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Sexual Precocity in a 16-Month-Old
, v2 w' N' o" Y5 K% H5 `Boy Induced by Indirect Topical
. N. _5 g7 b" b9 qExposure to Testosterone
: I9 ]8 i0 Z: g* [. T0 c& j, fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 g% L- o4 l( i1 ]) A& f( z
and Kenneth R. Rettig, MD1
4 ^4 T: q% @2 dClinical Pediatrics
; R% P! w, {$ [3 h# @Volume 46 Number 6
- a: d0 Z0 `( YJuly 2007 540-543% [& e( d( t. @1 h/ i3 o
© 2007 Sage Publications
2 n3 b2 X. D5 o# z* z+ B0 }10.1177/0009922806296651& w! i# ?& [4 q' h. |/ {7 p
http://clp.sagepub.com3 I1 P/ H7 F' U; [3 l( B' |/ O( m' {
hosted at& c- e* P# X1 W' T2 `/ {2 ]
http://online.sagepub.com1 W- c* {1 q8 N4 V/ G" [
Precocious puberty in boys, central or peripheral,
4 |7 E- Z* X1 `is a significant concern for physicians. Central
: |5 q7 J4 T" Qprecocious puberty (CPP), which is mediated
7 y- [0 c9 u2 K1 M3 p; vthrough the hypothalamic pituitary gonadal axis, has
" ?( ^. c$ R- o0 E. g2 W- o7 Ba higher incidence of organic central nervous system
- W& G, T1 N$ ilesions in boys.1,2 Virilization in boys, as manifested9 I% ?5 q0 X: l9 K
by enlargement of the penis, development of pubic
& c' @! e4 j, W) H+ ~5 z3 w' p7 rhair, and facial acne without enlargement of testi-3 V# `9 w) M# {' Z; ~
cles, suggests peripheral or pseudopuberty.1-3 We# W) W; J8 ]( [+ i
report a 16-month-old boy who presented with the
% Y% \8 s8 a8 A( Z8 Ienlargement of the phallus and pubic hair develop-' `/ g4 X% H8 B; ~. }3 ~$ t9 g) p7 T
ment without testicular enlargement, which was due
% i) ~1 U) O& p. w( t* E3 Lto the unintentional exposure to androgen gel used by
( n/ g8 X& ^8 C* U, ]4 |the father. The family initially concealed this infor-
2 T7 V+ u$ m5 G4 a; Q3 l3 \mation, resulting in an extensive work-up for this7 v+ O# {) T6 S
child. Given the widespread and easy availability of
& Z; q) p5 T0 Z+ p( o2 j! Y, g2 `testosterone gel and cream, we believe this is proba-
0 P- q' B* X) Y9 x+ D$ hbly more common than the rare case report in the
5 ?/ h6 `, M) G; V; y, k! M9 V# dliterature.4. S4 ?& |# o4 [4 ?0 X/ f
Patient Report
* R- C" }# |2 E# ~, V' jA 16-month-old white child was referred to the# M: q$ w- K/ V
endocrine clinic by his pediatrician with the concern. } }$ M- Y$ ?+ k- c; J
of early sexual development. His mother noticed
% m6 F# [% h+ Y/ blight colored pubic hair development when he was
/ L3 E# |: ~9 j, b$ R3 J3 Z( SFrom the 1Division of Pediatric Endocrinology, 2University of a5 z+ V5 V: q
South Alabama Medical Center, Mobile, Alabama.. s6 F# @5 T) m1 I i4 e8 }- b
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 o- E/ d, J8 e* K9 E
Professor of Pediatrics, University of South Alabama, College of5 [5 \+ Y- I8 B8 ?7 O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 x6 e0 k v( K6 ]
e-mail: [email protected].
