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Sexual Precocity in a 16-Month-Old
% F( E/ n, g3 ]! T8 @Boy Induced by Indirect Topical) g% ^9 D/ b) ]2 i+ w6 |2 Z
Exposure to Testosterone, J7 ]' A0 D) M" ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 R2 Q7 F& D, i: hand Kenneth R. Rettig, MD17 b. G' D O4 U1 @7 C
Clinical Pediatrics3 \; c$ b6 ~; w7 `( n5 U
Volume 46 Number 6; p: ~1 v9 A9 m
July 2007 540-5436 V) x. M6 g- y# T2 s
© 2007 Sage Publications
& T2 {3 s! J5 W- C# n) s& I10.1177/0009922806296651
8 J! |' s* T$ H) Z/ ~http://clp.sagepub.com. [( x- `2 T ~' R' _7 `: `) F# g
hosted at; q9 A8 ?3 n# R9 y
http://online.sagepub.com
5 x. ~2 b2 l$ j: e; }# gPrecocious puberty in boys, central or peripheral,
+ h9 n! @" B% X# e# G7 h$ uis a significant concern for physicians. Central- N$ Q3 e) @; ^5 q6 G6 Y: }! M2 f
precocious puberty (CPP), which is mediated1 g+ T% R* E0 _5 {/ `7 k" `) ?
through the hypothalamic pituitary gonadal axis, has) g% s) U$ S" X" \5 D5 Y+ ~
a higher incidence of organic central nervous system
! [# [) d. W$ W* hlesions in boys.1,2 Virilization in boys, as manifested2 @/ {' b9 |5 q5 F
by enlargement of the penis, development of pubic$ G; C; J$ P j9 W
hair, and facial acne without enlargement of testi-& c% v: P: n( l
cles, suggests peripheral or pseudopuberty.1-3 We
; U; ~+ _9 W9 c. @4 c, O2 [" Kreport a 16-month-old boy who presented with the/ x/ l9 k9 S! {: ?; O7 e' A, L1 @
enlargement of the phallus and pubic hair develop-
, @3 A1 c" o. B' Nment without testicular enlargement, which was due
6 Z5 d1 E) f1 n. x/ ~& Oto the unintentional exposure to androgen gel used by
/ a/ U9 J% w4 b# T/ Lthe father. The family initially concealed this infor-/ C [* n5 G+ K- e8 W! ?
mation, resulting in an extensive work-up for this$ C3 t: b/ @ O+ Z
child. Given the widespread and easy availability of
; G& I( M0 p9 d( ~- ?+ ltestosterone gel and cream, we believe this is proba-# Q! \$ A6 C6 g" e
bly more common than the rare case report in the3 l8 ~, S6 {8 j- U0 B$ M8 U+ U
literature.4/ H( C% ^* Z. u m
Patient Report) T* X5 ~7 w1 u" ^% V; u
A 16-month-old white child was referred to the
0 }6 I; I3 t+ Qendocrine clinic by his pediatrician with the concern" @. k; q6 |( A& e3 e/ T2 H. A; c! K
of early sexual development. His mother noticed5 y7 g3 w6 x9 C, r% O2 g' w. E
light colored pubic hair development when he was( U9 t# a/ j1 k- m/ O3 e% I
From the 1Division of Pediatric Endocrinology, 2University of
# u+ ~ z6 k% @2 _2 |4 h+ a zSouth Alabama Medical Center, Mobile, Alabama.
, z3 Z1 C* L1 {, ^! ]Address correspondence to: Samar K. Bhowmick, MD, FACE, `4 h6 x- x$ ~( J! F' @
Professor of Pediatrics, University of South Alabama, College of" |+ b9 E/ V8 l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- h% i/ r1 N' o8 w4 [6 v
e-mail: [email protected].
