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Sexual Precocity in a 16-Month-Old
$ Z/ [' M& p. ^9 S& {Boy Induced by Indirect Topical
' [. a5 ^5 S6 tExposure to Testosterone# Q) Y0 j' j/ n7 t9 }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" V) D+ |% o7 B% [4 ~5 F6 fand Kenneth R. Rettig, MD1
9 Q. u: x( z0 \, W# Q: D2 |Clinical Pediatrics6 [) I2 [9 E4 m/ { p( r4 @; o
Volume 46 Number 6$ u3 K$ U0 E, Y I4 t" Z8 g3 L
July 2007 540-543
( D% g [7 n- R© 2007 Sage Publications# _. f* e( ?* G
10.1177/0009922806296651; c) }( b; ~: n1 I
http://clp.sagepub.com p3 y2 @4 i( R1 `
hosted at
& b* q4 g- ]9 `2 i7 S( R. ]http://online.sagepub.com
3 o$ _, v# g) w' S# F8 }2 l' g. uPrecocious puberty in boys, central or peripheral,
3 G9 x* A' L" {* Q9 R0 j5 u+ Ois a significant concern for physicians. Central
& J2 J6 V1 K% p+ y, Xprecocious puberty (CPP), which is mediated
. C) E* n E4 z! r# v9 Vthrough the hypothalamic pituitary gonadal axis, has P& ` R0 p2 q1 s3 E
a higher incidence of organic central nervous system# K8 Z3 F( R4 n9 T' ?2 C
lesions in boys.1,2 Virilization in boys, as manifested1 D% o* T* e, J6 @
by enlargement of the penis, development of pubic- \' p7 }& w( j1 a) r4 ~$ h# N4 k
hair, and facial acne without enlargement of testi-
: y6 e6 h) q* [; G7 U7 @, o/ {% pcles, suggests peripheral or pseudopuberty.1-3 We
5 m) Y% Y) I% f& I+ L' V: T* S% I" H, Y# oreport a 16-month-old boy who presented with the
6 f9 Y% k: f0 n& W# Uenlargement of the phallus and pubic hair develop-$ `4 Q& K) i' U: l N8 _- A
ment without testicular enlargement, which was due; \8 z3 c& A* p' C; ]+ }# f
to the unintentional exposure to androgen gel used by; K+ e6 i: i5 x9 ]% r- x$ n
the father. The family initially concealed this infor-
$ X1 X9 P) o# S S0 y5 ?! Gmation, resulting in an extensive work-up for this) N/ D/ U; }5 |7 I% _; d: u, n
child. Given the widespread and easy availability of+ }( L, U5 _, j9 K8 E1 W. q
testosterone gel and cream, we believe this is proba-
. k, X. N& J7 I" Dbly more common than the rare case report in the/ M# S$ O' N" s
literature.4
- Y8 S" ]% |7 K- RPatient Report7 _& H4 C* y( O: r8 E* y$ C
A 16-month-old white child was referred to the+ R9 j) X( T5 _. v
endocrine clinic by his pediatrician with the concern
% E6 ]6 @; x& d4 j7 x% P: K% Lof early sexual development. His mother noticed' s) m+ p- t; ?& ]) X- \ r
light colored pubic hair development when he was+ \$ P/ D" Z) a- |' x
From the 1Division of Pediatric Endocrinology, 2University of% J4 X1 S: k2 a" {) L
South Alabama Medical Center, Mobile, Alabama.- r8 a) |; N/ b
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 E9 v$ F# m; n: F2 RProfessor of Pediatrics, University of South Alabama, College of; F! C" H0 X; T# u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 \' t8 y' W- de-mail: [email protected].& V6 R+ |( |% p( r2 {% t: M
about 6 to 7 months old, which progressively became, A' o# N( ?* Z2 T! ^
darker. She was also concerned about the enlarge-7 v' C5 b4 u* `0 W+ Y
ment of his penis and frequent erections. The child; X6 @$ I+ i8 |$ s9 ~2 Q% j
was the product of a full-term normal delivery, with
7 V# I& {' a" Y* E) N0 {" Ia birth weight of 7 lb 14 oz, and birth length of3 _! ^7 B& |! }
20 inches. He was breast-fed throughout the first year
1 A( e5 p2 Z4 j5 C) A) q# |" y9 y# cof life and was still receiving breast milk along with
& M9 j# ]. @, U$ G$ y" B3 r( D) ysolid food. He had no hospitalizations or surgery,
4 [4 r; e1 o& u3 t% O/ band his psychosocial and psychomotor development
7 a3 U+ l4 p3 T; Qwas age appropriate.
