- 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$ k K! S4 Q2 i f
Boy Induced by Indirect Topical" @ j' {5 c3 d0 n7 F
Exposure to Testosterone
1 O/ G+ s, i, `- R$ XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 a3 x, Y% Y+ L O, m j4 |* [$ ~
and Kenneth R. Rettig, MD1
+ c8 U: c' _5 N8 b& y+ n; PClinical Pediatrics# W' w3 h- M, A6 W3 c, ^ Z
Volume 46 Number 6
3 J; l f: z( h, b) {; m5 `. O+ \4 MJuly 2007 540-5432 w! x% v3 u, n! m/ M$ l$ q7 _( W( l
© 2007 Sage Publications
+ ?' x7 S' x+ _' r3 E7 ]10.1177/0009922806296651: M, ?/ u- Z& ?7 n7 C+ }% l
http://clp.sagepub.com
' M: w, z. t& F7 x$ ^! k/ a" phosted at
7 M6 Q1 }6 Q/ \. h4 ^http://online.sagepub.com, l" \! J. h2 U
Precocious puberty in boys, central or peripheral,
& d" J' y$ F% b+ i2 iis a significant concern for physicians. Central
5 O4 z3 @" K" l; A$ r# @precocious puberty (CPP), which is mediated- T* |1 `# v Z' A) |, S
through the hypothalamic pituitary gonadal axis, has1 t: R5 h* x* x) ~+ m7 R! C
a higher incidence of organic central nervous system$ z% N, F4 d6 K- R
lesions in boys.1,2 Virilization in boys, as manifested( }8 ?# k' Z- Y" W8 W
by enlargement of the penis, development of pubic8 {. @5 X, ]4 x/ o
hair, and facial acne without enlargement of testi-
& r( l3 u7 Y- u/ T0 a. B/ A4 vcles, suggests peripheral or pseudopuberty.1-3 We
+ d$ o' Y- K5 Dreport a 16-month-old boy who presented with the- L# s2 I/ A! O3 I2 F' |5 e5 p8 C
enlargement of the phallus and pubic hair develop-1 }0 ~" [) B" }7 e7 L0 q8 |. _
ment without testicular enlargement, which was due7 L6 Z( V+ c/ b2 }* h/ ?$ B3 R
to the unintentional exposure to androgen gel used by
7 u6 @" q+ i! D5 `. Vthe father. The family initially concealed this infor-
3 }% G) V$ [5 l6 G; kmation, resulting in an extensive work-up for this
! D) p' N( E& `! Mchild. Given the widespread and easy availability of
* c+ j. q8 s2 dtestosterone gel and cream, we believe this is proba-
}$ j! q4 _& Y0 L! s9 Hbly more common than the rare case report in the
g9 F( _/ ^5 P! w* P0 j. C" ^6 Y+ vliterature.40 G) E* Q9 V1 S3 B
Patient Report, n& l: l9 M8 Z7 g' E! q' H# C
A 16-month-old white child was referred to the
2 X3 J O) G! e: `) U9 jendocrine clinic by his pediatrician with the concern, f' E: o0 T& u7 J' p) c5 o% F
of early sexual development. His mother noticed
/ X) K" t" C/ W& Slight colored pubic hair development when he was
( _+ H) j# _$ ?4 B9 M0 iFrom the 1Division of Pediatric Endocrinology, 2University of
/ K5 y+ Z" C1 V& ?4 g- v: ySouth Alabama Medical Center, Mobile, Alabama.
7 z* t$ N' N4 }# N' x! b5 kAddress correspondence to: Samar K. Bhowmick, MD, FACE,* A" b# [- l B8 r. c
Professor of Pediatrics, University of South Alabama, College of/ R1 Y: }( Y: R2 P' w
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- a; H: }9 l, `* I9 [1 z
e-mail: [email protected].9 n4 f. T# o/ w
about 6 to 7 months old, which progressively became
' [' E2 f9 U! \: _! }1 Qdarker. She was also concerned about the enlarge-
) G5 E8 J" Y& _% ]ment of his penis and frequent erections. The child+ @2 o/ j$ X: b9 O8 l
was the product of a full-term normal delivery, with' }. y! F6 ~: I; b7 b C
a birth weight of 7 lb 14 oz, and birth length of8 O6 A2 L, f0 s! A) X8 Z0 k+ ?- m
20 inches. He was breast-fed throughout the first year
V3 S; [/ X. O6 W& Z9 f1 g1 N0 Rof life and was still receiving breast milk along with, k: \- d3 |5 `) P1 f# K
solid food. He had no hospitalizations or surgery,( A' p2 i5 H) d! A* e/ y
and his psychosocial and psychomotor development
$ E% |! D+ g; b/ X1 gwas age appropriate.
