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Sexual Precocity in a 16-Month-Old
! ~8 m- V( @& GBoy Induced by Indirect Topical7 d" H. N: Z( ?+ C8 K _
Exposure to Testosterone
+ I: Q. h6 f! q- OSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ H& R+ v5 {. H, }and Kenneth R. Rettig, MD1
8 W) i9 B w& T3 v, VClinical Pediatrics
2 v$ n; G8 y" p8 |+ Y7 R$ ^Volume 46 Number 6
) u9 z5 c( E2 r, _8 H: hJuly 2007 540-543
3 ^$ U8 _9 X% P( g1 H5 l) J* L© 2007 Sage Publications
/ L7 D- A+ X& A* n10.1177/0009922806296651* Z8 I: ?+ k1 G5 E
http://clp.sagepub.com. Y" V: L7 B+ q' i
hosted at
3 x$ C- t6 M2 p: O8 G* jhttp://online.sagepub.com
z; p9 U! N" v) H; UPrecocious puberty in boys, central or peripheral,) Q& k1 R: u& x4 e
is a significant concern for physicians. Central
' I! s, E' n2 \! N# v& d0 l: Dprecocious puberty (CPP), which is mediated
0 ?7 k' W) p% j, h! ^; a% Z, f- Othrough the hypothalamic pituitary gonadal axis, has
6 H* G5 Z4 i3 l. P' Pa higher incidence of organic central nervous system5 a; ?. W5 s1 O8 b U' b% @. {
lesions in boys.1,2 Virilization in boys, as manifested3 r9 b2 v& H: J/ X5 P
by enlargement of the penis, development of pubic
6 G% o _' L+ b- a4 N' J5 ]5 k! ohair, and facial acne without enlargement of testi-
. d D9 U' t) @ ]cles, suggests peripheral or pseudopuberty.1-3 We
4 u! L) J# _. Vreport a 16-month-old boy who presented with the
5 F7 _$ z8 O, F# ]enlargement of the phallus and pubic hair develop-
' n) P: G! J( q% S/ c7 tment without testicular enlargement, which was due
, W% ?* G; L& {3 X3 n5 \+ sto the unintentional exposure to androgen gel used by8 _7 @7 ?/ D5 U+ V
the father. The family initially concealed this infor-
* M' l4 E) k5 z1 ~/ ?7 Omation, resulting in an extensive work-up for this
5 {/ V' r2 v/ @1 E& a3 Q% P- g* M) @child. Given the widespread and easy availability of
X- E; y, n8 L* W5 N4 ftestosterone gel and cream, we believe this is proba-1 o" N! h! h* K7 J7 f" @
bly more common than the rare case report in the
6 ~: i1 x; ]5 ]2 P8 Xliterature.4
0 s9 v" Z4 `$ l4 G& V( ^Patient Report! B/ ] R$ e5 }7 f! R5 A
A 16-month-old white child was referred to the
6 O `- Y% B' Fendocrine clinic by his pediatrician with the concern
) F, L8 N* J. D" a% Iof early sexual development. His mother noticed! o+ n& k' \" w+ X1 ^' Y N
light colored pubic hair development when he was) V2 [6 M* W' W/ n& x: \0 Z- w" r$ Q
From the 1Division of Pediatric Endocrinology, 2University of. v2 J) l6 l7 U2 s, q9 @! `
South Alabama Medical Center, Mobile, Alabama.) L/ O) l, P0 T7 p- x7 o' ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# } ~+ j( I/ AProfessor of Pediatrics, University of South Alabama, College of% P: H4 ?' Z; s5 ?, g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 F8 [* @9 I3 J' H) Z B2 @- H
e-mail: [email protected].
+ n! R- s8 h& T8 tabout 6 to 7 months old, which progressively became: m, `% S6 n8 z" G% S. w6 V
darker. She was also concerned about the enlarge-8 S0 l4 ~+ |4 G' R# h
ment of his penis and frequent erections. The child0 `. X4 a+ v8 Z; ~! B
was the product of a full-term normal delivery, with
1 i" B9 A# h+ L9 [' |* z% ^, La birth weight of 7 lb 14 oz, and birth length of: @ @- t7 l( S3 [
20 inches. He was breast-fed throughout the first year
: @- ?- y! }" |3 D. O$ M! o% l4 h. Cof life and was still receiving breast milk along with, X) R! I7 s" Z+ K- F
solid food. He had no hospitalizations or surgery,8 d) O9 O, w, Q% `1 D2 S e# h
and his psychosocial and psychomotor development! T8 B. n) @8 Z+ [
was age appropriate.
