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Sexual Precocity in a 16-Month-Old2 R/ i/ @1 o: ?& `
Boy Induced by Indirect Topical( R" e) P& ^( m, b; H, c! D" i
Exposure to Testosterone
2 B! ?0 h3 Z4 C% W6 V7 M4 ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 T0 l+ G5 x8 H) D; t G" pand Kenneth R. Rettig, MD1
" Z* L R! u: b! q7 Z, |; WClinical Pediatrics
5 Z8 J5 U$ H5 J/ n$ i' e+ TVolume 46 Number 60 d* M4 M/ H; E
July 2007 540-543
6 ^# y( ~ h, l! k© 2007 Sage Publications
, K4 S1 c/ [ H; V' y10.1177/0009922806296651
! N! x) _4 s8 Ghttp://clp.sagepub.com! {; L0 Z% s; A
hosted at
( b6 C9 W& c; z @5 `$ z& lhttp://online.sagepub.com
6 s9 D7 {3 @( K2 ^( b! dPrecocious puberty in boys, central or peripheral,$ _; j: G- M- ~' V: s
is a significant concern for physicians. Central2 `* h' n+ k* H. q
precocious puberty (CPP), which is mediated" l2 S( Z+ y3 `* ]" x0 c
through the hypothalamic pituitary gonadal axis, has
9 c+ t# q8 o# ha higher incidence of organic central nervous system8 |7 i; z; l' `; S: V& i
lesions in boys.1,2 Virilization in boys, as manifested
7 G# v% Z/ L0 x- b* wby enlargement of the penis, development of pubic
: z2 E0 Y9 F3 K( \+ uhair, and facial acne without enlargement of testi-
9 v% n$ }3 `) `cles, suggests peripheral or pseudopuberty.1-3 We
`1 s* a$ S5 _8 n" W5 u# Rreport a 16-month-old boy who presented with the5 n: `6 Q3 W" a1 [2 {! P" ?
enlargement of the phallus and pubic hair develop-
) C/ p/ ]! ?: S' x& Kment without testicular enlargement, which was due) `/ G0 r, R6 h
to the unintentional exposure to androgen gel used by+ D: o2 T8 {; ]
the father. The family initially concealed this infor-4 K) m! T- _6 y& C! F
mation, resulting in an extensive work-up for this3 O+ R9 E3 X" f" q2 P
child. Given the widespread and easy availability of* n5 ^7 W, V( m
testosterone gel and cream, we believe this is proba-
3 ]6 w+ `% {2 B7 u, p* b# Y" Nbly more common than the rare case report in the" i1 t6 J3 P8 \/ O
literature.41 U K9 j* u2 O5 _3 X
Patient Report
- g2 i1 m0 N9 `: H/ _+ YA 16-month-old white child was referred to the
8 H0 N: ~$ Q# b7 G1 c3 Mendocrine clinic by his pediatrician with the concern
9 a, H) G5 e' Kof early sexual development. His mother noticed% V7 ^" M) h( l2 ]& j
light colored pubic hair development when he was
2 T `: ?+ B1 A% W: V2 J: H4 hFrom the 1Division of Pediatric Endocrinology, 2University of( i6 e2 V0 S) H) ~4 O+ }$ s; O2 p) ]
South Alabama Medical Center, Mobile, Alabama.
/ a6 d! K6 D; d8 s7 SAddress correspondence to: Samar K. Bhowmick, MD, FACE,
3 z, b5 V3 d$ k1 K! D* lProfessor of Pediatrics, University of South Alabama, College of/ S( V: p. Z5 I4 `2 u2 z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- o- ^$ l2 l5 J2 a' i! a! i/ ie-mail: [email protected].
