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Sexual Precocity in a 16-Month-Old6 `; P4 g6 E! U7 I R
Boy Induced by Indirect Topical
! n$ D) D% }5 J& zExposure to Testosterone% p( G% ?) K) E, L; @! O
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- u( O/ k+ H; \3 \1 C
and Kenneth R. Rettig, MD1% z# E& H1 ^6 C4 ] h) n) X
Clinical Pediatrics$ [, x* w: I/ f$ b5 ?
Volume 46 Number 6
5 b& J2 K7 s- m SJuly 2007 540-543, ~8 X' m! \, t3 C. n3 j
© 2007 Sage Publications9 n/ n) K" f8 C- F
10.1177/0009922806296651
# S5 M" V0 C; q+ I, F0 I' I$ mhttp://clp.sagepub.com. ^: k2 ~% u* Z0 d
hosted at5 c0 J$ t7 d' \8 h8 ]/ I6 j
http://online.sagepub.com, x( Z( A* S' A) c5 `
Precocious puberty in boys, central or peripheral,. a I h5 Z) x3 Z+ y+ `
is a significant concern for physicians. Central% X- D! i( [) z6 z: }& a, G
precocious puberty (CPP), which is mediated4 Y r- Y( ?, \% _$ `" D+ k5 A
through the hypothalamic pituitary gonadal axis, has
- L3 S+ D6 G7 Pa higher incidence of organic central nervous system' [, [! j/ G J$ R0 j2 [ v
lesions in boys.1,2 Virilization in boys, as manifested3 J$ x( P; P/ o6 d
by enlargement of the penis, development of pubic2 n6 a( e" ^. H, l
hair, and facial acne without enlargement of testi-
/ e0 H' P- L7 ^9 Hcles, suggests peripheral or pseudopuberty.1-3 We) _4 S4 e1 R. e' ^1 F B
report a 16-month-old boy who presented with the2 G) c+ r( _% c6 K7 o* l% h3 |
enlargement of the phallus and pubic hair develop-# D5 Y0 d: z9 u( i$ V! p
ment without testicular enlargement, which was due
! d2 g6 X) Y4 D2 ~5 Wto the unintentional exposure to androgen gel used by* }! Y n0 o! _& ?
the father. The family initially concealed this infor-
! k q2 ?1 X; @" F" Hmation, resulting in an extensive work-up for this6 ~) U1 n- w1 o5 a, O
child. Given the widespread and easy availability of
6 A, I1 N$ d8 o! i* e% Etestosterone gel and cream, we believe this is proba-# r0 L: E. q2 s! H/ c1 j
bly more common than the rare case report in the1 r* @4 g: t7 i6 {, \( s) k. X3 u
literature.4
: _4 W; @' f) R0 RPatient Report, n3 F4 l9 |* f0 C( Y
A 16-month-old white child was referred to the4 g+ W- @/ @% p1 q7 N! P) c6 ]9 P
endocrine clinic by his pediatrician with the concern3 M s- J8 f1 F. n
of early sexual development. His mother noticed
8 f V% Z9 @7 d/ o( \* k6 r( z5 Wlight colored pubic hair development when he was
2 C" T8 `- o3 Z/ P' O: ~From the 1Division of Pediatric Endocrinology, 2University of! E1 ^1 n, r* s3 V. n
South Alabama Medical Center, Mobile, Alabama.