1 A5 h( i/ _# A' ^' A" Z, bThe family history was remarkable for the father,4 M0 v3 I1 y0 K! U- p: ]! i
who was diagnosed with hypothyroidism at age 16,) f4 J' z0 f( I: @
which was treated with thyroxine. The father’s0 Y$ H2 U3 _/ }& H
height was 6 feet, and he went through a somewhat
( R7 \8 b8 r3 Q* h0 ^0 x. j5 Cearly puberty and had stopped growing by age 14.
+ z/ X# J0 ~, ~* AThe father denied taking any other medication. The' k2 A+ h3 E9 j
child’s mother was in good health. Her menarche
1 f2 _! V% z3 o1 a1 Swas at 11 years of age, and her height was at 5 feet5 ] g: p1 ^ o' w
5 inches. There was no other family history of pre-( X" A! X% v* W0 p- N5 F3 A, r
cocious sexual development in the first-degree rela-; C8 z5 C3 G+ E, n' k! G
tives. There were no siblings.
- A& k8 ~3 e& |Physical Examination
5 e% F2 e: ]/ u0 Q; TThe physical examination revealed a very active,1 h' A0 I$ F6 _# H+ y
playful, and healthy boy. The vital signs documented: s' k' Q, Q8 U; w. Q/ M
a blood pressure of 85/50 mm Hg, his length was, }# F. l ]) T* |3 n
90 cm (>97th percentile), and his weight was 14.4 kg
6 g, D2 k N9 j: w6 S+ Z(also >97th percentile). The observed yearly growth5 j* l7 ]2 f r/ q2 X
velocity was 30 cm (12 inches). The examination of
: g" o- c7 Q z3 W ~% Q* H6 mthe neck revealed no thyroid enlargement.
. S! o! [$ n4 d& q* d( L+ RThe genitourinary examination was remarkable for: F- z1 B) a3 X# ]$ W
enlargement of the penis, with a stretched length of
1 B* P) X$ }: Q1 [3 B3 Q8 cm and a width of 2 cm. The glans penis was very well
7 k- H3 d2 s! r2 ^; x) Odeveloped. The pubic hair was Tanner II, mostly around
* \! A' I6 f7 \) ?+ Q" D* p- H* V540
9 X$ [5 u! Y b5 t8 T. Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) \5 v- c0 K: d1 S# f0 E
the base of the phallus and was dark and curled. The; |3 \4 K5 L; F+ G8 T
testicular volume was prepubertal at 2 mL each.
" r: p! D: T, V% j- EThe skin was moist and smooth and somewhat9 Q9 S8 t4 ~$ S6 z' W* \' s3 N
oily. No axillary hair was noted. There were no
9 i7 m* t: x* A* Mabnormal skin pigmentations or café-au-lait spots.2 }$ t' F1 j, Q
Neurologic evaluation showed deep tendon reflex 2+
1 ~. L0 s: R7 v6 r& G" V' N3 \- Wbilateral and symmetrical. There was no suggestion
6 z6 T- h. B* A+ [' C" Mof papilledema.- Z, Z ]: H8 D: R H3 W9 x6 {
Laboratory Evaluation: p5 i% \ c- S( i* V
The bone age was consistent with 28 months by
+ M1 m1 m( i4 g qusing the standard of Greulich and Pyle at a chrono-/ U A/ { V2 [2 b9 B
logic age of 16 months (advanced).5 Chromosomal
" ` R7 v$ d3 G Z& E2 r& ]- vkaryotype was 46XY. The thyroid function test4 [+ X% h: x4 u7 W1 u# V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
' [3 B( B# B1 @lating hormone level was 1.3 µIU/mL (both normal).' W/ K, a5 x+ r Y6 O; A7 j
The concentrations of serum electrolytes, blood2 H# H$ h; b9 Q1 O1 b: X
urea nitrogen, creatinine, and calcium all were
( }6 W# G) H# i/ X: e1 c# E; f1 Zwithin normal range for his age. The concentration
$ b( z' X7 x# ]0 g2 Jof serum 17-hydroxyprogesterone was 16 ng/dL& }' @- K! {& S
(normal, 3 to 90 ng/dL), androstenedione was 20
3 W# j/ J5 I& t& L* E+ Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& W- U# {/ }, O3 s1 tterone was 38 ng/dL (normal, 50 to 760 ng/dL),& W# M( C+ Z7 y. x; `* V+ y+ e4 I( H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 ]0 L" L* Q/ b- q& q1 p. [49ng/dL), 11-desoxycortisol (specific compound S): r } J+ d2 N' Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
