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Sexual Precocity in a 16-Month-Old, }' @+ v, H8 _7 k$ C6 q
Boy Induced by Indirect Topical9 Z3 x0 z3 [2 X+ p# ~
Exposure to Testosterone
# x# R( Q1 l& K7 pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ X4 F7 ]1 A7 S, S; y) h/ T8 P, Y
and Kenneth R. Rettig, MD1
. o7 h) `/ z0 `) D( s2 H/ vClinical Pediatrics9 z( q4 [; R) i$ z1 _
Volume 46 Number 68 Z, `% E* {( l, c. ^1 G) t; G
July 2007 540-543) c/ H/ e* D( u+ ]/ i
© 2007 Sage Publications
G0 m+ L# X; Y" W10.1177/0009922806296651 h, ]. S1 U$ @$ @* }
http://clp.sagepub.com; y% `- ?# h e( }
hosted at5 g/ P6 V- h+ A7 u
http://online.sagepub.com8 K) ], b7 U& A/ g3 e$ X
Precocious puberty in boys, central or peripheral,
; f% i) S- P# R3 [8 ]7 Wis a significant concern for physicians. Central
; b2 p& R5 f: T& `3 uprecocious puberty (CPP), which is mediated* ?3 }0 O2 C# f# B/ G
through the hypothalamic pituitary gonadal axis, has4 I1 `, ?; @4 m# C; _0 l
a higher incidence of organic central nervous system) F% j( O. f( q
lesions in boys.1,2 Virilization in boys, as manifested
8 j. W& g; f. \& g9 lby enlargement of the penis, development of pubic
+ j1 m9 H+ C R$ [( @1 C8 {3 ~' M( @hair, and facial acne without enlargement of testi-
' @! j; r/ `' D" {: R3 \: ~cles, suggests peripheral or pseudopuberty.1-3 We
5 T1 l% {. g. ?0 i6 v1 n) Creport a 16-month-old boy who presented with the; \( k& X; L* }( |2 ~5 r! t ?
enlargement of the phallus and pubic hair develop-. i& q7 V4 c( g2 T5 S' I# o8 {
ment without testicular enlargement, which was due
& N+ y& w' `4 t j) ito the unintentional exposure to androgen gel used by
% d1 d" ]6 X# W& T0 Z& ? v* dthe father. The family initially concealed this infor-) ]# \# @4 |4 M* l2 P
mation, resulting in an extensive work-up for this5 I4 R7 V$ p: u2 H
child. Given the widespread and easy availability of" p: \# A/ W; B8 U* }
testosterone gel and cream, we believe this is proba-
& q3 F: c" e! v D3 r0 ^& nbly more common than the rare case report in the6 y z" g" W1 r- J
literature.4
9 ? B* R0 Y5 }( S' Y2 @Patient Report
* S8 W! ?* z6 l8 F$ J+ oA 16-month-old white child was referred to the
6 O! ~/ B5 S# w% S; H1 w: qendocrine clinic by his pediatrician with the concern# [/ }! o2 B, C6 m
of early sexual development. His mother noticed
' T$ w- O5 E0 {* M8 O# mlight colored pubic hair development when he was7 u' d4 @' n, A7 Z8 d! b& ]% L1 Z6 n
From the 1Division of Pediatric Endocrinology, 2University of! y9 S: A/ z& A
South Alabama Medical Center, Mobile, Alabama.
