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Sexual Precocity in a 16-Month-Old& G8 @ c" c# D3 z. \
Boy Induced by Indirect Topical p* q7 w" r! N& a1 H$ I
Exposure to Testosterone7 c* {6 F1 ?8 v5 j. s* U& m$ A" L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" V3 q8 w. p( x; C! h; aand Kenneth R. Rettig, MD1
; w o( j" `8 y" {8 U( c( G9 {Clinical Pediatrics- [# ^1 R1 X! j. w2 H6 A
Volume 46 Number 6/ |9 q. e" h" S ?' k/ p
July 2007 540-543% e4 {$ K1 v& l' T" [1 ^5 _. \
© 2007 Sage Publications
9 D2 U/ |* ` h$ V* ^. s2 a3 I+ B10.1177/0009922806296651
' ^ x% ^( \1 Vhttp://clp.sagepub.com E) h1 M3 n5 `. d/ t& d
hosted at
- H+ H( e8 N& W% uhttp://online.sagepub.com. f) F7 T( Z/ }3 d* l8 k1 ?; h
Precocious puberty in boys, central or peripheral,6 u: ~+ }% D3 x! O, R
is a significant concern for physicians. Central! a& w* {: X. i8 p2 M
precocious puberty (CPP), which is mediated& a" e' W! e! V: U" N, Z
through the hypothalamic pituitary gonadal axis, has$ n) N7 A( Z2 |; C& I/ K
a higher incidence of organic central nervous system- {, B% ?1 c; r8 D, U- ?
lesions in boys.1,2 Virilization in boys, as manifested
- [1 ]0 n( I6 P1 o8 |6 M I# r+ K; ~8 tby enlargement of the penis, development of pubic; @" r$ `% t/ k2 ]$ E$ |
hair, and facial acne without enlargement of testi-$ [: Q% R6 ~3 L/ c8 |! @
cles, suggests peripheral or pseudopuberty.1-3 We: x/ a; A1 z% l% @$ s1 f8 A: m0 f
report a 16-month-old boy who presented with the
. H# v% g3 }5 Y; uenlargement of the phallus and pubic hair develop-) L9 L+ A" l( i! f( [" ?
ment without testicular enlargement, which was due
0 H. Q s0 H( o; z8 p! {to the unintentional exposure to androgen gel used by
/ |7 u4 J7 `( A+ G! b6 T8 Zthe father. The family initially concealed this infor-
& Y' E) q1 I' p& s4 cmation, resulting in an extensive work-up for this3 @: C0 V m. V$ W6 t1 `: X" d
child. Given the widespread and easy availability of
9 M. k7 _+ `) gtestosterone gel and cream, we believe this is proba-
2 d' c& |# f- C7 U7 o1 ibly more common than the rare case report in the: v" O# a6 p1 P+ e
literature.4: y4 l' k6 _6 q) B3 z% z# `& R( T6 W* |- x
Patient Report
$ C, e" E4 o1 b' mA 16-month-old white child was referred to the, F0 w1 [6 H$ g* a* B
endocrine clinic by his pediatrician with the concern) }9 v* g( v" \' a
of early sexual development. His mother noticed
- F3 H4 r8 K: l6 _+ N7 ulight colored pubic hair development when he was) |$ g* B9 d9 v; T( F! N5 H
From the 1Division of Pediatric Endocrinology, 2University of
- A0 W, u/ z2 S P; ^South Alabama Medical Center, Mobile, Alabama.0 g" g+ ], `& W( _/ l1 N& a& u! U
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% k# P/ V8 k, O/ C: |+ ~1 ]Professor of Pediatrics, University of South Alabama, College of
! g7 r0 e0 J( Y8 z4 fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; q( r, m2 x7 A( y8 r1 f; K# [e-mail: [email protected].
