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Sexual Precocity in a 16-Month-Old
/ H; g4 C8 G& R: w" ~! CBoy Induced by Indirect Topical( r$ Z, Q! ^6 R4 S/ r9 B- j
Exposure to Testosterone) X) }( Q% ]+ o9 Z2 d" i! A7 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 R' y) l- {# U# D
and Kenneth R. Rettig, MD1- \! a) P3 z/ i8 L- B M
Clinical Pediatrics3 d8 p. [- G, [- k I/ Y4 ?3 A: |
Volume 46 Number 6
* ~5 a3 I& I8 R5 a3 eJuly 2007 540-543
* M* `4 \) x, \# j+ ^# a% @" H© 2007 Sage Publications0 N- ?. b% u& [
10.1177/0009922806296651
/ b3 x$ R9 a8 E+ ]$ M; s! phttp://clp.sagepub.com
$ O& A+ _' J( Q( @8 Ghosted at
4 V% r M; @1 K1 phttp://online.sagepub.com! }9 y- x; f. {* L3 Q
Precocious puberty in boys, central or peripheral,6 ?3 A9 }1 ~- W' g- @
is a significant concern for physicians. Central* T& Y% A( Q' p
precocious puberty (CPP), which is mediated
, g$ D0 p8 y- h( ^8 q) v* Qthrough the hypothalamic pituitary gonadal axis, has
5 P5 Q- Z) B @! N" O+ }* }* xa higher incidence of organic central nervous system
$ b' b" t) D# @; G/ M9 n; D$ P/ `lesions in boys.1,2 Virilization in boys, as manifested) M$ e: [* J& L" G9 D- ?. {
by enlargement of the penis, development of pubic# U0 U1 c$ ]+ ` Q/ Y# H
hair, and facial acne without enlargement of testi-7 l1 p, C+ t1 t
cles, suggests peripheral or pseudopuberty.1-3 We) l/ A( d% Y& t8 B
report a 16-month-old boy who presented with the
+ R% h$ g. S' t' K( G0 m: Ienlargement of the phallus and pubic hair develop-
; t6 ?/ x4 T z' Wment without testicular enlargement, which was due- V* N4 x/ t7 m/ J" V' j- M, a
to the unintentional exposure to androgen gel used by8 X& j0 w1 H0 E2 g
the father. The family initially concealed this infor-! W" q* e& L* k2 }1 x' s
mation, resulting in an extensive work-up for this/ r9 G$ e- O' O
child. Given the widespread and easy availability of7 \; J4 ~% [# ~- g( G9 {
testosterone gel and cream, we believe this is proba-% \! T7 j0 F3 K9 n
bly more common than the rare case report in the7 w. c( A5 k, l4 T% s
literature.4
2 l. U7 N3 G, P! ?; u+ pPatient Report
$ Q$ v) j3 p2 ?$ K" l! |& KA 16-month-old white child was referred to the
4 H* ^4 q& z' }7 ]4 Q" Kendocrine clinic by his pediatrician with the concern7 B8 R( v H4 {- F" Y# ?) \
of early sexual development. His mother noticed% p6 I) o9 |5 @
light colored pubic hair development when he was7 ~3 f3 { b5 b7 \, g8 I
From the 1Division of Pediatric Endocrinology, 2University of5 M+ t) I) H" q( O! x
South Alabama Medical Center, Mobile, Alabama.6 M7 o' D/ {2 v8 S3 k `+ X+ T/ P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 l3 V! k, Q* i$ [Professor of Pediatrics, University of South Alabama, College of% l, v5 I. n1 u/ O' @2 g' B4 Q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% G& a1 b) I* G
e-mail: [email protected].! A4 `) |, A. R, D9 K
about 6 to 7 months old, which progressively became
. D, y4 O9 _! o1 wdarker. She was also concerned about the enlarge-
; s# P, M2 v) s5 x( u& J8 Bment of his penis and frequent erections. The child ` w* q/ g* C3 x/ W+ G
was the product of a full-term normal delivery, with
0 H8 \7 f) _) q, J- T4 S# @a birth weight of 7 lb 14 oz, and birth length of
