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Sexual Precocity in a 16-Month-Old
4 k$ p( \8 V0 \: M, s3 EBoy Induced by Indirect Topical
" o6 \, o+ v+ {8 v- p& pExposure to Testosterone Q7 X) k: H* D% `$ K, x
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 s, s6 c0 p |& z
and Kenneth R. Rettig, MD1+ c0 V$ O# o( r* Q% G# {8 x
Clinical Pediatrics
7 R |0 M% q C8 P9 u& {/ y9 o& A* BVolume 46 Number 6+ S! N1 L4 x. w- D# f
July 2007 540-543; y& S g9 \4 Z* s/ ^- \
© 2007 Sage Publications6 U: c, p4 E5 X0 @4 C
10.1177/0009922806296651/ v2 h# Q0 n3 f3 l1 M6 ~; v L8 q
http://clp.sagepub.com
E/ T% S) c* W B+ `0 Z. hhosted at
" g9 v3 u8 o* Khttp://online.sagepub.com
9 k" C- e; h. d; E/ r2 p8 KPrecocious puberty in boys, central or peripheral,+ y, d! R6 Z0 i! |
is a significant concern for physicians. Central
0 p/ u D% T7 P! x1 S" w1 w0 Gprecocious puberty (CPP), which is mediated" R( U) t% O. f( `- \
through the hypothalamic pituitary gonadal axis, has
$ E6 Z$ A8 K' Y/ wa higher incidence of organic central nervous system
9 b- Q m+ [6 Clesions in boys.1,2 Virilization in boys, as manifested3 @1 b' z; O( `: M! D% R" H, ]
by enlargement of the penis, development of pubic1 x% M6 f# a& B2 m6 I3 U4 J
hair, and facial acne without enlargement of testi-: h# Z. o; m5 d q+ b" B
cles, suggests peripheral or pseudopuberty.1-3 We* F4 L, }! ?$ _' j* r
report a 16-month-old boy who presented with the
, a8 \/ O6 |+ henlargement of the phallus and pubic hair develop-
) \' l- D+ M- g& D/ Nment without testicular enlargement, which was due
: w$ y# _0 ]/ w( ]. ~" |to the unintentional exposure to androgen gel used by& m# F6 c( O: T; E8 @( p+ l. N5 R
the father. The family initially concealed this infor-9 F* S4 k' p9 Q0 n" m; L
mation, resulting in an extensive work-up for this8 P( H- M1 f8 Q6 W( h; {
child. Given the widespread and easy availability of7 [. B& G7 r Z( O
testosterone gel and cream, we believe this is proba-
& X4 L* G' ]' l6 G$ |: Kbly more common than the rare case report in the
3 V$ {. w8 a# J3 ?; nliterature.4
$ G) E8 G% y" c, X O Z; r" W+ NPatient Report6 j6 Z, s1 B% I
A 16-month-old white child was referred to the
6 t; o+ |6 K- J7 r- r) wendocrine clinic by his pediatrician with the concern
& ?+ @+ I4 B$ Pof early sexual development. His mother noticed
% {0 G( l V$ c" mlight colored pubic hair development when he was C6 h2 f: K9 R' ~6 b3 X
From the 1Division of Pediatric Endocrinology, 2University of: f4 o9 b& {2 U/ T+ _
South Alabama Medical Center, Mobile, Alabama.% k. O2 j. A9 Y: @
Address correspondence to: Samar K. Bhowmick, MD, FACE,! ~4 W2 o4 ~8 f5 V c D
Professor of Pediatrics, University of South Alabama, College of8 M. v3 S" [5 P; E( N( N9 N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ l5 L* J/ m+ i/ W) R* {e-mail: [email protected].
