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Sexual Precocity in a 16-Month-Old
7 g! x/ Q% o5 D- Q! cBoy Induced by Indirect Topical
m8 k1 O, \* U D; {- A9 iExposure to Testosterone
. n' Z) E& Q7 WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 ^& E" l4 B- cand Kenneth R. Rettig, MD1
' x: r! ~2 x" d& iClinical Pediatrics
6 ~1 }8 w4 [* p5 FVolume 46 Number 6! c& Z8 ~7 n: ~
July 2007 540-543
; q' I+ C ?2 s. i- F© 2007 Sage Publications" m v" Q9 j1 F- Z
10.1177/0009922806296651
3 ~. u$ y! q% Z9 Y; Ghttp://clp.sagepub.com. J+ w- J+ i6 Y5 W* D: p, d* g% ^% Y
hosted at1 ]' {+ J" c: d7 y2 s2 v2 }" v
http://online.sagepub.com# h. U% V) A! }- r
Precocious puberty in boys, central or peripheral,& W W: p2 A4 r7 j
is a significant concern for physicians. Central
5 Y% R& h- c/ q3 S! Dprecocious puberty (CPP), which is mediated# I2 T0 C$ G8 U
through the hypothalamic pituitary gonadal axis, has
+ n: p: i( f0 J8 k9 E& Pa higher incidence of organic central nervous system
4 [. t7 [0 ?6 P1 b7 i9 K% H8 n4 [lesions in boys.1,2 Virilization in boys, as manifested+ P" ?! a( |! r9 p' n' Y$ ^
by enlargement of the penis, development of pubic
( s, p$ Q2 D: W' B d: Ihair, and facial acne without enlargement of testi-
- U- h8 l8 ~& C5 t+ rcles, suggests peripheral or pseudopuberty.1-3 We
# B- v$ `" w! Y( v6 D s) u' B6 ~report a 16-month-old boy who presented with the
( a( \8 q( [7 e% b8 h: L# a+ _ Genlargement of the phallus and pubic hair develop-9 C% k, _0 I3 V9 e! A
ment without testicular enlargement, which was due$ [# y- `# _$ d1 X; o
to the unintentional exposure to androgen gel used by4 w) U2 f3 Q. L9 }$ U2 s; r1 |# f
the father. The family initially concealed this infor-" s0 r4 U( J( I! e5 \* b
mation, resulting in an extensive work-up for this
! I- _# d+ l: g/ D I8 gchild. Given the widespread and easy availability of
( X' K# `. [, G5 l0 A. Ltestosterone gel and cream, we believe this is proba-
- o+ w. M) h; R! t1 n1 ]+ Cbly more common than the rare case report in the
: a; d* E6 Z; y6 K% \/ @literature.44 e% a/ a3 v" F- @( f2 ^1 \
Patient Report
7 \4 ~- `4 N, h, ^# e7 a. a- c9 LA 16-month-old white child was referred to the
0 R0 F4 Y1 y( k, U' E$ Sendocrine clinic by his pediatrician with the concern
6 {, M( B& j4 a1 |" t( E$ ?5 @. tof early sexual development. His mother noticed" Z$ n9 ~9 E g8 |
light colored pubic hair development when he was1 M5 I) E$ D+ d
From the 1Division of Pediatric Endocrinology, 2University of
# V* |1 {5 Y1 v9 e6 ySouth Alabama Medical Center, Mobile, Alabama.0 I/ F( Y* m3 v
Address correspondence to: Samar K. Bhowmick, MD, FACE," {9 y; u* W0 e) @ w4 h3 _
Professor of Pediatrics, University of South Alabama, College of/ O9 T/ k/ ^6 Q1 B4 V- l% L8 ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: V w. f3 U2 y+ Z7 oe-mail: [email protected].
