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Sexual Precocity in a 16-Month-Old0 i. m' Y% G0 r+ B2 N( r9 K- j+ ^
Boy Induced by Indirect Topical; d1 A$ A. h# [/ Z# Q& W( a+ k7 X
Exposure to Testosterone H- }' E$ t5 p
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 p8 V9 y& k9 e& A' \, j; d3 y
and Kenneth R. Rettig, MD1" n! T. R5 z! @1 a+ |
Clinical Pediatrics; V( C" k2 u. g2 }: y
Volume 46 Number 62 x h3 E2 H% |$ @! D- l t
July 2007 540-543: ]- t: _( e! V! ^* H: r
© 2007 Sage Publications& A2 q: s D" G& T( X2 h
10.1177/0009922806296651
O/ s$ n1 [. } I+ p1 C ?http://clp.sagepub.com
; ^; ^1 U+ O6 L2 I3 V4 ahosted at
9 l7 R' f' o) k- `4 ], [http://online.sagepub.com# b% [. ]/ R* d% w0 L Y+ C
Precocious puberty in boys, central or peripheral,
! a* S p9 ^. d p L* u" W, h$ ]+ fis a significant concern for physicians. Central
1 E) d2 z) X3 V5 u! Z, d/ _( F/ nprecocious puberty (CPP), which is mediated
( `: `& H, p, athrough the hypothalamic pituitary gonadal axis, has6 _# R/ k4 X9 j0 Z) N0 a9 T/ U
a higher incidence of organic central nervous system
# m `" P5 l4 Y1 X) v: \lesions in boys.1,2 Virilization in boys, as manifested* k- J: Y& E ^* ]9 j3 @
by enlargement of the penis, development of pubic7 N: P3 o9 U7 g3 e0 Z
hair, and facial acne without enlargement of testi-
3 [( A0 E" G% L: y3 R0 ycles, suggests peripheral or pseudopuberty.1-3 We
9 |/ \' D4 M7 N) a9 yreport a 16-month-old boy who presented with the5 t& t. z, G: `# C
enlargement of the phallus and pubic hair develop-
+ f! n+ g: P9 V* ement without testicular enlargement, which was due
& }$ k( |% J: R, ^# e2 fto the unintentional exposure to androgen gel used by, l+ @( r* B" j# u$ {
the father. The family initially concealed this infor-. w0 c9 I% y! s- Y* R
mation, resulting in an extensive work-up for this
5 a6 S1 _# {# g! s7 Wchild. Given the widespread and easy availability of# M4 Y. S6 @' }% ^
testosterone gel and cream, we believe this is proba-% Z, F% K+ j4 h- ]; S
bly more common than the rare case report in the
2 Z( T$ [. Q: E7 Y0 i% |% cliterature.4
# b& a, m6 \1 bPatient Report
* H' v, A; w3 _7 q! z7 Y% w+ BA 16-month-old white child was referred to the4 ?5 t2 m+ t! d
endocrine clinic by his pediatrician with the concern% F4 O: z# g: R( j! P `
of early sexual development. His mother noticed
( Z& T/ }" ]3 I9 k* O j8 hlight colored pubic hair development when he was1 u8 T5 T% x& [; ?0 w% v* A
From the 1Division of Pediatric Endocrinology, 2University of
0 D6 C/ E% O8 ] }" w8 ZSouth Alabama Medical Center, Mobile, Alabama.' i% n* A/ \5 q9 x
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 H+ N2 u, H" E6 Z0 XProfessor of Pediatrics, University of South Alabama, College of0 D2 ^- K' f# Y$ D% X
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. @7 K* e. D" V9 }$ n8 w. g! K
e-mail: [email protected].
