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Sexual Precocity in a 16-Month-Old
% c% _* O# B/ l5 MBoy Induced by Indirect Topical
3 ^. z% n1 J |Exposure to Testosterone7 z9 i# h f5 V, D, `8 z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: _0 ?$ O0 P4 _, t7 |, `: qand Kenneth R. Rettig, MD13 D) b+ u- l/ U, z: L" K y9 A
Clinical Pediatrics
* z3 I, r3 U- E% ]& VVolume 46 Number 6
$ X. X& p& j6 [$ H* jJuly 2007 540-543
4 g. l+ P- L2 H! U2 H: t& ~© 2007 Sage Publications
3 _- c% @$ s( q: c" J10.1177/0009922806296651/ @3 t# w A$ M0 I- o9 L; D4 F; _
http://clp.sagepub.com9 T) o4 {" I( ~% I3 n! N5 B- L
hosted at
/ V' w) {% p C1 Ghttp://online.sagepub.com$ E# Q: M7 T/ G/ f7 A4 l" J- C
Precocious puberty in boys, central or peripheral,6 ^2 \, {' b2 b& H8 T! D) W0 K
is a significant concern for physicians. Central2 q& H0 y! O8 T0 ~. V( u
precocious puberty (CPP), which is mediated
9 U" } \; k$ B I& Vthrough the hypothalamic pituitary gonadal axis, has
2 } r4 x& v0 H# P+ ia higher incidence of organic central nervous system
( G4 D/ I |0 F& e' ?- H/ L. S" |6 Rlesions in boys.1,2 Virilization in boys, as manifested, N0 }3 e' N" a, z7 `3 t
by enlargement of the penis, development of pubic8 E7 ^6 d% D5 `1 ]9 |
hair, and facial acne without enlargement of testi-
- b' _. o& X) }" \5 L* u! f( M+ ]+ Ocles, suggests peripheral or pseudopuberty.1-3 We
$ N% G7 d6 F% `: Ureport a 16-month-old boy who presented with the) b7 q$ n" u% Q' z/ b# @
enlargement of the phallus and pubic hair develop-5 G. L: n( h7 _ u9 Z( i, p& b
ment without testicular enlargement, which was due7 T }3 ?$ q: H3 D2 A
to the unintentional exposure to androgen gel used by
5 R1 I4 a8 _1 ~/ X$ G' x8 Sthe father. The family initially concealed this infor-
9 ]# A G R: Y; Z* ?mation, resulting in an extensive work-up for this
! S! I& g* Q* X5 achild. Given the widespread and easy availability of! m4 O+ _ W3 X" M5 `
testosterone gel and cream, we believe this is proba-% N, I0 L7 h1 ?% |
bly more common than the rare case report in the1 T4 J4 l; S! o& n* [
literature.4: f# }( k x, R2 H
Patient Report
9 R6 _" y+ d% V, i' X# TA 16-month-old white child was referred to the
2 O# z9 s' w2 w$ w$ U6 tendocrine clinic by his pediatrician with the concern: v- O+ h+ w4 P' F4 b$ q% ?$ x( _ d
of early sexual development. His mother noticed
% y& K- K6 d m- h# llight colored pubic hair development when he was
) E1 [+ ?5 `7 N* q3 fFrom the 1Division of Pediatric Endocrinology, 2University of w, f K3 T/ B( f5 i# j
South Alabama Medical Center, Mobile, Alabama.
. u+ B' C: N" n" W) L3 yAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 e+ A$ q7 S8 d6 F& J+ i0 CProfessor of Pediatrics, University of South Alabama, College of: ^5 S! D; |0 R( g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 Z% _8 @4 a! D' j( t6 [+ ~3 {
e-mail: [email protected].- |7 ]1 f- H4 G! A8 I* r- \( j- Y
about 6 to 7 months old, which progressively became
# Q& J) @ V/ Z/ z9 v0 s$ fdarker. She was also concerned about the enlarge-3 H4 P6 Z; V* }# H$ F3 _
ment of his penis and frequent erections. The child
5 c+ _; L" U, {$ A( | Wwas the product of a full-term normal delivery, with* W' V/ E; p+ {5 }5 n0 C
a birth weight of 7 lb 14 oz, and birth length of; p" Z. A7 m4 _& w& `
20 inches. He was breast-fed throughout the first year0 F! S' L" \0 r( |+ i; H% p
of life and was still receiving breast milk along with% E. i* Z* h# k* @
solid food. He had no hospitalizations or surgery," V% A l1 h9 J& v& x$ l
and his psychosocial and psychomotor development2 S9 V% @* |* H% v+ Z# S) v
was age appropriate.
