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Sexual Precocity in a 16-Month-Old1 I( f% F+ z( e' c; n _8 O
Boy Induced by Indirect Topical N* ]$ [0 S9 R2 H6 W4 g
Exposure to Testosterone
N8 P- J6 y6 z7 h0 j! B) MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ y& \5 Z. ^( Eand Kenneth R. Rettig, MD18 ?- k" @5 M2 D6 i, R6 O: q
Clinical Pediatrics4 E4 X0 H# M' ~5 e' V
Volume 46 Number 6
" @) {: G3 }( o( d3 A; jJuly 2007 540-5439 X" Y& u( p7 o/ t- B, R
© 2007 Sage Publications
8 I% }4 p% N1 y( u10.1177/0009922806296651
+ J$ s% R, `4 e( Jhttp://clp.sagepub.com' N1 r% K9 N) b( n) U
hosted at
1 U9 z: O) ^5 Dhttp://online.sagepub.com* [5 g2 w4 {0 g4 H; i
Precocious puberty in boys, central or peripheral,
/ J( d- G' [- j1 G2 K) [is a significant concern for physicians. Central
2 H5 f1 ~- b) C. ~# Fprecocious puberty (CPP), which is mediated( g+ Z; ?$ a0 k" ? q
through the hypothalamic pituitary gonadal axis, has
# ]* @8 y8 P f, S Ta higher incidence of organic central nervous system
8 `5 M i9 Y) y3 B/ Wlesions in boys.1,2 Virilization in boys, as manifested
2 d/ j, N5 J0 [( Qby enlargement of the penis, development of pubic% B) p2 P4 q4 h3 k s
hair, and facial acne without enlargement of testi-
5 n& h4 i, j5 Q, t% @' d* K) I8 b+ bcles, suggests peripheral or pseudopuberty.1-3 We9 q0 Q c+ G3 c8 c/ {, j
report a 16-month-old boy who presented with the
! e% u5 S. T7 _" C# C5 Xenlargement of the phallus and pubic hair develop-6 Y% e7 n5 m! b
ment without testicular enlargement, which was due
) i# H+ O4 K' M6 lto the unintentional exposure to androgen gel used by3 \$ z* j& }* t: l& f/ R- M: s# t
the father. The family initially concealed this infor-
. Z) _# K; G% Z. zmation, resulting in an extensive work-up for this
/ z$ c$ o* N; g* M4 E: a' |5 Lchild. Given the widespread and easy availability of) v1 }- E& d/ F1 O% P1 e
testosterone gel and cream, we believe this is proba-! @% i; E0 i! w# G# l* [' p6 i
bly more common than the rare case report in the
. F ~( W/ y# ]: d$ R) ?! P' p5 xliterature.4, o8 `6 B2 q% p2 w$ Z
Patient Report
# h9 M D" r3 Q: A# SA 16-month-old white child was referred to the k( H* g* G9 r
endocrine clinic by his pediatrician with the concern
' a' F3 h0 j9 L. p K" @of early sexual development. His mother noticed
/ N. U- R1 W; f) B, ]light colored pubic hair development when he was
4 D9 c9 h! N6 M. I3 B( X; `! g) oFrom the 1Division of Pediatric Endocrinology, 2University of
: G* k/ E4 f; U) E mSouth Alabama Medical Center, Mobile, Alabama.6 o8 t: O% o, c
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ }- o3 ?& K" X8 e8 L7 bProfessor of Pediatrics, University of South Alabama, College of
& M+ ?; U9 ]( HMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 v- r9 v& w6 v( b- [: we-mail: [email protected].
. o0 M' }) ]# p0 _, ^* Fabout 6 to 7 months old, which progressively became
# m8 y1 [1 C! Ddarker. She was also concerned about the enlarge-
% {! D2 j0 i) H, _8 t. vment of his penis and frequent erections. The child
( e; Z% t1 Z! U! D6 t. kwas the product of a full-term normal delivery, with" \+ t( [% G. h% N8 |$ d
a birth weight of 7 lb 14 oz, and birth length of! R" m* X) ^% f9 F) w* @
20 inches. He was breast-fed throughout the first year0 m# n, v0 G1 L7 j
of life and was still receiving breast milk along with, V% |" m$ u2 y3 p: T4 @2 @
solid food. He had no hospitalizations or surgery,! C) ?% X- V6 G# b
and his psychosocial and psychomotor development
|& j o. E" f! w: v( A9 ]1 L7 Twas age appropriate.
