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Sexual Precocity in a 16-Month-Old
4 @9 A: I8 n) C" _Boy Induced by Indirect Topical
" S$ K; r; A' O0 Z' \7 vExposure to Testosterone
7 ^8 t* Y" b) F/ iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% Y# T6 z: ]4 b- ]5 \/ L) |, pand Kenneth R. Rettig, MD1
. f$ z+ G8 F2 S- D/ m9 bClinical Pediatrics- n" X3 I$ E* I0 `, c) t9 }
Volume 46 Number 6' B: ^& q+ H h+ n8 A- y
July 2007 540-543% m1 h- B U2 q3 n
© 2007 Sage Publications
9 T( K& T0 _( _ z7 l- Z( J, q0 y10.1177/0009922806296651% S7 K% T% e) a" }: O
http://clp.sagepub.com7 q' ~6 {* M1 _" P4 g
hosted at _* f( u4 q4 r% N
http://online.sagepub.com
) N+ U; z% N6 X, c% SPrecocious puberty in boys, central or peripheral,' W- ^+ N) r' ~+ q8 x
is a significant concern for physicians. Central4 I1 F7 g; x" W* u: D3 H9 [, g
precocious puberty (CPP), which is mediated: k( P |' K& P+ {- |
through the hypothalamic pituitary gonadal axis, has' B2 J H" _9 _2 P8 k; {
a higher incidence of organic central nervous system8 H8 Y. m# o5 h. J: L+ h
lesions in boys.1,2 Virilization in boys, as manifested& T J1 Y2 n) S4 M1 e" `8 R
by enlargement of the penis, development of pubic. O, {6 D1 ?* o% [9 \
hair, and facial acne without enlargement of testi-
6 j! v6 W) l' o0 T- \4 qcles, suggests peripheral or pseudopuberty.1-3 We
1 s6 ^1 c a0 Preport a 16-month-old boy who presented with the
6 V/ S: n- A% h0 a) i4 S- ] z eenlargement of the phallus and pubic hair develop-
) q8 W3 W C. L! {7 R# \ment without testicular enlargement, which was due1 p, J; m9 \+ s5 W; H
to the unintentional exposure to androgen gel used by' p' `1 s2 ^) v" h. r
the father. The family initially concealed this infor-
- [' r" _/ [9 b1 S2 t0 O/ c \$ bmation, resulting in an extensive work-up for this8 j% i/ c6 K9 |/ f+ q9 P
child. Given the widespread and easy availability of
; X& q9 S6 R3 |/ r$ l/ e8 z3 g3 utestosterone gel and cream, we believe this is proba-3 Q3 K- _& a0 F
bly more common than the rare case report in the
0 ] p+ z% {4 \6 Lliterature.4( l' Q9 H/ ^* ~; W7 S5 R' g
Patient Report
' B% d& x: [& Q7 Q0 a6 ]A 16-month-old white child was referred to the
/ Z8 w7 w) j) [" p6 R9 @endocrine clinic by his pediatrician with the concern
, I6 y$ c" D: G! K) o8 E% F! m$ Tof early sexual development. His mother noticed: H" p$ `9 {: X9 B, `6 \( e
light colored pubic hair development when he was$ I0 I! x8 l$ [+ x; |( B, F5 d
From the 1Division of Pediatric Endocrinology, 2University of+ x, ]9 @# W% c! `
South Alabama Medical Center, Mobile, Alabama.
2 K% A$ w9 s% O6 X4 W) wAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ _: S M# M+ _, D# {; `Professor of Pediatrics, University of South Alabama, College of9 p0 g/ {. c1 E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' m6 C& D2 t$ p k4 G5 ^e-mail: [email protected]./ W d' B u5 X# T5 ]: i
about 6 to 7 months old, which progressively became/ W$ S# I- U: i4 p3 E
darker. She was also concerned about the enlarge-
$ f5 i+ Q% r6 [$ Iment of his penis and frequent erections. The child; Y9 M3 l$ t& D/ }- U" Z. c
was the product of a full-term normal delivery, with
( [( r$ V m2 h0 u$ ya birth weight of 7 lb 14 oz, and birth length of
8 ]" q6 t, F" j6 I9 Y20 inches. He was breast-fed throughout the first year
$ m& H$ Q2 N5 R% N3 @ @$ Qof life and was still receiving breast milk along with
: d; Z7 s& `8 D% {0 I9 X d2 isolid food. He had no hospitalizations or surgery,
- K+ q. `- Y9 M% xand his psychosocial and psychomotor development
9 u$ R+ ]0 C7 v0 cwas age appropriate.
