- 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
7 n' N- `3 C+ v# |9 o3 h& G- P& yBoy Induced by Indirect Topical
; I V4 }' o6 r4 L3 eExposure to Testosterone) Q" @6 K# M7 V. N8 }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 T$ A: D1 x# _3 S1 z7 z0 hand Kenneth R. Rettig, MD1" E3 H% L$ i" x- M( N* p, o4 F
Clinical Pediatrics$ L1 {0 u/ k! C
Volume 46 Number 6* y( t' C8 B" D
July 2007 540-543' j% |! c4 ~* j' X/ ~, i* s
© 2007 Sage Publications
) q+ K$ I0 ^* j2 q) }7 k, @; R10.1177/0009922806296651
4 ~4 m: N0 O4 V) { b, j0 i1 whttp://clp.sagepub.com
7 Q' U; Y& y, s1 |1 m- Ahosted at7 ]; F8 e/ I7 g9 C6 d$ Q1 i
http://online.sagepub.com3 ]- ~& O. y0 e8 E0 E5 A
Precocious puberty in boys, central or peripheral,
& x1 x3 z; | _2 Ois a significant concern for physicians. Central) |+ @/ s9 U2 i5 |; w
precocious puberty (CPP), which is mediated! ^$ L& z1 P4 V* G9 T% M7 s* X) {$ M
through the hypothalamic pituitary gonadal axis, has. S, j2 c$ i' r6 f' I
a higher incidence of organic central nervous system
8 F T* ~: _ n, L" l6 _lesions in boys.1,2 Virilization in boys, as manifested
6 Y4 h- z3 S D- _1 }7 o/ uby enlargement of the penis, development of pubic# i0 S* O; Z6 F* C# R" }2 A: ~( d& g% o
hair, and facial acne without enlargement of testi-& T# `8 e& p+ r9 D4 z3 A/ g6 v9 u1 h
cles, suggests peripheral or pseudopuberty.1-3 We
& C/ G3 a$ a+ x% Vreport a 16-month-old boy who presented with the
2 B! @( E& l1 F" z! V6 Yenlargement of the phallus and pubic hair develop-, J7 s q0 G2 \ @
ment without testicular enlargement, which was due9 S2 N- i" y0 Q4 `! c m6 T
to the unintentional exposure to androgen gel used by" L2 y9 t& g& ^- {. i
the father. The family initially concealed this infor-
8 p7 W( ?+ {/ _ |$ Zmation, resulting in an extensive work-up for this# q1 k8 x4 d7 b
child. Given the widespread and easy availability of' j; G3 R2 M+ W
testosterone gel and cream, we believe this is proba-
) y+ a, n/ y# }7 D( W; @bly more common than the rare case report in the$ p' D* z O/ k& f* H
literature.4
) ^0 B8 T8 n0 M1 ?2 p1 qPatient Report
* R9 P0 {# s: x, f9 `, VA 16-month-old white child was referred to the( Q/ ~( u5 ]; w8 ]2 @& p T0 f! w
endocrine clinic by his pediatrician with the concern) i) D4 U( p( K% U' ?+ ?- L: v
of early sexual development. His mother noticed
! D' f& m) z; U% k7 ^! _. Slight colored pubic hair development when he was
5 `# U k4 v$ GFrom the 1Division of Pediatric Endocrinology, 2University of7 j) E% J) `# [2 i5 b2 v( t
South Alabama Medical Center, Mobile, Alabama.
$ Q7 K7 G) h0 p9 |* ^$ }2 lAddress correspondence to: Samar K. Bhowmick, MD, FACE,: G* u% S) L( F6 ?# c6 x) j
Professor of Pediatrics, University of South Alabama, College of
8 M$ V; {6 \: O, H1 X c2 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 J- F2 S5 D; V: Z, m
e-mail: [email protected].% v4 G2 o, y+ a. {; W
about 6 to 7 months old, which progressively became
9 u( ~" o6 J+ \; @2 V' ^! f* W: Cdarker. She was also concerned about the enlarge-" N$ b6 [& M2 |0 z6 m# k( M
ment of his penis and frequent erections. The child, M8 R3 c! j9 e. w8 q
was the product of a full-term normal delivery, with. k3 u; m/ C8 W" c: P
a birth weight of 7 lb 14 oz, and birth length of o! V" z( {# T4 l
20 inches. He was breast-fed throughout the first year7 X; o+ ~- t. G
of life and was still receiving breast milk along with6 m7 S z5 d3 T: s/ U
solid food. He had no hospitalizations or surgery,( B& c" K1 t) b' _# _& D
and his psychosocial and psychomotor development
+ P3 T$ ~4 a6 m! y& q* Y1 {was age appropriate.
