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Sexual Precocity in a 16-Month-Old
5 [/ j. R/ ^1 k! z) m" |Boy Induced by Indirect Topical! }5 Q# Q3 Y, r3 D
Exposure to Testosterone
, w) m+ P% P4 E! O6 ?, s! T2 `, lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 [- u, M# \3 O# L8 X7 `
and Kenneth R. Rettig, MD1
( A8 U; b+ y! K% {, i% aClinical Pediatrics
/ t4 `5 ~+ t, w) n8 T) vVolume 46 Number 6
$ L) V: }* c9 l+ _$ r6 ~July 2007 540-543
* B/ \: M/ W- M" @& e+ g/ r; D© 2007 Sage Publications/ c- y4 k4 U2 S
10.1177/00099228062966515 @* l5 n. W: g$ _8 w
http://clp.sagepub.com% v! C0 Z# F$ I. u$ D4 L- q5 Y
hosted at k, r0 a* ?. \5 b8 g! s4 d
http://online.sagepub.com' |# k1 A6 I" W' n% A" k- F
Precocious puberty in boys, central or peripheral,9 f2 `4 h S. p V+ z
is a significant concern for physicians. Central
/ |8 ? B; ^3 k# \5 @3 B6 o& b: A4 Mprecocious puberty (CPP), which is mediated
0 K3 t# h" G! V* I. h9 Ethrough the hypothalamic pituitary gonadal axis, has
' y# y/ w: }) @: qa higher incidence of organic central nervous system: m3 u! s* n6 p- j
lesions in boys.1,2 Virilization in boys, as manifested
, J* F; }2 I+ J- C# u3 Nby enlargement of the penis, development of pubic6 y' F/ g1 G" V+ J
hair, and facial acne without enlargement of testi-
9 l2 \+ v0 b0 I( Wcles, suggests peripheral or pseudopuberty.1-3 We
0 u; C- @+ ?, zreport a 16-month-old boy who presented with the5 ?, G- y7 |. h7 [ N+ N
enlargement of the phallus and pubic hair develop-; T6 R: A" t, `- A; x- z! O. j
ment without testicular enlargement, which was due5 b1 L4 }, P( E' ?# B
to the unintentional exposure to androgen gel used by
[2 t5 s% e, F# rthe father. The family initially concealed this infor-! O9 i! l6 V) Q6 E. K( V
mation, resulting in an extensive work-up for this" V0 Q0 H$ z; q4 ~/ o
child. Given the widespread and easy availability of
$ Q( p; B7 N( a$ c3 ]5 ?testosterone gel and cream, we believe this is proba-2 L @# M5 Y/ p3 x5 B; [
bly more common than the rare case report in the9 g8 X+ u: |2 w% r# z7 D, h
literature.4
# O$ F( W6 T" d8 nPatient Report
& N: s; z* I: a( ?7 e+ pA 16-month-old white child was referred to the
9 B3 _) | f# Aendocrine clinic by his pediatrician with the concern3 r' N2 s5 g! ^3 u* N% y9 w3 e
of early sexual development. His mother noticed
* B* B8 O, I6 Olight colored pubic hair development when he was/ @% a; a" I' |& |
From the 1Division of Pediatric Endocrinology, 2University of
: \+ r" w9 U" ]6 \. o7 f& n/ gSouth Alabama Medical Center, Mobile, Alabama.
0 @! r# @2 f" G! C, ]; j( TAddress correspondence to: Samar K. Bhowmick, MD, FACE,
8 `5 z/ n# `( f1 ~$ W/ M! f+ L! @) {Professor of Pediatrics, University of South Alabama, College of
# c F& b9 l4 m1 D! BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! S( T6 {! t f; Q
e-mail: [email protected].6 ~& W7 @5 g9 `% c
about 6 to 7 months old, which progressively became
9 ^8 I! N) ]" x* Hdarker. She was also concerned about the enlarge-$ s0 Z2 k: e) | l
ment of his penis and frequent erections. The child
9 y! o m: A4 `+ [- e- X& i4 ]was the product of a full-term normal delivery, with4 C' M6 x1 o, `& |. J1 H, j
a birth weight of 7 lb 14 oz, and birth length of4 K- p/ m% _& [% F
20 inches. He was breast-fed throughout the first year
8 a( P1 l$ i. M( Tof life and was still receiving breast milk along with( {- L- X2 O5 @- S3 S, B$ c
solid food. He had no hospitalizations or surgery,4 t2 C6 ~( @ H* |
and his psychosocial and psychomotor development
1 p! Y# y5 L+ c3 j. P8 o' Bwas age appropriate.
