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Sexual Precocity in a 16-Month-Old2 B& D1 j. C8 {, S: [7 ~$ N
Boy Induced by Indirect Topical% j# S: l5 {+ G, N0 [
Exposure to Testosterone
$ }. z! M$ j5 g* cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; s. H2 D3 U8 D
and Kenneth R. Rettig, MD1
3 n" L8 a( W/ _Clinical Pediatrics
% l7 I, `$ k" |! r' t" p1 g3 WVolume 46 Number 6
* @& R: u0 P k) ?# }& n/ K( x" OJuly 2007 540-543" P7 f% }4 ?5 o: [/ ` ?
© 2007 Sage Publications
2 S% }& K6 P; Y- t3 c1 u0 |2 |! i10.1177/0009922806296651$ b% D0 a4 u! Y: O/ v6 L( o
http://clp.sagepub.com
5 t& A$ v3 `+ }3 O: h8 bhosted at
, R; _8 J/ [, G+ l; C/ t$ X, J2 Shttp://online.sagepub.com
4 e' E% j+ M) F: L! k$ aPrecocious puberty in boys, central or peripheral,5 @& O+ a0 e0 Q
is a significant concern for physicians. Central, N6 \' t5 K9 ], P2 ^' b! b1 C
precocious puberty (CPP), which is mediated
$ E5 K, k! \* B6 u% y, wthrough the hypothalamic pituitary gonadal axis, has
; S3 X' m, @ \a higher incidence of organic central nervous system( n7 c0 f9 O$ x' }+ z, N, h; @' W1 G( u
lesions in boys.1,2 Virilization in boys, as manifested) W6 `7 X) C G4 X5 h2 W3 O
by enlargement of the penis, development of pubic
5 ]5 B' w0 {' N& w" b5 D( M5 X) khair, and facial acne without enlargement of testi- i9 V8 A3 B" d# B/ [+ g
cles, suggests peripheral or pseudopuberty.1-3 We
9 W) O5 e3 O5 [ U- g' R" V6 u: q. q% ]report a 16-month-old boy who presented with the+ D7 S. ^8 R$ q- l4 N. U
enlargement of the phallus and pubic hair develop-
3 N( f! v0 S0 c; V6 z' T" F( rment without testicular enlargement, which was due
6 f4 ]7 o, r0 f9 G) O( bto the unintentional exposure to androgen gel used by) X: J8 v% K6 d; R
the father. The family initially concealed this infor-, f% S- z$ `) t5 p4 O/ f. l2 ?
mation, resulting in an extensive work-up for this
2 V- w# O+ q w uchild. Given the widespread and easy availability of
$ Z$ }) @; c4 o! w4 V# @testosterone gel and cream, we believe this is proba-
9 {& V5 `4 i$ o0 K" g/ g8 }" nbly more common than the rare case report in the
$ E/ P* W& i9 Wliterature.4
; p4 u: O1 q& T7 \Patient Report
' M8 ]* r; K& fA 16-month-old white child was referred to the+ s0 A _) L7 d* j! `" ^, P
endocrine clinic by his pediatrician with the concern
: n+ F/ D& {1 Gof early sexual development. His mother noticed
3 J, ^& i5 _$ `0 Jlight colored pubic hair development when he was5 H \+ d t" m0 X) r
From the 1Division of Pediatric Endocrinology, 2University of
; o! L' }( _) ISouth Alabama Medical Center, Mobile, Alabama.
