- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old Z9 O% d: l9 a8 G! i4 k
Boy Induced by Indirect Topical# h; Z: _- I( r1 Y' u
Exposure to Testosterone% r, h" O h; S0 i+ E# K& E- _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 W) z$ p! R$ e8 pand Kenneth R. Rettig, MD1
( `$ n2 g3 t4 }& x M! fClinical Pediatrics
! h% C' a3 v6 p ^Volume 46 Number 6
, W/ u7 G3 } |, @July 2007 540-543
) S! u% M# `( m" m& R© 2007 Sage Publications
# ?% }- A8 M0 F. Y10.1177/0009922806296651+ m1 i0 q% ~' j. U) Z
http://clp.sagepub.com& D0 h4 a+ `5 d7 T& I. P8 f
hosted at
# Q# j: ^* f. m; lhttp://online.sagepub.com0 x1 P% [" T0 g( C# z
Precocious puberty in boys, central or peripheral,
! B* ]# V( _. l. J$ W/ N6 b2 Dis a significant concern for physicians. Central
3 h' c8 f' F( s9 o4 rprecocious puberty (CPP), which is mediated
" x6 t6 o7 _' C5 Y3 qthrough the hypothalamic pituitary gonadal axis, has
8 [) X3 k. o; Y6 {" _) ga higher incidence of organic central nervous system
8 G3 i! `0 ~" N, D, olesions in boys.1,2 Virilization in boys, as manifested: G9 [/ [9 b3 b9 ]2 w
by enlargement of the penis, development of pubic
1 Y/ P% S/ g$ U! R9 ^0 y$ Ihair, and facial acne without enlargement of testi-
+ [* R# }4 N( K# f/ A+ g% E6 n( Qcles, suggests peripheral or pseudopuberty.1-3 We. _( ? i/ U+ r( w7 q6 O; f7 N
report a 16-month-old boy who presented with the
2 I* P( ?+ P5 \9 e( u2 l4 g% kenlargement of the phallus and pubic hair develop-0 w" H% C" f3 w. B+ d% P1 |
ment without testicular enlargement, which was due1 Y) \" W' P5 V% F/ k
to the unintentional exposure to androgen gel used by# Z! R8 p, f7 ?$ u
the father. The family initially concealed this infor-
# t* q A2 l3 m% C, p& tmation, resulting in an extensive work-up for this
# C* X' V7 D* S' g6 }child. Given the widespread and easy availability of7 g: U$ J/ W1 ~0 i" r- `: }
testosterone gel and cream, we believe this is proba-
# I" O: K* f& H7 e7 qbly more common than the rare case report in the
8 A/ s- R5 C3 j/ u. yliterature.4
+ o/ D$ A$ v# a* N6 e$ H; YPatient Report
' ?8 s& ?2 Q: H# F; cA 16-month-old white child was referred to the8 |- y" p9 e7 d9 F) |# O
endocrine clinic by his pediatrician with the concern% d7 o5 @1 r& q N/ j/ B& b. g [
of early sexual development. His mother noticed2 q( A7 P- H3 v
light colored pubic hair development when he was+ F4 I5 e: F( O: \( k) }; B- e
From the 1Division of Pediatric Endocrinology, 2University of+ {7 \/ A$ R) t6 E, D* R- z5 l
South Alabama Medical Center, Mobile, Alabama.! D4 X0 ]; a- I# j( t( R [
Address correspondence to: Samar K. Bhowmick, MD, FACE,3 G8 l$ H& P9 F4 C
Professor of Pediatrics, University of South Alabama, College of
$ _% R' _) s' Y' u% {% GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! h" D" [# Z* }- ]5 N% a7 s
e-mail: [email protected].$ y$ r8 u3 I5 m
about 6 to 7 months old, which progressively became4 H' h, U* v! l. b+ @
darker. She was also concerned about the enlarge-
+ X2 F& F2 ?7 A% x+ L! R, ^, V! }ment of his penis and frequent erections. The child
. x7 v) m" u9 w Q/ L! R4 dwas the product of a full-term normal delivery, with
( y# q$ |% k5 Xa birth weight of 7 lb 14 oz, and birth length of
$ c+ r4 N6 x" g; U* A20 inches. He was breast-fed throughout the first year
( a5 v* f$ [, T% o9 N0 m$ E" N( Eof life and was still receiving breast milk along with
/ N% A! W9 i$ k5 y( jsolid food. He had no hospitalizations or surgery," H8 y9 Y. p3 s/ i. g
and his psychosocial and psychomotor development
6 e; C/ V& ~# Z9 u, x# ~' \was age appropriate.* v D; P# O+ P1 T
The family history was remarkable for the father,
0 u& x' A7 F1 B3 Iwho was diagnosed with hypothyroidism at age 16,- M' v( X# N# v: ^2 _) ?! A
which was treated with thyroxine. The father’s/ a M1 T4 N4 Z8 W7 L4 b
height was 6 feet, and he went through a somewhat0 O2 K# u G' M# z
early puberty and had stopped growing by age 14.
