of a neg-+ J/ x+ f, [" p( z8 l- C5 n
ative initial history of androgen exposure, our0 Q( d; [* o8 Z6 V: S0 |% Z V" v: l
biggest concern was virilizing adrenal hyperplasia,1 O0 }! M) d8 M3 N( z, }
either 21-hydroxylase deficiency or 11-β hydroxylase o" Q( Z O: L) f x4 ~# L8 R
deficiency. Those diagnoses were excluded by find-2 C1 B- w+ _: N F6 p3 o
ing the normal level of adrenal steroids.8 m6 z( i. e: X' T: G/ y: G
The diagnosis of exogenous androgens was strongly% i2 ~9 S& k5 r/ z) u8 b& o2 N
suspected in a follow-up visit after 4 months because; [1 a8 V5 S& H/ X% x, O$ R/ R1 [
the physical examination revealed the complete disap-, D2 A+ Y8 [% B: a4 y+ S
pearance of pubic hair, normal growth velocity, and
# U* n7 S( t2 f7 C5 q7 J, Edecreased erections. The father admitted using a testos-3 v8 F2 I8 x% W; ?3 M. f$ |& o
terone gel, which he concealed at first visit. He was
/ t4 j# p8 C, L f; Y% Nusing it rather frequently, twice a day. The Physicians’
1 z& C' |3 H; ]6 ]! `3 c, X; x8 t. t1 NDesk Reference, or package insert of this product, gel or% M/ {* a; f0 \
cream, cautions about dermal testosterone transfer to' h5 A; X4 i6 q4 z% M
unprotected females through direct skin exposure.
6 ^0 }6 N' a( k' C. X1 w3 rSerum testosterone level was found to be 2 times the
5 ]7 f2 O0 a' m. S/ F' Qbaseline value in those females who were exposed to8 b Q: r1 H7 V- J( o
even 15 minutes of direct skin contact with their male
4 a. u4 W; ^: \; J) G5 fpartners.6 However, when a shirt covered the applica-: ^3 l* R7 u2 }0 H- B' j* x
tion site, this testosterone transfer was prevented., n3 e& M0 V: k9 R
Our patient’s testosterone level was 60 ng/mL,
G5 K8 x- @: n8 awhich was clearly high. Some studies suggest that m" W! [5 W) P0 c) j9 K
dermal conversion of testosterone to dihydrotestos-
5 T5 p2 W( s: \& Fterone, which is a more potent metabolite, is more% J. w+ ~+ R i/ H. Z( V f
active in young children exposed to testosterone: C7 ` }$ A. a, V5 K
exogenously7; however, we did not measure a dihy-
( w/ v( l" h/ {; ?: ~drotestosterone level in our patient. In addition to
" \8 D, s' a" m' A: B t# Jvirilization, exposure to exogenous testosterone in7 \, @4 s* F2 J9 Q
children results in an increase in growth velocity and
. U K' R1 N9 ~, [! e- y ?3 E& ^advanced bone age, as seen in our patient.
# r% o2 A! z7 D. ^. ~' p) @/ I- XThe long-term effect of androgen exposure during' n: ^# l& b0 T+ W H9 {0 q
early childhood on pubertal development and final
& V. H% K, I8 D+ w% badult height are not fully known and always remain S6 F, T" O- J5 I: L2 }
a concern. Children treated with short-term testos-& z7 A8 X5 c% t" e+ K* Z; L
terone injection or topical androgen may exhibit some# i# N* U N/ Y' R9 g8 Y
acceleration of the skeletal maturation; however, after
+ H; `+ U. u8 l0 O: H; u scessation of treatment, the rate of bone maturation4 `9 \& L9 Y8 T7 B! g2 d
decelerates and gradually returns to normal.8,93 ^7 q) H6 g$ B1 }
There are conflicting reports and controversy
5 \: w4 Z! e4 G% |. ~3 T7 |- p; w- _over the effect of early androgen exposure on adult) ^5 v" g9 y( [
penile length.10,11 Some reports suggest subnormal
. G% r, `! ^+ G4 E& w# Vadult penile length, apparently because of downreg-
! E0 ?$ e7 }1 R) x# Z, Dulation of androgen receptor number.10,12 However,
% ?( q) G% F" P7 Y' @" \Sutherland et al13 did not find a correlation between: M: ]4 Q6 e$ c" |
childhood testosterone exposure and reduced adult2 a- A$ w. S& J; m; Q& p
penile length in clinical studies.0 |' Q+ e9 |; C
Nonetheless, we do not believe our patient is) R5 s2 _* I- y$ K. G, v
going to experience any of the untoward effects from
) c- `+ Y) H, @; O6 Ctestosterone exposure as mentioned earlier because$ n* \9 s) J1 \8 f
the exposure was not for a prolonged period of time.
; C: P$ v) \$ S8 t7 I- ~! @Although the bone age was advanced at the time of) v" a$ n6 f6 E3 Z
diagnosis, the child had a normal growth velocity at J9 [4 \! z' h3 h5 _
the follow-up visit. It is hoped that his final adult
5 J) U+ ~( y: cheight will not be affected.. H1 h' U% M+ ?9 |9 }, U+ ]& x
Although rarely reported, the widespread avail-; x, ~0 H9 E7 ^/ F* U
ability of androgen products in our society may
0 A @+ O. g1 Q8 hindeed cause more virilization in male or female
* y- q! o/ p1 x3 bchildren than one would realize. Exposure to andro-
0 W* v- B S7 M3 T0 o8 N) Ngen products must be considered and specific ques-
5 }9 ~, _) T/ ~( ptioning about the use of a testosterone product or
9 a& b6 E/ u7 ^7 n2 A& L# `gel should be asked of the family members during, R' z7 n- `6 t2 ^$ o
the evaluation of any children who present with vir-2 U) w/ r. F' U3 a
ilization or peripheral precocious puberty. The diag-+ G/ e/ y- h1 n! ^( ^' E0 Y3 q
nosis can be established by just a few tests and by0 P, L4 H8 g! ^% ^/ ]" q) K
appropriate history. The inability to obtain such a
- X3 f Q' p. x) A9 Bhistory, or failure to ask the specific questions, may, M0 ?. v$ U: X2 h0 ]7 b
result in extensive, unnecessary, and expensive
% m/ Q+ S1 [7 \$ R: r3 Hinvestigation. The primary care physician should be
/ O. }* p) ] ~; y2 i% |2 C( Iaware of this fact, because most of these children9 x9 C* O7 F5 G+ \) Z0 O/ H
may initially present in their practice. The Physicians’ B4 D4 K8 G3 p+ m' N# \
Desk Reference and package insert should also put a
; E' B ]; D4 o1 m' o! A! w: L& g; o6 Awarning about the virilizing effect on a male or- O. l; h- u0 D# {
female child who might come in contact with some-/ K! [1 W0 K' ~* S6 Z
one using any of these products.
2 A, ]4 a3 l6 e5 ?References
. L3 v3 T5 {9 `3 U: G) W7 \3 Y1. Styne DM. The testes: disorder of sexual differentiation& a/ W! e% K: y- e) d: `$ p9 Z
and puberty in the male. In: Sperling MA, ed. Pediatric
) G4 \: q* b1 YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 m2 P/ [7 U* M7 \2002: 565-628. b' U, f9 i+ V! p D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& O1 |* O2 T+ f/ h9 N2 a
puberty in children with tumours of the suprasellar pineal |
|