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Sexual Precocity in a 16-Month-Old
7 J7 K5 Q+ d: S1 |, L, Y3 PBoy Induced by Indirect Topical
. m3 \/ Y9 a; k/ Q. l" XExposure to Testosterone
6 j7 t0 _! T& v) O* C8 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; [2 x. }& y' \ X7 k: aand Kenneth R. Rettig, MD12 |, K: J8 b( C/ T
Clinical Pediatrics
- X( B/ U+ `' }, b. P# A8 PVolume 46 Number 62 O) A* Z' T/ q0 ` ^6 g
July 2007 540-543. \! l( O' E" f9 {" Z% K
© 2007 Sage Publications
$ m5 f& I) }$ F4 T8 U) ?10.1177/0009922806296651
8 R% t4 v4 y; F* m3 }3 j) mhttp://clp.sagepub.com
! o% ?' K5 ]9 m2 x+ i5 I6 H1 Y) d. ?# ahosted at1 ?; F) O" y$ j5 d
http://online.sagepub.com
7 c, s3 q) X5 MPrecocious puberty in boys, central or peripheral,! V) X; S1 q0 ?5 F0 S, f1 o" X
is a significant concern for physicians. Central& x4 H1 A$ V! b3 T
precocious puberty (CPP), which is mediated, A" d2 k) n; V/ t$ H2 j/ M
through the hypothalamic pituitary gonadal axis, has' ?4 @ x, R) c8 A" O+ q8 p j
a higher incidence of organic central nervous system4 N; K4 w+ E; d7 L2 x) ]
lesions in boys.1,2 Virilization in boys, as manifested
1 Y o: w* z# }. I( lby enlargement of the penis, development of pubic
# i% j9 i9 T& X7 G$ Ehair, and facial acne without enlargement of testi-
1 U2 D* P, m8 ^3 O* x$ Gcles, suggests peripheral or pseudopuberty.1-3 We( I3 G, i) t- v1 x
report a 16-month-old boy who presented with the. J/ S# U' c7 E+ @8 Y' c- S; A
enlargement of the phallus and pubic hair develop-# g# w6 O* N9 E5 j$ P' Y4 U
ment without testicular enlargement, which was due9 m: e t1 B8 f( \* Q% q9 z
to the unintentional exposure to androgen gel used by
3 M& V$ }1 \4 Ythe father. The family initially concealed this infor-
2 u a! ^; v7 A: l" {* \1 {mation, resulting in an extensive work-up for this8 D; b/ m1 L5 R3 {
child. Given the widespread and easy availability of
0 T- l, I/ v5 s0 {# z7 ]: Gtestosterone gel and cream, we believe this is proba-1 L: p4 Y- g6 G1 K
bly more common than the rare case report in the
& o% y/ j8 ~' Xliterature.4
. I, @9 Y7 m9 Q3 ]7 l7 z$ F! K( [Patient Report
f& v# e+ }& }: Y$ o- sA 16-month-old white child was referred to the
; C. L2 p; J) j) X3 Cendocrine clinic by his pediatrician with the concern3 l+ w6 L2 q/ z/ u
of early sexual development. His mother noticed) L: x% D5 K" t* D9 A: x: g1 E
light colored pubic hair development when he was
& V( v$ l2 h, b0 ?: P. X0 `$ bFrom the 1Division of Pediatric Endocrinology, 2University of- P/ X5 K& x& j$ ]$ Q* ?3 A- S$ U
South Alabama Medical Center, Mobile, Alabama.
8 a/ ?4 Y9 Y; v* FAddress correspondence to: Samar K. Bhowmick, MD, FACE,; \4 J. F- V* t/ K( T ?+ b
Professor of Pediatrics, University of South Alabama, College of7 ~. ]# B5 |2 d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' ?! {9 N. x, P2 `' A+ Xe-mail: [email protected].
