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Sexual Precocity in a 16-Month-Old) \; T9 ?% W. ^# a7 l/ D
Boy Induced by Indirect Topical$ c/ A# @) W6 ~5 Y1 q2 ^" H$ a
Exposure to Testosterone
, O0 B( T' _" M# K% |4 |6 @+ qSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 E; K, N: L- F; pand Kenneth R. Rettig, MD1
$ ~) q% [2 P. h: b- }- IClinical Pediatrics+ ]0 I+ I0 A; Q8 D0 E: N% ?
Volume 46 Number 6
" o, C) W; E) ]1 C3 E3 nJuly 2007 540-543# _/ f$ L% y2 t. R
© 2007 Sage Publications9 O8 A; x# p" Y. t0 E" G
10.1177/0009922806296651
' D3 F0 M; y# s# Q- J" l4 K- Shttp://clp.sagepub.com
+ t1 y0 E6 w3 q0 X$ N! v% c( ~7 |4 Ghosted at8 T- V2 i5 e& {) M$ |
http://online.sagepub.com
& l+ c4 A; o2 i7 n- q3 [7 j kPrecocious puberty in boys, central or peripheral,7 N- ~) y) j6 T' \
is a significant concern for physicians. Central1 P5 K. P' i1 j' G8 q# Z$ g) Y
precocious puberty (CPP), which is mediated+ \8 K4 k7 ?! |# I4 h1 o7 F
through the hypothalamic pituitary gonadal axis, has
" ]7 g2 A# h, E1 A. E4 Sa higher incidence of organic central nervous system
. |0 w1 g% d9 j. i7 n2 Llesions in boys.1,2 Virilization in boys, as manifested9 x5 F1 T' d8 N1 L4 A5 S. o6 Q
by enlargement of the penis, development of pubic3 j) d' q) M4 m* T$ P6 ]- O/ S
hair, and facial acne without enlargement of testi-
* r; X2 H, S3 }# P* ^3 Jcles, suggests peripheral or pseudopuberty.1-3 We N% ]; w9 X. U+ U0 K* W, c
report a 16-month-old boy who presented with the p6 z: [0 N0 I; S
enlargement of the phallus and pubic hair develop-# q9 A. Z3 ~; }' @5 P: Q
ment without testicular enlargement, which was due
2 H2 s; W5 ?& @6 Z3 x# bto the unintentional exposure to androgen gel used by
( J& G$ S; \0 A0 v" L9 @& G: U4 Lthe father. The family initially concealed this infor-
9 E! J* X) f: z% G: e+ V# ?mation, resulting in an extensive work-up for this
; g4 F) H$ L* |child. Given the widespread and easy availability of
7 \; G) U; J, a u% Rtestosterone gel and cream, we believe this is proba-! W' }1 l" X( _7 p& }
bly more common than the rare case report in the
3 [* Q$ ~% l! i) q6 o0 }literature.4- Q E) w7 u: j' j# r! C
Patient Report1 a8 b/ j6 A6 g# d
A 16-month-old white child was referred to the5 N1 B) |( C1 T% q6 H) @
endocrine clinic by his pediatrician with the concern: b* y9 S9 S8 _) r
of early sexual development. His mother noticed
+ G9 G& p: u! F' p- |8 klight colored pubic hair development when he was/ y& _ P- \, O9 ]
From the 1Division of Pediatric Endocrinology, 2University of
. f. o# i, Z& l& x6 vSouth Alabama Medical Center, Mobile, Alabama.' ~/ G9 k8 O$ E' A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 M, E5 Y" L# qProfessor of Pediatrics, University of South Alabama, College of
d8 {6 E+ f" ?6 ?+ |4 DMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: T' ~9 J. p/ m8 S* `* Ce-mail: [email protected].