- {0 C& T( T6 iThe father denied taking any other medication. The3 v1 b `9 c5 n, R: t6 V; P5 }, }
child’s mother was in good health. Her menarche: t4 o7 i$ x3 c/ ?* M
was at 11 years of age, and her height was at 5 feet2 F( E% q- @& ^/ i% w4 S$ O: E
5 inches. There was no other family history of pre-
6 \! w$ N4 e; s6 ^8 k Wcocious sexual development in the first-degree rela-
* P' Y1 s" m8 n- Atives. There were no siblings.) R# n, g9 J9 e* M- f7 m: l* O
Physical Examination
, H1 H# B" c0 @. _% XThe physical examination revealed a very active,
' e6 Y) G$ r9 p: q# w% aplayful, and healthy boy. The vital signs documented( c5 N( `( N: Y- f1 G- e
a blood pressure of 85/50 mm Hg, his length was
6 n$ G- m8 ]2 T, N1 B6 m8 ]9 H( s90 cm (>97th percentile), and his weight was 14.4 kg9 U9 ?2 V( Q# K- h& }& P
(also >97th percentile). The observed yearly growth$ j! m0 z6 i6 K" e5 w8 l8 n4 s; U0 [
velocity was 30 cm (12 inches). The examination of, F' ~6 m* J$ E% n4 r u% _1 i4 W
the neck revealed no thyroid enlargement.
6 o: n! ?6 q0 o' v3 L ?1 E0 _+ yThe genitourinary examination was remarkable for
5 u0 i- k* J3 \1 a4 J4 a" Xenlargement of the penis, with a stretched length of0 K. B8 _+ ]( G! [: K
8 cm and a width of 2 cm. The glans penis was very well
1 y5 U% v- Z. t9 ~0 Ndeveloped. The pubic hair was Tanner II, mostly around
N Y! T5 N' Y" f) q, y. r540$ ^7 j" e$ v9 t$ O0 T; v- }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: `3 k/ @& f% e9 `$ J* N, `9 athe base of the phallus and was dark and curled. The& D. G8 v* f& [9 r6 C6 Y
testicular volume was prepubertal at 2 mL each.. R4 i' m% m, n& t! B' H
The skin was moist and smooth and somewhat
7 f2 @7 k/ r& A' K! E4 M- ~/ Soily. No axillary hair was noted. There were no
$ y2 |; X/ w0 N g! z! {abnormal skin pigmentations or café-au-lait spots.
7 ~# e+ Q$ U, v( N* TNeurologic evaluation showed deep tendon reflex 2+
" R, o& c$ F; Mbilateral and symmetrical. There was no suggestion2 B& T& d. e: A c; r+ P- A) C! U
of papilledema.
