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Sexual Precocity in a 16-Month-Old
B( \ O5 {8 gBoy Induced by Indirect Topical: H9 H$ E: Q4 X$ R! K5 C
Exposure to Testosterone2 D% ^' J7 @" J/ K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 h1 ^$ D7 A9 d) ]: X
and Kenneth R. Rettig, MD1! {' b; J- U3 l
Clinical Pediatrics4 ^+ K) | e" U0 g4 a& V, c
Volume 46 Number 69 V2 V; w3 D" b( c
July 2007 540-543
( d# p8 r! z1 g( F0 B8 ^© 2007 Sage Publications
* m) l2 I, L, R4 K6 h1 G7 ?2 b& p10.1177/0009922806296651 H. P9 D+ p) H
http://clp.sagepub.com
/ V$ U, H( J3 A. a: v. u& Thosted at
: M. o+ B3 {! ]* } w4 T9 Chttp://online.sagepub.com
* w7 D6 M' e4 C+ CPrecocious puberty in boys, central or peripheral,1 J% j. p7 Z" r4 N8 E+ w
is a significant concern for physicians. Central
* A. M0 k; p) b- k3 oprecocious puberty (CPP), which is mediated
4 u" S2 Q% j% }through the hypothalamic pituitary gonadal axis, has
. m3 N# c8 S6 g# g8 t: K5 @, Oa higher incidence of organic central nervous system
0 j H. `" H2 S$ a- w* Nlesions in boys.1,2 Virilization in boys, as manifested y; s1 t3 _7 y8 \0 a6 i/ l# H t
by enlargement of the penis, development of pubic
2 U6 e3 J9 R) n* L+ v$ p: \" |$ ihair, and facial acne without enlargement of testi-
. \) ^* d: B* Rcles, suggests peripheral or pseudopuberty.1-3 We& a) g# u8 R# b& X6 L4 y* l- A
report a 16-month-old boy who presented with the- y+ `+ Y! n6 `# [& A, e0 z. a
enlargement of the phallus and pubic hair develop-5 ~. J! [5 Y/ d% F; g2 n
ment without testicular enlargement, which was due3 |! a5 N3 M# a% H
to the unintentional exposure to androgen gel used by
( j" v* a0 N/ `" s0 N) Y7 {the father. The family initially concealed this infor-) | X' F y" x7 ^1 R
mation, resulting in an extensive work-up for this
. k/ C h& R9 Xchild. Given the widespread and easy availability of
* y$ k6 ] I' l# w5 _6 stestosterone gel and cream, we believe this is proba-( F. m" }* s/ P s5 A0 S' O+ i7 f
bly more common than the rare case report in the
0 L! ^6 o: t7 ?( `5 B9 Jliterature.4
) s& J) ?7 a6 ?Patient Report& v* S6 y' n( N- s u( {
A 16-month-old white child was referred to the
& [4 p% ^/ H! e& p5 R3 Dendocrine clinic by his pediatrician with the concern
: `5 ^% v. Y& k3 D( X) Q4 [ Iof early sexual development. His mother noticed; D( ~6 I$ o+ o- }- }6 o
light colored pubic hair development when he was% S' o" U! s7 X2 B$ Q- f# k( a' |
From the 1Division of Pediatric Endocrinology, 2University of
0 o1 L# Y& ?; X( A9 X. @8 USouth Alabama Medical Center, Mobile, Alabama.
