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Sexual Precocity in a 16-Month-Old8 u( L6 ^4 R% K3 P W+ M1 S5 A
Boy Induced by Indirect Topical
0 H2 l# t) M! Z! ` Q. CExposure to Testosterone: [. i% @" b. l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 }: w [! @* |- l. K0 fand Kenneth R. Rettig, MD1
) o; { R; { T6 HClinical Pediatrics
/ n& J, G" e9 QVolume 46 Number 6. O5 a m8 w9 n) q+ g: g
July 2007 540-543# b' q& f! s- ~
© 2007 Sage Publications
' Y, I& `+ B7 u$ B6 u, v10.1177/0009922806296651
Z1 Y* @. Y, v: Qhttp://clp.sagepub.com, b- Z/ p6 H9 e: [
hosted at
9 T3 `6 C$ w- l( a! V/ ]http://online.sagepub.com0 F& a) }; ] k) t& J1 K
Precocious puberty in boys, central or peripheral,
# k& W, _- Z% g$ z1 his a significant concern for physicians. Central
' g/ f% Z7 B; g* a! c& {( vprecocious puberty (CPP), which is mediated* w% b5 S# t v ?+ X2 g
through the hypothalamic pituitary gonadal axis, has
& Y C. A! x* j! g4 ?3 {a higher incidence of organic central nervous system
0 d! d( p) m- o3 V2 x" s1 _lesions in boys.1,2 Virilization in boys, as manifested
$ L( F: {' k) t2 P$ H( Bby enlargement of the penis, development of pubic
. C) ^# \1 T1 s0 r$ e% ]hair, and facial acne without enlargement of testi-8 c; F# _" ]5 W) w! |; b/ X' d
cles, suggests peripheral or pseudopuberty.1-3 We
# m+ y" F! j, I" J! c4 M. m4 b2 freport a 16-month-old boy who presented with the& W4 Y# _5 S- Y/ m Z$ \
enlargement of the phallus and pubic hair develop-
& s2 ~& k0 j4 u( ~) G( b5 O% a) oment without testicular enlargement, which was due7 X) a" B/ M P" b# b
to the unintentional exposure to androgen gel used by
1 H: E2 u5 d! m: a) H+ t! d& M, c8 gthe father. The family initially concealed this infor-
! y+ N9 k% B2 D. ?' a9 Smation, resulting in an extensive work-up for this/ |# w' ?8 [' w- B5 ]# U
child. Given the widespread and easy availability of, S- Z! w3 g9 e. C3 V
testosterone gel and cream, we believe this is proba-, {- b" v( E& p B8 {% g* w
bly more common than the rare case report in the
) W" r: U! [9 a; f2 Gliterature.47 E* f' m* W8 Y$ ^' D
Patient Report
: u8 W& X+ s+ U/ ^" ?' Z# E- mA 16-month-old white child was referred to the, R4 d. E4 D( P% Z8 p4 W' `/ P
endocrine clinic by his pediatrician with the concern% \& \0 i. h) {6 v
of early sexual development. His mother noticed5 U- Z1 T Y7 A, Y' J' n1 ?2 P1 z
light colored pubic hair development when he was
0 B/ `5 p% `) hFrom the 1Division of Pediatric Endocrinology, 2University of3 q# y; ?" H3 J0 Y
South Alabama Medical Center, Mobile, Alabama.
