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Sexual Precocity in a 16-Month-Old
6 {! v" J9 \ tBoy Induced by Indirect Topical5 k4 A D1 G( \+ d. }
Exposure to Testosterone
( O. o& s$ R* [' r& h7 i# y+ hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 l. P- n: X. f! ~: D+ Fand Kenneth R. Rettig, MD1
( {8 c9 t' w& v: C6 Q/ q3 DClinical Pediatrics8 B9 r# S5 l2 X4 v
Volume 46 Number 6* ~- ]2 u* B- ]: m0 G
July 2007 540-543
8 f6 X) A" K* G9 O% a! J% T( n+ y© 2007 Sage Publications
7 l& ^* @# ~6 m10.1177/0009922806296651+ M6 H+ d1 V6 J8 T
http://clp.sagepub.com% V3 y+ [8 T0 d9 l# Q
hosted at2 G* H5 O- r1 G7 B
http://online.sagepub.com
$ K, h, _+ v% h: oPrecocious puberty in boys, central or peripheral,
5 {# ~' [+ E0 ?1 U/ v2 yis a significant concern for physicians. Central
5 h. k6 ]4 s4 m5 b9 e' Wprecocious puberty (CPP), which is mediated
$ U, g8 {- d) ethrough the hypothalamic pituitary gonadal axis, has. p, C7 W$ D2 W) s) p& t `6 I
a higher incidence of organic central nervous system6 U2 O' ~) W7 Q
lesions in boys.1,2 Virilization in boys, as manifested
8 w+ \, F7 y0 M7 C# L& T) {by enlargement of the penis, development of pubic
% i# {5 U9 p+ ^% Z% _hair, and facial acne without enlargement of testi-& O4 u6 l; q6 x; O
cles, suggests peripheral or pseudopuberty.1-3 We- ?: U3 Z t; l1 A% f j
report a 16-month-old boy who presented with the
& N- @9 W7 `- [enlargement of the phallus and pubic hair develop-! O/ @; Z1 E8 z/ i: g6 ^/ l
ment without testicular enlargement, which was due
' k4 t1 i' T& n- B1 v; Eto the unintentional exposure to androgen gel used by
+ t- V- t% s. \' [( [5 m3 Z! Nthe father. The family initially concealed this infor-
, N7 a7 B. Z1 m; y. W! Ymation, resulting in an extensive work-up for this
! a/ `! l% @* K7 g; Vchild. Given the widespread and easy availability of3 S' t* h6 T1 K( Y
testosterone gel and cream, we believe this is proba-
9 h; i! i( i3 ^5 d fbly more common than the rare case report in the
% C8 a/ m0 K( n% [& c5 zliterature.46 X9 D7 X/ g" D3 v9 P; L
Patient Report- C1 U1 `2 C: W/ F
A 16-month-old white child was referred to the
& L9 r+ s: {6 F! P7 Wendocrine clinic by his pediatrician with the concern: M' S2 M! D' c/ ` G9 E2 y M
of early sexual development. His mother noticed
; a% K- V& ~2 P [; M0 slight colored pubic hair development when he was
; Z8 ~0 V, I0 p- f3 ?From the 1Division of Pediatric Endocrinology, 2University of# L) m' c1 }, d' u+ ?3 H
South Alabama Medical Center, Mobile, Alabama.
7 [% g# d3 d, T' D* g$ X8 Q3 GAddress correspondence to: Samar K. Bhowmick, MD, FACE,. u$ ~% E2 t/ v3 B* Z
Professor of Pediatrics, University of South Alabama, College of" M- W1 J5 {* @7 ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 s6 g( ~$ b P# d
e-mail: [email protected]./ k% P4 [5 D; I" X6 }
about 6 to 7 months old, which progressively became
: v. B! e! w/ w8 W" x: ]$ Odarker. She was also concerned about the enlarge-% o' i- H) h6 |% s3 Q v
ment of his penis and frequent erections. The child
* j8 Q0 E9 r. e% wwas the product of a full-term normal delivery, with
; a$ }. V% C9 ^9 N/ m- Ea birth weight of 7 lb 14 oz, and birth length of
% e" e$ {* G; r20 inches. He was breast-fed throughout the first year. t+ i% e: m; W7 u7 z
of life and was still receiving breast milk along with
# q1 {) {$ K& m5 g! P5 \7 ^solid food. He had no hospitalizations or surgery,
6 w: c3 t! A5 e n$ W( S2 Jand his psychosocial and psychomotor development7 w. b# ]$ e. S' b Q0 Q' s
was age appropriate.0 t3 V0 v7 R3 K! E
The family history was remarkable for the father,
' v2 L2 x9 A( f( O# R% q$ A1 Awho was diagnosed with hypothyroidism at age 16,
, E6 U$ M0 P" mwhich was treated with thyroxine. The father’s4 A. g! i- l( i* e- A
height was 6 feet, and he went through a somewhat
+ i. {- l; D7 d7 k% [5 Aearly puberty and had stopped growing by age 14.
