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Sexual Precocity in a 16-Month-Old
" L, G$ ]' j$ kBoy Induced by Indirect Topical
7 W4 ?6 l# M2 k% h: DExposure to Testosterone, z, U& s9 i' ~0 \& W/ H! @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! W! m( K' X) h; A' I( x, Q
and Kenneth R. Rettig, MD1
2 v' y! d" y, { T& ~) `9 KClinical Pediatrics
5 B- W. f/ R$ TVolume 46 Number 6
) T& a' d! K7 cJuly 2007 540-543
8 D8 _( o( T6 m( b4 ]+ v- r© 2007 Sage Publications; v9 A- R) E2 V8 L! g* O+ e
10.1177/0009922806296651
# G4 E2 G# o$ X3 ?" _http://clp.sagepub.com
! M" n1 b7 m9 ^. T4 ?5 ]$ e" Z) [hosted at9 A0 I/ F) h' {. c2 U0 O6 x; l
http://online.sagepub.com
' \# P& Q- m* c( Z: M5 ePrecocious puberty in boys, central or peripheral,
# l/ n4 T: e& y5 e% D( Nis a significant concern for physicians. Central/ z+ s% O1 I7 \* _" N5 B3 u
precocious puberty (CPP), which is mediated
2 k* K6 Z. o* i. a F: C/ A9 athrough the hypothalamic pituitary gonadal axis, has
4 L# Q. t4 M" ^' va higher incidence of organic central nervous system8 _3 `9 \' A3 S8 Z* a( F
lesions in boys.1,2 Virilization in boys, as manifested
6 y' T3 {1 F! fby enlargement of the penis, development of pubic
, ~$ u0 d% M, ]- v# h# C; Zhair, and facial acne without enlargement of testi-
. m; P0 K3 l/ s3 Icles, suggests peripheral or pseudopuberty.1-3 We R8 l2 r) e- m( s) u
report a 16-month-old boy who presented with the
. C1 v- w! s7 c3 Ienlargement of the phallus and pubic hair develop-& q" j0 Y$ K; i; _3 C' f
ment without testicular enlargement, which was due
, x' Q9 W& S, _( Xto the unintentional exposure to androgen gel used by
; g. _4 D/ Z1 p1 Y' @$ P( [7 zthe father. The family initially concealed this infor-
P7 L4 O7 [$ H# f+ Jmation, resulting in an extensive work-up for this
* L5 [5 t) C3 L$ T* |child. Given the widespread and easy availability of& q4 E$ Q1 u, I3 [7 q5 a" M
testosterone gel and cream, we believe this is proba-" o- ~9 d$ Q5 q, r
bly more common than the rare case report in the
2 \1 k" f8 o) N% j# cliterature.4
/ O' Z4 o% Q* G# \Patient Report
& p7 s1 r: O9 D+ w5 {A 16-month-old white child was referred to the1 l2 Q/ q. }/ c1 }, y
endocrine clinic by his pediatrician with the concern& s% P! i* t* ]' M7 V* I9 R
of early sexual development. His mother noticed) J/ i) S# r$ x* C: V u) C% g0 k9 N5 w V
light colored pubic hair development when he was
/ e% h2 K. e6 X1 d* fFrom the 1Division of Pediatric Endocrinology, 2University of
- k2 z- z! N/ W; e- ?1 {South Alabama Medical Center, Mobile, Alabama.' D0 H2 I5 E) \- J7 \3 h8 o1 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 d8 S" Q/ h3 w+ Z& N
Professor of Pediatrics, University of South Alabama, College of! Y# x& h& V9 c5 I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( Q& }5 @4 H; U* Re-mail: [email protected].
# R! q4 \8 ~4 F( Fabout 6 to 7 months old, which progressively became
: n; ]: y7 n5 H1 Q) k2 Adarker. She was also concerned about the enlarge-
* |* K3 p) M" J! M H6 j, H) Gment of his penis and frequent erections. The child' n& q7 e8 G1 ]+ T
was the product of a full-term normal delivery, with5 T: B: |& S! [
a birth weight of 7 lb 14 oz, and birth length of
; K2 {# f- M% M8 |3 h5 u; F20 inches. He was breast-fed throughout the first year- }( y- _# X( v# p: n9 y7 Y. |+ R
of life and was still receiving breast milk along with
* ]; v2 _$ J5 }, _/ Msolid food. He had no hospitalizations or surgery,
+ @6 L2 r8 h6 Q* @: D- nand his psychosocial and psychomotor development4 u7 Y9 Y2 n3 i
was age appropriate.
