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Sexual Precocity in a 16-Month-Old
: E. m% s6 D. K1 m2 SBoy Induced by Indirect Topical
) E4 m4 ^7 c* Y( g: K6 [7 YExposure to Testosterone
) O: ^) O f3 ]0 y$ P( NSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& F) N% {- W6 F6 Z3 T, ^* t
and Kenneth R. Rettig, MD1
) r: W; ^5 G; WClinical Pediatrics
. j5 q! W0 i2 e* _1 SVolume 46 Number 6
* F" p# A, H4 ]$ UJuly 2007 540-543# J/ b' W: M% d
© 2007 Sage Publications
( n+ }$ Y6 |! }& ?6 W4 k k10.1177/0009922806296651+ Q2 Y/ p) v" x4 O: _5 b9 J5 t4 w1 i
http://clp.sagepub.com
7 h5 c+ X9 b3 z6 z# whosted at0 z1 v! m" X+ u1 R; n
http://online.sagepub.com7 Y, o4 N$ D* p3 G4 e0 x/ y
Precocious puberty in boys, central or peripheral,2 e% B& v% n. a {: S
is a significant concern for physicians. Central
h0 r! y( \8 W! Z* g- l" vprecocious puberty (CPP), which is mediated
2 }2 [7 q z" ^0 hthrough the hypothalamic pituitary gonadal axis, has
) R# ]* T# Q% C" a; f( Qa higher incidence of organic central nervous system
/ ?. _7 X/ B1 `8 @lesions in boys.1,2 Virilization in boys, as manifested
$ {. G5 J( q' j6 G' Z. Lby enlargement of the penis, development of pubic
/ w, y5 u+ A+ `+ p1 hhair, and facial acne without enlargement of testi-
$ v" l a* Q: b; X4 \8 S9 icles, suggests peripheral or pseudopuberty.1-3 We
4 v: ?' d# P, o' xreport a 16-month-old boy who presented with the
4 M, W! Y& d8 ?enlargement of the phallus and pubic hair develop-
. M) v7 f+ y& a# E* m9 T9 ]ment without testicular enlargement, which was due
/ S/ h! |( V& U0 P9 Mto the unintentional exposure to androgen gel used by T( @ Z3 x, ~. M
the father. The family initially concealed this infor-0 X; \& G+ B% w3 q, m% _
mation, resulting in an extensive work-up for this; I3 u% Q K6 Q" o3 I5 l
child. Given the widespread and easy availability of6 b+ ` U8 t( w Y5 T0 p
testosterone gel and cream, we believe this is proba-" V6 @3 N% r2 x& d# G0 T
bly more common than the rare case report in the: q4 ^4 `' {$ X* D- [$ U: c
literature.48 _3 C" S6 b. p# o& l
Patient Report, G+ n" X& Z! }3 n
A 16-month-old white child was referred to the' m/ M3 D0 _# s6 ]6 _* x" \" B' R
endocrine clinic by his pediatrician with the concern5 y" P, w: A, k4 B1 J3 Q, M
of early sexual development. His mother noticed, z. J5 E( k& s/ f. t
light colored pubic hair development when he was) H- `9 n1 f* ^9 W8 J& S) |
From the 1Division of Pediatric Endocrinology, 2University of7 c4 ]+ o+ S; T* \$ B _7 d2 j, f
South Alabama Medical Center, Mobile, Alabama.- u }% `7 h: I. k
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ I. R) @+ a0 v5 fProfessor of Pediatrics, University of South Alabama, College of Y0 A; k6 f4 T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( U, {. S: A: U; F; y$ n+ D" E
e-mail: [email protected].- D9 `& y% x) ~, C' V
about 6 to 7 months old, which progressively became C3 u7 N% H8 W0 @( U1 p
darker. She was also concerned about the enlarge- ?6 J: ~( ]) q! V
ment of his penis and frequent erections. The child
6 I O* H T$ {- k8 F9 Q2 ewas the product of a full-term normal delivery, with
1 _( h a: [$ Da birth weight of 7 lb 14 oz, and birth length of
2 g7 R( { ]4 ~/ q1 f+ k. y9 D4 x20 inches. He was breast-fed throughout the first year" h+ ?; j. w* B2 F \5 O4 |
of life and was still receiving breast milk along with
! c: x& |+ R1 p) vsolid food. He had no hospitalizations or surgery,. z: J7 h4 m) Z5 j* v4 R$ G
and his psychosocial and psychomotor development( I" J7 d, L9 E. e% N
was age appropriate.
