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Sexual Precocity in a 16-Month-Old/ O% l( W/ N( }0 |+ M8 d V9 S' N
Boy Induced by Indirect Topical: v( ^# V& K1 K! [' j$ c r
Exposure to Testosterone
3 [: S; L4 S; ^7 `& mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* C& F ]+ ~4 U1 h* a( a6 C9 i
and Kenneth R. Rettig, MD1
! a: e$ I( {0 p }) a3 yClinical Pediatrics
, U: ]: u* W3 [! ~4 f2 `5 QVolume 46 Number 61 X3 J' h6 }9 ^, f
July 2007 540-543) R, m, T5 j8 ~. G8 ?
© 2007 Sage Publications
* ]% w" y( l4 d) V8 N( N% k8 K* @10.1177/0009922806296651
- a1 e7 ]/ p, F# w( G# D0 @http://clp.sagepub.com; s& ]; ]# B6 E* X, m6 V& ^
hosted at/ D9 d( l, E1 v$ i5 S' M' e+ f' |
http://online.sagepub.com9 [2 V& |5 a( b F9 l; j
Precocious puberty in boys, central or peripheral,
" b, o0 K8 W) V$ Bis a significant concern for physicians. Central: B! [5 |' D! N/ g* ?* @" c
precocious puberty (CPP), which is mediated
0 a) _4 L) k- z2 bthrough the hypothalamic pituitary gonadal axis, has
- _$ ` R" O" B5 |: B# X* Ha higher incidence of organic central nervous system
& \9 I6 y6 K% V0 F' blesions in boys.1,2 Virilization in boys, as manifested
1 N3 w0 u' R; y/ M$ }by enlargement of the penis, development of pubic. `% E2 M2 l: c5 f. v" B; ?, n- j4 u
hair, and facial acne without enlargement of testi-" ]) H2 p' L6 V# V
cles, suggests peripheral or pseudopuberty.1-3 We- c. J {2 \9 }; `3 w' {
report a 16-month-old boy who presented with the
7 u) p* ^/ F5 J0 }enlargement of the phallus and pubic hair develop-3 s3 b% ?- J0 p
ment without testicular enlargement, which was due) R. w1 c8 c; I+ I, L S
to the unintentional exposure to androgen gel used by
# h% ?. C8 E" J" E5 ]: o3 X& xthe father. The family initially concealed this infor-
- T1 y! H1 ?" Cmation, resulting in an extensive work-up for this
R9 C$ ~3 V1 j1 y" F9 _child. Given the widespread and easy availability of
* ?% x! b" i. [9 T5 v9 U- t! ^7 utestosterone gel and cream, we believe this is proba-' E+ _- C4 P. t. F! F6 {6 q
bly more common than the rare case report in the
/ z+ D( L0 S" j$ T* D( xliterature.4
! T' ? q( ~4 u' X, K# mPatient Report; n, D* v) }( g& z
A 16-month-old white child was referred to the
% A8 G; o9 E6 e/ u% {" ?endocrine clinic by his pediatrician with the concern
" B9 V5 p a% t I% kof early sexual development. His mother noticed
& L4 i2 E* Q# X& p$ a0 |2 r& alight colored pubic hair development when he was6 D! Q0 x; d, t% e1 A. U
From the 1Division of Pediatric Endocrinology, 2University of6 k$ k$ v$ ^$ r% S9 U" I
South Alabama Medical Center, Mobile, Alabama.
/ d; i. e! O# v2 P7 {Address correspondence to: Samar K. Bhowmick, MD, FACE,1 t4 F2 A5 ^3 x: W( w$ Q3 b2 @) v8 E1 H4 F
Professor of Pediatrics, University of South Alabama, College of
m# `% t u' ^Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( c( o, w4 O2 T3 w5 o. ~
e-mail: [email protected].
