- 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 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old/ R, o. ^6 w' \6 Z% o
Boy Induced by Indirect Topical
+ b: b3 r# i4 Q5 j! P5 c7 k" dExposure to Testosterone
) R4 y7 D5 O; B+ ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! a6 Z% V' [- j: ]- G- x6 a, U
and Kenneth R. Rettig, MD1: D2 n9 f; B- C! `# U
Clinical Pediatrics% A$ X4 A5 Y# F3 x
Volume 46 Number 6
7 P- ~& q4 e; K; nJuly 2007 540-5438 |, V- u. Y1 x$ r$ z! Z
© 2007 Sage Publications. \& X' y: ^1 P" H
10.1177/0009922806296651; W; a4 E0 M9 J j* R
http://clp.sagepub.com
3 m/ c- G4 v0 F5 phosted at
, G: B5 g) C7 ~* l9 e( W, w5 d }http://online.sagepub.com& I$ o9 @" H* T+ }" ^
Precocious puberty in boys, central or peripheral,
V2 H7 A; `! `( C$ X# G0 P3 [! ^- Bis a significant concern for physicians. Central
) I& J( n* z9 |, P6 {precocious puberty (CPP), which is mediated& c# {5 w1 `1 M7 V. d R; H
through the hypothalamic pituitary gonadal axis, has; W5 N: f8 x+ n) V, k8 F% s
a higher incidence of organic central nervous system. n/ P% c1 \9 d; N; \$ _4 ^
lesions in boys.1,2 Virilization in boys, as manifested
, ^1 j: c; M/ Y' v4 cby enlargement of the penis, development of pubic& a3 `" S8 ]! I/ \: I
hair, and facial acne without enlargement of testi-
H! \; a# N, Z& y, ?cles, suggests peripheral or pseudopuberty.1-3 We8 D( ]! X ?" ~ ^6 W
report a 16-month-old boy who presented with the
+ a7 k9 ?7 _7 ?/ c8 genlargement of the phallus and pubic hair develop-
0 m: E# W2 |& S" _# z) Cment without testicular enlargement, which was due& D' p# `4 W# l3 _# K& L
to the unintentional exposure to androgen gel used by
! w5 r/ x! s- bthe father. The family initially concealed this infor-
# v8 \! ]5 E _2 [ Imation, resulting in an extensive work-up for this
4 {# n i. n& p$ y0 r9 r( {' Wchild. Given the widespread and easy availability of
! C* g! B) }& T3 W/ H. z! ptestosterone gel and cream, we believe this is proba-. o- _$ O d( Z9 M8 t" B
bly more common than the rare case report in the
+ P/ c9 ~1 E; ~literature.4
& ^* I8 o3 M( V+ @& YPatient Report! n0 W: m/ z3 b
A 16-month-old white child was referred to the
8 f7 m& h8 r( i9 ~endocrine clinic by his pediatrician with the concern
3 z+ z3 O& i2 j0 w ~1 E) Kof early sexual development. His mother noticed* x4 X1 O5 m" C* \8 `0 a/ d; y
light colored pubic hair development when he was) W* i$ s9 z2 Z* T$ U' k6 Y
From the 1Division of Pediatric Endocrinology, 2University of; h9 C" e* q j) L
South Alabama Medical Center, Mobile, Alabama.8 b5 h4 X' x1 a, a& D8 t+ L" j9 o
Address correspondence to: Samar K. Bhowmick, MD, FACE,
) y# ?8 N/ p; d8 x& N' [Professor of Pediatrics, University of South Alabama, College of
$ A( g! l& A/ p7 BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! w, w6 k1 W0 I* x& `7 _
e-mail: [email protected].
" l& o; K8 j- `8 u* c& sabout 6 to 7 months old, which progressively became
$ L `+ r8 |; b, k x+ n! J. cdarker. She was also concerned about the enlarge-
3 I) ?# L0 v: l7 D/ s8 Z( h. [# _( pment of his penis and frequent erections. The child
4 i# ^ N( i" o; ]: A! ywas the product of a full-term normal delivery, with) o9 n3 a; L% B! P
a birth weight of 7 lb 14 oz, and birth length of
. [" c$ U: E0 ~ m# J20 inches. He was breast-fed throughout the first year
* V. q( }. X6 f% Hof life and was still receiving breast milk along with
' T3 b( k% i8 r8 Isolid food. He had no hospitalizations or surgery,7 r. I2 ]; C% c1 o3 ^6 S
and his psychosocial and psychomotor development
) [7 o9 N! N. i6 h" W# M! m: fwas age appropriate.
