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Sexual Precocity in a 16-Month-Old, r, T: h4 x' P9 F+ `
Boy Induced by Indirect Topical' l# c8 x8 C9 o
Exposure to Testosterone% K2 P2 h0 J: W- W% I; {* }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) L1 C; |9 J& Q( }, ]! U+ |8 C. L
and Kenneth R. Rettig, MD1
2 w# G* S. [( JClinical Pediatrics
; O1 f: O7 ~1 J2 q8 l4 JVolume 46 Number 6
/ P: u" _+ K* J. \* r& [) c4 FJuly 2007 540-543
) `! ]3 p2 l+ ~( t& s, A© 2007 Sage Publications5 r' M9 v$ u) @/ |: ]6 h
10.1177/00099228062966512 k7 f: c, H* k! i
http://clp.sagepub.com
( S8 c A2 R. H! f. Z2 }! ghosted at+ ^4 E: K) u, N( O! M5 o4 R
http://online.sagepub.com
3 N) l: j; o$ ?2 m' ~9 q" \( XPrecocious puberty in boys, central or peripheral,
+ c {/ y% W- {( F7 J5 R3 v0 L8 ?is a significant concern for physicians. Central: P/ V9 R7 J: o9 H
precocious puberty (CPP), which is mediated
8 `+ U. _+ ?/ W! u# w* ethrough the hypothalamic pituitary gonadal axis, has
7 Y% e9 Y B, A' m/ ka higher incidence of organic central nervous system
9 `' @7 p0 o' k* ?3 V+ x7 }* P% ?( Hlesions in boys.1,2 Virilization in boys, as manifested
- }# h, o$ c& S0 j" g# qby enlargement of the penis, development of pubic
0 Z1 B+ y4 T- x$ `. _hair, and facial acne without enlargement of testi-5 x2 d9 Y% B8 o: r8 V) }8 s
cles, suggests peripheral or pseudopuberty.1-3 We
3 m H0 @; Q' b& I0 X2 Nreport a 16-month-old boy who presented with the
9 y: G* H9 o% ^$ \* \3 Tenlargement of the phallus and pubic hair develop-7 a5 ?& l0 \' B* t: t
ment without testicular enlargement, which was due& }' x5 G& X0 q
to the unintentional exposure to androgen gel used by
6 D0 [ n, |1 o4 kthe father. The family initially concealed this infor-) e& v9 w. C2 C& G0 q$ V. B+ }) t' E" h
mation, resulting in an extensive work-up for this
, V7 q- X- X/ a3 P0 schild. Given the widespread and easy availability of2 W9 S6 c6 h# t! e. l
testosterone gel and cream, we believe this is proba-
' x& x; }( ]8 ?, L- T* X2 fbly more common than the rare case report in the
, N% K! J: g9 [2 ]: j. Sliterature.4
2 b' V. f# b- f1 P9 [1 ?! hPatient Report& E* i5 Y/ Y t; E: U; Y
A 16-month-old white child was referred to the# b$ R9 V! J9 S
endocrine clinic by his pediatrician with the concern
: w- k# P: c* K& O2 mof early sexual development. His mother noticed* f3 ]* w9 ~- U# d) r' K: d
light colored pubic hair development when he was5 t$ a8 ^" `# D* n
From the 1Division of Pediatric Endocrinology, 2University of
y# }) h1 T) h* X0 {, }4 PSouth Alabama Medical Center, Mobile, Alabama.
