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Sexual Precocity in a 16-Month-Old/ G8 K6 Q; ~' Y9 q+ z; T+ j
Boy Induced by Indirect Topical! X( P8 D+ }; ?9 ^* w' t3 L
Exposure to Testosterone2 G% s; Y, j4 a: S, b2 H5 Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' E4 L: E m6 k: L1 U& Q
and Kenneth R. Rettig, MD1/ d1 c, f6 O; t" l. t: L( P
Clinical Pediatrics
; |, Y2 ?0 t1 d$ A) V- I hVolume 46 Number 6
7 k u3 @# X% j G- ^+ dJuly 2007 540-543
x. T2 y" ]8 G" `© 2007 Sage Publications
" g; U3 K2 I9 y& {$ i( ~1 V10.1177/0009922806296651
: f9 x1 t, K0 P9 E, Rhttp://clp.sagepub.com
1 @$ V) ^% \" C$ q. `) e _* M: bhosted at) t# J( D( t2 g7 }) [4 Y6 [. B- G* w
http://online.sagepub.com
' N* r% O& K3 S9 _/ R0 f' x' `Precocious puberty in boys, central or peripheral,
- P4 ]+ h2 n. k8 q8 N! p1 U6 `/ \is a significant concern for physicians. Central4 `2 p, h2 a1 E1 v# P- W3 }
precocious puberty (CPP), which is mediated* \5 `# p' O" E; j. ? [
through the hypothalamic pituitary gonadal axis, has* Z" b- E+ `$ M, i
a higher incidence of organic central nervous system2 m$ t! e1 R& U9 t1 D
lesions in boys.1,2 Virilization in boys, as manifested, F( W( {- |8 k
by enlargement of the penis, development of pubic- v& @" q. r# s; P, C5 F
hair, and facial acne without enlargement of testi-6 D) ^: t. ~0 i4 A; }. u, \
cles, suggests peripheral or pseudopuberty.1-3 We, b% b, W; p, K5 i S2 ?
report a 16-month-old boy who presented with the
2 O0 \. H( w# U: v: r1 }. Menlargement of the phallus and pubic hair develop-$ a( `3 N( J2 j* f' w' _
ment without testicular enlargement, which was due: W, s5 r+ q+ Z2 @/ U5 L# t
to the unintentional exposure to androgen gel used by: @- Y' P5 ?8 V9 d2 f
the father. The family initially concealed this infor-) P( X( {7 n, S0 O
mation, resulting in an extensive work-up for this c7 S! O! g1 s
child. Given the widespread and easy availability of
d& n* G, Q F0 s: h9 T; z( dtestosterone gel and cream, we believe this is proba-
; h4 k$ [' G" B0 v! ?bly more common than the rare case report in the3 @# U6 s5 ^. b9 r& }, ^& T
literature.4: J9 ~4 M+ U9 D- i4 z+ Z: Z% U
Patient Report
) L+ y" v. d' @6 a, IA 16-month-old white child was referred to the
; h+ W1 L f& c9 T: e9 D9 q5 x# a7 Dendocrine clinic by his pediatrician with the concern% f4 K- W1 ^$ E& @) N
of early sexual development. His mother noticed
$ {9 w8 j& m$ C; A6 l# r- Ilight colored pubic hair development when he was3 V4 V% q+ V! |) u, n. N: @/ q
From the 1Division of Pediatric Endocrinology, 2University of! ~/ F/ j, ~) x5 Z1 a) p
South Alabama Medical Center, Mobile, Alabama.
$ q/ q2 C! U! c! E" U% }6 EAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 `! k6 }$ V7 O4 gProfessor of Pediatrics, University of South Alabama, College of
8 F: I0 n3 U( b/ c/ }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 a/ z5 m! W- c! G
e-mail: [email protected].