7 y4 P1 a/ v# P( K4 Uabout 6 to 7 months old, which progressively became
% X/ [8 D& g8 l3 w fdarker. She was also concerned about the enlarge-
0 j% g4 I3 I& |9 h! ement of his penis and frequent erections. The child+ x4 e0 g: m/ j' M: \4 w" C
was the product of a full-term normal delivery, with
( V3 ]/ s( e, L* m: d/ U& ?% da birth weight of 7 lb 14 oz, and birth length of! K/ M# j6 v# k8 H: H
20 inches. He was breast-fed throughout the first year: T9 `! x+ C. m& j
of life and was still receiving breast milk along with
/ x& ^3 l/ K. D5 s! c2 Psolid food. He had no hospitalizations or surgery,% e3 I( b0 H( \" z
and his psychosocial and psychomotor development' {! d3 y6 G- t, d6 A
was age appropriate.+ ]- Y+ L0 X r8 M. i/ Y1 S
The family history was remarkable for the father,+ P& ?4 Q- a, a& j1 \
who was diagnosed with hypothyroidism at age 16," L0 S' J. q$ A/ d7 H, x# d
which was treated with thyroxine. The father’s
$ g2 g$ n0 v0 }( a5 mheight was 6 feet, and he went through a somewhat3 ?5 f. L4 k( a0 L/ N+ c7 |. t% Z
early puberty and had stopped growing by age 14.+ W. e$ Y+ l( v, g7 M* |7 U/ L9 M
The father denied taking any other medication. The. O I) ]6 u9 r: [7 u
child’s mother was in good health. Her menarche6 e3 _' |* I0 ^4 f& B% d
was at 11 years of age, and her height was at 5 feet
. N) Z; j# Y! K, w' I0 n5 inches. There was no other family history of pre-3 V+ z' c7 E3 B
cocious sexual development in the first-degree rela-
/ J: d6 \ h5 Htives. There were no siblings.
& o3 H5 x* K. A ?* xPhysical Examination* F8 w/ Y( s, J4 }8 N& T. Q
The physical examination revealed a very active,* K& A: E- @1 _9 P5 a4 H. G( E! S+ l' j
playful, and healthy boy. The vital signs documented: I5 J% I0 w% b
a blood pressure of 85/50 mm Hg, his length was
3 ^3 `- r* e4 S6 [1 ?6 H! T( U# e90 cm (>97th percentile), and his weight was 14.4 kg' D j$ ^) e6 [; e7 Y. P- H! M
(also >97th percentile). The observed yearly growth
! t2 l& U" ]# i) q8 C1 {5 fvelocity was 30 cm (12 inches). The examination of1 v( O. k( }5 c" m$ u6 E7 m6 @4 g# {
the neck revealed no thyroid enlargement.
1 r6 c% A3 S2 Q. ^2 B# p/ cThe genitourinary examination was remarkable for" h0 ?8 q! G5 ~+ S. s& b
enlargement of the penis, with a stretched length of$ s `7 V C1 i, n
8 cm and a width of 2 cm. The glans penis was very well
$ X3 J# |" X$ z4 _developed. The pubic hair was Tanner II, mostly around) s! r+ c0 T& _' }: Z* X5 H' _7 |0 H3 x
540" C. v0 v( P% P4 y& f2 C+ l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 t$ d7 D5 h3 Q3 F0 d- n2 f; Hthe base of the phallus and was dark and curled. The
9 k" M& b1 \/ c) ~0 u, N! T8 Ytesticular volume was prepubertal at 2 mL each.0 Z3 `, C* {7 m
The skin was moist and smooth and somewhat9 P. V- R9 ~- n' l
oily. No axillary hair was noted. There were no! e) p3 v. E" ~9 M9 D7 ]: ?2 {6 D
abnormal skin pigmentations or café-au-lait spots.' C7 p' C% Q) m9 R; R) a
Neurologic evaluation showed deep tendon reflex 2+
! ^) m. A& [& y! `7 J! \bilateral and symmetrical. There was no suggestion
9 {, r* o, L7 X+ s/ Eof papilledema.
) c: u" [2 R6 ~7 a$ P' [% yLaboratory Evaluation+ l' W" |, p2 [% d$ G6 ?
The bone age was consistent with 28 months by! R' {, T2 }; j1 r
using the standard of Greulich and Pyle at a chrono-9 V2 N7 T( p+ k k5 m% p; U- J
logic age of 16 months (advanced).5 Chromosomal2 j7 t+ m; S$ |$ Q a
karyotype was 46XY. The thyroid function test- }2 ]) l0 Q$ d" H3 }
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- w R: E8 B+ h M( P( hlating hormone level was 1.3 µIU/mL (both normal).
