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Sexual Precocity in a 16-Month-Old) ]% A$ _+ P7 L7 K
Boy Induced by Indirect Topical
) D7 N! Y1 v" D; t5 e! }2 p* qExposure to Testosterone5 `+ b2 k4 u6 e8 }* A9 B* z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, }6 K0 L5 F5 L% A' u- L5 k
and Kenneth R. Rettig, MD17 R8 P( h/ i7 t! W6 x. f* `
Clinical Pediatrics
" h7 V: k+ `6 j9 V% Y4 {' t% vVolume 46 Number 6
@: V4 X/ w8 oJuly 2007 540-543
) m& K7 v' ~$ \# Y& r9 Y/ }© 2007 Sage Publications
7 s- g" f& H) s0 x7 K# e+ }10.1177/0009922806296651# f0 P6 O4 t+ y: R- A! O2 b8 w0 g
http://clp.sagepub.com7 c/ Q7 d6 b: y9 {
hosted at
2 f1 d( t8 j! }+ qhttp://online.sagepub.com, F8 L& q; J* u! j: ^% y- M/ K6 |
Precocious puberty in boys, central or peripheral,
9 W- O# h T6 B2 ]: Dis a significant concern for physicians. Central1 v3 t8 F F m8 y% u, l! d2 N1 S3 m
precocious puberty (CPP), which is mediated# b' g: c4 G" E! Y! p5 e
through the hypothalamic pituitary gonadal axis, has; O9 Q1 D( j6 S: G$ K3 ?3 C
a higher incidence of organic central nervous system
# U6 K9 J) P$ J% g) K' }lesions in boys.1,2 Virilization in boys, as manifested' c$ f8 }9 |* C
by enlargement of the penis, development of pubic" O+ l! Y# K7 X. f0 o$ {
hair, and facial acne without enlargement of testi-
& W) r. n' ?3 b) q2 Gcles, suggests peripheral or pseudopuberty.1-3 We
6 B: E& n1 R- G5 h2 U% Treport a 16-month-old boy who presented with the
2 w2 x- l( `8 @4 ienlargement of the phallus and pubic hair develop-. u/ D" S( ]+ p/ S3 O$ P2 s
ment without testicular enlargement, which was due3 ?' _5 K0 w3 N4 i3 o
to the unintentional exposure to androgen gel used by
5 C' n% L- D, c8 R' xthe father. The family initially concealed this infor-3 x- }; Z' W% ?) q, i& l( d9 n
mation, resulting in an extensive work-up for this
$ ]4 u: K D1 Pchild. Given the widespread and easy availability of
( [8 c1 N, t' l' z! q# l) j+ etestosterone gel and cream, we believe this is proba-
. F B$ N) s7 T9 u$ Ably more common than the rare case report in the
5 m7 V! U, n, ^: J+ aliterature.4! Z$ d+ @( k- W: h G! o: T
Patient Report
% ~ J! `$ W4 r3 H8 j/ ^ V$ v" QA 16-month-old white child was referred to the/ Z# r. Z8 \/ J9 h1 n. @! s: X1 y3 J! o
endocrine clinic by his pediatrician with the concern+ z! X" A- v$ _) T
of early sexual development. His mother noticed6 m8 P. Z% o0 G; l3 C2 k
light colored pubic hair development when he was
. `* P1 N6 a5 ]# I& |0 G, a" FFrom the 1Division of Pediatric Endocrinology, 2University of# j) e- J+ v8 p
South Alabama Medical Center, Mobile, Alabama.
