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Sexual Precocity in a 16-Month-Old
8 p0 s# u0 ?* f M* qBoy Induced by Indirect Topical
) `5 B, z- t, v$ z w" ]Exposure to Testosterone
4 S1 }; P) Y4 s3 KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: d$ Q9 A' |% ]2 R7 R" D
and Kenneth R. Rettig, MD1
) N8 W* f+ x! k& B2 vClinical Pediatrics
8 X, s3 z7 U, S+ dVolume 46 Number 6
5 Z1 h7 ?2 {7 W, @2 p) R4 jJuly 2007 540-543
. J. H, p4 {7 p- j/ M J2 C© 2007 Sage Publications) ^; y1 B/ _5 F) n# g. _
10.1177/0009922806296651
! D$ D' z$ S" |% phttp://clp.sagepub.com
" I" X. a( f* a* p6 u5 Ohosted at& j% a" ~. ^2 j( I# z7 R0 k/ S, w
http://online.sagepub.com
# P* n- d- @. W" IPrecocious puberty in boys, central or peripheral,1 \8 z% v. I. U1 _; B+ L1 w; q
is a significant concern for physicians. Central
# }2 Q0 O4 C% ?. H6 Oprecocious puberty (CPP), which is mediated$ [5 @- c0 x5 J9 x1 H6 {! {; h
through the hypothalamic pituitary gonadal axis, has
4 m. c! F8 J, L+ i0 ^a higher incidence of organic central nervous system$ M1 w9 q# o$ ]4 e, S" q. l0 l; r
lesions in boys.1,2 Virilization in boys, as manifested
- C" h& `& |" t& m0 G, A5 c" K# S# vby enlargement of the penis, development of pubic, p# `0 r0 K" v5 o7 e& o3 k0 l5 H
hair, and facial acne without enlargement of testi-( y# G1 U+ A5 F- i, ^" H
cles, suggests peripheral or pseudopuberty.1-3 We
) S, u% A4 c) i v' treport a 16-month-old boy who presented with the
9 f0 l, L, X& X( lenlargement of the phallus and pubic hair develop-; j1 v/ |9 E- b
ment without testicular enlargement, which was due/ N- V6 d. ~7 o1 _5 o/ f( v- L) h
to the unintentional exposure to androgen gel used by
" q0 u0 u, C$ Y9 @( j& Uthe father. The family initially concealed this infor-- f! m) s+ s$ Y6 n! Y K- k
mation, resulting in an extensive work-up for this
1 A# q% N8 X; i( p0 }6 p G5 ~child. Given the widespread and easy availability of
/ k' G4 f0 a. G0 ]' z$ `: a5 Y/ Atestosterone gel and cream, we believe this is proba-0 w" ~- E% @# o2 i* d
bly more common than the rare case report in the. f7 z9 a, }8 ~( j
literature.4) v. `6 P# R0 S: F8 T# ^
Patient Report
* T7 i9 L: ?/ \/ NA 16-month-old white child was referred to the. J7 v; ^: ^" y
endocrine clinic by his pediatrician with the concern
$ J. k4 k9 S4 F+ j0 u& Hof early sexual development. His mother noticed" ?7 f7 {* l: f8 u6 `/ n
light colored pubic hair development when he was
. v. B* a) Q) B+ EFrom the 1Division of Pediatric Endocrinology, 2University of: D7 t1 G) I( k% I Z! y
South Alabama Medical Center, Mobile, Alabama.$ G( b2 f8 N9 K5 f( i$ {# V: z6 i3 R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 K4 u; _. ^# J4 b2 E. p% ~Professor of Pediatrics, University of South Alabama, College of
' G. t1 b5 ~, y2 M. q5 m: I7 o) V5 YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 V6 K3 n" i( o ?
e-mail: [email protected].