- A# n' ]0 z, @& x( {! O4 z9 JAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 }+ z+ c" M' I1 h i
Professor of Pediatrics, University of South Alabama, College of' R. u$ J) @! g( V6 T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 R) ~% F5 e, s$ h$ ge-mail: [email protected].# y) ^: d5 [) i/ Y I. z. v% C: a
about 6 to 7 months old, which progressively became5 k- {+ R0 y1 o
darker. She was also concerned about the enlarge-
4 w" U ?# C4 f& T4 lment of his penis and frequent erections. The child- k- `0 O5 s0 S# j
was the product of a full-term normal delivery, with* a$ T3 B- C- ?8 ^' ?# E
a birth weight of 7 lb 14 oz, and birth length of% `+ P& q; E3 F8 P# ? g5 [: ~& w
20 inches. He was breast-fed throughout the first year0 Z* j' P8 h6 E
of life and was still receiving breast milk along with3 k7 q* P+ X4 M! z. a8 y5 ?( L
solid food. He had no hospitalizations or surgery,8 V; ]$ B. n$ Q# f- t2 u7 @6 m
and his psychosocial and psychomotor development
1 c- f+ Q+ X% h' D3 H, nwas age appropriate.) B r0 _6 V3 K5 E- Q ]
The family history was remarkable for the father,' J" c4 w2 |7 E6 ^* r- }
who was diagnosed with hypothyroidism at age 16,
2 \( X0 x/ V |+ g4 Iwhich was treated with thyroxine. The father’s
. P6 @% V m: ~( y6 m8 c- m! mheight was 6 feet, and he went through a somewhat
# U7 K$ x7 }/ N3 O5 K6 E# Aearly puberty and had stopped growing by age 14.& \# ~$ y! V) r$ ^
The father denied taking any other medication. The. z& }; A6 ]: g8 \# M& W2 j5 b
child’s mother was in good health. Her menarche
' `1 s( Z O& u( o, v1 O/ wwas at 11 years of age, and her height was at 5 feet+ G2 _8 B, m! r5 v' C
5 inches. There was no other family history of pre-
* \9 Y2 w8 T+ B" @+ D4 F! V+ ecocious sexual development in the first-degree rela-
, ]+ x, y M, k- a0 u! N3 s6 etives. There were no siblings.
, N. I" X" k* uPhysical Examination' T" U* e9 K5 u! e/ q/ P
The physical examination revealed a very active,, H! G0 X. l8 ~
playful, and healthy boy. The vital signs documented
D3 I- h: |7 ua blood pressure of 85/50 mm Hg, his length was
4 j8 |$ L' Y( K; W2 C2 ~90 cm (>97th percentile), and his weight was 14.4 kg
% c# K) @- v- M: S(also >97th percentile). The observed yearly growth# M. O6 k6 M) j; z8 K% b$ l$ M
velocity was 30 cm (12 inches). The examination of
/ F W6 A( f$ h( C1 M$ [the neck revealed no thyroid enlargement.
* ?: A+ ~5 b/ ~" K1 n5 q. S" EThe genitourinary examination was remarkable for, u8 i# h6 \ ?; J
enlargement of the penis, with a stretched length of
$ l4 _* }/ M' v( _7 b& @& f8 cm and a width of 2 cm. The glans penis was very well2 g1 r# }. h/ \7 l9 u# t
developed. The pubic hair was Tanner II, mostly around6 {8 Q; V) G! U& D% W- N
540
8 h9 Y# V b% w) |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# }' p9 v( ~6 F' C( f1 _& u3 m/ u
the base of the phallus and was dark and curled. The
+ C' J8 Z7 |! D6 D/ N& H1 n0 btesticular volume was prepubertal at 2 mL each.# I: K- r6 H+ \9 {+ s" o& e
The skin was moist and smooth and somewhat- j$ G6 ^4 s! N8 D. H
oily. No axillary hair was noted. There were no7 z1 ?& a A- ?& e& v* ?# ~
abnormal skin pigmentations or café-au-lait spots.7 K% x" y0 s L1 c0 o5 t6 W9 U+ b
Neurologic evaluation showed deep tendon reflex 2+4 X9 g0 ~1 s2 _& r
bilateral and symmetrical. There was no suggestion _# a2 J6 W1 y6 L
of papilledema.
4 m8 N* |. [" CLaboratory Evaluation/ P6 N0 V) P, A* y( U
The bone age was consistent with 28 months by
, U: L+ X4 d' N8 f7 g3 gusing the standard of Greulich and Pyle at a chrono-" K/ G$ |7 r2 h3 C4 I& {4 d9 e
logic age of 16 months (advanced).5 Chromosomal
! \8 `$ }1 E' U% f+ l) Z! ~karyotype was 46XY. The thyroid function test( d4 o8 @% y; O6 ?2 A5 e) H) F& Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- Q6 m: o' p& C& ]3 Y9 {% e
lating hormone level was 1.3 µIU/mL (both normal).
