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Sexual Precocity in a 16-Month-Old/ k: A% u! F6 k' k, t, \& v* ^
Boy Induced by Indirect Topical
- e8 P3 z# U5 O2 ^1 t" K# AExposure to Testosterone; ^ T& r t; l: T2 ?# B5 \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 A$ R8 f0 r* ~% T; w2 P
and Kenneth R. Rettig, MD1
$ O* O5 _' B$ CClinical Pediatrics9 F2 y4 P+ R; k: O' L& R
Volume 46 Number 6
3 o5 z8 x$ [% o( B6 rJuly 2007 540-5433 }5 L5 O) Q) u4 `& q2 K) k: f& R
© 2007 Sage Publications
" _( `: a4 _; [$ e2 D6 \10.1177/0009922806296651
; b k* J* l1 Q3 M7 \http://clp.sagepub.com& B* Z5 s1 C7 `4 a
hosted at" l. r% y- \: g9 h$ V
http://online.sagepub.com0 G( c) a) g3 r1 j
Precocious puberty in boys, central or peripheral,6 q5 {/ [! }4 ?, m' M& {' H# O* [
is a significant concern for physicians. Central
1 Z4 N7 d! P: @, t7 c6 mprecocious puberty (CPP), which is mediated9 r+ g8 u, C+ o8 Y4 Z" o$ `
through the hypothalamic pituitary gonadal axis, has+ \: X7 D; \$ @( L* G
a higher incidence of organic central nervous system
- w h7 ]+ z2 Xlesions in boys.1,2 Virilization in boys, as manifested
1 @& y @- S! Y5 a; l. Zby enlargement of the penis, development of pubic8 H7 L7 ]! b! g6 n( z$ e; _" x
hair, and facial acne without enlargement of testi-
+ H& x: {- H h4 c: L9 S+ p# T2 Rcles, suggests peripheral or pseudopuberty.1-3 We
$ T3 H) _ I- s7 |. p kreport a 16-month-old boy who presented with the# k5 u8 l4 g0 R; A0 L" K" O- F4 a% C" A
enlargement of the phallus and pubic hair develop-
0 {/ D! M4 o+ R9 f* rment without testicular enlargement, which was due% G/ h% A9 B+ O7 x7 K8 Y
to the unintentional exposure to androgen gel used by
% V4 o* x) \% `" W$ ythe father. The family initially concealed this infor-
1 [2 V4 X' f! m5 X9 Y! k" E, xmation, resulting in an extensive work-up for this
9 }+ z! m$ ?& B. [* vchild. Given the widespread and easy availability of
* L3 ?8 w1 V- j& ftestosterone gel and cream, we believe this is proba-9 i q: J' o$ u8 z/ W( {
bly more common than the rare case report in the' g; _4 E: K. g3 [+ a0 q* P6 N
literature.4. p: X8 |" E, k, X' ?
Patient Report
) a2 l( Q4 X9 q" t. {; F+ {A 16-month-old white child was referred to the- b9 ?, X1 F6 F+ V3 d
endocrine clinic by his pediatrician with the concern
6 e3 R( b' u' d$ D& |$ Yof early sexual development. His mother noticed
; R- G1 x% E5 a b& ylight colored pubic hair development when he was9 d6 d9 i% I7 k8 a) G
From the 1Division of Pediatric Endocrinology, 2University of7 Z3 @2 y) {+ q1 M+ e
South Alabama Medical Center, Mobile, Alabama.2 e2 c( h% u4 X% W& i/ C. S( T3 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 j5 i% f) ] q/ h) gProfessor of Pediatrics, University of South Alabama, College of
2 ?' h3 } `" Q, u0 Y X7 ~# s( }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! m" k/ P; ]. h2 D ^, ~% R
e-mail: [email protected].$ Y; Q" ?+ Z+ t4 u+ L
about 6 to 7 months old, which progressively became
, g, s4 I6 \# a3 U" |darker. She was also concerned about the enlarge-
$ t* D: x8 J' O" q7 [% Ament of his penis and frequent erections. The child- ~( n7 [) H6 U6 t/ Q }# k' G+ r
was the product of a full-term normal delivery, with/ S0 h& ?% i. M0 \5 _
a birth weight of 7 lb 14 oz, and birth length of! I7 H; c! o1 X* ]
20 inches. He was breast-fed throughout the first year
; E2 f9 F) O# rof life and was still receiving breast milk along with
7 w8 N/ Q7 U$ ssolid food. He had no hospitalizations or surgery," C8 Z1 j' M" N
and his psychosocial and psychomotor development
o" D( H, o; Uwas age appropriate.