9 K9 A) h) A+ Z+ a. }, dThe family history was remarkable for the father,
0 E1 G4 s- x1 J, e4 n' [who was diagnosed with hypothyroidism at age 16,5 G& ~: D" D" j% t) L* ~
which was treated with thyroxine. The father’s! i0 _! {# N0 Z a# ] X
height was 6 feet, and he went through a somewhat
# C8 r7 ^' K9 t. w, nearly puberty and had stopped growing by age 14.
+ G1 |: R7 V7 TThe father denied taking any other medication. The6 x: v/ @( Z! E6 M. v. l- r
child’s mother was in good health. Her menarche, k. J9 u3 @. k9 F9 k
was at 11 years of age, and her height was at 5 feet2 i& r7 n% m: v! |2 d
5 inches. There was no other family history of pre-
5 x& \6 ^/ |2 b6 C) H6 C u5 Zcocious sexual development in the first-degree rela-
* P) M5 ?% c4 j* [6 I, M A1 Vtives. There were no siblings.
) ]9 x/ x K9 O0 w: o- I9 t# [Physical Examination k' G. n! Y2 a% w
The physical examination revealed a very active,/ z z* d1 {, z4 E1 O( } u# B
playful, and healthy boy. The vital signs documented- ]9 h# B, u5 V4 @; m$ N6 L X x
a blood pressure of 85/50 mm Hg, his length was
0 A6 O* w7 u% x# {, C90 cm (>97th percentile), and his weight was 14.4 kg9 a- W! g, H' N9 U
(also >97th percentile). The observed yearly growth6 y4 @1 E2 x( C% v0 w0 Q( H
velocity was 30 cm (12 inches). The examination of
& k9 A0 R/ P- S/ P/ C* Kthe neck revealed no thyroid enlargement.! x( r5 X9 T$ r! q& G' ^$ O: Y
The genitourinary examination was remarkable for
5 p! Y2 \( q: h/ D v, Wenlargement of the penis, with a stretched length of) d9 ]% u( y2 l' Z& G
8 cm and a width of 2 cm. The glans penis was very well
" E/ M+ [: z( ~' p' Odeveloped. The pubic hair was Tanner II, mostly around7 j# c2 n) @1 L* s2 u
540
* o O! u, H! H. K: U- `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ N2 t5 \$ r y# W8 r0 l1 ]* q
the base of the phallus and was dark and curled. The
4 x- I0 F' p+ o" q+ S, }testicular volume was prepubertal at 2 mL each.
0 F/ c& d7 \# Y2 a* C1 T; W# V) XThe skin was moist and smooth and somewhat4 L# ]8 k- {% x3 B7 z$ z+ w
oily. No axillary hair was noted. There were no* B+ B6 l2 r5 n0 Y* @
abnormal skin pigmentations or café-au-lait spots.7 C* M2 N# {0 S
Neurologic evaluation showed deep tendon reflex 2+
- w- z" l3 j7 k' t# p% p% ]bilateral and symmetrical. There was no suggestion0 H3 i9 W; Y/ m. Q
of papilledema.+ o6 W4 `9 q, x, U* ]- h8 E+ j
Laboratory Evaluation
* P# D4 J$ c; x$ l- |4 \- gThe bone age was consistent with 28 months by) Y( y+ S/ D# b" O$ I; E: S( f* c
using the standard of Greulich and Pyle at a chrono-- ~9 W/ L) [& O Q E8 X
logic age of 16 months (advanced).5 Chromosomal) R" d1 A! \$ Y }$ U
karyotype was 46XY. The thyroid function test$ N$ b4 g; G/ F* P
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" O" f1 y5 c4 l( glating hormone level was 1.3 µIU/mL (both normal)." k3 w1 @0 G% S+ Q! W+ z
The concentrations of serum electrolytes, blood- `, P( M: ]& s5 l* a. d! w
urea nitrogen, creatinine, and calcium all were/ ~6 J$ h1 G# d; `/ e: S
within normal range for his age. The concentration
3 v$ H2 L( s) s8 u J" Kof serum 17-hydroxyprogesterone was 16 ng/dL
& b- P- K! `* N0 g9 R% k(normal, 3 to 90 ng/dL), androstenedione was 20
5 C; `7 h' \8 I0 v4 {' x4 dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ t5 A$ |% C7 ]4 I) ~+ j) Z" m2 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),( ]- \" J3 k/ o7 b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to) G( D1 R4 B% w% G
49ng/dL), 11-desoxycortisol (specific compound S)( k( s2 t% }2 Q! w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor- t8 M; c* ^+ ^
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 v6 o' L; _& z2 qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 W3 q3 J, c, I- |8 G. y( oand β-human chorionic gonadotropin was less than
& h' X3 D( i$ h3 X& @" r5 mIU/mL (normal <5 mIU/mL). Serum follicular
& J/ t# ]- W# k8 P$ ystimulating hormone and leuteinizing hormone5 i) l1 ^* l" P9 a4 U: f
concentrations were less than 0.05 mIU/mL
7 `6 j- j1 V! q" L6 Q(prepubertal).
