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Sexual Precocity in a 16-Month-Old
# w" ^6 O% f# l/ c1 hBoy Induced by Indirect Topical
1 @1 P8 ?/ ?: X4 B, t% x! jExposure to Testosterone3 f0 e3 D7 p7 r _; H& F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. H" {/ m7 D" j
and Kenneth R. Rettig, MD1
, ]$ ~4 {- ~) R* TClinical Pediatrics& I$ I# X1 E& M; j- n. j
Volume 46 Number 6
|- K A2 s2 J6 U' RJuly 2007 540-543. V% _+ a6 A# \+ K4 X# Y4 T
© 2007 Sage Publications
& z( z* D P- L, j10.1177/0009922806296651. ]6 P1 C" \7 X
http://clp.sagepub.com( f, X( |9 q% W. P8 W( J
hosted at
$ o, i+ u) m9 Z M$ |. P6 @http://online.sagepub.com
: E4 s! a+ X' f. V3 ^Precocious puberty in boys, central or peripheral,; q4 C6 ^* z1 @& C, Z
is a significant concern for physicians. Central, n4 D) q( {! A0 W7 \
precocious puberty (CPP), which is mediated
+ O; G! [8 v6 L7 m4 x* X3 nthrough the hypothalamic pituitary gonadal axis, has
; J/ P4 {( g8 M4 t. \: l, D- Xa higher incidence of organic central nervous system
" E- v, ~& R _5 d2 Mlesions in boys.1,2 Virilization in boys, as manifested/ ^) g a, T$ m4 H5 `2 ]4 ]
by enlargement of the penis, development of pubic
l+ X: w6 N4 R8 q* thair, and facial acne without enlargement of testi-% K! h# {# I' Y# z
cles, suggests peripheral or pseudopuberty.1-3 We
1 @, ]& L: z% r1 U* F# k. ?report a 16-month-old boy who presented with the
' P/ G; b8 _# o1 }' Genlargement of the phallus and pubic hair develop-
& _3 `$ m3 W4 Xment without testicular enlargement, which was due
8 ^ j2 d8 I! O+ `to the unintentional exposure to androgen gel used by' {$ C z& Q1 n5 [1 j3 [! N
the father. The family initially concealed this infor-
# ?$ }$ t2 U) @; u8 a3 p$ Cmation, resulting in an extensive work-up for this
$ e3 r4 q; e! w5 W/ Ychild. Given the widespread and easy availability of
( S5 J: q3 p, b0 D" Z9 @testosterone gel and cream, we believe this is proba-
! o$ Z2 t: ^, X( q) w4 X; L" lbly more common than the rare case report in the
8 Z$ x/ g; k U4 I& i. B7 Nliterature.4+ o9 h! @% R$ T$ u2 \8 ^
Patient Report1 `& B0 y! n( M$ K5 t
A 16-month-old white child was referred to the5 q' A% S$ F: @0 a+ `9 Y
endocrine clinic by his pediatrician with the concern1 N0 T& ]2 z2 v& @
of early sexual development. His mother noticed5 k: o! l4 z" @: E, n
light colored pubic hair development when he was
$ j* Q+ S3 G& Q e+ A5 iFrom the 1Division of Pediatric Endocrinology, 2University of2 ~8 \# U4 n+ i
South Alabama Medical Center, Mobile, Alabama.
- L7 f6 S. |/ SAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 m2 L1 {( _2 e" C5 M% F/ |5 m0 XProfessor of Pediatrics, University of South Alabama, College of1 B# q7 p: L' B% f9 i2 V; L3 @% }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 [9 K* c5 ~* g& }e-mail: [email protected].
0 s2 y/ u( J) X/ Jabout 6 to 7 months old, which progressively became4 Z- r. Y* y9 K
darker. She was also concerned about the enlarge-: C* c2 m* I3 H
ment of his penis and frequent erections. The child
) Q! L% v& F$ R7 Z. Z7 f7 z1 ]was the product of a full-term normal delivery, with* j; w3 _4 f; ?& y0 H6 r
a birth weight of 7 lb 14 oz, and birth length of. q2 a3 W7 g/ h8 X" N; j4 R* F) [
20 inches. He was breast-fed throughout the first year/ ^" h; }7 W+ M; r6 h3 u
of life and was still receiving breast milk along with
, g: n- r6 l4 Z) g4 gsolid food. He had no hospitalizations or surgery,
$ u q( w" L' X9 r6 k5 ~and his psychosocial and psychomotor development6 S; `5 i& V2 C% s; k* Q
was age appropriate.