7 _1 ^ Z, [7 q! m& wabout 6 to 7 months old, which progressively became A; u$ N$ O+ {) ^, z- U! N+ j
darker. She was also concerned about the enlarge-
+ r; i2 M3 M% c5 u% wment of his penis and frequent erections. The child2 q4 U2 N1 y0 e9 u, m9 f. X
was the product of a full-term normal delivery, with
" ]$ k3 X* C5 y Q ia birth weight of 7 lb 14 oz, and birth length of# p+ I3 E* z! M8 D
20 inches. He was breast-fed throughout the first year
9 A) M! H- Y2 q" l% j8 [ Yof life and was still receiving breast milk along with4 d$ Q/ [. m$ o6 P1 m( Z) T
solid food. He had no hospitalizations or surgery,7 s( n# T1 q8 X" O) M6 d6 Z6 [
and his psychosocial and psychomotor development
/ }# E, \8 c* Ywas age appropriate.
$ |1 ~4 R$ r" JThe family history was remarkable for the father,
: W$ J- \5 ]* d/ L6 gwho was diagnosed with hypothyroidism at age 16,7 ~5 y4 ]( s. E( s$ N
which was treated with thyroxine. The father’s; l/ V& l; T. X; e; @3 ?7 [
height was 6 feet, and he went through a somewhat
: q9 a4 s7 K) W, P- S0 iearly puberty and had stopped growing by age 14.
0 P" B& P+ j- \! s! k [The father denied taking any other medication. The' H: b+ T7 D }" R, Q: k# w9 m) N$ {9 x
child’s mother was in good health. Her menarche$ X+ m/ @" Z! i/ i0 Z9 ^/ `
was at 11 years of age, and her height was at 5 feet7 c$ z: ~; m) o" K% ~, t+ H" T6 J
5 inches. There was no other family history of pre-9 R- \( D. x% u V7 o7 o/ P+ z4 [
cocious sexual development in the first-degree rela-
! J6 }6 B2 Y1 j3 rtives. There were no siblings.
) }8 |; ? }1 d9 b6 T5 ~, e9 dPhysical Examination
0 z( g1 O# f- j) y1 n( f6 |The physical examination revealed a very active,2 t; \* x" _# z1 z1 T. J1 _1 A, o
playful, and healthy boy. The vital signs documented
) j( e9 W, _2 O& Oa blood pressure of 85/50 mm Hg, his length was! n% L6 x7 [5 U9 D; a
90 cm (>97th percentile), and his weight was 14.4 kg
/ w H$ K2 `- b( F/ I O(also >97th percentile). The observed yearly growth
3 p( x8 j& m$ a4 C. nvelocity was 30 cm (12 inches). The examination of7 m" h* S! g3 X1 x
the neck revealed no thyroid enlargement.- B+ m" R$ G7 Y
The genitourinary examination was remarkable for- U2 s3 a( p+ ~ M8 ~4 b) ~$ F
enlargement of the penis, with a stretched length of; W" g9 L- t7 N3 t/ G
8 cm and a width of 2 cm. The glans penis was very well
3 N& x0 U4 C1 u& Udeveloped. The pubic hair was Tanner II, mostly around$ u4 Y6 |$ r6 V
540
) Z8 @7 b& I1 m) K8 G2 A5 [: Y* `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* ]8 r2 p7 l7 R% x6 Y8 w. K
the base of the phallus and was dark and curled. The
8 j2 ~/ e' b. q ctesticular volume was prepubertal at 2 mL each.
