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Sexual Precocity in a 16-Month-Old
/ [( {) {, E/ z+ x$ R& a9 mBoy Induced by Indirect Topical/ i" ~( n; q! _8 U4 R0 v, t8 M5 G
Exposure to Testosterone5 C7 f0 C- I( F1 I9 @
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 V3 q4 y7 S; n8 s8 n) U2 Land Kenneth R. Rettig, MD13 e1 }4 R# I \" X$ F" S
Clinical Pediatrics
3 S" w+ c* n# W( p5 v4 AVolume 46 Number 6
; g# \8 ^& M% Z% b* q0 sJuly 2007 540-543
6 P5 _6 H6 V; U- |/ U© 2007 Sage Publications
4 y3 t" o2 L* A7 K& F) x10.1177/00099228062966511 w" d, d) ?9 K p- E
http://clp.sagepub.com
& v3 V$ N0 J' [hosted at) q( \' c. `8 V2 a1 K( E* N
http://online.sagepub.com
. w! a- p: m9 H, [" ePrecocious puberty in boys, central or peripheral,
2 x g- b# ~( ~1 O) ^is a significant concern for physicians. Central) p! @ E( W1 G) x6 h
precocious puberty (CPP), which is mediated
. g6 _9 i7 s( q. N& k% Gthrough the hypothalamic pituitary gonadal axis, has, N3 l& E0 b) ^- f& U
a higher incidence of organic central nervous system
' e7 j9 f" H) m4 F& Clesions in boys.1,2 Virilization in boys, as manifested3 o& n) M1 W. L
by enlargement of the penis, development of pubic1 T' Q$ _& C; ~5 g
hair, and facial acne without enlargement of testi-2 o9 k$ G% {7 ~6 f# Z$ i( H
cles, suggests peripheral or pseudopuberty.1-3 We+ J8 ]3 |/ s# g
report a 16-month-old boy who presented with the
% Z* n5 }" D/ Fenlargement of the phallus and pubic hair develop-& n9 g$ e2 y# H. R( i' O
ment without testicular enlargement, which was due! v8 h3 i7 I9 m; B. K, H
to the unintentional exposure to androgen gel used by5 J. p7 z( i2 C* N/ D7 _9 T
the father. The family initially concealed this infor-) d7 W' Q* I- l( l% G$ ?/ }6 ~
mation, resulting in an extensive work-up for this
9 ?& u% J2 ]' p* x: G5 r. a! L. Pchild. Given the widespread and easy availability of3 f/ d3 k: `# o$ ]; Q: W- s
testosterone gel and cream, we believe this is proba-
- S4 J6 W( p/ [bly more common than the rare case report in the
, b0 [4 V4 x5 P( e, J/ y3 _literature.4: }' w2 Z$ \- ~" I' X
Patient Report+ n0 s) @6 {5 C! X
A 16-month-old white child was referred to the0 J& N1 g1 `( N$ Z
endocrine clinic by his pediatrician with the concern
8 j% T+ y4 G. ?( r! Fof early sexual development. His mother noticed! V" ]) L1 K0 n% o1 k2 i3 B+ w
light colored pubic hair development when he was
& O" L) d: C; o4 bFrom the 1Division of Pediatric Endocrinology, 2University of
# U' J% _1 l6 |5 CSouth Alabama Medical Center, Mobile, Alabama.
. W) R& U; J, e' g/ v. A9 tAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, z! f, {* j3 b8 Z, Z( }8 [Professor of Pediatrics, University of South Alabama, College of& H2 g2 P% |" {3 v. Z1 S& \5 Q9 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& }% E5 r/ h& G2 r7 l* ?e-mail: [email protected].
