- 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
b4 o# o+ ~# X1 m' @' Y5 f! Q8 YBoy Induced by Indirect Topical
" T/ ?. k( r4 @" J7 WExposure to Testosterone7 u; l5 H$ b- o+ b* n0 I/ r ^4 d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 [& l- b$ V3 U( c. Y
and Kenneth R. Rettig, MD1
% f, P3 y( ~, ~/ i9 }+ [Clinical Pediatrics
" U: R$ H7 d" ^# [0 }) r# WVolume 46 Number 6
: @5 [! s/ s5 i. t& H5 c* VJuly 2007 540-5430 N3 J3 q& ~: b* z8 ^% s
© 2007 Sage Publications
9 B, `: T0 M+ Q! p: B" J10.1177/0009922806296651: I3 B+ I4 e; t" S! K- `
http://clp.sagepub.com( J4 ^$ u7 W9 B5 J/ ~( t' W$ E9 ]3 b) p
hosted at
# s. \, q" }9 z5 Hhttp://online.sagepub.com: ?3 G" l9 G3 {% F4 _' \6 y- k
Precocious puberty in boys, central or peripheral,
; M/ G o0 T- f/ G1 Y' kis a significant concern for physicians. Central2 F" ?0 S# }) B* h1 M: x
precocious puberty (CPP), which is mediated
/ V, f& l E! ]' x# T- ~; u" [through the hypothalamic pituitary gonadal axis, has
6 S" s2 _. l4 S' [a higher incidence of organic central nervous system
Y5 |$ W. x) v+ {5 V& U& rlesions in boys.1,2 Virilization in boys, as manifested( v& N& a+ B1 A% Z. L
by enlargement of the penis, development of pubic
4 G4 g$ t* A- ^, a, C1 m% X; uhair, and facial acne without enlargement of testi-: t6 p2 u6 x; `" x( e$ b
cles, suggests peripheral or pseudopuberty.1-3 We
+ J( d3 O' u; m, A6 Zreport a 16-month-old boy who presented with the' [1 c3 B- H! C+ N" k
enlargement of the phallus and pubic hair develop-4 x) R9 Q3 h- h
ment without testicular enlargement, which was due
/ }( S1 @. v3 ^' J8 _' Ito the unintentional exposure to androgen gel used by
5 e$ } O; \$ t; e) ^the father. The family initially concealed this infor-- P7 S* J; K3 M# F) H, F3 [# \% i
mation, resulting in an extensive work-up for this
( J4 h% K# H. J. R* e8 F4 |8 uchild. Given the widespread and easy availability of+ T: T% h# p/ ?% e# J
testosterone gel and cream, we believe this is proba-
# [( m. I$ [4 F9 i3 Ibly more common than the rare case report in the; f6 ?+ _1 `! K- M
literature.4( W- G1 i4 u& F1 T
Patient Report# }& j% i) f5 e: D
A 16-month-old white child was referred to the
6 e9 _' J) \ Y' w( Kendocrine clinic by his pediatrician with the concern
2 f: Y* u% @% Z9 pof early sexual development. His mother noticed0 B2 J; ~: b) q* r6 R& f M7 _: H
light colored pubic hair development when he was
% e6 `. r% Q& v% _; y0 {4 DFrom the 1Division of Pediatric Endocrinology, 2University of
3 ?& m" z- _9 X- cSouth Alabama Medical Center, Mobile, Alabama.4 X9 W3 w* [3 p5 P/ z$ T
Address correspondence to: Samar K. Bhowmick, MD, FACE,* N- g; G K) E* V
Professor of Pediatrics, University of South Alabama, College of
" {0 m9 f0 d' J" _. ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297; g1 y' a K& i% B* X' V
e-mail: [email protected].! a r# h9 @& A# X
about 6 to 7 months old, which progressively became0 F5 P; i" H6 ?8 S% o
darker. She was also concerned about the enlarge-
8 K+ r- S- v0 Z2 W8 X% Fment of his penis and frequent erections. The child+ z4 l' t% H) @
was the product of a full-term normal delivery, with
. d- j2 N" m+ d. ^: _a birth weight of 7 lb 14 oz, and birth length of
: v0 f8 h+ P8 {; f: z* G0 P' Z20 inches. He was breast-fed throughout the first year
; |' Y, k( |/ S7 O/ K+ X! Oof life and was still receiving breast milk along with: s/ s9 S* ^# n0 c; d7 D2 A7 E
solid food. He had no hospitalizations or surgery,- Z& D- }* t; c3 p7 C' q
and his psychosocial and psychomotor development$ V4 e% w/ k, I7 E5 R# L
was age appropriate.6 x; m+ N9 D5 l7 c
The family history was remarkable for the father,' Z7 Z7 R. j1 _/ Q1 f5 a
who was diagnosed with hypothyroidism at age 16,- c7 V6 K" n$ P$ l
which was treated with thyroxine. The father’s* X R% x8 a# f! ^
height was 6 feet, and he went through a somewhat3 j6 @% X2 p6 J
early puberty and had stopped growing by age 14.