) v* C+ i0 m2 u- \The skin was moist and smooth and somewhat; ]( J0 G- ]( a/ i; J- G
oily. No axillary hair was noted. There were no
: K# A0 ~( G) x, R+ v, qabnormal skin pigmentations or café-au-lait spots.8 o7 y- \% v5 R* u+ w9 ^+ k: z% i- |" W
Neurologic evaluation showed deep tendon reflex 2+
/ t7 b$ |0 O' a2 Q2 `bilateral and symmetrical. There was no suggestion% l4 e! n$ ^& w/ w
of papilledema.$ ]4 Y, y6 S. J y8 y8 n
Laboratory Evaluation
7 U0 P% |1 g1 \. h: qThe bone age was consistent with 28 months by, C3 }6 |" q: y2 L4 C7 s
using the standard of Greulich and Pyle at a chrono-. l+ x3 k+ E" B( l! [
logic age of 16 months (advanced).5 Chromosomal9 D4 M' Q6 x1 k! s2 U
karyotype was 46XY. The thyroid function test
% o4 L# u( C; }showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 L$ d3 u" N ^' s" l; ]" k
lating hormone level was 1.3 µIU/mL (both normal).* z1 p3 e6 { i) T% Z' n% n
The concentrations of serum electrolytes, blood
. Q2 ?( l4 e/ @3 lurea nitrogen, creatinine, and calcium all were% e( v, T0 [% E! t# s% m
within normal range for his age. The concentration
, l7 H2 E+ v/ Hof serum 17-hydroxyprogesterone was 16 ng/dL. Q3 l' y2 }2 \2 J
(normal, 3 to 90 ng/dL), androstenedione was 20
! S3 g: e4 j# K v- `5 W* |- F! D. vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ _- N& H1 R4 D; i W1 }/ z+ bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' c9 r! k7 l( n& _4 @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 m9 i) |- G/ a# @0 ^0 d( {49ng/dL), 11-desoxycortisol (specific compound S). N6 u. |+ B* q% i$ y, g9 A3 T# t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" x6 [- G; W: t! c5 B# ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- h: i8 r7 M; e/ z* Y* M" u+ Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) |1 ?1 o6 t+ n7 ~6 `6 T, V* [and β-human chorionic gonadotropin was less than" U3 C; ^* z) h, D9 f; ^; ~6 [/ s1 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular
. Y1 Q, |& K. ?' i6 astimulating hormone and leuteinizing hormone
|, k2 N1 s6 o5 V+ _ _concentrations were less than 0.05 mIU/mL
) W/ ~- F- v( `# B5 W0 ]8 l% U(prepubertal).0 b% ?' c) }" `9 p8 ~
The parents were notified about the laboratory0 x$ l F$ y% I8 m# x* T
results and were informed that all of the tests were# h$ z9 ]. K; r( I/ F3 w
normal except the testosterone level was high. The
$ g2 X2 Z$ W1 Q$ x4 vfollow-up visit was arranged within a few weeks to- G7 s( w3 `& |) k8 [8 l, [
obtain testicular and abdominal sonograms; how-
v. [( b& V6 b& _+ M& F0 w: Dever, the family did not return for 4 months.0 d% D5 T9 t5 N) x. y! S7 n
Physical examination at this time revealed that the% d: L6 D- b7 R% t# l
child had grown 2.5 cm in 4 months and had gained) L4 O; [" Y! m5 B; L
2 kg of weight. Physical examination remained0 y$ {, K, _# b2 d- F/ Z
unchanged. Surprisingly, the pubic hair almost com-5 S7 o1 M5 s6 i
pletely disappeared except for a few vellous hairs at
, s8 E, Q9 C: Jthe base of the phallus. Testicular volume was still 2
( H9 N' C( ?/ {' P# G. b. hmL, and the size of the penis remained unchanged.4 r) {" ]7 D1 {; [/ |
The mother also said that the boy was no longer hav-
: A+ Q- x! D& R8 ~ \ing frequent erections.8 t& w$ Q; P0 x7 m, h- E. [0 k: I% T
Both parents were again questioned about use of6 k9 t" ]+ e4 t" p! _
any ointment/creams that they may have applied to5 ^3 H# d5 k m/ C$ d
the child’s skin. This time the father admitted the# a: H! ~" u6 K5 [0 ~1 |( C" k
Topical Testosterone Exposure / Bhowmick et al 541
; N' t* O5 f5 Zuse of testosterone gel twice daily that he was apply-$ P9 u& ]. I7 w% {
ing over his own shoulders, chest, and back area for
3 {/ d9 m- i0 C Aa year. The father also revealed he was embarrassed
- n& [+ b, e0 d4 ato disclose that he was using a testosterone gel pre-6 s3 g0 r- ?. g4 B4 w
scribed by his family physician for decreased libido
% V* _: \6 ? W8 y: b! U4 i& R+ X/ `secondary to depression.
. A5 O& B" U3 e3 M% IThe child slept in the same bed with parents.
