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Sexual Precocity in a 16-Month-Old* t0 X; ?# w2 Q) Q, |
Boy Induced by Indirect Topical4 x9 e. k5 Z3 Y
Exposure to Testosterone7 H7 b$ R9 w2 |" l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* Y8 s2 }$ \' [1 J2 i
and Kenneth R. Rettig, MD1
! M# [$ W4 e6 l* f( MClinical Pediatrics
1 d% b2 w% D1 N$ S0 B' Z# AVolume 46 Number 6
7 W) [ a+ I) ~$ C XJuly 2007 540-543
" _' v5 V2 H- _8 D% Q. v/ ~, \© 2007 Sage Publications
' j! A9 }: ?- V2 U" [7 x10.1177/0009922806296651
. O# I# {# z* C' @8 [& H4 A% P" m2 Ahttp://clp.sagepub.com
6 t% P% {9 d& z0 i1 w2 G# ghosted at$ a% m' m% J- `' C% M! u9 H
http://online.sagepub.com( E* O& U8 b" f* R' x F2 }
Precocious puberty in boys, central or peripheral,; G; c, W% S- R& C+ C G3 f/ L
is a significant concern for physicians. Central
7 A4 m2 p) ?! _; J- b9 _: Gprecocious puberty (CPP), which is mediated0 v/ p5 f" H- h5 y3 [
through the hypothalamic pituitary gonadal axis, has
- C2 S9 f8 B, m; [- Z' h* q% [a higher incidence of organic central nervous system% e3 Y( p, ~9 C5 L+ y/ L
lesions in boys.1,2 Virilization in boys, as manifested/ K# P! p, q# m8 ~. e) g, z
by enlargement of the penis, development of pubic+ _: {! G: x) E8 f6 o5 e7 g
hair, and facial acne without enlargement of testi-
, ?5 F2 H* H: h! U) ~0 W. Scles, suggests peripheral or pseudopuberty.1-3 We4 h: U* t$ x' U& ?8 `
report a 16-month-old boy who presented with the
: O: c9 T% Y% Tenlargement of the phallus and pubic hair develop-
7 e( P+ f0 f' h% I3 d# W1 @6 mment without testicular enlargement, which was due* y N# Z( h, h/ j9 T# ~* z
to the unintentional exposure to androgen gel used by
- l5 y& |$ \+ ~8 o: ?+ |the father. The family initially concealed this infor-
A' c* |3 Y [+ j, Emation, resulting in an extensive work-up for this
$ c' C$ {6 I% N- bchild. Given the widespread and easy availability of; P5 j0 u0 G: A. W/ O
testosterone gel and cream, we believe this is proba-; f$ M) q6 G* F; P4 L( d$ b0 u
bly more common than the rare case report in the& M' c) O% \* p, Y+ f% W4 P4 z7 I
literature.4! z0 z. Q0 x& p; a
Patient Report7 k& T1 Q( e; p7 V# Q9 E
A 16-month-old white child was referred to the
. P) ^9 S* s( j+ {endocrine clinic by his pediatrician with the concern. _% A0 l* k. I3 Z) |+ I
of early sexual development. His mother noticed& W! ^: U& [) f- p& W3 }
light colored pubic hair development when he was
0 m- v/ B- ]% dFrom the 1Division of Pediatric Endocrinology, 2University of% s, T! s; q& s) D! V; q
South Alabama Medical Center, Mobile, Alabama.) B* I, d; m; m& z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 R! s* ?; ?' y& w9 w. l; @! G, O5 EProfessor of Pediatrics, University of South Alabama, College of/ D; p; D' R- |% B7 O7 i. f! {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' o! r8 J+ c2 E; l2 N, o* a1 S
e-mail: [email protected].4 b( l3 S- R2 D' f
about 6 to 7 months old, which progressively became
7 _( J+ E0 f& u2 @+ ydarker. She was also concerned about the enlarge- S# E+ ~8 g) Q) q. J
ment of his penis and frequent erections. The child: S) N% J0 `5 d# G) d
was the product of a full-term normal delivery, with