# D6 t5 }3 g! }/ zabout 6 to 7 months old, which progressively became2 s& y* i1 a/ Y7 s
darker. She was also concerned about the enlarge-: M2 q- f# P% n( z4 |% S4 X1 }
ment of his penis and frequent erections. The child, l2 @3 a s; k! K- N# _2 Q1 }
was the product of a full-term normal delivery, with/ {# X8 e* A$ b a9 B+ S. b. `
a birth weight of 7 lb 14 oz, and birth length of
: _9 C9 E- G7 C! x2 G( u20 inches. He was breast-fed throughout the first year
) q7 {5 f/ W l" K' w9 y# Jof life and was still receiving breast milk along with! F! c: m% q8 h
solid food. He had no hospitalizations or surgery,
/ r' c9 s1 q* j3 xand his psychosocial and psychomotor development
' e9 D1 M' q* W/ t& T$ gwas age appropriate.
^7 v3 W! C" ]: w! T$ L. cThe family history was remarkable for the father,
2 U M: s8 E' b: R1 e7 z7 `who was diagnosed with hypothyroidism at age 16,! R# h3 i: M: H+ T' Y# a
which was treated with thyroxine. The father’s
% ^- X4 ?7 v- \* h9 ^. c/ |height was 6 feet, and he went through a somewhat+ s% r3 a( D7 U/ ^- l# S
early puberty and had stopped growing by age 14.9 N" p& I: e) i7 d+ S$ h
The father denied taking any other medication. The
( v& p+ }/ T) r5 Ychild’s mother was in good health. Her menarche I- b; \* C0 w) J, X
was at 11 years of age, and her height was at 5 feet
k$ e7 o- ^1 K8 \( `, v5 inches. There was no other family history of pre-
/ S3 S; H( T& d; Q) r' jcocious sexual development in the first-degree rela-* O2 A: Y( w4 D) U6 z1 E, H! W
tives. There were no siblings.+ t7 H/ i l; \4 E
Physical Examination
, Z6 |: J# z, L& K, YThe physical examination revealed a very active,2 K5 K" F/ o5 k; \1 i6 V
playful, and healthy boy. The vital signs documented6 U" b+ ~+ [- R( L
a blood pressure of 85/50 mm Hg, his length was
; p4 i/ z& R" }5 x4 Z9 N90 cm (>97th percentile), and his weight was 14.4 kg7 o/ y8 ]# e8 C* F4 k/ m2 Y G6 d' K5 c
(also >97th percentile). The observed yearly growth
1 B4 V& t" N Z H3 e& Y5 I% `* U6 avelocity was 30 cm (12 inches). The examination of: r- M8 K0 W# g8 X& @" a
the neck revealed no thyroid enlargement., B) J8 p7 p, A& z- Y/ N0 X" ?
The genitourinary examination was remarkable for
6 `9 l1 O& P, c( senlargement of the penis, with a stretched length of
! n! n& R8 }( _0 ?1 Q8 cm and a width of 2 cm. The glans penis was very well; w( o, k' [& N
developed. The pubic hair was Tanner II, mostly around
5 l9 }1 t5 I1 r2 S* _540( C" D+ W. D2 j( ?3 d$ Q& `; {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; e( }) K: W* `/ r( l8 Y' O$ Tthe base of the phallus and was dark and curled. The
) n+ z0 F" g. o3 Jtesticular volume was prepubertal at 2 mL each.4 N1 L, K6 G7 ]/ p
The skin was moist and smooth and somewhat
1 j7 u9 U( r# d @5 Koily. No axillary hair was noted. There were no a% N5 h9 [" ^* L
abnormal skin pigmentations or café-au-lait spots.
