- 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 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old, j2 z9 ?3 s- U3 P) [
Boy Induced by Indirect Topical
/ x! R. D6 l) aExposure to Testosterone
* ^( p3 T3 E9 x& L2 k0 Z6 dSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: _4 I2 A+ b+ I' t* R+ Oand Kenneth R. Rettig, MD1
/ E0 p7 e1 n+ O R; r# D1 x }" ^Clinical Pediatrics) s5 H3 _7 m8 Z9 w
Volume 46 Number 6, b, D7 w2 Q- u4 Y
July 2007 540-543, f4 h$ D$ e& m! ?% j
© 2007 Sage Publications) w; c: c3 b! i5 P3 O: Y
10.1177/0009922806296651 y9 Z: M, ^# }1 T
http://clp.sagepub.com
5 J" h6 t& k; q. ?3 shosted at
; ?- `) e: A$ W: y5 ?/ v) C6 Ghttp://online.sagepub.com D R. g, f% ^; E) M' I
Precocious puberty in boys, central or peripheral,
; c1 L+ H9 k3 u4 x# o8 Q. L) Zis a significant concern for physicians. Central
4 D* l. Z5 h3 U) [0 ~precocious puberty (CPP), which is mediated. x+ L- ~ ~ L" \: E, c1 a
through the hypothalamic pituitary gonadal axis, has
+ U+ N5 H* \+ O6 t, @( Na higher incidence of organic central nervous system
0 C2 F! L! J% |0 {- ilesions in boys.1,2 Virilization in boys, as manifested
7 j8 ^. ?% ]$ I- A" P3 Rby enlargement of the penis, development of pubic) W! V, ?! [3 I
hair, and facial acne without enlargement of testi-
* {; o5 O/ y M$ H2 E7 vcles, suggests peripheral or pseudopuberty.1-3 We. h, n" i% H7 ?! {5 `% k& g
report a 16-month-old boy who presented with the
% S- A1 d/ o- j! l5 @. g: cenlargement of the phallus and pubic hair develop-9 g# M) K# I. c3 X0 S
ment without testicular enlargement, which was due, ?/ X8 z0 s/ F2 {
to the unintentional exposure to androgen gel used by
# `& `8 `* E: ^the father. The family initially concealed this infor-
8 }$ [4 l3 Z: A4 M) qmation, resulting in an extensive work-up for this
; E8 |1 b6 f/ t6 S4 \. Tchild. Given the widespread and easy availability of
( r# X9 W; d3 Q+ v& ?6 x! X3 r' ? rtestosterone gel and cream, we believe this is proba-8 U, h) H: R0 B* ~1 O( i' Q
bly more common than the rare case report in the1 q( g6 l$ b8 w% r0 \
literature.4
* x* }3 [! M6 \3 X BPatient Report
2 u2 ]5 S+ K- k w b( IA 16-month-old white child was referred to the
, d% y7 m- I# P2 kendocrine clinic by his pediatrician with the concern
2 s$ m4 d8 h$ G; {+ Nof early sexual development. His mother noticed
7 ]. \, Z8 Z$ d) g9 ^' L6 Alight colored pubic hair development when he was2 }1 Z' I, b# D7 G
From the 1Division of Pediatric Endocrinology, 2University of
6 n) ]* X& S% B6 Y2 `9 i: A7 h0 KSouth Alabama Medical Center, Mobile, Alabama.
2 |% Y. F3 N! {! i# q& U* H4 nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 m5 B6 o4 J$ S/ m, e% Y% q- W7 ]Professor of Pediatrics, University of South Alabama, College of
# f( ~, v* n9 Y% ]+ UMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( f& V2 K# ^$ g' z0 X( S
e-mail: [email protected].
% o+ o$ {$ {, }: a' i$ zabout 6 to 7 months old, which progressively became4 i, k- o# Q# O/ S. c
darker. She was also concerned about the enlarge-
7 ?5 Q: C' |$ J- f0 g" ~ment of his penis and frequent erections. The child
7 x+ V+ U3 X: R% Awas the product of a full-term normal delivery, with
' G7 S( ]+ v. b/ b4 C) I! u" k& oa birth weight of 7 lb 14 oz, and birth length of- h, r4 v5 K% ?. s7 k" f
20 inches. He was breast-fed throughout the first year7 L6 y* Q6 a/ g! B/ |
of life and was still receiving breast milk along with! H8 g, V+ Y3 {6 V6 Y
solid food. He had no hospitalizations or surgery,
7 j2 ^! [: f# e" E9 B6 Y% V+ qand his psychosocial and psychomotor development% v, ?& x8 v* o. m- M
was age appropriate.