% c1 t- j6 t* [/ f8 eLaboratory Evaluation
, N, X7 ^- q% aThe bone age was consistent with 28 months by7 x" Z; F3 M% m( y6 A0 c* n. U
using the standard of Greulich and Pyle at a chrono-8 P' k- H2 H7 U
logic age of 16 months (advanced).5 Chromosomal" g _. N' m1 G# L8 G
karyotype was 46XY. The thyroid function test
* C q: |, e+ ?3 jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-( W( u+ D2 ?. }" l- N
lating hormone level was 1.3 µIU/mL (both normal).! U1 h* h5 v1 N; E
The concentrations of serum electrolytes, blood
~2 t1 ^ Y3 X) a7 Jurea nitrogen, creatinine, and calcium all were, y- r, q" `- _2 _, d( h6 @0 c5 p. x/ a
within normal range for his age. The concentration
. n4 ^* q9 E/ w1 i( G zof serum 17-hydroxyprogesterone was 16 ng/dL
% _# _ p# c. b# i9 L/ T(normal, 3 to 90 ng/dL), androstenedione was 203 H3 \% m8 ]& i/ a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 t& ?/ V2 X! O! F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 c6 ]9 H! Z( K* [- udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ I0 t$ f( a- D, a% E49ng/dL), 11-desoxycortisol (specific compound S)
% J- E0 q" h" X: Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 B$ f9 P* }& [! s( \: `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; D# q) }8 {" ~3 z! b4 J0 s. \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ c* F ~9 n, \! m- D4 Hand β-human chorionic gonadotropin was less than0 e- s! n6 v1 [& l
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 M, S' o: t y9 T0 n
stimulating hormone and leuteinizing hormone/ E- e* f' v' L. a5 f8 v' E' P
concentrations were less than 0.05 mIU/mL
: {" r0 {% b$ d(prepubertal).
4 V$ U( Y9 H/ TThe parents were notified about the laboratory
5 b7 g: H5 e- f9 X7 q4 S3 |results and were informed that all of the tests were
8 ], X4 t* n |; W% I) K0 U/ j" tnormal except the testosterone level was high. The
% z: L+ f1 }2 r( Cfollow-up visit was arranged within a few weeks to
( r0 _* s* j' N! ? x B0 m6 N/ Robtain testicular and abdominal sonograms; how-- o1 S ?1 F, n0 d; `( ~3 [
ever, the family did not return for 4 months.
; T8 B8 o4 E$ M1 c- n, BPhysical examination at this time revealed that the
9 X9 p3 h+ d/ g9 e0 Tchild had grown 2.5 cm in 4 months and had gained
( U8 Y8 E; U- y! G. A) z" g, S1 k2 kg of weight. Physical examination remained
) G" W0 ]* g( |+ X8 t3 ^unchanged. Surprisingly, the pubic hair almost com-( j5 M6 \, R3 P+ F9 `: R
pletely disappeared except for a few vellous hairs at
; j2 p3 a6 {) G, E+ I$ ]# lthe base of the phallus. Testicular volume was still 2
) K5 @5 q( V! u& hmL, and the size of the penis remained unchanged.' y. L# ~* X o+ Q. v1 x
The mother also said that the boy was no longer hav-2 d# {6 ^- n' X8 _' {
ing frequent erections.& w" J1 Z/ S- E& Z& e% o5 r
Both parents were again questioned about use of
5 A2 _2 j# N+ @1 X7 w A6 J# oany ointment/creams that they may have applied to
. H" g5 g: ]( u+ L- ythe child’s skin. This time the father admitted the K2 I8 m" G7 Y7 Z& O: K8 i& P0 z' f
Topical Testosterone Exposure / Bhowmick et al 541
( G5 [: w/ H* u* h& J' p% juse of testosterone gel twice daily that he was apply-
% n4 Z0 S6 a6 f! t0 J2 w7 xing over his own shoulders, chest, and back area for
% w) x9 l7 G" P. |# k; ca year. The father also revealed he was embarrassed
$ O+ F0 I- T. K0 P" S! Y: Xto disclose that he was using a testosterone gel pre-8 G7 w$ Y" L5 u3 o) {7 o
scribed by his family physician for decreased libido
