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Sexual Precocity in a 16-Month-Old
0 I$ R7 W/ o' w' GBoy Induced by Indirect Topical |6 k; B! ^9 P q
Exposure to Testosterone
2 O( L5 h% ?3 l6 z6 `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ T; U: k/ R" j- d0 K
and Kenneth R. Rettig, MD1
& t) M* @( O/ `! i& qClinical Pediatrics
/ G1 v$ b6 n" h& Z& vVolume 46 Number 6) }: m% \ L5 w# n" t7 b6 f
July 2007 540-543
% {. F! R5 o3 q% ?9 F# H0 @; S$ P. q© 2007 Sage Publications q ~ x( p: k6 `" C$ A$ ~" J
10.1177/00099228062966519 ^. d) a. O" [8 G1 u" g
http://clp.sagepub.com
# V+ N4 j( r1 G( Xhosted at
8 @% o# j* q6 S1 w6 }) chttp://online.sagepub.com
6 P/ Q) F8 I; _& e T" @0 O/ QPrecocious puberty in boys, central or peripheral,7 x* g9 R% F9 O- s- o, }, e' L! ^
is a significant concern for physicians. Central1 [5 {* H$ ^2 ]& @
precocious puberty (CPP), which is mediated
3 F; C' p4 W& ?* H6 Nthrough the hypothalamic pituitary gonadal axis, has" U1 O8 ^$ p3 s, g
a higher incidence of organic central nervous system
* T' X; y1 ^: llesions in boys.1,2 Virilization in boys, as manifested* U" l% o$ D# V0 X0 @! c" N) L
by enlargement of the penis, development of pubic; T1 p3 q* w+ u# l
hair, and facial acne without enlargement of testi-% w2 J0 N4 l6 r5 Z8 S) d2 G
cles, suggests peripheral or pseudopuberty.1-3 We9 U8 v/ ^ r0 a7 w
report a 16-month-old boy who presented with the
; W* x0 _, g2 L9 A5 K0 Ienlargement of the phallus and pubic hair develop-
) B; b6 D4 \/ Z7 \ment without testicular enlargement, which was due
u8 N) i' B3 R1 w `( \$ Rto the unintentional exposure to androgen gel used by, N% H1 W) k% M/ \ v
the father. The family initially concealed this infor-
+ ~6 K2 T2 z3 B2 N2 s# ~4 T+ kmation, resulting in an extensive work-up for this& l/ n" `1 y) D; P! O# W
child. Given the widespread and easy availability of* |& l+ B# p% ]" k
testosterone gel and cream, we believe this is proba-
& r1 h3 i) k5 x/ Bbly more common than the rare case report in the
& d5 ^ b0 h+ X9 M5 c6 k7 [literature.4
3 N" l# `# e( `! ^* APatient Report- v2 U& a5 @% f
A 16-month-old white child was referred to the
/ x# V$ c. J7 U$ Q/ j4 ]endocrine clinic by his pediatrician with the concern3 k1 F- @. {# M! Z& `+ c
of early sexual development. His mother noticed
- z9 C3 N/ i# ~5 L. A$ R" q' ]light colored pubic hair development when he was; n. U/ r5 P: s. r7 u, ?
From the 1Division of Pediatric Endocrinology, 2University of
- }# b9 b/ f. o: Z& y/ [3 J% p5 dSouth Alabama Medical Center, Mobile, Alabama." z# z* U" E' v' a0 N3 y! i) K
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: i y1 Z9 t2 w# e$ d1 kProfessor of Pediatrics, University of South Alabama, College of
+ e, u, M$ S# q4 `) }% aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" a3 Q% a/ @4 X9 L- g
e-mail: [email protected].
