- 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 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
+ R/ U+ {6 h% Q; [Boy Induced by Indirect Topical! u( v7 _1 X7 K" J7 k( y
Exposure to Testosterone4 }) g- A3 w0 {9 d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! m; F7 D! B$ z
and Kenneth R. Rettig, MD1
2 Q5 T: v! N& UClinical Pediatrics
6 L& U: R" \* ?7 L. v: G" B8 WVolume 46 Number 6$ H! w/ ]8 ], H' l2 C
July 2007 540-543
( |% g: M/ Y/ \: s2 t7 J© 2007 Sage Publications
/ @6 |4 K! W# Z' L& g" V10.1177/0009922806296651. s) M& F4 ?0 a: k9 U) y
http://clp.sagepub.com6 Z% r0 ?3 t/ a! r) d
hosted at& a6 \/ Y0 d6 C6 j' k
http://online.sagepub.com& D: ^! A" c" J; a! x
Precocious puberty in boys, central or peripheral,
* l4 z2 Z) q7 n- v, ois a significant concern for physicians. Central
, e6 O" L* b5 C7 |) s9 `precocious puberty (CPP), which is mediated) N- i6 A0 O/ q9 C4 ^
through the hypothalamic pituitary gonadal axis, has" k; l* V. b# {- J# v1 i
a higher incidence of organic central nervous system# d/ j/ }- V2 h6 B0 b, s I
lesions in boys.1,2 Virilization in boys, as manifested/ x# G4 G3 e' k1 n3 V+ c( d
by enlargement of the penis, development of pubic/ }& U( U3 b/ f! D9 f2 r
hair, and facial acne without enlargement of testi-; T' M: ^2 J3 j$ c/ }* O% p5 d7 H; z
cles, suggests peripheral or pseudopuberty.1-3 We- h' U( h; ]- I+ F5 s5 {- y$ y
report a 16-month-old boy who presented with the) v) d @' A# H# W% g
enlargement of the phallus and pubic hair develop-
- o/ F+ X5 V1 s1 fment without testicular enlargement, which was due5 A% m& H; y0 e- q) ^! Y3 T( Y6 ~
to the unintentional exposure to androgen gel used by
M6 l: \+ a4 N0 h( cthe father. The family initially concealed this infor-
$ d* W0 K9 U% ?$ amation, resulting in an extensive work-up for this
- l4 C1 y* k3 c6 U4 q! E Ychild. Given the widespread and easy availability of
% `" G+ d# v1 z9 [1 x% A" Ptestosterone gel and cream, we believe this is proba-
/ R/ |% D; M& |2 \( Y5 w! hbly more common than the rare case report in the& k2 t4 \- B( W, L
literature.4
% R- r0 B+ L& h QPatient Report: B$ I2 T5 ]" t5 O" E2 i( O& l
A 16-month-old white child was referred to the" W3 u; k! b O
endocrine clinic by his pediatrician with the concern
4 W, s7 _/ G; P! G7 ?' Gof early sexual development. His mother noticed
3 E/ x. }, B/ v$ C2 @light colored pubic hair development when he was4 R# R: U1 f1 w9 L7 Z4 H
From the 1Division of Pediatric Endocrinology, 2University of
9 y; w9 h v0 X H0 aSouth Alabama Medical Center, Mobile, Alabama.0 P( S; O5 q x
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 N0 d$ `# w1 A% r5 i3 ZProfessor of Pediatrics, University of South Alabama, College of N8 j# C# W# S i" d9 u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 V; Z9 ~0 H. R6 B" b$ x7 M) se-mail: [email protected].& u @# Z4 G4 G H8 M
about 6 to 7 months old, which progressively became
# x1 M, A2 H: ]darker. She was also concerned about the enlarge-2 Q: u$ G* F# ~$ [% y
ment of his penis and frequent erections. The child( ` N" c+ f+ y7 q
was the product of a full-term normal delivery, with
" I) M9 F K+ Wa birth weight of 7 lb 14 oz, and birth length of
* l. F, G3 u6 z% }20 inches. He was breast-fed throughout the first year, M) ?* S- f6 F: ~+ @, N: ^
of life and was still receiving breast milk along with9 C2 a- ]2 L! V' | F) S
solid food. He had no hospitalizations or surgery,* o8 I5 x( r' g* Z' S( G
and his psychosocial and psychomotor development
) @/ K. Y* P. c% A3 {& ywas age appropriate.