8 H' X- W: K# _+ K% s. Q9 IThe family history was remarkable for the father,( ]) y6 x g+ W* H- H5 Q8 _
who was diagnosed with hypothyroidism at age 16,5 M& g) B6 }# X& L) J, b
which was treated with thyroxine. The father’s+ g3 z5 Q" a' [ h, |
height was 6 feet, and he went through a somewhat
, ~# P; @9 M! {* b8 i( Q7 h' iearly puberty and had stopped growing by age 14.& K, J3 g9 J5 s. q
The father denied taking any other medication. The$ n& A; i+ B+ p
child’s mother was in good health. Her menarche
" ` t% x. _& ]( {was at 11 years of age, and her height was at 5 feet* G0 d& \1 V- M6 J' P' ?) }1 T6 m
5 inches. There was no other family history of pre- N4 r7 [5 O8 S* @5 J
cocious sexual development in the first-degree rela-
' o v! }, T* S* k& d% H5 ztives. There were no siblings.
7 _, h; S1 o5 m& @Physical Examination) W! h2 e2 w, o! ^6 E/ ~. N
The physical examination revealed a very active,# q6 u+ C, f W% F3 i
playful, and healthy boy. The vital signs documented
$ {+ h5 O/ t. L) Za blood pressure of 85/50 mm Hg, his length was
' g0 |! N7 j2 b6 ?8 c9 F90 cm (>97th percentile), and his weight was 14.4 kg& J( T# i- g" c1 J
(also >97th percentile). The observed yearly growth/ ^/ B8 k& n8 `! b$ z" Y
velocity was 30 cm (12 inches). The examination of
6 q/ h9 I; x6 Q8 bthe neck revealed no thyroid enlargement.
5 [" Z* Y$ @1 k& c8 i& V" O! ?The genitourinary examination was remarkable for( j( ~( Y0 S4 X/ U5 J
enlargement of the penis, with a stretched length of
) }+ L/ u' _4 s* Y) x0 c$ ^* u8 cm and a width of 2 cm. The glans penis was very well
% f9 _& I! ~# c0 wdeveloped. The pubic hair was Tanner II, mostly around$ {: D7 v: Z4 _5 b! I7 }2 O7 |3 `
540
b0 |( j) {0 k, t* L% O. c% n$ fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# l* Q" k$ T* ]: A O
the base of the phallus and was dark and curled. The/ R( o# F. o8 R$ A8 }9 Y
testicular volume was prepubertal at 2 mL each.5 k% h) K" X4 ]8 S2 R2 K" D
The skin was moist and smooth and somewhat, N7 N0 o4 s: k
oily. No axillary hair was noted. There were no
6 F7 P, H% ] S& p' Eabnormal skin pigmentations or café-au-lait spots." U* `+ F7 X) V0 K/ D
Neurologic evaluation showed deep tendon reflex 2+) x6 r3 X5 V0 C3 z1 u7 m5 t# X
bilateral and symmetrical. There was no suggestion
( ~ x3 k1 b5 E, l; E1 Qof papilledema.6 \7 x F4 S# _) k) ?7 `! s
Laboratory Evaluation- x; @( \4 P5 `3 Q0 b
The bone age was consistent with 28 months by; u' Y- r# Z" i3 v2 G5 k( B
using the standard of Greulich and Pyle at a chrono-5 \# r+ l; s8 `5 }6 W; E
logic age of 16 months (advanced).5 Chromosomal1 a M8 N1 E. Y! \
karyotype was 46XY. The thyroid function test( ~5 d5 L* Q" O0 f. h1 `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# v( I% I3 E8 Q4 `" g! W
lating hormone level was 1.3 µIU/mL (both normal)." v! |. `" K& t ~* W4 u& d
The concentrations of serum electrolytes, blood
. z9 b% E( x& S( Nurea nitrogen, creatinine, and calcium all were
