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Sexual Precocity in a 16-Month-Old
, o7 W$ d) C2 N( S, D/ b7 ]Boy Induced by Indirect Topical
$ @, C* Z: Y B! @, _7 e) `Exposure to Testosterone5 r' X+ r4 f) A1 q/ g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' Y6 p5 y! C; ~+ q3 x- _) m2 |and Kenneth R. Rettig, MD1
* Q4 K$ x/ Z% M: T) }" JClinical Pediatrics$ g- B: g& c' z+ S* {' d) h
Volume 46 Number 6 |& _9 R6 e, w |/ T" W8 N
July 2007 540-543
' _; P* g. Q/ D© 2007 Sage Publications
% H( _$ j5 K. v10.1177/0009922806296651
) y* U+ H$ H8 M8 s& z5 u$ ehttp://clp.sagepub.com
# Z7 n! I! H! N8 ?. O3 ~hosted at
7 h5 \* P9 U2 C. |5 W8 F% Nhttp://online.sagepub.com
1 ~8 j, I, q9 y% o4 p. U1 }Precocious puberty in boys, central or peripheral,8 K) I' N3 i5 {9 {/ t
is a significant concern for physicians. Central
! | m6 O3 B! s3 Uprecocious puberty (CPP), which is mediated
: G9 t$ i- G+ p# u- T0 uthrough the hypothalamic pituitary gonadal axis, has
- Z5 y6 B+ L7 n9 c& F! t2 _7 ~3 x0 K' Da higher incidence of organic central nervous system1 i9 c( S; u: x2 H
lesions in boys.1,2 Virilization in boys, as manifested9 _5 n# u3 u0 G. _6 l
by enlargement of the penis, development of pubic
7 L Z5 o ?$ ~8 Y; N% H% ?; @- [hair, and facial acne without enlargement of testi-
1 B& ^& v; C+ n- {8 V+ ~. rcles, suggests peripheral or pseudopuberty.1-3 We! ~. O) z$ q/ j' H/ w
report a 16-month-old boy who presented with the
! |* t8 P$ ]) s, ]+ ~6 i6 u0 Oenlargement of the phallus and pubic hair develop-
8 R. C$ X% f6 y2 E tment without testicular enlargement, which was due' ]" y; [* a; s
to the unintentional exposure to androgen gel used by4 ^& \" G" z' D( V
the father. The family initially concealed this infor-
0 d. s- U* x( U. ], @5 f5 Y8 Nmation, resulting in an extensive work-up for this
' g; I0 c: X, e; ichild. Given the widespread and easy availability of
' z! z l( w! O2 I7 itestosterone gel and cream, we believe this is proba-
& w! c( g; s& n4 w- r7 zbly more common than the rare case report in the
: q" G& @% G4 y$ v5 Bliterature.4
" D. B$ K0 {9 [# G" e, f& \Patient Report
: W7 P; M7 B) q2 f7 pA 16-month-old white child was referred to the
+ t* e5 [# q. }endocrine clinic by his pediatrician with the concern' g ~, {2 _0 c4 J% b0 e, C0 A0 W( \
of early sexual development. His mother noticed
; {, D( j8 S5 j/ P3 Z# |light colored pubic hair development when he was" \8 f; n) V+ e
From the 1Division of Pediatric Endocrinology, 2University of1 ]$ S7 F O/ x
South Alabama Medical Center, Mobile, Alabama.) e" L1 v- {' q" m
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: G* Z- H5 A5 \Professor of Pediatrics, University of South Alabama, College of% d. @) R1 U# G& e N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 Y# Q9 ^) f9 V9 L8 Oe-mail: [email protected].
[6 p: j1 u; w wabout 6 to 7 months old, which progressively became5 T- y. Y% ^7 |9 L
darker. She was also concerned about the enlarge-
6 x. R' D- @1 N$ j6 ?) I* W: W7 y5 kment of his penis and frequent erections. The child
6 N8 G$ i- @# {5 X6 ?. \( t3 Xwas the product of a full-term normal delivery, with) T: s$ Q, V$ w
a birth weight of 7 lb 14 oz, and birth length of
5 V- M* i, W/ I20 inches. He was breast-fed throughout the first year9 \- J2 A' r# g7 a6 L
of life and was still receiving breast milk along with+ r% L3 B9 B% ^& r- ]! j& \- c8 f2 j9 `
solid food. He had no hospitalizations or surgery,2 W2 B( S0 @' B3 d$ z
and his psychosocial and psychomotor development
, D J; _8 J; J Owas age appropriate.
