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Sexual Precocity in a 16-Month-Old4 y; ]0 R2 }4 P! ~6 O; j
Boy Induced by Indirect Topical& E2 {4 q' I1 y' i# m+ c
Exposure to Testosterone
5 U* h# T' o, mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. |, |! _' u1 U9 e$ k; |+ U" tand Kenneth R. Rettig, MD1
d% B* }4 o0 o7 @0 P. E& x* B1 NClinical Pediatrics1 w+ X6 |( `7 G5 D
Volume 46 Number 6
$ w) x; W: c7 U$ D- c9 bJuly 2007 540-543$ e% h5 W: b3 v- V7 c" U* ~7 j$ D
© 2007 Sage Publications* Y4 U9 L9 E) G, R
10.1177/00099228062966517 `, q7 v0 p& K4 h$ Q, O% W
http://clp.sagepub.com# U2 h6 X3 c- J! H$ ]
hosted at
: u/ q/ o3 m8 O/ Y# v! j [6 zhttp://online.sagepub.com( a3 U& t; \: t1 ~! p. [0 f
Precocious puberty in boys, central or peripheral,
' r/ U. f; Q6 ~; ~; b6 a7 |0 f) dis a significant concern for physicians. Central
; h5 @5 h5 z. Zprecocious puberty (CPP), which is mediated- n. k! a: c s% |( U% u: [
through the hypothalamic pituitary gonadal axis, has
( P8 g+ C2 `+ ^1 K8 u6 d: ]a higher incidence of organic central nervous system3 h& z" i! w& z3 L3 Y. B0 S
lesions in boys.1,2 Virilization in boys, as manifested
: N; X. B6 B" | C2 G" P. Rby enlargement of the penis, development of pubic2 E0 _& c* N3 F/ V w7 d
hair, and facial acne without enlargement of testi-0 T' _' f/ q9 j. S
cles, suggests peripheral or pseudopuberty.1-3 We! t. X8 s. V: ~; v' ]: R
report a 16-month-old boy who presented with the
1 s, x7 b" h3 x+ ~/ Z0 f3 Yenlargement of the phallus and pubic hair develop-
; W% ?6 g6 ?& R0 P E' R& C; ^' Oment without testicular enlargement, which was due
" d$ n- U+ L4 h, U' z! E$ p3 Ato the unintentional exposure to androgen gel used by V% B5 x( P2 b. T0 f
the father. The family initially concealed this infor-
/ |0 A1 Q$ ` M2 h7 umation, resulting in an extensive work-up for this0 z" L9 Y" W- X/ g# C* g$ z9 _% w. n
child. Given the widespread and easy availability of8 u1 y' V" B- ^ {, H
testosterone gel and cream, we believe this is proba-. D; W, Z; `5 J0 w
bly more common than the rare case report in the% a, n8 v* s, \2 V1 D) e
literature.45 C9 |# ~/ y3 n9 U# N( {
Patient Report; E9 H' F' X7 w
A 16-month-old white child was referred to the1 ^0 |) H3 ~! _0 l8 a1 D+ Q. p
endocrine clinic by his pediatrician with the concern) a7 l- h! X* ^6 `
of early sexual development. His mother noticed
H2 Q/ F- H( W3 ?5 elight colored pubic hair development when he was
5 Q7 K/ n. u( _: C$ n/ hFrom the 1Division of Pediatric Endocrinology, 2University of, G3 `6 o/ ?7 L. f; J
South Alabama Medical Center, Mobile, Alabama.
+ r+ h; n. c2 L5 y% b+ ?- ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 g2 |( a8 |1 v2 v9 z d" X
Professor of Pediatrics, University of South Alabama, College of
0 s, V- z2 v+ i$ K! X' ?" KMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& ?1 x5 o& J4 G0 S
e-mail: [email protected].