- D- Q, o+ P Q8 Mabout 6 to 7 months old, which progressively became
5 s, v- F6 h I0 p, c! ?darker. She was also concerned about the enlarge-
& A( A1 p5 Q% mment of his penis and frequent erections. The child$ O4 r: `$ T, i8 a% U) b2 s! ]- Y
was the product of a full-term normal delivery, with
/ G9 f9 P* b1 q* f3 Ma birth weight of 7 lb 14 oz, and birth length of$ r: u! J) g! J8 n, s+ ?- x" M
20 inches. He was breast-fed throughout the first year
+ Y6 K- {9 |$ M7 {$ z) S) ~3 tof life and was still receiving breast milk along with2 [ y* _7 Q1 A- J# _
solid food. He had no hospitalizations or surgery,% R L+ l( s' Q6 J1 z5 l6 @
and his psychosocial and psychomotor development% C6 \- d: C4 G; i1 B! Z
was age appropriate.
" f5 p/ f( x( r! yThe family history was remarkable for the father,
$ q% Q- s& j1 H; gwho was diagnosed with hypothyroidism at age 16,
/ R6 t# H. U- _9 U5 dwhich was treated with thyroxine. The father’s
6 Y) H; o1 q) r+ P6 Xheight was 6 feet, and he went through a somewhat
7 H( N! K. T5 ~; wearly puberty and had stopped growing by age 14.
6 E( }" D; ^0 ?! D6 iThe father denied taking any other medication. The, f0 H+ O3 U8 V, H) W2 q" n3 g- ?
child’s mother was in good health. Her menarche- i: I1 Q, [/ U, n+ i0 n
was at 11 years of age, and her height was at 5 feet8 m0 o9 Y7 P* j
5 inches. There was no other family history of pre-
6 N5 h# o6 V& V& {, }% L6 M( }cocious sexual development in the first-degree rela-" z7 d5 P( P" f7 h( u# c
tives. There were no siblings.
: p# \$ z1 ?* ?) e8 u. \Physical Examination1 B. I( v8 M" o9 J7 ]1 W
The physical examination revealed a very active," C" b* h9 n# b( v
playful, and healthy boy. The vital signs documented
/ ]2 \, \- G% ^! R% P0 X9 fa blood pressure of 85/50 mm Hg, his length was6 n1 S/ y2 V/ A) B# G) F
90 cm (>97th percentile), and his weight was 14.4 kg w, d) O" I/ y0 o
(also >97th percentile). The observed yearly growth
@5 u! `2 n9 ?4 O, \velocity was 30 cm (12 inches). The examination of# u" \- D1 b- a# _8 P3 T$ y9 `
the neck revealed no thyroid enlargement.
: @% t/ ~: f# E+ m y) uThe genitourinary examination was remarkable for% j4 D. h" Q, s1 v4 b/ o. b
enlargement of the penis, with a stretched length of/ i0 q! P/ y' X! m; q5 t+ v E
8 cm and a width of 2 cm. The glans penis was very well/ Z5 |3 j; I0 q1 E, c/ y" M" d
developed. The pubic hair was Tanner II, mostly around
6 b5 U. _. P0 D4 C, u5 N4 t540
. c, G( \' t0 g7 d- qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 j5 i& Y1 C" }& m# bthe base of the phallus and was dark and curled. The
; X. t5 _9 c/ Ktesticular volume was prepubertal at 2 mL each.1 [2 q' @% O& J1 J' F
The skin was moist and smooth and somewhat7 T; T# J: y+ E9 @
oily. No axillary hair was noted. There were no
6 A s& [0 U; X9 n9 m4 K habnormal skin pigmentations or café-au-lait spots.
5 A$ p3 {: U* X' M r3 Z6 u5 {Neurologic evaluation showed deep tendon reflex 2+
. O) B! M F9 u+ dbilateral and symmetrical. There was no suggestion
! s# M/ U' c& B! W9 c* aof papilledema.3 a, {' t, d" Y8 }- P$ D# a: B/ u- A
Laboratory Evaluation. K& I$ X& w% g& G
The bone age was consistent with 28 months by
- e0 L" ~/ x) N( dusing the standard of Greulich and Pyle at a chrono-
" j1 Z+ A3 A" s: O1 Y: Xlogic age of 16 months (advanced).5 Chromosomal* p7 U1 j1 ]# g |% W: M- b! m
karyotype was 46XY. The thyroid function test
; j" f( ?* t3 l2 kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-$ P" ^7 p& b _" e5 d4 G: a
lating hormone level was 1.3 µIU/mL (both normal).