; @- T1 [3 A9 I4 X% @0 W y* Labout 6 to 7 months old, which progressively became
* ^$ k; x4 n* s5 Ydarker. She was also concerned about the enlarge-# j7 n5 [; J9 I9 A1 r D7 h
ment of his penis and frequent erections. The child/ P% B# s, m+ V, y
was the product of a full-term normal delivery, with
) B( L, P: b; G4 Sa birth weight of 7 lb 14 oz, and birth length of- i! @" E! M# n6 L. B; z& ^
20 inches. He was breast-fed throughout the first year
" x0 t# n1 e8 p) ]$ p/ q/ xof life and was still receiving breast milk along with# c/ p5 o$ P; E% @% z& \) c5 J1 w
solid food. He had no hospitalizations or surgery,
- z" l( t+ X& f: Z7 d: U; rand his psychosocial and psychomotor development
$ g! ~7 o& j) M, @was age appropriate.0 F4 j* A f5 G; Q( ]: ~
The family history was remarkable for the father," z& E$ v2 m. P" b0 s3 w5 J
who was diagnosed with hypothyroidism at age 16,
4 ]" P5 \& e* Jwhich was treated with thyroxine. The father’s
4 z2 ?' c/ _) w2 `" mheight was 6 feet, and he went through a somewhat
6 i7 S+ i& h/ e; Oearly puberty and had stopped growing by age 14.% k0 V5 y" a9 v
The father denied taking any other medication. The/ R7 c X3 [* \5 O; j; U+ ]
child’s mother was in good health. Her menarche
% Y& c& _0 ^, D6 ?was at 11 years of age, and her height was at 5 feet8 y0 y8 Q5 P! m6 C( L4 q5 p
5 inches. There was no other family history of pre-
& E$ j: Z. m' k, tcocious sexual development in the first-degree rela-+ E( m& P1 |* O0 _+ z1 s6 y
tives. There were no siblings. {4 g: Q: W% `4 k" B
Physical Examination4 @$ i9 C% q" E% Y) i- h6 C! z
The physical examination revealed a very active,
( Q0 C& ?) W) D A4 R; u+ M- |playful, and healthy boy. The vital signs documented2 t4 i* ]& T5 P5 [: L# J, C
a blood pressure of 85/50 mm Hg, his length was
/ {+ P2 B$ p; n u90 cm (>97th percentile), and his weight was 14.4 kg
( T: k5 S: |# ], R: d% m1 d(also >97th percentile). The observed yearly growth
+ L& K' v6 @/ r# [5 M' X5 ^velocity was 30 cm (12 inches). The examination of
* @0 Q! T7 {/ P2 f: _" W. ~4 Athe neck revealed no thyroid enlargement., J: f" F& u) i" R6 i2 |
The genitourinary examination was remarkable for
3 S0 G9 m* F, S, m& Venlargement of the penis, with a stretched length of
& z5 {/ I, k b4 e# N( U$ l. U, [* c8 cm and a width of 2 cm. The glans penis was very well/ @( t! C- q \$ F
developed. The pubic hair was Tanner II, mostly around
6 x D. D' b# Z3 J2 }) z& ?8 t540; f7 T. ^) n2 t: V0 u& n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, B; A% O. i% c/ p% k3 F: S, o
the base of the phallus and was dark and curled. The
: H# m+ Q$ S+ B9 `. N9 ?testicular volume was prepubertal at 2 mL each.! U. k- n0 {' z& `
The skin was moist and smooth and somewhat3 n+ P" }5 T4 G+ e- k
oily. No axillary hair was noted. There were no5 Q% E6 m, N% M3 p% S% ~
abnormal skin pigmentations or café-au-lait spots.
; G" _2 i+ r8 L% ^9 cNeurologic evaluation showed deep tendon reflex 2+6 e+ U! A F: _$ D
bilateral and symmetrical. There was no suggestion. {/ _# I" d0 _" l
of papilledema.2 }% T& T1 L4 o6 T' _ S
Laboratory Evaluation
' @2 _) M9 F. ?. R, N- Y2 e) \The bone age was consistent with 28 months by% x. h2 {- J5 Y' F8 [
using the standard of Greulich and Pyle at a chrono-! u3 s+ b) P- t8 z' v2 v
logic age of 16 months (advanced).5 Chromosomal
! B7 V; O1 t+ r/ d$ E/ akaryotype was 46XY. The thyroid function test
( A4 v) i" F! [# h& S3 k6 Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ R9 V' u x0 u. i* J
lating hormone level was 1.3 µIU/mL (both normal).