/ K+ S2 {+ q! O8 `. F3 [20 inches. He was breast-fed throughout the first year
) i$ A# v: G8 d8 j/ T/ M. u9 Iof life and was still receiving breast milk along with/ z# x/ z3 i# K) b
solid food. He had no hospitalizations or surgery,3 X2 U8 o' D" [
and his psychosocial and psychomotor development4 l" C. R v( I, J( R: Z, c9 {
was age appropriate. r. ?! z4 O: q& ~+ p/ @
The family history was remarkable for the father,9 S& Q, L, r. g$ ~- i
who was diagnosed with hypothyroidism at age 16,# U) z1 q0 C. V7 H" o2 F
which was treated with thyroxine. The father’s' E( [+ o$ Z |3 a3 Q
height was 6 feet, and he went through a somewhat
6 X+ g) b, h. m% o7 Dearly puberty and had stopped growing by age 14.7 z \( r; f# C* o- i
The father denied taking any other medication. The
, N6 m. c9 _4 _3 Y& e; s2 h7 h, ochild’s mother was in good health. Her menarche
0 z. W/ [( O e) hwas at 11 years of age, and her height was at 5 feet
# S2 J' p! A8 B# b* m5 inches. There was no other family history of pre-
' g6 |: o. y# `! dcocious sexual development in the first-degree rela-) C% ]. _& r8 \
tives. There were no siblings.: I; p9 l* \* x5 X; n
Physical Examination( M5 x: e: j- i' j, z
The physical examination revealed a very active,
5 @9 u9 g9 b9 S: _' J0 Rplayful, and healthy boy. The vital signs documented
* m1 [7 W \$ Na blood pressure of 85/50 mm Hg, his length was
( R3 y8 i$ `* K' M* e% B* c( r90 cm (>97th percentile), and his weight was 14.4 kg
' u8 @4 J3 \* l3 e) n, ]& @3 j(also >97th percentile). The observed yearly growth
4 K# Y& i: ^7 m3 z7 mvelocity was 30 cm (12 inches). The examination of
& ?6 U/ v/ I1 tthe neck revealed no thyroid enlargement.% p2 _8 E: K2 g% x3 L, ~2 D0 Z+ x
The genitourinary examination was remarkable for
' m h: t! c) M' Q* }+ Y% Uenlargement of the penis, with a stretched length of6 a# T6 y' ?; H5 D% \
8 cm and a width of 2 cm. The glans penis was very well
$ W5 B* n6 n5 O; Bdeveloped. The pubic hair was Tanner II, mostly around) i+ ~( Y8 a& o% r+ W
540& P# u4 {1 m( O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ \6 D$ R& w9 |( O" z: |
the base of the phallus and was dark and curled. The
. I n. w) _8 otesticular volume was prepubertal at 2 mL each.
4 h0 F V" ^7 V3 e: ?6 x L. @The skin was moist and smooth and somewhat
s" f2 s- L0 \* }8 d4 ioily. No axillary hair was noted. There were no/ P9 ] _. S) u
abnormal skin pigmentations or café-au-lait spots.) v8 x4 U' F3 O4 o. f+ ]4 C3 {
Neurologic evaluation showed deep tendon reflex 2+
' F+ z% l2 F. T2 Kbilateral and symmetrical. There was no suggestion9 @ _) Y5 x+ G& [
of papilledema.- Q/ F# L! x! P3 l
Laboratory Evaluation1 s6 v" m* c8 J+ d; F
The bone age was consistent with 28 months by
+ v6 c. ?- `$ F* A' K9 Husing the standard of Greulich and Pyle at a chrono-. z2 S9 M/ D; E' t$ S
logic age of 16 months (advanced).5 Chromosomal, i/ D$ W9 J$ N6 X
karyotype was 46XY. The thyroid function test# H/ G& V9 @' X0 \( J% _
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. G, D, k$ w9 m. ?4 D1 klating hormone level was 1.3 µIU/mL (both normal).. i q- V" n9 I5 u3 {2 d7 V
The concentrations of serum electrolytes, blood
* a8 L* _! Z/ g% L3 N, P4 E8 [urea nitrogen, creatinine, and calcium all were
