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Sexual Precocity in a 16-Month-Old
) n0 o; J2 y# A& ?9 UBoy Induced by Indirect Topical
# z+ i# o) b, F8 s0 p( uExposure to Testosterone) I/ c9 U1 m5 b/ j, p) k4 C
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- F2 S, c1 B; g0 r. jand Kenneth R. Rettig, MD1
0 P. A. U, M- P1 n lClinical Pediatrics
; }8 b `( L* a. {+ {$ h' RVolume 46 Number 6
. l0 U) k$ o6 u: DJuly 2007 540-5432 M! \4 w @! g r
© 2007 Sage Publications
1 S! E4 r" Z- Y7 x% o10.1177/0009922806296651
0 _1 B2 }+ `1 N6 }- L, z0 U! ^8 P# t8 lhttp://clp.sagepub.com
- H3 v2 v8 V, Z$ {. H( Mhosted at
& H5 r" S ?$ j* r9 x9 G2 Q9 V" Z$ Dhttp://online.sagepub.com7 u [; c: U2 Q/ i6 w
Precocious puberty in boys, central or peripheral,
: [- S5 N' Z2 b, h5 His a significant concern for physicians. Central% O5 X) D% A5 L4 ^3 w# |/ p
precocious puberty (CPP), which is mediated8 Z/ u1 c% Z0 w
through the hypothalamic pituitary gonadal axis, has
" D; Z3 H, j9 o7 ^- j' ~3 ]( T {9 [a higher incidence of organic central nervous system. F) [* d1 x5 u. {2 `6 K' H
lesions in boys.1,2 Virilization in boys, as manifested
; F W7 d% g# F* dby enlargement of the penis, development of pubic
8 C: G0 C( @6 Ghair, and facial acne without enlargement of testi-( m* L/ u% u6 Q* ^% e7 Z
cles, suggests peripheral or pseudopuberty.1-3 We" U: m: M4 b* w4 R
report a 16-month-old boy who presented with the- _( N o) m& |. E1 P0 X' r+ E
enlargement of the phallus and pubic hair develop-1 E" ~, e4 S3 r2 j$ c) ]; |. r- F
ment without testicular enlargement, which was due8 d/ O: s6 d6 @
to the unintentional exposure to androgen gel used by0 L$ P! y- T; f! @6 j/ {
the father. The family initially concealed this infor-/ Z2 x# }9 j" U: w& k
mation, resulting in an extensive work-up for this0 b6 h( q& C% i2 R3 K/ o$ W
child. Given the widespread and easy availability of
: ]' g+ d! K i! \5 etestosterone gel and cream, we believe this is proba-
1 R* r" e1 H) X& j. rbly more common than the rare case report in the' ~& S1 s' H& _
literature.4
$ \9 q+ w T6 o/ y) {Patient Report
" z4 I# P; ~6 r# L/ q6 G8 I" vA 16-month-old white child was referred to the, s( T% h/ w: n' \/ b! \
endocrine clinic by his pediatrician with the concern& N8 x# r. X* h# u0 c; g2 o
of early sexual development. His mother noticed
" T, i. p$ e+ a9 s: l# Tlight colored pubic hair development when he was7 V2 @+ W K' C! E) r1 j( V, X7 m6 T
From the 1Division of Pediatric Endocrinology, 2University of
4 b. t) B7 `- |9 {# b8 U6 WSouth Alabama Medical Center, Mobile, Alabama.: y) |: J" y, Q7 T- K7 f0 v
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 _) ?' k$ I8 Z& ZProfessor of Pediatrics, University of South Alabama, College of) L4 Y" e8 V' o, {0 S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 W4 n6 g* H/ J0 @e-mail: [email protected].$ s8 K9 i' t X# O p" ?- b- d
about 6 to 7 months old, which progressively became: u% Z3 Q3 e; Q9 Q }- j- W
darker. She was also concerned about the enlarge-5 F0 E) U4 ]% v
ment of his penis and frequent erections. The child) P: F, p7 h$ T+ O! [2 r+ w
was the product of a full-term normal delivery, with
# Y4 X( w. o1 F2 }1 M+ Ha birth weight of 7 lb 14 oz, and birth length of
' m7 |9 m6 w2 V. Q4 y20 inches. He was breast-fed throughout the first year! e9 O% X1 i# o, N7 c1 |
of life and was still receiving breast milk along with1 b, {, e. M8 y+ t
solid food. He had no hospitalizations or surgery,
% Z' \% ~+ }" Q1 n. r/ eand his psychosocial and psychomotor development% y& z0 Q8 ^/ l+ r$ y! d' S) x
was age appropriate.