( Z& n( |4 _' \. r" x4 [. wThe family history was remarkable for the father,
7 D. _( c: f; d: f- _4 b _: jwho was diagnosed with hypothyroidism at age 16,' Y/ _- V0 C. U6 k' m0 ?' d6 r
which was treated with thyroxine. The father’s, k2 r- h9 o4 D/ o
height was 6 feet, and he went through a somewhat
: ]% `5 U' T5 Qearly puberty and had stopped growing by age 14.
3 L' K: U( Q0 B) O" N& i1 Q- BThe father denied taking any other medication. The" j- O- l, \! t9 L! E' ^& t( N
child’s mother was in good health. Her menarche9 H' U4 q+ q6 L# g' z0 j
was at 11 years of age, and her height was at 5 feet
- |# E0 B( }6 u# X8 b5 inches. There was no other family history of pre-
U# _$ q* _1 acocious sexual development in the first-degree rela-
8 w# Y9 j1 O( C) _% M, m7 ltives. There were no siblings.
& X: @. H- U3 i) L3 V! GPhysical Examination
' @! ?* j. v& K: fThe physical examination revealed a very active,) @( L' y% M" W8 O5 Y) E+ G
playful, and healthy boy. The vital signs documented
8 {3 z+ v8 ], T: f. J oa blood pressure of 85/50 mm Hg, his length was+ k9 ~; l5 s5 D; Z/ l, h2 d. U4 X! w8 M
90 cm (>97th percentile), and his weight was 14.4 kg
4 H$ F' Q) V1 _ T& y0 [3 @- z(also >97th percentile). The observed yearly growth" t5 z5 V. v j# j2 K6 W. [
velocity was 30 cm (12 inches). The examination of
+ h: B, X' S# @7 ]+ P7 T4 qthe neck revealed no thyroid enlargement./ n9 h* x+ |$ i* n- W: W
The genitourinary examination was remarkable for
9 A$ J* v8 P9 P3 ~; O6 nenlargement of the penis, with a stretched length of. c! g: j* D2 i4 ]5 W0 A$ a
8 cm and a width of 2 cm. The glans penis was very well3 x w% a1 m# p w- P" M
developed. The pubic hair was Tanner II, mostly around& K4 a7 U3 j/ ^
540
2 n# q- v6 Y5 `6 d: r% {4 ]& ?6 bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: D( G; p4 T5 K( Q8 \9 C+ jthe base of the phallus and was dark and curled. The
; Z- ~1 |% N% U4 E+ Atesticular volume was prepubertal at 2 mL each.
' p+ z& ~- u5 V- d% \" [The skin was moist and smooth and somewhat6 w. X* \6 d, }# B+ _
oily. No axillary hair was noted. There were no
: a$ C f" {( u k$ g1 n- mabnormal skin pigmentations or café-au-lait spots.. G9 B5 F$ w* h9 A& }
Neurologic evaluation showed deep tendon reflex 2+% q+ k% A. j* i7 C: y% F Q
bilateral and symmetrical. There was no suggestion
; y0 ~) G* ^1 [of papilledema.
' M/ l# c( i4 i% g( w2 p: m4 |Laboratory Evaluation/ R( k1 `. H1 P4 u+ a
The bone age was consistent with 28 months by9 B n6 p+ e- y1 I; ^
using the standard of Greulich and Pyle at a chrono-1 r8 _/ ?$ L* M% k, o
logic age of 16 months (advanced).5 Chromosomal
6 R8 H* l7 @5 P4 {* Y7 `karyotype was 46XY. The thyroid function test
Y, h/ V5 _7 x8 o e! Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
) m) x! |5 Q5 X; A7 W; Q: w0 T# C4 olating hormone level was 1.3 µIU/mL (both normal).