8 d! m$ q0 y2 t. sabout 6 to 7 months old, which progressively became
1 A9 Y& M4 P: p: h4 Kdarker. She was also concerned about the enlarge-
' [# n- I" w6 D5 z( U6 Mment of his penis and frequent erections. The child( e0 V- s/ H. w' ~6 F# H: y
was the product of a full-term normal delivery, with' n0 f" J. X/ k: B2 Y8 c& P5 \
a birth weight of 7 lb 14 oz, and birth length of
8 x+ w, S/ F. B0 z% R: N; j20 inches. He was breast-fed throughout the first year+ x4 g) f* Y. I/ _8 \
of life and was still receiving breast milk along with( X$ o1 @' I1 J5 y
solid food. He had no hospitalizations or surgery,; T: M$ g. W# p" ?2 \0 R9 O
and his psychosocial and psychomotor development: [" F+ H# b' N+ [$ q" d, o
was age appropriate.
& b5 f" ]; W AThe family history was remarkable for the father,7 @) V! x- @! Y, L* \# J
who was diagnosed with hypothyroidism at age 16,0 n. Q1 A* z; p4 R1 }* H
which was treated with thyroxine. The father’s3 g# y- \( z; B4 m4 N. @$ z& K
height was 6 feet, and he went through a somewhat% ^; u) i" O2 E5 a. \
early puberty and had stopped growing by age 14.
( w+ ^, x5 J& c6 p* yThe father denied taking any other medication. The
0 _+ F( Q1 a5 G9 E3 Uchild’s mother was in good health. Her menarche
: S \7 f! L5 _; Hwas at 11 years of age, and her height was at 5 feet& k- t! v7 F! U" C
5 inches. There was no other family history of pre-
' s9 @: u1 z0 c0 d4 tcocious sexual development in the first-degree rela-
) i- J Z( F% r" J0 X% vtives. There were no siblings.2 r1 l: T4 v1 ~0 f# Z7 R) {' r
Physical Examination% W$ |4 L! }+ M8 ]* K2 b
The physical examination revealed a very active,& h0 k. e9 c2 C! R2 E9 Y5 q
playful, and healthy boy. The vital signs documented# I) {/ }; }% R& R
a blood pressure of 85/50 mm Hg, his length was
; g! b) _+ C$ ^. D90 cm (>97th percentile), and his weight was 14.4 kg6 c3 n( c% o& t3 R- \
(also >97th percentile). The observed yearly growth z7 H! }& @6 y7 U
velocity was 30 cm (12 inches). The examination of
& q, }! ^" }/ S/ X, b" F, wthe neck revealed no thyroid enlargement.# r( [1 |0 B' `( [# s
The genitourinary examination was remarkable for
! r7 M: E- j, Penlargement of the penis, with a stretched length of
+ y4 b% l0 O6 }& n' Y& H8 cm and a width of 2 cm. The glans penis was very well/ q, m1 _1 \0 Z( i
developed. The pubic hair was Tanner II, mostly around
! P- `9 o4 P# y; w" N+ {540
6 ?$ W( u3 R& M' L& ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 l# o% r# z; l, L1 s, R' o
the base of the phallus and was dark and curled. The
. W6 Q+ }4 @0 o+ h8 ~: I+ {: ytesticular volume was prepubertal at 2 mL each.4 A- u" z4 n9 _4 l
The skin was moist and smooth and somewhat W0 [$ ^9 s/ x) d
oily. No axillary hair was noted. There were no# i, T0 F! H( `& }9 e/ B
abnormal skin pigmentations or café-au-lait spots.
