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Sexual Precocity in a 16-Month-Old
! `6 J; v1 a$ D0 K. C0 jBoy Induced by Indirect Topical; b; O: S' B8 [8 |
Exposure to Testosterone
; K( [' U% i/ L$ i% xSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# f# n L8 K4 V/ G7 _* c& w
and Kenneth R. Rettig, MD1
+ U2 I. G$ Q& I1 Y- d3 UClinical Pediatrics
' ?. c2 E7 u1 ]' A$ B$ J+ [Volume 46 Number 63 ~2 J# s, a, |
July 2007 540-543 n! I, a/ |# F0 P
© 2007 Sage Publications
. G1 n$ i4 ^3 A: i% G) c& R* I* x10.1177/0009922806296651( G; G( N" i) K4 Z- i7 a
http://clp.sagepub.com
; B( A3 c/ k+ w+ C0 Whosted at
5 N+ R& z1 @/ ~$ V* _# ]# W% ghttp://online.sagepub.com* Q4 e! A0 W% J7 O5 J
Precocious puberty in boys, central or peripheral,, C. k1 u4 E) n$ e; @' `
is a significant concern for physicians. Central
$ } ~" w" M! r9 L4 p6 R: Nprecocious puberty (CPP), which is mediated$ y+ i5 K. }. i. j
through the hypothalamic pituitary gonadal axis, has
5 I: Y$ u( R I; j5 E/ l+ E" Qa higher incidence of organic central nervous system
4 ]: v- J) T9 a6 e: { ^lesions in boys.1,2 Virilization in boys, as manifested$ p- m$ H+ s% ^6 j4 { S* u
by enlargement of the penis, development of pubic
. h* r) C& p* z/ k ^hair, and facial acne without enlargement of testi-/ w6 K" u3 T5 }8 P
cles, suggests peripheral or pseudopuberty.1-3 We
" M% b+ w) [, [; F. A4 r& qreport a 16-month-old boy who presented with the
$ ?$ {5 \* O, {7 zenlargement of the phallus and pubic hair develop-- _. m; T' p ?) S. t+ _ H
ment without testicular enlargement, which was due
/ m1 `; X7 U) [7 @* Nto the unintentional exposure to androgen gel used by
2 S) O7 _; ?+ w" E* ^9 ~; cthe father. The family initially concealed this infor-7 J( o9 \7 o1 H7 X
mation, resulting in an extensive work-up for this/ P2 ]! C1 t0 _
child. Given the widespread and easy availability of
M( F3 u' C9 s+ r) k- `testosterone gel and cream, we believe this is proba-0 e+ I1 _: ?$ J; J x6 C
bly more common than the rare case report in the
$ Z7 ?( X( n( t4 j, x, P9 xliterature.43 Q8 v9 w% j% Z
Patient Report0 i) f% m6 r# n6 m- c- X
A 16-month-old white child was referred to the
1 X9 T* C/ |5 Z0 u0 B: Tendocrine clinic by his pediatrician with the concern
! \ U5 e) T( }& w9 Dof early sexual development. His mother noticed
4 L2 D+ s: m/ ]* E1 |light colored pubic hair development when he was2 C. O% Y2 S( z' U5 Z5 ~% e8 R) r
From the 1Division of Pediatric Endocrinology, 2University of* Z% j. m, O6 v5 s
South Alabama Medical Center, Mobile, Alabama.: \: P6 i: u5 h& j+ G Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- C7 v" t! C. z. O2 @2 KProfessor of Pediatrics, University of South Alabama, College of* E! ~# ?* I4 h& |2 N7 b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 v- x$ ^. ?5 R2 Ee-mail: [email protected]./ W/ n3 T( J7 h# D+ n/ R
about 6 to 7 months old, which progressively became
: u U. h" }3 ~% `: gdarker. She was also concerned about the enlarge-/ ?, w& t- A8 f
ment of his penis and frequent erections. The child+ `' r& Y, U5 V/ X1 G
was the product of a full-term normal delivery, with" n# f Y8 y. e
a birth weight of 7 lb 14 oz, and birth length of* m: q6 m; \* Z, z @2 H. V
20 inches. He was breast-fed throughout the first year
. z- u8 C' P7 B# P4 {& Kof life and was still receiving breast milk along with& N& M- p# A5 J
solid food. He had no hospitalizations or surgery,# u1 v: G& L- F$ k" j
and his psychosocial and psychomotor development/ c* }$ p7 n) ~6 m& h+ J8 a
was age appropriate.