( d. v# |0 {: c0 m/ Vabout 6 to 7 months old, which progressively became
) r! y# \7 D- {2 W$ Y6 O3 o: bdarker. She was also concerned about the enlarge-( ]: u5 Q+ p# H
ment of his penis and frequent erections. The child
; {* _9 A$ t* W% W/ [was the product of a full-term normal delivery, with
1 g" g+ N! A `- va birth weight of 7 lb 14 oz, and birth length of$ R+ z) k3 `& i; O" L1 d
20 inches. He was breast-fed throughout the first year0 Q( U4 d" e) T
of life and was still receiving breast milk along with/ d3 m1 H9 L. R$ Z
solid food. He had no hospitalizations or surgery,
; T8 I; b9 D7 q: C7 z( [& gand his psychosocial and psychomotor development6 j3 `! h( k) }) M
was age appropriate.$ b! `6 r% R) `* c% Z+ l4 x5 N
The family history was remarkable for the father,
. x9 T, J8 C- k# T- f" Ewho was diagnosed with hypothyroidism at age 16,3 L6 }1 o/ A# m$ @+ ]' f# H8 e
which was treated with thyroxine. The father’s
* I+ Z4 ?; R( L7 Y) j7 E) Sheight was 6 feet, and he went through a somewhat
; P0 P1 w: u# x7 h. q* a+ Fearly puberty and had stopped growing by age 14.& V9 L0 N- ~2 z
The father denied taking any other medication. The" ]7 k4 E2 _2 I( n$ Y: B8 m
child’s mother was in good health. Her menarche
3 r; L- {1 f g; f/ pwas at 11 years of age, and her height was at 5 feet7 T2 m& w, ?0 J1 Y0 |9 \9 {1 G- V+ |
5 inches. There was no other family history of pre-
2 X) F; `8 ?+ v% ~; u) Mcocious sexual development in the first-degree rela-8 j( w2 z' j2 f @
tives. There were no siblings.
7 B9 c3 f6 R' ?0 G( \Physical Examination
* L* b1 b y' W2 n' \! C( OThe physical examination revealed a very active,
# w1 ], h* g+ o1 gplayful, and healthy boy. The vital signs documented) W( X+ Y m7 A- }- L, v0 p
a blood pressure of 85/50 mm Hg, his length was& e5 _' ` t- b4 h
90 cm (>97th percentile), and his weight was 14.4 kg
$ q! D% D- u" J8 v6 B(also >97th percentile). The observed yearly growth
R/ D c5 C% O, [. g2 Yvelocity was 30 cm (12 inches). The examination of
* P9 X, {' D1 b3 j% [the neck revealed no thyroid enlargement.# v: t3 o+ N* V/ `8 c/ M- P2 m
The genitourinary examination was remarkable for, A& q0 p7 m+ D* {* I6 z
enlargement of the penis, with a stretched length of
! s0 X+ a. u% N; e8 cm and a width of 2 cm. The glans penis was very well
W8 ]2 h6 {4 h, g# w, }( Ideveloped. The pubic hair was Tanner II, mostly around
H% L/ J7 y! L# E$ T540, G4 X# q6 V2 x4 m6 r6 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* W& i3 p; S, H7 m
the base of the phallus and was dark and curled. The
% E, {, l4 K1 A3 Ntesticular volume was prepubertal at 2 mL each.
+ }0 a, N T" o6 s* `. K/ a/ QThe skin was moist and smooth and somewhat
" f# X, o( E7 r f! Q2 _4 goily. No axillary hair was noted. There were no( L# x- H* K6 [6 C( t7 y
abnormal skin pigmentations or café-au-lait spots.
