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Sexual Precocity in a 16-Month-Old* d4 h6 k2 k8 U5 P. B' j
Boy Induced by Indirect Topical$ w3 K7 j( R9 V: A3 H
Exposure to Testosterone& ?; ?/ Z! X0 ~: d z; j- j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: q2 p8 } f2 `( a8 V' Z8 y
and Kenneth R. Rettig, MD1
! M2 |- Z1 R( ]2 g J1 O7 T GClinical Pediatrics+ |6 @1 c# [6 G; V$ k
Volume 46 Number 6
- ~1 r3 R% U& @4 z: qJuly 2007 540-543
9 M0 h/ |+ H1 G/ `% l© 2007 Sage Publications
2 E4 H7 x6 W; r0 |+ F+ O2 s' ~10.1177/0009922806296651" S2 b D+ O c8 B3 N
http://clp.sagepub.com$ e8 f5 p* b( T6 u( c6 Y
hosted at8 V2 N6 z9 a. q6 ~0 S7 ]/ |5 I% |7 V
http://online.sagepub.com! x" o% M- `, o$ r/ d
Precocious puberty in boys, central or peripheral,& W! @9 O* D* V5 x+ G& g5 I3 c( ?
is a significant concern for physicians. Central
0 _( |$ X2 p& X5 }- lprecocious puberty (CPP), which is mediated
2 a9 j7 D J0 t' m& |1 Qthrough the hypothalamic pituitary gonadal axis, has
3 l$ X) |% d" ?a higher incidence of organic central nervous system9 K. c" @7 S1 g3 S1 k
lesions in boys.1,2 Virilization in boys, as manifested+ W6 u4 l# C1 x- T2 Y
by enlargement of the penis, development of pubic
5 Q2 r* p0 T- ~% Whair, and facial acne without enlargement of testi-+ j" B4 a/ S' U
cles, suggests peripheral or pseudopuberty.1-3 We6 c3 _3 S- Z- Z# U2 A
report a 16-month-old boy who presented with the' A7 D* ?, h: R- U# E& Y
enlargement of the phallus and pubic hair develop-
3 y# u+ [. A! u6 r$ ement without testicular enlargement, which was due
: W, C1 y9 t# ~* r% j# K4 M4 f6 v( Mto the unintentional exposure to androgen gel used by
: a! W2 P! y4 @ J( H2 Lthe father. The family initially concealed this infor-
' ~/ ^, C. d( {) I c. Vmation, resulting in an extensive work-up for this
. c5 p3 ^5 ?$ k. I8 v6 ]child. Given the widespread and easy availability of4 s8 S& a+ |* B, J! i2 F
testosterone gel and cream, we believe this is proba-$ b# @, G6 l, m, k- \. X, v2 ]
bly more common than the rare case report in the w% t" k" {& z( p+ {
literature.4) w# L& d8 x$ i# c5 p1 I1 }/ \
Patient Report
: ]" p t. E, S1 I0 X$ x" uA 16-month-old white child was referred to the. H" W- n, @( I; f& K
endocrine clinic by his pediatrician with the concern N: c5 J/ o Y6 L0 u% x: R
of early sexual development. His mother noticed5 P" ?) ^2 y0 }" d V
light colored pubic hair development when he was
# i& q# r7 B6 d0 a# n* ^From the 1Division of Pediatric Endocrinology, 2University of" I) S6 x8 a7 a# c2 X+ ]
South Alabama Medical Center, Mobile, Alabama.% }) Q8 W! t; o
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: o& O4 T, ]+ k, KProfessor of Pediatrics, University of South Alabama, College of
. t8 I. u: e) l4 k: D4 _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 F) i& d8 _' b% V1 o5 he-mail: [email protected].
7 _+ K. ?, _+ H; pabout 6 to 7 months old, which progressively became
" |; G/ G: d8 Q/ v' Ldarker. She was also concerned about the enlarge-
; M- _. p+ h. }( jment of his penis and frequent erections. The child
3 ? c( ?1 l1 q2 Q+ E7 `was the product of a full-term normal delivery, with
+ J/ A+ M0 j! i5 i$ J, m! ^a birth weight of 7 lb 14 oz, and birth length of
/ h+ t" _4 n A! L" b& W% ~& Y& f4 A20 inches. He was breast-fed throughout the first year
8 B) q3 Y9 ^) n8 _( nof life and was still receiving breast milk along with
- z k: ^( }! |solid food. He had no hospitalizations or surgery,
$ M0 M6 T2 O0 iand his psychosocial and psychomotor development4 F2 W' P S) ?# E' N
was age appropriate.
