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Sexual Precocity in a 16-Month-Old8 M8 U! X, v% y- s) q
Boy Induced by Indirect Topical
5 C: r/ P, H$ ]- QExposure to Testosterone
: T% @/ B7 n7 w4 n+ Q1 cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 h$ F# P- c+ }, n( }6 U6 ^' n
and Kenneth R. Rettig, MD1- p: O4 O0 V. L8 B8 r
Clinical Pediatrics- t- \ I& Z0 i1 S6 J
Volume 46 Number 6/ Y+ U% K, R3 j2 U* i
July 2007 540-543
- o" E# h* r) O5 { }© 2007 Sage Publications) Q+ M t9 V9 j5 q. ^
10.1177/0009922806296651
& h& [; o7 y2 S" I4 n& xhttp://clp.sagepub.com
/ ] V$ N4 `" @3 Q; Xhosted at
# q( S0 }9 e g. f8 G2 R+ s/ hhttp://online.sagepub.com
, D% ~/ z7 R! _8 q* ?Precocious puberty in boys, central or peripheral,
/ X# E3 ~" c, mis a significant concern for physicians. Central
2 j' X% ]0 K5 C9 J5 S% S' \2 M* Nprecocious puberty (CPP), which is mediated9 ?1 ~# K8 A7 i" |1 N
through the hypothalamic pituitary gonadal axis, has' X4 E- N# v# x; d2 X
a higher incidence of organic central nervous system, r* [, D. I' H- ^
lesions in boys.1,2 Virilization in boys, as manifested T ?7 a8 u& T& f7 r7 j
by enlargement of the penis, development of pubic7 x ]2 |/ j4 i, u' X& q
hair, and facial acne without enlargement of testi-4 b5 m6 @0 D+ a+ x& v
cles, suggests peripheral or pseudopuberty.1-3 We9 f( e8 J j; W* _9 n& [
report a 16-month-old boy who presented with the8 N) J' y: D( ?4 p
enlargement of the phallus and pubic hair develop-
) Z/ ?/ Y( V2 D3 H( P1 R$ |ment without testicular enlargement, which was due
' I" ^( F! x/ V! Rto the unintentional exposure to androgen gel used by
- O: y$ g& C: \" z2 bthe father. The family initially concealed this infor-
7 a- T$ [( i* mmation, resulting in an extensive work-up for this5 _& a7 F D! P0 h
child. Given the widespread and easy availability of
' m% F3 H5 a1 z: @2 p3 dtestosterone gel and cream, we believe this is proba-
% g4 S4 ~4 ~2 j- z# E3 _! @; K: ebly more common than the rare case report in the
2 Y7 w, H9 g& r2 p) G8 p3 e! Dliterature.4' H. n7 d' B7 R. k; c }! G
Patient Report, X4 F, h) g O% F* |0 e
A 16-month-old white child was referred to the* x& i: @: @$ |7 U
endocrine clinic by his pediatrician with the concern) q& m8 y" a1 m( ^: D
of early sexual development. His mother noticed
' z- Y/ }; Z- m8 L0 Olight colored pubic hair development when he was
6 R" E$ b# }) j/ m* \# m# b1 x; K4 sFrom the 1Division of Pediatric Endocrinology, 2University of
& f6 c/ e+ Y _: X- m& U7 y. XSouth Alabama Medical Center, Mobile, Alabama.+ W' W; T, H) Y& r8 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,! }; _, |8 V/ [3 C. M
Professor of Pediatrics, University of South Alabama, College of7 {4 V1 H! Q6 {5 X" `0 Q4 k5 k
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 G! V) t( S" {. j; be-mail: [email protected]. u9 k: E; b2 c; m+ V) A
about 6 to 7 months old, which progressively became4 |$ P% l6 `+ l! b2 ]. J5 ~; r8 N
darker. She was also concerned about the enlarge-
) z7 R4 q% h1 R$ sment of his penis and frequent erections. The child5 P4 Q$ T8 A0 z1 ^
was the product of a full-term normal delivery, with5 K" }) e$ g& Q! B0 c
a birth weight of 7 lb 14 oz, and birth length of
d- }. k- W% Y9 E- `20 inches. He was breast-fed throughout the first year
' F3 } m4 L( X2 iof life and was still receiving breast milk along with1 A. q s" P& S
solid food. He had no hospitalizations or surgery,
3 W* T5 S/ D/ f2 H, h4 Vand his psychosocial and psychomotor development
, U6 F" O% Q0 N, I; B2 H: G" Kwas age appropriate.! {+ P4 I9 J: r5 K" N
The family history was remarkable for the father,
U5 C: b: t- b) vwho was diagnosed with hypothyroidism at age 16, H4 F2 a6 a* O7 a H s
which was treated with thyroxine. The father’s/ W. R1 {6 b9 S( m& V
height was 6 feet, and he went through a somewhat2 O) ?3 [ L2 f/ d
early puberty and had stopped growing by age 14.* u9 V* L+ E9 f9 l& d3 Z8 ]
The father denied taking any other medication. The" K7 J0 n2 K- C. _2 q& Z
child’s mother was in good health. Her menarche
. E v3 n- |! u& O, Rwas at 11 years of age, and her height was at 5 feet7 u/ z: _1 x5 c0 d
5 inches. There was no other family history of pre-
; N7 B% R' @4 \# E- ]cocious sexual development in the first-degree rela-
* Q9 D7 q' |; d: atives. There were no siblings.