. b. ?1 j; ]& g) M3 \* nThe parents were notified about the laboratory
; ~. \/ S5 s% c: F- X0 }4 f! }# Fresults and were informed that all of the tests were
9 W3 U+ l. A& t$ Jnormal except the testosterone level was high. The
. ^) v ?! S' Cfollow-up visit was arranged within a few weeks to
* P8 H! V& E* P) h Wobtain testicular and abdominal sonograms; how-' I( X/ l* P7 u, E$ ~. i/ M# |
ever, the family did not return for 4 months.' m6 j" J; S2 o! R4 j7 x
Physical examination at this time revealed that the3 l9 a( m }% X7 a& @7 i
child had grown 2.5 cm in 4 months and had gained, A, W/ j3 _4 V G% P4 N# m
2 kg of weight. Physical examination remained
; ~, j3 O4 `5 d8 Q' O5 Munchanged. Surprisingly, the pubic hair almost com-
2 e( Y1 W# h1 T( G( n7 Ypletely disappeared except for a few vellous hairs at
# }! ^2 f4 B; u' s9 Uthe base of the phallus. Testicular volume was still 25 \( o" j ~' x& L
mL, and the size of the penis remained unchanged.
/ b5 s7 y7 A8 Q2 T& `The mother also said that the boy was no longer hav-$ R# D e, z. E& ^ k Y
ing frequent erections.) S/ W# y: {4 y# R* c
Both parents were again questioned about use of3 N+ _- S/ s B$ t( v
any ointment/creams that they may have applied to
; j8 h9 C/ w; V( n7 ]- _the child’s skin. This time the father admitted the7 x) A! y$ j5 b; m+ {' Z4 Z: C
Topical Testosterone Exposure / Bhowmick et al 541
9 r3 Z" ~$ [3 r4 l2 N8 ~# X- [use of testosterone gel twice daily that he was apply-7 I& f9 b' c+ Q8 ]' D0 r' k
ing over his own shoulders, chest, and back area for) _- e2 t9 k$ V( r, m M( b/ h
a year. The father also revealed he was embarrassed
0 q3 Z! L( U4 h y" Tto disclose that he was using a testosterone gel pre-
' ~8 D/ O$ Q, a# Z9 e. T9 R" l" a& Nscribed by his family physician for decreased libido0 j. r* ]( W3 m9 y5 F
secondary to depression.
6 @* \9 b( A: ]$ s; S% zThe child slept in the same bed with parents.
! A1 A* A/ V. ^! iThe father would hug the baby and hold him on his
( t! A8 m* B, X m; |chest for a considerable period of time, causing sig-
/ Z* w+ p- w4 P4 f4 q [nificant bare skin contact between baby and father.. x* z6 e ]$ u! H, ?7 `* ^) w
The father also admitted that after the phone call,1 E4 { o5 ?! ^$ y! r, Y' p) ]6 u
when he learned the testosterone level in the baby; L9 V$ l, K" K5 ^
was high, he then read the product information# L' t; G1 F9 J$ E$ r& [! \
packet and concluded that it was most likely the rea-5 i9 q* Z' e. h
son for the child’s virilization. At that time, they
: n$ A: }0 I% [% idecided to put the baby in a separate bed, and the! L% O( S4 \; F- R& ~7 h# O3 l+ R
father was not hugging him with bare skin and had. `8 v0 p, W9 S* V8 a
been using protective clothing. A repeat testosterone
9 W4 ?! o* {" P% Btest was ordered, but the family did not go to the( k7 L+ m: Z* w, u
laboratory to obtain the test.
