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Sexual Precocity in a 16-Month-Old
$ G# b- N! ]2 ?+ tBoy Induced by Indirect Topical
& e7 K1 n. R! g4 o% d, d; HExposure to Testosterone
: p- {! f1 X$ A4 C9 z6 ?( x* {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 g( X! w. ~0 ]7 C0 }and Kenneth R. Rettig, MD1
, Y6 ?( h4 ^9 z9 N8 A1 dClinical Pediatrics2 r2 b0 M8 l/ ]5 Z' Z
Volume 46 Number 6+ M( I R: F, L- A+ W# g: e
July 2007 540-5439 @7 d' [" j& v% N1 o
© 2007 Sage Publications# F* ?* k+ P4 \* C E z3 p
10.1177/0009922806296651. x6 P: }+ u4 K; k1 `
http://clp.sagepub.com
0 {: b6 K) ~0 ^- f: chosted at, c" j' E; S; d) Z* _5 ~. I
http://online.sagepub.com
; M& y4 L2 g- }Precocious puberty in boys, central or peripheral,# _" ]3 U/ t2 g6 q' E$ h
is a significant concern for physicians. Central
2 g, {% v% b* _9 y7 y! D; @9 Fprecocious puberty (CPP), which is mediated% O- ~% |5 G' ^# a/ {
through the hypothalamic pituitary gonadal axis, has
- X* D6 f6 @) j; a4 @* ta higher incidence of organic central nervous system9 A$ Z: t3 m( \
lesions in boys.1,2 Virilization in boys, as manifested: {* o8 D" c5 u5 G+ y. d1 l
by enlargement of the penis, development of pubic
+ p. c4 c) ~9 ]' t* `, a. H: b' g; Phair, and facial acne without enlargement of testi-5 o1 z5 p+ B2 l* f# c; R
cles, suggests peripheral or pseudopuberty.1-3 We
# f, h* z: u3 n" xreport a 16-month-old boy who presented with the
m. j' P# _8 {- R' b2 T& fenlargement of the phallus and pubic hair develop-, }' X7 o3 r% h2 u
ment without testicular enlargement, which was due
$ z" h. o. t& i- k! s% Nto the unintentional exposure to androgen gel used by/ w: u. U: t' o
the father. The family initially concealed this infor-+ S8 V O8 S! g# u
mation, resulting in an extensive work-up for this$ u r! ^" v5 V( q2 Y' f
child. Given the widespread and easy availability of3 j3 M( {7 d- z$ K) G( h
testosterone gel and cream, we believe this is proba-8 z$ D2 Z. P$ a; {
bly more common than the rare case report in the1 u1 j q8 S r' ?
literature.4( U: l' F/ e' y. O
Patient Report
2 y; ]4 s* i, T6 `! n& d7 SA 16-month-old white child was referred to the
' \' a9 k& h7 G+ P" ?$ nendocrine clinic by his pediatrician with the concern
, p" r: v& R4 C+ h* O/ Gof early sexual development. His mother noticed6 w5 |1 `2 D1 q! |2 x' m
light colored pubic hair development when he was7 V# s5 J3 P# t) D. U
From the 1Division of Pediatric Endocrinology, 2University of: d9 r; H: |- Z5 O! @
South Alabama Medical Center, Mobile, Alabama.
" \# w; l! O- s% S9 S% p( Y7 aAddress correspondence to: Samar K. Bhowmick, MD, FACE,( D; h* }0 J% H7 a$ H5 T
Professor of Pediatrics, University of South Alabama, College of0 Y c8 B% [* L9 U8 l) Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) _* F4 p; p. r* |$ v" f
e-mail: [email protected].