& C( B1 A1 M* MThe family history was remarkable for the father,0 z, n1 g3 \8 v
who was diagnosed with hypothyroidism at age 16,# y6 E" F% `& ]+ _3 F
which was treated with thyroxine. The father’s
' T0 J" S% n8 z5 iheight was 6 feet, and he went through a somewhat2 l& D6 w$ a. f7 {( ]* T3 h5 L
early puberty and had stopped growing by age 14.
$ d0 R: j# D! d3 V! J& i( y) BThe father denied taking any other medication. The
( ~) M( n& b4 ochild’s mother was in good health. Her menarche
# |2 | @6 l8 E: \" |was at 11 years of age, and her height was at 5 feet3 S* l8 L4 [: J q, c; t" v1 ^
5 inches. There was no other family history of pre-) p% }8 M/ w' ]+ [' ]
cocious sexual development in the first-degree rela-* p% ~% T, a/ M; A$ I
tives. There were no siblings.
( O' s" ~' S/ X2 q( D; ^, qPhysical Examination8 C' Q8 P9 U9 K$ A
The physical examination revealed a very active,
% f) A3 n1 G! q: Lplayful, and healthy boy. The vital signs documented
+ \0 z( I, y- I0 ba blood pressure of 85/50 mm Hg, his length was
) N0 v. W9 H" B$ }% }90 cm (>97th percentile), and his weight was 14.4 kg. E; }$ I% k8 I; y
(also >97th percentile). The observed yearly growth4 R' n, z5 r/ y0 ]
velocity was 30 cm (12 inches). The examination of
9 e. [ I3 l9 b( @6 ~! ?the neck revealed no thyroid enlargement.
0 o4 A4 f8 p: w. {( y! l# O6 ]3 OThe genitourinary examination was remarkable for' V7 W) v2 \1 ^' h/ S" o- E" `
enlargement of the penis, with a stretched length of8 q9 c0 T. _2 v5 u# N9 J
8 cm and a width of 2 cm. The glans penis was very well
" {& s5 j$ y6 g( }' \! ~developed. The pubic hair was Tanner II, mostly around
6 r `6 V) K4 R" v1 L& f( _0 ~540
4 }3 W$ w7 U3 lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 B. j) z5 M, l7 Z; r$ w3 X5 Sthe base of the phallus and was dark and curled. The
0 m7 y& x7 g$ o; xtesticular volume was prepubertal at 2 mL each.
# q- r+ A+ @- z' Z1 K6 }% oThe skin was moist and smooth and somewhat/ o5 E' p: K9 o3 H1 ]/ t
oily. No axillary hair was noted. There were no0 t5 ]! y, H8 z2 Q1 k
abnormal skin pigmentations or café-au-lait spots.
9 h/ h2 R, w4 R* u h6 |Neurologic evaluation showed deep tendon reflex 2+
& Q# ?( E @! H3 I; R- Abilateral and symmetrical. There was no suggestion9 H. S( r' h6 N' ^; z8 j6 e
of papilledema.
: n+ {; s0 O) {: h, W" r7 iLaboratory Evaluation
7 \( W2 s- c" k$ a( r9 U* A5 aThe bone age was consistent with 28 months by+ ? ?7 ^- q* E a* D
using the standard of Greulich and Pyle at a chrono-
9 `; N) N# n; P5 ?# n0 glogic age of 16 months (advanced).5 Chromosomal
$ u# V$ X& L, Ekaryotype was 46XY. The thyroid function test; I4 x0 t3 s+ b$ l! D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( a3 O& g3 B$ \, ` m3 w2 p
lating hormone level was 1.3 µIU/mL (both normal).