# y3 I: }( Y% H) m3 z9 B" OThe family history was remarkable for the father,
4 l) W: O1 d3 [6 A3 Xwho was diagnosed with hypothyroidism at age 16,
+ U. \$ S8 k$ P; T9 ~* ^which was treated with thyroxine. The father’s8 D& S$ M$ x7 F
height was 6 feet, and he went through a somewhat
, Y U7 I; A, }early puberty and had stopped growing by age 14.
' D9 [8 v) b+ p/ GThe father denied taking any other medication. The/ d) O; c5 w3 y8 ~8 S* E
child’s mother was in good health. Her menarche
5 d/ ~; u6 \% N) gwas at 11 years of age, and her height was at 5 feet
+ K8 d/ `. `- J- P! {) @5 inches. There was no other family history of pre-, H; A) e6 ?. z7 y ~) l, o1 D
cocious sexual development in the first-degree rela-
% j8 a/ k0 P) d: r- P% G0 t6 r& \; R/ }tives. There were no siblings.
" l( ]7 l! ]1 t# f/ _7 CPhysical Examination5 [2 m) U0 X, h* [9 \+ h
The physical examination revealed a very active,6 a7 \( o$ s" |9 g- K$ l+ F2 l( V
playful, and healthy boy. The vital signs documented) ~% o- F* M3 ]2 Q$ r6 [
a blood pressure of 85/50 mm Hg, his length was/ Y$ p0 @6 Q- R
90 cm (>97th percentile), and his weight was 14.4 kg
! a' B! C$ `! H) R. n4 p(also >97th percentile). The observed yearly growth
! A- [* m8 z3 o+ l5 V" t: pvelocity was 30 cm (12 inches). The examination of# P& i* V9 ^! U2 i }; s3 ]% B
the neck revealed no thyroid enlargement.
\6 L3 f4 J+ ?3 b& KThe genitourinary examination was remarkable for
' u/ k: F5 [* Denlargement of the penis, with a stretched length of
1 V' _" y# b' x* U w8 B+ M0 K8 cm and a width of 2 cm. The glans penis was very well# S' O0 F1 x) o0 B; e
developed. The pubic hair was Tanner II, mostly around
8 `$ A1 {# I# M% `540- L- S- a8 U' L1 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ ?# V1 C9 R2 b! N! T& x+ fthe base of the phallus and was dark and curled. The' m2 P! z" O) y, J1 c( W
testicular volume was prepubertal at 2 mL each.! w4 j7 N7 P6 c/ j
The skin was moist and smooth and somewhat
5 n/ a. [9 j+ [& l. N# q$ P9 ^8 h/ ~6 Uoily. No axillary hair was noted. There were no
e9 W3 t" h3 M( Habnormal skin pigmentations or café-au-lait spots.
6 K4 }( p. |: B4 W2 TNeurologic evaluation showed deep tendon reflex 2+0 w2 ?: r# z C5 M
bilateral and symmetrical. There was no suggestion3 A: ^! ?# l7 W
of papilledema.
