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Sexual Precocity in a 16-Month-Old
' D* Q2 p# G6 r0 E0 X6 G1 sBoy Induced by Indirect Topical R- T3 `8 I; A3 f( d; E+ k
Exposure to Testosterone
! m4 l1 P) d4 ^5 ]3 ]& [Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ n: i+ m9 R# |* Uand Kenneth R. Rettig, MD1
& b) r7 i/ f e1 d) s5 dClinical Pediatrics
9 R+ k. ]7 C: G/ y, }Volume 46 Number 6
! F W! t4 Q) `! V! h7 sJuly 2007 540-543 C+ x% i# |2 ]7 U! h$ d
© 2007 Sage Publications
2 R! G: P+ d. e7 F0 W: O7 ~" G10.1177/0009922806296651* W: n% A( [8 O# M. F5 N
http://clp.sagepub.com( |5 e |/ S( i* W- H
hosted at: }* }4 X! m7 O6 u. L
http://online.sagepub.com
/ d8 c1 b& P) t0 _' X% Z: \Precocious puberty in boys, central or peripheral,
8 @& i( _% [. @' Y- Pis a significant concern for physicians. Central
% X1 N. x5 f/ zprecocious puberty (CPP), which is mediated$ |4 x: M$ x/ v6 B& d3 F
through the hypothalamic pituitary gonadal axis, has
( `' Z- S; o) f9 C" w! C+ |1 l% Na higher incidence of organic central nervous system4 v0 ~1 R7 g4 S0 n
lesions in boys.1,2 Virilization in boys, as manifested4 _2 U8 j" H$ b7 v! X! Z
by enlargement of the penis, development of pubic
& c, _& F" V2 Y) C* P6 V- qhair, and facial acne without enlargement of testi-/ |3 `( r6 H" o3 U# S7 H8 M
cles, suggests peripheral or pseudopuberty.1-3 We% K5 X- a' o7 z o& g
report a 16-month-old boy who presented with the8 y/ X6 h5 ? x) ~/ y7 i: V
enlargement of the phallus and pubic hair develop-
! B$ u( O. s. y h- O' i3 Jment without testicular enlargement, which was due4 \' N! ~# Y7 c7 n6 S+ e
to the unintentional exposure to androgen gel used by/ z! u) r u# R+ Q7 H: H% q9 G( w
the father. The family initially concealed this infor-1 p- O1 @& ~* N. b* p
mation, resulting in an extensive work-up for this' N4 N5 e0 {: U! f
child. Given the widespread and easy availability of
, C, J- i, b+ O" Ftestosterone gel and cream, we believe this is proba-
5 R- ?- r1 i5 U: |7 hbly more common than the rare case report in the
4 h! B7 M- I+ O* {2 fliterature.4
, i& B6 O' S& w& z! b2 b' d" d( TPatient Report
a# T' y/ i! h5 `& _A 16-month-old white child was referred to the, Q" t' H+ N6 N6 K, U L) h
endocrine clinic by his pediatrician with the concern
- r3 b6 ^) O0 o* c9 i7 ~" oof early sexual development. His mother noticed3 ]( K6 W. i+ p# }2 K* X! U
light colored pubic hair development when he was. h4 k# U0 V4 |( T K+ Y [
From the 1Division of Pediatric Endocrinology, 2University of4 \9 I4 v7 |! b
South Alabama Medical Center, Mobile, Alabama.# |0 n& r; S' n. p- R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 _" B0 l! K. T. W9 `7 i" TProfessor of Pediatrics, University of South Alabama, College of
+ F1 z: a X( o" _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 T( z% b! X# F, l! t, o; L
e-mail: [email protected].