2 t8 y, z- I% i9 I% ~4 A8 PThe family history was remarkable for the father,/ P' o8 x' R* w) ^$ c
who was diagnosed with hypothyroidism at age 16,/ @' `. j, ^' |- g% j: h( s
which was treated with thyroxine. The father’s
# d! [! E2 F q- \! E: m, ?+ Iheight was 6 feet, and he went through a somewhat0 Q) Y, C! u0 k+ i5 e
early puberty and had stopped growing by age 14.; E1 V. v! c! P. f# o' Z0 m
The father denied taking any other medication. The2 T# q3 U! Z: S; W. j+ j9 }
child’s mother was in good health. Her menarche
# _3 H" y+ d: o- ?9 P$ C/ Gwas at 11 years of age, and her height was at 5 feet: _6 N- y7 n' H
5 inches. There was no other family history of pre- V' F5 G4 p7 k# C
cocious sexual development in the first-degree rela-. n. [( ]2 ?% z, b0 V7 z3 r
tives. There were no siblings.; Q# J, P# J- V: ~( |5 f
Physical Examination
7 d+ H3 H! _4 f* wThe physical examination revealed a very active,! ~9 S$ r3 _( D L7 S% h
playful, and healthy boy. The vital signs documented
* o" V1 B0 `+ ]a blood pressure of 85/50 mm Hg, his length was
1 g4 a% ?6 G& x, f4 Y90 cm (>97th percentile), and his weight was 14.4 kg& O. a) c) i0 h
(also >97th percentile). The observed yearly growth9 W5 L& O3 i- s' ?; y
velocity was 30 cm (12 inches). The examination of. e! T* |3 {; M* J2 G
the neck revealed no thyroid enlargement.- o1 g R/ D) G
The genitourinary examination was remarkable for
0 A6 r/ `8 F# E( g" b2 senlargement of the penis, with a stretched length of9 I( S" c5 m% i
8 cm and a width of 2 cm. The glans penis was very well0 U. R( ?; l* G5 R! m
developed. The pubic hair was Tanner II, mostly around
7 I9 v* e, U2 K. O; C' F7 A R5408 f7 u' u4 e' U I M8 w+ f- F: R0 X
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the base of the phallus and was dark and curled. The0 I, d) n5 m5 l
testicular volume was prepubertal at 2 mL each.
$ u! F3 w4 d2 e! K5 } u D4 P! zThe skin was moist and smooth and somewhat4 ~- h M" u" j
oily. No axillary hair was noted. There were no& W5 W7 @& k8 ~ B
abnormal skin pigmentations or café-au-lait spots.
& ]3 z4 S( R d1 \' E/ a6 rNeurologic evaluation showed deep tendon reflex 2+
( |. E. c2 {6 tbilateral and symmetrical. There was no suggestion+ T- y. i8 E3 L
of papilledema.