+ `9 w; u1 K- U/ ?0 _1 IThe concentrations of serum electrolytes, blood. C9 ]: l; f K- G J
urea nitrogen, creatinine, and calcium all were, i* R( L; a; k, L
within normal range for his age. The concentration
; t& C, w {, Z3 Pof serum 17-hydroxyprogesterone was 16 ng/dL+ t" D* [0 A1 A- J
(normal, 3 to 90 ng/dL), androstenedione was 20
* X, }5 W$ X( T7 m5 jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 Z* R, s7 x, B: uterone was 38 ng/dL (normal, 50 to 760 ng/dL),+ [' h/ ]; I2 c- c: N- Y9 L5 `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 F1 V/ s7 e! {: z' C0 [
49ng/dL), 11-desoxycortisol (specific compound S)
( i" m6 d8 @) N. mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- b" t* A) ~* q( h% Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
z, G K+ U, B4 W* T, j2 vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 T1 T) x4 u2 V) o, h' m. `$ Iand β-human chorionic gonadotropin was less than
: T* v \+ H/ ~% i6 P3 Q: b5 mIU/mL (normal <5 mIU/mL). Serum follicular' j" }8 O, T, j3 c5 T7 e1 a, }4 |
stimulating hormone and leuteinizing hormone0 P# Z7 F: m! U
concentrations were less than 0.05 mIU/mL
) D6 h4 r5 Z O! C- P2 Y- I. r1 ~(prepubertal).2 q6 ]+ H2 l# X2 [" q G5 N, N
The parents were notified about the laboratory$ T4 c" T F4 d. G
results and were informed that all of the tests were
5 f" M/ P# q5 d3 _3 ?: e bnormal except the testosterone level was high. The
. N" _$ a/ S1 y' {/ S4 b# `follow-up visit was arranged within a few weeks to
4 H6 o+ c; C! {obtain testicular and abdominal sonograms; how-! a) t" p) O o% n
ever, the family did not return for 4 months.! k S' h( Q6 _/ U) @; r, Y
Physical examination at this time revealed that the, V& j- k! ]) z( e/ G0 E
child had grown 2.5 cm in 4 months and had gained
Z6 ^$ Q- `9 y. D2 kg of weight. Physical examination remained
: x2 L! i' b& nunchanged. Surprisingly, the pubic hair almost com-( C& x# ?9 m8 p6 m& c8 `# Y
pletely disappeared except for a few vellous hairs at
' g" C B; i6 p6 [& o* K, u' jthe base of the phallus. Testicular volume was still 21 U& {7 K9 m& j+ z" X$ P- t( V
mL, and the size of the penis remained unchanged.
' f1 p) X1 x3 JThe mother also said that the boy was no longer hav-
" Y% W3 v: [6 t& }3 L1 eing frequent erections.
% B: ` p% F* H6 E8 n3 pBoth parents were again questioned about use of# z: y; u" }/ T. [1 \: W1 ^/ n e
any ointment/creams that they may have applied to& K( L$ W8 J/ C; k: h$ a
the child’s skin. This time the father admitted the
8 Y' U9 \- e3 `; f/ _6 nTopical Testosterone Exposure / Bhowmick et al 541- y6 I5 V$ B y- y& I
use of testosterone gel twice daily that he was apply-* p& f( X# @# B& B o3 z
ing over his own shoulders, chest, and back area for* \4 Q$ y# G) x/ f9 p. ~
a year. The father also revealed he was embarrassed
& s2 K/ r6 c, ~) S1 _5 A% Pto disclose that he was using a testosterone gel pre-
) u: B2 _4 l% }' _2 c: fscribed by his family physician for decreased libido
3 Z; H! L! [6 Nsecondary to depression.3 \7 ]) g: s# d1 L- l/ T2 D
The child slept in the same bed with parents.