5 L* _( L) a3 _7 oabout 6 to 7 months old, which progressively became
% R! v* ]2 k [7 C5 B; @. j4 Adarker. She was also concerned about the enlarge-
9 ^* h2 w4 o( ^2 X6 Dment of his penis and frequent erections. The child, [ z1 F7 F) z3 b9 h4 M
was the product of a full-term normal delivery, with& m' l. I+ q ^4 {# P u5 E
a birth weight of 7 lb 14 oz, and birth length of
8 D% P+ O& C# T, W! g% X0 e20 inches. He was breast-fed throughout the first year9 `8 l5 j) J- M
of life and was still receiving breast milk along with+ q4 A: N; N+ B7 z
solid food. He had no hospitalizations or surgery,
4 c6 m3 k! b/ M. Z" S) i; C, qand his psychosocial and psychomotor development
/ T( P6 A5 r8 K7 qwas age appropriate.
" l8 p. r4 O: M) V6 iThe family history was remarkable for the father,6 g, F8 d' x; r6 A+ i
who was diagnosed with hypothyroidism at age 16,( ^/ i$ F' ^% R( D$ @
which was treated with thyroxine. The father’s
a5 W) l1 A! D% X6 J; pheight was 6 feet, and he went through a somewhat3 k: b0 K, f& I4 Q- P
early puberty and had stopped growing by age 14.# O5 L# N: C/ `8 e& Z1 a
The father denied taking any other medication. The6 L3 O, y, c1 X$ e0 C# q7 g
child’s mother was in good health. Her menarche
* b; a( O) w8 j% W, @: j" o# o9 swas at 11 years of age, and her height was at 5 feet
/ l- Z: G; x2 a4 M5 inches. There was no other family history of pre-2 \' ]: [+ d0 _# {5 b+ ], B7 h
cocious sexual development in the first-degree rela-" ^/ p' Q1 j. m5 u7 f
tives. There were no siblings.# Z; W; L3 m4 T3 Q
Physical Examination
+ j* S: }1 i4 P$ L- d( d) m XThe physical examination revealed a very active,
& q4 c5 A R4 x, gplayful, and healthy boy. The vital signs documented+ E: u: ^7 l ]" r' d# N) {
a blood pressure of 85/50 mm Hg, his length was/ q# H. S1 r* A$ ^; M
90 cm (>97th percentile), and his weight was 14.4 kg* A% K. P' \" ~ l+ C; y3 T
(also >97th percentile). The observed yearly growth
; G. T+ \/ [' E; h6 @3 _9 Vvelocity was 30 cm (12 inches). The examination of( E/ B/ x6 x% r
the neck revealed no thyroid enlargement.. G- y' c! i' G$ X& a
The genitourinary examination was remarkable for/ g+ k# r" P- g. ]3 ?9 y5 ^( j: d
enlargement of the penis, with a stretched length of1 {! Q! }8 e* H! F
8 cm and a width of 2 cm. The glans penis was very well
7 P! ~! G L0 |9 N Wdeveloped. The pubic hair was Tanner II, mostly around+ M+ d, S: Y. f. n3 G6 h
540 j4 Q( J+ D7 r' ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* j7 o# L" w* w. R# {
the base of the phallus and was dark and curled. The) e0 r/ _/ T: I. {" L( E
testicular volume was prepubertal at 2 mL each.. l8 G9 W. |6 t! d; _% W; J' z
The skin was moist and smooth and somewhat3 t& _- s! i8 f- L2 w8 b/ F
oily. No axillary hair was noted. There were no
. ^' x( k; e. `4 t( babnormal skin pigmentations or café-au-lait spots.
% A$ r' o! v0 j$ @) C) QNeurologic evaluation showed deep tendon reflex 2+1 v9 d9 I' U$ M1 p
bilateral and symmetrical. There was no suggestion8 K y2 |$ R- j8 n
of papilledema.
) ]6 B7 E1 d- I- N. zLaboratory Evaluation
" t. p% X4 c$ ]( U: k h6 ?* ^3 B _) MThe bone age was consistent with 28 months by" D' |5 D& f- g8 U, c
using the standard of Greulich and Pyle at a chrono-
2 i1 ^$ s1 ?( Y# E( e, g% n* n& jlogic age of 16 months (advanced).5 Chromosomal) L8 `2 S' \, P, @' c
karyotype was 46XY. The thyroid function test
) } U \ |8 |+ e1 l# |% g# tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 I' |- @: }0 S9 c/ r
lating hormone level was 1.3 µIU/mL (both normal).