& p+ R, p( ^. D6 A; gwithin normal range for his age. The concentration1 W7 f- A1 c3 l# Z+ X% n* v6 ^0 F ^
of serum 17-hydroxyprogesterone was 16 ng/dL
; o# M, [; I2 c- D/ b4 c- @ p7 f& }(normal, 3 to 90 ng/dL), androstenedione was 20" s. M% \: u; G9 ^& f0 Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- q- y, V3 B$ n
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# @1 W# x' }( d" Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. @% n, r o0 h8 ~& q' [9 o
49ng/dL), 11-desoxycortisol (specific compound S)0 n* g1 p$ ]9 ?/ G4 k. y% h
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) E8 M; u& q* Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* M! T7 C0 o7 \/ N; @9 `
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, C- G0 Q1 m4 ^) x! Z$ x
and β-human chorionic gonadotropin was less than, [: H% ^9 r) y- J
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# R$ C& A4 U3 Mstimulating hormone and leuteinizing hormone
% ]& ?: Q/ `3 C& d3 k1 aconcentrations were less than 0.05 mIU/mL6 L6 D6 y& @$ {4 ?8 T+ X1 ` S
(prepubertal).
, f- i) J1 B" u9 p' rThe parents were notified about the laboratory
+ C2 }# U, w- i$ | k7 Y2 e: f" ]results and were informed that all of the tests were
2 ? c8 I. {2 D$ M( T; S& X! ?normal except the testosterone level was high. The
8 Q$ }5 ?: ~2 U9 rfollow-up visit was arranged within a few weeks to, A: J, O8 e4 K0 o+ X5 w! U+ S7 {- R
obtain testicular and abdominal sonograms; how-! X1 o0 _$ v' w: a- W
ever, the family did not return for 4 months.1 }; J8 [8 \- e* u& d" L% d& n9 e
Physical examination at this time revealed that the
/ G9 J1 k2 c& Rchild had grown 2.5 cm in 4 months and had gained: L% z' t4 e$ Y: R2 s: D
2 kg of weight. Physical examination remained
, Y! k, D7 m( ?unchanged. Surprisingly, the pubic hair almost com-
: N3 D* j0 P* Q' _7 D& m! p; q. `4 k% Mpletely disappeared except for a few vellous hairs at
6 [- k# I, ~! N9 ^1 a6 M8 A/ Nthe base of the phallus. Testicular volume was still 2, g6 R |/ X' z7 R, [0 j5 u
mL, and the size of the penis remained unchanged.
4 x5 m1 D1 g% g8 ~' _+ r4 HThe mother also said that the boy was no longer hav-
% H0 ]% O9 C. a% {ing frequent erections.$ G$ K* E" K4 t; |& F
Both parents were again questioned about use of
* b1 }7 }; }8 |( ]0 |" Xany ointment/creams that they may have applied to
1 O( Q- e8 J' z" Q5 K, \$ {9 uthe child’s skin. This time the father admitted the0 Q7 X5 C' a- P' ~- Y7 ]- j; p
Topical Testosterone Exposure / Bhowmick et al 541; i4 Q7 A( i7 G0 m
use of testosterone gel twice daily that he was apply-
( l$ }- |, ~6 w3 o; o1 u1 B* D- C+ ving over his own shoulders, chest, and back area for* e: K" f; s/ t$ _4 \
a year. The father also revealed he was embarrassed
: E: F% w2 A! G1 y" zto disclose that he was using a testosterone gel pre-& f2 x O5 i I9 }4 H
scribed by his family physician for decreased libido5 {# \; D: [: l) C
secondary to depression.
+ M5 I; h: E. V+ Q! S6 \' K4 ^The child slept in the same bed with parents.