, @. [7 y z! W9 q4 y/ f8 ^4 eThe family history was remarkable for the father,0 V2 t# y7 Y1 A
who was diagnosed with hypothyroidism at age 16,
8 E0 _% _5 ^- G1 ]/ J$ Pwhich was treated with thyroxine. The father’s
$ F3 B% j9 O2 qheight was 6 feet, and he went through a somewhat7 H* o/ n& C1 e6 q" I0 U
early puberty and had stopped growing by age 14.
" T3 r. G2 M S+ @! i) FThe father denied taking any other medication. The
4 o$ [! |0 a: R' Gchild’s mother was in good health. Her menarche( s7 J9 O6 S- H- g: @7 N- @5 n) s
was at 11 years of age, and her height was at 5 feet
( M3 ]; r3 Q/ x5 C* A0 `6 w1 z5 inches. There was no other family history of pre-0 x x x- e; g. U; s0 W
cocious sexual development in the first-degree rela-
0 y) U3 e" n' @8 {2 }5 s! Ctives. There were no siblings.
1 b4 H* | M9 i$ J, O5 A. y# n( |Physical Examination; M" u3 w9 l5 z
The physical examination revealed a very active,
( s0 k, j- V8 O7 B- _ |playful, and healthy boy. The vital signs documented9 ~, C) w9 K( d$ }, T# @6 M8 b, C
a blood pressure of 85/50 mm Hg, his length was0 e. N/ N X+ w& L; [& R4 m
90 cm (>97th percentile), and his weight was 14.4 kg
3 F) ~ U; d" t4 L! d(also >97th percentile). The observed yearly growth
+ O- y! g% B; u& y3 W8 {- P* bvelocity was 30 cm (12 inches). The examination of! ]2 o: ~. h. P, p) K
the neck revealed no thyroid enlargement.. T! S) Q1 @6 Z ~' m
The genitourinary examination was remarkable for
* ~ A% h+ S9 r" d; G/ |+ Benlargement of the penis, with a stretched length of
8 i0 r! K- H' i5 P$ k8 cm and a width of 2 cm. The glans penis was very well
2 i: [% i9 a- n9 Tdeveloped. The pubic hair was Tanner II, mostly around
, m7 H% w: }& O5 v% @! K: S5405 }. V7 `! |. a% d" Q) e* l$ m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 v9 I; [' i- o6 o
the base of the phallus and was dark and curled. The
1 H9 _6 n$ | y6 ktesticular volume was prepubertal at 2 mL each.5 z0 ~$ V4 \' L0 W3 Y3 v9 T5 X
The skin was moist and smooth and somewhat3 K5 X% q' i; E" G( p
oily. No axillary hair was noted. There were no- V0 i) b; {2 {/ `
abnormal skin pigmentations or café-au-lait spots.
) @2 D+ B$ F5 w v/ O+ V$ lNeurologic evaluation showed deep tendon reflex 2+ X# m2 I, a* ]. s! x
bilateral and symmetrical. There was no suggestion8 u" [- d# Q0 b- i$ _4 ^' T
of papilledema.
* g/ y: {2 i5 G+ y) T* x2 L+ `Laboratory Evaluation
" A% l/ ^+ i7 d6 ]The bone age was consistent with 28 months by
( y: ]& h6 l) L) V- X3 Uusing the standard of Greulich and Pyle at a chrono-
$ K% [: m; S6 A5 V9 Vlogic age of 16 months (advanced).5 Chromosomal
% n8 O; I! u: w- vkaryotype was 46XY. The thyroid function test
" V. J+ m: @( f+ d; ? @showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% f: l7 ^" J8 w( p1 A/ Dlating hormone level was 1.3 µIU/mL (both normal).