4 M6 ?, e9 ~" @( ~: Z$ Jabout 6 to 7 months old, which progressively became4 x& v i6 F& k% X/ g( m$ i
darker. She was also concerned about the enlarge-
- K" ^) F2 C$ z2 }ment of his penis and frequent erections. The child
3 M$ k/ o& W! Q+ Jwas the product of a full-term normal delivery, with6 C: F1 P9 j6 q* Q+ P# d
a birth weight of 7 lb 14 oz, and birth length of
" f# P" q( G, m& y2 O6 {; t20 inches. He was breast-fed throughout the first year
+ q! d% d8 ~3 ] y/ Gof life and was still receiving breast milk along with
; k9 {* w) d6 e0 i# ssolid food. He had no hospitalizations or surgery,
! |6 c2 f5 c' @7 p! Dand his psychosocial and psychomotor development4 @) f6 ]# Z3 U' P
was age appropriate.* @- K2 G" n) p4 J0 o' D# E
The family history was remarkable for the father,) V, J `8 A# |: A b( T) ]
who was diagnosed with hypothyroidism at age 16,- e# ^- T/ R/ V! f4 T
which was treated with thyroxine. The father’s
9 x8 _, L$ G, R ^height was 6 feet, and he went through a somewhat
- |$ p6 M2 Z6 U5 l0 H0 C5 hearly puberty and had stopped growing by age 14., f5 o+ [+ i' M
The father denied taking any other medication. The
6 e# _3 Z6 B& a$ `3 s. B' Bchild’s mother was in good health. Her menarche9 } x( v2 _4 ~: W; q3 c2 d2 i
was at 11 years of age, and her height was at 5 feet
6 N* v6 J; B% S7 I3 Z0 `) S2 z5 inches. There was no other family history of pre-
5 O- |' q m5 N; Scocious sexual development in the first-degree rela-3 {- u6 ^! X Z/ P+ K. t7 |# o1 n
tives. There were no siblings.
9 R9 L7 l# L' n! ePhysical Examination
4 D3 S/ w8 p) L/ _The physical examination revealed a very active,
+ q( S$ x% @; H, B. {- K8 ~playful, and healthy boy. The vital signs documented# d2 g& G% R- c1 ]) n
a blood pressure of 85/50 mm Hg, his length was
, [3 W! ?' t- x+ B1 O90 cm (>97th percentile), and his weight was 14.4 kg
7 e# m. }1 t+ z ? [(also >97th percentile). The observed yearly growth
\. `$ u( g/ Mvelocity was 30 cm (12 inches). The examination of% l6 z8 b% W* h, t7 g# D3 ^ h5 o
the neck revealed no thyroid enlargement.$ [' u* }1 o0 M. e; S3 X
The genitourinary examination was remarkable for% ~ }2 F% D8 ~' {1 j$ a9 [, Q& D) ?
enlargement of the penis, with a stretched length of; N6 t6 a+ u# f) b
8 cm and a width of 2 cm. The glans penis was very well
. I6 Z \* S. Ideveloped. The pubic hair was Tanner II, mostly around
3 k4 x* A8 ?: G5 \. R, D( g540
( h/ ^) ^6 x' }) C+ P8 Pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% g; [2 u2 A3 [' D C' c
the base of the phallus and was dark and curled. The
( { t# `( t7 }testicular volume was prepubertal at 2 mL each.
- u$ c5 b( c& d, g0 QThe skin was moist and smooth and somewhat$ U# v5 [7 ~2 d% C) p, X0 `4 [4 J; u
oily. No axillary hair was noted. There were no
) t! [ ]0 J" Z( wabnormal skin pigmentations or café-au-lait spots.
4 _$ _+ g% M5 f% l* KNeurologic evaluation showed deep tendon reflex 2+" C. @2 V$ @* _: z/ X
bilateral and symmetrical. There was no suggestion
7 |- h3 d6 f% ?( l+ {6 D# Dof papilledema.2 ~% I3 b) E4 l
Laboratory Evaluation
; u7 Z2 O# S" o- LThe bone age was consistent with 28 months by
; ]3 |3 A: t7 h1 n/ p. dusing the standard of Greulich and Pyle at a chrono-" [& r1 _: Y" {* o6 H" o
logic age of 16 months (advanced).5 Chromosomal
; T3 C9 ~# ]/ Rkaryotype was 46XY. The thyroid function test
/ Q$ P# m0 V" ?- p: u8 Y7 fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 p( [- H3 m0 R, a- D$ U! Jlating hormone level was 1.3 µIU/mL (both normal).
