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Sexual Precocity in a 16-Month-Old
" u$ R# {' i: D0 K5 ^0 qBoy Induced by Indirect Topical
. a. j9 `" C" L0 X* N/ L( zExposure to Testosterone
# G6 s# _) f: |4 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) L( _& I6 H# B9 ^+ j" M6 `
and Kenneth R. Rettig, MD17 I+ j3 i5 c6 ^: Y# l, Y" w3 e
Clinical Pediatrics( y" X2 C$ l# c" ~1 u- D3 w1 o
Volume 46 Number 6* N8 y7 A5 `; _9 I& H
July 2007 540-543 l+ Q% L7 ]9 s( s$ [( ]5 `- K( I% g, ]
© 2007 Sage Publications1 J3 e( z3 H4 K
10.1177/00099228062966518 A. L* p+ x" ?. Z! O
http://clp.sagepub.com
& w% U) p9 s6 V( N2 dhosted at# i8 i* V; L% ?1 H" u m* w5 ]9 ~4 Y
http://online.sagepub.com4 u2 |" {) y# z+ p4 h' U
Precocious puberty in boys, central or peripheral,6 k, N' F& D+ Z7 ~
is a significant concern for physicians. Central
: g9 k2 A# m* r2 \( Y R5 p9 C6 Hprecocious puberty (CPP), which is mediated7 p& n6 x- p! S: b% p/ _9 a2 r
through the hypothalamic pituitary gonadal axis, has+ W' H$ |; F8 ]5 R6 h
a higher incidence of organic central nervous system
" c6 G8 m+ x0 d5 @: q4 [/ P4 blesions in boys.1,2 Virilization in boys, as manifested
6 v7 W# S3 W8 B: ~4 Y. q2 p% ]by enlargement of the penis, development of pubic* @7 e5 |; a6 u
hair, and facial acne without enlargement of testi-' i* E* V- E' T1 |( r% ]
cles, suggests peripheral or pseudopuberty.1-3 We3 H4 H8 Q5 h( K
report a 16-month-old boy who presented with the. C- s! q% o) g g$ R. A7 n
enlargement of the phallus and pubic hair develop-6 f6 H8 j6 J3 |* r- D. r9 F: p" M( y
ment without testicular enlargement, which was due
- A0 ?# Z% d( l! @1 Q4 lto the unintentional exposure to androgen gel used by
' h/ d' E$ p' {6 n: g7 H. Uthe father. The family initially concealed this infor-& L: R7 L$ f. j6 |7 _
mation, resulting in an extensive work-up for this
! w1 d8 D+ Z; Y9 `# Q i' t+ rchild. Given the widespread and easy availability of
% q, _+ g0 Y0 U+ n4 h8 b( {. Gtestosterone gel and cream, we believe this is proba-1 [* o) p" q! r; ]# W
bly more common than the rare case report in the l$ D6 ]/ P# D5 g8 @
literature.4
4 q( ~4 s, R' N+ ?% fPatient Report2 r0 C0 ?( g3 o6 f
A 16-month-old white child was referred to the% x" f. t, S% p4 @
endocrine clinic by his pediatrician with the concern8 w8 i% Y3 E- y6 t* R& H/ i+ C( @
of early sexual development. His mother noticed
! v& ~$ i2 N/ a5 b$ _* L4 mlight colored pubic hair development when he was; \0 h$ c# u- l$ x& [% W
From the 1Division of Pediatric Endocrinology, 2University of
' W* m# m& M2 d$ NSouth Alabama Medical Center, Mobile, Alabama.
$ O& {1 F m8 Z- w s! K5 H0 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,: q" b! c1 Z0 A. I0 e6 f7 [
Professor of Pediatrics, University of South Alabama, College of. a: o6 X1 w7 m6 s" H3 m3 z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) a e6 R# j9 m. d' K- U5 S+ j4 b2 J0 G5 \- e
e-mail: [email protected].
