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Sexual Precocity in a 16-Month-Old0 j- a6 k5 C. U3 s
Boy Induced by Indirect Topical( @$ t; i: R) r1 v* F) Y. [6 g' W
Exposure to Testosterone+ {1 n2 W/ V5 z/ R. f+ |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ b7 x* s! w! Z! r: P! I: _
and Kenneth R. Rettig, MD1
1 i! g/ D u# B8 o' aClinical Pediatrics
$ @. m" ?8 c# ~/ p' _Volume 46 Number 6
0 C- B- Z7 D' w. Y/ S( G( wJuly 2007 540-543
: ?. r; W. I$ @0 i' A© 2007 Sage Publications
3 l! v6 T0 C3 U10.1177/0009922806296651
" c# {( N# Y7 i+ d% _5 shttp://clp.sagepub.com" V7 |8 F3 v6 q- d9 m
hosted at* \( T9 ~( K6 A1 N
http://online.sagepub.com! ^( Z6 o+ F( T( J
Precocious puberty in boys, central or peripheral,
& X$ M M# b& _; W- `, h% g/ iis a significant concern for physicians. Central
; {( w0 l6 @9 u+ ?3 v) D+ f- Vprecocious puberty (CPP), which is mediated
+ U2 a0 s1 m' Q2 nthrough the hypothalamic pituitary gonadal axis, has3 I* W H( a1 g: j7 C
a higher incidence of organic central nervous system$ I* Z n# e1 h( N/ M
lesions in boys.1,2 Virilization in boys, as manifested
0 r" v+ h+ E7 ?9 s+ w5 |. fby enlargement of the penis, development of pubic9 v. d h( a: o
hair, and facial acne without enlargement of testi-/ M) b# |$ t# o. o. R, h
cles, suggests peripheral or pseudopuberty.1-3 We
/ ]# b. `" `. ~/ ]8 P r5 Nreport a 16-month-old boy who presented with the
, A+ W* S Q9 N1 V2 `enlargement of the phallus and pubic hair develop-
" z, k% n' U* V- g% K; y/ Z0 wment without testicular enlargement, which was due
6 E9 m; T2 k, S6 i+ _/ Sto the unintentional exposure to androgen gel used by
; u( [2 P8 g0 u7 K+ e" ^2 a Q* ]the father. The family initially concealed this infor-
; Q* M u: N5 A& R5 g; Pmation, resulting in an extensive work-up for this
1 [; P5 J. X* m9 I5 Ichild. Given the widespread and easy availability of
! ]' a' t% X- d* htestosterone gel and cream, we believe this is proba-
: d8 W* K$ X+ `8 }# L4 Mbly more common than the rare case report in the( _0 X1 V3 B) m
literature.4
2 B6 e8 J, W: S: d$ H/ xPatient Report
& ]5 G0 m# `; p' L& l8 ?; _5 X. G$ G0 wA 16-month-old white child was referred to the
2 H( Y7 g- C+ p0 L7 [4 \1 N, e5 [endocrine clinic by his pediatrician with the concern' M/ _7 k% F% Z, E9 T
of early sexual development. His mother noticed9 q# }# h1 h1 Y0 P {/ D) g
light colored pubic hair development when he was7 w5 B! Y: t# n: R, E$ ^
From the 1Division of Pediatric Endocrinology, 2University of
% O. F2 D( C# {South Alabama Medical Center, Mobile, Alabama.
. _; p# Y2 N/ M: g( L% T& \5 wAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 |5 V4 y1 h2 D! M
Professor of Pediatrics, University of South Alabama, College of
0 N6 @1 v! Z$ d9 a2 r& K9 c; sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! L$ C& d5 D/ `- ^6 G/ K+ M" G
e-mail: [email protected].