7 u: Y; L1 U. t" w3 gThe concentrations of serum electrolytes, blood
4 J; K5 Z5 B, a6 B, Rurea nitrogen, creatinine, and calcium all were# o7 D' V7 {# B( w$ U5 d
within normal range for his age. The concentration
* W( ~) s3 F6 T2 q: y1 I' ?of serum 17-hydroxyprogesterone was 16 ng/dL" j# m4 {/ q' X0 M% Y
(normal, 3 to 90 ng/dL), androstenedione was 20* O/ P% Z, F7 X) P) o, a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 }% I9 v+ K0 f! M
terone was 38 ng/dL (normal, 50 to 760 ng/dL),% T& G% X: T' Z2 f7 a0 f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 q: t4 |# {1 e j. r3 w; ?/ M49ng/dL), 11-desoxycortisol (specific compound S)
, w6 |/ y+ V1 E. l; ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 Q5 w6 Q; J( Q! T- |$ P7 a2 r
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
X$ C" U' @! h7 F' r' c# S% gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
n/ ]4 L, `) r* E5 m" sand β-human chorionic gonadotropin was less than
# g$ ]" `5 I. f, c" q5 `5 A) n( J5 mIU/mL (normal <5 mIU/mL). Serum follicular6 l+ I% i6 K" L0 F3 h
stimulating hormone and leuteinizing hormone% d$ R( c5 e" o. N
concentrations were less than 0.05 mIU/mL7 D8 |/ q+ Z9 g% {7 a8 P$ j
(prepubertal).# D- G' ~' b+ ^/ K4 r
The parents were notified about the laboratory$ q* c0 N& p9 G5 j: s8 k
results and were informed that all of the tests were( p3 W+ O/ j7 o
normal except the testosterone level was high. The
. F5 J$ {5 k+ r; D% Hfollow-up visit was arranged within a few weeks to. y! _3 a+ s4 i/ l- k
obtain testicular and abdominal sonograms; how-
: K& M& y# U6 t+ y7 l/ ?5 Never, the family did not return for 4 months.; O* m+ {. t0 Y4 K2 d, K4 K$ p3 E3 S
Physical examination at this time revealed that the+ p% l9 T, W4 V' s
child had grown 2.5 cm in 4 months and had gained
5 F) w3 d, H" C$ ^% \* `- t2 kg of weight. Physical examination remained; `* b& I" s+ i" o! }1 L
unchanged. Surprisingly, the pubic hair almost com-
: N/ d/ B3 X6 ?% J4 c! p3 apletely disappeared except for a few vellous hairs at8 f$ Y% K4 W( }. Z- Z
the base of the phallus. Testicular volume was still 2
; r6 S- A% x# f. }mL, and the size of the penis remained unchanged.# X1 x3 i; P- ~
The mother also said that the boy was no longer hav-
& X! F2 |; [2 K. k$ c6 oing frequent erections.
; z1 _) T, Q) r: U5 GBoth parents were again questioned about use of1 G- U6 L, F+ Q1 p. f6 p% x0 S
any ointment/creams that they may have applied to
: z' ]- O' i0 G2 i. t, M) Q. ?2 Qthe child’s skin. This time the father admitted the% t1 L3 V: ]3 k2 L8 N+ a2 N
Topical Testosterone Exposure / Bhowmick et al 541
! g2 B6 l. f" J: I9 W5 B3 D1 yuse of testosterone gel twice daily that he was apply-
" m5 J0 j/ z# q% j2 {0 v- King over his own shoulders, chest, and back area for
* A. e) \" q' xa year. The father also revealed he was embarrassed9 o& `! w. b5 E$ Q, \
to disclose that he was using a testosterone gel pre-
* m1 q" `0 M$ |scribed by his family physician for decreased libido
& t5 P( w/ H' U. Nsecondary to depression.
0 c- i% Z2 L( W, rThe child slept in the same bed with parents.
5 {. V& d; c5 { tThe father would hug the baby and hold him on his( X" L+ |8 a! S* ]
chest for a considerable period of time, causing sig-- d% e/ B: {8 s" f/ a8 c4 c
nificant bare skin contact between baby and father.