: q: N2 l% Q ^: ]The concentrations of serum electrolytes, blood
- g* ? `+ a, J# Yurea nitrogen, creatinine, and calcium all were
5 i/ T- [3 }, b& {within normal range for his age. The concentration
6 K0 P, Q. `- ~$ H' t* N5 wof serum 17-hydroxyprogesterone was 16 ng/dL& ^ E% J. z6 d3 @! J" p6 [
(normal, 3 to 90 ng/dL), androstenedione was 20
6 d1 ^, ~, A( d5 K/ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 Y& c$ c% r! Y( L: i
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 X- J& |3 _& o. Q, J; o sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; D3 K, Z4 Y4 I# y3 w
49ng/dL), 11-desoxycortisol (specific compound S)! u4 P/ {: \6 P- x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 U1 H/ B% h3 ^! F' X8 _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 a1 }" C) i7 ~7 |! {, w# d8 ^testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* L# z1 w( B& w/ d2 ?and β-human chorionic gonadotropin was less than
+ K" q- r) t; y/ {+ C5 j V5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 o6 m) O2 n3 Q; L8 |3 ustimulating hormone and leuteinizing hormone) c+ K8 z7 Q2 ~- L. P1 c
concentrations were less than 0.05 mIU/mL
8 S6 s) S1 o& x0 I0 J(prepubertal).: p% D$ X/ x+ n; d# I+ g7 w
The parents were notified about the laboratory d# ~6 d9 U' F$ \* w. T+ c
results and were informed that all of the tests were
6 s( R! a+ b, Anormal except the testosterone level was high. The
# s, a4 `' l) N8 ~4 Afollow-up visit was arranged within a few weeks to
4 U1 Z f- X) qobtain testicular and abdominal sonograms; how-9 V8 L# h" v0 R7 R" V( @1 c
ever, the family did not return for 4 months.( Q9 x& I* O& O' j+ x
Physical examination at this time revealed that the5 t" @2 j; w2 d
child had grown 2.5 cm in 4 months and had gained% v, j+ ?" N& j- t/ h/ D
2 kg of weight. Physical examination remained
9 }: M, d; n# u! t/ cunchanged. Surprisingly, the pubic hair almost com-0 r: m$ D" V& e6 j' Q1 l3 v
pletely disappeared except for a few vellous hairs at
. g$ m0 j8 P8 w; C; W, J. U& c* Ethe base of the phallus. Testicular volume was still 29 S+ |1 N3 K, ^' i& z
mL, and the size of the penis remained unchanged.4 W4 n( S+ z7 h- ?$ _3 v/ J% d
The mother also said that the boy was no longer hav-
, t: @0 l& f# ?6 g9 l% p- ding frequent erections.' y. m0 J& C- k1 j/ O
Both parents were again questioned about use of
2 [8 K2 T) N; Y9 d' r4 F6 E2 tany ointment/creams that they may have applied to
% O5 X; H, b( `: z2 Z- v- cthe child’s skin. This time the father admitted the
, x/ s5 O- M& J% s: hTopical Testosterone Exposure / Bhowmick et al 541, e9 r R4 z+ G+ O+ h
use of testosterone gel twice daily that he was apply-6 [ @3 u8 m" S! f1 a
ing over his own shoulders, chest, and back area for o$ k' J7 O* ]% {% _ A8 W
a year. The father also revealed he was embarrassed
+ d+ Z5 t; B& T3 a: L! E2 Vto disclose that he was using a testosterone gel pre-- O# j. K7 e8 Y. c
scribed by his family physician for decreased libido- Z L$ h9 j w: s0 y: d- S
secondary to depression.) U/ F4 n0 _0 ]' k% P5 N
The child slept in the same bed with parents./ c p0 E4 h. |- W$ Z
The father would hug the baby and hold him on his
% B" w: k$ G- U# r/ @( ?9 ychest for a considerable period of time, causing sig-
9 \2 `# V1 ^6 Y; } I: Q vnificant bare skin contact between baby and father. b5 J& @' B% q4 v' W: d h