# [- e% F: v1 V c" ], k4 ]$ K E, Vabout 6 to 7 months old, which progressively became
$ W( z2 T6 |* t: r* D( p! e- Z! ldarker. She was also concerned about the enlarge-
# V' B; Q3 K G: w" |, W& s* c9 Xment of his penis and frequent erections. The child
4 u2 X# G2 D: dwas the product of a full-term normal delivery, with& V( s: {7 ~" K5 e+ k, d
a birth weight of 7 lb 14 oz, and birth length of. }: K# y( ^4 ^; [9 t/ m9 V7 n
20 inches. He was breast-fed throughout the first year7 Y* V' d4 ]4 N) m: q
of life and was still receiving breast milk along with2 a$ O! X* U4 E. |- ] l( V! D
solid food. He had no hospitalizations or surgery,3 {1 A& p/ q7 O- }+ y3 z
and his psychosocial and psychomotor development
3 G( B3 g5 c4 a+ Xwas age appropriate.
) K) m( v/ t) I7 rThe family history was remarkable for the father,
3 _4 \. U7 U5 p3 S N# t3 hwho was diagnosed with hypothyroidism at age 16,
8 `# h9 h7 h2 t& K) k6 A/ Qwhich was treated with thyroxine. The father’s7 c5 R% v, X8 d0 D5 x, r: Y
height was 6 feet, and he went through a somewhat A, U# x# D7 O. ]! z0 \
early puberty and had stopped growing by age 14.! {& ]3 V$ I h' E( W2 Y( H: S
The father denied taking any other medication. The
0 P8 L3 O7 |2 L: Achild’s mother was in good health. Her menarche
, d' u+ e- R! j5 }4 Swas at 11 years of age, and her height was at 5 feet4 t. Y% o' u- s2 |3 ?: R
5 inches. There was no other family history of pre-
# t" ? T' v7 l G& x& \, \* _+ Jcocious sexual development in the first-degree rela-
* G8 d" Z% g$ P% [. xtives. There were no siblings.
2 Z; @0 |2 r, u% V9 BPhysical Examination7 N% v, R6 A3 P, `: ?
The physical examination revealed a very active,
: b3 l* M2 q" |* v# D. zplayful, and healthy boy. The vital signs documented
! T; G% _$ H q- @a blood pressure of 85/50 mm Hg, his length was/ B# U1 @# K9 |9 }% g
90 cm (>97th percentile), and his weight was 14.4 kg$ l" T# U5 h9 V' e( A6 F7 L8 H3 }
(also >97th percentile). The observed yearly growth& c h4 |, {3 q7 x8 A4 `1 O
velocity was 30 cm (12 inches). The examination of
S% Z5 {. k6 p. [0 j) H7 jthe neck revealed no thyroid enlargement.
" Q8 j1 D- M/ Z: C( q: ?The genitourinary examination was remarkable for
) G5 f9 p% t( R% y* P# Nenlargement of the penis, with a stretched length of
. H6 B# O9 E) q& S% Q3 \8 cm and a width of 2 cm. The glans penis was very well, T" L [: r- ~# ?8 ?- j5 R
developed. The pubic hair was Tanner II, mostly around# U, Q" o: y+ u4 S2 `$ c3 O2 w
540' V& `+ k/ e/ F; _4 |9 g+ j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! E1 H/ S, Z! |$ Y6 K
the base of the phallus and was dark and curled. The. j7 B' B; J; ?5 A. q! y
testicular volume was prepubertal at 2 mL each.3 @9 I8 K3 t- K& S9 q2 Q& M
The skin was moist and smooth and somewhat$ R- s+ ~ _( ]( M" q) b% h
oily. No axillary hair was noted. There were no
S4 F8 R5 `1 W1 D- dabnormal skin pigmentations or café-au-lait spots.
5 s& |8 [( ]0 N; ?Neurologic evaluation showed deep tendon reflex 2+
a! a( n; X1 }) D1 r8 _bilateral and symmetrical. There was no suggestion: k. D8 }+ s% k) d
of papilledema. L4 T4 _9 _" C$ A
Laboratory Evaluation& T( @/ {! }& G0 Z8 c. [8 J
The bone age was consistent with 28 months by
. I5 P8 X$ L$ x6 I6 ^5 ~using the standard of Greulich and Pyle at a chrono-' G- T# W0 a1 ` R) d
logic age of 16 months (advanced).5 Chromosomal
7 {- }9 b% g% ?1 h8 E; L0 ]karyotype was 46XY. The thyroid function test
' ]4 T* G! W3 s4 h4 Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 r6 M7 l- k( [2 m, V5 y! ?