* ^- h/ B0 d8 a3 Z. XThe family history was remarkable for the father,4 E+ f3 o1 v/ p+ z
who was diagnosed with hypothyroidism at age 16,% c; w- P) Z# O: g8 k3 r
which was treated with thyroxine. The father’s7 v0 f+ X+ m, S6 n2 T
height was 6 feet, and he went through a somewhat
$ J8 E: C" R# }% n. W8 d Nearly puberty and had stopped growing by age 14.
, h5 \) ]& G* f, \- s4 kThe father denied taking any other medication. The3 U8 b/ k! E/ t& D. Z3 u8 D5 o
child’s mother was in good health. Her menarche
8 n3 J) m( `1 G! ?4 X" kwas at 11 years of age, and her height was at 5 feet
% {. o; n2 R3 j# V5 inches. There was no other family history of pre-
' a: E8 W$ L K1 z: vcocious sexual development in the first-degree rela-
) k w' m' c; q5 G/ B8 _7 dtives. There were no siblings.
/ n8 N& C) l* O- Y0 B: WPhysical Examination
3 j+ @4 f3 x( YThe physical examination revealed a very active,3 B& a. n$ `: b
playful, and healthy boy. The vital signs documented
: N- c" B+ b7 v) ?a blood pressure of 85/50 mm Hg, his length was, z, D' P4 q( G( C7 i: J4 \% _
90 cm (>97th percentile), and his weight was 14.4 kg
$ r" [* S/ A" E2 M! k- S: H(also >97th percentile). The observed yearly growth; g R# |$ J4 P( t2 D: M
velocity was 30 cm (12 inches). The examination of6 S" T# z* j: G& W* B, I
the neck revealed no thyroid enlargement.& m9 c; d1 N) e, y3 y
The genitourinary examination was remarkable for4 U2 e+ y5 ]& z6 r3 E) E: Y" E
enlargement of the penis, with a stretched length of
0 A4 s# f7 V: s! R, o' W8 cm and a width of 2 cm. The glans penis was very well" Q6 b. g+ B) ~" |; E; ~5 u
developed. The pubic hair was Tanner II, mostly around& o3 W' T; w# | i1 S
540" Q. G. b+ s3 z+ ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& b) R9 I1 q4 s. v. K, J: c
the base of the phallus and was dark and curled. The
" h o4 O9 V' d$ Ttesticular volume was prepubertal at 2 mL each." f) K) ^8 w, u3 N5 c6 C) V# R, E
The skin was moist and smooth and somewhat4 I$ p& _2 h5 O
oily. No axillary hair was noted. There were no
4 f$ f$ j/ d0 Uabnormal skin pigmentations or café-au-lait spots.
1 X: E; S) @, X+ q) QNeurologic evaluation showed deep tendon reflex 2+
- y8 K0 G) X, L1 w- L/ K$ Pbilateral and symmetrical. There was no suggestion
6 E! S9 K5 l. I. m) _) Dof papilledema.2 k$ a, `# }% ^3 O8 d& o6 K5 v) C% E
Laboratory Evaluation# C0 e* T& c# o
The bone age was consistent with 28 months by
; h# w- ?' h! m+ p8 Ausing the standard of Greulich and Pyle at a chrono-
" _* Z/ {, ? W M, Alogic age of 16 months (advanced).5 Chromosomal
# l. {3 Q2 B% ~1 k2 z* S* a3 Ikaryotype was 46XY. The thyroid function test$ f% o1 v, o$ k; V" ?- s5 z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- S& E, D) V! _: c! Y
lating hormone level was 1.3 µIU/mL (both normal).
