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Sexual Precocity in a 16-Month-Old1 I# c/ s! o! W$ ~
Boy Induced by Indirect Topical9 y7 P9 j+ J" I* ?0 v
Exposure to Testosterone# G. S# C9 S% u4 _! R2 \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. z7 ]+ }, s, d5 O
and Kenneth R. Rettig, MD1 Y% A) ] r- z5 P0 m% I" [$ `
Clinical Pediatrics- V6 s+ o5 |3 R
Volume 46 Number 69 H( q i [$ d2 s2 l$ `
July 2007 540-543
8 n. ~& a, K7 Y9 H; F+ |$ u© 2007 Sage Publications8 p$ W" }# p. f8 K
10.1177/0009922806296651
7 v, i3 R. ^, T/ |, Whttp://clp.sagepub.com& ?/ I/ T+ D/ s' Y" D# Q+ e
hosted at( W+ d: V. E) u& d$ l+ z) ?
http://online.sagepub.com
! w0 ^) P9 H! y+ R; _$ Q1 ?9 ` PPrecocious puberty in boys, central or peripheral,
: I- {+ r- ?; Y- @7 nis a significant concern for physicians. Central( s9 U P6 P5 V* ~2 a7 T, D
precocious puberty (CPP), which is mediated
5 f, w% H7 B1 N3 rthrough the hypothalamic pituitary gonadal axis, has
8 \4 H, w4 ^; v4 ja higher incidence of organic central nervous system( `( T- }+ z( _' B0 q( p( d3 K" U- X6 X; z
lesions in boys.1,2 Virilization in boys, as manifested/ q. f' O! m$ C4 D2 X' J( P4 ]
by enlargement of the penis, development of pubic- P/ c3 a6 ~, [' o ?( N
hair, and facial acne without enlargement of testi-
' e# M5 }( g! Z; [# t& ucles, suggests peripheral or pseudopuberty.1-3 We
$ x4 O6 l. S. T( f' o3 [report a 16-month-old boy who presented with the
( U% x; s" _/ p7 Renlargement of the phallus and pubic hair develop-
3 Z( w. a8 x1 C/ Z. k$ ?ment without testicular enlargement, which was due
; k+ }; J0 y( p- C8 Xto the unintentional exposure to androgen gel used by; p; R! n& \1 \" B' g' o1 A
the father. The family initially concealed this infor-0 g+ ]. A: L/ N& f: [ R' x4 o2 N
mation, resulting in an extensive work-up for this3 o' o' s6 O9 y
child. Given the widespread and easy availability of
$ w( \( D7 }* Q" jtestosterone gel and cream, we believe this is proba-
% J4 |, X2 r( E* l0 Dbly more common than the rare case report in the/ o# H+ M9 O* o6 v1 [# @& h/ Y; m- E
literature.4
0 l3 S B9 k: B; M; `" q) IPatient Report
2 x! }, ? N) H! s% M% ~3 SA 16-month-old white child was referred to the
+ v: ?# [' Q+ C! p) Eendocrine clinic by his pediatrician with the concern' R# I8 a3 X, P3 C1 o# K
of early sexual development. His mother noticed
3 t( j) d: D- Ulight colored pubic hair development when he was
; h9 q) _( N/ oFrom the 1Division of Pediatric Endocrinology, 2University of( x2 e# f* q9 X2 P4 T: ^4 D6 A1 i
South Alabama Medical Center, Mobile, Alabama.
% m5 i% z8 A8 q) n( sAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, `$ g- U8 I' c( @9 @5 e8 n3 WProfessor of Pediatrics, University of South Alabama, College of2 y0 i, F! d+ w5 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 t5 }( r1 \7 J& S% {e-mail: [email protected].