. c. a4 ^" ]) b4 j3 Jwithin normal range for his age. The concentration3 R" a9 T+ w v4 a9 [
of serum 17-hydroxyprogesterone was 16 ng/dL# S- X0 B, [$ t/ H( V4 K$ `# v. X: L
(normal, 3 to 90 ng/dL), androstenedione was 201 k, W5 j4 d# R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; Y, K$ Q. ?& g( h1 ~+ ~" g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 a7 H- Y0 J7 s" X$ Q+ g' V6 zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# V* Q$ h7 ]* L$ N w; t: v6 s9 W* p49ng/dL), 11-desoxycortisol (specific compound S)' o' e- j \0 K$ u- {! q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% |# d9 S4 R9 O" R" _8 d# c# N4 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 O K# S" U8 f9 ~& F2 u3 P: t0 R ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( f5 o# [# O/ r: h( _and β-human chorionic gonadotropin was less than
+ @( ]5 O' Y% r5 e( I; J6 @5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 ^9 x; x. J! L, c$ j6 x5 v4 N, Y/ Nstimulating hormone and leuteinizing hormone& Y" Y# s- c8 q3 O8 N4 {
concentrations were less than 0.05 mIU/mL
5 ]+ J5 ~$ ^+ ~: F7 H* U6 R(prepubertal).4 Z3 P [ Q) f# X' p$ ]6 t
The parents were notified about the laboratory: c8 p- ~- B8 P$ H- [. W7 ]
results and were informed that all of the tests were# N# C0 a9 K, `, r3 [; q
normal except the testosterone level was high. The3 H% |' h8 k$ ^$ z* a" t
follow-up visit was arranged within a few weeks to8 V7 E% K/ i3 b3 j0 `
obtain testicular and abdominal sonograms; how-( I0 H+ N3 [' J7 p
ever, the family did not return for 4 months.: M! [8 X# A0 O# @4 [6 w
Physical examination at this time revealed that the
) @, |5 |, l) \; r# s* r( Ichild had grown 2.5 cm in 4 months and had gained
- _* u2 s" r" l, _2 kg of weight. Physical examination remained
* p: j# m, }/ Zunchanged. Surprisingly, the pubic hair almost com-
' o, p- A0 y/ v5 hpletely disappeared except for a few vellous hairs at
; R" r6 y8 o+ I/ R4 j+ d& Othe base of the phallus. Testicular volume was still 2' @+ y, k0 G+ C' x- e
mL, and the size of the penis remained unchanged.1 b$ F6 i1 H# y0 Y
The mother also said that the boy was no longer hav- t$ H. i) G Y4 c6 g6 O0 {- c
ing frequent erections.! \5 j0 x: s) C2 o8 V( Y
Both parents were again questioned about use of* G3 z( _3 K" r: l4 N
any ointment/creams that they may have applied to- s$ ]9 f/ K5 E# i2 E
the child’s skin. This time the father admitted the
* B9 U( P8 s! JTopical Testosterone Exposure / Bhowmick et al 541( W0 M4 W8 z8 H) J7 E& o$ g0 _" s: s
use of testosterone gel twice daily that he was apply-, _' N w0 ?* a+ |# W3 W& V v
ing over his own shoulders, chest, and back area for/ i/ e' {* x9 ^; e( i
a year. The father also revealed he was embarrassed/ I* R* H, G) c; L6 ^6 j4 U
to disclose that he was using a testosterone gel pre-; c y) d% h/ Z) Y R6 j: S
scribed by his family physician for decreased libido
6 M$ \( T" S0 f7 `# Rsecondary to depression.
2 x- S: O1 R( x8 a" ^, x) IThe child slept in the same bed with parents.
9 D9 Q$ N& ~9 L `The father would hug the baby and hold him on his
& M3 k5 a! X0 i7 C/ e- ~) ichest for a considerable period of time, causing sig-* n* u" g3 |& Z: L
nificant bare skin contact between baby and father.