& [) _7 E" _, X( l) |/ K" r# dThe family history was remarkable for the father,; E& |0 c2 c. l" I( l
who was diagnosed with hypothyroidism at age 16,) X$ S j. d6 V4 b3 d' ~ K# Y
which was treated with thyroxine. The father’s; a1 _* ^/ B( k0 h$ h
height was 6 feet, and he went through a somewhat9 ]2 ^) O. D) r) j. T0 F' Y4 Q7 t
early puberty and had stopped growing by age 14. K1 c/ G; `* Q( }
The father denied taking any other medication. The
( D- x, C$ |4 }child’s mother was in good health. Her menarche
2 {+ u! I0 Z8 N t7 x: {+ kwas at 11 years of age, and her height was at 5 feet
8 g& G7 K5 C5 G* H4 G7 w5 inches. There was no other family history of pre-
2 S$ q. d% ~* C* V1 C/ X5 d8 D# Qcocious sexual development in the first-degree rela- j$ n% C& R9 U. v. u. L
tives. There were no siblings.
+ X' L- Q# i) p9 y9 kPhysical Examination O% K8 U) Z, u
The physical examination revealed a very active,
8 D0 @+ A- N7 {4 P5 S; R7 hplayful, and healthy boy. The vital signs documented
5 ?. l" W9 G+ ?& [! D# ka blood pressure of 85/50 mm Hg, his length was
, K2 k7 ]6 J; U0 Q) a0 G0 l/ x90 cm (>97th percentile), and his weight was 14.4 kg
. Z4 x; V8 x' s9 A" f4 d& m(also >97th percentile). The observed yearly growth
. h+ y& k1 D5 l& a) u! t* t6 y nvelocity was 30 cm (12 inches). The examination of- R! {& p$ ^% o6 t$ L
the neck revealed no thyroid enlargement.
/ I3 v; D" N1 y8 i3 q* |The genitourinary examination was remarkable for
" U% H) ]3 n4 D0 `4 i+ }3 zenlargement of the penis, with a stretched length of5 [! B2 M1 J+ Q0 V0 I- |
8 cm and a width of 2 cm. The glans penis was very well. N6 ]- k6 D2 K
developed. The pubic hair was Tanner II, mostly around6 |% `2 M; N% p
540
3 c$ l" d/ b) V2 ]$ Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 z, \1 E1 T, O( |3 Y: y! k$ W/ Ythe base of the phallus and was dark and curled. The
6 Y+ D# }0 s, O5 T% Etesticular volume was prepubertal at 2 mL each.
( ~( K6 y8 g0 p- t" VThe skin was moist and smooth and somewhat
. P$ r* K" ?5 t- y# G* toily. No axillary hair was noted. There were no
; t) M8 b/ Y8 n! V5 Xabnormal skin pigmentations or café-au-lait spots.0 l$ b5 j8 W$ ^
Neurologic evaluation showed deep tendon reflex 2+
8 M3 L' t: n" z+ |bilateral and symmetrical. There was no suggestion
8 D: F) E7 K% s$ zof papilledema.; z# I: K) Z8 j/ B2 R
Laboratory Evaluation
& C4 Y/ [: ~3 C R- dThe bone age was consistent with 28 months by
% B3 ]: B# {# ^, n, f. P" ?! Lusing the standard of Greulich and Pyle at a chrono-! ]( X6 R- B/ r) Q! ?, w+ `
logic age of 16 months (advanced).5 Chromosomal# i2 C! W6 a( ?/ ~2 b
karyotype was 46XY. The thyroid function test
) Z( {; g4 r4 V4 ?showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 y) u' k0 P: ?; C# q( blating hormone level was 1.3 µIU/mL (both normal).