: f. L+ p* ^) G# N7 L( fAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: p! C6 ? Q9 L2 K# Z7 Y, }7 W/ ]Professor of Pediatrics, University of South Alabama, College of& s3 b" |$ A) R0 i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ b- y' s% z: X4 `: P# Ae-mail: [email protected]./ |/ ]3 O7 B9 g, g
about 6 to 7 months old, which progressively became
' u ]) c/ n, N, Y" W8 qdarker. She was also concerned about the enlarge-: `, \9 t2 F; A& G1 w* Q
ment of his penis and frequent erections. The child
" F5 J) A5 J; ^was the product of a full-term normal delivery, with
8 {2 l3 J4 P; d" ^2 t; V1 |/ Xa birth weight of 7 lb 14 oz, and birth length of
$ G2 i( p Z7 F/ e8 R) d20 inches. He was breast-fed throughout the first year
$ q* c& ?: P* S4 R8 i, Z# {of life and was still receiving breast milk along with1 r' ]8 g* L+ _: ?; n2 e- e9 l
solid food. He had no hospitalizations or surgery,
* y( e+ l8 c4 ~, V1 u2 \$ Q _and his psychosocial and psychomotor development
( K+ ^- f% S# @) s3 h6 ~8 fwas age appropriate.: l/ i* @) f% x
The family history was remarkable for the father,
$ \: B2 ~ R! B( g# ^who was diagnosed with hypothyroidism at age 16,
) D, h; ?% R3 X: g2 S' u0 S d' fwhich was treated with thyroxine. The father’s
/ i, B% ]% o1 o1 Fheight was 6 feet, and he went through a somewhat% u2 A. O8 |9 ~( |
early puberty and had stopped growing by age 14.- g0 v8 K) l9 h z
The father denied taking any other medication. The
% n1 S+ O1 A6 W2 X2 n7 S" Y& zchild’s mother was in good health. Her menarche
% W7 n* q' K/ r/ x+ @7 q; {5 owas at 11 years of age, and her height was at 5 feet, ~4 g5 _! n5 M! I% J9 d
5 inches. There was no other family history of pre-
& _; T, X! ^# w2 Vcocious sexual development in the first-degree rela-
8 `7 M9 ^' I# V8 Q9 vtives. There were no siblings.% ^, p& Q; z/ X, B0 V3 a
Physical Examination* T& B0 A2 Q: s* W) _
The physical examination revealed a very active,
- d0 c# \; C: Y& f0 ~) O; hplayful, and healthy boy. The vital signs documented
" s6 h/ ]' b! ]* M; E) g4 J7 k Ea blood pressure of 85/50 mm Hg, his length was
& E1 \/ V5 i8 v6 C/ R; H( J+ z, L/ V90 cm (>97th percentile), and his weight was 14.4 kg
: m' L, N, m, S) y(also >97th percentile). The observed yearly growth
" g0 c7 F# ?; C7 |) Fvelocity was 30 cm (12 inches). The examination of9 l7 Z3 {% @" ]
the neck revealed no thyroid enlargement.
I3 R& @/ N3 f6 @: @& r a$ x+ qThe genitourinary examination was remarkable for" v- p' Y e7 T$ P
enlargement of the penis, with a stretched length of
1 c K: P6 M0 I. S8 cm and a width of 2 cm. The glans penis was very well
* N! M0 Q A' ^developed. The pubic hair was Tanner II, mostly around8 U& z0 I$ q; s2 O
5407 S% ?- w6 B8 T; a, j% b8 E- R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ ?" |, W% @* J$ P2 L' O1 o2 Tthe base of the phallus and was dark and curled. The7 ~5 |$ V8 j4 ^* V2 w: O2 v6 S
testicular volume was prepubertal at 2 mL each.
