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Sexual Precocity in a 16-Month-Old
, X* A1 A+ ^ D0 W4 d9 }Boy Induced by Indirect Topical$ [0 u! M4 n; |
Exposure to Testosterone7 \' g. x3 _0 X0 T
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 B) V0 s8 Y! D2 j# {4 D
and Kenneth R. Rettig, MD1# x4 e8 M- Z4 e0 Q. z( W
Clinical Pediatrics' H( T) d9 t# `6 r" J1 M( a
Volume 46 Number 6% l5 K- [; B" `& g7 a" d
July 2007 540-5435 w# p- t4 g: Y+ d) S) w- [4 B
© 2007 Sage Publications1 S& M/ c( j. Y) I% C4 O
10.1177/0009922806296651
7 G$ A* I& v: G, g4 x, M8 Uhttp://clp.sagepub.com
- X& L1 Z- R0 l' G, x/ Lhosted at
) _" e: s6 A Y) U% U/ c' Phttp://online.sagepub.com* s- z) f; b9 f7 }1 v3 K
Precocious puberty in boys, central or peripheral,
5 g2 [+ ^# z& ~! g( `is a significant concern for physicians. Central6 b! V) ?. Y1 Z8 j6 W- }
precocious puberty (CPP), which is mediated8 W$ Q& E! u1 V, x" `) P1 Y$ E/ @# g
through the hypothalamic pituitary gonadal axis, has
" r" f- y s% Za higher incidence of organic central nervous system: s# I, Q# D1 ]# h$ v
lesions in boys.1,2 Virilization in boys, as manifested
4 F D/ H1 X/ E0 O# sby enlargement of the penis, development of pubic
7 p7 a x5 {0 b' k5 l' i7 vhair, and facial acne without enlargement of testi-
) r8 N) i( t; v! H7 h8 Vcles, suggests peripheral or pseudopuberty.1-3 We
. y3 V/ }8 H$ I& Y4 d0 m D2 f, Xreport a 16-month-old boy who presented with the5 y; u: x- l# o A4 x: e
enlargement of the phallus and pubic hair develop-
5 k; |8 B% y2 a2 K! wment without testicular enlargement, which was due
/ k4 A$ ]* g a- @to the unintentional exposure to androgen gel used by
* |1 R& ^- u" M7 b, I- _- \the father. The family initially concealed this infor-
: v4 h, x$ M& q }; xmation, resulting in an extensive work-up for this- W4 E( M& v4 }$ _/ u
child. Given the widespread and easy availability of
/ n! l9 A+ v2 u0 |* z. T7 Ktestosterone gel and cream, we believe this is proba-
6 J8 B2 K/ \8 Q- tbly more common than the rare case report in the( O/ n& U; u+ U0 A$ ^! c
literature.4( V \! u2 c- f/ \5 ~' C, @
Patient Report
$ V& [0 Y% I* s6 G5 R3 z' eA 16-month-old white child was referred to the" A2 c; T: v# l. S* D o
endocrine clinic by his pediatrician with the concern3 ]2 v. r0 L, b) U" ]6 d$ k/ |
of early sexual development. His mother noticed
4 @1 v; R6 H* M) U9 nlight colored pubic hair development when he was+ K( i) u( v2 Y4 G
From the 1Division of Pediatric Endocrinology, 2University of) ]( ^) i8 U2 L
South Alabama Medical Center, Mobile, Alabama.9 d& w2 E( m* \2 @% ~2 Q# }
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ ^5 b' S7 j# }3 M ^
Professor of Pediatrics, University of South Alabama, College of
- l6 x( j) z1 q. \Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) X7 f& }& W* M: A4 f2 z# w
e-mail: [email protected].
/ B1 n( l$ u. K9 T8 w8 qabout 6 to 7 months old, which progressively became& o6 `. Y5 Y0 e( T
darker. She was also concerned about the enlarge-5 u7 L5 N6 q8 X
ment of his penis and frequent erections. The child5 y9 f( M: m2 B8 n* d
was the product of a full-term normal delivery, with) [7 T7 e- l1 i2 M9 o. {
a birth weight of 7 lb 14 oz, and birth length of
. |* v+ I5 i6 V$ e3 _! t20 inches. He was breast-fed throughout the first year& r; I5 E5 V" M" s" Q. b
of life and was still receiving breast milk along with. R% ]# \' u9 X6 o: ^
solid food. He had no hospitalizations or surgery,
0 R+ U; }5 |5 F& x1 Vand his psychosocial and psychomotor development
$ Z! q0 T2 R8 s! O1 R1 }was age appropriate.