# d1 w' ?, T; f9 tThe concentrations of serum electrolytes, blood
; j4 L$ s7 D* @: A5 g. vurea nitrogen, creatinine, and calcium all were! H6 e) e; G+ q% B
within normal range for his age. The concentration
8 Y Z! n8 U/ Fof serum 17-hydroxyprogesterone was 16 ng/dL
4 q: h: J! a4 O8 ~( N% x% J(normal, 3 to 90 ng/dL), androstenedione was 20
* a# F, O$ g9 ^1 hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ l% j9 G" k- h" `6 P! gterone was 38 ng/dL (normal, 50 to 760 ng/dL),3 X! s# K( G* S/ y; l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. M8 O: u, \! F# ~5 v# I
49ng/dL), 11-desoxycortisol (specific compound S)
0 W! y1 s! G5 M3 i/ p5 Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ r2 T5 J6 ~( U5 f! t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' ^+ j, A1 T" c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
I/ w. `, T& D/ Sand β-human chorionic gonadotropin was less than, U8 X0 r" d* m0 h* k
5 mIU/mL (normal <5 mIU/mL). Serum follicular! F; b1 ^# h' P# Z
stimulating hormone and leuteinizing hormone
* N6 n- c( p, S) zconcentrations were less than 0.05 mIU/mL, l) Q+ T% {7 R% S
(prepubertal).
% _- i+ m4 g% @0 u+ q- ~- E* ^The parents were notified about the laboratory
A, C0 A/ K! h2 x1 v0 Fresults and were informed that all of the tests were' ]' X5 N/ L0 U( S3 Z/ `
normal except the testosterone level was high. The, C/ U" q( H- n; z$ q/ g
follow-up visit was arranged within a few weeks to* _7 }& o; I0 B0 z3 N) ?# e
obtain testicular and abdominal sonograms; how-) t' r1 `. B. M/ J3 w7 Q
ever, the family did not return for 4 months.7 w- P! j: n; J2 ~
Physical examination at this time revealed that the
+ O1 {) B0 k& s1 @child had grown 2.5 cm in 4 months and had gained' v- x/ }) A1 f# V4 O5 S
2 kg of weight. Physical examination remained
- K4 j$ d. I Aunchanged. Surprisingly, the pubic hair almost com-
' V. l. e% z+ o" L# @pletely disappeared except for a few vellous hairs at
* T, }: ~9 g! y+ ]. M* r* F5 u; Kthe base of the phallus. Testicular volume was still 2, P; ^3 V; t) D/ |. s
mL, and the size of the penis remained unchanged.
^: g9 s# Y4 [/ @The mother also said that the boy was no longer hav-7 h. t8 }. T a
ing frequent erections.
+ M0 @- T7 l& d, h1 r9 UBoth parents were again questioned about use of
4 X: ?# C& p) `* h sany ointment/creams that they may have applied to" L4 o! ^4 I3 p# p& O
the child’s skin. This time the father admitted the2 {( _1 z- k/ i2 F0 W
Topical Testosterone Exposure / Bhowmick et al 541
: v! I) c; ?% O9 F9 p# y( ~0 muse of testosterone gel twice daily that he was apply-
" v& x' S/ E) |2 o7 X" H+ R$ xing over his own shoulders, chest, and back area for8 G [6 U( l7 F9 J0 ?
a year. The father also revealed he was embarrassed" p$ y5 }/ o9 y; d3 c( ^
to disclose that he was using a testosterone gel pre-
# {) C1 [" ~' Lscribed by his family physician for decreased libido) ^, ?4 Q" F: q1 o" R
secondary to depression.
% ]% Q* l! z5 GThe child slept in the same bed with parents.' n# m1 u: U( W+ r: w
The father would hug the baby and hold him on his2 S9 r1 ]! \& M1 B' L' |, A! m
chest for a considerable period of time, causing sig-0 Q1 A8 U6 |6 R
nificant bare skin contact between baby and father.