5 C( r' w; H5 F ^( `* i$ _The skin was moist and smooth and somewhat. u4 C1 S% d, F$ j$ c) ^8 ^8 B
oily. No axillary hair was noted. There were no
; h: a9 o7 X8 {# g' R0 Babnormal skin pigmentations or café-au-lait spots." y& v2 ^) ~- Q8 @
Neurologic evaluation showed deep tendon reflex 2+# g6 S# T* k; M8 ?+ _0 u: ^9 w
bilateral and symmetrical. There was no suggestion3 q8 j+ {- b$ W) {
of papilledema., R T! N" a! m" s# [$ Y2 n4 K$ z
Laboratory Evaluation
! r' O+ J; g$ q$ @The bone age was consistent with 28 months by
6 t: Q4 p8 C, Susing the standard of Greulich and Pyle at a chrono-/ `% I, G: L* X
logic age of 16 months (advanced).5 Chromosomal; `! K( f$ L& E" {9 y& R- j* J- i' B
karyotype was 46XY. The thyroid function test' r. U/ F8 p2 R x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ E8 O( r& f- i% M5 i! ?lating hormone level was 1.3 µIU/mL (both normal).1 {- u" f- x) o! B( y
The concentrations of serum electrolytes, blood
, o2 [+ z* a: T Q2 rurea nitrogen, creatinine, and calcium all were& _. D2 } p4 R
within normal range for his age. The concentration: q( ~- V* k! z q4 T$ F( s
of serum 17-hydroxyprogesterone was 16 ng/dL( }1 ^0 t3 z. Z* P) l* m
(normal, 3 to 90 ng/dL), androstenedione was 20% u! Z) _' E, s
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: E, Z" O: k" m% m0 y( t% `terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; B8 N# s& M) Z4 c' C! @3 zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ } E% {% {: d
49ng/dL), 11-desoxycortisol (specific compound S)
; \0 ?6 r5 Q. c% {& c" v- nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, w; t! O2 _/ q( s& `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* h& P0 Y; o* P& ]( U/ @+ s
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 W1 y3 @" P: r" N, y5 h
and β-human chorionic gonadotropin was less than8 J) u4 R" l( E! f8 ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: }6 S- A q, ^! v: E vstimulating hormone and leuteinizing hormone
! l8 X" K3 D" ]8 c" a1 I# L) A; nconcentrations were less than 0.05 mIU/mL
3 S9 l# s1 Z/ R(prepubertal).
: T y9 [2 @% d% a6 aThe parents were notified about the laboratory: ~$ O! E5 `, { F& M
results and were informed that all of the tests were- s$ i- S( ^5 m' x L3 d
normal except the testosterone level was high. The
U4 \1 n( h8 M! h5 I. Yfollow-up visit was arranged within a few weeks to. o, i0 i9 O! g$ T3 v
obtain testicular and abdominal sonograms; how-4 o% N, |( j K, }, t
ever, the family did not return for 4 months.* T0 ]7 i$ O" M
Physical examination at this time revealed that the
- i# ~& j$ k2 Echild had grown 2.5 cm in 4 months and had gained
% _5 a8 T: X/ I2 kg of weight. Physical examination remained
8 R2 a9 Q8 r$ \% C& o) p0 vunchanged. Surprisingly, the pubic hair almost com-9 {4 D2 s+ H! G) \! O' E
pletely disappeared except for a few vellous hairs at
$ p" X: H: S4 {3 ?6 b" |$ r: [* @the base of the phallus. Testicular volume was still 2
+ X: G: ]7 b- E$ u$ P! imL, and the size of the penis remained unchanged.
9 E2 c& d+ A( a" Y2 a8 X+ I" q1 sThe mother also said that the boy was no longer hav-
0 n7 `- Z- Q- w) x0 ting frequent erections.
( y5 S/ ]8 @6 W3 e) h LBoth parents were again questioned about use of! h, K0 e9 `2 x8 O+ N9 X0 f$ u* \
any ointment/creams that they may have applied to" v% A6 l8 g5 i+ ^8 e
the child’s skin. This time the father admitted the& u1 Z. y7 \1 f
Topical Testosterone Exposure / Bhowmick et al 541
E3 U5 R: o$ G# \$ suse of testosterone gel twice daily that he was apply-' p. P: d7 l q& r; {- J& d
ing over his own shoulders, chest, and back area for" f, F v0 `2 X. B
a year. The father also revealed he was embarrassed
2 j2 D* c5 t6 xto disclose that he was using a testosterone gel pre-$ T" R( s8 U% M5 T# E6 g
scribed by his family physician for decreased libido4 {" z" t. ^% l
secondary to depression.
# _5 a) f( C% c- m: YThe child slept in the same bed with parents.9 R& j1 B4 Q$ y
The father would hug the baby and hold him on his
( O, O, L( _+ L4 s1 A8 Fchest for a considerable period of time, causing sig-
, ~5 q. z/ e2 g6 w. xnificant bare skin contact between baby and father.1 R8 Q* E2 e$ p
The father also admitted that after the phone call,- `) I" e! p$ Q9 A& j4 t% n! a
when he learned the testosterone level in the baby2 c: M: ^3 M# j) K' [) V. U
was high, he then read the product information& l# T' y `) Z* X; Y5 b5 G
packet and concluded that it was most likely the rea-
3 W+ J0 h) Q/ G) e, Y; Hson for the child’s virilization. At that time, they7 q0 @; c% O. g6 n
decided to put the baby in a separate bed, and the/ C+ N' L/ o8 s/ U% Y" m( d5 g9 |
father was not hugging him with bare skin and had& S* A7 p$ y, s6 x
been using protective clothing. A repeat testosterone. i7 s# ^/ m( Y6 I3 a; V, H0 Z7 R
test was ordered, but the family did not go to the
- q( |" Q4 Y" S8 E: p/ Blaboratory to obtain the test." N# Y3 {4 N0 K+ b
Discussion5 p( m% Z& E' s7 M
Precocious puberty in boys is defined as secondary5 i- R6 i& r* t7 h& c7 ?
