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Sexual Precocity in a 16-Month-Old
$ u9 d$ a- M t6 L& a8 P5 rBoy Induced by Indirect Topical
1 }" s5 R: s9 ?: N7 o' SExposure to Testosterone
8 X$ x( U. }4 N2 ^6 v. |8 Q, USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ b( t6 Y% y2 F1 T8 T, D$ }- n- ?: iand Kenneth R. Rettig, MD12 y! D0 ?! R; b* R( Q8 F
Clinical Pediatrics
, ]$ K# J W$ i0 ?7 [0 IVolume 46 Number 66 K( d9 g t+ H5 s1 E9 U& O) h% m, }. H
July 2007 540-543; {, j9 |1 N. U/ _6 U% w
© 2007 Sage Publications, T. O& |2 }* C# n, L
10.1177/0009922806296651, w, V! \, j$ n) U! z* N
http://clp.sagepub.com
$ X0 [8 P8 A, ~hosted at" Y! f+ Q, b5 }; y2 x9 V8 p4 d
http://online.sagepub.com5 p9 j v* k: T Q; ^3 P2 [
Precocious puberty in boys, central or peripheral,
' g7 W$ I7 f- `" S( Gis a significant concern for physicians. Central/ V: O# r7 ]6 H" j
precocious puberty (CPP), which is mediated2 n9 p& [- g+ Z0 \
through the hypothalamic pituitary gonadal axis, has: O, P8 e; e: i( k5 z0 \
a higher incidence of organic central nervous system
& I& t% U. l2 R1 a3 o: \- r, Tlesions in boys.1,2 Virilization in boys, as manifested
# ^0 m/ i7 k6 |) I$ P6 G: ]1 M" L" fby enlargement of the penis, development of pubic
5 i' U3 S6 f! \- ?hair, and facial acne without enlargement of testi-
: J$ D( `' F: gcles, suggests peripheral or pseudopuberty.1-3 We
0 L% u- T$ I9 d1 G9 {report a 16-month-old boy who presented with the1 P+ q; U- ?! H$ j! W2 k1 B" l
enlargement of the phallus and pubic hair develop-
3 W4 S6 k7 M. m- W" f( fment without testicular enlargement, which was due( w# p* w' Y1 e. n* x e, l0 ]
to the unintentional exposure to androgen gel used by
5 @ L& u( t4 P: F1 O3 J$ Uthe father. The family initially concealed this infor-1 O! c$ w& i" Z
mation, resulting in an extensive work-up for this( ~- B$ R1 b3 T. f2 P: g0 k x
child. Given the widespread and easy availability of
. E* ~5 @ F1 C6 d. x3 r: ktestosterone gel and cream, we believe this is proba-
! w$ i! Z% T. O" V, Y- {1 Obly more common than the rare case report in the
' o2 W0 o- u( C3 [6 x( f" K! Z! Iliterature.4' `, u! ^5 c: k2 X- N- X+ `
Patient Report
D' [1 f! k. O1 f1 B+ D( BA 16-month-old white child was referred to the
" F8 O" U( ^1 ^endocrine clinic by his pediatrician with the concern3 W3 W' R: z5 X6 Y. b1 z
of early sexual development. His mother noticed
7 A9 e4 M/ J Z( }6 a* a2 mlight colored pubic hair development when he was; B8 E5 I: b' p3 P9 h7 K
From the 1Division of Pediatric Endocrinology, 2University of
, t# O7 t3 C: @! VSouth Alabama Medical Center, Mobile, Alabama.1 X& o: Z) [2 i$ N" A5 m4 x2 t/ y: d+ Y' [
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& L& e$ d+ ~7 E: ?. `/ @0 ?& s$ M' FProfessor of Pediatrics, University of South Alabama, College of) w* ^# q; W4 a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' |$ I: `" x3 p5 T0 }7 D
e-mail: [email protected].2 X) \# J( b9 t5 U- V* I
about 6 to 7 months old, which progressively became
8 w0 P6 \6 { |! |: [2 tdarker. She was also concerned about the enlarge-
3 g+ l" a- I! p% ?7 i$ [% oment of his penis and frequent erections. The child0 w8 x, w" n1 D, k. b% L0 H
was the product of a full-term normal delivery, with