$ ~, e5 ^6 f- sThe father would hug the baby and hold him on his
% d# c3 F& [; \1 ]7 a. E6 T: ^8 P8 mchest for a considerable period of time, causing sig-
( [3 E5 D* W2 |$ @5 S) [( \nificant bare skin contact between baby and father.2 D. B, i; r) `- c' u7 |% j
The father also admitted that after the phone call,( M6 C( h; \! l1 S
when he learned the testosterone level in the baby: x7 a- b4 y, s
was high, he then read the product information
8 N( l9 @+ S4 c& N+ Epacket and concluded that it was most likely the rea-
( [1 U2 V. @+ T) h$ \/ M0 ~' Uson for the child’s virilization. At that time, they
" w! X3 T5 E t, i0 tdecided to put the baby in a separate bed, and the
* _0 x8 @! @- \father was not hugging him with bare skin and had
6 v: l0 b. b& M: x: ^1 F9 fbeen using protective clothing. A repeat testosterone$ @- K3 R) k( t% l% @
test was ordered, but the family did not go to the
2 E2 L$ y+ `4 S2 mlaboratory to obtain the test.
6 D$ V, b" x- @9 z. \Discussion
4 A/ L5 C! T/ M1 gPrecocious puberty in boys is defined as secondary
( a! m8 p! H' r6 o8 j1 ?, A0 [sexual development before 9 years of age.1,4
9 Q* M) ~6 c' v) IPrecocious puberty is termed as central (true) when
, L6 I' c- m. |3 c1 Lit is caused by the premature activation of hypo-
$ N" G2 o6 S) g6 O" r0 F2 tthalamic pituitary gonadal axis. CPP is more com-% a8 I) `# k7 q: n* [, s8 d
mon in girls than in boys.1,3 Most boys with CPP5 w, Q- F( Q7 q$ n4 o
may have a central nervous system lesion that is P9 y* ]% J$ l& D9 t
responsible for the early activation of the hypothal-
/ m( r2 r/ L# p- J# Xamic pituitary gonadal axis.1-3 Thus, greater empha-
# q0 ^7 K8 V1 ?; ysis has been given to neuroradiologic imaging in+ e- G4 k4 R4 A7 }! h, S
boys with precocious puberty. In addition to viril-
3 l+ ` E+ H* Zization, the clinical hallmark of CPP is the symmet-1 S3 _" l( D8 _- o( v& c" a" d# U
rical testicular growth secondary to stimulation by
: L: B$ J7 n: ? l0 Xgonadotropins.1,3
( h2 s& d7 Z$ `9 |1 G* mGonadotropin-independent peripheral preco-
0 R! }4 V7 {* B. L& h/ }, ucious puberty in boys also results from inappropriate
7 T) l7 _0 a- I/ F* N j; p. Jandrogenic stimulation from either endogenous or
3 S. o, |0 `" p' _4 iexogenous sources, nonpituitary gonadotropin stim-
1 O# E* c( b. M3 W, Aulation, and rare activating mutations.3 Virilizing
5 I/ H. P* F8 N: a& E- ]congenital adrenal hyperplasia producing excessive* F5 T( E3 W, D& G8 I9 |
adrenal androgens is a common cause of precocious# P3 D d$ i2 @5 A
puberty in boys.3,46 }4 h- s0 t ~
The most common form of congenital adrenal$ ]+ ]4 V8 [# S: Y" O
hyperplasia is the 21-hydroxylase enzyme deficiency.! c/ n |2 F( S! v" Z: f8 ^7 Y
The 11-β hydroxylase deficiency may also result in' P1 L; j' `7 {* I
excessive adrenal androgen production, and rarely,. k' {: ?. H5 p+ P, F2 \
an adrenal tumor may also cause adrenal androgen
8 ^) D* ]9 O0 gexcess.1,3
3 N) r7 s1 J& V j' \4 tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( q! A5 H5 I) a% ]4 U" S7 ~
