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Sexual Precocity in a 16-Month-Old3 p8 W. z8 D1 [
Boy Induced by Indirect Topical0 |, G$ {7 I& n, s6 j
Exposure to Testosterone
2 Y% }- l5 }* u8 h- BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) |& X1 Y/ l( | o' t) Y$ oand Kenneth R. Rettig, MD17 P+ }; H* S; S% `
Clinical Pediatrics0 U5 \' G. f" n+ b1 a6 ^
Volume 46 Number 69 }* i( @( C. a3 w, E
July 2007 540-543
. r9 V J" i) C/ M© 2007 Sage Publications
) R! i7 A ?( n3 Y$ A! R; n10.1177/0009922806296651
, c9 W) ?. K. J) vhttp://clp.sagepub.com
' z* S; H/ M6 G3 }( P* ghosted at
$ f) ^: L9 Q0 q3 Y! ghttp://online.sagepub.com" W8 c4 Y4 N4 N5 i2 n8 _4 x
Precocious puberty in boys, central or peripheral,. M( b5 _; C. h: f/ w7 x; v
is a significant concern for physicians. Central
2 u" T3 ?8 a" e. C* @% i+ Yprecocious puberty (CPP), which is mediated% }9 b9 ]* s4 e2 h; N: e" W3 y
through the hypothalamic pituitary gonadal axis, has
* O6 A% s' v; M" u# ea higher incidence of organic central nervous system
6 v# A4 i& Q H$ b" w! m& glesions in boys.1,2 Virilization in boys, as manifested/ @4 G" I+ I/ N" p
by enlargement of the penis, development of pubic/ f+ g, W% G8 j& J. ?- e
hair, and facial acne without enlargement of testi-0 h# a, w+ Z. G: A; S# d+ x4 F/ f
cles, suggests peripheral or pseudopuberty.1-3 We
& X% H& D! t! Q& Z0 breport a 16-month-old boy who presented with the8 f" {- r* X# j$ t% N4 K
enlargement of the phallus and pubic hair develop-
* x# a+ }9 t* i! L5 Z/ ement without testicular enlargement, which was due
; Q: d# ?! q6 B# b3 Z- `to the unintentional exposure to androgen gel used by
2 i% }" {3 L2 o8 t. Dthe father. The family initially concealed this infor-
3 T3 g3 _* J+ @. bmation, resulting in an extensive work-up for this3 Q9 E' [) G) s" A, x
child. Given the widespread and easy availability of% F+ f% z# Y/ U
testosterone gel and cream, we believe this is proba-0 c- w; Z! z2 B$ f- ?
bly more common than the rare case report in the; S. Z; U; _$ Z# a- G
literature.4
, B( B% d5 x# B, HPatient Report
) N; m( V1 C) e6 M& a3 [% hA 16-month-old white child was referred to the* h8 T( O' L0 Z5 G C. l
endocrine clinic by his pediatrician with the concern/ R1 U/ r& b D" z9 l9 `* j3 z
of early sexual development. His mother noticed" T8 u$ }( D) |& j
light colored pubic hair development when he was! V3 E1 _+ [8 `/ g9 |' v1 Z
From the 1Division of Pediatric Endocrinology, 2University of4 i5 `8 y" f# r0 u0 g, `
South Alabama Medical Center, Mobile, Alabama.
/ c1 L9 \% e- `& Q, n. \% XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* n, D, Q+ c( O7 s5 OProfessor of Pediatrics, University of South Alabama, College of; z+ Q. }9 Z1 @ f( }. J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, `+ C& m- c/ J. J6 \8 V
e-mail: [email protected].