3 k8 c/ J! X. X9 d7 S1 `4 mabout 6 to 7 months old, which progressively became+ C# i7 m H) d" j5 F" E
darker. She was also concerned about the enlarge-
, _+ S5 L8 D" k# a6 L. Vment of his penis and frequent erections. The child+ f' H' o C6 E
was the product of a full-term normal delivery, with. D+ x' ~* {) u }+ @
a birth weight of 7 lb 14 oz, and birth length of
: f# I8 m4 t8 I& G3 M$ l) ~20 inches. He was breast-fed throughout the first year9 k; `0 j0 d0 ]
of life and was still receiving breast milk along with/ ~# Q1 S: q: n8 [
solid food. He had no hospitalizations or surgery,
! W/ q8 U* `8 l: ^and his psychosocial and psychomotor development
( M3 S" x- o8 R: ^was age appropriate.
8 h4 u7 e' h& q1 o) ^3 }The family history was remarkable for the father,
$ F9 x2 s" w6 Ewho was diagnosed with hypothyroidism at age 16,1 _7 n- a; w1 O5 i( G( |
which was treated with thyroxine. The father’s' \, p- d- t/ G- e; n0 j$ K
height was 6 feet, and he went through a somewhat
: }9 P: Y6 w6 ]1 D& {- u3 V$ nearly puberty and had stopped growing by age 14.3 o+ D0 ~, ~3 {# N* L! [
The father denied taking any other medication. The$ G/ a$ u& K f- a! u
child’s mother was in good health. Her menarche; Y/ ~5 k& b' Q3 t. L$ O
was at 11 years of age, and her height was at 5 feet
* L4 e; {, ^7 V b3 N# G' f, G; N* f5 inches. There was no other family history of pre-8 A2 l/ u) f2 I+ e( o
cocious sexual development in the first-degree rela-& N; o6 D( v6 I& N
tives. There were no siblings.4 Z" Q2 o" ~, j B
Physical Examination1 W+ Y. R: r7 r# @
The physical examination revealed a very active,# k% o- w+ D. U ~
playful, and healthy boy. The vital signs documented
: K# r; W0 G7 h$ Sa blood pressure of 85/50 mm Hg, his length was
0 |5 q7 o, H: \5 x90 cm (>97th percentile), and his weight was 14.4 kg
6 [* ]/ J- I+ L# i( s4 c8 x: `(also >97th percentile). The observed yearly growth K; g M4 U2 J
velocity was 30 cm (12 inches). The examination of2 ` T! g" _ l! {
the neck revealed no thyroid enlargement.+ H) K! {+ |! _1 _" B9 |+ ?% O, c
The genitourinary examination was remarkable for8 Z3 m8 `( q' J0 W& ]; D; _
enlargement of the penis, with a stretched length of
' X) V" c6 {" y5 x8 cm and a width of 2 cm. The glans penis was very well
% U/ ^; n6 {& ]: G( K- Hdeveloped. The pubic hair was Tanner II, mostly around
& J) v0 ^) A, D7 O6 v1 F0 Q# ?5404 b3 k& P1 C8 w: g* b' s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. d; P" `/ F; O5 Ethe base of the phallus and was dark and curled. The _: S, G, Q6 x2 h
testicular volume was prepubertal at 2 mL each.
2 S1 _; U( w* o/ S9 a% O, jThe skin was moist and smooth and somewhat9 Y7 I, L9 Z9 @
oily. No axillary hair was noted. There were no
- K# `+ A% m1 n/ o& v4 Habnormal skin pigmentations or café-au-lait spots.
$ }# u; P2 [& UNeurologic evaluation showed deep tendon reflex 2+
( T7 C& _2 f$ p, G! I! Mbilateral and symmetrical. There was no suggestion' u3 {4 w: D7 p' Z5 B8 ]8 l% E! L
of papilledema.