! `( e' }0 H3 D( H3 V. V o* rAddress correspondence to: Samar K. Bhowmick, MD, FACE,- C( G' R: @9 h/ W% R
Professor of Pediatrics, University of South Alabama, College of
2 _& b: I6 l# ]7 }0 pMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 ]# j: i; x" p7 ]$ ue-mail: [email protected].+ @4 R) h' S- W- N8 M: Z
about 6 to 7 months old, which progressively became1 X0 ?6 K! I e0 ?( ~! \
darker. She was also concerned about the enlarge-
7 Q' D& a' b& b _' E5 vment of his penis and frequent erections. The child
% V# c9 C: h% rwas the product of a full-term normal delivery, with
4 z2 r3 y+ d% h; f0 }a birth weight of 7 lb 14 oz, and birth length of
6 |* G0 P+ |) T& H. c9 u j7 g20 inches. He was breast-fed throughout the first year* _- [ W+ m" f; B! ]: ]
of life and was still receiving breast milk along with
4 ?* F8 [) d, q& psolid food. He had no hospitalizations or surgery,3 g/ p- _9 S# x5 L* J q& W) _( E
and his psychosocial and psychomotor development
4 I6 c, o( Y& A/ r q: m% Qwas age appropriate.2 `7 p7 X7 R. \
The family history was remarkable for the father,
4 P- H6 ?& m. C P) k9 owho was diagnosed with hypothyroidism at age 16,) t; h. m) \( o2 Z
which was treated with thyroxine. The father’s
% `. @0 u a8 {1 F8 ~; E6 D4 Theight was 6 feet, and he went through a somewhat
8 b/ e2 R2 H% ]early puberty and had stopped growing by age 14.- o- v( ~4 q3 M, e# |
The father denied taking any other medication. The
% \# y5 R3 G; u* ychild’s mother was in good health. Her menarche
- v- l- W9 Y, N5 Mwas at 11 years of age, and her height was at 5 feet
) @0 A* J) N" Z1 \% ~2 D I+ H4 Z5 U5 inches. There was no other family history of pre-
! v% O$ C& V- l4 tcocious sexual development in the first-degree rela-
0 m8 T8 F9 ~& S7 I- l$ G1 Ltives. There were no siblings.
2 R- {/ f2 O3 o+ p- E8 ]8 uPhysical Examination3 \& S, |: W" e: z3 w0 G7 z! {
The physical examination revealed a very active,9 Y! x1 i' P, M! g7 u
playful, and healthy boy. The vital signs documented
* [# l! y8 B- H+ q2 S5 q# @. oa blood pressure of 85/50 mm Hg, his length was
' G8 c' W% I9 z5 X90 cm (>97th percentile), and his weight was 14.4 kg f% \3 f2 k4 d3 U! ?" P
(also >97th percentile). The observed yearly growth
! n# |2 F* ~7 G. n7 E4 e% N+ Bvelocity was 30 cm (12 inches). The examination of2 T4 b. h* e8 b1 Z1 ~
the neck revealed no thyroid enlargement.; ~# K7 v# M" X! D. o! q' r6 u" y5 G
The genitourinary examination was remarkable for$ c- g1 K! F. J( g" [
enlargement of the penis, with a stretched length of7 F5 u/ Y7 d; v! R" ~ v0 F. f
8 cm and a width of 2 cm. The glans penis was very well
5 D6 ]" A; b5 L3 pdeveloped. The pubic hair was Tanner II, mostly around
, J. N3 @' `- j- E7 K540
5 b& q, _+ u6 P, u4 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- o8 B2 J$ K7 c% r$ cthe base of the phallus and was dark and curled. The8 H# G! w$ t+ V: @
testicular volume was prepubertal at 2 mL each.
) V2 M( w: j) i0 d% Z7 k ^+ ?$ R: \The skin was moist and smooth and somewhat
/ c; O8 @0 h; T0 S- Goily. No axillary hair was noted. There were no% U, }3 k7 [* }7 [
abnormal skin pigmentations or café-au-lait spots.
% f6 r3 ? S- n5 T SNeurologic evaluation showed deep tendon reflex 2+5 R2 r E1 V. O" R( T& j9 {& d
bilateral and symmetrical. There was no suggestion
$ _0 H- Y$ t) `) m9 Nof papilledema.& _7 P7 O% {, k0 ^- [- z4 n
Laboratory Evaluation# @7 Q- x5 s! y) ^8 C7 a# g
The bone age was consistent with 28 months by" |0 w: [+ i$ z
using the standard of Greulich and Pyle at a chrono-
0 l% |. i) y1 j5 K1 J- i$ Alogic age of 16 months (advanced).5 Chromosomal
8 F& q6 {; ?- c$ \5 I6 v- Ekaryotype was 46XY. The thyroid function test
9 |8 w3 o/ z' X3 \3 I% {showed a free T4 of 1.69 ng/dL, and thyroid stimu-) h u& s# h0 X
lating hormone level was 1.3 µIU/mL (both normal).
