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Sexual Precocity in a 16-Month-Old( [8 M$ u' X1 P, G( m
Boy Induced by Indirect Topical/ l" t6 P; \, h7 Z% ?3 B. b
Exposure to Testosterone5 k# v7 W r5 ?6 V/ b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! u% {$ \! L4 O5 g2 ?9 |) ]and Kenneth R. Rettig, MD1# D& t1 o: b ?; [3 R. b
Clinical Pediatrics {9 S2 @; U6 A
Volume 46 Number 6+ ?/ ^+ ]. v. l8 C, v3 i
July 2007 540-543
: x, ~0 [" Z* p& L© 2007 Sage Publications( e8 D ~' P. d8 c
10.1177/00099228062966516 F. f$ j& C* l6 K) f; v. c. Y
http://clp.sagepub.com7 V" Q7 A; X) k8 W/ L' x% x
hosted at$ D6 D3 @0 X* i8 M- k
http://online.sagepub.com
$ U) R7 W, Q7 Z7 j: {8 o5 ^Precocious puberty in boys, central or peripheral,
' U! H1 c @% C4 c5 ]* c6 Bis a significant concern for physicians. Central
! ^& ]* r$ S. |precocious puberty (CPP), which is mediated% h( E4 I6 x7 {
through the hypothalamic pituitary gonadal axis, has
~! P5 j! D- u0 F k( e" T, |a higher incidence of organic central nervous system
% Q: L6 H8 @7 }* N z4 _5 W* z9 dlesions in boys.1,2 Virilization in boys, as manifested
' P8 ?; D# J Q* C3 N* D1 Bby enlargement of the penis, development of pubic$ I- Y+ l% w! g% L. b1 A
hair, and facial acne without enlargement of testi-
' S, |, W& x1 A8 R* K: j% Qcles, suggests peripheral or pseudopuberty.1-3 We
7 H6 f3 U! e% z" f; w8 qreport a 16-month-old boy who presented with the
* P& k- x! J& X. j% o T! Lenlargement of the phallus and pubic hair develop-' Q" e* y& d _' L8 Y1 _0 ]! m/ J- F
ment without testicular enlargement, which was due- Q O% q8 B% A8 J7 `! \
to the unintentional exposure to androgen gel used by
; h7 {; w# R0 Z# o) Xthe father. The family initially concealed this infor-
1 \. D4 r9 F. d0 _5 Hmation, resulting in an extensive work-up for this& c7 u2 W @- \ |3 t% x
child. Given the widespread and easy availability of1 W t: {# A/ U& E/ l$ V
testosterone gel and cream, we believe this is proba-
4 s2 d% s0 J4 B( Q+ ?- }bly more common than the rare case report in the/ ]. y: q+ O4 J1 G: l2 @
literature.4
; V- M2 U& ?& J+ T3 BPatient Report0 j# g8 c Z2 ~
A 16-month-old white child was referred to the, t8 u5 ^5 A3 n% h) Q
endocrine clinic by his pediatrician with the concern
) b/ ?. t# z" O5 Y6 i$ @, Vof early sexual development. His mother noticed
6 Y( _/ w4 F4 S3 b; y- Ylight colored pubic hair development when he was
) L) c+ L q( G9 g2 mFrom the 1Division of Pediatric Endocrinology, 2University of
; C* [/ {- r. ^South Alabama Medical Center, Mobile, Alabama.# A) g/ |8 _& h1 G
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* L& |7 P: H: L( XProfessor of Pediatrics, University of South Alabama, College of
( H) r2 e# |* h( L9 aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: J i& p7 _: Be-mail: [email protected].% U; v, ]3 Q ~* J# c0 F9 e
about 6 to 7 months old, which progressively became
6 l- W* }6 P6 f4 |6 Jdarker. She was also concerned about the enlarge-
9 n# v1 c. x/ \' Kment of his penis and frequent erections. The child
" P; g8 F+ @% {. r" h$ k0 ~was the product of a full-term normal delivery, with
% N/ t2 I$ S' q" A9 @5 v1 k3 z: Na birth weight of 7 lb 14 oz, and birth length of
7 `! b, C7 ^1 ~: m20 inches. He was breast-fed throughout the first year2 w$ H4 z+ d5 Z6 Y
of life and was still receiving breast milk along with
' H/ ]; u+ U8 ?# b8 m% nsolid food. He had no hospitalizations or surgery,
9 j! P" i0 V% Mand his psychosocial and psychomotor development
! {! l% m, C; |$ n) P x- k7 dwas age appropriate., y! V$ a3 ^; T
The family history was remarkable for the father,- o9 _$ h2 ~' a" L- i
who was diagnosed with hypothyroidism at age 16,# V1 K: M( C, D0 q5 b
which was treated with thyroxine. The father’s
* c6 [% B' E% Zheight was 6 feet, and he went through a somewhat4 k& `% i3 |" J- d( D) f
early puberty and had stopped growing by age 14.