- N; b: H3 P1 xThe family history was remarkable for the father,
5 \9 h# N7 \- l, C1 Uwho was diagnosed with hypothyroidism at age 16,. U" V( l7 F; Q- a1 F; i
which was treated with thyroxine. The father’s
: j+ G+ ?9 \8 s2 w; b" S7 Qheight was 6 feet, and he went through a somewhat$ c7 t* G' E% ]: n& l
early puberty and had stopped growing by age 14.
, }* H, Y* t1 D d6 Q1 j% AThe father denied taking any other medication. The
. t, b( C) m% w! \& B; {0 nchild’s mother was in good health. Her menarche1 k" N9 ]2 {1 [( ~- r' `
was at 11 years of age, and her height was at 5 feet) ~+ \! f8 d% o
5 inches. There was no other family history of pre-- m. ~( s0 M2 X. W+ x& p$ S
cocious sexual development in the first-degree rela-
6 A- W# |9 y% Mtives. There were no siblings.* C5 C }- v( ]; |. r- T8 S
Physical Examination
3 z& T& p* S! M, h( [8 ^7 @The physical examination revealed a very active,% f( W1 X3 _* }: B4 n; y
playful, and healthy boy. The vital signs documented D* {9 j4 t3 l, y6 ^8 R% T
a blood pressure of 85/50 mm Hg, his length was
4 p# G3 a. J# F' ?) J9 P5 D9 a) J/ P90 cm (>97th percentile), and his weight was 14.4 kg2 C' Y$ S1 K. Y/ n1 Y
(also >97th percentile). The observed yearly growth1 ~/ s, W4 N6 A) b
velocity was 30 cm (12 inches). The examination of
: W; E- J# c. J% A* nthe neck revealed no thyroid enlargement.$ N0 g& `/ S5 w; O; J9 A- `+ e7 Q0 @
The genitourinary examination was remarkable for3 U- o# o5 k [' q
enlargement of the penis, with a stretched length of
7 p+ c% `3 v3 R6 K5 t$ g8 cm and a width of 2 cm. The glans penis was very well
7 R5 g k, s+ x+ r' H ldeveloped. The pubic hair was Tanner II, mostly around
8 e8 C5 e: M- l I# S+ Y: N; G2 x5403 P* M, X& ]; U. d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 Q# I6 W9 _$ _2 O; X- |the base of the phallus and was dark and curled. The% \2 g; U, z3 M( D0 \: ]
testicular volume was prepubertal at 2 mL each.4 r. i1 H5 M7 P8 P
The skin was moist and smooth and somewhat5 n# ]) ~0 K! Z
oily. No axillary hair was noted. There were no n$ m* A y7 f4 |, {# y+ d1 y
abnormal skin pigmentations or café-au-lait spots.
/ z ?* R" W8 ~ oNeurologic evaluation showed deep tendon reflex 2+
- Z' e3 r! h0 b% ?bilateral and symmetrical. There was no suggestion
2 u0 V) L7 u6 l+ O1 ?( _+ h0 Oof papilledema.
5 q; O% f, E- k# m; x3 JLaboratory Evaluation) T! s. ?* M- `3 U
The bone age was consistent with 28 months by* H- ?! @) D! I! Z6 c
using the standard of Greulich and Pyle at a chrono-
. p* R, b5 `* s5 f/ p2 glogic age of 16 months (advanced).5 Chromosomal; F: l- a- J$ J" \7 t+ g" R
karyotype was 46XY. The thyroid function test" i1 c4 }# X; T- ?; y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 ^3 ?# x4 s+ J, Jlating hormone level was 1.3 µIU/mL (both normal).
