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Sexual Precocity in a 16-Month-Old
5 n R% L; R- [) B4 D6 P( nBoy Induced by Indirect Topical
* @1 v3 k# q$ v5 eExposure to Testosterone
/ O; z" u1 ?3 d0 W) C. _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* Q- z; h ~1 Oand Kenneth R. Rettig, MD1
3 o/ G, c4 }# I! V+ LClinical Pediatrics, j0 G$ {0 Q+ T9 r0 h
Volume 46 Number 63 I; S J0 j% v. W/ e V
July 2007 540-543
5 i$ X+ [" \* l F Y# ` E© 2007 Sage Publications* m# j: u2 ~/ S1 X+ O" Z; ?* X9 N
10.1177/00099228062966516 Q9 ^5 r, Q+ t8 q5 \: I! w
http://clp.sagepub.com; g5 I1 s$ |5 ~; G. x' S
hosted at
( E( X5 `% z, O5 shttp://online.sagepub.com
; Z) O/ g6 l6 D R1 Y" gPrecocious puberty in boys, central or peripheral,: z& {/ @, ?$ N- D) B4 q8 F P1 X
is a significant concern for physicians. Central( [2 p! J0 {9 ~! B2 y
precocious puberty (CPP), which is mediated
3 H1 e' c( E' h5 U6 sthrough the hypothalamic pituitary gonadal axis, has3 ^$ n- C5 S. O7 @
a higher incidence of organic central nervous system
2 u6 u- O' `/ n+ j, _. Klesions in boys.1,2 Virilization in boys, as manifested
% x$ X- w% a0 u1 Dby enlargement of the penis, development of pubic/ z4 ^8 y2 q! G4 d1 P* E
hair, and facial acne without enlargement of testi-+ n& p/ o. ^: C2 h9 F
cles, suggests peripheral or pseudopuberty.1-3 We2 E2 ]( T V: e! c" `3 }; V: M* r
report a 16-month-old boy who presented with the9 ?+ k0 `$ c% `. n* s' x1 Y
enlargement of the phallus and pubic hair develop-8 a1 J i; \+ o6 W1 B
ment without testicular enlargement, which was due
* O1 m/ q$ U9 W* N/ g" Fto the unintentional exposure to androgen gel used by9 q+ J; ^( Y v7 h& }
the father. The family initially concealed this infor-
& R% w; _$ g' Z6 ?$ S* t. I2 i3 Lmation, resulting in an extensive work-up for this" ?1 k2 Z1 r0 h, B2 w$ C6 t6 a( L0 d
child. Given the widespread and easy availability of
) V. O* V5 I4 z6 L- C- ntestosterone gel and cream, we believe this is proba-
" q% ]5 {4 W, _( g2 j& S0 `bly more common than the rare case report in the
1 J, }8 c6 b, a* g; d; n/ ^literature.43 v1 R0 \' }& Z- K V5 D' }8 d S
Patient Report
4 K+ @, y8 V+ p# G2 i3 a. ^; CA 16-month-old white child was referred to the# ?3 M" |- c) e4 Y& M
endocrine clinic by his pediatrician with the concern
- R3 v$ h9 j5 [& h, _# Vof early sexual development. His mother noticed
8 p: R& g: `3 K# R7 ~" [light colored pubic hair development when he was
3 |" C. A( d0 Q6 r( }- Y. R$ u# g/ qFrom the 1Division of Pediatric Endocrinology, 2University of: Z v4 d" P4 @6 z8 @) Q
South Alabama Medical Center, Mobile, Alabama.
0 F" x1 Y, P. y5 o, VAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 _9 Y3 T4 \9 c1 A( f2 z/ M' |
Professor of Pediatrics, University of South Alabama, College of
1 h( I8 }$ @; B7 Z, _9 P# q6 @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 B, r0 n% G/ M- p& j R2 p( L
e-mail: [email protected].$ o) d( p& S( y8 q! X
about 6 to 7 months old, which progressively became
/ G/ b a+ k+ |/ L/ ?5 mdarker. She was also concerned about the enlarge-( I3 |& f5 f* j5 [+ p* x( G* U
ment of his penis and frequent erections. The child. S/ q$ A) X( l
was the product of a full-term normal delivery, with
% O" {, O0 x3 H- @a birth weight of 7 lb 14 oz, and birth length of2 ?4 A; ^ Z( g9 O6 _
20 inches. He was breast-fed throughout the first year
2 x$ @) r ?: W2 Q9 wof life and was still receiving breast milk along with0 ]- I z- y, _9 T" I, u
solid food. He had no hospitalizations or surgery,3 s9 ]1 }6 ~9 ?, W/ x
and his psychosocial and psychomotor development2 _ m F I7 d6 C* I' B2 A( p
was age appropriate.