3 q' ?. u0 J! o; ~ M3 QNeurologic evaluation showed deep tendon reflex 2+
4 c/ {) q* E- ]1 mbilateral and symmetrical. There was no suggestion( s/ v3 g2 K+ x v
of papilledema.# ]8 L) f0 M$ Y1 V/ z$ S3 e! ~
Laboratory Evaluation
" T1 y+ ^7 ~ d6 @% m: SThe bone age was consistent with 28 months by3 [3 {% ]9 `: C( R; y3 @
using the standard of Greulich and Pyle at a chrono-# S' X; u2 l! ]1 A+ v
logic age of 16 months (advanced).5 Chromosomal
" k( B f, X c, Q: Akaryotype was 46XY. The thyroid function test
& a, y5 T5 L( J, D- K9 i. Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 E! u) u7 W: n' Q! D2 ?lating hormone level was 1.3 µIU/mL (both normal).2 v3 D( R5 I, ]( h& @3 v5 a
The concentrations of serum electrolytes, blood; ~* N& N6 O7 R7 i0 l, [
urea nitrogen, creatinine, and calcium all were
. U" X1 [% l, vwithin normal range for his age. The concentration
# ~2 A4 A( {* C' V5 Z0 k- Mof serum 17-hydroxyprogesterone was 16 ng/dL
& f4 F! r# M2 j! R# R# t' t" l(normal, 3 to 90 ng/dL), androstenedione was 20
4 O7 g! ^& I$ o2 y0 Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
M+ ^3 p9 l8 iterone was 38 ng/dL (normal, 50 to 760 ng/dL),; R5 W- [3 X& B, b% C7 f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' b( m% t" p( ^- p0 W- b49ng/dL), 11-desoxycortisol (specific compound S)
- F9 L* F; X+ W4 q1 Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. N% @2 N- T+ }+ H$ T* htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 T0 R# x3 [$ ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 I; X. {+ H# A7 R6 B
and β-human chorionic gonadotropin was less than
! Y! @- f$ f. ^5 mIU/mL (normal <5 mIU/mL). Serum follicular/ W* v, Y& I& u# _8 x" N2 ]
stimulating hormone and leuteinizing hormone
5 @" p7 J& }7 W$ W' O( F7 K! Q- xconcentrations were less than 0.05 mIU/mL6 a- ^" p2 Z* Z. L; b, r
(prepubertal).# o Q8 d7 a; C& O/ C/ `. X
The parents were notified about the laboratory/ ?0 L$ n J; i; R8 |
results and were informed that all of the tests were
" B+ c% l; P2 u% \; h! t2 Ynormal except the testosterone level was high. The7 B# o5 A0 \# q* g
follow-up visit was arranged within a few weeks to, _1 U$ f. \4 O* H X
obtain testicular and abdominal sonograms; how-7 N4 l$ I1 X; o8 {. M/ z
ever, the family did not return for 4 months.
. C* i/ b+ w* e1 D8 tPhysical examination at this time revealed that the
$ ^0 _/ @/ W" v x; rchild had grown 2.5 cm in 4 months and had gained6 n: J: o& W9 K$ V
2 kg of weight. Physical examination remained: E: z |0 b( |: L! i$ w
unchanged. Surprisingly, the pubic hair almost com-$ q, n. U* g! `3 o6 y
pletely disappeared except for a few vellous hairs at1 q7 A( }5 m8 A9 B" q0 H, d& h
the base of the phallus. Testicular volume was still 2
" Z+ l2 i& F; }( cmL, and the size of the penis remained unchanged.: d) w0 S7 c" n8 K) x. a! J# G0 @
The mother also said that the boy was no longer hav-" s+ S% A9 ~; {% W
ing frequent erections.
% p3 v6 p H4 L) cBoth parents were again questioned about use of1 w/ \7 R/ {- R1 @3 e: B2 N( @
any ointment/creams that they may have applied to; @" r( @% M( J7 Z
the child’s skin. This time the father admitted the/ A- L F4 q3 p3 i& O% V4 c
Topical Testosterone Exposure / Bhowmick et al 541% M( a, c, B7 k8 N' K; M3 ~- \
use of testosterone gel twice daily that he was apply-
8 T4 t4 q: x/ _ing over his own shoulders, chest, and back area for* G l9 G& h$ {
a year. The father also revealed he was embarrassed5 i& E: l1 h& n0 q/ _/ x; N
to disclose that he was using a testosterone gel pre-/ w; H; l' |( L
scribed by his family physician for decreased libido
5 l+ N! u. `" i; Isecondary to depression.( B5 e8 M2 ^. ?( r% [
The child slept in the same bed with parents.
9 w% U$ l5 S% Z$ b* ^The father would hug the baby and hold him on his
" @8 W# X# u, ^2 v6 c% Qchest for a considerable period of time, causing sig-
+ a" \- J Q9 b/ qnificant bare skin contact between baby and father.