6 @1 `6 A C+ h+ a$ y& _5 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,' q% A! _+ C! j6 n% s
Professor of Pediatrics, University of South Alabama, College of+ ^, ~9 @4 y! K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ J5 Z$ u% \* v- W/ J- j! B7 ^e-mail: [email protected].# m% O0 S7 ^+ |. ?3 H
about 6 to 7 months old, which progressively became1 E# E. K) f f2 i4 ?2 [" D, m* n
darker. She was also concerned about the enlarge-
1 X: V. \! X+ R$ W6 ]1 n+ Wment of his penis and frequent erections. The child
8 C3 U$ C, ~; ?( Fwas the product of a full-term normal delivery, with' W1 `/ v( Z5 s- V* E4 C6 ^! U
a birth weight of 7 lb 14 oz, and birth length of
$ p! X/ n* ^4 W20 inches. He was breast-fed throughout the first year8 ?7 o; R4 j( Y
of life and was still receiving breast milk along with+ C% O7 P6 H- x, y6 ^* P2 e$ U
solid food. He had no hospitalizations or surgery,
( S7 p& z" A( @4 ?and his psychosocial and psychomotor development5 r5 u5 M. h# w7 k$ [; i6 W* r
was age appropriate.! E+ r' l# v1 h7 \! J6 j2 j2 k
The family history was remarkable for the father,
3 [ Z+ l3 R( E. \0 w$ Pwho was diagnosed with hypothyroidism at age 16,) Y/ P2 e, {# T5 o. O2 J1 o- }
which was treated with thyroxine. The father’s7 ] m+ Z' j5 X& a- U5 Y& n# m4 e
height was 6 feet, and he went through a somewhat+ j9 L4 V# n' U1 _2 `/ d7 D7 v" y
early puberty and had stopped growing by age 14.
m, h$ c* r0 hThe father denied taking any other medication. The
0 X* |) S& k3 \1 g3 ?1 @& schild’s mother was in good health. Her menarche
" q) ]6 s/ H* f gwas at 11 years of age, and her height was at 5 feet
* ]$ e- ^) E S+ H5 inches. There was no other family history of pre-$ v# r7 a( M+ H$ a( ?7 m. B- O p2 q
cocious sexual development in the first-degree rela-
9 w' m& y8 f& g c- ? Etives. There were no siblings." c5 S2 ^8 |* W) I
Physical Examination y2 ^3 t2 u1 Z2 O
The physical examination revealed a very active,
" r% Y+ K* M( T7 j% n: ]# ]. Pplayful, and healthy boy. The vital signs documented& r/ H+ p# h/ c! t
a blood pressure of 85/50 mm Hg, his length was8 {( Y% H9 x6 i% @" }, h5 T% z4 G# V
90 cm (>97th percentile), and his weight was 14.4 kg$ m% x0 V; s3 T) [4 j! z
(also >97th percentile). The observed yearly growth
' s* |2 ?8 f" w1 a1 o, Hvelocity was 30 cm (12 inches). The examination of
( ]. R, R& q% ^$ _; ~3 Athe neck revealed no thyroid enlargement.
2 n t/ t% |' g# B1 \The genitourinary examination was remarkable for( Z- E# m1 P& K h o
enlargement of the penis, with a stretched length of, b/ v4 P/ _: U2 R/ i
8 cm and a width of 2 cm. The glans penis was very well
3 _4 B9 {( r6 Z9 Y0 Q8 { L: Zdeveloped. The pubic hair was Tanner II, mostly around' U; x, b/ }- m$ d6 V2 K# n
540* I5 e* j2 ~' `9 o5 X. @, b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% ?' ~1 g+ L- s& ^( |/ Tthe base of the phallus and was dark and curled. The
5 w; \0 g/ r: P4 jtesticular volume was prepubertal at 2 mL each.- i$ a& q8 T# T9 [
The skin was moist and smooth and somewhat
, i8 @! U9 d1 ?oily. No axillary hair was noted. There were no
! k% n8 |) V6 S" R8 Babnormal skin pigmentations or café-au-lait spots.
V" q! a; ?9 k+ S2 s, f/ PNeurologic evaluation showed deep tendon reflex 2+
! i; N4 c9 a% L/ Obilateral and symmetrical. There was no suggestion! S- S2 G$ T; P2 x
of papilledema.# Z8 q2 P$ e3 f! u
Laboratory Evaluation
+ o8 `, Y; H6 h9 sThe bone age was consistent with 28 months by+ Z) C( v |% B
using the standard of Greulich and Pyle at a chrono-
1 S) X& a% P5 j* J1 d Q2 elogic age of 16 months (advanced).5 Chromosomal& A$ B% b" Q7 F. f
karyotype was 46XY. The thyroid function test3 Z( `% h& Q( _
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: u9 a6 x, f( |- n3 o& ]
lating hormone level was 1.3 µIU/mL (both normal).
