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Sexual Precocity in a 16-Month-Old
" T- y7 Z5 i* d2 U- PBoy Induced by Indirect Topical
; O0 N5 o/ x/ dExposure to Testosterone
% f$ q7 P5 W# m! J, u1 ~3 q& _; ^0 mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 o. _' E& J1 S$ E
and Kenneth R. Rettig, MD13 M3 T5 ^4 R6 Q8 R
Clinical Pediatrics* C) @0 q/ l( j+ t) I$ e* Z
Volume 46 Number 6/ \( f) `- l% ?* o
July 2007 540-5437 N! B( I, N9 }! |: f4 u
© 2007 Sage Publications9 C) @6 K$ R7 l) p
10.1177/0009922806296651
3 _$ E+ @1 @$ L2 `http://clp.sagepub.com. @" J: l7 M5 H( b9 D9 t, \
hosted at
7 n6 @3 w3 e$ b# E* c2 M4 j+ Dhttp://online.sagepub.com
( ^, ^; B! l3 l" [+ hPrecocious puberty in boys, central or peripheral,& u: h" G% A" S7 G" S& R
is a significant concern for physicians. Central
8 j/ x5 Z. y" k& u( [9 sprecocious puberty (CPP), which is mediated$ a/ t2 w A' R/ U$ x4 a
through the hypothalamic pituitary gonadal axis, has
3 i2 P Z+ A& G. ]: l- Na higher incidence of organic central nervous system# R4 U$ Y& E! O! V; o: _) D
lesions in boys.1,2 Virilization in boys, as manifested2 U8 n. [' H' e% O- O8 u8 V
by enlargement of the penis, development of pubic
" W* R* c+ O- q5 X5 |hair, and facial acne without enlargement of testi-9 l5 d' u' v# o" l8 k. j, d
cles, suggests peripheral or pseudopuberty.1-3 We
$ a" a; w* Z$ B6 }/ [% f hreport a 16-month-old boy who presented with the6 m. C0 P8 r- _: e) o$ Q/ N
enlargement of the phallus and pubic hair develop-
1 E" w8 k- E$ `$ \0 a$ t. gment without testicular enlargement, which was due, r9 y) O6 K2 y4 n; F4 m2 H
to the unintentional exposure to androgen gel used by5 r% d2 Y' L( R" D& ]" j, A
the father. The family initially concealed this infor-
0 B" m! b4 ^+ Pmation, resulting in an extensive work-up for this5 O4 Y2 l4 N4 }/ U8 N- Q
child. Given the widespread and easy availability of
. a0 Z2 ?' m5 q! o+ U% G* J3 Atestosterone gel and cream, we believe this is proba-
8 d# h7 x6 F) } J- P4 |bly more common than the rare case report in the
, |1 m' k) o: U; x- y# \( tliterature.42 m! \ _ |+ h: I9 I8 [9 F
Patient Report( @* C( c* Q' `" c' S6 }
A 16-month-old white child was referred to the
: D/ n* x! ^; O+ zendocrine clinic by his pediatrician with the concern
. A( L/ h; [, K( ]0 N/ a2 iof early sexual development. His mother noticed
5 h7 V' m; E; \# Z' a5 i; e! d* \+ p6 Ilight colored pubic hair development when he was
+ g6 j2 d$ v GFrom the 1Division of Pediatric Endocrinology, 2University of I) X) @6 Y" e% s9 Q
South Alabama Medical Center, Mobile, Alabama.+ ~4 U; j. d3 n, R0 z V# y: K
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 n( }, f" z# f- nProfessor of Pediatrics, University of South Alabama, College of
# @1 s9 J1 W+ O- G$ _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 l, m% a" e3 r1 xe-mail: [email protected].3 E9 G: s" |$ ]: w7 c) h
about 6 to 7 months old, which progressively became$ r& ?' e+ K5 z$ G
darker. She was also concerned about the enlarge-
7 x6 @, M* [6 c T! Y$ L- N' _ment of his penis and frequent erections. The child
, Q; s, `' O P# x, Rwas the product of a full-term normal delivery, with
! w9 K% P# s6 S Ya birth weight of 7 lb 14 oz, and birth length of
( P; l2 X1 v' K1 z; m20 inches. He was breast-fed throughout the first year! ~0 x5 N8 Y" Z% ]% }( w
of life and was still receiving breast milk along with- O9 H, h2 ]2 m
solid food. He had no hospitalizations or surgery,
- i+ Y+ X+ S# T4 uand his psychosocial and psychomotor development
. V" y: z$ r/ |' O+ _' o5 v& L) y% ~was age appropriate.