7 e8 K& l( _5 Labout 6 to 7 months old, which progressively became' A, ~2 A! O2 N9 A9 y. P
darker. She was also concerned about the enlarge-2 J9 y# f) e. i7 l9 p
ment of his penis and frequent erections. The child; p! b2 }1 B, r
was the product of a full-term normal delivery, with7 B1 p9 S9 S1 @. d F' e
a birth weight of 7 lb 14 oz, and birth length of
9 T C% @; P2 c20 inches. He was breast-fed throughout the first year
4 d" P7 _9 i. g8 J5 N% ]9 gof life and was still receiving breast milk along with
7 n8 J4 M1 v$ y) t z# N. j6 Msolid food. He had no hospitalizations or surgery,& z' V% p9 S5 N, u
and his psychosocial and psychomotor development5 o" f0 \4 R+ U1 P! H& b
was age appropriate.1 M% A, L+ ?3 N* ]4 y& G) ?$ n
The family history was remarkable for the father,) v% v J! x0 N: i& M0 H' u$ Q
who was diagnosed with hypothyroidism at age 16,
2 h. B3 b9 \& N+ K5 e" N: Cwhich was treated with thyroxine. The father’s S4 ]; B% H g, ^
height was 6 feet, and he went through a somewhat
/ G$ r( T. a; \0 Tearly puberty and had stopped growing by age 14.( x l" w+ D& v" U3 G+ @1 o. n
The father denied taking any other medication. The
8 i+ G3 U- k5 w8 mchild’s mother was in good health. Her menarche
, c1 W& ], b) {) \2 z3 Owas at 11 years of age, and her height was at 5 feet
- N0 ^: p2 m4 K3 I- D5 inches. There was no other family history of pre-
0 y8 }! G# Z4 M) t8 X$ Ococious sexual development in the first-degree rela-
- {$ C! G$ s! b K$ @ B' Ltives. There were no siblings.- O- Y1 q* ]3 k3 q6 J
Physical Examination* ]& M. s5 G. F$ x
The physical examination revealed a very active,( x3 J* i3 m- }! m
playful, and healthy boy. The vital signs documented& h6 k1 l$ i5 A2 L1 t
a blood pressure of 85/50 mm Hg, his length was. S" ~! @6 S4 [
90 cm (>97th percentile), and his weight was 14.4 kg( o" C9 E8 k& W7 C1 J% w
(also >97th percentile). The observed yearly growth
; T: K. B/ ~, C8 A" F2 C" avelocity was 30 cm (12 inches). The examination of; j1 N3 F0 z" f) ?% l% ^
the neck revealed no thyroid enlargement.; h( o1 B% x( D8 x! V
The genitourinary examination was remarkable for
4 ~( n! f& b3 Penlargement of the penis, with a stretched length of' ^+ k% N" {3 g, ?) B9 X+ j
8 cm and a width of 2 cm. The glans penis was very well
g2 F1 } I9 c* udeveloped. The pubic hair was Tanner II, mostly around
0 ], V: W' s( |% G3 v5 @540# Q7 [1 b& R5 \3 L+ x# e# s0 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 |. G- u* ?; }, z" ?
the base of the phallus and was dark and curled. The1 ]6 q, E) q* ?9 S
testicular volume was prepubertal at 2 mL each.
: j3 V7 {7 L# D: s* P) T' ZThe skin was moist and smooth and somewhat
4 u7 `- {/ |, d& c0 |2 o( O2 [! poily. No axillary hair was noted. There were no
9 I, s+ Q- |( D; {2 j2 Wabnormal skin pigmentations or café-au-lait spots.
) d J4 y4 ~ nNeurologic evaluation showed deep tendon reflex 2+
4 D: \+ g G& b: {bilateral and symmetrical. There was no suggestion
7 D: N: X9 W, h/ L k! N, A/ wof papilledema.
' u( J* J8 n, s/ x; _$ GLaboratory Evaluation
6 w$ z$ T( b3 F- X3 ~; HThe bone age was consistent with 28 months by6 L: R/ U6 Z4 n8 t6 A
using the standard of Greulich and Pyle at a chrono-
6 B, q! ?) d4 w. X0 C+ _logic age of 16 months (advanced).5 Chromosomal
7 |7 ]9 V \8 z6 u9 }karyotype was 46XY. The thyroid function test: [. f) X* J4 O, G! ^% J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# [& d: h( \% C6 E: r s9 Qlating hormone level was 1.3 µIU/mL (both normal).