1 P8 ?& @* `6 `6 c i9 rThe family history was remarkable for the father,+ n' y& f* x& P {2 r& Y' Y# I2 _" P
who was diagnosed with hypothyroidism at age 16,
8 B9 P2 J8 V% B7 q: j( Jwhich was treated with thyroxine. The father’s
. b6 e$ h9 O2 Z7 @height was 6 feet, and he went through a somewhat
, H& q! c7 f; {( fearly puberty and had stopped growing by age 14.8 R+ |( }, t0 [ s
The father denied taking any other medication. The
" D0 Y/ d* H) h/ mchild’s mother was in good health. Her menarche
8 o5 `- n* C. |# Z- l. _4 r7 Gwas at 11 years of age, and her height was at 5 feet' _. S2 l+ ^, Z
5 inches. There was no other family history of pre-
R0 W/ q9 h- d* G3 b9 m! ^cocious sexual development in the first-degree rela-
, f$ D7 k- ~& n7 R8 w" Stives. There were no siblings./ ? l( \8 M, N: p! V' q1 J- v% x/ _- r
Physical Examination
5 K* ]; ^6 o( `4 ^. ~The physical examination revealed a very active,
% c( s' S5 W* R0 x; O, V4 T4 oplayful, and healthy boy. The vital signs documented
, k* ]5 a. A5 Ka blood pressure of 85/50 mm Hg, his length was. C5 |# |, I3 R; ~
90 cm (>97th percentile), and his weight was 14.4 kg
; U" i) D1 @' e' G/ E# C(also >97th percentile). The observed yearly growth
6 O0 z( a' `9 gvelocity was 30 cm (12 inches). The examination of- X5 z7 k' D7 g% o7 V$ n" P
the neck revealed no thyroid enlargement.
) R. j% q) x4 r7 s0 `3 U: o. YThe genitourinary examination was remarkable for
* p4 P! s& v4 E: q3 n: Lenlargement of the penis, with a stretched length of$ Z3 L& P+ ?# o7 ?/ r# P
8 cm and a width of 2 cm. The glans penis was very well
# N; C3 L4 R2 hdeveloped. The pubic hair was Tanner II, mostly around2 f: H8 [/ m4 l# W+ s% r: T
5404 j0 Z4 {% L j. ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" T. J1 F) ^( E5 s! T* n5 sthe base of the phallus and was dark and curled. The( |* [4 c4 A, j0 w3 R7 Q; t
testicular volume was prepubertal at 2 mL each.( |# ]' o7 k/ d" P' Y; V# B
The skin was moist and smooth and somewhat
3 p% S! k% e( r9 l' [oily. No axillary hair was noted. There were no
4 B9 ]( J6 ]$ W, t4 p, k3 V- labnormal skin pigmentations or café-au-lait spots.
- V! o; f* J( n2 t3 gNeurologic evaluation showed deep tendon reflex 2+
2 _" A9 Q# x+ _7 O6 \1 D% s4 ?bilateral and symmetrical. There was no suggestion
/ x6 ?5 n% n! xof papilledema.- L4 u/ Z* P" l& J7 V1 a1 G, ~, L
Laboratory Evaluation$ D* i" W) ^! K p% a
The bone age was consistent with 28 months by
# G5 e6 P: n0 Musing the standard of Greulich and Pyle at a chrono-
7 x1 h* t9 T. \- h9 Y, k* H/ j& ^: o' Flogic age of 16 months (advanced).5 Chromosomal/ v2 |9 _; m: Z2 m- N4 }
karyotype was 46XY. The thyroid function test
" W4 Y6 m0 Q* u1 W( D. `showed a free T4 of 1.69 ng/dL, and thyroid stimu-* J' J, Q6 c' g: f$ L$ x
lating hormone level was 1.3 µIU/mL (both normal).
