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Sexual Precocity in a 16-Month-Old
/ \* z4 J9 N' Z) x+ jBoy Induced by Indirect Topical
, u( B4 \+ G/ RExposure to Testosterone
9 u: n/ D- H8 J" W& PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& [: H) x' V) x: W9 U' w6 a: Fand Kenneth R. Rettig, MD1. ?; Q# e5 S( X" _. G& h5 e
Clinical Pediatrics
$ P3 {/ g; i+ P3 w' a& \' D( lVolume 46 Number 6
" S: Q- u% G) ?/ I0 T) yJuly 2007 540-543& Z9 E4 m( a6 I, V8 ?3 [
© 2007 Sage Publications
, Q* {, X7 `7 u, i" X4 ?1 t1 `10.1177/0009922806296651
; b& P% N. ]. C5 k7 N- @9 ?http://clp.sagepub.com
, }3 T5 i$ J# Q4 b6 w* Lhosted at
9 c* I7 J" f L8 _9 F5 ahttp://online.sagepub.com$ }+ f, h) @0 W0 U) u _: h
Precocious puberty in boys, central or peripheral,
$ k/ L9 _) S* ?& e! @6 X% z3 N/ Gis a significant concern for physicians. Central
) Y( F+ o/ @9 \% Wprecocious puberty (CPP), which is mediated, [5 ?% L, _4 i7 ~, P
through the hypothalamic pituitary gonadal axis, has
; ~- @" Y5 E& M" u6 h4 m! Ia higher incidence of organic central nervous system4 \# C$ g+ G: C3 B
lesions in boys.1,2 Virilization in boys, as manifested
& W3 T' @' D2 u- Oby enlargement of the penis, development of pubic
8 I4 _0 V" S/ r1 r( `$ f' dhair, and facial acne without enlargement of testi-* I; d# j/ j( x
cles, suggests peripheral or pseudopuberty.1-3 We9 P8 g8 {& j( O9 b
report a 16-month-old boy who presented with the) n2 c& P! [4 S# |9 }
enlargement of the phallus and pubic hair develop-' K4 _% I9 D) ^3 ~
ment without testicular enlargement, which was due
7 t) M9 X8 r& @' i" K. y' Uto the unintentional exposure to androgen gel used by
) G" g5 I6 k# U5 U; ~the father. The family initially concealed this infor-
0 K. T2 i8 W5 [mation, resulting in an extensive work-up for this4 a- E( B1 u4 d+ b9 E6 Q
child. Given the widespread and easy availability of
+ F: a9 M* f* u4 e. ~9 a+ |testosterone gel and cream, we believe this is proba-; R7 H; I4 {5 h) H/ k
bly more common than the rare case report in the
1 F) }1 d: r" w6 Qliterature.4
+ ~# f- d: K8 v( z$ G J0 k- ~Patient Report# |4 {! a7 c2 ~5 T2 T$ K* s, ~$ R
A 16-month-old white child was referred to the6 d6 U. d6 D f8 u# q
endocrine clinic by his pediatrician with the concern+ B5 u& z) I9 ]$ `: \% z
of early sexual development. His mother noticed6 T3 H$ }7 s6 \' L H
light colored pubic hair development when he was
1 H- J' ~$ |+ `7 q. kFrom the 1Division of Pediatric Endocrinology, 2University of
9 X1 c1 X4 T( i% ]South Alabama Medical Center, Mobile, Alabama.
8 L' x' T" Z9 Q7 BAddress correspondence to: Samar K. Bhowmick, MD, FACE,* h; s1 {. W8 u# B9 U% h& H. j
Professor of Pediatrics, University of South Alabama, College of
8 t7 z3 J9 e p( vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, @# M" B" y6 g) b) O# M& P$ j+ l- O
e-mail: [email protected].: l% ]. e# ~1 g& x) ^( r% x
about 6 to 7 months old, which progressively became
6 ^; h. r6 Y* e9 `& G! \ S( Ddarker. She was also concerned about the enlarge-
0 a# q X& b1 G _# M! rment of his penis and frequent erections. The child) p% |# Z/ a$ {/ w M
was the product of a full-term normal delivery, with
# ]9 `; k( t+ V4 W- Q/ ya birth weight of 7 lb 14 oz, and birth length of1 B% a8 U8 E; p9 Z
20 inches. He was breast-fed throughout the first year
9 ]% Z# z7 |' r0 Aof life and was still receiving breast milk along with/ }# m+ f" w8 ?. R
solid food. He had no hospitalizations or surgery,
) o3 c& @. N% v. d) D: m) vand his psychosocial and psychomotor development
# m) g. O& S5 A1 T* wwas age appropriate.. l- _3 w! z6 o& @% W8 d
The family history was remarkable for the father,
( }$ g7 U, I. Mwho was diagnosed with hypothyroidism at age 16,6 h5 ] D2 h; Z( W
which was treated with thyroxine. The father’s& r9 p. @3 T1 h+ b* E ?