. y2 v' q6 o+ C/ m: WThe family history was remarkable for the father,4 |( z6 s, A/ n: u6 O
who was diagnosed with hypothyroidism at age 16,
# M, f) Z, U( u# n5 {2 \which was treated with thyroxine. The father’s
$ {3 F' B8 m( k- d; y- ^2 cheight was 6 feet, and he went through a somewhat0 I( j6 {8 x: ~# B
early puberty and had stopped growing by age 14.
' O# C3 i9 g, N8 ]8 t5 e A AThe father denied taking any other medication. The
" a( K; q% S7 U1 O( fchild’s mother was in good health. Her menarche
; e9 L4 A- F9 {9 A; D, Q- G- F cwas at 11 years of age, and her height was at 5 feet) Y; j8 A' ?+ L2 J' N
5 inches. There was no other family history of pre-; t9 _4 d7 \) P# m9 B
cocious sexual development in the first-degree rela-
+ p K2 j* p# s) E7 I+ G1 _tives. There were no siblings.* D; v& c& K5 U3 O. }0 t+ t( `* c
Physical Examination" w& a& n. M( h: {4 u
The physical examination revealed a very active,7 E' z) t# G2 p0 g, i1 ]
playful, and healthy boy. The vital signs documented& i5 c! }" n% F* m% p
a blood pressure of 85/50 mm Hg, his length was
2 r1 e/ d$ Q6 |9 ^. _6 L90 cm (>97th percentile), and his weight was 14.4 kg* ^9 J/ b% `" V
(also >97th percentile). The observed yearly growth
' ?1 v+ p; c" s4 o: evelocity was 30 cm (12 inches). The examination of. Z9 g# A0 k5 @* E/ y/ Q: h
the neck revealed no thyroid enlargement.
$ a1 ~4 M, `5 I5 ~2 Q2 MThe genitourinary examination was remarkable for$ G3 L. t j% p, w0 G G4 k' `( M
enlargement of the penis, with a stretched length of
* e. O6 T9 N) g+ o! h% r: G- _8 cm and a width of 2 cm. The glans penis was very well+ s3 P' O/ }1 t, n' m7 A2 {
developed. The pubic hair was Tanner II, mostly around
- _5 l$ f: j2 q0 l6 k& n- U( ~5 h540
+ m: w8 G* F1 L; L0 rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 I4 Q- ^8 L( {+ g
the base of the phallus and was dark and curled. The) G! R; G1 I' @8 y+ [7 X
testicular volume was prepubertal at 2 mL each.
$ B9 c! k, H6 \" `9 Q( _% gThe skin was moist and smooth and somewhat
5 P5 O3 I, ? Y! ~oily. No axillary hair was noted. There were no
/ _/ F: C' I: t" Nabnormal skin pigmentations or café-au-lait spots.2 k9 ~, `$ K/ d0 y- ]5 _
Neurologic evaluation showed deep tendon reflex 2+# q& ~2 N. a" ^! S- t
bilateral and symmetrical. There was no suggestion
5 S% D$ n: l9 S$ ^2 \/ U `$ Zof papilledema.) H0 {- }& m* T# n8 R6 K, M) l. n
Laboratory Evaluation
3 R" a9 O& s' T9 }The bone age was consistent with 28 months by
6 m! j) v( T' l ?' H( B! Susing the standard of Greulich and Pyle at a chrono-
( i8 h, h8 [2 B6 o" _, D* xlogic age of 16 months (advanced).5 Chromosomal0 M& p. z; e7 V @
karyotype was 46XY. The thyroid function test
. ]1 y" o5 `8 Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- u z+ ]- \4 @
lating hormone level was 1.3 µIU/mL (both normal).
