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Sexual Precocity in a 16-Month-Old8 y7 p+ I3 S; O! y7 f# }
Boy Induced by Indirect Topical9 c5 P$ B; e% e& k% N
Exposure to Testosterone
b6 L$ w/ R- cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# x* h+ m$ n2 q6 D) d0 V
and Kenneth R. Rettig, MD1
# p: y* q( q* x) G+ _0 q) DClinical Pediatrics Y- Y+ A+ _4 f% K* c: ~$ \
Volume 46 Number 6
: \6 q" f! D" p. C, n0 i% GJuly 2007 540-543, a1 n6 t2 H- M7 r; S
© 2007 Sage Publications0 X+ E, U- M( K1 @, U# Y
10.1177/0009922806296651
" \9 T. y1 a hhttp://clp.sagepub.com$ U+ |: q/ g% `/ o
hosted at
7 ?: K$ s6 A# I* w; {http://online.sagepub.com
7 f, A) G& K6 R! C/ z4 M2 @1 m) j5 o: t; OPrecocious puberty in boys, central or peripheral,' B" g! F" `, D
is a significant concern for physicians. Central
2 C( O; V( ^* x- m* ~precocious puberty (CPP), which is mediated
+ D- q% D0 [! C6 Q0 t \: wthrough the hypothalamic pituitary gonadal axis, has
6 _, K7 `' V+ u7 C( y6 }& la higher incidence of organic central nervous system
0 n' U; z# o/ Z6 F; W. o9 V# ~5 Ulesions in boys.1,2 Virilization in boys, as manifested( K8 q% i5 @: Z7 B8 C7 n8 a
by enlargement of the penis, development of pubic4 y) r9 j' Z# C; |" v
hair, and facial acne without enlargement of testi-
: Y8 Z& d; X% P, b' zcles, suggests peripheral or pseudopuberty.1-3 We |, w i' k2 o; F
report a 16-month-old boy who presented with the4 W H8 u( i* j3 [# y
enlargement of the phallus and pubic hair develop-
8 L' s0 ^1 H3 \ment without testicular enlargement, which was due
% C% c* { w/ Ito the unintentional exposure to androgen gel used by
7 g" h7 [( \3 d# T$ Rthe father. The family initially concealed this infor-
0 m& \4 P- w* D0 m3 w2 n( T6 n& omation, resulting in an extensive work-up for this* L& s3 S9 @- X2 A$ [
child. Given the widespread and easy availability of' q9 y: B0 d N) R0 a$ a
testosterone gel and cream, we believe this is proba-/ m, n% f }3 o! U& `! P/ e
bly more common than the rare case report in the# k( H6 x* W% v2 w5 W N
literature.4
, y; g( D7 h% ]+ f: Q8 b# }6 wPatient Report
) f5 R3 f* a$ o: AA 16-month-old white child was referred to the
6 c* S: n$ ~8 N/ n9 _! Sendocrine clinic by his pediatrician with the concern$ u/ G. N7 ~8 z4 B7 T! H1 S1 i+ b
of early sexual development. His mother noticed
1 M( V5 q( {! }& a5 xlight colored pubic hair development when he was
9 m( I! Y; c" s2 S2 r/ mFrom the 1Division of Pediatric Endocrinology, 2University of" |; j- r( D7 j8 _4 s
South Alabama Medical Center, Mobile, Alabama.6 R+ r/ k/ k1 q6 a! g5 x5 }* h. v
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& K) |5 t: {! @6 ~# nProfessor of Pediatrics, University of South Alabama, College of' V2 k; o9 o D5 d. U' x: q6 @" u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 o9 E/ \! p! ^- ~: j
e-mail: [email protected].