8 g. m! ^% k. dabout 6 to 7 months old, which progressively became* z3 O1 s" D; X* ~
darker. She was also concerned about the enlarge-0 I$ D- r( J7 Y* n1 _6 L
ment of his penis and frequent erections. The child( Z( \! b7 P5 E0 p( J6 q$ ]
was the product of a full-term normal delivery, with
7 s' ?" h0 w2 Oa birth weight of 7 lb 14 oz, and birth length of
; l3 x% v% u+ A9 a20 inches. He was breast-fed throughout the first year& T4 C0 [( c0 f
of life and was still receiving breast milk along with
* G- J3 {/ ^, A* H" U" L' c0 A3 bsolid food. He had no hospitalizations or surgery,3 M+ f8 U' R" E
and his psychosocial and psychomotor development
% f# S- g" D) V, y& ?' `* vwas age appropriate.( N& X) u; F: z, R" e( g3 I
The family history was remarkable for the father,
- [8 n2 T2 V! i u/ }6 F5 w. wwho was diagnosed with hypothyroidism at age 16,$ A7 m: k# [; O3 b
which was treated with thyroxine. The father’s4 z1 f4 j* f5 [) I6 y x/ w: O
height was 6 feet, and he went through a somewhat0 g' _8 P7 M, `3 I! p, U
early puberty and had stopped growing by age 14.7 M6 r7 B K/ B+ M, y$ L( m7 h5 T
The father denied taking any other medication. The
3 g: l& M! [) k4 K* u# bchild’s mother was in good health. Her menarche8 l8 {9 H' |6 G3 c5 v
was at 11 years of age, and her height was at 5 feet
7 f2 B9 Y, T2 N: n5 inches. There was no other family history of pre-: G2 H" t- D& z! o
cocious sexual development in the first-degree rela-
) E, e8 q- ` l* V' wtives. There were no siblings.
8 \' r/ ]' B5 u" W ZPhysical Examination
$ _5 ]2 Q+ y: D1 n: aThe physical examination revealed a very active," x, t+ a# ?; g9 `7 [7 N5 n
playful, and healthy boy. The vital signs documented' p" n% M& o" |' H0 F+ k: }3 d3 a0 C
a blood pressure of 85/50 mm Hg, his length was! ~: }: p+ a% v5 D* |; R1 S
90 cm (>97th percentile), and his weight was 14.4 kg1 ^) B; c7 P/ i8 O. y$ e
(also >97th percentile). The observed yearly growth
. y" m4 _3 B: f7 _6 ^velocity was 30 cm (12 inches). The examination of9 h/ [+ `$ W6 m; c+ @
the neck revealed no thyroid enlargement.1 k$ x( o5 ~0 W; z, S
The genitourinary examination was remarkable for9 z9 r2 [# W$ g V- i" h
enlargement of the penis, with a stretched length of( w$ R8 `& s( \1 G; v
8 cm and a width of 2 cm. The glans penis was very well
4 p6 @9 u& \ ]developed. The pubic hair was Tanner II, mostly around3 k7 \7 r* s4 X8 e
540
% v3 b( S# K, C$ u) d. o0 `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 o# N# P# g9 }- j G2 l
the base of the phallus and was dark and curled. The
$ J* E5 B6 E, Q ~! R( g! s( Btesticular volume was prepubertal at 2 mL each.
# P/ P/ ~; i b; N+ a) y& Z0 hThe skin was moist and smooth and somewhat
4 b* k* Y( ?5 Z$ V) s2 |oily. No axillary hair was noted. There were no/ ^! _6 ^6 k+ q* s
abnormal skin pigmentations or café-au-lait spots." |& |6 X- U, E* I, c3 _& P
Neurologic evaluation showed deep tendon reflex 2+: d* {6 V" F3 S- h. ?- [% c
bilateral and symmetrical. There was no suggestion7 i( _; _! f5 s* n2 ~: G& `' L/ }
of papilledema.