sexual development before 9 years of age.1,4
9 C7 V! t5 z! F/ ]: NPrecocious puberty is termed as central (true) when, W5 F' p1 S6 ?' n
it is caused by the premature activation of hypo-" R$ f9 N3 }5 w3 O1 \. T
thalamic pituitary gonadal axis. CPP is more com-4 O7 l) o, S: j! v. a4 V
mon in girls than in boys.1,3 Most boys with CPP
+ A, A5 A1 ?8 y: ~$ ^may have a central nervous system lesion that is, w( d* H) g) h/ z* ]% p `3 s
responsible for the early activation of the hypothal-, ~) n3 ~/ Z# N+ _' J
amic pituitary gonadal axis.1-3 Thus, greater empha-& O& X" U% |* W1 {
sis has been given to neuroradiologic imaging in
: g# _! [4 w+ `/ [/ V0 d' g" }+ Yboys with precocious puberty. In addition to viril- K9 M4 h9 q7 F6 O5 N; ?
ization, the clinical hallmark of CPP is the symmet-& ?) a1 G) p( z% K- N
rical testicular growth secondary to stimulation by
! V! D# c5 J1 X/ Xgonadotropins.1,33 f$ q$ m9 X% c+ C) e0 h
Gonadotropin-independent peripheral preco-7 s' C5 q& d* [8 l' r- @
cious puberty in boys also results from inappropriate5 D2 q, l* \! J7 d1 |
androgenic stimulation from either endogenous or
+ P$ _9 u' H8 Yexogenous sources, nonpituitary gonadotropin stim-, N2 M' l# x9 [* c5 L
ulation, and rare activating mutations.3 Virilizing
- r6 b/ W% e6 ^& K' R1 H8 |congenital adrenal hyperplasia producing excessive
7 C5 F5 k; w, @/ ^- uadrenal androgens is a common cause of precocious/ Z+ P q9 O7 ~% Q3 B. Y
puberty in boys.3,48 v2 c* R1 x g! O2 p9 U
The most common form of congenital adrenal8 H; x7 Q* c3 h
hyperplasia is the 21-hydroxylase enzyme deficiency.
. k* R8 B' [3 n- Q6 |The 11-β hydroxylase deficiency may also result in1 \5 D$ M& @6 c# l% J
excessive adrenal androgen production, and rarely,
1 b% i* C% j- ~' t5 I9 uan adrenal tumor may also cause adrenal androgen
L0 |/ O& R+ x! O; L' e" u: a6 ~1 R" M( rexcess.1,3
\! v8 n. ]* I- M2 Q+ h9 c2 L# Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ \, S( O' n! x0 _5 {
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ t5 u3 [+ h6 y& yA unique entity of male-limited gonadotropin-2 ]) G, J( L4 `! f. y3 N
independent precocious puberty, which is also known) c: b8 f& D3 Z, k9 {7 P# q* _
as testotoxicosis, may cause precocious puberty at a
, |- f: p& C6 U3 T4 Z+ Gvery young age. The physical findings in these boys' @. F. J4 c0 l0 {
with this disorder are full pubertal development,. j C6 f/ P9 I% E% o- L7 F! C
including bilateral testicular growth, similar to boys* E+ w3 ~, v4 \$ Q! u