: N0 _9 G' V+ GThe family history was remarkable for the father,: g) n% y0 h8 f
who was diagnosed with hypothyroidism at age 16,
- a# e# j* m2 n9 q3 Mwhich was treated with thyroxine. The father’s4 ~) o" A4 Q0 U o
height was 6 feet, and he went through a somewhat/ S- C' X8 V+ `0 ] T+ w) J
early puberty and had stopped growing by age 14.
1 a+ E8 Z4 s/ c! e/ o# NThe father denied taking any other medication. The
, ]# l. q/ U+ Bchild’s mother was in good health. Her menarche7 {( s/ o* h) }; l. y- J9 ^
was at 11 years of age, and her height was at 5 feet
* y' N* l. D0 A K5 inches. There was no other family history of pre-& d3 J* X+ S) c. o$ m! G8 H
cocious sexual development in the first-degree rela-4 |7 w* V( |" x/ a2 f
tives. There were no siblings.
" ^% C! J# q) |, oPhysical Examination
7 J- i3 V% C" ^+ W7 T, Y! B; }- HThe physical examination revealed a very active,4 b, Y, N9 C& O
playful, and healthy boy. The vital signs documented- k6 J/ V+ M# S+ s) h! `# O
a blood pressure of 85/50 mm Hg, his length was7 F9 p/ L! b3 H2 r- o t3 A& L4 P
90 cm (>97th percentile), and his weight was 14.4 kg
& I% M2 l. w, }8 l8 g0 b8 t(also >97th percentile). The observed yearly growth; z0 A L/ T6 c$ _* ?* {
velocity was 30 cm (12 inches). The examination of
3 B# V. j" L. ~8 u+ ?8 B3 O* [the neck revealed no thyroid enlargement./ R5 @% `) E0 } }; T2 @4 \
The genitourinary examination was remarkable for5 P# C: g E9 u- {0 ^7 a4 I8 J/ z
enlargement of the penis, with a stretched length of
! ~: p+ i; j# N2 Z1 G8 cm and a width of 2 cm. The glans penis was very well
/ ^$ g0 v0 l# W% g' O" j* Ideveloped. The pubic hair was Tanner II, mostly around+ L. o- S4 d, ?5 x
540
w% W. b* V9 M: Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 x' W: Q p0 f% k1 a& j/ s
the base of the phallus and was dark and curled. The
( Q) \. n0 D: [( s6 Dtesticular volume was prepubertal at 2 mL each.
/ Y( w0 F$ h7 R1 E( M7 [The skin was moist and smooth and somewhat0 h# U* ^, Y, ^, j1 M0 z: x
oily. No axillary hair was noted. There were no$ k+ `$ k4 q0 F* X
abnormal skin pigmentations or café-au-lait spots.
/ C4 h% q0 Y) @2 t. ANeurologic evaluation showed deep tendon reflex 2+7 g2 I1 i. Q/ k3 _
bilateral and symmetrical. There was no suggestion9 y" V- s4 K/ I1 [& t
of papilledema.
. m4 P1 Z( G+ D' A$ P( p6 wLaboratory Evaluation3 O' a( d$ `2 c+ k1 I" ], Y) t
The bone age was consistent with 28 months by
" [- f& u5 z; H* b- P1 {* H( Busing the standard of Greulich and Pyle at a chrono-3 @8 B' l. y4 |# r. ?7 O
logic age of 16 months (advanced).5 Chromosomal3 ~ Q1 W; v; m( b# X" \
karyotype was 46XY. The thyroid function test
7 t! C0 E0 ]5 a& m) Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 J9 t( r4 K( l. f2 a: P- J
lating hormone level was 1.3 µIU/mL (both normal).