: z- F0 z# V5 W/ [: a2 GNeurologic evaluation showed deep tendon reflex 2+( j- u' c: z X
bilateral and symmetrical. There was no suggestion: U* S$ | T, G6 e# ?) Q; S3 B( _
of papilledema.' g6 V9 g! s, r- g0 V
Laboratory Evaluation2 z2 K/ \, K* m; R' E, I/ |2 v! q
The bone age was consistent with 28 months by
! b# M$ q: f% h( ~* }1 Xusing the standard of Greulich and Pyle at a chrono-+ a! \. w6 r! t+ z9 d6 l ]$ `
logic age of 16 months (advanced).5 Chromosomal
* x! D8 h5 x: W# ^karyotype was 46XY. The thyroid function test
, t4 F/ R9 q+ P* z6 R3 M' {/ ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-% j8 [. s5 G0 [/ o' ?! \" Y( y$ m
lating hormone level was 1.3 µIU/mL (both normal).! G) _( a4 F9 J; h' S& F1 u4 h
The concentrations of serum electrolytes, blood
9 {9 ~* |3 c! d9 K4 F( O6 x& Curea nitrogen, creatinine, and calcium all were
0 W2 l. z; T; V: ?within normal range for his age. The concentration
t3 r( ?( [/ d% Q/ z. Cof serum 17-hydroxyprogesterone was 16 ng/dL
3 @( s9 D# L8 f, c( \& b, ?4 @(normal, 3 to 90 ng/dL), androstenedione was 20
1 U3 D' ~5 R, _$ I& Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 p! y* x5 A1 E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 { Z/ O( q, K ~. i `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: ]2 |4 `+ m: h0 q' S G
49ng/dL), 11-desoxycortisol (specific compound S)
6 S& _* c7 T$ W: r, H3 }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" c9 B) A) ^0 ]& \/ ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 l( C' G& o* U9 ~: d9 d) T9 G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 H8 {. r0 v+ ^' E2 o
and β-human chorionic gonadotropin was less than
$ S2 I$ B6 c. X" B& P5 mIU/mL (normal <5 mIU/mL). Serum follicular! c9 S+ F1 h0 o, z$ X+ U
stimulating hormone and leuteinizing hormone* R- U2 s t) @
concentrations were less than 0.05 mIU/mL
; x/ h* r% x9 y3 E: E(prepubertal).
! ^" X/ T3 e1 X \7 h$ ?, `) yThe parents were notified about the laboratory
# v( y* `+ k) k' ~, r* Aresults and were informed that all of the tests were6 H) v0 i$ }% t% Q4 U" G" s8 K
normal except the testosterone level was high. The, \& `$ b) b! b+ N% S9 i. [4 h+ L
follow-up visit was arranged within a few weeks to/ ]3 H/ S. u/ v! C
obtain testicular and abdominal sonograms; how-
, y1 t+ q2 W% P( j1 Mever, the family did not return for 4 months.
* d S, p2 d4 J0 R- k" v- ^# aPhysical examination at this time revealed that the
5 j: G; @$ x' l3 Y4 Z# uchild had grown 2.5 cm in 4 months and had gained) f) [- R( [4 j0 d, l
2 kg of weight. Physical examination remained m5 n! [ `, r. P( v/ e N; C
unchanged. Surprisingly, the pubic hair almost com-+ G$ _' E" p2 D. U: j% t
pletely disappeared except for a few vellous hairs at
. S( b4 g! q8 m( c# A9 Mthe base of the phallus. Testicular volume was still 2
2 s6 n6 ^# t; q, O7 ]' h AmL, and the size of the penis remained unchanged.
" X2 D* @( Q0 V" s; b& nThe mother also said that the boy was no longer hav-$ c, x5 s# v$ i( `+ @- ]4 e
ing frequent erections.
5 W' h* g2 \/ ], b% J, ?% OBoth parents were again questioned about use of
Y" S6 G) |, b9 y E V. Z7 V, jany ointment/creams that they may have applied to! p" a! L7 f4 D
the child’s skin. This time the father admitted the
, `# J( i# Y& ZTopical Testosterone Exposure / Bhowmick et al 541% m' J5 P. [8 n, E
use of testosterone gel twice daily that he was apply-
& G7 {" C/ m4 E- w8 k0 ^% d2 Jing over his own shoulders, chest, and back area for
- M" p. w0 S6 U8 w0 ka year. The father also revealed he was embarrassed+ g) @4 u6 `: F
to disclose that he was using a testosterone gel pre-6 F' O" i B2 H) b8 h
scribed by his family physician for decreased libido
& n: E3 {" a* ]. }1 f5 v3 m0 {secondary to depression.
+ g1 ^4 ^6 [$ Z4 w( \6 b; \# ]6 @' JThe child slept in the same bed with parents.- H+ h4 y: g9 \
The father would hug the baby and hold him on his" K1 @$ L; q/ d& c" Z' e
chest for a considerable period of time, causing sig-
7 H% ~7 A3 c8 `nificant bare skin contact between baby and father.
7 _5 o k6 L+ U6 ^The father also admitted that after the phone call,, g) c1 G! h5 m5 t% Q$ B- @1 a
when he learned the testosterone level in the baby: o( n7 x; z" }* P. K" A- F4 s
was high, he then read the product information( [% S: ]* A- M7 v1 Y+ ?
packet and concluded that it was most likely the rea-$ h/ q4 W: \/ Y; t4 x
son for the child’s virilization. At that time, they1 T3 u4 x4 w* g# k4 x1 Z
decided to put the baby in a separate bed, and the
9 _& I" `6 a, r' r* d+ r* I, bfather was not hugging him with bare skin and had6 p: g* n6 p ]) |' |$ K
been using protective clothing. A repeat testosterone
m1 [8 B1 A$ f$ l# d4 a- X2 A& g* otest was ordered, but the family did not go to the
Y8 |% ?) ?0 v9 elaboratory to obtain the test.
