- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
1 f# C8 z8 g% Y" X+ z; WBoy Induced by Indirect Topical" }, ]% H0 l) x: |
Exposure to Testosterone
1 D5 z6 P5 g' }( DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 ~) u9 d# r% U1 Hand Kenneth R. Rettig, MD12 b l2 q, `8 D+ Q* }) b1 ]7 L- p
Clinical Pediatrics0 v" U* F) R, G7 ~$ q
Volume 46 Number 6
5 Y* Z4 P" ~' k' BJuly 2007 540-543; u# {) ?& P8 m! d
© 2007 Sage Publications4 c# c9 M7 C8 v
10.1177/0009922806296651
* f X w/ @7 L. _6 whttp://clp.sagepub.com
% y! o7 e1 B/ ~; o% |hosted at
# r& j; Z$ B b% x0 _3 u: v4 l" Shttp://online.sagepub.com
# h( i Q- R& Y% l: X& c4 f$ nPrecocious puberty in boys, central or peripheral,3 |1 q. k1 N" u4 y
is a significant concern for physicians. Central+ d8 w) }, d( ?6 _2 s; k
precocious puberty (CPP), which is mediated, }( n! g, ^) U l7 G! c
through the hypothalamic pituitary gonadal axis, has
$ ?$ o! t/ c6 Y4 {a higher incidence of organic central nervous system
/ l+ p1 ~! F6 Hlesions in boys.1,2 Virilization in boys, as manifested
7 X5 |* f* h2 a! Eby enlargement of the penis, development of pubic
6 M; w8 B: ~* `, ?' }2 Bhair, and facial acne without enlargement of testi-# v4 g7 b" y7 Q! z# M
cles, suggests peripheral or pseudopuberty.1-3 We' T. K9 r! ^& M; J: v* r- c9 l
report a 16-month-old boy who presented with the& v# b* c/ o8 V. t, t
enlargement of the phallus and pubic hair develop-' G3 o2 E6 \1 {9 [9 N c* y
ment without testicular enlargement, which was due
% ^$ S, ?% i- @, ?; ?4 Fto the unintentional exposure to androgen gel used by
# o: c2 E: V! e# V, Ythe father. The family initially concealed this infor-
2 A8 w8 k$ `' v( M( v2 `mation, resulting in an extensive work-up for this
' h+ Y( p Z! M7 tchild. Given the widespread and easy availability of f% q5 H$ z3 [: A; L$ H4 }( i
testosterone gel and cream, we believe this is proba-
6 v& C* P% M% hbly more common than the rare case report in the
* D/ [, A1 c4 O, Z0 ^0 iliterature.4" _* M$ z- r3 R
Patient Report
; h; ]' C& f7 OA 16-month-old white child was referred to the
! w, p% j# G1 zendocrine clinic by his pediatrician with the concern
# I4 o5 u! L/ u" zof early sexual development. His mother noticed
# H$ V3 o0 j% Q m( P0 I \4 ]light colored pubic hair development when he was
8 I7 j3 |0 E) g# Q) jFrom the 1Division of Pediatric Endocrinology, 2University of
/ j) C$ b: ` V( Z9 p+ Z) n+ J$ cSouth Alabama Medical Center, Mobile, Alabama." h, U* q) c9 A0 {" t
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! E2 o" C* C" }4 [Professor of Pediatrics, University of South Alabama, College of
& t+ E8 S7 g N9 E( FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, A! b! u3 l6 E4 we-mail: [email protected].
