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Sexual Precocity in a 16-Month-Old/ d6 W( C8 X! L3 m% J; A
Boy Induced by Indirect Topical
( R, w- E- P' @2 n% vExposure to Testosterone
% Y2 ]: i& A w. tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 j: h# e9 b% s+ g
and Kenneth R. Rettig, MD1
, M) L- V* I5 S$ H# z0 WClinical Pediatrics# ~9 ?2 z V* }( C" m1 W
Volume 46 Number 6
6 \8 r& U$ y% Z) U( W8 [July 2007 540-543
; c; W: Q8 }: h5 R6 {$ K© 2007 Sage Publications
) P% I* C! i0 t" B& d10.1177/0009922806296651/ E- c6 u& K; O" @# Q
http://clp.sagepub.com/ \4 q7 N% _+ F7 U
hosted at
: w5 I; y; K, P+ l, ^" Phttp://online.sagepub.com
. T4 P* A9 ~0 F2 v4 ^Precocious puberty in boys, central or peripheral,& R0 g7 i* h- ]" |
is a significant concern for physicians. Central- H7 T, Z I1 `6 K
precocious puberty (CPP), which is mediated
. M7 z# s+ U0 @: {$ N) }through the hypothalamic pituitary gonadal axis, has9 X1 }- r) U6 g# L# O- F7 _+ t5 j( l
a higher incidence of organic central nervous system
9 N# r1 S: S' B* o/ Q$ ilesions in boys.1,2 Virilization in boys, as manifested
8 B, _1 l7 p! O6 ]/ ^by enlargement of the penis, development of pubic
4 n& N* ~2 x8 chair, and facial acne without enlargement of testi-
: o# [, ~2 C$ U! |. V" K; tcles, suggests peripheral or pseudopuberty.1-3 We
. T( u1 F; N$ Preport a 16-month-old boy who presented with the
2 V5 U' s4 `8 _) Genlargement of the phallus and pubic hair develop-7 B! c5 ?. c ?2 i9 Z
ment without testicular enlargement, which was due d- e4 j, J3 `# ^; X) s$ M
to the unintentional exposure to androgen gel used by2 O/ g) W+ Q" O
the father. The family initially concealed this infor-
2 w$ }4 N+ e1 H4 |, Cmation, resulting in an extensive work-up for this1 e: q% c4 M$ `; G5 k. A* q- e
child. Given the widespread and easy availability of
# y6 g- o4 C Otestosterone gel and cream, we believe this is proba-& A% v: h9 ?; i/ i; I; X- O, ~
bly more common than the rare case report in the. ~, i, a. u8 B& u- h5 Q- ?
literature.4
% e8 F: O% N0 ?- Z! m3 |7 ^7 tPatient Report- `. C. c" b) \, ?
A 16-month-old white child was referred to the
$ d" G' u1 p& \6 v/ Q4 d; @endocrine clinic by his pediatrician with the concern
% a( H: J9 f3 w( N) bof early sexual development. His mother noticed
- | `/ E5 j6 ^% M9 A" B% y1 n7 E: klight colored pubic hair development when he was
3 m- m, I3 W/ V( `, f N! x& _From the 1Division of Pediatric Endocrinology, 2University of# [ c# Q: b$ e' t1 g0 l
South Alabama Medical Center, Mobile, Alabama.
y6 g8 M% l8 H# o: O& O1 U4 kAddress correspondence to: Samar K. Bhowmick, MD, FACE,2 s8 I% {) K3 P
Professor of Pediatrics, University of South Alabama, College of
( ~' ? |! S/ D; GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 h, |) s% A0 ]# z# U' k+ h0 te-mail: [email protected].