$ c) N! ~; N! ~4 va birth weight of 7 lb 14 oz, and birth length of" t& M- H9 {0 |
20 inches. He was breast-fed throughout the first year/ }- X8 e) e" Y* e! `
of life and was still receiving breast milk along with
5 k0 u& e. f( G2 L5 wsolid food. He had no hospitalizations or surgery,
$ B$ D: l5 s0 c$ D6 L0 fand his psychosocial and psychomotor development. J( l8 o8 f# _/ F, X5 }+ {5 R% D
was age appropriate./ a5 I7 \1 A7 W' I8 B& K
The family history was remarkable for the father,
5 W& O8 W( v6 Y5 B, f0 `who was diagnosed with hypothyroidism at age 16,! h3 S1 o* H! U+ m8 [/ e
which was treated with thyroxine. The father’s
9 z+ M" [- H* l' x3 N- R+ B4 Zheight was 6 feet, and he went through a somewhat1 z/ L. ?# T" M/ x! t# P8 R1 s5 A7 _( u
early puberty and had stopped growing by age 14.' _ W/ y! q* E5 Q$ _8 Q- i# s
The father denied taking any other medication. The+ n- Q6 L- V; N6 t8 F
child’s mother was in good health. Her menarche* P% N; P8 @ ~* @
was at 11 years of age, and her height was at 5 feet/ X$ A& W" c, d- s
5 inches. There was no other family history of pre-
, w( L3 N$ z; b N1 z, acocious sexual development in the first-degree rela-' t. o1 h- {* ^# @7 {
tives. There were no siblings.
- z, \5 _8 l5 k0 NPhysical Examination3 G7 E! k9 l$ f* m
The physical examination revealed a very active,
6 k4 ?3 T1 i" {: Fplayful, and healthy boy. The vital signs documented" e- O+ w+ l! }* R+ [
a blood pressure of 85/50 mm Hg, his length was
, W" X9 C( ]3 H7 ]90 cm (>97th percentile), and his weight was 14.4 kg
. S' R3 o# u$ i) l1 y: p0 H# [(also >97th percentile). The observed yearly growth
! ]; L/ G; y0 X( I7 F3 C9 uvelocity was 30 cm (12 inches). The examination of1 u9 g$ y3 A ^+ Q
the neck revealed no thyroid enlargement.3 _- O) ^# @6 ?
The genitourinary examination was remarkable for5 b, B$ n9 c: T1 S$ J9 O) Q
enlargement of the penis, with a stretched length of
* D3 ]! ?5 _- ^+ j8 cm and a width of 2 cm. The glans penis was very well
2 \% m6 i/ g' J! F' J4 qdeveloped. The pubic hair was Tanner II, mostly around
/ v( h( T& H% m5 }" H5406 b& I' u, x. I7 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% B a& N$ d. l( u R" [the base of the phallus and was dark and curled. The- ~1 I2 K+ \" p7 V! y# N
testicular volume was prepubertal at 2 mL each.
4 D' E* b: Z8 U0 RThe skin was moist and smooth and somewhat1 A- {& X" A! I! j) m, A
oily. No axillary hair was noted. There were no6 r1 E# H$ K* W* {
abnormal skin pigmentations or café-au-lait spots.$ l! O& U: r. o% {$ W% l( S* @, Y
Neurologic evaluation showed deep tendon reflex 2+
1 m+ g% T6 P! `3 y% tbilateral and symmetrical. There was no suggestion
: {( O8 K( V8 o, wof papilledema.
/ D0 I K+ m2 [9 R3 y( G3 aLaboratory Evaluation
! R3 R ?& l0 m. E$ qThe bone age was consistent with 28 months by/ x. q9 R$ H+ V. C1 ?, I3 o" H
using the standard of Greulich and Pyle at a chrono-4 ~& _ W% R# j7 H3 W) C
logic age of 16 months (advanced).5 Chromosomal1 E7 [1 s3 G$ |7 d/ R
karyotype was 46XY. The thyroid function test. W5 Z2 k) X" C% |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! h7 S* M0 P. z/ k8 ~- i1 h0 v
lating hormone level was 1.3 µIU/mL (both normal).