6 |& s# P3 H6 G$ A8 G" w# E- L( GLaboratory Evaluation! I+ H7 }: E1 X" d8 }8 a( f
The bone age was consistent with 28 months by
: {9 O2 |2 ~: z) ^using the standard of Greulich and Pyle at a chrono-
' ~9 V# X3 c r6 d2 u m+ x6 r: _logic age of 16 months (advanced).5 Chromosomal( L% ^, @& g; [) ]7 H! ^
karyotype was 46XY. The thyroid function test
" ^2 D: o' \, W7 _! g5 ~9 ?showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# |) P( O3 V1 p; I% Rlating hormone level was 1.3 µIU/mL (both normal).0 R j$ y% Y+ G; l( U
The concentrations of serum electrolytes, blood
3 f) l# ^6 Y [, _urea nitrogen, creatinine, and calcium all were0 b3 z2 N3 S, A a
within normal range for his age. The concentration9 k, T" U8 @/ H
of serum 17-hydroxyprogesterone was 16 ng/dL! |" L& x( m3 S6 o
(normal, 3 to 90 ng/dL), androstenedione was 205 F/ l) @" Z6 M/ F9 n Y o o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, |) t* \" n0 d6 y2 a6 u/ U# mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
* B! G8 o) v: x6 ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to v- s! y+ ~( N
49ng/dL), 11-desoxycortisol (specific compound S)
" a8 a! g2 P- n* w% u1 S" G0 [: fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: g) ?9 Q) q# `7 Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: B6 |% J$ G' m: `5 U9 D) }testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," n6 B% T0 ~4 q u* C
and β-human chorionic gonadotropin was less than0 d' v! u9 W" i
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; w* X: c# d5 G' zstimulating hormone and leuteinizing hormone
# U, e& a* v; X- f# y" I \& sconcentrations were less than 0.05 mIU/mL
8 _1 z$ c( o" L) X- _% r(prepubertal).* p& O! P- S+ p6 X
The parents were notified about the laboratory. s, ]; n' I/ @# j, `/ U
results and were informed that all of the tests were
! ?, ?5 C3 Z6 ~) ?& j& b: }6 mnormal except the testosterone level was high. The
# O( S# U- \9 X% }4 i8 h' T: K' Ffollow-up visit was arranged within a few weeks to8 Z& e) y: p3 I3 ?4 q
obtain testicular and abdominal sonograms; how-6 a! ~1 k) `: ?3 m
ever, the family did not return for 4 months.9 S" o0 u+ k; k/ y/ V0 @
Physical examination at this time revealed that the. x$ H5 z& w0 d2 k& ^- g" e
child had grown 2.5 cm in 4 months and had gained
+ k7 y1 y0 O0 [& @) W: x0 L2 kg of weight. Physical examination remained
. F. U; `0 z( c) J. Iunchanged. Surprisingly, the pubic hair almost com-. P/ f! E. d: K3 R9 u3 P6 d2 \) t
pletely disappeared except for a few vellous hairs at9 u& X9 ^5 u/ _* r# N
the base of the phallus. Testicular volume was still 2
- v7 V5 H2 s& A$ f6 T# K$ UmL, and the size of the penis remained unchanged.7 Y- n& a- L: s( Y' i
The mother also said that the boy was no longer hav-4 U, B& m9 T) i' Z9 u( Z9 |
ing frequent erections.
* w( ^# v1 y: m/ a3 @Both parents were again questioned about use of# H# `! b! g9 a% }6 S
any ointment/creams that they may have applied to7 W- R0 k/ l; Z& [6 ^
the child’s skin. This time the father admitted the
J9 U$ Q- L X OTopical Testosterone Exposure / Bhowmick et al 541+ O @ [% V+ p2 A) L
use of testosterone gel twice daily that he was apply-
. b. s8 J* y1 q; jing over his own shoulders, chest, and back area for( T/ [, ?5 S( Z, b7 g; e0 y1 |' @
a year. The father also revealed he was embarrassed
) D6 Y4 }% N. Pto disclose that he was using a testosterone gel pre-
; A% ^3 S! X- E5 M1 a( bscribed by his family physician for decreased libido' m8 d) R( K& @( d4 w* I
secondary to depression.