% u* I& J* l! z% rabout 6 to 7 months old, which progressively became$ T9 v) L$ K# d$ f5 b* z
darker. She was also concerned about the enlarge-) O P" g% R& c$ T. z0 T
ment of his penis and frequent erections. The child+ e( v, n. N. {+ u
was the product of a full-term normal delivery, with
2 C, J3 X5 @9 Z& g) U0 H/ Da birth weight of 7 lb 14 oz, and birth length of
2 m1 T8 S, r8 I6 ]+ G! o3 V20 inches. He was breast-fed throughout the first year) c# \+ I, U' x* U Z
of life and was still receiving breast milk along with
$ e4 C: k! ]7 v- A* M! |" rsolid food. He had no hospitalizations or surgery,. N4 _4 ]* v! k
and his psychosocial and psychomotor development
6 u) F5 q$ D, Xwas age appropriate.# B7 E: W2 C3 h8 g5 v3 O
The family history was remarkable for the father,7 p6 e* c7 v2 G9 k
who was diagnosed with hypothyroidism at age 16,* ^, @ O$ f! ?8 n8 l
which was treated with thyroxine. The father’s
; S" E2 [3 P1 q6 r3 T3 m) kheight was 6 feet, and he went through a somewhat# d8 ^* F. ?( i( g0 b
early puberty and had stopped growing by age 14." s1 k! l. ^' O$ c
The father denied taking any other medication. The
8 D0 D8 r' o; j. lchild’s mother was in good health. Her menarche. N& v: l" @; Z
was at 11 years of age, and her height was at 5 feet
9 Y& n2 t( m- x4 h& f! S5 inches. There was no other family history of pre-( p m. p- L% ?
cocious sexual development in the first-degree rela-
0 F. X" |0 A( {tives. There were no siblings.
! N# k* @3 ~& V! i+ Z+ }+ ~Physical Examination
a& f3 X$ E& l) _7 T- TThe physical examination revealed a very active,
# `% M8 p n5 y uplayful, and healthy boy. The vital signs documented
2 x. `7 J. V7 k: T3 y0 ba blood pressure of 85/50 mm Hg, his length was* I& A; m0 J* s
90 cm (>97th percentile), and his weight was 14.4 kg+ G2 y8 T" B5 R+ Y* b2 i
(also >97th percentile). The observed yearly growth* T! ~8 X1 ^8 [: w+ W' m9 K
velocity was 30 cm (12 inches). The examination of" w' K& z3 i- S1 q
the neck revealed no thyroid enlargement.1 s$ H/ e: N3 b- {. f
The genitourinary examination was remarkable for
6 C! t2 r: r2 henlargement of the penis, with a stretched length of
$ m0 L* j# s2 W- X6 C/ ~9 a8 cm and a width of 2 cm. The glans penis was very well0 a- u* X9 |" A$ w
developed. The pubic hair was Tanner II, mostly around C* c( K* {! n/ O
540) n' |( ?( d! ?: {- g G5 u2 ]' I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ V& r) a# x. Ithe base of the phallus and was dark and curled. The6 R2 G5 _5 @: \. |8 T" E) t: q
testicular volume was prepubertal at 2 mL each.; z; C2 B3 R' z2 l2 `6 P N+ ~2 T) N
The skin was moist and smooth and somewhat- I0 O2 P1 e* d: {! D
oily. No axillary hair was noted. There were no A- `8 F5 c; R; w! ~/ z
abnormal skin pigmentations or café-au-lait spots.