8 e1 U. s! u1 `- o! Q1 Babout 6 to 7 months old, which progressively became
5 ~: i5 [, o0 s3 F, d. K0 k$ I" Gdarker. She was also concerned about the enlarge-4 W* m1 [5 z% @& ?7 W& M
ment of his penis and frequent erections. The child% M# T6 r6 [5 e% [" t3 t
was the product of a full-term normal delivery, with$ X6 n, C' [, o3 y
a birth weight of 7 lb 14 oz, and birth length of2 n- y$ E: K; t# O$ T3 L2 f
20 inches. He was breast-fed throughout the first year
3 |/ R: ]1 A5 f# G# V; Cof life and was still receiving breast milk along with
Y0 P/ o4 ~) O3 f8 Vsolid food. He had no hospitalizations or surgery,
/ A0 c! m0 k9 T1 @. Land his psychosocial and psychomotor development5 z7 v. E0 ~/ b% y# i: u- f. Q
was age appropriate.% `6 X: ]+ k) s* N& V
The family history was remarkable for the father,
& k1 X5 c' K: hwho was diagnosed with hypothyroidism at age 16,$ r1 |/ K' ^, M
which was treated with thyroxine. The father’s' Y2 m0 q$ }0 k) t8 u
height was 6 feet, and he went through a somewhat9 N: V/ H E' v5 a4 T
early puberty and had stopped growing by age 14./ @$ u' _. @/ v
The father denied taking any other medication. The# ]4 V' e5 T! u- `, u
child’s mother was in good health. Her menarche9 L6 g N. h' J4 X$ }+ Y' w
was at 11 years of age, and her height was at 5 feet
5 k: I" E. b8 J$ P2 J" {5 inches. There was no other family history of pre-8 b/ e$ V5 R' x, Z
cocious sexual development in the first-degree rela-
+ [' _: t( V- \# f5 C, X# Mtives. There were no siblings.. c$ L2 z3 B9 w7 G: z1 E+ f+ x
Physical Examination
; o) b8 ?3 ^2 U2 i! AThe physical examination revealed a very active,9 k7 A8 T) t. L" r- }! s
playful, and healthy boy. The vital signs documented* Y y0 k H F0 z5 a
a blood pressure of 85/50 mm Hg, his length was2 H# h2 V2 r. h) B8 R9 k- K. p
90 cm (>97th percentile), and his weight was 14.4 kg) k7 P5 L0 J8 H6 A4 _/ s9 H' e
(also >97th percentile). The observed yearly growth/ t- b* e* a z! m3 P4 n8 X
velocity was 30 cm (12 inches). The examination of% X6 D% {" G* m7 \: |. `
the neck revealed no thyroid enlargement.' _+ h4 Z; |, w9 P0 ~
The genitourinary examination was remarkable for
7 Q$ r6 X: i# H3 M0 e3 Menlargement of the penis, with a stretched length of+ w$ J: }- {, F L9 }
8 cm and a width of 2 cm. The glans penis was very well
3 I- E) a' B- |8 `: \# Fdeveloped. The pubic hair was Tanner II, mostly around
/ [# `! e2 s9 ]; i# {. t- U540
8 N9 C, O8 Y, e. [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( U3 i8 }2 X, t$ d
the base of the phallus and was dark and curled. The
4 j" P% T* N" N4 ~testicular volume was prepubertal at 2 mL each.* m, T0 B; l; F# n" ?9 |3 E
The skin was moist and smooth and somewhat
& y) F: r# _, @. { _( xoily. No axillary hair was noted. There were no% C5 @4 s3 P6 L X: z
abnormal skin pigmentations or café-au-lait spots.5 T) ^5 b# {* ?# T: k5 ~
Neurologic evaluation showed deep tendon reflex 2+3 T& n. G4 {+ S( n! \$ @2 I* x
bilateral and symmetrical. There was no suggestion
]5 q4 H) P" [. w( k8 Bof papilledema.