$ I6 P" s' X+ i! p# jThe concentrations of serum electrolytes, blood
9 N1 o# O5 h3 G7 C0 k1 N8 Z0 hurea nitrogen, creatinine, and calcium all were# j) R. e F8 C$ E6 ^, Q
within normal range for his age. The concentration
+ {7 j+ y' C9 H% @' B3 z. fof serum 17-hydroxyprogesterone was 16 ng/dL
# K! L# A& |% }* {. G% S( y(normal, 3 to 90 ng/dL), androstenedione was 209 O! d' \# U& ~, F) a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 z7 c7 \5 D9 O/ L/ }% G4 i2 s4 O0 N4 q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& x& M* \6 A! I% s; g% Y2 Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 N7 N- f2 @ p
49ng/dL), 11-desoxycortisol (specific compound S)
% i) s2 X M/ @" @5 Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 G% y7 Y: Q# m' N( S! @& c
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: Y8 o. @/ Q( w5 Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' P5 x+ d: n% |3 m& C' r9 k( f) ~and β-human chorionic gonadotropin was less than1 Z" Y3 a3 Y3 B
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% y( m$ p$ ], B0 m4 ? O9 ~" I, Ustimulating hormone and leuteinizing hormone
3 T* C7 V" V9 A4 v- u- ~concentrations were less than 0.05 mIU/mL& X+ [4 g z7 a# ^
(prepubertal).* \9 |1 w* F8 B* b. O1 W6 Q' d
The parents were notified about the laboratory$ e% d4 G. e: A% e( e# s
results and were informed that all of the tests were
; c$ N9 @* W# `2 ?! B! S' y; Y5 _ i, Anormal except the testosterone level was high. The
" A9 ^" q2 a3 P# Z& N- Mfollow-up visit was arranged within a few weeks to& T' ~) [# ^8 Q- O
obtain testicular and abdominal sonograms; how-; O) w n% L0 B0 {1 ?7 \
ever, the family did not return for 4 months.
, O! e' x; [3 P% x9 YPhysical examination at this time revealed that the$ }' e+ n5 j% Y) C8 y, z9 |
child had grown 2.5 cm in 4 months and had gained3 Y# V8 h( V0 B6 Q: e6 t& d
2 kg of weight. Physical examination remained7 v" W G- l+ I4 t
unchanged. Surprisingly, the pubic hair almost com-
4 N, X% G# k1 F( fpletely disappeared except for a few vellous hairs at
# g; ?9 f7 G( F, M" F* pthe base of the phallus. Testicular volume was still 2
- Y o- d3 W0 Z, V& O9 amL, and the size of the penis remained unchanged.
' I- D4 l) b- F% ?2 x$ R {1 ~The mother also said that the boy was no longer hav-! {! u, ^2 u- ?$ y$ m
ing frequent erections.
) h4 t8 Y. W% l2 a( ]# MBoth parents were again questioned about use of
1 k/ ~% ~, s; m# Z8 [any ointment/creams that they may have applied to
e" P; I3 V5 y2 v! Hthe child’s skin. This time the father admitted the5 N& J) C8 Q6 G
Topical Testosterone Exposure / Bhowmick et al 541! t" p& L" c) Y+ j! f
use of testosterone gel twice daily that he was apply-9 V( ~. `% A0 ]& b
ing over his own shoulders, chest, and back area for9 ^% m D7 T8 m' S! j' f
a year. The father also revealed he was embarrassed3 \. u2 j Q7 B# U$ R7 ]
to disclose that he was using a testosterone gel pre-+ j/ V0 w6 K8 A, M
scribed by his family physician for decreased libido
7 i6 W7 L4 `& `secondary to depression.
% ~) H! o0 q. j- JThe child slept in the same bed with parents.