; t* D4 L: T2 R4 {' C* j7 qThe family history was remarkable for the father,, m5 X: a/ A7 V7 x
who was diagnosed with hypothyroidism at age 16,
3 y8 p" P% l/ Q$ a: k0 F2 L( J3 Vwhich was treated with thyroxine. The father’s
% v, Y4 F: u2 ^0 M. H" s- zheight was 6 feet, and he went through a somewhat
( y. A K" L" l/ D, h/ k" m6 z) yearly puberty and had stopped growing by age 14.
- n) }1 n' b3 s- WThe father denied taking any other medication. The1 A0 v+ o2 W8 N- p2 d; C8 g
child’s mother was in good health. Her menarche
4 k2 \ b+ S, a$ t3 W" v8 z7 V7 Y$ M' xwas at 11 years of age, and her height was at 5 feet
* N1 |7 f$ B; h7 g. V8 v. R1 M% I3 u5 inches. There was no other family history of pre-
5 P0 m( O x# b4 ^* \cocious sexual development in the first-degree rela-+ Q) b2 O; Q9 A$ _- }: @# U
tives. There were no siblings.
8 y0 x0 f2 O! X+ @9 JPhysical Examination+ q! W3 b' {# ~5 x. S5 r8 V
The physical examination revealed a very active,
( J6 v! J, h8 \6 H4 B Pplayful, and healthy boy. The vital signs documented
( M6 p4 D5 ]: |6 |a blood pressure of 85/50 mm Hg, his length was
1 Y, G) A$ S# g4 Q8 D3 ?90 cm (>97th percentile), and his weight was 14.4 kg
5 [& o6 G- [& T6 q- \(also >97th percentile). The observed yearly growth& g6 C" a q1 M8 [$ i
velocity was 30 cm (12 inches). The examination of' @' J$ Q8 Z0 J U
the neck revealed no thyroid enlargement.
! A, V; R. O$ p1 A0 nThe genitourinary examination was remarkable for
+ }, ~: M+ V8 P" K1 M& i0 h5 oenlargement of the penis, with a stretched length of9 i! M& l) y! s% u4 R
8 cm and a width of 2 cm. The glans penis was very well5 ]/ n v; J1 @& e! j( f
developed. The pubic hair was Tanner II, mostly around
, D8 e/ I6 N+ E" X540. z2 |' U8 ]" {% ^) v* b0 [; F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, S; W C1 a' { l$ n$ f# G& _
the base of the phallus and was dark and curled. The
' Z S6 i Y4 t/ s" g4 h, C2 vtesticular volume was prepubertal at 2 mL each.
9 z9 E0 o: b3 x% A. i( y+ YThe skin was moist and smooth and somewhat
) q3 a7 ?; @* K. W$ x, W5 |oily. No axillary hair was noted. There were no5 D( ~: I5 Y, L0 d
abnormal skin pigmentations or café-au-lait spots.. `6 @- P+ I+ b+ F8 F7 F0 `% @
Neurologic evaluation showed deep tendon reflex 2+$ Z+ O& e$ I7 s s- U: K+ c0 T& j! x
bilateral and symmetrical. There was no suggestion7 R5 r' A# A8 ^0 C& c
of papilledema., e% d- U1 q, \) Q7 n
Laboratory Evaluation- Q# A: }1 R4 X: T% M
The bone age was consistent with 28 months by6 {. m& ?( w3 G: u3 ~
using the standard of Greulich and Pyle at a chrono-
# [" C% S' ]. U8 Wlogic age of 16 months (advanced).5 Chromosomal# Y' j4 z2 D J# ~
karyotype was 46XY. The thyroid function test
4 N0 L+ l8 g2 j$ ?( o6 ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* W# R' l9 o2 C5 }& M5 i* hlating hormone level was 1.3 µIU/mL (both normal).