' O% ~" M4 v0 j5 B' n9 S" n5 O- c& DThe concentrations of serum electrolytes, blood9 Q& w' `- S+ X1 U
urea nitrogen, creatinine, and calcium all were7 m$ E3 F8 u2 F/ _& n- s
within normal range for his age. The concentration3 [- e' Y& ^, G
of serum 17-hydroxyprogesterone was 16 ng/dL: i5 e3 d# [/ l& u: o/ o
(normal, 3 to 90 ng/dL), androstenedione was 20% ^3 J% F$ X* H D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 J6 h z) T4 Q# [! |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: }3 y; j3 x7 v% w& ^
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. h6 V2 k6 t& a
49ng/dL), 11-desoxycortisol (specific compound S)
7 f+ ~, u; @- Z9 j' e' pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ x1 o0 g) w: s; Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# U3 N8 e! m1 s2 {! [# a& J( ^. y$ V; _testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 j) n3 M5 h! S8 x1 x
and β-human chorionic gonadotropin was less than8 Y( N y5 x" S# J
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ v8 `: ?- x: Rstimulating hormone and leuteinizing hormone
W# N, y- @$ A( m& u# nconcentrations were less than 0.05 mIU/mL
$ H9 v$ W* I" ](prepubertal).( R% C2 l+ z& ~# w
The parents were notified about the laboratory6 a; N8 u, ~: V* ?
results and were informed that all of the tests were" D4 l. r- Y P: ]8 t! s$ D( @* m
normal except the testosterone level was high. The
, \' v$ m6 e5 \6 Y% ifollow-up visit was arranged within a few weeks to
2 s0 I( R8 y& O, k' Tobtain testicular and abdominal sonograms; how-$ l P# Q+ i3 r a
ever, the family did not return for 4 months.4 s* K8 Y( |- H0 Q
Physical examination at this time revealed that the
; i+ k- b( N/ w6 lchild had grown 2.5 cm in 4 months and had gained
; G: l& I3 g$ o8 z& `5 ]( q2 kg of weight. Physical examination remained% l4 r& T7 [; C3 ^
unchanged. Surprisingly, the pubic hair almost com- J8 F5 F1 F3 U3 c
pletely disappeared except for a few vellous hairs at- F. ^0 ]7 O# [
the base of the phallus. Testicular volume was still 2
) x% S/ _, \' q# b1 k# t2 j8 [mL, and the size of the penis remained unchanged.
s0 D8 K+ v9 J6 c: B0 M+ @7 PThe mother also said that the boy was no longer hav-" l- K O' B$ s# ?! k
ing frequent erections.
, k8 M/ u! l; j$ }% d. w( lBoth parents were again questioned about use of% x, b7 _1 Z! s9 g1 Y$ ^5 X/ N# s
any ointment/creams that they may have applied to
) {* Z, z7 X7 G+ G$ G# g+ k1 Ethe child’s skin. This time the father admitted the
* w% l8 C0 F4 h' ^Topical Testosterone Exposure / Bhowmick et al 541
$ D, F- p* S2 w7 T0 }. i* \use of testosterone gel twice daily that he was apply-. |* {/ j n' U% o# A
ing over his own shoulders, chest, and back area for/ ?( u0 W: R& B) M
a year. The father also revealed he was embarrassed1 G k1 P9 C" R* x
to disclose that he was using a testosterone gel pre-
) {- y% s* s8 d) y0 S; T, }scribed by his family physician for decreased libido( w% o/ A: q1 J n! p9 z; G, J
secondary to depression.
+ w. \& V5 h& P5 A7 kThe child slept in the same bed with parents.
]! E9 } I) M1 c! xThe father would hug the baby and hold him on his
7 M' i) n' m/ r9 ]chest for a considerable period of time, causing sig-5 r) T+ ~" Q3 i
nificant bare skin contact between baby and father.
