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Sexual Precocity in a 16-Month-Old
& y) U. H2 f! B7 N$ C) c7 Z" HBoy Induced by Indirect Topical. H D$ X" t5 m5 e- Y6 s
Exposure to Testosterone
0 a, Q2 i1 y% \% `8 r) V. pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 u, K6 p0 u4 B$ m1 \# w2 U$ Jand Kenneth R. Rettig, MD1
* S- N. r. C1 |) r0 S$ |0 a! qClinical Pediatrics
( h5 y4 v" f# H& \, n& }" ]Volume 46 Number 6
. K2 a; s9 `2 t' T" W* L* nJuly 2007 540-543( R! N, E" r; Q6 R( k9 v
© 2007 Sage Publications
2 y9 [ C8 I5 z10.1177/00099228062966517 Q% d% J5 q# U7 Z
http://clp.sagepub.com
& {) H0 V1 Q0 k4 ?hosted at8 L3 r4 A# [+ N+ C
http://online.sagepub.com
5 K- o9 q6 F, w% h+ D9 A' HPrecocious puberty in boys, central or peripheral,! {( e# E: ~9 F# N- Z
is a significant concern for physicians. Central8 i, h8 v: r! H0 {; f! N* b6 C
precocious puberty (CPP), which is mediated E0 b; ~- E3 \* E9 B* K) A
through the hypothalamic pituitary gonadal axis, has4 e# T, q* s- k( Z2 B6 U/ u
a higher incidence of organic central nervous system, Y. F' `; f9 l# T" |5 |
lesions in boys.1,2 Virilization in boys, as manifested
3 a7 @9 f# n, }) l! ~* R- c0 }by enlargement of the penis, development of pubic
5 i; d M r' ]2 D, z/ N( [hair, and facial acne without enlargement of testi-& l: r, u5 b, b( ]0 Z! b
cles, suggests peripheral or pseudopuberty.1-3 We, R% Z# o# U/ B2 V
report a 16-month-old boy who presented with the
( Y2 ~& W, N4 F) t) |* X [& _enlargement of the phallus and pubic hair develop-( |1 f9 D' W% d' U" Y; ^1 m
ment without testicular enlargement, which was due
% g% ?4 A& k1 P D! |+ d' T& Zto the unintentional exposure to androgen gel used by
P* [2 e9 J' A( B: A6 sthe father. The family initially concealed this infor-
- P! l5 l1 _6 G( \: l, \mation, resulting in an extensive work-up for this# J* m1 g6 ^; x" [
child. Given the widespread and easy availability of9 ^( Y* d n G3 C; i. O
testosterone gel and cream, we believe this is proba-
& _# ]+ e, _: f% O, Obly more common than the rare case report in the) j& J) m) q6 l. w) h
literature.4
: h( R# G/ D/ LPatient Report% l( @& l$ e1 A9 g0 {6 {
A 16-month-old white child was referred to the- V+ V9 L5 i* _) m% G$ d: }
endocrine clinic by his pediatrician with the concern
1 B. Z( Q ?' o/ y# {) { w# Yof early sexual development. His mother noticed( D5 [6 w2 }4 h( \' u, b5 y v
light colored pubic hair development when he was
9 v* D1 s* x2 C! CFrom the 1Division of Pediatric Endocrinology, 2University of
- j, u* @9 ]/ jSouth Alabama Medical Center, Mobile, Alabama.
3 G" M. [1 w+ m2 J( g, t0 w2 sAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 F6 l7 p3 ~. k) {! O/ ?# j; o% @
Professor of Pediatrics, University of South Alabama, College of5 \4 r8 D: r1 Q7 y" \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ ^# X& M! R' B |$ v, F3 v* ?e-mail: [email protected].