0 U+ s8 J: [2 ]6 xLaboratory Evaluation
7 R/ u4 F$ {2 e3 S' D9 S8 BThe bone age was consistent with 28 months by) ?& {1 W6 \, I2 }
using the standard of Greulich and Pyle at a chrono-9 w9 j7 W; a" L: r
logic age of 16 months (advanced).5 Chromosomal1 g+ N+ F2 r' l+ p( w( l. K' }- T
karyotype was 46XY. The thyroid function test
8 U7 [9 a6 X4 X" X' T- e' Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 ]$ ]* l. ?, V& g. B" A q
lating hormone level was 1.3 µIU/mL (both normal).7 v' }4 @4 O+ d- y$ W: i+ R
The concentrations of serum electrolytes, blood( B/ m) ^ T5 t- J. b
urea nitrogen, creatinine, and calcium all were9 U4 F& d/ i' ~& u. j
within normal range for his age. The concentration
, ]+ }! |3 r" c" fof serum 17-hydroxyprogesterone was 16 ng/dL& g7 K( x7 h4 X" \# b
(normal, 3 to 90 ng/dL), androstenedione was 20
; Q2 b9 v" ], x( \; J9 P$ F) Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" ?" k: S3 L% T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 p$ _# A/ A* i3 w) c9 [% E7 @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ Y! b e' u' f1 [49ng/dL), 11-desoxycortisol (specific compound S)4 b& C0 I7 z# u& H
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& V: q: o$ T' q* `/ q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 N, h( V$ u* O3 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% B& ~& b; X7 B- {1 @7 S/ yand β-human chorionic gonadotropin was less than9 }- S5 @' n1 N, _% I9 Q' b/ V
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: @) |( x# C4 R) {stimulating hormone and leuteinizing hormone) x$ y8 @: h8 Y! \8 y4 u0 h
concentrations were less than 0.05 mIU/mL$ K9 r% q/ G% @+ {( O
(prepubertal).( r( Q* ]7 J6 q6 m9 B) c& y x
The parents were notified about the laboratory9 a6 a# }. t0 t
results and were informed that all of the tests were
! i! ~+ C7 d% u4 ?3 F3 P8 znormal except the testosterone level was high. The+ K/ h$ t* E: U$ X
follow-up visit was arranged within a few weeks to
# r& G3 b! _& d5 Y I K, hobtain testicular and abdominal sonograms; how-5 j5 |7 G/ \+ e
ever, the family did not return for 4 months.8 k8 [7 W( E$ U# I
Physical examination at this time revealed that the
: o% y) A0 l. G6 ~0 S8 f. I& jchild had grown 2.5 cm in 4 months and had gained
) A- U0 \: r7 b: x+ e2 kg of weight. Physical examination remained+ v" {. e$ [& @6 l* D
unchanged. Surprisingly, the pubic hair almost com-
) Q) V5 m+ |: }- Npletely disappeared except for a few vellous hairs at
9 V8 p8 g3 H. n% Y: K3 Uthe base of the phallus. Testicular volume was still 21 r# F9 [. f/ K( }+ z ~8 C I
mL, and the size of the penis remained unchanged.
# a4 y) j, [. o1 h/ cThe mother also said that the boy was no longer hav-: R2 s5 U, R; H0 M) N B( N
ing frequent erections.; Z# r8 y/ ~ K# R
Both parents were again questioned about use of
+ P! i2 I7 ?; zany ointment/creams that they may have applied to, Z7 n5 E! U% Y1 D9 `/ z. g
the child’s skin. This time the father admitted the
( h5 f5 K5 @ s6 ~& }Topical Testosterone Exposure / Bhowmick et al 541
2 e# t; w4 ]% n$ E0 j3 |use of testosterone gel twice daily that he was apply-
* N& F/ [: ]6 ^$ S" U& [' g/ zing over his own shoulders, chest, and back area for; d) ]; W4 K% f# ?* a9 \! q5 u5 r9 P0 Q
a year. The father also revealed he was embarrassed
# G; d+ O0 R/ ` u; v% K/ M9 pto disclose that he was using a testosterone gel pre-, w: m" d# b3 Z2 _9 L$ G% }" c* H
scribed by his family physician for decreased libido* m/ l) t& x' a+ S
secondary to depression.
; s# i8 ]- ^4 }; DThe child slept in the same bed with parents.; n9 p; j* u. T+ D6 D
The father would hug the baby and hold him on his! z, ^9 U) S- j' M* J! r
chest for a considerable period of time, causing sig-% s. b3 n, H& y8 h- a' g
nificant bare skin contact between baby and father.
$ U4 V3 j8 c0 n+ H- RThe father also admitted that after the phone call,2 f# c( w# t! _
when he learned the testosterone level in the baby
* M: S( v. b; W. p/ vwas high, he then read the product information
* B, Z7 U- l# S- a# M7 L) ]packet and concluded that it was most likely the rea-
% T* s, A$ c$ @# }) e0 _son for the child’s virilization. At that time, they- b1 a7 \. s' p
decided to put the baby in a separate bed, and the% b2 T% l9 o$ m3 k: i
father was not hugging him with bare skin and had
' U: ~6 n+ y* ^been using protective clothing. A repeat testosterone
9 h E5 ?( A/ v. T* T! btest was ordered, but the family did not go to the
; j$ \' N6 b6 y, R6 r Jlaboratory to obtain the test.