' h* j' f4 B/ i- M) R( t5 ~The concentrations of serum electrolytes, blood& x: ?0 U9 d) E7 F
urea nitrogen, creatinine, and calcium all were; ~( D. p @1 y( w7 A+ r) h
within normal range for his age. The concentration' e, `; w- A! B
of serum 17-hydroxyprogesterone was 16 ng/dL1 n8 [% g) G2 M6 V$ b/ P; \+ O
(normal, 3 to 90 ng/dL), androstenedione was 20
1 i) s2 j% x& {( S. S8 H6 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 P" r, h% p1 q$ hterone was 38 ng/dL (normal, 50 to 760 ng/dL),# p7 I1 c6 o- r: ~5 z2 n+ W! }7 j
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& ^) L1 P8 t. L6 z5 y; Q
49ng/dL), 11-desoxycortisol (specific compound S)
5 d1 H- N; u: K, rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 Q+ ^; M6 u) ^ X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total i# M: @9 G/ {6 D6 U a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& W9 y6 |5 G$ v9 l- N% N3 Wand β-human chorionic gonadotropin was less than
6 S5 u$ z) _6 {2 p5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 F5 O! h7 `& k" ~1 P1 Mstimulating hormone and leuteinizing hormone/ V4 g2 g. m. P5 [3 d
concentrations were less than 0.05 mIU/mL9 r6 `5 ~$ x M) ]$ O
(prepubertal).% n, e0 L s$ @: {
The parents were notified about the laboratory
0 r0 l) m# s" n9 U% B4 F' qresults and were informed that all of the tests were5 ?% J& R- W+ C
normal except the testosterone level was high. The8 O) \! h, e; t# y
follow-up visit was arranged within a few weeks to
3 `$ ^* w. @0 s. sobtain testicular and abdominal sonograms; how-8 ]' \& T( ?/ s
ever, the family did not return for 4 months.1 p2 [( C* B3 F$ z, }" Q
Physical examination at this time revealed that the
4 ] f F+ |0 o4 X# ?child had grown 2.5 cm in 4 months and had gained
# A+ K7 |; h1 G3 E2 kg of weight. Physical examination remained
$ h% l, N, c4 c8 x3 l6 hunchanged. Surprisingly, the pubic hair almost com-/ e4 C" y5 G" k3 \+ h/ ^
pletely disappeared except for a few vellous hairs at
/ z4 v' {# e* N$ N1 ^the base of the phallus. Testicular volume was still 2
2 `6 j1 |9 F# v kmL, and the size of the penis remained unchanged.
8 ~+ P- }5 D# X3 x" \The mother also said that the boy was no longer hav-
: h" e- e% |" R* V" ]/ jing frequent erections.) i; n, @) ^/ U6 [; A- k4 n
Both parents were again questioned about use of, z- X6 J8 r. P% A! k
any ointment/creams that they may have applied to
. j2 v" E9 @) d( | B7 [* r2 j8 N; qthe child’s skin. This time the father admitted the7 s' A9 c! E( D/ e
Topical Testosterone Exposure / Bhowmick et al 541
1 d8 R5 N) y5 {% d- Y* buse of testosterone gel twice daily that he was apply-
3 P# a5 P, R4 V4 F, B. ~& A# E* uing over his own shoulders, chest, and back area for8 \7 @% S4 N/ t" L* X8 {/ J" y4 Z0 M
a year. The father also revealed he was embarrassed
! t- u2 n* F# s8 [. j. V$ x. f) Wto disclose that he was using a testosterone gel pre-$ ^. L" D' P+ B- t6 `. Z# R5 C
scribed by his family physician for decreased libido7 X; g1 o8 H1 ]6 u
secondary to depression.
: H% y- a! i9 _5 h; n4 ]The child slept in the same bed with parents.
3 @' E0 m9 X2 c- ]# ZThe father would hug the baby and hold him on his
0 L' t* V6 @+ O! |chest for a considerable period of time, causing sig- B) N. u# B4 y1 ~& W6 }5 m" j
nificant bare skin contact between baby and father.7 W+ [* X& i) A( D6 R% _% ]# c7 f: {0 \
The father also admitted that after the phone call,
& b# F6 E" o# r! N! {8 [8 mwhen he learned the testosterone level in the baby
# i! z0 V5 M6 a: x6 T9 M8 Iwas high, he then read the product information& x% y; Q7 V' i0 G; m$ ^: a& I
packet and concluded that it was most likely the rea-
# |: I) t, V2 D# t7 m" Gson for the child’s virilization. At that time, they4 B6 k. w4 L/ h3 Q
decided to put the baby in a separate bed, and the
( f) c, i" y) \3 hfather was not hugging him with bare skin and had
, @; F; r; V3 I+ F; d4 \been using protective clothing. A repeat testosterone5 M F8 `/ E3 U( A
test was ordered, but the family did not go to the( ^8 N& ]- z2 |5 \* D. }0 U
laboratory to obtain the test.