C' y9 z+ z- r* }2 vAddress correspondence to: Samar K. Bhowmick, MD, FACE,
! n( w, a6 y! s. K- Q" cProfessor of Pediatrics, University of South Alabama, College of7 Y$ O* s1 \. p/ \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, W7 h# R7 Z7 R6 T, Pe-mail: [email protected]./ M6 D) G" T7 d+ S
about 6 to 7 months old, which progressively became4 M, }: K2 q3 V) g" m" f0 J
darker. She was also concerned about the enlarge-
1 u" u7 |3 R s% z& E0 pment of his penis and frequent erections. The child
1 O0 a+ E6 [6 v( Q! Swas the product of a full-term normal delivery, with' }) J) s3 \7 C: l k
a birth weight of 7 lb 14 oz, and birth length of
( r! E3 k# |" f* c+ \20 inches. He was breast-fed throughout the first year3 R, T% G& D0 ]8 |9 U+ F/ K# Y) K
of life and was still receiving breast milk along with) n. _3 o, h/ I5 N8 o( F/ e
solid food. He had no hospitalizations or surgery,) ^2 O3 Z/ [" E4 i' y. A
and his psychosocial and psychomotor development
: t; F% R7 ~7 Z+ T1 Gwas age appropriate. i$ ]$ g: B2 ]6 o: L2 l& q. q
The family history was remarkable for the father,
: f- x4 S5 i7 Z, Q" O% lwho was diagnosed with hypothyroidism at age 16,- G. E3 y! m" O' i* l- |
which was treated with thyroxine. The father’s
2 D2 o; E0 f1 J' pheight was 6 feet, and he went through a somewhat
* n+ @# P; u8 s% h, gearly puberty and had stopped growing by age 14.6 G) A4 {( J/ i$ y- b
The father denied taking any other medication. The
q% a( [+ `, x3 x0 E+ cchild’s mother was in good health. Her menarche7 k/ I. i7 R F6 {) F0 [) m" S2 k
was at 11 years of age, and her height was at 5 feet! f0 d; d& _9 ~% h1 Z1 l
5 inches. There was no other family history of pre-
2 Y" _; L' a. c5 Ccocious sexual development in the first-degree rela-: Z0 C3 ^9 Q8 L* q
tives. There were no siblings.
9 b2 R- H7 s8 C* x& |- fPhysical Examination
: z( s' m& w7 ?. V' }8 _; k" `# rThe physical examination revealed a very active,& D: A. {. P0 ?5 R t/ f5 z8 q8 `
playful, and healthy boy. The vital signs documented
0 d( A o# ]/ L6 { Z+ x- H5 i% Za blood pressure of 85/50 mm Hg, his length was
( Z! s5 ^! J3 X: \, f7 B# l90 cm (>97th percentile), and his weight was 14.4 kg
% `+ h$ W& c8 u4 ~(also >97th percentile). The observed yearly growth
2 A/ v, b7 D6 k: Q4 q* Kvelocity was 30 cm (12 inches). The examination of
' p8 N b% q. g# J" r' e wthe neck revealed no thyroid enlargement.0 k* i6 [; E! Y
The genitourinary examination was remarkable for, t! V* ]# x# Y! `
enlargement of the penis, with a stretched length of# I8 c" a; u5 B- z! l Z
8 cm and a width of 2 cm. The glans penis was very well
- B) }/ V9 T+ cdeveloped. The pubic hair was Tanner II, mostly around5 t* f0 t' I* _
540
9 k7 i( v( ]3 J# T6 N: F$ s4 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' W6 n) Q$ j! }4 h* H3 U: K
the base of the phallus and was dark and curled. The0 o% o$ o8 e: @; v
testicular volume was prepubertal at 2 mL each.. a, `* y, ^9 q0 e1 n
The skin was moist and smooth and somewhat$ ~+ G: e6 b% \4 J% H! c
oily. No axillary hair was noted. There were no
" y1 m! q3 T* t2 `abnormal skin pigmentations or café-au-lait spots." x" v: h3 N" P" v
Neurologic evaluation showed deep tendon reflex 2+
% {# u( D: N" o8 sbilateral and symmetrical. There was no suggestion% W" b2 U j( P1 F: j
of papilledema." H0 ^, ]. z2 @
Laboratory Evaluation, h( x8 X" }4 [' d# U
The bone age was consistent with 28 months by* E: o# P7 |" O6 V- g
using the standard of Greulich and Pyle at a chrono-. b) T3 S- Z3 u+ [+ S% X