& _6 Y! j! d y+ P" s5 PThe father also admitted that after the phone call,6 h9 R% z9 y3 R# D8 i6 E$ l0 W
when he learned the testosterone level in the baby( h) W4 K/ a9 a: B4 G& z
was high, he then read the product information
. d% ^' b/ |" X) E0 Gpacket and concluded that it was most likely the rea-
4 b" {8 I1 \* l' f! T- s" Oson for the child’s virilization. At that time, they
. ?3 i& B! x2 D5 W* }5 L+ \# d/ bdecided to put the baby in a separate bed, and the
6 {! T) V5 n, ^# t; F: lfather was not hugging him with bare skin and had- i0 r- ~( F5 i9 o* R+ G
been using protective clothing. A repeat testosterone. i4 B( H# C; y8 n
test was ordered, but the family did not go to the
! Y4 ^" s5 i- {/ }$ X. O Flaboratory to obtain the test.
! y, V I0 p- b+ F) T) rDiscussion. d5 V8 S/ s% |. e6 [3 e6 O
Precocious puberty in boys is defined as secondary
2 o/ _) s& c! Q% H' ^* jsexual development before 9 years of age.1,4
( c' ~8 N+ }) i+ u' GPrecocious puberty is termed as central (true) when
' S3 H5 V( v9 D) C+ C6 J2 i9 Wit is caused by the premature activation of hypo-
2 `% ]: h! h' @- y! N# ethalamic pituitary gonadal axis. CPP is more com-8 U- p; _7 m U, y
mon in girls than in boys.1,3 Most boys with CPP6 [: y+ f4 M0 Y1 ~
may have a central nervous system lesion that is
# J0 s. K4 N5 Y$ |, {9 a" Z2 y: ?responsible for the early activation of the hypothal-
( j% y9 {/ I/ n# U6 Qamic pituitary gonadal axis.1-3 Thus, greater empha-
" e; T% W0 ?4 [: j. [+ Ysis has been given to neuroradiologic imaging in
5 v5 d3 a5 S: g" Uboys with precocious puberty. In addition to viril-
5 K9 N) f% r9 o; Kization, the clinical hallmark of CPP is the symmet-
9 O' F+ V6 m1 Xrical testicular growth secondary to stimulation by& p6 U8 M& M) z3 D
gonadotropins.1,3
& {6 T+ s0 ~& D, nGonadotropin-independent peripheral preco-1 j6 L5 [- }* q- D& K5 [5 I I
cious puberty in boys also results from inappropriate( ~, I" \5 x V& P0 D
androgenic stimulation from either endogenous or9 H7 v) F, N' t5 {6 v/ [
exogenous sources, nonpituitary gonadotropin stim-3 b: \% e% w( u
ulation, and rare activating mutations.3 Virilizing, j0 N& t8 ^" I6 i
congenital adrenal hyperplasia producing excessive5 P9 c8 j0 `' n3 l1 ^: h6 P% d
adrenal androgens is a common cause of precocious' k3 `) i5 q! V! ~( \: n. R
puberty in boys.3,4' _' H. \/ V( \8 f$ Z
The most common form of congenital adrenal
+ }2 A# L$ E) N) ihyperplasia is the 21-hydroxylase enzyme deficiency.
; T4 q% @7 H* r; {The 11-β hydroxylase deficiency may also result in4 V8 Y5 P, S0 k h1 M) W& N
excessive adrenal androgen production, and rarely,
( V; w% d' U3 z/ y) ?% o, P8 m6 D" Xan adrenal tumor may also cause adrenal androgen! l0 r$ g3 n1 Q6 i1 |
excess.1,3: Z& U' _0 d" s9 I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 g; p+ X2 x# ~) U0 u
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ [" O8 Z- c1 _4 A" _: ?3 y! tA unique entity of male-limited gonadotropin-
7 I' L. a% P5 H& L5 j: j; M) bindependent precocious puberty, which is also known
/ d( F9 @" W9 ^* [as testotoxicosis, may cause precocious puberty at a4 N$ i* K1 \# `* t6 G. I! W( L
very young age. The physical findings in these boys
" i- {+ H" ]* J2 d S* lwith this disorder are full pubertal development,/ a6 M! \# a$ E5 m2 i; }
including bilateral testicular growth, similar to boys
% w- n4 w1 _4 ~; @! T& i9 H" H2 fwith CPP. The gonadotropin levels in this disorder* u* j' J. {8 d6 O" g& Q7 K
are suppressed to prepubertal levels and do not show3 B; t9 q! c5 ?