* ?) ^( [% u8 @% _about 6 to 7 months old, which progressively became' a9 k* n& d9 T8 @
darker. She was also concerned about the enlarge-4 U4 T y$ Z) |, `
ment of his penis and frequent erections. The child8 s* j$ w7 M8 H. `8 m0 Q2 P
was the product of a full-term normal delivery, with
' h( W/ w5 G$ w$ `2 Ua birth weight of 7 lb 14 oz, and birth length of5 x% L* q9 L3 ]" Q
20 inches. He was breast-fed throughout the first year6 Z8 r7 I" ?: r+ z+ h! x
of life and was still receiving breast milk along with
j2 T7 A8 ~+ A: asolid food. He had no hospitalizations or surgery,
& D/ g& f& n' s4 A) R9 Sand his psychosocial and psychomotor development0 p5 c& ?( M; I3 l$ Z1 Y* F0 T7 J2 p
was age appropriate., S6 U* o, U# l( [
The family history was remarkable for the father,% B+ |7 l( w8 y, t5 T* q
who was diagnosed with hypothyroidism at age 16,2 }" D& H2 ^- s
which was treated with thyroxine. The father’s
4 a# C/ o) d4 F1 N5 Eheight was 6 feet, and he went through a somewhat8 O8 R' @' D+ n6 k' t
early puberty and had stopped growing by age 14.2 C# @3 g j4 }
The father denied taking any other medication. The {6 R* V& Q3 T
child’s mother was in good health. Her menarche
3 O& { o7 I9 r" p* w- m; V+ v! ?was at 11 years of age, and her height was at 5 feet1 M9 |$ g. `- q% H. |2 Y l0 P
5 inches. There was no other family history of pre-
" [; C7 |0 E. d$ A5 `$ P6 Z0 jcocious sexual development in the first-degree rela-
. X3 l& P. l9 ^2 H& ytives. There were no siblings.9 D$ w3 [" s) g/ h2 Q& w
Physical Examination
8 Y' ^8 [8 z0 } K8 s$ t' lThe physical examination revealed a very active,3 p/ f/ L* V' Z5 L* K) Q, s# B
playful, and healthy boy. The vital signs documented
N8 a6 L# ?5 ]a blood pressure of 85/50 mm Hg, his length was
; U& u7 B* O0 N6 @. D90 cm (>97th percentile), and his weight was 14.4 kg, f4 V0 w& @5 a8 j
(also >97th percentile). The observed yearly growth A- J* V) g& b6 ` R# _, M ^& `
velocity was 30 cm (12 inches). The examination of
* n! _4 I* q1 W, e" @: R* Dthe neck revealed no thyroid enlargement.0 I. U) s' {% ]) |3 N+ a
The genitourinary examination was remarkable for% ]& ?2 S, N' s6 y
enlargement of the penis, with a stretched length of& Y" w y! g( [" }4 O) A9 B
8 cm and a width of 2 cm. The glans penis was very well( ~, \9 ~; P9 |+ q+ I* t! d8 [" M& m% }
developed. The pubic hair was Tanner II, mostly around% l3 m+ E) b0 ]* B; H9 j$ @! @
540
# b8 A/ F/ a! V& ?( _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- n' B6 f: q) \# v) G3 }the base of the phallus and was dark and curled. The
5 L4 q' q$ S/ g6 d" M6 W- l8 k9 ctesticular volume was prepubertal at 2 mL each.
8 j. k) ^' _) A' j9 aThe skin was moist and smooth and somewhat7 }1 i# i% W5 i7 ^' V. y
oily. No axillary hair was noted. There were no8 x2 h1 e8 o, N2 {6 M
abnormal skin pigmentations or café-au-lait spots.