s+ U, P& r4 O: F* f/ l0 ^Laboratory Evaluation3 K( X' ?* S# @" d& U" b! g
The bone age was consistent with 28 months by
7 ~/ {# p7 `/ B4 i- nusing the standard of Greulich and Pyle at a chrono-4 J& z% V1 @3 i. J( S% I9 W# b; [
logic age of 16 months (advanced).5 Chromosomal
# D! d' X5 v7 {# V2 \karyotype was 46XY. The thyroid function test8 s, `- f" ]' W! d8 X+ ~1 [; D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( H6 \0 v& @+ y% B& Y5 h& L
lating hormone level was 1.3 µIU/mL (both normal).9 j& X/ A$ E; T6 n6 X% k
The concentrations of serum electrolytes, blood
5 s4 B; \" B9 @1 jurea nitrogen, creatinine, and calcium all were
; B+ f9 A+ H6 B0 U# |within normal range for his age. The concentration
1 W) w; j+ Z* ]6 Yof serum 17-hydroxyprogesterone was 16 ng/dL& Y) }* ?% U* ]5 ?3 L* O
(normal, 3 to 90 ng/dL), androstenedione was 20
3 ?4 z- V, u* Z m8 qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 _4 G; Y8 m0 I" P& z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- j0 K, x" F: W( q+ [2 M' b# ]: Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( O5 V6 N. O1 a" }* n$ X49ng/dL), 11-desoxycortisol (specific compound S)
: ?& J8 g. y9 U: Z" P1 qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& G. d( Z9 G1 B% Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& R3 ]7 R/ o; W9 H4 }$ h0 |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; S D, \4 R) Z, land β-human chorionic gonadotropin was less than
- i9 G0 S; m+ ~7 N3 ?4 m5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 c& U) w: t' g2 d& e6 g# wstimulating hormone and leuteinizing hormone5 ]# f% U! I- n" g J/ m1 m
concentrations were less than 0.05 mIU/mL' @8 M' q* S# t; D5 h: W! c9 G
(prepubertal).9 S+ p6 _4 F) A% N7 n
The parents were notified about the laboratory* ^2 J# i6 j3 t. A, d6 W, P
results and were informed that all of the tests were1 E* p$ ]: }% o( j5 x
normal except the testosterone level was high. The
/ ^5 ~3 y9 ]7 J {" xfollow-up visit was arranged within a few weeks to
" D0 k& W2 q- J1 Iobtain testicular and abdominal sonograms; how-- `% J0 f: M# S @- R8 s
ever, the family did not return for 4 months.) F7 D1 s7 }. [! }, T4 [
Physical examination at this time revealed that the
& @, M( c1 C6 _$ y3 L, E, U7 Y- zchild had grown 2.5 cm in 4 months and had gained; F+ c/ @# W9 ?! i( v! u- T
2 kg of weight. Physical examination remained* C: O' l1 \5 q- o$ b
unchanged. Surprisingly, the pubic hair almost com-
, x$ w( q- E$ N7 `pletely disappeared except for a few vellous hairs at o& Z8 U7 l# j t1 F* l
the base of the phallus. Testicular volume was still 2
! i: Y* S; h* V" I" E) TmL, and the size of the penis remained unchanged.0 q; I- q+ P" B* M# h
The mother also said that the boy was no longer hav-
9 I. Q5 `3 n* O0 P0 H3 z( @ing frequent erections.: U9 t$ s, `: t' ~
Both parents were again questioned about use of
# ]* |- m" H7 P9 ?( M0 K% Rany ointment/creams that they may have applied to
3 Q) u; S& x9 U* X3 ]: A9 othe child’s skin. This time the father admitted the! h8 n3 j: d' s- K: @& U
Topical Testosterone Exposure / Bhowmick et al 541
& Q- A% o& D, |. Duse of testosterone gel twice daily that he was apply-
* c, F$ a0 y$ k9 ying over his own shoulders, chest, and back area for% o& S. w5 ^$ R& s
a year. The father also revealed he was embarrassed$ S+ b: T+ {# I
to disclose that he was using a testosterone gel pre-) u9 R# m' t/ y f& ]
scribed by his family physician for decreased libido7 B8 M3 E( s1 W6 O
secondary to depression.
( x$ N: X- l: l3 tThe child slept in the same bed with parents.% d" [( R$ s8 ~! m* }% |
The father would hug the baby and hold him on his
8 z: [' T# w% ?9 Q" Hchest for a considerable period of time, causing sig-' A, i* U8 k. r; B% A4 @/ U' u
nificant bare skin contact between baby and father.' `# ^7 z* r0 v) c$ ~ ~# {$ v$ a
The father also admitted that after the phone call,/ \+ a" ~, z0 n% U! e+ `1 f' }9 y
when he learned the testosterone level in the baby2 @/ ]+ m+ ^2 O; o. u
was high, he then read the product information; ^! @* i3 s' `1 ?. N: A5 K8 [
packet and concluded that it was most likely the rea-
8 Y1 F3 M1 o$ x! [7 E! Json for the child’s virilization. At that time, they" Z, }! S+ a) P9 E3 A6 B l6 y
decided to put the baby in a separate bed, and the
/ g# \: n+ b+ ]( xfather was not hugging him with bare skin and had6 x, E3 I1 N( d
been using protective clothing. A repeat testosterone+ t3 O3 p6 n3 x: o7 }, U# `
test was ordered, but the family did not go to the
% O" C3 ^8 w: j4 xlaboratory to obtain the test.