1 \, X/ q9 F6 |4 a, @" E2 _0 o8 oThe family history was remarkable for the father,
8 n! S4 F; a( a _# }: y0 jwho was diagnosed with hypothyroidism at age 16,
! v, }& N4 {' Y& W7 y0 y" `which was treated with thyroxine. The father’s! H2 t& X+ V. H+ f
height was 6 feet, and he went through a somewhat
/ d3 F( S6 R' [9 Wearly puberty and had stopped growing by age 14.' Z; `* B$ j/ {7 w
The father denied taking any other medication. The
, W! F4 y2 p- A$ Zchild’s mother was in good health. Her menarche
! A5 U6 `2 ?: g. r Z) S6 Owas at 11 years of age, and her height was at 5 feet3 X8 Y7 i K- E4 W
5 inches. There was no other family history of pre-
1 r, g5 N v3 e2 qcocious sexual development in the first-degree rela-0 y6 G5 f7 i6 i2 W* g& ^
tives. There were no siblings.
# Q3 p. k% G' Z: ?Physical Examination
1 K4 W0 X3 A/ A) w" `% c# a4 vThe physical examination revealed a very active,1 P4 \, ]9 h+ k9 ~4 A4 o
playful, and healthy boy. The vital signs documented+ `( E: \2 t, ]2 z- t: D$ j
a blood pressure of 85/50 mm Hg, his length was6 t3 M, L5 h$ t6 U
90 cm (>97th percentile), and his weight was 14.4 kg
- N6 J2 j( j( u3 b; T a(also >97th percentile). The observed yearly growth& B/ w' [4 R7 ?# B* r# C
velocity was 30 cm (12 inches). The examination of
& K) P; t; ~* ithe neck revealed no thyroid enlargement.
: \, e3 c3 s8 o* V NThe genitourinary examination was remarkable for
7 s, \# b: J2 I- y. eenlargement of the penis, with a stretched length of
: E' Z; N0 q6 T# v7 Y7 _) A) f: S8 cm and a width of 2 cm. The glans penis was very well
3 g6 F! _: }2 P! O2 M- cdeveloped. The pubic hair was Tanner II, mostly around
" m# g' f: f9 j- r0 k2 r540$ ?* y# P% C: b5 N/ ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# u/ A6 R8 ^$ |" Z7 Lthe base of the phallus and was dark and curled. The
; J5 f, e! R! l" J: H& xtesticular volume was prepubertal at 2 mL each.+ @, I/ q* N' R s1 ?; G2 w4 _
The skin was moist and smooth and somewhat
/ w- ~* y* q7 h9 Goily. No axillary hair was noted. There were no5 B- O: T- z+ L \. Z% A: `2 P
abnormal skin pigmentations or café-au-lait spots.5 k5 l+ F$ S8 R* j: `
Neurologic evaluation showed deep tendon reflex 2+% [: S- f9 v; ]" B2 w4 j- z& M
bilateral and symmetrical. There was no suggestion
4 t/ a x5 l8 @( Z kof papilledema.. ^0 t) B: J) c% d( ?9 x; p ~
Laboratory Evaluation
; f( h+ o0 S! X# oThe bone age was consistent with 28 months by/ f6 M) ]1 `9 `
using the standard of Greulich and Pyle at a chrono-
5 v. |# D# A D/ qlogic age of 16 months (advanced).5 Chromosomal
; w5 k0 ~8 `5 c8 R# ckaryotype was 46XY. The thyroid function test
]( o6 e$ ^/ `7 j. O, Eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 Z& m5 b' t1 Z! H
lating hormone level was 1.3 µIU/mL (both normal).9 d: }% s$ [/ o( L! p( U
The concentrations of serum electrolytes, blood$ e# b5 j# n' ^( ?# T4 W/ x
urea nitrogen, creatinine, and calcium all were# Z" Z0 Q/ J% [
within normal range for his age. The concentration
- y5 B# C4 T6 E( V; f% A& [& M7 |of serum 17-hydroxyprogesterone was 16 ng/dL
6 W9 ^0 f, E S(normal, 3 to 90 ng/dL), androstenedione was 20
. A9 I) E$ {1 |2 h, Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* y( }) ~7 A$ ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: W5 ]9 M- ]) }; @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to% C4 ^# Z; b5 A3 e3 R