3 @" `* V2 t; d* i7 j' {, jLaboratory Evaluation
: Q2 p) q4 p! m: [. u$ S6 Z$ nThe bone age was consistent with 28 months by: A; o# }! i1 k
using the standard of Greulich and Pyle at a chrono-
) l3 [5 ^5 v* Z7 i7 [) ~logic age of 16 months (advanced).5 Chromosomal
\8 {2 A- `; K' |- i! y( Okaryotype was 46XY. The thyroid function test
7 j i. b, o( ^1 mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# \- V$ i6 z n) K% S, m$ A$ y: s- Tlating hormone level was 1.3 µIU/mL (both normal).: K+ c/ N: G3 I; x2 ]% t5 u
The concentrations of serum electrolytes, blood
1 [3 L" a$ l( } a# ^& e; A, turea nitrogen, creatinine, and calcium all were' E1 l# E4 O7 |2 P
within normal range for his age. The concentration
; H3 ] S6 G# k2 y6 eof serum 17-hydroxyprogesterone was 16 ng/dL3 k# f1 I+ @3 ?) L8 l
(normal, 3 to 90 ng/dL), androstenedione was 20) j5 d$ c3 c* ]9 i; t4 _+ [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 L0 I" e$ t2 M/ d! |+ uterone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 a' i5 x! J' F1 A9 [# k6 Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ e) U6 d0 E8 P9 K
49ng/dL), 11-desoxycortisol (specific compound S)
: \/ T) d6 i! {# m; ^! z% X; Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 V D) ?9 j( b+ ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" W$ J6 \7 G+ i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# @% S) P% x" {7 x6 n7 m) |
and β-human chorionic gonadotropin was less than
8 a+ R$ ~( A% R7 q F# k5 mIU/mL (normal <5 mIU/mL). Serum follicular: ^( t( P1 P' N8 F2 i9 S0 d# q
stimulating hormone and leuteinizing hormone
# E6 L: u$ i- i: A- V3 t) g. _concentrations were less than 0.05 mIU/mL
6 z' j2 A4 e/ A) D(prepubertal).& x0 M: g3 K9 w0 i; U) D3 F% |" A: t
The parents were notified about the laboratory' ]* G) P$ X5 a6 m4 B, y# R$ _
results and were informed that all of the tests were# e \0 f( y; a+ U3 H6 H
normal except the testosterone level was high. The
+ v' i/ @- m8 K. y* ^: ifollow-up visit was arranged within a few weeks to6 J8 D5 l. w2 A
obtain testicular and abdominal sonograms; how-' P# P" ?7 c8 l, u9 L
ever, the family did not return for 4 months.
+ K. F, ~3 k! D4 _) Q/ r; b: IPhysical examination at this time revealed that the
* G2 g) P* ]( d+ `7 |9 T, _child had grown 2.5 cm in 4 months and had gained, u) c. y# [7 C% ^) V0 ?8 @% m
2 kg of weight. Physical examination remained0 M& r5 d3 J, x3 O9 h7 J
unchanged. Surprisingly, the pubic hair almost com-+ E3 K7 Q) S7 d- B9 q1 `
pletely disappeared except for a few vellous hairs at2 z8 u6 }# N4 X
the base of the phallus. Testicular volume was still 2: T* z( j3 B. t) Q8 Q8 `& A5 ?
mL, and the size of the penis remained unchanged.: g0 m0 J$ {) I* U R
The mother also said that the boy was no longer hav-
, X6 v% r' A% `1 _( x+ ying frequent erections.* \" {: e" O% _
Both parents were again questioned about use of/ \' e9 W4 V# L3 l' Y
any ointment/creams that they may have applied to
& h) x. U8 v) {' d& L9 \. F1 e- kthe child’s skin. This time the father admitted the
6 ^+ x4 y3 ~" R; PTopical Testosterone Exposure / Bhowmick et al 541% D' U! L: s s
use of testosterone gel twice daily that he was apply-7 k0 H4 O0 v, J) a2 c# y( c3 E
ing over his own shoulders, chest, and back area for
. v/ F1 u$ H" c' ?- Ta year. The father also revealed he was embarrassed
4 U9 K: t6 }) c# p' k, ato disclose that he was using a testosterone gel pre-
% {. e. t- Z7 O9 X7 |scribed by his family physician for decreased libido
/ z' i; @: l0 O/ H& i* o8 xsecondary to depression.
& e" p4 H& C5 l5 t, X0 _0 iThe child slept in the same bed with parents.