) w9 d- c8 i: d1 y# n7 r: oThe concentrations of serum electrolytes, blood) I1 K% P( [% n) N) R% R
urea nitrogen, creatinine, and calcium all were# T s, ^; h* P7 Q; p
within normal range for his age. The concentration
) h9 A5 Q& w; E7 Kof serum 17-hydroxyprogesterone was 16 ng/dL7 C3 s S& g& ?! e
(normal, 3 to 90 ng/dL), androstenedione was 20
/ u* E7 n$ Y R$ P0 j( R. tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 K# {6 G7 }6 T; u- N X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 A1 ?( F. d4 v G% `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( {7 G Z) Z: ~0 i8 Z9 W8 U4 O
49ng/dL), 11-desoxycortisol (specific compound S)0 z3 h! N! ~# D5 t( c" }' v5 Y# |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 [0 B4 K! v/ xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 g$ F( l* P+ d8 |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL), B4 r8 G: S( a a9 B
and β-human chorionic gonadotropin was less than' V3 c$ ?5 F+ A
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 [' A/ T0 U# a* s% Z4 }
stimulating hormone and leuteinizing hormone
! G: h+ S0 j* b7 Yconcentrations were less than 0.05 mIU/mL9 w" P2 z/ {$ N8 N3 ?! o5 L9 A
(prepubertal).
1 j* B: | ~) ^. \/ k) U- y# UThe parents were notified about the laboratory
6 S' W& I1 {3 g, \: s/ H! {) xresults and were informed that all of the tests were9 ?! E' f: C# B
normal except the testosterone level was high. The
. W) u$ R. }% O. }/ w$ N% kfollow-up visit was arranged within a few weeks to
, l z; Q: _2 S$ Dobtain testicular and abdominal sonograms; how-, M" Y q# U) s+ B, H" U
ever, the family did not return for 4 months.
8 j' e5 [- h7 o% `5 lPhysical examination at this time revealed that the
6 R. F" s! s: O* r9 K3 Bchild had grown 2.5 cm in 4 months and had gained
8 v! }$ o5 Q9 w+ y2 kg of weight. Physical examination remained2 |$ c' U- t1 D$ r) u A
unchanged. Surprisingly, the pubic hair almost com-, _7 N4 O. H6 Q1 |% U, T1 X, o
pletely disappeared except for a few vellous hairs at
# i$ Z7 r: v9 S2 U1 e8 n: tthe base of the phallus. Testicular volume was still 2
3 x: W: u, S8 W) [ [mL, and the size of the penis remained unchanged.9 M3 L a4 j) J) D# u$ x; r# n
The mother also said that the boy was no longer hav-; ^* }% f& ~/ F% X% k y
ing frequent erections.: b7 Q h0 ?0 D7 ]* N, w8 ^# B% u
Both parents were again questioned about use of% n1 T% w0 @+ W: t9 P* n
any ointment/creams that they may have applied to1 S) X; E% h& t- h, h
the child’s skin. This time the father admitted the
/ E8 A; M$ S7 Y5 |8 ]Topical Testosterone Exposure / Bhowmick et al 541
! t' H3 ]: J& L. I- m1 |use of testosterone gel twice daily that he was apply-7 G# g8 Z5 N* |: p" X7 o
ing over his own shoulders, chest, and back area for y6 n& s! G& u3 o0 s, @4 F* q
a year. The father also revealed he was embarrassed
( U& h( D% }. z5 T4 b" y; q. Qto disclose that he was using a testosterone gel pre-
9 q5 S, P$ t* _- p# {$ rscribed by his family physician for decreased libido4 U( a8 x# M) h& ^. M' U* N
secondary to depression.