/ M9 E$ w- S! [& G$ E! OThe concentrations of serum electrolytes, blood+ B3 E+ ~! u! j% y& o
urea nitrogen, creatinine, and calcium all were
4 R/ n4 M# X% gwithin normal range for his age. The concentration: c2 d: h6 u! e8 U, Z" N
of serum 17-hydroxyprogesterone was 16 ng/dL
- K2 m1 p3 N7 }(normal, 3 to 90 ng/dL), androstenedione was 20
, g% T9 d5 h4 |/ N+ a( rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% ^/ K0 ^. P$ p j9 }3 H
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- e2 @4 X. P: J6 X% Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 N! f* U8 L0 w* {49ng/dL), 11-desoxycortisol (specific compound S)+ A7 U1 D4 u# k' Y) X+ V3 b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# s) `* [! Z# W2 r' o7 Ltisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) B L6 M" f4 ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 y$ W( g" h: A' m7 Q7 T d
and β-human chorionic gonadotropin was less than) d+ K) t, g4 T& E3 v
5 mIU/mL (normal <5 mIU/mL). Serum follicular' W0 E- J$ e5 K) d4 J o" ~( [
stimulating hormone and leuteinizing hormone
. x# j" ^; b; A# o& \7 ^concentrations were less than 0.05 mIU/mL7 p2 J. k F) `3 G- P
(prepubertal).% @0 M- M. l2 [2 L3 ]3 V8 d
The parents were notified about the laboratory& G% d4 f N& D k
results and were informed that all of the tests were
$ V; u$ ]- ?, S8 h# Cnormal except the testosterone level was high. The9 K2 q$ `( ~; r
follow-up visit was arranged within a few weeks to2 U$ m: I# p7 W4 [3 T9 _2 M
obtain testicular and abdominal sonograms; how-
8 s- F, M1 ]" O2 ?8 s4 F+ @ever, the family did not return for 4 months.
7 N p* z( m6 B$ m% i! C$ c0 s/ uPhysical examination at this time revealed that the0 D3 y, z+ G$ C$ R3 }
child had grown 2.5 cm in 4 months and had gained. v4 I( y. `# {2 r. i. m
2 kg of weight. Physical examination remained
, [# o, [, x6 Z, J: Uunchanged. Surprisingly, the pubic hair almost com-
/ T5 ?2 O/ I/ p, _; Q7 U! \pletely disappeared except for a few vellous hairs at6 G3 m% C- `+ i3 ?7 F
the base of the phallus. Testicular volume was still 2
* N1 p# N4 [5 B4 ?. {; {mL, and the size of the penis remained unchanged.
2 T- ?' V; J& t2 d# J6 W+ z; W" ~6 tThe mother also said that the boy was no longer hav-
/ R9 R3 u7 U! j8 Sing frequent erections.
: B" R: S2 C6 z- fBoth parents were again questioned about use of( g+ \( G7 I, o$ S4 W# O
any ointment/creams that they may have applied to
( F3 E! S! L+ U% Tthe child’s skin. This time the father admitted the
4 D: L; X5 [) ?+ S: F: V+ Q; s6 RTopical Testosterone Exposure / Bhowmick et al 541
, a" l- h6 a3 I, e" D( M$ Ouse of testosterone gel twice daily that he was apply-
$ h9 C5 g) t* {. C+ q! ying over his own shoulders, chest, and back area for+ n P$ ^) b8 a) k
a year. The father also revealed he was embarrassed
; @' |1 n7 B$ x* b% R* kto disclose that he was using a testosterone gel pre-# @/ u" q. U c0 _1 D F
scribed by his family physician for decreased libido
4 Z* D( y$ R: }1 n" J. z3 \secondary to depression.
$ C8 {9 k+ q1 \! P6 k+ xThe child slept in the same bed with parents.* D( n( f4 ?8 X8 X$ }/ W& ?7 E/ d
The father would hug the baby and hold him on his5 G% Z B$ d9 }- x" i" D
chest for a considerable period of time, causing sig-' y. g& G( ]6 x U, a5 M
nificant bare skin contact between baby and father.