# x" j U' i# O( P3 @" ~about 6 to 7 months old, which progressively became
0 O4 n" F+ ~/ ddarker. She was also concerned about the enlarge-$ i) \ z" X2 X/ @
ment of his penis and frequent erections. The child
# ~1 w7 c I" p3 G2 L$ nwas the product of a full-term normal delivery, with
. l7 S) s% j, B- ?5 sa birth weight of 7 lb 14 oz, and birth length of
; g! G# a) q: l! [20 inches. He was breast-fed throughout the first year- |" N D3 Q$ z- ?0 l* }
of life and was still receiving breast milk along with/ J/ l6 m% `$ E! A& E5 e! ~
solid food. He had no hospitalizations or surgery,. M" Q* d L7 ~- ^& n5 ?
and his psychosocial and psychomotor development% ^& w( E& V0 N9 T
was age appropriate.
7 v1 J8 v8 O6 u3 j& E5 y1 S, \The family history was remarkable for the father,
) U s6 R( f& H. K. \. |who was diagnosed with hypothyroidism at age 16,! F8 F5 r% Z4 i( x B" K. A9 T. I
which was treated with thyroxine. The father’s' L! c' f( f l9 H) l
height was 6 feet, and he went through a somewhat( z+ V2 Z2 r6 S$ l Q0 |
early puberty and had stopped growing by age 14.5 g% r$ J6 q/ \
The father denied taking any other medication. The
- f K" R4 W1 D4 c5 L7 Wchild’s mother was in good health. Her menarche. L+ K5 [ R- W, @. r) |) i) F
was at 11 years of age, and her height was at 5 feet" e8 B1 |' x% q; X& c- p
5 inches. There was no other family history of pre-5 i: q' u, P# A
cocious sexual development in the first-degree rela-
2 ?6 D% w9 i" _' htives. There were no siblings.
' X, C" r! |6 f- X4 r' \Physical Examination. x0 ? ]2 l' i, L) {0 q l
The physical examination revealed a very active,8 G7 S' `3 V/ I) O
playful, and healthy boy. The vital signs documented( u/ `4 Q: k# ~) m
a blood pressure of 85/50 mm Hg, his length was
- \: d! D& R6 X8 b90 cm (>97th percentile), and his weight was 14.4 kg" r' ]5 c R1 o; V. C! v
(also >97th percentile). The observed yearly growth
9 t3 |: r0 X0 b$ Y4 xvelocity was 30 cm (12 inches). The examination of
, f! a+ H! L* \6 q7 \the neck revealed no thyroid enlargement.& T$ E+ u% ~# y
The genitourinary examination was remarkable for
4 o, ]4 `6 ~! ?- X% Y3 [, lenlargement of the penis, with a stretched length of
Z0 T9 K! |. _3 f8 cm and a width of 2 cm. The glans penis was very well; S' [8 R+ y K- E
developed. The pubic hair was Tanner II, mostly around
* G ^) l5 M2 T7 `2 J540
, F, h9 }, M$ w9 p1 l6 ?- [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" @. a/ k* W. L0 ~
the base of the phallus and was dark and curled. The
. k2 u/ q: P( {0 Btesticular volume was prepubertal at 2 mL each.* B4 b, d/ m' P
The skin was moist and smooth and somewhat' r; g. v( p. T' o2 \
oily. No axillary hair was noted. There were no3 c B4 O) H" l. i @2 j5 N
abnormal skin pigmentations or café-au-lait spots.2 h* e3 F8 r* G: T) M
Neurologic evaluation showed deep tendon reflex 2+
- ^/ z. x# k/ U9 M/ o5 o$ l0 Zbilateral and symmetrical. There was no suggestion
" n7 `) o1 ^3 g$ zof papilledema.; ?3 K/ {# r% V. k
Laboratory Evaluation( l8 d1 W. J, n& V# H
The bone age was consistent with 28 months by
3 X0 c- b# g, z0 H8 h+ Wusing the standard of Greulich and Pyle at a chrono-" H3 Q( _& D6 _& d4 E( d
logic age of 16 months (advanced).5 Chromosomal
, n3 X$ y% _' n. ?4 ?+ q) vkaryotype was 46XY. The thyroid function test7 W5 ?, f5 {# x/ n" B: j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. }: i5 V4 ^4 T6 A" X/ Hlating hormone level was 1.3 µIU/mL (both normal).