8 O. |* Z& v: V9 T5 G. L( P/ RThe father also admitted that after the phone call,. }2 U; q& ^$ o6 U; z
when he learned the testosterone level in the baby
; D# G8 x x# \& M% g- D" Jwas high, he then read the product information
4 |. A# |+ |8 M9 \packet and concluded that it was most likely the rea-
7 M* f6 V. P5 Z4 _; @, L3 l/ D! ison for the child’s virilization. At that time, they
4 J) R9 a2 i8 [9 Z; G3 t4 qdecided to put the baby in a separate bed, and the
|% u5 R' n Z2 V1 Bfather was not hugging him with bare skin and had
* ]4 r3 y) O- d0 x: u; {, ^5 obeen using protective clothing. A repeat testosterone7 w( }, ~( `5 m, W" |) T1 Q
test was ordered, but the family did not go to the
% @* ?( F' r( J; ^# W; g/ g3 Mlaboratory to obtain the test.1 |, o) e0 X- D1 H; O+ o& I
Discussion
# J7 W+ a L2 e6 o7 wPrecocious puberty in boys is defined as secondary
' V/ k, y2 Z, asexual development before 9 years of age.1,4
, u' Z5 {; W% W% ]" A2 HPrecocious puberty is termed as central (true) when
" O" l1 y/ k2 t1 A% v/ ]it is caused by the premature activation of hypo-* I% g. @ ?. c# B0 \& O/ P
thalamic pituitary gonadal axis. CPP is more com-
0 [9 P, h( O* F- f3 R6 j0 tmon in girls than in boys.1,3 Most boys with CPP* ~2 e) T! Z' U& ]4 E8 T
may have a central nervous system lesion that is2 X( u- l' o; v- l
responsible for the early activation of the hypothal-4 y8 |; a- P; e3 n7 v
amic pituitary gonadal axis.1-3 Thus, greater empha-+ f. F: j6 v/ Y2 i. H
sis has been given to neuroradiologic imaging in
* R) }6 t* ~+ g$ V& [boys with precocious puberty. In addition to viril-* x1 t9 n$ i8 X. ?+ N# ^
ization, the clinical hallmark of CPP is the symmet-
# ~ V! s& @- I6 ^0 A9 Zrical testicular growth secondary to stimulation by
. B' Y( \* v% Lgonadotropins.1,3
' J" X W. k% qGonadotropin-independent peripheral preco-* W. ^+ {) ] y2 p9 {9 C# G0 A% Y
cious puberty in boys also results from inappropriate8 F- C% S) Q) f+ z
androgenic stimulation from either endogenous or
- P( ?* \- B$ H/ s6 d! R' Lexogenous sources, nonpituitary gonadotropin stim-
: B: A9 W. k& i! q+ i/ G- zulation, and rare activating mutations.3 Virilizing
8 j7 x3 _5 H! r6 o- _+ jcongenital adrenal hyperplasia producing excessive
' A: W% C. b$ b; F9 Badrenal androgens is a common cause of precocious- P% y0 z, ]6 {- ~ q, `9 o. T3 ?, B0 R7 M
puberty in boys.3,4( W1 E& P6 \2 W8 O0 v' M/ `. |
The most common form of congenital adrenal* ]- J7 b( S+ P8 o
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 I. k. K4 b2 w# P0 ?- AThe 11-β hydroxylase deficiency may also result in
- R# j* Z* r. p+ Q7 Xexcessive adrenal androgen production, and rarely,
; U, A8 E7 L8 A3 L- f$ Kan adrenal tumor may also cause adrenal androgen2 k( i, [7 V) ~) C8 l8 _0 n# c
excess.1,3) z1 P& x1 ^$ |9 Z7 K) H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ X" j% g# m+ l9 u2 A542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 Y" O# Y- k- M
A unique entity of male-limited gonadotropin-1 p# {: K5 _" X7 e% R
independent precocious puberty, which is also known9 i* D8 r( r6 }) d( i
as testotoxicosis, may cause precocious puberty at a, n3 F- ]% `8 j' W7 t7 v# J
very young age. The physical findings in these boys
" p* j& `: E" B9 }* {with this disorder are full pubertal development,