& E9 I0 [; `+ m5 j% ^: F7 WThe concentrations of serum electrolytes, blood C5 X; c7 T: K8 ~8 X* B8 J
urea nitrogen, creatinine, and calcium all were$ B8 q7 n& v; ~$ o" z2 I2 i- B
within normal range for his age. The concentration
8 n2 ?6 P0 M. T' {& Nof serum 17-hydroxyprogesterone was 16 ng/dL
; |& h( G3 S' D0 w" q0 _" @(normal, 3 to 90 ng/dL), androstenedione was 201 I' C+ B9 p- u% ?* Y3 t
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; d6 W# _& g6 q5 h* @terone was 38 ng/dL (normal, 50 to 760 ng/dL),% I6 n6 `9 ], G6 ]9 v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! f. I% {' E' Z7 k- E1 m0 Q! y p$ b2 F49ng/dL), 11-desoxycortisol (specific compound S)0 w9 p2 F; W( d0 w4 X8 L" @5 e& [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 y1 V4 Q5 `. O2 W2 ~( ^! ^
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* \: M1 L4 ^+ U" b2 O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 o% _' V/ A$ v) e3 _8 Mand β-human chorionic gonadotropin was less than
! K# D( x; M/ i$ U8 C$ V1 s+ W3 M5 mIU/mL (normal <5 mIU/mL). Serum follicular9 H! {! N% x5 |2 Y+ a1 k
stimulating hormone and leuteinizing hormone4 U' v# C, @' w+ P( `
concentrations were less than 0.05 mIU/mL9 z2 Y4 X4 S5 D" C
(prepubertal).9 c: W" X6 N. x- s$ p. ]
The parents were notified about the laboratory8 d3 U7 N( g5 \* T9 }
results and were informed that all of the tests were
: R) r. \% S5 c' @0 z' U8 X6 anormal except the testosterone level was high. The
+ o ^1 H5 {9 o" Hfollow-up visit was arranged within a few weeks to9 }) C, i3 A/ Z
obtain testicular and abdominal sonograms; how-3 k {7 g) C- h4 ]- Y* c+ B
ever, the family did not return for 4 months.
0 _! L7 U$ E7 `Physical examination at this time revealed that the9 y1 R% x" }1 C l9 I# R; \' Z
child had grown 2.5 cm in 4 months and had gained. v @* E, o: p, M' l$ D
2 kg of weight. Physical examination remained/ I: g6 c1 g6 J. r
unchanged. Surprisingly, the pubic hair almost com-
9 G" z/ F1 @0 n/ u7 {* }pletely disappeared except for a few vellous hairs at6 ?1 {1 y4 b/ d) u% `6 F' |
the base of the phallus. Testicular volume was still 2( j( [; J, A" G; l1 g
mL, and the size of the penis remained unchanged.+ H+ ^4 d5 v: y6 j; Z+ h
The mother also said that the boy was no longer hav-
# k* j& v# I+ y; O' X/ ling frequent erections.( p9 v/ h% H7 I, Y( y
Both parents were again questioned about use of
4 J* G( n: F( m& ~6 Z* B' K) B3 sany ointment/creams that they may have applied to
8 ?0 u& r# f/ [8 @the child’s skin. This time the father admitted the
& e' |# Q; Q: {* OTopical Testosterone Exposure / Bhowmick et al 541% |# b I I& w+ ~: H& z
use of testosterone gel twice daily that he was apply-' X1 W9 Z# ] ]2 s1 e
ing over his own shoulders, chest, and back area for4 n, L* j& n+ m( z
a year. The father also revealed he was embarrassed- V* `; R. u+ H/ Q) |" A! f# O
to disclose that he was using a testosterone gel pre-6 ~, ^ x. A$ u! G
scribed by his family physician for decreased libido+ A5 J( O1 H0 q' J; h( y
secondary to depression.0 T) ]6 n. B) z) `6 U
The child slept in the same bed with parents.: X& L/ G' G J4 x1 J: J
The father would hug the baby and hold him on his8 g& p, {; k; P- J: }* A! d
chest for a considerable period of time, causing sig-
9 h' O% p; s" Znificant bare skin contact between baby and father.