" k" z2 E# l# gPhysical Examination
/ Z. {2 W7 m p7 {! k) R3 SThe physical examination revealed a very active,. P2 u+ z8 I; p$ y& L
playful, and healthy boy. The vital signs documented5 B; \$ X) w, _: `" i
a blood pressure of 85/50 mm Hg, his length was
- D! Y. Y/ {6 s1 i, O90 cm (>97th percentile), and his weight was 14.4 kg
; n8 x5 G: t, A! Q( x(also >97th percentile). The observed yearly growth# f% Y6 \% D* ?+ q3 Z, T5 s
velocity was 30 cm (12 inches). The examination of
R% @, L. C1 kthe neck revealed no thyroid enlargement.0 z4 W6 J: ]% c+ B! L- e0 ?
The genitourinary examination was remarkable for' J( e: f2 L- k) F ]8 ]
enlargement of the penis, with a stretched length of1 `1 \6 K! m8 `0 P' [2 c
8 cm and a width of 2 cm. The glans penis was very well
4 U( W: i8 R" a/ w6 edeveloped. The pubic hair was Tanner II, mostly around8 ?$ w( ~) h% y5 B( j: y
540
: x1 _$ O: z6 k9 P" H8 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; X9 z# ?( t5 {the base of the phallus and was dark and curled. The2 w2 j) k( ~5 v* {
testicular volume was prepubertal at 2 mL each.
: ?/ Y- Y" j, b1 e! X1 C; ^, }* BThe skin was moist and smooth and somewhat2 Z5 B8 Y& d, Z! R' x, a# f* K+ [
oily. No axillary hair was noted. There were no
' v1 f5 R( x" m& Wabnormal skin pigmentations or café-au-lait spots.
/ K+ t8 ^0 Z' {: N8 UNeurologic evaluation showed deep tendon reflex 2+
$ d# Y$ H+ D, cbilateral and symmetrical. There was no suggestion
$ o6 u1 n& t5 z- gof papilledema.5 P4 [9 A: A. O. x7 y( n [& P
Laboratory Evaluation$ H8 q4 U3 J8 d
The bone age was consistent with 28 months by* {/ L! U" H- j3 `- n
using the standard of Greulich and Pyle at a chrono-8 L* a. }2 R* g/ z- @1 {' H
logic age of 16 months (advanced).5 Chromosomal
$ u- L1 ` c6 {; Y$ S( K& @karyotype was 46XY. The thyroid function test) u% U, i9 L+ w! ?3 d' t1 n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) @5 @* s2 ]$ ^& b3 rlating hormone level was 1.3 µIU/mL (both normal).