5 C( y, v2 w: H4 R& MNeurologic evaluation showed deep tendon reflex 2+- _, F; H( t5 x5 b
bilateral and symmetrical. There was no suggestion1 ?% d1 B7 S b% H$ Z
of papilledema.% h: ]1 g O. h+ M, S" c6 r* q
Laboratory Evaluation
3 ^0 m% a1 a" o5 j0 _1 o% }The bone age was consistent with 28 months by
& E! O9 j$ q4 B. j" F, h% tusing the standard of Greulich and Pyle at a chrono-
4 Y3 i' x* |! n& J; Qlogic age of 16 months (advanced).5 Chromosomal2 Z: G/ l8 w# m9 W
karyotype was 46XY. The thyroid function test
a/ `! r9 J* c, r& Kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 H& u8 K) |+ ]0 A) Alating hormone level was 1.3 µIU/mL (both normal).9 h! R9 I1 h# Y/ S3 j
The concentrations of serum electrolytes, blood
Q7 f! e& m0 }" V' C1 q0 A. @3 nurea nitrogen, creatinine, and calcium all were) g9 N/ }+ c, d
within normal range for his age. The concentration7 P# F, Q- |% c! L' N; a
of serum 17-hydroxyprogesterone was 16 ng/dL
$ u9 Y6 Q5 P6 Y: K, K( c(normal, 3 to 90 ng/dL), androstenedione was 20: l& x8 ]( a6 B% q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. P! Q4 o2 i" O1 c% H7 N' ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 `& }" X y3 x* `# W3 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( M6 a) D5 t" n( ~49ng/dL), 11-desoxycortisol (specific compound S)# O' E. e/ u0 Y6 \ ]- ^9 t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 N7 h. v( ]7 C+ w- Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 e1 c6 B; t/ s* }- w( |8 vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),( K* M* y5 _+ g- v+ ]
and β-human chorionic gonadotropin was less than! m) M9 u! B p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 s# e q2 a4 }stimulating hormone and leuteinizing hormone
# W( c' Q. B5 `& k: A. A+ Y6 X8 @concentrations were less than 0.05 mIU/mL4 `' }% W( M E5 ~
(prepubertal).) _, Z3 v0 R4 a P t* _* n4 G! @' a
The parents were notified about the laboratory
9 \& ?5 U8 ^6 W2 l: b7 Nresults and were informed that all of the tests were" s J$ Y; b" ^2 ^' |% V* p0 o% G
normal except the testosterone level was high. The
, [' P) Z4 z& {5 Zfollow-up visit was arranged within a few weeks to
/ k7 | r+ X4 nobtain testicular and abdominal sonograms; how-: x6 x8 [2 }7 c6 j
ever, the family did not return for 4 months.' q4 Y- B( u7 ?7 G2 U
Physical examination at this time revealed that the3 G! Q6 c' {7 \! e2 R0 P+ f
child had grown 2.5 cm in 4 months and had gained
% r1 W+ b9 q! n3 j/ ]2 kg of weight. Physical examination remained9 n7 C7 y2 C$ q n: t% W
unchanged. Surprisingly, the pubic hair almost com-
0 l0 O4 @/ h o- J& Zpletely disappeared except for a few vellous hairs at
" A: f: O3 J) X" Y) e- X% Mthe base of the phallus. Testicular volume was still 2
8 b! B a! f2 M: N# P; \& } zmL, and the size of the penis remained unchanged.
5 C2 [2 v6 N$ q# RThe mother also said that the boy was no longer hav-' C( Y4 B: v5 X E2 T* y6 _
ing frequent erections.- h) y. m0 n* M: L( Q; R" A
Both parents were again questioned about use of
6 j+ |3 H0 f4 p7 T0 }. R xany ointment/creams that they may have applied to' Z" x! t. M) a5 e; i, A
the child’s skin. This time the father admitted the
: P& B! M/ `3 \' u5 e/ o" `Topical Testosterone Exposure / Bhowmick et al 541
( }8 q0 G, L& V' r! F9 fuse of testosterone gel twice daily that he was apply-
; s* V& e* z3 u7 a! _1 Fing over his own shoulders, chest, and back area for9 P' A' U+ x1 {- V9 |" `( E
a year. The father also revealed he was embarrassed
4 c4 i" c4 x1 k! T+ _: mto disclose that he was using a testosterone gel pre-
; `1 k& ?7 T9 vscribed by his family physician for decreased libido0 l7 e9 [ n* V8 ?
secondary to depression.
' p& s! @" }6 G1 CThe child slept in the same bed with parents.. \# O5 r$ K3 i C8 S( h3 ~, L
The father would hug the baby and hold him on his
5 g- ~& c3 w7 G: L) w! Ychest for a considerable period of time, causing sig-! _( b' I+ d: y1 i2 x& n8 Y, ?* ]* R$ P
nificant bare skin contact between baby and father.