2 p7 D7 |/ m& |) {- J" UThe concentrations of serum electrolytes, blood! N2 P8 ~# v" \+ a3 e" k
urea nitrogen, creatinine, and calcium all were
2 e, v6 H0 I1 _within normal range for his age. The concentration
( O& P- U1 }7 ~+ A1 y Rof serum 17-hydroxyprogesterone was 16 ng/dL
7 B+ A1 ?4 W% g# U) y. a# v# V(normal, 3 to 90 ng/dL), androstenedione was 209 R0 i2 F& M' h2 _! ?" q4 V* _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' b x4 p" P6 o6 t/ n2 R
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ H( b# T( T1 w- h/ p2 edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
, e" L( _7 e/ Z4 @% [& s3 m, o# U# n; R# t49ng/dL), 11-desoxycortisol (specific compound S)
6 M( E% L, `' M" _2 d0 Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ g6 M; g/ M0 ^' h6 ]& }2 mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ u3 x; m% j$ `* j5 i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 e% n% ^; o& {# D; \# I
and β-human chorionic gonadotropin was less than" U: g3 ]( d( O4 ?8 ~$ @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 o# @% A; |; ^* u2 U6 X8 dstimulating hormone and leuteinizing hormone
' `9 |2 w: J3 s# K4 c4 Xconcentrations were less than 0.05 mIU/mL
. m: m) {$ G5 [% Y/ O! ?' S6 Z(prepubertal).
2 p9 S( O k w) L" p5 j1 _The parents were notified about the laboratory
4 x4 Y6 J+ t. J: _# {" j2 Vresults and were informed that all of the tests were
0 \! m8 c' C% ^$ k0 _, d" pnormal except the testosterone level was high. The
+ a+ x: K) D4 mfollow-up visit was arranged within a few weeks to
Q p, T* H4 m, q F0 E" R0 O! Oobtain testicular and abdominal sonograms; how-
8 f) r* N; _) C# u( lever, the family did not return for 4 months.
1 y/ ^7 K. @( P: rPhysical examination at this time revealed that the+ E5 y2 Y& U( ^: Q1 b+ C, `
child had grown 2.5 cm in 4 months and had gained
+ g# b' r% g: D- g9 k2 kg of weight. Physical examination remained
0 N: A- K5 ]0 m4 [% {unchanged. Surprisingly, the pubic hair almost com-8 ?2 Q" X% G2 s8 @
pletely disappeared except for a few vellous hairs at o- B3 H$ }5 {
the base of the phallus. Testicular volume was still 2: M% @3 Y5 ?, A% K
mL, and the size of the penis remained unchanged.
5 _" L* [8 F9 @) `The mother also said that the boy was no longer hav-
& |5 y4 _% y z- t" _ing frequent erections.
9 {3 F. e& [0 y$ y1 j' S2 u8 }Both parents were again questioned about use of
7 _/ `1 A% T, W( f6 q7 r6 H) P- ] eany ointment/creams that they may have applied to! H/ i2 C, N; n" H
the child’s skin. This time the father admitted the( N8 }, ^0 o- L. x' E+ c: u
Topical Testosterone Exposure / Bhowmick et al 541( ^3 |; v7 M ~
use of testosterone gel twice daily that he was apply-+ H9 R" p6 o. U" W! g
ing over his own shoulders, chest, and back area for: s0 O1 u$ _! \+ U( n- O
a year. The father also revealed he was embarrassed
4 X! }4 A; A- g& Q) Z Sto disclose that he was using a testosterone gel pre-; S0 U. |0 b S" y. e! a- E
scribed by his family physician for decreased libido* U a3 `' i8 Z7 E
secondary to depression.
) p$ h, E! ^3 @/ ?0 nThe child slept in the same bed with parents.: n. t7 G9 z" M/ V' ]
The father would hug the baby and hold him on his% l& I4 O j% W. l
chest for a considerable period of time, causing sig-2 {; t3 z3 n5 p( \4 M5 @9 \
nificant bare skin contact between baby and father.