- d! a- ^- K( J [Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 B* p! _4 v- j& `Professor of Pediatrics, University of South Alabama, College of
; B% \* K2 H4 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 b: y7 b# w4 |2 \1 A
e-mail: [email protected].' f1 z: ^# \: O6 ^# p. a
about 6 to 7 months old, which progressively became& ?# p8 c- S8 F3 S& X. u o
darker. She was also concerned about the enlarge-* Q, H& H6 f( K5 i) h2 g
ment of his penis and frequent erections. The child# l3 B" m: S& B O c; r
was the product of a full-term normal delivery, with Q# ]# \: }. W* N
a birth weight of 7 lb 14 oz, and birth length of" V, y# H6 V( k2 B
20 inches. He was breast-fed throughout the first year' v$ y2 G* t: w
of life and was still receiving breast milk along with
( \8 u1 B B: {) {! L% J% k3 Hsolid food. He had no hospitalizations or surgery,
% j/ W$ J/ _0 q* B% d Cand his psychosocial and psychomotor development) v5 a! R: k$ I
was age appropriate.8 f) v! |- d1 D2 [; \- J
The family history was remarkable for the father,
$ d T) t! |! d, p( g0 D+ ]who was diagnosed with hypothyroidism at age 16,& M( v, a( l$ [
which was treated with thyroxine. The father’s
) A$ j4 j: J4 b' d$ r: Qheight was 6 feet, and he went through a somewhat% X! A7 O: v7 O* a; C& b
early puberty and had stopped growing by age 14.8 a3 J) s! p, P, y. h/ x
The father denied taking any other medication. The0 n- k! ?0 y( C* y
child’s mother was in good health. Her menarche% k) M/ f' F2 L5 m+ O3 ]6 y/ i
was at 11 years of age, and her height was at 5 feet7 m! H9 g0 z5 F8 ^& s' E$ p2 E
5 inches. There was no other family history of pre-
/ L* U T! M8 J3 ? l! \# Zcocious sexual development in the first-degree rela-) V- G% M" h$ k' k, u- h
tives. There were no siblings.' F' c' C {5 C& |2 m' W
Physical Examination7 R1 i2 v. r( v$ @! { ~
The physical examination revealed a very active,
$ Z: S4 r. z0 Eplayful, and healthy boy. The vital signs documented
# E0 G8 t3 O8 _8 Aa blood pressure of 85/50 mm Hg, his length was
4 ]( J3 H: {% E+ L2 }90 cm (>97th percentile), and his weight was 14.4 kg: @2 g, B* V. J' ~6 G! V- U
(also >97th percentile). The observed yearly growth
$ Y$ A- w! f% b7 j A) Kvelocity was 30 cm (12 inches). The examination of' e! x: Z% `; w$ X, a
the neck revealed no thyroid enlargement.; z* N/ w& {4 G; k7 \5 g6 f# t$ j% a
The genitourinary examination was remarkable for
$ C+ m6 |7 a2 ]" jenlargement of the penis, with a stretched length of
. ~. Y, L- B5 w0 O0 ?8 cm and a width of 2 cm. The glans penis was very well( P7 G8 I* f4 @
developed. The pubic hair was Tanner II, mostly around
) H, Y- j8 i- P a% A540
]+ l( I, G" x; @2 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% c/ e% J f. z: Z' wthe base of the phallus and was dark and curled. The
5 K+ R! H v D. b+ [% Wtesticular volume was prepubertal at 2 mL each.
; i/ j' i- k4 Q5 S( MThe skin was moist and smooth and somewhat: e5 }& l* V5 K4 z `7 k( Z
oily. No axillary hair was noted. There were no6 L5 {2 c) A: T" H9 T4 r
abnormal skin pigmentations or café-au-lait spots.