: M% m1 U/ J+ {! i2 RThe concentrations of serum electrolytes, blood
( p. H$ f2 M, Kurea nitrogen, creatinine, and calcium all were
) K9 z, b+ s- Xwithin normal range for his age. The concentration
# G4 u! X$ o5 g0 z. E3 [' H) bof serum 17-hydroxyprogesterone was 16 ng/dL; F. D! a9 p9 Z. g
(normal, 3 to 90 ng/dL), androstenedione was 205 ^( d3 W/ b, o3 W+ b2 g
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 y4 Q9 G# j ^( }4 Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),1 b k2 j8 I$ n" e5 v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, G& L0 D2 ]/ c% s+ m" V7 k7 P
49ng/dL), 11-desoxycortisol (specific compound S)
* W' u9 ^, F7 O0 A7 Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; f2 K: t8 w/ u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) R! C8 Q; O7 Z: Y/ s) U Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL), y. U% f, A/ [: g) t6 X0 i( U
and β-human chorionic gonadotropin was less than
" l7 i8 o4 q% r. O8 U) J& ?8 O5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 x; @+ J# N- V) d0 A% @stimulating hormone and leuteinizing hormone
+ q8 Y# ?7 ~2 y/ s |- U) Rconcentrations were less than 0.05 mIU/mL# _6 A; C. j, i U. j0 i
(prepubertal)., w: \* ^/ a) y: Z/ w$ v
The parents were notified about the laboratory
* F1 Q2 l2 w! t/ O0 s! oresults and were informed that all of the tests were
5 ]: l$ P4 O: ~1 x* T5 K% Onormal except the testosterone level was high. The
4 @2 F& Z5 J3 n" Ufollow-up visit was arranged within a few weeks to; ?8 i2 U0 h# }" E8 H% U; N
obtain testicular and abdominal sonograms; how-
; I) E$ n+ t9 b* Aever, the family did not return for 4 months.+ T1 D- Y+ o/ P
Physical examination at this time revealed that the* M$ r6 n, n8 h0 W/ M
child had grown 2.5 cm in 4 months and had gained* h4 F6 P0 L& a5 l2 }2 S+ m
2 kg of weight. Physical examination remained5 G2 |/ Z0 _7 T' r( ~8 |
unchanged. Surprisingly, the pubic hair almost com-; t: Y; G9 Y2 z3 L, z% u# S
pletely disappeared except for a few vellous hairs at
0 A. e; V9 ~. D5 J2 y- u b- |4 `the base of the phallus. Testicular volume was still 28 Y; v7 |$ T% E4 G- n" v
mL, and the size of the penis remained unchanged.
- Z! @- L4 s/ }The mother also said that the boy was no longer hav-1 E5 n* B7 C6 l
ing frequent erections. a# T& C" r- z
Both parents were again questioned about use of
5 D, Q$ v$ Y8 Rany ointment/creams that they may have applied to# w8 E* l' h' m
the child’s skin. This time the father admitted the: m' U) ~ Y1 h) E
Topical Testosterone Exposure / Bhowmick et al 541
& j/ P X/ w0 ~" |3 Fuse of testosterone gel twice daily that he was apply-: J. N- j/ {6 I$ S& C. g
ing over his own shoulders, chest, and back area for! b$ M" W; G2 E- x4 b2 Y* i
a year. The father also revealed he was embarrassed
. }/ e: p0 l1 ?* ^3 |8 N9 Bto disclose that he was using a testosterone gel pre-0 e/ r5 {% N$ l
scribed by his family physician for decreased libido& \% A, I$ C' @% ]4 L9 A& q
secondary to depression.
' E m* ~, a1 Y/ ]) H3 B8 R, J# eThe child slept in the same bed with parents.