! X% d! }- E: @! I4 x0 MThe family history was remarkable for the father,
* `. L' o( [. twho was diagnosed with hypothyroidism at age 16, d) Y0 y( u: b9 H5 \
which was treated with thyroxine. The father’s( M2 L# @+ B t D9 O0 r Y9 [
height was 6 feet, and he went through a somewhat3 J k/ y5 `( e2 c, R% Q4 G W* ?! X
early puberty and had stopped growing by age 14. T5 R1 A; A% L) [( ^
The father denied taking any other medication. The
* b7 x% f* J& J/ s# B+ Z! _+ Wchild’s mother was in good health. Her menarche
, H: H" A. u: Z- C) Z5 Kwas at 11 years of age, and her height was at 5 feet7 y, u+ f' s( f" D$ W
5 inches. There was no other family history of pre-
" X( @* n2 c$ E/ }' H" f2 ~cocious sexual development in the first-degree rela-
% `% i: W, y% htives. There were no siblings.- G0 q9 I: J$ y8 l$ V
Physical Examination, \7 A5 ?, Z' q: [: w( M$ G
The physical examination revealed a very active,) n& @ r/ s7 B' X2 ?
playful, and healthy boy. The vital signs documented
O; q$ R. s$ Z) ?3 Ca blood pressure of 85/50 mm Hg, his length was
( p9 I; [+ d8 j1 l0 t; }5 Y h+ ^90 cm (>97th percentile), and his weight was 14.4 kg
! i% E6 c- f0 e; J- p; a(also >97th percentile). The observed yearly growth3 ]% u2 u2 c1 q9 g* f$ A
velocity was 30 cm (12 inches). The examination of
& h1 t& g L8 Rthe neck revealed no thyroid enlargement.# q$ K& E0 w# S, T: R" U0 c
The genitourinary examination was remarkable for
+ J) M7 _7 C/ _1 G) E! menlargement of the penis, with a stretched length of" W, J* K/ k+ S. A( H
8 cm and a width of 2 cm. The glans penis was very well l5 x4 ~' e% x' J" t
developed. The pubic hair was Tanner II, mostly around
, j# i: S; i) [8 A m540
' P: L- l, N8 \/ Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) k* p+ P3 g) E* V: p/ ]& I* d
the base of the phallus and was dark and curled. The
( C8 n4 ^# F& n3 W! t- Atesticular volume was prepubertal at 2 mL each.5 Q' @) p2 T+ K, ~5 X& g2 N
The skin was moist and smooth and somewhat
5 L4 z0 `- {* W3 ?oily. No axillary hair was noted. There were no/ ?3 w+ `) e! A9 `: }" n% P) ]0 c
abnormal skin pigmentations or café-au-lait spots.6 C' p5 j$ v5 o
Neurologic evaluation showed deep tendon reflex 2+3 c8 w4 D. m+ y& w! C
bilateral and symmetrical. There was no suggestion, J- n' K& G w$ @$ F f9 L* F. N
of papilledema.
3 s6 n- A5 y( GLaboratory Evaluation
, _' j' `) S6 |The bone age was consistent with 28 months by# I5 \1 C0 x9 I% M3 H# m
using the standard of Greulich and Pyle at a chrono-
M0 ^/ Q# A& @+ T9 h6 ], o, elogic age of 16 months (advanced).5 Chromosomal
9 H5 q6 F1 F. p6 d( ~4 X, m. Mkaryotype was 46XY. The thyroid function test
7 Z& c+ c+ }# Z! d/ T, Wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-* \; E# l& Y V! G
lating hormone level was 1.3 µIU/mL (both normal).