7 i8 ~( ~3 J3 X2 P/ }; l& k" zabout 6 to 7 months old, which progressively became
4 l! r7 y4 F9 b' xdarker. She was also concerned about the enlarge-/ b2 q( B& |6 \
ment of his penis and frequent erections. The child
- F1 O9 I/ m* K7 n- o# L! rwas the product of a full-term normal delivery, with3 Q: H# V+ N" u1 N6 i: q
a birth weight of 7 lb 14 oz, and birth length of+ H8 J0 s" I2 X( ]) U' |2 N
20 inches. He was breast-fed throughout the first year
. E1 R6 v$ Q Uof life and was still receiving breast milk along with
% @' D$ }2 R" K# \# E# esolid food. He had no hospitalizations or surgery,
* n7 o2 `1 ^2 I6 q& M2 }) Kand his psychosocial and psychomotor development4 q; F6 C3 H& c1 {% f
was age appropriate.4 k: I2 x, z+ O8 A7 _- F4 j: I
The family history was remarkable for the father,7 o/ U8 @7 m1 u! B8 s
who was diagnosed with hypothyroidism at age 16,
, m$ i; J# I& c9 Z9 zwhich was treated with thyroxine. The father’s9 _5 I: R; p6 J2 O1 B* W* g
height was 6 feet, and he went through a somewhat
' _1 ]. x: ~+ o- Qearly puberty and had stopped growing by age 14.
- q2 [' _- K& wThe father denied taking any other medication. The0 h, j2 r# U/ u: X
child’s mother was in good health. Her menarche% e- U# L" H+ S
was at 11 years of age, and her height was at 5 feet
: L6 |: G: [+ Z. x8 t4 x3 i5 J5 inches. There was no other family history of pre-9 a; Q4 W8 H5 x1 `; F
cocious sexual development in the first-degree rela-& u/ \% a- o9 e. `" o' h, [
tives. There were no siblings./ S6 r1 m, @5 m; g
Physical Examination' j" @4 P! n& `' C b7 G
The physical examination revealed a very active,0 j! W/ W" J- D/ G- Y
playful, and healthy boy. The vital signs documented! Z" c# u+ [, A. K9 c0 T- X! G v
a blood pressure of 85/50 mm Hg, his length was. ~- M: [' z/ ^0 Q6 @9 e Q
90 cm (>97th percentile), and his weight was 14.4 kg
# b5 o. x( H9 I6 }(also >97th percentile). The observed yearly growth
' G0 g3 V# i) Y3 D, `6 \+ _( Yvelocity was 30 cm (12 inches). The examination of& g5 Q- H% q) R
the neck revealed no thyroid enlargement./ e" F) p3 @- S! b3 N$ v0 k
The genitourinary examination was remarkable for
) a/ m# w* c7 C/ Henlargement of the penis, with a stretched length of
( {- D* T/ p% m, q/ g9 J: u8 cm and a width of 2 cm. The glans penis was very well
N$ S, \+ x! w; cdeveloped. The pubic hair was Tanner II, mostly around/ ?/ V! B* s$ V, n
540
+ b! J7 m- T7 e. Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
T% @% l$ }1 [) r; W+ f) _* H/ Nthe base of the phallus and was dark and curled. The
, i$ t$ B: D& _4 Q1 w* ~! Stesticular volume was prepubertal at 2 mL each.
+ d% v) l& g) U. }% e; q0 ~The skin was moist and smooth and somewhat
' |+ z, [. I1 xoily. No axillary hair was noted. There were no7 e) V) y+ B( c" a; {2 ]4 P( {
abnormal skin pigmentations or café-au-lait spots.8 m, Z _1 L6 t: P1 M8 M5 Y
Neurologic evaluation showed deep tendon reflex 2+
7 d+ x! O# _& [0 l0 Ebilateral and symmetrical. There was no suggestion
0 K, b1 A: H |* Z+ fof papilledema.$ z- ~3 j3 ~3 D( g; \% Y# q
Laboratory Evaluation9 z, a0 j, J8 U% d# l2 b
The bone age was consistent with 28 months by. ~4 g) }, i; ?9 M5 c
using the standard of Greulich and Pyle at a chrono-% [8 ?. K3 L6 K- J2 E0 h' Z8 l& Z
logic age of 16 months (advanced).5 Chromosomal( }7 L7 {5 s' G. N
karyotype was 46XY. The thyroid function test. _$ _- v" j7 g8 b4 b# C
showed a free T4 of 1.69 ng/dL, and thyroid stimu-- Y! ]9 W" ]/ |# |! e
lating hormone level was 1.3 µIU/mL (both normal).