( T2 D8 a7 M" T' lThe father also admitted that after the phone call,/ N0 V5 h/ L4 p% ^
when he learned the testosterone level in the baby
. `: c- g( ^5 J& ~/ Vwas high, he then read the product information) Y6 B2 {& M8 M" p: q
packet and concluded that it was most likely the rea-5 L! c& D6 w# \
son for the child’s virilization. At that time, they2 @) Y2 b+ ]( x2 l, ~0 ?% x
decided to put the baby in a separate bed, and the: ]! F) ~ Z! u0 p
father was not hugging him with bare skin and had9 c* N' d2 y% A) c: W+ z7 M
been using protective clothing. A repeat testosterone
, m3 Q: T! v9 ?7 O4 a. gtest was ordered, but the family did not go to the
& h7 \) X( B' g- N3 `laboratory to obtain the test.
1 R8 K9 G2 D8 t* h0 KDiscussion
+ N/ c; K8 B: R1 J/ e' M) }3 qPrecocious puberty in boys is defined as secondary+ o. |+ g/ k* N4 j$ F: T$ O- c0 q& T
sexual development before 9 years of age.1,42 H& y( C, z! m
Precocious puberty is termed as central (true) when
& U5 A0 a" V e( D1 F/ Q% B8 Sit is caused by the premature activation of hypo-
; L0 E% [3 u& U/ vthalamic pituitary gonadal axis. CPP is more com-7 p+ ? L9 b5 o' k! M F$ @
mon in girls than in boys.1,3 Most boys with CPP( }" B3 ^1 P. J4 P. _0 V
may have a central nervous system lesion that is
1 d, Y/ K# D3 t0 ^9 O6 N. Xresponsible for the early activation of the hypothal-* V D, Z/ u7 B0 k' }% [
amic pituitary gonadal axis.1-3 Thus, greater empha-5 g# \2 b' H$ y* @4 j6 q( W# s
sis has been given to neuroradiologic imaging in1 w0 A+ C3 Y/ t9 @3 Q$ l- _
boys with precocious puberty. In addition to viril-! V; q& X1 a; |) M8 x* m
ization, the clinical hallmark of CPP is the symmet-! F- ~& p0 U; Z
rical testicular growth secondary to stimulation by3 C2 U4 X7 b F" R6 s6 L2 ~' y8 F
gonadotropins.1,39 m7 \( K# K, y' b, `& ^
Gonadotropin-independent peripheral preco-6 b) b1 X6 H8 C
cious puberty in boys also results from inappropriate
' o# X0 i/ p& iandrogenic stimulation from either endogenous or- r1 |2 R8 @+ P- D
exogenous sources, nonpituitary gonadotropin stim-
G- _8 |0 o2 ~& S* Mulation, and rare activating mutations.3 Virilizing# Y; n T( B! G$ I
congenital adrenal hyperplasia producing excessive- ^3 a& z/ ?# a; @& d
adrenal androgens is a common cause of precocious
9 ^7 m' X1 U8 T1 Npuberty in boys.3,4( v* f) c# c# N3 u+ x- i
The most common form of congenital adrenal8 R6 B6 r5 U% s6 @: w& C
hyperplasia is the 21-hydroxylase enzyme deficiency.1 l+ U6 v1 f; h R
The 11-β hydroxylase deficiency may also result in
: b2 D1 a, H cexcessive adrenal androgen production, and rarely,: D1 k& G7 r6 ?) |: B" h
an adrenal tumor may also cause adrenal androgen
# }7 T5 P# q3 Cexcess.1,30 Q1 t- @" O/ \* i+ z# D% A3 E+ O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. _8 L+ O# O0 V: L542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 L( y9 k6 J* u# X& g$ ~/ T
A unique entity of male-limited gonadotropin-9 b, K. ]( j% j5 I* a; K
independent precocious puberty, which is also known6 {% I! Y$ @6 T- w, O8 W o
as testotoxicosis, may cause precocious puberty at a( T+ M/ k% M5 N4 V$ f5 j
very young age. The physical findings in these boys
0 A9 }1 U. D4 N/ F0 i. n$ S; Wwith this disorder are full pubertal development,/ P) {4 d5 F! x2 j
including bilateral testicular growth, similar to boys