. Z1 T+ R7 a) ~6 M4 Q$ h$ Uabout 6 to 7 months old, which progressively became
; g' v+ h. ?" z q2 xdarker. She was also concerned about the enlarge-1 K' N2 I8 i0 A9 g: _( s
ment of his penis and frequent erections. The child
3 B) g+ a9 _; g6 \was the product of a full-term normal delivery, with7 m- \5 y' U- q
a birth weight of 7 lb 14 oz, and birth length of
9 m5 V. T! X# g5 j4 E: M, B20 inches. He was breast-fed throughout the first year+ x% ^4 Y+ b' Q& |
of life and was still receiving breast milk along with Z7 V u# y6 N5 X! Y9 {; X7 M
solid food. He had no hospitalizations or surgery,
" K) m+ f6 ]. q* C# @( j. vand his psychosocial and psychomotor development
4 _# T6 r; h( G; T7 Dwas age appropriate.% ?+ m5 @4 d% U7 K8 ?/ `. b I' \
The family history was remarkable for the father,8 a6 E+ D) w( A$ | }
who was diagnosed with hypothyroidism at age 16,$ j$ Q5 b X3 ?" l6 F9 g7 p
which was treated with thyroxine. The father’s% L+ L; I2 a2 D3 u
height was 6 feet, and he went through a somewhat
6 O- U; I) B) A8 f& F$ D$ Eearly puberty and had stopped growing by age 14.
( Y0 M, c" {) h( _! q2 tThe father denied taking any other medication. The
6 W) ]5 D. n. Y& v! _8 hchild’s mother was in good health. Her menarche a {( P8 B, b9 {( \, H9 c0 Q
was at 11 years of age, and her height was at 5 feet
% t0 w; ~ o8 e2 V ]' T/ y5 inches. There was no other family history of pre-( z* _2 N# L& _2 ~- |- l
cocious sexual development in the first-degree rela-" {$ A& h( y3 K$ |9 b7 ]. r$ x7 ^) h' p
tives. There were no siblings.
+ s$ y2 F) C; s h! Z1 s3 _Physical Examination: g; f! a, R6 ]$ ~, n( }1 J
The physical examination revealed a very active,; q8 P$ g( Y! h
playful, and healthy boy. The vital signs documented/ ?3 I: u& m: Y& J/ b' m2 O
a blood pressure of 85/50 mm Hg, his length was Z6 j( C) f# b5 `
90 cm (>97th percentile), and his weight was 14.4 kg" T: Z: \: K0 x
(also >97th percentile). The observed yearly growth
/ H5 [% j9 n6 R0 ]7 N# }$ F! m' lvelocity was 30 cm (12 inches). The examination of
; u% r3 y% T- S/ V+ V9 [. u5 }the neck revealed no thyroid enlargement.4 x# k* Y+ K, h6 l. ], Z2 S) @
The genitourinary examination was remarkable for3 @7 O% H/ ^. {6 J2 e7 W. k
enlargement of the penis, with a stretched length of( b! J; E7 M) b4 H# M
8 cm and a width of 2 cm. The glans penis was very well* i, Q; d6 d$ ]7 g* q% `
developed. The pubic hair was Tanner II, mostly around
; \/ A/ @7 m, s7 P H# Z, h5401 T! i4 Z1 _0 X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* T( W: R/ J5 v" Y6 O/ c4 U# K3 fthe base of the phallus and was dark and curled. The# ?/ C4 i; Y. j0 M1 V
testicular volume was prepubertal at 2 mL each.8 \- a! `" k" s% p& x
The skin was moist and smooth and somewhat3 d7 w8 j7 c0 E2 x
oily. No axillary hair was noted. There were no
5 G4 j" v# U8 t& ~$ `* @$ c: xabnormal skin pigmentations or café-au-lait spots.3 r, J1 [+ H; y9 V) K" V8 s
Neurologic evaluation showed deep tendon reflex 2+: A( \1 {3 v# w) H! W, z6 M, \+ M
bilateral and symmetrical. There was no suggestion4 y! I* @( a7 d4 G3 q7 V
of papilledema.