4 h$ ~% p3 Z% ? S3 K9 Vabout 6 to 7 months old, which progressively became
( `: q! _9 v; r4 @, b! ^" z9 c. Rdarker. She was also concerned about the enlarge-2 L/ s9 ?$ W0 k; K- N a, n
ment of his penis and frequent erections. The child
) P# d; n' B2 d3 M1 g. T* R; ^was the product of a full-term normal delivery, with/ ^, v7 {! h# a# i; P
a birth weight of 7 lb 14 oz, and birth length of
1 [6 A1 I( n% S: n; u20 inches. He was breast-fed throughout the first year
5 ]2 H% d* z, A: A5 Mof life and was still receiving breast milk along with2 r O2 f1 U7 O8 ~, U
solid food. He had no hospitalizations or surgery,/ |3 P% C; h7 W, Y
and his psychosocial and psychomotor development
# K) r1 H, o3 k* B$ m. bwas age appropriate.
: }8 ~* V" O c' h* h" _: X8 XThe family history was remarkable for the father,% R) h& B. _( l( N" [) H0 F' l5 q
who was diagnosed with hypothyroidism at age 16,
# l8 m8 ^7 }' O$ twhich was treated with thyroxine. The father’s
7 u% Z; Y9 y4 aheight was 6 feet, and he went through a somewhat9 Q# C9 N5 t9 d" r
early puberty and had stopped growing by age 14./ B( ]5 R+ F: R8 t _$ p3 A
The father denied taking any other medication. The- Q: v0 M; ~7 K( c1 B" N: {* B. a
child’s mother was in good health. Her menarche
/ I8 u$ k7 B% e4 i1 awas at 11 years of age, and her height was at 5 feet
) C7 z4 S/ B" |; F$ e7 ]5 inches. There was no other family history of pre-
; z$ ]0 ~. w* Q( N& Rcocious sexual development in the first-degree rela-
5 I& @% x/ V0 G0 rtives. There were no siblings.
* g! V i/ F' I; B9 o8 ]: HPhysical Examination
4 @- U) C5 i2 EThe physical examination revealed a very active,# v/ W6 ]/ \ _. G$ N- ]5 q1 }3 g
playful, and healthy boy. The vital signs documented
! _/ I- }* s& K" g. V. W5 X& sa blood pressure of 85/50 mm Hg, his length was- A1 }2 n% n! c4 p
90 cm (>97th percentile), and his weight was 14.4 kg1 X/ X* ~0 {( l$ y- I
(also >97th percentile). The observed yearly growth0 K9 e Q# s- e8 a# Z
velocity was 30 cm (12 inches). The examination of
1 M6 F) n. J$ y) K5 E( e. ~the neck revealed no thyroid enlargement.
. T. E, J6 Q/ w0 Y1 e I8 o* k0 H& m9 SThe genitourinary examination was remarkable for: g9 x7 @8 j0 a2 b* n
enlargement of the penis, with a stretched length of
2 K6 E$ L+ V1 ] o2 q; s& _7 h; k8 cm and a width of 2 cm. The glans penis was very well
r% H% s5 t' _$ Mdeveloped. The pubic hair was Tanner II, mostly around
) y3 P6 ~. j: Y540( _5 j m% y/ R0 A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; }: R8 u$ d( Sthe base of the phallus and was dark and curled. The$ @6 ~5 }4 e. f. `9 F1 A
testicular volume was prepubertal at 2 mL each.