@$ r! C% Z: X( o* R# TDiscussion
6 M4 t$ A( a& z& B2 SPrecocious puberty in boys is defined as secondary
4 a4 R5 [! _5 E/ i: b6 K9 ^sexual development before 9 years of age.1,4$ |4 X% d# ]7 z( u# \2 V2 ]
Precocious puberty is termed as central (true) when% w# p4 V6 g: ?6 B3 e' H
it is caused by the premature activation of hypo-
" Y$ G, w) X. u0 Zthalamic pituitary gonadal axis. CPP is more com-; n% F: ]/ T) n
mon in girls than in boys.1,3 Most boys with CPP6 I9 q7 B2 U7 E6 n0 G! G
may have a central nervous system lesion that is0 @, b- R! L0 `( E8 a% _6 q
responsible for the early activation of the hypothal-
U+ I* c& R/ s% I6 G; r( eamic pituitary gonadal axis.1-3 Thus, greater empha-. J1 O2 S" x, g; X) L
sis has been given to neuroradiologic imaging in
7 Y( O3 s' d4 a3 u% nboys with precocious puberty. In addition to viril-
' j/ E! F5 A" {: R0 g0 tization, the clinical hallmark of CPP is the symmet-( V. S! q0 M8 }
rical testicular growth secondary to stimulation by; [3 z/ d. b h" J3 ?
gonadotropins.1,31 M: W* l5 B: [5 f! F
Gonadotropin-independent peripheral preco-, i# F* q8 _: ~( y! P: L, `8 Z
cious puberty in boys also results from inappropriate0 O5 j @+ U+ B2 R" ]: H- |
androgenic stimulation from either endogenous or0 d9 g# F/ y7 U' a( Q
exogenous sources, nonpituitary gonadotropin stim-; n+ j( C$ N# a$ x
ulation, and rare activating mutations.3 Virilizing
8 n- M; C5 p7 @# Lcongenital adrenal hyperplasia producing excessive
8 F0 O: j+ N3 z5 \. J Uadrenal androgens is a common cause of precocious! M( Y( ]6 N/ ?3 W+ g% h% L
puberty in boys.3,4
7 I: k5 \7 }9 rThe most common form of congenital adrenal8 {9 E) l f; R; T+ A
hyperplasia is the 21-hydroxylase enzyme deficiency.
1 |% f; E. I( H- V, P9 ZThe 11-β hydroxylase deficiency may also result in
! C* \) T6 W6 H0 s- P2 uexcessive adrenal androgen production, and rarely,4 a! d# m$ m5 I. g
an adrenal tumor may also cause adrenal androgen& T# K- z* ?4 a/ i
excess.1,3. ]/ p/ Z) r+ I+ \- j8 u. L) q+ V& A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! _% P) ~% |8 m* b" ]542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 v0 n8 V1 j% g3 i; w' H! Y
A unique entity of male-limited gonadotropin-
! A9 |& Y6 a9 v; k' Z8 f% Hindependent precocious puberty, which is also known
% Y6 ^7 ~. ^0 ?as testotoxicosis, may cause precocious puberty at a2 I. Q- z# I) a7 A8 K0 b# A
very young age. The physical findings in these boys" ]" D! q. g+ f' C. w
with this disorder are full pubertal development,
& t2 o; H# e2 S7 R4 b+ aincluding bilateral testicular growth, similar to boys
1 f5 y% a% _: e; {. h* s6 qwith CPP. The gonadotropin levels in this disorder/ M' X7 U T* K" G* g/ u
are suppressed to prepubertal levels and do not show& _" H- c# k6 b& _
pubertal response of gonadotropin after gonadotropin-$ P' W' Y! W0 \8 i
releasing hormone stimulation. This is a sex-linked n- D2 b) F3 s2 B5 I
autosomal dominant disorder that affects only
