- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
1 J. L6 E( e2 xBoy Induced by Indirect Topical
6 F6 b W# x" I+ X- nExposure to Testosterone
/ {- p5 c. w2 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ @( X" I# }" ^ [* }( Qand Kenneth R. Rettig, MD1, K6 J$ X" n, k( S% l
Clinical Pediatrics
( l& j, f' {. v, h1 }Volume 46 Number 6
% G( Y$ s* F6 pJuly 2007 540-543% S. K3 W, ^5 x) V# B# K# p+ R: o
© 2007 Sage Publications
4 C& d9 F0 t4 ~10.1177/00099228062966519 a( w% q1 e) ?* y* J
http://clp.sagepub.com( Z% B% A2 |: c& w* S
hosted at
4 M- ?0 O- {4 G0 \0 t, Q" rhttp://online.sagepub.com& A0 g2 Q. W8 i3 N7 i
Precocious puberty in boys, central or peripheral,. K" y7 v8 J! J A1 j7 n" S
is a significant concern for physicians. Central
5 Q2 c$ k$ X9 |* o$ V- U4 V- qprecocious puberty (CPP), which is mediated
3 S- V5 {: ~' h7 W& sthrough the hypothalamic pituitary gonadal axis, has
6 ?8 k, ^; L+ Oa higher incidence of organic central nervous system
$ v: h' ~; t. [9 klesions in boys.1,2 Virilization in boys, as manifested
5 E/ E; V% F! r4 r. {by enlargement of the penis, development of pubic; u7 }+ D/ S, j& K2 C
hair, and facial acne without enlargement of testi-
o8 [! C1 D' S$ W+ S; hcles, suggests peripheral or pseudopuberty.1-3 We
9 b- @ H: f6 p+ H+ L( e3 @9 G7 Greport a 16-month-old boy who presented with the
. \9 ~1 d+ f6 p, Y6 ~4 w3 z7 [enlargement of the phallus and pubic hair develop-
1 d+ q' \. B( K( x7 q" G- R W* Iment without testicular enlargement, which was due; R7 G. C% k( P; c! [
to the unintentional exposure to androgen gel used by) b) E' v% O% v w( M/ J
the father. The family initially concealed this infor-6 w$ I: u A6 P) \' J* z: l
mation, resulting in an extensive work-up for this! ?8 t- a Z' ^
child. Given the widespread and easy availability of
$ K$ d- }6 O" }3 @testosterone gel and cream, we believe this is proba-# F/ ^6 l5 N5 q+ N) U- L% p# P1 g! g
bly more common than the rare case report in the J s$ m( V+ Y& Y
literature.41 S! b! q8 T4 e5 e x& c
Patient Report0 S0 @0 F% ~% t$ A
A 16-month-old white child was referred to the; z8 G( K5 ?" |' j5 y. L
endocrine clinic by his pediatrician with the concern
" p5 r6 E7 d |. x7 s" \, P& nof early sexual development. His mother noticed
# y c6 B1 Z* B7 i' z |5 ]light colored pubic hair development when he was/ n0 X5 X3 c$ {$ h# S* u9 O" ?- I
From the 1Division of Pediatric Endocrinology, 2University of
% s$ N! x8 R! Z/ L1 XSouth Alabama Medical Center, Mobile, Alabama.