, O3 {" O0 M; _, ]1 z8 l. wabout 6 to 7 months old, which progressively became
# ?5 S! ]( N' Z. L0 [9 v odarker. She was also concerned about the enlarge-4 W. u) P+ J5 Y& V% O2 G
ment of his penis and frequent erections. The child
# X3 G' U# v x$ S/ ?was the product of a full-term normal delivery, with/ P9 x2 F! ~' q( r7 w
a birth weight of 7 lb 14 oz, and birth length of4 d C. m0 d- L6 I2 ]& n
20 inches. He was breast-fed throughout the first year
* s1 ~- ]6 e7 b# q6 Z6 ?of life and was still receiving breast milk along with
/ I4 E& k2 c9 ` K0 ksolid food. He had no hospitalizations or surgery," P( S0 A, A3 P! l# K
and his psychosocial and psychomotor development
/ E8 @% M ^' r5 F$ r: [4 i, Cwas age appropriate.
3 ~3 I) E; u# z& OThe family history was remarkable for the father,
% u: F4 H% E# P9 E& q+ G* zwho was diagnosed with hypothyroidism at age 16,- Q- M& U ]4 B! q1 _! Z+ J
which was treated with thyroxine. The father’s
# W) L( z% ~ j& m& ]! dheight was 6 feet, and he went through a somewhat
9 q, R8 K- }5 c$ r- {; [3 u+ Zearly puberty and had stopped growing by age 14.3 S/ H* N" A9 u
The father denied taking any other medication. The
$ y7 J5 M7 r, Y- Lchild’s mother was in good health. Her menarche! I2 B* x8 G8 G$ p8 B+ R
was at 11 years of age, and her height was at 5 feet
' ` d& P+ S7 z" [8 }5 inches. There was no other family history of pre-
. n% e& Z5 @, gcocious sexual development in the first-degree rela-5 \+ |5 L4 X3 B3 g/ s
tives. There were no siblings.* x9 c. p3 e9 Y* j9 T6 l) a+ F
Physical Examination
4 v* r* I- j: s9 uThe physical examination revealed a very active,
/ m }- Y- H7 L3 m* o4 i& Oplayful, and healthy boy. The vital signs documented1 Y# T$ M& X- Y3 ^- u" Y
a blood pressure of 85/50 mm Hg, his length was2 x W) x. j3 t; F
90 cm (>97th percentile), and his weight was 14.4 kg
, L" v6 h2 P, W T(also >97th percentile). The observed yearly growth
3 A! A" l5 f2 j# n6 pvelocity was 30 cm (12 inches). The examination of
) j" P! F# B) y8 b$ g! Hthe neck revealed no thyroid enlargement.
$ S, w; c+ ?! q- |$ jThe genitourinary examination was remarkable for
: Q) O7 ^1 f6 v1 N/ Oenlargement of the penis, with a stretched length of
6 ^9 O* K" B, N- ^- O" Q$ W7 q7 o4 v8 cm and a width of 2 cm. The glans penis was very well' U( }' [5 a. q K* @( u; U9 {
developed. The pubic hair was Tanner II, mostly around2 o( v, D2 p. c# @/ _4 _/ G+ g
540# d( D$ L: q( c( y1 }1 r/ i
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the base of the phallus and was dark and curled. The
. @& l$ G% E S$ |testicular volume was prepubertal at 2 mL each. X% R% |; z$ T: m7 j
The skin was moist and smooth and somewhat
, ]; b1 `' J$ S% t" X/ Y9 ]oily. No axillary hair was noted. There were no
" `* `, v" v3 q1 Rabnormal skin pigmentations or café-au-lait spots.
/ Q# Y- i4 k5 f6 r( _1 `Neurologic evaluation showed deep tendon reflex 2+* i2 w) U8 i5 `
bilateral and symmetrical. There was no suggestion
$ R) e" N6 {% lof papilledema.
U8 x+ ^) d" {- @9 F* o3 [Laboratory Evaluation2 f3 q% F! w, o7 B* N8 U& I
The bone age was consistent with 28 months by
+ ^$ A% K9 ]% [3 _' b, Tusing the standard of Greulich and Pyle at a chrono-
, P9 x4 U# i3 l+ V C# flogic age of 16 months (advanced).5 Chromosomal
" n8 l* |+ U6 C/ Hkaryotype was 46XY. The thyroid function test4 _$ ]9 m3 k! r, I. v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ k7 e8 v8 N Y7 I. |2 ?lating hormone level was 1.3 µIU/mL (both normal).