lating hormone level was 1.3 µIU/mL (both normal).& @( k4 l* |) P7 L
The concentrations of serum electrolytes, blood$ R4 K9 ` t/ [6 j* }4 m' Y
urea nitrogen, creatinine, and calcium all were
5 J, Q# _9 h n8 dwithin normal range for his age. The concentration" F, ` t, U# W, \" N
of serum 17-hydroxyprogesterone was 16 ng/dL, O6 {! u/ _( i; L+ o3 i9 ^
(normal, 3 to 90 ng/dL), androstenedione was 20% q& A* t% \( W
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 }$ V& m- h6 i: o% C6 Z3 `. J6 A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ {1 W: L5 X: t- R6 g1 q' n$ x, \8 Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 S1 o$ {; H7 @3 B6 L/ H1 a& n49ng/dL), 11-desoxycortisol (specific compound S)
& l. P; f9 ?! o1 V i' v1 Jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: \7 i* ]2 u g3 I! } I1 ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 Y/ _ o- y+ T$ \2 P1 ^& q+ Y0 xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, @3 r4 _0 A ~( t# @
and β-human chorionic gonadotropin was less than
% Q6 L* @, Y4 i, F# Y5 mIU/mL (normal <5 mIU/mL). Serum follicular9 `3 ]8 v3 A4 T' ]% l- D C
stimulating hormone and leuteinizing hormone) F3 w) h! Y+ F3 r. f% Y
concentrations were less than 0.05 mIU/mL7 [" C3 Q W) d1 k
(prepubertal).' k& R: k/ D( T
The parents were notified about the laboratory
8 R5 m+ _5 I3 p- Nresults and were informed that all of the tests were
0 W9 i6 \+ y2 S* x9 X# d# Anormal except the testosterone level was high. The
- U" w" x6 \( j4 _follow-up visit was arranged within a few weeks to
* \4 I" Z$ }3 m, Y9 }! } Cobtain testicular and abdominal sonograms; how-1 ^$ i; S% j2 L) Y5 a
ever, the family did not return for 4 months.
$ k2 N. {. I6 f: W+ Y5 ZPhysical examination at this time revealed that the8 F$ F" E' _0 a! S/ ?6 @, q
child had grown 2.5 cm in 4 months and had gained
" a% p! \! _# ]- W4 {- K2 kg of weight. Physical examination remained
& x# X; @+ E0 P. i+ O) Kunchanged. Surprisingly, the pubic hair almost com-
. O) W0 C7 I9 M6 W9 _3 Qpletely disappeared except for a few vellous hairs at
D- u0 {* s1 t& l8 Pthe base of the phallus. Testicular volume was still 29 E6 f0 k7 k1 U7 p+ ~
mL, and the size of the penis remained unchanged.( ^3 K: U: z5 V' O6 S/ N
The mother also said that the boy was no longer hav-6 ]8 l4 f7 E5 Y6 t5 ?& n
ing frequent erections.+ U) m; U$ h9 M
Both parents were again questioned about use of6 t M! t* S" t
any ointment/creams that they may have applied to
) ]5 x; X) w& Z4 F8 ^the child’s skin. This time the father admitted the
1 E$ R! x6 k3 K+ JTopical Testosterone Exposure / Bhowmick et al 541& j. j5 s. ?7 f4 ^
use of testosterone gel twice daily that he was apply-
3 a6 \8 |- `* j. M4 G6 Uing over his own shoulders, chest, and back area for
a, A; s3 O) J5 x$ ^a year. The father also revealed he was embarrassed" W" O/ |# g6 v" M6 t7 h+ Y
to disclose that he was using a testosterone gel pre-9 F5 q8 }7 ]- |$ r2 V! g9 k
scribed by his family physician for decreased libido
9 Y N' k$ m# q8 O5 @secondary to depression.
" b$ Z, n7 E/ G l0 IThe child slept in the same bed with parents.
4 x' P6 C# _+ ^' ]The father would hug the baby and hold him on his! R/ G( t3 ?' L# n6 J* K& n
chest for a considerable period of time, causing sig-5 V) D% a- m& D$ Q$ Y9 ?
nificant bare skin contact between baby and father.