; B! B" K) O, }, e5 M" c5 qThe concentrations of serum electrolytes, blood
* Q6 [5 e5 g7 S% h. Eurea nitrogen, creatinine, and calcium all were& @9 E# L0 m# F! A
within normal range for his age. The concentration: Y* a0 i. ~, M& Y9 X
of serum 17-hydroxyprogesterone was 16 ng/dL
- z; F8 L. s# f5 K' k(normal, 3 to 90 ng/dL), androstenedione was 208 W( P( B, M: m$ ~
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! A \( I: |1 E& T' D5 mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! a- ~+ l, U3 U. Y1 [) s9 Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 c6 s6 Q5 S! [8 a5 \9 l49ng/dL), 11-desoxycortisol (specific compound S)4 V# {/ q6 e: V: V6 m+ R I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 g3 `; w' O& P7 K5 q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ e6 X; X! q v5 ]( f5 L
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 D: e* a7 Q: [
and β-human chorionic gonadotropin was less than1 M# P, ^8 f/ [; d5 }' V4 m2 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular( \$ \5 E: E/ C) E7 q9 O
stimulating hormone and leuteinizing hormone
5 u0 ]: o. j( p: N5 ~6 }8 z! tconcentrations were less than 0.05 mIU/mL
7 r9 s, h, Q, c1 a! u% u(prepubertal).
) n0 |- F V6 k8 e; {8 Y1 xThe parents were notified about the laboratory, P: {( W$ K) C
results and were informed that all of the tests were1 x$ b$ \4 L O
normal except the testosterone level was high. The
# ?3 D7 Y! r: B) A% Ofollow-up visit was arranged within a few weeks to7 z$ w# I$ q" l8 P- P3 L! r
obtain testicular and abdominal sonograms; how-3 Y @& a, D& B% [7 d
ever, the family did not return for 4 months.+ \9 ?# A$ e) l4 ?- H; [$ D! E! c' {6 ?# u
Physical examination at this time revealed that the8 D5 P; ]3 g* C4 ?# Y/ R4 Q
child had grown 2.5 cm in 4 months and had gained
2 {! m: C9 k/ G3 X$ I' ?3 g+ w# D2 kg of weight. Physical examination remained7 C2 R+ V/ ]9 C5 g
unchanged. Surprisingly, the pubic hair almost com-9 W6 s- l$ D+ t# K# A, e1 {% Q5 a
pletely disappeared except for a few vellous hairs at
. N! e7 ~; q5 |5 }2 M# [6 jthe base of the phallus. Testicular volume was still 2* b9 }( V% y. M
mL, and the size of the penis remained unchanged.8 b+ m! ], ^- i# Z9 j1 v0 i
The mother also said that the boy was no longer hav-
" c' y6 Z# }) k0 D: r1 |ing frequent erections.+ t+ o0 k0 @; ?9 D
Both parents were again questioned about use of
! D: o4 o1 a3 O# }, i2 h1 [any ointment/creams that they may have applied to
8 E9 c+ C$ U. Wthe child’s skin. This time the father admitted the- T/ v g6 }5 T& l$ y9 M( a' ?
Topical Testosterone Exposure / Bhowmick et al 541# J0 z0 V8 |# r
use of testosterone gel twice daily that he was apply-% E+ [0 ~- Z Y
ing over his own shoulders, chest, and back area for" h n7 S h5 [' \6 i3 [$ G
a year. The father also revealed he was embarrassed
9 M, c' Y7 ?2 tto disclose that he was using a testosterone gel pre-
) N- R) t K4 f; y1 N5 \7 [scribed by his family physician for decreased libido
/ V: {" f4 e( S# A$ b9 vsecondary to depression.
2 |! b6 P5 o1 b z4 A2 j: U) GThe child slept in the same bed with parents.) x9 }9 U% _) h. l* h+ i" K
The father would hug the baby and hold him on his
, h, t# Y9 x/ B2 P. Ychest for a considerable period of time, causing sig-; ^$ @! I9 Y4 b+ \
nificant bare skin contact between baby and father.
