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Sexual Precocity in a 16-Month-Old
9 {' c1 C* j, e/ p, |& RBoy Induced by Indirect Topical
. m0 l4 @8 Q$ SExposure to Testosterone
; U. _/ U8 M+ }7 hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! T3 v) g1 A: N5 X h( H# V- E
and Kenneth R. Rettig, MD1
4 T$ a: F4 Y0 X9 n( G6 P- tClinical Pediatrics J3 k! v3 B8 R, q: |* ] W
Volume 46 Number 6
3 h$ P' K0 M4 oJuly 2007 540-5435 n3 l" k% t) u7 R" D
© 2007 Sage Publications
0 l' \$ ^ J0 J" s* E& z3 M10.1177/0009922806296651
$ v" P5 l0 S( fhttp://clp.sagepub.com6 a0 _ a4 ]8 o3 r& H4 Y9 I
hosted at
9 }2 f8 H! a" m. s6 E: i1 t- Nhttp://online.sagepub.com
% L, A* L% m. @5 D# J2 WPrecocious puberty in boys, central or peripheral,2 Q% L: p* V; `# Q% {+ U3 j
is a significant concern for physicians. Central7 F) W/ B$ W" t5 X
precocious puberty (CPP), which is mediated
, u: M! W6 Z. h, N/ o# uthrough the hypothalamic pituitary gonadal axis, has+ ?9 W3 S. f3 q) T' o% m
a higher incidence of organic central nervous system
, t- z c: ]( f; J* K+ ^% hlesions in boys.1,2 Virilization in boys, as manifested
: ?( W, t3 ]$ mby enlargement of the penis, development of pubic
/ F7 X+ r7 G+ }6 v2 U' Q$ \hair, and facial acne without enlargement of testi-% V9 j: H6 z) N3 O6 X5 ^8 N# M; M4 [1 Z
cles, suggests peripheral or pseudopuberty.1-3 We
! ^$ R; x0 n. C; z1 z# Wreport a 16-month-old boy who presented with the
* {8 Z* v! a5 Oenlargement of the phallus and pubic hair develop-
0 C6 Y1 l4 j4 Z' j% D2 I e5 Iment without testicular enlargement, which was due
; }8 h( M9 U5 ?! D9 J% {to the unintentional exposure to androgen gel used by
8 D! T/ I- o4 a; G* T, lthe father. The family initially concealed this infor-
. @5 M6 z+ M% J) Ymation, resulting in an extensive work-up for this; \! O2 ?* Q" l4 g" a. E% e6 `5 I
child. Given the widespread and easy availability of5 B$ ]9 [+ L: g8 k1 n( [7 u9 i4 |
testosterone gel and cream, we believe this is proba-5 G# i" s) y0 Q" l6 P! \: N
bly more common than the rare case report in the
8 G* J% `+ b$ _4 zliterature.43 h$ E8 N) k% b8 \+ V; |. d
Patient Report" a$ x& g7 `+ L& O& L
A 16-month-old white child was referred to the
8 v! s& R5 W. B/ w! ^7 p, W0 ?endocrine clinic by his pediatrician with the concern! d S# q9 `3 w1 X( y
of early sexual development. His mother noticed) Q/ ?. \+ C/ C% t1 C2 \
light colored pubic hair development when he was
b; N8 p w4 d# i; PFrom the 1Division of Pediatric Endocrinology, 2University of
# o4 e6 j/ z$ j! m, HSouth Alabama Medical Center, Mobile, Alabama.
% B3 @0 `0 R$ S; `8 I' v: LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
6 T+ U' r& k, l9 OProfessor of Pediatrics, University of South Alabama, College of- T N3 U1 ^- Q' s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! I3 N, s) E6 V& _( j* z% Re-mail: [email protected].- \# B' u' r8 ]. ^
about 6 to 7 months old, which progressively became
2 n7 y" T1 V( N* y5 H/ T! I( f( adarker. She was also concerned about the enlarge-
+ w! ~; ?( y% I- }6 v# A* Sment of his penis and frequent erections. The child
! E/ W- M8 z( D, k7 mwas the product of a full-term normal delivery, with, c3 ^6 ^, S' T% x' u( ?2 u
a birth weight of 7 lb 14 oz, and birth length of
8 g4 v2 A/ X+ A& f5 |5 ?' n5 J20 inches. He was breast-fed throughout the first year" I! J4 D! w: \; I
