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Sexual Precocity in a 16-Month-Old s( R D. Q' X5 l7 K7 _
Boy Induced by Indirect Topical! V z7 R# V( ~" z2 y( ^
Exposure to Testosterone
( _. ]6 l2 k3 \3 i5 F0 uSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 R, x S+ L) z* K
and Kenneth R. Rettig, MD10 M0 T+ M$ z. d: U- z. F: F/ Q
Clinical Pediatrics9 |0 ?+ u9 U" ~' l4 `
Volume 46 Number 67 N# T/ H$ b& G4 Q, Q i9 R/ u
July 2007 540-543
& Y6 W% v2 m& N" R M© 2007 Sage Publications* |5 Z$ Y4 D+ }1 Y7 b
10.1177/0009922806296651
! A+ I4 L6 b# \; F, n2 s5 Rhttp://clp.sagepub.com
8 O& Z: x+ B; _ Q2 ~, Bhosted at
1 P( u3 B2 L0 C/ A# ], L& a3 ?3 f0 khttp://online.sagepub.com
% M& n; f, T' Q! QPrecocious puberty in boys, central or peripheral,& O0 w- p. l& l
is a significant concern for physicians. Central# K4 i6 p- f0 n2 y( Z
precocious puberty (CPP), which is mediated
5 J( f5 b5 V4 Y) Vthrough the hypothalamic pituitary gonadal axis, has
9 z2 ~# ?9 w- O8 Y Ka higher incidence of organic central nervous system$ r: ^$ e4 }0 r, L6 q
lesions in boys.1,2 Virilization in boys, as manifested! d# w O4 w$ N
by enlargement of the penis, development of pubic
2 q2 `7 n- u( Y1 \% n# Z; H0 x; Dhair, and facial acne without enlargement of testi-& w' w1 }; i& o1 I+ V& X
cles, suggests peripheral or pseudopuberty.1-3 We# X5 `6 K8 P" a2 Z l
report a 16-month-old boy who presented with the0 Y' u) K/ O$ F3 i, w& G! k
enlargement of the phallus and pubic hair develop-
( }! {* x2 G8 \) Y' p3 |2 y& Pment without testicular enlargement, which was due
+ ^( F& y/ C7 @% lto the unintentional exposure to androgen gel used by
" r9 f1 A2 X8 x6 \the father. The family initially concealed this infor-5 v/ |# ^( X J" j! @
mation, resulting in an extensive work-up for this4 \+ m+ ~# b7 S2 C+ ?1 x
child. Given the widespread and easy availability of0 A6 O5 I; @" Z$ ?
testosterone gel and cream, we believe this is proba-
; U% o* P0 I! j) `7 f8 Vbly more common than the rare case report in the# x8 U$ [$ k1 d# x4 J
literature.4( x+ G, w6 v7 `6 i
Patient Report
+ @7 p7 R/ {$ o& l7 W: O5 @- gA 16-month-old white child was referred to the; a b* U) C( E8 ]$ y G
endocrine clinic by his pediatrician with the concern; e& U; d/ Y% i0 \/ Y6 D" E1 F! U
of early sexual development. His mother noticed4 ^% o( J3 r: l* f3 z% l, h5 u3 H$ {
light colored pubic hair development when he was/ P z: S1 E) X0 _( j
From the 1Division of Pediatric Endocrinology, 2University of
7 h* N( P: @4 Q" C1 p; u* g4 USouth Alabama Medical Center, Mobile, Alabama.8 `8 N" O4 T4 W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 N, j5 v- |( m* E# ?6 o( [) QProfessor of Pediatrics, University of South Alabama, College of. y- u4 Z- B3 j% L! U, {# |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- V9 m2 u8 ~0 D; [" D2 R
e-mail: [email protected].- U- W$ F( ?, b7 K+ R
about 6 to 7 months old, which progressively became N) W1 P! p, L0 w+ I9 G% G
darker. She was also concerned about the enlarge-; `$ _) S7 M5 Q! ^4 k3 _
ment of his penis and frequent erections. The child
3 l- C0 m( F# U# twas the product of a full-term normal delivery, with8 t' N' E# j7 J! F; b! z# ~
a birth weight of 7 lb 14 oz, and birth length of
9 k/ a. W" y' t6 F20 inches. He was breast-fed throughout the first year
% M* P2 N- J/ hof life and was still receiving breast milk along with5 A# C0 g- _( f2 c8 o* D) K
solid food. He had no hospitalizations or surgery,* I& ^; ?# E! d: I9 U
and his psychosocial and psychomotor development7 [' J8 i. H0 {- a! k
was age appropriate.2 w# X, L; f8 y' n
The family history was remarkable for the father,- K2 _% Z& V. {& v% g# _/ Y; B X# z
who was diagnosed with hypothyroidism at age 16,) e6 D: @0 V2 w% C
which was treated with thyroxine. The father’s
1 g2 d- X4 {6 k/ O: v' O: F4 I6 zheight was 6 feet, and he went through a somewhat/ Y9 h/ K' x8 B# S1 ~
early puberty and had stopped growing by age 14.