7 O, F* U1 L( ~- {Neurologic evaluation showed deep tendon reflex 2+
! I! b; r9 c. L2 Gbilateral and symmetrical. There was no suggestion
5 W) |/ T! W! s8 E% x& T. Wof papilledema.. y8 e2 C' r/ A4 ~! n
Laboratory Evaluation
. S1 o; }/ F3 O' l9 j& F+ uThe bone age was consistent with 28 months by
/ g; l5 T- B6 W0 xusing the standard of Greulich and Pyle at a chrono-
8 X) J; I: M) M9 rlogic age of 16 months (advanced).5 Chromosomal$ B7 J! V$ L+ q8 ]
karyotype was 46XY. The thyroid function test
0 k! O' N/ z* G7 F. c1 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 `5 L8 l* q: o; P7 klating hormone level was 1.3 µIU/mL (both normal).$ Y& S0 j# V& a+ k1 L
The concentrations of serum electrolytes, blood
% h4 a, D9 ?- Q/ @+ G# b* kurea nitrogen, creatinine, and calcium all were
- a: ~' U" Y6 S( Awithin normal range for his age. The concentration
& }$ }/ N* P( _* f$ w, m2 \of serum 17-hydroxyprogesterone was 16 ng/dL
+ j. i1 @. z' ^4 R(normal, 3 to 90 ng/dL), androstenedione was 20
% E6 L& s( f! i0 p/ G* j" X$ Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 u8 E; R- G, p$ G: |- nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: a4 b2 x5 Y8 w; cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ ]+ |9 |9 D' m/ Z0 G6 O9 [49ng/dL), 11-desoxycortisol (specific compound S)
% @* r- @% h4 q* b; d0 uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ O# E3 c1 @4 q$ ]- u% F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& `5 \; H- R+ b3 n9 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ a( V$ }) ~& E+ s" u9 l
and β-human chorionic gonadotropin was less than+ m- d2 F! }2 z0 F- ?& k* f" a( ]; m
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) z0 n6 c. O8 X. G! V2 x5 o8 ~stimulating hormone and leuteinizing hormone4 {, z$ B0 M( _% { U1 `
concentrations were less than 0.05 mIU/mL) R6 I0 t( Y) | ~4 S) m
(prepubertal).
, E4 ]& T- I+ T5 g5 [( q; nThe parents were notified about the laboratory
' T4 z. x& N, ]results and were informed that all of the tests were- W4 S- J; N) f6 y9 x2 I5 x2 f
normal except the testosterone level was high. The
. V4 l" N3 S: mfollow-up visit was arranged within a few weeks to
8 T! c' ?: R2 J0 i9 \4 c$ Iobtain testicular and abdominal sonograms; how-
8 j7 G5 O/ a; K2 T$ h6 }0 O- yever, the family did not return for 4 months.
3 I% j. O7 E6 l1 x, j1 K& fPhysical examination at this time revealed that the
4 R3 u) o. B) v0 f: G; Y( c* }child had grown 2.5 cm in 4 months and had gained- o$ B6 x% ^. J- h: X* n" U- T
2 kg of weight. Physical examination remained
: A( @* Q$ t% e+ G+ N6 |: Nunchanged. Surprisingly, the pubic hair almost com-
9 h$ \) j0 W& ?9 b" B0 Cpletely disappeared except for a few vellous hairs at# I: V% {7 D0 q" e
the base of the phallus. Testicular volume was still 2! J( b; v" `" `6 s
mL, and the size of the penis remained unchanged.
8 l* J- T9 c% ^ [2 gThe mother also said that the boy was no longer hav-, h& Y! `+ B! }
ing frequent erections.
* o# h ~' ?8 U- o" `! OBoth parents were again questioned about use of
- j& j# t( r! wany ointment/creams that they may have applied to F0 X4 t0 J* Y' B% F0 l: y
the child’s skin. This time the father admitted the9 |$ s) R$ a* u( H4 S
Topical Testosterone Exposure / Bhowmick et al 541! y8 J; N0 Y9 A
use of testosterone gel twice daily that he was apply-& ^1 J% ]/ M( g* v4 i
ing over his own shoulders, chest, and back area for, J( v- s+ m9 i7 {
a year. The father also revealed he was embarrassed
9 W, i" H6 k+ j. c! Zto disclose that he was using a testosterone gel pre-
3 F3 W" b7 R, D7 ~# d2 o6 c: Lscribed by his family physician for decreased libido
1 D" y t1 @3 v( I0 K( q+ _secondary to depression.# y0 s& u5 D" Z
The child slept in the same bed with parents.
- f2 B$ P6 j& r9 E8 pThe father would hug the baby and hold him on his
& _, r) `' c. |. ^! N+ nchest for a considerable period of time, causing sig-4 j8 K; t" v* t) ] s
nificant bare skin contact between baby and father.