; J \% V8 l* e0 ]3 a( j. Pabout 6 to 7 months old, which progressively became
3 x5 B. {2 \: j) M, Idarker. She was also concerned about the enlarge-
& `6 D8 F0 `( Qment of his penis and frequent erections. The child3 ~, A, M+ p5 q, f# B
was the product of a full-term normal delivery, with0 J' _1 N$ ?+ \* r
a birth weight of 7 lb 14 oz, and birth length of
$ |, T. I8 y+ c20 inches. He was breast-fed throughout the first year5 m# g3 _* s0 L- ]5 d4 ^" K
of life and was still receiving breast milk along with6 t5 ?# T, v' }' K
solid food. He had no hospitalizations or surgery,, A' Z& n, \/ ~2 |- c$ z6 Y
and his psychosocial and psychomotor development
% I. q) V" V6 z1 T, C/ W {was age appropriate.$ q# c2 c! |2 D6 V8 k- y% W
The family history was remarkable for the father,
& b6 s. N7 M3 T8 Y8 }who was diagnosed with hypothyroidism at age 16,% }/ u2 t& y) O) O+ s) b
which was treated with thyroxine. The father’s
# O T- ], x1 v# \) Eheight was 6 feet, and he went through a somewhat H. ]; W: g7 u1 \
early puberty and had stopped growing by age 14.0 {7 N5 N+ c2 S) j: F# u
The father denied taking any other medication. The* D) @2 @; s( C
child’s mother was in good health. Her menarche
2 v" V4 Q9 ?! {7 o7 q- owas at 11 years of age, and her height was at 5 feet& g. [7 M6 v" Z& Z7 G+ U5 @
5 inches. There was no other family history of pre-; ^6 A3 [: m2 J2 ~( ]% G- I5 B
cocious sexual development in the first-degree rela-7 d$ \- q3 B$ w, r" h# l3 [
tives. There were no siblings.) f! |1 ?$ k1 \1 b7 m0 U
Physical Examination' _* B2 ]% s- l' A; U4 `$ B, L" v
The physical examination revealed a very active,2 [* t2 h* c' ]$ C& w6 X9 U2 i& t3 T" X
playful, and healthy boy. The vital signs documented
7 Q- `; P/ r1 k4 I0 fa blood pressure of 85/50 mm Hg, his length was4 |8 s; K% Y9 y! Y, w* g
90 cm (>97th percentile), and his weight was 14.4 kg U, V: W- U9 p) i8 q
(also >97th percentile). The observed yearly growth
% O# a. A3 ~7 _ Svelocity was 30 cm (12 inches). The examination of
' g% K; l3 j2 Z \+ G. v, s; Pthe neck revealed no thyroid enlargement.
0 P- G: d7 }- I) ?9 t V9 pThe genitourinary examination was remarkable for4 L/ u T3 K4 @; `+ }
enlargement of the penis, with a stretched length of2 ~; A" U1 |' `4 P! V. }4 r
8 cm and a width of 2 cm. The glans penis was very well
/ J4 P3 z2 F6 u1 T. Sdeveloped. The pubic hair was Tanner II, mostly around/ g: }- f% N1 s F* L# W( ~# b1 n% Y
540
; U& z7 x9 A: z8 H$ L7 u: w) nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 q. r, S# V8 o, @3 A2 m3 Fthe base of the phallus and was dark and curled. The9 u+ P: t4 `0 n
testicular volume was prepubertal at 2 mL each.: Z1 w- J$ \; J* M
The skin was moist and smooth and somewhat+ ?0 }. f# \6 J0 |% k& ~' a
oily. No axillary hair was noted. There were no
L! K; h0 v% @/ iabnormal skin pigmentations or café-au-lait spots.8 S5 {4 X1 m: y+ U8 t# |
Neurologic evaluation showed deep tendon reflex 2+. X8 t `7 H$ |! N( D
bilateral and symmetrical. There was no suggestion
* Y+ D9 D) f8 I$ C+ f+ wof papilledema.
d/ k& _5 {# k! H/ KLaboratory Evaluation) A9 ^, v' H2 a) M. d% {
The bone age was consistent with 28 months by8 y6 z l. ^' v, I5 @6 C5 k6 ~
using the standard of Greulich and Pyle at a chrono-
. Y; r6 V4 K) p+ c9 B% \logic age of 16 months (advanced).5 Chromosomal+ p% P0 y p1 Q+ C0 E
karyotype was 46XY. The thyroid function test
v( i7 z8 m( F* E6 n& Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- f% Z' q3 f; {) {+ }
lating hormone level was 1.3 µIU/mL (both normal).
