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Sexual Precocity in a 16-Month-Old
/ G# c, v' v& DBoy Induced by Indirect Topical
1 w, M- a; |/ I5 ]Exposure to Testosterone
% l9 Y" K1 S; T4 X4 {% `3 ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ s% p$ k+ O+ \: land Kenneth R. Rettig, MD1
: e3 e d4 g/ A$ s y6 m! Q( J% Q4 W6 a+ RClinical Pediatrics: |: r- q7 j4 H% K1 y- g) I7 }% Y: x
Volume 46 Number 63 d. |# H8 Q) N9 A$ C9 b. c
July 2007 540-543
s. D2 {, r' Y! Q Y© 2007 Sage Publications
- `' d1 N0 ?4 X* P$ ]; X* {7 @8 S10.1177/0009922806296651
/ O1 t% p: K; Chttp://clp.sagepub.com
* V+ r+ g4 m* `0 \- x3 nhosted at
* m& n" z! v- r- ^9 _; p, nhttp://online.sagepub.com
# y. Y x; g- @0 y5 {Precocious puberty in boys, central or peripheral,- j% h9 }7 p7 o" l* J: l
is a significant concern for physicians. Central8 E) b- b# E7 x; C2 }$ M
precocious puberty (CPP), which is mediated, w' P5 C) e- n# `- u
through the hypothalamic pituitary gonadal axis, has
) S+ @0 |4 f! a& T o$ ^1 P% Oa higher incidence of organic central nervous system
) V1 M- d: y( n8 c0 J4 `5 i' Vlesions in boys.1,2 Virilization in boys, as manifested B, `% o$ a1 O% \- n' D' J
by enlargement of the penis, development of pubic) N8 t# M$ E; v+ O) E+ U1 U1 u
hair, and facial acne without enlargement of testi-
% i% f; V4 [# Lcles, suggests peripheral or pseudopuberty.1-3 We8 Z3 J) d7 A' O. y/ U
report a 16-month-old boy who presented with the: ^* a/ L8 N! p9 [5 `/ p; k
enlargement of the phallus and pubic hair develop-
+ A8 |( n, J: E. p) {3 Zment without testicular enlargement, which was due, ?2 R1 d" Z4 _0 z2 k" V
to the unintentional exposure to androgen gel used by
1 |: u; U% T) }: W- i, e: \; O3 |the father. The family initially concealed this infor-( u( Z3 h! V% F: O4 v" f
mation, resulting in an extensive work-up for this' n& V9 r' v$ g; z
child. Given the widespread and easy availability of
" O7 W. J1 g3 }) ]2 \0 Ttestosterone gel and cream, we believe this is proba-3 K% C) ]: f7 m7 C( f( {; n
bly more common than the rare case report in the2 F+ _& J4 D8 W
literature.4
* [1 P# R {4 W! X2 _# fPatient Report
% I6 T/ k7 n( P& E5 G! F& YA 16-month-old white child was referred to the
: e* M3 b1 u' a) uendocrine clinic by his pediatrician with the concern
% o) [& ^2 `( n3 g1 f9 V1 Oof early sexual development. His mother noticed, W/ ?5 v& n. B) l9 S: p9 F! ?
light colored pubic hair development when he was
: O6 ]% s% |4 f4 M/ [1 \$ ~6 dFrom the 1Division of Pediatric Endocrinology, 2University of
1 E- |8 I+ Y. j' lSouth Alabama Medical Center, Mobile, Alabama.
) V7 ]+ _; a+ `( B% B7 _ IAddress correspondence to: Samar K. Bhowmick, MD, FACE,& N9 ^$ N& g' Z- t7 X6 A$ Q/ A
Professor of Pediatrics, University of South Alabama, College of
% f1 p: Y) Q+ O$ [2 QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- T0 _" Z; _/ K; U; k7 Z
e-mail: [email protected].