" H) L6 j M3 z' x3 ~! `. fThe concentrations of serum electrolytes, blood& L, G; h! Q9 s- _4 ?* @% u
urea nitrogen, creatinine, and calcium all were
+ R# Q4 L8 s! x" Mwithin normal range for his age. The concentration
" Q" b7 G0 u' ]5 w$ j% K9 Lof serum 17-hydroxyprogesterone was 16 ng/dL
% p* _8 W# q( H. }(normal, 3 to 90 ng/dL), androstenedione was 20; O E9 i& V9 U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 B9 e8 e9 f/ [3 b2 [5 Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),9 X ^: U2 I: S: D, @+ Z6 [0 U3 O
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 s. M# P( @) x' H( n1 J49ng/dL), 11-desoxycortisol (specific compound S)- \% Y( {6 l1 m1 e& E8 Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) u, Q; K: M* m3 \tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total- k2 d% c: U/ N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! j1 E$ l9 h' M: f6 ]" f
and β-human chorionic gonadotropin was less than
6 o, E8 A: A/ @# B5 mIU/mL (normal <5 mIU/mL). Serum follicular$ M) J/ L9 p+ G$ b' k7 X
stimulating hormone and leuteinizing hormone- B+ N: c" l; ?5 w* o0 X
concentrations were less than 0.05 mIU/mL
. E* r+ L) Q& a" K1 H. [0 J(prepubertal).: a; c7 a" W* ~( q2 b0 O( T3 X) }
The parents were notified about the laboratory
3 C' m K- p# U- u7 P% }results and were informed that all of the tests were
a$ L: n0 ^4 d! @normal except the testosterone level was high. The1 i" q) ?% \3 n2 |3 A0 D
follow-up visit was arranged within a few weeks to. e0 K- o6 U; U
obtain testicular and abdominal sonograms; how-
* N- V* m- K; U4 r; Iever, the family did not return for 4 months.
5 k) }" I& x3 YPhysical examination at this time revealed that the
8 T, Y& A- L2 G, j% T* k* |: m# Wchild had grown 2.5 cm in 4 months and had gained6 x# z" L" J# N8 E( L2 Y- i: D/ P( i
2 kg of weight. Physical examination remained, Q/ S! S. _9 C o
unchanged. Surprisingly, the pubic hair almost com-* m3 C G3 D, @% y q
pletely disappeared except for a few vellous hairs at
3 ~# @9 ^7 F# U6 u6 n( [1 R& Lthe base of the phallus. Testicular volume was still 22 E: z0 M8 \' y1 z: _6 q1 {
mL, and the size of the penis remained unchanged.9 z- ?$ z3 `; ^8 d5 k: [3 W
The mother also said that the boy was no longer hav-' [9 |1 A! i( T" @5 t
ing frequent erections.
4 i2 x- |* m! |6 j2 b FBoth parents were again questioned about use of
' q2 {3 a- ^* f% U0 I7 Gany ointment/creams that they may have applied to
/ g4 n; `3 B4 N* Nthe child’s skin. This time the father admitted the( R% q: L& V" \$ t! v4 @+ c4 A6 u
Topical Testosterone Exposure / Bhowmick et al 541- H) Y3 S5 _/ y* t
use of testosterone gel twice daily that he was apply-; O& f* `% ?: p) R$ E7 Q# G
ing over his own shoulders, chest, and back area for
; {" j( D+ w) p& j: la year. The father also revealed he was embarrassed2 ~ N9 g" ^% p2 `4 J7 i* V
to disclose that he was using a testosterone gel pre-, o3 ^2 `/ k _. ~
scribed by his family physician for decreased libido
- Z, f2 j# K& z' X6 j- I8 _secondary to depression.
5 u# Z5 o; {; G) fThe child slept in the same bed with parents.