4 V/ h; k- ~, oThe father would hug the baby and hold him on his
$ y; k5 r5 P5 P/ d: Q9 xchest for a considerable period of time, causing sig-
2 d1 I o! s$ _3 Rnificant bare skin contact between baby and father.+ _, o4 w1 c1 ]2 r9 p. k8 M* @
The father also admitted that after the phone call,
0 ?' S4 q1 m9 f' j8 owhen he learned the testosterone level in the baby9 y, d& z, m$ L0 c2 b+ [
was high, he then read the product information
: L8 \# [0 a3 M" e0 Ipacket and concluded that it was most likely the rea-7 y$ m, B& c8 C6 \: X
son for the child’s virilization. At that time, they3 P! i$ U3 ~6 m6 u$ C
decided to put the baby in a separate bed, and the* J G8 B; R* E3 a2 T# y0 u& p9 ]
father was not hugging him with bare skin and had& G; ]% M5 x' Q- r8 w
been using protective clothing. A repeat testosterone3 Q$ \* l2 Q. }, [0 Z j% U
test was ordered, but the family did not go to the+ {" @1 y4 S) r. ]8 ^) ^/ r+ H7 @
laboratory to obtain the test." k" o9 M. ]" i6 m5 T W
Discussion
y5 i+ u% [7 Z& B9 @0 j2 ?Precocious puberty in boys is defined as secondary c+ S7 y. V5 M9 }7 D; @7 H
sexual development before 9 years of age.1,4
0 L6 [- N0 U/ u$ g% CPrecocious puberty is termed as central (true) when$ ~6 }0 _2 l# V% m
it is caused by the premature activation of hypo-
7 A1 R! n/ l U, E& _thalamic pituitary gonadal axis. CPP is more com-
/ g7 n7 i. y5 s! Jmon in girls than in boys.1,3 Most boys with CPP
0 n- \8 z" {! \3 q3 D9 Smay have a central nervous system lesion that is
7 W7 {/ N/ P5 H# vresponsible for the early activation of the hypothal-
: W3 y6 _5 j+ x( B3 Ramic pituitary gonadal axis.1-3 Thus, greater empha-
! Q) M) o$ E# M4 ^3 vsis has been given to neuroradiologic imaging in
- E% q W/ R: a/ a/ |+ N/ q/ [( _boys with precocious puberty. In addition to viril-$ m0 S& r& l5 _: C1 j; s
ization, the clinical hallmark of CPP is the symmet-1 u& x( D$ j0 G1 O
rical testicular growth secondary to stimulation by7 e$ k. Y1 |, M7 a' N: g) c
gonadotropins.1,3
/ ^: f- b9 ]7 M; n6 {Gonadotropin-independent peripheral preco-1 A0 o. Y$ w0 {+ |
cious puberty in boys also results from inappropriate7 A5 T1 Z: R1 C7 Y
androgenic stimulation from either endogenous or
! ]$ M9 [( |5 W& L# [! }2 a! s2 \exogenous sources, nonpituitary gonadotropin stim-
& F3 L4 l1 ?3 Uulation, and rare activating mutations.3 Virilizing
7 X( S- Y+ x8 x5 L) Pcongenital adrenal hyperplasia producing excessive! v* I3 @& T F5 o3 j8 A' r, A4 y
adrenal androgens is a common cause of precocious( x/ f2 I0 X' \" `: [4 g/ T% b
puberty in boys.3,46 b2 o, H' v) D5 a6 V* u
The most common form of congenital adrenal
/ y. n4 o0 g8 Bhyperplasia is the 21-hydroxylase enzyme deficiency.+ b d, ?/ m3 ?