+ j( x* T% `9 A& Q3 e; JAddress correspondence to: Samar K. Bhowmick, MD, FACE,7 d/ c; o* j% ?9 V/ }
Professor of Pediatrics, University of South Alabama, College of2 d# B! V& S+ `7 q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# |% t; [* c5 y( W0 I( M. q
e-mail: [email protected].- u( h3 l$ G& O
about 6 to 7 months old, which progressively became/ C. e2 q" `' }# L, f' c
darker. She was also concerned about the enlarge-
, |5 ]/ F0 D( f& U8 oment of his penis and frequent erections. The child
: a( a, p) V2 gwas the product of a full-term normal delivery, with' O, n8 R/ G% @) t# C8 _/ C
a birth weight of 7 lb 14 oz, and birth length of3 r; P( m- ]4 j, i
20 inches. He was breast-fed throughout the first year% z# i* {6 m* z7 K7 z7 z# _
of life and was still receiving breast milk along with
) S- E, }. O( ?6 d1 r2 s. Psolid food. He had no hospitalizations or surgery,
* X9 ^$ M" g% jand his psychosocial and psychomotor development" o H9 B0 ?/ P) ]
was age appropriate.& }. g6 o% L T: M, o0 o
The family history was remarkable for the father,5 {3 @& U2 T; ~/ A
who was diagnosed with hypothyroidism at age 16," s9 G' g$ s+ G7 q. c
which was treated with thyroxine. The father’s: m; |0 g/ V+ A$ ?# Q. R
height was 6 feet, and he went through a somewhat6 {9 Q; g; L# g( M8 ?8 I& ]/ _5 n
early puberty and had stopped growing by age 14.' ?7 b9 ~/ Y% M/ C( k
The father denied taking any other medication. The
! q' V6 y$ W" `) W- {" Y( ^child’s mother was in good health. Her menarche& ^/ F) {% O2 j4 I& r, _
was at 11 years of age, and her height was at 5 feet* S: ?- q$ t" W; U% s2 Z
5 inches. There was no other family history of pre-
9 }9 b+ s" }+ `+ gcocious sexual development in the first-degree rela-
2 Y; }. P1 F3 [: Btives. There were no siblings.
: p0 }7 a( X$ f8 y7 i3 d( xPhysical Examination& ]/ i* H6 r! H( g2 q8 x" B2 l0 g
The physical examination revealed a very active,. z4 [) |1 U) ^; B3 o" L H
playful, and healthy boy. The vital signs documented
+ S/ R1 B6 E6 A+ ia blood pressure of 85/50 mm Hg, his length was- q* B* R, W; A; x" N
90 cm (>97th percentile), and his weight was 14.4 kg* c! ?! w* t) \+ u' I& c: F- O
(also >97th percentile). The observed yearly growth
. i) K6 s" \: Jvelocity was 30 cm (12 inches). The examination of
- P& [' t9 I7 u) j$ Qthe neck revealed no thyroid enlargement.
; i. [1 e& M5 lThe genitourinary examination was remarkable for
2 C7 `9 ]! P/ e, jenlargement of the penis, with a stretched length of
. }) r: W! N* x9 i. c8 cm and a width of 2 cm. The glans penis was very well
v s0 L& L/ I: } `developed. The pubic hair was Tanner II, mostly around
5 A, _5 ?' d9 E% N' y* Y( [540' x* c- c5 V5 u- I: t; \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 @- ^% ] {: Q3 t- f6 r' wthe base of the phallus and was dark and curled. The
; f# Q, R0 B2 z5 P; R2 [5 stesticular volume was prepubertal at 2 mL each.8 {, ~' T% {; i7 F2 O) s( I+ A X
The skin was moist and smooth and somewhat- l0 q; X/ e2 a: g5 K$ \1 P! X
oily. No axillary hair was noted. There were no
' \4 }8 N- P& ^- H1 x1 fabnormal skin pigmentations or café-au-lait spots.2 [. W/ V2 O3 q3 a( M3 W- ?' d# F
Neurologic evaluation showed deep tendon reflex 2+0 ~& d& u# p4 ~
bilateral and symmetrical. There was no suggestion
& N. T5 F/ U3 Sof papilledema.
* S( c( y# ], _) N; GLaboratory Evaluation4 _/ F* j, T+ N; e8 I3 Y
The bone age was consistent with 28 months by
! b( P t% ~7 y' s8 H. eusing the standard of Greulich and Pyle at a chrono-
, i' D+ @3 s0 h2 ]' `logic age of 16 months (advanced).5 Chromosomal
, x, `5 f/ b$ Mkaryotype was 46XY. The thyroid function test
; g5 G9 j( R0 ~! Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, \7 i8 b0 s! P) W; R) C
lating hormone level was 1.3 µIU/mL (both normal).