) v( D7 C- ^- o' @& TThe family history was remarkable for the father,: t; \7 A6 X2 U/ W
who was diagnosed with hypothyroidism at age 16,
& V3 O# {) s8 p/ kwhich was treated with thyroxine. The father’s
7 M4 j& z* X- X( ^% l6 yheight was 6 feet, and he went through a somewhat/ d/ C" K5 v: J8 r4 y4 y
early puberty and had stopped growing by age 14.+ j( m7 O R/ x
The father denied taking any other medication. The
* B; i, W% [1 }3 w7 h4 Nchild’s mother was in good health. Her menarche
$ L3 E4 J7 `1 ] Zwas at 11 years of age, and her height was at 5 feet' q* v7 n. v( U* y0 s, L; w; @
5 inches. There was no other family history of pre-
; u4 u6 J, `/ Q# F: f" E H. {cocious sexual development in the first-degree rela-
& p8 R0 a+ V0 Ytives. There were no siblings.
; x( J- G3 o: @, G; W4 GPhysical Examination
3 F$ H( o+ ~7 x# V% o, s" @The physical examination revealed a very active,6 d# q1 ?3 Y$ g) W
playful, and healthy boy. The vital signs documented
1 N% a! D7 o' a1 r3 F @6 {: A W; Fa blood pressure of 85/50 mm Hg, his length was/ X5 w) d! w4 F: G4 l8 s( F
90 cm (>97th percentile), and his weight was 14.4 kg: ~0 ^. q1 u! ~& B) h+ k
(also >97th percentile). The observed yearly growth
5 V3 h8 v' g% s( P; x' b; f/ y' Q/ L; Rvelocity was 30 cm (12 inches). The examination of( P) [, s7 E" |5 l1 o
the neck revealed no thyroid enlargement.6 Z: B, W, e3 \9 k
The genitourinary examination was remarkable for
( y. ?* ~3 ^+ G2 _8 T- W- m# nenlargement of the penis, with a stretched length of
: @& r( c8 X' l" M8 cm and a width of 2 cm. The glans penis was very well. S% w. y N4 R" O9 E; y1 U
developed. The pubic hair was Tanner II, mostly around0 \ N( [4 y8 J H# l
540
& }+ ]) w8 q( k7 m% ^) [' N+ y1 qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# B( D* ?7 @% W' K! S! A, v! L
the base of the phallus and was dark and curled. The* N) r7 i/ ^! {+ ^4 u. y
testicular volume was prepubertal at 2 mL each.
% S2 A# F% D0 }The skin was moist and smooth and somewhat
6 f" B8 d2 B: Poily. No axillary hair was noted. There were no
, F }/ u: O/ r5 o& H1 J2 mabnormal skin pigmentations or café-au-lait spots.! Q: n1 [9 u) _7 t
Neurologic evaluation showed deep tendon reflex 2+
( E# D9 o* t! T! rbilateral and symmetrical. There was no suggestion
2 \# [6 ^1 p& _* ]of papilledema.
1 m$ v7 ?* |& d' V; A! FLaboratory Evaluation
& y4 g6 u8 X1 j1 z: u' d, fThe bone age was consistent with 28 months by, C6 o! G" Q }0 J4 K) ?
using the standard of Greulich and Pyle at a chrono-2 b( ]( O+ t; o% b
logic age of 16 months (advanced).5 Chromosomal
* [3 _, n: \2 Vkaryotype was 46XY. The thyroid function test2 v1 S0 h5 L/ l4 j! k0 O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; U- u8 ^) o: N* K; s0 F
lating hormone level was 1.3 µIU/mL (both normal).
