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Sexual Precocity in a 16-Month-Old2 R7 i# W. D+ O7 s2 V' H
Boy Induced by Indirect Topical
& T1 [: \: r( |; RExposure to Testosterone
" ^9 c- ?' s. [0 O+ F9 |4 \Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 o: @+ ?, J' F
and Kenneth R. Rettig, MD1
3 H, P, t R$ e& T1 iClinical Pediatrics! _5 Q8 `. B) @( i% ?4 Z
Volume 46 Number 6) `% n. I" L2 o$ o! q, v' f7 y1 G
July 2007 540-543
' o" J4 d) }* b1 W/ r! |/ Q& K© 2007 Sage Publications
# [, T; K: n$ l10.1177/0009922806296651/ q" B* Y1 L b3 a2 I$ S
http://clp.sagepub.com+ D) C+ w# r, e9 t5 e! U
hosted at
/ r, a. x' \1 c; A" u" ^" z: Nhttp://online.sagepub.com
& P4 }% Z. T/ G7 g; M9 { @Precocious puberty in boys, central or peripheral,
5 E0 }" P9 x9 ~! [is a significant concern for physicians. Central, b7 m: Q4 z; s, o
precocious puberty (CPP), which is mediated, o, B" K: R4 _
through the hypothalamic pituitary gonadal axis, has/ P( _3 \) o5 \( G1 c
a higher incidence of organic central nervous system4 m& o8 @, o9 o) |& @
lesions in boys.1,2 Virilization in boys, as manifested
9 P) r( o4 F2 R1 Y# q3 ]" i! gby enlargement of the penis, development of pubic% y2 S$ T# u. [0 H- R& H
hair, and facial acne without enlargement of testi-* r7 X, ?. x$ F" E
cles, suggests peripheral or pseudopuberty.1-3 We
" _2 j# j( Q+ X, F& Kreport a 16-month-old boy who presented with the
# M6 O- A0 P7 Uenlargement of the phallus and pubic hair develop-) {9 d5 E! {) H" p5 x r+ i6 F0 g
ment without testicular enlargement, which was due
" V: A9 t8 C8 lto the unintentional exposure to androgen gel used by
! a. l7 s7 D6 U' ^the father. The family initially concealed this infor-
" X8 ?! t# \, E0 V3 ~" J- emation, resulting in an extensive work-up for this$ v5 u3 U, T7 f Z! {
child. Given the widespread and easy availability of
7 J# q2 E- |1 D2 W, k2 Utestosterone gel and cream, we believe this is proba-
" R) j1 b `* sbly more common than the rare case report in the
: T8 i2 h! V! ]8 P9 u* qliterature.4
2 J/ Y. l1 _9 TPatient Report
, C! M7 \0 F% A8 C5 {& yA 16-month-old white child was referred to the
3 Z ~1 I6 _! }- b' ~endocrine clinic by his pediatrician with the concern. W5 I% o+ r$ X& d$ t
of early sexual development. His mother noticed
/ g: {. r+ x" w6 Ylight colored pubic hair development when he was
6 F9 k: Q( {/ z+ z! Z0 p& \3 ?From the 1Division of Pediatric Endocrinology, 2University of
+ r$ I8 l/ F# h& E6 e" t. m" HSouth Alabama Medical Center, Mobile, Alabama.
1 I% p: Z$ ?2 B, C- T) F3 LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' X; [) t* m' @: f0 {1 J& `Professor of Pediatrics, University of South Alabama, College of9 e: w6 x0 a' b, Z" d8 ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! h: d w1 _+ _
e-mail: [email protected].5 a6 O' ]1 Y* T/ [- G+ k
about 6 to 7 months old, which progressively became) `4 N+ t; v2 P6 `
darker. She was also concerned about the enlarge-% I* R/ G2 p2 _
ment of his penis and frequent erections. The child
+ D7 N# {# g5 H E) e' c7 A( jwas the product of a full-term normal delivery, with
( ^" M. X/ z/ I9 W4 [a birth weight of 7 lb 14 oz, and birth length of5 Y {4 Z- ~# j$ H5 V3 G
20 inches. He was breast-fed throughout the first year
+ l' M$ T! t" @% bof life and was still receiving breast milk along with$ w: Q! T4 h) L
solid food. He had no hospitalizations or surgery,0 ?9 u% a( c4 b- g! n
and his psychosocial and psychomotor development) T g/ N1 ^/ Q7 t* j/ @! o2 j. t
was age appropriate.8 S$ Y8 K. v# {: V% A" S9 c
The family history was remarkable for the father,
2 J+ q2 W6 A* ~. R0 gwho was diagnosed with hypothyroidism at age 16,
) N2 w. }1 h) Q5 ~which was treated with thyroxine. The father’s# h j- d% r8 Y1 P
height was 6 feet, and he went through a somewhat6 y5 Y/ d6 Q3 i' Y$ ^# j/ H" n
early puberty and had stopped growing by age 14.