w N2 T! }- Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" a' N# S/ y" z9 D9 ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ B5 V" e3 u* |: X; ?and β-human chorionic gonadotropin was less than, f# R- P! `* [# G# X
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( I/ p7 y) m( f* K1 R7 Astimulating hormone and leuteinizing hormone
7 h: A- @( z& q- g0 i5 j7 {concentrations were less than 0.05 mIU/mL
* _# L1 }, O$ M/ Q3 D(prepubertal).7 ]/ B- p9 B% t' ~$ F& a0 Q
The parents were notified about the laboratory! S1 j: @6 e+ Z1 f3 B! X2 K
results and were informed that all of the tests were
r4 a0 e+ {- u4 B* ^normal except the testosterone level was high. The
u3 o K' z. \9 o( ] {follow-up visit was arranged within a few weeks to
% x$ l, f, q& i" H7 N" c# Mobtain testicular and abdominal sonograms; how-
7 Y6 X3 Q7 P/ U. i8 _' l Pever, the family did not return for 4 months.7 {6 X: e4 r8 K+ U" _4 \' j! k3 `
Physical examination at this time revealed that the
) @) w3 C. R! g. y- \child had grown 2.5 cm in 4 months and had gained- G. j9 Y" j( |% Z: y
2 kg of weight. Physical examination remained
! L! h1 i* ~9 H/ e% M' B* A" ~2 runchanged. Surprisingly, the pubic hair almost com-
0 A( W$ o8 \7 A z$ B R( Zpletely disappeared except for a few vellous hairs at
; M; s' E& l7 f6 D9 M# nthe base of the phallus. Testicular volume was still 20 ?% E6 Y2 g, N; {7 B+ i; @2 s
mL, and the size of the penis remained unchanged.! C( q( e( x, Q1 N2 O* R4 d
The mother also said that the boy was no longer hav-
# q/ s$ T7 y7 u* uing frequent erections.
' K0 T9 }5 \9 k4 z) y5 u6 h( eBoth parents were again questioned about use of
5 _# w9 |, A& U# Nany ointment/creams that they may have applied to r2 c0 g6 b1 [4 Q$ l2 |: |
the child’s skin. This time the father admitted the& ~: y) p; x' H1 }
Topical Testosterone Exposure / Bhowmick et al 541
s+ A! o3 @5 f* y# Cuse of testosterone gel twice daily that he was apply-4 S+ F1 E2 P" ]7 M
ing over his own shoulders, chest, and back area for
4 A, g; d6 E" f# [5 | ]% O- va year. The father also revealed he was embarrassed
8 Y- C, S1 F9 Jto disclose that he was using a testosterone gel pre-
" A' E) y7 N: V, d bscribed by his family physician for decreased libido) z' ~/ J% s8 v7 ]) A( v
secondary to depression.0 n+ {" D! R" f" Y$ T
The child slept in the same bed with parents.: e( g4 R% I) ]: ~9 l$ c6 a2 r
The father would hug the baby and hold him on his& r: a2 \! s) x0 m( F
chest for a considerable period of time, causing sig-
1 f! H- m1 i" [. _' P+ inificant bare skin contact between baby and father.$ a& S& f( M, B
The father also admitted that after the phone call,
& I5 I( K* o; W. [% a! [when he learned the testosterone level in the baby/ |* J3 _7 V, l4 S2 D
was high, he then read the product information
9 C' Q0 M, l0 Y1 ?0 p' rpacket and concluded that it was most likely the rea-) S" r) L, x$ K: D% d7 R' j9 m# a
son for the child’s virilization. At that time, they B% i) V' f# h7 B' N
decided to put the baby in a separate bed, and the- x. y# v( c9 M0 l' r6 L% \1 p
father was not hugging him with bare skin and had o5 ]5 u( c% {6 S3 l i
been using protective clothing. A repeat testosterone
( [3 e2 M2 Y- R# w9 @& b0 R: Qtest was ordered, but the family did not go to the: ?; S, n4 n, [' S
laboratory to obtain the test.