' ?' V* r8 `+ S- x6 INeurologic evaluation showed deep tendon reflex 2+
% c, j$ u M$ {' Ubilateral and symmetrical. There was no suggestion
2 T2 ] u1 ]1 a" x/ Sof papilledema.* r% q% c" H8 v! M: q
Laboratory Evaluation
( k# C( o* ~" i6 P0 Q1 kThe bone age was consistent with 28 months by
9 \' z n; ~+ Z. `+ S. q1 E/ lusing the standard of Greulich and Pyle at a chrono-9 V$ ~- I7 u" S
logic age of 16 months (advanced).5 Chromosomal
}% f0 r, R/ n2 n1 m6 ukaryotype was 46XY. The thyroid function test# Q6 A+ ~8 n1 D: h4 d' j: Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 A& d, J3 D; N. S; G- t% rlating hormone level was 1.3 µIU/mL (both normal).- V* n+ q* `. T
The concentrations of serum electrolytes, blood
$ D/ }6 b! T q8 N" w% f# aurea nitrogen, creatinine, and calcium all were e( q0 b6 G) Q0 q- I6 r
within normal range for his age. The concentration
; P0 Y' ?9 I& [5 i9 zof serum 17-hydroxyprogesterone was 16 ng/dL# C" t9 y4 k2 ]1 {' W
(normal, 3 to 90 ng/dL), androstenedione was 20
& T' c( K0 M4 ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ G2 q! s0 l% j3 u4 O& d4 ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 ^2 L- b* w* u! O9 [7 d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ k0 P- T( l6 d( I& ~7 s
49ng/dL), 11-desoxycortisol (specific compound S)
/ v- e# m# X/ B* M7 ]( p" \was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ _; Y( H3 \1 Y6 _9 M8 N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: L. J; w1 r1 m1 G. T2 r; T* }+ N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! b; _+ l6 `7 J9 l7 b" nand β-human chorionic gonadotropin was less than
6 U3 P3 Q- c" c" S. j: Y4 m. K5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 ]3 y, e- k1 y1 o8 Hstimulating hormone and leuteinizing hormone
|$ i/ s3 G- Y$ m9 g* q- ?concentrations were less than 0.05 mIU/mL0 e" w# i: t. [" s4 |3 U9 e0 v
(prepubertal).- L U5 Q4 W1 V
The parents were notified about the laboratory" E! z- G: t- p; ?# @
results and were informed that all of the tests were; X2 n2 E: s5 z" E X
normal except the testosterone level was high. The
( t5 _3 W/ c' }0 ^; Pfollow-up visit was arranged within a few weeks to
/ J. ~/ \+ K+ {; x% {8 Mobtain testicular and abdominal sonograms; how-
1 V$ s1 N: j. g$ g) Yever, the family did not return for 4 months." |% m Q0 j; G; S4 e; r
Physical examination at this time revealed that the
! X1 J" M/ H; a1 E/ s0 V0 Dchild had grown 2.5 cm in 4 months and had gained$ K, O3 w$ ~' w. n3 X
2 kg of weight. Physical examination remained
& Y: l7 H: ~1 K, p3 k0 ]unchanged. Surprisingly, the pubic hair almost com-# {. U/ D; T+ F7 z" p2 q
pletely disappeared except for a few vellous hairs at% E* _% ?0 j& v" t' i R2 H
the base of the phallus. Testicular volume was still 2
/ f3 i* x7 P. l! W' hmL, and the size of the penis remained unchanged.
+ x8 Z# F+ S3 j+ j6 ~1 D4 C+ ?" m: nThe mother also said that the boy was no longer hav-
8 {3 D' _8 A8 d) W9 J$ U3 u+ {ing frequent erections.
8 h( C* W; Z c% r/ MBoth parents were again questioned about use of
?: ?" Y0 J- u: B5 W6 @+ e9 \! Xany ointment/creams that they may have applied to) Z# _0 k5 b- s6 {- {0 t) i! X" H& V1 U
the child’s skin. This time the father admitted the
8 a/ m8 M4 ~& c. yTopical Testosterone Exposure / Bhowmick et al 541( ?3 ^/ {: B L' @3 j9 q
use of testosterone gel twice daily that he was apply-
. x: {' B- D0 H7 ]# ~' T1 ving over his own shoulders, chest, and back area for8 T0 }1 w9 [# j. x3 o5 U" z2 [
a year. The father also revealed he was embarrassed
- @3 L$ t7 ^/ o! ?+ m! bto disclose that he was using a testosterone gel pre-
0 l1 f, l# l7 K# W5 z. U l/ xscribed by his family physician for decreased libido7 J' J6 @" c6 z, ~6 c
secondary to depression.
( |( w4 z, X8 R3 SThe child slept in the same bed with parents.% p/ q# V* ?& G
The father would hug the baby and hold him on his
, ]: N$ P b; C& f: kchest for a considerable period of time, causing sig-1 Z1 | K; S4 x* L! I' r2 |, C
nificant bare skin contact between baby and father.3 M& c/ u7 S- r; c( S# ?- X
The father also admitted that after the phone call,
, q: w. u7 D! I+ z% y( Swhen he learned the testosterone level in the baby, `9 t. m C; V2 R7 M s) Q$ G
was high, he then read the product information9 h6 U! P0 k) W2 G: \
packet and concluded that it was most likely the rea-
: v' r S/ g+ m9 H# X, Gson for the child’s virilization. At that time, they
5 C) O( o. v' S, W9 A& ?decided to put the baby in a separate bed, and the
" v9 A& X) |( \# D% e" j" B9 mfather was not hugging him with bare skin and had0 [/ F& p2 R2 f* B
been using protective clothing. A repeat testosterone/ m; V2 i2 |: v& U8 }
test was ordered, but the family did not go to the2 q8 B, {4 o! C: s6 S
laboratory to obtain the test.