+ C/ w- [+ x# B9 a: oThe father denied taking any other medication. The7 w3 n6 s5 x! B" \) `
child’s mother was in good health. Her menarche/ n% x* O0 F3 N3 L5 S, o; |
was at 11 years of age, and her height was at 5 feet
$ b* ]. e1 `( P* i5 inches. There was no other family history of pre-
9 y0 ~. U% J' r5 c/ N# Ococious sexual development in the first-degree rela-
. b. I& ?2 H# e% ^6 `: ktives. There were no siblings.
7 J3 B; }0 R2 WPhysical Examination
1 K' a1 G+ `& k/ A- pThe physical examination revealed a very active,
& q# O, O& r7 l% bplayful, and healthy boy. The vital signs documented
9 Q* f6 B$ x7 l9 \5 ~3 c2 Ma blood pressure of 85/50 mm Hg, his length was& Y. t r; ^' I) z; ]# k5 ~( R
90 cm (>97th percentile), and his weight was 14.4 kg$ l2 G$ i& C2 J2 c
(also >97th percentile). The observed yearly growth; b' s4 [* I2 y
velocity was 30 cm (12 inches). The examination of
' O3 T# S8 ]& bthe neck revealed no thyroid enlargement.: ^' W x8 D! g6 U
The genitourinary examination was remarkable for
) |, C8 p) H0 W z* m: Q f7 Cenlargement of the penis, with a stretched length of! v& `" g; r4 f# t8 d4 O' k" x
8 cm and a width of 2 cm. The glans penis was very well3 b L/ `/ a) L& j
developed. The pubic hair was Tanner II, mostly around
* i# f2 h1 o/ d540# M0 {; B. G3 N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* j/ O2 J/ I* H4 \6 J/ \the base of the phallus and was dark and curled. The0 g: z7 E% ?/ ?/ l% d
testicular volume was prepubertal at 2 mL each.
. x( G, \" q8 r" G2 z+ i$ m. H- g! ZThe skin was moist and smooth and somewhat
& @( u4 s: X2 F( Uoily. No axillary hair was noted. There were no
5 d& k' e: I' h5 x* q* ~& p1 {- }- Kabnormal skin pigmentations or café-au-lait spots.
% I- Z: F" K* V) A$ {$ }Neurologic evaluation showed deep tendon reflex 2+
% D# ~- S* L5 z+ ^) Gbilateral and symmetrical. There was no suggestion' b- l2 w8 Q. N( G
of papilledema.
7 p6 ^: X2 E% RLaboratory Evaluation
# {% k$ _' K4 v. n/ yThe bone age was consistent with 28 months by
3 j, w( v8 B* p, M" I0 tusing the standard of Greulich and Pyle at a chrono-
6 R$ ^8 q& R% O! x5 zlogic age of 16 months (advanced).5 Chromosomal1 Z9 E2 [! i/ K! J5 c- v
karyotype was 46XY. The thyroid function test; O1 {* X# V9 s8 N6 R# j9 Q! \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 F9 k+ k8 q* ~. f R2 [1 N* e0 vlating hormone level was 1.3 µIU/mL (both normal).
