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Sexual Precocity in a 16-Month-Old
2 z7 W: W. d' a: S, F6 |Boy Induced by Indirect Topical
" R0 ]$ n& y9 u8 I5 J9 `Exposure to Testosterone
( s7 \! b" }: t2 lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, T3 T1 v% u; L0 O# p% G9 M% j2 zand Kenneth R. Rettig, MD11 I5 k: W: ]" k$ ]9 F" r4 q% p
Clinical Pediatrics
5 e2 [' ^5 W3 [% uVolume 46 Number 6
# W4 j8 @. M |! T3 T' \, JJuly 2007 540-543. t) O0 \1 u6 b: X2 l
© 2007 Sage Publications+ @5 W; s. g# P& M- a2 v$ p
10.1177/0009922806296651
$ I+ C; V/ ]% ` {$ ahttp://clp.sagepub.com
% x# Z+ ~, T/ @7 |* \0 ~# ahosted at
1 F. H5 t$ ?/ }! {0 }! Hhttp://online.sagepub.com" q9 M" v1 e# C' P& z% z0 y
Precocious puberty in boys, central or peripheral,1 ] P- F" ^ m: ~
is a significant concern for physicians. Central
: u7 o( `7 V! M4 f& Wprecocious puberty (CPP), which is mediated
# |4 L& K. `. r- w! G: Y" T! g, bthrough the hypothalamic pituitary gonadal axis, has6 F/ y9 o% Y& b) g- I' E
a higher incidence of organic central nervous system
( D* p! x8 g, S; {& blesions in boys.1,2 Virilization in boys, as manifested2 K( M' {! k% l8 k8 t
by enlargement of the penis, development of pubic/ F d# }2 ~- }
hair, and facial acne without enlargement of testi-( k9 N! [. C# b: A" U* q3 F8 U
cles, suggests peripheral or pseudopuberty.1-3 We
; t' m; {# d; |report a 16-month-old boy who presented with the7 C& ^) r& R' [3 q4 N# V
enlargement of the phallus and pubic hair develop-
! x' V% T) t" r+ Iment without testicular enlargement, which was due' ` V* G `- G' c3 G
to the unintentional exposure to androgen gel used by
2 d- F' x0 V2 o( d7 _) S( ~the father. The family initially concealed this infor-- c' h2 Q6 q5 h: U7 y) I( F
mation, resulting in an extensive work-up for this, \& s" P, m4 N1 i* A
child. Given the widespread and easy availability of
. {: V( ]+ H1 f7 [6 z/ K' a' g1 qtestosterone gel and cream, we believe this is proba-$ z, q3 } M2 {8 W5 K
bly more common than the rare case report in the, C3 x5 J$ U3 T1 M
literature.44 Z+ S, K- b5 c# Z4 e9 `, D
Patient Report
6 k6 a0 S( [9 ]A 16-month-old white child was referred to the
2 @* w: C+ m& \; Sendocrine clinic by his pediatrician with the concern. ^* q1 o# D4 A/ C
of early sexual development. His mother noticed
$ \8 b# _- p( H9 V2 clight colored pubic hair development when he was4 [3 S* m z) v) g9 f4 p- [0 Y$ s: ]
From the 1Division of Pediatric Endocrinology, 2University of- e6 C' g3 w2 T" V _
South Alabama Medical Center, Mobile, Alabama.