' ?9 N. s3 K1 J, v0 ~! S6 [9 @The father denied taking any other medication. The7 C) d- G: [2 r& S- s% @
child’s mother was in good health. Her menarche
1 E$ a" \! e( y6 P6 y4 K' T% mwas at 11 years of age, and her height was at 5 feet0 {2 L9 S( ?) ^ m, c
5 inches. There was no other family history of pre-9 B- x& L5 h& J# e8 l) W) \
cocious sexual development in the first-degree rela-+ _) W0 V) H6 C
tives. There were no siblings.! i% n$ X4 Q( {: g; @3 l
Physical Examination
: L; _0 C1 Q6 D ]( s) ~3 cThe physical examination revealed a very active,
! F! E( Y$ Y- aplayful, and healthy boy. The vital signs documented0 `( y' I& U) A8 H& g. C/ N* n' `
a blood pressure of 85/50 mm Hg, his length was
& W7 h, h- }; U- k# M8 K90 cm (>97th percentile), and his weight was 14.4 kg
B8 ?6 a: r( k0 j: F( D(also >97th percentile). The observed yearly growth. V* R$ y1 x2 k3 K( }
velocity was 30 cm (12 inches). The examination of- S5 l$ r5 U2 a& o5 @& k" O) J
the neck revealed no thyroid enlargement.- U7 g/ V9 v1 e
The genitourinary examination was remarkable for
+ F# f$ a; C/ v t$ S' s3 Benlargement of the penis, with a stretched length of' h3 Q: b% Q# n. j/ v
8 cm and a width of 2 cm. The glans penis was very well8 E+ c% q j+ z9 |
developed. The pubic hair was Tanner II, mostly around
. F3 G4 z7 x$ E# d. H0 g& e2 \# m( j540
$ P9 L4 W8 y" q+ v1 \" I+ e4 \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ S) a0 z. u9 K; \6 O) Z0 Z- Nthe base of the phallus and was dark and curled. The
) G) x" e) m% e: C4 i1 otesticular volume was prepubertal at 2 mL each.
/ ?7 G7 v; l$ H# QThe skin was moist and smooth and somewhat) _+ ]" H4 C0 b6 q
oily. No axillary hair was noted. There were no% y, d$ @& [& x: [
abnormal skin pigmentations or café-au-lait spots.4 D( x( u- V" V' g& s( F& X9 v
Neurologic evaluation showed deep tendon reflex 2+
+ c" A# L% Z K+ Q# F# Wbilateral and symmetrical. There was no suggestion, W; g; m5 z+ h% H/ C' B$ L
of papilledema.
