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Sexual Precocity in a 16-Month-Old3 R, K6 p- b! \1 D6 ?5 [6 S
Boy Induced by Indirect Topical# b( B. d, G7 G7 l( G+ s6 D* O
Exposure to Testosterone8 a& d. f$ N* l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* |8 }% S4 z: @. J& aand Kenneth R. Rettig, MD1
, m/ V; |6 M( @, b+ c# L8 DClinical Pediatrics
2 M# W6 f7 p; n: UVolume 46 Number 6( M# z' e* g+ i# W
July 2007 540-5439 Q- N( n! t% ]' N( T# u) B# K' @) T! T
© 2007 Sage Publications
: a! l$ g6 e0 R: M10.1177/0009922806296651& z8 p, f1 P- j% s4 z) g3 {: x
http://clp.sagepub.com
1 C2 p" i# O5 x9 l; \hosted at, u& q" U" m8 K; \( s* S9 s
http://online.sagepub.com
. e+ z+ l, Z9 L% U* U9 wPrecocious puberty in boys, central or peripheral,* t' h) a- _ E6 j" @
is a significant concern for physicians. Central
2 L: w. f6 c2 B" E. Y6 P# Vprecocious puberty (CPP), which is mediated
6 K1 e" X, K* F, c: Y" Hthrough the hypothalamic pituitary gonadal axis, has
. j+ M$ m) `- s0 N5 c. G5 x3 ~7 za higher incidence of organic central nervous system
% ]- } W4 x( c$ @lesions in boys.1,2 Virilization in boys, as manifested6 F# ~9 o- `- u$ ? c" s. g
by enlargement of the penis, development of pubic, w# o3 E6 b+ V8 J
hair, and facial acne without enlargement of testi-
3 w, ~: E3 T6 z, _. n. ^5 Ocles, suggests peripheral or pseudopuberty.1-3 We# l' h, o' q; T" Q$ J$ `8 ]- n
report a 16-month-old boy who presented with the# |& i( S3 Q% z4 C
enlargement of the phallus and pubic hair develop-
. i& {0 d# G# x( t2 {! K# X8 gment without testicular enlargement, which was due7 @# l& K e: D, n, C- ~* q
to the unintentional exposure to androgen gel used by
2 F& }1 K- s; a8 Jthe father. The family initially concealed this infor-" z+ k: j- A: Y
mation, resulting in an extensive work-up for this
4 H. A# A/ B; }$ m4 s, \1 x) ~child. Given the widespread and easy availability of( |1 F x2 Y" I. |
testosterone gel and cream, we believe this is proba-/ w, t% r. ?0 m5 {# v- X7 U& e
bly more common than the rare case report in the
7 T8 ~ n" X" Q( f, wliterature.4
* J9 _0 e& D2 u$ oPatient Report1 M- Y- i9 {1 ]7 p% \
A 16-month-old white child was referred to the$ J: p' N8 l; i$ }5 {
endocrine clinic by his pediatrician with the concern
1 s4 ?: f: G: X' k; ~" hof early sexual development. His mother noticed
4 D9 o4 N* W5 C' h1 dlight colored pubic hair development when he was$ i y( L7 e3 t: d! _: O+ {
From the 1Division of Pediatric Endocrinology, 2University of% k! l* R' ~$ r) j, w2 n0 U, X
South Alabama Medical Center, Mobile, Alabama.