: _0 t3 T/ j0 h4 O iNeurologic evaluation showed deep tendon reflex 2+8 x l- M2 E( ~( V y4 {* k
bilateral and symmetrical. There was no suggestion; i5 p& I5 l/ X G5 @( \9 C
of papilledema.# E* O" a4 j$ X& H2 S8 G
Laboratory Evaluation% u1 y$ \0 w( f; [6 U- L( l4 G' x
The bone age was consistent with 28 months by
* c @0 ]8 d9 Q. _0 `' Rusing the standard of Greulich and Pyle at a chrono-; @& P; U# |5 _ S! [9 V
logic age of 16 months (advanced).5 Chromosomal% H$ U) _. A& x
karyotype was 46XY. The thyroid function test
: y/ |- H3 f( @/ _7 y4 `7 n: Oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" Y; n2 \+ W0 f* _3 `; v
lating hormone level was 1.3 µIU/mL (both normal).0 p! l; h+ j' c/ N$ v
The concentrations of serum electrolytes, blood
. c/ k. X2 T0 S" y, [ Ourea nitrogen, creatinine, and calcium all were
3 w& y$ V# W2 P6 k7 Swithin normal range for his age. The concentration
+ Z0 z' E! L2 Lof serum 17-hydroxyprogesterone was 16 ng/dL
6 i3 ?8 n: m- O6 C' f j: g(normal, 3 to 90 ng/dL), androstenedione was 20: ^, f; m3 x, a0 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 c& T7 P5 O& a4 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),( ^6 z s9 |6 P: j/ A# G
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( Q( J! d0 B5 \3 }
49ng/dL), 11-desoxycortisol (specific compound S)
9 w- H6 |, ]; E+ ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) N9 s+ `/ N# L' I6 Y# gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; h5 y; K7 k: `* N2 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ {0 {. L# X+ I8 ^8 S
and β-human chorionic gonadotropin was less than" y7 n2 g+ N Q# U4 t7 ~& }. v9 k" N
5 mIU/mL (normal <5 mIU/mL). Serum follicular# b2 J% L# ]# w" @1 s$ y
stimulating hormone and leuteinizing hormone* k1 B* N! B) x3 p1 u+ p+ }0 p
concentrations were less than 0.05 mIU/mL t4 |6 }% w1 S9 a$ l8 c4 y- I
(prepubertal)." W# { v, R% \
The parents were notified about the laboratory, H- l! r+ e9 g
results and were informed that all of the tests were
/ w) S% L/ d: x& Wnormal except the testosterone level was high. The2 M% U+ g: R7 E& [
follow-up visit was arranged within a few weeks to# H# r! l& a- I& U/ z3 h
obtain testicular and abdominal sonograms; how-
g, }( i' P2 L, t, Sever, the family did not return for 4 months.4 M! n0 V+ @& h0 P/ |8 C
Physical examination at this time revealed that the
" s" M! ~/ Q9 @child had grown 2.5 cm in 4 months and had gained' r* D5 E) W) B2 A
2 kg of weight. Physical examination remained& X2 }* u G- ~6 {( @9 G1 A1 D
unchanged. Surprisingly, the pubic hair almost com-
$ \/ x. _! Y8 [$ e3 b, Opletely disappeared except for a few vellous hairs at M* {8 f4 Z. H1 l! n( i+ p
the base of the phallus. Testicular volume was still 2* j- X8 a( @# }6 z- A: E# ?+ g; m
mL, and the size of the penis remained unchanged.
, p0 J, W, `; P! W9 d! CThe mother also said that the boy was no longer hav-
0 Y2 m. N5 I# Xing frequent erections.
/ U3 p1 Y; }6 X9 W2 YBoth parents were again questioned about use of
3 h8 A0 u9 u3 q; [' Z" F8 ?any ointment/creams that they may have applied to6 C. [$ K' a( s0 M
the child’s skin. This time the father admitted the
3 ?! x8 P, B* v$ S7 nTopical Testosterone Exposure / Bhowmick et al 541" w! H: {+ h/ A( ?
use of testosterone gel twice daily that he was apply-
& a: P3 D; V7 I$ M5 N6 Xing over his own shoulders, chest, and back area for9 `8 G1 d R: d, K% O
a year. The father also revealed he was embarrassed
* b% v! a9 S/ i% Vto disclose that he was using a testosterone gel pre-" O! p, l2 k- F, J
scribed by his family physician for decreased libido- p1 \ T" B) ]* c8 x9 H- ?) E! l, I, U
secondary to depression.