( n0 `' s5 W+ A# b" R6 Sa birth weight of 7 lb 14 oz, and birth length of
, u' R7 Y/ G4 S" L- X20 inches. He was breast-fed throughout the first year
2 J5 U- o. q- l$ u q& gof life and was still receiving breast milk along with
Q5 J9 A# W9 A- K) ]# ]solid food. He had no hospitalizations or surgery,
& V( W5 |8 b- ~: ?5 jand his psychosocial and psychomotor development
# A4 p" `5 z2 y; g/ ~2 Vwas age appropriate.. n) D8 U/ o$ C9 P) p# k
The family history was remarkable for the father,
4 i0 h0 @" A. C/ h2 J; swho was diagnosed with hypothyroidism at age 16,8 K) N3 _+ d: ~
which was treated with thyroxine. The father’s7 h/ B* a2 F% v% y- h. F
height was 6 feet, and he went through a somewhat
( E( b$ ~4 p' cearly puberty and had stopped growing by age 14.1 O2 ?# i, V& P4 ~
The father denied taking any other medication. The
. h; O- y* p, K" Hchild’s mother was in good health. Her menarche3 u- P* p6 g- F% A% q
was at 11 years of age, and her height was at 5 feet) m+ h5 w9 h8 s) n9 k
5 inches. There was no other family history of pre-' d' F- G' l( o- _) D6 p( x9 G& S, ~
cocious sexual development in the first-degree rela-
/ F& j1 u$ {% s5 h1 T* Utives. There were no siblings.' ]+ f6 v# W- J }2 h2 r1 n# f
Physical Examination a3 H4 m1 X; } ?6 o$ s
The physical examination revealed a very active,* P h1 a9 w& w2 @9 q& ]/ X
playful, and healthy boy. The vital signs documented5 B! h# H) P3 D: [" u
a blood pressure of 85/50 mm Hg, his length was
% r8 _1 e2 t/ o4 h: V90 cm (>97th percentile), and his weight was 14.4 kg/ Y) ?( Y& x+ x- ^( h J
(also >97th percentile). The observed yearly growth
+ o' t. J" ]' u) G) Avelocity was 30 cm (12 inches). The examination of
3 M/ f- D" S' }) m' L+ V/ }) Y- W3 Ethe neck revealed no thyroid enlargement." \% d0 t* ?6 E1 Z
The genitourinary examination was remarkable for
* W4 C3 D4 k. Q' v C0 Benlargement of the penis, with a stretched length of
8 x5 x4 }: ~1 y2 G8 cm and a width of 2 cm. The glans penis was very well, V( R! ?% g: `$ y# a! L' n3 g: Y( j( j
developed. The pubic hair was Tanner II, mostly around
; x$ k/ b* g1 O5405 U; T6 b* R/ y. n, u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 H$ b2 ^+ ]! I+ N
the base of the phallus and was dark and curled. The
) V6 n2 v6 |( G' B: W% Dtesticular volume was prepubertal at 2 mL each.
% R4 L0 M5 f9 C0 C: [The skin was moist and smooth and somewhat
: f+ C7 c$ O I' x) W2 yoily. No axillary hair was noted. There were no, h6 h+ _5 [$ R' \0 d$ I
abnormal skin pigmentations or café-au-lait spots.
, U4 E, T9 |% I: }$ F5 U+ HNeurologic evaluation showed deep tendon reflex 2+
, v; U, D6 a# o9 \5 xbilateral and symmetrical. There was no suggestion# C1 a4 m4 i( H0 {
of papilledema.0 m& ~0 F) P0 l. \! b$ a& j
Laboratory Evaluation5 m& j* j0 I O5 F; [# r a
The bone age was consistent with 28 months by9 L% X( \% M9 l- Y
using the standard of Greulich and Pyle at a chrono-
# c f% p! x4 k$ Dlogic age of 16 months (advanced).5 Chromosomal
+ [5 x. p, W' D$ |3 s. H- O, ekaryotype was 46XY. The thyroid function test
, X8 H4 w4 E; z* [showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 Q3 K/ K, X1 H6 B$ @! h- o& l' w
lating hormone level was 1.3 µIU/mL (both normal).