9 Y8 k" G# ]. d( M* \5 `9 jThe concentrations of serum electrolytes, blood
' H) V8 D! G; {6 ]4 |. z; @0 ?, `urea nitrogen, creatinine, and calcium all were5 _' l. @" m1 Q* W
within normal range for his age. The concentration
: n) D4 j2 z# c) F, O1 a3 Gof serum 17-hydroxyprogesterone was 16 ng/dL4 g+ G F+ p, X Z! i! w1 [, F
(normal, 3 to 90 ng/dL), androstenedione was 20 Z7 A6 X& u& R' x5 I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' ^+ W* o1 H! q ~. V' }6 u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 J# A# d% m$ w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* U+ D; d! ~7 S) _( {49ng/dL), 11-desoxycortisol (specific compound S)
0 _7 R* b& u3 ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 z+ a# n' s* ?- q( |. X0 dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. p. Y# |5 M! f, rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ g; v) b; _+ q8 y3 Pand β-human chorionic gonadotropin was less than
4 _ n, Z# e" X/ y8 l6 X& x5 mIU/mL (normal <5 mIU/mL). Serum follicular- H0 v; E% Z* j$ p
stimulating hormone and leuteinizing hormone* C' S2 X$ }& L& U) v7 G
concentrations were less than 0.05 mIU/mL
) w, D6 W0 _9 J1 @: W/ m! |(prepubertal).1 ]( c+ w$ Z/ J7 _0 |: `
The parents were notified about the laboratory
, ~- D" w4 e, }" }4 B3 T$ {results and were informed that all of the tests were
- P" Y( B8 z" t% d. e3 o8 e1 u8 k) Inormal except the testosterone level was high. The+ W& _6 H- U4 u U8 y3 a$ V+ A. U
follow-up visit was arranged within a few weeks to, n C5 s& {' i" B# V, S
obtain testicular and abdominal sonograms; how-
' L& C7 {* h" n1 Dever, the family did not return for 4 months.; C( [0 z5 b9 T! b& ~1 i+ L
Physical examination at this time revealed that the
0 q2 c& }. o& T$ k' W$ _child had grown 2.5 cm in 4 months and had gained9 z' l8 `3 w. h& W; w0 a9 J
2 kg of weight. Physical examination remained
: C) U& L% ~3 Z3 x, p; `unchanged. Surprisingly, the pubic hair almost com-
8 d5 d# M" F- B7 a. @+ D# a# z! Gpletely disappeared except for a few vellous hairs at5 s7 a) {, e1 T1 j5 Q7 V+ M1 j
the base of the phallus. Testicular volume was still 2# }& x3 m5 I$ d; }- b8 z6 L
mL, and the size of the penis remained unchanged.
+ K$ e7 B! y; V, [2 RThe mother also said that the boy was no longer hav-% G' _* B; @; A7 y& p
ing frequent erections.
% x5 g9 `5 a6 A4 D8 DBoth parents were again questioned about use of; m/ h2 A. V% Y0 J( t1 ` n3 k
any ointment/creams that they may have applied to8 S0 W9 w' c9 V& D
the child’s skin. This time the father admitted the
9 P' j6 ? Y: M; W& v, F6 ~Topical Testosterone Exposure / Bhowmick et al 541" k3 R" t( T0 o5 U" I# I
use of testosterone gel twice daily that he was apply-+ G$ u% y* [, D. i
ing over his own shoulders, chest, and back area for3 [; j1 {; L% f. i; ]
a year. The father also revealed he was embarrassed8 l$ P) S" p z" P E( U1 f
to disclose that he was using a testosterone gel pre-
" |& u% {. H! F T. b2 oscribed by his family physician for decreased libido
% I. C$ [0 n" Psecondary to depression.