3 {- b: R! }8 F EThe concentrations of serum electrolytes, blood4 P1 _, f5 _3 z4 F. g
urea nitrogen, creatinine, and calcium all were/ }9 G6 p% G# D- e
within normal range for his age. The concentration. M/ D6 \/ h2 m, C: l
of serum 17-hydroxyprogesterone was 16 ng/dL5 [5 o0 R! i; p, }" k1 _1 I
(normal, 3 to 90 ng/dL), androstenedione was 20
y( J* y% t2 ~5 ]ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. U$ n* D5 v/ O2 I. z# t0 F {* Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- M1 j: {5 T3 V3 Q5 idesoxycorticosterone was 4.3 ng/dL (normal, 7 to) a7 _- t& ]7 U! T
49ng/dL), 11-desoxycortisol (specific compound S)
0 \! a) c9 A' Q' C" Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- g9 g# D% v$ [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& J( K1 [0 f) a$ \7 L$ z( g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," Z3 Q! P8 @. C h
and β-human chorionic gonadotropin was less than
3 V. h/ v/ q" |- @& W2 a! I1 @5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 B4 R4 [* e( Estimulating hormone and leuteinizing hormone8 {6 b$ V" Y! r$ P5 d5 y
concentrations were less than 0.05 mIU/mL6 W" ?0 m9 i) Q
(prepubertal).
* l' s5 i) q1 t( A7 S3 q' cThe parents were notified about the laboratory/ i1 k& z ^6 b; C1 Z8 b
results and were informed that all of the tests were0 t' C, L0 t/ y [6 l- k
normal except the testosterone level was high. The9 Q1 O( w1 {2 E) E, t
follow-up visit was arranged within a few weeks to
9 m) z* V) E6 C0 sobtain testicular and abdominal sonograms; how-/ l5 ^2 g0 F M/ ]* B0 h- K
ever, the family did not return for 4 months.
' W( }; j h7 L& |Physical examination at this time revealed that the4 s8 q' {% ^8 _8 n, Y
child had grown 2.5 cm in 4 months and had gained
5 Y/ t8 Z" _9 s' L8 I4 Q! z2 kg of weight. Physical examination remained
4 w1 O, `% z8 D1 V2 Runchanged. Surprisingly, the pubic hair almost com-
1 j$ W. \) z3 M' Z3 d# a! Hpletely disappeared except for a few vellous hairs at
' {. m( F( ^; R! X6 F m! lthe base of the phallus. Testicular volume was still 26 I/ X3 {& d5 S) g0 T& f! T
mL, and the size of the penis remained unchanged.* `" h5 G: V3 w% b
The mother also said that the boy was no longer hav-- R F5 E- a4 a
ing frequent erections.
' a u! z, V& N6 t% d; ]4 q% {% \1 mBoth parents were again questioned about use of4 j9 H! R; m8 f! L* [; M$ }. D" J; h
any ointment/creams that they may have applied to
# z7 i4 W9 W( J9 l- [1 I$ S! i; vthe child’s skin. This time the father admitted the: r. B) \* b0 O/ c6 R: Z' ~0 b* C3 z: k
Topical Testosterone Exposure / Bhowmick et al 541. s! Q" @/ ~2 Y6 F# j& y2 Q7 ^
use of testosterone gel twice daily that he was apply-8 v9 @$ S" l) f h; T
ing over his own shoulders, chest, and back area for
5 T. w' K- b* Ha year. The father also revealed he was embarrassed
) \/ c; U f7 ?* Qto disclose that he was using a testosterone gel pre-
7 p) m' F4 G! f& m$ j% |+ Wscribed by his family physician for decreased libido9 R, C4 {; |/ r
secondary to depression.
3 G' {# O) O) }, R. E9 |The child slept in the same bed with parents.9 K: j$ ^; C8 z
The father would hug the baby and hold him on his
$ q6 q5 R4 v1 Z5 r' K# n, n* R6 Ichest for a considerable period of time, causing sig-