/ K* j5 G3 G5 x# @Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ M# l v) E1 ~5 pProfessor of Pediatrics, University of South Alabama, College of" x2 o4 w7 J' |+ |5 X
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. O2 Z; M2 ?+ a X& `, M7 f: Z
e-mail: [email protected].# {+ y& U9 `) }2 g
about 6 to 7 months old, which progressively became
" ?" \: k% I5 X" }darker. She was also concerned about the enlarge-
- I2 ~2 O3 T# r# ]ment of his penis and frequent erections. The child/ s/ `$ V% U% G! A4 {! a8 f
was the product of a full-term normal delivery, with
! u& a; d1 N: B) G2 A3 Ha birth weight of 7 lb 14 oz, and birth length of
7 K6 f& l. z# Z# S. a) F9 P0 B20 inches. He was breast-fed throughout the first year
$ H) p; v" ^1 ^" r" Z) y/ Rof life and was still receiving breast milk along with& d: v: q: T, d8 ?6 O
solid food. He had no hospitalizations or surgery,- Y5 P0 L- y a. l0 J/ P
and his psychosocial and psychomotor development" X7 h$ f) {' _; N/ \ a N* Z4 c$ U
was age appropriate.: ~# v* O' Y! ~( _5 ]0 ~ Q; t
The family history was remarkable for the father,1 }6 J* E3 F/ Y! G; v+ ~' N q
who was diagnosed with hypothyroidism at age 16,
7 W) t8 k4 p1 V& Fwhich was treated with thyroxine. The father’s3 {: v) W$ i9 a
height was 6 feet, and he went through a somewhat+ ?- [, ^; B: s$ M8 O
early puberty and had stopped growing by age 14.
4 I/ p5 h$ p% h! rThe father denied taking any other medication. The
d( e; h' S Q% ichild’s mother was in good health. Her menarche. ]/ g$ O+ I# B( { }5 }
was at 11 years of age, and her height was at 5 feet
3 \2 C* d3 g" x) \6 i5 inches. There was no other family history of pre-
, K! {7 t' i3 [% z9 K0 S9 Kcocious sexual development in the first-degree rela-5 K: X% }3 {& r' N4 r4 N) T5 i
tives. There were no siblings.
% ^+ O! d* ]1 u1 [( w5 a- BPhysical Examination+ ?- P6 w; h7 ^# o; z1 ` o
The physical examination revealed a very active,$ x! a+ }7 P( K' X( O0 n! f
playful, and healthy boy. The vital signs documented
( j! K. Y& T7 h2 f, E& e! da blood pressure of 85/50 mm Hg, his length was' K& K0 |1 F$ m" C5 e
90 cm (>97th percentile), and his weight was 14.4 kg
# e" U) n1 L0 y1 r5 R* j/ ~(also >97th percentile). The observed yearly growth
6 R2 V w; V& gvelocity was 30 cm (12 inches). The examination of
0 I) m8 g1 b" q: x& |% }8 Ythe neck revealed no thyroid enlargement./ Z# z7 T! S2 E2 \+ B1 h
The genitourinary examination was remarkable for
' D, S0 O5 _/ D3 E! oenlargement of the penis, with a stretched length of
, r2 O) ]# c, H, `2 n8 cm and a width of 2 cm. The glans penis was very well) ^" ^- x5 b* Z
developed. The pubic hair was Tanner II, mostly around1 X8 l! \% ^( r; T" o8 V
5402 ]2 z; m$ h1 ?! K1 g: j- I' q4 i' N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- Z7 [/ u: O7 V& D( Hthe base of the phallus and was dark and curled. The( y2 b3 |! t; T, S9 s
testicular volume was prepubertal at 2 mL each.2 O1 s+ D- K# N7 }# d8 N! b, X) n$ a* s
The skin was moist and smooth and somewhat
0 f M7 K% f( R7 a& X% a3 A3 o- voily. No axillary hair was noted. There were no
% l% f+ q. q4 s& z, Yabnormal skin pigmentations or café-au-lait spots.9 B$ z) P/ c/ S l( P* `
Neurologic evaluation showed deep tendon reflex 2+6 @' _$ ]7 m2 a: f+ `; W& \# J0 q
bilateral and symmetrical. There was no suggestion
9 r9 f8 Y; @: Yof papilledema.4 z9 R; S D0 `# f
Laboratory Evaluation
/ F: Z6 h* f; e9 ?" A8 mThe bone age was consistent with 28 months by. l7 ^: A/ R4 u* N' Q2 n
using the standard of Greulich and Pyle at a chrono-
7 R! X& w: g5 n+ V7 R6 z4 o3 {logic age of 16 months (advanced).5 Chromosomal
/ Y% p9 j, d- F) e, I' Bkaryotype was 46XY. The thyroid function test
3 D. c: C9 A5 @! w" q0 a3 ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-4 l$ c6 `) j3 Q2 T2 n2 ~: Z& j& n
lating hormone level was 1.3 µIU/mL (both normal).