- W* Q. g! g0 P$ h+ u7 W- DThe child slept in the same bed with parents.* E( v' S% H. l6 U5 a
The father would hug the baby and hold him on his' S& ?+ R0 S2 H2 e7 B) Q/ r- X
chest for a considerable period of time, causing sig-
* t7 B! r! t4 Nnificant bare skin contact between baby and father.+ v7 `$ P* L9 f1 X
The father also admitted that after the phone call,( g8 l( }7 \ p, d! M
when he learned the testosterone level in the baby* ^: t9 }0 c$ ^1 K" k
was high, he then read the product information
1 N, S* p% y% n. n" c1 c* X, apacket and concluded that it was most likely the rea-* M) g* D! _* X, n0 k
son for the child’s virilization. At that time, they
* _6 O2 H. E# V j6 e7 O/ f/ [decided to put the baby in a separate bed, and the3 [. [3 D( ]% d! Y# f& V
father was not hugging him with bare skin and had
$ s. o' A+ `# E4 nbeen using protective clothing. A repeat testosterone
3 L; L* g" r/ Q! _# y& m( Itest was ordered, but the family did not go to the
, d& z; d0 i3 Ilaboratory to obtain the test.
. g/ W2 ?9 n8 L9 i4 q$ UDiscussion
" \, {4 T# I; s r1 q4 KPrecocious puberty in boys is defined as secondary$ l. ~6 _$ [" X2 @. A
sexual development before 9 years of age.1,4 M+ w2 J0 U9 w# R
Precocious puberty is termed as central (true) when7 l% p+ G! O4 F# A+ S& M O
it is caused by the premature activation of hypo-
1 `; M: E8 g" @) z, f6 dthalamic pituitary gonadal axis. CPP is more com-
+ m8 @7 h- V" t) U; i% L7 ]3 \) Zmon in girls than in boys.1,3 Most boys with CPP
3 l1 {. Y7 P( wmay have a central nervous system lesion that is5 p; T3 i3 W0 V
responsible for the early activation of the hypothal-
! N1 ~4 q6 M1 |4 t6 Zamic pituitary gonadal axis.1-3 Thus, greater empha-+ l8 ^" {5 t& h( M" e& }
sis has been given to neuroradiologic imaging in
6 v. ]1 C. P/ j! y1 y$ K4 `boys with precocious puberty. In addition to viril-
. x m5 q p3 R( q0 Z3 {7 `ization, the clinical hallmark of CPP is the symmet-
1 }. U- I; N; n% Crical testicular growth secondary to stimulation by
2 {0 f4 [8 c% _( u4 C Rgonadotropins.1,3
- }+ I: g( i2 K& VGonadotropin-independent peripheral preco-8 X! F+ s$ ~2 }
cious puberty in boys also results from inappropriate, D* q A3 E! B- }) b& j) E2 G
androgenic stimulation from either endogenous or
% Q2 Q. o7 Z: s# ]* Texogenous sources, nonpituitary gonadotropin stim-
1 M/ V5 m" Z0 Q ]) Nulation, and rare activating mutations.3 Virilizing
- F+ [& v" b" D" j `* P6 w6 pcongenital adrenal hyperplasia producing excessive7 z9 [+ O" l, y* u( I7 ^
adrenal androgens is a common cause of precocious3 A0 E: `* _, f' b$ }1 B' X6 B3 N
puberty in boys.3,4
1 a, ]9 q# p% ZThe most common form of congenital adrenal
/ E% ~/ |2 r3 @0 i. ^6 ahyperplasia is the 21-hydroxylase enzyme deficiency.& M- c/ ^7 `8 _/ L- u: j
The 11-β hydroxylase deficiency may also result in
6 S3 y2 o- [3 s9 xexcessive adrenal androgen production, and rarely,1 s* x. O$ h% J$ E
an adrenal tumor may also cause adrenal androgen
# J, X, R9 ^9 Nexcess.1,3: T n* g7 D. j4 j! B. i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" L3 n6 L5 w+ E6 v) J542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 `4 N8 m2 N2 g T
A unique entity of male-limited gonadotropin-
- d0 N5 x/ E: O# v& p- Findependent precocious puberty, which is also known
+ M0 I" R/ ?/ b/ u5 Y* Sas testotoxicosis, may cause precocious puberty at a# c- M5 U; ]% k4 E
very young age. The physical findings in these boys