height was 6 feet, and he went through a somewhat
4 x. z2 C# o: v- s2 o4 Nearly puberty and had stopped growing by age 14.6 Z2 Z7 g; k: i! D9 w
The father denied taking any other medication. The
$ |( N. K4 I6 H- ^- \& Q$ j3 j6 dchild’s mother was in good health. Her menarche
5 M$ P& C5 G3 X; ^# Xwas at 11 years of age, and her height was at 5 feet" q% Z, Z: |, u- F
5 inches. There was no other family history of pre-
. | ^- q: j0 x# o, t% O$ ]cocious sexual development in the first-degree rela-
6 u/ a. H. ^6 `tives. There were no siblings.+ G/ Z) q, N+ k& V& Q1 q
Physical Examination! Z. o8 A1 H G" b7 z8 @
The physical examination revealed a very active,
3 ]8 _8 T* m6 t0 F' @# j( U# @playful, and healthy boy. The vital signs documented
5 z( r! g- [/ \ E7 u5 pa blood pressure of 85/50 mm Hg, his length was$ N- p1 }( U) y: P- x
90 cm (>97th percentile), and his weight was 14.4 kg
' `% E! J, e9 D0 |: z% d) l, Z(also >97th percentile). The observed yearly growth H& x+ A5 G% p. y6 O6 W
velocity was 30 cm (12 inches). The examination of
. f# ]- H) |& y* o7 gthe neck revealed no thyroid enlargement.$ E. @7 t0 |. i4 O' d" c
The genitourinary examination was remarkable for
* C! p8 w* C/ Z9 Nenlargement of the penis, with a stretched length of
- K, r1 I# n8 F$ q; X8 cm and a width of 2 cm. The glans penis was very well
/ ]- I, `8 }# i: qdeveloped. The pubic hair was Tanner II, mostly around
* ~1 Z6 l* {- G* | J5 r540" O4 u' H) B0 X* d' q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 O" l. ]( y" D: w8 S4 Kthe base of the phallus and was dark and curled. The+ Q$ N% r' p. f% Q
testicular volume was prepubertal at 2 mL each.
7 w5 X" U1 d5 n6 i! _% M+ lThe skin was moist and smooth and somewhat- a/ Y3 R; ?) W" k$ B u' }
oily. No axillary hair was noted. There were no
5 b1 _! a! [$ f# Jabnormal skin pigmentations or café-au-lait spots.
, o6 L5 k# F! H( b; P9 wNeurologic evaluation showed deep tendon reflex 2+
+ o4 i, D1 T3 s& O5 j! G1 R) T2 D9 Wbilateral and symmetrical. There was no suggestion+ J# K: l$ E' d( c' z( X
of papilledema.
