- 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
( w0 O5 G) h, o# ]+ p' |Boy Induced by Indirect Topical
0 D/ Y* o, a0 o& O: K# ?Exposure to Testosterone+ r4 `# Z4 x* r) q2 v1 D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 I8 r! Z" g7 a2 X/ tand Kenneth R. Rettig, MD1
6 g$ ~6 X0 j. y6 T3 ~Clinical Pediatrics
: R D+ [: C# J" bVolume 46 Number 6
% Q* X& n h5 R. RJuly 2007 540-5434 W/ c+ `; f! D! X: ?
© 2007 Sage Publications+ U. X7 \5 C9 z5 b) o) v/ \" y
10.1177/00099228062966515 t0 C2 G& {6 N P$ X1 a' T. C
http://clp.sagepub.com
( g) W4 }% u- w+ l3 Nhosted at
. ~' g5 F6 g; i1 H ^! _$ uhttp://online.sagepub.com
F9 z% B( ]* s8 K/ e+ ~* b5 cPrecocious puberty in boys, central or peripheral,6 E+ y9 V; Y% s" E3 _
is a significant concern for physicians. Central5 D7 }6 k& {" I2 i9 X F c- g
precocious puberty (CPP), which is mediated+ u. i5 ]4 t3 d9 q A5 e, I
through the hypothalamic pituitary gonadal axis, has, H6 c+ V) s# m5 e% G
a higher incidence of organic central nervous system
% ^$ g2 W* O |1 \lesions in boys.1,2 Virilization in boys, as manifested0 q' R4 e7 b. X9 s6 p3 }
by enlargement of the penis, development of pubic5 g% k8 n: g- d
hair, and facial acne without enlargement of testi-' e" e. v( D, _* R
cles, suggests peripheral or pseudopuberty.1-3 We9 g7 ^3 V% `' z' l4 q2 [9 {
report a 16-month-old boy who presented with the
0 L) G" }5 { Henlargement of the phallus and pubic hair develop-* O4 u5 K7 x4 j. n; H
ment without testicular enlargement, which was due6 |; F* U9 k, O
to the unintentional exposure to androgen gel used by
0 K! X. ^3 M; S: ?; sthe father. The family initially concealed this infor-
; G. L- t8 Q0 F0 x) J/ b& mmation, resulting in an extensive work-up for this- {1 R& p, y: O5 k/ t0 L& i
child. Given the widespread and easy availability of
3 j- x' n3 b$ T: ztestosterone gel and cream, we believe this is proba-
! k* i( h) p! l5 b$ {6 Hbly more common than the rare case report in the
+ P# h6 f" I& c* aliterature.4& Q! Q1 z9 a) h/ Y! M+ N5 d$ v2 f" t
Patient Report
* M. U+ e$ [: a0 y: uA 16-month-old white child was referred to the
/ T. s/ M; Q* ^5 z6 b4 e0 U6 Uendocrine clinic by his pediatrician with the concern& D. g7 _9 i- `8 x
of early sexual development. His mother noticed v2 p- P5 j. o5 s
light colored pubic hair development when he was- ]; I6 h, X5 P' U1 G# I
From the 1Division of Pediatric Endocrinology, 2University of
- M- M% I7 h8 A0 ISouth Alabama Medical Center, Mobile, Alabama.
5 R* v; V* X% A4 r( k9 r) JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; K" `& R) x2 wProfessor of Pediatrics, University of South Alabama, College of$ Z% S$ [# K: T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 u. _% R. F: Z1 b8 S4 ~, @e-mail: [email protected].& q$ V% ^) P3 V3 l$ I. x) B
about 6 to 7 months old, which progressively became" _; \1 m, y% W9 G
darker. She was also concerned about the enlarge-" Q" s$ U. v- }: F" O0 m- N- c) X3 U- M
ment of his penis and frequent erections. The child
! j) S* S7 y6 W; Twas the product of a full-term normal delivery, with0 S- {3 d7 f% O" C8 k ]' F' S
a birth weight of 7 lb 14 oz, and birth length of
9 }- x+ W( [: |, D4 [( g20 inches. He was breast-fed throughout the first year5 K" m! h2 ?7 Z- O* b
of life and was still receiving breast milk along with2 X# L/ N0 }# K& @, x
solid food. He had no hospitalizations or surgery,
2 Z* M7 ?& |3 f' `and his psychosocial and psychomotor development U: f/ g. V7 _3 R- A1 T
was age appropriate.