! z8 u8 l: I: p0 N& h7 E9 {The family history was remarkable for the father,
( c R+ F5 N* X8 i" I' rwho was diagnosed with hypothyroidism at age 16,
5 r$ B5 W8 N8 Rwhich was treated with thyroxine. The father’s
4 @2 E+ J' K* v7 O9 e' Dheight was 6 feet, and he went through a somewhat
: j% q8 R; a1 T+ Gearly puberty and had stopped growing by age 14.
' |, A9 Y6 e% Q, E2 G5 cThe father denied taking any other medication. The
( z! o, ^/ }" E/ n6 X2 x9 dchild’s mother was in good health. Her menarche
' F. z7 _( b" a+ I+ Awas at 11 years of age, and her height was at 5 feet4 T* w* q1 m; B9 _, @" X' R2 A
5 inches. There was no other family history of pre-: w# Y& B$ Q9 o
cocious sexual development in the first-degree rela-. I# h3 r5 Y+ i
tives. There were no siblings.
- T& W: Z% U0 a, JPhysical Examination
% t8 q% Y U* e3 |9 ]* CThe physical examination revealed a very active,! k- N7 n' [0 x1 _; x) {6 X8 |; W
playful, and healthy boy. The vital signs documented k! q5 p1 h8 K% U
a blood pressure of 85/50 mm Hg, his length was n' B' \ R; ]9 f
90 cm (>97th percentile), and his weight was 14.4 kg
N, n7 {7 {1 W- G3 s(also >97th percentile). The observed yearly growth; F/ \9 M2 m. Y
velocity was 30 cm (12 inches). The examination of7 \3 @$ {5 p0 z& B! }
the neck revealed no thyroid enlargement.
" y- v8 t c+ e( BThe genitourinary examination was remarkable for
/ T$ y* ~, j' G, @6 j4 Senlargement of the penis, with a stretched length of
) k7 r9 w! [0 c7 b, Y8 cm and a width of 2 cm. The glans penis was very well3 \' d2 |$ L4 A4 _
developed. The pubic hair was Tanner II, mostly around# C9 R4 n( D9 J
540, @4 s! a2 r- A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 y) f: J' q Z6 e1 \
the base of the phallus and was dark and curled. The i: O" h# Y( v* R3 R) H7 G
testicular volume was prepubertal at 2 mL each.
- E' y) Z3 d9 H! G$ JThe skin was moist and smooth and somewhat
, l% o- O1 H8 Ioily. No axillary hair was noted. There were no, Y0 p* F' E/ o& I1 J- R
abnormal skin pigmentations or café-au-lait spots.
) f* J- ^9 t0 L4 G0 Z3 rNeurologic evaluation showed deep tendon reflex 2++ |( v" K; C. B& ^/ E
bilateral and symmetrical. There was no suggestion3 v' I9 i2 n; w# E) ]- e. J
of papilledema.