* V4 @2 p4 V! S+ m) TThe concentrations of serum electrolytes, blood$ q! J0 U5 Z) f
urea nitrogen, creatinine, and calcium all were
: ?: F) x- S f$ `+ Hwithin normal range for his age. The concentration
6 c' L5 ]% f; u) z: q8 G: A# Dof serum 17-hydroxyprogesterone was 16 ng/dL
8 C, a }6 q* ^( k(normal, 3 to 90 ng/dL), androstenedione was 20" i l/ Z- G( M: Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 l# b; X m# t; T' T8 u4 w# N7 D8 B& P, fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 c( G4 t: V# t. `desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# R/ g" o; g3 b' T* w49ng/dL), 11-desoxycortisol (specific compound S)8 H' s, w4 {9 ], P1 R5 v& F+ @ B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) V! o) Q+ y8 t. w$ g6 m2 p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: x" ]+ m# C9 p- otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# f: Y+ V% X) f4 M# R% Fand β-human chorionic gonadotropin was less than& R9 R, G% b$ y0 g" H) O3 N6 ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: G( U* G% c9 r4 w3 ?2 lstimulating hormone and leuteinizing hormone s5 {; k \+ g6 ] x" B
concentrations were less than 0.05 mIU/mL F8 v9 i9 Y4 |8 Q
(prepubertal).. j% ?0 J8 K, x4 _: E- p% D& l
The parents were notified about the laboratory# Y$ U/ D. u" \+ ^ k' \" }& Y6 @
results and were informed that all of the tests were; r/ G4 P b' ] E4 k
normal except the testosterone level was high. The) i/ E, A. a4 G @
follow-up visit was arranged within a few weeks to5 J. K5 J6 N! l. T; {8 q8 W2 e0 |
obtain testicular and abdominal sonograms; how-( s9 |+ @, i- L3 C* K
ever, the family did not return for 4 months.
8 y6 E/ ^. k: @3 l0 l' g, XPhysical examination at this time revealed that the1 \! e8 h1 Y, I1 V) t
child had grown 2.5 cm in 4 months and had gained# v& ?' d9 X: Y: `- w. L- h& R5 Z6 P
2 kg of weight. Physical examination remained: x$ n6 r2 ~ M# b' R1 p
unchanged. Surprisingly, the pubic hair almost com-( w2 M6 M4 Z: h0 T' a- A% K
pletely disappeared except for a few vellous hairs at/ \$ B: a8 D6 \6 g. q7 c- P
the base of the phallus. Testicular volume was still 2
( c4 E3 ~- s: j- r" T7 MmL, and the size of the penis remained unchanged.6 h2 n. o' k$ B$ f# S" z+ d
The mother also said that the boy was no longer hav-: [( X v9 j O- H0 g( g
ing frequent erections.+ U5 i% r9 q& |' \" g- _. f( O* j
Both parents were again questioned about use of
* q" D# u1 w$ ]3 U, ~any ointment/creams that they may have applied to6 j" S8 X" s5 d5 a6 l Q
the child’s skin. This time the father admitted the+ u$ b1 K' a4 Q/ G" a
Topical Testosterone Exposure / Bhowmick et al 5416 N" E) H' H V8 \/ O" P0 O$ W8 E
use of testosterone gel twice daily that he was apply-
# g+ |( J( T6 c9 T ding over his own shoulders, chest, and back area for6 g5 Q. t" Y$ `( U
a year. The father also revealed he was embarrassed
h. _/ p+ p" c' d9 N2 x; a9 Gto disclose that he was using a testosterone gel pre-" h- c/ J( ~8 `8 f a$ G
scribed by his family physician for decreased libido
0 R( F7 r" c# ?' s% ]secondary to depression.4 m9 B# s9 Z/ ^' s' M) V0 I
The child slept in the same bed with parents.
8 s4 N) b8 T+ a [- cThe father would hug the baby and hold him on his4 o( L) P- ?: t g, v0 G" _
chest for a considerable period of time, causing sig-4 K" w8 u- @; w1 z2 O3 R- X" q
nificant bare skin contact between baby and father.