% _! `: d. l# u9 ^The father also admitted that after the phone call,
: L5 C: y8 z8 k& g3 Mwhen he learned the testosterone level in the baby3 v9 _7 o9 c- Q6 m- z
was high, he then read the product information
% R0 I, I, Y2 epacket and concluded that it was most likely the rea-
4 H& U: H' q1 \" ^* c& tson for the child’s virilization. At that time, they
4 ?0 F/ V! ~% O2 j, r/ e% s6 [: W: idecided to put the baby in a separate bed, and the
$ h) k6 h* W% ~5 O3 ^father was not hugging him with bare skin and had0 r: G4 O/ t8 B K5 b
been using protective clothing. A repeat testosterone
% u5 n: A2 e! ] o) }% xtest was ordered, but the family did not go to the
4 ^! ~! p f8 f& claboratory to obtain the test.
0 o3 n2 }- ^. `+ c4 W5 n: _8 ^Discussion4 o) q8 C/ j+ J* @+ n
Precocious puberty in boys is defined as secondary
! d# H5 }/ D. Y% \8 }sexual development before 9 years of age.1,4/ K' U* W# c! \
Precocious puberty is termed as central (true) when; v1 K) k0 d- E, W
it is caused by the premature activation of hypo-
5 C, K+ ]1 d/ j }+ Ythalamic pituitary gonadal axis. CPP is more com-
) c3 X( I7 b/ H6 { tmon in girls than in boys.1,3 Most boys with CPP
. z% _* I! v9 }6 p" g& Q# emay have a central nervous system lesion that is
! E5 b- }' T( i( \3 B6 U- J# u0 Zresponsible for the early activation of the hypothal-/ Y. Z) d$ f, N, P8 u. N
amic pituitary gonadal axis.1-3 Thus, greater empha-
. I: w) ~6 t+ h- n( V4 |& w8 esis has been given to neuroradiologic imaging in. u) @: d7 U$ {' u2 y4 E
boys with precocious puberty. In addition to viril-9 B8 [/ M7 E3 r
ization, the clinical hallmark of CPP is the symmet-
[3 C0 i5 j+ [! J4 brical testicular growth secondary to stimulation by
+ d3 ^# @: z8 o/ o( m6 q. w$ igonadotropins.1,3( @* p& j/ S7 T% d: U
Gonadotropin-independent peripheral preco-
0 ?7 T0 P; Z+ \4 p n) Z. }cious puberty in boys also results from inappropriate
?; ~" ` ^0 _" ] W, oandrogenic stimulation from either endogenous or+ G9 Q; \1 {, @) f& B3 D
exogenous sources, nonpituitary gonadotropin stim-7 k+ B" A: K9 {" @8 G; d
ulation, and rare activating mutations.3 Virilizing
v: m8 m* q# j ?congenital adrenal hyperplasia producing excessive. |0 I! l2 k8 U8 V
adrenal androgens is a common cause of precocious9 a }$ {' M% D, Q$ H, ?
puberty in boys.3,4
R# e& }* W8 m4 c- d7 e& ~The most common form of congenital adrenal `- Z. q8 Q8 u+ P7 f( n/ x
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 H2 e( A$ B; }# X/ S3 `The 11-β hydroxylase deficiency may also result in: X0 n1 r2 K2 }. y
excessive adrenal androgen production, and rarely,
; [8 Y7 M5 m/ R8 H0 k9 {an adrenal tumor may also cause adrenal androgen/ S7 c- F8 n5 \- e
excess.1,3/ E" h) ?. G2 V) A' o0 V) d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. L# }6 [( Q8 o+ l" N. `) P# j( ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) O8 Q% Y& l- E8 k- |* |6 N$ ]A unique entity of male-limited gonadotropin-8 r/ q$ D7 i9 R/ a2 R' I, C
independent precocious puberty, which is also known1 x5 M! J( `) r
as testotoxicosis, may cause precocious puberty at a9 s" k& k3 x* G& f7 H0 O1 X& r6 W7 N
very young age. The physical findings in these boys
, x& P4 g, I U1 b6 Swith this disorder are full pubertal development,
1 V2 N/ o5 G: i4 x0 Qincluding bilateral testicular growth, similar to boys