) W0 ~& r8 |) x+ w. S/ bmales; therefore, other male members of the family
* B$ m, r; A1 E( d/ H. kmay have similar precocious puberty.3
: ]. p' t# B2 QIn our patient, physical examination was incon-
2 i7 A/ M3 x$ V6 lsistent with true precocious puberty since his testi-: L$ g V: s; \6 Z* x
cles were prepubertal in size. However, testotoxicosis
) p, x4 j) m, J' w$ K. Bwas in the differential diagnosis because his father1 n6 W+ }2 U) V" E1 ]
started puberty somewhat early, and occasionally,
/ J2 _, `# z* r7 W( C( Btesticular enlargement is not that evident in the; e% t; W$ C, c
beginning of this process.1 In the absence of a neg-% w* U* b1 k7 }+ d) M, v; o
ative initial history of androgen exposure, our4 L5 a/ T: n- `& K: k0 L" ^
biggest concern was virilizing adrenal hyperplasia,
4 G5 A7 H% S1 s4 deither 21-hydroxylase deficiency or 11-β hydroxylase
. M. A2 _1 m9 P1 s% N3 H! G5 Bdeficiency. Those diagnoses were excluded by find-& g8 R3 z0 ?$ c
ing the normal level of adrenal steroids.
2 w1 ]1 T$ e) ~4 z$ }, HThe diagnosis of exogenous androgens was strongly
4 U! a% ~0 J7 ksuspected in a follow-up visit after 4 months because
8 @& i* m& ]. h. h6 _+ o. Sthe physical examination revealed the complete disap-6 j4 J, a+ I. ?3 K) K# S
pearance of pubic hair, normal growth velocity, and5 Y/ k* j! a& I P
decreased erections. The father admitted using a testos-
8 R- M/ l7 {+ f) N' h5 ?terone gel, which he concealed at first visit. He was/ P1 O- u' |) H! S$ O: b5 S# @
using it rather frequently, twice a day. The Physicians’
3 T9 b8 e/ S9 a% Y) C. ?8 m0 LDesk Reference, or package insert of this product, gel or1 Q+ t% C3 z. e3 ]; E1 [7 P( E
cream, cautions about dermal testosterone transfer to
$ A ^9 t8 k$ f, ^3 C+ tunprotected females through direct skin exposure.
' s6 a" O2 Z/ \. c' W' f3 VSerum testosterone level was found to be 2 times the
! F/ R+ D/ F, I; f5 X# E" Z1 Rbaseline value in those females who were exposed to
: u: V; H( Y9 y2 s' R# _7 meven 15 minutes of direct skin contact with their male8 N! V7 N- R- e! ~5 O
partners.6 However, when a shirt covered the applica-
" k$ b+ O% Y) d0 P- a/ btion site, this testosterone transfer was prevented.8 J+ q/ E( c+ {- S; C) P
Our patient’s testosterone level was 60 ng/mL,) N6 f, A) I7 }7 n5 i2 z0 b. v) L
which was clearly high. Some studies suggest that1 m, |1 ?2 \; R' x; ?4 c
dermal conversion of testosterone to dihydrotestos-! ]" Z$ P( }2 U1 n
terone, which is a more potent metabolite, is more
3 b( G$ ^( O+ i& Q; _active in young children exposed to testosterone
- {0 r, i4 P2 M' aexogenously7; however, we did not measure a dihy-+ Z! i0 g% E1 d0 b a' ?1 U
drotestosterone level in our patient. In addition to! u( ?- u" i; s/ M# H z9 K3 N
virilization, exposure to exogenous testosterone in
`" ^4 K4 k2 G" @! Cchildren results in an increase in growth velocity and
- T/ h" o5 d3 p6 P; tadvanced bone age, as seen in our patient.