- R' Y u# m2 Y5 }The concentrations of serum electrolytes, blood z/ ~/ T @0 B# Y7 S# g8 G" I, s
urea nitrogen, creatinine, and calcium all were$ h9 h! ?+ d4 [( r
within normal range for his age. The concentration* E0 D0 N6 M1 v# L" q. W4 o4 I
of serum 17-hydroxyprogesterone was 16 ng/dL
8 F4 q, i9 j9 \' f. y$ C(normal, 3 to 90 ng/dL), androstenedione was 20
2 P+ R7 ~7 f( c9 T+ I5 `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: u; K6 i" j! N% P( S. qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: k3 h* W9 @$ E, G8 sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to, h* V- I$ V2 i6 x9 m
49ng/dL), 11-desoxycortisol (specific compound S)
6 e4 G X0 _9 L1 nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" f( r3 c- C; H4 Z$ r$ V% B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 Z5 y# {) a* R
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 _2 J) E3 W. C/ g* ]* A* tand β-human chorionic gonadotropin was less than, f- Q4 q2 U$ y+ r2 O: W
5 mIU/mL (normal <5 mIU/mL). Serum follicular I+ R- e& x" X! g' Y1 N, i' t
stimulating hormone and leuteinizing hormone+ x+ }: ?3 C1 b; L% L' {1 \
concentrations were less than 0.05 mIU/mL
0 W+ q' `7 T9 p* A; S(prepubertal).
* v+ |' e z) g! _4 {The parents were notified about the laboratory" ^: d9 g+ n4 F4 @# j8 q6 m7 F9 S
results and were informed that all of the tests were, P2 B5 F3 n* ~
normal except the testosterone level was high. The, ?" m0 X5 B" c; k$ T
follow-up visit was arranged within a few weeks to0 z- d; w, N3 A' B0 r+ ^. H# S8 ~0 p$ }
obtain testicular and abdominal sonograms; how-
0 J% M5 Y" r4 bever, the family did not return for 4 months.
. z) U% F2 S" xPhysical examination at this time revealed that the+ N( l( g! h& c( j3 s$ \" j
child had grown 2.5 cm in 4 months and had gained, R& t5 D/ }4 A1 Y% q7 g2 U( m
2 kg of weight. Physical examination remained
$ a( D S: Y4 }9 E" R+ j8 Q/ Vunchanged. Surprisingly, the pubic hair almost com-9 a b& D1 ?3 B ~+ T
pletely disappeared except for a few vellous hairs at. ^! S& n: R+ W( F% R
the base of the phallus. Testicular volume was still 23 [: K! L( S" N1 ?" s, ]5 n* k& b
mL, and the size of the penis remained unchanged.
% n+ R" s& k& X+ I% d& _The mother also said that the boy was no longer hav-. Y+ D9 w$ w0 }8 [( O
ing frequent erections., a8 w. j% W% u) h3 X- R8 `
Both parents were again questioned about use of
8 m; I0 x* ]$ x! \6 p, e" V, Zany ointment/creams that they may have applied to2 {) l; D! U- ]5 R* I4 z
the child’s skin. This time the father admitted the
. Z/ ^4 ~: a! {' A- D. ZTopical Testosterone Exposure / Bhowmick et al 541
! d; v6 a4 [4 `, V! \use of testosterone gel twice daily that he was apply-
; m2 p2 k" v- X7 s; qing over his own shoulders, chest, and back area for
6 J! i7 ^0 P$ ya year. The father also revealed he was embarrassed
3 h3 Y+ H/ f' h5 v" Oto disclose that he was using a testosterone gel pre-& D% a( V( W( k
scribed by his family physician for decreased libido
$ e ^* P, N9 `% A# Csecondary to depression./ U- [* ]4 ?( u, c8 L7 f( L% S |
The child slept in the same bed with parents.
8 B% n0 @- @$ Q6 u1 KThe father would hug the baby and hold him on his/ s1 X1 H9 T$ Q/ n2 z9 L9 p1 x
chest for a considerable period of time, causing sig-; H# y- m; i/ m* j& ?3 ^2 L
nificant bare skin contact between baby and father.