& u5 g; x4 N5 J7 ILaboratory Evaluation
2 v4 T3 o k0 }The bone age was consistent with 28 months by
% Q7 m% R! F* fusing the standard of Greulich and Pyle at a chrono-
3 e- n9 F6 e" w( q! |logic age of 16 months (advanced).5 Chromosomal
0 T5 H9 P* R" B: d* Y# l2 Akaryotype was 46XY. The thyroid function test6 Y) j9 J/ x; U, w; _: g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. y2 ]/ b" o! u. l: hlating hormone level was 1.3 µIU/mL (both normal).3 B% p4 _6 S* G4 y9 U
The concentrations of serum electrolytes, blood
% F8 g' A/ k6 \' |0 r" Uurea nitrogen, creatinine, and calcium all were- H% b% p+ d) h4 _+ b( J, {- H3 z
within normal range for his age. The concentration) C7 ]! i& u8 q+ \. b+ `/ K
of serum 17-hydroxyprogesterone was 16 ng/dL1 _ Q6 t3 }5 u, F) r, C$ L1 U
(normal, 3 to 90 ng/dL), androstenedione was 205 C4 e- H: g1 [7 z" F; Y( P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 t3 g& j K9 H. l% e. U4 E+ F( o, N8 `4 ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. l# p0 p4 y7 u* |, D" Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ }* L- s9 W ?49ng/dL), 11-desoxycortisol (specific compound S)
: ?; J4 C% V1 N- N" z: Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ @/ M d a% Q- _) t; qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ m% H0 B O. O, G. f/ l; R$ O1 Y2 ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 T+ P/ q+ `6 p8 H, P+ o: R' r% Pand β-human chorionic gonadotropin was less than+ |5 g! \) {3 O8 t, M8 v: @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 n6 R9 D( S6 Wstimulating hormone and leuteinizing hormone5 \+ T4 Y7 Y G; _$ o- n, s. h
concentrations were less than 0.05 mIU/mL* ^7 q: T3 j; |$ m- V
(prepubertal).( a- Q! W# j: t6 `3 Z. c
The parents were notified about the laboratory
; z, [3 G* ?+ ~' v$ O7 kresults and were informed that all of the tests were
. u6 J5 i- P9 N5 y) _& u. gnormal except the testosterone level was high. The
; T/ ?1 K- o0 D6 @" C0 nfollow-up visit was arranged within a few weeks to
+ a# }* d& e2 ^2 G- uobtain testicular and abdominal sonograms; how-3 s6 k0 S! A, U- m8 V e0 z
ever, the family did not return for 4 months.5 m4 f# U* F* Z7 k! v) w0 d* B
Physical examination at this time revealed that the
0 m/ I9 V/ V* R9 G) p9 o% gchild had grown 2.5 cm in 4 months and had gained
9 f; h# L/ C# O* [. b2 kg of weight. Physical examination remained0 t+ C! @4 r* N. c- }& k
unchanged. Surprisingly, the pubic hair almost com-$ T7 V9 X4 T9 C/ M/ \
pletely disappeared except for a few vellous hairs at
( j# i: R0 }% Othe base of the phallus. Testicular volume was still 2& V4 m q; b$ F( S9 B# L
mL, and the size of the penis remained unchanged.+ ?/ g, a8 J/ v. G6 D
The mother also said that the boy was no longer hav-
! f4 t. o5 M+ |* f9 Oing frequent erections.6 b A8 m: n5 t% I) B H
Both parents were again questioned about use of
% ?5 X" c( Y4 tany ointment/creams that they may have applied to0 o2 m4 S& ^+ [: C6 b
the child’s skin. This time the father admitted the
6 y! `% Z) ?, ?1 `7 O C* NTopical Testosterone Exposure / Bhowmick et al 541
2 X& r5 E% Q8 B6 E. Q5 puse of testosterone gel twice daily that he was apply-
+ s9 H& \7 \$ [5 R' A0 v: r0 \2 ^ing over his own shoulders, chest, and back area for( n. I/ G0 Z! \& N" u2 S
a year. The father also revealed he was embarrassed/ a7 S! I* R Z2 s
to disclose that he was using a testosterone gel pre-. A- B6 F8 r2 I$ t7 {9 K
scribed by his family physician for decreased libido
0 B: `5 D3 P! M4 gsecondary to depression. s! ^' h) P; l7 A; x
The child slept in the same bed with parents.