/ v" Z) K4 j$ IThe father denied taking any other medication. The: v$ H# U2 R, a* f
child’s mother was in good health. Her menarche% ^; I, v, ~' u
was at 11 years of age, and her height was at 5 feet! X$ W- r4 {+ X3 C0 p1 R
5 inches. There was no other family history of pre-
2 _8 J2 A" I% Ecocious sexual development in the first-degree rela-
+ U+ z: d# k7 K Qtives. There were no siblings.
/ Z) v( Y2 S" p b3 e: ?Physical Examination( J% p( K( F0 Q& n& x
The physical examination revealed a very active,
; S; Z+ ?4 B/ Lplayful, and healthy boy. The vital signs documented5 W) I5 \ q1 y7 n& A
a blood pressure of 85/50 mm Hg, his length was) p+ u0 M3 D& ]) ]4 ?+ I
90 cm (>97th percentile), and his weight was 14.4 kg
# I3 Y$ h8 y! Y3 V(also >97th percentile). The observed yearly growth
; S3 o. W1 @, t* n0 n! Xvelocity was 30 cm (12 inches). The examination of
/ }/ P! ~# w" q0 Z7 C* H: h3 Lthe neck revealed no thyroid enlargement.1 [8 g7 Q, {3 H0 P4 H
The genitourinary examination was remarkable for, ]+ z' k7 u; j+ z; ~: I! h0 R
enlargement of the penis, with a stretched length of& V- V5 P4 L7 g [' J5 _1 m- x1 }
8 cm and a width of 2 cm. The glans penis was very well
5 g$ z9 T- r& s& @9 _3 X0 `developed. The pubic hair was Tanner II, mostly around
6 ], V# f) t& K9 M M540
, A0 E" }8 `$ Y3 k- ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: B7 X) J. N3 L% c0 _( x: _the base of the phallus and was dark and curled. The8 t- q1 } v- w4 [
testicular volume was prepubertal at 2 mL each.
3 F6 Y4 V4 @. U8 M( w6 IThe skin was moist and smooth and somewhat9 F) Q4 i: n: m$ V
oily. No axillary hair was noted. There were no
9 {- i# D4 u" V* M. X) Habnormal skin pigmentations or café-au-lait spots.
' W6 x5 t9 ]; KNeurologic evaluation showed deep tendon reflex 2+
6 A( E4 C/ I0 Q0 I2 y ~bilateral and symmetrical. There was no suggestion
! h( @2 R9 [9 O8 R, n; W" oof papilledema.
