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Sexual Precocity in a 16-Month-Old) D0 Z$ q6 M& Z
Boy Induced by Indirect Topical1 x, F$ a3 u( d0 c( r8 J% M
Exposure to Testosterone
8 @: v' \4 b- u! V# e oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ A( b8 b: G, p4 qand Kenneth R. Rettig, MD1' }. x" k& @5 o* U
Clinical Pediatrics
) K4 \3 w$ P( p3 g0 n1 DVolume 46 Number 69 T( g5 O: n9 L" n1 _
July 2007 540-543
# {5 i) g& F7 f) S; p$ T2 f© 2007 Sage Publications/ `' ?7 e+ Q8 g% _1 {
10.1177/00099228062966512 _6 M6 ^+ v% X6 O8 l3 x y
http://clp.sagepub.com% L! Y1 ^# }4 K
hosted at+ _! b, l! a, Y: M0 t
http://online.sagepub.com! X0 h( p. P) I' K8 `! P
Precocious puberty in boys, central or peripheral,
0 g/ q) [# A# e r" wis a significant concern for physicians. Central
! ^, J H4 ]) E% u' P3 M% H6 p0 Kprecocious puberty (CPP), which is mediated5 J( ~' T* f$ m9 @3 o
through the hypothalamic pituitary gonadal axis, has( C" K. S! `; m1 }& z n
a higher incidence of organic central nervous system) ]+ X: z. ]: s; Q/ s/ W! l( ] }
lesions in boys.1,2 Virilization in boys, as manifested6 |; }5 V/ N. r, c# L. L. [
by enlargement of the penis, development of pubic' U# s) r3 @0 ]. e% e- @
hair, and facial acne without enlargement of testi-3 c* E- G/ d, K( Q
cles, suggests peripheral or pseudopuberty.1-3 We: y" O3 k, G+ [" r2 }& H
report a 16-month-old boy who presented with the% g4 V0 @2 J/ V$ G9 ~2 q
enlargement of the phallus and pubic hair develop-4 ~1 H4 F- X' {% `
ment without testicular enlargement, which was due
! f* Q0 I& J1 E: b, y" f5 Ito the unintentional exposure to androgen gel used by- P" A0 s8 m; [
the father. The family initially concealed this infor-* a: Y# t; ~* u4 y8 C8 i5 F" q
mation, resulting in an extensive work-up for this
( L# _: L9 s6 Z/ U0 Uchild. Given the widespread and easy availability of
1 a, _; D6 C1 ~+ g% w. Htestosterone gel and cream, we believe this is proba-+ ~% j1 g( K) d. Q
bly more common than the rare case report in the- l/ Y+ B* {6 p! M& c$ E0 B, \9 ~
literature.4
0 n& ^' F. Z' X: [Patient Report# b! F+ }5 R, U* s) f: p
A 16-month-old white child was referred to the: Z+ ?; V1 O: j% x r R/ Z5 h
endocrine clinic by his pediatrician with the concern0 J5 n' t H' I
of early sexual development. His mother noticed2 k- k9 L5 G7 b0 l3 R6 L
light colored pubic hair development when he was. z8 `7 _- J; q6 t4 G
From the 1Division of Pediatric Endocrinology, 2University of( g0 i5 f, P' _
South Alabama Medical Center, Mobile, Alabama.! P& r: E/ A: c( x% A$ ^4 `+ ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,3 d9 I0 k6 x5 s2 J+ H* C- w
Professor of Pediatrics, University of South Alabama, College of5 q' ^, _- V3 M7 B/ d# x9 S' N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ a/ m: L- L5 z% Q! B
e-mail: [email protected].* @3 a! E& X6 H3 M1 q0 t/ ]
about 6 to 7 months old, which progressively became* P+ {& C) l: n w( ]
darker. She was also concerned about the enlarge-
" |% K% l6 H/ t8 C5 @8 Bment of his penis and frequent erections. The child# a! d N5 Q/ x5 j c' B: f
was the product of a full-term normal delivery, with
# [+ E% L" [/ Y' Na birth weight of 7 lb 14 oz, and birth length of6 _/ \2 H) x. ?# w* A
20 inches. He was breast-fed throughout the first year
! M# D( k2 N/ s& `of life and was still receiving breast milk along with
6 R. q# [1 j' N: K6 l, qsolid food. He had no hospitalizations or surgery,+ I1 W, ?/ Y2 `6 o, f+ y
and his psychosocial and psychomotor development
! K! b( q: o1 K k1 Gwas age appropriate./ Y: A/ m) E) ?# y+ V' u' \3 G
The family history was remarkable for the father,
8 p D3 ?9 c$ _% r4 iwho was diagnosed with hypothyroidism at age 16,
/ @9 X6 N) P" u8 O0 B/ lwhich was treated with thyroxine. The father’s
+ M& @3 p$ j! E, Z. Qheight was 6 feet, and he went through a somewhat3 g* t) g0 J( K1 M1 W
early puberty and had stopped growing by age 14.