" m- p k5 F- J1 ILaboratory Evaluation3 z3 S6 @( n( A* V/ m) u
The bone age was consistent with 28 months by. o/ w& l) V6 M# i* n; t1 O6 G
using the standard of Greulich and Pyle at a chrono-
% ?3 y" J& k# D# Blogic age of 16 months (advanced).5 Chromosomal
' F( V" F2 ~: d- nkaryotype was 46XY. The thyroid function test
, U2 t' n- N& h. ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 Q6 m: Z# x! n) H0 Rlating hormone level was 1.3 µIU/mL (both normal).4 x' C8 B; C6 q7 q7 b# u
The concentrations of serum electrolytes, blood* t: q* J b" {( D: O! } _
urea nitrogen, creatinine, and calcium all were
$ ]5 c* t0 Q: Q' Awithin normal range for his age. The concentration
" j/ X: q! M& |- ~9 F5 Oof serum 17-hydroxyprogesterone was 16 ng/dL
8 Q9 S$ V* I+ O0 X4 S(normal, 3 to 90 ng/dL), androstenedione was 206 S8 K3 g. |, H8 \ y5 ^$ w1 C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' \' Q9 ~5 `/ W& q) ~& C/ R* l
terone was 38 ng/dL (normal, 50 to 760 ng/dL), B# M% ~7 r3 m( r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! S0 W2 w# b s49ng/dL), 11-desoxycortisol (specific compound S)0 M0 t1 {; M- e4 b% a# a" O$ o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& U6 j- X- [5 B* `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 S8 b% a$ S2 s# f6 g* E' {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ {6 T$ E! r& [$ I/ V2 M8 ?and β-human chorionic gonadotropin was less than6 k1 y; E0 g+ D3 H/ b( \
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 h! T. k: j( ^' G, @# T( ?$ U: z# Ostimulating hormone and leuteinizing hormone% J4 Z' P5 }9 h0 |
concentrations were less than 0.05 mIU/mL
$ |2 h+ ?3 c9 c! Z1 O2 W8 ^- F6 ?(prepubertal).; ]+ K5 V( d) j3 ?( g
The parents were notified about the laboratory
$ J! i- ^& U) L# {# L1 Iresults and were informed that all of the tests were
2 m! g6 D3 z x% a% L9 Hnormal except the testosterone level was high. The
" W+ E" c x6 v; k6 o' Vfollow-up visit was arranged within a few weeks to) S; M6 g/ w) X' s1 A
obtain testicular and abdominal sonograms; how-
1 M5 p) T. q( s; z8 f/ i7 A( a. tever, the family did not return for 4 months.
4 v5 t2 i2 D9 _& [, lPhysical examination at this time revealed that the9 l* o5 s( \! u- _) t
child had grown 2.5 cm in 4 months and had gained r! o" T% e U0 s$ I, t9 d
2 kg of weight. Physical examination remained% Q6 x9 U2 O5 t! C3 b- U
unchanged. Surprisingly, the pubic hair almost com-& ]# D6 s& h5 c: L! T& B( H, [
pletely disappeared except for a few vellous hairs at
& G1 e" o) Y+ Z" ^1 I- i/ Vthe base of the phallus. Testicular volume was still 23 P* k1 q2 n8 y
mL, and the size of the penis remained unchanged.
& `9 e0 c8 J. W; z# q! gThe mother also said that the boy was no longer hav- `# E1 v4 @# @8 H3 V G" [* {
ing frequent erections.. u3 Z) ^2 ]' p: [; g6 a
Both parents were again questioned about use of
1 o) D/ W! Z& t. X' I+ Yany ointment/creams that they may have applied to( D+ m( G q) _( u& E
the child’s skin. This time the father admitted the4 ?- W2 Y2 r3 w# T" d6 q
Topical Testosterone Exposure / Bhowmick et al 541; \2 v. f c9 `& }6 `
use of testosterone gel twice daily that he was apply-
% C4 Z8 f3 z; `* a+ W7 u6 ting over his own shoulders, chest, and back area for+ r" C; {3 p- o* @% F! X
a year. The father also revealed he was embarrassed: _4 ^5 u! u9 @( t
to disclose that he was using a testosterone gel pre-