* I2 k' C3 ^) RThe concentrations of serum electrolytes, blood+ E* f2 G0 T' B7 J# K- ^1 P7 w
urea nitrogen, creatinine, and calcium all were
* r( o# f3 y- R5 Nwithin normal range for his age. The concentration
: @0 B) T, w0 aof serum 17-hydroxyprogesterone was 16 ng/dL/ Q+ [# O& Q/ k% k
(normal, 3 to 90 ng/dL), androstenedione was 20
+ O" M) n) h( t/ ]" @* @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 t+ {. R; y {
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 C Q' Y( b% V; E1 ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
z& o! D! ]0 Y4 W1 @, X: Y49ng/dL), 11-desoxycortisol (specific compound S). r5 \. j% B D' ]% b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: |0 O- A+ n/ l( D* q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% O5 L/ r, s4 ^1 ~5 Wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 o3 E; B! ]5 T( N& z7 aand β-human chorionic gonadotropin was less than; w/ l& W$ W4 u2 C. U7 }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
' l0 y, P" j4 b( b6 c1 C' `9 n; E w! Estimulating hormone and leuteinizing hormone: c; o& J* M& y% W
concentrations were less than 0.05 mIU/mL2 ]+ ?5 R) `) \8 _
(prepubertal).5 H. S0 P/ O' d1 l$ v
The parents were notified about the laboratory
9 x: _; j' t0 S9 Nresults and were informed that all of the tests were x" g. z* m0 v& r g+ H* K2 j
normal except the testosterone level was high. The0 d/ R2 k# i' \( j6 \
follow-up visit was arranged within a few weeks to5 D7 ] \8 C9 w
obtain testicular and abdominal sonograms; how-. g+ ~& o3 u1 ~, A8 A' e# q, J) y7 s
ever, the family did not return for 4 months.3 J# a P% P% D( k3 e. }
Physical examination at this time revealed that the1 i9 G, @( ^; l0 b
child had grown 2.5 cm in 4 months and had gained# M2 I: O2 l9 [
2 kg of weight. Physical examination remained
5 J; J8 o, z$ ^& ^( Junchanged. Surprisingly, the pubic hair almost com-: D! H' W! D" [/ [7 j, u
pletely disappeared except for a few vellous hairs at
, D; g- l' r" y! j# o, ~/ @the base of the phallus. Testicular volume was still 2, k2 T' H. f$ E( B" K7 e5 j) _
mL, and the size of the penis remained unchanged.
' I3 L5 C# R- ^& c0 T E: MThe mother also said that the boy was no longer hav-. @' q5 C$ C: d) k
ing frequent erections.0 |, H- d1 u" l& e; Y
Both parents were again questioned about use of
2 ^4 ~5 C( f6 O4 G& N0 `; Vany ointment/creams that they may have applied to
9 Q, c" ]6 O# A6 O8 Z3 a, M9 O' I: Xthe child’s skin. This time the father admitted the# c; \+ h, j* w; W6 V
Topical Testosterone Exposure / Bhowmick et al 541. u: z6 l9 V5 ] Y% W6 c
use of testosterone gel twice daily that he was apply-
. l0 o( P( U f; Zing over his own shoulders, chest, and back area for& c( @; X/ Q9 U) ~3 O) A# A
a year. The father also revealed he was embarrassed
$ r' T! D* ?% o9 K _; z7 r1 ^to disclose that he was using a testosterone gel pre-
+ _# W% N* G! u2 Xscribed by his family physician for decreased libido/ n$ r) x! W" w4 y3 t! I9 V
secondary to depression.
N) ^" I5 K7 q: @. N* |The child slept in the same bed with parents.
6 |2 y( I" g9 @* `5 D7 ^3 GThe father would hug the baby and hold him on his
6 e2 n# l( O3 rchest for a considerable period of time, causing sig-, u6 R$ A" ^& N: G# A+ B
nificant bare skin contact between baby and father.