; W( Y1 [% U- b/ wThe concentrations of serum electrolytes, blood n1 @' r& M1 f. j5 q. v
urea nitrogen, creatinine, and calcium all were
. f B1 Z" n6 B% W( m% u) Hwithin normal range for his age. The concentration6 O+ D3 \+ a% m7 x( h; G
of serum 17-hydroxyprogesterone was 16 ng/dL3 v% i" X7 V* V( A0 r
(normal, 3 to 90 ng/dL), androstenedione was 20
3 ^% W. @8 i M, K: ^# png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. Q6 B4 f4 ?1 ~' z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 r7 o: t. g2 n( Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ p6 y# M6 _; x( m' r49ng/dL), 11-desoxycortisol (specific compound S)
* \3 G* u5 ^/ M; w1 R5 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- t; f2 W3 V- i8 w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 ?. `; l8 a( k% k; c' o. C, Atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),- O' U. C7 f# f7 E' e$ ~( d
and β-human chorionic gonadotropin was less than9 b: X$ d( M0 _/ r0 |9 Z$ ?# P
5 mIU/mL (normal <5 mIU/mL). Serum follicular, K1 @2 e& a, ?" J
stimulating hormone and leuteinizing hormone* I5 o0 N1 u7 ^& G& i$ C+ l# v4 W
concentrations were less than 0.05 mIU/mL
- J! P2 D6 f5 J(prepubertal).
" L0 S# V' j8 e V' M4 J* }The parents were notified about the laboratory
4 k& {# y& W* F" L7 n* dresults and were informed that all of the tests were
) h$ O( P0 g' @' A& P& N6 @normal except the testosterone level was high. The7 g: ^3 a% ~5 g* `$ |# e
follow-up visit was arranged within a few weeks to
! ~ ~# b* t5 z; v- p% aobtain testicular and abdominal sonograms; how-6 Q, ]; H0 \: z4 l% G5 s C+ K. d
ever, the family did not return for 4 months.0 f! N5 B3 Y& z2 f/ r; U
Physical examination at this time revealed that the3 _3 i d; x* e- j4 R( N& h; a
child had grown 2.5 cm in 4 months and had gained
, r0 G% U. \2 l2 d, x2 F& M& {2 kg of weight. Physical examination remained
9 p! Z0 \5 i# Wunchanged. Surprisingly, the pubic hair almost com-
8 F+ f$ x2 K4 l) [pletely disappeared except for a few vellous hairs at
0 Y, Y; Z9 V C4 b2 X' Jthe base of the phallus. Testicular volume was still 2
) e+ F0 _# J) c; |mL, and the size of the penis remained unchanged.( z v# {5 h- ^/ e8 k
The mother also said that the boy was no longer hav-+ M' P& X" f+ }, t+ p
ing frequent erections.
2 E: w% j/ Y9 N, ?Both parents were again questioned about use of4 F) b1 X' i- k+ Q" A
any ointment/creams that they may have applied to
, O6 E3 n+ p- U; a5 G; pthe child’s skin. This time the father admitted the
% L: Y7 `) ?) s! ^1 pTopical Testosterone Exposure / Bhowmick et al 541$ O5 y5 f/ z# }; \# w
use of testosterone gel twice daily that he was apply-9 g0 U9 Y; k3 e- J8 W
ing over his own shoulders, chest, and back area for
- D( c0 \: d+ P Z/ \a year. The father also revealed he was embarrassed
1 v( A. k) f: d, yto disclose that he was using a testosterone gel pre-1 F& |: r8 N7 g- ~3 D- u# O
scribed by his family physician for decreased libido
$ B1 n" j; s. n8 o* qsecondary to depression.4 r5 g q4 n9 @$ x; O- e5 D$ \# j
The child slept in the same bed with parents.
- g# T! C6 [0 y3 RThe father would hug the baby and hold him on his
( R. U/ w9 j# K) Echest for a considerable period of time, causing sig-7 N( C5 |, I; q2 ~
nificant bare skin contact between baby and father.' n5 E9 e+ R% [& f. q( Z; n4 l3 N8 B
The father also admitted that after the phone call, ], |) ^+ I" v% R
when he learned the testosterone level in the baby
# o& n/ P( K% o% d6 z8 Awas high, he then read the product information) }+ u0 [# S% J4 s+ e2 L( N7 V
packet and concluded that it was most likely the rea-
0 [6 n! E+ D/ r$ a! V8 Bson for the child’s virilization. At that time, they
" I! b; Q6 p; q0 _: f* |4 {3 ^! w0 {decided to put the baby in a separate bed, and the8 w( K9 m U8 o) S$ E
father was not hugging him with bare skin and had
9 V5 x! k3 z( A$ qbeen using protective clothing. A repeat testosterone# P7 r' s: a/ A1 [. h( A
test was ordered, but the family did not go to the
; w' |$ h) _) u2 U: x1 Glaboratory to obtain the test.