0 Q& ^6 }1 C) P" NThe concentrations of serum electrolytes, blood r' e* z; H1 B1 H/ } R+ }, y! m
urea nitrogen, creatinine, and calcium all were' @8 V* ^' u$ K, V1 B$ g1 K
within normal range for his age. The concentration/ @0 L7 c7 Y7 w3 b O+ ~/ A
of serum 17-hydroxyprogesterone was 16 ng/dL) {* n: O( G- O$ {; s; K% D
(normal, 3 to 90 ng/dL), androstenedione was 20
) u( D: A3 ?# R8 J0 R7 Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, `! \: y# x$ {( wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, E. N% Y' `! x8 q5 @8 Gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to' @5 |$ k$ E* J7 B$ D3 f# \
49ng/dL), 11-desoxycortisol (specific compound S)! h+ B! v! `$ D+ O* E0 @/ }
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 z! g3 w/ ]- e- i" C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& p( r: t4 s3 w; Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL), c: N# P. O/ z
and β-human chorionic gonadotropin was less than8 |3 z* H- \( j' c o7 }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ j5 V, @' |' jstimulating hormone and leuteinizing hormone. Y% T3 X" k7 z: B' Q7 q+ Y
concentrations were less than 0.05 mIU/mL
4 C' g% Q3 g9 B' J$ m7 h' y(prepubertal).5 q) ^+ J* B T+ ]& a5 s3 a
The parents were notified about the laboratory% D" p3 u% j% L" K
results and were informed that all of the tests were" f [4 ?" ~3 d7 G- J7 I
normal except the testosterone level was high. The
+ o1 p& ^& ]4 V* d3 @: h3 @follow-up visit was arranged within a few weeks to
, }7 {, b9 G( i" }obtain testicular and abdominal sonograms; how-) H* d) }2 _+ I2 x" u
ever, the family did not return for 4 months." E3 P* v( R; c; a
Physical examination at this time revealed that the
+ H. x4 Z1 c; i4 @9 a- bchild had grown 2.5 cm in 4 months and had gained
" h; C- [% k$ O6 q/ e2 kg of weight. Physical examination remained, C+ q; \* ?8 R* }: b6 l
unchanged. Surprisingly, the pubic hair almost com-) e. [& G3 x' g3 J, Z8 Q
pletely disappeared except for a few vellous hairs at& c* L6 ]- z, z3 s/ E
the base of the phallus. Testicular volume was still 2% W9 ?& g. l* r, u8 b
mL, and the size of the penis remained unchanged.
' w& [. W }& x" R6 FThe mother also said that the boy was no longer hav-0 V- _8 D. x; {5 F
ing frequent erections.5 f4 R, {. B, }# p# b5 e
Both parents were again questioned about use of
3 L5 T. v- d$ `4 t3 i( Bany ointment/creams that they may have applied to5 l0 d1 O& p6 _4 Y) |- a+ n
the child’s skin. This time the father admitted the- C d/ G( b+ I# W
Topical Testosterone Exposure / Bhowmick et al 541, d, [8 t$ |( B/ Y& L
use of testosterone gel twice daily that he was apply-
4 X& ` b% c6 k' ]) }! V! Oing over his own shoulders, chest, and back area for3 o- K- i" H$ x/ {' |/ T* j
a year. The father also revealed he was embarrassed
8 B2 D2 g9 G! |5 L- nto disclose that he was using a testosterone gel pre-
) G2 W- d w6 j0 k1 I: M" Iscribed by his family physician for decreased libido3 d; F# d- |6 i/ N
secondary to depression.2 Q8 ]3 D2 }9 C, \
The child slept in the same bed with parents.0 L, Z5 p# `* m/ R
The father would hug the baby and hold him on his0 `+ T" `* W& }* r0 X
chest for a considerable period of time, causing sig-" l: _2 L8 `/ y$ z, b
nificant bare skin contact between baby and father." l% p5 L9 v x: h# T N# C
The father also admitted that after the phone call,( {( f& o& _& e