9 V6 O! m, B! h) k% R3 FLaboratory Evaluation
% z. F4 T" h& u. VThe bone age was consistent with 28 months by
) s0 k1 G9 ~( J8 D. `using the standard of Greulich and Pyle at a chrono-
6 ~' r1 p+ A( l9 j R7 flogic age of 16 months (advanced).5 Chromosomal# A4 F7 p1 u6 l4 ^, N
karyotype was 46XY. The thyroid function test- ]5 `8 T$ I+ L) }; A
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 k0 a- r5 F2 c9 l5 ?) Slating hormone level was 1.3 µIU/mL (both normal). n( I; j4 d7 P7 i1 I) |
The concentrations of serum electrolytes, blood- j. p% I! `" s6 _* o
urea nitrogen, creatinine, and calcium all were) n0 R" l% z6 x
within normal range for his age. The concentration
$ M' H! w+ Z8 n( q- Cof serum 17-hydroxyprogesterone was 16 ng/dL% r7 l# S+ Q+ ?1 [
(normal, 3 to 90 ng/dL), androstenedione was 20
! B h1 P4 s" J- _0 v. R; I7 [1 Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 w' B6 `% q5 k G. x8 T( ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 d0 \: H2 W( p# Z; l' A, E( r6 S1 ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: {: \* ^# u8 D8 p6 ~7 S49ng/dL), 11-desoxycortisol (specific compound S)
$ j& P# t9 r! T) Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 x- w& V+ I7 C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 }) i& T( D" g& G; K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, N" O7 l! q6 k+ [0 i
and β-human chorionic gonadotropin was less than
& a0 v4 @8 q1 { m$ V7 u5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 s0 q' [) Z+ Qstimulating hormone and leuteinizing hormone7 Z& p9 }: s% g8 J& X/ X% p
concentrations were less than 0.05 mIU/mL6 ?3 z3 Z! B0 G3 y
(prepubertal).
( `5 C7 S7 K% k: T( o8 b) hThe parents were notified about the laboratory0 N8 G# g- ]& B6 d$ w; u
results and were informed that all of the tests were; H2 A( Z/ |4 a+ A6 M3 G7 w
normal except the testosterone level was high. The& c- d. D- b; n k+ _: ]# n
follow-up visit was arranged within a few weeks to% |& o/ ]# \# ?$ P' R! R5 a
obtain testicular and abdominal sonograms; how-4 Y6 `9 b' i5 m$ }
ever, the family did not return for 4 months.( l- L& c8 O0 x b
Physical examination at this time revealed that the
. x. c! z! c. o# h- K: Zchild had grown 2.5 cm in 4 months and had gained
8 Q6 E1 n0 F# @/ Q2 kg of weight. Physical examination remained4 n: Y+ H2 _; q4 A% }
unchanged. Surprisingly, the pubic hair almost com-
, f2 N' `& L* w" Lpletely disappeared except for a few vellous hairs at
# i7 N9 f7 A2 y3 S( N, E3 Mthe base of the phallus. Testicular volume was still 26 e& b, F5 b5 h
mL, and the size of the penis remained unchanged." ~( g3 T- _3 Q5 T6 n/ i
The mother also said that the boy was no longer hav-
: i! X/ y" b8 c" G: E) u7 Ting frequent erections.. w4 y4 \! O5 ]0 x; p. o4 y
Both parents were again questioned about use of
' }8 ?( d; v+ A& m4 b4 M. ?8 cany ointment/creams that they may have applied to* R* H3 e( K& A4 Y% o% ~8 m
the child’s skin. This time the father admitted the
. j7 o) V# v" D/ gTopical Testosterone Exposure / Bhowmick et al 5412 k# ~/ @" y O2 ]$ c1 z+ L
use of testosterone gel twice daily that he was apply-# f& l, n% b$ s) q: C; R
ing over his own shoulders, chest, and back area for
. w. ^5 x: v5 k- wa year. The father also revealed he was embarrassed
" y; I0 R- K7 _5 J( r4 pto disclose that he was using a testosterone gel pre- ^: K! Z) w& v+ E" W8 {2 y
scribed by his family physician for decreased libido
3 `% G: w q1 n9 W2 o5 Lsecondary to depression., n0 ?& k! S% h% D/ |4 s
The child slept in the same bed with parents.