9 d) c5 z7 ?4 H5 p" fThe family history was remarkable for the father,
8 T0 z& D5 _' Hwho was diagnosed with hypothyroidism at age 16,, ]& V& w' W- a" ^, B6 u
which was treated with thyroxine. The father’s
8 y0 D8 C9 S ]9 R1 S( G2 d; rheight was 6 feet, and he went through a somewhat6 @$ g# W5 b) P
early puberty and had stopped growing by age 14.
' q, w: G9 n2 ?3 r6 wThe father denied taking any other medication. The% _, k) H' z$ e0 r3 f+ P
child’s mother was in good health. Her menarche S7 }" k- E8 h1 Z6 g
was at 11 years of age, and her height was at 5 feet
4 l; P2 k" |4 i' q5 inches. There was no other family history of pre-0 F+ X9 a; Q7 D7 L `2 D1 ?
cocious sexual development in the first-degree rela-
" y# J5 E# Q8 @0 j$ Z' l* ]; ztives. There were no siblings.8 i$ |, |4 z+ W' o7 n' _
Physical Examination/ n2 ^- a' J4 l- F$ l
The physical examination revealed a very active,7 z+ P+ \6 D2 M- s# t2 ?
playful, and healthy boy. The vital signs documented
# U4 X ^* A# I# ?a blood pressure of 85/50 mm Hg, his length was! g9 [- e8 @# W
90 cm (>97th percentile), and his weight was 14.4 kg" t4 R, u. ]6 E0 m& t5 A& k- ]& i
(also >97th percentile). The observed yearly growth" e( F. r+ t) S
velocity was 30 cm (12 inches). The examination of1 I( `. A% c( v7 j
the neck revealed no thyroid enlargement.
( X( |1 T3 ^' ~. yThe genitourinary examination was remarkable for
0 S5 H% b! F$ q6 ~enlargement of the penis, with a stretched length of
7 r$ z4 {* E: ]; x* e" b/ a2 w8 cm and a width of 2 cm. The glans penis was very well' ~! J3 B" W+ W
developed. The pubic hair was Tanner II, mostly around3 T) K" Q; B. ?- ~* [6 f- d- B; n
540
4 j9 \, q# [, i! W( y2 Z- |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 N# B6 p {, c5 _. lthe base of the phallus and was dark and curled. The
( E# ~( a, U5 m& w2 T( i" ctesticular volume was prepubertal at 2 mL each.
: l, ~, C2 b. L* U# _! VThe skin was moist and smooth and somewhat) e) ?! b( C5 P' e/ _' C4 }% g) t
oily. No axillary hair was noted. There were no
) g. d/ S7 p# h. o" `- Jabnormal skin pigmentations or café-au-lait spots.
' C% d, J# P/ s6 r2 TNeurologic evaluation showed deep tendon reflex 2+
- v$ c5 h8 R4 ~- M9 ybilateral and symmetrical. There was no suggestion
( | H8 T- h" V9 V C4 y* ~of papilledema.. c; {0 m; G. j2 A j8 m
Laboratory Evaluation2 Y0 a" o [$ ?0 X
The bone age was consistent with 28 months by+ H! W% z) o8 [3 M( K Y" U
using the standard of Greulich and Pyle at a chrono-
3 ?# B3 }! G) R) ^7 o$ T2 flogic age of 16 months (advanced).5 Chromosomal
/ f( n! {7 ~4 k, O% O4 Fkaryotype was 46XY. The thyroid function test3 e! F9 r4 o0 k5 F3 {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" q0 F! s. u; L/ C. _$ J, R
lating hormone level was 1.3 µIU/mL (both normal).