' W# Z8 I) f+ R. VThe family history was remarkable for the father,
5 P% [# v% Z1 a+ i7 R& {, [who was diagnosed with hypothyroidism at age 16,
; p4 t/ o% N* O5 c9 K; \which was treated with thyroxine. The father’s8 A& a% i3 Z+ R- Y8 J# N4 ^0 H) I7 D
height was 6 feet, and he went through a somewhat
# Y; V O5 L W$ Searly puberty and had stopped growing by age 14." ?& D$ ^, P7 y: \. }" Y
The father denied taking any other medication. The
# B% k, z) k. c& ~3 z2 Echild’s mother was in good health. Her menarche( | t: e `" Q6 z% U& W
was at 11 years of age, and her height was at 5 feet- K3 B8 g8 h& a! y! p
5 inches. There was no other family history of pre-0 p# K% i; ~1 l
cocious sexual development in the first-degree rela-' j, r! H4 @" C% Q: V) `
tives. There were no siblings.
4 e5 b$ s2 w2 e0 s! p3 X, IPhysical Examination% v. N4 \3 n. S, h2 ~
The physical examination revealed a very active,) \' j$ I- P' f' c7 M4 ^
playful, and healthy boy. The vital signs documented
9 e3 h- K- i& M) {) f% [" Ya blood pressure of 85/50 mm Hg, his length was3 G- S W7 k5 l1 Q5 V1 o
90 cm (>97th percentile), and his weight was 14.4 kg% N2 i* x/ @9 Q
(also >97th percentile). The observed yearly growth7 d/ o& n* Y6 w, d Z- _% H
velocity was 30 cm (12 inches). The examination of
0 U# z+ Q9 F; j; kthe neck revealed no thyroid enlargement.
' `2 U" }; h' }" G) c' v" m0 R% RThe genitourinary examination was remarkable for: H ?; t p5 t2 _/ X+ P
enlargement of the penis, with a stretched length of
2 @. P% X# Z! B/ `0 }$ j9 H4 t8 cm and a width of 2 cm. The glans penis was very well- I/ t b- ^+ L; v
developed. The pubic hair was Tanner II, mostly around
, o/ G r+ \# X# e: s540
" G) j0 e8 I0 Z* Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. m( T3 m6 ^- Y
the base of the phallus and was dark and curled. The
3 s! z+ s9 b) W% l! @- Ytesticular volume was prepubertal at 2 mL each.& z; Z; d+ K- M6 T" a' s7 V6 g o
The skin was moist and smooth and somewhat( h, Q9 y. u: I0 @$ X
oily. No axillary hair was noted. There were no$ R% B- E$ b) X% q! L5 i4 w, C g
abnormal skin pigmentations or café-au-lait spots./ _8 J' k+ e4 ~6 @: a, B
Neurologic evaluation showed deep tendon reflex 2+! b! m3 r$ V0 x) f
bilateral and symmetrical. There was no suggestion! {) p1 t9 B4 C; V
of papilledema.
& h$ D6 B7 M$ ]* x% ~+ v& ^6 @Laboratory Evaluation: S# ^# |: C x' d7 `2 m
The bone age was consistent with 28 months by5 ^ N* e6 i5 X3 N8 h
using the standard of Greulich and Pyle at a chrono-
: F1 e/ l# M: H1 U6 M' J9 h$ |logic age of 16 months (advanced).5 Chromosomal
' F- D6 j1 x# u! vkaryotype was 46XY. The thyroid function test
& T) w7 B/ y1 K; L+ O: Y! @0 \3 M1 ~4 Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 i* y- j( U+ S8 ]& y8 O$ ]lating hormone level was 1.3 µIU/mL (both normal).
