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Sexual Precocity in a 16-Month-Old% K, n" W+ n9 t9 a$ `
Boy Induced by Indirect Topical5 \5 l. o, u" T' H* v# u. \7 o
Exposure to Testosterone. B/ |" g6 Y% g7 ~. D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ R/ T7 S$ G, d) n7 Z; _
and Kenneth R. Rettig, MD1
0 {. Y2 P8 S& v4 B! o- fClinical Pediatrics
$ @4 W2 v/ W5 w8 a/ W6 t4 fVolume 46 Number 60 S$ P3 a r* G- M! N9 @
July 2007 540-543
2 p- \! ]% w2 z- U. r7 e! S© 2007 Sage Publications" f4 y9 _3 F# p& E$ u, B% x
10.1177/0009922806296651
& H9 B0 R" H1 g" _, X6 n2 z$ Ehttp://clp.sagepub.com
' _ K- ]2 I; O2 U7 n, ]) m5 P, [4 @hosted at
: H$ D6 g0 Z; R) P/ O! ^3 X; Zhttp://online.sagepub.com1 U8 ^ U. P9 \% t
Precocious puberty in boys, central or peripheral,0 {' o! i/ t& h. B4 L
is a significant concern for physicians. Central/ P0 f% ~8 E @$ W) ], _
precocious puberty (CPP), which is mediated6 U7 A* A& n+ i- P; o2 `5 _
through the hypothalamic pituitary gonadal axis, has
) j, V& n8 Y# i& g( J" f9 t. v9 Na higher incidence of organic central nervous system
3 X8 F# j4 R& \lesions in boys.1,2 Virilization in boys, as manifested
) q' O4 N0 }+ l' qby enlargement of the penis, development of pubic
6 ~4 _9 t: O" t+ K. m# E# ?hair, and facial acne without enlargement of testi-
& Q! s- W& E+ S. E$ X! Hcles, suggests peripheral or pseudopuberty.1-3 We# [1 e5 M5 X$ f6 a2 I
report a 16-month-old boy who presented with the% ]5 F- S0 Y, {' V2 m. W
enlargement of the phallus and pubic hair develop-
. a. j1 X5 e7 ~ment without testicular enlargement, which was due
( a+ k i7 R0 I# A; R2 ito the unintentional exposure to androgen gel used by
# ~* F9 I; S$ xthe father. The family initially concealed this infor-. h9 V9 ~" [2 @. L. O) n5 x! a
mation, resulting in an extensive work-up for this& U0 L' w: s/ Y4 _ g! N" b
child. Given the widespread and easy availability of- R' i; @! a" P& O5 x( U9 M
testosterone gel and cream, we believe this is proba-
1 J- ?' C/ a" a8 Tbly more common than the rare case report in the$ B3 }6 a3 T. ~3 f, V
literature.42 f/ y) W3 D& N
Patient Report( g2 f( L/ l7 G5 X2 Y
A 16-month-old white child was referred to the" U& g# t% s5 J, R
endocrine clinic by his pediatrician with the concern
x+ D2 V, i. a9 x# Q' W3 x3 nof early sexual development. His mother noticed& \" l; E2 J- J3 X6 `
light colored pubic hair development when he was+ F# y) \# E; K2 I. f g( s
From the 1Division of Pediatric Endocrinology, 2University of1 j# C' v: Z; d' o
South Alabama Medical Center, Mobile, Alabama. i$ B( Y) N) q" P! S' c
Address correspondence to: Samar K. Bhowmick, MD, FACE,- T! {4 h! X" @1 j' I0 N
Professor of Pediatrics, University of South Alabama, College of! M3 ^5 ?/ R. I, ~! x! u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 q, Q4 M. ^) T; F) Qe-mail: [email protected].0 c' N( _4 k$ ^3 o: V
about 6 to 7 months old, which progressively became5 |' M" g# j) _
darker. She was also concerned about the enlarge-4 D0 k4 R( r" X2 Q
ment of his penis and frequent erections. The child
2 m0 L9 h( r6 m* l% W2 cwas the product of a full-term normal delivery, with; ~" P- B9 Q4 X. q" [8 v
a birth weight of 7 lb 14 oz, and birth length of1 T7 Q2 o3 a7 T7 T2 R3 v" L
20 inches. He was breast-fed throughout the first year
5 D$ [- N* w( _1 \( D& _of life and was still receiving breast milk along with- ] n! j9 {0 H9 X
solid food. He had no hospitalizations or surgery,
$ S: q# E' _) {5 t# @and his psychosocial and psychomotor development
0 g- O/ A7 i, D" m5 u+ bwas age appropriate.* @. ~4 H/ p, r
The family history was remarkable for the father,* X$ t a1 X( c4 ^" x
who was diagnosed with hypothyroidism at age 16,. d. D) F% w; @
which was treated with thyroxine. The father’s
; N' q2 F) i- |height was 6 feet, and he went through a somewhat
( S6 f; {' G, Z- j W- i2 Tearly puberty and had stopped growing by age 14.