! g$ o) w' _$ C# ADiscussion
, L+ s6 x/ Z, e2 _Precocious puberty in boys is defined as secondary4 T( T2 O# }5 j" E
sexual development before 9 years of age.1,4
3 N+ J9 c: k6 [# [% TPrecocious puberty is termed as central (true) when; H( [# P1 R- \; N8 a- p, j
it is caused by the premature activation of hypo-; M0 e9 Z) T6 {4 ~
thalamic pituitary gonadal axis. CPP is more com-' c4 o) \6 f' u' f& z% A
mon in girls than in boys.1,3 Most boys with CPP
9 R- S4 c, O( k+ q5 B0 L4 Q1 C2 \0 Vmay have a central nervous system lesion that is
4 h! p& \, |( D( }# Uresponsible for the early activation of the hypothal-# |% Y" _# a3 R+ j
amic pituitary gonadal axis.1-3 Thus, greater empha-! w: A( n1 z# ?* S7 Y, J
sis has been given to neuroradiologic imaging in' T: q6 w; C* J" ?) x6 d# k
boys with precocious puberty. In addition to viril-1 \- j7 U9 v8 ?- d& ?3 k
ization, the clinical hallmark of CPP is the symmet-: W1 T; H* m% Z* ~' }9 N
rical testicular growth secondary to stimulation by
) |7 ]3 j8 @0 r( igonadotropins.1,3, }# K! s" o- s6 |/ D
Gonadotropin-independent peripheral preco-& |. }2 [2 [5 x8 Z
cious puberty in boys also results from inappropriate" Q5 B1 i: `$ a3 X
androgenic stimulation from either endogenous or. B* q" D1 C( y* |: r1 h
exogenous sources, nonpituitary gonadotropin stim-3 w% C0 }. Q, A6 ], a) h
ulation, and rare activating mutations.3 Virilizing
" M% X, q+ z0 w* h& Wcongenital adrenal hyperplasia producing excessive8 c" |. `- n. E. \
adrenal androgens is a common cause of precocious
& v# |; F- u# D' b: i' m" w$ kpuberty in boys.3,4
7 _+ ~4 E5 b/ H& D+ `% F3 j7 `The most common form of congenital adrenal
[' a% {9 d2 y- ]hyperplasia is the 21-hydroxylase enzyme deficiency.
& B6 P% G5 m4 H# Q5 e$ |; ]: D3 CThe 11-β hydroxylase deficiency may also result in
0 `# p, m. |$ Z( ?excessive adrenal androgen production, and rarely,' w1 Z5 {' ?- Y' |) N
an adrenal tumor may also cause adrenal androgen5 u" Y1 k& F. a6 P% w X! K, `
excess.1,3
" F% E/ \0 ?' x/ x& C" |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 U; A# f, `2 U2 d' @' k! A542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- A8 n8 f. |, c/ k( ?* O' K" l; J/ E
A unique entity of male-limited gonadotropin-. V+ d4 P9 `; \' |
independent precocious puberty, which is also known
+ Q, C/ A( W+ J# K) w, O4 Y6 Jas testotoxicosis, may cause precocious puberty at a
9 N! k/ m; N m9 _( Zvery young age. The physical findings in these boys. _ y% Q7 L+ ]- f9 @
with this disorder are full pubertal development,* Z- d1 i$ Z7 `7 x( r9 @
including bilateral testicular growth, similar to boys
' `* T! Q( \- s6 d s) `with CPP. The gonadotropin levels in this disorder
& y9 X& _$ O% U6 j# p' ~ \are suppressed to prepubertal levels and do not show" m4 m0 R! Y$ _# u0 H7 P- h5 `
pubertal response of gonadotropin after gonadotropin-
: j' b3 Y6 M) creleasing hormone stimulation. This is a sex-linked