1 w2 u% A0 J& l- T' u) B0 rThe father denied taking any other medication. The
) b8 s* Y" X# A4 I; m' |/ schild’s mother was in good health. Her menarche
5 ?* U u. K% ~* [# t4 q2 @was at 11 years of age, and her height was at 5 feet
2 B0 {! J" l$ K& f1 }7 q5 inches. There was no other family history of pre-
( E$ B$ h8 k/ {" Gcocious sexual development in the first-degree rela-
5 I9 u' n( Z9 u: ptives. There were no siblings.
1 ~1 l* E: a. F* h* OPhysical Examination
1 E" `/ n$ v' ?" j; l+ n1 ?3 `The physical examination revealed a very active,
6 {) V" a. P! A6 g- C3 E- fplayful, and healthy boy. The vital signs documented8 a+ n3 Q% \8 f2 P5 ]( M
a blood pressure of 85/50 mm Hg, his length was
' H1 f5 X! k* J+ j3 Q90 cm (>97th percentile), and his weight was 14.4 kg
: _! R3 W$ d# Z8 l3 L6 l1 N(also >97th percentile). The observed yearly growth, a0 g; G1 f( e3 V `6 ~9 c8 g
velocity was 30 cm (12 inches). The examination of2 R" R$ a8 Z; n0 P+ A/ W% B. X
the neck revealed no thyroid enlargement.
) r7 o4 f( ]& i3 O( NThe genitourinary examination was remarkable for" ]( U- L1 f! Q- a( D6 t
enlargement of the penis, with a stretched length of
9 l& M4 `3 _; ^8 cm and a width of 2 cm. The glans penis was very well) p3 o" k. {9 H; N& v" N
developed. The pubic hair was Tanner II, mostly around
. {6 ]$ e4 ~" s1 p540+ @+ H& z# p f& d" N6 B& }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& G) `( T+ B; C& L+ |8 Z
the base of the phallus and was dark and curled. The
7 }8 w8 ^1 Y. c2 T! Ytesticular volume was prepubertal at 2 mL each.) y* x1 f; V& |% f- Z
The skin was moist and smooth and somewhat/ N+ U" }1 v& j* u: i3 |0 j* A
oily. No axillary hair was noted. There were no
) |; i d( E; \2 G9 D( a, `0 a- Habnormal skin pigmentations or café-au-lait spots.3 O! y1 K8 i6 T, n) l
Neurologic evaluation showed deep tendon reflex 2+
# j, i( D X/ rbilateral and symmetrical. There was no suggestion& ]2 V. x' U& _6 V' Y/ `
of papilledema.7 f' w1 K) h- T1 O( D' F5 `" X
Laboratory Evaluation
5 M1 L) Q# h; ZThe bone age was consistent with 28 months by6 n% `' Y7 ?9 I+ F
using the standard of Greulich and Pyle at a chrono-
8 L1 e7 _% E' y/ @. n; W1 Glogic age of 16 months (advanced).5 Chromosomal% f0 o$ ^1 E/ J
karyotype was 46XY. The thyroid function test
! p' U; d" g' k1 m4 b+ ?& F- Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
e+ z/ R6 |! w: z) V Tlating hormone level was 1.3 µIU/mL (both normal).