8 k1 x0 @# W K$ U& ^ e; Twith CPP. The gonadotropin levels in this disorder
6 }/ R8 f% V# Y( dare suppressed to prepubertal levels and do not show" u7 Z2 X I0 ?3 p6 l' Q
pubertal response of gonadotropin after gonadotropin-
0 B/ o5 Y( K/ B6 C9 X/ W8 |releasing hormone stimulation. This is a sex-linked: c9 L8 ?2 ?2 d! T( {5 M2 X
autosomal dominant disorder that affects only3 ?4 Z; I* _' L9 e: L I3 D- C3 G
males; therefore, other male members of the family
r( y3 n, h/ Tmay have similar precocious puberty.3
# @! i4 [: l5 cIn our patient, physical examination was incon-
" n$ F/ i- b4 X6 |* Y& G3 I5 Xsistent with true precocious puberty since his testi-9 R( d9 Y, k# h m4 h. Q
cles were prepubertal in size. However, testotoxicosis8 S) h1 `$ H3 F
was in the differential diagnosis because his father0 z) |" i2 C" O0 F- V
started puberty somewhat early, and occasionally,0 d+ T$ J; C! \ P; O! y
testicular enlargement is not that evident in the* l9 C1 q( o1 J# v. _
beginning of this process.1 In the absence of a neg-
! h2 Q. v. Y0 ?5 i7 m/ N" ~# _ative initial history of androgen exposure, our4 K! i2 k8 l k2 o# @8 A) y/ z
biggest concern was virilizing adrenal hyperplasia,
% F, Y( g% I! S" jeither 21-hydroxylase deficiency or 11-β hydroxylase
% j+ J) @9 W7 L" Tdeficiency. Those diagnoses were excluded by find-
$ E& W, Y7 J% ding the normal level of adrenal steroids.
5 P0 W S. ^# U# c% X1 B: |The diagnosis of exogenous androgens was strongly
9 a- j! s" w: f# G2 Osuspected in a follow-up visit after 4 months because* w4 f* f( R! X# O
the physical examination revealed the complete disap-: U6 j: H/ O. e* p4 X
pearance of pubic hair, normal growth velocity, and
& g" _4 B- n+ {! I6 r+ p4 Bdecreased erections. The father admitted using a testos-+ `9 i a' A3 H( h, _
terone gel, which he concealed at first visit. He was& q$ `" {7 \* \2 A: Y5 @! d! H9 c
using it rather frequently, twice a day. The Physicians’
5 F$ [% ]7 r( W( l9 FDesk Reference, or package insert of this product, gel or
0 s" T8 W& E; R- Y) U5 c: m5 t" Kcream, cautions about dermal testosterone transfer to* h9 k* T7 z4 E7 q/ e1 L. a
unprotected females through direct skin exposure.
) s) T% K9 \+ S2 ?6 r. K0 B/ fSerum testosterone level was found to be 2 times the. d1 s9 V) [" @
baseline value in those females who were exposed to9 d# b4 t8 H7 v7 V* V3 z" W( {( N
even 15 minutes of direct skin contact with their male S& ]9 O0 j, T$ {+ O
partners.6 However, when a shirt covered the applica-
; j. d. \" l# xtion site, this testosterone transfer was prevented.
0 V) J9 G, [- {. Z4 m5 hOur patient’s testosterone level was 60 ng/mL,
4 X. L3 m& g# n2 `which was clearly high. Some studies suggest that% N4 `2 ~# F2 m, `/ H; c: A
dermal conversion of testosterone to dihydrotestos-" `3 p6 |2 k: f' b
terone, which is a more potent metabolite, is more0 o: ?. K7 N- k8 h. ^
active in young children exposed to testosterone& H1 x- l) L. I6 L* U
exogenously7; however, we did not measure a dihy-2 }+ D& z8 ]7 N; S9 a- g) b
drotestosterone level in our patient. In addition to
- N/ F5 h# a# p5 b; n' W+ J8 {virilization, exposure to exogenous testosterone in/ T6 G j* O8 l, V0 k
children results in an increase in growth velocity and }7 h% e7 _* U
advanced bone age, as seen in our patient.