% s- [3 q8 s9 q+ g% F$ `4 VLaboratory Evaluation
7 k; L0 e( S4 W# @" i# eThe bone age was consistent with 28 months by! Q. C9 A3 {- p
using the standard of Greulich and Pyle at a chrono-
9 n! g$ r! L# Rlogic age of 16 months (advanced).5 Chromosomal
3 \* |0 H1 s l% Y7 w# A6 _! Pkaryotype was 46XY. The thyroid function test
: p: ?. a; e( i$ ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-& @$ m+ M. ?& T U2 n% }& B
lating hormone level was 1.3 µIU/mL (both normal).! I1 Y, X. u* o$ `
The concentrations of serum electrolytes, blood
/ @, O7 }) w: q! E" Zurea nitrogen, creatinine, and calcium all were
! y) E, t4 d) p. C5 Vwithin normal range for his age. The concentration
& g% q) t+ ?+ y6 `7 i$ U: d Bof serum 17-hydroxyprogesterone was 16 ng/dL
6 x6 ?: q8 p& v8 g& I; m) q3 ^(normal, 3 to 90 ng/dL), androstenedione was 20: _# @$ `& U, I- b4 w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! w9 a, F+ c; v! ?8 X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ U! Y$ {/ Q( u t2 Xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. l9 T# R4 K% K3 e$ O/ w3 x+ P1 S( I
49ng/dL), 11-desoxycortisol (specific compound S)
4 w, _# s6 E/ M$ f* U, p. hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% F' r* l! r) `- o6 y. t& xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ P j* r& |0 a9 `. H/ M1 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ ~8 O' |2 G7 \, ?and β-human chorionic gonadotropin was less than
" u) O5 E; Y5 R% s5 mIU/mL (normal <5 mIU/mL). Serum follicular
# ]% k" O7 u% Q2 a, C! }stimulating hormone and leuteinizing hormone' k: ]2 d3 d, ~& ?3 P
concentrations were less than 0.05 mIU/mL
* c7 [2 f" m6 ~# p, u(prepubertal).* a. e4 Y _: Z- R
The parents were notified about the laboratory
2 m- E) D5 o% F# G, N1 {; h) a/ qresults and were informed that all of the tests were) G1 _; Q; X7 V. e- h9 m/ i
normal except the testosterone level was high. The8 s1 j# }8 b8 C4 k0 l( i( o! G
follow-up visit was arranged within a few weeks to
* U' Y8 y0 c! L' U! F2 f! g' iobtain testicular and abdominal sonograms; how-
3 W* J) W. Z5 t7 Kever, the family did not return for 4 months.& M7 u+ V5 c9 F1 F5 H& {1 J& c
Physical examination at this time revealed that the. N, o G4 _( U3 v5 i9 _. @/ J0 X
child had grown 2.5 cm in 4 months and had gained4 j4 D$ }3 @% Z$ Y6 \3 X# K
2 kg of weight. Physical examination remained
# K4 j7 J# s, N, {% p2 X0 W8 q+ Zunchanged. Surprisingly, the pubic hair almost com-* @ l: A! c! D y2 _; I ?
pletely disappeared except for a few vellous hairs at1 G4 S5 t, \# y: v4 m% L
the base of the phallus. Testicular volume was still 2
7 H! B+ R0 p/ W0 UmL, and the size of the penis remained unchanged.
* M" ? z9 ^, y- s, r) XThe mother also said that the boy was no longer hav-0 \; K$ @7 u- ] d2 Q3 B
ing frequent erections.
4 ^3 m9 x1 o/ r s/ IBoth parents were again questioned about use of
$ \0 a% b" [" _any ointment/creams that they may have applied to& i S7 R( w7 h, O$ C- [1 O
the child’s skin. This time the father admitted the2 O/ W$ x+ S0 e
Topical Testosterone Exposure / Bhowmick et al 541
/ r6 n1 z2 ?, guse of testosterone gel twice daily that he was apply-
5 c9 x A4 }: E- c4 h# @8 E& Aing over his own shoulders, chest, and back area for! {4 B# k5 P! P+ X1 J; j- [9 ?+ e
a year. The father also revealed he was embarrassed
0 C9 }& Y, d- d4 nto disclose that he was using a testosterone gel pre-
( {- p8 j, s; @# F2 n7 tscribed by his family physician for decreased libido
- d4 [* ]$ F1 ^9 y; Nsecondary to depression." s8 _; g. ~1 ?6 V5 C! H
The child slept in the same bed with parents.; w' r* [! a% _0 e
The father would hug the baby and hold him on his
1 i0 B3 O0 Q% X$ W5 k; j0 Lchest for a considerable period of time, causing sig-
% [- @) e+ w) a; _4 |5 snificant bare skin contact between baby and father.