49ng/dL), 11-desoxycortisol (specific compound S)
4 v* {: N4 T0 N" d- Ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 ]8 p( e( m* Y2 B8 y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& `6 J# h5 e" R P4 {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( F4 @- n9 ?4 k1 A+ D3 u
and β-human chorionic gonadotropin was less than
# \* z; n0 S! E; G5 m2 G5 v/ ?5 mIU/mL (normal <5 mIU/mL). Serum follicular: ^% j N& p# ~6 G
stimulating hormone and leuteinizing hormone
, b4 \8 p$ K: x+ l. q$ J! x: Aconcentrations were less than 0.05 mIU/mL( e5 | S, ?8 u; B3 @8 |8 N% u
(prepubertal).' [/ T C: I' O
The parents were notified about the laboratory
1 q. x9 h7 e2 E( W, J6 `results and were informed that all of the tests were
9 K7 K+ D7 T5 ?* f4 p Vnormal except the testosterone level was high. The
7 t- h+ L1 \3 H! Z5 yfollow-up visit was arranged within a few weeks to( ?: r Q5 I- b
obtain testicular and abdominal sonograms; how-
' B/ K- A: z4 Q. [3 j; x% yever, the family did not return for 4 months.
' Y5 M/ T2 }- _0 RPhysical examination at this time revealed that the
3 x- [# s8 g: B) Kchild had grown 2.5 cm in 4 months and had gained
" V" D% t% K/ ?6 W2 kg of weight. Physical examination remained1 f( L% S2 R4 s' A0 _! R9 u! k
unchanged. Surprisingly, the pubic hair almost com-0 r) ]+ N9 V: y5 x
pletely disappeared except for a few vellous hairs at2 W5 {* f% B) T; g$ q
the base of the phallus. Testicular volume was still 2& F7 w" ~: ~% c' f
mL, and the size of the penis remained unchanged.
" v; Y3 D6 U3 x: S, {The mother also said that the boy was no longer hav-
, f V- P# M; Iing frequent erections.5 f8 x4 D# L" m$ v7 h: R7 t
Both parents were again questioned about use of: u" M2 P! b0 l$ y' X
any ointment/creams that they may have applied to( E7 S8 i- r) e* p2 q0 a# D
the child’s skin. This time the father admitted the
4 S+ |; ^. u. a/ z% FTopical Testosterone Exposure / Bhowmick et al 541
0 A& H' V, [7 ]! y. l, Y) F! uuse of testosterone gel twice daily that he was apply-$ c1 x( M+ j- A4 e( U
ing over his own shoulders, chest, and back area for, J1 q2 U+ f" J
a year. The father also revealed he was embarrassed3 E& P$ P( B; H+ c4 g
to disclose that he was using a testosterone gel pre-7 c# y! T! K" w4 c8 o, _
scribed by his family physician for decreased libido- q* X. D, F5 T) Q0 T
secondary to depression.
+ v) y! v9 r- ` A1 l t0 R8 J1 P% }0 TThe child slept in the same bed with parents.; g: Z# l6 A) ~7 a6 s* k" |$ y
The father would hug the baby and hold him on his
* O5 E1 J& p9 \. E9 E) f1 fchest for a considerable period of time, causing sig-
4 H+ H- a8 g3 h) `/ Z2 Pnificant bare skin contact between baby and father./ q4 F1 _ H3 E3 W& _
The father also admitted that after the phone call,8 O: U; W- ~7 ]! ?* R' q
when he learned the testosterone level in the baby
0 {7 ^0 L5 }. V0 m* iwas high, he then read the product information
% w' {3 j: p; wpacket and concluded that it was most likely the rea-5 r' D! w- G6 d3 @
son for the child’s virilization. At that time, they
; K2 { @: n1 ^' x9 B6 k5 ldecided to put the baby in a separate bed, and the
4 C S' r; ?- t6 m; {' Tfather was not hugging him with bare skin and had2 H; [: [, E, e) j% x3 g
been using protective clothing. A repeat testosterone1 Y1 L E! X u: b: `% \
test was ordered, but the family did not go to the% p: b: \9 _9 ^8 y( s) ~
laboratory to obtain the test.