% i# Z# u- i: k! g" v0 Z* IThe skin was moist and smooth and somewhat
' R. l. i; l* I, coily. No axillary hair was noted. There were no
: S2 O! E6 f/ Aabnormal skin pigmentations or café-au-lait spots., X' u/ S" k _( G
Neurologic evaluation showed deep tendon reflex 2+* ]' u& v) H, f9 C
bilateral and symmetrical. There was no suggestion, o4 Y. n! L# u1 ]1 v9 \4 p: @
of papilledema." n1 \! n- B3 W4 e" W' V
Laboratory Evaluation. x, `5 R) X' Z
The bone age was consistent with 28 months by
: c* Y4 g7 \( M: U/ q' Busing the standard of Greulich and Pyle at a chrono-
5 S) k2 b8 ]# l# V blogic age of 16 months (advanced).5 Chromosomal
* r! q5 E; ]4 r a, Okaryotype was 46XY. The thyroid function test% Y; V$ F- F: |$ ~# `, {$ \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: t) G7 M2 O; l0 l* e4 e
lating hormone level was 1.3 µIU/mL (both normal).7 R5 _( A J5 w
The concentrations of serum electrolytes, blood4 e @8 V! c; z# X
urea nitrogen, creatinine, and calcium all were' P6 n J1 [7 Q; G# _" f
within normal range for his age. The concentration/ p$ X( {: ^" _: @) Z8 ~* U
of serum 17-hydroxyprogesterone was 16 ng/dL: {- T5 l2 O- I
(normal, 3 to 90 ng/dL), androstenedione was 20
* X1 b0 n" d( S9 c3 K: yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) r: l6 X8 p3 V, ^/ Z. oterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 U1 ]: L. M9 W2 n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 d" j1 }6 W- F8 t# W8 l6 d9 L' P
49ng/dL), 11-desoxycortisol (specific compound S): `% h2 V2 o# C; e! ]% f
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' U t$ m4 u3 N# w) z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 Q% M! @# v4 {( A( B3 u7 |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 i' l, Q$ ]: R5 Uand β-human chorionic gonadotropin was less than
( b" ^/ |4 U5 l' i: k3 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular. k* N8 C* \% d8 @
stimulating hormone and leuteinizing hormone
; M- t- i8 q: Kconcentrations were less than 0.05 mIU/mL
`, i: c. v1 q* j1 y, u(prepubertal).
6 Q# a, F* f5 VThe parents were notified about the laboratory* M) @6 v% {0 Q2 v
results and were informed that all of the tests were
3 H& {* J( K0 } H$ q5 S8 Q5 b5 x3 onormal except the testosterone level was high. The% i( `) I* R& e8 n! L4 p2 ?
follow-up visit was arranged within a few weeks to
9 {) H. b4 D$ t- Aobtain testicular and abdominal sonograms; how-
0 h _# \7 r9 ^) \ever, the family did not return for 4 months.- ^, K. m8 A: S
Physical examination at this time revealed that the$ P0 h+ y4 p4 ^# D! ^$ r
child had grown 2.5 cm in 4 months and had gained* M0 ?# O0 U6 X6 m+ I9 l2 ]! Z1 \
2 kg of weight. Physical examination remained
2 _2 H) z$ i) A- @( junchanged. Surprisingly, the pubic hair almost com-
. g. o% {) d! |9 I7 Qpletely disappeared except for a few vellous hairs at
: p# F; V% \- M9 bthe base of the phallus. Testicular volume was still 2
3 `! o! n+ A/ y, j3 emL, and the size of the penis remained unchanged.- t; l9 Y5 ~& c. ~) s9 J. b
The mother also said that the boy was no longer hav-4 h# o ~( }5 H
ing frequent erections./ g. x( ^# D( M/ [( x# f
Both parents were again questioned about use of" k3 B5 o0 X* {, e+ l9 T
any ointment/creams that they may have applied to# D2 M* d: t6 y! t% @) C