. `* Q( m2 I3 p6 I) p% {& N& |Discussion/ E+ h1 N; s4 Q7 e j# e% o7 A4 Y
Precocious puberty in boys is defined as secondary
9 t y% ?* b8 a0 a. Nsexual development before 9 years of age.1,4
' y! f; L9 P+ g+ XPrecocious puberty is termed as central (true) when
7 _+ s, F- v5 M& Zit is caused by the premature activation of hypo-
2 t2 }1 K" Q2 E- I. {thalamic pituitary gonadal axis. CPP is more com-
( Y4 \. |8 Z0 q4 m. W* x3 x, gmon in girls than in boys.1,3 Most boys with CPP2 C! z4 D) H! A
may have a central nervous system lesion that is0 e- _. v6 M/ C) Z6 [9 y9 O6 L9 D
responsible for the early activation of the hypothal-, B( y, m' j. z1 {6 n5 h Z) m
amic pituitary gonadal axis.1-3 Thus, greater empha-' s9 w/ o. H+ f; y/ T' z% O
sis has been given to neuroradiologic imaging in! ?7 P5 \; u, x- G8 r
boys with precocious puberty. In addition to viril-/ F& H' ?. T2 B! W2 v) _
ization, the clinical hallmark of CPP is the symmet-" i- B' x/ L4 H
rical testicular growth secondary to stimulation by: T+ c& [/ a6 L
gonadotropins.1,3
( y. ^5 {, f- u' d$ ~/ lGonadotropin-independent peripheral preco-
* \1 f3 c1 R" Z, Ncious puberty in boys also results from inappropriate
2 J- L, p; `: G# a* j1 ] Wandrogenic stimulation from either endogenous or
. o, _5 n. I8 l# J0 {exogenous sources, nonpituitary gonadotropin stim- n! ? f: B2 v5 E
ulation, and rare activating mutations.3 Virilizing
1 {& V+ ]1 P8 Y |" vcongenital adrenal hyperplasia producing excessive
: K# X6 P2 N- W, @, Yadrenal androgens is a common cause of precocious
. a9 p3 m$ O' e5 d- q3 }6 |puberty in boys.3,4
; H$ J3 S( O+ ^0 `+ tThe most common form of congenital adrenal
+ \: S) y& g& X8 N n7 p& Ahyperplasia is the 21-hydroxylase enzyme deficiency.
+ u4 W1 J& d8 q3 n: i9 Q4 ?, vThe 11-β hydroxylase deficiency may also result in( g+ s+ y' I5 y3 C1 ^
excessive adrenal androgen production, and rarely,
; J9 G3 o5 e7 Can adrenal tumor may also cause adrenal androgen
5 ^* q( \6 C6 R+ d4 qexcess.1,3- Q- `) C! u6 s8 J ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ o: L6 K4 j# s9 [1 [8 e4 I
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 ?0 q" x/ Z) Z3 F5 {7 {
A unique entity of male-limited gonadotropin-7 D0 @9 ~2 Q8 h) U
independent precocious puberty, which is also known% s+ P' S1 Q3 f- G; t3 _
as testotoxicosis, may cause precocious puberty at a
, x+ s& z7 k D. y# ivery young age. The physical findings in these boys
! z: o6 _1 c, zwith this disorder are full pubertal development,
1 V% Y2 N7 @ k; b, D% n9 f `including bilateral testicular growth, similar to boys
N9 y; A/ x+ j/ Zwith CPP. The gonadotropin levels in this disorder' k9 j/ g3 ]4 W/ m
are suppressed to prepubertal levels and do not show7 V& O% X7 x6 l3 @' Z' K5 D
pubertal response of gonadotropin after gonadotropin-
" ~; K6 C1 ~8 y% W, ~% rreleasing hormone stimulation. This is a sex-linked
, r7 Z& s1 d2 ]9 e Vautosomal dominant disorder that affects only& Q) l" r/ }% T. h8 }, l
males; therefore, other male members of the family0 Z, ~1 D' E* |8 F* I; u2 T5 @. l& P
may have similar precocious puberty.3# s S$ P1 y7 M
In our patient, physical examination was incon-
. I! ~& A4 s! _, f# p% Q5 e nsistent with true precocious puberty since his testi-. u8 u. N' w8 G
cles were prepubertal in size. However, testotoxicosis
4 U6 f; b( J: O5 A, k0 \was in the differential diagnosis because his father- `" e+ v, T8 @6 d4 q" C
started puberty somewhat early, and occasionally,0 A* U& D, m" }" ?1 I# t$ r) p
testicular enlargement is not that evident in the$ [) v' X" s4 [( s6 ?