. \8 b+ T9 O& ~& K& tThe concentrations of serum electrolytes, blood: w7 e: y) l$ d! s
urea nitrogen, creatinine, and calcium all were
" b$ f7 S9 O8 m2 `0 j. mwithin normal range for his age. The concentration$ F& p: Z, m# f+ E! Z
of serum 17-hydroxyprogesterone was 16 ng/dL8 s) i2 y; X) @8 `8 w+ p
(normal, 3 to 90 ng/dL), androstenedione was 20
1 z5 f/ _- g' S' Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% M9 r# ~2 h1 ?1 Z7 fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' k( k$ h! g* Y2 o; @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
, x6 @1 A% U: Y* k: C49ng/dL), 11-desoxycortisol (specific compound S)) u. c. ^) {4 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 o M( S: H0 {+ l O9 R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) O& i1 R1 A+ U+ S5 C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 l( O$ l2 M3 L/ J
and β-human chorionic gonadotropin was less than
) \7 ?* A! v% k+ X( t/ m. `5 mIU/mL (normal <5 mIU/mL). Serum follicular- [- f* [6 f$ X. p/ z% B n; V
stimulating hormone and leuteinizing hormone* T/ t* \& G: y3 s4 w
concentrations were less than 0.05 mIU/mL! s9 C: q9 B' t$ l
(prepubertal).+ M2 @3 F: s+ t$ G! A9 Q7 G# G
The parents were notified about the laboratory! y. J/ G8 o0 `7 t, x% b
results and were informed that all of the tests were
1 p% G1 o( D* ~, S/ `# t4 `normal except the testosterone level was high. The
9 L! N8 ]8 G P' Z0 I9 o }follow-up visit was arranged within a few weeks to1 U/ v# T. x$ ~3 v3 J C1 \$ c7 ]
obtain testicular and abdominal sonograms; how-
, x5 F- F* j# W# {3 Hever, the family did not return for 4 months.
* m! W7 J. k% R, P9 i7 lPhysical examination at this time revealed that the2 r% ] ?2 v/ q+ J
child had grown 2.5 cm in 4 months and had gained7 y4 F2 V; i$ b5 ?- V
2 kg of weight. Physical examination remained
& A. [# R6 }9 H4 H, xunchanged. Surprisingly, the pubic hair almost com-
3 [4 h! w2 V( h: x( \pletely disappeared except for a few vellous hairs at6 t# V9 j* K% g- F
the base of the phallus. Testicular volume was still 2% v; p3 f) b2 w: h! W, O* ^. U
mL, and the size of the penis remained unchanged.
; L9 d+ V" S0 m5 u0 _" SThe mother also said that the boy was no longer hav-
! K# F, B. G/ R, g- B) u( Aing frequent erections.
5 |; q/ W1 }! [$ \6 d; LBoth parents were again questioned about use of
3 x b! I6 B- Yany ointment/creams that they may have applied to- r4 U; i9 B5 J7 g- o$ i
the child’s skin. This time the father admitted the; A1 p+ |' y9 u8 G% y- y
Topical Testosterone Exposure / Bhowmick et al 541
- N D& y8 o' Muse of testosterone gel twice daily that he was apply-4 V( d- U0 W: Y- j# h# @
ing over his own shoulders, chest, and back area for9 c8 f+ s6 E+ X6 f: |
a year. The father also revealed he was embarrassed/ _" c) W0 M5 W8 t
to disclose that he was using a testosterone gel pre-% `9 o9 t5 e* g
scribed by his family physician for decreased libido, a1 F% Y' V% |" Q: s5 k
secondary to depression.6 o2 R( b4 u+ `( \' { l1 p
The child slept in the same bed with parents.
& {: ?* [1 F2 l' A# d2 a; e1 j5 yThe father would hug the baby and hold him on his
2 t2 z, l. q$ ^chest for a considerable period of time, causing sig-% C. @) r* t1 B6 v# t' G
nificant bare skin contact between baby and father.