8 a; p+ E$ q: q: P3 K3 LThe father denied taking any other medication. The
* l7 U: n8 @ P: a) b* x- t bchild’s mother was in good health. Her menarche( N( N0 G+ `+ I" l# m2 S: f! ?
was at 11 years of age, and her height was at 5 feet4 ?( {4 M0 v k7 v
5 inches. There was no other family history of pre-9 t% T- `% L$ U4 X4 C
cocious sexual development in the first-degree rela-
1 \" X+ t! A X- ?2 p5 d0 m% S; m& O" Dtives. There were no siblings.
. L8 D' r& O2 M! j% b& z' PPhysical Examination, z; m" Z6 S7 k9 Q2 M* S' ^$ C
The physical examination revealed a very active,6 L: N+ z1 g" L0 ^& A9 C" L" l3 `5 _0 S5 U
playful, and healthy boy. The vital signs documented
# z3 Y# Q0 C) La blood pressure of 85/50 mm Hg, his length was: Y3 b; K5 P6 d, d" q) Y6 M, j
90 cm (>97th percentile), and his weight was 14.4 kg
, J& b/ d. a1 C9 o2 Z* Y(also >97th percentile). The observed yearly growth3 r/ W8 u- M7 X7 U7 {$ Z
velocity was 30 cm (12 inches). The examination of
; r4 W) {/ |4 V6 Nthe neck revealed no thyroid enlargement.
% H4 L; d5 q" t: Y0 ZThe genitourinary examination was remarkable for. X1 d. M+ N: g; E: X
enlargement of the penis, with a stretched length of' d2 q j! w$ a! h, w) J& D7 a |8 U
8 cm and a width of 2 cm. The glans penis was very well
3 C7 g5 D1 H. |( ideveloped. The pubic hair was Tanner II, mostly around; [. M. P& J3 `
5408 O7 I, W1 ]3 O' x# d& \# F; j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% o' I. ?( [4 ?" @5 t( t) `# pthe base of the phallus and was dark and curled. The
" z2 G* m0 I: [9 L& s5 }; jtesticular volume was prepubertal at 2 mL each.; p2 |8 G; I2 S1 e1 w. G" b
The skin was moist and smooth and somewhat$ C6 o( d& G' P1 x
oily. No axillary hair was noted. There were no
* `8 E6 w2 Z7 K8 c' ?1 Eabnormal skin pigmentations or café-au-lait spots.
" g( ]! f9 r: g% M8 GNeurologic evaluation showed deep tendon reflex 2+ [6 o, C) ^/ R2 k d4 S% h! q
bilateral and symmetrical. There was no suggestion
( f+ O1 ?/ Z6 a2 f( Dof papilledema.. J w& e9 l* B" _' o* i6 v. W
Laboratory Evaluation
* v1 _+ g' V' ]) f f$ ^The bone age was consistent with 28 months by
2 S! ?$ w9 V6 H0 |; u7 uusing the standard of Greulich and Pyle at a chrono-
( _2 }$ R6 K2 n4 L) n5 X' K% Glogic age of 16 months (advanced).5 Chromosomal
5 n5 ^4 h* @. x8 d( ?, Lkaryotype was 46XY. The thyroid function test
3 W- U2 p2 ?% Q0 Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: i+ \: Z) l( Y t% I; i+ ^# V+ U
lating hormone level was 1.3 µIU/mL (both normal).