" c2 Z% z4 k+ v: mThe concentrations of serum electrolytes, blood7 t7 i2 W/ y4 a1 u
urea nitrogen, creatinine, and calcium all were% S, X* \8 F7 T3 N, @& V2 w) |) D+ M
within normal range for his age. The concentration
F' H- l8 {- F/ e& h- mof serum 17-hydroxyprogesterone was 16 ng/dL6 l- W& C, i+ n8 Q5 P
(normal, 3 to 90 ng/dL), androstenedione was 20
, B! ]: s1 d" ~$ ^/ S- Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 e( R% f0 I/ }! V. v5 u5 U" `* h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) `2 O# B( i8 Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! a$ d9 s! ^$ C* K49ng/dL), 11-desoxycortisol (specific compound S)$ |% E! _) t: a7 D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 ]3 z* [1 k' h+ W! L4 o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 o' k A; R+ ?- E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ D* `3 w1 S1 G9 U V3 Land β-human chorionic gonadotropin was less than
0 q7 ~; T3 Z( g5 mIU/mL (normal <5 mIU/mL). Serum follicular6 ]0 K$ s W* h) r% n# h8 ~: V
stimulating hormone and leuteinizing hormone) _- ^( ^. H' E& O- z
concentrations were less than 0.05 mIU/mL
1 p: W* d, H0 e# u1 ]1 U" r: q(prepubertal).2 c- g. Q6 E e
The parents were notified about the laboratory* v7 S) {) p9 m Q- X( E& R* U
results and were informed that all of the tests were, s3 ^/ G0 g- m5 D7 ~; ]- z- _4 F
normal except the testosterone level was high. The3 @. [7 y% _. T4 c% j9 t4 |& U1 E
follow-up visit was arranged within a few weeks to
" ~( V9 v$ J0 V. `- o: Zobtain testicular and abdominal sonograms; how-9 D. f: Y6 [4 g, z* z+ T5 X N
ever, the family did not return for 4 months.2 p( i- a+ q( T2 G
Physical examination at this time revealed that the! t5 C0 @, c+ ^! n
child had grown 2.5 cm in 4 months and had gained
& N0 G+ I( c9 M' y) b2 kg of weight. Physical examination remained8 p" \' K9 q: D$ R/ ~6 S' Z
unchanged. Surprisingly, the pubic hair almost com-
, l/ P, h( k' b+ O( h# F, Vpletely disappeared except for a few vellous hairs at/ q, q/ O0 I9 r) a1 r
the base of the phallus. Testicular volume was still 2
4 X# i& v3 \5 B$ mmL, and the size of the penis remained unchanged.
1 d# o) i2 ?9 y f& z) E4 D/ GThe mother also said that the boy was no longer hav-
& {& e$ Y" u4 m6 _ing frequent erections.: T+ _6 c" r1 a
Both parents were again questioned about use of( V1 U3 X1 q v' R" M5 G( x9 ?4 c
any ointment/creams that they may have applied to( I* t+ b3 N0 o' H) Q' W$ G
the child’s skin. This time the father admitted the
: V1 @3 }: [+ R2 W5 A0 gTopical Testosterone Exposure / Bhowmick et al 541% Z b Y. F& D) ]) G
use of testosterone gel twice daily that he was apply-) @* R1 k( K3 i; t% L
ing over his own shoulders, chest, and back area for, e% U2 v; {2 w# `
a year. The father also revealed he was embarrassed: \ [, J1 c* H* |: ^
to disclose that he was using a testosterone gel pre-& v* C! v p0 P. n% F8 l' q' j
scribed by his family physician for decreased libido
G1 T4 O& |5 W7 I% wsecondary to depression.
9 ^4 _. ~) w- S! YThe child slept in the same bed with parents./ v2 S; G+ @0 Z
The father would hug the baby and hold him on his c& k1 f k7 I2 c3 U' J' f
chest for a considerable period of time, causing sig-# [: V0 t: R6 I+ Z' H& T) N6 j
nificant bare skin contact between baby and father.