6 B! q3 r* Y2 HThe father also admitted that after the phone call, h ]1 A; P1 V* z6 U1 x+ G
when he learned the testosterone level in the baby. {, a* F3 d7 S9 y" P# m
was high, he then read the product information
2 @% n3 Z0 K [packet and concluded that it was most likely the rea-" z) }& i" ^% ^' F# a$ K
son for the child’s virilization. At that time, they- a4 b/ Q# W% B0 w& D$ _
decided to put the baby in a separate bed, and the' e5 [3 @3 ]& B- I6 I8 K" C
father was not hugging him with bare skin and had
0 S$ x7 _: p1 O2 w) s* }6 Q$ dbeen using protective clothing. A repeat testosterone
; }& Q5 A' C" P E. } Ptest was ordered, but the family did not go to the- @2 A# p5 H `. n( e
laboratory to obtain the test.% N& N: x N% {
Discussion) h5 }5 r; z9 g' Z3 r5 ]
Precocious puberty in boys is defined as secondary
0 N' |& o3 q7 Bsexual development before 9 years of age.1,4
# c9 p+ j& N0 B$ `) W2 w$ [. WPrecocious puberty is termed as central (true) when& w5 Z/ Q) x! K* x9 v
it is caused by the premature activation of hypo-7 l$ u! }; z, M T
thalamic pituitary gonadal axis. CPP is more com-
" q" L/ a+ ]' x; f3 mmon in girls than in boys.1,3 Most boys with CPP+ B7 D0 }4 _- s7 \3 N
may have a central nervous system lesion that is
3 v* k1 i6 d3 Q2 L8 gresponsible for the early activation of the hypothal-! t. e. C% R3 H7 |: {
amic pituitary gonadal axis.1-3 Thus, greater empha-0 ?8 |# ?, }, A3 T4 d. l
sis has been given to neuroradiologic imaging in
% k; J$ w6 y, I" n( [1 d, Lboys with precocious puberty. In addition to viril-
0 b7 u% p7 [4 A3 x1 o5 y- iization, the clinical hallmark of CPP is the symmet-
* ~8 ]( K* J4 y/ arical testicular growth secondary to stimulation by/ [$ Y* ~3 @# z! m- c$ u5 {, l
gonadotropins.1,3) N' P9 D0 d8 J+ `9 p
Gonadotropin-independent peripheral preco-
$ f, _; x, Q* N" M! pcious puberty in boys also results from inappropriate
+ {& S/ N5 H* X/ ]+ c8 Z& vandrogenic stimulation from either endogenous or1 n* v3 w1 z, W. a! O
exogenous sources, nonpituitary gonadotropin stim-+ C, y ]8 W: W/ k' M
ulation, and rare activating mutations.3 Virilizing
: u/ a$ \7 f4 V: v8 T3 z1 T3 q9 econgenital adrenal hyperplasia producing excessive
* Q( o( o2 B1 `adrenal androgens is a common cause of precocious
/ P P) R4 ]' ^% spuberty in boys.3,46 n$ V: D3 e; J* h2 y& _% \6 V% D& x
The most common form of congenital adrenal
$ _3 ]6 k3 o4 h" t7 [3 whyperplasia is the 21-hydroxylase enzyme deficiency.