when he learned the testosterone level in the baby
2 v& i' }; o, \% B- kwas high, he then read the product information
% C: e, H3 b3 D2 U- cpacket and concluded that it was most likely the rea-
# O k" o; G; m: I2 Rson for the child’s virilization. At that time, they
# z+ h1 J: m, |. s Gdecided to put the baby in a separate bed, and the
5 a! U/ a$ ?% Lfather was not hugging him with bare skin and had
) O4 w! g& G, A$ b" r5 ubeen using protective clothing. A repeat testosterone
0 t9 G I( r# M( gtest was ordered, but the family did not go to the6 U: i% |5 w5 p
laboratory to obtain the test.6 V! L. `9 I! y9 m* N' `+ v5 b
Discussion/ N1 d1 h# [0 P3 i! p
Precocious puberty in boys is defined as secondary; e5 R; D+ I0 M4 m3 E
sexual development before 9 years of age.1,4# \2 v' {. I5 H+ L8 j) I
Precocious puberty is termed as central (true) when
" q' ?) S7 \! ]( }: {9 ?- e4 w ^it is caused by the premature activation of hypo-1 l: N6 y9 c- |7 a* u5 Y# p( R
thalamic pituitary gonadal axis. CPP is more com-1 f3 l5 X0 E$ P' z% Q" k' U
mon in girls than in boys.1,3 Most boys with CPP
* l- X% V& g" Cmay have a central nervous system lesion that is
, W( w, q" |3 ] r5 U% ~; G9 jresponsible for the early activation of the hypothal-6 A% y) N2 s& c$ n" _& ?8 ?
amic pituitary gonadal axis.1-3 Thus, greater empha-
- u; v8 B8 i/ K" Psis has been given to neuroradiologic imaging in
5 x: a- z8 C1 T8 h% P9 |boys with precocious puberty. In addition to viril-
( f9 l4 L! q9 c; b4 s3 H8 fization, the clinical hallmark of CPP is the symmet-
* R$ R; a$ y6 xrical testicular growth secondary to stimulation by* l" y3 n! n+ ?5 u4 H' K
gonadotropins.1,3
9 v' s: e- Z, V8 Q* G( ?, }Gonadotropin-independent peripheral preco-
" k2 s* f- Z* n; C- r+ i3 j0 Rcious puberty in boys also results from inappropriate+ n$ R2 }0 Z$ I b% T3 X, T
androgenic stimulation from either endogenous or e# R* C J" @5 V
exogenous sources, nonpituitary gonadotropin stim-: H) ^1 r' C( d9 ]/ X7 _! e
ulation, and rare activating mutations.3 Virilizing! A! B8 ?# X1 ~/ Q
congenital adrenal hyperplasia producing excessive
' I% V3 F) b6 @ i6 T2 @adrenal androgens is a common cause of precocious
1 u/ j1 T" C4 I" _* D: @6 _6 [8 ^puberty in boys.3,4
5 O8 {' L! B! G, A, EThe most common form of congenital adrenal
7 p1 N. S$ y. i- J! \hyperplasia is the 21-hydroxylase enzyme deficiency.
7 U) B6 h# D0 g& X' iThe 11-β hydroxylase deficiency may also result in/ z2 P+ c$ t& K2 x
excessive adrenal androgen production, and rarely,
7 r) t4 \1 k" ]: B; m. q3 ^& _an adrenal tumor may also cause adrenal androgen: D; n2 O: ^7 [+ a1 H5 j) d4 o8 h( D* g
excess.1,30 C6 {+ P! g0 n% \3 M. j: f% L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: _2 |5 U* A$ K' x2 ]7 }8 \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( f+ i: E; s1 g5 W
A unique entity of male-limited gonadotropin-
$ X" f/ V0 p0 k& q/ sindependent precocious puberty, which is also known
2 U" Z2 Y& l H; eas testotoxicosis, may cause precocious puberty at a
7 {8 g0 z4 p @1 s# lvery young age. The physical findings in these boys
! M! F. D& m+ Y' fwith this disorder are full pubertal development,
0 c& }1 D$ q2 ?! Eincluding bilateral testicular growth, similar to boys: u: S- G3 Y: `3 O5 O$ _
with CPP. The gonadotropin levels in this disorder
, S! v2 c `1 G# R- \. C" sare suppressed to prepubertal levels and do not show