/ k* b5 _2 @% QThe father would hug the baby and hold him on his3 o* v: L3 Q5 X
chest for a considerable period of time, causing sig-1 z! D8 t- M0 D
nificant bare skin contact between baby and father." U5 h! `8 L* r* B) a
The father also admitted that after the phone call,
: J7 _( v ^1 D% z( y0 K* \7 ywhen he learned the testosterone level in the baby4 h4 d6 @7 ~# \
was high, he then read the product information- X7 k) y' q5 C+ _
packet and concluded that it was most likely the rea-$ ]7 R; D; ?" B+ ~
son for the child’s virilization. At that time, they
0 m% T& y# X' rdecided to put the baby in a separate bed, and the. z7 p/ a: f; v5 O
father was not hugging him with bare skin and had, ]2 ^9 ` I' K# [7 t Z
been using protective clothing. A repeat testosterone
; J2 s3 b# `! `4 E) y) T0 b9 ^test was ordered, but the family did not go to the, p* B! t+ k1 S, j$ l0 F
laboratory to obtain the test.9 @0 a+ a0 ^0 [5 U4 P
Discussion3 D3 a2 ^$ H3 J6 }% _! M0 A
Precocious puberty in boys is defined as secondary( z7 M% C. i/ }7 R
sexual development before 9 years of age.1,4
. R/ x) w9 I1 X' u3 K8 zPrecocious puberty is termed as central (true) when
+ H8 }1 }! s0 f. }0 xit is caused by the premature activation of hypo-: F' P& P& K5 C% z ]9 ]
thalamic pituitary gonadal axis. CPP is more com-
( D. W; ]% \( U6 Y1 `1 F0 Emon in girls than in boys.1,3 Most boys with CPP! i) {# W( n0 W4 U3 x; H3 T
may have a central nervous system lesion that is
8 B; t/ I# ~/ N, Jresponsible for the early activation of the hypothal-6 Q/ x& s3 A! w0 b- W, D
amic pituitary gonadal axis.1-3 Thus, greater empha-/ D9 i! q( J: M }0 r) }
sis has been given to neuroradiologic imaging in6 X1 J5 U- u; \, S. G: I* d
boys with precocious puberty. In addition to viril-
* o! G2 h. g# Zization, the clinical hallmark of CPP is the symmet-
* y. b* @, g) K. j+ o1 v1 U9 M, urical testicular growth secondary to stimulation by
" i& A. e5 d! v" bgonadotropins.1,3$ N& Q/ l' W0 v6 ?0 i7 n
Gonadotropin-independent peripheral preco-) Y7 k! m5 Z5 h! s: d$ l) L5 D
cious puberty in boys also results from inappropriate7 V( R, ^0 u5 ~1 Z
androgenic stimulation from either endogenous or
3 w2 o. o. q: t# rexogenous sources, nonpituitary gonadotropin stim-
9 a/ [( l# O6 L: }" a& Fulation, and rare activating mutations.3 Virilizing# M& D( r. v# y( D. F: G: e. n
congenital adrenal hyperplasia producing excessive1 E e: S$ u! g
adrenal androgens is a common cause of precocious
4 r* D, `& J. [$ U' `puberty in boys.3,4
; d K2 z- s2 E9 |$ ~8 i$ cThe most common form of congenital adrenal4 o/ G1 c/ ^1 Q9 O
hyperplasia is the 21-hydroxylase enzyme deficiency." f0 p( a8 b: j8 g+ v
The 11-β hydroxylase deficiency may also result in0 W6 ?( U( T/ ]8 ?/ A$ j9 _2 `: _
excessive adrenal androgen production, and rarely,
0 Q) _( ]* {3 i( Kan adrenal tumor may also cause adrenal androgen
) z, e2 p' j/ A) I4 pexcess.1,3, r4 W1 _5 a. P3 J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) j& |; q4 k0 B' p542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 M3 n0 o, h" ?6 G0 U+ r
A unique entity of male-limited gonadotropin-9 j' c( O) ~+ R# a7 Y) J3 C
independent precocious puberty, which is also known3 H9 o4 j( u7 h% N# S- f' B
as testotoxicosis, may cause precocious puberty at a
# u+ V% \6 k- w9 kvery young age. The physical findings in these boys Y0 F* ]4 q: x1 o. N% A2 y
with this disorder are full pubertal development,% p' j2 Z4 I, A6 H; S2 A$ {0 T2 C) B