( \0 |. y+ h7 B4 Z4 Habout 6 to 7 months old, which progressively became
/ h& J1 r$ s& d" _darker. She was also concerned about the enlarge-: H6 I I' O$ I2 N9 b, B; l
ment of his penis and frequent erections. The child2 Y, y4 p8 s- o4 c: h7 J' M
was the product of a full-term normal delivery, with
1 s/ W- S0 u2 ^' w; Qa birth weight of 7 lb 14 oz, and birth length of
( Z, e! g' U9 L L20 inches. He was breast-fed throughout the first year, N* ]" |2 ^' \: F
of life and was still receiving breast milk along with
( |! ~; F, ^/ `" Y& e; V5 ysolid food. He had no hospitalizations or surgery,
0 f+ n) w, C2 X. cand his psychosocial and psychomotor development
+ C- x" B, \" j T" p7 `was age appropriate.' x5 o9 H) C9 w
The family history was remarkable for the father,
6 `: k: |" ]% e1 B5 Q+ ~who was diagnosed with hypothyroidism at age 16,
" }( w2 f2 O8 Q+ E. I8 Vwhich was treated with thyroxine. The father’s9 T2 ?* Q' K% Q! a
height was 6 feet, and he went through a somewhat% m }, p/ `: X( a
early puberty and had stopped growing by age 14.1 o8 S# X0 o) ]- X
The father denied taking any other medication. The
0 _6 y* f8 {8 y. H9 wchild’s mother was in good health. Her menarche
# o5 w5 D7 s6 R* f- Owas at 11 years of age, and her height was at 5 feet' B! J2 e" X6 I
5 inches. There was no other family history of pre-# k4 A2 q' [) f( q; X4 N
cocious sexual development in the first-degree rela-
9 e% }" _$ h* Y# B8 Jtives. There were no siblings.
- J U; m8 `5 r. U+ L4 m7 iPhysical Examination. f# l+ s. L& E( T" z4 |2 z
The physical examination revealed a very active,- P R. ]3 u/ w5 Y5 |* p
playful, and healthy boy. The vital signs documented
( y7 a5 R0 v0 y" {a blood pressure of 85/50 mm Hg, his length was
* `/ { N! H6 y90 cm (>97th percentile), and his weight was 14.4 kg0 V0 X4 d( z) }# I
(also >97th percentile). The observed yearly growth
1 u4 h8 E% r2 j. G7 x0 P4 Xvelocity was 30 cm (12 inches). The examination of
) ]" r0 X0 R- w. Ethe neck revealed no thyroid enlargement.' U D1 r: V* M- H( F3 M9 g
The genitourinary examination was remarkable for
+ i i( i( i' y- L% G1 ?enlargement of the penis, with a stretched length of: x+ @1 Z9 \+ I2 m' w% D
8 cm and a width of 2 cm. The glans penis was very well# L$ H) q1 \" m. V: A
developed. The pubic hair was Tanner II, mostly around
% i4 r! C1 W9 z: Q1 W0 m2 m' a; T540
! g4 P$ E& `5 uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. l" u3 B4 w4 ~- C3 s
the base of the phallus and was dark and curled. The. ^5 }0 a# v& l5 f3 k
testicular volume was prepubertal at 2 mL each.
+ I( U7 ]0 f6 s. O; ` mThe skin was moist and smooth and somewhat* W9 r* D/ j5 U Y& M4 ]- Y
oily. No axillary hair was noted. There were no1 ~! _/ j% I* O/ p+ ?1 {& N
abnormal skin pigmentations or café-au-lait spots.
. r* @/ ?! k# j- WNeurologic evaluation showed deep tendon reflex 2+
* H- |, \+ g6 fbilateral and symmetrical. There was no suggestion
3 G: H$ G; L: c6 s' }+ p0 Uof papilledema.
0 l( ~& t! n- ]) F) R2 V7 N. E% nLaboratory Evaluation
7 n/ D- r: W- q. N% k: k# g$ m! bThe bone age was consistent with 28 months by3 E$ G7 @9 l7 _. {+ o! }
using the standard of Greulich and Pyle at a chrono- W8 {1 T s. ~$ e( Q3 d6 F5 s
logic age of 16 months (advanced).5 Chromosomal5 L0 J" A, T b/ W6 s# n9 s
karyotype was 46XY. The thyroid function test
9 y. x/ P4 t3 {7 y" F; V3 Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 L% k; h; p+ q1 J( n/ B8 @
lating hormone level was 1.3 µIU/mL (both normal).