pubertal response of gonadotropin after gonadotropin-: R& t' Z. n2 ^7 D& g2 c7 A# ^
releasing hormone stimulation. This is a sex-linked
8 l5 F" l6 G; [$ ~autosomal dominant disorder that affects only
3 ]1 w5 @% z' N. B! ?1 @- Cmales; therefore, other male members of the family. x+ X0 L) I. J8 f( p3 Q
may have similar precocious puberty.3
4 l) f+ s/ o0 q* t& M1 ^In our patient, physical examination was incon-3 N. d& u" G' ]1 g
sistent with true precocious puberty since his testi-
/ L- K8 r; p' j) D' _) E \7 T) xcles were prepubertal in size. However, testotoxicosis: w0 n+ G0 m- j+ o3 T4 A
was in the differential diagnosis because his father% M' V6 a+ J8 p: ~
started puberty somewhat early, and occasionally,0 n- R+ t- r5 p# c! H' b0 \) T
testicular enlargement is not that evident in the
; _) f; m9 ]3 ~- gbeginning of this process.1 In the absence of a neg-3 H9 b- K6 o: s2 O4 Y0 D! V- L
ative initial history of androgen exposure, our4 x1 [1 [7 i2 s, N& Z9 O
biggest concern was virilizing adrenal hyperplasia,
- [! Q2 m6 G; |4 meither 21-hydroxylase deficiency or 11-β hydroxylase. i# k- ~6 }& ]$ }
deficiency. Those diagnoses were excluded by find-
% `7 d+ c8 H+ s F: y& x+ X; hing the normal level of adrenal steroids.
3 S- Q8 J+ D y# o7 |& ?The diagnosis of exogenous androgens was strongly! D1 t2 [( g! D0 |4 u- a
suspected in a follow-up visit after 4 months because
7 @8 N, b1 `8 c8 w$ V, \, h! sthe physical examination revealed the complete disap-
' p1 a/ n$ u# u, p7 bpearance of pubic hair, normal growth velocity, and
0 p' E: A2 B7 t2 f; Tdecreased erections. The father admitted using a testos-# T8 K. v+ g# ~: i
terone gel, which he concealed at first visit. He was
+ t7 c7 r8 M. L8 f ?- u2 L. [using it rather frequently, twice a day. The Physicians’7 [; j# H, j% e
Desk Reference, or package insert of this product, gel or3 }& h: D e5 B. V
cream, cautions about dermal testosterone transfer to
! z; \, i4 b4 ^! V7 v5 s dunprotected females through direct skin exposure.
& K( J% ]3 G% o8 gSerum testosterone level was found to be 2 times the
8 ~+ L+ L3 z' P# X) P4 J4 pbaseline value in those females who were exposed to7 |2 y+ R1 M v' d: W1 ?
even 15 minutes of direct skin contact with their male
6 l1 V& S& a0 \, Q3 f6 `8 zpartners.6 However, when a shirt covered the applica-0 ]3 x6 h$ m' i8 }1 t
tion site, this testosterone transfer was prevented., ~" b- d5 } @, c
Our patient’s testosterone level was 60 ng/mL,( L$ S1 i, }2 b6 d. ?
which was clearly high. Some studies suggest that
$ G5 l1 W. V8 u" Y; mdermal conversion of testosterone to dihydrotestos-5 Q% c0 k) i+ Z3 v8 ^0 w$ m
terone, which is a more potent metabolite, is more- u$ t. x. ]4 a( L9 M5 ^5 _
active in young children exposed to testosterone
5 p4 L7 Z& e4 a1 X. \' b& gexogenously7; however, we did not measure a dihy-
) e, s4 v* L* \9 O6 F! w5 e+ Fdrotestosterone level in our patient. In addition to( x3 G1 P( c# U( y& c, s