& i- W ^& @- z4 Q; RThe father also admitted that after the phone call,
( |0 w1 Y2 Z+ W9 S. Ywhen he learned the testosterone level in the baby
, ^4 l# v; `' Q: vwas high, he then read the product information
5 a& a U: \# ]4 c$ U, C& p. hpacket and concluded that it was most likely the rea-% v# f3 a8 o8 t4 ^
son for the child’s virilization. At that time, they
0 w0 E) a( @9 x9 R5 F Udecided to put the baby in a separate bed, and the
3 V+ v* Y8 h" X8 M9 _father was not hugging him with bare skin and had
. Y/ ~# K1 d9 l# Jbeen using protective clothing. A repeat testosterone/ |* I L G3 x! T# p9 W$ N- _
test was ordered, but the family did not go to the
* _' E6 N" |5 z& B% @1 Claboratory to obtain the test.
. H+ D9 h6 m) ODiscussion' [9 k% H* J- }7 \! A" V! G
Precocious puberty in boys is defined as secondary. T5 L& o4 x# P J
sexual development before 9 years of age.1,40 S2 I/ Q+ I& A/ p( F; m
Precocious puberty is termed as central (true) when
v" F% R& S( T k$ Kit is caused by the premature activation of hypo-* k/ s+ p/ C: `# @8 p
thalamic pituitary gonadal axis. CPP is more com-% s, R: u3 H1 w3 ~
mon in girls than in boys.1,3 Most boys with CPP
3 S1 J$ K9 t* v5 n. q% l) mmay have a central nervous system lesion that is! v4 u+ b& N5 x6 ~* |
responsible for the early activation of the hypothal-
0 ^, ]$ O; E1 D4 c) g& camic pituitary gonadal axis.1-3 Thus, greater empha-
5 K2 j$ \ ]- |: _! Xsis has been given to neuroradiologic imaging in: C- `8 c* a5 l, g
boys with precocious puberty. In addition to viril-
- W5 e, P$ V5 N- h, Tization, the clinical hallmark of CPP is the symmet-
" b+ }$ ^2 [7 d& Srical testicular growth secondary to stimulation by
6 Z, ]/ t+ x9 A* tgonadotropins.1,32 f% Q+ z5 N7 l4 Q3 i
Gonadotropin-independent peripheral preco-8 Z8 M. o2 t3 y6 v' r. L! T8 |# z
cious puberty in boys also results from inappropriate0 c( f5 E' X. U+ F4 z3 L4 v% Y
androgenic stimulation from either endogenous or
3 f' H7 I5 _ t4 c3 I. n4 ^, `exogenous sources, nonpituitary gonadotropin stim-+ x$ }' V' v J; Y
ulation, and rare activating mutations.3 Virilizing
, ?- K6 h' C5 y" @congenital adrenal hyperplasia producing excessive+ ?7 b3 `& x7 z
adrenal androgens is a common cause of precocious u' I; M& k2 Y
puberty in boys.3,4
0 y: Y7 S: ^1 X/ Z; M7 z4 }7 OThe most common form of congenital adrenal4 Z+ E$ h6 @! s# P/ y
hyperplasia is the 21-hydroxylase enzyme deficiency.
- o3 B- X* R! LThe 11-β hydroxylase deficiency may also result in1 ~0 @! J% S7 R& v
excessive adrenal androgen production, and rarely,: R" Q* {1 J5 d( M
an adrenal tumor may also cause adrenal androgen+ R4 X5 K3 _& ]
excess.1,3
; ]2 e8 K7 d3 r+ L' B4 nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 E2 F+ F) Y4 ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% t0 M& q4 @8 ]* p4 ?- R; W9 g: A
A unique entity of male-limited gonadotropin-
% ^) Q! Y+ h0 k0 m( w. [$ dindependent precocious puberty, which is also known- o8 V3 J1 ?; b# K# _' i1 T9 p
as testotoxicosis, may cause precocious puberty at a
# L7 O! ~- }: [( Pvery young age. The physical findings in these boys) N6 G! x5 ^" Q- g: b) @) E
with this disorder are full pubertal development,5 x% }5 h# l. f( |) s4 t
including bilateral testicular growth, similar to boys
" s% P$ E2 k9 P) Twith CPP. The gonadotropin levels in this disorder
1 _) O+ R c# |1 J! ^are suppressed to prepubertal levels and do not show
7 L t0 e1 ^9 N2 _1 zpubertal response of gonadotropin after gonadotropin-- o7 ~" q/ u1 M9 _