6 J% V( z g1 s Y1 tThe child slept in the same bed with parents.7 V u. e2 T: b) C- J( {7 n% [8 c
The father would hug the baby and hold him on his
3 {7 S. g W7 ]# Y5 ychest for a considerable period of time, causing sig-
/ P' T: T, k1 T# o( C$ R" pnificant bare skin contact between baby and father.5 _7 i1 O, o" n
The father also admitted that after the phone call,
9 g" `# T7 ?: Z5 Wwhen he learned the testosterone level in the baby) q) i8 Z, `+ e4 P2 w- x
was high, he then read the product information5 J q. m/ M* i3 a
packet and concluded that it was most likely the rea-0 t5 V$ q* g9 w8 _( Z
son for the child’s virilization. At that time, they' C( b0 d9 ]/ c ^8 r$ C# R$ H0 m
decided to put the baby in a separate bed, and the
) s: H8 m/ o5 X/ C; w1 `7 Vfather was not hugging him with bare skin and had
* c$ ~& l$ y& N1 }" Z/ o7 g1 f$ ybeen using protective clothing. A repeat testosterone% q5 y, `* A4 R3 I, Y
test was ordered, but the family did not go to the
/ e' K' ~3 P- nlaboratory to obtain the test." O. c. P3 }+ T
Discussion& g' C& l, U8 e) r6 U
Precocious puberty in boys is defined as secondary
& ^5 ~! |7 G, G2 dsexual development before 9 years of age.1,40 q0 |) a$ v) Q; N9 x
Precocious puberty is termed as central (true) when" ` W8 q! i3 Q4 w R$ ]
it is caused by the premature activation of hypo-
- C# x( J; h: Y0 ~: ]thalamic pituitary gonadal axis. CPP is more com-# f" ~/ m* f; |" ]0 b2 I
mon in girls than in boys.1,3 Most boys with CPP7 Y* }; O0 @- K( b9 S2 j
may have a central nervous system lesion that is
! A! Z+ d" o4 m7 Gresponsible for the early activation of the hypothal-; ?; m7 H: m7 K9 b( E1 |+ F
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ M, t! [9 A1 S: Csis has been given to neuroradiologic imaging in0 v! J0 l" |2 K" y; q N! M
boys with precocious puberty. In addition to viril-
1 P! L) @. v: o! J0 B- \4 E. oization, the clinical hallmark of CPP is the symmet-
! Q5 M( V" _" a% F- A: Frical testicular growth secondary to stimulation by1 N& ~2 _" V; ^) r( [8 t
gonadotropins.1,3
( {' w+ [1 T2 l; I; e# @3 U0 sGonadotropin-independent peripheral preco-
+ h% m8 P5 i8 C& A& S, u8 @cious puberty in boys also results from inappropriate' J3 @, I9 g- I( Q1 e8 r
androgenic stimulation from either endogenous or4 F+ O/ r7 g1 h
exogenous sources, nonpituitary gonadotropin stim-
& F B: S4 N dulation, and rare activating mutations.3 Virilizing _. a8 s. q7 P1 B
congenital adrenal hyperplasia producing excessive
0 {$ G% U. f3 W! w0 Iadrenal androgens is a common cause of precocious$ F! y y4 ?# g! s0 Y% V
puberty in boys.3,4- L7 c# |' \" {( A3 M0 u
The most common form of congenital adrenal. s; y2 D# [* d4 W" l% e
hyperplasia is the 21-hydroxylase enzyme deficiency.6 J5 ]" t t, Q' j- T/ P
The 11-β hydroxylase deficiency may also result in/ a. X2 t* W5 B2 _+ N9 ^1 ^# e0 y4 @
excessive adrenal androgen production, and rarely,, p8 p) ^7 w2 L1 I5 x' O
an adrenal tumor may also cause adrenal androgen
. J5 F2 `9 O. _0 ?- v1 k# Uexcess.1,3) {- }. e0 n& O3 e7 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% j" X7 z# x; g4 h' ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 o! \8 U8 e: o* \& `: [A unique entity of male-limited gonadotropin-
# `! B5 e5 ~" Dindependent precocious puberty, which is also known0 C. [5 L9 O% c8 D$ T+ e* m
as testotoxicosis, may cause precocious puberty at a/ }: @5 [: N4 Q7 F- {
very young age. The physical findings in these boys7 Y: u2 w* y$ c4 g8 R) ?
