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Sexual Precocity in a 16-Month-Old
+ t1 U3 K% S! ?/ A4 y. J4 YBoy Induced by Indirect Topical
, v$ w$ o7 t D, y" W3 eExposure to Testosterone
M9 f& G a1 V& M, L' vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: k( ~; E* l- E8 G- B: ^and Kenneth R. Rettig, MD1
; ^' r4 X0 J( u6 JClinical Pediatrics
+ L2 G% s( z9 x# y2 T9 X0 fVolume 46 Number 6, ~4 s# a' s0 n: u R& v
July 2007 540-543
' p) s* d# X$ B1 ~. E© 2007 Sage Publications' G4 p1 U+ x) H1 m) I" j
10.1177/0009922806296651. u( ^5 F6 W$ n* Q1 Y( u1 b. @
http://clp.sagepub.com& L9 V* O$ Y1 s: [' s' K
hosted at4 p: E# D; ?# \* h
http://online.sagepub.com
0 O: q. r4 z x {/ \3 l R4 n5 ?2 _Precocious puberty in boys, central or peripheral,9 l v" j) p9 D
is a significant concern for physicians. Central) [) X# p5 H0 F2 m3 u
precocious puberty (CPP), which is mediated
% H, E4 }+ A2 ^ d d) q4 [through the hypothalamic pituitary gonadal axis, has- Y" Q* E C' U5 W5 d' W$ H, a8 T
a higher incidence of organic central nervous system: m( ~' A5 F, s! z( {- k7 I2 d K
lesions in boys.1,2 Virilization in boys, as manifested
4 w$ y. J5 W; [. d% Aby enlargement of the penis, development of pubic$ u3 o2 T9 k+ o' M) O/ C9 L/ S
hair, and facial acne without enlargement of testi-
$ b& ]. c% ]2 O) w- mcles, suggests peripheral or pseudopuberty.1-3 We/ q1 Q. ]9 i8 U' h* M4 k$ ]/ X
report a 16-month-old boy who presented with the' k1 Y8 ?$ t. B" `& t
enlargement of the phallus and pubic hair develop-
4 i% u9 J: S/ Y7 b. Z% G% z3 t8 Iment without testicular enlargement, which was due
4 Y: [% f# g4 I" u/ m Uto the unintentional exposure to androgen gel used by
: b6 |, a/ k" Cthe father. The family initially concealed this infor-
5 ]* ]% [' s7 kmation, resulting in an extensive work-up for this) Q, X9 P9 b6 e5 X) [- ^
child. Given the widespread and easy availability of% R1 ?; A* b, M, f- _ J" q
testosterone gel and cream, we believe this is proba-
V8 L" z, i3 dbly more common than the rare case report in the3 u$ h; R8 P4 V) X( ~
literature.4
/ d$ O' u% m- T' H% EPatient Report+ V# V, f" B& U& R% U/ D; @
A 16-month-old white child was referred to the
& n/ l5 a& N6 @6 P% dendocrine clinic by his pediatrician with the concern
3 T" K) F2 a# c* Oof early sexual development. His mother noticed
' F* X$ ` U Y9 V. K8 _light colored pubic hair development when he was7 K) }5 T/ L. W" C9 ?: Q
From the 1Division of Pediatric Endocrinology, 2University of
0 v& D) v; X) y" R' V. \( x' GSouth Alabama Medical Center, Mobile, Alabama.
% {. W# t* l& b; I8 RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; u# [2 L- c3 x2 j9 kProfessor of Pediatrics, University of South Alabama, College of4 _, W2 q0 C8 w, f; V# @ G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( Z8 S, [5 C" l9 r! Me-mail: [email protected].
. a; ]' I9 v3 K m( Rabout 6 to 7 months old, which progressively became0 I& g, M' t l% W2 P
darker. She was also concerned about the enlarge-' G6 u) @4 V3 ~! c6 U$ z' S v
ment of his penis and frequent erections. The child
7 ?" r9 C3 p3 I I2 W- Vwas the product of a full-term normal delivery, with
/ G c* ^" C# T- y, } l+ V5 ga birth weight of 7 lb 14 oz, and birth length of7 e2 w+ }! U9 L% B1 u; L
20 inches. He was breast-fed throughout the first year; A) W: [; R7 I# ~# o0 r8 |
of life and was still receiving breast milk along with2 Z! w; O3 Q$ o, A
solid food. He had no hospitalizations or surgery,
" y$ v& P7 P r# h# Land his psychosocial and psychomotor development m- p$ j1 ] F0 T% B( s
was age appropriate.