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 h" C- u. U4 y2 Y
A unique entity of male-limited gonadotropin-
/ S. V V0 v: t8 N' Uindependent precocious puberty, which is also known
' b2 t a+ O' k: ~( q0 @8 o8 Fas testotoxicosis, may cause precocious puberty at a
C6 ^% _ R* Nvery young age. The physical findings in these boys
: `8 A& x$ l/ {with this disorder are full pubertal development,
* I0 H1 |6 @' a: E0 |+ Tincluding bilateral testicular growth, similar to boys
* P" n- n& k! r* r2 Iwith CPP. The gonadotropin levels in this disorder
F$ J. Y, ^# x8 W x4 @/ {% E; R B% ^are suppressed to prepubertal levels and do not show
z; i: O G1 N- fpubertal response of gonadotropin after gonadotropin-: _- l/ d+ I, n+ `( s( f5 D# j7 s
releasing hormone stimulation. This is a sex-linked
1 x- D6 t4 o$ j& l: y xautosomal dominant disorder that affects only
; @$ G0 ]/ u9 v2 G& M9 f$ Fmales; therefore, other male members of the family
7 x. W4 L& J" M( s' ^may have similar precocious puberty.39 X8 _ n# k) q) L; @3 s. r9 |7 i
In our patient, physical examination was incon-' i. q: u- s. P$ Z2 S6 y
sistent with true precocious puberty since his testi-; {( k8 _1 a/ ^( n* p3 Z. h
cles were prepubertal in size. However, testotoxicosis. H: P. _0 a0 x2 Q1 Q
was in the differential diagnosis because his father3 R: x+ g# g9 p+ h7 Y' t+ K
started puberty somewhat early, and occasionally,
& w o! A- }6 ^2 H3 v# ?9 ktesticular enlargement is not that evident in the
/ t# l0 f+ u% U6 }/ r) ^beginning of this process.1 In the absence of a neg-. x% F6 b! A) q- j
ative initial history of androgen exposure, our1 k3 J/ g4 O! ]( N
biggest concern was virilizing adrenal hyperplasia, H9 m. S: B ~% f/ M8 D5 E% a# \
either 21-hydroxylase deficiency or 11-β hydroxylase. P; M" K! k. R5 s* p
deficiency. Those diagnoses were excluded by find-
' v3 p/ W* M: p. M" \( b$ O. ring the normal level of adrenal steroids.
! g2 Y/ u! Q# z6 P. m) pThe diagnosis of exogenous androgens was strongly8 ^6 P; M; R Y) @$ {3 Y8 `. W
suspected in a follow-up visit after 4 months because
& ]+ |3 g8 T. }: ?& Lthe physical examination revealed the complete disap-$ U, J* h! x6 {1 S9 x: R
pearance of pubic hair, normal growth velocity, and
$ R; K- B. L5 _. F: Y8 |decreased erections. The father admitted using a testos-
9 j2 x+ I6 W1 N) v9 v$ ?terone gel, which he concealed at first visit. He was9 l( F& o' R7 z. z
using it rather frequently, twice a day. The Physicians’( U4 [) X( P# X5 k3 F4 E, x
Desk Reference, or package insert of this product, gel or
* G* a! d- `4 f5 tcream, cautions about dermal testosterone transfer to2 E0 s+ [2 D# M2 t1 {2 F
unprotected females through direct skin exposure.7 S# D3 V/ v' O- b
Serum testosterone level was found to be 2 times the
+ {; S6 m" p; K! |' r. ]% C) k1 cbaseline value in those females who were exposed to# I& M9 f& O1 e% M7 P {( X
even 15 minutes of direct skin contact with their male4 F: g0 h0 `" X; B1 e
partners.6 However, when a shirt covered the applica-( H# I2 o8 o0 r( b; q+ V. i
tion site, this testosterone transfer was prevented.