% l2 f6 F9 b6 b% sDiscussion0 |6 v. ~: U8 `7 I3 k. r; t9 _
Precocious puberty in boys is defined as secondary
+ W q5 g# f1 i- E# _# {" F' b& wsexual development before 9 years of age.1,4* q: `. o5 p. W
Precocious puberty is termed as central (true) when
3 y; k9 F8 F1 x7 f8 pit is caused by the premature activation of hypo-
5 I9 ~( t' [' A) a$ nthalamic pituitary gonadal axis. CPP is more com-) y X* j/ X# Y7 e! v# M K" P) l
mon in girls than in boys.1,3 Most boys with CPP
9 }2 W" F- y) N3 Jmay have a central nervous system lesion that is8 E9 M' o: N. i9 w/ w
responsible for the early activation of the hypothal-
( P0 D3 J' i$ [0 J' Pamic pituitary gonadal axis.1-3 Thus, greater empha-
+ ~* i3 l+ L9 N0 r! j) x( G7 ssis has been given to neuroradiologic imaging in3 w, [0 B0 B! L5 `5 E
boys with precocious puberty. In addition to viril-4 ^ f$ ~( k6 B2 X( F% W' i
ization, the clinical hallmark of CPP is the symmet-
% M( }5 P+ z O$ r) }: h/ orical testicular growth secondary to stimulation by( U) j6 p- x/ T% J' m( T
gonadotropins.1,3
, I) B6 m( w: s1 ~- {Gonadotropin-independent peripheral preco-
* q0 r. R' K L( \; I6 y, Kcious puberty in boys also results from inappropriate* g% t$ n- W3 b) ?' @
androgenic stimulation from either endogenous or
$ Z7 f- K# n: F1 D) kexogenous sources, nonpituitary gonadotropin stim-/ ^. n: ^: M% M# }1 f" ^& \8 L
ulation, and rare activating mutations.3 Virilizing. W& \! ]) I: M8 G2 z6 M+ P
congenital adrenal hyperplasia producing excessive
. R7 J2 q) j& z B! q) L. kadrenal androgens is a common cause of precocious. r+ A+ x( B2 E' R. w. `0 s% J
puberty in boys.3,4' `8 W8 {7 B; H2 U$ A: v7 |
The most common form of congenital adrenal
; W9 l# k$ R( K( S! d; Nhyperplasia is the 21-hydroxylase enzyme deficiency.8 a0 f% ]( w! ~* S$ _
The 11-β hydroxylase deficiency may also result in
C4 Q$ A& Z1 O3 m2 d7 b# cexcessive adrenal androgen production, and rarely, ], g& F( Z0 v$ g4 A
an adrenal tumor may also cause adrenal androgen
+ w5 A: d+ W) J1 cexcess.1,36 j. l7 g" m0 z$ w* \4 r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
O0 B% `4 ?) u3 D4 y" q2 W- o542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 h: t$ P: Y! W
A unique entity of male-limited gonadotropin-
( M4 W& Z+ a: o7 `; J, ]: lindependent precocious puberty, which is also known, I4 c3 m' |/ F* r& n; V
as testotoxicosis, may cause precocious puberty at a
% E( e; ]! r. l+ `) @very young age. The physical findings in these boys
6 ?: C0 k2 a1 f. Dwith this disorder are full pubertal development,% ^6 A0 w6 F/ _! l' S# p+ v
including bilateral testicular growth, similar to boys
$ ~9 Y; I" D( Pwith CPP. The gonadotropin levels in this disorder
, }" n6 o5 b/ Q2 E# H1 P: x& Z: w( Lare suppressed to prepubertal levels and do not show
% ~& }& r! [ Z6 dpubertal response of gonadotropin after gonadotropin-# t4 d' \3 X, G3 P
releasing hormone stimulation. This is a sex-linked