. J% O" r- M( J3 W% r8 vThe family history was remarkable for the father,
0 A- B$ T2 g9 P$ Mwho was diagnosed with hypothyroidism at age 16,
: b, ~. Z+ R2 u0 Rwhich was treated with thyroxine. The father’s& k- v. m) m, w0 @0 ~
height was 6 feet, and he went through a somewhat
0 N1 Z# k7 R& P1 K* i5 cearly puberty and had stopped growing by age 14.
8 ?( y# i5 e+ d |% ~5 A( ?; AThe father denied taking any other medication. The
) G9 p& [, _+ y* M+ {& tchild’s mother was in good health. Her menarche. [+ O8 O9 v, Z9 `1 B5 X v6 g
was at 11 years of age, and her height was at 5 feet+ P4 v, Y, t7 w& B
5 inches. There was no other family history of pre-
' L: q$ \1 B. l. j8 h6 A6 ?cocious sexual development in the first-degree rela-
* G. S$ k. E3 xtives. There were no siblings.
: L6 ]! t$ S+ d: F: R. r; h: \0 XPhysical Examination
* |1 s( a. V* {) ^& XThe physical examination revealed a very active,
# e% ~- e) j! p8 G8 y' J( Wplayful, and healthy boy. The vital signs documented1 p6 j, z7 k) y# ? ^
a blood pressure of 85/50 mm Hg, his length was# `5 P; m/ l i' p% I
90 cm (>97th percentile), and his weight was 14.4 kg7 A1 Y. h1 e& d6 i* O7 K. ?
(also >97th percentile). The observed yearly growth
* v' B' v2 k( `2 H0 Z Hvelocity was 30 cm (12 inches). The examination of
9 Y$ W% y6 L1 e2 v9 ^/ l( L! K1 mthe neck revealed no thyroid enlargement.
# k s1 W( V: a" `) M1 {+ BThe genitourinary examination was remarkable for
' l5 c7 y: ]1 r' cenlargement of the penis, with a stretched length of, V% s# {, g# a) u# n) x; K: [- N0 G
8 cm and a width of 2 cm. The glans penis was very well
( s' F3 L6 ^; S3 N+ P( ]3 qdeveloped. The pubic hair was Tanner II, mostly around" F e7 T4 B) }: O7 Z
540
% O; L. r0 j" d) Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
P; @5 S( B/ _, m' S4 J' R: {the base of the phallus and was dark and curled. The9 H( R0 }; p! N7 `, E! ~( u: X
testicular volume was prepubertal at 2 mL each. ^: r1 }6 P9 W# Q( V
The skin was moist and smooth and somewhat
9 t& D! @+ d# H$ ?/ t6 ]oily. No axillary hair was noted. There were no4 R% ?# v8 c7 H( j
abnormal skin pigmentations or café-au-lait spots.) C& e: e8 m6 G/ M8 G
Neurologic evaluation showed deep tendon reflex 2+
5 s0 o( m& h5 ?bilateral and symmetrical. There was no suggestion& }2 `9 S9 `2 z" j4 K
of papilledema.0 y% X8 z+ n! r% ^: S4 W, d
Laboratory Evaluation
9 F' F- r+ o$ d" s. J# xThe bone age was consistent with 28 months by/ `& H# k( t* f
using the standard of Greulich and Pyle at a chrono-" F' N3 t k+ O3 G8 [9 L Q: P
logic age of 16 months (advanced).5 Chromosomal: F \% D- Q8 A: N* ]
karyotype was 46XY. The thyroid function test
/ o! M X& u' ~' Q; J+ B1 C0 @- _( v. F3 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. `' ~+ q5 a; k' R( ulating hormone level was 1.3 µIU/mL (both normal).! H. g! U) o: m2 q. b- L) f
The concentrations of serum electrolytes, blood
6 g7 a$ [5 [8 _0 Q! A* Z& {- ]urea nitrogen, creatinine, and calcium all were; f- K5 F j) _9 W5 \; [7 m
within normal range for his age. The concentration
