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Sexual Precocity in a 16-Month-Old, S/ f3 z5 C6 [ j# f
Boy Induced by Indirect Topical4 F- |3 T4 \2 T, [1 O4 Y! S1 v5 e
Exposure to Testosterone
& u4 j; E" |2 N6 ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' N* C# r& T: a9 n* |, V6 l+ }and Kenneth R. Rettig, MD1
" S' M s% L& n: XClinical Pediatrics
L0 f+ ~4 H: W" b; g1 G" [- gVolume 46 Number 60 \/ p+ g: C1 f
July 2007 540-543
7 k% r: A0 ?( ~6 g2 j9 ?© 2007 Sage Publications
8 |# q8 e% h9 o& h. h" w10.1177/0009922806296651* ]7 B3 H+ {! o, F, j5 i3 E) Q& O
http://clp.sagepub.com
" ]6 d0 ?* b) ^: Ahosted at1 J, t' R4 n, g1 q# ]/ [4 ?, h3 `
http://online.sagepub.com+ s- T$ C+ K- A/ K g5 Z
Precocious puberty in boys, central or peripheral,/ P k9 F2 B/ e8 |* `% Z
is a significant concern for physicians. Central0 K$ I3 a& W% ~
precocious puberty (CPP), which is mediated- w$ }+ S3 t P7 p, W0 G
through the hypothalamic pituitary gonadal axis, has
0 f9 t/ t, A' X6 G; I5 Da higher incidence of organic central nervous system
7 |8 L* S* g9 Clesions in boys.1,2 Virilization in boys, as manifested
+ e0 c# \8 p& }' V! @0 G- `# oby enlargement of the penis, development of pubic8 R1 R5 T4 f3 j8 I
hair, and facial acne without enlargement of testi-
+ Y* {9 S6 y6 Kcles, suggests peripheral or pseudopuberty.1-3 We3 T& E' [9 x5 S, M8 j
report a 16-month-old boy who presented with the
' v& A, e% m& T+ A- V0 A8 F$ menlargement of the phallus and pubic hair develop-
h3 w/ p* m9 O' ~ment without testicular enlargement, which was due
9 V7 u' T" w8 P N& L( ^to the unintentional exposure to androgen gel used by
6 m9 ]/ L! E: D5 G7 |& fthe father. The family initially concealed this infor-6 b9 O; N3 m p# c5 T$ W+ _( O7 Q
mation, resulting in an extensive work-up for this1 |1 H. ~1 y+ w3 K7 Y. p% g
child. Given the widespread and easy availability of8 w1 U4 P/ a& g5 O
testosterone gel and cream, we believe this is proba-
# t" E; M6 Q# Q, mbly more common than the rare case report in the2 F8 }: v' h8 @7 q# ?6 d; p+ u) |
literature.4) y* J. S7 q8 E/ h
Patient Report0 I6 x& \$ H0 C( r% H. _6 b4 X, W
A 16-month-old white child was referred to the# O. R! u2 ^. u" k
endocrine clinic by his pediatrician with the concern! j z; L2 w( r4 m/ B+ K T1 r
of early sexual development. His mother noticed
/ Y7 r# f- c" H/ y5 C T2 M$ a- xlight colored pubic hair development when he was! H4 B- h0 Q! Y" W& C# t: `
From the 1Division of Pediatric Endocrinology, 2University of
# c7 r- j$ l- l2 ]South Alabama Medical Center, Mobile, Alabama.
& P, [" i) K$ U8 b; m1 V% LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: g3 d: S' c9 A+ j. y+ ^6 n4 JProfessor of Pediatrics, University of South Alabama, College of
, f) f' x' ?. lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, S7 L1 v' C& N4 |- p: H
e-mail: [email protected].