0 R% `6 l) e0 Y; y, _The father also admitted that after the phone call,+ p1 J! s0 b: i2 |- @9 g
when he learned the testosterone level in the baby* ?6 A3 C- W# `: B0 M+ u
was high, he then read the product information
' R% i/ O: P* J. t. B m" p" ^packet and concluded that it was most likely the rea-
6 @) c6 K1 G5 ison for the child’s virilization. At that time, they# ?# b$ P" S8 m' T6 A
decided to put the baby in a separate bed, and the
+ E6 r( o2 n) N( y( `+ d) ffather was not hugging him with bare skin and had9 K3 d8 a4 g7 _* i
been using protective clothing. A repeat testosterone
& N% i6 `' x7 ~' c+ ytest was ordered, but the family did not go to the
: ?# f, U% J2 g& [( u8 ]5 K( q2 Ulaboratory to obtain the test.
: W; X1 v5 z' `. eDiscussion
* T. D& J8 q/ } O; jPrecocious puberty in boys is defined as secondary: v8 N7 d4 E" L' I) |2 [$ y
sexual development before 9 years of age.1,4
# W0 N' W# `+ ^; V* M! KPrecocious puberty is termed as central (true) when
' u" Q' v+ k1 Eit is caused by the premature activation of hypo-
* O0 p7 a0 _9 F4 rthalamic pituitary gonadal axis. CPP is more com-
4 u) j( R0 p- e% w9 Rmon in girls than in boys.1,3 Most boys with CPP1 L/ k! f: V$ I- k% U4 \
may have a central nervous system lesion that is
# V" C' C; `! ]' T8 F6 Lresponsible for the early activation of the hypothal-2 V, ~* u. V) c) ^& x
amic pituitary gonadal axis.1-3 Thus, greater empha-
* i" ~! K* o, v0 E: Asis has been given to neuroradiologic imaging in
: E) ^# O6 w7 a0 Bboys with precocious puberty. In addition to viril-
( A5 ]2 m0 Y l2 l* d/ ]ization, the clinical hallmark of CPP is the symmet-
. ]! [) ^* s- d6 ^& [rical testicular growth secondary to stimulation by
; F2 T1 q; a4 ^/ r2 kgonadotropins.1,36 X* k" m" @& v, X9 ^4 c. Y
Gonadotropin-independent peripheral preco-
8 h8 F. f8 B1 x9 Ccious puberty in boys also results from inappropriate
' P Q" Z) ^- t3 mandrogenic stimulation from either endogenous or& ^% l6 R' |* k0 |% j0 W
exogenous sources, nonpituitary gonadotropin stim-
3 d, |. H7 t9 Q5 Y+ B7 l: \2 Q! Culation, and rare activating mutations.3 Virilizing, H, o# ], @2 L+ w; j
congenital adrenal hyperplasia producing excessive7 K, W6 n/ Q5 M4 q1 i
adrenal androgens is a common cause of precocious6 Z3 x2 y1 Z {; Q1 x) u. o
puberty in boys.3,4
5 e4 |3 }% N# W- UThe most common form of congenital adrenal
n! D( E; i2 e. @) C( uhyperplasia is the 21-hydroxylase enzyme deficiency.