9 X9 j: I( v+ Q2 y7 uThe concentrations of serum electrolytes, blood
0 k; a# a( D6 Nurea nitrogen, creatinine, and calcium all were& b; D+ q# v: I! t9 t5 ^9 p
within normal range for his age. The concentration U; r& ]' G$ b
of serum 17-hydroxyprogesterone was 16 ng/dL d8 c. M5 s+ A
(normal, 3 to 90 ng/dL), androstenedione was 20) S* @: v7 Y* p4 e _7 C* J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; x# k8 W. W5 m, H# s2 ?; F8 B
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! I9 T6 S7 G; B- X& ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to X. C/ e3 z9 @7 N, {: J9 Q" J
49ng/dL), 11-desoxycortisol (specific compound S)- R( E( o N( i& R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 c2 x% w; S& D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- l8 R: ]1 M$ C+ dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 [5 Y$ ~+ r& Z) c# ?and β-human chorionic gonadotropin was less than% Y2 i4 X9 \9 k! c4 ^0 O
5 mIU/mL (normal <5 mIU/mL). Serum follicular; {8 r3 s" w% c- S9 d4 C, P% U
stimulating hormone and leuteinizing hormone4 U6 E2 d4 L4 W& Z) W
concentrations were less than 0.05 mIU/mL/ r6 U! l8 q+ ~1 M8 Q6 n7 t
(prepubertal).
& A' W1 t3 L2 o0 gThe parents were notified about the laboratory& @2 Y/ F' Q. N& K# D2 K$ q
results and were informed that all of the tests were
) {. |1 K, ~* \0 O4 Snormal except the testosterone level was high. The" @, I$ J" l4 ~6 T' o2 t3 L& m6 h
follow-up visit was arranged within a few weeks to- S" k% h/ p2 N2 P: L' R+ q* e" I
obtain testicular and abdominal sonograms; how-
0 u1 P) r. N% E! {ever, the family did not return for 4 months.0 e- j( F* t. i0 {2 R4 l
Physical examination at this time revealed that the
6 y& y3 R7 K: X) _/ \; {3 Cchild had grown 2.5 cm in 4 months and had gained' {* R; r/ ?0 ?" q( C# o" m% n
2 kg of weight. Physical examination remained
6 z u; C, Z* n3 v9 @5 Z* {unchanged. Surprisingly, the pubic hair almost com-# o6 F- w/ i4 v2 h8 J& w# C0 c- L
pletely disappeared except for a few vellous hairs at5 w0 |4 M' G# z0 l
the base of the phallus. Testicular volume was still 2# \+ P! k; \- @
mL, and the size of the penis remained unchanged.2 S+ [" {; y; c1 I
The mother also said that the boy was no longer hav-, F0 K& g4 T7 u8 H( V7 l
ing frequent erections.
/ }. ?& o- l6 P3 X; g# MBoth parents were again questioned about use of
) {2 Y' R- ?- ?7 l2 Sany ointment/creams that they may have applied to
7 j/ u2 }9 V5 p+ ~3 q1 bthe child’s skin. This time the father admitted the4 W9 z1 H4 k. q. k) ^8 q
Topical Testosterone Exposure / Bhowmick et al 541$ w X# N0 [: J3 d
use of testosterone gel twice daily that he was apply-
4 W+ t7 u2 J+ g2 X" T" n8 ring over his own shoulders, chest, and back area for8 S; x6 t! X! [* \# f
a year. The father also revealed he was embarrassed9 R2 {9 N: J# Y9 d9 e; o) f2 a, i y0 I
to disclose that he was using a testosterone gel pre-
2 G* g' j2 W6 Q) wscribed by his family physician for decreased libido( ]" B& {$ L: S, w# t- t! P. y+ R
secondary to depression.