of life and was still receiving breast milk along with
" w A p! U% r/ ^, xsolid food. He had no hospitalizations or surgery,
/ ?: G2 ?; w5 I1 x9 J& H9 wand his psychosocial and psychomotor development
2 Q2 k: u" W- L$ ? c. kwas age appropriate.
1 D& q. z( W9 E& {- vThe family history was remarkable for the father,' X7 F- v% P! O* j
who was diagnosed with hypothyroidism at age 16,$ {# y) j+ `! Y/ ~
which was treated with thyroxine. The father’s* \4 y; s6 B% V$ D% L. e* d; v
height was 6 feet, and he went through a somewhat) H* L. d g1 B' u9 g& |1 M
early puberty and had stopped growing by age 14.% J0 r. y3 G& b4 e; U
The father denied taking any other medication. The/ r/ e$ O- T4 w4 Q4 Q! H7 Y
child’s mother was in good health. Her menarche, ]0 M7 a+ `( s) {( {/ S
was at 11 years of age, and her height was at 5 feet
3 p3 q( M. @: [( K( j3 r5 inches. There was no other family history of pre-; A5 W2 K* f/ ]/ @( g; t# L7 T
cocious sexual development in the first-degree rela-
: s" k5 d" C9 x" W, ^/ M$ `/ Stives. There were no siblings.; h$ P6 z; A2 K
Physical Examination
, C2 a9 @2 p' G. z$ QThe physical examination revealed a very active,- r( v: x# l' H* @
playful, and healthy boy. The vital signs documented
, L$ q5 V- I( r, Ma blood pressure of 85/50 mm Hg, his length was
" Z1 p% ?# l- b& q/ m3 }2 }90 cm (>97th percentile), and his weight was 14.4 kg6 n5 H3 Q. j8 Z: R' @& T% |- p
(also >97th percentile). The observed yearly growth% l. Y9 O' ?1 N& M1 K
velocity was 30 cm (12 inches). The examination of$ ~+ C) z! [ Y1 k) e. B
the neck revealed no thyroid enlargement.
8 Z/ o) f! Q9 F3 A0 D) KThe genitourinary examination was remarkable for2 O' e0 ]9 ~* O/ g) S8 Y: Y2 _
enlargement of the penis, with a stretched length of
' K- p& q( c" w& J2 T! a8 cm and a width of 2 cm. The glans penis was very well* a6 v" J1 m% P6 N+ I
developed. The pubic hair was Tanner II, mostly around
4 |5 w' P. g) r+ r' z& O4 ?540
% Z; E6 h. m. Q, O) R# u- iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ~( j) f5 e6 L5 ?the base of the phallus and was dark and curled. The$ F6 U9 k: u" H0 n9 m
testicular volume was prepubertal at 2 mL each.7 I3 I( t: t' `. [' S
The skin was moist and smooth and somewhat
7 f' O) ~0 C1 ^7 [: k0 s1 y. Roily. No axillary hair was noted. There were no4 P. h3 |5 a2 Q9 _0 z
abnormal skin pigmentations or café-au-lait spots.
6 ]0 E8 a. c8 W# I' L" A! J$ rNeurologic evaluation showed deep tendon reflex 2+
% X* N8 F/ Q8 x9 Abilateral and symmetrical. There was no suggestion
: K* R2 X5 ^3 {5 ]of papilledema.5 e: d( {% M# }, k' z O
Laboratory Evaluation
- @' ]2 U9 V% u7 G% c$ sThe bone age was consistent with 28 months by
; F1 z4 N( P: e4 ]using the standard of Greulich and Pyle at a chrono-7 L3 o! U w7 z
logic age of 16 months (advanced).5 Chromosomal
. C- \- {( U6 D0 E6 f7 u- q& ?karyotype was 46XY. The thyroid function test
6 Z4 M1 Y9 W, s. |( l( R% hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
p# Q1 s+ v, [7 O7 K8 b7 klating hormone level was 1.3 µIU/mL (both normal).