+ E2 w8 n0 N! ]8 R1 @' U1 ~* E0 _1 jabout 6 to 7 months old, which progressively became+ a& d, X' e2 l X
darker. She was also concerned about the enlarge-
: V _! e' ~8 Lment of his penis and frequent erections. The child
# y6 d) o" g2 w1 V. G5 C4 Z* M9 Rwas the product of a full-term normal delivery, with
) |! c; E. ?8 b7 B3 Ta birth weight of 7 lb 14 oz, and birth length of
" @. u" D2 M% y9 o9 t8 A: ~5 _ t; }20 inches. He was breast-fed throughout the first year" j* E- m9 z8 w2 H
of life and was still receiving breast milk along with
1 v1 p* @" M' H: B" O1 Wsolid food. He had no hospitalizations or surgery,9 j, K' j, G$ f0 e! v, j
and his psychosocial and psychomotor development
3 C# g2 Q1 M" |; x: N) w- v* Wwas age appropriate.# A2 f' e5 a2 d
The family history was remarkable for the father,
8 P/ {! T6 f; v1 Z; [3 }& ~5 m) Pwho was diagnosed with hypothyroidism at age 16,
* L+ J8 r; f0 o1 Nwhich was treated with thyroxine. The father’s
/ \! x& b* g, A! ?height was 6 feet, and he went through a somewhat
, y( c" K" r( {. gearly puberty and had stopped growing by age 14.% q& u, A1 L" {# T
The father denied taking any other medication. The
0 Q: U4 A/ Y. [: R; Nchild’s mother was in good health. Her menarche
: t5 [+ G) c0 S, ~! Zwas at 11 years of age, and her height was at 5 feet
$ h* { q3 T2 `6 y3 }; x& F5 inches. There was no other family history of pre-
8 e) {; l' @2 f# d; |cocious sexual development in the first-degree rela-
, ^% ~& z$ o" L% J" d4 etives. There were no siblings.! M" r( o1 `) i, }) f" R7 H% M/ U
Physical Examination, B. T8 C& G5 I% [% |2 m
The physical examination revealed a very active,
: n, R- ~- S2 Yplayful, and healthy boy. The vital signs documented
9 ?1 g8 G( m2 R/ Va blood pressure of 85/50 mm Hg, his length was
7 o& J! P" @+ b7 _90 cm (>97th percentile), and his weight was 14.4 kg
9 K5 s" j2 q! f o! m(also >97th percentile). The observed yearly growth
- |+ E6 `& }* q) f6 F- ~5 U# Vvelocity was 30 cm (12 inches). The examination of k2 {1 m5 N2 n% u
the neck revealed no thyroid enlargement.
4 J8 n# J+ Q8 j0 Y- ]- lThe genitourinary examination was remarkable for+ T3 ~$ ?! a2 G0 F. q4 b
enlargement of the penis, with a stretched length of5 k7 E8 h% {( j
8 cm and a width of 2 cm. The glans penis was very well
/ x. c, H0 S$ z* T0 y" ?' Q& H. Kdeveloped. The pubic hair was Tanner II, mostly around
: m8 c; Z6 b) c* B3 ^8 f5406 ?# J1 o, A8 b5 }$ K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" V# C2 W4 L* v( [the base of the phallus and was dark and curled. The
b/ Z0 h" ~" C: b' X/ c. xtesticular volume was prepubertal at 2 mL each.$ V1 s: @, E1 V6 r/ b
The skin was moist and smooth and somewhat
/ H$ m! M5 h6 ?. G9 boily. No axillary hair was noted. There were no& G" x3 Q& I5 h6 A4 _; H
abnormal skin pigmentations or café-au-lait spots.
( ^+ w. x# j( v X2 vNeurologic evaluation showed deep tendon reflex 2+9 ]3 O+ U8 f1 u( |
bilateral and symmetrical. There was no suggestion3 S0 J2 ^& e8 L$ [) ?8 d1 \, z
of papilledema.
. d& x; }5 n1 U' }Laboratory Evaluation
/ }( T( ^0 u& \/ NThe bone age was consistent with 28 months by
0 G$ i3 V7 Y8 g$ u3 husing the standard of Greulich and Pyle at a chrono-
8 S+ K: P3 o+ Qlogic age of 16 months (advanced).5 Chromosomal
1 s O* _" X! _, s Fkaryotype was 46XY. The thyroid function test# a9 L" b/ i. v: y2 Y$ k' \( O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 D$ X4 f7 q' ]% [* t; h3 \lating hormone level was 1.3 µIU/mL (both normal).