$ s& h3 N) {# q8 YThe father would hug the baby and hold him on his
v6 m I8 @; D# Q$ N: U; m# ~chest for a considerable period of time, causing sig-
9 W, ^' v o2 o# |# ]. W1 Ynificant bare skin contact between baby and father.
8 o; ]; i5 x- a# f$ V: LThe father also admitted that after the phone call,' L7 d- J+ e: {0 U P
when he learned the testosterone level in the baby
/ `3 b) z3 s9 x! d9 `was high, he then read the product information9 Z3 Z5 q$ r8 ?8 _) Q; h/ _
packet and concluded that it was most likely the rea-7 Z3 }4 U8 f* M) k2 e& ~
son for the child’s virilization. At that time, they
0 D, L( y4 B. |decided to put the baby in a separate bed, and the+ D, o" G' t. ]! ?( d
father was not hugging him with bare skin and had
4 F7 D6 @, u* y; Z% c6 ]been using protective clothing. A repeat testosterone8 N; q3 }* S# y. r' p
test was ordered, but the family did not go to the, X4 q- A2 s, ^7 `
laboratory to obtain the test.
2 j; ^6 _$ V$ a( Q: Z' Q/ wDiscussion
2 ^6 a$ g! G X" v( X/ zPrecocious puberty in boys is defined as secondary
4 X8 o. n @- h- T( Xsexual development before 9 years of age.1,4$ C& Q1 [7 D# |- V, {2 |* {
Precocious puberty is termed as central (true) when u% Q$ x4 H1 s2 D" b4 U9 z
it is caused by the premature activation of hypo-, F4 I r8 S) |8 w: _* X2 N
thalamic pituitary gonadal axis. CPP is more com-' Z2 Q4 f! `! G
mon in girls than in boys.1,3 Most boys with CPP
; j. R: G: J/ N4 e$ P3 A* ^may have a central nervous system lesion that is
( n& D a& T5 D' @$ zresponsible for the early activation of the hypothal-. w% h; S8 C! H
amic pituitary gonadal axis.1-3 Thus, greater empha-5 R Z+ v9 A5 _5 p, K% ]
sis has been given to neuroradiologic imaging in* p) H+ {+ x {* \: P
boys with precocious puberty. In addition to viril-
* I D1 L" {. U3 x y, _! [ization, the clinical hallmark of CPP is the symmet-2 i8 \5 D2 \" x. P. \1 n. P- ^ T
rical testicular growth secondary to stimulation by* ]$ b4 q+ M9 M1 u& p0 u
gonadotropins.1,3
1 v; _- Y2 o, }9 @ ^/ p. j/ DGonadotropin-independent peripheral preco-" n, s% t' i, z2 D" T& _4 w
cious puberty in boys also results from inappropriate
- {3 [9 Y- W s8 Z4 S9 Uandrogenic stimulation from either endogenous or
/ x! T3 ^1 y% y9 xexogenous sources, nonpituitary gonadotropin stim-
+ D& V, \0 B' c* F6 V, lulation, and rare activating mutations.3 Virilizing
2 W4 P/ O8 }% G& G/ Scongenital adrenal hyperplasia producing excessive# S$ B. o0 s4 j+ e `9 e# }
adrenal androgens is a common cause of precocious) M) i/ m* m$ v
puberty in boys.3,4
( B7 |! A6 [( I6 ` G" _, _The most common form of congenital adrenal
: a4 h5 `7 u% _- L' xhyperplasia is the 21-hydroxylase enzyme deficiency.