with this disorder are full pubertal development,: @$ M2 d; Z3 {: O ? f. ]0 S
including bilateral testicular growth, similar to boys/ A0 Y& n; [7 A! T- q. U
with CPP. The gonadotropin levels in this disorder% R' \, o# @8 [6 l$ [7 l
are suppressed to prepubertal levels and do not show% Q. W, Z( s! G9 ^ p. b$ ~/ t7 a
pubertal response of gonadotropin after gonadotropin-. Z3 Z6 H; [& B! ^, @$ j: |0 F7 F
releasing hormone stimulation. This is a sex-linked
- [, W6 R9 K0 H- o$ N) d+ hautosomal dominant disorder that affects only
4 Z9 t; o' s7 N$ V1 t) [males; therefore, other male members of the family
& T, L& U+ p7 A2 s& n$ hmay have similar precocious puberty.3" J" M/ |) l4 A2 U
In our patient, physical examination was incon-" f9 [: N5 N5 b* B1 q2 R
sistent with true precocious puberty since his testi-
: {1 F* B7 t, @ L5 @cles were prepubertal in size. However, testotoxicosis+ l* X9 B" \3 A/ o
was in the differential diagnosis because his father
, X- H7 z7 G* }( b- N/ Lstarted puberty somewhat early, and occasionally,
! [3 X/ r `% _testicular enlargement is not that evident in the
7 l! ]' G5 X" g8 a* x9 H* }, P( Pbeginning of this process.1 In the absence of a neg-% s4 _/ j1 W8 ]! z/ e) P+ V1 q
ative initial history of androgen exposure, our
; _% M) Q& ?* _5 X8 gbiggest concern was virilizing adrenal hyperplasia,, S0 W* I: `4 p# |' n
either 21-hydroxylase deficiency or 11-β hydroxylase+ a3 y2 O+ c7 u" w' g4 p$ w4 W
deficiency. Those diagnoses were excluded by find-! L5 o) F3 N3 h
ing the normal level of adrenal steroids.
# w- B2 q6 U: VThe diagnosis of exogenous androgens was strongly
& G% J4 a: B/ r- k$ X. O5 ^: v& asuspected in a follow-up visit after 4 months because
# k. K. |& @+ Tthe physical examination revealed the complete disap-
; C, y! h' f. G g1 Z, ppearance of pubic hair, normal growth velocity, and; u4 B6 E- }: K- N! |5 d
decreased erections. The father admitted using a testos-, T1 B- }4 j! d" u+ w- }2 P
terone gel, which he concealed at first visit. He was3 P+ q, {' q3 Q; t* I; R
using it rather frequently, twice a day. The Physicians’ D; l/ H' D, |
Desk Reference, or package insert of this product, gel or
; p6 x2 @/ U1 l- d6 V4 Y5 Q z" Ucream, cautions about dermal testosterone transfer to
1 F2 l0 d2 D, j/ ~unprotected females through direct skin exposure.- s9 p. x: R' L; q1 B! b
Serum testosterone level was found to be 2 times the- x( \+ [" N6 {- n* c
baseline value in those females who were exposed to
4 s" B/ W6 o3 Meven 15 minutes of direct skin contact with their male6 S/ J. V/ ]7 V8 U w+ B3 f: Q
partners.6 However, when a shirt covered the applica-
$ x. J# a7 c- S7 Ction site, this testosterone transfer was prevented.+ J4 S3 C3 f' [/ ]1 D
Our patient’s testosterone level was 60 ng/mL,: \! w+ s$ T0 b5 b. k9 b4 @& w
which was clearly high. Some studies suggest that
. B1 z3 g9 p& A' ^: Ydermal conversion of testosterone to dihydrotestos-+ i! a; F5 K) g7 W' S3 y
terone, which is a more potent metabolite, is more
: E7 B$ Q: c- R/ yactive in young children exposed to testosterone
; Z/ d$ `( X3 E6 P+ z6 h+ Vexogenously7; however, we did not measure a dihy-
* b! \2 S8 _1 m1 {! @, c8 v$ adrotestosterone level in our patient. In addition to
3 C& o1 G8 l# N2 }' h/ t3 {virilization, exposure to exogenous testosterone in0 u- l) w) H; ?1 h
children results in an increase in growth velocity and
9 j% T8 e* o" j3 `) Dadvanced bone age, as seen in our patient.% ^: }) {+ i( K+ |; I- X! J
The long-term effect of androgen exposure during
$ N I6 {. ~5 W9 \/ n4 searly childhood on pubertal development and final' v1 Y; y) f8 h4 F$ z% j; f
adult height are not fully known and always remain
! R/ O( V5 a6 M& f* K8 {6 ^a concern. Children treated with short-term testos-
0 C T4 P. r% |terone injection or topical androgen may exhibit some
1 _# [ h: D( a% M; facceleration of the skeletal maturation; however, after) A. Y% x; \' {2 b0 X
cessation of treatment, the rate of bone maturation
: W: k- ^1 D+ ]# \0 tdecelerates and gradually returns to normal.8,9
( g0 M) G- s( @- nThere are conflicting reports and controversy9 z$ F. {! A, T4 W' ~% @8 ^2 u8 L8 q
over the effect of early androgen exposure on adult/ ~. b; _( Q0 y7 m4 a' Z+ `
penile length.10,11 Some reports suggest subnormal
( @7 n8 m5 z9 v7 }% n+ Z* Nadult penile length, apparently because of downreg-2 z3 e3 D% |7 P, Z% {" ~# r
ulation of androgen receptor number.10,12 However,+ I8 F- H9 W4 ~0 S: q _" @3 t
Sutherland et al13 did not find a correlation between! b8 l% F! q( M) y4 |/ s
childhood testosterone exposure and reduced adult
. `1 w$ S! W7 {" n% q& T' [- Upenile length in clinical studies.