# w0 \, Q- m$ P& _7 O* bThe father also admitted that after the phone call,
) \7 o8 X! w2 Swhen he learned the testosterone level in the baby9 e5 D9 M# d6 J6 h
was high, he then read the product information
; ^0 b3 V+ s# @# Upacket and concluded that it was most likely the rea-- o1 m- n+ z. K5 R
son for the child’s virilization. At that time, they
' B6 E! I4 j l$ X0 V8 F5 f8 ^* Qdecided to put the baby in a separate bed, and the
8 u% x: F9 f6 Jfather was not hugging him with bare skin and had
/ J p; Z- e7 D' _( m- |( gbeen using protective clothing. A repeat testosterone
* `$ J2 c1 q9 B( itest was ordered, but the family did not go to the
% X' d* `! R4 v- U+ E, I. Ylaboratory to obtain the test.& F8 H* N7 _& U8 a) z
Discussion
9 C0 _, A8 o$ o( \9 @! s% }9 RPrecocious puberty in boys is defined as secondary
* l' @3 U. l2 |sexual development before 9 years of age.1,4
' v) Y1 |; X6 _, u7 F. o; bPrecocious puberty is termed as central (true) when
( S. M6 L6 @0 C( V+ s7 lit is caused by the premature activation of hypo-: I2 K4 r6 y: ?9 l" G
thalamic pituitary gonadal axis. CPP is more com-
( [2 z: K' D& k7 \7 T1 S. omon in girls than in boys.1,3 Most boys with CPP
: q- U. h N; X3 K5 ^/ ?may have a central nervous system lesion that is# G# D0 O1 o. Q1 L, M( ]
responsible for the early activation of the hypothal-! y; w1 e; ?6 L' T
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 f* b5 z( r2 Q4 b( }sis has been given to neuroradiologic imaging in
: v6 f8 [9 z6 s: _' G7 @boys with precocious puberty. In addition to viril-3 S/ A: t& q }9 W* J: d
ization, the clinical hallmark of CPP is the symmet-
! E/ s1 ?% V9 X+ u7 Grical testicular growth secondary to stimulation by
. e# C% f. |* C3 Sgonadotropins.1,3' j+ m8 V& M1 _& X" n
Gonadotropin-independent peripheral preco-6 {2 g! X Y; f( K3 \
cious puberty in boys also results from inappropriate
0 {) C, b& M. f* N0 J% handrogenic stimulation from either endogenous or; a( m& s* l) A! g
exogenous sources, nonpituitary gonadotropin stim-
5 Z2 G' M* m3 sulation, and rare activating mutations.3 Virilizing+ q2 \0 W. `8 }& C3 Y7 x) u" ^- T# [
congenital adrenal hyperplasia producing excessive( u6 h- z9 ?' {% G/ q7 V
adrenal androgens is a common cause of precocious
# d" a7 A y* [! P8 opuberty in boys.3,42 v4 [. H" K# i Z
The most common form of congenital adrenal' i5 I% \$ Q2 t" U6 V
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 E X+ O( g6 ?( i: v6 a& RThe 11-β hydroxylase deficiency may also result in0 Z$ n: ^, H0 s$ r# f$ J5 j
excessive adrenal androgen production, and rarely,+ `; ]+ o+ |; \0 i2 N; H( P; |2 [+ Y
an adrenal tumor may also cause adrenal androgen% w9 C/ F8 Q+ H* @5 A6 R* S8 V
excess.1,31 b. ?6 i) A0 i P8 }1 P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& W; Y }) O9 v
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" r2 f5 p& d; B- DA unique entity of male-limited gonadotropin-* g1 @+ c' U# m+ _
independent precocious puberty, which is also known
% M# z. P0 D mas testotoxicosis, may cause precocious puberty at a
$ y2 x( V& p3 I4 ivery young age. The physical findings in these boys
- K; C. F1 V$ o# U X1 t& K% Xwith this disorder are full pubertal development,
! k3 P r- j- D, z6 m3 bincluding bilateral testicular growth, similar to boys1 {5 c5 f3 ~/ N5 s4 t
with CPP. The gonadotropin levels in this disorder
# W0 k1 x; }. W5 u8 c; ]# l: qare suppressed to prepubertal levels and do not show6 A- r( c2 j: ]5 i" e
pubertal response of gonadotropin after gonadotropin-& l9 O. }0 J- U7 D4 Y6 T/ E4 N
releasing hormone stimulation. This is a sex-linked
* c( H1 F2 l; h- _autosomal dominant disorder that affects only
+ w0 y! k5 j1 S: P0 N1 o, U3 vmales; therefore, other male members of the family4 \/ ~# ~0 Y% i2 g* Z
may have similar precocious puberty.3
$ b. Q/ g4 j! I% wIn our patient, physical examination was incon-