* ?0 N ^' L% v$ O2 rThe father would hug the baby and hold him on his
) N0 e7 G! L1 {+ R D7 y, {chest for a considerable period of time, causing sig-
5 S1 c' w8 y/ _nificant bare skin contact between baby and father.
4 `8 S; \! |& l( I5 ^) j2 aThe father also admitted that after the phone call,
. M/ e- i2 d8 ~5 e3 swhen he learned the testosterone level in the baby
: Z; o! J8 ^ G0 B8 _- E* Kwas high, he then read the product information7 J# O; V9 t b5 p, R
packet and concluded that it was most likely the rea-
( N" t# }% U6 G3 W& nson for the child’s virilization. At that time, they3 c6 a1 `* u( u k& _
decided to put the baby in a separate bed, and the4 ^% p2 ^9 C0 `3 a( I8 i
father was not hugging him with bare skin and had
& w4 x. f8 I5 A$ c; M% abeen using protective clothing. A repeat testosterone
# P& e5 K+ R1 D/ j4 w' ]4 Ytest was ordered, but the family did not go to the
6 v3 N$ f8 b5 V) klaboratory to obtain the test.
+ ~ G# A4 z b' ^, v2 P) TDiscussion
- G, w" |2 \- n% h& G% C* [( PPrecocious puberty in boys is defined as secondary
0 b1 o$ L2 I G0 {3 E$ s! bsexual development before 9 years of age.1,47 T6 n V+ y1 ~; G& K
Precocious puberty is termed as central (true) when1 S" {- m5 d" W: R6 O
it is caused by the premature activation of hypo-/ _6 p; P: @$ w) e
thalamic pituitary gonadal axis. CPP is more com- \2 o; k; K, H* d0 S, q, d
mon in girls than in boys.1,3 Most boys with CPP/ R7 e) C ^$ ?( U
may have a central nervous system lesion that is; [* h) I" ]! [
responsible for the early activation of the hypothal-
& E9 y* z, c" y* `' Samic pituitary gonadal axis.1-3 Thus, greater empha-/ t2 c9 p& e, s+ G1 Y! i
sis has been given to neuroradiologic imaging in9 f8 S3 H2 N/ l# x- T
boys with precocious puberty. In addition to viril-
- [" \6 j. [' x' i; H6 G4 E6 Jization, the clinical hallmark of CPP is the symmet-
9 b3 z, U; U* T) x/ e+ r- Srical testicular growth secondary to stimulation by/ u+ I$ Y A* V8 e0 z* \5 U
gonadotropins.1,37 i9 P7 q* z, t3 k5 F: ^
Gonadotropin-independent peripheral preco-
4 J7 ~* r0 G) T& F. bcious puberty in boys also results from inappropriate
9 {5 k5 x0 K3 ]; J' ^4 [0 f* Landrogenic stimulation from either endogenous or
7 j2 e* U' b1 c8 S; Wexogenous sources, nonpituitary gonadotropin stim-' X5 D- R8 f8 J- j) K1 s
ulation, and rare activating mutations.3 Virilizing2 t! G8 P# {5 z6 C% V
congenital adrenal hyperplasia producing excessive& g6 g) x2 S8 ^# s" a- I
adrenal androgens is a common cause of precocious: k4 o. D4 x/ B0 `! ?6 c& a
puberty in boys.3,4
; }, H5 k4 x) W1 N4 X3 Z! PThe most common form of congenital adrenal
* e0 c! t9 ]* {& V/ rhyperplasia is the 21-hydroxylase enzyme deficiency.
0 z4 P9 C+ `* d7 aThe 11-β hydroxylase deficiency may also result in+ U' M0 s2 t: q: s% `
excessive adrenal androgen production, and rarely,
& t/ o I- p, U. f8 o% yan adrenal tumor may also cause adrenal androgen
+ ]: f: p) S. nexcess.1,3- f% m2 B( p7 z( x- J9 D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# R' m8 }/ @' g: W" T6 S# L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, o+ m" D/ |( a: i$ Y6 v0 WA unique entity of male-limited gonadotropin-4 Q( x& m4 k% M7 n/ u/ Z
independent precocious puberty, which is also known
& h* v4 z2 [! C" gas testotoxicosis, may cause precocious puberty at a
! g% {/ y- Y7 I4 Yvery young age. The physical findings in these boys9 U- o+ u5 e( J: R& w8 P% J
with this disorder are full pubertal development,
. z; e, L; |3 Xincluding bilateral testicular growth, similar to boys% D0 n& G! m7 f4 W7 p' v3 |4 F
with CPP. The gonadotropin levels in this disorder' E6 p1 i; `- t$ ^4 N
are suppressed to prepubertal levels and do not show
: Q5 g9 k1 C' R: _2 ypubertal response of gonadotropin after gonadotropin- x9 e; d* @* |
releasing hormone stimulation. This is a sex-linked5 |$ k, F" @3 N7 M7 G. ?