The 11-β hydroxylase deficiency may also result in" }* l/ N* r; T& ~$ P
excessive adrenal androgen production, and rarely,
5 o! Q6 |; G! C/ X7 g7 G. \an adrenal tumor may also cause adrenal androgen
) S9 W$ _. t2 C2 w! y3 C, Pexcess.1,30 g& J6 v$ M5 R M$ L$ a9 y0 s" N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" q! V# }- h' `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- y* a. I7 J# ?; h( nA unique entity of male-limited gonadotropin-
; i/ M# I9 M5 R% D3 a: g" cindependent precocious puberty, which is also known
/ [6 L2 t u# R$ b4 Eas testotoxicosis, may cause precocious puberty at a
2 p! m- Z) n0 ]7 Fvery young age. The physical findings in these boys
. P; ]& B8 b0 _with this disorder are full pubertal development,
8 b% I+ n( s9 ?- J& M6 C* \0 {( B7 L$ }2 eincluding bilateral testicular growth, similar to boys& x% {% Y3 |9 i# h
with CPP. The gonadotropin levels in this disorder
" R7 ^' P8 g" U% Y# r* O/ |are suppressed to prepubertal levels and do not show
: H9 A) o* J( m% J1 ?9 f) Ipubertal response of gonadotropin after gonadotropin-
' i: K( x. A; ]% l% ureleasing hormone stimulation. This is a sex-linked
( x6 a0 |4 U4 [autosomal dominant disorder that affects only1 n4 ]4 k. I6 M; ^) x& O
males; therefore, other male members of the family
& b5 Z7 Q! F4 G% ^9 x* |may have similar precocious puberty.3/ _5 z) ?0 a% L8 G
In our patient, physical examination was incon-$ _4 e& f* ?$ o" r
sistent with true precocious puberty since his testi-
8 c7 P/ T/ q# [$ y: _# w! Qcles were prepubertal in size. However, testotoxicosis0 |! Z' Z+ X3 g2 A+ o+ j2 D
was in the differential diagnosis because his father
! Z* B* N" Y) A: o. j S+ ]started puberty somewhat early, and occasionally,
\% ^8 d1 G+ ptesticular enlargement is not that evident in the' B- M" |" V# f0 e' G( o
beginning of this process.1 In the absence of a neg-
2 v; O. W* H# Y2 iative initial history of androgen exposure, our$ c8 k6 V j% p2 n8 t
biggest concern was virilizing adrenal hyperplasia,& N, e8 X5 n" G+ F! D
either 21-hydroxylase deficiency or 11-β hydroxylase
1 j' y4 J2 r* u2 }deficiency. Those diagnoses were excluded by find-7 b) e2 h8 X( e) b
ing the normal level of adrenal steroids.2 |- L7 e& J5 l1 J6 ?
The diagnosis of exogenous androgens was strongly
% Q' Q+ o+ |9 a3 xsuspected in a follow-up visit after 4 months because4 Z! ? v* Y0 m8 H6 ?
the physical examination revealed the complete disap-
8 ~ D7 D/ G/ Y) s. i8 Jpearance of pubic hair, normal growth velocity, and% k; y+ _; J/ o2 w3 u1 Q, D; o9 g
decreased erections. The father admitted using a testos-# A7 P3 j- X' q/ p6 f$ p; Y
terone gel, which he concealed at first visit. He was
5 |# g- a# k. A9 ]6 n% zusing it rather frequently, twice a day. The Physicians’
$ S; ]8 g7 t) {2 P3 D# ODesk Reference, or package insert of this product, gel or( B$ Z! ?* d7 A+ N+ z) m
cream, cautions about dermal testosterone transfer to: o q$ U; X, K+ z) b$ `
unprotected females through direct skin exposure.
6 v J: L2 B7 Z7 W& y tSerum testosterone level was found to be 2 times the
9 R. J [+ K7 g# ~3 w# w5 E9 l& qbaseline value in those females who were exposed to2 B/ b5 H: h1 K, E% H: T- l8 B
even 15 minutes of direct skin contact with their male, q( M- ?" _( f7 s" d9 P$ w
partners.6 However, when a shirt covered the applica-( \5 _( v& }6 [9 F& l, O
tion site, this testosterone transfer was prevented.