beginning of this process.1 In the absence of a neg-. w8 m9 ?, J" h, Q% h/ ^
ative initial history of androgen exposure, our
# k, W2 f1 K* F9 V7 [5 _8 ?* ibiggest concern was virilizing adrenal hyperplasia,
2 G7 V0 u6 R3 K/ b& p! B2 heither 21-hydroxylase deficiency or 11-β hydroxylase w! u5 k4 _& N4 V8 W) h. G" l
deficiency. Those diagnoses were excluded by find-& ^3 H# B) @! B+ m) t. U; [. Y
ing the normal level of adrenal steroids.8 o6 @" W: }, s9 W) k) L
The diagnosis of exogenous androgens was strongly6 \$ {: c% J$ `4 _# Y
suspected in a follow-up visit after 4 months because, D, m7 _* Z0 I l/ M; B
the physical examination revealed the complete disap-
# N; s8 s3 `2 R4 n& L5 f' Fpearance of pubic hair, normal growth velocity, and
& s- e. p% Z* F, t, J; ^$ [( hdecreased erections. The father admitted using a testos-. ] }/ n0 A7 y3 ^% a, [
terone gel, which he concealed at first visit. He was3 `) ], o) C( }
using it rather frequently, twice a day. The Physicians’
# P9 v) I' l! o2 c o J9 E b! IDesk Reference, or package insert of this product, gel or
( H6 j! _6 @9 M' k4 W. j* scream, cautions about dermal testosterone transfer to4 D$ m5 j0 W4 p! ]
unprotected females through direct skin exposure.: h/ t3 Z o( V2 j# [) `& K
Serum testosterone level was found to be 2 times the
# \. d& p9 |( ~baseline value in those females who were exposed to
2 t8 Z5 z) k5 g/ n c! m4 a7 \; Heven 15 minutes of direct skin contact with their male: Y8 J$ N# G& W4 n
partners.6 However, when a shirt covered the applica-' l! ^% r- Z" M0 v$ e0 g
tion site, this testosterone transfer was prevented.
* r+ Y9 R) J9 POur patient’s testosterone level was 60 ng/mL,
7 J K1 R/ {- m- Kwhich was clearly high. Some studies suggest that9 p: X7 u3 r. O+ x# H& H
dermal conversion of testosterone to dihydrotestos-% q( Q% F8 w1 f/ f4 \
terone, which is a more potent metabolite, is more% Q: n) I6 F3 w7 y1 g
active in young children exposed to testosterone7 `1 f3 v* Q* t
exogenously7; however, we did not measure a dihy-
; |& J) W; C! R1 u3 R% z+ W$ udrotestosterone level in our patient. In addition to
* {1 c8 a2 q# C# \, ?7 ~2 Yvirilization, exposure to exogenous testosterone in- P% @# w/ u$ \, O: y+ k8 q! [. v
children results in an increase in growth velocity and
: Y* F- ]) H1 Jadvanced bone age, as seen in our patient.