$ O# G% c9 s3 p. c+ y# h& l- gOur patient’s testosterone level was 60 ng/mL,
$ P" `) I: f6 qwhich was clearly high. Some studies suggest that
0 U4 g$ K$ v+ l. i# A, w2 u9 Z/ L: U: c7 |dermal conversion of testosterone to dihydrotestos-
6 e. E5 u1 |1 ` i& ]terone, which is a more potent metabolite, is more
9 x+ i. H m: s& g/ lactive in young children exposed to testosterone
! e. W1 k' ^7 Q* k6 ]! I; T; uexogenously7; however, we did not measure a dihy-# h0 t3 e4 Y3 q- }6 ]: x% E1 B# o2 K
drotestosterone level in our patient. In addition to
4 W* O9 I, o' @virilization, exposure to exogenous testosterone in( q/ p* ^* L. a y
children results in an increase in growth velocity and( Z0 E* m3 y: ]1 S
advanced bone age, as seen in our patient.1 o; M, Y7 l% A
The long-term effect of androgen exposure during, P) }! q3 W ?, @2 ~+ Z# T0 N
early childhood on pubertal development and final! ^, K: h- D, }- N5 U: {4 p
adult height are not fully known and always remain; N3 w8 |4 ? K
a concern. Children treated with short-term testos-, Z$ m* v# A6 N9 H4 L
terone injection or topical androgen may exhibit some
; l& |" D- \( H) C$ r- G m$ X0 X0 Lacceleration of the skeletal maturation; however, after, G* M" y% z$ ]
cessation of treatment, the rate of bone maturation: B; w: e% G O/ G b
decelerates and gradually returns to normal.8,9
, R3 y9 [/ a+ b: ~5 h. P, rThere are conflicting reports and controversy8 l2 n% I: L9 @; c2 \
over the effect of early androgen exposure on adult
) j0 @! {) o9 ^+ B2 y' x$ K7 ]penile length.10,11 Some reports suggest subnormal' w2 B! D' B) I* b2 Z
adult penile length, apparently because of downreg-
9 i" e- E0 `0 l9 aulation of androgen receptor number.10,12 However,; ?! x5 h$ I9 Q
Sutherland et al13 did not find a correlation between3 g. D, L. k5 x% c% k
childhood testosterone exposure and reduced adult7 |1 N( y3 Q8 V: o9 p
penile length in clinical studies.) H4 z1 Z. J* U. W
Nonetheless, we do not believe our patient is! @+ E7 [6 \# J1 N' r$ \" L7 f
going to experience any of the untoward effects from
$ I5 Z w$ J$ b" r7 Qtestosterone exposure as mentioned earlier because
3 \4 G W9 f* ^7 W; E$ athe exposure was not for a prolonged period of time.# F# U+ Z4 U) _" i' R6 E
Although the bone age was advanced at the time of7 u, b; e9 l* S
diagnosis, the child had a normal growth velocity at* U/ h3 B' y* z
the follow-up visit. It is hoped that his final adult- q1 ?- D' P# M7 p( ]
height will not be affected.
$ O: B0 Z# ], V6 a8 rAlthough rarely reported, the widespread avail-: W* z# |1 [6 {
ability of androgen products in our society may
/ f# T- ^9 U% N" G ^( _/ sindeed cause more virilization in male or female; p" n9 B& j( S; T6 y& [$ a" B
children than one would realize. Exposure to andro-
8 @3 E3 N2 o! r! A) g1 ggen products must be considered and specific ques-
9 j' A1 o' J1 r9 j8 H. Stioning about the use of a testosterone product or
/ \. _' w p* l8 [5 T# l) O Ygel should be asked of the family members during
* V$ o9 M) F2 sthe evaluation of any children who present with vir-
4 `( P+ u5 J& U. }2 ^. V' `ilization or peripheral precocious puberty. The diag-% i# A+ \* w* i; e( l1 B
nosis can be established by just a few tests and by
) q) b: D/ V% p, N( `# l% |appropriate history. The inability to obtain such a8 k l7 c; F' d7 [" d1 |
history, or failure to ask the specific questions, may1 I( \2 o* D3 l& j; K1 M2 _* c
result in extensive, unnecessary, and expensive
q* J' W1 g7 n [, Zinvestigation. The primary care physician should be
+ |& G4 \# [4 h1 Iaware of this fact, because most of these children/ }8 J: F" e; s! V
may initially present in their practice. The Physicians’
4 f% ?) I4 F5 H2 I) E/ e# zDesk Reference and package insert should also put a
8 u7 E) A) `( Q; z( w9 S2 q+ c2 Awarning about the virilizing effect on a male or3 R+ D) N6 A; n* d' C2 P( L
female child who might come in contact with some-
$ Q/ q& U5 h- S2 H) uone using any of these products. i" h* Z. |* q- C& a" b
References
1 h/ o, b' T5 G& {1. Styne DM. The testes: disorder of sexual differentiation
9 Q1 n. {8 E- s0 H4 ^4 i) E6 s; land puberty in the male. In: Sperling MA, ed. Pediatric
. y+ q1 @2 R; \2 W) T" Q8 b; GEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 b1 k6 F" J3 _+ E* r! J
2002: 565-628.1 Y9 D/ r" R. s/ u# l' q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 ^7 C8 P: L' Q# R- O# D- ipuberty in children with tumours of the suprasellar pineal |
|