~3 F) z/ R/ j4 Y7 ^The concentrations of serum electrolytes, blood0 A. R6 P5 F/ }
urea nitrogen, creatinine, and calcium all were
1 \2 ]3 c v! x3 K( f& Ewithin normal range for his age. The concentration
5 _0 {2 c+ _4 A* z% J2 s d4 ~of serum 17-hydroxyprogesterone was 16 ng/dL: _. b" x5 K7 s/ @
(normal, 3 to 90 ng/dL), androstenedione was 209 E1 j7 y# d. m% ^ X! t. {# } F6 P3 P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, T4 J! M" ~- T2 j; x O' g5 L
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 ^% |5 [1 ?; n& W+ e* m/ L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; F. c; d l; p5 }9 x% F% T& } H6 F
49ng/dL), 11-desoxycortisol (specific compound S)3 n6 u0 `( ]+ m u) O' f
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* `% ^. \' v* j. ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
f9 z0 b& W8 H2 U4 \8 p9 v4 I1 k( Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 X& j/ j3 l( a$ p" z& `. x% e
and β-human chorionic gonadotropin was less than
- E( K+ \ J: w4 }, y& l5 mIU/mL (normal <5 mIU/mL). Serum follicular
, o, z8 O" ]6 ]1 N3 [, Wstimulating hormone and leuteinizing hormone; o4 }: P0 I2 Y6 I( N, x
concentrations were less than 0.05 mIU/mL
9 W7 u" v X' t& `* n(prepubertal).. J9 M/ a: F5 y% U; `% v/ O& O
The parents were notified about the laboratory9 z, {; w( F6 m% _/ y
results and were informed that all of the tests were/ D) A& D$ _& V/ b
normal except the testosterone level was high. The
3 `- w* W Z2 U" o$ c( ffollow-up visit was arranged within a few weeks to! q) F$ p2 @) {7 a
obtain testicular and abdominal sonograms; how-+ N3 x9 f6 S# L
ever, the family did not return for 4 months.
! ^( M4 V8 q7 |6 E7 [* hPhysical examination at this time revealed that the' z9 e0 g7 d( u! w& I1 {
child had grown 2.5 cm in 4 months and had gained
$ F0 Y, P( ^$ ~3 L( O2 kg of weight. Physical examination remained1 g0 s! e9 A- b8 X
unchanged. Surprisingly, the pubic hair almost com-; a8 H9 ?3 i* J8 L# o9 d# i7 ^. o
pletely disappeared except for a few vellous hairs at
/ l% z* a/ U$ e: f! S' pthe base of the phallus. Testicular volume was still 2# N8 s% q4 ^" s; s1 F- H
mL, and the size of the penis remained unchanged.
+ I9 L! c: N* K" w! R! w9 VThe mother also said that the boy was no longer hav-
, U+ N$ S) b, h2 ting frequent erections.
5 l% h+ s* t4 X. A: aBoth parents were again questioned about use of
?7 Q2 O2 } r0 iany ointment/creams that they may have applied to' T! B( V+ R; p) m `: [2 o6 F, p
the child’s skin. This time the father admitted the
% f! K( ?; V1 G4 \; z; F( V9 k+ I2 iTopical Testosterone Exposure / Bhowmick et al 5417 E- I* Q4 j# |
use of testosterone gel twice daily that he was apply-
, P8 E, `, e( w4 King over his own shoulders, chest, and back area for- A& R+ j! Z5 m
a year. The father also revealed he was embarrassed
2 {8 }6 m8 J e& I/ u/ W; F- Dto disclose that he was using a testosterone gel pre-8 |% d( J! w4 B+ g+ O+ c
scribed by his family physician for decreased libido
9 r7 ^8 v* e0 b" E6 fsecondary to depression.& F$ D' g, q8 j2 t+ w2 T
The child slept in the same bed with parents.
1 Z4 D* u& ]5 p f& [% e+ ?The father would hug the baby and hold him on his6 {' r- i) H' D0 ?: S$ G
chest for a considerable period of time, causing sig-2 I0 y0 x. g5 D& g
nificant bare skin contact between baby and father.