5 q2 _. M0 s+ O8 |& Qsistent with true precocious puberty since his testi-
; N E5 o& q7 `2 p) \9 Jcles were prepubertal in size. However, testotoxicosis2 P0 n a5 S5 |3 A o( }6 g' L
was in the differential diagnosis because his father- A" S* }; }$ V% [# Y" G
started puberty somewhat early, and occasionally,5 ?8 T* a5 U8 X7 o; L5 j
testicular enlargement is not that evident in the( h0 c( X! s W5 c$ S
beginning of this process.1 In the absence of a neg-
' \( V; z/ B* t# I. k! Uative initial history of androgen exposure, our
' } W+ b" n" j9 E" ^% mbiggest concern was virilizing adrenal hyperplasia,) u# m$ Q: m" O) ^# X' T1 d
either 21-hydroxylase deficiency or 11-β hydroxylase; W5 `9 X: s5 u9 _
deficiency. Those diagnoses were excluded by find-4 g- l6 v- G( M |) \- D& F; {( Q
ing the normal level of adrenal steroids.
H5 Q( f) C8 h9 Z- P- c3 Z" eThe diagnosis of exogenous androgens was strongly8 A9 D1 T; G8 B% g# K
suspected in a follow-up visit after 4 months because5 X$ F# r, v/ Y/ W. L2 f
the physical examination revealed the complete disap-
$ G% {% ^- J4 V8 L; ]3 kpearance of pubic hair, normal growth velocity, and
. G7 N. b; }+ o$ B1 bdecreased erections. The father admitted using a testos-
- Z( a9 t, `/ y+ I: L( v2 \; ? Cterone gel, which he concealed at first visit. He was
3 J, }7 O3 g) W2 Gusing it rather frequently, twice a day. The Physicians’$ {. A4 N- m# s) V1 ^+ ?
Desk Reference, or package insert of this product, gel or7 ?0 L! ~% k9 N- q
cream, cautions about dermal testosterone transfer to$ H% P* e: ~3 r$ b* s* U
unprotected females through direct skin exposure.
. R. Z" a- x- F& `4 s5 S" A7 lSerum testosterone level was found to be 2 times the7 |$ g; O9 P$ ?7 X
baseline value in those females who were exposed to# M9 L8 C* C9 Q) G$ i0 o
even 15 minutes of direct skin contact with their male
7 ?- ~8 U4 B4 S& m9 A' p, v" zpartners.6 However, when a shirt covered the applica-
' f6 t; F; \- x9 Z5 t+ xtion site, this testosterone transfer was prevented.
8 r/ \* T; ?, SOur patient’s testosterone level was 60 ng/mL,. q, W+ v7 b$ Z; D. x
which was clearly high. Some studies suggest that
" y4 c# @0 q' M A0 r1 idermal conversion of testosterone to dihydrotestos-
. \! ?3 T. V8 V$ a7 s0 s1 _terone, which is a more potent metabolite, is more
! z9 d3 E% E0 H% F5 n3 Nactive in young children exposed to testosterone, B m. g1 v# t
exogenously7; however, we did not measure a dihy-
$ u/ b Y$ @2 R- r' ^! C7 c& T% h9 ddrotestosterone level in our patient. In addition to# Z; ?# m* @) R
virilization, exposure to exogenous testosterone in5 Q( K; p6 e3 i
children results in an increase in growth velocity and
( G+ m5 J' w7 b- L5 Radvanced bone age, as seen in our patient. U% T4 O: v3 S3 {: G$ R% ^
The long-term effect of androgen exposure during
2 k( b( E# k* f! Q: Bearly childhood on pubertal development and final
6 ~' }4 `: h( Radult height are not fully known and always remain
6 s6 W& _" I7 f' ]/ wa concern. Children treated with short-term testos-
* O+ J1 E. C4 o# B xterone injection or topical androgen may exhibit some
2 E; k+ T; G2 Oacceleration of the skeletal maturation; however, after4 f5 N* j$ E" R( V6 }$ p5 @
cessation of treatment, the rate of bone maturation
2 O$ m: Q. ?- Fdecelerates and gradually returns to normal.8,9
$ S1 e6 T ?$ E, _; y% _There are conflicting reports and controversy% L8 Q* a. W+ X4 p1 y
over the effect of early androgen exposure on adult
. ?, N, g: ], e) ]penile length.10,11 Some reports suggest subnormal
. \, ^7 }% S$ |$ \ C1 W: ~adult penile length, apparently because of downreg-
5 w; I8 X0 a. \4 B% k' g8 pulation of androgen receptor number.10,12 However,
0 y' T$ o& u: S$ \9 GSutherland et al13 did not find a correlation between! I# V3 }$ A2 N3 t1 b! W% R) a
childhood testosterone exposure and reduced adult
, l2 C! P3 k( Y; [penile length in clinical studies.