; }0 P0 Y. T$ n9 \' UThe child slept in the same bed with parents.; p6 \ u! Z, |1 C; m+ i+ w. w# x' A
The father would hug the baby and hold him on his' |6 O" c: X' C- c8 {7 w' p7 d% C
chest for a considerable period of time, causing sig-: a1 O s2 q* | i/ @( r: A6 K9 B
nificant bare skin contact between baby and father.* A% L/ T1 k! z) ~: R/ _
The father also admitted that after the phone call,5 D1 |6 ?" L) g g: T8 }6 x5 r
when he learned the testosterone level in the baby) K7 Q2 n% s& u+ e* p# w3 {
was high, he then read the product information
. |/ t7 l3 {" F' ?# a( [packet and concluded that it was most likely the rea-
+ |& F7 b1 _6 S2 x7 i6 H2 Pson for the child’s virilization. At that time, they* s4 ^+ y' |( I% N
decided to put the baby in a separate bed, and the. T2 O1 y, J3 B) A
father was not hugging him with bare skin and had6 o4 U2 x! R0 x" H
been using protective clothing. A repeat testosterone
7 L/ X; j" y$ F& vtest was ordered, but the family did not go to the
- ]+ T& u; _2 h; \0 Vlaboratory to obtain the test.5 U, h) L& Y- H9 t; i8 Q3 U
Discussion
6 F9 g. d* F: z4 k0 uPrecocious puberty in boys is defined as secondary6 L# U5 ^9 L" V) b* v% {
sexual development before 9 years of age.1,4
% U6 K' \, J s5 n. @/ V3 k, SPrecocious puberty is termed as central (true) when
" F8 u! X* l3 S2 J0 G# ^it is caused by the premature activation of hypo-7 D5 f1 d, J9 v' u
thalamic pituitary gonadal axis. CPP is more com-
; D# Y3 S8 _( _; I" A4 s$ |* gmon in girls than in boys.1,3 Most boys with CPP
! U( r: w. Z; \0 U3 J" Umay have a central nervous system lesion that is i1 J( d' `5 | p" o3 l
responsible for the early activation of the hypothal-- r' p+ q3 N- y2 X: }3 O; B
amic pituitary gonadal axis.1-3 Thus, greater empha-
r- w7 J) u0 z7 psis has been given to neuroradiologic imaging in
$ N- @# i$ Z0 _6 J+ V% e. ^boys with precocious puberty. In addition to viril-/ V8 I/ W8 M5 H9 n2 d) A
ization, the clinical hallmark of CPP is the symmet-
, a3 o: a2 j& x+ e6 urical testicular growth secondary to stimulation by
9 v* d2 |9 @, ^+ Ugonadotropins.1,33 r0 S" {5 [& p# O0 s
Gonadotropin-independent peripheral preco-
: R& r6 A0 s! t( {7 q5 d9 ucious puberty in boys also results from inappropriate
6 f4 p2 H5 }; K1 }5 T" _5 _androgenic stimulation from either endogenous or
1 L" o% }/ m( bexogenous sources, nonpituitary gonadotropin stim-
5 u. M) Z- o. k' P/ mulation, and rare activating mutations.3 Virilizing) B9 F# [5 Z r- o8 H2 N# j
congenital adrenal hyperplasia producing excessive
- J7 X+ x4 u4 Padrenal androgens is a common cause of precocious
8 [) v( J) A, L* R; k) r2 ]puberty in boys.3,48 d- N9 X! A9 B M7 e
The most common form of congenital adrenal% r' d- G; y0 I& H* m
hyperplasia is the 21-hydroxylase enzyme deficiency.
" J* T+ f# H% mThe 11-β hydroxylase deficiency may also result in
2 l; ^) C8 u. e8 |excessive adrenal androgen production, and rarely,# k" {- x# q- X6 W( M
an adrenal tumor may also cause adrenal androgen
4 r; T' t3 {+ }( _3 t7 R; Sexcess.1,3
* e0 _ {6 Y; w2 Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. v3 [/ e9 z7 v) ~) {" o* [% a4 l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: F# t1 n4 w! D5 n+ Y0 i. W% _A unique entity of male-limited gonadotropin-
- X* j) {+ B. M' C5 b: V' Lindependent precocious puberty, which is also known
; m/ ?# E# E2 C: Y5 Sas testotoxicosis, may cause precocious puberty at a2 A) m. Z( T' D9 r$ B; U
very young age. The physical findings in these boys! p: a3 S7 d! _. b" {2 r% I3 h