3 V: t/ ]$ x2 U0 uDiscussion; U2 U+ _! m! ^' F' V- w: n" d
Precocious puberty in boys is defined as secondary. [0 V/ |3 V; {# I/ H0 ^ a
sexual development before 9 years of age.1,4
. `" [9 h. x3 L9 w2 u e3 BPrecocious puberty is termed as central (true) when
1 K3 B" \9 O* k3 N1 o& eit is caused by the premature activation of hypo-! j) }! C1 O5 |1 j$ d1 c
thalamic pituitary gonadal axis. CPP is more com-
- y+ B3 T. F% q7 ~3 {mon in girls than in boys.1,3 Most boys with CPP
) T* ~3 m1 F R2 ?3 imay have a central nervous system lesion that is* p3 n' d' J: F5 _& A
responsible for the early activation of the hypothal-
5 y9 G) ?. \6 e3 |* Pamic pituitary gonadal axis.1-3 Thus, greater empha-0 \( t# C6 t- P; B/ S
sis has been given to neuroradiologic imaging in
, ?9 i/ O; x) U# n- W9 uboys with precocious puberty. In addition to viril-* _8 K$ z# B: G: g
ization, the clinical hallmark of CPP is the symmet-
7 W' Q2 j# d7 O9 wrical testicular growth secondary to stimulation by5 w) ?% z9 x% G E
gonadotropins.1,3- s% ^9 F- y# u/ O6 O3 }$ [" ~
Gonadotropin-independent peripheral preco-
) P Y( L9 p5 I9 |8 V! ^$ A7 Rcious puberty in boys also results from inappropriate
/ V+ m7 l) ^: L6 F6 u: Aandrogenic stimulation from either endogenous or: U. I8 \) x1 ?! ]8 b/ L" ^/ f# Y
exogenous sources, nonpituitary gonadotropin stim-" J7 R/ t! W5 V$ }- b: B# Z/ _7 R
ulation, and rare activating mutations.3 Virilizing
- P/ k- q" }6 dcongenital adrenal hyperplasia producing excessive4 J7 S; @' _& @( s" H* ?8 R2 M
adrenal androgens is a common cause of precocious# w# Y0 O. O q6 E
puberty in boys.3,4
/ L* }* A9 `/ q3 IThe most common form of congenital adrenal0 i l/ h, x& m! E- `! {, L( D
hyperplasia is the 21-hydroxylase enzyme deficiency.: x+ w0 e% b! s. I
The 11-β hydroxylase deficiency may also result in2 l6 d, r1 D1 }7 o
excessive adrenal androgen production, and rarely,
& g9 r X& K0 R0 f, Ban adrenal tumor may also cause adrenal androgen
5 v% X$ F8 n5 Y) e$ Lexcess.1,31 d3 A6 J; `- G5 [, e7 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# n+ L) h6 ^; q/ i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- K! u! s8 A/ \" m- t, s0 CA unique entity of male-limited gonadotropin-
: y$ [" V4 r1 B1 l; lindependent precocious puberty, which is also known
# z: v" U3 w5 X/ gas testotoxicosis, may cause precocious puberty at a
9 y2 _+ f1 g' S& Vvery young age. The physical findings in these boys8 k) @. d7 c3 H: z
with this disorder are full pubertal development,
; `, w8 s( \# s) V% q1 `/ |including bilateral testicular growth, similar to boys