( c1 T* P$ S# [8 M' F4 eThe concentrations of serum electrolytes, blood
8 N# ~5 l7 a7 jurea nitrogen, creatinine, and calcium all were0 k1 s0 B6 r$ K" l
within normal range for his age. The concentration
$ V' c# h7 X# q0 \3 T/ _& Lof serum 17-hydroxyprogesterone was 16 ng/dL
* E+ Q- A% k& w* `/ K* E8 i" p) Z- r(normal, 3 to 90 ng/dL), androstenedione was 20
3 X* W; \5 M: x+ @' Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 h$ P/ q( M0 l' i! A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. e0 P7 Y% Z' J4 J+ cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ `5 Y! Y% N7 D0 Q( O5 a: C49ng/dL), 11-desoxycortisol (specific compound S)+ G( H- F) @& Z0 F, X3 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: f" K5 a! x5 y9 z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 C, |: F; w5 D6 e' r8 btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% }: B# _8 h r& A0 H4 mand β-human chorionic gonadotropin was less than
4 V# B/ U8 d6 S# N) I5 mIU/mL (normal <5 mIU/mL). Serum follicular6 A X: l7 z$ j
stimulating hormone and leuteinizing hormone
1 R; \& T! i8 p6 lconcentrations were less than 0.05 mIU/mL+ x2 _6 d0 M* y( j; C# W; K: j
(prepubertal).% G* L0 P! q1 E! D4 b) i& q) T
The parents were notified about the laboratory
4 r4 x" @* O" _results and were informed that all of the tests were
& }7 C! u6 a8 nnormal except the testosterone level was high. The
$ ~) ]* @3 Q$ V! O) p- zfollow-up visit was arranged within a few weeks to
" ~& A# B, @) M+ e' Vobtain testicular and abdominal sonograms; how-2 r, v; M- i3 x( N
ever, the family did not return for 4 months.
8 x. z* |8 w4 ~# z# HPhysical examination at this time revealed that the7 s# l4 c' L5 a* r3 Y4 q, E5 j
child had grown 2.5 cm in 4 months and had gained
! Y4 a# V+ m" B) e4 n& k' T: \2 kg of weight. Physical examination remained
5 w; A# g! \; K4 `7 k( Eunchanged. Surprisingly, the pubic hair almost com-$ q% s9 J1 G q2 F/ U" b- J* w' b
pletely disappeared except for a few vellous hairs at
! j# a5 }, ^# v( W! L! @& Pthe base of the phallus. Testicular volume was still 2
# e3 K' ~4 o* \$ L' n2 M+ a( q8 t" ?mL, and the size of the penis remained unchanged.3 c( Y# q) x2 \8 h5 _
The mother also said that the boy was no longer hav-7 r1 Y7 {3 h$ S5 p1 s) F. Y* Z+ L
ing frequent erections.
' k' u& E6 N; W p! c0 p9 CBoth parents were again questioned about use of& s: D# e& c. u4 c- m8 q% R8 l- |7 W
any ointment/creams that they may have applied to
: {: `. L5 p2 G/ e, j; O. Hthe child’s skin. This time the father admitted the
7 W! I) m: D1 Y/ b5 `# O; N3 R+ |4 }Topical Testosterone Exposure / Bhowmick et al 541+ b+ X7 R5 ]. i
use of testosterone gel twice daily that he was apply-+ l/ T$ C' q, s. F
ing over his own shoulders, chest, and back area for
V/ ? f" z0 E" p4 _a year. The father also revealed he was embarrassed
% P* {6 h$ r' E7 n& J+ U* kto disclose that he was using a testosterone gel pre-, d- V# G$ w i/ B
scribed by his family physician for decreased libido
3 B% p# K* t h# J' S7 Lsecondary to depression.
) ~! P$ p; T, D! d3 `' fThe child slept in the same bed with parents.
* _+ \2 T$ R" s3 P/ B8 k; r% w- W7 nThe father would hug the baby and hold him on his j, v% M* J, W( F3 F
chest for a considerable period of time, causing sig-$ w# ` K( I) w; t4 p# o4 ?
nificant bare skin contact between baby and father.