/ G& C. L! K) E) v2 e/ ?The concentrations of serum electrolytes, blood% O. p- M1 f6 ?1 j# x& b i9 h
urea nitrogen, creatinine, and calcium all were
) Q1 G: t4 \9 n& G6 P; ^, s. a, o% L6 t8 xwithin normal range for his age. The concentration
4 {8 n: t% I7 R Eof serum 17-hydroxyprogesterone was 16 ng/dL
4 ]: r0 v: E# Q; Y9 F* U(normal, 3 to 90 ng/dL), androstenedione was 20
7 h4 d; A, t* X5 e* M) c/ m; Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 m' B2 Z+ V! W6 C/ q) [8 x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; S' n; q/ N0 r$ [, y/ M" x, J! H( ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ K: Z/ O5 `8 o* X$ S$ I$ ]- C49ng/dL), 11-desoxycortisol (specific compound S)7 H( F2 ^3 I' {7 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& r: ?) O* _' }9 B" k& Xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. l4 q5 u; M* G4 n2 I/ M& W1 e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 [) M: O5 R1 K' s, r9 S( f
and β-human chorionic gonadotropin was less than+ [# D9 C! ?) {; D; v, F
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* H6 g/ N- }" I+ |( p* ?stimulating hormone and leuteinizing hormone
( C: Y U2 y. J8 ^2 q8 Y$ A. Gconcentrations were less than 0.05 mIU/mL' ~3 x1 C/ O" j" P6 z& |7 E
(prepubertal).
; {0 E9 a2 R( E8 t. LThe parents were notified about the laboratory$ p7 C7 o$ t/ [: C( Z4 v
results and were informed that all of the tests were
6 l' l4 T6 n1 }normal except the testosterone level was high. The* ? K# a9 E4 _+ U1 @
follow-up visit was arranged within a few weeks to
( ]0 L! t: J9 o7 P6 @3 T/ B- Mobtain testicular and abdominal sonograms; how-) o4 Y: q1 y$ f. I# e- n, z( J
ever, the family did not return for 4 months.
& m) v* F2 c4 _ x4 W. TPhysical examination at this time revealed that the
, k" l: K6 d+ Z& B* ~2 Q9 c" A' J5 R3 Bchild had grown 2.5 cm in 4 months and had gained5 G' m/ h" U& j# G; M! i
2 kg of weight. Physical examination remained8 i9 S/ v# P `7 i; r0 u
unchanged. Surprisingly, the pubic hair almost com-* \6 N$ d9 D; Y
pletely disappeared except for a few vellous hairs at
* ^1 q) ~7 Y. \4 k* Z& Q! {9 }& Pthe base of the phallus. Testicular volume was still 2
5 R$ C7 {( q0 @7 PmL, and the size of the penis remained unchanged.
8 L3 R7 L% B6 i# BThe mother also said that the boy was no longer hav-0 n8 Y0 `$ }- Z& |
ing frequent erections.0 n- {" K1 ^5 I! A
Both parents were again questioned about use of
' s ]7 E( x; z9 i: ?5 W- Y. z; fany ointment/creams that they may have applied to
+ k! ?/ K7 S7 H: dthe child’s skin. This time the father admitted the
, G! D2 p. K& LTopical Testosterone Exposure / Bhowmick et al 541
0 h1 k% t% q7 T4 s+ I3 guse of testosterone gel twice daily that he was apply-$ ~, Z: r- v% @4 ?
ing over his own shoulders, chest, and back area for
7 y6 q1 g# P- h4 da year. The father also revealed he was embarrassed, ]! J+ I% \5 V6 b& a
to disclose that he was using a testosterone gel pre-
5 G+ P3 a+ X9 M3 q) w+ sscribed by his family physician for decreased libido0 Q2 c; G( O. K2 r* \8 }
secondary to depression. S7 ?: V2 m; ~7 }# G4 g" J
The child slept in the same bed with parents.
/ N( h& d/ B+ p& c B6 `+ K; LThe father would hug the baby and hold him on his
% I* G! C3 G6 ]4 vchest for a considerable period of time, causing sig-
2 R& C5 u8 e Z7 ~nificant bare skin contact between baby and father.
, w+ m8 A1 ^! o$ Y7 h! C1 v! lThe father also admitted that after the phone call,! S) a3 A/ y1 {# ~0 L4 w' @! E
when he learned the testosterone level in the baby6 u& {/ S" q$ Q
was high, he then read the product information
$ O' g, B# ]$ f* Cpacket and concluded that it was most likely the rea-6 @4 c! V! Q O, F/ e
son for the child’s virilization. At that time, they6 b# _ e, [+ h2 w2 j/ A+ l6 a
decided to put the baby in a separate bed, and the
" ^4 r- ^( D0 u" lfather was not hugging him with bare skin and had
' k1 F" j9 p2 \7 N( _been using protective clothing. A repeat testosterone
2 N5 `" Z, \: K' L/ Rtest was ordered, but the family did not go to the9 `* C6 l$ I% S+ b8 I6 k
laboratory to obtain the test.