$ f. d8 \% {8 [. J% H2 |' K" i+ }The father also admitted that after the phone call,, |- A3 ]4 r! H6 q
when he learned the testosterone level in the baby
' p9 f1 o/ w5 N8 H/ u6 l. l8 Fwas high, he then read the product information1 v* M% j; l9 r5 U$ z
packet and concluded that it was most likely the rea-3 l, g7 e! T& X9 w" _' }, o- [: z& F
son for the child’s virilization. At that time, they3 [1 X& C. Q/ N$ x- n, i5 v
decided to put the baby in a separate bed, and the- [9 E0 W; E. W5 P5 H: ?) A& [
father was not hugging him with bare skin and had
; N( D' ^' @# m' Dbeen using protective clothing. A repeat testosterone
$ T2 } L$ {4 R& `/ J+ v& _8 gtest was ordered, but the family did not go to the! C3 p! |7 T0 E/ f4 O! @
laboratory to obtain the test.% r( S, p- R, }2 ?6 _$ y9 j
Discussion0 ^9 { `3 t4 Q1 W; H) R& T" g
Precocious puberty in boys is defined as secondary
: r" y# W3 u2 N7 {4 Qsexual development before 9 years of age.1,4- S. R* C* S8 I! s- j4 T3 q
Precocious puberty is termed as central (true) when; R. {! ~( V. d m+ w; \! D
it is caused by the premature activation of hypo-
2 F! Y/ Q; Q4 E! ~; [# m' uthalamic pituitary gonadal axis. CPP is more com-
! e; _: x% U* `" S2 u* @# ^mon in girls than in boys.1,3 Most boys with CPP& I7 p e6 k- x
may have a central nervous system lesion that is
: S& n/ k9 v1 N3 E) |8 m1 Rresponsible for the early activation of the hypothal-
1 a1 h4 f9 s! Bamic pituitary gonadal axis.1-3 Thus, greater empha-
# Y2 D1 t! d& r0 @$ J; L# Esis has been given to neuroradiologic imaging in
2 s7 Z$ i+ {7 z* s$ o/ Y0 _boys with precocious puberty. In addition to viril-
& M+ x$ W6 ~1 B2 {ization, the clinical hallmark of CPP is the symmet-9 \* Q6 Q# ~( g% K: [; {7 W
rical testicular growth secondary to stimulation by1 C5 ~4 a$ q9 x7 J5 U. ^) P+ r3 ?
gonadotropins.1,31 ~. P4 K- Q; f7 M
Gonadotropin-independent peripheral preco-' U, U: m+ ?: [: B( Y, \* u
cious puberty in boys also results from inappropriate2 Y: m3 t, g2 `! E
androgenic stimulation from either endogenous or' D7 g* J5 p+ t; p
exogenous sources, nonpituitary gonadotropin stim-9 R) z' @4 w- L
ulation, and rare activating mutations.3 Virilizing
( U U; p, n5 b/ @congenital adrenal hyperplasia producing excessive
9 F5 `( M, |# uadrenal androgens is a common cause of precocious
0 K5 x# N5 B; C- j! d' p. opuberty in boys.3,4
# m* m n3 U3 m8 `3 H3 s5 SThe most common form of congenital adrenal9 S: W# \1 {2 ]8 H
hyperplasia is the 21-hydroxylase enzyme deficiency.
' M& P# { `( L* N4 hThe 11-β hydroxylase deficiency may also result in
& |5 w! _) H5 F j) w Hexcessive adrenal androgen production, and rarely,1 z1 ]( D+ `; R
an adrenal tumor may also cause adrenal androgen
9 e, Y( M1 X' i) F# R% zexcess.1,3, j, U- y2 x t, l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. {% Y) s+ K6 U! C$ P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" D! \7 c; I* A: D* ~4 o0 Z% JA unique entity of male-limited gonadotropin-
0 v% Y( u& G* t2 P2 K- ]5 l% ~independent precocious puberty, which is also known) L5 ]# h: C1 z" K1 j
as testotoxicosis, may cause precocious puberty at a B* H1 W8 _, t* O5 _& C. h
very young age. The physical findings in these boys
( @ P2 A G( y; `4 P( Nwith this disorder are full pubertal development,$ A4 z2 `5 z7 o4 Q* U1 L9 C# _
including bilateral testicular growth, similar to boys
: ^# R. M3 [1 Kwith CPP. The gonadotropin levels in this disorder( Z7 M% b* L' q8 c
are suppressed to prepubertal levels and do not show