; l8 ~# R' L# B$ r bThe father denied taking any other medication. The
0 e$ v$ _; Y- @child’s mother was in good health. Her menarche) R! Q9 V1 S3 C( a1 G" R
was at 11 years of age, and her height was at 5 feet h, U& u6 t* I" O* z/ n
5 inches. There was no other family history of pre-/ L' i0 o9 q; e
cocious sexual development in the first-degree rela-
1 g" \$ r1 r3 n8 l( Dtives. There were no siblings.
) V1 `. `+ w; QPhysical Examination
$ h: y f7 X+ x6 z2 u6 O! N, [The physical examination revealed a very active,
# ^; S' s5 _$ j+ uplayful, and healthy boy. The vital signs documented
1 w( c4 L u4 M0 o" E9 Q Va blood pressure of 85/50 mm Hg, his length was9 H6 X9 y7 ?7 \7 _) O# {
90 cm (>97th percentile), and his weight was 14.4 kg A" O2 ^# d, h+ e" X# G
(also >97th percentile). The observed yearly growth" j: D& K4 W: M# u$ x: A1 ]
velocity was 30 cm (12 inches). The examination of2 L1 D. Y4 W5 q+ S( K, C
the neck revealed no thyroid enlargement.6 [. |. w- U7 ?- z. _! M' U
The genitourinary examination was remarkable for
! }% Q$ G3 m) e7 b p8 }enlargement of the penis, with a stretched length of
) v/ T0 a2 g( L5 ]- [$ R8 cm and a width of 2 cm. The glans penis was very well
% a, t0 ?1 I' zdeveloped. The pubic hair was Tanner II, mostly around
' K% w' J/ p2 T& ~/ e540% I! y: J1 h" x: b( T0 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; K! D8 s. V* j( r6 ethe base of the phallus and was dark and curled. The" H+ h! ^; k& y# v
testicular volume was prepubertal at 2 mL each.0 F+ B) Y2 c9 h$ `6 Y7 b; q7 @
The skin was moist and smooth and somewhat0 t9 }% X1 V z$ C; m# q
oily. No axillary hair was noted. There were no/ U. H m4 l) U
abnormal skin pigmentations or café-au-lait spots.# E& t3 P# z' M* H; H) w: {* o: m
Neurologic evaluation showed deep tendon reflex 2+' h! W# R& C4 l7 [( w, X. ?
bilateral and symmetrical. There was no suggestion
' N5 M& M0 e! B/ W9 G3 vof papilledema.
# r7 v/ {& {7 e. s8 C oLaboratory Evaluation
$ ^7 \8 p: C& g, f3 n2 XThe bone age was consistent with 28 months by
; a7 i. r- @" w, L2 }& j0 ?0 b$ Ousing the standard of Greulich and Pyle at a chrono-
1 Q$ O3 E5 f5 k8 L# t: k9 plogic age of 16 months (advanced).5 Chromosomal& e- M$ Q1 e* E* v8 k) M, F1 [
karyotype was 46XY. The thyroid function test3 W3 _" S& L. n0 G+ X; w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% A+ n( R. y4 u: m* C* w
lating hormone level was 1.3 µIU/mL (both normal).