logic age of 16 months (advanced).5 Chromosomal, `* y( w5 s' u0 @, s0 k. d1 t
karyotype was 46XY. The thyroid function test$ A" W9 M" ~( I, B& r3 X* r
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 S5 [# K2 [ ~4 _ E+ i, d$ F
lating hormone level was 1.3 µIU/mL (both normal).& n+ w$ _ u. ~. H4 e
The concentrations of serum electrolytes, blood* N+ l! c( A( Z8 H) E
urea nitrogen, creatinine, and calcium all were
3 E5 }' S' b2 o) mwithin normal range for his age. The concentration
! C8 P( @# M& _9 Q# o" ~* s `of serum 17-hydroxyprogesterone was 16 ng/dL
; G. N" Q3 G2 S7 p/ c(normal, 3 to 90 ng/dL), androstenedione was 201 A3 G+ C' @- |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; j0 ]. L5 i6 P7 C) F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& V- R4 Q) _4 r; A# X
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ y" N9 z0 |8 q, `
49ng/dL), 11-desoxycortisol (specific compound S)) H0 e, O, X9 r) n; g7 O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 s* c) q; S& E+ N9 |8 H% v, Etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: f0 G" L- C/ f. \, R4 O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
K ? i; o' I1 `" vand β-human chorionic gonadotropin was less than
/ n3 Q) M. n" @1 [7 \5 mIU/mL (normal <5 mIU/mL). Serum follicular" k0 G2 X1 Q$ c; U
stimulating hormone and leuteinizing hormone' }/ P" S8 z1 @ N
concentrations were less than 0.05 mIU/mL
5 s. U* T/ k1 y$ [% j1 E8 c4 s- W(prepubertal).. E$ N, F$ ]; ^# L( i% J5 H
The parents were notified about the laboratory
4 P2 u. j% m+ y B' D; p* I0 iresults and were informed that all of the tests were
0 p) C, P. E7 q8 `: M# H1 @normal except the testosterone level was high. The
7 j8 Q# G" R3 ~; r8 S4 Pfollow-up visit was arranged within a few weeks to7 W% W r1 Z4 `4 F* D! a% K6 V. b# I
obtain testicular and abdominal sonograms; how-* D$ {7 w, ~* \/ x# O
ever, the family did not return for 4 months.
8 T) ^8 o4 i5 TPhysical examination at this time revealed that the4 H! h) @0 X! t
child had grown 2.5 cm in 4 months and had gained I6 C0 D$ w$ R# ]# j
2 kg of weight. Physical examination remained
, W/ |7 l, o" S: l- Tunchanged. Surprisingly, the pubic hair almost com-, v# q$ Y2 k- X* v4 V! h
pletely disappeared except for a few vellous hairs at, U7 t! c1 x% I, x
the base of the phallus. Testicular volume was still 2) f& w5 g" ~/ B5 J4 \$ O( R
mL, and the size of the penis remained unchanged.
; `: \; I( y8 o1 P8 fThe mother also said that the boy was no longer hav-
8 O" j; ^$ V- a3 Xing frequent erections.
$ t4 a5 z( a0 |( L3 |Both parents were again questioned about use of
$ z7 o: z7 g% B0 p# Y( Vany ointment/creams that they may have applied to
5 ?; N u% G8 b( k! athe child’s skin. This time the father admitted the, y A2 V# G. k# |6 k3 n
Topical Testosterone Exposure / Bhowmick et al 541
6 r. F( w) b6 w9 e, muse of testosterone gel twice daily that he was apply-
- i6 u4 L2 ]2 b6 f3 W/ ^ing over his own shoulders, chest, and back area for
$ P. L( N/ X) y$ sa year. The father also revealed he was embarrassed
B4 _" ]5 N- M7 A. n" U: zto disclose that he was using a testosterone gel pre-
# q9 {5 L& ]0 m- N( yscribed by his family physician for decreased libido
4 @6 K j2 J) ysecondary to depression.
& o; K4 t' B. p/ D9 VThe child slept in the same bed with parents.
- a- n# E# U" [8 L& B0 ?The father would hug the baby and hold him on his
* T$ J2 G9 P; Jchest for a considerable period of time, causing sig-. Q6 L6 `9 U( x' M, y5 k0 Q
nificant bare skin contact between baby and father.