$ a; ?. L8 o6 M' ZThe father denied taking any other medication. The
- K3 `2 x' K6 A9 m2 W# hchild’s mother was in good health. Her menarche
2 t0 G1 ~1 C" O0 A" v- l7 y* Ywas at 11 years of age, and her height was at 5 feet% e3 }* E0 \/ A
5 inches. There was no other family history of pre-' D1 N/ B" |" y; w u
cocious sexual development in the first-degree rela-6 a. ]0 ^7 O9 Y
tives. There were no siblings.- u! X" j9 I7 e. [$ s
Physical Examination: s* u- w$ L9 \' L4 y
The physical examination revealed a very active,) W# E) d1 `, h! @# J
playful, and healthy boy. The vital signs documented% i. b4 ?6 m" p6 |- b$ j! u
a blood pressure of 85/50 mm Hg, his length was/ W5 o8 R2 t" W; v
90 cm (>97th percentile), and his weight was 14.4 kg
0 @& S9 L% ?7 L' q* Z. N6 X(also >97th percentile). The observed yearly growth
, b8 X& u' K" Z7 k& T5 Evelocity was 30 cm (12 inches). The examination of
5 s+ }& K& \9 S: E3 u* F0 G" \0 v7 ithe neck revealed no thyroid enlargement.
5 I; {+ q/ h2 PThe genitourinary examination was remarkable for3 |1 l/ D8 z( K: M* C, U
enlargement of the penis, with a stretched length of" i8 \6 C5 X+ U& G
8 cm and a width of 2 cm. The glans penis was very well
2 y5 S$ z$ C% \& |developed. The pubic hair was Tanner II, mostly around' Y' @" z0 p4 a! j5 I% K2 y1 x
5403 | g4 l3 W# z6 S9 s& I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ _1 W/ q5 Y! N2 a
the base of the phallus and was dark and curled. The9 K5 m; d. N6 M! E# ^, u) t
testicular volume was prepubertal at 2 mL each.
; j; I3 {0 V% R G% vThe skin was moist and smooth and somewhat' x; z& s9 T3 x+ i/ d; h
oily. No axillary hair was noted. There were no r- s8 o( J$ V, v6 T$ c/ P
abnormal skin pigmentations or café-au-lait spots.* {. S/ W& ^4 [/ _
Neurologic evaluation showed deep tendon reflex 2+
& p- @6 A% Q* j$ `bilateral and symmetrical. There was no suggestion
$ ^/ J4 o( k2 E$ [of papilledema.
* V' l3 d- d: ~# F2 m* c2 u* C4 GLaboratory Evaluation; ?. {9 a" ^. [4 e
The bone age was consistent with 28 months by
! d# i- ]; `) {: ]using the standard of Greulich and Pyle at a chrono-" v0 Y, x- q1 [8 K) X( n; \" E
logic age of 16 months (advanced).5 Chromosomal$ t: \/ l, v/ l' G: D
karyotype was 46XY. The thyroid function test
0 _+ |$ [+ X8 R: Eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ G" [# K+ I% a' e# T- \
lating hormone level was 1.3 µIU/mL (both normal).