% S, Y$ W3 L% t) vLaboratory Evaluation
& s" Y( B% m) G4 GThe bone age was consistent with 28 months by
) N5 `9 |* S" Z3 A% d' |+ cusing the standard of Greulich and Pyle at a chrono-, P0 B. D+ i. V( V
logic age of 16 months (advanced).5 Chromosomal/ X% k: U) J2 F5 K' U
karyotype was 46XY. The thyroid function test
L7 L9 D/ i# W: |. fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 @; I( X1 X9 N) v0 y
lating hormone level was 1.3 µIU/mL (both normal)., u$ B0 `: D/ n. M6 v& R
The concentrations of serum electrolytes, blood
! m4 W& Z8 |! Gurea nitrogen, creatinine, and calcium all were
: t7 I1 }8 H4 D' _within normal range for his age. The concentration
8 k+ ?' K/ D5 _2 e5 ]of serum 17-hydroxyprogesterone was 16 ng/dL8 l7 G4 O( ~0 w9 ^7 a
(normal, 3 to 90 ng/dL), androstenedione was 20
: H5 `* S% V8 f; `9 o0 V8 T$ M7 Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) h. d+ `% u& R' z# ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& m- a5 a' ~2 q* N+ l0 ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to' h6 l. T6 E. H
49ng/dL), 11-desoxycortisol (specific compound S)
& I3 n G! ^: l1 |, }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- u9 x: S- I. E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. s) q& o; K, k
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 T9 k2 w/ ^. y$ [1 `
and β-human chorionic gonadotropin was less than6 f# `0 ]8 I4 ]' _
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* M& Z( z( m3 l: j1 [stimulating hormone and leuteinizing hormone
; h. J* q+ I+ @concentrations were less than 0.05 mIU/mL1 \5 F3 h' m8 N
(prepubertal)., a* t4 I6 S r4 z, G
The parents were notified about the laboratory
/ j5 r8 C, m: v, X# H4 zresults and were informed that all of the tests were u# V( \! p& t; L& B
normal except the testosterone level was high. The
2 n+ Y! x$ P2 b7 [# vfollow-up visit was arranged within a few weeks to, g# G7 N5 n0 A
obtain testicular and abdominal sonograms; how-, r8 M d$ c# |! q) q# n- N/ `3 }
ever, the family did not return for 4 months.
" b9 E J2 f7 `1 k8 ]/ B9 nPhysical examination at this time revealed that the4 L# r8 o. [9 B: z A
child had grown 2.5 cm in 4 months and had gained& m* u6 j$ ~8 q0 [, Y
2 kg of weight. Physical examination remained
0 F$ D7 a" `7 S8 A! p, F/ ]unchanged. Surprisingly, the pubic hair almost com-
' V* i' M% R0 M Y$ |0 Spletely disappeared except for a few vellous hairs at; o, D' k! e& F% k8 I
the base of the phallus. Testicular volume was still 2
2 j G+ y$ y* c6 t" C' v5 y3 H. _mL, and the size of the penis remained unchanged.
3 h+ b& d% _; U! R2 ^8 @( S% SThe mother also said that the boy was no longer hav-
2 y. S& s; o) L/ w5 x9 |8 ?8 ]ing frequent erections.
, j. L7 ]- c& a: s; H6 VBoth parents were again questioned about use of: _( y8 v2 K% t( {; }
any ointment/creams that they may have applied to
2 Z0 h/ I1 z5 s9 Qthe child’s skin. This time the father admitted the8 u2 s U! K: S- |. N
Topical Testosterone Exposure / Bhowmick et al 5419 E$ l! I. y; q; _
use of testosterone gel twice daily that he was apply-4 |! |, w* H* X
ing over his own shoulders, chest, and back area for9 \2 Q* N1 o. J5 R$ [
a year. The father also revealed he was embarrassed
( }4 g0 [& N% X" q+ cto disclose that he was using a testosterone gel pre-
$ ^8 a; n4 z0 f% }2 o R* Yscribed by his family physician for decreased libido
) S/ r- b6 X ?secondary to depression.# n2 k; i: t2 q! o1 w
The child slept in the same bed with parents.& A2 M0 W7 G% ]( \; A3 ~. F. q
The father would hug the baby and hold him on his6 Q/ T: Q( f/ K& T& ?7 \
chest for a considerable period of time, causing sig-$ ?* Q5 w0 C% I6 z% g, `4 C
nificant bare skin contact between baby and father.