" K9 K/ `/ A6 S) u$ F" wautosomal dominant disorder that affects only+ }. i+ F$ t) M p' _ F$ a
males; therefore, other male members of the family
' P7 U0 Z' E% k* f* _) P) amay have similar precocious puberty.3$ x& ]2 v, Z( v
In our patient, physical examination was incon-
/ d8 B& @5 S- p4 e' M7 G' {sistent with true precocious puberty since his testi-
r& }5 {4 T, R# h2 o6 U. k3 x% D, fcles were prepubertal in size. However, testotoxicosis2 J6 b h% O' Z/ L! L8 _* A6 k6 e2 A
was in the differential diagnosis because his father
% q9 n8 x, {- ~4 e- jstarted puberty somewhat early, and occasionally, V5 g3 ^3 r2 q3 O5 }5 q& U+ y. _
testicular enlargement is not that evident in the$ u/ G) Y/ G. Y, r
beginning of this process.1 In the absence of a neg-
2 z* U E) i- {5 @$ G8 sative initial history of androgen exposure, our! s8 _; n, P. D6 ~6 o
biggest concern was virilizing adrenal hyperplasia,- X& g4 ^' @9 ~( |
either 21-hydroxylase deficiency or 11-β hydroxylase; j& S$ v+ V( U$ e
deficiency. Those diagnoses were excluded by find-
z. l; k9 ]( _) H4 o, `/ V# a# \ing the normal level of adrenal steroids., S, V9 }" _% g- A5 @2 K D$ m1 @
The diagnosis of exogenous androgens was strongly
, I1 e5 I. y0 V& x8 G' Xsuspected in a follow-up visit after 4 months because; A5 O( B/ t0 I' i; Q$ l0 A. }
the physical examination revealed the complete disap-
) w; n" n: m" @+ m" spearance of pubic hair, normal growth velocity, and2 ^+ Z7 }% r" k Y
decreased erections. The father admitted using a testos-6 @9 N5 Y! M0 T0 E6 q
terone gel, which he concealed at first visit. He was% n% ^, n2 ?( G( W
using it rather frequently, twice a day. The Physicians’
5 X) c7 }- R% x3 x& PDesk Reference, or package insert of this product, gel or O6 G9 k9 R( i8 f. p
cream, cautions about dermal testosterone transfer to8 z; Y" }( A) {9 \& x! Q
unprotected females through direct skin exposure.
' v, ^( L/ k3 x* P7 Q! ZSerum testosterone level was found to be 2 times the6 K+ n' E- Q3 i! ?( E. u
baseline value in those females who were exposed to
3 O% m- g: r' p5 G! `even 15 minutes of direct skin contact with their male0 \) {3 B9 A* t1 q4 s. T
partners.6 However, when a shirt covered the applica-
! z& a1 {4 o2 Gtion site, this testosterone transfer was prevented.
9 X5 S% @7 w! I8 v$ |+ J9 i& JOur patient’s testosterone level was 60 ng/mL,
# U1 _: q5 _9 Cwhich was clearly high. Some studies suggest that3 T9 R* u2 ~0 W% Q; ^
dermal conversion of testosterone to dihydrotestos-
, F+ s8 @. `2 e* R' x0 Rterone, which is a more potent metabolite, is more0 B4 l2 w$ |3 j* y2 F! n
active in young children exposed to testosterone
7 D9 S5 z5 t2 \$ D% Cexogenously7; however, we did not measure a dihy-
0 m" H3 U" A$ n" L5 u4 N' _$ Z( }drotestosterone level in our patient. In addition to/ D# a4 h% N9 w) a$ R/ @: v# g( x
virilization, exposure to exogenous testosterone in9 v% B) Q2 Y2 T
children results in an increase in growth velocity and0 N2 o3 R9 G w' k7 s/ f
advanced bone age, as seen in our patient.