! n/ ~9 [7 p2 ~/ G* J8 g7 Uabout 6 to 7 months old, which progressively became7 k( V" d4 W, i* j1 F+ r
darker. She was also concerned about the enlarge-
+ J3 Z# |* q/ o8 r% Z. O) w( ement of his penis and frequent erections. The child
9 X6 b, H$ `# _7 f: o3 B% ?was the product of a full-term normal delivery, with
5 {* u+ C5 h$ U3 y5 qa birth weight of 7 lb 14 oz, and birth length of9 Z8 v4 n: A! Z6 k6 q0 v3 m
20 inches. He was breast-fed throughout the first year. E2 y, G4 i- J ~
of life and was still receiving breast milk along with9 n5 b4 P, {! t
solid food. He had no hospitalizations or surgery,
. c8 U( y- E; i" k" d K! |and his psychosocial and psychomotor development0 I- K' A7 \# \* C) m P
was age appropriate.! s+ y; @6 f) B7 P/ z, o3 @5 P; o) q
The family history was remarkable for the father,
' @' S& T g* R7 H9 Owho was diagnosed with hypothyroidism at age 16,6 d* o: e% I5 u2 K' X9 K
which was treated with thyroxine. The father’s
% u( f9 A* Z$ e' X- M* r+ Cheight was 6 feet, and he went through a somewhat
$ w! c" r9 b7 Z8 z0 v7 Hearly puberty and had stopped growing by age 14.
8 K) B9 O: |! Z: @& G! c" X8 AThe father denied taking any other medication. The
; C% ]3 J) R8 n6 C* v" Tchild’s mother was in good health. Her menarche1 K# g) E5 V/ K
was at 11 years of age, and her height was at 5 feet' C# w: }& \& l4 i1 a- J5 B
5 inches. There was no other family history of pre-
) s8 J( s( ~" a3 B, d+ icocious sexual development in the first-degree rela-8 [# v6 V) P/ p+ g% W8 e) c7 D
tives. There were no siblings." L2 s9 v6 g5 n3 X2 m# |& i1 f7 S# K
Physical Examination6 T6 \8 P7 V" Y/ g, X V! _+ l- |
The physical examination revealed a very active,$ K( i# V8 U. W1 `7 s
playful, and healthy boy. The vital signs documented
! I& |; L5 f7 S. V% T: l; Ua blood pressure of 85/50 mm Hg, his length was. @/ O0 R; g1 Y2 d3 `" _* _
90 cm (>97th percentile), and his weight was 14.4 kg6 ]5 [ v2 s% M6 L1 M
(also >97th percentile). The observed yearly growth! s' Z1 r& g! s/ A, s8 [) w1 v
velocity was 30 cm (12 inches). The examination of
0 E% N$ n0 {7 L; _0 K. mthe neck revealed no thyroid enlargement.; c" n- J8 ?" D3 c5 ~
The genitourinary examination was remarkable for. `3 X7 O0 _- e- r
enlargement of the penis, with a stretched length of
3 R9 F+ M8 {/ S5 e( t8 cm and a width of 2 cm. The glans penis was very well
9 ~: E8 x3 ~; [developed. The pubic hair was Tanner II, mostly around
Z; A) H: a$ F6 ]3 G540
& p0 t# I1 |% K- aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 G5 c, X: A2 l5 T- j1 l
the base of the phallus and was dark and curled. The
7 V8 Y M7 A$ G3 [testicular volume was prepubertal at 2 mL each.
( i1 v) Q1 a, `# U* [3 M, [The skin was moist and smooth and somewhat
% Y( r) [9 p7 A6 Z9 Xoily. No axillary hair was noted. There were no2 S* c8 u5 @/ p) s9 x, V6 C
abnormal skin pigmentations or café-au-lait spots.
. D* A$ i" T& ~. R2 W3 {Neurologic evaluation showed deep tendon reflex 2+
/ Z, i! j* T7 P! G' rbilateral and symmetrical. There was no suggestion& k+ o$ a) p. `: b- q8 v
of papilledema.