The father also admitted that after the phone call,
% _9 n! l( Q, i2 d1 d& owhen he learned the testosterone level in the baby9 E) d9 W; ~+ `( L) s- p8 j7 G: @* r8 h
was high, he then read the product information; N* V+ U6 H$ t9 ~4 [$ j
packet and concluded that it was most likely the rea-
) B; I/ i) M) M4 _son for the child’s virilization. At that time, they
7 q% i, X0 M& p- e+ c' Wdecided to put the baby in a separate bed, and the/ e/ j. t+ D, F2 v- w
father was not hugging him with bare skin and had
. R8 e# w1 m4 gbeen using protective clothing. A repeat testosterone
+ g* u( _# K# y% B2 e0 _test was ordered, but the family did not go to the. _. f! c" P. T
laboratory to obtain the test.3 x2 C& c7 ^6 R( A' o# X$ _
Discussion q# W! ]+ s- G B/ O& E+ b* K
Precocious puberty in boys is defined as secondary
$ M. n4 f, Y& Xsexual development before 9 years of age.1,4
. }6 O Q q; O/ }* U7 B- C( s8 {+ QPrecocious puberty is termed as central (true) when3 \0 L0 J8 \, X' ~ X- e
it is caused by the premature activation of hypo-" I, U* W5 P2 L9 q% i
thalamic pituitary gonadal axis. CPP is more com-; T; d- q3 s: i. _2 W
mon in girls than in boys.1,3 Most boys with CPP
8 m3 e$ \, e. l2 Y6 _! _" H& f( Mmay have a central nervous system lesion that is
6 J8 s3 E+ L6 cresponsible for the early activation of the hypothal-1 q5 R* ^, g/ y, k
amic pituitary gonadal axis.1-3 Thus, greater empha-' o( H/ a$ a. A- @' ?
sis has been given to neuroradiologic imaging in# w& ^9 Q6 V- ~
boys with precocious puberty. In addition to viril-8 {- x2 L3 S, m5 q/ ]; m2 J
ization, the clinical hallmark of CPP is the symmet-' `8 Q: J8 l I1 t6 W: L! _/ B
rical testicular growth secondary to stimulation by& w" m P$ \. \
gonadotropins.1,3
, O' I& B- d+ q0 fGonadotropin-independent peripheral preco-
S; X Q% e- h; C) C3 K4 xcious puberty in boys also results from inappropriate
5 b: e% d) e6 R: R8 j+ oandrogenic stimulation from either endogenous or' U* ` t1 s+ [+ H* f
exogenous sources, nonpituitary gonadotropin stim-8 Y* B# @0 i* Z5 o
ulation, and rare activating mutations.3 Virilizing
7 u0 \ V4 ^9 w6 Fcongenital adrenal hyperplasia producing excessive" G2 o; T$ O1 A, s& K
adrenal androgens is a common cause of precocious7 T! ]9 O2 P5 @# @
puberty in boys.3,4* I" _, z$ ]# z# g; m- I5 ?3 h
The most common form of congenital adrenal
9 M) B+ s- x( W$ K2 ~hyperplasia is the 21-hydroxylase enzyme deficiency., D; w( f( j5 J$ b3 |* O$ U
The 11-β hydroxylase deficiency may also result in
: W+ D+ u9 z" ?7 U5 g. Zexcessive adrenal androgen production, and rarely,8 V" y7 Y* t- N* |9 Q7 S
an adrenal tumor may also cause adrenal androgen
- W% ^- p* ~8 S' p: v+ Rexcess.1,3* R# {$ U/ g1 \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 l' V& ]* C+ z. e( x+ g6 M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! ^5 x" q. R7 _5 [
A unique entity of male-limited gonadotropin-7 G A/ H$ ]; N% Y$ I6 l& t0 v! K
independent precocious puberty, which is also known
" p+ h: i9 M& ias testotoxicosis, may cause precocious puberty at a% G) H! P7 B2 t+ p$ Q
very young age. The physical findings in these boys# o9 R1 \: x; Z# j K4 @5 v+ z9 R
with this disorder are full pubertal development,) U+ O4 [& f1 n" d
including bilateral testicular growth, similar to boys