" z7 c2 U( {' ZThe family history was remarkable for the father,( {: l/ }& u8 b9 U6 e [
who was diagnosed with hypothyroidism at age 16,: o% T! z% X9 {. W5 u
which was treated with thyroxine. The father’s! c' w2 K. w! p; S
height was 6 feet, and he went through a somewhat
5 z& T7 R2 g _, B" y* yearly puberty and had stopped growing by age 14.
; Q- `! D, e2 EThe father denied taking any other medication. The7 M3 q0 \% f0 D3 b) M+ N
child’s mother was in good health. Her menarche
4 `' q' Y; o" z7 s, ~$ b; nwas at 11 years of age, and her height was at 5 feet% h$ ?+ C# a" `
5 inches. There was no other family history of pre-
8 D6 K. u5 `% \* _6 e" ^( bcocious sexual development in the first-degree rela-4 N+ H, s) W/ ]" x% r3 H
tives. There were no siblings.& I/ A# o) \9 G3 I, J8 \+ u/ |
Physical Examination
3 y! m8 I+ f( q0 [: c; p7 f+ a7 o! hThe physical examination revealed a very active,
, l3 P1 I: E& g, G, ^playful, and healthy boy. The vital signs documented4 Q1 `8 f3 ^) [) L4 \& _$ i
a blood pressure of 85/50 mm Hg, his length was0 {. U+ q& x0 n3 z& o0 q
90 cm (>97th percentile), and his weight was 14.4 kg
9 o6 F: W: f8 w1 ^# i5 {(also >97th percentile). The observed yearly growth
5 y9 r6 }- l' t# t: q( bvelocity was 30 cm (12 inches). The examination of8 o4 D9 k# X9 [" b! X* _
the neck revealed no thyroid enlargement.
/ E4 ~6 e( A( W# T( IThe genitourinary examination was remarkable for' v5 W8 _+ v" K$ ]# c7 k2 O
enlargement of the penis, with a stretched length of! j2 K5 K0 g5 T8 z
8 cm and a width of 2 cm. The glans penis was very well
9 c4 |" h [$ Q6 ?# H6 Mdeveloped. The pubic hair was Tanner II, mostly around% V9 I; E4 _& z0 \8 B
540! u) F6 O5 U" g2 ]/ ~' u! v) j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ X8 J/ I9 ]* Z; [
the base of the phallus and was dark and curled. The( J. {5 J0 a( h4 C) c
testicular volume was prepubertal at 2 mL each.
; x: d7 ?: s! c0 IThe skin was moist and smooth and somewhat7 c3 v% `! h; |" q
oily. No axillary hair was noted. There were no# R2 m5 f' h6 g4 X$ a
abnormal skin pigmentations or café-au-lait spots.
/ h) t" m: k. T+ e# u' Q0 _, `7 @" ~Neurologic evaluation showed deep tendon reflex 2+8 r0 O- H O: ^, L+ A
bilateral and symmetrical. There was no suggestion
& E! f- _ l( E. a# zof papilledema.
' Z, F" V P$ X |$ ALaboratory Evaluation
- s9 G8 f5 J- ]+ Y8 h( U% @The bone age was consistent with 28 months by
3 l ?& L o$ I( y8 @+ Z Yusing the standard of Greulich and Pyle at a chrono-
# \* _4 J" K8 L* C: A2 N0 b: y/ w# elogic age of 16 months (advanced).5 Chromosomal
8 {+ e* n* Y9 Y+ A" ?( g7 Rkaryotype was 46XY. The thyroid function test
! d- V6 L( X* M3 g5 cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 n( R7 S# X1 i6 K+ ^lating hormone level was 1.3 µIU/mL (both normal).
