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Sexual Precocity in a 16-Month-Old
% Q& J$ R1 ]! ]4 ]" S4 bBoy Induced by Indirect Topical5 |% @7 k% `4 ~: H5 W! o
Exposure to Testosterone
) S1 q V2 {2 B4 cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* m1 I7 W9 J2 x* ?* c
and Kenneth R. Rettig, MD18 z0 t2 G- @9 l7 Y, t; g
Clinical Pediatrics
" b5 r+ j" n j) X6 aVolume 46 Number 6
0 E0 p/ b! m5 b0 y; vJuly 2007 540-543. J, `7 Y; t8 o* B( t) v
© 2007 Sage Publications
/ z4 ~' `% Z* u r" r- j+ G10.1177/00099228062966518 ?& F2 a) i5 P! s) R1 O; t
http://clp.sagepub.com5 O7 L) k, x. D0 `3 x' z3 m
hosted at
/ y& Z4 ]* l7 ohttp://online.sagepub.com
$ t& M9 S6 r( T0 B3 j* e0 k# G. nPrecocious puberty in boys, central or peripheral,
; H# c4 ~0 W! ~8 m9 }is a significant concern for physicians. Central
3 _( Y+ R5 W1 {' o; kprecocious puberty (CPP), which is mediated
% C+ @+ f6 S; Z$ Ythrough the hypothalamic pituitary gonadal axis, has
' W9 }/ i3 n1 ~a higher incidence of organic central nervous system3 q. g" c2 { \4 b6 D+ G% E) x: Q* `
lesions in boys.1,2 Virilization in boys, as manifested1 v, ~! [& N) l8 o# \
by enlargement of the penis, development of pubic
$ O( e9 Q/ p& P9 K- G" I3 \hair, and facial acne without enlargement of testi-0 T% B8 W3 n( z
cles, suggests peripheral or pseudopuberty.1-3 We: t* e. S/ f: |1 n! l% L# X7 c' ]" g
report a 16-month-old boy who presented with the
8 ]9 F4 \! u* j) Xenlargement of the phallus and pubic hair develop-7 P5 @" s e4 j V" O K
ment without testicular enlargement, which was due7 P1 ` q. T S/ d
to the unintentional exposure to androgen gel used by
# m. X. p( g. F+ Vthe father. The family initially concealed this infor-9 d/ [# Q! w$ a) L. O. f
mation, resulting in an extensive work-up for this; a2 X( f2 m7 i" v. n# a$ v( Y
child. Given the widespread and easy availability of
9 K; X' |; }% j7 K/ R f4 r4 Stestosterone gel and cream, we believe this is proba-
! D+ L1 k O+ C2 p' Obly more common than the rare case report in the
2 S+ I2 G/ b y. uliterature.48 ^, j5 Q2 U7 y, B- X. D8 r) j
Patient Report0 ]5 t, n2 x% D5 k% {$ i
A 16-month-old white child was referred to the
L! I7 P6 e, M! R* g* wendocrine clinic by his pediatrician with the concern' t/ f% k6 @. Y1 A a. [
of early sexual development. His mother noticed+ W: E3 p( f2 x1 x$ L$ C5 e7 U7 X
light colored pubic hair development when he was3 t' Q" t) n1 S/ q
From the 1Division of Pediatric Endocrinology, 2University of
$ N* t( i% v: T7 A. q; d- sSouth Alabama Medical Center, Mobile, Alabama.$ {% y4 _* G% E- b: _
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% K( {; ^9 E6 y$ F0 M7 IProfessor of Pediatrics, University of South Alabama, College of
' A5 o/ m2 |: F7 t( vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ Z0 F r; J: {0 p! S
e-mail: [email protected]." H9 c1 `! x/ B; @ L1 j2 v% a
about 6 to 7 months old, which progressively became
+ t6 V: @( u7 [8 i0 qdarker. She was also concerned about the enlarge-
. r7 w/ z* N1 d+ Jment of his penis and frequent erections. The child
) ~ L1 F3 i) Q' b7 W! r8 x$ }9 swas the product of a full-term normal delivery, with; N! z8 z' F/ s3 u ~- Z& X
