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Sexual Precocity in a 16-Month-Old" g$ s9 \( Y4 v& G. A$ |
Boy Induced by Indirect Topical
% ]) ]3 R: O4 g: ]6 ^Exposure to Testosterone$ `/ `! ] R+ Y/ z/ Y% h) ?2 T
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! N) F+ Q ^$ i: w6 } f8 dand Kenneth R. Rettig, MD1
! [/ X# W! Z2 A! L6 U0 g; g2 fClinical Pediatrics e7 K+ o7 h& C7 N( D" l7 V" i
Volume 46 Number 66 Z0 n* p1 Y# L) O! t
July 2007 540-543; i, W( Q& |) z1 m8 r9 h
© 2007 Sage Publications
9 P' X) a& o2 o9 h) i% h2 U10.1177/0009922806296651: I1 e' V7 L2 X+ H. n
http://clp.sagepub.com* Z" R i1 a" W, ~7 {
hosted at
+ D) @& f. x. Ahttp://online.sagepub.com
2 g$ i, x* t- x/ R8 FPrecocious puberty in boys, central or peripheral,! K8 {4 @' Q9 d9 t4 M( C! Z
is a significant concern for physicians. Central7 X+ l7 L7 H1 _+ y: S3 t& z
precocious puberty (CPP), which is mediated n3 T7 @8 u% a5 S$ m; D
through the hypothalamic pituitary gonadal axis, has
( Y' d! B! _* ~. \: N# ?5 v+ ]6 xa higher incidence of organic central nervous system8 T# }' \7 w- j7 {
lesions in boys.1,2 Virilization in boys, as manifested4 r4 [ T2 [. |+ g. ^
by enlargement of the penis, development of pubic
4 I& s! G' K+ ]% L& `1 Ohair, and facial acne without enlargement of testi-
/ C, K! g- |, z- F' j; s2 Ycles, suggests peripheral or pseudopuberty.1-3 We+ s3 ~* H( _ s0 V
report a 16-month-old boy who presented with the
) D" S. `+ |$ F( Menlargement of the phallus and pubic hair develop-
) R2 N$ |0 z% v' ^8 Z3 [ment without testicular enlargement, which was due
- c) p% w7 C5 a4 B4 tto the unintentional exposure to androgen gel used by5 v5 n" j, M( Y
the father. The family initially concealed this infor-: I4 Z O0 x6 ~& y/ u
mation, resulting in an extensive work-up for this
+ e1 Y I' F: B* Nchild. Given the widespread and easy availability of7 A0 C% }* z8 F2 }; H7 d' _
testosterone gel and cream, we believe this is proba-
L; T8 v- Y1 [0 g( W' L4 N, t1 @bly more common than the rare case report in the8 Y3 a' X4 |% ^
literature.4
0 S) ~9 K& N! C X6 b, |+ b( mPatient Report2 p3 z) o5 t3 H/ z# w& {% i1 ~$ B8 m
A 16-month-old white child was referred to the4 K3 f; K* a- ^4 A% _
endocrine clinic by his pediatrician with the concern- {$ h( }# c' |: {0 Q4 U9 w4 [/ O
of early sexual development. His mother noticed2 P9 H4 q6 X& e- S+ \5 \# E* w# ~$ ?
light colored pubic hair development when he was
! |8 A* H# V G# k/ F) u9 o+ [From the 1Division of Pediatric Endocrinology, 2University of* H1 K5 N* @8 }: {% x9 E
South Alabama Medical Center, Mobile, Alabama.
' f, @" ~; ]1 PAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 T" E4 W! P( ]3 J' ?) u# [% K* M6 Q1 yProfessor of Pediatrics, University of South Alabama, College of% P# m- K' M" ?8 @; \3 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! |* T0 `! }3 s9 E/ R" be-mail: [email protected].) Y, U7 ]2 o+ ?4 q
about 6 to 7 months old, which progressively became
; l) S; q. Y$ o; T! y' udarker. She was also concerned about the enlarge-1 a0 F: \" m( J# M
ment of his penis and frequent erections. The child) \' a+ z. i3 ^; n' I2 N
was the product of a full-term normal delivery, with) |% @5 |8 ]- c/ L
a birth weight of 7 lb 14 oz, and birth length of
0 `+ n" B5 K& K/ z$ Y; ]20 inches. He was breast-fed throughout the first year" |2 v; z3 M8 s- Y' C
of life and was still receiving breast milk along with
) C% Z( R6 W5 [# lsolid food. He had no hospitalizations or surgery,4 _1 s5 K8 h2 I! N! ?