5 `; {9 g: |( }4 fsecondary to depression.# G) M! a6 ?: Y& v
The child slept in the same bed with parents.' S; U( X, ?# |% _( Z
The father would hug the baby and hold him on his" R2 R6 J7 M; ^# v
chest for a considerable period of time, causing sig-
7 Y, `/ u( Y" a4 G! Cnificant bare skin contact between baby and father.4 |1 p+ ^2 O0 E3 r i$ m" j
The father also admitted that after the phone call,
& P3 o! b; G, Z) G( p, j) Ywhen he learned the testosterone level in the baby% J V- I& s* q. T
was high, he then read the product information
* s6 y3 a0 A9 b# ~& k% V8 [ upacket and concluded that it was most likely the rea-5 P2 Y/ m% y1 \6 e6 d
son for the child’s virilization. At that time, they
, `" s( Z& w% }1 A( Udecided to put the baby in a separate bed, and the
- a; i0 z7 o9 f( t. N* ?father was not hugging him with bare skin and had8 ^# g8 s- N$ N$ m
been using protective clothing. A repeat testosterone! |0 g& g' X, @9 Y
test was ordered, but the family did not go to the$ r# E. w( e% U- d7 s% T% C+ ?/ K
laboratory to obtain the test.1 e0 c7 {; I8 v4 a' C
Discussion4 Y. f: n. o7 x$ j
Precocious puberty in boys is defined as secondary' M4 h! L& E# h- s' i# A
sexual development before 9 years of age.1,4
: y* o6 m) T4 f0 OPrecocious puberty is termed as central (true) when
: P& l% @& p' k4 u& Mit is caused by the premature activation of hypo-
K$ `5 Q G& l% o. O4 dthalamic pituitary gonadal axis. CPP is more com-
4 _- Q* M |& V9 q' q. n- `mon in girls than in boys.1,3 Most boys with CPP
8 K" @+ d3 \8 }/ tmay have a central nervous system lesion that is" K, i) z/ O7 j! s
responsible for the early activation of the hypothal-1 H9 I+ v6 R2 L2 M
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 g( ^2 n( k- `7 r ]sis has been given to neuroradiologic imaging in
' P& e7 K: p' b, Z6 ]boys with precocious puberty. In addition to viril-
% h9 M" ]2 m7 Z0 c/ oization, the clinical hallmark of CPP is the symmet-6 b" m9 d% E& m* s5 D- @
rical testicular growth secondary to stimulation by
/ L7 |5 B/ j" {, X+ mgonadotropins.1,3
9 k7 F$ D5 c# S8 R1 o& @1 GGonadotropin-independent peripheral preco-
5 c7 x" D5 y8 }! K% j' x+ y' _cious puberty in boys also results from inappropriate* F$ P: u# {; _" w7 o/ [
androgenic stimulation from either endogenous or
; V8 B7 F2 X( I, k0 U; H8 L- Fexogenous sources, nonpituitary gonadotropin stim-. ^8 |. J, O: H6 q* _% Q
ulation, and rare activating mutations.3 Virilizing
( {% s9 p4 i3 I: Acongenital adrenal hyperplasia producing excessive0 m* k2 k; [$ }. y% { D- A6 V- `+ w
adrenal androgens is a common cause of precocious
5 Z8 [4 {, x( A4 @puberty in boys.3,4
/ `1 P. M9 Q5 p! m1 _' w0 fThe most common form of congenital adrenal
# I- y& g/ V0 t+ j" n! \2 f" mhyperplasia is the 21-hydroxylase enzyme deficiency.9 J1 o$ }9 y6 E* T/ \
The 11-β hydroxylase deficiency may also result in2 s: ]% ]! `' Y [
excessive adrenal androgen production, and rarely,
: c. [. Y! s3 Y6 n# pan adrenal tumor may also cause adrenal androgen
3 E" \) i( c0 B6 T4 _+ v: m1 Lexcess.1,3) G" o& A/ [2 _. ]2 f7 S: d7 v5 r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# x: L$ t* I- [7 J; o; p; j4 T
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 U/ B: e) x; g7 m3 H
A unique entity of male-limited gonadotropin-/ E8 G0 T! J0 p, k2 v, o" K% w
independent precocious puberty, which is also known# i& N- k0 y- ~. B/ ` S
as testotoxicosis, may cause precocious puberty at a9 S! K/ q6 J+ t+ U