2 H1 P6 f z2 |; BThe concentrations of serum electrolytes, blood
9 p& x% p) f- e5 H4 D$ g" y" Eurea nitrogen, creatinine, and calcium all were
/ u s) R2 r3 V6 |! |: Rwithin normal range for his age. The concentration; ]. @6 O( X* i* I: T$ u
of serum 17-hydroxyprogesterone was 16 ng/dL
1 C/ c) a8 Z; ^2 Z: I5 g& U4 r2 _( n(normal, 3 to 90 ng/dL), androstenedione was 20
# @! H7 T* u2 ~2 ^+ w( {0 cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' n! F( V- R! F7 }! ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 T8 }7 h" ~; `' P2 ]( Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( T5 \0 ?0 d' d49ng/dL), 11-desoxycortisol (specific compound S)
. f; h4 Y2 N J8 n( s- _! }2 `4 r1 vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 j( D; C' {" F4 |* g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 T, }5 B8 n; s9 E6 d d' {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' u7 v7 q. c+ @+ U& O
and β-human chorionic gonadotropin was less than
/ G& v, `0 r: W4 o" B5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 _# T- }. S6 f! }) rstimulating hormone and leuteinizing hormone
8 e3 q) J3 Q3 `" v3 Xconcentrations were less than 0.05 mIU/mL
1 |6 L: ~0 v. K: K @% b/ K% R# N(prepubertal).$ \1 b4 L" Q; I
The parents were notified about the laboratory! E4 s! L: {$ O- B( B- B
results and were informed that all of the tests were
i; v5 ]+ S4 ?- l0 o$ K' ?normal except the testosterone level was high. The
; E" G' `3 w% _* @- E) r9 Gfollow-up visit was arranged within a few weeks to8 F* L7 \: |# O8 @
obtain testicular and abdominal sonograms; how-; i% m' F/ o7 W3 b: S' U
ever, the family did not return for 4 months.
1 W8 @# H) ?: c: u I2 [1 D$ MPhysical examination at this time revealed that the
% T- L9 d: K1 M( y6 kchild had grown 2.5 cm in 4 months and had gained
" C' Y! s( l. f2 K; @! k2 kg of weight. Physical examination remained; i5 v) v. ?( \1 r* G$ H2 V, B8 g0 p* U
unchanged. Surprisingly, the pubic hair almost com-
$ h% C7 Z7 ? v( G$ ?" U! I0 r, mpletely disappeared except for a few vellous hairs at3 D/ E% A* p" S9 E% K# h
the base of the phallus. Testicular volume was still 2
' D% j0 W- i& kmL, and the size of the penis remained unchanged.
6 p/ H- x% ^/ i DThe mother also said that the boy was no longer hav-
r" e( b5 ~) o" L! h" Ding frequent erections.4 T4 u( K# t' F' ~2 u5 v
Both parents were again questioned about use of* i2 y6 [* _2 k8 _
any ointment/creams that they may have applied to
/ l/ ]4 W; c, uthe child’s skin. This time the father admitted the4 o) ^7 N# a- W3 a# v8 g
Topical Testosterone Exposure / Bhowmick et al 541
( s" a" r- W [. e& q- i5 w) e3 juse of testosterone gel twice daily that he was apply-
2 {0 U) X' Q1 F1 f9 e" Uing over his own shoulders, chest, and back area for
7 c/ T9 G/ Y: {1 Y8 Z! pa year. The father also revealed he was embarrassed
" h( V3 A* C! a- f6 Q5 Sto disclose that he was using a testosterone gel pre-/ A9 W( o2 E! r% h+ ^' n5 C P
scribed by his family physician for decreased libido
. j1 ]- l" A) ^- y# y0 F8 }secondary to depression.
, p7 N8 W6 l2 P# y. n: v! m1 cThe child slept in the same bed with parents.