including bilateral testicular growth, similar to boys
: p& T; t% Z8 V9 c$ F- Xwith CPP. The gonadotropin levels in this disorder
% h/ K0 I& l6 m Q9 kare suppressed to prepubertal levels and do not show
$ L& G1 n; a& _0 Q$ l8 Epubertal response of gonadotropin after gonadotropin-0 I; O0 l5 v+ \& @ I/ _" m8 X6 k- d
releasing hormone stimulation. This is a sex-linked" H- o( B0 \- \+ y; f ]
autosomal dominant disorder that affects only
* y0 j# j; ~6 V. g* F* I' omales; therefore, other male members of the family
! P2 a$ L8 k* B" B( @may have similar precocious puberty.3
: A- w7 J% n& r' V: AIn our patient, physical examination was incon-
8 m' e% ?7 o4 w0 k$ s9 S8 dsistent with true precocious puberty since his testi-1 [' X! L1 Z; [) f9 _
cles were prepubertal in size. However, testotoxicosis$ [, Z: w8 t" B- c" y6 t
was in the differential diagnosis because his father
6 u# s" G2 c( M2 ^6 Z" U6 W4 Gstarted puberty somewhat early, and occasionally,
! I) w% L3 W. i0 etesticular enlargement is not that evident in the
4 D- e8 Q+ [! i2 E8 Bbeginning of this process.1 In the absence of a neg-! b7 S. P. A, h
ative initial history of androgen exposure, our
3 b9 L1 c- |8 f7 Nbiggest concern was virilizing adrenal hyperplasia,/ n0 B% F; d1 V( C0 p$ \
either 21-hydroxylase deficiency or 11-β hydroxylase
9 E( l F) `6 \7 |- [deficiency. Those diagnoses were excluded by find-% p! I4 j% N- ?3 `+ s
ing the normal level of adrenal steroids., d; X4 i. O: J5 `2 A
The diagnosis of exogenous androgens was strongly
6 {, Y6 l8 {" p" b# t8 I, b. Csuspected in a follow-up visit after 4 months because2 r) V8 k1 @5 }/ O& U0 u3 q
the physical examination revealed the complete disap-
' d1 G' H" c8 L( mpearance of pubic hair, normal growth velocity, and
3 ~( c7 f/ o; Z3 F. i5 Zdecreased erections. The father admitted using a testos-
, Q4 A+ Q6 n' v' D2 Gterone gel, which he concealed at first visit. He was8 K+ e. ]* s9 C1 K6 R, C2 T
using it rather frequently, twice a day. The Physicians’
1 |' v% `. g5 v2 g) x5 X' k) {Desk Reference, or package insert of this product, gel or
& _0 g# R- t* Z& r/ {7 Ccream, cautions about dermal testosterone transfer to0 i& m: A& J" Q/ m
unprotected females through direct skin exposure.; s- f7 `$ g! m! M
Serum testosterone level was found to be 2 times the9 Z0 D2 Y" n: c" _3 ^- y3 o
baseline value in those females who were exposed to
3 a% u9 b; }$ b. o3 k) A( Neven 15 minutes of direct skin contact with their male% F* x$ V9 E% F5 X9 H
partners.6 However, when a shirt covered the applica-
$ B! ]* X0 i3 V3 [tion site, this testosterone transfer was prevented.% X# @' R! M" s5 j3 i
Our patient’s testosterone level was 60 ng/mL, j) U+ p4 C% W( M) h# i( e' Z
which was clearly high. Some studies suggest that
4 y! R% @/ u1 V. ]dermal conversion of testosterone to dihydrotestos-4 a( q8 {' x8 b# |
terone, which is a more potent metabolite, is more
& j2 K7 X/ P1 L# f& |active in young children exposed to testosterone v* J+ a% b3 M& Y
exogenously7; however, we did not measure a dihy-
3 G2 O2 t) p! {6 D9 m0 x* xdrotestosterone level in our patient. In addition to
( M) ?$ b- ]8 i3 O# [virilization, exposure to exogenous testosterone in
+ \( U! I2 u4 g/ g( v: dchildren results in an increase in growth velocity and) ^- a* N6 A2 D' x: p% V
advanced bone age, as seen in our patient.