2 t6 H! T) j$ N+ j5 l, WThe father would hug the baby and hold him on his
% w1 ^# H( ^: h8 z! nchest for a considerable period of time, causing sig-/ a( E$ h, E; b: R- C7 }
nificant bare skin contact between baby and father.+ v+ E# S- f* y5 V6 U' n
The father also admitted that after the phone call,: f ~* c0 W; T3 z3 k
when he learned the testosterone level in the baby- i& V9 j" b8 t2 J B2 H$ A
was high, he then read the product information
9 a/ q$ F6 d; D7 d0 I6 K0 epacket and concluded that it was most likely the rea-2 X- M5 ~: l4 V U- ]' l6 m
son for the child’s virilization. At that time, they
: m; [, u2 J& h- Rdecided to put the baby in a separate bed, and the
' s- A: K* Y1 Xfather was not hugging him with bare skin and had$ g, F: y5 O6 k0 Y: j3 ~% c- ~) r8 R
been using protective clothing. A repeat testosterone
- O* r2 O% T8 htest was ordered, but the family did not go to the
k, P2 l1 V U5 |: hlaboratory to obtain the test.3 w1 g7 e7 q: M( }
Discussion9 F" ], N: O& A* Z( R
Precocious puberty in boys is defined as secondary
% |5 B/ n+ \+ w( |% j; K( V( qsexual development before 9 years of age.1,4
9 N4 [7 z/ \3 p wPrecocious puberty is termed as central (true) when
- P7 _4 t q# A, Lit is caused by the premature activation of hypo-
! A8 I, b# s$ p0 Y6 kthalamic pituitary gonadal axis. CPP is more com-, | h- h8 n' T! t/ N
mon in girls than in boys.1,3 Most boys with CPP
4 ]" H* t0 i. R, j/ @) gmay have a central nervous system lesion that is8 S' L, u2 N+ U/ I; F- n
responsible for the early activation of the hypothal-2 U$ f) [% g* d6 I8 j% O
amic pituitary gonadal axis.1-3 Thus, greater empha-* U) h3 O" E7 m8 k& k# [
sis has been given to neuroradiologic imaging in
) J/ |* L4 t H2 p' Z- \- sboys with precocious puberty. In addition to viril-
( y8 n& {/ J) ^6 ?: z$ O5 uization, the clinical hallmark of CPP is the symmet-* Y6 F5 J% C0 \8 l+ U
rical testicular growth secondary to stimulation by
/ k3 B" \- l- R% [2 X" h9 Y# J# `: O4 |gonadotropins.1,3& M+ F- L. V7 d& ]- U, Q( l+ l4 o8 v: l
Gonadotropin-independent peripheral preco-
N5 B, w8 m- i; C8 |; Icious puberty in boys also results from inappropriate
9 y7 w) g1 ]+ ~* [androgenic stimulation from either endogenous or: e/ n1 c: z: O# Q/ M6 r
exogenous sources, nonpituitary gonadotropin stim-* b4 Z9 x7 ~. N8 R7 u! ~; ~
ulation, and rare activating mutations.3 Virilizing9 p4 m$ C) J1 {% N, k/ ^
congenital adrenal hyperplasia producing excessive
) e, {( x! s" k6 s: U) V$ o2 K% Oadrenal androgens is a common cause of precocious9 u2 ]% W) z! h Q- e6 Q
puberty in boys.3,4
) L( [6 x, ^6 V. F, t2 j4 eThe most common form of congenital adrenal6 B4 |0 V6 [# T; v
hyperplasia is the 21-hydroxylase enzyme deficiency.