0 {1 v2 z! L. m: r7 `" I- w yThe concentrations of serum electrolytes, blood
3 o' ~+ [# x! E" }: \' b2 [7 ]urea nitrogen, creatinine, and calcium all were
+ y% U/ W l0 ?5 j' a# G4 pwithin normal range for his age. The concentration3 N5 F/ |) N S) j! d) q$ j
of serum 17-hydroxyprogesterone was 16 ng/dL
) H' H$ v7 @, q7 B; }0 w; e: a+ R) z(normal, 3 to 90 ng/dL), androstenedione was 20
1 R2 W4 w0 t: ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 @: {1 I. a' D- Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),! l& E9 f' E) ^1 T T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 p4 H5 [" U" l8 y1 t
49ng/dL), 11-desoxycortisol (specific compound S)4 g. [. s* {! l) m3 O; Q% n
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 |& X7 Q/ i R9 s9 i0 [3 @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" X" W- M0 c& s+ I) O0 M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 F# m) o$ S% d$ Z" Q2 o; J- T* Yand β-human chorionic gonadotropin was less than
$ ^% A5 {- b- u5 }9 n$ e- X5 mIU/mL (normal <5 mIU/mL). Serum follicular! y# }; m( ~# T
stimulating hormone and leuteinizing hormone
) W# R2 e7 @6 h# I' bconcentrations were less than 0.05 mIU/mL2 }' T$ M& i- U! c. O8 l7 C
(prepubertal).- E( ]$ ~2 v8 |4 u9 ~2 m, P( W. o
The parents were notified about the laboratory
+ e+ f6 U* [, I# Hresults and were informed that all of the tests were
* h' T$ b/ q- R; p) X+ Q+ U, k1 Lnormal except the testosterone level was high. The
, E+ N. z$ o( r0 T, `& g& bfollow-up visit was arranged within a few weeks to
3 @8 V& L, ^) U1 k. Xobtain testicular and abdominal sonograms; how-8 Q# N: k6 p0 I+ Z, s6 t# a( x
ever, the family did not return for 4 months.
! |7 A! \" W$ M5 g& mPhysical examination at this time revealed that the, J6 L# ~, I! M; B; f: I" N
child had grown 2.5 cm in 4 months and had gained9 _1 y% |1 C) }0 w7 k m" h
2 kg of weight. Physical examination remained% u" q. u4 i. m, X; ~
unchanged. Surprisingly, the pubic hair almost com-5 E8 T2 A. h) E* O/ B" D" L9 c4 t& G3 i
pletely disappeared except for a few vellous hairs at
9 E) M0 d% t2 t( cthe base of the phallus. Testicular volume was still 2$ k6 a* x3 R" h1 }# U- [
mL, and the size of the penis remained unchanged.% I7 a6 f$ A. G; K
The mother also said that the boy was no longer hav-
& R. E; I1 Q' n8 G2 @1 y# uing frequent erections.
# H0 [: O/ @% M5 A1 qBoth parents were again questioned about use of
! \0 ~) N2 I& }" _5 ]. Q$ many ointment/creams that they may have applied to B+ g' N9 D+ H- [9 I* q) M6 E- M: m
the child’s skin. This time the father admitted the
: X }: @7 F# W. ~; m! M- k9 l* ~3 WTopical Testosterone Exposure / Bhowmick et al 541
+ F* @- e; k, y5 T r0 T3 nuse of testosterone gel twice daily that he was apply-: M. @. Q! B1 A7 K
ing over his own shoulders, chest, and back area for
& w( r0 N& Y+ l( La year. The father also revealed he was embarrassed
8 W8 b& M% b) h4 l; s) eto disclose that he was using a testosterone gel pre-! R3 Y' h* X N9 R; H8 ?! U# _
scribed by his family physician for decreased libido2 M1 m F5 u4 R5 K/ q( d+ g
secondary to depression.
& e- T( G }7 V& MThe child slept in the same bed with parents.
! w- H9 [, u4 X6 tThe father would hug the baby and hold him on his
" k6 a% f. n( z Schest for a considerable period of time, causing sig-$ q' e% F% p4 k, _/ L: Y
nificant bare skin contact between baby and father.