, y2 C" h$ M1 V. v; p q0 TThe concentrations of serum electrolytes, blood
4 [) t' l$ g5 \' N* k* Lurea nitrogen, creatinine, and calcium all were
2 [: g t- [" y0 M a" X8 Q; rwithin normal range for his age. The concentration: W! e( G( q& R$ f
of serum 17-hydroxyprogesterone was 16 ng/dL
/ o x4 l3 G; D. H, ?$ j(normal, 3 to 90 ng/dL), androstenedione was 20
( ~, {2 I: N+ sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- a' \1 ]6 c" q, l% M; k; Z0 u" y0 nterone was 38 ng/dL (normal, 50 to 760 ng/dL),& w- I* a0 G6 t. A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" T+ \5 O* J# f/ {) `
49ng/dL), 11-desoxycortisol (specific compound S), n6 A% H( @- ^7 T% m# f, M) h4 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ N9 l) [" g f. Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 D8 x) D# K4 O/ h: h0 ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% Y. K6 X0 i! {( b' ~and β-human chorionic gonadotropin was less than
& W \, t9 F% M- b5 mIU/mL (normal <5 mIU/mL). Serum follicular
) K' Z8 U4 E+ ]/ v6 H0 K/ A7 h" Sstimulating hormone and leuteinizing hormone
( F1 K6 H3 |5 }2 F) A( z) Hconcentrations were less than 0.05 mIU/mL5 o& j$ {+ |- D* y( i# g
(prepubertal).
* {3 z. }, |- ?8 U: NThe parents were notified about the laboratory
& q* O6 m+ F" c# d% presults and were informed that all of the tests were
7 |: ]( m! F+ t# H8 ^& [6 Dnormal except the testosterone level was high. The* U0 }& r2 P" w3 f6 |( l( b2 O
follow-up visit was arranged within a few weeks to
) z- h, ]. O& W, g2 k' k oobtain testicular and abdominal sonograms; how-
: G# U* H: }8 E" Pever, the family did not return for 4 months.
( @' p! a5 m% M2 rPhysical examination at this time revealed that the& P9 R" h: H l; \4 }" k* }
child had grown 2.5 cm in 4 months and had gained, v. X$ ?. |/ @: O7 G
2 kg of weight. Physical examination remained
0 w" U$ A6 r3 z; r4 [unchanged. Surprisingly, the pubic hair almost com-
* j: Y* y4 Z8 S6 H" b2 Apletely disappeared except for a few vellous hairs at
8 {: c$ B+ x% athe base of the phallus. Testicular volume was still 2( _) U' b" P7 _8 u- S& K8 o
mL, and the size of the penis remained unchanged.
$ O5 i0 t$ I; Z4 @) z1 pThe mother also said that the boy was no longer hav-% d- }8 r, _9 D' ~
ing frequent erections. Z! a+ ~- |; t" r( b! F/ j
Both parents were again questioned about use of
! d1 ]- n# s5 v! G: q$ Gany ointment/creams that they may have applied to
+ I$ g: ]( T! Q1 d5 }* F4 s- dthe child’s skin. This time the father admitted the% x1 b$ j! p* L
Topical Testosterone Exposure / Bhowmick et al 541# J) P) l. ~! q# E, g. s2 n( ]
use of testosterone gel twice daily that he was apply-
' m6 Z% j+ x# Q$ [ing over his own shoulders, chest, and back area for
- K' {+ D* W1 X4 Na year. The father also revealed he was embarrassed4 k, c3 I7 D! u
to disclose that he was using a testosterone gel pre-$ y5 `; H. m$ m. @ K" l9 J6 q ^* H
scribed by his family physician for decreased libido+ ]* m$ V2 y1 b' d( B! t& `8 l1 a
secondary to depression.
( ]" E, a* \' a6 H5 j8 E* LThe child slept in the same bed with parents.. a/ z6 w7 ~5 P, i3 l3 R
The father would hug the baby and hold him on his
! A7 V$ c* o5 d0 l1 a) J7 R, ochest for a considerable period of time, causing sig-
0 ?1 S) _# |. r# u3 \5 Xnificant bare skin contact between baby and father.