# J3 R8 Z# M; w; d, ~The concentrations of serum electrolytes, blood
: @ r' ]) q+ i4 O0 \urea nitrogen, creatinine, and calcium all were
9 q% K" ]6 V" }4 L$ \) J: i, \within normal range for his age. The concentration+ [5 |$ _: d W1 ]
of serum 17-hydroxyprogesterone was 16 ng/dL5 ^2 z8 g; ^* {) w
(normal, 3 to 90 ng/dL), androstenedione was 205 h- T% E/ F, w" u R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# g* ?7 L) b0 \9 I3 B, Z) j! O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 X4 B3 ]* Q' H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 A. l: ?0 g9 v) n% }
49ng/dL), 11-desoxycortisol (specific compound S)
, k! T" W' N- W: w# j dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' m3 j7 M2 G% v% z# @- Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 J/ {* u2 q& d1 u
testosterone was 60 ng/dL (normal <3 to 10 ng/dL), j4 f x+ d$ L6 q) @
and β-human chorionic gonadotropin was less than
7 Z9 E8 r4 a% B' W, B5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ ]- A3 q. w& L. h f5 z# D: p" Pstimulating hormone and leuteinizing hormone
( J, w) o9 e; O" z, y6 Aconcentrations were less than 0.05 mIU/mL* ^+ B% `& t k) f; s7 F
(prepubertal).
1 @) I& \5 o( r) e8 s4 g/ MThe parents were notified about the laboratory- O; ?, e# ]9 E& F- \
results and were informed that all of the tests were
2 q& X. f* B% Z8 d( W4 G2 vnormal except the testosterone level was high. The2 g% S5 v9 f2 e" O( S3 }
follow-up visit was arranged within a few weeks to3 W% ~# p+ [. C4 e: o3 _- D* h8 o* j* d5 F
obtain testicular and abdominal sonograms; how-' T' E& g2 K2 E
ever, the family did not return for 4 months.: I' E. N. v& Z6 T8 W1 L
Physical examination at this time revealed that the& @# k0 q8 w/ a! D
child had grown 2.5 cm in 4 months and had gained
6 H" a- |8 W4 ^) [3 ?; e1 {3 ~2 kg of weight. Physical examination remained4 Q5 `$ q! Y0 M
unchanged. Surprisingly, the pubic hair almost com-
+ q) _- n' K/ R) `pletely disappeared except for a few vellous hairs at: E, F* a3 c4 ]% ?/ K- |# J8 T
the base of the phallus. Testicular volume was still 2
0 c3 A; e$ D& h6 ~; E" @mL, and the size of the penis remained unchanged.
1 X5 s) C5 O- vThe mother also said that the boy was no longer hav-
0 K# i1 @0 |$ `( Aing frequent erections.5 G0 Y' X3 |8 L/ {4 ?! G" Z3 c* X4 ]2 U
Both parents were again questioned about use of
' }3 a) E6 s6 v+ m+ v7 |3 ^6 f0 g5 Cany ointment/creams that they may have applied to2 F3 c1 E3 e/ y5 g5 }
the child’s skin. This time the father admitted the
* n* e- B8 e- p2 pTopical Testosterone Exposure / Bhowmick et al 541; |4 J. W. h& g5 A
use of testosterone gel twice daily that he was apply-
& \# F1 e( s- A# ]6 z( ] Zing over his own shoulders, chest, and back area for
$ W8 h% |1 Q5 F6 q. _% aa year. The father also revealed he was embarrassed6 _* x& Q# d R d
to disclose that he was using a testosterone gel pre-
+ j$ A0 Y& F0 a3 s$ [+ M5 Mscribed by his family physician for decreased libido6 ]+ G3 f1 w2 u( r3 ~; q$ v( G/ W! j
secondary to depression.8 N* w0 |9 y- L2 Z$ y4 n& }" X! Z3 V
The child slept in the same bed with parents.
. A2 ?- ^' ?6 T& ]( `' i* FThe father would hug the baby and hold him on his/ y5 c: q- n& `! o# O; y
chest for a considerable period of time, causing sig-
" r0 T' d$ o$ C6 n4 h! i mnificant bare skin contact between baby and father.