8 }# E8 F& [$ T/ ~pubertal response of gonadotropin after gonadotropin-% D; F' s2 Q5 S0 F' k
releasing hormone stimulation. This is a sex-linked V* e( t: m' C
autosomal dominant disorder that affects only
' P- Y, h" v& `! }$ smales; therefore, other male members of the family6 G5 P7 Q( r* @% ^
may have similar precocious puberty.3 l- u6 D! I$ W- f. M1 z7 l% `; Z1 A% F
In our patient, physical examination was incon-
, W/ y- l" d* \, M5 D9 ^3 lsistent with true precocious puberty since his testi-
8 a5 }( S- p" S# W' }cles were prepubertal in size. However, testotoxicosis: P: [: q4 I2 ]% o/ U; h
was in the differential diagnosis because his father
) n$ D3 ?4 B+ \3 pstarted puberty somewhat early, and occasionally,& B- A( f* N& p H; v& F' o6 q- Y+ o
testicular enlargement is not that evident in the
& R: f' W8 C) p* X- Xbeginning of this process.1 In the absence of a neg-4 B) G8 z2 ^/ C: T& \
ative initial history of androgen exposure, our
! b; E9 P' b0 b& V; F. }) gbiggest concern was virilizing adrenal hyperplasia,
& g+ `7 f4 [) d) G6 ceither 21-hydroxylase deficiency or 11-β hydroxylase; Y5 Z4 L4 @8 C' Q' N
deficiency. Those diagnoses were excluded by find-* t/ D/ q& v! s5 x" ^
ing the normal level of adrenal steroids.
$ `; w, A: `% ]" K' U$ sThe diagnosis of exogenous androgens was strongly- G. A# I, Q5 P, ]) ]1 P
suspected in a follow-up visit after 4 months because
7 r0 \7 N' l4 i1 j/ L& Zthe physical examination revealed the complete disap-3 ~3 }+ Y$ B6 b9 T8 [) f
pearance of pubic hair, normal growth velocity, and
4 g; B8 ?- H5 J+ b+ l. fdecreased erections. The father admitted using a testos-
( Y# {& T' ?+ zterone gel, which he concealed at first visit. He was# r5 K4 X) M' y7 o: b t, } j
using it rather frequently, twice a day. The Physicians’. R! Z$ n0 i! Y% m& B
Desk Reference, or package insert of this product, gel or; m. q2 B# c/ p: L$ m' ]6 c
cream, cautions about dermal testosterone transfer to! e3 S6 F9 @# }, a9 y/ V' |
unprotected females through direct skin exposure.
0 _* [* |6 f! \8 j; G) |4 ISerum testosterone level was found to be 2 times the
X+ h( V. ?/ d# v0 V1 l5 Sbaseline value in those females who were exposed to
9 D* u& i( c0 q2 Meven 15 minutes of direct skin contact with their male5 n4 b& R0 u$ n8 O! q
partners.6 However, when a shirt covered the applica-
' }" p. R# \; r! g Gtion site, this testosterone transfer was prevented.% s; f2 l9 U m7 l1 n
Our patient’s testosterone level was 60 ng/mL,
6 M% y; A9 B. q! T; x5 I* M* e6 \which was clearly high. Some studies suggest that
) c& j: I! E" I" }4 X5 W Vdermal conversion of testosterone to dihydrotestos-( m! M, }* m* S% @+ B" D ^
terone, which is a more potent metabolite, is more
' S: f! z6 P& a8 ]1 g7 T( R* K5 Y6 }active in young children exposed to testosterone% k; ~+ v$ }2 ?' U
exogenously7; however, we did not measure a dihy-
/ H- [" H I X6 u$ G7 Kdrotestosterone level in our patient. In addition to
# ^( J2 q& D3 z' \9 k+ B, Avirilization, exposure to exogenous testosterone in
8 F2 Z$ ?3 L; f+ x2 k! fchildren results in an increase in growth velocity and
, i0 k! l; n3 A. Z5 x( A7 Z; Gadvanced bone age, as seen in our patient.9 }2 w, _/ H' b* s( l, y
The long-term effect of androgen exposure during
" b$ v- V7 X" \+ {early childhood on pubertal development and final6 m( J- n) `6 L% i
adult height are not fully known and always remain
& d# {2 P9 C! {2 l' s5 xa concern. Children treated with short-term testos-0 Z. V) O$ \! U: [
