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Sexual Precocity in a 16-Month-Old, ]# [* o8 k7 k( V6 X& @* N
Boy Induced by Indirect Topical
: q% d! j I5 Q: V; j# ?, {$ dExposure to Testosterone
& Q, V# C7 c; ~& S7 I/ w$ L3 FSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, x( B# t1 q( s K" Y. @+ {; d3 J6 B4 ^
and Kenneth R. Rettig, MD1, i" v: I. X) h# P# x
Clinical Pediatrics) X( B. q# K# M
Volume 46 Number 6/ p7 L1 P# P$ X, `% ]! k3 Y. w
July 2007 540-543
# A+ c- y/ P( V" Y4 d© 2007 Sage Publications/ b. ~) A! Y% @8 \+ Y7 I0 P
10.1177/0009922806296651
6 r4 C/ m+ D4 Fhttp://clp.sagepub.com
0 y' {% I* c- F! ~- [hosted at' A) A! P% _* C9 m' P; ^: Z
http://online.sagepub.com4 K$ Q" l6 p* M. U+ o
Precocious puberty in boys, central or peripheral,* X" q7 x. O4 _1 V* {) r
is a significant concern for physicians. Central, s+ F8 r. {/ U; A1 b
precocious puberty (CPP), which is mediated# H, }, Z' g& f7 |! c# V
through the hypothalamic pituitary gonadal axis, has1 N& [2 Y2 d8 Z. E% m8 ~
a higher incidence of organic central nervous system# l" z* @" r+ Q9 q+ B D$ v
lesions in boys.1,2 Virilization in boys, as manifested
. V9 W% r" ^% q: A0 k8 a3 ^; D$ z* Lby enlargement of the penis, development of pubic$ l- {8 \0 D. l$ y% I
hair, and facial acne without enlargement of testi-2 D- v7 G& S+ t( J% n
cles, suggests peripheral or pseudopuberty.1-3 We0 R. a5 J" c* V0 n/ U
report a 16-month-old boy who presented with the
6 x8 R& q+ K- [3 renlargement of the phallus and pubic hair develop-& n3 g R! N; k W
ment without testicular enlargement, which was due
: M0 e- E& F! i s1 v8 e4 Gto the unintentional exposure to androgen gel used by6 D# y2 ?' b+ U4 w( B k3 c
the father. The family initially concealed this infor-
$ z/ T$ ^6 r/ M+ |; wmation, resulting in an extensive work-up for this9 f, I9 ~: k0 w, f+ o7 O8 a# F
child. Given the widespread and easy availability of( V2 d2 e& D0 ^: B* D' y9 X
testosterone gel and cream, we believe this is proba-& z8 Q6 T' `& j+ P+ d" p
bly more common than the rare case report in the/ L1 u& X* D! y% N# {
literature.4: B6 O( w; _. x e0 w& B% f8 t
Patient Report
) M7 a7 v5 p1 i, C! Q; W0 [A 16-month-old white child was referred to the; l" A( S7 l5 c, ~" I1 k; _
endocrine clinic by his pediatrician with the concern
; v" Z2 a$ F: iof early sexual development. His mother noticed
3 H! C/ |9 u5 b% N7 qlight colored pubic hair development when he was" B6 y* w; M0 N7 H: G+ k( D4 i
From the 1Division of Pediatric Endocrinology, 2University of" o; D/ @8 `/ V L4 e1 ]
South Alabama Medical Center, Mobile, Alabama.: g! b! E% S# m0 w
Address correspondence to: Samar K. Bhowmick, MD, FACE,0 C8 d9 ?% i9 @; V" w+ ^* W( b
Professor of Pediatrics, University of South Alabama, College of: @+ C+ J; c# n, L3 l. D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 D, y, B# w, o0 F* ke-mail: [email protected].0 b/ z8 H8 r3 g* |# `+ T# f
about 6 to 7 months old, which progressively became
3 ~" `# U" f2 ldarker. She was also concerned about the enlarge-
8 U4 S& n/ `+ a; P3 Qment of his penis and frequent erections. The child
) R" q3 S; ]0 m) i5 Ywas the product of a full-term normal delivery, with; F1 D8 I9 @- P4 d
a birth weight of 7 lb 14 oz, and birth length of
+ ~% u0 A d8 l3 Q( c7 V! n20 inches. He was breast-fed throughout the first year8 f. U1 I0 @8 P5 C3 g- t z) u
of life and was still receiving breast milk along with( T# p; Y) p. W, ^% R9 k5 V
solid food. He had no hospitalizations or surgery, |$ j5 ~, t( \4 U3 {
and his psychosocial and psychomotor development
% v5 d8 V5 x1 s% i X; ywas age appropriate.