8 C5 K, V+ ]* E; KThe father would hug the baby and hold him on his
) V0 p7 ~9 L5 {chest for a considerable period of time, causing sig-0 Z3 Z, n9 C* p7 n' Z2 u
nificant bare skin contact between baby and father." u1 B- `- W! A5 x
The father also admitted that after the phone call,( c) U: G! T2 Z* W
when he learned the testosterone level in the baby
- m$ g; z5 l% S- N/ F0 H! N5 Uwas high, he then read the product information
# Z2 j# P. i' ~packet and concluded that it was most likely the rea-
9 j" ]# X$ z( E( V- X7 K5 f6 Fson for the child’s virilization. At that time, they
% Q+ h4 [ ?$ N" I# Qdecided to put the baby in a separate bed, and the R& }- H$ k, ? n: V* f
father was not hugging him with bare skin and had0 O( t* ^7 g; z- q: c' C
been using protective clothing. A repeat testosterone
! |$ g, e" h7 u& Q% \+ `1 @( gtest was ordered, but the family did not go to the
6 d$ j1 F: G1 P, P' ?* ~5 _9 }laboratory to obtain the test.
, E: ]2 o( v3 K% S; w( pDiscussion
& c' c+ P* N! i: a' g* Q- I4 Q' G7 u. ~: UPrecocious puberty in boys is defined as secondary( Y# k- L* z# b! Y5 \( V
sexual development before 9 years of age.1,4
) v# [% F p, L' H7 g3 }Precocious puberty is termed as central (true) when
9 k' ^; ~8 ^- G" E$ wit is caused by the premature activation of hypo-7 n8 M% Z* y( O5 J8 H- j% k( V
thalamic pituitary gonadal axis. CPP is more com-
# K( ?. z) \ s# fmon in girls than in boys.1,3 Most boys with CPP3 v8 i C$ m: D/ C. i2 S8 S# J
may have a central nervous system lesion that is: b% S5 Q3 l) t+ L8 @/ l
responsible for the early activation of the hypothal-
; M( | A; e! kamic pituitary gonadal axis.1-3 Thus, greater empha-1 x# `) [; u c
sis has been given to neuroradiologic imaging in% [' k; S+ D: X1 C" j
boys with precocious puberty. In addition to viril-, g+ V- I* d) M& j, U# Z
ization, the clinical hallmark of CPP is the symmet-
: O) W; q! a' N+ w1 G# Arical testicular growth secondary to stimulation by
, r' e( C' \1 q, ]8 c4 T% K7 z9 D% Jgonadotropins.1,39 d5 r" C4 z: ^9 R
Gonadotropin-independent peripheral preco-0 w2 P! ~+ X: T7 g
cious puberty in boys also results from inappropriate
$ c- g6 W2 t* @) e6 L" N, C/ A4 |androgenic stimulation from either endogenous or5 r! h9 X; K H% q+ h+ q2 ?" g3 S
exogenous sources, nonpituitary gonadotropin stim-3 x% P/ ^" m2 I
ulation, and rare activating mutations.3 Virilizing
' G- j7 b- a) y* I0 Ucongenital adrenal hyperplasia producing excessive- T6 f% T. U6 t b
adrenal androgens is a common cause of precocious4 D/ G( B: {0 Q/ K2 y' o/ u$ {' O
puberty in boys.3,4) S# T. H6 R% B. I# r
The most common form of congenital adrenal, K" Q# w! C. H" C" g9 F
hyperplasia is the 21-hydroxylase enzyme deficiency.