autosomal dominant disorder that affects only/ H E) x8 y# C
males; therefore, other male members of the family9 N) m l$ @' _, u2 Q+ D
may have similar precocious puberty.3
. a9 o2 j) e8 D1 h$ O9 xIn our patient, physical examination was incon-
p9 S& _8 _1 Z1 {; hsistent with true precocious puberty since his testi-
5 f- w: }1 v2 g h* m% m! `* n6 D7 Ncles were prepubertal in size. However, testotoxicosis
' Y0 d: H; `3 Owas in the differential diagnosis because his father
. P7 k+ O" G2 B o5 g! estarted puberty somewhat early, and occasionally,
" o$ B$ D4 U7 k# k1 ^0 K1 ptesticular enlargement is not that evident in the
! A- O7 U& C+ q q/ Q" |6 rbeginning of this process.1 In the absence of a neg-% {! ^; J2 Z# n _
ative initial history of androgen exposure, our* D+ p; W9 A5 i5 H6 E Q
biggest concern was virilizing adrenal hyperplasia,$ F6 v6 o- [7 p7 j$ v
either 21-hydroxylase deficiency or 11-β hydroxylase7 m3 e; ^3 O, a5 D! C/ w
deficiency. Those diagnoses were excluded by find-7 I; u) A3 x9 m& }9 h* ^
ing the normal level of adrenal steroids.2 w! ?8 [( Q( b. w% V! O
The diagnosis of exogenous androgens was strongly
. M5 I, e( c% T/ N' bsuspected in a follow-up visit after 4 months because# Q$ c* S) f; R' ~/ i+ @
the physical examination revealed the complete disap-
4 M {& \9 H7 }2 H5 e6 K9 \- z4 jpearance of pubic hair, normal growth velocity, and
7 C) t9 `& {; ndecreased erections. The father admitted using a testos-/ {% S/ n( G9 M( W' M e
terone gel, which he concealed at first visit. He was; e3 s+ m" Q" f
using it rather frequently, twice a day. The Physicians’
. E' \# ?" E0 n1 @: H# PDesk Reference, or package insert of this product, gel or2 k- W, @2 a: K
cream, cautions about dermal testosterone transfer to
3 M) P/ T0 F- T' ?unprotected females through direct skin exposure.! g4 m9 U% W& Y5 I
Serum testosterone level was found to be 2 times the
$ H7 e" O3 B g, {7 Hbaseline value in those females who were exposed to- I% i7 x/ ]4 ]# k# Y
even 15 minutes of direct skin contact with their male- E4 ]6 v. t$ Q& d e
partners.6 However, when a shirt covered the applica-
5 {1 e% n" \; I& R9 {8 f' Btion site, this testosterone transfer was prevented.+ L- y' T8 D( |
Our patient’s testosterone level was 60 ng/mL,! S- I& I' _! s M8 O/ u3 D' Z# m8 t
which was clearly high. Some studies suggest that
, |! \# N4 K& M: R. `7 Ldermal conversion of testosterone to dihydrotestos-
J9 M3 O7 y4 I7 Z* k/ pterone, which is a more potent metabolite, is more1 ]8 Q, N5 C( j# M; |- ]
active in young children exposed to testosterone$ d9 J" g5 P$ _8 d" }
exogenously7; however, we did not measure a dihy-. F8 P5 S; _$ v# v: l6 S
drotestosterone level in our patient. In addition to
7 w) _" A/ N- Zvirilization, exposure to exogenous testosterone in
+ F+ M6 {. r- @1 O+ Echildren results in an increase in growth velocity and
1 y) }7 }3 F1 S, wadvanced bone age, as seen in our patient.