virilization, exposure to exogenous testosterone in
K4 ~3 f; }' Q4 P6 u9 bchildren results in an increase in growth velocity and
4 O0 j5 p* z6 j( O' e9 j& V, D* p; Gadvanced bone age, as seen in our patient.
2 H8 @# {" U$ iThe long-term effect of androgen exposure during
$ l* j% ?" \+ E$ gearly childhood on pubertal development and final; v9 u9 o2 F, s' o& h4 ~* ?6 P' C! V
adult height are not fully known and always remain, c, g% V+ n6 I% [. W
a concern. Children treated with short-term testos-% D- E! @8 [+ ~$ t
terone injection or topical androgen may exhibit some n5 L) _# S- U- `( |% p
acceleration of the skeletal maturation; however, after
2 ]2 m) t* j1 d1 J2 L$ E' ?$ h( |( Ycessation of treatment, the rate of bone maturation
) i" Q: s" v1 `% g5 f+ {decelerates and gradually returns to normal.8,91 ~+ X* @* T+ ^
There are conflicting reports and controversy6 Z; e: t$ s) h2 ^: O
over the effect of early androgen exposure on adult
& C; G1 R( v* Q7 Hpenile length.10,11 Some reports suggest subnormal
/ I0 h" d5 i' O" H0 Wadult penile length, apparently because of downreg-
. o( W( w+ w/ T) Oulation of androgen receptor number.10,12 However,
8 X5 O6 C7 q, \+ x6 R: G$ hSutherland et al13 did not find a correlation between0 Z [% I' T! S
childhood testosterone exposure and reduced adult
# e( n0 x. D0 X, s. J7 ipenile length in clinical studies.7 E U" M( T/ r1 x* ?' C. A
Nonetheless, we do not believe our patient is- c2 B1 ~# Q6 q( ]
going to experience any of the untoward effects from* ~ E: m0 p7 K) c8 ^) [; K
testosterone exposure as mentioned earlier because& x) P9 p9 ?6 ^. K! ~5 p
the exposure was not for a prolonged period of time.
& b! G; _ p( ?- a% b* _Although the bone age was advanced at the time of, E3 x& c5 w- m+ }0 I
diagnosis, the child had a normal growth velocity at
- T2 W3 i. F) }0 hthe follow-up visit. It is hoped that his final adult
0 W- d: y3 m: t" lheight will not be affected.
7 j4 E3 x1 ~4 O- f) ~1 }Although rarely reported, the widespread avail-- e6 }1 m. g& F6 d
ability of androgen products in our society may
) Q& A6 {8 g r" J5 Oindeed cause more virilization in male or female0 \+ i" w/ d8 r! K' r: o
children than one would realize. Exposure to andro-
8 M6 d5 v+ d, s' K5 H- c2 m) w% dgen products must be considered and specific ques-) o. i) @; J. g. V+ L
tioning about the use of a testosterone product or
% N# [) p9 }4 G) K) k2 ngel should be asked of the family members during
& u3 S1 }, r+ C3 k: U/ [" bthe evaluation of any children who present with vir-. f+ q* m# F/ g
ilization or peripheral precocious puberty. The diag-- M2 y+ z9 t) O, ^
nosis can be established by just a few tests and by3 i# r6 q4 u( J0 T
appropriate history. The inability to obtain such a
/ E# q& D9 s1 x) Z# Q# J5 Thistory, or failure to ask the specific questions, may1 T8 q6 Z! g* j3 g3 q9 ]
result in extensive, unnecessary, and expensive
) r1 [% U" H4 q: C$ R( Einvestigation. The primary care physician should be
% e. h9 @0 `4 q& uaware of this fact, because most of these children' \( N$ q2 q* j
may initially present in their practice. The Physicians’
# @% y( d3 z5 \8 d. p0 CDesk Reference and package insert should also put a
2 R2 Q( b5 O% N8 j; |( Z4 Rwarning about the virilizing effect on a male or. u) G0 n, S$ \8 w# T# @1 k( G+ p
female child who might come in contact with some-0 a T% m, z7 [
one using any of these products.
8 [* M) J/ {+ X+ cReferences
8 J2 A) N1 k( x ]8 f! w1 Z7 c1. Styne DM. The testes: disorder of sexual differentiation g2 b/ t2 j- Q* Z+ c2 Y U
and puberty in the male. In: Sperling MA, ed. Pediatric0 k5 e) n# e( o' P% e
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' a% h: q ]. i% H
2002: 565-628.' N3 F. D; E4 ~% N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 {* B2 l0 K0 |# e* w o
puberty in children with tumours of the suprasellar pineal |
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