( q6 R9 T- f E5 X9 h0 jwith this disorder are full pubertal development,
1 ]2 u; D+ ]- g/ z1 Q8 Q/ Gincluding bilateral testicular growth, similar to boys" Z4 ~* v% y5 b/ f
with CPP. The gonadotropin levels in this disorder% y" a# H9 Q9 d3 T" I( {% z
are suppressed to prepubertal levels and do not show
0 M( i6 m9 Z: D: F+ T9 p& _pubertal response of gonadotropin after gonadotropin-; D, `# P& B& b+ H+ }5 q
releasing hormone stimulation. This is a sex-linked
) F- G3 b) g( h# X# yautosomal dominant disorder that affects only
, l$ _8 z' j6 k, [males; therefore, other male members of the family
, s0 R" o v4 o6 P" ~# U/ omay have similar precocious puberty.3
9 c8 i, T4 {0 u; U% ^! D- X/ qIn our patient, physical examination was incon-1 {0 o, H5 c3 F9 ^
sistent with true precocious puberty since his testi-
/ |$ B) v: V; \" |- Ecles were prepubertal in size. However, testotoxicosis" D4 s, `) f5 ]7 _# }
was in the differential diagnosis because his father
8 O7 \4 Y% u2 x1 m; u/ u+ cstarted puberty somewhat early, and occasionally,
% Q- ~' n* r/ z8 b3 Ptesticular enlargement is not that evident in the
' j' H& Y, A: E# \beginning of this process.1 In the absence of a neg-. `. b7 C; l1 R
ative initial history of androgen exposure, our3 b: S8 Y" H" Z7 s. {1 u
biggest concern was virilizing adrenal hyperplasia,$ P' V h8 f9 f( Q
either 21-hydroxylase deficiency or 11-β hydroxylase
3 K$ Q0 ^3 W* A* G1 bdeficiency. Those diagnoses were excluded by find-
" [. W4 I E+ @# I/ A1 z' Ying the normal level of adrenal steroids.
; g+ [; ~ L: H% b- ?( B- kThe diagnosis of exogenous androgens was strongly
2 C, S' [8 r) i1 ]9 z, _0 K) \5 Rsuspected in a follow-up visit after 4 months because
a, r, |9 ^6 I* E* c# zthe physical examination revealed the complete disap-4 Q: d) l$ q5 ]1 i
pearance of pubic hair, normal growth velocity, and' ]) z. l) A& M
decreased erections. The father admitted using a testos-# g) _8 y8 L7 \# ~7 ~$ J" J
terone gel, which he concealed at first visit. He was; C+ m' z$ ]$ o" v/ s* n2 k
using it rather frequently, twice a day. The Physicians’
" O* O9 r! s( D7 T9 GDesk Reference, or package insert of this product, gel or' q6 |- y. S, h) P# R
cream, cautions about dermal testosterone transfer to
/ g. b' j7 @- y+ j9 |) ?unprotected females through direct skin exposure.4 o, G! v) n; }- Q c
Serum testosterone level was found to be 2 times the$ y' s! \9 q, u0 n
baseline value in those females who were exposed to
. P, y7 e* o0 |9 u+ w: s$ \even 15 minutes of direct skin contact with their male
7 h3 R: J, D0 S9 [- ypartners.6 However, when a shirt covered the applica-- T9 n+ t% a, D" L) o* f
tion site, this testosterone transfer was prevented.
9 g, s& k% b3 U2 K, A IOur patient’s testosterone level was 60 ng/mL,
5 b e$ _+ v7 q8 K9 d5 pwhich was clearly high. Some studies suggest that
' }9 R) G5 }6 q; p; j! Odermal conversion of testosterone to dihydrotestos-+ t8 D- v6 n2 i5 _; f
terone, which is a more potent metabolite, is more
0 k0 m3 C, p1 v; Z0 B5 h |active in young children exposed to testosterone
0 f( E: y4 c4 f+ @exogenously7; however, we did not measure a dihy-
, g: j4 y: v- R# ^8 V; Adrotestosterone level in our patient. In addition to2 Q) {( y( z A, b. j. }5 i0 z
virilization, exposure to exogenous testosterone in
" y, l1 |1 f2 A d) ~children results in an increase in growth velocity and
. U* q) \# O( B+ j2 N5 v9 v8 ?advanced bone age, as seen in our patient.