$ k* d: q4 f" F, cThe father also admitted that after the phone call,3 F% H6 j4 A6 u. `4 m3 M
when he learned the testosterone level in the baby$ ?0 W% X+ U5 {& @5 G1 O% M9 \
was high, he then read the product information
4 m0 r7 f$ f5 k5 U" V o/ spacket and concluded that it was most likely the rea-9 y& H+ `5 I5 {; F% _
son for the child’s virilization. At that time, they: q6 P0 Z: y7 B/ I
decided to put the baby in a separate bed, and the
9 [( ]$ t# F5 U& X& a0 e! Ofather was not hugging him with bare skin and had' D( k% ]& T) Y6 |, P. Y! _1 j
been using protective clothing. A repeat testosterone/ q" P2 Y# H. V0 f9 T
test was ordered, but the family did not go to the
" R% |# b; Y. o* s, J$ elaboratory to obtain the test.+ v& Q: v6 E7 {* u, K' A E
Discussion
: F4 ]* w6 l( j* j0 s" H+ p6 u% {Precocious puberty in boys is defined as secondary
0 n# B5 A y) tsexual development before 9 years of age.1,4
8 x) O" \4 t) RPrecocious puberty is termed as central (true) when8 G: [9 a2 W. ~7 ?2 w# D
it is caused by the premature activation of hypo-: u+ \2 }/ ^' r' K2 r8 ~- e8 I8 p
thalamic pituitary gonadal axis. CPP is more com-
3 ]1 A7 I6 T! m" Mmon in girls than in boys.1,3 Most boys with CPP O% k v' s/ C$ \0 L& V
may have a central nervous system lesion that is; w5 F! F3 J% {0 n
responsible for the early activation of the hypothal-5 E8 m* b1 S' H7 n6 w
amic pituitary gonadal axis.1-3 Thus, greater empha-5 u) i. K) l2 U) z/ `
sis has been given to neuroradiologic imaging in
( j1 i! {: G) L! y! W/ zboys with precocious puberty. In addition to viril-& E, q$ [- y1 s! R3 J9 D
ization, the clinical hallmark of CPP is the symmet-
" j8 E, G, ?( U6 h0 F! M1 D @rical testicular growth secondary to stimulation by
1 x; j% Z0 X; igonadotropins.1,3; m3 l8 y; H1 a; m! Y1 r
Gonadotropin-independent peripheral preco-
9 K& B0 Y0 }8 i# g$ kcious puberty in boys also results from inappropriate. d* k4 \7 @ Y' D9 _) }! S4 o3 v
androgenic stimulation from either endogenous or
2 }) x$ Q* p7 S" R! Sexogenous sources, nonpituitary gonadotropin stim-1 j: e) z+ T0 t3 B" i( X! c
ulation, and rare activating mutations.3 Virilizing }- Y, s* v( ~0 _8 J* h5 q
congenital adrenal hyperplasia producing excessive
, d- ^( X9 E# l0 V" d# i2 Xadrenal androgens is a common cause of precocious# u3 f9 e2 a7 f, F- g( J
puberty in boys.3,4) |/ k8 S5 M: ]) c% D! Q
The most common form of congenital adrenal. H8 P) \+ ^ C2 ?# y
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 |3 Q" F* v* E; QThe 11-β hydroxylase deficiency may also result in; m d! ]% [2 h5 V* s" x" n
excessive adrenal androgen production, and rarely,
5 O& d, p2 W( m3 P! z" Lan adrenal tumor may also cause adrenal androgen
1 \, ^7 Y4 }4 I7 c* A8 `excess.1,3% [. V+ E/ b& k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 @+ w2 r ?2 A; i# _- o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 l! g( U" ]2 e( o$ _A unique entity of male-limited gonadotropin-
4 u4 `. u! M' F, Qindependent precocious puberty, which is also known* m; l2 S2 B' I' G
as testotoxicosis, may cause precocious puberty at a
/ u. `6 Z. F& y( E( Wvery young age. The physical findings in these boys. s+ }& i: w1 m, {- R
with this disorder are full pubertal development,