and his psychosocial and psychomotor development/ g. k: K2 x7 v, s; ^5 X! J+ v
was age appropriate.) c3 U" D* i5 R, K6 M6 T! m; N m
The family history was remarkable for the father,
3 z1 d& ^( ~* Q: a$ |1 u7 y6 swho was diagnosed with hypothyroidism at age 16,
1 P& a# U" W) t5 Fwhich was treated with thyroxine. The father’s
$ Z5 v" k; K" t% aheight was 6 feet, and he went through a somewhat
$ S7 o# M9 B/ K! Aearly puberty and had stopped growing by age 14.
* Z$ r0 u9 b: a7 JThe father denied taking any other medication. The
8 ?/ p& ^/ _+ H) I, r% A( }- A jchild’s mother was in good health. Her menarche
! S& Y- N& ]+ u( F/ l, B kwas at 11 years of age, and her height was at 5 feet9 B5 z7 U! r+ c: ]) H/ x% T9 a
5 inches. There was no other family history of pre-
, l8 b) M0 }% E' a* ecocious sexual development in the first-degree rela-* r: u( X, J A% N+ [: \' n
tives. There were no siblings.+ b+ [! i8 \$ l
Physical Examination
$ `, q. v6 o' E; C* IThe physical examination revealed a very active,
7 l; `4 Z% e3 @5 X" v) Rplayful, and healthy boy. The vital signs documented
, C1 P" M& T% W2 z4 n) La blood pressure of 85/50 mm Hg, his length was; a' }8 M4 M- |7 c0 s) N. E
90 cm (>97th percentile), and his weight was 14.4 kg3 T& N1 H- ?# a! i# W( u
(also >97th percentile). The observed yearly growth
0 K" y" x# F3 G) D, V9 q3 g1 g: a6 fvelocity was 30 cm (12 inches). The examination of; C& \& ~6 H' d, }
the neck revealed no thyroid enlargement.
. v9 X/ g) H4 B: b( s3 XThe genitourinary examination was remarkable for
, p# Q( g3 m* l2 y. n9 qenlargement of the penis, with a stretched length of
0 w! c: F: o, P( q- Y4 C0 T" \2 t8 cm and a width of 2 cm. The glans penis was very well5 ?7 k+ G7 V2 w( c1 `
developed. The pubic hair was Tanner II, mostly around8 |/ M* z) T8 M8 C2 A( o W# N
540& @5 A E7 F b' C. {! p y" `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% Z$ x: q5 D6 t( ^- X' t: ]1 k
the base of the phallus and was dark and curled. The) d6 u# m2 K" E3 r+ v
testicular volume was prepubertal at 2 mL each.
4 j0 N' B9 ^- I- o6 v) }$ iThe skin was moist and smooth and somewhat9 y! e4 J# R* `6 o3 T
oily. No axillary hair was noted. There were no% Q' E' W! N( T0 s4 r
abnormal skin pigmentations or café-au-lait spots.
$ F% S& ^* |6 }# C. n4 o! ANeurologic evaluation showed deep tendon reflex 2+
9 ]1 s, c0 c" ~: {# zbilateral and symmetrical. There was no suggestion
7 @7 h5 L$ J6 d, V% Vof papilledema.; P* j1 Z5 R. K( n2 C/ J! }2 t
Laboratory Evaluation
4 ~/ H7 _$ |: S% q9 f+ S3 BThe bone age was consistent with 28 months by
/ l# z- S( {4 ], n3 V% T! p: z1 Husing the standard of Greulich and Pyle at a chrono-9 Q+ T8 ?; k0 |" d* |; w. d+ m6 K
logic age of 16 months (advanced).5 Chromosomal# r4 b, }) v; [) k# E/ f8 X, t0 z
karyotype was 46XY. The thyroid function test4 z# d9 ^+ L0 L7 N, s# t3 u1 m3 [7 j( E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 Y' z2 w) h, d- ?# i. @lating hormone level was 1.3 µIU/mL (both normal).