+ n) V6 m) \' r0 @The father would hug the baby and hold him on his
" Y g5 O2 a$ D8 I+ `# hchest for a considerable period of time, causing sig-
5 `9 ]3 M$ |; {! Z6 Enificant bare skin contact between baby and father.% Z1 X8 `4 y6 O. ^
The father also admitted that after the phone call,
! b' L, \4 ?* swhen he learned the testosterone level in the baby
g* L' N" ]# W% c+ s+ fwas high, he then read the product information# C d# P# G2 ^/ F# G) D
packet and concluded that it was most likely the rea-# Z2 r# h ]! Y$ \3 s4 R" B
son for the child’s virilization. At that time, they; F4 C5 ~' ~$ S/ b7 s
decided to put the baby in a separate bed, and the, z1 l* ?! l3 V8 U8 x ]* H8 L
father was not hugging him with bare skin and had4 o# b [7 o) W4 _, `. }% E/ u2 Y
been using protective clothing. A repeat testosterone' e/ }2 ^; l/ k' {; T6 G) M4 g4 B
test was ordered, but the family did not go to the7 m6 E4 D/ r+ h* X, B+ J
laboratory to obtain the test.. ^4 U" \9 `0 m5 \1 g; l
Discussion
! ]' |! l# e, Z) m4 ~- v3 }9 YPrecocious puberty in boys is defined as secondary6 W8 T7 B6 Z/ A8 j
sexual development before 9 years of age.1,41 u+ Q4 N. h/ Y
Precocious puberty is termed as central (true) when
) R$ l8 Z) N/ [+ Oit is caused by the premature activation of hypo-1 ^9 h" J! L' o0 R5 q
thalamic pituitary gonadal axis. CPP is more com-7 p, n) o# m8 O5 T
mon in girls than in boys.1,3 Most boys with CPP9 _! T, \5 C$ I" h7 Y& t
may have a central nervous system lesion that is. c+ Y/ ]2 H$ _0 @: F
responsible for the early activation of the hypothal-
1 c6 d' G: m+ g7 wamic pituitary gonadal axis.1-3 Thus, greater empha-9 G {2 A0 N0 Y
sis has been given to neuroradiologic imaging in
$ n. \& [! ~ Q- b; @boys with precocious puberty. In addition to viril-3 e) u. k6 I$ Z) P0 w# g2 t6 k
ization, the clinical hallmark of CPP is the symmet-
3 d: {+ c* o& [1 O) Wrical testicular growth secondary to stimulation by" V$ ^! Y3 s$ _ t8 i7 z
gonadotropins.1,3
6 l, y2 v4 N1 YGonadotropin-independent peripheral preco-
' H4 w* Q( i) q1 G8 ucious puberty in boys also results from inappropriate
* _2 E7 [# W: t, ]0 F+ q! Gandrogenic stimulation from either endogenous or" y3 H) I! B' _
exogenous sources, nonpituitary gonadotropin stim-
5 L3 V3 I2 {3 m& _. b2 S2 `ulation, and rare activating mutations.3 Virilizing/ K( E; F. W4 f7 q' Y
congenital adrenal hyperplasia producing excessive
7 a9 e( v4 t( k- x0 d8 aadrenal androgens is a common cause of precocious
) W, N( Z3 R6 c; A% |$ Fpuberty in boys.3,4! e( u) K, d7 Z) y, f1 \/ t; t
The most common form of congenital adrenal8 o& a- a. L) ~5 S* D
hyperplasia is the 21-hydroxylase enzyme deficiency.! L* E; ~% w$ p5 R
The 11-β hydroxylase deficiency may also result in
. F% H; h" Q" {: n. e/ _excessive adrenal androgen production, and rarely,: Q/ H5 v5 G @# K# P9 I1 b% [ s
an adrenal tumor may also cause adrenal androgen! T1 O. B7 d$ L
excess.1,3
: J/ V. C! ]5 H0 u# G3 t* bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" C7 x: ]! ], s" m0 b/ s( v. Q* h' o) e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 e5 f& M. P# n0 `* W9 d$ c' tA unique entity of male-limited gonadotropin-
' x" h+ X# a: z- gindependent precocious puberty, which is also known
7 j0 o3 ^5 ~' @" S. l6 Has testotoxicosis, may cause precocious puberty at a
7 w, D- y; {1 y: @! Ivery young age. The physical findings in these boys
2 [4 o3 r2 u) I$ N( i/ h# b( |with this disorder are full pubertal development,( p3 O- Z0 O# O) t
including bilateral testicular growth, similar to boys
/ Z# s9 i9 h6 Z8 `) Z0 Xwith CPP. The gonadotropin levels in this disorder) t1 l. d- H* G3 A9 ~9 Y0 o
are suppressed to prepubertal levels and do not show7 |! p6 w: X1 T: X
pubertal response of gonadotropin after gonadotropin-. t, J2 ?& A8 f* ?$ p
releasing hormone stimulation. This is a sex-linked2 P7 K# Y/ R3 n) P* s
autosomal dominant disorder that affects only* T6 C9 t+ B9 N5 p
males; therefore, other male members of the family5 C7 M/ s5 z: X! s' Z7 U% K4 k