1 ~& W5 F X* l# M+ [/ q! aThe concentrations of serum electrolytes, blood( e: Z7 R( o2 {4 }$ R5 m( p
urea nitrogen, creatinine, and calcium all were3 S: u' Y& ?7 l" L! T
within normal range for his age. The concentration
, k, E5 M8 d. I+ h/ g7 Y, y4 y( cof serum 17-hydroxyprogesterone was 16 ng/dL8 i* M- n# M6 X9 l- A& Y
(normal, 3 to 90 ng/dL), androstenedione was 20" K) {9 M2 F) `: m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ H2 A# D1 p6 L" l
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ V6 {# U8 J7 y, W! wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ K+ Y# \* v" ~9 V& }# ?49ng/dL), 11-desoxycortisol (specific compound S)
5 L- ^) K* e: U- N* \" Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 t( @! P( @8 @: t9 t/ G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. T; x2 |& `% d& Utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 p# h) [0 \/ `' Q1 g$ a( vand β-human chorionic gonadotropin was less than2 n1 O- }6 i' m1 [$ r- D* U8 E
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: W! b/ Q7 K, i5 q1 cstimulating hormone and leuteinizing hormone
9 S3 T" _, r4 Sconcentrations were less than 0.05 mIU/mL
& Q1 A: V- K d* v1 [(prepubertal).
1 {: w( e/ f2 a% }, C5 {' h6 x# RThe parents were notified about the laboratory! q) v" l5 h# F) J0 H0 a7 T2 F& Z
results and were informed that all of the tests were
% v: n/ A# g# k( L( o+ gnormal except the testosterone level was high. The6 I$ o; R3 K8 G5 `7 l8 w
follow-up visit was arranged within a few weeks to- C. H0 p& \5 L2 @! H6 c
obtain testicular and abdominal sonograms; how-% g9 V( q4 ~: a' p7 Q! f: i
ever, the family did not return for 4 months.$ u+ r3 o; m# q: Y5 g5 O
Physical examination at this time revealed that the
2 R6 I7 s" @: w0 r; ~child had grown 2.5 cm in 4 months and had gained+ P2 d' Y8 G% F2 }
2 kg of weight. Physical examination remained
% C- |, i& u. j$ N" Z, }unchanged. Surprisingly, the pubic hair almost com-
5 p- {/ P+ |' V$ F+ C; |pletely disappeared except for a few vellous hairs at
) z% r, E6 a# Ythe base of the phallus. Testicular volume was still 2
1 ~# {3 c/ r$ g7 ~, M1 ]- DmL, and the size of the penis remained unchanged.
6 d& k8 M$ \* l2 CThe mother also said that the boy was no longer hav-% Q# a# c3 P5 X( n3 T% g
ing frequent erections.( |5 ?3 I$ F5 u U# x* C
Both parents were again questioned about use of& S g$ R, s4 m
any ointment/creams that they may have applied to- h! m7 L& _: d% S- U2 r
the child’s skin. This time the father admitted the
6 f$ g% W* [: j" \7 `0 FTopical Testosterone Exposure / Bhowmick et al 541- b% z2 P9 Z# e- M, O
use of testosterone gel twice daily that he was apply-7 {; q2 ]6 I! D
ing over his own shoulders, chest, and back area for
l& p6 Z6 `" T9 g' k( C9 s Ta year. The father also revealed he was embarrassed8 N) c. O2 {, b# s6 h
to disclose that he was using a testosterone gel pre-! Z/ {6 p* `: u# u& x
scribed by his family physician for decreased libido4 Z& f1 h: Y3 Z0 r7 g3 h0 ?5 r
secondary to depression., O) t7 s5 L# U+ P
The child slept in the same bed with parents.