% n, Y2 r$ W \$ e/ w- E% b+ @5 lLaboratory Evaluation
) w( N' m9 M% d w3 L) y/ a7 Q- sThe bone age was consistent with 28 months by
$ Y8 \& d$ c3 H6 c1 Z: ]using the standard of Greulich and Pyle at a chrono-
/ d! }+ r w0 ~1 C0 F9 a% D: Klogic age of 16 months (advanced).5 Chromosomal+ Q' v5 d! O s$ W! X8 ]/ g
karyotype was 46XY. The thyroid function test
4 H: u# o9 S+ j' D, c1 Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# ]6 m% b# j% Q0 t! Q- A# _lating hormone level was 1.3 µIU/mL (both normal).5 w1 p! O7 s) H
The concentrations of serum electrolytes, blood f6 g* g, F- \2 `+ v2 s/ T
urea nitrogen, creatinine, and calcium all were
4 J' p+ W1 `& Q" Gwithin normal range for his age. The concentration
$ k0 M- ]. [. X9 m. m0 a* x% aof serum 17-hydroxyprogesterone was 16 ng/dL
; S! B8 T& |+ y(normal, 3 to 90 ng/dL), androstenedione was 20) s8 \0 p9 d2 C$ ^1 b3 Q$ G
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 E6 i8 L! f, }
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ O" T% L; e8 ?& X, |+ odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! u4 Z" s `1 ~5 [ s/ v0 y49ng/dL), 11-desoxycortisol (specific compound S)- R, U# m' `. ~5 ^2 y3 ~4 Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% b- X; X9 k0 M3 g/ Q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! o. q/ e- T" j) l! L1 ` {6 v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ _5 v* f2 b9 X/ ]9 g
and β-human chorionic gonadotropin was less than
6 s. {% A O# i7 F8 X5 mIU/mL (normal <5 mIU/mL). Serum follicular
! G5 G1 P- h: k4 Y( W* estimulating hormone and leuteinizing hormone
' k7 u8 ^6 P D- C! O: Vconcentrations were less than 0.05 mIU/mL
$ |3 F) W: |! F(prepubertal).4 F2 s7 d* k @# H
The parents were notified about the laboratory
8 r8 x( A1 U ?' O {4 ]results and were informed that all of the tests were, U+ a$ X7 n- U# v$ q
normal except the testosterone level was high. The% D7 E$ X: o0 c, H
follow-up visit was arranged within a few weeks to7 D- R, i4 i3 I* o
obtain testicular and abdominal sonograms; how-
& ^) G4 A* e) m6 k+ rever, the family did not return for 4 months.
) M2 w0 I1 P$ u3 EPhysical examination at this time revealed that the$ I3 k* u% a) e& Y) ~) u
child had grown 2.5 cm in 4 months and had gained6 w, l+ f1 V" ~, {" {( T4 @: r2 _* G
2 kg of weight. Physical examination remained
8 i) I& C; V; \0 {" Sunchanged. Surprisingly, the pubic hair almost com-
: B. F" t5 b- v" |0 Ipletely disappeared except for a few vellous hairs at
# k3 k8 ?, `& s ~the base of the phallus. Testicular volume was still 2" M9 a" o; Q/ t/ G- n
mL, and the size of the penis remained unchanged.
6 F& l- }& v+ Y7 ZThe mother also said that the boy was no longer hav-: t" [: u# {8 i. O/ D! q1 y
ing frequent erections.
/ {2 e3 _ I9 G9 n1 hBoth parents were again questioned about use of$ M$ i$ N4 w j E4 N3 E2 u* C
any ointment/creams that they may have applied to; i ]2 ?' O, V2 W4 O/ z* q$ ]: y
the child’s skin. This time the father admitted the
5 J. h9 k! d3 iTopical Testosterone Exposure / Bhowmick et al 541
( Y6 Z' U$ Y3 D: b0 \+ zuse of testosterone gel twice daily that he was apply-9 S; ^) K, Q; D& O
ing over his own shoulders, chest, and back area for( a I( ~7 |" p' R2 O0 M
a year. The father also revealed he was embarrassed9 y, e5 P. i; Y) l; Q9 E
to disclose that he was using a testosterone gel pre-
; w8 D' m: b( Qscribed by his family physician for decreased libido5 A+ \* V" D+ n1 n
secondary to depression.
: \4 j4 j; N. f# vThe child slept in the same bed with parents.3 `! ?# A8 r! I3 e3 ^
The father would hug the baby and hold him on his: D( e; q: l ?
chest for a considerable period of time, causing sig-) X b5 f% [7 e
nificant bare skin contact between baby and father.