+ u2 e0 e; |% ]7 q0 O7 k3 CAddress correspondence to: Samar K. Bhowmick, MD, FACE,( y( E, f0 B1 A0 Z
Professor of Pediatrics, University of South Alabama, College of
1 B) @* ]" @/ o+ R$ b) E( {( EMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) O# i3 b' S3 x: ue-mail: [email protected].% y9 ^# W1 f- b' z
about 6 to 7 months old, which progressively became
9 n( ~# x/ _: I3 O( adarker. She was also concerned about the enlarge-) x* q' p4 w# G' _" W
ment of his penis and frequent erections. The child
9 i E: U4 ]& Iwas the product of a full-term normal delivery, with' b8 ^6 m$ P: \& k- h
a birth weight of 7 lb 14 oz, and birth length of) h% `* D, y" l+ q" I9 L
20 inches. He was breast-fed throughout the first year7 b% B0 i+ n+ k- F8 W+ V
of life and was still receiving breast milk along with- e3 S5 R+ T5 ?% B' p7 u
solid food. He had no hospitalizations or surgery,
; ?6 q) X( e: Z- ^" R& u# zand his psychosocial and psychomotor development
* {$ \6 S$ [" Z. S; jwas age appropriate.% Q; f; c, v/ R9 V
The family history was remarkable for the father,
1 y2 J, v( }$ ]2 n; K6 M& i2 Vwho was diagnosed with hypothyroidism at age 16,* J9 W4 L9 L$ `! l( n% t9 T
which was treated with thyroxine. The father’s
) E# n5 \9 ?; i* Jheight was 6 feet, and he went through a somewhat
. P7 w4 a: ]7 [- l6 L; I. h/ K# yearly puberty and had stopped growing by age 14.
) o; `4 a; N9 A: YThe father denied taking any other medication. The
5 c9 {. Q4 R' v0 ], u+ _: rchild’s mother was in good health. Her menarche9 V& t9 h5 W2 H4 I/ Q/ j0 [
was at 11 years of age, and her height was at 5 feet+ c1 d4 o: }/ N( X0 Y# R
5 inches. There was no other family history of pre-
9 w+ Y5 _6 k& U) @/ s ?4 Hcocious sexual development in the first-degree rela-
5 B+ i1 {6 E1 P: u+ e' |tives. There were no siblings.2 ~0 o: h& l) {2 Q: }
Physical Examination6 g/ S) _/ v; z
The physical examination revealed a very active,; c1 D4 i) V( M
playful, and healthy boy. The vital signs documented& ]. K1 @' ~# \" t
a blood pressure of 85/50 mm Hg, his length was. p5 s: r! C' G4 _: X3 r. x
90 cm (>97th percentile), and his weight was 14.4 kg
K) ?2 K" t$ c6 h o- s1 }8 h(also >97th percentile). The observed yearly growth7 z1 _9 L% b; h9 J
velocity was 30 cm (12 inches). The examination of
3 T S' W' d4 rthe neck revealed no thyroid enlargement.. }" {0 ^0 [0 v
The genitourinary examination was remarkable for+ Q6 ]) ~* w0 i7 A' M/ e
enlargement of the penis, with a stretched length of2 |- T3 U" ]: a& X( C8 x) w' ]
8 cm and a width of 2 cm. The glans penis was very well9 K' C! }% W; L+ T7 C1 Q3 \
developed. The pubic hair was Tanner II, mostly around
4 k; d; L C s1 j5 x# q5408 t8 \4 z8 @8 o- w% m1 Q1 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ r" K- K: ~3 }% C5 l1 `7 Q
the base of the phallus and was dark and curled. The
6 {$ J* p ~# H3 T, ?testicular volume was prepubertal at 2 mL each.
0 t0 [4 ]. G- f* pThe skin was moist and smooth and somewhat, W- [$ X7 Y! G
oily. No axillary hair was noted. There were no v! Y0 Y5 y$ Z! e
abnormal skin pigmentations or café-au-lait spots.