4 U9 f w6 S& kThe father also admitted that after the phone call,
1 \* }, V* O$ g* V4 e7 p1 r; qwhen he learned the testosterone level in the baby
" I. M; L4 j" H9 v& I: [was high, he then read the product information
2 r0 F, T& l# s+ }( T; @! S5 Y6 Y& M5 [packet and concluded that it was most likely the rea-! x$ u# ?. M- I9 o9 F, `
son for the child’s virilization. At that time, they
6 I T7 f8 [$ sdecided to put the baby in a separate bed, and the
- p7 N0 }, D9 w, [+ y1 a/ Zfather was not hugging him with bare skin and had3 v- ]- W$ C" E
been using protective clothing. A repeat testosterone6 e2 W) }5 O1 i1 K Z, z6 s% x
test was ordered, but the family did not go to the, n; z3 f1 o2 x: M/ A' |
laboratory to obtain the test.3 k' R) I! u# l2 H& [
Discussion0 e( S0 e* r z/ E# z# N& g
Precocious puberty in boys is defined as secondary
s, F% f5 z) [8 Psexual development before 9 years of age.1,4: |$ y+ S' s4 F8 L; d& ]. d
Precocious puberty is termed as central (true) when- z/ J2 ?, T4 N! t- ^7 K6 @
it is caused by the premature activation of hypo-; l2 K/ T3 u! }; y
thalamic pituitary gonadal axis. CPP is more com-& G/ A3 L" R. s8 K; N; r
mon in girls than in boys.1,3 Most boys with CPP* n* ^- {9 _7 ~# \* d; t
may have a central nervous system lesion that is
$ _. ~. Z9 E. @, w2 {0 {: {responsible for the early activation of the hypothal-
7 X3 e0 j- J' m. R! famic pituitary gonadal axis.1-3 Thus, greater empha-
* h/ C' p; T! t3 rsis has been given to neuroradiologic imaging in& Y: y% A- ^- W% B& x6 U: o
boys with precocious puberty. In addition to viril-
, {% E3 M2 x2 zization, the clinical hallmark of CPP is the symmet-
9 w) w+ m T" p! I! Brical testicular growth secondary to stimulation by
% j+ `- Z* R7 a: Ggonadotropins.1,3
6 B& c( W2 }0 m F+ C; yGonadotropin-independent peripheral preco-
6 K2 i8 _, v; mcious puberty in boys also results from inappropriate
! H! Y" [1 [# {: W8 randrogenic stimulation from either endogenous or
, O: g+ C+ K# O# t8 q7 Iexogenous sources, nonpituitary gonadotropin stim-3 D& D+ K- C7 _ q6 G: q$ Z7 N
ulation, and rare activating mutations.3 Virilizing
% r: }; z! V) c- L9 H1 U4 i# icongenital adrenal hyperplasia producing excessive
: P4 Q4 d) B- H8 Iadrenal androgens is a common cause of precocious
" o# C" S3 r- Gpuberty in boys.3,4
# t6 b5 d0 _8 @; z: rThe most common form of congenital adrenal
4 R2 J+ \0 D/ y9 o9 ^hyperplasia is the 21-hydroxylase enzyme deficiency.
* m: \" \5 m- c( o+ d& t9 aThe 11-β hydroxylase deficiency may also result in
9 d2 k2 h4 [! M: e: Y: oexcessive adrenal androgen production, and rarely,
" W5 B9 f- |( Xan adrenal tumor may also cause adrenal androgen: b, r+ N; a* ?) T' b8 h- D6 D
excess.1,3/ R$ Z4 N; Z& K/ y |, G3 v3 |8 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 q [1 V! H; R, }" a! w c C4 n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ a- i' c) M6 h8 H$ \0 Y$ k! jA unique entity of male-limited gonadotropin-
, ~! ~0 p5 p0 C! M$ Gindependent precocious puberty, which is also known0 _# [' N+ `; D6 k F
as testotoxicosis, may cause precocious puberty at a% s6 Z' d; A/ J
very young age. The physical findings in these boys; d7 c2 ]6 w1 A( O
with this disorder are full pubertal development,; \/ @9 R+ t/ Y' ?