- f$ n! q( V; ]. m* q" t* r/ RDiscussion8 X2 t1 o3 @. o/ H7 B
Precocious puberty in boys is defined as secondary
1 E# v0 X7 R( G' u! B3 osexual development before 9 years of age.1,4
$ J# g' p2 s5 b4 n1 N4 Q* O7 m1 GPrecocious puberty is termed as central (true) when
9 T F+ N: O' Y1 r7 V% n+ {it is caused by the premature activation of hypo-
% Y; ~0 C5 H7 r- v9 m1 D: Kthalamic pituitary gonadal axis. CPP is more com-
- t+ I# s$ w) h6 a9 `6 A! m: rmon in girls than in boys.1,3 Most boys with CPP4 ~2 [ J/ @7 k$ J: v. H
may have a central nervous system lesion that is
) r% z _6 e& ?- l. n. x( Vresponsible for the early activation of the hypothal-' b- Z: S/ C0 r8 P
amic pituitary gonadal axis.1-3 Thus, greater empha-
" F4 i2 k' @3 fsis has been given to neuroradiologic imaging in2 o: e' h8 z' u$ c) A9 N
boys with precocious puberty. In addition to viril-
4 q/ G; z& t$ d) {: D4 \% Sization, the clinical hallmark of CPP is the symmet-
8 v% n+ t6 ^+ Y7 Urical testicular growth secondary to stimulation by* q2 d% T' q( i% p/ v" I
gonadotropins.1,31 t; y& x |9 d7 ?
Gonadotropin-independent peripheral preco-
9 e' O7 i$ k" h) w. b" p3 icious puberty in boys also results from inappropriate' b1 {" Q3 t! R3 n% |& r& W
androgenic stimulation from either endogenous or
7 e6 A0 Z, [9 E# ~; aexogenous sources, nonpituitary gonadotropin stim-
5 e2 P5 O" {( `2 mulation, and rare activating mutations.3 Virilizing
1 |5 S$ J+ P" l- I- }- J @congenital adrenal hyperplasia producing excessive# f& X' i# P9 A8 x/ y# }3 f6 e1 a5 V
adrenal androgens is a common cause of precocious
! i& @4 U+ c P4 O2 O H% H, lpuberty in boys.3,4
3 A" m" f( r+ B7 pThe most common form of congenital adrenal; |' N" l) P) \7 v
hyperplasia is the 21-hydroxylase enzyme deficiency.1 k2 U! V- v. M- ?5 B* s
The 11-β hydroxylase deficiency may also result in
3 t2 `. W& [# W) }- j: Kexcessive adrenal androgen production, and rarely,
7 Z3 o o+ c# s6 S) Zan adrenal tumor may also cause adrenal androgen! S* v- l, I/ O' v" L4 ^- [
excess.1,3$ |& k' _4 k2 f7 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' b- W# V4 H$ o" k2 A6 r# [) e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, N6 v5 e* j: a! {4 `4 d
A unique entity of male-limited gonadotropin-
& a, D* _; W2 u _8 g1 Yindependent precocious puberty, which is also known+ }' g, N8 x9 X1 G
as testotoxicosis, may cause precocious puberty at a
- O9 c7 o7 b, s cvery young age. The physical findings in these boys
3 ] p3 u3 s5 I5 G) l3 N. @" e5 Hwith this disorder are full pubertal development,
$ r; t n m! D5 s, dincluding bilateral testicular growth, similar to boys f/ T, F2 ^# k. T4 l
with CPP. The gonadotropin levels in this disorder
6 p& x, b. t0 [# Care suppressed to prepubertal levels and do not show# k0 \" d# {, Q" A
pubertal response of gonadotropin after gonadotropin-
9 K6 H" B4 |1 J0 m2 u6 Freleasing hormone stimulation. This is a sex-linked, q$ M3 i' e4 g! h2 a8 m5 x( W) _9 J
autosomal dominant disorder that affects only% m3 M5 q; b6 E+ S$ @1 O3 x& R1 J! Y# S
males; therefore, other male members of the family
" e( J: V. Y9 A" imay have similar precocious puberty.3
3 ~- M$ E o: l4 h& j- F; qIn our patient, physical examination was incon-. i, K- K$ u( C: c! v% Y- b