" V3 v7 b" S* A1 P. lThe family history was remarkable for the father,
/ C) E, ]/ a. N# L( P2 A2 [6 Lwho was diagnosed with hypothyroidism at age 16,
* C. A" P7 I4 g c- n/ x* \which was treated with thyroxine. The father’s
8 x7 y2 z1 O2 o+ H( U& fheight was 6 feet, and he went through a somewhat
2 Q+ _/ X8 Y2 O% [& s" }( Rearly puberty and had stopped growing by age 14.$ i1 N( O% D% _ W$ C' K( M/ |
The father denied taking any other medication. The
1 h, w9 e7 ^9 y5 c7 w4 lchild’s mother was in good health. Her menarche9 a) V' b' `( T
was at 11 years of age, and her height was at 5 feet
# {( P- z8 U$ X5 ^9 R" \, | |5 inches. There was no other family history of pre-# k. X4 c% F9 Q9 u. q6 t
cocious sexual development in the first-degree rela-9 G! E1 I" Q5 o3 X& ?- {
tives. There were no siblings.
; R' T# h4 h8 J9 R9 jPhysical Examination
+ x* f* d7 a" M. N l# dThe physical examination revealed a very active,
|7 X, E8 |' |/ [- I- c$ R' [& }playful, and healthy boy. The vital signs documented
- y# }3 {- I6 Na blood pressure of 85/50 mm Hg, his length was
# _2 K# G c& N9 ^1 c90 cm (>97th percentile), and his weight was 14.4 kg6 D: Y& j; _: r0 K! b
(also >97th percentile). The observed yearly growth
8 p! N, P3 P" ], o. pvelocity was 30 cm (12 inches). The examination of/ ^, u \: O/ b. k
the neck revealed no thyroid enlargement.
, }% e9 K! W% E% n' p4 _The genitourinary examination was remarkable for2 I3 {! X1 C. ^. y7 P
enlargement of the penis, with a stretched length of1 W$ @7 x9 J! G$ p- {
8 cm and a width of 2 cm. The glans penis was very well' T* D' Z) `& B& U
developed. The pubic hair was Tanner II, mostly around* c% U- k0 K3 F ~& H* i8 f
540
+ ^/ K! u* |" v" e2 _ Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
i. ]" l7 @% n! E ^/ x6 U6 Ythe base of the phallus and was dark and curled. The
3 e8 h2 a0 U- t: Y* `testicular volume was prepubertal at 2 mL each.
( f+ P4 w% S" W$ S" O9 {The skin was moist and smooth and somewhat
/ E) t* @% _; G" Voily. No axillary hair was noted. There were no
& j9 z. q' [: w4 A2 X* _/ A. ^abnormal skin pigmentations or café-au-lait spots.& D' F8 |$ M0 V5 W- d9 a3 r
Neurologic evaluation showed deep tendon reflex 2+" h5 e" V4 w' o
bilateral and symmetrical. There was no suggestion: d: p+ _5 o$ |: n5 ]; `2 [
of papilledema.
0 H/ Y2 w( F' ]: g* |! F0 G5 H; ]Laboratory Evaluation
8 g1 h, c1 v9 ?* ^ ^The bone age was consistent with 28 months by
! x& |7 M2 F1 {0 o2 c, P$ eusing the standard of Greulich and Pyle at a chrono-6 U; O3 F. w q6 Y/ K/ H8 P3 Z
logic age of 16 months (advanced).5 Chromosomal N6 S" e! o Q3 L0 a
karyotype was 46XY. The thyroid function test% L# n$ P8 N- w- d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 N2 R( \0 y$ f3 K
lating hormone level was 1.3 µIU/mL (both normal).