. R% a3 a7 E+ IThe concentrations of serum electrolytes, blood
7 I O7 A' k7 Y: r2 p# u3 j. p5 Xurea nitrogen, creatinine, and calcium all were
5 m- U9 v9 J) j/ xwithin normal range for his age. The concentration0 p: L' v h9 [- W3 F
of serum 17-hydroxyprogesterone was 16 ng/dL% s. }* p7 z" H' \% k
(normal, 3 to 90 ng/dL), androstenedione was 20 o: Z( Z7 E8 m! p9 j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 h, C/ U* |- I' _/ _9 [& X- zterone was 38 ng/dL (normal, 50 to 760 ng/dL),; {. L. N1 f9 h) I- ^
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% e0 F1 |( j. x% _49ng/dL), 11-desoxycortisol (specific compound S)7 y+ E7 F4 S3 g5 G3 @ c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# O B3 G6 ~4 @& i( N8 \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* x1 P+ V0 H1 R) B) i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; o; [2 Y: G1 Xand β-human chorionic gonadotropin was less than" z' B8 o6 B4 U( B; M' n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% l. l/ Z g$ Q& ~3 P7 O; |0 lstimulating hormone and leuteinizing hormone
6 I$ v2 h/ A3 I! S+ r" [6 O6 j: ]concentrations were less than 0.05 mIU/mL' u6 V L* X5 P# H# f1 S
(prepubertal).
3 T7 \& T+ t& Y) _% iThe parents were notified about the laboratory! {' j' c, Y y
results and were informed that all of the tests were2 l+ T0 Z" D8 g' w) z+ d {% y9 R0 Z
normal except the testosterone level was high. The
, G- B4 g9 E7 w; }* Z" S4 ofollow-up visit was arranged within a few weeks to+ e2 ?+ V8 M. s3 V
obtain testicular and abdominal sonograms; how-, n/ ^; `6 @0 U0 X( A& `
ever, the family did not return for 4 months.; e$ r7 w% y8 j$ |
Physical examination at this time revealed that the$ @* k E7 u( _# A1 w: J
child had grown 2.5 cm in 4 months and had gained
6 ?+ X/ P$ ^# k0 T" k x2 kg of weight. Physical examination remained. F, Z& [/ @) o3 c+ ?0 X' `
unchanged. Surprisingly, the pubic hair almost com-# y1 P p3 K! u, G; w
pletely disappeared except for a few vellous hairs at
4 W* t8 q3 D% g2 r: s: y7 ethe base of the phallus. Testicular volume was still 2
, }8 q4 J5 F& R6 F$ Z+ m" TmL, and the size of the penis remained unchanged.2 O9 Y5 D4 k2 |$ X* v" e
The mother also said that the boy was no longer hav-$ T/ @& C2 C8 Q& _/ B+ Z9 P
ing frequent erections.; X2 t6 K u& @, F' E
Both parents were again questioned about use of
) q R1 U% Z( Tany ointment/creams that they may have applied to
1 k- l( ?5 Q* X- o, P4 Ythe child’s skin. This time the father admitted the
3 a0 d' J( `. G' g' ^# kTopical Testosterone Exposure / Bhowmick et al 541
7 m/ v" { X1 @' z& _* Fuse of testosterone gel twice daily that he was apply-
2 [* W% w- F8 ^5 E# ]% c" Ying over his own shoulders, chest, and back area for
: G1 u# H8 _0 U1 Ja year. The father also revealed he was embarrassed3 e/ F* T! i3 \# T2 o3 \
to disclose that he was using a testosterone gel pre-) O' |3 E5 h$ w2 T% D, `2 f" \
scribed by his family physician for decreased libido _7 b5 T, y& A! {5 N: @1 R
secondary to depression.- j. J" Y: ?# t o H, q
The child slept in the same bed with parents.' {& e3 k& a+ b4 E. H
The father would hug the baby and hold him on his
" h" ]/ t' p) s5 B8 Hchest for a considerable period of time, causing sig-
0 S3 j) l, {5 znificant bare skin contact between baby and father.6 d- _( M6 ~7 U5 F" _0 `
The father also admitted that after the phone call,: B; r9 @( ?2 g, n6 F
when he learned the testosterone level in the baby4 E3 t" {% [; `4 a5 E, g, M
was high, he then read the product information
# U4 @/ |" A6 r* ~9 Z& ?$ E) Spacket and concluded that it was most likely the rea-
! R* {8 a9 f* Q, w% c& Z- yson for the child’s virilization. At that time, they- \& j: l) K2 d1 M, s; d
decided to put the baby in a separate bed, and the
: Q: c6 _) D5 }9 i4 ]* Afather was not hugging him with bare skin and had
. y, t, e, ]" Ibeen using protective clothing. A repeat testosterone) \. r0 M# T7 @, O5 ?- a A
test was ordered, but the family did not go to the0 ^) E% W) A/ B8 j/ x
laboratory to obtain the test.