. F n" G- a9 nDiscussion
- k7 q9 ~3 N; t9 |3 _Precocious puberty in boys is defined as secondary" a9 y! j2 u/ G' w' |6 N' W0 x0 t
sexual development before 9 years of age.1,4; l. } L! S2 E: w. ^
Precocious puberty is termed as central (true) when
3 w- x1 y! n4 Eit is caused by the premature activation of hypo-
; r0 u/ D q4 h" c: C% m4 V9 ?+ Jthalamic pituitary gonadal axis. CPP is more com-" v# p( p: g* a0 r! A, G
mon in girls than in boys.1,3 Most boys with CPP
; |. b+ Q+ a( a4 b! I1 V; Zmay have a central nervous system lesion that is
7 d/ s+ q7 o7 f$ z! l eresponsible for the early activation of the hypothal-
1 @; t8 d) ^& D! u0 N; A5 x) u( Yamic pituitary gonadal axis.1-3 Thus, greater empha-
; ]% A6 M8 n& P6 t9 T0 j( E' hsis has been given to neuroradiologic imaging in
4 j7 d6 d' ?+ E: yboys with precocious puberty. In addition to viril-2 E% K# [/ t: h2 }
ization, the clinical hallmark of CPP is the symmet-' O' k3 T" [- U
rical testicular growth secondary to stimulation by+ N5 v' g# i( u, R) w* N
gonadotropins.1,3' G7 t% V- H, C/ `0 B1 H( d
Gonadotropin-independent peripheral preco-; h( F! ]( D+ \
cious puberty in boys also results from inappropriate6 P9 z. F! {; _! e, b
androgenic stimulation from either endogenous or
" B6 v) ^9 C/ J$ G4 m5 Q9 ^: pexogenous sources, nonpituitary gonadotropin stim-
. q v5 @ Q; b3 ?0 P4 ~ulation, and rare activating mutations.3 Virilizing
9 y3 F9 a7 Y6 P) Q8 ]3 hcongenital adrenal hyperplasia producing excessive2 N* M; p, g* B6 m- c+ k4 Q
adrenal androgens is a common cause of precocious
0 b |# j8 n6 e. E, ^, tpuberty in boys.3,4
# Q9 V, ^$ c" F& Z. i) [8 ]9 C4 A' VThe most common form of congenital adrenal9 Z \! Q7 X% j2 b8 ]
hyperplasia is the 21-hydroxylase enzyme deficiency.
; l6 f8 P; k5 R9 C8 u; H( n AThe 11-β hydroxylase deficiency may also result in% |' H/ s- w3 O$ U
excessive adrenal androgen production, and rarely,
G5 u' J3 \7 can adrenal tumor may also cause adrenal androgen( o% |2 q# R5 Y2 M9 s( j8 r
excess.1,3
# n. j8 c0 s% rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. h2 g( j2 L5 Q; g: A% E) n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ S! c8 \4 q2 r/ OA unique entity of male-limited gonadotropin-
1 ^" ]' F" f5 Z; `independent precocious puberty, which is also known
8 S( X W* K S4 s& ~$ \1 e# qas testotoxicosis, may cause precocious puberty at a
1 N+ y7 A1 h" C: ~2 T2 vvery young age. The physical findings in these boys
8 j' A+ F4 e% Hwith this disorder are full pubertal development,
W; c+ u0 X Y4 e- j* sincluding bilateral testicular growth, similar to boys4 L+ K* S, c3 W" o8 b9 p
with CPP. The gonadotropin levels in this disorder5 `4 c7 _' ?7 P
are suppressed to prepubertal levels and do not show V& f. G" E. a9 {* F+ i4 q5 |$ ?