; F5 l; x4 e0 \0 Y; x6 a% e, k6 GLaboratory Evaluation% U4 M% J$ Z% d: B( h. [
The bone age was consistent with 28 months by
5 x* x/ x6 z: l+ ausing the standard of Greulich and Pyle at a chrono-9 \4 @) O% l/ S$ t+ @
logic age of 16 months (advanced).5 Chromosomal
% [, O. q3 p& \) `/ Jkaryotype was 46XY. The thyroid function test
# R/ q. z6 U; p" @; K: s Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, F+ s* T: S; B
lating hormone level was 1.3 µIU/mL (both normal).7 E. X& ^) W' \4 D% L
The concentrations of serum electrolytes, blood
6 z: v4 X5 v3 r8 wurea nitrogen, creatinine, and calcium all were% G* \& I( V- D% F
within normal range for his age. The concentration
3 ]0 n* D# O& \6 ~7 @* [! `of serum 17-hydroxyprogesterone was 16 ng/dL7 n% u+ f( V" V- ]
(normal, 3 to 90 ng/dL), androstenedione was 20
* w9 }( R/ P; F5 t* }7 Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 H1 ~4 h$ [8 k8 r; d1 g0 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 _, H! G3 Q) y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; Z! Q8 g a: X% \# W `
49ng/dL), 11-desoxycortisol (specific compound S)0 W+ C8 j: @# ^$ f3 o% M, l# x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" s5 [3 T( H* r2 U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, C- `, ]0 ^3 R/ \6 Stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& e- }" C3 V( F0 D
and β-human chorionic gonadotropin was less than
4 ^" X8 G/ C: ~5 mIU/mL (normal <5 mIU/mL). Serum follicular
- Q$ U9 P% n: X8 S% Astimulating hormone and leuteinizing hormone
8 w. {: F6 O: G9 Z" f- a7 s; Jconcentrations were less than 0.05 mIU/mL
; T# o5 j! N$ A3 T$ O+ |* f- g$ |8 \' k(prepubertal).& j1 t4 R$ R$ |2 u
The parents were notified about the laboratory
' Y: Y3 S: m, | R+ Q3 H" |results and were informed that all of the tests were
Q& p8 u3 Y% S- m2 G6 L5 xnormal except the testosterone level was high. The
5 ^, \. Y. O$ l1 t% i1 c8 {follow-up visit was arranged within a few weeks to# v) I. t' J: g% J# `+ A
obtain testicular and abdominal sonograms; how-
% j, _* D9 O6 Y$ o, A/ N; x: dever, the family did not return for 4 months.
7 Z& @' `2 Y% G+ \* sPhysical examination at this time revealed that the
+ e* d- E$ L: J% L% q' wchild had grown 2.5 cm in 4 months and had gained
; U# m( g' T" M. N2 kg of weight. Physical examination remained. r1 y$ _3 B- d; V% h
unchanged. Surprisingly, the pubic hair almost com-0 T8 F, \( n b
pletely disappeared except for a few vellous hairs at
0 l0 p( t/ C5 y4 r5 V' \) `the base of the phallus. Testicular volume was still 2
2 y5 n8 h$ u+ d& I4 O; ^mL, and the size of the penis remained unchanged.% v, Y9 ]/ N: v, T p
The mother also said that the boy was no longer hav-& r' }' h* n* Q5 [
ing frequent erections.
v/ P U5 W0 O( L/ O9 Y' ABoth parents were again questioned about use of2 D' M' [3 H, d% q0 x# B3 O: J
any ointment/creams that they may have applied to
' n" Q* a H7 Z# Vthe child’s skin. This time the father admitted the
# N% y, m$ J) q# `Topical Testosterone Exposure / Bhowmick et al 5416 Q; m: d; k6 S8 M' }) S& j5 W. i3 d
use of testosterone gel twice daily that he was apply-
. I5 e! E z0 v0 L. s1 Hing over his own shoulders, chest, and back area for
& q& h- E6 V8 |& _& {* L( o2 n, L( aa year. The father also revealed he was embarrassed; K1 D0 y# I' k2 r2 s+ C0 S
to disclose that he was using a testosterone gel pre-
& Y2 M4 `' \8 X+ Vscribed by his family physician for decreased libido7 K* T. j$ \8 b; o$ b: W! {& ~
secondary to depression.5 m+ Q- O% f' R9 o7 P: T% A
The child slept in the same bed with parents.
' e! }* _) X# h+ v# M1 dThe father would hug the baby and hold him on his
9 `6 G1 S6 n2 T3 tchest for a considerable period of time, causing sig-/ u# N- J" B8 `" Y y; o
nificant bare skin contact between baby and father.