1 \/ A" q( K+ t6 g. R; b, eThe concentrations of serum electrolytes, blood8 O/ R! g$ t+ i4 V4 o4 I# M
urea nitrogen, creatinine, and calcium all were
9 K8 W# A' @+ c) K& Hwithin normal range for his age. The concentration
# }# o: i( p7 ^; M( O8 Z4 Gof serum 17-hydroxyprogesterone was 16 ng/dL
! \- m5 G8 x: @9 O7 Z: @(normal, 3 to 90 ng/dL), androstenedione was 20, U. R" H* N' p1 {- {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& f, z: L) ]: A4 r& l, j4 j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& G3 ]; S. @8 f; {+ N/ o2 i) odesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 A( U/ f0 N! \ b8 j) N
49ng/dL), 11-desoxycortisol (specific compound S), J5 }. R6 g9 ~/ J0 ^9 G: H% ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" U# b4 U+ |5 `. K. M( \ |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( x" w3 d/ R ^( L5 V$ N$ {/ [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," b7 Q8 s. ]" J5 }
and β-human chorionic gonadotropin was less than
9 h! u' a" R1 C8 k; P1 E; T9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular: ^6 L' H. H- J$ W
stimulating hormone and leuteinizing hormone* |6 @" g2 J; w
concentrations were less than 0.05 mIU/mL0 c) b( p% P1 i# K, I
(prepubertal).
1 ^2 |3 Q4 |8 O- I7 v+ n% VThe parents were notified about the laboratory
4 u' }8 G o" [+ V) G# iresults and were informed that all of the tests were
, g5 |2 K, c6 P; B7 N& c& w# ynormal except the testosterone level was high. The
1 B! S9 ~- K a3 F& Sfollow-up visit was arranged within a few weeks to% m E4 d3 k4 r
obtain testicular and abdominal sonograms; how-/ e" Q' h/ Q( j% w4 m$ k* E- Q
ever, the family did not return for 4 months.
) L* D/ H* v4 n8 UPhysical examination at this time revealed that the- g2 G3 I6 h% m0 h8 G& L
child had grown 2.5 cm in 4 months and had gained
# }, ?0 W, ?0 G, Z2 kg of weight. Physical examination remained
% E* Y% X, @9 t/ cunchanged. Surprisingly, the pubic hair almost com-
9 h( x- A' K z5 C% Upletely disappeared except for a few vellous hairs at
& c; n; l& d3 h9 ^9 R! nthe base of the phallus. Testicular volume was still 2+ ^/ K3 H* Q9 i9 _3 N0 r
mL, and the size of the penis remained unchanged.( ^' h9 M( i( I
The mother also said that the boy was no longer hav-
% j: V8 J }; i. t& S1 l: \ Ping frequent erections.
, j0 p! P) y7 q4 s8 ^Both parents were again questioned about use of
0 c% }2 J5 `, q: J6 o( Zany ointment/creams that they may have applied to
0 {. y; `) o2 } K. ]the child’s skin. This time the father admitted the, a* ?. d. o+ s+ M3 @
Topical Testosterone Exposure / Bhowmick et al 541* s4 @- L, o/ _, T
use of testosterone gel twice daily that he was apply-
! R9 o4 e. I$ s1 ?, k1 A$ ~3 Ging over his own shoulders, chest, and back area for& \( ~- l$ H8 h' X \
a year. The father also revealed he was embarrassed; S1 I# {0 v3 I, j$ ~, ?( I& L
to disclose that he was using a testosterone gel pre-
$ R' F9 D! u$ r ^" x tscribed by his family physician for decreased libido
" P0 ^2 o* e6 a/ T; G2 dsecondary to depression.
: v5 ^. u$ q3 V2 tThe child slept in the same bed with parents.