2 C$ j0 Y0 r' m( _- |% IThe concentrations of serum electrolytes, blood) @ H$ f* `( w \
urea nitrogen, creatinine, and calcium all were$ ~4 c4 g, a( [' n2 o, i' w
within normal range for his age. The concentration
4 A# D( P; m" P% J3 I' pof serum 17-hydroxyprogesterone was 16 ng/dL, f& N9 J! l2 n1 Z% P
(normal, 3 to 90 ng/dL), androstenedione was 20
# b- S$ |4 X+ Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 Y% `# z& A9 ?' o- C/ |/ T) V( K. ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; D5 }. i# _2 D! q$ _desoxycorticosterone was 4.3 ng/dL (normal, 7 to) l7 R7 q- D5 |5 a
49ng/dL), 11-desoxycortisol (specific compound S)
6 s* J% K0 m' c% V2 Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 u5 y$ v) l2 R4 `$ }
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" f0 a7 q! k; X) J d# Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' q: r7 v0 N+ K2 J# Q* s( L
and β-human chorionic gonadotropin was less than. F( i: G5 R* E' o" {- d. O, Y- M9 g' K
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# |% H, Q* F6 b/ N1 tstimulating hormone and leuteinizing hormone
# B( v' H3 \5 Jconcentrations were less than 0.05 mIU/mL
2 P7 w, m$ S) g1 q(prepubertal).! k. c) I6 a3 r7 {3 M
The parents were notified about the laboratory$ s) f' U' I! @# u( j
results and were informed that all of the tests were
- ~) o1 X, o' T) B6 xnormal except the testosterone level was high. The+ [* u U# |+ {
follow-up visit was arranged within a few weeks to( t8 S' [- c3 t, M4 s' q* c
obtain testicular and abdominal sonograms; how-
8 ?4 k) M8 B( Q# q1 p! p- N/ ~ever, the family did not return for 4 months.
8 B) U$ d \5 n& U. w( kPhysical examination at this time revealed that the1 d# ?- b: `; ~+ n6 U; Y0 ~/ c, I
child had grown 2.5 cm in 4 months and had gained/ g1 d' z1 y. b _ M' T
2 kg of weight. Physical examination remained6 ^; n" U& i: l) l
unchanged. Surprisingly, the pubic hair almost com-1 Z9 B3 L: K2 v( h% g
pletely disappeared except for a few vellous hairs at
. u9 A0 `5 O1 L8 Kthe base of the phallus. Testicular volume was still 2
/ Z1 e( k9 O5 y* d ]mL, and the size of the penis remained unchanged.* I; Z" F' t( B! C7 B- f
The mother also said that the boy was no longer hav-
9 r& M2 w. A {! ]0 f- Ting frequent erections.
* f: a! Z$ m- ?- hBoth parents were again questioned about use of; x) M/ u0 @; @# T- K9 [9 q) b
any ointment/creams that they may have applied to; t0 y9 T' V" D, [4 Y
the child’s skin. This time the father admitted the
0 D: D! C9 I; Z. FTopical Testosterone Exposure / Bhowmick et al 541
0 R0 @8 C1 S: }8 Guse of testosterone gel twice daily that he was apply-
. g) ~% N& A; A" O% ^ing over his own shoulders, chest, and back area for ]; a1 I# H1 h8 c2 {
a year. The father also revealed he was embarrassed8 }; B! i8 D) V8 Y2 I! }! | O9 ^) f" g
to disclose that he was using a testosterone gel pre-
1 |* W" Z0 M& [6 |scribed by his family physician for decreased libido
! a! ^9 P7 f$ b( K# T% gsecondary to depression.
' w6 t- j" L$ ^: m2 d& P- i2 _The child slept in the same bed with parents.; p# h6 j% Q" h
The father would hug the baby and hold him on his6 O A# ?4 ~7 ?6 p5 d
chest for a considerable period of time, causing sig-
) G, F6 d- D8 c/ i/ L4 z! Snificant bare skin contact between baby and father.