# {& U: o( q- [8 ^( c0 s2 m* b" \about 6 to 7 months old, which progressively became: S$ }% h! q1 H+ l0 A
darker. She was also concerned about the enlarge-1 u6 n* O0 \% ?# N' u$ x1 ?- ~
ment of his penis and frequent erections. The child
1 [/ J- H! O, b! F8 w" Iwas the product of a full-term normal delivery, with
* |# ? s3 m9 }$ W: Ia birth weight of 7 lb 14 oz, and birth length of7 b; p* W1 G3 r2 w0 k2 p1 J8 h, r, d
20 inches. He was breast-fed throughout the first year+ K) @0 [; j: ^$ V# B9 T. `/ o
of life and was still receiving breast milk along with
& w: j: C1 u( _3 c& xsolid food. He had no hospitalizations or surgery,/ p# Z! R+ T7 K$ o$ |
and his psychosocial and psychomotor development
9 z# ?" @4 q7 s2 N5 ewas age appropriate.
7 L' j5 w" a+ v. e0 CThe family history was remarkable for the father,
8 y* @+ R4 B9 s- Iwho was diagnosed with hypothyroidism at age 16,! b& S& q7 ?3 U Y, h0 ~& C/ S$ w4 @- U
which was treated with thyroxine. The father’s
$ \$ s Y) E$ S: c1 uheight was 6 feet, and he went through a somewhat# q! |8 y& Y; D. g2 }
early puberty and had stopped growing by age 14.
8 k: T' t0 W6 ?# g u! l# AThe father denied taking any other medication. The
% O- V* ]! B7 c( vchild’s mother was in good health. Her menarche% d: X% |% Q0 ~ Q6 Y' D5 b V+ q) v
was at 11 years of age, and her height was at 5 feet% b }4 r+ P4 n
5 inches. There was no other family history of pre-
& Z' y1 N* i/ x5 Y/ _# kcocious sexual development in the first-degree rela-
8 V7 n( _0 J8 |; |tives. There were no siblings.2 y: f! f* z+ N! m& w, E- H K
Physical Examination' ?3 D% \6 s/ l+ K F
The physical examination revealed a very active,* C0 A! d% A: Z: {6 p
playful, and healthy boy. The vital signs documented
9 V8 n0 J6 K# d0 Q( _0 z% b; |a blood pressure of 85/50 mm Hg, his length was
) D2 j! M; |" f) D0 Z9 J90 cm (>97th percentile), and his weight was 14.4 kg6 i2 e# [5 T/ p
(also >97th percentile). The observed yearly growth2 w' ~: _" H" P8 Q& S* r0 C! K
velocity was 30 cm (12 inches). The examination of. I/ t& T' [/ O3 E9 u
the neck revealed no thyroid enlargement.
5 K- j2 P9 A' K8 d4 B4 nThe genitourinary examination was remarkable for$ m( p2 r2 t( A! M( R
enlargement of the penis, with a stretched length of
# D y, O D' ~8 cm and a width of 2 cm. The glans penis was very well
% ^* @. o3 M( gdeveloped. The pubic hair was Tanner II, mostly around3 _0 p8 x' x5 y" s& Y9 g! N" _9 B
540
) C* P' j7 i2 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' |0 {6 U. y+ {% @" ^- }& Dthe base of the phallus and was dark and curled. The: b, M B. Z1 _, a$ c4 O* w8 k
testicular volume was prepubertal at 2 mL each.