0 x* W- [9 K6 q( E9 D4 y+ j% }The concentrations of serum electrolytes, blood
( {6 ^( @% G: M$ o9 r- turea nitrogen, creatinine, and calcium all were
4 r& L7 d8 r, Jwithin normal range for his age. The concentration
& ~$ {8 s' \ E1 x0 _8 Y; T* A8 G/ ^of serum 17-hydroxyprogesterone was 16 ng/dL% O& W" e) N; M& c
(normal, 3 to 90 ng/dL), androstenedione was 20
: N( T: K# c! h2 Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( H5 j) [+ R/ f2 e# I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 T6 F0 a1 E2 \3 U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( \5 U ^$ X" x+ {# _) w
49ng/dL), 11-desoxycortisol (specific compound S)2 c- P6 r8 ~ o# p( R' O' v/ g8 E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 k: b5 f! f1 ?* ] J) gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ j4 {8 w( s: i7 B s3 Ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),( z6 p, g' t) y: m+ r1 F+ t; h1 ~& G
and β-human chorionic gonadotropin was less than: k! s" h7 r) d- M* `
5 mIU/mL (normal <5 mIU/mL). Serum follicular5 R7 y6 C6 U, ]0 O
stimulating hormone and leuteinizing hormone) a5 N& H/ g2 X0 W. f( Q
concentrations were less than 0.05 mIU/mL! {! ~# [, W6 N6 k$ U; F
(prepubertal).2 H' H I/ j" B+ I$ p5 g
The parents were notified about the laboratory/ n: q: a5 F& w( Y. C- D
results and were informed that all of the tests were$ F6 l. J7 m8 w: F* T
normal except the testosterone level was high. The
4 t6 a% z% @ ifollow-up visit was arranged within a few weeks to, d" y0 X$ m+ k% B! `3 j
obtain testicular and abdominal sonograms; how-# u% p7 C, F; \, f0 F
ever, the family did not return for 4 months.
( [, W1 Q6 t: H* L* JPhysical examination at this time revealed that the
* |, C$ f6 r0 b2 q* [child had grown 2.5 cm in 4 months and had gained
+ X: b3 M) g$ p$ b, Z5 ]; A4 |2 kg of weight. Physical examination remained: ^, H. L( h- {- x& N
unchanged. Surprisingly, the pubic hair almost com-. p. S+ N% v, N' \% r6 _( Z: ^
pletely disappeared except for a few vellous hairs at, r; ]' Z7 C' v7 i
the base of the phallus. Testicular volume was still 2
) w3 Z" q# j" W7 g4 }$ A) h) QmL, and the size of the penis remained unchanged.
# y( z9 {* h6 PThe mother also said that the boy was no longer hav-, E: T( k( i9 d: t( F6 [7 E4 E, j
ing frequent erections.
0 t8 h; I/ f& h' C H. xBoth parents were again questioned about use of0 H3 o% v8 F7 l
any ointment/creams that they may have applied to+ R8 ?" W/ G0 \7 @4 C) {: g
the child’s skin. This time the father admitted the4 u: R, p6 I* L5 Y
Topical Testosterone Exposure / Bhowmick et al 541$ s: |- ~- F% I2 a
use of testosterone gel twice daily that he was apply-8 B0 \7 ~: }, R& K% |; d% T
ing over his own shoulders, chest, and back area for- E' z# s* e5 k: p
a year. The father also revealed he was embarrassed
4 x2 ]6 {: o( p- Gto disclose that he was using a testosterone gel pre-
' Y P+ j3 n9 e5 V) c. Q$ ?scribed by his family physician for decreased libido
3 o7 k' _. C( |/ T0 N9 ~4 f" W! hsecondary to depression.; U0 L0 V' W8 s" ]
The child slept in the same bed with parents.; r# Q8 J# s5 k% T$ k: d ~' o
The father would hug the baby and hold him on his
3 @) l% O1 n9 U* Z( c+ p1 w! bchest for a considerable period of time, causing sig-0 W Y# R" B2 E/ s
nificant bare skin contact between baby and father.4 U$ J, I: O/ w2 g
The father also admitted that after the phone call,' f/ H% i* ], S& A
when he learned the testosterone level in the baby