1 I- k' s8 l" d$ f4 Z7 IThe concentrations of serum electrolytes, blood
; _1 ~& [" H1 t0 {2 K1 `urea nitrogen, creatinine, and calcium all were
# B2 {: g9 `2 _' Cwithin normal range for his age. The concentration! h* u0 _0 _5 W$ K5 S. T q
of serum 17-hydroxyprogesterone was 16 ng/dL) v4 e4 L: ?$ X0 N9 w/ ~$ ]
(normal, 3 to 90 ng/dL), androstenedione was 20: Y+ H7 P+ r1 ^" S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 h) Q/ f( M$ X* F& J( E: B/ Pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
P: T) z+ v* V. X* a- gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" B$ q) m; M7 u# e( b49ng/dL), 11-desoxycortisol (specific compound S)
9 Q- {. x4 Q. @% Q/ [8 Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 Q; N$ C: z7 o. u/ @. s; C8 Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 Z9 o! D; {7 Q, \2 O+ R- ]0 Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 v0 s8 i" Q! B }+ Q2 @/ hand β-human chorionic gonadotropin was less than& B4 q! _- S, A
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 {' V# [, d) |, M
stimulating hormone and leuteinizing hormone5 a9 m5 S- [ a0 h% F) R' @# o2 J
concentrations were less than 0.05 mIU/mL
3 j, `3 C4 S9 z(prepubertal).
. X- Y, H4 X, T# v5 P7 r9 K: RThe parents were notified about the laboratory
% v+ c- c G H/ _* x' Rresults and were informed that all of the tests were1 v# }. z& q6 Y
normal except the testosterone level was high. The
# c; t4 B/ \' s, |& l" nfollow-up visit was arranged within a few weeks to
( S6 X) f: Q c, h" bobtain testicular and abdominal sonograms; how-
! k- g8 i, f! x! H. zever, the family did not return for 4 months.
& D/ S3 a1 t. ?9 LPhysical examination at this time revealed that the8 v& q4 V" V2 |& p1 l6 K1 _9 c
child had grown 2.5 cm in 4 months and had gained
5 o8 r: ~+ J& F6 Q5 o2 kg of weight. Physical examination remained2 ~/ ]2 T+ g7 }( L
unchanged. Surprisingly, the pubic hair almost com-5 r- y* o. q8 N# W. Y+ t) i. i
pletely disappeared except for a few vellous hairs at& ?& O, d+ s# @ L `
the base of the phallus. Testicular volume was still 2
A/ p# `& d& _4 S+ YmL, and the size of the penis remained unchanged.
/ @5 y6 Y ^5 u2 D$ hThe mother also said that the boy was no longer hav-- U; T4 R' h4 [; N1 m1 D# `
ing frequent erections.
$ M+ d) i, { K" U* O9 w# mBoth parents were again questioned about use of
% ]7 Y }5 Q1 G" @! a1 u: I" M6 Hany ointment/creams that they may have applied to
: B u1 ^$ s2 @0 L7 Wthe child’s skin. This time the father admitted the
5 ]5 u. q4 X1 GTopical Testosterone Exposure / Bhowmick et al 541
( T8 Z! S1 }0 Guse of testosterone gel twice daily that he was apply-3 u! ~( N3 l5 R6 m" y8 |9 S6 P
ing over his own shoulders, chest, and back area for. [5 C" v* E9 K( M6 A
a year. The father also revealed he was embarrassed4 r+ d: ^3 G2 P% C
to disclose that he was using a testosterone gel pre-; Z3 {/ D1 |0 \+ Z' i
scribed by his family physician for decreased libido" g7 R) {* j2 u, n0 U: V X
secondary to depression.