) G2 S$ G0 z$ f$ x5 E B# qThe father would hug the baby and hold him on his
, W! k1 h5 n; Tchest for a considerable period of time, causing sig-, E7 ?9 k$ E- W0 P: q; o
nificant bare skin contact between baby and father.! ^6 c6 Q W$ E, {
The father also admitted that after the phone call,
; T5 F1 A1 X: s% c/ Z+ N0 b2 mwhen he learned the testosterone level in the baby+ s$ ?! C* Y3 t# [1 @. t
was high, he then read the product information# t5 {0 e$ t% f V0 m$ R8 _
packet and concluded that it was most likely the rea-5 G- Y8 G+ S3 p B
son for the child’s virilization. At that time, they
* b7 H8 ~) u/ ~# [decided to put the baby in a separate bed, and the
# U4 f+ A5 P4 F5 ofather was not hugging him with bare skin and had
/ P: ?: y, f$ j' |# z" z: Pbeen using protective clothing. A repeat testosterone
' m* G' B# f0 m1 |! `test was ordered, but the family did not go to the
+ r1 b1 N/ |$ p! @& [- ]laboratory to obtain the test.- P# A1 @$ ~5 [+ K
Discussion
8 D+ q' n" D' E/ E$ ^Precocious puberty in boys is defined as secondary8 F" t7 {) i5 [- {; @9 w7 h3 h
sexual development before 9 years of age.1,4
1 e9 J' O4 s8 |Precocious puberty is termed as central (true) when
1 [* U% B i1 G( zit is caused by the premature activation of hypo-9 l8 R3 P, I/ S% U, L5 s
thalamic pituitary gonadal axis. CPP is more com-! h9 ^8 b: L$ E$ N
mon in girls than in boys.1,3 Most boys with CPP( z- |; [/ [4 H; \$ K/ g* a( ^
may have a central nervous system lesion that is+ A) D; k8 R3 o; T& J. P% H+ ~
responsible for the early activation of the hypothal-! E% J9 ^: i9 N0 r% c
amic pituitary gonadal axis.1-3 Thus, greater empha-: S$ Q: i5 q! j+ T* C
sis has been given to neuroradiologic imaging in
8 t3 c5 O5 X* ^( aboys with precocious puberty. In addition to viril-
+ g3 D. Q0 ]2 B: Xization, the clinical hallmark of CPP is the symmet-
9 z4 M" |, ]1 W) K) o! Orical testicular growth secondary to stimulation by+ l# e. m! O1 b' C2 w: {
gonadotropins.1,3. ~ j' {/ b7 F* b* J5 }
Gonadotropin-independent peripheral preco-
5 i8 B0 z6 d$ n( ^- m Kcious puberty in boys also results from inappropriate0 s- t- ]/ n( j% M
androgenic stimulation from either endogenous or
" `) P# h6 f8 n& C) P' [+ _; D: qexogenous sources, nonpituitary gonadotropin stim-
! ?) T' m6 Y/ M! h: ^8 Fulation, and rare activating mutations.3 Virilizing
* |( g& T5 w. }2 k- @2 Xcongenital adrenal hyperplasia producing excessive) C! o( P4 `6 r' H4 ]
adrenal androgens is a common cause of precocious- X' i7 _6 R2 n0 d
puberty in boys.3,43 K, |, d( i7 B5 Z$ v
The most common form of congenital adrenal
8 r% r: ^5 }+ a/ Ahyperplasia is the 21-hydroxylase enzyme deficiency.