7 h' I$ Q( V D. M& X) IThe skin was moist and smooth and somewhat
; x& [1 {) s0 n7 u& {( R0 v+ Zoily. No axillary hair was noted. There were no
. o u, Z% G A' Q4 Z* aabnormal skin pigmentations or café-au-lait spots.6 b/ e4 n1 Q8 M' W
Neurologic evaluation showed deep tendon reflex 2+
! [! N" r6 H/ M% ubilateral and symmetrical. There was no suggestion
* `+ P9 N) i& ^& }; rof papilledema.0 T Z" |! I& f5 s
Laboratory Evaluation
$ s2 p: A: G1 O8 ^4 U% d9 JThe bone age was consistent with 28 months by
/ O* m! t1 ~; ]: J/ zusing the standard of Greulich and Pyle at a chrono-
4 T* ~' @) F) { p2 D2 _! Rlogic age of 16 months (advanced).5 Chromosomal; n$ F( l7 |2 t. c6 [( r3 g
karyotype was 46XY. The thyroid function test
! v' f- s7 ~& E2 Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
, z) N/ u+ C4 l7 @8 u2 klating hormone level was 1.3 µIU/mL (both normal).2 T9 k. c2 k. T
The concentrations of serum electrolytes, blood% e5 B! ?2 c1 b8 f a, f& Z% l
urea nitrogen, creatinine, and calcium all were* @8 `1 |* g' a7 a- }
within normal range for his age. The concentration
& g+ F }0 S/ \7 ]2 ]of serum 17-hydroxyprogesterone was 16 ng/dL, p: M2 u) P9 L$ ]# _6 A ]
(normal, 3 to 90 ng/dL), androstenedione was 205 n# A7 D* q: k' p/ L* _( F% ^) a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" D' c6 b# |* y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 D& s/ |" o+ e5 I2 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( K ^* C9 o$ i- C- a8 @( G49ng/dL), 11-desoxycortisol (specific compound S)6 F: P6 l9 J0 E0 p2 g* z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 a" A* H1 Y# T% \! Q+ p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 l$ `; c( H, X; E; S4 G' Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 ~0 T6 @( @ j
and β-human chorionic gonadotropin was less than
# N0 @( Y' d' a% H1 ]# @5 mIU/mL (normal <5 mIU/mL). Serum follicular
, [& L! ^7 {& q7 I1 _) ^7 Istimulating hormone and leuteinizing hormone
& [% n: u& }( v; i/ tconcentrations were less than 0.05 mIU/mL
" v( i# w; B3 _1 T2 E( A7 c/ V(prepubertal).
2 ?8 k& O. V jThe parents were notified about the laboratory
1 H* c+ T! D$ M6 Q% n- n7 Fresults and were informed that all of the tests were
( ?. d/ s0 H6 Z- X$ B: z& E+ inormal except the testosterone level was high. The
4 ~; r- y0 r. k, e2 [0 D, [# v1 ?follow-up visit was arranged within a few weeks to
, u7 L, ~% A9 [* m( ~. dobtain testicular and abdominal sonograms; how-
n) P) A- X v( W. t4 C& u& e: \ever, the family did not return for 4 months.7 m- p X+ @1 ]% ~! U
Physical examination at this time revealed that the+ n% v7 y( L$ |" E, m6 E' x
child had grown 2.5 cm in 4 months and had gained& l0 O, d/ i- s4 H6 f& E8 v& B0 K
2 kg of weight. Physical examination remained
0 t1 z/ S4 ]8 Vunchanged. Surprisingly, the pubic hair almost com-: }" e$ i; e: F( B" r
pletely disappeared except for a few vellous hairs at+ ~! c# m- ]7 G# S% l4 P
the base of the phallus. Testicular volume was still 26 ]2 H* L0 G8 w( ~0 K8 d, `
mL, and the size of the penis remained unchanged.( a2 Q# w" h5 t* r' }
The mother also said that the boy was no longer hav-
8 H& r' `) K6 R7 n6 ding frequent erections." B9 M; Q5 `4 Z5 T) d
Both parents were again questioned about use of
4 V* L# @/ ~. o1 Q; q" c8 Vany ointment/creams that they may have applied to3 S; E% T) r2 m" [( _) D; h7 y
the child’s skin. This time the father admitted the) g( v" K+ d; |! W& \" x2 t& P
Topical Testosterone Exposure / Bhowmick et al 541' p7 s4 V5 ^: A) E3 X. ]
use of testosterone gel twice daily that he was apply-
E: q4 K, r, @" u$ N& I; Bing over his own shoulders, chest, and back area for( T. K1 W# M' d# J
a year. The father also revealed he was embarrassed8 g2 L% f# l, ~+ [7 j7 U( c
to disclose that he was using a testosterone gel pre-8 n O) ~/ F9 W) S: e% w
scribed by his family physician for decreased libido x* k4 F% s. E' b* `
secondary to depression.) u( [8 S/ B5 d2 f/ k! O
The child slept in the same bed with parents.
! _9 |7 M0 o1 q7 |/ YThe father would hug the baby and hold him on his
' B# D* {5 s6 Y% P& C& L- |- jchest for a considerable period of time, causing sig-
/ H9 f- ]/ F( U1 j* O2 Cnificant bare skin contact between baby and father.