, A- q# y1 F7 \/ }! R; aThe father also admitted that after the phone call,
# B8 E) f' Z, w5 Z) U! f3 cwhen he learned the testosterone level in the baby/ M9 w& Q0 c# I! b& o* b
was high, he then read the product information/ F# m: [' ~% R# Y$ O( K: a' `( n
packet and concluded that it was most likely the rea-9 E5 z: j( ?, I9 i) S) K: p7 f
son for the child’s virilization. At that time, they
! C- U: v1 M2 idecided to put the baby in a separate bed, and the
4 X, m2 L* f2 }( Gfather was not hugging him with bare skin and had+ q+ i, A9 b3 n5 `: Y3 x
been using protective clothing. A repeat testosterone0 b' e4 O. W9 c7 x) B' g `
test was ordered, but the family did not go to the) T/ q; H" k' E0 U$ Y& R
laboratory to obtain the test.
4 x% U: y# v B. _0 `& f- QDiscussion9 f4 o. j: p* ~; O' E7 y8 Y1 T
Precocious puberty in boys is defined as secondary5 V6 X# v/ n3 d$ ~9 @
sexual development before 9 years of age.1,4
( |/ `7 ?& M% G% ?Precocious puberty is termed as central (true) when; Z( Q0 N7 z2 V' M) x1 e
it is caused by the premature activation of hypo-
% C: `* B1 q7 i& rthalamic pituitary gonadal axis. CPP is more com-
& C4 G2 |6 o; b/ @- Amon in girls than in boys.1,3 Most boys with CPP1 b/ X$ X4 p6 o5 o/ B
may have a central nervous system lesion that is: |9 ]7 H) O! B& c6 L4 W
responsible for the early activation of the hypothal-
! V- F# ?$ Y3 l. V. yamic pituitary gonadal axis.1-3 Thus, greater empha-
# t* c. X, X) w% O" f' W# asis has been given to neuroradiologic imaging in! v. ~+ e' T- Q' Y0 N% j( } I
boys with precocious puberty. In addition to viril-
. f; \' I$ n( n% Tization, the clinical hallmark of CPP is the symmet-% S% Z# z( y1 {
rical testicular growth secondary to stimulation by, c+ g7 a3 O: i3 F7 |# v! H- @
gonadotropins.1,30 L: p$ H8 Q3 P7 I5 `
Gonadotropin-independent peripheral preco-
+ l$ z% d( ] J2 p. Pcious puberty in boys also results from inappropriate6 X1 i+ ]! L" V2 Z3 O
androgenic stimulation from either endogenous or4 L/ N# v8 ~0 w2 i4 b* H
exogenous sources, nonpituitary gonadotropin stim-
. o: U$ x; z/ [% K1 @ulation, and rare activating mutations.3 Virilizing
. e3 Q7 G/ W) Y7 |- V/ D Acongenital adrenal hyperplasia producing excessive/ {7 _+ G$ q" J3 [% w1 @2 I
adrenal androgens is a common cause of precocious
- l8 G) M4 G+ D0 R9 s# g0 qpuberty in boys.3,4
7 J& D7 x4 }; ` v8 WThe most common form of congenital adrenal
$ H6 u2 y* O5 G. lhyperplasia is the 21-hydroxylase enzyme deficiency.