, \% n L7 m/ Y3 [Address correspondence to: Samar K. Bhowmick, MD, FACE,) @# E9 y/ t: b- Y) I% P3 L4 ~
Professor of Pediatrics, University of South Alabama, College of
. e: }" V$ F! B/ h3 rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297; w% f2 n+ S7 B) k8 j7 r- i
e-mail: [email protected].0 [' K- i4 K' g \* Q- D, e" Q7 ?+ O
about 6 to 7 months old, which progressively became5 \3 n3 D8 l3 U. O% h
darker. She was also concerned about the enlarge-+ L" g9 U q8 i1 ^9 U1 d
ment of his penis and frequent erections. The child
' ?( }1 I C+ R* D& Iwas the product of a full-term normal delivery, with: {. X- `0 h' e! h$ T4 e. r; I: s
a birth weight of 7 lb 14 oz, and birth length of
+ |& W% d; j* U: B0 ^20 inches. He was breast-fed throughout the first year
, l' ]! }% n6 K' v" y, fof life and was still receiving breast milk along with
, ^/ B" K/ e) p# \solid food. He had no hospitalizations or surgery,( `% r& a1 b/ U* L6 J1 {$ e
and his psychosocial and psychomotor development
/ S' @* ^( h0 \' i/ L, nwas age appropriate.4 ]9 w. g/ c, f& f' ~& X: O
The family history was remarkable for the father,
1 I* t/ ^3 X! ~) U* t. B% V1 jwho was diagnosed with hypothyroidism at age 16,# i" p: X+ h0 V- V' l
which was treated with thyroxine. The father’s7 ^. L E6 d- n4 z+ ?" m
height was 6 feet, and he went through a somewhat! a. S1 F! a; l( J* H' Z
early puberty and had stopped growing by age 14.4 f9 S3 U, R9 M5 G7 Y
The father denied taking any other medication. The
( }, [3 l. }$ ~1 J+ uchild’s mother was in good health. Her menarche' w4 P' n8 u$ Q
was at 11 years of age, and her height was at 5 feet
+ R o: {, `5 e5 inches. There was no other family history of pre- c2 ~% u5 H R+ Q, p3 C' y
cocious sexual development in the first-degree rela-
* T; I$ e# ~) u stives. There were no siblings.
' H3 _# [ C6 iPhysical Examination# T2 {7 X; |' P2 r/ f% [7 m) v
The physical examination revealed a very active,
' z" |- T/ o! }+ C% `7 h: ~playful, and healthy boy. The vital signs documented
. [7 L& }) f6 k: ua blood pressure of 85/50 mm Hg, his length was" c3 `0 x# d# l' ]8 l
90 cm (>97th percentile), and his weight was 14.4 kg& a. P. H% X/ J
(also >97th percentile). The observed yearly growth
% n9 H9 R6 t j6 b! T3 D# Pvelocity was 30 cm (12 inches). The examination of
3 q q* i; L7 p2 B, E L. Xthe neck revealed no thyroid enlargement." y! v( ?) z/ F: w4 N( V( r
The genitourinary examination was remarkable for
2 y( }( ?; g9 Q: m) nenlargement of the penis, with a stretched length of1 d! w0 e/ Q0 N S/ ^
8 cm and a width of 2 cm. The glans penis was very well
# Y: A, F Z; r2 tdeveloped. The pubic hair was Tanner II, mostly around5 b5 z8 u2 i- i/ m% z% ~
5406 A H6 [4 p' N- ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; ] U0 ~& m w6 }! ^8 A6 [the base of the phallus and was dark and curled. The
, T# E9 O& M: Z* Y' Ctesticular volume was prepubertal at 2 mL each.$ U5 [% i8 E8 u; g$ U. d- p
The skin was moist and smooth and somewhat% l- a1 t+ Z0 F! Z8 j5 l/ l% g
oily. No axillary hair was noted. There were no
" Y( Q* v! q, r6 a" A7 [2 \ Gabnormal skin pigmentations or café-au-lait spots.