3 o- H: \0 z4 r4 c1 ?The concentrations of serum electrolytes, blood `+ Q n" H0 O `% G
urea nitrogen, creatinine, and calcium all were
+ }3 I0 e4 H2 m' D, D! Xwithin normal range for his age. The concentration
" N, o3 K$ [2 ~$ z/ A; K: K9 yof serum 17-hydroxyprogesterone was 16 ng/dL
+ f- G1 h* n6 f! u9 s(normal, 3 to 90 ng/dL), androstenedione was 20
. c- {, s4 U) G* K9 A, I Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) O# m) ?8 X( y- [% `5 Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),! a) l, W0 }; k9 G! x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ \# F, K$ j6 b3 c! G. p
49ng/dL), 11-desoxycortisol (specific compound S)
\) d; d& c" X' ^0 r5 Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 k' z9 l5 [# e5 o: D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 ?. p5 O& V2 p: M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: V2 O( b: p5 Jand β-human chorionic gonadotropin was less than
$ v) ~, J7 }( q/ T; d7 J5 mIU/mL (normal <5 mIU/mL). Serum follicular
( M5 w$ y& W- l# z2 h: O% }. bstimulating hormone and leuteinizing hormone" X2 q( B [& d0 G
concentrations were less than 0.05 mIU/mL; _" o- O! q0 L, C2 G; r& t+ h* M
(prepubertal).$ A y+ e0 G6 C$ M
The parents were notified about the laboratory
% T5 ?3 U' \4 w$ t5 lresults and were informed that all of the tests were
S+ `! y8 v5 W& z% Lnormal except the testosterone level was high. The
4 R, Y" d" {7 Ofollow-up visit was arranged within a few weeks to6 i9 s8 E3 L: n9 h
obtain testicular and abdominal sonograms; how-
# s8 c- }1 o6 `& Y1 y i# jever, the family did not return for 4 months.. Z5 m$ l2 U5 P( g% c3 a
Physical examination at this time revealed that the
& E. j G; q# s1 f. R- G* s# ~child had grown 2.5 cm in 4 months and had gained+ {6 z% w& p) w
2 kg of weight. Physical examination remained4 |7 G- d& N6 I
unchanged. Surprisingly, the pubic hair almost com-) C. ]( S4 ` P, `* A" `5 c
pletely disappeared except for a few vellous hairs at
4 l. a0 C8 @' m! t1 M( gthe base of the phallus. Testicular volume was still 2
9 Z1 a& g5 N* {# N6 a: BmL, and the size of the penis remained unchanged.! w* ^" B( f( t- s
The mother also said that the boy was no longer hav-; R8 {. [( v4 u7 X' s! N/ _
ing frequent erections.9 w' X; t( T6 ^: r
Both parents were again questioned about use of5 E# B1 m3 D- k' ^% h
any ointment/creams that they may have applied to
9 x+ F! D @: a2 o1 zthe child’s skin. This time the father admitted the
E$ q6 Z3 |4 ]2 }) t# C& U1 ATopical Testosterone Exposure / Bhowmick et al 541
" t/ s/ I* l1 u9 D, ?use of testosterone gel twice daily that he was apply-
2 Y! ^" @4 P4 eing over his own shoulders, chest, and back area for
, S W) E, V! T$ Aa year. The father also revealed he was embarrassed
8 u$ w B7 z4 a( Dto disclose that he was using a testosterone gel pre-9 u; H: z c# j. s& \% U
scribed by his family physician for decreased libido* j- b7 t W: m. H1 ]
secondary to depression.9 Q: P @4 x b$ m* O* V
The child slept in the same bed with parents. m. I; f& t( C; B
The father would hug the baby and hold him on his& ^$ {1 [7 W: L. ^" V; z
chest for a considerable period of time, causing sig-3 y; n% S# Y( T6 s2 `# [6 K+ \
nificant bare skin contact between baby and father.1 G, @. L' J% r