' E% u4 r9 Z' s" uabout 6 to 7 months old, which progressively became9 Q" z" u+ F0 f) _* g H" j8 F
darker. She was also concerned about the enlarge-
: n( g9 l3 E7 q9 o+ z4 v, bment of his penis and frequent erections. The child
2 c# k# F+ j% ^* H" V% ]was the product of a full-term normal delivery, with
1 [! m4 z& K) Za birth weight of 7 lb 14 oz, and birth length of
h) o% d: t( O; R) A/ M; t4 {20 inches. He was breast-fed throughout the first year0 Z0 k/ K5 _; B- z
of life and was still receiving breast milk along with# ^ K( H" N. P+ a7 o: x, r
solid food. He had no hospitalizations or surgery,
! v4 ]' o+ h: u$ r6 C/ Fand his psychosocial and psychomotor development* n! m' ^1 ?; U" T; J3 P
was age appropriate.
v }" x! r5 v) T. @. G( l6 OThe family history was remarkable for the father,
" R# f9 y2 N- [; h& I9 Bwho was diagnosed with hypothyroidism at age 16,
) \1 B9 H) Y ^/ Gwhich was treated with thyroxine. The father’s' b0 W3 ?) I2 g8 |
height was 6 feet, and he went through a somewhat
# T# P. r7 B1 ?8 d& f$ E8 b5 D1 tearly puberty and had stopped growing by age 14.
* d! Q1 s$ k/ g, f, s0 l, n5 wThe father denied taking any other medication. The/ e0 s. z- {& j1 F# A* z" v
child’s mother was in good health. Her menarche
" O; | q" l q* D1 ~was at 11 years of age, and her height was at 5 feet: D- {9 a) y/ Q0 `
5 inches. There was no other family history of pre-* Y |' Z) c: A4 k
cocious sexual development in the first-degree rela-+ G# g* y; x( k. v q0 `$ l
tives. There were no siblings.. f- _# F+ B3 y) E% r9 W* P
Physical Examination
, W, C9 q5 z# j5 C7 C( gThe physical examination revealed a very active,- X: m/ L, {0 G
playful, and healthy boy. The vital signs documented
. G( B0 F$ X8 @7 O& |a blood pressure of 85/50 mm Hg, his length was
4 G0 _" p0 Y: D90 cm (>97th percentile), and his weight was 14.4 kg/ z$ i9 G1 X* Q9 i' M" d! G
(also >97th percentile). The observed yearly growth
/ q7 E5 j. N- C2 ^( }4 lvelocity was 30 cm (12 inches). The examination of. F1 q6 W. ~# _' _$ u: v* I
the neck revealed no thyroid enlargement.+ e$ [1 G7 u9 n$ w8 o
The genitourinary examination was remarkable for
) |. |& e" Z0 n& P! b4 zenlargement of the penis, with a stretched length of6 v7 g" w: @0 {5 v
8 cm and a width of 2 cm. The glans penis was very well9 c) h* |; _, l4 y, l
developed. The pubic hair was Tanner II, mostly around
: U5 k. O1 w. s/ k9 ^8 E2 F0 F540
% s2 |2 k5 [7 j: x7 X* fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) k( M, e6 u# I7 H% @' c' uthe base of the phallus and was dark and curled. The) }& A7 D" h' ], h" N- K
testicular volume was prepubertal at 2 mL each.
. w5 u t; ~# w4 c) O: X( [, ?The skin was moist and smooth and somewhat
9 B* [/ B* ?2 U1 moily. No axillary hair was noted. There were no, k3 [ p3 s& v `! {
abnormal skin pigmentations or café-au-lait spots.
! n5 V+ \& C9 w3 CNeurologic evaluation showed deep tendon reflex 2+
7 r0 K$ P5 `1 q5 wbilateral and symmetrical. There was no suggestion5 y" B/ T- A# l/ Q: v3 m
of papilledema.6 F ^1 ~2 J2 L( i4 _3 B
Laboratory Evaluation! a C) ?% p. {. ^$ g( p- E
The bone age was consistent with 28 months by8 Y& h6 s$ d: W) F' C
using the standard of Greulich and Pyle at a chrono-& z- L% O; h3 n! \# b3 j
logic age of 16 months (advanced).5 Chromosomal
1 _5 R- r5 J$ T* h! E6 [- _+ ckaryotype was 46XY. The thyroid function test- P, @# E# a' m* W- B# p5 ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 U/ G4 ~$ J. J; U0 \lating hormone level was 1.3 µIU/mL (both normal).