a birth weight of 7 lb 14 oz, and birth length of
+ u+ m, w7 r' ~8 ~ C0 Y n20 inches. He was breast-fed throughout the first year
2 S6 ^9 v4 m% G5 J$ {of life and was still receiving breast milk along with
& A" Z2 i4 [2 c* wsolid food. He had no hospitalizations or surgery,3 T) Q) n! B7 l. t
and his psychosocial and psychomotor development% M6 K7 R2 ~ _4 Y: E' v1 y
was age appropriate.3 [# @% c2 \% K. s
The family history was remarkable for the father,# _; u* w1 h- B) F$ Z
who was diagnosed with hypothyroidism at age 16,3 d: u: p- k1 d) y8 @
which was treated with thyroxine. The father’s
$ e6 H( j; [; Z$ t, }height was 6 feet, and he went through a somewhat
5 x) U% h8 Z0 y( nearly puberty and had stopped growing by age 14.: H% y' K$ f) h
The father denied taking any other medication. The
X' _% ~9 s& f3 Fchild’s mother was in good health. Her menarche
3 P% I" J3 K5 R( Iwas at 11 years of age, and her height was at 5 feet3 s* a' t9 w) K/ v, j$ U4 t
5 inches. There was no other family history of pre-
2 Z$ L D5 z6 N" pcocious sexual development in the first-degree rela-5 W% \, i- Q, A" C: M* s
tives. There were no siblings.3 c* c/ e9 O! p
Physical Examination% Q2 \; F9 M& N& m
The physical examination revealed a very active,, V1 U% S) }, K5 ~- A# e% O; h
playful, and healthy boy. The vital signs documented
. d( Q( @9 m. ~+ t. c# oa blood pressure of 85/50 mm Hg, his length was: T) S6 `9 ^% S8 v7 g1 ~. c& y, f
90 cm (>97th percentile), and his weight was 14.4 kg
6 S* B+ Z) |- o6 E" d- Q* z(also >97th percentile). The observed yearly growth
. ^; S7 Z" q- {velocity was 30 cm (12 inches). The examination of
6 j2 @/ S. ?- s/ Dthe neck revealed no thyroid enlargement.1 M) w1 U, V" _
The genitourinary examination was remarkable for1 v" G; {2 C5 V: a4 H
enlargement of the penis, with a stretched length of
* y+ ~! a/ n! ?8 cm and a width of 2 cm. The glans penis was very well0 K# |: `4 V7 b7 L
developed. The pubic hair was Tanner II, mostly around2 {1 X4 j m5 Q/ J$ X9 t \& u
540
7 y; n, t1 V4 l/ l- C3 x" wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 X* c4 S( b' e/ T
the base of the phallus and was dark and curled. The, U5 a$ }1 g) L% J M
testicular volume was prepubertal at 2 mL each.
3 F+ M. c9 V V' U+ [The skin was moist and smooth and somewhat
* y/ J# e b) \3 |3 m: B( A2 U6 Q/ Ooily. No axillary hair was noted. There were no) U$ r& c5 m$ I9 {- p9 q% b
abnormal skin pigmentations or café-au-lait spots.. A" k- f' p* n5 f
Neurologic evaluation showed deep tendon reflex 2+
# q7 E9 L' {2 K1 ]% jbilateral and symmetrical. There was no suggestion7 D$ E6 X A. M7 W# P
of papilledema.& N+ Z3 }: \4 R, V5 Y+ e7 E+ t
Laboratory Evaluation0 n) w0 A+ N( r9 {$ k/ K
The bone age was consistent with 28 months by3 \$ L+ F( e4 { V
using the standard of Greulich and Pyle at a chrono-2 [4 A/ J, u# [
logic age of 16 months (advanced).5 Chromosomal
i+ {* E. O* m+ W- @karyotype was 46XY. The thyroid function test5 t6 A1 ~, E m. R; e! S1 k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& `5 E4 }3 k) o, Z% C5 F
lating hormone level was 1.3 µIU/mL (both normal).