may have similar precocious puberty.3. m8 j( o1 G+ z& y8 C7 u" V
In our patient, physical examination was incon-7 ?, v' H$ ?7 [$ W8 s" e7 A) [
sistent with true precocious puberty since his testi-4 g) K) L5 j0 J7 v
cles were prepubertal in size. However, testotoxicosis* U5 G0 f8 p5 M( G/ Q$ i3 m3 `
was in the differential diagnosis because his father9 ?* ]& C! N& D9 ]) K- |1 n
started puberty somewhat early, and occasionally,
6 d+ X6 s5 d2 n4 X0 Btesticular enlargement is not that evident in the
$ l) j* ]6 S, \: wbeginning of this process.1 In the absence of a neg-
% U R, c( B) _; y; x# J5 Hative initial history of androgen exposure, our
1 A, j1 v0 c# hbiggest concern was virilizing adrenal hyperplasia,# t d- p- a) C) l
either 21-hydroxylase deficiency or 11-β hydroxylase
" {2 [4 @' m8 A/ l; Y7 W; e5 `deficiency. Those diagnoses were excluded by find-$ ]. n' e8 u' {3 q2 w9 @9 r+ ^
ing the normal level of adrenal steroids.
7 ~8 P' L5 l, ?4 O. xThe diagnosis of exogenous androgens was strongly
9 S7 a+ v' K+ Z5 r! o. jsuspected in a follow-up visit after 4 months because
" R4 v; O- n5 v- v* i) Kthe physical examination revealed the complete disap-
& W& @, z' ?" w: `pearance of pubic hair, normal growth velocity, and3 N6 Z. ~/ u% k. Z: E2 u' E6 q* s. l
decreased erections. The father admitted using a testos-- w) j" {- d, r3 ^& A5 ?& L
terone gel, which he concealed at first visit. He was0 d! e& ~ k3 ^0 h, c: w
using it rather frequently, twice a day. The Physicians’! v) N! ]+ n2 ~* G2 `
Desk Reference, or package insert of this product, gel or
5 W! j# q, b# Y/ scream, cautions about dermal testosterone transfer to
; w. m1 K; C' H- |# w5 l5 l% hunprotected females through direct skin exposure.
5 f& ? X& f( p! \: hSerum testosterone level was found to be 2 times the
% B+ C0 H% J1 fbaseline value in those females who were exposed to# {0 L% w& p4 c
even 15 minutes of direct skin contact with their male
6 {1 y# C Z# O2 |+ h7 Apartners.6 However, when a shirt covered the applica-: R: }$ j8 \3 ~" n' S% ~% z
tion site, this testosterone transfer was prevented.: k% ^! U% C8 _5 E1 @$ T/ Y: R
Our patient’s testosterone level was 60 ng/mL,/ e8 y( U. R4 E
which was clearly high. Some studies suggest that
% p8 h' Z$ ?' L, D9 \2 R- i, C) tdermal conversion of testosterone to dihydrotestos-
$ L7 ^2 P0 Y9 [$ oterone, which is a more potent metabolite, is more
. x1 v* R: R% hactive in young children exposed to testosterone
3 I: ^( Y( [' q' D3 Texogenously7; however, we did not measure a dihy-% O0 j) A# a6 l- ~, L) j, I; A
drotestosterone level in our patient. In addition to. r# G+ q1 f6 `0 C+ M& ]2 T
virilization, exposure to exogenous testosterone in
1 |5 X+ u9 l8 Schildren results in an increase in growth velocity and8 U' x8 J& L, ~3 j7 x) w: I
advanced bone age, as seen in our patient." _; P0 l u8 w V3 I
The long-term effect of androgen exposure during- D3 D! l% w7 @* b) G% N& c
early childhood on pubertal development and final
. m8 N a6 n- b* F' c9 t& T2 madult height are not fully known and always remain
! |: z: S6 y" Aa concern. Children treated with short-term testos-
/ ]( P& f$ x" O9 |terone injection or topical androgen may exhibit some/ ~' W- b) H$ ~
acceleration of the skeletal maturation; however, after9 J1 w( {) ]+ q# h3 k
cessation of treatment, the rate of bone maturation8 Z% o8 R# X2 b. \" e
decelerates and gradually returns to normal.8,9
+ _7 E2 W9 ?3 ]; XThere are conflicting reports and controversy
5 H8 X5 b8 e! R# }, u. ^4 Nover the effect of early androgen exposure on adult9 c2 [ W0 T' d( M
penile length.10,11 Some reports suggest subnormal" u" C8 w. k( K% u2 S
adult penile length, apparently because of downreg-4 H G! ]$ ^/ g) ^9 |* X# }) N( U
ulation of androgen receptor number.10,12 However,6 Q7 k8 M3 x5 P/ X9 j9 B/ Y
Sutherland et al13 did not find a correlation between2 w4 `, W+ `3 n9 R
childhood testosterone exposure and reduced adult
_* A9 m* l7 C' s. bpenile length in clinical studies.