5 s* L6 \( H- U. k9 s) L0 MThe father also admitted that after the phone call,
2 x; G3 `+ {0 i8 S/ ~0 _6 r% iwhen he learned the testosterone level in the baby* v# P$ f$ [1 {1 m% r: n) J
was high, he then read the product information/ L" T7 ^/ l z7 [$ I
packet and concluded that it was most likely the rea-
5 }/ j1 r- l- p6 {5 oson for the child’s virilization. At that time, they- j7 l% ?# J5 v8 |7 Y8 X
decided to put the baby in a separate bed, and the
: {* d2 _; U, g6 n9 \$ N0 ^father was not hugging him with bare skin and had
0 D( @5 u3 R8 X/ u! {$ H0 vbeen using protective clothing. A repeat testosterone
( F2 r1 _; B; C9 ?test was ordered, but the family did not go to the' X# C. ?, r& a9 N3 R
laboratory to obtain the test.- {/ @. j& @1 I6 o& P/ J/ o8 L
Discussion0 B+ J5 k6 d4 ?2 I8 @% X- N
Precocious puberty in boys is defined as secondary& x; Q/ T+ T) P
sexual development before 9 years of age.1,4
' U/ i7 N5 A6 Q3 s9 D8 m2 CPrecocious puberty is termed as central (true) when
- F2 ]5 n9 o2 rit is caused by the premature activation of hypo-$ x: o. O, @6 |* |8 @
thalamic pituitary gonadal axis. CPP is more com-
2 U2 y0 X5 x5 |mon in girls than in boys.1,3 Most boys with CPP
: o2 J$ x9 ~* {5 G& p# Jmay have a central nervous system lesion that is) D& ]+ u3 g' E. `" i( A
responsible for the early activation of the hypothal-* m h. l' R1 t% C6 N7 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-' a% v U0 [9 {
sis has been given to neuroradiologic imaging in# f W0 I" j4 z5 ~. e. Q
boys with precocious puberty. In addition to viril-
2 }' g I- r3 _' Cization, the clinical hallmark of CPP is the symmet-
/ x) j; B' {, y0 K- @3 Y* ]rical testicular growth secondary to stimulation by
6 C- r. T( A- ?" y, ?: ugonadotropins.1,37 c4 k; h3 `/ \ @% E
Gonadotropin-independent peripheral preco-( t' }6 g( L' k- J) N: R5 }1 ~0 l
cious puberty in boys also results from inappropriate" b# A" a3 `1 t2 T3 Q5 |+ w
androgenic stimulation from either endogenous or; O2 F, y7 R7 ]2 \: b: x8 ?, p
exogenous sources, nonpituitary gonadotropin stim-) M& e6 n+ v" r" V! O% ~- g
ulation, and rare activating mutations.3 Virilizing( N* v# T9 u5 D! F% X+ o2 S8 K& s1 s6 X
congenital adrenal hyperplasia producing excessive
+ ^: ]3 \1 M9 Oadrenal androgens is a common cause of precocious
. z( Q* y* g# U& o3 i2 F5 Opuberty in boys.3,45 j |' k4 Q" L
The most common form of congenital adrenal
- g% |2 P0 O! e& }hyperplasia is the 21-hydroxylase enzyme deficiency.
7 ~: i9 [! s: ]The 11-β hydroxylase deficiency may also result in& Q z8 {( [+ f1 [
excessive adrenal androgen production, and rarely,
7 Y4 V: H; n) ]an adrenal tumor may also cause adrenal androgen, ?& C; T3 b0 m7 ~2 Z0 j$ Z( S
excess.1,33 m0 C1 \2 v) ^% \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. `$ B# K/ \ P& y, G542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 i' M& i7 I# b, u2 F" a
A unique entity of male-limited gonadotropin-, C- p1 l% {; H" Z
independent precocious puberty, which is also known6 p: Y; b; b& f! ~3 ^# p/ V( N' d' P
as testotoxicosis, may cause precocious puberty at a& f. `7 p$ J1 l' d) i6 q