2 n; ?& ?3 c- E3 Y' Y iThe father also admitted that after the phone call,
8 h8 _6 Q. q0 Z' W% H& n, bwhen he learned the testosterone level in the baby
4 `" t' V; R5 n3 q. T# Xwas high, he then read the product information: T( m3 q* }" k N' h1 p* J5 h1 K2 N
packet and concluded that it was most likely the rea-& @$ V5 t5 e1 X6 {5 e
son for the child’s virilization. At that time, they
5 [1 k3 _2 R; v' vdecided to put the baby in a separate bed, and the
7 H# W8 V* Y7 m' E& @& Ofather was not hugging him with bare skin and had
8 v# n4 {- S K. ^been using protective clothing. A repeat testosterone
* `" K- E/ v i. K9 \) htest was ordered, but the family did not go to the* Q- j5 A3 F" M5 D) E9 o# M* J
laboratory to obtain the test.; m$ U7 _, m+ s- l
Discussion
r# m$ b2 V* k5 z6 w5 RPrecocious puberty in boys is defined as secondary
% K: v+ ]! y0 Y1 _0 Fsexual development before 9 years of age.1,4
0 N( E1 j7 }: V" L1 v* YPrecocious puberty is termed as central (true) when( m9 [3 K6 _, X1 Y0 b) S" _
it is caused by the premature activation of hypo-
, D/ C8 p4 P) W5 z" Z! d' T# |! kthalamic pituitary gonadal axis. CPP is more com-
7 b" Q1 v" F: Jmon in girls than in boys.1,3 Most boys with CPP3 }4 Z" z9 D( q! A, E7 [" V! W9 [( e, ^+ P
may have a central nervous system lesion that is l3 S7 G" X4 x# Z1 N) n8 x- s( U
responsible for the early activation of the hypothal-
9 v v# R. ]% T% t$ K3 ramic pituitary gonadal axis.1-3 Thus, greater empha-4 ?, I4 h, z- V/ @" v5 L
sis has been given to neuroradiologic imaging in
( p5 v& @: w8 V% z2 M% Y+ Tboys with precocious puberty. In addition to viril-
0 N+ s& O6 g5 r3 Uization, the clinical hallmark of CPP is the symmet-
1 L7 {' S' J% c! U+ C' c" {% Qrical testicular growth secondary to stimulation by- F+ t' n5 N9 K9 @
gonadotropins.1,3" I& o$ ]% U. m
Gonadotropin-independent peripheral preco-! T5 T3 }$ q" R" a2 H# f
cious puberty in boys also results from inappropriate
, y" } {; d t) r$ bandrogenic stimulation from either endogenous or
3 y% M- V& V* d8 sexogenous sources, nonpituitary gonadotropin stim-
; b3 }3 b# s# Q8 M" c" c- xulation, and rare activating mutations.3 Virilizing5 d5 F& R) D( {/ J1 ^
congenital adrenal hyperplasia producing excessive! X' y" Y+ ^3 N9 m
adrenal androgens is a common cause of precocious
1 C( X* I8 D9 Q& _$ ppuberty in boys.3,4
" U, s- p- B8 ~+ z3 d: UThe most common form of congenital adrenal
8 g. Z/ ^4 P! t% U# m7 I4 d6 Jhyperplasia is the 21-hydroxylase enzyme deficiency., d1 |5 M# Q) ]$ ]4 n5 p& u" B7 r
The 11-β hydroxylase deficiency may also result in6 p3 \- v8 ^2 z" l$ p
excessive adrenal androgen production, and rarely,
' m8 y `: G9 R2 Z- T! lan adrenal tumor may also cause adrenal androgen# a* {& f- x4 ]' r' C
excess.1,3
3 t5 B0 e5 B( `! Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 k7 a) B9 ~" p+ q- V542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% N+ P0 T" w+ X& H3 B& c: ]6 j" bA unique entity of male-limited gonadotropin-8 X4 W+ u. C( m8 ^0 l/ o9 N
independent precocious puberty, which is also known
' t6 K# N1 v" ]& V- yas testotoxicosis, may cause precocious puberty at a k w$ [/ \4 ], j; } D- W
very young age. The physical findings in these boys
: l( E3 N# P _/ g3 \with this disorder are full pubertal development,
: a+ u! D$ ]' a2 o8 H2 r6 C% P2 t8 Zincluding bilateral testicular growth, similar to boys* m; q% `5 ?1 D7 j7 A8 f
with CPP. The gonadotropin levels in this disorder1 O: E$ H+ T( I" O
are suppressed to prepubertal levels and do not show( [) w6 @: W" v* L+ l% q
pubertal response of gonadotropin after gonadotropin-& C4 Y, ^3 _5 X
releasing hormone stimulation. This is a sex-linked
- \& L7 Q3 c" c) ]: ?autosomal dominant disorder that affects only, C+ x6 \, S$ \% w3 k/ T7 j9 @
males; therefore, other male members of the family9 n$ O: o' C, }6 C; n1 x7 ?