) [0 g" i$ }; \0 w5 Z0 B. b/ H4 n5 [The father also admitted that after the phone call,
# j" J$ e: N& H+ owhen he learned the testosterone level in the baby u- M) N- V$ A- E% Y: e
was high, he then read the product information
T* r% J0 `7 I; I2 N# Tpacket and concluded that it was most likely the rea-
! t* y" m& |: Q* F1 ]son for the child’s virilization. At that time, they6 ~( g& k/ ?* C! m
decided to put the baby in a separate bed, and the7 ~6 x( d1 }9 G1 Y' ?; x& O
father was not hugging him with bare skin and had
' c! M; O+ ~, O1 b- C" j b0 Vbeen using protective clothing. A repeat testosterone
7 n. q+ {1 h' F- z [test was ordered, but the family did not go to the
' a% @- N: ^$ p/ Q7 xlaboratory to obtain the test.1 ~7 n- z0 n- [$ Q) D
Discussion& ?# l/ l- e5 G* c" p) A$ a
Precocious puberty in boys is defined as secondary
$ ^% x* e% f5 `# N- B7 r' n0 Rsexual development before 9 years of age.1,4& `0 h% _/ J( q* q; R
Precocious puberty is termed as central (true) when
L$ z* \4 H# u' {# sit is caused by the premature activation of hypo-
" E$ J% A& \6 o( w' z8 qthalamic pituitary gonadal axis. CPP is more com-
. x$ @. H' M6 C( ~4 O7 amon in girls than in boys.1,3 Most boys with CPP% g9 x, ~# B h' Q
may have a central nervous system lesion that is
1 j: F! V* T' L; Y- A0 qresponsible for the early activation of the hypothal-
% u' d* l& w2 X' u/ mamic pituitary gonadal axis.1-3 Thus, greater empha-6 ]5 n* l% ^; i Q
sis has been given to neuroradiologic imaging in
3 h" E f: z& F; }- x! ~& S, C6 Wboys with precocious puberty. In addition to viril-7 j0 R+ X) ?' t1 ]! c8 _+ ^
ization, the clinical hallmark of CPP is the symmet-
" o9 t+ d# {/ r2 Q( r) vrical testicular growth secondary to stimulation by8 B' x* b7 W/ ~; f, J: V/ @
gonadotropins.1,3
- u0 n" Q) T2 ]4 f9 m% u* k4 g, tGonadotropin-independent peripheral preco-) i: ], V6 T3 S) {" v% g
cious puberty in boys also results from inappropriate
8 H9 M, u$ t, d- M* Uandrogenic stimulation from either endogenous or4 {( f3 e2 r4 e: M. d3 Y |" A
exogenous sources, nonpituitary gonadotropin stim-
# w3 E7 b" @) i* l! h/ u1 Zulation, and rare activating mutations.3 Virilizing
" W# I3 s9 h; ~ j- p Ncongenital adrenal hyperplasia producing excessive
2 b4 Y \' C1 i2 [! dadrenal androgens is a common cause of precocious$ W) k* l$ h o, U4 C1 w
puberty in boys.3,43 r `+ @( C; |) S
The most common form of congenital adrenal+ B5 n& ?, h1 _$ b( ]# b& z
hyperplasia is the 21-hydroxylase enzyme deficiency. l% s" [3 v$ ]: { |% i% R
The 11-β hydroxylase deficiency may also result in
& ?( n. r, s/ m# p$ o, ^excessive adrenal androgen production, and rarely,4 P2 n; `# B9 m1 V6 _% A4 h& d" d
an adrenal tumor may also cause adrenal androgen- q5 ~1 r: _/ f( w
excess.1,3
" E/ t6 H$ ]& `1 r5 Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ d! F4 A9 L4 Q! w9 x
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ s) D1 W) ?. U2 j$ ~" N$ J
A unique entity of male-limited gonadotropin-
6 x9 O [+ g4 O$ {independent precocious puberty, which is also known
& D# C5 ?" q( Q A" Ias testotoxicosis, may cause precocious puberty at a! S2 M3 m P, G- d) ?$ H
very young age. The physical findings in these boys
6 z9 c# y1 s* n* F0 _with this disorder are full pubertal development,2 n! s' q) E( O5 Q5 i B
including bilateral testicular growth, similar to boys
, U, u8 F. M" H ^with CPP. The gonadotropin levels in this disorder: `% `2 Z0 j9 ~3 _5 b u
are suppressed to prepubertal levels and do not show
! }& y/ d# ] ipubertal response of gonadotropin after gonadotropin-. J! K! y4 l2 E
releasing hormone stimulation. This is a sex-linked
8 W) p, w! l( f; s$ hautosomal dominant disorder that affects only
+ N. v+ k6 a9 k8 Pmales; therefore, other male members of the family& P0 C4 c5 o% d; H* q. P
may have similar precocious puberty.30 X- J4 M% G7 d1 f" ]: c
In our patient, physical examination was incon-
1 C! G+ J; Y1 u% ~% X1 lsistent with true precocious puberty since his testi-+ ~& k% Q) ~; }) a3 p+ k; @
cles were prepubertal in size. However, testotoxicosis% X6 S6 D: g) v, O+ E: c0 ?