7 ^, K- d& a1 [' n7 F3 MDiscussion
5 R2 s& o7 f- l- e, p, k2 pPrecocious puberty in boys is defined as secondary P% j; p$ E. ~' z
sexual development before 9 years of age.1,4
0 a* |" k- {; \) {( n3 ^; l; rPrecocious puberty is termed as central (true) when5 N: S0 m" ?5 X2 y' e
it is caused by the premature activation of hypo-
0 K( K9 S6 l+ k5 S0 \5 q5 f. wthalamic pituitary gonadal axis. CPP is more com-9 x9 o" B. H- [: m- i" m, i. H* ?2 w
mon in girls than in boys.1,3 Most boys with CPP
5 Q4 {" s! @" ?+ I9 ]- Fmay have a central nervous system lesion that is: T- j+ Q8 ^5 R. s- I. g* X) V
responsible for the early activation of the hypothal- ~6 N& U p3 }/ D
amic pituitary gonadal axis.1-3 Thus, greater empha-
; W. f0 t# Y! a* k6 S+ J5 a; Y6 A& I9 hsis has been given to neuroradiologic imaging in- Z/ ~2 f' z- H/ |0 _
boys with precocious puberty. In addition to viril-* {$ d o( M; S9 p. C! x" Z
ization, the clinical hallmark of CPP is the symmet-3 `% J# s; m, B k( r
rical testicular growth secondary to stimulation by3 P* T$ S8 G5 m# e) d/ X
gonadotropins.1,32 v5 D$ l" f& g# n( Z
Gonadotropin-independent peripheral preco-
& N5 i+ j5 k5 M; t" Kcious puberty in boys also results from inappropriate
5 a& u8 ^0 e5 ]2 bandrogenic stimulation from either endogenous or
0 `% `5 y1 T, |9 S3 s3 |& _exogenous sources, nonpituitary gonadotropin stim-
3 m% v5 J: R# Y& U' s) s0 rulation, and rare activating mutations.3 Virilizing
N6 b* g* O p$ g+ r+ |! scongenital adrenal hyperplasia producing excessive
0 u" L) M. }5 A+ Q& ?) Kadrenal androgens is a common cause of precocious
$ o$ P+ d8 @* f. i( \puberty in boys.3,4
1 L, j" C8 |. bThe most common form of congenital adrenal
/ J7 {! j5 O+ O8 R; T9 Ihyperplasia is the 21-hydroxylase enzyme deficiency.' R7 g: d- a2 u6 a
The 11-β hydroxylase deficiency may also result in
K% T0 n$ j( \( Hexcessive adrenal androgen production, and rarely,
- u) \' i1 r/ f7 L9 Nan adrenal tumor may also cause adrenal androgen
) [* {8 S1 ~( o. `* lexcess.1,3
1 K5 u7 B9 h+ ~ _' Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. w# Q- J8 _' W. }" u7 I! b
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. l9 s# I: t! _
A unique entity of male-limited gonadotropin-, p# v/ Q6 U; W+ \! q' T
independent precocious puberty, which is also known
" M9 h8 Q3 X; h3 U Jas testotoxicosis, may cause precocious puberty at a
0 p0 O6 @' R4 t: }3 rvery young age. The physical findings in these boys
$ p* u0 N! {5 K% Hwith this disorder are full pubertal development,) H+ l$ k. s# S" W( |+ C
including bilateral testicular growth, similar to boys2 ~6 ^' N* V& t% ^) [
with CPP. The gonadotropin levels in this disorder
: L8 G: g/ |, Z+ Iare suppressed to prepubertal levels and do not show
% o# V0 z1 A9 P ?% {2 Vpubertal response of gonadotropin after gonadotropin-. V( e8 A8 D V/ B. ?6 v
releasing hormone stimulation. This is a sex-linked
- `# A$ ^( X, h0 @9 r# ~# [: |( _autosomal dominant disorder that affects only# C. ]* X1 e9 \/ v6 f4 L
males; therefore, other male members of the family
6 b& ]' h( R; ~ H$ ], nmay have similar precocious puberty.3$ n0 V" ?2 R8 z1 m* B
In our patient, physical examination was incon-, g2 s5 X" O8 i0 _- p
sistent with true precocious puberty since his testi-
/ a! H# E! Q9 b$ T' z* J! ], bcles were prepubertal in size. However, testotoxicosis
3 f0 x5 s4 d7 v3 } _# y% wwas in the differential diagnosis because his father9 m. D% X8 U# _( p; J3 B$ Y
started puberty somewhat early, and occasionally,