: s# h; i( ?1 F G+ D; {5 iThe father would hug the baby and hold him on his
4 v* v9 Q2 J6 g% l5 pchest for a considerable period of time, causing sig-+ o a; W" |; `0 A. c6 ?
nificant bare skin contact between baby and father.* G# i8 C& j# s; @. r) [
The father also admitted that after the phone call,+ s6 s% N* e. B+ R9 k/ C2 X. x
when he learned the testosterone level in the baby
8 M* `& L# D" J" G2 S4 Awas high, he then read the product information/ Y) W. w' B5 _0 f- f4 G
packet and concluded that it was most likely the rea-4 ^: U( B* F/ n, B' |6 u% J
son for the child’s virilization. At that time, they
c6 l( F; x B3 i& Wdecided to put the baby in a separate bed, and the" U3 @0 r/ z% F
father was not hugging him with bare skin and had) A" S; t2 U3 Y7 ]
been using protective clothing. A repeat testosterone
4 b- u E1 I9 K8 o$ ^- Y1 A) atest was ordered, but the family did not go to the" i+ |, _6 g: E7 ?. z
laboratory to obtain the test.
: j$ ?% ?5 P! h% T2 C8 u2 IDiscussion9 s; K: O; X, S
Precocious puberty in boys is defined as secondary
/ Q& }1 ?- N1 S$ F9 N# Dsexual development before 9 years of age.1,4
A9 C4 N; y' |" C. E" B/ MPrecocious puberty is termed as central (true) when6 e/ G2 ^+ C! N6 i$ E- f
it is caused by the premature activation of hypo-
- z/ o' ?$ C7 Z. G( {thalamic pituitary gonadal axis. CPP is more com-: D3 w0 ~8 z; G" ^, X7 V2 o
mon in girls than in boys.1,3 Most boys with CPP
( f1 z4 n [$ y3 Bmay have a central nervous system lesion that is. ^4 K2 W3 Y+ ^! l
responsible for the early activation of the hypothal-1 Z t3 c! t Z% q/ L+ q1 O- m
amic pituitary gonadal axis.1-3 Thus, greater empha-0 n5 B6 `. v- G, R
sis has been given to neuroradiologic imaging in
/ u+ Q* j/ C. m' q7 mboys with precocious puberty. In addition to viril-4 B* N, b, H8 [3 v3 J% w
ization, the clinical hallmark of CPP is the symmet-; J: T, |! I5 R& p4 z- E
rical testicular growth secondary to stimulation by" x1 Y: U% j; ^- G4 p/ H
gonadotropins.1,3( ]+ T: l" q1 U! F( _0 L: ^2 n
Gonadotropin-independent peripheral preco-+ g' j- T2 D, m }+ r! {9 l" v
cious puberty in boys also results from inappropriate3 P! P) i* i4 D; U* z" x
androgenic stimulation from either endogenous or
6 j" J+ h2 i6 Zexogenous sources, nonpituitary gonadotropin stim-( X7 i; _) e8 B3 S& B
ulation, and rare activating mutations.3 Virilizing
; X! ]& ]& i6 ocongenital adrenal hyperplasia producing excessive
3 o) R1 i" E8 q0 ^- y' zadrenal androgens is a common cause of precocious
) N/ d. w& X4 K! jpuberty in boys.3,4% F3 U4 S& j) p m% \
The most common form of congenital adrenal9 l6 v% L: h- \) }8 [9 r
hyperplasia is the 21-hydroxylase enzyme deficiency.