- x x$ [$ N4 aThe 11-β hydroxylase deficiency may also result in. k: b; z$ q+ C& ]
excessive adrenal androgen production, and rarely,2 N1 i% f E$ d% i7 ~
an adrenal tumor may also cause adrenal androgen
/ Z& O3 [; d; Dexcess.1,3
( ~2 I5 }5 s1 _0 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& O% e& L6 K, t2 U- n" G2 s7 |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# k3 X' Z k/ g0 T7 wA unique entity of male-limited gonadotropin-
, Z. q2 t) J8 d7 iindependent precocious puberty, which is also known& I6 p* @ x w; L
as testotoxicosis, may cause precocious puberty at a
* o$ Z9 |" [- A* C4 ~1 S5 l! H, Bvery young age. The physical findings in these boys
( N7 _8 y& J# {4 N# H. i* P; hwith this disorder are full pubertal development,
& Y& d7 O$ _' H6 X! C: ^/ t" Oincluding bilateral testicular growth, similar to boys
0 i* I1 T' C% H8 a2 Dwith CPP. The gonadotropin levels in this disorder2 n- S5 W0 E4 B
are suppressed to prepubertal levels and do not show8 \' Y T$ d% R1 L+ a8 o
pubertal response of gonadotropin after gonadotropin-! d+ l, X+ u0 W; X( n
releasing hormone stimulation. This is a sex-linked
6 u/ |& k% P' O6 Y) c- ?4 gautosomal dominant disorder that affects only
K1 E, S$ Y4 `& a: omales; therefore, other male members of the family
2 h' s3 ]" E3 l6 M2 }' `may have similar precocious puberty.3- V# e0 D' K# v+ `% ~, Z. l5 t
In our patient, physical examination was incon-. a. \! @& I# H+ K6 Y3 r( N
sistent with true precocious puberty since his testi-- V" [, Z9 l7 P$ N0 g- r
cles were prepubertal in size. However, testotoxicosis6 z0 v" f$ N# D: S6 A) ~# \6 |
was in the differential diagnosis because his father
- f7 k& Q' \2 pstarted puberty somewhat early, and occasionally,
: u- \1 n9 I0 ttesticular enlargement is not that evident in the7 x3 t! P- S0 q
beginning of this process.1 In the absence of a neg-& ]7 Y b/ e. c) g
ative initial history of androgen exposure, our) B/ E* g6 v5 W) U1 Y+ W: ? B
biggest concern was virilizing adrenal hyperplasia,
( M: P- z3 {7 a6 k6 Veither 21-hydroxylase deficiency or 11-β hydroxylase' Q; z3 b! J6 b# n
deficiency. Those diagnoses were excluded by find-8 R, ]0 a( Y- R2 Y3 `% `
ing the normal level of adrenal steroids.
8 H& _ ^5 d3 P) k4 [. ~. W2 B0 eThe diagnosis of exogenous androgens was strongly
8 H0 p, x# r% G8 D0 J# wsuspected in a follow-up visit after 4 months because
/ \" v2 L$ w* |4 C. m+ Uthe physical examination revealed the complete disap-
# f& z& E$ z; tpearance of pubic hair, normal growth velocity, and7 e8 T1 E! L$ Q/ Y* @9 ^
decreased erections. The father admitted using a testos-$ K1 _ g o" _8 Q1 m
terone gel, which he concealed at first visit. He was
- f; \: L# t- y& k u: g* x- qusing it rather frequently, twice a day. The Physicians’0 n( ]: b3 a2 \# v) U* b8 ]
Desk Reference, or package insert of this product, gel or- O# D4 t& |# H# U7 D/ f
cream, cautions about dermal testosterone transfer to# v4 y: ^9 V- S: H5 F
unprotected females through direct skin exposure.
5 ~0 X. F) _" |$ ?% oSerum testosterone level was found to be 2 times the
; A4 [" J5 o1 h# c5 w7 hbaseline value in those females who were exposed to8 k; @" v7 z' E0 b
even 15 minutes of direct skin contact with their male
- n% b6 b1 V7 L, r$ `* upartners.6 However, when a shirt covered the applica-
( S6 m( z0 X1 u1 `1 etion site, this testosterone transfer was prevented.1 X0 g# X0 u# t7 U* D' j
Our patient’s testosterone level was 60 ng/mL,
: c0 b# E- e( ewhich was clearly high. Some studies suggest that) G- ^4 V- [! I/ I. H% y0 X
dermal conversion of testosterone to dihydrotestos-
+ w7 ]( \" I# ^' Y1 m/ O Z0 n! f3 Wterone, which is a more potent metabolite, is more1 ~; |% \: x6 v7 A* c" t$ l$ [
active in young children exposed to testosterone
0 V1 z* M. F" K+ L+ R0 Pexogenously7; however, we did not measure a dihy-1 C' G2 k4 r3 [- `. p
drotestosterone level in our patient. In addition to8 K0 V8 M6 ]/ E& s: I