) @6 A/ g8 m2 cThe family history was remarkable for the father,
6 m$ r% l; s3 |( y F' lwho was diagnosed with hypothyroidism at age 16,
d. ^5 f' E4 _: c' t' Q2 [) Hwhich was treated with thyroxine. The father’s
2 g( p7 u. V. R* l9 Uheight was 6 feet, and he went through a somewhat
. v$ f( V* N' P6 x+ o" uearly puberty and had stopped growing by age 14.
/ u( b8 W! w0 G% d9 wThe father denied taking any other medication. The
7 c2 H6 \* e; s- h6 m- t# Kchild’s mother was in good health. Her menarche
& c$ k' d: ?7 J. {was at 11 years of age, and her height was at 5 feet
/ t$ |+ D2 P3 y& m) G" |$ Z/ ~5 inches. There was no other family history of pre-
$ A9 \: J N( |7 J9 Y2 ?$ tcocious sexual development in the first-degree rela-
/ M- u j) J( m% s* c' p+ ^tives. There were no siblings.* k) f3 K' Y o/ k! x
Physical Examination* T) V l1 M5 ^! ~" d& V
The physical examination revealed a very active,* M8 P" t4 h# x$ R* q
playful, and healthy boy. The vital signs documented
- T$ t" F, W; E6 g5 l p Y) H8 }a blood pressure of 85/50 mm Hg, his length was
0 J3 S/ L" w/ |. c( O90 cm (>97th percentile), and his weight was 14.4 kg. U6 h; p: q1 y; V- Q$ N0 u
(also >97th percentile). The observed yearly growth0 @* b$ G+ l* ]3 a. P g, w% N
velocity was 30 cm (12 inches). The examination of
% c' h% ?0 ^5 W& Z% n2 Gthe neck revealed no thyroid enlargement.
% v4 S8 g/ R6 rThe genitourinary examination was remarkable for
6 J0 ^9 ^- e: I+ n+ Nenlargement of the penis, with a stretched length of/ N0 }" a4 W. n
8 cm and a width of 2 cm. The glans penis was very well
$ \. p, P4 }8 C0 Ideveloped. The pubic hair was Tanner II, mostly around
' I; h0 Q4 h3 e7 X/ U! F# G540
+ ~- ~# ^: K N4 o- iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# B* @6 v4 d' l- ^# E! p9 L$ U" B
the base of the phallus and was dark and curled. The! H2 a6 Z3 d" z! d" ?
testicular volume was prepubertal at 2 mL each.
, w I! O g# `9 k! WThe skin was moist and smooth and somewhat
8 c! t- |, H2 Z) O O& Ioily. No axillary hair was noted. There were no
( }) r9 c, }# {0 |9 U# w( G3 |, ~abnormal skin pigmentations or café-au-lait spots.
0 I4 F8 M8 d" J* fNeurologic evaluation showed deep tendon reflex 2+
5 F' e5 P# y9 T' W/ S& zbilateral and symmetrical. There was no suggestion
, P) L5 W+ q- D; o5 S: A- m& xof papilledema.
7 O- V& H& B' c& eLaboratory Evaluation' \ e- b+ i( n) j0 q+ v
The bone age was consistent with 28 months by7 j ^$ |& C! I) X. I. v: b# S R
using the standard of Greulich and Pyle at a chrono-2 U0 M8 @" W+ l, R
logic age of 16 months (advanced).5 Chromosomal1 W" [/ d D$ g+ t) F
karyotype was 46XY. The thyroid function test1 f0 O( X$ E( d$ }, l/ C7 G7 l2 S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ {6 T) s" l$ U" G/ J$ [
lating hormone level was 1.3 µIU/mL (both normal).