) x. g w g/ O% ^* vincluding bilateral testicular growth, similar to boys
% h2 }6 o0 E! Z; fwith CPP. The gonadotropin levels in this disorder$ S- X, z3 {* H$ H4 h7 [/ _
are suppressed to prepubertal levels and do not show, l4 g1 v1 e A
pubertal response of gonadotropin after gonadotropin-
5 ?; S. r, r7 J* i& q/ C6 Creleasing hormone stimulation. This is a sex-linked
* k* t2 w" Q$ u7 C$ M/ z( k5 `- Oautosomal dominant disorder that affects only
7 K" R% z1 p- l0 K( ~5 I' fmales; therefore, other male members of the family
! z7 `! v1 |# {% a7 ymay have similar precocious puberty.3
$ N: J* p( j. |' G, {In our patient, physical examination was incon-/ q4 T$ ]2 A" J' s F( [9 |& U$ K
sistent with true precocious puberty since his testi-5 ]& p- n+ {/ o+ v1 U
cles were prepubertal in size. However, testotoxicosis4 S, Q9 z+ z" w! P! W4 E9 J! H
was in the differential diagnosis because his father
! c& T8 [ ]1 @2 M) [/ s! Xstarted puberty somewhat early, and occasionally,
: s4 M( h% L/ K+ G3 \" }$ `testicular enlargement is not that evident in the9 a- `. i1 Y$ L& L, Q7 [* h
beginning of this process.1 In the absence of a neg-
4 Q+ U. {, r( ^1 I* ?ative initial history of androgen exposure, our
% c" \/ p* \$ Pbiggest concern was virilizing adrenal hyperplasia,
. o8 m" A, L& l' }5 reither 21-hydroxylase deficiency or 11-β hydroxylase
4 h8 G; {$ A/ s( Z' |8 Cdeficiency. Those diagnoses were excluded by find-+ g8 P3 ?: b% G2 ?, ` ~8 E
ing the normal level of adrenal steroids.! M( J# u% Z& C, ^5 e8 F( A8 ?, S
The diagnosis of exogenous androgens was strongly, T& C1 q3 N, U
suspected in a follow-up visit after 4 months because) x/ u$ g1 l: F- c8 z6 X5 V
the physical examination revealed the complete disap-
7 l0 i8 `& G8 d. T' P: A' Ppearance of pubic hair, normal growth velocity, and" G# n' V; y# K- F% w
decreased erections. The father admitted using a testos-5 X- ]! H1 A9 F2 q. w- x: a
terone gel, which he concealed at first visit. He was
# A9 n, J* w, Y- w* Xusing it rather frequently, twice a day. The Physicians’
1 j3 T3 E) Z5 EDesk Reference, or package insert of this product, gel or. q" D- J+ D) K, j) F2 j
cream, cautions about dermal testosterone transfer to
( \9 f' J1 m1 @% l- punprotected females through direct skin exposure.
$ ]4 W5 `' F. p- J! SSerum testosterone level was found to be 2 times the+ [' b- c& D$ y8 G
baseline value in those females who were exposed to
% w- q3 e# \1 ^4 V; l: ~% }3 eeven 15 minutes of direct skin contact with their male
$ ^9 R% Z5 k. Ppartners.6 However, when a shirt covered the applica-4 P$ B8 u/ X0 i* t
tion site, this testosterone transfer was prevented.% J# c4 B7 k3 c% c, l2 s
Our patient’s testosterone level was 60 ng/mL," m5 e7 i8 R! G9 G! ?/ J5 v
which was clearly high. Some studies suggest that! S$ Y, W( r) k' C8 \: V
dermal conversion of testosterone to dihydrotestos-0 R" W: p9 P4 ]
terone, which is a more potent metabolite, is more' s* y% b" C0 H& u" d
active in young children exposed to testosterone
6 V. Z z) G7 x1 ]exogenously7; however, we did not measure a dihy-& p* B) \- e" p
drotestosterone level in our patient. In addition to
' N5 ^, L1 h, T2 |6 S: Wvirilization, exposure to exogenous testosterone in+ Q; i, s/ G C1 B; H