' B2 X+ w* O5 u2 v3 u: \5 B, _The concentrations of serum electrolytes, blood, ~, [, ^3 V( W) b% L
urea nitrogen, creatinine, and calcium all were( w8 r, H' \2 |6 t( \
within normal range for his age. The concentration
8 U C9 w' @( c& j# zof serum 17-hydroxyprogesterone was 16 ng/dL
0 C2 [: i7 R. l/ d8 T4 b9 |) G(normal, 3 to 90 ng/dL), androstenedione was 20
9 I' x0 @4 ]( G: I3 {. Ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, r0 [! v+ A! Z2 X& I* V
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 L; g( g. ~3 Z- P Z$ U3 O; A6 H. Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: c' t4 S7 L* K+ O( g: z& p8 g49ng/dL), 11-desoxycortisol (specific compound S)* f. h$ u9 P }; d/ ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 k! g% \* K0 g1 v* e) \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ z* n$ x8 M# m" Utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),! G! n" o* S% t/ s
and β-human chorionic gonadotropin was less than! B P; Z6 C9 G
5 mIU/mL (normal <5 mIU/mL). Serum follicular
- P' H$ P7 I' h, `' ?& C; B, q1 g6 Jstimulating hormone and leuteinizing hormone
* \% b' ?& n& Gconcentrations were less than 0.05 mIU/mL
( o2 J- V% D! z. s* ]4 i0 Z9 I; A(prepubertal).
8 V) n; @6 ]+ m* FThe parents were notified about the laboratory
+ }2 G7 B; ~8 X) c. T# W$ ~" Jresults and were informed that all of the tests were4 o1 |! H+ j: g9 ? G9 d, J
normal except the testosterone level was high. The1 q2 \. j8 F( m0 i" v
follow-up visit was arranged within a few weeks to# Q1 ^. P& c5 U
obtain testicular and abdominal sonograms; how-
5 y" o+ d& E4 E8 c* x! fever, the family did not return for 4 months.
( v# _: L. {3 F7 z1 D" X2 y. @Physical examination at this time revealed that the; m( d2 ]% Y5 i# ~* N3 k
child had grown 2.5 cm in 4 months and had gained
7 }1 I1 h3 B. Y# `* I9 q2 U7 z2 kg of weight. Physical examination remained& n. T. h; O5 A5 T8 v8 s3 ]; z
unchanged. Surprisingly, the pubic hair almost com-
' k7 r2 ?5 z2 Wpletely disappeared except for a few vellous hairs at
; `% H5 t" x C5 ~the base of the phallus. Testicular volume was still 2
. \4 X- _* t O- M: DmL, and the size of the penis remained unchanged.
# L+ }$ A1 N! h" K, O: p, P- AThe mother also said that the boy was no longer hav-
4 k0 N3 j4 L0 f) i$ }2 n3 s1 ving frequent erections.
d/ J* }0 l, T) ~6 Z+ {; pBoth parents were again questioned about use of
$ q* b2 z T" O7 Cany ointment/creams that they may have applied to
' C o8 A2 h! ^6 dthe child’s skin. This time the father admitted the
7 z0 h3 t6 b4 VTopical Testosterone Exposure / Bhowmick et al 541
1 G& ] n+ s* W4 a( |- K3 Ouse of testosterone gel twice daily that he was apply-% _+ _3 G1 O) e# f/ K' ^
ing over his own shoulders, chest, and back area for
9 H/ i0 {0 q* d$ o6 ?; da year. The father also revealed he was embarrassed M- A V0 h4 o4 a
to disclose that he was using a testosterone gel pre-# @; O2 _! k% c$ R
scribed by his family physician for decreased libido
% j. b" V, v' Y: U( C" Osecondary to depression.# n+ E0 }9 {, i
The child slept in the same bed with parents.
' o; C* E- R9 e# ?- GThe father would hug the baby and hold him on his3 W# f2 \' a+ L6 Y( I
chest for a considerable period of time, causing sig-
! t" H- e' v- M, y' C6 wnificant bare skin contact between baby and father., C, y% c4 i, z- @; x
The father also admitted that after the phone call,. Y. v. D# B( A9 e6 W# G
when he learned the testosterone level in the baby
" u6 {' S0 A: _$ \was high, he then read the product information5 R7 Q7 p4 R) u; t$ x
packet and concluded that it was most likely the rea-
7 o& {2 |3 p9 B, Q2 m: ison for the child’s virilization. At that time, they6 X9 \$ @1 h! `6 w: G% j9 E3 d
decided to put the baby in a separate bed, and the$ Y3 g: C5 O* a1 F2 e; ]
father was not hugging him with bare skin and had
: {6 `5 B7 g/ f V3 J, Y+ Dbeen using protective clothing. A repeat testosterone1 D: x. J" l: c8 o
test was ordered, but the family did not go to the
* J: B6 N1 b4 y3 s) Flaboratory to obtain the test.