. x9 i/ {! a# \7 v3 aDiscussion
1 p8 [ H9 p; s E) }Precocious puberty in boys is defined as secondary, z3 [) b1 p0 V. i2 _" _% `# s! g
sexual development before 9 years of age.1,4$ n: A9 I0 l. b* }
Precocious puberty is termed as central (true) when1 A) Z- G/ k5 F" K3 x
it is caused by the premature activation of hypo-
% F z% Z5 \& Ethalamic pituitary gonadal axis. CPP is more com-
2 d8 H X! I4 P4 @7 tmon in girls than in boys.1,3 Most boys with CPP
7 d' {/ |- B: v( Bmay have a central nervous system lesion that is
) q8 j7 n0 D! e" ]3 ]7 i& ]3 L, \7 i6 jresponsible for the early activation of the hypothal-, k: C, ^! I0 ]& U! [6 {
amic pituitary gonadal axis.1-3 Thus, greater empha-
: G5 O% E! u& C+ q+ g0 v$ S6 ?sis has been given to neuroradiologic imaging in
+ n4 @; b* L# b, A* y$ C: Hboys with precocious puberty. In addition to viril-
: f$ z5 o8 G, ]/ `ization, the clinical hallmark of CPP is the symmet-
9 ^7 ?9 |" J1 T5 z. L1 Srical testicular growth secondary to stimulation by) Q/ O/ ?3 `! J( ~ ^
gonadotropins.1,31 T% B4 T1 F: L, h/ D0 V5 |
Gonadotropin-independent peripheral preco-
; F1 q+ ~5 W: bcious puberty in boys also results from inappropriate
+ U4 x/ Z! H9 ]androgenic stimulation from either endogenous or
( o) P$ X# r. O0 c8 Bexogenous sources, nonpituitary gonadotropin stim-
8 R1 E9 ~* N1 |, c) Z0 yulation, and rare activating mutations.3 Virilizing
. w! K7 u0 k! Icongenital adrenal hyperplasia producing excessive( K" l _0 `6 o( x$ _- M- M
adrenal androgens is a common cause of precocious( Z# `5 G* Y* F5 O
puberty in boys.3,4
- I; j/ B$ F) l. V0 z' CThe most common form of congenital adrenal& m; ^' f9 V5 E6 V2 c9 |, Y. D
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 ]1 P2 r# @( k- RThe 11-β hydroxylase deficiency may also result in
" p: Q) b7 p8 z Oexcessive adrenal androgen production, and rarely,
2 Y5 k+ A; v; kan adrenal tumor may also cause adrenal androgen
+ a* F$ O, P6 n( j7 E# v' ^% Cexcess.1,3
4 l1 c1 H/ v; C/ W/ b# t3 zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 S2 q/ {/ K: {+ e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ _! d% v2 ?4 u2 W1 @! ]0 z7 qA unique entity of male-limited gonadotropin-# Q. y% [. h! r* a$ N
independent precocious puberty, which is also known
; ~7 q9 O6 ^% g+ C# [as testotoxicosis, may cause precocious puberty at a
/ G: J3 x4 g3 Z1 K* Kvery young age. The physical findings in these boys4 f# q0 ~- l9 J- P0 H
with this disorder are full pubertal development,% J( s1 P9 e8 r: m1 N5 ~
including bilateral testicular growth, similar to boys
) V Q. F0 H8 T, q) j6 E- L2 Fwith CPP. The gonadotropin levels in this disorder
' a& O1 M) R% _; Y* l7 D; Mare suppressed to prepubertal levels and do not show; d$ U1 h& l" l6 b! C3 Z" B
pubertal response of gonadotropin after gonadotropin-. X1 }* S; p: @3 ^" g6 V5 j
releasing hormone stimulation. This is a sex-linked
+ Z: n: s) F8 ~6 fautosomal dominant disorder that affects only1 @5 K- S8 L8 D: O
males; therefore, other male members of the family2 U, I. J* a: l6 Y% j; a7 K
may have similar precocious puberty.3
+ ~) ~. K0 G: e; D; SIn our patient, physical examination was incon-2 O! i2 M$ k% i6 x% O6 z- H
sistent with true precocious puberty since his testi-
1 T( `2 \! b$ Scles were prepubertal in size. However, testotoxicosis
/ U7 j, e5 ~5 v9 ^7 U, vwas in the differential diagnosis because his father