$ o$ Z9 ]% P% B/ |with CPP. The gonadotropin levels in this disorder
5 X- N: |" _( Vare suppressed to prepubertal levels and do not show
$ G/ C4 c6 u2 `4 [3 _9 g5 ~$ qpubertal response of gonadotropin after gonadotropin-+ L `& A& d3 a8 h6 w i! }9 \
releasing hormone stimulation. This is a sex-linked8 d3 [" m; K- f0 S2 j* m, l
autosomal dominant disorder that affects only' `8 H9 O# n7 R7 Y* U
males; therefore, other male members of the family4 a6 {5 h# I/ A2 S+ q
may have similar precocious puberty.3
5 h$ }( @0 I; }8 NIn our patient, physical examination was incon-
9 s& Z2 S( M! x( I+ R5 T9 tsistent with true precocious puberty since his testi-# [& Y/ A8 \1 A6 B6 U5 K* `/ v
cles were prepubertal in size. However, testotoxicosis$ D6 y: _4 }, N
was in the differential diagnosis because his father
% e- q2 u; F* ^- S$ K; {7 @+ Istarted puberty somewhat early, and occasionally,. P* m. v6 b2 n7 @6 W
testicular enlargement is not that evident in the
4 J0 F2 j# b& tbeginning of this process.1 In the absence of a neg-1 \) e" H3 J6 J7 I4 k; g, v9 o r
ative initial history of androgen exposure, our, A8 `. X: z* T+ K/ J. g, l
biggest concern was virilizing adrenal hyperplasia,$ s, O+ |1 s. A
either 21-hydroxylase deficiency or 11-β hydroxylase+ `$ y* h n4 L, Y
deficiency. Those diagnoses were excluded by find-
9 V0 J- ~1 G7 Z% ~+ a6 n0 x9 S8 `- fing the normal level of adrenal steroids.
1 L: U& q+ X2 z$ F0 qThe diagnosis of exogenous androgens was strongly
$ g; i4 s, l' V: L' Isuspected in a follow-up visit after 4 months because
]# V4 y, J- X- {7 l1 y, zthe physical examination revealed the complete disap-' d) d( G6 S6 A+ `: f* C
pearance of pubic hair, normal growth velocity, and
2 I b7 P9 X% ^1 E. B3 Ndecreased erections. The father admitted using a testos-) N) |, A3 ~# g$ i/ w* n; C6 s# {. l
terone gel, which he concealed at first visit. He was$ C1 q9 c' Z# s. \" n( Y# x
using it rather frequently, twice a day. The Physicians’- U( d3 P' U$ Y! I: v$ r( c* O( j
Desk Reference, or package insert of this product, gel or# l/ q/ A& Y) T+ d2 o" G3 [
cream, cautions about dermal testosterone transfer to- D7 H* Q. h. N& @
unprotected females through direct skin exposure.
$ E& ^. e5 K1 m0 s$ O. |Serum testosterone level was found to be 2 times the7 r* L/ J" \7 Z# H# Q C$ ?
baseline value in those females who were exposed to0 d; I7 i* ], `8 J0 ~- l O1 _% ]
even 15 minutes of direct skin contact with their male1 J$ ~& a* ~, U* U. a5 `
partners.6 However, when a shirt covered the applica-4 k4 _3 Z3 h4 S) _, A
tion site, this testosterone transfer was prevented.