' F. {' \& Y' @. WThe father would hug the baby and hold him on his
% \1 @: T% E, u3 z* {chest for a considerable period of time, causing sig-
4 k1 N; b1 ~' y0 Wnificant bare skin contact between baby and father.# m5 s$ T- N, a/ p% X, r
The father also admitted that after the phone call,. G3 G G/ q& @" @
when he learned the testosterone level in the baby7 F; b' h, `6 G% g
was high, he then read the product information
& Q6 ?& n3 E$ ^' C( X+ \packet and concluded that it was most likely the rea-' Z: R$ P* R# @& J) D
son for the child’s virilization. At that time, they
; x$ W! I+ E" q& f) w3 ]" C& @( edecided to put the baby in a separate bed, and the7 Z7 z( m2 M9 m
father was not hugging him with bare skin and had
2 A s4 A2 X# Ibeen using protective clothing. A repeat testosterone. {7 \+ f$ A0 u1 ~7 A' k
test was ordered, but the family did not go to the( I' ] k% B3 {6 O. o, N
laboratory to obtain the test.
8 L/ m6 Z: `" O6 I: W, x( n# EDiscussion8 [* U+ e' p" L6 j7 U% x! d
Precocious puberty in boys is defined as secondary' E$ L. g% L8 D3 j, z) q, C
sexual development before 9 years of age.1,40 F* X$ h# l9 W- t6 W1 A6 @9 X& l
Precocious puberty is termed as central (true) when
, j2 _& U4 i8 n i" o- N7 ?it is caused by the premature activation of hypo-
- \: G" }' l) i! \thalamic pituitary gonadal axis. CPP is more com-# \3 G" c* t! B6 a, Y
mon in girls than in boys.1,3 Most boys with CPP
9 H( _. b( {2 h' h+ jmay have a central nervous system lesion that is" w1 M3 K3 E' l% v0 b; l0 r
responsible for the early activation of the hypothal-8 s D* v4 I( ^& c- _, m6 c. y
amic pituitary gonadal axis.1-3 Thus, greater empha-) w3 ^9 O$ P7 i: ^
sis has been given to neuroradiologic imaging in
& j$ i: Z! O% |! xboys with precocious puberty. In addition to viril-
. P# {4 A, Q0 {0 l; \) w$ Y1 Nization, the clinical hallmark of CPP is the symmet-
. @8 w& ^+ C) }4 W8 C. [rical testicular growth secondary to stimulation by
$ `3 T! \6 S0 S# Z# Hgonadotropins.1,3* `2 Y0 N' ^2 K6 G9 M# I# h
Gonadotropin-independent peripheral preco-0 ~$ C0 U1 ?) u* t- |) @: l+ O9 i
cious puberty in boys also results from inappropriate
4 i9 B7 r% p7 M' j9 {$ o* ?9 i7 T9 Vandrogenic stimulation from either endogenous or
4 y; n* |2 N |2 w0 I' Wexogenous sources, nonpituitary gonadotropin stim-
( g$ X2 O2 ~" i/ Wulation, and rare activating mutations.3 Virilizing
9 F) t" t2 Y0 e8 ~congenital adrenal hyperplasia producing excessive+ B, M9 }% ]: U+ q4 i7 ~
adrenal androgens is a common cause of precocious
. Q4 j. b% n$ g0 z0 Rpuberty in boys.3,4
" |0 @1 z; |& n" N- H' w- W7 |The most common form of congenital adrenal
% f2 B0 O B3 T. yhyperplasia is the 21-hydroxylase enzyme deficiency.; @) W$ U4 Q; Q
The 11-β hydroxylase deficiency may also result in. D& s9 y2 Y8 H8 ]
excessive adrenal androgen production, and rarely,
0 q+ T7 y1 f' kan adrenal tumor may also cause adrenal androgen
) g9 S6 _, P' ~" \8 }excess.1,3
; C) k+ E6 s2 V9 t, Y% b0 h" Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# C& [% w7 H! d1 ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# Q' I/ ? A0 n* t4 U9 M: d
A unique entity of male-limited gonadotropin-
/ ]# V) X& x3 ^( W2 {; m9 D; sindependent precocious puberty, which is also known
6 s; }( y K! b1 `, Xas testotoxicosis, may cause precocious puberty at a$ [/ ?( A# w Y' S3 X A
very young age. The physical findings in these boys