The father also admitted that after the phone call," o" T, D; s4 u
when he learned the testosterone level in the baby
: P. V+ Q8 t; C' b+ Twas high, he then read the product information* ]: c' i. _4 [/ p9 F' S: Z
packet and concluded that it was most likely the rea-
: |6 `! A+ u+ V( `* ^4 eson for the child’s virilization. At that time, they2 o' j% f1 v9 R! V7 a0 c0 b
decided to put the baby in a separate bed, and the, t4 E7 ?- j, U/ g
father was not hugging him with bare skin and had
& r, F3 R; o4 [( Obeen using protective clothing. A repeat testosterone
0 q q6 r. P4 }! U9 ztest was ordered, but the family did not go to the: ?* F2 E! o9 d2 {' v; S
laboratory to obtain the test., B( j4 v Y9 A- x2 b8 o ^ M
Discussion8 g, w/ s% d- Z: u; Z7 y& M" {
Precocious puberty in boys is defined as secondary
: t' ~. X) A8 xsexual development before 9 years of age.1,40 w Y& @+ i. }9 {* d! z1 C
Precocious puberty is termed as central (true) when
4 c; I0 }2 B- Q) j' z; {it is caused by the premature activation of hypo-$ n* W2 Q% w1 }+ o
thalamic pituitary gonadal axis. CPP is more com-
v- v) Y: F& K0 mmon in girls than in boys.1,3 Most boys with CPP" F- p* z3 M, a: `. l
may have a central nervous system lesion that is6 j6 S3 k( g( _6 v" l b0 L
responsible for the early activation of the hypothal-$ L5 v2 w0 l5 Q# g# s# t
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 {! G( _0 r+ l: wsis has been given to neuroradiologic imaging in3 a* }$ h! g$ S
boys with precocious puberty. In addition to viril-
$ n- m& F5 v$ `* b0 J. u/ Tization, the clinical hallmark of CPP is the symmet-, y3 }! }3 S1 H4 P. c* y
rical testicular growth secondary to stimulation by% C5 M& }, p7 ^& H' N/ B4 k% ^+ H
gonadotropins.1,3/ u! R8 x+ K& J1 z! j$ k! q
Gonadotropin-independent peripheral preco-
& K$ O* \4 s4 {cious puberty in boys also results from inappropriate
1 X& H' ?- G: G5 `3 {9 eandrogenic stimulation from either endogenous or* K* d* _- }) i, G r w3 n8 B
exogenous sources, nonpituitary gonadotropin stim-2 n2 K- s1 t! Z5 \. X
ulation, and rare activating mutations.3 Virilizing" t f1 }& r6 Q5 H
congenital adrenal hyperplasia producing excessive
; W4 j9 E5 g4 A9 Q7 P) Aadrenal androgens is a common cause of precocious
- `) ^7 K+ Y! {7 L& j% W+ t9 Mpuberty in boys.3,4
1 b$ J, e7 e1 _6 HThe most common form of congenital adrenal
+ u3 `* V X: yhyperplasia is the 21-hydroxylase enzyme deficiency.$ d3 u* i1 s9 ^' {
The 11-β hydroxylase deficiency may also result in
( n1 V# x- h" m7 Hexcessive adrenal androgen production, and rarely,/ j6 D. D g' N8 W
an adrenal tumor may also cause adrenal androgen/ L7 O: |9 y& F% H% g/ \5 _
excess.1,3# L5 I1 L M: G' T! C* n' H! s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% P9 N2 g. q4 K3 }! G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! a, e) U8 Q" t# m) wA unique entity of male-limited gonadotropin-
: `4 ]7 Y: j# M& r1 Windependent precocious puberty, which is also known
1 S9 B3 p2 q6 q, [; ]9 b$ xas testotoxicosis, may cause precocious puberty at a; _6 i% ^7 o2 M& B; h0 s6 b
very young age. The physical findings in these boys9 t( R, p9 G' K( G& b
with this disorder are full pubertal development,# l) ?; ~' r1 a
including bilateral testicular growth, similar to boys+ m% U4 H5 e( |' _! {8 j! {' d