8 n I) y+ j; s! ?3 u4 _The concentrations of serum electrolytes, blood
1 { }( M! @3 ~9 j, J! I" [urea nitrogen, creatinine, and calcium all were
1 r! P5 @/ _0 T3 Z1 J7 owithin normal range for his age. The concentration
& p$ c0 Z8 Y" oof serum 17-hydroxyprogesterone was 16 ng/dL
0 T5 T. Q! D* J2 u2 w" y0 Y B(normal, 3 to 90 ng/dL), androstenedione was 209 O7 T; o4 r; C$ k/ j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% P( r2 I% D3 [8 g0 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
* A1 F& D) n$ B, p5 }' i7 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 M( W9 W+ x) _! K& s49ng/dL), 11-desoxycortisol (specific compound S)
! W9 |3 l4 S/ ], gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) q, D+ C3 O4 O q6 {2 ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% E" e5 l3 H4 \2 p. _. |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* V' ]1 D5 ?* ^) wand β-human chorionic gonadotropin was less than
1 Y9 X. z% T/ M( r5 mIU/mL (normal <5 mIU/mL). Serum follicular5 N7 l" ]- |' s. d
stimulating hormone and leuteinizing hormone
) a3 k" z( T! _+ B3 \3 u0 hconcentrations were less than 0.05 mIU/mL1 T% J2 m% p5 U$ H5 @2 j, V
(prepubertal).
: ?8 a1 F& f! @ K$ ]% B* CThe parents were notified about the laboratory* A, s P" i. q- ~5 \" O7 ]
results and were informed that all of the tests were
6 ~* L' |3 @( pnormal except the testosterone level was high. The
- t7 Y4 U' m$ d1 v7 i G' B7 R' ?follow-up visit was arranged within a few weeks to. m/ n% `/ v V3 `3 N8 B* B
obtain testicular and abdominal sonograms; how-2 c" ~* j I2 F3 V* X. d
ever, the family did not return for 4 months.
! _; `& w& J9 \7 B' zPhysical examination at this time revealed that the
0 H* l( y; ?' G! t, W( x$ cchild had grown 2.5 cm in 4 months and had gained
" U5 E6 F; W" R2 i# Y4 g ]+ C: }: ~2 kg of weight. Physical examination remained
. p( z8 E, B% i0 gunchanged. Surprisingly, the pubic hair almost com-
l) e: M' C8 G, D7 jpletely disappeared except for a few vellous hairs at
0 t/ z/ G+ k0 tthe base of the phallus. Testicular volume was still 2# P. U, h. @% k1 |
mL, and the size of the penis remained unchanged.
9 v, R) M, r9 U# R- M: cThe mother also said that the boy was no longer hav-
1 d/ c R7 }) `* Y+ n$ hing frequent erections.$ `* \) I) _7 T1 B' I9 v: E
Both parents were again questioned about use of6 U# Z5 o! b C. j" [- y7 r
any ointment/creams that they may have applied to4 y4 f1 I; b; `: y o( Z* R
the child’s skin. This time the father admitted the% X$ f# e1 o: P; @( V1 g3 l) Z/ {
Topical Testosterone Exposure / Bhowmick et al 541! [5 ~0 Z4 Q" \/ E
use of testosterone gel twice daily that he was apply-5 X$ u1 { ^4 J3 S/ w- L5 A6 n
ing over his own shoulders, chest, and back area for& g C4 x- _/ }# I
a year. The father also revealed he was embarrassed
8 ?' a; w4 A5 u" e3 z* A4 Rto disclose that he was using a testosterone gel pre-/ v* x1 I# _: s" `0 V
scribed by his family physician for decreased libido) B, L) r0 @" z, S& H
secondary to depression.3 R! o( B5 Q; e6 F. H7 O6 K! j# T; O
The child slept in the same bed with parents.
! ?" m( [- W+ E4 S# F2 tThe father would hug the baby and hold him on his1 s+ I0 G+ A" N8 u& F9 h
chest for a considerable period of time, causing sig-/ s& Z9 [/ Y' d: L4 p
nificant bare skin contact between baby and father.