2 c; I9 j5 _- T& P6 v* Q+ k8 {" q$ BOur patient’s testosterone level was 60 ng/mL,
7 l6 n8 Q8 e% l b8 {1 R8 Gwhich was clearly high. Some studies suggest that
# a; A' K7 v! A3 J" U. u, gdermal conversion of testosterone to dihydrotestos-0 E5 y, b- w ^" }
terone, which is a more potent metabolite, is more. e- K6 X( ~* n' q9 J4 J
active in young children exposed to testosterone; ~ p/ h! _/ V- t5 H
exogenously7; however, we did not measure a dihy-; T. [* F: x" y( e4 ~+ c
drotestosterone level in our patient. In addition to% j- U0 B/ T+ }
virilization, exposure to exogenous testosterone in: X3 e7 n( _* A7 W! C
children results in an increase in growth velocity and
p. Z3 Y& Z A* B8 oadvanced bone age, as seen in our patient.0 Q7 p; Y Y# { n) p0 q: w
The long-term effect of androgen exposure during; K9 U5 r+ T# [9 |
early childhood on pubertal development and final
) a" M N) C$ T' t( qadult height are not fully known and always remain
$ \+ I' d: W% X( o# P8 z0 ya concern. Children treated with short-term testos-
1 z3 ?: `5 F5 y% ^# sterone injection or topical androgen may exhibit some
, ?% t3 \$ c. Z7 ?, J0 y4 nacceleration of the skeletal maturation; however, after* v3 w# c, D1 I( o
cessation of treatment, the rate of bone maturation
9 d' P4 d" W# _7 ]" x* t8 wdecelerates and gradually returns to normal.8,9! f* a8 y3 |7 ]+ T
There are conflicting reports and controversy. R& O3 ~3 X; w4 y% p& L, l' {
over the effect of early androgen exposure on adult0 j2 F2 v, g' `* j
penile length.10,11 Some reports suggest subnormal
/ m7 p& N( k9 Uadult penile length, apparently because of downreg-
; _ `- b ]% v0 Z; \1 H' N0 Yulation of androgen receptor number.10,12 However,
9 O u/ [7 h7 {9 ESutherland et al13 did not find a correlation between
3 q" \" O5 E+ v' kchildhood testosterone exposure and reduced adult" Q& p' ^4 o( j! A; j
penile length in clinical studies.- t! n [5 C. M1 B
Nonetheless, we do not believe our patient is4 D' t$ U( m U* c* F# `
going to experience any of the untoward effects from, a& P7 N8 i1 o- o$ V
testosterone exposure as mentioned earlier because
0 O' Q& s/ M3 hthe exposure was not for a prolonged period of time.! p! t9 {+ A n8 z4 I" I6 x$ f
Although the bone age was advanced at the time of; j5 f' ?. i c; K& l
diagnosis, the child had a normal growth velocity at* y1 Q' W+ h; ^) L$ o; I
the follow-up visit. It is hoped that his final adult
: K" H. [% T7 [height will not be affected.
& b: D- j. `# U0 L tAlthough rarely reported, the widespread avail-* U: O; @9 _, U& N* P$ }/ ]1 w; G
ability of androgen products in our society may1 s0 B, p, z/ l
indeed cause more virilization in male or female
% F4 `' v M5 |9 ^children than one would realize. Exposure to andro-
2 v5 ~% p/ Y$ `. j7 g& _# ygen products must be considered and specific ques-. ]" G" ^ g$ F I
tioning about the use of a testosterone product or
! _9 Q9 K% q9 _5 r/ l! ?gel should be asked of the family members during1 z: ]9 C" m+ M. S8 E, ^) @. |+ u
the evaluation of any children who present with vir-
- J; }* s7 \4 l8 p2 f% dilization or peripheral precocious puberty. The diag-" q' z# n/ Y7 f3 W$ A
nosis can be established by just a few tests and by
) p- m9 y: K) |1 k; `appropriate history. The inability to obtain such a
2 G6 \: L) Z' |3 [; h# }history, or failure to ask the specific questions, may
0 N# F6 r1 ~! S& zresult in extensive, unnecessary, and expensive
! O2 P; h; @6 B8 }investigation. The primary care physician should be
E% V" o( r6 b @& laware of this fact, because most of these children3 d, i0 Y2 @9 n K5 m
may initially present in their practice. The Physicians’( c& }( F" }* T- @- b) i- _
Desk Reference and package insert should also put a
; j. P$ ^- a( J& N/ h4 ]# hwarning about the virilizing effect on a male or
* {9 f a+ s% h1 p6 l8 g Mfemale child who might come in contact with some-+ ]1 S. }7 w t! _, _
one using any of these products.
) e- j+ B; N4 p# w4 AReferences* V: q+ O5 J- Z) Z x: G& b7 w
1. Styne DM. The testes: disorder of sexual differentiation: _4 a( _8 @3 d; @5 N- `
and puberty in the male. In: Sperling MA, ed. Pediatric
- x( M+ U" v d* ^3 e" oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- o! E% H9 k) F$ S( L, F2002: 565-628.; v) Y; w) T! j+ Z( U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; T6 a1 Q! ~2 r* _" a* K; e
puberty in children with tumours of the suprasellar pineal |
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