sistent with true precocious puberty since his testi-4 G! Y. Q% B# }4 H8 F
cles were prepubertal in size. However, testotoxicosis
' a6 n$ P7 t8 u5 O# h: vwas in the differential diagnosis because his father
2 q+ o% p5 O/ Z* |. Z, J+ k x; q1 Q4 O9 Fstarted puberty somewhat early, and occasionally,
( E/ b7 u7 z1 `testicular enlargement is not that evident in the0 |, ?! Z1 ^* `% i# e* Y; z
beginning of this process.1 In the absence of a neg-
; W. }4 W* N) O# }5 ?1 h! P: Oative initial history of androgen exposure, our+ R% w) ~0 F* X; z' w5 d( |
biggest concern was virilizing adrenal hyperplasia,
' e% W1 p# d( k! ~! b3 O4 B. Geither 21-hydroxylase deficiency or 11-β hydroxylase. n @( w" ^6 n2 }7 i
deficiency. Those diagnoses were excluded by find-4 h8 P k; w1 t7 d$ k4 X
ing the normal level of adrenal steroids.
& A9 d1 s5 w! P' S6 v7 j8 eThe diagnosis of exogenous androgens was strongly
0 Y: Q9 d* M3 G7 `$ V' O: Asuspected in a follow-up visit after 4 months because4 K( Z- h# P: ?( H. b/ s. H
the physical examination revealed the complete disap-
7 f# O v9 n/ {7 R' w* b& Zpearance of pubic hair, normal growth velocity, and
! R# r( I9 _0 l+ ^+ h3 w7 A+ T$ e+ l% udecreased erections. The father admitted using a testos-
( u& C# n0 W, `3 \9 M* Jterone gel, which he concealed at first visit. He was) b$ O( s: {" o$ m& S! J
using it rather frequently, twice a day. The Physicians’
. o& Q. |9 J: cDesk Reference, or package insert of this product, gel or3 k/ E% _ `- E9 ]$ q) K
cream, cautions about dermal testosterone transfer to Y: d- o: x0 N/ M
unprotected females through direct skin exposure.
9 b7 f- A% c( m$ C! `Serum testosterone level was found to be 2 times the
$ ~, Q* W+ G8 F, d8 O* r) rbaseline value in those females who were exposed to
& _8 Y, W& C/ r! heven 15 minutes of direct skin contact with their male- S8 O o$ [! u+ m: k
partners.6 However, when a shirt covered the applica-# c% N8 j" m% k- R) d5 |# R
tion site, this testosterone transfer was prevented.* F) |# K9 s+ Y
Our patient’s testosterone level was 60 ng/mL,4 g7 u. |* L- N; \7 W7 a" U8 B! ^( d
which was clearly high. Some studies suggest that4 [" P) [! R: @& z* S6 x* c
dermal conversion of testosterone to dihydrotestos-
: G! C' f1 w" Rterone, which is a more potent metabolite, is more
8 y( i9 L+ H$ I& cactive in young children exposed to testosterone1 \& f" i: X( p
exogenously7; however, we did not measure a dihy-
: } u# h8 `7 j |drotestosterone level in our patient. In addition to
7 n+ W6 P, H6 M' z8 V2 M8 @virilization, exposure to exogenous testosterone in
( k- j+ j' Y3 Y/ ^1 H# jchildren results in an increase in growth velocity and3 t9 `- A! e4 `( p0 W
advanced bone age, as seen in our patient.1 E1 B3 D* d; }8 }$ d a
The long-term effect of androgen exposure during
* p7 g- K* z/ S" d+ a eearly childhood on pubertal development and final# l* h ~* ~3 x h9 B8 L; x6 A
adult height are not fully known and always remain
0 a- [$ Q* `, S% l- Xa concern. Children treated with short-term testos-* W( M. u# D& W3 m
terone injection or topical androgen may exhibit some/ R7 a2 I% K8 F# Q! z$ d; I
acceleration of the skeletal maturation; however, after6 _3 S7 B4 C. T4 X" p