% ] t K: \4 P8 g; TThe father also admitted that after the phone call,
$ k- N" b+ E/ W9 p6 ^2 uwhen he learned the testosterone level in the baby5 {1 w) b. f Q! b* I4 n( ~
was high, he then read the product information
* G3 G i. k2 p. ] mpacket and concluded that it was most likely the rea-
" F* ^1 s: A$ k( f2 Fson for the child’s virilization. At that time, they
0 m Q3 D$ G% Pdecided to put the baby in a separate bed, and the# E; O+ ~, p4 j' l& H
father was not hugging him with bare skin and had
6 G! f, g: A! T rbeen using protective clothing. A repeat testosterone
* C5 ~7 r' l3 ?- h! Jtest was ordered, but the family did not go to the U% P# [4 G" i/ z
laboratory to obtain the test.6 @6 e% e$ X3 g9 U
Discussion
, c4 ^+ O$ C9 q B$ uPrecocious puberty in boys is defined as secondary% E% P3 L: i: j: A7 ^& f. t
sexual development before 9 years of age.1,4( u5 N- [8 Y! _ J
Precocious puberty is termed as central (true) when/ g4 e; A" l- f
it is caused by the premature activation of hypo-
8 ~1 ^% \ q l+ M7 mthalamic pituitary gonadal axis. CPP is more com-
, g7 E3 U- _, j f/ k, B3 L$ Wmon in girls than in boys.1,3 Most boys with CPP
' S+ W f7 V' b9 D' G% |! n- }+ Wmay have a central nervous system lesion that is
$ \. c& v! p# \: N4 Iresponsible for the early activation of the hypothal-/ P% z4 c+ D, B$ E ^1 B D% T
amic pituitary gonadal axis.1-3 Thus, greater empha-. u- J8 @4 w b* d
sis has been given to neuroradiologic imaging in
. ^% ~' t( |2 N+ uboys with precocious puberty. In addition to viril-
- _0 w1 p \; w' e9 s4 y3 B, uization, the clinical hallmark of CPP is the symmet-
' g: L4 e5 y( z3 A- `rical testicular growth secondary to stimulation by) Y4 t+ q+ O! G" m4 s' i5 |