# I% V5 [ \; _( U1 M/ V9 m) rThe 11-β hydroxylase deficiency may also result in
+ S2 P1 j9 n* j$ Xexcessive adrenal androgen production, and rarely,
. J0 Q7 i( g! q( W) Ran adrenal tumor may also cause adrenal androgen' k9 U- w, f b
excess.1,37 k; \/ V, C# ]6 D) f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 | ]$ o6 A4 w( m1 M542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% X1 P: ?9 C* h+ ]$ A1 IA unique entity of male-limited gonadotropin-
# p# w# F3 m$ G% d9 i% Rindependent precocious puberty, which is also known9 v U# @1 W5 k0 T- `
as testotoxicosis, may cause precocious puberty at a' l# U4 |1 l& g" u: w; a3 n V
very young age. The physical findings in these boys1 |9 c0 r, t' J/ [( t
with this disorder are full pubertal development,
3 b7 K6 @/ s" C' Gincluding bilateral testicular growth, similar to boys; f+ l/ m4 q* y( A- i
with CPP. The gonadotropin levels in this disorder7 `' q. N0 B4 v1 l) g
are suppressed to prepubertal levels and do not show
5 ^1 j) @( J# T" ]1 j+ A9 Ypubertal response of gonadotropin after gonadotropin-
- ?/ m/ n, r+ zreleasing hormone stimulation. This is a sex-linked$ r7 s4 E4 A9 J4 B' T* e7 z$ A
autosomal dominant disorder that affects only5 f% \4 o3 e8 b. H3 Q4 k& m6 q
males; therefore, other male members of the family4 ^; X; G$ ~# i3 K
may have similar precocious puberty.32 u( q' o4 _" r+ k1 H) r! H
In our patient, physical examination was incon-3 v: F3 c7 h7 G2 F, t" z9 W( G4 N
sistent with true precocious puberty since his testi-$ m! S' X; D# B1 C7 ~* K% }
cles were prepubertal in size. However, testotoxicosis+ F1 @& L- w6 g
was in the differential diagnosis because his father
2 P" L; l5 M- h E; Vstarted puberty somewhat early, and occasionally,3 x1 x/ _ n* R4 ^
testicular enlargement is not that evident in the$ y; B* ^) `! v& A
beginning of this process.1 In the absence of a neg-% w0 n% _7 v8 G3 w- t( o3 {
ative initial history of androgen exposure, our
& S0 K" @7 c2 `$ ?4 Y! U: s8 G& w8 Tbiggest concern was virilizing adrenal hyperplasia,
! C0 A# d% M/ @either 21-hydroxylase deficiency or 11-β hydroxylase
. A! ^, ^3 r( }deficiency. Those diagnoses were excluded by find-
: P) p/ |: l2 G1 G. Ming the normal level of adrenal steroids.! P/ \! I) y b8 T; z
The diagnosis of exogenous androgens was strongly
P3 y5 m4 L" J4 u' R2 Fsuspected in a follow-up visit after 4 months because
3 w6 z0 ^2 m; i+ I. W& b# gthe physical examination revealed the complete disap-
. I" \( k6 u9 X; c# y! wpearance of pubic hair, normal growth velocity, and
]+ e/ h7 F% a- U4 Ydecreased erections. The father admitted using a testos-; F4 c( z9 a4 c; G
terone gel, which he concealed at first visit. He was$ Q- P: c: J" c# z! X
using it rather frequently, twice a day. The Physicians’% B. y) e( C4 v* f. O
Desk Reference, or package insert of this product, gel or5 |, ^4 j4 g% E' t! L( u. d
cream, cautions about dermal testosterone transfer to
4 w `# ^* v# _2 r- cunprotected females through direct skin exposure.6 B2 Q1 M& l8 I: e; L
Serum testosterone level was found to be 2 times the7 W2 i5 ^& v; |' h
baseline value in those females who were exposed to$ L% F: G% M& x6 }! X* A- @
even 15 minutes of direct skin contact with their male5 h" ]4 q6 G4 m0 c- x$ Q& B
partners.6 However, when a shirt covered the applica-. Z2 u Y" |* I) M) [
tion site, this testosterone transfer was prevented.
! j7 L0 T4 x+ a' P; POur patient’s testosterone level was 60 ng/mL,
) [6 {% Y9 C" b! r3 {which was clearly high. Some studies suggest that9 s" X( z! m8 @+ _: I
dermal conversion of testosterone to dihydrotestos-3 ?" r2 c6 q7 l3 f) g# _
terone, which is a more potent metabolite, is more
- g/ K! u( ]/ _5 a2 Uactive in young children exposed to testosterone4 I, g, y. h& M$ h6 K: O* ?