8 R$ p$ V9 v" S; o) m. mDiscussion$ b, |& u& ^9 E7 l2 G
Precocious puberty in boys is defined as secondary m( B2 M5 Z X2 j p
sexual development before 9 years of age.1,4/ W) T* p4 z0 A7 m
Precocious puberty is termed as central (true) when
/ N* P! W& A* q6 \3 \% bit is caused by the premature activation of hypo-
- R8 o& r/ o" pthalamic pituitary gonadal axis. CPP is more com-
5 B5 N0 G8 i! c4 Mmon in girls than in boys.1,3 Most boys with CPP
4 J$ h; M+ M& t4 X( R5 d: q1 zmay have a central nervous system lesion that is
' t$ Z5 ^& A% P- i( z0 p5 wresponsible for the early activation of the hypothal-
Y) S( d8 k; a) d4 Z$ tamic pituitary gonadal axis.1-3 Thus, greater empha-* t7 v! n* E7 i- h; m+ E3 M
sis has been given to neuroradiologic imaging in
. Q- t% J: m, Jboys with precocious puberty. In addition to viril-0 q& G. O j) C& D \% W$ @
ization, the clinical hallmark of CPP is the symmet-4 B0 f: ^" U$ J" H2 n3 [
rical testicular growth secondary to stimulation by! V9 g @, Y! p8 J( S; B5 Z
gonadotropins.1,3$ S7 T1 ^( B* O7 i, c# Q; y
Gonadotropin-independent peripheral preco-
" }7 E1 s; r% M4 f0 Y+ qcious puberty in boys also results from inappropriate
! J: i% d3 A! O; b6 s/ Eandrogenic stimulation from either endogenous or
1 O' y6 x. l I- n% u7 w6 Vexogenous sources, nonpituitary gonadotropin stim-" H. G' v; u. E% O
ulation, and rare activating mutations.3 Virilizing! F( Y* t! Y; {% l. J/ U
congenital adrenal hyperplasia producing excessive& L b) M& r) o
adrenal androgens is a common cause of precocious9 S" ~. \# {$ Q) I% G, Z+ Q; u
puberty in boys.3,4
( C3 W6 b2 o$ D) EThe most common form of congenital adrenal( z. ~* Y4 ~: u5 d# _
hyperplasia is the 21-hydroxylase enzyme deficiency.
. ~! H' S9 d7 fThe 11-β hydroxylase deficiency may also result in' I& F, _8 X2 h6 N4 o( m C
excessive adrenal androgen production, and rarely,
G3 a3 P0 N- Nan adrenal tumor may also cause adrenal androgen
- I1 x3 @$ E& z$ `excess.1,3
+ G6 _6 w$ Y: D& ]2 D% X- rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) j5 M* l: G- ^1 x# L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 z& s3 H _+ r% zA unique entity of male-limited gonadotropin-
3 Z1 G' T* Y8 A) r: U. `, a2 Tindependent precocious puberty, which is also known. Y5 @. F$ T. z0 k. ^
as testotoxicosis, may cause precocious puberty at a% w. l1 F4 h ~6 z7 N
very young age. The physical findings in these boys
9 I7 K2 q0 N1 Z3 ywith this disorder are full pubertal development,# b$ g; q% |* b( _
including bilateral testicular growth, similar to boys
. Z# s0 N/ F2 s2 _9 {, [. pwith CPP. The gonadotropin levels in this disorder
' u& M S5 h. N$ ^0 rare suppressed to prepubertal levels and do not show* P$ }6 Z7 F9 E1 G& d& d, k
pubertal response of gonadotropin after gonadotropin-
( h/ z+ m" y) i& s! Xreleasing hormone stimulation. This is a sex-linked
0 }4 O9 u% b* l( O! S7 Oautosomal dominant disorder that affects only( Y" Q- j7 w) q. B* J