2 H: ? f% k4 J$ w7 k( `, D7 BThe concentrations of serum electrolytes, blood
+ r- H" W2 k* t( f8 k& p+ ]urea nitrogen, creatinine, and calcium all were- Y! _3 b6 l3 R
within normal range for his age. The concentration
# v* A- e- O$ o) b9 G' Aof serum 17-hydroxyprogesterone was 16 ng/dL
$ f" s* z. V% j) s; \(normal, 3 to 90 ng/dL), androstenedione was 20
Y, n \$ A% t4 ?* ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 b3 y6 ?4 ]* j4 D" C: |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),' ]# \3 P5 V) g0 @: v2 b! l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 z$ h; k* G- |
49ng/dL), 11-desoxycortisol (specific compound S)7 V5 Q) m0 v6 C% ^% |6 |, l& m1 g
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
s2 f, }& ^% |8 A+ v0 n7 [4 t2 ]6 @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 B8 d- w8 q O _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, I* W# I7 G7 K% }7 i
and β-human chorionic gonadotropin was less than/ b& |4 f |' [0 t9 o4 l A3 i
5 mIU/mL (normal <5 mIU/mL). Serum follicular( J6 t3 S4 n; E7 f2 o5 F& D% ^, ]: P# B
stimulating hormone and leuteinizing hormone
- @3 [0 V4 H+ V9 i' Lconcentrations were less than 0.05 mIU/mL
0 u4 Y" u$ R1 C$ q, h) P(prepubertal).9 k% Z( D* N5 Q! v8 y/ Z2 M5 a. M; \: K
The parents were notified about the laboratory( f- c# e9 F* s# W/ d
results and were informed that all of the tests were
1 ~+ \- l0 u& ~7 xnormal except the testosterone level was high. The
7 y. v8 ]% F6 g$ R* g& ]% Hfollow-up visit was arranged within a few weeks to
# r3 n" A5 N- e3 v! J, nobtain testicular and abdominal sonograms; how-
% i0 D- o6 V2 c+ K4 s& zever, the family did not return for 4 months.8 L) G8 `) q# N4 |) m* [9 J, x
Physical examination at this time revealed that the4 l" `8 r9 P7 E( }+ ^9 o
child had grown 2.5 cm in 4 months and had gained
% b% L. O8 K8 q5 e5 [2 kg of weight. Physical examination remained" F$ z' Z6 g% ^* t: `4 ?0 f9 E
unchanged. Surprisingly, the pubic hair almost com-. ?$ h$ H( G* n
pletely disappeared except for a few vellous hairs at
* D" n- Q( J- F8 mthe base of the phallus. Testicular volume was still 2
+ ^+ v! ~9 _" N1 x" o" {0 dmL, and the size of the penis remained unchanged.. t" p$ e' v6 {3 b' {' r1 ~ |
The mother also said that the boy was no longer hav-" G# A; q" z3 o4 U4 k) ?
ing frequent erections.) Q# k; o0 I9 ~: c* ~, X& [* U
Both parents were again questioned about use of5 a' m/ |$ e5 A+ V' |
any ointment/creams that they may have applied to5 |, C$ J$ ~1 R
the child’s skin. This time the father admitted the# q( f/ n2 L* U& q/ n
Topical Testosterone Exposure / Bhowmick et al 541, r0 a2 F) L; ]9 T# d
use of testosterone gel twice daily that he was apply-
. z0 Q/ A$ }4 n2 A# A( Cing over his own shoulders, chest, and back area for
# U: _: S) N9 t: b& i9 Y- |a year. The father also revealed he was embarrassed
3 d: q4 f8 s# A& rto disclose that he was using a testosterone gel pre-
! F! {! Z* ]% rscribed by his family physician for decreased libido8 Q2 \! I5 b, n0 _; q
secondary to depression.