) {: |' i2 f. rThe 11-β hydroxylase deficiency may also result in! V/ Q# _, h- n! L% p
excessive adrenal androgen production, and rarely,
' K6 [2 ]4 o9 z) T) han adrenal tumor may also cause adrenal androgen
1 i. d: y$ L+ w. y$ \excess.1,3& T! p4 G% w+ _0 {7 t1 @1 N/ U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, V2 W* {$ n; [! q. T" t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 o# @, F; G2 a# g& yA unique entity of male-limited gonadotropin-
# ^( p# H2 y1 S/ Oindependent precocious puberty, which is also known- N' C* [+ |! A1 U6 o' _( C8 J9 m
as testotoxicosis, may cause precocious puberty at a; E9 Q% W! v' ]& j& E& G
very young age. The physical findings in these boys
1 [$ C: j8 K' m- awith this disorder are full pubertal development,
a( L: x" M0 Qincluding bilateral testicular growth, similar to boys
f( P) M/ ?5 M1 h( |with CPP. The gonadotropin levels in this disorder
9 |1 d. z1 T3 uare suppressed to prepubertal levels and do not show
! @1 @7 X6 g9 ^. n8 apubertal response of gonadotropin after gonadotropin-% E# @% R; q: F% J2 G% s/ L
releasing hormone stimulation. This is a sex-linked6 Z( F+ k) F# l9 `
autosomal dominant disorder that affects only; u) ?: B9 N& U( I; s
males; therefore, other male members of the family
& w& H5 ]" f! }, `2 gmay have similar precocious puberty.3
9 U" q( U) M! u6 y. a2 @9 YIn our patient, physical examination was incon-
: t, U7 s! v- z: K# usistent with true precocious puberty since his testi-
* r0 X" ^" ^7 z6 J% A8 ?* i$ Rcles were prepubertal in size. However, testotoxicosis" y8 [! v$ b7 n) H/ Y; z
was in the differential diagnosis because his father
% c( D( B* \4 i! lstarted puberty somewhat early, and occasionally,
" c, h& F1 | f& h1 F" c3 htesticular enlargement is not that evident in the
) B a1 H/ D0 ]! K% Z' L- P, }, Pbeginning of this process.1 In the absence of a neg-
3 d9 [+ \4 X& M" `/ G: C) }ative initial history of androgen exposure, our
# Z. M4 U J' o- d2 h/ cbiggest concern was virilizing adrenal hyperplasia,
6 W* W$ M2 w4 Q% yeither 21-hydroxylase deficiency or 11-β hydroxylase3 L- o6 w5 g9 s1 K' s; t: k( k
deficiency. Those diagnoses were excluded by find-
6 f3 g9 B. T; q, Ying the normal level of adrenal steroids.# u2 {: @. M% R: F/ }+ Q. _
The diagnosis of exogenous androgens was strongly# W* [+ q) `. w5 \; W5 d o: _, i
suspected in a follow-up visit after 4 months because
1 v* ]* ^) D# ~5 P* U7 ythe physical examination revealed the complete disap-. F( O2 n- d- k+ }6 E
pearance of pubic hair, normal growth velocity, and8 w- Q, I/ m9 C- u1 C7 H
decreased erections. The father admitted using a testos-
& Y3 Z3 `5 Q/ F3 G- v& ]terone gel, which he concealed at first visit. He was2 k: r; G/ w: Z
using it rather frequently, twice a day. The Physicians’
" R, A. l2 \6 V) QDesk Reference, or package insert of this product, gel or4 k' M3 |7 A1 h, z
cream, cautions about dermal testosterone transfer to
/ N: R; H9 z- m- d2 g5 sunprotected females through direct skin exposure." v, G" a' k2 z
Serum testosterone level was found to be 2 times the
$ ?" q: W3 I" c4 Sbaseline value in those females who were exposed to7 b8 [, q7 M4 W% [
even 15 minutes of direct skin contact with their male4 ]0 z) V9 @7 y; ?6 C( m
partners.6 However, when a shirt covered the applica-
9 G+ f) |" O! U/ R+ wtion site, this testosterone transfer was prevented.
3 W$ a0 `# @ O' v# V9 g& WOur patient’s testosterone level was 60 ng/mL,
- ]( v( _. O; G( Y* Vwhich was clearly high. Some studies suggest that
/ P8 O7 _) U. O9 _2 r" }dermal conversion of testosterone to dihydrotestos-$ L+ k3 z( ]8 n+ t& K6 C
terone, which is a more potent metabolite, is more
7 m, K6 M0 j* d3 dactive in young children exposed to testosterone5 S/ J: s- {9 c" [" D" I
exogenously7; however, we did not measure a dihy-9 E, o, m, \# g6 G K% A
drotestosterone level in our patient. In addition to
, T) P2 T# P3 G& Hvirilization, exposure to exogenous testosterone in* U: k6 C$ D# U" W( A2 Y