. W+ X- W& t% [& ` HThe concentrations of serum electrolytes, blood
! D* I$ A/ P3 W) w4 V1 }% _urea nitrogen, creatinine, and calcium all were0 ?; \* M8 Z& x" E% @) z
within normal range for his age. The concentration2 i0 N; R5 |; b8 `8 y
of serum 17-hydroxyprogesterone was 16 ng/dL: _2 k6 C- s4 |: y( n7 M
(normal, 3 to 90 ng/dL), androstenedione was 20
9 ~; [3 S2 ~, Z9 U( K3 K2 F7 u ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ f5 V2 q j5 D; i. x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 i9 _3 K& e) @$ P3 k- |, p" g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- w) J: O" A+ { f7 U( L# B49ng/dL), 11-desoxycortisol (specific compound S)
) E' n/ h, U' T5 M3 \/ Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 Q8 w+ f8 [- a7 u' z5 d J% h6 x2 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 C3 ]& a3 [4 Q) vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ }8 ]7 w e& [4 p6 Qand β-human chorionic gonadotropin was less than! M( y0 g9 q# t/ `
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" _/ L, M" x4 R; l! b0 I. L3 Xstimulating hormone and leuteinizing hormone
7 I g" @8 y2 S- N6 T' y2 Tconcentrations were less than 0.05 mIU/mL* X% C9 C7 c3 P2 p. J
(prepubertal).
7 w! y+ _# q9 V* F, M$ EThe parents were notified about the laboratory+ F6 m4 \- }7 {- R8 _! y
results and were informed that all of the tests were) _8 ~7 V. G$ |. S% W4 D( s
normal except the testosterone level was high. The
, R( }& h" }" a# M1 nfollow-up visit was arranged within a few weeks to
, ^# Z) n& S4 u7 D P0 qobtain testicular and abdominal sonograms; how-
* \5 b, N/ _3 f x' v3 Pever, the family did not return for 4 months.$ Q6 C6 D4 q6 z6 u
Physical examination at this time revealed that the$ O3 T% c, q, }' @
child had grown 2.5 cm in 4 months and had gained, W/ I# ]9 P8 e+ }% [7 @4 J9 q
2 kg of weight. Physical examination remained
& v- n# F4 i' w" tunchanged. Surprisingly, the pubic hair almost com-3 `. g- w o/ B# l
pletely disappeared except for a few vellous hairs at3 i$ e+ i% u- I1 Q! _6 G, O% S
the base of the phallus. Testicular volume was still 2. d- }' `7 t" m
mL, and the size of the penis remained unchanged.! L8 B7 C) Y2 h6 [7 o' W* N8 j
The mother also said that the boy was no longer hav- w! S* u7 q0 l, q, s. S5 v b
ing frequent erections.0 n. n5 f( S4 w3 G) `, r8 r6 D
Both parents were again questioned about use of$ D* \: _% @7 S. } l0 m# o$ L( K7 {
any ointment/creams that they may have applied to- E" [8 F5 ~3 j2 f R. M% ?, `: A' {
the child’s skin. This time the father admitted the8 N5 B T3 _" `* N4 D( ]' b7 {3 u/ J
Topical Testosterone Exposure / Bhowmick et al 541
) q# O( W1 |: M* L! {use of testosterone gel twice daily that he was apply- l9 g& x8 U% E8 u
ing over his own shoulders, chest, and back area for
$ f r/ I0 Q5 H! [0 ]6 h) i7 da year. The father also revealed he was embarrassed B B ]) F' L
to disclose that he was using a testosterone gel pre-5 N0 u( H* c) K2 t. ~
scribed by his family physician for decreased libido
3 ~& p2 A+ X1 h. S8 h7 X& {% Ksecondary to depression.
! z, ?4 \1 M9 z. J8 u7 r$ n+ NThe child slept in the same bed with parents.