- W, P4 L1 z( O! W9 MOur patient’s testosterone level was 60 ng/mL,. }$ C; u9 @& ?. b, q1 r+ r
which was clearly high. Some studies suggest that, ]7 p3 J9 q: {; O. z' u4 \
dermal conversion of testosterone to dihydrotestos-& y3 v: X+ {3 I% j4 ^' e
terone, which is a more potent metabolite, is more
& s; R* x' h1 }active in young children exposed to testosterone- X3 U: q8 V6 C& Z
exogenously7; however, we did not measure a dihy-
* C2 T3 ~8 P, Hdrotestosterone level in our patient. In addition to+ n; k5 A& k o( n5 A& ^# e+ p
virilization, exposure to exogenous testosterone in; V4 z/ x7 O T& d- A/ r
children results in an increase in growth velocity and$ P+ r9 F6 U8 l: J- y: q. O
advanced bone age, as seen in our patient.- ^3 Z* r/ g1 \( l4 P
The long-term effect of androgen exposure during( M9 j) @% B0 P+ Q; a9 d3 l+ W4 o
early childhood on pubertal development and final8 {; l; l- s6 A% N9 d& K6 ~+ \3 l
adult height are not fully known and always remain- p3 c' D* q: Q* Z& z5 V$ Y/ ^# r6 o
a concern. Children treated with short-term testos-, Z, H9 @/ ?: }3 Q1 V5 J
terone injection or topical androgen may exhibit some2 B" p: E7 z, v5 x5 i
acceleration of the skeletal maturation; however, after/ L+ t. [/ K) C3 ?2 l' A
cessation of treatment, the rate of bone maturation
3 W/ U4 {7 M, R- m' R2 Ndecelerates and gradually returns to normal.8,9
0 G8 |: _3 q" v0 g/ C2 w$ PThere are conflicting reports and controversy- l6 p, ]% K; Y
over the effect of early androgen exposure on adult; ?3 ?' o- l& S
penile length.10,11 Some reports suggest subnormal
/ [9 L: S# ^3 u, S; V: gadult penile length, apparently because of downreg-* N# m/ V \+ k9 H5 x: N
ulation of androgen receptor number.10,12 However,
, b( x* {7 Z. t; v [Sutherland et al13 did not find a correlation between
5 l/ j# X9 y$ o A+ i- xchildhood testosterone exposure and reduced adult8 I t) m! _, B2 a# N; X
penile length in clinical studies.0 X- u% y+ g9 Z/ B) Q) d6 n& Y
Nonetheless, we do not believe our patient is
- F) }! {) D3 w( Q4 Xgoing to experience any of the untoward effects from- R& Y+ |) b: o
testosterone exposure as mentioned earlier because
/ c+ N% Z; Q9 g. Y6 t' tthe exposure was not for a prolonged period of time.
; T' D' ?8 {; c8 ]9 M# e" f: fAlthough the bone age was advanced at the time of
( x, O! X* v0 ~3 Adiagnosis, the child had a normal growth velocity at0 q: e( _( u, l5 X- ?- D' M
the follow-up visit. It is hoped that his final adult0 I( h8 D9 v6 q
height will not be affected.
. V8 L; K. U, S1 }Although rarely reported, the widespread avail-
7 o4 n% Y6 T% H. v: a# V$ ^! n4 Fability of androgen products in our society may
$ H* Q h6 u; s5 x5 Pindeed cause more virilization in male or female* z- U! }- y$ K; @' f' y
children than one would realize. Exposure to andro-7 W- b9 Y4 Q5 e
gen products must be considered and specific ques-
' h( k1 y. J4 C2 t% M* {tioning about the use of a testosterone product or# z' @3 s8 [0 O/ E- ?6 S
gel should be asked of the family members during
3 P! @9 F3 p' m9 ~the evaluation of any children who present with vir-* h! r1 i0 K( R7 ^! O; y
ilization or peripheral precocious puberty. The diag-& q) ^; p+ b# U* \
nosis can be established by just a few tests and by
: u, h& {2 V* ^2 t# }/ Happropriate history. The inability to obtain such a! h" R: E, j! g9 s9 M
history, or failure to ask the specific questions, may
9 o) M* ?. d7 Y4 R: j4 L* k8 t- {) t& jresult in extensive, unnecessary, and expensive* U" y- r( n5 L
investigation. The primary care physician should be
8 }5 N4 Q; l0 [, N6 `aware of this fact, because most of these children
" \+ P/ S6 Y5 G T4 M s( n2 i8 emay initially present in their practice. The Physicians’
2 s/ |2 S0 ?$ @1 mDesk Reference and package insert should also put a( k! G7 U. u7 q4 S. E5 D
warning about the virilizing effect on a male or Q/ E m3 K4 t" i* \: w
female child who might come in contact with some-* w$ K" @2 w# `6 s) O
one using any of these products.
1 O8 ~4 R6 i# e; N: z ^References( t9 v% ^6 y; d. z; ^" y# Y3 F
1. Styne DM. The testes: disorder of sexual differentiation
- f+ M1 C) B5 l% p/ y8 d" j; e: Hand puberty in the male. In: Sperling MA, ed. Pediatric
@9 x9 z. S- HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 n# F0 N( Y5 b' X
2002: 565-628.0 S5 Q/ s6 H/ D- |- P) Q1 B0 c
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( n7 M! b8 [ ^5 Dpuberty in children with tumours of the suprasellar pineal |
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