& R. p2 z5 F% I9 Hof serum 17-hydroxyprogesterone was 16 ng/dL N) ^& E# F1 E/ t7 ]* j% {& u, _) r% |
(normal, 3 to 90 ng/dL), androstenedione was 20
# T) k1 I/ R7 T9 y. A# {( Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# ]5 _6 E9 w/ p- t, U/ mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: G8 Q+ `& W/ pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 |/ {/ c3 c6 ?1 ]" l5 Y; n8 x# k( n
49ng/dL), 11-desoxycortisol (specific compound S)# [, j5 p2 S$ t+ D5 V/ I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 t5 Q. {- E* c" @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 X, f: ~6 [% P8 o: `# Z2 q' r8 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 w9 z5 j: @0 m& ]# Zand β-human chorionic gonadotropin was less than6 j$ I! @" _, L$ h/ P, ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 s! F* U7 ~5 v# ]
stimulating hormone and leuteinizing hormone
9 I; ?6 ]) i) N5 `concentrations were less than 0.05 mIU/mL1 u9 |: Q. S# m. {$ {4 f( K, c
(prepubertal). g% j Z9 D$ n) K* |3 K6 y
The parents were notified about the laboratory
% K# q) @1 a: zresults and were informed that all of the tests were
, { E, u# `. l* K* @) hnormal except the testosterone level was high. The
# v( m" l3 j( p8 {0 s. Pfollow-up visit was arranged within a few weeks to2 D0 _' O) y7 Z g. N- j/ k
obtain testicular and abdominal sonograms; how-% m# O0 K3 A1 x/ [( f
ever, the family did not return for 4 months.
- l* |7 m; h/ Q. kPhysical examination at this time revealed that the* b3 o# C4 a; _& C3 A6 H( W( ?
child had grown 2.5 cm in 4 months and had gained
5 w' ^8 Y/ N: e) E, `2 kg of weight. Physical examination remained( | K0 e5 h' t
unchanged. Surprisingly, the pubic hair almost com-
. T# Y K4 ?5 C, x# l) B6 jpletely disappeared except for a few vellous hairs at# M5 N# Z' W* b) L g
the base of the phallus. Testicular volume was still 2
: }! }5 K3 ]& T" e# G# A, t! `& KmL, and the size of the penis remained unchanged.
4 s* ^$ E: O; i# o9 G. [7 BThe mother also said that the boy was no longer hav-5 u6 C; H& H3 w' ~2 \6 m
ing frequent erections.
+ s4 F5 }/ Y4 | f* @- I. {Both parents were again questioned about use of
4 S9 d( o. a$ \4 m- I! Nany ointment/creams that they may have applied to
4 @& ?4 r* H# o( \9 A" q0 ?the child’s skin. This time the father admitted the
' F! C% q; W p% f4 gTopical Testosterone Exposure / Bhowmick et al 541
4 D' D, W5 K" z }5 z" n4 R8 Puse of testosterone gel twice daily that he was apply-
1 S* ^: a. h R3 \: K) ^$ King over his own shoulders, chest, and back area for! I# E! i& u1 _" `5 g
a year. The father also revealed he was embarrassed
. |8 z" A; M" M: T& M' e" Tto disclose that he was using a testosterone gel pre-
5 r+ J5 U8 N7 K, O: m) jscribed by his family physician for decreased libido
2 b1 g4 B8 Z6 G2 ]secondary to depression.
/ w1 r) s2 F: `: c+ W6 Y2 |9 YThe child slept in the same bed with parents.
4 \- d0 ~3 m' MThe father would hug the baby and hold him on his
$ }6 v( T' i" X+ ^; lchest for a considerable period of time, causing sig-" ^4 k) ?; d) X; ?+ s. l, x# B
nificant bare skin contact between baby and father.