very young age. The physical findings in these boys
4 ?! }! j( J. m, B# z- B0 owith this disorder are full pubertal development,& M+ d% o$ S5 V" ^% c/ q" J
including bilateral testicular growth, similar to boys
3 H0 {1 K$ @% R* m L. dwith CPP. The gonadotropin levels in this disorder4 ?' m% {7 ^$ z/ g7 W" R) H
are suppressed to prepubertal levels and do not show* v# W" E T8 O4 D" `9 {
pubertal response of gonadotropin after gonadotropin-. r% @3 R% l n. L9 C
releasing hormone stimulation. This is a sex-linked
, k- y( D/ s; W+ O, Hautosomal dominant disorder that affects only
- U' @2 a0 u* @" Nmales; therefore, other male members of the family$ P- r. [5 ]7 u1 N: s/ @: n
may have similar precocious puberty.38 o9 n& k$ {8 }) N5 T: c/ c/ Q
In our patient, physical examination was incon-
4 w5 a$ }$ n" L8 } usistent with true precocious puberty since his testi-
$ O2 \+ L3 P7 e2 y* icles were prepubertal in size. However, testotoxicosis
9 O. G3 ]6 U. {was in the differential diagnosis because his father
3 ~" p0 B \8 z9 S }" kstarted puberty somewhat early, and occasionally," m3 r0 k/ U4 d# D
testicular enlargement is not that evident in the& U1 `: g) p1 B k6 V
beginning of this process.1 In the absence of a neg-# ?6 V( ~( c( M8 a; a; q
ative initial history of androgen exposure, our
3 ?3 `9 W6 I) z& Jbiggest concern was virilizing adrenal hyperplasia,
5 D) {; H* Z' Z, v; ^either 21-hydroxylase deficiency or 11-β hydroxylase5 j n( l; g- X6 l9 u( j% l
deficiency. Those diagnoses were excluded by find-
, w3 y4 e, s2 ^+ @( W3 t9 B9 Bing the normal level of adrenal steroids.) N+ S# W; D% p" [. I* E0 c
The diagnosis of exogenous androgens was strongly3 X0 ?" E4 {5 Q) b$ @" v, [! M$ C
suspected in a follow-up visit after 4 months because& v0 C/ l, ~/ j* Q) C+ `# G
the physical examination revealed the complete disap-5 c4 p( z7 k8 g
pearance of pubic hair, normal growth velocity, and$ M+ A' F: a- k# J0 C6 o
decreased erections. The father admitted using a testos-5 j, x# @% |1 [- e: M* u
terone gel, which he concealed at first visit. He was* |# O/ k5 d) w7 A# G* b. \
using it rather frequently, twice a day. The Physicians’/ C5 X1 ?5 d( O, g: x6 G4 D+ F
Desk Reference, or package insert of this product, gel or$ Y7 s: T7 G& S& b$ r
cream, cautions about dermal testosterone transfer to
+ V+ {% z0 E5 ]unprotected females through direct skin exposure." Z; ^: }) y! x
Serum testosterone level was found to be 2 times the
& R8 F- k7 `1 g9 c3 P. A8 Cbaseline value in those females who were exposed to8 b( q4 N* T0 w) J+ ]! ^, [
even 15 minutes of direct skin contact with their male$ T" [1 [1 S; X: }8 M5 J- R
partners.6 However, when a shirt covered the applica-
% L- J4 G3 K6 M. Ytion site, this testosterone transfer was prevented.
& e* ]9 H3 h0 Q) J( b. s/ K2 k# NOur patient’s testosterone level was 60 ng/mL," v! |7 e* l/ ~/ s
which was clearly high. Some studies suggest that+ R ?; F6 ^# l" Z* K
dermal conversion of testosterone to dihydrotestos-
+ D& R, D j2 ^5 kterone, which is a more potent metabolite, is more+ s( M- x; L2 c4 B' K7 D