gonadotropins.1,32 v3 a0 _1 S+ `% \. y% r( x. q+ T
Gonadotropin-independent peripheral preco-3 d) {& J. L* h6 e- C( d D
cious puberty in boys also results from inappropriate+ h6 m: Z! x7 D! b7 z
androgenic stimulation from either endogenous or
4 N( N& s2 E+ p! s2 N/ xexogenous sources, nonpituitary gonadotropin stim-
9 G6 k* q. E8 X* Zulation, and rare activating mutations.3 Virilizing
1 B; K# j1 @2 o. ncongenital adrenal hyperplasia producing excessive
6 n$ ~* g% ]# k0 T& f! X( {adrenal androgens is a common cause of precocious
! ?/ |1 Y( C6 spuberty in boys.3,4
L& _! @: Z& wThe most common form of congenital adrenal
5 U! m7 L7 P* uhyperplasia is the 21-hydroxylase enzyme deficiency.
0 @# ^( G X7 ~. ]The 11-β hydroxylase deficiency may also result in0 X8 U5 h+ _9 p5 h j7 p
excessive adrenal androgen production, and rarely,
2 D$ N/ I# v s$ s/ j" can adrenal tumor may also cause adrenal androgen, U' o) r8 B0 {, o7 P
excess.1,3
: V) k3 N0 d, Y* H. ^6 g, }5 Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( ~" G: S/ B( M, D! x8 K542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 ]! L/ u) P1 |- l. o- s( ?A unique entity of male-limited gonadotropin-
$ {, z! ~/ e1 Kindependent precocious puberty, which is also known
7 C; `8 C' W8 D1 F x2 yas testotoxicosis, may cause precocious puberty at a
+ J5 m2 O+ r4 e1 xvery young age. The physical findings in these boys2 t( ]; i$ E( V$ T. K
with this disorder are full pubertal development,
: M3 E$ i8 t+ d$ X8 J- Uincluding bilateral testicular growth, similar to boys
# d$ }. F; S# n, K" bwith CPP. The gonadotropin levels in this disorder- _! N8 g# i' G4 f+ l7 w
are suppressed to prepubertal levels and do not show
; g4 G4 X$ G) |1 Zpubertal response of gonadotropin after gonadotropin-% Z7 \' q+ b' }
releasing hormone stimulation. This is a sex-linked4 d U! j; Q1 C
autosomal dominant disorder that affects only/ I' |3 @" p3 j# W
males; therefore, other male members of the family
+ N0 T, F9 L [& ^' u# \6 Gmay have similar precocious puberty.31 D. ~* t5 [# V$ c
In our patient, physical examination was incon-" F5 ^; r, h+ A; E% R3 O* j
sistent with true precocious puberty since his testi-
! A+ R: B8 w* T7 D% ecles were prepubertal in size. However, testotoxicosis
: m# C) r/ W0 N: i3 Cwas in the differential diagnosis because his father
# S6 i x/ c; J3 D; A/ Astarted puberty somewhat early, and occasionally,) i$ e" g0 T K( x5 F0 h
testicular enlargement is not that evident in the
+ S5 b* {1 R6 c# j5 K9 d1 h6 _beginning of this process.1 In the absence of a neg-
; x. {. }( p2 n8 J2 v, Tative initial history of androgen exposure, our4 K5 e+ d, u& ^
biggest concern was virilizing adrenal hyperplasia,, `3 G% u7 r% _$ ?( R3 s
either 21-hydroxylase deficiency or 11-β hydroxylase
" |' u! @' P) @! |* G. {5 i3 \ ~deficiency. Those diagnoses were excluded by find-( H5 C" e7 n( M k3 }
ing the normal level of adrenal steroids.! y: ?7 z6 K% a- l! k
The diagnosis of exogenous androgens was strongly
! y5 H+ Y# M. fsuspected in a follow-up visit after 4 months because
5 B" b9 ], R' ?9 X- dthe physical examination revealed the complete disap-
! X/ k' N& ~: u! {; ^( Qpearance of pubic hair, normal growth velocity, and
. `% z& K' ~6 xdecreased erections. The father admitted using a testos-
9 s1 F* r6 k" V* iterone gel, which he concealed at first visit. He was4 L: L" _9 ]+ f
using it rather frequently, twice a day. The Physicians’/ G @6 j0 P A I
Desk Reference, or package insert of this product, gel or
1 V' u- O; J( R1 H. ?3 x" }# ?cream, cautions about dermal testosterone transfer to
0 m. X1 r. e3 O" Z4 runprotected females through direct skin exposure.
- q( r1 ?% i, h+ j9 ~: qSerum testosterone level was found to be 2 times the
9 |' X8 j( D# i: Obaseline value in those females who were exposed to1 w5 Y, @1 W( n$ N* c) Z R2 U! W" P
even 15 minutes of direct skin contact with their male1 b: ~3 B; R2 H r
partners.6 However, when a shirt covered the applica-* {5 x2 ?+ D/ f* k
tion site, this testosterone transfer was prevented.
6 d3 n, M& d1 u. |/ XOur patient’s testosterone level was 60 ng/mL,! x. u2 y$ Q3 `7 P
which was clearly high. Some studies suggest that
/ M% Y8 m2 F6 g1 @, v0 `' Rdermal conversion of testosterone to dihydrotestos-+ B7 D% z1 K* v+ F' [ c9 C I
terone, which is a more potent metabolite, is more7 a) p8 t% ~+ K1 y
active in young children exposed to testosterone
1 f! I5 M/ Q, o/ Rexogenously7; however, we did not measure a dihy-% r" J0 j# T8 }" P( _
drotestosterone level in our patient. In addition to6 i v$ ?7 K% T) R
virilization, exposure to exogenous testosterone in% q7 ]% G i- ?9 S
children results in an increase in growth velocity and
/ r9 s2 V- j. x& ]advanced bone age, as seen in our patient.