including bilateral testicular growth, similar to boys2 y8 ]' n8 {( K6 J( v8 y( y
with CPP. The gonadotropin levels in this disorder
: y1 m' A5 ?" l% uare suppressed to prepubertal levels and do not show
) w, e: L5 }$ t" }5 O; }. apubertal response of gonadotropin after gonadotropin-
' m. S, i# w( ~9 A) areleasing hormone stimulation. This is a sex-linked. t$ C# J" Q$ `% f2 C3 }$ N9 t' i7 e+ r) p
autosomal dominant disorder that affects only
: `% x; X, v/ ]' Tmales; therefore, other male members of the family
# R' U# g/ G/ {7 e, L7 }* h9 W; g4 Jmay have similar precocious puberty.3
( g. Q# p: e% T# LIn our patient, physical examination was incon-
+ h" L# n* U, ?/ ~7 Ssistent with true precocious puberty since his testi-; \. u; o; R5 L, T# E, T0 B6 j+ L1 L
cles were prepubertal in size. However, testotoxicosis
5 I; U! d$ s# Nwas in the differential diagnosis because his father
5 l3 g/ t! h Ostarted puberty somewhat early, and occasionally,
- O" Y4 V2 B0 w2 C/ N0 @testicular enlargement is not that evident in the
! L# D& v6 u3 D8 H6 a/ Q' Hbeginning of this process.1 In the absence of a neg-
1 r2 k* c, s- eative initial history of androgen exposure, our' t9 _8 o" r% w) w
biggest concern was virilizing adrenal hyperplasia,* _, P: q' x; ^$ C" A4 J
either 21-hydroxylase deficiency or 11-β hydroxylase
3 t% f Y7 ^* p. e! r- w( z4 p* ^deficiency. Those diagnoses were excluded by find-& h+ U: |. ~- A" P1 y/ S
ing the normal level of adrenal steroids.
6 a/ E! t- U" c7 s) m$ B) x' zThe diagnosis of exogenous androgens was strongly
+ a4 p* f0 |- G2 dsuspected in a follow-up visit after 4 months because6 R9 z' X3 k6 p
the physical examination revealed the complete disap-
0 s. I/ w) f$ Upearance of pubic hair, normal growth velocity, and
; d7 j/ v A' e* rdecreased erections. The father admitted using a testos-( T& x4 ]! m5 F- s" f+ C9 l
terone gel, which he concealed at first visit. He was) G! w# ?8 c1 p" E3 |- J+ o
using it rather frequently, twice a day. The Physicians’" F6 j! W6 r6 r+ @5 E$ q
Desk Reference, or package insert of this product, gel or
8 S2 L: B, D/ ^" L4 v' |cream, cautions about dermal testosterone transfer to$ j1 T7 K/ x6 Q* C
unprotected females through direct skin exposure.4 k. J' B2 b! v* K! L/ G4 p
Serum testosterone level was found to be 2 times the: r6 K. P2 G. B
baseline value in those females who were exposed to
- d. ~1 V8 d. Qeven 15 minutes of direct skin contact with their male0 i: n. H9 V' C' z' K' `* J/ Z r
partners.6 However, when a shirt covered the applica-
; S4 m5 H' V3 X' J, J4 @tion site, this testosterone transfer was prevented.; V8 S9 j' i6 c
Our patient’s testosterone level was 60 ng/mL,
% ~$ ]7 C t8 V% \2 G' m0 pwhich was clearly high. Some studies suggest that
. H! X; _) Q' M4 v, Adermal conversion of testosterone to dihydrotestos-
) F! O& q- L' D' }, B0 F/ `3 ?7 Iterone, which is a more potent metabolite, is more
$ u% }& @+ `- tactive in young children exposed to testosterone0 f* w( y2 S4 t; w( J8 `
exogenously7; however, we did not measure a dihy-
' w( N- S# l5 N8 e- o: }" o* edrotestosterone level in our patient. In addition to
, x7 e6 q7 f% J# e0 t) {, Vvirilization, exposure to exogenous testosterone in$ f2 z; Y5 b+ B4 F# J
children results in an increase in growth velocity and
% g" h* H0 P1 ^5 Q& r9 q8 l$ }advanced bone age, as seen in our patient.+ \8 F! K. j% n! e
The long-term effect of androgen exposure during6 R% u, Z: F1 ~+ x* ~$ i
early childhood on pubertal development and final