with this disorder are full pubertal development,
* `( z: B: u. Dincluding bilateral testicular growth, similar to boys7 X5 ~6 S: l: Q3 x+ x
with CPP. The gonadotropin levels in this disorder
7 W6 R" n6 Z: @9 G, N" B3 Vare suppressed to prepubertal levels and do not show
9 n' L) j' I: apubertal response of gonadotropin after gonadotropin-* y3 S/ o2 u ?, s7 T
releasing hormone stimulation. This is a sex-linked
7 z( u2 G& v) B" Fautosomal dominant disorder that affects only
' I* x% ~2 T6 [$ ?+ ^males; therefore, other male members of the family' D6 g# M% @/ r( N `
may have similar precocious puberty.3
$ |3 o+ N! e) O" H6 UIn our patient, physical examination was incon-
8 U4 { K4 l6 _8 {& P1 a0 \$ jsistent with true precocious puberty since his testi-
W0 x+ J, `- S. I+ v9 ycles were prepubertal in size. However, testotoxicosis; J: \6 {% @: I: ]* X$ ]; Y3 K! u" M
was in the differential diagnosis because his father
# e" ?$ S+ Q+ U7 c+ X3 Y! ystarted puberty somewhat early, and occasionally,9 o8 E0 }0 x, u' t- l9 y) A
testicular enlargement is not that evident in the5 A8 ]4 w# J$ M3 F4 @
beginning of this process.1 In the absence of a neg-' U8 f+ x& H5 N# w
ative initial history of androgen exposure, our
: O$ f( m4 A/ u# N C, T6 @biggest concern was virilizing adrenal hyperplasia,
]0 V. ^4 @( Q, E1 Leither 21-hydroxylase deficiency or 11-β hydroxylase
& w+ c r! P6 G1 W# C! Z% B: ^deficiency. Those diagnoses were excluded by find-* B& [" |$ q8 U7 d' S) H. J$ r
ing the normal level of adrenal steroids.
: L6 X9 `1 y# e2 MThe diagnosis of exogenous androgens was strongly
- S4 z- ?% u' n! m& Q5 _( d) Ssuspected in a follow-up visit after 4 months because# `% y5 ~& W$ ]$ a$ Z, |& a/ R
the physical examination revealed the complete disap-
' v' V- S$ N" |, g& p" y$ opearance of pubic hair, normal growth velocity, and
9 m4 }9 F5 w; U' @! [2 Vdecreased erections. The father admitted using a testos-
# S& K, e" A6 t4 E- `! s$ a: e ^) uterone gel, which he concealed at first visit. He was
, \) u$ y$ ]* p7 Lusing it rather frequently, twice a day. The Physicians’! s' ]0 v7 v& l$ `, J8 Q( O9 o
Desk Reference, or package insert of this product, gel or" R9 @" B+ Y' _% n5 Z
cream, cautions about dermal testosterone transfer to2 `: v9 x+ N& `# ~
unprotected females through direct skin exposure.
- \3 t3 a8 j8 }3 v3 nSerum testosterone level was found to be 2 times the9 D+ @. f& H2 Y+ ]" E0 M) [
baseline value in those females who were exposed to
* L$ B6 h- O1 H# G# geven 15 minutes of direct skin contact with their male
& e" |# w; g7 H, A y' Epartners.6 However, when a shirt covered the applica-4 Z1 S2 D' B1 ?6 n, Z( T; l" b
tion site, this testosterone transfer was prevented.* H2 P4 a W8 D# \1 N) x% D
Our patient’s testosterone level was 60 ng/mL,
! c$ P+ ]+ z. K% u6 w% W- Iwhich was clearly high. Some studies suggest that
, b; e: Z0 u7 b! z1 kdermal conversion of testosterone to dihydrotestos- w+ l4 r* w) Z. ?
terone, which is a more potent metabolite, is more+ g2 w' F" G$ p7 F' o3 w
active in young children exposed to testosterone6 c4 C! a% [# D4 b3 d) U ?* [
exogenously7; however, we did not measure a dihy-) q. E* b/ K9 G4 U
drotestosterone level in our patient. In addition to, d+ ]4 Y# q; {0 ~% U
virilization, exposure to exogenous testosterone in: q' F+ v4 G5 x' d4 ]7 D/ `1 B: r
children results in an increase in growth velocity and
* Q& ^" Z. A& [ gadvanced bone age, as seen in our patient.