very young age. The physical findings in these boys
_4 ~9 U' G" A2 kwith this disorder are full pubertal development,
! k" c0 D8 u- ?& ]8 R; h9 V6 l' uincluding bilateral testicular growth, similar to boys% m) Q8 G. c( |2 Z
with CPP. The gonadotropin levels in this disorder$ O P0 E% v; J" W. w) |* \; |, j9 a
are suppressed to prepubertal levels and do not show7 ~2 f( g) u: h& w# _4 d
pubertal response of gonadotropin after gonadotropin-
% {' m) C' X0 creleasing hormone stimulation. This is a sex-linked
: w0 |* W S# m8 uautosomal dominant disorder that affects only9 a4 j, k$ [0 V$ f3 B2 s% r
males; therefore, other male members of the family
" O1 k' X/ w8 omay have similar precocious puberty.3% ]- {- D/ @8 E+ s6 L, {
In our patient, physical examination was incon-
% O* p7 f5 w4 O2 b8 o) Qsistent with true precocious puberty since his testi-
# i& b g4 U; E2 N Rcles were prepubertal in size. However, testotoxicosis" {0 }8 r M9 C$ }
was in the differential diagnosis because his father$ B7 L- p' X; I+ y: S$ e6 R! I0 D
started puberty somewhat early, and occasionally,
: ?7 z% R* I' a, F# W, ktesticular enlargement is not that evident in the
5 Q. [3 D. c0 @. qbeginning of this process.1 In the absence of a neg-
* R& D% o: B- lative initial history of androgen exposure, our
8 X6 K, D# }" t+ rbiggest concern was virilizing adrenal hyperplasia,
, _. W1 ~/ M$ r( ^2 R% [either 21-hydroxylase deficiency or 11-β hydroxylase* D( [6 n9 O! r. h
deficiency. Those diagnoses were excluded by find-
; t) g) `! `. [7 b' qing the normal level of adrenal steroids.& W! n* l" n1 ~6 f
The diagnosis of exogenous androgens was strongly4 Y7 b0 f% ]7 [, K9 V
suspected in a follow-up visit after 4 months because
, k- V2 A9 C' u7 jthe physical examination revealed the complete disap-' l2 p' Q8 d0 s0 R* o
pearance of pubic hair, normal growth velocity, and
$ N- F' V3 ~4 C0 E5 K( [6 Fdecreased erections. The father admitted using a testos-( ?8 U# p1 D# M
terone gel, which he concealed at first visit. He was
& v+ I0 ^8 ~& t6 @4 |using it rather frequently, twice a day. The Physicians’) _, x( v) w6 b4 ]: w- \; h
Desk Reference, or package insert of this product, gel or
& ]0 V- @' w$ o$ A1 l, H' d0 _cream, cautions about dermal testosterone transfer to& U3 X8 o) }6 V3 {( i a5 p9 M, i
unprotected females through direct skin exposure., v: R! V' l; E' j
Serum testosterone level was found to be 2 times the! a4 {5 r" c9 d! Z6 y: i+ ?
baseline value in those females who were exposed to
6 J7 @5 v8 G$ N& f' Qeven 15 minutes of direct skin contact with their male
; Z6 G$ @) o# @( w3 q7 rpartners.6 However, when a shirt covered the applica-& k0 Z3 v5 m6 Y; ]6 t* q; N
tion site, this testosterone transfer was prevented.
; f! ~( U: B' n- z9 TOur patient’s testosterone level was 60 ng/mL,# \) B, F6 [( S3 ~9 W0 l
which was clearly high. Some studies suggest that
( ?) e- _ y3 w4 ^) ?dermal conversion of testosterone to dihydrotestos-
; P' r9 S, F: B+ l* R( iterone, which is a more potent metabolite, is more/ |0 J* {- p$ [. {
active in young children exposed to testosterone/ |. B3 F4 ?3 |% O2 j) p
exogenously7; however, we did not measure a dihy-% Y/ u1 p) _2 @/ h( ^+ C# y
drotestosterone level in our patient. In addition to1 L, \( m# p$ I2 V0 q
virilization, exposure to exogenous testosterone in# R/ y- M6 }8 u4 G
children results in an increase in growth velocity and' g2 e, E% h* X7 Y0 e) }
advanced bone age, as seen in our patient.