' N' c2 v& O8 VThe father also admitted that after the phone call,
% u+ k- v, f7 K1 K4 I2 g: qwhen he learned the testosterone level in the baby+ B6 B+ h% D+ a! x) J
was high, he then read the product information
4 V' O7 {7 V5 x9 Hpacket and concluded that it was most likely the rea-
4 [/ Z/ ~! \7 E# E; s: qson for the child’s virilization. At that time, they* v4 Z# l: ~2 ]
decided to put the baby in a separate bed, and the
0 @8 f# Q: N% c; Sfather was not hugging him with bare skin and had w& E8 a& i, d. ]0 Z; \. u
been using protective clothing. A repeat testosterone0 `* z3 k2 I+ V9 q b0 z
test was ordered, but the family did not go to the" h# r4 r, q2 K/ C# K
laboratory to obtain the test.! S6 r4 _" t* o, a8 }
Discussion
9 |. q) {, g) s9 IPrecocious puberty in boys is defined as secondary( W$ h- U6 K. v- q/ g- ~
sexual development before 9 years of age.1,4- u/ f$ H, j" {5 a8 X# N" B
Precocious puberty is termed as central (true) when9 I% N+ g H# Y6 m5 L' |+ o3 A
it is caused by the premature activation of hypo-
5 N2 n. [8 k+ c6 s/ Fthalamic pituitary gonadal axis. CPP is more com-& m) s- B {% v
mon in girls than in boys.1,3 Most boys with CPP
1 i2 J6 D- T [* M. `1 T5 n5 c' gmay have a central nervous system lesion that is
* b! f2 e# G+ w/ e, M, Hresponsible for the early activation of the hypothal-
9 G; w' o! u: X6 }6 Kamic pituitary gonadal axis.1-3 Thus, greater empha-
# v, s4 o6 |: {/ j9 Msis has been given to neuroradiologic imaging in
8 F9 Z4 M, i. q- B) [( fboys with precocious puberty. In addition to viril-( G9 P: O# X, Q' S
ization, the clinical hallmark of CPP is the symmet-7 W$ h* G: F7 e* j: O4 C
rical testicular growth secondary to stimulation by
B" \* N9 c# [" J7 o$ z9 N8 L0 Vgonadotropins.1,3$ o1 @: Y: v. J
Gonadotropin-independent peripheral preco-' m. I$ E# U/ w6 }* c; w. G
cious puberty in boys also results from inappropriate
: A; Y; r: U6 `8 Mandrogenic stimulation from either endogenous or
* G$ |5 n: ~5 \, O, texogenous sources, nonpituitary gonadotropin stim-% ]. X+ J. I2 v' ^7 |, d
ulation, and rare activating mutations.3 Virilizing& G4 O/ Y$ |( Q W/ o% N: [8 x( S
congenital adrenal hyperplasia producing excessive1 P1 F* I0 @- H) }: ]
adrenal androgens is a common cause of precocious' m& Q) x" b- t* W
puberty in boys.3,4" s D/ [2 F) i+ m
The most common form of congenital adrenal
4 S& q/ [5 ~, } e2 v) dhyperplasia is the 21-hydroxylase enzyme deficiency.
( X, T. B1 h; O8 T v* AThe 11-β hydroxylase deficiency may also result in! r) @( U2 A" p/ [! C
excessive adrenal androgen production, and rarely,
8 g( Z0 ~! S) s. O M8 ?an adrenal tumor may also cause adrenal androgen. x, V2 M) B, Y' c
excess.1,39 \/ p% f0 A7 t/ s1 P6 L! d B9 u. o$ q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# @0 j. D4 r( U542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 Y4 k& L! f- O7 ?* a( `4 \# l5 y
A unique entity of male-limited gonadotropin-7 _$ W7 m5 E6 f3 a3 w1 U" d
independent precocious puberty, which is also known6 `) o" j/ I& b: Y
as testotoxicosis, may cause precocious puberty at a
9 W6 U7 ?: V( h3 v4 ]very young age. The physical findings in these boys+ a- \7 \1 y$ v+ l: A" v0 U' g
with this disorder are full pubertal development,, O1 `( M% ^' O$ Y8 p( f- f# _
including bilateral testicular growth, similar to boys6 T Y4 i$ ]! N" r& T
with CPP. The gonadotropin levels in this disorder3 a) }* E M2 ~
are suppressed to prepubertal levels and do not show