/ W4 Q) `4 T% R jThe father also admitted that after the phone call,
, Y7 F4 x+ t% ?$ G" e4 uwhen he learned the testosterone level in the baby, Z" z0 q+ \# ~% M
was high, he then read the product information7 C+ E& D: P& T6 O# A& \4 o. N
packet and concluded that it was most likely the rea-
4 K8 K' U4 k# e. U6 g Z8 sson for the child’s virilization. At that time, they4 X1 H, ~$ \! h* ?' m O
decided to put the baby in a separate bed, and the8 [- k8 E! `- c, N
father was not hugging him with bare skin and had* t1 I" u# w/ O, C) D7 r
been using protective clothing. A repeat testosterone
3 h- I! ^. e& Q! jtest was ordered, but the family did not go to the
$ M& j j& o2 `7 ulaboratory to obtain the test.2 B# y: k, M4 t& y0 A! D
Discussion
" d! d; U% I4 d. ~' \. V- x- j3 @Precocious puberty in boys is defined as secondary
3 \9 X5 z4 J: u* a0 Osexual development before 9 years of age.1,4
$ v: Q& P5 H" X" M$ p* c- bPrecocious puberty is termed as central (true) when
) M H _' b* m1 h& G6 S( T! Y7 tit is caused by the premature activation of hypo-# l# W; _ s# ^5 o. V
thalamic pituitary gonadal axis. CPP is more com-; F! @0 G! L2 p D" X
mon in girls than in boys.1,3 Most boys with CPP; W- ~0 y! P* Q8 M: }
may have a central nervous system lesion that is
! c0 Q* s8 ]9 J$ P! k# V# Gresponsible for the early activation of the hypothal-' o1 H' U0 V7 T5 I$ Q
amic pituitary gonadal axis.1-3 Thus, greater empha-' o0 [: U# `& w" e! \& h
sis has been given to neuroradiologic imaging in! N4 z! q' G" v5 G, c+ L# o2 U" y
boys with precocious puberty. In addition to viril-
' I: Z2 q' J4 `" P0 z+ x* wization, the clinical hallmark of CPP is the symmet- Q j+ V8 i5 |# [& y
rical testicular growth secondary to stimulation by4 l3 ` z0 T2 f9 @" |" _) @; u
gonadotropins.1,3
: n, E, E3 w" Q5 l+ F( BGonadotropin-independent peripheral preco-5 U# F* C4 [$ t+ Z' W
cious puberty in boys also results from inappropriate5 t3 k8 n. w+ Z
androgenic stimulation from either endogenous or
) P) l& m5 C" K! vexogenous sources, nonpituitary gonadotropin stim-# T# ?# Y* p# R' ]
ulation, and rare activating mutations.3 Virilizing+ S3 l1 E1 n7 j' {' M* v6 G
congenital adrenal hyperplasia producing excessive3 i8 n7 Q0 r8 u5 }
adrenal androgens is a common cause of precocious: ~; @$ O1 y9 M8 g
puberty in boys.3,4* |/ |5 s% v7 C
The most common form of congenital adrenal
, A1 O; c+ m# ~% h; t: ^hyperplasia is the 21-hydroxylase enzyme deficiency.
" \: w2 S. j) L, b& S7 l9 zThe 11-β hydroxylase deficiency may also result in; Y2 u) K1 H4 d0 X; L& T7 t
excessive adrenal androgen production, and rarely,
. M+ c8 y3 S7 a4 ?2 k, ean adrenal tumor may also cause adrenal androgen& ]9 x) k! Y1 u' N6 H" J
excess.1,3+ H* v* m8 ~; G& X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, v S4 U& j v4 u542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 C6 [" _, ~1 y RA unique entity of male-limited gonadotropin-
7 R4 d( V( r6 k# Zindependent precocious puberty, which is also known
5 F+ ^2 Q* q* R o& d8 G" D/ O2 |as testotoxicosis, may cause precocious puberty at a
" d. N [$ L1 D1 Dvery young age. The physical findings in these boys7 a# g( w% m; X" d o
with this disorder are full pubertal development,
; Z0 R$ `1 T4 F* ]including bilateral testicular growth, similar to boys
) O4 V0 C% X- Jwith CPP. The gonadotropin levels in this disorder! I2 G1 Y$ }8 ^' E5 R# n. }) S
are suppressed to prepubertal levels and do not show- C$ |5 x, e; Z0 v4 U
pubertal response of gonadotropin after gonadotropin-
. n2 A2 z' x' areleasing hormone stimulation. This is a sex-linked { G8 [ j/ P' @" j6 w- q! B
autosomal dominant disorder that affects only
: p2 T! E4 p' C8 O% e, _3 Rmales; therefore, other male members of the family
H+ z8 G N* V7 qmay have similar precocious puberty.3
1 Q1 h/ ^# Q6 q' G) a. tIn our patient, physical examination was incon-0 Z+ b4 v4 y% }: C* N
sistent with true precocious puberty since his testi-
J$ |4 L5 W6 h: e5 Kcles were prepubertal in size. However, testotoxicosis0 l0 z- k: C! T$ f$ b3 ?