; [* ]$ k0 O: m9 T- bThe long-term effect of androgen exposure during. m' P3 E) [- [8 `
early childhood on pubertal development and final9 R5 p4 H2 t& i+ ], @2 o; J7 s7 d" q
adult height are not fully known and always remain6 j: H: H: c& [
a concern. Children treated with short-term testos-
. i2 K/ Z3 D9 W* Eterone injection or topical androgen may exhibit some
. E" l. I% l6 d& ~0 Zacceleration of the skeletal maturation; however, after9 b7 b+ H) o" _- N2 C
cessation of treatment, the rate of bone maturation: Z4 o. b) J' t
decelerates and gradually returns to normal.8,9
3 ~" H' Z- ?2 ~* F5 ?, ^# s5 I2 C4 ZThere are conflicting reports and controversy) J; D9 i7 v" T
over the effect of early androgen exposure on adult- p, R2 a/ q6 Q0 e# N6 p: g
penile length.10,11 Some reports suggest subnormal
2 g$ z- o3 ]: kadult penile length, apparently because of downreg-
' C) ~) d$ P2 Mulation of androgen receptor number.10,12 However,, O& {3 k8 {) j% f0 x& k3 I/ I. U
Sutherland et al13 did not find a correlation between \2 y: O5 B; S
childhood testosterone exposure and reduced adult
" R; t$ d. z1 o* `8 {penile length in clinical studies.* a- F* T% C _/ k. T$ h( l% u5 o+ Y
Nonetheless, we do not believe our patient is
1 i5 G: F; O( e, ~7 s0 Y# i' ^going to experience any of the untoward effects from, `: Z+ J8 D: l% {
testosterone exposure as mentioned earlier because
+ M4 b, ]# m$ {2 ethe exposure was not for a prolonged period of time.- R. I0 h( [7 k0 ?5 H# @
Although the bone age was advanced at the time of/ |0 l% H, W! N9 J6 s( Z
diagnosis, the child had a normal growth velocity at) `* |5 `. v/ r% t9 d
the follow-up visit. It is hoped that his final adult
; a' p4 \7 h- ?* xheight will not be affected.1 l4 X* B8 _" D. `
Although rarely reported, the widespread avail-
7 U, [6 G, s6 dability of androgen products in our society may
6 ?- g& W: l! z3 S6 Dindeed cause more virilization in male or female" X4 {2 q9 D0 A1 ]
children than one would realize. Exposure to andro-; I. W( A S% M' q4 }1 y
gen products must be considered and specific ques-
; `. R( \9 T" k, u, x5 r* Z; b( itioning about the use of a testosterone product or
+ ?& p, N: ?" P. a9 Ggel should be asked of the family members during1 l/ s9 M8 l9 ]0 N' [
the evaluation of any children who present with vir-
: F, v4 j6 S' m" s, y( N0 Uilization or peripheral precocious puberty. The diag-# Z% n- a8 K8 C2 l
nosis can be established by just a few tests and by. R0 r2 j$ E6 R, R; X$ @
appropriate history. The inability to obtain such a8 o$ I% y3 N2 t# `. ^/ g: ^% }
history, or failure to ask the specific questions, may
- @0 J' s2 d; e1 Cresult in extensive, unnecessary, and expensive, S, H, L4 @& f1 D/ D2 _2 t
investigation. The primary care physician should be
& p% j& N2 V$ X0 A3 yaware of this fact, because most of these children; I5 [% e2 b1 P
may initially present in their practice. The Physicians’
* B5 l5 }! K x% m$ h2 \Desk Reference and package insert should also put a0 B% m1 T% x& I s5 k9 g; K1 [
warning about the virilizing effect on a male or( w& W1 H6 D8 r2 X6 M/ P
female child who might come in contact with some-
( X2 H/ O1 I3 Gone using any of these products.% i1 N/ x$ R$ r; J5 u) H8 ?# j
References+ |" P7 ^8 R T, \5 b" u+ t
1. Styne DM. The testes: disorder of sexual differentiation
0 N( J% E" }1 Q/ q/ Rand puberty in the male. In: Sperling MA, ed. Pediatric
) x+ Y! E h" g" n% BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% X$ r/ D$ A$ ^% i. M
2002: 565-628.
2 b' v7 z0 |% b2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ Z' P& M! V; k6 ?' t9 G) d
puberty in children with tumours of the suprasellar pineal |
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