* J8 s9 R8 I, O# A: tThe child slept in the same bed with parents.% [! a8 \) T& j
The father would hug the baby and hold him on his
0 M, {9 ^% }, e# P% @( F* N- p6 Hchest for a considerable period of time, causing sig-
# @% O! g: M. S3 q# nnificant bare skin contact between baby and father.
8 h; a+ T& s5 H" F3 D I3 PThe father also admitted that after the phone call,/ F/ ~% J1 H7 m
when he learned the testosterone level in the baby
- A: K0 m: {/ s/ ]3 y! W" rwas high, he then read the product information
& w, w# x& x; S; ?: fpacket and concluded that it was most likely the rea-
4 l. x P% c9 h3 o g/ Sson for the child’s virilization. At that time, they
0 A2 u" V* A& p2 vdecided to put the baby in a separate bed, and the
' M: d( u/ l& g* A& G0 Z( Ifather was not hugging him with bare skin and had- T/ M0 a. `1 E: u8 _% C
been using protective clothing. A repeat testosterone2 }/ K) p0 G2 U9 j* E( Y
test was ordered, but the family did not go to the1 K9 @# D( o$ X; B/ j
laboratory to obtain the test.( _% {) P+ N0 @
Discussion
9 O U" h/ o5 M$ @+ B. q5 z9 \; dPrecocious puberty in boys is defined as secondary q% j8 R. M4 t
sexual development before 9 years of age.1,4
, g: C: x1 q( f, s. ZPrecocious puberty is termed as central (true) when y: S- r& p" u9 q4 |
it is caused by the premature activation of hypo-; r4 Q* l% z8 i, S; \
thalamic pituitary gonadal axis. CPP is more com-
4 f8 e4 B, i# h8 _3 O2 emon in girls than in boys.1,3 Most boys with CPP
+ e, I9 K6 q. q" D Q- L1 Bmay have a central nervous system lesion that is/ b5 A+ e0 a- H) B$ w0 `: B8 Y" ~
responsible for the early activation of the hypothal-9 D9 j7 m& z% v6 y
amic pituitary gonadal axis.1-3 Thus, greater empha-7 m! u3 Z3 X5 u) C L& x0 q6 c% i
sis has been given to neuroradiologic imaging in
4 |! ?$ B( n/ V3 f: C, q" c( v- i# }boys with precocious puberty. In addition to viril-
$ k) z; M1 t2 @% h0 |% Aization, the clinical hallmark of CPP is the symmet-5 p j3 U* F M$ C1 E) T; R8 l
rical testicular growth secondary to stimulation by
1 S& E& x, g) q: Ugonadotropins.1,3
3 B! @& O7 Y- {' _Gonadotropin-independent peripheral preco-
+ w7 |3 }1 [7 h* Zcious puberty in boys also results from inappropriate
4 T, z3 o0 s. G# handrogenic stimulation from either endogenous or) a" _/ s8 @, d7 ]4 A# e( k3 M
exogenous sources, nonpituitary gonadotropin stim-
; x! S2 x! Y0 b$ Bulation, and rare activating mutations.3 Virilizing
& C/ K9 a$ ?2 Q( _: N2 e9 ~3 R! xcongenital adrenal hyperplasia producing excessive! j) X# Y+ c, k0 W
adrenal androgens is a common cause of precocious
$ ^6 e/ c: C! |puberty in boys.3,4
, _1 F! V, W$ n, KThe most common form of congenital adrenal2 |1 S; z: A0 b. Q8 W3 C% W
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ a1 Y- H- F; ]; ]The 11-β hydroxylase deficiency may also result in+ m% C2 N. o4 Y$ [
excessive adrenal androgen production, and rarely,
. X& Y- T! l+ x! E/ ban adrenal tumor may also cause adrenal androgen
0 [& F$ y& `! f- h! Jexcess.1,33 r3 l; X" C: _7 ~4 M9 `5 W `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# J! @( J: ^3 T$ N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. ^& R- `5 \8 K6 |A unique entity of male-limited gonadotropin-
8 m2 U9 e. y6 f+ g. q2 r( D# o* d9 Kindependent precocious puberty, which is also known
2 |1 ?. z, g7 X$ X. [8 [% Vas testotoxicosis, may cause precocious puberty at a
- E, r, e9 ?! m- G4 H, q, K; @very young age. The physical findings in these boys
3 p2 r3 P5 g" dwith this disorder are full pubertal development,
X1 x& f. X8 P7 ~! O# L' gincluding bilateral testicular growth, similar to boys
; T2 l& q, w. ]with CPP. The gonadotropin levels in this disorder
; [: Y3 t6 I$ w; f; Uare suppressed to prepubertal levels and do not show
9 \3 `7 S6 m2 `1 a$ ^7 Z* v, I5 U' V( Vpubertal response of gonadotropin after gonadotropin-9 u. Z8 L! O& n7 M5 l
releasing hormone stimulation. This is a sex-linked
; s- ?# `! i2 P) x/ K% Jautosomal dominant disorder that affects only& d$ B. z0 R) K8 y7 V2 D% ?