, |6 |! Q2 ^2 F$ p+ X% qThe father also admitted that after the phone call,
+ e0 L) Q$ Y) ^( a9 U$ f6 {when he learned the testosterone level in the baby6 u5 v2 y. C; P8 R' q
was high, he then read the product information7 o5 k+ @2 O: C/ ^+ H9 n
packet and concluded that it was most likely the rea-$ n$ ~: n# U' r8 h" |3 Y+ d
son for the child’s virilization. At that time, they! f# s) q) g7 d/ Z: G
decided to put the baby in a separate bed, and the- e6 ~* A7 X2 c! V
father was not hugging him with bare skin and had Y8 ]/ p, H& v% y4 C% B [
been using protective clothing. A repeat testosterone5 M4 _- }2 b8 [) y! [5 l
test was ordered, but the family did not go to the3 N7 W9 i* @8 E4 ]& A
laboratory to obtain the test.: A9 D9 z5 S- f; E$ V
Discussion- w) z R- O' B; d
Precocious puberty in boys is defined as secondary8 c1 i! Y7 o; Y Q( [; d5 s
sexual development before 9 years of age.1,42 {) O: P& t; m$ x4 ?" F
Precocious puberty is termed as central (true) when
$ K$ d, A* I) x2 D, P$ Fit is caused by the premature activation of hypo-
0 ?2 m" J" L* @. `5 H3 sthalamic pituitary gonadal axis. CPP is more com-; |; q( Z! c+ `9 ]5 a
mon in girls than in boys.1,3 Most boys with CPP
8 O2 L5 _( A0 {, cmay have a central nervous system lesion that is% X+ ?9 w. l. U6 t7 h$ O
responsible for the early activation of the hypothal-0 ^' }2 U! ]" v7 _
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 q+ r1 K x& E6 W6 w- W6 H* z( dsis has been given to neuroradiologic imaging in
' C( ^' K: [6 }boys with precocious puberty. In addition to viril-1 e: W. H! \) S0 ^1 a; R
ization, the clinical hallmark of CPP is the symmet-
! `& p- {' p$ g1 p, Z- T5 rrical testicular growth secondary to stimulation by6 \3 H& i! _ e/ j( _
gonadotropins.1,3
+ E& y5 w6 u. PGonadotropin-independent peripheral preco-
$ K- g3 z' d: t7 l4 u- fcious puberty in boys also results from inappropriate
% T. p4 S1 C H, w$ ?) O7 K; @androgenic stimulation from either endogenous or
3 k& U0 r1 F0 R7 ~0 \- b% Yexogenous sources, nonpituitary gonadotropin stim-9 G# H! i" i' D2 Z% ~' K% x
ulation, and rare activating mutations.3 Virilizing
% D8 }8 O) n5 x: @congenital adrenal hyperplasia producing excessive
; V3 p2 b. G, _( Vadrenal androgens is a common cause of precocious& N, p9 K7 I. |. y# g4 P3 o) G0 w
puberty in boys.3,4: R3 ^9 c6 \- |! C/ W% h& U
The most common form of congenital adrenal, b3 j! d" [& |( S- E3 f
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 |) R9 y0 h8 S# A4 k+ `The 11-β hydroxylase deficiency may also result in
) w4 c! J! M! v: Q4 Q9 N9 eexcessive adrenal androgen production, and rarely,- r* c( {; x m1 J0 z
an adrenal tumor may also cause adrenal androgen
9 c: Y: C* C$ [( n% [4 S; \excess.1,3
( w1 p% D4 ]7 }# ~( [8 [! X4 Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 h$ u& _9 l# a, m8 F" h7 r! ^1 T
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 d L) {+ c, T7 @ s1 [" |# J
A unique entity of male-limited gonadotropin-
# G+ v1 b: q" p* oindependent precocious puberty, which is also known6 l0 ?/ v: S1 R1 }/ ^
as testotoxicosis, may cause precocious puberty at a$ D9 o& [+ J; B4 x- W+ C' f# W! |
very young age. The physical findings in these boys: N1 w+ k' N! `2 V2 I3 Q M
with this disorder are full pubertal development,
, f' ^" s+ F' E! T J! g5 ^including bilateral testicular growth, similar to boys/ r5 q6 f0 y% a: A- {6 g8 K
with CPP. The gonadotropin levels in this disorder
0 ]4 }- e& T: a. aare suppressed to prepubertal levels and do not show+ T) B- A @4 `" }: n$ [2 v5 _% {
pubertal response of gonadotropin after gonadotropin-
5 V- y& W C1 b% g8 Preleasing hormone stimulation. This is a sex-linked7 y- @3 l d% [
autosomal dominant disorder that affects only
5 L6 d) N# ~; {males; therefore, other male members of the family
' Y S* m8 e. C8 g; n c/ }* cmay have similar precocious puberty.3
" K5 e) A! J5 p) L& iIn our patient, physical examination was incon-