( [7 ~, v, q1 S' t! L. [2 |The long-term effect of androgen exposure during# G( K Q% T0 A- _4 j+ I
early childhood on pubertal development and final1 i9 o0 P( y) ]+ \: i6 [9 K6 r
adult height are not fully known and always remain# ~- N& ~& F& ^
a concern. Children treated with short-term testos-/ r- ^+ ]" r. E! l* f
terone injection or topical androgen may exhibit some2 }, V5 l$ ~' T: p
acceleration of the skeletal maturation; however, after
0 q& A/ w8 W9 ~( Lcessation of treatment, the rate of bone maturation
$ J& Q6 X! A( E/ N7 x% n% Xdecelerates and gradually returns to normal.8,9* [" L, v. I7 x! J
There are conflicting reports and controversy
, C7 e1 r4 w) |7 s1 c7 l; ~' vover the effect of early androgen exposure on adult
/ |9 b% C5 N gpenile length.10,11 Some reports suggest subnormal
* I0 z) O" T7 Y9 m: Z9 d tadult penile length, apparently because of downreg-) p# h. B2 I# a1 k7 h% g" M
ulation of androgen receptor number.10,12 However," a$ s& f/ [ b4 g
Sutherland et al13 did not find a correlation between% p+ V/ ~ T: t8 y
childhood testosterone exposure and reduced adult6 G- C2 h# H) a! z+ T- q
penile length in clinical studies.. W6 O) G, H* a5 { A
Nonetheless, we do not believe our patient is1 [+ P) m) ^9 @
going to experience any of the untoward effects from( d4 ]- d. \% D3 y2 O& Q5 t
testosterone exposure as mentioned earlier because( }# `% R8 q) f; B1 r: @$ i' f
the exposure was not for a prolonged period of time.
, Z, ?% {. a3 l- J9 y" ]Although the bone age was advanced at the time of# L5 c0 y- d# U/ c6 X. w" n9 `
diagnosis, the child had a normal growth velocity at6 _7 _+ s6 Y; C$ S/ C
the follow-up visit. It is hoped that his final adult" Z$ x7 N: M$ I
height will not be affected.# r4 n4 }0 }' j) r; B7 x, V
Although rarely reported, the widespread avail-1 c2 j3 d$ R- W6 M, L; w
ability of androgen products in our society may0 j4 Q2 O2 C! ^$ ]
indeed cause more virilization in male or female% }1 t: f& l, d) [" J1 O, a
children than one would realize. Exposure to andro-7 B9 Q9 [, B7 P: f
gen products must be considered and specific ques-: k/ \: b; G9 p
tioning about the use of a testosterone product or( o# d( _8 n% }& N
gel should be asked of the family members during
: Z6 b" d% U0 H9 h$ U" p3 uthe evaluation of any children who present with vir-
* u) h6 v$ X/ vilization or peripheral precocious puberty. The diag-8 w0 g. y9 P; C9 f I0 u
nosis can be established by just a few tests and by
5 M; I1 u$ N9 h0 i3 s% aappropriate history. The inability to obtain such a: B/ l5 C4 a& I2 u# K
history, or failure to ask the specific questions, may
1 ~$ m& y/ a' hresult in extensive, unnecessary, and expensive/ i$ ?! b4 {/ x* }/ X
investigation. The primary care physician should be
# H( o* }* p1 w6 @/ T$ p" ~aware of this fact, because most of these children
( I$ Z& N7 M/ j9 smay initially present in their practice. The Physicians’) W7 e' ?) c p$ i: D
Desk Reference and package insert should also put a
/ l9 C2 J; _& e, |% |4 Iwarning about the virilizing effect on a male or& S4 g. T0 D7 K! `& m) K( G- w: H
female child who might come in contact with some-
- N# S# S+ s `- `' L4 Xone using any of these products.1 q% B% h9 o/ H
References
* a+ ^% R: c2 {0 y( Y1. Styne DM. The testes: disorder of sexual differentiation
7 e( l3 `7 w& K$ C. P6 e) Dand puberty in the male. In: Sperling MA, ed. Pediatric: V# S5 Z0 S1 X8 F# ] k8 h/ X. s9 |
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! Z3 @& v _& J7 x; h/ ]
2002: 565-628.
6 s* q o$ i* K% w. {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" V. o( N7 d$ S: H+ vpuberty in children with tumours of the suprasellar pineal |
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