4 F9 O8 y) o! Z; r# [The long-term effect of androgen exposure during
+ @* u+ m) J2 [# B% searly childhood on pubertal development and final" d% w4 `0 v i7 ?- K" j
adult height are not fully known and always remain
) L# n9 T$ D1 W8 |! w3 ua concern. Children treated with short-term testos-# G) A2 Q$ V H6 L+ v# a
terone injection or topical androgen may exhibit some" e; O+ v% G! i2 R- s, E
acceleration of the skeletal maturation; however, after
4 p+ x3 X" `1 O* H% Dcessation of treatment, the rate of bone maturation
& v# h# b% u6 C. ?( Rdecelerates and gradually returns to normal.8,9
' o- |" D- a) S; qThere are conflicting reports and controversy& f. ? u8 U" h" I* j" S) v
over the effect of early androgen exposure on adult
& d8 j' M. ^4 Ypenile length.10,11 Some reports suggest subnormal
9 ?9 z+ P4 N' w) ?2 o5 Uadult penile length, apparently because of downreg-
3 J% D6 ?# V# x" fulation of androgen receptor number.10,12 However,' f) ?- E0 I" ^2 R$ L& M" x. d1 ^
Sutherland et al13 did not find a correlation between% q& p) V/ ]! E
childhood testosterone exposure and reduced adult
1 T0 `, z8 ~4 Mpenile length in clinical studies.8 r5 a& V. c8 F2 [& |7 P
Nonetheless, we do not believe our patient is
8 r1 x/ g( E* H W' p/ pgoing to experience any of the untoward effects from5 n& T. D7 ^) Y
testosterone exposure as mentioned earlier because1 f; ?6 t0 T. B) _5 d! F0 r) o
the exposure was not for a prolonged period of time.' m! e* G! J) q
Although the bone age was advanced at the time of \1 K8 \2 |1 s9 S
diagnosis, the child had a normal growth velocity at
6 F7 I( a% C' r) F' Bthe follow-up visit. It is hoped that his final adult7 s, g, B2 |3 y; c& X2 Y3 ]
height will not be affected.
3 _2 F3 _5 X8 F* m p- ]5 X1 GAlthough rarely reported, the widespread avail-
* f' x& \7 G! ~ Z @ability of androgen products in our society may9 E4 U4 {) Q% O/ |) Z) k, F
indeed cause more virilization in male or female
" m2 O0 q! Y' y$ }' l- g: Pchildren than one would realize. Exposure to andro-- D. X2 r. c( ~5 `
gen products must be considered and specific ques-
$ q5 N0 D9 \/ }+ _# wtioning about the use of a testosterone product or
1 V0 [8 z% X* \! l9 ?gel should be asked of the family members during
- X) [2 l# i& h: i9 e; ?3 v" O% lthe evaluation of any children who present with vir-% a: h& U) N7 v, J
ilization or peripheral precocious puberty. The diag-, m. y8 J& O$ m( y# D
nosis can be established by just a few tests and by% N7 F3 F7 p) A5 \3 G+ h. k d0 Z4 j c
appropriate history. The inability to obtain such a3 V* k1 F- d" _! ]0 h$ F$ g- T
history, or failure to ask the specific questions, may* T$ O8 W+ h6 Z( u4 L
result in extensive, unnecessary, and expensive# F) }7 d* u% L
investigation. The primary care physician should be
6 c% V: W8 `" c7 K+ z/ w8 F) Eaware of this fact, because most of these children% M1 B! |# j- I: ~3 J' q
may initially present in their practice. The Physicians’2 M" q) b: L0 y, f4 d, b
Desk Reference and package insert should also put a9 k1 T' v8 i. l0 d
warning about the virilizing effect on a male or- b3 K8 u: v4 b
female child who might come in contact with some-
8 p) w6 a3 U% ~7 Q% lone using any of these products.' a9 G p3 R+ \* t2 \% E- F
References
8 V/ R/ Y. e, g9 `1. Styne DM. The testes: disorder of sexual differentiation% r& K. v" f/ _% R/ @9 u
and puberty in the male. In: Sperling MA, ed. Pediatric8 O+ E9 c# S- G# A/ U2 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 W9 H% c: A0 s8 ]+ v3 f2002: 565-628.
0 N, v N- J8 j$ V) N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' J: S' o( P. i a- {1 R' k. @
puberty in children with tumours of the suprasellar pineal |
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