( w& l% `* k4 Z/ BThe father also admitted that after the phone call,/ y0 Z$ O8 U2 z8 ~
when he learned the testosterone level in the baby4 ^# ~5 X8 X* t' C
was high, he then read the product information
7 G8 J9 n- x8 k7 O( z8 R$ k; s6 _packet and concluded that it was most likely the rea-) X( z3 f$ M$ ?0 l! G( J
son for the child’s virilization. At that time, they
$ l$ z% H9 m2 P$ M& k/ Y, n; ldecided to put the baby in a separate bed, and the
: t4 ^: l# c% g( h( nfather was not hugging him with bare skin and had
6 j2 @2 Q& P; \+ Ebeen using protective clothing. A repeat testosterone: J+ X2 u- m4 {$ ^- @0 Z
test was ordered, but the family did not go to the
4 k. r+ u/ H4 a; jlaboratory to obtain the test.6 @ r; S; Y) P- L% k4 K& T! y
Discussion
" I1 v& n9 G' L7 v+ VPrecocious puberty in boys is defined as secondary
' e% Q3 A+ U' @sexual development before 9 years of age.1,4% U u) o9 v8 w, V5 l, Y
Precocious puberty is termed as central (true) when! O. T: A1 d( w5 G, E" m2 Z' k
it is caused by the premature activation of hypo-* v- m! s2 X8 s) Z* O( c
thalamic pituitary gonadal axis. CPP is more com-
7 B1 d- A; }* }+ F+ zmon in girls than in boys.1,3 Most boys with CPP
, |: ?, G1 u5 E" qmay have a central nervous system lesion that is1 u! q+ f( i% j8 e3 ?, X: b6 Y
responsible for the early activation of the hypothal-
" a+ @3 @, W3 A( t/ }amic pituitary gonadal axis.1-3 Thus, greater empha-
+ M, s$ T% F# C( Q. ?* w6 |% dsis has been given to neuroradiologic imaging in
; s+ e+ `2 b2 K ^1 Vboys with precocious puberty. In addition to viril-
& q0 c* H h( T8 E& ^" e2 yization, the clinical hallmark of CPP is the symmet-
1 q6 q4 J; A) Trical testicular growth secondary to stimulation by8 M$ m8 h6 T4 q8 h! k$ Q. D
gonadotropins.1,38 b+ O" k* U. e! D+ a6 F) D- C
Gonadotropin-independent peripheral preco-; Y# N0 t8 k- p0 v' e; s5 d2 A8 `
cious puberty in boys also results from inappropriate+ E1 L, S/ D& ]0 i) _
androgenic stimulation from either endogenous or
q9 C" M& `3 K+ M7 U5 Yexogenous sources, nonpituitary gonadotropin stim-# e3 u8 Z4 o, F- h7 v/ |/ l
ulation, and rare activating mutations.3 Virilizing9 t! ?8 \5 f7 n8 T4 R9 ^- y
congenital adrenal hyperplasia producing excessive
' a; y1 R( _2 k. Y) V8 Iadrenal androgens is a common cause of precocious
# p. o4 O1 z: D Dpuberty in boys.3,4
8 O; J* F: @& j: cThe most common form of congenital adrenal$ _' W: q3 G: ]( d% P4 ?
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 K& ~* z2 E" n6 [4 A% iThe 11-β hydroxylase deficiency may also result in
5 Q1 [& \( C5 X# _( H- ]) _excessive adrenal androgen production, and rarely,( _: O, Y2 _9 ^, H
an adrenal tumor may also cause adrenal androgen
3 K" c' @3 H5 |+ @excess.1,3$ u& }# b. y. n+ t, o# V/ x+ _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ S0 u- D' \& A2 L a- C% ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ C6 |/ N& ?4 l/ @, G5 M* e9 ^A unique entity of male-limited gonadotropin-" n, ?# J. N2 s+ N0 R! Q
independent precocious puberty, which is also known' v3 J$ o. ?2 R
as testotoxicosis, may cause precocious puberty at a' D' n3 a0 E( w! ?3 K: n
very young age. The physical findings in these boys
7 m. X9 O% e$ `: k( W; h0 O- ~; ^with this disorder are full pubertal development,7 M- i! f) P- L& y& I
including bilateral testicular growth, similar to boys
: C5 S- e1 F. f% i gwith CPP. The gonadotropin levels in this disorder