! L. T: n8 c8 ^1 d5 a! |' HThe father would hug the baby and hold him on his
0 R3 Z0 O6 q+ z( ^7 \( `6 K/ b6 qchest for a considerable period of time, causing sig-
3 t/ _% P2 A9 G: o0 B# h( I8 T+ L' ]nificant bare skin contact between baby and father.; q7 R" v7 y: T8 U% Y2 a% D
The father also admitted that after the phone call,
% p5 H6 O/ F8 ]$ Rwhen he learned the testosterone level in the baby, Y. x4 D# @8 \* }
was high, he then read the product information
% Q* X# s0 K9 e/ K1 U9 ~, apacket and concluded that it was most likely the rea-
& A, y3 e' W0 P' j6 I; I+ f+ Json for the child’s virilization. At that time, they
% H+ F" p& ^$ I, ddecided to put the baby in a separate bed, and the
' C* @- [2 o4 E) N/ }7 w" v/ z0 |father was not hugging him with bare skin and had
1 ^3 K( E' `" U2 G4 Vbeen using protective clothing. A repeat testosterone0 M& ^9 [1 ~' E; @ Z% _/ C4 g4 H9 I
test was ordered, but the family did not go to the7 e9 _; c( ^ n- V0 M) ?
laboratory to obtain the test./ s( F; F2 m0 q& y( y ?
Discussion0 e9 @0 @) T4 ?( ^/ A; C, T' o( `
Precocious puberty in boys is defined as secondary
! o9 _$ k+ w0 o* K9 ^4 d/ lsexual development before 9 years of age.1,4# T4 E6 k# l- V' p6 i0 \6 S
Precocious puberty is termed as central (true) when( X9 q8 ^7 g% z0 e) \
it is caused by the premature activation of hypo-
, h+ j2 b* f( T3 othalamic pituitary gonadal axis. CPP is more com-7 l0 q3 B( k: P1 d3 {$ G. b
mon in girls than in boys.1,3 Most boys with CPP
3 [; H& p7 A# K7 F# C2 Nmay have a central nervous system lesion that is2 ^" M2 i$ t; y
responsible for the early activation of the hypothal-5 s R# c8 Y0 T, u( x
amic pituitary gonadal axis.1-3 Thus, greater empha-/ V# C( z, @" E, J& s
sis has been given to neuroradiologic imaging in" g* i! _2 c/ J6 B, U
boys with precocious puberty. In addition to viril-
9 u. s# @2 i; V3 B# Kization, the clinical hallmark of CPP is the symmet-% w! w/ v5 x6 X. m6 T6 p$ b
rical testicular growth secondary to stimulation by! E1 S, P* q2 f4 p6 L" a
gonadotropins.1,3
6 m; ^+ }2 _# U8 d% KGonadotropin-independent peripheral preco-' w6 x9 M: x6 a
cious puberty in boys also results from inappropriate7 b- a i) ^- v1 c" |8 r+ l
androgenic stimulation from either endogenous or* H$ A5 Y9 H+ c1 D
exogenous sources, nonpituitary gonadotropin stim-$ F) g x% s3 Z) {+ d* {
ulation, and rare activating mutations.3 Virilizing
; |0 |+ D2 b3 @, N$ c% S/ [0 H3 acongenital adrenal hyperplasia producing excessive
; @5 a5 ?; A+ }$ `) b& r" p& ~5 s4 Nadrenal androgens is a common cause of precocious
- ?) ?) `5 j" i; Qpuberty in boys.3,4
, c" L5 q# d/ e4 W: ]! V* XThe most common form of congenital adrenal+ A# `6 y) _9 [. G i B7 J
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ G' c1 D1 [0 [" {The 11-β hydroxylase deficiency may also result in3 h" H9 ]9 n- Z) |& x
excessive adrenal androgen production, and rarely,
) U; `$ {2 w) k* Z! J6 uan adrenal tumor may also cause adrenal androgen
+ Y x3 f& ]3 V& }$ Q8 `excess.1,3* Y0 B! u/ Z$ O( M$ w r+ j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) I4 L& Y5 R7 m
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 {. `# \" i! _" R3 L/ S7 \
A unique entity of male-limited gonadotropin-$ L: j9 ~2 I) P
independent precocious puberty, which is also known
9 n3 v- b `6 L* G: @as testotoxicosis, may cause precocious puberty at a
9 e* D! W6 N6 p* _ k% ] Cvery young age. The physical findings in these boys
6 z! L# {" @& W' z3 X0 uwith this disorder are full pubertal development,4 R* ?0 i1 E& j" E" V5 r