" k! B) \6 ?6 p" [; J5 N5 ZNeurologic evaluation showed deep tendon reflex 2+" o8 u# K1 T1 U! C; ^% X! @
bilateral and symmetrical. There was no suggestion5 }* d, k) L1 r6 }1 J
of papilledema.. R' ~# z" J' ~: r- u
Laboratory Evaluation
" j! A* |$ O5 o6 M/ h) c( }The bone age was consistent with 28 months by: ?4 V% q3 n6 i! z" J' J1 m
using the standard of Greulich and Pyle at a chrono-
" s& B# A1 S: `8 ?6 _% jlogic age of 16 months (advanced).5 Chromosomal
, v; Z% m: b; n: okaryotype was 46XY. The thyroid function test
) W0 [& X- G @% X$ h- u0 Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ \+ t& P6 D- P+ I* P5 ilating hormone level was 1.3 µIU/mL (both normal).# h8 M9 h$ F4 d n* q* a6 L
The concentrations of serum electrolytes, blood
* V1 t. V. i* r; t4 d' Aurea nitrogen, creatinine, and calcium all were- u8 g* t) q( P/ B
within normal range for his age. The concentration7 ]3 m, L( j Y, Q$ ]! O
of serum 17-hydroxyprogesterone was 16 ng/dL
; o. K+ d2 i0 `+ @/ }1 T(normal, 3 to 90 ng/dL), androstenedione was 20* g1 z$ ^' ~$ A- p2 M+ `2 C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ n: a; X' A% D3 f& s( J9 P! _: @
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 A# d' T' U* Y# B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 C# I, G2 c ? f0 F& v0 } K
49ng/dL), 11-desoxycortisol (specific compound S)6 {8 m+ e5 J, R$ q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, ^1 D; k; F. l$ I7 z$ z# d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 H2 M0 z; I W2 i, { J" Y5 ?testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& ? @8 A3 P' }- T, i
and β-human chorionic gonadotropin was less than
% Z0 S' ?# ]0 J" F4 K8 r- F5 mIU/mL (normal <5 mIU/mL). Serum follicular
. Y u" {$ [3 d) Pstimulating hormone and leuteinizing hormone0 t; o5 ?: n/ x8 Y9 F1 g3 \5 |5 C
concentrations were less than 0.05 mIU/mL6 I2 ^ Y8 {$ d7 L7 R0 ]
(prepubertal).
' g& s$ z* r. W& P. X9 S1 @The parents were notified about the laboratory9 }, a# I/ I" i) \
results and were informed that all of the tests were
- T" _2 {9 }1 m! t+ R: fnormal except the testosterone level was high. The
& U5 i+ ?" R9 }2 P( qfollow-up visit was arranged within a few weeks to$ {: y! S0 Z5 v' C0 T% E5 ?) P
obtain testicular and abdominal sonograms; how-
/ X% o4 L' u7 P8 w; y; pever, the family did not return for 4 months.
8 d1 T) Q. S3 C! N4 V7 ~Physical examination at this time revealed that the1 H& p& }1 J3 B9 {+ ~, n
child had grown 2.5 cm in 4 months and had gained, _; y( y+ j2 u; Q7 _4 E+ e3 {) C
2 kg of weight. Physical examination remained c! c r+ m, V( y; T, f
unchanged. Surprisingly, the pubic hair almost com-2 P4 D q$ n3 u8 V0 }
pletely disappeared except for a few vellous hairs at& c+ P. \ B0 K1 U1 }
the base of the phallus. Testicular volume was still 2
8 h9 g* o# _+ [0 C. e2 V- y5 TmL, and the size of the penis remained unchanged.+ c/ r* c. |+ M9 b, x3 m: D$ L" u8 D
The mother also said that the boy was no longer hav-9 b) c) P- v3 A5 H4 E+ d
ing frequent erections.
# [8 p7 Z* l5 H" \9 dBoth parents were again questioned about use of6 Y. c3 E% P6 m) f
any ointment/creams that they may have applied to$ d6 j$ \( M9 y }. q' l b
the child’s skin. This time the father admitted the3 _, ~2 q* Z& R& I+ u& v
Topical Testosterone Exposure / Bhowmick et al 541+ a# U1 H9 z* |: j/ E7 C5 c7 ~
use of testosterone gel twice daily that he was apply-, g5 q& P" i& [, F
ing over his own shoulders, chest, and back area for& S' }' u1 ^ m- g) B+ R; `
a year. The father also revealed he was embarrassed
! p; N% y' d, k6 L; S* p1 gto disclose that he was using a testosterone gel pre-
" H9 i+ }( ?. N8 }9 w5 Iscribed by his family physician for decreased libido7 D$ W4 e: s4 n
secondary to depression.# w4 J$ O8 ~1 L$ V* S
The child slept in the same bed with parents.# O4 H2 }4 A# K" O/ F
The father would hug the baby and hold him on his
8 @% l" x0 y6 _) T! K+ }; Xchest for a considerable period of time, causing sig-! \( Z* H: E1 J* k
nificant bare skin contact between baby and father.$ L3 [8 b' z, I2 ?