3 L- u/ T: x2 h7 m( @9 v0 [2 s9 I6 J+ xThe father also admitted that after the phone call,# r; f/ Q, U0 S) b% m2 Y2 C
when he learned the testosterone level in the baby9 n* Q3 i$ _, Z* Z
was high, he then read the product information
5 n- N3 c+ u' B: A, Jpacket and concluded that it was most likely the rea- ^! b; m$ j4 `( s7 v
son for the child’s virilization. At that time, they
5 o. \* D/ R" Y9 `6 i4 ^1 Pdecided to put the baby in a separate bed, and the
, t/ q+ R' _+ L- [father was not hugging him with bare skin and had
8 p$ @( x9 K# I5 T- l3 Abeen using protective clothing. A repeat testosterone
n. W* }- E# E, t: [" L2 vtest was ordered, but the family did not go to the
; w2 F0 f; n$ ^2 Zlaboratory to obtain the test.
, h- u& Z$ o9 h% Y* Z, bDiscussion
* K4 H, m/ w! _3 f9 w* APrecocious puberty in boys is defined as secondary7 U' o$ s- i: f" x
sexual development before 9 years of age.1,4' V* d# g) |+ F" v! c$ Z% M
Precocious puberty is termed as central (true) when* }5 G8 \' v3 ^' T8 s
it is caused by the premature activation of hypo-* c4 z0 P( u* [. w* F1 ^# h4 z# c
thalamic pituitary gonadal axis. CPP is more com-9 @( ]( u2 S' Z( J( Y% Y& U
mon in girls than in boys.1,3 Most boys with CPP- @+ S/ Q+ H& ?+ q4 k- n( \& x
may have a central nervous system lesion that is
[4 `0 Z5 b$ c8 M2 eresponsible for the early activation of the hypothal-! t: T0 Z: _9 |% O# b
amic pituitary gonadal axis.1-3 Thus, greater empha-6 Z; B0 \( @6 G, k5 @
sis has been given to neuroradiologic imaging in
+ b/ o( d+ V; M" \- w1 ]& L; ~boys with precocious puberty. In addition to viril-" h% n$ b) R, a' ?
ization, the clinical hallmark of CPP is the symmet-4 Z, N U& s4 v- j* u
rical testicular growth secondary to stimulation by
& J% P: M8 ~/ y7 [2 @* j, Agonadotropins.1,3+ E; o! X* L# u
Gonadotropin-independent peripheral preco-
/ }; u4 u X' C \$ Ccious puberty in boys also results from inappropriate( n) w7 t7 q/ g" z8 A u
androgenic stimulation from either endogenous or6 Q: x" R+ I7 p7 S4 d* M
exogenous sources, nonpituitary gonadotropin stim-: n1 w/ o: H6 Y6 y. E
ulation, and rare activating mutations.3 Virilizing6 M. K/ @6 Z! @; v. z
congenital adrenal hyperplasia producing excessive1 R. H- A; d9 T* v% J; @- u
adrenal androgens is a common cause of precocious
0 m% X0 x& p/ Tpuberty in boys.3,4
1 K3 O- L( s5 K# I9 N: S, C* \8 nThe most common form of congenital adrenal2 |" {3 M, h0 _ Y7 Q" S! J
hyperplasia is the 21-hydroxylase enzyme deficiency.