, y# G- ~0 E7 o5 r" WThe child slept in the same bed with parents.' ^$ j# o0 h c) o
The father would hug the baby and hold him on his3 J; x q" ~( M5 i3 t4 e! v9 _
chest for a considerable period of time, causing sig-* |, e& X. i$ X# @
nificant bare skin contact between baby and father./ h! Z3 h: ?, r; O
The father also admitted that after the phone call,3 s, `, p% Y! u3 c# _" x' r( \4 ]
when he learned the testosterone level in the baby% l- o+ s( g& X0 W2 j$ a
was high, he then read the product information# f# K V, ^1 p1 N7 V
packet and concluded that it was most likely the rea-
$ P/ a# v4 M# _9 c Yson for the child’s virilization. At that time, they
3 C1 P6 f! j; L6 Mdecided to put the baby in a separate bed, and the
2 l5 F( ?* X p- ofather was not hugging him with bare skin and had
# j( W) x: H6 Ubeen using protective clothing. A repeat testosterone
. q) t: _" V: ~3 F; ^/ @4 Z* ]test was ordered, but the family did not go to the
/ O7 m* o0 e* ?$ B$ x. elaboratory to obtain the test.
9 m2 a8 N2 K2 o' H# pDiscussion. e# G) a8 E0 `; U- @, h1 _
Precocious puberty in boys is defined as secondary
; s/ d* K9 n" |sexual development before 9 years of age.1,4
. g- U* o% F$ U6 a- |" |Precocious puberty is termed as central (true) when
6 M2 m7 ~# {& r } l: n. Tit is caused by the premature activation of hypo-
- c5 M* Y( h, A8 ithalamic pituitary gonadal axis. CPP is more com-* F9 s' ]. G5 o) Q7 p% ]$ f
mon in girls than in boys.1,3 Most boys with CPP1 z: {7 s* w% X! R$ _7 k8 ]
may have a central nervous system lesion that is7 O/ U: ]7 S1 \1 R
responsible for the early activation of the hypothal-
2 m( O0 ?$ ^- O @amic pituitary gonadal axis.1-3 Thus, greater empha-
' q) |* r' D5 C$ \6 fsis has been given to neuroradiologic imaging in
# ^. O5 K5 |! u4 d) Aboys with precocious puberty. In addition to viril-1 X2 Y) f6 X: D2 O
ization, the clinical hallmark of CPP is the symmet-% n! K) O( `7 P1 u& i' i3 Q/ m5 Z' I
rical testicular growth secondary to stimulation by
5 k, \1 E' Y% ~, f" u! Pgonadotropins.1,3
' H c5 n! D5 V, R( g( H; T0 l( XGonadotropin-independent peripheral preco-
- K. \' r7 p" O& Ocious puberty in boys also results from inappropriate' w' Q( n: e# C: M; [6 k
androgenic stimulation from either endogenous or& ^3 k( ~) C& O
exogenous sources, nonpituitary gonadotropin stim-$ C: o/ s4 d; ^3 R1 p
ulation, and rare activating mutations.3 Virilizing
- H9 G! D( S3 Dcongenital adrenal hyperplasia producing excessive2 c0 w' i, }$ b `
adrenal androgens is a common cause of precocious
o9 l& h- {) q* k* `puberty in boys.3,47 } o( X i3 _( Z
The most common form of congenital adrenal! h% I m$ ?6 l! ^# P) b7 R
hyperplasia is the 21-hydroxylase enzyme deficiency., I6 v T+ G& i$ }6 j: O
The 11-β hydroxylase deficiency may also result in
& ^" p9 {. R! D. g5 W, L, z/ Hexcessive adrenal androgen production, and rarely,% {6 Y' _* A: `: P4 u# }" C
an adrenal tumor may also cause adrenal androgen: w4 y% z- D; L! z) |
excess.1,3* c2 P" @; ?5 W. |* Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 V5 O& I+ M$ P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
h; M/ G4 y/ Q. @- J/ f3 x& \# P2 F6 mA unique entity of male-limited gonadotropin-
7 T2 D) T: ^, F; j* o& x: Sindependent precocious puberty, which is also known
5 i8 ~* `* `' p: k) h/ Uas testotoxicosis, may cause precocious puberty at a
2 K( n( q! [1 l8 Q" T" `very young age. The physical findings in these boys/ S# o- G; j g0 d, t. ]- \