; e1 |$ f: x7 } E! M" e+ MDiscussion7 l7 _8 {$ B8 h6 t( @) `! Q
Precocious puberty in boys is defined as secondary
; t$ E; t7 O4 Z3 Msexual development before 9 years of age.1,43 t4 J0 e8 \" ]. e+ C( `3 ~
Precocious puberty is termed as central (true) when
9 Z* Z: H, M" x* p& a# s3 B @it is caused by the premature activation of hypo-
8 {3 ]2 K; j4 K+ i9 k2 nthalamic pituitary gonadal axis. CPP is more com-6 d R, {0 P& P4 y! C
mon in girls than in boys.1,3 Most boys with CPP+ V5 X( B$ ^2 f0 K! m$ h( j" T
may have a central nervous system lesion that is. g9 D# _: `0 \5 o Q
responsible for the early activation of the hypothal-
, R: ?* m0 u. y: `2 D2 kamic pituitary gonadal axis.1-3 Thus, greater empha-2 Y3 V) G1 U+ s& ^2 A: ^
sis has been given to neuroradiologic imaging in
0 m3 Z5 ?8 y, u. ~2 d1 O- j+ b+ _ Rboys with precocious puberty. In addition to viril-
9 @: A* v( E# Z& K) W- ]ization, the clinical hallmark of CPP is the symmet-
0 A; @0 {* u& M+ d2 f X9 ^8 lrical testicular growth secondary to stimulation by( M6 b u5 C. n4 \- d! C/ O ?3 H
gonadotropins.1,36 C* w0 ~4 |5 k: z/ I9 j- P. t
Gonadotropin-independent peripheral preco-! W, e* s% I0 K" S1 w
cious puberty in boys also results from inappropriate/ P' R" \& O! ~* B1 r9 A/ I/ s
androgenic stimulation from either endogenous or
8 w# r( e0 a1 j# ~- |2 Jexogenous sources, nonpituitary gonadotropin stim-
* E2 V/ I# D, [" N5 Pulation, and rare activating mutations.3 Virilizing
+ j! `7 x6 I/ C& Fcongenital adrenal hyperplasia producing excessive
$ d, Q/ k0 o9 B, o+ o, ^7 K9 sadrenal androgens is a common cause of precocious, N3 r7 O4 f$ N& H- Y
puberty in boys.3,4
4 y% N3 K+ V+ \) A6 BThe most common form of congenital adrenal
+ m# g2 v6 S" B1 }2 g$ W) lhyperplasia is the 21-hydroxylase enzyme deficiency.