3 S. J8 F) Y+ L. P" F: P2 }4 ?6 CThe concentrations of serum electrolytes, blood% u& s4 Q/ s% z$ o; Q" b/ P& p1 i
urea nitrogen, creatinine, and calcium all were, |! S0 r! K7 |4 ]
within normal range for his age. The concentration
8 Y% N; {5 F$ l* [; _" bof serum 17-hydroxyprogesterone was 16 ng/dL
$ j% a5 a$ q- } }+ o3 K. Y; o(normal, 3 to 90 ng/dL), androstenedione was 20
) V) A% S$ `9 f/ [9 j$ _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) W* @, f3 U* f+ K& D) Y" Z3 x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 W' K* D; g! n2 j4 b% {6 _desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 i8 ?9 g. d. D* w1 {0 v- R49ng/dL), 11-desoxycortisol (specific compound S). A* ?( T- O, }; r+ l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& ~7 g' m3 W3 ], P) etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" q0 o+ S. T/ P" n1 M J- P$ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& ~, Y7 ~8 r1 t+ F" qand β-human chorionic gonadotropin was less than
4 ]$ b( `+ n/ f1 a1 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
" l" ]" c' o$ J# Y% R' Mstimulating hormone and leuteinizing hormone7 e9 P! `- R5 o4 E, I. L2 D- @3 |
concentrations were less than 0.05 mIU/mL9 z, _# T. N7 n0 G0 R+ K
(prepubertal).
% o9 w. K4 b( X8 F+ D8 wThe parents were notified about the laboratory. |( E5 {& P4 J; {6 r' G
results and were informed that all of the tests were E% {# l! k: u. H: P1 a/ \ x8 b& c
normal except the testosterone level was high. The: D i; o9 X/ G, @/ r7 \$ K
follow-up visit was arranged within a few weeks to- Z ?. I5 M+ b& M/ s7 t5 {* v
obtain testicular and abdominal sonograms; how-& V- J- [7 j9 l4 w9 h! W& i
ever, the family did not return for 4 months.
. W) ~: [- c8 _1 `& oPhysical examination at this time revealed that the x6 A' R, y7 ~! D6 _8 P
child had grown 2.5 cm in 4 months and had gained9 k# K& v, Z: K% H
2 kg of weight. Physical examination remained& Y3 \9 l& X' l0 V9 [) L8 y' M% T
unchanged. Surprisingly, the pubic hair almost com-% L; {7 B! f* d6 a% u- H
pletely disappeared except for a few vellous hairs at
5 g3 j! J& j# W' Y: A0 E vthe base of the phallus. Testicular volume was still 2
) w: j0 t- G4 f1 a9 x' V+ EmL, and the size of the penis remained unchanged./ j* m3 G) t9 M' K" v0 p% P
The mother also said that the boy was no longer hav-
* N* C+ w6 x# j. ]& ging frequent erections.
3 {, R% M9 z" l+ j: M9 d- Q, p5 }Both parents were again questioned about use of
* i$ ?/ ?9 w! B: Rany ointment/creams that they may have applied to
) V* F% N9 I0 ^the child’s skin. This time the father admitted the
. b& X" R% {. D( d" tTopical Testosterone Exposure / Bhowmick et al 541
( P0 l! k- b. E! T* p1 }use of testosterone gel twice daily that he was apply-7 i, {- b4 {; ]$ f( R, i. ]
ing over his own shoulders, chest, and back area for$ T9 a! p$ R6 m. b
a year. The father also revealed he was embarrassed1 m9 R2 b, ?6 y
to disclose that he was using a testosterone gel pre-# S- o% ?, C2 l- o! c
scribed by his family physician for decreased libido
3 L/ m9 q/ q! x1 j( Isecondary to depression.
. d$ \5 h& r; k7 T1 Q) BThe child slept in the same bed with parents.8 P$ i- d! w- H1 m
The father would hug the baby and hold him on his8 D* D7 q& E1 W- Q) E
chest for a considerable period of time, causing sig-
, |% O' o7 j$ J' tnificant bare skin contact between baby and father.: _; R& B. u7 S" a4 u
The father also admitted that after the phone call,
2 w) f; e+ u) G( o4 _when he learned the testosterone level in the baby
% `$ \* I0 ^# j. C# w' T1 Awas high, he then read the product information5 ]' X" ~& X. c# [6 K7 U Q5 R& O
packet and concluded that it was most likely the rea-
3 b1 w8 @+ m; _3 { ^# ]son for the child’s virilization. At that time, they4 m. R# E0 ?; F5 A R
decided to put the baby in a separate bed, and the& H6 H$ T- P ?/ R4 j5 g
father was not hugging him with bare skin and had
) H" m& k& {3 u2 V9 \been using protective clothing. A repeat testosterone. W; u2 l+ a" |+ ^/ N% s3 ~