males; therefore, other male members of the family2 ?5 N& i0 A5 S& t- k
may have similar precocious puberty.3+ u/ C+ h% p; L9 ^& J' B
In our patient, physical examination was incon-! i" V$ B c7 {' B1 {/ R
sistent with true precocious puberty since his testi-& l8 Y- P/ U: C p- q' ~7 [7 v
cles were prepubertal in size. However, testotoxicosis
0 K3 Q4 T! p( P o7 w3 Kwas in the differential diagnosis because his father
2 B0 o. L* c; x0 [# t' n p* R" jstarted puberty somewhat early, and occasionally,
8 Z) b* D7 J3 Ltesticular enlargement is not that evident in the
' [9 [1 t5 k G- h K) Obeginning of this process.1 In the absence of a neg-
0 O# y2 i/ q ?% w' a# l7 S8 B/ Vative initial history of androgen exposure, our
0 y( l+ s! u9 Z+ h4 W5 Vbiggest concern was virilizing adrenal hyperplasia,
4 G" @6 Z& s; X4 k; Neither 21-hydroxylase deficiency or 11-β hydroxylase
9 t1 ^- O1 s# I& l2 W1 W3 Tdeficiency. Those diagnoses were excluded by find-6 [ I- v# O) x t
ing the normal level of adrenal steroids.0 y6 i" g8 J1 M+ v( `( N5 Q
The diagnosis of exogenous androgens was strongly7 n- S/ z4 C7 n! ]+ W. ?$ w
suspected in a follow-up visit after 4 months because
. z* R; j. e6 ^. Othe physical examination revealed the complete disap-
2 v) {% x# C1 A, O! a; |% wpearance of pubic hair, normal growth velocity, and& M' k! G- n; O, z9 N
decreased erections. The father admitted using a testos-9 J& Y9 I- ]1 _9 L9 `
terone gel, which he concealed at first visit. He was6 _2 x" Q' P2 V, A* \# Q
using it rather frequently, twice a day. The Physicians’4 q+ y3 F3 ~0 `! d
Desk Reference, or package insert of this product, gel or2 F: h5 M- i) Q. h8 D# z. m
cream, cautions about dermal testosterone transfer to
. k. {: _' u( I1 N, _) [7 Eunprotected females through direct skin exposure.
& h" x: \8 m# t2 s- o) J2 PSerum testosterone level was found to be 2 times the
" f7 @' h% _3 L( nbaseline value in those females who were exposed to
- j! k' a9 ?) @! z6 weven 15 minutes of direct skin contact with their male
' j; A. J n$ Epartners.6 However, when a shirt covered the applica-, ?+ E! L$ ~1 [, o) l6 ]
tion site, this testosterone transfer was prevented.& N$ _' r4 c0 ?2 [9 |! e( s# n
Our patient’s testosterone level was 60 ng/mL,
3 T: M6 u1 `, |# a5 S9 o% k9 ^" a% u5 rwhich was clearly high. Some studies suggest that+ J* q( E0 ]) s/ x, E# W
dermal conversion of testosterone to dihydrotestos-
3 G/ e0 K5 E4 [7 S/ N! oterone, which is a more potent metabolite, is more/ ~) A$ N% Q- h0 f
active in young children exposed to testosterone
1 b. K0 s/ n, i" z/ x7 v9 S1 q8 @exogenously7; however, we did not measure a dihy-
_" |2 Q& n4 M+ A9 F9 e5 hdrotestosterone level in our patient. In addition to, E+ W R7 b# s# Y- B0 I
virilization, exposure to exogenous testosterone in
( f E Q" C1 ^0 l5 q: p$ y8 xchildren results in an increase in growth velocity and( d, h ]5 S' p- X8 R$ c2 l# O
advanced bone age, as seen in our patient.