0 o* K4 d2 @0 M o* GThe child slept in the same bed with parents.9 B }. t5 S$ A$ l W" E
The father would hug the baby and hold him on his
" ^' R) w& s8 x% p1 _chest for a considerable period of time, causing sig-
5 q. w) N; Z& G& r4 Hnificant bare skin contact between baby and father.: c6 S: b. u; b+ C- D
The father also admitted that after the phone call,
: J7 ?: N7 o. d4 d4 ywhen he learned the testosterone level in the baby U$ q: h2 O/ ?2 f
was high, he then read the product information
4 `7 j% L( \' ypacket and concluded that it was most likely the rea-
. L6 r$ t! S- D. Y" z7 E L! @son for the child’s virilization. At that time, they
' d& u; v1 o! T( y1 q4 Hdecided to put the baby in a separate bed, and the) @" F! U1 b8 H7 O5 S
father was not hugging him with bare skin and had
0 O- F- e/ V2 z& Y( dbeen using protective clothing. A repeat testosterone
8 _0 J `; ]% l5 V, }test was ordered, but the family did not go to the$ u1 q5 }" t6 g7 [; }
laboratory to obtain the test.# G5 X2 D+ x1 ?% I* w' A
Discussion
( n5 o+ u% y4 UPrecocious puberty in boys is defined as secondary
! d" C' A8 C* L) H: psexual development before 9 years of age.1,4( E) `( O' \6 Y- h3 k1 A- B3 p e
Precocious puberty is termed as central (true) when. k# }) B" G, T) a: r7 V8 `" P' \$ w
it is caused by the premature activation of hypo-) c6 [/ O) w! s" \# d O6 _
thalamic pituitary gonadal axis. CPP is more com-! S& r. g8 F' ?) {" p4 f6 e
mon in girls than in boys.1,3 Most boys with CPP8 l" u! B3 g! a9 h' ]
may have a central nervous system lesion that is. `( I B# d" M' t& O. w4 X
responsible for the early activation of the hypothal-. w( H! g2 f# M I1 M4 Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
- s- O4 H4 s, C T& D1 z9 |sis has been given to neuroradiologic imaging in. H8 a) L3 O4 r. f& O5 Y
boys with precocious puberty. In addition to viril-
. t0 G& d6 {$ `ization, the clinical hallmark of CPP is the symmet-5 o% [% u: _3 h. `
rical testicular growth secondary to stimulation by7 @( E+ \: [' ^
gonadotropins.1,3
8 w+ a( r7 b/ h1 l. h1 tGonadotropin-independent peripheral preco-1 p8 B" ?" @2 }, C3 a
cious puberty in boys also results from inappropriate/ X4 }; W9 T5 f
androgenic stimulation from either endogenous or
9 T% r1 o% L, ~0 _exogenous sources, nonpituitary gonadotropin stim-4 {9 a% M/ h( e- f8 q1 F5 `
ulation, and rare activating mutations.3 Virilizing
! @' B' Z o, k Y5 s2 B- m# ?+ jcongenital adrenal hyperplasia producing excessive5 N' B$ I" D% F7 Z$ s" M* `( H) F4 @
adrenal androgens is a common cause of precocious
2 K" \0 i0 B5 B) |puberty in boys.3,47 z) u4 a6 L7 ^- H) N
The most common form of congenital adrenal) V4 K) O( Q, Y9 t1 H
hyperplasia is the 21-hydroxylase enzyme deficiency.- L) q+ ^7 b) u
The 11-β hydroxylase deficiency may also result in
# E6 F# \2 O4 N4 Q( Z) ^( I' E: @3 hexcessive adrenal androgen production, and rarely,/ T3 e8 O5 o: t8 K& v
an adrenal tumor may also cause adrenal androgen
/ P$ @6 Q# s$ h( rexcess.1,3
' S/ F* R9 M8 Z9 @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* f5 x$ ^4 F0 X( R% B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 `" k8 W+ s# U. \7 c: \4 eA unique entity of male-limited gonadotropin-
% Z6 S& _( I# x4 q% E8 N* S) pindependent precocious puberty, which is also known/ O$ K/ \- h/ T% n( q0 N
as testotoxicosis, may cause precocious puberty at a F( ^/ h5 H' T8 x( | p
very young age. The physical findings in these boys& @' E2 g: a8 ?0 a- Z
with this disorder are full pubertal development,
; R7 _" T* i, e# A7 [7 qincluding bilateral testicular growth, similar to boys; P" _9 S! I: o& `; g: \; m
with CPP. The gonadotropin levels in this disorder J- M* k$ J; C7 E- i
are suppressed to prepubertal levels and do not show
+ D, g# F; D' \: @6 opubertal response of gonadotropin after gonadotropin-9 O8 s" t' g7 t/ j
releasing hormone stimulation. This is a sex-linked O0 d, L0 j- n8 C9 ]
autosomal dominant disorder that affects only
) V0 a6 [# c5 k; D. S3 u7 A: m1 o3 j) \males; therefore, other male members of the family