: M+ Z" X3 b# INeurologic evaluation showed deep tendon reflex 2+
* g+ t- r& U5 _0 G3 W* ~& g, \bilateral and symmetrical. There was no suggestion
) r: V+ P0 v) f( S3 Dof papilledema.7 W; \/ j6 Y7 N& l
Laboratory Evaluation
l6 r- E4 o3 ]1 XThe bone age was consistent with 28 months by
7 h2 i8 ?6 m) l% F) C1 Z& A8 Xusing the standard of Greulich and Pyle at a chrono-6 U; p2 O3 p6 I3 B) F4 O1 K% V4 q
logic age of 16 months (advanced).5 Chromosomal5 l( [' E; H2 H2 K6 `
karyotype was 46XY. The thyroid function test# g: Y7 P9 e6 J: h) [6 l) N. V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
& g% [ J% j! f* m- ?lating hormone level was 1.3 µIU/mL (both normal).# ]% r) |8 d6 ?0 ?; m4 @
The concentrations of serum electrolytes, blood
' ~5 Q: _4 ?# xurea nitrogen, creatinine, and calcium all were
1 G" m. r8 C+ ~! }0 Gwithin normal range for his age. The concentration
& W3 C+ S6 ~4 N% H \& X3 Z* xof serum 17-hydroxyprogesterone was 16 ng/dL
/ `2 N! J c! {$ B, w2 g' a(normal, 3 to 90 ng/dL), androstenedione was 20
* \" q% \0 `/ Y# K# Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ K3 h4 v3 k6 m4 ^0 Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 k; k/ t1 |9 B) X# _# X2 e! k$ a- [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ a& a2 u+ S6 D% u49ng/dL), 11-desoxycortisol (specific compound S)0 q. O, j7 i& w6 N+ N x. {
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ \& v" O, w6 N' b5 a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# C; T3 ^) ?/ H2 r7 h7 c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 ~- Q) I" K1 P2 x7 `2 w: q3 P
and β-human chorionic gonadotropin was less than
% s( F% r, Y6 O- ~8 s7 H5 mIU/mL (normal <5 mIU/mL). Serum follicular
) x4 L9 w) f9 |stimulating hormone and leuteinizing hormone( S. Z' p7 K8 f
concentrations were less than 0.05 mIU/mL0 {; z1 P O, \) V
(prepubertal).
" t3 R0 O% \: z' @" n0 }, ^4 }The parents were notified about the laboratory" X) {/ ~8 B. H$ c1 z
results and were informed that all of the tests were( U. k9 K/ W! Y! r0 Q; s
normal except the testosterone level was high. The1 }6 ?, N5 z# F1 ?4 Y' \7 j
follow-up visit was arranged within a few weeks to; h- Y1 R# ~+ s2 D( D. n6 g; _9 h
obtain testicular and abdominal sonograms; how-7 w- l; x4 _2 s; T
ever, the family did not return for 4 months.! U, s- N/ q6 b% I7 c
Physical examination at this time revealed that the
8 d' ]. r! o0 V" K. Pchild had grown 2.5 cm in 4 months and had gained
5 A4 r& r/ ^& u! t2 kg of weight. Physical examination remained( `) `, P( H. _2 i
unchanged. Surprisingly, the pubic hair almost com-6 _2 O3 f5 i! I" m4 ^$ o
pletely disappeared except for a few vellous hairs at
; I G B1 \1 |4 Z; t1 C% k% Dthe base of the phallus. Testicular volume was still 2
2 a% n! w6 z; r/ z: q mmL, and the size of the penis remained unchanged.' {* d. Z0 P" @
The mother also said that the boy was no longer hav-/ b3 S9 Y* r" N4 l! B3 l: t; {
ing frequent erections.0 J. z9 n1 R9 A4 c3 _& _3 P1 l7 O
Both parents were again questioned about use of6 z/ {2 X7 R6 Z& E
any ointment/creams that they may have applied to# h8 \. S( J1 G, q
the child’s skin. This time the father admitted the
0 \+ n6 ?- ~1 wTopical Testosterone Exposure / Bhowmick et al 541) i% x/ |6 }2 G, R% g
use of testosterone gel twice daily that he was apply-) i D$ l f2 p, @
ing over his own shoulders, chest, and back area for4 ^6 s, t2 E$ J
a year. The father also revealed he was embarrassed" w, G* T' e% d6 H) v, I3 t& ^
to disclose that he was using a testosterone gel pre-# @% l" h/ w! I1 n: K! e
scribed by his family physician for decreased libido% }$ o& j% k0 z5 ], D( a
secondary to depression.* b. `' H/ h1 c2 _4 n
The child slept in the same bed with parents.