% ]5 O8 x$ P5 W8 j2 V+ jThe father also admitted that after the phone call,. s! c) u) Z: T5 |
when he learned the testosterone level in the baby) m1 O; G& R0 \. d& e1 }
was high, he then read the product information$ V) ^8 k' }9 r5 e4 p: w9 _7 g
packet and concluded that it was most likely the rea-
. L$ F6 A8 S: k* v* \. i1 Q& Rson for the child’s virilization. At that time, they/ v, g& ?5 @$ y) b: T: z6 b2 y/ M
decided to put the baby in a separate bed, and the4 x8 }8 L( Z! G! j8 l
father was not hugging him with bare skin and had+ M% _& o0 D, Q( R' Y0 X
been using protective clothing. A repeat testosterone4 j/ \0 o& `+ S) I! K& m
test was ordered, but the family did not go to the) ?4 ?: ?% g" }8 f- x' S1 l/ P9 n
laboratory to obtain the test.: Z; J( C- Z* k T# \) b: P, b8 l
Discussion5 S5 Q) a, f" H
Precocious puberty in boys is defined as secondary
5 U! W7 l6 z$ K/ s- X2 @sexual development before 9 years of age.1,4
; V5 E% l3 K/ }+ |, t8 JPrecocious puberty is termed as central (true) when; z/ i6 N* m& x9 n9 E/ i# [; `! z; Z
it is caused by the premature activation of hypo-8 W' e9 |! g6 V# p. Z
thalamic pituitary gonadal axis. CPP is more com-. h+ h- D9 m; A p
mon in girls than in boys.1,3 Most boys with CPP* P0 H$ |' M0 [5 n* D: [
may have a central nervous system lesion that is' e+ @5 k) G2 ^! v9 s
responsible for the early activation of the hypothal-' u' |" F% o/ j4 U
amic pituitary gonadal axis.1-3 Thus, greater empha-- E' ?) ~% e3 k/ t
sis has been given to neuroradiologic imaging in7 z7 B& l @7 A. F- v
boys with precocious puberty. In addition to viril-* p+ M- v4 B3 X3 b3 _1 N
ization, the clinical hallmark of CPP is the symmet-) n0 c; ]1 x# N4 |
rical testicular growth secondary to stimulation by
2 t$ a( C7 f$ |% Agonadotropins.1,3
: [- w" D; y; r8 c8 c! LGonadotropin-independent peripheral preco-, x3 H/ Z, Y/ B( {8 U# W
cious puberty in boys also results from inappropriate. f6 h1 }. ^. B; }- z
androgenic stimulation from either endogenous or
8 V5 D% D2 {( J8 W+ V p( D3 y; _exogenous sources, nonpituitary gonadotropin stim-8 p: J( r' b3 v8 j/ D
ulation, and rare activating mutations.3 Virilizing
. j6 B: ^) E2 e5 P, J7 B/ Gcongenital adrenal hyperplasia producing excessive
4 J- S+ N+ F" y9 m" F; \1 F4 d+ tadrenal androgens is a common cause of precocious
# g4 V! t+ Q A* L$ ]$ {& bpuberty in boys.3,4
' G& s% S/ `) ]7 I7 ?The most common form of congenital adrenal; l- U5 K# L; g
hyperplasia is the 21-hydroxylase enzyme deficiency.4 x% u5 A% p3 A1 ^4 M7 \! N
The 11-β hydroxylase deficiency may also result in
1 l; J1 B, f" r$ {excessive adrenal androgen production, and rarely,/ S7 M% Q9 l2 M6 J: y3 d
an adrenal tumor may also cause adrenal androgen/ m( m S) g3 L4 ~* K
excess.1,31 F& D; ]" R$ t6 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 `- W( p8 z6 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ ^- T0 @+ j% Q! }
A unique entity of male-limited gonadotropin-