[: u5 U$ U9 ?The father would hug the baby and hold him on his* q& R- S5 ^2 ~' G
chest for a considerable period of time, causing sig-
7 K) C5 D+ B1 _9 Lnificant bare skin contact between baby and father.4 A+ o8 Z2 y* X/ S) V& Y' B
The father also admitted that after the phone call,
2 ^4 {# W! q7 Gwhen he learned the testosterone level in the baby" Y" T- ], k- Z( ?/ O
was high, he then read the product information
5 I/ I2 V# u3 t1 h4 S$ b2 fpacket and concluded that it was most likely the rea-9 Y) W" ^7 |8 S0 {6 r
son for the child’s virilization. At that time, they0 u( _7 C, o! z9 \+ l" B+ B- A
decided to put the baby in a separate bed, and the
9 l; ^. `7 U# X3 _* c% S! W- Y8 j4 qfather was not hugging him with bare skin and had; [9 J' b6 r z( n6 N4 `
been using protective clothing. A repeat testosterone
6 G! O6 i0 z Y! j) ttest was ordered, but the family did not go to the
$ R S/ Y6 S, q9 `! h' ilaboratory to obtain the test.+ t, G f1 ?, I8 z' H1 |) h
Discussion
5 U0 a. d2 _. M' E: y! [" vPrecocious puberty in boys is defined as secondary/ t2 \; G0 d* _6 X
sexual development before 9 years of age.1,47 p( ~5 y+ p' }8 V; I
Precocious puberty is termed as central (true) when6 b, Z% h" h3 Q, e
it is caused by the premature activation of hypo-
5 T8 F4 ]# j; @6 y4 h* qthalamic pituitary gonadal axis. CPP is more com-
! s T# V. b# Fmon in girls than in boys.1,3 Most boys with CPP* h3 I) }4 k4 ~" A8 D7 s) M8 X: B6 K
may have a central nervous system lesion that is
! U' m0 _0 Z* M& _- G9 Yresponsible for the early activation of the hypothal-+ ^; a! q$ `8 ]1 t8 @% x% z
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ L3 z$ V2 ^! w# } R4 asis has been given to neuroradiologic imaging in& J; h$ Y. ~9 x' {1 Z J, S* \* [* e) K
boys with precocious puberty. In addition to viril-
4 x& O+ T1 E( v3 V( S1 k/ iization, the clinical hallmark of CPP is the symmet-
$ J3 J& X& i8 Y# l4 v+ erical testicular growth secondary to stimulation by$ i3 M( D6 g! M
gonadotropins.1,30 ` l# Y5 c q D- y+ m
Gonadotropin-independent peripheral preco-1 L$ E( y4 a* X* \6 W
cious puberty in boys also results from inappropriate
! d7 {' Z8 A& g( @) eandrogenic stimulation from either endogenous or3 ?+ Q8 s. _# G* l) |2 N2 s
exogenous sources, nonpituitary gonadotropin stim-9 x: z* {* ~* y8 g$ |! a3 `/ D! ~1 {) @