The father also admitted that after the phone call,
: ?- f+ O r1 [- jwhen he learned the testosterone level in the baby8 N* y2 U! V7 D
was high, he then read the product information8 p# K! t4 ?2 _# k( H* k2 j6 q
packet and concluded that it was most likely the rea-
5 M& S% H5 c0 l0 y9 I5 b9 Yson for the child’s virilization. At that time, they
! T# S7 j1 ]" E y" Ydecided to put the baby in a separate bed, and the3 \( T$ \/ c, U* ]$ y
father was not hugging him with bare skin and had8 @. c/ @/ K0 X* p9 B+ }2 e
been using protective clothing. A repeat testosterone
4 z1 p6 n* v! \+ Ytest was ordered, but the family did not go to the
R) k6 W+ M$ n- E( G2 U% X; llaboratory to obtain the test.
% m: p( F, @1 S* g/ i) d. gDiscussion5 K+ q2 z( D2 ~: e
Precocious puberty in boys is defined as secondary
- h* D. i( t1 V N7 O7 `sexual development before 9 years of age.1,4" g, A. O5 B1 S/ }8 K
Precocious puberty is termed as central (true) when$ e. Z1 z- @2 p9 Y1 j* J
it is caused by the premature activation of hypo-2 c9 U$ k/ o @6 Y5 H" t
thalamic pituitary gonadal axis. CPP is more com-& ^; V3 q( S+ X
mon in girls than in boys.1,3 Most boys with CPP
4 v* C- H5 [/ g; u. g5 H2 Pmay have a central nervous system lesion that is- G) v% g1 E0 S9 \
responsible for the early activation of the hypothal-2 ~" c3 H" Q! r+ d( Q, F
amic pituitary gonadal axis.1-3 Thus, greater empha-
% O/ Z8 p+ w, F. l) z4 H6 {sis has been given to neuroradiologic imaging in
4 S. r5 u- P* N, v) W2 `2 X/ K+ jboys with precocious puberty. In addition to viril-
3 D+ W5 J9 _1 h- ~8 Mization, the clinical hallmark of CPP is the symmet-$ W9 o- t5 F" R6 t6 T' \1 z; N, f
rical testicular growth secondary to stimulation by+ `7 Z5 Z z0 q5 e U0 I
gonadotropins.1,3- U% c/ k/ z2 L( U! @" ^& N
Gonadotropin-independent peripheral preco-3 u: Y, ?8 ~/ g4 E7 L
cious puberty in boys also results from inappropriate; J* @! E" j- Q' I
androgenic stimulation from either endogenous or1 z3 ?6 w2 }: w8 z+ r! p2 K
exogenous sources, nonpituitary gonadotropin stim-
5 {- A# q! R# [; z4 X' d! `ulation, and rare activating mutations.3 Virilizing
- t- I M/ k+ w }/ u' hcongenital adrenal hyperplasia producing excessive
# L3 L3 @* z# X3 k M: Q- S) aadrenal androgens is a common cause of precocious4 D& y( i$ N* Q6 r! [
puberty in boys.3,4
: M3 H! _9 x7 j4 L0 J7 G- UThe most common form of congenital adrenal9 C$ G+ [* l {- `" p
hyperplasia is the 21-hydroxylase enzyme deficiency.- P# }! L) O ^- {% x/ K
The 11-β hydroxylase deficiency may also result in: O0 x9 Z. `0 T2 l9 P
excessive adrenal androgen production, and rarely,9 b2 \. Y- l) @
an adrenal tumor may also cause adrenal androgen9 Q: Q8 ~& ^: g" H
excess.1,3. q6 Z" C* k% r3 N/ g8 q2 n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# x: H9 O( d8 f* a6 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- _ J+ \* f! P% ~
A unique entity of male-limited gonadotropin-
. a4 X8 L% Q6 ^, U! p Gindependent precocious puberty, which is also known
! z. Q' B9 ]& X1 C I% c: fas testotoxicosis, may cause precocious puberty at a. s, Z: _; z6 l, \7 W
very young age. The physical findings in these boys
; l# t* i- |- Awith this disorder are full pubertal development,% i6 L, d3 V: B9 v* B+ n3 \
including bilateral testicular growth, similar to boys9 H3 v' N" r. |9 N- }/ o