& j1 p u9 W# X, s( p1 Opubertal response of gonadotropin after gonadotropin-
5 J/ d+ h" E, O/ W" m6 lreleasing hormone stimulation. This is a sex-linked
0 f: d, O' [9 p0 o& g- C# H5 C: Wautosomal dominant disorder that affects only
3 h7 E# N V: x9 I* t& t( r; omales; therefore, other male members of the family: c$ ]* f, q2 v
may have similar precocious puberty.3
7 O" B# R. |- W aIn our patient, physical examination was incon-; ~- _# p/ w9 b* _9 z( y4 Y
sistent with true precocious puberty since his testi-. N6 ~2 w% `8 [. d* b" z/ z
cles were prepubertal in size. However, testotoxicosis; v' A; }$ U( t0 f
was in the differential diagnosis because his father. f1 k" q' x1 r S* c- Q
started puberty somewhat early, and occasionally,+ p5 ~( A: a4 ^( P1 o S+ P
testicular enlargement is not that evident in the
; h) O+ u# U" d# sbeginning of this process.1 In the absence of a neg-( S3 z) @ W+ h
ative initial history of androgen exposure, our
. J( b8 d# J" }8 {! H% Abiggest concern was virilizing adrenal hyperplasia,
$ d6 J9 m" e9 [; u! |' ceither 21-hydroxylase deficiency or 11-β hydroxylase# d7 v- z) ]5 d0 _3 j k7 S
deficiency. Those diagnoses were excluded by find-3 |: P/ d2 z' R1 C" L+ {+ b$ M/ d
ing the normal level of adrenal steroids.
2 J; `0 l; N% L$ A" D; gThe diagnosis of exogenous androgens was strongly
: _ D0 @/ ^* B# l) m. W. jsuspected in a follow-up visit after 4 months because' P/ _8 ?& q: W4 T3 N
the physical examination revealed the complete disap-
6 \& I# Y' D# K6 tpearance of pubic hair, normal growth velocity, and
3 a) i6 w! G x4 M! Bdecreased erections. The father admitted using a testos-/ I, K# s5 u) P
terone gel, which he concealed at first visit. He was% h# \; N, y6 x' t7 `* Z
using it rather frequently, twice a day. The Physicians’
, V7 N4 s3 x8 k8 RDesk Reference, or package insert of this product, gel or# `$ \* ]5 `' y6 B& b% j) ]" y3 [
cream, cautions about dermal testosterone transfer to
; N, i- w: {( [unprotected females through direct skin exposure.
' l% {& y# O3 x: J) h( r$ Z g( T; S9 qSerum testosterone level was found to be 2 times the0 I$ M" z7 t. P ~; G
baseline value in those females who were exposed to0 L6 t/ {. v+ \) `% I9 K& z
even 15 minutes of direct skin contact with their male
9 P {5 i' @0 `! x2 K* p, T/ mpartners.6 However, when a shirt covered the applica-
{1 ?9 [7 t2 P1 T9 Ition site, this testosterone transfer was prevented.
& z2 r# a+ W4 DOur patient’s testosterone level was 60 ng/mL,: `7 d, P% F% p5 C3 W
which was clearly high. Some studies suggest that
0 k' q2 u9 T0 l( @8 ]dermal conversion of testosterone to dihydrotestos-
1 @( {* w% \ a1 ]/ gterone, which is a more potent metabolite, is more
4 h7 r3 N) x! k4 l: factive in young children exposed to testosterone
2 E; v4 r! C4 ?: D8 \3 Q3 b3 i7 {$ K+ Qexogenously7; however, we did not measure a dihy-& C* ~2 D" T8 K' X
drotestosterone level in our patient. In addition to
6 [# v$ F9 h& Q6 u1 v* a6 Q; vvirilization, exposure to exogenous testosterone in
: e9 C8 O# h& s2 @" O0 o6 Rchildren results in an increase in growth velocity and/ J; n" F% x6 Z8 d& x
advanced bone age, as seen in our patient.$ N% r8 V" `" o8 ^" ~ E1 G
The long-term effect of androgen exposure during
3 V" p! b/ }+ E! ?% D; cearly childhood on pubertal development and final- S9 o+ P! t1 o! l ^. @
adult height are not fully known and always remain
/ X9 O! [0 H, T2 n+ `; Xa concern. Children treated with short-term testos-* Z- W+ j/ p- ]/ {: D( T2 \. a