% I- [6 h5 I6 I& Q1 I" B; D$ J0 JThe 11-β hydroxylase deficiency may also result in' L9 f _- f5 Z
excessive adrenal androgen production, and rarely,: |- R9 r2 s/ h& L9 z! x
an adrenal tumor may also cause adrenal androgen
* }* G7 t( r& G$ r$ M% nexcess.1,3
) _) V6 e3 G+ L. _7 p3 K/ U) W9 hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ e0 C7 {. Y" l5 A* d& r
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. ~' ^+ l( p0 u3 s5 l5 Q* i7 [A unique entity of male-limited gonadotropin-$ J* v2 X% F) X+ J
independent precocious puberty, which is also known( Q) u) m3 S. [$ i6 W" y
as testotoxicosis, may cause precocious puberty at a
8 ]0 d% _# A* w! C9 c* Yvery young age. The physical findings in these boys
% r0 u6 t' {! |: b; P7 [" k8 Gwith this disorder are full pubertal development,
+ L S, r) Y, ]including bilateral testicular growth, similar to boys
2 u8 a6 A$ H( t9 r+ awith CPP. The gonadotropin levels in this disorder8 H1 m2 A0 _/ M5 Y
are suppressed to prepubertal levels and do not show+ O% `: [ h1 N/ D5 A
pubertal response of gonadotropin after gonadotropin-# d4 M) ^; M) B# [, x9 y& B) c
releasing hormone stimulation. This is a sex-linked* c6 K/ c* b- P3 N
autosomal dominant disorder that affects only) w) G! c& [$ v9 L9 @ K
males; therefore, other male members of the family* O+ r9 o. \- W( m
may have similar precocious puberty.3$ Q8 Z) R) P9 c* p
In our patient, physical examination was incon-
7 X3 @; i& b- }; V' L( Fsistent with true precocious puberty since his testi-
- Q) P( [; K P' _) Y" ncles were prepubertal in size. However, testotoxicosis
& F% t2 j0 j6 h0 }was in the differential diagnosis because his father
Q. {6 U/ v+ L. F% tstarted puberty somewhat early, and occasionally,! M% ?7 @0 j& }9 d/ g
testicular enlargement is not that evident in the9 b) I- W% g4 K4 t9 c$ S j
beginning of this process.1 In the absence of a neg-
6 L g* p! C& T* k {7 `2 oative initial history of androgen exposure, our
9 i1 U' ]0 ]3 Ibiggest concern was virilizing adrenal hyperplasia,
* ^0 B4 S {7 _, T( C$ @( J( @either 21-hydroxylase deficiency or 11-β hydroxylase
7 V) _0 `' Y- S+ c, `deficiency. Those diagnoses were excluded by find-5 v4 n+ k& T2 A5 z: r+ D6 M V1 c3 e
ing the normal level of adrenal steroids.& _+ s7 \; u+ `! h
The diagnosis of exogenous androgens was strongly
8 ?4 O, s- g6 ]suspected in a follow-up visit after 4 months because: C9 L3 }- V9 t( v
the physical examination revealed the complete disap-
9 {' ?% J L, t( P( ~pearance of pubic hair, normal growth velocity, and9 y. t$ K2 z7 ~6 h0 R* e# @# Z7 c3 D
decreased erections. The father admitted using a testos-* \; J! S* ?; }: t1 k
terone gel, which he concealed at first visit. He was
0 g' v# X$ S5 w* s+ ?& E0 tusing it rather frequently, twice a day. The Physicians’ m3 r- S- i2 \/ [/ a& h
Desk Reference, or package insert of this product, gel or
* A4 Q1 p7 ^ [0 { `6 t+ rcream, cautions about dermal testosterone transfer to
4 N! F0 O$ \& s( f vunprotected females through direct skin exposure.
* X6 N( G3 S" D. x: |' jSerum testosterone level was found to be 2 times the& S" \6 c# d, n) C. J
baseline value in those females who were exposed to
$ t& M8 S5 z, m7 X0 g4 Ueven 15 minutes of direct skin contact with their male7 z0 b1 j+ J# D* G
partners.6 However, when a shirt covered the applica-' u! _2 j* r3 `" X9 C0 N
tion site, this testosterone transfer was prevented.