3 }- W) w8 U2 H+ t% hThe long-term effect of androgen exposure during
% m$ C; B- e6 t* c- Y: Yearly childhood on pubertal development and final% K5 N" C1 i) L$ V) p
adult height are not fully known and always remain
9 w; V: i! z- \% Z' ^3 y4 P8 Aa concern. Children treated with short-term testos-
/ c4 G9 @: D& Iterone injection or topical androgen may exhibit some$ Q% [7 n- ~0 A
acceleration of the skeletal maturation; however, after/ g, i& @" w3 Q3 ^
cessation of treatment, the rate of bone maturation
+ N! j* ^/ i4 o7 X; h4 Rdecelerates and gradually returns to normal.8,9
& f5 ]& i ^/ B& ]7 zThere are conflicting reports and controversy
8 T. S+ L2 F( @over the effect of early androgen exposure on adult) @) S9 } ~4 g- p7 B5 \7 I
penile length.10,11 Some reports suggest subnormal- o& ^& \% j) K: @8 ]
adult penile length, apparently because of downreg-5 s" C8 ]1 H2 j7 Z+ J/ S
ulation of androgen receptor number.10,12 However,
0 }: z( T+ y4 q7 o L+ n9 q. sSutherland et al13 did not find a correlation between
) }+ G: @+ y9 i$ e7 R$ N/ Tchildhood testosterone exposure and reduced adult
2 O6 t( M/ \, V" f2 Spenile length in clinical studies.
6 D1 O7 G8 v2 I b# m, GNonetheless, we do not believe our patient is7 _) e- B2 @5 I, H5 y: g0 u
going to experience any of the untoward effects from
& ~+ z# n7 [2 Itestosterone exposure as mentioned earlier because
% l1 C! X, |. z' f4 s, kthe exposure was not for a prolonged period of time.
2 ~5 @# x, Q& @6 l, B: k: ~# u8 V& oAlthough the bone age was advanced at the time of
3 M: j2 S. E C! J- c% Z0 i5 R9 ddiagnosis, the child had a normal growth velocity at3 Y* d( y& q: H- d* q/ H
the follow-up visit. It is hoped that his final adult; h% U; T( m" H' L
height will not be affected.
, I. m; {# E% U# fAlthough rarely reported, the widespread avail-/ \/ M$ F3 Y* U
ability of androgen products in our society may
* M: f: F' c4 t; A. O) l uindeed cause more virilization in male or female7 j' K0 Z* W! M: _2 ~
children than one would realize. Exposure to andro-& x* N+ E8 L/ ]8 v8 h! \
gen products must be considered and specific ques-
! w& B$ r7 B! n' v9 C% `" Utioning about the use of a testosterone product or0 L" l- G( w- ?/ W& |1 U
gel should be asked of the family members during- T# I0 t; K# P p0 z6 z( K
the evaluation of any children who present with vir-* N3 M1 v) Y# p
ilization or peripheral precocious puberty. The diag-
6 E% O! ?. H& t! `$ |; {nosis can be established by just a few tests and by( ~- a# z6 f" f. i
appropriate history. The inability to obtain such a, q! T! B/ H8 X: l" S7 U4 C
history, or failure to ask the specific questions, may M3 h+ M3 j2 p9 X! K2 B
result in extensive, unnecessary, and expensive! r6 }* u0 x8 p5 ^
investigation. The primary care physician should be
' E7 T' n$ R- saware of this fact, because most of these children
- h3 r& O0 s" t. ~may initially present in their practice. The Physicians’
+ o0 h6 F$ k! x0 eDesk Reference and package insert should also put a
, f4 R [. I8 a9 ~8 E0 t9 |warning about the virilizing effect on a male or: `/ ?- z2 X. g
female child who might come in contact with some-
" i* ]' g q' p. C5 m9 O1 ?one using any of these products.
8 e, h8 O) H3 }- }+ cReferences
# G9 f u5 u* w- j3 J4 x1. Styne DM. The testes: disorder of sexual differentiation& W& R, _+ [, \# V8 _
and puberty in the male. In: Sperling MA, ed. Pediatric
! |+ t+ k# p, J$ {3 i5 MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ L; [$ R' M6 J9 l; X
2002: 565-628.
3 ~ `; v7 H# Z% o# n3 x \ L: `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 k" L( i: S# I/ ?1 m5 s# V" N
puberty in children with tumours of the suprasellar pineal |
|