# F2 h, y& B4 n WNonetheless, we do not believe our patient is
5 x: }7 b) \; H5 ~+ Jgoing to experience any of the untoward effects from) z: \% y" k1 N/ d6 ~, W& u! P* i
testosterone exposure as mentioned earlier because/ b3 i- r! C9 Q+ i) t3 s1 }$ X! A: ^; t
the exposure was not for a prolonged period of time.- k# V" @" G0 ^/ N c
Although the bone age was advanced at the time of @. P$ K& t# q# s( S5 r
diagnosis, the child had a normal growth velocity at- Z/ S2 ^# Y W; I) j* V
the follow-up visit. It is hoped that his final adult
$ W1 n. S- `! b( R3 C& {height will not be affected.
. f# E) t$ Z0 |0 [: X% b- I0 W6 \Although rarely reported, the widespread avail-
2 h6 v0 q' p$ k2 M6 Tability of androgen products in our society may! }( [* D$ o( E9 H/ ]
indeed cause more virilization in male or female
: n A! J: T: d2 d. ^( c+ }& C j0 bchildren than one would realize. Exposure to andro-4 k2 a8 q8 C2 I/ W3 D H
gen products must be considered and specific ques-
/ E. L: I$ o( d% r& N, Ntioning about the use of a testosterone product or' O) t. O. S6 A" T3 @' _2 Q
gel should be asked of the family members during
# f U0 M; `: n( K7 Dthe evaluation of any children who present with vir-
6 @ n! k) X7 @7 k- x l5 y/ qilization or peripheral precocious puberty. The diag-: h+ H7 A9 B/ W+ J& ]
nosis can be established by just a few tests and by4 o- O! q9 g' @& ~
appropriate history. The inability to obtain such a! ?/ Z4 S4 {# {" j4 u' W
history, or failure to ask the specific questions, may
( M. ?* t" ?" aresult in extensive, unnecessary, and expensive8 d/ F' I& `1 y8 j l5 [$ z. j
investigation. The primary care physician should be
8 Q! Y. V: E2 \# A; t& p; j. caware of this fact, because most of these children4 b( d! I4 z& h0 ^6 D& j0 j( [
may initially present in their practice. The Physicians’
( |/ `6 |* M4 Y3 y7 U+ _, ]5 M9 pDesk Reference and package insert should also put a3 g& ^" S0 a9 U1 J* D% |6 u) t
warning about the virilizing effect on a male or
1 w) w' m% P% z3 H) P. y% R3 q9 jfemale child who might come in contact with some-- V7 M6 Z: @: h: v
one using any of these products.1 @6 m- H0 f) b2 d9 r& C& T
References: }3 F2 {. y6 i0 _, I/ a5 w
1. Styne DM. The testes: disorder of sexual differentiation- Y7 W' j5 s: m3 P: r% J& W- n
and puberty in the male. In: Sperling MA, ed. Pediatric- b$ D' d( Z4 b2 B2 V& o2 ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
l7 ^' n0 n) p% y8 o; e5 F2002: 565-628.; K% z; e1 d/ |) r' f( i8 R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( k e; ^( [+ m- b/ W; }
puberty in children with tumours of the suprasellar pineal |
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