: Q% w' q' ?! G. Z. B& ~- J# KThe father also admitted that after the phone call,* I* [# G$ |/ t. F
when he learned the testosterone level in the baby
1 X3 d# c8 d( ~+ [, y5 `. Jwas high, he then read the product information% P: W; S% A1 T
packet and concluded that it was most likely the rea-7 ]. z. E/ f( i6 U( f4 g
son for the child’s virilization. At that time, they
6 e6 o- T9 e' \' edecided to put the baby in a separate bed, and the
* b/ S: E7 j* U( D" P' N" ^6 Pfather was not hugging him with bare skin and had
5 v& ~ K! P/ D& G- O0 G" \) B5 rbeen using protective clothing. A repeat testosterone) c( t; u3 C1 c) x" j: T$ j+ |
test was ordered, but the family did not go to the# z) f7 V' e7 q: c
laboratory to obtain the test.
5 r4 T8 F% |) _0 F/ F) LDiscussion
5 {6 W) {; x! j \& WPrecocious puberty in boys is defined as secondary
& D" \/ t) t9 W8 _* K8 x0 c0 s, {sexual development before 9 years of age.1,4
4 ~: l- t8 ?; S1 S5 OPrecocious puberty is termed as central (true) when* f! p' s. R5 B" C( ?" Z
it is caused by the premature activation of hypo-
# g& S$ S1 s/ F2 H( e: Uthalamic pituitary gonadal axis. CPP is more com-$ L9 U |" L5 u# z7 R6 I
mon in girls than in boys.1,3 Most boys with CPP/ q) N( V9 d1 \5 i% Y
may have a central nervous system lesion that is# p6 Q0 A8 Z4 W/ A6 u
responsible for the early activation of the hypothal-
, S9 \% i# A: S6 O0 }* Namic pituitary gonadal axis.1-3 Thus, greater empha-7 g; ?# q0 A3 }* M/ h% Z6 j
sis has been given to neuroradiologic imaging in
7 ~ N- L0 }' f" }+ X$ xboys with precocious puberty. In addition to viril-, W" ^, Q+ S, W- i# \
ization, the clinical hallmark of CPP is the symmet-& o, S0 ]! K& r3 u
rical testicular growth secondary to stimulation by
B, [0 ]. ?4 R( k' h4 sgonadotropins.1,31 k# t: |& H( b
Gonadotropin-independent peripheral preco-
3 Q. I3 F( z) [7 F9 Ucious puberty in boys also results from inappropriate# {; L! h% ?: J& X- T
androgenic stimulation from either endogenous or
$ j" g) p7 y- v2 a1 p7 pexogenous sources, nonpituitary gonadotropin stim-
/ l, A0 Z. D" o% k' b# Julation, and rare activating mutations.3 Virilizing6 Z: R6 B3 x5 h) \/ \
congenital adrenal hyperplasia producing excessive
0 r: a. y3 s: L6 V' m9 P; X! k" Jadrenal androgens is a common cause of precocious' C! S: G4 ~! a- u2 z
puberty in boys.3,4
7 d- ~7 R* N, c( YThe most common form of congenital adrenal
7 d0 {8 t, s3 `hyperplasia is the 21-hydroxylase enzyme deficiency. l& \/ c0 e4 h9 @
The 11-β hydroxylase deficiency may also result in
1 W L, B3 r& H3 Jexcessive adrenal androgen production, and rarely,/ {1 V4 Z6 N1 x$ X1 o0 \% m
an adrenal tumor may also cause adrenal androgen; h; i' w2 |4 Y& s8 v, R
excess.1,3
9 X# S# `3 P2 W+ n: i" ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 b& f: S+ J% r
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 G- E! {5 E3 c l9 X" [
A unique entity of male-limited gonadotropin-$ N( a9 ?2 H5 B1 p
independent precocious puberty, which is also known+ i e* [% _" M
as testotoxicosis, may cause precocious puberty at a
' S; N! o$ H# S0 f; I( rvery young age. The physical findings in these boys* _8 ^/ |! c6 @" y& X E
with this disorder are full pubertal development,7 P3 t8 a; N) R& V8 |
including bilateral testicular growth, similar to boys3 P1 d A" L, x1 n" _