' N! e; y" I) s J* Mare suppressed to prepubertal levels and do not show. E+ U6 E1 G: c+ A
pubertal response of gonadotropin after gonadotropin-3 ]% w0 l T I" }$ T
releasing hormone stimulation. This is a sex-linked
9 R* Z, Y& B9 M, Z" Cautosomal dominant disorder that affects only
, _) s6 q/ c, [+ J: D$ t, [males; therefore, other male members of the family- b# ?4 W6 g' u4 q% x
may have similar precocious puberty.3
$ U2 a6 F6 H. t: A' iIn our patient, physical examination was incon-: \9 Q! n" i7 _/ `
sistent with true precocious puberty since his testi-$ v) ]$ {0 k0 `
cles were prepubertal in size. However, testotoxicosis9 b4 D% Q; ]( ^7 K Q
was in the differential diagnosis because his father1 b( c) J) v% C; Z7 `) Q, e
started puberty somewhat early, and occasionally,3 M- `; H; e, G7 X, I) @+ e
testicular enlargement is not that evident in the* @: G O I/ o9 w7 |" E/ ~ B% ^
beginning of this process.1 In the absence of a neg-
& H' k/ V/ J+ g, a3 C" @- Lative initial history of androgen exposure, our- y' n* Y- @) p {# H: N4 I
biggest concern was virilizing adrenal hyperplasia,5 N4 [: v! ]: I; K
either 21-hydroxylase deficiency or 11-β hydroxylase; s& p+ C& P0 Y
deficiency. Those diagnoses were excluded by find-
. A N, b. ~: y$ f. H$ j3 zing the normal level of adrenal steroids.6 ] o% ]3 ^* z4 F/ e: u t3 ?
The diagnosis of exogenous androgens was strongly1 ~( R0 j2 o% L4 T# G
suspected in a follow-up visit after 4 months because8 x9 d* s. Q6 o9 d- \/ F
the physical examination revealed the complete disap-. Y N/ L+ m- g7 z* i; _
pearance of pubic hair, normal growth velocity, and
* E2 B& A& N. E6 l- l3 e2 m3 Bdecreased erections. The father admitted using a testos-
% n" J; u. r( E( V& Nterone gel, which he concealed at first visit. He was. o1 ` }, z- H5 ?
using it rather frequently, twice a day. The Physicians’
! m; f3 g% ]( U) h% ~5 V! q( FDesk Reference, or package insert of this product, gel or
% w2 K" K9 {: T+ w' }cream, cautions about dermal testosterone transfer to
; b, U3 G4 Y" p% ^1 D6 E! u# Bunprotected females through direct skin exposure.
# x7 T0 O5 }' v9 V* F' |Serum testosterone level was found to be 2 times the
' y7 c! n: A% Ibaseline value in those females who were exposed to
, ?: Z: A# b3 Feven 15 minutes of direct skin contact with their male1 j ?- z) @0 A6 O2 ^) I# S
partners.6 However, when a shirt covered the applica-
$ T) r5 @) m ltion site, this testosterone transfer was prevented.; ^' m& i% S9 M% w
Our patient’s testosterone level was 60 ng/mL,
' `; t2 h, K! awhich was clearly high. Some studies suggest that9 }1 d4 R, W8 p
dermal conversion of testosterone to dihydrotestos-# B' y( ~1 M2 Y9 A ]' i) G: J
terone, which is a more potent metabolite, is more
, f, r8 k% R& D! p/ p4 factive in young children exposed to testosterone
+ u: W) C) n5 n6 N( Eexogenously7; however, we did not measure a dihy- s6 p. S1 j: J; k* i- T
drotestosterone level in our patient. In addition to
: F7 y& y p" L2 F9 V" |& yvirilization, exposure to exogenous testosterone in
/ E, M: F! J6 Ychildren results in an increase in growth velocity and4 B; C L: ] Y" \! L9 X
advanced bone age, as seen in our patient." x; k0 F; Y4 Y
The long-term effect of androgen exposure during
2 n E. N; j8 b8 B6 u( Yearly childhood on pubertal development and final' z* f3 N/ x( E9 l% ^% g5 _
adult height are not fully known and always remain1 H2 i; {0 l4 U0 `- x
a concern. Children treated with short-term testos-8 p' K4 a+ e# x/ Q# I! n! _, H