6 G4 x- e6 Z5 }nificant bare skin contact between baby and father.
7 p9 H. E8 O' [. pThe father also admitted that after the phone call,. b$ u. E* [4 b" k3 K% Y% M9 ~
when he learned the testosterone level in the baby; m0 p h" w3 e0 s7 M8 z; m u0 R) Y
was high, he then read the product information
3 I# J) X! v; y) P1 a9 H) Xpacket and concluded that it was most likely the rea-
$ h8 R2 o" U6 A1 H) Ison for the child’s virilization. At that time, they5 i$ w6 o4 m8 j
decided to put the baby in a separate bed, and the
" Z! K* ~5 _- R) f# bfather was not hugging him with bare skin and had
" g5 k, F; ?1 p3 Wbeen using protective clothing. A repeat testosterone0 i q7 y: m& F4 z% g
test was ordered, but the family did not go to the) v, a5 L8 B. s/ a. n. t' Y0 K
laboratory to obtain the test.+ x8 L* ^! D3 w1 B+ N6 T a
Discussion4 J; d' o0 A5 c9 I4 `
Precocious puberty in boys is defined as secondary, A2 {6 M8 Q2 {& N" L' l) K
sexual development before 9 years of age.1,4$ }. d' b( T4 N
Precocious puberty is termed as central (true) when X ~: b8 y0 \' P4 l1 h s! a( w
it is caused by the premature activation of hypo-
5 _9 S: l# f& _9 Ythalamic pituitary gonadal axis. CPP is more com-
- q4 ^% ^! n1 h7 l, f" L4 Z! Q* emon in girls than in boys.1,3 Most boys with CPP
1 S1 ]5 O; D5 T" b8 n2 Amay have a central nervous system lesion that is" x A: K9 p6 d6 S- N Q( K; A
responsible for the early activation of the hypothal-
9 Q4 N ~& }/ j: \7 ?amic pituitary gonadal axis.1-3 Thus, greater empha-
) ]' a8 w. N4 vsis has been given to neuroradiologic imaging in
?& H& n0 N5 {) s$ e: fboys with precocious puberty. In addition to viril-4 Q" p3 Q( z, w9 J1 E! k5 K
ization, the clinical hallmark of CPP is the symmet-+ o2 E4 D% Y* l1 O w
rical testicular growth secondary to stimulation by
7 s- ~ J* _* U, }gonadotropins.1,34 B) M' c9 o& P. R) X% x$ L
Gonadotropin-independent peripheral preco-1 n. F9 `8 X/ s/ R' e) T2 }
cious puberty in boys also results from inappropriate
$ z: ?# o) Y- K! Z. mandrogenic stimulation from either endogenous or
+ |( s$ s. v: G: pexogenous sources, nonpituitary gonadotropin stim-8 X4 C9 h8 k7 u
ulation, and rare activating mutations.3 Virilizing$ H3 v/ E9 t5 n3 z
congenital adrenal hyperplasia producing excessive; x/ G$ M" D0 Q, u0 V' b% \
adrenal androgens is a common cause of precocious
$ k3 ?8 M- D. C0 u/ J; s" opuberty in boys.3,46 v/ X. g$ R! Y; a" K' |$ N! k
The most common form of congenital adrenal
) ]; J" w4 w8 i5 Shyperplasia is the 21-hydroxylase enzyme deficiency.
( w3 v0 m. j/ w YThe 11-β hydroxylase deficiency may also result in
; ^8 P* U; f. N5 \) s) nexcessive adrenal androgen production, and rarely,
4 l" B T( m, j" m7 B% _# }+ Oan adrenal tumor may also cause adrenal androgen5 ~( l2 v4 _3 Q0 e s) S
excess.1,38 X. C: z, U1 N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ M- N, _. i* h542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) J0 l( M" i$ `6 g% l9 q/ v) w
A unique entity of male-limited gonadotropin-3 C# N! ?: @) P& `3 [
independent precocious puberty, which is also known
, W! O( `, v1 M0 z5 ias testotoxicosis, may cause precocious puberty at a
9 X+ r" a0 v: [/ E( tvery young age. The physical findings in these boys, v" M% b4 X! Y8 f7 I2 z
with this disorder are full pubertal development,