7 k; x2 @4 J9 F8 r9 h. _8 d; u5 ?The father also admitted that after the phone call,8 y4 y& e9 g9 S# Q- {
when he learned the testosterone level in the baby
7 d- Q$ Y8 z* h9 P# \was high, he then read the product information% e/ a2 A7 d( R* @4 @
packet and concluded that it was most likely the rea-
, `% T, D# Y4 ^. ?2 Gson for the child’s virilization. At that time, they
' L2 |; @+ G9 b* w; p$ H& c- s6 edecided to put the baby in a separate bed, and the4 o |1 [" e$ a. G2 |6 E4 y" E
father was not hugging him with bare skin and had. |8 F3 Y/ X, Z; U" V t
been using protective clothing. A repeat testosterone1 s* ~& x3 D( q6 n
test was ordered, but the family did not go to the5 o- X$ g0 u; `
laboratory to obtain the test.
q ^0 |7 X- o F) j8 ^Discussion- y9 q0 L+ Z# ?
Precocious puberty in boys is defined as secondary. o1 X; z# B0 u7 h8 s2 n
sexual development before 9 years of age.1,49 q. W. J1 Z: [
Precocious puberty is termed as central (true) when! o3 _# M# y8 @& [) U
it is caused by the premature activation of hypo-& o- V" g4 x, S- k* v
thalamic pituitary gonadal axis. CPP is more com-
M8 @. k" q1 ^& D1 {; E% X% R6 pmon in girls than in boys.1,3 Most boys with CPP
, G0 n/ o( N/ T; g# jmay have a central nervous system lesion that is( I: t* I6 ~( r' h: L" z
responsible for the early activation of the hypothal-
! a a3 g% { M/ q# V3 e& T8 Mamic pituitary gonadal axis.1-3 Thus, greater empha-
% ?, v+ K1 V# ]2 R3 Z2 A6 Msis has been given to neuroradiologic imaging in q" C2 r d+ z5 i* m/ [
boys with precocious puberty. In addition to viril-9 h' L- f3 s" @7 u0 q- R
ization, the clinical hallmark of CPP is the symmet-0 H* K1 l! |6 M. p
rical testicular growth secondary to stimulation by/ F7 i2 R& s- m! H
gonadotropins.1,3
. \# X7 O: r& @/ d. jGonadotropin-independent peripheral preco-
( s3 ~3 g: t1 x: m8 F6 bcious puberty in boys also results from inappropriate
' N( C) D1 n1 n% D* A5 m9 vandrogenic stimulation from either endogenous or+ ?# U5 S1 |& n' T
exogenous sources, nonpituitary gonadotropin stim-8 _7 {2 a5 G3 d) Z3 n. h& G0 e
ulation, and rare activating mutations.3 Virilizing
: J2 M# g$ y( `0 j Wcongenital adrenal hyperplasia producing excessive ^; S! s+ V& [6 W, p- n9 J9 W
adrenal androgens is a common cause of precocious
. m0 Y* \' @' S. F# M6 ^3 q1 Ppuberty in boys.3,4
, n" d' y( a" SThe most common form of congenital adrenal9 E) P' D0 r: y
hyperplasia is the 21-hydroxylase enzyme deficiency.) C# A5 g c0 ^" B1 p: x
The 11-β hydroxylase deficiency may also result in- Y7 t6 w& r5 `0 J' f( H. s
excessive adrenal androgen production, and rarely,
7 s/ [7 j3 K0 ^* K9 J a% W5 Nan adrenal tumor may also cause adrenal androgen
?7 L& I0 R, ~* ]: x+ jexcess.1,3
" F {; w2 Z$ g8 i' J% {4 j# Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' A8 u$ T& G: {2 |2 G {
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- w! v- P1 I3 b) b2 pA unique entity of male-limited gonadotropin-; P1 s* b( X v% L# U0 o
independent precocious puberty, which is also known) X' ^: M% T7 j1 x: l
as testotoxicosis, may cause precocious puberty at a
+ [5 q# W" a6 ^4 ~+ }* r) Lvery young age. The physical findings in these boys4 l$ Y) W0 w' z- O* z6 n& ?1 G) F
with this disorder are full pubertal development,
2 j# f# M" w) E5 M4 G) C6 j! ]. vincluding bilateral testicular growth, similar to boys; }+ s8 Q& p' @" X