) c9 f* m7 [( B. ^The long-term effect of androgen exposure during, j* m! R& T' c7 c; M
early childhood on pubertal development and final
[% w4 ?8 ]. i: zadult height are not fully known and always remain
4 s( f$ Q& n: \( g }( b0 ra concern. Children treated with short-term testos-
$ \: W A) [: _terone injection or topical androgen may exhibit some3 I7 Y/ j4 R( l2 L7 z+ N& [* V
acceleration of the skeletal maturation; however, after& J% C: Z& \4 d0 x7 \4 q6 w
cessation of treatment, the rate of bone maturation
3 \/ r! B- t( `1 A |decelerates and gradually returns to normal.8,9
/ \3 q6 H6 o, h0 {$ ]1 _9 i, H1 JThere are conflicting reports and controversy
$ l( ^* i5 E# E/ ]over the effect of early androgen exposure on adult
I0 @7 N; v6 }' ]penile length.10,11 Some reports suggest subnormal7 r/ s: @- T. _1 G" c
adult penile length, apparently because of downreg-
. w4 e1 m+ E6 Y3 S' Eulation of androgen receptor number.10,12 However,4 ?- I, a4 \5 J
Sutherland et al13 did not find a correlation between) j( n# B7 l! A" F
childhood testosterone exposure and reduced adult
4 I. Y7 m# }- h# i4 {4 I% vpenile length in clinical studies.: V5 D1 t: [. H: s
Nonetheless, we do not believe our patient is
- Q5 [5 h& C7 U/ M6 g( pgoing to experience any of the untoward effects from9 k, w& B4 c. ?, u. U* t7 h
testosterone exposure as mentioned earlier because+ b# e6 P% @) m s1 U% J9 C
the exposure was not for a prolonged period of time.5 C; s0 Y7 y0 Q V4 M: _4 u" B
Although the bone age was advanced at the time of
4 i! r& Z# D' Q8 Ydiagnosis, the child had a normal growth velocity at8 e6 b. N9 O/ {& {* _) `; J$ A) v
the follow-up visit. It is hoped that his final adult
$ ]! v, h; \4 T; G- F2 N: Uheight will not be affected.$ P: S/ j; w4 `9 o
Although rarely reported, the widespread avail-+ X% N' f8 m( H4 N) a% A$ @
ability of androgen products in our society may
" _) A$ H0 U U V1 qindeed cause more virilization in male or female+ M* R% U3 t; x: `/ j
children than one would realize. Exposure to andro-; y3 G1 |" A+ `: c9 k1 |9 j1 }
gen products must be considered and specific ques-" x0 \- e4 ^, F1 Z! Y% c' p
tioning about the use of a testosterone product or
' N" G' L( f3 G4 a; [$ ugel should be asked of the family members during
; K3 O' ^) g6 x, _5 u9 n9 \ x5 Wthe evaluation of any children who present with vir-
7 ^* @4 J2 N; S% H. Dilization or peripheral precocious puberty. The diag- U. u5 o2 ?2 D! l- S& f
nosis can be established by just a few tests and by2 b1 H$ E P% v: h* a3 O
appropriate history. The inability to obtain such a
) d5 W# w; g4 Lhistory, or failure to ask the specific questions, may
3 w) D+ O) R4 V1 @# v; s% aresult in extensive, unnecessary, and expensive) N1 t- {% B$ Y6 f5 U" \
investigation. The primary care physician should be
( y1 J/ u7 L% n& M8 _aware of this fact, because most of these children
X# P6 f; x/ y$ C8 ^& \may initially present in their practice. The Physicians’0 C9 m. D% z1 B- M, n- ~: G) t) j
Desk Reference and package insert should also put a; `! `1 N0 i* q6 S- O+ f
warning about the virilizing effect on a male or
8 S8 m+ @* `# L0 Ofemale child who might come in contact with some-. M5 @+ d: C, W5 v
one using any of these products.
( _7 e1 ~! Z0 V0 k7 T8 UReferences' N {& e# X% g. O# I
1. Styne DM. The testes: disorder of sexual differentiation
K& g) @4 E2 g8 c5 i& eand puberty in the male. In: Sperling MA, ed. Pediatric% I+ m% Q; D# O" e
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 R8 b! I( Z; u1 @* v7 X2002: 565-628.' C. r" X& V9 U+ ^! v
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, b& `: a: e1 B* w8 k! u. Spuberty in children with tumours of the suprasellar pineal |
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