including bilateral testicular growth, similar to boys/ e J4 D( ]4 O
with CPP. The gonadotropin levels in this disorder2 A6 a+ O* R' _) I, H
are suppressed to prepubertal levels and do not show
0 R- V9 i# E3 e7 d, z: M' o% e- Wpubertal response of gonadotropin after gonadotropin-9 ~5 m6 U0 s8 Z! P7 S0 `* R$ I; z
releasing hormone stimulation. This is a sex-linked8 Q* |% Q) ?2 L" E
autosomal dominant disorder that affects only
" M" ?9 ~+ b1 G4 ]+ kmales; therefore, other male members of the family8 n& r/ m) V c+ f
may have similar precocious puberty.3
4 m- n- y) ~' W$ b9 f5 W& NIn our patient, physical examination was incon-
) F3 q9 ~$ ~" \% d, csistent with true precocious puberty since his testi-
% \3 P1 S1 X5 W5 i0 zcles were prepubertal in size. However, testotoxicosis
3 B4 ~1 N! B2 D8 Vwas in the differential diagnosis because his father) m8 v) q4 C% Y4 I$ r# Z
started puberty somewhat early, and occasionally,
9 J5 T6 q) X! b( b7 Utesticular enlargement is not that evident in the
. m8 X% F K7 w. x `beginning of this process.1 In the absence of a neg-; s& E; C% \( _+ d1 U2 p! h
ative initial history of androgen exposure, our
9 J! o! D- r2 p S' Q r2 xbiggest concern was virilizing adrenal hyperplasia,
/ t# S. N- i& ^3 x0 u! xeither 21-hydroxylase deficiency or 11-β hydroxylase
% b M& P4 G' v4 o- L) b% `3 l- mdeficiency. Those diagnoses were excluded by find-
5 ^! D) }1 s5 d9 s7 k! _ ~( _ing the normal level of adrenal steroids.
+ Y# C7 ~% k# I. tThe diagnosis of exogenous androgens was strongly) p* n" ]! X! T' P
suspected in a follow-up visit after 4 months because, n+ m3 }- N4 A" d( O* e! i" ^
the physical examination revealed the complete disap-- G7 j- H" L6 T m" M6 b7 D/ C
pearance of pubic hair, normal growth velocity, and
! I' B" w4 p+ d& @' udecreased erections. The father admitted using a testos-
# D) ^+ [' `; O/ N* qterone gel, which he concealed at first visit. He was
6 p: U/ K/ T0 S# V7 F1 dusing it rather frequently, twice a day. The Physicians’
' i2 b8 V1 r5 R& x2 ?8 LDesk Reference, or package insert of this product, gel or
! U, _7 f% B: R6 i. r- r4 |cream, cautions about dermal testosterone transfer to
* B- v1 ]( J% U/ x! sunprotected females through direct skin exposure.; m Z9 W E$ |+ J$ N
Serum testosterone level was found to be 2 times the/ \* M' p9 Q. ?/ p. ^! V" M* H
baseline value in those females who were exposed to6 D8 i' ]0 n5 \5 h% t1 R
even 15 minutes of direct skin contact with their male
% P& O- {6 ]0 ~" b, e( Dpartners.6 However, when a shirt covered the applica-1 }/ t( l# K0 h' H1 U/ t% p
tion site, this testosterone transfer was prevented.7 x( O5 m0 `3 \ J
Our patient’s testosterone level was 60 ng/mL,
, Y6 t/ H% B: s/ G" s. Rwhich was clearly high. Some studies suggest that' V+ E! D) w5 o, |6 y
dermal conversion of testosterone to dihydrotestos-/ f z8 Y+ o9 F3 T
terone, which is a more potent metabolite, is more
$ {2 y# q% Q# W& I) `2 kactive in young children exposed to testosterone
9 l! c+ ^" w2 _. J/ W; [exogenously7; however, we did not measure a dihy-( [& k* l2 ?( n) e- l+ [" v
drotestosterone level in our patient. In addition to& h% U# T6 h9 y& e9 o( f
virilization, exposure to exogenous testosterone in
& U) a. V$ \: `, J! y+ [children results in an increase in growth velocity and
' V, w- U/ o; |* r7 x6 Zadvanced bone age, as seen in our patient. ?' P" B! m2 {1 q3 X
The long-term effect of androgen exposure during$ S3 y2 r& t1 L1 _: t( _- @
early childhood on pubertal development and final