. E' w$ ]3 t' ]2 K: Tscribed by his family physician for decreased libido
7 q; X2 ^6 [7 b+ h7 _secondary to depression.( R) Z6 d/ j) k
The child slept in the same bed with parents.; ?- e Q |( K) m5 ^7 K. ^8 @1 p" L% X
The father would hug the baby and hold him on his
% J2 s4 u' ^* f' x7 v* h7 ochest for a considerable period of time, causing sig-
* w8 O5 d+ I2 Q# l# Y4 B* \) lnificant bare skin contact between baby and father.( b( ]& p1 J! K p
The father also admitted that after the phone call,
! U% m$ Y) Y3 O t9 Z! Mwhen he learned the testosterone level in the baby
, |) v5 i8 p' p: N7 n' }was high, he then read the product information
+ z, T( s D2 e) k- I7 T& Qpacket and concluded that it was most likely the rea-8 R8 F+ R3 D+ l1 R
son for the child’s virilization. At that time, they+ e4 P8 S( [- B5 |& y
decided to put the baby in a separate bed, and the6 j" s4 o: Z. L Z
father was not hugging him with bare skin and had, J1 I& G7 J, }
been using protective clothing. A repeat testosterone
$ T1 k E# v9 Btest was ordered, but the family did not go to the
' M5 C+ v4 s, t4 S1 @' U# S: f slaboratory to obtain the test.- J5 j( F" f: N$ |) l. P t
Discussion1 V- y! b& p k' o
Precocious puberty in boys is defined as secondary
1 I8 y& k# Q$ Qsexual development before 9 years of age.1,4
. O4 N7 }' ~; N* o, T0 A: }Precocious puberty is termed as central (true) when" g! a* O$ E3 P) \ c6 n! G
it is caused by the premature activation of hypo-
6 K; w- M1 u4 K% z# ]1 R) S: Othalamic pituitary gonadal axis. CPP is more com-% {# j* ~5 p( e. [
mon in girls than in boys.1,3 Most boys with CPP
" r: x: ~. D' x5 e0 D, j% G5 g5 R: omay have a central nervous system lesion that is4 p: x3 ~$ D0 u
responsible for the early activation of the hypothal-. o8 Z6 s6 ] [
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 ?9 q% c: B5 R( Z3 A% {sis has been given to neuroradiologic imaging in
6 ]& v$ K2 c$ i" N6 tboys with precocious puberty. In addition to viril-1 H6 ]/ L' s) z% M
ization, the clinical hallmark of CPP is the symmet-
( e2 I6 V* V9 \, j' t0 ?; Brical testicular growth secondary to stimulation by$ {2 x$ |" }9 t
gonadotropins.1,34 v+ d6 z. i2 w, o0 N
Gonadotropin-independent peripheral preco-
* \% O! h$ F% `3 H. m6 \3 w$ ecious puberty in boys also results from inappropriate
$ i8 W: L: v) oandrogenic stimulation from either endogenous or( ~$ u3 X" h" Y* V3 H
exogenous sources, nonpituitary gonadotropin stim-
0 h9 u, x, N; R) p5 t* z' vulation, and rare activating mutations.3 Virilizing/ R3 l! ~3 @4 v
congenital adrenal hyperplasia producing excessive$ X# K+ g u( ?2 L
adrenal androgens is a common cause of precocious6 F0 E: y, m+ n) d
puberty in boys.3,4
- i* C0 x9 d6 s/ K mThe most common form of congenital adrenal7 N3 }7 B$ ~* g
hyperplasia is the 21-hydroxylase enzyme deficiency.0 {/ O" \+ P6 r Q% q X
The 11-β hydroxylase deficiency may also result in, S @4 S% j) t6 H* v7 N
excessive adrenal androgen production, and rarely,
" W0 F% {+ t8 a& ~) \6 Can adrenal tumor may also cause adrenal androgen+ _0 E6 d; i7 h/ j$ D
excess.1,3
0 @3 U# {# w7 u2 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
T( N: U6 o3 L5 K542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! @, \# ]2 n: `) k: F1 ?. g: ?A unique entity of male-limited gonadotropin-
- P" e6 a+ y7 k$ Y7 b3 Findependent precocious puberty, which is also known