test was ordered, but the family did not go to the
8 F7 ?# v; K& ?6 J4 A5 Alaboratory to obtain the test.
( V, B8 u& _6 A% T; gDiscussion) L/ G! {/ ~! [
Precocious puberty in boys is defined as secondary6 E, }, O' P5 n3 h- C& ?
sexual development before 9 years of age.1,4
* Q& W- t6 O* V& e" v6 ePrecocious puberty is termed as central (true) when! t- A3 E# h r8 C
it is caused by the premature activation of hypo-
4 h1 C! Z& T) Q7 R0 t# Athalamic pituitary gonadal axis. CPP is more com-
# t1 E- i% p1 v9 I- b0 W# Q5 Mmon in girls than in boys.1,3 Most boys with CPP
2 _1 d1 O, ^) x2 Lmay have a central nervous system lesion that is5 _$ B. m# n# m. j* p- c
responsible for the early activation of the hypothal-$ F3 L5 i9 M0 b% |/ O+ N
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 j" M T, H, Z! a) e; @0 K Ksis has been given to neuroradiologic imaging in
- M/ J+ M& T6 {* E7 `& |, zboys with precocious puberty. In addition to viril-/ @2 l0 ~$ V% l0 c* D
ization, the clinical hallmark of CPP is the symmet-
' O$ \- l; ]% C! u* W, `rical testicular growth secondary to stimulation by
8 z8 ~: T0 B3 |) Y" Fgonadotropins.1,3' R+ S) p. W# l
Gonadotropin-independent peripheral preco-: K; M& h+ H! c1 J
cious puberty in boys also results from inappropriate
) O% U! W' D# s- g, pandrogenic stimulation from either endogenous or
. v$ ^* o- u, U. g/ Eexogenous sources, nonpituitary gonadotropin stim-8 \9 l/ P$ W" ^. M0 H
ulation, and rare activating mutations.3 Virilizing
- o7 s4 R" R: @" vcongenital adrenal hyperplasia producing excessive5 q: \, A$ y( ^+ X
adrenal androgens is a common cause of precocious
/ S7 n, L% F2 F+ z; hpuberty in boys.3,4
I# P% B& d" i9 I* _8 b- L( {The most common form of congenital adrenal/ Z' o; o% w8 S, s4 J3 m0 O$ L
hyperplasia is the 21-hydroxylase enzyme deficiency.& n( v+ [* I1 `; X; U
The 11-β hydroxylase deficiency may also result in
- S7 a$ X, a( d2 g$ E$ Rexcessive adrenal androgen production, and rarely,
. f8 T# |3 w# m4 Uan adrenal tumor may also cause adrenal androgen! w% l. B* s6 J) F6 E7 i
excess.1,3% p( w$ R* N+ P- _9 z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ T6 v) o4 f+ S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 K7 N: I+ j* d3 B' f) IA unique entity of male-limited gonadotropin-
- E2 _% h' }* w4 E# B9 Pindependent precocious puberty, which is also known$ @& ~7 c0 `# w1 w1 ~. m- Z1 d
as testotoxicosis, may cause precocious puberty at a
8 {6 ^" S( X; {$ \ Z; gvery young age. The physical findings in these boys5 d; m5 {, ?5 ?( N/ w0 \
with this disorder are full pubertal development,
6 a; W( H, ?1 L/ o1 S) ?+ U: bincluding bilateral testicular growth, similar to boys
3 ?. G& E, p4 [# U0 ~# zwith CPP. The gonadotropin levels in this disorder/ F9 V# Q$ M7 S5 {9 q' y
are suppressed to prepubertal levels and do not show" Q0 d9 B1 y6 X, G7 o
pubertal response of gonadotropin after gonadotropin-& a! z' n3 x* B
releasing hormone stimulation. This is a sex-linked- [# j/ w& Q( Y$ V4 F1 K/ l
autosomal dominant disorder that affects only0 ~1 D! V9 I% r, Q
males; therefore, other male members of the family
; ^/ }3 h6 t4 t: G* emay have similar precocious puberty.3
! H- F8 Y' ~2 \' l, Z4 }In our patient, physical examination was incon-3 p0 ]' Q) o, T0 C