: D3 d' `. k& eThe 11-β hydroxylase deficiency may also result in: _/ f8 K8 n* R! [
excessive adrenal androgen production, and rarely,: E- j4 H9 z9 M' o
an adrenal tumor may also cause adrenal androgen( |" h+ N1 I6 d$ @
excess.1,38 S1 U- i9 @( c( T# Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. G3 ?2 Q2 }0 k4 t; j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: z* _4 ?" Z7 v) OA unique entity of male-limited gonadotropin-7 W; o( m- W/ n0 S+ k" _: X
independent precocious puberty, which is also known2 P$ T8 k2 _4 m
as testotoxicosis, may cause precocious puberty at a
; K% |3 c/ r; k: ~: Zvery young age. The physical findings in these boys1 ?' R( m: `( z( d5 c
with this disorder are full pubertal development,
* T, ]" e0 A3 L5 o2 X0 ]including bilateral testicular growth, similar to boys
- y" Q2 @( D* D3 c" U" O+ L5 owith CPP. The gonadotropin levels in this disorder
( [6 r% n3 `8 p+ j) s l6 Gare suppressed to prepubertal levels and do not show( \! p+ @! z1 n# b: I
pubertal response of gonadotropin after gonadotropin-
8 J' Q: H1 A! \0 X7 L6 {$ a& oreleasing hormone stimulation. This is a sex-linked8 D5 I4 t+ u" G3 f/ b+ c
autosomal dominant disorder that affects only7 N! m, B5 \; z0 p4 G- l
males; therefore, other male members of the family" m) M6 H& T" R- u
may have similar precocious puberty.3* m s" g. D$ K7 C$ T3 K* f
In our patient, physical examination was incon-
5 u" p8 m! G4 wsistent with true precocious puberty since his testi-) c6 r$ ?5 E! J- c) q
cles were prepubertal in size. However, testotoxicosis
" V" ]% T# C7 O: t4 R) ~8 Vwas in the differential diagnosis because his father O& V* R, s8 R8 L+ u
started puberty somewhat early, and occasionally,
: }2 \5 E+ N( G htesticular enlargement is not that evident in the
: J: G, d. z4 Q, A. Mbeginning of this process.1 In the absence of a neg-! L+ g1 _9 W; P
ative initial history of androgen exposure, our
5 l7 l/ B0 Q' f- q# }; ]" Qbiggest concern was virilizing adrenal hyperplasia,
7 g" R: B1 C3 @8 r3 ]5 Geither 21-hydroxylase deficiency or 11-β hydroxylase% _! [3 D! x! {9 w) H0 s
deficiency. Those diagnoses were excluded by find-
9 E" E; H4 ^% q( ]( k+ I' qing the normal level of adrenal steroids.
, W& c" T4 o) i) g6 ?8 rThe diagnosis of exogenous androgens was strongly: ?+ l/ f" j* h0 l0 S- x
suspected in a follow-up visit after 4 months because
+ g; r4 d) |* e& sthe physical examination revealed the complete disap-
6 `' Q, f L! l1 opearance of pubic hair, normal growth velocity, and
: `1 l4 z0 y; _9 K6 F5 h5 cdecreased erections. The father admitted using a testos-
) p6 z, B: A! u) c( F- @terone gel, which he concealed at first visit. He was. C3 S% x8 ?# W7 O% m
using it rather frequently, twice a day. The Physicians’0 Z5 c0 I: {. _# h& s
Desk Reference, or package insert of this product, gel or- b# Q* s. [) T3 l) }; `; c, w/ |
cream, cautions about dermal testosterone transfer to
T. ^4 n# c5 aunprotected females through direct skin exposure.
+ y4 F U H* _6 c+ FSerum testosterone level was found to be 2 times the
# Q1 f& I" _4 b; H) R1 ^& D$ V' Tbaseline value in those females who were exposed to# q" s. C6 g* y* E7 B
even 15 minutes of direct skin contact with their male, w8 a2 M( R" s+ O
partners.6 However, when a shirt covered the applica-- u& A( c- R8 E( H# [: A
tion site, this testosterone transfer was prevented.1 \. O+ [1 ~' h2 _" G U
Our patient’s testosterone level was 60 ng/mL,
" ^" M3 L( O8 W; gwhich was clearly high. Some studies suggest that
) b3 T# o" _& H; w& Adermal conversion of testosterone to dihydrotestos-9 o" o8 C+ |8 Y/ [' @
terone, which is a more potent metabolite, is more Q9 m0 I0 m! g; s: e% t. A8 E
active in young children exposed to testosterone& L& K/ c- c; @( O
exogenously7; however, we did not measure a dihy-
/ f7 Z% ~) @/ z4 |$ l" h, c4 ndrotestosterone level in our patient. In addition to
- x# }8 J% G y- fvirilization, exposure to exogenous testosterone in/ @, E+ I1 ]1 w- c4 J `
children results in an increase in growth velocity and
) L0 e; [ Z* Vadvanced bone age, as seen in our patient.' F* N: b& N' ^5 A) o
The long-term effect of androgen exposure during! W w) X" v4 V1 `. h3 A q8 `
early childhood on pubertal development and final% A3 X" i& ~2 n
adult height are not fully known and always remain/ ^3 N3 a4 \. p( X
a concern. Children treated with short-term testos-
0 c( L: I/ d# I/ m% q3 W3 B( t" cterone injection or topical androgen may exhibit some
! ], d% G$ c1 eacceleration of the skeletal maturation; however, after( [2 q j; D# R
cessation of treatment, the rate of bone maturation
, t8 l. p& w! |7 Y, S# Fdecelerates and gradually returns to normal.8,9* D1 Z6 a2 g9 h; a
There are conflicting reports and controversy8 g" y* Y4 s: N ^! l4 H; f
over the effect of early androgen exposure on adult8 X- e- N- f# |( _( ~7 C+ R
penile length.10,11 Some reports suggest subnormal
4 b7 w" p0 W5 U8 A6 madult penile length, apparently because of downreg-
- K/ N7 Y- X$ ~6 f3 Tulation of androgen receptor number.10,12 However,
0 o& O; _$ M% t, }$ h* USutherland et al13 did not find a correlation between
: Z% C- C+ V$ Z5 x0 J* cchildhood testosterone exposure and reduced adult0 k" p8 l4 H; p. l+ Z7 G
penile length in clinical studies.