with CPP. The gonadotropin levels in this disorder
- _: w2 i& F/ `are suppressed to prepubertal levels and do not show
9 c3 y: v7 [$ n/ i x$ Z8 [4 T9 opubertal response of gonadotropin after gonadotropin-5 L% k5 ]8 R0 a' L9 ^
releasing hormone stimulation. This is a sex-linked
2 z* r3 }5 T9 z; z! n5 s& ^autosomal dominant disorder that affects only
. ?5 t Z% F) K1 @% [males; therefore, other male members of the family+ u# z. w* S1 a0 X7 G0 H! h
may have similar precocious puberty.3
6 z3 V7 a. D/ F4 EIn our patient, physical examination was incon-1 q( o- r( E9 j& a8 f3 `
sistent with true precocious puberty since his testi-
# A" b9 h! ~/ }/ X- {' J: x* vcles were prepubertal in size. However, testotoxicosis
9 y& t, C# P9 x" {was in the differential diagnosis because his father/ v, V8 T- q4 J8 D+ j
started puberty somewhat early, and occasionally,3 Z% i6 B5 f& t, ]2 T
testicular enlargement is not that evident in the
" ]) n+ K) Y h0 l) a E" kbeginning of this process.1 In the absence of a neg-
8 g9 `$ ?9 I, r+ W, aative initial history of androgen exposure, our
0 I' ?4 f9 d; B# L+ Mbiggest concern was virilizing adrenal hyperplasia,* [+ ^5 E: @# q. f' F& G0 h& P% d, R
either 21-hydroxylase deficiency or 11-β hydroxylase
0 s. R) M2 N0 t. Hdeficiency. Those diagnoses were excluded by find-! U0 i( y# J4 P" Q0 X
ing the normal level of adrenal steroids.
5 S2 c- z( v5 Q; D8 _8 @; L# Z' iThe diagnosis of exogenous androgens was strongly
1 J: {7 f0 e ?4 Fsuspected in a follow-up visit after 4 months because
, v6 {1 ~' t1 V4 P7 [( P4 ~' b0 H( pthe physical examination revealed the complete disap-$ ~3 a2 O. Y, h4 t# V Y- {
pearance of pubic hair, normal growth velocity, and
; \9 ^7 [8 v) D: ndecreased erections. The father admitted using a testos-7 b: d; q2 s) ? H
terone gel, which he concealed at first visit. He was1 W/ X; d/ n; Z9 c
using it rather frequently, twice a day. The Physicians’
/ r+ D! Y# L3 T. {- v+ Q9 fDesk Reference, or package insert of this product, gel or) h, B Q1 n( h+ P, z L# V
cream, cautions about dermal testosterone transfer to
; H+ G% c. Q) W! k1 ?' _unprotected females through direct skin exposure.
4 J- {0 \# |' Y% l% z! L5 kSerum testosterone level was found to be 2 times the* k3 _5 i& K& j/ g
baseline value in those females who were exposed to) }# j; d% _# [. o
even 15 minutes of direct skin contact with their male" s. [$ K1 `4 g' P3 T
partners.6 However, when a shirt covered the applica-
@; {" g* F; S+ A K9 ttion site, this testosterone transfer was prevented.2 _$ x' ~0 }& l. |4 ~
Our patient’s testosterone level was 60 ng/mL,8 ^9 [/ J- Y" `
which was clearly high. Some studies suggest that
+ c% P4 T. Y7 B* `& ^dermal conversion of testosterone to dihydrotestos-
9 ^. I2 u* ?/ R) F% N$ Nterone, which is a more potent metabolite, is more
8 |- ]# D" E1 yactive in young children exposed to testosterone: i" R! V# b8 l0 R" O6 _
exogenously7; however, we did not measure a dihy-% @( z2 V) h; {% d% J* v
drotestosterone level in our patient. In addition to- W" c, Q$ M6 ~+ H, i, b
virilization, exposure to exogenous testosterone in+ v8 c4 z+ Z& k
children results in an increase in growth velocity and
* K( {: M- p' T8 @; s! |advanced bone age, as seen in our patient.