, |) ^8 z& x/ \) d0 j4 r: { tautosomal dominant disorder that affects only: c7 G) j0 J+ t; W+ r$ L
males; therefore, other male members of the family
# B. m- ?- I" T, K1 Z& e8 [may have similar precocious puberty.3
6 W. E* b1 M7 T9 @& ^In our patient, physical examination was incon-
4 N4 _! `3 f0 s* E z. R7 z$ Xsistent with true precocious puberty since his testi-# r( h' f) E- q" V' H3 l) p: @
cles were prepubertal in size. However, testotoxicosis
2 p" y2 }3 E \" P* E: ^4 Jwas in the differential diagnosis because his father
) A" Y+ A2 e' g# P, _started puberty somewhat early, and occasionally,
2 W1 K, s' X j I% c) jtesticular enlargement is not that evident in the
9 x$ `! L/ ~3 x9 xbeginning of this process.1 In the absence of a neg-8 p# R& A- j; G5 Z6 s. A; v
ative initial history of androgen exposure, our
6 x; A% b6 W" C3 J+ U5 rbiggest concern was virilizing adrenal hyperplasia,! Y7 k# _* ?2 B {$ N2 t. D
either 21-hydroxylase deficiency or 11-β hydroxylase
& ?7 ]/ D" I$ j4 |' q2 j/ T# mdeficiency. Those diagnoses were excluded by find-, q( a3 ]1 E2 M5 S8 l; v4 ]+ s
ing the normal level of adrenal steroids.
5 b- X/ f: R3 b: ]& A$ cThe diagnosis of exogenous androgens was strongly
0 T) \) @, f2 B* ?+ N* ~* a6 L6 qsuspected in a follow-up visit after 4 months because) p. @2 e. o/ U, v
the physical examination revealed the complete disap-; U9 X8 ^( S; Y2 Y4 o1 D
pearance of pubic hair, normal growth velocity, and
$ T& Z2 f9 T" ^$ J4 ?) [! j/ Zdecreased erections. The father admitted using a testos-4 E7 X. Y3 q5 w& s4 G: D z% k
terone gel, which he concealed at first visit. He was3 _, A4 l8 ^6 V+ o; q( {3 C+ ?
using it rather frequently, twice a day. The Physicians’! u9 ?5 N# `' K; d/ \
Desk Reference, or package insert of this product, gel or. p8 d5 U7 W( n8 S4 S
cream, cautions about dermal testosterone transfer to) O- X2 B5 h( o6 O
unprotected females through direct skin exposure.
1 U8 r0 R9 }4 kSerum testosterone level was found to be 2 times the
4 [, v% L: |/ fbaseline value in those females who were exposed to
: J$ j" L; |4 L L$ Jeven 15 minutes of direct skin contact with their male! |% \' R* ]) Z& v) J! ?
partners.6 However, when a shirt covered the applica-) \' K/ U; ]4 |5 w. z( ~
tion site, this testosterone transfer was prevented.+ Y; }' f3 p9 X8 r: C
Our patient’s testosterone level was 60 ng/mL,2 z+ z$ I% C9 k
which was clearly high. Some studies suggest that
" O% H/ W5 {/ ]dermal conversion of testosterone to dihydrotestos-& P) }% k' J1 B. L% I
terone, which is a more potent metabolite, is more
: V. ?% I+ P0 b$ vactive in young children exposed to testosterone
& ?" j3 t3 |. H. M& W. |" }3 nexogenously7; however, we did not measure a dihy-" o1 d! P$ b9 c3 w" v" f8 N
drotestosterone level in our patient. In addition to
6 T( `4 t3 N4 P0 N, ^virilization, exposure to exogenous testosterone in
$ l- y% B6 i [7 qchildren results in an increase in growth velocity and/ {# c- o+ w+ x
advanced bone age, as seen in our patient.