with CPP. The gonadotropin levels in this disorder
4 Q4 k$ z. \0 l: @are suppressed to prepubertal levels and do not show
6 _" C- U8 X1 f/ ?9 _- O+ Jpubertal response of gonadotropin after gonadotropin-' I( W( N$ B" x- ? `
releasing hormone stimulation. This is a sex-linked7 Y$ i- B: F% G5 ?! s) ]
autosomal dominant disorder that affects only' w7 v9 X% {8 e& X! A9 V
males; therefore, other male members of the family8 d# r( }% c7 P! Z3 E) f1 m
may have similar precocious puberty.3
; j3 t) c/ W4 B. F# G) jIn our patient, physical examination was incon-
( Z R' b7 ~, U3 P. vsistent with true precocious puberty since his testi-
8 N# v2 ]; T z8 B& p: D8 ]- H, V/ _+ ]cles were prepubertal in size. However, testotoxicosis
- i/ d( s4 V# e' D0 ~' `was in the differential diagnosis because his father
, @ | j( L1 Z0 U. Z5 Zstarted puberty somewhat early, and occasionally,
% V ^& q2 q- A+ ]* }/ P1 xtesticular enlargement is not that evident in the
, I5 D9 c; n5 z4 ^$ _: Ubeginning of this process.1 In the absence of a neg-( k2 P, h, b) Q7 ~% N: l
ative initial history of androgen exposure, our/ K) A9 n9 B1 F( s
biggest concern was virilizing adrenal hyperplasia,7 G I- r6 B: n! V
either 21-hydroxylase deficiency or 11-β hydroxylase
# a `; F4 X4 L' ]deficiency. Those diagnoses were excluded by find-
9 s1 [, Q3 `# x$ ring the normal level of adrenal steroids.
' p' f; {/ G/ xThe diagnosis of exogenous androgens was strongly
+ R$ @3 G! `" T8 p) r- ssuspected in a follow-up visit after 4 months because/ K# y/ d3 Y+ x5 K1 F2 a
the physical examination revealed the complete disap-
+ c2 E: I8 z' Q1 d( Epearance of pubic hair, normal growth velocity, and
2 w1 B) A& t: D# gdecreased erections. The father admitted using a testos-( f5 k+ q6 A2 o3 M) m$ [( [
terone gel, which he concealed at first visit. He was
2 q2 l" C, ~# |/ ?using it rather frequently, twice a day. The Physicians’
! a5 I1 d, T! t0 d; w6 p3 Y* oDesk Reference, or package insert of this product, gel or
/ ]: q7 I) B4 j, P2 |- Ecream, cautions about dermal testosterone transfer to
+ n' r& C7 S' D1 ^unprotected females through direct skin exposure.' [' Q- Y" k# Z" W7 ~! T
Serum testosterone level was found to be 2 times the8 h( k* V; w+ K" M# Z7 f
baseline value in those females who were exposed to
( i" q- z1 u, O5 a& }9 v5 b2 x/ O/ eeven 15 minutes of direct skin contact with their male
5 r& a! A* e" @$ f2 Y; Xpartners.6 However, when a shirt covered the applica-
, z: N1 ~, x) Ztion site, this testosterone transfer was prevented.
* E8 S, w! y9 b/ q aOur patient’s testosterone level was 60 ng/mL,
+ M, A! I# O4 {/ _! m" iwhich was clearly high. Some studies suggest that, b# R5 g& S+ g. z4 L9 v
dermal conversion of testosterone to dihydrotestos-2 }& L0 q( h" t; x. Y7 P
terone, which is a more potent metabolite, is more( n( I _$ R- v. Q5 J
active in young children exposed to testosterone
& ?% a1 o/ V% q* R' O: E( uexogenously7; however, we did not measure a dihy-4 } f$ |1 G u2 d* c F
drotestosterone level in our patient. In addition to% O( @! b& d, W! @9 E
virilization, exposure to exogenous testosterone in
. p {0 x) x) Q& j2 a( ]1 K- Fchildren results in an increase in growth velocity and
- Q$ x# \ H0 \* D5 tadvanced bone age, as seen in our patient.