0 D) f) F2 G- h- ~3 s# S. \The father also admitted that after the phone call,4 n# G+ ~; w, A4 z" Z# } V0 [) G
when he learned the testosterone level in the baby: a3 E, m, `2 C, A8 S+ Q
was high, he then read the product information4 Z `7 m, x* \6 L. h
packet and concluded that it was most likely the rea-
P$ s& f0 X& N: J. o# G, d+ w0 Yson for the child’s virilization. At that time, they
9 L N7 |3 q( z3 S Y. }' Qdecided to put the baby in a separate bed, and the
; v% w5 K9 J& |% Vfather was not hugging him with bare skin and had
& i4 g; v& B$ v Xbeen using protective clothing. A repeat testosterone
k6 z- V. ^1 e+ ztest was ordered, but the family did not go to the$ c+ ]4 l' {! R/ k
laboratory to obtain the test.
! L% o! x3 t7 r5 _/ q3 |Discussion1 h0 |, G2 h% e9 p$ u- w
Precocious puberty in boys is defined as secondary y, c: N$ p% H/ E* w) u3 H2 |
sexual development before 9 years of age.1,4
1 ~: n- `7 I$ a0 O! n/ |. K; SPrecocious puberty is termed as central (true) when
, m( R2 y+ Y& \; _0 [+ J; X1 eit is caused by the premature activation of hypo-- K5 a5 E e. o- i
thalamic pituitary gonadal axis. CPP is more com-3 j1 y; S7 x4 q+ n& |
mon in girls than in boys.1,3 Most boys with CPP
6 S5 n* ?2 p! Emay have a central nervous system lesion that is/ @* R( N6 v: U! w, }- l! n* k' {
responsible for the early activation of the hypothal-& N, [9 u0 N/ E" P
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 {- ~: v. C. }# i ~* |" R* Lsis has been given to neuroradiologic imaging in7 t! F8 S5 K1 k( }9 L+ L
boys with precocious puberty. In addition to viril-
9 T2 S( u8 l- ^+ Qization, the clinical hallmark of CPP is the symmet-
' N& O* C, a) K% B: `! {) }1 D# |rical testicular growth secondary to stimulation by' ?, J" b7 e/ _; [- \- T
gonadotropins.1,3: t! V; B/ t+ t$ s
Gonadotropin-independent peripheral preco-
b( x. r ~8 i9 pcious puberty in boys also results from inappropriate
; A/ \# q5 j [& \5 U+ kandrogenic stimulation from either endogenous or/ p( r% B- ~# h0 c
exogenous sources, nonpituitary gonadotropin stim-# ~5 H% g F7 L: m
ulation, and rare activating mutations.3 Virilizing6 R# S q0 L5 {3 Q
congenital adrenal hyperplasia producing excessive1 B$ x) D. v4 F4 _. f* h& A& x
adrenal androgens is a common cause of precocious" D1 f. f4 S5 e6 _% @' i
puberty in boys.3,4
& h0 H) {$ O$ Z& M6 r1 F* \The most common form of congenital adrenal, N$ S- g3 w+ Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
; w$ g: J9 [# B2 `% r- OThe 11-β hydroxylase deficiency may also result in
- O y5 Z( k% x2 B0 N8 g, Eexcessive adrenal androgen production, and rarely,4 z; Q8 B, ^! O! f4 h5 I
an adrenal tumor may also cause adrenal androgen9 D( D" W% D8 q5 Q
excess.1,3$ c' f3 o, n- _+ N% l+ W: d/ Y8 b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 y* {2 ?1 U% h' ]/ N F, \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 K: f$ @0 h; Z( E8 mA unique entity of male-limited gonadotropin-) v. O! `8 s r0 p( R1 ?