1 Q9 }$ J n) n( p6 `" P. }! K# O* _The father also admitted that after the phone call,
# v. `: n5 F- k, d( L5 r! | rwhen he learned the testosterone level in the baby4 u) V* T# |; t, v
was high, he then read the product information/ k" [! c. h& m! w0 o( P: R
packet and concluded that it was most likely the rea-3 v: }; p& J) g! M
son for the child’s virilization. At that time, they3 B9 i- }6 T h
decided to put the baby in a separate bed, and the
( K9 }3 a$ m- b# u2 I8 u! j3 sfather was not hugging him with bare skin and had
6 `' Q' f5 o: n# o5 N; ^: ybeen using protective clothing. A repeat testosterone
4 j5 D* y2 _) }0 @test was ordered, but the family did not go to the- Z1 E3 j6 n1 x; E' b; x4 H7 P
laboratory to obtain the test.
2 \: J( p+ l/ h; q4 {8 J- BDiscussion
+ m: s6 ^9 E) V; r+ |# O8 _9 r. MPrecocious puberty in boys is defined as secondary- I8 x$ X/ ^' E" a: K$ Z% v' k
sexual development before 9 years of age.1,4+ v, A! ? _7 s1 d
Precocious puberty is termed as central (true) when3 r# g8 W- d9 Q0 X# c; w% S+ l1 j
it is caused by the premature activation of hypo-; S+ b& W- E& C7 T, ^8 z! C* |+ V
thalamic pituitary gonadal axis. CPP is more com-1 x* H% ]' ^5 s- ^
mon in girls than in boys.1,3 Most boys with CPP
! v- W* j: l0 @9 A+ C& k' n/ W! bmay have a central nervous system lesion that is
1 T2 T! i- B! R- tresponsible for the early activation of the hypothal-
+ h' h! q1 Q/ \) W% Samic pituitary gonadal axis.1-3 Thus, greater empha-
/ w3 o" S( v4 ]: Usis has been given to neuroradiologic imaging in
7 C3 q1 X) F h& xboys with precocious puberty. In addition to viril-
" |# ]& P0 v1 l; {% oization, the clinical hallmark of CPP is the symmet-
" D# q! V- j) [rical testicular growth secondary to stimulation by5 Y9 [/ i m; a: e
gonadotropins.1,3$ B2 [# k1 u& E$ A8 \. L4 ~
Gonadotropin-independent peripheral preco-
( F' _; ]- t& X2 ~5 f1 A7 N3 E7 bcious puberty in boys also results from inappropriate
, \: {8 W' [8 g, Bandrogenic stimulation from either endogenous or* {7 K7 V: [6 ]& x# g- Z' B2 y, s G
exogenous sources, nonpituitary gonadotropin stim-# p+ L, i9 a: }% N$ y
ulation, and rare activating mutations.3 Virilizing1 }8 _" `7 x; \0 @& `
congenital adrenal hyperplasia producing excessive+ \2 \# Q- z4 J+ P. X
adrenal androgens is a common cause of precocious
2 U2 Y1 z# @8 ^7 X+ D) b) ?* [. _* @puberty in boys.3,4
7 \( R0 E9 |* h" FThe most common form of congenital adrenal9 N c& O' r" |9 N& m* ?* K% Q5 q
hyperplasia is the 21-hydroxylase enzyme deficiency.