$ f4 { y2 [& t' G& ~The child slept in the same bed with parents.% v+ o8 e; n$ h4 ~! e+ k
The father would hug the baby and hold him on his0 l# g) x/ n0 g$ t
chest for a considerable period of time, causing sig-
& K- H p' a0 n4 W; n% [+ ~8 wnificant bare skin contact between baby and father.- ?" X, S n: y" u0 V3 \
The father also admitted that after the phone call,' o6 X4 X$ s% }6 ?+ F- [; W/ b
when he learned the testosterone level in the baby
3 ] ^) L' _2 i) h. C# q5 Y6 Cwas high, he then read the product information! L! V& P) X9 z$ {/ Y1 ]5 d* a I
packet and concluded that it was most likely the rea-' l$ @. G A& k$ |2 ]/ H/ l
son for the child’s virilization. At that time, they
* w) O7 `/ }' o, Fdecided to put the baby in a separate bed, and the1 D9 {( R3 o1 k/ `( v
father was not hugging him with bare skin and had
) n9 Q5 W$ I- f, z# Rbeen using protective clothing. A repeat testosterone$ h/ b, v8 a7 z, z% s% U. X% M
test was ordered, but the family did not go to the. } m2 c% o8 |0 w: F
laboratory to obtain the test.% T! g/ ~$ U' I/ u5 P* }% F% Y
Discussion, C& b: _5 f2 T9 T, j/ k
Precocious puberty in boys is defined as secondary
7 b3 p( N `, R5 X {sexual development before 9 years of age.1,4
% @: \. F' x8 Q# s0 B3 UPrecocious puberty is termed as central (true) when
2 |# t" H3 r1 V0 @# q7 e+ nit is caused by the premature activation of hypo-% e, q# a4 \5 p8 u- l0 D
thalamic pituitary gonadal axis. CPP is more com-1 G* D9 h- j& c
mon in girls than in boys.1,3 Most boys with CPP& v8 @& ?7 c5 Q- S
may have a central nervous system lesion that is! T! e" E2 ^; X. d
responsible for the early activation of the hypothal-0 F% Q, t( b7 J" S
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ w- x2 f& x; x# Psis has been given to neuroradiologic imaging in
* ]. D# D! O [% n# wboys with precocious puberty. In addition to viril-& n, i* C- g: o$ u
ization, the clinical hallmark of CPP is the symmet-' S5 m3 p+ ?7 }: A' y
rical testicular growth secondary to stimulation by9 X; r& H7 } _6 z6 d
gonadotropins.1,32 G$ v. u4 j# S4 ]; i( b8 I/ C
Gonadotropin-independent peripheral preco-, H- T' I4 P+ O' m3 z3 W; M: W; V
cious puberty in boys also results from inappropriate6 b" W8 X8 M9 r. R2 [
androgenic stimulation from either endogenous or& f; j& ?! S0 M: ]0 ?8 I6 R# h
exogenous sources, nonpituitary gonadotropin stim-
~5 u3 c2 r5 m3 V$ E- mulation, and rare activating mutations.3 Virilizing1 P1 g+ R$ f1 l, a2 x. L' E- H9 f( V
congenital adrenal hyperplasia producing excessive. P# n# Z8 h, ` t- G$ ], s( a
adrenal androgens is a common cause of precocious, H' c- c- m3 u+ H ^
puberty in boys.3,4
5 \ w' x# A9 ]+ }. zThe most common form of congenital adrenal
1 ?( w* W2 V! s* ^$ M: b* Nhyperplasia is the 21-hydroxylase enzyme deficiency.' v5 j0 j' Q6 E+ Y6 e7 }1 a( Y* o
The 11-β hydroxylase deficiency may also result in
9 p* t* r2 Z2 }" ^9 Q j: {( Z& mexcessive adrenal androgen production, and rarely,- V2 l5 O! [9 [! {" c
an adrenal tumor may also cause adrenal androgen
% f- D* L0 b' ?+ B/ ^excess.1,3
: r/ {/ R+ F6 p) _% o. J1 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 v$ o" v8 E' D) z, e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 e3 f& a) G6 \0 z9 D! HA unique entity of male-limited gonadotropin-! I0 c1 x. _5 l2 W3 t2 \) K
independent precocious puberty, which is also known6 \6 R# a$ ?. L/ \( z# u$ L
as testotoxicosis, may cause precocious puberty at a3 p, j8 I5 v4 W
very young age. The physical findings in these boys
$ D, S; S# n9 |8 Z, `with this disorder are full pubertal development,( g$ U2 V: o3 \* E1 c) N4 i