- Z" v( G% Z- N; Y6 Hindependent precocious puberty, which is also known
5 o( M4 F) ~8 z: v8 \, Eas testotoxicosis, may cause precocious puberty at a: d' j4 s, g8 u1 A
very young age. The physical findings in these boys9 U% P% S7 ~4 k/ o
with this disorder are full pubertal development,
8 p5 {6 e$ H4 ]0 Cincluding bilateral testicular growth, similar to boys5 ]& D b0 `5 |- _9 t* }+ c x3 R
with CPP. The gonadotropin levels in this disorder7 w, M" N6 x% {
are suppressed to prepubertal levels and do not show: g. O2 I+ B) {; |: g* i
pubertal response of gonadotropin after gonadotropin-
: t" t' X+ V: dreleasing hormone stimulation. This is a sex-linked3 x" {' T& E) Y: Z
autosomal dominant disorder that affects only- V* ]; M i) T
males; therefore, other male members of the family
& O, G; v" h& ]+ M; |( j) jmay have similar precocious puberty.3
9 f- J; D$ o5 O* \% zIn our patient, physical examination was incon-
* }" _, z p+ e; L4 F- R! l/ hsistent with true precocious puberty since his testi-5 G7 S& j! G/ O( U# D1 x
cles were prepubertal in size. However, testotoxicosis
: k- c% b x& P8 C! v B+ Lwas in the differential diagnosis because his father D/ f% L% o3 G4 H8 w: g. I
started puberty somewhat early, and occasionally,
2 I3 S# g- s; L( C/ Itesticular enlargement is not that evident in the
( s9 ^; U% e, e9 Rbeginning of this process.1 In the absence of a neg-
* l* V, V4 c6 K& a! Y) m$ a2 Z4 k6 Sative initial history of androgen exposure, our
+ r' s% b0 K, R1 Ibiggest concern was virilizing adrenal hyperplasia,0 t8 L; L# h# o- f {
either 21-hydroxylase deficiency or 11-β hydroxylase
2 V6 t" R& m6 _! v8 }2 k, gdeficiency. Those diagnoses were excluded by find-
1 s. H7 x6 y$ c+ R9 jing the normal level of adrenal steroids.
( X/ X1 X: I: w8 V% I7 q9 UThe diagnosis of exogenous androgens was strongly6 t% e" i. j+ h5 i% | }- y
suspected in a follow-up visit after 4 months because) o+ L' Z" Z5 A4 p1 v1 D
the physical examination revealed the complete disap-
. s* p. c% X6 a3 cpearance of pubic hair, normal growth velocity, and+ O8 A# l# |. a
decreased erections. The father admitted using a testos-7 k( g9 [4 w% z( Q3 k2 u3 X
terone gel, which he concealed at first visit. He was2 z; X0 P# B+ w
using it rather frequently, twice a day. The Physicians’
2 N/ v0 y; q% WDesk Reference, or package insert of this product, gel or5 n) j9 [* M. v1 L# e+ }8 U
cream, cautions about dermal testosterone transfer to
- ^" s* r6 R" j, ?; A- R7 junprotected females through direct skin exposure.+ q0 f+ M! P) g! U) M" t* ?5 B+ G3 t
Serum testosterone level was found to be 2 times the
. T0 z' p8 m1 Z8 }6 J+ zbaseline value in those females who were exposed to
% r+ i4 y0 Y& s7 k2 [( W p7 _# peven 15 minutes of direct skin contact with their male
) i7 L; E/ Y) O+ P" _" Cpartners.6 However, when a shirt covered the applica-6 I. r8 N: }4 B* i$ W7 U9 S
tion site, this testosterone transfer was prevented.