/ {7 S. Z: k. y) o2 t Y4 Y: n' ~5 @The father also admitted that after the phone call,
) o) ~! @( l7 `9 H$ U9 ~when he learned the testosterone level in the baby
; |2 N$ E4 o7 S swas high, he then read the product information x- |5 T0 G: @* S7 ]
packet and concluded that it was most likely the rea-
. V6 {9 K3 k2 {! y1 qson for the child’s virilization. At that time, they
) Z' a# h: y& I* g8 D+ @! xdecided to put the baby in a separate bed, and the
4 X! W5 t# J1 m/ Yfather was not hugging him with bare skin and had
. y0 H8 o( A4 J4 x# P, rbeen using protective clothing. A repeat testosterone
* g) r+ T8 E0 V" jtest was ordered, but the family did not go to the
0 |3 V9 w* ]/ P+ e& ]" zlaboratory to obtain the test.
' A: \+ t6 e9 L& tDiscussion
* [! T) t: v/ C6 X0 SPrecocious puberty in boys is defined as secondary8 G2 d8 x: ~+ d) _
sexual development before 9 years of age.1,45 T' a/ V m- Q% T. p0 Q
Precocious puberty is termed as central (true) when
/ e" e# o0 |0 D: K# ]/ ^3 xit is caused by the premature activation of hypo-
1 }( o* }/ I. r" w9 o2 rthalamic pituitary gonadal axis. CPP is more com-
2 L3 O/ y7 W0 ?mon in girls than in boys.1,3 Most boys with CPP
4 P8 q. u4 k2 E O7 nmay have a central nervous system lesion that is
! J) [' h1 `' T! E, S( j" sresponsible for the early activation of the hypothal-: q1 N- ^! X: Z7 |: p* D# I D! _
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ R% d2 h- l1 r7 O; u1 U4 nsis has been given to neuroradiologic imaging in. O# K: o! C# X7 d7 {3 A0 D/ f9 U
boys with precocious puberty. In addition to viril-
( B5 J' j) w/ z% ]ization, the clinical hallmark of CPP is the symmet-
% B9 ?8 y! H+ P3 h4 Y, |# ?" ~2 [8 Vrical testicular growth secondary to stimulation by& J% E9 [$ L0 [# `2 Z! z2 A; I
gonadotropins.1,3
6 Z% Q: B) L4 y/ h5 F# z! R4 n0 oGonadotropin-independent peripheral preco-
a0 e9 K+ s9 j9 ?- Z6 T- e1 mcious puberty in boys also results from inappropriate; `& ~, [6 Z7 n- ~) C8 J3 _8 L
androgenic stimulation from either endogenous or* m! M9 ?4 j' a
exogenous sources, nonpituitary gonadotropin stim-4 s* B) G7 d- Y3 m: n+ Z
ulation, and rare activating mutations.3 Virilizing6 i! N6 H) J1 o2 @, i, t0 `
congenital adrenal hyperplasia producing excessive2 a2 H; Y: {% N/ R& J
adrenal androgens is a common cause of precocious3 ]! U3 l. u6 r% a
puberty in boys.3,4
( Q+ d2 h' t- V; s! FThe most common form of congenital adrenal
: i2 d. L4 p- ?: R% mhyperplasia is the 21-hydroxylase enzyme deficiency.