A7 R- h9 b3 |2 ppubertal response of gonadotropin after gonadotropin-& G. m# j& d0 l+ D
releasing hormone stimulation. This is a sex-linked
3 a2 i. m5 Q$ tautosomal dominant disorder that affects only U' H$ \, k- m x
males; therefore, other male members of the family2 @& @8 G3 s0 w, P: a ~' [% Y0 B
may have similar precocious puberty.3
5 L X1 b5 ~7 b+ T& bIn our patient, physical examination was incon-' ^* ]* a, j5 R" F( ?# a9 z9 P: m
sistent with true precocious puberty since his testi-
/ Y' @) j7 X' _+ s$ A' jcles were prepubertal in size. However, testotoxicosis
) k" r/ o) d8 U }8 P. b5 k8 |was in the differential diagnosis because his father4 f1 _) N% w5 ^; [3 h
started puberty somewhat early, and occasionally,0 O! }! Y* f2 t# B$ j1 B4 J
testicular enlargement is not that evident in the4 |: A# @' _! R2 N3 X# T& Y9 u7 Z
beginning of this process.1 In the absence of a neg-
: X k# D8 A& r4 u$ u) H* V" vative initial history of androgen exposure, our
! C& A3 @, q6 c( ^- xbiggest concern was virilizing adrenal hyperplasia,. J4 G- x" r* A
either 21-hydroxylase deficiency or 11-β hydroxylase% E. [$ D! f: l) A/ @8 X5 ]9 l
deficiency. Those diagnoses were excluded by find-
' R: M9 g7 K0 H# S& Ging the normal level of adrenal steroids.
+ ^1 [2 l0 L* f6 q/ IThe diagnosis of exogenous androgens was strongly+ }7 _3 B3 R! k9 H+ P
suspected in a follow-up visit after 4 months because
9 o0 U. M9 E5 d2 M* Lthe physical examination revealed the complete disap-5 h9 k8 x! X2 z# ]7 T( B: O: P
pearance of pubic hair, normal growth velocity, and
& G* C) M& c8 ^. S$ Bdecreased erections. The father admitted using a testos-
4 y% F% }/ \" t! C5 G3 j$ Fterone gel, which he concealed at first visit. He was% O0 {8 \( `$ C$ V3 e
using it rather frequently, twice a day. The Physicians’
6 U% r, b W( r* n# F0 Z' zDesk Reference, or package insert of this product, gel or
/ t" _; t6 Q4 `cream, cautions about dermal testosterone transfer to
/ S6 H% t# T4 D: Wunprotected females through direct skin exposure.6 N1 U; O: H2 y, f3 q2 ]4 P
Serum testosterone level was found to be 2 times the
' U# U0 A" u( ~ U5 |- B# }) ]baseline value in those females who were exposed to
( |! g0 y' L+ H9 K1 B, N( }& r8 `even 15 minutes of direct skin contact with their male
: P' q# T* \& ^: u8 u( @3 |partners.6 However, when a shirt covered the applica-
9 B( _" d/ [0 e2 @/ Y; Ption site, this testosterone transfer was prevented.+ A2 N& L7 |+ A2 d
Our patient’s testosterone level was 60 ng/mL,
+ F3 O; q) r0 xwhich was clearly high. Some studies suggest that- f3 m, g D- t0 U1 K* F' b
dermal conversion of testosterone to dihydrotestos-8 [3 `' s/ B) c7 ~
terone, which is a more potent metabolite, is more4 q0 O- Q' m9 A3 v0 ]. u
active in young children exposed to testosterone$ `8 Y+ u5 v! \9 t
exogenously7; however, we did not measure a dihy-7 ~% L2 s3 P- k
drotestosterone level in our patient. In addition to% X0 N( a% ~+ n; d
virilization, exposure to exogenous testosterone in
+ v( T5 S; Y$ D! h, ~5 X! xchildren results in an increase in growth velocity and
2 S F% e g5 qadvanced bone age, as seen in our patient.9 `. W0 W' Z! I* u- `
The long-term effect of androgen exposure during
3 k5 J" L) k3 L4 learly childhood on pubertal development and final, J {4 H% q9 u0 ~! ^; J8 V
adult height are not fully known and always remain