was in the differential diagnosis because his father! G! y, v" d5 R4 T& K
started puberty somewhat early, and occasionally,
: l1 Z: G. A- P' Y$ ^testicular enlargement is not that evident in the
' q! V3 i' i4 [6 ybeginning of this process.1 In the absence of a neg-
$ q9 r9 \# T0 |$ Mative initial history of androgen exposure, our4 o" b$ L8 R- x: A& W
biggest concern was virilizing adrenal hyperplasia,
3 l6 _3 D" N8 b: Q* \8 j3 N5 h8 R4 qeither 21-hydroxylase deficiency or 11-β hydroxylase' B/ h0 v. n+ H+ L e1 L4 P u
deficiency. Those diagnoses were excluded by find-
' X+ o% a; z- _ Q, u. ]! m' Eing the normal level of adrenal steroids.
- f. K$ y) W! E6 G' }3 o" Z* aThe diagnosis of exogenous androgens was strongly
$ \9 s3 u- R/ Ksuspected in a follow-up visit after 4 months because' ?6 u8 u1 N: X& S0 u6 x
the physical examination revealed the complete disap-9 J1 M; i; w& M; M" Y
pearance of pubic hair, normal growth velocity, and
* U( M7 |7 }! @. Udecreased erections. The father admitted using a testos-
5 M( [3 A( b: I% mterone gel, which he concealed at first visit. He was
5 y% T' N( E" T8 O1 uusing it rather frequently, twice a day. The Physicians’4 h8 p3 X% }, G8 r# P
Desk Reference, or package insert of this product, gel or F( p- C. w% W
cream, cautions about dermal testosterone transfer to0 c! K% I( T# ^7 @% Z3 Z% u( k
unprotected females through direct skin exposure.
1 n2 n+ z* s4 K# jSerum testosterone level was found to be 2 times the
9 ]/ _1 ?# w3 e6 ]( |baseline value in those females who were exposed to* z: i- h: @* a# K' c
even 15 minutes of direct skin contact with their male2 d3 t- A% }8 m( \
partners.6 However, when a shirt covered the applica-* P% l9 k; f. J" U2 T/ W! k7 H, `
tion site, this testosterone transfer was prevented.% j0 e1 [$ T( y" y. \* \
Our patient’s testosterone level was 60 ng/mL,3 s+ j; t0 r3 d
which was clearly high. Some studies suggest that0 i+ n/ K4 c' \
dermal conversion of testosterone to dihydrotestos-
2 u7 q% d% ^. _; Gterone, which is a more potent metabolite, is more/ h2 g& x* G2 a N( k
active in young children exposed to testosterone
9 D8 V$ n H% m6 O# t/ ^exogenously7; however, we did not measure a dihy-% u* |0 w, [: v# @( c% v
drotestosterone level in our patient. In addition to
& v3 n- j# d. z6 Ovirilization, exposure to exogenous testosterone in
: R/ l, h# P" h# d# x: ?children results in an increase in growth velocity and
2 l& d8 }3 }$ _0 Q0 [6 kadvanced bone age, as seen in our patient.