* d' A* Y: b" w" m% |The 11-β hydroxylase deficiency may also result in' d ~, a2 u$ W4 \9 J# f
excessive adrenal androgen production, and rarely,4 ]7 ^! [3 F8 v/ G
an adrenal tumor may also cause adrenal androgen
# M8 W4 C( h; u( m% `! w- B gexcess.1,36 a6 P7 R) i1 }; b2 }+ \+ F k/ n ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 N( z' U0 b# X1 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 ~/ I: W% Z8 P% p0 p; gA unique entity of male-limited gonadotropin-$ L/ I! a5 X, T8 D/ D
independent precocious puberty, which is also known9 R3 q2 K( }7 T6 n
as testotoxicosis, may cause precocious puberty at a2 J" I; o" y% Y2 P9 S( u' S Y) a
very young age. The physical findings in these boys' L- H# v/ R( P. H" P3 m
with this disorder are full pubertal development,
" o+ Q A0 w/ S( [2 r8 iincluding bilateral testicular growth, similar to boys/ C% K7 k! H* [; m* \& z
with CPP. The gonadotropin levels in this disorder
) n3 z) }* P4 ^! R' Kare suppressed to prepubertal levels and do not show, @" r4 g! E' e2 p' I
pubertal response of gonadotropin after gonadotropin-. M8 Y0 |( U7 k% a3 j
releasing hormone stimulation. This is a sex-linked
; z& a) n Q. ^) m8 X6 t7 t' ]autosomal dominant disorder that affects only
, ~) s7 L c% kmales; therefore, other male members of the family
& i6 b- ~8 }1 n, i& J" Kmay have similar precocious puberty.3
) f# I3 g, J1 x9 _In our patient, physical examination was incon-5 W0 r) _" D) {+ K/ Z( z2 F
sistent with true precocious puberty since his testi-5 G! {+ C8 R7 S
cles were prepubertal in size. However, testotoxicosis
" E) a: e" G: X. O* fwas in the differential diagnosis because his father
& F \/ }, e' V0 i8 n) R% nstarted puberty somewhat early, and occasionally,
1 y" U% o" C7 c6 Gtesticular enlargement is not that evident in the
: b' k$ G9 K& V4 v1 O7 {) E: Y" z0 abeginning of this process.1 In the absence of a neg-
% m+ `* u/ o$ q0 R! {9 O" H- E+ cative initial history of androgen exposure, our
' u+ W# j1 v% k! i& F8 k1 \' Kbiggest concern was virilizing adrenal hyperplasia,0 I/ f3 L: J! U- [/ X+ }: X: Y; Y
either 21-hydroxylase deficiency or 11-β hydroxylase
- x! B, m9 q# B& a; i+ ^deficiency. Those diagnoses were excluded by find-. p. Z( d+ A7 q, }$ b3 b
ing the normal level of adrenal steroids.8 ?. N t: ^+ D# e0 \: ~! p8 W
The diagnosis of exogenous androgens was strongly5 F9 M' H# ^* c) e
suspected in a follow-up visit after 4 months because
2 g1 @2 b5 |8 l( cthe physical examination revealed the complete disap-
" {# {& Y3 Y# O t2 x" \, o7 r9 cpearance of pubic hair, normal growth velocity, and
/ t# b* o3 y1 w0 s4 E, ldecreased erections. The father admitted using a testos-4 ~/ q7 F7 v \! B) N+ b3 c
terone gel, which he concealed at first visit. He was' k4 W' } ?! P. ?
using it rather frequently, twice a day. The Physicians’: ^& L. [- Z8 Z7 t
Desk Reference, or package insert of this product, gel or
0 A% D% F. G6 t' K$ [' |& Ncream, cautions about dermal testosterone transfer to" ?1 U6 w8 l0 {# Q) N
unprotected females through direct skin exposure.# T r6 B+ ]5 p" S4 g" e7 X
Serum testosterone level was found to be 2 times the
0 o1 Q; ?7 Y, @baseline value in those females who were exposed to
! L9 u! m, l; K/ G) ^/ ?1 Geven 15 minutes of direct skin contact with their male2 d) Q/ L v2 c# q* }( r
partners.6 However, when a shirt covered the applica-
' p* x* S* [! ]) W) q5 vtion site, this testosterone transfer was prevented.; ^7 r, s; W; c. ~3 n' P4 |8 H
Our patient’s testosterone level was 60 ng/mL,5 y$ n& V- ~" k3 T) T# i
which was clearly high. Some studies suggest that
- A# K2 ]* y" P+ }1 Bdermal conversion of testosterone to dihydrotestos-. P3 x+ P6 ^! V4 A' g' o$ L
terone, which is a more potent metabolite, is more. N) h1 M; t# C+ s( ?4 |/ v
active in young children exposed to testosterone
' q' t' ?% `* bexogenously7; however, we did not measure a dihy-
* p) F. O. w4 g- ]drotestosterone level in our patient. In addition to