5 A% v' ?4 c5 P; iNonetheless, we do not believe our patient is) b9 p S4 A, D) ? i
going to experience any of the untoward effects from% y2 Z* r. @$ Z4 ~% J
testosterone exposure as mentioned earlier because
) F0 R) B. Y( m, G0 ]" Q) xthe exposure was not for a prolonged period of time.
6 L! j4 W. f3 }0 [# QAlthough the bone age was advanced at the time of0 g7 a: L l0 d! K& E
diagnosis, the child had a normal growth velocity at
% S7 O4 Q6 k$ L' Bthe follow-up visit. It is hoped that his final adult
& T4 K$ }0 l' | dheight will not be affected.
& ]* f1 x, K9 U; `: J7 ^& iAlthough rarely reported, the widespread avail-& V7 A! }, t0 \8 V
ability of androgen products in our society may
& w0 `0 r6 q$ t% t* N& I/ F9 o2 lindeed cause more virilization in male or female" M b# Q% z3 Q
children than one would realize. Exposure to andro-
" Q: t1 }& `# R1 ` ]' o1 P6 ngen products must be considered and specific ques-
+ ` d: x! `; l" [, P4 N9 |tioning about the use of a testosterone product or
, T$ y+ v, C) Hgel should be asked of the family members during9 j m& a* t" L1 s0 E* A: f
the evaluation of any children who present with vir-
) s: K3 O; D J' p; j3 z7 Pilization or peripheral precocious puberty. The diag-. L: \5 W+ M4 I5 [/ [' [' J! w
nosis can be established by just a few tests and by
' x n: E' b$ p1 j+ v bappropriate history. The inability to obtain such a7 C: `7 Z5 }1 B
history, or failure to ask the specific questions, may
6 A$ q* ?5 e x2 {. {result in extensive, unnecessary, and expensive
2 C: X& N9 q# O% q Y- }6 E) Hinvestigation. The primary care physician should be
1 f9 S* Q* I' e0 daware of this fact, because most of these children
2 C2 h. M3 s1 |" a/ vmay initially present in their practice. The Physicians’; M0 `2 O5 _! S `
Desk Reference and package insert should also put a0 r, p5 U1 q1 T2 [
warning about the virilizing effect on a male or
7 N$ }( l: U# m$ {female child who might come in contact with some-
0 d2 J- F1 R; i, d% [7 Wone using any of these products.: K) ]& [6 M9 d8 y2 I9 a
References. l7 H9 }/ Y1 ?# B7 [7 d
1. Styne DM. The testes: disorder of sexual differentiation8 [" M& x$ [% a+ J Q9 d
and puberty in the male. In: Sperling MA, ed. Pediatric
: Z5 z4 [, ]% S; R* VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 A3 ~$ f% @! ]& N0 H0 `0 U) Q# Z2002: 565-628.$ |) M w- _, l/ Y7 \1 }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious E" l. y7 h' E" Y
puberty in children with tumours of the suprasellar pineal |
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