! D1 D& a# d3 o8 }. Y/ |The 11-β hydroxylase deficiency may also result in/ g% k' C- W% X" Y1 e) e
excessive adrenal androgen production, and rarely,0 @% R! Z1 c+ P0 c n
an adrenal tumor may also cause adrenal androgen
+ }. ?& k7 ?* w( J5 w- Zexcess.1,3
: M8 o/ x: j- q. Y) ^8 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. ^# G' w3 @' e6 m* Q) c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% I( v0 Z% k3 m+ PA unique entity of male-limited gonadotropin-
* V( u. G& C9 q- }- Cindependent precocious puberty, which is also known
6 { o8 N2 D, H: oas testotoxicosis, may cause precocious puberty at a6 u: K. I/ Z) o; m; x9 T
very young age. The physical findings in these boys
" {5 y9 s8 U, H$ Rwith this disorder are full pubertal development,9 ]7 h+ H8 h0 h% F$ i5 W) u& X
including bilateral testicular growth, similar to boys& M0 k' p3 [& m" f
with CPP. The gonadotropin levels in this disorder
$ K# f/ r% I# R7 h2 f, z, z6 Hare suppressed to prepubertal levels and do not show
* f3 a$ i, j, X; k M. Fpubertal response of gonadotropin after gonadotropin-
6 h3 r+ p4 W- Y& W% rreleasing hormone stimulation. This is a sex-linked
( s* n; y2 P/ L k- eautosomal dominant disorder that affects only
' R2 F5 J' t5 d4 F& ^ ?7 Zmales; therefore, other male members of the family# l1 R, q( e8 s
may have similar precocious puberty.3
1 I1 @, X2 G' F6 U mIn our patient, physical examination was incon-
3 e( A/ S1 ]* ~( L: b# n# Vsistent with true precocious puberty since his testi-
1 i& \5 g7 P+ D0 o+ rcles were prepubertal in size. However, testotoxicosis4 A9 p X: C1 U/ A; W& {0 y
was in the differential diagnosis because his father
/ U5 S5 I. ~6 S. }% y9 H' Q+ Dstarted puberty somewhat early, and occasionally,
: g/ |; w$ B) c$ g- e( Wtesticular enlargement is not that evident in the
- b" s% ?' c2 \# R# _beginning of this process.1 In the absence of a neg-
( \+ k6 h: h1 g6 V) Mative initial history of androgen exposure, our
0 |% z& O r4 t$ V; l) vbiggest concern was virilizing adrenal hyperplasia,
8 v! x. ^5 A: Weither 21-hydroxylase deficiency or 11-β hydroxylase3 q) G/ N4 p/ h# L" b$ ?" o, ]& b
deficiency. Those diagnoses were excluded by find-. w* Z/ g+ A- }) U$ C6 y' a/ t
ing the normal level of adrenal steroids.
6 j. ^0 t6 Z2 w; X& u: t* a& UThe diagnosis of exogenous androgens was strongly
: e! }% M4 Y5 C" Fsuspected in a follow-up visit after 4 months because ^, E/ V8 a; H. w& u' I2 D8 p4 `! D
the physical examination revealed the complete disap-4 a/ l+ T9 p( ?
pearance of pubic hair, normal growth velocity, and1 V8 S6 K$ x8 q) X
decreased erections. The father admitted using a testos-
* J, U7 Y3 g! u3 B8 eterone gel, which he concealed at first visit. He was
: r8 v( R5 D- Nusing it rather frequently, twice a day. The Physicians’
, s& n* {: [2 O2 E! y8 WDesk Reference, or package insert of this product, gel or% l- Q% M' `* V) l, s3 b
cream, cautions about dermal testosterone transfer to
/ f8 V! D. o& Y5 Munprotected females through direct skin exposure.0 L. b2 g2 Q8 h- T# W
Serum testosterone level was found to be 2 times the5 }$ n2 @$ z5 W0 `$ u' Y
baseline value in those females who were exposed to
8 I4 R" }* q* s0 ?* ?even 15 minutes of direct skin contact with their male+ D7 c9 \4 T [
partners.6 However, when a shirt covered the applica-7 w7 _+ n7 u! H% P
tion site, this testosterone transfer was prevented.8 `- }4 Z) {; r ]8 ]
Our patient’s testosterone level was 60 ng/mL,
; M" E; b4 n3 l+ d7 C% hwhich was clearly high. Some studies suggest that0 K: B+ F4 z* d' H& p" t
dermal conversion of testosterone to dihydrotestos-
. m% O9 h- w6 |& d0 Q% O; x0 vterone, which is a more potent metabolite, is more% ?3 Z5 n; M t$ P# R% M$ H
active in young children exposed to testosterone9 ^# V& G6 l& m7 X2 ?! H/ G
exogenously7; however, we did not measure a dihy-
6 Q, Z4 l3 M/ P, o! ~1 W8 Y& gdrotestosterone level in our patient. In addition to) b; S3 m; U7 V, X3 j7 B
virilization, exposure to exogenous testosterone in% T: N* s8 B. ]
children results in an increase in growth velocity and
) ]$ a6 b. m6 n% Z# K! @- F' madvanced bone age, as seen in our patient.