was in the differential diagnosis because his father
$ }% o+ L3 f' sstarted puberty somewhat early, and occasionally,, k3 V- v h$ I3 N9 {
testicular enlargement is not that evident in the
, a* J! R* Q* u" sbeginning of this process.1 In the absence of a neg-
9 A: O6 _$ d/ C( l3 H, Yative initial history of androgen exposure, our" x* |$ T2 M' j8 }
biggest concern was virilizing adrenal hyperplasia,
S- |1 |, ^9 w( d2 Xeither 21-hydroxylase deficiency or 11-β hydroxylase* O* R- T9 c9 u" f: H+ I1 z1 i z' o
deficiency. Those diagnoses were excluded by find-
9 [3 R. R% c4 y+ K- ^! e, qing the normal level of adrenal steroids.
8 `9 q( S) E j/ y. w* ^% t% e; FThe diagnosis of exogenous androgens was strongly- H& U! \3 z1 X- l1 w
suspected in a follow-up visit after 4 months because# Y8 B+ j7 n* u( ]% F! D
the physical examination revealed the complete disap-
! F% d" G( T3 {/ _pearance of pubic hair, normal growth velocity, and& U; {* x( n' b' [4 o7 p
decreased erections. The father admitted using a testos-0 Q% o& e3 v; e" P& U
terone gel, which he concealed at first visit. He was
6 p) U# _# D' {( ~0 E4 husing it rather frequently, twice a day. The Physicians’/ w. o7 r) e0 ~5 g
Desk Reference, or package insert of this product, gel or' f- q1 g5 D( v/ |
cream, cautions about dermal testosterone transfer to# h4 a5 p6 F- Z: N
unprotected females through direct skin exposure.0 ^) [% Z( m p( b
Serum testosterone level was found to be 2 times the
, }; U- _: T& y! L5 W) ~3 Rbaseline value in those females who were exposed to
* F7 }8 z$ |! D! C9 m& d, H3 seven 15 minutes of direct skin contact with their male
4 S. n$ \! K3 Y& a4 I0 ypartners.6 However, when a shirt covered the applica-
; ~: K# m- O( c9 C2 ltion site, this testosterone transfer was prevented.
9 F) H, W- ?1 _; d9 jOur patient’s testosterone level was 60 ng/mL,
] ?3 c* \/ Awhich was clearly high. Some studies suggest that0 D2 U+ J- y- k" w4 ?9 H; b
dermal conversion of testosterone to dihydrotestos-% l1 p5 s+ t5 x# t* Y, ~" o$ W I6 p
terone, which is a more potent metabolite, is more
& V. y! h* L+ P/ R' d) x- i; nactive in young children exposed to testosterone
9 m$ I" `; V8 fexogenously7; however, we did not measure a dihy-$ X, C$ ]% B, y( Q2 {/ s# T3 D
drotestosterone level in our patient. In addition to
4 u! N+ Z& ~% E/ I: U0 [4 uvirilization, exposure to exogenous testosterone in
" U+ o( e' O' u- Y8 k1 Z7 N; `children results in an increase in growth velocity and. u% ]2 h. z. K$ F
advanced bone age, as seen in our patient.