2 C* Q! F8 \. nThe 11-β hydroxylase deficiency may also result in
! K4 ?2 C1 v s6 h" O# k9 P! vexcessive adrenal androgen production, and rarely,
4 ^4 l( H, b: u9 s$ z4 i& ean adrenal tumor may also cause adrenal androgen
, R" [+ L& R/ \excess.1,3" g" f" |* m) y7 \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' {6 n6 N' l' h3 Y! p' y$ c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ k, t4 m/ n) G7 g: E/ X
A unique entity of male-limited gonadotropin-
- U: n8 O4 D: D0 P' R: d- I5 U P- M! Qindependent precocious puberty, which is also known
8 w3 {$ a; V& W: u# Ias testotoxicosis, may cause precocious puberty at a4 C& n: v1 F+ Y# h" }# Z
very young age. The physical findings in these boys
5 s9 D' B6 v1 h) j1 kwith this disorder are full pubertal development,
, C: w | a1 Oincluding bilateral testicular growth, similar to boys
8 `8 W5 i; T$ p4 O; Y; S3 f5 h, M7 jwith CPP. The gonadotropin levels in this disorder
" S* l) @8 v* t# h1 k/ sare suppressed to prepubertal levels and do not show
* z4 a4 J8 C9 c% M9 @" I; E5 hpubertal response of gonadotropin after gonadotropin-! L5 {5 O4 C+ E' c
releasing hormone stimulation. This is a sex-linked
+ ?9 u5 n) s2 o7 {autosomal dominant disorder that affects only- }7 m! U3 N) y' h: i
males; therefore, other male members of the family
S* l$ O3 N' p$ b( \2 Kmay have similar precocious puberty.3
3 ^8 }+ c$ n! L" Y6 J; JIn our patient, physical examination was incon-
# G" R# V# `5 Z. P' L+ P0 B) C' ^sistent with true precocious puberty since his testi-) B! D7 Z3 n( Z$ r/ `& m$ H
cles were prepubertal in size. However, testotoxicosis4 X, o1 f: P# t$ w: T8 ?! P9 n' f) M
was in the differential diagnosis because his father
: y/ `- p4 r0 S Q9 Estarted puberty somewhat early, and occasionally,
3 O/ x* b* s0 o% ^5 S; F+ utesticular enlargement is not that evident in the
, X. H& Y3 y9 ^% K1 C5 ^$ w* |beginning of this process.1 In the absence of a neg-
* x0 [* q( n' L/ {1 n' h: _- vative initial history of androgen exposure, our
! u1 C4 V7 o9 n6 `biggest concern was virilizing adrenal hyperplasia,) c: e+ a9 H5 F
either 21-hydroxylase deficiency or 11-β hydroxylase
; _4 p. `0 P4 ~! Z. \deficiency. Those diagnoses were excluded by find-# _5 a) t" E% C5 x$ o
ing the normal level of adrenal steroids. X; S) v+ j+ Y/ F. c o
The diagnosis of exogenous androgens was strongly1 a- g6 E; O3 {) K( G
suspected in a follow-up visit after 4 months because; Y) ?* W; V3 t3 \- H
the physical examination revealed the complete disap-( m1 ?1 K2 z+ ]- Z
pearance of pubic hair, normal growth velocity, and
5 Z9 n" O% d/ A, S5 L, }decreased erections. The father admitted using a testos-
$ z& S, c4 E' I5 z, ~terone gel, which he concealed at first visit. He was5 q. _; P3 @$ }' C5 N/ S
using it rather frequently, twice a day. The Physicians’
0 H& r- E; ]( a# ]# J2 S: JDesk Reference, or package insert of this product, gel or" |: p, }& M6 P/ a
cream, cautions about dermal testosterone transfer to
7 } ~0 i% c6 D: m. ~, z: }1 Runprotected females through direct skin exposure.6 j! K" y( t/ A# |
Serum testosterone level was found to be 2 times the
% @& j Q0 ~! ^2 {( L- S0 R, ?baseline value in those females who were exposed to: `6 W8 M( |: [( d! h
even 15 minutes of direct skin contact with their male3 u% s3 {* n7 @3 L1 Q7 F
partners.6 However, when a shirt covered the applica-
2 W3 C( E. }; y4 u3 ition site, this testosterone transfer was prevented.+ Y7 ]2 X+ B! o$ Q" Z' i/ N8 l
Our patient’s testosterone level was 60 ng/mL,
% t5 }9 o# z7 m: bwhich was clearly high. Some studies suggest that
/ Z! u/ x- s( u5 h3 I9 `9 v$ gdermal conversion of testosterone to dihydrotestos-. @3 b% v# g' a1 ?" t
terone, which is a more potent metabolite, is more
( }% d6 h" i) Y6 Mactive in young children exposed to testosterone8 e5 X1 E$ w+ b. o( s: Q, p+ l8 B
exogenously7; however, we did not measure a dihy-
. q% Q) r( O o1 C# I5 x, gdrotestosterone level in our patient. In addition to: U; W+ m% Q, E! g/ K
virilization, exposure to exogenous testosterone in
4 q: U# k9 t% z( _9 Jchildren results in an increase in growth velocity and
2 [1 R8 S% g) E3 I' ladvanced bone age, as seen in our patient.