children results in an increase in growth velocity and
3 D1 l% n0 C, h& ~9 ^( {advanced bone age, as seen in our patient.
) ~. s/ p% \& ?The long-term effect of androgen exposure during
% l J( E4 J- f" S1 v* y; A& ^early childhood on pubertal development and final5 ?! J; [- P" B
adult height are not fully known and always remain, S+ v) G7 V; [& W* a
a concern. Children treated with short-term testos-* i- h6 i- s. O! G
terone injection or topical androgen may exhibit some+ p3 ~) w0 D0 t* B
acceleration of the skeletal maturation; however, after8 d! j% H4 {+ }" E! C8 }, I2 _. N
cessation of treatment, the rate of bone maturation
# Z: H- w' K! P7 Kdecelerates and gradually returns to normal.8,9
\) X( h1 ~* }* IThere are conflicting reports and controversy$ I$ B) j) M6 _5 p+ R
over the effect of early androgen exposure on adult0 r+ s; `. k1 X) L& I
penile length.10,11 Some reports suggest subnormal! K- m; E8 o) `4 M3 b, l
adult penile length, apparently because of downreg-
( e' r3 P5 q( X1 c& lulation of androgen receptor number.10,12 However,. X/ X% a7 |5 ^
Sutherland et al13 did not find a correlation between
( h: ~& |. l9 b5 achildhood testosterone exposure and reduced adult' R5 I4 ~- R" o! g( n- t3 H9 G
penile length in clinical studies.) V1 W3 J+ ^( ^/ Z1 t2 F
Nonetheless, we do not believe our patient is
" o6 t8 h; ]; X" g7 d* N O1 @, _: {going to experience any of the untoward effects from
% v! E1 G3 x) k ^+ Ztestosterone exposure as mentioned earlier because& J) D* Q: [# h m9 ?' d% V
the exposure was not for a prolonged period of time.
1 M( I* L3 k+ E# u- J/ xAlthough the bone age was advanced at the time of
4 t- X1 } E) Sdiagnosis, the child had a normal growth velocity at
( E( g r! x# ~$ v5 w8 D' M* Jthe follow-up visit. It is hoped that his final adult
7 f9 U6 k3 J" w4 f( g- _height will not be affected.
% w$ S8 M x& u5 \Although rarely reported, the widespread avail-
0 k9 C2 N8 U7 t2 I/ hability of androgen products in our society may" \1 ]: N ?- Z$ P9 B1 {& n
indeed cause more virilization in male or female
) x' n2 k: |! cchildren than one would realize. Exposure to andro-) y0 f, ^# ]8 g# F5 X R
gen products must be considered and specific ques-
4 A# C0 O4 ? x. ytioning about the use of a testosterone product or
q9 S( I" f/ u8 Rgel should be asked of the family members during
/ I8 h, j" |& u; J' lthe evaluation of any children who present with vir-% r9 ?! ^8 n! L
ilization or peripheral precocious puberty. The diag-6 P9 G9 _9 D7 L& r4 [2 y0 T
nosis can be established by just a few tests and by6 t# L& y b8 G2 K! |2 \; U3 j, `
appropriate history. The inability to obtain such a# \5 ` l q3 K- J$ \2 y
history, or failure to ask the specific questions, may$ a; P6 B* x" g
result in extensive, unnecessary, and expensive0 D5 P w/ ]; \" Y- X) g
investigation. The primary care physician should be/ w5 b! T1 v( v
aware of this fact, because most of these children
& n- o1 z2 ]$ \( p/ _/ c1 `may initially present in their practice. The Physicians’
$ c- O3 a2 n; P+ g2 Q4 ?Desk Reference and package insert should also put a' ?5 W: |; B' Z. }! j
warning about the virilizing effect on a male or0 g( R6 t/ @6 y1 ]1 _
female child who might come in contact with some-
* h! U) o0 A) J8 T; ]one using any of these products.
0 H2 C M; g1 R6 {$ v4 cReferences
# s$ R% E8 W ^. j+ x; m7 l1. Styne DM. The testes: disorder of sexual differentiation7 G% b# L# k% s2 p4 t. r: Q
and puberty in the male. In: Sperling MA, ed. Pediatric0 u) } i! v0 b% e' e! k, z# ?7 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' M7 g$ w5 D4 i3 F/ ^, {
2002: 565-628.
, [6 f2 M* r. g" m) B+ y8 J7 a4 a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
U: o d$ V5 ?+ @ Y2 y8 ?. d! Npuberty in children with tumours of the suprasellar pineal |
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