with CPP. The gonadotropin levels in this disorder
8 P2 b' @) G+ {are suppressed to prepubertal levels and do not show% U( D' h) f! L" e% z
pubertal response of gonadotropin after gonadotropin-
, J1 w% g( V" b: j Y- `releasing hormone stimulation. This is a sex-linked- N( A2 t0 x7 k$ U5 K8 `
autosomal dominant disorder that affects only2 j4 [4 |3 q, D% o7 E% Z
males; therefore, other male members of the family% G/ k+ R* g5 I3 o. Y& V9 ~4 S
may have similar precocious puberty.3
9 l$ o+ s1 o# y$ C- I9 gIn our patient, physical examination was incon-6 A( o- O' u+ p' g( r( i, L* Q- W
sistent with true precocious puberty since his testi-
6 x$ f, H% _+ ^( Z5 U `! @+ Dcles were prepubertal in size. However, testotoxicosis! l! X) `# v6 ^" Y* O2 l
was in the differential diagnosis because his father4 P+ ]5 R! G6 a, ^8 w! ^
started puberty somewhat early, and occasionally,$ N1 [5 \0 i. p. W
testicular enlargement is not that evident in the& F2 ~ n7 }0 e, v. ^. s) T5 v9 f
beginning of this process.1 In the absence of a neg-% P1 ~- s/ L7 g; N/ H8 ^" t6 d
ative initial history of androgen exposure, our
% m& m% Z3 ]" rbiggest concern was virilizing adrenal hyperplasia,
- U) \& O" q3 Neither 21-hydroxylase deficiency or 11-β hydroxylase
8 p1 D& }- {2 G2 \: u1 ?deficiency. Those diagnoses were excluded by find-% K/ ?7 q% W" k& V! ]6 }
ing the normal level of adrenal steroids.; x$ W' N: H% o( W) A$ x
The diagnosis of exogenous androgens was strongly. Z z7 |& P( l" N' \7 h3 g+ g5 d
suspected in a follow-up visit after 4 months because
- ^+ Y/ i8 C {8 qthe physical examination revealed the complete disap-% e1 Q6 e* V- j6 T6 R4 o. S
pearance of pubic hair, normal growth velocity, and' x N& H5 N% V& t
decreased erections. The father admitted using a testos-
5 j D. U. C) E1 i' Y/ pterone gel, which he concealed at first visit. He was
" x0 w: \: ~5 a* F: {using it rather frequently, twice a day. The Physicians’
, X7 Y2 D' ~' TDesk Reference, or package insert of this product, gel or
, @* c& }- I$ A0 @/ Q9 [0 _" M( H7 ?cream, cautions about dermal testosterone transfer to
6 P4 Z0 m& t1 T2 M9 punprotected females through direct skin exposure.
3 _! x8 ?9 B5 Z6 b0 eSerum testosterone level was found to be 2 times the
# V8 ~; D: {3 V% ~" O7 u6 z6 l0 N3 gbaseline value in those females who were exposed to
/ R) k* b6 F& r9 X7 C Z& zeven 15 minutes of direct skin contact with their male1 `) @9 i; z9 |
partners.6 However, when a shirt covered the applica-
( K# F& j) M. etion site, this testosterone transfer was prevented.
7 r, y7 W* @8 N j+ n cOur patient’s testosterone level was 60 ng/mL,8 p3 f2 J- |) b& b9 ]
which was clearly high. Some studies suggest that
1 H* `; z# v1 e6 S# }dermal conversion of testosterone to dihydrotestos-& T# j4 w. j8 N, j Z9 D
terone, which is a more potent metabolite, is more$ d$ G7 X2 v. [! g
active in young children exposed to testosterone
7 K/ Q4 J w$ V* L* uexogenously7; however, we did not measure a dihy-
- u( B3 A3 L- {0 @% l) tdrotestosterone level in our patient. In addition to
/ j' K1 t! Q$ j% Y+ E- Z$ Kvirilization, exposure to exogenous testosterone in. U* J) s( B. L9 K1 _4 V
children results in an increase in growth velocity and8 h7 N$ ]- b- a0 T9 Z; {
advanced bone age, as seen in our patient.