with this disorder are full pubertal development,$ n4 d0 `7 ?/ Y H6 o. {3 n
including bilateral testicular growth, similar to boys
( M9 T! H1 U# D ^& M: mwith CPP. The gonadotropin levels in this disorder3 C5 C) v; n1 K, x
are suppressed to prepubertal levels and do not show/ j9 T9 A G; B
pubertal response of gonadotropin after gonadotropin-! L1 \" Q; `- B) r- }
releasing hormone stimulation. This is a sex-linked
. Y$ u- A( h+ hautosomal dominant disorder that affects only/ M' v% p+ R/ }4 n$ v( w" a
males; therefore, other male members of the family
/ [+ Z7 r4 P, V7 J- ^& `; O8 i0 S: m' n; Mmay have similar precocious puberty.3
_" S. y- P QIn our patient, physical examination was incon-
# y& W7 j; g/ Ksistent with true precocious puberty since his testi-
) k+ ?6 I$ D' H m1 A9 r' M) ^cles were prepubertal in size. However, testotoxicosis/ C* P& d3 s- C! G7 X7 F
was in the differential diagnosis because his father
3 D$ o: s: M8 V! ]; s/ O' Wstarted puberty somewhat early, and occasionally,
; P% l+ n u- D$ L( \! {4 n" Btesticular enlargement is not that evident in the
- I* `) _: u% c* B+ ^beginning of this process.1 In the absence of a neg-
: u; r8 O! p6 V) }6 lative initial history of androgen exposure, our! q# {, H- o8 X7 C3 V
biggest concern was virilizing adrenal hyperplasia,5 r- J. h, d, W! i% l! e9 n
either 21-hydroxylase deficiency or 11-β hydroxylase
$ T4 y' x: n5 I2 c5 F. Z# odeficiency. Those diagnoses were excluded by find-
9 s/ i" n4 S' h4 v- G2 J* Ging the normal level of adrenal steroids.
w6 O5 @' g- m% N& KThe diagnosis of exogenous androgens was strongly4 o2 s" ]8 J( m9 S$ y3 W
suspected in a follow-up visit after 4 months because( E$ w4 Y( x8 S& `, J2 e
the physical examination revealed the complete disap-" ?: A7 |' |! F8 |" b
pearance of pubic hair, normal growth velocity, and
! L" k. w1 u2 j# r' Rdecreased erections. The father admitted using a testos-
) `4 Z5 q- ?. h {terone gel, which he concealed at first visit. He was4 U3 I- ?; n$ S! @. W
using it rather frequently, twice a day. The Physicians’
! b q7 }# J# H+ e3 tDesk Reference, or package insert of this product, gel or
9 B1 b6 X" f* h+ [9 X5 p+ ]cream, cautions about dermal testosterone transfer to# p4 W' h8 y6 s- \
unprotected females through direct skin exposure.
6 j' v& k9 K/ T3 O" n zSerum testosterone level was found to be 2 times the, ^, r' }6 Z. A7 r' M/ }. j* S1 K7 `
baseline value in those females who were exposed to$ y& p F& J2 u) ?: A- }; _
even 15 minutes of direct skin contact with their male
: ~4 c3 f1 E- ?) Cpartners.6 However, when a shirt covered the applica-
* D# j% h2 `' e' r5 Ttion site, this testosterone transfer was prevented.+ k* C ]& C. n4 t* w, x
Our patient’s testosterone level was 60 ng/mL,0 r2 ^/ t8 h3 e& o& ?, S
which was clearly high. Some studies suggest that
) k; |" e; C! p/ a8 `. n3 V0 [dermal conversion of testosterone to dihydrotestos-7 j: F7 b9 V4 n% Y, t3 V
terone, which is a more potent metabolite, is more
7 G' @6 i5 f. h4 A$ \: tactive in young children exposed to testosterone5 W) q* G4 [. B
exogenously7; however, we did not measure a dihy-: n' j% Q: G* Y2 \. \7 ?" Y
drotestosterone level in our patient. In addition to8 f4 k5 W+ e. F( Y( m0 N7 C
virilization, exposure to exogenous testosterone in$ Y# k! u1 D& s1 x
children results in an increase in growth velocity and
' {6 n+ f* A2 d0 m. M: L8 Madvanced bone age, as seen in our patient.