sistent with true precocious puberty since his testi-
o1 N' z) ? U# Kcles were prepubertal in size. However, testotoxicosis3 `0 G- A- G {9 _2 e
was in the differential diagnosis because his father
1 C' i+ M" l8 D( p2 g: pstarted puberty somewhat early, and occasionally,. N5 Z4 q; N6 z: t) R, T
testicular enlargement is not that evident in the/ G6 n% v) A3 ^ y* }7 }
beginning of this process.1 In the absence of a neg-" M) R7 N6 r* P3 l7 { x' V
ative initial history of androgen exposure, our5 ~( O% { C/ D# E8 o- r: k
biggest concern was virilizing adrenal hyperplasia,2 N) B' P. ^% Z; m% d
either 21-hydroxylase deficiency or 11-β hydroxylase
, ]! X n6 Z4 i1 ?! t5 `deficiency. Those diagnoses were excluded by find-- i+ I: s+ N+ p$ j( O8 ^
ing the normal level of adrenal steroids.# z$ t$ V/ p' \, A& k) s3 R
The diagnosis of exogenous androgens was strongly
% U+ ^' \9 L- qsuspected in a follow-up visit after 4 months because; e4 m- V, R4 u9 F3 d
the physical examination revealed the complete disap-
# r% s' | Z7 o( L- e2 k* Xpearance of pubic hair, normal growth velocity, and
2 E) ?. V: x8 Y: ndecreased erections. The father admitted using a testos-- K8 g/ X, m6 \1 d' R* r E
terone gel, which he concealed at first visit. He was. p1 z+ X9 g) [" `9 Y
using it rather frequently, twice a day. The Physicians’* C- U5 W, ^; m/ o6 C2 x
Desk Reference, or package insert of this product, gel or' ]( N6 O0 Y0 ], a7 G
cream, cautions about dermal testosterone transfer to
7 W2 D; q) W- S5 h9 Zunprotected females through direct skin exposure.* s. [: N+ |0 f" d8 ^
Serum testosterone level was found to be 2 times the
P* F% [3 A4 q: Vbaseline value in those females who were exposed to
! S+ c7 H5 C3 x) qeven 15 minutes of direct skin contact with their male( H" i1 R g p: L
partners.6 However, when a shirt covered the applica-
- a- d9 S7 f: j! @tion site, this testosterone transfer was prevented.
4 H% O! w3 |; p @3 LOur patient’s testosterone level was 60 ng/mL,! R, B2 f. }" V# y
which was clearly high. Some studies suggest that
6 u5 E+ M2 e4 p5 l. n! i3 Tdermal conversion of testosterone to dihydrotestos- z9 D- K6 p4 ~6 m
terone, which is a more potent metabolite, is more
! X0 h2 A# g8 eactive in young children exposed to testosterone
5 ^, H% H7 E0 ~exogenously7; however, we did not measure a dihy-
0 C0 M0 J3 u) a' O S' i( Kdrotestosterone level in our patient. In addition to4 y( [& P! p% N q, ~1 z
virilization, exposure to exogenous testosterone in
1 t j/ S& {5 v- ]) K' tchildren results in an increase in growth velocity and
# x0 I6 b# G0 J7 }. x- I! Padvanced bone age, as seen in our patient.( g+ O6 n/ F. H0 H5 B2 f
The long-term effect of androgen exposure during7 b* n- h" [; } d( v! ^9 `
early childhood on pubertal development and final3 s" r8 ^( ?2 b+ K! W* V1 g0 c( A
adult height are not fully known and always remain! H2 y; i3 q" G9 Z
a concern. Children treated with short-term testos-, x% q# n! o, y) S% F6 j0 C* e/ [
terone injection or topical androgen may exhibit some' P. a4 g N3 [" C7 D# o$ b; x& y4 J
acceleration of the skeletal maturation; however, after) e: z% \* Q3 q9 d% E' f
cessation of treatment, the rate of bone maturation$ w- |9 q0 Q4 R% \0 c