the child’s skin. This time the father admitted the
4 i9 r/ J4 q7 \7 tTopical Testosterone Exposure / Bhowmick et al 5410 C/ O8 I# A6 M, c
use of testosterone gel twice daily that he was apply-; Y) s$ P: g9 I0 @6 z- o @
ing over his own shoulders, chest, and back area for+ S% Y. {; z) z% @
a year. The father also revealed he was embarrassed
6 h( ?- z, I5 P1 h/ n8 eto disclose that he was using a testosterone gel pre-6 T3 l. X0 ^, H& Y! |2 n
scribed by his family physician for decreased libido
* ?& z/ S1 K" R0 ^5 }secondary to depression.1 H9 i; Q5 U% K, Y% k, ]
The child slept in the same bed with parents.# U+ {$ M1 F. k" @
The father would hug the baby and hold him on his# t! b- m" i5 _
chest for a considerable period of time, causing sig-
" q$ x4 N# b+ ~/ hnificant bare skin contact between baby and father.7 x/ j3 w6 }8 [3 x+ A
The father also admitted that after the phone call,
1 y9 ?. h, M, @when he learned the testosterone level in the baby! H6 _4 Q: b3 v3 a2 T
was high, he then read the product information
, ^6 Q, R% q/ z- Spacket and concluded that it was most likely the rea-; w9 r4 R( V: y
son for the child’s virilization. At that time, they
/ Y, J v) D8 M+ U# [/ _3 Fdecided to put the baby in a separate bed, and the
5 H1 f# p, u2 X, p% d4 Pfather was not hugging him with bare skin and had
+ q% ?1 z& [ K" z8 U8 dbeen using protective clothing. A repeat testosterone t1 i0 q9 n z3 x0 h+ W# R( U% n6 Y3 v
test was ordered, but the family did not go to the. S7 M& d! m/ k
laboratory to obtain the test.& Z6 k1 ?: R& Z8 ]
Discussion
7 \- P0 M! V/ |) [ M$ w; v U& tPrecocious puberty in boys is defined as secondary
5 x% q" P% j5 _/ O: a0 g7 `sexual development before 9 years of age.1,4! k& }* L" u( t$ t3 u0 [5 v2 O
Precocious puberty is termed as central (true) when& T- \8 F6 w, Z1 B7 P% ~
it is caused by the premature activation of hypo-* I6 x5 H. @* ]' n( G
thalamic pituitary gonadal axis. CPP is more com-
9 ~9 l" V# ~) o+ Fmon in girls than in boys.1,3 Most boys with CPP
) L$ {' ^( ^9 j& Mmay have a central nervous system lesion that is7 ^) W' p- P: @
responsible for the early activation of the hypothal-
# O$ d' T& J# k& ?) @8 b7 hamic pituitary gonadal axis.1-3 Thus, greater empha-
3 e, a5 K$ o b' }0 ] M! qsis has been given to neuroradiologic imaging in
: u( w0 \' a; l% c- k) Z. U- Iboys with precocious puberty. In addition to viril-
5 F6 g5 J% c) A% U6 C% \ization, the clinical hallmark of CPP is the symmet-. Z; F: r0 k+ Q+ Z% M3 A
rical testicular growth secondary to stimulation by
2 A6 Q' ]5 E+ j! W- @gonadotropins.1,3
1 ?$ @5 r! X% m" X# Y* JGonadotropin-independent peripheral preco-
h; R1 o8 x7 @ r* |' Pcious puberty in boys also results from inappropriate
# K3 P: R5 y+ [androgenic stimulation from either endogenous or
; ~$ X# P5 m4 A7 L, B/ p; jexogenous sources, nonpituitary gonadotropin stim-
. w. h0 T& z0 _ulation, and rare activating mutations.3 Virilizing1 [. M& ]* n) D
congenital adrenal hyperplasia producing excessive9 q) t7 S. K! J+ L6 j
adrenal androgens is a common cause of precocious
6 n. O1 i9 L( b: R8 q8 [1 Upuberty in boys.3,4
3 ?% v; t) c6 F {8 nThe most common form of congenital adrenal/ V3 S, f! k! T q
hyperplasia is the 21-hydroxylase enzyme deficiency.