8 R& L0 r2 z) ^( y) p1 c, I: }The long-term effect of androgen exposure during
* a' k* x1 H' Wearly childhood on pubertal development and final
! |1 H9 e0 |) D3 l8 t1 wadult height are not fully known and always remain
4 k, |" `! `, }a concern. Children treated with short-term testos-$ y T; b4 W. y, _( f
terone injection or topical androgen may exhibit some
- ]0 A O8 `/ v8 ^) _) aacceleration of the skeletal maturation; however, after
; ]+ ^& s+ f8 wcessation of treatment, the rate of bone maturation
9 a L$ a- C' `: Udecelerates and gradually returns to normal.8,9' U8 k2 f( ~' @
There are conflicting reports and controversy
! ]. c1 g# P. {) A; Mover the effect of early androgen exposure on adult
: p* N2 u3 x9 @8 [4 \penile length.10,11 Some reports suggest subnormal4 x5 w" s2 r9 K1 i
adult penile length, apparently because of downreg-$ A3 z0 n/ f% b* p: A! h
ulation of androgen receptor number.10,12 However,3 B7 C+ z) n! g+ O9 D/ a
Sutherland et al13 did not find a correlation between% W- w, u2 c* t' z
childhood testosterone exposure and reduced adult! l% {$ @; b1 e: S) C, U
penile length in clinical studies.
4 c8 ]( ?- l/ P8 r; q' l6 hNonetheless, we do not believe our patient is! e, a9 Z8 c' R7 [% _
going to experience any of the untoward effects from# y" H: v% [$ n* ~5 |8 A7 _# a
testosterone exposure as mentioned earlier because7 G8 I: o' i. ?
the exposure was not for a prolonged period of time.; e( j- M9 e+ h }- f
Although the bone age was advanced at the time of
; n* D3 n! r& i! _* d: q- x. Adiagnosis, the child had a normal growth velocity at
7 s8 I' I% W4 R7 `the follow-up visit. It is hoped that his final adult9 Z6 c) H7 L! E1 i; q1 J2 R# z- V* Z
height will not be affected.+ q& f+ R% h0 M( \6 }1 u% m& |
Although rarely reported, the widespread avail-
3 x V6 D t+ I* z1 Z; _ability of androgen products in our society may
9 I* C# p. A) M# oindeed cause more virilization in male or female
3 ?3 e' w$ O9 }# V- {. D( `children than one would realize. Exposure to andro-. N% s4 E. r3 j# j" i
gen products must be considered and specific ques-/ s0 O9 L3 h6 c$ D7 e+ J
tioning about the use of a testosterone product or
) X3 w5 N& ^5 Z4 [6 n# ^gel should be asked of the family members during: O4 M }; m" V) N! V: P
the evaluation of any children who present with vir-% z0 U( [! ]/ a0 d) H
ilization or peripheral precocious puberty. The diag-
; y3 \9 ~; T/ s! w( f: i Onosis can be established by just a few tests and by9 n4 i U2 s5 c8 c" F/ o4 d
appropriate history. The inability to obtain such a/ u8 K$ j" h, f! L* V; T* I; [
history, or failure to ask the specific questions, may% V1 d# R) C9 B" F6 Q: a% o
result in extensive, unnecessary, and expensive0 Y9 A7 m/ y: T0 G8 G, O4 t8 e1 r( [" O
investigation. The primary care physician should be3 I0 H5 K) y" w: u5 W( U' G: h0 v
aware of this fact, because most of these children8 U8 V! G3 D: e
may initially present in their practice. The Physicians’
3 P; V8 t) _6 d9 D$ l" V0 zDesk Reference and package insert should also put a5 B' u3 T- U, P# c) j! V* y0 B. U) B
warning about the virilizing effect on a male or
9 P. j. m: \$ M7 k, V) U$ a$ Jfemale child who might come in contact with some-/ H! Z" ?' V0 S9 M" {
one using any of these products.# Z, A9 Q4 @2 r" D6 x6 ^, x
References" `7 ]" p" F! S; S0 A9 z
1. Styne DM. The testes: disorder of sexual differentiation
: D* {; O$ g: o( w1 k& Rand puberty in the male. In: Sperling MA, ed. Pediatric$ i$ v+ u- e' ~: O5 Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders; Z6 h3 `8 ?! D6 ]' x+ c
2002: 565-628.
1 _, j" P0 z7 b* F4 r5 J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! ~7 Q1 ^+ m8 a
puberty in children with tumours of the suprasellar pineal |
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