ulation, and rare activating mutations.3 Virilizing. C; i6 O5 S+ d9 g. T0 J
congenital adrenal hyperplasia producing excessive' ~/ {. d7 J, H# F/ a; J+ w. H
adrenal androgens is a common cause of precocious
% Z, U" L7 o0 @9 Epuberty in boys.3,4
7 J4 ~# b" Y, s; y: t9 ^0 UThe most common form of congenital adrenal
1 Z# X$ l' Z6 I3 s, m: L4 Qhyperplasia is the 21-hydroxylase enzyme deficiency.
& C5 e. l$ W2 n9 [- O9 YThe 11-β hydroxylase deficiency may also result in
+ ~" A+ i s( ?1 qexcessive adrenal androgen production, and rarely,6 [6 ^5 p4 ?9 D; P7 @, _
an adrenal tumor may also cause adrenal androgen& i" b# ~/ ~, O
excess.1,37 P; @4 q- _# E9 b* f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 e* [1 t% j, F+ D0 x" G! g2 j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ Z$ t2 x. e# r7 q7 BA unique entity of male-limited gonadotropin-
; F ?* S# z- M i1 ^$ K- Mindependent precocious puberty, which is also known& m2 _3 _+ R: u8 b5 F
as testotoxicosis, may cause precocious puberty at a" G# I- k' y9 o2 A, e
very young age. The physical findings in these boys
) Q% Q) S' T4 U5 ^& ^/ q) Nwith this disorder are full pubertal development,
, Z! Y0 V) [2 y! f* Eincluding bilateral testicular growth, similar to boys! q6 S/ W- B6 v! c- y! [
with CPP. The gonadotropin levels in this disorder
1 Y% J' b7 ?1 j% [# _7 g+ ^are suppressed to prepubertal levels and do not show
/ k; c4 S8 J2 O8 Ypubertal response of gonadotropin after gonadotropin-# t+ t7 N8 k: R; |
releasing hormone stimulation. This is a sex-linked
1 F3 R4 c2 ~" T7 `/ b9 `' K7 cautosomal dominant disorder that affects only' D+ J5 m8 T/ B& e5 D5 n
males; therefore, other male members of the family/ g8 i) {7 I3 S1 o
may have similar precocious puberty.3
0 a; n0 a9 Q& k( CIn our patient, physical examination was incon-
* n. g7 S* y7 w- l( s& msistent with true precocious puberty since his testi-
% v; i2 m' S" Acles were prepubertal in size. However, testotoxicosis
; C \6 ? S$ X! {) Rwas in the differential diagnosis because his father/ b& A! L$ A4 v$ e' o
started puberty somewhat early, and occasionally,3 ^5 { o- l, o
testicular enlargement is not that evident in the, w1 \' x9 }* L- P+ O5 O
beginning of this process.1 In the absence of a neg-8 O. w- J+ g4 ~2 X" x. m, s
ative initial history of androgen exposure, our( L! L7 m8 K8 {( }4 M% n% A
biggest concern was virilizing adrenal hyperplasia,
5 e: N! [4 e- T. f! d* deither 21-hydroxylase deficiency or 11-β hydroxylase# Y2 I8 _5 F7 ]* T3 y" Z* ]
deficiency. Those diagnoses were excluded by find-2 U/ C2 @2 S) m5 J
ing the normal level of adrenal steroids.
$ | \* `0 x+ N+ z1 rThe diagnosis of exogenous androgens was strongly7 R& R( N+ k/ b, O( W
suspected in a follow-up visit after 4 months because. U7 g; L+ B$ o' O- F; {
the physical examination revealed the complete disap-4 G. s5 s/ p6 ^! w' r5 {8 `# I
pearance of pubic hair, normal growth velocity, and+ P( s, a5 ?$ b9 V
decreased erections. The father admitted using a testos-7 i7 c: o7 t9 O7 { v0 |
terone gel, which he concealed at first visit. He was4 j+ s3 a+ ~& x* h! y; B% H0 x
using it rather frequently, twice a day. The Physicians’
! ?. u3 n& e9 H, O) sDesk Reference, or package insert of this product, gel or, t7 X% P$ w5 \9 D' [( r7 D
cream, cautions about dermal testosterone transfer to6 Z8 T7 F+ ^2 U1 B" `
unprotected females through direct skin exposure.- `' H! z K' v
Serum testosterone level was found to be 2 times the
0 ]/ r5 a9 }4 |4 B8 Qbaseline value in those females who were exposed to3 p i/ X- b; X8 @
even 15 minutes of direct skin contact with their male; A. n* y' I; [/ l5 [- N
partners.6 However, when a shirt covered the applica-
+ A" b" J+ e2 O0 o, Y9 P. ction site, this testosterone transfer was prevented.; M2 T4 h# b3 m$ A& H4 Z3 ?+ t
Our patient’s testosterone level was 60 ng/mL,; W# W- b$ n+ _3 B+ J2 v
which was clearly high. Some studies suggest that
5 Z E+ ~( Y2 P. m# U+ o5 P \dermal conversion of testosterone to dihydrotestos-! [8 m1 m$ k; K a- t0 y+ a
terone, which is a more potent metabolite, is more! k- z! u, c% {) q# y) g6 w0 B$ n# V
active in young children exposed to testosterone
! u2 A- J; _/ X+ x" ^( R# Eexogenously7; however, we did not measure a dihy-7 h& X% v* R7 S1 c* \5 v+ @
drotestosterone level in our patient. In addition to
3 {3 \, p6 [. [7 L( L+ Tvirilization, exposure to exogenous testosterone in! E& l* F6 F a6 [' X8 J
children results in an increase in growth velocity and
: c( {7 s4 r; u4 x9 g% p/ sadvanced bone age, as seen in our patient.