+ M c; O2 z+ v# KThe long-term effect of androgen exposure during. y* g$ @* I* @8 j S
early childhood on pubertal development and final3 w* W* e: f( y/ f! c' N4 Y
adult height are not fully known and always remain
7 i, k- t" N2 ?5 s' ga concern. Children treated with short-term testos-
& {! k- l; s1 s6 y7 K, Zterone injection or topical androgen may exhibit some
% t) }9 |# x3 u. n* p, j8 Racceleration of the skeletal maturation; however, after" V7 j* p; S% j
cessation of treatment, the rate of bone maturation
5 _& v% \4 z1 r8 Fdecelerates and gradually returns to normal.8,92 r6 W' z4 `: J4 H: ?7 t$ H
There are conflicting reports and controversy' J9 b) x* o/ Y4 u% ^9 \
over the effect of early androgen exposure on adult
" s" h3 q, e7 n0 upenile length.10,11 Some reports suggest subnormal% Q/ c5 C8 w1 y9 Z; }2 n
adult penile length, apparently because of downreg-
0 G2 L$ L' X2 P( J9 M/ Lulation of androgen receptor number.10,12 However, E/ b, d6 F5 q+ l* O- h5 e
Sutherland et al13 did not find a correlation between
2 P* B S( Z3 J Xchildhood testosterone exposure and reduced adult7 k) I! Q7 G0 b( r' X, R: V7 D
penile length in clinical studies.
# q8 [8 C' o' jNonetheless, we do not believe our patient is
$ X) g0 H5 k& ~( v% \" lgoing to experience any of the untoward effects from
1 w1 u. U4 j6 i7 I1 ntestosterone exposure as mentioned earlier because
; K2 i0 n( [* v+ p) M V. V7 y% kthe exposure was not for a prolonged period of time.
3 J" W9 m# U; h/ x6 hAlthough the bone age was advanced at the time of' E }6 W6 R% z2 h
diagnosis, the child had a normal growth velocity at
& q0 O' \9 f: }& m) @$ Pthe follow-up visit. It is hoped that his final adult! E% S7 H3 h- l9 W8 E% z3 m
height will not be affected.1 W, A$ ?5 r' x5 H o4 }
Although rarely reported, the widespread avail-
; [5 U- {" T3 gability of androgen products in our society may+ E4 w0 Y5 s' k q. I
indeed cause more virilization in male or female( g6 ]* P+ ^/ p( m
children than one would realize. Exposure to andro-
9 x- R2 S7 ~. J. J' bgen products must be considered and specific ques-
# s3 @) N( I# }- n/ }' I K# t+ ftioning about the use of a testosterone product or
4 K& y) N. ?: R+ lgel should be asked of the family members during9 s; V+ ~+ x: _7 P5 h2 O& e
the evaluation of any children who present with vir-
% r% X6 D& R7 ]# u% vilization or peripheral precocious puberty. The diag-9 b. g. S; E1 a( M0 q2 y
nosis can be established by just a few tests and by
9 I0 r. V2 V$ j o$ d/ X8 S1 kappropriate history. The inability to obtain such a7 \2 t" U) H! t6 P" H
history, or failure to ask the specific questions, may" ^- _ ~3 U; p, J* R# ~% A
result in extensive, unnecessary, and expensive
. H7 I; ~1 u! h" o7 i/ H% @investigation. The primary care physician should be3 j4 K/ N' I0 l) W; j. K
aware of this fact, because most of these children
2 |( O: v5 G F2 dmay initially present in their practice. The Physicians’
' s5 B3 g) L# p7 z# |' EDesk Reference and package insert should also put a1 n; J+ z% a: Z4 J
warning about the virilizing effect on a male or
7 ^7 @% V5 z/ Q' w1 K2 L: vfemale child who might come in contact with some-* r% J: k9 L( |' A# e6 Q
one using any of these products.
6 ~% K7 R$ X6 d; \* \1 z1 }References* L. j( n$ z9 R8 ?9 p" E
1. Styne DM. The testes: disorder of sexual differentiation" o/ s; }8 ?4 n; s" [
and puberty in the male. In: Sperling MA, ed. Pediatric
; i: M1 F. R4 J, [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 T5 c, G/ r+ f) k2002: 565-628.
5 A1 ]5 Q" W0 T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 }+ d L6 L' S# ?puberty in children with tumours of the suprasellar pineal |
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