* [1 s5 A5 G4 P$ O8 a8 {6 LThe long-term effect of androgen exposure during; h8 R2 @. ]9 j1 ~# T$ \
early childhood on pubertal development and final
3 }4 c8 R9 C3 ^1 i% Tadult height are not fully known and always remain
4 Q5 [& r0 e/ S$ }a concern. Children treated with short-term testos-9 }# S' |2 H) O" p/ f8 Z
terone injection or topical androgen may exhibit some
+ s0 A, H$ \) V2 C9 N8 qacceleration of the skeletal maturation; however, after
, c$ H$ m2 _0 bcessation of treatment, the rate of bone maturation3 D; }; J7 s, [- z/ I$ l
decelerates and gradually returns to normal.8,9
4 z! X# I/ u3 h A3 {. LThere are conflicting reports and controversy* J7 }8 J p$ r1 `- `
over the effect of early androgen exposure on adult' Z: v8 ]0 E) Y1 _
penile length.10,11 Some reports suggest subnormal: a- T* x4 H, z6 B+ N; l
adult penile length, apparently because of downreg-
' D% {& a, @/ ]2 ]8 c) Aulation of androgen receptor number.10,12 However,% }) Z) N9 [; ~5 i. k8 S# [; I
Sutherland et al13 did not find a correlation between
3 k3 `, j* d# Kchildhood testosterone exposure and reduced adult
9 I% n8 O7 h0 X; }penile length in clinical studies.- B6 ~- S( Q7 M. h; G) D
Nonetheless, we do not believe our patient is2 Z+ W1 v# H2 I- i. b
going to experience any of the untoward effects from8 c. W* t* ]- _8 B! v
testosterone exposure as mentioned earlier because
4 n7 B; b6 V, T$ a1 ~the exposure was not for a prolonged period of time.
2 c; z5 R, r. q$ c2 H: b% {0 lAlthough the bone age was advanced at the time of
3 |. L- v D v& `1 odiagnosis, the child had a normal growth velocity at
, [/ w, v0 r6 P% [. i9 D$ tthe follow-up visit. It is hoped that his final adult
# ]" [; j. N4 T" p( N( Q$ T# E9 C- lheight will not be affected.
" R! v8 Z8 Z. g' V, yAlthough rarely reported, the widespread avail-' m* [3 k3 F' a1 [7 [9 s
ability of androgen products in our society may1 D! D4 O: H1 }; U1 l ]
indeed cause more virilization in male or female
/ E& ]( X' }5 Tchildren than one would realize. Exposure to andro-+ z% ]$ `4 m! V
gen products must be considered and specific ques-
" M/ h+ j4 o5 N& Ztioning about the use of a testosterone product or* n# ~! G' W3 r
gel should be asked of the family members during
# C, ~0 w; x3 _' S/ P8 jthe evaluation of any children who present with vir-1 E U: [: g2 H8 b n3 Q8 a
ilization or peripheral precocious puberty. The diag-# Z E# k" _4 b6 ?# N: u
nosis can be established by just a few tests and by
# Z; m8 d9 s8 K3 X& {4 @! gappropriate history. The inability to obtain such a( W" l! n6 r. y5 |7 ?0 h5 Z9 y
history, or failure to ask the specific questions, may
* i, m' E( h1 ?/ R# ?8 C1 j, \result in extensive, unnecessary, and expensive7 { P- A% P4 E- ^8 h
investigation. The primary care physician should be$ O1 b: n& R0 z* \9 g
aware of this fact, because most of these children Q( }: U& q. G
may initially present in their practice. The Physicians’( \1 @" \8 m! X5 Z
Desk Reference and package insert should also put a$ N! o# K$ W) s6 r x: Z& k$ {
warning about the virilizing effect on a male or
4 w7 n; ]6 C$ y1 Wfemale child who might come in contact with some-
0 \0 ~7 o" I4 l2 Done using any of these products.
& L+ r7 X: k1 U+ k6 _3 fReferences
& j% A" S( p& p0 j Z, L: B1. Styne DM. The testes: disorder of sexual differentiation
. {" O, V8 S( M$ I) Xand puberty in the male. In: Sperling MA, ed. Pediatric$ I/ L7 k. ?: L
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' n$ i% X/ }! Z( m- X2 l
2002: 565-628.+ `* O0 l* Y$ M2 }: T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- g8 y4 r2 w0 L' b6 t0 \
puberty in children with tumours of the suprasellar pineal |
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