4 H7 b% X) N8 W* ^/ u) Q2 C) VThe long-term effect of androgen exposure during$ d' S' z" P! y! J1 z
early childhood on pubertal development and final
2 ?. ?! B" w0 |% O' [adult height are not fully known and always remain
7 }- Q" A& K! a5 z; v1 {a concern. Children treated with short-term testos-2 u9 [. k2 {0 |/ ~, |% u
terone injection or topical androgen may exhibit some
8 m! p1 t% { _6 u2 @acceleration of the skeletal maturation; however, after5 h4 g+ D' m) ]$ P
cessation of treatment, the rate of bone maturation
( i" M6 x: i6 N" I- x# {; Qdecelerates and gradually returns to normal.8,9
. u! j: h5 I9 j( }# RThere are conflicting reports and controversy" Y& L5 X4 E; @: \ R) |
over the effect of early androgen exposure on adult
. L1 w; B: G# h! }+ a1 Ypenile length.10,11 Some reports suggest subnormal( J* Q' ^: s" d0 D
adult penile length, apparently because of downreg-
7 d0 e- k: B' ]2 dulation of androgen receptor number.10,12 However,# a1 H l/ E: J ], w* f' s
Sutherland et al13 did not find a correlation between
$ f# M; u' o2 N' T, h- Rchildhood testosterone exposure and reduced adult% @) U6 j/ f' s& T+ |
penile length in clinical studies. G1 @' t/ c! V$ R
Nonetheless, we do not believe our patient is/ G# K: w9 k4 X3 V
going to experience any of the untoward effects from+ ~3 o( z* I- B
testosterone exposure as mentioned earlier because
2 @ J8 |7 v$ X* ^8 x% B+ [. r! gthe exposure was not for a prolonged period of time.
0 x: p5 {( I9 b% r1 gAlthough the bone age was advanced at the time of) Z: m* N5 S/ f
diagnosis, the child had a normal growth velocity at4 U6 w' g' V6 W
the follow-up visit. It is hoped that his final adult0 p) B0 U5 i8 O& Q) }
height will not be affected.; W- P9 K/ Y# |8 a& a+ C4 g
Although rarely reported, the widespread avail-
% E( M. H1 |( J2 C$ \ability of androgen products in our society may
$ J3 I# P9 ^& t, h; _$ Tindeed cause more virilization in male or female
- k4 U. x5 {- L/ r2 g) s" B7 schildren than one would realize. Exposure to andro-
/ r0 Y: W2 P" Q8 U, rgen products must be considered and specific ques-
$ {4 _. J; {& L% ptioning about the use of a testosterone product or
% x( ]; U6 W: p" J; j8 igel should be asked of the family members during8 N; O ~1 v( @0 q( ^+ }" i, r
the evaluation of any children who present with vir-+ d0 M: ~ \! R, E
ilization or peripheral precocious puberty. The diag-: w3 Y! A* i# Z) v9 W
nosis can be established by just a few tests and by
) S: X" O; e7 n) a5 zappropriate history. The inability to obtain such a
( w4 r9 X( T3 Y6 Q' [7 \ s" nhistory, or failure to ask the specific questions, may
9 t: Z: A" S5 v! O. Tresult in extensive, unnecessary, and expensive
R% j; B% G0 ?, i1 P% ]investigation. The primary care physician should be4 b2 Z f8 E/ ]: Z
aware of this fact, because most of these children; b. l4 h- G% v. Q! C
may initially present in their practice. The Physicians’. Y% [: x" i; S0 a8 U
Desk Reference and package insert should also put a! q: k- h6 {) ~; \" ~) @* X7 Q$ x% w1 m
warning about the virilizing effect on a male or
3 A `7 {$ J6 r3 g" K- bfemale child who might come in contact with some-
1 _. a# y+ f/ a( O0 Zone using any of these products.
4 p3 [7 l2 b. w/ R. N u. oReferences2 k; T" i/ d( ?- m* F. B o2 C" E: d
1. Styne DM. The testes: disorder of sexual differentiation9 F; a+ `3 N: ]# C! N
and puberty in the male. In: Sperling MA, ed. Pediatric- k# T/ J/ D8 t& E5 X) c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! z, N: ]3 g2 G5 m& @- Z; i4 w
2002: 565-628.
; o3 y. X, d" h( y p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* P1 O W+ q( O7 L$ W
puberty in children with tumours of the suprasellar pineal |
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