z9 D0 o1 E! x3 p5 w7 h# RThe 11-β hydroxylase deficiency may also result in# P; `$ v% H# p7 u
excessive adrenal androgen production, and rarely,. Y; E7 X: \, i% g( u
an adrenal tumor may also cause adrenal androgen* T% L5 Q' g6 C
excess.1,3 s- N+ d: I4 w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ p, v& s& L+ ]! f. t0 q( Q8 Y" T- i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* v) {( j `8 A6 Z
A unique entity of male-limited gonadotropin-
7 X9 [5 Z& s' [/ I- aindependent precocious puberty, which is also known! A4 E3 h w+ L! t
as testotoxicosis, may cause precocious puberty at a
6 b8 Z" a8 ~" F% G! Ivery young age. The physical findings in these boys
+ c* w' g* g# L, ~with this disorder are full pubertal development, ~: {3 v! H* C1 p) m
including bilateral testicular growth, similar to boys3 k% ]! k8 J4 T M# q; ?/ ~
with CPP. The gonadotropin levels in this disorder
$ p$ u- n$ G4 B0 }, |are suppressed to prepubertal levels and do not show
$ S. l8 _0 A0 B. R% Qpubertal response of gonadotropin after gonadotropin-3 e% {! Q4 z, ^. H4 A! o
releasing hormone stimulation. This is a sex-linked
8 h; z, a( E. p! g) E7 Jautosomal dominant disorder that affects only E2 a0 U9 M! |8 u7 W
males; therefore, other male members of the family- Y I1 D5 [' d5 I
may have similar precocious puberty.32 h F. k6 P4 _9 y" u5 F
In our patient, physical examination was incon-% _4 S" {7 X: W( f) I% P* j
sistent with true precocious puberty since his testi-
3 _0 _0 X1 V9 K" a* P* Pcles were prepubertal in size. However, testotoxicosis
4 v% q$ j; ]- u( j/ q" ywas in the differential diagnosis because his father
1 F1 i$ z4 t( z6 n2 n. hstarted puberty somewhat early, and occasionally,# y7 G2 W% Y: ~7 z. w
testicular enlargement is not that evident in the# C/ a# K6 K2 }' a) {
beginning of this process.1 In the absence of a neg-
9 @/ G: O2 s4 W0 D0 p6 a' V3 Uative initial history of androgen exposure, our
1 ^" P% m: ~2 v& }biggest concern was virilizing adrenal hyperplasia,3 d1 S% K* I" u; Y$ |$ G5 y
either 21-hydroxylase deficiency or 11-β hydroxylase; I7 `: R! O( H3 K0 Y
deficiency. Those diagnoses were excluded by find-' j7 Q" O1 h N# {
ing the normal level of adrenal steroids.: [; |6 J$ f, a% M( n+ N1 v U
The diagnosis of exogenous androgens was strongly7 P# w( K9 J: k- [4 j, w
suspected in a follow-up visit after 4 months because
& M) q' r3 [2 O& W% qthe physical examination revealed the complete disap-% A* y- n9 Q! j, `+ n# c* F6 X
pearance of pubic hair, normal growth velocity, and
# E. j& ]6 v" P5 g9 }+ r, T# idecreased erections. The father admitted using a testos-
2 Y+ e/ o- o4 l0 Cterone gel, which he concealed at first visit. He was* `" d+ [& f c
using it rather frequently, twice a day. The Physicians’* y$ _' m6 D% w' Q
Desk Reference, or package insert of this product, gel or+ q a' U0 s$ J0 T3 x# Y, A
cream, cautions about dermal testosterone transfer to
# T$ }! }; a }! s: Z+ V% Uunprotected females through direct skin exposure.
( X( ~+ ?; ^ n# @3 JSerum testosterone level was found to be 2 times the
1 \; [- J9 Q, d3 ]! fbaseline value in those females who were exposed to" L5 Z0 d# c+ k) j9 M& e- [
even 15 minutes of direct skin contact with their male
0 c) f8 P7 t/ O) ~ @partners.6 However, when a shirt covered the applica-$ B: v/ ]. ^; A; B S
tion site, this testosterone transfer was prevented.* Y5 `% V4 a H* I* C$ ^
Our patient’s testosterone level was 60 ng/mL,
6 Y+ x ~$ f" ]which was clearly high. Some studies suggest that+ G7 m' k9 v) R' q5 `
dermal conversion of testosterone to dihydrotestos-6 u; B# F% `5 M1 }# T/ T
terone, which is a more potent metabolite, is more
7 a- z1 D% o( q' kactive in young children exposed to testosterone5 Q% z4 X N" i/ v* ^2 n
exogenously7; however, we did not measure a dihy-
8 g( i: T: r4 A7 t% I1 Udrotestosterone level in our patient. In addition to; `# {7 x2 @: J( J