' |& P% L& Y( S( @! vDiscussion
8 c' x$ q) ~3 u1 D( N9 J( zPrecocious puberty in boys is defined as secondary
! q3 [2 y# ?) isexual development before 9 years of age.1,4
" v" ?1 f/ m6 ^( QPrecocious puberty is termed as central (true) when
0 }, Y3 a y% @it is caused by the premature activation of hypo-4 h5 B6 v5 O$ F. a/ b( h
thalamic pituitary gonadal axis. CPP is more com-
! A0 C" o- p* G6 d& q4 w+ a8 h6 S8 Wmon in girls than in boys.1,3 Most boys with CPP
9 H; k5 q/ O% Smay have a central nervous system lesion that is
( Y" T' x5 H( r( X8 yresponsible for the early activation of the hypothal-
! R1 [+ F4 F s5 ~& E6 vamic pituitary gonadal axis.1-3 Thus, greater empha-
, H, p |; Y S( ^sis has been given to neuroradiologic imaging in% G1 E( H0 X6 L6 x/ ^, ~
boys with precocious puberty. In addition to viril-& X% c* J1 L3 Y) [
ization, the clinical hallmark of CPP is the symmet-
% ?$ k5 k! p: o0 `rical testicular growth secondary to stimulation by% \4 J: |, _. M, n
gonadotropins.1,3/ ?+ s4 k7 ^4 N9 H, q. a
Gonadotropin-independent peripheral preco-
* U# g; h/ ]* Y$ k) M5 _0 jcious puberty in boys also results from inappropriate
* H v; l8 O6 U5 g/ i6 V# S0 ?androgenic stimulation from either endogenous or2 t; d4 l8 q% \" G( Q/ `3 J
exogenous sources, nonpituitary gonadotropin stim-- u1 U2 I9 @2 R" C+ Y a8 p _5 f
ulation, and rare activating mutations.3 Virilizing
2 k m9 X. k6 |1 X. k$ `congenital adrenal hyperplasia producing excessive$ ]0 ]2 q! ?7 c( j6 Y* @3 v: T
adrenal androgens is a common cause of precocious! h2 n* [+ \% h1 f: @" X+ R$ }. m( Q
puberty in boys.3,48 J+ f0 V% R5 d6 g' S' x) a
The most common form of congenital adrenal
8 d2 U* e2 O5 G" m' u0 s- Xhyperplasia is the 21-hydroxylase enzyme deficiency.