. E7 x5 r$ x! {3 S p/ Kmay have similar precocious puberty.3: Z. q3 q5 M: u( {' U& h2 x
In our patient, physical examination was incon-
7 o- ?. I/ \ W* ^( `sistent with true precocious puberty since his testi-4 c0 y7 q" q, Z3 t5 `6 o) ^* m
cles were prepubertal in size. However, testotoxicosis
. H$ X' ]1 H9 c& ]was in the differential diagnosis because his father
i" ~; {8 W, C" S% {started puberty somewhat early, and occasionally,% f( x2 r8 J8 s1 z3 G, e. e* A
testicular enlargement is not that evident in the
+ j2 e) b5 ?5 j" k* Q/ w9 Cbeginning of this process.1 In the absence of a neg-6 q% N7 B- n' V7 p
ative initial history of androgen exposure, our4 L2 z# @3 E/ A
biggest concern was virilizing adrenal hyperplasia,5 v3 ]0 \' ?9 ~; m! E& S$ h: w
either 21-hydroxylase deficiency or 11-β hydroxylase
% b$ }& ?5 z& q6 X, kdeficiency. Those diagnoses were excluded by find-
2 m; t. }9 e1 U king the normal level of adrenal steroids.
1 K( e+ X) C+ N2 Q: |! pThe diagnosis of exogenous androgens was strongly8 {8 T: Z5 g5 c5 t7 @: T7 M
suspected in a follow-up visit after 4 months because
) B$ U$ e3 j3 Vthe physical examination revealed the complete disap-
# z0 X" n; v4 Tpearance of pubic hair, normal growth velocity, and, O( t2 C* f7 e8 v, [
decreased erections. The father admitted using a testos-; u: D! q7 i# W3 W3 v( D3 |9 M, W( P
terone gel, which he concealed at first visit. He was
/ _7 [, J# Q3 w4 N6 Uusing it rather frequently, twice a day. The Physicians’
2 k) W9 m2 B' T& N! aDesk Reference, or package insert of this product, gel or
( z+ Q/ O" |$ U+ Jcream, cautions about dermal testosterone transfer to
/ L, K3 n, o. ?6 S O! Dunprotected females through direct skin exposure.
4 F; h6 }& W6 e, SSerum testosterone level was found to be 2 times the2 F0 Q, I% a# c5 }# b3 @7 d
baseline value in those females who were exposed to
+ J% [& m2 r3 k, J5 Keven 15 minutes of direct skin contact with their male: w1 h2 _! i* z0 N. {
partners.6 However, when a shirt covered the applica-" J0 s* ]4 K+ c; Z. Y( ~
tion site, this testosterone transfer was prevented.: e/ X$ |0 r3 \# Q3 e9 J9 h' w
Our patient’s testosterone level was 60 ng/mL,
2 E+ ~/ ^6 |* d" Pwhich was clearly high. Some studies suggest that4 ^7 [+ m0 v, C. J0 s4 U& @
dermal conversion of testosterone to dihydrotestos-! ?0 V" P% [0 A
terone, which is a more potent metabolite, is more
6 [# {, J' p- Uactive in young children exposed to testosterone! j) g, y6 ~* Z0 Q
exogenously7; however, we did not measure a dihy-; U1 e1 ^( f5 F, J* r8 r
drotestosterone level in our patient. In addition to' o& W* t& K W
virilization, exposure to exogenous testosterone in; T8 M: Y; u2 ?& ]' B: v* X! k _
children results in an increase in growth velocity and- e! J7 h3 ^4 i# H9 o
advanced bone age, as seen in our patient.* [8 M4 B0 `3 ?8 U5 }7 ]
The long-term effect of androgen exposure during2 k2 y# _# [3 z7 C" v/ @) |
early childhood on pubertal development and final% `" }' V) W) m
adult height are not fully known and always remain* t) N5 W, A& G, \( d
a concern. Children treated with short-term testos-' K9 H$ [9 e3 }' q5 _/ g
terone injection or topical androgen may exhibit some. S- j, @' i0 T( u$ h' V% J
acceleration of the skeletal maturation; however, after
! I0 F- o. L4 hcessation of treatment, the rate of bone maturation
0 k1 k' F: k# V# i- X$ Idecelerates and gradually returns to normal.8,9 Y, A& G' d3 J0 i& r
There are conflicting reports and controversy
1 E- g: h h5 v8 g4 vover the effect of early androgen exposure on adult4 ?2 H# Y" O( m7 ^( g8 J7 o6 e
penile length.10,11 Some reports suggest subnormal n# l( ]% t! {2 ]
adult penile length, apparently because of downreg-! h8 s2 _+ O' x) c; F. ^$ u& g4 ~
ulation of androgen receptor number.10,12 However,+ t# \* G% N6 s# |/ a- k
Sutherland et al13 did not find a correlation between9 v8 H( j" U- w& T' N" e* |
childhood testosterone exposure and reduced adult, x9 m8 e) G: i/ e$ o/ f: K$ T
penile length in clinical studies.