1 M3 e0 N: `' rThe concentrations of serum electrolytes, blood
) |2 c( X; O2 y/ n# zurea nitrogen, creatinine, and calcium all were. ?$ V. F4 A5 S2 ?
within normal range for his age. The concentration
# z5 T, Z1 V) D& O6 jof serum 17-hydroxyprogesterone was 16 ng/dL
1 |; g! t2 m( Z8 l(normal, 3 to 90 ng/dL), androstenedione was 20
% ~! t% t6 y& P% rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" c% D. i, e+ z: m" W) U
terone was 38 ng/dL (normal, 50 to 760 ng/dL),' L; C, ^8 D; @" e
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 s. Z( p9 V) J' Q( U# e5 q49ng/dL), 11-desoxycortisol (specific compound S)1 v% A# R6 }2 U D1 M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 D( _9 H7 f8 m, r7 Ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 r. P7 |$ O& Q0 Q$ p) u2 Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 d4 l5 s/ C, h4 i- r* I
and β-human chorionic gonadotropin was less than
0 W1 C% d% @) Y+ _. o0 V" p5 mIU/mL (normal <5 mIU/mL). Serum follicular6 s7 O) H- L$ u
stimulating hormone and leuteinizing hormone# O' R- w4 |. O
concentrations were less than 0.05 mIU/mL
2 b# G& f: c7 N _3 h1 t(prepubertal).$ P& r9 u1 m4 l* B9 h8 t
The parents were notified about the laboratory1 o( P6 x+ O! ~0 ]1 V1 P
results and were informed that all of the tests were0 N# L* M8 q9 A4 B w
normal except the testosterone level was high. The: X2 c( l, ]. J* J
follow-up visit was arranged within a few weeks to
8 o% C# ~8 F b2 e) Cobtain testicular and abdominal sonograms; how-
( S5 g" ^. K5 `# Cever, the family did not return for 4 months.
1 Q" w% T: \2 ]: A5 I' LPhysical examination at this time revealed that the$ h' g3 y. V v1 b W) {* \" _0 F$ ]
child had grown 2.5 cm in 4 months and had gained. x' p" y/ _9 s0 H" P# r* U
2 kg of weight. Physical examination remained
0 z9 i% n+ h# D+ a) L5 z% B" p. {unchanged. Surprisingly, the pubic hair almost com-
; L8 Y( S3 }/ e2 X' C; r8 |pletely disappeared except for a few vellous hairs at
5 V4 E# N2 q L' J) w' Pthe base of the phallus. Testicular volume was still 2. Q& H9 |+ ?" z+ S$ {1 V) n2 s8 E
mL, and the size of the penis remained unchanged.$ Q( s: X4 L/ D: a/ ?- N
The mother also said that the boy was no longer hav-0 @! o( P" } i1 h9 o% u
ing frequent erections.( {2 f+ O+ }3 ?. A) t
Both parents were again questioned about use of
K6 e* N u6 q% h! l0 O) u& iany ointment/creams that they may have applied to
5 l+ r% j8 ?. E9 v" l6 kthe child’s skin. This time the father admitted the( V. A% N3 v. s% x$ F
Topical Testosterone Exposure / Bhowmick et al 541* [4 w7 p" k, {+ t T* a) i& Y
use of testosterone gel twice daily that he was apply-
% |0 C( O( H* J/ h* s! d# Qing over his own shoulders, chest, and back area for
+ B3 {3 l5 F G2 P* t- ka year. The father also revealed he was embarrassed
) {$ V3 n) ^& I8 kto disclose that he was using a testosterone gel pre-
% G8 G& |" K! k; \scribed by his family physician for decreased libido* {- V. ^3 k3 _: h ]# x/ j
secondary to depression.
S1 f; }: Q% z& B& QThe child slept in the same bed with parents.- A) G! ~6 F9 @# h% P