males; therefore, other male members of the family
2 [- ]& t! n4 I# ?- w1 {may have similar precocious puberty.3
3 B M0 t& I3 T. E3 eIn our patient, physical examination was incon-2 g: N0 w' `- B
sistent with true precocious puberty since his testi-8 w; S4 f8 A0 q2 X3 T
cles were prepubertal in size. However, testotoxicosis3 [9 E) z/ q+ ?+ h# v
was in the differential diagnosis because his father1 n$ `9 _* b1 [+ [% V( T1 ^
started puberty somewhat early, and occasionally,8 `3 j3 q+ K j1 r6 P
testicular enlargement is not that evident in the
: Y: P# \' k* ^8 L$ a0 d* {beginning of this process.1 In the absence of a neg-
; F4 U6 K0 g0 {8 [- ^* X, p$ }! Wative initial history of androgen exposure, our+ Q/ w$ n" I/ }# x+ n0 G& \
biggest concern was virilizing adrenal hyperplasia,
, |* o; k- \8 n: g6 ?1 E& {! Deither 21-hydroxylase deficiency or 11-β hydroxylase: Q# \* j! J) j' H q, @* z3 g
deficiency. Those diagnoses were excluded by find-& F" B6 B$ O( M1 i" g& \' @
ing the normal level of adrenal steroids.
: d* C' V4 f+ U1 o& V8 \The diagnosis of exogenous androgens was strongly
7 J- q& @* u7 l, @4 s& l- ^3 nsuspected in a follow-up visit after 4 months because) l( t" I% h. g: P: Y
the physical examination revealed the complete disap-
. a! r+ T% e* |) Qpearance of pubic hair, normal growth velocity, and1 j/ |- M* {3 }, g
decreased erections. The father admitted using a testos-
6 k) } a, q' @# j2 qterone gel, which he concealed at first visit. He was
+ z+ E2 _0 A9 H; y. jusing it rather frequently, twice a day. The Physicians’" X8 @$ C! W1 H, F( w
Desk Reference, or package insert of this product, gel or
4 M$ `0 D3 h' Dcream, cautions about dermal testosterone transfer to. d& l! A1 ?' t
unprotected females through direct skin exposure." _3 R0 |; ~9 V# l+ w- k5 y, w" v. _" H
Serum testosterone level was found to be 2 times the/ m6 y2 s+ C5 C, T4 W8 X6 [- c- [
baseline value in those females who were exposed to
" [2 K9 N) }' k2 Q; [3 C- h% feven 15 minutes of direct skin contact with their male
, `9 @" `0 }( u6 mpartners.6 However, when a shirt covered the applica-
- L, W, c; ?( z3 z" u3 Gtion site, this testosterone transfer was prevented.- `. n" g; O/ X/ @- d0 J/ L
Our patient’s testosterone level was 60 ng/mL," m/ x5 V, ]" P, s- }
which was clearly high. Some studies suggest that: X8 P' H) K3 [+ G7 r
dermal conversion of testosterone to dihydrotestos-
( [; `. r9 \: z) j' J' hterone, which is a more potent metabolite, is more; f& `/ M5 v) [8 A
active in young children exposed to testosterone
% a' m6 {1 u8 S) d8 m) \) m7 gexogenously7; however, we did not measure a dihy-: e) d0 L( B6 I, q* D1 O7 \
drotestosterone level in our patient. In addition to
8 |6 e, ~2 a: x# T5 Yvirilization, exposure to exogenous testosterone in
$ ]: \4 J Y: {: bchildren results in an increase in growth velocity and
5 o1 `# K f' r; }9 z' r5 `advanced bone age, as seen in our patient.