children results in an increase in growth velocity and
( `* J" M+ z9 @; C5 F& i1 t/ oadvanced bone age, as seen in our patient.' @7 z/ c& U: {
The long-term effect of androgen exposure during. v( I3 x% h7 ~
early childhood on pubertal development and final
$ k' h0 C6 j2 j9 l& B" g( ~adult height are not fully known and always remain. M1 F" I' V1 n5 S
a concern. Children treated with short-term testos-4 W) Q; ]; x# U" @. K$ ^, i
terone injection or topical androgen may exhibit some
: R( M- p G0 P+ ?* Jacceleration of the skeletal maturation; however, after
& @' q- o" O/ Q ~% hcessation of treatment, the rate of bone maturation
. p, B' {5 ^% {3 |( B" y: T5 y' Z Xdecelerates and gradually returns to normal.8,9
, X* y8 _4 p, ^5 u- y' VThere are conflicting reports and controversy
- E8 ?& i1 r D6 H+ t1 Jover the effect of early androgen exposure on adult8 f& c+ _" L6 @. p. e- z/ j7 }/ N5 a
penile length.10,11 Some reports suggest subnormal, n" n9 L4 b) A7 b. q
adult penile length, apparently because of downreg-0 h3 j) M9 m4 M0 `
ulation of androgen receptor number.10,12 However,
' e& Q2 n x; F2 I/ q. F4 \Sutherland et al13 did not find a correlation between
+ ?1 N3 z! ~, j7 o0 n+ C/ |childhood testosterone exposure and reduced adult1 w ~# K8 e* i7 A, R0 k# S
penile length in clinical studies.. F% p' q8 z2 i: R, s% c9 C. c2 n
Nonetheless, we do not believe our patient is
& Y8 M. V: L0 d0 l" j. tgoing to experience any of the untoward effects from% s& W! O; U' b
testosterone exposure as mentioned earlier because
( y* L' d; x; _; q G; ^the exposure was not for a prolonged period of time.
0 N8 q# ~& Q" ]% r: R# ]2 ZAlthough the bone age was advanced at the time of
" f) k5 j% q* @$ o: p0 V9 ^diagnosis, the child had a normal growth velocity at4 G1 Q) f5 B4 E; g/ {
the follow-up visit. It is hoped that his final adult
8 m. t/ b) R) P8 I" Sheight will not be affected.9 P2 c" K# `* X0 \' d B X- H
Although rarely reported, the widespread avail-
o" y% |/ G' i. A- O. F6 I; vability of androgen products in our society may/ z8 y. L2 A. \0 T" w5 d! w
indeed cause more virilization in male or female- G1 u' Z2 |9 A& \
children than one would realize. Exposure to andro-8 g* _2 ^9 d, d5 J( p$ h
gen products must be considered and specific ques-/ u8 P* |. e) q2 n" W% [
tioning about the use of a testosterone product or R% Z8 F+ W1 C. Q
gel should be asked of the family members during
& U7 u/ \: X% g5 G* k! Bthe evaluation of any children who present with vir- w% H+ X3 v5 j6 P4 C
ilization or peripheral precocious puberty. The diag-
) l: r3 V, T5 X- U/ Q7 x; H" @nosis can be established by just a few tests and by$ [9 G+ y; \$ s! }& P- _ Q
appropriate history. The inability to obtain such a7 {0 g( n. i6 C3 l
history, or failure to ask the specific questions, may7 z: z) v% h- T) U0 W
result in extensive, unnecessary, and expensive: M, `" m' C7 ~! T- }4 _( B
investigation. The primary care physician should be
* p, M4 f, m O$ Raware of this fact, because most of these children/ y1 `' u8 K1 B% Q: O2 d: n! K% w- ~& F
may initially present in their practice. The Physicians’
! r0 E' R) u3 W d+ ODesk Reference and package insert should also put a
7 G% T1 p2 J/ s; k; R+ G; Mwarning about the virilizing effect on a male or
" @( ?" J2 W [, `4 Sfemale child who might come in contact with some-2 ?$ q/ U3 [( l' D `4 j
one using any of these products.
# X4 w! V5 t; _References. F1 p y. T$ f7 p, w+ H! U
1. Styne DM. The testes: disorder of sexual differentiation8 R/ X" H5 h5 t; `( T1 f
and puberty in the male. In: Sperling MA, ed. Pediatric
) `: A) H1 k7 h& z! zEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
o% Y7 E6 |3 K5 d7 z2002: 565-628.1 ~9 y- A; W" M+ G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% ]8 o ~( K) ?5 M Q
puberty in children with tumours of the suprasellar pineal |
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