_# W, q7 j4 R! xThe father also admitted that after the phone call,
' i& \( S, @, bwhen he learned the testosterone level in the baby% K# j: X- d& ~2 a5 R
was high, he then read the product information
+ y X9 a7 a, A/ A' n0 Zpacket and concluded that it was most likely the rea-( g j+ O/ w2 l: n
son for the child’s virilization. At that time, they( ?1 V. ?7 R% P1 _
decided to put the baby in a separate bed, and the
# O& O# y4 g1 W$ g4 u/ m% {father was not hugging him with bare skin and had
! n) g7 A m; O) C# rbeen using protective clothing. A repeat testosterone
Y6 J& ], O& o2 \7 f. L# _test was ordered, but the family did not go to the
+ U5 c. v+ R* Mlaboratory to obtain the test., P( M4 |7 ` N* y3 P. b9 z
Discussion
7 P+ {0 S. _3 C$ f; i% mPrecocious puberty in boys is defined as secondary
) c0 |& p& t9 [) e! M8 L+ L3 m( {2 asexual development before 9 years of age.1,4* @4 v4 n8 N n6 ?/ J
Precocious puberty is termed as central (true) when# d; \" ?$ ]/ V& G
it is caused by the premature activation of hypo-' S" [) U1 r2 f- p: _! y; h$ e2 K
thalamic pituitary gonadal axis. CPP is more com-+ u" D# O. l+ e$ j8 u
mon in girls than in boys.1,3 Most boys with CPP# z3 B; a& v0 S/ l2 M
may have a central nervous system lesion that is; @* x/ w/ ?8 h9 e: O7 G7 g
responsible for the early activation of the hypothal-1 O8 }" ~4 ]5 n4 F* e
amic pituitary gonadal axis.1-3 Thus, greater empha-( F4 P+ E8 B6 S/ ?) b1 u, V
sis has been given to neuroradiologic imaging in, U" L4 |$ j1 z7 K5 u
boys with precocious puberty. In addition to viril-0 X+ I4 }' L, D7 {. e' v: C
ization, the clinical hallmark of CPP is the symmet-) s* D, S. a; \/ l
rical testicular growth secondary to stimulation by
7 o# u$ }/ L4 L. ^gonadotropins.1,34 o: Y, S0 h9 n3 @, B+ `
Gonadotropin-independent peripheral preco-. ^! X" `" K* N5 l h
cious puberty in boys also results from inappropriate
) f* B, I- J4 R1 b5 mandrogenic stimulation from either endogenous or
7 u5 M/ B- l1 B& _exogenous sources, nonpituitary gonadotropin stim-4 L0 j' q* [9 s2 V" h
ulation, and rare activating mutations.3 Virilizing" \0 S3 |0 @8 O8 W }& o
congenital adrenal hyperplasia producing excessive
/ U8 u# _) E1 W# C1 nadrenal androgens is a common cause of precocious0 u5 M$ g- V+ j) I: O) {
puberty in boys.3,4
# C1 m$ s7 I& T w' ~The most common form of congenital adrenal
# ?( E6 l: W8 _* j" W9 ]hyperplasia is the 21-hydroxylase enzyme deficiency.
7 d. Z0 t. x9 [9 [/ nThe 11-β hydroxylase deficiency may also result in; @ `' q/ T: G7 N% f5 z. B
excessive adrenal androgen production, and rarely,* A4 t5 ]$ m! x$ \+ L3 b
an adrenal tumor may also cause adrenal androgen
; y& Q% \; I- K& Mexcess.1,3
; s- B$ _" l* W, ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. m. C. V; j; f1 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 H$ j; }) w5 NA unique entity of male-limited gonadotropin-# d9 n7 c3 h$ `0 \6 M" e7 ~
independent precocious puberty, which is also known+ |7 V7 G; B8 }) n* Q
as testotoxicosis, may cause precocious puberty at a
& E Z/ u, r- G# M+ P0 U% nvery young age. The physical findings in these boys
3 T: K6 Z! d( j7 m% }* Q8 Dwith this disorder are full pubertal development," ~7 A$ ~( H3 H+ \8 O
including bilateral testicular growth, similar to boys( A: [0 Q/ t* V6 D% ]