independent precocious puberty, which is also known
3 T6 b- P/ \" [8 r5 B, U f% I( N4 k% Yas testotoxicosis, may cause precocious puberty at a4 _0 X/ T* P# q
very young age. The physical findings in these boys/ C5 A: a2 E7 j9 n: G
with this disorder are full pubertal development,6 |) i; H: x0 J. w" D J
including bilateral testicular growth, similar to boys
% c4 o; B# _! q+ }# D. _/ T. q+ \with CPP. The gonadotropin levels in this disorder9 ~, C. A+ x% E) a4 P) V
are suppressed to prepubertal levels and do not show
7 {1 ~6 [5 `) G* U+ O, Opubertal response of gonadotropin after gonadotropin-
& d+ w |/ b G. R4 Q3 c5 lreleasing hormone stimulation. This is a sex-linked
2 y' o; W' D6 f$ T, Iautosomal dominant disorder that affects only
F, g4 f0 Y5 d) u+ \6 h8 }males; therefore, other male members of the family
* x3 C4 ]8 X, m6 N. B( N& T `may have similar precocious puberty.3, ]+ @+ N. x/ t$ F0 n) X& [1 Q
In our patient, physical examination was incon-
- i0 z, @3 B3 n. `" ~5 o: Gsistent with true precocious puberty since his testi-; u9 N4 Z; R5 i; H
cles were prepubertal in size. However, testotoxicosis p Y0 B! Q( Y. a6 c4 u1 C
was in the differential diagnosis because his father
% Q$ Z) q5 t9 o0 `started puberty somewhat early, and occasionally," F' H# O4 [! K2 E
testicular enlargement is not that evident in the
& \6 {5 m8 ]+ ]% F# {5 q4 F0 K0 tbeginning of this process.1 In the absence of a neg-
: N5 U$ g! e( M$ S7 ~. Zative initial history of androgen exposure, our/ L7 o3 Q( M0 v& D( ~# }' ?
biggest concern was virilizing adrenal hyperplasia,7 v3 v, L& j! S5 j( O2 `
either 21-hydroxylase deficiency or 11-β hydroxylase
+ Y9 N' Z* a, k! zdeficiency. Those diagnoses were excluded by find-
, J2 x% `& P* N- @: }ing the normal level of adrenal steroids.2 w0 R% q5 |% s1 y; @
The diagnosis of exogenous androgens was strongly
5 U1 V( W ~# ]) [9 X0 vsuspected in a follow-up visit after 4 months because$ b6 r" `; C- P$ h& J/ @/ V. B
the physical examination revealed the complete disap-; l) p: A2 r1 G$ L2 F. U1 A% w
pearance of pubic hair, normal growth velocity, and
# n# q+ U' d2 l6 \9 P9 Kdecreased erections. The father admitted using a testos-& u" m; }7 e& x4 B" j8 r
terone gel, which he concealed at first visit. He was# _( q* s q- H" y' E+ V
using it rather frequently, twice a day. The Physicians’+ F( {/ V' E' G: q" T' d
Desk Reference, or package insert of this product, gel or' Q* v# o, p* u& `8 S6 k) Z
cream, cautions about dermal testosterone transfer to
( \ v3 b2 B) l: J* p Runprotected females through direct skin exposure.8 n7 @# `3 Z' o- B1 r
Serum testosterone level was found to be 2 times the
1 u; d* |5 i% Qbaseline value in those females who were exposed to; F3 j: T: ~2 t; @3 Y$ g2 H
even 15 minutes of direct skin contact with their male
+ c. c& T; k5 z7 b5 j5 W- I1 s2 }- Y! ]partners.6 However, when a shirt covered the applica-
1 t# k; M& z" ]" b8 U) otion site, this testosterone transfer was prevented.
# W( }+ c3 P% k. A6 }6 gOur patient’s testosterone level was 60 ng/mL,
$ X- v3 h6 |8 Z( r5 Ewhich was clearly high. Some studies suggest that# [4 a2 W* Y- P2 L8 w( G& u
dermal conversion of testosterone to dihydrotestos-+ E7 a- Z& e; G( f
terone, which is a more potent metabolite, is more; k! }- H/ K# h9 L4 @
active in young children exposed to testosterone
- C/ X) k7 b) M* I. I+ f9 g5 Texogenously7; however, we did not measure a dihy-
2 U1 {9 ]! S& |$ Z# x6 qdrotestosterone level in our patient. In addition to
# ?& d( c, O- b2 @+ J1 tvirilization, exposure to exogenous testosterone in
: H# e4 N; @: ~6 n/ ~# rchildren results in an increase in growth velocity and8 `9 y: x Y$ i' c# R, f. h& a
advanced bone age, as seen in our patient.9 y1 ?( o9 h" F* c
The long-term effect of androgen exposure during
( W1 b3 U/ a; Y0 h0 Jearly childhood on pubertal development and final! z/ I8 D; f# j) d% W. X
adult height are not fully known and always remain. C7 N; ~- }+ A# v
a concern. Children treated with short-term testos-
; P) S6 [8 M6 E/ f* _9 X* jterone injection or topical androgen may exhibit some$ E* g& j4 W: R2 X( V( B
acceleration of the skeletal maturation; however, after8 m: F9 k6 _+ g* s
cessation of treatment, the rate of bone maturation& F$ [! M, }* ?+ S! A. Q/ |2 p
decelerates and gradually returns to normal.8,9
2 B0 U+ n2 f: L9 S' }There are conflicting reports and controversy
' } J9 K7 M4 \& @* s& |. b0 Qover the effect of early androgen exposure on adult
' V9 o6 i" _' ?& X6 i! Xpenile length.10,11 Some reports suggest subnormal5 {" n }3 N. z$ c8 D6 k