virilization, exposure to exogenous testosterone in
& s& I; n$ x& [& Lchildren results in an increase in growth velocity and
1 h5 y v9 e4 K! F, Xadvanced bone age, as seen in our patient.3 x7 I3 _% C6 r; c
The long-term effect of androgen exposure during" ~' }# b( Y+ m) d d$ j* H
early childhood on pubertal development and final
( i& \, T$ d5 H6 A& S; i Radult height are not fully known and always remain
1 c$ G0 `5 W, `, V. M8 g. J6 Ia concern. Children treated with short-term testos-
7 C# Q: q+ M( w! z/ S9 c+ dterone injection or topical androgen may exhibit some
" o$ l; S3 ?, T0 _acceleration of the skeletal maturation; however, after
, Z S J+ H& z) _% ]( [& t& R8 \cessation of treatment, the rate of bone maturation9 y: X) C% r/ y; h9 H
decelerates and gradually returns to normal.8,97 U: s9 F, i4 P
There are conflicting reports and controversy: C l+ s p5 w: W; ~# i- f7 R5 L% g6 K( u) d
over the effect of early androgen exposure on adult
" _1 C5 D. I/ V5 h L+ ~# d2 `penile length.10,11 Some reports suggest subnormal
/ e! N+ W! s: E1 \5 ~& C; wadult penile length, apparently because of downreg-& p8 N1 Q; h8 V
ulation of androgen receptor number.10,12 However,
$ l1 ?( S' A+ y. o6 |$ i1 D8 GSutherland et al13 did not find a correlation between
0 x. [$ P& k0 A1 B: b7 {childhood testosterone exposure and reduced adult) D) E7 a5 D% Z% |9 P4 ?! A
penile length in clinical studies.5 K2 K; \9 h+ w& K$ k% X
Nonetheless, we do not believe our patient is& j9 u3 n3 Z5 M( j
going to experience any of the untoward effects from- V" a g w. H3 `" v6 }, C, g3 y
testosterone exposure as mentioned earlier because' k7 Y* m1 a% ?
the exposure was not for a prolonged period of time.
5 y6 y, \& z5 r) HAlthough the bone age was advanced at the time of, ~' g3 U2 R' z5 w2 K$ @5 }
diagnosis, the child had a normal growth velocity at5 r0 g. ^% x3 T
the follow-up visit. It is hoped that his final adult
: i8 p, I5 ~1 zheight will not be affected., H. `8 o% a; f r" D+ U; e
Although rarely reported, the widespread avail-
9 g J2 n; A: K5 A: r: Dability of androgen products in our society may) w/ X2 x- I0 O+ ?: C
indeed cause more virilization in male or female$ N1 M/ w) a: w$ ?7 r5 h
children than one would realize. Exposure to andro-4 [7 k* [2 {3 i: s
gen products must be considered and specific ques-- p( ^$ M( R3 a
tioning about the use of a testosterone product or
$ s1 g) `% Y# t, Ngel should be asked of the family members during
2 d/ a! [- C; u4 y( Jthe evaluation of any children who present with vir-
5 S6 b, j* R1 Ailization or peripheral precocious puberty. The diag-
3 G! H$ |9 N1 \, M- Tnosis can be established by just a few tests and by" {/ H s1 b& ~0 {, b* ?
appropriate history. The inability to obtain such a1 {2 }& X- c9 t f
history, or failure to ask the specific questions, may
# v# B1 y. [' C. h4 vresult in extensive, unnecessary, and expensive
4 O2 v4 F6 `) l" ~; N- binvestigation. The primary care physician should be
# i- u3 J4 ~8 ]4 A5 {: Q1 p1 kaware of this fact, because most of these children
2 k% O6 J% T% z$ qmay initially present in their practice. The Physicians’
$ Y& r8 j) E" g5 ^+ _Desk Reference and package insert should also put a- T s% s5 U0 R- w% B+ s, a
warning about the virilizing effect on a male or
6 R, b8 F. V6 rfemale child who might come in contact with some-$ ?7 e- J' _" k+ c) n& @
one using any of these products.
8 j# ?! [* _/ h$ j* Q& ~References
# s. M& b% h: K/ P8 q1. Styne DM. The testes: disorder of sexual differentiation% y# f) U; Y1 S: ~
and puberty in the male. In: Sperling MA, ed. Pediatric
* I0 @5 L) s! M( u6 @, h0 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# N3 x4 c* E, j2002: 565-628." I/ ^ w- o! W% T9 j$ W V
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; x- d ]1 c3 h, E4 f3 u" U
puberty in children with tumours of the suprasellar pineal |
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