terone injection or topical androgen may exhibit some
3 e, I4 y- y( C8 F& lacceleration of the skeletal maturation; however, after' J% x) w: o6 J' o0 J' @! J4 K
cessation of treatment, the rate of bone maturation8 O# r/ I: q# _* K" y
decelerates and gradually returns to normal.8,9& c5 y0 X# B/ _8 T
There are conflicting reports and controversy+ F5 M. b- E- N1 h; _
over the effect of early androgen exposure on adult
+ A0 \5 _8 }7 Ypenile length.10,11 Some reports suggest subnormal1 K% ]! J* E# ?9 ~
adult penile length, apparently because of downreg-
9 U, @+ y. W {4 h! o/ X4 hulation of androgen receptor number.10,12 However,
! b; f* U9 a0 B1 {) H: SSutherland et al13 did not find a correlation between
* P q' T' d2 `7 b& P# k9 Zchildhood testosterone exposure and reduced adult
6 s/ ~$ \: m3 O: A2 t6 apenile length in clinical studies.. F1 l+ f% I. }+ K: i4 P
Nonetheless, we do not believe our patient is
# M& d8 U% [4 C+ t* ~& xgoing to experience any of the untoward effects from
- `- K" f7 Q9 E" P8 }+ A8 P9 mtestosterone exposure as mentioned earlier because
" H& o1 R/ H# C9 H; \the exposure was not for a prolonged period of time.2 ~% ?6 H# B7 P+ c
Although the bone age was advanced at the time of1 G" y* ?) o/ u
diagnosis, the child had a normal growth velocity at
3 z: y# d* f8 E2 f) u& o/ qthe follow-up visit. It is hoped that his final adult
+ @9 F/ Q0 {; n+ |; Fheight will not be affected.
/ o1 q) j$ M6 }# ^+ g: k0 y+ g: dAlthough rarely reported, the widespread avail-2 w* r% N) ~ g S8 O( K4 E6 \
ability of androgen products in our society may
# R4 o3 M7 G, f3 ~indeed cause more virilization in male or female
4 B% E1 \! M0 e3 I4 b" Jchildren than one would realize. Exposure to andro-9 u( M) w/ c) Q( x2 U8 }( B
gen products must be considered and specific ques-& v9 m" j' a6 y
tioning about the use of a testosterone product or
1 H( h8 H% }+ E) f5 xgel should be asked of the family members during
% {9 [6 Y; x/ E1 Q. qthe evaluation of any children who present with vir-
# q! M* Z% B* o* \2 {5 jilization or peripheral precocious puberty. The diag-1 b9 ?# a6 v" I3 e# N/ w+ s0 k
nosis can be established by just a few tests and by
$ G- O! l6 Y& ^9 P6 l& U! oappropriate history. The inability to obtain such a
5 Z4 q7 d7 `, ~ Uhistory, or failure to ask the specific questions, may
8 K/ o0 o; \: d# kresult in extensive, unnecessary, and expensive
. a% b4 a$ W# Iinvestigation. The primary care physician should be3 D1 |- i" r0 h, ? T3 r- r
aware of this fact, because most of these children
9 f9 K5 g8 q; Q4 D5 H( z1 mmay initially present in their practice. The Physicians’
( G% n# o8 I9 @4 IDesk Reference and package insert should also put a
- }( |" O! f& A; [; l1 X r/ twarning about the virilizing effect on a male or
% B" N' M E/ w) Yfemale child who might come in contact with some-1 Q6 z, x' [3 V5 p: Y6 V ]. J6 s
one using any of these products.
. x# W& T4 v% }6 n( O7 Z( X2 jReferences L/ F1 p: `, F C8 \
1. Styne DM. The testes: disorder of sexual differentiation
; T9 J% P" U/ Q8 gand puberty in the male. In: Sperling MA, ed. Pediatric
# M7 K) k6 j' D) K/ tEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 {# { P, Q9 l% K2002: 565-628.1 y6 `9 E9 y# W% F& F4 }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# f9 y+ p" E! A8 `( m/ \ Npuberty in children with tumours of the suprasellar pineal |
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