- S1 c& D+ O# T2 _" d" CThe 11-β hydroxylase deficiency may also result in& ?* B4 ~ x P
excessive adrenal androgen production, and rarely,
; X+ T6 t) T; E' Pan adrenal tumor may also cause adrenal androgen
- Z% I6 c" ~5 m+ A4 v! | F) pexcess.1,32 F* s. ~& G- b! V6 W) h/ @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! g# ^& ~7 [ F* |4 ^5 s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: j! l* k2 [4 \% L, x( L$ eA unique entity of male-limited gonadotropin-
! \ f' c. o. H3 lindependent precocious puberty, which is also known
8 {/ ]- S* N" tas testotoxicosis, may cause precocious puberty at a/ @) E/ y" v2 M# t8 j0 b0 h N
very young age. The physical findings in these boys5 L I9 X- C; y' T
with this disorder are full pubertal development,
- y( f! J6 B* y8 b. @: \including bilateral testicular growth, similar to boys" ^: ~3 G4 L( _; T3 T( m7 [
with CPP. The gonadotropin levels in this disorder
! l+ f* @% a0 M* Y: Z8 Q7 ~6 i( jare suppressed to prepubertal levels and do not show
8 e; u) U6 E0 {+ i1 D$ C3 W2 ]2 ~pubertal response of gonadotropin after gonadotropin-; `; z4 b/ E1 t7 o- ]9 |
releasing hormone stimulation. This is a sex-linked9 \' @; H/ g/ W
autosomal dominant disorder that affects only
# _, S; K) Y( R* M! x; E/ wmales; therefore, other male members of the family
* x. g) y d' m! kmay have similar precocious puberty.3( `$ X) ~# ~" M1 B$ _% x; d( d7 i7 d
In our patient, physical examination was incon-
% q( {: `5 n' X9 lsistent with true precocious puberty since his testi-/ t+ J7 X& v: x1 r, A4 I* ]# ~* F' o
cles were prepubertal in size. However, testotoxicosis
, T+ t& I& }9 E% f5 G) ewas in the differential diagnosis because his father
0 Y, n' n* D$ b: V0 s2 F- H1 ?started puberty somewhat early, and occasionally,
# Q/ U1 |0 p2 R, R, e, u; Ctesticular enlargement is not that evident in the1 j4 F" G2 |6 y/ p$ C, Q
beginning of this process.1 In the absence of a neg-1 j/ Q- y( `2 w6 X. F) I& s; b
ative initial history of androgen exposure, our
w0 j* a- c# C# S# P$ p5 Hbiggest concern was virilizing adrenal hyperplasia,- d6 A. y3 G/ Z+ m3 O: ^( h
either 21-hydroxylase deficiency or 11-β hydroxylase
5 D3 C6 i k9 k0 Vdeficiency. Those diagnoses were excluded by find-
" }, `1 _ n3 H' V7 y( ming the normal level of adrenal steroids.
9 w* x' g0 {% y+ r5 f* KThe diagnosis of exogenous androgens was strongly
! r9 y% g0 X' R$ z% l- isuspected in a follow-up visit after 4 months because5 c9 u8 q# j* s0 {4 d3 g
the physical examination revealed the complete disap-) P* b) V& P( T8 D& Q W1 n
pearance of pubic hair, normal growth velocity, and! T1 _/ S3 e3 L8 f
decreased erections. The father admitted using a testos-0 D( m4 t# _3 v8 S) C" \
terone gel, which he concealed at first visit. He was+ l. t/ z; v9 O& {$ g$ F
using it rather frequently, twice a day. The Physicians’- d) G+ {; q! V# A
Desk Reference, or package insert of this product, gel or
7 M) ], M: v9 i* Y3 {cream, cautions about dermal testosterone transfer to' k# E: z* a( a; A
unprotected females through direct skin exposure.
* n( ]0 q5 b: ]) ?. C" ^Serum testosterone level was found to be 2 times the1 T! B- \- f5 X' D# @5 j; b
baseline value in those females who were exposed to
6 |) B0 M, U) ~% N3 C/ |: |. Geven 15 minutes of direct skin contact with their male
2 R. m) N" h# v0 i$ Q# S* K3 `partners.6 However, when a shirt covered the applica-' M& h! D/ F" ~+ i8 f T
tion site, this testosterone transfer was prevented.
0 ~$ w& n0 ^5 I* ^5 aOur patient’s testosterone level was 60 ng/mL,
{2 m9 A, J+ y: o& `; U! B2 owhich was clearly high. Some studies suggest that; z# l" p' V! J+ x
dermal conversion of testosterone to dihydrotestos-
% @! K9 I% \* z3 g% fterone, which is a more potent metabolite, is more1 m* G4 \7 U1 M. H: P1 z& w
active in young children exposed to testosterone
0 F( I( P$ W2 B4 \$ T: k& Qexogenously7; however, we did not measure a dihy-
' z b2 o- c5 {; S8 _0 W/ t, bdrotestosterone level in our patient. In addition to) _6 X& N& J b% m
virilization, exposure to exogenous testosterone in
4 f' K/ w; l3 t+ @- ]+ jchildren results in an increase in growth velocity and) W' Z E% H; l
advanced bone age, as seen in our patient.