1 ^" f# s/ x0 Qwas high, he then read the product information Y6 [) S7 E, h- X$ [9 ^) |
packet and concluded that it was most likely the rea-
, ^) f2 }, J; x/ j5 \" k. [ d- Kson for the child’s virilization. At that time, they+ v( @, e1 Q1 t
decided to put the baby in a separate bed, and the
; w( E- O k& a" u& h2 L% rfather was not hugging him with bare skin and had
' s, @, J3 ?4 Hbeen using protective clothing. A repeat testosterone4 w3 l# f- g1 m! C
test was ordered, but the family did not go to the
! B/ x; O3 D) E) G; T5 Ilaboratory to obtain the test.( {# w' t3 m. j, u
Discussion P2 q, k' B' k$ e. n
Precocious puberty in boys is defined as secondary
8 r# t+ W, l- L3 F! H4 d/ e" Wsexual development before 9 years of age.1,4: h: n6 B ?% H5 |, A* C( J
Precocious puberty is termed as central (true) when5 F9 U* k8 L% z# N9 O! |
it is caused by the premature activation of hypo-! I$ N2 K: A+ }4 j' k/ r% Z
thalamic pituitary gonadal axis. CPP is more com-$ P4 ]$ ^: a2 i( u- h
mon in girls than in boys.1,3 Most boys with CPP2 Y; Y! Z' j9 D# s% Q6 L: j
may have a central nervous system lesion that is; n1 A* _& T5 D8 l( A
responsible for the early activation of the hypothal-6 T& l! L* k6 B8 C2 d
amic pituitary gonadal axis.1-3 Thus, greater empha-0 n, n) e" c4 l- M
sis has been given to neuroradiologic imaging in
. t0 X; U# d) N+ D8 pboys with precocious puberty. In addition to viril-
+ u, K+ O4 J! x8 w) R2 s- \ization, the clinical hallmark of CPP is the symmet-7 d) ^/ k1 ?) ^4 a8 }
rical testicular growth secondary to stimulation by( z$ W0 y& I2 }2 A! L2 x4 s% e
gonadotropins.1,3
9 B7 N1 Q+ l' ^4 X4 eGonadotropin-independent peripheral preco-
7 d O8 f. [ q& Lcious puberty in boys also results from inappropriate
o) I4 g0 w6 _androgenic stimulation from either endogenous or" ^# d* F; ~; N+ p
exogenous sources, nonpituitary gonadotropin stim-
( p. C2 t9 Z6 Vulation, and rare activating mutations.3 Virilizing; v. |$ ]0 Z, b9 B3 D+ k E* W
congenital adrenal hyperplasia producing excessive
6 b" f" \0 i7 cadrenal androgens is a common cause of precocious
& E, q6 x) |: [- n5 ^ }5 Zpuberty in boys.3,40 {. M' x; n5 T- c5 @/ ~
The most common form of congenital adrenal
5 s- L6 `" J7 }+ `: Ghyperplasia is the 21-hydroxylase enzyme deficiency.
& S( \* W6 Z1 J" n' dThe 11-β hydroxylase deficiency may also result in
. E8 l8 }, c) @; K4 |excessive adrenal androgen production, and rarely,+ r5 g7 b0 [4 v5 J* G4 f% ]+ f
an adrenal tumor may also cause adrenal androgen
- @% X7 P3 c" X: r" F8 dexcess.1,3& A6 {2 V- S# `6 w' E; w4 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 R A) M! ^/ y# b542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( r3 \, Q% P9 X! I0 I3 d8 [, z
A unique entity of male-limited gonadotropin-
' I s2 _2 D0 A) s9 R7 F6 i, cindependent precocious puberty, which is also known
# x6 d$ Q* @: ?) {; c3 K! Sas testotoxicosis, may cause precocious puberty at a4 n* t- i" l$ @- Q a) Y0 I1 u% l
very young age. The physical findings in these boys
' ]$ C( E. X, {0 Hwith this disorder are full pubertal development,
0 y9 o" n8 E1 t$ e- z zincluding bilateral testicular growth, similar to boys% J2 Z# F/ ~7 {) g; [% V( ^
with CPP. The gonadotropin levels in this disorder4 k4 [6 C) f T0 B4 `' `0 t
are suppressed to prepubertal levels and do not show3 }, h2 p9 E; D
pubertal response of gonadotropin after gonadotropin- v4 w" b8 X |3 w5 ?' h
releasing hormone stimulation. This is a sex-linked