3 @+ ~! |9 G1 w& U! W3 |" o1 l/ ^The father would hug the baby and hold him on his
2 a+ V' q* Q3 n# L, y. ^+ achest for a considerable period of time, causing sig-
. a! e7 [1 _- W. f' W$ ^# enificant bare skin contact between baby and father.7 j; u% `. F, z q! E# c$ u) O% x
The father also admitted that after the phone call,
0 G2 g4 d$ p( z+ e8 W" r) J) }when he learned the testosterone level in the baby
% N3 X: g: g c6 |: I7 D8 f0 Vwas high, he then read the product information* U/ m# L0 x3 ~9 l
packet and concluded that it was most likely the rea-2 u/ V4 ^4 i/ Q, B& r
son for the child’s virilization. At that time, they
( o `- N. H) Odecided to put the baby in a separate bed, and the
. g* f6 y- E4 Ifather was not hugging him with bare skin and had" n6 F6 | j* y1 d8 X
been using protective clothing. A repeat testosterone! x$ I- {# o" X- }0 D
test was ordered, but the family did not go to the
?) N1 T; y) @' J6 f) Alaboratory to obtain the test.
. b0 f) R; r5 { @Discussion
7 u$ d9 u0 x8 _7 p2 JPrecocious puberty in boys is defined as secondary' Z3 L& L# k' F2 e7 b
sexual development before 9 years of age.1,4
: G# n/ F7 g2 s7 oPrecocious puberty is termed as central (true) when# l1 ]& h! C- \
it is caused by the premature activation of hypo-
! P/ F* N" P- t3 I: vthalamic pituitary gonadal axis. CPP is more com-
) T2 i* V8 U+ \5 o3 _mon in girls than in boys.1,3 Most boys with CPP/ ~* ]5 T0 l, n1 p( r
may have a central nervous system lesion that is
6 Q* E) v& Q3 U) G$ Y [" Y. _responsible for the early activation of the hypothal-1 G- K+ [, \. y5 }3 j$ U
amic pituitary gonadal axis.1-3 Thus, greater empha-
v: O* f5 a, }; R" _. ]: u3 ^sis has been given to neuroradiologic imaging in. a6 x7 h4 y G1 d
boys with precocious puberty. In addition to viril-8 A5 u/ v _1 H# v4 h: d7 A
ization, the clinical hallmark of CPP is the symmet-
4 s2 z* I9 \9 q Krical testicular growth secondary to stimulation by+ I( K# J/ [4 M
gonadotropins.1,3
1 f/ `+ o6 E' j1 |7 k: TGonadotropin-independent peripheral preco-
. |7 g J. z, a2 \2 ^+ N5 hcious puberty in boys also results from inappropriate
K, u1 B# M+ h" z3 |1 _androgenic stimulation from either endogenous or7 l7 p# t9 e& u: Y6 N; E# [9 |
exogenous sources, nonpituitary gonadotropin stim-
' m7 B! m& ]! W& a7 mulation, and rare activating mutations.3 Virilizing
" u2 E ]+ K) |' N4 E$ Q( c' Scongenital adrenal hyperplasia producing excessive4 \7 F7 s! _5 ]; h* w
adrenal androgens is a common cause of precocious
( |! M. h. X% Opuberty in boys.3,4# L0 t6 ~0 W/ k# j9 t
The most common form of congenital adrenal
D; U( y7 ^) w& x; V$ ^/ Y5 mhyperplasia is the 21-hydroxylase enzyme deficiency.$ b" X/ g& P' S. z+ _
The 11-β hydroxylase deficiency may also result in5 a3 M X" J. F* x! Y
excessive adrenal androgen production, and rarely,. z; n6 o3 [) R
an adrenal tumor may also cause adrenal androgen2 {. c0 c' c, }+ {" U" v" o
excess.1,3; `+ d! n0 s" ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ c: X9 C0 u: k7 @: s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ r1 [& Q% u+ a5 c) f' y
A unique entity of male-limited gonadotropin- p: K- ^; g) J! c1 K$ f) Y3 Y* j
independent precocious puberty, which is also known
% h% _- D! R( Z) ~# Yas testotoxicosis, may cause precocious puberty at a
M' W4 q/ e" v' k- g0 ~very young age. The physical findings in these boys O5 L4 \* s$ d, f0 X
with this disorder are full pubertal development,
0 k9 |9 m( G$ \* v4 U" w E- zincluding bilateral testicular growth, similar to boys
. }3 y+ `. ^% K1 O Iwith CPP. The gonadotropin levels in this disorder8 h3 ^" p, M& G) s
are suppressed to prepubertal levels and do not show
; Q1 U0 ]7 A$ d3 Y' d8 `pubertal response of gonadotropin after gonadotropin-: a7 {7 f; [$ g; C: \# C
releasing hormone stimulation. This is a sex-linked# m0 y1 c# O# f; e& l2 x' G Q
autosomal dominant disorder that affects only
% J h ?( u, E; Pmales; therefore, other male members of the family8 \9 \" u B4 O' {# b
may have similar precocious puberty.3
1 W6 x% J. p( b$ S" ?In our patient, physical examination was incon-
% m+ \+ _0 r8 @( w( \sistent with true precocious puberty since his testi-
& s* O2 p( }1 ucles were prepubertal in size. However, testotoxicosis0 G) Q- q! a. C9 L1 E3 C3 ]+ `
was in the differential diagnosis because his father; v( O% U5 U6 w! F* ]- a
started puberty somewhat early, and occasionally,/ ~) n% M( w# x6 |( n
testicular enlargement is not that evident in the1 Y( _1 Y3 S, ?