3 E* h6 s8 A! R' E6 yThe concentrations of serum electrolytes, blood0 a" @3 ]3 R: ^% d: ^
urea nitrogen, creatinine, and calcium all were. ]( \- J& a) u' ^) t
within normal range for his age. The concentration6 ]6 n" j2 z$ J% o. b& i* K# p- E2 _
of serum 17-hydroxyprogesterone was 16 ng/dL* B V! ^ Z1 ]* k' m6 A3 `$ \
(normal, 3 to 90 ng/dL), androstenedione was 20: S7 l4 @- J- z- M# x: ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 i1 M1 ^3 [, g8 W% A: t l) ^# X5 q' yterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ v/ ?2 h% X: F+ I" a/ o) B' | X
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 ~& B( L2 y3 x \' l& e u49ng/dL), 11-desoxycortisol (specific compound S)5 v) G' x, s9 O6 S/ a& ^' t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! a! R/ e# @ |. l. W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( I! [( T7 F, a- z$ X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* Z5 a. E) n: |3 [* g, w8 Jand β-human chorionic gonadotropin was less than
9 L0 V" I! W$ ~0 I( C8 Q: Z* k( a5 mIU/mL (normal <5 mIU/mL). Serum follicular3 y) R, [, I+ o& M. T
stimulating hormone and leuteinizing hormone5 |8 P* o* c/ N( v/ ? b9 K
concentrations were less than 0.05 mIU/mL
3 Z+ H u7 U* [, }2 V(prepubertal).
0 {/ M- j _0 z' XThe parents were notified about the laboratory
) {2 S L$ f8 M' yresults and were informed that all of the tests were. j# M4 Z3 P6 o; T a+ k7 V
normal except the testosterone level was high. The1 t6 F0 Y0 x* j- X- p
follow-up visit was arranged within a few weeks to
3 \, _$ w& r/ ~1 i7 a/ W, Y' y; sobtain testicular and abdominal sonograms; how-, b/ ~- f' D2 V% Y
ever, the family did not return for 4 months.& A" [, L( ]3 i4 \- |( U
Physical examination at this time revealed that the$ q r$ P& R4 S& M% X) r7 [
child had grown 2.5 cm in 4 months and had gained! o. D/ m+ ^! g7 s$ e2 y
2 kg of weight. Physical examination remained% `" ?$ b* C! }3 I! E5 u3 E
unchanged. Surprisingly, the pubic hair almost com-3 e% K9 _: `0 P
pletely disappeared except for a few vellous hairs at s; F2 I; d5 Z0 T* ^* J5 h. u" T6 ~
the base of the phallus. Testicular volume was still 26 a& t! N0 O/ [1 Z2 N. Z$ C$ \
mL, and the size of the penis remained unchanged.+ B( Y- @+ ] ]) ~& z g& u
The mother also said that the boy was no longer hav-" t1 x, ?' a. S* C A: x; o: Y
ing frequent erections.
. Z9 k8 D5 e+ u2 v! C! N. IBoth parents were again questioned about use of$ d: U; A6 _4 O6 H
any ointment/creams that they may have applied to
i2 w: S6 a( S, z p! c8 Bthe child’s skin. This time the father admitted the
* x9 d( _7 S9 B; w! ]Topical Testosterone Exposure / Bhowmick et al 541. ` }: {* i( l4 ?- O- f2 D
use of testosterone gel twice daily that he was apply-
7 W% C( r& V* V1 q' ying over his own shoulders, chest, and back area for `6 ~ Y( M! X' d- v
a year. The father also revealed he was embarrassed0 v: o) \& d9 w$ F. d- h7 c
to disclose that he was using a testosterone gel pre-0 F" [1 O) |5 | M- d
scribed by his family physician for decreased libido& H$ D7 Y8 I e
secondary to depression.2 ]6 [" ]: M) d4 ?( e
The child slept in the same bed with parents.