g6 U+ p- @& ?" R. T# R) TThe long-term effect of androgen exposure during& I: M8 b, D0 _
early childhood on pubertal development and final
# a" E Q1 n6 p" V0 H8 iadult height are not fully known and always remain
1 `0 |+ Q/ H2 n0 C m; h* ja concern. Children treated with short-term testos-
; e; |( |. Z4 _terone injection or topical androgen may exhibit some8 M0 S* Z9 \! m- F( z# M; E
acceleration of the skeletal maturation; however, after
, u: n" |8 Q. ucessation of treatment, the rate of bone maturation6 M. |& e# V) ~; t E3 p" |( l
decelerates and gradually returns to normal.8,9$ T* w. |+ q* t4 `/ O) B
There are conflicting reports and controversy2 \5 F: X: t' ~
over the effect of early androgen exposure on adult
" Q8 o& @9 z+ ?' i8 zpenile length.10,11 Some reports suggest subnormal D# I& S9 P# [* [; S* M
adult penile length, apparently because of downreg-
8 U: q- }: J1 U+ X* q: Vulation of androgen receptor number.10,12 However,
, B( V0 ^; b9 tSutherland et al13 did not find a correlation between* k' k6 s: t% k% z8 Y7 G c5 i
childhood testosterone exposure and reduced adult
8 U& z) [! m! ~ ^3 z' _3 Dpenile length in clinical studies.
" ~ B n, w# V ?# }Nonetheless, we do not believe our patient is
% \! E1 C6 R; D& B$ kgoing to experience any of the untoward effects from
6 g2 t3 \( q" y5 g/ C% Ztestosterone exposure as mentioned earlier because
4 Z- @! s/ t2 @3 r5 F Z! _the exposure was not for a prolonged period of time.0 q( J' ^# m" S% }, C
Although the bone age was advanced at the time of
8 d7 V$ u3 j8 Y U) {1 U2 @ v) Pdiagnosis, the child had a normal growth velocity at
1 K% b$ z1 G, S- c" cthe follow-up visit. It is hoped that his final adult
* u$ R; t* y- Y8 w: P3 u' G/ uheight will not be affected.- J* Q. Z7 S$ L' c# t' P
Although rarely reported, the widespread avail-3 q6 j) K9 K9 g
ability of androgen products in our society may3 k: {6 S$ r* a* K1 j2 q# k, F
indeed cause more virilization in male or female
% A. n' I# n$ o0 w' f2 u, t, Zchildren than one would realize. Exposure to andro-2 [' a, M8 l: z h. O# N
gen products must be considered and specific ques-
+ U8 r/ w2 \/ h% btioning about the use of a testosterone product or$ |3 Z6 J, C' x+ V9 L* w6 T
gel should be asked of the family members during1 f4 G+ P5 M8 o$ ~/ @9 W
the evaluation of any children who present with vir-' g; n, k- z% K5 }/ y# Y' t& g! O
ilization or peripheral precocious puberty. The diag-( r) i% A2 D# z9 e6 U3 c2 x
nosis can be established by just a few tests and by; o: I1 g% e# N, y3 T
appropriate history. The inability to obtain such a
9 Y5 B& j6 z# |history, or failure to ask the specific questions, may
1 n8 z. J; M7 T. I7 B: ~9 R. cresult in extensive, unnecessary, and expensive$ n' E( H- x4 X! v+ `3 B
investigation. The primary care physician should be
1 t; {+ t6 S' s# f# Yaware of this fact, because most of these children' f. _2 X$ T" U- B; I
may initially present in their practice. The Physicians’5 `) A1 b3 c- V* p1 o5 A
Desk Reference and package insert should also put a( E" T& [% u& i1 `3 j
warning about the virilizing effect on a male or
# O, Q& |$ R2 s1 ]; K% D! c9 @female child who might come in contact with some-; U( i7 ] ?3 r \: k; x. `3 c
one using any of these products.* g+ y8 s( R9 b
References% H% H3 b9 F& q4 H8 d8 `- r
1. Styne DM. The testes: disorder of sexual differentiation
' p$ q) F0 C. {' Oand puberty in the male. In: Sperling MA, ed. Pediatric
+ @$ `& ?7 K) C+ g" @% oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- u# E. }+ A6 J8 w0 r4 h
2002: 565-628.
4 J4 C3 ~2 X' ^2 a' v2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 N# W1 h' d2 b( \
puberty in children with tumours of the suprasellar pineal |
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