The father would hug the baby and hold him on his8 f/ r7 M* @, }: l3 S
chest for a considerable period of time, causing sig-
2 A* {! ]: o# w6 l9 Fnificant bare skin contact between baby and father.
* `1 ?- d1 i5 h; J/ \# W7 bThe father also admitted that after the phone call,& @+ t7 k* S( o x
when he learned the testosterone level in the baby
0 Q# S* b8 h3 \ M) T& {was high, he then read the product information
! Z! x, r) P6 u w, ?9 Xpacket and concluded that it was most likely the rea-
( v+ ~7 V% Z& f* J$ u& X+ sson for the child’s virilization. At that time, they
4 b" g4 n9 v! _5 l$ _: [decided to put the baby in a separate bed, and the
5 T3 O2 P/ {/ yfather was not hugging him with bare skin and had; `' u7 ?7 z& ~
been using protective clothing. A repeat testosterone
# ?7 N% {4 \/ B1 ptest was ordered, but the family did not go to the
5 M. B5 ^# i& r& ulaboratory to obtain the test.7 C2 l( {) o6 a, T% z# v5 K
Discussion1 N- W' B& f! `4 t+ m
Precocious puberty in boys is defined as secondary
$ w/ L* N$ k s' v+ e8 Nsexual development before 9 years of age.1,4
& `5 i1 A1 B6 }! Q) oPrecocious puberty is termed as central (true) when
0 M* l7 h5 f2 [8 o' }it is caused by the premature activation of hypo-6 R9 n" M2 t5 ~; P7 U
thalamic pituitary gonadal axis. CPP is more com-
8 B8 M- }0 H1 U+ W8 w8 qmon in girls than in boys.1,3 Most boys with CPP
" O1 T* g+ h8 w9 Nmay have a central nervous system lesion that is" r1 b$ t8 ~* Y
responsible for the early activation of the hypothal-* H8 @9 B: E; ~8 ]4 t8 |. ~" s
amic pituitary gonadal axis.1-3 Thus, greater empha-8 ^4 A3 T5 G# R4 ^2 Q% N. V% |
sis has been given to neuroradiologic imaging in$ \% X: w R! W8 {- e- |
boys with precocious puberty. In addition to viril-) o% R3 g$ b' j4 ~4 k9 R; T8 V
ization, the clinical hallmark of CPP is the symmet-
# ?& w% w6 D U4 V- M# c. g$ Rrical testicular growth secondary to stimulation by
& b/ h; X6 r# U Vgonadotropins.1,3
. Z# `5 w( }' o8 O" Y% uGonadotropin-independent peripheral preco-
! A7 v1 I9 K" ` s2 j; H. lcious puberty in boys also results from inappropriate
* D( U/ N, `* z& C; mandrogenic stimulation from either endogenous or
: T4 _7 j2 m5 V% k: {exogenous sources, nonpituitary gonadotropin stim-
. X' _4 p6 i5 ~4 y# }ulation, and rare activating mutations.3 Virilizing) |1 r; R! l7 g5 s J* P
congenital adrenal hyperplasia producing excessive) w4 O2 M9 }, s
adrenal androgens is a common cause of precocious% d. y8 F7 k4 a7 D
puberty in boys.3,46 W9 B8 S' n& a
The most common form of congenital adrenal
* D/ O0 v- }8 B) k% C& X/ V' ohyperplasia is the 21-hydroxylase enzyme deficiency., O; b" C# v0 u: k- e/ V
The 11-β hydroxylase deficiency may also result in
1 Y" C( B, r6 [5 ^2 |2 Texcessive adrenal androgen production, and rarely,
9 J1 B/ u% l2 \! c! Van adrenal tumor may also cause adrenal androgen, h$ ^+ N6 i$ D" ?6 k/ S
excess.1,3
4 m, Q9 M3 J4 W& h3 Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; W8 q$ }- n2 N' B/ I. I' U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 N& N. ~ Y }A unique entity of male-limited gonadotropin-