: w# y* L7 H: n! DThe father would hug the baby and hold him on his: Z- e8 t3 F$ t% S2 ?
chest for a considerable period of time, causing sig-
& S7 I7 m* W' hnificant bare skin contact between baby and father.: W8 z2 v" n" @0 g6 s
The father also admitted that after the phone call,
" n: \5 F. z* B+ x( ?when he learned the testosterone level in the baby
& J( h4 i3 X. ?# d* a$ Ewas high, he then read the product information
; S i) P& O/ opacket and concluded that it was most likely the rea-
o9 g, j9 R" _& w$ O7 Vson for the child’s virilization. At that time, they: \' ?! E' k7 q6 Y# n f
decided to put the baby in a separate bed, and the7 ]' K6 m( [7 } G
father was not hugging him with bare skin and had3 ]+ W; l9 \& Q2 e; i) k
been using protective clothing. A repeat testosterone
' f" S3 Q0 v* y$ G: D8 q8 _test was ordered, but the family did not go to the7 x P, m& }- \- C$ Z: A5 t; l
laboratory to obtain the test.
, j7 i! ~ { J& Z* A+ KDiscussion7 @6 m) ?/ X; V1 D2 h4 ]
Precocious puberty in boys is defined as secondary) d# y: f4 Y/ s! O* ]
sexual development before 9 years of age.1,4, A4 U5 q3 ?) R
Precocious puberty is termed as central (true) when# Q" ?6 n$ O. @) R
it is caused by the premature activation of hypo-
* e; t" n$ E J4 N4 o" Uthalamic pituitary gonadal axis. CPP is more com-
7 \% t! P+ J: R3 s# Pmon in girls than in boys.1,3 Most boys with CPP
: z3 z2 Q O. p( V% n5 X0 H& U' L- {9 C% bmay have a central nervous system lesion that is' P/ I6 {9 m+ ^0 e* Q
responsible for the early activation of the hypothal-3 D0 H2 { N% g: n/ x. f
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 ~2 u4 h- m8 O8 {, B% Esis has been given to neuroradiologic imaging in: W; P9 M$ ^6 Z' |- c3 u/ _
boys with precocious puberty. In addition to viril-
2 j( |$ ~7 S! ^9 _- C2 r. lization, the clinical hallmark of CPP is the symmet-& {+ p/ Y# r+ g6 d' r" e
rical testicular growth secondary to stimulation by9 C8 r* k# ]9 y7 a k
gonadotropins.1,3# _. P3 x4 S# G4 U l
Gonadotropin-independent peripheral preco-
4 x$ T3 _" O0 k' ]6 I7 Hcious puberty in boys also results from inappropriate
) X4 t" @7 \! U- o, {& dandrogenic stimulation from either endogenous or) `' E. z, N8 j
exogenous sources, nonpituitary gonadotropin stim-
- D) W6 Z" }2 ^; z* X1 g2 a- ~. hulation, and rare activating mutations.3 Virilizing8 q$ t) s0 L' e
congenital adrenal hyperplasia producing excessive
* n1 Z: y( l4 sadrenal androgens is a common cause of precocious! I4 j4 ?2 o/ j$ e% W
puberty in boys.3,4
8 Y! w. n: T' B+ P A9 d8 \The most common form of congenital adrenal
& ~' N/ R3 S/ c# A i8 ?8 ghyperplasia is the 21-hydroxylase enzyme deficiency.
+ `' V/ ^$ M( K3 X" P" SThe 11-β hydroxylase deficiency may also result in7 ]8 B3 W& {1 W
excessive adrenal androgen production, and rarely,; @ t- y+ s. P3 ]6 v
an adrenal tumor may also cause adrenal androgen
) R! M& b+ |& I" z* t$ Y( sexcess.1,3
1 _7 ? O5 n" v) V8 M( Z# Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 H2 Z4 @& C5 y& p9 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 T, d$ S. {8 r6 i) a8 ]* |A unique entity of male-limited gonadotropin-' c3 q$ Z& ], S& F0 Z+ X- W
independent precocious puberty, which is also known
. g0 G5 G( `1 e% Tas testotoxicosis, may cause precocious puberty at a
! S: p' K" {6 q' n6 X/ Xvery young age. The physical findings in these boys4 U5 O+ q0 X* P- p" E