cessation of treatment, the rate of bone maturation: e C7 u$ L$ |( y
decelerates and gradually returns to normal.8,9% x+ @% W0 B7 D# c, L2 M+ P; p
There are conflicting reports and controversy
T/ y$ X, \2 @8 P: b. Jover the effect of early androgen exposure on adult% F! W' K) a# p
penile length.10,11 Some reports suggest subnormal
. d. J6 \2 i! \7 a+ Radult penile length, apparently because of downreg-
9 u8 p' M0 Y, ^. c0 X. r s! _: `$ ~ulation of androgen receptor number.10,12 However, e/ U" n& O* G8 v' a7 @2 b
Sutherland et al13 did not find a correlation between. G# a6 l9 E2 J# g8 T- a( N
childhood testosterone exposure and reduced adult) L+ ~. R6 `( z7 ~2 i8 p; I
penile length in clinical studies.3 m6 Z0 | B- D. L. f
Nonetheless, we do not believe our patient is
0 P! m( d) D# N- |going to experience any of the untoward effects from& A' D: p/ b3 B1 K" s0 ^
testosterone exposure as mentioned earlier because5 j& S9 ~) @. A5 x5 D$ ?
the exposure was not for a prolonged period of time.
a9 |0 t; L: q5 OAlthough the bone age was advanced at the time of
; \8 h8 V" {$ {- a8 O, z3 a/ tdiagnosis, the child had a normal growth velocity at. t% L* h+ c |6 O
the follow-up visit. It is hoped that his final adult, F" r9 {0 e0 D5 i( E
height will not be affected.
" ~! k2 B% G: oAlthough rarely reported, the widespread avail-
" e8 N% \+ r9 {8 r! p; Y* Kability of androgen products in our society may) b; N, v; i! w! O
indeed cause more virilization in male or female
: y( u9 f- }5 v. f. @* Achildren than one would realize. Exposure to andro-! \2 C* ~% \) U% ^0 z
gen products must be considered and specific ques-
, E# Q1 O( i& d* s, ?8 l5 e0 B4 Ptioning about the use of a testosterone product or
+ H- K% W* U% ]* Kgel should be asked of the family members during
, ]/ t5 R( g# zthe evaluation of any children who present with vir-
1 G5 L* F' H) g( e8 S" s" J' Nilization or peripheral precocious puberty. The diag-
& g1 R+ J! i3 Q2 Hnosis can be established by just a few tests and by
, q/ b D7 ?9 @6 x5 Lappropriate history. The inability to obtain such a
$ m( E! r; H l* Y% qhistory, or failure to ask the specific questions, may
, z0 ^+ q! J# E. j* fresult in extensive, unnecessary, and expensive$ ~6 X3 b) X8 \( e' ]: \" |% q
investigation. The primary care physician should be
$ n! b$ F; ]9 Eaware of this fact, because most of these children4 P, B7 d3 t% m; r
may initially present in their practice. The Physicians’+ z( z2 }) r) x0 V! R
Desk Reference and package insert should also put a
c% v3 i7 ~' }! u/ q5 |) s* h7 S3 v( Fwarning about the virilizing effect on a male or( U2 F$ V9 ^8 j8 e
female child who might come in contact with some-
- [( R0 y7 \3 g7 ~2 D) y7 h- Rone using any of these products., l) \0 ?( N% I3 [1 `, u* @
References
k( } d1 p$ R4 i9 A3 P2 |: x1. Styne DM. The testes: disorder of sexual differentiation
+ v1 _, G& w1 Zand puberty in the male. In: Sperling MA, ed. Pediatric: }( ?) {4 Y/ n5 f' Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& Y* @$ {6 h7 m/ i8 d2002: 565-628.
5 k1 a3 k9 Q' |5 q# u- l" S/ Y; a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 k1 w1 n7 g/ J! N' \/ K0 o! L3 mpuberty in children with tumours of the suprasellar pineal |
|