( u; s2 r& R q1 G2 k: I. ]2 WThe long-term effect of androgen exposure during
8 N: ]$ d: E d$ n* d: tearly childhood on pubertal development and final) K% V X* v7 S1 }* @ [
adult height are not fully known and always remain
& Q Z5 [6 Y4 X$ ?, s! ea concern. Children treated with short-term testos-( k3 c0 X5 o* `* t' q; t
terone injection or topical androgen may exhibit some
6 j4 r1 v6 ]1 N' l' Z W7 B% d9 lacceleration of the skeletal maturation; however, after4 G' n' i) i' W6 ]3 d. X
cessation of treatment, the rate of bone maturation
* S5 m; k6 m0 o! sdecelerates and gradually returns to normal.8,9/ Z: L/ B# L. y% T) P4 L
There are conflicting reports and controversy. S& Y9 M: v* p2 F8 B
over the effect of early androgen exposure on adult4 |( C' V z5 {9 g
penile length.10,11 Some reports suggest subnormal& b7 t# x2 f1 W" ^" v
adult penile length, apparently because of downreg-
" o) H; G* [5 I4 Z& lulation of androgen receptor number.10,12 However,) {, d+ w! M6 |! R# O
Sutherland et al13 did not find a correlation between) E. X! r( e& B1 O5 ?5 H
childhood testosterone exposure and reduced adult
w" w4 K* ?& q4 `" rpenile length in clinical studies.
& Q3 l3 ^) L# CNonetheless, we do not believe our patient is
2 W/ R ~" k% j5 _1 |& l% u" Pgoing to experience any of the untoward effects from
6 v# d7 \, l/ f# l% o7 ?4 Rtestosterone exposure as mentioned earlier because j; i5 s/ w9 h: V+ o
the exposure was not for a prolonged period of time.% D% j. J7 a- _' ~! m8 q7 _3 D7 _
Although the bone age was advanced at the time of3 p1 D$ {; p$ O
diagnosis, the child had a normal growth velocity at
/ v c% R$ E( H. J0 V, othe follow-up visit. It is hoped that his final adult
( \4 U. k# t6 q! Y. c# z5 I& Rheight will not be affected." j5 S3 a$ T a! r% I, }
Although rarely reported, the widespread avail-2 H5 }" c; N, k; P7 m8 [
ability of androgen products in our society may
; Y6 p+ e, ]: [6 m/ l9 Dindeed cause more virilization in male or female
6 L6 a. Y. v/ V1 h! tchildren than one would realize. Exposure to andro-1 R$ L0 g6 i7 Q" ~1 C' U
gen products must be considered and specific ques-
: w( P) ?/ g7 r: `6 \, xtioning about the use of a testosterone product or
) l+ ~1 Q, q. Y9 j: c( \gel should be asked of the family members during
1 d4 Y; R! @. ?& W5 C' ethe evaluation of any children who present with vir-! m- ^. ?2 I( U
ilization or peripheral precocious puberty. The diag-
$ n5 x# B' J3 vnosis can be established by just a few tests and by
& W+ d% m, ?. t* Q! W7 `0 U' |appropriate history. The inability to obtain such a7 E( r2 {8 M; S( Y3 c
history, or failure to ask the specific questions, may
+ [, v" r0 l& d3 sresult in extensive, unnecessary, and expensive+ D2 ]& Q) B4 u9 L/ y3 ^; G
investigation. The primary care physician should be4 f e. L z3 p3 C, w6 L
aware of this fact, because most of these children3 C5 c: C* U* h9 p
may initially present in their practice. The Physicians’
6 D& H' ]$ b1 f% M; Z* iDesk Reference and package insert should also put a' a3 l' w& U7 \9 z: T
warning about the virilizing effect on a male or
9 e+ w6 B) A# U: Bfemale child who might come in contact with some-
; p; f. E. q# y3 G( n; x) @one using any of these products.! f& L6 T$ S0 b0 L! N3 x5 k
References4 _! l' ]5 l" R3 Q' o) \' x' H
1. Styne DM. The testes: disorder of sexual differentiation
$ v, u/ P0 W6 ]1 o) j9 R: Fand puberty in the male. In: Sperling MA, ed. Pediatric/ M% B. b$ l; X8 e
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" F' [7 V0 w" u! \# c2002: 565-628.
/ b1 `1 Y4 B0 D# b" L/ w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( s: r! L( J* c- \) }puberty in children with tumours of the suprasellar pineal |
|