with this disorder are full pubertal development,; F/ i1 D! P( q9 L, E
including bilateral testicular growth, similar to boys) h" _, R6 X2 F! m- p5 }
with CPP. The gonadotropin levels in this disorder! Y0 c% G# W" }* B
are suppressed to prepubertal levels and do not show
7 y7 G- r. h4 `5 Zpubertal response of gonadotropin after gonadotropin-
# l& v" p0 K# `4 y9 Breleasing hormone stimulation. This is a sex-linked, \7 D% Z# c: u, N: ?5 Q1 S( k3 u
autosomal dominant disorder that affects only
8 G8 ~+ w/ l1 _; V& _$ i# l, O Zmales; therefore, other male members of the family
6 M/ y; S0 _/ C7 Tmay have similar precocious puberty.3
, x4 t( m* ], u4 E5 QIn our patient, physical examination was incon-
& @5 D, `4 s' O# J9 |; `sistent with true precocious puberty since his testi-
: {$ ?* O8 Q9 m& ncles were prepubertal in size. However, testotoxicosis3 Z" ^, b4 [0 r* r6 F9 D5 q; M
was in the differential diagnosis because his father1 }; D( t1 b/ B; G
started puberty somewhat early, and occasionally,
- B: A" W% U- J# ]# H5 z' itesticular enlargement is not that evident in the s, G$ f @" l' t* F/ W
beginning of this process.1 In the absence of a neg-! G$ O1 u: ]0 j* ?: ]% f( L7 i
ative initial history of androgen exposure, our
) z! y4 r# A. w4 a, zbiggest concern was virilizing adrenal hyperplasia,
" n" T7 L' w; }1 N4 j, R' P; zeither 21-hydroxylase deficiency or 11-β hydroxylase
8 m7 t! R- h! n) P9 hdeficiency. Those diagnoses were excluded by find-; m3 q9 C- {3 S. t6 F. g
ing the normal level of adrenal steroids.
4 v' l/ m- _+ K) e9 S/ CThe diagnosis of exogenous androgens was strongly/ j8 s2 m8 m) C, N; A7 A6 D% q# N
suspected in a follow-up visit after 4 months because
5 c& ]- u0 H4 gthe physical examination revealed the complete disap-
$ F6 k; J4 {9 Ypearance of pubic hair, normal growth velocity, and
7 j, x- m4 H/ G$ t% {, m) fdecreased erections. The father admitted using a testos-
4 `# Y+ ?. E: ^6 X2 _, eterone gel, which he concealed at first visit. He was
& c9 L( O7 F, [* o' N4 I \% N+ Dusing it rather frequently, twice a day. The Physicians’8 D; x2 N) F0 n& e$ b" F7 k
Desk Reference, or package insert of this product, gel or
" T# |* M% {, v/ `5 Gcream, cautions about dermal testosterone transfer to6 n% p. v, w& O" a0 j* ]
unprotected females through direct skin exposure.
7 I% j1 ?1 Q4 hSerum testosterone level was found to be 2 times the
& X- h6 f& F" T: z8 E% T x/ Dbaseline value in those females who were exposed to1 x2 S: K) e8 V Z6 S& d, D
even 15 minutes of direct skin contact with their male
& m2 P& Q2 F4 E- r8 A; Wpartners.6 However, when a shirt covered the applica- e: C" d% B' z, [
tion site, this testosterone transfer was prevented.
, v! e( f% r+ a. P: ]) x* \4 P6 XOur patient’s testosterone level was 60 ng/mL,9 {: n. G) t, d- l) e
which was clearly high. Some studies suggest that" W: p2 ^* {) L' b& Y$ s; ^+ C/ a
dermal conversion of testosterone to dihydrotestos-( U8 |. W! I, `* Z6 u
terone, which is a more potent metabolite, is more
0 A: I4 J- F5 V1 d7 a. gactive in young children exposed to testosterone
! k2 @8 h0 F0 H, k, fexogenously7; however, we did not measure a dihy-/ `- ]8 p) f7 U, e. g5 q- v! k
drotestosterone level in our patient. In addition to
3 l# ^2 Q8 I9 j2 lvirilization, exposure to exogenous testosterone in
+ I; d x1 Z" x. qchildren results in an increase in growth velocity and0 M5 \) M) D8 L' A+ M+ T
advanced bone age, as seen in our patient.