6 |' W2 q4 J* R1 l* _started puberty somewhat early, and occasionally,
" R7 S8 Z- l8 a- R( h) T6 atesticular enlargement is not that evident in the6 d6 Y5 m- e2 p4 ~
beginning of this process.1 In the absence of a neg-
- {1 q; v m$ A4 l4 n7 Native initial history of androgen exposure, our
' h* b2 X, @/ s0 A' \biggest concern was virilizing adrenal hyperplasia,$ e7 ~ ^8 _, m1 v5 e% P: M# p2 J3 U
either 21-hydroxylase deficiency or 11-β hydroxylase
' |$ ^1 x6 b! I# J8 ~( [deficiency. Those diagnoses were excluded by find-
: {$ ]* |+ m R* f7 u% Jing the normal level of adrenal steroids.1 W# t, s( \" c. K
The diagnosis of exogenous androgens was strongly. W+ ?5 k0 k) }0 C2 \: E
suspected in a follow-up visit after 4 months because
/ H' e6 P" D. c; W7 lthe physical examination revealed the complete disap-
% o& }& E; l4 }/ c, B, Vpearance of pubic hair, normal growth velocity, and4 M+ I K5 y0 U+ R- V. l$ c5 Q
decreased erections. The father admitted using a testos-+ c# O( Y, L0 h; W7 g+ Z* U
terone gel, which he concealed at first visit. He was# M+ J" h) |1 T P
using it rather frequently, twice a day. The Physicians’
+ ]/ |: Q/ a& ^% v% L$ l$ UDesk Reference, or package insert of this product, gel or
! Q! [1 ^: t, j* S% Kcream, cautions about dermal testosterone transfer to
- j$ u6 j% @2 |3 o+ C! Aunprotected females through direct skin exposure.0 o+ e- T8 o" u* t3 ]
Serum testosterone level was found to be 2 times the
0 C K3 S8 Z# \. x7 \- ]1 Z7 wbaseline value in those females who were exposed to- a) Y& [ A5 ^/ h# T. \
even 15 minutes of direct skin contact with their male
% O; Z V+ x6 R6 V7 l; i, Lpartners.6 However, when a shirt covered the applica-6 H: R- V( b7 z' w$ q
tion site, this testosterone transfer was prevented.
2 o3 ?+ B Z( b5 J7 tOur patient’s testosterone level was 60 ng/mL," I) x+ `; ~8 }
which was clearly high. Some studies suggest that. X1 Y$ N8 r/ n( k t5 J: w0 p. T6 Z
dermal conversion of testosterone to dihydrotestos-
8 m- g' w% i: e" k/ S+ o* V6 \terone, which is a more potent metabolite, is more' o& f; Q9 s+ {* d- O! f6 q# Q( s
active in young children exposed to testosterone- u5 p5 R8 S$ Z% k; n5 ]7 [
exogenously7; however, we did not measure a dihy-0 u: P8 d! E+ U0 @3 z. H
drotestosterone level in our patient. In addition to
. a; K1 f1 F& c5 B; Q$ H& _# t F! B% Qvirilization, exposure to exogenous testosterone in5 s6 z, k2 k- G) Z0 }
children results in an increase in growth velocity and# c3 B$ ]1 i! U. f3 }. h! \# o3 y
advanced bone age, as seen in our patient.7 z6 [7 G& C& }# ]7 f7 v$ G
The long-term effect of androgen exposure during
! Y( k' C5 C4 F& I% G& u- Iearly childhood on pubertal development and final% l1 e9 {" o' u- D
adult height are not fully known and always remain, c- f9 j; D$ e! Q9 K
a concern. Children treated with short-term testos- Q+ e; q2 x, V2 E' R- i3 L0 X
terone injection or topical androgen may exhibit some
1 q% T6 K6 d) n, Q0 O- Uacceleration of the skeletal maturation; however, after, f' s3 I/ V2 a8 w0 P$ ^
cessation of treatment, the rate of bone maturation O: a; G" G2 b4 D4 S
decelerates and gradually returns to normal.8,9
$ N# N: p. Z9 c- D3 C( b) S4 IThere are conflicting reports and controversy
- v% @1 |5 ~% Tover the effect of early androgen exposure on adult$ d* s) n& { b0 c
penile length.10,11 Some reports suggest subnormal" X6 a; B3 K( Z. R' v, I3 ~, m3 ?