. d N4 Y) }5 i, n9 `with CPP. The gonadotropin levels in this disorder
: k5 {& A9 x( u" X% care suppressed to prepubertal levels and do not show3 O1 `) {. z: x; A
pubertal response of gonadotropin after gonadotropin-5 Z% j1 t6 h, }) V# y
releasing hormone stimulation. This is a sex-linked
6 Z- W) G# @9 n4 L7 b6 _# |autosomal dominant disorder that affects only& [4 U7 F: [! ^( U, s! L
males; therefore, other male members of the family/ V: t- x6 d0 p9 N; ]
may have similar precocious puberty.36 n. _& b5 F8 x `
In our patient, physical examination was incon-
" d# b* b1 X; \; lsistent with true precocious puberty since his testi-
+ X/ E# h+ B& f1 M7 {cles were prepubertal in size. However, testotoxicosis
$ e# r. J4 \$ ~' Lwas in the differential diagnosis because his father
4 Y7 n9 b9 L; i. @5 vstarted puberty somewhat early, and occasionally,
$ e1 F6 b% W% e- Utesticular enlargement is not that evident in the
" D$ m {8 \* T- s( F) @2 r+ ?$ I! Ibeginning of this process.1 In the absence of a neg-
' u' z& o( }, }& r1 ^6 pative initial history of androgen exposure, our
# l/ s, e& K6 Sbiggest concern was virilizing adrenal hyperplasia,
; q( g8 ^% ^5 A. z- \either 21-hydroxylase deficiency or 11-β hydroxylase" }1 ^: w' ?3 O7 t7 o+ m5 y
deficiency. Those diagnoses were excluded by find-
+ r0 }- n1 v jing the normal level of adrenal steroids.+ d2 i: q. @8 v! g+ L+ h2 Q1 W
The diagnosis of exogenous androgens was strongly
9 W8 D5 {4 C7 R+ y( G( S% Y' {2 fsuspected in a follow-up visit after 4 months because
# B/ ?$ k9 O% w0 lthe physical examination revealed the complete disap-5 i% x2 |6 A8 _6 r9 m' l6 A0 e* [# ]# A
pearance of pubic hair, normal growth velocity, and9 o; G( {1 P; O7 q4 k8 z
decreased erections. The father admitted using a testos-- s1 j) G" |' U
terone gel, which he concealed at first visit. He was4 G. X+ ]7 i( `
using it rather frequently, twice a day. The Physicians’ C; P: {7 N3 l" I9 K8 P
Desk Reference, or package insert of this product, gel or5 x! Y5 T: [5 y' ]+ u8 r+ k$ M! M
cream, cautions about dermal testosterone transfer to; k- k; x$ S, Y( Q" z& g0 r
unprotected females through direct skin exposure. ~0 S' [5 W4 h* S S
Serum testosterone level was found to be 2 times the
# O# ^! d% b6 g+ L! Ubaseline value in those females who were exposed to
& [$ R: i }6 a4 p, l( Veven 15 minutes of direct skin contact with their male/ l" E9 x6 L* @4 b1 D9 L7 }
partners.6 However, when a shirt covered the applica-
$ {( W- }) X! B% ction site, this testosterone transfer was prevented.
" K! j# P# e: G- r1 g1 M0 gOur patient’s testosterone level was 60 ng/mL,
% t: @+ n/ @; m+ N& }5 [7 uwhich was clearly high. Some studies suggest that
2 t- g+ ~. H% @5 Z, ]1 n- Ldermal conversion of testosterone to dihydrotestos-: O0 O2 t7 u+ i+ H
terone, which is a more potent metabolite, is more
- R0 ]. }3 S5 bactive in young children exposed to testosterone) s! B, y* l6 z- i- W& x) @8 G# Z
exogenously7; however, we did not measure a dihy-, {1 p. v6 W f# j r2 L: c
drotestosterone level in our patient. In addition to0 n: ]5 N/ l5 R
virilization, exposure to exogenous testosterone in; c) ?6 |6 ~9 M2 k2 W
children results in an increase in growth velocity and9 {0 |$ q4 z+ H k
advanced bone age, as seen in our patient.