with CPP. The gonadotropin levels in this disorder( Y9 j( |; R: o* o" s
are suppressed to prepubertal levels and do not show
! `& s- Q2 T$ R' ]# l8 cpubertal response of gonadotropin after gonadotropin-+ ^9 |! i4 M: s% v1 U4 s5 F! l5 @) y$ l- d
releasing hormone stimulation. This is a sex-linked$ u6 g9 V: ~. p1 W
autosomal dominant disorder that affects only
+ h8 q4 g6 i0 t0 v% c# J: umales; therefore, other male members of the family& L. ~3 G2 K/ F0 u! r! F
may have similar precocious puberty.3
/ s/ \4 h3 U: y; z/ OIn our patient, physical examination was incon-! U. g6 S" f, [- n6 u# W J/ E( o
sistent with true precocious puberty since his testi-
& V# V; }! A" c/ F/ Pcles were prepubertal in size. However, testotoxicosis
# P( k! f) ]0 k8 ]+ lwas in the differential diagnosis because his father
6 C4 a6 B. R6 z5 c! ?6 a* hstarted puberty somewhat early, and occasionally,
; Q! a, ^) x6 g; ?( m3 otesticular enlargement is not that evident in the0 H6 I: W1 d3 a/ ~- @# l
beginning of this process.1 In the absence of a neg-
- a: r0 Y/ P9 V- Z, F1 R: f( Wative initial history of androgen exposure, our
7 V7 x* k/ F/ t4 K6 qbiggest concern was virilizing adrenal hyperplasia,
`. a9 R6 M: z" H; seither 21-hydroxylase deficiency or 11-β hydroxylase. h2 I# O4 {- O0 T& `! [
deficiency. Those diagnoses were excluded by find-8 m+ X/ F$ _9 y7 p' n8 }
ing the normal level of adrenal steroids.
6 ?' D6 l& p) y. n$ p: [7 l8 mThe diagnosis of exogenous androgens was strongly8 n% g& g. b) u% Z' p& F8 D! M2 I
suspected in a follow-up visit after 4 months because
+ r/ d; j: ]. p$ u0 ~9 Dthe physical examination revealed the complete disap-4 A3 D# B% T7 a# {$ U% t0 b/ \. i. w
pearance of pubic hair, normal growth velocity, and
& t3 O5 r: d7 Ddecreased erections. The father admitted using a testos-
; a8 u$ C0 j0 i' K6 Nterone gel, which he concealed at first visit. He was
5 }8 E' [1 [' Tusing it rather frequently, twice a day. The Physicians’
' m; P d; _' W9 P- T p3 [Desk Reference, or package insert of this product, gel or' Y t2 i& M4 s. ]4 _
cream, cautions about dermal testosterone transfer to7 l& y) a1 k& x! B3 g
unprotected females through direct skin exposure.
, z; D% F% v/ z% {0 j kSerum testosterone level was found to be 2 times the4 Z5 }" i% L. X) T% o! F
baseline value in those females who were exposed to
9 ~) Y( o* c2 `$ m# A, i- @# Reven 15 minutes of direct skin contact with their male
0 z3 Q5 _ U: E, Mpartners.6 However, when a shirt covered the applica-
m( S% G8 K2 I3 {) I( e6 rtion site, this testosterone transfer was prevented.
. W6 J+ h a" V( p/ {+ L+ J0 a8 ]3 {Our patient’s testosterone level was 60 ng/mL,+ q, o+ T3 l% A* }6 ~' X m
which was clearly high. Some studies suggest that
4 |; O+ S: P& Q" P0 Ydermal conversion of testosterone to dihydrotestos-
# G7 H- K* h6 J4 cterone, which is a more potent metabolite, is more
( T; V F0 g2 b) e& a! sactive in young children exposed to testosterone
: h$ S* H2 f1 U+ F1 ]3 e Gexogenously7; however, we did not measure a dihy-
' F( ^: c2 A0 B2 {. G7 D1 ~drotestosterone level in our patient. In addition to
* i/ p+ [4 ]# K' r* N- zvirilization, exposure to exogenous testosterone in9 o8 `( p+ n! U- A6 a; y) ]4 V
children results in an increase in growth velocity and
$ e W. l1 R+ B* O" C$ Ladvanced bone age, as seen in our patient.