, ?) Y; \' k' X4 dThe long-term effect of androgen exposure during8 {. v( t! ~! K- j* ]5 v7 x2 }
early childhood on pubertal development and final+ [, |* m) D; D' r3 I( |
adult height are not fully known and always remain
) r& S8 b- I9 Q) ]. _: ?+ S5 a- z, Sa concern. Children treated with short-term testos-9 O9 p* E2 P' @5 @+ e
terone injection or topical androgen may exhibit some5 ]9 }/ W' Z, n/ N
acceleration of the skeletal maturation; however, after
! O: z# x' u7 H vcessation of treatment, the rate of bone maturation) c/ F9 _4 y9 q1 Y/ o0 a
decelerates and gradually returns to normal.8,9
" N5 k( i6 i2 v% RThere are conflicting reports and controversy1 l5 J* u8 V {+ S6 }) N
over the effect of early androgen exposure on adult
% j6 Z7 D' r+ jpenile length.10,11 Some reports suggest subnormal- b8 m' G1 K) W8 o9 A4 ~5 v& p8 b
adult penile length, apparently because of downreg-0 j$ `; z+ K+ w7 z% {
ulation of androgen receptor number.10,12 However,
& H. l1 Z/ S& {3 V, x1 wSutherland et al13 did not find a correlation between
d! @/ Z( D3 ^0 jchildhood testosterone exposure and reduced adult
, v0 U+ G' ]% {* o3 {! fpenile length in clinical studies.
9 h3 Q8 p6 ^3 A4 d) y. XNonetheless, we do not believe our patient is
2 l$ K/ t, X" H6 M1 t! wgoing to experience any of the untoward effects from
: v& L+ q) K2 b1 q2 I5 Rtestosterone exposure as mentioned earlier because* {5 R6 |3 j+ y3 F
the exposure was not for a prolonged period of time.
o! v$ E. i" h5 c' N! w- H o' JAlthough the bone age was advanced at the time of
4 \8 R8 G- x, e$ ^diagnosis, the child had a normal growth velocity at
5 \( ^' q% \( D! G( O/ @" [! V Xthe follow-up visit. It is hoped that his final adult
$ w) w+ |. p' T$ Y; v' d$ \height will not be affected.7 @4 z+ ?. r9 u+ h% W; I. W6 {
Although rarely reported, the widespread avail-
- p, l* b6 Z* M/ u5 S3 Lability of androgen products in our society may* k1 R( J1 d. k2 i* [( ~* u6 r% q5 _
indeed cause more virilization in male or female& R: G+ S9 p, D7 A3 n
children than one would realize. Exposure to andro-, l, I; ~# X% G; w
gen products must be considered and specific ques-
- U: ~7 t4 z: N3 l+ O% Z; n; E. itioning about the use of a testosterone product or
- [/ ?. X0 y" [, @6 I8 ]gel should be asked of the family members during, i( c! _) r+ D
the evaluation of any children who present with vir-, _; @: g( e% v# [! S% `, j+ v
ilization or peripheral precocious puberty. The diag-
1 y# V" l& E8 H6 T+ onosis can be established by just a few tests and by- L a3 M. j6 f5 o) e8 J
appropriate history. The inability to obtain such a4 j0 z: O6 {' n" D2 }; K' V
history, or failure to ask the specific questions, may
) A+ T' b# c8 |- \' Wresult in extensive, unnecessary, and expensive
& i7 y/ X0 K! Tinvestigation. The primary care physician should be
7 f5 O) e, f- G1 m/ M4 ^; H3 U# s- ^aware of this fact, because most of these children2 c' L, C& Z. e
may initially present in their practice. The Physicians’" C/ z" V; ?. L4 A, E* }5 i6 |5 N
Desk Reference and package insert should also put a
$ F4 |, u4 {) Kwarning about the virilizing effect on a male or+ O+ i- ]2 ~& Z3 [
female child who might come in contact with some-
7 y4 X0 ]5 d& C( X6 C. U' pone using any of these products.! y1 U: b- X) G5 B/ H) g
References
( A2 A2 ]% O" k6 l$ V: I; }1. Styne DM. The testes: disorder of sexual differentiation
% k1 J) c# X; B) i( Tand puberty in the male. In: Sperling MA, ed. Pediatric/ C4 c' |3 N V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 ^ _+ U/ m& L: Q/ b* P2002: 565-628.
$ I# a6 W+ K g2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 N9 y G0 x: l1 J, ]puberty in children with tumours of the suprasellar pineal |
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