0 |# B( f' p5 R# C8 n3 pThe long-term effect of androgen exposure during# R1 r D4 t" R2 d5 a% r
early childhood on pubertal development and final
* @" G/ n- t" [) Q4 [' z9 Eadult height are not fully known and always remain6 w% l0 m6 ^7 s/ ^2 y
a concern. Children treated with short-term testos-
/ \: W. K) M8 i- Y3 O7 g0 v0 L- ~terone injection or topical androgen may exhibit some
( m6 n5 X! Y2 ]acceleration of the skeletal maturation; however, after Z1 X6 T* @5 P8 w
cessation of treatment, the rate of bone maturation
# P" V( C( ?' q7 A+ Fdecelerates and gradually returns to normal.8,9 B6 q. V# A0 f, O- y
There are conflicting reports and controversy5 U5 L3 z" { j
over the effect of early androgen exposure on adult
7 n/ f( K1 H: J8 o# z8 Xpenile length.10,11 Some reports suggest subnormal
9 m9 d* N8 ?4 @/ W5 t+ q/ q9 C7 ~adult penile length, apparently because of downreg-, A" z5 l% |, g/ J
ulation of androgen receptor number.10,12 However,) Y4 S0 E% u9 _; f! |9 W- e. B
Sutherland et al13 did not find a correlation between
J: J, ^( _' |- F! v+ N* ~' Jchildhood testosterone exposure and reduced adult k; j; Z, h& |0 \0 l
penile length in clinical studies.
$ U' I+ W+ p" ^) ]& DNonetheless, we do not believe our patient is, U* ?+ p; Q- k' {$ k1 ~9 t
going to experience any of the untoward effects from2 x* M( R7 G' Z) V! C- D
testosterone exposure as mentioned earlier because# W+ s9 Q, ~0 J- S7 K; r, d
the exposure was not for a prolonged period of time.* V4 G5 O+ ^9 [8 b
Although the bone age was advanced at the time of: J; g# r( U: A$ |
diagnosis, the child had a normal growth velocity at
r( [6 y3 z% G. v# U3 W8 j4 zthe follow-up visit. It is hoped that his final adult
% w. P& S( F% `2 I1 d& b0 lheight will not be affected.
$ T# M5 z+ L1 k7 L5 g+ m ~Although rarely reported, the widespread avail-# r7 v6 s, g5 B" W0 v. C, I) F
ability of androgen products in our society may/ {3 |) j( L, [: V8 R5 J; h
indeed cause more virilization in male or female& }6 |; L6 M( M n; [) ` }
children than one would realize. Exposure to andro-: v* _( F5 t' D3 {. H/ v
gen products must be considered and specific ques-
0 M, H8 k I4 i; c6 Xtioning about the use of a testosterone product or2 w1 ^6 B) T5 D7 P& o0 L+ {
gel should be asked of the family members during
* R3 _, f0 j% Bthe evaluation of any children who present with vir-
0 P( k, \6 L& E- w+ eilization or peripheral precocious puberty. The diag-
, X$ e# Y8 [$ J' Anosis can be established by just a few tests and by
+ i; h1 D7 \5 ~) P5 x! Y# a) Xappropriate history. The inability to obtain such a5 Z3 R6 e6 W$ B
history, or failure to ask the specific questions, may/ A$ T" m. x" n0 c6 j" `/ Y
result in extensive, unnecessary, and expensive- i2 D0 I# e& w& f5 F
investigation. The primary care physician should be3 J$ u, o# F& H/ T/ Q6 D
aware of this fact, because most of these children7 S* T6 z8 P9 _& W6 Q0 D
may initially present in their practice. The Physicians’
' X: f2 E( N9 M6 t! q9 b0 VDesk Reference and package insert should also put a& c$ j7 o% c. b* B" Z7 W
warning about the virilizing effect on a male or
' x1 U; I, B6 \1 R( [8 E: nfemale child who might come in contact with some-
7 e( L% ]4 r( a$ v8 Y1 a. v1 d& }one using any of these products.& {) x2 c n5 M7 s
References
0 R6 O% m+ A9 a2 r$ W1. Styne DM. The testes: disorder of sexual differentiation
+ u1 I2 t# j5 u1 h" q7 M$ Q1 r( [and puberty in the male. In: Sperling MA, ed. Pediatric$ u$ l G( l# d+ }# `( s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) z! ~6 U* F2 `
2002: 565-628.
! y& b4 a# `) O2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' `5 S( c J r0 Z
puberty in children with tumours of the suprasellar pineal |
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