$ C& F( G+ m3 {# ?4 j+ @4 H8 Q( {* YThe long-term effect of androgen exposure during9 O6 |8 N! }- o. B
early childhood on pubertal development and final
* _& u! e, d* r1 {! xadult height are not fully known and always remain0 T* X g C/ \) d7 ]* r }. O
a concern. Children treated with short-term testos-
" O# d* c8 y# E" W0 [6 J+ _) Lterone injection or topical androgen may exhibit some) N. V1 Z8 U/ f+ \, } i+ d
acceleration of the skeletal maturation; however, after
, Z4 q) i/ B# l$ l& i) R/ P+ ~cessation of treatment, the rate of bone maturation
$ A/ ^: E; V$ Y2 u# A* @decelerates and gradually returns to normal.8,9% a' v/ c7 f* S% q2 o' l% L
There are conflicting reports and controversy
' r% X4 x/ n. P' Y. g' uover the effect of early androgen exposure on adult
$ F. O7 V9 T o' U$ @penile length.10,11 Some reports suggest subnormal4 e; R: x8 E8 }" K
adult penile length, apparently because of downreg-
- S( w2 }6 y- i0 {2 @ Q& n0 Oulation of androgen receptor number.10,12 However,9 O$ |. U2 C6 E9 f$ J9 y
Sutherland et al13 did not find a correlation between
5 e8 G u% _$ r; [, ^: xchildhood testosterone exposure and reduced adult% m- `1 s) A2 {( E! \) i
penile length in clinical studies.
4 Y+ e% o& V0 u ?1 KNonetheless, we do not believe our patient is
R6 V6 z5 j3 b9 N7 M: N$ ]) ?0 Wgoing to experience any of the untoward effects from
8 \6 }" c6 C4 |& C3 S8 h+ j6 otestosterone exposure as mentioned earlier because2 o U# p- ~% C4 s
the exposure was not for a prolonged period of time.5 U! \ H( e. r
Although the bone age was advanced at the time of
9 \9 Z& d+ ]0 `; j7 P/ odiagnosis, the child had a normal growth velocity at, Q4 Q5 I0 m7 u/ y# {" ?: v: N
the follow-up visit. It is hoped that his final adult3 A$ K. Z. q) ^* B: Q; Y
height will not be affected.2 E) Q' @, |9 n& d0 E9 V
Although rarely reported, the widespread avail-
& R8 m: t- Q! T( \4 k* o# j+ n |ability of androgen products in our society may
) K. L, i' |! \9 C! o6 l [. nindeed cause more virilization in male or female1 ?( S2 t! V8 z0 L* U
children than one would realize. Exposure to andro-
) f4 s- P7 H2 {9 p' U' O7 d igen products must be considered and specific ques-
$ c4 x- I& ~" I, Rtioning about the use of a testosterone product or
$ w" v, g; S6 L$ X9 {2 i2 r' egel should be asked of the family members during
/ L; X7 h# O$ H+ Vthe evaluation of any children who present with vir-- e$ s9 V( c/ r# W/ J+ R6 w/ ]8 }
ilization or peripheral precocious puberty. The diag-0 z' \5 p' @- C( Q8 M* j
nosis can be established by just a few tests and by8 l) U5 Q5 R" S. X1 |! J( n4 \' l
appropriate history. The inability to obtain such a
, |( B/ l- S2 @2 [history, or failure to ask the specific questions, may
5 @3 X8 _8 t5 ^2 I, P; H$ Uresult in extensive, unnecessary, and expensive, c/ Q! [" u9 r' }& |
investigation. The primary care physician should be. C% J( e3 A ]6 T
aware of this fact, because most of these children, p B( B0 A; E; A- {$ @
may initially present in their practice. The Physicians’% @" I) ]. h( i
Desk Reference and package insert should also put a8 c0 g4 t& b( ^, I2 K& D7 e
warning about the virilizing effect on a male or/ I2 u3 I& [. m0 \2 m7 k0 q8 v
female child who might come in contact with some-
( Y$ H, `' A1 Done using any of these products.4 a. |8 j% E* r7 }, p' S
References. u( d- z2 L f
1. Styne DM. The testes: disorder of sexual differentiation& \( E: ]3 }. B& N9 Y3 p
and puberty in the male. In: Sperling MA, ed. Pediatric2 o2 Z7 f. m9 f3 u* d' n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. ^* h& V- J% l1 [2 F2002: 565-628.
4 I5 _: k/ G5 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 r# I& S! c9 G. K" v8 X6 [
puberty in children with tumours of the suprasellar pineal |
|