- A: U" T& r/ LThe long-term effect of androgen exposure during" u1 m. {5 Y8 o, J9 J, Q s% I
early childhood on pubertal development and final
1 P- N3 v* I, p+ i; |6 s8 S7 qadult height are not fully known and always remain; R0 A& T) l I( G5 X
a concern. Children treated with short-term testos-4 `( }2 q( W7 {% b" e
terone injection or topical androgen may exhibit some
* {# e& H6 y# {8 {4 U1 [: ?; ~! Kacceleration of the skeletal maturation; however, after
' `, ?" b7 r/ e M" k) t* ecessation of treatment, the rate of bone maturation0 d: R2 Q E: k* a$ k/ l8 |
decelerates and gradually returns to normal.8,93 u4 K2 y- f$ p$ W! J
There are conflicting reports and controversy
- A6 Q( _: R, }% T% g! m' G, Gover the effect of early androgen exposure on adult
9 ^! S( O) U* [( Rpenile length.10,11 Some reports suggest subnormal
1 l1 t+ a# {4 k% ]0 Y$ @% E8 Nadult penile length, apparently because of downreg-
( [$ P6 H/ m# V- ~5 qulation of androgen receptor number.10,12 However,, [$ R5 U' F, x0 X+ P7 U
Sutherland et al13 did not find a correlation between! L( O) w; E" f9 Y
childhood testosterone exposure and reduced adult
% N, ^0 z" u$ wpenile length in clinical studies.' \, I! i5 P4 d4 |7 g; ~0 j& E& f
Nonetheless, we do not believe our patient is6 n" X7 C# e4 s( r, \6 J( M
going to experience any of the untoward effects from% t- K; k* P: Y4 X
testosterone exposure as mentioned earlier because
1 a: F: a- I, P2 bthe exposure was not for a prolonged period of time.
0 P9 @" ], {, Y4 P% M/ OAlthough the bone age was advanced at the time of
' [4 W4 ~. h' f* c9 ldiagnosis, the child had a normal growth velocity at
. q- U4 n) O F' r! V7 uthe follow-up visit. It is hoped that his final adult7 D9 n/ K! ~! i7 K* W5 X
height will not be affected.
) \2 L1 [0 M# J% fAlthough rarely reported, the widespread avail-, A# V t( _' {8 u, n
ability of androgen products in our society may
2 ]- \( V" X. w3 _+ I) o1 windeed cause more virilization in male or female# N% A4 k9 T8 w2 q+ l8 s; d
children than one would realize. Exposure to andro-
- x* g' z! P/ fgen products must be considered and specific ques-% w& T5 x1 V" [8 B
tioning about the use of a testosterone product or( ~& z8 M- z- x0 v( \% V
gel should be asked of the family members during
+ Y5 r' w8 D* Bthe evaluation of any children who present with vir-2 @; m o! F7 ~9 a
ilization or peripheral precocious puberty. The diag-& V! N5 G4 l- K5 e4 M% ~; K
nosis can be established by just a few tests and by
5 j& H( a! @) S0 E; n% G ]appropriate history. The inability to obtain such a7 X M5 A" ~9 {; u& x
history, or failure to ask the specific questions, may X; L$ \ J9 X* I8 {& k9 d
result in extensive, unnecessary, and expensive/ P% Q5 F. W( D+ E/ r
investigation. The primary care physician should be, @- ^3 {" r3 ~0 G$ c, A& ~
aware of this fact, because most of these children3 [$ L% h" _! f/ p S6 e- L
may initially present in their practice. The Physicians’
: {6 s& d5 u, N5 @Desk Reference and package insert should also put a1 J% f K. X7 B& u% S/ Y- v
warning about the virilizing effect on a male or6 f8 `' J- o% S
female child who might come in contact with some-1 z( K- a: a* u
one using any of these products., J" z& g7 L- d) x7 I, g
References1 O( ]5 X2 u w' B
1. Styne DM. The testes: disorder of sexual differentiation
: N& y$ V k8 z0 uand puberty in the male. In: Sperling MA, ed. Pediatric( o/ M, L* F; ]) {0 Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) M7 J3 i* E; c* L# j6 L
2002: 565-628.
! A7 e7 K8 }" K$ N! v" c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 \: V! E; a) Q' F0 W z5 K; vpuberty in children with tumours of the suprasellar pineal |
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