pubertal response of gonadotropin after gonadotropin-
2 Q( T1 F5 |% sreleasing hormone stimulation. This is a sex-linked. d3 `% C$ |0 `" r8 g. \# N6 u
autosomal dominant disorder that affects only- ], ^& b7 H5 y. V
males; therefore, other male members of the family
1 @: [) w0 {" E; Zmay have similar precocious puberty.3
" H6 Z& F: ]$ v, ~& \; ZIn our patient, physical examination was incon-& Z& [6 H7 [, H0 B5 }6 n
sistent with true precocious puberty since his testi-3 p+ M3 q6 b a5 }! ]( R5 F* x
cles were prepubertal in size. However, testotoxicosis4 ~; r3 k' s' f* f
was in the differential diagnosis because his father% O$ i- |5 T# I5 r5 n' _3 t' j3 j
started puberty somewhat early, and occasionally,
/ w* o5 }+ s% [testicular enlargement is not that evident in the
4 n! r; X9 W, m, ibeginning of this process.1 In the absence of a neg-
/ Z8 p9 K, N; i2 Qative initial history of androgen exposure, our
" m+ N' u9 F9 N4 S+ i$ ybiggest concern was virilizing adrenal hyperplasia,3 @- }5 U* l# I
either 21-hydroxylase deficiency or 11-β hydroxylase* l% X( E) ]& } o& p [
deficiency. Those diagnoses were excluded by find-
+ R$ V9 R6 ~, Aing the normal level of adrenal steroids." @ H1 C; F8 L K; r; y
The diagnosis of exogenous androgens was strongly( z" z, j0 U! e$ o4 W
suspected in a follow-up visit after 4 months because
$ {1 M5 I1 G( s ?& Fthe physical examination revealed the complete disap-
4 d, M1 u8 i* v" S) ?pearance of pubic hair, normal growth velocity, and
# D. g$ W/ k& |9 G# Adecreased erections. The father admitted using a testos-
$ a) _5 N" a' Pterone gel, which he concealed at first visit. He was2 ~! p; c1 F" S( O
using it rather frequently, twice a day. The Physicians’% g) @ u' m: z
Desk Reference, or package insert of this product, gel or2 V1 Z1 ^% V% g& R" e
cream, cautions about dermal testosterone transfer to. n! q8 J: h$ _/ j! R1 `1 m. |
unprotected females through direct skin exposure.) y0 g/ [# U# \" O1 ~
Serum testosterone level was found to be 2 times the4 @6 p) A% Z/ L# _
baseline value in those females who were exposed to ~) x( s* v1 l' o2 @/ a
even 15 minutes of direct skin contact with their male
! A6 x$ L ^: C/ Npartners.6 However, when a shirt covered the applica-
/ X4 y4 P! }+ k! H. t/ Etion site, this testosterone transfer was prevented.* U( [! R2 \" Z- ^+ h
Our patient’s testosterone level was 60 ng/mL,
k& [$ |: B8 Y( Lwhich was clearly high. Some studies suggest that3 h8 k5 b* T6 O6 }
dermal conversion of testosterone to dihydrotestos-
; a/ K7 W0 ~8 c# xterone, which is a more potent metabolite, is more
/ e/ B/ ?& L/ s+ Gactive in young children exposed to testosterone8 ~$ Q k6 d u! A5 L; B$ A @
exogenously7; however, we did not measure a dihy-5 }* d% d8 ^! j# P5 }6 k, ]
drotestosterone level in our patient. In addition to
+ _/ f/ a% X6 r9 S4 F" Z2 Cvirilization, exposure to exogenous testosterone in* k& f# g! }2 @/ J" R3 D. U
children results in an increase in growth velocity and
% L6 { o4 A+ x8 G# Gadvanced bone age, as seen in our patient.