1 C3 X( f* p4 } W& T: MNonetheless, we do not believe our patient is) _+ }' J6 B7 x8 L
going to experience any of the untoward effects from: e6 a( z8 {- a* j4 n
testosterone exposure as mentioned earlier because
. i* U: ]$ [$ j8 [9 K( L8 ?, Mthe exposure was not for a prolonged period of time.2 m2 \1 p! S; q( S) h; q4 y# o
Although the bone age was advanced at the time of
* _, L; l( d1 w4 @( }diagnosis, the child had a normal growth velocity at
2 L4 H: G6 C: f u, h% |$ _the follow-up visit. It is hoped that his final adult
1 p. i. V5 K. G: theight will not be affected.
: E2 A& q/ w) I" F9 W1 Z5 C# `, jAlthough rarely reported, the widespread avail-
% u3 |9 h4 {& L6 ?1 S' p; b5 Wability of androgen products in our society may. R7 T0 {1 Q# k Y. U
indeed cause more virilization in male or female
$ i+ v( G- [4 G5 r3 t. gchildren than one would realize. Exposure to andro-
3 L9 t' f/ C8 O. Lgen products must be considered and specific ques-
% J4 q& N4 ]& F5 A4 C! T: P4 R# ztioning about the use of a testosterone product or
1 ]4 I/ c. f3 d f% Qgel should be asked of the family members during
# U7 k7 f! k+ j" _9 M! u$ Ethe evaluation of any children who present with vir-! _" W) s* w4 T% b1 M$ B+ p* T
ilization or peripheral precocious puberty. The diag-5 |# n$ o6 I! x2 D/ p/ d
nosis can be established by just a few tests and by5 C1 C0 A6 Q3 Z0 y# b
appropriate history. The inability to obtain such a- j" Z( ` U6 t; K
history, or failure to ask the specific questions, may
; [+ x2 d4 d% Q n) d: \9 z% a8 Iresult in extensive, unnecessary, and expensive
2 ^6 @; @' j' b3 Iinvestigation. The primary care physician should be
- F1 u; Y1 d( w3 d' G& c! Kaware of this fact, because most of these children) d7 b$ ?+ y+ t& G% T0 s% L
may initially present in their practice. The Physicians’2 ]- k' N+ c5 ], ~. Q
Desk Reference and package insert should also put a
- d! d- Q( f! awarning about the virilizing effect on a male or/ o6 Z* g6 }" v- z
female child who might come in contact with some-
7 {$ x0 O5 O; u# None using any of these products.* y" t% ?# ^6 X# A( s2 Z) `
References) {8 T2 v3 b+ P: A9 d1 U6 u, m
1. Styne DM. The testes: disorder of sexual differentiation; k5 y% m7 H# K# m3 k
and puberty in the male. In: Sperling MA, ed. Pediatric0 |+ ?% a( ^ n K6 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; @# E: K. ?6 u+ L2002: 565-628." C4 A) v6 V: a/ y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 s7 [5 O7 X3 C
puberty in children with tumours of the suprasellar pineal |
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