with CPP. The gonadotropin levels in this disorder0 F6 x! q/ }7 u. ^, M
are suppressed to prepubertal levels and do not show0 n7 Y. z! L/ L& n
pubertal response of gonadotropin after gonadotropin-
, M! p7 P. k) k7 s5 hreleasing hormone stimulation. This is a sex-linked
" D: R/ h7 U; S" X/ p! Oautosomal dominant disorder that affects only
& x$ x+ k4 C5 M& umales; therefore, other male members of the family
- U% H0 ~+ p/ ?2 nmay have similar precocious puberty.3
F7 O0 D; O! s# \. H( h1 T! bIn our patient, physical examination was incon-- }7 ^ R& Z. J5 Y' J* x, ~
sistent with true precocious puberty since his testi-
p' c4 i* F5 L5 E, _+ f; D, Acles were prepubertal in size. However, testotoxicosis
3 E9 g. a8 K- E. V/ g, Z2 |+ `was in the differential diagnosis because his father
7 v5 P# a( ^- `' p. @' Astarted puberty somewhat early, and occasionally,* f) l( L* E; [4 g; V: B
testicular enlargement is not that evident in the
+ i% O( N5 e& [' ~beginning of this process.1 In the absence of a neg-
0 A6 k6 p5 o8 |2 G. Aative initial history of androgen exposure, our
, n. [- R/ N' H* Gbiggest concern was virilizing adrenal hyperplasia,
1 T6 F# m0 B' ]+ R R( Veither 21-hydroxylase deficiency or 11-β hydroxylase
+ m2 e0 t( i/ m/ }' K- H) _0 |deficiency. Those diagnoses were excluded by find-. {3 e/ i. W$ w; `5 O$ F' ]$ I
ing the normal level of adrenal steroids.
% @; w2 w: z1 K9 F4 pThe diagnosis of exogenous androgens was strongly
8 X1 v8 `) m: B+ A3 O w$ z8 Tsuspected in a follow-up visit after 4 months because" q7 n+ x0 X2 R" O% U* M2 r
the physical examination revealed the complete disap-; |7 f2 i. F$ D* m/ V
pearance of pubic hair, normal growth velocity, and
' I% d0 c; A4 o0 mdecreased erections. The father admitted using a testos-, ]- x w; Q8 O* _1 j* u9 @. J! e1 C% w. `
terone gel, which he concealed at first visit. He was, }) S# P6 o5 p0 N. O
using it rather frequently, twice a day. The Physicians’
" u4 {! x) }$ }, y) ?Desk Reference, or package insert of this product, gel or
& ]* T/ ]5 G! f5 Q4 Ycream, cautions about dermal testosterone transfer to6 o7 ?- ^) w8 Z
unprotected females through direct skin exposure.7 z. I$ n- \: }% A
Serum testosterone level was found to be 2 times the
* h! `& t: F( g6 B/ ubaseline value in those females who were exposed to; ~" u' `% K, i$ Z
even 15 minutes of direct skin contact with their male
# K. W5 G/ K7 L9 p6 z5 r/ epartners.6 However, when a shirt covered the applica-* l, w) s% u/ r" d4 K
tion site, this testosterone transfer was prevented.