7 F& b7 U: U1 |! w* g" U+ AThe 11-β hydroxylase deficiency may also result in" @3 X9 Y$ f, V3 J, k1 N O, F, w }
excessive adrenal androgen production, and rarely,/ l4 o3 h l4 U% t
an adrenal tumor may also cause adrenal androgen
+ ~$ ~" J- w" Z) j$ j# P( x5 bexcess.1,3
9 e* I. `/ h; o1 O. v# N" Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* y! \+ L1 `+ ~$ f6 i& d* [" k! r
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, V0 ~: M; z- {A unique entity of male-limited gonadotropin-
& e# c' t. I1 bindependent precocious puberty, which is also known
/ |0 m* z' e! \3 Q5 w) Das testotoxicosis, may cause precocious puberty at a
4 d9 z) s$ @4 [* }4 U$ vvery young age. The physical findings in these boys; a4 U0 N4 B: n( W: h2 m
with this disorder are full pubertal development,. z8 k/ Z* o0 k+ b
including bilateral testicular growth, similar to boys
4 b1 P; g9 a! O5 Twith CPP. The gonadotropin levels in this disorder
5 I$ A- `0 ?& }3 z" ]are suppressed to prepubertal levels and do not show
: _. u! [+ C" K9 H& d# X* ]3 }pubertal response of gonadotropin after gonadotropin-
! _2 B% l% t g) }; A" D: \9 \releasing hormone stimulation. This is a sex-linked
6 M8 _) X5 _9 W' x9 }autosomal dominant disorder that affects only8 H* K4 ^- o' a: c, {
males; therefore, other male members of the family h; p8 z4 L+ l
may have similar precocious puberty.3
" F0 E! }# R0 J) D( l! bIn our patient, physical examination was incon-
7 j* E8 W& |) U0 R* Rsistent with true precocious puberty since his testi-
- f" [$ P/ c% t: [8 |cles were prepubertal in size. However, testotoxicosis8 n% O, o' d/ Q
was in the differential diagnosis because his father
! t8 d. {$ o5 ?: m1 F% ^started puberty somewhat early, and occasionally,
1 P# o( ?7 o! g: \testicular enlargement is not that evident in the
4 X+ `) z' O4 o5 n$ r0 k0 jbeginning of this process.1 In the absence of a neg-, _- }) \7 g* U- K# \7 a0 L
ative initial history of androgen exposure, our
* j+ [4 u% {- R" ybiggest concern was virilizing adrenal hyperplasia,# ?: r8 x& {& E* E- c8 Q2 T
either 21-hydroxylase deficiency or 11-β hydroxylase
- f, d/ t. F0 Q% s- C2 zdeficiency. Those diagnoses were excluded by find-7 V- A: p9 u0 I: ^ d) |
ing the normal level of adrenal steroids.
3 ^7 l% d, v2 YThe diagnosis of exogenous androgens was strongly
" ]: s8 p* x% d5 N" wsuspected in a follow-up visit after 4 months because
0 \% C5 Z2 _$ K. r5 {; ethe physical examination revealed the complete disap-: q+ m6 n. v1 g! t1 t
pearance of pubic hair, normal growth velocity, and5 ?; Q2 K& {, ^* Z% U0 d# o, K
decreased erections. The father admitted using a testos-
$ L7 m X9 O0 Z o K7 t! { I$ rterone gel, which he concealed at first visit. He was% N! }$ Y0 ^. e9 n0 A
using it rather frequently, twice a day. The Physicians’& E6 b3 z/ w/ T
Desk Reference, or package insert of this product, gel or$ U( a g; G" _7 o
cream, cautions about dermal testosterone transfer to
`+ U/ \7 S( [4 r/ `1 q7 D) Ounprotected females through direct skin exposure.2 m7 y+ R: P+ K
Serum testosterone level was found to be 2 times the7 v3 N9 F; Z# V0 X5 w
baseline value in those females who were exposed to
4 ] K1 ~) T$ L; x: [$ x6 Jeven 15 minutes of direct skin contact with their male/ }& k1 `; E* O/ A' d3 s
partners.6 However, when a shirt covered the applica-
s* Y# x! X& ztion site, this testosterone transfer was prevented., ^) h4 B. L' d
Our patient’s testosterone level was 60 ng/mL,& S# h2 d) v& q- M$ K$ L8 D; A [3 x
which was clearly high. Some studies suggest that j( A4 |$ U: t, Q- W; ]+ s
dermal conversion of testosterone to dihydrotestos-) B7 l; k$ P" s3 l
terone, which is a more potent metabolite, is more
0 A4 r) J/ @1 q8 o) i+ [; {1 gactive in young children exposed to testosterone
$ q5 F& v7 H6 F$ aexogenously7; however, we did not measure a dihy-/ @. T) @" y! Z: z8 Y, j
drotestosterone level in our patient. In addition to
% a9 U5 x& [4 ?7 P1 Yvirilization, exposure to exogenous testosterone in
1 T" k9 e) Y5 N* G3 o$ vchildren results in an increase in growth velocity and8 l4 o% d% e a# u
advanced bone age, as seen in our patient.