7 ^- |. h) a: U3 EThe long-term effect of androgen exposure during
; y+ r( Z* r5 ^# T" xearly childhood on pubertal development and final
- i0 d* J- h6 J. ^/ cadult height are not fully known and always remain, E5 W0 R: ` N. G. h
a concern. Children treated with short-term testos-# i* q8 i4 z+ t3 U
terone injection or topical androgen may exhibit some
4 i4 o: `5 g: y, M7 pacceleration of the skeletal maturation; however, after
% M; Y$ ^1 z0 F* R1 R& Tcessation of treatment, the rate of bone maturation
6 F. ?+ y6 ]* Cdecelerates and gradually returns to normal.8,9: Z' ], I! X/ o- R" u# \4 A
There are conflicting reports and controversy
; \9 D+ z" B0 W+ h& G+ Nover the effect of early androgen exposure on adult+ ?* q* u6 @9 T+ U
penile length.10,11 Some reports suggest subnormal, [& {& C/ v3 f! h# z; [' ]
adult penile length, apparently because of downreg-4 q4 U$ c- M2 o" l1 [" R! }- {
ulation of androgen receptor number.10,12 However,- @/ r7 ?" i6 }8 _$ N2 V
Sutherland et al13 did not find a correlation between; R8 k. s/ @4 j' T. j* F0 h3 f; a
childhood testosterone exposure and reduced adult
$ A* J& i7 w7 rpenile length in clinical studies.! g0 w6 p9 h( B" E7 _& D
Nonetheless, we do not believe our patient is- j: y) i0 b2 U7 E
going to experience any of the untoward effects from
- s$ I- q" x7 S @. H- ^8 p& ltestosterone exposure as mentioned earlier because
! v8 o# _6 q F |& f; r. jthe exposure was not for a prolonged period of time.
/ I4 l' M8 ?) S; fAlthough the bone age was advanced at the time of: D2 K! a# ?, h, E3 G8 v7 v) l
diagnosis, the child had a normal growth velocity at1 b; e3 V& s' l
the follow-up visit. It is hoped that his final adult
! _% \# \, i( eheight will not be affected.
, ]7 f5 d8 _. p# c! \. G& a: xAlthough rarely reported, the widespread avail-
# b5 e9 @9 n) s7 J9 K9 |4 q; bability of androgen products in our society may! d6 d4 P& S6 |& q$ n- T
indeed cause more virilization in male or female
( J/ I$ ~; y7 ~2 zchildren than one would realize. Exposure to andro- Q: ^0 r. |& m$ P t
gen products must be considered and specific ques-
1 {6 t- h6 S- \( S/ htioning about the use of a testosterone product or8 O0 ]/ ]: `2 d# Y* s
gel should be asked of the family members during) j% `: {% \1 s8 `' n# B
the evaluation of any children who present with vir-
' l+ n$ c. x s, h/ Uilization or peripheral precocious puberty. The diag-1 X, g+ o3 W7 [8 s# ]4 O9 }
nosis can be established by just a few tests and by
( H. ^* ?4 F& k, S ?. Z+ Uappropriate history. The inability to obtain such a& X( b& E0 {0 g" i
history, or failure to ask the specific questions, may
" H5 y3 H4 N( Y3 ]result in extensive, unnecessary, and expensive
/ ^3 y# N0 C) B2 p% P" D1 n, uinvestigation. The primary care physician should be. b9 B5 k( }( r$ b5 v- t
aware of this fact, because most of these children9 d- z* D q. O, L: \
may initially present in their practice. The Physicians’; s" a8 ?) {. F/ \
Desk Reference and package insert should also put a
+ k" B, K1 y8 a0 P* nwarning about the virilizing effect on a male or
* [ I/ X8 ~' Q3 a) t2 d. ~' Ifemale child who might come in contact with some-* ~! F) c. Y) A
one using any of these products.
7 g, f. K* u6 m# {References
5 U! B( k7 C! ]% q1. Styne DM. The testes: disorder of sexual differentiation& ? `& r4 A/ T8 k
and puberty in the male. In: Sperling MA, ed. Pediatric8 W7 J( W0 `9 ]4 ?' {) h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( X" ^- r/ `* h1 r4 j o# \- J- h2002: 565-628.$ L. H. ?" P+ P/ P% E. n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' {0 m# {/ i& p3 @8 z
puberty in children with tumours of the suprasellar pineal |
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