2 W; U1 i1 |, w; SOur patient’s testosterone level was 60 ng/mL,0 K% c& f9 e7 B2 S1 Q$ P2 o& v; F
which was clearly high. Some studies suggest that
% Q3 S. h$ d# ]" e Fdermal conversion of testosterone to dihydrotestos-7 G+ ?% w& D1 T% t( d
terone, which is a more potent metabolite, is more
A* o) W2 g6 ^( xactive in young children exposed to testosterone
" a+ G% e8 [/ ^" m6 D$ p! ~- k6 |0 z- qexogenously7; however, we did not measure a dihy-
8 E% C Q5 ?* u3 G! Q: l* c; ^drotestosterone level in our patient. In addition to6 z: z, x. v; F% B
virilization, exposure to exogenous testosterone in2 r7 e k! ^) W3 U! q$ K
children results in an increase in growth velocity and
0 z& ~) x f' ?- o# O6 Eadvanced bone age, as seen in our patient.) G y$ z& P/ G; p. _, _9 q4 |
The long-term effect of androgen exposure during% V2 c# i7 U4 ?. l
early childhood on pubertal development and final
/ {* u- M9 ^/ F5 Q1 \# C3 }1 g. Y3 n4 madult height are not fully known and always remain
# \. _2 c0 e# P$ l ma concern. Children treated with short-term testos-
/ ^, f8 L! J) V# z' Mterone injection or topical androgen may exhibit some$ b1 Z* o! v- V U. m
acceleration of the skeletal maturation; however, after' H. E; J0 D6 V# m! S
cessation of treatment, the rate of bone maturation6 H* J$ Y4 w7 M% J0 X2 u3 G
decelerates and gradually returns to normal.8,9
+ U0 O9 W' i$ t5 \; T' m1 O: NThere are conflicting reports and controversy
1 ~# {( n& g7 l f4 A* f' ]over the effect of early androgen exposure on adult. M- F( J& @0 ~4 p
penile length.10,11 Some reports suggest subnormal7 P4 N; A8 S# C! a& t7 N- \
adult penile length, apparently because of downreg-* m0 J$ w, `) L
ulation of androgen receptor number.10,12 However,
% I( p4 u# v+ |% _* XSutherland et al13 did not find a correlation between
+ G. X* H2 I/ F8 \+ Fchildhood testosterone exposure and reduced adult
O8 b7 L3 J2 E1 \' Y1 Fpenile length in clinical studies.* R% C0 i& K) u* _
Nonetheless, we do not believe our patient is
7 l6 ?: K5 p% E" t& [going to experience any of the untoward effects from
7 ~5 Y/ K) Q" V( Q7 Qtestosterone exposure as mentioned earlier because; N1 j; Z9 W3 k5 b* G
the exposure was not for a prolonged period of time., L3 M& ?" I1 ]: W* I/ K0 D
Although the bone age was advanced at the time of
7 A2 R9 F0 [& E1 h* Ediagnosis, the child had a normal growth velocity at8 Y+ v% x8 B% D
the follow-up visit. It is hoped that his final adult. I6 T& C' P0 `9 m! M
height will not be affected.7 O9 b* o' V, f8 ?( t7 h
Although rarely reported, the widespread avail-! z" G8 s: p# E$ E1 g9 B
ability of androgen products in our society may+ [9 o. L9 @; B) X
indeed cause more virilization in male or female- ?/ b, O/ ~0 Y- V2 K
children than one would realize. Exposure to andro-
( Y6 C# Q, O' n1 vgen products must be considered and specific ques-
/ j0 Q2 V4 s- N/ M* m1 I& ]tioning about the use of a testosterone product or7 O7 T1 y Z& r
gel should be asked of the family members during T' s" j( ]" N6 l. m/ ^! _3 `
the evaluation of any children who present with vir-
6 c/ q- W& E! Z5 zilization or peripheral precocious puberty. The diag-; m. T- d% [. D0 I y
nosis can be established by just a few tests and by
# c5 G7 X, D! z5 b5 Jappropriate history. The inability to obtain such a( S) f9 G4 U; E/ ?. E
history, or failure to ask the specific questions, may' D+ Z& p8 F e6 i) g* V2 r* R. M
result in extensive, unnecessary, and expensive
) j7 m- w8 F' `investigation. The primary care physician should be, g: k7 X+ R6 x3 m- T$ v; t
aware of this fact, because most of these children
4 W$ `8 A; k6 n2 smay initially present in their practice. The Physicians’: |. e! H0 M* ~$ l! f K
Desk Reference and package insert should also put a
# x7 X. S& R+ r0 `& z! |warning about the virilizing effect on a male or
2 P! C$ [2 D I; c4 @female child who might come in contact with some-
" B. P1 ~/ m8 h0 [6 {one using any of these products." P+ M9 G- P! I3 }: O
References( i( D4 r0 J8 U$ X s- @* U2 G6 Q
1. Styne DM. The testes: disorder of sexual differentiation3 @4 U) n3 O2 d8 n3 o* y
and puberty in the male. In: Sperling MA, ed. Pediatric) o# `8 z \( e/ _& @6 n c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% T7 ^# ]8 c9 o3 s/ Z" B0 a$ o3 v2002: 565-628.
2 U% s8 v# P- j' I6 m, @2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 W$ q& y' K. k4 R3 Z
puberty in children with tumours of the suprasellar pineal |
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