releasing hormone stimulation. This is a sex-linked
# ?8 F9 O) F0 {autosomal dominant disorder that affects only0 P2 s! S% m5 a& |/ k
males; therefore, other male members of the family1 j; _/ _" ]4 I. a
may have similar precocious puberty.3
' n2 g0 P' h! R+ y6 XIn our patient, physical examination was incon-, ?$ v! G% F c Q: ?# j" w7 @0 J
sistent with true precocious puberty since his testi-, B) r% f1 g% J* W
cles were prepubertal in size. However, testotoxicosis/ \8 B" [- i! ?( g7 A* Z& G
was in the differential diagnosis because his father3 |4 A6 ^' k. O0 c
started puberty somewhat early, and occasionally,1 h* a+ v1 K; q6 `2 f: ^
testicular enlargement is not that evident in the
" x% J6 ]" y* S1 t) I6 A% e) z. Qbeginning of this process.1 In the absence of a neg-
9 ~4 ]% W; m f* T5 V" Oative initial history of androgen exposure, our
- |1 I/ O- V, S* U j3 W5 ybiggest concern was virilizing adrenal hyperplasia,
- u: c4 d- [$ n; heither 21-hydroxylase deficiency or 11-β hydroxylase# B; A7 w: e6 F Z* ?: t
deficiency. Those diagnoses were excluded by find-3 U0 J% m8 P! f+ {6 x! P
ing the normal level of adrenal steroids.
5 S( G4 b% _# U: JThe diagnosis of exogenous androgens was strongly' I5 a" \5 o( Q& Q
suspected in a follow-up visit after 4 months because
3 z5 v, o4 ]! v( H6 q/ o% y& ithe physical examination revealed the complete disap- |: C4 |( B" j/ X9 f) h
pearance of pubic hair, normal growth velocity, and' e+ r2 m) N' B% N! _0 l' I
decreased erections. The father admitted using a testos-+ Q% F$ M. B& `, i8 U2 g( Y
terone gel, which he concealed at first visit. He was. I [% b, s0 I R
using it rather frequently, twice a day. The Physicians’
/ S: o8 s+ h8 l6 VDesk Reference, or package insert of this product, gel or
! c5 D! Z9 Q4 H+ w) U, b! C, acream, cautions about dermal testosterone transfer to
5 g" U% X4 P5 k- h, O9 y9 M7 Funprotected females through direct skin exposure.
. R4 j. h" u# T4 w. O% p8 M* v# ^Serum testosterone level was found to be 2 times the3 `- o! m; g' ^) y) ~
baseline value in those females who were exposed to+ H* g/ `# b8 k# D
even 15 minutes of direct skin contact with their male1 T. f. t& U/ V# k
partners.6 However, when a shirt covered the applica-$ i/ c F: z' g" M4 W
tion site, this testosterone transfer was prevented.
8 p0 ?5 p0 o4 b! x2 {$ C9 O$ VOur patient’s testosterone level was 60 ng/mL,4 S5 D+ l+ g- s: G* V0 v
which was clearly high. Some studies suggest that6 n0 }) l a4 D2 k7 v( F
dermal conversion of testosterone to dihydrotestos-( N8 Z& l! d4 [- |5 M. O2 z
terone, which is a more potent metabolite, is more
, E4 q& K8 n+ {6 t |$ Dactive in young children exposed to testosterone- M* O3 P5 _+ c
exogenously7; however, we did not measure a dihy-
' A' P8 W- ]' v# \9 l/ w9 y4 Mdrotestosterone level in our patient. In addition to
8 g4 s1 C8 o/ Svirilization, exposure to exogenous testosterone in5 D% P0 |# y7 I2 i4 q! Q0 {/ t' A& {
children results in an increase in growth velocity and
% A8 p9 B& p) _9 oadvanced bone age, as seen in our patient.! Y: J. x( e$ G, Y
The long-term effect of androgen exposure during4 h) }6 O5 ?9 G3 q+ s8 }
early childhood on pubertal development and final
; l! i7 r. N2 A7 N7 t8 H% X9 Yadult height are not fully known and always remain
, d$ H, S7 |7 \' z& l4 R$ oa concern. Children treated with short-term testos-+ Q: S) ]: y9 E
terone injection or topical androgen may exhibit some
" M! b' I0 D# |acceleration of the skeletal maturation; however, after+ {+ m, e9 [ x X: }( c+ ?