- {4 a/ l" o( s' lThe long-term effect of androgen exposure during# x; s0 A/ \5 q; ]9 M/ M) G5 ^
early childhood on pubertal development and final
6 E. s. `- R# j6 V, b% Fadult height are not fully known and always remain
' o: F4 Z# | ~a concern. Children treated with short-term testos-
! p5 Z e9 D) g& v$ rterone injection or topical androgen may exhibit some2 S$ f" X4 ~. m. i1 C
acceleration of the skeletal maturation; however, after
0 x( Q7 ]8 ^/ \+ \9 e4 |4 ncessation of treatment, the rate of bone maturation0 X2 F# `$ W# q. w Y
decelerates and gradually returns to normal.8,91 x' w) _" k- l$ b J
There are conflicting reports and controversy
( e5 U: \3 k) q1 S9 Nover the effect of early androgen exposure on adult
! Y' K0 B0 U& ]: N* Z7 Xpenile length.10,11 Some reports suggest subnormal
3 y* q6 q: C$ w) d' Z7 l, qadult penile length, apparently because of downreg-
7 x/ K( P8 u& N- culation of androgen receptor number.10,12 However,
% f: P3 G* ?, o3 N; H b6 oSutherland et al13 did not find a correlation between
9 _ U% t/ Q3 ]# X+ Z) |childhood testosterone exposure and reduced adult [; X" M: b4 x! T; I( Z) N: B
penile length in clinical studies.$ ]. c" m6 G: q
Nonetheless, we do not believe our patient is
7 c/ O' b- X- \going to experience any of the untoward effects from- p6 x$ w* E) p _+ t2 h
testosterone exposure as mentioned earlier because- Z+ B9 B* e% i6 R! v
the exposure was not for a prolonged period of time.
0 b8 f7 P2 W" c" kAlthough the bone age was advanced at the time of
/ u6 p" X4 r/ j+ @8 t- y5 e% Fdiagnosis, the child had a normal growth velocity at
d: Z J( N* P' d1 ^1 {the follow-up visit. It is hoped that his final adult
2 K/ E) I- p; g& F& }height will not be affected.
; n# d9 _1 l q! v* [Although rarely reported, the widespread avail-7 K9 f9 [' E. [! L, J' S9 Q
ability of androgen products in our society may
) @4 Y5 v( b/ @" h/ N/ ]+ K- Cindeed cause more virilization in male or female
- m0 h5 b( p$ X, G. e# a1 rchildren than one would realize. Exposure to andro-
) G8 }7 }: y @1 ggen products must be considered and specific ques-
+ @3 l( y% h2 ktioning about the use of a testosterone product or
" m3 V; D3 ]8 pgel should be asked of the family members during
0 ^4 G2 g" Q; L& `5 B0 H# sthe evaluation of any children who present with vir-' {7 a& @+ D3 u# H
ilization or peripheral precocious puberty. The diag-& @& w1 V* B) s' e
nosis can be established by just a few tests and by+ V) l8 o0 r7 K! k9 e
appropriate history. The inability to obtain such a
& e! I$ U, p4 d# xhistory, or failure to ask the specific questions, may
% S# J+ j' G: i* ^& L4 C1 Xresult in extensive, unnecessary, and expensive D. D% G2 a5 J
investigation. The primary care physician should be, n% e9 ?( c g Z5 V* s1 M9 V
aware of this fact, because most of these children, d' e' @0 v2 |$ G5 U
may initially present in their practice. The Physicians’* D) O8 D; c! f
Desk Reference and package insert should also put a
0 d1 C" ?+ o2 }warning about the virilizing effect on a male or
& i* G& y9 c1 }. E( z( l. K1 vfemale child who might come in contact with some-
% B+ q9 J* \, B; `8 Xone using any of these products.
) R- [( x0 O$ m, _( b# IReferences1 `/ g: G+ l3 H7 _# s' V
1. Styne DM. The testes: disorder of sexual differentiation
2 Y+ L2 x+ d* m% ]5 Qand puberty in the male. In: Sperling MA, ed. Pediatric
- Y) i4 L* c& ^% B6 @& o4 kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, y& ?4 A2 A6 R1 h9 x9 n2002: 565-628.
/ b# W2 q( S- L( o* {+ {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' m2 E B' v4 k' n u
puberty in children with tumours of the suprasellar pineal |
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