1 W4 c8 e; P/ @2 ~1 C+ ]' NThe 11-β hydroxylase deficiency may also result in
4 H E5 f( {: X, l6 Z; u- kexcessive adrenal androgen production, and rarely,
- n! \3 C" w1 M( D" w0 E5 Can adrenal tumor may also cause adrenal androgen
- U2 p/ _3 D7 texcess.1,3
$ r9 I/ Q# ~( w o. Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* N, E( U6 x- @& S+ U; {; z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" \) P$ l! v( f4 x j1 M3 AA unique entity of male-limited gonadotropin-6 E6 {! k9 L% l
independent precocious puberty, which is also known
/ M! M" z; a% Eas testotoxicosis, may cause precocious puberty at a
% i! o$ l% _8 l2 }/ J: C( ?$ \very young age. The physical findings in these boys
; }, V7 D5 I3 ~1 Kwith this disorder are full pubertal development,
5 S* [1 I# r: {5 {including bilateral testicular growth, similar to boys
- z- d% a" A p5 jwith CPP. The gonadotropin levels in this disorder$ W9 {3 z! G, V4 _- b' R( e
are suppressed to prepubertal levels and do not show5 l% l, j/ t1 Y
pubertal response of gonadotropin after gonadotropin-
3 W) ^ V8 I( K1 nreleasing hormone stimulation. This is a sex-linked" {; ?3 m r5 c! Y0 r
autosomal dominant disorder that affects only
1 u- `6 s6 X5 A0 n# dmales; therefore, other male members of the family
6 W4 `+ m0 j. E- ?) ]+ R: Tmay have similar precocious puberty.3$ ]( l7 u8 l; d) u9 Z# N
In our patient, physical examination was incon-4 {8 x/ Z; U/ _" l$ F) T/ i! ?+ a
sistent with true precocious puberty since his testi-- {9 y" j3 P; f# K5 x
cles were prepubertal in size. However, testotoxicosis4 e1 Z8 J2 \1 q4 @
was in the differential diagnosis because his father
( [" w; E7 `- l- t2 Ustarted puberty somewhat early, and occasionally,
- _' H& c, P/ v6 X) t5 F. otesticular enlargement is not that evident in the3 e, N" ]1 l: T' |2 ~% o. V
beginning of this process.1 In the absence of a neg-
5 b! H8 E: r/ |" c7 ~ative initial history of androgen exposure, our! X8 y6 R; V2 ?7 n) Y
biggest concern was virilizing adrenal hyperplasia,0 f% `8 |$ M) A
either 21-hydroxylase deficiency or 11-β hydroxylase
" _& P5 }0 ~0 i$ cdeficiency. Those diagnoses were excluded by find-5 {5 p0 m+ F* {, l
ing the normal level of adrenal steroids.
$ T9 f6 ?8 d6 }! ~/ I# e" I: ^The diagnosis of exogenous androgens was strongly
Y' c+ G$ H5 ksuspected in a follow-up visit after 4 months because/ C$ T4 ?* @4 G
the physical examination revealed the complete disap-
; T( P* i/ F0 F, V& ]$ Y% cpearance of pubic hair, normal growth velocity, and# @' O5 d6 t! X5 M5 p
decreased erections. The father admitted using a testos-- m& B# `. f; K6 }
terone gel, which he concealed at first visit. He was
) n7 X* E* G, l4 J$ b: H5 d8 O4 m7 f1 Wusing it rather frequently, twice a day. The Physicians’! K( I" k% S2 O6 C! f
Desk Reference, or package insert of this product, gel or
( d2 W8 O" |2 U# Ccream, cautions about dermal testosterone transfer to
1 J0 t, Y8 U8 a/ lunprotected females through direct skin exposure.2 B+ T0 |" h1 ?9 A& l; q4 g6 D
Serum testosterone level was found to be 2 times the
- ` L) x U, Bbaseline value in those females who were exposed to
' L; n- @3 G7 K$ q0 p. Q5 Teven 15 minutes of direct skin contact with their male
9 I! e A# O, F; b, F2 y u/ E, bpartners.6 However, when a shirt covered the applica-
p" {2 N7 |& T, S2 dtion site, this testosterone transfer was prevented. ? C% x4 @9 Y$ ]8 W; {% l1 z8 c. A
Our patient’s testosterone level was 60 ng/mL,
0 q& c; R; E6 r' a" Jwhich was clearly high. Some studies suggest that% b# y2 Q/ g% ?* r' y2 c2 D
dermal conversion of testosterone to dihydrotestos-
" F l8 P+ Y: \; q; A) [terone, which is a more potent metabolite, is more; N. `/ {& J5 h/ s3 N& }, J
active in young children exposed to testosterone3 n* s# p' _/ B. f* |1 y+ G
exogenously7; however, we did not measure a dihy-
! r5 n& I, y& V" i6 Qdrotestosterone level in our patient. In addition to! N3 W: N8 F: C3 F& j
virilization, exposure to exogenous testosterone in
# I: l* V, g# i1 ychildren results in an increase in growth velocity and- u5 l" M- i4 m7 `9 X* F
advanced bone age, as seen in our patient.; P* q+ ]8 P" t3 l% ?) b
The long-term effect of androgen exposure during
- ?' ~! O) ~" l4 p# Vearly childhood on pubertal development and final
4 E$ ]- Q/ e& Kadult height are not fully known and always remain0 f' h5 z: A) n) `; q, j5 j; [$ [$ N
a concern. Children treated with short-term testos-$ ]$ T" Z6 G6 _# \' j" j! F
terone injection or topical androgen may exhibit some
1 Z* J! {) r% A9 zacceleration of the skeletal maturation; however, after
1 J3 b0 S8 \7 G/ hcessation of treatment, the rate of bone maturation; w/ i1 j: ?; r- i
decelerates and gradually returns to normal.8,9
0 n0 J# k" N# |) T& |There are conflicting reports and controversy' T2 A. i3 a- w9 e4 p8 R8 s' Q
over the effect of early androgen exposure on adult) ?& W4 \9 f# z, k
penile length.10,11 Some reports suggest subnormal
( `4 _# }) l! L; Nadult penile length, apparently because of downreg-$ `, Z T! j3 g! M9 v' ]. ^* U