5 r3 O) X* q$ P1 I; X- ANonetheless, we do not believe our patient is) V; A( N* C0 T: Z) A1 F
going to experience any of the untoward effects from
1 I( y: C' |9 H7 v/ d- Wtestosterone exposure as mentioned earlier because- R3 T; Y8 @2 V3 q) J! I Y
the exposure was not for a prolonged period of time.# u3 y5 H2 e! {" }. v
Although the bone age was advanced at the time of
/ E. ~; A6 q/ p& qdiagnosis, the child had a normal growth velocity at D& {! J' K* Q( O
the follow-up visit. It is hoped that his final adult T) E2 J! E* X1 Z3 t
height will not be affected.
, X) y* ~$ q, Q5 Z( uAlthough rarely reported, the widespread avail-
; z7 w1 i& k( Mability of androgen products in our society may5 H, S. N' J4 u" F: u( N
indeed cause more virilization in male or female! x9 V# |' n7 Q, H0 Y
children than one would realize. Exposure to andro-4 U: Z- z# M# a& P
gen products must be considered and specific ques-
1 q1 [' a$ \' z; y8 @: [. V0 stioning about the use of a testosterone product or; o2 C% C1 L9 F3 i" a( p) T
gel should be asked of the family members during" T! M: i i; V8 ]
the evaluation of any children who present with vir-% T/ c1 d4 d/ [: N# a
ilization or peripheral precocious puberty. The diag-
9 \- Z9 h8 q) o9 M2 \/ O; \nosis can be established by just a few tests and by6 Q6 R) C. J7 X6 s+ E
appropriate history. The inability to obtain such a
" B7 e( [1 u" O, o6 Y9 Q5 e5 ~' A0 }history, or failure to ask the specific questions, may! G8 L) [1 U& X: E$ t0 B* o. z
result in extensive, unnecessary, and expensive
0 I& c: y8 J$ v) m/ m3 M! ?investigation. The primary care physician should be
3 D: C6 G0 z: K3 |* N- N- a: eaware of this fact, because most of these children! X1 d- K8 V& E# u
may initially present in their practice. The Physicians’
4 Y, A! I! {2 s9 x6 SDesk Reference and package insert should also put a
/ }' J" g O- y! ~* Twarning about the virilizing effect on a male or
! r$ O$ G3 i/ d+ lfemale child who might come in contact with some-: Y. X, _) z8 L
one using any of these products.. K- B5 U% ]" x5 ?+ z; a6 u
References6 Y! ^8 C0 ?. q/ m
1. Styne DM. The testes: disorder of sexual differentiation0 q& W) }/ o; Z3 ~$ G# X$ l" q
and puberty in the male. In: Sperling MA, ed. Pediatric
6 U+ r+ P8 k8 N/ F8 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 o5 N0 R0 Y' C* V2 I, ]7 q% O2002: 565-628.
! P9 j) G: c% f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 b# F$ p% E0 [9 V. `4 v( E
puberty in children with tumours of the suprasellar pineal |
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