& y0 c# z% g4 c, p- dThe father also admitted that after the phone call,
Y- L" e% R/ {/ y% v# kwhen he learned the testosterone level in the baby. s$ h; J5 n0 E3 V+ [, o
was high, he then read the product information9 a' n; a* m$ z, ]1 A+ O
packet and concluded that it was most likely the rea-! B. {( t6 g. F, c8 |
son for the child’s virilization. At that time, they+ g5 n( r, f& X, I
decided to put the baby in a separate bed, and the& s6 ~5 Q! N. B+ B
father was not hugging him with bare skin and had6 H- n7 ]0 i3 q+ L# e
been using protective clothing. A repeat testosterone5 f" q, N7 P" V1 C: p
test was ordered, but the family did not go to the$ f( O H \( S9 a1 z
laboratory to obtain the test.& y7 G0 n7 g, b& g
Discussion! q2 F p7 F$ ^2 Z
Precocious puberty in boys is defined as secondary& K7 [1 L8 M# p2 V
sexual development before 9 years of age.1,4; t, ]& U' C* a
Precocious puberty is termed as central (true) when
8 E; g5 E: T( [$ k3 Zit is caused by the premature activation of hypo-: H- L. {0 D/ d8 p' Q* o, A
thalamic pituitary gonadal axis. CPP is more com-/ a5 Z4 p3 v' V, w3 t
mon in girls than in boys.1,3 Most boys with CPP7 f/ b# i: D- _ D" D1 c% W( A
may have a central nervous system lesion that is
' A, V" ^" {. Z* o+ Q; sresponsible for the early activation of the hypothal-* q. q; x+ Z- a0 u; `
amic pituitary gonadal axis.1-3 Thus, greater empha-. v- S/ W# }- G; D0 B+ E
sis has been given to neuroradiologic imaging in
Q% d8 \ I4 h! n2 K$ V& M0 e4 Aboys with precocious puberty. In addition to viril-
7 G, O2 u% b# f, Z. ~2 Y2 jization, the clinical hallmark of CPP is the symmet-
2 J2 v: L2 d, Q5 W1 Jrical testicular growth secondary to stimulation by
. ~2 H9 m1 ]+ C/ Ngonadotropins.1,3" h5 n/ B2 p$ E4 R
Gonadotropin-independent peripheral preco-" Q' f8 l: [5 e
cious puberty in boys also results from inappropriate- ~1 n* d) }/ ^* f/ o7 x
androgenic stimulation from either endogenous or* p$ p5 F4 A8 U$ b3 T3 h
exogenous sources, nonpituitary gonadotropin stim-1 T5 z! u7 k2 w
ulation, and rare activating mutations.3 Virilizing
3 i+ @! A, ?4 o5 {8 T7 a- x% wcongenital adrenal hyperplasia producing excessive0 w5 [2 x& a- M b7 G' o
adrenal androgens is a common cause of precocious% ]+ b" c+ E4 }; h. D
puberty in boys.3,47 o" w. d! \# t1 K! X3 ?- D
The most common form of congenital adrenal
) {% A& @5 _- A; ^2 ?hyperplasia is the 21-hydroxylase enzyme deficiency.8 b5 Z: c1 a0 A5 G* i, |4 x
The 11-β hydroxylase deficiency may also result in
" E1 `+ [9 S* D# H1 Cexcessive adrenal androgen production, and rarely, ?4 T/ z( a/ j8 S) C
an adrenal tumor may also cause adrenal androgen
2 x8 U! [. J) c; Z3 iexcess.1,3; N, _* p' u! f$ G2 E" i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 s2 L6 s+ j5 v3 w542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 f: }6 B9 k+ i9 u5 `- T' _% v
A unique entity of male-limited gonadotropin-
! ?* g& @; t$ ?3 H5 cindependent precocious puberty, which is also known3 q, Y9 X; I8 u; z
as testotoxicosis, may cause precocious puberty at a' y$ o5 U4 N/ {# S2 q6 [
very young age. The physical findings in these boys
9 R5 K& @1 Z% _0 Qwith this disorder are full pubertal development,1 I& K( D1 w V
including bilateral testicular growth, similar to boys