6 Z# Z4 D0 k0 p- M; j4 fThe 11-β hydroxylase deficiency may also result in
6 i6 ^ ?. f* Oexcessive adrenal androgen production, and rarely,
/ n2 A* s, A2 P+ j, ^, m! [an adrenal tumor may also cause adrenal androgen
2 T! i* W! c7 Aexcess.1,3
8 G5 i& T) N' J# Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 a1 g q7 L4 @% x5 P6 C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ @" V0 c5 g# K& b) u @
A unique entity of male-limited gonadotropin-- |# J7 b: C B0 P2 v
independent precocious puberty, which is also known, i. o- _. T8 H/ G7 c' W( a
as testotoxicosis, may cause precocious puberty at a
6 K5 P6 ?7 G* Q( _4 Tvery young age. The physical findings in these boys
( Z& C3 l8 F, h8 B7 zwith this disorder are full pubertal development,
& g% [' y# {0 i" `including bilateral testicular growth, similar to boys+ E& o0 y! x7 a7 ~0 ]* L. ^& }
with CPP. The gonadotropin levels in this disorder
. e! a- ~( H: d- F- sare suppressed to prepubertal levels and do not show
2 V% n* W/ e: T$ ^pubertal response of gonadotropin after gonadotropin-
2 h& Q/ P9 c+ z2 ureleasing hormone stimulation. This is a sex-linked
# C {: F. B* l+ F- Vautosomal dominant disorder that affects only
8 g' i4 G! x" U; x+ jmales; therefore, other male members of the family
; b+ e7 n' c2 r: B" l V( L- ymay have similar precocious puberty.3
* A2 M, }% h& _- {# B( TIn our patient, physical examination was incon-
/ q: {% y8 o; h, h) Asistent with true precocious puberty since his testi-* p/ I) u$ T" [2 D1 ~1 t5 o
cles were prepubertal in size. However, testotoxicosis ^0 [1 p$ O- y$ t
was in the differential diagnosis because his father
9 H" ]1 |' A8 ~, gstarted puberty somewhat early, and occasionally,7 t* E( q% E j( e. F+ B6 H& J8 q
testicular enlargement is not that evident in the. u4 [) _- w" {' ^8 E( ^" ^$ l
beginning of this process.1 In the absence of a neg-
3 M% v \( E5 X! ?- f& O9 R' p" cative initial history of androgen exposure, our, ]. H% k$ J# J4 t- e- M
biggest concern was virilizing adrenal hyperplasia,
$ w8 E1 u# x5 z/ Peither 21-hydroxylase deficiency or 11-β hydroxylase
x" Z' Y$ z1 g2 ]deficiency. Those diagnoses were excluded by find-8 O2 Z( c& A8 q- m B
ing the normal level of adrenal steroids.
2 ]+ P4 @ N% k; d1 o0 XThe diagnosis of exogenous androgens was strongly
# W5 d) G( [ v0 M2 d$ ysuspected in a follow-up visit after 4 months because
* k9 T. |( H' r, H- j) G" vthe physical examination revealed the complete disap-
0 e& @' ?( t( ]: kpearance of pubic hair, normal growth velocity, and9 U- u! d6 D# v! d: f+ _
decreased erections. The father admitted using a testos-' z8 n2 T& d5 n( h
terone gel, which he concealed at first visit. He was! I' L, q, r7 T2 f
using it rather frequently, twice a day. The Physicians’
! e, {3 _8 W3 i9 q$ N! U1 ]Desk Reference, or package insert of this product, gel or2 b5 p0 e4 X* Z( t& Z: z
cream, cautions about dermal testosterone transfer to0 b- k- A& E: D) G' D8 {8 ]4 [: N& G
unprotected females through direct skin exposure.
; E6 R% A+ |, S7 XSerum testosterone level was found to be 2 times the) K! w5 t8 s0 b% H' u2 g" t
baseline value in those females who were exposed to6 B: | S* ?+ J" f# [9 C# B* Y
even 15 minutes of direct skin contact with their male
7 c' Z3 ?* n: h- C* Dpartners.6 However, when a shirt covered the applica-+ S n: P0 N) c4 P( P
tion site, this testosterone transfer was prevented.# Y4 l( Y" t7 V
Our patient’s testosterone level was 60 ng/mL,
; J! D) Y. C9 p, Vwhich was clearly high. Some studies suggest that
9 E9 R" j/ \; i7 Z- ]dermal conversion of testosterone to dihydrotestos-9 t e4 t1 f$ K$ ?8 m
terone, which is a more potent metabolite, is more, D( s" k% _$ \; a4 p* e+ ?5 k
active in young children exposed to testosterone# q4 e4 h; ~# H# [# Z; v
exogenously7; however, we did not measure a dihy-
0 J! Y0 K/ y& l, W" sdrotestosterone level in our patient. In addition to S( H# c" G: R! G, Y. f& \
virilization, exposure to exogenous testosterone in7 z, B4 c; J$ T6 ~
children results in an increase in growth velocity and" o$ D* C6 X% R3 l: c
advanced bone age, as seen in our patient.