& N* {! Y6 l0 q( t7 Osistent with true precocious puberty since his testi-; l. ]! N3 M) W Y& A3 i; S
cles were prepubertal in size. However, testotoxicosis* n2 _8 }) \& p' f# L7 G5 J! R
was in the differential diagnosis because his father3 H( S9 c) I W u1 }2 n8 y; @
started puberty somewhat early, and occasionally,+ E# W: s$ h0 b
testicular enlargement is not that evident in the
3 o6 o9 T( j. E4 a3 @, P/ hbeginning of this process.1 In the absence of a neg-
! m) E$ X$ }# ], T( tative initial history of androgen exposure, our
% l. f4 s# P$ n/ P) ]- A" [8 A% X/ cbiggest concern was virilizing adrenal hyperplasia,7 z5 G' x9 o: I9 A6 k1 M8 ~0 C; F6 @/ V
either 21-hydroxylase deficiency or 11-β hydroxylase
! B; ^" I2 {. a5 a( m. O7 edeficiency. Those diagnoses were excluded by find-
3 F1 P0 B* @6 P+ c5 fing the normal level of adrenal steroids.; |, w$ j+ t! ]- @( P
The diagnosis of exogenous androgens was strongly J" e0 x$ Y" y* |7 T
suspected in a follow-up visit after 4 months because
9 W/ o* |, f& m2 F3 k2 Rthe physical examination revealed the complete disap-
% r5 t4 x' x1 Qpearance of pubic hair, normal growth velocity, and
- _$ e1 T& v) N% qdecreased erections. The father admitted using a testos-, t) {2 M0 u. \( Q
terone gel, which he concealed at first visit. He was
. ]7 L% E! L6 t n' Dusing it rather frequently, twice a day. The Physicians’: |1 Y O g) T; ~
Desk Reference, or package insert of this product, gel or
2 O/ t7 u$ V" _( Mcream, cautions about dermal testosterone transfer to
y# [' W6 }7 M# Gunprotected females through direct skin exposure.
9 M0 A" P- ~0 s2 h" Q3 ZSerum testosterone level was found to be 2 times the
- p- V5 A- c5 abaseline value in those females who were exposed to; ~* s0 ?$ L0 s$ U
even 15 minutes of direct skin contact with their male0 x" M- ]5 e$ Q& s
partners.6 However, when a shirt covered the applica-
7 [, q8 H. Y! _1 D. wtion site, this testosterone transfer was prevented.* [. ?5 @% F2 t
Our patient’s testosterone level was 60 ng/mL,
5 c5 c# L6 ]# I/ L% j$ v' G# U" pwhich was clearly high. Some studies suggest that: m" O ?! T, A7 ~: O! P
dermal conversion of testosterone to dihydrotestos-7 Q4 }" \% T& A
terone, which is a more potent metabolite, is more
( ]+ m ^2 G' T1 ?9 tactive in young children exposed to testosterone
0 Q; V5 n" T4 i; y3 f. D7 cexogenously7; however, we did not measure a dihy-/ H1 ^# y1 {. B% f! \
drotestosterone level in our patient. In addition to
. j- ]$ _+ b" Y) r& l& Y8 d) Hvirilization, exposure to exogenous testosterone in0 R+ n4 A ~. \7 M; o
children results in an increase in growth velocity and
0 {5 K' V% o# @# ]# oadvanced bone age, as seen in our patient.2 k- f7 w2 Z; \" A& f' V
The long-term effect of androgen exposure during4 L. z& J, O* z5 w
early childhood on pubertal development and final
( x8 b% T2 E/ M5 badult height are not fully known and always remain; N6 v* l: W$ }5 {
a concern. Children treated with short-term testos-
* H z+ ]4 z7 h% q' Oterone injection or topical androgen may exhibit some
4 B& \7 P; F3 y2 v& c+ xacceleration of the skeletal maturation; however, after3 Q1 A6 t4 T3 g. ]" Q0 O# N
cessation of treatment, the rate of bone maturation1 ~) p' N. C( ?( |$ L: g
decelerates and gradually returns to normal.8,9
$ ]- l+ l0 Z- t& d0 X, G" GThere are conflicting reports and controversy/ b2 H. M6 G, f# A+ p+ O
over the effect of early androgen exposure on adult
0 h, v6 z+ |! _' W& P2 M3 p( Bpenile length.10,11 Some reports suggest subnormal
, C( r$ \1 i% {2 N: O7 M( @% Badult penile length, apparently because of downreg-7 N9 Z) ?& ?9 F3 v& C
ulation of androgen receptor number.10,12 However,/ y% m8 ^+ N& r: c3 [0 p
Sutherland et al13 did not find a correlation between
+ C5 ~1 Q. k- d5 G5 R6 M$ m8 _childhood testosterone exposure and reduced adult
! f5 l9 n1 b8 y. z* U, k, Ppenile length in clinical studies.