& s# g5 ^% @, zadult height are not fully known and always remain
; z0 f! n7 k- j: h/ P9 ba concern. Children treated with short-term testos-
- G7 `. p! Q ]0 E! R' g9 dterone injection or topical androgen may exhibit some1 `6 W' G+ S# {0 i( ~* A& M2 H
acceleration of the skeletal maturation; however, after
% P8 j! q2 s* k* m4 |cessation of treatment, the rate of bone maturation
2 b5 w7 J3 G7 C6 C4 ^0 tdecelerates and gradually returns to normal.8,94 e9 r4 E* A( v
There are conflicting reports and controversy
7 `1 z3 v1 ?3 B* X6 h) l: R vover the effect of early androgen exposure on adult/ v& T" a4 n+ J/ `
penile length.10,11 Some reports suggest subnormal3 u8 m. ~2 p, g
adult penile length, apparently because of downreg-4 H {+ j. c2 M* {! j! X7 f
ulation of androgen receptor number.10,12 However,/ c7 f7 P2 P; a) C( d
Sutherland et al13 did not find a correlation between1 {5 H x+ a& O
childhood testosterone exposure and reduced adult
) `' H, G" F7 gpenile length in clinical studies.. b0 k @( |4 _! [: Q
Nonetheless, we do not believe our patient is
. b- Y0 _# P& m T) x- L: i. Fgoing to experience any of the untoward effects from9 Z1 t4 t' w7 O) S6 q
testosterone exposure as mentioned earlier because$ H* X1 f( w) W k0 D3 p* z
the exposure was not for a prolonged period of time.! X5 }. z' `6 A' K- C# F& {6 r1 }
Although the bone age was advanced at the time of
) B9 h8 ?8 A% @8 Ldiagnosis, the child had a normal growth velocity at$ c1 @7 K0 t8 f/ m A2 o
the follow-up visit. It is hoped that his final adult! P- t, K1 y7 s: g, A
height will not be affected.5 i0 k& ` o& J8 z) n2 e3 ~& w' x9 A4 s
Although rarely reported, the widespread avail-
Q6 I1 R' Y3 D3 ?ability of androgen products in our society may7 e6 s. l0 @ }
indeed cause more virilization in male or female
6 J8 y( T8 y, J# nchildren than one would realize. Exposure to andro-3 e1 _" }5 h. [- Q
gen products must be considered and specific ques-
! i& t5 x' f) t8 c( otioning about the use of a testosterone product or: A. S1 }* b- ^( p3 w' ~! P
gel should be asked of the family members during2 w" \3 A/ @8 P
the evaluation of any children who present with vir-8 a& d$ V* E6 Z: n
ilization or peripheral precocious puberty. The diag-
, }) h0 y' W& ?6 cnosis can be established by just a few tests and by6 y# w% N @3 e4 W; t2 h
appropriate history. The inability to obtain such a+ s8 D7 V' f, T V
history, or failure to ask the specific questions, may
! E$ r! W+ {, s7 |6 ^# sresult in extensive, unnecessary, and expensive
9 W% [/ P8 @5 D1 J9 ninvestigation. The primary care physician should be1 D/ @" Y) x% d/ ]/ J! F
aware of this fact, because most of these children
X% A. O5 [) l2 emay initially present in their practice. The Physicians’
7 L! H6 H3 p2 K3 {: K' r3 SDesk Reference and package insert should also put a
6 ]3 X. {$ G$ a2 w+ F7 ^& ^warning about the virilizing effect on a male or
$ N9 {8 N& _0 Y1 Afemale child who might come in contact with some-
, _" u) e) p: n8 k e7 ~one using any of these products.
5 `) T4 }7 X, c1 hReferences
7 i# |& @& i: b7 z0 t8 k5 L8 I1. Styne DM. The testes: disorder of sexual differentiation1 _, `0 B: b- p6 a
and puberty in the male. In: Sperling MA, ed. Pediatric( Q1 D! z L7 T2 Z$ K) s8 ]3 {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ N5 @( F2 n/ C5 e
2002: 565-628.2 _! `. z$ T8 } o" D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 _: c W/ `9 ^% Z) y; Opuberty in children with tumours of the suprasellar pineal |
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