I6 f4 f0 C g) dThe 11-β hydroxylase deficiency may also result in
7 z) K$ t6 X' p' [- K8 gexcessive adrenal androgen production, and rarely,: p$ H3 t/ G3 f! u. n0 x
an adrenal tumor may also cause adrenal androgen
8 H* o$ l4 T* O. \( D% { ~# Iexcess.1,3; O: t7 L* @" @6 t) b% K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& [0 O- I& L" E o
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 N/ b$ L1 ?- V4 S8 C& S- WA unique entity of male-limited gonadotropin-
, k2 ^! \- i& {& }( jindependent precocious puberty, which is also known/ U9 b0 n q) N8 r* [' A$ r0 q
as testotoxicosis, may cause precocious puberty at a+ |) {/ a3 ~' b& j3 U; o
very young age. The physical findings in these boys- T2 x, C% a5 H6 M, I8 W
with this disorder are full pubertal development,
1 N. l; x! Y# b% R* v# Vincluding bilateral testicular growth, similar to boys
; i x; U" \: K+ H3 a# e0 d: t- u+ Gwith CPP. The gonadotropin levels in this disorder& a1 H3 {6 e# ?! ]# }
are suppressed to prepubertal levels and do not show* Z" D: G$ o( N: b' S1 \8 t9 o
pubertal response of gonadotropin after gonadotropin-
& [ K! S& @+ N- k) B* creleasing hormone stimulation. This is a sex-linked
7 g- @5 z4 X4 e5 m7 E# F; V2 lautosomal dominant disorder that affects only
5 j i- y, J7 ?! m% r9 zmales; therefore, other male members of the family. A( t- K4 H$ h, c i$ s _% l
may have similar precocious puberty.3% i* f/ i5 z) u* d2 L* Y. b
In our patient, physical examination was incon-
0 q5 G1 m# g4 N1 h- ~* P& i# ?+ [( vsistent with true precocious puberty since his testi-
4 _+ W/ m9 X7 j2 o( r0 A3 Bcles were prepubertal in size. However, testotoxicosis }% N( ]) }, y( x
was in the differential diagnosis because his father
4 t" ^$ v- y, g2 w7 g7 ~! I7 @started puberty somewhat early, and occasionally,
; b! j- e* k, u+ j) t+ {$ ftesticular enlargement is not that evident in the
. |' u$ P+ m8 n, Wbeginning of this process.1 In the absence of a neg-
$ u7 r# M* s% bative initial history of androgen exposure, our- v7 |& }% x( R7 C# y3 E
biggest concern was virilizing adrenal hyperplasia,
* g1 l7 v; |9 ]4 x1 B' ^* _either 21-hydroxylase deficiency or 11-β hydroxylase
Q5 ?8 F& p* f$ I3 Rdeficiency. Those diagnoses were excluded by find-
$ v. _9 I" ~& F, n- Ping the normal level of adrenal steroids.
( [% M1 Q8 `$ X( l6 u% `The diagnosis of exogenous androgens was strongly$ \. A6 y6 B v( W: p3 l. y0 C2 @
suspected in a follow-up visit after 4 months because
4 ~; a. e4 P, O) ~the physical examination revealed the complete disap-9 \& y8 b S: |6 I' \
pearance of pubic hair, normal growth velocity, and7 [: z, v: b5 M
decreased erections. The father admitted using a testos-* O a* ~$ t1 n H u
terone gel, which he concealed at first visit. He was4 E* k, E+ v9 ]9 B5 |
using it rather frequently, twice a day. The Physicians’
, x5 I1 L# {) A/ r, s" ]4 ~Desk Reference, or package insert of this product, gel or& b6 u; e) _" {" l; d
cream, cautions about dermal testosterone transfer to6 @ { l# Q* Q; q
unprotected females through direct skin exposure.
" o8 Y$ J9 E! U1 ESerum testosterone level was found to be 2 times the6 p2 T& h$ Z- M9 X7 v! j; \( F& O
baseline value in those females who were exposed to" o9 U6 u9 L) ^' }4 |* }* `
even 15 minutes of direct skin contact with their male9 T. }* O0 a4 d I" \4 A. K9 T! Q
partners.6 However, when a shirt covered the applica-
- ]# u1 M0 K2 u8 Q2 ction site, this testosterone transfer was prevented.. c2 {8 o6 S ], c& ^' c6 Z
Our patient’s testosterone level was 60 ng/mL,
2 p; o5 {) K- X+ z5 u$ Awhich was clearly high. Some studies suggest that
$ V& l4 W9 }% u ?! A( ~dermal conversion of testosterone to dihydrotestos-
! X, J- _( }2 t4 V# }0 wterone, which is a more potent metabolite, is more& y* V9 ~1 d) ~1 F$ Y
active in young children exposed to testosterone- K; A. o: I( Q0 ?* W; n! x4 _3 c7 {
exogenously7; however, we did not measure a dihy-