2 f0 ]7 @# N0 e* HThe long-term effect of androgen exposure during
; C( A' a9 k% h1 r1 jearly childhood on pubertal development and final) S5 h( ~3 A2 j5 A. P0 z
adult height are not fully known and always remain
5 S8 g9 w/ B- l8 t( l/ X( `a concern. Children treated with short-term testos-
+ o2 V+ X6 ]. n4 J) zterone injection or topical androgen may exhibit some: J, V5 J8 f/ g! @7 D
acceleration of the skeletal maturation; however, after+ ]0 I5 s: d4 P' u" @6 E
cessation of treatment, the rate of bone maturation: S% t7 M" y; G7 d
decelerates and gradually returns to normal.8,9( ~, F7 ^! c9 e
There are conflicting reports and controversy
# C1 e0 P: N' F* \over the effect of early androgen exposure on adult& O/ d v) Z/ m( g
penile length.10,11 Some reports suggest subnormal
! q8 ^0 N! e& e6 _* S" Fadult penile length, apparently because of downreg-$ ?; f: P6 q7 F9 d
ulation of androgen receptor number.10,12 However,
) G( {! v0 [' |Sutherland et al13 did not find a correlation between4 t7 A0 X9 d* I! d" H
childhood testosterone exposure and reduced adult
* e3 m( N v0 C P' `penile length in clinical studies.- D- B5 n% _/ [) ?4 Q
Nonetheless, we do not believe our patient is
i( y8 l. [: ^8 j* X' Mgoing to experience any of the untoward effects from5 L" Q/ C, E2 Z( F! W1 o2 t0 z* ^9 I
testosterone exposure as mentioned earlier because2 S! f* h3 C) a8 w2 B
the exposure was not for a prolonged period of time.5 r8 m0 n6 R% C5 p7 a$ Z
Although the bone age was advanced at the time of
2 _4 ]* c4 c& @! Z1 I% [; Ediagnosis, the child had a normal growth velocity at5 {4 o! p: t4 o/ }4 V" O# c
the follow-up visit. It is hoped that his final adult
& w7 L7 G+ |) K3 vheight will not be affected.4 S" ^4 r2 w/ `- V
Although rarely reported, the widespread avail-
( F. x* b) w1 Z/ v# cability of androgen products in our society may
7 S* S) i/ e* |' E, E) a1 `. O9 cindeed cause more virilization in male or female7 m3 i$ |1 x5 ]1 T- j
children than one would realize. Exposure to andro-+ W, y6 M \( P( I" p8 C
gen products must be considered and specific ques-& ?3 E" O0 b t4 `2 G# \0 H
tioning about the use of a testosterone product or' N: v5 n2 F1 F4 N6 v0 A( d
gel should be asked of the family members during
" L- m' j$ x$ U+ }! Hthe evaluation of any children who present with vir-0 N5 H" S! L, N; G5 P, v1 T" k: D
ilization or peripheral precocious puberty. The diag-
8 p6 O7 i4 G& P, S" x0 ?nosis can be established by just a few tests and by
|3 n7 q& U0 G4 O$ p: q4 J" Gappropriate history. The inability to obtain such a
/ u. m n; C) ?! C1 zhistory, or failure to ask the specific questions, may
/ q( e" z2 g Hresult in extensive, unnecessary, and expensive
2 p$ `5 w' i" s5 I. o3 c3 X8 finvestigation. The primary care physician should be. b8 |+ _1 H: [
aware of this fact, because most of these children; q! a0 k& D% Y- a1 F$ v
may initially present in their practice. The Physicians’. x# q# C$ ]' h+ F
Desk Reference and package insert should also put a5 x; z" J( @8 F0 L( b, z, g) m
warning about the virilizing effect on a male or! a Z9 l, ?4 l2 t
female child who might come in contact with some-
; s4 e3 O6 Q6 Z5 ~7 cone using any of these products.' y% t8 w$ J: K7 R, _
References' m/ X3 \& i$ ^: I$ ^2 g, \8 f% U
1. Styne DM. The testes: disorder of sexual differentiation9 c( G7 @' c+ z2 k* j+ p
and puberty in the male. In: Sperling MA, ed. Pediatric
6 z) {/ s5 @, [4 k# ~2 z4 JEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. c, T6 J. N9 N% R; }
2002: 565-628.
$ g( e- C$ z z) O, e5 z% u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious X8 l1 a$ W- l* X& k t; B: B
puberty in children with tumours of the suprasellar pineal |
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