. b5 ]# r5 V& {- kas testotoxicosis, may cause precocious puberty at a8 q# I% q O6 T. b
very young age. The physical findings in these boys
1 O3 \0 p0 g0 u; owith this disorder are full pubertal development,
+ H; O9 q" d$ S/ e1 H6 c) cincluding bilateral testicular growth, similar to boys
' A- d9 O# {6 |* o! c% Nwith CPP. The gonadotropin levels in this disorder
: A0 ~( N1 x R1 z4 Z" ]2 U. @are suppressed to prepubertal levels and do not show! M/ m5 B3 q. C) D7 d5 Y
pubertal response of gonadotropin after gonadotropin-
( A9 o2 D/ x4 j1 ]releasing hormone stimulation. This is a sex-linked
8 ?: q2 a& c" l2 @) H: ~autosomal dominant disorder that affects only% u$ B1 T) I. n* c9 i9 M% p
males; therefore, other male members of the family! G7 K. h* _' Y0 n
may have similar precocious puberty.3
+ m; ~ [ U1 m4 t/ W/ {In our patient, physical examination was incon-
. x. i$ P. d7 G! \sistent with true precocious puberty since his testi-# h# R% {1 K$ h% p0 h
cles were prepubertal in size. However, testotoxicosis9 q8 x9 U; n6 i8 T
was in the differential diagnosis because his father
4 `- ~6 Y3 n) f M! x1 \+ @started puberty somewhat early, and occasionally,
- p5 k' p: v& s$ O! ptesticular enlargement is not that evident in the
6 N7 W8 l- K3 M3 b1 w3 @6 g; A# Rbeginning of this process.1 In the absence of a neg-4 X$ w- I$ c+ v( R
ative initial history of androgen exposure, our2 m8 i- Q0 I* z% \4 Y5 H& S
biggest concern was virilizing adrenal hyperplasia,
6 R: p/ F5 l3 b Y, Neither 21-hydroxylase deficiency or 11-β hydroxylase/ W. R/ r- d2 f, X' B
deficiency. Those diagnoses were excluded by find-
" ?$ X7 ?9 x% _8 u4 a1 t( D7 [7 h4 `ing the normal level of adrenal steroids.
8 e" C5 ]% v$ x. OThe diagnosis of exogenous androgens was strongly
; o9 A: U2 b% a# o9 @suspected in a follow-up visit after 4 months because$ Z" ?- e5 a1 e9 `3 X: B# W% ?
the physical examination revealed the complete disap-/ ?/ J6 \- m3 \& S0 C9 D, C
pearance of pubic hair, normal growth velocity, and; T8 R# I1 D5 B$ M0 R
decreased erections. The father admitted using a testos-' D; \( J4 C' U$ ]7 J* H+ g3 |
terone gel, which he concealed at first visit. He was
- X, h& L; N! ^! H# Y2 jusing it rather frequently, twice a day. The Physicians’: j, O. H% L' L0 S1 k1 s' L2 G
Desk Reference, or package insert of this product, gel or
% ?1 }/ o2 _7 ?2 {8 y/ rcream, cautions about dermal testosterone transfer to7 V- `" n" F ]7 {
unprotected females through direct skin exposure.$ v d, ]: B2 j8 M, d: X4 g: o
Serum testosterone level was found to be 2 times the% F: v, ^3 Y' W/ A+ q& f; G
baseline value in those females who were exposed to& R) v+ }! r" }$ U
even 15 minutes of direct skin contact with their male, z$ Q+ B b$ v, t2 F
partners.6 However, when a shirt covered the applica-- W9 j" T4 E# A: x" J0 V' \
tion site, this testosterone transfer was prevented.
1 U2 H$ t7 O% M9 W% y& [& JOur patient’s testosterone level was 60 ng/mL,
% p3 c1 I- }* X" c# uwhich was clearly high. Some studies suggest that/ Q7 V+ v9 J! j: w
dermal conversion of testosterone to dihydrotestos-# y' n- D/ m9 L7 x) ~9 Q5 w: \
terone, which is a more potent metabolite, is more/ V7 _+ H: |* {/ [
active in young children exposed to testosterone
% s0 T% @5 _; r- F- qexogenously7; however, we did not measure a dihy-3 O& S( l, w2 [ H! f- r, ?