may have similar precocious puberty.3
& t% [6 w, P$ c; J- SIn our patient, physical examination was incon-7 N6 i+ C8 {/ \
sistent with true precocious puberty since his testi-& g1 F6 _* ] \& k* d3 D6 f6 z( }
cles were prepubertal in size. However, testotoxicosis
+ R) E, o: |/ t: }! p4 nwas in the differential diagnosis because his father
0 u; c! j+ }/ y0 M2 J) ?6 W* Fstarted puberty somewhat early, and occasionally,
3 C* G( k3 a7 x9 p! u" }3 ~/ h* t/ a6 ltesticular enlargement is not that evident in the% E" {: E5 ~. A9 B2 o
beginning of this process.1 In the absence of a neg-* Z& f; M8 X' Z2 a! B* L2 s6 b
ative initial history of androgen exposure, our3 h3 n$ l' j7 |' P( A
biggest concern was virilizing adrenal hyperplasia,# {; n7 ~3 q" J' x9 q5 L* C8 ]
either 21-hydroxylase deficiency or 11-β hydroxylase
/ b9 M9 h2 t" j& `0 t- `deficiency. Those diagnoses were excluded by find-
3 Q) K8 |9 |7 ?- U! qing the normal level of adrenal steroids.8 Q1 v1 A. |- J$ c
The diagnosis of exogenous androgens was strongly
2 k& j- t4 Q6 d& V/ S$ dsuspected in a follow-up visit after 4 months because/ E/ Z' L1 ]% ~
the physical examination revealed the complete disap-" q* g2 v* \! ~- F: M+ ?( N! B
pearance of pubic hair, normal growth velocity, and3 I4 y9 x6 _8 s, M) y* U5 ^
decreased erections. The father admitted using a testos-7 X7 {/ h" m* I# R! J* n
terone gel, which he concealed at first visit. He was
2 U7 F, r6 _* Q' Uusing it rather frequently, twice a day. The Physicians’; Z$ Y0 c* D! q0 |9 O+ I
Desk Reference, or package insert of this product, gel or
/ v4 `! U/ U4 u, C/ p/ Lcream, cautions about dermal testosterone transfer to
! m9 `! Q* V' ?- x Dunprotected females through direct skin exposure." @2 G7 e( d' o) |; Y
Serum testosterone level was found to be 2 times the
5 [' N# m% }' t# A9 ?3 xbaseline value in those females who were exposed to3 n1 Z! z( g: d
even 15 minutes of direct skin contact with their male
- \0 K a' M7 i0 k# tpartners.6 However, when a shirt covered the applica-
" p9 F J; P8 ction site, this testosterone transfer was prevented.5 c% | Y" n, U, `4 K$ K" i( S
Our patient’s testosterone level was 60 ng/mL,' w1 {3 l" b S7 k, \$ J
which was clearly high. Some studies suggest that( n3 \4 S/ B. m9 @2 u4 ~
dermal conversion of testosterone to dihydrotestos-
. x% P( N B* b# W" ?2 Oterone, which is a more potent metabolite, is more& J3 v" V: t1 t, z- i+ C7 t2 I, g
active in young children exposed to testosterone
9 s( M- x& c) x: }) jexogenously7; however, we did not measure a dihy-
) o9 Y. ~" z# i, G! N- f# \) udrotestosterone level in our patient. In addition to8 T" o2 i$ q( I/ a: @3 u
virilization, exposure to exogenous testosterone in5 j9 O& V7 w6 {% Z
children results in an increase in growth velocity and( F s$ n6 w: U7 m
advanced bone age, as seen in our patient." L- v7 K: }- [0 n1 i- v6 q1 P5 v
The long-term effect of androgen exposure during
. j @6 z1 Q) }: `- I4 ^* ~ cearly childhood on pubertal development and final7 Q& b0 i3 T1 n
adult height are not fully known and always remain
9 v. z# M# L" C. H& F. q7 a* Ra concern. Children treated with short-term testos-; W, n- _6 \& {' \
terone injection or topical androgen may exhibit some
3 X @: Z4 [% k; ~8 B) x bacceleration of the skeletal maturation; however, after
- L4 F: ?! A- X' N9 H# bcessation of treatment, the rate of bone maturation( w" \8 @% L$ ?# B2 |, K- U/ p
decelerates and gradually returns to normal.8,9& y( t3 x7 M, u3 `2 X
There are conflicting reports and controversy
0 _, H$ ^+ X, b3 {over the effect of early androgen exposure on adult
! N0 ?' F" }# z# i' k3 |penile length.10,11 Some reports suggest subnormal
* u( m) s N) X# J. C* G0 _( vadult penile length, apparently because of downreg-3 i. n2 J# H3 c' N& U
ulation of androgen receptor number.10,12 However,
) f+ ^7 c" k" L4 oSutherland et al13 did not find a correlation between" U' k1 _) h. [3 F% y. J
childhood testosterone exposure and reduced adult V# D6 g# O; }2 ~6 R; k
penile length in clinical studies.