) H7 V6 J6 |4 ]The concentrations of serum electrolytes, blood
9 G# H5 K- l' I4 v4 Turea nitrogen, creatinine, and calcium all were
2 X9 X' T! X7 }7 Q! i f' Qwithin normal range for his age. The concentration6 O& x* }: c Q: U# [. S5 H
of serum 17-hydroxyprogesterone was 16 ng/dL
0 c3 i2 n9 {; S(normal, 3 to 90 ng/dL), androstenedione was 20
. }6 G6 I7 p# X* Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 Y. ~1 G W5 I( x* nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: K, a7 v/ J% {" x9 Gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 O5 B; A" a, v% }( s
49ng/dL), 11-desoxycortisol (specific compound S)7 K6 ~; U) s+ g& o- [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 u t# q4 k/ ~# t8 B% f0 [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; i1 S$ b a9 A! A
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( R; b) ~, L" M% N3 C5 d8 Vand β-human chorionic gonadotropin was less than; r& y& n0 o0 y2 a
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 Y! R4 i( q0 |" E
stimulating hormone and leuteinizing hormone
2 {& ]' x/ j' h" A* L4 ?concentrations were less than 0.05 mIU/mL+ y: K$ i1 Z) H
(prepubertal).# e2 P, x0 G [6 A# |& m3 P; c
The parents were notified about the laboratory4 f6 u1 r" X3 `- |
results and were informed that all of the tests were
# J: @" {% [! V8 O: H N1 W4 r$ [( ]normal except the testosterone level was high. The, j- U' y3 n3 h0 a
follow-up visit was arranged within a few weeks to
: @8 f1 V+ F) `+ [5 _' [obtain testicular and abdominal sonograms; how-
' q- k. N* J, P. X9 N# y+ V& Aever, the family did not return for 4 months.
* b8 ^; @8 H! X* lPhysical examination at this time revealed that the3 H5 P4 \" y" p! W6 }- Q4 w
child had grown 2.5 cm in 4 months and had gained
% B4 A% ?) m4 }; S, X3 E2 kg of weight. Physical examination remained3 X( j; ^: O4 R. ^. a% z8 ^
unchanged. Surprisingly, the pubic hair almost com-* r0 l$ F0 a/ _2 |" K: H: _: x
pletely disappeared except for a few vellous hairs at- r& o+ j8 [) g( d
the base of the phallus. Testicular volume was still 25 s1 J( @5 @8 P+ ]( E- `1 `
mL, and the size of the penis remained unchanged.
0 c1 X4 [- T( }3 HThe mother also said that the boy was no longer hav-8 Z: X0 P# {( B4 Y, g8 i8 b" \, W9 b& S
ing frequent erections.; y9 [" ^; f" V- ?
Both parents were again questioned about use of
0 L# c2 W9 G4 u: V; g& qany ointment/creams that they may have applied to3 U+ H' ]7 F& U+ l/ k9 K- R
the child’s skin. This time the father admitted the
3 [8 j/ Y; G5 j: h& q: mTopical Testosterone Exposure / Bhowmick et al 541
) H9 G8 s* V' }! V; {( tuse of testosterone gel twice daily that he was apply-. }. a9 f7 J, u) ]% f% [% K" _& \
ing over his own shoulders, chest, and back area for/ _3 p. X: ~6 T* @
a year. The father also revealed he was embarrassed9 \. V$ \; y9 L5 ?9 H, V* R: j1 W
to disclose that he was using a testosterone gel pre-
3 M1 ^9 _' ~: }: G( q, `5 @scribed by his family physician for decreased libido4 B7 W6 j1 d' O# T3 k
secondary to depression.5 u# c6 M7 O' O- F! H7 t6 U
The child slept in the same bed with parents.
/ `4 `4 g7 M8 a9 V+ v5 m+ T7 KThe father would hug the baby and hold him on his
3 W# e& P- E9 D0 ]) D- X2 gchest for a considerable period of time, causing sig-
g& n3 O8 u8 y7 s' Xnificant bare skin contact between baby and father.