drotestosterone level in our patient. In addition to, ] Y7 @7 }3 X
virilization, exposure to exogenous testosterone in" c) Y* Y; A. o1 h
children results in an increase in growth velocity and+ O, v: S4 F' v3 z7 j: {$ D+ u
advanced bone age, as seen in our patient., M8 _/ \" O j { R# J/ J, T5 r
The long-term effect of androgen exposure during. l, M! f, ?6 p. d% e. w
early childhood on pubertal development and final
- s* s3 B1 B% S; X9 Padult height are not fully known and always remain0 K" y5 h( Y2 m. p3 {
a concern. Children treated with short-term testos-; |, J- T6 m m1 l1 }4 B
terone injection or topical androgen may exhibit some% b% F% h$ G4 w$ N
acceleration of the skeletal maturation; however, after9 y* ?8 v: S" t/ b6 Z/ u/ c
cessation of treatment, the rate of bone maturation6 z$ @0 @0 R. l1 v
decelerates and gradually returns to normal.8,9
) K+ A D& @5 k6 G1 o' `( ~: AThere are conflicting reports and controversy
8 E0 J4 \% g6 W1 w* [over the effect of early androgen exposure on adult. Y" |0 L8 Y) h; {
penile length.10,11 Some reports suggest subnormal
: s% i- G7 C- T( U! w, ladult penile length, apparently because of downreg-) @7 } b$ l9 Y: \5 u7 u
ulation of androgen receptor number.10,12 However,
' |1 h z/ i" ~3 aSutherland et al13 did not find a correlation between4 ~4 ?' B$ P6 ?+ h9 u# Q Q. c
childhood testosterone exposure and reduced adult
: r P/ w* c$ @: Tpenile length in clinical studies.
) P5 _/ V1 H5 V, N3 L9 B: YNonetheless, we do not believe our patient is$ X9 A- r5 F9 c2 @, R) |
going to experience any of the untoward effects from6 c9 y+ e/ n4 ~0 \
testosterone exposure as mentioned earlier because5 k3 t3 r! R& D1 h n4 }
the exposure was not for a prolonged period of time.
5 x$ t% I' Y, d, M7 P2 ]1 AAlthough the bone age was advanced at the time of) S1 K3 W$ `+ A- C
diagnosis, the child had a normal growth velocity at0 V$ u, X$ k, }% z* V4 x
the follow-up visit. It is hoped that his final adult
8 Z% m) a# w5 h; i" Z7 Bheight will not be affected.
6 \2 `* _2 I7 B' BAlthough rarely reported, the widespread avail-
7 W- }. |8 D1 i" r3 N3 iability of androgen products in our society may" | U0 y7 E/ D" w% q
indeed cause more virilization in male or female6 P0 F- X4 [' }
children than one would realize. Exposure to andro-2 f: R, r0 O5 N$ {: {3 M' y
gen products must be considered and specific ques-
7 M- \: J8 m, \# o1 Otioning about the use of a testosterone product or
0 r: }* w& c0 Z8 g* Lgel should be asked of the family members during
% t, G+ i7 z9 r4 Y$ lthe evaluation of any children who present with vir-5 R) p% A2 q0 F0 o
ilization or peripheral precocious puberty. The diag-
: D: N0 w+ t, J) C- enosis can be established by just a few tests and by. g& y7 Z0 N9 u4 N& q1 c3 D
appropriate history. The inability to obtain such a
2 a/ y+ I5 I, w( U$ Dhistory, or failure to ask the specific questions, may0 q y1 ^, I+ o: U
result in extensive, unnecessary, and expensive4 Q9 {5 |" E9 M
investigation. The primary care physician should be; n1 w# {7 |3 j3 f0 y3 C
aware of this fact, because most of these children
5 H. u3 S/ N2 _! xmay initially present in their practice. The Physicians’
( S0 [9 _, q1 D( A4 k z8 ~% QDesk Reference and package insert should also put a
t \1 H9 x/ {$ _8 iwarning about the virilizing effect on a male or
$ R: @% j! F3 N4 h9 g8 X. rfemale child who might come in contact with some-; Z% {* m$ [$ ^5 |; Y( x1 r
one using any of these products.) S, i3 T( J7 p* q( q
References6 @& @0 ]8 N! r q7 S' {
1. Styne DM. The testes: disorder of sexual differentiation; A: y- Y, ^, s; U) X
and puberty in the male. In: Sperling MA, ed. Pediatric- h! v0 P$ D1 w; [3 G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& n" ^/ n; B( S* C2002: 565-628.
) X4 s( q( W7 [) }9 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( B) Z$ b- M$ N; K6 e0 Q
puberty in children with tumours of the suprasellar pineal |
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