- `! `: ~: ~8 U6 N" p& _8 gThe long-term effect of androgen exposure during
8 i6 L9 ]5 D$ x& Q7 S( L+ ~. W$ C( k) learly childhood on pubertal development and final
7 A+ s; E) l4 y" d# r) x+ b0 M4 hadult height are not fully known and always remain
, ?: f3 ?2 k5 h# q M* Z3 ba concern. Children treated with short-term testos-# I5 E9 m+ T6 S0 i. U
terone injection or topical androgen may exhibit some
( _# d% a: o# l: ?9 cacceleration of the skeletal maturation; however, after [; R" E+ a7 k6 T. @( s0 L3 u& w
cessation of treatment, the rate of bone maturation
8 _1 `& {' h0 c$ i6 |, M& Ydecelerates and gradually returns to normal.8,9
, m. o3 b& l" C5 h& w% ?. [There are conflicting reports and controversy
$ x/ `) f& _# T6 qover the effect of early androgen exposure on adult2 f8 j5 V7 N6 N% [
penile length.10,11 Some reports suggest subnormal
( {9 l4 X* u5 b, T! f, hadult penile length, apparently because of downreg-* F i$ V( F* o. N
ulation of androgen receptor number.10,12 However,; v. I/ n& j) w9 n- ~/ ?& k
Sutherland et al13 did not find a correlation between# M' S9 L/ X# C- |. D) M
childhood testosterone exposure and reduced adult
# R7 ?3 _1 T7 l$ l! z2 a1 gpenile length in clinical studies.* L# D. G8 {' [: v# N
Nonetheless, we do not believe our patient is
. Y+ ^+ C* }4 hgoing to experience any of the untoward effects from6 k% T: H; m1 q* x1 \
testosterone exposure as mentioned earlier because& v! h/ p1 e/ h. R* x
the exposure was not for a prolonged period of time.1 T; W3 H5 `5 |$ W* x
Although the bone age was advanced at the time of7 \) m. Q) K% K# K6 u. a
diagnosis, the child had a normal growth velocity at
' |$ J# }( e( d, Fthe follow-up visit. It is hoped that his final adult# w& }; ]2 B% z: @+ z! Z4 X
height will not be affected.
- ?0 s. k4 V( _, P, O3 D# k1 ~Although rarely reported, the widespread avail-
9 X- r2 G% ]8 I9 Rability of androgen products in our society may
$ s/ M/ Z8 m4 E' J( findeed cause more virilization in male or female2 c( z V- _: m. w
children than one would realize. Exposure to andro-; J7 y- u; I' U. p
gen products must be considered and specific ques-9 \1 ?1 X; @6 h! H4 O! a& c
tioning about the use of a testosterone product or& V% h i7 q/ ?) b" v% p$ Z
gel should be asked of the family members during7 x- [7 ^2 _; G" z
the evaluation of any children who present with vir-
! m) N# N( N, {ilization or peripheral precocious puberty. The diag-
4 [% B' {! _- Z8 Jnosis can be established by just a few tests and by3 h" y8 y5 x: t* m' A3 t7 T
appropriate history. The inability to obtain such a/ Z. q4 o3 \ m2 C# d
history, or failure to ask the specific questions, may" `. ?+ u" Y8 U* o
result in extensive, unnecessary, and expensive2 ]" h+ D' n- h1 |
investigation. The primary care physician should be' Y# }; o9 A5 A/ q0 s9 C$ X" \7 c T
aware of this fact, because most of these children8 |: p; [4 D+ G
may initially present in their practice. The Physicians’
9 m% d! Y9 T8 M* L& j: |Desk Reference and package insert should also put a9 f' i5 r& H) b5 [( Y
warning about the virilizing effect on a male or
7 f% T/ Q7 i& [1 Vfemale child who might come in contact with some- b: c$ s: x* V3 ]8 J7 K5 W( L
one using any of these products.
2 @1 E+ ]+ b5 kReferences
" r, N, K$ K1 f1. Styne DM. The testes: disorder of sexual differentiation+ L K/ s7 g1 D
and puberty in the male. In: Sperling MA, ed. Pediatric0 J2 L* k8 A) w: Z( h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 s# l$ x4 H- q% w
2002: 565-628.
, x& B' T8 k5 s0 T2 I7 K( L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ _ a7 p7 l) q2 c, ?3 H
puberty in children with tumours of the suprasellar pineal |
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