with CPP. The gonadotropin levels in this disorder
; \/ I. r; i2 b/ }0 Qare suppressed to prepubertal levels and do not show" \$ N8 a5 B& s) O+ E8 Z- u$ w
pubertal response of gonadotropin after gonadotropin-
% S! O: k( X7 W1 [: @: ~releasing hormone stimulation. This is a sex-linked- Q( M) r! g) w% ~
autosomal dominant disorder that affects only4 j+ q" K+ M# O$ T i
males; therefore, other male members of the family6 g. F% t$ Z7 s5 D
may have similar precocious puberty.3; Z9 S8 W1 k( y; R' _$ n S3 V
In our patient, physical examination was incon-
& r7 W# L% P" G/ ` B, ?2 Z: B$ O5 ksistent with true precocious puberty since his testi-7 i9 I; G4 ?. [7 q2 x
cles were prepubertal in size. However, testotoxicosis
% m1 V( J" ^7 U. h+ p- C8 Swas in the differential diagnosis because his father
6 x% m% k/ `- P0 P- k, C/ qstarted puberty somewhat early, and occasionally,% \4 i) ^9 O0 j- G* [' \: N7 _" i
testicular enlargement is not that evident in the0 b- d# f% |: r5 k' ]- H
beginning of this process.1 In the absence of a neg-- x) ~, U! l2 @) n8 P1 g
ative initial history of androgen exposure, our
2 Z) O2 z/ I& j& v. {biggest concern was virilizing adrenal hyperplasia,
5 j5 ?$ _# g0 L3 O! l- Feither 21-hydroxylase deficiency or 11-β hydroxylase
# p! n6 X. C) Hdeficiency. Those diagnoses were excluded by find-: K6 k9 w! M6 \
ing the normal level of adrenal steroids.
1 S6 z' s$ Z* `6 V# c+ m, P0 dThe diagnosis of exogenous androgens was strongly+ t( H; r* r0 p& Q; C! L' ?8 s: U
suspected in a follow-up visit after 4 months because7 e z% F1 [5 @' [9 h7 C
the physical examination revealed the complete disap-
! m4 j+ d% `$ K$ ~' J) xpearance of pubic hair, normal growth velocity, and
# z$ a% A+ C" ` D2 s3 ndecreased erections. The father admitted using a testos-+ b0 f5 `& f! M( G1 I
terone gel, which he concealed at first visit. He was; V0 g* L! o: s0 {2 Y
using it rather frequently, twice a day. The Physicians’
. x1 B8 I4 X- a) O# N" FDesk Reference, or package insert of this product, gel or |; I( }$ U) _2 u/ j
cream, cautions about dermal testosterone transfer to# E. l, | T! T8 @4 m8 V, N
unprotected females through direct skin exposure.0 E- j x: h* M& t
Serum testosterone level was found to be 2 times the1 U% t; A: S5 y. @/ C3 W
baseline value in those females who were exposed to
- Q& h* ~: d/ I C+ @* [" ]even 15 minutes of direct skin contact with their male* E8 U4 {0 G; o t! r6 l8 w) M
partners.6 However, when a shirt covered the applica-
( ?+ o+ f4 ^. k& \ v" H% ition site, this testosterone transfer was prevented.
- R3 \& e8 X0 lOur patient’s testosterone level was 60 ng/mL,
' a- | _# }: e& iwhich was clearly high. Some studies suggest that" V/ Q' i; j6 s8 T( z7 w
dermal conversion of testosterone to dihydrotestos-5 q: U- a0 ~3 d* z% {
terone, which is a more potent metabolite, is more8 m& M& J" b$ V8 z# }- S9 Y6 v
active in young children exposed to testosterone! [6 }$ P: H, U/ ?5 u7 B( V
exogenously7; however, we did not measure a dihy-( G5 G4 n" ` l, w/ S- h3 _ k
drotestosterone level in our patient. In addition to
/ j1 d0 Y! X& B: w7 C c. cvirilization, exposure to exogenous testosterone in0 X$ J0 V( _! F6 b
children results in an increase in growth velocity and
D6 C( a ~: b' Q2 }/ }advanced bone age, as seen in our patient.