# V7 [. Y* \' l1 f% ]a concern. Children treated with short-term testos-- z6 ~% C6 X# T: ? \
terone injection or topical androgen may exhibit some6 E* z7 ^/ ]1 X( G3 |
acceleration of the skeletal maturation; however, after) g, m. i- L" R$ h( g) c! [1 W: h
cessation of treatment, the rate of bone maturation
) V3 ~+ s+ s. G: Adecelerates and gradually returns to normal.8,9. B6 b+ d9 I3 J8 _: `+ @# y
There are conflicting reports and controversy3 d3 V& U' e3 ]5 O
over the effect of early androgen exposure on adult
$ l# ^, G8 q3 P! q' Kpenile length.10,11 Some reports suggest subnormal
/ n: O& F9 V+ l: Q4 Zadult penile length, apparently because of downreg-' l8 N1 t& |( \/ ]0 m4 U5 z
ulation of androgen receptor number.10,12 However,
/ k. d- `% u- s, \# JSutherland et al13 did not find a correlation between
$ [: e8 t) ]$ X! rchildhood testosterone exposure and reduced adult
" i$ M# e! G1 [. k3 Zpenile length in clinical studies.* `: P% u: m1 d: l- q3 x
Nonetheless, we do not believe our patient is
( c: T, W6 M Cgoing to experience any of the untoward effects from, M, n1 r J' x' M) E8 s
testosterone exposure as mentioned earlier because
7 L3 x; q* r e9 {the exposure was not for a prolonged period of time.
2 d+ l5 Q/ _1 u1 D3 @$ `Although the bone age was advanced at the time of
t. ]4 `- v$ D) F# Qdiagnosis, the child had a normal growth velocity at
7 ?2 F0 C9 b4 v1 a: R( zthe follow-up visit. It is hoped that his final adult
! E4 p! }+ a# _4 |height will not be affected.$ p/ `5 _" T% z% [8 T
Although rarely reported, the widespread avail-
% u% J9 |/ |9 B, i1 r: }8 z% Kability of androgen products in our society may
& X9 H: _: R7 z, B, ~/ m4 Zindeed cause more virilization in male or female/ P6 {/ ^: g. x* x
children than one would realize. Exposure to andro-
. W' Q( f4 r( ~, q, K' L; jgen products must be considered and specific ques-) u$ O& J6 j3 K# D% c
tioning about the use of a testosterone product or
. }0 j' L1 a* ?; F+ Ygel should be asked of the family members during* H: a/ j2 \- }6 s# N) S
the evaluation of any children who present with vir-
?- m6 \" N9 B8 N& gilization or peripheral precocious puberty. The diag-% v8 J6 o; {. W" ]3 k& ^
nosis can be established by just a few tests and by
& f9 _) r, C! O9 Q @appropriate history. The inability to obtain such a
( T0 I! J1 _* n4 z: ^history, or failure to ask the specific questions, may
) q2 l& ~: K( X1 F3 cresult in extensive, unnecessary, and expensive
4 M/ N8 R' K d3 ~" ?" w* Sinvestigation. The primary care physician should be
$ T, z. o" ?% u1 [% l$ Z: Saware of this fact, because most of these children
' O% s2 F: @( L3 i. l- S2 t6 Z: ~may initially present in their practice. The Physicians’5 u' K4 l! L$ w3 O
Desk Reference and package insert should also put a6 C( E2 Y% ?9 W: `# |
warning about the virilizing effect on a male or
" T# B N9 y d8 d/ L" i3 N4 z+ Mfemale child who might come in contact with some-7 c+ [- X% Z3 i- c1 B" @7 d
one using any of these products.
5 O9 n4 h2 e. {References1 u4 r. P, c5 b3 k3 d T1 \
1. Styne DM. The testes: disorder of sexual differentiation0 [% y# o" `& ?. v3 W
and puberty in the male. In: Sperling MA, ed. Pediatric4 r1 d4 Q3 y; p) a) X- K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# d3 l! ~8 H9 O4 o2002: 565-628.
0 O7 t w( ~! W; n$ W$ U) t( \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 d( e5 A! ~" f+ J9 C2 d" Z/ ]& Ypuberty in children with tumours of the suprasellar pineal |
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