adult penile length, apparently because of downreg-# _+ [ V z9 y
ulation of androgen receptor number.10,12 However,
* j5 v) }% t, `3 FSutherland et al13 did not find a correlation between! A' K4 F) i2 Z. {3 j0 E" d
childhood testosterone exposure and reduced adult
2 c- O0 h' i, \8 f/ z8 p& ?penile length in clinical studies.
5 \1 U- n: w- C1 A6 c1 CNonetheless, we do not believe our patient is' \, N3 A! _) T1 _1 k$ o
going to experience any of the untoward effects from
6 l# o8 Y# _) V6 Q1 o% e4 otestosterone exposure as mentioned earlier because' B/ U1 D; e Z
the exposure was not for a prolonged period of time.
6 S0 E. r1 g$ y( h& b6 ZAlthough the bone age was advanced at the time of
v. G# r1 E, e, M+ g7 F' S. [diagnosis, the child had a normal growth velocity at
9 G7 s* Q. y# wthe follow-up visit. It is hoped that his final adult5 B8 g: R1 X" _/ h
height will not be affected.
7 R5 o) k+ h9 }! N- {. f" G) h* vAlthough rarely reported, the widespread avail-
% s }( f0 B7 `3 }% j! Aability of androgen products in our society may1 k/ F8 r' F8 Y' `$ K: q
indeed cause more virilization in male or female
0 _6 Z, h- X; Y9 vchildren than one would realize. Exposure to andro-
3 `( G/ r* d! Tgen products must be considered and specific ques-* q" }1 L% i, ^
tioning about the use of a testosterone product or
7 ~5 Z9 p- f D Lgel should be asked of the family members during
1 p( S3 `% d" e) ], mthe evaluation of any children who present with vir-& }0 u3 O5 [/ q7 q" w/ I
ilization or peripheral precocious puberty. The diag-
) a2 T5 ?8 m8 Y9 X; B) i. ^# \3 l2 Bnosis can be established by just a few tests and by
( ] f* q: x2 ?5 Iappropriate history. The inability to obtain such a
3 K3 v3 `# U) h) X6 z* P( khistory, or failure to ask the specific questions, may
" K; g8 U7 p8 f, m" j- O8 \result in extensive, unnecessary, and expensive# J' |8 `2 N8 l0 S) A* F8 b: j
investigation. The primary care physician should be
' m2 k. S% W& Y& Z: ^, A5 qaware of this fact, because most of these children9 p+ W# t' I' M
may initially present in their practice. The Physicians’ S( }4 e6 S* |$ p$ |
Desk Reference and package insert should also put a. Y$ @ m( F4 H3 ] t; z2 L
warning about the virilizing effect on a male or6 K0 n( e+ K4 ]3 o q$ X5 ~
female child who might come in contact with some-+ A+ q# ~/ a" {, o
one using any of these products.
9 B4 c D) P# @' s9 W6 ]1 QReferences
9 \6 l1 e* q+ p, c; b$ ?. M H1. Styne DM. The testes: disorder of sexual differentiation3 t! a9 n, L/ S0 ?2 c/ H- o* t
and puberty in the male. In: Sperling MA, ed. Pediatric
* s$ y+ W( t; q3 @. x8 AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 O% N5 ^4 _; [7 o1 p: F X! q
2002: 565-628.% Q# [* H2 D9 C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 t" n6 E7 O; q* }. r0 wpuberty in children with tumours of the suprasellar pineal |
|