: d- y+ G F2 w" ?5 k1 U dNonetheless, we do not believe our patient is7 u( E: A9 y$ F9 i
going to experience any of the untoward effects from
/ Z$ P+ Z6 N% n! {- @9 a+ ]testosterone exposure as mentioned earlier because
& Z, M3 L; V0 z" ?7 J% ythe exposure was not for a prolonged period of time.6 M; w0 J) ^- V- D
Although the bone age was advanced at the time of. f; m! ]4 D" r, b* L P
diagnosis, the child had a normal growth velocity at
# K, h% g4 d0 ^0 r! J$ _+ d# I* [the follow-up visit. It is hoped that his final adult
1 t. k u# ~* yheight will not be affected.$ q3 g& X& W' h, |4 Y
Although rarely reported, the widespread avail-+ K: R; y2 K, q
ability of androgen products in our society may
- `* ?' w, |2 K9 Hindeed cause more virilization in male or female
@: ]/ m$ b' o$ `. B- @* ?8 I" [. Qchildren than one would realize. Exposure to andro-
. r9 C) H2 w" T8 Lgen products must be considered and specific ques-
' X/ C, a: `& e6 Mtioning about the use of a testosterone product or0 j4 Y. Z. H5 G! q
gel should be asked of the family members during
* H8 [& v. x% J; ~the evaluation of any children who present with vir-7 l7 S( h1 U; Y
ilization or peripheral precocious puberty. The diag-( j8 N- L; J$ E/ `
nosis can be established by just a few tests and by
2 P; v0 I7 W% \9 A; M* xappropriate history. The inability to obtain such a# p8 w! @& n2 z; ^% p* I
history, or failure to ask the specific questions, may
6 W! x& T4 s5 ^result in extensive, unnecessary, and expensive
/ Z* p) d7 T# M/ l% Z1 X( x, \# Oinvestigation. The primary care physician should be
& w6 d2 J8 \( Y# L7 _aware of this fact, because most of these children
4 V8 d% s* O+ P% L8 L% M2 L u3 _may initially present in their practice. The Physicians’
! b( ~" D. ^: ~7 q, [, r8 A7 t: wDesk Reference and package insert should also put a
8 K6 o) ~) R2 b$ ?: V$ r( zwarning about the virilizing effect on a male or% z' k, i# X4 j
female child who might come in contact with some-/ w. p3 c' w4 \
one using any of these products.
1 K* S6 B: p% f. [References5 I8 r. r1 w9 u; X3 [& K+ ]2 c% r
1. Styne DM. The testes: disorder of sexual differentiation
0 r+ P( ^/ s' J( Pand puberty in the male. In: Sperling MA, ed. Pediatric; g1 G/ |) d1 V8 T3 [/ d# A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 ]4 Z8 ?) e& `& B5 `: g2002: 565-628.
2 w6 J7 B3 c4 v8 X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- n' c: z% D9 ]9 j. O4 fpuberty in children with tumours of the suprasellar pineal |
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