2 @2 ^- C4 T# @3 Hindependent precocious puberty, which is also known* y5 z5 S4 X& x1 X
as testotoxicosis, may cause precocious puberty at a
/ v) Z; K4 g. `2 l3 m# d$ P% Kvery young age. The physical findings in these boys
) q; e$ u' k2 N; \- \with this disorder are full pubertal development,
0 y% z- ~7 ~ K- k. Z! j' pincluding bilateral testicular growth, similar to boys7 g9 s0 [ a* ?1 J+ N% U+ r
with CPP. The gonadotropin levels in this disorder
H" a' m. h7 {3 Q W1 mare suppressed to prepubertal levels and do not show4 T0 Y& h1 ]8 ]2 ?/ P8 e# \
pubertal response of gonadotropin after gonadotropin-1 Q6 L3 _* D* ^6 @& u6 G
releasing hormone stimulation. This is a sex-linked
6 k# p/ k4 b1 g5 l2 U$ |1 G$ Kautosomal dominant disorder that affects only
U k& \% H0 [males; therefore, other male members of the family: [, P# h# K7 v; v- s8 M! H5 u6 T
may have similar precocious puberty.3# w$ q% y' ]6 Y# J. w) w
In our patient, physical examination was incon-
/ J2 b6 j! ^3 T7 q) h2 g& isistent with true precocious puberty since his testi-
2 l& V$ G" |" j0 h' [' @cles were prepubertal in size. However, testotoxicosis- t8 \9 b# ~) S8 i: H
was in the differential diagnosis because his father7 D" K/ C0 I7 }; K5 p2 F
started puberty somewhat early, and occasionally,6 Q- Q% G; t/ o
testicular enlargement is not that evident in the
6 H) I# h- s/ `" D& w! {+ U9 lbeginning of this process.1 In the absence of a neg-
3 y& O. q, v' m: \$ [ative initial history of androgen exposure, our f4 t. s1 T9 o3 Y) u# S. ]9 G
biggest concern was virilizing adrenal hyperplasia,
3 a/ h7 j0 |7 ^' V. deither 21-hydroxylase deficiency or 11-β hydroxylase
4 w A, N( o. o3 [7 v* j5 ?deficiency. Those diagnoses were excluded by find-
& h" \7 `# Y) D. ying the normal level of adrenal steroids.
$ U! H y3 w2 O0 _The diagnosis of exogenous androgens was strongly# H7 P8 q( o5 v( e( k6 Z
suspected in a follow-up visit after 4 months because
j, F) Q& L% D" ]" q; M# wthe physical examination revealed the complete disap-
[6 @8 _' L" k5 t1 Epearance of pubic hair, normal growth velocity, and4 Y3 h4 ^$ i* N8 w0 z' i' z& e
decreased erections. The father admitted using a testos-
; W: z: M1 ~ \; H/ K8 U; `2 oterone gel, which he concealed at first visit. He was3 C8 b, X1 r8 T# t: l: L
using it rather frequently, twice a day. The Physicians’
" }: { ~1 l+ p# h* ?, EDesk Reference, or package insert of this product, gel or. R6 d M4 D2 ]8 `, R: f: p
cream, cautions about dermal testosterone transfer to
/ M+ i/ u8 M+ E6 G. q/ Dunprotected females through direct skin exposure.
; h7 w& N `- {# M! e/ d3 D8 wSerum testosterone level was found to be 2 times the2 o- Y( K, c) [- p Y
baseline value in those females who were exposed to! r* X$ ~* M0 s7 ]0 Q2 |0 S
even 15 minutes of direct skin contact with their male
' G8 u7 k* C: u9 [/ hpartners.6 However, when a shirt covered the applica-* A& x, J+ b, Q- L: P' g# @' L
tion site, this testosterone transfer was prevented.