. L0 x; V* f5 KThe father also admitted that after the phone call,
! L; F- Q1 \& M7 r6 h Vwhen he learned the testosterone level in the baby
: o9 f- q5 e/ l" i, ~. lwas high, he then read the product information: f) ~8 U" Y1 s
packet and concluded that it was most likely the rea-/ p) B0 W E6 x/ c' }. N, c5 ~& }
son for the child’s virilization. At that time, they
2 Z0 ~( P& e2 {0 _3 B) f/ d# edecided to put the baby in a separate bed, and the' S5 H- g/ C" H, z
father was not hugging him with bare skin and had
9 g' f$ V5 a9 |( P' u: V+ s! Zbeen using protective clothing. A repeat testosterone
' r: Q( y7 U0 w' t( L$ stest was ordered, but the family did not go to the
9 Q* ?2 S/ D5 ilaboratory to obtain the test.
0 v h, x# _/ N6 WDiscussion
& }9 [+ J8 d; O" x- ?# wPrecocious puberty in boys is defined as secondary1 h. f. \# X/ x, S* q
sexual development before 9 years of age.1,4
& J( J c$ k) q7 S" b& q% MPrecocious puberty is termed as central (true) when- `. E3 D& q" z2 Q( O
it is caused by the premature activation of hypo-1 [1 ]7 m7 b: ]5 k8 u
thalamic pituitary gonadal axis. CPP is more com-; r" e4 r2 P; r' B& P- x2 m
mon in girls than in boys.1,3 Most boys with CPP
- h, L% `+ B' W! mmay have a central nervous system lesion that is' H+ y* V& Z# {5 t$ M) F1 ^2 B- D
responsible for the early activation of the hypothal-
* d$ A {8 h4 M. }! y4 I0 Hamic pituitary gonadal axis.1-3 Thus, greater empha-
V1 `/ ^2 z1 F5 }2 Fsis has been given to neuroradiologic imaging in5 p( v8 g9 f/ _. U5 B: b! R
boys with precocious puberty. In addition to viril-
# G) I1 {% w" i; z6 T3 Dization, the clinical hallmark of CPP is the symmet-
' l/ Q/ h0 H; a* k, _$ hrical testicular growth secondary to stimulation by* r5 T$ a) g( A( A) g8 b
gonadotropins.1,3
- L* Y4 s& g# S1 eGonadotropin-independent peripheral preco-# c6 V5 C6 g0 X# F6 s: Z6 Y
cious puberty in boys also results from inappropriate5 N, S- p' a8 `0 o6 b* C$ i1 N0 k
androgenic stimulation from either endogenous or
- D4 Q2 A/ t* @- [( m8 D; Aexogenous sources, nonpituitary gonadotropin stim-& X0 X# A0 P* f8 M; {
ulation, and rare activating mutations.3 Virilizing4 |2 u+ g1 B3 _ D/ I9 r
congenital adrenal hyperplasia producing excessive1 _9 G L4 [4 z: G/ O( q% S& M
adrenal androgens is a common cause of precocious7 {4 I# U5 w( M, @1 H% q5 l
puberty in boys.3,4
8 U$ h) T: S9 P; J$ h {The most common form of congenital adrenal
. j& m+ l# E; Q$ q# C* \hyperplasia is the 21-hydroxylase enzyme deficiency.) _6 O. |& [* {7 B) s* A' T
The 11-β hydroxylase deficiency may also result in
- e' A$ r' Q5 e) l1 w Hexcessive adrenal androgen production, and rarely,
, K2 ^. s4 s) Wan adrenal tumor may also cause adrenal androgen; \' z' m9 I# V
excess.1,3) j. m7 D4 X% w+ U) J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' @6 ~3 p5 m. y; a542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. w/ i' |2 d ^. b
A unique entity of male-limited gonadotropin-
6 t/ w+ {8 @ n; {4 }3 eindependent precocious puberty, which is also known
$ l/ }1 ]5 ], y' Pas testotoxicosis, may cause precocious puberty at a