beginning of this process.1 In the absence of a neg-' k% _3 e8 @* h
ative initial history of androgen exposure, our) `" P* e4 j% \
biggest concern was virilizing adrenal hyperplasia,
3 H' d3 D1 i& ^6 w! _: F" r7 i( ^2 Qeither 21-hydroxylase deficiency or 11-β hydroxylase% c4 h7 a' H+ w3 Q
deficiency. Those diagnoses were excluded by find-
. |2 p2 S! u5 S( x& S) c& @ing the normal level of adrenal steroids.
, F* n- {2 W: m9 q* L7 W! QThe diagnosis of exogenous androgens was strongly
" Y) E" c. L' E6 F" M xsuspected in a follow-up visit after 4 months because- E Y* v4 |; C2 ~6 D
the physical examination revealed the complete disap-' j4 F+ l7 ^) S3 m5 |+ v! C) V
pearance of pubic hair, normal growth velocity, and
* c* x% v( _8 o( ^# bdecreased erections. The father admitted using a testos-. s# `& j! B) p# n) c0 O7 K
terone gel, which he concealed at first visit. He was; E0 {/ I+ T) Y- |# @1 a7 T l$ M. c
using it rather frequently, twice a day. The Physicians’3 q( W7 e; j$ ^" G5 B
Desk Reference, or package insert of this product, gel or0 M1 k* S' D- V' ]$ o/ i2 G
cream, cautions about dermal testosterone transfer to! R. k7 R7 A2 A8 w* r
unprotected females through direct skin exposure.
+ |) F# G$ p& e fSerum testosterone level was found to be 2 times the6 ~, ~* M$ L z. d
baseline value in those females who were exposed to
0 a- t J+ q3 w; m" m- Jeven 15 minutes of direct skin contact with their male
' j% N9 @" [- ~) v3 Hpartners.6 However, when a shirt covered the applica-; N$ c& h, {4 D/ R
tion site, this testosterone transfer was prevented.. k- ~, j( s* Z
Our patient’s testosterone level was 60 ng/mL,
4 X/ g# k4 z6 ^which was clearly high. Some studies suggest that# Q# h# G! X- M2 u' @$ M
dermal conversion of testosterone to dihydrotestos-2 P! \; n- ~. m% `8 M) C$ e
terone, which is a more potent metabolite, is more
% `0 ?: |9 M/ C8 C) K/ {active in young children exposed to testosterone9 Y7 n5 S! A- d6 y/ W6 Q l
exogenously7; however, we did not measure a dihy-, J; ~8 ], ]+ V. w" E' l+ x+ S7 h
drotestosterone level in our patient. In addition to" C* v$ |. v `. f
virilization, exposure to exogenous testosterone in
; G8 O7 p2 O' M! P( |children results in an increase in growth velocity and
8 m" w0 \. M9 `- H0 Hadvanced bone age, as seen in our patient.