% b! o0 _, _, F5 _testicular enlargement is not that evident in the2 {# f7 I, _. p* q6 c( K: u! _5 f
beginning of this process.1 In the absence of a neg-3 }, e' k9 E# _$ S! r
ative initial history of androgen exposure, our6 p/ H. z& Q ?' k( i
biggest concern was virilizing adrenal hyperplasia,* p; w+ ^* X8 j( r
either 21-hydroxylase deficiency or 11-β hydroxylase
: S P- {5 @8 }- \/ e7 Cdeficiency. Those diagnoses were excluded by find-- r, X% J9 v; M
ing the normal level of adrenal steroids.- @! r N' I; j: j
The diagnosis of exogenous androgens was strongly# n. h8 o2 A: Q9 h, W- M5 [
suspected in a follow-up visit after 4 months because7 t1 a) g8 `2 ~- n
the physical examination revealed the complete disap-
# ]3 C' _' y8 i" I8 C: m1 {: vpearance of pubic hair, normal growth velocity, and
8 d6 l4 D5 L2 k2 p6 Q, p5 Hdecreased erections. The father admitted using a testos-
4 B3 S, b9 i8 v/ A, pterone gel, which he concealed at first visit. He was
) n$ E) y$ E0 `using it rather frequently, twice a day. The Physicians’2 b) R" ~( y& F9 e3 | M
Desk Reference, or package insert of this product, gel or
4 ^' d% F, p/ S% }3 h3 s+ O; P' z# ]cream, cautions about dermal testosterone transfer to
5 K; ~7 a5 \, L! o5 hunprotected females through direct skin exposure.% L, N1 t P& X% i
Serum testosterone level was found to be 2 times the
- x1 ]. }7 d, r8 g- l. H" \5 D) vbaseline value in those females who were exposed to
) q4 W3 X" ?6 V8 a; [$ [' Jeven 15 minutes of direct skin contact with their male) T2 @/ [/ o, P( \
partners.6 However, when a shirt covered the applica-2 r3 {; e" K* a( y1 ?9 Q
tion site, this testosterone transfer was prevented.
1 w% D8 T1 p" U# N/ dOur patient’s testosterone level was 60 ng/mL,7 A' L1 w; P# A$ j+ C
which was clearly high. Some studies suggest that5 N& ] s+ h) A+ q A/ F6 _
dermal conversion of testosterone to dihydrotestos-6 M4 M. i# p7 u
terone, which is a more potent metabolite, is more/ s! E, W/ G+ L. O# k( ~1 e
active in young children exposed to testosterone* y' R& S/ a4 E6 m/ R
exogenously7; however, we did not measure a dihy-# B) C0 H5 b2 H2 r
drotestosterone level in our patient. In addition to
e7 G7 ~8 x" @virilization, exposure to exogenous testosterone in6 ?9 ^# M, b7 z/ `) s
children results in an increase in growth velocity and* t0 v% B1 K# ^7 m/ v
advanced bone age, as seen in our patient.; e1 s+ I! k8 w( x( G$ n7 J
The long-term effect of androgen exposure during+ N* A/ l- X: f
early childhood on pubertal development and final* n7 q. Q% T6 Q+ ~% {5 e
adult height are not fully known and always remain
5 A! O3 l; O/ Na concern. Children treated with short-term testos-; O8 l n' a3 _+ A& _4 i
terone injection or topical androgen may exhibit some
! Z7 V. L; D( nacceleration of the skeletal maturation; however, after" D) R2 Z! K0 R4 u
cessation of treatment, the rate of bone maturation
4 `1 y K4 g C. _; q* Tdecelerates and gradually returns to normal.8,9
2 l2 Y3 l6 y9 \' ]+ q, z$ JThere are conflicting reports and controversy
/ h. m* G ~* y: @. I% aover the effect of early androgen exposure on adult7 v7 \& V$ r# `+ v/ q
penile length.10,11 Some reports suggest subnormal7 V5 k8 |* W2 ~% f& ^2 S V: k% w
adult penile length, apparently because of downreg- G `" l5 {+ r
ulation of androgen receptor number.10,12 However,, E6 z8 g x4 E: J/ Z
Sutherland et al13 did not find a correlation between1 }0 P0 a q5 j& _# R8 p8 J
childhood testosterone exposure and reduced adult/ s5 Q+ s5 z; c
penile length in clinical studies.