3 x% }% N/ k+ X u$ N% d9 M) Fvery young age. The physical findings in these boys3 w6 O# R, M% B0 j
with this disorder are full pubertal development, m v" g' Q( B% V D a
including bilateral testicular growth, similar to boys [4 Q, ]3 O1 o) Q: Q/ Q
with CPP. The gonadotropin levels in this disorder' d( u7 a2 ?, K
are suppressed to prepubertal levels and do not show
4 V% r& ^ M) v7 j4 Tpubertal response of gonadotropin after gonadotropin-
- k) Y4 _7 k5 J! m0 x areleasing hormone stimulation. This is a sex-linked
1 n9 o6 E( @* I1 h4 X1 yautosomal dominant disorder that affects only9 m8 u1 }/ U, L4 Y, z3 b# @
males; therefore, other male members of the family% x* [. n% `. C- F" J8 Y5 T0 w
may have similar precocious puberty.39 ]7 h1 |! b) U+ _" U
In our patient, physical examination was incon-. V7 q" Y3 {" ^( P
sistent with true precocious puberty since his testi-
; {* ^5 i- i1 T* I2 ]4 Bcles were prepubertal in size. However, testotoxicosis, ^; U) n! }1 A; E0 v
was in the differential diagnosis because his father% i2 w' E# U0 v( c0 ?+ {
started puberty somewhat early, and occasionally,
" o" C# I# e5 {: T, U7 stesticular enlargement is not that evident in the
1 N: F" @6 L2 w7 t3 lbeginning of this process.1 In the absence of a neg-
1 K6 h2 \& r x! i8 M4 ]ative initial history of androgen exposure, our
9 |4 Z- x$ N4 u \9 a0 k3 `, W# Rbiggest concern was virilizing adrenal hyperplasia,
: _! [, u! a5 meither 21-hydroxylase deficiency or 11-β hydroxylase2 l6 R; e4 V% a& G
deficiency. Those diagnoses were excluded by find-: q1 ^# A3 i; c* d6 G
ing the normal level of adrenal steroids.( j" Y9 a& m3 I6 m
The diagnosis of exogenous androgens was strongly' }/ V2 _+ |, h: A9 T
suspected in a follow-up visit after 4 months because4 z0 {& F3 Q+ w. B& P5 q
the physical examination revealed the complete disap-/ ^4 {9 y' ~) Z' E, J
pearance of pubic hair, normal growth velocity, and( z" F0 Y2 n' x) i% j& F) a" T5 q/ A6 h
decreased erections. The father admitted using a testos-
) I4 D& P% a' c+ Z3 r1 [terone gel, which he concealed at first visit. He was8 G J+ i: |1 k. w5 R9 b3 g
using it rather frequently, twice a day. The Physicians’5 B3 [. f: V- @5 m
Desk Reference, or package insert of this product, gel or
2 @6 {# F* h; N; Y1 acream, cautions about dermal testosterone transfer to
* U+ }9 M4 ~1 N7 t; D- G6 kunprotected females through direct skin exposure.
' M- J' n! A `4 K& \$ oSerum testosterone level was found to be 2 times the
! r4 c, Q6 n& N" C& ~9 m% P1 D, Lbaseline value in those females who were exposed to
R V' ?% G/ r6 K( t2 y; \) N- ~# leven 15 minutes of direct skin contact with their male+ c H; _+ j0 g5 l0 F0 ?" a8 N
partners.6 However, when a shirt covered the applica-( ?1 L' W q5 ]" _2 z7 j* H
tion site, this testosterone transfer was prevented.) f4 {- O* C" W8 W2 k
Our patient’s testosterone level was 60 ng/mL,4 F3 @4 v* [& x) O0 I
which was clearly high. Some studies suggest that& n% z ^* X& a/ `8 i( w4 i
dermal conversion of testosterone to dihydrotestos-5 Z. N& j- i" i, V! ?