3 k# ^9 v3 D1 f/ K' eThe long-term effect of androgen exposure during* _, x# t) t# D; e# K5 W
early childhood on pubertal development and final
8 u' k9 X+ b) \adult height are not fully known and always remain% B2 T9 D+ y5 J' r& a' R
a concern. Children treated with short-term testos-9 u) U. Q3 P0 v" u1 l' v
terone injection or topical androgen may exhibit some% J1 M8 T- T- I M! ?0 Y* J
acceleration of the skeletal maturation; however, after5 |: |( M# Y, s, ]$ M- C6 S
cessation of treatment, the rate of bone maturation
7 i' S3 _4 w- hdecelerates and gradually returns to normal.8,9# o0 X5 R7 U# s5 p4 ~
There are conflicting reports and controversy, R, L- z- P1 k7 W5 g$ f5 d
over the effect of early androgen exposure on adult4 h. p6 n( C! y* [- t
penile length.10,11 Some reports suggest subnormal! X* B) J F2 k
adult penile length, apparently because of downreg-
# B J, C% k- H) @! b! }5 Qulation of androgen receptor number.10,12 However,8 _# x; N" o' O P! ?( f7 M" z
Sutherland et al13 did not find a correlation between
) ~+ p+ H: ]* c$ m; C: X: P8 kchildhood testosterone exposure and reduced adult
" A A8 l; g% E! o# Lpenile length in clinical studies.: H. b6 A$ d: W4 u1 p2 ~
Nonetheless, we do not believe our patient is( F, ^2 n# R- K: C. X9 G
going to experience any of the untoward effects from, G3 Z% T2 v4 m* d
testosterone exposure as mentioned earlier because
5 h+ R2 o: b; s$ E1 Rthe exposure was not for a prolonged period of time.7 S5 n+ r/ q4 A9 t& ~6 w
Although the bone age was advanced at the time of
% ~2 h" N$ {" N sdiagnosis, the child had a normal growth velocity at3 W8 f& q4 l) O! X* O
the follow-up visit. It is hoped that his final adult
& k) J7 ~) B% X# y- A8 zheight will not be affected.! T, E: a" i$ |: m" M' q
Although rarely reported, the widespread avail-+ y0 y, N5 U3 ]* }5 ?) s1 B7 w
ability of androgen products in our society may, S$ h3 U d/ z1 w
indeed cause more virilization in male or female
4 R; f; L/ K! A5 ?( _2 B& v3 Tchildren than one would realize. Exposure to andro-
- D3 B- b8 G: A- b7 Ogen products must be considered and specific ques-
7 h/ C* j% d! s: vtioning about the use of a testosterone product or, K# F: _& y3 y
gel should be asked of the family members during
( b, w5 V' D0 `8 b/ P; I) fthe evaluation of any children who present with vir-
7 w9 x/ n# T+ n- I6 H1 p) \/ Hilization or peripheral precocious puberty. The diag-& _4 _. q1 Q% O6 p
nosis can be established by just a few tests and by: c& Y, i/ u, h2 \. w0 {* [
appropriate history. The inability to obtain such a# D2 Q# ? E8 a4 C. m( c
history, or failure to ask the specific questions, may
4 I1 r, _) S0 x' m( b& W1 g1 cresult in extensive, unnecessary, and expensive
2 b* o/ M8 |" H* _2 r) O8 Oinvestigation. The primary care physician should be
" i, I# u5 X1 l9 P3 q$ c, uaware of this fact, because most of these children
. D! @' l7 ?2 `' `9 Zmay initially present in their practice. The Physicians’5 c4 g% v4 ~3 Z. x
Desk Reference and package insert should also put a; d R. n8 C' @- A9 y) c" o
warning about the virilizing effect on a male or
1 H6 h0 T. X0 Z( J5 tfemale child who might come in contact with some-
N7 o' M! q! ^' Ione using any of these products.6 ?' H$ T; q) ?7 G
References
8 ?) K3 o. |* ]! W" Q& x1. Styne DM. The testes: disorder of sexual differentiation
7 }( K( C4 Q4 ? v5 D& `and puberty in the male. In: Sperling MA, ed. Pediatric
5 B+ i0 O- d! uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' p# _) p) u7 x! r" w$ _/ ?
2002: 565-628.
: c3 }4 ~9 [1 L$ E# X( l. g. [+ f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' B' [9 g h2 I7 [) j6 y2 {
puberty in children with tumours of the suprasellar pineal |
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