j+ d9 w. g; o' ?Nonetheless, we do not believe our patient is
% t+ p# ~2 u4 o: h- V' m/ e3 j3 ugoing to experience any of the untoward effects from
5 _- E b$ E. }2 ztestosterone exposure as mentioned earlier because
" ]* y6 ^7 g1 |- Q6 Othe exposure was not for a prolonged period of time.# Q! W: b# A. L# Y1 Q. C" c: o! B
Although the bone age was advanced at the time of
$ z& y G$ X4 p5 K1 d' t, A1 vdiagnosis, the child had a normal growth velocity at
. t0 b! |) o( M# O7 B# R6 C( ythe follow-up visit. It is hoped that his final adult- o1 k) s& o8 p0 c, f( j. f
height will not be affected.
L F9 [( Y: Q, O D0 S' rAlthough rarely reported, the widespread avail-& k& E+ j+ V# M) m9 v/ G
ability of androgen products in our society may6 g7 y4 }/ Q( s3 k1 l2 l( g2 R5 w2 e
indeed cause more virilization in male or female
4 t2 f3 Z5 y' i5 ~ B) J% ]children than one would realize. Exposure to andro-/ P$ }4 n6 ]; g
gen products must be considered and specific ques-8 i! a5 |/ F- M7 |: B! Q6 ^
tioning about the use of a testosterone product or
7 N/ v& @0 Q! _! F6 Y, Pgel should be asked of the family members during! _9 B6 ^$ K3 y. X. T
the evaluation of any children who present with vir-* P* D9 F! u4 Q
ilization or peripheral precocious puberty. The diag-9 _2 L0 |6 g X/ {3 S, f
nosis can be established by just a few tests and by' h P7 {7 g$ J1 f) k, P# }+ C7 ~
appropriate history. The inability to obtain such a
9 F @+ D* u$ U/ S. ]' R/ Z6 Thistory, or failure to ask the specific questions, may
* [/ O9 R$ W: J* X, uresult in extensive, unnecessary, and expensive; r u5 m+ o, S
investigation. The primary care physician should be
8 B2 Q9 M) b: A2 K. k7 ]aware of this fact, because most of these children$ Q4 T0 |# Y4 K+ S
may initially present in their practice. The Physicians’. E/ o% a) x/ s4 D7 r
Desk Reference and package insert should also put a& C) `* ]1 o, D) a& t3 H
warning about the virilizing effect on a male or
0 s( |8 z4 W% i) ufemale child who might come in contact with some-
# @9 M. _0 e* g8 I- @8 Vone using any of these products.
. Q2 i3 k" ]+ B A9 HReferences* ~3 D p3 i" O5 T0 f$ P' u8 C
1. Styne DM. The testes: disorder of sexual differentiation5 i0 W% g$ P( a) {( e$ x
and puberty in the male. In: Sperling MA, ed. Pediatric b) X& _+ z& ~* @4 h5 K2 n! t7 o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' ?$ \2 i K% D, d$ G2 `; X
2002: 565-628.
* b3 y9 U* ~2 h$ R9 p9 w B' A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: c/ m7 @" K8 T" u9 |# F
puberty in children with tumours of the suprasellar pineal |
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