$ _% R7 K3 l( J( [9 ]with CPP. The gonadotropin levels in this disorder
9 c/ @2 k+ v* F3 G. c- R$ a8 ~are suppressed to prepubertal levels and do not show( _5 k( [; `- m1 C$ n
pubertal response of gonadotropin after gonadotropin-
t8 p4 @0 Z& G* xreleasing hormone stimulation. This is a sex-linked
5 |+ G g1 u1 E4 {2 {" G- Zautosomal dominant disorder that affects only9 }0 b1 f. \. M! Y6 Q
males; therefore, other male members of the family
: |' b0 l6 B7 \may have similar precocious puberty.3
# X: {$ T2 g$ {+ s) TIn our patient, physical examination was incon-- L, _8 Z! W) F; ?! B1 g3 R! E$ s
sistent with true precocious puberty since his testi-
/ p1 l7 J! J9 p4 ~* g- [cles were prepubertal in size. However, testotoxicosis
: Y+ b5 D) X' g& m! U0 ewas in the differential diagnosis because his father
' q# \% H) g* O9 lstarted puberty somewhat early, and occasionally,
/ r/ B3 S* ]1 j0 Ctesticular enlargement is not that evident in the
/ x& P- y: ]2 @- Pbeginning of this process.1 In the absence of a neg-' y' n' t8 c- n& q0 p
ative initial history of androgen exposure, our4 l" I! D6 Z: F: T% @) [; J
biggest concern was virilizing adrenal hyperplasia,0 d! J. O+ H! K/ ]2 K
either 21-hydroxylase deficiency or 11-β hydroxylase' e5 V( k4 `: @0 |( I/ w; T
deficiency. Those diagnoses were excluded by find-3 E. H- }1 E$ Z
ing the normal level of adrenal steroids.
( X; V- n& P: ?! t+ C/ M8 FThe diagnosis of exogenous androgens was strongly
5 n1 @ D: S7 t, n5 u. ?suspected in a follow-up visit after 4 months because
. [/ J$ @+ Z1 ?5 Dthe physical examination revealed the complete disap-) J, w" Q4 ~" X7 e7 n
pearance of pubic hair, normal growth velocity, and
' Y# k$ r) [( x7 ]8 adecreased erections. The father admitted using a testos-
, P/ `% W' Z, R3 Bterone gel, which he concealed at first visit. He was% J8 v1 L3 }, c! e
using it rather frequently, twice a day. The Physicians’
$ o( u# V$ x$ B' u2 y w+ ZDesk Reference, or package insert of this product, gel or
* [/ `, M3 t+ @" w4 x" Y/ V( W& |- pcream, cautions about dermal testosterone transfer to
. [+ X1 c4 f# ]* x- w; H) [unprotected females through direct skin exposure.7 y P, e: }) R8 F6 U# C
Serum testosterone level was found to be 2 times the
1 I9 h2 o# H4 y/ X9 ?- c: A* @% wbaseline value in those females who were exposed to2 A8 [! R ^2 C& x9 B/ P7 `
even 15 minutes of direct skin contact with their male
$ A* m6 u# u2 J: C8 r3 k1 z! apartners.6 However, when a shirt covered the applica-
- \2 I$ P& B1 K! qtion site, this testosterone transfer was prevented.
8 n' N/ c" q9 b) rOur patient’s testosterone level was 60 ng/mL,
, g5 J: U$ [( `) Y0 D$ Lwhich was clearly high. Some studies suggest that- d4 g2 q1 ~- [! D( O8 ]
dermal conversion of testosterone to dihydrotestos-
8 j g4 ?8 o8 z) k7 U1 mterone, which is a more potent metabolite, is more
3 E/ I* u- r. C5 j. i& B* aactive in young children exposed to testosterone" a* U0 R- J4 i
exogenously7; however, we did not measure a dihy-3 a! X6 {6 J2 u9 u9 D1 x
drotestosterone level in our patient. In addition to; n5 v v5 Q1 j2 ?) \5 I/ v
virilization, exposure to exogenous testosterone in! W. J L8 A8 f' H s
children results in an increase in growth velocity and
/ X2 N8 G& X# ^advanced bone age, as seen in our patient.