terone, which is a more potent metabolite, is more
' N; m/ r9 I: ~8 q' P Cactive in young children exposed to testosterone
: `7 T' H0 a O# bexogenously7; however, we did not measure a dihy-
1 `% h9 H$ V. }. O9 Y. Z) Y& zdrotestosterone level in our patient. In addition to2 i1 y3 H+ j5 d5 p# H
virilization, exposure to exogenous testosterone in
, m% s) O z9 F6 jchildren results in an increase in growth velocity and
( T3 b- o. E# h5 J* M" ?advanced bone age, as seen in our patient.. y' c0 N; x6 ]
The long-term effect of androgen exposure during- x6 `$ b# j1 a' D1 p. d
early childhood on pubertal development and final
# J# H4 p; Z8 a& ~% E4 N Uadult height are not fully known and always remain/ C4 b2 p: K* G
a concern. Children treated with short-term testos-
5 o! v# F0 {+ Y4 z5 q+ \1 E) {terone injection or topical androgen may exhibit some
/ E% G, R6 `- T, aacceleration of the skeletal maturation; however, after$ r" X; ^6 X* P
cessation of treatment, the rate of bone maturation* z, V% U: X+ k, o3 H$ ^
decelerates and gradually returns to normal.8,91 Q% I' C+ R+ Q
There are conflicting reports and controversy* z l1 I, r4 |; o& S$ v
over the effect of early androgen exposure on adult
G/ ~; e( m9 epenile length.10,11 Some reports suggest subnormal
0 U K& O8 E) }' Z% ~& Xadult penile length, apparently because of downreg-
2 f; {6 D5 H8 _# b3 R" aulation of androgen receptor number.10,12 However,
4 O4 V* t% Q& {, S9 qSutherland et al13 did not find a correlation between
( h: j) `' H+ u1 B& p& w8 Schildhood testosterone exposure and reduced adult
9 `5 f# ^$ Y% L( v' k( o2 ]% D* x0 O2 npenile length in clinical studies.
7 e( ^( K* n8 E hNonetheless, we do not believe our patient is" p1 k1 l6 R3 o) F
going to experience any of the untoward effects from
5 w7 W8 j% V2 c9 j' d6 ttestosterone exposure as mentioned earlier because( x0 r# ~" D# @
the exposure was not for a prolonged period of time.2 C; d: s# Q, g0 H& A) d
Although the bone age was advanced at the time of/ a4 k$ }" d4 d* f: N. @) g
diagnosis, the child had a normal growth velocity at
7 J! r5 N5 K6 a- g9 rthe follow-up visit. It is hoped that his final adult
% I! j. A0 l kheight will not be affected.9 G. x$ c* @2 N# I3 h
Although rarely reported, the widespread avail-8 h8 A" f. I( W$ ~& A) m- b
ability of androgen products in our society may" {' o7 O- [6 V7 i9 d
indeed cause more virilization in male or female" m: O: m; E$ O
children than one would realize. Exposure to andro-+ [% g, D5 ~) f+ Z$ n( ^3 J$ J
gen products must be considered and specific ques-. Y- N1 \" x% Z/ E! X
tioning about the use of a testosterone product or$ D, [& E3 ~. H( h
gel should be asked of the family members during
% V! R5 n! t0 O- Mthe evaluation of any children who present with vir-0 ^- }7 K. K4 Q- d7 |
ilization or peripheral precocious puberty. The diag-: m- t* P4 d: R" Q* v2 t( R" c
nosis can be established by just a few tests and by9 R+ f5 N$ B, F" \2 G$ _
appropriate history. The inability to obtain such a
0 m# M7 q. F8 i2 G# }# [history, or failure to ask the specific questions, may! u! V8 {: i' d/ w0 g" j! ?
result in extensive, unnecessary, and expensive
4 a6 q# e, @7 [' b$ Hinvestigation. The primary care physician should be, l4 N) F' T7 j( D) W- d
aware of this fact, because most of these children6 V; }, Q2 E0 H& i9 `- Y0 V& i
may initially present in their practice. The Physicians’
; v7 x7 f7 E# X9 i3 r* @Desk Reference and package insert should also put a9 z# r J% p' e0 D; f; h! x
warning about the virilizing effect on a male or
; l% p5 ?1 Y$ H2 E' ^6 B% Bfemale child who might come in contact with some-2 [4 ]- c6 f. ?7 E6 Z' S5 b
one using any of these products.
7 _" L P6 `/ GReferences$ G @8 r7 E. r: i5 L# I6 Z' n
1. Styne DM. The testes: disorder of sexual differentiation0 o- f, j4 L, H5 o% j
and puberty in the male. In: Sperling MA, ed. Pediatric: M/ I6 n: B( T1 I/ A' l. s1 \
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 b+ W6 h/ z' K3 q9 q* f, ]2002: 565-628." N/ \7 B( [* ]$ y4 G2 [ }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; k4 b: G- v) N$ ~; J. D; _" P
puberty in children with tumours of the suprasellar pineal |
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