, v& s3 F( U4 O* \" aThe long-term effect of androgen exposure during+ m; C; x- O1 x3 r1 c- i
early childhood on pubertal development and final. e0 l) K- [1 l# _/ X
adult height are not fully known and always remain
) A: r# B& o/ o, Ka concern. Children treated with short-term testos-
' ~. j$ {3 Y' Mterone injection or topical androgen may exhibit some
. q, b+ r6 c/ k- X! z9 ]" m! Racceleration of the skeletal maturation; however, after4 {1 S& f) \6 i( D
cessation of treatment, the rate of bone maturation
" p! h6 h9 n! ]* r. J. b p4 ^decelerates and gradually returns to normal.8,9
+ W$ n3 @$ h, Z; H0 R0 f9 O* L3 P! z, tThere are conflicting reports and controversy5 @: `* L) r: b( z" x0 \( c# Z
over the effect of early androgen exposure on adult; h* H# j$ t& i- Q, W) o
penile length.10,11 Some reports suggest subnormal& t" t, {: X$ g1 [
adult penile length, apparently because of downreg-
$ |) m2 F& f/ l7 r5 u1 ?+ R0 i$ z6 bulation of androgen receptor number.10,12 However,
/ r( y# g8 ]* }$ w' x, x* |8 CSutherland et al13 did not find a correlation between
$ J5 }- @4 g8 o% y6 {childhood testosterone exposure and reduced adult+ z8 [! u4 ?3 a% D" ^- E
penile length in clinical studies.
" g) n9 h; _$ k, l5 P u' UNonetheless, we do not believe our patient is }* k8 j( f- ?" K' K8 _. E; N
going to experience any of the untoward effects from
7 w+ \% \) L- d, Rtestosterone exposure as mentioned earlier because
+ Y7 r# y; Q( T1 o9 Z; P; s" s [the exposure was not for a prolonged period of time.# r" D; o. q. p/ o- S# I5 C# w
Although the bone age was advanced at the time of% @5 Z s+ b r% i' |) I' Y& G }5 T
diagnosis, the child had a normal growth velocity at
! F) q' A/ T* W2 ~/ J9 V, Kthe follow-up visit. It is hoped that his final adult
' ]0 j$ D+ Y8 g3 ~6 O1 R$ Mheight will not be affected.
Q8 `+ \; h" J4 x: R2 DAlthough rarely reported, the widespread avail-
: B0 p* q+ N% g8 r& E. Qability of androgen products in our society may
) d/ M' U) a1 `# X& x5 L6 ?indeed cause more virilization in male or female+ m8 E4 d% B( p' v# S
children than one would realize. Exposure to andro-
, A5 x9 p3 Y0 G, qgen products must be considered and specific ques-
6 R7 S) I0 ^! R9 Y. z& n/ _( xtioning about the use of a testosterone product or
- E V+ \; {4 F- T ygel should be asked of the family members during Y9 G/ _2 V$ Z5 k9 C
the evaluation of any children who present with vir-8 M8 L: V2 j# ^( X9 L
ilization or peripheral precocious puberty. The diag-
7 t# q. I- ~2 Inosis can be established by just a few tests and by
1 i2 i8 ]1 N" x, y& f; q7 ]: {appropriate history. The inability to obtain such a
/ g$ F" ~# W8 V3 G: V- h5 I8 \history, or failure to ask the specific questions, may( E5 f1 g$ g; [ Z
result in extensive, unnecessary, and expensive
% B( G( k+ ^) j. ]+ w; |investigation. The primary care physician should be4 d4 \! V9 a9 u/ o" H. x
aware of this fact, because most of these children
- T) S3 O8 A. l7 |may initially present in their practice. The Physicians’* S9 H, O2 T- s$ _. v" o6 U
Desk Reference and package insert should also put a) |. c3 ^5 e; i5 K) g8 a, u) }1 J4 g
warning about the virilizing effect on a male or$ Z- h" I1 i1 ?( [
female child who might come in contact with some-# H) s; w7 P9 V2 `$ R, v, r
one using any of these products.
. b. B7 H- F1 n" l* VReferences: d; \8 n4 {7 {* x9 d7 ~
1. Styne DM. The testes: disorder of sexual differentiation
, V) I/ D8 P5 j# t6 ]( r" \, Band puberty in the male. In: Sperling MA, ed. Pediatric
* w* w! s7 Q2 B' p% [$ @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 H) |* S# T$ M/ w0 k2002: 565-628.1 Y5 O" y o' x( t' b3 l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" C7 ^: `$ \ D% i7 V7 G; y* \
puberty in children with tumours of the suprasellar pineal |
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