1 Z8 X- k A( O/ d1 l/ g' kThe father also admitted that after the phone call,( H" x m: V4 ^1 J# {' J
when he learned the testosterone level in the baby+ ~) x; ` }# h# S: L/ Y
was high, he then read the product information m" e# y, U" A3 a5 j
packet and concluded that it was most likely the rea-* Z. E2 `- d0 Z
son for the child’s virilization. At that time, they
+ j6 w, o! t* gdecided to put the baby in a separate bed, and the* \% h9 l& I) v+ q, W
father was not hugging him with bare skin and had
% o' o& Q7 v7 ]$ `been using protective clothing. A repeat testosterone/ w% N5 `) X" @/ i$ \( X, k
test was ordered, but the family did not go to the! s+ D8 h; f7 D8 i% F, f: H& B- }
laboratory to obtain the test.* Y) s' e, ?6 B1 Y1 R3 R( {
Discussion
& A( e( T! \3 ~4 YPrecocious puberty in boys is defined as secondary
& v6 a5 ?; o9 Q& k! }sexual development before 9 years of age.1,4$ K9 u; R! f- v$ M' F( M+ E r( y& ^
Precocious puberty is termed as central (true) when
6 b* K, @+ m& W0 f W0 \it is caused by the premature activation of hypo-! H- l9 j- S, o2 p- S! z
thalamic pituitary gonadal axis. CPP is more com-# L, V& M* x9 `' W- }
mon in girls than in boys.1,3 Most boys with CPP
& l' c( B. Q+ o/ `2 Q6 m+ Pmay have a central nervous system lesion that is
6 b0 s) B" k& l' d' @responsible for the early activation of the hypothal-6 ]9 H' `- {" w: g0 g( _
amic pituitary gonadal axis.1-3 Thus, greater empha-: |+ @2 X3 V7 \( {$ H/ {
sis has been given to neuroradiologic imaging in
* q/ W/ U, A6 Qboys with precocious puberty. In addition to viril-0 m% H7 H2 S* l- l
ization, the clinical hallmark of CPP is the symmet-
5 t' s5 k* x7 x7 L4 g* v6 rrical testicular growth secondary to stimulation by
% r T- G8 s2 u3 ^gonadotropins.1,3
( a: D" Q g3 w+ V9 gGonadotropin-independent peripheral preco-
/ R8 j \2 n5 k) tcious puberty in boys also results from inappropriate
8 d9 g- ]. D0 b, \* c* z) candrogenic stimulation from either endogenous or3 Z5 `8 ]9 d, L
exogenous sources, nonpituitary gonadotropin stim-5 q5 |2 ^# o2 W+ _* i
ulation, and rare activating mutations.3 Virilizing& R9 O* O9 \! V
congenital adrenal hyperplasia producing excessive
: ~9 T: W3 U c' x N- y& Eadrenal androgens is a common cause of precocious
1 ^3 S5 ~3 X/ epuberty in boys.3,42 j p/ j. L* P
The most common form of congenital adrenal) U7 a) \) k% ~& Y# I$ }$ P
hyperplasia is the 21-hydroxylase enzyme deficiency.