: e9 e+ r+ H, R$ jThe long-term effect of androgen exposure during; T9 w: j+ U& S# ]& e, J+ b$ A
early childhood on pubertal development and final+ y2 m& R/ S+ l+ ]
adult height are not fully known and always remain+ n6 g, Q) ^. \# q5 G
a concern. Children treated with short-term testos-, R8 @: ]7 Z% }/ G q& {, A7 i Z
terone injection or topical androgen may exhibit some
/ y3 P: p2 o* X( \" Kacceleration of the skeletal maturation; however, after L# \- `/ z8 A7 D; q
cessation of treatment, the rate of bone maturation1 n0 P; ]* H( v9 V& R+ u) _
decelerates and gradually returns to normal.8,9& g) e, O4 N/ U
There are conflicting reports and controversy: ~4 G: ^9 w# P/ T( ?& d
over the effect of early androgen exposure on adult* P, ?) K; d- {( t5 u1 g) \. y
penile length.10,11 Some reports suggest subnormal
% L! V& n- \: j Y- e8 }) `adult penile length, apparently because of downreg-: y2 `( e, m; F5 K
ulation of androgen receptor number.10,12 However,, k I! b+ T+ Q$ P
Sutherland et al13 did not find a correlation between
& {% G! T, N8 t( Jchildhood testosterone exposure and reduced adult* N1 H7 M3 Q; [" P# F
penile length in clinical studies.# u H7 N+ t6 H2 |# X
Nonetheless, we do not believe our patient is* W( `8 k; {! [& s5 v6 F3 K' p* |
going to experience any of the untoward effects from
$ a1 a2 n0 e4 rtestosterone exposure as mentioned earlier because7 h2 Z# n5 t% Q8 n
the exposure was not for a prolonged period of time.
% H$ t, Q/ i8 t# r' Y. oAlthough the bone age was advanced at the time of
- z) M, o. G" [+ w# cdiagnosis, the child had a normal growth velocity at! X3 W+ U |& N
the follow-up visit. It is hoped that his final adult9 u- f4 W0 P9 {7 y3 U& e) O' v
height will not be affected.4 u2 O5 r$ U/ s* W" @4 a4 U
Although rarely reported, the widespread avail-& O0 I* z4 w$ d1 c0 Y/ m
ability of androgen products in our society may
5 c# ^0 R( ]! Sindeed cause more virilization in male or female; _, D! r% G" e; ]) ?, m3 x4 g
children than one would realize. Exposure to andro-
# O7 W* @' Q! Q. x8 agen products must be considered and specific ques-
( Y7 F) o# [# d( C' |tioning about the use of a testosterone product or
$ x0 x1 N+ q, x; {! a7 D2 ogel should be asked of the family members during, ` r7 w; Z( u! Q
the evaluation of any children who present with vir-
2 n! F% D" A; Cilization or peripheral precocious puberty. The diag-
8 g$ Z% s ^* q8 S& ?. q* qnosis can be established by just a few tests and by, J1 U# P$ y$ a q4 d5 N, L2 q: S
appropriate history. The inability to obtain such a; [9 ~$ I) N/ Y$ T5 V
history, or failure to ask the specific questions, may
" ]1 C0 t+ Q, `! Y$ Zresult in extensive, unnecessary, and expensive% o$ A/ e: h* a x! i
investigation. The primary care physician should be2 z% Y1 ?9 S( z- J; H0 l
aware of this fact, because most of these children
: |2 @% w3 M4 I& M5 _/ ?may initially present in their practice. The Physicians’
; U/ D$ C7 M3 \. Q% eDesk Reference and package insert should also put a* M$ I4 B4 y2 I" R
warning about the virilizing effect on a male or1 n& H9 @0 W3 g& d9 a& d" \" V" M
female child who might come in contact with some-( f7 ~' V" r2 _2 J
one using any of these products.
- m* \4 u; R- S! GReferences4 ?, p4 q( u/ T9 o8 q
1. Styne DM. The testes: disorder of sexual differentiation. i/ H, N' Z' O1 x
and puberty in the male. In: Sperling MA, ed. Pediatric
# {$ ^- A2 y- f: K9 _ IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ c6 @( h8 C1 C& L( `4 Y# o
2002: 565-628.
2 O/ U5 G8 \6 O" `4 v) i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 t: p+ A; Q/ I2 u% A* k
puberty in children with tumours of the suprasellar pineal |
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