8 \7 s' {# N: K c g) u7 {The long-term effect of androgen exposure during
" N5 @1 x2 J) M- `early childhood on pubertal development and final2 ^+ ~- ^% k: N' q+ o7 H) l
adult height are not fully known and always remain) r+ ?2 d& ^ I" }& Q+ F
a concern. Children treated with short-term testos-$ M8 [6 O2 H+ Q6 L3 t$ i
terone injection or topical androgen may exhibit some
: D& t! C8 |8 `acceleration of the skeletal maturation; however, after
! X" j& B! o% t$ ^( y& }cessation of treatment, the rate of bone maturation
* \: ~" F3 o5 X) n8 cdecelerates and gradually returns to normal.8,97 Y& m' z7 z! K6 m8 G$ n# l
There are conflicting reports and controversy
5 j3 m& V u+ H9 S2 R& @; Fover the effect of early androgen exposure on adult" J2 L6 ]$ s' X
penile length.10,11 Some reports suggest subnormal; h j( C( ?# \' b
adult penile length, apparently because of downreg-
% Y' E; `7 n. p6 Qulation of androgen receptor number.10,12 However,# J0 o& n: e# b0 d' N+ ~( A3 j
Sutherland et al13 did not find a correlation between
2 H1 t; P8 x1 F" {7 Lchildhood testosterone exposure and reduced adult
+ d6 Y }6 a: y2 g. Npenile length in clinical studies.! |/ O' k$ v; B! K B/ |8 `
Nonetheless, we do not believe our patient is- O. Q9 t4 k' ?% p" c) f- ~! x, E1 T
going to experience any of the untoward effects from/ k2 o5 ^3 W$ T5 z3 A+ _ o# Y- p
testosterone exposure as mentioned earlier because2 [+ C. V, E/ T! t
the exposure was not for a prolonged period of time.9 d& c f! f& X
Although the bone age was advanced at the time of
$ I8 }* B, u* E, q7 f8 ~ C4 U" ydiagnosis, the child had a normal growth velocity at7 y# Y7 J8 g" B1 Z& f( A$ |# _
the follow-up visit. It is hoped that his final adult( I+ f& z* W% @, B( {' z# t
height will not be affected.
9 t! C9 K+ X: u+ ^Although rarely reported, the widespread avail-/ N2 |- T, \. I
ability of androgen products in our society may
% I! c0 x" {6 }; ~ mindeed cause more virilization in male or female( c2 u, j# e' e2 p. I
children than one would realize. Exposure to andro-
7 |9 v0 m2 {# U( C1 o, n0 P6 }gen products must be considered and specific ques-4 |6 y! P: M7 G7 a& E
tioning about the use of a testosterone product or
' f7 {. d2 ]( H1 u. Hgel should be asked of the family members during
t7 b+ _9 Q( a% Y: T$ z7 xthe evaluation of any children who present with vir-
0 L' Y4 n* k% {/ G p! T( `ilization or peripheral precocious puberty. The diag-5 ?- X( o! u0 ]4 Y/ R) G5 j, I
nosis can be established by just a few tests and by
9 ]4 Z- Y. u- o! u, xappropriate history. The inability to obtain such a
5 x% T; Y p7 ]! f* D9 Z phistory, or failure to ask the specific questions, may3 _# G$ t8 _) B
result in extensive, unnecessary, and expensive, m* m& a( l8 v \! x7 p6 g" d
investigation. The primary care physician should be
/ ?# O' u' ?8 u! }4 xaware of this fact, because most of these children- S, ~5 C* s% x
may initially present in their practice. The Physicians’6 H9 v8 f, p3 L" H- z
Desk Reference and package insert should also put a
- V$ K6 _) ~ Z; b9 nwarning about the virilizing effect on a male or
, @9 c( l5 u9 `) f: Ffemale child who might come in contact with some-
* }2 [( p: k6 Z2 N! _ done using any of these products.$ t, Q5 o- z7 h/ z1 m
References
1 u7 G5 ~' R; |, `1. Styne DM. The testes: disorder of sexual differentiation
3 I; w8 n) p2 X' F6 k, e0 F& xand puberty in the male. In: Sperling MA, ed. Pediatric4 j: `# H# h `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 L/ E& }. k9 F( S9 M
2002: 565-628., A; C. o1 @1 F9 D. F2 K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# q) M+ Z( {! {3 z
puberty in children with tumours of the suprasellar pineal |
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