) P. y: P9 g- o }( K5 wThe father also admitted that after the phone call,
/ w/ \# v( U5 D7 u* X1 ywhen he learned the testosterone level in the baby, V- p0 z O5 S( {( S r, D
was high, he then read the product information- H6 c0 ]$ y- P$ F$ V+ [$ |
packet and concluded that it was most likely the rea-
' K3 U i$ Q u" q1 Gson for the child’s virilization. At that time, they s5 T) U, h. y' K6 V) L8 a/ F: J
decided to put the baby in a separate bed, and the6 @/ E0 M0 }1 B# I) m
father was not hugging him with bare skin and had6 [; Z6 N0 M1 q. J2 u; Z6 N! J6 o0 U9 @
been using protective clothing. A repeat testosterone4 [* C+ J; }' [6 g
test was ordered, but the family did not go to the3 c; r% v) _' B$ a) V
laboratory to obtain the test.
- X) i" Z3 p1 G _4 s5 BDiscussion
7 X# E5 X g1 D, Z, } m: SPrecocious puberty in boys is defined as secondary
0 W8 d2 ?+ Y# A2 H( D# w B8 `- u vsexual development before 9 years of age.1,4 X u* P u; `- E% p* d
Precocious puberty is termed as central (true) when( E) E, ]1 X" `/ L1 x
it is caused by the premature activation of hypo-
' M/ \! T" j, `- S9 k. Hthalamic pituitary gonadal axis. CPP is more com-
7 G. W: d9 t% Nmon in girls than in boys.1,3 Most boys with CPP
/ o/ }! Z! D$ vmay have a central nervous system lesion that is
2 W4 M* l0 x# c$ ^8 y+ Zresponsible for the early activation of the hypothal-
& P5 i- B3 R8 j3 ?: L" ^% Damic pituitary gonadal axis.1-3 Thus, greater empha-
% J$ D% ]3 [( E, t& _sis has been given to neuroradiologic imaging in
2 R+ |* R3 _& u5 ?boys with precocious puberty. In addition to viril-
1 a6 B8 J1 A5 z% i; g6 i- Zization, the clinical hallmark of CPP is the symmet-
+ W# q+ a- L) Q2 Srical testicular growth secondary to stimulation by" ]3 i; F6 T U7 K' j, P8 \3 J o
gonadotropins.1,35 j$ e U' @ ~9 S) d$ u
Gonadotropin-independent peripheral preco- L) f2 e* u% t1 |6 v6 {( Z/ |
cious puberty in boys also results from inappropriate
$ l8 r" i) m9 K1 Fandrogenic stimulation from either endogenous or
% ~& h8 b4 S1 o% `exogenous sources, nonpituitary gonadotropin stim-+ U0 H% [3 i6 \8 e/ a8 C- G
ulation, and rare activating mutations.3 Virilizing" |* l; P2 G; G9 k+ F- {' E9 Z
congenital adrenal hyperplasia producing excessive
4 e9 b3 g7 X5 G8 @* n, t+ a) ~adrenal androgens is a common cause of precocious
+ G7 W4 ]7 l! r8 _! opuberty in boys.3,48 D: Q- f' q7 G% z2 ~: Y0 j; V' b
The most common form of congenital adrenal4 _! t; } X, N: }& y
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 v" `5 E2 {/ _) n8 C( aThe 11-β hydroxylase deficiency may also result in( n' R. @/ W7 S* ` Y* |4 M
excessive adrenal androgen production, and rarely,9 B0 q2 u! h( J& G" g+ i' D
an adrenal tumor may also cause adrenal androgen
9 L- A% e2 U8 w4 m6 l8 \! Cexcess.1,3
) n) i' |7 ~# h' o7 q1 U# e- s _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 {; q* M1 X8 T# W" d( @8 p0 {542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 c9 V# ]+ E9 q" x+ MA unique entity of male-limited gonadotropin-