; \2 G; `- x$ ~. V6 D0 E: YThe long-term effect of androgen exposure during
& D5 A8 n/ w, ^8 \4 a& }) nearly childhood on pubertal development and final) }9 h( N: F, v0 P
adult height are not fully known and always remain
, j0 R, o7 S1 _) t& b5 na concern. Children treated with short-term testos-/ R; J% I5 y$ t/ f0 s
terone injection or topical androgen may exhibit some) I) k/ T( n2 r
acceleration of the skeletal maturation; however, after- ~1 d, `8 \* d
cessation of treatment, the rate of bone maturation
0 y6 b! Y0 w; |% odecelerates and gradually returns to normal.8,9# V/ I' H! A$ E% L. U$ a. b
There are conflicting reports and controversy/ [1 X9 i" t ?$ z
over the effect of early androgen exposure on adult, ]6 g% F; `+ E' u) F# G2 L
penile length.10,11 Some reports suggest subnormal A! ^4 s: A+ f' n' J- g* g
adult penile length, apparently because of downreg-
* N3 Q6 `* y2 I* o- vulation of androgen receptor number.10,12 However,
; V/ X) r+ @- B: I: R; p7 iSutherland et al13 did not find a correlation between* |# b7 X. @+ X# a" ~" d, l: y9 C
childhood testosterone exposure and reduced adult! e+ s: X- V9 m
penile length in clinical studies.
+ h0 D0 [) b4 x( r. A* T( hNonetheless, we do not believe our patient is
8 n r* n$ b4 k5 ]( y# R% kgoing to experience any of the untoward effects from. v# r3 h' C8 q" L S- t) l' ?
testosterone exposure as mentioned earlier because0 g7 E9 C5 g: K% _% ^# c* o. `
the exposure was not for a prolonged period of time.% J {! A R! P+ f
Although the bone age was advanced at the time of6 C, T& y& r# N, [" S
diagnosis, the child had a normal growth velocity at
7 m0 P- m' z1 Mthe follow-up visit. It is hoped that his final adult
* `% a" S! K8 d3 e" pheight will not be affected.% b% h+ q. J7 ~9 I J2 C
Although rarely reported, the widespread avail-
/ y1 E, v, P& S4 T- C: rability of androgen products in our society may
8 j& ]( M4 s, a+ Lindeed cause more virilization in male or female+ v, L( |* |8 F- v* B& _
children than one would realize. Exposure to andro-
) b9 m" y9 Y/ Jgen products must be considered and specific ques-
8 g p2 O! j# [) t# ctioning about the use of a testosterone product or; ? Y; ~" f9 a* ^; R4 p
gel should be asked of the family members during
& x7 W7 J* Z7 R% rthe evaluation of any children who present with vir-
; ^9 z+ z& M# ]- N' g Q) xilization or peripheral precocious puberty. The diag-
+ h8 p) t0 l6 \5 i' l8 Z: vnosis can be established by just a few tests and by
! r5 ~3 Z; P, u5 V) |/ T% V, U. D8 ~ u2 Nappropriate history. The inability to obtain such a
2 R, J, l* y- x hhistory, or failure to ask the specific questions, may' R& ?! y1 T' Y1 H! @
result in extensive, unnecessary, and expensive
' @3 n2 s1 x4 O4 F# ]investigation. The primary care physician should be
* Q1 ]& Q9 A2 kaware of this fact, because most of these children0 a% X& Z( K" j% X U4 g$ a9 w/ U
may initially present in their practice. The Physicians’/ k6 Z9 R9 E4 i+ d J) M, h0 C, I4 p
Desk Reference and package insert should also put a8 a% U: ^; R5 @* k! i$ w
warning about the virilizing effect on a male or
# g' _; J W* J, v5 yfemale child who might come in contact with some-3 G R' ~: V; `7 W
one using any of these products.3 A R' @# ]2 A; ^! V+ n6 j! d- C
References
$ h8 J) a0 G" D# g2 s. C( a1. Styne DM. The testes: disorder of sexual differentiation
. B9 K" `. H2 Tand puberty in the male. In: Sperling MA, ed. Pediatric
2 J" V% Q( f) l5 ?6 DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ V5 N* v) o! k5 i" |6 I2 I2002: 565-628.6 O S4 v3 _; m$ d1 {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% A" @- p& S& X' b* [3 a
puberty in children with tumours of the suprasellar pineal |
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