including bilateral testicular growth, similar to boys( S3 g% N% f3 j
with CPP. The gonadotropin levels in this disorder2 i, b9 t8 H% g( k/ [, _
are suppressed to prepubertal levels and do not show
% I* e+ B2 ~# `# Bpubertal response of gonadotropin after gonadotropin-
& s6 l! X8 R0 {7 Vreleasing hormone stimulation. This is a sex-linked
/ k r- { {, G+ f6 A: dautosomal dominant disorder that affects only" g9 r' X2 V1 s% \7 O# T/ M" f$ [
males; therefore, other male members of the family
% v E" E: y* |" @# u# @( ^# v0 ~may have similar precocious puberty.33 M" z$ }. l ^+ q
In our patient, physical examination was incon-8 }& `3 d+ h, ^. V6 s' W4 O+ J+ c
sistent with true precocious puberty since his testi-
- o3 a- B4 R4 b% qcles were prepubertal in size. However, testotoxicosis1 X" y& |8 b5 A5 G( ]9 _; @" y
was in the differential diagnosis because his father
6 Z* D* S: }, A2 ~! N! N' ostarted puberty somewhat early, and occasionally, L" i: E, ^# S* F! i
testicular enlargement is not that evident in the2 Z# d4 P8 H; i, R+ l0 K
beginning of this process.1 In the absence of a neg-
8 y9 J. V& F$ f7 c+ ~ative initial history of androgen exposure, our) |4 |: ^1 [; }9 D: d0 B! |8 F+ F
biggest concern was virilizing adrenal hyperplasia,
, V+ u [* V/ seither 21-hydroxylase deficiency or 11-β hydroxylase3 }6 c; g/ m; S3 Z8 Z
deficiency. Those diagnoses were excluded by find-
, u* W8 k9 |* N' w) v8 u& Q0 @' W0 ting the normal level of adrenal steroids.
! o: Y! {0 v0 p1 q5 P9 _4 cThe diagnosis of exogenous androgens was strongly4 |6 D( ?6 ~, n0 M/ T7 [
suspected in a follow-up visit after 4 months because
% {. h% f2 x6 R9 J: P' f, nthe physical examination revealed the complete disap-
: N& }* @* f0 d' Y/ Y, d+ i) l( h3 xpearance of pubic hair, normal growth velocity, and
) ?3 D7 D" a/ m1 @0 C0 Kdecreased erections. The father admitted using a testos-$ j" E7 E7 C$ U% e( Z6 q. a7 h4 g
terone gel, which he concealed at first visit. He was
9 U& \' U; o6 @& zusing it rather frequently, twice a day. The Physicians’
2 a8 G9 l: S/ Q3 [3 J1 }- ~Desk Reference, or package insert of this product, gel or' B+ Y+ x, }( `' A4 e# _
cream, cautions about dermal testosterone transfer to
9 n6 s! ?" r |* u7 U% w+ T9 [unprotected females through direct skin exposure.& f8 E0 l0 Z4 C1 B C. o
Serum testosterone level was found to be 2 times the& F. Q {: n+ |6 x5 b9 [# S
baseline value in those females who were exposed to, l5 Y1 B! U9 K% [: A+ Z( X
even 15 minutes of direct skin contact with their male
4 }% z* B, i3 H* `7 }- gpartners.6 However, when a shirt covered the applica-: e5 J9 h1 m. d0 p7 z& _& K
tion site, this testosterone transfer was prevented.
$ q* s$ Q% v$ L. oOur patient’s testosterone level was 60 ng/mL,) I) K) u% i7 _1 W
which was clearly high. Some studies suggest that4 Q- \, Q& C3 J7 b/ R( x
dermal conversion of testosterone to dihydrotestos-( L4 D- F% }( z; J, F- z7 I/ ^& w. v
terone, which is a more potent metabolite, is more: H; c$ y) s% c) ]" Y
active in young children exposed to testosterone
+ y2 a. |' b9 Z8 xexogenously7; however, we did not measure a dihy-# Y' f1 S% k/ \" a" [1 Y0 C
drotestosterone level in our patient. In addition to! K; B& k# V4 W _/ r) a3 }6 O
virilization, exposure to exogenous testosterone in
|' @2 ^/ N2 o3 P4 \: x( rchildren results in an increase in growth velocity and
; y9 u$ L! @; m+ g* @. tadvanced bone age, as seen in our patient.7 q4 p* _3 g. U4 z1 W, o# V
The long-term effect of androgen exposure during
1 g4 _6 K: I/ k" ]3 }7 [0 mearly childhood on pubertal development and final; u' V( J5 h* I