& t" Z' R' V qincluding bilateral testicular growth, similar to boys
! x8 t* s: r: ]8 Z- Mwith CPP. The gonadotropin levels in this disorder; @. {! ?4 s p% e# C& U8 R7 H
are suppressed to prepubertal levels and do not show5 p9 O0 A" q' c- y# V2 }. M
pubertal response of gonadotropin after gonadotropin-
0 N% k9 \8 a" _8 b, C( ?& Zreleasing hormone stimulation. This is a sex-linked/ ?9 Z; f) O9 T
autosomal dominant disorder that affects only
, f; T5 k- l/ X3 j4 t$ ~males; therefore, other male members of the family$ _5 } {- M* d! y) T
may have similar precocious puberty.3
: ~" i- T$ B8 }: }( LIn our patient, physical examination was incon-# j1 F: U7 X$ H
sistent with true precocious puberty since his testi-
N1 `1 {5 O" rcles were prepubertal in size. However, testotoxicosis" G/ o4 [- d* X3 K( M7 V
was in the differential diagnosis because his father0 C! V+ x1 \9 l: K
started puberty somewhat early, and occasionally,
, n% }. M( H! qtesticular enlargement is not that evident in the- A L$ g6 K! z: M* p
beginning of this process.1 In the absence of a neg- O+ y$ ?( y: v- }
ative initial history of androgen exposure, our' E! Q6 {# i0 M3 u T) S
biggest concern was virilizing adrenal hyperplasia,) {! m; a, B$ ~
either 21-hydroxylase deficiency or 11-β hydroxylase
+ t, ]& \! L; R: Ddeficiency. Those diagnoses were excluded by find-) K9 |6 K; {# O# S+ q$ Z# {4 G8 H" `
ing the normal level of adrenal steroids.
" `7 V' H4 t) Y4 y, vThe diagnosis of exogenous androgens was strongly2 N1 c& k, Y6 G' {
suspected in a follow-up visit after 4 months because
9 ?; {5 A8 \& P" E$ o d+ Kthe physical examination revealed the complete disap-
9 E* u; i1 Z; S" w# I5 ]pearance of pubic hair, normal growth velocity, and
I6 M- P1 u& {$ bdecreased erections. The father admitted using a testos-
9 ^$ M: Q, p/ s5 W& eterone gel, which he concealed at first visit. He was; A3 T a5 _ ~2 L6 P
using it rather frequently, twice a day. The Physicians’& a& T; ]1 R D7 ^5 J
Desk Reference, or package insert of this product, gel or
8 N ?, @) Z! O, v# x: ~cream, cautions about dermal testosterone transfer to( n% w. d5 r6 U6 J4 ? ]" d1 U
unprotected females through direct skin exposure.
) [5 `9 g# z# ISerum testosterone level was found to be 2 times the3 ~' F# h0 u$ \
baseline value in those females who were exposed to* _' ^6 E. \2 c# e5 l$ T; \
even 15 minutes of direct skin contact with their male7 d7 m; R8 \3 I
partners.6 However, when a shirt covered the applica-$ N( P8 |9 u" B D/ m2 T
tion site, this testosterone transfer was prevented.' V; V* W. K' o# o! X% A
Our patient’s testosterone level was 60 ng/mL,7 N4 u- M- k q( \5 y6 c. p- R( T
which was clearly high. Some studies suggest that* M6 I6 u( Z% j
dermal conversion of testosterone to dihydrotestos-
; g; T) U. I5 fterone, which is a more potent metabolite, is more# D8 ?* D( L( J2 u8 p
active in young children exposed to testosterone
( Q8 m/ Z/ P! h- F: yexogenously7; however, we did not measure a dihy-
: _+ x4 P0 P( M; e0 I6 a) `drotestosterone level in our patient. In addition to' _; s, n: H! K. q+ Z, X$ D4 L
virilization, exposure to exogenous testosterone in( K) ~& R& s- P. u2 A
children results in an increase in growth velocity and5 \0 N% o ~0 e. A3 N7 g7 a; y
advanced bone age, as seen in our patient.