' w, h2 {% |& cwith CPP. The gonadotropin levels in this disorder3 E& [. \' J3 R4 }0 w
are suppressed to prepubertal levels and do not show
- P" K) w' f/ P# {pubertal response of gonadotropin after gonadotropin-
* ?3 R) ~" O: Ireleasing hormone stimulation. This is a sex-linked' x0 J, J. I8 f V
autosomal dominant disorder that affects only. w8 }9 p& z$ |8 d; s6 E4 z1 ^
males; therefore, other male members of the family# A+ g: D4 D; y6 b, R
may have similar precocious puberty.37 P5 S5 Z" x4 H2 {) {
In our patient, physical examination was incon-" H$ Z3 S4 U" \4 Q9 j/ T
sistent with true precocious puberty since his testi-* k1 o4 D/ O. S9 f- ]9 M
cles were prepubertal in size. However, testotoxicosis4 G3 i2 m4 |4 h6 I _$ U
was in the differential diagnosis because his father- o% f$ b4 k3 r/ K! o3 B2 L. J
started puberty somewhat early, and occasionally,
/ n, R5 O( L. q0 E/ r& G& ?2 _6 ctesticular enlargement is not that evident in the& E9 \% _# F4 n! R
beginning of this process.1 In the absence of a neg-
. _. ^; @- Z& r0 k6 ~( pative initial history of androgen exposure, our
7 C% @3 `2 g- lbiggest concern was virilizing adrenal hyperplasia,# v- y# v9 Y8 l1 o$ x
either 21-hydroxylase deficiency or 11-β hydroxylase. u \2 b5 T# i: N4 |& k$ {" U
deficiency. Those diagnoses were excluded by find-
* C- ^( ^4 j2 n ]0 U. King the normal level of adrenal steroids./ I8 F2 D. d" i. K
The diagnosis of exogenous androgens was strongly, ]# U& v# k# F
suspected in a follow-up visit after 4 months because* s7 R5 N3 Y% k1 c2 c
the physical examination revealed the complete disap-
+ e8 ?7 @( S0 ~$ w% J, Hpearance of pubic hair, normal growth velocity, and! Q% X& v f+ ^7 X; O4 R& T
decreased erections. The father admitted using a testos-
2 K3 Y3 P8 Q* P }. G: sterone gel, which he concealed at first visit. He was$ f8 d/ q* ]% K; l) {; L& y
using it rather frequently, twice a day. The Physicians’
0 T/ ~4 Z3 N z1 W7 f3 TDesk Reference, or package insert of this product, gel or
5 T* r* m% _/ x, F( {( n+ a* g0 S" Gcream, cautions about dermal testosterone transfer to8 c/ G j/ f' ]. P. ~
unprotected females through direct skin exposure.
# M0 R. k& E k% Z! DSerum testosterone level was found to be 2 times the/ G$ Y" ~* r, v+ P
baseline value in those females who were exposed to
" q" S) c9 _+ }) q$ Z' j7 Neven 15 minutes of direct skin contact with their male
% g7 B2 @5 F3 [- d1 a& X jpartners.6 However, when a shirt covered the applica-
$ ^0 z" S. `) j, A( ~tion site, this testosterone transfer was prevented.
$ K4 }7 {3 |2 @& {3 DOur patient’s testosterone level was 60 ng/mL,
Y2 P; N7 b: e3 Q. vwhich was clearly high. Some studies suggest that6 [7 A& d) ?5 L: C( K% L3 y
dermal conversion of testosterone to dihydrotestos-
- H* n5 V x. ?9 S& g- a+ k6 Pterone, which is a more potent metabolite, is more5 v( U. E- y5 ?+ F: X1 E5 z) k8 |
active in young children exposed to testosterone8 J- h! L% Y2 R# g* a. a
exogenously7; however, we did not measure a dihy-
! }# ]$ a9 E- ] c# ~drotestosterone level in our patient. In addition to
. G; \- H: Z9 Q3 z; p) E9 a2 H( ]virilization, exposure to exogenous testosterone in
5 Z* f8 q, b4 a. W- z0 gchildren results in an increase in growth velocity and
. h8 v9 ~1 ]7 F: wadvanced bone age, as seen in our patient.' Z! G4 n, G. N6 ?