- @ O. t; B' `) AThe long-term effect of androgen exposure during
, M5 z+ P# A* |! Q5 @- }early childhood on pubertal development and final
% S* C; {4 O7 cadult height are not fully known and always remain
0 G2 [- Y3 o, G1 y, a# W2 T/ s% Qa concern. Children treated with short-term testos-* T9 ^8 w/ f4 o% q* T: o
terone injection or topical androgen may exhibit some
& i# c# X- ]8 F: l; A+ Uacceleration of the skeletal maturation; however, after! v+ x4 A& L( E
cessation of treatment, the rate of bone maturation
) F. q1 ^" h5 I @( X( `/ O) Kdecelerates and gradually returns to normal.8,9
( g0 [( C: h' a* O( VThere are conflicting reports and controversy: s7 c/ V2 C, T9 ]
over the effect of early androgen exposure on adult) H- Z& n: e4 d l" x
penile length.10,11 Some reports suggest subnormal- x! N* T7 ~. d, ^2 c
adult penile length, apparently because of downreg-
8 f) c1 h! t) e2 Y8 j$ Q7 Sulation of androgen receptor number.10,12 However,
$ F) J) d5 c3 Q, E( }) xSutherland et al13 did not find a correlation between, k& \& d0 o5 c$ T
childhood testosterone exposure and reduced adult
. G6 |/ k1 q b5 \7 A/ b7 y! @8 xpenile length in clinical studies.* K N, Y& r3 m- [9 N7 p
Nonetheless, we do not believe our patient is; C6 D* s3 w2 r. C; T: {
going to experience any of the untoward effects from
# r& Z3 P' [4 w2 T( G: qtestosterone exposure as mentioned earlier because. G* l8 n7 H& c
the exposure was not for a prolonged period of time.
& y) C5 p# D, J9 h; W8 YAlthough the bone age was advanced at the time of- n* g- q0 ]$ k/ M2 E
diagnosis, the child had a normal growth velocity at
9 M& R+ h5 c$ e# ]the follow-up visit. It is hoped that his final adult
* g0 b/ W2 r" M2 Oheight will not be affected.
& |( \0 u1 ^4 y& ^, t4 Z) fAlthough rarely reported, the widespread avail-& m, e. @; P! l" y5 o* Z5 G. n
ability of androgen products in our society may
/ l1 \ y* h# f" o( X8 |+ Rindeed cause more virilization in male or female
; l+ _2 C, { j C7 D gchildren than one would realize. Exposure to andro-
3 P2 ~7 ~9 _. a7 t: Dgen products must be considered and specific ques-; R( A5 ]% q% `
tioning about the use of a testosterone product or
, w% H7 O2 [% {, |, Ygel should be asked of the family members during
. t9 m( U9 w5 d) G: `the evaluation of any children who present with vir-: J9 W7 g; y" Z$ I" M
ilization or peripheral precocious puberty. The diag-
! F- w2 r1 G) b5 Q9 `9 Snosis can be established by just a few tests and by
; F3 R0 S4 ~$ ^ I' {appropriate history. The inability to obtain such a
3 h, c" z8 q# z0 P7 ^. [history, or failure to ask the specific questions, may, `. o6 ?9 M/ U- Q/ ?
result in extensive, unnecessary, and expensive( R' W0 f$ N% i" p( C
investigation. The primary care physician should be
! [4 D0 J; u2 Y- H, u7 u& o& g( Maware of this fact, because most of these children
j! s0 a* e, t0 p! H$ r1 Cmay initially present in their practice. The Physicians’
' U, [) L0 @+ {$ \$ G" k( E4 n3 @Desk Reference and package insert should also put a1 V! F3 T! ^# V. i% J
warning about the virilizing effect on a male or
+ A7 D6 d0 i+ |# Cfemale child who might come in contact with some-$ g$ i9 v( Q0 e# E0 n
one using any of these products. ^- G! o5 n5 F7 d
References6 }% P% L3 J6 C3 r) S+ v
1. Styne DM. The testes: disorder of sexual differentiation3 a3 V9 p# F/ w k
and puberty in the male. In: Sperling MA, ed. Pediatric
) z5 N$ `0 N/ G* c' o3 i8 PEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. c( j* |# p+ P, Z2002: 565-628.
+ O- f: z# X1 ~9 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! \$ ?, o! r6 y0 D1 W5 hpuberty in children with tumours of the suprasellar pineal |
|