1 I! Y2 r/ a5 @% l: W6 L6 G" nNonetheless, we do not believe our patient is/ B: Y! Q1 H& I+ _5 y6 ~
going to experience any of the untoward effects from
1 O/ u4 f9 @+ W. t' E- G( dtestosterone exposure as mentioned earlier because
; [9 ~ r' A' l3 }0 A) n Athe exposure was not for a prolonged period of time., p7 j$ e% y6 _* v& Q
Although the bone age was advanced at the time of) K5 Z: {3 ], I& d# L: F6 C
diagnosis, the child had a normal growth velocity at
7 [$ R% x" v, l6 C. Hthe follow-up visit. It is hoped that his final adult
( p+ g- v! {$ z4 }height will not be affected.4 I3 N. C& N3 s$ Y
Although rarely reported, the widespread avail-
! L1 k3 }* H; n+ M2 dability of androgen products in our society may
0 L4 s3 v5 W+ W. v! I3 Q2 qindeed cause more virilization in male or female! n) _3 e. k9 |- \
children than one would realize. Exposure to andro-" N& y& P* G- \8 \/ r C
gen products must be considered and specific ques-' C9 ]7 E5 f# J# g
tioning about the use of a testosterone product or# r' H$ V4 `+ D
gel should be asked of the family members during4 E1 e8 S+ I+ `6 ?% W8 `, c
the evaluation of any children who present with vir-5 r- I2 W: `8 I( v, l0 W) W
ilization or peripheral precocious puberty. The diag-3 c3 m3 Y* w, ~, m9 |0 c
nosis can be established by just a few tests and by
7 G6 Y/ p3 q. h2 B% Nappropriate history. The inability to obtain such a
/ V$ U3 T& e4 a; w8 \% c+ V; x7 p' G$ R) Yhistory, or failure to ask the specific questions, may
k( j# u3 z: {' l, aresult in extensive, unnecessary, and expensive& U2 W' A; }0 G% N5 |
investigation. The primary care physician should be
4 J$ m; l4 x8 H5 w# ?- t9 @aware of this fact, because most of these children& H( D# L* f4 `) X7 X: P8 Q
may initially present in their practice. The Physicians’
' @! B# s0 _& G* k8 l5 K, LDesk Reference and package insert should also put a( g1 h) t3 e4 b% p3 V
warning about the virilizing effect on a male or
, i8 N) i8 c1 U2 rfemale child who might come in contact with some-
6 T- c' N3 p2 V1 Y0 J z5 oone using any of these products.. A1 l0 b6 h* M! F0 o
References
: o) o3 }1 Q6 v; ?1. Styne DM. The testes: disorder of sexual differentiation
, u3 S) v" d$ Eand puberty in the male. In: Sperling MA, ed. Pediatric
0 t, l% D% B3 u# n/ wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 W+ |+ O; ?5 b& B. E5 [9 E- q
2002: 565-628.
' Z+ T; t f* Z& T" ~' i2 w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& w8 y. L% `8 M4 b' H# Xpuberty in children with tumours of the suprasellar pineal |
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