adult penile length, apparently because of downreg-
6 F( {" o7 c3 q( A3 P% C: H; P. l$ f, Oulation of androgen receptor number.10,12 However,8 H6 x, q O: Q- q
Sutherland et al13 did not find a correlation between
$ r3 f8 Z' L5 y* `+ l9 ^childhood testosterone exposure and reduced adult
7 S* C, h- M4 N# N! ^& @penile length in clinical studies.
2 A3 m- h8 L/ B$ LNonetheless, we do not believe our patient is
; }; B# o+ A6 {+ Ngoing to experience any of the untoward effects from4 g4 ~* W |' }( f
testosterone exposure as mentioned earlier because* C3 o( @1 x- f$ `$ {* G
the exposure was not for a prolonged period of time.! E4 g. `0 u. B( ?1 P5 k
Although the bone age was advanced at the time of0 r1 D2 M$ E2 h4 n. i
diagnosis, the child had a normal growth velocity at
# K$ s2 j& {/ \$ Q- d0 G3 Q- V' [the follow-up visit. It is hoped that his final adult
0 O: X/ W- L6 x7 A ^height will not be affected., r7 q7 E$ f* ^" t& ^3 S a
Although rarely reported, the widespread avail-
, D" z8 `- O1 F6 E/ @% @ability of androgen products in our society may
X, u+ q, L: m- [2 w4 V7 L$ rindeed cause more virilization in male or female
- Z: j n, Z8 b- lchildren than one would realize. Exposure to andro-
5 a+ l' A0 B ?$ wgen products must be considered and specific ques-: S4 v; h" |3 R. p6 D
tioning about the use of a testosterone product or
9 T' v! j; k& ygel should be asked of the family members during4 H4 T2 s1 p- b! M/ C3 T
the evaluation of any children who present with vir-
4 @8 i1 n' `4 |ilization or peripheral precocious puberty. The diag-
( t% a7 J1 W$ {# R* A# Q; ?6 h; `& lnosis can be established by just a few tests and by
~/ P1 W/ u, n: w( cappropriate history. The inability to obtain such a
3 R4 }8 t- @9 o( m+ |history, or failure to ask the specific questions, may
; E9 N* y H$ I% _/ i) }: `result in extensive, unnecessary, and expensive
1 L( ^' e( |4 ^investigation. The primary care physician should be
' d6 B$ C T3 N, O. Q0 yaware of this fact, because most of these children0 \- m2 E5 m7 m) w0 F. ^. \* N+ J
may initially present in their practice. The Physicians’
* O+ W2 P' e7 vDesk Reference and package insert should also put a# [7 _$ v0 o" S0 O
warning about the virilizing effect on a male or
* n# ^* q1 r& afemale child who might come in contact with some-
9 [$ s4 K; d7 k S3 v/ s2 I& L5 N/ h( cone using any of these products.
' V% q8 T3 M6 q3 J! Y4 A0 bReferences* v b/ h- h8 r) t0 h- M
1. Styne DM. The testes: disorder of sexual differentiation
) r! q) R- V2 e( J3 P! B9 b+ i! zand puberty in the male. In: Sperling MA, ed. Pediatric
/ t, @* u" K* I8 ]2 dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ `! m+ k7 ]; P+ J
2002: 565-628.# k7 u8 u; A/ X; O4 U* p/ x9 i& Z8 ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. R6 _; G0 V5 S2 H) P
puberty in children with tumours of the suprasellar pineal |
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