9 t- W7 `4 j( G5 GOur patient’s testosterone level was 60 ng/mL,+ ], P6 s4 e6 R; }$ S
which was clearly high. Some studies suggest that
1 ]" c* `; K- Z$ o" sdermal conversion of testosterone to dihydrotestos- l+ D( ]( w, @ r$ U
terone, which is a more potent metabolite, is more
* u6 K) v1 j# N$ o4 K" r5 K: n- nactive in young children exposed to testosterone
/ Q! v/ X) \! ]2 sexogenously7; however, we did not measure a dihy-
, P2 l) C$ g& o! d+ ddrotestosterone level in our patient. In addition to
' A' z: R+ d1 }* V: A1 p. ~5 a/ U3 H* |* mvirilization, exposure to exogenous testosterone in( w4 l& g9 X4 X1 d8 E3 }/ b* A
children results in an increase in growth velocity and
/ D8 y0 j0 j" Padvanced bone age, as seen in our patient.. X {7 T6 N& @ O1 v! r
The long-term effect of androgen exposure during
% _& o! g2 N8 |4 [early childhood on pubertal development and final
5 }- j+ K E5 p, t. `" c s% n5 _) fadult height are not fully known and always remain0 U# P$ S4 f- O! |1 U8 i# e. Q/ m
a concern. Children treated with short-term testos-+ n) b% J, B2 }3 D! e
terone injection or topical androgen may exhibit some- U6 O) h( ?& E" E+ ?: j
acceleration of the skeletal maturation; however, after
b4 z1 D9 V% ]% B( |( x. x0 ucessation of treatment, the rate of bone maturation
/ r! _4 P9 f; [. X9 L* N5 adecelerates and gradually returns to normal.8,9! k5 h- ?5 G# Y9 M* j# P
There are conflicting reports and controversy& [2 M: Z F& z8 h% ?2 V6 x# l9 X" u
over the effect of early androgen exposure on adult' W, e% T6 z+ L# P
penile length.10,11 Some reports suggest subnormal( Y1 D% R3 a, J, a% F) q
adult penile length, apparently because of downreg-
# D7 x+ m; C- O4 W7 a* Xulation of androgen receptor number.10,12 However,4 `( g' h! N: |0 f
Sutherland et al13 did not find a correlation between! Y, K& `5 ^4 N+ d# t! |# C
childhood testosterone exposure and reduced adult
- h& z" I9 u/ b) f. [ M0 X1 Spenile length in clinical studies.
! B! H& U$ g6 ^+ }, yNonetheless, we do not believe our patient is
% d- v( Y, g) u/ V t0 E& ]3 ?going to experience any of the untoward effects from
5 l" Q5 n2 I2 @. t2 `8 atestosterone exposure as mentioned earlier because3 Y& r6 e1 G- y4 r6 p0 M
the exposure was not for a prolonged period of time." I8 u0 Q; ^, F
Although the bone age was advanced at the time of. H1 i9 F3 I- Q0 e
diagnosis, the child had a normal growth velocity at
$ K; `3 A" D* X) {9 f0 w& ythe follow-up visit. It is hoped that his final adult" ^) F- z9 U4 U4 j& m
height will not be affected.
3 e8 N7 V7 h0 [4 \ vAlthough rarely reported, the widespread avail-
% x# Q1 B5 E, o( {& Q) lability of androgen products in our society may k* f% n/ [* F6 `: x2 W& [
indeed cause more virilization in male or female
5 K8 y8 I; C. N; l$ nchildren than one would realize. Exposure to andro-8 k2 N0 b" C# d4 M
gen products must be considered and specific ques-
- r# p) `( v0 ]4 h# e; x5 V; O" `tioning about the use of a testosterone product or( }1 B- K+ {+ O# f8 @
gel should be asked of the family members during2 H& b8 h% g8 I
the evaluation of any children who present with vir-
# s- z8 V/ e) f# m( silization or peripheral precocious puberty. The diag-/ k5 N' y k+ h3 L" ? g8 w
nosis can be established by just a few tests and by
K, `' o- e. J) `3 [ Y: Bappropriate history. The inability to obtain such a
- Z5 L: a( H3 G4 ]history, or failure to ask the specific questions, may! a* {; X+ h6 h! P# [" k
result in extensive, unnecessary, and expensive4 t& p4 U+ [$ G/ J; Q
investigation. The primary care physician should be( ^! `. t8 j! ^1 p# g/ \
aware of this fact, because most of these children, M1 Q, I! k8 u( U8 u5 j
may initially present in their practice. The Physicians’
. t' U" @5 C) ODesk Reference and package insert should also put a
! [( L. G& X4 \warning about the virilizing effect on a male or
$ D6 L* q2 k; ]3 K) wfemale child who might come in contact with some-
; ]' p- T" ~2 [one using any of these products.
7 D7 H1 z8 m* C% ZReferences
% g: e1 ]3 z% m1 E C1. Styne DM. The testes: disorder of sexual differentiation
9 B+ _- \" s1 P: g/ gand puberty in the male. In: Sperling MA, ed. Pediatric; S# w: n, _% J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# X6 x* u8 l5 T% w0 D
2002: 565-628.% _$ j2 ^* r2 l3 g k5 y7 t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 R3 ~& e1 V2 D) w- b" @7 d Rpuberty in children with tumours of the suprasellar pineal |
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