# g; o- ~$ x0 N! ] OThe long-term effect of androgen exposure during" \8 p8 R2 c2 q9 H
early childhood on pubertal development and final% O$ r9 g, j |0 I% M
adult height are not fully known and always remain
: g3 @+ Y/ [* ^$ f: B3 Ra concern. Children treated with short-term testos-
5 j6 R: m4 f5 h$ m' j |, P/ I) ]terone injection or topical androgen may exhibit some
2 Q; t1 ]+ F, [: Facceleration of the skeletal maturation; however, after
$ a% ?, L; b" dcessation of treatment, the rate of bone maturation K& t! l6 _! m% R1 e: V7 O
decelerates and gradually returns to normal.8,9
5 X9 e M) I! FThere are conflicting reports and controversy
% s2 H8 ?% T4 [# I" Q1 n; Yover the effect of early androgen exposure on adult
4 `& \0 A3 w- Vpenile length.10,11 Some reports suggest subnormal- W' H& N) C+ O! @9 f1 V n6 S4 d# u
adult penile length, apparently because of downreg-! _/ _, w% e0 B' K# U9 C! B5 l
ulation of androgen receptor number.10,12 However,* G0 z; l( y- J* e
Sutherland et al13 did not find a correlation between
' C i# \5 N g& w. B! N( a8 Vchildhood testosterone exposure and reduced adult$ H- k8 g" l9 t' J; F0 ]9 Q F
penile length in clinical studies.. }. q( |% I" ^
Nonetheless, we do not believe our patient is
5 a& L/ d* X; I4 H* ?' Q" ygoing to experience any of the untoward effects from
1 R2 x: E# G1 [; x( [6 A! } Gtestosterone exposure as mentioned earlier because
3 z' f; D8 j7 L0 `the exposure was not for a prolonged period of time.2 X4 D' ^! V* f' N: v( B d
Although the bone age was advanced at the time of
! n! |$ ~" s9 _. ]* h" ldiagnosis, the child had a normal growth velocity at! B) ]% y5 Y& j9 c- [+ s5 @1 Z
the follow-up visit. It is hoped that his final adult; i+ d# d- i7 _: O$ P& u+ e
height will not be affected.: k f8 l/ Y9 d
Although rarely reported, the widespread avail-! e& E9 V+ `& x& a, l" z, k
ability of androgen products in our society may) O# a. U- _9 m
indeed cause more virilization in male or female/ _- B. I$ C8 e; X
children than one would realize. Exposure to andro-
! h% i0 S; x; W9 [4 q2 N- ygen products must be considered and specific ques-
6 t6 f3 s" B3 }8 I5 t9 @tioning about the use of a testosterone product or
; R0 p, |" M5 G# m- N$ c5 igel should be asked of the family members during
2 A2 U$ w9 v9 G$ B- Ythe evaluation of any children who present with vir-
0 W; k. H6 E. a, T. c2 g5 ]ilization or peripheral precocious puberty. The diag-
* x8 }* D& B X$ @9 ~: Q% H* ynosis can be established by just a few tests and by
6 F; k' |( V- z0 E7 happropriate history. The inability to obtain such a
" x9 H5 E1 m& I* B, ^history, or failure to ask the specific questions, may3 t8 C6 y- |' H# C, h
result in extensive, unnecessary, and expensive. W! M$ u7 d% q" _3 }7 r7 N
investigation. The primary care physician should be
7 w3 t, P# F% Taware of this fact, because most of these children2 [$ T& R$ Z& A6 \; e$ r
may initially present in their practice. The Physicians’# a3 S0 l5 C; L
Desk Reference and package insert should also put a
) z$ u' k" ?0 F: `! dwarning about the virilizing effect on a male or
) Z6 S- I+ j8 N3 zfemale child who might come in contact with some-
6 C# K6 f; d& {! E3 [one using any of these products.# Q1 h6 V2 m! _$ Q6 w
References& k! u% z2 Q/ A
1. Styne DM. The testes: disorder of sexual differentiation
( i! V& E' S1 ?# F4 q$ rand puberty in the male. In: Sperling MA, ed. Pediatric
, o* {% B/ e2 ~: E8 r) J, o( K; [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 U- Y: B- A/ S, J5 R2 g9 \' m( g w# [2002: 565-628.
5 ~. k2 ?+ |0 f6 r, |0 y# z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. L Y9 b# S8 K6 P0 ~
puberty in children with tumours of the suprasellar pineal |
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