# y3 @) ^; J* t1 }including bilateral testicular growth, similar to boys
# t1 i/ G% ]5 D/ B" ^with CPP. The gonadotropin levels in this disorder
6 ^9 u: h: s& m8 G" v, nare suppressed to prepubertal levels and do not show
3 ?2 r# v7 a4 Kpubertal response of gonadotropin after gonadotropin-
& z" q O- m Y7 treleasing hormone stimulation. This is a sex-linked& q0 j0 u2 X* _. y6 `, X
autosomal dominant disorder that affects only3 K# a& Z* F. ]. L$ M/ ]5 R* `3 c
males; therefore, other male members of the family
* I; g8 k, _) Jmay have similar precocious puberty.3
7 I9 c' R$ e* B- b! q! S# ]# ZIn our patient, physical examination was incon-
( A$ S* b1 j& `* tsistent with true precocious puberty since his testi-. Z7 l( w: j/ @5 n# Y0 q( e0 a [
cles were prepubertal in size. However, testotoxicosis. E, |* C5 t2 ]
was in the differential diagnosis because his father
( J3 t7 |- O; h3 Xstarted puberty somewhat early, and occasionally," V# W) b( x1 B e5 k% I9 R
testicular enlargement is not that evident in the6 ^6 u5 L0 t' V
beginning of this process.1 In the absence of a neg-
, a6 }- `# F* _9 `6 R( Xative initial history of androgen exposure, our
( E+ Q* Q9 H- ^# q- f, Rbiggest concern was virilizing adrenal hyperplasia,; M7 s, M5 M7 Q* I' N8 }- {" |7 L
either 21-hydroxylase deficiency or 11-β hydroxylase
' D! Q, a1 V9 I7 h: T. Tdeficiency. Those diagnoses were excluded by find-
! K7 |, J) S5 e& e# C' V3 p. Hing the normal level of adrenal steroids.
$ f [5 E4 E" Z4 _8 w3 YThe diagnosis of exogenous androgens was strongly, F0 |7 y) X$ y$ o" X1 B3 {2 S
suspected in a follow-up visit after 4 months because
' I/ V# [: a3 d1 R/ M" ]the physical examination revealed the complete disap-! u9 m, k' a) A6 n3 t, ?
pearance of pubic hair, normal growth velocity, and
# V% z- ^. G/ h( _decreased erections. The father admitted using a testos-- I e. \! O% ?+ S
terone gel, which he concealed at first visit. He was
# K7 b# C5 i1 m0 r. k0 {using it rather frequently, twice a day. The Physicians’
/ C9 ^" d+ L/ p# L; q2 i- wDesk Reference, or package insert of this product, gel or
# J8 G S+ T m; r s% U1 `+ B. `cream, cautions about dermal testosterone transfer to; F5 I! E! s9 Q& Y
unprotected females through direct skin exposure.
, z% l& V% d/ f: L' m5 T1 ISerum testosterone level was found to be 2 times the; t5 \* m& x; w ?
baseline value in those females who were exposed to
0 m3 ~, k; O) M N2 J4 K( D9 qeven 15 minutes of direct skin contact with their male/ j- h N1 D% p7 v
partners.6 However, when a shirt covered the applica-
' s+ q( T4 Y; b& y7 ^: t6 f9 qtion site, this testosterone transfer was prevented.
( h) L) y) K+ F/ W4 {2 e0 Z$ ?Our patient’s testosterone level was 60 ng/mL, Z8 x K* u- ` y
which was clearly high. Some studies suggest that2 B/ n5 E' a1 d+ L6 P
dermal conversion of testosterone to dihydrotestos-! l9 _1 G/ K, L& C
terone, which is a more potent metabolite, is more# m7 U! B/ v! Y* D6 z2 I2 n
active in young children exposed to testosterone: P1 s0 y7 S; r3 J$ u% m
exogenously7; however, we did not measure a dihy-) p( [* Q9 e$ `1 o, k4 j" c
drotestosterone level in our patient. In addition to v7 E) X0 v) K }" W- X
virilization, exposure to exogenous testosterone in. q) z0 N1 ~3 e7 j2 P
children results in an increase in growth velocity and) ]# a9 S9 u: ]$ [9 z6 G
advanced bone age, as seen in our patient.