2 z" O0 A) _* g. S- F! ^# s8 T9 PThe long-term effect of androgen exposure during- f; A1 O8 Y% L4 d( P
early childhood on pubertal development and final- I6 Q# E+ S* Q& f; u2 x
adult height are not fully known and always remain- c0 c0 t4 J; w
a concern. Children treated with short-term testos-
( R* z% H# F7 } v$ O N' Hterone injection or topical androgen may exhibit some
. B% ~% p! N1 K1 l+ Q" Q% ~acceleration of the skeletal maturation; however, after
# b9 b2 ~; Y* |1 e! K5 w. l0 n! Mcessation of treatment, the rate of bone maturation
& v: D: G' \) Q4 G8 f4 P; s4 Ldecelerates and gradually returns to normal.8,9. c& M2 o& e1 I
There are conflicting reports and controversy
. S% ]; W% c+ w8 n6 v7 Gover the effect of early androgen exposure on adult
9 M% A: ^) }$ G8 n$ v kpenile length.10,11 Some reports suggest subnormal
A5 V9 j( w9 t5 \, \adult penile length, apparently because of downreg-
& E7 Q1 T; L9 {" k7 Wulation of androgen receptor number.10,12 However,8 H) {: z5 d y6 g' @- |$ N. c
Sutherland et al13 did not find a correlation between3 E4 ~' |! U6 q; w/ H& z
childhood testosterone exposure and reduced adult
3 a. \, ]; T( b# P; c0 Spenile length in clinical studies.
: q, P5 s. ^5 S/ D9 ~: nNonetheless, we do not believe our patient is
6 Z2 C: k' g! w2 U! f8 [+ e7 D- f. Tgoing to experience any of the untoward effects from4 l$ G) H! E0 d; o
testosterone exposure as mentioned earlier because" U3 D) V. z, }) r* V7 V: \$ o
the exposure was not for a prolonged period of time.
5 g$ i0 D7 O. x6 j: IAlthough the bone age was advanced at the time of v( G' A5 q' l; Y: c
diagnosis, the child had a normal growth velocity at
" i& d8 W0 B9 v& Uthe follow-up visit. It is hoped that his final adult
4 }# F0 T" S; ^height will not be affected.$ C0 U0 a+ ^/ G* K! W7 b
Although rarely reported, the widespread avail-6 S9 B- P/ W4 T6 _, @! G# q
ability of androgen products in our society may
0 f9 Y: c( c2 D' W& M! Z+ eindeed cause more virilization in male or female" ~) v+ u3 C \0 o9 W/ _! j: T
children than one would realize. Exposure to andro-
$ @6 }. b4 H, N' T3 |2 Ogen products must be considered and specific ques-6 f* j- F3 X& }" K
tioning about the use of a testosterone product or5 G& ^+ O- n* d5 O
gel should be asked of the family members during
; a2 B7 l( W3 C; W8 |( A( S+ Mthe evaluation of any children who present with vir-
! O9 S0 b c* S0 y* G* F$ d, a! milization or peripheral precocious puberty. The diag-
9 v# p; s* ~$ o8 _nosis can be established by just a few tests and by. N+ Q: y5 ^& H! ?+ H
appropriate history. The inability to obtain such a/ [4 C ?5 Y! U& V, L/ M
history, or failure to ask the specific questions, may) l4 r: U0 _/ G' j6 u1 Z
result in extensive, unnecessary, and expensive8 B' A/ B* H3 _, A' k
investigation. The primary care physician should be
2 W# c& X& q D. }) uaware of this fact, because most of these children( a! P3 m% A5 x3 Z6 }6 o; S8 W
may initially present in their practice. The Physicians’4 H# [# \, u' ^
Desk Reference and package insert should also put a
) [% e5 k) N0 V. W: wwarning about the virilizing effect on a male or
! G: _: x F7 \ `4 }* d/ Efemale child who might come in contact with some-- n+ Z* }# s% }+ d9 O
one using any of these products.
' O! S3 v8 K. M' u; n7 l3 BReferences
+ f, T' t8 J) o$ T( H% @( z$ N& T* L1. Styne DM. The testes: disorder of sexual differentiation2 S; T6 c3 w0 I1 F" J* n+ A$ B7 c
and puberty in the male. In: Sperling MA, ed. Pediatric
+ b( g0 a1 c" Q# n" {5 n, U) BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! D9 P- p! W: ?4 V' h' c, J2002: 565-628." h. b; q# U6 x2 W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& R$ J& y. h9 O& K
puberty in children with tumours of the suprasellar pineal |
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