# z" |4 @1 ?( @2 S; Gadult height are not fully known and always remain
9 r+ t3 G. ]0 o0 G Aa concern. Children treated with short-term testos-* ?' a4 z5 C) i- I
terone injection or topical androgen may exhibit some; b o, p, C) M5 [
acceleration of the skeletal maturation; however, after
: X& q/ ]5 I* w, ocessation of treatment, the rate of bone maturation2 }9 d' @& ]" f- S
decelerates and gradually returns to normal.8,9! ~) T* j0 b- }
There are conflicting reports and controversy ^4 U" e2 w2 R! g9 e
over the effect of early androgen exposure on adult/ l, _& G9 G8 t. N( _
penile length.10,11 Some reports suggest subnormal
6 V. T" h9 I" qadult penile length, apparently because of downreg-
4 @1 ^4 ~8 ]% Vulation of androgen receptor number.10,12 However,2 B, O* G$ E- m8 O- j' M
Sutherland et al13 did not find a correlation between3 R1 s; F1 D$ G0 g# X' a
childhood testosterone exposure and reduced adult5 G! o$ X7 B$ [6 t9 T
penile length in clinical studies.) M& n+ f& T. S8 O' B$ A0 N
Nonetheless, we do not believe our patient is, Z" z2 N3 n4 u) o# Q! [
going to experience any of the untoward effects from
# j2 \9 k- F6 R3 `testosterone exposure as mentioned earlier because5 H' s/ A4 B: K6 R# Z+ A6 w$ s
the exposure was not for a prolonged period of time.
\' S8 b& R; }) x" e( zAlthough the bone age was advanced at the time of( _( F' ]% S6 \; ~% {) q
diagnosis, the child had a normal growth velocity at3 `2 G* h; ?" X9 h" x3 d# C
the follow-up visit. It is hoped that his final adult# D$ F1 S+ F6 p1 ?4 G# D4 Z
height will not be affected.& p7 `; f: {, g7 R8 Y
Although rarely reported, the widespread avail-9 z0 J/ Z0 K! t( D
ability of androgen products in our society may
3 P- j% F: @- T# iindeed cause more virilization in male or female% n* N+ a/ i/ y, g% D! P& X1 B
children than one would realize. Exposure to andro-
. x2 G2 B x$ t, I, n7 u* Y- Qgen products must be considered and specific ques-- ^ C8 y% D# H. F) O$ W
tioning about the use of a testosterone product or
! Z; C% \+ S& _7 d5 O' tgel should be asked of the family members during2 r# c$ G0 t; z; V8 X' k; P' L$ f; q& y
the evaluation of any children who present with vir-6 E8 H' E# H8 A: m6 ~- r: [
ilization or peripheral precocious puberty. The diag-& ]. v3 q% J! v" K, z1 q, ~
nosis can be established by just a few tests and by
9 S5 L' h! Y. ]6 }+ ?- }. yappropriate history. The inability to obtain such a: t. ?" r$ O5 e* L
history, or failure to ask the specific questions, may' x% F% W; D9 H/ h7 x2 Y
result in extensive, unnecessary, and expensive
9 X q+ H) Q, m6 Y) ainvestigation. The primary care physician should be
8 f' J) |5 ~6 |& z! f0 Yaware of this fact, because most of these children
8 v2 _, K1 R- ?may initially present in their practice. The Physicians’; }9 ]# A( c' O& Z" j% `
Desk Reference and package insert should also put a; W' C5 C N( ]8 R3 X+ ~
warning about the virilizing effect on a male or/ x4 d1 J- z! N- N/ H$ C6 ^
female child who might come in contact with some-# c% ~. w! @7 c2 A
one using any of these products.4 {) W, r# C1 j$ M8 f1 z W
References
) l m! D' U. C1. Styne DM. The testes: disorder of sexual differentiation
0 P: ~4 f* @! T' f: M1 @and puberty in the male. In: Sperling MA, ed. Pediatric
1 i$ @9 U; r2 J; _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) [: B+ v6 h' m& O2002: 565-628.
6 L: Q* N( Z5 H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ h8 F3 u, t; P7 m4 U# u( v; b+ S
puberty in children with tumours of the suprasellar pineal |
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