: P3 u9 `) I1 l- U) h6 fThe long-term effect of androgen exposure during
( \+ w, D5 w( R) wearly childhood on pubertal development and final
9 N$ U2 A* Z; Z: t( }9 ladult height are not fully known and always remain
! [8 I8 B2 G8 U6 o; ?, ?/ m8 k3 \a concern. Children treated with short-term testos-) }6 F$ X. P$ t# N7 N9 ~6 B. w
terone injection or topical androgen may exhibit some, X3 b9 h- {* t
acceleration of the skeletal maturation; however, after% y/ I: @) y, K Q2 b
cessation of treatment, the rate of bone maturation
0 m3 ~. {" |# g1 U' T7 ^+ k; A$ sdecelerates and gradually returns to normal.8,9
! L) b7 G8 p1 k' z- v6 r" Q3 qThere are conflicting reports and controversy
5 W; I2 D' Z# xover the effect of early androgen exposure on adult
' [' V% C$ \5 K3 I7 B# `penile length.10,11 Some reports suggest subnormal* a3 n' j/ o, k5 `+ X& U! n8 f
adult penile length, apparently because of downreg-$ x: ]3 Q$ }& J; A
ulation of androgen receptor number.10,12 However,& O6 B# h& {- z, ~7 P( j8 j3 b
Sutherland et al13 did not find a correlation between3 f0 f7 Z, m; B' s7 K! N
childhood testosterone exposure and reduced adult4 y. `( V- l4 g/ m9 ~
penile length in clinical studies.3 H( ~' |9 L, A2 p1 P
Nonetheless, we do not believe our patient is8 t1 t$ r, W" z
going to experience any of the untoward effects from. a/ M8 u* B6 e% K6 X
testosterone exposure as mentioned earlier because
% a9 X2 D8 e9 w k I) dthe exposure was not for a prolonged period of time.4 x$ `$ z1 d% K+ M
Although the bone age was advanced at the time of
" P2 G& |: y7 R, y5 c- Gdiagnosis, the child had a normal growth velocity at
7 l$ p' Z: r! W) U# S! A( _the follow-up visit. It is hoped that his final adult
x) J; ^6 L( X, A+ ^$ v0 z0 sheight will not be affected.& R# k0 }5 j6 U9 h# M) o
Although rarely reported, the widespread avail-% |% F+ I% F7 D. ^% S
ability of androgen products in our society may. Z; s9 n0 F2 f" L! }0 i
indeed cause more virilization in male or female+ N; w. P& J4 @! Q! b$ J0 h( V) w
children than one would realize. Exposure to andro-
$ L/ |5 I$ l# {! x+ o! mgen products must be considered and specific ques-' @3 b- F2 q$ d$ Y
tioning about the use of a testosterone product or1 y0 T$ F5 K" |( a# j
gel should be asked of the family members during
) ~0 X! C0 C6 J0 |the evaluation of any children who present with vir-
& D9 k+ ]& z8 q1 iilization or peripheral precocious puberty. The diag-. Q8 g; P; A0 d$ K' ^) E0 h
nosis can be established by just a few tests and by
1 L7 n- D' X9 }8 `" Xappropriate history. The inability to obtain such a: b9 Y* q# y# Q1 u2 D) t# Z6 {9 q e
history, or failure to ask the specific questions, may
3 c+ G# N/ X5 i* t& a1 {4 }5 j2 z/ U* T5 Oresult in extensive, unnecessary, and expensive
& \4 q: A' k1 q k% e5 O4 m0 Winvestigation. The primary care physician should be
6 l! t3 {" H6 Q9 f. caware of this fact, because most of these children
+ i# w! i0 T2 J4 K2 imay initially present in their practice. The Physicians’9 K1 h' W* L) w( D- g; x$ o
Desk Reference and package insert should also put a
! p+ s1 H' w$ l. ~" rwarning about the virilizing effect on a male or0 Z2 ]1 i! f9 C* k0 v
female child who might come in contact with some-+ ?8 S; E- ~( B( w$ A! p
one using any of these products./ n. z Y9 d; t: }
References# d8 e8 B; a, h: d4 A
1. Styne DM. The testes: disorder of sexual differentiation }4 a' y+ L. X% ^
and puberty in the male. In: Sperling MA, ed. Pediatric5 _4 k$ D' j4 H5 F. k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( i9 N. M5 }2 R* {0 L$ i# d) m2002: 565-628.
7 f- E4 O* q1 g. q0 W4 [2 A! Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 O8 b/ [1 H3 |6 k
puberty in children with tumours of the suprasellar pineal |
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