cessation of treatment, the rate of bone maturation
1 S' l; V8 W/ F9 n. t" a6 Gdecelerates and gradually returns to normal.8,9
, }: N6 k! d! v) t p! ~6 I7 G) l( pThere are conflicting reports and controversy
/ I, t; P+ _* a0 L- Qover the effect of early androgen exposure on adult! s4 k) a8 |+ x; {+ f, _- q
penile length.10,11 Some reports suggest subnormal
, ]4 o' A+ z0 e- c* c& madult penile length, apparently because of downreg-
4 h( V/ N; r+ C: w3 x( xulation of androgen receptor number.10,12 However,
' f! X; K7 r' [% U2 I' hSutherland et al13 did not find a correlation between
: x* Q! Y" l+ A% v0 {& B6 W" Achildhood testosterone exposure and reduced adult. |9 K3 k/ O9 O& r, E" A6 \
penile length in clinical studies.
- r: e" P7 k) \6 ]Nonetheless, we do not believe our patient is$ T% [* f& u, j) T0 K
going to experience any of the untoward effects from
7 L0 U, e% G! N9 h+ f0 U! Dtestosterone exposure as mentioned earlier because
) g( R8 z1 M4 \) B3 othe exposure was not for a prolonged period of time.
, g |; w# `$ B) t3 d" T9 T% Q+ nAlthough the bone age was advanced at the time of
+ I# a1 T6 Z4 Adiagnosis, the child had a normal growth velocity at9 j/ Y$ y8 n9 {, r1 u3 B2 I
the follow-up visit. It is hoped that his final adult: H1 b5 i: j) \6 i; y8 K A
height will not be affected.4 n( s0 ~2 C/ r1 N6 G+ H* d
Although rarely reported, the widespread avail-# I) e. o u J8 N- n' Z
ability of androgen products in our society may
; ]% R( A+ ~ Y( p4 @* ^indeed cause more virilization in male or female
9 W. F% g) I! Z5 s# \children than one would realize. Exposure to andro-# I+ }6 ~8 k9 f3 @& {& w; E8 u' t
gen products must be considered and specific ques-
/ v4 b5 Q/ w. s, o T3 X' y5 ptioning about the use of a testosterone product or
/ K& C u3 o4 R P; Y' o0 Fgel should be asked of the family members during; b! H% s2 G: w& k
the evaluation of any children who present with vir-0 n. V& w" h9 |
ilization or peripheral precocious puberty. The diag-
2 @0 {; W' t3 m! |( ?nosis can be established by just a few tests and by
9 @5 X1 q! b, O% r: tappropriate history. The inability to obtain such a
& L" q0 q( u. z: }% S7 Lhistory, or failure to ask the specific questions, may7 _3 o- P( o- ]! W* B
result in extensive, unnecessary, and expensive
! Y; b* q5 T4 W0 ^+ H: p3 ~investigation. The primary care physician should be
- S, T8 v8 N9 |/ |% e9 C- ?; Iaware of this fact, because most of these children
! a! q, R: w3 c9 M. A( Emay initially present in their practice. The Physicians’7 q, t- u$ ?: v! s. i$ c% q$ [% m& r
Desk Reference and package insert should also put a/ s" t9 Z; O$ u3 q1 E
warning about the virilizing effect on a male or# [0 _; k* J1 ?! ~6 z5 s
female child who might come in contact with some-
1 J4 b6 o+ n# w7 W& z- Rone using any of these products., N& G& W, h" I3 G
References4 _9 K' e" ~' u5 O4 D' M2 t
1. Styne DM. The testes: disorder of sexual differentiation
/ [3 h$ B7 W' p3 I0 X) pand puberty in the male. In: Sperling MA, ed. Pediatric
4 X& E6 `- d' q; z; v, z9 bEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& {; O t! |, s5 v$ @; E
2002: 565-628.
: T* l& \9 A9 u* ?8 Q6 t2 c4 U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" ^# N: q" H- } k5 j2 spuberty in children with tumours of the suprasellar pineal |
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