decelerates and gradually returns to normal.8,9
/ w6 p1 R6 m2 I+ [6 JThere are conflicting reports and controversy* x2 y0 J$ _8 e# @5 P8 U: F
over the effect of early androgen exposure on adult
/ x: Z; ^1 B' z7 n. cpenile length.10,11 Some reports suggest subnormal9 g. [. i0 N' l3 `
adult penile length, apparently because of downreg-3 \% W9 w+ S: v- y! C) _8 u6 L$ e/ u
ulation of androgen receptor number.10,12 However,
- W8 L. y! z- {+ y J- f$ c: kSutherland et al13 did not find a correlation between4 g7 x% _" X/ [ W6 p& [
childhood testosterone exposure and reduced adult
+ ` v& ?2 z2 ^% Openile length in clinical studies." K9 t2 Y6 V# s' J7 b2 q: |
Nonetheless, we do not believe our patient is
3 }* o8 Z6 K9 m4 Rgoing to experience any of the untoward effects from1 i' q4 @/ J& M
testosterone exposure as mentioned earlier because
" \/ I& V' G/ T1 @+ A; l3 O2 othe exposure was not for a prolonged period of time.
5 Q4 ?3 j: q, m4 FAlthough the bone age was advanced at the time of
' O3 [% d- j7 R2 W9 l! e/ Jdiagnosis, the child had a normal growth velocity at, k- i& H" U' Z* X% m
the follow-up visit. It is hoped that his final adult/ s+ H4 P r; G- A4 W: L. \: ]8 y
height will not be affected.
$ h' a& l8 C. KAlthough rarely reported, the widespread avail-
; m/ \# I h! C! C4 [ability of androgen products in our society may) F5 Y' L5 i/ B) F2 V' ^. r
indeed cause more virilization in male or female
+ X9 }8 R: I. \5 I- w# s% hchildren than one would realize. Exposure to andro-4 d) p$ g) h& k# {
gen products must be considered and specific ques-
' l: n0 K) \1 Y5 ytioning about the use of a testosterone product or2 O, b0 ~: A0 e* ~8 j
gel should be asked of the family members during
8 K( j1 X- Y6 l: I5 ]: Y2 h3 Cthe evaluation of any children who present with vir-' K; ~) z6 `. e4 y y" E$ o
ilization or peripheral precocious puberty. The diag-
( x' P& G* P* E! w4 C& F' G" pnosis can be established by just a few tests and by) R$ {# [: f$ h) g/ h. M
appropriate history. The inability to obtain such a
4 z0 V0 |$ }8 Q. i. w" I2 @. o2 lhistory, or failure to ask the specific questions, may
9 Q; \: I# A7 I( n2 ~; ]result in extensive, unnecessary, and expensive
* f: E$ A! b- e4 l+ rinvestigation. The primary care physician should be
1 S4 L: Q( M- B% t" b8 |6 Jaware of this fact, because most of these children
/ F7 |/ R: i, Q* u2 Amay initially present in their practice. The Physicians’8 C! J, s8 x% r% C7 I; A* p! b2 |: |
Desk Reference and package insert should also put a
1 F5 A* J! P/ C. C% [- s6 Xwarning about the virilizing effect on a male or/ G9 ]) D0 j( {# G" H; h& u/ G
female child who might come in contact with some-0 Z( ~8 v6 k! R
one using any of these products.8 @' D$ r. F2 K
References9 O( O/ w1 r$ x' D% t; O$ W- p, T
1. Styne DM. The testes: disorder of sexual differentiation
! R; @4 B4 Y9 g* ~) Dand puberty in the male. In: Sperling MA, ed. Pediatric
" \. P$ j6 l% H0 ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' z6 k; L4 y. m
2002: 565-628./ D# E) t H$ e2 m6 @# r& e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 V- i0 f0 }6 @: `
puberty in children with tumours of the suprasellar pineal |
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