! l# [3 ~$ A# \) G3 \, wautosomal dominant disorder that affects only! l" }3 G) V) \+ L& s
males; therefore, other male members of the family* h, Y5 e6 a( a6 V6 b5 K: \+ O
may have similar precocious puberty.3# t% G' g4 X: ^ l/ I" @
In our patient, physical examination was incon-
, ?5 X, o1 S" a, o e8 ksistent with true precocious puberty since his testi-
7 ]* c b6 `- Q* O* hcles were prepubertal in size. However, testotoxicosis
8 M, j( k: E7 S- J2 ^' `was in the differential diagnosis because his father% W, e) ~+ A* {
started puberty somewhat early, and occasionally,3 I4 J& N* H: k3 {3 z1 z% B
testicular enlargement is not that evident in the5 d, t1 F3 z8 [6 f
beginning of this process.1 In the absence of a neg-
3 e- ^; p7 d" ^& `9 v. ^- Fative initial history of androgen exposure, our# d t& _% a( h( D' n; f
biggest concern was virilizing adrenal hyperplasia,
$ e; Z/ N* y' S* ]either 21-hydroxylase deficiency or 11-β hydroxylase% m+ s" N9 {; w8 K. ~. [
deficiency. Those diagnoses were excluded by find-8 p* q0 w8 l( j* ~9 D n& \' o
ing the normal level of adrenal steroids.
: m6 m" ~! D' |3 J' C; h5 UThe diagnosis of exogenous androgens was strongly6 \% f1 M9 E. Z/ B& f9 s' j/ ^0 `
suspected in a follow-up visit after 4 months because9 \. P; B/ C# P9 b
the physical examination revealed the complete disap-
% M# G6 v2 O# e& W, Y, l3 _5 Y% o9 x7 R" Fpearance of pubic hair, normal growth velocity, and
- G9 A, @. R# o, L- X, u, X% |decreased erections. The father admitted using a testos-: O; P; O8 w% f2 b! \0 N q* l& g, ^
terone gel, which he concealed at first visit. He was" M: p7 K! [- k$ i8 H( e
using it rather frequently, twice a day. The Physicians’
8 j% a$ F9 U0 c# }2 F0 g" J$ sDesk Reference, or package insert of this product, gel or$ @! m( r- u* e
cream, cautions about dermal testosterone transfer to6 O- V7 R/ b1 p9 c0 G2 c
unprotected females through direct skin exposure.2 O) Z$ y' h( r8 v) G# L! [
Serum testosterone level was found to be 2 times the
7 Y* K3 N3 l0 V7 @3 [ S1 nbaseline value in those females who were exposed to
( m! e' z' Z6 j7 Peven 15 minutes of direct skin contact with their male
( p c% I1 C) O; B: {6 z$ xpartners.6 However, when a shirt covered the applica-
1 s( k& ~9 x# C% \+ x4 s& y6 ition site, this testosterone transfer was prevented.+ {! ^( \, |4 w, a+ b i
Our patient’s testosterone level was 60 ng/mL,
* _/ y* _+ k) D3 y' _which was clearly high. Some studies suggest that4 v+ F* E% L- ?& ~7 X$ S! r
dermal conversion of testosterone to dihydrotestos-6 q" Q, v2 ?& A4 v
terone, which is a more potent metabolite, is more9 x& w/ o5 }$ B! V/ @/ S4 f0 v
active in young children exposed to testosterone
2 }9 \, x6 s) f4 c9 S; w( Iexogenously7; however, we did not measure a dihy-
, R' I5 m' r( p- A8 ]drotestosterone level in our patient. In addition to
& P* i2 z1 ?! j& V0 X: @virilization, exposure to exogenous testosterone in
& { E! k# Y+ g' G- kchildren results in an increase in growth velocity and
# Z+ j7 \+ | m) _' \advanced bone age, as seen in our patient.# r( Z) s. @6 z. p8 }8 B: E5 c
The long-term effect of androgen exposure during7 \8 P/ G0 X! }- T
early childhood on pubertal development and final7 o* R' J) L$ s, J8 f8 x
adult height are not fully known and always remain
" H4 d" V9 d6 _9 e ^a concern. Children treated with short-term testos-0 }0 m; x2 |' {5 t# x
terone injection or topical androgen may exhibit some6 k# M& [& x! I7 ?