; Q# s% C- U3 D+ i: F: mindependent precocious puberty, which is also known
6 I- S2 h$ \$ g$ R, was testotoxicosis, may cause precocious puberty at a" h2 `9 N: |( s9 y) J
very young age. The physical findings in these boys
; f4 {/ \. r& Z" O8 J7 q9 `with this disorder are full pubertal development,/ H) H! I8 t, ?& ~' n+ c! |
including bilateral testicular growth, similar to boys
8 p& A8 z- C fwith CPP. The gonadotropin levels in this disorder
/ R& A0 ?( r: C6 u1 Eare suppressed to prepubertal levels and do not show
3 m* b0 T$ ^' h ~# Apubertal response of gonadotropin after gonadotropin-+ E- f7 z" ?, {
releasing hormone stimulation. This is a sex-linked# x9 `) ~: v3 J4 Q0 H
autosomal dominant disorder that affects only! x: q+ G, u U4 V5 W& i! y/ t
males; therefore, other male members of the family
6 f) }: t# `7 O: h# z6 omay have similar precocious puberty.3& Y% g+ Q1 K6 C8 B( x
In our patient, physical examination was incon-
) G; |' V9 y, G5 F5 O3 G9 C# wsistent with true precocious puberty since his testi-
+ k. s) N! {; d5 c* v6 a) [cles were prepubertal in size. However, testotoxicosis2 H$ q: d0 r/ B: m" `" J4 p. b
was in the differential diagnosis because his father( _. C" \' @; N& A; _( ]6 c% d
started puberty somewhat early, and occasionally,
* }5 p: ^ \5 i' {' ?) e+ \testicular enlargement is not that evident in the
0 C% l( ]' A( w' a; a& @/ Kbeginning of this process.1 In the absence of a neg-
0 m2 ?' y9 A- d1 B3 e" Rative initial history of androgen exposure, our( E1 `! k# i4 a' |) s
biggest concern was virilizing adrenal hyperplasia,
) z# e. z$ C7 k# }either 21-hydroxylase deficiency or 11-β hydroxylase
0 l2 m! L) a1 E6 K2 a" ~/ X8 [deficiency. Those diagnoses were excluded by find-
/ w9 x$ H( A; i6 n- F% F+ ~! Ming the normal level of adrenal steroids.
" x7 m: I& W- v8 ~; g( ^$ DThe diagnosis of exogenous androgens was strongly& i5 V- R/ \( W( \/ ` W+ `5 y- D0 K
suspected in a follow-up visit after 4 months because
, t& {9 G) J8 o4 z9 Hthe physical examination revealed the complete disap-
! d# K% `; _" ppearance of pubic hair, normal growth velocity, and
; u k$ f; \ C& }1 Hdecreased erections. The father admitted using a testos-
8 N: X% G, \" [9 ]1 V; d/ c4 Q6 Gterone gel, which he concealed at first visit. He was
& s q' `& a4 O2 J$ h4 q+ qusing it rather frequently, twice a day. The Physicians’! W4 [: U. F, }- W9 t/ N2 R; J+ f+ J, G
Desk Reference, or package insert of this product, gel or# d& k* ]: C) u# H# H% u' i
cream, cautions about dermal testosterone transfer to
# F1 J6 i! g; u F* Tunprotected females through direct skin exposure.8 C8 w& Z0 j. r) I$ z. e
Serum testosterone level was found to be 2 times the$ t; ?, n- S8 u
baseline value in those females who were exposed to: D# p- A4 U# `6 h8 W
even 15 minutes of direct skin contact with their male# P. h. l; g2 r1 p+ i" Z- ]* f& k2 X+ C& U
partners.6 However, when a shirt covered the applica-0 R) ~; a# m$ ~ ^( c T
tion site, this testosterone transfer was prevented.