active in young children exposed to testosterone
3 F( X# \; k; _5 ]7 hexogenously7; however, we did not measure a dihy-' }* ~* m( t0 i H/ z4 `; l; W4 [
drotestosterone level in our patient. In addition to
3 G$ o3 |: f( F* bvirilization, exposure to exogenous testosterone in
$ @) R& K4 n/ t5 n }children results in an increase in growth velocity and
7 M( ^, u% h; y l# W' Nadvanced bone age, as seen in our patient.
" z1 T# P! T* W/ a$ B6 i* R9 P8 W1 AThe long-term effect of androgen exposure during
$ F! f( X, @6 A5 F- |: M+ Kearly childhood on pubertal development and final( c, `3 V- c! ?, P% m9 Z5 ] K
adult height are not fully known and always remain
6 u+ N0 E- U- }0 p) a5 s0 |a concern. Children treated with short-term testos-' E2 I" ^9 U! v2 [9 k ~: C
terone injection or topical androgen may exhibit some& J( U- K; S& y; P3 U' D
acceleration of the skeletal maturation; however, after
" c$ W Q \6 i2 b$ O: Z8 gcessation of treatment, the rate of bone maturation4 n5 R2 Q( z% z, b
decelerates and gradually returns to normal.8,9* y- U/ p8 A" N* g" _
There are conflicting reports and controversy: e5 k$ ?* H9 g
over the effect of early androgen exposure on adult
7 S, ]& u) t v2 D$ _( Q) lpenile length.10,11 Some reports suggest subnormal6 |# x2 j9 ~) L! z
adult penile length, apparently because of downreg-% o. O( f$ @6 K9 Q. e
ulation of androgen receptor number.10,12 However,
( J6 i" ?9 i+ m: }, D6 K: w! lSutherland et al13 did not find a correlation between
/ b6 N8 M8 W5 }; M6 m* o! bchildhood testosterone exposure and reduced adult
$ x2 [2 R; S3 j9 s+ Cpenile length in clinical studies.
$ U7 O9 H# Q. g; o/ J" I5 wNonetheless, we do not believe our patient is
O- y, @7 g. J& w% fgoing to experience any of the untoward effects from
1 D) C+ m& _1 l& a, Gtestosterone exposure as mentioned earlier because
' Q4 J! R6 a z/ ]8 {the exposure was not for a prolonged period of time.
# t; F" B. }* ]; D% q% a: cAlthough the bone age was advanced at the time of
, O7 p& \, ` D- q3 ldiagnosis, the child had a normal growth velocity at
, p0 i+ E7 ?% ]! D' c/ a" R/ Nthe follow-up visit. It is hoped that his final adult" c6 l0 E0 H o9 b4 w
height will not be affected.) U3 n9 P, i, L/ j
Although rarely reported, the widespread avail-; V$ f4 V" `4 R0 R1 @
ability of androgen products in our society may, Y0 F$ m7 a& r; q# l* [, Q0 ]$ s3 D
indeed cause more virilization in male or female
! z! z: c) S0 W# S& `1 Wchildren than one would realize. Exposure to andro-
9 c" V4 H3 J3 l$ W, q8 Igen products must be considered and specific ques-
S ]9 v7 j, Jtioning about the use of a testosterone product or
* a. h+ m* X: R; s8 M) [ o0 P6 E1 b7 `gel should be asked of the family members during
, |6 e: w" }0 q S4 o4 V0 mthe evaluation of any children who present with vir-0 V; r" A2 M. e2 D% G% F
ilization or peripheral precocious puberty. The diag-
! g t7 ] l3 Gnosis can be established by just a few tests and by
- [* I7 \ Y' r: g1 Sappropriate history. The inability to obtain such a W9 ?% w3 T/ V
history, or failure to ask the specific questions, may
U8 M$ y0 n) Z6 g$ P, I2 {result in extensive, unnecessary, and expensive
5 t2 i# W" Q0 C4 U' Z) jinvestigation. The primary care physician should be$ R/ |" {+ W3 ?. m
aware of this fact, because most of these children
" ]+ C9 s" }$ `1 Hmay initially present in their practice. The Physicians’; t( |2 P2 Z" W+ S/ U& E
Desk Reference and package insert should also put a
. H/ f0 j+ F2 z+ y) ~4 ^: Lwarning about the virilizing effect on a male or% n6 J) @( q% D" B2 W+ @
female child who might come in contact with some-
; U- U2 `. z! u; C# eone using any of these products.6 Q+ X( e" K$ F3 X0 ^+ Q! _1 T; o) i
References. ~% v \2 t: Y8 V" r; Z
1. Styne DM. The testes: disorder of sexual differentiation
3 h: @4 y* |+ c6 d# z5 X2 @and puberty in the male. In: Sperling MA, ed. Pediatric' d# l+ K; \/ z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' z/ @1 _+ I( O* Q% N: [
2002: 565-628.! O" E! u) O% @6 T# M/ G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 P8 M8 h; K# S1 Xpuberty in children with tumours of the suprasellar pineal |
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