ulation of androgen receptor number.10,12 However,1 w5 [5 D9 G, w( ]. k' Z3 J
Sutherland et al13 did not find a correlation between9 W* @$ g9 Y* b
childhood testosterone exposure and reduced adult
# Q, Z- E. b3 z0 [penile length in clinical studies.
0 `" e, j1 Y2 GNonetheless, we do not believe our patient is
. s- K) @; t5 Q! Z2 wgoing to experience any of the untoward effects from
: _. o, `1 d# u4 g8 [testosterone exposure as mentioned earlier because5 ]& a- p0 P5 \6 }9 u2 U. z2 n
the exposure was not for a prolonged period of time.
- h" b* G8 h, p5 }Although the bone age was advanced at the time of& i9 E H( k* {: g2 N0 L
diagnosis, the child had a normal growth velocity at
7 X! T6 [5 b& m0 Hthe follow-up visit. It is hoped that his final adult
) `" T( Q# S, E6 k" p. E( A) l% Nheight will not be affected.- i3 z! F; q8 @( E4 G" q
Although rarely reported, the widespread avail-
1 }* |+ k! Q. zability of androgen products in our society may
& W* }+ G9 r9 {9 L! ~0 Zindeed cause more virilization in male or female( l# h- @' b" @
children than one would realize. Exposure to andro-
$ n# U$ v& b' k- S/ u' a4 hgen products must be considered and specific ques-" }, J$ w$ u5 }! V# A, R
tioning about the use of a testosterone product or- g4 K$ k/ y9 D. t) V2 u
gel should be asked of the family members during
0 d: {! J E- k8 n% Xthe evaluation of any children who present with vir-
! u/ C2 @0 K; v" c8 E3 }7 o# Nilization or peripheral precocious puberty. The diag-3 G9 |! l6 c& H$ P' N- c/ A' Q! j* e
nosis can be established by just a few tests and by( s2 \+ Z7 g) G5 \
appropriate history. The inability to obtain such a4 J8 r5 L; q# x9 M9 v% P- D
history, or failure to ask the specific questions, may
' `; y7 q: R( ~8 uresult in extensive, unnecessary, and expensive
1 {6 \& y; q& m( `* Winvestigation. The primary care physician should be
# O9 g I* J: N8 S- Eaware of this fact, because most of these children
5 Z5 N: [) z& _" N( N( u9 K# bmay initially present in their practice. The Physicians’7 p1 c( g* d, n. i% S+ N% c
Desk Reference and package insert should also put a O4 M+ f9 B& y7 X& s
warning about the virilizing effect on a male or0 p/ p7 D2 K: v3 s3 H
female child who might come in contact with some-5 }4 M+ Q6 a4 ]
one using any of these products.
4 u3 {) {* n# oReferences1 A; L8 P. T, {' p' I
1. Styne DM. The testes: disorder of sexual differentiation
( ~7 D' V$ M: O4 w- R; [and puberty in the male. In: Sperling MA, ed. Pediatric
) X* s- W3 C' k+ o. m% k9 {& @2 BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ X% Z5 N% p6 p
2002: 565-628.) W) n& G; [8 }) _' u3 h' `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ P: p% G( d% `4 n4 \+ f$ ^puberty in children with tumours of the suprasellar pineal |
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