$ s; H; w# p9 r! oNonetheless, we do not believe our patient is ~7 Z9 i1 [. ^+ s0 v
going to experience any of the untoward effects from
) z! O+ N8 D) p5 @3 X7 ~$ z; }2 ?testosterone exposure as mentioned earlier because1 d. K' v8 T) D
the exposure was not for a prolonged period of time.
/ E, v& j9 G: n) e# xAlthough the bone age was advanced at the time of
+ x. I! }( f4 K9 Gdiagnosis, the child had a normal growth velocity at6 B: ~: @1 N9 O. |. I+ M
the follow-up visit. It is hoped that his final adult _, o% G/ V' w) O4 K2 h
height will not be affected.
8 b, |. g/ Q2 i3 s- X) sAlthough rarely reported, the widespread avail-
4 R- h: S/ l$ P- I4 Y3 j$ \# `: vability of androgen products in our society may3 [! V9 @& v) K) z
indeed cause more virilization in male or female
: I* U1 Q9 I0 M+ ]+ `children than one would realize. Exposure to andro-
/ _6 t2 u. d, z0 l: w, ^' t) y fgen products must be considered and specific ques-& |: N6 ]' c1 H, V( N* C% w
tioning about the use of a testosterone product or$ ~0 W$ y1 _% o$ N; V
gel should be asked of the family members during
- ]/ i/ ~. b" F& @9 s' lthe evaluation of any children who present with vir-9 \" o Y# ^1 c' l. i$ Y# e" F
ilization or peripheral precocious puberty. The diag-- k2 |/ L* J( h4 n
nosis can be established by just a few tests and by
- g1 B3 R4 o9 M0 o; fappropriate history. The inability to obtain such a
' H* `1 { E& p1 C+ Ehistory, or failure to ask the specific questions, may/ d2 e1 ~( H9 V2 H( W
result in extensive, unnecessary, and expensive, ]# q3 D2 N9 S9 A! \( P
investigation. The primary care physician should be1 R' z' B% v; i/ r& N
aware of this fact, because most of these children
( |8 ]) W! n4 s% C" s) dmay initially present in their practice. The Physicians’4 E* i# o$ s* z& q3 y* [
Desk Reference and package insert should also put a
0 n8 Q' c' O3 ~: D8 E' j+ Mwarning about the virilizing effect on a male or
9 g q, N% B; W" Q: y6 q- kfemale child who might come in contact with some-$ j a" ~. k, m* h3 _, F/ ]" x
one using any of these products.
6 v* S7 W' E4 {2 I5 z& s9 P- T( I& UReferences
" S+ V A* w/ `) S& U1. Styne DM. The testes: disorder of sexual differentiation) }+ S" ~4 t* ?; o" j. l# y% b# Y/ U
and puberty in the male. In: Sperling MA, ed. Pediatric! U- P! X, N' m& [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! m+ T T1 {3 x$ _
2002: 565-628.3 j5 m( g* i2 W9 [3 P
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! k" a9 i$ |2 c% T/ d upuberty in children with tumours of the suprasellar pineal |
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