terone injection or topical androgen may exhibit some' _, b9 j# K: ?5 ?0 @
acceleration of the skeletal maturation; however, after
; i# A! ?) B! D9 gcessation of treatment, the rate of bone maturation
$ h( k) R. _% p. ^, p! F+ @4 g0 Ndecelerates and gradually returns to normal.8,93 q" g- G( X$ S. n. N
There are conflicting reports and controversy
/ k. b( e$ n2 o- i- O# D& W+ pover the effect of early androgen exposure on adult
9 q# p% n! e, Apenile length.10,11 Some reports suggest subnormal. q5 u( z( Z5 g# ^9 X; }) ]
adult penile length, apparently because of downreg-! q4 W6 m9 }0 ~- P
ulation of androgen receptor number.10,12 However,
% J) _4 x- _0 A) RSutherland et al13 did not find a correlation between
) Q c' a( V' X2 Z& g4 E5 Achildhood testosterone exposure and reduced adult# a! i/ A9 |7 `9 z9 X2 ~
penile length in clinical studies.4 d8 }8 ~3 m4 f! j+ a y1 z' w# A: z
Nonetheless, we do not believe our patient is
3 }1 L# y+ B- N5 e7 @going to experience any of the untoward effects from$ ?& u6 K4 W, o' e; \; v" o5 }
testosterone exposure as mentioned earlier because- Y, N& |( m2 B. I
the exposure was not for a prolonged period of time.
% p! Z' d: Y/ A' m, k$ JAlthough the bone age was advanced at the time of
/ ?+ j5 I, w" W: P0 m7 cdiagnosis, the child had a normal growth velocity at9 @4 j+ n, M- G- z' h
the follow-up visit. It is hoped that his final adult' ]. v: b( J9 N7 F0 @8 n, v' a' r
height will not be affected.
6 H# W) F) f/ j* e O0 AAlthough rarely reported, the widespread avail-$ S: p" \* P2 d( p: u0 ~/ y$ A
ability of androgen products in our society may
4 U/ _8 H) w2 @2 {' V+ Hindeed cause more virilization in male or female6 H5 y: V8 C5 e- L
children than one would realize. Exposure to andro-
: o8 E' a; P0 @; A' A0 S i3 E" _gen products must be considered and specific ques-# U z2 K4 O4 I: d
tioning about the use of a testosterone product or5 P% K( [! Q( v
gel should be asked of the family members during' k0 V& O/ r& U
the evaluation of any children who present with vir-6 B- l. Z( O+ L2 G! C0 C- [4 |
ilization or peripheral precocious puberty. The diag-
, n) F" x. c& x8 a h/ [nosis can be established by just a few tests and by
' y6 r3 l: @. Eappropriate history. The inability to obtain such a
0 m, J$ q1 q/ Phistory, or failure to ask the specific questions, may P, W: M O5 k) i
result in extensive, unnecessary, and expensive
" K/ U8 h* b% t- rinvestigation. The primary care physician should be
2 ?+ C% L3 F3 }- X' Q6 p5 h( Maware of this fact, because most of these children: w$ F6 b3 G$ p6 {7 q# x3 j" ^
may initially present in their practice. The Physicians’
8 q9 j5 z* i% P1 I# U8 z2 KDesk Reference and package insert should also put a$ P M* q! d3 q- n9 ^, o) e1 N
warning about the virilizing effect on a male or
% v. r% [" H$ j4 rfemale child who might come in contact with some-
6 B; \% l+ V! S4 mone using any of these products./ K$ v6 ]6 g4 n
References
; s' L9 Z: V1 K W. P$ {$ k, l4 c$ S1. Styne DM. The testes: disorder of sexual differentiation0 C4 k8 D8 S! u' w
and puberty in the male. In: Sperling MA, ed. Pediatric
$ S' R8 S j" a+ { t) x. E% f( UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 F' o; d. w0 w L: s2002: 565-628.
* A* B$ }$ U3 N M& B8 `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ V5 i- {; P' T4 O/ ~0 u) vpuberty in children with tumours of the suprasellar pineal |
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