) a, Y5 l- B$ q3 [The 11-β hydroxylase deficiency may also result in
3 \6 @/ K5 L4 sexcessive adrenal androgen production, and rarely,$ r6 D2 U( f A: o. {- Z' D! X1 g
an adrenal tumor may also cause adrenal androgen
$ b- {- `* C9 p: [+ xexcess.1,3$ e; m$ V! d2 s2 @% ^5 @; G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* l6 s2 o! R* |1 d* b" h542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 ~! ]+ m* ~& r3 G' E) aA unique entity of male-limited gonadotropin-
- c2 ~- v4 d* n. w1 oindependent precocious puberty, which is also known; k" y/ Q6 c9 X. u: m
as testotoxicosis, may cause precocious puberty at a V/ ^; S$ D' b0 e# K. a7 s
very young age. The physical findings in these boys
: I, y7 G: H7 i2 a# `8 lwith this disorder are full pubertal development,
# j+ S: A: p1 N9 n3 iincluding bilateral testicular growth, similar to boys4 h' S& y) E) v* ]; p2 |! Y
with CPP. The gonadotropin levels in this disorder' X j" B. q% v
are suppressed to prepubertal levels and do not show; r* Q$ X4 N! N8 G& w3 \
pubertal response of gonadotropin after gonadotropin-
5 ~. F. ^& n' W% \, S p/ D) r/ Hreleasing hormone stimulation. This is a sex-linked
5 j0 ?0 _% u. O4 A+ Rautosomal dominant disorder that affects only; T. ^# D) y5 j
males; therefore, other male members of the family
0 [2 ~1 Z* g, A" d& X1 t. kmay have similar precocious puberty.36 y, G( W7 L) n* A2 g
In our patient, physical examination was incon-" N! H) u& B( o ^, U6 `& U
sistent with true precocious puberty since his testi-
, R. s$ x! \& ~& L6 Y. R- qcles were prepubertal in size. However, testotoxicosis
3 ?6 C7 S/ \, B4 Nwas in the differential diagnosis because his father/ M0 \& b8 S9 b7 k0 m0 v
started puberty somewhat early, and occasionally,
! c( v/ M6 n; G2 I) p& x. V* Utesticular enlargement is not that evident in the
2 S3 s! L5 `* m; Z6 W- l; obeginning of this process.1 In the absence of a neg-
0 N" I6 w0 s- q4 a, V% gative initial history of androgen exposure, our
) Z* w. w2 h# q" cbiggest concern was virilizing adrenal hyperplasia,) y, T' [: H# i, Y Z
either 21-hydroxylase deficiency or 11-β hydroxylase2 x3 ` R s0 P+ T9 L
deficiency. Those diagnoses were excluded by find-
" ?' h# P) ~" L! I* o& }% @ing the normal level of adrenal steroids.
, s* _0 A7 C: ` [) ?! qThe diagnosis of exogenous androgens was strongly' e! W# R5 Z1 A' \' b4 J
suspected in a follow-up visit after 4 months because
0 n* f, V" J' J; {; B$ x8 lthe physical examination revealed the complete disap-7 w' n0 `. A$ W% k5 z% k2 a3 P
pearance of pubic hair, normal growth velocity, and2 X% E# \3 g% U; T8 y, K
decreased erections. The father admitted using a testos-0 Q# ?1 P+ x: s, ^8 J5 M5 Q/ [
terone gel, which he concealed at first visit. He was
2 _: R, {- W. \6 D! c# j5 Yusing it rather frequently, twice a day. The Physicians’# C" [: O7 n' p/ c9 H* B
Desk Reference, or package insert of this product, gel or u, ?: n; R; X4 X
cream, cautions about dermal testosterone transfer to# b. w6 K3 j: a) m$ H
unprotected females through direct skin exposure.9 [6 L0 l m, }: ~
Serum testosterone level was found to be 2 times the
1 z# h# m& @0 h. P1 A8 b1 w$ k3 Obaseline value in those females who were exposed to
: E$ s& L5 l* geven 15 minutes of direct skin contact with their male
' G. R' P- Q; Mpartners.6 However, when a shirt covered the applica-! D: ~; B9 Y% ?: u0 {
tion site, this testosterone transfer was prevented.) M5 l( C. f6 d2 u; T6 G1 u
Our patient’s testosterone level was 60 ng/mL,
& q2 _: n( Y* c) J+ { xwhich was clearly high. Some studies suggest that
2 X& ~. E; {0 p( X6 Ddermal conversion of testosterone to dihydrotestos-7 a( P+ Q1 H! j: L
terone, which is a more potent metabolite, is more
7 P, S% D! ]6 M9 T! Sactive in young children exposed to testosterone% P4 h6 _2 v- J1 O
exogenously7; however, we did not measure a dihy-
$ n& |- D5 I( [; ]* udrotestosterone level in our patient. In addition to( f" M9 [, N4 I3 e
virilization, exposure to exogenous testosterone in) q7 R' P0 m* ?5 @; {3 x5 |
children results in an increase in growth velocity and, d- p9 W6 g7 N G6 N+ S; y
advanced bone age, as seen in our patient.