7 } @0 l9 x R$ D" ?! gThe long-term effect of androgen exposure during
# _; S' P$ r) F( T Q) A" c0 Q+ d- searly childhood on pubertal development and final( V: k6 z1 s1 N: b: h0 W, ]
adult height are not fully known and always remain0 N9 l) M3 l2 J0 p
a concern. Children treated with short-term testos-5 a9 R) |0 Y( q$ r0 \* L
terone injection or topical androgen may exhibit some
! [9 }8 w1 ~2 F, c- xacceleration of the skeletal maturation; however, after# \* x7 X) m2 u* p" l7 P% _, J
cessation of treatment, the rate of bone maturation
4 A6 Q7 t( a i& i* Y/ [! H; [# ]decelerates and gradually returns to normal.8,9
. R) k) G5 }/ s, t9 ~There are conflicting reports and controversy. e" p8 S t+ S
over the effect of early androgen exposure on adult
. E, ]( p0 C! e. G0 Z& Xpenile length.10,11 Some reports suggest subnormal
! ^" W7 G' b$ S5 P/ v* f3 Zadult penile length, apparently because of downreg-4 W2 e! [- c/ P+ b
ulation of androgen receptor number.10,12 However,; h: R/ r5 \% a0 I: M5 u
Sutherland et al13 did not find a correlation between) ]3 {2 o3 H* J j3 E9 }2 m
childhood testosterone exposure and reduced adult& L% z2 d/ e1 ^0 v t9 I* M8 E
penile length in clinical studies.
3 t+ h/ {* D- b) S) d$ B/ p8 LNonetheless, we do not believe our patient is
; w' O, j3 _3 \9 \9 S/ \5 Zgoing to experience any of the untoward effects from% `& m. X* o2 W/ A! u* `$ n& N8 r
testosterone exposure as mentioned earlier because
% P! L- { ~) Q6 K( d1 Z, fthe exposure was not for a prolonged period of time.
* l! a I0 }: ` TAlthough the bone age was advanced at the time of( ` |* T% x* R, [
diagnosis, the child had a normal growth velocity at
5 o9 y: G$ Z# y5 }the follow-up visit. It is hoped that his final adult8 Y2 K9 ?: A% {3 A8 n
height will not be affected.
: w( z6 ~) Z9 l# a, ?# iAlthough rarely reported, the widespread avail-" s+ N0 f. b9 H, e" @8 K7 m
ability of androgen products in our society may
, N+ l. n1 ^$ G. R7 V: S% Z) pindeed cause more virilization in male or female
% K/ @- h( j. S- z% N; P, ^children than one would realize. Exposure to andro-
# N/ ]# [. e0 Mgen products must be considered and specific ques-- p9 N( Z m5 l6 ^
tioning about the use of a testosterone product or5 a6 I0 T& [8 o4 _2 N4 a' |
gel should be asked of the family members during3 a5 u/ A; R* X3 l
the evaluation of any children who present with vir-
' o0 E2 E0 r0 i/ W1 z- Cilization or peripheral precocious puberty. The diag-
0 B8 N0 R) o3 [+ tnosis can be established by just a few tests and by( H, B- d7 R" ?+ V
appropriate history. The inability to obtain such a
! v5 ^1 E' q8 A: t" u, F3 }0 [history, or failure to ask the specific questions, may
. c+ a) T% v9 t, h( D! G5 L Z4 G2 n8 Bresult in extensive, unnecessary, and expensive
; ]# U* @! l3 K$ {5 @6 ^: dinvestigation. The primary care physician should be
u5 U8 f* }2 O, t3 S) W K( maware of this fact, because most of these children
2 }" q( Q A- J& Hmay initially present in their practice. The Physicians’0 E' b$ v* q( Y" |3 y
Desk Reference and package insert should also put a
6 P2 Y2 Y: y: ?; _1 V3 | {warning about the virilizing effect on a male or- B5 B$ O& o# J, {3 n
female child who might come in contact with some-
, _! r6 F% G6 Pone using any of these products.$ @) H6 }+ B; T) ^5 ?
References
: i# A# }! ]1 L: [9 y1. Styne DM. The testes: disorder of sexual differentiation1 K" q0 H/ O: Q5 Y9 }; _$ U& \% d0 g* \
and puberty in the male. In: Sperling MA, ed. Pediatric
0 M7 j) V- P) a: rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& O2 v! M/ i1 ~9 H2002: 565-628.
4 b" K; X' T0 l& l0 I- S3 Z, F2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! S: v) ^, R9 d, R
puberty in children with tumours of the suprasellar pineal |
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