adult height are not fully known and always remain! q$ W K0 T+ {8 p/ C$ l
a concern. Children treated with short-term testos-
1 Y! N( F" F( }2 z( Rterone injection or topical androgen may exhibit some9 d$ Y. y( l9 d6 I5 t3 h$ z4 |/ i
acceleration of the skeletal maturation; however, after
3 z. U* u8 @" j% t8 i0 z/ D4 G% f% Fcessation of treatment, the rate of bone maturation* H" j$ W4 o$ [& l
decelerates and gradually returns to normal.8,9
$ h: d# w- e3 K+ K/ @6 a. FThere are conflicting reports and controversy W* M, f' n0 M- t- l/ B
over the effect of early androgen exposure on adult* {" u; u* C- |& M
penile length.10,11 Some reports suggest subnormal I& E& H) M) u6 X5 P. M
adult penile length, apparently because of downreg-
( ^ v L+ e& N2 C1 }# A3 oulation of androgen receptor number.10,12 However,
8 b3 ?; Z& ^5 m$ @1 S8 rSutherland et al13 did not find a correlation between
! D, c; c! O/ j( f6 kchildhood testosterone exposure and reduced adult* ?- ^0 N* b# V* Y3 s+ Q- K! A2 h* W7 i
penile length in clinical studies.) V! O4 d" z$ e% V, p: _: h
Nonetheless, we do not believe our patient is
' L' r; o% U. c$ v) S" t9 j% U/ O Egoing to experience any of the untoward effects from9 U/ t# |$ S% F+ A9 x1 g0 z( u" c
testosterone exposure as mentioned earlier because
1 u7 _# N ?5 E9 i+ P7 othe exposure was not for a prolonged period of time.7 v$ t5 c3 O" E2 y& {- ^2 l
Although the bone age was advanced at the time of S9 `% E( U) u' a( A
diagnosis, the child had a normal growth velocity at
/ F( B7 i" o+ R9 Ithe follow-up visit. It is hoped that his final adult5 X* f5 p7 R; l: O# v
height will not be affected.2 ~2 \6 {& X* i4 j$ r6 R; L& |
Although rarely reported, the widespread avail-
5 t. B4 u- @2 j' nability of androgen products in our society may- r! ^& c1 v5 n$ V
indeed cause more virilization in male or female$ N% l2 f* y* U; |& G+ d/ f
children than one would realize. Exposure to andro-* {0 Q# s% B4 z3 U1 w1 n( O' U
gen products must be considered and specific ques-" Z P3 e2 o3 A
tioning about the use of a testosterone product or
4 w) Z7 R1 L+ r( n6 Rgel should be asked of the family members during5 a. r _$ e: {$ O% F) N8 x( `
the evaluation of any children who present with vir-
b9 V- e7 z' t( C0 ^ilization or peripheral precocious puberty. The diag-6 r8 D+ I0 \8 {" _6 _7 @; i
nosis can be established by just a few tests and by! c; S" {: b" ?& `! F% W
appropriate history. The inability to obtain such a1 N6 V3 R/ v' }! Z3 K, M! e
history, or failure to ask the specific questions, may
& Y4 K7 O: A) k- s# w3 iresult in extensive, unnecessary, and expensive4 k1 q1 e* p$ J O3 O
investigation. The primary care physician should be
4 W. [0 P, g- jaware of this fact, because most of these children% G5 t. k5 V7 t, }( f0 ^) j/ z
may initially present in their practice. The Physicians’
1 N$ M( m+ S/ A$ E# U- N+ ?* UDesk Reference and package insert should also put a
+ g% a& ~1 A' |* \$ x, z( U$ m$ p: bwarning about the virilizing effect on a male or
2 S7 v5 K2 q# n2 w: u% D0 H( Sfemale child who might come in contact with some-" i5 ^) e0 M0 H: x
one using any of these products.+ h% g' T, Z K! W" ?) u
References5 u! n2 b; J$ G4 ?0 [: K
1. Styne DM. The testes: disorder of sexual differentiation
" M9 V8 [ Z4 Q1 j' @and puberty in the male. In: Sperling MA, ed. Pediatric
: I) b* i8 E* u, j- VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: I( \: O+ s8 f% ]4 Z
2002: 565-628.
: X6 h \# C( j, {0 U- x R1 w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 p" i x5 P9 k" {
puberty in children with tumours of the suprasellar pineal |
|