! s( Q2 V+ W% h: d' w* L" @virilization, exposure to exogenous testosterone in
/ ?! i' O u' c) ~children results in an increase in growth velocity and
9 F( M7 E8 C: C( O$ aadvanced bone age, as seen in our patient.) D- h- `# A( U9 x0 z2 v
The long-term effect of androgen exposure during5 ~: D' N( i& X; Y7 a6 k% S# b
early childhood on pubertal development and final' l" |5 m+ x3 [+ G6 H
adult height are not fully known and always remain( _% w0 G: e5 [1 a
a concern. Children treated with short-term testos-3 x) l" V* E- G
terone injection or topical androgen may exhibit some
1 y t4 i( s- N( Bacceleration of the skeletal maturation; however, after. I3 P, ~! h; u) f
cessation of treatment, the rate of bone maturation( D: h; V, c" X) `# Q/ j
decelerates and gradually returns to normal.8,9
+ S( Z9 W' g3 c% Q0 W' P1 ]There are conflicting reports and controversy) n5 B2 u4 L4 `: B9 F/ \$ F, P, w
over the effect of early androgen exposure on adult
' G x4 M, m+ L Ipenile length.10,11 Some reports suggest subnormal0 N: Q: F. T8 T; m1 g" V7 g1 {. Q
adult penile length, apparently because of downreg-
4 C( ?- i+ \# g' eulation of androgen receptor number.10,12 However,: x8 V# B/ J! i' n& h, o1 {! i7 V
Sutherland et al13 did not find a correlation between7 d7 V8 c" Y4 v5 W* E) b# u
childhood testosterone exposure and reduced adult
: D0 B) F* U' `1 ~' {0 ypenile length in clinical studies.9 N: h5 N' f" [. }* y
Nonetheless, we do not believe our patient is
* i4 x4 b7 F& c) X0 }+ j9 u, Rgoing to experience any of the untoward effects from
8 F! X0 C) F" t' ^' |testosterone exposure as mentioned earlier because
- P4 G" N( @) R p* @' l, U6 Y% f. ~the exposure was not for a prolonged period of time.. a8 |2 A# n% |% i! d; O
Although the bone age was advanced at the time of }$ B; W4 X1 O. P% |5 ~
diagnosis, the child had a normal growth velocity at l. ~% F8 X1 w' k [8 {2 \* P& _
the follow-up visit. It is hoped that his final adult3 r* ?( j6 v# {4 l6 S
height will not be affected.; X' W4 l2 y5 U/ C- Q; v' X: N
Although rarely reported, the widespread avail-
, X2 i! s; q% E$ r) n2 e- e) hability of androgen products in our society may) ~" n1 H7 j1 @0 P
indeed cause more virilization in male or female
1 ~: t/ M, h1 q5 l% Z, H" pchildren than one would realize. Exposure to andro-( w0 M. I& \6 T& F1 X3 F$ j
gen products must be considered and specific ques-/ g. F9 S) v" `3 F
tioning about the use of a testosterone product or
. e' f2 N) h2 i9 h0 X( [ n& Ggel should be asked of the family members during7 ^* n" a! Y/ u2 O5 @8 t
the evaluation of any children who present with vir-+ g- y" `' t9 F: F3 b' h3 F4 E
ilization or peripheral precocious puberty. The diag-+ n4 P. d$ l% M/ Z% R
nosis can be established by just a few tests and by
( ?; U9 W0 b! q2 Y8 o& u* dappropriate history. The inability to obtain such a
& B P/ Z" t4 R8 l- g/ Ohistory, or failure to ask the specific questions, may
# f# T/ t% l% [result in extensive, unnecessary, and expensive
# X5 h& U/ S0 M2 Binvestigation. The primary care physician should be& ^! R" r; w' J% l l
aware of this fact, because most of these children
7 o9 H# \/ W. w5 wmay initially present in their practice. The Physicians’: Z9 m$ C( k9 T! X
Desk Reference and package insert should also put a4 I& g; ^5 i$ M1 k# I
warning about the virilizing effect on a male or1 u0 _4 p7 I2 A) I
female child who might come in contact with some-
7 s5 B+ I9 b# M5 ?one using any of these products.
, B3 m; @' K" J; C. GReferences
^9 j; ]8 V, k9 E7 o3 K3 r' G1. Styne DM. The testes: disorder of sexual differentiation2 x& v; s- N3 Y4 L. B
and puberty in the male. In: Sperling MA, ed. Pediatric
- }3 K+ I9 r& W f; _& y9 B- F% F8 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! R& _# u, a: ~. A- L$ f
2002: 565-628.3 ~! h; L! |% |5 u/ C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* [9 P, s6 Q& Z7 [! r
puberty in children with tumours of the suprasellar pineal |
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