+ T! T6 x; k% AOur patient’s testosterone level was 60 ng/mL,# r: m* ^7 ~! C$ J( P% b
which was clearly high. Some studies suggest that% k: S* {: b; r' e3 N* M
dermal conversion of testosterone to dihydrotestos-
! h# E5 W1 @/ w5 m; ?* F; |* _terone, which is a more potent metabolite, is more3 y+ I: J3 }4 r+ j
active in young children exposed to testosterone
, |* z# k2 |3 C3 E% ~* sexogenously7; however, we did not measure a dihy-* ^$ L- ^% j5 y8 Q1 c6 n
drotestosterone level in our patient. In addition to1 a& B: ^/ g @; ?' r7 I8 V
virilization, exposure to exogenous testosterone in/ V1 y( [( i4 Q3 Y, z1 H
children results in an increase in growth velocity and
$ a% ~, K# E0 t, [advanced bone age, as seen in our patient.6 s0 i8 J. D6 G3 I% F
The long-term effect of androgen exposure during
+ h" l- \' Z8 q7 N2 ?early childhood on pubertal development and final7 w& t T6 K; O! k# y g; V
adult height are not fully known and always remain
9 A9 R6 j/ X/ ]a concern. Children treated with short-term testos-
$ h2 u% k H" V7 i* fterone injection or topical androgen may exhibit some& n8 T8 s" y# e
acceleration of the skeletal maturation; however, after
% V4 P# l' q1 H2 K' p [cessation of treatment, the rate of bone maturation* |) N! t% U" {: Y
decelerates and gradually returns to normal.8,9; h6 Q9 T0 q2 B4 v6 Q
There are conflicting reports and controversy
( ^. z# c% S2 d$ n `$ [4 S1 jover the effect of early androgen exposure on adult
# n0 M2 ^) r* i1 D- G$ E G. bpenile length.10,11 Some reports suggest subnormal5 F. B5 G8 r. U+ @; R. R
adult penile length, apparently because of downreg-
; z8 q( c4 ^5 w u& A+ |( d0 j3 bulation of androgen receptor number.10,12 However,% } B+ `: B9 Y8 \( Y2 K, f% j, ]
Sutherland et al13 did not find a correlation between, \5 s" V; A) b# q( \
childhood testosterone exposure and reduced adult
2 `8 q6 E6 o! G6 O1 L! y! G$ m+ ppenile length in clinical studies.
Z9 E. }, M K# b3 yNonetheless, we do not believe our patient is
6 D3 T7 N9 f2 ` Fgoing to experience any of the untoward effects from
: c) R6 ?4 Z' K7 N4 qtestosterone exposure as mentioned earlier because
/ J) H5 ~ p" ]2 U* _7 t- ithe exposure was not for a prolonged period of time.
3 s* \$ l0 _1 c: R- r! z( C0 ]Although the bone age was advanced at the time of" ?; |3 d- V7 B% J6 c9 ?
diagnosis, the child had a normal growth velocity at
( S& x. T5 T; Z' Lthe follow-up visit. It is hoped that his final adult* C; R% s4 i, L2 s0 j; s& Z+ J
height will not be affected./ [) D7 h1 B# H. W; N9 ~
Although rarely reported, the widespread avail-
! P3 H0 |: p% O9 o3 p( X. ~0 _3 Fability of androgen products in our society may: u5 o. t* ^& x
indeed cause more virilization in male or female
3 N; z% A: F0 P8 M. i. b7 Hchildren than one would realize. Exposure to andro-
" {9 U3 u) D9 c+ I @% Hgen products must be considered and specific ques-$ t; y# n9 h+ T0 b7 T4 h/ a9 {1 E0 n. }1 t
tioning about the use of a testosterone product or
* Z( _+ o. j5 ]6 egel should be asked of the family members during
" T3 X4 y. \8 L0 s0 othe evaluation of any children who present with vir-
4 Y" x/ U; Q b Vilization or peripheral precocious puberty. The diag-" W$ l3 G+ n, P. g9 o, g
nosis can be established by just a few tests and by
# R4 l* A* z, q9 [, d- t. F+ pappropriate history. The inability to obtain such a2 v D. i3 M1 i; y
history, or failure to ask the specific questions, may
" s: r+ T! ?5 J3 X- C% {6 ?. x5 t/ Lresult in extensive, unnecessary, and expensive
0 Y. P3 ^8 ?& a! F% ^investigation. The primary care physician should be! P' d6 ]# N! B; x# B
aware of this fact, because most of these children
; U7 j! u6 U' t) c* T% p' X9 N- [may initially present in their practice. The Physicians’ J u, N0 b2 Z
Desk Reference and package insert should also put a* j4 f$ H" N! J4 P. ~8 p3 }3 v5 v
warning about the virilizing effect on a male or4 ]; ~0 @- {' R7 v; x
female child who might come in contact with some-0 B% Z J. K* @7 M
one using any of these products.% Y) k( @+ s& q9 ]
References8 E4 w7 D$ d8 l3 _ y
1. Styne DM. The testes: disorder of sexual differentiation
& g5 C; Q% U; v$ V% Sand puberty in the male. In: Sperling MA, ed. Pediatric
5 T4 @0 p3 S( S' z, DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ E; Y! X9 ~9 R& h8 M) `/ e
2002: 565-628.
9 M7 M* c- Q- N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, \: P. e4 H: P0 b# {" j3 Xpuberty in children with tumours of the suprasellar pineal |
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