: F4 m3 A+ k4 m5 _" E' B6 ^' jThe long-term effect of androgen exposure during* z `* k; [' L* U' X& Q8 V% ^
early childhood on pubertal development and final
+ K4 y$ ^- O* O8 l% d, Dadult height are not fully known and always remain
) w& m5 m5 N" Q# Q2 J6 q2 Z G9 L5 oa concern. Children treated with short-term testos-6 _" K3 o" D7 r9 X4 m s9 |
terone injection or topical androgen may exhibit some E: K3 J! h2 [
acceleration of the skeletal maturation; however, after
0 P6 n' s5 g0 Hcessation of treatment, the rate of bone maturation) _; M$ L6 V0 D% ?2 X# Q
decelerates and gradually returns to normal.8,9: i9 L9 A. Q7 v W
There are conflicting reports and controversy
! B# O7 n$ z- G1 x* p2 C% v9 xover the effect of early androgen exposure on adult/ f y8 Q% o6 ^, Y
penile length.10,11 Some reports suggest subnormal
- n" w% c( i( V& X3 x7 Fadult penile length, apparently because of downreg-
# e& l+ A+ l$ p1 x3 p- s B5 aulation of androgen receptor number.10,12 However,
( n' u3 ~5 o, j4 zSutherland et al13 did not find a correlation between4 h$ m1 s0 y1 W5 n. V
childhood testosterone exposure and reduced adult U# O4 v) |. v* G6 U$ R
penile length in clinical studies.
, B: _+ E h- X6 l0 `Nonetheless, we do not believe our patient is
0 P) i9 d/ S* @( k) D' @going to experience any of the untoward effects from$ \, A$ w! ~* P* D/ _' b) Q
testosterone exposure as mentioned earlier because
; w6 E& P* K6 g0 O# _the exposure was not for a prolonged period of time./ s Z" O. J: T/ ] t4 j9 I( N
Although the bone age was advanced at the time of
7 \% W; D. x& K M) N* Cdiagnosis, the child had a normal growth velocity at
6 } e9 z9 } `* Othe follow-up visit. It is hoped that his final adult P% N m+ u1 d4 O, D
height will not be affected.9 o% u _) f v4 P( i( `: Y
Although rarely reported, the widespread avail-
6 n) R% A2 Q- e/ I& vability of androgen products in our society may0 S- \) k4 \# ?# \; z1 `* z) _) U
indeed cause more virilization in male or female2 G7 D R7 s) m0 \5 Y; C
children than one would realize. Exposure to andro-5 F2 n" `. v5 H
gen products must be considered and specific ques-! V8 }; @1 |6 G$ ~8 k2 x! P
tioning about the use of a testosterone product or" a; C& S5 l, ~# N
gel should be asked of the family members during2 F" D1 @# z9 a( F, @
the evaluation of any children who present with vir-. w) P+ c4 r+ \2 A5 N+ ?
ilization or peripheral precocious puberty. The diag-
) z ^" v- f. p3 ?& r1 Nnosis can be established by just a few tests and by
6 {$ E ^& ], {- rappropriate history. The inability to obtain such a
6 @, Z. B: B. yhistory, or failure to ask the specific questions, may
y* D" Y" ?; r$ m( {! J4 lresult in extensive, unnecessary, and expensive2 z: ^3 Q! T, C9 A3 v
investigation. The primary care physician should be
. l2 L5 e: c6 M, Gaware of this fact, because most of these children
% z! I( U: u) m- fmay initially present in their practice. The Physicians’
' I% q. a5 V3 v# w/ W$ M4 o3 jDesk Reference and package insert should also put a
" n: |" x: M2 Y: V5 Twarning about the virilizing effect on a male or
$ C0 X* P$ ~3 ofemale child who might come in contact with some-2 @' I9 S: b3 }& v% v
one using any of these products." L% j+ o9 N$ z! g. p
References
4 Z8 J0 X9 f# j4 w+ `; c1. Styne DM. The testes: disorder of sexual differentiation) w) d* A$ S R K; R) j/ d6 I* e
and puberty in the male. In: Sperling MA, ed. Pediatric
9 }7 P9 e% ~1 n% t3 J0 {0 e" lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 `4 k! a4 g% ^: i/ w' m2002: 565-628.! R4 g+ D" \/ j T4 r4 _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# V5 D6 P/ f* T i
puberty in children with tumours of the suprasellar pineal |
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