' J9 f4 B3 d; a. s/ J0 zwith this disorder are full pubertal development,: [' t8 s l* ]! a
including bilateral testicular growth, similar to boys
" a" c8 J8 K$ q$ F% [with CPP. The gonadotropin levels in this disorder
& j" i( ~# L$ g( c8 n, i1 Care suppressed to prepubertal levels and do not show% E) @: }; B) Z& E N
pubertal response of gonadotropin after gonadotropin-
: [/ Q" t9 ~& {$ a8 F; [# _1 Ureleasing hormone stimulation. This is a sex-linked
$ }2 `) W K+ B; i1 o$ ?& Cautosomal dominant disorder that affects only5 |& |- n. J" T$ X
males; therefore, other male members of the family
6 M9 t( y# h G& Smay have similar precocious puberty.3
, l% n9 |) ~) t7 V3 N% yIn our patient, physical examination was incon-' |, v6 K! \' P$ i
sistent with true precocious puberty since his testi-
& q# e+ m. z% v% V" Ecles were prepubertal in size. However, testotoxicosis) ]3 C' k: c7 z" \ o5 z
was in the differential diagnosis because his father. U* N4 _* {/ H# O7 F& J
started puberty somewhat early, and occasionally,
3 C" x0 ?; w) v0 Ctesticular enlargement is not that evident in the
/ @$ I/ {5 F4 G$ Ibeginning of this process.1 In the absence of a neg-
2 I, D' T( n. kative initial history of androgen exposure, our$ Z4 I# H3 P1 V" z F
biggest concern was virilizing adrenal hyperplasia,
) h( \% O6 X0 j, _9 S' I- ?either 21-hydroxylase deficiency or 11-β hydroxylase
* m, A5 i0 Q$ ideficiency. Those diagnoses were excluded by find-' z" F; ~5 M, I: q/ z" Z
ing the normal level of adrenal steroids.
, l) g9 _9 z0 b1 P+ bThe diagnosis of exogenous androgens was strongly; N/ y9 A6 ]' {$ e2 M' Y5 M, i# M
suspected in a follow-up visit after 4 months because
# n3 k, d( O( s1 F. ^) Y9 P1 ethe physical examination revealed the complete disap-5 @; C, h ^6 k x
pearance of pubic hair, normal growth velocity, and
4 ]+ r1 u/ D/ zdecreased erections. The father admitted using a testos-
/ h% A" H6 t, gterone gel, which he concealed at first visit. He was
5 |$ C0 |2 ]8 k( s1 @' yusing it rather frequently, twice a day. The Physicians’
0 x. o6 G: C6 `7 A% @: n) |$ p$ sDesk Reference, or package insert of this product, gel or
o( x' O/ M% b' F' E fcream, cautions about dermal testosterone transfer to
/ \/ M- S- b- C. j d/ c; funprotected females through direct skin exposure.5 X. B9 Z: Q) }/ V+ Q
Serum testosterone level was found to be 2 times the
5 v7 m9 @6 D$ A1 \3 C8 Ubaseline value in those females who were exposed to8 c. G+ U9 |3 W
even 15 minutes of direct skin contact with their male
/ a( A7 M ?! ^) Z# e2 y. R+ L: Vpartners.6 However, when a shirt covered the applica-
' Z v+ z n H& T: @8 H& d0 v9 s; \tion site, this testosterone transfer was prevented.& U4 F9 [9 h( k6 q4 [* Q3 _
Our patient’s testosterone level was 60 ng/mL,2 W5 W5 h* H1 t$ _* n. O
which was clearly high. Some studies suggest that
; v: \- X5 @) `dermal conversion of testosterone to dihydrotestos-
2 _0 s! j/ f! R. l& Z4 i7 oterone, which is a more potent metabolite, is more1 n% a+ z ?& G; i% o
active in young children exposed to testosterone, d* h$ V6 ~2 Y, P& ?* g8 h% q
exogenously7; however, we did not measure a dihy-( F& @$ @( B9 c( ?
drotestosterone level in our patient. In addition to
: P: r, b0 H; C( U6 a vvirilization, exposure to exogenous testosterone in
! M) q) S8 y8 C4 x3 o( ichildren results in an increase in growth velocity and) q2 A, o6 R5 }+ q
advanced bone age, as seen in our patient.