terone injection or topical androgen may exhibit some/ Z' S' ]. w" A8 v* u7 ~
acceleration of the skeletal maturation; however, after
3 S4 v* h; I+ R# {$ t( bcessation of treatment, the rate of bone maturation# A" H/ B F+ ~! r' y
decelerates and gradually returns to normal.8,9
7 c5 B+ ?2 } b+ _ q* f, }% [There are conflicting reports and controversy
8 F0 w" \# |/ _: B8 Cover the effect of early androgen exposure on adult
+ p# j& D) o6 Kpenile length.10,11 Some reports suggest subnormal
, s" f; ?! J) }; {/ ]adult penile length, apparently because of downreg-" D) O: s5 T! n4 t
ulation of androgen receptor number.10,12 However,7 ~2 e- n% e" ?7 M8 t
Sutherland et al13 did not find a correlation between
7 u7 m3 D/ U" _5 t0 u8 T# Fchildhood testosterone exposure and reduced adult& f2 Y/ b; k2 K4 ?+ j7 P
penile length in clinical studies.' h0 `+ K! m4 T% j# M
Nonetheless, we do not believe our patient is
( ^3 _$ X9 p. x3 f" F: Kgoing to experience any of the untoward effects from9 d, v( F9 O% X5 V! q0 u, \5 N( Z
testosterone exposure as mentioned earlier because
8 A8 G% G; \( ?2 J3 gthe exposure was not for a prolonged period of time.
7 V6 b% F( `9 o" s+ U) c" C; JAlthough the bone age was advanced at the time of
z5 S4 |8 P# ediagnosis, the child had a normal growth velocity at
5 E8 g! ^6 d7 M& Kthe follow-up visit. It is hoped that his final adult
% Q; c& g& e7 t) W. bheight will not be affected.- k* q. e8 { v2 E, ]; l) h7 ]9 w
Although rarely reported, the widespread avail-4 N, N- a; F: t
ability of androgen products in our society may
; \* L, U3 `0 l) Eindeed cause more virilization in male or female v; s- E* S4 h
children than one would realize. Exposure to andro-
$ s0 y% X" M: V3 j3 @* H* Q, @gen products must be considered and specific ques-8 }# l5 D0 t3 O. q9 Z& Z7 _6 F9 V
tioning about the use of a testosterone product or+ N2 S t5 O" u8 p& ^6 _( u8 E- ]
gel should be asked of the family members during5 F5 O& m# S& z3 H
the evaluation of any children who present with vir-
G$ q, ~; ^: s0 Iilization or peripheral precocious puberty. The diag-* s7 M% F6 z. |, l4 @* w
nosis can be established by just a few tests and by
2 R7 p& y. K. A4 G5 D6 _appropriate history. The inability to obtain such a& ^, ~3 O( n, Q- M0 b9 K4 M5 g
history, or failure to ask the specific questions, may
+ O T" p2 k7 C% d+ u" f, M Wresult in extensive, unnecessary, and expensive
: S; a; r: V$ }$ Winvestigation. The primary care physician should be% K. d3 ?5 `* y/ w, D' N f
aware of this fact, because most of these children4 @) _; B$ f+ e) O
may initially present in their practice. The Physicians’
# ]" D' H" T4 P1 B9 j+ X! `Desk Reference and package insert should also put a
8 ~$ T/ J8 M5 r% D- f& \warning about the virilizing effect on a male or0 e( g7 P6 N+ G+ |+ M6 f$ P
female child who might come in contact with some-
& @9 @8 s8 d; |: r6 O1 d! eone using any of these products.2 Z6 M8 F6 T( s0 ]- [& l
References( c/ Z: O' D+ r2 i/ |; @
1. Styne DM. The testes: disorder of sexual differentiation& N: z M" W9 }
and puberty in the male. In: Sperling MA, ed. Pediatric
6 Z; S2 y3 w2 ~$ nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( A( w& J t6 Z3 h2002: 565-628.% E8 D) K% D7 l1 l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 E& P7 I, h8 |: Y; n1 l
puberty in children with tumours of the suprasellar pineal |
|