3 d# W% e1 l$ [4 \; zOur patient’s testosterone level was 60 ng/mL,4 R7 N+ W4 t/ w0 V$ i, c7 {
which was clearly high. Some studies suggest that
7 x* w0 R! z p3 ~) m4 i* m& Mdermal conversion of testosterone to dihydrotestos-
) q- l, y6 O$ W: i' Zterone, which is a more potent metabolite, is more
4 o; A% ~) g) B$ c) iactive in young children exposed to testosterone
3 }" R% y# l; f |$ e# f6 K& Vexogenously7; however, we did not measure a dihy-6 y$ R3 h1 I9 ?9 _( `3 A
drotestosterone level in our patient. In addition to5 B" x, `! M) X9 I _& f9 I3 x6 a
virilization, exposure to exogenous testosterone in
" K- D& p G$ D5 ], ~children results in an increase in growth velocity and8 U/ F& l; p% q, G
advanced bone age, as seen in our patient. _4 h0 x9 ~: W1 D5 T C
The long-term effect of androgen exposure during F, \* D, S& f2 P: y4 y; P- j
early childhood on pubertal development and final: u7 H, z" x N5 }* A5 [
adult height are not fully known and always remain
' |* A! w3 _- {9 v& O7 w/ Na concern. Children treated with short-term testos-/ |8 m W$ [% Q, e- m! S
terone injection or topical androgen may exhibit some
/ B$ [- j0 F. t' [ a% Cacceleration of the skeletal maturation; however, after0 D! p3 ]8 Z6 @5 n. W7 I: @: }* c! f
cessation of treatment, the rate of bone maturation
" _3 w# ]) ?. q& T% p0 |9 Jdecelerates and gradually returns to normal.8,9. B1 a6 ]0 n/ f% r. G
There are conflicting reports and controversy5 Z- r+ f3 i- D* V- X9 F. x
over the effect of early androgen exposure on adult
% _ _4 y3 F; H/ |0 E1 r9 u$ ]penile length.10,11 Some reports suggest subnormal, `: D. _( S. F k$ T5 }& u! O
adult penile length, apparently because of downreg-
: A, B9 Z) \2 R; ?# x' Dulation of androgen receptor number.10,12 However,- A6 R- y; N/ Z0 t$ ~: h( v4 v
Sutherland et al13 did not find a correlation between( l! k% l, ~* R8 R" Q- \
childhood testosterone exposure and reduced adult
! b3 E8 V3 `+ x# h, u" Ipenile length in clinical studies.
5 N* e7 g0 w0 i: O; GNonetheless, we do not believe our patient is
# H% b1 z0 P' g# f& n& mgoing to experience any of the untoward effects from; M$ W' ?' U. D1 T+ C
testosterone exposure as mentioned earlier because, `( y8 i7 J) |9 H; c) |. _# X
the exposure was not for a prolonged period of time.0 }' K) h6 Z$ [ L
Although the bone age was advanced at the time of6 M" R* \ [: X
diagnosis, the child had a normal growth velocity at
6 ?4 ~2 R. r* T; h" Ythe follow-up visit. It is hoped that his final adult
& `! r) S* S, Y" [+ T. sheight will not be affected.
# K4 V, }* P3 |Although rarely reported, the widespread avail-
9 S+ S( _- F( `9 Q! j# X6 Q* Xability of androgen products in our society may
: r9 R/ m5 R# Vindeed cause more virilization in male or female
" J9 H4 T+ \3 x: P0 Dchildren than one would realize. Exposure to andro-
9 `8 R' B' A* Q0 d% Mgen products must be considered and specific ques-
; c, l) Q9 F* w# E) Ltioning about the use of a testosterone product or7 O. n" y. L! ~7 q) J
gel should be asked of the family members during
0 F% R, z- ] r7 [ B( }! Jthe evaluation of any children who present with vir-
8 C i) y; U5 ]ilization or peripheral precocious puberty. The diag-+ Z! V, ~5 ^" k/ D+ F& {8 W
nosis can be established by just a few tests and by( Q4 y: n2 I: g" Q
appropriate history. The inability to obtain such a7 K) {& h8 P9 e7 C& y
history, or failure to ask the specific questions, may
& x \0 k! u: x8 H& Q. eresult in extensive, unnecessary, and expensive! W5 N+ p6 U1 V, u5 ~: `
investigation. The primary care physician should be- J2 h+ m g8 }
aware of this fact, because most of these children/ e% _7 u0 c% a; n
may initially present in their practice. The Physicians’3 y0 }; E9 L" y
Desk Reference and package insert should also put a& R/ {. }+ R- [6 `. L% C0 _4 R
warning about the virilizing effect on a male or
2 m7 O8 n$ O" {% H" v% pfemale child who might come in contact with some-. r& X% u' M, g5 c
one using any of these products.0 K; P, c& B' ?, o }
References. s/ ^! a5 u5 g, r
1. Styne DM. The testes: disorder of sexual differentiation
/ P5 b. @; }! U( X) I" ^) F: L4 t8 \and puberty in the male. In: Sperling MA, ed. Pediatric
1 s5 T8 e) [9 g2 l1 e& A6 XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* e/ c- `( N K. f1 x! R
2002: 565-628.
9 r$ A0 P, a `4 t! g/ Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) W3 t/ e( @3 y
puberty in children with tumours of the suprasellar pineal |
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