$ H: e, l) g$ p; f4 p7 [The long-term effect of androgen exposure during7 a0 Y( x+ ?) w* f, p
early childhood on pubertal development and final4 i0 [6 \) e& N! l
adult height are not fully known and always remain
- v5 i$ Z; ?% h( j3 A+ e, aa concern. Children treated with short-term testos-: V+ ~0 P; c% N7 M( {0 j5 K+ s
terone injection or topical androgen may exhibit some, P( Y7 `+ |* E' [: R: o( H# B
acceleration of the skeletal maturation; however, after
8 K; k# i( B, G% }) [cessation of treatment, the rate of bone maturation4 s3 s4 H7 c% y7 Q
decelerates and gradually returns to normal.8,9
7 ? o8 C, ]& ^0 P6 a& L h8 AThere are conflicting reports and controversy2 A4 G V) j7 {% Z
over the effect of early androgen exposure on adult+ N3 B5 Z8 f. b9 B
penile length.10,11 Some reports suggest subnormal8 o. x! a2 |! H/ j& J( p/ `* a( a
adult penile length, apparently because of downreg-
' e+ B6 ~# p8 Dulation of androgen receptor number.10,12 However,
; i' U8 e0 w5 hSutherland et al13 did not find a correlation between
+ x) F e; H/ C. a6 |& o4 ]childhood testosterone exposure and reduced adult' ?% W2 ^& a p0 w, L4 ~
penile length in clinical studies.6 k3 f1 D8 ~7 h" |# K7 V
Nonetheless, we do not believe our patient is" c& c! Y1 a7 y
going to experience any of the untoward effects from4 c- {8 ?' M; `+ i" M1 \
testosterone exposure as mentioned earlier because* v9 W0 e$ R6 C
the exposure was not for a prolonged period of time.
( {. A( R5 [* D& x0 u6 X) w& o* xAlthough the bone age was advanced at the time of
) M1 K( b, {& S6 O* L- ydiagnosis, the child had a normal growth velocity at1 C: E, u/ Q" o' v1 T
the follow-up visit. It is hoped that his final adult" R4 H( U7 D1 @; f& h2 ~- f# m M
height will not be affected.7 v1 ^: I Z5 G# g8 A/ f* K0 p- J
Although rarely reported, the widespread avail-
8 ^3 _: C7 ]% B: z S5 Yability of androgen products in our society may
4 t4 |4 R# W" H( @indeed cause more virilization in male or female+ x t, z1 u: y8 j, v; p
children than one would realize. Exposure to andro-
/ [; w9 E$ x: c0 ?' D7 `gen products must be considered and specific ques-7 _3 r. F) i5 N1 W
tioning about the use of a testosterone product or2 i# r% `' x# [( P6 y C
gel should be asked of the family members during
/ p( P! u+ \( o) b7 _the evaluation of any children who present with vir-
- ^9 q8 N ~7 @+ c0 uilization or peripheral precocious puberty. The diag-
1 E1 z* g" a8 U' O8 mnosis can be established by just a few tests and by
. E8 f" w9 [+ a6 kappropriate history. The inability to obtain such a
, ]" S o+ R# l' zhistory, or failure to ask the specific questions, may
$ q0 a, I5 m+ @5 D( S9 G8 H/ Vresult in extensive, unnecessary, and expensive
' n. O4 w1 e t7 hinvestigation. The primary care physician should be8 j1 C$ @7 K& G0 T
aware of this fact, because most of these children4 {' U4 x; X! k; ^2 A/ Y0 p
may initially present in their practice. The Physicians’
/ K% v& N6 g0 MDesk Reference and package insert should also put a
/ Z. h( c& x( Q8 \& _, gwarning about the virilizing effect on a male or
- }, H+ x9 Q( s& P [- Z) E" t& Nfemale child who might come in contact with some- \7 T; g4 G1 l& A! i
one using any of these products." S" `" D% A" X) }: x
References
: T+ r& Q& l& Z/ t8 l/ y1. Styne DM. The testes: disorder of sexual differentiation
- A3 h9 @4 N% i: dand puberty in the male. In: Sperling MA, ed. Pediatric0 b- F$ X/ ]& E* L# k( i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 D+ z) |' ^) } H- U
2002: 565-628.8 U4 L7 x6 m* r: R4 M) @% q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 [' \ k* S; P8 L4 k1 p7 V h, Hpuberty in children with tumours of the suprasellar pineal |
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