/ n9 V6 E8 X7 @; e5 |The long-term effect of androgen exposure during9 e6 u0 U1 P' `8 k3 V) L! r+ m
early childhood on pubertal development and final( Y* r2 S0 I) G& U3 S5 p) f4 j: t
adult height are not fully known and always remain1 W) [6 x% c" j- `( ~
a concern. Children treated with short-term testos-$ z6 h3 ?" M; P/ I/ z( F
terone injection or topical androgen may exhibit some
8 b# f( D9 v+ ?) B7 Gacceleration of the skeletal maturation; however, after
i0 Y; r4 Y/ ~2 F* N! b. xcessation of treatment, the rate of bone maturation3 W- P! z" q; t' a4 H
decelerates and gradually returns to normal.8,9
% _5 V- B! k. t) Y5 Y$ w1 E7 O7 oThere are conflicting reports and controversy, k- M, }! o5 V9 N% M5 f8 ?
over the effect of early androgen exposure on adult: X8 g) O+ k1 X( N6 J
penile length.10,11 Some reports suggest subnormal0 J- g; A' P* B: l0 {
adult penile length, apparently because of downreg-9 s9 ~2 g0 }) c! f3 ]
ulation of androgen receptor number.10,12 However,
" f5 e" z* j. eSutherland et al13 did not find a correlation between/ o* q) y' G1 _0 b0 l2 S {2 F( L" C
childhood testosterone exposure and reduced adult
7 c# }/ C# ^9 _) s& a& \penile length in clinical studies.
4 A% ?1 y* k: s/ }- \! `( _* ]Nonetheless, we do not believe our patient is* Q G+ [, O: A, e: d/ s+ w
going to experience any of the untoward effects from" |! C; i0 R/ G% Q. Y8 T" y0 {
testosterone exposure as mentioned earlier because6 A. \% N- Q! Q, q2 K1 E
the exposure was not for a prolonged period of time.3 M' |$ c! N$ M
Although the bone age was advanced at the time of
6 Z8 i! G! V, M6 W$ ediagnosis, the child had a normal growth velocity at
# R6 V2 p/ c% x1 ~, l: |" \+ l! P* athe follow-up visit. It is hoped that his final adult
* O N0 G; S* aheight will not be affected.9 H/ j) K" L+ j
Although rarely reported, the widespread avail-
7 y9 v Y( n. Z; k K6 b* ]ability of androgen products in our society may0 |$ y& e1 X2 T+ \
indeed cause more virilization in male or female s8 U3 A# H$ N
children than one would realize. Exposure to andro-
9 _. N. W# a2 \$ v' N0 egen products must be considered and specific ques-
: _. ?! Q& T3 vtioning about the use of a testosterone product or
# k* \$ ~) T. c! Sgel should be asked of the family members during
' f, z$ q/ Z6 V- _) ethe evaluation of any children who present with vir-& N/ _7 E6 M( v) o, m q. [
ilization or peripheral precocious puberty. The diag-
h) t9 B+ Y. W. F5 Inosis can be established by just a few tests and by5 d+ e+ I( }% }) C# t! v% V
appropriate history. The inability to obtain such a* g+ @0 h, c4 {" Z
history, or failure to ask the specific questions, may
* L8 E a! o) U' l4 K4 V2 J$ d& Gresult in extensive, unnecessary, and expensive: Q- D) N' o! m" Y6 G* q$ U
investigation. The primary care physician should be
; s2 f! m4 n' t: aaware of this fact, because most of these children5 d$ O* S( u8 _) Z( u
may initially present in their practice. The Physicians’
: K. A0 q1 i5 y, w, [3 ADesk Reference and package insert should also put a ]( G0 N- l" Z5 m( F+ _+ g
warning about the virilizing effect on a male or; x$ N0 {4 V; E: d0 C' G
female child who might come in contact with some-8 j: B5 |7 C. N% R2 w# F2 F
one using any of these products.
9 w' |3 i3 Z. ^2 a: r3 V( CReferences
3 \) P' S. Z l- [1. Styne DM. The testes: disorder of sexual differentiation" x9 s& u9 t/ x) n8 [
and puberty in the male. In: Sperling MA, ed. Pediatric3 Q& O5 e) ~4 I( X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 X; L" A* `( G7 e+ A. m# d0 _ ]2002: 565-628. G) h/ q1 P- E9 y+ y# [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. L: r, F% a- u( Z, g+ mpuberty in children with tumours of the suprasellar pineal |
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