acceleration of the skeletal maturation; however, after
$ E( U6 I- o* Rcessation of treatment, the rate of bone maturation
H+ [6 e6 V" S" b7 v' r8 E2 N% _decelerates and gradually returns to normal.8,9
/ I, t9 v. S( fThere are conflicting reports and controversy
) t$ w# p3 V+ N& [' m% i: jover the effect of early androgen exposure on adult! _& Q) Q. |3 S x6 z7 L
penile length.10,11 Some reports suggest subnormal- w* y9 n6 U% T" Q* D1 h
adult penile length, apparently because of downreg-
5 z/ Z' V! G8 }2 sulation of androgen receptor number.10,12 However,
2 X1 [( i% e2 [! R' e- ySutherland et al13 did not find a correlation between
# J2 z, T3 F: {8 B5 ]# G* Wchildhood testosterone exposure and reduced adult
/ i! F/ I: v% Q, v# K* Zpenile length in clinical studies.
: ^& }% d( K5 z4 o4 m5 G4 Q6 a' CNonetheless, we do not believe our patient is" q: v( r$ q: x) [0 V/ m' O
going to experience any of the untoward effects from
( J( _0 [ X; O) Wtestosterone exposure as mentioned earlier because' M2 I5 `% T0 \
the exposure was not for a prolonged period of time.6 I. y3 V6 R$ ]& [) o3 k
Although the bone age was advanced at the time of( m& ]4 u( P3 E3 i! ^1 K, Q- A
diagnosis, the child had a normal growth velocity at
5 |3 r$ t- f# ?4 cthe follow-up visit. It is hoped that his final adult: G' b/ |1 t' k$ ^; R
height will not be affected.+ x% r0 ~9 J. d. A
Although rarely reported, the widespread avail-
+ U' T( j# |" O7 ^# R) kability of androgen products in our society may
" y8 f" G6 H7 y {9 ?: hindeed cause more virilization in male or female
/ d$ V. |; v* ?$ ~, g: y+ q/ Y ^5 Nchildren than one would realize. Exposure to andro-
( ^0 U- W6 J3 Sgen products must be considered and specific ques-
2 R1 h( N; h9 e7 k5 ^5 Vtioning about the use of a testosterone product or
% L, Y8 X* u, R- Pgel should be asked of the family members during& T- A9 p3 Y# T, A U
the evaluation of any children who present with vir-, ]8 a& C8 Q- n
ilization or peripheral precocious puberty. The diag-
1 {9 {' b+ x6 @) D0 gnosis can be established by just a few tests and by
) q" R" A/ U# [) z. z4 X) A: [appropriate history. The inability to obtain such a1 i1 T6 D6 r" p) r. e/ C1 B
history, or failure to ask the specific questions, may
/ O! f X. C# F: h7 O2 f5 \2 aresult in extensive, unnecessary, and expensive
7 n+ F9 G, d- Ainvestigation. The primary care physician should be
" q# d1 C" W/ q$ O) B% Maware of this fact, because most of these children0 y( i0 d) M1 i# J& i
may initially present in their practice. The Physicians’
: S8 P) \; P, Q8 ^' uDesk Reference and package insert should also put a
+ U6 e; y+ B' v5 @( Qwarning about the virilizing effect on a male or
* l$ d( U& G3 H$ Z/ ]: U" M% Q, Jfemale child who might come in contact with some-0 F2 I# z: g* B. k6 U
one using any of these products.
2 G3 A" [* w3 e! d2 LReferences/ P( [: f9 K) ]/ G, F
1. Styne DM. The testes: disorder of sexual differentiation
+ u; C; m3 x. W7 T6 ?4 n( vand puberty in the male. In: Sperling MA, ed. Pediatric. y2 }2 U n6 S$ T! ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 G0 @/ H7 n) q2 e8 ^1 U2002: 565-628.
- s' r" @, ~% O V- ~' d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) K$ ]: t$ r, v
puberty in children with tumours of the suprasellar pineal |
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