! N/ L# E4 a2 }+ qdrotestosterone level in our patient. In addition to7 y K2 n3 X+ z
virilization, exposure to exogenous testosterone in5 K; ^: e" Q0 Q, u% F& D# F0 f
children results in an increase in growth velocity and
' f1 X4 h; k6 x2 Cadvanced bone age, as seen in our patient.) @8 I( ?1 q; Q1 t4 l) Q4 O
The long-term effect of androgen exposure during
3 ?, Q6 j4 w% v2 Eearly childhood on pubertal development and final
; Y7 k' c5 e. Vadult height are not fully known and always remain
+ j$ o, v3 F$ j9 u6 H7 Ha concern. Children treated with short-term testos-
5 Q$ X+ r7 \6 [3 g4 H+ h6 Gterone injection or topical androgen may exhibit some& q) g1 p y) w& U
acceleration of the skeletal maturation; however, after
, Q6 h2 S% C: E; y; Scessation of treatment, the rate of bone maturation
* o' l2 T: _3 n" a7 g b) \decelerates and gradually returns to normal.8,9% b" L" T1 e! _4 K [$ c. J Z3 u
There are conflicting reports and controversy
+ @) T3 G3 h8 Q( `over the effect of early androgen exposure on adult6 ?- N, m; k6 X$ ~
penile length.10,11 Some reports suggest subnormal) I# P2 f0 O" p" ? d( R, M
adult penile length, apparently because of downreg-
; J0 ?! I- E. R, t r' Wulation of androgen receptor number.10,12 However,
' _* F; _: j$ c6 dSutherland et al13 did not find a correlation between. C! {2 S" e9 c
childhood testosterone exposure and reduced adult# z, f) [* T: \" A% w* u+ H
penile length in clinical studies.6 P, d5 I8 e7 P( v- a- x
Nonetheless, we do not believe our patient is( I' g' c9 Z$ W- c, x [, E
going to experience any of the untoward effects from! a3 }; o! h4 t+ @9 ^3 s# {$ ?
testosterone exposure as mentioned earlier because
" L G7 j0 ?. T. {. r1 w kthe exposure was not for a prolonged period of time.
' w4 ]3 z+ ]2 sAlthough the bone age was advanced at the time of
: W. E) V) g9 n' b( D. z) Ndiagnosis, the child had a normal growth velocity at3 v1 K, P" P2 H" \0 W5 L" W% K" F* S5 h, y
the follow-up visit. It is hoped that his final adult, _8 z/ O' Z' s4 M, I4 `
height will not be affected.
7 Z4 w( S/ ?0 b; Y% `Although rarely reported, the widespread avail-% D7 q5 `5 q) ]/ m
ability of androgen products in our society may. y: i9 E& G' c. U! Y. V" D
indeed cause more virilization in male or female
+ X8 H3 S) }* L6 c) kchildren than one would realize. Exposure to andro-: t' D7 x' w7 t+ h+ j3 @" y o
gen products must be considered and specific ques-; M8 A1 ~- |* P
tioning about the use of a testosterone product or
: C/ u, r$ A" e2 o6 C( w. I6 B4 Ugel should be asked of the family members during
0 {* h) A" [; W7 u W! \the evaluation of any children who present with vir-
. {" Q/ o1 {* v! H& q/ e+ Nilization or peripheral precocious puberty. The diag-
4 n: F, d# Q* [nosis can be established by just a few tests and by
8 u. `: p: J- F9 Tappropriate history. The inability to obtain such a9 G! b; D# N0 y0 k& u' z! }
history, or failure to ask the specific questions, may$ B7 l! p. e' N1 N% {: Z' u
result in extensive, unnecessary, and expensive8 \, V3 r, s4 D6 q$ N; b. Z
investigation. The primary care physician should be
+ ~) f/ V& a2 y1 vaware of this fact, because most of these children
* V" E6 H1 s! v: p6 N% Tmay initially present in their practice. The Physicians’
' m: r. V3 {+ c& X, o$ O# ]/ ?$ _Desk Reference and package insert should also put a
( B; r0 P6 G0 w& B v4 ewarning about the virilizing effect on a male or9 b& @0 f' g! a( Q" J
female child who might come in contact with some-/ b' O% p5 A) A' i- Y
one using any of these products./ J6 Q- D$ A% [3 S
References
( O" B% J6 c/ h* x1. Styne DM. The testes: disorder of sexual differentiation
k( T# W2 Q# a, t7 Y7 Xand puberty in the male. In: Sperling MA, ed. Pediatric8 }3 X7 e4 [: j" G6 S. |5 f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& X2 J, K2 D$ L# ~ P6 c2002: 565-628.( s( M7 E: j6 g
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 S5 u5 z$ \2 Q8 Opuberty in children with tumours of the suprasellar pineal |
|