The long-term effect of androgen exposure during
8 e2 ?" d2 D! F- hearly childhood on pubertal development and final
# Y0 m _6 K: badult height are not fully known and always remain
, d! M7 z$ Y7 i- S* U( oa concern. Children treated with short-term testos-
+ O) i. `" m; ^/ L6 f" k. c- Sterone injection or topical androgen may exhibit some$ r* \# i- s' `1 S
acceleration of the skeletal maturation; however, after8 X0 _- `% `! [. X# d
cessation of treatment, the rate of bone maturation
* F( D3 R( T0 x/ X1 o$ U" S* }decelerates and gradually returns to normal.8,9
, g! l' y$ H- l0 k2 D/ nThere are conflicting reports and controversy
- @; @8 a" Y& p' V2 l. [# iover the effect of early androgen exposure on adult
! S* F" f+ P, h8 ^# x( Bpenile length.10,11 Some reports suggest subnormal
. ~6 M# ]1 \' ]adult penile length, apparently because of downreg-/ M/ \ x3 a; w% H" E8 ?' [
ulation of androgen receptor number.10,12 However,
. Z- i3 X3 R8 J5 L$ ^Sutherland et al13 did not find a correlation between
, @7 y& E% N8 v) W, nchildhood testosterone exposure and reduced adult5 C7 \$ u/ b: P1 W
penile length in clinical studies.( i }+ O; A( f5 c1 \
Nonetheless, we do not believe our patient is
* a5 `% t N4 a8 T, c6 F. ygoing to experience any of the untoward effects from
, Q" D: g. ?4 |- Utestosterone exposure as mentioned earlier because/ \' A* @( _* L
the exposure was not for a prolonged period of time.
) p" K/ U: V! ]Although the bone age was advanced at the time of) ~% s7 f2 P" u# p
diagnosis, the child had a normal growth velocity at* A/ l4 ]& L, p" e- L7 ~4 v
the follow-up visit. It is hoped that his final adult
s4 z, q- H2 L. d# t; yheight will not be affected.$ b0 v* f/ r* [+ e
Although rarely reported, the widespread avail-: X1 a7 h& [6 S' k/ O, i, n9 n( ~
ability of androgen products in our society may
- Y) {( J5 {! A* `" mindeed cause more virilization in male or female# O. l) z$ s* p& i1 {! X5 o
children than one would realize. Exposure to andro-
) v( N0 n0 j4 X, `' ^. zgen products must be considered and specific ques-
$ y+ a6 I+ M& |3 o6 a6 Gtioning about the use of a testosterone product or( ]( D* T; N: H8 A
gel should be asked of the family members during7 N. _% y- R) h( T8 M
the evaluation of any children who present with vir-
! u. y% C- g. F8 @. A2 W tilization or peripheral precocious puberty. The diag-
. b& \ O2 G. z( N: anosis can be established by just a few tests and by
4 ]. d+ \- u/ happropriate history. The inability to obtain such a
& ]5 a: a9 q$ E! L0 R0 {# ^* uhistory, or failure to ask the specific questions, may* k/ V3 G+ `- O. s8 Z
result in extensive, unnecessary, and expensive
q" y6 l3 X3 Q/ k' F9 a6 rinvestigation. The primary care physician should be
2 @3 q- n9 @. k4 E# taware of this fact, because most of these children9 J9 d, Z) ~- |! }3 c
may initially present in their practice. The Physicians’
) B6 H' i# J; o7 ?% tDesk Reference and package insert should also put a' _' t4 V# B6 n( ?$ ?7 } R
warning about the virilizing effect on a male or
. u9 U; Y; @) p' tfemale child who might come in contact with some-7 f/ M7 C: z4 x1 R6 x# m
one using any of these products.) Z5 y8 j; h! V9 A5 M: ~
References
* u" e: ]$ d3 {5 g6 w6 E+ @) y, M1. Styne DM. The testes: disorder of sexual differentiation9 q. z. Z* P) L5 [$ g6 g Y
and puberty in the male. In: Sperling MA, ed. Pediatric
4 I& p& k4 ]/ V9 q" |6 s0 T2 nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( y3 ^# Z, M- y& Q, ?" X2002: 565-628.9 u7 I% X/ M% U$ }9 [2 p4 B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* w) l' T0 _. t: B7 p% t" Epuberty in children with tumours of the suprasellar pineal |
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