" Y# Q1 _0 ]5 D- w6 G: w+ `4 vOur patient’s testosterone level was 60 ng/mL,
/ I4 p% P! r3 z* u G6 n1 nwhich was clearly high. Some studies suggest that: s* P j# t/ C g1 w7 O
dermal conversion of testosterone to dihydrotestos-
7 d5 F# T) A+ v) l5 X8 rterone, which is a more potent metabolite, is more( e3 k, @, i9 M, H/ z5 }5 k ^
active in young children exposed to testosterone
* I* H; ?- U1 n W$ o3 y: z1 X$ dexogenously7; however, we did not measure a dihy-' ~4 o9 r; L* A) g
drotestosterone level in our patient. In addition to
0 [' J/ y; w* Q2 d* V; W0 Bvirilization, exposure to exogenous testosterone in6 @9 p" \* l1 y7 _0 ^
children results in an increase in growth velocity and4 Q4 b8 l* J6 r9 V7 i
advanced bone age, as seen in our patient.! n& B3 R ?0 ^
The long-term effect of androgen exposure during
! B% @" t* u! |, z) ]" jearly childhood on pubertal development and final
, O- c2 A5 ]! q; B" N8 |: vadult height are not fully known and always remain( a0 f. U, M# G) i
a concern. Children treated with short-term testos-) i4 f% H/ B% j8 O. B
terone injection or topical androgen may exhibit some
* p& t& n* J7 Vacceleration of the skeletal maturation; however, after
3 b7 B& z6 C; r. ^cessation of treatment, the rate of bone maturation4 g* F( G, ~( R# t7 ?' S
decelerates and gradually returns to normal.8,9
% |0 _) I9 w! A* TThere are conflicting reports and controversy
! \' P3 X @8 f! n: U Dover the effect of early androgen exposure on adult
+ u6 Z5 U5 Q2 f) ?3 lpenile length.10,11 Some reports suggest subnormal5 l& m$ t+ x8 a+ q/ B
adult penile length, apparently because of downreg-3 u; ?( v6 S& L: K5 A+ C5 Y
ulation of androgen receptor number.10,12 However,: }$ k: Q. G: i. o5 u$ z
Sutherland et al13 did not find a correlation between; Y j; d( E' `6 Q
childhood testosterone exposure and reduced adult- z/ o. a7 V( e! C+ i
penile length in clinical studies." |, j) m6 N% ?9 M& }
Nonetheless, we do not believe our patient is8 ^; ^* _/ M% ?
going to experience any of the untoward effects from% q3 ^' a- {* I6 C4 ]+ i& l
testosterone exposure as mentioned earlier because. \: m% i! y* n, u; S% b
the exposure was not for a prolonged period of time.+ X% l5 Y4 g; ^) P4 Q
Although the bone age was advanced at the time of
' F# i" x7 v5 v! m' x9 Q0 H5 q$ N2 [diagnosis, the child had a normal growth velocity at6 ^$ t8 J/ P3 Y: C
the follow-up visit. It is hoped that his final adult2 s) x5 ?, o( `
height will not be affected.2 q* K% }1 b: \3 B
Although rarely reported, the widespread avail-
8 g& U8 g7 F N7 m7 Tability of androgen products in our society may9 z6 _* w5 p! J% N
indeed cause more virilization in male or female
4 X: g* x' k! Q# Mchildren than one would realize. Exposure to andro-" N, U, }+ ]( M( o3 n; E# I8 K
gen products must be considered and specific ques-9 S5 o: C, N$ O7 e
tioning about the use of a testosterone product or
4 a- Z( p. Y3 y6 ~, J, Qgel should be asked of the family members during9 C3 g* ?* E+ B+ _4 k* u* E
the evaluation of any children who present with vir-5 o5 n8 e9 c. \3 u* o4 T. w. R
ilization or peripheral precocious puberty. The diag-
/ a* ^3 J- F3 i" z/ S5 Enosis can be established by just a few tests and by& c+ g! J5 H6 R
appropriate history. The inability to obtain such a* h/ h5 M6 p2 O8 x
history, or failure to ask the specific questions, may, e8 g: y6 [3 [! X
result in extensive, unnecessary, and expensive% b1 P& j% U+ m
investigation. The primary care physician should be! Z7 M1 y4 {" I
aware of this fact, because most of these children
# E. a/ k7 M* `+ _* gmay initially present in their practice. The Physicians’
- I5 e* o6 ?3 DDesk Reference and package insert should also put a
- P/ L$ ]5 d. s4 I3 Z( ~warning about the virilizing effect on a male or1 x! e* b7 g, I' J) O% V
female child who might come in contact with some-
: \ z4 c# }: H P# Y- L yone using any of these products.
0 V8 U7 m! \! EReferences
! P- {2 G0 m+ h a; E1. Styne DM. The testes: disorder of sexual differentiation
/ p! z0 R9 S8 L% _4 band puberty in the male. In: Sperling MA, ed. Pediatric+ W6 L5 z% I7 D7 C& h' J+ a
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" `8 B% v4 {2 x# y m) z: t2002: 565-628., {+ ]3 B0 P7 e; O; C: Q. f, `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ s% y, Z& r/ k- ~! f3 C
puberty in children with tumours of the suprasellar pineal |
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