0 [$ I+ f6 t1 hThe long-term effect of androgen exposure during
! V5 x* P: Q" B+ i8 p- ^early childhood on pubertal development and final
( D/ g- c2 V$ N: y1 l: radult height are not fully known and always remain
. z) p& a, {% K4 }a concern. Children treated with short-term testos-( R1 K X6 K9 t7 r
terone injection or topical androgen may exhibit some
8 n& o# p; Y! U8 ]0 {% q0 vacceleration of the skeletal maturation; however, after/ h& F$ y/ a8 e# B/ X
cessation of treatment, the rate of bone maturation
$ x# N& X6 k4 s; Udecelerates and gradually returns to normal.8,9% I& I& S1 T7 `! M
There are conflicting reports and controversy
# ?( p2 [* D1 k- S* rover the effect of early androgen exposure on adult
$ `) x% `' M2 |3 N( ~# Dpenile length.10,11 Some reports suggest subnormal
& o; F, c, S! eadult penile length, apparently because of downreg-" b2 c c- _- k- N' H, a6 v
ulation of androgen receptor number.10,12 However,
7 b7 `5 K& j* B) B1 o6 r7 TSutherland et al13 did not find a correlation between i& l. _- h' V* n% j
childhood testosterone exposure and reduced adult
! @- Q3 Y& \3 e+ L1 Spenile length in clinical studies.
; e. d- |7 R- c1 q3 uNonetheless, we do not believe our patient is* b2 r; t/ R0 X$ I# D0 x& Q9 m
going to experience any of the untoward effects from
, ^2 M0 |! E' Btestosterone exposure as mentioned earlier because; g. v! b* @( q
the exposure was not for a prolonged period of time.
. W6 ?# V( ?1 N nAlthough the bone age was advanced at the time of
/ V2 E9 n# J0 p, xdiagnosis, the child had a normal growth velocity at
8 j/ c' Q5 U4 D1 |( wthe follow-up visit. It is hoped that his final adult
# a* [ k$ G3 I3 L/ zheight will not be affected.
! N( h* h6 }4 I- r) ^Although rarely reported, the widespread avail-
9 u6 z6 U6 c. t( {9 j. Fability of androgen products in our society may4 u0 e8 x$ Y2 a0 j1 Q& B
indeed cause more virilization in male or female3 l* k& M+ y0 L! a( r6 ^
children than one would realize. Exposure to andro-
9 V4 \. D8 r% w; `4 qgen products must be considered and specific ques-% X4 i9 L W! ~4 J2 g
tioning about the use of a testosterone product or
9 L7 X. `8 ^% ^% S9 I4 d9 Jgel should be asked of the family members during
+ r9 j7 ^2 W( s& n4 D0 v) Ythe evaluation of any children who present with vir-3 S; l P8 _5 P6 Q, ~
ilization or peripheral precocious puberty. The diag-. h1 x( p- i* |" A1 t! \
nosis can be established by just a few tests and by
" [9 f8 a9 ]! c- F! X. eappropriate history. The inability to obtain such a+ s' O) G3 x- V: k
history, or failure to ask the specific questions, may2 L- D0 {' u2 k# [, P
result in extensive, unnecessary, and expensive( N |) G, x1 G1 n8 H' [5 Q
investigation. The primary care physician should be
& K$ ?1 p+ W# G7 U5 Oaware of this fact, because most of these children! G2 ?4 \) {- c1 x8 Z" p
may initially present in their practice. The Physicians’
, j3 [4 A3 g4 K" Y; f- MDesk Reference and package insert should also put a( _. G* a, w+ V
warning about the virilizing effect on a male or6 S- y& m9 V( \" p1 P
female child who might come in contact with some-
. ?# u4 Y/ |3 s& ~2 h" M4 q, f. j$ done using any of these products.
( Q% ^+ O2 H) k3 \8 O) ^References7 o. _5 n6 b% N* p9 |6 _ ~: \
1. Styne DM. The testes: disorder of sexual differentiation
) i3 {$ d2 T" P! Y) Land puberty in the male. In: Sperling MA, ed. Pediatric
/ p3 O! c/ W0 g5 @ J+ G' LEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& R4 Z( m! O c* o: {* g
2002: 565-628.
0 z4 S* F2 ^7 C7 C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 s" l, u/ i1 F/ \, o. ?9 \$ a/ }
puberty in children with tumours of the suprasellar pineal |
|