exogenously7; however, we did not measure a dihy-: {0 i) W% U1 B4 s* e7 V# n9 O* f; W; Y
drotestosterone level in our patient. In addition to
* d" s' a) N- {2 Z# \virilization, exposure to exogenous testosterone in* X# g; D, ~1 w' p' j
children results in an increase in growth velocity and- c: S4 X- @6 u! L& l: u5 v
advanced bone age, as seen in our patient." u1 c' \+ G( A! K' v' N
The long-term effect of androgen exposure during
0 }# F" {' V( \( {# `% J! Mearly childhood on pubertal development and final: s' v0 V/ O8 u! N
adult height are not fully known and always remain7 G, F% t* m O) i: B
a concern. Children treated with short-term testos-
2 c% K! e7 I3 i, O, e& v$ L1 Vterone injection or topical androgen may exhibit some; A% P& f7 S3 e! P/ u
acceleration of the skeletal maturation; however, after {5 ]: f9 u9 z4 x: m% n0 ?6 y
cessation of treatment, the rate of bone maturation
8 J. v# p3 n' w' V7 [1 qdecelerates and gradually returns to normal.8,9
" @8 D" c2 u% y2 Y3 iThere are conflicting reports and controversy5 K; N u; |3 `; Y9 M
over the effect of early androgen exposure on adult* U, b3 o, u/ U2 c& U! v/ i0 |. E4 ]
penile length.10,11 Some reports suggest subnormal3 {0 @% P% {, f# w& a0 v
adult penile length, apparently because of downreg-! s G, B2 H* ^* p! p: H( c- |
ulation of androgen receptor number.10,12 However,
7 Y% ]) U; f1 y0 ~+ eSutherland et al13 did not find a correlation between% }7 K+ }$ X4 O. ^- @7 L% ~
childhood testosterone exposure and reduced adult
9 A& S+ U2 h* C( q( g5 hpenile length in clinical studies.
, w% A2 k; \; A( H' t2 F+ `Nonetheless, we do not believe our patient is7 u. k- ]$ O! B+ _+ _
going to experience any of the untoward effects from- s1 t# v3 F/ H) [
testosterone exposure as mentioned earlier because
' q4 Q( [6 g3 Ethe exposure was not for a prolonged period of time.
7 G: z3 ~( K( u% I* pAlthough the bone age was advanced at the time of, M. c( g2 q" \# L, o6 q4 T: ~
diagnosis, the child had a normal growth velocity at2 Q# ?# W3 q4 G5 h3 B
the follow-up visit. It is hoped that his final adult1 N1 T5 Y0 B: j- @- n: B
height will not be affected., D( L' I: t8 D+ T# ~7 i# s
Although rarely reported, the widespread avail-
1 ?6 m+ K5 O; \ability of androgen products in our society may2 d$ e5 D5 Q1 X+ f9 S4 }
indeed cause more virilization in male or female# y) u& F7 D X: U7 A
children than one would realize. Exposure to andro-1 _. D& u' ^4 u6 S2 i
gen products must be considered and specific ques-
$ C d% ~: W- _tioning about the use of a testosterone product or' r4 Q0 |& e; S; T; @! q
gel should be asked of the family members during( }* D7 u1 c: L$ n% k
the evaluation of any children who present with vir-5 c! {: _9 @( i1 s
ilization or peripheral precocious puberty. The diag-
0 j) c. y* X% anosis can be established by just a few tests and by
6 R( W }( Y7 Rappropriate history. The inability to obtain such a
8 B2 d; g+ p ]8 Phistory, or failure to ask the specific questions, may6 s: b0 u2 s; H/ L
result in extensive, unnecessary, and expensive
9 ], Y$ S- S% d! Z* U5 b5 Einvestigation. The primary care physician should be
, s' ~9 k M1 N/ qaware of this fact, because most of these children
9 D# X4 B* ?+ I& s ]9 x3 G. Y: @may initially present in their practice. The Physicians’
6 O- G1 p' D* Q) q! F1 PDesk Reference and package insert should also put a g6 `9 S- j% y
warning about the virilizing effect on a male or
( V5 }3 @, Y! xfemale child who might come in contact with some-
7 X0 H2 |, Y9 oone using any of these products.
, y2 M7 z! [4 E$ ^2 ?References* z$ S# w0 J, q+ G$ Y
1. Styne DM. The testes: disorder of sexual differentiation( I1 ]: u& R y
and puberty in the male. In: Sperling MA, ed. Pediatric& M. _5 }& E/ H5 Z3 p8 B( V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 P- a" R" g% M* y* p8 X5 Y
2002: 565-628.$ a, p& m: A i* {$ R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 M/ v& Z ?4 d# Ipuberty in children with tumours of the suprasellar pineal |
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