virilization, exposure to exogenous testosterone in
d: x( _; O( cchildren results in an increase in growth velocity and
' u; h# Y" c) B- M2 t% Cadvanced bone age, as seen in our patient.0 a/ t4 M' w: }; u6 o
The long-term effect of androgen exposure during4 V0 Y/ o% b, f; ~7 f9 Y* y, O
early childhood on pubertal development and final
) t$ u$ n/ i! E: Nadult height are not fully known and always remain6 Q4 D+ x+ I. j! `- f- c
a concern. Children treated with short-term testos-
6 j: m, ~% E4 Z. u1 Vterone injection or topical androgen may exhibit some+ d/ a! a4 o1 E+ F1 @- q- E$ a
acceleration of the skeletal maturation; however, after) q- U! u+ V ~+ B8 K1 f
cessation of treatment, the rate of bone maturation
5 J& J! ^1 \+ C* Xdecelerates and gradually returns to normal.8,9! i8 L5 u {4 [* c1 B
There are conflicting reports and controversy
. D# a# }: [) O% {' |over the effect of early androgen exposure on adult( x& ?7 c5 t. M) o1 O* F
penile length.10,11 Some reports suggest subnormal
; L0 z, b5 t" C, Q! u# _* g+ Zadult penile length, apparently because of downreg-+ m" x4 n* L0 h( X
ulation of androgen receptor number.10,12 However,
( l( T% L" g3 U. U9 r. Y) USutherland et al13 did not find a correlation between& I) {. W. j9 B. I& B
childhood testosterone exposure and reduced adult
/ ?( D% k3 n- J+ [( j+ Mpenile length in clinical studies.: ~- W& @1 ~0 ~& s0 @
Nonetheless, we do not believe our patient is
" b1 ~: q# ?& @going to experience any of the untoward effects from8 _1 w/ w6 a" C/ n
testosterone exposure as mentioned earlier because0 b4 ~; D/ O$ C/ Q) [* i
the exposure was not for a prolonged period of time.* |; {" R5 ~% q. ~3 d+ n. A! B
Although the bone age was advanced at the time of
. l9 R& `1 N: a- a, r7 M; ^diagnosis, the child had a normal growth velocity at+ k$ Z3 S8 ?( ?! ]1 }
the follow-up visit. It is hoped that his final adult* ~& Q/ t" e2 b' W7 N! F
height will not be affected.9 s% `1 B8 Y) ~4 T- b7 _
Although rarely reported, the widespread avail-
" Q! L" f* ^% u4 B6 mability of androgen products in our society may
2 `2 \: A; y7 X7 a L3 zindeed cause more virilization in male or female
( P1 D4 L# A. k/ m' @4 achildren than one would realize. Exposure to andro-
+ [# w+ H/ K/ ^! A! v" _gen products must be considered and specific ques-
* W7 n! q5 g$ u+ b4 V# z8 }7 p) ~tioning about the use of a testosterone product or
. O& X4 n- a' [& r" L4 g9 jgel should be asked of the family members during
4 o1 `( T0 @" b% Y, y5 _the evaluation of any children who present with vir-3 s, ]. j1 h% @. r; n7 Y7 J
ilization or peripheral precocious puberty. The diag-
( p$ N1 m- }+ s6 U Fnosis can be established by just a few tests and by
: D: n- d+ }2 Y8 |: V m$ g1 Sappropriate history. The inability to obtain such a
9 |- T2 n; }) S, v# Q' y* H) jhistory, or failure to ask the specific questions, may
* Q, g4 w9 x$ Rresult in extensive, unnecessary, and expensive# r! ?8 n) b# e5 |) s
investigation. The primary care physician should be# Q% E; P/ C) G
aware of this fact, because most of these children0 p3 O1 U. _! B
may initially present in their practice. The Physicians’5 k0 D/ ?& h5 m+ b
Desk Reference and package insert should also put a
2 Q- U5 }& a8 g+ {* I x; v8 xwarning about the virilizing effect on a male or
$ K" a- Y3 T2 p* O2 xfemale child who might come in contact with some-" m. h. y3 X8 p2 j- |
one using any of these products.
_$ L6 u1 ^( r9 tReferences, W; O1 ^: s# U2 S* K$ |, K
1. Styne DM. The testes: disorder of sexual differentiation/ \' B; V+ F1 c. P5 u4 S6 I
and puberty in the male. In: Sperling MA, ed. Pediatric: k' _9 C4 A9 m% L0 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 X4 N; O/ o& o2 ^5 \2 a
2002: 565-628.
6 M1 E* \% {$ @6 ~- O2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 _" R3 T) V, q/ v/ Q2 k- N
puberty in children with tumours of the suprasellar pineal |
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