4 U1 d0 ?& k; S# S0 x" o" dThe long-term effect of androgen exposure during2 b7 L1 B7 D I
early childhood on pubertal development and final
1 i r x! V6 J$ C+ q6 K1 zadult height are not fully known and always remain, b3 z/ d/ D: }% n& {. o( l! |& x
a concern. Children treated with short-term testos-
1 l9 ]1 k k# |0 ~& z# Pterone injection or topical androgen may exhibit some
( ]- }1 `; V0 B- sacceleration of the skeletal maturation; however, after
! e2 |6 R4 }- O& gcessation of treatment, the rate of bone maturation- w$ T6 W$ Y/ r# h% S
decelerates and gradually returns to normal.8,9
- O+ x5 _2 |+ ?% F; Y" gThere are conflicting reports and controversy
! M) i9 {! D1 B% ^8 Mover the effect of early androgen exposure on adult- I, g5 b& Z9 u
penile length.10,11 Some reports suggest subnormal9 v5 [- k' |7 l8 H8 P# ?4 t
adult penile length, apparently because of downreg-
5 d. E$ @1 F, @! }+ m% gulation of androgen receptor number.10,12 However,% |$ \" D9 i3 }$ @, c
Sutherland et al13 did not find a correlation between
2 }" {( o6 S rchildhood testosterone exposure and reduced adult" N ^5 N+ b7 \% j
penile length in clinical studies.! j" D2 Z# ~; H- T1 M4 d
Nonetheless, we do not believe our patient is& W/ i B0 R" [6 t3 D' \: W6 D0 B
going to experience any of the untoward effects from) k+ W. _- p! s& R9 L) n3 E0 `/ i
testosterone exposure as mentioned earlier because6 ~, {8 L+ p5 c: v: g
the exposure was not for a prolonged period of time.2 ]2 Z/ r% s& p3 `) d0 X& A
Although the bone age was advanced at the time of
: r( h: p0 P5 G; I% {diagnosis, the child had a normal growth velocity at# _6 ~* D5 f4 {( E- Q4 L3 Y# U) l
the follow-up visit. It is hoped that his final adult
" C r' T( w: B( Y* ~4 Aheight will not be affected.
4 c, h% W. E2 J M X# xAlthough rarely reported, the widespread avail-
* h8 _ B1 l* ?+ E3 Dability of androgen products in our society may! M# l' t1 B4 n$ E- Z* y/ j3 S
indeed cause more virilization in male or female
7 U$ H& a6 c# I. G( [7 f, t5 Vchildren than one would realize. Exposure to andro-
% }' ?! [: F. W9 p2 s- P+ Lgen products must be considered and specific ques-( l3 K6 a0 o: X- F( `; o+ o
tioning about the use of a testosterone product or2 g* Q2 }7 O. L+ U; n/ \
gel should be asked of the family members during
7 {; c3 s2 b% `7 M/ k9 m3 mthe evaluation of any children who present with vir-
' C2 @/ g: Q- g5 |# I% \: Vilization or peripheral precocious puberty. The diag-
. C+ s2 [. P- ]nosis can be established by just a few tests and by; S+ V7 R8 s6 T. _5 W/ L% J
appropriate history. The inability to obtain such a( B2 Y' Z, t4 {* Z! y0 Q" u
history, or failure to ask the specific questions, may5 D5 o8 e/ A( C. U3 i7 z
result in extensive, unnecessary, and expensive
6 G8 s/ _: [. T, \% G0 K" einvestigation. The primary care physician should be4 y# W: k, F& Z1 i7 E
aware of this fact, because most of these children( Z: m8 b2 j5 `) V3 B( H( e8 @7 |. y
may initially present in their practice. The Physicians’
6 X7 M! R8 S6 C" F4 |3 B& w* n" RDesk Reference and package insert should also put a; C& o1 _, E8 ?7 |* K
warning about the virilizing effect on a male or
8 K( ?6 J4 m0 |: @, C0 P( @female child who might come in contact with some-
. ~8 S, w5 S- N1 `, ?6 vone using any of these products.
% q8 P6 n$ o% _; Q. X1 ^+ \References) f0 R/ v- i }; v
1. Styne DM. The testes: disorder of sexual differentiation
% W! b% R0 `! b7 j) m( eand puberty in the male. In: Sperling MA, ed. Pediatric! \( h4 @8 H9 i# N3 V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. R# T9 @! @- I9 K( J- L$ k2 x
2002: 565-628.
( w: N4 }$ z) r2 [) U* J. Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; X; m* R& T( v$ N0 z; }+ kpuberty in children with tumours of the suprasellar pineal |
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