. i& M$ J6 ^8 W6 mThe long-term effect of androgen exposure during
0 [, Z) K% q1 Xearly childhood on pubertal development and final
& ~7 w$ J8 c5 E6 v3 r# J& D& C5 Badult height are not fully known and always remain
( a) W$ J2 j1 xa concern. Children treated with short-term testos-
) J- v7 ~/ {9 u' G$ n& w. jterone injection or topical androgen may exhibit some% h3 k9 ]% ^8 `5 U( @* t, k3 J
acceleration of the skeletal maturation; however, after# J6 C. K3 _6 Q
cessation of treatment, the rate of bone maturation
# G9 q! D8 k( ldecelerates and gradually returns to normal.8,9; x% P% b! t7 }3 Y" T' E) x8 k
There are conflicting reports and controversy# ]! j! H& j. B, e* ?
over the effect of early androgen exposure on adult; @) T# Z3 G! J9 n( p/ F( _
penile length.10,11 Some reports suggest subnormal
; ~# p. w5 p- s6 R4 fadult penile length, apparently because of downreg-8 y W4 E/ Y x2 E5 g$ p
ulation of androgen receptor number.10,12 However,- t3 ^: {" M5 f& a T
Sutherland et al13 did not find a correlation between
$ L" \4 g0 t7 k7 V2 r/ h, S: ichildhood testosterone exposure and reduced adult
0 g6 C* u1 G2 ` F& upenile length in clinical studies.
i/ K& j! ]* `9 jNonetheless, we do not believe our patient is. x+ b; t- ]+ }+ u) T; K
going to experience any of the untoward effects from% D5 {5 d; ^; I9 G. j
testosterone exposure as mentioned earlier because
! }/ w% K4 S8 R. c3 gthe exposure was not for a prolonged period of time.8 ^/ S# i6 k# k) ^* J8 D8 ?
Although the bone age was advanced at the time of6 D: ^+ o* c; S0 G3 b
diagnosis, the child had a normal growth velocity at8 H1 ^3 L' f8 n: P! N
the follow-up visit. It is hoped that his final adult# ]! a: d' k) z8 N; K6 {0 z7 r9 N
height will not be affected.4 U( a# z- M6 Z* e2 u
Although rarely reported, the widespread avail-" c) y8 }8 q: m, `" s
ability of androgen products in our society may% a% j; S7 I0 v$ I% a4 @) V# d9 t
indeed cause more virilization in male or female
, D. G) f# Q+ }" k! wchildren than one would realize. Exposure to andro-
5 E' d1 A" _ N/ s& e+ e% K( _- Qgen products must be considered and specific ques-
8 T6 p5 r0 |1 e% P% N5 z6 v4 c# Ntioning about the use of a testosterone product or& O: ]8 n( I" T5 P" J6 w7 |
gel should be asked of the family members during
! Q2 j: a3 r$ K& zthe evaluation of any children who present with vir-: y6 ?( p7 {# P; f4 P
ilization or peripheral precocious puberty. The diag-. O2 S5 h1 W' C! U4 _ c/ u
nosis can be established by just a few tests and by+ W8 [* s8 \: ^. j0 Z, U
appropriate history. The inability to obtain such a- v% ]; F3 {4 p: z2 e, X3 B
history, or failure to ask the specific questions, may
, @ v7 M- E8 \result in extensive, unnecessary, and expensive, G7 ?. t N& a; X
investigation. The primary care physician should be+ M1 c: ?; Z% i8 w8 @; g; O* a
aware of this fact, because most of these children
1 F! s5 e+ X8 Hmay initially present in their practice. The Physicians’8 Y o# r6 V- ^& [# x% x
Desk Reference and package insert should also put a! O5 p3 o7 X% R0 D
warning about the virilizing effect on a male or
- o( z. z1 Y+ \) A$ A) dfemale child who might come in contact with some-" D* d4 a6 ~7 c
one using any of these products., ]: e Z$ d, c |! a3 `8 z
References& i0 j0 ]; P( b6 r* U# u( L$ K, J# N
1. Styne DM. The testes: disorder of sexual differentiation
; L$ ~. `; z# m" J. n) E5 jand puberty in the male. In: Sperling MA, ed. Pediatric$ P- A2 L/ B2 @* F/ n. f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: l" w/ A+ X- D, }+ ]2002: 565-628.* w) e: T" \1 m& x3 _- s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* q3 l9 Z, h; X% N) R0 E* P* G
puberty in children with tumours of the suprasellar pineal |
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