) o0 U& y: M* o2 i0 qThe long-term effect of androgen exposure during8 U# o* f1 W9 H% B: g( i
early childhood on pubertal development and final1 c* u1 c4 @9 w8 ]6 F
adult height are not fully known and always remain
2 A5 m d" [0 Q6 V6 Ua concern. Children treated with short-term testos-" j- F1 ^- Z+ K* R5 p) k2 k
terone injection or topical androgen may exhibit some
1 s% w6 r) u; K) h8 z7 Uacceleration of the skeletal maturation; however, after% h+ U" N, V* K) l. j
cessation of treatment, the rate of bone maturation& u* f3 C( G/ ]- q2 n, g
decelerates and gradually returns to normal.8,95 c' F7 e* v. X- i
There are conflicting reports and controversy4 j- Z6 M3 ]7 r9 g
over the effect of early androgen exposure on adult8 p2 L1 T6 W# |; x! B, @
penile length.10,11 Some reports suggest subnormal
# g E- }: ?; h7 Y; qadult penile length, apparently because of downreg-
! `4 L8 f2 @7 [& v# \: j1 }0 dulation of androgen receptor number.10,12 However,6 | t/ c M( `/ a
Sutherland et al13 did not find a correlation between
: Q' z G5 w& a6 vchildhood testosterone exposure and reduced adult
) E6 q; m5 n, C6 v" R" S+ Ypenile length in clinical studies.
7 _' G, q; f8 }Nonetheless, we do not believe our patient is
0 j" a& J% Q7 bgoing to experience any of the untoward effects from
9 ^% l' n4 l1 S! ~% [testosterone exposure as mentioned earlier because
! R- ]. p# @4 Z4 r& o$ rthe exposure was not for a prolonged period of time.9 J6 d3 L1 E8 l4 A/ d
Although the bone age was advanced at the time of
& q( o3 }( _, O1 P: x. Ldiagnosis, the child had a normal growth velocity at5 H. }/ G' \, D- y6 {& @5 O
the follow-up visit. It is hoped that his final adult
$ |: o& Y) y+ rheight will not be affected.
# M: _' A/ d. l p) A/ }8 }4 a1 s; `Although rarely reported, the widespread avail-
$ X3 {, l) s: e8 Iability of androgen products in our society may- m: m6 U- d' |- z( L8 P% T U
indeed cause more virilization in male or female" n4 x i, R! d, V) @; I
children than one would realize. Exposure to andro-
3 x* R6 ]( r3 l- x2 L9 O/ [4 q0 w- Igen products must be considered and specific ques-
. \/ c3 Q! Z: U3 C" x& d! Itioning about the use of a testosterone product or% Z. p4 \, g+ Q6 m
gel should be asked of the family members during
# } C% G( n$ t+ ~) \the evaluation of any children who present with vir-; s6 W6 c4 l5 J7 w% \: q8 |
ilization or peripheral precocious puberty. The diag-
% d# w/ z. j7 R9 onosis can be established by just a few tests and by
2 {5 o7 J; |2 t; }! \# xappropriate history. The inability to obtain such a
. W: J5 W3 d" P4 g* f$ Y0 dhistory, or failure to ask the specific questions, may& F& }0 `) p! F9 b( \. s; C+ X
result in extensive, unnecessary, and expensive1 H# B; E% ?' c$ }, S0 Y0 z
investigation. The primary care physician should be
8 S9 t' Z! \* uaware of this fact, because most of these children
& |2 ~7 B$ T; u dmay initially present in their practice. The Physicians’
/ ^. }. F9 c) Y HDesk Reference and package insert should also put a
0 b1 Q9 Z' d8 l/ ?" r* Pwarning about the virilizing effect on a male or! [5 {: w% V9 y5 S- V: H
female child who might come in contact with some-, P+ v: S* D8 s) m+ X9 V
one using any of these products.
8 X( Q* C. `- yReferences: B6 B( B- W) I
1. Styne DM. The testes: disorder of sexual differentiation [6 ?8 \7 f* k: t: S0 D! E! l
and puberty in the male. In: Sperling MA, ed. Pediatric
6 x& i. o6 K+ L7 R& FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, ~ H: F2 y' t8 }/ S( n% d
2002: 565-628.6 @6 f2 h7 O5 M- B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 n# u* r" K4 l! I f- L/ W
puberty in children with tumours of the suprasellar pineal |
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